BRIEF OR NEW

T
he process of referring students to occupational
therapy often needs clarification as individual
school districts struggle to define who does and
does not qualify for this service (Drobnyk & Siciliano,
Poor Handwriting: Who 1989), Although the situation is more straightforward for
students with obvious or severe disabilities (Kauffman,
is Referred? 1988), it is less clear for students lacking a specific diagno-
sis and for those with mild disabilities, These students
may not receive the help they need, especially in their
early years of schooling. Additionally, educators some-
Judith E. Reisman
I times have difficulty understanding the value of a medi-
cally oriented profession in an educational setting, be-
Key Words: education, special. tests, by title, cause "education is often product oriented" ,and
occupational therapy tends to be process oriented"
Minnesota Handwriting Test
(American Occupational Therapy Association [AOTA],
1989, p, 147),
School occupational therapists may see only those
students who have edUCationally related problems
(AOTA, 1989; Education For All Handicapped Children
Act [Public Law 94-142], 1975), Thus, children with con-
ditions such as poor motor coordination or postural in-
stability are not referred to occupational therapy in a
school setting, The problems that occupational therapists
address must be framed in terms of academic tasks,
Handwriting problems often serve as this academi-
cally relevant route to occupational therapy (Oliver,
1990), The demands of the task are easily understood to
be within both the educator's and occupational thera-
pist's domains, While the teacher is primarily responsible
for handwriting instruction, "the therapist's role is to de-
termine underlying postural, motor, sensory integrative,
or perceptual deficits that might interfere with the devel-
opment of legible handwriting" (Stephens & Pratt, 1989,
p, 321), Intervention for identified deficits may then in-
volve both professions.
Although therapists use both standardized tests and
clinical judgment when assessing a student's needs, stan-
dardized testing is urged whenever possible (AOTA,
1989; Carr, 1989), To document progress as well as defi-
cits in handwriting, we need tests that proVide quantita-
tive as well as diagnostic information. The Denver Hand-
writing Analysis (Anderson, 1983) and the Children's
Handwriting Evaluation Scale are examples of tests that
evaluate cursive writing (Phelps, Stempel, & Speck,
1982),
Fewer tests of printing are available. Perhaps the
most commonly used test for this purpose is the Chil-
dren's Handwriting Evaluation Scale for Manuscript Writ-
ing (Phelps & Stempel, 1987), This test is advantageous in
that it applies to both conventional manuscript and
D'Nealian (Thurber, 1981) print and reports separate
scores for rate and quality of printing for first and second
Judith E. Reisman, PhD, OTR, is Assistant Professor, Program in
graders, Unfortunately, the scoring system is not well
Occupational Therapy, University of Minnesota, Box 388
UMHC, Minneapolis, Minnesota 55455.
defined, Another test, the Diagnosis and Remediation of
Handwriting Problems (Stott, Moyes, & Henderson,
This article was accepted for publication December 3, 1990. 1984), has more detailed scoring instructions and pro-

The American journal of Occupational Therapy 849

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 vides information on specific writing faults. This test,
however, requires that students have at least 2 years of
writing instruction, which generally limits its use to third
graders and above.
Some broad academic assessments include the eval-
uation of a handwriting sample that is usually elicited for
other purposes, such as language skills (Brigance, 1978;
Markwardt, 1989; Woodcock &Johnson, 1989). The scor-
ing gUidelines tend to rely heavily on rater judgment With-
out clear scoring criteria. Several other tests rate legibility
through comparison with a graded series of samples
(e.g., Larsen & Hammill, 1989; Zaner-Bloser, 1984). Al-
though this method provides a quick screen for compari-
son with a standard, the specific elements of handwriting
are not quantified. This limits its sensitivity to change and,
therefore, its usefulness to therapists.
The Minnesota Handwriting Test (Reisman, 1987),
which proVides a more quantitative measure of handwrit-
ing in the early grades, was developed to address some of
these concerns. Because the route of referral to occupa-
tional therapy usually begins with the classroom teacher,
I have assumed that the teacher's proficiency in judging
handwriting quality affects the decision of who will re-
ceive intervention for this perceived problem. In the pres-
ent study, I compared teachers' judgment of poor hand-
writing with scores on the Minnesota Handwriting Test
(pilot version). The study question was as follows: Is
there a significant difference between the Minnesota
Handwriting Test scores of students referred to occupa-
tional therapy for poor handwriting and the scores of
those students who are not referred?
Method
Subjects
All of the second graders (N = 565) in public elementary
schools in 27 classes served as the subjects. This was a
convenience sample based on the involvement of 14 oc-
cupational therapists throughout the country who were
willing to participate in the study. Each class contained at
least one special education student who was receiving
occupational therapy for problems contributing to poor
handwriting, as stated on the individualized education
program (IEP). All of the students were in the classroom
during the handwriting instruction periods. No attempt
was made to control the amount or type of instruction the
students received. Nine classes of students, therefore,
were taught the D'Nealian method of printing, whereas
the remaining 18 classes were taught manuscript print-
ing, such as the Zaner-Bloser (1984) style. No student
received additional handwriting instruction in occupa-
tional therapy. The study population was divided into
four groups based on Minnesota Handwriting Test scores
and teachers' referral or nonreferral for special education
intervention, as appropriate:
850
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1. Croup I-Students in regular education class-
rooms who were receiving no special education
and who achieved a handwriting score of > - 1.0
SD from the mean of the entire regular education
group (n = 428 [out of 484 regular-education
students])
2. Croup 2 - Mainstreamed students in the same
regular classrooms who spent part of the day in
special education and who did not receive occu-
pational therapy (n = 30).
3. Croup 3 - Students in regular classrooms receiv-
ing no special education but who were identified
as having poor handwriting. P00r handwriting
was defined by a score on the Minnesota Hand-
writing Test of at least 1.0 SD below the mean of
the total regular education sample (n = 56). Pick-
ard and Alston (as cited by Alston & Taylor, 1987)
have recommended the use of - 1.0 SD as the
cutoff point for identification of students with
handwriting problems.
4. Croup 4- Mainstreamed students in the same
regular classrooms who spent part of the day in
special education and who received occupational
therapy for problems contributing to poor hand-
writing, as stated on their IEPs (n = 51). Because
this study occurred at the beginning of the school
year, many students were just entering occupa-
tional therapy. Others had received occupational
therapy intervention before reaching second
grade and were carried over because it was deter-
mined that they continued to need this interven-
tion to reach the IEP goal of improved
handwriting.
Instrument
The Minnesota Handwriting Test is a near-point copy task
(i.e., each test paper contains the stimulus words). To
take the test, students copy a sample containing the
words (in mixed order) for the common sentence, "The
quick brown fox jumped over the lazy dogs." Samples are
given in either manuscript or D'Nealian printing style to
fit the instructional style of each classroom. In the pilot
version of the test, the samples were not timed.
Scoring of the samples requires the application of
specific criteria and the measurement of individual let-
ters. Each letter may receive up to 4 points, which are
awarded if the letter meets the criteria for legibility, size,
form, and conformity to the baseline. If a letter fails to
meet the legibility criterion, then scoring is discontinued
for that letter and it loses all 4 points. The objective here
is to give greater weight to legibility while still recognizing
other common areas of difficulty. Points ar~ also deleted if
word and letter spacing fail to meet specific criteria.
Interrater reliability on the pilot version of the scor-
ing directions was established with the use of four raters,
September 1991, Volume 45, Number 9
 who each scored 30 samples. The correlations among
pairs of raters ranged from 0.77 to 0.88. The raters' errors
were of two types: misinterpretation of scoring directions
and the human errors of measurement and failure to
follow directions. A revised version of the scoring direc-
tions is being developed to address both issues.
Procedure
After obtaining consent for participation, an occupational
therapist or teacher read the standardized instructions to
a classroom of students. The students wrote their names
on the test sheets and then copied the stimulus words.
After the test, an adult recorded the appropriate category
of group membership (e.g., regular education, special
education) using a prearranged coding system. The stu-
dents' names were cut from the papers to preserve their
anonymity.
Most of the tests were scored by the occupational
therapists in each cooperating school district. A few of the
classes were scored by research assistants hired for the
study. All data were sent to me, and I then performed a
single-factor analysis of variance on the students' scores
to determine any signiftcant differences among the
groups (Abacus Concepts, 1986). This was followed by
Scheffe post hoc analyses (Abacus Concepts, 1986) for a
comparison of scores of each group with every other
group.
Results
The Group 1 students (i.e., those in regular education
classes) had the highest mean test score, 95.8% (SD =
3.5), whereas the Group 4 students (i.e., those receiving
occupational therapy) had the lowest, with a mean score
of76.0% (SD = 16). The Group 2 students (i.e., those in
special education who were not receiving occupational
therapy) had a mean score of 89.4% (SD = 9.5). The
Group 3 students (i.e., those in regular classes who had
poor handwriting but did not qualify for any form of
special education) had a mean score of 80.5% (SD = 5),
thus placing them between the special education stu-
dents without handwriting needs and the occupational
therapy students with handwriting needs. The differences
among the groups were statistically significant (F =
218.7, P < .0001). In addition, all post hoc comparisons
were significant at the 99% level (see Table 1).
Discussion
Are teachers making appropriate referrals to occupation-
al therapy? According to the scores obtained from the
Minnesota Handwriting Test, it seems that they are. Stu-
dents referred to occupational therapy achieved the low-
est scores on this test.
The American Journal of Occupalional Therapy
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Table 1
Post Hoc Comparisons Between Pairs of Groups of
Second-Grade Handwriters
Comparison Groups M Difference Scheffe F Test"
Group 1 vs. 2 8.628 8.771
Group 1 vs. 3 27.526 145.093
Group 1 vs. 4 21.405 95338
Group 2 vs. 3 -18898 28347
Group 2 vs. 4 12.776 13399
Group 3 vs. 4 - 6.122 4203
No/e. 1 = regular education students, 2 = special education students,
3 = poor handwriters in regular education, 4 = occupational therapy
students.
*p <01.
Those students in special education who were not
referred to occupational therapy also seemed appropri-
ately placed. Their scores were significantly higher than
those of the students with poor handwriting both in regu-
lar education and in occupational therapy, although their
scores were still somewhat lower than those of most of
their classmates in regular education. Although some Stu-
dents in the regular classroom who have poor handwrit-
ing should perhaps be referred to special education, most
are appropriately placed. Anderson (1983) noted that
teachers often have students in their classrooms who
have poor handwriting but have no other problem that
interferes with academic performance.
In summary, it seems that only those students with
the poorest handwriting in the regular classroom are re-
ferred for occupational therapy. We must next examine
whether occupational therapy is effective in remediating
handwriting problems. To be objective, we as occupation-
al therapists must have quantitative measures. The Min-
nesota Handwriting Test may prove to be a useful addi-
tion to the instruments that occupational therapists
employ in both assessment and research ....
Acknowledgments
I acknowledge Julie Haugen, PhD, OTR, for statistical consultation;
Judith Bullock, OTR, and Patricia Haggerty, OTR, for ideas related
to developing the Minnesota Handwriting Test; the occupation-
al therapists who participated as data collectors and scorers;
and the occupational therapy students who served as research
assistants.
This study was supported in part by grants from the Ameri-
can Occupational Therapy Association and the University of
Minnesota Undergraduate Research Opportunities Program.
References
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