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Handwriting and Dysgraphia (and Visual-Perception too)
The bottom line:  how to work on improving these skills

What is Dysgraphia?

Very simply, dysgraphia means difficulty producing legible handwriting in the absence of intellectual impairment. Here is a link to the Wikipedia article on it. There are a couple of types, which boil down to motor problems or visual-perceptual problems. It is often suggested to differentiate the motor from other types through finger-tapping speed, but I don't think that is necessarily the best way. I think once you understand the background of fine motor skills and visual-perception difficulties, dysgraphia just beomes a fancy word for summarizing some combination of these that make handwriting difficult.

Motor versus Visual-perception and handwriting:

The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI-5) is a commonly used tool for occupational therapists who work with school children. It has a main part and two supplements, and the supplements are designed to tease out whether difficulties copying the forms on the test (circles, diamonds, crosses with arrow tips, and the like) are due to motor or visual-perception difficulties. Taken to the extremes, a child with only motor problems would be able to see and understand clearly the details of each form, and to see their own errors, but could not physically control the pencil to make accurate lines to replicate the forms. The lines may instead by wobbly or wavery. Or the child may be unable to slow his or her movements (as in a child with attention deficit hyperactivity disorder [ADHD]), instead of dashing off hasty and inaccurate lines. Or they may be unable to figure out what direction to move the pencil to make the curves and angles that they can see (see motor planning). 

Motor skills are remediable through practice in many cases. If someone has weak muscles in their hands, those can be strengthened. If they have developed poor grasps as a habit, that can be addressed. Practicing controlling a tool will improve accuracy with that tool (think tennis, wood working, or playing guitar). Motor planning difficulties are a little more complex, but there is evidence that this area can be improved through remediation, especially before adolescence.

Meanwhile, a child with purely visual-perceptual difficulties would be able to trace lines with accuracy, but they would not see or understand the details of the forms. They may copy a triangle as a lumpy circle and not see any difference, or make all their letters different sizes and with no spaces between words and not understand why the teacher is correcting them. They may not "see" the writing lines on the paper and may copy a sentence as a string of letters  that get bigger and smaller and wander around the page. They may have visual memory problems and not be able to recall what each letter is supposed to look like.

How can we address weak visual-perception skills in school?

Visual perception is a cognitive skill, like language processing, verbal memory, or problem-solving. Children with poor visual perceptual skills often also have difficulty with mathematics beyond memorizing math facts. A subset (or overlapping set?) of visual perception is visual memory - holding an image in the mind's eye and being able to retrieve an image when needed. 

The usual approach to visual perceptual problems is to work around them, not to try to improve them.  In the 1960s and 1970s it was thought that practice would improve visual pereception. There was a spate of materials produced where children identified the missing part of a picture or tried to match what a shape would look like if it were flipped upside down. In the end, research found that children got better at the very specific subtasks of these workbooks, but that it did not carry over to real world situations such as speeding up their copying of letters and numbers, or being able to find objects in a jumbled background.  I don't want to be taken as saying that there is no point in learning materials where children manipulate objects in space (Tangrams, block design puzzles, measurement blocks, etc).  Of course learning about visual-spatial concepts and the visual characteristic of the world around us is important and is developmental. But when visual-perception is an area of weakness in a person, it will not become an area of strength through worksheets.

Several people have contacted me to ask for a reference for the statement, "visual perception cannot be remediated through practice." I have not been able to find any peer-reviewed study that comes to this conclusion. If anyone knows of one, I'd love to have the reference. This was information that I gained from class and other lectures, and it makes some sense if you logic it through. However, I have recently been looking at information about a resurgence of educational programs that break down practical skills into bits of cognitive function and then trains for those isolated functions, such as the Arrowsmith School in Toronto. This program, for children with average or better intelligence but specific learning disabilities, has children spend a significant amount of time each day engaged in what seems to be nearly meaningless busy work, such as tracing nonrepresentational figures over and over, in order to improve specific brain functions. You can read more about this program in the founder's book, The Woman Who Changed Her Brain. It is also featured, along with Fast ForWord, and other approaches that seek to change neural pathways in specific sub-skills, in the book The Brain That Changes Itself, written by a psychiatrist.

SO, having re-thought all of this, here is my current thinking on it: the brain is plastic, you can learn new skills and improve old ones all the way through your life, and that could well include underlying processes such as perception of visual information, auditory memory, visual memory, etc. There is a better chance of being able to do this if other brain processes are strong (high overall intelligence), if the material is interesting and/or motivating for the individual, and if some serious time and attention is given over to that skill. For example, if you are not musically inclined, with some serious effort and time you could train your ear to hear pitches more accurately, your hands to play an instrument, and your body to move to rhythms. Meanwhile, if we go back to visual perception as a weakness in handwriting, does it make sense to put other learning on hold in order to devote the time and energy to improve that specific area? Less time on reading, content area in science and social studies, mathematics, social interactions, etc. In some cases, that may be the thing to do (see again the Arrowsmith School information, above). But in most cases, being able to size, space and place letters accurately on writing lines is not the top priority for the students we will be seeing. Getting the information down on paper so that they can study and learn it, work math problems without misaligning numbers, and telling what they know through written language is going to be the point of their time spent in school.

THEREFORE, weaknesses in visual perception are usually addressed by working around them. This can be done by enhancing cues for visual/spatial elements. That means:

Vision therapy:

If you find that a child with whom you are working seems to have some visual compromises, you may want to consider referral for evaluation to a developmental optometrist (not a standard optometrist or opthalmologist) for vision therapy. Vision therapy is a bit controversial and is not a service that most schools will cover as part of services per se, but if you are interested you can learn and carry over some of the exercises for visual-motor strengthening.

The term vision therapy is used by different practitioners to encompass different things, much like chiropracty. Within the more straight-forward interpretation, the one that health insurance will sometimes cover, vision therapy addresses muscular weaknesses (and some associated neurological processing) that can really make trouble. Since we do so much of our learning and taking in of information through vision, having double vision, difficulty shifting focus between two places, focusing on things at our midline or at our peripheral vision, etc., can lead to severe problems with learning (especially learning to read and write). Important to know is that vision therapy works on aspects of seeing that are NOT acuity (meaning ability to see near and far, such as would be corrected by glasses). Prime suspects: children with low muscle tone.

Signs to look for that may indicate problems that could be addressed by vision therapy: covering one eye or turning head to block vision from one eye when reading/writing, tilting head to look at things often, lots of blinking and/or head shaking with visual work, unable to track a ball or other moving object with eyes. There are lots of other signs to look for and some things you may be able to do in treatment. Often, balance and vestibular processing appear to be involved. Here is a link to the office of some eye doctors in my area that have a good reputation. Their website will explain what all of this is about in much more detail.

Also, I have been using this book, Developing Ocular Motor and Visual Perceptual Skills by Kenneth Lane, OD, FCOVD with some of my clients. When there is a definite difficulty in eye tracking, such as eyes get "stuck" at midline, I incorporate some of this before working on visual-motor tasks. I can tentatively say I think it has made a difference for some students. One boy's eye tracking improved and his reading level went up 2 grade levels in 1 year. Of course he was also receiving reading remediation and speech and language therapy at the same time, so who knows?

There is also Astronaut Training by Mary Kawar through Vital Links, but I don't see how you could implement this in most school settings. You need a spinning board, music player, and time.  I used it in a clinic and again saw small increases in eye tracking and balance skills.

How can we address weak fine motor skills in school?

OK, here's the thing:  I have long pages on this site on how to work on fine motor development and why it is important for skilled use of the hands. However, when working in the schools people often want the "real problems" (usually sloppy handwriting and cutting) "fixed" right away.  Unfortunately, in most schools today purely developmental skill work has gone by the by. If you can't test it, it doesn't get worked on, and buttoning and lacing (not to mention social skills) are not on the test.

Plus, there is the evidence that pencil grasps don't directly correlate to handwriting legibility!  Research is pointing to less of a connection than OTs have historically touted. Here is a link to the article that made many of us throw years of handouts, theory, gripper and favorite activities for pull out therapy out the window:
Effect of Pencil Grasp on the Speed and Legibility of Handwriting in Children.
More likely there is a common issue behind poor grasp patterns and poor handwriting skills.

So even given that it is a valuable thing to remediate underlying fine motor weaknesses in children who have them, how do we do that effectively AND work on the specific skill needed?  I typically work with children once or maybe twice per week. I can spend that whole time doing fun activities that target that child's exact fine motor weaknesses, but the carry-over to classroom tasks may or may not happen without direct coaching too.  Most teachers past Preschool nowadays aren't going to devote any class time to playing tic-tac-toe with tongs or flipping pennies. As we all know, doing an exercise once a week is not going to do very much in the way of strengthening weak muscles and motor planning of those smaller muscles, let alone improving specific handwriting/cutting/coloring/drawing skills. Unless parents are going to step in and work with children at home with provided exercises and activities, or the child will do them on their own, they probably aren't going to get done.

The solution:  find some "exercises" that can be worked into what the child is doing in class anyway.  If they are in Kindergarten or 1st grade, the teacher will most likely be happy to adopt some small group activities into center times. Instead of tic-tac-toe, bring in some tongs and cottonballs and a number line to practice counting and  addition.  To learn about measurement, use eye droppers and a measuring cup to move colored water. Encourage the use of an easel during art activities. For older grades, have children do some written work with the paper up on the board or wall. Use play-doh or wikki-stix to learn the parts of a plant. If there is a fun enough and portable activity, children will *sometimes* do it on their own. I often send home tennisballs with "mouths."  (make one here)

Do students really need to learn correct pencil grasps?

I hate to say it, but we fine-motor-working-on OTs get made liars of every day.  Walk into any 5th grade classroom and you're going to see a variety of odd pencil grasps; fingers wrapped around pencils, pencils sticking out at strange angles, wrists bent down painfully, and so on. Pencil grasps don't get taught in most schools. Most teachers don't learn how to teach handwriting, let alone pencil grasps. And I'll bet that the neatest handwriting in the class does not come from the girl (it's almost always a girl) with the "best" pencil grasp.  So, does pencil grasp, arm positioning, and trunk stability really matter for handwriting?  Yes and no. There are many people who have developed lovely handwriting despite an atrocious grasp, and students with good grasp patterns and poor handwriting. I suppose it's akin to playing an instrument well despite not holding it the way you are really supposed to. And again, here's this article that found no correlation between grasp and legibility!

BUT, if you are working with a child whose handwriting is illegible, AND he or she has a poor pencil grasp, AND you think you can get them to change it, then that is one obvious place to start. There are some specific handwriting problems that can be linked directly to grasps. For example, r's that look like v's and a's that look like u's are because of difficulty rounding over the top of the letter and usually go with a thumb-wrap grasp, where the thumb isn't free to move.  Basically, I think it's worth a try with younger students, those who are motivated to change their grasp, or those where it's easy (a gripper or adaptive pencil does the trick quickly and easily).

Here is a link to a page with pictures of different poor grasps and what they are called.

For the quickest results, try pencil grippers or adaptive pencils. The little squishy tubular ones that you see everywhere? Useless for actually changing grasps. When you introduce a gripper to change the way a child holds the writing tool, remember it is going to feel awkward and probably "mess up" his or her writing for a while. A good way to work through this is to only have them use the gripper for fun activities for the first week or two - give them a stash of dot-to-dot's, mazes, my pencil obstacle courses, or coloring or drawing if they like those activities. Have them use the gripper for 10-15 minutes a day on these activities, then work it into writing.  I tell the kids who say, "I don't need this," that they only need it until they can hold the pencil better without it.  On the other hand, there are always 5 students nearby who ask when they will get a gripper too. Sometimes I capitalize on this by loaning a gripper to the neighbor student so that the targeted student doesn't feel separated out and embarrassed.

My favorite grippers and the problems they address:
Recommended Gripper or Tool
Thumb wrapped over index finger A gripper that puts a divider between thumb and index fingers such as the StartRight, Crossover, or Grotto
Student has adequate strength and fine motor skills but needs a "reminder" of how to place fingers Stetro or Solo
Unable to separate two sides of hand. Have the child spend a few minutes a day writing with something small held under the pinky and ring fingers, such as the Handi-writer set up.
Base of thumb joint is very unstable, and/or grippers just don't seem to make a difference: Teach an alternative grasp, known as "stenographer's grasp," shown here with a gripper too. Now a Y-shaped, or wishbone mechanical pencil is widely available for this grasp. It is called the Twist'N'Write (scroll down). I am finding it VERY helpful with many of the children I work with.
Weaker hands that just have a hard time controlling a pencil without a death grip:
The Pencil Grip or The Pencil Grip Jumbo  provide bigger surface areas. A fat pencil, like the ones we had when I was in Kindergarten, does the same thing to a lesser extent.  Many mechanical pencils now have built-in triangular and "fat" grip areas (the PhD Pencil, for example).
All fingers are on the pencil, which limits circular movements, and pencil is held straight up and down or even angled away from the body.
A Handiwriter pulls the pencil back into the thumb-index webspace. Usually I combine the use of one of these with a pencil gripper to help correct finger placement at the same time. Sometimes you need to add a pompom under pinky & ring too.
Pencil Pal rings and other ring grippers do the same thing.

Assistive technology/alternative means of writing:

There is definitely a place for assistive technology in writing. We have been using typewriters and computers for a long time now, and many of us are much faster and more legible when typing. It is much easier to edit your work on a computer than pencil and paper (rewrite!).  Parents and teachers are often resistant to "letting" a child type rather than handwrite, because they don't want that child to fail to ever learn to write legibly. That is a valid argument. This is usually my approach:  when a child has gotten to a certain age, say 3rd or 4th grade, and his or her handwriting is not functionally legible (say less than 80% is legible to others), or it takes so long for that student to get things down in writing that he or she could easily dictate, then it is time to look at keyboarding.  Not every written task needs to be done on the keyboard, however, so that handwriting practice is still taking place. 

Common sense:  those writing tasks that don't simultaneously require speed and writing and thinking about what you are writing can be a good way to practice BEST handwriting.  For example, copying spelling words three times each.  While taking notes from a teacher's lecture where keywords are written on the board and you have to keep up with the discussion AND get those words down so that you can remember why they are important and study for the test later?  Provide a copy of the notes from teacher or another student, or let the child who can type quickly use an Alphasmart portable keyboard (they no longer make these; I buy them used on ebay or Amazon).  A test where essay responses are required?  Are you testing what the child actually knows about the subject, or are you testing how quickly and neatly they can write?  You may want to allow them to type again, or to give short answers or even dictate to a scribe.  Many teachers will allow extra time, but if handwriting is laborious and difficult a student will still often shorten the answer, rather than telling all that they know,  to avoid writing as much. All of these accommodations can be included in an IEP.

Here is a compromise that I often propose to educational teams when they think that the student COULD do better than they usually do in handwriting:  allow keyboarding for longer responses, and spend time teaching the child to type up to speed (a 5th grader should be able to produce familiar written work at about 50 letters per minute, or 10 words per minute).  At the same time, pick one assignment a day or a week and tell the child that he or she is expected to use his or her best handwriting on that assignment. If it isn't up to the teacher's standard, that student will be expected to do the assignment again until it is.  Of course, if the student is trying very hard and just cannot write neatly, this is cruel and unusual punishment and the adults in that child's life need to be made to understand that and encourage the child to use other means to produce things that other people will be expected to read. 

Tips for teaching handwriting:

As I mentioned above, most educational degree programs barely address teaching handwriting. In most of my school districts, there is no county-wide handwriting program. Different schools have adopted different programs, and in some schools there isn't even a standard - each teacher has to choose her own materials for teaching. Many people use D'Nealian or Zaner-Bloser. There are a zillion different workbooks and sets of teacher's materials.  Lots of OTs like Handwriting Without Tears. It was designed by an OT and incorporates a lot of good approaches that have been found to work well. There are some things about that program I don't like - such as the formation of some of the numbers. And I don't agree that the little pencils are right for all younger children. Mary Benbow designed a program called Loops and Other Groups for teaching cursive, and I like it much better than the Handwriting Without Tears cursive books.

There are lots of other programs out there. The Sensible Pencil, First Strokes, and Big Strokes for Little Folks are three that I have no personal experience with, but have heard other OTs say they use them. The last one (Big Strokes) is specifically remediable and for working one-on-one with a child.

I think that just about any handwriting worksheets (or even just blank lined or unlined paper) can be used to teach handwriting, given the right approach. The thing is, even if you have the best workbooks for students to work from, they still need instruction and correction that actually helps them.  It is hard to correct the three different ways that three different children are mis-forming a letter within a group of 22 that you are simultaneously teaching.  I really like to co-teach with a teacher in a whole Kindergarten or 1st grade class, where you have more ability to "catch" the poor habits before they form.

Here are the characteristics of a handwriting teaching program that I find most successful:

Multisensory.  Everyone has heard this, but what does it really mean?
Developmental approach
Group the letters by initial strokes

Work letter writing practice into reading work

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