Effectiveness of a Low-Intensity,High-Frequency,Short-Duration Handwriting Intervention

PURPOSE: Handwriting is a complex and important skill used during a variety of occupations. Handwriting difficulties may impede children from accurately expressing their knowledge, limiting successful participation in occupations and negatively affecting self-esteem. Handwriting interventions described in the literature differ across a number of components, including dosage. Therapeutic dosage is an important component of clinical practice and likely influences the effectiveness of interventions.

Effective handwriting interventions in the literature have ranged in intensity from 20 to 60 min, with frequencies ranging from weekly to daily and durations ranging 8 to 48 sessions. A 2011 systematic review by Hoy and colleagues suggested that handwriting interventions should occur for at least 20 sessions. These higher intensity and high duration sessions may be burdensome to families, teachers, and children. Moreover, this dosage may not be ideal for real-world environments.

Prior studies have also included children with varying degrees of handwriting function; therefore, it remains unclear which children benefit most from handwriting intervention. The purpose of this secondary analysis was to compare the effectiveness of a top-down handwriting intervention using a therapeutic dosage of low intensity, high frequency, and short duration for children with below-average handwriting compared with those with average handwriting.

METHOD: This quasi-experimental design study was a secondary analysis from a randomized controlled trial on the effectiveness of slant boards combined with handwriting practice. Of 27 children entering the second and third grades who participated in a summer enrichment program and were recruited via email and mailed flyers, 21 children were enrolled. The sample included children with varying degrees of handwriting function who were English speaking and had difficulties with academic participation. Participants did not have a medical musculoskeletal diagnosis that limited range of motion and did not use a slanted surface to write on a daily basis.

Visual inspection of the data identified a trend that children with below-average handwriting at the start of the study improved whereas those with average handwriting did not. Therefore, the data were analyzed to compare improvement in letter formation between children with below-average handwriting and those with average handwriting.

The Test of Handwriting Skills, Revised (Milone, 2007) was used as the primary outcome measure for letter formation. The assessment was completed on the first 2 days and last 2 days of the program. Children completed a total of 15 group sessions lasting 15 min each with a frequency of three to five times a week. Sessions included instruction and practice using a modified Handwriting Without Tears curriculum. An independent samples t test was used to determine whether there was a significant difference (p < .05) between mean change in letter formation performance of children with below-average handwriting and those with average handwriting at the start of the study.

RESULTS: There was a significant difference in the change in letter formation performance between the children with below-average handwriting (M = 9.0, SD = 6.83) and those with average handwriting (M = –0.45, SD = 9.57), t(19) = 2.58, p = .02, suggesting that those with below-average handwriting made significant gains whereas those with average handwriting did not change.

CONCLUSION: This study contributes to the field of occupational therapy by providing preliminary evidence that low-intensity, high-frequency, short-duration handwriting intervention may be effective for children with below-average handwriting but may not generate changes for those with average handwriting. This dosage may be more feasible and less burdensome for families and children compared with high-intensity, low-frequency practice. Given the limited evidence comparing intervention dosages, clinicians should consider that low-intensity, high-frequency dosages may be effective for children with below-average handwriting skills.

References

Feder, K. P., Majnemer, A., & Synnes, A. (2000). Handwriting: Current trends in occupational therapy practice. Canadian Journal of Occupational Therapy, 67, 197–204. https://doi.org/10.1177/000841740006700313

Gee, B. M., Lloyd, K., Devine, N., Tyrrell, E., Evans, T., Hill, R., . . . Magalogo, K. (2016). Dosage parameters in pediatric outcome studies reported in 9 peer-reviewed occupational therapy journals from 2008 to 2014: A content analysis. Rehabilitation Research and Practice, 2016, 3580789. https://doi.org/10.1155/2016/3580789

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. https://doi.org/10.2182/cjot.2011.78.1.3

Milone, M. (2007). Test of Handwriting Skills revised manual. Novato, CA: Academic Therapy Publications.