Psychology can help with Intellectual Disability

H A N D W R I T I N G W I T H O U T T E A R S

Teaching handwriting skills to children with intellectual disabilities

using an adapted handwriting programme

CORINNA F. GRINDLE, RINA CIANFAGLIONE, LIZ CORBEL, EMILY V. WORMALD,

FREDDY JACKSON BROWN, RICHARD P. HASTINGS, and J. CARL HUGHES

Children with intellectual disabilities often struggle with handwriting, but there is very little research to inform intervention approaches. In this study, we developed a teaching manual based on Handwriting Without TearsVR , a comprehensive handwriting programme designed for typically developing children. Three children with intellectual disabilities participated in the study and received handwriting instruction based on the manual three times a week over a 32-week period. Our aims were to explore whether Handwriting Without TearsVR can be used as a comprehensive handwriting curriculum for children with intellectual disabilities and to evaluate improvement in hand- writing skills. We found that the intervention was successfully incorporated into small group teaching sessions within the child’s regular classroom, and that all three children made improvements. Our data show promising results and support the need for larger evaluation studies.

VC 2018 NASEN DOI: 10.1111/1467-9604.12178

Key words: handwriting, Handwriting without TearsVR , intellectual disability.

Background

Handwriting is an important and functional life skill. Legible handwriting is a

life-long skill used in many important areas including completing examinations,

job applications, writing cheques, taking notes, and compiling shopping lists

(Feder and Majnemer, 2007). Fine motor tasks including handwriting take up a

substantial proportion of children’s time at school every day (Marr, Cermak,

Cohn, and Henderson, 2003, McHale and Cermak, 1992), and being able to

form coherent and legible writing is crucial for most forms of assessment and

demonstrations of learning outcomes (Donica, Goins, and Wagner, 2013). By

the end of primary school (age 11), children in England are expected to write

‘legibly and fluently’ (Department for Education, 2013, p.36).

For children who have handwriting difficulties, wider implications for their aca-

demic performance and more general development can be significant. Poor

handwriting skills may reflect an underlying difficulty with fine motor control

that may manifest in difficulties with other important tasks, such as tying shoela-

ces and doing up buttons (David et al., 2009). Poor handwriting may also lead to lower academic attainment; children who find handwriting more difficult and

effortful may become fatigued more quickly than their peers, and may be less

able to demonstrate their knowledge and comprehension through written assign-

ments (Donica, Goins, and Wagner, 2013). Indeed, research suggests that poor

handwriting is a predictor of lower future academic attainment (Cahill, 2009).

Additionally, studies have shown that when two pieces of writing containing

identical content are graded, but one is written in poor handwriting, it will be

graded more harshly than the one in legible writing (Chase, 1968; Sweedler-

Brown, 1992). Later in life, employers may also judge a job application more

harshly if it is written with poor handwriting (Cahill, 2009). Handwriting diffi-

culties, then, may severely limit a child’s opportunities in later life.

Children diagnosed with autism and/or an intellectual disability may be particu-

larly at-risk for developing motor impairments and subsequently experiencing

314 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

handwriting problems. Up to 90% of individuals with an intellectual disability

may present with handwriting and/or fine motor difficulties (e.g., Tarnopol and

Tarnopol, 1977). A diagnosis of an intellectual disability often involves specific

motor impairments, which are likely to contribute to deficits in handwriting

skills. For example, David et al. (2009) found that children with an intellectual disability demonstrated poor co-ordination of fine motor movement and tended

to use a tighter or stronger grip than was required when using a precision grip.

Conversely, children with autism have been shown to have weaker grip strength

than typically developing peers, and this difference has been shown to increase

with age (Alaniz, Galit, Necesito, and Rosario, 2015). Additionally, some studies

have found that children with autism demonstrate poorer handwriting, according

to standardized tests of handwriting, than typically developing children (e.g.,

Fuentes, Mostofsky and Bastian, 2009).

Following the introduction of the new Children and Families Act in 2014 (UK),

statutory guidance to those providing educational services to children with spe-

cial educational needs placed a very strong emphasis on preparation for adult-

hood as the guiding principle for selecting outcomes for improvement

(Department for Education, 2014). Given that handwriting is an important func-

tional skill, and that many children with an intellectual disability and/or a diag-

nosis of autism demonstrate poor handwriting, these children may require

targeted intervention to improve handwriting skills.

While many advocate keyboarding as an alternative writing strategy for those

with handwriting difficulties, there are several benefits of handwriting instruction

over typing. Children who practise spelling using handwriting may acquire spell-

ings faster than those using typing (Cunningham and Stanovich, 1990). Addition-

ally, teaching children to spell through handwriting may support letter recognition

and subsequent reading skills; this has not been shown in those taught through

typing (Longcamp, Zerbato-Poudou, and Velay, 2005). Direct handwriting

instruction has also been shown to improve subsequent word reading level with

year one students who had been identified as having difficulties in reading

(Berninger et al., 2006). Finally, a programme to support writing skills in children with handwriting difficulties may also lead to increases in self-confidence and

thereby improve general academic attainment (Erhardt and Meade, 2005).

If we accept the argument that good handwriting skills is beneficial, the impor-

tant question is what is the evidence on how best to teach these skills to children

with moderate to severe intellectual disabilities? We could find no examples of

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 315

specific programmes or curricula that have been developed and evaluated for

this population. Neither could we find many examples of comprehensive curric-

ula that offer a systematic and gradual approach to teaching that would be nec-

essary for successful learning with a population of children with diverse

learning needs. One solution to this dearth is to adapt a mainstream evidence-

based programme. However, such a curriculum would need to feature several

key components that would predict successful adaptation to this population. It

would have to be: (1) designed for young children in the first years of school, so

that it would be suitable even for a child with little or no handwriting skills; (2)

informed by extensive research on how children construct their handwriting

knowledge; (3) evidenced-based (i.e., data available on the programme in peer

reviewed research showing it to be effective with typically developing children);

and (4) usable for individualised teaching, adaptable to each child’s needs, a

necessity stemming from the wide variation of ability levels within the intellec-

tual disability population. The Handwriting Without TearsVR (HWT) programme

fulfills all of these key requirements.

The HWT programme was developed by occupational therapist Jan Olsen

and is increasingly being used in schools as a curriculum to teach handwrit-

ing skills, mostly to typical learners (Olsen and Knapton, 2013). This com-

prehensive approach covers handwriting instruction from the initial stages

of pencil grip at preschool level to cursive writing and grammatical con-

cepts in year six. The stages of the curriculum follow a developmental

sequence of fine motor skills, beginning with scribbling and colouring, sim-

ple lines and shapes, capital letters, and lower-case letters. Stages are taught

through imitation (modelling), then copying, and finally independent writ-

ing. Following this teaching order, the demands on the child become pro-

gressively more difficult. For example, capital letters, which are the same

size and consist mainly of simple lines and curves, are taught before more

complex lower-case letters. There is also a focus on a multi-sensory

approach with tactile activities, such as manipulating wooden shapes to

form letters, and music as core components of HWT lessons.

HWT utilises a number of evidence-based teaching strategies to teach handwrit-

ing. For example, a task analysis, which involves the breaking down of skills

into individual units and teaching these sequentially, has also been used to teach

skills such as self-help (Stokes, Cameron, Dorsey, and Fleming, 2004; Veazey,

Valentino, Low, McElroy, and LeBlanc, 2016), leisure (Libby, Weiss, Bancroft,

and Ahearn, 2008; Schleien, Wehman, and Kiernan, 1981) and social skills

316 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

(Neurnberger, Ringdahl, Vargo, Crumpecker, and Gunnarsson, 2013). In HWT,

a task analysis is provided for each letter to provide a consistent verbal cue. For

example, ‘big line down, little line across, little line across’ for a capital letter F.

A modelling, or imitation, procedure is also used extensively in the HWT

approach. Modelling is also well documented as an evidence-based teaching

strategy for social skills (Argott, Townsend, and Poulson, 2017; Whitehill,

Hersen, and Bellack, 1980) and functional life skills (Garcia, Dukes, Brady,

Scott, and Wilson, 2016).

There is some evidence for using HWT with typically developing children. For

example, Owens (2004) demonstrated the positive effects of HWT with students

in Key Stage One classrooms. Students from this study demonstrated statistically

significant improvement in the areas of letter size and spacing compared to stu-

dents receiving traditional handwriting instruction. Teachers involved in this

study were satisfied with the curriculum’s effectiveness and usability and contin-

ued to use the curriculum after the study was completed. In an urban year one

classroom (Hape et al., 2014), pre and post test results showed significant improvements in letter orientation, placement, size and spacing of letters after

children had been on the programme. Overall, research exploring the effective-

ness of HWT with typically developing children has shown that Olsen’s curricu-

lum can improve handwriting skills (Marr and Dimeo, 2006). Moreover, HWT

has also been shown to be more effective than other approaches such as teacher-

directed instruction (Roberts, Derkach-Ferguson, Siever, and Rose, 2014), Head

Start teaching (Lust and Donica, 2011), the Peterson Directed Handwriting pro-

gramme (Salls, Benson, Hansen, Coles, and Pielielek, 2013), and the Fine Motor

and Early Writing Curriculum (Donica, Goins, and Wagner, 2013). These stud-

ies have mostly included up to 20-minute instructional sessions (consistent with

Olsen and Knapton’s, 2013) recommendation of 15-minute teaching sessions)

and the use of standardized motor skill and handwriting assessments in order to

measure outcomes.

Although most of the evidence base for using HWT is from typically developing

children, there is some preliminary research on using HWT with children with a

diagnosis of autism and/or an intellectual disability (Thompson et al., 2012; Coussen et al., 2012; Cosby, McLaughlin, and Derby, 2009. There are, however, a number of limitations to this research:

(1) Evaluations of HWT with children with an intellectual disability have

not yet been carried out in the UK;

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 317

(2) The vast majority of studies have focused on 1:1 instruction, despite the

fact that most special education settings in the UK are often not

adequately staffed to provide this type of teaching;

(3) The children studied so far have been between 4- and 6-years old, and so

the use of HWT with older children with intellectual disabilities has not

been adequately explored;

(4) These studies, mostly with a focus on teaching the child how to write

their name, have also utilised a very limited sample of the curriculum as

outlined by HWT (Olsen, 2003; Olsen and Knapton, 2013), in spite of its

recommendation as a full comprehensive curriculum that can teach a

range of writing skills following the developmental sequence of letters;

(5) It is also unfortunate that teaching sessions in most research studies have

lasted just 5–10 minutes; Olsen and Knapton (2013) recommend 15-

minute lessons in order to implement HWT. Additionally, in a systematic

review of interventions to improve handwriting, Hoy, Egan and Feder

(2011) concluded that handwriting instruction should take place for no

less than 20 minutes three times per week to be effective;

(6) Much research carried out has relied on non-standardized assessments of

handwriting proficiency such as teacher ratings.

The primary aim of the present study was to investigate the feasibility of adapt-

ing the HWT curriculum to use with three older children with a diagnosis of

autism and intellectual disability (111 years of age) in a UK school context

where small group handwriting instruction was utilized three times a week dur-

ing 20 minute teaching sessions. We developed a detailed teaching manual

(available upon request from the first author) to ensure fidelity of teaching. The

second aim was to investigate, using a standardized assessment of handwriting

proficiency, whether the teaching sessions using the adapted HWT curriculum

was able to improve the handwriting skills of the children in this study.

Children, and school context

Children

Children in this study were one girl and two boys; two of the children (the

boys) had a diagnosis of autism, the girl had a combined diagnosis of ADHD,

epilepsy and MoyaMoya syndrome (a progressive disorder where arteries in the

brain are constricted, blocking blood flow). At the time of the study Craig was

318 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

aged 11 years 1 month, Trevor was 14 years 1 month and Leila was 14 years 10

months (these names are pseudonyms).

To be eligible to participate in the study, the children had to be performing

below the level expected for their chronological age in handwriting and to have

the following prerequisite skills considered necessary for them to benefit from

the adapted HWT programme: Sitting willingly to engage in learning activities

for short periods of time (up to 10 minutes), accepting feedback (praise, or cor-

rection), receptive and expressive labelling of at least 50 objects and pictures,

following one or two-step teacher instructions (e.g., ‘clap hands, and turn

around’), matching and sorting of pictures and cards depicting individual letters;

and receptive and/or expressive labelling of at least 5 letters using either the cor-

responding letter sound or name of the letter. In addition, so that motor prompts

could be utilized throughout teaching, the children had to be able to imitate

gross and fine motor movements. All children were capable of self-initiated

speech (typically, communicating using at least three word sentences).

School and classroom setting

The children attended a mixed special school in the UK for pupils with severe

and profound multiple learning disabilities. At the time of the study, there were

approximately 120 pupils in the school aged 2–19. The three children in this

study were all in the same class at school (age range 11–15 years). In total, there

were 9 pupils in the class who were supported by one qualified class teacher

and three classroom assistants. Teaching sessions were mostly conducted in the

children’s regular classroom. The three children sat at a rectangular table

together with the classroom assistant or teacher. The six other children in the

class did not participate in the study. Some of these pupils worked at the same

table (on other tasks) or on other tables in the classroom, but did not participate

in the HWT teaching session.

Handwriting programme

To promote a systematic approach to teaching handwriting to children with an

intellectual disability, we developed a teaching manual based on the HWT

Teachers’ Guides (Olsen and Knapton, 2008). The adapted teaching manual (the

Handwriting without Tears – Intellectual Disability version) depicted teaching

programmes recommended for preschool children (from the HWT ‘get set for

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 319

school’ curriculum), for reception age children (from the HWT Kindergarten

Curriculum, and for children in Year One (from the HWT 1 st

Grade Printing

curriculum). There was an emphasis on teaching handwriting readiness skills in

the preschool curriculum, on teaching printing of capital letters in the reception

curriculum and printing lower case letters in the year one curriculum. Our man-

ual did not extend to the later stages of the HWT curriculum (year two and

above where there was more of an emphasis on teaching cursive handwriting

and the writing of sentences). As the children had already developed the neces-

sary handwriting readiness skills from the preschool curriculum, we decided to

use the reception phase of the manual for teaching. This focused on teaching

correct formation of capital letters, a skill lacking in the children.

There were some elements of the HWT Teachers Guide that we felt were essen-

tial to include: (1) For all the letters taught, the same standardized instructional

language was used to describe the right way to write the letter as in the original

HWT Teachers Guide and student workbooks (e.g., for the letter ‘F’, the teacher

would model writing the letter at the same time as saying, ‘big line down, little

line across, and little line across’); (2) All lesson plans described how to use

teacher modelling, as one of the main components of teaching. Modelling strat-

egies included writing the letter on the child’s worksheet for them to copy (and

modelling the language as they were writing the letter), or writing the letter on a

white board.

Despite these similarities, however, there were several adaptations to the original

programme that we made that were reflected in our adapted HWT (a- HWT)

teaching manual:

(1) Because each phase of the HWT curriculum (preschool, reception, year

one, etc.) is developmentally sequenced to fit around a 9–12 month

school year and we were working with children with an intellectual dis-

ability of secondary school age where it could potentially take longer to

teach the full curriculum, we provided a more condensed ‘catch-up’ ver-

sion of the HWT curriculum which focused predominantly on ‘printing’

with fewer sensory motor activities. To help us decide what should be

included in the manual we considered only the non-negotiable and age

appropriate features of the training that we judged were necessary for

children to learn how to print their letters. Subsequently, some multi-

sensory activities like using play-doh or putting wooden pieces together

to make letters were omitted from the adapted HWT (a-HWT) manual.

320 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

(2) There were also some differences in the order in which the letters

were recommended to be taught and the subsequent order of lesson

plans in the adapted manual. For example, as recommended by HWT

for the reception phase, all children learnt ‘Frog Jump’ capitals first

(e.g., F, E, D, P, B, R, N, M). These letters start at the top left corner

with a big line on the left. When the first line is on the left, the next

part of the letter is on the right side. This prevents reversals and

teaches good stroke habits. HWT recommend that next teachers focus

on ‘Starting Corner Capitals’ (e.g., H, K, L, etc) before moving to

Centre Starting Capitals (e.g., C, O, Q, etc). For our condensed catch-

up on a-HWT curriculum, we recommended that, after teaching the

Frog Jump Capitals, teachers move to the Starting Corner Capitals but

that they target first those that have the same formation as lowercase

letters but only bigger (e.g., K, V, W, X, Z), followed by the Centre

Starting Capitals that have the same formation as lower case letters

(e.g., C, O, S) before moving onto any other letters (e.g., A, I, T).

This modification was considered necessary so teachers could work

concurrently on the lower case letters immediately after they had mas-

tered the capital letter (e.g., the letter formation was the same but

smaller). It was thought that, if the teaching curriculum for printing

lower case letters started with the letters that were the same as their

capital partners, children would have been prepared for writing half of

the lower case letters through their upper case letter practice. This

methodology has similarities to the ‘general case’ order of teaching

recommended by the Direct Instruction teaching approach (e.g., Engel-

mann and Carnine, 1991).

(3) We also conducted task analyses on the more complex skills (i.e. broke

down complex skills into smaller steps for learning). For example, for

teaching the letter F, the teacher first demonstrated writing the letter, say-

ing out loud the instructions as they wrote with the child attending,

‘Watch me write F, Starting at the corner, Big line down, frog jump up. Little line across the top, Little line across the middle’ before moving through a number of teaching steps until the child was able to self

instruct as they wrote the letters and then finally complete the worksheet

accurately without self instruction.

(4) We also provided some suggestions for prompting and prompt-fading

strategies for each step of the target skill. These strategies corresponded

to different levels of assistance so that the teacher could adapt the teach-

ing procedure to individual children’s needs. For example, in the task of

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 321

writing the letter ‘F’, visual prompting strategies suggested included

teachers using an adapted worksheet with larger examples to copy or

rather than having a blank space for students to copy a letter, the teachers

wrote the letter with a highlighted pen for the student to overwrite and

this prompt was gradually faded.

(5) Because children with a diagnosis of autism and intellectual disability do

not always generalize skills taught, we added a generalization step to

every programme to ensure the child could be successful with the task in

different environments, with a variety of materials or with a different

teacher. For example, asking the child to write a letter with a variety of

different writing tools, writing in the school handwriting workbooks and

not just on the HWT worksheets, and performing the task with different

members of staff.

(6) To help keep children motivated to work through new, difficult tasks,

instructions for differential reinforcement were included. It was sug-

gested that unprompted and accurate handwriting efforts be rewarded

with tokens which would later be exchanged for a favourite activity. If

the child needed assistance, it was recommended that they receive verbal

praise but no token be delivered.

(7) The goals for learning were clearly specified so that they would be

observable and measurable. We also described a mastery criterion as a

way of objectively determining whether the goal had been achieved.

Instructions for data collection were included.

We recommended to teachers that they use a variety of materials from HWT as

part of their delivery of the programme, such as the HWT Teachers’ Guide for

reference and the student workbooks. The resources needed for delivery of the

HWT programme were listed in the manual with details of from where the

resources could be sourced. We also created some resources for generalization

of skills (e.g., different worksheets and handwriting writing games), which were

also described in the manual.

For letters that children were currently learning, children used the standard hand-

writing pencils provided by the class teacher and the HWT student workbooks.

For generalization, teaching resources were extended to using a variety of writ-

ing tools (crayons, chalk felt tip pens, etc.) and different handwriting media

(wipe boards, different handwriting worksheets, handwriting workbooks pro-

vided by the school).

322 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

Token systems and a variety of reinforcing items and/or activities were used

during the initial stages of teaching for each child. For example, a child would

be working on their handwriting tasks for ten minutes and, during this time, the

teacher provided ticks on a chart or tokens that could later be exchanged for pre-

ferred objects or other rewards. The handwriting sessions quickly (i.e., in 1 or 2

sessions) became a highly preferred activity. Once handwriting was established

as an enjoyable activity, it was possible to fade the token systems.

Measurement of handwriting skills

The primary outcome measure administered was the Minnesota Handwriting

Assessment (Reisman, 1999). This assessment was chosen because of its validity

(e.g., Feder & Majnemer, 2003; Roston, Hinojosa and Kaplan, 2008), because it

has a short administration time of 2.5 minutes, and because it is a widely used

measure in handwriting research.

The MHA is a norm-referenced evaluation tool that assesses manuscript hand-

writing for year one and year two students including the five quality categories

of legibility, form, alignment, size, and spacing, along with assessing the stu-

dents’ rate of handwriting. The protocol provides clear criteria for how to score

each quality category. Alignment, size and space are judged on the basis of

ruler measurement; legibility and form require a subjective measurement. The

MHA has been used to determine students’ progress by comparing scores of

multiple tests over time to show the effectiveness of instructional programmes,

interventions, or students’ maturation (Cornhill and Case-Smith, 1996; Feder

and Majnemer, 2003; Reisman, 1999; Roston et al., 2008).

In this study, the children were administered the manuscript version of the

MHA (see Figure 1). The children were required to copy words from a printed

stimulus sheet that depicts the following words: ‘The brown jumped lazy fox

quick dogs over’ (see Figure 1 for example). This phrase is intentionally short in

length and contains all letters of the alphabet. The words are scrambled to

reduce any memory advantage of more fluent readers (Reisman, 1993).

At the beginning of the rating process, a total of 34 points were given to each of

the 5 qualitative categories (one point per letter). During rating, the total number

of scores in each category are subtracted from this total. The rate score was

determined based on the number of letters completed in the 2.5 minutes.

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 323

Combining the 5 qualitative scores with the rate score, each of the 34 letters

could earn up to 6 points, for a maximum total score of 204. For the purpose of

this study the norms for year one were used as all students had significant diffi-

culties in handwriting.

The scores are then used to classify students as ‘performing like peers’ (Legibil-

ity: 33–34; Form: 30–34; Alignment: 29–34; Size: 27–34; Spacing: 30–34; Rate:

18–34). ‘performing somewhat below their peers’ (Legibility: 32; Form: 25–29;

Alignment: 20–28; Size: 15–26; Spacing: 26–29; Rate: 11–17) and ‘performing

well below their peers’ (Legibility 31 or fewer; Form: 24 or fewer; Alignment:

19 or fewer; Size: 14 or fewer; Spacing: 25 or fewer; Rate: 10 or fewer). We

administered the MHA twice: before the beginning, and at the end of the inter-

vention period.

Data were recorded for each letter written on the worksheet using a data sheet

developed for this study (see Figure 2). The teacher scored for each letter

whether the letter was correct or incorrect according to four quality criteria from

the MHA (legibility, form, alignment, and size). Operational definitions for the

quality criterion were provided on the worksheet to help teachers score accu-

rately. Thus, for legibility the correct letter needed to be present, it needed to be

instantly recognizable as the target letter and not look like any other letter, and

all parts of the letters needed to be complete. If any of these components was

missing then the letter would be scored as incorrect.

Figure 1. The Minnesota Handwriting Assessment

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The mastery criterion for each letter was 80% of letters correct (across each of

the four dimensions) per worksheet across three consecutive sessions (work-

sheets). Typically, the child needed to complete at least 10 letters correct per

worksheet. This data collection procedure allowed the teachers to identify if

there was a particular area of quality of handwriting that the child was consis-

tently struggling with. For example, if a child was regularly scoring incorrectly

for size, but was correct for the other areas, then the teachers would discuss this

with the child and provide extra practice for size. Typically the extra practice

would involve teaching component responses before composite ones (i.e., teach-

ing the child to ‘discriminate before they operate’, Calkin, 2003). Thus, if a

child was frequently writing a letter that was too large, they would be taught to

discriminate between samples that were too big/too small or just right before

practising writing the letter again.

Delivery of the handwriting programme

Immediately before starting the intervention, the children were assessed using

the Check for Readiness Skills from Handwriting Without Tears. This assesses

certain prerequisite skills that HWT recommend children have to be able to ben-

efit from the HWT curriculum: That the child uses a variety of strokes for col-

ouring, that they can grip a crayon correctly and leave a mark on the paper, that

Figure 2. Data sheet for handwriting

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 325

they can hold a piece of paper steady on the table using a helping hand, that

they can trace and copy shapes and that they can draw a rough approximation of

each main part of a person’s body. All children completed this test to the

required proficiency level to be able to proceed with the handwriting

intervention.

As required by school policy, Health and Safety Risk Assessments and where

necessary Behaviour Risk assessments and Support Plans were in place for all

pupils. Engagement in the intervention did not pose any further risks, as the

teaching methods used were standard practice within the class and school set-

ting. Teaching took place approximately three times a week for 32 weeks in a

20–30 minute session at the start of the day. No other specific handwriting

teaching occurred during the duration of this study. On average, each student

received 60–90 minutes of group based handwriting instruction each week.

Teachers/classroom assistants who normally worked with the child carried out

the sessions. At the start of each handwriting session all children were asked to

complete together a handwriting exercise that they could perform easily and

without help (i.e., they performed a mastered handwriting task for example,

practice at picking up the pencil correctly, colouring exercises).

Following this warm up, the teacher delivered approximately five minutes of

individualized teaching to each child in turn. Individualized teaching was con-

sidered necessary because the children were learning target letters at different

rates and so had different targets on acquisition. For example, Craig was work-

ing on learning how to write lower case letters correctly when the other two

children were learning upper case letters. The session was concluded by all chil-

dren working in the group again on a mastered handwriting task or on general-

ization activities that they could complete independently. When the child was

not receiving individualized instruction they either continued with mastered

worksheets or generalization activities (if they had not yet received their individ-

ualized instruction for that session), or they continued for the remainder of the

time practising their target letters that had been covered in the individualized

session.

In keeping with the recommendation from HWT, modelling was a key compo-

nent of individualized teaching (Olsen and Knapton, 2013; Olsen, 2003). A

small specification, however, was to use the Model, Lead, Test teaching proce-

dure to give clear guidelines for modeling and the fading of modeling prompts

(e.g., Bechtolt, McLaughlin, Derby and Blecher, 2014). Here, teaching began

326 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

with the teacher modelling on a wipe board or worksheet how to write the letter

using the correct letter formation, and saying out loud the standardised instruc-

tions for writing the letter as they did so. Next, for the lead component, the child

was encouraged to say out loud the standardised instructions for forming the let-

ter as the teacher continued modelling the letter on the wipe board or worksheet.

Finally, for the test component, the students were given a HWT worksheet to

write their own letters using the correct letter formation. If necessary, the teach-

ers provided the child with the verbal instruction to prompt correct letter forma-

tion, but this was faded as soon as possible, until the child was writing the letter

using correct letter formation without any verbal cues from the teacher. Correct

responding was reinforced by providing, for example, praise, or a token which

could later be exchanged for preferred activities. Initially prompted responses

were reinforced but this was gradually faded until only unprompted correct let-

ters were followed with reinforcement.

To increase the children’s independence with their handwriting, a few weeks

into the study they were taught a self-monitoring procedure (Reid, 1996). Self-

monitoring involved having the children keep track themselves of whether or

not each letter that they wrote was meeting the quality criterion on which they

were being scored. It was hoped that this skill would ultimately teach the chil-

dren to be able to self-correct their own handwriting independently whenever

they made errors.

For each letter, the child had to circle a tick or a cross regarding whether it was

‘clear’ (this corresponded to the legibility domain of the MHA), the right

‘shape’ (form from the MHA), ‘on the line’ (alignment from the MHA) or the

right ‘size’ (size from the MHA). For each quality criterion, the key word (clear,

shape, line or size) was written next to tick or cross with a corresponding sym-

bol to aid understanding (see Figure 3). These key words were chosen as it was

believed that they would be easier for the children to understand than the words

from the MHA.

Teacher prompts were gradually faded until the child was able to self-monitor

independently and accurately:

(1) First, the teacher sat with the child and showed a model of what the cor-

rect letter should look like; then, as the child completed each letter, for

that letter the teacher presented in turn the questions that corresponded to

the rules for correct handwriting depicted on the score card. For example,

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 327

‘Does your K look like this K?’ (for legibility/clarity), ‘Is your K the

same shape as this one?’ (for form/shape), ‘Is your K on the line like this

one?’ (for alignment/line), ‘Is your K the same size as this one – not too

big and not too small’? After each question the teacher would discuss

with the child the accuracy of the child’s letter and then encourage them

to score their letter by ticking or crossing on the score card which was

on the table in front of them.

(2) Next, the teacher placed the self-monitoring card and an example of the

correct model of the letter on the table in front of the child and gradually

faded asking their questions. The teacher prompted the child to stop after

writing each letter, to say the rule (‘Is it the right size?’ etc.) and then to

highlight the tick or cross on the sheet. The teacher then discussed with

the child whether or not they agreed with their scoring and the reasons

why.

(3) In step three, the student independently stopped after each letter, saying

the rule and highlighting the tick or cross on the sheet. The teacher only

provided feedback when the child had scored all of the letters on their

worksheet.

(4) In step four, the score sheet was faded. The child independently paused

after writing each letter, they said the rules and then self-corrected their

handwriting on the sheet.

(5) In step five, the child no longer needed to ask themselves the questions,

they self-corrected their letters as and when necessary while they were

Figure 3. Self-monitoring checklist [Colour figure can be viewed at wileyonlinelibrary.com]

328 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

writing. An additional outcome of teaching self-monitoring to the chil-

dren was that they were able to check each others’ work by saying the

rules out loud, and then correct their letters together. This was an aspect

of the procedure that they all enjoyed.

Prior to the beginning of the intervention, we conducted one 1-hour training ses-

sion on the adapted HWR programme with two teachers (classroom assistants)

who were responsible for the delivery of the programme throughout the interven-

tion. During this training, the HWT manual was described completely, including

suggested teaching strategies, directions for data collection and a list of teaching

materials that would be needed to deliver the programme. After this initial train-

ing, ongoing supervision of staff was provided by the first and second author dur-

ing regular overlap sessions (at least 5% of teaching sessions), Each observation

lasted approximately 10–20 minutes. Using observational judgement, the first and

second authors noted if teachers were following the teaching manual (fidelity of

intervention) and in particular, if there were any concerns regarding the organiza-

tion of the session, delivery of instructions, prompting procedures and evidence of

the child’s learning throughout the study. During and after each session, the

observer provided feedback on any relevant issues. In this study, data were not

collected directly on intervention fidelity. This level of training helped to ensure a

consistent approach in the teaching of handwriting skills and similar expectations

about how each child should respond. Fortnightly staff meetings were conducted

to discuss individual children’s progress. Any issues around HWT targets were

discussed alongside the other areas of each child’s learning.

For data collection fidelity, the teachers delivering the intervention and the sec-

ond and third authors retrospectively scored completed handwriting worksheets

using the criteria described previously. During the fortnightly staff meetings the

teachers and the first, second, and third authors compared their scores and dis-

cussed reasons for any disagreements. This process was continued until such

time that the there was a minimum of 80% agreement in scores whenever hand-

writing sheets were retrospectively scored.

Study findings

All children spent 32 weeks on the handwriting programme. The summary data

for the number of lower case and upper case letters mastered in this time are

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 329

presented in Table 1. Craig mastered all upper case and lower case letters when

the criteria for legibility, size, alignment and form were taken into consideration.

Leila and Trevor mastered 16 upper case letters but, in accordance with working

through the developmental trajectory for teaching handwriting, had received

minimal instruction on lower case letters. Subsequently, they did not have the

opportunity to master many of these letters within the time frame of the study.

Pre-and post-intervention scores for each child on the Minnesota Handwriting

Assessment (MHA) are presented in Table 2. All children made gains on this

test by the end of the Handwriting Intervention.

Craig made an improvement in scores for all the domains in the MHA. Leila

and Trevor improved in three domains, but decreased or remained the same for

two of the domains (i.e., alignment and size).

Table 1. Number of letters mastered

Number of letters mastered

Child Age (years, months) Upper case Lower case

Craig 11,1 26 26 Leila 14, 10 16 2 Trevor 14, 1 16 1

Table 2. MHA test results pre-and post-adapted Handwriting without Tears intervention

Participants MHA domains Pre-test Post-test

Craig Legibility 24 29 Form 22 25 Alignment 4 12 Size 1 19 Spacing 12 23

Leila Legibility 18 27 Form 16 25 Alignment 0 0 Size 1 0 Spacing 17 25

Trevor Legibility 19 28 Form 17 28 Alignment 6 0 Size 4 0 Spacing 18 28

Note. Underlined scores in bold text show where the child has moved from the ‘performing well below peers’ category on the MHA to ‘performing somewhat like peers’ (Reisman, 1999)

330 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

On the MHA, children’s scores can be categorized as performing like peers, per-

forming somewhat like peers and performing well below peers. At baseline, the

children’s scores across all of the handwriting domains were assessed to be

‘well below peers’. At post-test, 33% of the children’s scores had improved

such that their performance was judged to be ‘somewhat below peers’. For all

children this change in category status was evidenced for the form domain.

Conclusions

This pilot study presents an adaptation of the HWT programme for children

with intellectual disabilities. It describes in detail how the standard HWT proce-

dure can be adapted to become a comprehensive handwriting curriculum that is

effective at improving the handwriting skills for children with intellectual

disabilities.

The results of this pilot study are promising and demonstrate the feasibility of

adapting the HWT programme for children with intellectual disabilities. It

showed how the students could be taught handwriting skills in a small group

alongside their peers in a typical special education classroom, which has impli-

cations for the costs of programme implementation. As part of the programme,

the children were also taught to self-check their handwriting performance and

this was an important factor in their ability to work independently in groups.

The study also demonstrates that the programme can be incorporated into child-

ren’s daily educational curriculum.

Although no social validity data was collected following the intervention, the

adapted programme was regarded positively by the children and other stakehold-

ers. The children reported that they liked the handwriting lessons and were

excited to show staff and other pupils their completed handwriting worksheets.

In addition, teaching staff reported that they felt positively towards the pro-

gramme. They noted improvement in handwriting on school literacy tests, and

made display boards in the classroom of children’s handwriting sheets.

The relatively older age of the children is another point to mention. The three

children were aged 11–14 years at the start of the programme and this is older

than children in previous studies in mainstream (e.g., Hape, 2014; Owens, 2004)

and special education (Cosby et al., 2009; Coussens et al (2012). This raises the upper limit of starting the intervention and challenges often unstated

VC 2018 NASEN Support for Learning � Volume 32 � Number 4 � 2017 331

presumption that if older children haven’t learned handwriting skills when

young, they will never do so.

In relation to the pre-post data, the children made most progress in the ‘form’

category of the Minnesota Handwriting Assessment (MHA). This is of interest

because research has suggested that children with autism find learning to make

the ‘form’ (i.e., shape) of letters (as opposed to their size, alignment and posi-

tioning) particularly difficult when compared to age and intelligence matched

controls (Fuentes, Mostofsky and Bastian, 2009).

Conversely least progress was made on the size and alignment categories, with

Trevor even showing a loss of skills for both categories. The most likely possibil-

ity for this finding is the confusion caused by the three lines in the MHA stimulus

sheet (top line, middle dotted line and base line). Even with reminders

children did not always know where to place their letters in relation to these lines

(e.g., they used the dotted middle line as their baseline) and it is important to note

that Handwriting without Tears does not teach children to write their letters

using a dotted middle line (only a solid baseline). According to the scoring guide-

lines for the MHA error points are scored for size and alignment if children do

not line their letters up correctly using the stimulus sheet lines. Additionally, there

was a much greater focus in the Handwriting without Tears lessons on achieving

accuracy with legibility and form than with size and alignment. For example,

children could self-instruct (e.g., ‘Big line down, little line across, little line

across’) to help achieve accuracy with formation and legibility for the letter F, but

self-instruction would have little bearing on whether or not they wrote the letter

the correct size (not too big, not too small) or directly on the baseline (for

alignment).

While the data from this pilot study are promising and demonstrate the feasibil-

ity of adapting the HWT programme for children with intellectual disabilities,

the weak ‘pre-post’ design and small number of participants limits the conclu-

sions that can be made. In addition, no fidelity data was recorded during the

implementation of the programme. Intervention fidelity monitors the extent to

which an intervention has been implemented as planned and is critical for evalu-

ating the reliability, validity, efficacy and effectiveness of studies Smith et al. (2007). Future studies in this area would benefit from collecting fidelity data so

that clearer conclusions about the mediating variables at work can be drawn.

332 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

Finally, future studies could also evaluate the wider impact of the handwriting

intervention by examining a wider range of outcomes in addition to handwriting.

For example, evaluating whether following the HWT program leads to increases

in self- confidence or greater academic attainment more generally.

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Correspondence: Dr Corinna Grindle

Collaborative Institute for Education Research, Evidence and Impact

School of Psychology

Bangor University

Penrallt Road

Bangor, Gwynedd, UK

LL57 2AS

E-mail: [email protected]

336 Support for Learning � Volume 32 � Number 4 � 2017 VC 2018 NASEN

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