Clinical Occupational Therapy

Prewriting and Handwriting

Skills

BY
Dr. Waleed Fares
 OBJECTIVES
By the end of this lecture,
The students will be able to
 Define and describe development of prewriting
and handwriting skills

 Identify the factors contributing to handwriting

readiness for young children.

 Describe the role of the occupational therapist in

the evaluation of children with handwriting
difficulties.
 Introduction
 Occupational therapy practitioners view the occupations of
children to be activities of daily living, education, work, play
and social participation.
 In the area of education, school-aged children occupations
encompass:
 Academic skills such as literacy (including reading and writing),
calculation and problem solving
 Nonacademic or functional tasks: may include navigating around
classroom furniture and classmates, sharing school supplies with a
peer, placing a notebook into a locker, cutting with scissors, and
writing words on paper-all of which support a student’s academic
performance in the classroom.
What are Handwriting
Skills …?
 Writing is a tool for communication; it provides a means to
project thoughts, feelings, and ideas.
 Writing is a complex process requiring the synthesis and
integration of memory retrieval, organization, problem solving,
language and reading ability, ideation, and graphomotor
function.
 Handwriting is more than a motor skill; it requires connecting
the letter name with a letterform and recalling a clear visual
picture of the letterform from memory, as well as being able to
execute the motor pattern required to produce the from
Occupational Development
of Prewriting and
Handwriting Skills
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.
Development of Prewriting and Handwriting in
Young Children
Writing Development of School-
Aged Children
 The development of a child’s writing process in the early

elementary grades includes not only mastering the

mechanical and perceptual processes of graphics but also

the acquisition of language and the learning of spelling

and phonology. Children’s writing and reading skills

develop in parallel processes with one another.

 Most children learn to write letters in kindergarten,
but do not develop fluency until the third or fourth
grade, and they do not demonstrate adult speed in
writing until the ninth grade.
 Correlational studies have found that handwriting
skill is strongly linked to eye-hand coordination and is
moderately associated with dexterity.
 Handwriting requires the integration of both lower-
level perceptual- motor processes and higher-level
cognitive processes.
The perceptual-motor processes of handwriting includes:

 Visual perception (e.g. when copying from a model)

 Auditory processing (e.g., when words are dictated)

 visual motor integration (e.g. when combining the

components to write).

The cognitive processes involved include:

 Executive planning and use of working memory

 Handwriting also requires specific language processes
including the ability to hear a word and identify what
letters form that word (i.e., turning spoken language into
written language).
 In primary grades, when students are learning handwriting
by copying letters, visual-motor coordination and motor
dexterity are critical skills.
 In older students, who are required to produce substantial
amounts of writing, cognitive processes become more
important (e.g., planning and linguistic skills).
Pencil Grip Progression
 Primitive grip: Children commonly begin by holding
the writing tool with the whole hand and using the

shoulder to move the pencil.

 A transitional pencil grip: is seen with the pencil

being held with flexed fingers. Initially, the forearm

is pronated (thumb side downward); later, the

forearm is usually supinated.

Typical Development of Pencil Grasp in Children
I. From 1-2 years old
II. From 2-3 years old
III. From 3-4 years old
 The mature pencil grip;, the pencil is stabilized by the distal
phalanges of the thumb and index, middle, and possibly ring
fingers, the wrist is slightly extended yet dynamic, and the
supinated forearm rests on the table
 Dynamic tripod pencil Grasp: the writing utensil rests against the
distal phalanx of the radial side of the middle finger while the pads
of the thumb and index finger control it.
 In older elementary children, the dynamic quadruped and lateral
quadruped grips have been identified as functional and mature
pencil grasps. Thus, the lateral tripod, the dynamic quadruped, and
the lateral quadruped grips may all be considered acceptable
alternatives to the traditionally preferred dynamic tripod grip.
IV. From 4-6 years old
V. From 5-7 years old
 Handwriting Readiness

Some children may exhibit handwriting readiness

at 4 years of age, whereas others may not be
ready until they are 6 years old
 The readiness factors needed for
handwriting require:

Integrity of a number of
sensorimotor systems

Visual Motor

Sensory Perceptual
Six prerequisite skills for children necessary before
handwriting instruction begins:
 Small muscle development.
 Eye-hand coordination.
 The ability to hold utensils or writing tools.
 The ability to form basic strokes smoothly, such as circles and lines.
 letter perception, including the ability to recognize forms, notice
likenesses and differences, infer the movements necessary for the
production of form, and give accurate verbal descriptions of what was
seen.
 Orientation to printed language, which involves right-left discrimination
and visual analysis to determine when a group of letters forms a word.
 Some authors define readiness for handwriting on
the basis of a child’s ability to copy geometric forms.
Other authors suggested that instruction in
handwriting postponed until after the child is able to
master the first nine figures in the Developmental
Test of Visual- Motor Integration (VMI). The nine
figures are a vertical line, a horizontal line, a circle, a
cross, a right oblique line, a square, a left oblique
line, an oblique cross, and a triangle.
The first nine figures in the Developmental
Test of Visual Motor integration (VMI).T
Consequences of handwriting difficulties at school
may include the following:
 Teachers may assign lower marks for the writing quality of
papers and tests with poorer legibility but not poorer content.
 Students slow handwriting speed may limit compositional
fluency and quality.
 Students may take longer to finish assignments than their peers.
 Students may have problems with taking notes in class and
reading them later.
 Students may fail to learn other higher-order writing processes
such as planning and grammar.
 Writing avoidance may develop, contributing later to
arrested writing development.

The role of the occupational therapist is to view the student's

performance by focusing on the interaction of the student, the
school environment, and the demands of school occupation.
Evaluation of handwriting:

An individual evaluation is needed because each

child with handwriting dysfunction varies from

every other child with handwriting problems

A comprehensive evaluation of a
child's handwriting includes

The analysis of
Occupational
occupational
profile
performance
I- Occupational Profile
 The occupational profile describes the student's occupational therapy
history, experiences, patterns of daily living, interests, values, and needs.
 The information for the occupational profile can be gathered by
interviewing the child, parent(s), teacher, and other team members.
 Interviews:
 Interviewing the child helps the therapist to understand what is important and
meaningful to the child.
 Because teachers observe their students' daily performance in class, they can
share information about the student's abilities and achievements and how the
student responds to instruction.
 Parents are also a valuable resource for occupational therapists; they provide a
different perspective on the child and the child's handwriting abilities.
II- Analysis of Occupational Performance
Performance components associated with
handwriting include:

Motor planning In-hand

manipulation
Visual-motor Eye-hand
integration coordination
A comprehensive evaluation of a child's
handwriting includes

B- Reviewing the
A-Examining written
child's educational
work samples
and clinical records

C-observing the child D- Evaluating the

writing in the natural child's actual
setting (i.e., school, performance of
home). handwriting
A-Work samples
 As part of the evaluation process, the occupational therapist accesses the
child's handwritten class work or homework.
 Written work samples may include spelling lessons, mathematical problems,
or a story.
 These samples should represent a typical handwriting performance of the
child.
 When reviewing the child's written product, a comparison of the writing
samples of the child's peers is also warranted to clarify the classroom
standards and teacher expectations.
 Informal evaluation of the work samples for alignment, size, letter
formation, legibility, and slant may indicate the need for further evaluation
B-File review
Relevant information regarding:
 Past academic performance.

 Special testing or receipt of special services.

 Medical or clinical reports related to the child's education.

 The child's parents may share academic records and reports with

clinic- and hospital-based occupational therapists

C- Direct observation
 Observing the student during a writing activity in the classroom is
an essential step in the evaluation process. Skilled observation by the
examiner usually occurs in the child's classroom and focuses on task
performance, attention to task, problem solving, behavior of the
child, the student's organizational abilities, movement through the
classroom, interactions with the teacher and peers, transitions
between activities, and overall performance of other school tasks.
 School contextual features (e.g., the classroom arrangement,
lighting, noise level, instructional media), as well as the actual
instruction from school personnel, should all be considered in
relationship to the student's performance
D- Measuring handwriting performance

In evaluating the actual task of children's handwriting,

the following areas need to be examined:

1- Domains of 2- Legibility
handwriting components.

3- Writing speed. 4- Ergonomic factors.

 Domains of handwriting
Evaluating the various domains of handwriting to
determine which tasks the child may be having
difficulty with and address those tasks in the
intervention plan including the following:
 1-Writing the alphabet in both uppercase and lowercase letters
along with numbers.
 2-Copying is the capacity to reproduce numerals, letters, and words
from a similar script model, either manuscript to manuscript.
Uppercase and lowercase manuscript letter

Uppercase and lowercase cursive letters

 3-Near-point copying is producing letters or words from a nearby
model, commonly on the same page or on the same horizontal
writing surface, as when an elementary pupil copies the meaning of
a word from a nearby dictionary.
 4-Copying from a distant vertical display model to the writing
surface is termed far-point copying, demonstrated by early
elementary students writing the words "Happy Valentine's Day" on
construction paper cards from the teacher's modeled words on the
class chalkboard.
 5- More advanced than copying, manuscript-to-cursive transition
requires a mastery of letterforms in both manuscript and cursive as
the child must transcribe manuscript letters and words to cursive
letters and words
 6- Writing dictated words, names, addresses, and telephone

numbers is a skill children will need at school and at home.

 Composition is the generation of a sentence or paragraph

by the child demonstrated by writing a poem, a story, or a

note to a friend. The composing process uses the cognitive

functions of planning, sentence generation, and revision

thus; this writing task involves complex integration of

linguistic, cognitive, organizational, and sensorimotor skills

 2- Legibility
Legibility is often assessed in terms of its
components:

Letter
Spacing
formation

Slant

Alignment Size
 Legibility

Letter formation, there are five features

affecting legibility
 Improper letterforms.
 Poor leading in and leading out of letters.
 Inadequate rounding of letters.
 Incomplete closures of letters.
 Incorrect letter ascenders and descenders.
leading in and leading out of letters.
Inadequate rounding of letters.
Incomplete closures of letters.
letter ascenders and descenders.
 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 on the entire
sheet of paper.
 Size, refers to the letter relative to the writing guidelines
and to the other letters.
Finally, the uniformity or consistency of the slant or the angle
of the text should be observed
 Legibility
 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.
Word legibility percentage
= Total number of readable words / Total number of written
words
4/8 = 50%
 3- Writing Speed
 A child's rate of writing or the number of letters written per
minute, and its legibility are the two cornerstones of functional
handwriting.
 The studies show that children's handwriting speeds develop
gradually, becoming faster in each succeeding grade.
 Writing speed typically decreases when the amount of written
work or complexity of the writing task increases.
 Students may take longer to complete written assignments,
have difficulty taking notes in class, lose their train of ideas for
writing and become frustrated when their handwriting speed is
slower than that of their peers.
4- Ergonomic Factors
 I- Writing posture

 Sitting posture in the classroom should be observed.

 Does the child rest his or her head on the forearm or

desktop when writing?

 Is the child falling out of or slumping in his or her chair?

 Does the child stand beside the desk or kneel in the chair?

 Are the desktop and the chair at suitable heights?

 II- Upper extremity stability and mobility.

 The ability to keep the shoulder girdle, elbow, and wrist

stable allow the dexterous hand to manipulate the writing
instrument.

 Does the child write with whole-arm movements?

 What are the positions of the trunk and writing arm?Does

the non-preferred hand stabilize the paper?

 Does the child apply excessive pressure to the writing tool?

 III- Pencil grip

 An ergonomic focus for most occupational therapy

practitioners is whether a child is holding the pencil
properly, or using an atypical pencil grasp
 Poor writers tend to demonstrate a greater variety of
atypical grasp patterns than legible writers.
 Mature pencil grips for children now include the dynamic
tripod, the lateral tripod, the dynamic quadrupod, and the
lateral quadrupod.
 Unconventional pencil grips do not necessarily affect the
speed or the legibility of the child's handwriting
Atypical and inefficient pencil grasp