Research in Developmental Disabilities 33 (2012) 1301–1309

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Research in Developmental Disabilities

Handwriting performance and underlying factors in children with

Attention Deficit Hyperactivity Disorder
I-Hsuan Shen a,*, Tsai-Yun Lee b, Chia-Ling Chen c,d
a
Department of Occupational Therapy, Chang Gung University, Taiwan
b
Department of Rehabilitation, Saint Mary’s Hospital Luodong, Taiwan
c
Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taiwan
d
Graduate Institute of Early Intervention, Chang Gung University, Taiwan

A R T I C L E I N F O A B S T R A C T

Article history: Preliminary evidence suggests that handwriting difficulties are common to children with
Received 13 December 2011 Attention Deficit Hyperactivity Disorder (ADHD). However, the nature of the task-specific
Received in revised form 10 February 2012 impairments is needed to be clarified. The aim of this study was to describe handwriting
Accepted 13 February 2012 capacity in ADHD children without DCD and identify underlying factors of performance by
Available online 29 March 2012 use of outcome-oriented assessments and a digitizing tablet. Twenty-one children with
ADHD (8.59  1.25 years) and 21 match controls (8.5  1.08 years) were recruited. Children
Keywords: with ADHD scored lower than controls on Tseng Handwriting Problem Checklist and writing
Attention Deficit Hyperactivity Disorder
composite of Basic Reading and Writing Test, indicating the ADHD group wrote less legibly.
Handwriting
The ADHD group spent more on-paper time to copy 50 Chinese characters and exhibited more
Motor skill
Visual perception
writing time during the writing process. The ADHD group scored significantly lower on tasks
Visual-motor integration demanding upper limb and eye–hand coordination and visual-motor integration compared
with controls. Furthermore, motor skill and visual-motor integration were positively
correlated with the legibility. Motor skill was negatively correlated with writing time, in-
air time, and in-air trajectory.
ß 2012 Elsevier Ltd. All rights reserved.

1. Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is the most common neurobehavioral disorder in childhood (DSM-IV,
American Psychiatric Association, 1994). The core symptoms of ADHD as defined by DSM-IV are inattention, impulsivity and
hyperactivity. However, motor difficulties have also been reported in this population (Fliers et al., 2008; Pitcher, Piek, & Hay,
2003; Stray et al., 2009). Poor fine motor coordination in children with ADHD has been reported and a high percentage of
ADHD children have difficulty with handwriting and penmanship has been noted (Barkley, 1998; Harvey & Reid, 2003; Piek,
Pitcher, & Hay, 1999).
The importance of handwriting for performance in school has been well documented. Although students’ use of computers
to process work is very popular, legible handwriting skill is still very important for them nowadays. Limited writing
performance directly affects students’ functional performance in academics, and results in poor self-esteem, and poor self-
acceptance (Mather & Roberts, 1995). Weintraub and Graham (2000) reported that children’s gender, finger functioning, and
visual-motor status resulted in the correct classification of 77% of the 5th grade participants as good or poor handwriters.

* Corresponding author at: Department of Occupational Therapy, Chang Gung University, 259, Wen-Hwa 1st Rd, Kwei-Shan, Tao-Yuan 333, Taiwan.
Tel.: +886 3 2118800x5534; fax: +886 3 2118700.
E-mail address: shenih@mail.cgu.edu.tw (I.-H. Shen).

0891-4222/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2012.02.010
1302 I.-H. Shen et al. / Research in Developmental Disabilities 33 (2012) 1301–1309

Further, according to Tseng and Chow (2000), for the normal speed handwriters, age and upper-limb speed and dexterity were
two significant predictors. However, age, visual-motor abilities, and visual processing were critical predictors for the slow
handwriters. It is widely believed that performance components associated with handwriting include motor planning, eye–
hand coordination, visual-motor integration, kinesthetic, and in-hand manipulation (Schneck & Amundson, 2010).
Typical handwriting difficulties for the students are poor legibility, taking longer to finish written class assignments, and
the lack of automaticity of handwriting. Handwriting difficulties become apparent when the written work is difficult to read
or when children write too slowly to record sufficient quantities of work (Ziviani & Wallen, 2006, chap. 11). Therefore,
handwriting quality and quantity could translate into legibility and speed respectively. To identify underlying possible
factors relating to poor handwriting is helpful for intervention. Traditional studies of handwriting are restricted to
observational outcome-oriented tests. However, computer and digitizer-based technology has led to the development of an
innovative approach to handwriting evaluation. That is, a digitizing tablet could provide an insight into the writing process
during the actual performance of a written task.
Research on the handwriting in ADHD is relatively scarce. In the study of Tucha and Lange (2001), children with ADHD
showed poorer handwriting legibility and accuracy compared to the typical controls when they withdraw from medication by
using a digitizing tablet with a wireless pen. Moreover, decreased fluency was identified while children with ADHD were
treated on medication (Tucha & Lange, 2004). Brossard-Racine, Majnemer, Shevell, Snider, and Be’langer (2011) argued that
poor handwriting legibility and slow writing speed were common in children newly diagnosed with ADHD and were associated
with motor abilities. Although preliminary evidence suggests that handwriting difficulties are common to children with ADHD,
the factors predicting these task-specific impairments remain to be clarified in this population (Brossard-Racine, Majnemer,
Shevell, & Snider, 2008). The core characteristic of developmental coordination disorder (DCD) involves a marked impairment
in the development of the motor coordination. This impairment has a negative impact on activities of daily life and academic
achievement through poor handwriting skills (Fliers et al., 2008). Many studies have also observed a high co-occurrence of
ADHD with DCD (Brossard-Racine et al., 2008, 2011; Flapper, Houwen, & Schoemaker, 2006; Fliers et al., 2008). Pitcher et al.
(2003) found poorer fine motor performance in children with both ADHD and DCD than in children with only ADHD. Therefore,
previous studies observed children of ADHD with handwriting difficulties may, in part, be due to the co-occurrence of ADHD
with DCD, which was not ruled out (Brossard-Racine et al., 2011; Flapper et al., 2006; Piek et al., 1999). The underlying
mechanism of the association of ADHD and motor coordination problems remains unclear. However, the handwriting
performance of ADHD children without DCD has not been studied and this gap deserves to be filled.
The present study aimed to compare the handwriting performance of ADHD children without DCD to typical developing
children by using observational outcome-oriented handwriting assessments as well as with the help of an objective
computerized handwriting assessment tool. The purpose of this study was to examine (a) differences in the handwriting
performance between children with ADHD and match controls, (b) differences in the motor and perceptual abilities between
the two groups, and (c) the relationships between motor and perceptual abilities and handwriting legibility and speed. We
hypothesized that ADHD children without DCD would show poorer writing performance than controls. On motor and
perceptual tests, ADHD children without DCD would perform more poorly than controls.

2. Methods

2.1. Participants

Data were obtained from a sample of twenty-one children with ADHD (17 male, 4 female; mean age 8.59  1.25 years) and
21 match controls (12 male, 9 female; mean age 8.5  1.08 years) from grade 1 to grade 4. Both groups were matched in age and
intelligence quotient (IQ). The ADHD group consisted of children diagnosed with ADHD according to DSM-IV criteria (American
Psychiatric Association, 1994), 10 children with a diagnosis of ADHD combined type, 5 children as the hyperactive–impulsive
type, and 6 children as the inattentive type. Children with ADHD were recruited through referral by psychologists, pediatric
psychiatrists, and through advertisement by Naivety ADHD Taiwan Association. The Chinese version of the Swanson, Nolan and
Pehlam version IV scale parent form (SNAP-IV) was used to confirm the diagnosis (Gau et al., 2008). Children with known epilepsy,
severe anxiety, or psychotic disorders except conduct disorder and oppositional defiant disorder were excluded from the study. It
has been recommended that children scoring at or below the 5th percentile on the Movement Assessment Battery for Children,
2nd edition (M-ABC-2) have significant motor coordination difficulties and may require intervention; children scoring at or below
the 15th percentile on M-ABC-2 are thought to have significant motor coordination difficulties, and should be followed and re-
assessed periodically to determine if intervention is required (Henderson, Sugden, & Barnett, 2007). Participants who scored
below the 15th percentile on the M-ABC-2 were excluded in this study. All children were right-handed. Nine children with ADHD
children taking Methylphenidate (MPH) had been off medication for at least 24 h before starting the experimental task. None of
the ADHD children was on medication during the experiment.

2.2. Measuring instruments

2.2.1. IQ test and the rating scale

The Chinese version of the Test of Nonverbal Intelligence, 3rd edition (C-TONI, 3rd ed.) was translated from the third
version of TONI (Brown, Sherbenou, & Johnsen, 1997) and standardized for children from the ages of 4 years to 16 years
 I.-H. Shen et al. / Research in Developmental Disabilities 33 (2012) 1301–1309 1303

and 5 months in Taiwan (Wu et al., 2007). The Test of Nonverbal Intelligence (TONI) was originally designed to measure
nonverbal cognitive abilities in terms of problem solving and abstract reasoning (Brown et al., 1997). Scores from the
TONI-3 have been shown moderately positively correlated with the Full Scale IQ of the Wechsler Intelligence Scale for
Children – fourth edition (WISC-IV) (Banks & Franzen, 2010). C-TONI has been used as a nonverbal IQ test in this study.
The Swanson, Nolan, and Pelham rating scale (SNAP; Swanson, 1992; Swanson et al., 2001) directly employs the core
symptoms defined by the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American
Psychiatric Association, 1994). The Chinese version of the Swanson, Nolan and Pehlam version IV scale parent form
(SNAP-IV) demonstrated similar three factor structure (Inattention, Hyperactivity/Impulsivity, and Oppositional) as its
English version, and satisfactory test–retest reliability, internal consistency, concurrent validity, and discriminant
validity (Gau et al., 2008). This 26-item rating scale consists of the DSM-IV symptoms for the inattention (Items 1–9) and
the hyperactivity/impulsivity (Items 10–18) of the criteria for ADHD, and the oppositional symptoms (Items 19–26) of
the criteria for oppositional defiant disorder. Each item is rated on a four-point rating scale (0 = ‘not at all’, 2 = ‘just a little’,
3 = ‘quite a bit’, and 4 = ‘very much’).

2.2.2. Handwriting
The Tseng Handwriting Problem Checklist (THPC; Tseng, 1993a) is a 24-item checklist that was developed to assess
handwriting problems in Chinese elementary school students. The 24 items cover six factors of handwriting as follows:
(1) construction; (2) sequencing; (3) behavior; (4) accuracy; (5) motor; and (6) directionality (Tseng, 1993a). The items
are scored on 4-point Likert scale, ranging from 1 = always to 4 = seldom, with lower scores indicating poorer
performance. The factorial validity of THPC has demonstrated the six factors as distinct, well defined constructs (Tseng,
1993a). The concurrent validity of THPC has been verified for the motor, accuracy, and construction composites of the
THPC. Furthermore, both the construction and accuracy factors of the THPC reflect measures of legibility aspect of
handwriting (Tseng, 1993b), and these two factors are chosen to evaluate the relationship with motor and perceptual
abilities.

2.2.3. Reading and writing performance

The Basic Reading and Writing Comprehensive Test (BRWCT) (Hung, Chang, Chen, Chen, & Lee, 2003) was used to
measure the reading and writing performances of the children. The BRWCT is a standardized test of basic Chinese reading
and writing ability from first to third grade students. The content of the BRWCT includes several subtests. Raw score of each
subtest can be converted into age-referenced percentile ranks and T score. Two composite scores are computed from the test:
a reading composite score and a writing composite score. Both composite scores can be converted into age-referenced
percentile ranks and T score. The writing composite comprises dictation and far-point copying tasks.

2.2.4. Computerized apparatus and handwriting task

The apparatus included a digitizer (WACOM UD-1218E) with a wireless inking pen and the OASIS software (De Jong,
Hulstijn, Kosterman, & Smits-Engelsman, 1996). The x, y, and z (axial pen pressure) positions of the pen were sampled with
a frequency of 206 Hz. Participants copied 50 Chinese characters on a digitizing tablet controlled by a PC. These 50
characters were selected from the data pool of the Chinese common vocabulary in Taiwan elementary schools by National
Institute for Compilation and Translation (1996). These 50 characters were shown in 5 columns of 10 characters on one half
portion of a piece of paper. The participants were instructed to copy the characters on the other half portion of the same
piece of paper with a 5  10 grid pasted on the writing board of the tablet. The trajectory of the pen was collected regarding
the positions, sequence of strokes, and pen pressure of writing. The following variables were calculated: (1) total writing
time (s); (2) total in-air time, which is the length of time when the pen is held in air (s); (3) total on-paper time, which is the
length of time the pen touches paper (s); (4) in-air trajectory, which is the length of distance when pen is held in air (cm); (5)
speed (cm/s), which is the value: the length of distance when pen touches paper/the length of time the pen touches paper;
(6) axial pen pressure, which is the mean pressure of the pen perpendicular to the digitizer in grams; (7) average character
width, which is the average width of 50 characters (cm); (8) average character height, which is the average height of 50
characters (cm).

2.2.5. Motor skills

The Movement Assessment Battery for Children, 2nd edition (M-ABC-2; Henderson et al., 2007) is a revision of the
Movement ABC (M-ABC; Henderson & Sugden, 1992). The M-ABC-2 test consists of eight items in each of three age
bands. These items measure different aspects of motor ability which are divided into three major performance areas
called components: manual dexterity (MD), aiming and catching (AC) and static and dynamic balance (BAL). For each
child, the raw item scores can be transformed into item standard scores (ISS). Three subtotal component scores are each
obtained by summing the appropriate item standard scores respectively. Then, the component standard scores (CSS)
and percentile ranks for the three components can be determined. A total test score (TTS) can be determined by
summing the eight item standard scores. After that, total standard score (TSS) and percentile rank (PR) can be
transformed. The total percentile score and total test score (TTS) can be used for classification purposes. Children
who score 215th percentile (TTS 2 67) are classified as children with potential motor problems (at risk or impaired).
In clinical practice, this 215th percentile cut-off score is used to make diagnostic and intervention decisions.
1304 I.-H. Shen et al. / Research in Developmental Disabilities 33 (2012) 1301–1309

Inter-observer reliability of the original version of the M-ABC-2 was high (1–0.95) (Smits-Engelsman, Fiers, Henderson,
& Henderson, 2008). Furthermore, the structural validity of the M-ABC-2 has been validated by use of confirmatory
factor analyses (Schulz, Henderson, Sugden, & Barnett, 2011).

2.2.6. Perception (visual-perceptual and visual-motor skills)

DTVP-2 (Developmental Test of Visual Perception second edition; Hammill, Pearson, & Voress, 1993) was applied to
assess visual perception and visual-motor integration skills of the children. Satisfied evidence of content validity and
construct validity were provided for the DTVP-2 (Hammill et al., 1993). It is structured in eight subtests. Half of them are
designed to test visual-motor integration (eye–hand coordination, copying, spatial relationship, and visual-motor speed),
providing an index named Visual-Motor Integration Quotient (VMIQ). The other four subtests are designed to test perceptual
ability free of motor control (position in space, figure-ground, visual closure, and form constancy) and furnish an index called
Motor Reduced Visual Perception Quotient (MRPQ). The combination of the two indexes gives a third composite quotient of
General Visual Perception Quotient (GVPQ). Raw scores for each subtest are corrected for age in order to obtain a standard
score (SS). The Motor Reduced Visual Perception Quotient (MRPQ), the Visual-Motor Integration Quotient (VMIQ), and the
General Visual Perceptual Quotient (GVPQ) are each calculated by adding the appropriate subtests standard score and
converting each sum to a quotient. SS quotients are classified as follows: (a) 90–110: average; (b) 80–89: below average; (c)
70–79: poor; (d) <70: very poor.

2.3. Procedure

The study was approved by Institutional Review Board Ethics Committee in Chang Gung Medical Foundation. Participants
were recruited by referral from pediatric psychiatrists, through web advertisement, and advertisement by Naivety ADHD
Taiwan Association. Written informed consent was obtained from all children and parents.
Before the study was conducted, all parents first completed the Chinese version of the Swanson, Nolan and Pehlam
version IV scale parent form (SNAP-IV) (Gau et al., 2008) and an information sheet to screen for stimulant use, handedness,
and history of health or physical concerns. All children completed the Chinese version of the Test of Nonverbal Intelligence
(C-TONI, 3rd ed.). A score of 80 or above on the C-TONI was required. Children who scored less than 15th percentile rank on
the M-ABC-2 were excluded. The children were administered the Basic Reading and Writing Comprehensive Test (BRWCT),
the M-ABC-2, and the DTVP-2. Participants also copied 50 Chinese characters on a digitizing tablet with a wireless inking pen.
The Tseng Handwriting Problem Checklist for children’s writing sample was performed by an occupational therapist that
was blinded to group allocation. All participants conducted the experiment in a private room individually.

2.4. Statistical analysis

The Wilcoxon–Mann–Whitney test was used to investigate group differences on THPC. The chi-square analysis was used
for comparing gender distribution. One way ANOVA was used to investigate group differences on BRWCT, M-ABC-2, DTVP-2,
and the variables measured by the digitizer. In previous studies, age was found to be an important predictor of handwriting
(Brossard-Racine et al., 2011; Tseng & Chow, 2000). Therefore, partial correlation coefficients were used to examine the
relationship between motor–perceptual performance (M-ABC-2 and DTVP-2) and writing performance (the scores of THPC,
BRWCT and the variables measured by the digitizer) after age was controlled. Due to multiple testing of this study, a
significance level of p = 0.01 was adopted.

3. Results

3.1. Psychometric variables

Gender distribution between the two groups showed no significant difference (x2 = 0.64, df = 1, p = 0.42). Children with
ADHD scored significantly higher than the comparison group on all subscales of the Chinese version of SNAP-IV, with average
ADHD scores falling in the clinical range for inattention and hyperactivity problems (Table 1).

Table 1
Basic data in the ADHD and control groups.

Group ADHD Control F p

Age (year) 8.49 (1.28) 8.50 (1.08) 0 0.99

Gender distribution (M:F) 17:4 12:9 (x2 = 0.64, df = 1, p = 0.42)
Nonverbal IQ 99.57 (12.7) 104.71 (14.94) 1.44 0.23
SNAP-IV
Attention 17.66 (4.94) 5.57 (3.18) 88.82 <0.0001***
Hyperactivity 15.85 (5.36) 3.19 (3.51) 81.8 <0.0001***
*** p < 0.0001.
Standard deviation values are shown in parentheses. SNAP-IV, Swanson, Nolan and Pehlam version IV.
 I.-H. Shen et al. / Research in Developmental Disabilities 33 (2012) 1301–1309 1305

3.2. Handwriting problem and reading and writing capacity

The ADHD group showed poorer handwriting performance than the comparison group on THPC. The ADHD group scored
significantly lower in construction, sequencing, behavior, accuracy, motor, and directionality factors. Furthermore, the
ADHD group scored significantly lower than the comparison group on writing composite (F(1,40) = 6.14, p = 0.01, h2 = 0.15)
(see Table 2).

3.3. Handwriting task

Table 3 shows the differences between the two groups in handwriting task. Significant group differences were found in
the total writing time (F(1,40) = 7.04, p = 0.01, h2 = 0.18) and total on-paper time (F(1,40) = 7.22, p = 0.01, h2 = 0.18). The total
in-air time, average character width, and average character height reached a borderline significance level between the two
groups (F(1,40) = 5.16, p = 0.02, h2 = 0.13; F(1,40) = 4.69, p = 0.03, h2 = 0.12; F(1,40) = 5.04, p = 0.03, h2 = 0.13). The group with
ADHD spent more time to copy 50 characters than the controls. The ADHD group demonstrated more on-paper time to
execute the handwriting task. Moreover, the group with ADHD seemed to have larger size handwriting.

3.4. Motor and perceptual skills

With respect to motor performance, the ADHD group scored lower significantly than the comparison group in aiming and
catching component standard scores (F(1,40) = 20.84, p < 0.001, h2 = 0.52), the total test score (F(1,40) = 15.59, p < 0.001,
h2 = 0.39), and the percentile rank of the M-ABC-2 (F(1,40) = 17.61, p < 0.001, h2 = 0.44). Regarding visual-perceptual and
visual-motor skills, two children with ADHD scored below the average (in the range 80–89) on GVPQ. Three ADHD children
scored below average on MRPQ (in the range 80–89) and three ADHD children scored below average on VMIQ (two in the
range 80–89 and one in the range 70–79). Thus, the ADHD group scored lower significantly on Visual-Motor Integration
Quotient (VMIQ; F(1,40) = 14.61, p < 0.001, h2 = 0.37) and General Visual Perception Quotient (GVPQ; F(1,40) = 11.761,

Table 2
Performance on THPC and BRWCT in the ADHD and control groups.

Group ADHD Control Z p

THPC
Construction 18.66 (5.65) 26.28 (3.25) 4.33 <0.0001***
Sequencing 9.0 (3.16) 11.85 (0.65) 3.64 0.0003**
Behavior 11.61 (3.0) 19.09 (1.75) 5.49 <0.0001***
Accuracy 7.95 (1.8) 10.95 (1.35) 4.56 <0.0001***
Motor 11.71 (3.87) 14.71 (1.84) 2.92 0.003**
Directionality 7.66 (3.65) 7.8 (0.6) 2.17 0.02

Group ADHD Control F p h2

BRWCT
Phrase making (T score) 54.09 (9.35) 58.61 (4.34) 4.04 0.05 0.1
Character pronunciation (T score) 52.04 (8.87) 55.28 (5.87) 3.35 0.07 0.08
Reading composite score (T score) 52.80 (9.08) 57.19 (3.77) 4.17 0.04 0.1
Far-point copying (T score) 58.52 (10.75) 59.09 (11.63) 0.03 0.8 0.00
Dictation (T score) 47.42 (12.28) 56.47 (12.19) 5.74 0.02 0.14
Writing composite score (T score) 53.28 (12.32) 62.28 (11.19) 6.14 0.01* 0.15
* p < 0.01.
** p < 0.005.
*** p < 0.0001.
THPC, Tseng Handwriting Problem Checklist; BRWCT, Basic Reading and Writing Comprehensive Test.

Table 3
Handwriting performance in the ADHD and control groups.

Group ADHD Control F p h2

*
Total writing time (s) 261.28 (105.37) 189.26 (66.19) 7.04 0.01 0.18
Total in-air time (s) 120.13 (68.55) 82.15 (34.3) 5.16 0.02 0.13
Total on-paper time (s) 141.14 (46.48) 107.1 (34.78) 7.22 0.01* 0.18
In-air trajectory (cm) 2416.94 (679.85) 2074.34 (718.19) 2.56 0.11 0.06
Speed (cm/s) 1.33 (0.66) 1.55 (0.43) 1.7 0.2 0.04
Axial pen pressure (g) 329.58 (67.97) 339.26 (53.94) 0.26 0.61 0.01
Average character width (cm) 1.18 (0.03) 1.02 (0.24) 4.69 0.03 0.12
Average character height (cm) 1.44 (0.39) 1.19 (0.3) 5.04 0.03 0.13
* p < 0.01.
1306 I.-H. Shen et al. / Research in Developmental Disabilities 33 (2012) 1301–1309

Table 4
Performance on M-ABC-2 and DTVP-2 in the ADHD and control groups.

Group ADHD Control F p h2

M-ABC-2
MD 8.57 (2.37) 10.14 (2.05) 5.25 0.02 0.13
AC 8.71 (1.55) 11.14 (1.87) 20.84 <0.0001*** 0.52
BAL 13.33 (2.28) 13.8 (2.27) 0.46 0.5 0.01
TTS 78.42 (7.35) 87.33 (7.26) 15.59 0.0003** 0.39
PR 48.28 (20.06) 72.57 (17.34) 17.61 0.0001*** 0.44
DTVP-2
VMIQ 106.19 (16.07) 121.95 (9.93) 14.61 0.0005** 0.37
MRPQ 103.85 (13.87) 112.09 (15.32) 3.33 0.07 0.08
GVPQ 105.47 (13.24) 117.9 (10.01) 11.76 0.001*** 0.29
** p < 0.005.
*** p < 0.0001.
Standard deviation shown in brackets. M-ABC-2, Movement Assessment Battery for Children, 2nd ed.; DTVP-2, Developmental Test of Visual Perception,
2nd ed.; TTS, total test score; MD, manual dexterity; AC, aiming and catching; BAL, balance; PR, percentile rank; VMIQ, Visual-Motor Integration Quotient;
MRPQ, Motor Reduced Visual Perception Quotient; GVPQ, General Visual Perception Quotient.

p = 0.001, h2 = 0.29) than the control group. However, the two groups of children performed comparably on Motor Reduced
Visual Perception Quotient (MRPQ) (see Table 4).

3.5. Correlation

Correlation coefficients between motor and perceptual abilities and measures of THPC, BRWCT, and digitizer in children
after controlling for age are reported in Table 5. As for the M-ABC-2, the manual dexterity component was positively
correlated with the writing composite score of the BRWCT. The aim and catch component was positively correlated with the
two factors of legibility and negatively correlated with total on-paper time and average character width. The percentile rank
was also positively correlated with the two factors of legibility, the writing composite score of the BRWCT and negatively

Table 5
Correlation coefficients of motor and perceptual skills and measures on THPC, BRWCT, and the digitizer in children after controlling for age.

MD A&C BA PR VMIQ MRPQ GVPQ

THPC
Construction 0.32 0.56 0.08 0.51 0.59 0.28 0.52
ns (0.0001)*** ns (0.0005)** (<0.0001)*** ns (0.0005)**
Accuracy 0.24 0.51 0.15 0.43 0.52 0.38 0.54
ns (0.0006)** ns (0.004)** (0.0005)** (0.01)* (0.0002)**
BRWCT
Reading 0.29 0.08 0.04 0.23 0.1 0.23 0.19
ns ns ns ns ns ns ns
Writing 0.4 0.24 0.22 0.43 0.19 0.4 0.36
(0.008)** ns ns (0.004)** ns (0.008)* (0.01)*
Digitizer
Writing time 0.3 0.35 0.13 0.39 0.27 0.22 0.3
ns ns ns (0.009)* ns ns ns
In-air time 0.25 0.26 0.21 0.39 0.11 0.25 0.11
ns ns ns (0.01)* ns ns ns
On-paper time 0.29 0.37 0.03 0.31 0.38 0.14 0.32
ns (0.01)* ns ns (0.01)* ns ns
In-air trajectory 0.35 0.26 0.21 0.42 0.11 0.36 0.25
ns ns ns (0.005)** ns ns ns
Speed 0.13 0.002 0.03 0.12 0.11 0.25 0.12
ns ns ns ns ns ns ns
Pen pressure 0.15 0.15 0.006 0.11 0.05 0.099 0.09
ns ns ns ns ns ns ns
Average character width 0.22 0.37 0.16 0.36 0.36 0.16 0.25
ns (0.01)* ns (0.01)* (0.01)* ns ns
Average character height 0.14 0.19 0.05 0.18 0.47 0.15 0.28
ns ns ns ns (0.001)** ns ns
* p < 0.01.
** p < 0.005.
*** p < 0.0001.
Significant p-values are shown in parentheses.
THPC, Tseng Handwriting Problem Checklist; BRWCT, Basic Reading and Writing Comprehensive Test; MD, manual dexterity; A & C, aiming and catching;
BA, balance; PR, M-ABC-2 percentile rank; VMIQ, Visual-Motor Integration Quotient; MRPQ, Motor Reduced Visual Perception Quotient; GVPQ, General
Visual Perception Quotient.
 I.-H. Shen et al. / Research in Developmental Disabilities 33 (2012) 1301–1309 1307

correlated with total writing time, total in-air time, total in-air trajectory, and average character width. Regarding the DTVP-
2, the Visual-Motor Integration Quotient (VMIQ) was positively associated with the two factors of legibility and was
negatively associated with on-paper time, average character width, and average character height. The Motor Reduced Visual
Perception Quotient (MRPQ) was positively associated with the accuracy factor of THPC and the writing composite score of
the BRWCT. General Visual Perception Quotient (GVPQ) was positively associated with the two factors of legibility and the
writing composite score of the BRWCT.

4. Discussion

In this study, handwriting performance of children with ADHD was measured on outcome-oriented tests and digitizing
tablet. As expected from our hypothesis, ADHD children without DCD showed poorer penmanship than controls. In
comparison with their peers, children with ADHD scored less on THPC, indicating the ADHD group wrote less legibly. These
findings are consistent with previous findings (Brossard-Racine et al., 2008; Flapper et al., 2006) that handwriting
performance in the children with ADHD is of poor quality. Moreover, children with ADHD scored less than controls on
writing composite of BRWCT. The writing composite score comprises dictation and far-point copying tasks. Dictation task
involves cross-modal perception; that is, children needed to translate the sound of a character into its visual form before
producing it by hand movement. The number of words that children copied from a distant vertical display in 2 min is the
score on far-point copying task. Besides the motor skills, the visuo-spatial working memory may play an important role in
the performance of writing composite of BRWCT. Findings in connection with impaired visuo-spatial working memory in
ADHD have been reported (Kibby & Cohen, 2008; Martinussen, Hayden, Hogg-Johnson, & Tannock, 2005). Further study is
necessary to clarify this point.
In contrast with previous studies, we excluded children who scored less than 15th percentile rank on the M-ABC-2 in the
present study; even so the standard scores of aiming and catching component and the percentile rank for the ADHD group
averaged lower significantly than the control group. Differences on the standard score of manual dexterity between the two
groups reached borderline statistical significance. The manual dexterity component comprises tasks such as placing pegs,
threading lace and tracing a path, incorporating additional visual and perceptual motor skills to the in-hand manipulations.
Consistent existing evidence on handwriting suggests that in-hand manipulations such as the translation and the rotation
are associated with legibility (Cornhill & Case-Smith, 1996; Feder, Majnemer, Bourbonnais, Blayney, & Morin, 2007).
There seems to be more obvious differences between the two groups on aiming and catching component, because the
effect size is large (h2 = 0.52). The aiming and catching component measures upper limb and eye–hand coordination through
ball and beanbag target and catch tasks. The aim and catch component and percentile rank of M-ABC-2 were correlated
strongly with the legibility. A similar strong association was found in children newly diagnosed with ADHD between word
legibility and M-ABC ball skill index (Brossard-Racine et al., 2011).
As to visual perception and visual-motor skills, the ADHD group scored lower significantly on VMIQ, not on MRPQ, than
controls. Therefore, there seems to be better visual perception skill than visual-motor integration in the ADHD group. The
Visual-Motor Integration Quotient (VMIQ) and General Visual Perception Quotient (GVPQ) were correlated strongly with
legibility. These findings were supported by previous studies which showed that children with ADHD frequently exhibited
difficulty on tasks requiring visual-motor perception (Raggio, 1999; Resta & Eliot, 1994). In contrast, visual-spatial
processing has been reported as one of the main deficits associated with DCD (Piek & Dyck, 2004). Children with ADHD who
scored less than 15th percentile rank on the M-ABC-2 were excluded in the present study; this could then explain our results.
Again, results lend general support to our hypothesis that ADHD children without DCD performed more poorly than controls
on both motor and perceptual tests.
The manual dexterity component and percentile rank on M-ABC-2 were positively correlated with the writing composite
score of the BRWCT. The Motor Reduced Visual Perception Quotient (MRPQ) and General Visual Perception Quotient (GVPQ)
were positively correlated with the writing composite score of the BRWCT.
Even though there was no difference between two groups in writing speed, the ADHD group spent more in-air time and
on-paper time to copy 50 characters, exhibiting more writing time during the writing process. Our results also found the aim
and catch component was negatively correlated with total on-paper time. The percentile rank on M-ABC-2 negatively
correlated with total writing time, total in-air time, and total in-air trajectory. It seems plausible that inadequate motor skills
and poor motor coordination could explain slow handwriting speed in the ADHD group (Berninger & Rutberg, 1992; Sovik,
Arntzen, & Teulings, 1982). However, both faster and slower handwriting speeds for ADHD have been reported in the
previous studies (Rosenblum, Epsztein, & Josman, 2008; Tucha & Lange, 2004), task variation and heterogeneous participants
may explain the divergence. Furthermore, the Visual-Motor Integration Quotient (VMIQ) was negatively associated with on-
paper time. It seemed that better visual-motor integration leads to proficient handwriting and spend less time on writing
task.
Interestingly, borderline significance was found on character width and height between the two groups; that is, the ADHD
group was observed to have increased character width and height indicating larger size handwriting. Our findings agree with
the previous report, letter height increased in children with ADHD when writing the same sentence several times (Frings
et al., 2010). The aim and catch component and percentile rank on M-ABC-2 were negatively correlated with average
character width. The Visual-Motor Integration Quotient (VMIQ) was negatively correlated with average width and height of
character. It seems larger size handwriting in children is caused by poor coordination and inadequate visual-motor skills.
1308 I.-H. Shen et al. / Research in Developmental Disabilities 33 (2012) 1301–1309

However, in view of the small sample sizes in this study, the reported results would need to be replicated with larger samples
in the future. Besides, due to the small sample sizes, it is not possible to distinguish among ADHD subtypes.

5. Conclusion

The present study provides new evidence on handwriting performance and underlying factors in ADHD children without
DCD, using standardized evaluation tools and an objective computerized tablet. In brief, children with ADHD performed
poorer than controls on handwriting quality and quantity, characterized by illegible writing product and slow execution
process. As to underlying factors, children with ADHD scored lower significantly on tasks demanding upper limb and eye–
hand coordination and visual-motor integration compared with controls. Motor skill and visual-motor integration were
positively correlated with the legibility. Moreover, motor skill was negatively correlated with writing time, on-paper time,
in-air time, and in-air trajectory. Therefore, ADHD children without DCD are still affected by substantial motor problems and
inefficient visual-motor skill that warrant further assessment and treatment in school to overcome handwriting problems.

Conflict of interest statement

The authors declare no conflict of interest.

Acknowledgements

We are grateful to the children and their parents for their participation in this study. The work presented in this
manuscript is supported by a research grant from the National Science Council of the Republic of China, Grant No. NSC 98-
2511-S-182-004-MY2. The authors would like to thank two anonymous reviewers for helpful comments on an earlier
version of this manuscript.

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