🧠 Building Brains Through Visual-Motor Integration: The Role of the Beery VMI in Pediatric Occupational Therapy

Introduction

Pediatric occupational therapy works to support children in acquiring the sensory, motor, perceptual, cognitive, and self-care skills they need to participate meaningfully in home, school, and play environments. Among these, visual motor integration (VMI), the ability to coordinate visual perception with fine motor execution, is foundational to many daily tasks such as handwriting, drawing, cutting, and play. When VMI is disrupted, children may struggle academically or socially, particularly in neurological or neurodevelopmental conditions. The Beery–Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) is among the most used standardized instruments in pediatric OT to assess VMI. In this article, we review how the Beery VMI is standardized, what it measures, its psychometric strengths and limitations, and how it ties into neuroplastic rehabilitation in children with neurological or developmental diagnoses.

The Beery VMI: Standardization, Structure, and Administration

Standardization and normative basis

The Beery VMI is a norm-referenced, standardized instrument, typically published by Pearson (or affiliated assessment publishers). The 6th edition is current in many settings. It provides age-based norms (for example, from approximately age 2 through adulthood), allowing comparison of a child’s performance to typical peers (McCrimmon, Altomare et al. 2012) [13]. The standardization sample is drawn from a broad representation of children, and normative tables convert raw scores to standard scores, percentile ranks, and age equivalents.

Because the same basic forms are used across a broad age span, the Beery VMI can be used longitudinally, allowing a child to be tested with the same tasks over time, which is valuable in tracking intra-child change (Harvey et al. 2017).

One caution is cultural and population differences: some studies found that performance differed significantly from U.S. norms, suggesting that cultural or experiential factors may influence interpretation of “typical” performance in some populations (Li et al. 2025).

Structure and subtests

The Beery VMI consists of three core components:

1. Visual Motor Integration (VMI) subtest (core); The primary task: the child copies a series of geometric forms of increasing complexity, from simple shapes to more complex forms. The intention is to examine how visual perception is translated into motor output (drawing).

2. Visual Perception (VP) supplemental subtest; The child is shown a target figure and must select the identical figure from among several similar shapes; this isolates purely perceptual discrimination without requiring drawing.

3. Motor Coordination (MC) supplemental subtest; The child completes fine motor tasks such as drawing within narrow paths or connecting dots within constraints, isolating motor control demands.

   
   

The supplemental VP and MC subtests help differentiate whether a child’s difficulties on the VMI come more from perceptual processing, motor execution, or a combination of both. The supplemental subtests are optional but clinically useful for profiling.

Standard test instructions, scoring rules, time limits, item discontinuation criteria, and normative conversions are included in the administration manual to promote standardized application.

Psychometric properties: reliability, validity, and sensitivity

Reliability

• Inter-rater reliability (i.e. scoring consistency across different scorers) in Harvey et al.’s sample of 163 students ranged from r = 0.75 to 0.88 for the core VMI subtest (no significant scorer bias) (Harvey et al. 2017).

• Test-retest reliability (same child tested on two separate occasions) was more moderate: correlations ranged from ~0.54 to 0.58 for the core VMI, with 95% limits of agreement ±24 to ±26 raw score points (i.e. large measurement variability) (Harvey et al. 2017).

• Some sources and reviews report somewhat stronger reliability for earlier editions: “excellent” test-retest reliability in the range .84–.88, and interrater reliability in .90–.98, with internal consistency around .81–.82.

• However, some critics caution that the test may lack sensitivity to small but clinically meaningful changes, and that scoring subjectivity or ceiling/floor effects may limit detection of change.

• A specific study examined whether a “minimal clinically important difference” (MCID) could be established for the Beery, but concluded there was currently no widely accepted MCID, limiting confident use of the test for tracking small functional gains (Wells et al. 2024).

  
  

Validity

• The instrument is generally considered to have construct validity and concurrent validity. For example, correlations with other visual motor or perceptual tests are moderate to strong

• The Beery VMI is often used in research and clinical settings as a predictor or correlate of handwriting, academic performance, and fine motor tasks, supporting its predictive validity (McCrimmon et al. 2012).

• In clinical populations, the Beery VMI has been shown to distinguish among performance levels and to reflect group differences.

  
  

Given these psychometric properties, the Beery VMI is widely accepted and commonly used, but results should always be integrated with clinical judgment, observation, ecological performance, caregiver/teacher report, and complementary assessments.

Neuroplastic Rehabilitation in Pediatric OT: Concepts and Evidence

Principles of neuroplasticity and relevance in pediatrics

Neuroplasticity refers to the brain’s capacity to reorganize itself, structurally and functionally, in response to experience, training, injury, and development. In children, plastic potential is generally higher, especially for sensorimotor, perceptual, and cognitive circuits.

Key principles of experience-dependent plasticity include use it or lose it, use it and improve it, specificity, repetition, intensity, salience, transference, and interference. OT interventions that are meaningful, repetitive, progressively challenging, and embedded in functional tasks are more likely to engage neuroplastic change.

In pediatric populations such as cerebral palsy, acquired brain injury, stroke, congenital malformations, studies of gross motor interventions (e.g. constraint-induced movement therapy, locomotor training) have documented changes in motor cortical maps, connectivity, and activation patterns that correlate with functional improvements (Hilderley et al. 2022). While much of the neuroplastic motor research focuses on gross motor skills, the same principles apply to fine motor and visuomotor systems.

Integrating Beery VMI with neuroplastic rehab in OT

The Beery VMI can inform neuroplastic-focused intervention planning in several ways:

1. Baseline quantification and goal setting: The standard score and percentile from the Beery provide objective quantification of VMI status, which can inform individualized goal writing. Supplementary VP/MC subtest performance helps disaggregate perceptual vs motor contributions to deficits, guiding more precise intervention targets.

   
   

2. Targeted intervention design:

   • If the VP subtest is relatively weak but MC is stronger, interventions should emphasize perceptual discrimination, form constancy, visual memory, visual spatial tasks, scanning, figure-ground, and matching tasks.

   • If MC is the primary weakness, focus on graded fine motor strengthening, dexterity tasks, in-hand manipulation, tool use (scissors, pencils), bilateral hand coordination.

   • In cases where both are weak (i.e. integrated VMI deficit), integrate tasks that demand both perception and motor response (copying, tracing, drawing, functional tasks) with increasing complexity and variability. The guiding principle is task specificity, training the child on activities closely aligned with target functional goals (e.g. copying from whiteboard, tracing classroom worksheets, drawing shapes, visual puzzles, timed copy tasks).

     
     

3. Dosage, intensity, and periodic reassessment: For neuroplastic learning, frequent, repetitive, high-dosage practice is often more effective than infrequent sessions. Blocks of intensified intervention may accelerate gains. Periodic re-administration of the Beery allows measurement of change, adjustment of goals, and documentation of progress.

   
   

4. Transfer and generalization: To maximize generalization, embed tasks in context such as copying from the whiteboard, writing on worksheets under timed conditions, or classroom simulations. Vary the environment and task demands to promote adaptability of skills.

   
   

5. Cross-environment collaboration and accommodations: Share results and profiles from the Beery with caregivers, teachers, and other providers to facilitate consistent strategies across home and school. Recommend accommodations such as larger writing spaces, copy from peers, visual cues, and adapted tasks while the child is learning. This reduces performance barriers so the child can engage while gradually improving capacity.

   
   

Pediatric Neurological and Developmental Conditions: Clinical Relevance of Beery VMI and Neuroplastic OT

Below are some common pediatric conditions in which VMI deficits are prevalent and in which the Beery VMI may be clinically useful.

Condition	Common VMI / visuomotor challenges	How Beery VMI helps	Neuroplastic OT implications
Cerebral Palsy (CP)	Fine motor control, spasticity, motor planning, visual perception, hand–eye coordination issues	Beery may show lower VMI, highlight motor vs perceptual contributions (Carsone et al. 2021)	Use intensive, repetitive, graded tasks (e.g. CIMT, bilateral hand tasks), scaffolded practice, feedback, and progression to shape visual motor circuits
Autism Spectrum Disorder (ASD)	Motor planning, visuospatial perception, copying deficits, motor coordination variance	Studies show children with ASD often score lower on Beery than peers (Beery VMI in ASD)	Use structured visuomotor tasks, scaffolded support, repeated practice, increasing challenge, and integrate with social and play contexts
Developmental Coordination Disorder (DCD)	Clumsiness, poor fine motor control, slow speed, poor coordination	Beery helps differentiate perceptual vs motor limitations, supporting targeted intervention	Emphasize motor planning, multi-sensory input, graded difficulty, motor learning strategies, augmented feedback
Acquired Brain Injury / Stroke / TBI	Damage to visual pathways, sensorimotor integration deficits, visual perceptual deficits	Beery can detect residual VMI deficits, track recovery over time	Neuroplastic strategies: constraint, shaping, repeated practice, feedback, visual retraining where applicable
Cerebral Visual Impairment (CVI) / visual pathway lesions	Impaired visual perception, contrast sensitivity, spatial processing	Poor VMI scores likely; VP subtest may be disproportionately weak	Combine visual perceptual retraining, compensatory strategies (contrast, cueing), incremental motor tasks aligned with visual capacity
Brachial Plexus Injury	Fine motor impact, asymmetry, hand control	In cohort studies, Beery VMI used to monitor gains post-OT in children with CP, ASD, BPI (Carsone et al. 2021)	Focus on constrained use, graded motor tasks, bilateral tasks, neuroplastic facilitation of the affected limb

An example: a study by Carsone and colleagues (2021) analyzed OT intervention in children with ASD, cerebral palsy, and brachial plexus injury and found that Beery VMI scores tended to improve post intervention in relation to OT dose and baseline performance, highlighting its utility as one component of outcome measurement (Carsone et al. 2021).

Evidence & Research Linking Beery VMI, OT Interventions, and Neuroplastic Outcomes

• Cho et al. (2015) found that visual perceptual intervention improved both VMI and ADL performance in children with cerebral palsy, suggesting that targeted perceptual training can support functional gains.

• In the Chinese preschooler study, regression analysis revealed that both VP and MC subtest scores significantly contributed to total VMI variance, explaining about 25% of variance, reinforcing the notion that interpreting subtest patterns is meaningful (Li et al. 2025)

• More broadly, functional neuroplastic changes have been documented in motor skill interventions in children such as changes in cortical activation and connectivity parallel behavioral improvements (Hilderley et al. 2022). While most such studies focus on gross motor skills, they corroborate the principle that repetitive, task-specific training can reorganize neural circuits.

  
  

Practical Recommendations for Clinicians & Researchers

1. Use Beery VMI as one piece of a multi-dimensional evaluation: combine with handwriting samples, classroom copying tasks, observation, teacher/parent questionnaires, and complementary perceptual or motor assessments (e.g. DTVP, TVPS, motor dexterity tests).

2. Interpret subtest patterns (VP vs MC) to direct what to target first in intervention rather than focusing only on the core VMI score.

3. Plan neuroplastic-aligned interventions: ensure high repetition, meaningful tasks, progressively increasing challenge, variability, feedback, and scaffolding. Incorporate goal-related tasks such as copying classwork rather than purely abstract shapes alone.

4. Use dosing strategies strategically: when possible, deliver blocks of more frequent sessions to accelerate gains.

5. Monitor and document change: re-administer the Beery at clinically meaningful intervals, but be cautious interpreting small changes given measurement error and lack of established MCID. Triangulate with functional and ecological outcomes.

6. Advocate for accommodations while skills develop: share Beery profiles with teachers/caregivers to guide classroom modifications, visual cues, adapted writing formats, or assistive tools.

7. Contribute to the evidence base: if feasible, design OT intervention studies or case series with clear dosing, Beery pre-post data, and functional outcomes to help advance understanding of effective VMI interventions.

Conclusion

The Beery VMI is a well-established, widely used, standardized tool that helps quantify children’s visual motor integration performance and guides targeted intervention planning in pediatric occupational therapy. While it is not without limitations (e.g. measurement noise, limited sensitivity to small gains), when used thoughtfully within a broader evaluation battery its subtest patterning is valuable and clinically meaningful. Embedding Beery-derived insights into neuroplastic rehabilitation plans with repetition, task specificity, intensity, and meaningful challenge and can support neural reorganization and functional improvement in children with neurological and developmental conditions. For maximum impact, pair standardized assessment (Beery) with ecological, functional outcome measures and cross-environment collaboration (school, home, family) to support transfer and sustained progress.

References

1. Beery, K. E., & Beery, N. A. (2010). The Beery-Buktenica Developmental Test of Visual-Motor Integration: Administration, Scoring, and Teaching Manual (6th ed.). Pearson.

2. Carsone, B., Green, K., Torrence, W., & Henry, B. (2021). Occupational therapy and Beery VMI scores of children with autism spectrum disorder, brachial plexus injury, and cerebral palsy. F1000Research, 10:515. https://doi.org/10.12688/f1000research.52435.1  

3. Cho, M., Kim, D., Yang, Y. (2015). Effects of visual perceptual intervention on visual-motor integration and ADL performance of children with cerebral palsy. Journal of Physical Therapy Science, 27(2), 411–413 (cited in Li et al. 2025)

4. Hilderley, A. J., et al. (2022). Functional neuroplasticity and motor skill change. PMC (Public Health). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9896542  

5. Harvey, E. M., Leonard-Green, T. K., Mohan, K. M., Kulp, M. T., Davis, A. L., Miller, J. M., … Dennis, L. K. (2017). Inter-rater and test-retest reliability of the Beery VMI in schoolchildren. PMC (NIH). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443123 

6. Li, X., et al. (2025). Clinical value of Beery visual-motor integration and supplemental tests in Chinese preschoolers. Frontiers in Pediatrics. https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2025.1531192/full

7. McCrimmon, A. W., Altomare, A. A., Matchullis, R. L., Jitlina, K. (2012). The Beery Developmental Test of Visual-Motor Integration: Test review. Journal of Psychoeducational Assessment, 30(6), 588–592. (ERIC Review)

8. Physio-pedia. (n.d.). Beery-Buktenica Developmental Test of Visual-Motor Integration. Retrieved from https://www.physio-pedia.com/Beery-Buktenica_Developmental_Test_of_Visual-Motor_Integration 

9. SRAlab (Shirley Ryan AbilityLab). Beery Buktenica Developmental Test of Visual-Motor Integration. Retrieved from SRAlab rehabilitation measures database.

10. Wells, et al. (2024). No evidence of a minimal clinically important difference for the Beery. PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12033894 

11. Tandfonline study. (2023). Examining the association between the Computer-Aided Scoring System (CASS) and Beery VMI scoring. https://www.tandfonline.com/doi/full/10.1080/19411243.2023.2275569