Handwriting Intervention for Children with Writing Limitations

Examining the effectiveness of handwriting intervention for children

with deficiencies in writing legibility, speed, and accuracy

Abby Call and Hannah McCord

University of Utah
Handwriting Intervention for Children with Writing Limitations

Introduction

Handwriting is an integral facet of our lives in particular throughout a persons

education and in communication throughout the lifespan. Deficiencies in completing this

activity produce problems not only in school success, but have consequences in areas such as

ones self-esteem, social participation, and creativity. Furthermore, these deficiencies create an

imbalance in the amount of energy expended during cognitive tasks, primarily in academics.

Affecting anywhere from 5-33% of school-aged children, handwriting deficits are a growing

concern (Overvelde & Hulstijn, 2010). As use of technology in our school systems and our

society at large increases, the emphasis placed on developing this skill is decreasing.

When considering the activity of handwriting, it is important to note its complexity.

What seems to most adults as a naturally occurring phenomenon is in reality, an intricate

process involving several elements, including visual-perceptual and fine-motor movement

components. Deficiencies in any of these areas could cause decrease in handwriting ability,

especially in legibility, speed, and accuracy. Conditions affecting visual/perceptual input and or

processing, or motor deficits including Joint Hypermobility Syndrome are examples of such

deficiencies.

It is imperative to note the typical development of handwriting in order to attend to

children that show signs of deviation of the norm. Identifying children with handwriting deficits

and those at risk of developing deficits is an important first step of rectifying the problem of

writing limitations. Many professionals play a key role in treating these deficits including

occupational therapists and educators.

Handwriting Intervention for Children with Writing Limitations

As interest in the topic of handwriting grows more research around handwriting

interventions are being conducted. Progress is being made in determining the typical way

handwriting develops among children. Effective therapies addressing handwriting abilities

among children with deficiencies are being examined and scrutinized for validity and efficacy.

Several articles have reported findings supporting the use of different handwriting

interventions in improving writing ability among school-aged children. While other studies

report finding unsuccessful outcomes. The purpose of this review is to examine the strength of

various handwriting interventions facilitated by occupational therapists among children who

present with handwriting deficiencies.

Methods

Five scientific research databases were used for this systematic review; PubMed,

CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Education Resource

Information Center), OTSeeker (Occupational Therapy Systematic Evaluation of Evidence), and

Cochrane. A total of 73 articles were originally found using the following key terms:

handwriting intervention, children, and occupational therapy. There was no date criteria used

during the original search.

To narrow down our articles, the following inclusion criteria were used. First, a

publishing date of 2006 or more recent was specified; however, this date range was too

restrictive. Therefore, the date criteria were expanded to 15 years. Second, for the purposes

of this review the goal was to analyze the validity of the known handwriting interventions used

among occupational therapist for grade school children with deficiencies in writing technique

and skill. For this reason articles selected to be included in this systematic review had a broad
Handwriting Intervention for Children with Writing Limitations

inclusion of handwriting interventions. Third, to further narrow the findings an age criteria was

implemented to include only school aged children; 5 to 12 years of age. Of the 66 articles

found pilot studies and other systematic reviews were excluded.

After a thorough review of the articles found a total of eight were selected to be

included in this systematic review of handwriting therapy. The inclusion criterion for these

articles was based on level of evidence, generalizability across populations, and comprehensive

handwriting interventions. Those chosen represented a broad degree of populations of school

aged children with handwriting deficiencies. Moreover, the articles chosen reflected a varied of

handwriting interventions implemented by occupational therapist; including co-taught

intervention with teachers, intensive intervention during a summer program, use of Write Start

method, use of Handwriting Without Tears method, independently applied outside of the

classroom, and use of splinting technique. Furthermore, only articles with a level of evidence

of III or higher were chosen to be included in this review. In total, one level I RCT was included

with a PeDRO score of 6 of 10, one level II study, and five level III studies were selected.

Results

A study conducted by Case-Smith (2002) found a classroom-based occupational therapy

handwriting intervention to be effective for increasing legibility. The randomized control trial

included 7 to 10 year old participants randomly assigned to handwriting intervention or

standard instruction; 29 to the intervention group and 9 to the control group. Case-Smith

tested the participants using three collection methods pre-intervention and post-intervention

with the use of the Developmental Test of Visual Perception (DTVP), Bruininks-Oseretsky Test

of Motor Proficiency (BOTMP), and Evaluation Tool of Childrens Handwriting (ETCH). The
Handwriting Intervention for Children with Writing Limitations

finding of this level I study showed a 14.2% increase in legibility score for the intervention

group compared to the control group which showed a 5.8% increase in legibility score.

Additionally, the findings showed a significant increased score in in-hand manipulation and

position in space among participants. This randomized control trial has a PeDRO score of 6 of

10. However, limitations of this study to be considered are sample size, disproportion of group

size between control and intervention groups, and lastly the use of a single geographical area

for participant selection.

A research study conducted by Case-Smith, Holland, and White (2014) examined the

Write Start handwriting program embedded in a classroom setting. The participants of this

study were 67 first grade students from one district in the Midwest. The children were split into

two group; one receiving the Write Start program and the other receiving standard instruction.

Data were collected at baseline, immediately after the program, and 6 months post program.

Legibility, fluency, and written expression were examined by the researcher. When the two

groups data were compared the results indicated a significant improvement in legibility and

fluency found in the Write Start group paralleled to the control group. Written expression did

not have a significant difference in scores between groups. Limitations of this study are small

sample size, lack of randomization, and lack of blinding participants and testers.

Furthermore Case-Smith, Weaver, and Holland (2014) explored the Write Start program

co-taught by teachers and specialty teachers collaborating with occupational therapists. Their

rationale for this study included the notion that developed handwriting abilities can lead to

more focus on attaining actual subject knowledge and less energy and faculties expended on

handwriting tasks. The main questions this study centered around not only evaluating the
Handwriting Intervention for Children with Writing Limitations

effectiveness of Write Start compared to regular school handwriting curriculum, but also to

gage how much this program could make a difference in handwriting abilities in general in

terms of speed, fluency, and written composition. The intervention took place in four first grade

classrooms and the control group also consisted of four first grade classrooms. These

classrooms were not randomized. Intervention lasted 12 weeks, with two sessions a week, both

lasting 45 minutes each. In these sessions, the Write Start Program co-teachers worked on all

letters of the alphabet. Instruction, small group practice, reflection, and story writing activities

were part of the session. The comparison group engaged in the normal writing curriculum,

spending approximately 20 minutes three or four times a week to learn or review one or two

letters of the alphabet and then using the letters in a sentence. The student would then engage

in a small writing activity; such as writing a note to a family member. Results showed a

significant increase in legibility and speed among both groups however a greater significance

was found in the Write Start Program. Limitations of this study included the non-randomization

of the group placements and limited blinding of the researchers and administrators. There was

also low socioeconomic variation among the sample of participants.

Research by Howe, Roston, Sheu, and Hinojosa (2013) found a significant increase in

handwriting legibility in 1st and 2nd grade students. A total of 72 students participated in this

study and were placed into one of two handwriting clubs; club group A and club group B. Howe

et al. found students who received handwriting interventions after a 12 week period of 45

minute sessions significantly increased their handwriting legibility when compared to those

who received traditional writing instruction. However, no significant results were found

pertaining to speed or visual-motor skills between groups. The main limitations of this level III
Handwriting Intervention for Children with Writing Limitations

study include: lack of randomization of club groups, lack of blinding of participants and

occupational therapists, and the threat to internal validity from possible events that may have

transpired in the school during the study.

Moreover, Overvelde and Hulstijn (2010) examined the process of handwriting

acquisition among children in grades 2 and 3. Their rationale included that handwriting

contributes to self-esteem and school performance. Additionally, problems with handwriting

are a component used in diagnosing Developmental Coordination Disorder. The methods used

in this study were intended to follow handwriting acquisition patterns and give a concrete

definition of normal, at-risk, and dysgraphic handwriting. The researchers used a pretest

posttest design using the Concise Assessment Method for Childrens Handwriting and the

Developmental Test of Visual Motor Integration to test the participants; once at the beginning

and once at the end. The BHK tested handwriting ability, more specifically quality and speed of

writing, by having the participant copy a text for five minutes. The VMI test was designed to

determine handwriting quality, rather than ability. To complete the test, the participants copied

shapes by looking at a picture and drawing them on their own paper within a timeframe of

three minutes. Previous studies showed low correlations between VMI scores and dysgraphic

handwriting. VMI scores were determined unnecessary and excluded in the results of this

study. Findings included the need to wait until approximately the middle of grade 3 to make an

occupational therapy referral to work on handwriting due to maturation.

Marr and Dimeo (2006) postulated a concentrated handwriting summer course

implemented by occupational therapists might serve as a positive supplement to the school-day

handwriting therapies. According to Marr et al. intervention applied during the summer
Handwriting Intervention for Children with Writing Limitations

months allows for children to relate to peers about common challenges of handwriting abilities

and creates an environment focused on skill development without other stresses of school

performance. Research was conducted in upstate rural New York to study to effectiveness of a

summer handwriting course; specifically on legibility of uppercase and lowercase letters. A

total of 36 children participated in a two week intense class for two summer session in the

years 2002 and 2003. The researcher used a single-group pretest posttest design and the

occupational therapists utilized the Handwriting Without Tears curriculum. The findings from

this study showed a significant improvement in the legibility of both uppercase and lowercase

alphabet. Furthermore, parents reported positive improvements in their childs handwriting 3

months post intervention. The main limitations of this study are the small sample size, lack of

control group and lack of randomization.

Lastly, the research conducted by Frolich, Wesley, Wallen, and Bundy (2012) explored

the effects of splinting on handwriting with ninth and tenth grade students with Joint

Hypermobility Syndrome. The researchers surmised that pain has a negative effect on

handwriting by decreasing ability. A multiple baseline single system design was used with the

intervention being a neoprene wrist/hand splint worn during activities involving handwriting.

The primary outcomes measured included speed, pain, and endurance. Secondary outcomes

included grip strength and self-perception of handwriting skills. Speed was tested using the

Handwriting Speed Test (HST3m and HST9m), both over three minutes and nine minutes, using

letters per minute to measure speed. Pain was assessed by a 100 mm visual analogue scale

(VAS). A pain score of 0 mm represented no pain and a pain score of 100 mm was associated

with pain felt like never before. Endurance was measured by considering handwriting speed on
Handwriting Intervention for Children with Writing Limitations

HST9m and change in pain while engaging in the task. A CITEC dynamometer measured grip

strength and The Handwriting Proficiency Screening Questionnaire was filled out by the

participants. Participants were randomly placed into one of four groups: A1, B1, A2, or

prolonged baseline. A phases indicated baseline and no treatment and the B phase

indicated intervention. Each of the phases was completed in four weeks. The HST provided

excellent interrater reliability and the VAS provided sufficient reliability and validity. Overall

findings concluded that wearing this particular splint did not improve handwriting speed and

did not alleviate increasing pain. Limitations of this study include the timing of the studys

conduction and the age of participants. For some participants, this study occurred during the

holiday recess, a time in which a decrease in handwriting activities typically occurs. Additionally,

the use of the splint and its effects on handwriting might be influenced by the age of the

participants. By high school handwriting ability and habits such as grip have already been well

established.

Discussion

The results of this systematic review indicate that certain handwriting interventions

performed by occupational therapists have validity and merit for treatment among school aged

children with writing deficiencies. However, upon examination it is clear there are some

limitations to the research found. First, there is an apparent lack of randomized control trials

preformed on handwriting interventions. Second, many of the studies found were conducted

using a small sample sizes and often within one geographic region which limits generalizability.

Third, many of the studies found lacked blinding of participants, occupational therapists, and/or

administrators. All of these limitations create threats to the internal validity and soundness of
Handwriting Intervention for Children with Writing Limitations

the studies conducted. It can be concluded that more research needs to be conducted;

particularly randomized control trials.

Additionally, of the eight studies included in this review 7 found significance in their

outcome measures while only 1 concluded the handwriting intervention to not be a success for

participants. The common significant outcome measure found between these studies was a

significant increase in legibility of handwriting. Speed and fluency significance varied among

studies. The mixed results in the data give us indication that there is a need for more high level

research to be conducted on handwriting therapies.

From our examination we concluded the research found to rate at a level B, class IIa due

to the limited populations, lack of RCTs, small sample sizes and lack of randomization within

studies. Still, handwriting intervention performed by occupational therapist for children with

writing limitations and challenges would be recommended as being effective in improve writing

skills.
Handwriting Intervention for Children with Writing Limitations

References

Case-Smith, J. (2002). Effectiveness of school-based occupational therapy intervention on handwriting.

American Journal of Occupational Therapy, 56, 17-25.

Case-Smith, J., Holland, T., White, S. (2014). Effectiveness of a co-taught handwriting program for first
grade students. Physical and Occupational Therapy in Pediatrics, 34 (1), 30-43.

Case-Smith, J., Weaver, L., & Holland, T. (2014). Effects of a classroom-embedded occupational
therapistteacher handwriting program for first-grade students. American Journal of
Occupational Therapy, 68, 690698. http://dx. doi.org/10.5014/ajot.2014.011585.

Frohlich, L., Wesley, A., Wallen, M.; & Bundy, A. (2012). Effects of Neoprene wrist/hand splints on
handwriting for students with Joint Hypermobility Syndrome: a Single System Design study.
Physical & Occupational Therapy in Pediatrics, 32(3), 243-255. doi:
10.3109/01942638.2011.622035.

Giroux, P., Woodall, W., Weber, M., & Bailey, J. (2012). Occupational therapy practitioners perceptions
of important competencies for handwriting evaluation and intervention in school-aged children.
Physical & Occupational Therapy In Pediatrics, 32:1, 66-79, DOI:
10.3109/01942638.2011.592573.

Howe, T. H., Roston, K. L., Sheu, C. F., & Hinojosa, J. (2013). Assessing handwriting intervention
effectiveness in elementary school students: A two-group controlled study. American Journal of
Occupational Therapy, 67, 19-27. http://dx.doi.org/10.5014/ajot.2013.005470

Hoy, M. M. P., Egan, M. Y., & Feder, K.P. (2011). A systematic review of interventions to improve
handwriting. Canadian Journal of Occupational Therapy, 78, 13-25. doi:10.2182/cjot.2011.78.1.3

Mackay, N., McCluskey, A., & Mayes, R. (2010). The Log Handwriting Program improved childrens
writing legibility: A pretest-posttest study. American Journal of Occupational Therapy, 64, 30-
36.

Marr, D., Dimeo, S. B., (2006). Outcomes associated with a summer handwriting course for elementary
students. American Journal of Occupational Therapy, 60, 10-15.

Overvelde, A., & Hulstijn, W. (2010). Handwriting development in grade 2 and grade 3 primary school
children with normal, at-risk, or dysgraphic characteristics. Research in Developmental
Disabilities, 32(2), 540-548. doi:10.1016/j.ridd.2010.12.027.

Roberts, G. I., Derkach-Ferguson, A.F., Siever, J.E., Rose, M.S. (2014). An examination of the
effectiveness of handwriting without tears instruction. Canadian Journal of Occupational
Therapy, 81(2), 102-113.
 Handwriting Intervention for Children with Writing Limitations

Table I
Study Level of Age Assessment Methods Aim of study Outcome
Evidence

Case-Smith I 7-10 yrs. Pre-test Post-test Legibility, manipulation Significant increases in in-hand
(2002) DVTP, BOTMP, ETCH and positioning, manipulation and position in space scores.
Furthermore they improved more in
handwriting legibility.
Legibility increased by 14.2% in students
who received OT services and by 5.8% in
the students who did not receive services.

Case-Smith et al II 5.5-7.5 yrs. Baseline, Week One, 6 Legibility, fluency, Significant improvement legibility and
(2014) months post Intervention speed fluency.
ETCH, WJ-III No significance improvement in speed.

Case-Smith et al. III Grade 1 Evaluation of Tool of Determine All had significant improvements in
(2014) Childrens Handwriting- effectiveness of the handwriting, but Write Start Program more
Manuscript assessed interdisciplinary taught in lowercase legibility
lowercase legibility and Write Start program Both groups made significant progress in
speed speed, but Write Start Program improved
Writing fluency and more
Writing Samples tests of Write Start Program made more
the Woodcock-Johnson III improvement in the Writing Fluency test
Tests of Achievement

Write Start Program

Howe et al. III Grades 1 & 2 Pre-test Post-test MHA, Handwriting speed, Significant improvements in handwriting
(2013) VMI legibility, visual motor legibility.
skills No significant results found in speed or
visual-motor skills between the two groups

Overvelde et al. III Grades 2 & 3 BHK, VMI Define normal, at risk, VMI was an inappropriate testing measure
(2010) and dysgraphic
populations OT referral should not be made too quickly.
Results showed that handwriting was
developing until the middle of grade 3
Handwriting significantly better in grade 3
compared to grade 2
Significant improvements for first to second
analysis seen in grade

Marr et al. III Elementary Pre-test Post-test ETCH Significant improvements in two subtest of
(2006) age ETCH

Frohlich et al. III Grades 9 & Handwriting Speed Tests Determined Overall splinting not effective
(2012) 10 (HST3m and HST9m) effectiveness of
100 mm visual analogue neoprene splint on
scale (VAS) handwriting among
CITEC dynamometer to those with Joint
measure grip strength Hypermobility
The Handwriting Syndrome
Proficiency Screen
Questionnaire