Functional Handwriting Performance in School-Age

Children With Fetal Alcohol Spectrum Disorders

Cherie J. Duval-White, Tracy Jirikowic, Dianne Rios, Jean Deitz,

Heather Carmichael Olson

MeSH TERMS Handwriting is a critical skill for school success. Children with fetal alcohol spectrum disorders (FASD) often

fetal alcohol syndrome present with fine motor and visual–motor impairments that can affect handwriting performance, yet
handwriting skills have not been systematically investigated in this clinical group. This study aimed to

handwriting
comprehensively describe handwriting skills in 20 school-age children with FASD. Children were tested

prenatal exposure delayed effects with the Process Assessment of the Learner, 2nd Edition (PAL–II), and the Visuomotor Precision subtest of

psychomotor performance NEPSY, a developmental neuropsychological assessment. Participants performed below average on PAL–II
measures of handwriting legibility and speed and on NEPSY visual–motor precision tasks. In contrast,
PAL–II measures of sensorimotor skills were broadly within the average range. Results provide evidence of
functional handwriting challenges for children with FASD and suggest diminished visual–motor skills and
increased difficulty as task complexity increases. Future research is needed to further describe the prev-
alence and nature of handwriting challenges in this population.

Duval-White, C. J., Jirikowic, T., Rios, D., Deitz, J., & Olson, H. C. (2013). Functional handwriting performance in school-
age children with fetal alcohol spectrum disorders. American Journal of Occupational Therapy, 67, 534–542. http://
[Link]/10.5014/ajot.2013.008243

Cherie J. Duval-White, MS, OTR/L, is Staff

Occupational Therapist, Seattle Children’s Hospital,
Seattle. At the time of the study, she was Graduate
O ccupational therapists view the occupational performance of children within
the context of age-appropriate self-care, play, and school tasks (American
Occupational Therapy Association, 2008). The functional use of written
Student, Master of Science Program, Department of
Rehabilitation Medicine, University of Washington, Seattle. communication is a critical component of participation in school-based activ-
ities. Handwriting is often the primary method that school-age children use to
Tracy Jirikowic, PhD, OTR/L, is Assistant Professor,
Division of Occupational Therapy, Box 356490, University demonstrate knowledge, participate in learning tasks, and transcribe written
of Washington, Seattle, WA 98195; tracyj@[Link] narratives. Therefore, it is critical to understand the nature of handwriting
difficulties for children who are at risk for handwriting dysfunction.
Dianne Rios, ScD, OTR/L, is Postdoctoral Fellow,
Department of Rehabilitation Medicine, University of
It has been estimated that elementary school–age students may spend up to
Washington, Seattle. one-quarter to one-half of their school day engaged in paper-and-pencil tasks,
which include handwriting (McHale & Cermak, 1992). Difficulties with hand-
Jean Deitz, PhD, OTR/L, FAOTA, is Professor
writing thus can adversely affect many aspects of a child’s classroom participation.
Emeritus, Department of Rehabilitation Medicine,
University of Washington, Seattle. For example, poor handwriting can increase frustration with and avoidance
of classroom tasks, thereby negatively influencing behavior (Kern & Bambara,
Heather Carmichael Olson, PhD, is Senior Lecturer, 2002). Decreased legibility and quality of handwritten text can affect a teacher’s
Division of Child Psychiatry, Department of Psychiatry and
Behavioral Sciences, Seattle Children’s Research Institute perceptions of written content and of the student’s academic knowledge, which
and University of Washington, Seattle. may result in lower grades (Cahill, 2009). Also important is that the ability to use
handwriting for composition in the early grades has been identified as a critical
factor in solidifying skills such as symbol memory and retrieval, which are im-
portant to literacy development and composition proficiency (Berninger, 2009;
Berninger, Abbott, Augsburger, & Garcia, 2009).
Children with fetal alcohol spectrum disorders (FASD) often exhibit fine
motor and visual–motor difficulties that place them at risk for handwriting dys-
function (Adnams et al., 2001; Jirikowic, Olson, & Kartin, 2008). An estimated

534 September/October 2013, Volume 67, Number 5

0.2–1.5 in 1,000 newborns are diagnosed with the full fetal who were participants in a larger study that examined
alcohol syndrome (FAS), and the prevalence of all diagnoses the efficacy of the Families Moving Forward (FMF)
grouped under the umbrella term of FASD is as much as Program. The FMF Program is a tailored behavioral
5 times greater (May & Gossage, 2001). Sensorimotor im- consultation intervention designed for families raising
pairments, including decreased visual–motor abilities and preschool- and school-age children with FASD who
persistent fine motor delays, have been widely described in show high levels of externalizing behavior problems.
children and adults affected by prenatal alcohol exposure The larger study had several aspects, including a small
(Adnams et al., 2001; Connor, Sampson, Streissguth, training study; a larger intervention study; and several
Bookstein, & Barr, 2006; Jirikowic et al., 2008; Kalberg descriptive substudies, including the present hand-
et al., 2006). For children with FASD, however, these im- writing study. The institutional review boards of a
pairments have not been examined in the context of functional children’s research institute and a state department of
handwriting. This absence is surprising, given clinical and social and health services (for foster children) approved
anecdotal reports of handwriting dysfunction and the and monitored all aspects of the study. All participating
importance of these foundational sensorimotor skills for caregivers and caseworkers (when applicable) consented,
writing success (Benbow, 2006; Berninger & Rutberg, and all children assented. Study researchers also met reg-
1992; Weil & Amundson, 1994). ulations required by the Health Insurance Portability and
Poor handwriting and challenges with fine motor skills Accountability Act (45 C.F.R. x 164.102 et seq., 2007).
in the classroom are among the most common reasons children
are referred to occupational therapists in school-based settings Participants
(Chandler, 1994). Information that identifies risk factors Participants enrolled in the larger study were recruited
and describes the nature of handwriting dysfunction among from an FASD clinical database, and all had a diagnosis
children with neurodevelopmental disabilities serves as an within the umbrella category of FASD. The database
important guide for assessment, therapeutic intervention, and contains data on a clinical population of patients with
classroom accommodations. To that end, the purpose of this confirmed prenatal alcohol exposure systematically di-
study was to comprehensively describe the performance of agnosed by an interdisciplinary team (Astley & Clarren,
children with FASD on measures of handwriting legibility, 2000; Clarren, Carmichael-Olson, Clarren, & Astley,
speed of written production, visual–motor control, and sen- 2000) using the FASD Four-Digit Diagnostic Code, which
sorimotor performance as related to functional handwriting
is a rigorously defined and validated diagnostic system
skills. We addressed three research questions:
(Astley, 2004; Astley et al., 2009a, 2009b). The four
1. How do school-age children with FASD score on mea-
digits of the code reflect the magnitude of expression of
sures of handwriting legibility, specifically the Handwrit-
the four key diagnostic features of FASD: (1) growth
ing Total Automatic Letter Legibility Composite and
deficiency, (2) facial features, (3) central nervous system
the Handwriting Total Legibility Composite of the Pro-
damage or dysfunction, and (4) maternal alcohol con-
cess Assessment of the Learner, 2nd Edition (PAL–II;
sumption during pregnancy. The magnitude of expres-
Berninger, 2007)?
sion of each feature is ranked independently on a 4-point
2. How do school-age children with FASD score on a mea-
Likert scale ranging from 1 5 complete absence of the FAS
sure of speed of handwriting production, specifically the
Handwriting Total Time Composite of the PAL–II feature to 4 5 strong classic presence of the FAS feature.
(Berninger, 2007)? Every four-digit diagnostic code is grouped into a set of
3. How do school-age children with FASD score on mea- distinct clinical diagnostic categories, including the fol-
sures of sensorimotor performance and motor control, lowing that fall under the designation of FASD:
specifically the Finger Sense subtests of the PAL–II • FAS/alcohol-exposed
(Berninger, 2007) and the NEPSY Visuomotor Preci- • FAS/alcohol exposure unknown
sion subtest (Korkman, Kirk, & Kemp, 1998)? • Partial FAS/alcohol-exposed
• Static encephalopathy/alcohol-exposed
Method • Neurobehavioral disorder/alcohol-exposed.
See Astley (2004) for a full explanation of the FASD
Research Design Four-Digit Diagnostic Code, including diagnostic meth-
The study described in this article was a descriptive ods and categories, and Astley (2010) for a comprehensive
substudy of handwriting function in children with FASD profile of the clinical population.

The American Journal of Occupational Therapy 535

 In addition to presence of FASD, study inclusion handwriting substudy tests by a licensed school psychol-
criteria included clinically concerning behavior problems. ogist and a licensed clinical psychologist. The examiners
Children were aged 4–12 yr at enrollment; spoke English; were trained by reading the study protocol and test
were of any gender, ethnicity, or socioeconomic status; manuals, observing test administrations, and completing
and lived within a large geographic catchment area that the full battery on three or more prestudy pilot test
allowed in-home intervention services. Children lived participants.
with their birth, adoptive, or foster family or with a legal
guardian. Children had to have lived with their current Instruments
family for at least 4 mo at enrollment, and the caregiver Process Assessment of the Learner, Second Edition. The
had to indicate willingness to continue caregiving for at PAL–II measures a variety of reading, writing, and math
least 18 mo after study enrollment. Children with di- processes for children in kindergarten to Grade 6 (K–6).
agnosed psychotic disorders, behavior problems (e.g., The PAL–II handwriting tasks include Alphabet Writing,
serious, repetitive fire setting) beyond the scope of the in which the child is asked to print the alphabet in
FMF intervention, other birth defects leading to cognitive lowercase in alphabetic order as quickly and accurately as
impairment, or uncorrected significant hearing or vision possible; Copying Task A, in which the child is asked to
problems were excluded. Families with a primary care- copy a sentence in manuscript as quickly and accurately
giver who reported current hazardous alcohol use were as possible; and Copying Task B, in which the child is
also excluded. Although all children initially recruited asked to copy a short paragraph as quickly and accurately
into the larger study had an FASD and met the inclusion as possible. Subtest scaled scores measuring speed of
and exclusion criteria, no parameter related to hand- production and legibility are derived independently for
writing function or academic achievement was consid- each task. Three summary scores—Handwriting Total
ered, and the intervention did not focus on any aspect of Automatic Letter Legibility Composite, Handwriting
handwriting or sensorimotor function. Total Letter Legibility Composite, and Handwriting
Of the 36 participants in various aspects of the larger Total Time Composite—are generated from the subtest
study, 22 met one additional inclusion criterion for this scaled scores. PAL–II subtest and composite scaled scores
substudy of handwriting function: entering or being en- are derived from normative data and have a mean of 10
rolled in Grades 1–6. Grade placement was defined as the and a standard deviation of 3.
child’s grade at the time of follow-up testing, when the The PAL–II also includes subtests that assess sen-
data for the current substudy were collected. For children sorimotor skills involving the coordination of finger
tested in the summer, grades were determined using movements and tactile perception, which are important
a July 1 cutoff; if a child was tested on or after July 1, the sensorimotor foundations for handwriting performance.
child was considered to be in the next grade. Of the These Finger Sense subtests include Finger Repetition, in
22 children enrolled in the handwriting substudy, 1 was which the child touches the index finger rapidly to the
unable to meaningfully participate in the study measures thumb 20 times; Finger Succession, in which the child
because of significant cognitive delays and was dropped. touches each of the four fingers in succession to the
Another child was dropped because the child’s diagnosis thumb for five repetitions; and Fingertip Writing, in
(i.e., four-digit diagnostic code) did not fall in a category which the examiner traces letters onto the child’s finger-
that met substudy inclusion criteria. tips with a blunt stylus while the child’s vision is oc-
cluded. All Finger Sense subtests are performed on both
Procedures hands.
As part of the larger study, participants and their caregivers Test–retest stability coefficients for PAL–II norms for
were administered a comprehensive battery of standard- Grades K–3 derived using the Pearson product-moment
ized assessments at baseline and follow-up. Data for the correlation were .54 for the Handwriting Total Auto-
current substudy were collected by adding two hand- matic Letter Legibility Composite, .78 for the Hand-
writing and sensorimotor assessments to the follow-up test writing Total Letter Legibility Composite, and .75 for the
battery. Three examiners administered the follow-up test Handwriting Total Time Composite. For Grades 4–6,
battery, including the handwriting substudy assessments. test–retest stability coefficients were .62 for the Hand-
The examiners were enrolled in graduate study programs writing Total Automatic Letter Legibility Composite, .54
in school psychology or clinical psychology. They had for the Handwriting Total Letter Legibility Composite,
extensive child assessment experience and were trained and and .64 for the Handwriting Total Time Composite.
supervised in the larger study assessment battery and the Test–retest reliabilities for the Finger Sense subtests

536 September/October 2013, Volume 67, Number 5

ranged from .67 to .78. For Grades K–6, average internal gram. The interrater agreement for the training sample
consistency reliability coefficients, calculated with a Fisher’s was 80% for the Handwriting Total Automatic Letter
z transformation, ranged from .72 to .81 for the hand- Legibility composite and 58% for the Handwriting Total
writing composite scores and .69 to .74 for the Finger Legibility Composite.
Sense subtests. After the two raters further discussed the rating
NEPSY. The NEPSY developmental neuropsychological guidelines and specific situations that occurred when
assessment is a comprehensive assessment that evaluates rating protocols for the training sample, data collection
children aged 3–12 yr in the areas of attention and ex- began for the study sample. To check interrater agreement
ecutive function, language, memory and learning, social for the study sample, the first author and the second rater
perception, sensorimotor processing, and visual–spatial independently scored six protocols from the study sample
processing. The Visuomotor Precision subtest from the chosen using a stratified random approach. Interrater
NEPSY was included in this test battery to measure the agreement for the study sample was 77% for the Auto-
child’s visual–motor coordination and ability to use a matic Letter Legibility composite and 78% for the Total
pencil with speed and precision in a nonwriting task. For Letter Legibility composite.
the Visuomotor Precision subtest, the child uses his or
her preferred hand to draw a line between two outlines
Results
through a series of shaped, narrow pencil paths. The
child’s product is scored for accuracy on the basis of The final handwriting substudy sample consisted of 20
number of errors observed (e.g., child’s line crossing over children aged 7.1–13.0 yr (mean [M] 5 9.5 yr, standard
the parallel line for every marked interval on the record deviation [SD] 5 1.8). The average full-scale IQ of the
form). NEPSY scaled scores are derived from norma- participants, determined with the Differential Ability
tive data and have a mean of 10 and a standard de- Scales—2nd Edition (Elliot, 2007), assessed at baseline
viation of 3. approximately 18 mo before this assessment, ranged from
The NEPSY has evidence of content validity and 65 to 107 (M 5 88.2, SD 5 12.2). The mean IQ of this
sound test structure. For the Visuomotor Precision subtest sample was in the low average range, but the sample in-
for children aged 5–12 yr, internal consistency has been cluded children with IQ scores that reflected well below
reported at .68, average test–retest stability coefficient at average to average cognitive abilities. Scores from all mea-
r 5 .56, and interrater reliability at r 5 .99. sures were reported as valid. Additional participant charac-
teristics are outlined in Table 1.
Observation of Grasp and Hand Function Descriptive statistics for the PAL–II handwriting
The examiner observed and recorded each child’s hand legibility and speed composite scores and task scaled
preference during the performance of writing tasks. The scores are presented in Table 2. The mean scores for this
examiner also recorded the child’s grasp pattern with sample of children with FASD were well below average
a standard Number 2 pencil using visual diagrams for on both Handwriting Automatic Letter Legibility and
scoring and descriptions of the following grasp patterns: Handwriting Total Letter Legibility Composite scores
palmar supinated grasp, digital pronated grasp, static and below average for the Handwriting Total Time
tripod grasp, and dynamic tripod grasp. Composite. This group of children had poorer perfor-
mance than the PAL–II normative sample across all three
Interrater Agreement writing tasks, which included Alphabet Writing (single
The written portions of the PAL–II were scored by the letter production from memory), Copying Task A (copying
first author (Duval-White), who has 10 yr of experience a sentence), and Copying Task B (copying a short para-
with handwriting assessment and intervention. Interrater graph). Handwriting speed and accuracy also decreased with
agreement for scoring the PAL–II handwriting samples task complexity, with the highest mean score seen on Al-
was completed in two stages. First, to establish interrater phabet Writing total time and the lowest mean score seen
agreement before scoring protocols from the study sam- on Copying Task B legibility at 90 s. Figure 1 illustrates the
ple, the PAL–II handwriting tasks were administered to distribution of the PAL–II handwriting legibility and speed
a convenience sample of six children with typical de- outcomes for the sample.
velopment in Grades K–6. These training sample pro- Descriptive statistics for PAL–II motor control and
tocols were scored by the first author and a second sensorimotor subtests and the NEPSY Visuomotor Pre-
independent rater who was an experienced pediatric oc- cision subtest are reported in Table 3. The mean score
cupational therapist enrolled in a doctoral training pro- for the Finger Sense subtests was well within the normal

The American Journal of Occupational Therapy 537

Table 1. Participant Characteristics (N 5 20) Table 2. Results for Handwriting Legibility and Speed Composite
Scores and Scaled Scores
Characteristic n (%)
Sex PAL–II Scores na M Mdn Min Max SD
Female 6 (30) Composite scores
Male 14 (70) Automatic Letter Legibility 18 5.06 4.00 1 11 2.99
Race Total Letter Legibility 20 4.90 5.50 1 9 2.75
White 14 (70) Handwriting Total Time 20 7.95 7.00 1 15 3.80
African American 1 (5) Task scaled scores
Mixed race or ethnicity 5 (25) Alphabet Writing
Grade in school Automatic Legible Letter Writing 17 7.06 7.00 3 13 2.86
1 3 (15) Legible Letter Writing 20 5.95 6.00 1 11 2.67
2 7 (35) Total Time 20 8.20 7.50 1 16 4.66
3 2 (10) Copying Task A
4 3 (15) Automatic Legible Letter Writing 19 5.53 5.00 1 11 2.43
5 3 (15) Legible Letter Writing 19 6.05 6.00 1 12 3.74
6 2 (10) Total Time 19 7.26 7.00 1 13 3.33
Educational program Copying Task B
General education with special education services 11 (55) Legible Letter Writing at 30 s 20 6.30 6.00 1 13 2.56
Special needs classroom 5 (25) Legible Letter Writing at 60 s 20 6.10 6.50 1 14 3.08
General education (no special education services) 4 (20) Legible Letter Writing at 90 s 20 5.20 6.00 1 12 3.07
Four-digit diagnostic code Copy Accuracy 20 5.70 6.50 1 14 3.29
Fetal alcohol syndrome (alcohol-exposed) 1 (5) Note. M 5 10, SD 5 3 for scaled scores on the PAL–II. M 5 mean; max 5
Partial fetal alcohol syndrome (alcohol-exposed) 2 (10) maximum score; Mdn 5 median; min 5 minimum score; PAL–II 5 Process
Static encephalopathy (alcohol-exposed) 4 (20) Assessment of the Learner, 2nd Edition; SD 5 standard deviation.
a
Neurobehavioral disorder (alcohol-exposed) 13 (65) Sample size varies because of missing data.
Additional diagnosesa
Attention deficit hyperactivity disorder 16 (80) alphabet, sentence, and paragraph writing tasks and during
Intellectual disability 6 (30)
performance of visual–motor tasks requiring motor ac-
Speech or language delay 8 (40)
curacy and precision. Handwriting speed also was below
n 5 19; children could have more than one additional diagnosis.
a
average, with both speed and accuracy decreasing as tasks
progressed in difficulty from simple alphabet writing
range compared with test norms for the PAL–II Finger to paragraph copying. In contrast, basic sensorimotor
Sense subtests of Finger Repetition and Finger Succession functioning as measured by the PAL–II Finger Sense
on both dominant and nondominant hands, and it was subtests (i.e., finger tapping and thumb–finger touching
within the average range for the Fingertip Writing sub- speed) was generally within age expectations. Results in-
test. In contrast, the mean score for the NEPSY Visuo- dicate that children with FASD are at risk for hand-
motor Precision subtest was well below average compared writing dysfunction and that the nature of their
with test norms. Figure 1 illustrates the distribution of handwriting performance difficulties may not be fully
the sensorimotor scores on the PAL–II and NEPSY. explained by impairments in foundational sensorimotor
When completing testing tasks, 18 of the children components.
held the pencil in their right hand and 2 held the pencil in In this study, only about one-third of the children
their left hand. Eighteen children used a dynamic tripod with FASD demonstrated letter writing legibility within
grasp (three digits in contact with the pencil, with the average range compared with PAL–II test norms.
movement at the distal fingertips while writing), and 2 Although legibility challenges were seen across different
used a static tripod grasp (three digits in contact with the writing tasks, in general the participants performed best
pencil, with no movement at the distal fingertips while on the task requiring single-letter alphabet writing from
writing). memory. Poorer performance was seen on tasks involving
near-point copying of a sentence and near-point copying
of a short paragraph of text. Among children with FASD,
Discussion as among children with typical development, difficulties
This study is the first to comprehensively describe func- with legible letter writing can compromise the ability of
tional handwriting skills in school-age children with educators and peers to accurately assess the content and
FASD. The children with FASD in this sample demon- quality of written work. This difficulty, in turn, may
strated clear challenges with handwriting legibility across negatively influence others’ perceptions of the child’s effort

538 September/October 2013, Volume 67, Number 5

Figure 1. Distribution of scores of children with FASD on the PAL–II and NEPSY.
Note. Average 5 scores ±1 SD from the mean; below average 5 scores between 1 SD and 2 SD below the mean; substantially below average 5 scores ³2 SD
below the mean. D 5 dominant hand; FASD 5 fetal alcohol spectrum disorders; ND 5 nondominant hand; NEPSY 5 developmental neuropsychological
assessment; PAL–II 5 Process Assessment of the Learner, 2nd Edition; SD 5 standard deviation.

and actual content knowledge as well as grades earned legibility. The poorest performance was seen on paragraph
(Cahill, 2009). copying over time, which suggests difficulty with sustained
The children in this sample also demonstrated legible letter production and a trade-off prioritizing speed
functional impairments in the speed of written production over accuracy. Children who consistently show impair-
across handwriting tasks, but to a lesser degree than in ments in speed of written production are likely to have

Table 3. Results for Measures of Motor Control and Sensorimotor Processing

Measure na M Mdn Min Max SD
PAL–II
Finger Repetition, Dominant Hand, Total Time 19 11.58 12.00 7 15 2.50
Finger Repetition, Nondominant Hand, Total Time 19 11.37 11.00 7 17 2.39
Finger Succession, Dominant Hand, Total Time 19 10.95 11.00 7 14 2.22
Finger Succession, Nondominant Hand, Total Time 19 10.95 11.00 8 14 1.93
Fingertip Writing 20 8.30 9.00 5 11 1.95
NEPSY
Visuomotor Precision 20 6.45 6.50 2 11 2.82
Note. M 5 10, SD 5 3, for scaled scores on the PAL–II and NEPSY. M 5 mean; max 5 maximum score; Mdn 5 median; min 5 minimum score; NEPSY 5
developmental neuropsychological assessment; PAL–II 5 Process Assessment of the Learner, 2nd Edition; SD 5 standard deviation.
a
Sample size varies because of missing data.

The American Journal of Occupational Therapy 539

difficulties with classroom tasks that involve taking dic- The handwriting challenges demonstrated by the
tation, keeping pace during timed tests or quizzes, and children with FASD in this study are similar to those
producing longer written compositions (Weil & Amundson, described among children with attention deficit disorder
1994; Ziviani & Wallen, 2006). (ADD) or attention deficit hyperactivity disorder (ADHD;
In contrast to handwriting performance, the majority Racine, Majnemer, Shevell, & Snider, 2008). Racine et al.
of children with FASD demonstrated performance within (2008) reported that children with ADD or ADHD
the average range on PAL–II sensorimotor tasks. This showed decreased legibility or inappropriate speed of ex-
finding was unexpected given previous reports of fine ecution, or both, when compared with the performance
motor and visual–motor difficulties in this population of children without ADD or ADHD. Although it is not
(Adnams et al., 2001; Jirikowic et al., 2008). The as- known whether Racine et al.’s sample included children
sessment of sensorimotor function in this study included with prenatal alcohol exposure, the majority (80%) of
finger tapping speed, speed of sequential thumb–finger children with FASD in the current study also met criteria
movements, and mental mapping of tactile input. The for ADD or ADHD by caregiver report, consistent with
ability to accurately perform these basic hand and finger other clinical samples of children affected by prenatal al-
movements has been identified as an important motor cohol exposure (Mattson et al., 2011). This finding sug-
foundation for handwriting (Berninger & Rutberg, 1992). gests that attention problems, as in children with ADD or
However, in combination with clinical observations of the ADHD, may significantly affect handwriting performance
participants’ grasp patterns and hand dominance that were in children with FASD, even though the type of attention
relatively typical for age, these results suggest that foun- deficit in the two clinical populations differs (Vaurio,
dational sensorimotor impairments may not be a primary Riley, & Mattson, 2008).
barrier to efficient and fluent handwriting performance for Further, in this sample 40% of the children had
many children with FASD. a reported speech or language impairment. Thus, the
Relative to performance on the PAL–II Finger Sense challenges seen in functional handwriting performance
subtests, the children’s performance on the NEPSY among these children could also be attributable, in part, to
Visuomotor Precision subtest (Korkman et al., 1998) was language problems, which commonly occur among chil-
much poorer. The mean scaled scores for the PAL–II dren with FASD (Coggins, Timler, & Olswang, 2007).
Finger Succession and Finger Repetition subtests were Berninger (2009) correlated the broader context of
11.5 and 10.9, respectively, compared with a mean scaled writing performance, including both handwriting and
score of 6.2 for the NEPSY Visuomotor Precision subtest. composition, with the ability to use symbols, letters, and
This finding shows that the performance of the children words to represent and convey thoughts. These skills
with FASD declined as the complexity of the task in- appear to be linked to phonemic (sound) skills, word
creased from speed of simple finger movements to the skills, sentence skills, and text skills, all of which are
coordination of hand function, tool use, attention, and language-based processes (Berninger, 2009). Given the
visual–motor abilities. Findings suggest that compro- important link between language and written commu-
mised visual–motor integration may be a contributing nication, future studies examining handwriting as a
factor to the handwriting difficulties of children with means of written communication among children with
FASD. FASD should account for language function, ideally as-
Visual–motor impairments and greater difficulty sessed from a process perspective.
performing complex tasks are challenges that have also
been found in other studies of children with FASD
(Kodituwakku, 2007, 2009; Mattson, Crocker, & Nguyen,
Strengths and Limitations
2011). Additionally, our findings are congruent with results This descriptive study had several strengths. The study
from a study that examined the relationship between sen- focused on a systematically diagnosed sample of children
sorimotor skills, visual–motor integration, and handwriting with FASD ranging across the elementary school grades. A
in a diverse sample of children with learning or behavioral standardized test battery was used to assess foundational
disabilities or both (Klein, Guiltner, Sollereder, & Cui, sensorimotor skills and multiple aspects of handwriting
2011). The researchers found that although sensorimotor performance. Study results are limited by a relatively small
skills explained little of the variance in handwriting pro- sample size and lack of a comparison group, although
ficiency, visual–motor integration was a significant predictor psychometric norms were available for comparison purposes.
in classifying children as either “skilled” or “unskilled” Although the PAL–II was chosen as the primary as-
handwriters. sessment tool for its relative ease of administration, recent

540 September/October 2013, Volume 67, Number 5

normative data for children in Grades 1–6, and strong transitions as grade-level expectations and writing de-
theoretical and empirical development, one disadvantage mands change and increase.
of this instrument became evident during the study. The • Even for children who do not show early handwriting
interrater agreements for the handwriting subtests of the or sensorimotor problems, the pattern of difficulties
PAL–II were relatively weak despite careful examiner noted in this study suggests that periodic monitoring
training on administration and scoring. In addition to and screening of children with FASD across the ele-
more specific descriptive criteria, more visual scoring mentary grades could help identify emerging problems
models of both lowercase and uppercase letters likely and ensure timely evaluation and intervention.
would improve the scoring reliability of the PAL–II. • Timely evaluation and intervention, in turn, could bet-
The scope of sensorimotor performance examined in this ter support these children’s ability to successfully par-
study was also limited. Graded motor control (Nguyen, Levy, ticipate in the many important school-based activities
Riley, Thomas, & Simmons, 2013) and visual–spatial pro- that require written communication. s
cessing (Mattson et al., 2011) are other relevant sensorimotor
performance areas reported as diminished among children Acknowledgments
affected by prenatal alcohol exposure that warrant more re-
search in terms of potential impact on handwriting function. This research was partially supported by funding from the
Finally, handwriting is a complex task that requires Centers for Disease Control and Prevention, Grant
integration of sensorimotor, cognitive, and executive func- U01-0000DD038-05, awarded to Heather Carmichael
tion and linguistic processes (Berninger, 2009). Contextual Olson. This portion of the research took place at the
factors such as the classroom environment, grade-level Seattle Children’s Research Institute. In addition, we thank
writing expectations, and handwriting curriculum standards Jennifer Nash and the FMF Program participants, fami-
also affect handwriting function and competence. There- lies, and research team.
fore, future studies of children with FASD should in-
vestigate handwriting performance in the broader context of References
these other important child characteristics and contextual Adnams, C. M., Kodituwakku, P. W., Hay, A., Molteno,
demands. C. D., Viljoen, D., & May, P. A. (2001). Patterns of
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