Handwriting: More Than Fine Motor Coordination

Difficulty with writing legibility is frequently the reason a referral is made for an occupational therapy observation and/or evaluation in a school setting. The Occupational Therapist may determine if simple adaptions such as different writing paper would resolve the problem, or the therapist may need to dig deeper in order to tease out the underlying factors adversely affecting a student’s writing legibility.

The development of the Common Core State Standards, National Governors Association & Council of Chief School Officers, 2010 made writing and the teaching of writing an important part of the school reform movement in the United States. The document provided benchmarks for a variety of writing skills, and applications students are expected to master for each grade and across grades. In the elementary grades, this includes spelling, handwriting, typing, and sentence construction (including grammar skills), which include planning and revision strategies. The document also included the expectation of writing different types of text (persuasive, narrative, and informative), writing for different purposes (facilitates text comprehension and content learning), and using technology to support the writing process. If elementary teachers are to meet CCSS for writing, they require effective instructional tools (HW21, 2019).

Disabilities in the written expression are estimated to occur in approximately 7 to 15 percent of school-age children, depending upon the criteria used to define the disability. Writing disabilities may be attributed to a range of neurodevelopmental weaknesses or disabilities. Children with learning disabilities of written expression may present with difficulty copying text effectively, display excessive errors in grammar and punctuation, produce overly simple written text, and/or produce disorganized text (text that doesn’t flow).

Differential diagnosis of disorders of written expression includes:

• Handwriting or graphomotor weaknesses or problems with visual-spatial perception.
• Difficulty encoding, which is the ability to match a spoken word with its corresponding letter or letter combination. Problems with spelling always accompany reading decoding problems and are indicative of an underlying problem in phonics.
• Grammar and syntax (understanding and using language to write grammatically correct sentences).
• Formulating, expressing, and organizing ideas in writing (Von Hahn 2019).

If handwriting is not learned and practiced in the earlier grades, children may miss the opportunity to experience the related benefits such as improved brain activation, increased performance on all academic subjects, and a more solid foundation for higher-level skills (Saperstin, 2012).

One study reported that handwriting develops into an autonomous skill by third grade and becomes independent of other cognitive components such as reading and language production. Handwriting shares cognitive resources with reading and language production in first grade but depends on its own specialized resources by third grade, children’s spelling capabilities begin to match the difficulty of the transcription task. Slow writing speed in first grade that persisted in second and third grades was indicative of lower spelling performance in second and third grades. Depending on the school curriculum, handwriting, spelling, and reading all have different and individual developmental timespans. By the end of first grade, typically developing children should be able to reach acceptable handwriting speed. By the end of first grade and in grades 2 and 3, literacy skills should be taken into account when assessing handwriting performance; in these grades, slow handwriting speed is not prevalent, and writing speed may be compromised by spelling and reading capabilities versus sensory-motor deficits (Bosqa-Stork et al., 2016).

I have repeatedly noticed in my practice as a school-based occupational therapist that teachers, parents, and OT’s use handwriting to describe fine motor coordination. Frequently when I am asked to observe a student, the teacher will report that the student has fine motor coordination difficulties evidenced by poor handwriting legibility. Parents will request an occupational therapy evaluation because they believe that their child has difficulty with fine motor coordination because they do not write legibly. I have seen over and over again on occupational therapists’ reports under the heading of Fine Motor Coordination a description of how a student writes. Do we measure fine motor coordination exclusively by how a student writes? Or are there other skills that are equally important for handwriting legibility?

Children typically begin to develop prewriting skills by first scribbling on paper and then imitating prewriting shapes such as lines, circles, squares, and triangles. As pre-writing skills develop, their grasping skills develop in a predictable pattern, and the child learns to hold the writing utensil effectively. Pre-schoolers learn to distinguish letters from numbers and begin to recognize the letters in their name. Many children of the pre school age begin to recognize their name in print and subsequently learn that print has meaning (Stelle et al., 2015).

Below is an overview of the Written Language Production Standards for Handwriting & Keyboarding (grades PreK-8). For more detailed information, check out the References page of this document for the link to the full document. In the area of form and production, kindergartners are expected to print letters and letter-like forms with help. They are expected to create identifiable words, print their first and last name, and begin to copy sentences. First-grade students are expected to print legible letters, and numbers, and use punctuation independently. They are also expected to print letters, words, and sentences with proper proportion size, spacing, speed, and fluency appropriate for their grade. Second and third-grade students are expected to write legibly in manuscript without reversals or rotations, write with proper proportion size and spacing, and third graders will begin cursive writing (HW21, 2019). In order to meet the expectations of the production standards, it would appear that the underlying physical and cognitive components needed for these skills would need to be well developed and functioning synergistically. Writing speed plays an important role because the number of words produced per minute has been found to predict compositional quality in both typically and atypically developing children. If a child has difficulty with aspects of handwriting performance such as speed and/or legibility, it can significantly hinder progress in the classroom and lead to academic underachievement (Prunty & Barnett, 2017).

Children begin to integrate visual and proprioceptive information by copying shapes and letters in pre-school; when they start school, they typically learn to associate movements with the visual image of letters. They learn to write from dictation and to control the movements required for writing, practicing their newly learned writing abilities allows the process of handwriting to become automatic. Acquiring good handwriting sets the foundation for more advanced literacy skills such as the production of written texts, children who have difficulty with automatic handwriting will likely have fewer resources for planning the content of the text (Iman, 2015). If young writers have to devote large amounts of working memory to controlling lower-level processes such as handwriting, there may be little working memory available for higher-level processes. The writer needs adequate working memory for generating ideas, selecting vocabulary, mental planning, and text revision, to avoid crowding out the composing processes. This makes another case for the need for automaticity of writing to eliminate the need for conscious attention to letter formation, freeing more mental space for working memory. Some research suggests that automatic letter writing is the single best predictor of length and quality of written composition in the primary years (Brown & Link, 2016).

De Vries reported that two of the characteristics needed for effective handwriting include a stable pencil grip and controlled dynamic finger movements. Difficulty with fine motor coordination may impair a writer’s ability to control the writing utensil. In-hand manipulation was studied in relation to handwriting, and the results indicated that there is a strong relationship between handwriting performance and in-hand manipulation skills. In-hand manipulation skills differed significantly between good and poor performers in tasks involving translation with stabilization and with rotation. Translation was the most important predictor of handwriting speed tasks (Scordella et al., 2015). In-hand manipulation is the movement of objects within the hand post-grasp. Rotation, translation, and stabilization are the three types of in-hand manipulation. Rotation is the movement of an object around one or more of its axes, translation involves the manipulation of an object between fingertips and palm for storage, and stabilization entails the use of these skills while objects are stored in the palm (Medwell & Wray, 2014).

Schwellnus stated that functional handwriting depends on the complex interplay of a variety of abilities, including skillful fine motor coordination, force regulation, cognitive, perceptual, and language skills. Given the need for the complex integration of skills, learning to write can be challenging for children. The number of typically developing children who struggle with handwriting varies, with reported prevalence worldwide ranging from 6% to 34% (De Vries et al., 2015).

Steele reports that handwriting is a difficult skill to learn. Environmental factors, which appear to be inhibiting an individual’s capacity to acquire the ability to write, involves an intricate exchange of cognitive, visual motor, hand strength, and fine motor skills. Stating that the most important skill required for writing individual letters is muscle memory and that hands, arms, and eye muscles, may work effectively, but the writing muscles need to be exercised correctly and adequately in order to acquire the proper habit of making a letter (Stelle et al., 2015). In OT language it appears that the authors are saying that the proper letter formation needs to be taught so the student is not learning poor formation habits or motor engrams that later will be difficult if not impossible to correct. Acquiring the habit of making a letter, could be translated to automaticity of letter formation.

Handwriting does not only involve hand movements; it involves training the memory and hand to work together to generate the correct mental codes for the production of letters and to translate these codes into motor patterns. With this in mind, the authors go on to state that handwriting is a language act, not just a motor act performed to record words. They state that focusing exclusively on formation, neatness, and speed, may only be a small part of the handwriting process (Prunty & Barnett, 2017).

Handwriting is considered a complex skill which involves multiple processes: “synthesis of cognition, visual perceptio12 (enables a person to comprehend what they see and form judgments about spatial relationships and dimensions of objects), 10 motor skills, integration of memory, problem solving, organization, reading and language ability, ideation, and graphomotor function.” Handwriting involves all of these skills and could be considered a type of creativity training. An analysis of each of the factors that impact handwriting should be completed to design an effective remediation program, a good remedial program should focus on legibility and speed. Handwriting automaticity is important, so the individual does not need to take up precious memory and focus on the content rather than the process of writing. This cannot be achieved unless the writer is able to form letters and words swiftly and effortlessly. Researchers found that training for 10,000 hours makes expert hand writers and children should start in kindergarten in order to be prepared to receive the information that comes to them in subsequent grade levels. This is felt to be important before students begin to use technology, handwriting is effective for working student’s minds, and technology is effective for broadening their minds in order to move them towards creative writing (schwellnus et al., 2013).

Current research seems to agree that there is not one underlying skill, such as fine motor coordination that solely contributes to functional handwriting or even individual letter or number legibility. So, let us start with the occupational therapy evaluation, be it in a hospital, clinic, or school system. If/when the referral is made for an occupational therapist to address handwriting concerns, we should start with a comprehensive evaluation.

The occupational therapy evaluation needs to focus on what the child wants and needs to do and to look at the factors that either support or prevent participation. According to the Occupational Therapy Practice Framework, this is referred to as the analysis of occupational performance (AJOT, 2017). It is commonly reported in the occupational therapy literature that the evaluation should include examining written work samples, observing the child in their natural environment, reviewing records to look for past interventions, services, evaluation reports, and evaluating any suspected performance skill difficulties related to the handwriting concerns. Client factors will need to be considered according to the OT Framework; these are factors that reside within the client and may affect performance in areas of occupation such as a diagnosis of cerebral palsy or a sensory or cognitive impairment (Jackson, 2007). Evaluation of performance skills should include standardized and non-standardized assessments to glean relevant information about a student’s abilities and or limitations. Performance skills would encompass biomechanical and ergonomic factors such as sitting posture and stable grasp, perceptual-motor and sensory processing skills, and environmental factors such as table and chair height, and speed and legibility of handwriting (Brown & Link, 2016). It is important to consider the context where the student will be using the skills, We have been talking about school, but a clinic-based therapist would look at how handwriting may be used at home or in the community, both therapists may be looking at work-related writing or writing alternatives.

Natasha, a 9-year-old with a medical diagnosis of traumatic brain injury was referred for an occupational therapy evaluation due to illegible handwriting. The occupational therapist noted that she demonstrated poor fine motor coordination, in hand manipulation skills, attention span, and poor impulse control. English is a second language for Natasha, and she struggles to understand the language symbols, words, and syntax. Her attention span interferes with learning new concepts and attending to the teacher’s directions and her desktop work. The occupational therapist needs to analyze all of the factors to understand how they influence the occupation of handwriting. The therapist notes that since reading and writing are parallel learning processes Natasha’s writing would be impeded and that her writing will likely improve when effective strategies are in place to improve her attention and knowledge and use of English. In this case it would make sense for the therapist to work with the team to integrate strategies into the school environment in order to improve her attention; this might include addressing her placement in the classroom, decreasing auditory and/or visual distractors, or providing paper with colored lines that might help with letter placement and improve attention (Case-Smith, 2005).

It is beyond the scope of this paper to list all the possible assessments that could be utilized to look at the underlying factors that may be affecting an individual’s handwriting. Below is a list of a few commonly used handwriting assessments along with a brief description:

• The Evaluation Tool of Children’s Handwriting (ETCH) A criterion-referenced tool designed to evaluate manuscript and cursive handwriting skills in children grades 1 - 6. It addresses legibility and speed of handwriting using tasks similar to ones used in the classroom.
• The Print Tool evaluates upper and lowercase letters, and numbers, including specific handwriting components: memory, orientation, placement, size, start, sequence, and word spacing.
• Test of Handwriting Skills – Revised (THS-R) Assesses manuscript and cursive writing with nationally stratified norms through age 18.

Student’s writing speed was measured using sentence dictation. They were asked to write for 2 minutes; the average writing speed was determined by the number of letters written in 1 minute. Letters written per minute was determined to be the most appropriate way to measure writing speed. The grid below indicates the average writing speed of boys and girls within their respective grade levels (Memis, 2018).

Current research indicates that there is a wide variety of foundation skills underlying the occupation of functional handwriting performance, many of them falling solidly within occupational therapy’s area of expertise. New guidelines support the need for formal handwriting instruction, including the reinstatement of cursive writing in the elementary grades. This appears to be a move in the right direction and a path toward improved automaticity of letter and number formation which will free up working memory so the student can focus on the content of their writing. What is important to remember is that within occupational therapy scope of practice fine motor is only one of the many skills needed for adequate handwriting speed and legibility. The skills most applicable to occupational therapists include; a stable grip, in-hand manipulation skills, gradation of force, visual perception, motor planning/praxis, visual motor coordination, and visual memory. We as experts in our field must do a thorough investigation to tease out any underlying skills that may be interfering with functional handwriting performance and articulate our distinct role and skill set as health professionals and team members.

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