Functional task at school: handwriting

MONICA D. KEEN*

Key terms

Handwriting

Prewriting strokes

Compensatory strategies

The most frequent referral for occupational therapists in the school setting is for problems with handwriting.⁴ As a result, handwriting remediation programs are often delivered on site at school, either individually or in small groups.¹³ Handwriting is one of the functional tasks required of a child in his or her occupation as student. McHale and Cermak report that as much as 60% of a school day can be spent on fine motor tasks, including handwriting.¹⁵ It is an important part of the educational process because handwriting is the most common means by which a student expresses knowledge of the material being taught. In addition, a student uses writing to summarize information taught in class, complete assignments, take tests, and interact with others for noneducational purposes.²¹ Between 10% and 30% of elementary school children struggle with handwriting.⁹ Likewise, experts claim that illegible handwriting has secondary effects on school achievement and self-esteem.⁷^,¹⁴

Handwriting difficulties in children include illegible handwriting and speed-related issues; in addition, areas that affect the legibility of handwriting include letter formation, horizontal alignment, size, spacing, and slant.¹³^,¹⁵^,¹⁸

Handwriting is one of the tools teachers use to measure a student’s academic comprehension. Handwriting allows children to express themselves, learn information, organize their work, and communicate with others. It is vital that occupational therapy (OT) practitioners working in schools address handwriting difficulties to improve students’ performances in their occupation.¹⁵^,¹⁸

The Appendix to this chapter provides an overview of commercially available handwriting programs that OT practitioners may find useful when providing interventions to children.

Evaluation and assessment of handwriting skills

CASE Study

Molly is a first grader at Lincoln Elementary. She sits at a table at the front of the class and loves to participate in most of the classroom activities. She is not able to draw most of her shapes; when encouraged to draw freely, her drawings appear very immature. When asked to write, she becomes nervous. She has trouble remembering the letters of the alphabet, and when called on to identify a letter, she is not always able to provide the correct answer. She has difficulty recalling the letters of the alphabet and then struggles with forming any letter on paper. She tends to write large letters, so the entire page is covered with very little writing. She is able to write her first name, but she starts all of her letters from the bottom of the line and sometimes uses multiple strokes to form one letter.

Handwriting is a multifaceted developmental task. When a student is unable to put prewriting strokes together to form simple shapes, it is quite a challenge, if not impossible, for the student to form a letter. When evaluating a student’s handwriting, the OT practitioner looks at myriad components that are needed to successfully perform this task. Visual, perceptual, and fine motor skills must be assessed. In addition, considering the child’s developmental stage provides insight into where his or her handwriting abilities may fall. It is the job of the OT practitioner to analyze the task and determine what components are missing or weak. Lastly, considering how the student’s sensory systems are being impacted by this task requires consideration.

Handwriting is an important occupational skill requiring motor, sensory, perceptual, and cognitive abilities.¹³ Formal and informal assessments of the ability to imitate and copy lines and shapes, hold a pencil or tool, and complete perceptual motor tasks help identify the factors for intervention. Figures 21-1 and 21-2 are examples of checklists which may be used to identify a child’s prerequisite skills for handwriting.

FIGURE 21-1 Handwriting checklist—manuscript.

The OT practitioner is responsible for evaluating all aspects of handwriting; designing intervention or compensatory strategies; and consulting with children, teachers, and parents. The goal of OT in the school is to promote participation in the general educational curriculum. As such, teachers and parents benefit from recommendations to enhance handwriting skills. Compensations and accommodations allow the student to be successful in the classroom or home (refer to the section on classroom accommodations later in this chapter).

Handwriting assessments

A variety of different handwriting assessments that can be used to evaluate a child’s handwriting are available (Box 21-3). Assessments can be standardized or nonstandardized and include clinical observations. The evaluating OT practitioner needs to know the purpose of the evaluation. Do the results need to be standardized? Does the OT practitioner, parent, or teacher want to know where this child’s handwriting abilities are in comparison with his or her peers, or is getting an example of the child’s handwriting abilities the goal? Is the OT practitioner interested in learning how the child is writing or spacing letters and words? The nature of the evaluation will determine which type of assessment(s) is to be used.

BOX 21-3 Handwriting Assessments

• The Children’s Handwriting Evaluation Scales (Stott et al., 1984) measures the speed and quality of the child’s handwriting skills.

• The Evaluation Tool of Children’s Handwriting (ETCH) (Amundson, 1995) evaluates legibility and speed in six areas of handwriting: (1) alphabet production of lower and uppercase letters from memory, (2) numeral writing of 1 to 12 from memory, (3) near-point copying, (4) far-point copying, (5) speed, and (6) sentence composition in both manuscript and cursive formation.¹⁵ The ETCH provides legibility scores for the child’s age level.

• The Print Tool TM is a nonstandardized assessment from Jan Olsen’s Handwriting Without Tears curriculum. “The Print Tool focuses on the eight key components of handwriting: memory, orientation, placement, size, start, sequence, control, and spacing.” In addition to being an assessment, The Print Tool also “helps pinpoint the cause of difficulty and provides guidance for a remediation plan specific to the child’s needs.”

Classroom observation

Most of a child’s handwriting occurs in the classroom. Therefore, it makes sense that the student be observed doing this task in this environment. Classroom observations allow OT practitioners to see how children work, how they organize their work/desk surface, and how they use their time. When evaluating a child’s handwriting, observation of the child’s performance in the classroom is beneficial.

Classroom observation allows the OT practitioner to view the functional task (e.g., handwriting) in the context in which it occurs. Understanding the child’s performance within the context of the classroom guides the intervention plan. For example, examination of the physical context provides information on such things as classroom space, seating arrangements, the height of the desk, visual stimuli, and environmental supports. Molly may be sitting in a chair that is too high, and the classroom space may not be conducive to writing. In terms of personal context, classroom observation may reveal information about Molly’s needs. Perhaps she is easily distracted by the noise outside the door or by the decorations on the walls or hanging from the ceiling of the classroom. OT practitioners will want to consider the writing demands of a Grade 1 classroom as well as Molly’s temperament and attitude toward the writing task. From the case study presented earlier, it is apparent that Molly becomes nervous during writing assignments, which provides the OT practitioner a window into her feelings. Temporal context refers to the time of day in which the handwriting task is performed. If handwriting is performed in the afternoon, Molly may very well be tired and restless; however, Molly produces her best work in the morning. Classroom observation may provide insight into how Molly is managing her time as well. Cultural context refers to expectations with regard to the classroom. How organized is the teacher? Are accommodations a natural part of the classroom? Is the classroom too busy for a child who requires a quiet environment for writing? Is the child able to interact easily with his or her peers?

Classroom observations provide valuable information on the factors that may be interfering with function in the classroom. Teachers are able to provide OT practitioners with information about the child’s performance in the classroom, classroom expectations, and possible solutions. In addition, the teacher is able to provide the OT with handwriting samples done by the student at various times of the day.

CLINICAL Pearl

Visual or auditory distractions in the classroom may interfere with visual attention to handwriting tasks.

CLINICAL Pearl

Asking teachers and families what strategies they have used in the past and using those strategies in OT interventions may help children succeed. Matching strategies to the classroom is effective.

Developmental sequence

Referrals to OT for handwriting are made based on children not performing at age-appropriate standards. Teachers notice that the child is not as fluent, clear, or legible as his or her classmates. OT practitioners are called in to determine the developmental level at which the child is functioning and the cause(s) for the handwriting difficulties so that an appropriate intervention can be designed. Development occurs through the learning, experiencing, and acquisition of the skills. The rate of development and the progression of skills vary in children but usually follow sequential patterns.

Prewriting

Prewriting strokes are the foundation for making shapes and letter formation. A child must understand and be able to stroke positional concepts such as down (vertical) and across (horizontal) before they can put them together to form letters For example, when providing verbal prompts for stroking the capital letter “L,” the student would hear, “ Big line down, little line across.”

Motor, cognitive, and sensory systems must work together for success in pre-writing. Children start performing prewriting activities at a very early age. Consider the child putting open hands into the chocolate pudding and rubbing the pudding on the high-chair tray in circular motions. Then there is the toddler who takes Mom’s marker and makes numerous marks on the kitchen wall. As their little hands strengthen, they take crayons and paper and scribble with abandon. As they are taught about circles and vertical and horizontal lines, they start to put them together to make shapes such as squares, rectangles, circles, and intersecting lines. Diagonals are the last prewriting strokes to develop. The child is then able to put them together to form triangles and diamonds. Prewriting strokes develop at the following ages:

• 2- to 3-year-olds: vertical and horizontal lines

• 3- to 4-year-olds: circles and intersecting lines

• 4- to 6-year-olds: diagonal lines and the ability to form shapes

Grasping patterns

Children with handwriting difficulties show a less mature grasp, immature pencil grip, and inconsistent hand preference.³ The most mature grasps are the dynamic tripod (Figure 21-3, A) and lateral tripod grasps. By definition, in a tripod grasp three fingers are used for holding the writing utensil. The thumb is bent, the index finger points to the top of the writing utensil, and the writing utensil rests on the side of the middle finger. The last two fingers are curled in the palm and stabilize the hand.¹⁶ The lateral quadrupod and four-finger grip can be as functional as the dynamic tripod, lateral tripod, and dynamic quadrupod pencil grips in Grade 4 students.¹⁰ A quadrupod grip (four fingers) is another way children may hold their writing utensil. The thumb is bent, the index and middle finger point to the top of the writing utensil, and the writing utensil rests on the ring finger.¹⁶

FIGURE 21-3 A, Dynamic tripod grasp. B, Cross-thumb grasp.

In the dynamic tripod grasp, finger movements are used rather than those of the whole hand or arm. When forming a letter, dynamic movements of the fingers create smooth curves. Awkward grasping patterns result in poor letter formation, fatigue, and poor handwriting. Hank holds the pencil tightly with minimum web space and a cross-thumb grasp (see Figure 21-3, B). The resulting strain and contraction of the wrist and finger muscles may cause pain, fatigue, and discomfort.

Preschool children have small hands. It is difficult for them to manipulate regular-sized pencils and markers. Some teachers have preschool children use large pencils and/or triangular pencils to promote functional grasps. However, preschool children should use only short crayons and small pencils for writing/coloring. Crayons are made of colored wax, which provides resistance (and strengthening) when coloring. This also provides kinesthetic feedback to the user. Golf ball–sized pencils or regular pencils broken into two are perfect for children with small hands. Smaller pencils/crayons help prepare the child’s hand for a good pencil grip and encourage the child to use a tripod grasp, which allows for better control of the pencil.

Knowledge of the progression of grasping patterns is useful to the OT practitioner in evaluating handwriting.¹⁸ Cross-thumb (thumb wrap) or static tripod grasps can be fatiguing or painful but offer more stability and power. Tight grasps limit the variety of movements and make smooth, flowing motions difficult. Writers using tight grasps often press hard on the paper, which results in the formation of dark, sometimes smeared, letters.¹⁸

CLINICAL Pearl

Many adults use a variety of pencil grasps with minimum web space and a very tight grasping pattern. Look around and observe the variety of grasping patterns that are used.

Developmental stages in writing readiness

As children grow and develop, so does their handwriting ability. Table 21-1 provides an outline of the sequence of writing development. The children’s ability to manipulate writing/coloring utensils as well as their ability to use their “helper hand” improves. As they become more comfortable with the task of scribbling, coloring, and ultimately writing, their posture during this task changes and matures. A 2-year-old uses all of his or her fingers to hold a crayon in the palm of the hand. The helping hand is of no use, as the upper extremity is usually retracted at the shoulder, flexed at the elbow, adducted to the side, with semicontracted fingers. This is a position of stability for the child. In addition, the hand performing the scribbling is abducted at the shoulder and flexed at the elbow, and the wrist is pronated and does not make contact with the paper at all. The posture of the 3-year-old is more advanced in that the child starts to use the helping hand. The shoulders are still elevated but are not as retracted. All of the fingers may still be used to hold the utensil, and the wrist of the dominant hand continues to be in the air. As the fourth year approaches, the utensil is being held with a more mature grasp. Shoulders are relaxing to a certain extent but continue to be elevated and somewhat retracted for stability. In addition, the child uses the helper hand to hold the paper in a more deliberate fashion. The elbow of the dominant hand is still elevated, and the writing hand still is not making contact with the surface of the table. By the fifth year, a mature grasp has evolved, and the dominant elbow, wrist, and hand all lie comfortably on the surface of the table. The shoulders are relaxed, and the child sits confidently at the table for handwriting and coloring activities.

TABLE 21-1

Prewriting Skill Development *

ITEM NAME	AGE (MONTHS)
Stirring spoon	12
Scribbling—1 scribble 1 inch long	14
Imitating vertical line 2 inches long	23-24
Imitating horizontal line 2 inches long	27-28
Copying circle—end points within half inch of each other	33-34
Copying cross—intersecting lines within 20 degrees of perpendicular	39-40
Tracing line—deviates <2 times	41-42

^*Based on Peabody Developmental Motor Scale–2.

In-hand manipulation

In-hand manipulation refers to the precise and skilled finger movements made during fine motor tasks. In-hand manipulation is correlated with handwriting legibility.²¹ In order to perform in-hand manipulation tasks, the child needs to be able to adjust objects within the hand while maintaining the grasp on the object. A general example of this skill is working coins from the palm of the hand to a pincer grasp to deposit the coins into a piggy bank. In-hand manipulation skills during writing are observed when a child rotates the pencil to use the eraser. Another example is manipulating the pencil to write dynamically with a tripod grasp while the ring and little fingers remain still to stabilize the hand. In-hand manipulation requires strength, timing, and coordination. Examples of exercises that can strengthen the intrinsic muscles of the hand for improved in-hand manipulation include the following:

• Shifting: working items from the palm of the hand to the tips of the fingers without dropping items

• Translation: using only the fingers, the student “walks” his or her hand from the lead end of the pencil to the eraser end without the aid of items for stabilization

• Rotation: turning the pencil from the lead end to the eraser end without putting the pencil down on the table or using the chest to stabilize the pencil while turning it.

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