Effectiveness of an Integrated Handwriting Program for

First-Grade Students: A Pilot Study

Jane Case-Smith, Terri Holland, Beth Bishop

KEY WORDS We developed and piloted a program for first-grade students to promote development of legible handwriting
 cooperative behavior and writing fluency. The Write Start program uses a coteaching model in which occupational therapists and
teachers collaborate to develop and implement a handwriting–writing program. The small-group format with
 faculty
embedded individualized supports allows the therapist to guide and monitor student performance and
 handwriting provide immediate feedback. The 12-wk program was implemented with 1 class of 19 students. We
 occupational therapy administered the Evaluation of Children’s Handwriting Test, Minnesota Handwriting Assessment, and
 program evaluation Woodcock–Johnson Fluency and Writing Samples test at baseline, immediately after the Write Start
program, and at the end of the school year. Students made large, significant gains in handwriting legibility
and speed and in writing fluency that were maintained at 6-mo follow-up. The Write Start program appears
to promote handwriting and writing skills in first-grade students and is ready for further study in controlled
trials.

Case-Smith, J., Holland, T., & Bishop, B. (2011). Effectiveness of an integrated handwriting program for first-grade stu-
dents: A pilot study. American Journal of Occupational Therapy, 65, 670–678. doi: 10.5014/ajot.2011.000984

Jane Case-Smith, EdD, OTR/L, FAOTA, is Professor

and Chair, Occupational Therapy Division, School of
Allied Medical Professions, Ohio State University,
H andwriting is a critical life skill for elementary school students (Cahill,
2009). It is also a complex skill that requires the integration of lower-level
perceptual–motor skills (e.g., visual–motor coordination) and higher-level
406 Atwell Hall, 453 West 10th Avenue, Columbus,
OH 43210; [Link]-smith@[Link] cognitive skills (e.g., language, executive function; Graham & Weintraub,
1996; Weintraub, Yinon, Hirsch, & Parush, 2009). Although some children
Terri Holland, MS, OTR/L, is Occupational Therapist,
Dublin City Schools, Columbus, OH.
appear to learn handwriting automatically, most children must be taught
handwriting to achieve writing fluency. Unfortunately, with the increasing
Beth Bishop, MOT, OTR/L, is Occupational Therapist, emphasis on reading and math in the United States, handwriting instruction
Cincinnati Children’s Hospital Medical Center,
appears to be decreasing (Berninger et al., 2006). Too often in public schools,
Occupational and Physical Therapy Department, The Kelly
O’Leary Center for Autism, Cincinnati, OH. fundamental handwriting skills are not explicitly taught, and students who
struggle with these skills are not identified until the demands for written pro-
duction increase.
Graham et al. (2008) completed a survey of first- through third-grade
teachers’ perceptions of teaching handwriting. Only 39% of the teachers sur-
veyed indicated that their students’ handwriting was adequate, and only 46%
indicated that their students’ handwriting speed was sufficient to keep up with
classroom demands. The teachers reported that almost 25% of students ex-
perienced difficulty with handwriting (Graham et al., 2008). Although the
teachers agreed that handwriting had important consequences for students,
they also reported that they had not been adequately prepared to teach
handwriting.

Students Who Struggle With Handwriting

Poor handwriting in young students can have several detrimental consequences.
Students may focus on how to form the letters rather than on the words they are
writing. They are also likely to lose some of their ideas given the extra effort and

670 November/December 2011, Volume 65, Number 6

time that it takes for them to write. Teachers may not from a model without any cueing. The intervention as-
appreciate and reinforce students’ efforts in written work sociated with the best performance applied visual cues
if their words are not legible. In their survey of teachers, and memory retrieval; children who received this in-
Graham et al. (2008) found that although teachers pro- tervention improved on 7 of 10 outcome variables, in-
vided struggling students with extra encouragement and cluding legibility and fluency scores. Berninger et al.
extra time to complete writing assignments, they did not hypothesized that visual cues and memory were most
provide adapted strategies to help students resolve the effective because the visual cueing facilitated automaticity
underlying problems affecting handwriting or use specific and writing from memory created an efficient retrieval
techniques to promote their handwriting skills. In a simi- routine. They concluded that handwriting is not just
lar survey, Graham and Harris (2005) found that teachers a motor process; it requires developing memory represen-
tend to adapt writing assignments for struggling stu- tation and memory retrieval so that writing can become
dents by allowing them to give verbal answers or re- automatic.
quiring fewer written responses. These compensatory Graham et al. (2000) also examined the effects of
strategies do not help students improve their hand- supplementary handwriting instruction on the writing
writing legibility. performance of first-grade students who demonstrated
Children who have difficulty with handwriting strug- difficulty in handwriting. Their sample consisted of 36 first-
gle when asked to compose stories. Baker, Gersten, and grade children from 12 classrooms, 14 of whom had a dis-
Graham (2003) found that handwriting is a predictive ability. Half were assigned to handwriting instruction, and
factor in determining the length and quality of compo- half were assigned to a phonological awareness program.
sition. Students who struggle to form letters often have The handwriting instruction consisted of 27 lessons in
difficulty switching their attention between the motor which all the letters were taught. Alphabet practice and
planning for letter formation and the concept or idea that copying sentences quickly were emphasized. The students
they are trying to express (Cahill, 2009). In a study of 600 in handwriting instruction improved more than did the
children in Grades 1–6, Graham, Berninger, Abbott, Abbott, control group on alphabet production, number of cor-
and Whitaker (1997) found that handwriting fluency rect letters, and composition fluency. The gains were
contributed directly to writing fluency. When students do maintained at 6-mo follow-up testing. The Graham
not need to think about their handwriting, they can focus et al. study is important in that it demonstrated the
their cognitive resources on their ideas and their relationship between learning handwriting and learning
knowledge of the subject (Berninger et al., 2006). Thus, to write. Students who received handwriting instruction,
handwriting legibility and speed can affect students’ including those with disabilities, were able to write more
grades across all academic subjects (Cahill, 2009). fluently.
Occupational therapy scholars have also examined the
effects of handwriting interventions on students with
Handwriting Interventions handwriting problems. Jongmans et al. (2003) studied an
Handwriting intervention programs for typical students approach using the principles of motor learning that in-
(Graham, Harris, & Fink, 2000), at-risk students (Berninger cluded students applying handwriting in a meaningful
et al., 1997; Peterson & Nelson, 2003; Weintraub et al., context (e.g., writing a story) and self-evaluating their
2009), and students with disabilities (Jongmans, Linthorst- legibility. In a trial with children with and without poor
Bakker, Westenberg, & Smits-Engelsman, 2003) have handwriting, the intervention group significantly im-
been researched. In a seminal study using at-risk first-grade proved in handwriting quality compared with a control
students (N 5 144), Berninger et al. (1997) demonstrated group, with a strong effect (d 5 1.14) for the children with
that neurodevelopmental training helped students improve poor handwriting. In a randomized experimental design,
the accuracy and legibility of letter formation. This study Peterson and Nelson (2003) examined the effects of
used a tutorial group (24 biweekly sessions) that included a handwriting program on first graders in a school for
experimental warm-up activities followed by handwriting economically disadvantaged children. The intervention
instruction. Five different warm-up interventions were included a 5-min warm-up session of sensorimotor “heavy
applied: (1) motor imitation, in which participants imi- work” activities, a 20-min session of activities to improve
tated someone writing letters; (2) visual cueing, in which motor planning and letter formation, and 5 min of
the participants copied a model that had arrows in- handwriting practice. The students who received in-
dicating the direction of drawing; (3) memory retrieval; tervention improved in legibility more than did the control
(4) visual cues and memory retrieval; and (5) copying group, achieving moderate to strong effects (d 5 0.67).

The American Journal of Occupational Therapy 671

 Denton, Cope, and Moser (2006) compared senso- teachers’ philosophies, and classroom rules. Another ad-
rimotor intervention to motor learning (practice) in- vantage of providing occupational therapy services in the
tervention using a sample of 6- to 11-yr-old children classroom is that the occupational therapist can model for
(N 5 38) who had difficulty with handwriting but did the teachers, suggest interventions that are practical and
not receive special education. The interventions were realistic, and more easily provide services to students at
provided 4 times per week for 5 wk to small groups of risk but not in special education.
2–3 children. The children who received the therapeutic
practice intervention improved significantly more in
legibility than did the children who received sensorimotor Coteaching Models
interventions. One model of inclusive services is the coteaching model.
In a study that partially replicated Graham et al. Coteaching evolved from models of collaborative teaching
(2000), Zwicker and Hadwin (2009) compared the designed to promote full inclusion of children with dis-
effects of a cognitive intervention, a multisensory inter- abilities. It was originally developed as an instructional
vention, and a control group in a randomized trial. approach in which a general educator and a special ed-
Seventy-two students in first and second grade parti- ucator share the teaching responsibility (Cook & Friend,
cipated and were assigned to one of the intervention 1995). In coteaching, the related service provider (e.g.,
groups or a control group. After 10 wk of intervention, occupational therapist) models strategies for the regular
30 min/wk, the groups did not demonstrate any signi- education teacher, allowing the teacher to learn methods
ficant differences from pretest to posttest. Both intervention for adapting and modifying instruction for the children
groups demonstrated a medium effect (ds 5 0.48–0.51) with special needs. Typically, in coteaching the related
when compared with the control group. The intervention service provider is responsible for modifying the in-
may not have been of sufficient intensity to show a strong struction and monitoring student progress, and the gen-
effect. eral education teacher is responsible for the content of the
In a randomized controlled trial, Weintraub et al. instruction (Weiss & Brigham, 2000). Cook and Friend
(2009) compared an intervention emphasizing executive (1995) defined five variations of coteaching: (1) one
functions with one emphasizing sensorimotor activities. teaching and one assisting, (2) station teaching, (3) par-
Children in general education were assigned to a sen- allel teaching, (4) alternative teaching, and (5) team
sorimotor group, a task-oriented (executive functions) teaching. Our program used station teaching, in which
group, or a control group. Both groups used mnemonics the class is divided into groups and students move
to help the children remember letter formation, self- through stations, each led by an occupational therapist or
evaluate their work, and transfer learning through writing a teacher. We also used team teaching, in which the oc-
practice in the classroom. Both the sensorimotor and the cupational therapist led the handwriting instruction and
task-oriented intervention groups had better overall the teacher led the writing applications, and all adults
legibility than the control group, and both groups im- supported individual student performance.
proved significantly in legibility and letter formation. Key elements of coteaching include a common
On the basis of these studies, what handwriting in- planning time, defined roles and responsibilities, high-
tervention is most beneficial and which children benefit level communication skills, and administrative support
from handwriting programs are not clear. Most of the (Arguelles, Hughes, & Schumm, 2000). In a synthesis of
interventions were applied to small groups of children qualitative research studies, Scruggs, Mastropieri, and
outside the classroom. Interventions outside the classroom McDuffie (2007) identified attributes and resources that
may lack alignment with the curriculum, and students special education and general education teachers need to
may not transfer newly learned skills into classroom ac- succeed in coteaching. One common theme from the
tivities. Classroom-embedded occupational therapy pro- studies was that teachers need administrative support,
grams have been developed. Bazyk et al. (2009) evaluated planning time, and training. In particular, planning to-
the fine motor and emergent literacy outcomes of in- gether is essential to coordinating teaching styles and
tegrated occupational therapy services for kindergartners goals. Although coteaching may seem to require more
with and without disabilities. This model follows the time, the benefits to students can outweigh the cost.
current emphasis on inclusive services and may be a more Students generally receive more individualized attention
efficacious model for handwriting interventions (e.g., and benefit from having the input of two teachers.
Graham et al., 2000). Inclusive models allow the occu- In addition, teachers learn new skills from the occupa-
pational therapist to align services with the curriculum, tional therapists (Scruggs et al., 2007). Flexibility and

672 November/December 2011, Volume 65, Number 6

adaptability of the teacher and occupational therapist are gram and that the teacher be willing to implement the
important. program. We also recruited an intervention specialist to
Coteaching models have not yet been extensively participate in the program.
researched. Murawski and Swanson (2001) completed
a meta-analysis in which they synthesized six studies of Intervention
coteaching. Most effect sizes were moderate (mean [M] 5 The Write Start program included twenty-four 45-min
0.40). These authors and others (e.g., Kloo & Zigmond, sessions that were implemented twice a week for 12 wk.
2008; Volonino & Zigmond, 2007) concluded that ad- The program was developed by occupational therapists
ditional studies of coteaching are needed. and educators with the explicit goals of preventing
Given that both occupational therapists and teachers handwriting problems and promoting fluent writing in
have expertise in handwriting and writing, with an em- students of all ability levels. The six core elements of the
phasis on different aspects of the skills, coteaching a Write Start Program were as follows:
handwriting intervention program may be an effective 1. Each session was planned and implemented by a co-
way to enhance students’ handwriting and writing skills. teaching team of two teachers and an occupational
Using the skills of an occupational therapist to provide therapist.
a handwriting program that is integrated into the class- 2. The teachers and therapist modeled letter formation
room may provide benefits to students who struggle with and provided simple, consistent verbal cues for letter
handwriting but are not eligible for direct occupational formation.
therapy services. A coteaching model involving occupa- 3. The students copied from the model and engaged in
tional therapists and teachers can provide comprehensive repeated practice.
instruction, allow emphasis on handwriting within the 4. The students were placed in groups of 6–7 that rotated
writing curriculum, and enable students to link hand- through stations emphasizing complementary aspects
writing skills to writing and composition. of handwriting and writing.
5. The teachers and therapist provided frequent feedback
Purpose that included correcting errors, encouraging self-
evaluation, and praising the students’ efforts.
The purpose of this study was to develop and pilot test an 6. The team monitored and assessed students’ perfor-
integrated handwriting program, Write Start, for first- mance to guide their selection of handwriting instruc-
grade students. Specific research questions were tional strategies.
1. Can a cotaught, classroom-embedded handwriting pro- Each week, the teachers and occupational therapist
gram be implemented for 12 wk with high fidelity? met to plan that week’s handwriting–writing sessions.
2. What effect does the program have on students’ legi- These planning sessions began with a review of the stu-
bility and writing fluency? dents’ progress using handwriting samples from the pre-
3. Are the handwriting and writing skills developed dur- vious week. Individual and overall class performance
ing the Write Start program maintained at 6-mo from the previous week was used to select the strategies
follow-up? and emphasis for the next week, including adaptations
and supports for individual students. Two to three letters
Method were taught each week, and a developmental writing
curriculum was followed.
Research Design The first and second sessions had a specific format that
We used a single-group pretest–posttest design with time was followed each week. In Session 1, the occupational
as the independent variable. The participants were mea- therapist instructed the students in two to three letters, and
sured before and after intervention and at 6-mo follow- the students practiced each repeatedly. The teachers and
up. The study protocol was approved by the appropriate therapists provided specific descriptive feedback during this
institutional review board of the Ohio State University practice. Then the students rotated in small groups, each
Office of Responsible Research Practices. focused on activities that emphasized (1) motor planning,
kinesthetic input, and manipulation; (2) visual–motor in-
Participant Selection tegration; and (3) cognitive strategies for learning hand-
One first-grade class in a Midwest suburban school par- writing. Most of the activities focused on letters and used
ticipated in the study. Inclusion criteria were that the class multisensory strategies for learning letter formation. In
have ³2 students with an individualized education pro- Session 2, the therapist reviewed the letters that were

The American Journal of Occupational Therapy 673

taught in Session 1, and the students copied a sentence as 8,782 participants. Reliability for the Writing Fluency and
a writing sample, rotated through two small-group activ- Writing Samples subtests was .89 in a sample of 6-yr-olds.
ities, and then spent 20–30 min writing stories or writing In the Writing Fluency subtest, students were in-
an assignment. This final period of Session 2 was called structed to compose sentences from three words written
the “writing workshop.” The teacher emphasized good beside a picture. The test requires minimal idea generation
handwriting during the writing workshop using the con- but requires the child to link words in a complete sentence
sistent terms introduced to the students during the hand- under a time constraint. Students who did not produce
writing instruction. A manual was developed for the three grammatical sentences within 2 min were told to stop.
program, including core principles, session and intervention Those who produced three grammatical sentences were
descriptions, and activity instructions. allowed to continue for 7 min. One point was awarded for
each grammatical sentence using all the written words
Measures without modification. In the Writing Samples subtest, the
A fidelity measure developed from the core principles student wrote a meaningful sentence for a given purpose (a
defined expected therapist and teacher behaviors and child picture). The test requires retrieval of word meaning and
responses. The fidelity instrument was trialed in three syntactic information. We used raw scores in the analysis.
sessions and then revised. Using the finalized measure, The students were evaluated 3 times: (1) at baseline,
authors Case-Smith and Bishop independently rated in- (2) the week after the program ended, and (3) 6 mo after the
tervention fidelity for the same five sessions with 90% program ended. Author Bishop evaluated them individually
agreement. After this reliability check, Bishop or Case- in a quiet space. The tests were scored with the evaluator
Smith rated fidelity during the sessions 16 times (6 times blinded to whether they were pretests or posttests; all of the
for Session 1 and 10 times for Session 2). follow-up tests were scored at a later time.
Handwriting legibility and speed were assessed using
the Evaluation Tool of Children’s Handwriting–Manuscript Data Analysis
(ETCH–M; Amundson, 1995) and the Minnesota
We calculated summary scores, percentage scores, or both
Handwriting Assessment (MHA; Reisman, 1993, 1999).
for each subtest of the ETCH–M, MHA, and WJIII
The following ETCH–M sections were administered:
measures and entered them into the SPSS version 18.0
lowercase alphabet writing, near-point copying, far-point
database (SPSS, Inc., Chicago). Means and standard de-
copying, and dictation. We computed percentage scores
viations were computed. We used a general linear model
on the basis of number of legible letters or numbers.
to investigate within-subject effects for the three mea-
Speed scores from the letters were used in the analysis.
surement times and calculated post hoc t tests to examine
The ETCH–M demonstrated fair test–retest reliability for
differences in the measures for each time period. Bon-
letter legibility (r 5 .77) and word legibility (r 5 .71)
ferroni corrections were used to estimate significance in
when first- and second-grade students were tested 1 wk
paired differences for the three measurement times;
apart (Diekema, Deitz, & Amundson, 1998). Feder,
therefore, the a priori a level was p £ .017. Effect sizes
Majnemer, Bourbonnais, Blayney, and Morin (2007)
were calculated to estimate the program effect using
examined the validity of the ETCH–M and found that
pretest and follow-up measures.
teachers’ rating of handwriting correlated with ETCH–M
scores. The MHA measures legibility and speed on the
basis of a single sample in which students write a sentence Results
that contains all letters of the alphabet. The maximum Nineteen students (8 girls and 11 boys; M age 5 77.5 mo,
score is 34, and the rate is computed as the number of standard deviation [SD] 5 6.0, range 5 68–86 mo) com-
letters completed in 2.5 min. Test–retest reliability in pleted the program. Two of the students received special
a sample of 69 first-grade children was .72 for legibility education services; 1 received occupational therapy and
and .50 for rate (speed). No validity studies of the MHA speech–language pathology services. One student was on
have been published (Feder & Majnemer, 2003). a response-to-intervention program in which she received
We measured writing performance using the Writ- intervention specialist services. One student received free
ing Fluency and Writing Samples subtests from the lunch. Students were African-American (n 5 1), Asian (n 5
Woodcock–Johnson Tests of Achievement, 3rd edition 3), and White (n 5 12). Two students missed one of the
(WJIII; Woodcock, McGrew, & Mather, 2007). The testing sessions (1 girl’s dominant hand was casted at the
WJIII is a well-used, well-developed test of academic time of the pretest, and 1 boy was absent for posttesting);
achievement that was recently renormed on a sample of therefore, although all 19 participated, we obtained complete

674 November/December 2011, Volume 65, Number 6

data on 17 students. Attendance was recorded, and 85%– therapist–teacher team implemented the program with
100% of the students were present at each session. high fidelity (93% sampling for 16 of 24 sessions); this
fidelity suggests that the procedures can be consistently
Fidelity Measure implemented with first-grade students. In addition, the
The fidelity of the program was high, supporting the Write students were engaged, followed the instructions, dem-
Start program’s feasibility. Therapists and teachers dem- onstrated focused writing practice, and responded to the
onstrated from 93% to 94% fidelity (M % 5 93.5, SD 5 therapist’s and teachers’ feedback. The high fidelity of
10) for individual sessions, meaning that they correctly students’ responses (i.e., students demonstrated the ex-
and consistently followed the principles and procedures pected response 88% of the time for the 16 sessions) is
almost 94% of the time. The students’ engagement and somewhat surprising because their initial handwriting
responsiveness were also measured as a complementary skills varied widely. The handwriting instruction ap-
component of treatment fidelity. Students responded to peared to be sufficiently interesting and motivating to
the instruction and were engaged in handwriting or consistently engage most of the students.
writing tasks 83%–93% of the time (M % 5 88, SD 5 The students made large gains in handwriting legibility
9.5) across the 16 fidelity measures. that were maintained through the end of the school year.
During the 12-wk period, the students’ legibility on the
Handwriting and Writing Performance ETCH–M progressed from a mean of 62% to 87%
(change score 5 25%). The M score (87%) at the end of
The Ms and SDs for assessments at the three measure-
the Write Start program is considered to indicate legible
ment times are presented in Table 1. The general linear
handwriting that one can read without effort. This level of
model indicated that both a linear and a quadratic model
legibility was maintained 6 mo later. They also made
were highly significant (suggesting that progress leveled
substantial improvements in handwriting speed and re-
after the program ended). The linear significance and
duced the time required to write the alphabet from >3.0 min
t-test results are given in Table 2 with estimated effect
to 1.5 min. This increase in handwriting speed suggests
sizes for pretest-to-follow-up testing. We used Bonferroni
that students became much more efficient in handwriting.
correction to determine significance between testing
The writing fluency scores continued to increase through-
times. The students made significant gains in handwriting
out the year, and students made highly significant gains
legibility and speed and in writing fluency and samples
during the program that continued after its end.
from pretest to posttest. Handwriting legibility and speed
Although inclusive models for intervention ser-
scores were maintained, and writing fluency scores con-
vices are advocated, the research on cotaught, classroom-
tinued to improve 6 mo after the intervention ended.
embedded interventions is minimal (Bayzk et al., 2009;
Mastropieri et al., 2005; Scruggs et al., 2007; Volonino
Discussion & Zigmond, 2007). The Write Start program is a pre-
We examined the feasibility of a cotaught classroom- ventative intervention in which an occupational therapist
embedded handwriting intervention. The occupational and teachers team to provide handwriting and writing

Table 1. Means and Standard Deviations for Pretest, Posttest, and Follow-Up Measures (N 5 17)
Variable Pretest M (SD) Posttest M (SD) Follow-Up M (SD)
ETCH–M
Lowercase letters, % legible 60.8 (25.0) 87.7 (11.5) 86.8 (11.2)
Lowercase letters, s 201.8 (94.6) 96.2 (34.0) 83.5 (35.8)
Near copy, % legible 83.9 (13.3) 94.1 (8.0) 94.8 (8.8)
Far copy, % legible 81.7 (14.8) 90.4 (9.1) 91.5 (9.1)
Dictation, % legible 52.4 (25.1) 79.4 (20.4) 80.0 (19.0)
Total % legible 65.5 (19.3) 87.1 (10.1) 88.0 (10.1)
Minnesota Handwriting Assessment
Rate, no. letters in 2.5 min 22.2 (7.1) 32.0 (3.9) 33.2 (0.2)
Legibility, no. legible letters 29.2 (4.3) 31.7 (2.2) 32.0 (2.3)
Woodcock–Johnson Tests of Achievement
Fluency 0.9 (0.8) 4.5 (4.5) 6.9 (5.5)
Writing samples 7.7 (2.7) 14.8 (4.6) 16.7 (3.6)
Note. ETCH–M 5 Evaluation Tool of Children’s Handwriting–Manuscript; M 5 mean; SD 5 standard deviation.

The American Journal of Occupational Therapy 675

Table 2. General Linear Model With Post Hoc t-Test Results (N 5 17)
Within-Subjects Pretest to Posttest Posttest to Follow-Up Pretest to Follow-Up Pretest to Follow-Up
Variable F (p) t (p) t (p) t (p) Effect Size (Cohen’s d)
ETCH–M
Lowercase letters, % legible 21.46 (<.001) 24.92 (<.001) 0.52 (0.614) 24.98 (<.001) 1.40
Lowercase letters, s 26.00 (<.001) 5.09 (<.001) 1.90 (0.080) 5.24 (<.001) 1.80
Near copy, % legible 13.00 (<.001) 23.35 (.004) 20.95 (0.355) 27.06 (<.001) 0.99
Far copy, % legible 8.70 (.001) 23.33 (.004) 20.58 (0.572) 23.77 (.002) 0.82
Dictation, % legible 14.69 (<.001) 24.67 (<.001) 0.00 (1.000) 24.17 (.001) 1.25
Total % legible 32.23 (<.001) 25.48 (<.001) 20.76 (0.460) 26.79 (<.001) 1.53
Minnesota Handwriting
Assessment
Rate, no. letters in 2.5 min 32.07 (<.001) 24.40 (<.001) 21.46 (0.164) 25.73 (<.001) 2.37
Legibility, no. legible letters 6.37 (.005) 22.50 (.024) 20.59 (0.564) 23.67 (.002) 0.85
Woodcock–Johnson Tests of
Achievement
Fluency 13.95 (<.001) 23.53 (.003) 22.05 (0.059) 24.84 (<.001) 2.19
Writing samples 82.44 (<.001) 210.35 (<.001) 22.40 (0.029) 213.63 (<.001) 2.86
Note. ETCH–M 5 Evaluation Tool of Children’s Handwriting–Manuscript. For all F and t tests, df 5 16. With Bonferroni correction applied, p £ .017 is significant.

instruction. Writing activities and story composition fol- that were applied, including specific instruction in letter
lowed the handwriting practice. By monitoring and re- formation, extended practice at each session, activities to
inforcing students in small groups, this team guided correct promote underlying motor learning and visual–motor
letter formation and emphasized the importance of good skill, student self-evaluation, frequent visual cueing, and
handwriting when composing stories or writing assignments. monitoring of performance with immediate feedback.
The study’s findings offer some support to Berninger’s
hypothesis that automatic, legible handwriting allows Limitations
fluent writing and enables more advanced composition
(Berninger et al., 1997). Although participants’ hand- Because this was a pilot study, the sample was small and
writing and writing skills improved significantly, a more limited in diversity. In addition, a ceiling effect on the
rigorous study design with a control group and a larger ETCH–M and the MHA may have limited the amount
sample are necessary to test how and to what degree these of gain in handwriting legibility that the students could
skills are linked. demonstrate. Without a control group, only limited con-
The gain scores for our participants were greater than clusions about the Write Start program effects can be
those in comparable studies (e.g., Denton et al., 2006). For made. Although the students made significant progress
example, students who completed the Write Start pro- when pretest and posttest scores were compared, the
gram gained 25% on the ETCH–M compared with degree to which maturation and the first-grade curricu-
participants in the handwriting program researched by lum accounted for student progress is unknown.
Zwicker and Hadwin (2009), who gained 15%–20% on
the ETCH–M. The coteaching model, in which three Conclusion
adults with common goals contributed to instruction, Write Start is a classroom-embedded, cotaught hand-
monitoring, and reinforcement, may account for the writing program for first-grade students that can be
students’ gains. The positive results may relate to the implemented with high fidelity by a trained occupational
model of service delivery in which occupational therapy therapist and teachers. Students who participated in the
services were integrated into the classroom and the cur- 12-wk program made highly significant gains in hand-
riculum (Case-Smith & Holland, 2009). The occupa- writing legibility and speed and writing fluency. Trials
tional therapist provided tools for students to use, with a control group are needed to further investigate the
consistency in how handwriting was taught, and methods effects of the Write Start program. s
to reinforce students’ learning. A third reason may be the
direct linkage of handwriting to writing so that students
had a meaningful context for learning handwriting and Acknowledgments
gained an understanding of the importance of legibility. A This research was funded by the U.S. Department of Ed-
fourth reason may have been the evidence-based strategies ucation, Institute for Educational Sciences (R324A090004,

676 November/December 2011, Volume 65, Number 6

2009–2012). We acknowledge the contributions of Nate program. Physical and Occupational Therapy in Pediatrics,
Kelly and Sandy Odenweller in implementing the project 27, 43–62.
and of David Bloome and Alison Lane in conceptualizing Graham, S., Berninger, V., Abbott, R., Abbott, S., &
Whitaker, D. (1997). The role of mechanics in com-
the project. In addition, we thank the parents and chil-
posing of elementary school students: A new methodo-
dren and the Dublin City Schools administrators for their
logical approach. Journal of Educational Psychology, 89,
willingness to participate in the project. 170–182.
Graham, S., & Harris, K. R. (2005). Improving the writing
References performance of young struggling writers: Theoretical and
programmatic research from the Center on Accelerating
Amundson, S. J. (1995). Evaluation Tool of Children’s Hand-
Student Learning. Journal of Special Education, 39, 19–33.
writing. Homer, AK: OT Kids.
Arguelles, M. E., Hughes, M. T., & Schumm, J. S. (2000). doi: 10.1177/00224669050390010301
Co-teaching: A different approach to inclusion. Principal, Graham, S., Harris, K. R., & Fink, B. (2000). Is handwriting
79, 50–51. causally related to learning to write? Treatment of handwrit-
Baker, S., Gersten, R., & Graham, S. (2003). Teaching ex- ing problems in beginning writers. Journal of Educational
pressive writing to children with learning disabilities: Psychology, 92, 620–633. doi: 10.1037/0022-0663.92.4.
Research-based applications and examples. Journal of 620
Learning Disabilities, 36, 109–123. Graham, S., Harris, K. R., Mason, L., Fink-Chorzempa, B.,
Bazyk, S., Michaud, P., Goodman, G., Papp, P., Hawkins, E., Moran, S., & Saddler, B. (2008). How do primary grade
& Welch, M. A. (2009). Integrating occupational therapy teachers teach handwriting? A national survey. Reading
services in a kindergarten curriculum: A look at the out- and Writing, 21, 49–69. doi: 10.1007/s11145-007-
comes. American Journal of Occupational Therapy, 63, 9064-z
160–171. doi: 10.5014/ajot.63.2.160 Graham, S., & Weintraub, N. (1996). A review of handwriting
Berninger, V., Rutberg, J., Abbott, R., Garcia, N., Anderson research: Progress and prospects from 1980 to 1994. Ed-
Youngstrom, M., Brooks, A., et al. (2006). Tier 1 and Tier ucational Psychology Review, 8, 7–87. doi: 10.1007/
2 early intervention for handwriting and composing. Jour- BF01761831
nal of School Psychology, 44, 3–30. Jongmans, M. J., Linthorst-Bakker, E., Westenberg, Y., &
Berninger, V. W., Vaughan, K. B., Abbott, R. D., Abbott, Smits-Engelsman, B. C. M. (2003). Use of a task-oriented
S. P., Rogan, L. W., Brooks, A., et al. (1997). Treatment self-instruction method to support children in primary
of handwriting problems in beginning writers: Transfer school with poor handwriting quality and speed. Human
from handwriting to composition. Journal of Educational Movement Science, 22, 549–566. doi: 10.1016/[Link].
Psychology, 89, 652–666. doi: 10.1037/0022-0663.89.4. 2003.09.009
652 Kloo, A., & Zigmond, N. (2008). Co-teaching revisited: Re-
Cahill, S. M. (2009). Where does handwriting fit in? Interven- drawing the blueprint. Preventing School Failure: Alterna-
tion in School and Clinic, 44, 223–228. doi: 10.1177/ tive Education for Children and Youth, 52, 12–20. doi:
1053451208328826 10.3200/PSFL.52.2.12-20
Case-Smith, J., & Holland, T. (2009). Making decisions about Mastropieri, M. A., Scruggs, T. E., Graetz, J., Norland, J.,
service delivery in early childhood programs. Language,
Gardizi, W., & McDuffie, K. (2005). Case studies in
Speech, and Hearing Services in Schools, 40, 416–423.
co-teaching in the content areas: Successes, failures, and
doi: 10.1044/0161-1461(2009/08-0023)
challenges. Intervention in School and Clinic, 40, 260–270.
Cook, L., & Friend, M. (1995). Co-teaching: Guidelines for
doi: 10.1177/10534512050400050201
creating effective practices. Focus on Exceptional Children,
Murawski, W. W., & Swanson, H. L. (2001). A meta-analysis
28(3), 1–16.
Denton, P. L., Cope, S., & Moser, C. (2006). The effects of of the co-teaching research: Where are the data? Remedial
sensorimotor-based intervention versus therapeutic prac- and Special Education, 22, 258–267. doi: 10.1177/
tice on improving handwriting performance in 6- to 074193250102200501
11-year-old children. American Journal of Occupational Peterson, C. Q., & Nelson, D. L. (2003). Effect of an occu-
Therapy, 60, 16–27. doi: 10.5014/ajot.60.1.16 pational intervention on printing in children with eco-
Diekema, S. M., Deitz, J., & Amundson, S. J. (1998). Test– nomic disadvantages. American Journal of Occupational
retest reliability of the Evaluation Tool of Children’s Therapy, 57, 152–160. doi: 10.5014/ajot.57.2.152
Handwriting–Manuscript. American Journal of Occupa- Reisman, J. (1993). Development and reliability of the research
tional Therapy, 52, 248–255. doi: 10.5014/ajot.64.1.37 version of the Minnesota Handwriting Test. Physical and
Feder, K. P., & Majnemer, A. (2003). Children’s handwriting Occupational Therapy in Pediatrics, 13, 41–55.
evaluation tools and their psychometric properties. Physi- Reisman, J. (1999). Minnesota Handwriting Assessment. San
cal and Occupational Therapy in Pediatrics, 23, 65–84. Antonio, TX: Psychological Corporation.
Feder, K. P., Majnemer, A., Bourbonnais, D., Blayney, M., & Scruggs, T. E., Mastropieri, M. A., & McDuffie, K. A. (2007).
Morin, I. (2007). Handwriting performance on the Co-teaching in inclusive classrooms: A metasynthesis of
ETCH–M of students in a grade one regular education qualitative research. Exceptional Children, 73, 392–416.

The American Journal of Occupational Therapy 677

Volonino, V., & Zigmond, N. (2007). Promoting research- support? In T. E. Scruggs & M. A. Mastropieri (Eds.),
based practices through inclusion. Theory Into Practice, Educational interventions: Advances in learning and behav-
46, 291–300. doi: 10.1080/00405840701593873 ioral disabilities (Vol. 14, pp. 217–245). Stamford, CT:
Weintraub, N., Yinon, M., Hirsch, I. B.-E., & Parush, S. JAI Press.
(2009). Effectiveness of sensorimotor and task-oriented Woodcock, R. W., McGrew, K., & Mather, N. (2007).
handwriting intervention in elementary school-aged stu- Woodcock–Johnson III Tests of Achievement. Rolling Meadows,
dents with handwriting difficulties. OTJR: Occupation, IL: Riverside.
Participation and Health, 29, 125–134. doi: 10.3928/ Zwicker, J. G., & Hadwin, A. F. (2009). Cognitive versus mul-
15394492-20090611-05 tisensory approaches to handwriting intervention: A random-
Weiss, M. P., & Brigham, F. J. (2000). Co-teaching and the ized controlled trial. OTJR: Occupation, Participation and
model of shared responsibility: What does the research Health, 29, 40–48. doi: 10.3928/15394492-20090101-06

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