Getting Real with Mama OT

Getting Real with Mama OT

Mama OT interviewed Dr. Bev in 2014.  Her readership loved to learn about Size Matters and continued to circulate the following Q and A for years.  Enjoy!

Q1. In this age of technology, is handwriting really that important?

Yes.  But you’re not alone in questioning it.  The prevalence of computers in our classrooms and the potential they have to transcribe volumes of work in record times has led many to believe that handwriting is antiquated and that handwriting instruction an unnecessary use of time.

But here are the facts:

Handwriting is not a self-evident skill. Normal development and the passing of years don’t ensure that students will acquire habits and patterns that are either efficient or effective. This is confirmed by the research. Children may be able to make letters that are recognizable in isolation or small groups.  But in time when speed and volume are factors, their appearance often deteriorates significantly.

Keyboarding is not a faster skill. In fact, research has shown that children write more words and do so more quickly in grades 2, 4 and 6 when then print them than when they type. Furthermore, handwriting instruction supports automaticity, speed and output. In other words, when children have the skills to print legibly and neatly, they write more, and they write faster.

The manual task of handwriting stimulates centers of the brain associated with learning, memory, creativity and more.  MRI studies show a clear difference between students taught to print and those visually shown letters.  In one of the neuroimaging studies by Dr. Karin James from Indiana University, four weeks of each approach showed a marked contrast in the electrical activation of the brain.  Students who were instructed and practiced printing had brain maps illuminated comparably to that of adults.  In comparison, there was no change in the electrical activity for children simply regarding letters.  The implication is that the brain is exponentially engaged during the process of printing. These measurable results and imaging pictures argue forcefully for the inclusion of printing instruction as the process itself helps reinforce early learning.

Writing letters by hand has been proven to help children recognize and remember letters more easily than if they typed them.  Compounding the argument for the importance of putting pencil to paper are studies that show heightened neural stimulation during printing versus keyboarding.  In addition, students remember less when typing as compared to while printing.  

Q2. In my experience working as an OT, I've found that handwriting is one of the main reasons students are referred to OT for screenings and assessments in the school-based setting. Why do you think that is?  

There are several reasons for this.  The easiest is the prevalent but erroneous belief that printing is a self-evident skill, and that instruction is therefore not needed.  Strangely, that philosophy is often paired with a popular linguistic philosophy that encourages students to write without attention to the mechanical aspect, as if doing so would dampen the love of immortalizing thoughts onto paper.  These romantics seemed convinced that students couldn’t handle correction.  

It is no small coincidence then that surveyed teachers admitted to not being comfortable with handwriting instruction.  In fact, only 12% noted that they’d had any formal background in the subject.  That lack of understanding has led many to assume that printing could be mastered by simply completing worksheets independently after all other work is done.

Together, along with the overall economic cutbacks confronting school districts across the country, many administrators deem as superfluous the consumable workbooks required by most handwriting instructional programs.  

In turn, districts are forced to make hard choices.  Services, subjects, personnel and more are put on the chopping block.  

But as if all of the above was not enough to discourage even the most stalwart of handwriting instruction supporters, the mandates to differentiate instruction, obtain voluminous data, intercede at the earliest signs of struggle and procure proficiency scores on all local, state and national tests, have forced teachers to cry ‘uncle.’  They’ve just run out of time.  They are often unable to cover curriculum aside from that required by tests used to determine future funding.  In fact, it feels like No Child Left Behind has actually left a lot of curriculum behind… handwriting being one of them.

Q3. In your experience, what do OTs most often focus on when working on handwriting with students?

OTs are nothing if not holistic.  We’ve been trained to be analytic, comprehensive, methodical and inventive in evaluating, treating and documenting our treatments.  Toward that end, we have relied on the wealth of theories that have informed our understanding of development, perception, motor skills and cognition.  And being the professionals that we are, it stood to reason that we’d apply equal zeal in addressing all of the deficits, building the foundation skills and layering on accommodations identified by allied professions and our own ingenuity.

The problem is not that we have not been diligent, consistent or deferential to the literature.  Lots of therapists are using marvelous techniques, energy and wisdom to plug in all the holes, to remediate perceptual delays of visual discrimination and spatial relations, to strengthen the core and maximize in-hand manipulations.  Traditional approaches to instruction based on the formation of letter shapes pervade the existing options and our orientation to the issue.  We’ve been cognizant of logical times to push-in support, like handwriting instructional time.  Plus, our students are seen regularly.  Yet we acknowledge as a group that carryover and follow through are ongoing concerns.

But the research is only starting to catch up with the real variables impacting legibility.  Process-oriented interventions (i.e. all the traditional treatments we’ve pursued heretofore) have been shown to be inconclusive or mixed at best and do not appear to promote function.  And that’s the word that is slow to get out there.  Performance-oriented techniques hold the most promise in promoting function and participation.  The evidence shows that specific skills like handwriting respond best to specific skill training.

It’s not glamorous and it’s not consistent with our impairment-oriented roots.

But it is consistent with best practice.  

What we have to do requires a significant paradigm shift.  We need to work smarter and to embed handwriting sensibility into the curriculum so that good skills are utilized throughout the day.  We need to suspend disbelief, as it were, and attend to the task specific training required to be neat printers.  Function and participation must be our mission, even if it means leaving contributing or popular factors unattended.  Pencil grip, letter shapes and yes, directionality of stroke, too—none of these impact readability as much as we have previously thought.

AOTA has been vocal on this front.  They caution us to focus less on building skills outside of the classroom or with materials not germane to the curriculum.  But historically, that’s exactly what we’ve done.  We’ve got cool stuff in our therapy rooms, cool apps on our iPads and even cooler manipulatives that can be transformed into letters.  But unless we are able to give teachers concepts, sound bites, goals, materials and strategies that are fun, easy, measurable and cut across all subjects, we are sentencing ourselves to ever-enlarging caseloads.  Worse, we’re not fostering the independence students need for success.

Q4. I've heard that you have been successful taking a slightly different approach to handwriting intervention, focusing more on letter size than letter formation. Can you please explain a little more about that?

For many years, I was a school-based therapist drowning in handwriting referrals.  Using my knowledge of neuromotor, fine motor, perceptual and cognitive development as well as popular intervention programs, I worked tirelessly to correct deficits and teach letterforms.  I assumed that once interfering factors were controlled, children would be amenable to structured lessons and on the road to neat printing.  Unfortunately, I never seemed to get my students to the point of consistency and legibility, carryover and graduation.

That’s when I started playing around with variables that seemed more impactful.  I noticed that by focusing on letter size, form followed quickly.  On top of that, the overall appearance of the written page changed dramatically if not immediately.  In a short amount of time, the special education children were becoming the neatest printers in the school.

Motivated by those achievements, I put my toe into regular education classrooms to see if the strategies translated.  The reception was astounding.  Teachers reported instant changes in students’ printing.  Children consciously and carefully began making letters the right size to earn stars—the incentive that evolved into our scoring system.  One teacher shared the story of a parent confessing to scolding her daughter for being so irresponsible, bringing home someone else’s assignment book.  She didn’t recognize her own daughter’s printing after one 30-minute lesson.

Those early successes led me to formalize, conceptualize and test my approach.  While it is one thing for my students to experience triumph, it’s another matter entirely for other therapists or teachers to replicate the feat, and another still to have it proven. 

Once I’d finished my doctoral program, I remained affiliated with Temple University in Philadelphia.  I asked my professors that if they ever had students looking for a study, to test my methods.  Within a couple years, we had two willing candidates.  One did a meta-analytic review of the literature and reached the same conclusion as me.  Direct instruction was the most effective way to go, along with embedded lessons, mnemonics, self-monitoring, verbal cuing, visual modeling, home involvement and more—all features of my program.

The other did a controlled empirical study, the largest of its kind.  Using two school districts, one in rural upstate New York and another in urban Massachusetts, our demographics included over 200 students in grades Kindergarten, First and Second Grades.  Assigned to either a control or intervention groups, each student participated in 8 weeks of instruction using either the Size Matters Handwriting Program or a teacher-directed incidental approach.  Comparing the change scores from before and after, the difference was huge.  Significance was achieved at a .001 level.  In other words, the students in the treatment group showed such a profoundly measurable difference in printing in terms of legibility, form, size, and alignment that the statistician volunteered to write the discussion section for the journal.   He wanted ‘in’ on a result of this magnitude.

The Size Matters Handwriting Program is a concept-driven approach.  It is not workbook driven.  There is a lot of upfront teaching to ensure that children have the knowledge to critique their efforts and to print neatly.  Both our Practice Framework and the research attest to the importance of empowering patients/clients/students with information and decision-making.  It contributes to their investment in the process and the outcomes.  On many levels, Size Matters does just that.

On top of that, it is realistic and reflective of the time constraints and economics that plague our educational system.  First of all, since it is concept-driven, no materials are actually needed at all.  Therapists or teachers can use their own dice, run off good, adapted paper, drawn writing lines on the board and use colored markers to indicate letter size.  Most importantly, by extracting handwriting legibility to its essence—Letter Size—one can embed handwriting awareness into the entire school day for any subject at any time.  

The premise is this:  Letters come in 3 sizes—Size One, Size Two and Size Three.  When you focus on Letter Size, form follows.  Since there are only 3 sizes, it is easy to remember, especially since ‘The Rules’ come packaged as a ‘song and a dance.’  Correcting errors in Letter Size makes an immediate difference in the consistency and appearance of the written page.  And this is the prime variable influencing readability.

The Dice Game is an instant hit.  It’s the modality used to determine practice and remediation.  In time, the audible sound of clinking dice reminds students to ‘think Letter Size.’  It’s embarrassingly simple but undeniably powerful.  

Scoring for Letter Size occurs by noting whether Letter Lines TOUCH the Writing Lines in all the right places.  This is an observable and measurable commodity.  Students count the number of letters written followed by the number of letters printed the right size.  With the first number placed in the denominator and the second in the numerator, all parties can track progress on letter size accuracy.  Children learn to score themselves.  Parents and teachers can do it, too.  

Scoring for spacing is encouraged only after 80% accuracy is achieved on Letter Size.  This is done through drawing Spaghetti or Meatballs (i.e. yellow lines or red circles) inside or between words respectively.  Equally engaging, students relish the concrete and fun concepts that explain how to make their printing look its best.

Q5. Is it really more effective to address letter size vs. letter formation?


There are 62 different letterforms.  There are only 3 letter sizes.  When children concentrate on shape, they may make recognizable letters in isolation.  But within the context of the entire page, the inconsistencies and poor regard of the letter lines contribute to the perception of the writing as a whole as illegible and messy.

When children focus on letter size, the overall appearance of the written page changes dramatically and immediately.  The variability of letter placements is now removed.  Form seems to self-correct as children focus on making their letters touch the writing lines in all the right places.  Letters are more easily identifiable as they now sit accurately between the writing lines.  

Plus, the Rules on Letter Size are playful, concrete and informative.  Children easily learn to score the accuracy of their printed letters based on whether their pencil strokes are properly touching the correct lines.  Empowered with knowledge on what Star-Worthy printing looks like, students are able to self-monitor and self-score.  

Q6. Are OTs the only ones who can teach this approach to handwriting, or is it something that parents and other professionals can use as well?

OTs are not the only ones who can teach this approach.  Teachers, parents, aides… even the students themselves can learn the program and turn others onto it.  In the Handwriting Clubs I’ve run, it is the veterans of the program that bring the newest members up to speed.  

If anything, the simplicity of the Rules and the fact that this is a concept-driven approach speaks to the beauty and applicability of SMHP.  It is grounded in the very real-life circumstances—the need to still teach handwriting but the demand to do so the most efficient way possible.  

Add to that the limited time, the call for data, the slashed school budgets….

There really is no mystery to handwriting legibility.  It’s just that we’ve been looking in the wrong place and placing unrealistic demands on administrators to invest in yearly workbooks.  

Q7. Where can people learn more?

There are several ways to learn more.  

Check out our website:  Read the blogs and view the product videos.  They give you snippets of how to use the materials and the program.

Host a workshop.  As an approved provider of continuing education through AOTA, I can bring a full day Size Matters Handwriting Program to your school or therapy group.

Write to me.  The service part of our business is equally important.  I love brainstorming, problem solving and otherwise teaming with therapists.  We can talk about SMHP or any other practice issues.  After 38 years as a pediatric therapist, most of which were spent in the schools and a number of years as a national lecturer, I have a unique and broad perspective.  Plus, the stories shared by therapists like you across the country round out the communal experience of school life.  Don’t hesitate to call me at 877-864-2010 or to write  

Sign up for a Webinar.  We are currently in the process of expanding our approved providership to include distance education.  This will enable me to host Live Webinars as well as offered recorded ones.  Send me your email address now.  As that paper process is completed, I will be able to notify you about the series.  Live Webinars will be supported through Go-to-Webinar and will be scheduled at various times and days.  The Independent Study Webinars are supported by Go-to-Meeting and allow you to view a prerecorded meeting at your convenience.  Both require a score of 70% or above on a posttest to earn credit.  The content covers the learning objectives clearly and multiple times.  I promise… this is not a difficult step.

Attend a BER conference.  Go to to learn about my touring dates.  As a national lecturer for the Bureau of Education and Research, I travel the country presenting “Practical Strategies for Increasing the Effectiveness, Efficiency and Impact in your School-Based Occupational Therapy practice.”  While SMHP is included in the day, it is only a preview.  Still the products are on display for you to peruse.  Plus I’m available for questions.

Come to AOTA’s national conference in Baltimore in 2014 or Nashville in 2015.  If your state conferences are interested in speakers and exhibitors, we are happy to join you there, too.  

Friend us on Facebook and Twitter.  We are constantly sending out little updates and posts.  Invite me into a discussion group.  We are the new kids on the block, but we have a growing following.  After 3 years, Real OT Solutions and the Size Matters Handwriting Program are already being used in over 40 states.  Become an early adopter and turn your friends onto this researched and evidence-based approach that is already changing how we teach and remediate handwriting.

This is not rocket science.  But there are methods that are more effective than others and that are realistic responses to the very real state of education today.

Learn more about the Size Matters Handwriting Program.  

And let’s graduate your students into the ranks of legible printers already!!

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