Ah, handwriting. The source and summit of our profession, right? (Just kidding.) However, while a lot of school OT’s like to remind people, “we are not handwriting teachers,” (I agree) it also makes sense as to why OT’s are called into action when a child’s handwriting is preventing them from participating in their school day.
Where do we start? What program or method do we use? Personally, I started with what information was handed down to me on Handwriting Without Tears. I particularly like the idea of developmental teaching order that they use. I think sometimes people think, “Oh, A is the first letter of the alphabet, let’s start with A.” There are diagonal lines in A, though, and children start forming those around 4 ½ years old. So, makes sense to me to start with the straight line letters first.
In recent years, I’ve been intrigued by the Size Matters program. It was new to me and I like some of the concepts I picked up from learning about it. All this to say, which program should we use?
Journal American Journal of Occupational Therapy (SNIP score 1.121)
Article Title Curriculum-Based Handwriting Programs: A Systematic Review with Effect Sizes
- 1A Systematic review of homogenous RCTs
- 1 B Well-designed individual RCT
- 2A Systematic review of cohort studies
- 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies*
- 3A Systematic review of case control studies
- 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
- 4 Case series (and low-quality cohort and case control study)
- 5 Expert opinion without explicit critical appraisal
- * This was a systematic review which included many two-group non-randomized studies. As this type of systematic review doesn’t fall into either 2A nor 3A, I chose to categorize it into a level 2B study. The evidence reviewed was higher than case studies but lower than cohort studies.
Methods
A systematic review gathered articles from January 2006-December 2015 that included curriculum-based programs and handwriting intervention for students in preschool through 5th grade.
The researchers included 13 studies total, with 10 Level II, 2 Level III and 1 Level II-III studies.
Findings
Handwriting Legibility
For legibility, the programs with the largest effect size was the Explicit Handwriting Program. Medium to large effects on legibility came with the Size Matters Handwriting Program and Write Start.
Programs with small or very small effect sizes on legibility included the Fine Motor and Early Writing Pre-K Curriculum, Handwriting Without Tears, Write Direction and Intensive Handwriting Practice.
Handwriting Speed
The Explicit Handwriting Program also the largest effect size on speed. The Write Start and Intensive Handwriting Practice programs had small to medium effect sizes.
Size Matters Handwriting Program had small to medium effect size in the opposite direction, meaning kids wrote slower.
Fluency
Four studies assessed fluency, all investigating the Write Start program. There were significant differences for fluency in three of four studies. The authors noted that the studies being too similar and variations in post-test findings led them to determine there is insufficient evidence to speak to the effects of the program on fluency.
Handwriting Program Characteristics
All interventions lasted a minimum of 6 weeks, with the majority lasting more than 12 weeks. However, the total number of hours of intervention did not show a relationship with the impact on legibility and speed of writing.
The only two programs to have a larger than small effect size on both legibility and speed were the Write Start program and Explicit Handwriting Program.
Choosing a Handwriting Curriculum Based on Your Needs
An interesting highlight of this review is that different curriculums had significant effects on different outcomes. The authors suggest that OT’s consider this when choosing a curriculum to use. It may be most effective to choose a curriculum that improves legibility if that’s what you’re most concerned with.
So, the findings from this review may suggest that at this point in time, an OT may consider the following:
Legibility
The largest effect size on legibility came from students using the Explicit Handwriting Program. My initial thought was, “Okay! Let’s explore this. Seems like the best option!” Upon reading the program characteristics, it was very detailed. Intervention included dexterity exercises, discussions about context of writing with children, learning 2-3 letters in cursive per session given modeling, etc. (Kaiser, Albaret, & Doudin, 2011, p. 613, 614). That is to say, it was thorough, but is not a standardized program. The may be why the authors suggested the use of Size Matters Handwriting Program over Explicit Handwriting Program. On average, children using the Size Matters Handwriting Program and Write Start Program showed medium to large effects for improved legibility. For my part, I’m going to investigate Write Start in more detail.
Speed
From their review, the authors suggest that Explicit Handwriting Program, Write Start or Intensive Handwriting Program may be the best choices for curriculum if your primary concern is speed.
Things to Consider
The authors mention that they did not include level I studies in the review, as there were not any studies of that level of evidence that met inclusion criteria. Level I studies would give us more robust evidence to make our decisions on which program to use. The authors also mentioned that the way they measured their data on effect sizes did not take into consideration for repeated measures. They note that they intentionally did this to be conservative, but that this method may have produced effect sizes that were smaller than they really were.
What Do You Think?
What programs do you typically use with your students? Which programs mentioned here are new to you?
References
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(3). doi:10.5014/ajot.2018.027110
Kaiser, M., Albaret, J., & Doudin, P. (2011). Efficacy of an Explicit Handwriting Program. Perceptual and Motor Skills, 112(2), 610-618. doi:10.2466/11.25.pms.112.2.610-618
