Citation: Loizzo, A.; Zaccaria, V.;
Caravale, B.; Di Brina, C. Validation
of the Concise Assessment Scale for
Children’s Handwriting (BHK) in an
Italian Population. Children 2023,10,
Academic Editors: Caroline Jolly and
Received: 31 December 2022
Revised: 19 January 2023
Accepted: 25 January 2023
Published: 27 January 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
Validation of the Concise Assessment Scale for Children’s
Handwriting (BHK) in an Italian Population
Annalivia Loizzo 1, Valerio Zaccaria 2, Barbara Caravale 3,* and Carlo Di Brina 2
1Centro di Riabilitazione Didasco, Via Pescosolido 160, 00158 Rome, Italy
2Department of Human Neurosciences, Sapienza University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
3Department of Developmental and Social Psychology, Sapienza University of Rome, Via dei Marsi 78,
00185 Rome, Italy
Handwriting difﬁculties represent a common complaint among children and may cause a
signiﬁcant delay in motor skills achievement. The Concise Assessment Scale for Children’s Hand-
writing (BHK) assesses handwriting skill in clinical and experimental settings, providing a quick
evaluation of handwriting quality and speed through a copying text. The aim of the present study
was to validate the Italian adaptation of the BHK in a representative primary school population.
Overall, 562 children aged 7–11 from 16 public primary schools of Rome were included and asked
to copy a text in 5 min using cursive handwriting. Handwriting quality and copying speed were
measured. The included population followed a normal distribution for the BHK quality scores. Sex
inﬂuenced the total quality scores, whereas school level inﬂuenced the copying speed. The BHK
quality score was higher in girls (p< 0.05) and resulted as a stable parameter along the school years,
without signiﬁcant variations with regard to the years spent in handwriting exercise (p= 0.76). The
handwriting speed was inﬂuenced by school level, and signiﬁcant differences were found for each of
the grades from the second to the ﬁfth (p< 0.05), but not for gender (p= 0.47). Both BHK measures
represent a helpful tool for the characterization and assessment of children with handwriting difﬁ-
culties. The present study conﬁrms that sex inﬂuences total BHK quality score, while school level
inﬂuences handwriting speed.
Keywords: BHK; handwriting skills; handwriting difﬁculties; primary school children
Children spend an average of 31 to 60% of their school time performing handwrit-
ing and other ﬁne motor tasks [
]. Difﬁculties in ﬁne motor tasks represent a common
complaint among children in the general school population, and 11–12% of female stu-
dents and 21–32% of male students are estimated to have handwriting difﬁculties, with
a global prevalence of 10–34% of school-aged children [
]. Handwriting is indicated as
an important school readiness skill and a predictor of the academic success [
], and it
can be included among the core symptoms of the developmental coordination disorder
], with potential consequences in the academic progress, emotional well-being,
and social functioning of the individual [
]. In fact, according to the DSM 5 [
], the DCD
includes among its diagnostic criteria the delayed acquisition of motor milestones, with
clumsiness, slowness, and inaccuracy in the performance of motor skills, both on the gross
motor side and on the ﬁne motor side. In addition, this motor skills deﬁcit starts in the
developmental age, and it signiﬁcantly interferes with daily living activities. However, the
DSM 5 does not discriminate between different subtypes of DCD, although individuals
could be predominantly impaired in the gross motor skills as well as in ﬁne motor skills,
such as handwriting, which seems to have a predictive validity with respect to the diagnosis
of DCD itself [
]. Moreover, handwriting difﬁculties affect daily living activities [
Children 2023,10, 223. https://doi.org/10.3390/children10020223 https://www.mdpi.com/journal/children
Children 2023,10, 223 2 of 10
and persist noticeably into adulthood [
], being frequently considered the reason for
referral to occupational therapy [
] and task-based training [
]. Therefore, handwriting
competence is commonly affected in these children, with frequent repercussions on the
legibility and speed of written texts. Furthermore, handwriting has proven to be remark-
ably discriminative in children at risk of DCD at the Movement Assessment Battery for
Children-2 (MABC-2) [
], which was validated in children aged 4–12 years and is currently
considered the gold standard assessment tool used to identify impairments or delays in
motor development. In particular, the MABC-2 includes 24 subtests and three domains
(manual dexterity, balls skills, and balance). Results are usually interpreted as percentiles,
5 percentile pinpointing a deﬁnite motor impairment, whereas
15 percentile sug-
gests a borderline motor impairment. Another assessment instrument employed in clinical
and research settings is the Developmental Test of Visual–Motor Integration (VMI) [
which provides information about the visual and motor abilities of the subject, being consid-
ered a useful screening tool for DCD. In particular, the VMI contains three subtests oriented
to explore different aspects of the symptom: visual motor integration, visual perception,
and motor coordination. Results are interpreted as percentiles,
with ≤5 percentile
ing a clinical impairment which is worthy of a deeper evaluation. However, these tests
explore primarily and almost exclusively gross motor skills; thus, other motor competences
such as handwriting should be assessed separately through different standardized and
psychometrically sound measures .
In order to assess handwriting skill in clinical practice and in experimental settings,
the Concise Assessment Scale for Children’s Handwriting (BHK) is often used in a few
]. It represents an analytic scale that provides a quick evaluation
of handwriting quality and speed through a copying text. It can be used as a screening
tool, as well as a diagnostic test. Instructions and normative values are derived from the
Dutch original version [
]; references for normative values on quality of handwriting are
available for children in grade two (age 7–8 years) and three (8–9 years), while references
on speed are available for all grades. [
]. The Dutch norms for writing speed derived
from handwriting samples collected from 895 school children in ﬁrst to sixth grade (ages
roughly ranging between 78 and 150 months) [
]. The psychometric properties of the
BHK were investigated by extensive research, and the scale was also adapted and validated
for the French school population [
]. Other diagnostic tools are available in Italian for
the assessment of handwriting skills, but they usually do not assess handwriting quality
and investigate only writing speed. For example, the BVSCO explores writing speed of
disyllables, single words, and numbers [
]. Furthermore, the BHK is preferred to the
BVSCO due to its good psychometric properties, which were widely investigated in the
literature, along with differences between boys and girls in handwriting quality and the
deterioration of the form aspects of writing along the different grades of the primary
]. Moreover, in contrast to other tools, the BHK explores both handwriting quality
and speed, and it is used in different languages and teaching methods, and, therefore, is
able to be used extensively in clinical and research settings. A short version is the Systematic
Screening for Handwriting Difﬁculties Test (SOS) [
], for which, however, sensitivity and
speciﬁcity should also be investigated.
French students have l’ecriture cursive in their curriculum; the handwriting teaching
method in this country involves the use of special papers with grids to ensure students keep
their writing straight and at the right height and size. The Dutch handwriting teaching
method plans the explicit sequencing of each letter movement, with the use of visual
prompts such as the trafﬁc light colors. The letter tracing is guided from the starting point
(the green light) until the stop point (red light). Conversely, there are no clear guidelines
regarding the timing and method for teaching handwriting in primary schools in Italy, the
calligraﬁa is no longer in the curriculum of Italian students and teachers are free to choose
different techniques [
]; global methods (without explicitly sequencing the movement of
the letters) are widespread .
Children 2023,10, 223 3 of 10
Considering the differences that are likely to occur between the Dutch, the French, and
the Italian teaching methods in handwriting, the aim of the present study was to validate
the Italian adaptation of the BHK [
] in a representative primary-school population in
order to gather handwriting parameters values and provide Italian norms, comparing them
with Dutch and French ones. The BHK demonstrated to be suitable for describing changes
in the handwriting characteristics during the intervention monitoring [
between skilled writers and poor hand writers, but it has a broad borderline range. Previous
authors labeled scores between 22 and 29 as at risk of poor handwriting [
] or ambiguous
]. Secondly, the present study was aimed at exploring the distribution
scores of the general population in order to suggest a cut-off score which allows through
Z-scores for a better understanding of the level of impairment of the individuals in relation
to the mean performances on the scale.
2. Materials and Methods
2.1. Study Design and Participants
The present cross-sectional study was conducted by physicians and other healthcare
professionals, such as neuropsychomotor therapists of the developmental age. We ran-
domly selected the 13.7% of the total children population of an area of Rome counting
attending the primary school; 16 public primary schools were identiﬁed
out of a total of 22 in one of the largest municipalities of Rome (XX municipality), which
includes both inner city and outskirts. Thus, this area was considered to be sufﬁciently
representative of the socio-economic status (SES) of the population of Rome, since some
studies showed that writing skills may be inﬂuenced by SES [
]. Children attending
the second to ﬁfth grade classes of primary school, with an age range between 7 and
11 years old
, were included in the study whether they met the following inclusion criteria:
(a) at least two years of schooling in Italy; (b) ability to write in cursive; and (c) ability of
producing a text at least ﬁve lines long. We excluded from the sample students attending
the ﬁrst-grade class of primary school with the aim of avoiding the effect of factors related
to practice and to the early stages of the learning of the written language. Seven to eight
classes for each grade level were randomly selected and entirely assessed. The number of
the selected classes was determined in proportion to the number of classes present in the
districts and in the respective schools to which they belonged, and the classes were selected
according to a simple random design.
2.2. Informed Consent and Ethical Approval
All the followed procedures were in accordance with the ethical standards of the
responsible committee on human experimentation, as well as with the Helsinki Declara-
tion (1975, revised in 2008). The study was approved with the Prot. Number P-434-13
(30 October 2013) of the Pediatrics and Child Neuropsychiatric Department of Rome. The
parents of all children enrolled in the study were informed about the research project by
researchers and teachers through organized meetings at school and explanatory leaﬂets,
and they provided their written informed consent.
Children’s task was to copy a text using cursive handwriting, within a time limit
of 5 min, at the rate at which they usually wrote. Black roller pens were distributed in
order to control the possible writing instrument bias. We excluded texts written in block
letters and those less than ﬁve lines long. These handwriting samples were collected in
May, at the end of the school year. Handwriting was tested with the Italian version of
the Concise Assessment Scale for Children’s Handwriting [
]. The Italian copying text
adaptation maintains the original design of the Dutch version [
]. It is in fact designed
with a structure of increasing complexity: the ﬁrst 5 lines contain simple monosyllabic
words that children met in ﬁrst grade; then, the text becomes more challenging, and
the size of the letters decreases. The entire adaptation procedure was approved by the
Children 2023,10, 223 4 of 10
developer (Dr. Hamstra-Bletz, personal communication, January 2008). Back translation
was not considered necessary due to the low effect of the meaning of words in the copy
task. The handwriting task is to copy a text in 5 min on an unprinted A4 sheet. Four
neuropsychomotor therapists of the developmental age trained in the scale administration
procedures performed a copy test in group sessions. The same operators, after a few
meetings aimed at homogenizing the evaluation criteria and establishing a consensus
around each parameter of the scale, proceeded to evaluate the individual copy tests.
The BHK quality is evaluated through 13 parameters scoring from 0 to 5
(total score 0–65)
according to legibility. The 13 parameters are: (1) letter size, (2) left-hand margin, (3) word
alignment, (4) word spacing, (5) acute turns in joins or letters, (6) irregularities in joins, (7)
collision of letters, (8) inconsistent letter size, (9) incorrect relative height of letters, (10) odd
letters, (11) ambiguous letter forms, (12) correction of the letters, and (13) unsteady writing trace.
Three categories of writers were deﬁned in the original BHK guidelines: children
with a total score of 29 or higher are classiﬁed as non-proﬁcient writers, those with a total
score between 22 and 28 as at-risk writers, and children with a total score of 21 or less are
classiﬁed as proﬁcient writers .
On the other hand, BHK speed is calculated by counting the number of letters written
in 5 min, excluding punctuation marks and including letters that have been erased. Four
child therapists skilled in motor development assessments were speciﬁcally trained on BHK
procedures in order to homogenize evaluation criteria on writing samples and ameliorate
the agreement among them.
2.4. Statistical Analysis
Data were analyzed with SAS v9.1 Statistical Package. Descriptive statistics were used
to describe the sample population according to school level and gender. Internal consistency
and test–retest reliability were calculated. Uniformity of circular (“directional”) data was
assessed with Wilks’
(lambda) and with Rao’s
(rho) tests. Furthermore, MANOVA test
for general variance and ANOVA were performed. Signiﬁcant difference was assessed for
Overall, 594 children from 31 classes were enrolled in the study. Thirty-two partici-
pants (5.3%) used block letters or produced a sample shorter than ﬁve lines, and thus were
excluded from the study. A total of 562 written samples were therefore analyzed. Children
had a mean age of 9.3 years (SD 1.0; range 7.3–11.1); eight children (1.4%) had special needs
and required a supporting teacher. Distribution of the sample is reported in Table 1. The
Shapiro–Wilk Test was performed to assess the normal distribution of BHK quality scores,
with a value of 0.979, compatible with a Gaussian distribution.
Table 1. Number of children of the sample divided for grade level and gender.
Male N (%) Female N (%) Total N
2nd 73 (55) 59 (45) 132
3rd 57 (48) 62 (52) 119
4th 81 (52) 74 (48) 155
5th 72 (47) 84 (53) 156
Total 283 (50) 279 (50) 562
Internal consistency was calculated over the whole sample of 562 children, whereas
test–retest reliability among the four evaluators was calculated considering only 144 writing
pieces randomly selected and independently evaluated by each therapist.
Children 2023,10, 223 5 of 10
At ﬁrst, the reliability of the technicians’ scores was tested. Therefore, Kendall’s
correlations for all pairs of technicians were performed for both parameters (BHK quality
and BHK speed scores), and the results showed a sufﬁcient to high concordance among
technicians. Inter-rater reliability obtained through Kendall test was between 0.82 and 0.93
for writing speed, and between 0.42 and 0.63 for writing quality.
tests were performed for the uniformity of circular data
(Table 2) and a MANOVA (multivariate analysis of variance) was applied, treating level and
gender as independent variables and BHK quality and BHK speed as
Table 2. General evaluation of the sample.
EFFECT Wilks’ λRao’s ρdF 1 dF 2 p-Level
Class 0.545400 65.14954 6 1104 0.000000 *
Gender 0.968243 9.05249 2 552 0.000135 *
1, 2 0.995753 0.39194 6 1104 0.884502
Note: 1 is for class; 2 is for gender; Wilks’ λ(lambda); Rao’s ρ(rho). * indicates signiﬁcant differences.
P levels were highly signiﬁcant (p< 0.00014); thus, the reliability of data was accepted
and MANOVA was performed for both genders for each one of the two parameters,
i.e., number of graphemes and BHK score.
3.2. Handwriting Quality (BHK Quality)
We obtained that 21.6% of the sample was classiﬁed as borderline/at-risk writer. The
10% (weighted value) of the sample is over the cut-off score of 29; these children (n = 56)
are classiﬁed as non-proﬁcient writers.
Table 3describes the results of MANOVA performed on handwriting quality for
genders and grades.
Table 3. Handwriting quality (BHK quality): General MANOVA.
dF MS dF MS
EFFECT EFFECT EFFECT ERROR ERROR F p-Level
1 3 75.97 553 41.76 1.819 0.1425
2 1 743.16 553 41.76 17.796 0.000029 *
1, 2 3 16.11 553 41.76 0.386 0.7632
Note: 1 is for grade; 2 is for gender. * indicates signiﬁcant differences.
The effect of the variable gender on the handwriting quality was checked.
This analysis evidenced consistent differences for genders F (3.553) = 17.796,
No consistent differences were found for grades, and neither was consistent interaction
BHK quality mean cumulative values were 20.3 with a standard deviation of 6.1 for
boys, whereas they were 18.1 with a standard deviation of 6.7 for girls (Table 4).
Table 4. BHK quality mean values by gender.
Total Males Females
Mean 19.3 20.3 18.1
SD 6.5 6.1 6.7
Note: SD: Standard Deviation.
Scores which stood one SD and a half above the mean (SD
1.5) were considered
indicative of a poor handwriting quality, and thus used as cut-off values [
the BHK quality cut-off values were 29.45 for boys and 28.15 for girls.
Children 2023,10, 223 6 of 10
3.3. Copying Speed (BHK Speed)
Results of MANOVA performed on handwriting speed for genders and grades
are shown in Table 5. The analysis indicated signiﬁcant differences for school level:
F (3.553) = 150.15; p< 0.00001.
Table 5. Copying speed (BHK speed): General MANOVA.
dF MS dF MS
EFFECT EFFECT EFFECT ERROR ERROR F p-Level
1 3 531,550 553 3,540,189 150.14 0.000000 *
2 1 1822.4 553 3,540,189 0.5148 0.4733
1, 2 3 1448.9 533 3,540,189 0.4093 0.7464
Note: dF = degrees of Freedom, MS = Mean Squares; 1 is for grade; 2 is for gender. * indicates significant differences.
No consistent differences were found for gender; no signiﬁcant interaction between
school level and gender was evidenced as well. These analyses showed similar results to
the French study [
], where signiﬁcant differences were obtained for school level as well,
and French girls showed a higher copying speed than boys. Likewise, the Dutch studies on
the argument [
] reported an increase in handwriting speed as the grades progressed
Comparison among the speed in three different versions of the BHK (Italian, French, and
Dutch) for school level.
School Grade BHK It BHK Fr BHK Du
2nd 137.4 118.3 120
3rd 185.2 170.5 175
4th 242.5 224.5 230
5th 276.9 229.1 270
Note: all values are considered for the end of the school year.
Then, we applied the Duncan test to evaluate class differences for the number of
graphemes. According to the Duncan test, all grades were consistently different from other
grades, whereas no consistent differences were found between genders.
The mean number of graphemes cumulated for boys and girls, for each grade, was
137.4 (SD 29.5) for second grade; 185.2 (SD 46.2) for third grade; 242.5 (SD 63.6) for fourth
grade; and 276.9 (SD 80.3) for ﬁfth grade. These values may be considered as indicative for
class level in a normal control population. Scores below one standard deviation and a half
for the grade should be considered indicative of a slow handwriting performance .
Inter-observer reliability can inﬂuence the BHK total score (BHK quality), and therefore
can inﬂuence the ﬁnal judgment on the global legibility of a piece of handwriting; therefore,
performing preliminary consensus sessions on ambiguous voices of the BHK scale can
ameliorate the inter-rater reliability from moderate to good. In a previous study, inter-
rater reliability varied between r = 0.71 and r = 0.94, depending on the grade level and
number of evaluators [
]. For writing speed, the agreement is excellent and does
not require consensus sessions. The included population followed a normal distribution
for the BHK quality scores, as it was shown for the 837 children studied for the French
validation of the scale [
]. The variables of sex and school level both inﬂuenced global
BHK scores (quality and speed). In particular, sex, but not school level, inﬂuenced the
total quality score; conversely, school level, but not sex, inﬂuenced the copying speed.
This means that different normative values should be considered for sex to be used in the
Children 2023,10, 223 7 of 10
correction of a piece of handwriting at school age. Handwriting quality was higher in girls
than in boys. This is consistent with other studies on the subject, on French and Dutch
The results conﬁrmed that the BHK total quality score is a stable parameter along
the school years and does not vary signiﬁcantly with regard to the years spent in the
handwriting exercise, from second to ﬁfth grade. Other authors have observed that gender
affects the quality of writing [
], and that stability of handwriting quality occurs only in
those children whose scores fall within the normal range. In fact, children with proper
writing reached their ﬁnal quality level at the end of ﬁrst grade, while children with
dysfunctional writing can improve signiﬁcantly until second grade [
]. The French
validation of the tool [
] found that school level and age had a signiﬁcant effect on
the BHK quality score; this can be explained by the fact that their sample included also
6- and 7-year-old children (at the beginning of primary school). We excluded from the
sampling these age groups because children with typical development showed a rapid
quality improvement in handwriting during the ﬁrst grade (age 6–7 years old), with a
stability reached by second grader (age 7–8 years old and over) [
], when handwriting had
become more automatic and organized. Differences in the BHK quality scores between our
data and the French sample (boys M = 15.2, SD = 6.6; girls M = 12.5, SD = 4.5) are probably
explained by differences in handwriting teaching methods. The mean and SD values we
obtained for BHK quality in boys and girls allow us to suggest 29 as the cut-off value for
both genders; therefore, children obtaining a total score of 29 or higher are classiﬁed as
The handwriting speed is inﬂuenced by grade, and a signiﬁcant difference for each
of the grades from the second to the ﬁfth was found. These data are to be considered
in the norm referenced correction tables for speed, when child performance is compared
(mean and SD). This ﬁnding is consistent with the previous data on the argument [
Speed values reported in this study in the BHK Italian sample [
], French sample [
Dutch sample [
] are compared with the writing speed of BVSCO [
] in subtests “le”,
“uno”, and “numeri” (Figure 1).
Children 2023, 10, x FOR PEER REVIEW 8 of 10
Figure 1. Comparison among the speed in three different versions of BHK (Italian, French, and 296
Dutch) and the three subtests of the BVSCO (“le”, “uno”, and “numeri”) for school level. 297
These studies described a continuous and somehow linear increase in the writing 298
speed through the second to the fifth grade. The comparison with second- and third-grade 299
Dutch children  reveals a similar speed for the second and third graders (with a higher 300
SD in the Dutch sample). Other instruments that measure the writing speed that are in 301
use in Italy, such as the BVSCO, use a self-dictation of disyllables, single words, and num- 302
bers. Higher speeds shown in this test are probably in relation to a simpler task. 303
The present study confirms that sex influences total BHK quality score (i.e., legibility) 304
and that school level within primary school influences handwriting speed (i.e., fluency). 305
However, this study presents some limitations. A first limitation is the high inter-rater 306
variability which was found in the final BHK quality judgment, despite the use of specif- 307
ically trained evaluators on the BHK scoring procedures; therefore, we underline the im- 308
portance of maximizing the inter-rater consensus regarding BHK quality judgment, 309
through a training among evaluators on ambiguous voices. In any case, a learning period 310
is necessary to master the scoring system involved in final quality judgment. A second 311
limitation of this study is the fact that we did not collect the exact socio-economical status 312
of the students along the sampling, in absence of dedicated anagraphic cards. Conse- 313
quently, the influence of this variable on legibility and speed was not investigated. 314
5. Conclusions 315
The use of both the BHK measures represents a helpful tool in the clinical practice for 316
the characterization and the assessment of children with handwriting difficulties . 317
Thus, the present test could be useful in a developmental evaluation in association with 318
other tools which investigate global and fine motor skills, such as the Movement Assess- 319
ment Battery for Children (Movement-ABC) , or in place of other tests such as the 320
Developmental Test of Visual–Motor Integration (VMI) , which has proved to be in- 321
adequate as a screening tool for children’s writing problems . Therefore, the BHK is a 322
reliable instrument in handwriting evaluation, and it should be considered as part of a 323
larger neuropsychological investigation, as it is recommended for the DCD diagnostic 324
process . Nevertheless, the gold standard of any assessment is in the sum of all data 325
resulting from the neuropsychological testing and the clinical evaluation of the child. 326
Author Contributions: Conceptualization, A.L. and C.D.B.; methodology, C.D.B. and V.Z.; soft- 327
ware, C.D.B., V.Z. and B.C.; validation, C.D.B.; formal analysis, V.Z. and C.D.B.; investigation, A.L. 328
Comparison among the speed in three different versions of BHK (Italian, French, and
Dutch) and the three subtests of the BVSCO (“le”, “uno”, and “numeri”) for school level.
These studies described a continuous and somehow linear increase in the writing
speed through the second to the ﬁfth grade. The comparison with second- and third-grade
Dutch children [
] reveals a similar speed for the second and third graders (with a higher
Children 2023,10, 223 8 of 10
SD in the Dutch sample). Other instruments that measure the writing speed that are in use
in Italy, such as the BVSCO, use a self-dictation of disyllables, single words, and numbers.
Higher speeds shown in this test are probably in relation to a simpler task.
The present study conﬁrms that sex inﬂuences total BHK quality score (i.e., legibility)
and that school level within primary school inﬂuences handwriting speed (i.e., ﬂuency).
However, this study presents some limitations. A ﬁrst limitation is the high inter-rater vari-
ability which was found in the ﬁnal BHK quality judgment, despite the use of speciﬁcally
trained evaluators on the BHK scoring procedures; therefore, we underline the importance
of maximizing the inter-rater consensus regarding BHK quality judgment, through a train-
ing among evaluators on ambiguous voices. In any case, a learning period is necessary to
master the scoring system involved in ﬁnal quality judgment. A second limitation of this
study is the fact that we did not collect the exact socio-economical status of the students
along the sampling, in absence of dedicated anagraphic cards. Consequently, the inﬂuence
of this variable on legibility and speed was not investigated.
The use of both the BHK measures represents a helpful tool in the clinical practice for
the characterization and the assessment of children with handwriting difﬁculties [
the present test could be useful in a developmental evaluation in association with other
tools which investigate global and ﬁne motor skills, such as the Movement Assessment
Battery for Children (Movement-ABC) [
], or in place of other tests such as the Develop-
mental Test of Visual–Motor Integration (VMI) [
], which has proved to be inadequate
as a screening tool for children’s writing problems [
]. Therefore, the BHK is a reliable
instrument in handwriting evaluation, and it should be considered as part of a larger neu-
ropsychological investigation, as it is recommended for the DCD diagnostic process [
Nevertheless, the gold standard of any assessment is in the sum of all data resulting from
the neuropsychological testing and the clinical evaluation of the child.
Conceptualization, A.L. and C.D.B.; methodology, C.D.B. and V.Z.; software,
C.D.B., V.Z. and B.C.; validation, C.D.B.; formal analysis, V.Z. and C.D.B.; investigation, A.L. and
C.D.B.; resources, A.L. and C.D.B.; data curation, V.Z. and C.D.B.; original draft preparation, V.Z. and
B.C.; review and editing, C.D.B. and V.Z.; visualization, C.D.B.; supervision, C.D.B.; project adminis-
tration, C.D.B. and A.L. All authors have read and agreed to the published version
of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
The study was conducted in accordance with the Declara-
tion of Helsinki, and approved by the Ethics Committee of the Pediatrics and Neuropsychiatric
Department of the Sapienza University of Rome (Prot. Code P-434-13–30 October 2013).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
The data presented in this study are available on request from the
Conﬂicts of Interest: The authors declare no conﬂict of interest.
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