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HANDWRITING

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Handwriting is a complex process of recording language by hand, often by using paper and a pen or pencil.
The production of legible and efficient handwriting requires intact skills in the areas of postural control, eye hand coordination, visual perception, fine motor control, ocular control, and pencil grasp. A child’s handwriting abilities have significant influence on their academic performance.

Pre-Writing Skills
Pre-Writing Skills need to be developed before any letter formation or other handwriting skills are mastered. Pre-writing skills are the lines and strokes children from 12 months of age make using a crayon. Each of these scribbles/lines/strokes are typically developed in a specific sequence.

This developmental sequence is:
* Vertical Line – (Age 2 imitates, age 3 copies/masters)
* Horizontal Line – (Age 2 1/2 imitates, age 3 copies/masters)
* Circle Shape – (Age 2 1/2 imitates, 3 copies/masters)
* Cross Shape (+) – (Age 3 1/2 imitates, age 4 copies)
* Square Shape – (Age 4)
* Right/Left Diagonal Line – (Age 4 1/2)
* X Shape – (Age 5)
* Triangle (Age 5)

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Handwriting is a fundamental skill for anyone school age and above.
The underlying skills required for handwriting, as well as ideas for therapeutic activities to address handwriting with children, are reviewed in the following chart.

Skill	Description	Example	Therapeutic Activities	Photo/Video
Visual Tracking	Visual tracking is 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 and 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.	A student uses his finger to help him keep his place while reading.	– Dot-to-dot pictures – Use tracing paper to trace pictures. – Trace letters with chalk. – Complete mazes	Visual Tracking Definition, Exercises and Activities
Visual Perceptual Skills: Visual memory	The ability to remember what was just seen. Visual memory affects the following areas of handwriting: -the ability to write letters and words from memory -the ability to write letters with the correct orientation on the page -eliminating letter reversals in handwriting (common until about age 7)	A kindergarten student is able to write his first name on his paper without looking at his name card for the first time.	-Ask the child to look at his or her name card and then cover it up. Tell the child to write his or her 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” looks like a bed.	A vision therapist demonstrates visual memory activities for children and explains how they help improve functional skills.
Visual Perceptual Skills: Visual discrimination	The ability to distinguish similarities and differences between two objects. This skill applies to the ability to notice differences in letters with similar appearances during handwriting, such as a and o, b and d, p and q.	A first grade student writes the letters “a” and “o” using the same pencil patterns and must go back to add the stick on the “a” after a visual reminder.	-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 an a”* -Use puzzles, vertical writing, and multisensory writing methods to reinforce correct letter formation to emphasize the differences between similar letters.	A vision therapist demonstrates a visual discrimination activity and explains how it helps improve functional skills.
Visual Perceptual Skills: Visual spatial orientation	The ability to tell the orientation and placement of objects in relation to each other. For handwriting, 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.	A second grade student uses his finger to make spaces between words as he writes a sentence.	-Use darkened writing lines, highlighted writing paper, or raised line paper to give children multiple methods of input regarding line placement. -Make a “spaceman” spacer from a small, craft size clothespin (draw a face on the top) and have a student place the spaceman between words to make the spaces. A finger or a 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.”	Example of the Rey-Osterrieth Complex Figure, used to test visual spatial orientation and visual memory.
Visual Perceptual Skills: Figure-ground	The ability to distinguish an object against a background. This skill relates to the ability to copy using handwriting from a board or another piece of paper without missing letters or words.	A classroom teacher writes the instructions for a science project on the classroom white board, using a different color for each step to make the instructions stand out.	-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.	The game “I Spy” is based on the skill of figure-ground discrimination.
Ocular-Motor Skills: Saccades	The ability to move the eyes in a synchronized and precise fashion between two visual points. During handwriting, this skill is used when changing lines or paragraphs, as well as during copying from a far point.	A high school student is unable to keep up with note taking during a teacher’s lesson as she is not able to switch her gaze quickly and the teacher is switching note slides at a fast pace.	-Play trail making games on a large board and on paper. -Play fast moving games such as ping pong or badminton. -Have students copy single sentences from a far point, such as a white board or a Smart board, against a timer.	A man demonstrates how saccades affect eye movements during reading.
Visual Motor Skills	The ability to coordinate the eyes and the hands to execute precise movements. During handwriting, 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.	A first grade student with attention deficit and hyperactivity disorder (ADHD) loses focus while writing a sentence, causing his letters to slope off the writing line.	-Use large motor movements to draw letters with correct formation in the air. -Practice letter formation by writing letters vertically on a white board, Smart board, chalkboard or easel.
Gross Motor Skills: Proximal Stability	The 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.	A kindergarten student with cerebral palsy and resulting poor core strength lies prone on elbows to practice writing the letters of her name.	-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.
Fine Motor Skills: In-hand manipulation skills	In-hand manipulation is the ability to hold and move an object within one hand. There are three components. 1. Translation: The ability to move an object from the palm of the hand to the fingertips and back to the palm. 2. Shift: The linear movement of an object between the fingers such as moving your fingers up and down the shaft of a pencil. 3. Rotation: The movement of an object with the finger around one or more of its axis, such as when you spin a pencil around with your fingers. All these categories include stabilization which is the ability to hold an object with the ring and little fingers while moving another object with the thumb, index and middle fingers. In-hand manipulation skills are essential to the handwriting process because they allow the student to make the necessary adjustments to the pencil for writing.Simple rotation or complex rotation is used to pick a pencil up, off of a table, and to rotate it in-hand to position it for use.Complex rotation is used turn the pencil from the writing to erasing end with one hand.	A four-year-old kindergarten student must use his other hand to help adjust the pencil in his writing hand prior to drawing a picture.	-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 fingers.	A woman demonstrates in-hand manipulation skills. Complex rotation.
Fine Motor Skills: Fine motor coordination	During handwriting, fine motor coordination 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.	A kindergarten student writes very slowly, clamping his fingers on the pencil and moving his wrist and forearm as a unit while writing his name.	-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 splint to stabilize the thumb and strengthen the pencil grasp.
Fine Motor Skills: Fine motor control	This skill affects a student’s ability to write with precision, controlling for letter size and neatness.	A 4th grade student shows improvement in the neatness of her written assignments after 2 months of occupational therapy sessions.	-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 use a stylus to practice with a tablet app. -Have a student use a tweezers to pick up raisins or beads to develop isolated finger grasp. -Use vertical writing at a chalk board, white board or Smart board to help develop a mature pencil grasp and correct wrist position.
Bilateral Motor Coordination	The ability to coordinate the use of two hands together to complete a task. During handwriting, bilateral motor coordination is used when one hand completes the act of writing while the other hand stabilizes the paper.	A student with a traumatic brain injury learns to use his affected hand as a “helper hand” to stabilize the paper as he writes his name.	-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 the paper while writing.
Praxis – also called Motor Planning	The ability of the brain to plan an action and then send signals to the body to carry out that action. During writing, 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**	A third grade student with a learning disability forms all of her letters from the bottom up.	-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.*	Directions are given for a homemade game activity that addresses motor planning skills. A child demonstrates the game.
Sensory Integration: Tactile processing	The ability to tolerate the presence of and feel the shape and position of objects in the hand. -Tactile defensiveness – sensitivity to touch in the hand. This may affect a student’s ability to hold a pencil comfortably. Tactile discrimination – the ability to feel the size, shape and position of an object in the hand. This may affect a student’s ability to determine how to position the fingers to hold a pencil.	A first grade student with tactile defensiveness uses a large, squishy pencil grip when writing to make the pencil more comfortable to hold.	-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 similar items. -Prepare for writing by having a student find small toys in a bin of sand, dry rice, dry beans, or another textured substance.
Sensory Integration: Proprioceptive processing, also called kinesthesia.	The 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. During writing, proprioception affects the ability to form and efficient grasp pattern, exert appropriate force on the pencil, and write in a line when a writing line is not present. Proprioception also affects fluidity of movement, information about directionality, sitting posture, joint stability, and handwriting speed. -Research shows that students who have poor proprioception rely in visual input for writing, slowing the writing process.^	A third grade student uses small weights on his pencil to help him hold the pencil in the correct position while writing.	-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 a student 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.	Children demonstrate how problems with the proprioceptive system affect function.
Sensory Integration: Vestibular processing	The ability to sense the body’s position in relation to its 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 function 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.	A first grade student sits on a ball chair to improve posture during handwriting. (Research supports sitting on a ball to improve handwriting ^^.)	-Complete visual motor 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 visual motor 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.	Children demonstrate how problems with the vestibular system affect function.