Curriculum-Based Handwriting Programs: A Systematic

Review With Effect Sizes

Courtney Engel, Kristin Lillie, Sarah Zurawski, Brittany G. Travers

Challenges with handwriting can have a negative impact on academic performance, and these challenges are
commonly addressed by occupational therapy practitioners in school settings. This systematic review ex-
amined the efficacy of curriculum-based interventions to address children’s handwriting difficulties in the
classroom (preschool to second grade). We reviewed and computed effect sizes for 13 studies (11 Level II,
2 Level III) identified through a comprehensive database search. The evidence shows that curriculum-based
handwriting interventions resulted in small- to medium-sized improvements in legibility, a commonly re-
ported challenge in this age group. The evidence for whether these interventions improved speed is mixed,
and the evidence for whether they improved fluency is insufficient. No clear support was found for one
handwriting program over another. These results suggest that curriculum-based interventions can lead to
improvements in handwriting legibility, but Level I research is needed to validate the efficacy of these curricula.

Engel, C., Lillie, K., Zurawski, S., & Travers, B. G. (2018). Curriculum-based handwriting programs: A systematic review
with effect sizes. American Journal of Occupational Therapy, 72, 7203205010. https://doi.org/10.5014/ajot.
2018.027110

H andwriting difficulties are observed in 10%–30% of school-age children

Courtney Engel, MOT, OTR, is Occupational Therapist,
Chicago, IL. At the time of the research, she was Master’s
with and without identified disabilities (Feder & Majnemer, 2007).
Student, Occupational Therapy Program, Department of
Kinesiology, University of Wisconsin–Madison. Children experiencing handwriting impairments tend to have lower achieve-
ment in mathematics, lower verbal IQ, and greater attention difficulties than
Kristin Lillie, MOT, OTR, is Occupational Therapist, their peers without impairments (Sandler et al., 1992), resulting in decreased
Milwaukee, WI. At the time of the research, she was
ability to interact and engage in classroom settings. Poor handwriting can also
Master’s Student, Occupational Therapy Program,
Department of Kinesiology, University of Wisconsin– lead to limited compositional fluency (Graham, Berninger, Weintraub, &
Madison. Schafer, 1998), issues with taking legible notes and reading them later, and
more time needed to finish assignments (Graham, 1992). Moreover, hand-
Sarah Zurawski, MSE, OTR/L, is Lecturer,
Occupational Therapy Program, Department of
writing impairments have been linked to reduced working memory capacity
Kinesiology, University of Wisconsin–Madison. and lower reading and spelling scores (McCarney, Peters, Jackson, Thomas, &
Kirby, 2013), suggesting that handwriting challenges early in life may have
Brittany G. Travers, PhD, is Assistant Professor,
cascading negative effects on learning and academic performance.
Occupational Therapy Program, Department of
Kinesiology, University of Wisconsin–Madison, and To address handwriting difficulties, several curriculum-based handwriting
Assistant Professor, Waisman Center, University of programs have been developed. These programs are taught within the classroom
Wisconsin–Madison; [email protected] setting and are geared toward improving handwriting in all children, not just
those exhibiting difficulties. Occupational therapy practitioners in the schools
often facilitate these interventions; handwriting deficiencies are one of the
primary causes for referral to occupational therapy among school-age children
(Barnes, Beck, Vogel, Grice, & Murphy, 2003).
Handwriting Without Tears (HWT; Olsen & Knapton, 2008), a develop-
mentally and multisensory-based handwriting curriculum, can be implemented
in the classroom by both teachers and occupational therapy practitioners. The
Write Start program (Case-Smith, Holland, & Bishop, 2011; Case-Smith,
Holland, Lane, & White, 2012), another cotaught classroom-embedded in-
tervention, is aimed at promoting writing fluency in grade school children of all

The American Journal of Occupational Therapy 7203205010p1

ability levels. These and other curriculum-based programs specific curricula rendered the largest treatment effects; and
(see Table 1) target handwriting performance in children’s (3) whether specific characteristics of curricula (e.g., age at
classroom setting. The curriculum-based approach aligns intervention, length of intervention) led to more sub-
with the Every Student Succeeds Act of 2015 (Pub. stantial treatment effects.
L. 114-95), a reauthorization of the No Child Left Behind
Act of 2001 (Pub. L. 107-110), which allows schools to
address the needs of all students but particularly focuses on
Method
children who are not meeting academic standards. Align- Search Strategy
ing handwriting interventions with classroom curricula is
We conducted a systematic search of the literature to
thought to promote greater generalization of skills to
identify curriculum-based handwriting interventions for
handwriting-based activities within the classroom.
children. The previous systematic review of handwriting
Despite the availability of curriculum-based programs,
little research has been conducted on the efficacy of these interventions covered December 1978 to January 2010
interventions in improving handwriting performance. A (Hoy et al., 2011). The current review included studies of
previous systematic review found that handwriting inter- curriculum-based handwriting interventions published
ventions (a blend of both curriculum-based and non– from January 2006 to December 2015. Figure 1 shows
curriculum-based programs) were effective when they the number of studies identified, screened, eligible for,
provided sufficient time for handwriting practice (Hoy, and included in the systematic review. With the help of a
Egan, & Feder, 2011). However, this review did not medical librarian, our team systematically searched the
specifically evaluate curriculum-based handwriting inter- following databases: PubMed, EBSCOhost (including
ventions, and the majority of the literature on curriculum- Academic Search Premier), CINAHL Plus With Full
based programs has been published since the review. Text, Education Full Text, ERIC, MEDLINE, PsycINFO,
Therefore, the objective of the current study was to Social Sciences Full Text, SocINDEX with full text, and
systematically review the efficacy of curriculum-based OTseeker. For PubMed, key terms included childp and
handwriting programs in improving handwriting in class- handwritp and (intervention or therapy or program). For
room activities for children with and without identified EBSCOhost, terms included childp (and handwritp in-
disabilities. Combining our systematic review with effect tervention or handwrit p program). For OTseeker, the
size calculations from each study, we specifically aimed to broad term “handwriting” was used to encompass a wide
examine (1) whether curriculum-based handwriting inter- range of articles. The searches were further narrowed by
ventions in general made meaningful changes to children’s the use of filters, including peer-reviewed journal articles,
handwriting legibility, speed, and fluency; (2) whether publication within the past 10 yr, and clinical trials.

Table 1. Handwriting Curriculum-Based Interventions Examined in the Reviewed Studies

Curriculum Description
Write Start (Case-Smith, Holland, & Bishop, Integrated handwriting and writing program cotaught by occupational therapists and teachers using
2011) small group work, individualized support, peer and self-modeling, and frequent feedback
Handwriting Without Tears (Olsen, 2003; Olsen & Sensorimotor-based handwriting curriculum emphasizing stages of learning and play-based instruction
Knapton, 2008) for printing and cursive writing
Handwriting Without Tears–Get Set for School Sensorimotor-based handwriting curriculum designed to teach preschool children prewriting skills
(Olsen & Knapton, 2008) necessary for kindergarten using music and movement and station teaching with multisensory tools
to learn body awareness and fine motor skills
Peterson Directed Handwriting Curriculum Handwriting curriculum focused on movement sequence and rhythm to develop movement patterns
(Nelson, 2006) for writing automaticity using the “We Write to Read” method (connection between reading and
writing fluency)
Fine Motor and Early Writing Pre-K curriculum Handwriting readiness program using station teaching with adapted writing tools, workbooks, and
(see Donica, Goins, & Wagner, 2013) sensory activities
Size Matters Handwriting Program (Moskowitz, Handwriting program focused on letter size in an effort to improve readability and including direct
2009) instruction, memorable mnemonics, motivational incentives, parent involvement, frequent visual cuing,
and self-critique and self-monitoring
Write Direction (Taras, Brennan, Gilbert, & Eck Curriculum addressing letter formation through body movements, kinesthetic awareness, and
Reed, 2011) visual–motor skills
Handwriting Clubs (Howe, Roston, Sheu, & Handwriting intervention in the form of school clubs with a focus on either intensive practice or
Hinojosa, 2013) visual–perceptual–motor approaches
Explicit handwriting program (Kaiser, Albaret, Handwriting program consisting of digital dexterity exercises, cursive writing, and metacognitive
& Doudin, 2011) tasks combined with discussion and handwriting practice

7203205010p2 May/June 2018, Volume 72, Number 3

 Identification
Records identified through Additional records identified
database searching through other sources
(n = 455) (n = 0)

Records after duplicates removed

Screening (n = 252)

Records screened Records excluded by title

(n = 252) (n = 99)

Records screened Records excluded by

(n = 153) abstract
(n = 121)
Eligibility

Full-text articles assessed Full-text articles excluded

for eligibility interventions implemented
(n = 32) outside of classroom
(n = 19)

Studies included in
Included

qualitative synthesis
(n = 13)

Figure 1. Flow diagram of articles identified, screened, eligible for, and included in the systematic review.
Figure format from “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, and D. G.
Altman; PRISMA Group, 2009, PLoS Medicine, 6(6), e1000097. https://doi.org/10.1371/journal.pmed.1000097

The search terms were developed to capture relevant used in our review were assessed for outcomes related to
articles and to ensure that the terms relevant to the specific overall handwriting performance, such as legibility, writing
thesaurus of each database were included. Additionally, speed, and fluency.
the American Journal of Occupational Therapy was hand
searched to ensure that all appropriate articles were Effect Size Computations
included. Using the reported means and standard deviations pub-
lished in each study, we calculated Hedge’s g using the
Selection Criteria compute.es package (Del Re, 2013) in R (R Core Team,
Articles selected for review included those that had used 2015). Hedge’s g is an effect size measure that permits
handwriting interventions and curriculum-based pro- comparison of the size of the intervention effect across
grams for children in preschool through fifth grade. We studies and measures. A Hedge’s g of 0.20 is considered a
chose to exclude articles addressing children above the fifth- small effect, 0.50 is considered a medium effect, and 0.80
grade level to focus on the years when children typically or greater is considered a large effect. Compared with
learn handwriting fundamentals. We included studies of Cohen’s d, Hedge’s g may provide a better estimate of
curriculum-based handwriting programs used for children effect size in small samples (Grissom & Kim, 2005). In the
both with and without identified disabilities, who together case of repeated measures analyses, we followed the rec-
form the target population of these interventions. Other ommendations of Morris (2008) by calculating Hedge’s g
inclusion criteria were interventions that took place in a for the pre–post change in each group and then subtracting
general education classroom, interventions longer than one the Hedge’s g for the control group from the Hedge’s g for
session, and interventions with a clear beginning and end. the treatment group. Because this procedure did not ac-
Specific exclusion criteria were studies with adult participants, count for repeated measures, it may have led to decreased
interventions implemented outside the classroom setting, and estimates of effect sizes for these analyses. Positive effect
studies that lacked a distinguishable intervention. The studies sizes represent the size of effect in the expected direction

The American Journal of Occupational Therapy 7203205010p3

(i.e., faster, more fluent, or more legible handwriting), effect sizes between the 10 Level II studies and the 3 Level
whereas negative effect sizes represent the size of the effect III studies (including the Level II–III study) was robust,
in the unexpected direction (i.e., slower, less fluent, and we contrasted the average effect sizes of the analyses. Level
less legible handwriting). II studies had an average effect size of 0.32 (small to
medium effect; range 5 20.90 to 1.96), whereas Level
III studies had an average effect size of 2.69 (very large
Results
effect; range 5 20.19 to 9.98). The Level III effect sizes
From the original search, we identified 252 studies matching were on average eight times larger than the Level II ef-
our search terms. Of these studies, 99 were excluded because fect sizes, suggesting that maturation effects play a large
the titles did not include handwriting or children in pre- role in curriculum-based handwriting intervention re-
school through fifth grade. Abstracts of the remaining 153 search. Because of this large discrepancy, we report find-
were screened, and 121 were excluded because of the ab- ings from all studies but effect sizes of only the Level II
sence of an explicit handwriting intervention or program studies.
(see Figure 1).
Supplemental Table 1 (available online at http:// Effects of Curriculum-Based Handwriting
otjournal.net; navigate to this article, and click on Interventions
“Supplemental”) summarizes the 13 included stud- Handwriting Legibility. Handwriting legibility was
ies. Levels of evidence were assigned on the basis of measured as an outcome in 12 of the 13 studies. Quality
AOTA guidelines (Sackett, Rosenberg, Gray, Haynes, & was considered a proxy for handwriting legibility. Because
Richardson, 1996). There were 0 Level I studies, 10 letter formation is a main component of legibility
Level II studies, 2 Level III studies, and 1 study we (Hammerschmidt & Sudsawad, 2004), letter formation
classified as Level II–III because it had two distinct in- was interpreted as legibility. Eight studies showed sig-
tervention groups but no control. Several curricula were nificant improvements in at least one component of legi-
examined by the 13 studies, including Write Start bility. Therefore, moderate evidence exists for improved
(Case-Smith, Holland, & Bishop, 2011), HWT (Olsen, handwriting legibility after curriculum-based handwriting
2003; Olsen & Knapton, 2008), HWT–Get Set for programs. The reviewed interventions had an average effect
School (Olsen & Knapton, 2008), Peterson Directed size of 0.39 (range 5 0.02 to 1.05), suggesting small to
Handwriting Curriculum (Nelson, 2006), the Fine medium effects on legibility.
Motor and Early Writing Pre-K curriculum, the Size Handwriting Speed. Nine of the 13 studies assessed
Matters Handwriting Program (SMHP; Moskowitz, handwriting speed or rate. Five of these studies found
2009), Write Direction (Taras, Brennan, Gilbert, & Eck significant improvements in speed. However, 3 studies
Reed, 2011), and Handwriting Clubs (Howe, Roston, found no difference in speed, and Pfeiffer, Rai, Murray,
Sheu, & Hinojosa, 2013). Table 1 presents a brief description and Brusilovskiy (2015) found that the intervention group
of each curriculum. became significantly slower after training than the control
group. Therefore, the evidence is mixed regarding whether
Risk of Bias
curriculum-based interventions enhance handwriting
Because the studies under review were nonrandomized, we speed. The reviewed interventions had an average (mean)
assessed risk of bias according to the Preferred Reporting effect size on speed of 0.13 (range 5 20.90 to 0.77).
Items for Systematic Reviews and Meta-Analyses (PRISMA; Because of the large range, we also calculated the median
Moher et al., 2009) guidelines using ROBINS–I (Sterne (0.22). Therefore, the intervention effects on handwriting
et al., 2016). As seen in Supplemental Table 2 (available speed were variable and, when averaged, were small to
online), the majority of studies had low risk of bias across very small.
domains. Handwriting Fluency. Only 4 of the 13 studies assessed
fluency, and all 4 investigated the Write Start program.
Effects of Level II Versus Level III Studies Only 3 of these studies found significant differences in
Because Level III studies, by definition, do not have a fluency at posttest. Because of the similarity of the studies
control group, pre–post treatment effect sizes may be and some inconsistencies in posttests, the evidence is
overestimated because they likely reflect not only im- insufficient for curriculum-based handwriting programs to
provements from the intervention but also maturation improve fluency. Given the discrepancy in effect sizes of
effects and benefits from completing the same or a similar the 2 Level II studies that assessed fluency (range 5 20.08
measure twice. To examine whether the difference in to 0.74), we did not calculate an average effect size.

7203205010p4 May/June 2018, Volume 72, Number 3

Effects of Specific Curricula Effects of Specific Characteristics of Curricula
We compared effect sizes for legibility and speed across the Age at Instruction. Effect sizes for legibility (17 effect
different curricula (see Figure 2). For legibility, an explicit sizes) and speed (8 effect sizes) were examined as a function
handwriting program (Kaiser, Albaret, & Doudin, 2011) of the grade at which the intervention took place (inter-
had the largest effect size, but this study was the only one ventions that took place in Grades 1 and 2 were coded as
to use this intervention. SMHP (Pfeiffer et al., 2015) and 1.5). Legibility effects showed a medium-sized but not
Write Start (Case-Smith, Holland, & White, 2014; Case- significant correlation with age at instruction, r 5 .33,
Smith, Weaver, & Holland, 2014) on average had me- p 5 .25. Speed effects did not vary according to age at
dium to large effects on legibility. The Fine Motor and instruction, r 5 2.06, p 5 .89.
Early Writing Pre-K Curriculum (Donica, Goins, & Instruction Length. The length of intervention varied
Wagner, 2013), HWT (Donica, 2015; Donica et al., across studies; however, all interventions lasted a mini-
2013; Lust & Donica, 2011; Roberts, Derkach-Ferguson, mum of 6 wk. The majority of handwriting programs
Siever, & Rose, 2014; Salls, Benson, Hansen, Cole, & lasted ³12 wk and yielded handwriting improvements in
Pielielek, 2013), Write Direction (Taras, Brennan, at least one of the specified outcome areas. Given the
variability in session time and frequency across inter-
Gilbert, & Eck Reed, 2011), and intensive handwriting
ventions, we calculated an estimate of the total number of
practice (Howe, Roston, Sheu, & Hinojosa, 2013) all had
hours of intervention for each of the studies. Total hours
small or very small effects on legibility. However, many
of intervention ranged from 6 hr (Donica et al., 2013) to
of these studies used active and rigorous control condi-
90 hr (Donica, 2015), with the latter occurring over a
tions, which might have diminished the size of these
2-yr time span. Omitting the 90-hr intervention outlier,
effects.
total intervention hours were not correlated with the
For speed, the explicit handwriting program (Kaiser
effect sizes for legibility, r 5 .27, p 5 .37, or speed,
et al., 2011) had the largest effect size. Write Start (Case-
r 5 2.11, p 5 .79.
Smith et al., 2011, 2012; Case-Smith, Holland, &
White, 2014; Case-Smith, Weaver, & Holland, 2014)
and intensive handwriting practice (Howe et al., 2013) Discussion
had small to medium effect sizes. Intriguingly, SMHP This systematic review aimed to examine the evidence for
(Pfeiffer et al., 2015) had a small to medium effect size curriculum-based handwriting interventions to improve
but in the opposite direction, suggesting that this cur- handwriting legibility, speed, and fluency. From our ex-
riculum significantly enhanced legibility while promoting tensive literature search, 13 curriculum-based handwriting
slower writing. studies met inclusion criteria for review (10 Level II studies

Legibility (14 studies) Speed (8 studies)

Write Start

Write Direction

Size Matters Handwriting Program

Intensive practice compared with VPM

HWT (kindergarten)

HWT-GSS

HWT

Fine Motor and Early Writing Pre-K curriculum

Explicit handwriting program

-0.9 -0.5 -0.2 0.0 0.2 0.5 0.8 -0.9 -0.5 -0.2 0.0 0.2 0.5 0.8
Hedge’s g

Figure 2. Effect sizes (Hedge’s g) for legibility and speed, by curriculum.

Note. Effect sizes are interpreted as follows: 0.20 5 small effect, 0.50 5 medium effect, 0.80 5 large effect. Negative effect sizes reflect intervention changes in the
opposite-than-expected direction (i.e., slower handwriting after the intervention). HWT 5 Handwriting Without Tears; HWT–GSS 5 Handwriting Without Tears–Get
Set for School; Pre-K 5 prekindergarten; VPM 5 visual–perceptual–motor training.

The American Journal of Occupational Therapy 7203205010p5

and 3 Level III studies). Conspicuously, there were no This allowed us not only to estimate effect sizes across the
randomized controlled trials (Level I evidence). Our sys- whole body of evidence but also to compare effects across
tematic review rendered two major findings: (1) Curriculum- different curricula, ages, and lengths of intervention.
based handwriting interventions in general demonstrated An important question has been whether one type of
small to medium effects in improving legibility, and (2) curriculum-based handwriting intervention outperforms
although certain programs may be better suited for targeting the others. In other words, does it matter which curric-
speed versus legibility, other characteristics of the programs ulum a school uses? From our comparison of effect sizes,
(i.e., age at intervention and hours of intervention) did not no one handwriting program appeared to outperform the
appear to influence efficacy. other programs across all domains. Intriguingly, the Write
Start program and the explicit handwriting program from
Efficacy of Curriculum-Based Handwriting Kaiser et al. (2011) were the only programs to have non–
Interventions small effects on both legibility and speed. However, other
The findings suggest that curriculum-based handwriting programs had medium to large effect sizes in each of those
interventions can successfully elicit small- to medium-sized domains (just not consistently across domains). Therefore,
improvements in legibility. Although the size of these effects different programs may excel at targeting different outcomes.
was not large, even small gains in legibility may be important In an ideal situation, the needs of the children in the
because poor handwriting legibility can greatly compromise classroom would dictate which curriculum is used. For
a child’s functioning in school and lead to lower grades example, our results suggest that SMHP may be best for
(Graham, Harris, & Fink, 2000; Schneck & Amundson, classrooms for which the primary goal is legibility but not
2010). These effect sizes may have been smaller than ex- speed. Alternatively, for classrooms for which the primary
pected because many of the reviewed studies implemented goal is handwriting speed, the explicit handwriting pro-
active control groups (handwriting was taught, but in a gram from Kaiser et al. (2011), Write Start, or the intensive
different way) rather than passive control groups. Using an handwriting program from Howe et al. (2013) might be
active control group is more rigorous but may result in best suited.
underestimation of the size of the intervention effect. We also used the effect sizes to examine the ideal length
In contrast, curriculum-based interventions did not of intervention, and we found that more intervention hours
appear to enhance handwriting speed. Speed effect sizes did not appear to lead to substantially larger handwriting
varied greatly, and the average speed effect size was small. improvements. This finding suggests that 6 wk of in-
One possible explanation is that when legibility and form tervention may be sufficient, even though a previous review
are emphasized in a curriculum, slower handwriting pro- of curriculum-based and non-curriculum-based handwrit-
duction may result. Indeed, several studies demonstrated ing interventions suggested that handwriting interventions
that when legibility improved, speed declined or showed no should occur at least two times per week for a minimum of
improvement (Howe et al., 2013; Roberts, Siever, & Mair, 20 sessions to be effective (Hoy et al., 2011).
2010; Weintraub & Graham, 1998). Another possible Interestingly, we found that the grade at which the
explanation is that improvements in letter quality may be intervention occurred had a nonsignificant but medium to
observed before improvements in speed because of the large relation to how big the intervention-based legibility
additional practice time needed for speed to develop (Hoy effects were, which suggests a trend for older grades to be
et al., 2011). Consequently, speed effects may not be as associated with larger effects. Although this association was
evident in studies that focus on young learners. not statistically significant and should be interpreted with
Writing fluency was a variable of interest because the extreme caution, the size of the effects for different ages
end goal of efficient handwriting is to allow children to and grades might be useful in designing future research.
focus on higher order aspects of writing. However, not
enough studies measured fluency to be able to draw con- Limitations
clusions. This is a critical gap in the literature and a key A limitation of this review is that no Level I studies met
avenue for future research because writing fluency likely inclusion criteria, restricting our ability to draw firm
reflects the more functional aspects of handwriting ability. conclusions on the efficacy of curriculum-based hand-
writing interventions. The lack of Level I studies may be
Program Characteristics That Demonstrated the attributable to the fact that curriculum-based interven-
Highest Efficacy tions, by definition, take place in the classroom, pre-
We calculated effect sizes for all studies in the systematic venting random assignment of students to one condition or
review to supplement our interpretation of the literature. another. However, a large-scale study that randomly

7203205010p6 May/June 2018, Volume 72, Number 3

assigns different classrooms to the intervention or control pCase-Smith, J., Holland, T., & Bishop, B. (2011). Effective-
condition would provide higher levels of evidence in ness of an integrated handwriting program for first-grade
support of curriculum-based interventions. students: A pilot study. American Journal of Occupational
Therapy, 65, 670–678. https://doi.org/10.5014/ajot.2011.
Another limitation is that our calculation of effect
000984
sizes did not account for repeated measures, which may pCase-Smith, J., Holland, T., Lane, A., & White, S. (2012).
have led to decreased estimates of effect sizes. We chose Effect of a coteaching handwriting program for first graders:
this as a conservative approach, but some of the effects may One-group pretest–posttest design. American Journal of
be underestimated. Other limitations include inconsistency Occupational Therapy, 66, 396–405. https://doi.org/10.5014/
in definitions of handwriting components (e.g., legibility), ajot.2012.004333
pCase-Smith, J., Holland, T., & White, S. (2014). Effectiveness
limited descriptions of participants, and lack of long-term
of a co-taught handwriting program for first grade students.
follow-up in the studies reviewed. Physical and Occupational Therapy in Pediatrics, 34, 30–43.
https://doi.org/10.3109/01942638.2013.783898
Implications for Occupational pCase-Smith, J., Weaver, L., & Holland, T. (2014). Effects of
a classroom-embedded occupational therapist–teacher
Therapy Practice handwriting program for first-grade students. American
The results of this study have the following implications Journal of Occupational Therapy, 68, 690–698. https://
doi.org/10.5014/ajot.2014.011585
for occupational therapy practice:
Del Re, A. C. (2013). compute.es: Compute effect sizes [Com-
• Curriculum-based handwriting programs, in general, puter software]. Retrieved from http://cran.r-project.org/
appear to successfully target legibility in preschool, web/packages/compute.es
kindergarten, and young school-age children. pDonica, D. K. (2015). Handwriting Without Tears®: Gen-
• Specific curriculum-based handwriting programs may eral education effectiveness through a consultative approach.
be better at targeting speed than legibility (or vice American Journal of Occupational Therapy, 69, 6906180050.
versa) and ideally should be selected on the basis of https://doi.org/10.5014/ajot.2015.018366
pDonica, D. K., Goins, A., & Wagner, L. (2013). Effectiveness
whether the primary need of the classroom is hand-
of handwriting readiness programs on postural control,
writing speed or legibility. hand control, and letter and number formation in Head
• For the majority of children, 6 wk (z15 hr) was Start classrooms. Journal of Occupational Therapy, Schools
enough to make gains in legibility. However, children & Early Intervention, 6, 81–93. http://dx.doi.org/10.1080/
with handwriting challenges may need more time. Fu- 19411243.2013.810938
ture research is needed to determine the ideal length of Every Student Succeeds Act of 2015, Pub. L. 114-95.
Feder, K. P., & Majnemer, A. (2007). Handwriting develop-
curriculum-based handwriting programs.
ment, competency, and intervention. Developmental Med-
• A key need exists for future Level I research to examine icine and Child Neurology, 49, 312–317. https://doi.org/
curriculum-based handwriting. s 10.1111/j.1469-8749.2007.00312.x
Graham, S. (1992). Issues in handwriting instruction. Focus on
Acknowledgments Exceptional Children, 25, 1–14.
Graham, S., Berninger, V., Weintraub, N., & Schafer, W.
This work was supported by the Eunice Kennedy Shriver (1998). Development of handwriting speed and legibility
National Institute of Child Health and Human Devel- in Grades 1–9. Journal of Educational Research, 92, 42–52.
opment (Grant U54 HD090256 to the Waisman Center), https://doi.org/10.1080/00220679809597574
the Brain and Behavior Research Foundation (NARSAD Graham, S., Harris, K., & Fink, B. (2000). Is handwriting
Young Investigator Award to B.G.T.), and the Hartwell causally related to learning to write? Treatment of hand-
Foundation (to B.G.T.). We thank Karla Ausderau and writing problems in beginning writers. Journal of Educa-
tional Psychology, 92, 620–633. https://doi.org/10.1037/
Lauren Bishop-Fitzpatrick for their insights and help
0022-0663.92.4.620
with this systematic review. We also thank Michael Grissom, R. J., & Kim, J. J. (2005). Effect sizes for research: A
Venner for his expertise and assistance with our database broad practical approach. Mahwah, NJ: Erlbaum.
search. Hammerschmidt, S. L., & Sudsawad, P. (2004). Teachers’
survey on problems with handwriting: Referral, evaluation,
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