GMT Vol. 52 No.

Box and Block Test of Wan al Dex,

Norms for 6-19 Year Olds
by Virgil Mathiowetz, Susan Federman and Diana Wiemer

Occupational therapists frequently

evaluate and treat persons with
deficits in manual dexterity.
Therefore, it is essential for occupational therapists to have objective
tools to measure an individual's
level of dexterity skill. The Box and
Block Test (Trombly, 1983) is one
tool that has been suggested for
measuring gross or manual dexterity. However, there is limited normative data for individuals age 6-19
years which makes interpretation of
the test difficult for these ages.
According to Smith (1961) the
Box and Block Test was designed by

Virgil Mathiowetz, M.S., 0.T.R., Assistant

Professor, Department of Occupational
Therapy, College of St. Catherine, 2004
Randolph, St. Paul, MN 55105. He was
formerly Assistant Professor, Occupational
Therapy Program, University of WisconsinMilwaukee, Milwaukee, WI.
Susan M. Federman, 0.T.R. and Diana M.
Wiemer, 0.T.R. were Senior occupational
therapy students, University of WisconsinMilwaukee, Milwaukee, WI at the time of the
study.
Diana M. Wiemer is presently staff occupational therapist at the Milwaukee County
Mental Health Complex, Milwaukee, WI
53266.

December/Dcembre 1985

Ayres and Holser to evaluate the

gross manual dexterity of adults
with cerebral palsy. It was later
changed and copyrighted in its present form in 1957 by Holser (currently Buehler) and Fuchs. The test
was designed to be durable and simple enough that persons with severe
dexterity deficits could be tested.

Therapists should be
certain that the test
measures the abilities
they are trying to
quantify.
Test-retest reliability at six month
intervals has been reported as a rho
coefficient of .976 and .937 for the
right and left hands respectively
(Cromwell, 1976). Inter-rater
reliability produced correlations of
r = 1.000 and r = .999 for the right
and left hands respectively
(Mathiowetz, Volland, Kashman, &
Weber, 1985). Concurrent validity

of the Box and Block Test has been

supported by a previous study which
correlated it with the Minnesota
Rate of Manipulation Test (placing
subtest) at r = .91 and with the
General Aptitude Test Battery
(Part 10) with r = .86 (Cromwell,
1976). These correlations would
indicate these three tests measure
similar types of dexterity. Therefore
therapists who use the Minnesota
Rate of Manipulation Test might
consider the Box and Block Test as
an alternative measure of manual
dexterity.
In selecting the Box and Block
Test for evaluation, therapists
should be certain that the test
measures the abilities they are trying
to quantify. Through research,
Henry (1968) found that there were
many different types of dexterity
and that a slight change in a task
may require a different type of dexterity. This conclusion is in contrast
wit h t he occupational therapy
literature which typically suggests
there are two types of dexterity:
gross and fine (Hopkins & Smith,
1983). Fleischman (1964) identified
five types of dexterity and defined
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Vol. 52 -- No. 5

manual dexterity as, "the ability to

make skillful, well-directed, armhand movements in manipulating

fairly large objects under speed conditions." In Fleishman's study, the
Minnesota Rate of Manipulation
Test (placing and turning subtests)
was found to be the best measure of
this ability. Since the blocks of that
test and the Box and Block Test are
similar in size and the two tests correlate highly (r = .91) with each
other (Cromwell, 1976), it would
appear that either test could be used
to measure manual dexterity.
Related to dexterity is the issue of
hand dominance or manual laterality. These terrns refer to the tendency
of an individual to preferentially use
the same hand in voluntary motor
acts. The assumption that an individual is more dextrous with their
dominant than nondominant hand
was generally true for right handers
but not for left handers (Benton,
Meyers, & Polder, 1962; Mathiowetz,
Volland, et al., 1985) In both
studies, left-handed subjects, aged
16-75 + years were less lateralized
than right-handed subjects when
asked to perform tests of manual
dexterity. In fact. left-handed subjects often performed better with
their right or nondominant hand A
third study (Mendell, Nelson, &
Cermak, 198a) demonstrated
similar results of diminished
lateralization in left-handed
children, ages five and seven years.
However, an increase in lateraliz,tion was shown at age nine when
there was virtually no difference in
degree of lateralization between
right-handed and left-handed subjects. Thus most subjects with the
exception of these nine year olds
were less lateralized with their left
hands than their right hands. This
third study primarily used writing
skills as an indicator of hand
dominance.
Roszkowski &
Smelbecker (1981) evaluated 15 different tasks to determine which
tasks correlated most highly with
hand dominance. They found that
for individuals, 9 to 18 years old,
the highest task correlations were
drawings (r = .87), hammer (r =
.86), and writing (r = .86). Thus
their study would support the use of

242

writing as an indicator o
dominance.

hand

The Box and Block Test can be

used as a measure of manual dexterity and can provide one indication of hand dominance. In 1961,
normative data were collected on
seven, eight, and nine year old
children (Smith, 1961). Data has
also been collected on normal adults
(Mathiowetz, Volland et al., 1985)

and adults with neuromuscular

involvement (Cromwell, 1976).
However, there is limited normative
data for the Box and Block Test for
individuals age 6-19 years. Therefore, the primary purpose of this
study was to collect normative data
on the Box and Block Test for these
ages. The secondary purpose of this
study was to describe the effects of
age, sex, and hand dominance on
manual dexterity.

December/Dcembre 1985

CJOT Vol. 52 No. 5

Methods
Subjects

This study included 471

volunteers (231 males and 240
females) aged 6 to 19 years. Subjects, aged 6-17 years, were required
to have signed parental consent
prior to participation in the study.
Subjects were recruited from
schools within the seven county
Milvvaukee area which included urban, suburban, and rural areas.
Male and female subjects were
divided into seven, two year age
groups (Table 1). All subjects
reported that they were free from
disease or injury that could affect
their upper extremity dexterity or
strength. Individuals identified as
learning disabled by their teachers
were excluded from the study. This
study was part of a larger study of
hand strength and dexterity
(Mathiowetz, Wiemer, & Federman,
in press). The Box and Block Test
was administered first, followed by
four tests of hand strength.
Description of Test

Booster seats were used to increase

their sitting height so that their chins
were at least 10.15 cm (four inches)

There is a steady
increase in scores from
age six to nineteen.

The Box and Block Test consisted

of a wooden box 53.7 cm by
25.4 cm which was divided into two
equal compartments by a 15.2 cm
high partition. The subject was instructed to transfer as many 2.5 cm
cubes as possible from one compartment to the other in one minute.
The subject's score was the number
of cubes transferred in one minute.

above the middle partition of the

test while sitting erect. This height
was selected after observation and
feedback from several children
determined the minimal height
necessary to achive optimal performance.

Procedures

Results

After a brief interview to evaluate

whether subject criteria were met,
subjects were asked, "Are you
right-handed or left-handed?" If
the subjects reported that they were
unsure as was the case with some
younger subjects, the writing hand
was used as the indicator of hand
dominance.
Complete Box and Block Test
construction information and administration procedures have been
reported (Mathiowetz, Volland et
al., 1985). However, one adaptation
of the standardized procedures was
made in the case of small children.

As would be expected, the highest

scores were achieved by the oldest
subjects and the lowest scores were
achieved by the youngest subjects.
There was a steady increase in scores
from age 6 to 19 (Table 2). When
adult norms for the Box and Block
Test (Mathiowetz, Volland et ai.,
1985) were added to the norms from
this study (Figure 1) it is clear that
maximal performance occurs in the
20 to 24 year old age groups for
both males and females. Figure I
also demonstrates that performance
gradually decreases with age after
the 20-24 year age groups.

December/Dcembre 1985

When male scores were compared

to female scores, females generally
scored better than males from age
six to eleven. From age 12 to 19 the
male scores were slightly higher than
the female scores. Subjectively it appeared that adolescent males were
more competitive than adolescent
females which may account for their
slightly better performance.
On average, right-handed subjects performed better with their
dominant hand, while left-handed
subjects performed better with their
nondominant hand (Table 3). Clearly right-handed subjects were more
lateralized than left-handed subjects. Since left-handers generally
scored better with their right hands,
data for left hand dominant subjects
were combined with the data for
right-hand dominant subjects in
Table 2. The normative data collected for the Box and Block Test
was compared to the normative data
collected by Smith (1961) for seven
to nine year olds. The mean scores
for this study averaged 3.4
blocks /mi ute less than the Smith
study.

Discussion
The trend of hnproving performance from age 6 to 19 years was
expected based on recent studies on
the Purdue Pegboard (Gardner &
Broman, 1979; Mathiowetz,

243

CJOT Vol. 52 No. 5

tients seen in Occupational Therapy
have difficulty or are unable to
stand.
A disadvantage of the Box and
Block Test was the amount of noise
it made during testing. This was partially alleviated by placing selfadhesive foam cushions on the bottom (outside) of the test box and on
the bottom (inside) of the box
used to count the blocks.

Summary

Rogers, Dowe, Donahoe, Rennells

in press). The curvilinear relationship between age and dexterity
(Figure 1), would suggest the need
for norms stratified by age. Most
dexterity tests have generalized
"adult" norms which are frequently
applied to both adolescents and the
elderly. This practice should be
questioned in light of the results of
this and other recent studies.
There were several differences
between this study and Smith's
study which may account for the
variance in scores. For example,
Smith grouped her subjects' scores
according to dominant and nondominant hands (right hand of
right-handers combined with left
hand of left-handers) whereas this
study grouped subjects as "right"
and "left" regardless of hand
dominance. Smith used a 60 second
practice trial before testing whereas
this study used 15 seconds. With
adults (Mathiowetz, Volland et al.,
1985) the shorter practice trial did
not affect scores. However, with
children the extra practice may have
improved scores. Other possible
variables include geographical differences (Southwest vs. Midwest),
year differences (1961 vs. 1984), or
differences in blocks used (sanded
hardwood vs. colored blocks).
Future research should systematically address hand dominance,
244

block, year, anci geographic differences, as possible variables that

might affect test scores. The latter is
particularly important since the normative data for this study was collected in a small geographic area. In
addition research should assess
whether manual dexterity tests as
the Box and Block Test or Minnesota Rate of Manipulation Test
correlate with functional activities
(e.g. self-care, homemaking, work
and leisure) when performed by
individuals with impaired dexterity.
Currently it is assumed that performance on dexterity tests correlates highly with performance of
functional activities. This relationship needs to be documented. Other
research should evaluate the effectiveness of occupational therapy
activities for improving manual dexterity.
There are several advantages to
the Box and Block Test. First, it is
very easy to construct and cost is
minimal. Blocks may be purchased
commercially if a clinic does not
already have them. Second, the test
has general applicability to individuals with limited cognitive ability,
short attention span, or poor endurance. Finally the standardized sitting position is an advantage in contrast to the Minnesota Rate of
Manipulation Test which uses the
standing position, since many pa-

The Box and Block Test is a simple, inexpensive, and effective

method for measuring manual dexterity. It is well suited for children as
well as adults because of the simple
instructions and brief time of
administration. With the normative
data presented here, therapists can
objectively assess their patients level
of manual dexterity. This test
should also be useful in assessing the
effectiveness of treatment programs
designed to improve manual dexterity.
REFERENCES
Benton, Al. L., Meyers, R., & Polder, G.J.
(1962). Some aspects of handedness.
Psychiathia et Neurologia, 144, 321-377.
Cromwell, F.S. (1976). Occupational

Therapist's Manual for Basic Skill Assessment; Primary Prevocational Evaluation.

Altadena, CA: Fair Oaks Printing Co.
Fleischman, E.A. (1964). The Structure and

Measurement

of Physical Fitness.

Englewood Cliffs, NJ: Prentice-Hall.

Gardner, R.A., & Broman, M. (1979). The
Purdue Pegboard: Normative data on
1334 school children. Journal of Clinical
Child Psychology, Fall, 156-162.
Henry, F.M. (1968). Classical Studies on
Phy.sical Activities. Englewood Cliffs, NJ:
Prentice-Hall.
Hopkins, H.L., & Smith, H.D. (Eds). (1983).
Willard and Spackman's Occupational
Therapy (6th edition). Philadelphia, PA:
J.P. Lippincottt Co.
Mandell, R.J., Nelson, D.L., & Cermak,
S.A. (1984). Differential laterality of hand
function in right-handed and left-handed
boys. American Journal of Occupational
Therapy, 38, 114-120.
Mathiowetz, V., Rogers, S.L., Dowe, M.,
Donahoe, L., & Rennells, C. (in press).
The Purdue Pegboard: Norms for 14 to 19
year olds. American Journal of Occupa-

tional Therapy.
Mathiowetz, V., Volland, G., Kashman, N.,
& Weber, K. (1985). Adult norms for the
Box and Block Test of manual dexterity.

American Journal of Occupational

Therapy, 39, 386-391.

December/Dcembre 1985

CJOT VoL 52 No. 5

Mathiowetz, V., Wiemer, D.M., & Federman,
S.M. (in press). Grip and pinch strength:
Norms for 6 to 19 year olds. American
Journal of Occupational Therapy.
Roszkowski, M., & Snelbecker, G. (1981).
Children's, adolescents', and adults' report
of hand preference: Homogeneity and
discriminating of selected tasks. Journal
of Clinical Neuropsychology, 3, 199-213.
Smith, D.A. (1961). The Box and Block Test:
Normative data for 7, 8, 9 year old
children. Unpublished master's thesis,

University of Southern California, Los

Angeles, Ca.
Trombly, C.A. (1983). Occupational
Therapy for Physical Dysfunction (2nd
edition). Baltimore, MD: Williams and
Wilkins

Acknowledgements
The authors wish to thank Franklin Stein,
Ph.D., and James McPherson, M.S., for

research and statis:ical consultation; Cary

Backman (Nicolet High School), Jean Bartow (Riverside High School), Eileen Wastak
(Hartford Avenue School), Jeanne Johns
(Templeton Middle School), Mary Beth
Ahmed, and Dewey Snart (Maple Elementary
School) for coordinating the study at their
schools; Mary Dowe, Lori Donahoe, Sandra
Rogers, Cheryl Rennells, and Kelly
Beauchene for assisting in data collection;
and the students for participating in the
study.

Rsum
Cette tude a eu pour but de recueillir les donnes normatives pour les
personnes ges de 6 19 ans, sur la base du test des botes et des cubes
(Box and Block test) servant valuer la dextrit manuelle. Quatrecents soixante-et-onze sujets (231 fminins et 240 masculins) ont t
recruts parmi les sept comts de la rgion de Milwaukee. Les sujets
issus de milieu urbain, de la banlieue et de la campagne ont ainsi t
reprsentatifs d'un registre tendu de milieux socio-conomiques. Les
donnes ont t stratifies en sept groupes d'ges de deux ans d'intervalle. Les rsultats ont dmontr que la dextrit manuelle accrot en
proportion directe avec l'ge chronologique. Les sujets fminins ont
gnralement dmontr des rsultats suprieurs entre 6 et 11 ans, alors
que les sujets masculins ont atteint des rsultats lgrement suprieurs
entre 12 et 19 ans. En moyenne, droitiers et gauchers ont obtenus de
meilleurs rsultats avec la main droite, bien que les sujets droitiers ont
clairement fait preuve d'une meilleure latralisation que les gauchers.

If you are interested n writing

book reviews for the Canadian
Journal of Occupational Therapy,
please forward your name, mailing
address, telephone number, areas of
interest and language preference to:
Si vous tes intress(e) crire
des rvisions de livres pour la Revue
Canadienne d'Ergothrapie, veuillez envoyer vos nom, adresse postale, numro de tlphone, sujets
d'intrt et langue prfre a:
Jane Virro
C.10T Book Review Columnist
Lyndhurst Hospital
520 Sutherland Drive
Toronto Ont. M4G 3V9
December/Dcembre 1985

Are you an Occupational

Therapist who has completed a

thesis at either the doctoral or

rnaster's level?
Have you sent a copy of the
thesis Abstract to CJOT for publication?
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School of Medical Rehabilitation, University of Manitoba
770 l3annantyne Avenue, 'Winnipeg, Manitoba R3E OW3
245