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Table of Contents
Year : 2019  |  Volume : 51  |  Issue : 3  |  Page : 85-89

To develop an occupational therapy kit for handwriting skills in children with dysgraphia and study its efficacy: A single-arm interventional study

1 Department of Rehabilitation Sciences, Sarth Foundation, DAWN Autism School, Pune, Maharashtra, India
2 Department of Rehabilitation Sciences, Jamia Hamdard University, New Delhi, India
3 Department of Occupational Therapy Unit, Sir Ganga Ram, Max Healthcare and Apollo Cradle Hospital, Delhi and Head of Sensitivity Early Intervention Centre and Child's Skill Enhancement Clinic, New Delhi, India

Date of Submission10-Dec-2018
Date of Acceptance01-Jul-2019
Date of Web Publication20-Sep-2019

Correspondence Address:
Dr. Monika Verma
G55 A, East Vinod Nagar - Mayur Vihar, Phase 2, Delhi - 110 091
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijoth.ijoth_20_18

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Background: Handwriting is a complex perceptual-motor skill dependent on the maturation and integration of a number of cognitive, perceptual, and motor skills. Handwriting develops through instruction and is a complex process of managing written language by coordinating the eyes, arms, hands, pencil grip, letter formation, and body posture. Handwriting Without Tears Methodology™ (HWT) is an established handwriting curriculum created by Jan Olsen and is used by occupational therapy (OT) practitioners in traditional one-on-one service delivery. It is also designed for full classroom implementation and instruction and is used in thousands of Mainstream and Special Schools across the world. Objectives: The objective of the study is to analyze the impact of handwriting intervention with OT Kit (OTK) in treating children with dysgraphia (OTK included HWT products, other multisensory material, and fine-motor activities) and to establish the norms on OTK to enable it to be used by therapists for handwriting intervention in India. Study Design: Single-arm interventional study design was chosen for the research. Methods: In a pre- and post-single-arm interventional study design, 40 children diagnosed as dysgraphia (age group 6–11 years; male:female: 31:9) were recruited from a regular school and OT clinic. The handwriting performance was assessed using HWT Screener™ for 1st, 2nd, 3rd, and 4th Grade from mainstream school and the Print tool®. The intervention using OTK was based on HWT program™, multisensory activities, and fine-motor activities. Results: Boys had difficulty in lowercase formations more than girls, and 9-year olds were found to have maximum difficulties in sequencing and memory components of written production. Variables of memory, placement, letter, and word spacing have shown maximum improvement. Where the primary outcomes are P < 0.05; 95% confidential interval [CI]: −4.15 to −1.61 (memory), −14.58 to −4.91 (letter spacing). Analysis of HWT screener shows memory, placement, orientation, and sentence formation to have maximum improvement in students of Grade 1st to 3rd where P < 0.05; 95% CI: −18.56 to −10.18 (memory) and P < 0.05; 95% CI: −12.49 to − 5.88 (placement). In Grade 4th variables, word and capital cursive have shown better improvement than lowercase cursive P < 0.05; 95% CI: −31.54 to − 11.49 (word cursive). Conclusions: OTK (HWT™ manipulatives, multisensory products, and fine-motor activities) was found to be beneficial in improving the handwriting skills in Indian children with dysgraphia. Significant benefits were seen in boys and younger children, when receiving HWT curriculum instructions.

Keywords: Dysgraphia, Handwriting Without Tears™, Occupational Therapy Handwriting Kit

How to cite this article:
Verma M, Begum R, Kapoor R. To develop an occupational therapy kit for handwriting skills in children with dysgraphia and study its efficacy: A single-arm interventional study. Indian J Occup Ther 2019;51:85-9

How to cite this URL:
Verma M, Begum R, Kapoor R. To develop an occupational therapy kit for handwriting skills in children with dysgraphia and study its efficacy: A single-arm interventional study. Indian J Occup Ther [serial online] 2019 [cited 2023 Jun 7];51:85-9. Available from: http://www.ijotonweb.org/text.asp?2019/51/3/85/267479

  Introduction Top

Handwriting is a complex perceptual-motor skill that is dependent on the maturation and integration of a number of cognitive, perceptual, and motor skills.[1] It is a complex process of managing written language by pencil grip, letter formation, and body posture. Handwriting is not only the most important academic requirement but is also used in our daily life, e.g., filling forms, taking notes, making lists, putting up reminders, and so on. Poor handwriting can have a significant effect on school performance and children who lack some of these skills may miss learning opportunities and lack self-esteem. Handwriting difficulties are reported more frequently among boys than girls but most improve, given the right help.[2]

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, considers specific learning disabilities to be a type of neurodevelopmental disorder that impedes the ability to learn or use specific academic skills (e.g., reading, writing, or arithmetic), which is the foundation for other academic learning.[3] Dysgraphia is a deficiency in the ability to write, primarily handwriting, but also coherence. Dysgraphia is a transcription disability, meaning that it is a writing disorder associated with impaired handwriting, orthographic coding, and finger sequencing the movement of muscles required to write.[4],[5]

Occupational therapist implement methods described in the Handwriting Without Tears (HWT) program based on the specific needs of the child. HWT manipulatives used to reinforce the learning include use of stamp and see-screen and wet-dry-try method using sponges, chalk, and chalkboard. Handwriting practice using other multisensory products include Play-Doh, therapy putty, and colored sand.[6]

The objectives of the study were to analyze the impact of handwriting intervention with Occupational Therapy Kit (OTK) in treating children with Dysgraphia (OTK included HWT products, other multisensory material, and fine-motor activities) and to establish the norms on OTK to be used by therapists for handwriting intervention in India.

  Methods Top

Study Design and Participants

We conducted a preintervention and postintervention single-arm interventional study to investigate the efficacy of OT treatment on handwriting skills of children diagnosed with dysgraphia. Convenience sampling was used from schools and OT clinics, wherein 40 children of age group 6–11 years; (male: n=39 and female: n=9) were recruited in the study. Children with handwriting difficulties in grades 1st to 4th from various schools were selected, and they underwent detailed psychometric analysis to diagnose dysgraphia. The diagnosed children fulfilling the criteria were selected for the study. Few children diagnosed with dysgraphia who were attending Sensitivity Clinic for their intervention were enrolled in the study. The study protocol period was conducted from January 20, 2017 to March 25, 2017 at Sensitivity Early Intervention Centre and Child's Skill Enhancement Clinic, Delhi.


Permission was obtained from various schools. Children were selected as per the inclusion criteria, i.e., age group 6–11 year, children diagnosed with dysgraphia by a clinical psychologist and exclusion criteria were children with long-term medical problem such as epilepsy, any injury, fracture, and overlapping diagnoses such as attention-deficit hyperactivity disorder (ADHD) or autism spectrum disorder. The written informed consent form upon approval from the Ethics Committee was filled by their parents/guardians. The Print Tool™ and Handwriting Screener™ were used to assess the handwriting of children. Due permission was obtained for both the scales, though Handwriting Screener is a free to use scale. Administered individually, the Print tool evaluates capitals, numbers, lowercase letters, and seven specific handwriting components: memory, orientation, placement, size, start, sequence, and word spacing. When scored, the evaluation form shows exactly which letters/numbers and components are causing difficulty. Identified children were subjected to treatment sessions on three sessions per week program for 2 months including 12 therapy sessions and 2 detailed pre- and post-assessments, and duration of 45 min each was devoted for each session. OT tool kit was implemented to improve handwriting skills. The posttherapy assessment was done after 2 months, and data were analyzed statistically.

Outcome Measure

  1. The Print Tool description: The Print Tool is a complete printing assessment for students age six and older. The Print Tool assesses capitals, numbers, and lowercase letter skills. The skills evaluated include: memory, orientation, placement, size, start, sequence, control, and spacing[7]
  2. HWT™ Screener: It seeing the need for a tool that teachers can use to quickly and easily identify classes and students struggling with handwriting, HWT, and a team of OT and educators developed the screener of handwriting proficiency. This whole class screening tool let's focus classroom instruction in handwriting by monitoring critical and measurable skill areas where students need instruction and intervention throughout the year.[7]


  1. HWT™: Handwriting workbook (as per child's level), HWT notebook paper, pencils for little hands, HWT stamp, and see screen and wet-dry-try method
  2. Multisensory activities: Play-Doh, Therapy putty, finger spacer, Wikki Stix, and colored sand
  3. Fine-motor Activities: Tennis buddy and small manipulatives, therapy band, just right pressure kit, pom pom balls, and animal tongs.

Data Analysis

IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, New York was used to analyze the data. For single group pre- and posttherapy comparison of data, paired sample t-test was used. The level of significance was set at P < 0.05 and 95% confidence level (95% confidential interval) values were also computed for the analysis.

  Results Top

The handwriting performance was assessed using The Print Tool and HWT Screener which was administered to each child prior and postintervention session. The scores were computed and data were recorded to analyze changes. The data were analyzed in consultation with an expert statistician. In Grade 1st, 2nd, and 3rd variables of memory, placement, and sentences are highly significant. In grade 4th, word and capital cursive are highly significant [Table 1] and [Table 2], and in Print Tool, capitals, lowercase, letter spacing, and word spacing are highly significant [Table 3]. Boys have shown better improvement in memory of alphabets and sequence and formation of lowercase letters.
Table 1: Comparison between Pre- and Post-Intervention Score of Handwriting Without Tears Methodology™ Screener Grade 1, 2, and 3

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Table 2: Comparison between Pre-and Post-intervention score of Handwriting Without Tears Methodology™ Screener Grade 4th

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Table 3: Comparison between the Pre-and Post-intervention score of the Print Tool

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  Discussion Top

Handwriting difficulties are observed in 10%–30% of school-age children with and without identified disabilities.[8] Children experiencing handwriting impairments tend to have lower achievement in mathematics, lower verbal IQ, and greater attention difficulties than their peers without impairments,[9] resulting in decreased ability to interact and engage in classroom settings. Poor handwriting can also lead to limited compositional fluency,[10] issues with taking legibility of handwriting notes and reading them later, and more time needed to finish assignments.[11]

In this study, the OTK was established as a comprehensive “oneinall” kit, [Table 4] including HWT manipulatives, multisensory products, and finemotor activities to intervene in children with dysgraphia. As mentioned in the definition, all areas of deficit were targeted using the OTK specifically orthographic coding, finger sequencing, and transcription difficulty. OTK has been adapted from a previous Study “School-Based Tele rehabilitation in OT: Using Tele rehabilitation Technologies to Promote Improvements in Student Performance.”[6] In the study, specific use of the HWT double-lined paper improved the “size” component of handwriting significantly. Grade 1 students were able to generalize this learning.[12] Students received handwriting instructions in all areas for uppercase letters in a developmental sequence.[13] HWT Workbook “Letters and Numbers for me” taught the placement and sequence of lowercase letters.[14] We implemented the exact methods described in the HWT curriculum teacher's guides. HWT manipulatives used to reinforce the learning include use of stamp and see-screen and wet-dry-try method using sponges, chalk, and chalkboard.[6],[15]
Table 4: Occupational Therapy Tool Kit

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In a previous study,[6] the OTK was developed for a telerehabilitation program, where the therapist provided online consultation specifically focusing on OT intervention for students with deficits in the area of fine-motor or visual-motor skills that affected handwriting performance. The students involved in this program revealed 100% satisfaction with the overall quality of the program.[6] Our study worked specifically on children with dysgraphia in a clinical setting. The authors intend to expand the scope of the study by implying online consultation with the provision of OTK. The study could also be expanded to other areas of handwriting deficit not limited to dysgraphia.

Limitation of the Study

  • Duration of the study was very short that is 8 weeks
  • Children with dysgraphia need more therapy sessions for significant improvement to occur
  • The sample size was small
  • Narrow age range study can provide better ideas in planning therapy protocol and OTK
  • We excluded children with overlapping ADHD, which could have provided variations to the results and methodology applications.

Future Recommendations

The study provided a structured OT protocol to improve handwriting skills in children, including the materials to be used, the OTK. For further research, the study should be conducted with a larger sample group. Number of sessions should be increased to improve the quality of intervention and effectiveness of the strategies. The OTK can be used to study its efficacy in children with handwriting difficulties not limited to dysgraphia. We can conduct studies in younger age group, especially at 3–4 years of age when children start showing early sign of writing difficulties to have early and sustained outcome. An online model, based on the previous study, should be modeled as the need of the hour.

  Conclusions Top

It was found that OTK (using multisensory, fine motor, and HWT) is beneficial in improving the handwriting skills. Particular benefits were seen in boys and younger children who performed better when receiving HWT instructions. Structured handwriting programs such as HWT can be used more widely to establish better efficacy on handwriting and academic performance.

Children were interested and happy to perform the multisensory activities, fine motor, and handwriting in a playful manner and have shown good results in various domains.


I would like to thank the Almighty God and my Parents. I extend my deepest gratitude to Prof M. Yaqoob Kharadi, Dean, School of Medicine and Prof. R.C. Jiloha, HOD, Department of Rehabilitation Sciences, Jamia Hamdard for giving me the permission to conduct this study. I would like to thank Dr. K.P Singh and Ms. Shilpa Chawla to permit me the data collection. I would like to give special acknowledgment for all my children's and their parents.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

  References Top

Hamstra-Bletz L, Blöte AW. A longitudinal study on dysgraphic handwriting in primary school. J Learn Disabil 1993;26:689-699.  Back to cited text no. 1
BrockFernette E. Hyperion. The Mislabeled Child: how understanding your Child's Unique Learning Style Can Open the Door to Success. 1st ed. Greater Seattle Area Education Management University of California, San Francisco - School of Medicine, Founders of Eide Neurolearning Clinic; 2006.  Back to cited text no. 2
Tannock, R. DSM-5 Changes in Diagnostic Criteria for Specific Learning Disabilities (SLD): What are the implications? International Dyslexia Association 2014. Available from: https://www.psychiatry. org/.../specific-learning-disorder/what-is-specific-learning-disorder... [Last accessed on 2019 Aug 01].  Back to cited text no. 3
Princeton- Spince Brain Anatomy: Dynamic Assessment from American Speech-Language-Hearing Association Dysgraphia; 2000. [Last updated on 2015 Mar 13].  Back to cited text no. 4
Dysgraphia. Available from: http://ldaamerica.org/types-of-learning-disabilities/dysgraphia. [Last retrieved on 2015 Mar 15].  Back to cited text no. 5
Criss MJ. School-based telerehabilitation in occupational therapy: Using telerehabilitation technologies to promote improvements in student performance. Int J Telerehabil 2013;5:39-46.  Back to cited text no. 6
Zwicker JG, Hadwin AF. Cognitive versus multisensory approaches to handwriting intervention: A randomized controlled trial OTJR: Occupation, Participation and Health 2009;29:40-48.  Back to cited text no. 7
Feder KP, Majnemer A. Handwriting development, competency, and intervention. Dev Med Child Neurol 2007;49:312-317.  Back to cited text no. 8
Sandler AD, Watson TE, Footo M, Levine MD, Coleman WL, Hooper SR, et al. Neurodevelopmental study of writing disorders in middle childhood. J Dev Behav Pediatr 1992;13:17-23.  Back to cited text no. 9
Graham S, Berninger V, Weintraub N, Schafer W. Development of handwriting speed and legibility in grades 1-9. J Educ Res 1998;92:42-52.  Back to cited text no. 10
Engel-Yeger B, Nagauker-Yanuv L, Rosenblum S. Handwriting performance, self-reports, and perceived self-efficacy among children with dysgraphia. Am J Occup Ther 2009;63:182-192.  Back to cited text no. 11
Roberts GI, Derkach-Ferguson AF, Siever JE, Rose MS. An examination of the effectiveness of handwriting without tears instruction. Can J Occup Ther 2014;81:102-113.  Back to cited text no. 12
Delegato C, McLaughlin TF, Mark Derby K, Schuster LD. The effects of using handwriting without tears and a handwriting racetrack to teach five preschool students with disabilities pre handwriting and handwriting. J Occup Ther Sch Early Interv 2013;6:255-268.  Back to cited text no. 13
Donica DK. Handwriting without tears(®): General education effectiveness through a consultative approach. Am J Occup Ther 2015;69:1-8.  Back to cited text no. 14
McHale K, Cermak SA. Fine motor activities in elementary schools. Preliminary findings and provisional implications for children with fine motor problems. Am J Occup Ther 1992;46:898-926.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4]

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