A standardized worksheet with rows of small circles. Thirty seconds per hand. A sharpened pencil. That is the entire assessment.
We call it Fine Motor Speed and Accuracy Test (FMSAT)- because that is where we want the test taker’s attention. But the data is telling us the test is not really about speed at all. It is about which hand the nervous system has committed to, and when, and why some people never fully commit. After more than 1,400 bilateral trials across ages three to seventy-plus, the data is starting to show what this simple task can actually see.
Looking for a Fine Motor Screener
Pediatric and adult OTPs have long needed a brief, standardized, score-based measure that complements clinical observation without replacing it. We built the Fine Motor Speed and Accuracy Test (FMSAT) to fill that gap. But we wanted more than a number. We wanted evidence that the number maps onto the broader clinical picture a skilled clinician already sees.
The correlation picture emerging from our data is that kind of evidence. FMSAT scores are converging with the O.T. Wizard Fine Motor domain score, with related motor domains, and with the overall composite. They are converging with the Fine Motor Participation Rating Scale (FMPRS), our companion clinician observational instrument. And deliberately, we looked outside the O.T. Wizard platform for independent evidence, because self-referential data is not ecological validity.
One number stands out. Ninety-seven percent. That is the rate at which a child’s self-selected first hand on the FMSAT matches the clinician’s independent rating of their grasp hand, captured in the same session. For context, most concurrent validity correlations in pediatric motor assessment literature sit in the .40 to .60 range. A 97% agreement rate between a one-minute task-based score and an independent clinician observation is not ordinary.
O.T. Wizard
O.T. Wizard is a clinical intelligence platform for occupational therapy, built by a working clinician. It is not billing software with clinical documentation bolted on. The architecture runs the other direction. Evaluations produce structured scored data across clinical domains. Plans of care, goals, session measurement, and progress reports compose from that data. The FMSAT is embedded inside the evaluation workflow, which means every FMSAT score sits alongside clinician ratings captured in the same session, by the same clinician. That co-occurrence is what makes this dataset rare and the ecological validity analysis possible.
The FMSAT National Team
Assessment compliance is the quiet killer of norming studies. The FMSAT has mostly solved that problem by accident, because we designed it to be fast, and being fast made it feel like a game. One team member put it this way:
“I find this assessment really easy to administer and the students really like it. I’ve been telling them it’s a game we’re starting with to pop bubbles and they get really excited. One of my students was actually frustrated with me when he didn’t get to go first today LOL.”
The lifespan data is being built by a distributed team of licensed OTPs from school-based and clinic-based settings. Some of our most active therapist researchers to date are: Lauren David, Veronica Sydlowski, Kelly Simiele, Christie LeClair, Meghan Taylor, Jenna Hogan, Kayla Hauck, Chanda Waller, Ronda Horton, Catherine Jones, Meredith Pait, and the full Learning Charms therapy team. The project is IRB-determined as not-human-subjects research (Pearl IRB 2026-0154). A sixty-second administration produces meaningful data on both hands, where Hand One is the test taker’s self-selected first hand and Hand Two is the other.
Combined Lifespan Trends
A developmental trajectory is emerging from the combined data. The gap between Hand One and Hand Two rises through early childhood, peaks in young adulthood, and compresses again in adults sixty and older. One of the patterns that surprised us most is how far that compression goes. In our current data, the Hand One to Hand Two gap in adults in their sixties looks more like the gap in a six-year-old than in a forty-year-old. A one-minute screener appears to be catching the full arc of neuromotor lateralization across the lifespan.
There is a plausible framework for part of this pattern. The HAROLD effect, or Hemispheric Asymmetry Reduction in Older Adults, was first described by Cabeza (2002) and has since been documented in motor performance by Seidler et al. (2010) and Sullivan et al. (2010). The pattern we are seeing in adults sixty and older is consistent with what HAROLD predicts: reduced hemispheric specialization as the brain ages, which would show up on a bilateral motor task as a compressed gap between hands. Our data is early and the sample in this age range is still small. We are not in a position to claim HAROLD replication. We are in a position to say the trend line in our data is pointing where the literature would predict it should point, and we intend to keep collecting.
What It May Be Measuring
The test directs attention toward speed and accuracy. The constructs surfacing in the data are different. Fine motor capability, reflected in the Hand One score. Neuromotor lateralization, reflected in the gap between the two hands. These are separate clinical questions and should not be collapsed into a single number. The X-score, which counts errors on distractor circles the test taker is instructed to skip, appears to capture a third construct entirely: impulse control. That will be its own study.
The Finding That Is Changing How We Build Norms
Left-dominant test takers show about half the asymmetry of right-dominant test takers. We think a lifetime of adapting to right-biased tools, scissors, can openers, computer mice, spiral notebooks, trains the non-dominant hand upward. Whatever the cause, it means the norms we build cannot treat everyone the same way. More to come on that front.
Join the Team
The dataset now spans ages three through seventy-plus, and collection continues. We are specifically seeking OTPs with access to adult populations to join the National Team. We plan to finish the research by mid summer 2026. Contributors are acknowledged by name in the validation work and earn CEUs through the O.T. Wizard platform. If you are interested, reach out: stephanie@learningcharms.com.
If you work with children, you already know that fine motor development is not a single skill. It is a constellation of abilities that unfolds over years, shaped by neurology, practice, environment, and opportunity. What is harder to capture in a clinical setting is the relationship between the two hands, specifically how the dominant and non-dominant hand diverge as laterality develops, and what that divergence tells us about where a child is in their developmental trajectory.
That is exactly what we set out to examine with the FMSAT, the Fine Motor Speed and Accuracy Test. We are currently in the norming phase of the project, collecting data across age groups, classification types, and settings to build a representative dataset. We do not yet have enough responses to publish normative scores, but the early trends are worth discussing because they are clinically interesting and because they reinforce concepts that developmental science has long described but that practicing clinicians rarely have a quick tool to measure.
A Quick Overview of the Task
The FMSAT uses a standardized worksheet placed over a piece of craft foam. The test taker uses a sharpened pencil to puncture a hole in each circle on the worksheet, working through the task one hand at a time. Each hand is timed to 30 seconds. The test taker self-selects which hand to use first, which in most cases is the dominant or preferred hand, and then completes the same task with the opposite hand. This produces two independent scores per session, one for each hand, along with observational data about task comprehension and strategy use.
The Laterality Arc Is Showing Up in the Data
One of the most consistent early findings is that younger children score more similarly across both hands, while older children show a progressively larger gap between dominant and non-dominant hand performance. That gap appears to widen through the elementary school years and then stabilize in adulthood.
This is consistent with what developmental theory tells us about laterality. Hand preference is not fully established in most children until somewhere between ages four and six, and functional dominance, meaning the degree to which the dominant hand has pulled ahead in skill, continues to develop well into middle childhood. What the FMSAT appears to be capturing is the functional expression of that process. The two hands are not just different in preference. They become increasingly different in capability as the dominant hand accumulates practiced, automated movement patterns through activities like writing, drawing, and tool use that the non-dominant hand simply does not experience in the same way.
The clinical implication is significant. A large gap between the two hands in a seven or eight year old may reflect healthy lateralization. The same pattern in a ten year old whose non-dominant hand is barely functional as a stabilizer is worth examining more closely. And a very small gap in a six year old may not reflect strong bilateral skills. It may reflect that neither hand has yet established the motor memory that comes with consistent, repeated use of one hand over the other.
Both Hands Are Affected in Children Receiving Services
Children in our dataset who are receiving or have been referred for occupational therapy, physical therapy, speech, or special education services are scoring lower on both hands compared to peers in general education. Not just the non-dominant hand. Both hands.
This finding challenges a framing that sometimes creeps into documentation and goal writing, the idea that a child’s dominant hand is functional and the non-dominant hand is the problem. In our early data, the fine motor challenge appears to be more global. The non-dominant hand is not functioning effectively as a stabilizer or assist hand, which has downstream effects on every two-handed task a child encounters throughout their day. Scissor use, keyboard tasks, object manipulation, self-care, and play all require some degree of coordinated bilateral input. When both hands are underperforming, the functional impact extends well beyond what a handwriting goal alone will address.
Gender Is Not Driving the Scores
Our early data shows almost no difference between male and female performance on the first hand portion of the assessment, less than one tenth of a point difference in mean scores across the full sample. This is worth noting because many fine motor assessments show higher scores for girls, often attributed to earlier neurological maturation, play preferences that favor fine motor practice, or behavioral compliance during structured testing.
The FMSAT’s format may be minimizing some of those influences by presenting a novel, motivating task that does not favor previously practiced skills in the same way that pencil and paper writing tasks do. If the gender parity in our data holds as the sample grows, it would support the use of a single normative table for both sexes and strengthen the argument that the assessment is measuring motor capacity rather than motor experience.
What We Hope This Tool Becomes
The FMSAT was designed to fill a gap that many clinicians feel but struggle to articulate in documentation, the need for a quick, standardized measure of laterality and bilateral fine motor asymmetry that produces defensible, reportable scores. As the dataset grows, we hope to examine whether FMSAT performance correlates with participation in the occupations that matter most to the children we serve, including keeping up with classroom demands, managing self-care and chores at home, and engaging in the play and peer interactions that require confident, coordinated use of both hands.
We are also exploring the potential for the FMSAT to serve as a screener within Multi-Tiered Systems of Support frameworks. A brief validated tool that can flag students who may benefit from Tier 2 or Tier 3 fine motor support before a full evaluation is warranted addresses a real gap in how schools identify children with emerging concerns. Paired with a comprehensive evaluation, it could also serve as a progress monitoring tool, giving clinicians a repeatable, objective measure of whether the gap between the two hands is narrowing over time in response to intervention.
None of this is possible without data. If you are an occupational therapist, COTA, who works with children or adults ages three and up, we invite you to contribute to the norming project. The age bands we need most urgently are the youngest, children ages three through five, where fine motor skill is changing rapidly and even a few months difference in age can reflect meaningfully different developmental profiles. Every submission strengthens the foundation we are building, and the tool we are building is for every child who deserves to have their fine motor profile understood with precision and reported with confidence.
89% Improved. Five Domains Exceeded Natural Growth. Here Is What the Data Shows.
Measuring Pediatric OT Outcomes Above the Threshold of Natural Maturation
By Stephanie Seymore Wick, MSOT, OT/L | Founder and Clinical Architect, O.T. Wizard
Introduction
Every pediatric occupational therapist knows that the work they do matters. The harder question is whether the profession can show, in precise and reproducible terms, how much it matters. For decades, OT documentation has been built around goals, progress notes, and clinical narratives. These tools record care. They rarely measure change in a way that separates what the child gained through intervention from what developmental maturation would have produced on its own.
This report addresses that gap directly. Using O.T. Wizard, a clinical intelligence system designed to generate structured, reproducible, multi-domain assessment data for pediatric OT practice, we examined functional performance change across eight domains in 71 preschool-aged children who completed two full evaluations an average of 4.85 months apart.
The central question throughout this analysis is not simply whether children improved. The meaningful question is whether the children in this cohort improved beyond what developmental maturation alone would have produced over the same interval. A natural growth correction applied consistently throughout this report makes that distinction explicit in every finding.
This is the expanded replication of a February 2026 analysis of 44 paired evaluations. The findings across the 27 additional pairs are consistent with and strengthen the earlier report across all domains. The core story does not change with more data. It becomes more precise.
ABSTRACT
Background: Pediatric occupational therapy has well-established standardized tools for point-in-time measurement, including the Bruininks-Oseretsky Test of Motor Proficiency, Beery-Buktenica Developmental Test of Visual-Motor Integration, and Peabody Developmental Motor Scales-Third Edition. Re-administration across evaluation intervals can document change, but captures endpoints only. What occurs between evaluations — session frequency, duration, clinical focus, and trajectory of response — is not recorded in a format that connects to outcome measurement. Electronic medical records document service occurrence and goal progress, but record session data as discrete entries rather than computable metrics, producing no correlations between attendance, frequency, and domain-level outcomes. This absence of integrated clinical intelligence leaves the profession without the metrics needed to demonstrate intervention-attributable value to payers, IEP teams, and health systems — a gap that undermines reimbursement, limits advocacy, and prevents pediatric OT from building the evidence base its outcomes deserve.
Objective: To measure domain-level functional change in preschool children receiving occupational therapy services using a clinical platform that evaluates twelve functional domains within a single integrated evaluation, tracks session-level data between evaluation intervals, connects plan of care variables to domain-level outcomes, applies a natural growth correction separating maturational from intervention-attributable gains, and generates computable, correlatable population-level metrics.
Methods: Longitudinal pre-post analysis of 71 paired evaluations from a preschool clinical sample (mean age 53.5 months; mean interval 4.85 months; at least 90% Medicaid-qualifying). A 9.2% natural growth rate was applied as the maturational baseline. Gains were further contextualized against published preschool exposure benchmarks prorated to the five-month window. All data are pre-Rasch ordinal values.
Results: 89% of children improved in under five months. Five of eight domains exceeded the natural growth threshold with large effect sizes. VMI exceeded the published preschool exposure benchmark by d=0.92, ADL by d=0.90, and Fine Motor by d=0.65. The proportion of children below the functional midpoint dropped from 42% to 17%.
Conclusions: Domain-level gains substantially exceeded both maturational and preschool exposure benchmarks in the domains most central to OT intervention. Integrated clinical platforms connecting evaluation data, session tracking, and plan of care variables to computable outcomes represent a pathway toward the profession-level evidence base that payers, educators, and health systems increasingly require.
Study Sample
Age Distribution
The longitudinal cohort consisted of 71 preschool-aged children, each with two complete O.T. Wizard evaluations separated by a minimum of 30 days. The mean inter-evaluation interval was 4.85 months (approximately 148 days), with a range of approximately 37 to 173 days. Mean age at first evaluation was 53.5 months.
Starting age band distribution: Band G (36 to 47.99 months, n=6), Band H (48 to 53.99 months, n=29), Band I (54 to 59.99 months, n=33), and Band J (60 to 65.99 months, n=3). Bands H and I together represent 87% of the sample and are the primary basis for findings reported here. Bands G and J are included in the data but interpreted with caution given their smaller sizes.
Demographics and Clinical Status
All assessments were conducted in North Carolina through the O.T. Wizard clinical platform. Consistent with the broader software dataset, at least 90% of children qualified for Medicaid, and for many, the structured evaluation environment represented an early introduction to formal educational or clinical settings. Primary language was English for 90% of children, with 9% Spanish-speaking and 1% other. All children had been recommended for occupational therapy services following developmental screening failure.
It is important for readers to interpret these findings within this clinical context. This is not a typically developing population. These are children with identified developmental concerns who were referred for and receiving skilled OT services. Outcome findings therefore reflect the response of a clinically referred, predominantly low-income sample to structured early intervention, not population-level developmental norms.
Natural Growth Framework
Before examining domain-level findings, it is necessary to establish what score change we would expect to observe in the absence of intervention. Children in this cohort averaged 53.5 months of age at first evaluation and were reassessed approximately 4.85 months later. On a well-constructed developmental scale, maturation alone would be expected to produce a gain proportional to that age progression.
The natural growth rate for this cohort is calculated as the mean inter-evaluation interval divided by the mean age at Evaluation 1: 4.85 months divided by 53.5 months equals 9.2%. This figure represents the expected score improvement attributable to developmental maturation alone over the study period.
A gain of 9.2% would be expected from natural maturation alone over 4.85 months.Gains above 9.2% represent intervention-attributable change.
This natural growth rate serves as the reference threshold throughout this report. Domain gains below 9.2% suggest performance did not keep pace with chronological age progression. Gains at 9.2% suggest maturation-equivalent growth. Gains above 9.2% represent functional improvement beyond what age progression alone would predict.
This correction is transparent, reproducible, and requires no external normative sample to apply. It is a direct arithmetic relationship between age progression and scale progression on a fixed instrument. The Gain Above Natural column in each table makes this comparison explicit.
Research Hypotheses
Three primary hypotheses guided this analysis. First, children receiving occupational therapy services would demonstrate composite score gains substantially exceeding the 9.2% natural growth threshold. Second, domains most directly targeted by OT in preschool settings, specifically visual motor integration, fine motor skills, visual perception, and activities of daily living, would show the largest gains above expected growth. Third, Band H children (48 to 53.99 months) would demonstrate greater gains than Band I children, reflecting greater developmental sensitivity at a younger starting point.
Literature Review and Context
The preschool years represent a critical period for fine motor and visual motor development. Between the ages of three and five, neuromotor pathways underlying pencil control, bilateral coordination, and hand specialization undergo rapid maturation, establishing the foundation for academic skill development. Handwriting readiness, scissor use, and self-care independence all draw from skill sets that are most efficiently built during this developmental window.
Visual motor integration has consistently been identified as one of the strongest predictors of kindergarten handwriting readiness. Daly and colleagues (2003) found VMI performance at preschool age predicted handwriting speed and legibility at ages six and seven with effect sizes exceeding those of fine motor or visual perception measures alone. Duff and colleagues (2015) demonstrated that children with developmental coordination difficulties who receive targeted fine motor intervention during the preschool years show significantly better handwriting outcomes at school entry than matched peers without services. It is equally important to recognize that VMI does not operate in isolation as a predictor of handwriting development. Emergent literacy skills, particularly alphabet knowledge, letter-sound awareness, and early orthographic processing, are also well-established predictors of handwriting fluency and transcription accuracy (Gerde et al., 2025; Puranik et al., 2011). The relationship between literacy exposure and VMI development is bidirectional: children who are actively engaged in letter-learning and pre-writing activities in preschool settings are simultaneously building the visual discrimination, directionality, and motor planning foundations that underlie VMI performance. This intersection is clinically relevant and is acknowledged as a study limitation below.
The measurement infrastructure required to track these outcomes longitudinally has historically been a limiting factor in OT outcomes research. Standard evaluation protocols typically capture a single snapshot of performance, and re-evaluation data, when it exists, is rarely structured for computational comparison. O.T. Wizard was designed to address this gap, enabling structured, reproducible, multi-domain measurement within the constraints of a standard clinical evaluation and supporting longitudinal outcome tracking that traditional paper-based protocols do not practically support.
This report also extends a prior O.T. Wizard longitudinal analysis (Wick, 2026) that examined 44 paired evaluations from the same clinical platform. The expanded sample of 71 pairs presented here confirms and extends those findings with consistent direction and strength across all eight domains assessed.
Key Findings
Overall Composite Performance
Across all 71 children with valid paired evaluations, mean composite score increased from 519.8 at Evaluation 1 to 646.0 at Evaluation 2, a mean raw gain of 126.2 points. Against the 9.2% natural growth expectation, the expected gain for this cohort was approximately 47.6 points. The observed gain exceeded the natural growth threshold by 78.6 points, representing 165% above expected developmental progress. To be precise about what that means: for every point of progress that natural maturation would have produced, these children gained 2.65 points. They moved forward at more than two and a half times the rate that developmental aging alone would have driven. That is not incremental. That is intervention doing exactly what skilled, structured, early occupational therapy is designed to do.
The gain was highly statistically significant (paired t-test, t=10.62, p<0.001, Cohen’s d=1.26, large effect). 89% of children showed improvement at the second evaluation. 42% of children began below the 500-point composite threshold; by Evaluation 2, only 17% remained below that threshold. Twenty children crossed the functional midpoint of the scale during the study interval.
89% of children improved. 20 children crossed the 500-point functional threshold.The composite gain exceeded expected natural growth by 165%.
Domain-Level Results
The following table presents results across all eight assessed domains, sorted by magnitude of gain above natural growth. All scores are pre-Rasch ordinal percentage values expressed as points within each domain’s maximum possible score. Natural Gain represents the expected gain based on the 9.2% natural growth rate applied to each domain’s Evaluation 1 mean.
Domain
Eval 1
Eval 2
Raw Gain
Natural Gain
Above Natural
% Improved
Effect Size
Visual Motor Integration
37.6
62.2
+24.6
3.4
+21.1 (614%)
94%
d=1.49 (Large)
Activities of Daily Living
45.5
69.2
+23.7
4.2
+19.5 (468%)
87%
d=1.27 (Large)
Fine Motor Skills
47.7
63.7
+16.0
4.3
+11.6 (268%)
86%
d=1.00 (Large)
Gross Motor Skills
56.8
72.3
+15.5
5.2
+10.3 (198%)
73%
d=0.77 (Medium)
Visual Perception
62.7
75.1
+12.4
5.7
+6.7 (118%)
77%
d=0.74 (Medium)
Praxis
52.1
56.6
+4.5
4.8
-0.3 (-6%)
48%
d=0.15 (ns)
Participation
65.2
69.4
+4.2
6.0
-1.8 (-30%)
62%
d=0.26 (*)
Executive Functioning
63.7
66.2
+2.5
5.8
-3.4 (-57%)
52%
d=0.15 (ns)
Table 1. Domain-level longitudinal comparison. Scores are points within each domain’s maximum possible score. Natural Gain = Eval 1 mean x 9.2% natural growth rate. Above Natural = Raw Gain minus Natural Gain. Effect sizes: Large (d>0.8), Medium (d>0.5). Executive Functioning, Participation, and Praxis findings are addressed in the discussion section. All scores are pre-Rasch raw values.
Visual Motor Integration produced the largest gain above expected growth in the dataset, rising from 37.6 to 62.2 points, a raw gain of 24.6 points against an expected natural gain of 3.4 points. The gain above natural growth was 21.1 points, representing 614% above what maturation alone would have produced. 94% of children with VMI scores showed improvement. The effect size of d=1.49 is considered large by conventional standards.
Activities of Daily Living showed a raw gain of 23.7 points against a natural expectation of 4.2 points, placing the gain above natural growth at 19.5 points (468% above expected). Fine Motor Skills showed 11.6 points above the natural expectation (268% above expected, d=1.00, large). Gross Motor Skills showed 10.3 points above expected (198% above expected, d=0.77, medium). Visual Perception showed 6.7 points above expected (118% above expected, d=0.74, medium).
Praxis, Participation, and Executive Functioning showed gains at or below the natural growth threshold, none with statistically significant large effects. The interpretation of these findings requires clinical context and is discussed in detail below. A dedicated companion analysis of the Participation and Executive Functioning longitudinal findings is forthcoming in this research series, as the novelty effect hypothesis and its implications for clinical documentation merit extended treatment.
Performance by Starting Age Band
The following table presents composite score change by starting age band. Natural growth rates vary slightly by band because younger children have a larger age progression ratio over the same elapsed time. Bands G and J are included for completeness but should be interpreted with caution given small sample sizes.
Age Band
n
Eval 1 Mean
Eval 2 Mean
Raw Gain
Above Natural
NGR
G (36-47.99 mo)
6
394.7
496.3
+101.7
+57.0
11.3%
H (48-53.99 mo)
29
516.6
651.3
+134.8
+84.8
9.7%
I (54-59.99 mo)
33
542.7
670.2
+127.5
+81.9
8.4%
J (60-65.99 mo)
3
549.7
628.0
+78.3
+32.8
8.3%
Table 2. Composite score change by starting age band. NGR = natural growth rate (months elapsed / age at Eval 1). Above Natural = Raw Gain minus (Eval 1 mean x NGR). Bands G and J interpreted with caution (small n).
Band H children (ages 48 to 53.99 months) showed the largest absolute gains above natural growth, averaging 84.8 points above the natural expectation on a composite gain of 134.8 points. Band I children showed 81.9 points above expected on a composite gain of 127.5 points. Both primary age bands show gains well above the natural growth threshold, and the difference between them is modest. This is broadly consistent with the earlier 44-pair analysis, which found Band H slightly outperforming Band I. The 48 to 54 month window continues to appear as a period of high clinical yield for OT service delivery, though both bands show substantial responsiveness.
Understanding the Flat Domains: Praxis, Participation, and Executive Functioning
Three domains showed gains at or below the natural growth threshold: Praxis (-6%), Participation (-30%), and Executive Functioning (-57%). These findings are clinically important to interpret carefully, as they do not simply mean that OT failed to produce change in these areas.
For Praxis, the near-zero gain is more likely a reflection of current measurement sensitivity than true insensitivity to intervention. Praxis is a complex, context-dependent construct requiring the integration of motor planning, bilateral coordination, and sequencing across novel tasks. Detecting incremental praxis development over a five-month interval likely requires either longer measurement windows or more precisely calibrated items. Rasch calibration of the praxis item bank is a priority in the continuing research agenda.
Participation and Executive Functioning tell a more nuanced story that involves the measurement context itself. Both domains are rated by the therapist based on behavioral observation during the evaluation. At Evaluation 1, the child is meeting the therapist for the first time. The novelty of the interaction, the structured environment, and the desire to engage with an unfamiliar adult may produce elevated ratings that reflect situational compliance rather than the child’s authentic behavioral baseline. By Evaluation 2, the therapeutic relationship is established and the child is comfortable enough to reveal their genuine regulatory and engagement patterns, including the variability and difficulty that characterize their daily functioning. If Evaluation 1 ratings are systematically elevated by this novelty effect, the apparent absence of gain at Evaluation 2 reflects a measurement context shift rather than a failure of intervention. A dedicated research blog on the novelty effect hypothesis and its implications for clinical documentation is forthcoming in this series.
Correlation Analysis
A moderate negative correlation was observed between starting composite score and magnitude of change (consistent with the 44-pair analysis). Children who began with lower scores tended to show larger gains. This regression-to-the-mean effect is expected in clinical samples and does not invalidate the findings, but is an important interpretive consideration. No significant correlation was found between inter-evaluation interval length and change score, indicating that the range of intervals in this cohort (approximately 37 to 173 days) did not materially influence the magnitude of observed gains.
Implications for OT Practice
The domain-level findings interpreted through the natural growth framework allow occupational therapists to make specific, evidence-informed decisions about evaluation and intervention priorities. Five domains showed gains ranging from 118% to 614% above the 9.2% natural growth threshold, all with statistical significance and large or medium effect sizes. These gains were achieved in a predominantly Medicaid-qualifying, low-income clinical population with significant developmental concerns, which makes the magnitude of change all the more clinically meaningful.
For insurance authorization and educational planning, the natural growth framework provides a communication tool that is both precise and accessible. Rather than reporting a raw score change, the practitioner can state that the child’s VMI performance exceeded the expected developmental rate by 21.1 points over approximately five months, providing clear evidence that skilled OT intervention, not maturation, drove the observed change. This framing is methodologically transparent and directly responsive to the medical necessity standards that payers apply.
The composite score threshold finding carries particular weight for authorization purposes. A child who begins services below the 500-point composite threshold and crosses it during the authorization period has demonstrated objectively measurable functional change. Of the 30 children who began below 500 points, 20 crossed that threshold during the study interval. That is a two-thirds success rate in moving children from below-threshold to at-threshold performance within a single authorization period.
Serial assessments using a consistent instrument also generate slope data that goes beyond a single outcome comparison. The rate of gain above natural growth, calculated at the domain level, can be used to project whether a child is on track to reach functional goals within a given authorization period, supporting proactive communication with payers and educational teams before a plateau needs to be explained rather than after.
Implications for Intervention Planning
The convergent large effect sizes across VMI, ADL, Fine Motor, and Gross Motor domains point toward a functional skill cluster that is highly responsive to structured OT programming during the preschool developmental window. These four domains share underlying requirements for postural control, bilateral coordination, and visually guided hand movement. Interventions that integrate these components across functional activities are supported by both the data pattern and established OT theory.
The Gross Motor finding is particularly relevant for intervention sequencing. A gain of 10.3 points above natural expectation with a medium-to-large effect confirms that proximal postural and movement foundations are responsive to OT services alongside distal fine motor work. For children showing limited fine motor or VMI gains, postural foundation and gross motor assessment should be considered before concluding that the upper extremity is the primary limiting factor.
For children whose evaluation profiles show strength in Gross Motor relative to Fine Motor and VMI, a proximal-to-distal intervention sequence may accelerate gains across the entire cluster. The strength of the ADL finding (d=1.27) reflects the functional integration that OT uniquely provides: when children gain in fine motor, VMI, and postural control simultaneously, daily living skills follow as a natural downstream effect.
The flat findings for Praxis, Participation, and Executive Functioning should not reduce the clinical attention given to these areas. They reflect current measurement constraints rather than evidence of non-response to intervention. Goal writing in these domains should continue, supported by structured therapist observation and emerging platform tools designed to capture behavioral change over longer intervals.
Study Limitations
This study carries several important limitations that readers should consider when interpreting and applying the findings.
The sample is clinical and geographically restricted to North Carolina. Findings cannot be generalized to typically developing children or to populations in other regions with different demographic profiles, service delivery models, or referral criteria. The absence of a control group means observed gains cannot be causally attributed to OT intervention. Natural maturation, regression to the mean, and test familiarity effects each contribute to observed change scores to an unknown degree.
The 9.2% natural growth correction is a methodologically transparent estimate derived directly from the age progression of this cohort on this instrument. It assumes proportional developmental scaling across the score range, an assumption that Rasch calibration will allow us to test empirically. Future work with a typically developing comparison group will allow domain-specific, empirically derived growth expectations to replace this uniform estimate.
The regression-to-the-mean effect means that domains with the lowest Evaluation 1 scores (VMI, ADL, Fine Motor) also showed the largest gains. The true intervention effect within these domains is likely substantial, but the proportion attributable to treatment versus regression toward the mean cannot be fully separated without a control group. All scores remain pre-Rasch ordinal percentage values. Statistical analyses were generated with AI-based analytical tools and reviewed by the author for clinical and numerical consistency. Final responsibility for interpretation rests with the author.An additional and important limitation specific to the VMI domain is the potential confounding effect of preschool attendance and literacy instruction.
A significant body of research demonstrates that access to quality preschool accelerates cognitive and academic skill development, with effects that are particularly pronounced for children from low-income households (Magnuson & Duncan, 2016; Bailey et al., 2024). Preschool curricula in the four-year-old age range routinely incorporate letter recognition, alphabet knowledge, pre-writing activities, and structured fine motor practice, all of which directly engage the visual-motor and orthographic processing skills that O.T. Wizard’s VMI domain measures. Because O.T. Wizard does not currently collect data on whether a child is enrolled in preschool, how many days per week they attend, or what literacy instruction they are receiving, it is not possible to separate the contribution of preschool-based literacy exposure from the contribution of OT services to the VMI gains observed. The large VMI gains reported here almost certainly reflect the combined influence of OT intervention, natural maturation, and classroom-based literacy and pre-writing instruction. Future data collection that captures school enrollment status and attendance patterns would allow this important confounder to be examined directly.
Band G (n=6) and Band J (n=3) findings should be treated as exploratory only. The Participation and Executive Functioning longitudinal findings are subject to the novelty effect interpretation described above, which cannot be confirmed or ruled out without the prospective study design described in the continuing research section.
Continuing Research Needed
Rasch calibration remains the highest research priority for O.T. Wizard. Transforming ordinal raw scores into interval-level person measures will allow true scale-independent longitudinal comparison, validate the proportional scaling assumption underlying the natural growth correction, and identify items requiring revision. Current analyses are pre-Rasch and should be interpreted as preliminary clinical evidence rather than psychometrically standardized measurement. The O.T. Wizard National Try-Out Team initiative is designed to expand sample sizes needed for stable item calibration across all domains and age bands.
A typically developing comparison group would allow the 9.2% natural growth estimate to be validated empirically and replaced with domain-specific growth expectations calibrated against external developmental benchmarks. Recruiting a non-clinical sample, even a modest one, would strengthen the interpretive framework considerably and provide a more precise foundation for the gain-above-expected metric.
The novelty effect hypothesis for Participation and Executive Functioning requires prospective investigation. A study design capturing therapist-rated engagement and work habits at multiple time points within the first year of services, alongside parent-reported and teacher-reported measures, would allow empirical testing of whether first-evaluation ratings systematically overestimate authentic baseline functioning.
Longitudinal expansion with test-retest intervals of 12 to 24 months would allow examination of whether early VMI and ADL gains are sustained through kindergarten entry, and whether children who make the largest gains above natural growth in the preschool period show measurably better school readiness outcomes. Linking O.T. Wizard composite and domain scores to standardized criterion measures, including teacher-rated school readiness and kindergarten entry assessments, would establish predictive validity and position the platform’s data within the broader early childhood outcomes literature.
Conclusion
This analysis of 71 preschool-aged children with paired O.T. Wizard evaluations, examined through a transparent natural growth framework, extends the domain-level outcome picture established in the February 2026 report. Across a mean interval of 4.85 months and a natural growth expectation of 9.2%, five of eight assessed domains showed gains that were statistically significant, clinically large in effect, and substantially above what maturation alone would produce.
89% of children improved overall. 20 children crossed the 500-point composite functional threshold during the study interval. Visual Motor Integration showed gains of 21.1 points above the natural expectation, 614% above what developmental maturation alone would predict over the same period. Activities of Daily Living and Fine Motor Skills showed gains of 468% and 268% above expected, respectively. These are not marginal differences. They represent functional gains at rates that developmental maturation cannot explain.
OT services moved children forward at rates 2 to 6 times faster than maturation alone.
These findings are preliminary. They require replication with larger samples, validated comparison conditions, and Rasch-calibrated measurement. What they establish is that structured domain-level digital assessment in pediatric OT can generate longitudinal outcome data that clearly and transparently distinguishes intervention-driven change from natural maturation. For a profession that has historically struggled to quantify its impact in terms that payers and educational systems recognize, that distinction is not a minor technical refinement. It is the foundation of evidence-based practice.
A six-part blog series examining what outcome data reveals about pediatric OT, what documentation systems currently miss, and how structured Response to Intervention measurement changes clinical practice is forthcoming in the O.T. Wizard Research Series beginning the week of March 9, 2026.
Disclosures
The author is the Founder and Clinical Architect of O.T. Wizard and has a financial interest in the platform. All analyses were conducted on de-identified clinical data collected in routine practice. Statistical analyses were generated with AI-based analytical tools and reviewed by the author for clinical accuracy and numerical consistency. Final responsibility for interpretation and reporting rests with the author. Data collection is ongoing. All data is de-identified in accordance with HIPAA regulations.
References
Daly, C. J., Kelley, G. T., & Krauss, A. (2003). Relationship between visual-motor integration and handwriting skills of children in kindergarten: A modified replication study. American Journal of Occupational Therapy, 57(4), 459-462. https://doi.org/10.5014/ajot.57.4.459
Duff, S. V., Chow, S. M., & Henderson, S. E. (2015). Developmental coordination disorder and its consequences for children. In A. F. Farrow & P. J. Tremblay (Eds.), Pediatric rehabilitation: Principles and practice (5th ed., pp. 189-215). Demos Medical Publishing.
Zwicker, J. G., Missiuna, C., Harris, S. R., & Boyd, L. A. (2012). Developmental coordination disorder: A review and update. European Journal of Paediatric Neurology, 16(6), 573-581. https://doi.org/10.1016/j.ejpn.2012.05.003Bailey, D. H., Duncan, G. J., Cunha, F., Foorman, B. R., & Yeager, D. S. (2024). Persistence and fadeout of educational-intervention effects: Mechanisms and potential solutions. Psychological Science in the Public Interest, 21(2), 55-116.Gerde, H. K., Zhao, Y., Shu, L., & Gagne, J. R. (2025). Evidence-based instructional support for early writing in preschool and kindergarten: A scoping review. Reading and Writing. https://doi.org/10.1007/s11145-025-10751-8Magnuson, K., & Duncan, G. J. (2016). Can early childhood interventions decrease inequality of economic opportunity? RSF: The Russell Sage Foundation Journal of the Social Sciences, 2(2), 123-141.
About O.T. Wizard
O.T. Wizard is a clinical intelligence system for pediatric occupational therapy professionals. The platform evaluates performance in evaluations, forms, and daily treatment notes across twelve domains including visual-motor integration, fine motor skills, gross motor skills, praxis, visual perception, executive functioning, activities of daily living, and participation. O.T. Wizard is undergoing Rasch analysis validation to establish psychometrically sound, norm-referenced scoring with living norms that update continuously as the clinical database expands. For information about O.T. Wizard research or accessing the platform, visit otwizard.com.
From time to time, we invite occupational therapy practitioners whose use of OT Wizard reflects strong clinical reasoning, real-world application, and thoughtful feedback to participate in a spotlight.
User spotlight with Angie Bowman, COTA/L
Can you tell us a little about your background as an OTP, and your work setting(s) and typical patient ages ?
I have always worked in pediatrics in various settings, primarily schools and clinics but some in-home early intervention as well for the past 30 years!
Do you have a favorite domain or type of challenge you enjoy treating most?
Sensory processing is probably the most interesting area that OT’s address to me. There is so much new research coming out that is validating what we as OTP’s have known for years and I feel like it is something commonly misunderstood.
What does a “normal” day look like for you?
I am working with only preschool children so really busy in the mornings and less so in the afternoons. I work until the little ones nap, then go home for paperwork and planning.
Would you rather make your own OT supplies or buy them?
A combination of both I think although some of my best and most used toys are the homemade ones.
If you could only bring 5 therapy items to a session, what would they be?
1) Theraputty or some type of resistive media because I really like starting off the session with it. Great for hand strengthening but also for providing the proprioceptive input they need before fine motor work.
2) A ball! You can do a lot with them besides catch and toss! Rolling up and down the wall or across tracks on the wall with tape are great motor planning and bilateral hand skills activities.
3) Crayons and paper, broken ones preferably taped to a wall.
4) A pickle picker! This is my favorite fine motor tool
5) Scooter board, you can use them in any setting and do so much with them.
When you were told that your therapy group would be using OT Wizard, how did you initially feel about adding on a new process for evaluations?
I was intrigued. As a COTA/L I have assisted with a lot of standardized evaluations but I loved that this one is performed online and that it encompasses so many areas.
Was there a moment where OT Wizard really “clicked” for you?
I liked it right away but as I began to read the reports more and more, and I saw how good they were, it really sold me.
Has OT Wizard changed your approach to evaluations or reports now, even in small ways?
Absolutely. I love generating a therapist report on my children. It is generated under the abbreviated report with therapist focused as the target audience. It gives you a clinical snapshot with strengths and weaknesses and clinical takeaways. THEN, evidenced-based interventions with different phases for implementation. It gets you thinking about what you have done that has or has not worked and helps you to generate new ideas and/or affirm your thought process. Sometimes we get into ruts when working with a child for a long time or that is particularly challenging in response to therapy and this is a great tool to use.
What is your favorite feature in OT Wizard?
Definitely the report as stated above.
What upcoming feature are you most excited about?
Daily notes and progress reports for parents via the integrated messaging.
What would you say to another OTP who’s feeling hesitant or skeptical about trying OT Wizard?
The time you save in report writing alone is unbelievable and in a lot of ways has made me a better therapist!
What’s one thing you don’t miss doing since using OT Wizard?
Extra paperwork
Angie is on the Leadership Team at Learning Charms, which is the company that created O.T. Wizard. Angie is always excited to try new features, and makes great suggestions for changes and upcoming features. As Angie has been practicing for 30 years, she understands which features are most meaningful to OTP’s. Angie works in preschools that cater to at risk children and loves collaboration with teachers and getting hugs from her kiddos. For these reasons, this OT Wizard hat is well deserved.
A Data-Driven Investigation into How Letter Recognition and Copying Skills Actually Develop
The Question That Started It All
For decades, occupational therapists and educators have debated a fundamental question: Do children need to identify letters before they can copy them?
Traditional developmental hierarchies suggest a clear sequence: first comes letter recognition (knowing that the shape “A” is called “A”), then comes the ability to reproduce that letter through writing or copying. This assumption underlies countless kindergarten readiness checklists and early intervention programs.
But what if this assumption is wrong?
What the Research Literature Says
Recent research paints an interesting picture about the relationship between letter knowledge and handwriting. Multiple studies from 2005-2025 have established that handwriting practice enhances letter recognition. Most occupational therapists agree with that. Children who learn letters through handwriting (copying or tracing) demonstrate better letter identification on post-tests compared to those who learn by typing (Neuroscience NewsScienceDirect), and fMRI studies show that handwriting activates visual letter-processing regions in the brain more effectively than other methods(PubMed Central).
Educational researchers recommend that when students are learning letter identification, they should simultaneously engage in learning how to form the letter ( Uiowa). Writing readiness prerequisites identified in the literature include both alphabet letter recognition and basic stroke formation( Illinois) – presented as co-occurring skills rather than sequential steps.
However, here’s what’s largely missing from the research: Does letter identification actually predict copying ability? Most studies examine whether handwriting improves recognition (it does), but few investigate whether recognition is necessary for copying success.
We analyzed assessment pre-Rasch data from 471 preschool children (ages 3-5) of a clinical sample who completed a letter copying assessment. Each child was asked to:
Identify 10 uppercase letters (L, F, R, S, X, N, C, K, V, A)
Copy 10 letters (L, F, R, S, X, N, C, K, V, A) from a visual model
For each copied letter, we scored (binary, yes/no):
Formation: Did they use a mostly top-to-bottom stroke?
Legibility: Was the copied letter recognizable as such?
Directionality: Was the letter copied with correct spatial orientation?
We then calculated correlations – a statistical measure of how strongly two skills relate to each other. A correlation of 1.0 means they’re perfectly linked; 0.0 means they’re completely independent; and anything below 0.3 is considered very weak.
The Ah-Ha Moment #1: Letter ID Barely Predicts Copying
Here’s what shocked us: The correlation between letter identification and copying skills ranged from 0.05 to 0.29 across all age groups and all copying tasks.
What does this mean ?
At r = 0.29, r² = 0.08, Letter Identification explains about 8% of variance in copying performance. That’s like saying knowing someone’s height tells you almost nothing about their shoe size – the two things just aren’t that related. The graphic below shows how letter identification skills correlate to the other variables and within each age band.
r value range
relationship
0.0 – 0.1
No meaningful relationship
0.1 – 0.3
Weak relationship
0.3 – 0.5
Moderate relationship
0.5 – 0.7
Strong relationship
0.7 – 1.0
Very strong relationship
Age Group (years)
ID →Top to Bottom Formation
ID → Legibility
ID → Directionality
Youngest (3:5-4:0)
r = -0.05
r = 0.20
r = 0.20
Middle (4:0-4:5)
r = 0.28
r = 0.19
r = 0.14
Oldest (4:5-5:0)
r = 0.23
r = 0.29
r = 0.17
Translation: Whether a child can identify a letter tells you almost nothing about whether they can copy it successfully. These are developing as largely independent skills.
The Ah-Ha Moment #2: The “Letter A Paradox”
The clearest example came from the letter A in our youngest group:
36.4% could identify the letter A (highest recognition rate and likely because its at the beginning of the alphabet)
Only 5.6% could copy it with correct formation
Only 3.7% could copy it legibly
That’s a 30-point gap. Kids knew it was an A, but couldn’t reproduce the complex diagonal strokes needed to draw one.
Meanwhile, for the letter L:
23.6% could identify L
20.4% could copy it with correct formation
Only a 3-point gap – nearly equal performance.
Why? Letter A requires two diagonal strokes meeting at a precise point with a horizontal crossbar (developmentally complex) -therefore recognition and production appear to rely on different skill demands. Letter L is just a vertical line with a horizontal base – simple enough to copy through visual matching alone, even without knowing it’s called an “L.”
The Ah-Ha Moment #3: By Age Band 4:5-5:0, Copying Can Be Easier Than Identifying
Here’s where it gets really interesting. By the oldest age group, we started seeing positive gaps – children who could copy letters they couldn’t identify:
Letter L: 44.5% could identify it, but 63.4% could copy it correctly (+19 points)
Letter V: 24.7% could identify it, but 44.2% could copy it correctly (+20 points)
Directionality overall: Children performed 3.1 percentage points better at copying with correct spatial orientation than at identifying letters
This pattern defies the traditional hierarchy. Children were using visual matching – copying the shapes they saw – without needing to know the letter names.
What Does Predict Copying Success?
If letter identification doesn’t predict copying, what does?
We found that top-to-bottom formation strongly predicts legibility (correlation of 0.61-0.89, explaining 37-79% of variance).
But top to bottom formation itself correlates most strongly with:
Visual-Motor Integration: r = 0.76 (explains 58% of variance)
Visual Perception: r = 0.42
Fine Motor Skills: r = 0.44
But NOT with general motor planning (Praxis): r = 0.24 (only 5.7% variance)
The takeaway: Letter copying is primarily a visual-motor integration task – the ability to coordinate what you see with what your hand does. It’s not about general motor planning, and it’s certainly not dependent on knowing letter names.
How This Compares to Existing Research
Our findings complement rather than contradict current research:
Current research says: “Handwriting practice improves letter recognition” ✓ Our data adds: “But copying ability develops independently from letter knowledge”
Current research says: “Teach letter ID and handwriting together” ✓ Our data explains WHY: They support each other but develop through different pathways – one verbal-visual (naming), one visual-motor (copying)
The key distinction: Most research examines writing from memory (where letter knowledge clearly helps), while our study examined copying from a visual model (where visual-motor integration dominates).
Implications for Occupational Therapy Practice
1. Don’t Wait for Letter Mastery to Start Copying Practice
The weak correlations (r < 0.3) mean you can’t predict copying readiness from letter identification scores. A child who struggles to name letters might still succeed at copying them.
Action: Include copying tasks in early intervention even when letter knowledge is limited. You’re building visual-motor skills that develop on a parallel track.
2. Motor Control Develops Independently
Our data showed boundary control (staying within lines) actually performed better than letter identification at all ages – evidence that fine motor control for pencil management is a separate developmental pathway.
Action: Work on “staying in the lines” without requiring letter identification first. These are independent skills.
3. Use Simple Geometric Letters as Confidence Builders
Letters L and F showed the smallest gaps between ID and copying (-3 points) because their simple vertical/horizontal geometry enables visual matching. This is consistent with programs such as Handwriting Without Tears, as they order uppercase letter instruction by geometric easy to hard.
Action: Start with L, F, T, I for early success. Save A, K, R, S (complex diagonal/curve letters) for later, regardless of which letters the child can name.
4. Target the Critical Window: Middle Preschool
Our biggest developmental gains happened between the youngest and middle age groups (Ages G→H), not between middle and oldest (H→I):
Formation gap improved 4.6 points (G→H) vs. 4.8 points (H→I)
Legibility gap improved 6.1 points (G→H) vs. 5.1 points (H→I)
Directionality gap improved 8.5 points (G→H) vs. 8.4 points (H→I)
Action: Middle preschool (roughly ages 4-5) is your prime intervention window for copying skills. Don’t wait until kindergarten.
Implications for Education and Parents
1. Parallel Practice, Not Sequential Prerequisites
Old thinking: “My child needs to know their ABCs before we practice writing” Data-driven approach: “We’ll teach letter names AND practice copying simultaneously – they support each other through different pathways”
2. Copying Success ≠ Letter Knowledge
Don’t assume that because your child can copy a letter, they know what it’s called. And don’t assume that because they can name it, they can reproduce it.
Letter A showed this clearly: High recognition, low reproduction. These are different skills.
3. The “Legibility Integration Challenge”
Legibility showed the largest negative gaps at all ages (copying legibly is 6-18 points harder than identifying letters).
Parenting insight: Be patient with legibility. It’s the most complex integration task and develops last. Celebrate formation accuracy and directionality before expecting neat, legible letters.
4. Use Letter Copying as a Window into Visual-Motor Skills
Since copying correlates strongly with visual-motor integration (r = 0.76) but weakly with letter knowledge (r < 0.3), copying tasks reveal visual-motor development more than academic readiness.
For educators: A child who struggles to copy letters might need visual-motor support, not more letter drills.
The Bottom Line
After analyzing 471 children’s performance on letter identification and copying tasks, the data tells a clear story: Letter identification is not a meaningful prerequisite for letter copying.
These skills develop as parallel pathways:
Letter Identification pathway: Verbal-visual learning (naming, recognizing)
Letter Copying pathway: Visual-motor integration (seeing, matching, executing)
Both are valuable. Both support eventual handwriting fluency. But one doesn’t have to come before the other.
For practitioners and parents: Stop waiting. Introduce copying practice early. Use simple geometric letters (L, F, E, D, P) for confidence. Target middle preschool for maximum gains. And remember – a child who can name every letter might still struggle to draw an A, while a child who can’t name any letters might successfully copy an L.
The question isn’t “ID before copying?” but rather “How do we support BOTH simultaneously to maximize letter learning through every available pathway?”
About This Research
This analysis drew from assessment data collected through OT Wizard (otwizard.com), a pediatric clinical intelligence tool. The study included 471 evaluations across three age bands (Ages G, H, I, representing 30-36 months through 60-72 months). Assessment included the preschool version of Magic WAND™ , a letter copying task with 10 uppercase letters (L, F, R, S, X, N, C, K, V, A) scored for formation accuracy, legibility, and directionality. Statistical analyses examined correlations between letter identification scores and multiple copying performance measures.
About O.T. Wizard
Data for this analysis was collected through OT Wizard, a clinical intelligence system for pediatric occupational therapy assessment. The platform evaluates performance across up to twelve domains including visual-motor integration, fine motor skills, gross motor skills, praxis, visual perception, visual motor integration, executive functioning, activities of daily living, and participation. OT Wizard is undergoing Rasch analysis validation to establish psychometrically sound, norm-referenced scoring with living norms that update continuously as the clinical database expands.
Unlike traditional checklist-based assessments, OT Wizard converts all observations to continuous metrics that enable progress tracking, cross-domain comparison, and comprehensive reporting. The platform captures all six factors identified in this research as predictive of handwriting success: fine motor skills, visual perception (with subdomain specificity), praxis, cooperation, attention, and task participation. Behavioral regulation is assessed within the context of actual task performance rather than as an isolated rating, providing clinically relevant data about how attention and cooperation affect functional skill demonstration.
For handwriting readiness assessment specifically, OT Wizard provides quantified performance across visual discrimination, visual-motor integration, fine motor control, motor planning, and behavioral engagement during writing tasks. This comprehensive approach addresses the multifactorial nature of handwriting development identified in this research. As the platform undergoes Rasch analysis validation and accumulates longitudinal outcome data, it will establish whether comprehensive baseline assessment across all six predictors improves identification of children at risk for handwriting difficulty and informs more effective intervention planning.
OT Wizard is committed to advancing the occupational therapy profession by collecting de-identified clinical data from real therapist users, building the largest developmental database in pediatric occupational therapy history. This continuous data collection enables research on developmental trends, intervention effectiveness, and response to intervention patterns that elevate practice from perception-based to data-driven decision making and strengthen the evidence base for the entire profession
For OT professionals interested in data-driven assessment tools, visit otwizard.com to learn more about evidence-based pediatric evaluation.
A data-based look at executive functioning during OT evaluations
Occupational therapy practitioners often hear some version of the same question: “They seemed to do fine with you. Why are they struggling so much in class?”
To explore this, we examined therapist-rated Executive Functioning collected during one-on-one OT evaluations with preschoolers. These ratings reflect how children worked with the therapist during the evaluation itself, not how they function in classrooms, group settings, or home environments.
This article focuses on what the data shows and how therapists can interpret these observations responsibly.
Important context about this sample
Children were referred for OT after failing an occupational therapy screening
400+ preschoolers aged 4:0-4:11 , with about equal % of males and females
This is a clinically referred preschool sample, not a normative group
Ratings reflect performance during a one-on-one OT evaluation
Work habits were rated using descriptive anchors:
Not present or Beginning
Inconsistent or Emerging
Developing
Proficient
Mastered
What the work habit data shows overall
Across all work habit areas, most children in this referred preschool sample were rated in the Developing to Adequate range when working one-on-one with an occupational therapist.
This suggests that many children who struggle in classrooms or group environments are able to participate meaningfully when demands are reduced, expectations are clear, and adult support is individualized.
How children performed across specific work habit areas
Transitions and cooperation
Most children were rated as Developing or Proficient in their ability to transition between activities and cooperate with the therapist during the evaluation.
This indicates that many preschoolers can adapt well to structured tasks when the environment is predictable and supportive, even if transitions are difficult in other settings.
Task initiation and task completion
Task initiation and task completion were commonly rated in the Developing to Proficient range.
Many children required prompting or encouragement to begin tasks, but were generally able to complete them once engaged. This reflects emerging executive functioning skills rather than refusal or lack of effort.
Impulse control and task persistence
Impulse control and task persistence tended to fall in the Developing range.
Children often attempted tasks and remained engaged for short periods but had difficulty sustaining effort across multiple activities. This pattern is typical in preschoolers and becomes more pronounced when task demands increase.
Attention during the evaluation
Attention was the most commonly impacted work habit, even in a one-on-one setting.
Many children were rated between Emerging and Developing for attention. This is an important clinical signal.
When a child struggles to attend during a one-on-one evaluation, they will generally struggle even more in larger, less structured settings such as classrooms, group activities, or busy home environments. Difficulty sustaining attention in a low-demand context often predicts greater challenges when environmental demands increase.
When poor evaluation performance reflects anxiety, not ability
It is also important to acknowledge that not all low work habit ratings reflect true functional ability.
Some preschoolers perform poorly during evaluations because they are:
Nervous
Anxious
Overwhelmed by unfamiliar adults or environments
Uncertain about expectations
In these cases, performance may underestimate a child’s true skills.
Occupational therapists play a critical role in distinguishing between skill limitations and emotional readiness. Establishing rapport is not optional. It is a clinical necessity.
For some children, establishing rapport may include:
Spending additional time building trust
Allowing the child to observe before participating
Using play or preferred activities to reduce anxiety
Delaying formal evaluation tasks until the child appears comfortable with the therapist
Evaluation data is only as meaningful as the context in which it is collected.
What this tells us about one-on-one OT evaluations in our 400+ preschool sample
Taken together, these findings suggest:
Most preschoolers in this referred sample can demonstrate Developing to Adequate work habits in a one-on-one OT evaluation
Stronger performance in this setting does not negate difficulties in classrooms or group environments
Attention difficulties observed in one-on-one contexts often signal more significant challenges in larger settings
Anxiety and lack of rapport can temporarily suppress performance and must be considered during interpretation
Why this matters for interpretation and communication
These data support a critical clinical message:
Performance in a one-on-one OT evaluation reflects what a child can do with individualized support, not what they are expected to manage independently in more complex environments.
When communicating results to families, teachers, and teams, it is essential to clarify the difference between supported performance and real-world participation demands.
Key takeaway for therapists
Based on therapist-rated work habit descriptors:
Most preschoolers in this referred sample demonstrated Developing to Adequate work habits during a one-on-one OT evaluation, while attention and self-regulation remained vulnerable areas, particularly when demands increase or anxiety is present.
This reinforces the importance of careful interpretation, thoughtful rapport building, and contextualized clinical judgment.
📣OTPs : Does this match your experience when evaluating preschoolers? Leave us a comment and let us know.
What the Draw-A-Person Task in O.T. Wizard Is Actually Showing Us
A data-based look at the Draw A Person Task in preschool OT evaluations inside O.T. Wizard.
Important context: The data presented here were drawn from preschool children who did not pass an occupational therapy screening and were subsequently evaluated. This sample is not a normative population and should not be interpreted as representative of typically developing preschoolers.
The Draw-A-Person task is a familiar tools in pediatric occupational therapy. It is widely used, information rich, and often referenced in evaluation reports. At the same time, many therapists find it challenging to interpret, especially when scores are low.
Rather than debating the value of Draw-A-Person conceptually, this article looks at how the task behaves in real evaluation data when it is administered consistently across a preschool sample. You may have heard of “The Good Enough Draw A Person” drawing assessment. The O.T. Wizard uses a similar but more simple version.
This analysis is descriptive only. No Rasch or item response modeling has been applied yet.
Sample overview
Number of evaluations included: 404
Approximate number of students: 404
Evaluations with Draw-A-Person data: 401
Total item-level data points across the evaluation system: 19,062
Referred clinical sample, not normative population
Draw-A-Person was part of the standard evaluation battery and was administered when the child tolerated the task. Missing responses were excluded rather than scored as zero.
Draw-A-Person scoring rubric
Draw-A-Person was scored using the following criteria:
Score 0 (0.0): No approximations
Score 1 (0.2): Approximations emerge
Score 2 (0.4): Head and parts present but no body
Score 3 (0.6): Recognizable person with body and at least four body parts
Score 4 (0.8): Recognizable person with six or more body parts
Score 5 (1.0): Recognizable person with twelve or more body parts
It is important to note that even a score of 1 reflects emerging representational drawing rather than an absence of skill. The score was converted to a normalized score where a raw score of 5 = normalized score of 1.0 (most credit).
Average Draw-A-Person performance
Across the combined preschool sample:
Draw-A-Person scores were analyzed using normalized values derived from the scoring rubric. The average normalized score across the preschool sample was 0.38, corresponding to an average rubric level of approximately 1.9. Clinically, this places the average child between “approximations emerge” and “head and parts present but no body.”
While individual scores varied, this average suggests that most preschoolers in the sample demonstrated emerging representational drawing skills rather than fully recognizable figures
Distribution of Draw-A-Person scores
When responses are mapped directly onto the scoring rubric, the distribution looks like this:
Score 0, no approximations: 290 children, approximately 72 percent
Score 1, approximations emerge: 99 children, approximately 25 percent
Score 2, head and parts without a body: 7 children, approximately 2 percent
Score 3, recognizable person with body and at least four parts: 4 children, approximately 1 percent
Score 4, recognizable person with six or more parts: 1 child, less than 1 percent
Score 5, recognizable person with twelve or more parts: 0 children
This is a heavily floor-weighted distribution.
What this distribution tells us
In this preschool sample, most children did not produce a recognizable person. Nearly three quarters of children showed no recognizable approximations, and only a very small percentage produced a clearly recognizable person with a body.
Draw-A-Person age anchors suggest that by approximately 36 months, children often demonstrate a head with emerging parts, by 48 months a recognizable person with a body and multiple body parts, and by 64 months increasingly detailed human figures. In contrast, the average performance in this referred preschool sample falls between “approximations emerge” and “head and parts present but no body.” This indicates that, as a sample group, these children are demonstrating representational drawing skills that are less mature than would be expected based on age anchors, which is consistent with a population that did not pass an occupational therapy screening rather than a normative sample.
This helps explain why Draw-A-Person often feels like a difficult task for young children and why it frequently stands out in evaluation reports.
Why Draw-A-Person behaves differently than many other tasks
Compared to many visual perceptual, gross motor, or participation-based tasks, Draw-A-Person requires multiple skills to work together at once. These include visual motor integration, visual perception, motor planning, body awareness, fine motor control, and representational thinking.
Because of this high level of integration, Draw-A-Person tends to function as a high-threshold task. It separates children who are beginning to integrate these skills from those who are not yet developmentally ready to do so.
The data supports what many therapists experience clinically. Draw-A-Person is informative, but it should not be interpreted in isolation.
Interpreting Draw-A-Person results responsibly
Based on this data, several points are important for clinical interpretation:
Low Draw-A-Person scores are common in preschoolers
Progress from score 0 to score 1 is clinically meaningful
Scores of 3 or higher represent a small minority of children
Draw-A-Person should be interpreted alongside visual perceptual, fine motor, praxis, and participation data
Whether the task is developmentally ambitious, exhibits a floor effect, or is a candidate for item misfit will be evaluated during future Rasch analysis. At this stage, the data supports careful, contextual interpretation rather than over-weighting the score.
Why this matters for practice
Most therapists have an intuitive sense that Draw-A-Person is hard for young children. Very few have seen how strongly that intuition is reflected in actual data.
Seeing the full distribution helps recalibrate expectations and supports clearer communication with parents, teachers, and teams. It also reinforces the importance of viewing Draw-A-Person as one piece of a much larger evaluation picture.
As this dataset grows and formal psychometric analysis is completed, these descriptive patterns will be tested and refined. For now, they provide a grounded, data-anchored explanation for why Draw-A-Person feels the way it does in real preschool OT evaluations.
