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

Visual Motor Integration (VMI ) is the ability of the eyes &
hands to work together in smooth, efficient patterns. It
involves visual perception and eye-hand co-ordination.1
Visual-Motor skills require the ability to translate visual
perception into motor functioning and involve motor control,
motor accuracy, motor co-ordination and psychomotor speed.
Visual motor integration is an important variable to a child’s
handwriting skills, particularly when copying or transposing
from printing material to cursive or manuscript writing. There
are various factors like visual-perceptual, motor planning,
motor memory, sequencing etc for handwriting performance
but Sovik found visual-motor integration was the most
*Occupational Therapist
** Professor & Head OT Deptt.
Place of Study : LTMMC & GH, Mumbai
Period of Study : 2001 - 2002
Correspondence :
Dr. (Ms.) Reepa K. Sanghavi
1003/Giriraj, Neelkanth Valley, Rajawadi, 7th Road,
Ghat-Kopar (E), Mumbai - 400 077
Tel. : 022-25136242, 9820870989
E-mail: reepa99@hotmail.com
Many researchers have explained the importance of VMI in
learning academic skills. Beery believes that before the child
learns to write, the basic geometric shapes have to be
mastered.3 It has been observed that as subject’s ability to
copy the forms on the VMI increases, a concomitant increase
in ability to copy letters accurately is seen, which was
supported by Weil in his study.4 Mati-zissi observed that there
is a correlation between performance in written language
and drawing or design copying tasks.5 Failure on visual-motor
tests may be caused by underlying visual-cognitive deficits
including visual discrimination, poor fine motor skills,
inability to integrate visual – cognitive and motor processes,
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
integration problems in children. According to Berry, visual-
motor integration is defined as the ability to copy geometric
shapes. He suggested that the first nine figures in this DVMI
should be mastered before a child learns to write.
Subsequently many researchers have found high correlation
of DVMI with writing readiness, handwriting skills, coping
abilities, reading,mathematical abilities,academic

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

performance in children.7, 8, 9, 10, 11
The deficits in VMI have been observed in learning disabled
children. Since learning disabilities are closely associated
with integrational problems, the reproduction of geometric
forms may be a relatively sensitive measure of neurological
integrity.12 Tranopol reports that 90% of learning disabled
children has visual motor defects.13 Learning disabled
children with poor visual-motor integration have difficulty
in doing the fine activities like drawing geometric forms,
cutting with scissors, copying design, pasting, coloring etc.
Mattison analyzed the visual-motor problems of children with
learning disabilities and found that they had significantly
more trouble than normal children with design-copy tasks
involving visual-motor components. 14 Oliver found
significant improvement in children’s writing readiness skill
after giving occupational therapy intervention.7
It is evident from literature that learning disabled children
do suffer from visual-motor integration deficit and
occupational therapy intervention helps in remediation.
Keeping in mind all these aspects, this study was conducted
to explore the significance of VMI and effects of occupational
therapy intervention on VMI in learning disabled children.
AIMS AND OBJECTIVE
• To study and compare the performance of normal and
learning disabled children on visual-motor integration
by using Beery and Buktenica’s ‘Development Test of
Visual-Motor Integration’.
• To provide occupational therapy intervention for
improving visual-motor integration in the learning
disabled children and observe the effectiveness of
therapy.
METHODOLOGY
This study used an experimental design where children aged
10 to 14 years were taken & divided into three groups. Group
A consisted of normal children (N=80), group B was the
Experimental group of LD children (N=16) & Group C was
the control group of LD children (N=16). The subjects in
‘B’ & ‘C’ group were attending the LD clinic of the hospital.
The instrument used for testing visual motor integration was
3rd edition of Berry’s Developmental Test of Visual Motor
Integration (DVMI).
Group A:
The subjects for this study included 80 normal Indian children
aged from 10 years to 14 years. This sample was selected
from 5th to 8th standard of a private school. The school
represented high as well as low socioeconomic strata and a
variety of ethnic backgrounds. In an effort to obtain a sample
IJOT : Vol. XXXVII : No. 2
of normal children, the teachers were instructed to exclude
children with upper extremity impairment, visual impairment
and learning disabled children.
PROCEDURE
The Subjects were tested in groups on DVMI. The booklet
consists of 24 geometric forms. All subjects used a standard
HB pencil without an eraser. The subjects were given
instructions about how to perform the test. The time required
to complete the VMI was 10-15 minutes. Depending upon
their performance on visual-Motor Integration scale, scores
were calculated.
Group B and Group C:
Experimental and control group consisted of 32 learning
disabled children aged from 10 to 14 years representing from
high as well as low socioeconomic groups and variety of
ethnic backgrounds.
Inclusion criteria:
1. Children diagnosed as learning disabled by a qualified
professional.
2. Learning disabled with Attention deficit hyperactive
disorder.
Exclusion criteria:
Patient with diagnosis of Cerebral palsy, mental retardation,
autism, neuromuscular disorders, musculoskeletal disorders
were excluded from groups.
Procedure:
The authors with the help of parents filled a detailed proforma
that included demographic data, family history, educational
& developmental history. Perceptual & cognitive functions
of the child were evaluated in details. The tests conducted
by the psychologists such intelligence quotient was noted
down. The DVMI Test was administered individually by
therapist. Depending upon performance on VMI Test, scores
were calculated.
Subjects from group ‘B’ & ‘C’ were referred to occupational
therapy department for intervention. Children from the
experimental group used to attend therapy once in a week.
Supplementary therapy as prescribed by therapist was given
by parents regularly at home. Children & parents of control
group were given counseling about activities that can help
to improve VMI. The therapist did not give formal training
to this group in the department.
OCCUPATIONAL THERAPY INTERVENTION
Occupational Therapy intervention was given to group ‘B’
according to patient’s level of functioning and level of
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
as percentage to normal value (Table 3, graph 2) show that
there is improvement in raw score in both the groups. This
means that both the groups benefited from therapy.
However, when performance of two groups was compared,
the‘t’ & ‘p’ value being highly significant supports the fact
that improvement in experimental group was more than that
in control group (Table 4 & 5, graph 3 & 4). These findings
are consistent with that of Oliver who found that there was
improvement in the performance of writing readiness skills
in children following the sensorimotor occupational therapy
program.7
Various factors may have contributed for this improvement.
In experimental group, the unique element of occupational
therapy program was its combination of direct therapy with
an ongoing supplementary program. In this program, with
therapist’s guidance and appropriate input, the child
performed the activity in graded fashion and in correct way,
which may not be possible by parents alone. Usually parents
of LD children focus on academics goals, which may be
monotonous while the program used in this study for the
experimental group involved play activities having
therapeutic values. The parents’ participation is important
in the therapy to practice new skills but what is equally
important is type of activities and rapport with child, which
is provided by occupational therapist.
Georgia in her study supports motor learning theory and states
that skills are developed through practice and feedback
mechanisms.19 Current theories of motor learning support
the notion that skills are developed through practice and
feedback mechanisms that allow a generalized motor program
to be developed for related skills.
Fisher has suggested that children with right hemisphere
dysfunction have difficulty with visual-constructive and
visual-spatial tasks.20 Hence, in the current study treatment
was aimed at activating the right hemisphere through therapy
activities like building blocks, puzzle etc.
It is evident from the literature that occupational therapy
program is of utmost importance in dealing with VMI deficit
in learning disabled. The present study provides further
support for the value of occupational therapy program. Thus,
in remediation of learning disabled children with VMI
problem, the occupational therapy program has to be
considered as valuable technique.
Another inference that can be drawn from this study is that
DVMI needs to be standardized on larger Indian population
before using it for screening and diagnostic purpose since
Indian children attained mean raw score at younger age as
compared to American children.
IJOT : Vol. XXXVII : No. 2
However, one of the limitations of this study was that the
randomization could not be done. Also, the group was not
further divided into clumsy and non-clumsy children. That
would have given further understanding about other factors
such as fine motor skill deficits, or the dexterity problems
which could be contributing or coexisting with the visual
motor integration dysfunctions in LD children. Also,
inclusion of a handwriting scale would have given insight
into the correlation between visual motor integration &
writing skills.
CONCLUSION
It can be concluded from the study that normal Indian children
aged 10 to 14 years attain mean raw score on DVMI at
younger age than normal American children. Hence there is
need of standardization of DVMI on larger Indian population.
It was evident from the study that due to direct therapy,
improvement in experimental group is more as compare to
control group. In future, studies can be carried out to assess
the long lasting effects of OT intervention after discontinuing
the therapy and to find the co-relation between VMI and
handwriting skills.
ACKNOWLEDGEMENT
We are grateful to Dr. M.E.Yeolekar, Dean, L.T.M.M.C. &
G. H., Sion, Mumbai, and Professor & Head of pediatrics
Department Dr. Mrs. Madhuri Kulkarni, for allowing us to
conduct this study.
Our sincere thanks to Mrs. Swarna Venkat, Principal,
Headmistress at Smt. M.D. Bhatia High English Medium
High School, for permitting us to carrry out VMI test on
normal children and Prof. J.C. Sharma for helping in
statistical analysis, the patients and their family members
without whom this study would have been impossible.
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