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Development of handwriting skill in children with unilateral cerebral palsy

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 Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20

Development of handwriting skill in children with

unilateral cerebral palsy (CP)

ŞŞermin Tükel Kavak & Ann-Christin Eliasson

To cite this article: ŞŞermin Tükel Kavak & Ann-Christin Eliasson (2011) Development of
handwriting skill in children with unilateral cerebral palsy (CP), Disability and Rehabilitation,
33:21-22, 2084-2091, DOI: 10.3109/09638288.2011.560335

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Disability and Rehabilitation, 2011; 33(21–22): 2084–2091

RESEARCH PAPER

Development of handwriting skill in children with unilateral cerebral

palsy (CP)

ŞERMIN TÜKEL KAVAK & ANN-CHRISTIN ELIASSON

Neuropediatric Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden

Accepted January 2011

Abstract
Aim. To investigate the development of handwriting, fine motor skills and school marks in children with unilateral cerebral
palsy (CP) and relate the performance in handwriting skill to age and IQ at a 16-month follow-up.
Method. Data from 16 children (5 females, 11 males; mean age 11 years 4 months, SD 1 year 6 months, range 8–13 years)
with left-sided hemiplegia were collected. The Minnesota Handwriting Assessment (MHA) for handwriting skill, the
Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) for fine motor skills, the Wechsler Intelligence Scale for Children
Revised (WISC-R) for IQ, the Manual Ability Classification System (MACS) and school marks of children were used.
Results. Handwriting quality, handwriting speed and fine motor skills improved over 16 months but the children with
unilateral CP still performed below their peers. School marks did not change. The regression model (Adj. R2 ¼ 0.76)
revealed that age and IQ were negatively correlated and good predictors for the improvement in handwriting quality. No
relationship was found between handwriting speed and age or IQ.
Conclusion. Children with unilateral CP continued to develop handwriting skill over a longer time period than expected.
Age and IQ predicted the rate of development in handwriting quality. Children kept up school marks despite the increasing
demands of the succeeding grade.

Keywords: Unilateral cerebral palsy, cerebral palsy, handwriting, cognition, fine motor skills

Introduction handwriting skill has earlier been reported as a

Literacy acquisition is one of the first goals in
education. Therefore, writing and reading skills are
of primary importance during the first years of
education. Students are typically expected to learn
handwriting during the first three years in school.
Later on, they have to use handwriting as a tool for
communicating knowledge, thoughts and feelings
both in school and social settings. In typical writing
development, handwriting, spelling and composition
of text are identified as separable but interrelated
skills [1]. In addition, problems in handwriting could
create a barrier that prevents children from accom-
plishing higher order skills like spelling and composi-
tion of creative and well-structured text [2–4].
Educational attainment is found to be low in
individuals with cerebral palsy (CP) [5] and poor
problem although they use their non-involved hand
for handwriting [6–8]. Unilateral CP typically is
diagnosed if limbs on one side of the body are
involved; however, bilateral effect on hand function
has earlier been described; the non-involved hand
differs from the dominant hand of typically develop-
ing children in several aspects [6,9,10]. Visual–motor
coordination, speed and dexterity, response speed,
kinesthesia and graphesthesia were found to be lower
than those of typical children in our previous study
[6]. Fingertip-force coordination during object ma-
nipulation in the non-involved hand was also less
than for typically developing children [9]. Moreover,
the children seem to have a deficit in movement
planning, which results in slow, inefficient and
sequential behaviours even in the non-involved hand
[10]. The consequences of these deficits for learning

Correspondence: Şermin Tükel Kavak, Neuropediatric Research Unit, Astrid Lindgren Children’s Hospital Q2:07, SE-171 76 Stockholm, Sweden.
Fax: þ46-8-517-773-49. E-mail: sermin.tukel-kavak@ki.se
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2011 Informa UK, Ltd.
DOI: 10.3109/09638288.2011.560335
 Development of handwriting skill in CP 2085

handwriting skill have only recently been investigated
[6–8].
Although children with unilateral lesion have
overall less functional limitation than those with
other types of CP, the cognitive level is known to vary
[11] even if most of the children are included in
regular education. Parents and teachers have
reported writing difficulties mostly in dictation, and
maintaining neatness at speed and over longer
periods of time for children with unilateral CP [7].
Even though the relationship between cognitive skills
like visual-spatial perception and visual–motor orga-
nisation were related to handwriting skill [6], the
effect of IQ, which is a more general indicator for
learning disability on the acquisition of handwriting
skill is not fully understood. In a study focusing on
special education, teachers reported lower expecta-
tions for future writing development of kindergarten
students with CP especially for those with low IQ.
Furthermore, 25% of teachers reported they did not
know what to expect [12].
In a previous study, we found that children with left
sided unilateral CP had decreased handwriting
quality but about the same handwriting speed when
using the right, non-involved hand compared to
typically developing peers. As expected, the control
group of elementary school children with typical
development had reached the ceiling effect of
Minnesota Handwriting Assessment (MHA) whereas
most children with unilateral CP performed below
peers in all quality categories of handwriting [6]. The
question is whether children with unilateral CP have a
prolonged learning phase or cease learning at a lower
level. Therefore, the aim of this study is to follow-up
the development of handwriting skill regarding speed
and quality of letter production; fine motor skills and
school marks of a previously studied group of
children with unilateral CP and relate the perfor-
mance in handwriting skill to age and IQ.
Method
Design
This study is a 16-month follow-up of children with
unilateral CP. Hacettepe University Ethical Com-
mittee gave ethical approval for the study. Informed
consent was obtained from all participating children
and their parents.
Participants
Twenty-six children from a previous study were
invited to be reassessed after 16 months [6]. Seven-
teen of them could be reached for the reassessment.
One child did not want to participate and thus
16 participants aged from 8 years 9 months to 13
years 7 months (mean 11 years 4 months, SD 1 year
6 months; 5 females, 11 males) were included. The
non-responders did not differ in age (mean 11 years,
range 9 years 5 months to 12 years 11 months,
5 females, 5 males). Table I shows the characteristics
of the participants. All of them had left sided
unilateral CP and were writing with the right hand.
Twelve children were enrolled in regular education
classes. The remaining four children were in special

Table I. Characteristics of children with unilateral CP.

Subject Age Sex MACS IQ Grade Education

1 8y9m Female 2 107 3 Regular education

2 9y1m Male 2 51 2 Special education
3 10 y Male 1 125 4 Regular education
4* 10 y 6 m Female 1 53 NA Regular education
5{ 10 y 7 m Male 2 60 4 Regular education
6 11 y 1 m Male 1 53 3 Regular education
7 11 y 1 m Male 1 123 5 Regular education
8{ 11 y 3 m Male 3 43 3 Special education
9 11 y 4 m Female 1 80 5 Regular education
10 11 y 5 m Male 1 82 5 Regular education
11 11 y 10 m Male 2 74 6 Regular education
12{ 12 y Female 2 40 5 Special education
13 12 y 1 m Male 3 52 4 Special education
14 12 y 6 m Female 2 73 8 Regular education
15 13 y 4 m Male 3 49 6 Regular education
16 13 y 7 m Male 2 41 5 Regular education

The children are listed according to age.

*
Child had 1-year school leave.
{
Child had 3 months school leave.
{
Children had severe epilepsy seizures reported by their parents.
NA, Not available.
2086 Ş. T. Kavak & A.-C. Eliasson
education classes within the mainstream schools.
Thereby, children in special education classes were
taught handwriting at the first grade like peers. The
children were recruited from rehabilitation centres
and were located in different schools.
In the time between the two data collections,
children did not receive any treatment targeting
handwriting problems. They continued their educa-
tion but two participants had school leave. One of
these had 1-year school leave because of hip surgery
(see footnote * in Table I). It resulted in missing data
for school marks. The other one had 3-month school
leave because of surgery in the hemiplegic arm (see
footnote{ in Table I). Presence of severe epileptic
seizures was reported for two other participants while
one was hospitalised the week before the assessment
(see footnote{ in Table I).
Materials
The MHA was used to assess manuscript writing of
children [13]. It measures (1) speed and (2) quality
categories of handwriting. For speed, the number of
letters that are copied in 1 min was taken [14]. The
quality categories are legibility, form, size, alignment
and spacing. There is no composite score for quality
in MHA but for the purpose of this study the total
sum was calculated. Categories have same interval
and scoring criteria. Unidimensionality of categories
was confirmed by factor analysis on previous data
set. Principal component analysis revealed one factor
(eigenvalue ¼ 4.1) that each quality category loaded
on between 0.67 and 0.96 and explains 81% of the
variance. This result allowed using the quality
composite score (range: 0–170).
The procedure for MHA is that the examinee is
asked to copy a stimulus sentence that includes all
the letters of the Turkish alphabet to the line below
[14]. The order of words in the sentence was
changed to reduce the speed and memory advantage
of better readers. With this procedure, all students
refer to the stimulus sentence word by word. Each
letter is scored individually for each of the quality
categories according to the criteria described in the
MHA manual [13]. The MHA has norms for first
and second grades [13]. We used the norms for 2nd
grade because it is the ceiling of the test and all
children in our sample were at or above 2nd grade.
Items of Bruininks-Oseretsky Test of Motor
Proficiency (BOTMP) were used to assess fine
motor skills [15]. The same items were used as in
the previous study [6]. They were: touching a
swinging ball with the preferred hand, response
speed, copying a triangle, placing pennies in a box
with the right hand and drawing vertical lines with
the right hand. These items belong to different
subtests, and because of this a total score is not
available on the BOTMP. Factor analysis to get a
total score could not be performed because intervals
of the items are different from each other, Kaiser–
Meyer–Olkin values were lower than the recom-
mended value of 0.6, and the Barlett Test of
Sphericity was not significant (p 4 0.05).
The Wechsler Intelligence Scale for Children
Revised (WISC-R) was administered as a measure
of general intellectual functioning to the children.
The WISC-R provides a full-scale score (FSIQ); the
result can also be divided into a verbal IQ and a
performance IQ. The Turkish standardised version
of WISC-R was used. The scale has acceptable
reliability (0.98, 0.98 and 0.96, respectively for Full
Scale, Verbal and Performance) and validity [16].
School marks were collected from the years 2006–
2007 and 2007–2008. The marks can vary between
zero (the lowest) and five (the best) and a mean mark
of 2.5 is required to pass on to the next grade. The
school marks were collected either from the official
website of the Turkish Ministry of Education or from
the school administration with permission of parents.
The Manual Ability Classification System (MACS)
was used to describe children’s manual ability when
handling objects in daily life and their need for
assistance or adaptations in five different levels [17].
Children with unilateral CP typically appear in level
I–II and some in level III [18].
Procedure
The same investigator administered the BOTMP,
MHA and MACS on both occasions. Certified
psychologists administered the WISC-R test. Stan-
dard administration and scoring procedures were
followed throughout the analysis process for all tests.
The investigator was blind to the earlier scores.
Statistical analysis
The SPSS 17.0 for Macintosh was used to screen
and analyse all data. Descriptive statistics and
distributions of variables were examined. The scores
of MHA have interval level, therefore allowing
parametric statistics to be applied. Factor analysis
with principal component analysis was used to show
the unidimensionality of quality categories in the
MHA. Thus, the composite for handwriting quality
was calculated. Data regarding development were
analysed by using the Wilcoxon signed rank test to
compare data from the previous study (assessment 1)
[6] with this data collection (assessment 2) of
handwriting, fine motor skills and school marks of
children with unilateral CP. The Mann–Whitney
 Development of handwriting skill in CP 2087

U test was used to compare IQ groups. Pearson
correlation coefficients were examined between
handwriting speed, quality, age and IQ. Multiple
linear regression analysis was conducted to predict
the development of handwriting quality from age
and IQ. Sample size ratio was taken as 1:5 [19].
Histogram was performed to check normality and
residual analysis to examine assumptions of linearity
and homogenous variance. An interaction test was
performed and multicollinearity problems checked.
A Variation Inflation Factor (VIF) greater than 4 was
considered as a cut-off criterion for deciding when a
given independent variable displayed ‘too great’
multicollinearity problem [19]. A Cook’s distance
value (D) 4 4/n – k 7 1 was taken as a criterion to
indicate a possible outlier problem, where ‘n’ was the
sample size and ‘k’ is the number of predictor
variables [19]. The final parsimonious model is
presented below. The level of significance was
specified at 0.05.
Results
Handwriting quality composite increased at the 16-
month follow-up (p ¼ 0.03, Table II). When inves-
tigating the separate quality categories, improvement
was found in two of the five categories, alignment
(p ¼ 0.017) and size (p ¼ 0.048) (Table II). From an
individual perspective, 12 of 16 children showed
improvement in quality composite whereas four of
them showed regression. However, it should be
noted that regression was only seen in those children
who suffered an epileptic seizure or took school leave
during the study period (see method). The number
of children reaching the ceiling of MHA increased
from four to seven in legibility, one to six in
alignment, zero to two in size and two to six in
spacing (Figure 1). Neither in the first nor in the
second assessment did any children reach the ceiling
in the form category. The rest of the children stayed
below the ceiling of MHA, which represents 2nd
grade level.
Handwriting speed increased between the two
assessments (p ¼ 0.008, Table II). Thirteen of the
hemiplegic children showed progress; whereas two of
them showed very mild regression and one child
remained at the same speed of performance. Chil-
dren who showed regression in speed are different
from those who regressed in quality composite.
For the BOTMP, three of five items improved
over time. Response speed (p ¼ 0.011), visual–motor
control (p ¼ 0.025) and the task of drawing vertical
lines in the upper-extremity speed and dexterity
subtest (p ¼ 0.003) had improved at the second
assessment (Table II). Visual tracking (p ¼ 0.366)
and the task of placing pennies in the upper-
extremity speed and dexterity subtest (p ¼ 1.00) did
not differ significantly between the two assessments.
On a group level, school mark was not different
between occasions (p ¼ 0.925, Table II). All children
passed to the next grade. On the individual level,
eight of 15 children had somewhat increased school
marks whereas one of them kept up and six of them
decreased.
For further analysis on quality of handwriting, only
children who showed improvement were included.
When they were grouped according to IQ, the
children with IQ 4 70 achieved higher scores than
children with IQ 5 70 in the quality composite both
in 1st (p ¼ 0.01) and in 2nd (p ¼ 0.005) assessments
(Figure 2).

Table II. Comparison of handwriting, fine motor skills and school marks between assessment–1 and assessment–2.

Assessment–1 Assessment–2 p

Handwriting skill
Legibility 31 (0–34) 31 (19–34) 0.156
Form 25 (0–30) 26.5 (12–31) 0.088
Alignment 26 (0–34) 29.5 (6–34) 0.017
Size 10 (0–31) 12.5 (0–34) 0.048
Spacing 29 (0–34) 29.5 (17–34) 0.078
Handwriting quality composite* 123 (0–156) 128.5 (59–163) 0.032
Handwriting speed 5.5 (0–11) 7.0 (5–19) 0.008
Fine motor skills
Visual tracking (0–3) 1.5 (0–3) 1 (0–3) 0.366
Response speed (0–17) 0 (0–4) 1.5 (0–6) 0.011
Visual-motor control (0–2) 2 (0–2) 2 (1–2) 0.025
Upper-extremity speed and dexterity (placing pennies) (0–8) 1.5 (1–4) 2 (0–4) 1.000
Upper extremity speed and dexterity (drawing vertical lines) (0–9) 2 (1–4) 3 (2–7) 0.003
School marks 3.97 (2.60–5.00) 4.10 (2.50–5.00) 0.925

Numbers represent median and range from minimum to maximum.

*Hand writing quality composite is the sum of legibility, form, alignment, size and spacing.
p Values less than 0.05 are shown in bold.
2088 Ş. T. Kavak & A.-C. Eliasson

Figure 1. Number of children reached the ceiling of MHA in 1st and 2nd assessment sessions for the different quality categories of
handwriting.

Figure 2. Handwriting quality composite scores in the first and in the second assessments for three different groups. Box-plots show median,
interquartile range and outliers. I ¼ Children with IQ 4 70, II ¼ Children with IQ 5 70, III ¼ Children either with reported epilepsy seizure
or with school leave.

There was a linear relationship between improve-
ment in handwriting quality and age and IQ, whereas
no linear relationship was found between the
improvement in handwriting speed and age or IQ.
A multiple linear regression analysis was performed
to predict the improvement in handwriting quality.
Age (in months) and IQ were used as predictor
variables. The difference between previous and
present handwriting quality scores was used as an
outcome variable. The model was significant
 Development of handwriting skill in CP 2089

(F ¼ 18.3, df ¼ 9, p ¼ 0.001) and explained 76% of Discussion

the variance (Adj. R2 ¼ 0.76) in the improvement of
handwriting quality (Table III). It showed that both
age (B ¼ 71.5) and IQ (B ¼ 70.9) were negatively
correlated, i.e. the children with low IQ and younger
children made greater improvement, and they con-
tributed independently to the prediction of improve-
ment in handwriting quality for children between 8þ
to 13þ years of age (p 5 0.005 for both, Table III).
We did not observe any interaction, multicollinearity
or autocorrelation problems (VIF ¼ 1.3). None of
the individuals except one showed a Cook’s distance
value, D 4 4/n 7 k 7 1. Residual analysis revealed
that assumptions of linearity and Homoscedasticity
were not violated. Moderate deviation from normal-
ity was observed and transformation of the outcome
variable was performed but the result was similar,
which indicates the model is fine. The predicted
values via using the model are shown in Figure 3.
Children with unilateral CP, 8–13 years of age,
improved the quality and speed of handwriting
skill. For fine motor skills speed and visual-motor
control improved, and the children kept up their
school marks over the 16-month follow-up period.
Three additional children, now 7 of the 16 children,
reached the ceiling in handwriting legibility, the most
important quality category. Still almost no children
have reached the ceiling for form and size. So,
although there are improvements, the children with
unilateral CP have lower performance than typically
developing children. Typical children are known to
have a dramatic improvement through the second
grade, at 8 years of age in Turkey, and they
commonly reach the ceiling effect of the MHA in
this period [13,20]. Our result suggests that improve-
ment of handwriting continues over a considerable

Table III. Regression model with improvement in handwriting quality as dependent variable.

Variable B SE B b t p 95% CI for B VIF

Constant 298.83 45.85 6.5 50.001 195.10 402.55

Age (month) 71.48 0.27 70.93 75.3 50.001 72.11 70.86 1.36
FSIQ 70.88 0.17 70.89 75.1 0.001 71.26 70.49 1.36

Adj. R2 ¼ 0.76; F ¼ 18.25, df ¼ 9, p ¼ 0.001.

Figure 3. Standardised predicted value for improvement in handwriting quality via using regression equation [Improvement ¼ 298.83 7
(1.48 6 Age-month) 7 (0.88 6 FSIQ)]. Scatter plot shows the correlation between observed and predicted values (Pearson r ¼ 0.89,
p 5 0.05) that indicates the accuracy of the model.
2090 Ş. T. Kavak & A.-C. Eliasson
time period for most children with unilateral CP
although they are writing with the right dominant
hand. Delayed development of handwriting skill has
also been seen for dysfunctional handwriters, where
half of a group caught up with peers but not until
fifth grade [21]. This prolonged learning process of
age-related skills seems to be typical for both
dysfunctional handwriters and children with cerebral
palsy. Even for other activities like independence in
self-care, children with CP with good hand function
at MACS level I and II needed additional years to
be independent compared to peers [22].
The speed of handwriting was similar to that of
peers already at the first assessment [6], and
continues to increase at the 16-month follow-up.
This suggests that children adapt the handwriting
speed to catch up with their peers but have a struggle
with producing letters. Consequently, the develop-
ment of speed before a good quality of handwriting
may result in ‘fairly fast but illegible handwriting’.
This difference and the prolonged development of
quality might affect higher order skills like spelling
and composition of writing [2–4], which are very
important for success in higher education.
Children with left-sided hemiplegia were included
in this study to minimise the influence of the
functional reorganisation in hand dominance result-
ing from brain lesion. In addition, problems in
handwriting skill might relate to language problems.
This is more probable in children with right-sided
hemiplegia since a lesion in the left hemisphere might
cause slower language development because of inter-
hemispheric reorganisation [23].
In this study, the handwriting task was to copy one
sentence. In spite of the simplicity of the writing task,
the cognitive ability influenced the outcome in quality
(accuracy in producing and organising letters).
Children with IQ 4 70 had better handwriting quality
than children with IQ 5 70 in both previous and
present assessments. Both age and IQ predicted the
rate of development in handwriting quality. Regres-
sion model showed that children in younger ages and
children with lower IQ made greater improvement
based on those children, who have been healthy
during the examined period. The small number of
children is of course a limitation of this study;
however, from a statistical perspective we found the
result acceptable. There was a moderate deviation
from normality in the regression model but since
linear regression is a strong parametric test and the
transformed results were not different from the
untransformed, we believe that the result is accep-
table. In addition, one child showed a Cook’s
distance value D 4 4/ n 7 k 7 1 since he was the
youngest individual and made the greatest improve-
ment. The model was still significant without this
outlier. However, we kept this child in the model
since he represents this age in our sample. The main
challenge in the handwriting task seems to be of
visual-spatial character since the cognitive demands
of memory and reading were minimised in this task.
Poor quality of handwriting has earlier been particu-
larly related to a deficiency in visual–motor integra-
tion both for children with handwriting problems
and younger children during typical development
[24,25]. Yet, the poor handwriting quality might also
be a problem of motor planning to execute the
formation of the letter. Cognitive demands of a fine
motor task have earlier been shown to limit the
performance in children with unilateral CP [10].
All participants passed to the next grade. This is in
agreement with earlier study by Ballantyne et al.,
who showed that academic functions followed a
stable course of development during the school age
years for children with unilateral CP [26]. On the
other hand, the presence of seizures has been
reported to influence cognitive development
[11,26]. The four children in this study who showed
regression in handwriting quality either had school
leave or suffered severe epileptic seizures reported by
their parents. Obviously, the presence of seizures
and lack of practice during school leave interfered
with the development of handwriting skill in this
group of children.
In conclusion, development of handwriting and of
fine motor skills, continued for a longer period of
time in children with unilateral CP than typically
developing children. Age but also cognitive ability
influenced the rate of development; children with
low IQ as well as children with younger ages showed
greater improvement in handwriting quality within
the age range of 8–13 years. This late development of
handwriting in children with hemiplegic CP should
be considered in educational and clinical settings.
The children may benefit from practicing hand-
writing at early age in a systematic way and the effect
of intervention of handwriting needs to be evaluated.
Acknowledgements
Authors wish to express their deepest gratitude to the
children and families who participated in this study.
Authors thank Dr. Gonca Bumin for the help to
recruit children and the psychologists for performing
WISC-R evaluations. Authors would also like to
thank Dr. Ersen Kavak and Dr. Mesfin Kassaye
Tessma for their support about statistical analysis.
Declaration of interest
Financial support was granted from the Department
of Habilitation Services for Children and Youth,

Research Unit, Stockholm, Swedish Research Coun-
cil, Stockholm County Council, FoU Committee,
Stiftelsen Frimurare Barnhuset, and Sunnerdahls
handikappfond.
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