Article

An examination of the effectiveness of Handwriting Without Tears® instruction

Examen de l’efficacite ́ du programme Handwriting Without Tears®
Gwenyth I. Roberts, Alanna F. Derkach-Ferguson, Jodi E. Siever, and M. Sarah Rose
Key words: Handwriting; Occupational therapy; Schools; Teaching. Mots cle ́s : e
́coles; e ́criture; enseignement; ergothe ́rapie.
Canadian Journal of Occupational Therapy 2014, Vol. 81(2) 102-113
DOI: 10.1177/0008417414527065
a CAOT 2014
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Abstract
Background. Handwriting is an important childhood occupation, and implications of
poor handwriting may have significant long-term effects. Purpose. The purpose of
this study was to determine the effectiveness of Handwriting Without Tears1 (HWT)
on Grade 1 students’ handwriting and perception of skills. Methods. A cross-over
design was used. Repeated measures, at three points, included the Minnesota
Handwriting Assessment (MHA) and performance rating scales. Findings. Eighty-three
boys and 66 girls with an average age of 6.2 years participated in the study.
Students receiving HWT achieved significantly higher improvements compared to
students with teacher-designed instruction in MHA Total Test Score and in MHA
components of form, size, space, and alignment (all p < .05). Students had higher
average performance ratings when receiving HWT in the first half of the school
year. Implications. Instruction using HWT improves students’ perception and skill
in handwriting performance.
Abre ́ ge ́
Description. L’e ́criture est une occupation importante de l’enfance et les conse
́quences d’une pauvre e ́criture peuvent avoir des effets a` long terme. But. De
́terminer si le programme Handwriting Without Tears 1 (HWT) est efficace pour ame
́liorer l’e ́criture des e ́le`ves de la premie`re anne ́e du primaire, de meˆme que
leur perception face a` leurs compe ́tences en e ́criture. Me ́thodologie. Un sche ́ma
d’expe ́riences croise ́es a e ́te ́ utilise ́. Des mesures re ́pe ́te ́es ont e ́te ́
effectue ́es, a` trois points, a` l’aide du Minnesota Handwriting Assessment (MHA)
et d’e ́chelles d’e ́valuation du rendement. Re ́sultats. Quatre-vingt-trois garc ̧ons
et 66 filles dont l’aˆge moyen e ́tait de 6,2 ans ont participe ́ a` l’e ́tude. Des
ame ́liorations plus significatives ont e ́te ́ observe ́es chez les e ́le`ves ayant
suivi le programme HWT que chez les e ́le`ves ayant rec ̧u un enseignement conc ̧u par
un enseignant, en ce qui a trait au score total obtenu au MHA et aux composantes de
la forme, de la taille, de l’espace et de l’alignement du MHA (tous les p < 0,05).
Les e ́le`ves ayant suivi le programme HWT dans la premie`re moitie ́ de l’anne ́e
scolaire ont obtenu de meilleurs scores en ce qui a trait au rendement moyen. Conse
́quences. L’enseignement a` l’aide du programme HWT ame ́liore la perception des e
́le`ves, de meˆme que leurs compe ́tences en e ́criture.
Funding: This study was funded by the Alberta Children’s Hospital Foundation
(Ethics ID # E-20634, Account #RT733993), the Child and Adolescent Health Research
Development Fund, the Allied Health Research Award, and the Regional School Health
Program (Principal Investigator: Alanna F. Derkach-Ferguson).
Corresponding author: Gwenyth Roberts, Regional School Health, Alberta Health
Services, Acadia Community Health Centre, 132, 151-86 Avenue SE, Calgary, AB, T2H
3A5, Canada. Telephone: 403-944-7929. E-mail: [email protected]
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Canadian Journal of Occupational Therapy 81(2)

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Handwriting is a meaningful occupation in childhood. It is the primary method for
students to demonstrate their knowledge in school, despite advances in tech- nology
(Amundson, 1992; Case-Smith, 2002; Olsen, 2005). Pro- ficient handwriting is seen
as a prerequisite for later academic achievement (Graham, Harris, & Fink, 2000) and
is reported to be important in fostering a feeling of competence and improved self-
esteem (Sassoon, 2003; Stipek & Mac Iver, 1989).
Handwriting instruction in the classroom occurs through a variety of approaches
(see Graham et al., 2008), although several authors recommend explicit handwriting
instruction as part of the regular curriculum (e.g., Ste-Marie, Clark, Findlay, &
Lati- mer, 2004). The superiority of particular instructional methods, or specific
tools that facilitate handwriting production, has not been established (e.g.,
Asher, 2006). It is reported that handwrit- ing instruction has been neglected due
to the use of technology, lack of time, inadequate teacher knowledge, and teachers
not receiving specific instruction on how to teach handwriting (Asher, 2006; Graham
et al., 2008; Kiss, 2007; Olsen, 2005). Generally manuscript handwriting
instruction has occurred at the Grade 1 or 2 level (ages 5 to 8 years) (Graham et
al., 2008) although some early education programs may include the teach- ing of
letter forms prior to this level (Wade, 2002).
Learning to form letters correctly is reported to be a funda- mental objective of
any handwriting curriculum (Olsen, 2009). Other quality components of handwriting
instruction and evalua- tion include appropriate size of letters, placement, and
alignment of letters on the writing lines and spacing between the letters and
words. These components are generally measured by evaluating the discrepancy from
model forms and calculating the distances from the writing lines and between
letters or words. Speed of writ- ing is calculated by counting the letters formed
within a specified time period. Any one of these components may affect the read-
ability of handwriting, generally assessed through copying, com- posing, and/or
dictation of written work (Amundson, 1992).
Difficulties with handwriting are reported in 10% to 34% of school age children,
depending on variables of sex, grade, selec- tion criteria, and instruments used
(Berninger et al., 1997; Hamstra-Bletz & Blo ̈te, 1993; Karlsdottir & Stefansson,
2002; Smits-Engelsman, Niemeijer, & Van Galen, 2001). More specif- ically, a lower
quality of handwriting has been reported in males and younger students (see Graham,
Berninger, Weintraub, & Schafer, 1998). In a study by Graham et al. (2008),
teachers indi- cated, on average, that 23% of the children in their classroom
experienced difficulty with handwriting. The most common problems identified were
overall neatness, spacing, letter size, letter formation, alignment, and reversals.
Potential negative outcomes for students with handwriting difficulties may include
lower grades due to reduced legibility, constraints in composi- tion, shortened
written assignments, and noncompliance with writing tasks (Briggs, 1980; Graham et
al., 2000, 2008).
Occupational therapists support children in schools who have handwriting problems.
Feder, Majnemur, and Synnes (2000) and Woodward and Swinth (2002) surveyed school-
based occupational therapists, and the majority reported using a multisensory
approach when treating students with
handwriting difficulties. Despite this, there is limited research and inconsistent
findings evaluating the efficacy of a multi- sensory approach (see Lockhart & Law,
1994; Weintraub, Yinon, Hirsch, & Parush, 2009; Woodward & Swinth, 2002; Zwicker &
Hadwin, 2009).
Handwriting Without Tears1 (HWT) is a developmentally and multisensory based
handwriting curriculum conceived by an occupational therapist (Olsen, 2003; Olsen &
Knapton, 2008). According to Olsen (2013), the program promotes developmen- tally
appropriate practice by using stages from imitation to copy- ing to independent
writing, by grouping the letters of similar difficulty, and by using a letter style
that uses simple vertical lines. It uses a multisensory approach by modeling letter
forma- tions, using verbal descriptions of the strokes, finger tracing, drawing
letters in the air, and using various materials to reinforce letter formations. The
approach is reported to follow research that demonstrates children learn more
effectively by actively doing with materials that address all styles of learning.
It uses three principles: (a) materials that are intuitive, engaging, and
developmentally progressive; (b) instruction that engages chil- dren as active
participants as they move, sing, talk, and expe- rience the lessons; and (c)
support for expansion of teacher knowledge. One of the primary aims is for children
to develop good, consistent habits in written work for size, letter forma- tion,
and placement of the letters (Olsen, 2009).
There is limited empirical research evaluating the effec- tiveness of HWT. In three
unpublished master’s theses, Pon- tello (1999), Wade (2002), and Owens (2004) found
that students who used HWT improved significantly in some aspects of handwriting
skills as compared to a control group. Pontello compared HWT instruction with a
ball-and-stick method of instruction in Grade 1 students and found signifi- cantly
better improvements in overall handwriting change scores and in components of
alignment and size for those who received HWT instruction. Components of spacing,
legibility, form, and rate did not consistently demonstrate significantly better
improvements at the monthly test periods. Wade (2002) found overall improvement in
a group receiving the HWT program versus a nontreatment group in kindergarten age
students (4 to 6 years), with significant improvements noted in specific areas of
alignment and spacing. Owens compared HWT instruction of Grade 2 students with
typical handwriting instruction and found significantly greater improvements in
size and spacing components but not for overall handwriting skill or in components
of legibility, form, alignment, and rate. Marr and Dimeo (2006), after using the
HWT program with students in Grades 1 through 6, found significant improvements in
single-letter formations and in parent ratings of handwriting but not in copying,
dictation, composition, or legibility scores. Schneck, Shasby, Myers, and DePoy
Smith (2012) compared a teacher-designed handwriting instruction with HWT for Grade
1 students and found the handwriting of both groups improved, with greater
improvements in the teacher-designed instruction group. The results of research
studies outline mixed findings, indicating the need for further study. Our study
further contri- butes to the body of evidence examining the HWT program.
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Roberts et al.
Primary
Study Objectives
Sample size. The sample size was calculated using esti- mates from Pontello’s
(1999) Total Test Scores (TTS) of the Min- nesota Handwriting Assessment (MHA)
(Reisman, 1999). Pontello’s data indicated that the control group improved by 19
points in TTS, with a common standard deviation of 19, during the intervention
period. It was expected that the mean change from Test 1 to Test 2 in Group B
(control) would be approximately 19.0 and the common standard deviation between the
two groups would be 19.0. To observe a difference of 50% in the mean change between
the TTS of the intervention and control groups (i.e., Group A increase 1⁄4 28.0 and
Group B increase 1⁄4 19.0), a sample size of 70 children was required in each group
(a 1⁄4 .05; b 1⁄4 .80) using a two-tailed, two-sample t test. To account for
attrition, a total of 90 students per group were recruited.
Data Collection
Instrumentation.
Assessing handwriting performance. The MHA (Reisman,
1999) is an educationally relevant evaluation of handwriting for Grade 1 and 2
students. Content validity and reliability data yield moderate to very good
estimates for interrater, intrarater, and test-retest reliabilities (Reisman,
1999).
Students copy the handwriting stimulus, ‘‘the brown jumped lazy fox quick dogs
over,’’ at near-point, a phase that contains all letters of the alphabet and is
reported to be in mixed order to adjust for speed, memory, and reading level
differences (Reisman, 1999). Specific scoring criteria are used to assess the
handwriting sample including rate and five quality components: legibility, form,
alignment, size, and spacing, with scores ranging from 0 to 34 points in each
category. Rate is derived by counting the num- ber of letters completed in a 2.5-
minute time period. Legibility is judged by characteristics of the letter, which
are recognizable out of context, with all parts of the letter complete and present,
and not rotated or reversed. Legibility is weighted more heavily than other
components; if a letter earns an error point for legibility then an error point
will be included in each of the other four quality com- ponents for that letter.
Form is judged by the quality of the letter formation, including the absence of
gaps or overlaps greater than one-sixteenth inch. Alignment is judged by letters
that rest within one-sixteenth inch above or below the solid base line. Size is
judged by referencing the individual letters within one-sixteenth inch above or
below the solid top line, the middle dotted line, or the lower dotted line. Spacing
includes letter and word spacing where letters within or between words may not
touch, and have no more than a quarter inch between letters within a word and at
least a quarter inch of space between words. TTS, used in previous research to
assess overall legibility of handwriting (Pontello, 1999), combines the MHA quality
categories (without rate) and was also used with our study.
Assessing self-perception of handwriting. The Canadian Occu- pational Performance
Measure (COPM) (Law et al., 2005) is an outcome measure designed to detect change
in a client’s perception of performance and satisfaction in self-identified prob-
lem areas. Data support good test-retest reliability, validity, and
1. Determine if HWT is an effective program for improv- ing handwriting in Grade 1
students (age 5 to 7 years) compared to teacher-designed instruction.
2. Determine the specific components (legibility, form, alignment, size, spacing,
rate) where students achieve the greatest improvement in their handwriting.
3. Determine the impact of HWT for students who are per- forming in the bottom 25%
of the group (the students who are potentially having handwriting difficulties in
the classroom).
Secondary
1. Determine if students who use HWT perceive gains in their competence in
handwriting skills.
2. Determine if teachers who instruct using HWT perceive changes in their
performance and satisfaction in hand- writing instruction.
Methods
This quasi-experimental study used a crossover design. Repeated measures evaluated
change over time in handwriting quality and speed and in student and teacher
perceptions.
Participants
Recruitment and inclusion criteria for schools.
Administrators from elementary schools in Calgary, Alberta, Canada were contacted
to describe the research study. From those that qualified, four schools were
randomly drawn for par- ticipation. Eligibility of schools were (a) a minimum of
two English, Grade 1, non–special education classes; (2) school administrator and
Grade 1 teachers agreed to participate; and (3) commitment to use the HWT program
as outlined in the research protocol. Ten classes with 10 different teachers were
identified from four schools. The schools, all with 24 to 26 classrooms from
kindergarten through Grade 6, were located in the urban area from three quadrants
of the city.
Inclusion/exclusion criteria for students. Teachers were provided with Student
Screening Questionnaires to outline student characteristics and determine
eligibility. The inclusion criteria specified (a) informed parental consent; (b)
full-time, Grade 1 students; (c) age 5 years, 5 months to 7 years, 6 months at
beginning of school year; (d) ability to understand and speak English; and (e)
sufficient attention to participate in a 15-minute lesson. The exclusion criteria
specified (a) atten- dance problems (< 75%); (b) retention in Grade 1; (c) signifi-
cant upper extremity impairment; (d) severe developmental learning problems; (e)
known neurological impairments; (f) previous exposure to HWT; and (g) receiving
occupational therapy. These students were excluded from data collection but not
instruction.
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105
responsiveness (Law et al., 2005). Based on the COPM, a modified performance
rating scale (PRS-1) using a Likert-type scale of 1 to 10 (1 1⁄4 not able to do it,
10 1⁄4 able to do it well) was accompanied by a continuum of sad to happy faces.
Students were asked to rate handwriting performance in response to the question
‘‘How well do you print?’’ This 10-point performance rating scale was used with the
first four study classes, resulting in extreme positive responses. Literature
regarding scales with younger children was reviewed (e.g., Chambers & Johnston,
2002), and a shorter 5- point performance rating scale (PRS-2) was developed for
use with the last six study classes. This scale used a similar question, language
cues, and continuum of sad to happy faces.
Assessing teacher perception of handwriting instruction. A modi- fied version of
the COPM was also used with the teachers in this study. Teachers were asked to rate
importance, performance, and satisfaction on the three COPM 10-point scales in
response to the following three questions: ‘‘How do you feel about the importance
of printing instruction in the Grade 1 curriculum?’’; ‘‘How do you feel about your
instruction in printing?’’; and ‘‘How satisfied are you with your program of
printing instruction?’’.
Procedure
Timeline. The study took place over two school years, with
four classes in the first year and six classes in the second year. Baseline testing
(T1) occurred at the beginning of the school year. Five classes, assigned to Group
A, received the HWT program during the 9-week period of Block 1 (October to
January). During this same time, five classes, assigned to Group B, received hand-
writing instruction (other than HWT) at the teacher’s discretion. Test 2 (T2)
occurred after Block 1. During Block 2 (February to May), the second 9-week period,
Group B received the HWT program while Group A received handwriting instruction
(other than HWT). Test 3 (T3) occurred after Block 2.
Testing. A research assistant, blind to group assignment, administered the MHA to
each of 10 classrooms. Students were seen individually for administration of the
performance rating scale (PRS-1 or PRS-2). At the three test points the teachers
were asked to rate handwriting instruction using COPM rating scales: importance,
performance, and satisfaction.
Intervention. In the HWT program students learn to print letters, words, and simple
sentences. The HWT kindergarten resources were used to ensure students had exposure
to readiness skills and capital letter instruction prior to lowercase letter
instruction. The resources included the Kindergarten Teacher’s Guide, the Letters
and Numbers for Me workbook, and multisen- sory materials (Wood Pieces Set for
Capital Letters, Capital Let- ter Cards, Mat for Wood Pieces, Slate Chalkboard,
Little Chalk Bits, Little Sponge Cubes, Print Alphabet Desk Strips, Print Wall
Cards, and Rock, Rap, Tap & Learn CD).
For teacher-designed instruction, the method (other than HWT) was chosen by the
teacher. The teachers were asked not to use HWT techniques and the HWT materials
were not available to them.
Procedural reliability. Before beginning HWT instruc- tion, the teachers received a
HWT in-service, previewed the HWT materials for 1 week, and consulted with the
principal investigator as required. Teachers were asked to refrain from sharing the
HWT information with other study teachers in the school as per the research
protocol.
The Kindergarten Teacher’s Guide provides detailed les- son plans for the first
letter of each letter formation grouping. To promote consistency, the investigators
created replica les- son plans for each remaining letter in the alphabet. The occu-
pational therapist (principal investigator) taught the first capital and lowercase
lessons to the classes; the teachers taught the remaining lessons. The therapist
connected with the teacher midway through the block for consultation on the HWT
inter- vention. All teachers were provided with a daily logbook to record (a)
handwriting practice activities, (b) frequency and duration of handwriting
instruction, (c) student absences, and (d) any issues.
For further fidelity, the co-investigator observed a teacher- instructed HWT
session at the midpoint to ensure that teacher instruction was complying with the
protocol. A common memo was sent to the teachers who were using the HWT program,
outlining their strengths in delivering the program and provid- ing reminders for
consistent instruction.
Data Analysis
MHA scoring reliability. Initially the research assistant (a) reviewed the MHA
manual, (b) scored two sample test forms, and (c) met with investigators to review
scoring proce- dures. Prior to scoring the MHA at each test period the research
assistant was provided with 16 practice test forms to score; the investigator
provided feedback.
Statistical analysis. Descriptive statistics using frequen- cies and percentages
were conducted on categorical variables including: age, gender, handedness,
ethnicity, and English as a second language. Baseline data on handwriting skill and
stu- dent perceptions of handwriting were described using the med- ian and
interquartile range for non-normal data. Comparisons between Groups A and B were
carried out to assess similarities prior to intervention. A Fisher’s exact test was
conducted for categorical variables, and a Wilcoxon rank sum test was used for
continuous measures.
Analyses were conducted in Stata S/E Version 12.0 and based on available data.
Students were only omitted from anal- ysis when corresponding change scores could
not be calculated as student absences occurred. Due to the multiple comparisons
tested and reported, the chance of spuriously significant p-values is high and p-
values should be interpreted with caution.
Primary objectives. A multivariable linear regression model was developed using a
robust variance estimator (to take into account the intrasubject correlation due to
repeated mea- sures on each student). The outcome was the change in TTS in each
time interval (T1 to T2, T2 to T3). The main predictor
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Roberts et al.
variables were group (Group A, Group B) and time interval (T1 to T2, T2 to T3).
Potential confounders determined a priori were baseline handwriting skill,
determined by TTS at T1 (low: bottom 25% of students; high: top 75% of students),
age (<6.2 years, 􏰀6.2 years), and gender (male, female). All two-way interactions
were assessed and included in the model if they were significant at p < .05 using
the likelihood ratio statistic. Variables not included in the interactions were
considered eli- gible for entry in the multivariable model if p < 1.0 in an indi-
vidual regression model and retained in the multivariable model if p < .05. Due to
evidence of significant complex inter- action terms between baseline skill and both
the main predictor variables, the analysis was stratified by baseline skill level
and used a separate regression model for each baseline level. The results are
presented using descriptive statistics for the change scores (mean and standard
deviation); the difference between the change scores was estimated from each model
(with asso- ciated 95% confidence intervals [CI] and p-value), first for the
overall group and then for each baseline level. A t test was con- ducted from T1 to
T3 to examine differences in overall change scores between Groups A and B.
To determine which components of the TTS may have contributed to the intervention
effect, a similar regression model for each handwriting component of the MHA
(legibility, form, alignment, size, spacing, and rate) was developed with an
interaction between group and time interval.
Secondary objectives. To analyze students’ perceptions of their handwriting, PRS-1
and PRS-2 were combined to deal with sparse data. Students were considered to have
‘‘high’’ perception of their handwriting skills if they scored 10 on the PRS-1 or 5
on the PRS-2 as compared to lower scoring on these measures. A Fisher’s exact test
was conducted at each time point to examine differences between students in Groups
A and B.
To assess teachers’ perception of their instruction, scores on the COPM’s
importance, performance, and satisfaction ratings were reviewed descriptively.
Importance ratings were averaged at each test point. Change scores were calculated
for performance and satisfaction ratings for each group. A change score of two or
more was considered clinically significant (Law et al., 2005).
Ethical Approval
Ethical approval to conduct this study was granted by the Uni- versity of Calgary
Conjoint Health Research Ethics Board and the Calgary Board of Education Ethics
Review Board.
Findings
Demographic Characteristics and Baseline Handwriting Skill
A total of 184 students were invited and 149 participated in this study, with 77
students in Group A and 72 students in Group B (see Figure 1). The 83 boys and 66
girls ranged in age from 5
Figure 1. Participant flow diagram.
years, 8 months to 7 years, 1 month upon initial testing (average age: 6 years, 2
months). Comparisons between Groups A and B in demographics, handwriting skills,
and performance ratings showed no differences at baseline (see Tables 1 and 2). Of
the 37 students who scored in the bottom 25% of the group at base- line, 68% were
boys and 62% were less than 6.2 years.
Handwriting Instruction Results
The teacher logs for the 10 classes revealed that HWT was taught, on average, 20
minutes per day (range: 13 to 29 minutes). During each HWT intervention period,
similarities were demonstrated for the groups in total instruction time
(approximately 800 minutes) and percentage of the workbook completed (range: 63% to
100%).
For the teacher-designed instruction, some teachers did not complete the log during
this time and others entered data incon- sistently. A summary of the teacher-
designed instruction could not be completed.
Primary Outcomes
Mean changes in each time period by group and baseline skill are presented in Table
3. From T1 to T2, students receiving HWT (Group A) demonstrated an average increase
in TTS of 6.5 points (95% CI [1.2, 11.8]) higher than students not receiving the
pro- gram (Group B). From T2 to T3, students in Group B, who received HWT,
demonstrated a greater average increase in TTS by 8.4 points (95% CI [3.4, 13.5])
as compared to Group A. There were no differences between groups in the overall
change scores from T1 to T3 (mean difference 1⁄4 2.1; 95% CI [–8.8, 4.6]).
Students recruited N = 184
Group B
Parent consent received N= 80
Student met inclusion criteria N = 72
Time 1
N = 71; 99% of participants (1 student absent)
Time 2
N= 71; 99% of participants (1 student absent)
Student met inclusion criteria N = 77
Group A
Parent consent received N = 77
Time 1
N = 77; 100% of participants (0 students absent)
Time 2
N = 74; 96% of participants (3 students absent)
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Canadian Journal of Occupational Therapy 81(2) 107 Table 1

Characteristics of Children, by Group, at Baseline
Group A Group B Total
Demographic n%n%n%p
 Age
Younger (<6.2 years) Older (􏰀6.2 years)
Gender Male
Female Handedness
Right
Left Ethnicity
Canadian/American Asian
North American Indian European
Middle Eastern EastIndian Other
English as a second language No
Yes
Note. p 1⁄4 two-tailed p-value.
Table 2
Baseline Handwriting Skill and Student Performance Rating by Group
303937516745 .141 476135498255
405243608356 .410 374829406644
69 7
55 9 2 5 3
91 67 9 5
71 48 12 9 3 0 6 5 4 3
93 136
7 12 8
67 103
13 18 12
0 2 1 7 10 7 4 6 4
001111 346896
72 94 66 (92) 138 (93) .760
5 6 6 (8)
11 (7)
Total
Median IQR p
135 113-149 .552
32 30-33 .762 26 21-29 .411 25 20-29 .455 23 14-29 .661 29 26-32 .855 14 9-21 .382
92 .766
69 .736
Minnesota Handwriting Assessment Median
Total Test Score 135 Component
Legibility 32 Form 26 Alignment 25 Size 24 Spacing 29 Rate 14
Group A
IQR 112-148
29-33 21-29 22-29 14-29 26-32
Median 133
30
25
25
23
29
15
n
38
Group B
IQR 115-149
30-33 21-28 18-29 13-29 26-32 10-22
9-19 Performance Rating Scale n %
%n 53.5 82
% p 55.4 .741
High perception 44 57.1 Note. IQR 1⁄4 inter-quartile range; p 1⁄4 two-tailed p-
value.
Neither age nor gender were significant predictors of change in TTS, both in the
univariate analysis (p 1⁄4 .453 for age; p 1⁄4 .454 for gender) and after
controlling for the variables in the final model (p 1⁄4 .520 for age; p 1⁄4 .791
for gender).
For students scoring in the bottom 25% of the group at base- line, there was no
statistically significant difference between Groups A and B from T1 to T2,
although, Group A achieved a higher average increase in scores (see Table 3). From
T2 to T3, Group B increased by an average of 18 points more than Group A (95% CI
[3.2, 32.8]), a statistically significant difference. Sim- ilar results occurred at
both time intervals for students performing in the top 75% of the group at baseline
(see Table 3).
Figure 2 illustrates the average score at each time point by baseline skill level
and group. Students who were per- forming in the bottom 25% of the group
demonstrated an average of 50.7 points lower (95% CI [44.5, 55.9]) than their peers
at the start of the school year, to an average of 20.2 points lower (95% CI [14.0,
26.5]) by the end of the school year (see Figure 2).
The mean change scores for Groups A and B at both time intervals, with statistical
comparisons, are provided for each com- ponent of the MHA in Table 4. Students in
Group A achieved higher statistically significant scores for both form and spacing
from T1 to T2 when compared to Group B. From T2 to T3,
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108 Roberts et al.

Table 3
Mean Change in Total Test Score and Differences in Change Scores Between Groups for
the Overall Sample and Within Each Handwriting Skill Level at Baseline, for Each
Time Interval
Test 1 to Test 2 Test 2 to Test 3
N MD SD N MD SD
Overall Group A
Group B Difference 95% CI
p
Low baseline skill Group A
Group B Difference 95% CI
p
High baseline skill Group A
Group B Difference 95% CI
p
74 70
17 18
56 53
17.5 11.0 6.5 [1.2, 11.8] .017
36.9 25.2 11.7 [–2.9, 26.2] .113
11.2
6.4
4.8 [–0.4, 10.0] .072
20.3 17.4
22.8 21.9
14.9 13.0
74 68
17 18
56 51
–0.4 11.3 8.0 18.9
–8.4 [–13.5, –3.4] .001
1.1 23.9 19.1 12.0
–18.0 [–32.8, –3.2] .017
–0.8 8.5 4.4 14.5
–5.2 [–9.8, –0.7] .022
Note. SD 1⁄4 standard deviation; MD 1⁄4 mean change; CI 1⁄4 confidence interval; p
1⁄4 two-tailed p-value.
Figure 2. Average Total Test Score at each test point, by group and baseline
printing skill.
students in Group B achieved higher statistically significant scores for form,
alignment, and size when compared to Group A. Since there was no difference between
the two groups in over- all change scores, differences in the quality components
were not examined from T1 to T3. The overall change in rate between groups was not
significant from T1 to T3 (mean difference 1⁄4 1.3; 95% CI [–4.9, 2.3]), nor for
each time interval (see Table 4).
Secondary Outcomes
Using the combined PRS-1 and PRS-2, 67.6% of students in Group A had high
perception of their handwriting skill after receiving the HWT program compared to
47.9% of students
in Group B at T2 (Fisher’s exact p 1⁄4 .019). After Group B received the HWT
instruction at T3, the percentage of students with a high perception of their
handwriting skill increased to 50.7% compared to Group A at T3, who remained
unchanged at 67.6% (Fisher’s exact p 1⁄4 .043).
On average, at each test point, teachers rated the impor- tance of handwriting at
8.9 or greater out of 10. When using HWT, 80% of the teachers rated improved
performance of their instruction (50% clinically significant) as compared to 30% of
teachers using teacher-designed instruction (10% clinically sig- nificant). When
using HWT, 100% of teachers reported improved satisfaction (70% clinically
significant) as compared to 10% of teachers using teacher-designed instruction.
Discussion
Students who received the HWT program scored, on average, 6.5 to 8.4 points higher
in TTS on the MHA than students who received teacher-designed instruction. The
significant improvement in overall quality of handwriting skills as com- pared to
other instructional methods supports previous HWT research by Pontello (1999),
although not in a study by Schneck et al. (2012).
Recent studies have shown that other explicit handwriting programs have
demonstrated positive outcomes (e.g., Case- Smith, Holland, & Bishop, 2011; Kaiser,
Albaret, & Doudin, 2011; Mackay, McCluskey, & Mayes, 2010; Shaw, 2011).The
superiority of the HWT program over any other structured pro- gram cannot be
determined from our study.
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Table 4
Mean Change and Difference Between Group A and Group B for Each Component of
Handwriting at Each Time Interval
Group A
MD SD 1.4 2.8
Test 1 to Test 2 Group B
Test 2 to Test 3 Group B
MD SD Difference 0.7 2.5 –0.5
0.9 4.3 –1.7 2.7 6.2 –2.5 3.1 7.3 –2.9 0.6 3.3 –0.7 3.2 11.3 –1.3
significant changes in the quality categories; she hypothesized first-grade
students are handwriting as well as they will by January. In contrast, our study
shows when students receive explicit, regular instruction in the second half of the
school year using HWT, they made significant changes in three quality components on
the MHA as compared to those receiving teacher-designed instruction. These changes
would indicate that HWT instruction has an impact on the quality of handwrit- ing
in the second half of the Grade 1 school year.
Improvement in form, which occurred in both blocks, is important. Significant
positive changes in form have not been demonstrated in other studies examining the
effectiveness of the HWT program. Letter formation is identified as one of the main
components in determining good versus poor handwriting legibility (Hammerschmidt &
Sudsawad, 2004; Reisman, 1999). Form is targeted in the HWT program: Letters are
taught in groups, based on similar formation, using modeling, imita- tion, copying,
arm and finger tracing, visual models of the let- ters, and progresses
developmentally from easier to more complex letter forms (Olsen, 2013). Letter
formations are likely enhanced in the HWT program by using consistent verbal cues
to sequence the letters strokes. This feature is supported in research where using
explanations with modeling was more effective than explanations or modeling alone
(Jones & Chris- tensen, 1999). The verbal cues also would appear to be helpful in
developing the motor plan, seen as a predictor of legibility (Tseng & Murray,
1994). The ‘‘Learn and Check’’ task in the HWT workbooks likely reinforces
awareness of correct let- ter formation as it encourages students to check their
letter, word, and sentence skills, another feature also sup- ported by research
(Denton, Cope, & Moser, 2006; Jong- mans, Linthorst-Bakker, Westenberg, & Smits-
Engelsman, 2003; Kaiser et al., 2011).
The improvements in spacing, alignment, and size found in our study are supported
in previous HWT studies (alignment, size: Pontello, 1999; size, spacing, alignment:
Owens, 2004; spacing: Wade, 2002). These improvements may be related to specific
HWT features: spacing in the ‘‘Learn and Check’’ feature where sentences are
checked for word spacing; align- ment in the use of the double line HWT paper with
the bottom
MHA component
MD SD 1.1 2.8
Difference
0.3 1.8 1.3 1.9 1.2
95% CI
p
0.463 0.012 0.173 0.106 0.039 0.841
Group A
MD SD 0.2 1.9
–0.9 3.6 0.2 3.6 0.2 4.1
95% CI
[–1.3, 0.3] [–3.2, –0.3] [–4.3, –0.6] [–5.2, –0.6]
p
0.225 0.015 0.009 0.013 0.232 0.410
Legibility Form Alignment Size Spacing Rate
2.4 4.4 4.6 6.1 6.2 8.2 2.8 3.7 3.7 8.1
0.6 4.9 3.3 6.2 4.3 7.7 1.6 3.7 4.0 9.9
[–0.5, 1.1] [0.4, 3.2] [–0.6, 3.1] [–0.4, 4.2] [0.1, 2.3] [3.4, 2.7]
–0.1 3.0 1.9 7.6
[–1.8, 0.4] [–4.3, 1.8]
–0.3
Note. MHA 1⁄4 Minnesota Handwriting Assessment; CI 1⁄4 confidence interval; MD 1⁄4
mean change; SD 1⁄4 standard deviation; p 1⁄4 two-tailed p-value.
Few studies have compared the effectiveness of an explicit handwriting program
delivered to the classroom with those of a regular program of instruction (teacher-
designed instruction) (e.g., Kaiser et al., 2011). The HWT program in our study was
implemented by the teacher to the entire classroom for an aver- age of 20 minutes
per day, for a period of 9 weeks. The occu- pational therapist supported the
teacher but did not implement the program, utilizing a universal method of service
delivery (Deshler & Cornett, 2012). This was shown to be an effective method of
service delivery for the HWT program and is sup- ported in previous HWT research
(see Kiss, 2007; Owens, 2004; Pontello, 1999; Wade, 2002).
There are a number of factors that may have contributed to the higher scoring in
the groups that received HWT. HWT is labeled a multisensory program, and it is
suggested that this approach, which includes a variety of sensory strategies
(visual, tactile, auditory, kinesthetic), is beneficial. Sylwester (1995) explains
that a memory stored using multiple senses is more powerful and accessible than a
memory stored in just one sensory area. HWT also incorporates other recommended
methods for teaching handwriting, including cognitive (model- ing and imitation,
guided practice, and self-evaluation) and motor learning activities (Benson, Salls,
& Perry, 2012). Research by Zwicker and Hadwin (2009) found that neither a
cognitive nor a multisensory-based intervention delivered to Grade 1 students in 5
hours of therapist-implemented instruc- tion was superior. In our study, though,
the combined approaches used in the HWT program, delivered in 13 hours of
intervention to the whole class, accrued benefits to the stu- dents. It may also
suggest that more time or practice is required for skill change.
In our study, students who received the HWT program achieved higher average change
scores in each MHA quality component as compared to those receiving teacher-
designed instruction, in both blocks. Statistically significant differences were
identified in favour of the HWT group for form and spac- ing during the first block
(October to January) and form, align- ment, and sizing during the second block
(February to May). Reisman (1999) administered the MHA in January and again in
April with Grade 1 students and found there were no
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Roberts et al.
line keeping the writing straight, and in the specific verbal instructions (e.g.,
‘‘bump the lines’’); and size in the placement of the main part of the letter
within double lines (Olsen, 2013). Research has indicated issues with the double-
lined paper for size of letters and in carryover to typical workbooks (Benson et
al., 2012; Reidlinger, Candler, & Neville, 2012). In our study, when following
instruction using the HWT double- lined paper, significant improvements in size
were noted using the interlined paper of the MHA, indicating that Grade 1 stu-
dents were able to generalize this learning.
The legibility component, although mean change was higher in the HWT group, only
improved slightly in both the teacher-designed and the HWT instruction groups and
was not significantly different. The legibility scores on the MHA were high for the
majority of students at baseline, with a median score of 32 out of 34 points for
the entire group. This high scor- ing for legibility, as compared to other
categories, is noted in other studies, including Pontello’s (1999) results (mean
legibil- ity baseline for three groups: 30.9 points) and Peterson and Nelson’s
(2003) results (mean legibility baseline for two groups: 30.6 points), and may
indicate that the legibility com- ponent of the MHA is not sensitive in
discriminating skill lev- els. Another possibility is related to the test-retest
reliability with Reisman (1999) reporting the lowest score for this cate- gory
at .60. This would potentially reduce the chances of find- ing differences between
the groups (Peterson & Nelson, 2003).
No differences were found between rate scores in the teacher-designed instruction
group and the HWT group. Even though the quality of handwriting improved more in
the group receiving HWT, a corresponding improvement in rate did not occur.
Previous research has not found a linear relationship between handwriting quality
and the rate of writing (e.g., Graham et al., 1998). As well, it is reported that
measurement instruction may impact the quality and speed of the written product and
may not reflect actual functional performance. Weintraub and Graham (1998) found
that when children were asked to write neatly, the speed of their handwriting
decreased, and when asked to write quickly, the quality of their handwrit- ing
decreased. The MHA rate instructions emphasize neatness and not speed (Reisman,
1999). As well, the HWT program emphasizes formation of the letters during
instruction, preced- ing focus on the speed of handwriting, as suggested in other
research (e.g., Mackay et al., 2010).
One of the objectives of our study was to examine the out- come of students who
were performing with lower handwriting legibility, those potentially referred for
occupational therapy. Previous research has examined the effectiveness of HWT with
special education students (see Kiss, 2007; Owens, 2004; Schneck et al., 2012) but
has not explored the effectiveness of HWT with the lower scoring 25% of the
classroom, those identified by teachers as having handwriting difficulties (Graham
et al., 2008). For students who were in the bottom 25% of the group at baseline,
higher average changes in TTS were seen when they received HWT instruction as
compared to teacher-designed instruction, and in the second half of the school year
the change was statistically significant. In the first
half of the school year, all lower performing students are improving, as outlined
by Marr and Cermak (2003), who found very large changes in handwriting legibility
from kindergarten to the middle of Grade 1. In the second half of the school year,
the students who demonstrated lower performance in handwrit- ing skills in our
study benefited from explicit, regular handwrit- ing instruction using HWT.
Improvements in handwriting have been found in other studies following explicit
instruction and may have implications for future performance in handwriting skill,
composition, and academics (Berninger et al., 1997; Denton et al., 2006; Graham et
al., 2000; Jones & Christensen, 1999; Jongmans et al., 2003; Lockhart & Law, 1994).
The majority of students in the lower performing group consisted of boys (68%) and
younger students (62% less than 6.2 years old). This finding is in line with
previous research (see Graham et al., 1998). In our study, the amount of change
that occurred in the groups was not different for age or gender.
It is important to note that students in the bottom 25% approached close to the
same scoring on TTS as the higher per- forming group by the end of the school year.
The higher per- forming students were scoring with high handwriting quality at the
beginning of the school year, and the magnitude of their improvement was limited,
as documented in previous research (Marr & Cermak, 2003). It was felt these
students were devel- oping automaticity through overlearning of satisfactory pat-
terns (Stones, 2003).
As proposed by Denton et al. (2006), an attempt was made to provide a meaningful
context for the children in our study by asking them to rate their performance in
handwriting. Chal- lenge with measurement of perception in young children is
reported in the literature (e.g., Missiuna & Pollock, 2000), indi- cating that
students often perceive inflated ratings of skill com- petence (Stipek & Mac Iver,
1989). This was found to be the case in our study, with over 75% of students
choosing high val- ues of 8, 9, or 10 on a 10-point scale and 76% choosing high
values of 4 or 5 on a 5-point scale at baseline. The combined data from the scales,
using the highest score as the indication of high perception, revealed higher
ratings in those students who received HWT in the first half of the school year and
these higher ratings were maintained. The students who received HWT instruction at
the beginning of the school year may have felt that they were more competent in
their handwriting skills from the outset, and this perception was sustained
throughout the rest of the school year. The initial learning and feedback pro-
vided in the HWT program may have impacted their feelings of competence (Olsen,
2013). When skills are enhanced, per- ceived competence may be enhanced, bolstering
self-esteem, and further improve future performance. (e.g., Baumeister, Campbell,
Krueger, & Vohs, 2003).
Teacher perception ratings in our study indicated that handwriting instruction was
very important, which is reflected in previous research (e.g., Hammerschmidt &
Sudsawad, 2004). The majority of teachers felt they improved in their instructional
practices when using the HWT program and were much more satisfied with their
ability. Teacher satisfaction with the HWT program is supported in other studies
(Benson
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111
et al., 2012; Kiss, 2007; Owens, 2004). In our study, teacher instruction was
supported by coaching, provided by the occupa- tional therapist and the HWT manual,
and seen as an effective method of promoting best practice (Deshler & Cornett,
2011).
Limitations
This study has several limitations. One of the main limitations is that the amount
of time and the techniques used by teachers for handwriting instruction other than
HWT was not consis- tently recorded in teacher log books and therefore could not be
summarized. The experience of the participating teachers was not determined. The
improvements seen in this group of children were not compared to a group that
received HWT throughout the school year or a group that did not receive HWT
throughout the school year. In addition, our study may be underpowered for
analyzing differences between the lower per- forming groups due to small sample
sizes. A population in four urban schools within a single school district was used,
and cau- tion is recommended in generalizing results.
Conclusion
HWT is seen as an effective method for improving the quality of handwriting skills
in Grade 1 students when delivered to the entire class, with teacher coaching
provided by an occupational therapist. Specific handwriting quality components of
form, size, spacing, and alignment demonstrated significant change improvements
when receiving HWT as compared to teacher- designed instruction. Particular
benefits were seen in lower per- forming students, comprised primarily of boys and
younger students, who performed better when receiving HWT instruc- tion,
particularly in the second half of the Grade 1 school year. Students perceived
improved performance in their handwriting skills, especially when receiving HWT in
the first half of the school year. Teachers felt handwriting instruction was impor-
tant and perceived improved performance and satisfaction with their handwriting
instruction when using HWT. The HWT pro- gram contains many features cited in the
literature as important aspects of good handwriting instruction, and it is felt
that it can be recommended with greater confidence. It would be benefi- cial to
look at comparing HWT instruction to other structured handwriting programs as well
as longitudinal studies to deter- mine if early HWT instruction has later impact on
handwriting and academic performance.
Key Messages
􏰁 Handwriting Without Tears1 (HWT) is an effective method for improving quality of
print in Grade 1 students, with particular benefit to students with lower quality
skills.
􏰁 Form, a key component in handwriting legibility, is improved with HWT
instruction.
􏰁 Teacher instruction of a structured handwriting program such as HWT is
recommended to benefit all the students in the classroom, with occupational therapy
referral for stu- dents requiring more specialized service.
Acknowledgements
We would like to thank Melissa Myers for ideation and supportive work throughout
the project, Brenda Wilson for her assistance with program design and fund-
sourcing, and Lori Craig for administrative support and arrangement of clinical
release time. We would like to thank the research assistants, Brigitte Roy, Gina
Blumes, Aynsley Wennberg, Donna Dressler-Mund, and Erica Roberts for substantive
contribution to the work. Lastly, thank you to the students, teachers, parents, and
administrators within the Calgary Board of Education for their participation in
this study and allowing us to learn from and with you.
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29, 125–134. doi: 10.3928/15394492-20090611-05
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Book Review
Woelke, Sharie. (2012).
Brain injury rehabilitation basics series: A guide to providing community- based
intervention.
Ottawa, ON: Woelke Occupational Therapy.
US$35.00 (e-book series).
DOI: 10.1177/0008417413520490
This manual, available as an e-book series, provides occupa- tional therapists with
clear directions for their community brain injury practice. The series consists of
seven e-books that progress logically and include practice worksheets for use. The
e-books are (1) The Framework of Intervention; (2) Symptom- Based Intervention:
Part 1; (3) Symptom-Based Intervention: Part 2; (4) Intervention in the Home; (5)
Intervention in the Community; (6) Intervention in the Workplace; and (7) Case
Studies and Printable Worksheets.
Each e-book’s first 8 to 12 pages are a repetition of the introduction and
intervention philosophy. The intent is that by following this review of process and
philosophy, each book can stand on its own. It is a foundation series to assist new
prac- titioners in the area of community brain injury and an opportu- nity for
seasoned practitioners to reflect on their process skills.
Zwicker, J., & Hadwin, A. (2009). Cognitive versus multisensory approaches to
handwriting intervention: A randomized controlled trial. OTJR: Occupation,
Participation and Health, 29, 40–48. doi:10.3928/15394492-20090101-06
Author Biographies
Gwenyth I. Roberts, MSc, BOT, OT(C), is Occupational Therapist, Regional School
Health, Alberta Health Services, Acadia Community Health Centre, 132, 151-86 Avenue
SE, Calgary, AB, Canada, T2H 3A5.
Alanna F. Derkach-Ferguson, MSc(OT), OT(C), is Occupational Therapist, Vancouver
Regional Pediatric Team, Vancouver Coastal Health, Pacific Spirit Community Health
Centre, 2110 West 43rd Avenue, Vancouver, BC, Canada, V6M 2E1. At the time of this
study Alanna was Occupational Therapist, Regional School Health, Alberta Health
Services, Acadia Community Health Centre, Calgary, AB, Canada.
Jodi E. Siever, MSc, is Senior Analyst, Population and Public Health, Alberta
Health Services, 10101 Southport Rd SW, Atrium #2255, Calgary, AB, Canada, T2W 3N2.
M. Sarah Rose, PhD, is Biostatistician, Rho-Sigma Scientific Consultants, 119
Valencia Rd NW, Calgary, AB, Canada, T3A 2B7.
Although there are references to literature and research for the ‘‘intervention
philosophy’’ section, there is no substantial reference material related to
practice after this. This reviewer found the presented information easy to follow,
but at times, it would have been useful to have further references throughout the
series. For example, although the printable worksheets found in the seventh e-book
may be useful, their relation to practice rigour (in terms of reliability/validity)
is unclear. Having said that, these worksheets would be helpful for practi- tioners
who like to have an outline or base organizational level provided for intervention
and then modify those intervention/ tools as needed.
This e-series gives cookbook-like directions to and examples for practitioners in
the community brain injury field. It does not provide objective bases from which to
practise but assists therapists in looking at their interventions through prac-
tical lenses. This series is a good review and an excellent reminder of the
valuable contributions occupational therapists bring to this area of practice.
Marie Nelson
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Therapists on April 26, 2016
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