What to Know About Scheduling Pediatric Therapy

It’s fair to say there’s a lot more than meets the eye when it comes to scheduling and maintaining productivity in a pediatric therapy clinic. In the name of transparency, let’s discuss a few things that both families and therapists have to consider when making a therapy schedule work.


Finding a weekly appointment time can be challenging:

Therapy is a commitment, and not necessarily a light one, as it typically requires a weekly appointment for an extended period of time. Making sure caregivers can get a child to and from said appointment all while juggling work, extra-curriculars, homework, and sibling schedules can be difficult.

After the initial evaluation, I typically ask when an “ideal” weekly appointment would be. I need to stop doing that, because I often find myself immediately following up with, “yeah, I don’t have that.”

After-school appointments are hard to come by due to their popularity. Often, people will resolve to start their therapy sessions at a less ideal time, with the hope of getting first dibs on a coveted after-school appointment as soon as it opens up. Others might instead opt for a week-to-week schedule, calling in to see what cancellations the therapist has for the week.

I have to note that lately I’m seeing less therapists even offering those after-school hours due to the fact that they have to pick up their own kids or might only work part-time. Some clinics mandate that therapists offer certain later hours, or the extremely rare Saturday time, but these are still difficult to come by.


Many children end up getting pulled from school for therapy:

Therapist schedules are usually slammed first thing in the morning or late in the afternoon. Those awkward middle-of-the-day appointments are great for younger children who aren’t in school yet, or maybe children in feeding therapy that need sessions around meal times.

However, I’ll throw out that I have had some really great sessions with school-age kids mid-day if their parents can swing the hassle of getting them in and out of school. Depending on the child, sometimes missing an hour out of the middle of the day is least disruptive to their academic schedule, and they might be able to return to school with more focus and better regulation.

Others find that missing the last 20 minutes of the day or arriving a few minutes late in the morning is beneficial as well. A talk with the child’s teacher can reveal what part of the day (if any) is easiest to miss once a week.

Some schools are incredibly open to this idea of children missing a bit of their day for an appointment, while others are very particular about students being pulled out, coming late, or leaving early.

I’ve had parents ask if it was “worth it” for their child to miss part of their school day to come to therapy, and I can understand their concern. I’m obviously a bit biased, but receiving direct 1:1 services in the clinic should be beneficial to the child’s overall skill development, and should support the skills they need in the classroom. We just want to make sure it works out so they aren’t missing other important resources in their school day.


5:00 is a dreaded appointment time for everyone:

With only so many after-school hours in the day, the last resort is adding an appointment at or after 5:00.

I’d love to hear if others out there have had consistently good luck with these later appointment times. In my experience, the child is often exhausted, the therapist is exhausted, and the session can turn into a battle of wills. Some older children have done well in this time slot, but overall, it’s a tough time for many children to try to do therapy. These later times should be reserved for those children that can still receive maximum benefit from the timing of the session, which might just be a matter of trial and error.


Transitions between appointments can be tricky:

I promise you that no one can make a mess like a pediatric therapist.  It’s almost as if you look around the room after about 45 minutes and think, “how did this happen?” It seemed like such a good idea to bust out that sensory bin at the time, but now the rice has wedged itself into every available crevice of the room and my next patient is walking in the door.

While trying to clean up between patients can throw off the schedule, therapists might also find themselves jumping from a session with a 6 month old baby to a session with a teenager, so switching gears can take a moment. Some might also be running in the door from a home health visit in the community, or unexpectedly locked in an intense conversation with a parent at the tail end of a session. All I can say is that your therapist will try their very best to stay on the established schedule.


Running behind for one patient sets the whole day off:

When you are scheduled back to back, those run-overs make it difficult to catch back up. Sometimes a parent is late in picking up, or a conversation just goes long. In order to give everyone their fair session, it often means running behind most of the day if the therapist is the one starting late.

However, I think it’s important to throw out that if a caregiver brings a child to a session 15 minutes late, this does not mean the session automatically extends 15 minutes late as well, unless the therapist specifically states they can see the child longer than their scheduled appointment time. This miscommunication has happened on multiple occasions in a back to back scheduling scenario, which leads to unexpected setbacks.


Cancellations can make or break a day: 

Maybe it’s just me, but it feels like cancellations are an “all or nothing” part of my day.  Either everyone comes, or 75% of my day cancels like a domino effect. Some clinics have strict cancellation policies which require that missed sessions are rescheduled, or perhaps a fee is assessed for “no-shows” or last minute cancellations.

To be honest, these policies often work well to keep people accountable for their scheduled sessions. (Not just for our sustainability as a practice, but if you miss a lot of sessions, it’s hard to prove medical necessity to insurance providers.) Although on the negative side, it also leads to a lot of sick kids coming to therapy. There’s nothing worse than little Johnny coughing in your face saying, “I didn’t go to school today because I was sick!” So I encourage people to cancel when necessary, with the intent of making up the session if possible.

And also, while talking about cancellations, I know things often come up last minute when it comes to children, but the more notice you give your therapist that you can’t be there, the more opportunity they have to offer your time to someone on a waiting list.


Un-billable time has to be limited: 

In an ideal world, every evaluation would have a sit-down meeting with a parent afterwards to go through the entire write-up. This doesn’t always happen. Why? Productivity. I’ve seen various expectations of productivity in different clinics, which I’d say average around 75-80%. That means only around 20% of my day can be spent outside of billable treatment hours for things like paperwork, phone calls, parent meetings, treatment planning, set-up, etc. Therapists often find themselves doing a lot of things on their personal time to keep up with the work flow. So if it takes a while for a therapist to type up an extra note or communicate with another therapist, it likely has to do with finding that elusive “extra” time.


Therapists understand the commitment involved in bringing a child to therapy, and regardless of the challenges that can arise from scheduling, seeing the progress from week to week hopefully makes those sessions worth the extra effort!

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Techniques for Coloring in the Lines

Coloring in the lines? That’s so…conformist! Ok, so maybe it’s an important skill when it comes to fine motor control and spatial awareness. Recently, I’ve found myself working on this skill quite a bit, so I went to Pinterest to find a few new ideas to refresh my approach a bit.

I picked three different techniques to try, as outlined below, all of which provide some sort of boundary to reinforce the idea of coloring “inside” vs. “outside” of a shape:

Full disclosure, I have also tried this technique in the past using Wikki Stix to outline the shape, (Remember when I tried to make those myself? Yikes. I can still smell the chemical reaction…) and they provided a similar boundary to the 3D art paint. However, I found the Wikki Stix to be a lot more obnoxious because the kids that applied more pressure to their coloring would send those things flying off the page.

My top pin-spirations (Oh my, is that a word? Is it bad I sort of like it? Let’s move on…) was from a blog called HeyDay Living which focused on trying Montessori techniques at home, and an awesome post from The OT Toolbox about line awareness.

So, how did they work out? Check out this example:

Embroidery Hoop
This was a HIT! The children repeatedly asked if they could try this one again and again. They felt incredibly successful, which makes sense, because this technique provided the highest amount of assistance.

The high boundary of the hoop provided:
-more success staying within the guidelines.
-increased tactile feedback when they hit the edge.
-high awareness of “inside” vs. “outside” the lines.
-an easy edge to grasp with their helper hand for bilateral coordination.

3D Art Paint
Who doesn’t love glitter? Wait, let’s rephrase that: Who doesn’t love glitter suspended in paint that doesn’t get everywhere?

This was another technique that kids were excited to try, simply because it looked so cool. “Do you have more?” they would ask, rooting around my pile of papers. And let’s face it, any time you have a child asking for more repetitions of a challenging skill, you are winning.

Plus, with this technique, you can play around with high or low contrast, trying different paint and paper color combinations until you find the right cue for the child.

School Glue
This is by far the lowest amount of assistance. It’s low contrast, adding just a slight tactile edge to the shape. My heavy-handed colorers burned right through that edge with little awareness. It is best used with those that just need a little cue or increased awareness of the guideline.

These techniques are basically a hierarchy of assistance. I might start with the hoop, move to 3D paint, then on to glue as the child gains control and understanding of the concept, eventually moving away from any additional cues at all.

The downside of using the 3D art paint and the school glue is that you must prep these at least a day ahead of time; that stuff is not going to dry within a session. OR… just dedicate an entire morning to gluing and painting tons of papers, using every available surface of your home as a drying rack, like I did one Sunday. Whatever floats your OT planning boat!

(If you want to check out previous Pinterest Test Pins, click here.)

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10 Realities of the OT Brushing Protocol

If you are familiar with occupational therapy in a pediatric or sensory setting, you have likely been introduced to “the brush.” But how much do you really know about this intervention tool?

1. You’re not supposed to call it “brushing.”

Officially, this intervention is called the Wilbarger Deep Pressure and Proprioceptive Technique, or DPPT. The term “brushing” is supposed to be avoided, because the goal of the intervention is to provide deep pressure, and the creators have noted that “brushing” doesn’t accurately represent that intention.

2. The technique was developed for sensory defensiveness.

The creator of the technique, Patricia Wilbarger, MEd, OTR, FAOTA, is a leading expert on sensory defensiveness. (This is basically when the nervous system over-reacts to stimuli that would not typically be perceived as negative or harmful.) The entire technique takes around 3 minutes, and includes deep pressure input applied to the child’s hands, arms, back, legs and feet, followed by joint compressions to the extremities. This is typically followed up by engagement in “sensory diet” activities.

While the technique was created based on this concept of sensory defensiveness, many occupational therapists introduce the DPPT as a way to provide deep pressure input to sensory “seekers” or those with higher thresholds for sensory input.

3. There’s only one brush officially recommended by the creators.

The Therapressure brush was designed specifically for the DPPT, supposedly for its ergonomic shape and appropriate bristle density. It also tends to make it more expensive. (Of course, anything with the term “therapy” applied to it instantly becomes more expensive.) However, in the reality of practice I’ve seen tons of brushes used other than the official Therapressure brush.

4. You should be taught by someone with specialized training, but that’s hard to do.

One of the most important components of this intervention is applying the “right” amount of pressure, which is why learning in-person is key. However, finding a way to get trained as a therapist is hard to do these days. I haven’t seen consistent seminars offered by the Wilbargers for a long time. However, after some searching, I was able to locate one training seminar… in Ireland. So you might just have to settle for being trained by someone who was trained by someone years ago. (This just happens to be how I acquired my “hands-on” training on the subject.)

5. It’s a high intensity intervention.

The recommendation is to complete the technique every 90-120 minutes of a child’s waking hours. Yes, you read that right. Sometimes that recommendation alone is enough to scare a parent away from trying it. According to the theory, this is the amount of time the positive, modulating effects of deep pressure and proprioception last in the nervous system.

6. Even if you follow the protocol, there are several factors that make it difficult to implement.

There are many nuanced components of this technique. The amount and consistency of pressure, how you move the brush across the skin, how you transition between the arms/legs/back, keeping track of the brush when you take it home… it’s a lot to remember and complete with confidence.

Parents have come to me saying they just couldn’t get their child to engage at home the way we could in a session. Sometimes parents or children have anxiety with the anticipation of applying touch, and the process suddenly becomes a whole big “thing” or source of stress. We never want to force any intervention on a child, especially within the context of sensory integration theory.

We also typically ask parents to try it at the recommended frequency for at least two weeks in order to gauge effectiveness. However, I rarely see follow through for the entire two weeks. Often, if results aren’t seen right away, the technique is quickly abandoned.

7. There are things you aren’t supposed to do.

This is where that whole training thing comes in handy. There are areas of the body to avoid with the brush, such as the stomach or face. Completing the protocol sporadically might cause more issues than it helps. Using too light of touch might actually tickle or scratch as opposed to provide deep pressure. There may be individual precautions due to other diagnoses related to nervous system function. The list goes on…

8. There are many versions or variations online, which is not a good sign.

A quick internet search will lead you to YouTube videos, online tutorials, or various different websites. In fact, almost every OT I’ve ever met has their own DPPT “worksheet” to give parents in order to explain the protocol. And guess what? Every one of those is slightly different. Information is passed between therapists, collected from different settings, and becomes somewhat of a game of intervention “telephone.” For something we describe as a protocol, one might expect more uniformity in the execution.

9. The evidence that it’s effective is virtually nonexistent.

Harsh reality time: The evidence, if you want to call it that, is largely anecdotal. You’ll hear many therapists and parents swear that it works based on their own experiences, but high quality studies just don’t exist. Weeks, Boshoff, & Stewart (2012) screened over 300 research studies related to the effectiveness of the Wilbarger protocol. After a systematic review, their results concluded that there wasn’t “high quality evidence” to support or refute this technique. As therapists that should be relying on evidence based practice, this can raise some serious questions about whether or not we should be implementing this technique in our daily practice without further evidence of its effectiveness.

10. Regardless of the evidence, there is a high demand for this intervention.

This technique has kind of become “that thing pediatric OTs do.” I’ve seen it implemented in every clinic I’ve ever worked in, with slight variations, of course. Some parents come in with the sole purpose of being trained. And in all fairness, as a student, I was simply taught by other trained therapists that it was an effective intervention. However, after many unsuccessful attempts to appropriately implement the technique into home programs, and keeping up with the literature, I’m less inclined to rely on this technique as a “go-to” in practice.

 

Resources:

Weeks, S., Boshoff, K., & Stewart, H. (2012). Systematic review of the effectiveness of the Wilbarger protocol with children. Pediatric Health, Medicine and Therapeutics, 3, 79-89.

Wilbarger, J.L. & Wilbarger, P.L. (2002). Wilbarger approach to treating sensory defensiveness. Section in Alternative and Complementary Programs for Intervention, Chapter 14. In Bundy, A.C., Murray, E.A., & Lane, S. (Eds.). Sensory Integration: Theory and Practice, 2nd Ed. (pp 335-338). Philadelphia, PA: F.A. Davis.

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Pencil Grasp Basics – An Infographic

Considering the fact that handwriting problems are the primary reason for referral to occupational therapy services in school-age children (Schwellnus et al., 2012), I wanted to put together an infographic with a few “pencil grasp basics” to keep in mind. I hope you find the information helpful!

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Why School and Clinic Therapists Can’t Easily Communicate

School is officially back. That means new teachers, new classrooms, new IEPs, and new therapists. It’s also that time of year when parents ask their clinic therapists to “touch base” with their child’s school therapists.

So, how do you connect your child’s school and clinic therapists?

Easy – you don’t.

Ok, ok, so it’s not that cut and dry, but it sure feels like that sometimes, doesn’t it? Allow me to tell you, this communication is not nearly as easy (or helpful) as you might be thinking. While we can all appreciate the theory of why we need to communicate, the real world tends to get in the way of our good intentions.

To give a better perspective on this topic, let’s talk about the basic challenges of this request.

  • Yes, you absolutely have to fill out release forms.

This is not a casual chat. This is protected health information that we are being asked to share and discuss. It might not feel that way when we are working in pediatrics and the education realm, but I frequently have to remind parents that we need signed releases to speak to each other on both ends. There is often a delay in even initiating contact with another therapist while we wait for the proper forms to be signed and returned.

  • It’s almost impossible to get a hold of each other.

School and clinic schedules are basically incompatible. They work the school day, and we are slammed with after school appointments. We could maybe, just maybe, catch each other at a cancellation, or late in the evening. But we often have families to go home to, kids to pick up, and we are constantly just missing each other.

Speaking of schedules, we are both swamped. School therapists are unsung heroes. They carry extremely large caseloads (50 kids a week, anyone?) have meetings, paperwork, and travel time between schools. In the clinic, we are usually scheduled back to back with patients, with a lunch break typically used to cram in notes or paperwork. Finding that time to reach out to someone is definitely a challenge, but it doesn’t mean we don’t try!

All of this boils down to the fact that our communication typically consists of a quick conversation that starts, “I just have five minutes…” or a string of emails returned a few days/weeks/months apart from one another. It’s not ideal, but it’s what we’ve got.

  • There are only a few things we really need to discuss.

To be honest, there isn’t much we need from one another. We are both professionals specializing in our respective treatment settings. We have assessed your child in the setting in which we work with them, and have developed a treatment plan accordingly. So what would prompt a collaborative conversation?

-Specific problem solving.
Maybe there is an area that the child is struggling with in school or in the clinic that we just can’t figure out. Teaming with each other, we might be able to come up with a creative solution, or maybe one of us stumbled upon an awesome and unique technique that we really need to share.

-Prompts/Programs we are using.
This can be a simple report. Are they using Handwriting Without Tears? The Alert Program? Which pencil grip are they using? Any specific adaptive equipment? If we can use similar techniques, it helps the child reinforce consistent concepts across all settings. (Although don’t expect these techniques to always match up, as I’ll explain below…)

  • No one wants to be told how to do their job.

Let’s be honest, this is a touchy subject. I’m certainly not going to call a school OT and tell them what to do with a child, although I have had parents request I do just that. Regardless of a therapist’s approach to teaming with another professional, the very nature of these calls can lead to uncomfortable and defensive conversations which don’t feel productive at all.

There will always be therapists that disagree with each other’s courses of treatment. Some are strictly against pencil grips. Some disagree with certain aspects of sensory integration theory. Some want a child to learn their name in upper and lowercase, some will start just with upper case. It’s the nature of pediatric occupational therapy – there are multiple evidence-based frames of reference to choose from, and there isn’t always a general consensus on the “best” course of action when it comes to many of the areas we work on.

  • We both follow a different set of rules.

By the definition of our practice settings, we work on different things. A school therapist must work on goals that are directly related to a child’s academic performance. In the clinic, we don’t have those bounds. So that means what the school therapist must work on doesn’t always match up with what we are working on in the clinic. The rules are simply different.

With all of that being said, we will still continue to try our best to connect and work together. To my wonderful school OT colleagues, I fully appreciate how hard you work – you guys are amazing. Let’s talk soon. 🙂

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Don’t Miss the “Little Wins” of Therapy

This job is hard.

I realize pediatric therapy is the sort of career that prompts people to say, “Oh wow, that’s amazing,” or, “How wonderful that you help these children!”

I want to say, “Yes, but it’s HARD.”

So many times it seems like we aren’t allowed to say it out loud. Not even just as therapists; I know parents feel the pressure of a similar gag order. Yes, we both love and appreciate the beauty and strength of these amazing kids with special needs. We fight for them. We frantically piece together new solutions when plans A-Z have all fizzled out. We will shut someone down if they even try to underestimate them. But yeah, I think it’s fair to say it’s also really, really hard.

A parent apologized to me the other day because they missed a session when their child had a meltdown. Like a not-safe-to-drive-in-the-car-full-on-dangerous meltdown. And they felt awful for missing a session. I wanted to put my hands on that parent’s shoulders and say, “No. Don’t. Please don’t feel awful for that moment. In fact, can we just agree that that day sucked for you? You’re allowed to say it. It was terrible.”

I’ve had tears in my eyes from a previous patient pinching me, pulling my hair, or biting me, and I have taken approximately three seconds to suck it up and move on. When I was a student, a patient started violently punching me, and as I awkwardly scurried away, wide eyed and stunned, my supervisor caught my attention. He pointed to the hallway and said, completely deadpan, “Go pull yourself together.” That’s what our job entails. Pull yourself together and get going. There are more people to help.

It’s difficult to be present when the challenges of life get you down. When the losses just keep rolling your way. You are supposed to be a superhero. A therapist. A parent. But also? A human being.

Listen, I’m not against positivity. While I fully embrace my cynicism, I find myself leaning on that positivity all the time. I see the absolute awesomeness of what these parents are doing. I see the relentless effort of the therapists I work with every day. But I also want to face plant on the couch some days and just grumble, “Today, I lost.”

Have you read the letter from Abby Banks entitled “Dear Weary Therapist?” If not, I encourage you to go do it now. It straight up made me cry real you get me tears. It is a blessing to meet a parent that just gets it. A parent that makes you feel like we’re in this journey/struggle/adventure together.

So what gets us through day after day without burning out? Those darn baby steps. Not literally, (Although the phrase totally works if you are a physical therapist.) I mean the little wins. I’m not even talking about reaching a formal goal. I’m talking about a baby step towards reaching a goal. A moment that makes you go, “Yes!” Maybe it’s a moment of eye contact, of purposeful play, of holding the crayon correctly for a few seconds, of imitating a phrase, of controlled movement. A moment of, “Whoa, did you see that?”

Have I teared up because a child purposefully handed me a toy in play instead of chucking it at my face? Maybe. Because I was overly emotional? Sure. But man, I needed that win. That moment that charges your batteries. The moment that makes you think, “Hey, maybe I am making a difference.” Most people claim I’m easily amused in life, but I think I’ve just trained myself to be excited about the tiniest of victories.

I am certain we don’t notice those moments enough. That part of a session that shows us we are on the right track. That the work of dedicated parents and therapists and caregivers and teachers and aides are all making a difference. We are so quick to point out the negatives. The things that still aren’t going right. The behaviors. The frustrations. We get lost in the weeds and forget how far we’ve all come.

But those little wins guys, look for the little wins.

Posted in Lessons Learned, Occupational Therapy, Therapy Process | Tagged , , , | 2 Comments

Handwriting Paper: What’s Really Between the Lines?

Handwriting.

You focus on letter memory, formation, sizing, spacing, and line placement.

You try to find the right handwriting program from choices like Zaner-Bloser, D’Nealian, and Handwriting Without Tears.

You make sure a child’s little hand is ready for writing, maybe having some luck after numerous strength building exercises and sifting through different sizes and shapes of pencils or grippers.

But then, after all of that, you still have to think about which handwriting paper to use.

Never fear, my friends. That’s where this post comes in. To be honest, my head is still spinning after trying to put this together, mostly because I know it’s nearly impossible to compile a complete list of all the different types of handwriting paper out there. Occupational therapists are creative people, and always seem to be coming up with new ideas. Every time I thought I was done, I’d think of another, or run across something new online.

(FYI – I added a few links to actual examples of handwriting paper below. It’s just a random assortment of websites to give you a better idea of what I’m talking about. I don’t have have any affiliation or receive anything from the sources I’ve linked here.)

So here’s my attempt to familiarize you with most of what’s available.

Why?

As an OT, it is pretty important to know what type of paper a child is using at school so that I can better cue them in our sessions. Using primary writing paper at school and Handwriting Without Tears paper in sessions can be a bit confusing, as you’ll see why. Plus, choosing a specific type of paper can assist a child in targeting certain handwriting errors.

  • Primary writing paper:

Ah yes, the classic – 3 lines with the dash in the middle. A natural progression from big, wide lines to smaller, more narrow lines as the child moves through school and works towards switching to regular notebook paper. I’m sure you’ve seen these handwriting lines on copies of school worksheets or writing journals. As you’ll see below, these lines can be modified in many different ways in order to target certain handwriting errors.

  • Narrow Lines / Midline shift: 

When children are attempting to make that switch over to notebook paper, they really need to learn how to make their letters much smaller; hence the narrowing primary writing lines as children get older.

Some handwriting paper (Like the adapted notebook paper used in the First Strokes program- here.) even shifts that dashed midline down a bit for older children in order to avoid filling the entire space between notebook lines. 

  • Color cues for placement:

These colors provide a simple visual cue for line placement, letter sizing, and even letter starting points. Green for “go” and red for “stop” might help the child fill the lines appropriately so the letters don’t float in the middle, above, or below the line when they aren’t supposed to. (Fundanoodle makes a handwriting paper that uses these color cues, but I usually find myself using red and green markers to draw over the lines of regular paper.)

  • Raised lines:

With raised line paper, a child can actually feel the boundaries they are supposed to be bumping into. This is great for kids who need more of a tactile cue than a visual cue. You can find this paper in primary handwriting lines, as well as regular notebook lines. (Mead makes a reasonably priced option which has been fairly easy to find at places like Target.)

  • Highlighter cue:

This is one of the easiest ways to work on line placement and letter sizing. Yes, there is paper available to buy that comes pre-highlighted, but the cue is easy to apply to almost any paper you are using. (You can find an example of the “official” stuff here.)

  • Sky/Ground/Dirt visuals:

This is a good time to talk about cues we give children for sizing their lower case letters. There are tall letters (b, d, f, h, k, l, t) that touch the top line, there are short letters (a, c, e, i, m, n, o, r, s, u, v, w, x, z) that typically go under the dashed line, and then whatever you want to call the hanging/dragging/in the dirt letters (g, j, p, q, y).

Paper with the sky/ground/dirt visuals comes in handy when discussing these letter sizes and placement. You can tell a child the tall letters go up into the sky, the short letters go on the ground, and the hanging letters go down in the dirt. This usually makes the process more fun, especially if the child is resistant to handwriting. That way if “g” isn’t going past the baseline, you can point out that he needs to go hang out with the worms in the dirt. You know, usual handwriting conversation.

Again, you can do this with your own markers (are you noticing a trend here?) or buy the paper with the decals already applied. (Smart Start makes one here.)

  • Targeted areas:

There are several different paper styles that work to highlight target areas for letter sizing and placement.  In this example, there is a highlighted space in the middle with blank space above and below, which makes it similar to the sky/ground/dirt paper, just with different visual targets. (Find an example here.)

You’ll also notice the sizing between rows usually starts very large for most of these examples, which assists children in limiting the amount of visual information they are processing at one time.

Regular notebook paper can be overwhelming for a child trying to accurately scan and keep things organized on the lines. Skipping a line, or highlighting every other line can help them sort information more effectively.

  • Grid lines for spacing:

While most of the paper mentioned previously attempts to assist children with letter sizing and placement along the line, this paper is more focused on spacing between letters and words. Some people just use regular graph paper for this purpose (which is also great for aligning math problems for children with visual-spatial difficulties), but there is, of course, commercially available paper. (Find an example here.)

In order to fade away from this high level of support for spacing, I will often switch to a “Space Man,” which is just a decorated popsicle stick that kids can place between words to make sure they leave enough space. Also, you can use the analogy of spaghetti spaces (between letters in a word) and meatball spaces (between words), as you shift away from the grid paper.

I was also just recently introduced to LegiGuide paper, which is a combination of grids lines and highlighter cues together.

  • Handwriting Without Tears progression:

Handwriting Without Tears plays by its own rules. Which can be great, or a little more difficult to merge into other programs. They start with Pre-K pages that involve tracing, and then work into grey blocks which assist children in sizing and correctly orienting their upper case letters.

Once they progress to lower case letters, they use two lined paper, but not like a typical notebook paper. In this program, those short letters fill the space between the two lines, with tall or hanging letters emerging from the top or bottom of the lines. I find that this makes sense to children as they learn lower case letters, since their typical urge is to fill the entire writing space given to them.

This program then fades the top line to a lighter grey, eventually moving the child to writing on a single baseline. I sometimes find it a little bit more difficult to transition into regular notebook paper with this program, so I might use something in between, or fall back to the highlighter cue for children that are having trouble.

  • Regular notebook paper:

With any of this paper, the ultimate goal would be to wean the visual/verbal/tactile cues down until the child can write on regular lined paper without any additional cues. We would call that process remediation. Or, you can use any of these papers as a compensatory method for a child that knows their letters, but maybe just doesn’t attend to guidelines. It depends on the child, their treatment plan, and what their therapist is focusing on at the moment.

I know there are still others out there, as well as several variations or combinations of the cues I’ve mentioned. Be sure to leave your experiences in the comments below for others to see! Happy writing!

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