The Importance of Handwriting

• Writing is a tool for communication to project thoughts, feelings and ideas.
• Handwriting is more than a motor skill.
• Handwriting requires connecting a letter name with a letter form and recalling a clear visual picture of the letter form from memory, then executing the motor pattern required to produce the form.
• Writing is a complex process requiring the synthesis and integration of memory retrieval, organization, problem-solving, language and reading ability, ideation, and graphomotor function.
• Students with neurologic impairments, learning problems, attention deficits, and developmental disabilities often spend extended time and effort learning to write legibly.
• Handwriting difficulties can lead to:
  • Lower marks for writing quality, even with good content
  • Limited compositional fluency due to slow handwriting
  • Taking longer to finish assignments
  • Problems taking notes in class
  • Difficulty learning higher-order writing processes
  • Writing avoidance.
• Occupational Therapists focus during evaluation and intervention on:
  • Domains of handwriting and components problematic for the student
  • School context
  • Student's context (cultural, temporal, spiritual, physical)
  • Student experiences interfering with handwriting.
• Writing includes:
  • Integration of memory retrieval.
  • Organization.
  • Problem solving.
  • Language and reading ability
  • Ideation.
  • Graphomotor Function.

The Writing Process

• The writing process encompasses:
  • Preliteracy writing development of young children
  • Writing development of school-aged children
  • Handwriting readiness
  • Pencil Grip progression.

Pre-Literacy Writing Development of Young Children

• Handwriting is a complex skill that develops over years.
• Children start drawing and scribbling after grasping a writing tool.
• As children mature, they write intentionally meaningful messages with pictures, scribbles, letter-like forms, and letters.
• Early elementary writing development includes graphics, language acquisition, spelling and phonology.
• If a child can't recognize letterforms or that letterforms represent written language, they cannot be expected to write.
• Children's scribbles and pictures evolve into handwriting specific to their culture.

Sequential Stages of Prewriting and Handwriting

• There are sequential stages of prewriting and handwriting:
  • Controlled scribbles
  • Discrete lines, dots, or symbols
  • Straight line or circular uppercase letters
  • Uppercase letters
  • Lowercase letters, numerals, and words.
• Age levels of handwriting progression are approximate due to skill development variations.

Writing Development of School-Aged Children

• Most children learn to write letters in kindergarten but develop fluency and adult speed in writing until 3rd/4th and 9th grade, respectively.
• Handwriting requires integration of lower-level perceptual-motor and higher-level cognitive processes.
• Visual-motor integration is the strongest handwriting legibility predictor.
• Perceptual-motor processes include visual perception, auditory processing (dictation), and visual-motor integration (combining components).
• Cognitive processes include executive planning and working memory.
• Handwriting requires specific language processes to hear a word and identify what letters form that word.
• Handwriting skill is strongly linked to eye-hand coordination and moderately linked to dexterity.
• Adults rely on kinesthetic input when writing, but children learn by visually analyzing form and space, then linking the image of a letterform to a motor plan.
• Practicing visually guiding hand movement develops a kinesthetic memory of letterforms.
• Writing becomes automatic with minimal cortical processing.
• In primary grades, visual-motor coordination and motor dexterity are critical for copying letters.

Development of Prewriting and Handwriting in Young Children

• 10-12 months: Scribbles on paper.
• 2 years: Imitates horizontal, vertical, and circular marks on paper.
• 3 years: Copies a vertical line, horizontal line, and circle.
• 4-5 years: Copies a cross, right oblique cross, some letters and numerals, and may be able to write own name.
• 5-6 years: Copies a triangle, prints own name, copies most lowercase and uppercase letters.

Handwriting Readiness

• Differing maturity, environmental experiences, and interest levels influence handwriting readiness.
• Some children are ready at 4, others at 6.
• Mastery of handwriting readiness skills is important before handwriting instruction.
• Teaching handwriting before readiness can discourage children and develop poor writing habits.
• Readiness can be defined by a child's ability to copy geometric forms.
• Nine figures in the Developmental Test of Visual-Motor Integration (VMI) are a vertical line, horizontal line, circle, cross, right oblique line, square, left oblique line, oblique cross, and triangle.
• Some children with cognitive or physical impairments may need a computer with word processing and word prediction software.
• Some children can learn to write their names even without prerequisite components for handwriting, through practice.
• Occupational therapists must determine when it is appropriate for the young child to work on prerequisite handwriting skills, handwriting itself, or all the above.

Six Prerequisite Skills Needed Before Handwriting Instruction

• Small muscle development.
• Eye-hand coordination.
• Ability to hold utensils or writing tools.
• Ability to form basic strokes smoothly (circles, lines).
• Letter perception, including recognizing forms, noticing likenesses/differences, inferring necessary movements, and verbally describing what was seen.
• Orientation to printed language involving right-left discrimination and visual analysis to determine when a group of letters forms a word.

Six Developmental Classifications Underlying Skilled Hand Use for Pencil

• Upper extremity support.
• Wrist and hand development.
• Visual control.
• Bilateral integration.
• Spatial analysis.
• Kinesthesia.

Pencil Grip Progression

• Pencil grip development follows a predictable course in typically developing children but can vary among cultures.
• Children begin with a primitive grip, holding the writing tool with the whole hand or extended fingers, forearm pronated, and using the shoulder to move the pencil.
• Between 18 and 30 months, a transitional pencil grip appears with flexed fingers, pronated (thumb side downward) forearm, then supinated forearm.
• In the mature pencil grip, the pencil is stabilized by the distal phalanges of the thumb, index, possible middle and ring fingers, with a slightly extended yet dynamic wrist and supinated forearm resting on the table.
• Mature pencil grips include the dynamic tripod grasp, the lateral tripod, the dynamic quadripod, and the lateral quadripod.

Evaluation

• Handwriting evaluation involves an occupational profile, interviews, and analysis of occupational performance.

Occupational Profile

• The occupational profile describes the student's occupational therapy history, experiences, patterns of daily living, interests, values, and needs.
• It aims to understand the client's perspective and background.
• Information is gathered by interviewing the child, parent(s), teacher, and other team members.

Interviews

• Interviewing the child helps the therapist understand what is important and meaningful to the child.
• Teachers can share information about the student’s abilities and achievements and how the student responds to instruction.

Analysis of Occupational Performance

• Analysis involves:
  • Examining written work samples
  • Reviewing educational and clinical records
  • Observing the child writing in a natural setting (school, home)
  • Evaluating handwriting legibility and speed
  • Assessing performance skills suspected of interfering with handwriting.

Measuring Handwriting Performance Areas

• Domains of handwriting.
• Legibility components.
• Writing speed.
• Ergonomic factors.

Domains of Handwriting

• Handwriting tasks include:
  • Writing the alphabet in uppercase and lowercase letters along with numbers.
  • Copying numerals, letters, and words from a similar script model (manuscript to manuscript or cursive to cursive)
  • Near-point copying: producing letters/words from a nearby model.
  • Copying from a distant vertical display is termed far-point copying.
  • Manuscript and cursive: transcribing manuscript letters/words to cursive letters/words.
  • Writing dictated words, names, addresses, and telephone numbers.
  • Composition: generating a sentence/paragraph by writing a poem, story, or note to a friend.

Legibility Components

• Five features affecting legibility include:
  • Improper letterforms
  • Poor leading in and leading out of letters
  • Inadequate rounding of letters
  • Incomplete closures of letters
  • Incorrect ascenders and descenders.
• Components of legibility:
  • Alignment, or baseline orientation, refers to the placement of text on and within the writing guidelines.
  • Spacing includes the dispersion of letters within words and words within sentences and text organization the entire sheet of paper.
  • Size refers to the letter relative to the writing guide and to the other letters.
  • Uniformity or consistency of the slant or the angle text should be observed.
• Legibility is determined by counting the number of readable written letters or words and dividing it by the total number of written letters or words in a writing sample.

Writing Speed

• Rate of writing, or the number of letters written per minute, is a cornerstone of functional handwriting.
• Students may take longer to complete written assignments, have difficulty taking notes, lose their train of ideas, and become frustrated when their speed is slower than peers.
• Writing speed decreases when written work/complexity increases.
• Compare student's writing speed with rates of classroom peers.
• Handwriting speed is problematic when a student can't complete written school assignments on time.

Ergonomic Factors

• Stability and mobility of the upper extremities (shoulder girdle, elbow, and wrist stability) allow the dexterous hand to manipulate the writing instrument.
• Efficiency in handwriting performance improves when biomechanical and ergonomic factors are optimal.

Intervention Areas

• Sitting posture.
• Paper, surface position.
• Pencil grip.
• Writing tools.
• Cognitive intervention.

Intervention - Sitting Posture

• Alternative writing positions.
• An optimal posture includes the student sitting with the feet planted firmly on the floor, for postural shifts and adjustments.
• This position lets the student experience symmetry and stability while performing written work.
• Adjust desk/chair heights, footrests for children, adding seat cushions/inserts, or repositioning a child's desk.

Paper Position and Writing Surface

• Paper should be slanted on the desktop parallel to the writing hand forearm when the child's forearms are resting on the desk with hands clasped.
• Paper angle enables the student to see work/avoid smearing.
• Right-handed students may slant the top of the paper approximately 25 to 30 degrees to the left and paper to the right of the body's midline.
• Conversely, slant 30-35 degrees to the right/paper to the left of midline for students using a left-handed tripod grasp.
• Slanting the paper to the left is appropriate for the student with a left-handed "hooked" pencil grasp lacking lateral wrist movements.
• The writing instrument should be held below baseline/non-preferred hand should hold paper.
• Writing on a slanted surface (20-30 degrees) can improve a child's pencil grasp, positioning the hand in wrist extension and tending to angle the hand into some supination.
• The hand on a slanted surface is closer to the eyes, facilitating the eyes' tracking of the hand's movement.
• A vertical or semi-vertical surface promotes more upright posture.

Pencil Grip

• Benbow defined the ideal grasp as a dynamic tripod with an open web space.
• Common grasp patterns include lateral quadripod, dynamic quadripod, and lateral tripod.
• Stetro grips, triangular pencils, moldable grips, and pencil grips may facilitate tripod grasp.
• Writing muscle tension/fatigue may be reduced for some children with a wide-barreled pencil.
• Radial digits may need greater mobility, requiring holding a small eraser against the palm with the ulnar digits.
• Older children with hand hypotonicity may achieve pencil grasp by holding the pencil shaft between web space/index and middle fingers with thumb opposition.

Writing Tools

• Children should choose among writing tools; parents/teachers may help determine which utensil is most efficient and comfortable.

Cognitive Intervention

• Cognitive interventions for handwriting are based on learning theories with self-instruction/verbal mediation and strategies of imitation, practice, self-evaluation, and feedback.
• One top-down cognitive approach is Cognitive Orientation to (daily) Occupational Performance (COOP).
• Therapists use verbally-based, individualized problem-solving techniques to facilitate motor skill acquisition.