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Validation of the Concise Assessment Scale for Children’s Handwriting (BHK) in an Italian Population

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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 Handwriting (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 difficulties. The present study confirms that sex influences total BHK quality score, while school level influences handwriting speed.
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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,
223. https://doi.org/10.3390/
children10020223
Academic Editors: Caroline Jolly and
Jérémy Danna
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://
creativecommons.org/licenses/by/
4.0/).
children
Article
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
*Correspondence: barbara.caravale@uniroma1.it
Abstract:
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
1. Introduction
Children spend an average of 31 to 60% of their school time performing handwrit-
ing and other fine motor tasks [
1
]. 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 [
2
,
3
]. Handwriting is indicated as
an important school readiness skill and a predictor of the academic success [
4
6
], and it
can be included among the core symptoms of the developmental coordination disorder
(DCD) [
7
,
8
], with potential consequences in the academic progress, emotional well-being,
and social functioning of the individual [
9
11
]. In fact, according to the DSM 5 [
8
], 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 [
12
14
]. Moreover, handwriting difficulties affect daily living activities [
15
]
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 [
16
], being frequently considered the reason for
referral to occupational therapy [
1
,
17
] and task-based training [
18
]. 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) [
19
], 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,
with
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) [
20
],
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
suggest-
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 [21].
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
countries [
1
,
3
,
4
,
9
,
19
,
22
26
]. 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 [
22
]; 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. [
24
]. 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) [
22
]. The psychometric properties of the
BHK were investigated by extensive research, and the scale was also adapted and validated
for the French school population [
27
]. 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 [
28
]. 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
school [
29
]. 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) [
30
], 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 [
31
]; global methods (without explicitly sequencing the movement of
the letters) are widespread [32].
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 [
33
] 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 [
34
], distinguishing
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 [
24
] or ambiguous
handwriting [
34
]. 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
4322 students
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 [
35
]. 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.
2.3. Measures
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 [
33
]. The Italian copying text
adaptation maintains the original design of the Dutch version [
22
]. 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 [24].
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’
λ
(lambda) and with Rao’s
ρ
(rho) tests. Furthermore, MANOVA test
for general variance and ANOVA were performed. Significant difference was assessed for
p< 0.05.
3. Results
3.1. Sample
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.
Grade
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.
Moreover, Wilks’
λ
and Rao’s
ρ
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
dependent variables.
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,
p= 0.000029.
No consistent differences were found for grades, and neither was consistent interaction
was observed.
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 [
30
]. Therefore,
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 [
26
], 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 [
23
,
32
] reported an increase in handwriting speed as the grades progressed
(Table 6).
Table 6.
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 [30].
4. Discussion
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 [
22
,
24
]. 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 [
27
]. 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
samples [7,15,16,27,29,36].
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 [
23
], 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 [
24
]. The French
validation of the tool [
27
] 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) [
24
], 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
non-proficient writers.
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 [
27
,
29
,
36
].
Speed values reported in this study in the BHK Italian sample [
33
], French sample [
27
], and
Dutch sample [
29
] are compared with the writing speed of BVSCO [
28
] in subtests “le”,
“uno”, and “numeri” (Figure 1).
Children 2023, 10, x FOR PEER REVIEW 8 of 10
295
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 [24] 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 [32]. 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) [19], or in place of other tests such as the 320
Developmental Test of Visual–Motor Integration (VMI) [20], which has proved to be in- 321
adequate as a screening tool for children’s writing problems [24]. 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 [37]. 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
Figure 1.
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 [
24
] 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.
5. Conclusions
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 [
32
]. Thus,
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) [
19
], or in place of other tests such as the Develop-
mental Test of Visual–Motor Integration (VMI) [
20
], which has proved to be inadequate
as a screening tool for children’s writing problems [
24
]. 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 [
37
].
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.
Author Contributions:
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
corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.
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... where grapheme NS,class and NS,class are respectively the mean and standard deviation in number of graphemes produced in the NS group in the same class and trimester. 3 If the inequality is satisfied, the child's overall handwriting performance graphme child < grapheme NS,class − 2 NS,class The BHK test is the Italian standardized version of the original Dutch "Beknoptebeoordelingsmethode voor kinderhandschriften: BHK" (Hamstra-Bletz et al., 1987) assessing presence/absence of dysgraphia in children between second and fifth grade (Di Brina & Rossini, 2010;Loizzo et al., 2023). In the BHK children are asked to copy within five minutes as much as they can of a 28-line text shown to them on a printed sheet and composed of phrases with progressive level of difficulty. ...
... where OPS NS,G and σ NS,G are respectively the average and standard deviation of the OPS measured for the NS data considering the same gender of the child. 4 The handwriting is judged 'inadequate', or dysgraphic, when OPS' ≤ − 1.5; in all other cases it is considered 'adequate' (Di Brina & Rossini, 2010;Loizzo et al., 2023). ...
... Measuring handwriting speed has always been considered relevant in primary school from early studies onwards (Ayres, 1912;Freeman, 1914;Graham et al., 1998) as testified also by numerous tests focusing on this parameter in multiple languages/writing styles (e.g., the Flemish, French and German BHK tests, the Flemish test for writing speed, the Minnesota Handwriting Assessment, the Handwriting Speed Test, the Detailed Assessment of Speed of Handwriting) (Simons & Probst, 2014). However, while multiple studies in different languages have shown that cursive handwriting speed progressively increases with each grade paralleling growth in skill acquisition (Gosse et al., 2021;Hamstra-Bletz & Blöte, 1993;Loizzo et al., 2023;Phelps et al., 1985;Ziviani, 1996), some authors have underscored that this increase may not always be linear (Blöte and Hamstra-Bletz 1991). Graham and colleagues' (1998) analysis of handwriting speed in children from first to ninth grade in the USA (using print, cursive and mixed handwriting), shows that both girls and boys become gradually faster during the first years of primary school, but plateau between fourth and fifth grade (Graham & Weintraub, 1996;Graham et al., 1998). ...
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A growing number of primary school students experience difficulties with grapho-motor skills involved in handwriting, which impact both form and content of their texts. Therefore, it is important to assess and monitor handwriting skills in primary school via standardized tests and detect specific grapho-motor parameters (GMPs) which impact handwriting legibility. Multiple standardized tools are available to assess grapho-motor skills in primary school, yet little is known on between-test agreement, on impact of specific GMPs on children’s overall performance and on which GMPs may be specifically hard to tackle for children that are starting to consolidate their handwriting skills. These data would be extremely relevant for clinicians, therapists and educators, who have to choose among different assessment tools as well as design tailored intervention strategies to reach adequate performance on different GMPs in cases of poor handwriting. To gain better understanding of currently available standardized tools, we compared overall performance of 39 Italian primary school children (19 second graders and 20 third graders) experiencing difficulties with handwriting on three standardized tests for grapho-motor skills assessment and explored the impact of individual GMPs on child performance. Results showed some agreement between tests considering all children in our sample, but no agreement in second grade and only limited agreement in third grade. Data also allowed highlighting significant correlations between some GMP scores and children’s overall performance in our sample. Finally, children in our sample appeared to experience specific difficulties with some GMPs, such as letter joins and alignment.
... The subjective methods present articles assessing children's graphonomy only through rater-administered assessments. The articles in the Table 2 have been evaluated on tasks with BHK [2,42], DASH [3,28,58], EGWA [38], Handwriting Legibility Scale (HLS) [3], Head-Toes-Knees-Shoulders (HTKS) [11], Instructional activities for early writing improvement (IAEWI) [40], Indicadores de Progreso de Aprendizaje en Escritura (IPAE) [30,40], Just Write! (JW) [6], Perceive, Recall, Plan and Perform (PRPP) [45], Standardized Test for the Evaluation of Writing with the Key-board (TEVET) [38], VMI [6] and Wechsler Objective Language Dimensions (WOLD) [45]. ...
... time [58]. The number of participants in these studies highlights one study with 4,950 [72], but most groups range from 150-738 [2,3,11,28,30,40,42]. ...
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Handwriting is a complex task that involves the coordination of motor, perceptual and cognitive skills. It is a fundamental skill for the cognitive and academic development of children. However, the technological, and educational changes in recent decades have affected both the teaching and assessment of handwriting. This paper presents a literature review of handwriting analysis in children, including a bibliometric analysis of published articles, the study participants, and the methods of evaluating the graphonometric state of children. The aim is to synthesize the state of the art and provide an overview of the main study trends over the last decade. The review concludes that handwriting remains a fundamental tool for early estimation of cognitive problems and early intervention. The article analyzes graphonometric evaluation tools. Likewise, it reflects on the importance of graphonometric evaluation as a means to detect possible difficulties or disorders in learning to write. The article concludes by highlighting the need to agree on an evaluation methodology and to combine databases.
... The interrater reliability was between 0.82 and 0.93 for writing speed and between 0.42 and 0.63 for writing quality. 37 The correlation between the BHK and the De Ajurlaguerra Dysgraphia Scale 38 is reported to be 0.78. 37,39 The SOS ...
... 37 The correlation between the BHK and the De Ajurlaguerra Dysgraphia Scale 38 is reported to be 0.78. 37,39 The SOS ...
Article
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... The subjective methods present articles assessing children's graphonomy only through rater-administered assessments. The articles in the Table 2 have been evaluated on tasks with BHK [2,42], DASH [3,28,58], EGWA [38], Handwriting Legibility Scale (HLS) [3], Head-Toes-Knees-Shoulders (HTKS) [11], Instructional activities for early writing improvement (IAEWI) [40], Indicadores de Progreso de Aprendizaje en Escritura (IPAE) [30,40], Just Write! (JW) [6], Perceive, Recall, Plan and Perform (PRPP) [45], Standardized Test for the Evaluation of Writing with the Keyboard (TEVET) [38], VMI [6] and Wechsler Objective Language Dimensions (WOLD) [45]. The Movement Assessment Battery for Children-2 (MABC-2) [58] was included to assess the motor status of the participants. ...
... time [58]. The number of participants in these studies highlights one study with 4,950 [72], but most groups range from 150 -738 [2,3,11,28,30,40,42]. ...
Chapter
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Handwriting is a complex task that involves the coordination of motor, perceptual and cognitive skills. It is a fundamental skill for the cognitive and academic development of children. However, the technological, and educational changes in recent decades have affected both the teaching and assessment of handwriting. This paper presents a literature review of handwriting analysis in children, including a bibliometric analysis of published articles, the study participants, and the methods of evaluating the graphonometric state of children. The aim is to synthesize the state of the art and provide an overview of the main study trends over the last decade. The review concludes that handwriting remains a fundamental tool for early estimation of cognitive problems and early intervention. The article analyzes graphonometric evaluation tools. Likewise, it reflects on the importance of graphonometric evaluation as a means to detect possible difficulties or disorders in learning to write. The article concludes by highlighting the need to agree on an evaluation methodology and to combine databases.
... In contrast, the development of handwriting legibility appears to level off much earlier than writing speed (Gosse et al., 2021;Loizzo et al., 2023). For example, in Graham et al.'s (1998) study, improvements in handwriting legibility were found primarily in the intermediate grades and were then maintained in Grades 7-9. ...
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This study compares the writing skills of students with different socioeconomic statuses, using the quantitative research method designs of “survey study” and “causal-comparative study”. The study group included 67 Turkish teachers and a total of 120 eighth-grade students from four different middle schools in the province of Gaziantep, Turkey, and the study was conducted during the 2016–2017 academic year. The socioeconomic status determination survey was applied to the students in order to ascertain their socioeconomic status. The students’ written texts and the teachers’ responses to the questionnaire were used as the study data. The written expression texts were evaluated by two experts according to the written expression evaluation form. NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) software was used to analyze the data. In the analysis of the data, in addition to descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, and maximum values), Mann-Whitney U test was used for the paired comparison of data which did not display a normal distribution. The results revealed there to be a significant difference between the students with high and low socioeconomic status, in favor of the group with high socioeconomic status in terms of the form, content formation, content organization, word choice, and grammar dimensions of the written expressions. The results failed to show a significant difference between the two groups in terms of the students’ skills in “conducting research on the writing subject” and “building a draft of the text to be written” but did show a significant difference in “evaluating their writing”, in favor of the students with high socioeconomic status.
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Full-text available
Introduction There is substantial evidence to support the relationship between transcription skills (handwriting and spelling) and compositional quality. For children with developmental coordination disorder, handwriting can be particularly challenging. While recent research has aimed to investigate their handwriting difficulties in more detail, the impact of transcription on their compositional quality has not previously been examined. The aim of this exploratory study was to examine compositional quality in children with developmental coordination disorder and to ascertain whether their transcription skills influence writing quality. Method Twenty-eight children with developmental coordination disorder participated in the study, with 28 typically developing age and gender matched controls. The children completed the ‘free-writing’ task from the detailed assessment of speed of handwriting tool, which was evaluated for compositional quality using the Wechsler objective language dimensions. Results The children with developmental coordination disorder performed significantly below their typically developing peers on five of the six Wechsler objective language dimensions items. They also had a higher percentage of misspelled words. Regression analyses indicated that the number of words produced per minute and the percentage of misspelled words explained 55% of the variance for compositional quality. Conclusion The handwriting difficulties so commonly reported in children with developmental coordination disorder have wider repercussions for the quality of written composition.
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Research on the use of speed, as an indicator of motor handwriting problems, is controversial and the legibility of the text is the measure mostly examined in children. This case-control study compared handwriting legibility and speed in 25 children with Developmental Coordination Disorder (DCD) and 75 typically developing peers matched by school grade (third and fourth grade). Children with DCD achieved significantly lower scores than their peers in both legibility and speed measures, overall and in the third and in the fourth grade independently. These measures represent a good insight into children’s writing abilities and could be both used to screen and monitor.
Article
Aim This study aimed to examine the differences in developmental skills between children with and without handwriting difficulties in their last year of kindergarten education. Methods Standardised tests on handwriting performance and developmental skills were administered to 20 typically developing children, 21 children with handwriting difficulties in Chinese and 23 children with handwriting difficulties in both Chinese and English. We used one‐way MANOVA, univariate ANOVA and post hoc comparisons, to compare the developmental skills between children with and without handwriting difficulties. Multiple regression analysis was used to identify the significant predictors of developmental skills for Chinese and English handwriting performance. Results Higher proportion of children faced handwriting difficulties in Chinese than in English. Their major problem in Chinese handwriting was on stroke formation, while the results did not indicate the key factor leading to English handwriting difficulties. The results also showed that children with handwriting difficulties had significantly poorer visual motor integration, some aspects of visual perception and fine motor skills than typically developing children. Reading skills were not a key factor contributing to handwriting performance. In addition, visual and fine motor integration and spatial relationship were the significant predictors of Chinese and English handwriting performance, which accounted for 39.7 and 43.6% of the variance respectively. Conclusion First, the results suggested that more resources should be devoted to coaching children to learn Chinese than English handwriting. Second, besides direct repetitive practice on handwriting, there is a need to incorporate learning activities to facilitate the development of visual motor skills, visual perception, and fine motor skills as a preparation for learning to write or in improving handwriting performance among kindergarten children.
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Handwriting is one of the most complex skills that is learnt and taught. It requires motor, sensory, perceptual, praxis and cognitive functions, and the integration of these functions. When the complex nature of this skill is considered, it comes as little surprise that many children experience difficulty in mastering this area. When an occupational therapist observes that a child referred to the service is having difficulty with handwriting, it becomes necessary for the therapist to administer procedures to identify the strengths and weaknesses that will then become the basis for a remedial programme. This article presents a conceptual framework for evaluating and treating handwriting difficulties presented by children in mainstream education with specific developmental disorder, such as dyspraxia or dyslexia. The performance components and functional performance of handwriting are briefly reviewed. Both evaluation and intervention procedures are discussed in order to guide the therapist in developing remedial and instructional programmes. The article highlights the unique role of the occupational therapist in evaluating and treating a child's functional performance of handwriting skills.
Article
-Evidence suggests that task-based training approaches can improve the performance of children with handwriting difficulties. The present case study tests the efficacy of the Handwriting Task Program (HTP). Three male children (9-10 yr. old) with poor handwriting skills and different developmental disorders participated in the HTP, twice per week, for 13 wk. Handwriting legibility was assessed through the Concise Evaluation Scale for Children's Handwriting, and fine motor performance and handwriting speed were evaluated at pre- and post-treatment with the Visual Motor Integration Test and the Battery for the assessment of writing skills of children from 7 to 13 yr. old. The results showed that motor efficiency and global handwriting quality improved in all the children, although some handwriting difficulties still persisted in one child with Developmental Coordination Disorder (DCD). Further study may confirm on a larger sample that a visual-spatially based training may improve the handwriting legibility of children with DCD.