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Handwriting
performance in
preterm children
compared with
term peers at
age 6 to 7 years
Katya P Feder* PhD OT (C), Rehabilitation Science;
Annette Majnemer PhD OT (C), Associate Professor, School
of Physical and Occupational Therapy, McGill University;
Daniel Bourbonnais PhD OT, Professor, School of
Rehabilitation, University of Montreal;
Robert Platt PhD, Departments of Pediatrics, Epidemiology,
Biostatistics, and Occupational Health, McGill University,
Montreal, Quebec;
Marc Blayney MD, Department of Neonatology, Children’s
Hospital of Eastern Ontario, Ottawa, Ontario;
Anne Synnes MD MHSc, Department of Pediatrics,
University of British Columbia, Vancouver, BC, Canada.
*Correspondence to first author at 187 Goulburn Avenue,
Ottawa, Ontario, K1N 8E3, Canada.
E-mail: kfeder@cyberus.ca
Preterm infants are at high risk for developmental impairments
at school age. However, the impact of these impairments on
important life skills, such as handwriting, is unknown. Forty-
eight first-grade children (27 males, 21 females; mean age 6y
7mo, SD 3.9mo; range 6y 1mo to 7y 3mo) born preterm
(birthweight <1250g; gestational age <34wks), without
major physical or cognitive disabilities, were matched to 69
healthy, term control children (32 males, 37 females; mean
age 6y 10mo, SD 3.6mo; range 6y 3mo to 7y 4mo) by sex and
school class. All children were assessed using the Evaluation
Tool of Children’s Handwriting-Manuscript and several
sensorimotor measures. Preterm children demonstrated
significantly lower legibility and slower speed scores (p<0.01)
compared with control children for most of the handwriting
tasks. Factors associated with legibility were visual
perception and eye–hand coordination (r≤ 0.50; p<0.05) and
sex (r≤ 0.12; p=0.01). In-hand manipulation and finger
identification (r≤ 0.43; p<0.01) were significantly correlated
with slow handwriting speeds. Behaviour difficulties
associated with hyperactivity and poor attention (Connors
Abbreviated Symptoms Questionnaire) had a confounding
influence on both legibility and speed. These findings may
help guide early identification efforts and medical/therapeutic
interventions for preterm children.
See end of paper for list of abbreviations.
Developmental Medicine & Child Neurology 2005, 47: 163–170 163
Handwriting is an important task learned during the early
school years. A high proportion of a child’s school day is taken
up with learning to write, which is an essential ingredient for
success at school (McHale and Cermak 1992). This complex
perceptual-motor skill requires adequate performance in visu-
al-motor coordination, motor planning, cognitive/perceptual
skills, and tactile and kinesthetic sensitivities (Maeland 1992).
There is evidence of deficits in motor, perceptual-motor, and
visual-motor integration skills in children born preterm (Mar-
low et al. 1993, Goyen et al. 1998, Luoma et al. 1998), which
may interfere with handwriting competency.
The rate of major neurological impairment in preterm
infants is approximately 5–20% (Vohr et al. 2000, Tommiska et
al. 2003). However, a larger percentage of children (30–50%)
demonstrate learning and behavioural difficulties at school age
(McCormick et al. 1990). Despite average intellectual ability in
the majority of preterm children (Bohm et al. 2002, Bowen et
al. 2002), comparative studies have documented developmen-
tal difficulties in up to 50% of such children compared with
term-born peers (Goyen et al. 1998, Saigal et al. 2000, Doyle et
al. 2001). Factors such as the extent of prematurity, perinatal
medical complications, behavioural difficulties, sex, maternal
education, and self-concept may be important predictor vari-
ables (Zelkowitz et al. 1995, Samson et al. 2002).
Persistent motor impairments are common features in
preterm children. At age 12 to 13 years, one-third of such chil-
dren show significant motor impairment compared with their
term peers, with pronounced differences in manual dexterity
tasks (Powls et al. 1995). These minor motor impairments,
often not documented until early school-age, range from 25%
to over 50% (Goyen et al. 1998), with variability due to the
measures used and population characteristics. Although pre-
term infants are at high-risk for motor deficits, the impact on a
functional skill such as handwriting, to our knowledge, has
not been addressed. The one controlled study that docu-
mented handwriting ability in this population did not use a
standardized measure (Marlow et al. 1993).
The first objective of this study, therefore, was to describe
handwriting performance in preterm, first-grade children
compared with term, sex-matched peers from the same class.
Second, we investigated the relationship between handwriting
performance and sensorimotor skills in the preterm group,
including fine motor coordination, in-hand manipulation, visu-
al-motor integration, visual perception, proprioception, and
sensory awareness of the fingers. Third, the association bet-
ween handwriting and psychosocial factors was determined.
Method
Preterm cohorts born 1992–1994 in first grade (age 6–7y) of
elementary school were recruited from the Children’s Hospital
of Eastern Ontario (CHEO) Neonatal Follow-Up Clinic and
represents a regional sample. This study was approved by the
hospital’s Science and Ethics Committee.
Potential preterm participants who met the inclusion crite-
ria were extracted from the records of the CHEO Neonatal
Follow-Up Clinic. Inclusion criteria were: a documented birth-
weight of <1250g and gestational age <34 weeks. Exclusion
criteria (for both groups) were: children diagnosed with cere-
bral palsy, cognitive impairment (defined as repetition of an
academic year), chromosomal abnormalities, genetic syndro-
mes, major auditory impairment requiring hearing aids, or vis-
ual impairment of <20/200 visual acuity. Preterm children with
grade 3 intraventricular hemorrhage were excluded. Parents participants, letters were distributed to parents of all first grade
were contacted, the study was explained to them, and written children in the selected school classes. Inclusion criteria for the
consent was returned. Participants attended 40 different ele- control children were being the same sex as the preterm child
mentary schools from three School Boards, including three and gestational age of >37 weeks. Appointments were booked
private schools. Permission was obtained from the School for the first two children who met the inclusion/exclusion
Boards and individual school principals. To recruit the control criteria.
Those conducting the tests and teachers were blinded as to
group assignment (preterm or control). All participants attend-
ed regular first grade classes and were proficient in English.
Participants were assessed individually by an experienced
Table I: Preterm group performance on Evaluation Tool of
occupational therapist in an enclosed room at CHEO using a
Children’s Handwriting-Manuscript (ETCH-M; Amundson
standard height table (74cm) and chair (48cm). A battery of 10
1995; n=48)
tests was administered in random order during a 2-hour peri-
ETCH-M Quartiles od with a rest midway. The tests included sensorimotor tests, a
Mean (SD) 25 50 75 handwriting evaluation, and a perceived self-competence mea-
sure. Parents were asked to complete the Connors Abbreviated
Legibility
Symptoms Questionnaire (Connors ASQ; Connors 1989) and
Word, % 49.2 (28.2) 23.8 53.1 66.7
three questions indicating maternal education level; the class-
Letter, % 68.0 (15.6) 60.7 68.2 78.6 room teacher was asked to complete a handwriting rating
Numeral, % 80.1 (19.2) 66.2 88.2 94.1 scale for each participant. The instruments used (described in
Appendix I) are widely used clinically to evaluate children of
Speed early school age and they have acceptable psychometric prop-
Lower-case alphabet 205.6 (126.7) 108.7 153.5 302.7 erties. Unless otherwise specified, a cut-off standard deviation
writing, s (SD) of 1.5 below the mean was used. This cut-off is based on
Upper-case alphabet 171.8 (88.4) 109.5 141 205.7 test recommendations and/or cut-offs that are believed to be
writing, s clinically relevant in identifying children with difficulties.
Numeral writing, s 45.2 (19.7) 30.2 38.5 54.5
STATISTICAL METHODS

Near-point copying, 15.6 (6.0) 10.5 15.4 19.3 Descriptive statistics, paired t-tests, and χ2 analyses were car-
letters/min ried out to compare performance between preterm children
and controls on handwriting and sensorimotor measures; six
Far-point copying, 14.1 (4.7) 10.4 13.9 17.4
preterm participants with no matched controls were exclud-
letters/min
ed. Pearson’s product moment correlation was carried out
Sentence composition, 13.7 (9.4) 5.6 14.2 19.6
letters/min between handwriting performance measures and sensori-
motor variables (all continuous). Multiple linear regression
analyses were used to determine the significant predictors of
handwriting legibility and speed (p<0.50). Conditional mul-
tiple linear regression analysis was also performed to identify
important factors (p<0.50) contributing to performance dif-
Table II: Mean (SD) scores for legibility and speed in
ferences between matched pairs. Birthweight and behavioural
Evaluation Tool of Children’s Handwriting-Manuscript
difficulties were entered into all models as possible con-
(ETCH-M; Amundson 1995) for preterm and control groups
founders. Other independent variables that were analyzed
ETCH-M Preterm group Control group Paired t-test included: age, sex, maternal education, intraventricular hem-
(n=42) (n=42) (p) orrhage (IVH), retinopathy of prematurity (ROP), and bron-
chopulmonary dysplasia (BPD).
Legibility
Word, % 49.7 (29.8) 67.0 (21.6) 0.004
Results
GROUP CHARACTERISTICS
Letter, % 67.7 (16.5) 76.9 (12.9) 0.005 A total of 48 children (92% participation rate), born preterm
and proficient in English, were tested (27 males, 21 females;
Numeral, % 79.8 (19.2) 85.8 (15.6) 0.078 mean age 6y 7mo, SD 3.9mo; range 6y 1mo to 7y 3mo). Pre-
term children were matched to controls (mean age 6y 10mo,
Speed SD 3.6mo; range 6y 3mo to 7y 4mo) by sex and class attended.
Upper-case, s 82.3 (89.0) 138.8 (46.4) 0.005 Twenty-four of the preterm group had two controls with an
average of their scores (control A and B) used for analysis; 18
Lower-case, s 221.0 (127.9) 127.9 (43.0) 0.0001 preterm children had one control and six children had no con-
trols due to recruitment difficulties. The majority of children
Near-point, 14.8 (5.9) 21.8 (7.4) 0.0001 demonstrated a right-hand preference (preterm 44/48; con-
letters/min trols 58/69) and all were tested during the first grade school
year except for one from the preterm group and nine controls
Far-point, 13.5 (4.4) 17.1 (5.5) 0.001
letters/min
who were tested during the summer following first grade.
Nine preterm children and one control child wore corrective

164 Developmental Medicine & Child Neurology 2005, 47: 163–170

eyeglasses. A significantly greater number of preterm children
reported receiving remedial help in an identified academic area
(preterm 12/48 vs control 8/69; p<0.001) and in occupational
therapy services (preterm 16/48 vs control 4/69; p<0.001)
during the school year. The majority of preterm children and
controls (60.4% and 62.3% respectively) had not attended a
nursery/preschool program, but the majority (73% and 78.3%
respectively) had attended kindergarten (age 4 years).
HANDWRITING PERFORMANCE
Preterm handwriting performance (n=48) and comparative
analyses between preterm children and controls (n=42 pairs)
are shown in Tables I and II. Handwriting performance in the
controls is described elsewhere (Feder et al. Forthcoming).
Handwriting legibility
There was a significant difference (p<0.01) in word and let-
ter legibility between matched pairs, with scores lower for
preterm children. The percentage of preterm children scoring
<1.5SD below the mean for word, letter, and numeral legibili-
ty was 10.4%, 6.2%, and 4.2% respectively. Simple regression
demonstrated a significant association between sex and letter
legibility (r≤0.12; p=0.14). A significant sex difference in let-
ter legibility (t=–2.5; p=0.14) and numeral legibility (t=–2.2;
p=0.031) in preterm children was noted with lower scores for
males, which is similar to control group findings (Feder et al.
Forthcoming).
Manuscript (ETCH-M; Amundson 1995) legibility/speed for
preterm children (r=–0.56–0.54; p≤ 0.040) and controls
(r=–0.43 to –0.41; p≤ 0.002), such that better teacher ratings
were associated with better ETCH-M performance.
FACTORS ASSOCIATED WITH HANDWRITING PERFORMANCE IN
PRETERM CHILDREN
Sensorimotor tasks
A comparative analysis of sensorimotor variables appears in
Table IV. The percentage of preterm children scoring 1.5SD
below the mean was approximately threefold greater than con-
trols for the following subtests of the Bruininks-Oseretsky Test
of Motor Proficiency (BOTMP; Bruininks1978): Fine Motor
Composite, Upper Limb Speed and Dexterity, Upper Limb
Coordination, Test of Visual-Perceptual Skills, and Visual Motor
Integration (VMI). The majority of preterm children (41/48)
achieved perfect scores on the proprioception subtest. On
Motor Accuracy (MAC; Ayres 1989), part of the Sensory Inte-
gration and Praxis Tests (SIPT; Ayres 1989), and Finger Iden-
tification (part of SIPT), 31.2% and 8.5% of preterm children
scored within the mild or definite dysfunction categories res-
pectively, while one-third demonstrated difficulties on the
Steadiness Test. In rotation and translation (In-hand Manip-
ulation Skill Test; Exner 1992), 35.4% and 41.7% of the preterm
children demonstrated difficulties that were proportionally

Handwriting speed Table III: Teacher rating of handwriting performance in

Preterm children demonstrated significantly slower speeds preterm children and controls
compared with controls in most tasks (p<0.005; Table II) Handwriting performance Preterm ratings Control ratings
except numeral and sentence composition with wide vari- (n= 38) (n= 59)
ability in speed evident for both groups (Table I). Consistent
with control group findings, no significant sex difference in Legibility
writing speed was noted. Above average/acceptable 23 46
Needs improvement/very poor 15 13
Pencil grasp Speed
The static tripod graspa was the most common in preterm Above average/acceptable 21 45
children (46.5%), followed by the lateral tripodb grasp Needs improvement/very poor 17 14
(25.6%). Thumb placement was opposite other fingers (rather
than flexed into palm, crossed over the top of other fingers, or
any other position) in 66.7% of the preterm group with finger
position mid-range in 60.4%; web space was open or elliptical Table IV: Means (SDs) and paired t-tests on sensorimotor
in most preterm children (47.9% and 41.7% respectively). variables for preterm and control groups
Pencil grasp was not always maintained consistently during
the handwriting evaluation. These findings were remarkably Sensorimotor variables Preterm Control p
similar (p<0.05) to control group findings. group group
(n=42) (n=42)
Teacher rating of handwriting performance Fine Motor Compositea 44.6 (11.9) 49.8 (9.7) 0.014
The majority of teachers (preterm children 38/48; controls Upper Limb Coordinationa 10.5 (5.5) 13.9 (5.4) 0.001
59/69) completed the handwriting rating scale (Table III). An Response Speeda 2 (5.6) 18.1 (5.5) 0.086
inverse correlation exists between teacher rating of hand- Visual Motor Controla 13.0 (6.1) 15.7 (5.7) 0.014
writing and the Evaluation Tool of Children’s Handwriting- Upper Limb Speed and Dexteritya 13.6 (5.4) 14.9 (3.8) 0.034
Visual Motor Integration (11.7) 96.4 (9.0) 0.005
aStatic tripod grasp: pencil rests in open web space and is stabilized Test of Visual-Perceptual Skills 109.8 (17.2) 7.3 (14.5) 0.034
against thumb and index pulp with fully opposed thumb and wrist Motor Accuracy –0.67(0.97) –0.45 (0.62) 0.064
slightly extended with forearm resting on desk top. Fingers posed Finger Identification –0.23 (1.1) 0.35 (0.76) 0.010
in tripod posture but hand moves as a unit. Steadiness Test 14.9 (14.3) 7.2 (10.5) 0.021
bLateral tripod grasp: pencil is braced at index pulp and radial side Rotation 57.6 (15.7) 46.3 (8.8) 0.0001
of third digit against adducted thumb with web space partially to Translation 60.3 (22.8) 46.7 (10.2) 0.0001
completely closed; fourth and fifth digits flexed. Localized
aBruininks–Oseretsky Test of Motor Proficiency subtests
movement of three radial digits and wrist movement with slight
wrist extension, forearm resting on desk (Amundson 1995). (Bruininks 1978).

Handwriting in Preterm Children Katya P Feder et al. 165

five times greater than the control children.
Correlational analysis was carried out to determine the
association between these sensorimotor tasks and handwrit-
ing difficulties (Table V and Table VI).
Perinatal variables
Mean gestational age of our preterm sample was 27.8 weeks
(SD 2wks; range 24–34wks) and the mean birthweight was
997.3g (SD 174.8g; range 470–1235g). Correlational analysis
revealed no significant association between these variables
and legibility or speed. Medical records indicated 17/48 of
the preterm group had IVH (grade 1–2), 23/48 had BPD
(grade 1–3), and 16/48 had ROP (grade 1–3). No significant
difference in handwriting performance between groups with
or without these medical complications was demonstrated.
behavioural difficulties (score>20). In our sample, behaviour-
al difficulties, including hyperactivity and decreased attention
(Connors ASQ), was associated with word (r=–0.40; p=0.005)
and letter legibility (r=–0.41; p=0.003), lower-case (r=0.374;
p=0.009) and upper-case alphabet writing (r=0.31; p=0.033),
and near-point copying speeds (i.e. copying from a paper
placed in front of the child; r=–0.39; p=0.005), such that chil-
dren with behavioural difficulties had lower legibility and
slower speeds. Simple regressions also demonstrated associa-
tions with legibility (r≤ 0.16–0.17; p<0.005), and speed
(r≤0.09–0.16; p<0.05). All participants scored medium/high
on the Pictorial Scale of Perceived Competence and Social
Acceptance Scale (PCSAS; Harter and Pike 1983) with no sig-
nificant difference between matched pairs. No association
between PCSAS and handwriting was found.

Psychosocial factors MULTIVARIATE ANALYSIS

Most preterm children scored within the average range (mean The best-fitting multivariate regression models (Table VII)
8, SD 6; range: 0–28) on the Connors ASQ, with only two chil- revealed that the Test of Visual-Perceptual Skills (TVPS; Gardner
dren in each group (preterm and control) rated as having 1982) was a significant predictor for letter legibility (p=0.027),

Table V: Pearson’s correlations for sensorimotor tasks and handwriting legibility in preterm group

Sensorimotor tasks Evaluation Tool of Children’s Handwriting-Manuscript

Word legibility Letter legibility Numeral legibility

BOTMP Fine Motor Composite 0.36a 0.38a 0.47b

Visual Motor Control 0.39a 0.52b 0.57b
Upper Limb Coordination 0.22a 0.21a 0.26
Upper Limb Speed and Dexterity 0.20a 0.29a 0.38b
Visual Motor Integration 0.34a 0.38b 0.36a
Test of Visual-Perceptual Skills 0.40b 0.54b 0.49b
In-hand Manipulation
Rotation –0.21a –0.28a –0.26
Translation –0.12a –0.09a –0.05
Steadiness Test –0.10a –0.24a –0.39b
Sensory Integration Praxis Test
Motor Accuracy 0.30a 0.46b 0.39b
Finger Identification 0.28a 0.37a 0.29a

BOTMP, Bruininks–Oseretsky Test of Motor Proficiency (Bruininks 1978). ap<0.05; bp<0.01.

Table VI: Pearson’s correlations for sensorimotor tasks and handwriting speed in preterm group
Sensorimotor tasks Evaluation Tool of Children’s Handwriting-Manuscript: Speed Tasks
Upper-case Lower-case Near-point Far-point
alphabet alphabet copying copying

BOTMP Fine Motor Composite –0.28 –0.24 0.22 0.09

Visual Motor Control –0.30a –0.25b 0.21 0.14
Upper Limb Coordination –0.29a –0.22 0.16 0.06
Upper Limb Speed and Dexterity –0.32a –0.32 0.29a 0.06
Visual Motor Integration –0.27 –0.37a –0.22 –0.03
Test of Visual-Perceptual Skills –0.27 –0.31a 0.25 0.17
In-hand Manipulation
Rotation 0.24 0.19 –0.28a –0.10
Translation 0.44a 0.43b –0.31a –0.22
Steadiness Test 0.07 0.01 –0.20 0.00
Sensory Integration Praxis Test
Motor Accuracy –0.31a –0.34a 0.17 0.07
Finger Identification –0.22 –0.33a 0.10 0.17

BOTMP, Bruininks–Oseretsky Test of Motor Proficiency (Bruininks 1978). ap<0.05; bp<0.01.

166 Developmental Medicine & Child Neurology 2005, 47: 163–170

even when adjusting for confounders (behavioural difficulties,
sex). ROP, IVH, and BPD were entered into each model togeth-
er with a weak confounding influence on MAC found in letter
legibility, only such that clinical conclusions were not affected.
Multivariate analyses were not carried out for numeral legi-
bility, proprioception, or perceived competence as the sample
distribution was skewed to higher end performance.
Translation (In-hand Manipulation Test) was an important
predictor (p≤0.01) for all speed tasks, except far-point copying
(i.e. copying from a wall chart or blackboard), even when
adjusting for confounders (behavioural difficulties, birth-
weight, age at testing). In lower-case alphabet writing, Finger
Identification was also an important predictor (p=0.015). In
lower- and upper-case alphabet writing, no confounding effect
of sex or maternal education was seen.
Conditional linear regression analysis was used to test the
association between predictor variables contributing to the dif-
ference in scores between matched preterm and control pairs.
These findings reinforced those of multiple linear regression
such that TVPS was significantly associated with differences
between pairs in both word (r≤0.18; p=0.005) and letter legi-
bility (r≤0.33; p<0.0001) and translation was significantly
associated with differences in lower-case (r≤0.09; p=0.056)
and upper-case alphabet writing speeds (r≤0.13; p=0.018). In
near-point copying, MAC was an important predictor acco-
unting for 18.2% of the variance with no confounding effect
seen (p=0.005). Finger Identification was also significantly
associated with lower-case speed (r≤0.19; p=0.004) and rea-
ched borderline significance in predicting upper-case speed
differences when modelled with translation (r≤ =0.20;
p=0.067). There was a confounding effect of behavioural diffi-
culties for letter and word legibility whereas a confounding
influence was demonstrated by behavioural difficulties and/or
age for handwriting speed tasks and, therefore, these were
adjusted for in the above models.
Discussion
In this study, preterm children performed significantly worse
on handwriting performance measures compared with term
peers, demonstrating lower legibility and slower writing speeds.
Preterm children also demonstrated difficulties on most sen-
sorimotor skills, including fine motor coordination, manipu-
lative skills, visual motor integration, visual perceptual skills,
and sensory awareness of the fingers.
As handwriting is influenced by the nature of instruction
received and the extent of practice, it is important to evaluate a
children’s handwriting compared with their peers from the
same instructional setting (Ziviani 1995). One of the strengths
of this study is the matched design using same-classroom
peers. In addition, our preterm cohort represents a regional
sample with a high participation rate. We controlled for sex
because of its important confounding influence on handwrit-
ing (Maeland 1992, Karlsdottir and Stefannson 2002, Feder
et al. Forthcoming).
In our study, specific sensorimotor factors emerged as hav-
ing important associations with handwriting performance. The
TVPS, a non-motor visual perceptual test, was closely associat-
ed with handwriting legibility whereas Translation (In-hand
manipulation test) demonstrated a strong association with
most handwriting speed tasks. These two variables were also
important factors in explaining the differences in legibility
and speed between matched pairs. In studies of typically
developing children, poor hand writers scored lower on the
TVPS compared with good writers, with the TVPS being the
best predictor. Visual Sequential Memory, a TVPS subtest, was
a significant predictor of handwriting speed (Tseng and
Murray 1994, Tseng and Chow 2000). Our findings validate
the important association between visual perceptual skills and
handwriting ability in preterm children.
The relationship between other sensorimotor components
and handwriting is documented in several studies. Tseng and
Murray (1994) found that poor hand writers scored worse on
the TVPS, the MAC, the VMI, Upper Limb Speed and Dexterity,
with the VMI and the MAC being the best predictors. These
associations were also demonstrated in our population. In par-
ticular, the relationship between MAC and handwriting perfor-
mance has been supported by several investigations (Maeland
1992, Tseng and Murray 1994, Cornhill and Case-Smith 1996).
According to Cornhill and Case-Smith (1996), MAC is a tracing
task different from the copying or dictation style handwriting
performed by first grade children, and should only be evaluat-
ed when legibility is poor and more reliant on the visual system.
Our study supports their conclusion that eye–hand coor-
dination is a fundamental component of handwriting.
Translation, was an important predictor of most handwrit-
ing speed tasks in our study. Cornhill and Case-Smith (1996)
found that in typically developing children, translation and
rotation emerged as significant predictors of legibility using the
Minnesota Handwriting Test (Reisman 1993); however, speed
was not measured. No association between finger localization
or identification and alphabet writing was found in studies of
typically developing children (Berninger and Rutberg 1992,
Feder et al. Forthcoming). However, evidence indicates that
this component may be important in high-risk populations or
children with known motor/handwriting impairments. A study
of preterm children at school age documented worse finger
identification scores compared with normal values (De-Maio-
Feldman 1994). Our correlational findings corroborate those
Table VII: Best fitting multivariate regression models:
handwriting legibility/speed in preterm group
Predictor models β coefficient r2 p
Legibility
Letter
Test of Visual-Perceptual Skills 0.262a 0.502* 0.027
Motor Accuracy 3.43a 0.087
Word
Test of Visual-Perceptual Skills 0.431a 0.260 0.071
Speed
Lower-case alphabet writing (s)
Translation 2.272b 0.429* 0.004
Finger Identification –35.522b 0.015
Upper-case alphabet writing (s)
Translation 1.693c 0.284 0.001
Near-point copying (letters/min)
Translation 0.0854d 0.299 0.014
aAdjusted for confounders, behavioural difficulties, sex; badjusted
for confounders, behavioural difficulties, birthweight; cadjusted for
confounder, behavioural difficulties; dadjusted for confounders:
behavioural difficulties, age at testing. *Indicates r2 for two
predictor variables modelled together.
Handwriting in Preterm Children Katya P Feder et al. 167
reported by Malloy-Miller et al. (1995) in a subgroup of chil-
dren demonstrating execution/coordination difficulties.
Proprioception/kinesthesia may also play a role in hand-
writing performance by providing directionality informa-
tion/cues for keeping within boundaries and influencing grip
and degree of pressure applied during writing (Cornhill and
Case-Smith 1996). However, handwriting studies incorporat-
ing proprioception have produced conflicting results high-
lighting measurement challenges in evaluating this function
(Cornhill and Case-Smith 1996). Proprioceptive deficits were
not documented in our sample, which may be due to our
selection of test instruments.
Sex was an important confounder for legibility in our study
while behavioural difficulties had a confounding influence on
speed and legibility. Our study supports the substantive litera-
ture indicating that males have worse legibility than females
(Karlsdottir and Stefansson 2002). Attentional or behavioural
factors, often not considered in handwriting studies, were
found to be important factors in handwriting performance.
Tseng and Chow (2000) found that poor hand writers exhib-
ited decreased performance on a normalized vigilance task,
which corroborates our findings.
There is evidence that domains of perceived competence
diminish from the ages of 6 to 9 years in preterm children
(Zelkowitz et al. 1995, Jongmans et al. 1996). However, our
sample demonstrated average to above average perceived
competence in all domains. It may be that in first grade,
these children have not yet developed an appreciation of
their difficulties, which is reflected in their perceived com-
petence scores.
Handwriting is a functional skill that children must perform
daily during the early school years. Children spend from 31
to 60% of their school day performing handwriting/fine motor
tasks (McHale and Cermak 1992). Our findings suggest, there-
fore, that children born preterm are more likely to face multi-
ple challenges in their daily functioning at school. Functional
limitations in preterm children have been documented in a
number of areas (mobility, self-care, communication; Msall
and Tremont 2000). In this context, handwriting performance
difficulties present an additional functional limitation for this
high-risk group. Furthermore, handwriting problems are linked
to lower academic success and poor self-esteem (Mather and
Roberts 1995). Future studies should evaluate the relationship
between sensory, cognitive, and language skills and hand-
writing performance.
Clinical significance
Our findings provide a detailed elucidation of handwriting dif-
ficulties in preterm infants. The identification of variables asso-
ciated with handwriting performance may guide therapeutic
interventions for preterm children. Furthermore, our findings
underscore the importance of early targetting and manage-
ment of behavioural difficulties in this population. Screening
for handwriting problems may facilitate early intervention
and circumvent secondary problems associated with deficient
handwriting in this population. It is critical that rehabilitation
specialists, educators, and medical practitioners minimize the
impact of longstanding handwriting difficulty on children’s
daily functioning, from both an academic and psychosocial
point of view.
DOI: 10.1017/S0012162205000307
168 Developmental Medicine & Child Neurology 2005, 47: 163–170
Acceptance date 27th May 2004.
Acknowledgements
I would like to thank the children and families who participated in
this study. A special thank you to Louise LaFleur for administrative
assistance, and Sue Harcourt for occupational therapy assessments;
to Montreal Children’s Hospital Biostatistical Consulting Service for
statistical support and Vicki Stuhec for assistance with data entry; to
our research assistants, Emily Dawson, Kiersten Leus, Christine
MacDonald, Caroline Senior, Sonia Singh, and Tim Flood. These
study results were presented at the 2003 annual conference of the
American Academy of Cerebral Palsy and Developmental Medicine
in Montreal, Quebec. This project was supported by grants from
REPAR (Quebec), the Children’s Hospital of Eastern Ontario
Research Institute, and the Scottish Rite Charitable Foundation. A
2-year doctoral studentship was awarded to Katya Feder from the
Canadian Institutes of Health Research/Canadian Occupational
Therapy Foundation Partnership Fund.
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ASQ Abbreviated Symptoms Questionnaire
BOTMP Bruininks-Oseretsky Test of Motor Proficiency
BPD Bronchopulmonary dysplasia
ETCH-M Evaluation Tool of Children’s Handwriting-Manuscript
IVH Intraventricular haemorrhage
MAC Motor Accuracy
PCSAS Pictorial Scale of Perceived Competance and Social
Acceptance Scale
ROP Retinopathy of prematurity
SIPT Sensory Integration and Praxis Tests
TVPS Test of Visual-Perceptual Skills
VMI Visual Motor Integration
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Appendix I: Test instruments
Evaluation Tool of Children’s Handwriting-Manuscript (ETCH-M)
The ETCH-M (Amundson 1995) is a criterion-referenced,
standardized tool that evaluates legibility and speed of manuscript
writing and includes six different writing tasks reflecting classroom
performance demands (lower/upper-case alphabet writing,
numeral writing, near-point copying, far-point copying, dictation,
and sentence composition). Domains of letter, word, and numeral
legibility incorporate all tasks combined and are expressed as total
legibility percentages based on the number of readable letters,
words, or numbers subtracted from the possible number in each
case. Writing speed is calculated for all tasks except dictation. The
test–retest reliability coefficients for first and second grade children
are 0.71 for total word legibility, 0.77 for total letter legibility, and
0.63 for total numeral legibility (Diekema et al. 1998). The teacher
completed a checklist, designed by the authors, in which each
child’s handwriting and speed was rated compared to classmates. A
checkmark was placed under the most appropriate heading (above
average, average, needs improvement, or very poor) for legibility
and speed of writing.
Bruininks-Oseretsky Test of Motor Proficiency (BOTMP)
The BOTMP (Bruininks 1978) is a standardized test of motor deve-
lopment for children from 41⁄2 to 141⁄2 years of age. The Fine Motor
subtests of Response Speed, Visual-motor Control, and Upper Limb
Speed and Dexterity were administered as well as Upper Limb
Coordination. Raw scores were converted to standard scores
(mean 15, SD 5).
In-hand Manipulation Skill Test
The In-hand Manipulation Skill Test (Exner 1992) is a timed
procedure in two parts to evaluate rotation and translation using
the dominant hand. For the rotation test the child grasps a 21⁄2cm
peg from pegboard, rotates it 180 degrees in fingertips and returns
it to pegboard hole. The child is timed while turning the peg five
times over two trials with the preferred hand. The test is
administered twice and a summary score obtained. The translation
test is a timed task of palm-to-fingers and fingers-to-palm translation
using a 21⁄2cm peg. For each task, the child is asked to pick up a
specific number of pegs (i.e. two, three, four, and then five pegs)
one at a time, hide them in the palm and then replace them in the
pegholes. Scores are timed in seconds for both tasks.
Developmental Test of Visual-Motor Integration–Revised (VMI)
The VMI Short-Form test (Beery and Buktenica 1989) is designed to
assess visual-motor skills in 3- to 8-year-old children by copying a
series of geometric forms (15) of increasing difficulty in a prepared
booklet. The scoring procedure has well defined criteria and is based
on the number of correct forms completed up to three consecutive
failures. A standard score can be derived (mean 100, SD 15).
Test of Visual-Perceptual Skills (Non-Motor; TVPS)
The TVPS (Gardner 1982) evaluates strengths and weaknesses in
seven component areas in children aged 4 to 13 years. These areas
include: visual discrimination, visual memory, visual-spatial
Handwriting in Preterm Children Katya P Feder et al. 169
relationships, visual form constancy, visual sequential memory,
visual figure-ground, and visual closure. The child is asked to select
from four to five choices that match a visual model. The number of
correct responses for each subtest is calculated and a scaled score
(1–19) is derived (mean 10).
Finger Identification
Finger Identification is part of a battery called the Sensory
Integration and Praxis Tests (SIPT; Ayres 1989) and measures tactile
sensory awareness in children. With vision occluded, the child is
asked to indicate which finger the examiner touched. Examiners are
required to complete a comprehensive written and practical
training course to administer the SIPT. Scoring is computerized;
a z-score is derived with a range of –3.0 to 3.0.
Motor Accuracy (MAC)
MAC is part of the SIPT battery (Ayres 1989) that measures the degree
of change in sensorimotor coordination in the arms and hands,
guided by visual cues. This test, which incorporates speed into the
scoring system, emphasizes the motor aspect of tracing over a large
butterfly pattern. Scoring is the same as for Finger Identification.
Steadiness Test
This Steadiness Test (Birnbaum et al. 1999) comprises a metal grid
on a stand with graded circular openings as well as a stylus which is
attached to a silent impulse counter designed to record the number
of times the stylus touches the edge of the hole during a 15 second
period. The child is asked to place the stylus in a designated circular
hole and to hold it steady in the opening without touching the
sides. This instrument was used to measure upper extremity
steadiness with forearm supported. Two trials of 15 seconds were
administered for the dominant hand and forearm supported
position only. The numeric value on the automatic counter was
recorded and the average of the two trials was used for data analysis.
A value of 41 or above for females is abnormal; a value of 49 or
above for males is abnormal.
Sensory Assessment Battery
This proprioception subtest (Cooper et al. 1993) was administered
to evaluate the index finger of the dominant hand only. The child’s
hand is supported by the examiner and vision occluded using a
screen while the child’s metacarpophalangeal joint is moved up or
down, holding the proximal phalanx laterally. The child verbally
identifies the direction of movement by responding ‘up’ or ‘down’.
The number of correct responses out of five is recorded. Cut-off
value is established at 5.
The Pictorial Scale of Perceived Competence and Social
Acceptance for Young Children (PCSAS)
The PCSAS (Harter and Pike 1983) measures a child’s self-
perception within each of the following four subscales containing
six items each: (1) cognitive competence, (2) physical competence,
(3) peer acceptance, and (4) maternal acceptance. Items are
presented in pictorial format. The examiner reads a statement
about the child in each picture following which the participant is
asked to select the picture and statement that is most like him/her.
Scores are obtained for each subscale ranging from low (1) to high
(4) with the higher score indicating a higher level of perceived
competence.
Connors Abbreviated Symptoms Questionnaire (Connors ASQ)
Connors ASQ (Conners 1989) is a quick, easily administered 10-item
screening tool for behaviours associated with hyperactivity and
poor attention in children aged 3–17 years. The questionnaire is
completed by parents with each item of the ASQ rated on a 4-point
Likert scale ranging from (0), not at all to (3), very much. Cut-off
score is >20.

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Duties emphasize inpatient care and include outpatient care and opportunities for clinical
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