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OTSH 82: Handwriting With At-Risk Kindergarteners (Journal Club)




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Have you ever wondered if that handwriting intervention you provide is helpful? Or how about what that intervention in the research article actually looked like?


In this episode of the OT School House Podcast, we are going beyond the article with the authors of the 2016 AJOT article titled Effectiveness of a Handwriting Intervention With At-Risk Kindergarteners.


Join me, along with Sheryl Zylstra, DOT, MS, OTR/L & Beth Pfeiffer, PhD, OTR/L, BCP, as we dive deeper into this journal article that shows how a handwriting intervention can impact at-risk kindergarteners.


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Amazing Narrator

Hello and welcome to the OT School House podcast, your source for school-based occupational therapy tips, interviews, and professional development. Now to get the conversation started, here is your host, Jayson Davies. Class is officially in session.


Jayson Davies

Hey there, everyone and welcome to another episode of the OT School House podcast. Thank you so much for joining me today. My name is Jayson Davies and I am a School-based Occupational Therapist down in Southern California. But I love interacting here on the podcast with all of you, no matter where you are. We have international listeners. We have listeners from the UK, from Australia, and of course the United States of America, Canada. And I just love. I love knowing that you're out there listening gaining from this experience. But I also love hearing back from you, whether it be on Instagram, Facebook, or even an email at jayson@otschoolhouse.com. I really love hearing from all of you. So please, if you love this episode, let me know. You can also leave a comment down in the comments if you're listening on Apple Podcasts. Really appreciate any review that can be a five-star review, I would love that. But I'd love any review just as much helps me to grow. So, let's get into today's content. Today we have on Dr. Sheryl Zylstra and Dr. Beth Pfeiffer. Sheryl Zylstra is a school-based OT by trade. And she is actually the primary researcher on an article that we're going to be discussing today. And we are so lucky to have her on because she's going to be here talking about her article. We also have on Dr. Beth Pfeiffer who was actually the researcher, the academic behind the article, she helped Sheryl with making sure that everything was going according to plan on this article. And she's going to give us insight as well as Sheryl, on kind of what this whole experience will look like, as well as what we lead to what the outcomes lead to. And so I'm super excited to have both of these amazing occupational therapists on the show today to really give you an idea of how this, this research came together, what the outcomes were, and even maybe what you could do if you would like to dive into research yourself. At the very end, we talk about some of the barriers and facilitators to research and so be sure to stick around for that, as well as everything about the article that is titled "Effectiveness of a Handwriting Intervention with at-risk Kindergartens". This article was published back in 2016, in the American Journal of Occupational Therapists, and the researchers were Dr. Sheryl Zylstra and Dr. Beth Pfeiffer. So enjoy this interview with them talking about their article "Effectiveness of a Handwriting Intervention with at-risk Kindergarteners". Good morning, Beth. Good morning. Sheryl. How are you doing today? You know what, let's go ahead and start with Sheryl, I'll give you a chance to speak first.


Sheryl Zylstra

Oh, good. Thank you. Thank you for having me. I'm excited to talk about one of my favorite subjects.


Jayson Davies

Awesome. Yeah. And I'm excited to have you...excited to let you share your research. You know, there are so many school-based OTs out there. And it's hard to find time to read the research. So I'm happy to have you on here to share a little bit about what you did. And over to Beth, how are you doing this morning?


Beth Pfeiffer

I'm doing well. I'm delighted to be here with both of you today.


Jayson Davies

Well, thank you. I'm really happy to have both of you on. And we're going to talk about so much today. But first, I want to actually give you both the chance to kind of share a little bit about your OT career, how you got to where you are today. So Sheryl, would you like to go ahead and start?


Sheryl Zylstra

sure I've been an OT for over 30 years kind of stopped counting at 30. But the majority of it and pediatric practice but not all of it. And then the last six years or so I've been teaching full-time at the University of Puget Sound.


Jayson Davies

Awesome. And what about you Beth?


Beth Pfeiffer

I've been in OT for about 25 years, mostly in pediatric practice as well. I'm an associate professor in the Department of Health and Rehabilitation Sciences in the College of Public Health at Temple University. I've been there for about 15 years, most of my time there was spent directing a research lab. So I'm very invested in research, but I also try to keep my hand in clinical practice as well. And that's mostly school-based practice.


Jayson Davies

Awesome. We are so happy to have you here today. And you mentioned Temple University, correct? And that's outside of Philadelphia?


Beth Pfeiffer

Yes, it is.


Jayson Davies

Awesome. Okay.


Beth Pfeiffer

What else?


Jayson Davies

Yeah, in Philadelphia. Sorry. You're outside of Philadelphia. But the university is in Philadelphia.


Beth Pfeiffer

Yeah.


Jayson Davies

And sure. What about you? Where are you joining us from?


Sheryl Zylstra

I'm in Washington State near Tacoma, Washington. And I did my doctoral work at Temple University, which is how I met Beth and she was my faculty mentor there.


Jayson Davies

That makes so much sense now. It's like how do people from two different areas of the country come together and University and Graduate School research that tends to be one keyway so that's awesome that you guys had that opportunity to, to come together in that way. All right. So let's go ahead and jump into the research. That you conducted. Sheryl, it sounds like you did a big part of this research. But how was Beth instrumental in this?


Sheryl Zylstra

Yeah, great question. So this was my Doctoral Capstone, I wanted to do research. And I wanted to do something surrounding handwriting because that's an area that I'm very interested in. And when I got to Temple, I just started talking to Beth. And she gave me a lot of different ideas, and then really was integral in helping with the design of the project, I had a lot of lofty ideas about what I could do what we do in practice. And she would say, you know, that's great in practice, that sounds like a lot of fun, but we have to streamline it so that we can research it. So that's how that went.


Jayson Davies

Awesome. And so were you working in a school at that time when you started your doctorate?


Sheryl Zylstra

Yes, I was. I have almost 15 years of school-based practice. And so I was doing my Doctorate while I was working in the school, School District here in Washington.




Jayson Davies

Gotcha. All right, perfect. And so you said that you had an interest in handwriting? I mean, can you go a little bit further on that? Why handwriting? And then was there any particular part of handwriting that you're interested in?


Sheryl Zylstra

Yeah. So as an OT, I love working on handwriting. And I feel like it gets a little bit of a bad rap. And one thing that I've been reading about in recent years is really expanding our discussion of handwriting into talking about literacy. And when I work with children in handwriting, really, we're working on early literacy skills. And we're really promoting a variety of written language skills. And so I really encourage OTs to talk about handwriting in the broader sense of literacy. And one of the reasons I've really loved working in that area is because I see progress. I just see a lot of progress when I'm working with kids in that area.


Jayson Davies

Absolutely. And feel free to speak. And you know, you're right, we oftentimes are considered the handwriting therapist, the handwriting teacher, the handwriting something. And yes, we do want to have more roles at school-based OT, they really do think that OTs have so much more value to offer. But at the same time, I don't know. Did your research did you figure out what percentage of the day kids spent handwriting? I know that wasn't the whole point of your research, but it's got to be a large part, right?


Sheryl Zylstra

Yeah, it is. And it is in the research. It needs to be redone. But the most recent numbers set about 25% of the day for young kids.


Jayson Davies

So 25%?


Sheryl Zylstra

25% of the day spit specifically spent handwriting for kindergarten first grade age students.


Jayson Davies

Wow. So a quarter of our of the child's day is spent basically with a pencil in their hand. That is an occupation itself, right? I mean, that is such an important part of a child's school day. So there is a good reason that we do focus on that handwriting. Definitely Believe me there. All right, well, I have never done any research. But one of the things I always value in a good article is the background information and the research review of the literature that we have to look up. Before we even really get started with our project. As you decided to look into handwriting, what are some of the things you discovered through your literature review? And actually, along with that, how did Beth help you with a literature review?



Sheryl Zylstra

Great questions, I learned so much from the literature review, there were two to three articles that really stuck out for me. And they were really new at the time. And the first article is Hoy et all. So let me see, it's Hoy Fetter. And I've got it here. It'll come to me in just a second. And they really looked at they did a systematic review of the literature, and really helped determine what works, what's evidence-based, and what isn't really working to improve handwriting outcomes. So that was huge for me because that really taught me that some things that I was doing, weren't necessarily shown to be helpful.


Jayson Davies

Gotcha. And so Beth, I want to actually yeah, I want to go ahead. And as I know, you weren't the primary researcher on this, but you help a lot of primary researchers. And so what are some of the tips that you give researchers, specifically Sheryl when it comes to that lit review?


Beth Pfeiffer

Well, Sheryl came in with such incredible experiences, she had this clinical background, and she had a real insight into what kind of questions should we be asking what should we be doing? And then my job is to come in and really narrow that focus because as clinicians, we think big and we think broad and we think very functionally. And then with research, you have to bring that to a specific question and methodology to be able to do that and, and look at that. So. So when looking at the literature, it does go back to what is your question? What are you trying to answer and how can you justify that and I think one of the things that really came out of this and why I really value this article quite a bit in the area of handwriting is because it makes that connection to really functional outcomes, it's not just about getting words down on paper, which I think is really important. That's not to diminish how important that is. And being able to read, those words and then information and to be able to demonstrate that you know the answer and you know the information. So it can be evaluated in a school setting. But there's also this link that was made. And I think Sheryl did a great job of connecting that to the literacy component that she's talking about these pre-reading skills. Not a lot of people really understand that relationship and how substantial it is. So if you take 25% of the time looking at actually physically handwriting in the classroom, but how much more time is spent reading and learning how to read, and being able to obtain information through reading. So that's another big aspect of this. And I feel like that literature review really highlighted that and identified the importance of it.


Jayson Davies

Wow. And Sheryl, were you able to find actually a number that of the literacy component of the day? You said its 25% was spent in handwriting? Was there also a number for that? If not, no worries, I just wanted to throw it out there.


Sheryl Zylstra

Yeah, I don't have that number. But what I do know is that researchers are talking a lot about how handwriting itself is being de-emphasized. Because the Common Core is so focused on reading. And so students aren't being taught, specifically taught how to write the same way that they used to be taught. And but if we can go to our administrators and say, Look, there's this direct link between handwriting and early reading skills, then there'll be more likely to allow this time to be spent on handwriting instruction, and not just on what they consider to be reading. So it's all part of literacy.


Jayson Davies

Absolutely. And you know, handwriting without tears, as well as the size matters handwriting program, which I know we're going to talk about a little bit. I always mess up her last name. So I'm going to call her Dr. Bev, she has done so much. And she continues to emphasize handwriting in the schools. And I really think that is part of the reason not just because of the handwriting like you're saying, but also again like you're saying, you know, there's so much beyond the physical action of getting the letters on paper. There's so much more than that. So absolutely. Before we move on from the literature review part, I actually want to open up a question and you know, what, maybe there's an answer, maybe there's not, but when you were doing your literature review, was there anything shocking? Was there anything like oh, my gosh, I can't believe this exists? Or, on the flip side, wow, this, how come this doesn't exist? Was there anything really shocking to you?


Sheryl Zylstra

Well, thanks for getting back to that, because I wanted to mention this article, it's white Egan, and Fetter 2011. And the name of the article is a systematic review of interventions to improve handwriting. And that was hugely helpful for me, as I mentioned earlier because it taught me that some of the things I was doing weren't evidence-based in terms of improving outcomes. And another article that was hugely informative to me was the James and Engelhart, in 2012. And what they found, they looked at children were either copying letters, or they were punching the same letter on a keyboard, so they were copying a C, or they were keyboarding, a C. And what they found was when they were copying the letter when they were doing the physical act of handwriting, parts of the brain lit up that were directly related to reading, when they were keyboarding, that letter, those parts of the brain did not light up. And so again, it just showed from a neurological standpoint where the physical act of handwriting was impacting the parts of the brain that are specifically related to supporting reading. So those were huge articles to me.


Jayson Davies

Wow. Yeah. You know, we always it's funny, you hear something on the news, right? You hear just a quick 22nd clip on the news about something. And I remember, I don't know, maybe about five years ago, it was like handwriting helps you with memory more than keyboarding does, you're actually gonna remember something more, if you write it down versus type it, you know, and it's only like a one minute clip on the news. But you have no idea where that research comes from. They don't mention the author's or what journal it comes from, or anything. But I would imagine that maybe what you're talking about right there might have had an influence on that. And it's something we all hear but I don't think we often really hear how it was conducted and the research behind it. So thank you so much for sharing that.


Sheryl Zylstra

Yeah.



Jayson Davies

All right. I have to touch on this because RTI is one of my most favorite ideas within the schools, tiered intervention, MTSS, RTI, PB is all of it. I love it. And you mentioned RTI in your article. And so I just want to ask you, were you able to find RTI articles out there? And if so, what impact has that had on you? Because I know RTI in the grand scheme of things is actually relatively new. It's been probably around 20 years, but it's just now starting to really get embedded. So I just want to ask you, if there's any, what do you know about RTI? Was there any research in relation to occupational therapy, or in general?


Sheryl Zylstra

Yeah, you know, there wasn't a lot of research, especially related to occupational therapy and RTI. But what happened to me as I worked in two different school districts at the same time, and one of the school districts I worked in was implementing RTI heavily, and the other district wasn't implementing it at all. And that's a choice school districts can make that choice. But what I was seeing in the school district that was implementing the RTI was amazing. And so I was, I became so interested in it, and I could see the impact it was having on the kids. And those are the kids we typically work with as occupational therapists, we don't typically work in general education settings, we're typically working with the at-risk kids or the kids that have already been selected for individualized education plans.


Jayson Davies

Yeah, yeah. Thank you so much for sharing that. Beth, do you want to add?


Beth Pfeiffer

Yeah, I think that's what really made this, um, this research study so important was it was really it was looking at a group of students that were receiving either RTI or that did have IEP interventions. And, and not much of the literature really look at that population, you would think that most of our Handwriting Outcome Research would look at that, but it's really with the general population. So this was really unique in that way, especially with the RTI and I think it also provides some real important justification for why OT should be involved in RTI more, I don't always think we're there. And I think we need to be.


Jayson Davies

Absolutely, and you know, there's so much more research going on even now than there was a few years ago with RTI and OT, we have Dr. Bazyk who's doing her every moments counts program, where they're really embedding OT into, into the curriculum into the everyday places and, and other OTs are doing similar things. So I think it's awesome. All right, I actually want to come back to you, Beth, for this next question. Because in my experiences, you really have to do that deep dive into the literature review, to find out what you know, and what you don't know. And then you kind of come up with a hypothesis. That's my experience. But I won't ask you Is that right? Or Is that wrong?


Beth Pfeiffer

Oh, absolutely. I think that when we're generating research questions, we get the information we need from different sources, and one of them is clinical experience. So someone like Sheryl, who comes in with a wealth of clinical experience in the school system really can identify where we need to target our research. So that's essential. And that's where that clinician and researcher pairing is so important. So I think that's one area and the other one is the literature. We don't want to be answering a question that's already been answered. Right. So that's something that we need to know is that already, do we already do this work? Do we already know that information? Do we have the evidence? So we need to go in there and find that out? And then we need to really find out what question we should be asking. And that tells us what is missing? What do we need to know? And so that's where that literature comes into play.


Jayson Davies

And that leads us right down to you Sheryl, what was the question that was missing? And what did you decide to tackle?


Sheryl Zylstra

Yeah, so the question, in a nutshell, was that I wanted to answer was basically, is what I'm doing working, is what I'm doing every day when I go to work, which is a lot of handwriting groups, a lot of early literacy groups that make it different. And that's what I wanted to answer. So I have this specific question here. If you want to hear the long question.


Jayson Davies

Go for it.


Sheryl Zylstra

Will at-risk kindergarteners participating in the handwriting intervention group, utilizing the size matters, handwriting program, improve their handwriting legibility skills? And then in addition to that, we also wanted to look at, will this OT lead handwriting intervention, improve their pre-reading skills, as well?


Jayson Davies

So there are two parts to that. It sounds like yeah, the reading side, as well as the handwriting side. And I want to ask you because I think every time we read an article, we have to consider all factors involved. And you specifically, were looking at the size matters handwriting program. Was there a reason behind that? And if so, was it because you had experienced with it because you and Dr. Beth, were close, and you kind of knew about it? Or was the research behind it? What kind of drove that decision?


Sheryl Zylstra

Yeah, I will tell you briefly, and then I will let Beth take over this question. I actually had was working in a school that was using D'nealian handwriting. And I had some concerns about that because there wasn't any research that I had found to support D'nealian and D'nealian is when you add the little monkey tails to the letters, it was sort of supposed to promote that transition to cursive handwriting. And right as I was getting ready to work on designing the research project with Beth, the school dropped the D'nealian and said, we're not going to use it anymore, which I thought was great, but it left me a little bit stranded. And so I talked to Beth and she said, Well, I have this great new program that we're starting to do some research on, let me tell you about it. And so I'll let her tell you about that connection.


Jayson Davies

Oh, go for it.


Beth Pfeiffer

So, um, Dr. Moskowitz was actually I'm also a doctoral student, and she started the development and besides matters, handwriting program in Temple's Doctoral Program, so I had worked with her quite extensively on that. And then we continue to work together, she was very, very committed to having evidence for the program and evidence-based practice across the board. So that's something she did when she was developing this and conceptualizing it, that was something that she really integrated into the development process, as well as her long-term plan after she left the program, so we had done some work. And we had just finished a study, looking at the effectiveness of the size matters handwriting program in the general school population. And we had really incredible outcomes, very strong outcomes that suggest that this improves legibility, this improves your handwriting. And so that's always helpful when you're starting to go beyond the initial question of is this effective, you know, does this have efficacy. And Sheryl was in a place where she was looking at it with a very unique population and one that we needed to know more information about. So we knew that this had evidence that it is an intervention that can work and improve handwriting legibility. So that's a really good place to start. And now we need to take it to this next level. And this was a really nice transition into Okay, now let's look at it with a different population. Let's look at it in we did look at it within the natural context of the schools before, but within the natural service provision that was happening in terms of RTI and IEP services. So it really seemed to be a good fit and next step.


Jayson Davies

Okay. So just to kind of rehash what I heard was that the size matters program, there was already some research out there. And the population for that was mostly just general education, maybe middle elementary age.


Beth Pfeiffer

Yes, exactly. We had mostly elementary students in the initial study, and it was just with the general population.


Jayson Davies

Gotcha. And that leads us into our next question for Sheryl, then you were going to a more specific targeted audience. And I'll let you explain that.


Sheryl Zylstra

Right. Well, I know as an occupational therapist in the schools, I wasn't working with the general education population, I was working with kids that had IEPs, or that were at risk of potentially having IEPs as they got older, that were struggling with their handwriting skills. And those are the kids that I wanted to look at because those were the children that I see.


Jayson Davies

Gotcha. So again, you went with kindergarten kids, right?


Sheryl Zylstra

Yes.


Jayson Davies

And then it was with at-risk, what turns them as at risk? Or what made them at risk? How are they identified?


Sheryl Zylstra

Yeah, good question. So I typically work in what they called at the time and probably still call a resource room, where kids who are struggling to gain the kindergarten level skills are put to get extra time to learn those skills, basically. And so those children were a combination of children that already had IEPs, or that were being given extra intervention to potentially avoid having an IEP put into place.


Jayson Davies

Gotcha. So again, just to kind of reiterate, or not reiterate, but just kind of express what I'm hearing is that those kids either had an IEP, or they are already in tier two, maybe even tier three of the RTI process, meaning that they're getting small group or maybe even more of an individual type of service through the resource room, correct?


Sheryl Zylstra

Yes, exactly. It was a true tier two, because especially when I went in, I was seeing them in a group, and not individually.


Jayson Davies

Gotcha. All right, perfect. So let's go with that. Then explain what that looked like. What did it look like when you were working with these students?


Sheryl Zylstra

So it was really fun. Doing groups is one of my favorite things. So I would go into the classroom. And this is where, you know, again, as a clinician, I have these ideas, but Beth, as the clinician slash reach researcher, was really able to help me fine-tune what I was already doing, and make it sort of study able. So we would go in half an hour, twice a week. And I would lead a group using the size matters handwriting program, and we would just have a lot of fun. And we would use the principles, we had the workbooks, we would do a variety of activities that incorporated handwriting, one of the primary things that we did that is important to the size matters handwriting program is that we taught handwriting. So as an OT, I've been into many, many, many classrooms where teachers who are doing the best that they can and don't have a lot of knowledge about handwriting instruction, are printing out worksheets from the computer and giving the students worksheets to work on their own. But sometimes they're lacking structured handwriting instruction. This is how you make an H you start at the top you make a line down. That's really important. The actual there, there are some kids they say about 30% who are gonna pick it up. But there's this other group of children who aren't going to pick it up on their own. They need explicit instruction in order to learn handwriting.


Jayson Davies

Gotcha. And so you were doing this in the resource room. So were kids coming from their main classroom to the resource room, and then you were meeting with them in the resource room. Is that correct?


Sheryl Zylstra

Exactly.


Jayson Davies

Gotcha. Okay, perfect. Just so everyone has a chance to hear that. Awesome. So you're doing this in the group? You're doing it in the resource room? And did you have a chance to actually work with the teachers at all? Or was this strictly with the students?


Sheryl Zylstra

No, that's a really great point, it was really required that the teachers be an active part of the group. So the teachers were always in the room, I went in the COTA, the excellent COTA that I worked with also went in with me, the teacher was always in the classroom. And the teacher's assistant was always in the classroom. And the reason that was so important is that the teacher was learning the program as well. And she was incorporating the principles on a daily basis. So that was hugely important. That's one of the concepts that the Hoy et all article really pointed out to me is that practice, practice practice. You've got to repeat what you're doing in OT, outside of OT to make it work.


Jayson Davies

Yeah, absolutely. I like to tell therapists as well as other practitioners that work with students that, you know, sometimes we can spend a half-hour with one student and impact that one student's life. Other times, we can spend that same half-hour with a teacher, and we can impact 30 students lives with that half-hour with a teacher, and then the 30 students that the teacher has next year, and the year after that, and the year after that, just by training them a little bit. And so sometimes, you know, you can have more of an impact by stepping away from the student and working with the teacher a little bit. So absolutely. Alright. So when it comes to research, whenever you're going to look at the effectiveness of something, typically, you have to compare it to something. And so now, what were you comparing the size matters handwriting program to?


Sheryl Zylstra

Yeah, so Beth may be able to answer this question better than I, but I'll attempt it first. We were comparing it to the standard handwriting practice. So teachers often come up with their own handwriting curriculum. And so whatever that teacher in that classroom was using was what we implemented in the control group. So we said, we're going to come into this classroom, and we're going to do the OT lead size matters, handwriting program, you are going to do whatever you've been doing, and what's been working for you.


Jayson Davies

Gotcha. Beth, did you want to add to that, or


Beth Pfeiffer

It's exactly what I would just say, as well. It's really when we're trying to do research that's in the natural context. And I think for school-based practice, it's very important for us to be implementing our interventions and looking at their effectiveness in those environments. You know, oftentimes, you're comparing the situation to the standard practice. So and that's essentially what it is, was what they as his services or as his interventions. So in this case, it was what the teacher was doing to teach handwriting within that context for those groups of kindergarteners. And we know in kindergarten handwriting is something that they are starting to learn. And it's part of the curriculum just naturally. So that was really what it was compared to.


Jayson Davies

So we don't we don't technically know the specifics of that handwriting program, if you want to call it that, is we just know that in kindergarten teachers teach handwriting, and therefore this was compared to that. Alright, that makes sense to me. I hope everyone understands that. So then basically, you then compared students who came to work with you and compared them to students who didn't come to work with you. Is that right?


Beth Pfeiffer

Yes.


Jayson Davies

Okay, perfect. at all, it's all coming together to make sense now.


Beth Pfeiffer

In a lot of ways that we're actually comparing somewhat two curriculums, it's just that we don't have the one standard curriculum defined, because that can look differently, especially with handwriting. I don't think their standard curriculums in all the districts are in all the classrooms that are being used. Sometimes teachers make determinations on how they're going to teach that. So we're really comparing almost two different curriculums in some ways in the school setting, you know, a very, yes, this matters, handwriting curriculum, and program, you knew to what the standard curriculum was.


Jayson Davies

Yeah. And so just, again, just to kind of wrap this up, Sheryl, did you actually speak to the kindergarten teachers at all? And like, ask them, Hey, are you using the handwriting program or find out anything about that? Or do we know what they were using at all? Were they just using a made-up curriculum? Or did they have a specific curriculum that the district might want them to follow?


Sheryl Zylstra

Yeah, you know, again, it's often teacher specific. And I think what we're finding more and more is that I just read an article yesterday that talked about how using a specific handwriting program is important. We don't necessarily, it doesn't necessarily matter which handwriting program as long as it's presented in a very specific, repetitious, and consistent way. And so I do know that this particular teacher in the control group was a teacher with a wealth of experience many, many, many years of experience, and had taught handwriting in her kindergarten classroom for 20 plus years, and was using that same curriculum that she had developed over time.


Jayson Davies

Perfect. No, that's fine. Yeah, as long as we kind of know what they're doing, I feel like I know that they're actually doing it, I'd hate to, to measure our something versus something that isn't happening at all. And so that's great, we at least know that this teacher has some experience, they knew what they're doing, they had been doing it for a long time. And, you know, a school-based OTs, we've all walked into a kindergarten classroom, we've all seen what they're doing. We've all seen the letters up on the wall, we've seen them using the long stick to trace the letters and kind of show the kids how to how they do it. And so that's just wanted to see what that teacher might have been doing. So thank you.


Sheryl Zylstra

Yeah, I do. I do just want to add that I think this is where OTs can have a huge impact in the schools as well. Because after talking to a lot of teachers, you do learn that in their education programs, handwriting curriculum, or handwriting is not one thing they're very well trained in. And so they're asking us often what they should be doing, and they're doing their best, but often they are pulling things together. And it might be better to introduce them to a researched a well-researched program so that they can be more consistent in their approach.


Jayson Davies

Absolutely. And I actually had any experience doing this, I kind of did something similar to what you're talking about, except I went into a first-grade classroom. And I helped that first-grade teacher, the entire classroom, it wasn't a specific program, it was kind of a combination of all the knowledge I had a little bit from size matters, training a little bit from the handwriting, without tears training, I kind of put together my own 10-week curriculum. And I went into the first-grade classroom, I did it. And then low and behold, 12 weeks later, the administrator was much more open to listening to me about implementing some sort of program. And the next year, there was money available. And so the entire kindergarten, first grade, second-grade classroom all had the handwriting without tears program, which was awesome. And they sent several the teachers through the training. So you don't have to start big, you don't have to just go to your admin and demand something. Start small start with one classroom or one teacher and, and work up from there.


Sheryl Zylstra

Yeah, that's great. I love that story.



Jayson Davies

Thank you. So before we get into the results, let's talk about how you measured the success of the students. What tools did you use to determine if the size matters handwriting program was working or not working?


Sheryl Zylstra

So we started with the test of handwriting skills revised because it's really important if you're going to be assessing handwriting that you're using a handwriting assessment. So we use the test of handwriting skills. And then we used it because we were really interested in finding out whether this intervention would also potentially impact pre-reading skills. We used a screening tool that looked at letter sound-letter recognition and letter-sound recognition. So basically, there was a template with the alphabet on it. The letters were all mixed up. And I would point to a letter and I would say, What letter is this? What letter is this? And then the next time through, I would say, What sound does this letter make? What sound does this letter make? To assess if they knew the alphabet, and they knew the sounds of the alphabet?


Jayson Davies

Great. And Beth, do you want to add anything when it comes to figuring out what tools to use and kind of how you go about doing that?


Beth Pfeiffer

I think it's really important. It's an area that I'm particularly invested in this idea of outcome measures, we need to make sure that the tools we choose can actually measure change a lot of the tools, not a lot. But some of the tools that we use in practice, really are to help us guide our interventions. But they're not always sensitive enough to pick up the change. So it's very, very important to have a well-developed tool that you know, has been used either in the past or that you know, that can demonstrate that there'll be changes made. And we actually did a study specifically with handwriting, another study where we looked at the outcomes of handwriting, and it was with the size matters program again, but and we used a visual-motor integration tool, I think we use the berry and we used the test of handwriting skills revised. And what we found was that after the intervention, that there were substantial changes, significant statistical changes in the test of handwriting skills, revise, but not in the visual motor measure. So you can really, this is an area where you may be having an impact. But if you don't choose the right tool, or you don't measure the construct that you're targeting, that you might not see that change remaining. Don't be able to document it and research so it's really, really important. And when we were looking at the tools, the test of handwriting skills revised was a well-developed tool that had been used in handwriting studies in the past It also went down to a lower age range. That's one of the areas that was a real challenge and choosing a tool. This one only went down to six. And we were looking at kindergartens. Nurse. So we had some five-year-olds that we had to have had adjusted work, but it did go within the age ranges for the most part that we needed. So that was another factor as well. And then Sheryl actually had experience with the other assessment that really looked at kind of letter recognition and sounds. And so she had experienced that one before, and we were able to integrate that one as well.


Jayson Davies

Absolutely. I'm really familiar with the THSR, the tester handwriting skills, revise, it can be cumbersome to grade, you got to give every letter needs a one, two or three. And then you got the timing that you got to do. Yeah, but it is very sensitive, I would, I would say because it really details out a letter that has a gap is automatically scored at two, if I remember right, or no, I can't remember off the top of my head. But yeah, you got to look at that chart. And if it's crossing over, then it's a different number. So yeah, I'm glad you were able to find something that really helped fit the age of the kids and was also sensitive. So that leads us to our results. Obviously, the school-based OTs that are listening, we are not researchers, we are not good with T scores and P scores and all those other values that we often see in research. But what were some of the significant outcomes that you found?


Sheryl Zylstra

We had some really great results, and I'm gonna let Beth take this one.


Beth Pfeiffer

None of us would take this one. So as a researcher, I need to know a little bit about statistics. But I do think that we make statistics very scary for people. So I'm going to make this very non-statistic based and just summarize and say that there were significant changes in handwriting, legibility, and performance in the group that had the intervention, not the standard group in the group that had the intervention, there were some real substantial, significant changes there. And significance. Essentially, you always hear these terms like a P, that's, you know, .05. And essentially, what that means is that we are just 95% confident that that change was impacted by the intervention we provided. So that's, that's the interpretation of it, there's always this little chance that it wasn't this 5% chance, but 95% is pretty good. So and that's essentially what that means. And additionally, we also saw the same types of changes in letter recognition as well. So letters and the letter recognition as well. So there were significant changes in both those areas for the group that had the intervention, compared to the group that had the standard handwriting curriculum.


Jayson Davies

Was it just a letter recognition or both recognition and sounds? Was one of the other?


Beth Pfeiffer

It was on that test that assesses both letter sounds and letter recognition.


Jayson Davies

Gotcha.


Beth Pfeiffer

Watching the discourse.


Jayson Davies

Gotcha. And Sheryl, do you want to add?


Sheryl Zylstra

Yeah, sorry, I was gonna just point out that it's important to note that both groups made changes because we're talking about kindergarteners and a big chunk of their year. And there's maturation, and there's a lot of learning going on, and all the teachers were excellent teachers. So it's not that the control group didn't make progress. They just didn't make nearly as much progress as the intervention group made.


Jayson Davies

Gotcha. Perfect. And thanks for explaining that. For anyone who might have skipped past the first 20 minutes of this podcast, and maybe me who kind of we've already gone 20 minutes later, remind me again, really quickly, how long this was the program? How long did you do the program over? And were you very strictly adhering to the size matters? handwriting program?


Sheryl Zylstra

Yes, good questions. I'm going to I believe it was 16 weeks, twice a week for 16 weeks. And yes, we were This is one thing I really learned from Beth, is that I wanted to do a lot of fun little activities, in addition, and do some cutting and some coloring and this and that. And she really taught me about the concept of fidelity, and how I really did need to have a strong fidelity measure and be really true to the size matters handwriting program for this project.


Jayson Davies

Great. Thank you for sharing that. Because I know again, Dr. Moskowitz, I know she has so much fun in her training that the size matters handwriting program. It has a lot of fun components to it. You got the dice game, and you got star letters and whatnot. But you're right, you really have to adhere to it. Otherwise, what are you measuring? And so you got to make sure that what you're saying you're measuring is actually what you're measuring. So thank you for sharing a little bit more about that. And that is going to bring us to the all-important question of how can school-based OTs use this information. You did this research a few years back where a few years later, what can someone listening to this podcast take back to their school, their district, and use tomorrow.


Sheryl Zylstra

Yeah, several things. I think one of the biggest things is this idea of practice, practice, practice. And one thing I think we really need to ask ourselves is if we're still using sort of a pullout once a week model, is that the best model? Is that a model that's going to allow us to have this repetition and practice that the research is telling us we need to have? So that's really important. And then the other idea is this, really teaching the concepts using a cognitive approach to teach the concepts. There are those few students that will pick up learning how to write from a worksheet, but there's a large group of children that will not pick that up. And we really need to teach it in a consistent, constructive way.


Jayson Davies

I absolutely love what you just said, because I have never read an article that says school-based OT kids need once-a-week therapy services. But I have read articles like what you're talking about, I mean, your article, other articles, the size matters, other articles with other programs. They tell you how many times typically, they met with a student or with a kid over how many weeks? And that's awesome. That's something that more OTs, I think myself, we need to look on to that part of the article. A lot of times we just look at the article, did it? Did it work? Did it help did the program work? But we forget to take into account how much they actually saw the students. And you know, there are some articles out there that we have to almost dismiss school-based OTs because the program's four hours a day, we're never gonna have four hours a day with a student. But like what you're saying 16 weeks, 30 minutes twice a week is right, is that correct?


Sheryl Zylstra

Right.


Jayson Davies

That is something an IEP team can handle probably.


Sheryl Zylstra

Yes. And this leads me back to the Hoy article again, which I keep referring to. And even though it's becoming a little bit older, I highly encourage everyone to read it, because it really just talks about what works. But it also talks about what doesn't work. And one of the things that do not work is sensory-motor activities. And I will admit that as an OT with 30 years of experience, I've spent a lot of time doing fine motor dexterity activities with kids, thinking that it was going to help improve handwriting skills. And again, it doesn't mean that doing fine motor dexterity activities is bad if that child has fine motor dexterity concerns. But if my goal is handwriting, I need to work on handwriting.


Jayson Davies

Yeah, absolutely. So great. Now, obviously, school-based OTs can take this information tomorrow, they can implement it, they know that they need to potentially up their services for some kids who that might be beneficial for or potentially reduce services or work with the teacher because they can do that more frequently than we can in some instances. Now, I know like almost the last line in every single article is famous, there needs to be more research. And so if you were handing this off to a new doctoral student, someone who wants to go ahead and get back into research, what would you say the next piece of research to be when it comes to handwriting in schools?


Sheryl Zylstra

Well, I'll tell you what I'm thinking about right now. And COVID really played into this is because so many classes went online and schools were online. What is the effectiveness of our OT interventions when they're online? or via telehealth? So we're I'm looking at the friend right now about if we were to do a similar handwriting literacy intervention via telehealth, what would the outcomes be? How would that look, would we have similar successes?


Jayson Davies

That sounds amazing. So you would take the same program, basically the same research, it would just be over more than likely Zoom or Google?


Sheryl Zylstra

Exactly, exactly, to see if our results would be similar?


Jayson Davies

So does that mean you're working on that?


Sheryl Zylstra

We're, we're talking about working on it.


Jayson Davies

Awesome, awesome. Well, I can't wait. I'll give you about three years and looking at the AOTA journal and I'm sure I'll see something. So I could not be more appreciative to both of you, Sheryl, that because of the research that you do, I mean, I really appreciate you being here today sharing this a little bit. But even more so both of you and all the other therapists that do research that give us something to stand on. You know, this is something that an OT could, I always recommend that OTs have like a book of articles, and you know, taking that book, this is an article that you could put in that book. And when you need to refer to something in an IEP or if you need to go talk to your admin about something that's important to the kids that you work with. This is an article that you can take with you and share with your admin. You know This is why I'm justifying twice a week for this student because this is the program and it worked. And it was twice a week. That's why I'm recommending twice and not once a week, per se. And so again, I really appreciate you both for all the information that you have researched. And, of course, so much for coming on here today. So thank you. And the last question I have to ask is, are there anywhere? Or are there any websites or any other resources that you both would like to share? Where OTs would like to learn more? I know, you've already mentioned a lot about the Hoy article, and I will be sure to put that in the show notes so that people can find that. But are there any other websites or any other resources you'd like to make known?


Sheryl Zylstra

Yeah, so I would like to add the Jameson Engelhart article to that 2012, Lenin Grotto and Goodman have been doing a lot of work on promoting literacy. So again, taking that handwriting and making it bigger, are really talking about literacy. And then I also want to really quickly add that the minute to chime in here, that clinicians can do research. So if you're a clinician, and you're interested in doing research, by all means, collect the data. And then if you don't understand how to statistically analyze it, that's where you call someone like Beth, or you hook up with your local university and you say, I've got all this great data that I'm collecting in the clinic, can you help me make something of it.


Beth Pfeiffer

You actually said exactly what I wanted, Sheryl, that was perfect was that don't be afraid teller shy away from doing the research or thinking that you can't be the person that does it. Because there's a lot and lots of ways to collect that information. This study was a pre and post-test study. And we used what they call a convenient sample. So that means that we didn't separate people out randomly into groups, we looked at them in their natural context and their natural classroom environment. And that's really important information. And you can do that. And as long as you're using measures that target what you want to know changes, you can collect that very easily, just as part of your progress monitoring. So we need to do that in school-based practice, we need to monitor our progress. And we can incorporate collecting some of this information during those times. And we can really use that to one demonstrate that either need for services, and the value of occupational therapy, and advocate for what we think is the best approach in that situation, then also get that information out there to the profession to show that what we're doing and how we do it works.


Jayson Davies

Alright, I have a follow-up to that, Beth, what is the one? What's the one barrier that clinicians come to you most with? That is it just an absolute myth? What is something that therapists come to you and say, you know, what I can't do? I can't do the research because of a blank and why is it a myth? Or what is your response?


Beth Pfeiffer

I think, and I don't think it's a myth. I think it's a reality. But time is the factor, time and resources are always the factors that come up. And I think that it's not a myth because we all were also stretched for time, we have large caseloads in school-based practice. And we have limited resources in schools. We're under-resourced, to begin with, I think the thing we can do to overcome those barriers is to be innovative in our thinking. And also to realize it doesn't have to be this huge project outside of what we're already doing. So we can be collecting information as part of the natural process of providing services in the schools that we can look at some of the before and after. As I said before, we need to document our progress anyway. And that's part of the school-based practice. And so we can use targeted measures to be able to do that, and then collect that information. And it can be pretty easy to then have a small research study going over time. So I think there are ways and ways that we can overcome some of those barriers. The other thing I would encourage I know, Sheryl said this as well, working with your local institutions, there are a lot of graduate students in OT that would be delighted to help you in those settings and get that experience and they have research requirements. So using those resources, and accessing those, I think is a really important step as well.


Jayson Davies

Definitely. Well, thank you so much, Beth, thank you, Sheryl. Really appreciate you coming on sharing, not just about handwriting and literacy a little bit, but also a little bit about how you can get into some research if that's something you might want to do. So thank you both so much, really appreciate you taking the time to be here. And also really appreciate you being willing to go to the next step and do some research. Really appreciate that that supports all of us out here. So one last time. Thank you so much. I really appreciate you both being here.


Sheryl Zylstra

Thank you. Take care.


Jayson Davies

All right, one more time, please give it up for Dr. Zylstra and Dr. Beth Pfeiffer really appreciate having them on here. Like I just got done mentioning at the end of that interview, I really do appreciate them going a little bit further going beyond the clinician role and doing that research so that we have something to take back to our administrators to show them. Now with that said, I want to ensure that you actually go beyond that. So be sure to click over to the show notes and read this article, we covered a lot, but it is definitely worth a quick read over to make sure you didn't miss anything. Some things that you always need to read when you're looking at articles are those limitations and biases. And right after I hung up the phone with them, I realized I forgot to ask them. Now there isn't anything too big in there. But that's something that you should always look at with any article you read okay? So, head on over there, read the article, check out the other articles. And my favorite thing to do actually is when I'm done looking at an article is look at the citations. You don't have to go and click on every single one and read every single article that's in those citations. But you might be surprised by what you find. And you might find a really good article that again, will help you support yourself, support the students and support the teachers you serve as a school-based OT. So one more time. Thank you so much to Dr. Zylstra. Thank you so much to Dr. Pfeiffer. Really appreciate having you on and of course, thank you one last time to you, the OT practitioner listening to this podcast right now. I am so happy so excited. so thrilled to know that you want to make yourself a better occupational therapy practitioner, especially in the schools. Take care. Have a great rest of your day, and I'll see you next time on the podcast. Bye.


Amazing Narrator

Thank you for listening to the OT School House podcast. For more ways to help you and your students succeed right now, head on over to otschoolhouse.com. Until the next time, class is dismissed.





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