Monday, August 13, 2018

The Grind: EBP Review - A Systematic Review of the Efficacy of Handwriting Programs

Last year, I completed two courses in Evidenced Based Practice (EBP).  Prior to them, I thought I was doing my due diligence in reading and applying knowledge learned through continuing education courses and reading articles both peer reviewed and not.  But I was completely missing the ball on being an effective consumer of research. It's not just about reading the content, but also analyzing it.  Basically, how efficiently did the authors answer the WH questions of who? what? when? where? why? how?   Therefore, in an effort to keep my brain percolating with the evidence to make informed decisions in treatment and evaluation, I will share my interpretations of current studies and how they might apply to school-based services.  

Welcome to The Grind.

I was intrigued when I came across the systematic review by Engel, Lillie, Zurawski, and Travers (2018).   Engel et al. searched through 455 sources to get to 13 studies that met the extensive criteria of peer-reviewed journal articles within 2006 and 2015 that examined if, which, and by how much handwriting curricula were effective in improving legibility, speed, and fluency.  Ultimately, the studies that were robust enough to be included in the analysis focused on the following handwriting curriculum-based interventions:
  • The Write Start
  • Peterson Directed Handwriting Curriculum
  • Handwriting Without Tears (PreK and Elementary)
  • Fine Motor and Early Writing Pre-K curriculum (which seems to be a part of the Pathways to Learning by Mead)
  • Size Matters
  • Write Direction (only found a reference to it on YouTube)
  • handwriting clubs
  • Explicit Handwriting Program
Nitty Gritty
  • Curriculum-based handwriting programs (CBHP) do have a positive effect on legibility/letter formation.  Size Matters, Write Start, and Explicit Handwriting Program had the biggest effect sizes on legibility
  • There is mixed evidence that supports CBHPs improving speed of handwriting, in fact it may slow some children down
  • There isn't enough evidence that CBHP improves fluency of writing
  • There were not significant relations between age of instruction or amount of time spent on instructing and outcome on legibility or speed
So what did this mean to me?
  • I have been a user of Handwriting Without Tears for years.  I can say that I may not use every piece of the curriculum with the fidelity to the extent that I would like, but I believed that the curriculum was based in research.  But clearly, there are many other handwriting curricula available on and off the market that can have an impact. 
  • I am going to have to do some professional development on the Write Start and Size Matters.  It might be worth it for me to expand my repertoire of interventions to see if either would be relevant for my caseload.  Heck, I am pretty confident I have a manual somewhere in my office at work for at least one of them.   
  • I could not find anything about what exactly the Explicit Handwriting Program was or how it was implemented, so it's not high on my radar.
  • And if the curriculum do not impact speed of handwriting, what does? Guess I'll have to do more searching.
The nice thing about systematic reviews is that the authors are taking on the brunt of the work.   Are there limitations?  Of course!  As a consumer of research,  you are dependent on the authors to include what you are looking for in population, intervention, and outcome.   However, systematic reviews typically give you the most bang for the buck.  You can always dive further into specifics by weeding through the references.  If you don't have NBCOT or AOTA membership, I highly recommend that you get it.  They provide you with access to research relevant to practice.  It really is worth every penny.  If not, there are other avenues to try, that I will address in later posts.

Let me know what you thoughts are. 

Engel, C., Lille, K., Zurawski, S. & Travers, B. G. (2018). Curriculum-based handwriting programs: A systematic review with effects sizes.  American Journal of Occupational Therapy, 72,


  1. I found this article interesting as well as I do for most research reviews. So helpful, to us as clinicians and applying the research into practice. Here is some evidence on handwriting speed

    1. Thank you! I thought it was really interesting that there wasn't much on speed in particular; that being said I figured as motor fluency improves then it would carryover to speed. If not, then assistive technology options should really be considered. Can't wait to read your findings on speed!