This paper was published online in July 2024, but more recently in the print edition. It presents results from three different studies conducted in the Netherlands. The overarching theme is how handwriting difficulties, particularly legibility, interact with spelling difficulties, reading and dyslexia.

In the first study, they confirmed what many of us observe: children with dyslexia do more frequently experience difficulties with legible handwriting compared to their peers without dyslexia. Just as a note, they used parents’ rating of handwriting legibility to determine handwriting difficulties. Their same size however was large, there were a total of 636 children, with over 300 children in each group. They also found that boys, more often than girls, struggle with handwriting legibility. This is something I have always seen in clinical practice, so I am sure it’s not a surprise to most of the paediatric occupational therapists listening.

The second study explored how the reading and spelling of 311 of the dyslexic children in study 2 linked to the parents’ rating of handwriting legibility. The study found a clear connection between handwriting legibility and spelling level in children with dyslexia. Meaning, if a child’s handwriting was often difficult to read, their spelling scores were significantly lower suggesting a relationship between legible handwriting and spelling proficiency. However, they found no significant relationship between handwriting legibility and reading level. The authors explain that as reading skills advance, handwriting becomes less critical for reading fluency, but it remains important for spelling practice.

The third study was a dyslexia intervention. The authors were trying to understand whether handwriting legibility difficulties would impact the outcomes of the dyslexia intervention. 249 of the children in study 2 chose to continue and take part in study 3. The intervention targeted reading and spelling spells using the Protocol Dyslexia Diagnostics and Remediation intervention. This intervention was quite intense with children receiving weekly 45-minute sessions with reading specialists and homework that needed to be completed four times a week over 3 months.

The study investigated whether poor handwriting legibility hindered progress in reading and spelling during the dyslexia intervention program. The researchers found that all participants improved both their reading and spelling scores, regardless of their handwriting challenges. There was no difference between groups on reading scores post intervention, indicating that handwriting difficulties didn’t affect reading intervention response. While the spelling results improved for all children post-intervention, children who often had poor handwriting legibility scored significantly lower than those who never did. The group rated as having poor handwriting legibility ‘sometimes’ fell in between.

What this means is that the dyslexia intervention worked for reading regardless of handwriting ability. But for spelling, frequent handwriting difficulties created a persistent gap – these children improved but remained behind their peers. 

So, it raises a question for us as OTs. Given that handwriting legibility challenges seem to create an additional barrier for spelling success: Should we be advocating more for addressing handwriting legibility alongside literacy interventions to support spelling? I know logistically this is not something that most public health teams can support in targeted ways, but it could be a great target for universal provision. If schools were following best practices when teaching handwriting from the beginning, such as teaching similar motor patterns together rather than using alphabetical or phonics order, this could have benefits for all children, including those who are finding learning handwriting more challenging.This paper presents results from three different studies conducted in the Netherlands. The overarching theme is how handwriting difficulties, particularly legibility, interact with spelling difficulties, reading and dyslexia.

This article used the handwriting legibility scale and the Evaluation of Ayres Sensory Integration, the EASI for those familiar with it, to evaluate how the sensory integration abilities impact handwriting.  

Population

The study included 33 children. These children were chosen before the tests were administered, and as a result there were only 6 children in the handwriting difficulty group and 27 with average scores on the Handwriting Legibility Scale.

Results

More children in the handwriting difficulties group had scores lower than 1 standard deviation from the mean on the EASI. However, I’ll pause here just to highlight the data presentation. The researchers have used percentages to show the number of children scoring below the mean on the EASI tests. Given the differences in group sizes 6 versus 27 and the small number in the handwriting difficulty group, the percentages probably make the differences look more dramatic than they really are. One child in the handwriting group represents about 17% of the sample, so these percentages can be quite deceptive. 

The tests on the easy with the largest differences between the two groups were 

1. Tactile Perception Designs (TP:D) – effect size .46
2. Praxis Sequences (Pr:S) – effect size .44
3. Tactile Perception Localization (TP:L) – effect size .42
4. Praxis Positions (Pr:P) – effect size .40
5. Ocular motor
6. Ocular praxis
7. Bilateral integration

These all had a medium effect size. However, while these effect sizes look impressive, we need to be cautious. With only 6 children in the HD group, just one child with particularly severe difficulties could be driving these entire results. These statistics might look robust, but they’re actually quite fragile given the tiny sample size. We’re essentially making conclusions about the links between sensory integration difficulties as measured on the EASI and handwriting difficulties using data from half a dozen children. It was also interesting to me that the mean scores on two of the EASI tests (tactile perceptions of designs and praxis sequences) were over 1 standard deviation below the mean in the non-handwriting difficulty group. This raises questions regarding the validity of these sub-tests. That is, whether they are measuring what they suggest they are, or if there are issues with the normative sample. 

Recommendations

This study recommended that we should be looking at underlying sensory patterns to support handwriting. However, I want to acknowledge this perspective while also noting that it sits within a broader ongoing debate in our field. There’s substantial research suggesting that if we want to improve handwriting, we need to work directly on handwriting skills using functional, task-specific approaches rather than focusing on underlying components.

My goal with this podcast isn’t to dismiss any particular approach, but rather to keep you informed about all the research being published so you can make evidence-informed decisions for your practice. I think it’s important that we acknowledge these different perspectives exist and continue to critically evaluate the evidence as it emerges. This study adds more information to our evidence base, but it is not without its limitations. Clinically we should be mindful there is currently stronger evidence focused on specific task instruction when developing handwriting skills (Novak, 2019).

This paper aimed to understand what early career teachers, or teachers in their first two years after qualification, in the UK know about handwriting and supporting handwriting development in children who have difficulties. The study received questionnaires from 124 ECTs and completed focus groups with six ECTs in Kent which is a county in the south east of the UK just to the bottom right of London on the map.

Results

Overall the results of the questionnaire indicate that teachers who I am assuming training in the UK received very little information on handwriting during their training. Over 80% of the teachers reported that they did not receive training on handwriting development, handwriting pre-requisites, or how to identify if children have handwriting difficulties. A whopping 98.3%, so pretty much all of the sample indicated they did not receive any instruction regarding which handwriting programmes could support children with difficulties. Essentially the survey indicated that teachers get very little information on handwriting, and there is a role for OTs to support them with this. We might also need to adjust our thinking, given handwriting is such a big part of school, it’s valid to assume teachers receive some training in this, but this study provides evidence that they do not, and we might need to explore some of the fundamental basics of handwriting development with them first. The areas that teachers reported they would like more training in were:

• How to support handwriting difficulties
• Expectations for each year group
• How to support pencil grasp development
• How to improve fine motor skills
• Reasons/barriers to handwriting development
• Strategies to support letter formation

The focus group explored feedback from six teachers following an OT workshop that covered some of the knowledge gaps identified in the questionnaire. Three themes were identified, these aligned with the questionnaire results:

• Teachers reported they realised how much they didn’t know following the workshop,
• Teachers realised they need to understand the pre-writing stages of development to teach handwriting,
• The more in-depth understanding of how and why difficulties occur and the available interventions was helpful and following the training they felt more equipped to support children with handwriting difficulties.

Practical takeaways

From an OT perspective, the study suggests that there are gaps in teachers’ handwriting knowledge and that OTs play a role in providing training to teachers to help them to understand when children are ready to start working on letter formation, and how to support them if they are not.