When it comes to analyzing handwriting, there is no escaping handwriting if you are a pediatric OT. Handwriting evaluations and interventions is a main task of school-based occupational therapists. It’s no wonder when you consider that handwriting is one of the primary tasks that school-aged children engage in, and is one of the most prominent reasons for an OT referral in the school and outpatient settings. Today we’re talking handwriting analysis and clinical observations related to assessing handwriting.
Seems like handwriting should be pretty easy right? The challenge in teaching handwriting is often the limited exposure we receive prior to entering the field, and ensuring that we are providing a skilled service and not tutoring.
Handwriting Clinical Observations
When I was in school, we briefly touched on fundamentals of handwriting, and the Handwriting without Tears program. I later had some great exposure to handwriting during my Level 2 fieldwork in a school setting, but still felt unprepared to really dive into what prohibited kid’s from learning to write, and to then decipher those findings.
Since practicing on my own, I have developed a set of clinical observations that are relevant to the handwriting process as it relates to OT and what they meant in terms of function. Check out the list of clinical observations below.
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Below are strategies to use in analyzing handwriting. THese are clinical observations that can impact the legibility of written work.
This one seems like an obvious one, but there have been many times that I have sat down to write an evaluation and realized that I didn’t note anything about the grip pattern. Yikes! The major points of clinical observations of pencil grips to keep in mind are that you watch for dynamic finger movement, hyperextension of joints and overall functionality.
Here are some important things that therapists wish parents and teachers knew about pencil grasp.
Dynamic Finger Movements and Pencil Grip
Dynamic finger movement is a big key to preventing fatigue. If the hand or wrist move as a unit, fatigue and endurance significantly increase. Dynamic movements also allow for more control of the utensil within a given space.
Once dynamic movements have developed, it is exponentially easier for the kiddo to color or write in small spaces, form multi-step lower case letters and produce smaller sized letters and numbers.
Hyper-Extended Fingers and Pencil Grip
When a child hyper-extends a joint when holding a writing utensil, the grip typically appears “tight” or “too hard”. Hyperextension can lead to damage in the joint itself, along with uncomfortable feelings to the fingers, increased levels of fatigue, poor overall endurance, and hinder dynamic movement.
Children with poor overall joint stability or poor strength often exhibit this pattern of pencil grips. The “tight” or “too hard” grip that leads to hyperextension is a compensatory strategy to increase motor control and dexterity within the task. Due to the variety of pencil grips that children display, it is important to assess the functionality of the grip before attempting to change it.
Functionality of Pencil Grip
Current EBP indicates that there are several functional pencil grip patterns outside of the standard tripod grasp pattern that we all identify as “the best” or “most functional” grip pattern. Other patterns include static and dynamic variations of tripod and quadropod grips.
However, I really encourage you to just take a minute to see if the child is functional with their current grip pattern. Trying to change the pattern they are functional with is not always the best option for addressing handwriting.
If they are able to control the utensil for accurate execution of strokes, are able to remain in the given boundary and are not showing signs of poor endurance or fatigue—then they are functional and other components of handwriting should be addressed.
Posture and handwriting
I want to touch on posture’s impact on handwriting quickly because you can learn some interesting things about a child’s handwriting this way.
If they are slouched over or use their hand to hold their head up, poor core and upper body strength may be the culprit. This will greatly impact their fine motor skills. Without a strong foundation, dexterity skills will not develop.
It’s also important to note if the hand that is holding the child’s head up is covering one eye consistently. This may indicate that there is an underlying vision issue that needs to be addressed. Children typically cover the eye that is making them see double or causing blurred vision.
This is not only an issue from a vision standpoint, but also because you now don’t know what the child is seeing for letters or strokes. Once the vision concern is addressed, the child may have to “relearn” the letters and strokes which can appear as a regression of skills.
Similar concerns are also noted when the child is consistently adjusting their head position in location to the paper.
Dominance plays a large role in handwriting and if a child does not display a dominant side, or has mixed dominance, delays in handwriting can occur.
Lack of dominance can prevent adequate levels of motor practice of strokes and letters from being completed. This can then lead to sloppy or illegible writing, along with confusion on the sequence of strokes to form letters. Children who display these motor patterns typically have delayed automation of handwriting, may have a higher incidence in reversals and struggle with getting their thoughts onto paper.
These three simple tips on hand dominance, laterality, and functional activities are a resource in establishing this essential skill.
Segmental drawing is when a child “draws” or writes a letter using singular strokes with clear, and abrupt stops between the strokes. This is time consuming, and requires a high level of active thought for the child. Essentially, it’s very non-functional and needs to be addressed.
Segmental drawing not only provides a picture about the child’s writing skills, it also provides insight to the therapist on how they process information. Children who typically utilize segmental drawing are only able to process small or shorter pieces of information at one time. For example, they may need directions given in short bursts or in simple statements to be successful.
Sequence of Strokes and Handwriting
Building on segmental drawing is the sequence in which strokes are completed. Letters in our culture flow from top to bottom, and left to right. A child who is demonstrating a bottom to top orientation or sequence of strokes, when writing may have a significantly harder time learning to form letters correctly and fluidly. Their brains may be “wired” naturally to move in this pattern, or they may be compensating for a visual motor impairment such as spatial relations deficits.
Case Use and Handwriting
The case a child chooses to write in, or the combination of case they use provides information on letters that they may be unable to recall, are unsure of their direction (reversal prevention/compensatory strategy), or are unable to execute. By analyzing the use of upper case and lower case letters you can determine where the break down in skill is.
Fluidity and Handwriting
Finally, as all of these observations come together, the final piece is fluidity. This looks at a few different things including the child’s speed of writing, whether they talk to themselves or watch their hand when they write, and if they demonstrate any motor overflow.
The amount of time that a child takes to write can be an indication of poor memory recall and lack of automation of the writing process. The longer the task takes, the more difficulties the child is having retrieving the information from their memory and utilizing it effectively.
Children who are struggling with writing often talk themselves through the process—from where to start to the verbal cues taught to them. This external processing further indicates poor processing speeds. This can also be seen in the form of oral motor overflow. This is when a child’s mouth moves in odd patterns, they stick their tongue out or some combination of jaw and tongue movement.
Along with motor overflow and outward verbal processing, a child may watch her hand when writing. By watching her hand, the child ensures that the stroke she recalled from her memory is indeed correct and that she is able to execute it. This pattern further hinders the automation of handwriting and indicates challenges with processing and memory recall. When writing requires this much active thought for just the formation of the letters, spelling, sizing, spacing, and thought completion often go by the way side.
Handwriting is such a large part of being a kid, and being a pediatric OT, that it deserves more attention than it often gets. There are so many foundational skills that go into handwriting, and many places for the skills to become a challenge for a kiddo.
Hopefully everyone from seasoned OT’s to brand new grad’s found this post helpful and learned something new in handwriting analysis and clinical observations needed to assess handwriting.