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Handwriting: It Is A Big Deal

Handwriting: It Is A Big Deal
Megan Pagen, MOT, OTR/L, ASDCS
September 28, 2022

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Editor's note: This text-based course is a transcript of the webinar, Handwriting: It Is A Big Deal, presented by Megan Paben, MOT, OTR/L, ASD-CS.

Learning Outcomes

  • After this course, participants will be able to:
    • Identify the foundational skills of upper extremity development for handwriting.
    • Recognize the pyramid for learning and strategies used for promoting skills used in handwriting.
    • List the resources necessary to build treatment sessions and for further fine motor acquisition.

Introduction

Thank you so much, everybody, for joining us today. I look forward to sharing this information with you. 

Foundation of Hand Skills

Let's start with the foundation of the hand in Figure 1.

Figure 1

Figure 1. Hand anatomy (OpenStax College, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons). Click here to enlarge the image.

  • Bones 
  • Muscles
  • Joints/Ligaments
  • Nerves
  • Skin

The key areas we will look at within those hand skills are bones, muscles, joints and ligaments, nerves, and skin.

Bones

  • Congenital absence: amniobands, syndrome caused
  • Trauma, cancer, accident

Regarding bones, the different deficits we see are congenital absences and specific diagnoses, like amniobands. Amniobands is a syndrome in which the fetus becomes tangled with amniotic bands within the womb that restrict blood flow and can cause amputation of a limb or some digits. We can also see changes in those with Down syndrome. A typical hand at birth has 27 bones. At birth, they can have 23 or fewer. Other factors contributing to the dysfunction of the bones of the hands are trauma, like a fracture, or cancer. 

These children may go from using their dominant hand to using their non-dominant hand. How can we support that within the classroom? 

Muscles

  • Tone issues caused by a variety of diagnoses
    • Cerebral palsy
    • Down syndrome
    • Stroke
    • Accident 
    • Muscular dystrophy

Muscles are the next area. There may be tone issues caused by various diagnoses, like cerebral palsy, Down syndrome, strokes, accidents, muscular dystrophy, or spinal cord injury. Snowboarding and skiing are very popular here in Colorado, and I see many children with injuries from those activities. I recently had a student who had sustained a snowboarding injury. We may need to look at upper body and core strengthening.

Joints/Ligaments

  • Fixed joints
  • Hyper/hypomobility
  • Curvature
  • Arthritis

Are joints and ligaments fixed, hypermobile, or hypomobile? Do the students have arthritis or curvature in their joints? What are the factors that could contribute to deficits in their written communication?

Nerves

  • Erb's palsy
  • Spinal cord injury
  • Accident
  • Illness

Conditions affecting the nerves, like Erb's palsy or a spinal cord injury, could lead to some muscle deficits.

Skin

  • Burns
  • Webbing
  • Sensory processing
  • Kinesthetic awareness

Their skin can be affected by burns, or they can have webbing issues. Sensory processing and kinesthetic awareness affect skin and touch. I had a learner who was in a house fire. In the process of getting out of the fire, she burned her hands. She had a limited range of motion and had to relearn different skills to maintain her grasp during writing tasks.

We must figure out how to support our students with issues in these different areas and provide accommodations and modifications throughout their school day. 

Developmental Factors

  • Infants
  • Toddler
  • Pre-school
  • Elementary

Moving on from looking at the structures of the hand, we need to assess developmental factors. Our foundational skills start with infancy, and I refer to that often.  

Infant

  • Reflexes-unintegrated
  • Tummy time for all ages
  • Upper weight bearing
  • Neck extension
  • Two hand skills
  • Visual tracking
  • Grasping
  • Balance
  • Protective responses

In infants, we may see unintegrated reflexes. Have they gotten tummy time, or do they avoid it? What about upper extremity weight bearing? This goes hand in hand with that tummy time. If they avoid tummy time, they are not building those big muscles and joints or working on neck extension. Tummy time is crucial, and we support this even within our school populations. One example is having the students read on their stomachs. 

We also want to look at bilateral hand skills. Are they passing their toys back and forth or holding things at midline? What are they doing as they are developing those skills? All of this is going to be necessary later on.

Visual tracking can be seen as they start to explore their world and hold and play with toys. Infants also track parents and caregivers while talking to them and moving around the environment.

What are those grasp patterns? Are they using a gross grasp? As they get a little older, they play with toys and food. We will go into that as we look at toddlers.

When looking at balance, you can sit them upright to look for a head lag and core strength. This goes hand in hand with protective responses. If they start to fall over, can they get their hand out? What can they do to begin to show some of those protective responses?

Birth histories are taken in a medical facility and include their early development. We do not always have that luxury in the school system. I am very fortunate to work on a fantastic IEP team. Our school district has a nurse as part of the IEP team. One of the questions asked is, "What were their milestones?" This allows us to help problem-solve as a team about what interventions we need to put in place to help support that child. 

Toddler

  • Body awareness
  • Orientation of items
  • Fine motor refinement
  • Language
  • Self-feeding
  • Modeling adult actions-pretend play
  • Multi-step activities
  • Constructional praxis

Toddlers start to learn about body awareness and the orientation of items. They are also building fine motor control. They go from a gross grasp to a more refined position as the intrinsic muscles of the hand strengthen via feeding and play. As a result, toys change as we get to the toddler stage.

We also need to look at language development. I was the parent that would go through the grocery store and talk about everything. "This box is square and blue."

How is their self-feeding? Do they have a sensory aversion or any oral structure issues? They are starting to build strength and explore new foods at the toddler stage.

At this stage, they also start modeling adult actions and pretend play. Do they have a play kitchen and model what mom is doing? Do they pull pots and pans out of the cupboard pretending to stir while mom cooks at the stove?

Can they follow multi-step activities? "Go throw your diaper away and come back," or "Go pick up the purple ball and bring it to me." 

We also want to think about constructional concepts like building or putting puzzles together.

These are different developmental foundational skills necessary to help us later in life.

Preschool

  • Pre-writing strokes
  • Pre-scissor skills
  • Dressing-independence
  • Cooperative play
  • ADL-independence
  • Sustained attention to the task
  • Group games-tag, duck-duck-goose

Kids may or may not go to preschool. We have kindergartners who may not have gone to preschool; this is their first school exposure. The State of Colorado was looking at implementing universal preschool. We may have to add some of these skills for the students if they have not had exposure at home.

In preschool, activities include pre-writing strokes, scribbling, and pre-scissor skills. For example, can they use big snowball tongs or small tweezers? We must expose kids to different activities to help them build early skills before putting a pencil or scissors in their hands.

What about dressing and other ADLs? Are they able to help with dressing?

If they are in a preschool setting, are they working on sharing and cooperative play? Can they be in the kitchen at the same time as each other? Can they follow those simple demands? Are they able to clean up after themselves? Are they able to follow school routines?

Looking at other ADLs, are they using more silverware to feed themselves?

Do they have sustained attention to a task? Can they sit for songs or listen to a story? They should also be able to participate in tag, duck-duck-goose, et cetera.

Currently, we are about six days into school. Many teachers are concerned about kindergarteners who have never been in a school setting. They do not know how to attend to activities or hold a pencil. We have to remind them that there are activities that we can put into place to help build some of those foundational skills necessary for writing.

We use a system that is called, Every Child a Writer. Some of our buildings are great. Before starting this or Handwriting Without Tears, they first show children how to hold a pencil and walk them through the curriculum before expecting them to start writing words and sentences. By the end of kindergarten, the expectation is that they should be writing two full sentences.

We are first working on those foundational skills and teaching spatial boundaries and awareness. 

Elementary

  • Attention!
  • Language
  • Formal teaching of letters and formation
  • Stamina/endurance with fine motor
  • Decreased gross motor time
  • Large blocks for lessons
  • Hand dominance

Moving to elementary school-aged kids, we expect our kids to sit and attend for long periods. I do not like to sit all day, and I am an OT for that reason. There have even been discussions about how long students should sit during carpet time. What is a reasonable expectation? We must work with teachers on ways to naturally embed movement opportunities throughout the school day. For example, what movement things or games can we do while learning spelling words or listening to a story to help build their attention to task and feed their muscles and joints?

During this time, we also see some of their language mature. Right now, we are seeing a lot of "COVID babies." These are kids who have not been in school and now enrolling. Many speech-language pathologists colleagues have said that these kids do not know how to communicate. There are other kids with language barriers. 

You may see children who do not know how to do "X, Y, and Z," and we have to take it back to a kindergarten level. We may also have to increase their stamina and endurance for fine motor tasks. There is often decreased gross motor time. My son only has two 10-minute recesses. How can we get these kids up and moving? And how can we naturally embed those throughout our school day?

Some buildings have large blocks for lessons, like 90 minutes long. How can we help our teachers set students up for success?

Lastly, they should learn hand dominance at the elementary level and be successful writers.

Grip Progression

Figure 2 highlights grip progression. My son was a great model for this.

Figure 2

Figure 2. Grip progression from 1 to 7 years old.

There is grip progression over time. Starting at one to one and a half years, we see a cylindrical or palmer-type grasp. At two to three years, they move to a pronated grasp. At three and a half, it moves to a modified tripod grasp. This looks very different in individuals, but you will often see an all-finger or a four-finger grasp. Finally, around four and a half to seven years, as they go to school, we see more of a tripod grasp as the intrinsic muscles strengthen. Even though this is my child and an "OT" kid, he still wants to stabilize with his middle digit in the lower right image, but it is still a functional grasp.

Is the utensil in their webspace? Do they hold their pencil in a vertical alignment? I had a student every year until fifth grade who held a pencil between the first and the second digits with his thumb. He had excellent mobility and writing, but no one liked how he held his pencil. We need to weigh these things with our students. Should we modify a functional grasp, or at what point can we work to change it? Typically, we need to expose them when they are younger.

Before We Write

  • Work with learners on getting ready to write
  • Fine motor tasks to help build hand strength and tripod grasp
  • Gross motor tasks to help with crossing midline or building strength
  • Vertical surface play: paint, color, etc.
  • Work proximal to distal

We need to do vital things before getting our learners ready to write. I want to highlight we had an excellent preschool teacher who, before COVID, worked with our motor team to start working on the kids' upper bodies. She worked on fine motor development, core strength, and upper body strength. She took baseline data on their pencil-to-paper activities and the data from the previous year. She had a time every day when the students worked on fine motor centers that included Play-Doh and other strategic items to build intrinsic muscles. She also integrated core strengthening activities like "spaghetti and meatballs" with alternating prone extension and supine flexion to build overall strength. She found that after these activities when they finally sat down at the table, they were much more successful with their written communication. They were more ready to learn, had appropriate pressure on their paper, and were quick with the tasks. Getting buy-in from this preschool teacher was huge. We set it as a student learning objective for the district, and we saw huge growth with these kids. We also noticed less need for OT because she focused on this skill development. 

Fine motor activities include Play-Doh, Legos, and tweezer tasks. We were very strategic in many of our preschool rooms about sensory play and embedding fine motor skills. For example, children moved ice cubes with large tongs. In little ways, you can naturally build those opportunities into the classrooms to garner a teacher's buy-in.

We also want to work on gross motor tasks to help them to cross the midline and build strength. This could be songs and movement activities like patting pancakes or fluffing clouds.

We also need to add vertical surface play. We can have them color while in a plank position or on big posters on the wall. We also want them to work from proximal to distal. I have had teachers say that some kids use their entire arms to write. That is okay, and we will work on that. We need to help strengthen them proximally so they can work on things distally.  

Crayons and Coloring

  • Exposure to broken crayons and smaller tools
    • Small crayons help to promote a pincer and tripod grasp.
  • Fill in Coloring-Colors, Pictures, and Shapes
    • Teaches deliberate movements
    • Creates awareness of spatial boundaries
    • Exposure to different strokes (back and forth, up and down, or side to side)

I love coloring. I always joke that broken crayons still color and always had them in the waiting room. I had a parent bring me a brand-new box of crayons and say, "Here, I thought you needed these." I explained that smaller utensils like broken crayons work on fine motor tasks. Golf pencils are also great options as they fit their hands well. They even make those skinny PIP squeak markers that are a great way to help promote some of that grasp.

When thinking about coloring, they fill in shapes with attention to spatial boundaries, learn colors and shapes, and make deliberate movements like vertical, horizontal, and diagonal strokes. We also encourage some circular patterns, which are excellent skills for letter acquisition. All of these activities are also going to help the wrist and digit movement.

Benefits of Coloring

  • Attention
  • Crayon grip
  • Control
  • Posture/strength/endurance
  • Use of helper hand
  • Part to whole

Coloring requires sustained attention. We can also look at their grip, posture, endurance, and overall motor control. Can they sit at the table and complete it? And If you put them on a vertical surface, is one hand stabilizing while the other is coloring? What are we doing to build that overall strength?

Coloring teaches them to use a helper hand. I always say handwriting has to be a two-handed activity because we want to fire both sides of the brain. We have some great kindergarten teachers that support that.

Coloring also helps them to recognize parts as a whole. For example, the point is part of the whole star, or a dog's nose is part of its body. There are also other academic skills that our students have to work on later down the road.

Developmental Stages in Writing Readiness

  • 2-year-old: Scribble mark, vertical line, horizontal line
  • 3-year-old: Circle, cross
  • 4-year-old: Square, triangle
  • 5-year-old: Diamond

There are different developmental stages in writing readiness. Can a two-year-old make scribble marks and vertical and horizontal lines? This also goes hand in hand with some cognitive functioning we expect. If we have a student functioning at an 18-month level, are we expecting them to write their name? A 3-year-old should be able to make a circle and a cross. Developmentally, a 4-year-old should be able to draw a square and triangle. Five-year-olds can make diagonal shapes and an emerging diamond, but this is hard for many. I was not nice with my son's name as it is long and has many diagonals.

I do not know about you guys, but we have children that are still four when they come to kindergarten. They are jumping right into writing and cannot do many of the skills. We are going to go over some of the strategies to support them.

Teach Grip

  • Work on creating a hand preference
  • Small writing tools to better fit the hand of the user
  • Be a model and demonstrate grip
  • Allow for standard and alternate grip patterns

First, we must work on creating a hand preference with our students. They also need to use small writing tools to better fit their hands. I have had some individuals who think they need the big pencils, but their hands are tiny. Again, one child had functional and beautiful writing with an alternative grasp. We can coach our teachers. I often ask if I can join their rooms a few times a month during writing tasks to assist them. I may say, "I modeled this pattern on this task," or "Please watch the grip pattern on this for this friend." I even have kindergarten teachers use broken crayons to facilitate the tripod grasp and work on intrinsic muscles. 

Pre-Writing

Figure 3 shows my lovely shape drawings.

Figure 3

Figure 3. These are shapes we are looking for in pre-writing skills.

Capitals

  • Capitals are easier
  • Capitals all start at the top
  • Capitals are all the same height
  • Capitals all occupy the same space
  • Capitals are all easy to recognize and identify

Capital letters are more manageable for our students, as they all start at the top, are the same height, occupy the same space, and are easy to recognize and identify. Handwriting Without Tears talks a lot about this.

Lowercase

  • Use a lazy eight/alphabet eight to teach lowercase letters

For lowercase letters, I like using a lazy eight or the alphabet eight to teach those lowercase letters (Figure 4). 

Figure 4

Figure 4. Lazy eight or alphabet eight image for lowercase letters.

This image helps kids cross the midline and form lowercase letters. I also used it in the medical clinic to work on integrating eye muscles. You can see in Figure 5 how the image is an excellent way to teach big muscle and body movements for the direction of some of these letters.

Figure 5

Figure 5. Lazy eight or alphabet eight image showing where the letters fall.

Often students reverse some letters, and this illustration helps them to visualize what directions they should go. For example, they can feel that the "a" goes to the left side of the body. Overall, it is a nice way to help children learn the patterns for big muscle movements for writing. It also helps with right and left discrimination of their body. I see a lot fewer reversals using this method.

Name Writing

  • Teach the student how to write their name
  • Model starting their letters at the top
  • Model making the letters sit on the baseline
  • Model orienting to the left margin
  • Model each and every letter

Do we teach students to write their names starting at the top and sitting on the baseline? Are we modeling orienting letters to the left margin? And are we modeling each and every letter? We need to support students with these concepts. Often, I feel like our kindergarten teachers forget this because kids can write their names but with poor formation, as they have never learned how to write them formally. I have had many children with a beautiful formation of sentences, but they still write their names in a poorly patterned way. It is essential to teach them how to write their name and model it for them.

Analysis of Writing

  • Constraints of the classroom
  • Spacing
  • Formation
  • Placement on the line
  • Orientation
  • Working memory—directions repeated?
  • Vision-near vs. far point copy

There are some other things that we need to look at when we are working with these students. What are the constraints and spacing within the classroom for writing? What paper are they given? What is their formation? Do they have good formation? Do they use Zaner-Bloser or D'Nealian? Are they able to do placement on the line, or are they floating all over the place? Are they orienting the letters correctly or reversing some of their letters? Do they understand the right versus the left side of their body? What is their working memory? Do they need the directions repeated? Can they write the alphabet from memory? We also need to look at near-point versus that far-point copying.

Pyramid of Learning

As we analyze the classroom, these areas on the pyramid of learning are other things to consider (Figure 6).

Figure 6

Figure 6. Pyramid of Learning (Adapted from Taylor and Trott, 1991). Click here to enlarge the image.

Academic learning is at the top of the pyramid. All other foundational things need to be in place before being able to succeed in academic learning. I want to now talk about these different areas and work our way up the pyramid to see how we, as OTs, can be supportive and model some of these things within the classrooms.

Pyramid of Learning: Sensory 

  • The big three include (on the pyramid):
    • Tactile
    • Vestibular
    • Proprioception
  • The next level of senses includes:
    • Olfactory
    • Visual
    • Gustatory
    • Auditory

At the bottom of the pyramid is the central nervous and sensory systems. The big three are the tactile, vestibular, and proprioceptive systems. The pyramid was around before the concept of interoception came out. Interoception would also fall into this area. Why is a child having a meltdown without noticeable triggers? There may be CNS or sensory variables and factors impacting them.

The next level includes the olfactory, visual, gustatory, and auditory senses. We will not dive into that level as much, but these are senses affected by environmental factors. For example, how does the classroom smell? I have been in buildings that have allowed different oils or scents to diffuse. What is calming for one student can be very noxious for another student. Some people also wear very strong perfumes that can be triggering.

Additionally, the environment can be visually cluttered and overwhelming. The lights could be distracting. Our district has removed all the fluorescent bulbs and added softer, more natural lights. Now, there is no buzzing or flickering. Light covers or dimmers are also options. For taste, children may be oral seeking, the first learned motor pattern. What can we do to help them not eat their clothing or the erasers off pencils? There can also be auditory stimuli like a ticking clock or a blowing fan.

There are many things we take for granted that affect these children. We need to be detectives to help our learners. 

Tactile

  • The touch receptors in the skin provide information about the environment.
  • A child with tactile difficulties:
    • May get hurt and not realize it
    • May know that he was touched but not exactly where
    • May not realize he dropped an item he was carrying
    • Can't discriminate objects by feeling them
    • May have poor body awareness with vision occluded
    • May seek out touch, constantly touching
    • Poor handwriting

Touch receptors are in the skin to provide information about the environment. Students with tactile difficulties may get hurt and not realize it. They might know they are being touched but cannot tell you where. They might drop items and not know it, have trouble discriminating the feel of objects, and have poor body awareness with occluded vision. They might constantly seek out touch and have poor handwriting.

  • Functional Components
  • Protective: 
    • Alerts the child to danger 
      • Based on need for survival
  • Discriminatory: 
    • Provides information about the qualities of objects in their environment
    • If the child has a poor ability to inhibit input, they may never lose awareness/sensation of the feeling of clothes on body; may have difficulty attending to other outside input

There are two functional components in the tactile system. One function is protection as touch alerts that child to danger and is based on our need for survival. The discriminatory function provides information about the qualities of their objects. If the child cannot inhibit input, they might never lose the feel of their clothing on their body and have difficulty attending. These kids may kick off their shoes or be bothered by clothing tags. 

  • Tactile issues may affect:
    • Body Awareness: Internal awareness of where our body parts are without vision and where they are in space
    • Body Concepts: Beginning of number concepts, math skills, and pre-reading/writing skills

Impairments in the tactile system may also impact body awareness and body concepts. Body awareness is knowing where our body parts are without using our vision. Body concepts include math, pre-reading, and pre-writing skills.

Vestibular

  • Receptors are located in the inner ear and are stimulated by movement of the head and input from other senses.
  • Movement, gravity, and changing head position impacts:
    • Vision, posture, balance, movement, helps regulate behaviors

Vestibular receptors are located in the inner ear. Vestibular sense impacts vision, posture, balance, movement, and the regulation of behavior.

  • Vestibular issues may affect:
    • Spacing letters and words on a line
    • Size constancy of letters
    • Staying between 2 lines
    • Orientation errors/reversals in numbers and letters
    • Fine motor tasks requiring spatial accuracy (Gluing)
    • Right/left discrimination

Vestibular issues can impact the spacing of letters and words on a line, size constancy of letters, staying between two lines, orientation errors, and reversals in numbers and letters. It can also impact fine motor tasks like gluing and right-left discrimination.

  • The vestibular system impacts the reticular activating system, which is the arousal system in the brain stem-ATTENTION
  • Keeps the child awake and alert while producing a calming/inhibiting effect which can help the child filter out excess peripheral stimuli

The vestibular system impacts the brain stem's arousal system, which moderates our attention. Students need to move to activate this system. The reticular activating system keeps the child awake and alert while producing a calming effect.

What can we provide to feed into their system to help them focus? One child had to do vestibular heavy work before completing written tasks.

You can do little things within full classrooms to work with a vestibular system. One example is a yes/no game. With this activity, you are moving the vestibular fluid. We can work on overall movement, like jumping jacks and recess. 

Proprioception

  • The receptors are located in the muscles and joints.
  • Gives information about where body parts are and what they are doing
  • Timing and force of movement
  • Works with the visual system and vestibular system for good balance

Receptors for proprioception are located in the muscles and the joints and give information about body parts and their actions. It also provides information about the timing and force of movement by working with the visual and vestibular systems.

All of my buildings have sensory walks because we know that our kids need to move to maximize their learning.

Sensory Interventions

  • Liquid pencil
  • Art pencils
  • Sand Paper
  • Foam under paper
  • Raised line paper
  • Color coded paper
  • Weighted pencil
  • Dynamic seating

Here are some other interventions for proprioception. Whether they are avoiders or seekers, we can use items like liquid pencils, art pencils, sandpaper, or foam under their paper, if they push too hard. Raised line paper is excellent if they are under registers. Color-coded paper, weighted pencils, and dynamic seating are other options. Some learners only need tactile cues before writing.

  • Theraband
  • Velcro under desk
  • Seating accommodations
  • Build up pencils
  • Writing in mixed media
  • Gel in ziplock bags

We can put theraband around their chair to push on to get out some of their wiggles. Velcro under their desks is another option for fidgeting. Depending on their deficits, they may need built-up pencils or writing using mixed media. We want to add tactile and sensory opportunities, like writing in shaving cream, salt on a tray, or gel within a ziplock.

Pyramid of Learning: Sensory Motor 

  • Postural security
  • Awareness of two sides of the body
  • Motor planning
  • Body scheme
  • Reflex maturity
  • Ability to screen input

We addressed the sensory system at the bottom layer of the pyramid. Now, we will move to the sensory motor level of the pyramid. This area includes postural security, awareness of the two sides of the body, motor planning, body scheme, reflex maturity, and the ability to screen input.

For postural security and core strength, we want to look at their seated posture.

Are they aware of the two sides of their body? We have had students who never cross the midline shift their bodies instead.

Motor planning, body scheme, and reflex maturity are other areas. Many kids sit in supported positions, so they are not climbing and building muscles. Again, we want to look at activities where we can naturally embed movement opportunities. One of my buildings does the pledge of allegiance, announcements, and a "morning mindfulness." They are very strategic about the movement opportunities that they provide. We have collaborated with them to see what else to add during this activity. We have added some exercises to naturally integrate ATNR and STNR patterns and yoga poses. Teachers are now naturally using these throughout the day. 

Lastly, are the kids able to screen input? Is it a noisy classroom? What other strategies can we add to help them sit and focus? Do they need their own workstation or noise-canceling headphones? Perhaps one child is an extreme fidgeter beside a child who is easily distracted. Can we separate them?

Interventions

  • Tape boundaries
  • Photographs to model what "ready" looks like
  • 90-90-90
  • Placement in the classroom
  • Use of helper hand
  • Holding paper to a vertical surface
  • Chair push ups
  • Stringing beads
  • Noise canceling headphones
  • Cutting
  • Armrest on chair

Can we set up the classroom to support the children? We can set up tape boundaries around desks. If a child needs to pace can pace, they need to stay within these boundaries. We can provide photographs to model how "ready" for learning looks. They may need only a visual cue. Depending upon the individual's needs, a 90-90-90 seating position or somewhere near that may be achieved with some modifications.

What can we do to help children use their helper hand? Can they work on a vertical surface, perform chair pushups to build that upper body strength, or string beads to cross the midline? Other interventions include noise-canceling headphones, cutting tasks, or armrests on a chair.

Pyramid of Learning: Perceptual Motor

  • Eye-hand coordination
  • Ocular motor control
  • Postural adjustment
  • Auditory language skills
  • Visual spatial perception
  • Attention center functions

The next level is the perceptual motor, including eye-hand coordination, ocular motor control, postural adjustment, auditory language skills, visual-spatial perception, and attention center functions.

We see a lot of vision concerns, and our school nurses can do a full battery of tests. We can also look at convergence and pursuits. There are developmental optometrists in the area to whom we refer to set up the children and families for success. We can also strategically modify their environment to help with that as well. Teachers ask where to place a child or how to set up the classroom for the best success. 

  • Sticky notes to mark the spot
  • Mini Spiral graphs
  • Rulers
  • Simon Says
  • Mazes
  • Wind up toys
  • Poppers

Interventions for perceptual motor deficits are sticky notes to mark your spot, rulers, Simon Says, mazes, wind-up toys, and poppers. When I was in the clinic, there was an activity called teapot, a visual processing computer program. It is outdated, but it was great because it worked on right-left discrimination, form constancy, and all of those excellent skills.

Team Approach

  • Ocular motor control
  • Auditory language skills
  • Vision and speech-language pathologist consults are important!
  • Physical therapist

Using a team approach is crucial. Here we have a nursing staff that can do some referral processes for auditory language and vision skills. We can consult with speech-language pathologists and physical therapists.

Pyramid of Learning: Cognition

  • Daily living activities
  • Behavior
  • Academic learning is at the top!

Thinking about cognition, we want to assess if they struggle with daily living activities. What is their behavior? Academic learning is at the top of the pyramid. We intervene for behavioral interventions, social and emotional learning deficits, and general cognition.

Compensations

  • Changes in body position
  • Turning pages
  • Move body to avoid crossing midline
  • No helper hand
  • Head "supporters"
  • "Mirror" kids
  • Posturing
  • Fatigue

Here are some general compensations that you might see. They may show changes in their body position and how they turn pages. They may move their body to avoid crossing midline or avoid the use of a helper hand.

"Mirror kids" are those that watch everything, which can be a great strength. They mimic their peers' activities and movements.

We want to observe their chair position and assess their overall fatigue.

Once again, we need to be detectives within the classroom environment, as there is so much more that goes into a writing task than hand position.

Interventions: Core and Shoulder Strength

  • Holding paper to a vertical surface to work
  • Chair pushups 
  • Washing windows or erasing the board (whiteboard), or wiping off the table
  • Wall pushups 
  • Carry laundry basket, a crate of books, drawing, coloring, writing on paper held to the underside of a low table/chair while laying on the floor, Zoom Ball, swinging

Interventions for core and shoulder strength include writing on a vertical surface, chair pushups, washing windows, wall pushups, and carrying the laundry basket. 

Interventions: Body Awareness

  • Identify or match
  • Copy body positions given by an adult 
  • Have a peer or adult trace a letter or shape on the child's back or play "golf"
  • Grading movement games
  • Flashlight

Some body awareness tasks are copying body positions or finding colored dots on their body. "I need you to find the orange dot on your left elbow." Think of all the fun and ways we can naturally work on skills while the students think they are playing.

Interventions: Working Memory

  • Go Fish or Old Maid card games
  • Memory or concentration games
  • Repeat after me 
  • Word memory game 
  • Simon Says and Bop It 
  • Hulabaloo by Cranium 
  • Connect 4 
  • Battleship

On this slide, you will see some interventions for working memory, like Go Fish, repeat after me games, Simon Says, Connect 4, and Battleship.

Interventions: Manual Dexterity

  • Playing card games 
  • Tenzi 
  • Jacks 
  • Picking up coins one at a time and holding them in the palm while picking up additional coins.
  • Placing coins into a plastic coin holder or through the slit cut in a tennis ball 
  • Writing with broken crayons or golf pencils

Playing cards is excellent for manual dexterity and a cheap intervention. Other activities include coins, Etch A Sketch, filling in small dots, tracing activities, et cetera.

Adaptations/Modifications

  • Near/far copy
  • Desk/chair fit
  • Vertical surface
  • Easel-wrist extension
  • Orientation to the board
  • Word prediction programs

For near/far point copy, we need to address the chair size, vertical surface use, and classroom position. We can also think about the size of pencils, pencil grips, writing aids, writing windows, voice-to-text, and even the use of their fingertips. They may require modified paper.

Pre-Writing

  • Highlighter vs. dot-to-dot
  • Bubble letters
  • Sky, grass, ground
  • Raised line
    • Wiki sticks
    • Glue
  • Writing on other surfaces/mediums
  • Light bright to promote pincer grasp
  • Theraputty

With the pre-writing, are they learning the whole stroke pattern versus just connecting the dots? Can they trace within bubble letters, or do they need modified paper? We can use raised lines or Wiki sticks to help them attend to boundaries. A Lite Brite and theraputty can be great for pincer grasp and how to build overall awareness.

Team Members

  • Vision consultant
  • Eye care professional
    • Developmental optometrist
  • Physical therapist
    • Wheelchairs
    • Good hip stability/solid foundation
  • Resource teachers
  • Speech-language pathologist
  • Custodians/maintenance team

We have great team members, and I cannot highlight the importance of that enough. Do you have eyecare professionals like developmental optometrists? Physical therapists may consider wheelchair seating (as can OTs) and hip stability.

Resource teachers are also important because they live in the building, while we may float between several buildings. You also need to consult with speech-language pathologists, custodians, maintenance teams, and secretaries, as they may help to modify desks and get the different things you need. 

Questions and Answers

When should utensil use begin? Many of my students in elementary school eat with their fingers and cannot hold or use utensils.

It depends on the learners, and I have children of various cognitive levels. It might be difficult if you have a student operating at the one-year level. What modifications can we put in place? I think the more that we expose them to activities, the better, even if it is fine motor utensils. I had a teacher who took my advice, and instead of putting pencils in their hands on day one, they gave them stamps for a more extensive motion and grasp pattern. Depending on their cognitive level, they may not be able to achieve some of those skills. We have a lot of different adapted tools that we can model. Tactile prompting may also help.

Can you expand on how to use the eight-letter formation?

This is a great question. On a whiteboard, I will create a lazy eight drawing, about shoulder-to-shoulder size for the student and roughly at chin level, and I have them lined up with that dot at the midline. I have them trace the lazy eight pattern. I then integrate the alphabet letters and provide tactile prompting. "We will go to the lazy eight, make an 'a', up, over, up, down. Let's make a 'b' with a big line down and a big curve."

As you provide that verbiage, you have them feel that movement. I always make a lazy eight pattern in between the letters. With this pattern, they are learning the sides of their body to use and the direction of the letters. 

Many children are dysregulated because they have challenges communicating their feelings.

In the first few weeks, we want to build relationships and teach daily patterns like, "This is where we sit on the carpet," and "Now, we go sit at the table." We may pair these activities with a positive reinforcer. As we get to know the students, we do not want to start immediately with writing. You have to help build rapport and respect their autonomy. What can you do to arm their system before learning? Do we need to help them regulate, or do they require heavy work activities? Can we animal walk to the table to feed into their muscles and joints? Once they are there, what do we see once they have had some of those regulatory activities? 

Do you have teachers instructing students in writing through a larger curriculum? For example, this week, I was in a classroom where they teach letters in alphabetical order, capitals, and lowercase. They also have verbal cues that are supported as well. 

Some teachers say, "Nope, this is how we have to do it." We must educate them on the developmental sequence and why we write in a particular order. "I respect you have to use this curriculum, but can we introduce it in this pattern?" I have had good luck with teachers saying, "Let's start with lowercase 'I' and use the book to support that." I have been an OT for 16 years, but I sometimes still fight these battles.

References

Benbow, M. (n.d.). Neurokinesthitic approach to hand function and handwriting. https://Www.Clinicians-View.Com/University/PDF/HF01/HF01TextPreview.Pdf. Retrieved February 28, 2022, from https://www.clinicians-view.com/University/PDF/HF01/HF01TextPreview.pdf

Biotteau, M., et al. (2019). Developmental coordination disorder and dysgraphia: signs and symptoms, diagnosis, and rehabilitation. Neuropsychiatric Disease and Treatment, 15: 1873–1885. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626900/

Caramia, S., Gill, A., Ohl, A., & Schelly, D. (2020). Fine motor activities in elementary school children: A replication study. The American journal of occupational therapy: Official publication of the American Occupational Therapy Association, 74(2), 7402345010p1–7402345010p7.

Children's Hospital. (n.d.). Amniotic band syndrome. https://Www.Childrenshospital.Org/Conditions-and-Treatments/Conditions/a/Amniotic-Band-Syndrome. Retrieved February 28, 2022, from https://www.childrenshospital.org/conditions-and-treatments/conditions/a/amniotic-band-syndrome

Dennison, Paul E., and Dennison, Gail E (2007) Brain Gym 101: Balance for daily life. Ventura, CA: Edu-Kinesthetics, Inc. 

Fisher, A. G. (2013). Occupation-centred, occupation-based, occupation-focused: same, same, or different? Scand J Occup Ther, 20(3):162-73.
doi: 10.3109/11038128.2012.754492. Epub 2013 Jan 14. PMID: 23311311

Gillen, G., Hunter, E. G., Lieberman, D., and Stutzbach, M. (2019). AOTA's Top 5 Choosing Wisely® recommendations. Am J Occup Ther, 73(2):7302420010. https://doi.org/10.5014/ajot.2019.732001

Occupational Therapy Practice Framework: Domain and Process—Fourth Edition. (2020). Am J Occup Ther, 74(Supplement_2):7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Olson, J.Z. and Knapton, E.F. (2008). Handwriting Without Tears Pre-K Teachers Guide, 9, 60-61, 65. 

Steinhart, S., Weiss, P.L., Friedman, J. (2021). Proximal and distal movement patterns during graphomotor task in typically developing children and children with handwriting problems. Journal of NeuroEngineering and Rehabilitation. http://doi.org/10.1186/s12984-021-00970-9

Skubik-Peplaski, C., Hight, J., Bray, L. (2021).What improves handwriting: Occupation-based or handwriting interventions? The American Journal of Occupational Therapy, (75)2. https://doi.10.5014/ajot.2021.75S2-RP348

Taylor, K.M. and Trott, M. (1991) in Williams, M.S., & Shellenberger, S. (1996). "How Does Your Engine Run?" ® A leader's guide to the Alert Program® for self-regulation. Albuquerque, NM: TherapyWorks, Inc.  

Citation:

Paben, M. (2022)Handwriting: It is a big deal. OccupationalTherapy.com, Article 5543. Available at www.OccupationalTherapy.com

 

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megan pagen

Megan Pagen, MOT, OTR/L, ASDCS

Megan Paben received her master’s degree in occupational therapy at the College of Saint Mary in Omaha Nebraska in 2007. Megan began her career as a school therapist in rural Nebraska serving several small schools.  After two years in the school setting, Megan transitioned into an outpatient pediatric clinic working with a variety of different diagnoses and worked as the marketing coordinator.  After a couple of years, Megan took over the manager position within the medical clinic.  During this time, she worked in a school within the community as well as worked with the adult population clinic that was connected to her medical clinic.  In 2018, Megan and her family relocated to Colorado where she is an occupational therapist for a growing school district.  In her current position, Megan is the lead motor staff member, she serves 5 center-based classrooms for social communication as well as affective needs.  Megan is a Crisis Prevention Intervention trainer for her district.  She also is an Autism Spectrum Disorders Clinical Specialist. 



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