Abstract
Handwriting is an essential skill young children must acquire; it is emphasized in preschool through elementary grades. Handwriting is more than a simple fine motor task; it requires performance in perceptual–motor skills, motor planning, visual perception, visual–motor integration, bilateral hand skills, in-hand manipulation, kinesthesia, sustained attention, sensory processing, and the presence of proper biomechanical components for posture and hand grip (Asher, 2006; Denton, Cope, & Moser, 2006; Erhardt & Meade, 2005; Feder & Majnemer, 2007; Woodward & Swinth, 2002). In the United States, handwriting difficulties may affect up to 27% of school-aged children, a rate that is significant because up to 60% of the school day includes fine motor tasks (McHale & Cermak, 1992). Kindergarten students spend up to 46% of their day completing fine motor activities, of which 42% are paper-and-pencil tasks (Marr, Cermak, Cohn, & Henderson, 2003). By contrast, preschool students spend an average of 37% of their school day engaged in fine motor activities, of which only 10% are paper-and-pencil tasks (Marr et al., 2003).
Handwriting difficulty is the most common reason school-age children are referred for occupational therapy services (Schneck & Amundson, 2010). Multiple studies have illustrated the importance of developing handwriting skills. Because of the importance of handwriting as a daily occupation in all life stages, the consequences of handwriting difficulties are extensive and can be detrimental to academic performance and self-esteem (Erhardt & Meade, 2005; Feder & Majnemer, 2007; Jackman & Stagnitti, 2007). Children who struggle with handwriting skills have difficulty with self-expression, completion of assignments, and mental flexibility to complete composition activities. In addition, handwriting difficulties may predict reading challenges, whereas success in name writing may predict future success in reading achievement (Berninger et al., 2006; Haney, 2002). Moreover, difficulty with early automatic handwriting mechanics and speed correlates with difficulties in subsequent keyboarding skills (Connelly, Gee, & Walsh, 2007).
As a result of increased handwriting demands in kindergarten, handwriting skills in preschool have become a predictor of kindergarten handwriting performance (Fogo, 2008). Multisensory handwriting intervention has been effective in improving handwriting skills (Peterson & Nelson, 2003; Zwicker & Hadwin, 2009). Some educators have suggested that handwriting skill deficits exist because insufficient attention is given to handwriting skill development during school, not because specific client factors limit student abilities (Asher, 2006). Occupational therapists are trained to properly assess how client factors affect prewriting and writing performance and to address how a child's environment and context will influence school success (Cahill, 2009). In fact, recent reports indicated that school systems are the primary place of employment for 23% of all occupational therapists in the United States (National Board for Certification in Occupational Therapy, 2008). Having preschool classroom teachers implement an occupational therapy–based curriculum to teach handwriting readiness skills reflects a more inclusive service model that benefits all students.
Head Start is a federal initiative implemented through the U.S. Department of Health and Human Services (DHHS) “to promote the school readiness of low-income children by enhancing their cognitive, social, and emotional development” (Chandler & Lucas, 2010, p. 27). Bowman and Wallace (1990) established that children from lower socioeconomic backgrounds had a higher risk of challenges with hand strength, visual–motor development, and praxis, of which all affect handwriting. Local nonprofit organizations, in conjunction with local education agencies, administer the Head Start programs. During fiscal year 2009, Head Start served 904,153 children nationally and has served >27 million children since 1965 (DHHS, 2010).
A 5-yr randomized study of approximately 5,000 3- and 4-year-old children clearly demonstrated the benefit of Head Start programs for children's learning experiences through effects on cognitive development, health development, and parenting practices (Puma et al., 2010). Seemungal (2009) found that preschoolers attending a Head Start program scored higher than those without preschool experience on the Developmental Indicators for the Assessment of Learning, 3rd Edition (Mardell-Czudnowski & Goldenberg, 1998) in their total score, motor, concepts, and language scores but not higher than students who attended other school programs.
Peterson and Nelson (2003) demonstrated the effectiveness of occupational therapy interventions in significantly improving handwriting skills. First-grade children from economically disadvantaged families received 20 biweekly sessions incorporating biomechanical, sensorimotor, and teaching and learning principles. Each 30-min session included 5 min of small-group (5 students each) sensorimotor “heavy work” activities, including jumping and running; 20 min of individualized activities (including motor planning, motor memory, and self-monitoring of writing position and posture); and 5 min spent practicing writing letters. Together, these studies suggest that preschool and elementary school children from low socioeconomic backgrounds may be at greater risk for having handwriting challenges, and an occupational therapy–based approach to assist handwriting development may be beneficial.
Occupational therapists in the school system help students benefit from the general education curriculum. Therefore, improving students' ability to take notes and complete written work is a concern of the occupational therapist. The role of the school occupational therapist is evolving from that of a direct service model to a more inclusive model that incorporates teacher training, consultation, and curriculum decisions (Donica, 2010). The current study is an example of this progression; it demonstrates the effectiveness of embedding occupational therapy strategies and techniques into a Head Start setting using the Handwriting Without Tears®–Get Set for School (HWT–GSS) handwriting readiness curriculum (Olsen & Knapton, 2008) to improve handwriting skills.
HWT, developed by an occupational therapist for multiple grade levels, is a full curriculum for developing prewriting and writing skills; it uses multisensory activities presented in developmentally appropriate sequences. The HWT–GSS program was designed to help preschool children develop the prewriting skills necessary for kindergarten by incorporating playing, singing, motor skills, social and emotional development, body awareness skills, cognitive and language skills, sensory processing, and visual–perceptual skills (Olsen & Knapton, 2008). Similar multisensory approaches have been recommended in the mainstream elementary classroom, including drawing large letters on the blackboard, tracing letters in multisensory substances, forming letters using modeling clay, and tracing large letters in the air (McMurray, Drysdale, & Jordan, 2009). HWT–GSS has been studied with another student group, but methodological considerations limit the usefulness of the findings and provide little guidance in extrapolation to the current study population (Carlson, McLaughlin, Derby, & Blecher, 2009). To our knowledge, no studies have been published evaluating HWT–GSS effectiveness in a preschool classroom. In addition, we identified no other handwriting readiness curriculum effectiveness studies.
Although data suggest that an occupational therapy–based handwriting curriculum should be both effective and useful if implemented in a Head Start setting, there is little direct supporting evidence. We used a nonrandomized, two-group, controlled trial to determine the relative effectiveness of implementing the HWT–GSS program in a Head Start setting. We attempted to answer the following three research questions:
Was HWT–GSS more effective than the traditional Head Start curriculum for teaching handwriting readiness skills, as identified by the Learning Accomplishment Profile, 3rd Edition (LAP–3; Hardin & Peisner-Feinberg, 2004) Pre-Writing domain test scores?
Did using HWT–GSS lead to greater improvement in kindergarten readiness skills, as identified by comparing Check Readiness (Olsen & Knapton, 2008) and name writing scores?
Did HWT–GSS activities lead to improvement in handwriting-nonspecific fine motor skills, as demonstrated by comparing the Bruininks–Oseretsky Test of Motor Proficiency, 2nd Edition (BOT–2; Bruininks & Bruininks, 2005), Fine Manual Control composite and subtest scores?
Method
Research Design
We conducted a two-group, nonrandomized controlled trial using a pretest–posttest design at a rural Head Start program. All aspects of the study were reviewed and approved by the East Carolina University Health Systems Institutional Review Board before initiation. Written approval was obtained from appropriate Head Start administrators. Informed parental consent was obtained for all participants using permission forms signed by the Head Start director and principal investigator.
Instruments
Components of three instruments were used in data collection, the Pre-Writing domain of the LAP–3, the Check Readiness tool in the HWT–GSS student workbook, and the Fine Manual Control composite of the BOT–2.
Learning Accomplishment Profile, 3rd Edition.
The LAP–3 is a criterion-referenced test to assess skill development of children ages 36–72 mo in gross motor, fine motor, prewriting, cognitive, language, self-help, and personal and social skills. Only the Pre-Writing domain was used for this study. The LAP–3 has well-documented test–retest reliability for ages 37–72 mo (r = .99) and interrater reliability for ages 33–73 mo (r = .97).
Check Readiness.
Check Readiness is a nonstandardized tool used to show skill progression related to developmental kindergarten readiness skills. It includes crayon grasp, object recognition, coloring, tracing and copying shapes, number and letter recognition, drawing a person, and printing first name in capital letters. The number of successful responses in a series of activities is counted. To generate statistical comparisons between groups, we normalized all raw scores as a percentage of the maximum possible score. Within each activity, average raw scores were compared, and comparisons were made using the percentage correct of total responses. This scoring system is semiquantitative, based on a series of present or absent skill demonstrations, and has not yet been validated in the literature.
HWT–GSS includes only capital letters as the preschool expectation, and the Check Readiness score was determined on that basis. The local Head Start program, however, expects students to write their names using upper- and lowercase letters. Therefore, participants wrote their first name a second time using upper- and lowercase letters (which are taught in the kindergarten HWT curriculum). The two name components (all capitals and upper- and lowercase) were scored using an adapted version of the Print Tool (Olsen & Knapton, 2006), which was previously validated for this purpose but not for this age group. The Print Tool includes eight scoring criteria, of which four were selected for use with the scoring of student names: (1) memory (writing the letter without a sample), (2) orientation (correct directionality), (3) start (correct position), and (4) control (fluidity and neatness). Students received a point for each correct criterion for each letter attempted. Total points and total possible attempts were computed for each criterion. The total points and attempts were calculated and then divided, resulting in the average modeling the Print Tool scoring process.
Bruininks–Oseretsky Test of Motor Proficiency, 2nd Edition.
The BOT–2 is a commonly used standardized test designed to quantify the motor skills of people ages 4–21 yr. It includes four composites of two subtests each. For this study, only the Fine Manual Control Composite, including Fine Motor Precision (Subtest 1) and Fine Motor Integration (Subtest 2), was administered. Fine Motor Precision addresses bilateral hand skills and accuracy with cutting, folding paper, and coloring. Fine Motor Integration measures visual–motor skills determined by copying various shapes. Both subtests evaluate participants' skills in integrating visual perception with hand and finger motor movements. Internal consistency reliability for Fine Manual Control has been established in 4-yr-olds (r =.87) and 5-yr-olds (r = .86). The BOT–2 has published test–retest reliability for Fine Manual Control with 4- to 7-yr-olds (r = .81; Bruininks & Bruininks, 2005).
Participant Selection
The participants were children enrolled in one of two classrooms in a rural Head Start program. For convenience, the Head Start director selected the participating classrooms. All students in one classroom were arbitrarily assigned to the control group, and all the students in another classroom were assigned to the experimental group. Pretest scores from all students were compared to verify that sampling bias was not inadvertently introduced on the basis of the groupings. Inclusion criteria included enrollment in one of the two identified classrooms, age 4 or 5 yr, and parental permission. Exclusion criteria included any identified cognitive or physical deficit(s) that could interfere with fine motor task ability. None of the participants were excluded from the trial on the basis of these criteria.
Intervention
The experimental group participated in HWT–GSS in addition to the Head Start curriculum, whereas the control group completed only the standard Head Start curriculum. Scheduled interventions began with a 5-min warm-up activity, led by two occupational therapy graduate students, followed by a 15-min small-group activity (1 adult, 5 students). The adults included the two graduate students, the authors, and a Head Start teacher. Small-group activities included body awareness skills, directional concepts, and letter-play activities and progressed to coloring and tracing of capital letters and shapes. All intervention activities followed the HWT–GSS program and were child friendly, developmentally appropriate, and multisensory (Olsen & Knapton, 2008). Each session ended with a brief whole-class review, positive feedback, and a closing song.
Intervention Schedule
Intervention sessions occurred 3 times/wk from October to March, as regular school calendars allowed, with suggested follow-up activities for the teacher to facilitate the other days. A total of 47 sessions occurred; all students participated in at least 31 sessions. Students attended an average of 42 (standard deviation [SD] = 4.66; 89.3%) sessions, and 15 of the 17 students attended at least 38 sessions. The HWT–GSS Teacher Guide (Olsen & Knapton, 2008) provided a 5 day/wk classroom instruction schedule that was used as a template for developing the 3 day/wk intervention schedule used in the current study. Everyone conducting interventions had uniform training of the HWT–GSS curriculum to ensure consistency, which was important because the study design precluded randomization or blinding procedures.
Data Collection Schedule
Pre- and posttest data were collected within a 2-wk time frame immediately before and immediately after the study. Because of a limited time frame for data collection, additional occupational therapy graduate students, who had been trained in the assessments, assisted with test administration. Interrater reliability testing was not performed because of its potential effect on children's performance and unnecessary additional time out of class. Investigators were not blinded to group assignment during assessment. Opportunity for subjective observer bias in testing was limited by the objectivity of the scoring instruments used. We reviewed all data scoring.
Intervention Fidelity
Everyone administering the HWT–GSS programming was formally trained in the curriculum, and everyone administering the assessment instruments had been trained in the proper administration of the battery. Graduate students met with us weekly to review progress, and we were on site and actively engaged in all aspects of the intervention and assessment process. Finally, we reviewed all data scoring, without respect to grouping or person administering the test, to verify accuracy of reporting and scoring.
Data Analysis
Statistical comparison between pretest and posttest performance within a group was performed using paired t tests, and comparisons between the experimental and control groups were performed using unpaired t tests. In each case, significance was accepted when p < .05. GraphPad Prism (3rd ed.; GraphPad Software, Inc., San Diego, CA) was used to conduct the data analysis. Primary analysis was conducted on BOT–2 Fine Manual Control composite standard mean score, the LAP–3 individual Pre-Writing domain mean score, and HWT–GSS total percentage score. Secondary analysis was conducted on BOT–2 Fine Motor Precision and Fine Motor Integration standard scores and on Check Readiness individual percentage scores for each of the 13 items.
Effect Size
Effect size was calculated using standard formulas, and Cohen's d value was reported as the coefficient representing effect size. Effect size was assigned as small when 0.2 ≤ d ≤ 0.49, as medium when 0.5 ≤ d ≤ 0.79, and as large when d ≥ 0.80 (Cohen, 1988).
Results
Participant Flow and Demographics
At the onset of the study, there were 40 participants, ranging in age from 4 yr, 0 mo, to 4 yr, 11 mo. All students were classified as minority, and all came from low socioeconomic status families. The experimental group and the control group each had 20 students, and pretesting was completed with all 40 students. Eight participants dropped out during the 5-mo study (experimental group, n = 3; control group, n = 5). The loss of participants was caused by circumstances beyond our control, primarily family relocation. For final data collection, only the 32 students with both pretest and posttest data were included in the final data analysis. The groups were not different by average age (at pretest, mean [M] age ± SD = 55.9 ± 3.48 mo in the control group and 55.4 ± 3.74 mo in the experimental group, p = .69) but were significantly different in gender distribution (experimental group: 8 boys, 9 girls; control group: 10 boys, 5 girls, χ2 = 14.492, df = 14, p < .001).
Sample Size Justification and Power Analysis
Using an anticipated score improvement of 30%, a standard deviation in measurement of 5%, a power of .80, and α = .05, power analysis predicted a minimum of 12 participants per group to detect a statistically meaningful result. On this basis, the starting sample size of 20 per group and the final sample size of at least 15 per group were adequate for the study design.
Equivalence of Experimental and Control Groups
No statistically significant differences between the groups were found in average age, minority status, or socioeconomic background, but as noted, the difference in gender distribution was significant. Individual socioeconomic levels were not determined directly, but income eligibility for Head Start is legislatively defined. Federal statute requires that at least 90% of participating children come from families below the Federal Poverty Level, receive public assistance, or be involved in foster care (DHHS, 2007).
Pretesting with each of the instruments revealed no differences between the groups on any of the performance indexes tested, either by score or by variance in score. Pretesting was completed and equivalence was verified before the study was begun.
Summary of Findings
There were no significant differences between the two groups in pretesting scores for the LAP–3 Pre-Writing domain (Ms ± SDs = 22.00 ± 5.19 control and 22.38 ± 4.54 experimental, p = .83); the Check Readiness tool (Ms ± SDs = 26.27 ± 12.46 control and 34.59 ± 14.68 experimental, p = .09), or the BOT–2 Fine Manual Control composite (Ms ± SDs = 34.73 ± 10.43 control and 40.76 ± 8.06 experimental, p = .75).
The pre- and posttesting LAP–3 sum scores for the Pre-Writing domain in each group are presented in Figure 1. Significant improvements in the posttest sum scores were observed in both the experimental group and the control group, but the experimental group scored significantly higher (Ms ± SDs = 24.00 ± 4.87 control, 29.00 ± 4.65 experimental, p = .0058). In comparing the means, a large treatment effect was determined (d = 1.05).
Significant improvements in the Learning Accomplishment Profile, Third Edition (LAP–3) Pre-Writing domain scores were observed in the experimental group (large treatment effect [d = 1.05]; p values for individual comparisons are as noted).
The pre- and posttesting Check Readiness sum scores are presented in Figure 2. Significant improvements in posttest sum scores were observed in the experimental group and the control group, but the experimental group scored significantly higher (Ms ± SDs = 34.27 ± 11.51 control, 44.59 ± 12.63 experimental, p = .022), consistent with a large treatment effect (d = 0.86). Comparing individual components of the Check Readiness tool indicated that the improvement in sum score was related to significant differences in five major components that generally demonstrated large treatment effects (name in capitals, 0.78; name in title case, 0.77; crayon grip, 0.31; copy shape, 1.15; draw a person, 1.79) and are summarized in Table 1. There were no differences between the groups at pretesting in any of the identified items. Although summary scores improved in both groups, for these components, improvements between pre- and posttesting were seen in only two of five items in the control group, compared with five of five items in the experimental group. Moreover, where improvements were seen, the improvements were consistently greater in the experimental group.
Significant improvements in the Check Readiness sum scores were observed in both the control and the experimental groups (large treatment effect [d = 0.86]; p values for individual comparisons are as noted).
Summary of Pretest and Posttest Scoring in Components of the Check Readiness Tool
Note. Name in capitals and name in upper- and lowercase were scored using four criteria described by Olsen and Knapton (2006). Pre vs. Pre = pretest control group compared with pretest experimental group score; Post vs. Post = posttest control group compared with posttest experimental group score; Pre vs. Post (CON) = pretest score compared with posttest score in the control group; Pre vs. Post (EXP) = pretest score compared with posttest score in the experimental group.
Significant improvements in the pre- and posttesting BOT–2 Fine Manual Composite scores were not observed in either the experimental group or the control group, but the posttest scores were significantly higher in the experimental group (Ms ± SDs = 33.80 ± 10.46 control, 42.18 ± 8.27 experimental, p = .017) also showing a large treatment effect (d = 0.89). The composite score varied by individual students within each group. In contrast to the LAP–3 and the Check Readiness sum scoring patterns, whereby each student typically showed a measure of improvement with or without treatment, the BOT–2 composite scores showed more a pattern of responders and nonresponders with respect to score improvement. In the control group, only 5 of 15 students (33%) showed improvements of ≥10%, whereas 10 of 17 students (59%) in the experimental group showed composite score improvements of ≥10% (χ2= 27.94, df = 14, p < .001).
A more detailed analysis of the BOT–2 scoring is presented in Figure 3, where the results of the two subtests, Fine Motor Precision (Subtest 1) and Fine Motor Integration (Subtest 2) standard scores are summarized. Fine Motor Precision standard posttest scores were significantly higher in the experimental group (M ± SD: 8.47 ± 4.31 control, 11.29 ± 3.33, experimental, p = .045) and demonstrated a medium treatment effect (d = 0.74). Similarly, Fine Motor Integration standard posttest scores also were significantly higher in the experimental group (Ms ± SDs = 7.47 ± 5.08 control, 12.00 ± 5.37 experimental, p = .021) showing a large treatment effect (d = 0.87).
Neither the experimental group nor the control group showed significant improvement between pretest and posttest scores on the Bruininks–Oseretsky Test of Motor Proficiency, 2nd Edition (BOT–2), Subtest 1 (Fine Motor Precision) or Subtest 2. Posttest Subtest 1 and Subtest 2 scores were significantly higher in the experimental group (p = .045, medium treatment effect [d = 0.74]; p = .021, large treatment effect [d = 0.87], respectively).
Discussion
Students in both the experimental group and the control group made significant improvements in their handwriting readiness skills over the course of the study. Therefore, the study extends the findings that Head Start programs are effective in improving general preschool readiness and handwriting readiness specifically (Puma et al., 2010). However, this is the first report to demonstrate that supplementing the standard Head Start curriculum with an occupational therapy–based, multisensory approach significantly improves handwriting readiness beyond what is accomplished by Head Start programming alone. Calculated effect sizes for the HWT–GSS experimental group ranged from moderate to very large, compared with Head Start programming alone. Therefore, HWT–GSS remains effective in improving handwriting readiness skills, even when administered in a modified schedule, and LAP–3 is a sensitive instrument for detecting the effects.
Peterson and Nelson (2003) previously reported that providing occupational therapy intervention to first-grade children from lower socioeconomic backgrounds could improve handwriting skills. Our study extends these effects in school-aged children to preschool children. It remains to be determined whether the improvement seen in the current study will ultimately improve handwriting skill development in the schools and reduce the occupational therapy referrals of children who need handwriting intervention (Asher, 2006; Jackman & Stagnitti, 2007, Schneck & Amundson, 2010).
The revised edition of HWT–GSS includes additional multisensory activities and tracing workbook pages and a 28-wk teaching guideline for implementation of the curriculum (Olsen & Knapton, 2008). Although other prewriting materials are commercially available, to our knowledge, no handwriting readiness classroom curricula have evidence-based findings published.
The HWT–GSS program is multisensory based. Activities include making letters with wooden pieces, singing songs with coordinated actions, rolling modeling clay into letter shapes, tracing letters with a magnetic stylus, and using chalk and a wet sponge for writing letters on a small chalkboard. A natural question, given the nature of these kinds of activities, was whether implementing the HWT–GSS curriculum specifically would produce benefits in other fine motor parameters that were not handwriting specific. Therefore, the current study also incorporated assessment of fine motor precision and fine motor integration using the BOT–2 and determined that HWT–GSS did produce improvements in some elements of the BOT–2 that were significantly better than students receiving the Head Start curriculum alone. Specific areas of greater improvement included bilateral hand skills, cutting with scissors, folding paper, and copying various shapes.
As identified by the experimental group's BOT–2 posttest scores, this study found generalized improvement in aspects of fine motor ability using the HWT–GSS curriculum and is consistent with previous findings by Case-Smith (2002). In that study, interventions that focused on improving handwriting and were based primarily in direct handwriting activities and visual–motor activities also led to generalized improvement in visual–motor control and in-hand manipulation skills for 7- to 10-yr-old children.
Although it is convenient to think of handwriting as a relatively discrete motor task, the current study and the previous study by Woodward and Swinth (2002) clearly demonstrate the superiority of a multisensory approach to improving handwriting. In fact, the HWT–GSS curriculum uses three of the top six multisensory modalities and activities used by 60% of the respondents in the study by Woodward and Swinth (2002).
The Check Readiness tool that accompanies the HWT–GSS curriculum was created as an informal means for assessing the effectiveness of the preschool program specifically, but the Check Readiness tool is nonstandardized and has not been validated as a formal assessment of kindergarten readiness using independent, well-established instruments. The current study compared the outcomes from HWT–GSS interventions using multiple assessments. The similar results obtained using the LAP–3 Pre-Writing domain suggest that the Check Readiness tool is reliable.
Clinical Application
Results from this study support using the HWT–GSS curriculum in Head Start programs. In fact, the effect sizes associated with this treatment approach, and in this setting, provide compelling data to drive evidence-based practice resulting in modifications to include occupational therapy–based preschool handwriting readiness programs. Some of the HWT activities can be done as a whole class in circle time or in small groups. The study modified the curriculum to be carried out 3 rather than 5 times/wk, as outlined in the teacher's guide (Olsen & Knapton, 2008). These changes were made to support other Head Start curriculum objectives. Two to three occupational therapists or occupational therapy graduate students, all of whom had received training in the HWT–GSS curriculum, carried out the prewriting program. However, the HWT–GSS program was developed for implementation by school educators who had ideally been trained in the prewriting program. Using a more inclusive model through curriculum development rather than a more traditional, occupational therapy direct service model (Donica, 2010) could assist all students and could have the benefit of releasing trained occupational therapists to focus on more complicated fine motor deficits where direct services might still be appropriate and required.
Limitations and Future Research
The general premise of our work is that long-term benefits result from addressing improved handwriting readiness skills in the preschool population. These benefits may improve upper-grade skills, such as keyboarding, that have been shown to have a strong association with early handwriting ability (Erhardt & Meade, 2005; Feder & Majnemer, 2007; Jackman & Stagnitti, 2007). Although an acute benefit was identified in the current study, the durability of the effect in subsequent school settings remains unknown: Puma et al. (2010) reported that the gains made from Head Start programming in the students' performance were minimal by first grade. Other limitations include treatment dosing. For example, although we were able to determine an effect at this level of intervention, it is unknown whether more or less treatment would produce scalable effects. In addition, it is unlikely that any classroom setting will have access to two additional HWT–GSS trained personnel to supplement instruction. Plans for future research include longitudinal follow-up to determine whether the early differences established by the current study are sustained overtime.
In summary, our study demonstrates that HWT–GSS is effective in improving preschool handwriting readiness in a rural Head Start program beyond what is accomplished by the Head Start curriculum alone. The multisensory foundation of the HWT curriculum may also produce benefits in fine motor skills beyond those specific to the handwriting occupation. Although occupational therapy based, the HWT–GSS curriculum can be implemented in a general classroom setting, provided that the educator demonstrates appropriate competence with the program and trained occupational therapy practitioners are available to consult when needed. The initial results are encouraging, but the long-term benefits of this preschool intervention have not yet been determined.
Footnotes
Acknowledgments
Special appreciation goes to Emily Garner and Amy Harris for conducting the study; Robert M. Lust for data analysis and manuscript review; the Head Start director, staff, and students at the research site; Handwriting Without Tears®, for donating materials and training; Kaplan Early Learning Company, for donating assessment booklets; and East Carolina University's 2008 Clinical Scholars, Spring 2009 Graduate Assistants, and Department of Occupational Therapy.