Occupational therapists are very familiar with handwriting development. Due to the fact that written communication is a significant “occupation” of school-aged children, we see a lot of referrals for difficulties in this area.
I’ve written before about how we assess handwriting when a child comes in for an evaluation, (You can read that post here.) but what comes after that? How do we actually address the issue? Do we focus on the underlying visual motor skills? Visual perceptual difficulties? Poor motor control? Decreased endurance?
Based on the difficulties observed, a therapist will formulate an individualized treatment plan. Maybe we’ll try multi-sensory activities to increase tactile or kinesthetic feedback: writing in different mediums like shaving cream, making letters with plah-doh snakes, or tracing sandpaper letters. We might focus on increasing hand strength or dexterity. We may also use instructive methods to teach letters in groups of common characteristics or writing strokes ala Handwriting Without Tears.
And all of this makes a significant difference, right?
Well, I sure hope so.
I found myself reading a research article the other day, as we all do on a super regular basis, right guys? Right?! I came across a systematic review of handwriting interventions by Hoy, Egan, & Feder (2011). I’m not even going to lie, I dove right in because I found the topic very interesting, and I encourage other OT’s to do the same. It contained some very insightful perspectives on many of the interventions we implement on a daily basis. But for the purpose of this post, I wanted to highlight one significant finding. Something that we take for granted, or inherently know, but forget as we get caught up in our creative treatment approaches.
There was one thing across the board that improved handwriting outcomes. Are you ready for it to blow your mind? You’re sure? Ok, here it goes…
No, seriously. Practice – it improves handwriting.
That means that if our interventions target common underlying skills such as pencil grasp, dexterity, or increased tactile feedback, but don’t provide handwriting practice, we aren’t likely to see direct and significant changes in handwriting.
Now, before I make it sound like skilled treatment isn’t necessary, I’m also going to throw in the idea that there are many factors that can cause a child to avoid this crucial handwriting practice. This might very well be linked to those issues I first mentioned above – their hand gets tired, they have sensory processing issues and can’t sit still, their oculomotor or visual perceptual skills are poor and they can’t see what’s on the paper, etc. This means occupational therapy intervention might be important to improve and increase a child’s participation in handwriting practice by addressing underlying skill deficits.
I also feel as if we try to drill this concept of consistent home programming all the time in our sessions. We know a lot of kids don’t get enough handwriting practice time in school. (This is not to blame the teachers; they have so many things they are required to teach, it makes my head spin.) But if a child doesn’t get that letter formation locked down the first few times around, they might not have a formal chance again.
So, how much practice do they really need, you ask? In their review, the researchers found that handwriting programs required practice two times per week for at least 20 sessions in order to see significant improvement in handwriting outcomes.
That’s just to improve overall handwriting legibility. What about speed? Well, that likely requires even more practice, which makes sense from a motor learning perspective. The more familiar the motor plan, the more efficient it can be, and thus writing can become faster with more practice. So if parents come in week after week telling their therapist, “My child’s handwriting is still messy! And slow!” the therapist needs to ask – what’s the situation in terms of follow through at home and additional practice time?
Would you expect to make big changes in your body by going to the gym just one time a week? What about dieting one day a week? I mean, maybe? Like, a little bit? But the gains you really want to see come from practice. Repeated practice. And likely a little more practice after that. But with most therapy sessions occurring once a week, there needs to be additional practice elsewhere.
In this particular research article, the authors also made an interesting observation that perhaps as therapists, our time should be spent advocating for increased practice time in school. This in itself might reduce the number of OT referrals for handwriting difficulties. Then we could truly weed out who needs the specific skilled intervention and who just needs to practice a bit more. It’s also important because kids these days are more scheduled than ever. They have tons of school homework, extra-curricular activities, and you know, trying to be kids too, I suppose. Adding in extra practice can seem daunting to some families and children, but the gains might just be worth the extra time.
So what’s the take away message? Do your homework, kids.
Hoy, M. M. P., Egan, M. Y., & Feder, K.P. (2011). A systematic review of interventions to improve handwriting. Canadian Journal of Occupational Therapy, 78, 13-25.