Ot Guidelines Child Specific

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO
Clinical Guidelines of
Occupational Therapy to
Children with Specific
Learning Disabilities
Child and Adolescent Working Group,

Occupational Therapy Coordinating Committee,
Hospital Authority
2004
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List of contributors:
Magdalene Poon, Kwai Chung Hospital

Rita Ng, Yaumatei Child Psychiatric Centre
Shiren Wong, Castle Peak Hospital
Sanne Fong, Princess Margaret Hospital
Catherine Fung, Princess Margaret Hospital
Sally Choy, Kowloon Hospital
Pheobe Chan, Kowloon Hospital
Winnie Fok, Tuen Mun Hospital
Rosita Yip, Tuen Mun Hospital
Kitty Lai, Pamela Youde Nethersole Eastern Hospital
Jenet Wan, Northern District Hospital
Rebecca Chan, David Trench Rehabilitation Centre
Phoebe Cheung, Queen Mary Hospital
Linda Yau, United Christian Hospital
Cecilia Leung, Queen Elizabeth Hospital
Barbara Chan, Prince of Wales Hospital
Ingrid Ngan , Prince of Wales Hospital
Carol Chan, Alice Ho Miu Ling Nethersole Hospital
Statement of Intent
This guideline is not intended to be construed or to serve as a standard of medical care. Standards of
care are determined on the basis of all clinical data available for an individual case and are subject to
change as scientific knowledge and technology advance and patterns of care evolve.
These parameters of practice should be considered guidelines only. Adherence to them will not
ensure a successful outcome in every case, nor should they be construed as including all proper
methods of care or excluding other acceptable methods aimed at the same results. The ultimate
judgment regarding a particular clinical procedure or treatment plan must be made in light of the
clinical data presented by the patient and the diagnostic and treatment options available. However it
is advised that significant departures from any local guidelines derived from it should be fully
documented in the patient's case notes at the time the relevant decision is taken.
Co-ordinating Committee in Occupational Therapy, Hospital Authority
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CHAPTER ONE
INTRODUCTION
Specific learning disabilities (SLD) (sometimes referred to as “specific learning difficulties”

and “learning disabilities”) is a generic term that refers to a heterogeneous group of disorders that
covers a variety of disorders in area of spoken and written language, mathematics, perceptual motor
skills and the social and emotional components of learning. It is developmental in nature and may
impact to varying degrees on all aspects of the affected children’s lives at school, at home and at play.
Unless given intervention appropriately and systematically, SLD problems may persist to adulthood
(Scientific Committee of the Working Party on SLD 1999). In Hong Kong, Leong (1999) estimated
that there are about 15% of the students having these problems. Occupational therapists often
encounter these children when they had numerous functional problems in visual perception, writing,
reading, managing academic work and other daily living tasks. The most common SLD subgroup
cases referred for occupational therapy intervention includes developmental dyslexia (DD)
(sometimes written as dyslexia) and developmental coordination disorders (DCD) (also known as
developmental dyspraxia or clumsy child syndrome).
Developmental dyslexia (DD) is the largest SLD subgroup. It refers to children who show
measurably below-age reading and written language development despite average or above-average
intelligence, intact emotional adjustment and instructions. According to ICD 10, DD is included
under the specific reading disorder (World Health Organization 1992). There are about 10 to 20% of
children being affected with specific reading difficulties (Lam 1999). On the other hand, DCD and
developmental dyspraxia refers to children who show inefficiencies in visual, tactile, kinesthetic
and/or vestibular related motor processing. These difficulties can be manifested in either or both fine
and gross motor areas such as balance, postural control and graphomotor skills. In ICD 10, these two
diagnoses are under the branch of specific developmental disorder of motor function (World Health
Organization 1992).
Functional Problem of Children with SLD
Occupational therapists are concerned with the role performance of the children and its related
dysfunction. Children with SLD interfere the most basic and familiar tasks in writing, reading,
playing and activities of daily living. These domains of occupational performance are the scope of
practice of occupational therapy. Specifically, children with DCD are not only unable to complete
some tasks, but also have difficulties in quality of motor production and task completion (Coster and
Haley 1992).
Handwriting and Reading Skills

Handwriting skills are fundamental to children while they learn and study at school. McHale and
Cermak (1992) found that 31 – 60% of the children’s school day consisted of fine motor activities
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and of these tasks, much time was employed in paper and pencil tasks. The prevalence of children
with handwriting problems was 10 – 34% (Rubin & Henderson, 1982; Smits-Engelsman et al., 1995;
2001). Difficulty in mastery of the mechanical aspects of handwriting may interfere with higher
order processes required for the composition of text (Berninger & Graham, 1998). It is also
significantly related to fluency and quality of composition. Children may forget the ideas and plans
held in memory when they write too slow. They may have low performance at school, stressful
feelings and loss of self-confidence.
Handwriting problems of the children with SLD may include:
- poor accuracy;
- poor readability of letters, words and sentences;
- inappropriate spacing between letters or words;
- incorrect or inconsistent shaping of letters;
- poorly graded pencil pressure;
- letter inversions; and
- mixing of different letter forms.
In addition, there are also specific demands in writing Chinese characters which are square
shaped and occupied a uniform area in text. The structure of the characters is usually in left-right,
top-bottom, circular and semi-circular structures. Thus, in writing Chinese characters, it demands
much pen-lifts, sharp turns, following specific stroke sequences, attention to details of character
formation and writing within confined space (Tseng and Hsueh, 1997).
Reading is basically involving two steps: auditory process in retrieving meaning from graphic
symbols and conversion to sound and auditory acquisition to relate the written word to its
pronunciation as well as meaning (Woo and Hoosain, 1984). McBride-Chang and Chang (1995)
suggested two basic cognitive functioning related to reading, the phonological memory and
orthographic memory, in which reading Chinese characters required the latter skills more. In addition,
Chinese words generally consist of two or more characters. And the same Chinese character can
have multiple meanings and pronunciations, depending upon context, thus, it demands the person’s
metacognition (strategies readers use to comprehend and on how they plan, monitor and repair their
comprehension). Huang and Hanley (1995) conducted a study between children’s reading ability in
China, Hong Kong and Taiwan and concluded that reading Chinese depended less on phonological
awareness skills than English but more closely related to visual skills. Thus, Chinese children with
visual perceptual problems should have more difficulties in reading than children studying in
English.
Children with reading problems often have difficulties in recognizing and memorizing Chinese
characters. Therefore, they experience great difficulties in comprehension of the passage with
unrecognized words in between which seriously affect the learning process. In addition, they usually
perform poorly in dictation for they cannot memorize the Chinese characters.
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Activities of Daily Living
Children with DCD, in particular, may also have self care development and associated problems
in use of chopsticks in eating and the motor clumsiness may also affect the child’s organization of
work in performing other self care activities such as buttoning, zipping, shoe tying and cutting nails.
In managing school work, children with SLD will have difficulties in packing school bags and
maintaining a well organized place for study. Thus, they need help to maintain notebooks for
assignments, records of their work and drafts of their assignments (Cermak and Larkin 2002).
Play Skills
DCD children were reported to have poor performance of various gross motor skills such as
balancing, throwing and catching a ball, skipping, hopping, or jumping. They also found to have
difficulties in engaging ball games and group sports such as soccer, basketball, and baseball. Some
of these children were unable to maintain their own personal body space and as a result, they bump
into other people and objects easily.
One study by Puderbaugh and Fisher (1992) examined play skills of children with
developmental dyspraxia between the ages of 12 and 54 months. They examined the qualitative
aspects of play and found that the children with motor coordination delays had poorer play skills
than typical peers in the areas of motor skills (including skills such as reaching, moving, and
manipulating objects) and in process skills (including skills such as sequencing, organizing and
investigating objects and actions). Clifford (1985) noticed that they often have history of quitting
community-sponsored physical activity programs. May-Benson (1999) found that 50 % of children
with dyspraxia had problems riding a bicycle, 67 % had poor ball skills and 71 % had difficulty with
sports.
Social Skills
Social skills was defined as a child’s ability to develop and maintain appropriate peer
relationships is considered to be an important predictor of positive adult adjustment and behavior
(Cowen, Pederson, Babigan, Izzo and Trost, 1973). Research documented that children with SLD
exhibited deficits in social skills. Factors contributing to the social skills deficits included social
perception, behavioral problems, problem solving ability, and verbal communication (Cermak &
Aberson ,1997). McConaughty and Ritter (1986) examined the social competence and behavioral
problems of boys with SLD ages 6-11 by using CBCL. Parental reports indicated that boys with SLD
displayed significantly more behavioral problems in comparison to the normative sample.
LaGreca and Stone (1990) concluded that children with SLD had significantly lower peer
acceptance, fewer positive nominations, lower feelings of self worth and more negative self
perceptions regarding social acceptance.
Other literature also indicated that children with SLD had been found to have deficits in social
perception and are less attuned to nonverbal communication than typical peers (Axelrod, 1982;
Jackson et al., 1987; Sisterhern & Gerber, 1989). Studies also showed that a child’s difficulty in social
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skills may relate to problems reading non-verbal cues, which were due to visual perceptual problems
(Harnadek & Rourke, 1994).
Self-esteem /Emotion control
O’Dwyer (1987) found that 11-year-old boys with motor coordination problems were less
outgoing, less emotionally stable, less tough-minded and self-reliant, less shrewd and calculating,
less self-assured, and more introverted, and had lower self-esteem and poorer peer acceptance than
their more coordinated peers. Schoemaker and Kalverboer (1994) also found that clumsy children
were more anxious, had low self-concept, were more insecure and isolated, and were less competent
in social and physical skills than their peers.
Koomar (1996) found that anxiety co-occurred with dyspraxia for 5- and 13- year-old children,
with a greater degree of anxiety manifesting with more severe dyspraxia.
Comorbidity
In addition, a variety of disorders may co-exist in a significant percentage of children with SLD
such as attention deficit and hyperactivity disorder (ADHD). SLD was present in 70% of children
with ADHD and children with such co-morbidity had more severe learning problems than children
with SLD but no ADHD (Mayes,Calhoun & Crowell, 2000).
Furthermore, among the children with disabilities, children with SLD had more problems in
perceived competence than those with physical or visual impairment. They tended to perceive
themselves as lacking in competence and consider failure as an indication of their own lack of
competence and thus as threat to their self-esteem (Weisz & Stipek, 1982). They either hid their
emotions, or reacted aggressively in achievement situations and following failure.
According to Child behavioral checklist (CBCL) and Teachers report form (TRF), the dyslexic
group had significantly more behavioral problems than the control group. They had higher scores on
total behavioral problems, internalizing and externalizing sub-domains and the subscales attention
problem (Heiergang, Stevenson, Lund & Hugdahl, 2001).
For adolescents who were diagnosed with DCD at younger age, research indicated that reading
problems were associated with some increases in disruptive behavior in their teenagers.
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Conclusion
SLD affects the children in many aspects. Outcome studies showed that the problem affects the
children’s educational attainment, mental health and adult social functioning. Lam (1999)
commented that these negative outcomes were the result of inadequate effective help and
intervention in early years of the children. She suggested that early identification and intervention
against the negative effects of SLD were therefore essential.
A survey done in paediatric and child psychiatric settings in Hospital Authority in 2003 found
that it was among the five most common diagnoses referred to occupational therapy service (Child
and Adolescent Working Group, OTCOC, 2003). Occupational therapists provide individual and/or
group treatment in children in day and out patient services aiming at improving their functional skills
in learning and coping with daily activities.
This clinical guidelines aim at streamlining occupational therapy service provision for children
in SLD within different settings in Hospital Authority so as to improve the quality of service to these
children and ensure maximal independence in their daily lives.
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CHAPTER TWO
CONCEPTUAL FRAMEWORK AND

COMMON TREATMENT APPROACHES
Treatment Approaches for Children with SLD
In treating children with SLD, the model of practice frequently adopted by occupational
therapists is the Canadian Model of Occupational Performance (CMOP). Under this model, it
defines “occupational performance” of a person as the result of a dynamic relationship between
persons, environment, and occupation over a person’s lifespan. It refers to the ability to choose,
organize and satisfactorily perform meaningful occupations that are culturally defined and age
appropriate for looking after one’s self, enjoying life, and contributing to the social and economic
fabric of a community (Canadian Association of Occupational Therapy 1997). Specifically, we may
consider playing and learning being the major occupations of children. Occupational therapists
introduce environmental change aiming at enhancing occupational performance, or enabling persons
to restore, develop, maintain, or discover their occupational potential in their environment.
The process of occupational therapy practice is divided into seven stages:
Stage 1: Name, validate and prioritize occupational performance issues related to self-care,
productivity and leisure
Stage 2: Select theoretical approach(es)
Stage 3: Identify occupational performance components and environmental conditions
Stage 4: Identify strengths and resources
Stage 5: Develop action plan with clients
Stage 6: Implement plans through occupation
Stage 7: Evaluate occupational performance outcomes (Canadian Association of Occupational
Therapy 1997).
There are a number of treatment approaches in which occupational therapists will adopt during
the treatment of children with SLD. These approaches assist in focusing the core problems of
children for remedial therapy and adaptation to daily life activities.
Perceptual Motor (PM) Approach

Perceptual motor approach focus on the person’s ability in perceiving sensory information from
environment, then responding with judgment and executing a coordinated motor response (Hong,
1984; Folio & Fewell, 1983). Perception is needed for all activities. Different from sensation, it has
to be learned. It means that the child has to interpret what he sees, hears, feels and smells from the
environment. Perceptual motor theorists all have similar assumptions that motor learning is a
foundation for perceptual development (Kephart, 1971, Frostig, 1973 and Getman, 1965). They
contended that learning problems occurs mainly because children fail to acquire normal
perceptual-motor development.
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The PM approach is a kind of bottom up intervention. It involves a variety of different
intervention procedures based on the assumption that a causal relationship existing between motor
abilities and that underlying perceptual qualities (Mandich et al., 2001; Sigmundsson et al., 1998).
Perceptual motor dysfunction is regarded as a sensory input disorder which results in maladaptive
motor responses (Parush & Hahn-Markowitz, 1997). The goal of the PM training programs is to
remediate the underlying component of perceptual motor dysfunction which results in learning
deficits.
Sensory Integration Therapy

Sensory integrative approach is one of the most frequently used approaches to treat children
with SLD that have sensory integrative dysfunction (Mandich, Polatajko, Macnab & Miller, 2001;
Vargas & Camill, 1999; Chu, 1996; Cemak, 1985). Evidences supported that sensory integration
therapy is effective in remediation of these children (Vargas & Camilli, 1999; Kaplan, Polatajko,
Wilson & Faris, 1993; Wilson, Kaplan, Fellowes, Gruchy & Faris, 1992; Polatajko, Law, Miller,
Schaffer & Macnab, 1991; Humphries, Wright, Snider & McDougall, 1990; Densem, Nutall,
Bushnell & Hoen, 1989).
Sensory Integration (SI) is a theory of brain-behavior relationships. SI refers to the ability to
organize, integrate, and use sensory information from the body and the environment. The concept of
SI arose from a body of work that was developed by Jean Ayres (an occupational therapist and
licensed clinical psychologist) based on studies in the neurosciences, physical development, and
neuromuscular function.
Sensory integration theory has three components. The first pertains to development and
describes typical sensory integrative functioning; the second defines sensory integrative dysfunction;
and the third guides intervention programs. SI intervention procedures are based on the premise that
plasticity exists within the CNS. Therefore, therapy was designed to effect changes in the brain by
improving the efficiency with which the nervous system interprets and uses sensory information for
functional use. The control of tactile, vestibular, and proprioceptive sensory inputs is believed to
enhance nervous system function.
Biomechanical Approach
Biomechanics is a system of assumptions about forces affecting the human body. It is based
primarily on the mechanics of musculoskeletal system with the use of direct strengthening
techniques involving the application of resistance. It is commonly applied to impairments of the
musculoskeletal, cardio-pulmonary, integumentary, and nervous systems with its goal to increase
strength, endurance, and joint range of motion. In treating children with SLD, the application of
biomechanical approach mainly concerns the ergonomic of the children and the related
compensatory techniques in writing. The treatment considerations include: stabilities of posture,
shoulder and wrist and the environmental adaptations in the furniture arrangements and the
development of the pencil grip. In addition, the strength and endurance of the child’s
musculoskeletal function of the hand will also be emphasized.
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Other Approaches
During the treatment intervention, there are numerous treatment approaches which the therapist
may apply. These include developmental approach, cognitive approach, compensatory approach,
adaptive approach, functional approach and behavioural approach. Developmental and cognitive
approaches are always fundamental to the treatment to children. Therapists will consider the
developmental sequences and establish their performance skills the children have or can develop at
their current level of function. Cognitive approach focuses on examining the underlying cognitive
deficits of the children. The investigation of the cognitive deficits in relation to the children with
SLD and plan related training activities is very essential. Therapists need to update themselves with
recent neurological studies and the relationship with these children’s problems. Compensatory and
adaptive approaches need to be considered as the children still show residual symptoms after an
intensive course of training. When adopting these approaches, therapists may consider the
prescription of aids and adaptive devices together with the other human and non-human
environmental considerations. Throughout the process, the therapist will also apply the
biomechanical approach to ensure that the decisions made are practical to the children.
Very often, the treatment intervention involves teaching learning, thus, the incorporation of
behavioral approach is common. The behavioral theory based on the premise that most behaviors are
learned and the interaction between the human beings and the environment attributed to the learning
of behavior. Thus change of behaviors can be resulted by monitoring the environment through the
application of various learning principles.
The techniques based on operant conditioning had been widely adopted for treating children
with SLD. Shaping which included breaking down the target behavior such as hopping in sequence
into steps and reinforce for achieving certain step of the target such as imitate hopping for once only
or reinforce for approximation to the target behavior such as praising for touching a throwing ball
instead of really able to catch the ball. Children with SLD often faced frustration when performing
tasks which they had difficulties in doing. Shaping lowered the level of the tasks and thus effectively
set a more achievable target for the children. Positive reinforcement is also a frequently used
technique to increase or maintain the desired behaviors. The reinforcers used may include either
immediate positive feedback from the therapist or through a token system. Behavioral contract and
token economy can be designed to increase the compliance and motivation of home program
prescribed during training. Time out and response cost procedures are designed to decrease or
eliminate undesirable behaviors by removing reinforcing events from the child’s environment. In
particular, the children with SLD comorbid with ADHD may need these procedures in order to
maintain the disciplines and group orders so as to ensure effective treatment. Therapist could remove
the child from the activities to time out in a corner when the child is overly impulsive,
non-compliance, temper tantrum during training. In response cost, therapist could give tokens to
specific behaviors such as remain seated, asked permission before acting out and child would lose
the token once he or she cannot achieve the specific behaviors. In addition, inappropriate behaviors
such as hyperactivity or tantrum could also be reduced by stimulus control, that is by avoiding
situations that produce conflict, by avoiding the over stimulating activities and by engaging the child
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in individual training instead of group training.
All in all, occupational therapists always consider the functional level of the children in daily
lives. Thus, the functional deficits at school, home and play, the three major areas of the children are
essential to the formulation of treatment plan of these children.
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CHAPTER THREE
TREATMENT INTERVENTION FOR CHILDREN WITH SLD
Occupational therapy intervention to children with SLD mainly related to three sets of training
activities based on perceptual motor approach, sensory integrative approach and the functional skills
training. Occupational therapists will first identify the child’s major problems in the daily activities,
mostly related to their academic difficulties. Then, therapists will assess the related performance
components of the problems. For detail of the assessments done to the children, please refer to
Appendix 1. The treatment programs given will either be in individual or group format or both.
Parent involvement is very important throughout the treatment.
Common Treatment Intervention
Perceptual Motor Intervention

Perceptual motor (PM) programs require the child to perform specific tasks so as to increase
perceptual motor skills necessary for optimize functioning (Parush & Hahn-Markowitz, 1997;
Sellers, 1995). It aims to ameliorate the process that results in learning deficits by treating the
underlying component deficits (Schaffer et al., 1989). Occupational therapists would manipulate and
structure the environment by a sequence of activities with specific task instruction in the way that to
elicit positive visual perceptual response from the child. Different from general educational program
used in school, PM program put more emphasis on skills teaching. Therapists would direct the child
to do the tasks, starting from simple tasks and move on to more complex tasks (Kephart, 1971;
Platzer, 1976). The approach also believes that repetitive practice would help the child to master
skills (DeGangi et al, 1993; Seller, 1995). Home program is suggested to encourage child to practice
their skills at home. Besides, parents were encouraged to participate in the program, and the therapist
assisted them to identify and understand their children’s difficulties.
Perceptual motor training can be provided in group session or individual session. The activities
that are commonly employed in PM programs include fine and gross motor tasks, visual-motor tasks,
visual perceptual tasks, eye-hand coordination tasks and visual perceptual tasks. Examples of
therapeutic activities that can be used are putty games, sponge stamp art, drawing maze, etc.
Sensory Integration Intervention

Sensory Integration treatment for children with SLD using a SI frame of reference initially
focuses on facilitating improvement in the functional support capabilities (FSCs) (Cermak & Larkin,
2002). Deficits in functional support capabilities are viewed as key components contributing to poor
praxis (Ayres, 1985). And poor praxis is one of the weakness area found in children with SLD. The
functional support capabilities are mainly physical capabilities that underlie and support praxis and
other abilities. They help integrating the two distinct types of sensory systems input, alert/arousal,
and discrimination, through providing avenues for modulation of alert. Arousal input and avenues
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for interpretation of discriminative input. Treatment is aimed at underlying deficits rather than
specific behavior or skill development.
The purpose of using a sensory integration approach is to build a repertoire of motor responses
based on good or improved functioning of the functional support capabilities, which support the
child’s improvement in the process of motor planning (versus a particular motor skill). Sensory
integration relies on the building of motor patterns by using multiple contexts, and changes in the
surface characteristics of the task. For example, an activity that includes challenges to proprioception
and balance would help improve functioning in those areas as well as increase muscle tone and
cocontraction, all in preparation for an activity demanding more difficult motor planning. Hopping
ball is one of the activities that provide proprioceptive stimulation along with a variety of balancing
challenges. This activity can be incorporated with different kinds of tossing activities and obstacles.
Functional support capabilities are also incorporated into therapeutic activities aimed specifically at
improving praxis. The child with tactile discrimination problem may lead to poor fine motor
coordination (for writing, cutting, eating, fastening clothing, etc.). The child cannot locate where his
body is being touched. His/her performance is much like someone trying to pick up and put together
tiny nuts and bolts while wearing gloves. The muscles and nerves are working adequately, but the
sensations do not accurately direct the brain to carry out the necessary fine motor control. Thus,
when attempting a task, the child’s movements may be awkward.
A child with inadequate kinesthesia and proprioception awareness may lead to handwriting
problems such as applying excessive pressure in writing, poor pencil control, etc. Activities that
include challenges to tactile, kinesthesia and proprioception senses may improve the child’s fine
motor skills and handwriting. For example, Feeley-Meeley is one of the commonly used activities
that can improve child’s stereognosis. In addition, activities related to the kinesthetic abilities such as
balancing on swing, scooter board, etc. All this adds multiple sensory systems and the opportunity to
increase integration of those senses (SI), with adaptive responses resulting in increased support for
accomplishing praxis. The types, intensity, frequency, and duration of sensory input are carefully
evaluated and modified to achieve an optimal level of arousal.
Functional Skills Training in Reading and Writing

Reading
Reading is one of the major deficits of children with SLD. It highly affects the child’s learning
from books and other written references. Learning to read Chinese characters involved three basic
skills included phonological process, orthographic process and semantic process. Reading training
will therefore be focused on learning radicals, stroke patterns, characters with same phonetic
meaning and Chinese word structure. For more advanced reading skill, learning of word types such
as noun, verbal and adjectives; reading comprehension; identify key words in sentence; the
understanding of what, why, when, who, where, whose and how questions would be stressed. These
skills would help children with SLD to deal with functional problems in doing homework. It
facilitated their understanding and reading of key words in questions. Children also learnt the
techniques to search and give relevant information to questions. It increased the association between
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the phonetics, orthographic and semantic meaning of a character and hence decreased the confusion
for characters of similar characteristics. The child would have increased accuracy in both dictation
and reading of the characters. Throughout the training process, in order to increase the child’s basic
sensory and motor performance, occupational therapists will adopt multi-sensory teaching
techniques: the use of tactile, visual, auditory and proprioceptive input while teaching. In addition,
the children with SLD usually have poor motivation to learn owing the past failure experience,
reinforcement program should also incorporated in order to improve child’s motivation, attention
and compliance of the training program. Parent training is also essential as part of the program.
Parent will be invited to practice the learnt skill with child at home. The content of parent training
may include general guidelines on
- the choice of time for reading practice;
- coaching techniques in reading such as paired reading and
- handling child’s misreads.
Handwriting
Handwriting is a complex skill encompassing visual motor co-ordination, cognitive, perceptual
skills as well as tactile and kinesthetic sensitivities (Maeland, 1992). Handwriting problems in SLD
children are often the contribution of more than one of these components. As a starting point,
occupational therapists will deal with these core component skills first. Sensorimotor and perceptual
skills are the two major focused areas. These include postural control, shoulder stability, ulnar
stability, power and pinch strength, in-hand manipulation and dexterity, bilateral integration,
oculomotor control, kinesthetic and proprioception awareness, visual discrimination, position in
space, spatial relationship, visual memory, form constancy etc.. Throughout the training,
biomechanical, perceptual motor and sensory integration activities are incorporated.
Generalization of these core skills in functional handwriting is the key of efficient writing.
Treatment plan will follow the developmental sequence of children. Skills like pencil grip and pencil
control, pressure of stroke are addressed through multisensory feedback and perceptual motor
activities. Sometimes assistive writing grip will be used to facilitate a functional pencil grip.
Besides the mechanical aspect, writing also involves stroke control, stroke and form identification.
As mentioned in last session, Chinese characters are a combination of different strokes and radicals,
putting together in a specific spatial alignment. So learning of component strokes and radicals is the
pre-requisite of writing. Next is the general rule of spatial alignment in Chinese characters. Visual
scanning training and strategies are also included in training program. These training will facilitate
Chinese characters identification as well as writing legibility, which in turn enhancing accuracy and
speed.
Environmental modification is another strategy that occupational therapist usually employs in
handwriting treatment. Examples are ergonomic factors of chair, table with reference to the body
position and use of slope table. Besides, human environment modifications such as adjustment of
school demand like homework load and examination time should be made. Liaison with school and
parents are crucial for the successful integration in daily living.
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Focus of Occupational Therapy Intervention at Different Stages of Development
Individuals with SLD may need occupational therapy treatment in different age range ever since
they start to learn reading and writing. Thus, specific focuses of these individuals who receive
treatment at preschool age, school age and adolescence stage will be discussed below.
Focus of Occupational Therapy Intervention at Preschool Children

Preschool children with Specific Learning Disabilities (SLD)
Children with SLD are those who exhibit difficulties in managing skills and purposive
movement in the absence of abnormal intelligence, limited physical strength and gross sensory
deficits using the standards and conventional neurological assessment (Gubbay, 1975; Aryes, 1979).
It is a heterogeneous group although all of them show some degree of inability in performing skilled
or complicated motor tasks. Very often, parents would detect their problems rather early. For
examples, they might have found their children poor in hand dexterity or handwriting skills, poorly
manage simple self-care tasks like buttoning, fall frequently and so forth. General characteristics of
the group include poor tactile perception abilities, poor body scheme, poor gross and fine motor
skills, poor coordination, difficulties in transferring skills in daily tasks; and articulation deficits
(Ayres, 1979; Williams, 1983). These problems clearly create lots of distress in the children, and are
associated with a high incidence of learning difficulties, school failure and psychological problems.
These problems would become a major barrier as they progress to increasing academic demands.
Assessment for the Pre-school children with SLD
A comprehensive and thorough assessment is required to measure the different abilities level of
these children (Appendix I). Using various measurements to assess these children, researchers found
that these children present different patterns of strengths and weakness in terms of their abilities
level (Hartlag & Telzrow, 1983; Fletcher, 1985). O’Brien, Cermak and Murray (1988) indicated that
degree of clumsiness was significantly correlated with the degree of visual perceptual, visual-motor
deficits, but clinical manifestations of these deficits could vary greatly among individuals. For
pre-schoolers, assessment will focus more on their hand strength, eye-hand coordination and in-hand
manipulation in managing simple task/play, how they get use of the simple hand tools such as
chopsticks management and scissors manipulation; and their visual perceptual skills. Assessment
should be conducted in relation to their age-level.
Intervention for the Preschool children with SLD
To design the treatment program to preschool children with SLD, various approaches have been
adopted by occupational therapists. The common goal is to reduce the degree of dysfunction and to
promote/ maximize the preserved skills. Both group and individual sessions can be held. Parents’
participation is also necessary for the effectiveness of the program. The focus of intervention based
on the major treatment approaches are listed as follow:
Perceptual motor training:
- Aims to remediate the underlying components of perceptual motor dysfunction which results in
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learning deficits
- e.g. Eye-hand coordination training, in-hand manipulation training, pre-writing skill training,
visual perceptual training
Sensory integration therapy:
- Focus on all senses, i.e. vestibular, tactile, proprioceptive, auditory, visual and olfactory.
- Aims to build a repertoire of motor responses which support the child’s improvement in the
process of motor planning.
Functional skills training of preschool children includes teaching the specific hand function
skills such as buttoning, use of knife and fork, use of scissors, shoe-lacing, etc. and also assess and
train their writing skills or pre-writing skills required at nurseries or kindergartens.
In general, preschool children referred are over 4 years old in which the children have started
pre-writing or writing activities in their nurseries/kindergartens. Their attention is relatively short
and the fine motor skills are not well developed. Thus, activities assigned will be shorter in duration
and fun-based so as to minimize their negative feelings towards writing.
Focus of Occupational Therapy Intervention at School Aged Children

School-aged Children with SLD
During school age, where children experienced loads of academic demands with new Chinese
and English vocabularies, children with SLD experience many academic difficulties in all the major
subjects. With frustration and frequent failures, some might have emotional, social and family
conflicts (Silver, 1989).
Assessment for School-aged Children with SLD
Assessment for school-aged children with SLD emphasis on functional skills in writing, reading
and the related core problems in visual perceptual and motor performance of the children (Appendix
I).
Intervention for School-aged Children with SLD
Similar to the intervention for children at pre-school age, the major approaches adopted are
perceptual motor, sensory integration and biomechanical approach. The goals are to
promote/maximize the preserved skills and reduce the degree of dysfunction. Early intervention and
detection is crucial as the common and major vocabularies are introduced in the first two years in the
primary school. Both group and individual sessions can be given to the children. Parents’
participation is essential so as to ensure the effectiveness of the home programs and increase their
understanding towards the children’s difficulties. Close liaison with the school teachers is also
important as the children may need environmental adaptations to cope with the school work. These
include cutting of demand in homework and extension of examination time for these children.
16
The major elements in implementation of the treatment programs under different approaches
are as follows:
Perceptual Motor Approach
- Use individualized treatment program in a structured and graded way to remedy
perceptual-motor deficits
- e.g. fine motor skills training, visual perceptual training and functional skills training such as
reading, writing
Sensory Integration Therapy
- Use multi-sensory approach such as visual, auditory, tactile, kinesthetic or vestibular modes to
reinforce learning and facilitate the process of motor planning
Biomechanical Approach
- Apply this approach on muscle strengthening for motor learning and processing, and
compensate deficits on functional tasks such as writing.
Functional skills training for the school age children, in addition to those in pre-school age,
will involve more coping skills training in dealing with the academic work at school and at home.
These may include strategies in packing school bags, planning homework schedule and general
organization in work at home and at school. Sometimes, compensatory approach is needed where
occupational therapists will advice the teachers in the amount of homework assigned and the need in
lengthening the examination time for the children.
As the children often comorbid with ADHD and other emotional problems, treatment provided
will also emphasize the application of behavioral principles to increase motivation and facilitate
learning especially on academic skills and deficits area.
Focus of Occupational Therapy Intervention at Adolescence

Adolescents with Specific Learning Disabilities (SLD)
As experiencing a normal development, adolescents can master and integrate their
neuron-developmental function (namely, physical or somatic growth, neurological, motor (gross and
fine), visual, cognitive, auditory, language, kinaesthetic, psychosocial, perceptual-motor, integrative
and adaptive) maturely. If deficits in one or all of these neuro-developmental domains are found,
clients may have attention, cognitive and learning problems. Such problems will become more
severe when they reach the adolescence stage and enter an educational setting where the
environmental demands of social interactions and academic performance become more complex.
They will experience serious impairment in function in one or more of the following areas:
mathematical reasoning or calculation, expressive (written or oral) or receptive language (listening
and comprehension), basic reading skills or comprehension, sustained attention, and goal directed
behavior. Problems in attention can affect eye-tracking ability and thus impact their reading ability
(Pratt, 2002). Therefore, it is important to have intervention for the clients with SLD.
17
Assessment for the Adolescents with SLD
Comprehensive assessment should be done and recorded (App.1) in order to provide important
clues to designing effective treatment intervention. Additional screening and assessment may be
necessary to assess the clients’ self esteem and problem solving abilities since they have been
exposed to the SLD dysfunctions for a prolonged period.
Intervention for the Adolescents with SLD
The treatment goal for the adolescents with SLD is minimizing disability and maximizing
potential. Both individual and group treatment sessions can be held. Home program will be provided
as well. As it is mentioned before, SLD is a life long problem to the clients from childhood to
adulthood. Their learning skills may reach a plateau in the adolescent stage. As a result, their ability
may not able to meet the demand of a complex society. Their self-esteem and self confidence may be
affected. In order to maximize their residual ability and prepare for the social and vocational life in
future, the intervention for the adolescents with SLD should not only be focused on special teaching
technique, skill training, but also emphasized more on the compensatory technique. Furthermore, the
intervention on psychosocial aspect of the clients e.g. social skill, life goal / expectation adjustment,
self-confidence development etc. will be addressed to as well. The following recommendations are
listed as reference:
1. Skills training:
- Fine-motor training, transfer of skill training, problem solving skill training can be provided to
adolescents with writing, mathematics problems.
2. Adaptive / compensatory intervention:
- Extend exam time limit, use type writers / computers to lessen the stress caused by fine motor
deficits
- Use aids like ruler or bookmark as a place holder to focus attention
3. Advice parents/teachers in the teaching techniques to the adolescents:
- Teach concepts or comprehension skills through direct instruction
- Provide specific intensive courses / tutors in reading, arithmetic and writing etc.
- Improve memory skills by teaching through repetition, cue cards etc.
- Tape recording of lectures to allow slow learners to have repeated revises on the lectures
- Goal / expectation adjustment to both the client and parents if necessary
4. Evaluation on the need for pre-vocational skill development by vocational assessments and
vocational exploration assessments. Advices on the vocational choice or areas for further studies can
also be given
5. Self-confidence, motivation and self-esteem establishment through the successful experience gain
from the treatment session
18
CHAPTER FOUR
GLOSSARY OF TERMINOLOGIES
Area Terminology Definition

Visual Perception
Visual attention Alertness It is reflective of the child’s natural state of
arousal
Selective attention It is the ability to choose relevant information
while ignoring the less relevant information
Visual vigilance It is the conscious mental effort to concentrate
and persist at a visual task
Shared attention It is the ability to respond to two or more
simultaneous tasks
Visual memory Short term memory It is the location necessary for newly acquired
data perceived from the environment. The
information gathered by visual short-term
memory disappears if it is not processed further
Long term memory Visual memories that endures for days and years
19

Visual Object/form Object/form It is the ability to identify the object by its
Discrimination perception recognition features
Object/form It is the ability to note the similarities among
matching specific objects
Form It is the recognition of forms and objects as the
constancy same in various environment, position and sizes
Figure ground It is the differentiation between foreground and
background forms and objects. It is the ability to
separate essential important data from distracting
surrounding information
Visual closure It is the identification of forms or objects from
incomplete presentations.
Spatial Spatial It is the ability to understand how to place one
perception concept object in relation to another. For example: in, on,
under, out of, together, away from, up top, apart,
toward, around, in front of, high, in back of, next
to, beside, bottom, backward, forward, down,
low, behind, ahead of, first, last, etc.
Spatial It is the ability to determines the position of
relation objects relative to each other, the ability to
determine the direction of forms
Directionality It refers to the way print is tracked during reading
and lay down during writing
20

Sensory Motor
Sensory Tactile Tactile input is received through tactile receptors
that are found throughout the skin and, are
activated by externally applied stimuli such as
touch, pressure, pain, and temperature
Vestibular Along with the visual and proprioceptive system, it
is responsible for detecting changes in the direction
and rate of rotary head movements, linear head
movement and head tilt
Proprioceptive/Kinesthesia Those receptor mechanisms, most noticeably in the
joints, muscles, and tendons, that signal
information about the posture and movements of
the body as a whole. It referred to the awareness of
where the body parts are in space and the position,
force and extent of their movement that arise from
information from the muscles, joints, and skin. It
promotes awareness of extent, weight, timing, force
and direction of movements
Motor Planning/Praxis It is the process of organizing a plan for action. It
involved the choosing of starting point, the
direction, the speed, and the exact time to change
direction, and the place to terminate the movement
21

Motor Postural motor Joint stability It refers to the contraction of muscles around a joint
control to hold it steady. It includes balance reactions;
trunk control against gravity; shoulder
cocontraction and joint stability; arm and hand
strength; and the ability to isolate movement of the
arm from the shoulder and the trunk
Muscle It is essential for the development of the
strength development of well-formed hand arches, which in
turn are important for efficient pencil grips
Muscle tone It is the resistance of a muscle in passive elongation
or stretching
Fine motor In-hand It is defined as an adjustment of an object in hand
skills manipulation after grasp
Eye-hand It is the development of highly refined fine motor
coordination skills. Its development is based on the integration
of sensorimotor control mechanism that can locate
the hand and object in visual space and bring them
together
Bilateral hand It involves a sequence of bimanual movements in
coordination which the child simultaneously controls arm and
hand stabilization and movement. These
movements can be asymmetric and dissociated
when performing the task with both hands
Sequence and Reaction and Reaction time analyzes important information
timing movement about the speed and accuracy of sensory
time information processing, the translation of that
processing into a plan of action and the initiation of
an overt response.
Movement time is a measure of the speed of
movement execution and can be viewed as an
indirect indicator of the efficiency of motor system
function
22
APPENDIX I
OCCUPATIONAL THERAPY DEPARMENT

Gum Label Occupational Therapy Assessment Report
Date of Assessment :
Date of Report :
I. History
Birth/Medical History (only applicable for cases with history with very low birth weight)
Gestation Period : Weeks

Mode of Delivery: • NSD • CS • Vacuum • Others________
Birth Weight : kg
Complications :
Social History
Family Background:
Major care taker Time spent with child on homework________
Siblings:
EB/ES/YB/YS EB/ES/YB/YS EB/ES/YB/YS EB/ES/YB/YS
Age: Age: Age: Age:
Education level: Education level: Education level: Education level:
Academic performance: Academic performance: Academic performance: Academic performance:
Parent’s concern and attitude:
Major complaints and concern
Expectation
Current strategies in handling
23
Schooling:
School name Grade Hx of repeat
Academic performance (performance in Chinese, English & other major subjects)
Peer relationship
Special Service
• At school • At Special Education • Educational Manpower • Other rehabilitation
Dept Bureau services
II. General Behaviour
III. Clinical Observation
Postural Stability
Muscle tone:
Sitting tolerance:
Fine Motor Skills
Hand dominance: _______

Power grip: (unit ___) R L
Pinch grip: (unit ___) R L
24
Tripod grip: (unit ___) R L
Dexterity/in-hand manipulation:
Bilateral coordination:
Copying and writing skills
Pencil grip:
Pencil control: (Tension on pencil, pressure on paper, pencil manipulation)
Legibility:
Accuracy:
Stroke
Sequence:
Speed:
Self Care
25
IV. Assessment Results**
Movement Assessment Battery for Children (Movement ABC)
Motor Score Percentile(HK/US norm)*
Manual Dexterity
Ball Skills
Static and Dynamic Balance
Total Impairment Score
* Remarks : < 5 percentile = severe; 5-15 percentile = borderline; > 15 percentile = no problem
**Select specific assessments where appropriate
26
Brunininks-Oseretsky Test of Motor Proficiency (BO Test)
Gross Motor Composite

Subtest Standard score
(mean = 15, S.D. =5)
1.Running Speed and Agility
2.Balance
3.Bilateral Coordination
4.Strength
Gross motor composite Standard score Percentile

(subtest 1-4) (mean = 50, S.D. = 10) (US norm)
Fine Motor Composite

Subtest Standard score
(mean = 15, S.D. =5)
5.Upper limb coordination
6.Response speed
7.Visual motor control
8.Upper-limb and dexterity
Fine motor composite Standard score Percentile

(subtest 6-8) (mean = 50, S.D. = 10) (US norm)
Complete Battery
Subtest Standard score Percentile

(US norm)
Upper limb coordination (mean =15; S.D. = 10)

Gross motor composite (mean= 50; S.D. = 10)
Fine motor composite (mean= 50; S.D. = 10)
Battery composite (mean= 50; S.D. = 10)
27
Peabody Developmental Motor Scales
Development Motor (mean =100; S.D. =15)

Quotient
Gross motor subtest Mean S.D.
Skill A : Reflex
Skill B : Balance
Skill C : Non-locomotor
Skill D : Locomotor
Skill E : Receipt & propulsion
Total score
Age equivalent
Fine motor subtest Mean S.D.

Skill A : Grasping
Skill B : Hand use
Skill C : Eye-hand
coordination
Skill D : Manual dexterity
Total score
Age equivalent
Remarks: <-1.5 SD= sever deficit; -1 to –1.5 S.D. = moderate deficit; >-1 S.D. = no deficit
28
Developmental Test of Visual-Motor Integration (VMI)
Percentile Age equivalent (US/HK norm)

Visual motor integration
Visual perception
Motor coordination
Developmental Test of Visual Perception II (DTVPII)
Subtest Percentile
(mean = 10; S.D. =3)
1.Eye-hand coordination
2.Position in space
3.Copying
4.Figure-ground
5.Spatial relations
6.Visual closure
7.Visual-motor speed
8.Form constancy
Composite Quotients
(mean = 100, S.D. =15)
General visual perception
Motor-reduced visual
perception
Visual motor integration
29
Test of Visual Perceptual Skills (TVPS)
Subtest Percentile Rank

Visual discrimination
Visual memory
Visual-spatial relations
Visual form constancy
Visual sequential memory
Visual figure-ground
Visual closure
Median Perceptual Age

Percentile Rank
Tseng’s Chinese Handwriting Speed Test
Word per minute

Mean S.D.
Legibility
Error
Sensory Integrative Function
Sensory Modulation:
Sensory Processing
Tactile
Vestibulo-proprioceptive
Motor planning
30
V. Interpretation of Result
VI. Conclusion & Recommendation
Occupational Therapist
31
Key References:
American Psychiatric Association .(1994). Diagnostic Criteria from DSM-IV. Washington, DC:
American Psychiatric Association.
Amundson, S.J. & Weil, M. (1996). Prewriting and handwriting skills. In J. Case-Smith, A. Allen
and P. Pratt (Ed.), Occupational Therapy for Children. Chicago: Mosey.
Axelrod, L. (1982). Social perception in learning disabled adolescents. Journal of Learning

Disabilities, 15, 610-613.
Bundy, A.C., Lane, S.J., & Murray, E.A. (2002). Sensory integration: Theory and practice. (2nd
ed.). Philadelphia: F.A. Davis.
Canadian Association of Occupational Therapists. (1997). Enabling Occupation: An Occupational

Therapy Perspective. Ottawa: CAOT Publications ACE.
Cantell, M., Smyth, M., & Ahonen, T. (1994). Clumsiness in adolescence: Educational, motor, and
social outcomes of motor delay detected at 5 years. Adapted Physical Activity Quarterly, 11,
115-129.
Case-Smith, J. (1995). The relationships among sensorimotor components, fine motor skill, and
functional performance in preschool children. American Journal of Occupational Therapy, 49,
645-652.
Cermak, S.A., & Aberson, J.R. (1997). Social skills in children with learning disabilities.
Occupational Therapy in Mental Health, 13(4): 1-24
Cermak, S.A., & Larkin, D. (2002). Developmental coordination disorder. Albany: Delmar
Thomas Learning.
Chow, S. M. K (1999). What do we know about Developmental Coordination Disorder? The Hong
Kong Society of Child Neurology and Developmental Paediatrics Specific Learning Disabilities,
Position Statement and Papers. Hong Kong: The Hong Kong Society of Child Neurology and
Developmental Paediatrics
Chu, S. (1999). Assessment and treatment of children with handwriting difficulties. In Barchers, S.
(1994). Teaching language arts: an integrated approach. Minneapolis: West Publishing.
Feldman, L.B. and Siok, W.W.T. (1997). The Role of Component Function in Visual Recognition
of Chinese Characters. Journal of Experimental Psychology, 23, 3, 776-781.
32
Frostig, M. (1973). Frostig program for the Development of Visual Perception: Teacher’s Guide.
Chicago: Follett
Henderson, A. & Pehoski, C. (1995). Hand Function in the Child. Foundations for remediation. St.
Louis, Missouri: Mosby-Year.
Hong, C.S. (1984). Occupational Therapy for children with perceptual motor disorder. A Literature
Review. British Journal of Occupational Therapy, 47, 39-42
Lam, C. C. C. (1999). Current Practice in Specific Learning Disabilities in Hong Kong:

Developmental Paediatrics Perspective. The Hong Kong Society of Child Neurology and
Developmental Paediatrics Specific Learning Disabilities, Position Statement and Papers. Hong
Kong: The Hong Kong Society of Child Neurology and Developmental Paediatrics
Leong, C. K. (1999). Psychological and Educational Aspects of Cantonese-Speaking Children in

Hong Kong with Developmental Dyslexia. The Hong Kong Society of Child Neurology and
Developmental Paediatrics Specific Learning Disabilities, Position Statement and Papers. Hong
Kong: The Hong Kong Society of Child Neurology and Developmental Paediatrics
Mandich, A.D., Polatajko, H.J., Macnab, J.J., & Miller, L.T. (2001). Treatment of children with
developmental coordination disorder: What is the evidence? Physical & Occupational Therapy in
Pediatrics, 20, 2-3, 51-68.
McBride-Chang, C. & Chang, L. Memory, Print Exposure, and Metacognition: Components of

Reading in Chinese Children. International Journal of Psychology, 30, 5, 607-616.
Paillard (1990). Basic neurophysiological structures of eye-hand coordination. In C. Bard, m.

Fleury, & L. Hays (Eds.), Development of eye-hand coordination (p.26-74). Columbia, SC:
University of South Carolina Press.
Scientific Committee of the Working Party on SLD (1999). Definition of Specific Learning
Disabilities: Position Statement. The Hong Kong Society of Child Neurology and Developmental
Paediatrics Specific Learning Disabilities, Position Statement and Papers. Hong Kong: The Hong
Kong Society of Child Neurology and Developmental Paediatrics
Tseng, M. H. & Cermak, S. A. (1993). The Influence of Ergonomic Factors and Perceptual-Motor
Abilities on Handwriting Performance. American Journal of Occupational Therapy, 47, 10,
919-926.
33
Vargas, S., & Camilli, G. (1999). A meta-analysis of research on sensory integration treatment.
American Journal of Occupational Therapy, 53, 2, 189-198.
World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders.
Geneva: World Health Organization.
34

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What is the purpose of this guideline?

What is the purpose of this guideline?

What are some common SLD subgroups referred for occupational therapy?

What are some common SLD subgroups referred for occupational therapy?

Child and Adolescent Working Group, Occupational Therapy Coordinating Committee, HAHO

Child and Adolescent Working Group,

Magdalene Poon, Kwai Chung Hospital

Co-ordinating Committee in Occupational Therapy, Hospital Authority

Specific learning disabilities (SLD) (sometimes referred to as “specific learning difficulties”

Functional Problem of Children with SLD

Handwriting and Reading Skills

CONCEPTUAL FRAMEWORK AND

Treatment Approaches for Children with SLD

Perceptual Motor (PM) Approach

Sensory Integration Therapy

TREATMENT INTERVENTION FOR CHILDREN WITH SLD

Common Treatment Intervention

Perceptual Motor Intervention

Sensory Integration Intervention

Functional Skills Training in Reading and Writing

Focus of Occupational Therapy Intervention at Different Stages of Development

Focus of Occupational Therapy Intervention at Preschool Children

Focus of Occupational Therapy Intervention at School Aged Children

Focus of Occupational Therapy Intervention at Adolescence

Area Terminology Definition

Area Terminology Definition

Area Terminology Definition

Area Terminology Definition

OCCUPATIONAL THERAPY DEPARMENT

Gestation Period : Weeks

Age: Age: Age: Age:

Education level: Education level: Education level: Education level:

Academic performance: Academic performance: Academic performance: Academic performance:

Parent’s concern and attitude:

Major complaints and concern

Current strategies in handling

II. General Behaviour

III. Clinical Observation

Fine Motor Skills

Hand dominance: _______

Copying and writing skills

IV. Assessment Results**

Movement Assessment Battery for Children (Movement ABC)

Motor Score Percentile(HK/US norm)*

**Select specific assessments where appropriate

Brunininks-Oseretsky Test of Motor Proficiency (BO Test)

Gross Motor Composite

Gross motor composite Standard score Percentile

Fine Motor Composite

Fine motor composite Standard score Percentile

Subtest Standard score Percentile

Upper limb coordination (mean =15; S.D. = 10)

Development Motor (mean =100; S.D. =15)

Fine motor subtest Mean S.D.

Developmental Test of Visual-Motor Integration (VMI)

Percentile Age equivalent (US/HK norm)

Developmental Test of Visual Perception II (DTVPII)

Test of Visual Perceptual Skills (TVPS)

Subtest Percentile Rank

Median Perceptual Age