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Running head: EFFICACY OF HANDWRITING INTERVENTION

Quantitative Analysis: Efficacy of Handwriting Intervention


Galileo Basilio and Kelsey Puliafico
Touro University Nevada

EFFICACY OF HANDWRITING INTERVENTION

Research (PICO) Question


Does handwriting intervention improve handwriting legibility in elementary school-aged
children?
How does this study relate to your research question?
This study relates to our research question in that it investigates how effective
occupational therapy (OT) interventions are in school settings for improving childrens
handwriting. The results of the study prove that students who received OT demonstrated
improved letter legibility, but speed and numeral legibility did not demonstrate positive
intervention effects.
What is the purpose of the study?
The researchers were concerned with how school-based OT affected childrens
handwriting skills such as legibility and how fast the child was able to write. They also looked at
how OT services affected other school related skills such a visual-motor skill, visual-perception
skill, dexterity, and in-hand manipulation skills (Case-Smith, 2002, p. 18).
What are the research questions/hypotheses?
The researchers came up with two questions to guide their study. The questions were as follows:
1. Compared with a control group of students with poor handwriting who do not receive
occupational therapy, will students with poor handwriting who receive occupational
therapy services make greater improvements in visual-motor skill, visual-perception skill,
dexterity, in-hand manipulation skills, legibility, and handwriting speed? (Case-Smith,
2002, p. 18)
2. Will students with poor handwriting who receive occupational therapy services
demonstrate statistically significant improvement over the course of the school year in

EFFICACY OF HANDWRITING INTERVENTION


school functions associated with visual-motor and manipulative skills? (Case-Smith,
2002, p. 18)
Does the literature review justify the need for this study?
According to the literature review, other studies have been conducted over the years to
support continued research in the area of school-based OT and handwriting interventions. They
suggest that handwriting is one of the most common reasons for referrals to OT services within
school-based practice. In addition, with the increased use of technology and the prevalence of
computers in schools, children are less inclined to practice handwriting thus creating deficits in
this area. One of the studies suggested that children with handwriting difficulties expend more
effort to correctly form letters and their muscles fatigued quickly. This article suggested that
these students were more likely to submit shortened assignments. Other research studies have
concluded that there are a number of variables that affects a childs handwriting skills. Visualmotor integration skills consistently have been found to be important for handwriting legibility.
For example, a study by Case-Smith in 2002 found that visual-motor and in-hand manipulation
skills correlated highly with handwriting skills in second-grade students. Finally, research has
shown that individuals with decreased muscle tone and postural instability have problems with
handwriting.
What is the study design/type of study? What is the level of evidence?
The design of this study was a two-way design, more specifically a two-way ANOVA. This
design included two independent variables in conjunction with the response variable (i.e.
dependent). The advantage of using this type of design is it allows for greater efficiency when
measuring two factors at once. It also allows for interactions between the two factors to be
measured (Siegle, 2015). This specific study examined differences between the pretest and

EFFICACY OF HANDWRITING INTERVENTION

posttest, as well as the two groups. This article is a level II, two group, non-randomized study
(pre and posttest).
How many participants?
There were 44 students recruited to participate in the research study. The students ranged
from 2nd to 4th grade and 31 of the students received OT services while 13 did not.
How were the participants recruited and selected?
The students were recruited from five different school districts in the Ohio and Illinois
area. The students asked to participate in this study were recognized by teachers as having poor
handwriting. The study defines poor handwriting as problems in how they formulated letters, as
well as spacing and size. After teachers identified students with poor handwriting, they were
further assessed for medical issues which could exclude them from the study. Once the final list
of participants was determined, parents gave written informed consent to allow their child to
participate in the study.
How were participants assigned to groups?
Participants in the study were assigned to one of two groups, the intervention group or the
comparison group. The intervention group consisted of students who received OT services. They
must have exhibited poor handwriting as identified by their teachers, handwriting as a goal in
their individualized education plan (IEP), and had cognitive functioning within normal limits. In
contrast, individuals assigned to the comparison group were those that had poor handwriting as
identified by their teacher, but did not receive OT services.
Participant Demographics
As stated before, participants in the study were recruited from within five school districts
in Ohio and Illinois. The 44 students ranged in age from seven to ten years old, and were from

EFFICACY OF HANDWRITING INTERVENTION

2nd, 3rd or 4th grade classes. For the intervention group, there were 24 males and five females
participants. 28 of those participants were Caucasian and one was African American. Diagnoses
represented by the intervention group included: 15 individuals with learning disabilities, 11 with
developmental disabilities and three with emotion-behavior disability (Case-Smith, 2002). The
researchers also consider what other services these students were receiving. One student was
receiving physical therapy while six other students received speech therapy. For the comparison
group, there were four males and five females participants. Eight of those participants were
Caucasian and one was African American. The diagnoses represented in the comparison group
included: four with learning disabilities, and five with emotion-behavior disabilities. The
individuals in the comparison group were not receiving any additional related services.
What are the variables?
The dependent variables in this research study were handwriting legibility and
handwriting speed. The independent variable in this research study was whether or not students
received OT services.
What measures were used?
There were numerous assessments used to gather information regarding participants
skills. In addition to administering the Evaluation Tool of Childrens Handwriting (ETCH) to
determine students handwriting legibility and speed, the Developmental Test of Visual
Perception (DTVP) the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), and School
Function Assessment (SFA) were also used. The DTVP was used to measure students
recognition of position in space, figure, figure-ground perception and copying skills. The
researchers used two of the subtests from the BOTMP to determine fine motor function in the
students. The BOTMP helped determine visual-motor coordination skills, as well as speed and

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dexterity of hand and finger movements. Finally the SFA was used to evaluate student
participation levels in school-related activities (Case-Smith, 2002).
The ETCH assessment was specifically used to measure handwriting skills in both the
intervention and comparison groups. There are two versions of the ETCH: the manuscript
version and the cursive version. Of the students included in the intervention group, 23 were
administered the manuscript version and six were administered the cursive version. In the
comparison group, six were administered the manuscript version and three were administered the
cursive version.
What is the intervention?
After results from initial assessments were gathered the handwriting intervention took
place over a seven month period. During this time, 12 OTs provided intervention services to the
students within the intervention group. All of the students in the intervention group received
regular OT services in their school. The therapists providing services were required to keep track
of the duration of their sessions in minutes, the format of intervention and whether they provided
individual or group services. Documentation of parent contact was also noted. In order to
determine the effectiveness of the handwriting intervention posttests were administered to both
groups and results were statistically analyzed to help confirm results.
What statistical analyses were used?
For gathering initial pre-test data, the researchers used standardized tests (i.e. DTVP,
BOTMP. SFA).The Statistical Package for the Social Sciences version 10 (SPSS) was used to
compute means and standard deviations for all tests. T-tests were used to measure levels of
change made by those students in the intervention group by comparing pre and posttest scores.

EFFICACY OF HANDWRITING INTERVENTION

In order to determine effectiveness of OT intervention on handwriting skills, the


researchers used two-way analyses of variance (ANOVAs) to compare the intervention group
with the comparison group. Using ANOVAs, researchers compared pretest and posttest scores,
differences between the two groups, and the interaction between test scores and group
membership.
What are the findings?
38 of the 44 originally recruited students completed both beginning and end-of-year
testing. 29 of those students were from the intervention group, and 9 were from the comparison
group. Information from the OT intervention sessions were recorded on a standardized form over
the course of the year. This included average session duration of 32.2 minutes, the average
number of sessions was16.4 (about twice per month or slightly more), total time that direct OT
services were provided to each student, whether it be in a 1:1 or small group format, was 528
minutes (Case-Smith, 2002). Handwriting practice activities were used to improve handwriting
in 77% of sessions. The other intervention approaches that were used put emphasis on a certain
skill that seemed to limit individual student progress.
The pre and posttest scaled scores of the performance component tests (in-hand
manipulation, DTVP, & BOTMP) were compared using t-tests. From these analyses students in
the intervention group made significant changes in in-hand manipulation (t= 3.78), visual-motor
control (t= -2.1) and position in space perception (t= -2.44). ANOVA scores indicated students in
intervention group improved more in in-hand manipulation and visual-motor control than those
students in the comparison group. However, progress in other performance components was no
greater for individuals who received OT versus those who did not.

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Beginning and end-of-year ETCH and SFA scores were also compared using t-tests.
ANOVA scores showed comparison group faired less than the intervention group in total
percentage of legible letters (p= .054) (Case-Smith, 2002).
Do these findings support the hypothesis?
The first research question asked whether students with poor handwriting who received
OT services would make greater improvements in visual motor skill, visual perceptual skill,
dexterity, in-hand manipulation, legibility, and speed. Based on the results of the intervention,
increases were shown in the performance areas of in-hand manipulation, visual-motor skill,
awareness of position in space and letter legibility percentage. Handwriting speed increased in
the control group, however this increase was not significant.
The second research question asked whether students demonstrating poor handwriting
skills, who received OT services, would show a significant improvement in their school
functioning in relation to visual-motor and manipulation skills after intervention. The results
support an increase in these skills for the individuals in the intervention group.
How do the findings relate to previous research as described in the literature review?
These finding relate to previous studies as they indicate that OT intervention would
improve handwriting. However, the study did not address the issue of increased technology in
school-based academia, which is one of the potential reasons as to why handwriting has been an
increasing problem in schools. The handwriting speed of students in the intervention group
increased from 32 to 37 letters per minute. In contrast, another similar study reported
handwriting speed in individuals within the age range of 7 to 10 years as being 35 and 73 letters
per minute, suggesting that the students in the present study remained somewhat slow in
handwriting (Case-Smith, 2002, p. 24).

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Does the author state any clinical implications for the findings?
The sample of students recruited for participation in the study was representative of those
who often receive OT services in the schools. The interventions used were representative of
school-based OT; a variety of techniques were used and intervention sessions were tailored to
specific student needs. Therapists communicated with teachers frequently over the course of
intervention, indicating therapists wish to establish carryover of the program into classroom
activities.
In this study, the intervention group improved more in in-hand manipulation than the
comparison group. Another study found similar results in preschool children receiving OT; they
also improved more in in-hand manipulation and position in space when compared to a group
who did not receive services. This suggests that these skills may consistently increase with OT
intervention (Case-Smith, 2002, p. 22).
What are the limitations that the author identifies?
Some of the limitations mentioned within this study were pre & post evaluation, sample
size, and gender. In regards to pre and posttest evaluation, the same researcher completed both
evaluations. In addition, researchers who assisted the leading researcher were aware of the study
which could lead to biases. As for sample size, the study included only 38 individuals. Gender
was also a limitation, as it was mostly males.
Does the author discuss implications for future research?
In terms of future research, some of the positive results from the study indicate that
clinical trials of specific handwriting interventions is a next step in clarifying what approaches
result in optimal outcomes.

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What would you say about the sample size? Do you think it is adequate?
The sample size within this study included 44 students; however, six dropped out by the
end of the study. This small sample size did not allow for generalizability and was mentioned as
a limitation within this study. Although the results of study indicated significance within this
legibility it is difficult to use this article as a reference due to the sample size.
If the researcher did not find a significant difference between the groups, is it possible that
this is due to a Type II error? If so, why do you think so?
The researchers within this study found significant differences between the control group
and those who received OT. Finding suggest that of the 29 students who participated in the study
at the beginning of the year, 15 of them increased their handwriting legibility from poor to better
than 90% legibility. In addition, there was an increase of 14% legibility throughout all the
participants within the study (Case-Smith, 2002).
Is there a control or comparison group? If so, is the control or comparison group
comparable to the experimental group on key features?
In this article there were both a control group and a comparison group. The control group
consisted of students who receive OT. It must be noted that both groups had to have poor
handwriting skills. The comparison group consisted of the students who did not receive OT.
Some of the key features examined within both groups in relation to handwriting were: visual
motor, visual-perceptual, in-hand manipulation, handwriting legibility, and speed.
Are those administering the outcome measures blind to group assignment?
This is not applicable to the research study as no one was blind to group assignment.

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Are the participants blind to group assignment?


Participants were not blind to their group assignments. They were aware of whether they
received OT services or not. Receiving OT services would automatically put the student in the
intervention group, whereas students not receiving services were automatically apart of the
comparison group.
Does the researcher account for drop-outs in the study? Could drop outs have influenced
the outcomes?
The researcher does account for drop-outs within the study suggesting that of the 44
students who were originally chosen at the beginning of the school year, six individuals dropped
out by the end of the second measurement. Two of the students in the intervention group dropped
out due to developmental neurological problems. In the comparison group, four of the students
dropped out due to various reasons including one due to expulsion, two were referred to OT
services, and one was not available for end-of-year testing.
Does the researcher report reliability and validity of the outcome measures? Are there
questions about the outcome measures chosen?
This study suggested various reliabilities in regards to the assessments used to measure
handwriting. In regards to DTVP the test-retest reliability ranged from 0.71-0.86. In addition, the
interrater reliability was 0.98. For the BOTMP, the reliability ranged from 0.77 to 0.88 for testretest and 0.98 for interrater reliability. This was based on a standardized sample of 765 children.
The ETCH reported fair to good reliability with an interrater range of 0.82 to 0.84, as well as a
test-retest of 0.77. For the SFA, internal consistency ranged from 0.92 to 0.98 as well as a testretest of 0.80 to 0.98. This was based on a standardized sample of 363 children (Case-Smith,
2002).

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What confounding factors could contribute to or influence the study outcomes?


Confounding factors are those which interfere with the two main variables being
measured thus distorting the association between the two. In regards to this study, a confounding
factor was the childs level of academic skills or lack thereof. For instance, a child in the control
group could have had a high level of cognition, but only suffered from poor handwriting;
therefore, their ability to conceptualize and formulate a letter would equate to increased
handwriting legibility. An additional confounder that could influence the outcomes of the study
was the determination of the control group, as this was based on the teacher opinion. This could
be seen as a bias within the study and could affect the overall outcome of the study.
What are the major strengths of this study?
Some of the major strengths within the study included: the screening process, pre and
posttesting, and large range of domains. As mentioned earlier, this article provided an array of
information on assessments that could be used to address handwriting. Pre and posttesting
allowed for greater validity within this study as it measured handwriting across the entire school
year. Furthermore, this study encompassed a wide range of domains within handwriting
including such areas as visual motor, visual-perceptual and in-hand manipulation.
What are the major weaknesses of the study?
A major weakness of this study was the sample size as it was limited to only 38
individuals. This small of sample size does not allow for generalizability of their findings and
would be more effective if the sample was larger. Another weakness of the study was the
geographic area in which this research took place. The researchers only used limited amount of
schools within those two areas. The last weakness was the use of a descriptive outcome design

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which limited the interpretation of why the intervention was effective. In addition, no
information was gathered on childs academic program.
How would you use this article as a therapist?
As a therapist this article could be useful in a variety of ways; however, is most effective
in providing evidence and support of particular interventions related to handwriting.
Furthermore, this article suggest some useful assessments that could be implemented by an OT
when addressing handwriting. For instance, subsets within the BOTMP were mentioned in the
article to assess visual-motor control when addressing handwriting with future clients.
Furthermore, OTs could use this article as a reference when developing interventions activities
for addressing handwriting issues. This article provided many examples of intervention activities
that could be used.
How does this article support/not support participation in occupation and the field of
occupational therapy?
This article supports participation in occupation (i.e. handwriting) as its findings
concluded that children who participated in OT showed gains in-hand manipulation, as well as
handwriting legibility. Furthermore, this study found that of the 29 students who were examined,
15 of them improved the legibility by the end of the school year. The results of this research
study are significant to the field of OT, and specifically to the intervention of handwriting.

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References
Case-Smith, J. (2002). Effectiveness of school-based occupational therapy
intervention on handwriting. American Journal of Occupational Therapy, 56(1), 17-25.
doi: 10.5014/ajot.56.1.17
Siegle, D. (2015). A variety of statistical procedures exist. Retrieved from:
http://www.gifted.uconn.edu/siegle/research/OtherStats/SampleStats.htm

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