The Indian Journal of Occupational Therapy

: 2019  |  Volume : 51  |  Issue : 1  |  Page : 14--20

Visual-perceptual training for handwriting legibility and speed in children with handwriting difficulties: A single-arm interventional study

Pooja Pankaj Mehta1, Hemant Parshuram Nandgaonkar2,  
1 Anmol Child Development Clinic; OT School and Center, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
2 OT Training School and Centre, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Pooja Pankaj Mehta
202, Punit Ganga, Gokhale Road, Dahanukar Wadi, Kandivali (W), Mumbai - 400 067, Maharashtra


Background: Empirical evidence relating motor-free visual-perception (VP) skills and handwriting (HW) legibility and speed is sparse, despite the theoretical belief that VP is necessary for letter recognition and is an essential component of HW. Therefore, the study was carried out to investigate the effect of VP training on scanning skills, motor-free VP skills, and HW legibility and speed. Objectives: The main objective is to study the effect of VP training on HW legibility and speed; motor-free VP skills and scanning skills. Study Design: This was a single-arm interventional study design was chosen for the research. Methods: Single arm of 10 children of either gender between 6 and 10 years of age, with HW difficulties meeting the inclusion and exclusion criteria, was recruited by convenience sampling. They were assessed pre- and post-training (6th and 12th week) using the letter cancellation test (LCT), Test of VP Skills-3rd Edition (TVPS-3) and Evaluation Tool of Children's Handwriting (ETCH). The intervention included individualized VP training weekly twice along with home program. Results: The mean scores of LCT, TVPS-3, and Evaluation Tool of Children's Handwriting-Manuscript (ETCH-M) of n = 10 were analyzed. Post 12-week intervention, statistically significant improvement were found in mean scores of LCT (P < 0.05, 95% confidence interval [CI] [0.411,0.699]) and on TVPS-3 subtests (P < 0.05, 95% CIs [13.14, 17.46], [11.60, 15.60], [11.46, 14.14], 11.73, 15.87], [11.33, 15.27], [11.66, 15.44] and [11.56, 15.44] sequentially) and on overall mean scores (P < 0.05, 95% CI [12.67, 16.13]). Statistically significant improvements were calculated on ETCH-M subtests- total letter, number, and word legibility scores (P < 0.05, 95% CIs [88.91, 95.69] [100,100] and [79.01, 93.19] respectively); and on near-point copying speed (P < 0.05, 95% CI [35.98, 55.42]) but non-significant improvement was seen on far-point copying speed (FPS) (P = 0.103, 95% CI [23.69, 36.31]). Conclusion: VP training, without HW practice, has an effect in improving scanning skills, motor-free VP skills, and HW legibility and speed (except FPS). Thus, VP training may influence HW legibility and speed.

How to cite this article:
Mehta PP, Nandgaonkar HP. Visual-perceptual training for handwriting legibility and speed in children with handwriting difficulties: A single-arm interventional study.Indian J Occup Ther 2019;51:14-20

How to cite this URL:
Mehta PP, Nandgaonkar HP. Visual-perceptual training for handwriting legibility and speed in children with handwriting difficulties: A single-arm interventional study. Indian J Occup Ther [serial online] 2019 [cited 2020 Sep 19 ];51:14-20
Available from:

Full Text


Handwriting (HW) skill is the ability to write legibly, quickly, and efficiently.[1] Thus, poor HW skills affect overall school performance and child's behaviors. Interventions based on approaches such as task-oriented,[2] process-oriented, multisensory, and self-instructional[3] are recommended to teach HW. However, there is little empirical evidence suggesting advantage of one approach over the other.[3] Visual-perception (VP) helps in correct letter formation, discriminates spatial orientation of similar letters, remember the correct sequence of letters in the word, spacing, alignment, and uniformity in letter size.[4] Correlational studies[1],[5] showed that motoric VP influences HW legibility and speed. Empirical evidence relating motor-free VP skills and HW legibility and speed is sparse,[6] despite the theoretical belief that VP is necessary for letter recognition and is an essential component of HW.[4] Hence, the objective was to study the effect of VP training on scanning skills, motor-free VP skills, and HW legibility and speed.


Study Design

The single-arm interventional study design was selected. The study was approved by the Committee for Academic Research Ethics, Institute Review Board. Written informed parental consent and assent from children above aged 7 years were obtained.


Single arm of 10 children (9 boys and one girl), between 6 and 10 years of age, were recruited for the study using convenience sampling. The gender difference, with boys more affected than girls, was consistent with Indian prevalence and interventional studies.[7],[8] The small sample size (n = 10) was justified considering the selection criteria of the study, prevalence of dysgraphia (14%) in children with specific learning disability,[9] and lack of awareness of and poor referral to occupational therapy services outside the school for HW intervention at the time of the study.[10] This sample size was similar to other outpatient department-based institutional studies conducted for HW intervention.[8],[11] Dropouts due to inconvenient institute timings for these school-going children also limited the sample size. The mean age of children was 7.3 years (±1 year). Of 10 participants, 6 children were aged between 6 and 8 years and 4 children were aged between 8 and 10 years of age. There were equal right- and left-handed children. These children satisfied the following inclusion and exclusion criteria:

Inclusion Criteria

Age: 6–10 years, referred to occupational therapy department for HW difficulties by Child Guidance Clinic of the instituteScore of [12],[13]Intelligent Quotient on Wechsler's Intelligence Scale for Children done by clinical psychologist ≥90Children able to copy the first 9 figures of Berry's Visual-Motor Integration[4]Minimum 1 year of exposure to reading and writing English language.

Exclusion Criteria

Children with uncorrectable vision/hearing impairment, frank neurological involvement, medical illness such as hypo/hyperthyroidism, seizure disorder, genetic condition, and physical disability which interferes with HW.

Assessment Tools

Letter cancellation test (LCT), Test of VP Skills-3rd Edition (TVPS-3), and the ETCH-M were used. LCT is a timed test that assesses scanning skills by measuring speed of striking out target letter H. Quality of search index, that is, Q score is calculated as ratio of correct responses to total targets multiplied by ratio of correct responses per unit time.[14] Higher scores reflect efficient scanning performance.[14] LCT has been used as the outcome measure tool post-6-week intervention in adult study.[15] Test-retest reliability is 0.78 for Indian school-going children.[16] TVPS-3 is an individually administered, standardized multiple choice test (non-written) designed to assess motor-free VP skills by means of 16 items in each 7 subtests, arranged progressively according to the difficulty level. Participants' responses are recorded as individual and total raw scores. Raw scores are converted to scaled scores with the help of manual as per child's age. Scaled scores have a mean of 10, that is, 50 percentile rank and standard deviation (SD) of 3. Test-retest reliability is 0.97 for the test as a whole.[17] ETCH-M measures HW legibility (percentage) and speed (letters/min). Legibility components – letter formation, spacing, size, and alignment are examined. HW speed was represented by near-point and far-point copying writing time.[12] All ten children wrote in manuscript; hence, ETCH-M was used which is similar to systematic review findings[3] that most studies used ETCH-M. Assessment of the child on subtests of TVPS-3 assisted the therapist in determining which areas needed to be emphasized during VP training.


Fifteen children between 6 and 10 years of age, referred for HW difficulties were screened. Of which, 11 fitted the inclusion criteria and 1 child dropped out due to inconvenient timings of school and the institute. Thus, 10 children were assessed pre- and post-VP training (6th and 12th week) using the LCT, TVPS-3, and ETCH-M. Intervention included individualized VP training sessions along with a home program.

Visual-Perceptual Training

Individualized VP training session was given as per the child's baseline scores on LCT, TVPS-3 (nonmotor), and ETCH-M, taking into consideration child's interests and play history. The VP training was given by the first author. It requires activity analysis to identify graded activities requiring VP skills.[18] The training program was conducted in a spacious room with table-chair of appropriate height for the child to perform tasks.

Gradually, complexity of activities was increased as per the child's progress noted during the 6th-week reassessment. The VP training was given twice weekly for 12 weeks, that is, 24 sessions of 45 min each, considering the other effectiveness studies done.[19],[20],[21]

Using visual information analysis frame of reference; following points were incorporated in the therapy session:[18]

Variety of visual stimuli addressing the same goal was used to assist the child in engaging and maintaining child's selective attention for learningIn the initial sessions, activities of child's choice were listed to the child in order to give a predictable structure to the sessionTo keep child engaged in the session, child was encouraged to select tasks/material for the sessionsTimer was incorporated in session to improve speed of performance after first 2 weeksPositive reinforcement was given to child on task behavior.

The VP training session comprised of:[18],[22]

Preparatory activities (5–10 min): Ball catching, throwing, kicking at a target/random, balloon tapping, hopscotch over alphabets/numbers/shapes, etc., on commandTable-top activities: Clay modeling activities – giving outline to diagram; making alphabets/numbers; solve jigsaw puzzles; two-dimensional (2D) and 3D geometric/construction designs in increasing order of complexityPaper-pencil task: Copy join dots as demonstrated, solving mazes, tracing, target cancellation; figure-ground tasks: Find hidden object in picture; silhouette matching, etc.; functional tasks: Searching word in dictionary, finding item in cupboard. In tasks involving paper-pencil, participants were not given practice for the components of HW to prevent training from confounding post-therapy assessment results of ETCH-M.

Home Program

A customized weekly home-program chart in consultation with parents, child's preferences, and availability of resources was given to each child following each session. Activities done in the week were checked. Activities such as categorizing the plates according to their sizes in the dish-stand, sorting pulses, drawing and coloring, canceling vowels in newspaper passage, making straw/toothpick, and candy stick design/greeting card making. The chart helped parent and child to adhere with the home-program and schedule.

Data Analysis

Ten children attended all 24 training sessions and completed pre- and post-training assessment. The data analysis was done using the SPSS (Statistical Package for the Social Sciences), Version 16 (2007). P < 0.05 was set as level of significance and 95% confidence interval (CI) values were also calculated. Possible differences in LCT, TVPS-3, and ETCH-M scores between three time-slots – preintervention (0 weeks), post-6 weeks of intervention (6 weeks), and immediately post-12 weeks of intervention (12 weeks) were checked using Wilcoxon-Signed Ranks test.


Descriptive statistics (mean and SD) of LCT, TVPS-3, and ETCH-M items obtained in three assessment sessions are shown in [Table 1], [Table 2], [Table 3], respectively.{Table 1}{Table 2}{Table 3}

Statistically highly significant improvement were found in the mean scores of LCT (P < 0.01, 95%CI [0.411, 0.699]), post-12-week VP training with increase in the mean quality of search index (Q) scores from 0.389 to 0.555 [Table 1].

Comparative results of TVPS-3 at 0 week and 6 weeks demonstrated significant differences in the mean scores of all subtests and overall performance except visual-spatial relations (VSR) (P = 0.905, 95% CI [8.51, 12.09]). However, comparative results at 0 weeks and 12 weeks demonstrated significant differences in the mean scaled scores of all 7 subtests of TVPS-3 and overall performance (P < 0.05, 95% CIs [13.14, 17.46], [11.60, 15.60], [11.46, 14.14], [11.73, 15.87], [11.33, 15.27], [11.66, 15.44], [11.56, 15.44] and [12.67, 16.13] sequentially) [Table 2]. Preintervention children's mean scaled scores on all subtests were below 10, i.e., 50th percentile rank except VSR (10.3) and visual sequential memory (VSM) (10.2), with children scoring lowest in visual memory (VM), i.e., 7.6, i.e., 16th percentile rank. The postintervention mean scaled scores on all subtests ranged between 12.8 and 15.3, i.e., 80th to 94th percentile rank, i.e., above average performance. The difference in scaled scores, post-12-week intervention, showed maximum improvement in visual discrimination (VD), i.e., 6.9 points followed by visual figure ground (VFG), i.e., 6.3 points and least improvement in VSR, i.e., 2.5 points [Figure 1].{Figure 1}

Analyzing the results of ETCH-M at 0 weeks and 6 weeks, significant differences were found in all components except total numerical legibility (TNL) (P = 0.105, 95% CI [81.09, 93.31]). However, statistical analysis at 0-week and 12-week assessment, significant difference was demonstrated in scores of ETCH-M subtests (P < 0.05, 95%CIs [88.91, 95.69], [100, 100], [79.01, 93.19] in TLL, TNL and TWL scores, respectively, and P < 0.05, 95% CI [35.98, 55.42] in near-point copying speed (NPS) except in far-point copying speed (FPS) (P = 0.103, 95% CI [23.69, 36.31]) [Table 3].


The children in the study showed VP deficits along with HW dysfunction. They were provided with structured VP training. Efficient scanning skill helps children gather relevant information from the environment improving selective attention. Scanning and selective attention are important foundational skills for VP, as shown by Warren's hierarchical pyramid of VP skills development.[4] Thus, improvement in scanning skills can be attributed to VP training. It supports the theoretical postulate of VP frame of reference that although each VP skill develops in its own sequence, acquisition of each skill affects the acquisition of other skills.[4] That is, the acquisition of scanning skills affected the acquisition of VP skills and vice versa. Ability to efficiently scan affects VP, which in turn affects child's writing speed.[23] Thus, theoretically, both HW legibility and speed are influenced by scanning and VP skills.

VP allows a person to make accurate judgments on the size, configuration, and spatial relationships of objects. However, of the seven subtests of TVPS-3, VSR is the type of spatial perception, while rest are object perception types. Preintervention, spatial perception showed average performance, while object perception performance showed below average performance [Table 2]. Interestingly, the findings similar to studies done on individuals with brain damage have shown that spatial perception and object perception are independent, i.e. disturbances of object perception can occur without spatial perception disability and vice versa.[4]

Post-6-week intervention, children scored between 10 and 12 on the subtests and overall 11.6 suggestive of average VP performance [Table 2]. Similar findings were observed in the study,[24] wherein participants showed significant difference in overall, VD, VM, and VFG after 6 weeks of computerized VM training. Hence, a future study to find the effectiveness of short term, i.e., 6-week VP training program can be done.

VD showed maximum increment in score from baseline [Figure 1], as it is the basic process of VP underlying all of the VP tasks[12] and involving ability to recognize, match, and categorize.[4] VD helps with ability to detect change, which is an effective training strategy to improve VM. The study[24] has shown that VM training also affects VD and VFG.

[Table 3] showed statistically significant improvements in TWL, TLL, TNL, and NPS tasks scores of ETCH-M, but no significant improvement in FPS scores post-12-week intervention. These findings are in accordance to the findings of the Case-Smith study[20] where participants who received OT services (mean: 16.4 sessions) demonstrated improved TLL, but FPS and TNL did not demonstrate positive intervention effects.[20] FPS showed increase in HW speed from 25.4 to 30 letters/min, i.e., 18.11% increase; while the other studies[8],[20] showed similar increase in HW speed from 32 to 37 letters/min, i.e., 15.63% increase. Studies[20],[25] have found that children in the age group of 6–10 years; has the writing speed of 35–73 letters/min; while Indian study[6] gave 32–60 letters/min as FPS for 8–9 years children. A study by Addis (1999) found that average writing speed of 6-year-old is 30 letters/min,[6] thereby suggesting that children in the study with the mean age of 7.3 years wrote at speed as that of 6-year-olds, i.e., children in the present study remained relatively slow in FPS.

The achieved scores after the training for TWL (86.1%) and TLL (92.3%) is more than the established cutoff score of 85% and 90%, respectively, to distinguish between children with and without HW problems.[13] This finding is supported by the findings of the studies,[8],[20] wherein their results showed that the pretest mean was <80% legibility and had >90% legibility posttest.

Furthermore, children in this study showed low performance in the writing speed as well had lowest scores on VM. This finding is in accordance with the study,[5] in which it has been reported that children with low performance on the writing speed have lowest scores on VM and VSM.

The study showed that children with HW dysfunction in legibility and speed also showed VP deficits and on VP training, these children showed statistically significant improvement in both VP skills and HW legibility and NPS. Hence, improvement in HW legibility and NPS can be attributed to improvement in scanning skills, VP skills, and to VP training. This strengthens the suggestion that VP training of 12 weeks, without practicing components of HW; may be effective in improving not only VP and scanning skills but also be effective in improving academic functioning in form of HW legibility and speed except in the FPS.

However, these findings are in contrast with the study findings that interventions without HW practice were ineffective.[19] Hence, a future randomized controlled trial study with a larger sample can be undertaken to find the effectiveness of therapeutic HW practice.

Subjective Observations Made by the Therapist and Caregiver

All ten participants showed decrease eraser-use, a smaller number of substitutions, omissions, and additions; punctuations were better and frequent appropriate use of upper case and lower case. Spelling mistakes were notably less. Most of the participants presented with complaints of incomplete schoolwork and inattention during writing tasks. According to their parents, the regularity with which they completed their schoolwork increased, and these complaints from their teachers also decreased. It was also noted that all participants were more enthusiastic about trying out new activities and were willing to explore more challenging table-top games, thus observed increase in sitting tolerance. Another important observation reported by the mothers was that their children's self-esteem, coping skills, and social interaction improved. Hence, a future study on the effect of HW on psychosocial health of children can be undertaken.

Limitations of the Study

The major limitation of the study was the absence of control group with which to compare outcomes. For ethical and service delivery reasons, there was no control group. Consequently, this was an outcome study rather than a clinical trialConvenience sampling used and small sample size meant that findings derived are not necessarily representative of the whole population; results of this study should be interpreted cautiouslyPractical difficulty in providing pure VP therapeutic activities, without any motoric response in therapy sessions. Hence, the future studies should involve VP activities with minimal or nonmotoric response in VP training programFollow-up was limited to one occasion immediately after VP training program was concluded. It was not proved statistically in this study that improvement in HW continued even after the last session; however, parents reported improvements in HW as they continued the home program provided.


Despite small sample size, VP training demonstrated a statistically and clinically significant change in HW legibility and NPS, along with scanning skills and motor-free VP skills, on appropriate statistical tests. The findings are likely to be further strengthened using larger sample size and on randomization.


In the present study, children with HW difficulties also showed VP affectations. Hence, the VP training, without practice of HW components, was designed to address HW difficulties. It was based on bottom-up approach that improvement in performance components: VP skills would improve performance areas of HW skills. The results of the study indicate VP training was successful in improving HW legibility and speed (except FPS), as well as scanning and motor-free VP skills. Thus, specific intervention in training VP skills should be given to improve HW legibility and speed.


We thank the past Director (ME & MH) Dr. Sanjay N. Oak Sir and the current Director (ME & MH) Dr. Sandhya Kamat Madam, for permission to conduct the study and publish the study. Sincere gratitude to Dr. (Mrs.) Jayashri Kale; HOD of OT Training School & Centre, Seth GS Medical College, Parel, Mumbai; for permission to conduct the study and support through the study. I would like to sincerely thank Dr. Pratap Jadhav, PSM Department, Seth G. S. Medical College and K.E.M. Hospital for guiding me with the statistics. Sincere thanks to Dr. Ashwini Vaishampayan, OTD, OTR/L, and Dr. Namita Shenai MOTh (Developmental Disabilities), for their help and encouragement. Special thanks to all the children and their parents for utmost cooperation and sincerity in following the program. Last, but not the least, special thanks to God, my parents, teachers, and friends for constant support and valuable advice throughout the study.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.


1Weil MJ, Amundson SJ. Relationship between visuomotor and handwriting skills of children in kindergarten. Am J Occup Ther 1994;48:982-988.
2Asher AV. Handwriting instruction in elementary schools. Am J Occup Ther 2006;60:461-471.
3Moskowitz B. What is the Effectiveness of a Task-Oriented Approach Compared to a Process-Oriented Approach on Handwriting Legibility among Elementary School Children? [Thesis]. Temple University; 2009.
4Schnek C. Visual perception. In: Case-Smith J, editor. Occupational Therapy for Children. 4th ed. St. Louis: Mosby; 2001. p. 382-411.
5Tseng MH, Chow SM. Perceptual-motor function of school-age children with slow handwriting speed. Am J Occup Ther 2000;54:83-88.
6Kumar V, Rao S. Influence of visual perception on far point and near point copying handwriting speed among normal and slow learners of 8 to 9 years. Indian J Occup Ther 2011;43:4-13.
7Goswami U; Government Office for Science. Learning Difficulties: Future Challenges. Mental Capital & Wellbeing Project, Foresight. UK: John Wiley & Sons; 2008. p. 727-766.
8Daftary R, Jaywant S. To study the efficacy of “cognitive orientation to occupational performance” in children with handwriting difficulties. Indian J Occup Ther 2015;47:89-96.
9Karande S, Kulkarni M. Specific learning disability: The invisible handicap. Indian Pediatr 2005;42:315-319.
10Tennyson J. Effective Occupational Therapy Intervention for Handwriting/Fine-Motor Difficulties. [Thesis]. Humboldt State University; 2006.
11Baldi S, Nunzi M, Brina CD. Efficacy of a task-based training approach in the rehabilitation of three children with poor handwriting quality: A pilot study. Percept Mot Skills 2015;120:323-335.
12Amundson SJ. Evaluation Tool of Children's Handwriting: ETCH Examiner's Manual. Homer, Alaska: OT Kids, Inc.; 1995.
13Duff S, Goyen TA. Reliability and validity of the evaluation tool of children's handwriting-cursive (ETCH-C) using the general scoring criteria. Am J Occup Ther 2010;64:37-46.
14Brucki SM, Nitrini R. Cancellation task in very low educated people. Arch Clin Neuropsychol 2008;23:139-147.
15Almeida OP, Tamai S. Clinical treatment reverses attentional deficits in congestive heart failure. BMC Geriatr 2001;1:2.
16Pradhan B, Nagendra HR. Normative data for the letter-cancellation task in school children. Int J Yoga 2008;1:72-75.
17Martin NA. Test of Visual-Perceptual Skills. 3rd ed. Novato, California: Academic Therapy Publications; 2006.
18Kramer P, Hinojosa J. Frames of Reference for Pediatric Occupational Therapy. 2nd ed. Philadelphia: Lippincott, Williams and Wilkins; 1999.
19Hoy MM, Egan MY, Feder KP. A systematic review of interventions to improve handwriting. Can J Occup Ther 2011;78:13-25.
20Case-Smith J. Effectiveness of school-based occupational therapy intervention on handwriting. Am J Occup Ther 2002;56:17-25.
21Dankert HL, Davies PL, Gavin WJ. Occupational therapy effects on visual-motor skills in preschool children. Am J Occup Ther 2003;57:542-549.
22Kephart NC. The Slow Learner in the Classroom. 2nd ed. Columbus, Ohio: Charles Merrill Publishing Company; 1971.
23Cunningham S, Reagan C. Handbook of Visual-Perceptual Training. 1st ed. Illinois, USA: Thomas Books, Bannerstone House; 1972.
24Li-Tsang CW, Wong AS, Tse LFL, Lam HYH, Pang VHL, Kwok CYF, et al. The effect of visual memory training program on Chinese handwriting performance of primary school students with dyslexia in Hong Kong. Open J Ther Rehabil 2015;3:146-158. Available from: [Last accessed on 2019 Mar 27].
25Ziviani J, Watson-Will A. Writing speed and legibility of 7-14 year old school students using modern cursive script. Aust Occup Ther J 1998;45:59-64.