Pediatrics: Handwriting

development of handwriting

• 2 yr olds

• 3 yr olds

• 4 yr olds

• 6 yr olds

• 2 yr olds

  • scribble

  • circular scribbles

  • vertical lines

• 3 yr olds

  • horizontal lines

• 4 yr olds

  • circles

  • intersecting lines

• 6 yr olds

  • S: shapes

  • I: letters

  • X: diagonal lines

ideal pencil grip

dynamic tripod and/or lateral tripod grasps (not much difference)

• 3 fingers on pencil

• last 2 fingers in the palm of the hand

• slightly extended wrist

• forearm supinated + resting on the table

• open webspace

functional— but not ideal pencil grip

lateral quadrupod and four-finger grip

• 4 fingers on the pencil instead of 3

legibility components

• letter formation— most critical to determine legibility

• alignment

• spacing

• size

• slant

proximal stability leads to

distal mobility

• positioning is key for handwriting

• if we have multiple motor problems, we always address the most proximal one first

• proximal —> distal

  • pelvis —>

    • trunk —>

      • shoulder —>

        • arm —>

          • wrist —>

            • fingers

grading

grade task to be challenging but possible until the child achieves MASTERY

• grading — mastery, grading — mastery

  • this is how we try to catch up to where they should be developmentally

more than motor

may be other issues going on with handwriting

• if motor

  • fine motor, gross motor, positioning

• if not motor

  • sensory

    • e.g., vestibular issues— poor balance, requiring 1 UE to always hold onto something

    • e.g., dislike of paper or pencil feel

  • cognitive

    • e.g., being easily distracted

  • psychosocial

    • e.g., low motivation/meaning

assessments

• Children’s Handwriting Evaluation Scale (CHES-C & CHES-M)

• Denver Handwriting Analysis

• Evaluation Tool for Children’s Handwriting (ETCH)

• Here’s How I Write (HHIW)

• Minnesota Handwriting Assessment

• Test of Handwriting Skills, Revised (THS-R)

• The Print Tool

interventions— models of practice

• acquisitional/motor learning

repetition and practice are important

• once mastered, use letters immediately to write words (and then eventually sentences)

• combine newly acquired letters with mastered letters

interventions— models of practice

• sensorimotor

providing multi-sensory input reinforces learning

• felt-tip, scented, glittered, glow-in-the-dark pens/crayons

• paintbrushes

• weighted pens

• mechanical pencils

• vibratory pens

• chalk

writing surfaces and positions are also considered sensorimotor

• colored lines (visual component)

• raised lines (tactile component)

• upright orientation (e.g., easel)

interventions— models of practice

• biomechanical approaches

ergonomics influence handwriting quality and speed

• sitting posture

  • optimal posture:

    • 90-90-90 (at knees, hips, ankles)

    • feet planted firmly on the floor

    • table surface should be 2 inches above the flexed, neutral elbows

    • elbow resting on the table

  • can also adjus height of desks and chairs; add footrests, seat cushions and inserts; or reposition the desk

• paper position

  • slanted positions facilitate wrist extension and eye tracking of the hand’s movement

    • right-handed: slant paper to the left

    • left-handed: slant paper to the right

  • use of a vertical or semi-vertical surface can also promote upright posture

    • easel

    • white board

    • taped on wall

• pencil grasp

  • pencil grips

    • stetro grips

    • moldable grips

  • for those with tight-fisted grasp

    • wide-barreled pencil

    • triangular pencils

  • for promotion of tripod grasp

    • hold a small eraser against the palm with the ulnar digits

    • rubber band sling for promotion of tripod grasp

• writing instruments

• type of paper

interventions— models of practice

• cognitive interventions

Cognitive Orientation to Occupational Performance (CO-OP)

• C—>Goal-

• O—>Plan-

• O—>Do-

• P—>Check

reduce distractions

• uncover only current work

focus attention

• black mat for contrast

• cardboard cutout window

auditory

• using verbal cues or self-talk when writing

visual

• writing strip

• word walls

• modeling

• visual cues on the paper

interventions— models of practice

• psychosocial approach

make handwriting meaningful; e.g.,

• writing a note to parents

• Thanksgiving Day card

• share work with small integrated group

• handwriting clubs

strategies for

• spacing

• placing text on lines

• sizing

• speed

• spacing (e.g., words/letters are too close)

  • —> finger, stick

• placing text on lines

  • —> raised or colored lines

• sizing

  • —> individualized boxes on graph/grid paper

• speed

  • —> start projects early

alternatives to handwriting

compensatory strategies to augment handwriting

• keyboarding

• word prediction

• reduce the amount of written assignments

• dictate assignments

• study buddies or peer

assistive technology

• text-to-speech —>

• electronic spell check —>

• picture library —>

• abbreviated expansion —>

• word prediction —>

• voice recognition software —>

• text-to-speech —> speaks for the student

• electronic spell check —> spell checks

• picture library —> story using pictures

• abbreviated expansion —> fewer keystrokes required to get a word out

• word prediction —> slow typer

• voice recognition software —> hands-free text entry system (i.e., you talk into the system, as it types out what was said)

evaluation considerations

• determine the writing tasks that are most difficult for the child

• track the behaviors that are evident when the child is required to write

• determine what assistance or cueing (if any) the child needs to complete writing tasks

• determine whether the child is distracted by any visual or auditory stimuli

• consider where the child sits in the classroom

• review the handwriting curriculum (if any) being used

• location of the teacher when instruction is being given

• determine how the writing difficulty affects the child’s learning

• consider ergonomic factors, such as…

  • writing posture

  • upper extremity stability and mobility

  • pencil grip