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

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.， 2003， Oliver， 1990， Parush 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。

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）。

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.， 2003， Oliver， 1990， Parush 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。

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.， 1999， Lifshitz 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。