The Indian Journal of Occupational Therapy : Vol. XXXVII : No.

2 (August - November, 05)

VISUAL-MOTOR INTEGRATION AND LEARNING
DISABLED CHILDREN
*Reepa Sanghavi, MOT Student; Co-Author : **Rajni Kelkar, MOTh.
OT School & Centre, LTM Medical College & General Hospital, Sion, Mumbai
Abstract :

Objectives:
• To study and compare the performance of normal and learning disabled children (LD) on Beery and Buktenica’s Developmental
• Test of Visual-Motor Integration (DVMI).
• To provide occupational therapy intervention for improving visual-motor integration in the LD children and observe the
• effectiveness of therapy.
Methodology: Three groups were assessed on DVMI. Normal children (n-80) were assessed in groups. Experimental group and
control group, each consisting of 16 LD children were assessed individually. Experimental group was given occupational therapy
intervention in the department and supplementary therapy by parents, guided by therapist, regularly for 12 weeks. OT intervention
included ergonomic factors, gross and fine motor activities. Control group was given counseling about OT program for 12 weeks.
Post therapy, patients were re-assessed on DVMI and raw scores obtained were analyzed in order to examine the efficacy of OT
program.
Results: It was found that normal Indian children aged 10 to 14 years attain mean raw score in DVMI at younger age than
normal American Children. It was evident from DVMI raw scores that improvement in experimental group was more as compare
to control group (P< 0.001). Thus occupational therapy has wide scope in treating learning-disabled children with the help of
O.T. program.
Keywords: Visual-motor integration, Learning disabled, Developmental test of visual-motor integration.

INTRODUCTION significant predictor of handwriting performance.2

Many researchers have explained the importance of VMI in
Visual Motor Integration (VMI ) is the ability of the eyes &
learning academic skills. Beery believes that before the child
hands to work together in smooth, efficient patterns. It
learns to write, the basic geometric shapes have to be
involves visual perception and eye-hand co-ordination.1
mastered.3 It has been observed that as subject’s ability to
Visual-Motor skills require the ability to translate visual
copy the forms on the VMI increases, a concomitant increase
perception into motor functioning and involve motor control,
in ability to copy letters accurately is seen, which was
motor accuracy, motor co-ordination and psychomotor speed.
supported by Weil in his study.4 Mati-zissi observed that there
Visual motor integration is an important variable to a child’s is a correlation between performance in written language
handwriting skills, particularly when copying or transposing and drawing or design copying tasks.5 Failure on visual-motor
from printing material to cursive or manuscript writing. There tests may be caused by underlying visual-cognitive deficits
are various factors like visual-perceptual, motor planning, including visual discrimination, poor fine motor skills,
motor memory, sequencing etc for handwriting performance inability to integrate visual – cognitive and motor processes,
but Sovik found visual-motor integration was the most or combination of these abilities.6
The Berry’s Developmental Test of Visual Motor Integration
(DVMI) has been extensively used in order to measure the
*Occupational Therapist
** Professor & Head OT Deptt. integration problems in children. According to Berry, visual-
Place of Study : LTMMC & GH, Mumbai motor integration is defined as the ability to copy geometric
Period of Study : 2001 - 2002 shapes. He suggested that the first nine figures in this DVMI
Correspondence : should be mastered before a child learns to write.
Dr. (Ms.) Reepa K. Sanghavi Subsequently many researchers have found high correlation
1003/Giriraj, Neelkanth Valley, Rajawadi, 7th Road,
Ghat-Kopar (E), Mumbai - 400 077
of DVMI with writing readiness, handwriting skills, coping
Tel. : 022-25136242, 9820870989 abilities, reading,mathematical abilities,academic
E-mail: [email protected]

IJOT : Vol. XXXVII : No. 2 33 August - November, 2005

performance in children.7, 8, 9, 10, 11 of normal children, the teachers were instructed to exclude
children with upper extremity impairment, visual impairment
The deficits in VMI have been observed in learning disabled
and learning disabled children.
children. Since learning disabilities are closely associated
with integrational problems, the reproduction of geometric PROCEDURE
forms may be a relatively sensitive measure of neurological
integrity.12 Tranopol reports that 90% of learning disabled The Subjects were tested in groups on DVMI. The booklet
children has visual motor defects.13 Learning disabled consists of 24 geometric forms. All subjects used a standard
children with poor visual-motor integration have difficulty HB pencil without an eraser. The subjects were given
in doing the fine activities like drawing geometric forms, instructions about how to perform the test. The time required
cutting with scissors, copying design, pasting, coloring etc. to complete the VMI was 10-15 minutes. Depending upon
Mattison analyzed the visual-motor problems of children with their performance on visual-Motor Integration scale, scores
learning disabilities and found that they had significantly were calculated.
more trouble than normal children with design-copy tasks Group B and Group C:
involving visual-motor components. 14 Oliver found
Experimental and control group consisted of 32 learning
significant improvement in children’s writing readiness skill
disabled children aged from 10 to 14 years representing from
after giving occupational therapy intervention.7
high as well as low socioeconomic groups and variety of
It is evident from literature that learning disabled children ethnic backgrounds.
do suffer from visual-motor integration deficit and
Inclusion criteria:
occupational therapy intervention helps in remediation.
Keeping in mind all these aspects, this study was conducted 1. Children diagnosed as learning disabled by a qualified
to explore the significance of VMI and effects of occupational professional.
therapy intervention on VMI in learning disabled children.
2. Learning disabled with Attention deficit hyperactive
AIMS AND OBJECTIVE disorder.

• To study and compare the performance of normal and Exclusion criteria:

learning disabled children on visual-motor integration Patient with diagnosis of Cerebral palsy, mental retardation,
by using Beery and Buktenica’s ‘Development Test of autism, neuromuscular disorders, musculoskeletal disorders
Visual-Motor Integration’. were excluded from groups.
• To provide occupational therapy intervention for Procedure:
improving visual-motor integration in the learning
disabled children and observe the effectiveness of The authors with the help of parents filled a detailed proforma
therapy. that included demographic data, family history, educational
& developmental history. Perceptual & cognitive functions
METHODOLOGY of the child were evaluated in details. The tests conducted
by the psychologists such intelligence quotient was noted
This study used an experimental design where children aged
down. The DVMI Test was administered individually by
10 to 14 years were taken & divided into three groups. Group
therapist. Depending upon performance on VMI Test, scores
A consisted of normal children (N=80), group B was the
were calculated.
Experimental group of LD children (N=16) & Group C was
the control group of LD children (N=16). The subjects in Subjects from group ‘B’ & ‘C’ were referred to occupational
‘B’ & ‘C’ group were attending the LD clinic of the hospital. therapy department for intervention. Children from the
The instrument used for testing visual motor integration was experimental group used to attend therapy once in a week.
3rd edition of Berry’s Developmental Test of Visual Motor Supplementary therapy as prescribed by therapist was given
Integration (DVMI). by parents regularly at home. Children & parents of control
group were given counseling about activities that can help
Group A:
to improve VMI. The therapist did not give formal training
The subjects for this study included 80 normal Indian children to this group in the department.
aged from 10 years to 14 years. This sample was selected
OCCUPATIONAL THERAPY INTERVENTION
from 5th to 8th standard of a private school. The school
represented high as well as low socioeconomic strata and a Occupational Therapy intervention was given to group ‘B’
variety of ethnic backgrounds. In an effort to obtain a sample according to patient’s level of functioning and level of

IJOT : Vol. XXXVII : No. 2 34 August - November, 2005

performance on Development Test of Visual-Motor Table - 1
Integration. The therapy was individualized in the form that Raw score and corresponding age equivalent according
the children with severe deficit in VMI progress to complex to Beery’s DVMI test for 80 normal Indian children
activity at slower and gradual rate than children with milder aged 10 to 14 years.
deficit. Treatment was based on visual perception, Eye-hand Chronological age Mean Raw score Mean age -equivalent
co-ordination and Ergonomic factors. group
The gross motor activities like overhead ball throwing, 10-1 to 10-3 33 11-5
punching the suspended ball, drawing a line or circle on 10-4 to 10-6 33 11-5
blackboard and building towers of blocks were given to LD
10-7 to 10-9 34 11-8
children.15 To vary the sensory stimulation and to heighten
interest and responsiveness, fine motor activities like beads 10-10 to 11-0 35 12-0
stringing, clay modeling, mosaic design, cutting with scissors, 11-1 to 11-3 36 12-5
joining the dots, coloring the figure, filling the missing part,
11-4 to 11-6 37 12-9
abstract mazes and puzzles,7,16 draw part of alphabet in order
to produce alphabet were given to LD children17. 11-7 to 11-9 37 12-9
11-10 to 12.0 38 13-1
Ergonomic factors considered were as follows:
12-1 to 12-3 39 13-5
• Positioning: In positioning, shoulder girdle stabilization
was emphasized. For right-handed patient, the paper was 12-4 to 12-6 40 13-8
slanted to left side closer to midline and vice versa.18 12-7 to 12-9 41 14-0

• Triangular plastic grip or broad padded holder for pen 12-10 to 13-0 42 14-5
was given.18 13-1 to 13-3 43 14-9
After 12 weeks of intervention both groups ‘B’ and ‘C’ were 13-4 to 13-6 43 14-9
re-assessed on VMI test. The raw scores obtained were 13-7 to 13-9 44 15-2
tabulated and analyzed in order to examine the efficacy of
13-10 to 14-0 45 15-7
occupational therapy program. Experimental Control
Table(n=16)
-2
DATA ANALYSIS AND RESULTS Group Group (n=16)
Pre and Post intervention raw score of the
Raw score Mean 20
Descriptive statistics including mean, standard error mean, experimental and control groups done on20DVMI test.
standard deviation,’t’ and ‘p’ value were computed on the Pre-intervention S.D 6 5
basis of performance of subjects on VMI. The data were Raw score Mean 26 21
analyzed with SPSS statistical package. Post-intervention S.D 6 5
The mean raw score on VMI test and corresponding age
equivalent for 80 normal children were analysed as shown
in table (1). When compared with the norms available in the
manual it shows that the Indian children have obtained mean
raw scores at a younger age as compared to their counterparts
in North America.
Further the pre and post intervention raw score of the control Table - 3
and experimental group were computed (Table 2). It is Pre and Post intervention raw score of the
observed that there is improvement in raw score in both the experimental and control groups as percentage to the
groups. normal value done on DVMI test.
Experimental Control
The Pre and Post intervention raw score of the experimental
and control groups as percentage to the normal value done Group (n=16) Group (n=16)
on VMI test was also analyesd (Table 3). This shows that Raw score as % of normal Mean 52.18 52.87
there is improvement in raw score as percentage to normal Pre-intervention S.D 13.74 12.93
value in both the groups.
Raw score as % of normal Mean 68.24 54.91
A Comparison between the experimental and control groups Post-intervention S.D 12.66 12.92
pre and post intervention raw score on VMI test was done

IJOT : Vol. XXXVII : No. 2 35 August - November, 2005

 Table - 4 Graph - 3
Comparison between the improvement in raw score on Comparison between the improvement in VMI mean raw score in
the Experimental & Control groups
DVMI test in the experimental and control groups pre
and post intervention.
Mean S.D S.E 't' value 'P' value 7
Mean 6
Experimental 5
Improvement Group (n=16) 6.06 2.08 0.52 4 Control
3 group
Experimental
in Raw score Control 9.703 0.000
group
Group (n=16) 0.75 0.68 0.17 2
1
0
Table - 5 Pre and post
Comparison between the improvement in raw score as intervention
percentage to normal value on DVMI test in the Graph - 4
experimental and control groups pre and post Comparison between the improvement in
intervention. VMI Mean raw score as % of normal in
Mean S.D S.E 't' 'P'
Experimental & Control groups
Mean value value
Improvement Experimental
in raw score Group (n=16) 16.060 5.097 1.27 10.308 0.000 1
6
1
as percentage Control 4
1
to normal Group (n=16) 2.0383 1.903 0.47 2
1 Control
08 group
Experimental
6 group
4
Graph - 1 2
0
Pre and Post Intervention VMI mean raw score Pre and post
of Experimental and Control group intervention

30
by using‘t’ test (Table 4). Table (5) shows comparison
25 between the improvement in raw score as percentage to
20 normal value in the experimental and control groups pre and
P re -Interven tion
15
P ost-In terve ntion
post intervention. Both the tables ‘p’ value being highly
10
significant which supports that there is significant
5
0
improvement in raw score in experimental group as compared
E xperim en ta l group C ontrol g ro up to control group.
DISCUSSION
Graph - 2 The results obtained show that normal Indian children
Pre and Post Intervention VMI mean raw score of attained means raw score on DVMI at younger age than
Experimental and Control groups as % of normal normal American children (Table 1). The factors contributing
value to difference could be as follows:

80
Fine prehension: Use of fine prehension by Indian children
is more than American children. E.g.: Eating with fingers
60
P re -Interven tion
instead of using spoon.
40
P ost -In te rve ntio n
Early exposure: There is early exposure to activities
20
involving hand functions like formal writing, paper and pencil
0
E xpe rim en ta l grou p C ontrol g ro up task etc. in Indian children at 3 1/2 years as compare to
western countries at the age of 5 years.
The analysis of pre and post intervention DVMI raw score

IJOT : Vol. XXXVII : No. 2 36 August - November, 2005

of the control and experimental group (Table 2, graph 1) and However, one of the limitations of this study was that the
as percentage to normal value (Table 3, graph 2) show that randomization could not be done. Also, the group was not
there is improvement in raw score in both the groups. This further divided into clumsy and non-clumsy children. That
means that both the groups benefited from therapy. would have given further understanding about other factors
such as fine motor skill deficits, or the dexterity problems
However, when performance of two groups was compared,
which could be contributing or coexisting with the visual
the‘t’ & ‘p’ value being highly significant supports the fact
motor integration dysfunctions in LD children. Also,
that improvement in experimental group was more than that
inclusion of a handwriting scale would have given insight
in control group (Table 4 & 5, graph 3 & 4). These findings
into the correlation between visual motor integration &
are consistent with that of Oliver who found that there was
writing skills.
improvement in the performance of writing readiness skills
in children following the sensorimotor occupational therapy CONCLUSION
program.7
It can be concluded from the study that normal Indian children
Various factors may have contributed for this improvement. aged 10 to 14 years attain mean raw score on DVMI at
In experimental group, the unique element of occupational younger age than normal American children. Hence there is
therapy program was its combination of direct therapy with need of standardization of DVMI on larger Indian population.
an ongoing supplementary program. In this program, with
therapist’s guidance and appropriate input, the child It was evident from the study that due to direct therapy,
performed the activity in graded fashion and in correct way, improvement in experimental group is more as compare to
which may not be possible by parents alone. Usually parents control group. In future, studies can be carried out to assess
of LD children focus on academics goals, which may be the long lasting effects of OT intervention after discontinuing
monotonous while the program used in this study for the the therapy and to find the co-relation between VMI and
experimental group involved play activities having handwriting skills.
therapeutic values. The parents’ participation is important ACKNOWLEDGEMENT
in the therapy to practice new skills but what is equally
important is type of activities and rapport with child, which We are grateful to Dr. M.E.Yeolekar, Dean, L.T.M.M.C. &
is provided by occupational therapist. G. H., Sion, Mumbai, and Professor & Head of pediatrics
Department Dr. Mrs. Madhuri Kulkarni, for allowing us to
Georgia in her study supports motor learning theory and states conduct this study.
that skills are developed through practice and feedback
mechanisms.19 Current theories of motor learning support Our sincere thanks to Mrs. Swarna Venkat, Principal,
the notion that skills are developed through practice and Headmistress at Smt. M.D. Bhatia High English Medium
feedback mechanisms that allow a generalized motor program High School, for permitting us to carrry out VMI test on
to be developed for related skills. normal children and Prof. J.C. Sharma for helping in
statistical analysis, the patients and their family members
Fisher has suggested that children with right hemisphere without whom this study would have been impossible.
dysfunction have difficulty with visual-constructive and
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