Assessing Handwriting Intervention Effectiveness in

Elementary School Students: A Two-Group

Controlled Study

Tsu-Hsin Howe, Karen Laurie Roston, Ching-Fan Sheu, Jim Hinojosa

MeSH TERMS This study examined the effectiveness of two approaches used in elementary schools to improve children’s
 child handwriting. Participants were 72 New York City public school students from the first and second grades. A
nonequivalent pretest–posttest group design was used in which students engaged in handwriting activities
 handwriting
using two approaches: intensive handwriting practice and visual–perceptual–motor activities. Handwriting
 occupational therapy speed, legibility, and visual–motor skills were examined after a 12-wk Handwriting Club using multivariate
 psychomotor performance analysis of variance. The results showed that students in the intensive handwriting practice group
 treatment outcome demonstrated significant improvements in handwriting legibility compared with students in the visual–
 visual perception perceptual–motor activity group. No significant effects in handwriting speed and visual–motor skills were
found between the students in intensive handwriting practice group and the students in visual–perceptual–
motor activities group. The Handwriting Club model is a natural intervention that fits easily into existing
school curriculums and can be an effective short-term intervention (response to intervention Tier II).

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

Tsu-Hsin Howe, PhD, OTR, is Assistant Professor,

Department of Occupational Therapy, Steinhardt School of
Culture, Education, and Human Development, New York
O ccupational therapy practitioners working in schools must provide services
that are educationally relevant and consistent with the individual school’s
curriculum and policies. When practitioners provide integrated interventions,
University, 35 West Fourth Street, 11th Floor, New York,
NY 10012; [email protected] they adapt them to be contextually appropriate to meet children’s needs. One
area of educational relevance is the facilitation of improved handwriting per-
Karen Laurie Roston, DPS, OT, is Occupational
Therapist, New York City Board of Education, New York.
formance for children with poor handwriting.
Occupational therapy practitioners focus on handwriting as a performance
Ching-Fan Sheu, PhD, is Professor, Institute of skill and often address children’s handwriting performance using developmental
Education, National Cheng Kung University, Tainan,
frameworks. Studies of handwriting remediation provide evidence to support
Taiwan.
intervention effectiveness despite varying duration, frequency, and method
Jim Hinojosa, PhD, OT, BCP, FAOTA, is Professor, of treatment (Case-Smith, 2002; Denton, Cope, & Moser, 2006; Feder &
Steinhardt School of Culture, Education, and Human Majnemer, 2007; Marr, 2005; Marr, Windsor, & Cermak, 2001; Sudsawad,
Development, New York University, New York.
Trombly, Henderson, & Tickle-Degnen, 2001; Volman, van Schendel, &
Jongmans, 2006; Woodward & Swinth, 2002). In this study, we adopted two
commonly used interventions and provided them within a school club model
that we called the Handwriting Club. The interventions used a practice-based
approach based on motor learning (Roston, 2010) and a visual–perceptual–
motor approach (Beery, Beery, & Evans, 2004a, 2004b). Therapists commonly
use both approaches to improve children’s handwriting legibility and speed
(Feder, Majnemer, & Synnes, 2000).
A practice-based approach based on motor learning is advocated in the
literature as a useful strategy in handwriting remediation. Schmidt and Lee
(1999) defined motor learning as “a set of internal processes associated with
practice or experience leading to relatively permanent changes in the capability

The American Journal of Occupational Therapy 19

for motor skill” (p. 264). Practice, in the motor learning not been studied. Thus, in this study we examined two
approach, is the most important factor responsible for short-term group interventions commonly used by school-
permanent improvement in the ability to perform a based occupational therapy practitioners to improve
motor skill. If all other factors are held constant, then children’s handwriting speed and legibility. These group
skill improvement is generally considered to be positively interventions were provided in the context of a Hand-
related to the amount of practice, and the practice must writing Club, which was consistent with the school’s
occur under varying conditions with contextual in- curriculum and philosophy that included various clubs
terference and different sensory inputs (Guadagnoli & that children could join. This study had two questions.
Lee, 2004). In this study, we asked students in the in- First, would students’ handwriting legibility and speed
tensive handwriting practice group to perform different improve when they participated in intensive practice and
types of handwriting tasks under various conditions. We visual–perceptual–motor interventions when provided in
gave them opportunities to practice both low-level (i.e., a Handwriting Club? Second, which intervention (i.e.,
copying letters and words, handwriting games) and high- intensive practice or visual–perceptual–motor) is more
level (i.e., text generation) handwriting skills. effective in improving students’ handwriting legibility and
Another common method of handwriting reme- speed when provided in a Handwriting Club?
diation is the visual–perceptual–motor approach. The
sensory–motor and motor activities used in this approach
are based on the frame of reference of developmental
Method
vision training (Kaiser, Albaret, & Doudin, 2011; Keogh, Research Design
1974). In this approach, visual–motor integration is
viewed as an important variable in handwriting perfor- A nonequivalent pretest–posttest group design was used
mance, particularly when copying or transposing from in which students were assigned alternately to two groups
text to cursive or manuscript writing. Several studies have that provided a variety of handwriting activities using two
found visual–motor integration to be one of the most different approaches. To recruit participants, we sent
important predictors of handwriting performance, with letters to parents and guardians of all first- and second-
strong correlations documented between visual–motor grade students in one New York City elementary school
integration and writing legibility (Maeland, 1992; during the 2007–2010 academic years announcing the
Tseng & Murray, 1994; Volman et al., 2006; Weil & Handwriting Club and describing the research. Recruit-
Amundson, 1994) or speed of handwriting (Tseng & ment letters and consent forms were sent in both English
Chow, 2000). Research (Tseng & Murray, 1994) has and Spanish. Once we received parents’ or guardians’
shown that children with poor handwriting have poor consent, we asked children for their assent before testing.
results on tests such as the Ayres Motor Accuracy test Student participants were selected on the basis of their
(Ayres, 1989) and the Beery–Buktenica Test of Visual– legibility scores on the Minnesota Handwriting Assess-
Motor Integration (VMI; Beery, Buktenica, & Beery, ment (MHA; Reisman, 1999).
2004). There was also a positive relationship between A list with all tested children’s legibility scores from
VMI assessment scores and students’ ability to copy letter both first and second grade was constructed in a ranking
forms legibly (Daly, Kelley, & Krauss, 2003). order. Students who had extremely high scores were not
Although occupational therapy practitioners routinely invited to participate in the study. We started group as-
address handwriting performance for children with iden- signments with students of medium scores on the list and
tified disabilities, handwriting difficulties are often not worked outward in both directions. Students were assigned
addressed for typically developing children. Creating alternately to two intervention groups. For example, we
programs for typically developing children with poor assigned the first student ranked above medium to Group
handwriting is consistent with a response to intervention A and the first student ranked below medium to Group B.
(RtI) paradigm. RtI is an evidence-based initiative that We then assigned the student ranked second above me-
seeks scientific evidence supporting the efficacy of inter- dium to Group B and the student ranked second below
ventions in education and focuses on early support to medium to Group A. The assignment process continued
children (Fuchs & Fuchs, 2006). until 8 students had been selected for each group. This
Although there is support for the effectiveness of both assignment method was an attempt to create balanced
intensive practice and visual–perceptual–motor inter- cohorts for each group. The selection procedure was re-
ventions, delivering these interventions in the context of peated when each new session of the Handwriting Club
a natural school setting in the form of a school club has began during the data collection years of 2008–2010.

20 January/February 2013, Volume 67, Number 1

 Research procedures were approved by the University a commercial handwriting book, Handwriting Without
Committee on Activities Involving Human Subjects and Tears (Olsen, 1999), which is part of the school’s hand-
the New York City Department of Education Proposal writing curriculum. All sessions ended with handwriting
Review Committee. All children were given the MHA and games such as Hangman, Scattergories, Scrutineyes, and
the VMI (5th ed.; Beery, Buktenica, & Beery, 2004) Mad Libs.
before and after their participation in the Handwriting
Club. Data Collection
Karen Laurie Roston and an experienced occupational
Instruments therapist administered and scored all pretests and post-
The MHA is a norm-referenced assessment that tests tests. Both therapists were blind to students’ identities
a child’s handwriting legibility and speed by asking the during the scoring process. Interrater reliability between
child to copy 34 letters in 2.5 min. Reisman (1999) re- the two therapists was established with a correlation of
ported good content validity and excellent interrater (r 5 .95. Pretest data were collected from all students whose
.98) and intrarater (r 5 .98) reliability. In this study, we parents had consented to having their child considered
used a manuscript version and measured handwriting for the Handwriting Club. Posttest data were collected
speed on the basis of the total number of letters produced only from students who participated in the Handwriting
in 2.5 min and handwriting legibility on the basis of the Club.
total number of errors in the 34 letters.
The VMI is a norm-referenced, evaluative measure of Data Analysis
visual–motor integration for children ages 2–15 yr. The Data were analyzed using SAS/STAT Version 9.03 for
paper-and-pencil assessment has children copy a de- Windows (SAS Institute Inc., Cary, NC), and the graphics
velopmental sequence of geometric forms. Studies have were generated by a package in the statistical software R
reported that the VMI has acceptable test–retest (r 5 (Helmreich & Pruzek, 2009). Descriptive and multivar-
.89), interrater (r 5 .92), and internal (r 5 .92) reliability iate analyses were conducted for major variables. The
(Beery, Buktenica, & Beery, 2004) and acceptable con- level of significance for testing was set at .05. A cluster
struct validity (Brown, Unsworth, & Lyons, 2009). analysis procedure was used to form homogeneous groups
of students with similar characteristics in terms of age,
Intervention handwriting legibility, speed pretest scores on the MHA,
The Handwriting Club met during regular class hours and pretest scores on the VMI. Students were grouped on
before the end of the school day twice a week for 12 the basis of the closeness of their combined measure of
sessions that each lasted 40–45 min. Two occupational distance over the four variables. Subsequently, two clus-
therapists with extensive experience working in the school ters of each variable were produced on the basis of the
conducted all the group sessions and followed the es- students’ pretest performance.
tablished protocol (see the Appendix). Neither occupa- In this study, students were not randomly assigned to
tional therapist was blind to group assignment. either intensive practice or visual–perceptual–motor ac-
Intervention consisted of two approaches commonly tivity groups. Unequal baselines between the two in-
used to improve the legibility and speed of children’s tervention groups of pretest scores in all three dependent
handwriting. In the club, the children performed dif- variables and of age were inevitable. The cluster analysis
ferent activities depending on their group allocation. provides a way to match key baseline characteristics
Children in the intensive practice group participated in for within-cluster participants (Johnson, 1967; Michel
20 min of their grade-level handwriting curriculum and et al., 2000) to facilitate between-cluster comparisons.
their grade-level writing tasks. In the intensive practice The method used to form clusters was agglomerate hi-
group, students were encouraged to participate in dif- erarchical clustering, and the complete-link or furthest-
ferent levels of handwriting activities, including letter neighbor technique was applied to determine which cases
formation and composition. or clusters should be combined at each step (Michel et al.,
Because the emphasis of the Handwriting Club was on 2000). The complete-link clustering method defines the
legibility and speed, mistakes in spelling were not cor- cluster distance between two clusters to be the maximum
rected. The children in the visual–perceptual–motor distance between their individual elements. A multivari-
group participated in 20 min of activities from My Book ate analysis of variance (MANOVA) was then performed
of Letters and Numbers and My Book of Shapes (Beery et al., to test the treatment effects between the intensive practice
2004a, 2004b). Students from both groups worked with and visual–perceptual–motor activity groups.

The American Journal of Occupational Therapy 21

Results Table 2. Multivariate and Univariate Analyses of Variance F
Ratios for Handwriting Measurement
A sample of 72 students (38 in the visual–perceptual–
Univariate
motor activity group and 34 in the intensive practice
Multivariate Legibility Rate VMI
group) participated in this study. We found no significant Fa p Fb p Fb p Fb p
differences between the two groups in age, pretest score of
2.44 .072 5.86 .018* 2.02 .16 2.52 .117
writing speed on the MHA, or pretest scores on the VMI.
Note. Multivariate F ratio was generated from Pillai’s statistic. VMI 5 Beery–
Significant differences were found in the pretest score of Buktenica Test of Visual–Motor Integration.
legibility measured by the MHA (p 5 .01; Table 1). a
Multivariate df 5 3, 67. bUnivariate df 5 2, 69.
*p < .05.
Performance changes in terms of handwriting speed,
legibility, and visual–motor skills were examined using
MANOVA. The results showed a marginal overall come means are larger than the means of the control
treatment effect, F (3, 67) 5 2.44, p 5 .07. Univariate group ( visual–perceptual–motor activity group). This is
analysis was then performed to examine individual per- true for all outcome variables except the posttest speed of
formance. We found significant treatment effects in Cluster 2 (Figure 1B). In other words, mean scores on
handwriting legibility, F (2, 69) 5 5.86, p 5 .018. That handwriting posttest legibility and speed, as well as mean
is, students who participated in the intensive practice scores on the posttest VMI, in the intensive practice
group demonstrated significant improvements in hand- group were better than those of the visual–perceptual–
writing legibility compared with students who partici- motor group except for the posttest speed of Cluster 2,
pated in the visual–perceptual–motor activity group. No echoing the results presented in Table 1.
significant effects in handwriting speed or in the visual–
motor skills measured by the VMI were found between Discussion
students in the intensive practice group and the visual–
This study compared the short-term effectiveness of two
perceptual–motor activities group (Table 2).
interventions designed to improve children’s handwriting
Figure 1 shows the sizes and direction of the treat-
performance. Results indicate that the students exposed
ment effects of the three outcome variables on assessment. to traditional handwriting instruction that included in-
For each plot, circles represent clusters. The size of the tensive practice and repetition produced handwriting
circles varies according to the size of the clusters. In our scores that were significantly better in legibility than the
study, Cluster 1 consisted of 65 students and Cluster 2 of students exposed to visual–perceptual–motor activities. This
only 7 students. Circles positioned below the identity line finding echoes those of most studies of handwriting in-
(y 5 x) indicate that for the corresponding cluster, out- tervention, which have reported an improvement in the
legibility of children’s handwriting but no significant
Table 1. Characteristics of Children and Evidence Using Cluster changes in speed (Feder & Majnemer, 2007; Jongmans,
Analysis on Pretest Data
Linthorst-Bakker, Westenberg, & Smits-Engelsman, 2003).
Group
In this study, we did not find significant intervention
Intensive Practice Visual–Perceptual–Motor effects in handwriting speed between students in the in-
Characteristic (n 5 34) Activity (n 5 38) t Test
tensive practice group and those in the visual–perceptual–
Age, yr .28
Mean 6.69 6.57
motor activities group. We cannot draw conclusions
SD 0.42 0.50 about handwriting speed because of the limitations of the
Range 5.93–7.67 5.81–7.93 MHA. A large percentage of the students in both groups
Speed, mean ± SD .44 (65.8% visual–perceptual–motor activity group, 73.5%
Pretest 26.88 ± 6.30 25.61 ± 7.46 intensive practice group) completed the test within the
Posttest 32.35 ± 3.05 30.79 ± 5.44
time limit after intervention. In accordance with MHA
Legibility, mean ± SD .01**
Pretest 30.56 ± 2.53 27.89 ± 4.84
scoring, students began to lose points for rate only if they
Posttest 33.0 ± 1.44 31.97 ± 2.01 did not complete the test within 2.5 min. A student who
VMI score, mean ± SD .40 took 1 min to complete the test received the same rate
Pretest 58.68 ± 30.78 52.93 ± 26.45 score as a student who took 2 min. Differences in speed
Posttest 62.44 ± 30.28 52.16 ± 26.33 between these students were therefore difficult to assess.
Note. Speed and legibility were measured using the Minnesota Handwriting Rather than setting a predetermined time limit, future
Assessment. SD 5 standard deviation; VMI 5 Beery–Buktenica Test of
Visual–Motor Integration. studies should look for group differences in average
**p < .01. completion time. In addition, although the readability

22 January/February 2013, Volume 67, Number 1

 of a handwriting sample seems to be considered more
important than speed, one should not ignore the con-
tribution of handwriting speed, especially for students
who perform higher-order skills such as composition.
Graham, Berninger, Abbott, Abbott, and Whitaker
(1997) reported that handwriting speed accounted for
a significant proportion of the variability in children’s
compositions.
Our study demonstrated no significant differences in
students’ visual–motor integration skills after intervention.
Previous studies reported that visual–motor integration
contributes significantly to quality (Maeland, 1992; Volman
et al., 2006; Weintraub & Graham, 2000) or speed (Tseng
& Chow, 2000) of handwriting only in children with motor
problems, such as children with developmental coordination
disorder or children with handwriting difficulties. No sig-
nificant changes in visual–motor integration skills after in-
tervention were expected because students in our study were
all recruited from mainstream classes.
The use of visual–motor integration skills as a pre-
dictor of handwriting performance continues to be de-
bated because the underlying mechanisms responsible for
handwriting difficulties are not yet understood (Feder &
Majnemer, 2007; Volman et al., 2006). Goyen and Duff
(2005) examined the ability of the VMI to discriminate
between children with and without handwriting dys-
function. They found that the VMI correctly identified
only a small number of the children with handwriting
dysfunction (sensitivity 5 34%). They concluded that
although the VMI provides reliable and valid information
regarding visual–motor deficits, which may contribute to
poor handwriting, the VMI should be used with caution
as a screening tool for children with poor handwriting
(Feder & Majnemer, 2007; Goyen & Duff, 2005;
Overvelde & Hulstijn, 2011). Consequently, the VMI
may have limitations in measuring the effectiveness of
intervention.
In this study, MANOVA was used to detect the effects
of intervention. Despite the fact that we found no general
effect in MANOVA when we considered multiple vari-
ables including age, speed, and legibility together, we were

direction of outcome. (B) The two clusters are in the opposite

direction of outcome.
Note. Although the effect direction of Cluster 2 is different, it reflects only 7
students. The circles represent clusters, the heavy dotted line indicates over-
all adjusted outcome, and the dashed lines indicate weighted means for the
control and treatment groups, respectively. The centers of circles are pro-
jected parallel to the identity line to the lower left line segment, where the
crosses show the distribution of cluster differences; the heavy dotted line
Figure 1. Assessment plot of (A) posttest legibility, (B) posttest corresponds to the mean of this distribution of differences. The heavy line
speed, and (C) posttest scores on the Beery–Buktenica Test of segments perpendicular to the identity line are 95% confidence intervals for
Visual–Motor Integration. (A) Both clusters are uniform in the the estimator population treatment effect.

The American Journal of Occupational Therapy 23

able to demonstrate that students who participated in the was mediated by independent scoring of the MHA and
intensive practice group had significantly better scores in VMI by another senior occupational therapist.
legibility than students who were in the visual–perceptual– Falk, Tam, Schellnus, and Chau (2011) proposed a
motor activity group in univariate analysis. The possible computer-based handwriting assessment tool to objec-
reason for the lack of overall effect in multivariate analysis tively quantify handwriting proficiency in children. They
is that students’ performances on writing speed and combined the MHA with an instrumental utensil and
legibility were not normally distributed in our sample. digitizing tablet to assess children’s handwriting perfor-
Therefore, the data distribution might not support the mance. This computer-based handwriting assessment tool
multivariate analysis. Specifically, the distributions of measures essential biomechanical quantities such as grip
MHA scores collected in this study were all shifted up- force, vertical pressures, and timing during writing, in
ward. That is, most of the students tended to have higher addition to the five categories that the MHA traditionally
scores in both the speed and the legibility categories. assesses (legibility, form, alignment, size, and space). We
One of the drawbacks of observational study is the believe that this newly developed tool offers an innovative
inability to control the participants’ group assignments to dimension to research on handwriting components.
achieve balanced covariance between the two groups prior Moreover, high-level handwriting skills such as compo-
to interventions. In this study, scores on handwriting sition should also be considered as an outcome variable
speed between the two groups differed significantly before for future studies (Case-Smith, Holland, & Bishop,
intervention. This unbalanced baseline between treat- 2011).
ment and comparison groups is most likely inherited
when randomized controlled design is not observed Implications for Occupational
(Cousens et al., 2011). Consequently, generating a con- Therapy Practice
founded effect estimate (one that mixes the effects of the
Researchers in handwriting instruction have continued to
intervention with other causal effects) is a risk of such
recommend a direct and structured approach (Jongmans
a study.
et al., 2003), which is supported by the current study.
The cluster analyses used in this study served to
Occupational therapy practitioners should consider the
control confounding variables by putting students with
following implications of this study:
similar attributes into one group before the comparison
• Repetition and practice are important elements en-
analyses. In the study, two clusters were formed after
hancing children’s handwriting skills.
cluster analyses. Seven students were separated from the
• The work of school-based occupational therapists
majority of students to form the second cluster. A close
should be entwined with the school curriculum.
examination of the students in this cluster found that 5 of
• The Handwriting Club model is a natural intervention
the 7 were later identified as students with individualized
that fits easily into existing school curriculums. It al-
education programs (IEPs), and 2 had significantly higher
lows the students to intensively practice handwriting
performance scores. This finding explains why this cluster
with a variety of tasks that are embedded in the cur-
behaved differently from Cluster 1, which contained the
riculum based on motor learning principles. Addition-
majority of students (see Figure 1).
ally, student participants enjoyed participating and
demonstrated improved legibility.
Limitations and Directions for
Further Research Conclusion
The major limitations of this study are the lack of ran- In this study, both groups showed improvement in
domization when assigning participants to the groups, lack handwriting legibility. However, students in the intensive
of blinding to group assignment of occupational therapists practice group improved significantly more than students
conducting the groups, small sample size, and the ceiling in the visual–perceptual–motor activity group. This study
effect of the MHA. In addition, internal validity is limited is important to practice because it evaluates the results of
a short-term RtI Tier II intervention model for providing
by possible coincidental events that may have occurred in
occupational therapy services in the school environment
the school such as an increased interest in handwriting by for at-risk students, for students with IEPs, and for
teachers because of the initiation of the Handwriting Club. children with handwriting difficulties as identified by
The possibility also existed of bias by the primary re- their parents. Students in the handwriting group reported
searcher in the scoring of the MHA and VMI. This bias enjoying practicing their handwriting and demonstrated

24 January/February 2013, Volume 67, Number 1

pride in the completion of their final product. Parents tool to objectively quantify handwriting proficiency in chil-
and teachers were also impressed that their children’s dren. Computer Methods and Programs in Biomedicine, 104,
handwriting improved. One parent commented, “Before e102–e111. http://dx.doi.org/10.1016/j.cmpb.2010.12.010
Feder, K. P., & Majnemer, A. (2007). Handwriting develop-
the Club, I could never read my child’s handwriting.
ment, competency, and intervention [Review]. Developmen-
Now I can!” (parent communication, April 2010). s tal Medicine and Child Neurology, 49, 312–317. http://
dx.doi.org/10.1111/j.1469-8749.2007.00312.x
Acknowledgments Feder, K., Majnemer, A., & Synnes, A. (2000). Handwriting:
Current trends in occupational therapy practice. Canadian
We acknowledge the support of the New York City Journal of Occupational Therapy, 67, 197–204.
Department of Education. We thank all the children for Fuchs, D., & Fuchs, L. S. (2006). Introduction to Response
their participation in the study. We also recognize the to Intervention: What, why, and how valid is it? Reading Re-
support of Katy Rosen, Debbie Tortomasi, and the par- search Quarterly, 41, 93–99. http://dx.doi.org/10.1598/RRQ.
ticipating teachers. In addition, we thank all the New York 41.1.4
Goyen, T.-A., & Duff, S. (2005). Discriminant validity of the
University students who assisted with data collection.
Developmental Test of Visual–Motor Integration in re-
lation to children with handwriting dysfunction. Austra-
References lian Occupational Therapy Journal, 52, 109–115. http://
Ayres, A. J. (1989). Sensory Integration and Praxis Test (SIPT). dx.doi.org/10.1111/j.1440-1630.2005.00488.x
Torrance, CA: Western Psychological Services. Graham, S., Berninger, V. W., Abbott, R. D., Abbott, S. P., &
Beery, K. E., Beery, N. A., & Evans, L. (2004a). My book of Whitaker, D. (1997). Role of mechanics in composing of
letters and numbers. Minneapolis, MN: NCS Pearson. elementary school students: A new methodological ap-
Beery, K. E., Beery, N. A., & Evans, L. (2004b). My book of proach. Journal of Educational Psychology, 89, 170–182.
shapes. Minneapolis, MN: NCS Pearson. http://dx.doi.org/10.1037/0022-0663.89.1.170
Beery, K. E., Buktenica, N. A., & Beery, N. A. (2004). The Guadagnoli, M. A., & Lee, T. D. (2004). Challenge point: A
Beery–Buktenica Developmental Test of Visual–Motor Inte- framework for conceptualizing the effects of various prac-
gration (5th ed.). Minneapolis, MN: NCS Pearson. tice conditions in motor learning. Journal of Motor Be-
Brown, T., Unsworth, C., & Lyons, C. (2009). An evaluation of havior, 36, 212–224. http://dx.doi.org/10.3200/JMBR.
the construct validity of the Developmental Test of Visual– 36.2.212-224
Motor Integration using the Rasch measurement model. Helmreich, J. E., & Pruzek, R. M. (2009). PSAgraphics: An R
Australian Occupational Therapy Journal, 56, 393–402. package to support propensity score analysis. Journal of
http://dx.doi.org/10.1111/j.1440-1630.2009.00811.x Statistical Software, 29, 1–23.
Case-Smith, J. (2002). Effectiveness of school-based occupa- Johnson, S. C. (1967). Hierarchical clustering schemes. Psychome-
tional therapy intervention on handwriting. American trika, 32, 241–254. http://dx.doi.org/10.1007/BF02289588
Journal of Occupational Therapy, 56, 17–25. http://dx. Jongmans, M. J., Linthorst-Bakker, E., Westenberg, Y., &
doi.org/10.5014/ajot.56.1.17 Smits-Engelsman, B. C. (2003). Use of a task-oriented
Case-Smith, J., Holland, T., & Bishop, B. (2011). Effective- self-instruction method to support children in primary
ness of an integrated handwriting program for first-grade school with poor handwriting quality and speed. Human
students: A pilot study. American Journal of Occupational Movement Science, 22, 549–566. http://dx.doi.org/10.
Therapy, 65, 670–678. http://dx.doi.org/10.5014/ajot. 1016/j.humov.2003.09.009
2011.000984 Kaiser, M.-L., Albaret, J.-M., & Doudin, P.-A. (2011). Efficacy
Cousens, S., Hargreaves, J., Bonell, C., Armstrong, B., Thomas, of an explicit handwriting program. Perceptual and Motor
J., Kirkwood, B. R., & Hayes, R. (2011). Alternatives to Skills, 112, 610–618. http://dx.doi.org/10.2466/11.25.PMS.
randomisation in the evaluation of public-health interven- 112.2.610-618
tions: Statistical analysis and causal inference. Journal of Epi- Keogh, B. K. (1974). Optometric vision training programs
demiology and Community Health, 65, 576–581. http://dx. for children with learning disabilities. Journal of Learn-
doi.org/10.1136/jech.2008.082610 ing Disabilities, 7, 36–48. http://dx.doi.org/10.1177/
Daly, C. J., Kelley, G. T., & Krauss, A. (2003). Relationship 002221947400700407
between visual–motor integration and handwriting skills Maeland, A. F. (1992). Handwriting and perceptual–motor
of children in kindergarten: A modified replication study. skills in clumsy, dysgraphic, and “normal” children. Per-
American Journal of Occupational Therapy, 57, 459–462. ceptual and Motor Skills, 75, 1207–1217. http://dx.doi.
http://dx.doi.org/10.5014/ajot.57.4.459 org/10.2466/pms.1992.75.3f.1207
Denton, P. L., Cope, S., & Moser, C. (2006). The effects Marr, D. (2005). Consistency of handwriting performance
of sensorimotor-based intervention versus therapeutic across the early elementary grades. OTJR: Occupation, Par-
practice on improving handwriting performance in 6- to ticipation and Health, 25, 143–148.
11-year-old children. American Journal of Occupational Marr, D., Windsor, M., & Cermak, S. (2001). Handwriting
Therapy, 60, 16–27. http://dx.doi.org/10.5014/ajot.60.1.16 readiness: Locatives and visuomotor skills in the kinder-
Falk, T. H., Tam, C., Schellnus, H., & Chau, T. (2011). On garten year. Early Childhood Research and Practice, 3,
the development of a computer-based handwriting assessment 1–17.

The American Journal of Occupational Therapy 25

Michel, J. P., Hoffmeyer, P., Klopfenstein, C., Bruchez, M., of Occupational Therapy, 55, 518–523. http://dx.doi.
Grab, B., & d’Epinay, C. L. (2000). Prognosis of func- org/10.5014/ajot.55.5.518
tional recovery 1 year after hip fracture: Typical patient Tseng, M. H., & Chow, S. M. K. (2000). Perceptual–motor
profiles through cluster analysis. Journals of Gerontology, function of school-age children with slow handwriting
Series A: Biological Sciences and Medical Sciences, 55, speed. American Journal of Occupational Therapy, 54,
508–515. http://dx.doi.org/10.1093/gerona/55.9.M508 83–88. http://dx.doi.org/10.5014/ajot.54.1.83
Olsen, J. Z. (1999). Handwriting without tears (5th ed.). Po- Tseng, M. H., & Murray, E. A. (1994). Differences in perceptual–
tomac, MD: Author. motor measures in children with good and poor handwriting.
Overvelde, A., & Hulstijn, W. (2011). Handwriting develop- OTJR: Occupation, Participation and Health, 14, 19–36.
ment in Grade 2 and Grade 3 primary school children Volman, M. J. M., van Schendel, B. M., & Jongmans, M. J.
with normal, at risk, or dysgraphic characteristics. Research (2006). Handwriting difficulties in primary school chil-
in Developmental Disabilities, 32, 540–548. doi: 10.1016/ dren: A search for underlying mechanisms. American Jour-
j.ridd.2010.12.027 nal of Occupational Therapy, 60, 451–460. http://dx.doi.
Reisman, J. (1999). Minnesota Handwriting Assessment. San org/10.5014/ajot.60.4.451
Antonio, TX: Psychological Corporation. Weil, M. J., & Amundson, S. J. C. (1994). Relationship be-
Roston, K. L. (2010). A frame of reference for the development tween visuomotor and handwriting skills of children in
of handwriting skills. In P. Kramer & J. Hinojosa (Eds.), kindergarten. American Journal of Occupational Therapy,
Pediatric occupational therapy (3rd ed., pp. 425–460). 48, 982–988. http://dx.doi.org/10.5014/ajot.48.11.982
Philadelphia: Lippincott Williams & Wilkins. Weintraub, N., & Graham, S. (2000). The contribution of
Schmidt, R. A., & Lee, T. D. (1999). Motor control and gender, orthographic, finger function, and visual–motor
learning: A behavioral emphasis. Champaign, IL: Human processes to the prediction of handwriting status. OTJR:
Kinetics. Occupation, Participation and Health, 20, 121–140.
Sudsawad, P., Trombly, C. A., Henderson, A., & Tickle- Woodward, S., & Swinth, Y. (2002). Multisensory approach to
Degnen, L. (2001). The relationship between the Evalua- handwriting remediation: Perceptions of school-based occu-
tion Tool of Children’s Handwriting and teachers’ pational therapists. American Journal of Occupational Ther-
perceptions of handwriting legibility. American Journal apy, 56, 305–312. http://dx.doi.org/10.5014/ajot.56.3.305

Appendix: Handwriting Club Group Format

Activity Category and Time Frame Intensive Practice Group Activities Visual–Perceptual–Motor Activity Group Activities
Setup Sign in on the attendance sheet. Sign in on the attendance sheet.
Activities designed by therapists Answer question of the day in their best handwriting Work on visual–perceptual worksheets.
using different approaches: in their journals.  Select from a variety of colored pencils or markers
20 min Work in handwriting book with a variety of pencils of different diameters.
and pencil grips.
 Select pencils.
 Try on pencil grips.
Engage in sharing and feedback.
 When a page is finished, circle the three most
legible words.
 Trade page with another student.
 Circle the most legible word on each other’s pages.

Handwriting activities for both Work in commercial handwriting book Handwriting Work in commercial handwriting book Handwriting
groups: 15 min Without Tears. Without Tears.
Receive instruction (e.g., letter models with arrows,  Select pencils.
demonstration of letter formation).  Try on pencil grips.
Text generation: Practice higher-level handwriting skills.
 Letter writing (e.g., write letters to teachers, classmates, Engage in sharing and feedback.
parents, or principal on own choice of topic)  When a page is finished, circle the three most
 Recipe contest (e.g., write down favorite snacks and legible words.
a recipe for how to make them)  Trade page with another student.
 Circle the most legible word on each other’s pages.

Handwriting game: 10 min Hangman, Scattergories, Scrutineyes, Mad Libs, or other Hangman, Scattergories, Scrutineyes, Mad Libs, or other
games that use handwriting on a vertical whiteboard games that use handwriting on a vertical whiteboard
Closure Clean up and go home Clean up and go home
Note. The club met at the end of the school day twice a week for 12 sessions that lasted 40–45 min each.

26 January/February 2013, Volume 67, Number 1

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