Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Health Sciences


Rehabilitation Sciences

First Advisor

Dr. Camille Skubik-Peplaski


Across the United States, there has been a push to improve the literacy of our population, especially in the school systems. This has resulted in emphasizing reading skill development; however, literacy encompasses more than just reading. Literacy is the internal processes needed to create and understand contextualized visual, written, and verbal information. According to the Common Core State Standards, foundational literacy skills include reading, but also writing, listening, and speaking abilities. Handwriting is an area of literacy that is often forgotten, but has significant positive correlations to writing composition, spelling, and early reading skills. In fact, the Simple View of Writing developed by Berninger et al. affirm handwriting as a low level writing skill needed to be mastered in order to excel in the higher compositional writing skills.

In recent years as the dependency on technology increases, explicit instruction of handwriting is frequently overlooked in curricula. Accordingly, the percentage of children struggling with handwriting is on the rise. Associations with handwriting difficulties can include pain with writing; decreased written content; anxiety; low self-efficacy; and avoidance of handwriting. The most common referral for a school-based occupational therapist remains handwriting issues. Currently, there is no standard of care for addressing handwriting goals, but evidence suggests that practice and instruction of handwriting is imperative.

Concurrently, the use of telehealth service delivery in pediatric occupational therapy has significantly increased in utilization since the COVID-19 pandemic. The research into the effectiveness of pediatric occupational therapy interventions delivered via telehealth is still emerging. Thus, the overarching purpose of this dissertation is to determine the effectiveness of handwriting interventions on handwriting and spelling outcomes delivered via telehealth. Through this investigation, further insight will be provided into the feasibility of handwriting interventions via telehealth as well as the relationship between handwriting and spelling.

This two-part dissertation began with a pilot case study to gain insight into the feasibility and effectiveness of delivering the Handwriting Without Tears® curriculum, a frequently used multi-sensory handwriting program, via telehealth. The case study was conducted with a first grader who was typically developing to gain understanding into the relationship between handwriting and spelling. The results of this pilot study informed and streamlined the subsequent case series study. This investigation was conducted with children with literacy issues of handwriting and/or spelling delays, who would be more representative of a pediatric occupational therapy caseload. This dissertation project aims to build on the handwriting-focused literacy research as well as grow the evidence for pediatric occupational therapy telehealth interventions.

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