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Effects of a Kinesthetic Cursive Handwriting

Intervention for Grade 4-6 Students

Article in The American journal of occupational therapy.: official publication of the American Occupational
Therapy Association September 2010
DOI: 10.5014/ajot.2010.08128 Source: PubMed

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Gwenyth I Roberts Jodi E Siever

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 Effects of a Kinesthetic Cursive Handwriting Intervention
for Grade 46 Students
KEY WORDS
 handwriting
 kinesiology, applied
 kinesthesis
 task performance and analysis
 treatment outcome
Gwenyth I. Roberts, MSc, BOT, is Occupational
Therapist/Clinical Leader, Regional School Health
Program, Alberta Health Services, and Occupational
Therapy Research Affiliate: Decision Support Research
Team, Alberta Childrens Hospital, Alberta Health Services,
Acadia Community Health Centre, 132-151 86th Avenue
SE, Calgary, Alberta T2H 3A5 Canada; gwen.roberts@
albertahealthservices.ca
Jodi E. Siever, MSc, is Senior Analyst/Biostatistician,
Public Health Innovation and Decision Support,
Population and Public Health, Alberta Childrens Hospital,
Alberta Health Services, Calgary, Alberta, Canada.
Judith A. Mair is Occupational Therapist, Neurosciences
Program, Alberta Childrens Hospital, Alberta Health
Services, Calgary, Alberta, Canada.
The American Journal of Occupational Therapy
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Gwenyth I. Roberts, Jodi E. Siever, Judith A. Mair
OBJECTIVE. We studied whether Grade 46 students who participated in a kinesthetic writing intervention
improved in legibility, speed, and personal satisfaction with cursive handwriting.
METHOD. Small groups of students with handwriting difficulties were seen weekly for 7 wk using a kin-
esthetic writing system. A repeated measures design was used to evaluate change in global legibility, in-
dividual letter formation, specific features of handwriting, and personal satisfaction.
RESULTS. Analysis revealed (1) a significant increase in ratings of global legibility (p < .01; clinically
significant improvements in 39% of students); (2) significant improvements in letter formation and legibility
features of baseline, closure, and line quality (all p < .05); (3) increased handwriting speed (p < .05; not
clinically significant); and (4) significant increase in measures with personal satisfaction of handwriting
(p < .01).
CONCLUSION. A kinesthetic handwriting intervention may be effective in improving the skills of students
with handwriting challenges.
Roberts, G. I., Siever, J. E., & Mair, J. A. (2010). Effects of a kinesthetic cursive handwriting intervention for grade 46
students. American Journal of Occupational Therapy, 64, 745755. doi: 10.5014/ajot.2010.08128
L earning to write legibly and efficiently is an important occupation for school-
age children. The quality of handwriting may influence academic outcomes,
with higher marks assigned for neatly written papers (Sweedler-Brown, 1992).
The nature and extent of instruction affects a students ability to perform skilled
handwriting, with explicit instruction increasing the legibility and efficiency of
written work (Goldberg & Simner, 1999), as well as improving composition
skills (Berninger et al., 1997; Graham, Harris, & Fink, 2000). Cursive script, in
which the letters within words are connected by joined strokes, has been tra-
ditionally reported to be the form of writing preferred for efficiency in legibility
and speed, although controversy does exist (Graham, Weintraub, & Berninger,
1998).
Legibility of cursive writing has been evaluated using global rating scales that
compare the individuals performance with a series of model specimens (Feder,
Majnemer, & Synnes, 2000). Legibility has also been judged in terms of
components: slant, alignment, spacing, size, and letter formation (Feder &
Majnemer, 2007). Speed has been evaluated using letters per minute, but the
use of varied instructions and task demands confounds the ability to determine
typical writing speeds across ages (Graham, Berninger, Weintraub, & Schafer,
1998).
Some students struggle in their written work, and teachers typically estimate
that 12% of children in their class have difficulties with handwriting (Barnett,
2005). Boys have primarily been identified with poor handwriting skills
(Berninger et al., 1997; Graham et al., 2000), as well as children with motor
coordination or learning disabilities (Jongmans, Linthorst-Bakker, Westenberg,
745
 & Smits-Engelsman, 2003; Missiuna et al., 2008). Graham
and Harris (2005) indicated that inadequate instruction
results in writing challenges. Handwriting difficulties may
lead children to avoid writing (Berninger et al., 1997;
Graham et al., 2000) and may affect a students motiva-
tion, self-image, and academics (Piek, Baynam, & Barrett,
2006).
Handwriting difficulties are cited as one of the most
frequently mentioned reasons for student referral to school-
based occupational therapists (Feder et al., 2000; Missiuna
et al., 2008). Studies have found that handwriting can be
improved after 910 hr of individualized occupational
therapy intervention (Case-Smith, 2002; Peterson &
Nelson, 2003). Feder et al. (2000) found that 56% of
occupational therapists surveyed provided handwriting
remediation sessions on a weekly basis.
Several studies have described features of remediation
programs to help develop handwriting skills. Laszlo and
Broderick (1991) reported that kinesthetic instruction
had a positive effect on the handwriting of students who
had difficulties, whereas Sudsawad, Trombly, Henderson,
and Tickle-Degnen (2002) found that handwriting diffi-
culties could not be improved by means of kinesthetic
training. Studies have supported reintroduction of the
letter forms explaining each form visually and verbally
(Karlsdottir, 1996), self-instruction ( Jongmans et al.,
2003), random practice (Ste.-Marie, Clark, Findlay, &
Latimer, 2004), and model/review of stroke direction be-
fore practice (Berninger et al., 1997). Little consensus has
been reached on the most effective strategy for remediation,
and further research on current remediation practices has
been recommended (Asher, 2006; Bonney, 1992).
Many occupational therapists recommend the pro-
gram Loops and Other Groups: A Kinesthetic Writing Sys-
tem (Benbow, 1990). This program focuses on the motor
aspects of cursive handwriting, with letters taught in
groups that share movement patterns. It combines sen-
sorimotor techniques, along with letter formation prac-
tice, and includes modeling and verbal analysis of letters,
motor learning through tracing, revisualization, verbal
self-guidance, handwriting from memory, and self-
assessment of letters most accurately produced. We could
not find any peer-reviewed studies evaluating the effec-
tiveness of this program; therefore, the need to evaluate
its effectiveness is evident.
Objectives
Our primary objective was to determine whether children
who participate in a kinesthetic writing intervention
would improve significantly in legibility of cursive
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handwriting. Secondary objectives were to determine
whether children who participate in a kinesthetic writing
intervention would (1) improve in speed of handwriting
at 4 mo postintervention and (2) improve in their personal
satisfaction with handwriting.
Method
Research Design
A repeated measures design, with four time points, was
used to evaluate change in legibility, speed, and personal
satisfaction with handwriting over time. The study re-
ceived ethics approval from the health region and two
school district ethics review boards.
Participants and Recruitment
A convenience sample was obtained by contacting 72
schools in Calgary and outlining the study objectives and
protocol. Participants were identified by their teachers as
having handwriting problems, determined on the basis of
the students handwriting performance within the class-
room setting. We screened the students through parent and
caregiver contact. Students who had moderate to severe
physical limitation, identified cognitive impairment, or
persistent behavioral concerns; were receiving occupational
therapy services for handwriting difficulties; or whose pa-
rents did not give informed consent were excluded.
Instruments
Handwriting Skill. Three handwriting samples were
collected from each participant to measure skill:
Copying: the phrase The quick brown fox jumped
over the lazy dogs (Sovik, 1975);
Composition: the Handwriting Subtest from the Test
of Written Language (Hammill & Larsen, 1983); and
Alphabet samples: both connected and unconnected.
Handwriting Quality and Speed. We used the following
methods of rating the quality and speed of the handwriting
samples:
The Test of Written Language (TOWL) Handwriting
Subtest Rating Scale rates global legibility of a students
composition by comparing it with a series of graded
specimens with a value ranging from 0 to 10, which is
then standardized on a scale ranging from 0 to 20.
Testretest reliability is reported at .89, interscorer
reliability at .76, and criterion validity with teacher
ratings at .46.
The Handwriting Evaluation Scale (HES; Malloy-
Miller, 1985) evaluates legibility by direct analysis of
handwriting errors, on the basis of definitions for
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 seven components of spacing within words, spacing
between words, size of letters within words, size be-
tween words, baseline orientation, closure, and line
quality. A percentage correct score (0%100%) is ob-
tained for each of the components. This instrument is
reported to have face validity by using handwriting
errors directly related to in-school handwriting tasks
(Malloy-Miller, Polatajko, & Ansett, 1995). Interrater
reliability of the HES has been reported at r 5 .94
(Roberts & Samuels, 1993).
Speed was evaluated on the copying sample, with the
student writing the phrase repeatedly until 2 min had
elapsed (Sovik, 1975). Letters per minute were calcu-
lated.
Personal Satisfaction With Handwriting. The Attitude
Scale was developed specifically for this study to measure
personal satisfaction on the basis of the semantic differ-
ential, as outlined by Mueller (1986). It consists of seven
evaluative adjective pairs specific to handwriting. State-
ments are provided, and the student places an X on one
of seven spaces on a visual analog scale that has an ad-
jective at each end. An example statement is, I feel my
handwriting is . . . with the evaluative pair ugly and
beautiful at either end of the scale. The total score on this
measure ranges from 7 to 49 points. We piloted the scale
with 122 Grade 5 and Grade 6 students, and a descriptive
analysis of the data, using histograms, successfully showed
a range in responses for each question. The Student In-
ventory (Alberta Childrens Hospital, 2001) is a non-
standardized attitude scale that includes eight questions,
each with five pictures that range from a picture of a very
happy dog (rated as 1) to one of a very unhappy dog
(rated as 5). An example of a question is, How do you
feel about how neatly you write? The total score ranges
from 8 to 40 points.
Parent and Teacher Reports. Questionnaires for parents
and teachers were designed for this study. Open-ended
questions determined the type and amount of instruction
and handwriting practice in which students participated at
home and school. Nine questions regarding attitude,
speed, and legibility were rated on a 10-point visual analog
scale; 0 indicated a poor response, and 10 indicated a good
response (e.g., How would you rate the legibility of your
childs [this students] written work?). The teacher
questionnaire included a 10th question asking whether it
was expected that written work be completed in cursive
handwriting.
Procedure and Data Collection
Testing Procedure. Testing consisted of three hand-
writing samples and the two measures of personal satis-
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faction and took place 4 times during this study. Parents
and teachers completed the questionnaires concurrently.
Intervention Procedure. The remediation program was
based on the Loops and Other Groups program and was
provided by an occupational therapist and a therapy as-
sistant. The program was extended from a 6-wk in-
tervention to a 7-wk intervention by dividing one session,
in which several new letters were introduced, into two
sessions. Small groups of students were seen once a week
for an hour after school in a quiet room in the therapy area
of a local childrens hospital. The students were evaluated
to ensure correct seating at a table as well as functional
finger and wrist posture. Pencil grips were provided as
required. Hand and arm activities occurred for 10 min at
the beginning of each session in preparation for handwrit-
ing. The letters of the lowercase alphabet were taught in
four groupings according to shared movement patterns.
These included clock climbers (a, d, g, q, c), kite strings
(i, u, w, t, j, p, r, s, o), loop group (h, k, b, f, l, e), and
hills and valleys (n, m, v, y, x, z). During the remediation
program, the student received homework sheets to be
completed nightly with their parents for 1520 min.
Data Collection. After Test 4, the composition samples
from each of the test sessions (with the date of testing
excluded) were provided to the caregiver, the teacher, and
an occupational therapist to rate global legibility using the
TOWL. Scoring instructions were provided. The occu-
pational therapist involved in the data collection was not
the same occupational therapist who administered the
intervention.
Interrater reliability of the HES was completed by two
occupational therapists who independently scored the
same three handwriting samples, after agreeing on scoring
criteria. Pearsons productmoment correlation co-
efficients ranged from .78 to .96 for the seven compo-
nents; the overall r 5 .86. The two therapists, blind to
the time of testing, scored half of the copying, compo-
sition, and alphabet samples independently, calculating
the percentage of correct responses for each of the seven
legibility components.
Sample Size. The sample size was estimated using the
paired t test of mean differences to allow for analysis of
within-participant changes preintervention and post-
intervention. Using an a of .05 and power of 80%,
a sample size of 30 was chosen because it would detect
a minimum change of 3.0 standard scores in the TOWL
(standard deviation [SD] 5 2.0), detect a minimum
change of 5.0 points in the HES (SD 5 10.0), and allow
for stratification by grade and gender.
Data Analysis. Data were entered into Microsoft Excel
2003 spreadsheets, scored with a higher score relating to
747
 a more positive outcome, and then transferred into Stata
S/E, Version 9.2 (StataCorp, College Station, TX) for
analysis. Data were checked and corrected for entry errors
by producing the range, frequency, and histogram for each
variable; no data required elimination as a result. De-
scriptive analyses were performed to examine the char-
acteristics of the children who participated in the study
and all outcome measures. Categorical variables were
expressed as frequencies and percentages, and continuous
variables were reported as means with standard deviations.
For the primary objective, graphical displays of the
median value at each time point were constructed for the
TOWL and the HES for composition, copying, and al-
phabet samples. The occupational therapists TOWL
scores were used because the return rates from the
caregiver and teacher ratings were too small to be in-
cluded. The distribution of the TOWL and all compo-
nents of the HES scores were each assessed individually
for normality using the WilkShapiro test (Shapiro &
Wilk, 1965). The normality assumption was violated;
therefore, the nonparametric Wilcoxon signed-rank test
(Wilcoxon, 1945) was used to examine the paired data
for all outcome measures (i.e., TOWL and HES).
Four separate statistical comparisons were carried out
to test the impact of the handwriting intervention: (1) Test
1 results were compared with Test 2 results to establish any
natural improvement in handwriting technique over time
without the intervention, (2) Test 2 results were compared
with Test 3 results to determine whether the intervention
was effective, (3) Test 3 results were compared with Test 4
results to assess long-term improvement after the hand-
writing intervention, and (4) Test 4 results were compared
with Test 1 results to determine improvement from the
start of the study to 4 mo postintervention.
To define a clinical indicator of success in handwriting
improvement, the five graded specimens provided in the
TOWL manual were examined a priori, and an increase of
3.0 points on the TOWL standard scale (811 yr) was set
as a clinically important change from a less to a more
legible specimen. Differences in demographic varia-
bles (e.g., gender, grade), attendance at intervention, and
reported homework practice were examined using Fish-
ers exact test (Agresti, 1992; Fisher, 1922) for a differ-
ence in proportions from Test 1 to Test 4 on the TOWL.
For the secondary objectives, speed and satisfaction
with handwriting were both examined using the non-
parametric Wilcoxon signed-rank test at the various time
points, and graphical displays of the median change over
time were constructed. Speed by grade level, as well as parent
and teacher reports, were examined descriptively with the
mean and standard deviation reported for each time point.
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All statistical tests for both primary and secondary
objectives were two-tailed, with p values of .05 considered
to be statistically significant. Childrens samples were
excluded from all analyses if students did not attend
a minimum of four treatment sessions. Analyses were
based on available data from all instruments completed in
a valid manner. Several students printed, scribbled, or left
blanks during the testing sessions; therefore, the de-
nominator varied for each measure at each time point.
Results
Recruitment, Participation, and Baseline
Characteristics
Forty-two students from 28 schools were recruited to the
study, and 32 students attended four or more of the
treatment sessions. Six group interventions occurred, with
a range of 37 students per group. There were more boys
(84%) than girls (16%), with an average age of 10.5 yr
(range 5 8 yr, 7 mo, to 11 yr, 11 mo). One-third of the
students were in each of Grades 4 (n 5 11), 5 (n 5 11),
and 6 (n 5 10). Although 25 students completed the
postintervention testing session, only 18 of those students
produced valid handwriting samples.
Primary Outcome: Legibility of Handwriting
Global Legibility. Table 1 and Figure 1 show the sta-
tistical comparisons and median scores, respectively, on
the TOWL. Scores increased during the intervention
period, and gains were maintained. There were im-
provements in handwriting from Test 1 to Test 4.
TOWL scores showed that 39% of students (7 of 18)
improved by a score of 3 or more from Test 1 to Test 4.
Seventy-five percent of Grade 6 students (6 of 8), 20% of
Grade 5 students (1 out of 5), and 40% of Grade 4
students (2 of 5) improved in their ratings on the
TOWL. However, statistically significant differences were
not found in grade-level proportions (p 5 .18), gender
(boys 5 53%, girls 5 33%, p 5 1.00), attendance at
intervention (5 sessions 5 100%, 6 sessions 5 57%, 7
sessions 5 40%, p 5 .65), or amount of homework
practice reported (<30 min per week 5 60%, 30 min
per week 5 45%, p 5 1.00).
Legibility ComponentsAlphabet Samples. Table 1 and
Figure 2 show the statistical comparisons and median
scores, respectively, for letter formation and baseline
orientation, closure, line quality, size, and space (only for
connected alphabet) components using the HES. There
were no changes in the median scores from Test 1 to Test
2, except in closure for the connected alphabet. For the
intervention period, there were positive changes for all
September/October 2010, Volume 64, Number 5
 Table 1. Statistical Comparisons Over Time for the Test of Written Language (TOWL), the Handwriting Evaluation Scale (HES), and
Personal Satisfaction With Handwriting
Test 1 to Test 2 Test 2 to Test 3 Test 3 to Test 4
(Preintervention (Intervention (Postintervention Test 1 to Test 4
Period) Period) Period) (Overall)
Measure z p z p z p z p
TOWL: Composition task n 5 24 n 5 25 n 5 18 n 5 18
2.01 .04 3.87 <.01 20.48 .64 2.70 <.01
HES: Connected alphabet n 5 24 n 5 28 n 5 19 n 5 18
Letter formation 1.87 .06 4.60 <.01 22.30 .02 3.22 <.01
Size of letters 20.33 .74 4.44 <.01 23.27 <.01 1.61 .11
Letter space 1.80 .17 4.60 <.01 21.87 .06 3.30 <.01
Baseline 1.46 .14 4.32 <.01 21.36 .17 3.44 <.01
Line quality 1.43 .15 4.62 <.01 22.57 .01 3.54 <.01
Closure 2.18 .03 4.53 <.01 21.82 .07 3.62 <.01
HES: Unconnected alphabet n 5 29 n 5 29 n 5 19 n 5 19
Letter formation 1.41 .16 4.68 <.01 22.76 <.01 3.55 <.01
Size of letters 0.32 .75 4.68 <.01 23.20 <.01 2.42 .02
Letter space 0.99 .32 4.34 <.01 21.50 .13 3.63 <.01
Baseline 0.32 .75 4.71 <.01 23.21 <.01 3.49 <.01
Line quality 1.49 .14 4.70 <.01 23.08 <.01 3.69 <.01
HES: Copying task n 5 25 n 5 25 n 5 18 n 5 17
Size within words 0.89 .37 3.61 <.01 22.57 .01 2.13 .03
Size between words 20.50 .62 2.59 .01 21.63 .10 0.62 .54
Baseline 20.11 .91 2.25 .03 1.33 .18 2.11 .04
Letter space 20.82 .41 3.11 <.01 1.11 .27 0.39 .70
Word space 20.28 .78 0.63 .53 20.76 .45 0.66 .51
Line quality 21.12 .26 3.14 <.01 2.24 .03 3.15 <.01
Closure 20.63 .53 2.11 .04 0.20 .85 1.56 .12
HES: Composition task n 5 24 n 5 24 n 5 18 n 5 18
Size within words 0.36 .72 3.00 <.01 22.16 .03 20.28 .78
Size between words 21.90 .06 2.33 .02 20.76 .45 20.68 .50
Baseline 21.70 .09 2.57 .01 21.15 .25 1.63 .10
Letter space 20.92 .36 1.87 .06 20.41 .68 0.54 .59
Word space 21.67 .95 1.67 .10 0.28 .78 20.20 .85
Line quality 0.59 .56 2.60 .01 20.81 .42 1.48 .14
Closure 21.53 .13 2.31 .02 0.37 .71 1.98 .05
Personal satisfaction n 5 31 n 5 25 n 5 25 n 5 25
Attitude Scale 2.28 .02 2.73 .01 20.77 .44 2.52 .01
Student Inventory 0.08 .94 3.54 <.01 20.27 .79 3.29 <.01
Note. The nonparametric Wilcoxon signed-rank test was used for all paired comparisons.

components in both alphabet samples. There was a de-
crease in several median scores of measures, including
letter formation, size of letters, and line quality in both
alphabet samples and in the closure variable for the un-
connected alphabet from Test 3 to Test 4. From Test 1 to
Test 4, there were significant increases in all components
in the unconnected alphabet and in all but size of letters
in the connected alphabet.
Legibility ComponentsCopying and Composition. Ta-
ble 1 and Figure 3 show the statistical comparisons and
median HES scores, respectively, for the copying and
composition samples. In the copying samples, there were
increases from Test 2 to Test 3 in all legibility components
except word space. From Test 3 to Test 4, a decrease was
noted in the size of letters within words, whereas an in-
crease was noted in line quality. There were increases from
Test 1 to Test 4 in the size of letters within words, base-
line, and line quality components. In the composition
sample, there were increases in all HES components from
Test 2 to Test 3 except in letter space and word space. The
size of letters within words demonstrated a decrease from
Test 3 to Test 4. There was an increase from Test 1 to Test
4 for the closure component. Visual inspection of Figure 3
shows that scores for the size-within-words component
were higher for the composition task, whereas scores for
line quality were higher for the copying task.
Secondary Outcome: Speed of Handwriting. Copying
speed increased from Test 1 to Test 2 (t 5 2.78, p < .01,

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 Figure 1. Global ratings of handwriting legibility on the Test of Written Language Handwriting Subtest Rating Scale.

N 5 25) and from Test 2 to Test 3 (t 5 1.98, p < .05,
N 5 25). From Test 3 to Test 4, gains were maintained,
but there were no further increases in speed post-
intervention (t 5 0.87, p 5 .38, N 5 18). An increase
was noted between Test 1 and Test 4 (t 5 2.11, p 5 .04,
N 5 17). Mean letters per minute changed from 18.7
(SD 5 16.0) at Test 1 to 23.8 (SD 5 15.8) at Test 4.
An increase in average speed of writing between Test 2
and Test 3 was observed for Grades 4 and 5 but not for
Grade 6. Increased writing speed was noted for all grades
from Test 1 to Test 4, and the greatest gains were observed
in Grade 4 students (Table 2).
Secondary Outcome: Personal Satisfaction With Handwriting.
Student Inventory scores showed an increase in personal
satisfaction over the preintervention phase. For both
measures of personal satisfaction, there was an increase
during the intervention period (Test 2 to Test 3) and overall
(Test 1 to Test 4; Table 1 and Figure 4).
Parent and Teacher Reports. Classroom instruction and
practice was reported by 9 of 24 teachers (38%), ranging
from 1 to 5 times per week for 430 min per session.
Handwriting practice at home was reported by 4 of 32
parents (13%), from 1 to 5 times per week for 525 min
in length. Table 3 shows increased ratings in the areas of
attitude, speed, and legibility on the parent and teacher
questions, with the parents reporting greater preinter-
vention to postintervention changes. Both parents and
teachers reported the largest increase on the question that

Figure 2. Component scores for the unconnected and connected alphabet.

750 September/October 2010, Volume 64, Number 5

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 Figure 3. Component scores for the copying and composition tasks.

rated the childs feelings toward handwriting. The
teachers average score for student expectation to com-
plete written work using cursive writing was 3.7 (N 5
24) preintervention and 3.5 (N 5 11) postintervention.
Discussion
The greater proportion of boys than girls recruited was
representative of the gender difference found in hand-
writing problems (Berninger et al., 1997). The Loops and
Other Groups program, presented in a small-group for-
mat, was shown to be effective in improving the partici-
pants skills. More than one-third of the students
demonstrated improvement in global legibility of cursive
handwriting in composition samples. A significant im-
provement in the cursive formations of individual letters
reflected the primary strategy of the intervention pro-
gram and is of great importance in legibility (Feder &
Majnemer, 2007). Significant improvements were identified
in the legibility components of baseline, closure, and line
quality, which are reported to relate to kinesthetic feedback
(Malloy-Miller, 1985). Parents and teachers reported im-
provements in aspects of legibility, speed, and attitude.
We found that students improved more in the
copying task than in the composition task. In the copying
samples, there were significant increases in six handwriting
components during the intervention period and in three of
the components from preintervention until 4 mo post-
intervention. In the composition sample, significant
increases occurred in five handwriting components during
intervention and in one component from preintervention
to 4 mo postintervention. Composition is reported to

Table 2. Handwriting Copying Speed, by Grade

Test 1 Test 2 Test 3 Test 4
Grade Mean Letters/Min (SD) Mean Letters/Min (SD) Mean Letters/Min (SD) Mean Letters/Min (SD)
4 6.4 (4.8) 9.9 (5.3) 15.9 (5.6) 13.3 (6.4)
n58 n58 n57 n55
5 19.0 (17.6) 18.4 (20.0) 24.0 (10.4) 20.9 (8.6)
n59 n58 n 5 10 n55
6 28.4 (14.3) 33.5 (16.2) 31.0 (13.2) 32.2 (19.4)
n 5 10 n 5 10 n 5 10 n58
Note. The number of students at each test time varies because of absences or incomplete data. SD = standard deviation.

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 Figure 4. Attitude Scale and Student Inventory for personal satisfaction with handwriting.

involve an integration and synthesis of cognitive skills
more complex than those needed for a simpler writing
task, such as copying (Amundson, 1992, p. 67). When
children focus on the mechanical aspect of handwriting,
they may not be able to fully attend to the content of
their work and vice versa (Berninger et al., 1997; Graham
& Harris, 2005). The copying phrase was used several
times in this study, and the students may have developed
skill in the formations and joins in this task. The com-
plexity of composition imposes challenges to optimal
performance of the legibility components, and consider-
ation should be given to students who have difficulties
in this area. More time and instructional probes would
be beneficial so that improved legibility could be in-
corporated gradually into compositional work.
Spacing between words did not improve significantly
on either the copying or the composition tasks, a com-
ponent that the Loops and Other Groups program does
not address. Few errors were observed in the spacing-
within-words component, and we question whether it
should be evaluated when examining handwriting legi-
bility (Roberts & Samuels, 1993). Immediately after
treatment, the students wrote larger in the provided line
space for the copy task (1.4 cm high), but initially and at
4 mo postintervention, they demonstrated a preference to
write smaller, within half of this space, eliciting size er-
rors. Fewer size errors occurred in the composition task
in which the line spacing provided for handwriting was
smaller (0.8 cm high). Studies of space size with
younger students reported more correct letter strokes
with wide-spaced paper than with normal-spaced paper
(Hill, Gladden, Porter, & Cooper, 1982; Waggoner,
LaNunziata, Hill, & Cooper, 1981). Benbow (1990),
however, found that Grade 4, 5, and 6 students scored
significantly better on the TOWL writing scale when
using narrow-ruled paper.
The speed of writing improved initially with the
students but did not continue to improve with time, as

Table 3. Parent and Teacher Report of Childs Attitude, Speed, and Legibility of Written Work
Parent Report Mean Score (SD) Teacher Report Mean Score (SD)
Test 1 Test 2 Test 3 Test 4 Test 1 Test 2 Test 3
Characteristic n 5 32 n 5 29 n 5 27 n 5 24 n 5 24 n 5 27 n 5 11
Childs attitude
1. Attitude toward completing written work 4.3 (2.6) 4.4 (2.5) 6.2 (2.1) 6.1 (2.4) 5.0 (2.2) 5.6 (2.5) 6.0 (1.8)
2. Willingness to complete written work 4.5 (2.6) 4.4 (2.6) 6.3 (2.0) 6.4 (2.4) 5.1 (2.4) 5.8 (1.3) 6.0 (1.6)
3. Feelings about handwriting 3.6 (2.3) 6.7 (2.4) 6.4 (2.6) 3.0 (2.2) 6.0 (1.0)
Childs speed
4. Completes written work in a given timeframe 4.3 (2.3) 4.7 (1.8) 6.4 (2.2) 6.1 (2.2) 4.4 (3.0) 4.9 (2.6) 5.8 (3.0)
Childs legibility
5. Writes legibly 4.3 (1.9) 4.4 (2.3) 6.2 (2.0) 6.2 (1.8) 4.2 (2.0) 5.4 (2.2) 5.1 (2.0)
6. Does not erase work 3.4 (2.0) 3.5 (2.2) 4.4 (1.7) 4.3 (1.8) 5.2 (2.3) 4.9 (1.8) 5.2 (1.4)
7. Writes normal-sized letters 4.2 (2.4) 4.6 (2.2) 6.2 (2.0) 6.2 (2.2) 4.4 (2.2) 5.0 (2.1) 5.0 (2.4)
8. Writes on a line without staying above or below the line 4.7 (2.4) 4.8 (2.6) 6.5 (2.2) 6.4 (2.3) 5.0 (2.5) 5.4 (2.0) 4.7 (2.0)
9. Makes spaces between words 6.0 (2.6) 6.1 (2.4) 7.0 (2.1) 7.1 (1.7) 5.5 (2.7) 6.3 (1.7) 5.8 (1.7)
Teacher expectation
10. Student is expected to use cursive handwriting in assignments 3.7 (3.1) 3.5 (2.8)
Notes. Scores range from 0 5 poor response to 10 5 good response; Test 4 teacher report was omitted because of new school year with a new teacher. 5 data
missing because of administrative error.

752 September/October 2010, Volume 64, Number 5

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 would be expected with practice of the skill. Even with the
significant gains made from preintervention to post-
intervention, the students continued to be well below the
norm for their grade on handwriting speed. The students
had average speeds of 1824 letters per minute, compared
with norms for Grade 4 students of 34 letters per minute,
Grade 5 of 39 letters per minute, and Grade 6 of 56
letters per minute (Coulter, Pollock, & Lockhart, 1992).
This finding is in keeping with other researchers (Jongmans
et al., 2003; Volman, van Schendel, & Jongmans, 2006),
who found that children with handwriting problems
had slower speeds of writing. On the basis of the premise
that greater handwriting speed develops with practice
(Graham, Berninger, et al., 1998), a period of >4 mo may
be required to produce ongoing increases in the speed of
handwriting. A reason for the lack of progress during the
postintervention phase may be that these students were
not expected to practice cursive writing skills in the
context of classroom work (Asher, 2006). In this study,
low teacher expectation was reported for written work to
be completed in cursive handwriting, and the students
may not have chosen to practice their newly learned skills.
A higher percentage of Grade 6 students improved in
legibility than Grade 4 or 5 students, although this finding
was not statistically significant, perhaps because of the
relatively small sample size. Graham, Berninger, et al.
(1998) found that childrens handwriting became more
legible with advancing elementary grades. The Grade 6
students had slower speed of handwriting after the in-
tervention. They may have taken more time to demon-
strate improvement in the quality of handwriting.
Weintraub and Graham (1998) found that when children
were asked to write quickly, there was a corresponding
decline in legibility; when asked to write neatly, their
speed of handwriting decreased.
Personal satisfaction improved in the students after the
intervention program. Moreover, parents and teachers
perceived a noteworthy improvement in the students
feelings toward handwriting. The cooperative, small-
group format and the improvements in cursive handwrit-
ing skills may have contributed to this improved attitude
(Townsend & Hicks, 1997). It is possible that the students
reported improved attitudes toward handwriting because
they knew that they were not alone in facing their hand-
writing challenges (Wentzel & Caldwell, 1997).
Future Research
Further research is needed to determine the intervention
programor combination of intervention components
and timing of the intervention that is most effective
(Asher, 2006; Berninger et al., 1997). Teacher and student
The American Journal of Occupational Therapy
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expectations regarding style and use of written output
needs to be explored more fully. Examination of this
programs effectiveness when delivered by others, such as
teachers, would be valuable. Explicit instruction and
practice in the motor aspect of handwriting in the regular
classroom has been recommended (Asher, 2006; Berninger
et al., 1997; Ste.-Marie et al., 2004), including monitoring
of students who present with handwriting challenges
(Graham et al., 2000). It may be that some handwriting
challenges would be reduced or eliminated with im-
plementation of a program such as Loops and Other
Groups in the classroom. Use of a structured program in
the classroom may eliminate the need for referral and in-
tervention by occupational therapy for some students.
Limited resources could then focus on the students who
would benefit most from this service (Asher, 2006).
Limitations
Several limitations, some inherent in intervention studies
with children, may have affected the results of this study.
The study used a small, convenience sample, which may
have been biased by teacher and parent interest in the
study. Some teachers may have identified their students as
having handwriting difficulties because of problems ob-
served in print style. The sample was not geographically
representative of all children in Calgary. It is not known
what influence teaching style and instruction in the
classroom had on the performance of the participants.
Data were incomplete, because not all of the children
attended all of the intervention sessions, some children
were lost to follow-up, and some test forms were not
completed adequately for analysis. Hence, given the small
sample size based on available data at each time point and
multiple testing required, caution needs to be taken when
interpreting the results.
Conclusions
The objective of this study was to determine whether
Grade 46 students who participated in a kinesthetic
writing intervention would improve in legibility, speed,
and their personal satisfaction with handwriting. The
group of students recruited was primarily boys with
handwriting challenges. Global legibility and components
of legibility improved, as well as speed of handwriting
and personal satisfaction with handwriting. The Loops
and Other Groups program appears to have had an im-
pact on developing handwriting skills with these students,
particularly in components that have been reported to be
related to kinesthetic feedback, with better performance
on copying tasks and with narrow-ruled paper. This
753
 program can be used and recommended by occupational
therapists with greater confidence, with the provision of
supplementary instruction in word spacing. Further study
is required to confirm these findings. In addition, further
evaluation of teacher expectations for cursive handwriting,
the ongoing integration of skills into daily compositional
tasks, and the use of this program in the classroom would
be beneficial. s
Acknowledgments
The study team acknowledges the children, parents, and
teachers who participated in the study. We thank the
Decision Support Research Team, particularly Suzanne
Tough, Brenda Wilson, and Karen Tofflemire; intervention
teams (Aynsley Wennberg, Chandra Kipfer); research staff
(Brigitte Roy, Gina Blumes); and leadership support (Lori
Craig, Darlene Winder, Jane Pollack). Financial support of
the Alberta Childrens Hospital Foundation and the Oc-
cupational Therapy Service and Regional School Health
Program of Alberta Health Services is acknowledged.
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