Fine Motor Skills and Handwriting: They Go Hand in Hand

Weak fine motor skills and poor handwriting often lead to questions and referrals for physical therapists (PTs) or occupational therapy practitioners (OTPs). Through discussion with the teacher or caregiver, therapists can often determine if it is related to weakness or environmental factors and if an occupational therapy (OT) or physical therapy (PT) evaluation is required. Although teachers are the ones who teach handwriting to students, most do not receive formal education in the specific areas of letter formation and the prerequisite fine motor skills. While OTPs are traditionally the ones to perform a handwriting assessment, PTs may be involved in strengthening and range of motion activities to facilitate the performance of the fine motor skills necessary to improve handwriting. This is where we, as therapists, can support teachers.

Fine motor skills are precise and refined movements of the entire upper extremity and actions of the wrists, fingers, and hands that allow for the dexterity of movement (OTTB, n.d., a). Fine motor skills are necessary for every aspect of daily living, from self-care and work-and-play activities to grasping a pencil and producing handwriting.

Many components make up fine motor skills.  The following are areas that affect a person's fine motor skills (OTTB, n.d., a):

• Bilateral hand coordination: Bilateral hand coordination is important for skills like feeding yourself, handwriting, dressing, self-care, and more. Without good bilateral hand coordination, a child may appear clumsy, may drop items, or have difficulties with tasks that require a dominant hand and a helper hand (such as holding a piece of paper still while writing with the other hand).
• Gross grasp: Gross grasp is required when all the fingers shut around an object. Developing an arch with the hand and the thenar web space is also important.
• In-hand manipulation: Three aspects of in-hand manipulation include using the fingers to translate or move smaller items from palm to fingertips (translation), shifting an object using the pads of the fingertips, and rotating or rolling an object using the fingertips.

In terms of fine motor skills required for handwriting or other tasks that require precise manipulation of objects, many forms of grasp and specific areas need to be strong enough to accomplish these movements. This includes the following types of grasp: pincer, tripod, cylindrical, and spherical grasp and opposition. The child must have enough functional finger strength, intrinsic muscle strength in the hand, thenar eminence, and hypothenar eminence (OTTB, n.d., a). There must also be adequate wrist mobility and stability.

While fine motor skills are typically thought of as finger, hand, and wrist movements, an important component of fine motor skills starts proximally. It is important to have proper core, shoulder, and scapular stability to properly position the upper extremity to complete the distal function. Development of this proximal stability starts very early for children and includes appropriate strength of the shoulder girdle down the extremity to the fingers. Fine motor development begins with the large muscles in the shoulders and progresses to the smaller muscles of the fingers and intrinsic muscles of the hand. Strengthening the shoulders and elbow complexes starts to develop early in life with periods of tummy time during infancy. This is placing the child on a mat, floor, on the caregiver's chest, or towel, and the child uses their neck muscles and arms to push up to turn their head or hold it up to look around. This strengthening continues as an infant learns to crawl and perform proximal movement while stabilizing through their upper extremities. This type of strengthening activity is not just important for babies. Still, as children age, they can color, write, do puzzles, draw, or talk while using their elbows under the shoulders and pushing through their elbows, forearms, and fingers.

tummy time

Another activity to strengthen shoulders, wrists, and fingers is to draw, color, or write on vertical surfaces. These activities should be fun and engaging for the student to encourage participation. It could be drawing with chalk, writing a story, writing spelling words, painting, or turn-taking for pre-writing strokes. Ways to strengthen the wrist and fingers include Play-Doh, using tongs to pick up small items, using pincer fingers to pick up small snacks, playing with dolls and dressing them in different clothing, and pushing a small car back and forth.

Fine motor skills include: “manual development, dexterity, hand-eye coordination, manual control, visuomotor skill, graphomotor skill, and visual-motor integration” (Suggate et al., 2023). Typical development of fine motor skills occurs naturally for children during functional activities like play and activities of daily living, but the spread of technology for young children has affected this development. Isnaini and Katoningsih (2021) completed a literature review investigating methods of improving fine motor skills in children between the ages of 5 and 6. Their study found that problems improving fine motor skills included a lack of learning media (just pencil/paper activities) and learning methods (Isnaini & Katoningsih, 2021). In their conclusion, they also state that other ways to increase fine motor skills include play, learning planning, preparatory work, the environment, obesity, and the child's motivation (Isnaini & Katoningsih, 2021).  If there is a delay in a child’s fine motor skill development, OT and PT professionals can thoroughly assess each of the discussed components and create interventions to help.

According to the National Handwriting Association (NHA), handwriting is a means of expressing language that leaves lasting evidence; it is a universal skill and an expression of our self-image (NHA, nd, a). It is also a complex skill involving linguistic, cognitive, and motor components that must all be coordinated to produce the final writing product; it is a difficult skill to master(NHA, nd, a). But why is handwriting important? Handwriting is part of our daily lives and is a primary form of communication and transference of information. In recent years, however, technology has changed how we communicate through writing, and many people primarily communicate through electronic writing methods. Still, handwriting with pen and paper is an important skill from early childhood through our adult lives and can be a critical component of many professional careers (NHA, nd,b).

Handwriting starts with scribbling, and the child has fun filling the paper, sidewalk, or surface. Slowly, they are introduced to lines, coloring in the lines and using them as a border. Children then start imitating or tracing horizontal and vertical lines followed by diagonals (left and right), a circle, a plus sign, an X, a square, and a triangle. One can look online and see the expectations for developing writing skills, but there is no magic age; there are ranges. Handwriting comprises many components, including letter formation, line use, spatial awareness, letter size, the ability to grasp and control a pencil, and motor planning for writing (OTTB, n.d., b). Proper development in all of these components is important for proficient writing skills. Seo (2018) found a high correlation between fine motor skills and handwriting, specifically a high correlation between fine motor accuracy and in-hand manipulation that affects handwriting legibility. It was also discovered that students improve fine motor skills through fun activities (Seo, 2018).

Developing handwriting fine motor skills

There are multiple handwriting programs to consider for therapists and teachers. This is not a complete list, as things are constantly updating and emerging. Some people believe in teaching in a specific order for stroke development or for the phonics of specific programs. Over the years, I have tried various programs and methods, and in the end, I am just happy if the school is consistently teaching letter formation to the students in a specific way. To decrease confusion and keep consistent expectations, it is best if the therapist uses the method the child is beginning to be exposed to in school.

• Learning Without Tears(n.d.) is a program developed by an OT. It was initially created to help her son. This web-based, evidence-based multisensory approach supports prewriting in preschool up to cursive.
• Size Matters is a program that an OT started.  This evidence-based program focuses on the letters' size versus the letters' formation.
• UFLI (University of Florida Literacy Institute) is a research-based reading program that also targets teaching letter formation. They focus on foundational skills that promote the development of proficient reading.
• Zaner-Bloser is a writing program that teaches students print and cursive handwriting through a three-step model to teach handwriting.
• Foundations (Wilson Language Program) is an evidence-based structured reading and writing program. It uses multisensory techniques and works with the science of reading program.

Strategies to work on handwriting vary depending on the child's abilities, goals, and grades. Some strategies are mentioned above for strengthening fine motor skills. Other strategies can include:

• Adaptive paper (raised lines, blocks for writing)
• Dictating and copying
• Practice
• Learning cursive
• Movement with letter identification
• Writing
• Completing activities with peers
• Taking turns (teacher or practitioner writes a letter or word, then the student writes a letter or word)

There are multiple ways to teach and engage children in handwriting activities. Remember to keep it fun and intertwine the activities with their interests.

Over the years, the research and relationship between fine motor and handwriting skills have increased. Years ago, school-based therapists pulled students from academics into a therapy room and worked on skills in isolation with no follow through to the student's classroom. The pendulum is now swinging in the opposite direction to therapists integrating into classrooms to support students in academics. Additionally, years ago, therapists wrote discipline-specific goals for students. In 2022, the American Speech Language-Hearing Association, American Occupational Therapy Association, and Academy of Pediatric Physical Therapy published a joint statement about the benefits and strengths of collaborating on therapy goals with the team (Barreca et al., 2023).

Grajo et al. (2020) systematically reviewed OT interventions for increasing academic participation. They found moderate support for interventions that support handwriting, such as practice, self-evaluation of writing, performance feedback, and support for therapeutic practice. There was little support for sensorimotor techniques to increase handwriting legibility (Grajo et al., 2020).

Wiley and Rapp (2021) completed a study looking at the benefits of handwriting practice and how the benefits of handwriting generalize to other activities in adults. They found that the benefits of handwriting training include faster learning, and this learning speed generalized to other activities not writing-related. The authors also found that handwriting practice positively affected written language learning and spelling skills and strengthened reading(Wiley & Rapp, 2021). Similarly, a study involving 173 students in elementary school in the Netherlands found that the more years students write, the more the writing quality increases without intervention (Duiser et al., 2020).

Lopez-Escribano et al. (2022) determined that children with handwriting intervention improved writing fluency compared to children who did not have writing instruction. They also found that students who received multicomponent handwriting lessons made progress (Lopez-Escribano et al., 2022). These articles demonstrate the need for handwriting support from OTPs for students to increase literacy skills, spelling, and written language.

When evaluations are requested, as pediatric therapists, we usually consider a static assessment versus a dynamic assessment (the requirements for testing vary from state to test, so be sure to check with your state requirements). A static assessment is a standardized assessment that “identifies knowledge previously learned” and “provides a baseline from which progress can be measured”(Toglia & Cermak, 2009). For OTPs, this could be the Bruininks-Oseretsky Test of Motor Proficiency-2 (BOT-2), Peabody Developmental Motor Scale, Bayley Scales of Infant and Toddler Development, 4th Edition (Bayley-4), and Developmental Test of Visual Perception, to name a few. These standardized assessments show the child's knowledge at a given point in time. Sometimes, from observations and discussions with caregivers, we know the child has not been exposed to certain activities or experiences, such as pre-writing strokes, etc... A dynamic assessment is a “fluid evaluation process that changes with development and learning” and “focuses on the individual variations and changes”(Toglia & Cermak, 2009). This assessment can show the therapist the skills and deficiencies of the student. For example, it can show OTs that a student can find a specific letter and copy it onto their paper, although they cannot write the letters of the alphabet from memory if given an alphabet chart. Using both dynamic and static assessments can provide OTPs with the missing piece to understanding the child and their skill set.

Spreij et al. (2020) used static and dynamic assessments to consider the cognitive demand on people with visuospatial neglect. They found that some participants did better on the dynamic assessment and some better on the static assessment. This demonstrates the need for both types of assessments and further research to tie static and dynamic assessments into fine motor and writing skills (Spreij et al., 2020).

Some examples of handwriting assessments that are frequently used include:

• The Print Tool - This static assessment was developed by Learning Without Tears (mentioned above has a handwriting program). This assessment looks at the recall of letters, orientation, formation, placement, start, and spacing of uppercase and lowercase letters and numbers. The Print Tool can be used from kindergarten to 5th grade (Olsen & Knapton, 2006).
• The Evaluation Tool of Children’s Handwriting (ETCH) - This static assessment looks at children’s handwriting, both printed and cursive. It looks at copying and writing from memory and legibility and speed. The ETCH can be used on children ages 2 -6 (Duff & Goyen, 2010).
• Schoodles Fine Motor Assessment- This dynamic assessment looks at fine motor and writing skills. The school looks at cutting, prewriting lines and shapes, copying, writing from memory, puzzles, and coloring. The assessment can be used for children three and older (Frank & Wing, 2016).

When performing a handwriting assessment, a practitioner will need to assess the following skills (OTTB, 2013):

• Pencil grip or grasp pattern
• Dynamic finger movement
• Finger, hand, and wrist mobility
• Joint positioning
• Posture
• Visual motor skills, segmental drawing, and line skills
• Hand dominance
• Letter formation
• Size, spacing, line use
• Sequence and strokes of pencil lines
• Fluidity of the handwriting

As you can see, a huge correlation exists between a child's fine motor skills and the ability to write. The effect of fine motor skills on handwriting is becoming more noticeable as young children spend more time on technology.

Handwriting assessment

Some disabilities could affect a child's ability to write, for example, dyslexia and dysgraphia. OT and PTs do not typically assess this since we cannot diagnose and support in school-based practice; this is done through accommodations, observation, interviews with the child, caregiver, and teacher, and assessments (static and dynamic). Speech Therapists may also become involved with some disabilities. A multi-professional team approach can be an ideal tactic.

Billy is a seven-year-old first grader in the local elementary school with an educational diagnosis of developmental delay. Due to fine motor and writing concerns, the OTP has been asked to evaluate Billy. Upon observation, the OTP sees that Billy can hold his pencil functionally; he stabilizes the paper and can easily flip the pencil to the eraser (in-hand manipulation). He was observed completing spelling words, writing, and drawing a picture to go with the word. The writing was large, but there was no top line on the paper, and the drawings were simple, but the therapist knew the words to the picture. The teacher says Billy does not know all his letters and wants the OTP to teach them to him. The OTP asks about the student's reading level, and Billy is not yet reading.

The OTP recommended to the general education teacher that Billy have an alphabet strip on his desk as well as for Billy to have lines when writing to work on the size of writing.

This course has covered a wide topic on a surface level with support from research. Fine motor skills and development are important for the development of writing skills. Writing skills are related to academics and literacy and can affect a student on many different levels, including fluency, spelling, and writing language. It is important to remember to focus on the child, their abilities, and what they have been exposed to educationally. Working as a team in the best environment for the child is important.

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