RESEARCH ARTICLE

Evaluating Fine Motor Coordination in Children Who Are

Not Ready for Handwriting: Which Test Should We Take?
Liesbeth de Vries1*†, Margo J. van Hartingsveldt2,3, Edith H. C. Cup2,
Maria W. G. Nijhuis-van der Sanden2,4 & Imelda J. M. de Groot2
1
Center for Rehabilitation, University of Groningen, University Medical Center Groningen, CD 35, Dilgtweg 5 9751 NJ Haren,
The Netherlands
2
Nijmegen Center for Evidence-based Practice, Department of Rehabilitation 898, Radboud University Medical Center, P.O. Box 9101 6500
HB Nijmegen, The Netherlands
3
Institute Health – Occupational Therapy C1.46, Amsterdam University of Applied Sciences, Tafelbergweg 51 1105 BD Amsterdam,
The Netherlands
4
Scientific Institute for Quality of Healthcare 114, Radboud University Medical Center, P.O. Box 9101 6500 HB Nijmegen, The Netherlands

Abstract
When children are not ready to write, assessment of fine motor coordination may be indicated. The purpose of this
study was to evaluate which fine motor test, the Nine-Hole Peg Test (9-HPT) or the newly developed Timed Test of
In-Hand Manipulation (Timed-TIHM), correlates best with handwriting readiness as measured by the Writing Read-
iness Inventory Tool In Context-Task Performance (WRITIC-TP). From the 119 participating children, 43 were poor
performers. Convergent validity of the 9-HPT and Timed-TIHM with WRITIC-TP was determined, and test-retest re-
liability of the Timed-TIHM was examined in 59 children. The results showed that correlations of the 9-HPT and
Timed-TIHM with the WRITIC-TP were similar (rs = 0.40). The 9-HPT and the complex rotation subtask of the
Timed-TIHM had a low correlation with the WRITIC-TP in poor performers (rs = 0.30 and 0.32 respectively).
Test-retest reliability of the Timed-TIHM was significant (Intraclass Correlation Coefficient = 0.71). Neither of these
two fine motor tests is appeared superior. They both relate to different aspects of fine motor performance. One of
the limitations of the methodology was unequal numbers of children in subgroups. It is recommended that further
research is indicated to evaluate the relation between development of fine motor coordination and handwriting profi-
ciency, on the Timed-TIHM in different age groups. Copyright © 2015 John Wiley & Sons, Ltd.

Received 10 June 2014; Revised 19 December 2014; Accepted 12 January 2015

Keywords
handwriting; fine motor coordination; Nine-Hole Peg Test, Timed Test of In-Hand Manipulation (Timed-TIHM); Writing Readiness Inventory
Tool in Context-Task Performance (WRITIC-TP)

*Correspondence
Liesbeth de Vries, Center for Rehabilitation, University of Groningen, University Medical Center Groningen, CD 35, Dilgtweg 5 9751 NJ
Haren, The Netherlands.
†
Email: L.de.vries@umcg.nl

Published online 23 February 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1385

Introduction participation in a regular classroom environment

During the first years in school, children learn to (Rosenblum, 2008). Handwriting difficulties have
write. Proficient handwriting is essential for a child’s negative effects on a child’s academic performance

Occup. Ther. Int. 22 (2015) 61–70 © 2015 John Wiley & Sons, Ltd. 61
Fine Motor Coordination and Handwriting de Vries et al.

and self-esteem (Bart et al., 2007). Early identification perceptual–motor skill of preliminary writing, “visual
of children who are not ready to learn the mastery of motor integration” and “fine motor coordination”
handwriting can provide information for tailored ad- are important performance components (Volman
vice and timely interventions in order to prevent the et al., 2006). Fine motor coordination (motor plan-
negative consequences of handwriting difficulties. ning and execution) has proven to be a key compo-
From the literature, we know that in the develop- nent in the early learning stages of handwriting
ment of handwriting, several processes are involved. (Berninger, 2009).
These processes are represented in a conceptual To assess handwriting readiness in the pre-
model, comprising factors related to handwriting writing phase, a new occupation-based instrument
readiness (Figure 1) (Berninger et al., 1992; Abbott has been developed: the Writing Readiness Inven-
and Berninger, 1993; Volman et al., 2006; van tory Tool in Context (WRITIC; van Hartingsveldt
Hartingsveldt et al., 2014a). Handwriting readiness is et al., 2014a, 2014c). The WRITIC has items in
the stage before handwriting (Marr et al., 2001; three domains and six subdomains: child (“interest”
Schneck and Amundson, 2010) and is defined as a de- and “sustained attention”), environment (“physical”
velopmental stage at which a child has the capacity to and “social”) and paper-and-pencil tasks (“task per-
profit satisfactorily from the instruction given in the formance” and “intensity of performance”). In a se-
teaching of handwriting (Marr et al., 2001). The con- ries of studies, the reliability and validity of the
ceptual model, based on the model of Berninger, is WRITIC have been established (van Hartingsveldt
used to identify the perceptual–motor and cognitive et al., 2014a, 2014c).
factors relating to handwriting readiness. This model In the WRITIC, handwriting readiness is measured
shows that learning “text writing” is based on differ- as having a proper seating posture (Pollock et al.,
ent processes: the perceptual–motor process “hand- 2009; Schneck and Amundson, 2010), a mature pencil
writing” and the cognitive language processes of grasp (Schwellnus et al., 2012, 2013) and performance
“spelling” and “composition” (Abbott and Berninger, of age-appropriate tasks such as colouring, writing pat-
1993). In the phase in which children learn the terns, writing own name and copying letters and

Figure 1. Conceptual model of handwriting readiness and its relation to handwriting, text writing and performance components, based on
the model of Berninger (Abbott and Berninger, 1993; Berninger et al., 1992; van Hartingsveldt et al., 2014a, 2014b; Volman et al., 2006)

62 Occup. Ther. Int. 22 (2015) 61–70 © 2015 John Wiley & Sons, Ltd.
de Vries et al. Fine Motor Coordination and Handwriting

numbers. The WRITIC discriminates between children 63.7% of the variance in scores on a handwriting test
who are ready for instruction in handwriting and (Cornhill and Case-Smith, 1996). Feder et al. (2005)
children who are not (van Hartingsveldt et al., 2014c). determined that IHM significantly correlated with
slow handwriting speed (r = 0.43; p < 0.01).

Fine motor coordination

The International Classification of Function Disability Evaluation of fine motor coordination
and Health for Children and Youth (ICF-CY) defines
When children are not ready to learn handwriting
fine hand use as “performing the coordinated actions
based on the WRITIC, it is recommended that perfor-
of handling objects, picking up, manipulating and re-
mance components, such as fine motor coordination,
leasing them using one’s hand, fingers and thumb,
be assessed. This is carried out to identify the underly-
such as required to lift coins off a table or turn a dial
ing mechanism, which may help to provide appropriate
or knob” (WHO, 2007, p. 155). Exner (2010) defines
support and interventions in order to make the child
fine motor coordination as skills of the hand that are
ready for handwriting and to prevent the potential neg-
needed to attain and manipulate objects. She describes
ative influences caused by writing difficulties. In a sys-
different patterns of fine motor coordination. These
tematic review of standardized tests of handwriting
include reaching, grasping, carrying and voluntarily
readiness (van Hartingsveldt et al., 2011), two tests
releasing objects, as well as more complex skills such
were found that consist of only fine motor coordina-
as in-hand manipulation (IHM) and bilateral hand
tion tasks: the Nine-hole Peg Test (9-HPT) (Smith
use. IHM develops over a long period, from the age
et al., 2000) and the Test of In-hand Manipulation Re-
of approximately 18 months to 7 years. Progression
vised (TIHM-R) (Pont et al., 2008).
can be observed in the transition from simple to more
The aim of the current study is to examine which
complex manipulation skills (Exner, 2010) and in im-
fine motor test, the 9-HPT or the newly developed
provements in the dimensions of speed, strategy and
Timed Test of In-Hand Manipulation (Timed-TIHM),
consistency (Pehoski et al., 1997b). Between the ages
correlates best with handwriting readiness as measured
of 3 and 6 years, IHM develops most rapidly, and
by the Writing Readiness Inventory Tool in Context –
hand movements become more and more refined
Task Performance (WRITIC-TP).
(Pehoski et al., 1997a). Fine motor skills are important
Based on research (Feder et al., 2005; Volman et al.,
in a child’s development and interaction with the en-
2006), we hypothesize that both fine motor coordina-
vironment (Exner, 2010). These skills contribute to
tion tests will have a moderate correlation with the
the achievement of daily occupations such as hand-
WRITIC-TP. We hypothesize that the revised Timed-
writing. Two of the characteristics for skilled hand-
TIHM will have a higher correlation to the WRITIC-
writing are stability in pencil grip and controlled
TP than the 9-HPT. Handwriting involves complex
dynamic finger movements (Ziviani and Wallen,
controlled dynamic finger movement, and we hypoth-
2006). Difficulties in fine motor coordination may re-
esized that the movements as tested in the Timed-
sult in an inability to direct pencil movements and
TIHM had a better ability than the less complex move-
correct errors of movement, particularly those of small
ments in the 9-HPT to indicate which children were,
amplitude observed in handwriting (Ziviani and
from a fine motor perspective, not yet ready to write
Wallen, 2006).
and thus would show a higher correlation to the
In-hand manipulation is also studied in relation to
WRITIC-TP.
handwriting. Cornhill and Case-Smith (1996) found a
strong relationship between handwriting and IHM
(r = 0.80 for translation and r = 0.85 for rotation). In
their study (n = 48, mean age 7.3 years), IHM differed
Methods
significantly between good and poor performers in a In this clinimetric study, we evaluated the convergent
task involving translation with stabilization and a task validity of the Timed-TIHM and 9-HPT with the
involving rotation, although translation was also an WRITIC-TP. As the Timed-TIHM is a newly devel-
important predictor of most handwriting speed tasks. oped test, the test–re-test reliability of the Timed-
Translation was the main predictor and accounted for TIHM was also studied.

Occup. Ther. Int. 22 (2015) 61–70 © 2015 John Wiley & Sons, Ltd. 63
Fine Motor Coordination and Handwriting de Vries et al.

Participants inter-rater agreement through the use of a videotaped

administration with the second author.
For the study of convergent validity, we recruited 120
children aged 5 and 6 years by asking 20 directors of el-
ementary schools in the middle and eastern parts of the Instruments
Netherlands for their participation. In each school, we
Nine-hole Peg Test
asked one kindergarten teacher to select six children
per class: three with good performance on paper-and- The 9-HPT evaluates simple fine motor patterns, in-
pencil tasks (good writers) and three with poor perfor- cluding reaching, grasping, carrying, entering and re-
mance on paper-and-pencil tasks (poor writers). When leasing with the time taken to perform these tasks as
parents’ consent was received, we asked children for the outcome measure (Smith et al., 2000). The 9-HPT
their assent before testing. Children were excluded if has been validated in a study population of 826 chil-
they were not able to complete the items of the dren between 5 and 10 years of age. High inter-rater
WRITIC because of a medical diagnosis or visual or au- and test–re-test reliability was established, and strong
ditory impairment. construct validity was obtained. Normative values are
To examine test–re-test reliability, 60 children aged available for children in this age category (Smith
5 and 6 years from the western part of the Netherlands et al., 2000).
were recruited. Fourteen kindergarten teachers were The 9-HPT is a simple timed test of fine motor coor-
asked to select four children: two with good perfor- dination in which nine pegs are inserted one by one
mance on paper-and-pencil tasks and two with poor and consecutively removed in a pegboard. The child
performance on paper-and-pencil tasks. The parents completes the task twice with the dominant hand.
signed to give their informed consent. The local ethical The best time score is used, with a high score (more
committee provided formal ethical approval. The stud- time needed to perform the task) corresponding to
ies were in full compliance with the Committee on Re- poor fine motor performance.
search Involving Human Subjects (known by its Dutch
initials, CMO) of the Arnhem–Nijmegen area. Timed Test of In-hand Manipulation
The Timed-TIHM assesses three skills of IHM: (1)
translation from finger to palm; (2) translation from
Procedure
palm to finger; and (3) complex rotation of 360° (Pont
For the convergent validity study, children were et al., 2009). The test is designed for children from 5 to
assessed first on the WRITIC and then on the Timed- 6 years of age and takes 5–7 minutes to administer. For
TIHM and the 9-HPT. The Timed-TIHM and the the Timed-TIHM, the nine-hole pegboard was used
9-HPT were administered in the same session outside (same as the pegboard from the 9-HPT). The child
the classroom in a one-to-one situation in random or- was asked to successively pick up two, three, four and
der. Hand use was determined by the WRITIC as this is five pegs with his or her dominant hand, manipulate
an item within the WRITIC. The WRITIC was admin- the pegs with his or her fingertips to the palm and keep
istered individually in the classroom during a time them in the palm of the hand (translation from finger
when all the children were doing different tasks in to palm with stabilization [Task 1]) and then to replace
small groups. Test administrators included three paedi- the pegs one by one into the pegboard (translation from
atric physical therapists and one paediatric occupa- palm to finger with stabilization [Task 2]). The tasks
tional therapist. with two, three and four pegs were included as practice
To determine test–re-test reliability, the Timed- items, whereas the task with five pegs was scored. The
TIHM was administered twice with an interval of third task was a complex rotation task in which the
7–14 days (Streiner and Norman, 2008). Test adminis- child was asked to rotate one peg 360° for a total of five
trators included three occupational therapy students. times using the fingertips of the dominant hand.
To become competent in administering the tests, all In both the rotation and translation tasks, two trials
administrators (1) attended training from the second were given. The best time score was used as the out-
author (M. v. H.); (2) practised the WRITIC with two come measure, with a high score corresponding to
typically developing children; and (3) checked their poor fine motor performance. The number of drops

64 Occup. Ther. Int. 22 (2015) 61–70 © 2015 John Wiley & Sons, Ltd.
de Vries et al. Fine Motor Coordination and Handwriting

and the times an external surface was used to compen- for the subgroups with poor and good performance
sate were recorded as supplemental qualitative on paper-and-pencil tasks.
information. Correlation is interpreted according to Andresen
The Timed-TIHM was modified from the TIHM-R (2000): strong correlation rs > 0.60, moderate correla-
with approval of the test developers (Pont et al., tion rs = 0.30–0.60 and weak correlation rs < 0.30. A
2008) to allow for separate scores for the three ele- high correlation was expected between the Timed-
ments of IHM (finger-to-palm translation, palm-to- TIHM and the 9-HPT, because both are timed tests
finger translation and rotation), to consider compo- evaluating fine motor coordination. A moderate correla-
nents in the literature on hand skills (Exner, 2010) tion was expected between the Timed-TIHM and 9-HPT
and to use the timed scores of these three elements as with the WRITIC-TP. Test–re-test reliability was calcu-
an outcome measure: the Timed-TIHM. lated using the intraclass correlation coefficient (ICC).
Agreement of the ICC was interpreted using the classifi-
cation of Portney and Watkins (2008): 0.01–0.50 = poor,
Writing readiness inventory tool in context
0.50–0.75 = moderate and 0.75–1.0 = good. To process
The WRITIC is an occupation-based measurement the data, SPSS 19.0 (SPSS Inc., Chicago, IL, USA)
to evaluate handwriting readiness in 5- and 6-year-old was used.
children. The WRITIC contains items in three do-
mains: child, environment and paper-and-pencil tasks
Results
(Figure 2). The WRITIC is administered in the class-
room, where the influence of the context can be taken Convergent validity study
into account. First, the child’s interests in paper-and- In total, 119 children were included, of which 60
pencil tasks are evaluated. After that, the child com- (50.4%) were boys. One child was excluded because
pletes a drawing booklet with five paper-and-pencil the parents did not give their written consent. In the
tasks (including tracing, colouring, making pre-writing group of poor writers (n = 43), there were 36 boys
patterns, name writing and copying letters and (83.7%), and in the group of good writers (n = 76),
numbers) while an assessor observes and scores there were 24 boys (31.6%). Because teachers selected
performance. more children who in their opinion had good perfor-
The subdomain “task performance”, used in this mance on paper-and-pencil tasks than children who
study, consists of seven items scored on a 3-point scale in their opinion had poor performance on paper-and-
and six items scored on a 7-point scale (range 0–50). pencil tasks, as they did not meet the selection criteria,
The other subdomains are criterion referenced and the groups of good writers and poor writers were not
provide valuable information for advice and interven- equally divided.
tion. The WRITIC-TP has high internal consistency af- The mean age of the total group was 70.4 months
ter factor analysis, discriminates between children with (70.1 months for the poor writers and 70.6 months
good and poor performance of paper-and-pencil tasks for the good writers). The majority of the children were
and has excellent test–re-test and inter-rater reliability right-handed (84% of the total group, 79.1% of the
(van Hartingsveldt et al., 2014a, 2014c). The poor writers and 86.8% of the good writers). Fifteen
WRITIC-TP, administered in kindergarten, is found percent of the children in total were left-handed
to be the main predictor for handwriting quality (20.9% of the poor writers and 11.8% of the good
(van Hartingsveldt et al., 2014b) evaluated in Grade 1 writers), and only one had a variable hand use (in the
by the Systematic Screening for Handwriting Difficulties group of good performers). Neither age nor handed-
(Smits-Engelsman et al., 2005). ness was significantly different between the two sub-
groups, although gender distribution was significantly
different between the two groups (p < 0.000).
Data analysis
The good writers differed significantly (p < 0.001)
Raw scores were used for the Timed-TIHM, 9-HPT from the poor writers on the WRITIC-TP, on the
and WRITIC-TP. Because the WRITIC scores at an or- Timed-TIHM and on the 9-HPT (Table 1) with the
dinal level, convergent validity was calculated using poor writers performing more poorly on each of the
Spearman’s rho correlation for the total group and measures.

Occup. Ther. Int. 22 (2015) 61–70 © 2015 John Wiley & Sons, Ltd. 65
Fine Motor Coordination and Handwriting de Vries et al.

Figure 2. Overview of the domains and subdomains of the Writing Readiness Inventory Tool in Context with the number of items, sort of
scale and range in each

For the total group, the correlations of the WRITIC- (Table 2), but did not show a significant correlation
TP with the Timed-TIHM and the 9-HPT were all sta- with either of the translation tasks of the Timed-TIHM.
tistically significant except the finger-to-palm transla-
tion task (p = 0.065). The correlations of the total
scores of the Timed-TIHM and 9-HPT with the scores Test–re-test study
of the WRITIC-TP were similar (rs = 0.40 and The study population consisted of 59 children with
rs = 0.40 respectively). 57.6% boys (n = 34); one child was excluded because
The correlation of the total scores of the Timed-TIHM of an incomplete dataset. The mean age was 66 months
with the scores of the 9-HPT was rs = 0.40 (p < 0.001). (range 59–81, standard deviation [SD] 4.6), the major-
For the poor writers, the WRITIC-TP had a signifi- ity was right-handed (88.1%), 8.5% was left-handed
cant moderate correlation with the complex rotation and two children had variable hand use (3.4%).
task of the Timed-TIHM and the 9-HPT, rs = 0.32 The ICC of the total scores of the Timed-TIHM was
(p = 0.042) and rs = 0.30 (p = 0.05), respectively moderate, r = 0.71, p = 0.001. The ICCs for the different

66 Occup. Ther. Int. 22 (2015) 61–70 © 2015 John Wiley & Sons, Ltd.
de Vries et al. Fine Motor Coordination and Handwriting

Table 1. Descriptive data of the outcome scores (mean, ranges) for the total group and for the subgroups of poor and good performers

Total group (n = 119) Gooda (n = 76) Poora (n = 43)

Test Mean (SD) Mean (SD) Mean (SD) p-value Mann–Whitney U

Timed-TIHM (seconds)b

Total score 31.2 28.8 35.4 <0.001

(8.55) (9.12) (7.24)
Finger-to-palm translation task 4.4 4.1 4.9 0.002
(1.38) (1.47) (1.23)
Palm-to-finger translation task 11.3 10.6 12.4 0.010
(4.05) (4.02) (3.96)
Complex rotation task 15.6 14.1 18.1 <0.001
(5.75) (6.89) (4.43)
9-HPT (seconds)c 26.3 25.2 28.4 <0.001
(3.64) (4.12) (2.82)
WRITIC-TP (points)d 41.5 43.3 38.3 <0.001
(5.19) (5.07) (4.31)

SD = standard deviation; Timed-TIHM = Timed Test for In-hand Manipulation; 9-HPT = Nine-hole Peg Test; WRITIC-TP = Writing Readiness
Inventory Tool in Context – Task Performance.
a
Poor and good performers as rated by the teacher.
b
A high score corresponds to poor in-hand manipulation.
A high score corresponds to poor fine motor coordination.
c

d
A high score corresponds to good writing readiness.

Table 2. Correlations of the Timed-TIHM and 9-HPT with the WRITIC-TP for the total group and for the subgroups of poor and good
performers

WRITIC-TP total group (n = 119), WRITIC-TP good performersa (n = 76), WRITIC-TP poor performersa (n = 43),
Spearman r (p-value) Spearman r (p-value) Spearman r (p-value)
Timed-TIHM

Total score 0.402 (p ≤ 0.000) 0.243 (p = 0.040) 0.251 (p = 0.114)

Finger-to-palm 0.384 (p ≤ 0.000) 0.450 (p ≤ 0.000) 0.043 (p = 0.786)
task
Palm-to-finger 0.170 (p = 0.065) 0.068 (p = 0.564) 0.027 (p = 0.862)
task
Complex 0.427 (p ≤ 0.000) 0.248 (p = 0.036) 0.319 (p = 0.042)
rotation task
9-HPT 0.404 (p ≤ 0.000) 0.178 (p = 0.126) 0.301 (p = 0.053)

Timed-TIHM = Timed Test for In-hand Manipulation; 9-HPT = Nine-Hole Peg Test; WRITIC-TP = Writing Readiness Inventory Tool in Context
– Task Performance.
a
Poor and good performers as rated by the teacher.

tasks were r = 0.53 (p < 0.001) for the finger-to-palm However, the Timed-TIHM did not show better corre-
translation task; r = 0.63 (p < 0.001) for the palm-to- lation with the WRITIC-TP in the total group or the
finger translation task; and r = 0.60 (p < 0.001) for the group of poor writers than the 9-HPT, in contrast to
complex rotation task. what we expected. Thus, our hypothesis that the
Timed-TIHM is more closely related to writing readi-
ness in children who are not ready for handwriting is
Discussion not supported. The complex rotation task of the
Our hypothesis that both fine motor coordination tests Timed-TIHM and the 9-HPT showed similar correla-
would have a moderate correlation with the perfor- tions with the WRITIC-TP in the total group and in
mance of paper-and-pencil tasks was supported. the poor-performance group.

Occup. Ther. Int. 22 (2015) 61–70 © 2015 John Wiley & Sons, Ltd. 67
Fine Motor Coordination and Handwriting de Vries et al.

In contrast with our hypothesis, the correlation be- than the poor performers. This is in line with the devel-
tween the Timed-TIHM and the 9-HPT was moderate. opment of IHM as described by Exner (2010). Manip-
This could be explained by the assumption that these ulation tasks with stabilization (the translation from
tests measure different aspects of fine motor coordina- finger to palm and from palm to finger in the Timed-
tion. The Timed-TIHM evaluates complex patterns, in- TIHM) are more difficult than those without stabiliza-
cluding IHM skills, and the 9-HPT evaluates simple tion (the complex rotation in the Timed-TIHM).
patterns of fine motor coordination (picking up, Therefore, translation from finger to palm is easier
placing and releasing pegs). This needs further than translation from palm to finger, which is in agree-
investigation. ment with the correlations. Until the age of 7 years,
Overall, the correlations of the Timed-TIHM and IHM skills develop progressively into more complex
the 9-HPT with the WRITIC-TP were moderate. This skills (Exner, 2010), and there is still a large variety in
is comparable with studies that show the correlation the skills that children master. The three different tasks
of fine motor coordination with the quality of hand- of the Timed-TIHM show a large variety in scores. This
writing (Feder et al., 2005; Volman et al., 2006). This might represent a wide range of scores in the perfor-
can be explained by the fact that fine motor coordina- mance of these IHM skills in these children. Large var-
tion is one of several factors that are involved in hand- iation in performance is an indication that these skills
writing (Figure 1). are not yet fully automatized, children are still
For the poor writers, the highest correlations were searching for the most efficient strategy and these
found between the 9-HPT and the WRITIC-TP and be- IHM skills are still in the developmental phase (Pehoski
tween the complex rotation subtask of the Timed- et al., 1997a, 1997b). Using the Timed-TIHM could
TIHM and the WRITIC-TP. This could mean that the thus possibly show how far children are in their devel-
9-HPT and this complex rotation subtask of the opment of IHM, marking their progress from master-
Timed-TIHM are most appropriate for evaluating fine ing complex rotation (without stabilization) to
motor coordination in this group and for discriminat- mastering translation from finger to palm and, finally,
ing between good and poor fine motor skills in this translation from palm to finger (with stabilization).
age group. The 9-HPT has the advantages that (1) nor- This is an advantage of the Timed-TIHM over the 9-
mative values are available for children between 5 and HPT.
10 years of age (Smith et al., 2000); (2) it is an interna- For the current study, we adapted the TIHM-R and
tionally well-known test; and (3) it is quicker and easier developed the Timed-TIHM. Changes were made in
to apply. order to improve sensitivity of scores and test–re-test
The Timed-TIHM consists of three different tasks reliability. The Timed-TIHM is now easier and quicker
that show different correlations with the WRITIC-TP. to assess, because only time scores are used as com-
These three different tasks of the Timed-TIHM require pared with the TIHM-R in which time scores and qual-
different finger–thumb movements and are of different ity scores are combined. The stability of the test scores
complexity. The complex rotation task shows the best of the Timed-TIHM is acceptable, which is shown in
correlation with the WRITIC-TP, and the palm-to- moderate test–re-test reliability for the total score as
finger translation task shows the poorest correlation well as for the three subtasks. This was not expected be-
and is more variable than the other tasks in the poor cause children are likely to use different performance
performers and also in the total group. The reason for strategies during the test and the re-test.
this could be that this task requires movements that In this study the “finger succession task” or “sequen-
are too complex and not (yet) well developed in this tial finger movements” task was not included.
age group. This is especially the case in the poor Berninger et al. (1992, cited in Berninger, 2009) deter-
writers, and therefore, children are using different and mined that sequential finger movements have a closer
varying strategies (Pehoski et al., 1997a, 1997b). On relationship to handwriting than other fine motor tasks
the other hand, the palm-to-finger translation task only do (r = 0.32). In this task, the child has to touch the
correlates significantly with the WRITIC-TP in the thumb with each finger in sequential order, starting at
good-performance group; the variance in scores is the little finger and moving to the index finger, as
smaller, which could mean that this group is more ma- quickly as possible. In Berninger’s interdisciplinary,
ture and uses a more consistent and efficient strategy programmatic line of research on writing over the past

68 Occup. Ther. Int. 22 (2015) 61–70 © 2015 John Wiley & Sons, Ltd.
de Vries et al. Fine Motor Coordination and Handwriting

25 years, the sequential finger movements task was a different skills that seem related to handwriting, so we
frequently used fine motor test (Berninger, 2009). Be- suggest the use of both tests.
cause the finger succession task falls outside the scope
of the definitions of fine motor coordination by Exner
Conflict of interest
(2010) and the ICF-CY (WHO, 2007), we did not in-
clude this in our research on fine motor tests. Possibly, The authors declare no conflict of interest.
this test has a significant correlation with the 9-HPT
and/or the Timed-TIHM. To investigate this, further Acknowledgements
research is needed.
We would like to thank the children who participated
The correlations that were found are specific for chil-
in the study, as well as their parents and kindergarten
dren aged from 5 to 6 years. Findings and conclusions
teachers. Thanks to Nicole Arink; Mariette Stroo and
might be different in other age groups, such as in chil-
Edith Thijssen (students in the School of Occupational
dren aged over 8 years who have already mastered the
Therapy, Hogeschool van Amsterdam); and Janine
skill of handwriting and are more stable in their fine
Grootendorst, Priscilla Hardus and Inge Hanssen
motor performance. Future studies are recommended
(students in the master’s programme in Paediatric Physi-
on the Timed-TIHM in different age groups to evaluate
cal Therapy, Avans Hogeschool) for their data collection.
the relation between development of fine motor coordi-
nation and handwriting proficiency.
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