Canadian Journal of Occupational

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A Systematic Review of Interventions to Improve Handwriting

Monica M. P. Hoy, Mary Y. Egan and Katya P. Feder
Canadian Journal of Occupational Therapy 2011 78: 13
DOI: 10.2182/cjot.2011.78.1.3

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A systematic review of interventions to improve handwriting
Monica M. P. Hoy, Mary Y. Egan, Katya P. Feder
Key words
Handwriting
Pediatric occupational therapy
Schools, elementary
Mots clés
Écoles, élémentaires
Écriture
Ergothérapie en pédiatrie
Monica M. P. Hoy, MScS, OT Reg. (Ont.)
is Occupational Therapist, Five Coun-
ties Children’s Centre, 9 Russell St. East,
Lindsay, ON K9V 1Z7.
Mary Y. Egan, PhD, OT Reg. (Ont.) is
Associate Professor, School of Rehabilita-
tion Sciences, University of Ottawa,
451 Smyth Rd., Ottawa, ON K1H 8M5.
Telephone 613-562-5800, ext 8043.
E-mail: megan@uottawa.ca
Katya P. Feder, PhD, OT Reg. (Ont.)
is Postdoctoral Fellow, University of
Montreal and Adjunct Professor, School
of Rehabilitation Sciences, University of
Ottawa, 451 Smyth Rd., Ottawa, ON
K1H 8M5.
T
Citation: Hoy, M. M. P., Egan, M. Y., &
Feder, K. P. (2011). A systematic review of
interventions to improve handwriting.
Canadian Journal of Occupational Therapy,
78, 13-25. doi: 10.2182/cjot.2011.78.1.3
Submitted: 17 March 2010;
Final acceptance: 23 July 2010.
This study was funded by a grant from
the Canadian Occupational Therapy
Foundation.
Downloaded from cjo.sagepub.com at UNIVERSITE DE MONTREAL on November 16, 2014
© CAOT PUBLICATIONS ACE
Abstract
Background. Handwriting difficulties are among the most common reasons for re-
ferral of children to occupational therapy. Purpose. To determine the effectiveness
of handwriting interventions. Methods. A systematic review was carried out. Includ-
ed studies were randomized or nonrandomized controlled trials of interventions that
could be used by an occupational therapist to improve written output (printing or
writing) among school-aged children identified as having difficulties with handwrit-
ing. Electronic searches of relevant databases were conducted up to January 2010.
Findings. Eleven studies met the inclusion criteria. These studies tested (1) relaxation
and practice with or without EMG, (2) sensory-based training without handwriting
practice, and (3) handwriting-based practice (including sensory-focused or cognitive
focused handwriting practice). Regardless of treatment type, interventions that did
not include handwriting practice and those that included less than 20 practice ses-
sions were ineffective. Implications. Effective occupational therapy for improving
handwriting must include adequate handwriting practice.
Résumé
Description. Les troubles de l’écriture comptent parmi les raisons les plus courantes
pour aiguiller un enfant vers des services d’ergothérapie. But. Déterminer l’efficacité
des interventions visant à améliorer l’écriture. Méthodologie. Revue systématique
des essais cliniques randomisés et non randomisés portant sur des interventions
pouvant être utilisées par un ergothérapeute en vue d’améliorer la productivité écrite
(documents imprimés ou écrits à la main) chez des enfants d’âge scolaire ayant de
la difficulté à écrire. Des recherches électroniques dans des bases de données perti-
nentes ont été effectuées jusqu’en janvier 2010. Résultats. Onze études répondaient
aux critères d’inclusion. Ces études évaluaient : 1) des séances de relaxation et de
l’entraînement à l’écriture avec ou sans EMG, (2) un entraînement sensoriel sans
exercice d’écriture, et (3) de l’entraînement à l’écriture (y compris de l’entraînement
à l’écriture axé sur des aspects sensoriels ou cognitifs). Les interventions qui ne
faisaient pas appel à de l’entraînement à l’écriture et celles qui comprenaient moins
de 29 séances d’exercices ont été inefficaces, et cela, peu importe le type de traite-
ment utilisé. Conséquences. Pour être efficaces, les interventions ergothérapiques
visant à améliorer l’écriture doivent comprendre des exercices d’écriture.
he Canadian Association of Occupational Therapists (2007) defines occu-
pational therapy as “the art and science of enabling engagement in everyday
living, through occupation” (p. 20). In the lives of children, school provides
a context for engagement in a variety of occupations. Independent functioning at
school generally requires an effective method of producing written output (Case-
Smith, 2005).
Many academic activities require children to put their thoughts to paper either
in the form of printing or cursive writing. As much as 30 to 60% of a child’s school
day is comprised of fine-motor activities, with handwriting tasks accounting for
the majority of this time (McHale & Cermak, 1992 as cited in Peterson and Nel-
son, 2003). Handwriting has been described as a “complex perceptual-motor skill
Canadian Journal of Occupational Therapy February 2011 78(1) 13
Hoy et al.
encompassing a blend of visual-motor coordination abilities,
motor planning, cognitive, and perceptual skills, as well as tac-
tile and kinaesthetic sensitivities” (Feder & Majnemer, 2007, p.
313). An estimated 10 to 30% of school-aged children experi-
ence handwriting difficulties (Karlsdottir & Stefansson, 2002).
Children with handwriting difficulties often require more
time to complete assignments, which affects their academic
performance (Berninger, Mizokawa, & Bragg, 1991). Com-
position is affected by handwriting difficulties; children may
run into increasing difficulties as they progress in school and,
due to handwriting problems, shy away from expressing what
they know (Medwell & Wray, 2008). When students demon-
strate poor handwriting legibility, and classroom efforts to
improve legibility do not result in substantial change, teachers
frequently refer students to occupational therapy (Hammer-
schmidt & Sudsawad, 2004). In fact, handwriting remediation
is one of the most common reasons for referral of school-aged
children to occupational therapy (Feder, Majnemer, & Synnes,
2000).
Occupational therapists offer a variety of services to
improve handwriting. Therapy may be provided to the child,
or consultation may be provided to the teacher (Cramm, Pol-
lock, Dennis, Subramaniam, & Carkner, 2009; Hutton, 2009).
In addition, the approach taken may focus on remediat-
ing potential causes of handwriting problems (e.g., impaired
kinaesthesia), or concentrate on the activity of handwriting
itself (Sugden & Chambers, 1998). While different theoretical
approaches to handwriting intervention are recognized, Feder
and her colleagues (Feder et al., 2000) found that therapists
surveyed from across Canada reported using an “eclectic” ori-
entation that included sensorimotor (90%), perceptual-motor
(74%), motor-learning (68%), cognitive training (64%), bio-
mechanical (64%), sensory integrative (50%), and neurode-
velopmental (42%) approaches. A survey of occupational
therapists’ interventions in the United States demonstrated a
similar diversity of approaches (Woodward & Swinth, 2002).
In a review of the literature, Bonney (1992) suggested
that occupational therapists must be aware of “the body of
knowledge on handwriting performance and intervention”
(p. 7) in order to provide occupational therapy appropriate
for each child’s unique difficulties, and urged that systematic
investigation be undertaken to examine the area of hand-
writing assessment and intervention (p. 14). Feder, Racine,
and Majnemer (2008) carried out a narrative review of the
evidence and concluded that “many of the studies reviewed
reported that handwriting intervention resulted in significant
gains for most children, regardless of the treatment duration or
approach used” (p. E69). The objective of the current study was
to systematically review the effectiveness of interventions that
occupational therapists may use for children with handwriting
difficulties to both update and better quantify the conclusions
from this narrative review.
Methods
In a systematic review of effectiveness, such as the one reported
here, one methodically locates and examines, using explicitly
defined criteria, the results of research regarding the effective-
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14 Revue canadienne d’ergothérapie février 2011 78(1)
ness of a particular intervention, with regards to one or more
specific outcomes. Such a review provides a synthesis of the best
evidence regarding treatment effectiveness (Elwood, 2007).
This systematic review included studies that were ran-
domized or nonrandomized controlled trials of interventions
that could be used by an occupational therapist to improve
written output (printing or writing) among school-aged chil-
dren identified as having difficulties with handwriting. Stud-
ies were excluded from this review if they did not include a
control group, addressed the effectiveness of interventions that
would not be used by an occupational therapist (e.g., medica-
tion), examined interventions designed to improve typewrit-
ten or computer-generated output, or included children who
did not demonstrate problems with written output. As well,
studies were excluded if they were published in a language
other than French or English.
Electronic searches were conducted up to July 2008 and
then updated in January 2010 using the following well-rec-
ognized sources: MEDLINE from 1950, CINAHL from 1982,
Cochrane CENTRAL, Education Abstracts at Scholar’s Portal,
Education: A SAGE Full-Text Collection, Educational Admin-
istration Abstracts, EMBASE from 1980, ERIC (education
database), PsycINFO from 1806, and SPECTRE (Campbell
Collaboration). Search terms were identified by a reference
librarian with extensive experience in systematic reviews and
are available upon request from the authors.
Search results were independently examined by two of
the authors (MH and ME). Articles were retrieved if either
reviewer deemed that the title or abstract indicated that the
article might describe the results of a study that met the inclu-
sion criteria. Retrieved articles were reviewed for inclusion by
both of these authors and decisions regarding inclusion were
made by consensus. The first author (MH) then extracted the
following information: type of design, number of participants
in each group, age and gender of participants, details regard-
ing the intervention (procedure, frequency, duration), out-
come measures and post-test results. This information was
verified by the second author (ME). Following this, extracted
data were entered into RevMan version 5 (Review Manager,
2008), which was then used to calculate standardized effect
sizes of the mean difference between the post-test scores of the
treatment and control groups (Cohen’s d) and 95% confidence
intervals. Finally, to examine study quality, risk of bias was
evaluated by assessing the adequacy of sequence generation,
allocation concealment, whether the study was free of selective
reporting, and whether the assessor was masked (Higgins &
Green, 2009).
Results
From the original search, 296 studies were identified. Of
these studies, 34 were retrieved for review, and 25 were later
excluded. The updated search produced 24 articles, of which 2
were retrieved for review and included. Studies were most often
excluded on the basis of methodology, specifically absence of a
nontreatment control group (Table 1).
Of the 11 included trials, 9 were randomized controlled
trials (including 1 randomized cluster trial) and 2 were non-
 Table 1
Excluded Studies

Reason For Exclusion

Study (Author, Year) Data Inadequate No Non-treat- Single-subject Children without No handwriting Medication- Computer-
to allow use ment Control design handwriting dif- outcome based based
ficulties included intervention intervention

Baroody & Kaufman (1993) X

Burkhalter & Wright (2002) X
Christensen (2004) X X X
Chwirka, Gurney, & Burtner (2002) X X
Graham, Harris, & Fink (2000) X
Hall & Case-Smith (2007) X
Handley-More, Deitz,
Billingsley, & Coggins (2003) X X
Harris & Livesey (1992) X
Hartley & Salzwedel (1980) X
Hirsh & Niedermeyer (1973) X
Karlsdottir (1996)
Krzesni (1971) X
Lerer, Lerer, & Artner (1977) X
Maybee (1988) X
McFadden (1998) X
McGarrigle & Nelson (2006) X
Peterson & Nelson (2003) X
Ratzon, Efraim, & Bart (2007) X

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Roberts & Samuels (1993) X
Schilling, Washington, Billingsley, & Deitz (2003) X
Shen, Kang, & Wu (2003) X
Ste-Marie, Clark, Findlay, & Latimer (2004) X
Tallal, Chase, Russell, & Schmitt (1986) X
Tam, Reid, Naumann, & O’Keefe (2002) X X
Tucha & Lange (2005) X

Canadian Journal of Occupational Therapy February 2011 78(1) 15

Hoy et al.
 Table 2
Included Studies—Description
Study Design Treatment
Berninger et RCT
16 Revue canadienne d’ergothérapie
al. (2006) (cluster)
février 2011
78(1)
Berninger et RCT
al. (1997)
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Carter & Russell RCT
(1985)
Sample
N
Age/
Grade
% Boys
Experimental Group
53 81 Gr. 4
Control Group
41 71 Gr. 4
Total % boys: 76
Exp. (Motor Imitation)
24 U Gr. 1
Exp. (Visual Cue)
24 U Gr. 1
Exp. (Memory)
24 U Gr. 1
Exp. (Visual Cue + Memory)
24 U Gr. 1
Exp. (Copy)
24 U Gr. 1
Control (Phonological Awareness)
24 U Gr. 1
Study 1
Experimental Group
16 100 Elem.
Control Group
16 100 Elem.
Participants in Study 1 and Study 2
were boys classified as having a
learning disability and attending
special resource classes
Hoy et al.
Doseage
of
session
sessions
sessions
Time per
Total # of
Frequency
Experimental condition—Writing club
In groups of 6-14 children
Children gave secret password, shared riddles and jokes (5 min).
Warm-up activities to promote automatic letter writing and
automatic phoneme-grapheme correspondences in spelling 56 60 min 2/wk for
(15 min). 7 mo
Teacher-directed composing activities (“Writers` work”) (25
min).
Word-play activities (10 min).
Control condition—regular classroom instruction only.
Experimental conditions
Motor imitation: copying teacher’s movement.
Visual cue: following arrows next to letter.
Memory retrieval: looking at letter, covering then printing.
24 20 min 2/wk
Visual cue + memory retrieval.
Copy: from model, no cuing.
Control condition
Phonological awareness training.
NB: All conditions were carried out by children working in groups of 3.
Study 1:
Experimental condition—EMG and visual imagery for relaxation
and homework exercises
5 two-minute EMG readings recorded during first 10 minutes
of session, followed by completion of handwriting exercises 10 + HW 50 min 2/wk for
during remaining 50 minutes of session. At home, listened to 5 wks
prerecorded 10-minute audiotape using passive muscle relax-
ation and visual imagery and then completed hand-writing
homework exercises.
Control condition - No intervention. Continued ....
 Table 2 Included Studies—Description (continued)
Case-Smith NRCT
(2002)
Densem RCT
et al. (1989)
Denton RCT
et al. (2006)
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Jackson & RCT
Hughes
(1978)
Canadian Journal of Occupational Therapy February 2011 78(1) 17
Study 2
Experimental Group
15 100 Elem.
Control Group
15 100 Elem.
Experimental Group
29 83 8.6
Control Group
Experimental Group
19 79 8.1
Control Group
17 82 7.1
68% boys
Mean age: 9.0 (1.1)
Experimental Group
10 50 Gr 4
Control Group
10 50 Gr 4
Study 2:
Experimental condition—EMG only
6 weeks of EMG + handwriting exercises (No visualization or
homework).
Control condition
No intervention.
Experimental condition—School-based direct occupational
therapy
Handwriting practice or activities designed specifically to Mean Mean Approx
improve handwriting were implemented in 77% of the 16.4 32.2 2/m
sessions (eclectic approaches). Range Range
Control group— 10-25 25-49
No occupational therapy min
Experimental group—Occupational therapy Mean
Activities for improving balance, fine and gross motor skills,
responsiveness to touch, integration of both sides of the OT
body, and motor movement planning. 17.4 60 min 4.5 mo
Control group—Physical Education
Fitness activities, teaching and practice of physical skills and PE
games. 16
Experimental group—Sensorimotor treatment
10 minute sessions each of visual perception, visual-motor
integration, proprioception/kinesthesia, and in-hand
manipulation activities. 20 40 4/wk
Experimental group—Therapeutic practice over 5 wks
Handwriting practice books prepared for each participant,
including worksheets to practice, dictated and copied
handwriting and writing from memory, and real-life writing
practices.
Control group
No intervention
Experimental group—Relaxation
Listened to relaxation tape then copied a 6-line paragraph 9 U 3/wk
Control group— for 3
Listened to verbal instruction on handwriting then copied on a 6 wks
line paragraph
Hoy et al.
 Table 2 Included Studies—Description (continued)
Sample Doseage
Hoy et al.

Study Design Treatment

N
of

Age/
Grade
session

% Boys
sessions
sessions

Time per

Total # of
Frequency

Experimental Group Experimental Group

Experimental group
18 78 8.9
In groups, children instructed in guided self-correction of letter 48 30 min 2/wk for
Jongmans NRCT Control Group formation with a model. 6 mo
et al. (2003) (cluster)
6 100 9.7 Control group
No intervention.

18 Revue canadienne d’ergothérapie

Kinaesthetic training Experimental group—Kinaesthetic training
15 U Gr. 1 2 training tasks for position and movement of arms in space.
Handwriting Practice Experimental group—Handwriting practice
Sudsawad RCT 6 30 min 6 school days
15 U Gr. 1 Children copied letters, words, and sentences. Verbal and visual
et al. (2002) over 2 wks

février 2011
Control Group feedback provided.
15 U Gr. 1 Control Group

No intervention

78(1)
Task oriented Experimental group—Task oriented
13 100 Gr. 2-4 Handwriting practice and feedback 8+
Weintraub RCT Sensorimotor Mneumonics, self-evaluation, word games, functional activities
et al. (2009) 13 77 Gr. 2-4 (e.g., writing birthday party invitations). 10 min
Control Group Experimental group—Sensorimotor HW 60 min 1/wk
17 100 Gr. 2-4 Preparatory activities (posture, coordination, stability, fine motor). Each
Kinesthetic, tactile, and auditory feedback. Mneumonics, self- day
evaluation.
Control group
No intervention

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Experimental Group (Cognitive)
24 U Gr. 2
Zwicker & RCT Experimental Group (Multisensory)
Hadwin 24 U Gr. 2
(2009) Control Group
24 U Gr. 2
71% of total sample were boys.
Experimental group—Cognitive intervention
Alphabet warm-up: naming and identifying letters.
modeling, discussion of letters, talking through forming the letter,
self-evaluation. 10 30 min 1/wk
Experimental group—Multisensory intervention
Letter groups named and formation demonstrated.
Practice with enhanced sensory feedback (e.g., writing on sand-
paper).
Children copied each letter on regular lined paper and a work-
sheet page.
Control group
No intervention

Note. Ages given in years unless otherwise stated; U = unknown; Gr. = grade; elem = elementary school; HW = homework

randomized controlled trials (including 1 nonrandomized
cluster trial). Within the included studies, a variety of inter-
ventions to remediate handwriting difficulties were examined.
These interventions were categorized as (1) relaxation and
practice with or without electromyogram (EMG) biofeedback,
(2) sensory-based training without handwriting practice, and
(3) handwriting-based practice (Table 2).
Results of these interventions compared with control
conditions are presented in Table 3. The effects of practice
following relaxation exercises were examined in two studies.
Carter and Russell (1985) reported a statistically significant
difference between the change scores of handwriting qual-
ity for children receiving EMG biofeedback for muscle relax-
ation, visualization exercises for relaxation recorded on an
audiotape, and handwriting homework practice. However,
an effect size for the post-test differences between the inter-
vention and control groups could not be calculated due to
absence of post-test data. It should be noted that this study
included a substantial handwriting practice component (50
minutes, twice per week over five weeks plus nightly home-
work). Jackson and Hughes (1978) also studied the effects of
relaxation training on handwriting quality and speed; results
were not significant for this intervention. Notably, in this
study both experimental and control participants carried out
some handwriting practice.
Sensory-based training without handwriting prac-
tice interventions were examined in three studies (Densem,
Nuthall, Bushnell, & Horn, 1989; Denton, Cope, & Moser,
2006; Sudsawad, Trombly, Henderson, & Tickle-Degnen,
2002). The effect sizes were small (Cohen, 1988) and not sig-
nificant for improvement in handwriting legibility, speed,
or proportion of errors. In fact, in some cases, children who
received this intervention did more poorly than children in the
control conditions.
Interventions that included handwriting were examined
in seven studies. These studies tested interventions with a sen-
sorimotor focus (Weintraub, Yinon, Hirsch, & Parush, 2009;
Zwicker & Hadwin, 2009) or a cognitive focus (Berninger et
al., 2006; Berninger et al., 1997; Jongmans, Linthorst-Bakker,
Westenberg, Smits-Engelsman, 2003; Sudsawad et al., 2002;
Weintraub et al., 2009; Zwicker & Hadwin). In one study of
a direct school-based intervention, the focus was not iden-
tified (Case-Smith, 2002) but likely varied from therapist to
therapist.
In the two studies that examined handwriting practice
with a sensorimotor focus, students received enhanced kin-
aesthetic, tactile, or auditory feedback while practising letter
formation. Following this intervention, children in the treat-
ment group did no better than those in the control group in
terms of legibility and speed (Weintraub et al., 2009; Zwicker
& Hadwin, 2009).
In the studies with handwriting practice using a cognitive
focus, students received instruction to help them think their
way through letter formation and self-correction. Berninger et
al. (1997) examined the impact of different types of group prac-
tice on the number of letters formed correctly in 60 seconds.
Motor imitation and practice writing letters from memory
with or without visual cues (e.g., direction arrows) produced
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Canadian Journal of Occupational Therapy February 2011 78(1) 19
Hoy et al.
significant improvement over the course of 24 sessions.
In a subsequent study, Berninger et al. (2006) combined
these forms of practice with a “handwriting club” interven-
tion. During 60-minute sessions, twice per week over seven
months, members of the club carried out exercises designed
to engage them as writers (e.g., students adopted a nom de
plume, and composed their own stories). There was a small
intervention effect that approached significance on the WJ-R
3 Writing Samples (effect size: 0.32; 95% CI: -0.09, 0.73). In
addition, students who had taken part in the club intervention
were almost 3 times more likely to pass a statewide high stakes
writing examination than students in the control group (odds
ratio: 2.75; 95% CI: 1.06, 7.14), an effect that was statistically
significant.
Weintraub et al. (2009) observed no change in speed, but
a significant improvement in legibility, following eight weekly
sessions of task-oriented handwriting practice supplemented
by 10 minutes of daily homework practice. In contrast, Jong-
mans et al. (2003) obtained no significant improvement over
48 sessions of self-guided correction, Sudsawad et al. (2002)
found no improvement in legibility or speed following six
sessions of handwriting practice carried out over a two-week
period, and Zwicker and Hadwin (2009) saw no significant
improvement over 10 weekly sessions of cognitively focused
handwriting practice. Case-Smith (2002) found no significant
improvement over an average of 16 sessions of handwriting
practice (average of 2 session per month, focus of intervention
not specified).
When differences in post-test data between interven-
tion and control groups were reviewed according to the dose
of treatment received, a trend was noted in terms of the rela-
tionship between number of sessions and intervention effec-
tiveness. All studies with fewer than two practice sessions per
week and fewer than 20 practice sessions in total (homework
included) demonstrated ineffective results.
In terms of risk of bias, potential threats to validity that
arose often in both the randomized controlled trials and non-
randomized controlled trials included unclear sequence gen-
eration and allocation concealment. Incomplete data was a
potential issue in only 2 of the 11 included studies, in all of the
11 studies there was avoidance of selective reporting of data,
and in 8 of the 11 studies the authors clearly stated that the out-
come assessors were masked. The quality of the included stud-
ies was therefore generally good. The quality of studies did not
vary enough to warrant separate analysis by level of quality.
A post hoc analysis of effect sizes using change scores
with imputed standard deviations of change was carried out.
In only two cases did this change the significance of the results
(Case-Smith, 2002; Jongmans et al., 2003). The interventions
in both studies included substantial amounts of handwriting
practice.
Discussion
Nine randomized, controlled trials and two nonrandomized
controlled trials provided the evidence in this systematic
review. These results seem to clearly demonstrate that a prac-
tice component is necessary for handwriting improvement.
 Table 3
Evidence Table for Studies of Handwriting Interventions for Children with Disabilities and Handwriting Difficulties
Hoy et al.

Risk of bias

Study Comparison Outcome Standardized effect size

Adequate Sequence
Generation
Allocation Concealment
Incomplete Outcome
Data a Concern
Free of Selective
Reporting
Outcome Assessors
Masked

20 Revue canadienne d’ergothérapie

Berninger et Handwriting and Composition WJ-R 3 Writing Samples 0.32 [-0.09, 0.73] U U N Y U
al. (2006) Club vs. no treatment Met the state standard for writing on the 2.75 [1.06, 7.14]*
state-wide test: (odds ratio)

février 2011
Berninger et Number of correct words/60 seconds Copy1 0.93 [0.34, 1.53]*
al. (1997) Motor imitation vs. control Number of correct letters/60 seconds Dictation2 0.83 [0.24, 1.43]*

78(1)
WJ Writing Fluency 0.21 [-0.36, 0.78]

Number of correct letters/60 seconds Copy1 0.55 [-0.03, 1.13]

Visual cues vs. control Number of correct letters/60 seconds Dictation2 0.39 [-0.18, 0.97]
WJ Writing Fluency 0.22 [-0.34, 0.79]

Number of correct letters/60 seconds Copy1 0.70 [0.12, 1.29]* U U N Y Y

Memory practice vs. control Number of correct letters/60 seconds Dictation2 1.51 [0.86, 2.16]*
WJ Writing Fluency 0.38 [-0.19, 0.95]

Visual cues and memory Number of correct letters/60 seconds Copy1 1.17 [0.55, 1.79]*
practice vs. control Number of correct letters/60 seconds Dictation2 1.69 [1.03, 2.36]*

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WJ Writing Fluency 0.93 [0.33, 1.53]*

Copying practice without Number of correct letters/60 seconds Copy1 0.58 [0.00, 1.16]
cuing vs. control Number of correct letters/60 seconds 0.13 [-0.44, 0.70]
Dictation (words)2 0.23 [-0.34, 0.80]
WJ Writing Fluency

Carter & EMG and visual imagery for Handwriting legibility3 Not estimable (no standard
Russell (1985) relaxation and homework vs. deviation provided)
no treatment

EMG and visual imagery for Handwriting legibility3 Not estimable (no standard U Y Y Y Y
relaxation vs. no treatment deviation provided)
Continued ...
 Table 3
Evidence Table for Studies of Handwriting Interventions for Children with Disabilities and Handwriting Difficulties (continued)

Case-Smith School-based occupational Total letter legibility4 -0.26 [-1.01, 0.49]

(2002) therapy (direct service) vs. no N N N Y N
treatment Speed4 -0.02 [-0.77, 0.73]

Densem et al. Sensory integration interven- Proportion of letter errors5 0.22 [-0.44, 0.88]
(1989) tion vs. no treatment
U U N Y Y
Physical education interven- Proportion of letter errors 5 0.00 [-0.65, 0.65]
tion vs. no treatment

Denton et al. Sensorimotor intervention vs. Handwriting quality- from memory6 -0.24 [-1.08, 0.60]
(2006) no treatment Handwriting quality- dictated6 0.07 [-0.77, 0.91]

Therapeutic practice v.s no Handwriting quality- copied6 -0.14 [-0.98, 0.70] U U N Y Y

treatment Handwriting quality- from memory6 0.42 [-0.42, 1.25]
Handwriting quality- dictated6 0.99 [0.11, 1.88]*
Handwriting quality- copied6 0.98 [0.10, 1.86]*

Jackson & Relaxation training vs. no Handwriting quality7 2.21 [1.01, 3.40]* U U N Y Y
Hughes (1978) treatment

Jongmans et Guided self-correction of letter Handwriting quality8: 0.74 [-0.21, 1.70] N N N Y Y

al. (2003) formation with a model vs. no Speed8 0.20 [-0.72, 1.13]
treatment

Sudsawad et Kinaesthetic training vs. no Total letter legibility4 -0.26 [-0.98, 0.46]
al. (2002) treatment Total word legibility4 -0.40 [-1.12, 0.33]
Speed4 0.38 [-0.35, 1.10] U U N Y Y
Handwriting practice vs. no Total letter legibility4 -0.71[-1.43, 0.04]
treatment Total word legibility4 -0.69 [-1.43, 0.05]

Downloaded from cjo.sagepub.com at UNIVERSITE DE MONTREAL on November 16, 2014

Speed4 0.02 [-0.69, 0.74]

Weintraub et Task oriented approach vs no Speed9 0.03 [-0.48, 0.54]
al. (2009) treatment Overall legibility9 1.14 [0.36, 1.93]* U U Y Y U

Multisensory approach vs no Speed9 -0.04 [-0.69, 0.62]
treatment Overall legibility9 0.48 [-0.18, 1.15]

Zwicker & Cognitive approach vs no Total Letter Legibility4 -0.07 [-0.64, 0.49] U U N Y Y
Hadwin (2009) treatment
Multisensory approach vs no Total Letter Legibility4 0.06 [-0.50, 0.63]
treatment

Note. Standardized effect size is the standard mean difference between post test scores unless otherwise stated. 1Number of letters correctly copied from a text in 90 seconds; 2Number of letters correctly written from dictation (26 letters of

Canadian Journal of Occupational Therapy February 2011 78(1) 21

alphabet randomly presented); 3Wide Range Achievement Handwriting subtest; 4Evaluation Tool of Children’s Handwriting (ETCH); 5Proportion of errors in writing name and address and copying a writing sample, Test of Handwriting Skills
Hoy et al.

(THS); 7Assessed quality of a copied 6-line paragraph; 8 Concise Assessment Scale for Children’s Handwriting (BHK); 9 Hebrew Handwriting Evaluation (HHE). * Statistically significant (p< 0.05).
Hoy et al.
That is, activities that target writing-related performance com-
ponents, such as in-hand manipulation or kinaesthetic aware-
ness, without providing opportunity for handwriting practice,
do not appear to be effective in improving written expression.
Practice of handwriting is required to improve this skill. These
findings confirm the results of the previous narrative review
(Feder et al., 2008) by demonstrating that not all interventions
are equal. Furthermore, they extend these results by demon-
strating the need for a minimum amount and frequency of
practice.
An approach to handwriting remediation that focuses
on handwriting practice is consistent with the theory of motor
learning, a theory that is increasingly key to occupational ther-
apy intervention. Based on work by Schmidt and Lee (2005),
Zwicker and Harris (2009) described motor learning as “a set
of processes associated with practice or experience leading to
relatively permanent changes in the capability for movement”
(p. 302). As noted above, the results of this review demonstrate
that handwriting intervention approaches that do not include
a handwriting practice component do not result in changes in
handwriting performance. Furthermore, the findings of our
systematic review indicate that a minimum number of prac-
tice-based intervention or intervention and homework ses-
sions are required for handwriting to improve. These findings
are consistent with the current definition and understanding
of motor-learning theory as put forward by Zwicker and Har-
ris (2009).
It is unclear from our review whether this handwrit-
ing practice component requires a cognitive or sensorimotor
component or some combination of the two. However, in the
one study with adequate practice time that examined interven-
tions that focused on either cognitive or sensorimotor-based
activities, significant results were achieved only in the cogni-
tively focused intervention (Weintraub et al., 2009). Interest-
ingly, Zwicker and Hadwin (2009) reported an improvement
in Grade 2 children using the cognitive focus whereas Grade
1 students demonstrated better results when the sensorimo-
tor-focused intervention was applied. This might indicate a
developmental or maturational effect that may need to be con-
sidered when selecting the type of handwriting practice used
in an intervention.
Only Berninger’s (Berninger et al., 2006; Berninger et
al., 1997) studies demonstrated any improvement in speed of
handwriting. Both of these studies evaluated interventions with
a relatively high number of practice sessions. Both legibility
and speed are important concerns when examining the func-
tionality of children’s handwriting (Amundson, 1992; Feder &
Majnemer, 2007). It is reasonable to believe that improvements
in letter quality may precede improvements in speed, the latter
requiring additional practice time.
The clinical implications of the association of a minimum
number of handwriting practice sessions to effect change in
handwriting are multiple. First, to ensure effective interven-
tion, occupational therapists need to determine ways to ensure
adequate practice time despite funding limitations. Potential
solutions include group rather than individual sessions. Two of
the three studies that examined the effects of an intervention
provided in groups demonstrate positive changes in handwrit-
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22 Revue canadienne d’ergothérapie février 2011 78(1)
ing (Berninger et al., 2006; Berninger et al., 1997). Interven-
tions including assigned homework practice also demonstrated
effectiveness (Carter & Russell, 1985; Weintraub et al., 2009).
Second, it is paramount that building motivation for writ-
ing practice be incorporated into the treatment plan and strat-
egy. Ryan and Deci’s (2000a) Self-Determination Theory may
provide a useful framework for occupational therapists work-
ing with students who, for multiple reasons, have varying lev-
els of motivation for handwriting. This empirically supported
theory underscores the importance of encouraging the child
to move toward integrated motivation, that is, a point at which
he or she values the activity for what it can do for them. This
is carried out by ensuring that intervention strategies allow for
the development of competence through optimal challenges
while supporting both the child’s sense of relatedness through
development of good relationships with the teacher and other
students and his or her sense of autonomy through allowing
choice in the activity (Ryan & Deci, 2000b). Berninger et al.’s
(2006) writers’ club demonstrated effective use of such strate-
gies through providing effective practice strategies, supporting
the development of relationships through shared activity, and
allowing the children choice regarding their writing personas
and writing topics.
In addition, it will be important for occupational thera-
pists to consult with teachers, parents, and students to deter-
mine whether handwriting practice should be the key focus of
intervention or whether other methods of producing written
work (e.g., keyboarding, scribing, voice-activated technolo-
gies) should be explored or expanded upon; the question of
which written output strategy would be more advantageous to
attaining the child’s academic goals at that point in time, as
well as in the future, would need to be discussed. Consider-
ations may include the child’s interest in pursuing this prac-
tice and the opportunity cost of doing so. That is, how will the
time spent in practicing this handwriting detract from other
valued occupations (such as school work, extracurricular
activities, and family time)? Additional important consider-
ations include the present and future availability of alternative
methods of written communication. Occupational therapists
are often involved in recommending alternative methods for
the production of written work (Freeman, MacKinnon, Miller,
2004; Marr & Dimeo, 2006; Rigby & Schwellnus, 1999). The
results of this study may be helpful to therapists as they weigh
the potential impact of remediation.
Finally, given the importance of handwriting practice
underlined by this review, one might ask whether occupa-
tional therapy time may be better spent advocating for more
handwriting instruction and practice for all children. Indeed,
a number of writers have pointed out that curriculum changes
have dramatically lessened the amount of writing instruction
and practice. In many cases students who have not sufficiently
mastered basic writing tasks are forced to move on too quickly
to more advanced written assignments, and this is likely the
cause of most handwriting problems in this population (Asher,
2006; Donica, 2010; Karlsdottir & Stefansson, 2002). It may be
better to advocate for more practice for all children and inten-
sive practice for those who continue to have problems with
handwriting, with therapeutic intervention offered only for

those who have difficulty even after intensive practice (Feder
& Majnemer, 2007).
Such an alternative approach to the problem of handwrit-
ing is more closely aligned to a consultative model of occu-
pational therapy. Such a model may be most effective when
occupational therapists are integrated into the school rather
than coming in from an outside agency and providing teach-
ers with recommendations that they perceive as unfeasible
in their classrooms (Cahill, 2010; Hutton, 2009; Wehrmann,
Chiu, Reid, & Sinclair, 2006).
This systematic review of handwriting interventions was
carried out with a number of features to ensure validity. These
included: a priori selection criteria, a search designed by a
research librarian with systematic review expertise, indepen-
dent selection of articles, verification of extraction, and quality
assessment of included studies. However, three main limita-
tions remain.
The first limitation was that few studies included in this
review considered individualization of the intervention to
respond to each child’s specific problem areas (e.g., visual per-
ception, motor planning, etc.). However, given the effective-
ness of interventions involving higher levels of practice and the
ineffectiveness of interventions that addressed performance
components relating to handwriting only, practice may be
more critical than specific identification of underlying issues.
The second limitation was that the sample sizes of the
included studies tended to be small. Small samples lead to
greater variability in outcome scores, leading to fewer statisti-
cally significant findings even in the presence of large effect
sizes. However, it should be noted that effect sizes were often
small to moderate in the included studies, indicating that
increasing the size of samples may not have had an impact on
the clinical significance of the results.
The third limitation was that post-test scores rather than
change scores were used to determine the effect sizes. This was
done because use of change scores requires that assumptions
be made regarding the standard deviation of the change scores,
and effect sizes can vary greatly depending on the assumptions
made, leading to unstable estimates (Higgins & Green, 2009).
Use of post-intervention scores may lead to more conserva-
tive estimates of effect, particularly when pretest score means
are different for the intervention and control groups. How-
ever, post hoc analyses done using change scores and imputed
standard deviations revealed no findings that contradicted the
overall conclusion of the review.
Given our findings, we disagree that future research
should further compare different modalities included in
practice-based intervention (Feder et al., 2008; Woodward &
Swinth, 2002). Rather, since it appears that amount of practice
is the essential ingredient for effective outcomes, we believe
future research should examine interventions with enhanced
practice time using delivery methods that maximize practice
time (such as group intervention, inclusion of homework)
while promoting student motivation. As well, outcomes
should give consideration to both speed and legibility results.
Exploration of the impact of intensive practice time on other
activities, using both subjective and objective data, should also
be considered. Finally, population-based studies carried out
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Canadian Journal of Occupational Therapy February 2011 78(1) 23
Hoy et al.
in conjunction with educators examining the effectiveness of
providing more handwriting practice to all students as a pre-
ventative measure against the development of handwriting
problems appear to be warranted.
Summary
This systematic review offers convincing evidence that hand-
writing interventions that involve handwriting practice and
that include practice at a minimum twice per week for a total
of at least 20 sessions are effective for improving handwriting
outcomes in children with handwriting difficulties. Handwrit-
ing interventions that do not provide handwriting practice
have been shown to be ineffective.
Key messages
• To be effective, interventions must allow for handwrit-
ing practice at a minimum twice per week for a total of
at least 20 sessions.
• Improvements in handwriting speed appear to require
even higher levels of practice.
• Subsequent handwriting intervention research should
examine the effectiveness of programs designed to
maximize practice time.
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