RESEARCH SCHOLARS INITIATIVE

Effectiveness of a Handwriting Readiness Program in

Head Start: A Two-Group Controlled Trial

Carol A. Lust, Denise K. Donica

KEY WORDS OBJECTIVE. This study measured skill improvement in prewriting skills, kindergarten readiness, first-
 early intervention (education) name writing, and handwriting-nonspecific fine motor skills of students at Head Start who participated
in Handwriting Without TearsÒ–Get Set for School (HWT–GSS) programming.
 handwriting
METHOD. We conducted a two-group, nonrandomized controlled trial using a pretest–posttest design at
 motor skills
a rural Head Start. The effectiveness of adding the HWT–GSS curriculum in one preschool classroom was
 rural population
compared with a control classroom.
RESULTS. On posttesting, the experimental group made significant improvements compared with the
control group in prewriting, kindergarten readiness, and fine motor skills. Both groups made significant
improvements between pretesting and posttesting in prewriting, first name writing, and school readiness.
CONCLUSION. Adding HWT–GSS to the Head Start program would be beneficial in improving hand-
writing readiness skills.

Lust, C. A., & Donica, D. K. (2011). Research Scholars Initiative—Effectiveness of a handwriting readiness program in Head
Start: A two-group controlled trial. American Journal of Occupational Therapy, 65, 560–568. doi: 10.5014/
ajot.2011.000612

H
Carol A. Lust, EdD, OTR/L, is Associate Professor, andwriting is an essential skill young children must acquire; it is emphasized
Occupational Therapy Department, East Carolina
in preschool through elementary grades. Handwriting is more than a simple
University, Greenville, NC.
fine motor task; it requires performance in perceptual–motor skills, motor
Denise K. Donica, DHS, OTR/L, BCP, is Assistant planning, visual perception, visual–motor integration, bilateral hand skills, in-
Professor, Occupational Therapy Department, East
hand manipulation, kinesthesia, sustained attention, sensory processing, and the
Carolina University, 600 Moye Boulevard, Health
Science Building 3305, Greenville, NC 27834; presence of proper biomechanical components for posture and hand grip
donicad@ecu.edu (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

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 assignments, and mental flexibility to complete compo- Assessment of Learning, 3rd Edition (Mardell-Czudnowski
sition activities. In addition, handwriting difficulties may & Goldenberg, 1998) in their total score, motor, con-
predict reading challenges, whereas success in name cepts, and language scores but not higher than students
writing may predict future success in reading achievement who attended other school programs.
(Berninger et al., 2006; Haney, 2002). Moreover, diffi- Peterson and Nelson (2003) demonstrated the effec-
culty with early automatic handwriting mechanics and tiveness of occupational therapy interventions in significantly
speed correlates with difficulties in subsequent keyboarding improving handwriting skills. First-grade children from
skills (Connelly, Gee, & Walsh, 2007). economically disadvantaged families received 20 biweekly
As a result of increased handwriting demands in sessions incorporating biomechanical, sensorimotor, and
kindergarten, handwriting skills in preschool have become teaching and learning principles. Each 30-min session in-
a predictor of kindergarten handwriting performance cluded 5 min of small-group (5 students each) sensori-
(Fogo, 2008). Multisensory handwriting intervention has motor “heavy work” activities, including jumping and
been effective in improving handwriting skills (Peterson running; 20 min of individualized activities (including
& Nelson, 2003; Zwicker & Hadwin, 2009). Some ed- motor planning, motor memory, and self-monitoring of
ucators have suggested that handwriting skill deficits exist writing position and posture); and 5 min spent practicing
because insufficient attention is given to handwriting skill writing letters. Together, these studies suggest that preschool
development during school, not because specific client and elementary school children from low socioeconomic
factors limit student abilities (Asher, 2006). Occupational backgrounds may be at greater risk for having handwriting
therapists are trained to properly assess how client factors challenges, and an occupational therapy–based approach to
affect prewriting and writing performance and to address assist handwriting development may be beneficial.
how a child’s environment and context will influence Occupational therapists in the school system help
school success (Cahill, 2009). In fact, recent reports in- students benefit from the general education curriculum.
dicated that school systems are the primary place of Therefore, improving students’ ability to take notes and
employment for 23% of all occupational therapists in the complete written work is a concern of the occupational
United States (National Board for Certification in Oc- therapist. The role of the school occupational therapist is
cupational Therapy, 2008). Having preschool classroom evolving from that of a direct service model to a more
teachers implement an occupational therapy–based cur- inclusive model that incorporates teacher training, con-
riculum to teach handwriting readiness skills reflects sultation, and curriculum decisions (Donica, 2010). The
a more inclusive service model that benefits all students. current study is an example of this progression; it demon-
Head Start is a federal initiative implemented through strates the effectiveness of embedding occupational ther-
the U.S. Department of Health and Human Services apy strategies and techniques into a Head Start setting using
(DHHS) “to promote the school readiness of low-income the Handwriting Without TearsÒ–Get Set for School
children by enhancing their cognitive, social, and emo- (HWT–GSS) handwriting readiness curriculum (Olsen
tional development” (Chandler & Lucas, 2010, p. 27). & Knapton, 2008) to improve handwriting skills.
Bowman and Wallace (1990) established that children HWT, developed by an occupational therapist for
from lower socioeconomic backgrounds had a higher risk multiple grade levels, is a full curriculum for developing
of challenges with hand strength, visual–motor develop- prewriting and writing skills; it uses multisensory activities
ment, and praxis, of which all affect handwriting. Local presented in developmentally appropriate sequences. The
nonprofit organizations, in conjunction with local edu- HWT–GSS program was designed to help preschool
cation agencies, administer the Head Start programs. children develop the prewriting skills necessary for kin-
During fiscal year 2009, Head Start served 904,153 chil- dergarten by incorporating playing, singing, motor skills,
dren nationally and has served >27 million children since social and emotional development, body awareness skills,
1965 (DHHS, 2010). cognitive and language skills, sensory processing, and
A 5-yr randomized study of approximately 5,000 visual–perceptual skills (Olsen & Knapton, 2008). Sim-
3- and 4-year-old children clearly demonstrated the benefit ilar multisensory approaches have been recommended in
of Head Start programs for children’s learning experi- the mainstream elementary classroom, including drawing
ences through effects on cognitive development, health large letters on the blackboard, tracing letters in multi-
development, and parenting practices (Puma et al., 2010). sensory substances, forming letters using modeling clay,
Seemungal (2009) found that preschoolers attending a and tracing large letters in the air (McMurray, Drysdale,
Head Start program scored higher than those without pre- & Jordan, 2009). HWT–GSS has been studied with
school experience on the Developmental Indicators for the another student group, but methodological considerations

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 limit the usefulness of the findings and provide little book, and the Fine Manual Control composite of the
guidance in extrapolation to the current study population BOT–2.
(Carlson, McLaughlin, Derby, & Blecher, 2009). To our Learning Accomplishment Profile, 3rd Edition. The LAP–3
knowledge, no studies have been published evaluating is a criterion-referenced test to assess skill development of
HWT–GSS effectiveness in a preschool classroom. In children ages 36–72 mo in gross motor, fine motor, pre-
addition, we identified no other handwriting readiness writing, cognitive, language, self-help, and personal and
curriculum effectiveness studies. social skills. Only the Pre-Writing domain was used for
Although data suggest that an occupational therapy– this study. The LAP–3 has well-documented test–retest
based handwriting curriculum should be both effective reliability for ages 37–72 mo (r 5 .99) and interrater re-
and useful if implemented in a Head Start setting, there liability for ages 33–73 mo (r 5 .97).
is little direct supporting evidence. We used a non- Check Readiness. Check Readiness is a non-
randomized, two-group, controlled trial to determine the standardized tool used to show skill progression related to
relative effectiveness of implementing the HWT–GSS developmental kindergarten readiness skills. It includes
program in a Head Start setting. We attempted to answer crayon grasp, object recognition, coloring, tracing and
the following three research questions: copying shapes, number and letter recognition, drawing
1. Was HWT–GSS more effective than the traditional a person, and printing first name in capital letters. The
Head Start curriculum for teaching handwriting number of successful responses in a series of activities is
counted. To generate statistical comparisons between
readiness skills, as identified by the Learning Accom-
groups, we normalized all raw scores as a percentage of the
plishment Profile, 3rd Edition (LAP–3; Hardin &
maximum possible score. Within each activity, average
Peisner-Feinberg, 2004) Pre-Writing domain test
raw scores were compared, and comparisons were made
scores?
using the percentage correct of total responses. This
2. Did using HWT–GSS lead to greater improvement in
scoring system is semiquantitative, based on a series of
kindergarten readiness skills, as identified by compar-
present or absent skill demonstrations, and has not yet
ing Check Readiness (Olsen & Knapton, 2008) and
been validated in the literature.
name writing scores? HWT–GSS includes only capital letters as the pre-
3. Did HWT–GSS activities lead to improvement in school expectation, and the Check Readiness score was
handwriting-nonspecific fine motor skills, as demon- determined on that basis. The local Head Start program,
strated by comparing the Bruininks–Oseretsky Test of however, expects students to write their names using
Motor Proficiency, 2nd Edition (BOT–2; Bruininks & upper- and lowercase letters. Therefore, participants
Bruininks, 2005), Fine Manual Control composite and wrote their first name a second time using upper- and
subtest scores? lowercase letters (which are taught in the kindergarten
HWT curriculum). The two name components (all
Method capitals and upper- and lowercase) were scored using an
adapted version of the Print Tool (Olsen & Knapton,
Research Design 2006), which was previously validated for this purpose
We conducted a two-group, nonrandomized controlled but not for this age group. The Print Tool includes eight
trial using a pretest–posttest design at a rural Head Start scoring criteria, of which four were selected for use with
the scoring of student names: (1) memory (writing the
program. All aspects of the study were reviewed and ap-
letter without a sample), (2) orientation (correct di-
proved by the East Carolina University Health Systems
rectionality), (3) start (correct position), and (4) control
Institutional Review Board before initiation. Written
(fluidity and neatness). Students received a point for each
approval was obtained from appropriate Head Start ad-
correct criterion for each letter attempted. Total points
ministrators. Informed parental consent was obtained for
and total possible attempts were computed for each cri-
all participants using permission forms signed by the terion. The total points and attempts were calculated and
Head Start director and principal investigator. then divided, resulting in the average modeling the Print
Tool scoring process.
Instruments
Bruininks–Oseretsky Test of Motor Proficiency, 2nd
Components of three instruments were used in data Edition. The BOT–2 is a commonly used standardized
collection, the Pre-Writing domain of the LAP–3, the test designed to quantify the motor skills of people ages
Check Readiness tool in the HWT–GSS student work- 4–21 yr. It includes four composites of two subtests

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 each. For this study, only the Fine Manual Control gested follow-up activities for the teacher to facilitate the
Composite, including Fine Motor Precision (Subtest 1) other days. A total of 47 sessions occurred; all students
and Fine Motor Integration (Subtest 2), was adminis- participated in at least 31 sessions. Students attended an
tered. Fine Motor Precision addresses bilateral hand skills average of 42 (standard deviation [SD] 5 4.66; 89.3%)
and accuracy with cutting, folding paper, and coloring. sessions, and 15 of the 17 students attended at least
Fine Motor Integration measures visual–motor skills de- 38 sessions. The HWT–GSS Teacher Guide (Olsen &
termined by copying various shapes. Both subtests eval- Knapton, 2008) provided a 5 day/wk classroom in-
uate participants’ skills in integrating visual perception struction schedule that was used as a template for de-
with hand and finger motor movements. Internal con- veloping the 3 day/wk intervention schedule used in the
sistency reliability for Fine Manual Control has been current study. Everyone conducting interventions had
established in 4-yr-olds (r 5.87) and 5-yr-olds (r 5 .86). uniform training of the HWT–GSS curriculum to ensure
The BOT–2 has published test–retest reliability for Fine consistency, which was important because the study de-
Manual Control with 4- to 7-yr-olds (r 5 .81; Bruininks sign precluded randomization or blinding procedures.
& Bruininks, 2005).
Data Collection Schedule
Participant Selection Pre- and posttest data were collected within a 2-wk time
The participants were children enrolled in one of two frame immediately before and immediately after the study.
classrooms in a rural Head Start program. For convenience, Because of a limited time frame for data collection, addi-
the Head Start director selected the participating class- tional occupational therapy graduate students, who had
rooms. All students in one classroom were arbitrarily been trained in the assessments, assisted with test admin-
assigned to the control group, and all the students in an- istration. Interrater reliability testing was not performed
other classroom were assigned to the experimental group. because of its potential effect on children’s performance and
Pretest scores from all students were compared to verify that unnecessary additional time out of class. Investigators were
sampling bias was not inadvertently introduced on the basis not blinded to group assignment during assessment. Op-
of the groupings. Inclusion criteria included enrollment in portunity for subjective observer bias in testing was limited
one of the two identified classrooms, age 4 or 5 yr, and by the objectivity of the scoring instruments used. We
parental permission. Exclusion criteria included any reviewed all data scoring.
identified cognitive or physical deficit(s) that could interfere
with fine motor task ability. None of the participants were Intervention Fidelity
excluded from the trial on the basis of these criteria. Everyone administering the HWT–GSS programming was
formally trained in the curriculum, and everyone admin-
Intervention istering the assessment instruments had been trained in the
The experimental group participated in HWT–GSS in proper administration of the battery. Graduate students
addition to the Head Start curriculum, whereas the met with us weekly to review progress, and we were on site
control group completed only the standard Head Start and actively engaged in all aspects of the intervention and
curriculum. Scheduled interventions began with a 5-min assessment process. Finally, we reviewed all data scoring,
warm-up activity, led by two occupational therapy graduate without respect to grouping or person administering the
students, followed by a 15-min small-group activity test, to verify accuracy of reporting and scoring.
(1 adult, 5 students). The adults included the two graduate
students, the authors, and a Head Start teacher. Small- Data Analysis
group activities included body awareness skills, directional Statistical comparison between pretest and posttest per-
concepts, and letter-play activities and progressed to color- formance within a group was performed using paired t tests,
ing and tracing of capital letters and shapes. All intervention and comparisons between the experimental and control
activities followed the HWT–GSS program and were child groups were performed using unpaired t tests. In each case,
friendly, developmentally appropriate, and multisensory significance was accepted when p < .05. GraphPad Prism
(Olsen & Knapton, 2008). Each session ended with a brief (3rd ed.; GraphPad Software, Inc., San Diego, CA) was
whole-class review, positive feedback, and a closing song. used to conduct the data analysis. Primary analysis was
conducted on BOT–2 Fine Manual Control composite
Intervention Schedule standard mean score, the LAP–3 individual Pre-Writing
Intervention sessions occurred 3 times/wk from October domain mean score, and HWT–GSS total percentage
to March, as regular school calendars allowed, with sug- score. Secondary analysis was conducted on BOT–2 Fine

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 Motor Precision and Fine Motor Integration standard that at least 90% of participating children come from
scores and on Check Readiness individual percentage families below the Federal Poverty Level, receive public
scores for each of the 13 items. assistance, or be involved in foster care (DHHS, 2007).
Pretesting with each of the instruments revealed no
Effect Size differences between the groups on any of the performance
Effect size was calculated using standard formulas, and indexes tested, either by score or by variance in score.
Cohen’s d value was reported as the coefficient repre- Pretesting was completed and equivalence was verified
senting effect size. Effect size was assigned as small when before the study was begun.
0.2 £ d £ 0.49, as medium when 0.5 £ d £ 0.79, and
Summary of Findings
as large when d ³ 0.80 (Cohen, 1988).
There were no significant differences between the two
groups in pretesting scores for the LAP–3 Pre-Writing
Results domain (Ms ± SDs 5 22.00 ± 5.19 control and 22.38 ±
Participant Flow and Demographics 4.54 experimental, p 5 .83); the Check Readiness tool
(Ms ± SDs 5 26.27 ± 12.46 control and 34.59 ± 14.68
At the onset of the study, there were 40 participants, experimental, p 5 .09), or the BOT–2 Fine Manual
ranging in age from 4 yr, 0 mo, to 4 yr, 11 mo. All students Control composite (Ms ± SDs 5 34.73 ± 10.43 control
were classified as minority, and all came from low socio- and 40.76 ± 8.06 experimental, p 5 .75).
economic status families. The experimental group and the The pre- and posttesting LAP–3 sum scores for the
control group each had 20 students, and pretesting Pre-Writing domain in each group are presented in Figure
was completed with all 40 students. Eight participants 1. Significant improvements in the posttest sum scores
dropped out during the 5-mo study (experimental group, were observed in both the experimental group and the
n 5 3; control group, n 5 5). The loss of participants was control group, but the experimental group scored signifi-
caused by circumstances beyond our control, primarily cantly higher (Ms ± SDs 5 24.00 ± 4.87 control, 29.00 ±
family relocation. For final data collection, only the 32 4.65 experimental, p 5 .0058). In comparing the means,
students with both pretest and posttest data were included a large treatment effect was determined (d 5 1.05).
in the final data analysis. The groups were not different The pre- and posttesting Check Readiness sum scores
by average age (at pretest, mean [M] age ± SD 5 55.9 ± are presented in Figure 2. Significant improvements in
3.48 mo in the control group and 55.4 ± 3.74 mo in the posttest sum scores were observed in the experimental
experimental group, p 5 .69) but were significantly dif- group and the control group, but the experimental group
ferent in gender distribution (experimental group: 8 boys, scored significantly higher (Ms ± SDs 5 34.27 ± 11.51
9 girls; control group: 10 boys, 5 girls, x2 5 14.492, df 5 control, 44.59 ± 12.63 experimental, p 5 .022), consis-
14, p < .001). tent with a large treatment effect (d 5 0.86). Comparing
individual components of the Check Readiness tool in-
Sample Size Justification and
dicated that the improvement in sum score was related
Power Analysis
Using an anticipated score improvement of 30%, a standard
deviation in measurement of 5%, a power of .80, and a 5
.05, power analysis predicted a minimum of 12 partic-
ipants 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 socioeco-
nomic background, but as noted, the difference in gender
Figure 1. Significant improvements in the Learning Accomplish-
distribution was significant. Individual socioeconomic levels
ment Profile, Third Edition (LAP–3) Pre-Writing domain scores
were not determined directly, but income eligibility for were observed in the experimental group (large treatment effect
Head Start is legislatively defined. Federal statute requires [d 5 1.05]; p values for individual comparisons are as noted).

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 posite 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 ³10%, whereas
10 of 17 students (59%) in the experimental group
showed composite score improvements of ³10% (x25
27.94, df 5 14, p < .001).
A more detailed analysis of the BOT–2 scoring is
presented in Figure 3, where the results of the two subtests,
Figure 2. Significant improvements in the Check Readiness sum Fine Motor Precision (Subtest 1) and Fine Motor In-
scores were observed in both the control and the experimental
groups (large treatment effect [d 5 0.86]; p values for individual tegration (Subtest 2) standard scores are summarized. Fine
comparisons are as noted). Motor Precision standard posttest scores were significantly
higher in the experimental group (M ± SD: 8.47 ± 4.31
to significant differences in five major components that control, 11.29 ± 3.33, experimental, p 5 .045) and dem-
generally demonstrated large treatment effects (name in onstrated a medium treatment effect (d 5 0.74). Similarly,
capitals, 0.78; name in title case, 0.77; crayon grip, 0.31; Fine Motor Integration standard posttest scores also were
copy shape, 1.15; draw a person, 1.79) and are summa- significantly higher in the experimental group (Ms ± SDs 5
rized in Table 1. There were no differences between the 7.47 ± 5.08 control, 12.00 ± 5.37 experimental, p 5 .021)
groups at pretesting in any of the identified items. Al- showing a large treatment effect (d 5 0.87).
though summary scores improved in both groups, for
these components, improvements between pre- and
posttesting were seen in only two of five items in the Discussion
control group, compared with five of five items in the Students in both the experimental group and the control
experimental group. Moreover, where improvements group made significant improvements in their hand-
were seen, the improvements were consistently greater in writing readiness skills over the course of the study.
the experimental group. Therefore, the study extends the findings that Head Start
Significant improvements in the pre- and posttesting programs are effective in improving general preschool
BOT–2 Fine Manual Composite scores were not ob- readiness and handwriting readiness specifically (Puma
served in either the experimental group or the control et al., 2010). However, this is the first report to dem-
group, but the posttest scores were significantly higher in onstrate that supplementing the standard Head Start
the experimental group (Ms ± SDs 5 33.80 ± 10.46 curriculum with an occupational therapy–based, multi-
control, 42.18 ± 8.27 experimental, p 5 .017) also sensory approach significantly improves handwriting
showing a large treatment effect (d 5 0.89). The com- readiness beyond what is accomplished by Head Start

Table 1. Summary of Pretest and Posttest Scoring in Components of the Check Readiness Tool
Pretest Scores Posttest Scores p
Pre vs. Post Pre vs. Post
Item Control Experimental Control Experimental Pre vs. Pre Post vs. Post (CON) (EXP)
Name in capitals 14.33 ± 23.33 31.94 ± 27.43 27.13 ± 23.29 45.41 ± 23.68 .062 .035 .036 .010
Name in upper- 13.27 ± 23.65 23.94 ± 27.99 24.40 ± 28.90 46.24 ± 28.01 .256 .038 .178 .002
and lowercase
Crayon grip 1.43 ± 0.85 1.35 ± 0.79 1.67 ± 0.62 1.82 ± 0.39 .799 .392 .165 .007
Copy shapes 2.07 ± 1.62 3.18 ± 1.81 3.53 ± 1.19 4.71 ± 0.85 .079 .003 .010 .001
Draw a person 3.87 ± 2.33 5.53 ± 3.28 3.80 ± 1.52 7.53 ± 2.65 .113 .001 .909 .011
Note. Name in capitals and name in upper- and lowercase were scored using four criteria described by Olsen and Knapton (2006). Pre vs. Pre 5 pretest control
group compared with pretest experimental group score; Post vs. Post 5 posttest control group compared with posttest experimental group score; Pre vs. Post
(CON) 5 pretest score compared with posttest score in the control group; Pre vs. Post (EXP) 5 pretest score compared with posttest score in the experimental
group.

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 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 pre-
cision 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.
Figure 3. Neither the experimental group nor the control group As identified by the experimental group’s BOT–2
showed significant improvement between pretest and posttest posttest scores, this study found generalized improvement
scores on the Bruininks–Oseretsky Test of Motor Proficiency, 2nd in aspects of fine motor ability using the HWT–GSS
Edition (BOT–2), Subtest 1 (Fine Motor Precision) or Subtest 2.
Posttest Subtest 1 and Subtest 2 scores were significantly higher
curriculum and is consistent with previous findings by
in the experimental group (p 5 .045, medium treatment effect Case-Smith (2002). In that study, interventions that fo-
[d 5 0.74]; p 5 .021, large treatment effect [d 5 0.87], cused on improving handwriting and were based pri-
respectively). marily in direct handwriting activities and visual–motor
activities also led to generalized improvement in visual–
programming alone. Calculated effect sizes for the motor control and in-hand manipulation skills for 7- to
HWT–GSS experimental group ranged from moderate 10-yr-old children.
to very large, compared with Head Start programming Although it is convenient to think of handwriting as
alone. Therefore, HWT–GSS remains effective in im- a relatively discrete motor task, the current study and the
proving handwriting readiness skills, even when admin- previous study by Woodward and Swinth (2002) clearly
istered in a modified schedule, and LAP–3 is a sensitive demonstrate the superiority of a multisensory approach to
instrument for detecting the effects. improving handwriting. In fact, the HWT–GSS curriculum
Peterson and Nelson (2003) previously reported that uses three of the top six multisensory modalities and
providing occupational therapy intervention to first-grade activities used by 60% of the respondents in the study by
children from lower socioeconomic backgrounds could Woodward and Swinth (2002).
improve handwriting skills. Our study extends these ef- The Check Readiness tool that accompanies the HWT–
fects in school-aged children to preschool children. It GSS curriculum was created as an informal means for
remains to be determined whether the improvement seen assessing the effectiveness of the preschool program spe-
in the current study will ultimately improve handwriting cifically, but the Check Readiness tool is nonstandardized
skill development in the schools and reduce the occupa- and has not been validated as a formal assessment of
tional therapy referrals of children who need handwriting kindergarten readiness using independent, well-established
intervention (Asher, 2006; Jackman & Stagnitti, 2007, instruments. The current study compared the outcomes
Schneck & Amundson, 2010). from HWT–GSS interventions using multiple assessments.
The revised edition of HWT–GSS includes addi- The similar results obtained using the LAP–3 Pre-Writing
tional multisensory activities and tracing workbook pages domain suggest that the Check Readiness tool is reliable.
and a 28-wk teaching guideline for implementation of
the curriculum (Olsen & Knapton, 2008). Although Clinical Application
other prewriting materials are commercially available, to Results from this study support using the HWT–GSS
our knowledge, no handwriting readiness classroom curriculum in Head Start programs. In fact, the effect
curricula have evidence-based findings published. sizes associated with this treatment approach, and in this
The HWT–GSS program is multisensory based. setting, provide compelling data to drive evidence-based
Activities include making letters with wooden pieces, practice resulting in modifications to include occupa-
singing songs with coordinated actions, rolling modeling tional therapy–based preschool handwriting readiness
clay into letter shapes, tracing letters with a magnetic programs. Some of the HWT activities can be done as
stylus, and using chalk and a wet sponge for writing a whole class in circle time or in small groups. The study

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 modified the curriculum to be carried out 3 rather than tioners are available to consult when needed. The initial
5 times/wk, as outlined in the teacher’s guide (Olsen & results are encouraging, but the long-term benefits of this
Knapton, 2008). These changes were made to support preschool intervention have not yet been determined. s
other Head Start curriculum objectives. Two to three
occupational therapists or occupational therapy graduate
Acknowledgments
students, all of whom had received training in the HWT–
GSS curriculum, carried out the prewriting program. Special appreciation goes to Emily Garner and Amy Harris for
However, the HWT–GSS program was developed for conducting the study; Robert M. Lust for data analysis and
implementation by school educators who had ideally manuscript review; the Head Start director, staff, and students
been trained in the prewriting program. Using a more at the research site; Handwriting Without TearsÒ, for do-
inclusive model through curriculum development nating materials and training; Kaplan Early Learning Com-
rather than a more traditional, occupational therapy pany, for donating assessment booklets; and East Carolina
direct service model (Donica, 2010) could assist all University’s 2008 Clinical Scholars, Spring 2009 Graduate
students and could have the benefit of releasing trained Assistants, and Department of Occupational Therapy.
occupational therapists to focus on more complicated
fine motor deficits where direct services might still be References
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