Elsevier

Research in Developmental Disabilities
发育障碍研究

Volume 30, Issue 6, November–December 2009, Pages 1168-1176
第 30 卷,第 6 期,2009 年 11 月至 12 月,页码 1168-1176
Research in Developmental Disabilities

Comparing different short-term service delivery methods of visual-motor treatment for first grade students in mainstream schools
比较主流学校一年级学生视觉运动治疗的不同短期服务提供方法

https://doi.org/10.1016/j.ridd.2009.03.008Get rights and content 获取权利和内容

Abstract 抽象

To compare the efficacy of three different short-term service delivery methods on first grade children with soft neurological signs who suffer from visual-motor difficulties. One hundred and forty seven first grade students who scored below the 21st percentile on the Visual-Motor Integration Test (VMI) were recruited from schools and randomly divided into three intervention groups and an additional control group. One group received Direct Treatment Model (DT), the second group received Collaborative-Consultation Treatment Model (CC) and the third group received a Combined Treatment Model (CT). The CC included treatment administered by teachers, after Collaborative-Consultation with an occupational therapist (OT). The CT included the two models (DT, CC), administered simultaneously. Pre- and post-intervention tests were administered to both groups. Students in all three intervention groups made significant gains in comparison to the control group suggesting that all three service delivery methods had the same effect on children's visual-motor skills. Therapists in school settings who are obliged to be more efficient are encouraged to use the CC or the CT service delivery methods which would enable them to treat more children during the same time-frame, with full confidence that the treatment goals will be achieved as if using the DT.
比较三种不同的短期服务提供方法对患有视觉运动困难的具有软神经体征的一年级儿童的疗效。从学校招募了 147 名在视觉运动统合测试 (VMI) 中得分低于第 21 个百分位的一年级学生,并随机分为三个干预组和一个额外的对照组。1 组接受直接治疗模型 (DT),2 组接受协作会诊治疗模型 (CC),3 组接受联合治疗模型 (CT)。CC 包括在与职业治疗师 (OT) 合作咨询后由教师进行的治疗。CT 包括两种模型 (DT 、 CC),同时给药。对两组进行干预前和干预后测试。与对照组相比,所有三个干预组的学生都取得了显着进步,这表明所有三种服务提供方法对儿童的视觉运动技能具有相同的影响。鼓励学校环境中有义务提高效率的治疗师使用 CC 或 CT 服务提供方法,这将使他们能够在同一时间范围内治疗更多儿童,并完全相信治疗目标将像使用 DT 一样实现。

Keywords 关键字

Visual-motor skills
Short-term treatment
School-based intervention

视觉运动技能
短期治疗
以学校为基础的干预

1. Introduction 1. 引言

Children with soft neurological signs often suffer from visual-motor difficulties and do not tend to achieve maturation of visual-motor integration skills at the beginning of the elementary school years (Martins et al., 2008). According to the literature, only a minority of these children are referred for diagnosis and therefore most parents will not search out early intervention. Often neither parents nor others who interact with these children are aware of the impact that this delay can have on these children when entering the educational system. The archaic notion that maturation will develop with given time is misleading since it is known that the disparity between children with visual-motor difficulties who are not treated, and their classmates, tends to remain constant over the ensuing years (Marr & Cermak, 2001).
具有软神经体征的儿童通常患有视觉运动困难,并且在小学开始时往往无法达到视觉运动整合技能的成熟(Martins et al., 2008)。根据文献,这些孩子中只有少数被转诊诊断,因此大多数父母不会寻求早期干预。通常,父母或与这些孩子互动的其他人都没有意识到这种延迟对这些孩子进入教育系统的影响。认为成熟会随着给定时间的发展而形成的古老观念具有误导性,因为众所周知,没有得到治疗的视觉运动困难儿童与他们的同学之间的差距,在接下来的几年里往往会保持不变(Marr & Cermak,2001)。
Visual-motor integration is defined as integration between visual, perceptual, and motor skills (Exner, 2005). Visual-motor integration is a part of visual perception skills with emphasize on its motor component. Good visual-motor integration function is depend on maturation, and integration of cognitive, visual, perceptual, and motor skills (Tseng and Chow, 2000, Yinon and Weintraub, 2000). Gombert and Fayol (1992) suggest that visual-motor integration is one of the main activities to prepare children for handwriting. Handwriting, and copying, the same as visual-motor integration, require visual identification of form and position in space, giving meaning to letters’ form, and performing motor manipulation for producing letters. Studies focusing on handwriting prove to show significant associations between visual-motor integration and handwriting quality, fluency and legibility (Sortor & Kulp, 2003). Moreover, visual-motor integration was significantly correlated with writing speed, letters formation, and spelling in the first four grades of elementary school (Cornhill and Case-Smith, 1996, Hagborg and Aiello-Coultier, 1994, Phelps and Stempel, 1991, Tseng and Murray, 1994, Weintraub and Graham, 2000). In addition, visual-motor integration was found as the best predictor for handwriting legibility in the second and third grades of school, and for school adjustment (Bart et al., 2007, Yochman, 1995).
视觉运动整合被定义为视觉、知觉和运动技能之间的整合 (Exner, 2005)。视觉运动整合是视觉感知技能的一部分,强调其运动成分。良好的视觉运动整合功能取决于成熟度,以及认知、视觉、知觉和运动技能的整合(Tseng 和 Chow,2000 年,Yinon 和 Weintraub,2000 年)。Gombert 和 Fayol (1992) 认为视觉运动整合是让儿童准备书写的主要活动之一。手写和复制与视觉运动整合一样,需要对形式和空间中的位置进行视觉识别,赋予字母形式意义,并执行运动操作以产生字母。专注于笔迹的研究证明,视觉运动整合与笔迹质量、流畅性和易读性之间存在显著关联(Sortor & Kulp,2003)。此外,在小学前四年级,视觉运动整合与书写速度、字母形成和拼写显著相关(Cornhill 和 Case-Smith,1996 年,Hagborg 和 Aiello-Coultier,1994 年,Phelps 和 Stempel,1991 年,Tseng 和 Murray,1994 年,Weintraub 和 Graham,2000 年).此外,视觉运动整合被发现是学校二年级和三年级笔迹易读性和学校调整的最佳预测指标(Bart 等人。,2007 年,Yochman,1995 年)。
Considering the importance of visual-motor skills for writing and the fact that most children with visual-motor difficulties will arrive at school with no diagnosis or referral to treatment, it is essential to detect as early as possible children with visual-motor difficulties, evaluate them and offer them an intervention program.
考虑到视觉运动技能对写作的重要性,以及大多数患有视觉运动障碍的儿童在没有诊断或转诊治疗的情况下到达学校的事实,尽早发现有视觉运动困难的儿童,评估他们并为他们提供干预计划是至关重要的。
With the enforcement of integrating laws in many countries it has become more common to meet health professions such as occupational therapists (OTs) within the mainstream educational system. Although OTs are trained to evaluate and treat children with visual-motor difficulties there are few evidence-based studies available on treatment of visual-motor skills of school aged children in mainstream education (Lahav et al., 2008, Ratzon et al., 2007).
随着许多国家/地区整合法律的实施,在主流教育系统中与职业治疗师 (OT) 等卫生专业人员会面变得越来越普遍。尽管 OT 接受过评估和治疗视觉运动困难儿童的培训,但关于主流教育中学龄儿童视觉运动技能治疗的循证研究很少(Lahav 等人,2008 年,Ratzon 等人,2007 年)。
In fact, an early intervention has been found to improve visual-motor skills of children in preschool children and children in their first years of school (Dankert et al., 2003, Oliver, 1990, Parush and Hahn-Markowitz, 1997). The lack of evidence studies concerning children in mainstream schools emphasizes the need for an effective, economic, and evidence-based intervention for children with visual-motor difficulties in these settings.
事实上,已经发现一种早期干预可以提高学龄前儿童和上学第一年儿童的视觉运动技能(Dankert et al., 2003Oliver, 1990Parush and Hahn-Markowitz, 1997)。缺乏关于主流学校儿童的证据研究强调需要对这些环境中有视觉运动障碍的儿童进行有效、经济和循证的干预。
In the present study there is an attempt to compare different service delivery methods for short-term treatment in mainstream school settings, in order to provide evidence-based recommendations for children with mild visual-motor problems.
在本研究中,试图比较主流学校环境中短期治疗的不同服务提供方法,以便为患有轻度视觉运动问题的儿童提供循证建议。
Specifically, the objective of this study was to evaluate the efficacy of various short-term service delivery methods on the visual-motor skills of first grade students in mainstream schools. Based on the idea that school-based therapy should integrate the intervention within the school setting, and learning content, we compared the Collaborative-Consultation (CC), the traditional Direct Treatment (DT), and the Combined Treatment (CT; a combination of monitoring and DT) in the mainstream school setting. We hypothesized that visual-motor scores (DTVP-2) in the treatment group would be higher after short-term intervention in comparison to the control group, and that there would be a difference in scores of DTVP-2 between the different service delivery methods (DT, CC, and CT).
具体来说,本研究的目的是评估各种短期服务提供方法对主流学校一年级学生视觉运动技能的疗效。基于基于学校的治疗应该将干预整合到学校环境和学习内容中的想法,我们比较了主流学校环境中的协作咨询 (CC)、传统的直接治疗 (DT) 和联合治疗 (CT;监测和 DT 的结合)。我们假设与对照组相比,治疗组在短期干预后视觉运动评分 (DTVP-2) 会更高,并且不同服务提供方法 (DT 、 CC 和 CT) 之间的 DTVP-2 评分存在差异。

2. Method 2. 方法

2.1. Participants 2.1. 参与者

Participants were first grade children from six Arab and Jewish mainstream elementary schools in Jaffa, Israel. Students attending these schools came from a low socio-economic population. The schools met the following criteria: (a) attendance of an occupational therapist at the school (b) allocation of an occupational therapy room at the school and (c) a commitment by the school to carry out the study.
参与者是来自以色列雅法 6 所阿拉伯和犹太主流小学的一年级儿童。就读这些学校的学生来自较低的社会经济人口。这些学校符合以下标准:(a) 职业治疗师在学校出勤 (b) 在学校分配职业治疗室,以及 (c) 学校承诺进行研究。
At the beginning of 2 sequential years (teachers and OT's were the same, and no differences in curriculum occurred during these 2 years), all first grade students attending the schools (805 children) were subjected to the Visual-Motor Integration Test (VMI, Beery & Buktenica, 1997). Scores of 25–75% are considered average (Beery & Buktenica, 1997). A score of 21% and less was taken as the cut-off point for this study. 322 (40%) children scored under the cut-off point. 251 (78%) parents signed a consent form approving their child's participation in the treatment process. Exclusion criteria for participants were: (a) a medical diagnosis indicating a central-nervous system dysfunction such as mental retardation, cerebral palsy or autism, (b) severe sensory loss (i.e., visual or auditory impairment), (c) indication of emotional, behavioral or mental problems, as reported by the teachers, (d) children from Special Education Programs who are integrated, part time, into mainstream classes, (e) children who had been receiving occupational therapy or physiotherapy treatment and (f) children failing to complete the study program, due to repeated absence from school.
在连续两年开始时(教师和职业训练相同,这两年的课程没有差异),所有在学校的一年级学生(805名儿童)都接受了视觉-运动整合测试(VMI,Beery & Buktenica,1997年)。25-75%的分数被认为是平均水平(Beery & Buktenica,1997)。21% 及以下的分数作为本研究的分界点。322 名 (40%) 儿童的分数低于分界点。251 名 (78%) 家长签署了一份同意书,批准他们的孩子参与治疗过程。参与者的排除标准是: (a) 表明中枢神经系统功能障碍的医学诊断,例如智力低下、脑瘫或自闭症,(b) 严重的感觉丧失(即视觉或听觉障碍),(c) 教师报告的情绪、行为或精神问题的迹象,(d) 来自特殊教育计划的儿童,兼职融入主流班级, (e) 一直在接受职业治疗或物理治疗的儿童,以及 (f) 由于多次缺勤而未能完成学习计划的儿童。
After applying the exclusion criteria, the 147 remaining children were placed in one of three study and one control groups; DT group (n = 29), CC group (n = 38), CT group (n = 24) and control group (n = 56). Mean age of study population was 76.63 months (±4.03). The four groups were compared for gender, ethnicity origin (χ2), age, and pre-test (VMI and DTVP-2) scales. One-way MANOVA revealed that there were no significant differences between the four groups (Multivariate Wilks; F(6,45) = .97; p = NS). No significant differences were found between the participants of the first and second year (ps > .21).
应用排除标准后,将剩余的 147 名儿童分为 3 项研究组和 1 个对照组之一;DT 组 (n=29) 、 CC 组 (n=38) 、 CT 组 (n=24) 和对照组 (n=56)。研究人群的平均年龄为 76.63 个月 (±4.03)。比较四组的性别、种族来源 (χ2)、年龄和前测 (VMI 和 DTVP-2) 量表。单因素多元方差分析显示,四组之间无显著差异(多变量 Wilks;F(6,45)=.97;p=NS) 的第一年和第二年的参与者之间没有发现显着差异 (ps>.21)。

2.2. Measures 2.2. 措施

2.2.1. Visual-Motor Integration
2.2.1. 视觉运动整合

The Beery–Buktenica Developmental Test of Visual-Motor Integration (VMI) (Beery & Buktenica, 1997) is routinely used in these schools as a screening measure. The test involves a developmental sequence of geometric forms to be copied using paper and pencil. The full 27-items were administered by group procedure in the classroom by the school OT in about 10–15 min. The test is reliable and valid. Test–retest reliability is reported as .87, and inter-scorer reliability is reported as .94 (Marr, Windsor, & Cermak, 2001). Inter-rater agreement was examined for this study using Pearson coefficient of correlation. The resulting correlation between both school occupational therapists on a set of 10 student tests was .97. In the present study the VMI was carried out by the local OT at the beginning of each first grade year, after obtaining parental consent.
Beery-Buktenica视觉-运动整合发展测试(VMI(Beery & Buktenica),1997年)在这些学校中经常被用作筛查措施。该测试涉及使用纸和铅笔复制的几何图形的发展序列。完整的 27 个项目由学校 OT 在课堂上通过小组程序在大约 10-15 分钟内进行管理。该测试是可靠和有效的。重测信度报告为.87,评分者间信度报告为.94(Marr, Windsor, & Cermak, 2001)。本研究使用 Pearson 相关系数检查评分者间一致性。在一组 10 名学生测试中,两所学校职业治疗师之间的相关性为 .97。在本研究中,VMI 由当地 OT 在每个一年级开始时在获得父母同意后进行。

2.2.2. Developmental Test of Visual Perception (DTVP-2)
2.2.2. 视觉感知发育测试 (DTVP-2)

Developmental test of visual perception (DTVP-2) (Hammill, Pearson, & Voress, 1993): The Test of Visual Perceptual Skills--Revised is a well-constructed and effective psychometric test frequently used by pediatric occupational therapists to evaluate children and youth with apparent visual-perceptual dysfunction (Brown et al., 2003, Cheung et al., 2005). It includes eight subtests of which only four were administrated in this study to measure visual-motor integration performance: eye–hand coordination, copying, spatial relations and visual-motor speed; all are motor related measures that served as dependant variables. Norms for DTVP-2 were developed using a sample of 1972 children 4–10 years of age. During test development, a series of reliability and validity studies were conducted. Test–retest reliability for the DTVP (n = 88) ranged from r = .71 to r = .86 and was r = .96 for the total score. Inter-rater reliability (n = 88) was r = .98 for the total test (Hammill et al., 1993). The test was administered and scored before and after treatment by two of the authors, both of whom were unaware of the children's group categories. Reliability for the overall score of the DTVP-2 between the two investigators was r = .907.
视觉感知发展测试(DTVP-2)(Hammill, Pearson, & Voress, 1993):视觉感知技能测试--修订版是一种结构良好且有效的心理测试,经常被儿科职业治疗师用来评估有明显视觉感知功能障碍的儿童和青少年(Brown等人,2003年,Cheung等人,2005年).它包括 8 个子测试,其中 4 个子测试在本研究中仅进行了 4 个子测试,以测量视觉运动整合性能:眼手协调、复制、空间关系和视觉运动速度;所有这些都是作为因变量的运动相关度量。DTVP-2 的规范是使用 1972 名 4-10 岁儿童的样本制定的。在测试开发过程中,进行了一系列信度和效度研究。DTVP (n=88) 的重测信度范围为 r=.71 至 r=.86,总分为 r=.96。总测试的评分者间信度 (n=88) 为 r=.98 (Hammill et al., 1993)。该测试由其中两位作者在治疗前后进行管理和评分,他们都不知道儿童组的类别。两名研究者之间 DTVP-2 总分的可靠性为 r=.907。

2.2.3. Service delivery methods
2.2.3. 服务交付方式

All service delivery methods were short-term interventions and consisted of enhancing visual-motor skills by paper and pencil assignments and in-hand manipulation activities. The short-term service delivery methods used in this study are based on motor learning principles (Polatajko et al., 1995), on the multi-sensory writing program principles (Lockhart & Law, 1994), and on research that found associations between dexterity skills and normal development of visual-motor proficiency (Benbow, 1995, Cornhill and Case-Smith, 1996, Humphry et al., 1995, Levine et al., 1981). The activities and tools chosen for this intervention program were also based on clinical experience and Benbow's recommendations (Benbow, 1995). The sequence of the sessions in all the three service delivery methods was similar: Approximately 1/3 of each session was dedicated to playful fine motor activities (preparing masks and greeting cards, origami, arts and crafts) while the remaining 2/3 of each session was dedicated exclusively to pencil and paper activities such as copying figures, and lined up numbers.
所有服务提供方法均为短期干预,包括通过纸笔作业和手部操作活动提高视觉运动技能。本研究中使用的短期服务提供方法基于运动学习原则(Polatajko等人,1995),多感官写作程序原则(Lockhart & Law,1994),以及发现灵巧技能与视觉运动能力正常发展之间存在关联的研究(Benbow,1995,Cornhill和Case-Smith,1996Humphry et al., 1995Levine et al., 1981)。为该干预计划选择的活动和工具也基于临床经验和 Benbow 的建议 (Benbow, 1995)。所有三种服务提供方法的会议顺序都相似:每节课大约 1/3 专门用于有趣的精细运动活动(准备面具和贺卡、折纸、艺术和手工艺),而其余 2/3 的每节课专门用于铅笔和纸活动,例如复制数字和排队数字。

2.2.4. Direct Treatment 2.2.4. 直接处理

DT was provided by 10 OT students during their clinical studies after they had finished their academic training in pediatric OT. They administered the intervention sessions to each pair of pupils in the school's OT room. All OT students were supervised weekly by an experienced pediatric OT, guiding them on applying the intervention principles. Various activity tools were prepared by the supervising OT in 12 pre-made kits, a kit for each week's session. The intervention included 12 sessions, each held once a week for 45 min.
DT 由 10 名 OT 学生在完成儿科 OT 学术培训后的临床研究期间提供。他们在学校的 OT 室为每对学生进行干预。所有 OT 学生每周都由经验丰富的儿科 OT 监督,指导他们应用干预原则。监督 OT 在 12 个预制工具包中准备了各种活动工具,每个工具包用于每周的会议。干预包括 12 次会议,每周举行一次,每次 45 分钟。

2.2.5. Collaborative-Consultation Treatment
2.2.5. 协作咨询治疗

The CC was administered in the classroom (to all the students) by the class teacher and the local school OT for 12 consecutive weeks. The two occupational therapists who conducted this intervention were both experienced local school occupational therapists. While the students in the class appointed to the CC group were getting treatment, the rest of the students in the class beneficiated from it as well.
CC 由班主任和当地学校 OT 在课堂上(针对所有学生)连续 12 周进行。进行这项干预的两名职业治疗师都是当地经验丰富的学校职业治疗师。虽然被分配到 CC 组的班级学生正在接受治疗,但班上的其他学生也从中受益。
In addition to the treatment given in the classroom, the CC included occupational therapists’ and teachers’ consultation meeting once a week. The consultation's focus was on analyzing each of the treatment group participants’ treatment goals (as seen during the treatment sessions) and each child's difficulties were addressed in the subsequent treatment intervention.
除了在课堂上接受治疗外,消委会亦包括每星期一次的职业治疗师及教师咨询会。咨询的重点是分析每个治疗组参与者的治疗目标(如在治疗过程中看到的),并在随后的治疗干预中解决每个孩子的困难。
The CC method was designed based on the school curriculum. Prior to the beginning of the school year, teachers presented to occupational therapists the academic content planned to be taught to the entire class (i.e., “Me and my body”, “My family”, “Seasons of the year”, etc.). Teachers and occupational therapists tried to integrate OT treatment principles, techniques and activities for improving visual-motor integration into that context.
CC 方法是根据学校课程设计的。在学年开始之前,老师向职业治疗师介绍了计划向全班教授的学术内容(即 “我和我的身体”、“我的家庭”、“一年中的季节 ”等)。教师和职业治疗师试图将 OT 治疗原则、技术和活动整合到该环境中,以改善视觉运动整合。

2.2.6. Combined Treatment
2.2.6. 联合治疗

CT consisted of a combination of two service delivery methods (DT and Monitoring). Treatment protocols included a combination of DT as presented above and monitoring model treatment provided by school teachers after consultation with an experienced OT. The DT was administered by 8 OT students and the CT by 4 permanent teachers of the class who have had consultation with the occupational therapists who had administered the CC (only in this group the occupational therapists did not participate in the classroom activities). The CT enabled the child to receive in addition to 45 min of DT, another15 min treatment, three times a week. Following the OT monitoring, the teacher assigned a special activity to the student, which he had to complete as a self-assignment in the classroom. This procedure enhanced the teachers’ awareness of the child's visual-motor difficulties and provided them with a variety of visual-motor activities which could be integrated into the academic context.
CT 由两种服务提供方法 (DT 和 Monitoring) 的组合组成。治疗方案包括上述 DT 和学校教师在咨询经验丰富的 OT 后提供的监测模型治疗的组合。DT 由 8 名 OT 学生进行,CT 由该班的 4 名常任教师进行,他们与管理 CC 的职业治疗师进行了咨询(仅在该组中,职业治疗师不参加课堂活动)。CT 使孩子除了接受 45 分钟的 DT 外,还接受了每周 3 次 15 分钟的治疗。在 OT 监控之后,老师为学生分配了一项特殊活动,他必须在课堂上作为自我作业完成。该程序增强了教师对孩子视觉运动困难的认识,并为他们提供了各种可以融入学术环境的视觉运动活动。

2.2.7. Control group 2.2.7. 对照组

This group received no treatment during their 12-week participation in the study and served as non-treated controls. Upon conclusion of the 12-week period and after being assessed on the DTVP 2 and finishing their participation in the study, they received the DT treatment.
该组在参与研究的 12 周期间未接受治疗,并作为未治疗的对照。在 12 周期结束时,在接受 DTVP 2 评估并完成参与研究后,他们接受了 DT 治疗。
The classic monitoring method was not used in this study since the schools participating in the study objected to using it. They had participated in a previous pilot study, conducted in their schools, in which children did not show significant improvement after being treated with the monitoring method (Metzger, 2003).
本研究没有使用经典的监测方法,因为参与研究的学校反对使用它。他们之前参加了在他们的学校进行的一项试点研究,在该研究中,儿童在接受监测方法治疗后没有表现出显着改善(Metzger,2003 年)。
10 OT students (DT Group) and 8 OT students (CT Group) conducted the intervention as part of their fieldwork experience. They administered the intervention sessions to each pair of pupils in the school's OT room. All OT students were supervised weekly by an experienced pediatric OT, guiding them on how to use the weekly kit and analyzing the children's performances on the session. The experienced occupational therapists who administered the CC and had consulted with the teachers were also weekly supervised by the same experienced pediatric OT who had supervised the students. The OT supervisor provided the school occupational therapists with the same kits, adjusted to the academic assignment context. The fact that the same person supervised and directed both students and professional occupational therapists on a weekly basis enabled control over the similarity of the intervention process.
10 名 OT 学生(DT 组)和 8 名 OT 学生(CT 组)进行了干预,作为他们实地考察经验的一部分。他们在学校的 OT 室为每对学生进行干预。所有 OT 学生每周都由经验丰富的儿科 OT 监督,指导他们如何使用每周工具包并分析孩子们在课程中的表现。管理 CC 并咨询过老师的经验丰富的职业治疗师也每周由监督学生的同一位经验丰富的儿科 OT 监督。OT 主管为学校职业治疗师提供了相同的工具包,并根据学术作业情况进行了调整。同一个人每周监督和指导学生和专业职业治疗师这一事实使干预过程的相似性得到控制。

2.3. Procedure 2.3. 操作步骤

The present study is a prospective study. Written permission approving this study was obtained from the chief scientist of the Israeli Ministry of Education. All parents of first grade students signed consent forms for administering the VMI. The forms included a separate consent form with an explanation that if necessary, it would include further evaluation and intervention. Children below the VMI cut-off point were randomly assigned to either DT, to CC Treatment, to CT or to the Control group. Participants were further evaluated before and after intervention using the DTVP-2. Both pre- and post-evaluations were administered within the 2 weeks prior to the beginning of the intervention and 2 weeks after termination of the intervention. After the first evaluation the children underwent 12 further intervention sessions over a period of 3 months.
本研究是一项前瞻性研究。批准这项研究的书面许可是从以色列教育部的首席科学家那里获得的。一年级学生的所有家长都签署了管理 VMI 的同意书。这些表格包括一份单独的同意书,并解释说,如有必要,它将包括进一步的评估和干预。低于 VMI 临界点的儿童被随机分配到 DT、CC 治疗组、CT 组或对照组。参与者在干预前后使用 DTVP-2 进行了进一步评估。评估前和评估后均在干预开始前 2 周和干预终止后 2 周内进行。第一次评估后,儿童在 3 个月内接受了 12 次进一步的干预。
Data collection on the DT (N = 29) was performed during the first year and on the CT (N = 24) and CC (N = 38) during the second year. The classes chosen to receive either the CC or the CT were randomly chosen. Since CC was administered as a group intervention program, we included all children under the 21st percentile in the classes chosen for CC in one group. In classes where CT was administered, children were randomly assigned to either the CT or control group. The same randomization applied during the first year (assignment to either DT or control). During both years the control groups included N = 30 in the first year and N = 26 in the second year.
第一年进行 DT (N=29) 数据收集,第二年进行 CT (N=24) 和 CC (N=38) 数据收集。选择接受 CC 或 CT 的班级是随机选择的。由于 CC 是作为团体干预计划进行的,因此我们将第 21 个百分位数以下的所有儿童纳入一组为 CC 选择的班级中。在进行 CT 的班级中,儿童被随机分配到 CT 组或对照组。第一年应用相同的随机化(分配到 DT 或对照)。在这两年中,对照组第一年为 N=30,第二年为 N=26。

2.4. Statistical analysis
2.4. 统计分析

According to the literature on intervention efficacy studies, it is preferable to use raw scores rather than standard scores or percentiles (Wilson, Polatajko, Kaplan, & Faris, 1994). Therefore, calculations in the present study were done with raw scores. In order to determine the effect of intervention on the study groups, repeated measures MANOVA were conducted (time × group × DTVP-2 4 measures) and repeated measures ANOVA were conducted in order to compare study and control groups in their total DTVP-2 standard score. To detect the source of difference between the groups while controlling the preliminary pre-test scores, ANCOVA with Bonferroni post hoc test was done (pre-test score was the co-variant).
根据关于干预效果研究的文献,使用原始分数比标准分数或百分位数更可取(Wilson, Polatajko, Kaplan, & Faris, 1994)。因此,本研究中的计算是使用原始分数完成的。为了确定干预对研究组的影响,进行了重复测量 MANOVA (time×group×DTVP-2 4 项测量) 和重复测量方差分析,以比较研究组和对照组的 DTVP-2 总标准评分。为了在控制初步验前分数的同时检测组间差异的来源,进行了 ANCOVA 和 Bonferroni 事后检验 (验前分数是协变量)。

3. Results 3. 结果

Repeated measure (RM) MANOVA revealed significant interaction effect (F(12,241) = 4.45; p < .001) of group × intervention. The four DTVP-2 subtests scores served as dependant variables. The following Univariate RM ANOVA tests indicated that the source of variance was eye–hand coordination (EHC) (F(3,94) = 2.70; p < .05), copying score (F(3,94) = 5.87; p < .01) and spatial relations (SR) (F(3,94) = 9.82; p < .001). Additional post hoc ANCOVA between groups on post-test scores with pre-test scores as COVARIATE showed that all children involved in the service delivery methods significantly improved their performance as compared to control group whose improvement was not significant. Means and SD are presented in Table 1.
重复测量 (RM) 多元方差分析显示显著的交互效应 (F(12,241)=4.45;p<.001)×的干预组。四个 DTVP-2 子测试分数作为因变量。以下单变量 RM 方差分析检验表明方差来源是眼手协调 (EHC) (F(3,94)=2.70;p<.05),复制分数 (F(3,94)=5.87;p<.01) 和空间关系 (SR) (F(3,94)=9.82;p<.001)。以 COVARIATE 为协变量的后测分数组间额外的事后 ANCOVA 表明,与改善不显着的对照组相比,所有参与服务提供方法的儿童的表现都显着提高。平均值和 SD 见表 1

Table 1. DTVP-2 raw scores (mean ± SD) by group and time.
表 1.按组和时间划分的 DTVP-2 原始分数 (mean±SD)。

Empty CellEye–hand coordination 眼手协调Copying 复制Visual-motor speed 视觉运动速度Spatial relations 空间关系
Empty CellPre-M(SD) M(标清)Post-M(SD) M后(SD)Pre-M(SD) M(标清)Post-M(SD) M后(SD)Pre-M(SD) M(标清)Post-M(SD) M后(SD)Pre-M(SD) M(标清)Post-M(SD) M后(SD)
Direct Treatment 直接治疗134.96 (22.56)152.79 (15.79)16.00 (4.62)19.62 (4.62)9.46 (4.04)14.83 (5.47)23.08 (9.62)35.79 (6.49)
Collaborative-Consultation
合作咨询
138.63 (16.48)152.33 (11.33)17.62 (5.33)22.83 (5.10)5.00 (3.53)7.96 (5.41)18.08 (9.86)27.75 (11.03)
Combined Treatment 联合治疗143.45 (16.33)150.18 (16.91)22.77 (5.08)25.18 (5.11)9.18 (5.54)13.14 (5.51)26.82 (11.03)30.05 (10.37)
Control 控制143.57 (15.21)149.32 (11.59)16.64 (3.41)17.71 (3.67)10.39 (4.40)14.75 (6.70)24.25 (8.85)29.14 (8.46)
The one-way ANOVA revealed a significant difference between study and controls on the total score of DTVP-2. Additional post hoc between groups on the total score showed that all children involved in either of the service delivery methods significantly improved their performance as compared to control group (F = 6.32, p < .001).
单因素方差分析显示研究和对照组在 DTVP-2 总分方面存在显著差异。总分组间的额外事后显示,与对照组相比,参与任何一种服务提供方法的所有儿童的表现都显着提高 (F=6.32,p<.001)。

4. Discussion 4. 讨论

All three service delivery modalities used in the present study significantly improved children's visual-motor skills in comparison to the control group who received no treatment. The DT, CC, and CT were proved to be effective in significantly promoting eye–hand coordination, copying abilities, and spatial relations skills of the children who participated in the study. These results add to the evidence-based research which confirms the concept that intervention has been found to improve visual-motor skills of children in the early school years (Dankert et al., 2003, Oliver, 1990, Parush and Hahn-Markowitz, 1997). As was mentioned earlier, children were given varied fine motor activities such as using scissors, gluing, and drawing. Albeit, children were not trained to succeed in the tests, the experience and practice improved their visual-motor skills as was manifested on the subtests of the DTVP-2. The uniqueness of the study lies in its focus on early short-term intervention for first graders from low socio-economic backgrounds. Until now, most studies have proved the efficacy of long interventions of at least 7 months to improve visual-motor integration skills (Case-Smith, 1996, Case-Smith, 2002, Parush and Hahn-Markowitz, 1997). The ability to improve children's visual-motor skills in a 3-month period during only 12 therapeutic sessions is of great importance. First of all it is an effective and rapid method which can save resources to the educational system. Second, it helps children to improve their skills rapidly and catch up with their class mates. By improving their visual-motor skills they can cope with school assignment and acquire writing skills without developing significant gaps.
与未接受治疗的对照组相比,本研究中使用的所有三种服务提供方式都显着改善了儿童的视觉运动技能。DT 、 CC 和 CT 被证明可有效显着促进参与研究的儿童的手眼协调、复制能力和空间关系技能。这些结果增加了循证研究,证实了干预可以改善学龄早期儿童视觉运动技能的概念(Dankert et al., 2003Oliver, 1990Parush and Hahn-Markowitz, 1997)。如前所述,孩子们接受了各种精细运动活动,例如使用剪刀、粘合和绘画。尽管孩子们没有接受过在测试中取得成功的训练,但正如 DTVP-2 的子测试所体现的那样,这种经验和实践提高了他们的视觉运动技能。该研究的独特之处在于它侧重于对来自低社会经济背景的一年级学生进行早期短期干预。到目前为止,大多数研究已经证明了至少 7 个月的长期干预对提高视觉运动整合技能的有效性(Case-Smith,1996 年,Case-Smith,2002 年,Parush 和 Hahn-Markowitz,1997 年)。仅 3 次治疗即可在 12 个月内提高儿童视觉运动技能的能力非常重要。首先,它是一种有效且快速的方法,可以为教育系统节省资源。其次,它可以帮助孩子快速提高技能并赶上他们的同学。 通过提高他们的视觉运动技能,他们可以应付学校作业并获得写作技能,而不会产生明显的差距。
Each service delivery modality was effective in improving children's visual-motor skills; however the addition of 15 min three times a week given by teachers after OT monitoring, in the CT group did not add to the effectiveness of the suggested intervention. It might be that CT did not have a synergistic effect because children improved their visual-motor skills up to a level that actualized their potential as much as children in the DT group and CC group and could not benefit more from the CT service delivery method. Although the three service delivery methods had similar effect and none of them had an advantage on the others, teachers seems to be more satisfied from the CT and CC methods. Teachers who were involved in the study reported that the CT and CC programs contributed to their understanding of the children's difficulties and changed their point of view. For example one teacher said: “At the beginning, I thought he was lazy, but now, after the intervention, I can detect his difficulties and interpret his behavior differently.” Studies that assessed teachers’ satisfaction with occupational therapists intervention showed that the combination between CC and DT was the most satisfactory, and that the collaboration with occupational therapists helped them apply the acquired knowledge to other situations in the class and academic contexts (Kemmis & Dunn, 1996). The Occupational Therapists who participated in this study were also satisfied and beneficiated from experiencing the different treatment modalities.
每种服务提供方式都有效提高了儿童的视觉运动技能;然而,在 CT 组中,教师在 OT 监测后每周 3 次增加 15 分钟并没有增加建议干预的有效性。可能是 CT 没有协同效应,因为儿童将他们的视觉运动技能提高到与 DT 组和 CC 组儿童一样能实现其潜力的水平,并且无法从 CT 服务提供方法中受益更多。尽管三种服务提供方法的效果相似,并且没有一种比其他方法更有优势,但教师似乎对 CT 和 CC 方法更满意。参与研究的教师报告说,CT 和 CC 计划有助于他们理解儿童的困难并改变他们的观点。例如一位老师说:“一开始,我觉得他很懒,但现在,经过干预,我可以察觉到他的困难,并以不同的方式解释他的行为。评估教师对职业治疗师干预满意度的研究显示,CC和DT之间的结合是最令人满意的,而且与职业治疗师的合作帮助他们将获得的知识应用于课堂和学术环境中的其他情况(Kemmis & Dunn,1996).参与这项研究的职业治疗师也对体验不同的治疗方式感到满意并从中受益。
It should be noted, that this study is novel in that it was conducted in mainstream schools where the participants were children with minor problems which are frequently not even identified by the educational system (Muhlenhaupt, 2003, Spencer et al., 2006). Providing treatment for those children and explaining to the school team that part of their behavior is a consequence of their difficulties, as well as offering methods of early intervention proved to improve children's skills in this study.
应该指出的是,这项研究是新颖的,因为它是在主流学校进行的,参与者是有小问题的孩子,这些问题甚至往往不被教育系统发现(Muhlenhaupt,2003 年,Spencer 等人,2006 年)。为这些孩子提供治疗,并向学校团队解释他们的部分行为是他们困难的结果,以及提供早期干预的方法,在这项研究中被证明可以提高儿童的技能。
In conclusion, the findings of the present study suggest that all three service delivery methods had the same effects on children's visual-motor skills. Therapists in schools, who are asked to be more efficient, are encouraged to use the CC or the CT service delivery methods which would enable them to treat more children during the same time-frame, with full confidence that the treatment goals will be achieved as if using the DT.
总之,本研究的结果表明,所有三种服务提供方法对儿童的视觉运动技能具有相同的影响。学校的治疗师被要求提高效率,鼓励他们使用 CC 或 CT 服务提供方法,这将使他们能够在同一时间范围内治疗更多的儿童,并完全有信心实现治疗目标,就像使用 DT 一样。

5. Limitations and future directions
5. 限制和未来方向

Mastering visual-motor skills is accepted as a parameter for evaluation of writing readiness by many investigators (Beery and Buktenica, 1997, Daly et al., 2003, Laszlo and Broderick, 1991). We did not asses the effect of the treatment on writing skills. In Israel, according to the alphabetic Hebrew handwriting assessment, the outcome measure of handwriting activity can only be assessed in the second year of school (Erez et al., 1999, Lifshitz and Parush, 1999). This constraint limits the ability to accurately assess writing acquisition of first grade students. This dictates assessing only the visual-motor skills, which are related to handwriting.
掌握视觉运动技能被许多研究人员接受为评估写作准备情况的参数(Beery 和 Buktenica,1997 年,Daly 等人,2003 年,Laszlo 和 Broderick,1991 年)。我们没有评估治疗对写作技能的影响。在以色列,根据按字母顺序排列的希伯来语笔迹评估,笔迹活动的结果测量只能在学校的第二年进行评估(Erez et al., 1999Lifshitz and Parush, 1999)。这种限制限制了准确评估一年级学生写作习得的能力。这要求仅评估与笔迹相关的视觉运动技能。
OT's can apply different treatment models in the school system in order to improve visual-motor skills of children in the first grades of school. As all methods proved to be effective, selecting the appropriate method should be dependent on the specific context and school system. Best would be to consult with the school team on the most adjustable and suitable method.
OT 可以在学校系统中应用不同的治疗模式,以提高学校一年级儿童的视觉运动技能。由于所有方法都被证明是有效的,因此选择合适的方法应取决于具体情况和学校系统。最好的办法是与学校团队协商最合理和合适的方法。
The movement toward evidence-practice in health care increasingly calls to find and use evidence as a basis for interventions. The treatment plan proposed in this research was used in school settings with low socio-economic populations. This should be the basis for additional research in other socio-economic populations and other mainstream settings.
医疗保健中走向循证实践的运动越来越呼吁寻找和使用证据作为干预的基础。本研究中提出的治疗计划用于社会经济人口较少的学校环境。这应该成为对其他社会经济人群和其他主流环境进行额外研究的基础。
Another possible future research could extend clinical observations and evaluate performances related to school settings and out-of-school settings. In addition, a longitudinal study regarding how these children do when they move on to second grade and they actually do engage in handwriting, should be conducted. Assessing writing as an outcome measure would contribute to the prediction validity of our intervention. Finally, further experimentally oriented research is needed to assess the change in teachers’ attitudes after participating in the different service delivery methods presented in this study, and if and how they implement this new knowledge into their teaching.
另一项可能的未来研究可以扩展临床观察并评估与学校环境和校外环境相关的表现。此外,应该进行一项纵向研究,了解这些孩子在进入二年级时的表现,并且他们确实会写字。将写作作为一种结局指标进行评估将有助于我们干预的预测有效性。最后,需要进一步以实验为导向的研究来评估教师在参与本研究中介绍的不同服务提供方法后态度的变化,以及他们是否以及如何将这些新知识应用到教学中。

Acknowledgments 确认

This study was supported by the Price Brody Fund.
这项研究得到了普莱斯布罗迪基金的支持。
We thank all the OT students who provided the treatment plan, the teachers for their cooperation, the parents for their consent, and the children who willingly attended the 12 treatment sessions.
我们感谢所有提供治疗计划的 OT 学生、老师的合作、家长的同意以及自愿参加 12 次治疗课程的孩子们。

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