Article Critique

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Article Critique

• Effectiveness of School-Based Occupational
  Therapy Intervention on Handwriting

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Case-Smith, J. (2002). Effectiveness of
school-based occupational therapy
intervention on handwriting. American
Journal of Occupational Therapy, 56, 17-
25.
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Purpose

• To study the impact of occupational therapy
  intervention on handwriting in children and on
  other school activities.

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Hypotheses

• Compared with a control group of students with
  poor handwriting who do not receive occupational
  therapy, will students with poor handwriting who
  receive occupational therapy services make
  greater improvements in visual-motor skill,
  visual-perception skill, dexterity, in-hand
  manipulation skills, legibility, and handwriting
  speed?
• Will students with poor handwriting who receive
  occupational therapy services demonstrate
  statistically significant improvement over the
  course of the school year in school functions
  associated with visual-motor and manipulative
  skills?
• (Case-Smith, 2002, p. 18)

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Literature Review

• Handwriting is a primary reason for school system
  referral to occupational therapy
• Problems associated with poor hand writing
• Associated components of handwriting demonstrated
  to be problematic - visual-motor skills, in-hand
  manipulation skills
• OT interventions for handwriting skills -
  biomechanical interventions from Benbow and
  others, sensory integrative components -
  (Amundson, 2001 Cermak, 1991)
• Compensatory approaches to handwriting (computer)

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Sample

• Recruited from 5 school districts in central Ohio
• Teacher identification of students with
  handwriting problems
• 43 second, third and fourth grade students (see
  Table 1)
• (31 with intervention, 13 without)
• None with diagnosed medical conditions
• Informed consent from all
• Comparison group older, more second and third
  graders, slightly more males, primarily
  Caucasian, varied diagnoses (LD, ED, DD)

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Were the groups comparable?What about the
students who didnt receive therapy - why not??
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Outcomes Measures

• Visual perception
• Visual motor skills
• In-hand manipulation
• Handwriting
• Using materials and written work

• Subtests of the Developmental Test of Visual
  Perception
• Subtests of the BOTMP
• Components of in-hand manipulation using the 9
  hole peg board test
• ETCH
• Subtests of the School-based Function Assessment

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Reliability and Validity

• Reliability and validity reported for the DTVP,
  BOTMP, reliability for the ETCH, and SFA
• In-hand procedures described in earlier
  Case-Smith studies but no reliability or validity
  studies
• ??? Process of using subtests rather than the
  whole battery use of subtests negates
  reliability and validity studies

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Frequency of Outcomes Assessment

• Assessments were carried out pre and post
  intervention pre-intervention measures taken in
  September/October of 1998/1999 and 1999/2000
• Post intervention measures taken in April-May of
  1998/1999 and 1999/2000

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Intervention

• All students receiving intervention received
  regular direct intervention (approx. 30 min per
  week on the IEP)
• Records kept of each session - duration,
  frequency, goals, group vs. individual
  intervention, type of activities
• Mean time of session interventions and overall
  summed times calculated
• Frequency of the following parameters were
  calculated - sessions, goals, activities, and
  service delivery models

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Follow-up interviews were held with all treating
therapists to clarify issues in the data.
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Could you replicate this study easily?
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Results

• Performance Components
• Means comparison given for IG students only
• IG made significant changes in 2 DVPT subtest and
  in-hand manipulation
• ANOVA indicates that significant IG group changes
  over CG were seen in visual-motor control and
  in-hand manipulation

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Table 2. Means and Standard Deviations for the
Visual-Motor, Manipulation and
Visual- Perceptual Measures  
Intervention Group Comparison Group
Pretest Posttest
Pretest Posttest Performance Component
M (SD) M (SD)
M (SD) M
(SD)   BOTMP visual-motor 9.14
(5.4) 11.25 (6.3) 15.44
(4.8) 16.78 (5.5) BOTMP speed
and dexterity 11.15 (5.8) 11.16 (5.5)
12.89 (5.7)
10.89 (5.4) DTVP position in space
6.78 (2.9) 7.93 (3.3)
7.88 (2.9)
8.50 (1.9) DTVP figure group
8.30 (3.2) 8.85 (2.7)
10.5 (2.8)
9.62 (3.0) DTVP copying
8.21 (2.2)
8.44 (2.4) 9.0
(2.4) 10.22 (2.4) In-Hand
manipulation 25.65 (8.8)
19.9 (3.4) 20.12
(3.9) 16.49 (3.1)
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Results

• Handwriting and School Function Results
• The only significant change was in the IG, which
  made significantly more improvement in total
  percentage of legible letters.

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Drop-outs

• 38 of 44 students completed all testing
  procedures (29 getting intervention, 9 in the
  control group)
• two students (IG) dropped because they developed
  neurological problems
• 4 students (CG) never finished testing - 1
  student expelled from school, 2 referred for OT,
  1 not available for testing.

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Data lost on an additional 4 students in the IG
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Interesting Features

• t test outcomes on CG never shown
• Author and 4 OTs completed the testing
• The author did most of the testing
• The testers were not blinded.
• Other school interventions received by either
  group were not recorded (PT, resource room)
• Maturation addressed by using standardized scores

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Clinical Importance

• Were significant differences really significant??
• Most important aspect of this study (my opinion)
  was the information on practice amount and type
  of intervention, amount of communication between
  therapist and teacher

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Conclusions

• Students with intervention improved most in
  handwriting letter legibility
• Need for study of specific interventions for
  handwriting
• No discussion of changes seen in the control
  group
• Is the time and effort spent on increasing
  handwriting worth it???