Journal of Occupational Therapy, Schools, & Early

Intervention

ISSN: 1941-1243 (Print) 1941-1251 (Online) Journal homepage: http://www.tandfonline.com/loi/wjot20

Effectiveness of an intensive handwriting program

for first grade students using the application
LetterSchool: A pilot study

Géraldine Jordan OT, Bsc, Fanny Michaud OT, Bsc & Marie-Laure Kaiser OT,
Msc, PhD

To cite this article: Géraldine Jordan OT, Bsc, Fanny Michaud OT, Bsc & Marie-Laure Kaiser OT,
Msc, PhD (2016) Effectiveness of an intensive handwriting program for first grade students
using the application LetterSchool: A pilot study, Journal of Occupational Therapy, Schools, &
Early Intervention, 9:2, 176-184, DOI: 10.1080/19411243.2016.1178034

To link to this article: http://dx.doi.org/10.1080/19411243.2016.1178034

Published online: 07 Jun 2016.

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 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION
2016, VOL. 9, NO. 2, 176–184
http://dx.doi.org/10.1080/19411243.2016.1178034

Effectiveness of an intensive handwriting program for first

grade students using the application LetterSchool: A pilot
study
Géraldine Jordan, OT, Bsca, Fanny Michaud, OT, Bscb, and
Marie-Laure Kaiser, OT, Msc, PhDc
a
Puzzle Consulting sÁrl, Bulle, Switzerland; bAlter-ergo, Romont, Switzerland; cOccupational Therapy
Department, University Hospital of Lausanne, Lausanne, Switzerland
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ABSTRACT ARTICLE HISTORY

The purpose of this pilot study is to analyze the efficacy of a program Received 24 July 2014
that combines fine motor activities, animated models, exercises on a Accepted 2 December 2015
digital tablet and paper-pencil exercises. The 10-week program with a KEYWORDS
45-minute session and daily exercises was implemented in a class of 16 Handwriting; occupational
students of first grade (mean age = 6.9 years old), with another class of therapy; school; technology
14 students following the regular program (mean age = 6.7 years old).
Among these two classes were five pairs of twins (8 girls, 2 boys). In this
article, we present the results of only these 10 children. The BHK, Concise
Assessment Method for Children’s Handwriting, was administered at
baseline and immediately after the program. Twins of the experimental
group made significant gains in handwriting legibility compared with
the twins in the control group. No difference was found for handwriting
speed. The implemented program appears to promote handwriting
quality in the early stage of learning but needs further investigations.

The ability to write is one of the most fundamental occupations a child must learn during
the first years of school. Despite the increase of computer use, handwriting is still the most
important means used by students to show academic learning (Chien, Brown, &
McDonald, 2010). Students are very frequently referred to occupational therapists (OT)
because of illegible handwriting (Hammerschmidt & Sudsawad, 2004).
Several factors influence handwriting. There are intrinsic components (internal capacities
of the child) and extrinsic components (environmental and biomechanical factors) (Kaiser,
2009). Intrinsic components are fine-motor function, visual perception, eye-hand coordina-
tion, motor planning, visual-motor integration, reading, sentence memory, visual attention,
and sensory functions. We can add age and sex of the child. (Cornhill & Case-Smith, 1996;
Feder & Majnemer, 2007; Kaiser, 2009). Visual-motor integration, gender, and fine-motor
control seem to have a predictive value of handwriting quality among young children (Feder &
Majnemer, 2007).
Fine-motor control plays a role in handwriting legibility. Volman, Van Schendel, and
Jongmans (2006) found a significant difference between poor and good writers in a test
measuring finger and manual dexterity. Cornhill and Case-Smith (1996, p. 738) found a strong

CONTACT Géraldine Jordan geraldinejordan2@gmail.com Puzzle Consulting sÁrl, Fin des Fourches 24, 1673 Rue,
Bulle, Switzerland.
© 2016 Taylor & Francis
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 177

correlation between the quality of handwriting and movements of translation and rotation.
Regarding handwriting speed, translation movements are the best predictors of quality of
handwriting. However, these findings are controversial because Bara and Gentaz (2011)
found nonsignificant results regarding the influence of fine-motor control on handwriting.
Extrinsic factors also influence the quality and fluidity of handwriting. The most
important factors are described in this article. Effective methods are investigated in
many studies. First, a global practice should be preferred to a partial practice. A global
practice is suitable for tasks wherein different parts must be coordinated with each other
frequently (Schmidt & Lee, 2005). A global practice means to write the entire letter instead
of each part separately. The programs described in the literature as effective use entire
letters or groups of letters (Case-Smith, Holland, & Bishop, 2011; Denton, Cope, & Moser,
2006; Kaiser, Albaret, & Doudin, 2011; Lust & Donica, 2011).
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The use of models has been studied in the literature. According to Schmidt and Lee (2005,
p. 330), providing only verbal instructions is not sufficient to facilitate motor learning. An
interesting technique is modeling: the execution of a demonstration by the teacher to enable
the learner to observe elements of the action. Berninger et al. (1997) compared approaches to
automating processes related to motor control. Five teaching methods were tested among 144
children of grade 1. Teaching handwriting using whichever method is more effective than
training the control group in phonological awareness. The group who follows the method
with visual clues—model of the letter with arrows indicating the direction—and memory
retrieval achieved the best results in terms of quality. In 2010, Vinter and Chartel tried
different ways of teaching with a model among children age 5.6 years. The best-performing
group was the one who benefited from an animated model of the letter.
Two ways of teaching handwriting that are frequently used and that provide intrinsic
feedback are tracing and copying. Studies struggle to establish the superiority of tracing
compared to copying. Tracing is most appropriate for visual feedback but is not recom-
mended for storage. Copying is more advantageous in terms of theories of learning
transfer and storage (Gonzalez et al., 2011).
The purpose of this study is to investigate the effects of a program combining fine-
motor exercises, animated models, intrinsic feedback, and modeling provided by the
application LetterSchool on a digital tablet. Handwriting quality and speed were measured
and compared with the results of a class with an ordinary program.

Methodology
Despite the fact that there is no sample randomization, a quasiexperimental pretest/
posttest control group design was utilized. Teachers of two first grade classes of an
English-speaking school in Switzerland volunteered their students to be participants in
the study. One class constituted the experimental group and the other, the control group.

Participants
The experimental group included 16 children, 5 boys and 11 girls of first grade (mean age
= 6.9 years); the control group comprised 14 children, 6 boys and 9 girls (mean age = 6.7
years). The exclusion criterion was the refusal of parents to allow the child’s participation
in the study. The inclusion criteria are (1) student was enrolled in two classes during the 3
 178 G. JORDAN ET AL.

months, and, for students in the experimental group, (2) 80% had completed major
sessions of our program and (3) had completed the pre- and postassessment as a whole.
The basis sample included five pairs of twins (8 girls, 2 boys, mean age = 6.7 years), with
one twin in the experimental group and one in the control group. Two sets of twins were
homozygous and three, heterozygous. Of these three heterozygous pairs, one pair was a girl
and a boy. None of the 10 children were excluded from the study. Thus, we chose to analyze
this subpopulation because the children had similar socioeconomic and educational back-
grounds and, for the two pairs of identical twins, the same genetic attributes. The equiva-
lence between the twins in the experimental group and control group at pretest was verified
by the Wilcoxon Signed Rank Test because the samples are time dependent (Portney &
Watkins, 2009, p. 503). There is no significant difference between the twins of the experi-
mental and control groups regarding the quality (p = 0.4) and speed of handwriting (p =
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0.69), showing a high degree of homogeneity in this subgroup. For this reason, this feature
was interesting to highlight the results between the experimental and control groups.

Outcomes measures
The BHK, Concise Assessment Method for Children’s Handwriting, (Charles, Albaret, &
Soppelsa, 2004) was used to compare handwriting quality of the students. This instrument
was used during both pretest and posttest to document any significant differences within the
classrooms and to determine progress after the use of our program versus a teacher-designed
format. This scale was developed in the Netherlands in order to have a tool to establish a rapid
and early diagnosis of disturbances of writing in children 6 to 10 years (Charles et al., 2004).
After writing, the analysis is performed according to 13 criteria: (1) letter size, (2) left-margin
widening, (3) poor word alignment, (4) insufficient word spacing, (5) acute turns in connecting
letters or too long joining (chaotic writing), (6) irregularities in joining strokes, (7) collision of
letters, (8) inconsistent letter size, (9) incorrect relative height of letters, (10) letter distortion,
(11) ambiguous letter forms, (12) correction of letter forms, and (13) unsteady writing trace.
Because we were in an English-language school and the BHK is not validated in this
English, we took the text proposed in the McMaster Handwriting Assessment Protocol
(Pollock et al., 2008). Regarding metric qualities, BHK shows good sensitivity to changes in
age for the total score by the French calibration of Charles et al. (2004). For concurrent
validity, the results of the Dutch calibration appointed by Charles et al. showed a correlation
of 0.78 with the scale of dysgraphia (Ajuriaguerra, Auzias, & Denner, 1964). Construct
validity was demonstrated following a comparison of a group with dysgraphia and a control
group. Indeed, dysgraphic children have results within 8.6% of the highest calibration BHK,
which are significantly different from those of the control group (Hamstra-Bletz as cited in
Charles et al., 2004, p. 62). Using the McMaster Handwriting Assessment Protocol text, the
validity of this study was not as good as the use of the original BHK text.
To measure handwriting speed, students’ writing was timed during the pretest and the
posttest.

Procedure
The project has received the school direction and the Human Research Ethics Committee of
the Vaud agreement. The experimental handwriting program took place every school day and
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 179

was planned as follows: 10 minutes of writing exercises each day and a 45-minute handwriting
lesson on Wednesday. During this longer lesson, one OT student who created the program
was providing assistance. The experimental teacher and the student collaborated closely
through email exchanges. The teacher was really involved in the program, understood well
the issues of the study, and followed it thoroughly.
The second OT student was not present during the program and did the administration
and scoring of the assessment. Therefore she could not be influenced by the experimental
procedure. All assessment (experimental and control) were scored by this same blind
assessor.
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Intervention
For this study, we set up a 10-week program combining different lessons of handwriting.
The program began on Wednesday with a lesson session of 45 minutes. Until the next
Wednesday, the children performed 10 minutes of daily exercises. Wednesday’s lesson
consisted 10 minutes of fine-motor exercises, 20 minutes of learning two or three lower-
case letters with LetterSchool, and 10 minutes of paper and pencil exercises on white
paper. During the paper-pencil exercises, the children copied several times the letters
learned during the session. On Thursday, the children worked for 10 minutes on upper-
case letters with LetterSchool. On Friday, 10 minutes were devoted to handwriting
exercises on paper, providing a transition between blank and lined sheets. On Monday,
the paper-pencil exercises were done on lined paper, and Tuesday was dedicated to the
creation of words containing the letters of the week, also on lined paper.
The program guides the overall learning of the letter without the training of the various
parts of the letter (e.g., vertical lines, oblique lines). Each week, the children were learning
two or three letters. The learning sequence followed the one proposed by Graham, Harris,
and Fink (2000) with some modifications. In fact, letters starting in the same direction were
grouped. 1: c-a-d; 2: g-q-o; 3: b-h-p; 4: m-n-r; 5: i-l-t; 6: f-j; 7: e-s; 8: k-x-z; 9: v-w; 10: u-y.
Fine-motor exercises were provided for 10 minutes each week. As noted, these
exercises can play a role in handwriting quality and speed. Exercises that require digital
dexterity and translational or/and rotational movements were chosen (Albaret &
Soppelsa, 2007) and adapted to the age of the children. For example, once, children
played football fingers to improve dexterity. Another time, they engaged in Chinese
shadow making or finger painting. For letter practice, a digital tablet was used. It was
chosen for several reasons. The tablet allows adaptable, scalable exercises and provides
visual and auditory feedback when the child interacts with the program. With
LetterSchool, visual indications of the letters with directions indicated, combined
with memory copy are respected. We have seen that the layout gives very good,
continuous visual feedback on the trajectory of the pen but tracing does not lead to
memorization and could affect learning. Copying, meanwhile, involves a greater sto-
rage. Therefore, tracing is best for visual feedback, and copying will be most advanta-
geous for memory. These assumptions justify following LetterSchool exercises with
paper and pencil exercises because tracing on a digital tablet offers good interactive
feedback and copying and handwriting on paper promotes storage.
 180 G. JORDAN ET AL.

Statistical analysis
The data were analyzed using R software (R Development Core Team, 2011). To highlight the
results concerning quality, the Wilcoxon Signed Rank Test was performed (Portney & Watkins,
2009, p. 503) to measure the differences between the twins in the experimental group and the
control group at pretest, the evolution of each group, and the difference in growth between the
groups. As the samples are matched in all cases because of the presence of twins, the Wilcoxon
Signed Rank Test was used because it is appropriate for relative scores.
To determine the effectiveness of this program with regard to writing speed, the same
statistical analysis procedure is required.
A significance level of 5% was used to determine statistically significant results.
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Results
The pretest scores were not significantly different between the twins of the control and the
experimental groups on measures of quality and speed of handwriting (Table 1). This
suggests that these groups were similar in their handwriting ability prior to intervention.
The BHK posttest scores were significantly better in the experimental group than in the
control group (p < 0.01). The twins of this experimental group showed a significant
difference in progress (p < 0.05). Again for the BHK measures, the mean posttest score
of the control group was higher than its pretest score, showing a degradation of the global
quality of handwriting for this group. The letter size increased for both groups between
pretest and posttest. However the mean letter size of the twins of this experimental group
was significantly better on the posttest measure (p < 0.05) and the difference in progress
was significant between the groups (p < 0.05). No significant difference was found in the
speed of handwriting although there was improvement was present in both groups.
The pretest scores of the BHK items were similar between the experimental and the
control groups. The twins from the experimental group obtained better posttest scores for
six items: “insufficient word spacing,” “acute turns in connecting letters or too long
joining” (chaotic writing), “collision of letters,” “inconsistent letter size,” “irregularities
in joining strokes,” and “incorrect relative height of letters.” The control group was better
for two items: “unsteady writing trace” and “ambiguous letter forms.” The item “incorrect
relative height of letters” shows the biggest difference in progress between the two groups.

Table 1. Comparison of the mean pretest and posttest handwriting skill scores for the twins of the
control and the experimental groups.
Control group (= 5) Experimental group (= 5)
Mean (SD) p value O1–O2 Mean (SD) p value O1–O2 p value between groups
Quality of handwriting
BHK O1 8.2 (2.59) 0.272 9.6 (1.52) 0.058 0.396
O2 9.8 (0.44) 5.4 (1.34) 0.009**
Letter size O1 0.47 (0.09) 0.06 0.60 (0.12) 0.312 0.056
O2 0.888 (0.14) 0.65 (0.06) 0.016*
Speed of handwriting
Letter/minute O1 12.12 (3.92) 0.1 12.12 (7.18) 0.063 0.69
O2 19.14 (5.88) 19.69 (7.54) 0.68
*p value O1–O2 is the p value according to the Wilcoxon test, between the mean of the pretest and the posttest.
*p < 0.05, **p < 0.01.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 181

The scores for the item “poor word alignment” was identical for both groups on the
pretest and posttest measures and got the lowest mark for 97% of the children. The
children of both groups did therefore not master the word alignment.

Discussion
Our findings demonstrated the effectiveness on quality of handwriting of a 10-week
teaching program including the use of the application LetterSchool, fine motor activities,
and paper-pencil exercises. The results can be explained by the progress in fine-motor
abilities of the experimental group. The literature widely supports the link between these
abilities and the quality of handwriting (Cornhill & Case-Smith, 1996; Smits-Engelsmanm,
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Niemeijer, & Van Galen, 2001; Volman et al., 2006).

The results concerning the items of the BHK, Concise Assessment Method for
Children’s Handwriting, allow a more detailed analysis of the evolution of the quality of
handwriting. The item “incorrect relative height of letters” showed a large difference
between the two groups in favor of the twins of the experimental group. The lined
paper provided to the experimental group could explain this difference. The paper
includes three lines with a line in the middle to distinguish trunk letters and stems letters.
We followed Albaret, Kaiser, and Soppelsa (2013), who recommend introducing the lines
to bring a spatial constraint only after the motor program of the letters is mastered on
blank sheets of (unlined) paper.
The novelty of the handwriting program implemented here involves the use of the
application LetterSchool for learning the letter formation with animated models. The
experimental groups of Overvelde and Hulstijn (2011b) and Vinter and Chartrel (2010)
also used an animated model in this learning stage and obtained positive results. Visual
feedback is essential for young children because they are part of the formation of the
motor program (Chartrel & Vinter, 2006). Our findings support the hypothesis that a
moving model of the letter promotes the transfer of visual information into motor
program (Vinter & Chartel).
Both groups demonstrated an increase in letter size between pre- and posttest. Studies
of Hamstra-Bletz and Blote (1990) and Overvelde and Hulstijn (2011a) demonstrated that
improvement in handwriting is characterized by a decrease in letter size, which appears at
grade 2. The participants of the present study are in the lower grade and have perhaps not
yet reached the stage of motor control allowing for this decrease in letter size. Their
handwriting is not automated and is formed in a closed-loop system (Schmidt & Lee,
2005) with a strong visual control. Handwriting letters of large size provides more time to
analyze the visual feedback and to adjust movements. We can also make the assumption
that the exercises on LetterSchool contributed to increasing letter size because the written
characters presented are bigger on the digital tablet than on a sheet of paper. The paper-
pencil exercises were supposed to correct this problem but we hypothesize that the
amount of practice was not sufficient.
To our knowledge, no other study has compared samples of twins receiving different
handwriting teaching programs. However other studies have investigated the effectiveness
of handwriting programs set up for whole classes. Among them, the intervention of Case-
Smith et al. (2011) had similarities with the one implemented here in terms of duration of
 182 G. JORDAN ET AL.

the intervention, grade of the participants, and teaching method. Their results found
significant gains in handwriting legibility and in writing fluency.

Limitations
The results discussed here should be interpreted with caution because of the small sample
size and, thus, low statistical power. This research was carried out among a group of
children of grade 1 attending a private school. Generalization of the results is therefore
compromised by the lack of diversity of our population.
For the outcomes measures, several assessments have been combined to match the
characteristics of the population and have thereby lost their psychometric properties. A
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test measuring fine-motor control should have been administered to sustain the results
concerning the evolution of the quality of handwriting.
Finally, the study was conducted in a natural setting and many elements could not be
controlled. The first is the influence of other interventions occurring during this study.
Only the handwriting lessons were controlled and we cannot exclude that other interven-
tion or school subjects improved the quality or speed of writing. Moreover, children in the
experimental group received more attention during the 10 weeks of the study, sometimes
with the presence of extra persons during the handwriting lessons. Therefore, the
Hawthorne effect could have led the children of the experimental group to be more
motivated to progress than their peers in the control group.

Conclusions
Though this study did not indicate that our program is better than the usual handwriting
program for speed, the findings demonstrate that for some characteristics of handwriting
and for legibility—specifically for “chaotic handwriting ” and “incorrect relative height”—
this program was better than the usual program. It would be interesting to repeat this
study with a bigger sample to have stronger statistical results. Moreover, this handwriting
program demonstrated its feasibility in a natural environment and could also be easily
implemented in other schools. Financial limitation exists because of the requirement of a
digital tablet for each student. To work around this financial issue, we could imagine using
the digital tablets that many families have at home nowadays. Then it would be possible to
use LetterSchool for homework thus supporting the handwriting lessons and possibly
improving the quality of handwriting. The rest of the material of this program is freely
available and no special training for teachers is required.
The results of the present study offer some support to the hypothesis that positive
results may arise from a model in which OTs are integrated into the classroom and the
curriculum (Case-Smith et al., 2011; Lust & Donica, 2011; McGarrigle & Nelson, 2006). It
shows that students need training in specific components to encourage good handwriting.
In this study, OT can offer support for therapeutic methods for helping children with
handwriting difficulties. This conclusion can emphasize the role of the occupational
therapist in school; as yet OTs do not work in Switzerland schools. It shows as well that
close collaboration between teacher and OT is necessary and can help children’s learning.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 183

Acknowledgments
We thank the students, teachers, and administrators who approved and participated in the study.
We especially thank Marie-Laure Kaiser and Sylvie Ray-Kaeser for help and advice throughout the
study. We thank Yann Fragnière for helping with statistics and Jonathan Savio and Marie-Josee
Dousse for their assistance with the literature review.

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