The Ohio State University College of Optometry, Columbus, Ohio
Received June 28, 2001;
revision received November 25, 2002.
Marjean Taylor Kulp, OD, MS, FAAO
The Ohio State University
College of Optometry
320 West 10th Ave.
P.O. Box 182342
Columbus, OH 43218-2342
Supported, in part, by Ohio Lion’s Eye Research Foundation grants to MTK.
Purpose. Children may perform poorly on a test of visual-motor integration due to deficits in one or more of the following: visual analysis/visual spatial ability, motor coordination, visual conceptualization, or visual-motor integration. The VMI Supplemental Developmental Test of Visual Perception (VP) and VMI Supplemental Developmental Test of Motor Coordination (MC) were developed to help differentiate between such difficulties after administration of the Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI). However, the clinical value of the VMI supplemental tests has not been reported.
Method. The VMI, VP, and MC were administered to 193 children (mean age = 8.77 years).
Results. Multiple linear regression revealed that the supplemental tests were significantly related to the VMI (VP: β = 0.212 ± 0.044, p < 0.001; MC: β = 0.422 ± 0.299, p < 0.001) but explained only 36.2% of the variance in the VMI. Poor performance was defined as a score >1 SD below the mean for study population norms and below the 16th percentile for published norms. Using study population norms, 35 children did poorly on the VMI, 20% of whom scored poorly on VP, 14.3% of whom scored poorly on MC, 17.1% of whom scored poorly on both supplemental tests, and 48.6% of whom scored within normal on both supplemental tests. Using the published norms, 40 children scored poorly on the VMI. Twenty-eight children scored poorly on VP, 39% of whom scored within normal on the VMI. Fifty-six children scored poorly on MC, 54% of whom scored within normal on the VMI.
Conclusion. There was a significant amount of variance in performance on the VMI that was not explained by performance on the tests of VP or MC alone. Each area should be individually assessed during the visual perceptual examination of children, regardless of performance on the VMI. Even children who perform within normal limits on the VMI may show a deficit in VP or MC.
Visual-motor integration is the ability to coordinate visual perceptual and motor skills. 1 Numerous studies have supported a relation between visual perception ability, such as visual-motor integration, and academic achievement. 2–14 Furthermore, even authors who have expressed a difference of opinion 15 have reported similar differences between good and poor readers (e.g., on a test that involved copying geometric figures, a “draw a bicycle” test (p < 0.0001), and the “draw a clock” test).
In addition, several studies have shown that deficits in visual perceptual skill can be remediated with therapy. 16–20 For example, Seiderman 18 performed a pilot study to determine whether visual perceptual training would improve reading skills among learning disabled children aged 7 to 12 years with visual perceptual difficulties. Thirty-six learning disabled children who were diagnosed with visual perceptual lags were divided into two groups. The experimental group received perceptual therapy (including visual-motor tasks) for 30 min per day for 4 days per week. The control group participated in physical education, art, or science classes for the same amount of time per week. Both groups received daily special reading instruction from a reading specialist. The program continued for two academic years. Although intelligence was not controlled for, the experimental group demonstrated significantly greater improvement (p < 0.05) than the controls in visual perceptual and reading ability (as measured by the Informal Reading Inventory and the Stanford Achievement Test word reading and paragraph meaning). 18
A similar effect was demonstrated by Halliwell and Solan 19 on 105 potentially reading disabled students. Three groups of 35 students each were formed, matched for gender and performance on the Metropolitan Achievement Test. Group one received perceptual therapy in addition to regular reading instruction. Group two received special reading assistance in addition to regular reading instruction. Group three participated only in the regular reading instruction to serve as the control group. After a 7-month training period, the Metropolitan Achievement Test was re-administered. Wilcoxon matched-pairs signed-ranks test revealed a greater improvement (p < 0.05) for reading comprehension on the Metropolitan Achievement Test among those who received visual perceptual therapy and regular reading instruction compared with control subjects. 19
Because visual perceptual skill has been shown to be related to academic ability and because research suggests that it can be improved with therapy, visual perceptual skills are often evaluated during comprehensive pediatric vision examinations. The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI) is a standardized copy forms-type test that is frequently used to assess visual-motor integration. 1,21–23 The VMI has been shown to differentiate between children with normal and reduced visual-motor perceptual ability. 22,23 It can be used in children as young as 3 years and has a clinically objective scoring system. Furthermore, it is regarded as one of the most valid and reliable instruments for the assessment of visual-motor integration. 1,21 Children may perform poorly on a test of visual-motor integration due to deficits in visual analysis/visual spatial ability, motor coordination, visual conceptualization, and/or integration of visual and motor abilities. 1 For example, the child could have a specific deficit in visual perceptual or motor coordination ability. On the other hand, a child could have adequate visual perceptual and motor coordination skills but difficulty integrating the two abilities. Finally, a child could have a deficit in two or more of the above-mentioned skills (i.e., visual perception, motor coordination, and/or integration). Therefore, two supplemental tests were designed and standardized, namely the Visual Perception test and the Motor Coordination test, to allow practitioners to formally differentiate between visual analysis and visual-motor difficulties. To maximize the ability to compare performances on these tests, the VMI supplemental tests contain the same forms, use the same scoring system, and were standardized on the same population as the VMI. Administration of the supplemental tests is performed individually after completion of the VMI.
The Supplemental Developmental Test of Visual Perception assesses the child’s visual analysis/visual spatial skills in a motor-reduced fashion by asking the child to identify each matching form. Administration of the Visual Perception test is performed after the VMI and requires approximately 3 minutes. The Supplemental Developmental Test of Motor Coordination minimizes the analysis requirement to focus on the child’s motor coordination ability. In the Motor Coordination test, the child “traces” each form by connecting the given dots and staying within the paths provided. Administration of the Motor Coordination test should be last in the sequence and requires approximately 5 minutes.
The purpose of this study was to investigate the clinical value of the information provided by the VMI supplemental tests.
All children in the second, third, and fourth grade classes from a primarily white, middle class, suburban elementary school near Columbus, Ohio were invited to participate in this approved study. Informed consent/assent was obtained from a parent/guardian and the children who participated. Sixteen children did not participate due to lack of parental consent or absence during the study. A total of 193 subjects (mean age, 8.77 ± 0.92 years) participated in the study. This unselected group consisted of 53 second graders, 78 third graders, and 62 fourth graders.
The VMI, VMI Supplemental Developmental Test of Visual Perception (VP), and VMI Supplemental Developmental Test of Motor Coordination (MC) tests were individually administered in that order to each student as described in the VMI Administration, Scoring, and Teaching Manual (4th edition). 1 Each perceptual test was scored according to the published instructions. 1
All of the children in the sample completed the VMI and the Supplemental Developmental Tests of Visual Perception and Motor Coordination. Descriptive statistics were determined using SPSS Base 8.0 for Windows for each visual perceptual test (Tables 1 to 3). Sample means and standard deviations were sufficiently normal.
Pearson’s correlation analysis revealed significant correlations between the standard scores on the VMI and the supplemental tests (Visual Perception and VMI: ρ = 0.453, p < 0.001; Motor Coordination and VMI: ρ = 0.539, p < 0.001). A significant correlation was also found between the supplemental tests of Visual Perception and Motor Coordination (ρ = 0.356, p < 0.001) (Table 4). The correlations found were stronger than those previously published. 1 Multiple linear regression revealed that the supplemental tests explained 36.2% of the variance in the VMI and were significantly related to the VMI (VP: β = 0.212 ± 0.044, p < 0.001; MC: β = 0.422 ± 0.299, p < 0.001).
For the following analyses using the sample population norms, poor performance on each test was defined as a score >1 SD below the mean as has been suggested previously 9,24 and is often used in clinical practice. Thirty-five children (18.1% of total sample) did poorly on the VMI. The number of children who did poorly on both the VMI and one or both supplemental tests (VP and/or the MC) was then determined. Of the 35 children who did poorly on the VMI, 20.0% (7) did poorly on the Visual Perception test alone, and 14.3% (5) did poorly on the Motor Coordination test alone, whereas 17.1% (6) did poorly on both the Visual Perception and Motor Coordination tests. In addition, 48.6% (17) of the children who did poorly the VMI did not do poorly on either supplemental test.
For the following analyses using the published norms, poor performance was defined as a score below the 16th percentile (approximately 1 SD below the mean). Forty (20.7%) children did poorly on the VMI. Twenty-eight (14.5%) children did poorly on the Test of Visual Perception, 11 (39%) of whom scored in the normal range on the VMI (within 1 SD of the mean). Fifty-six (29%) children did poorly on the Test of Motor Coordination, 30 (54%) of whom scored in the normal range on the VMI.
Significant correlations were found between the VMI and its supplemental tests. Furthermore, regression analysis revealed that the supplemental test scores were significantly predictive of VMI score. This supports the hypothesis that Visual Perception and Motor Coordination are parts of overall Visual-Motor Integration. 1 On the other hand, multiple linear regression analysis revealed that the supplemental tests only explained 36% of the variance for the VMI. Therefore, there was a significant amount of variance in performance on the VMI that was not explained by performance on the tests of Visual Perception or Motor Coordination alone. It would be expected that the ability to integrate visual and motor skills contributed to this unexplained variance.
A significant correlation was also found between the Visual Perception and Motor Coordination tests. Although the correlations found were stronger than those previously published, 1 both the correlations found in this study as well as those found by Beery 1 were statistically significant. This contradicts previous research concluding that visual perceptual and visual-motor skills are separate abilities. 25 However, the difference in findings between studies may be due to the use of the same shapes for all three types of assessments with the Beery VMI.
In the children who scored >1 SD below the mean on the VMI in this population, the supplemental tests revealed either a visual perception or motor coordination deficit in 34.3% (12) (Visual Perception: 20.0% ; Motor Coordination: 14.3% ). In addition, 17.1% (6) of the children showed deficits in both visual perception and motor coordination, and 48.6% (17) did satisfactorily on both supplemental tests, suggesting a deficit of visual-motor integration alone. Thus, the supplemental tests provided additional clinical information that could allow a practitioner to more efficiently manage approximately 83% of these children. For example, children who showed a deficit in Visual Perception would be expected to benefit from motor-free visual perceptual therapy in addition to integrative therapy, whereas children who showed a deficit in Motor Coordination would be expected to benefit from motor therapy in addition to integrative therapy. On the other hand, integrative therapy would be the primary focus for children who scored poorly on the VMI alone.
Because 39% of children who scored below the 16th percentile in Visual Perception and 54% of children who scored below the 16th percentile in Motor Coordination scored within normal limits on the VMI, this study suggests that each area (Visual-Motor Integration, Visual Perception, and Motor Coordination) should be assessed even in children who perform adequately on the VMI.
We thank Dr. Brett Dietz for technical assistance.
1. Beery KE. Administration, Scoring, and Teaching Manual for the Beery-Buktenica Developmental Test of Visual-Motor Integration with Supplemental Developmental Tests of Visual Perception and Motor Coordination. New Jersey: Modern Curriculum Press, 1997.
2. Rosner J, Rosner J. Comparison of visual characteristics in children with and without learning difficulties. Am J Optom Physiol Opt 1987; 64: 531–3.
3. Solan HA, Mozlin R, Rumpf DA. The relationship of perceptual-motor development to learning readiness in kindergarten: a multivariate analysis. J Learn Disabil 1985; 18: 337–44.
4. Solan HA, Mozlin R, Rumpf DA. Selected perceptual norms and their relationship to reading in kindergarten and the primary grades. J Am Optom Assoc 1985; 56: 458–66.
5. Solan HA, Mozlin R. The correlations of perceptual-motor maturation to readiness and reading in kindergarten and the primary grades. J Am Optom Assoc 1986; 57: 28–35.
6. Taylor Kulp M. Relationship between visual motor integration skill and academic performance in kindergarten through third grade. Optom Vis Sci 1999; 76: 159–63.
7. Cornhill H, Case-Smith J. Factors that relate to good and poor handwriting. Am J Occup Ther 1996; 50: 732–9.
8. Weil MJ, Amundson SJ. Relationship between visuomotor and handwriting skills of children in kindergarten. Am J Occup Ther 1994; 48: 982–8.
9. Williams J, Zolten AJ, Rickert VI, Spence GT, Ashcraft EW. Use of nonverbal tests to screen for writing dysfluency in school-age children. Percept Mot Skills 1993; 76: 803–9.
10. Keogh BK, Smith CE. Visuo-motor ability for school prediction: a seven-year study. Percept Mot Skills 1967; 25: 101–10.
11. Coleman HM. West Warwick visual perception study: II. J Am Optom Assoc 1972; 43: 532–43.
12. Coleman HM. The West Warwick visual perception study: I. J Am Optom Assoc 1972; 43: 452–62.
13. Leton D, Miyamoto L, Ryckman D. Psychometric evaluations of learning disabled students. Psychol Schools 1987; 24: 201–9.
14. Wright D, DeMers S. Comparison of the relationship between two measures of visual-motor coordination and academic achievement. Psychol Schools 1982; 19: 473–7.
15. Helveston EM, Weber JC, Miller K, Robertson K, Hohberger G, Estes R, Ellis FD, Pick N, Helveston BH. Visual function and academic performance. Am J Ophthalmol 1985; 99: 346–55.
16. Solan HA, Ciner EB. Visual perception and learning: issues and answers. J Am Optom Assoc 1989; 60: 457–60.
17. Rosner J. The clinical management of perceptual skills disorders in a primary care practice. J Am Optom Assoc 1986; 57: 56–9.
18. Seiderman AS. Optometric vision therapy: results of a demonstration project with a learning disabled population. J Am Optom Assoc 1980; 51: 489–93.
19. Halliwell JW, Solan HA. The effects of a supplemental perceptual training program on reading achievement. Except Child 1972; 38: 613–21.
20. Streff JW, Poynter HL, Jinks B, Wolff BR. Changes in achievement scores as a result of a joint optometry and education intervention program. J Am Optom Assoc 1990; 61: 475–81.
21. Preda C. Test of visual-motor integration: construct validity in a comparison with the Beery-Buktenica Developmental Test of Visual-Motor Integration. Percept Mot Skills 1997; 84: 1439–43.
22. Wesson MD, Kispert K. The relationship between the Test for Visual Analysis Skills (TVAS) and standardized visual-motor tests in children with visual perception difficulty. J Am Optom Assoc 1986; 57: 844–9.
23. Demsky Y, Carone DA Jr, Burns WJ, Sellers A. Assessment of visual-motor coordination in 6- to 11-yr-olds. Percept Mot Skills 2000; 91: 311–21.
24. Richman JE, Garzia RP. Developmental Eye Movement Test (DEM) Version 1: Examiner’s Booklet. South Bend, IL: Bernell, 1987.
25. Leonard P, Foxcroft C, Kroukamp T. Are visual-perceptual and visual-motor skills separate abilities? Percept Mot Skills 1988; 67: 423–6.