Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. The requirements for handwriting performance continue to increase for children entering kindergarten. There is a general lack of consensus on a quantitative measure of handwriting specifically in the preschool age group. The Just Write! is a tool written by the researchers to measure functional handwriting and shows promising results in the initial standardization phase. Primary Author and Speaker: Tiffany Bolton Additional Authors and Speakers: Brittney Stevenson, William Janes

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. This scoping review, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, reviews and critiques the efficacy of interventions used to remediate handwriting skills of adults poststroke. Data sources were OT SEARCH, PubMed Central, PubMed, PsycInfo, CINAHL, and MEDLINE. Search terms were CVA, stroke, adults, handwriting, fine motor, rehabilitation, and remediation. Nineteen studies were critiqued and organized by intervention type. Few studies address remediation of handwriting skills of adults poststroke. More research is needed. Primary Author and Speaker: Beth Ekelman Contributing Authors: Kaylee A. Buchenic, Sara E. Connelly, Mallory M. Deel, Morgan M. Haynik,Joseph Morrison, and Kelle Deboth

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. Handwriting difficulties (HD) are a top reason for referral to OT. Executive function (EF) was described as an underlying mechanism of daily functioning and HD. This study found differences between handwriting of adolescents with HD and their peers with other daily function difficulties but no relation between EFs and legibility. The Handwriting Legibility Scale is suggested for evaluation of legibility in adolescents. Primary Author and Speaker: Liat Hen-Herbst

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. Aims: This quantitative study compared effects of occupation-based versus handwriting interventions on handwriting. Methods: Twenty-seven participants, mean age 6.3, participated in a 3-week study. Initially, there was no significant difference between groups on handwriting. Results: Occupation-based interventions were more effective on handwriting and visual–perceptual skills. Handwriting interventions lead to a greater gain in perceptual–motor skills. Conclusion: Both interventions are beneficial. Primary Author and Speaker: Camille Skubik-Peplaski Additional Authors and Speakers: Jennifer Hight, Laura Bray, and Carol Rushing-Carr

Date Presented 04/13/21 This presentation describes the preliminary psychometric properties of the TeleWrite, a handwriting assessment tool for children in first through third grade administered via telehealth. A series of pilot studies have been completed to determine initial interrater reliability, content validity, and clinical utility using classical test theory. Conversation about clinical use and research plans for construct validation will be facilitated. Primary Author and Speaker: Julia M. Guzman

Date Presented 04/13/21 Literature indicates a decline in musculoskeletal (MSK) fitness in school-age children. This study explored changes in Indiana schools over the generations that have impacted MSK performance. Rapid integration of technology was the primary change, with no corresponding adjustments in physical activity or physical environment. OTs can lead educational initiatives on ergonomics in the schools to promote MSK health and reduce risk of musculoskeletal disorders in students. Primary Author and Speaker: Priya Bakshi Additional Authors and Speakers: Sherrilene Classen, James Wersal Contributing Authors: Virginia Sisiopiku

Importance: Instrumental activities of daily living (IADLs) are important for independence, safety, and productivity, and people with Parkinson’s disease (PD) can experience IADL limitations. Occupational therapy practitioners should address IADLs with their clients with PD. Objective: To systematically review the evidence for the effectiveness of occupational therapy interventions to improve or maintain IADL function in adults with PD. Data Sources: MEDLINE, CINAHL, PsycINFO, OTseeker, and Cochrane databases from January 2011 to December 2018. Study Selection and Data Collection: Primary inclusion criteria were peer-reviewed journal articles describing Level 1–3 studies that tested the effect of an intervention within the scope of occupational therapy on an IADL outcome in people with PD. Three reviewers assessed records for inclusion, quality, and validity following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Findings: Twenty-two studies met the inclusion criteria and were categorized into four themes on the basis of primary focus or type of intervention: physical activity, specific IADL-focused, cognitive rehabilitation, and individualized occupational therapy interventions. There were 9 Level 1b, 9 Level 2b, and 4 Level 3b studies. Strong strength of evidence was found for the beneficial effect of occupational therapy–related interventions for physical activity levels and handwriting, moderate strength of evidence for IADL participation and medication adherence, and low strength of evidence for cognitive rehabilitation. Conclusions and Relevance: Occupational therapy interventions can improve health management and maintenance (i.e., physical activity levels, medication management), handwriting, and IADL participation for people with PD. Further research is needed on cognitive rehabilitation. This review is limited by the small number of studies that specifically addressed IADL function in treatment and as an outcome. What This Article Adds: Occupational therapy intervention can be effective in improving or maintaining IADL performance and participation in people with PD. Occupational therapy practitioners can address IADL function through physical activity interventions, interventions targeting handwriting and medication adherence, and individualized occupational therapy interventions.

Importance: Students with dysgraphia often receive test accommodations to enhance their handwriting legibility or speed. However, these accommodations are seldom individualized to ensure that they actually improve the performance of a specific student. Therefore, a need exists for an evidence-based protocol (henceforth, the Protocol) for selecting individually tailored test accommodations for students with dysgraphia. Objective: To establish the Protocol’s content validity, interrater reliability, and preliminary outcomes through a pilot study. Design: Descriptive and exploratory design. Setting: Research laboratory at a large university in central Israel. Participants: The sample consisted of 25 students (mean age = 24.9 yr, standard deviation = 2.1), of whom 88.0% were male. Inclusion criteria included a previous diagnosis of a specific learning disability and handwriting difficulties. Exclusion criteria were a physical condition or medication intake that may have affected students’ handwriting or typing ability. Results: The Protocol was found to have face validity and high interrater reliability (κ = .80). Its initial use showed that the most suitable accommodations for students with dysgraphia varied and were not always intuitive (e.g., extended time was not always the best accommodation for students with slow handwriting). Conclusions and Relevance: The Protocol appears to be a promising tool to assist occupational therapists in selecting the most appropriate accommodations for students with dysgraphia in a systematic manner. However, additional studies are required to further support these results. What This Article Adds: This study indicates that the selection of the most appropriate accommodation for students with dysgraphia is not always intuitive. It describes a Protocol that enables occupational therapists to select accommodations that are tailored to students’ writing abilities, following a systematic process, while considering the students’ writing performance with and without accommodations.

OBJECTIVE. Our objective was to translate the Here’s How I Write: A Child’s Self-Assessment and Goal Setting Tool (HHIW) to Portuguese; adapt it to the Brazilian culture; and analyze its reliability, validity, and clinical feasibility. METHOD. The study was developed in two steps: adaptation of the HHIW to Brazilian Portuguese, followed by experimental application to examine its validity and reliability. The participants were 60 children and their teachers, divided into two groups: Group 1, whose members had handwriting difficulties, and Group 2, whose members did not. RESULTS. Children with poor handwriting scored lower on the HHIW for both self- and teacher report. Test–retest reliability of the children’s (.96) and teachers’ (.93) questionnaires as well as internal consistency (.91 and .95, respectively) were excellent. There was good agreement (.74) between the children’s and teachers’ total scores. CONCLUSIONS. This study adds further evidence of validity and reliability and supports the international use of the HHIW. The HHIW is a useful resource to engage children and teachers in a collaborative relationship to improve handwriting.

OBJECTIVE. This study investigated the psychometric properties of the Here’s How I Write–Hebrew (HHIW–HE) and compared handwriting self-awareness between children with and without dysgraphia. METHOD. Fifty-eight children (29 with and 29 without dysgraphia) completed the HHIW–HE. Occupational therapists provided corresponding ratings that were based on objective handwriting assessments. Self-awareness was measured through child–therapist consensus. RESULTS. The HHIW–HE has an internal consistency of α = .884. Children with dysgraphia rated themselves as significantly more impaired than controls on 6 of 24 HHIW–HE items and on the total score, with medium to large effect sizes (0.37–0.61). Mean child–therapist agreement was significantly higher for the controls than for the research group, t(56) = 4.268, p = .000. CONCLUSION. Results support the HHIW–HE’s validity. Children with dysgraphia reported more handwriting difficulties than did controls; however, they tended to overestimate their handwriting abilities.

Challenges with handwriting can have a negative impact on academic performance, and these challenges are commonly addressed by occupational therapy practitioners in school settings. This systematic review examined the efficacy of curriculum-based interventions to address children’s handwriting difficulties in the classroom (preschool to second grade). We reviewed and computed effect sizes for 13 studies (11 Level II, 2 Level III) identified through a comprehensive database search. The evidence shows that curriculum-based handwriting interventions resulted in small- to medium-sized improvements in legibility, a commonly reported challenge in this age group. The evidence for whether these interventions improved speed is mixed, and the evidence for whether they improved fluency is insufficient. No clear support was found for one handwriting program over another. These results suggest that curriculum-based interventions can lead to improvements in handwriting legibility, but Level I research is needed to validate the efficacy of these curricula.

Handwriting is the cornerstone of written performance and communication for school-age children. This mixed-methods study explored the impact of Common Core State Standards on handwriting instruction and its effects on perceptions regarding children’s written responses in elementary school. Using surveys and interviews of elementary teachers, occupational therapists, and administrators in New York State public schools, we sought to understand current trends in handwriting instruction, changes in time spent on handwriting instruction in the classroom, supports offered to students who did not meet expectations for handwriting, and the impact of Common Core on children’s written expression. Themes emerged revealing decreased handwriting instruction time and inconsistent use of handwriting instructional programs in the classroom after implementation of Common Core. Handwriting should be considered as a greater component in the foundational standards in Common Core. Occupational therapy services can support handwriting instruction implementation.

OBJECTIVE. We examined the effectiveness of an occupational therapist–led handwriting intervention for special education and at-risk kindergarteners. METHOD. We incorporated a two-group, pretest–posttest design. Both groups consisted of kindergarteners receiving individualized education program (IEP) or Response to Intervention (RtI) support. An occupational therapist provided biweekly group handwriting instruction using the Size Matters Handwriting Program to students in the intervention group (n = 23). The control group (n = 12) received the standard handwriting instruction. RESULTS. Students in the intervention group demonstrated significantly greater gains in handwriting legibility than students in the control group. Students in the intervention group also demonstrated significantly greater gains in the prereading skills of uppercase letter recognition, lowercase letter recognition, and letter sound recognition. CONCLUSION. This study provides preliminary support for an occupational therapist–led handwriting intervention to improve writing legibility and letter recognition in kindergarteners receiving RtI and IEP supports.

We determined whether a widely used assessment of visual–motor skills, the Beery–Buktenica Developmental Test of Visual–Motor Integration (VMI), is appropriate for use as an outcome measure for handwriting interventions. A two-group pretest–posttest design was used with 207 kindergarten, first-grade, and second-grade students. Two well-established handwriting measures and the VMI were administered pre- and postintervention. The intervention group participated in the Size Matters Handwriting Program for 40 sessions, and the control group received standard instruction. Paired and independent-samples t tests were used to analyze group differences. The intervention group demonstrated significant improvements on the handwriting measures, with change scores having mostly large effect sizes. We found no significant difference in change scores on the VMI, t(202) = 1.19, p = .23. Results of this study suggest that the VMI may not detect changes in handwriting related to occupational therapy intervention.

OBJECTIVE. To establish hand strength development trends in children with autism and to investigate correlations between grip and pinch strength, components of handwriting, and functional activities in children with and without autism. METHOD. Fifty-one children were divided into two groups: typically developing children and children on the autism spectrum. Each child completed testing for pinch and grip strength, handwriting legibility, pencil control, and independence in functional activities. RESULTS. The children with autism followed the same strength development trends as the typically developing children. Grip strength correlated with pencil control in both groups and with handwriting legibility in the typically developing children but not in the children with autism. Grip and pinch strength correlated with independence with functional activities in both groups. CONCLUSION. This study provides evidence that grip and pinch strength are important components in developing pencil control, handwriting legibility, and independence with functional fine motor tasks.

Handwriting is a critical skill for school success. Children with fetal alcohol spectrum disorders (FASD) often present with fine motor and visual–motor impairments that can affect handwriting performance, yet handwriting skills have not been systematically investigated in this clinical group. This study aimed to comprehensively describe handwriting skills in 20 school-age children with FASD. Children were tested with the Process Assessment of the Learner, 2nd Edition (PAL–II), and the Visuomotor Precision subtest of NEPSY, a developmental neuropsychological assessment. Participants performed below average on PAL–II measures of handwriting legibility and speed and on NEPSY visual–motor precision tasks. In contrast, PAL–II measures of sensorimotor skills were broadly within the average range. Results provide evidence of functional handwriting challenges for children with FASD and suggest diminished visual–motor skills and increased difficulty as task complexity increases. Future research is needed to further describe the prevalence and nature of handwriting challenges in this population.

OBJECTIVE. We investigated differences in handwriting kinetics, speed, and legibility among four pencil grasps after a 10-min copy task. METHOD. Seventy-four Grade 4 students completed a handwriting assessment before and after a copy task. Grip and axial forces were measured with an instrumented stylus and force-sensitive tablet. We used multiple linear regression to analyze the relationship between grasp pattern and grip and axial forces. RESULTS. We found no kinetic differences among grasps, whether considered individually or grouped by the number of fingers on the barrel. However, when grasps were grouped according to the thumb position, the adducted grasps exhibited higher mean grip and axial forces. CONCLUSION. Grip forces were generally similar across the different grasps. Kinetic differences resulting from thumb position seemed to have no bearing on speed and legibility. Interventions for handwriting difficulties should focus more on speed and letter formation than on grasp pattern.

OBJECTIVE. Pencil grasps other than the dynamic tripod may be functional for handwriting. This study examined the impact of grasp on handwriting speed and legibility. METHOD. We videotaped 120 typically developing fourth-grade students while they performed a writing task. We categorized the grasps they used and evaluated their writing for speed and legibility using a handwriting assessment. Using linear regression analysis, we examined the relationship between grasp and handwriting. RESULTS. We documented six categories of pencil grasp: four mature grasp patterns, one immature grasp pattern, and one alternating grasp pattern. Multiple linear regression results revealed no significant effect for mature grasp on either legibility or speed. CONCLUSION. Pencil grasp patterns did not influence handwriting speed or legibility in this sample of typically developing children. This finding adds to the mounting body of evidence that alternative grasps may be acceptable for fast and legible handwriting.

OBJECTIVE. We explored the efficacy of robotic technology in improving handwriting in children with impaired motor skills. METHOD. Eighteen participants had impairments arising from cerebral palsy (CP), autism spectrum disorder (ASD), attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), or other disorders. The intervention was robotic-guided three-dimensional repetitive motion in 15–20 daily sessions of 25–30 min each over 4–8 wk. RESULTS. Fine motor control improved for the children with learning disabilities and those ages 9 or older but not for those with CP or under age 9. All children with ASD or ADHD referred for slow writing speed were able to increase speed while maintaining legibility. CONCLUSION. Three-dimensional, robot-assisted, repetitive motion training improved handwriting fluidity in children with mild to moderate fine motor deficits associated with ASD or ADHD within 10 hr of training. This dosage may not be sufficient for children with CP.

OBJECTIVE. We examined the relationship between handwriting and keyboarding performance and between these writing modes and underlying performance skills. METHOD. Sixty-three young, healthy adults who used the computer daily were recruited for this study by means of a convenience sample (mean = 25.3, standard deviation = 3.0); 15 were slow keyboarders and 17 were fast keyboarders. Participants were administered handwriting and keyboarding assessments, as well as measures of finger function, kinesthetic processing, and eye movement. RESULTS. Although handwriting and keyboarding speed were moderately correlated, these activities did not share underlying performance skills. In addition, different correlation patterns between written communication modes and performance skills were found among slow and fast keyboarders. CONCLUSION. Results suggest that occupational therapists and educators should consider a variety of factors before recommending keyboarding as an alternative written communication method for people with handwriting difficulties. Moreover, different recommendations appear to be warranted for slow and fast keyboarders.