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Handwriting: Are you using the best approach for those students with executive functioning difficult

Occupational therapists working within the school setting and environment receive a large amount of referrals for students due to poor or illegible handwriting. It is important for school-based occupational therapists to have a strong understanding of the complexities and processes involved in handwriting. Often times teachers and other personnel within the school assume poor handwriting is the result of fine motor, visual motor integration deficits, or an improper grasp. At times it can be any of those things; however there are often times that poor handwriting legibility is the result of multiple factors that can include attention, planning, organization, language deficits, visual processing difficulties, and/or a lack of handwriting instruction. So how do we address these other areas to improve our student's access to classroom work that requires handwriting?

Anytime we are pulling students from their educational setting it is important to justify the need for the services and be sure we are supporting the child’s occupational performance in the least restrictive setting. We as occupational therapists need to be utilizing an evidence based approach when we recommend services or provide treatments for students. This means utilizing the most effective tools and efficient strategies to improve the student’s handwriting to meet the performance demands of the classroom.

So, in an age of technology why is it that we are even focusing on handwriting as a skills necessary for classroom performance? Handwriting Without Tears conducted a survey in 2013 that indicated that anywhere from 23 to 58% of classroom tasks require handwriting in elementary grades K-5 indicated that handwriting is utilized frequently as a means for students to express their knowledge and convey meaning during their school day. Development of fine motor and visual motor integration skills can be refined through the occupation of handwriting. Handwriting instruction is essential as it is a necessary skill to have when participating in the classroom setting.

The occupation of handwriting, it could be argued, is a form of "language". As handwriting skills develop writing becomes automatic and the student is able to express their ideas without much thought as to letter formations or even the spelling of words. Handwriting in school-age children becomes reinforcing for learning new information and is an essential component of literacy skills as often times reading and writing skills are linked. Handwriting helps to reinforce learned concepts and once habituated is the most efficient and effective tool for language expression apart from speaking.

Handwriting skills are a valuable skill as an adult as well. We view good handwriting as a sign of intelligence Handwritten notes convey emotion and connection better than receiving a typed email. Writing notes can help with memorizing information or reinforcing learned information.

One of the teachers I work with provides printed paper and stationary for students to write handwritten notes to each other on. This helps with communication as well as provides the students for expression maybe when they are unable to verbally communicate. Writing things by hand can allow the writer to slow down and analyze their emotions and thoughts. This is why when people journal it is often handwritten in a notebook.

When we view another’s writing we are likely to make assumptions about their intelligence based on the style of writing, grammar, and spelling. Therefore, it is important for students to develop writing skills that reflect their ability level. When writing is impoverished in a student’s classroom performance in many areas. Self-esteem, behavior, and confidence can all be impacted by handwriting difficulties. Students may begin to avoid writing tasks, have difficulty attending, or act out when tasks that required handwriting are presented. It is important to address the root cause of handwriting if this is the case in order to help the student better function within the school setting.

Handwriting difficulties may or may not stem from fine motor control difficulties. Some research has shown that the pencil grasp of a student may not even have an impact on the handwriting. At times it is processing, planning, and language difficulties that play a large role in the student's ability to perform classroom tasks that require handwriting. Think of those students who demonstrate functional fine motor skills but their handwriting is extremely poor. These students often times demonstrate difficulties related to executive functioning skills such as attention, planning, and organizational skills.

Difficulties in executive functioning skills can greatly impact the legibility, fluidity, and speed of a child's handwriting. Once a child with or without poor handwriting becomes older handwriting legibility will decrease as the student is writing for composition and getting their ideas onto paper more so than having the focus of handwriting tasks be on the legibility or spelling of words. If the student has not had consistent handwriting instruction it is going to impact their handwriting legibility all the more and past grade 3 it becomes nearly impossible to impact handwriting legibility in most students regardless of their fine motor or visual motor integration skills.

The instruction on a consistent program and practice develop the muscle memory early on in school (preK through 2nd grade) allows the student to develop functional speed and fluidity for writing. If handwriting instruction throughout these years is not implemented with fidelity and consistency students with difficulties in attention, planning, and organization will struggle all the more in performing the majority of classroom tasks as they get older as they have not developed the foundational skills. It is up to us as the occupational therapists to decide what is the best strategy for students with handwriting deficits to access the demands of school/classroom tasks. I often times do not receive referrals in time to correct poor handwriting habits and am force to come at addressing illegible writing in alternative ways.

Recently I had inherited a student who had an academic IEP goal that he was having difficulty meeting. The goal was written by his classroom teacher and sounded something like this:

Student will legibly write arguments to support claims with clear reasons and relevant evidence gathered from text in 4 out of 5 trials with 70% accuracy.

Now I know this is not a measurable goal, but as I said I inherited this student.

This goal has multiple layers and components. The students demonstrated difficulties with self-regulation, attention, and organizational difficulties. Motor skills were all functional and within the average range on the BOT-2. He had significant deficits in auditory processing as well as visual processing skills. His handwriting was illegible and he had a history of significant behavioral difficulties and anxiety related to school-environments. He had been in school inconsistently throughout his elementary age years therefore he never received consistent handwriting instruction. Parents main concern was his ability to read and write. His verbal ability was far more advance than his writing skills could convey. Parents were aggressively insistent that he improve his handwriting legibility. When I had him write the alphabet from memory he was able to legibly write each individual letter and perform near and far point copying with excellent legibility. He had little carryover of legibility when writing in classroom work or when writing from his own thoughts. How would you approach this case? Do you think his handwriting legibility could be improved? How? Would you begin keyboarding skills?

Let me tell you how I addressed this. I first established a true baseline of this student's ability level when it came to overall writing skills with the classroom teacher. He was unable to form a sentence nor understand written sentence structure. He was able to speak in sentences and seemed to have a more complex understanding of ideas when he was able to express them verbally. He was also reading at a first grade level. I decided to not work on fine motor or visual motor integration skills as these appeared to be functional and average. I instead broke down the task of composing a paragraph on a topic via task analysis and introduced a linear (top to bottom and left to right) graphic organizer as well as a series of sentence frames and began to instruct the student on prewriting strategies. Once he was able to get his flood of ideas out without regard for grammar, spelling, or legibility he was able to then follow the graphic organizer and sentence frame to write sentences and a paragraph legibly onto college ruled paper with just a dotted line for letter placement legibly.

It is important for occupational therapists to break down the classroom task being impacted by handwriting before jumping to motor skills, visual motor integration deficits or even sensory processing in order to understand what it is impacting the student's performance. Had I focused on self-regulation or visual motor integration/processing I would have missed that what was mostly impacting him was his ability to break down a writing task and complete each individual step. He there for would write limited ideas and phrases versus whole sentences. I believe over time the supports of sentence frames can be reduced and he will develop the independent use of graphic organizers to organize his ideas. Building capacity with him with tools and strategies for organization of ideas and collaborating with the teacher on ways to break down composition tasks to his independent ability level will give him the greatest therapeutic benefit from OT services and improve his handwriting legibility which was the main area of concern for teacher and parents.

As occupational therapists we may get referrals for odd pencil grasps, poor penmanship, and difficulties with fine motor skills it is our job as the occupational therapists to look to the functional performance of the whole student. Next time you get that referral for extremely poor penmanship think outside the box. You might find that relying on those good old task analysis skills may be just the ticket!

What ways are you helping your students with executive functioning skills and difficulties? What strategies have you found success with in the classroom? Please comment and share on Facebook or Twitter to keep the conversation going!

Thanks for reading! Come back soon!



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