Visual-Motor Integration (VMI) and Graphomotor (Handwriting) Problems as a

Barrier to Learning.

Julie Wiid

Difficulty in producing legible handwriting is so visible and yet is often overlooked

and poorly understood. Students who are reluctant to produce written work are often
dismissed as lazy, unmotivated, or oppositional (Thorne, n.d). Mental, social and
emotional inadequacies are also often inferred from poor handwriting (Beery, 1997),
yet for children with graphomotor problems: neat handwriting at a reasonable pace
is often not a choice (Thorne, n.d).

Handwriting is the natural vehicle of teaching (Beery, 1997). A child who can
neither capture work content adequately in written form nor produce written outputs
that reflect her understanding or verbal abilities therefore experiences significant
barriers to learning.

VMI has been identified in numerous studies as a more important factor than general
intelligence, finger dexterity and visual perception in determining handwriting
performance (Berry, 1997, Tseng & Murray 1994, Weil & Armundson, 1994, Williams
et al, 1993, in Beery, 1997).

VMI is: the degree to which visual perception and finger-hand movements are well
coordinated (Beery, 1997). Through integration of visual input and motor output,
motor tasks (e.g. writing) are planned, executed, monitored (http://www.visionand
learning.org/visualintegration.html, n.d ) and adjusted
(http://www.childrensvision.com/reading.htm, n.d). While VMI may therefore be
affected by deficits in visual perception and/or motor coordination, some children
with adequate visual perceptual and motor co-ordination skills still perform poorly in
VMI assessments (Kulp, Mazzola & Mazzola, 2003), suggesting that VMI is greater
than the sum of its parts (Beery, 1997) and that the hyphen in visual-motor (Beery,
1997) represents the integrated complexity of interactions between factors such as
cognition, visual perception, shoulder stability (Calder, 2010) ; proprioception,
directionality and planning (van der Zee, 2010); and fine motor control, co-ordination
and psychomotor speed (Sanghavi, 2005).

In considering this definition of VMI and the developmental objectives of the primitive
reflexes (Appendix 1), it can be seen that development of VMI is dependent upon the
inhibition of these reflexes. Wilkinsons study (1994, in Goddard-Blythe, 2001)
identified primitive reflexes as a contributing factor to learning disabilities and
underachievement. Furthermore, children with learning disabilities have a high
prevalence of VMI deficiencies (Beery, 1997; Tranopol in Sanghavi, 2005;
http://www.visionand learning.org/visualintegration.html, n.d.). Underachievement
may, in many cases, therefore be a direct result of inability to produce adequate
written outputs for accurate assessment of progress.

Mind Moves Institute, Johannesburg. 2011 1

VMI manifests in graphomotor problems as difficulties in:

Spatial organisation on paper

Letter/number formation
Following/staying in lines
Alignment e.g. numbers in columns
Recognising mistakes
Pencil grip and desk posture

(http://www.visionand learning.org/visualintrgration.html, n.d)

Fig1: Examples of written outputs exhibiting typical characteristics of poor VMI Occupational
Therapy commenced when child was 5years 8 months and specific reflex inhibition interventions
commenced at the age of 7 years and 2 months

Note midline crossing

Poor spatial organisation on Difficulty in drawing on lines; poor spatial Poor spatial organisation of
paper (positioning of name); organisation; poor number formation written output
poor letter formation (approx 6 yrs 2 months) (approx 6 yrs 11 months)
(approx 6yrs 3 months)

Note: due to poor pencil grip some lines were too light to be reproduced. They have therefore been
darkened and so do not reflect the childs pencil grip in terms of pressure applied to paper.

The ability to copy basic shapes ( / \ X ) is a pre-

requisite for writing (Van der Zee, 2010) and an indication of the extent to which an
individuals visual and motor abilities have been integrated (Beery & Buktenica,
1997) ( Figure 2).

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Fig 2: Comparison of performance over time on the Developmental Test of Visual-
Motor Integration (Beery and Buktenica, 2005) to illustrate development of VMI
ability plus changes in drawn and written output with development of VMI

Note: Test not administered for assessment purposes at 8 yrs 2 months, but only for comparative purposes as
illustration for the topic of this essay. The child completed the task in test conditions.

Geometric form to be copied

Developmental Test of Visual
Motor Integration Items 4-6
( Beery & Buktenica, 2005)

Age 5years 8 months

Age 6years 7 months

Age 8years 2 months

Geometric form to be copied

Developmental Test of Visual
Motor Integration Items 7-9
( Beery & Buktenica, 2005)

Intended to draw
Age 5years 8 months a square

Age 6years 7 months

Application of developing
skill in drawing tasks

Age 8years 2 months

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Fig 2: continued

Geometric form to be copied

Developmental Test of Visual
Motor Integration Items 10-12
( Beery & Buktenica, 2005)

Age 5years 8 months

Age 6years 7 months

Age 8years 2 months

Geometric form to be copied

Developmental Test of Visual
Motor Integration Items 13-15
( Beery & Buktenica, 2005)

Age 5years 8 months

Age 6years 7 months

Age 8years 2 months

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Fig 2: continued

Geometric form to be copied

Developmental Test of Visual
Motor Integration Items 16-18
( Beery & Buktenica, 2005)

Age 5years 8 months

Age 6years 7 months

Age 8years 2 months

Comparison of skills required for reproduction of such shapes with reflex-driven

development further highlights the importance of primitive reflexes in development of
VMI and thus graphomotor abilities (Appendix 2).

It is observed, however, that even when handwriting skills develop, the discrepancy
between written and verbal skills may remain marked as production of written words
to reflect thoughts appears to be at the expense of flow and correctness of content
and sentence structure (Figure 3).

Figure 3: Illustration of discrepancy between verbal and written skills . Verbal skills assessed using WPPSI 3
test

Word order, usage and sentence structure as

seen in this example of written output differ
markedly from this childs verbal communication
abilities. VI = Verbal Intelligence
IN = Information
VC = Vocabulary
WR = Word Reasoning

VC superior range
IN high average
WR high average

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This suggests that representing thoughts and ideas through handwriting (i.e.written
output driven by thought/language as opposed to copying, but monitored and
corrected using VMI) entails more complex processing. If, however, production of
legible, meaningful handwriting is an indication of improved VMI abilities, it is surely
also an indicator that the reflex-driven neurodevelopment required to support
development of higher, more complex processes is becoming established. The
development of graphomotor abilities is therefore the fundamental starting point for
production of written output.

Using Mind Moves to design a home programme to address graphomotor

problems due to poor VMI abilities

Graphomotor problems and their impact are highly visible and resulting low self-
esteem/self-confidence and behaviours associated with physical and emotional
immaturity present additional barriers to learning.

As graphomotor skills require VMI and VMI is dependent upon inhibition of primitive
reflexes, a home programme based upon a bottom-up and top down approach in
parallel is to be most effective.

The bottom-up approach refers to systematic identification and inhibition of aberrant

reflexes, starting with the earliest aberrant reflex in the developmental order and
progressing up through the order to develop the essential sensory-motor neural
pathways and interconnections between the physical, emotional and cognitive
brains. This is achieved through specific Mind Moves exercises mimicking reflexive
movements and additional activities to stimulate the appropriate senses and
muscles. The objective of developing these pathways and interconnections is to
build a solid neural foundation for sustained skill development.

The top-down approach incorporates Mind Moves exercises to prime existing

pathways to support production of an output in class. As the output here would be
legible, meaningful handwriting, the following exercises would be recommended:

Power ON
Rise and Shine
Mousepad
Visual Workout
Bi-lateral Integrator
Bi-lateral Walk
Finger fight
Palm Stretch

(De Jager, 2009)

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 APPENDIX 1: DEVELOPMENTAL OBJECTIVES OF INTRA-UTERINE ,
PRIMITIVE AND BRIDGING REFLEXES

REFLEX DEVELOPMENTAL OBJECTIVE

Sensory Brain Muscle

Withdrawal Touch Receptive/back
Proprioception
Moro Vestibular system Receptive/back Entire motor system
(balance) Expressive/front
Kinesis
Auditory
Rooting and Olfactory Receptive/back Neck
Sucking Gustatory Emotional/bottom Mouth
Primitive vision
Tonic Vestibular system Receptive/back Neck
Labyrinthine Auditory Expressive/front Core
Primitive vision Emotional/bottom
Cognitive/top
Palmar Touch Receptive/back Hands
Expressive/front Fingers
Left and Right Fine Motor
Cognitive
Plantar Touch Receptive/back Feet- balance and
Expressive/front weight bearing
Left and Right Gross and fine motor
Cognitive
Asymmetrical Vestibular system Receptive/back Neck
Tonic Neck Vision and sight Cognitive/top Core
Limbs
Eye hand
Head stability
Spinal Galant Touch Receptive/back Core
Hearing - vibrational Expressive/front Trunk rotation
Emotional/bottom
Cognitive/top
Symmetric Balance Receptive/back Neck
Tonic Neck Vision Expressive/front Core flexion and
Emotional/bottom extension
Cognitive/top Shoulder
Hip

(De Jager, 2009)

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APPENDIX 2: Alignment of reflexive development with the ability to copy basic
shapes as pre-requisite skills for writing as illustrated using Beery &
Buktenicas Development Tests of Visual-Motor Integration (1997)

Ability to hold a pencil and organise output on paper are assumed

Directionality required for all below: near sensory system Withdrawal,
Moro, TLR, ATNR, STNR

Basic Shape Comment Reflex-driven

developmental
requirement
Directionality - up and
down; away from/towards

Cross horizontal midline

Vertical line easier to draw than TLR

Horizontal line Directionality left /right;
away from /toward

Laterality

Cross vertical midline

ATNR
Children <6yrs tend to draw away Directionality away
from self perception that centre of from/toward
universe
Proprioception and
6 + yrs draw circle from top balance
towards body left/right centre
seems to be forehead i.e. top brain Withdrawal, Moro, TLR,
corresponds with development of ATNR, STNR
bi-lateral integration
4-6 year olds horizontal line Directionality
weaker than vertical line
Laterality
Frequent segmenting of horizontal
midline at midline Bilaterality

Crossing of horizontal and

vertical midlines

TLR, ATNR
Develop later because requires co- Directionality
ordination of vertical and horizontal
movement and midline crossing Laterality

Typically left to right mastered Bilaterality

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 Basic Shape Comment Reflex-driven
developmental
requirement
before right to left
Crossing of horizontal and
vertical midlines

TLR, ATNR
First form requiring drawing in one Directionality
direction, stop, then change
direction Laterality

Requires perception of spatial Bilaterality

relations among sides
Crossing of horizontal and
Required to draw vertical and vertical midlines
horizontal lines, see corners and
organise the components as such TLR, ATNR

A tendency to therefore circularize

is therefore common in older
children
Vertical and horizontal lines and Directionality
oblique lines in each direction must
X be mastered to produce this shape Laterality

Bilaterality

Crossing of horizontal and

vertical midlines

TLR, ATNR
Co-ordination of oblique lines Directionality

Tendency to circularize if this not Laterality

mastered
Bilaterality

Crossing of horizontal and

vertical midlines

TLR, ATNR

(Shapes and Comments: Beery, K, Buktenica, N, 1997)

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References

Beery, K, Buktenica, N 1997. Developmental Test for Visual Motor Integration: New
Jersey. Modern Curriculum Press

Calder, C. 2010 Visual and Sensory Perception: An Occupational Therapy

Perspective. Presentation Seeing Your Way to Reading (SAALED). 11 /09/10

De Jager, M. 2009 Mind Moves Advanced Instructor Training Course Manual.

Linden Johannesburg. Mind Moves Institute

Goddard Blythe, S. 2001. Neurological Dysfunction as a Significant Factor in

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Conference [online]. http://www.bdainternational
conference.org/2001/presentations/sat_s1_a_1.htm [accessed 10 August 2010]

Kulp, M, Mazzola S, Mazzola, J 2003. Clinical Value of the Beery Visual Motor
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Sanghavi, R, Kelkar, R, 2005 Visual Motor Integration and Learning Disabled

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Thorne, G. n.d.. Graphomotor Skills Why Some Kids Hate to Write [online].
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[accessed 17 September 2009]

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