Handwriting (Peds)

Question 1

Keys to successful handwriting (6 keys)

Answer 1

the production of legible and efficient handwriting requires intact skills in the areas of…
- postural control
- eye contact coordination
- visual perception
- FM control
- ocular control
- Pencil grasp

Question 2

Prewriting skills

Answer 2

the lines and strokes children from 12 months of age make using a crayon, developed in a specific sequence

Question 3

Pre-writing Developmental sequence

Answer 3

1. Random scribble (1-2 years)
2. Vertical line (age 2: imitates, age 3: copies/masters)
3. Horizontal line (age 2.5: imitates, age 3: copies/masters
4. Circle shape (age 2.5 imitates, age 3 copies/masters)
5. Cross shape (age 3.5 imitates, age 4 copies
6. Square shape (age 4)
7. Right/left diagonal line (age 4.5)
8. X shape (age 5)
9. Triangle (age 5)

Question 4

Underlying skills required for handwriting

Answer 4

• visual tracking
• visual and perceptual skills: visual memory, visual discrimination, visual-spatial orientation, figure-ground
• Ocular motor skills: saccades
• visual motor skills
• Gross motor skills: proximal stability
• Fine motor skills: In-hand manipulation, FM coordination, FM control
• Bilateral motor coordination
• Praxis (motor planning)
• Sensory integration: tactile processing, proprioceptive processing (kinesthesia), vestibular processing,

Question 5

Visual Tracking

Answer 5

• defined as efficiently focusing on an object as it moves across a person’s visual field. The eyes have the ability to track an object in the vertical, horizontal, diagonal, and circular planes. For efficient visual tracking, there should also be an ability to track an object across the midline, with smooth pursuit of the object

Therapeutic activities:
- dot-to-dot pictures
- use tracing paper to trace pictures
- trace letters with chalk
- completes mazes

Question 6

Visual perceptual skills: visual memory

Answer 6

• ability to remember what was just seen; affects the following areas of handwriting:
• the ability to write letters and words from memory
• ability to write letters with the correct orientation on the page
• eliminating letter reversals in handwriting (common until age 7)

Therapeutic activities:
- Ask child to look at his or her name card, then cover it up. Tell the child to write their name without looking.
- write a letter in sand or shaving cream, then quickly erase it and have the child write the same letter.
- Give a child picture analogies for common words, such as the word “bed” (it looks like a bed)!

Question 7

Visual perceptual skills: visual discrimination

Answer 7

• ability to distinguish similarities and differences between two objects. applies to the ability to notice differences in letters with similar appearances during handwriting (a and o, b and d, p and q)

Therapeutic activities:
- Talk the child through the formation of similar letters using verbal cues such as “over, around, up and down” or “ make magic C, then turn it into a”
- use puzzles, vertical writing, and multi-sensory writing methods to reinforce correct letter formation to emphasize the differences between similar letters.

Question 8

Visual perceptual skills: visual spatial orientation

Answer 8

• ability to tell the orientation and placement of objects in relation to each other. this skill applies to letter case, size, spacing, and placement on the writing line. For older students, it also applies to organizing a written assignment on the page.

Therapeutic activities:
- use darkened writing lines, highlighted writing paper, or raised line paper to give children multiple methods of input regarding line placement.
- make a “spacerman” spacer from a small, craft-sized clothespin (draw a face on the top) and have a student place the spacerman between words to make spaces. A finger or plastic spacer also works.
- use verbal cues to help the student visualize correct alignment, such as “your letters are floating away, make them sit on the line”

Question 9

Visual perceptual skills: figure-ground

Answer 9

• ability to distinguish an object against a background. skill relates to the ability to copy using handwriting from a board or another piece of paper without missing letter or words.

Therapeutic activities:
- make “word art” projects such as stencil painting a student’s name or writing words using scratch art.
- have students play hidden picture games, finding words instead of pictures.

Question 10

Ocular motor skills: Saccades

Answer 10

• ability to move the eyes in a synchronized and precise fashion between two visual points. this skill is used when changing lines or paragraphs, as well as during copying from a far point.

Question 11

Visual motor skills

Answer 11

• ability to coordinate the eyes and the hands to execute precise movements. this skill is used to sequence pencil strokes for pre-writing figures and correct letter formation, as well as for motor control to produce correct letter size, alignment and spacing.

Therapeutic activities:
- use large motor movements to draw letters with correct formation in the air
- practice letter formation by writing letters vertically on a whiteboard, smart board, chalkboard, or easel.

Question 12

Gross motor skills: proximal stability

Answer 12

• ability to maintain the correct posture and arm position during handwriting; core strength refers to the strength and control of the trunk muscles to maintain sitting balance; proximal stability refers to the stability and position of the neck, shoulder, and elbow during writing.

Therapeutic activities:
- Using an NDT treatment approach, have a student move to a more stable posture while writing, such as prone on elbows or all fours.
- Enhance core strength by having a student sit on a t-stool or ball chair to facilitate co-contraction of the trunk muscles.
- Have a student kneel at the table while writing to develop core strength.

Question 13

Fine motor skills: In-hand manipulation

Answer 13

• the ability to hold and move an object within one hand (three components–> translation (palm to fingertips), shift (linear movement up and down shaft of pencil), and rotation

Therapeutic activities:
- play pencil manipulation games where a student is required to move, roll, and rotate a pencil using only the writing hand.
- isolate the thumb, index, and middle fingers to practice manipulation skills by having the student hold an object against his or her palm with the ring and little finger

Question 14

Fine motor skills: FM coordination

Answer 14

• affects a student’s pencil grasp, as well as the ability to move the fingers in a dynamic fashion while stabilizing the wrist and forearm. This affects the student’s writing precision and speed.

Therapeutic activities:
- use a visual model and verbal cues to correct a student’s pencil grasp
- issue an appropriate pencil grip to students who experience difficulty adjusting pencil grasp
- stabilize a student’s forearm while the student is writing and cue the student to use his or her fingers to move the pencil.
- for a student with an unstable thumb MCP joint, use a neoprene thumb spica to stabilize the thumb and strengthen the pencil grasp.

Question 15

FM skills: FM control

Answer 15

• this skill affects a student’s ability to write with precision, controlling for letter size and neatness

Therapeutic activities:
- have students practice tracing letters slowly, paying attention to precision.
- Use writing apps such as Letter School or i Write Words for tablets to practice letter formation. make sure student uses a stylus to practice.
- Have student use a tweezers to pick up raisins or beads to develop isolated finger grasp.
- Use vertical writing on a chalkboard, whiteboard, or smart board to develop a mature pencil grasp and correct wrist position.

Question 16

Bilateral motor coordination

Answer 16

• ability to coordinate the use of two hands together to complete a task; used when one hand completes the act of writing while the other hand stabilizes the paper.

Therapeutic activities:
- prompt students to “hold the paper” with the non-dominant hand during writing.
- place the writing paper on a clipboard or a vertical surface and have the student use the non-dominant hand to stabilize paper while writing.

Question 17

Praxis (motor planning)

Answer 17

• ability of the brain to plan an action and then send signals to carry out that action. the brain must tell the hand and fingers how to move to execute the movements involved in writing correctly; crucial when children are first learning to write as praxis is needed to execute unfamiliar movements. Necessary when writing detailed and complex sequences of letters.
• Constructional Praxis: the ability to know the starting point of a letter and then use the correct directionality to “build” the letter.
• Visuopraxis: a combination of visual construction, visual perception, and visual motor skills.
• research shows that legibility is strongly impacted by praxis.

Therapeutic activities:
- use verbal cues that provide a concrete picture, such as “line down, frog jumps up”
- Sing songs and play body games related to letter position, such as “where do you start your letters? At the Top!”
- Repeatedly practice correct letter formation using multi-media. The wet-dry-try method is a good example.

Question 18

Sensory integration: tactile processing

Answer 18

• ability to tolerate the presence of and feel the shape and position of objects in the hand
• tactile defensiveness may affect a child’s ability to hold a pencil in the hand.
• Tactile discrimination: ability to feel the size, shape and position of an object in the hand (may affect the child’s ability to determine how to position the fingers to hold a pencil.

Therapeutic activities:
- use manipulatives to form letters, such as blocks, sticks or small objects.
- Have students make letters out of play-doh by making snakes and forming them into letters.
- adapt the size and surface of pencils for students with tactile defensiveness by using pencil grips, fuzzy pencil shaft covers or other items.
- prepare for writing by have a child find small toys in a bin of sand, dry rice, dry beans, or another textured substance.

Question 19

Sensory integration: proprioceptive processing (kinesthesia)

Answer 19

-ability to sense the body’s position in relation to itself, which parts of the body are moving, and the amount of force exerted during movement. proprioception affects the ability to form an efficient grasp pattern, exert appropriate force on the pencil and write in a line when a writing line is not present; also affects the fluidity of movement information about directionality, sitting posture, joint stability, and handwriting speed. Research shows that students who have poor proprioception rely on visual input for writing process.

Therapeutic activities:
- complete activities while seated on a therapy ball to help improve posture and core stability.
- play catch with a weighted ball to provide proprioceptive input to the arms and hands
-trace letters in sand or shaving cream with eyes closed.
- make “body letters” by forming the letters of the alphabet with the whole body.
- use wooden pieces or blocks to form letters
- have child use a weighted pencil to provide input to the hand on pencil position and writing pressure.
- Use vertical writing activities to reinforce correct pencil grasp and wrist position.
- If a student continues to have difficulty by age 9 or 10, practice cursive writing as an alternative, as cursive writing provides a natural visual flow.

Question 20

Sensory integration: vestibular input

Answer 20

• the ability to sense the body’s position in relation to it’s surroundings, including the ability to sense and tolerate movement. Affects sitting posture and the ability to know when posture is correct- helps to prevent leaning on the desk, table or other students. Affects bilateral motor control for use of “helper hand” critical for the development of proper ocular motor functioning by providing a stable visual field and working in a coordinated fashion with the visual system to mediate eye movements. foundational for visual-spatial abilities, affects eye-hand coordination for motor accuracy

Therapeutic activities:
- complete VM activities while lying prone on a swing, scooter board, or therapy ball to reinforce visual motor skills in different postural positions.
- complete vertical handwriting or VM drawing tasks while standing on a balance board.
- have a student use a ball chair during classroom desk or table top activities. Make sure there is a base on the ball to prevent the ball from rolling.

Question 21

Tripod Grasp

Answer 21

Thumb and index fingers “pinch” the pencil just above the tip and the DIP joint of the middle finger is placed behind the pencil, creating a tripod support as the child writes.

Question 22

Three types of tripod grasps

Answer 22

1. Static tripod grasp: develops between AGES 3-4’ child forms the grasp with the fingers but movement is initiated at wrist.
2. Dynamic Tripod Grasp: develops by AGE 5. The child forms a tripod grasp with the fingers and moves the fingers to move the pencil.
3. Lateral tripod grasp: variation of the grasp, where the thumb is placed next to the index finger, rather than opposite, to brace the pencil. The web space is closed and more wrist extension is required to write using this grasp.

Question 23

Quadrupod grasp

Answer 23

The thumb, index, and middle fingers hold the pencil and the DIP joint of the ring finger is placed behind the pencil, creating a four sided or quadrupod support.

Static quadrupod: typically between ages 3 and 4; child forms the grasp with the fingers, but movement is at the wrist

Dynamic quadrupod: the child forms the grasp with the fingers and moves the fingers to move the pencil

Question 24

Adapted tripod grasp

Answer 24

The grasp is often used by children with poor finger strength, as it requires less strength to stabilize the pencil. The shaft of the pencil is placed between the index and middle fingers while the thumb, index, and middle fingers form the tripod grasp just above the pencil tip.

Question 25

Developmental grasps (used before age 5, but considered dysfunctional after age 5)

Answer 25

1. palmar supinate grasp (also called gross grasp, cylindrical grasp, or fisted grasp; develops between 12-18 months and is used for scribbling; pencil is held with the thumb and fingers curled around the shaft, with the tip of the pencil on the ulnar side of the hand; the child supinates the forearm slightly while scribbling; will transition to next developmental grasp by age 2
2. Digital pronate grasp: emerges around age 2; child holds the pencil with the forearm and pronated and the palm down. The shaft of the pencil is held by curling all four fingers around the shaft, tucking the pencil into the palm. The tip of the pencil is on the radial side of the hand; child will transition from this grasp and move to the next developmental grasp around age 3
3. Multi-finger transitional grasp: develops around three and children will transition to static tripod or quadrupod around age 4; the thumb is placed on one side of the pencil shaft and 3 or 4 fingers are placed on the other side. The child moves the forearm, wrist, and hand as a unit while drawing or writing.

Question 26

Dysfunctional Grasps

Answer 26

1. Thumb wrap grasp: instead of positioning the thumb NEXT to the index finger for support, thumb slides forward and wraps around the index finger, completely closing web space. movement is limited in the fingers, with more wrist movement to compensate; often develops when a child has weak hand and finger muscles or poor prehension patterns.
2. Thumb tuck grasp: thumb is place on the pencil shaft but is tucked under the DIP joint of the index finger; may form in children who have unstable CMC joints in the thumb.

Question 27

Three treatment tips for dysfunctional pencil grasps:

Answer 27

1. EI is very important. children’s motor patterns related to pencil grasps are usually ingrained in the brain by age 8 or 9, after which time it is very difficult to change the pattern.
2. Children with motor control, motor learning, or visual impairments may have more difficulty changing pencil grasp and may require additional intervention in other areas.
3. Children with sensory processing problems may have difficulty feeling where their fingers are in relation to the pencil and may have difficulty reproducing functional grasp patterns.

Question 28

Poorly integrated palmar reflex… what grasp may result and what treatment may be appropriate?

Answer 28

• palmar supinate grasp

treatment:
- squeezing and opening the hands repeatedly, either with hands empty or using a small stress ball
- Play activities that require strong, forceful grasp (monkey bars etc.)
- Forceful, hand-based heavy work, such as putty exercises with resistive putty, squeezing cylindrical glue bottles
- Picking up small items with tweezers or connected chopsticks

Question 29

Inadequate prehension patterns (fingers do not form a quality, forceful tip to palmar pinch d/t poor thumb stability, low finger strength, motor learning or motor control problems… resulting grasp and treatment methods

Answer 29

• multi-finger transitional grasp, lateral grasp, thumb wrap grasp, thumb tuck grasp, hook grasp

Treatment:
- putty exercises focusing on tip and palmar pinch
- activities that require pinch
- placing clothespins, placing small pegs, popping bubble wrap
- coloring using broken crayons- the size of the crayons forces the fingers to form a tripod grasp. Hand over hand assistance may be hlepful

Question 30

Decreased thumb strength…resulting grasps and treatment methods

Answer 30

• lateral grasp, thumb tuck grasp

Treatment:
- putty exercises focusing on thumb strength.
- lateral pinch activities
- a soft thumb spica may be helpful if weakness is not correctable.

Question 31

Difficulty with finger isolation…resulting grasps and treatment methods

Answer 31

• palmar supinate grasp, multi-finger transitional grasp, hook grasp

Treatment methods:
- activities that isolate index finger (pushing buttons, finger painting etc.)
- Flicking games
- Pressing keys on a piano or keyboard with hands in set position
- holding a small toy or coin in the ring and little fingers while writing to keep them tucked
- Coloring using broken crayons

Question 32

Adaptations for pencil grasp

Answer 32

• pencil grip
• pencil weights
• triangular pencils
• writing charms
• Elastic writing aid (Handi-Writer- or you can make with a rubber band)
• weighted pencil
• penAgain Twist N’ Write Pencil (accommodates adapted tripod grasp)
• Writing glove (holes for thumb, index and middle finger, ring and pinky stay inside- can use a sock)
• Hand weights
• Slant board