Dyspraxia: Is it the hidden handicap?

Dyspraxia:  Is it the hidden handicap?

by Katherine J. Collmer, M.Ed., OTR/L

Dyspraxia, most concisely described, is a learning difficulty that “possesses the most interesting ‘melting pot’ mix of physical and mental characteristics.” (Patrick 2015 p. 11)  Once called a “disorder of sensory integration by Jean Ayes in 1972 and then labeled as “Clumsy Child Syndrome” in 1975, dyspraxia continues to be a confusing condition to classify.   The terms “Dyspraxia” and “Developmental Coordination Disorder” are commonly used interchangeably, however, it is felt by some professionals that they are not the same condition.  Dyspraxia is defined by the Dyspraxia Foundation USA as “a neurological disorder throughout the brain” that often comes with a variety of comorbidities, the most common [of these being] Developmental Co-ordination Disorder (also known as DCD). (“1 in 10 Odds”)  The UK branch further explains that “while DCD is often regarded as an umbrella term to cover motor coordination difficulties, dyspraxia refers to those people who have additional problems planning, organising and carrying out movements in the right order in everyday situations” and can also experience difficulties with “articulation and speech, perception and thought.” (“What is Dyspraxia,” Section “What is Dyspraxia?”)   Alison Patrick, in her book “The Dyspraxic Learner,” stresses that “the significant role that the mind plays in this condition cannot be underestimated.” (Patrick 2015 p. 17)

Developmental Dyspraxia, the term more commonly used to describe the developmental problems observed in children who are clumsy, describes the condition as “a failure to learn or perform voluntary motor activities despite adequate strength, sensation, attention, and volition (Missiuna & Polatajko, p. 620)”  It is felt that the term was chosen as a result of the belief that a link existed between apraxia and dyspraxia.  Due to the lack of empirical data that shows a causative link between apraxia – the condition that involves “the loss of ability to perform previously acquired movements” most commonly observed in adults who have experienced a cerebrovascular accident resulting in brain damage – and the problems of children who have the symptoms described above, the condition is often labeled simply as “Dyspraxia.” (Missiuna & Polatajko 1995 p. 620)  The roots of this confusion over labelling stem from two facts:  first, that there is no internationally agreed upon definition for the term “dyspraxia” and second, that the DSM-V does not list it among diagnosable conditions.  Instead, it is felt that dyspraxia would most suitably fall under the new reclassification of “Neurodevelopmental Disorders-Motor,” as some consider it a developmental coordination disorder (“Highlights of Changes”).  Steinman, et. al. make a further distinction that developmental dyspraxia should be considered in terms of praxis “rather than a diagnostic label” and referred to instead as “a specific neurologic sign of impaired execution of skilled learned movements. (p. 5)”  The authors stress that it can exist in children who demonstrate no other signs of neurological impairments, as well as in conjunction with other neurodevelopmental disorders such as autism and language disorders.  After all the discussions have been heard, it is not difficult to imagine a more fitting label than “the hidden handicap.” (Udoh & Okoro 2013, Kirby 1999)

It is difficult to estimate exactly how many children are affected by DCD/Dyspraxia due to the lack of an official diagnosis and consistent use of behavioral information to identify them.   However, 2009 study results out of the UK “suggested that up to one in every 20 children between seven and eight years of age may be affected by the condition to some degree.  It is felt that the disorder occurs three or four times more in boys than girls and that the condition “sometimes runs in families.”  (Developmental Co-ordination, Section “Who is affected).

Despite the confusion, understanding developmental dyspraxia remains an important concern for occupational therapists who are often presented with referrals for children who have handwriting difficulties, problems with self-care management, and social isolation that results from their clumsiness and uncoordinated behaviors (Missiuna & Polatajko 1995).  Without a clear definition for dyspraxia nor a diagnosis that outlines the symptoms associated with it, our assessment will be based upon our knowledge of the condition itself.  Children who present with these school-, home-, and socially based needs will appear physically capable, will not have intellectual needs, and often will not have any identifiable disease or medical condition.  Since dyspraxia is a developmental condition, it can present itself in the early years as children meet the prescribed developmental gross-motor milestones late and experience difficulty with fine-motor activities of daily living, such as tying their shoes or fastening buttons, very much like developmental coordination disorder.  From an occupational therapy standpoint, then, dyspraxia and the behaviors associated with it must be differentiated from those same behaviors that exist with a motor coordination condition.  Dyspraxia, in our practice area, is not viewed as a primary problem in motor coordination and the child must present with difficulties with ideation and planning to be regarded as dyspraxic from our point of view. (9)  Rather than be the result of a problem with motor execution, dyspraxic behaviors are felt to be a difficulty in formulating a plan of action, the problem presenting itself as the inability to efficiently plan and carry out skilled non-habitual motor acts in the correct sequence.   Although children with dyspraxia may have difficulty learning a new task, once they are able to master the skills that it demands, they can use those skills to repeat the task.  (9)  Their ability to use their skill development in the mastery of other similar activities is limited, however, as they are not able to effectively plan and execute new motor actions or generalize motor actions in a new situation.  (9)  From an occupational therapy standpoint, the child with dyspraxia will present with the following behaviors (10) that can be fall into four categories: (7)

Dyspraxic Behaviors Chart
Dyspraxic Behaviors
Categories of Dyspraxia

The appearance of “clumsiness” stems from their difficulty in transitioning from one body position to another, their poor discrimination of tactile input, an overall difficulty in relating their bodies to physical objects and space, and challenges with imitating actions or perceiving the direction of movement.  They are slower to develop both gross- and fine-motor skills and are often referred to occupational therapy for these reasons, particularly handwriting.  They may tend to prefer talking rather than performing and will often avoid new tasks altogether.  Their social behaviors result from their becoming frustrated with new situations because they are unable to approach these activities in an organized manner. The culmination of these symptoms and behaviors can be low self-esteem or self-concept.  (9)

Patten, in her newsletter article, “Dyspraxia from an Occupational Therapy Perspective,” suggests a battery of standardized assessments that will assist in the assessment process.  Goodgold-Edwards and Cermak, (10) stress that we must also have an understanding of the motor, sensory integrative, and cognitive and conceptual components of movement as we observe the children in both standardized testing environments and the performance of everyday activities.  Treatment strategies we select can include sensory integrative, perceptual motor, sensorimotor, cognitive goal-directed, and compensatory skill development approaches. (9)  These will most likely be combined in a remedial plan that addresses each child’s individual needs and will include skill areas such as rule learning as it applies to motor planning and motor learning; planning for managing movements as they occur that include goal-directed activities with performance expectations; the use of tasks that have a clear, functional identification within the practicing environment; the inclusion of cognitive strategies that allow for the child’s learning abilities and styles; and, perhaps most importantly, will be fun as well as challenging.  (10)  Of course, the complex nature of dyspraxia and the multiple needs that a child may experience will necessitate the development of a team approach. (7)

The implications of dyspraxic behaviors for the school-based occupational therapist are that we must consider the “whole child” in our development of a remedial plan or recommendations for adaptations.  Although the child may have been referred to therapy because of handwriting difficulties, it is vital that we look below the surface and develop the overall picture of his behaviors, from home, to school, to the playground, and the community.  With or without an official diagnosis, dyspraxia exists and will continue to present itself in our therapy rooms and clinics.

Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine
Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine

occupational therapist who specializes in the assessment and remediation of handwriting skills. In her current book, Handwriting Development Assessment and Remediation: A Practice Model for Occupational Therapists, she shares a comprehensive guide and consistent tool for addressing handwriting development needs. She can be contacted via her website, Handwriting With Katherine.

Collmer Handwriting Development Assessment and Remediation

 
 
 
 
 Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
Photos are the property of Handwriting With Katherine and are not to be used in any fashion except as links to the appropriate blog or the Handwriting With Katherine website without the expressed, written permission of Katherine Collmer.  Those photos that include a link to the Pixabay site should be used only if they include the link to the photographer’s page that is provided with them.
 
  1. Patrick, Alison. “Introduction and Chapters 1 and 2.” The Dyspraxic Learner: Strategies for Success. 2015 ed. London: Jessica Kingsley Pub., 2015. 11-54. Print.
  2. “1 in 10 Odds Are That You Know Someone With Dyspraxia.” Dyspraxia Foundation USA. Dyspraxia Foundation USA, n.d. Web. 08 Oct. 2015. <http://www.dyspraxiausa.org/>.
  3. “What is Dyspraxia?” Dyspraxia Foundation.org.uk. Dyspraxia Foundation UK, n.d. Web. 8 Oct. 2015. <https://www.dyspraxiafoundation.org.uk/about-dyspraxia/>.
  4. Missiuna, C., and H. Polatajko. “Developmental Dyspraxia by Any Other Name: Are They All Just Clumsy Children?” American Journal of Occupational Therapy 49.7 (1995): 619-27. Web. 8 Oct. 2015.
  5. “Highlights of Changes From DSM-IV to DSM-5.” Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013): n. pag. DSM5.org. American Psychiatric Publishing. Web. 8 Oct. 2015. <http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf>.
  6. Steinman, K. J., S. H. Mostofsky, and M. B. Denckla. “Toward a Narrower, More Pragmatic View of Developmental Dyspraxia.” Journal of Child Neurology 25.1 (2009): 71-81. Web. 8 Oct. 2015.
  7. Udoh, Nsisong A., and Cornelius C. Okoro. “Developmental Dyspraxia—Implications for the Child, Family and School.” International Journal of Academic Research in Progressive Education and Development IJARPED 2.4 (2013): 200-14. Web. 9 Oct. 2015.Caroline Lacey. London:
  8. Caroline Lacey, 1997. Ludlowlearning.com. OAASIS, Cambian Education Services. Web. 8 Oct. 2015. <http://www.ludlowlearning.com/downloads-icpa/Oaasis-Dyspraxia.pdf>. OAASIS website: www.oaasis.co.uk Cambian Education Services website: cambianeducation.com
  9. Patten, Natasha, Bcc OT. Dyspraxia from an Occupational Therapy Perspective (n.d.): n. pag. Dyspraxia Foundation.org.uk. Dyspraxia Foundation UK. Web. 8 Oct. 2015. <http://dyspraxiafoundation.org.uk/wp-content/uploads/2013/10/dyspraxia_and_Occupational_Therapy.pdf>.
  10. Goodgold-Edwards, S. A., and S. A. Cermak. “Integrating Motor Control and Motor Learning Concepts With Neuropsychological Perspectives on Apraxia and Developmental Dyspraxia.” American Journal of Occupational Therapy 44.5 (1990): 431-39. Web. 8 Oct. 2015.
  11. Kirby, Amanda. Dyspraxia: The Hidden Handicap. 2002 ed. London: Souvenir, 1999. Print.
  12. “Developmental Co-ordination Disorder (dyspraxia) in Children .” NHS Choices. National Health Services UK, n.d. Web. 09 Oct. 2015. <http://www.nhs.uk/Conditions/Dyspraxia-(childhood)/Pages/Introduction.aspx>.
 

Should we worry about pencil grip?

“Should we worry about pencil grip?”

by Katherine J. Collmer, M.Ed., OTR/L

balanced-literacy1Handwriting mastery has been determined to be a leading factor in literacy.  Research has proven that early handwriting instruction, if done right, improves students’ handwriting and that poor handwriting skills place the earliest constraints on writing development. (1)  Writing* instruction, and its favorable effect on improving reading fluency, has been given the rating of “strong confidence” among research experts. (2)  This is significant in the light that reading skills lie “at the heart of education,” with learning to read and write providing the foundation for both academic and economic success. (3)  Such as that is, handwriting mastery continues to remain a skill that 10%-34% of school-age children continue to fail to achieve, (4, qtd. in 5) with handwriting problems being prevalent in up to 25% of typically developing children. (6) That may explain why results from a survey of 167 occupational therapists revealed that 98% reported problems with handwriting to be the most common reasons for referrals from teachers. (7, 8)

Handwriting is a complex skill that involves sensory, perceptual, motor, cognitive, and language functions and encompasses many layers of prerequisite skills.  These include the ability to

  • balance without use of the hands,
  • grasp and release an object voluntarily,
  • use of the hands in a led-and-assist fashion,
  • interact with the environment in the stage of constructive play,
  • hold utensils and writing tools and to form basic strokes smoothly, and
  • perceive letter and orientation to printed language. (9)

It is the role of the occupational therapist to evaluate these underlying skill areas to determine the student’s strengths and weaknesses and to develop a remedial treatment plan to address those needs that are preventing him from achieving handwriting mastery.  Among the ergonomic mechanisms that affect the production of handwriting are body positioning, pencil positioning, pencil grip positioning, and pencil grip type. (10)  Each of these factors has been considered to be a significant factor in determining handwriting mastery and, hence, an assessment of each has been included in the traditional occupational therapy evaluation of handwriting development skills.  Pencil grip efficiency has been the long-established benchmark for “good handwriting,” with the dynamic tripod grasp encouraged by teachers and occupational therapists.  Therefore, when a student fails to achieve Abby for Website 2013-10-23that level of mastery, his pencil grip is the first factor that gains attention and at times claims the lion’s share of time, energy, and resources.  If he is not using the “optimal” pencil grasp, then changes are implemented.  Pencil grip adaptations can be easily and inexpensively obtained and sent into the classroom or to home as quick remedies for illegible and incorrect handwritten work.  And hours of extra practice with a grip or a “better pencil grasp” are often prescribed as a plan to fix handwriting problems.  But, is the pencil grip the most advantageous aspect to review when a student presents with a poor handwriting style?  Should that be the first place to start when he is referred to us for services or the teacher asks us to suggest classroom adaptations?  Does pencil grasp, or the dynamic tripod grasp in particular, have a major impact on handwriting mastery?

Not according to the research.  In fact, research suggests that 50% – 70% of children in a given sample use the dynamic tripod grasp (11), with more than half of second grade children surveyed using the dynamic quadrupod grasp.  (12, qtd in 13).   The results of a study conducted with 4th grade students determined that there were four mature handwriting grasps that were equally functional for children of that age:

  • Dynamic Tripod
  • Dynamic Quadrupod
  • Lateral Tripod
  • Lateral Quadrupod. (14)

Most importantly, the researchers also found that “no relationship was found between grasp and handwriting legibility or sped when children used of the mature grasp patterns” (Collmer, p. 29) below:

Grasp Patterns for Functional Writing. Adapted from “Effect of pencil grasp on the speed and legibility of handwriting after a 10-minute copy task in Grade 4 children,” by H. Schwellnus et al. (2012). Australian Occupational Therapy Journal, 59(3), 180-187. (PHOTO PROPERTY OF COLLMER, K., REF. 18)

In another study conducted to discover the “Effect of Pencil Grasp on the Speed and Legibility of Handwriting in Children,” (15) it was found that although the fourth-grade participants utilized the dynamic tripod and lateral quadruped grasping patterns equally, they also displayed the use of the other two mature grasps identified in the study above.  In addition, this study found that 20% of the participants switched grasp patterns during the writing, with an equal percentage switching between the dynamic and lateral tripod and between the dynamic and lateral quadrupod.  Analysis of the results indicted that grasping patterns did not have an effect on legibility or speed.  This study used a 2-minute writing task for assessment.  The authors of the study indicated that alternating between two grasping patterns with the thumb position switching from opposition to adduction across the top of the pencil may indicate the need to cope with pain or discomfort during a longer-writing task.  This would presume to result in a slower writing speed accompanied with periods of rest.  However, in an additional study of fourth graders who participated in a 10-minute writing task, it was found that while the quality of the legibility of the handwriting decreased after the copy task, the speed of writing actually increased.  After analyzing the results, the researchers concluded that there was no difference in the quality or speed scores among the different pencil grasps before and after the task and questioned the practice of having students adopt the dynamic tripod grasp. (13)

Photo is property of Handwriting With Katherine.

Although 40% of teachers surveyed identified “uncorrect” pencil grasp as a common handwriting difficulty” (16 qtd in 13), researchers found that pencil grasp played a significantly less role then is perceived in a child’s ability to master handwritten tasks.  Instead, it was revealed that body positioning, pencil positioning, and consistency of pencil grip presented a significantly higher correlation with the measure of handwriting efficiency – legibility and speed. (10)  The implication of the findings of these studies for pediatric occupational therapy is that we must look beyond the seemingly obvious and traditionally accepted cause for handwriting problems.  Handwriting development skills can lie deeper than pencil grasp and their needs can be uncovered only with an assessment that targets them.

* Handwriting vs Writing:  Handwriting  is the process through which the writer uses his hand to produce letters, words, and sentences on the page in order to create, whereas writing is the skill  that “enables him to express his knowledge and thoughts.”  (Clark, Gloria Jean, “The relationship between handwriting, reading, fine motor and visual-motor skills in kindergarteners” (2010).  Graduate Thesis and Dissertations. Paper 11399. p. 1)
Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine
Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine

Katherine J. Collmer, M.Ed., OTR/L, is a pediatric occupational therapist who specializes in the assessment and remediation of handwriting skills. In her current book, Handwriting Development Assessment and Remediation: A Practice Model for Occupational Therapists, she shares a comprehensive guide and consistent tool for addressing handwriting development needs. She can be contacted via her website, Handwriting With Katherine.

Collmer Handwriting Development Assessment and Remediation

  Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
Photos are the property of Handwriting With Katherine and are not to be used in any fashion except as links to the appropriate blog or the Handwriting With Katherine website without the expressed, written permission of Katherine Collmer.  Photos that include links to an outside site are the property of those sites and should not be used in any fashion excepts when they include links to those sites.

References:

  1. Graham, Steve. “Want to Improve Children’s Writing? Don’t Neglect Their Handwriting.” American Educator Winter.2009-2010 (n.d.): 20-25. Web. 26 June 2015.
  2. Graham, Steve, and Michael Hebert. “Writing to Read: A Meta-Analysis of the Impact of Writing and Writing Instruction on Reading.” Harvard Educational Review 81.4 (2011): 710-44. Web. 7 Oct. 2015.
  3. Gentry, J. Richard, Ph.D., and Steve Graham, Ed.D. Creating Better Readers and Writers: The Importance of Direct, Systematic Spelling and Handwriting Instruction in Improving Academic Performance. Saperstein Associates. Saperstein Associates, 2010. Web. 24 June 2015. <http://www.sapersteinassociates.com/downloads/Color%20National%20Whitepaper%20Executive%20Summary.pdf>.
  4. Smits-Engelsman, B.c.m., A.s. Niemeijer, and G.p. Van Galen. “Fine Motor Deficiencies in Children Diagnosed as DCD Based on Poor Grapho-motor Ability.” Human Movement Science 20.1-2 (2001): 161-82. Web. 7 Oct. 2015.
  5. Schwellnus, Heidi, PhD, Heather Carnahan, PhD, Azadeh Kushki, PhD, Helene Polatajko, PhD, Cheryl Missiuna, PhD, and Tom Chau, PhD. “Effect of Pencil Grasp on the Speed and Legibility of Handwriting in Children.” The American Journal of Occupational Therapy 66.6 (2012): 718-26. Web. 11 July 2015.
  6. vanderMerwe, Joanne, BScOT, M OT, Neeltje Smit, B OT, B Hons OT, MBA, and Betsie Vlok, M OT. “A Survey to Investigate How South African Occupational Therapists in Private Practice Are Assessing and Treating Poor Handwriting in Foundation Phase Learners: Part I Demographics and Assessment Practices.” South African Journal of Occupational Therapy December 41.3 (2011): 3-11. South African Journal of Occupational Therapy. Web. 7 Oct. 2015. <http://www.sajot.co.za>.
  7.  Case-Smith, J., (2002). Effectiveness of school-based occupational therapy intervention on handwriting. American Journal of Occupational Therapy, 56, 17-25.
  8. Hammerschmidt, S. L., and P. Sudsawad. “Teachers’ Survey on Problems With Handwriting: Referral, Evaluation, and Outcomes.” American Journal of Occupational Therapy 58.2 (2004): 185-92. Web. 15 Aug. 2015.
  9. Chu, S. “Occupational Therapy for Children with Handwriting Difficulties: A Framework for Evaluation and Treatment.” The British Journal of Occupational Therapy 60.12 (1997): 514-20. Web. 5 Oct. 2015.
  10. Rosenblum, S., S. Goldstand, and S. Parush. “Relationships Among Biomechanical Ergonomic Factors, Handwriting Product Quality, Handwriting Efficiency, and Computerized Handwriting Process Measures in Children With and Without Handwriting Difficulties.” American Journal of Occupational Therapy 60.1 (2006): 28-39. Web.
  11. Zivani, Jenny, and Margaret Wallen. “The Development of Graphomotor Skills.” Hand Function in the Child: Foundations for Remediation. 2006 ed. St. Louis, MO: Mosby/Elsevier, 2006. 217-36. Print.
  12. Benbow, M. (1987). Sensory and motor measurements of dynamic tripod skill. Unpublished Thesis, Boston University.
  13. Schwellnus, Heidi D. “Pencil Grasp Pattern: How Critical Is It to Functional Handwriting?” Thesis. University of Toronto, 2012. Print.
  14. Koziatek, S. M., and N. J. Powell. “Pencil Grips, Legibility, and Speed of Fourth-Graders’ Writing in Cursive.” American Journal of Occupational Therapy 57.3 (2003): 284-88. Web. 7 Oct. 2015.
  15. Schwellnus, Heidi, PhD, Heather Carnahan, PhD, Azadeh Kushki, PhD, Helene Polatajko, PhD, Cheryl Missiuna, PhD, and Tom Chau, PhD. “Effect of Pencil Grasp on the Speed and Legibility of Handwriting in Children.” The American Journal of Occupational Therapy 66.6 (2012): 718-26. Web. 11 July 2015.
  16. Graham, S., Harris, K. R., Mason, L., Fink-Chorzempa, B., Moran, S., & Saddler, B. (2008). How do primary grade teachers teach handwriting? A national survey. Reading and Writing, 21(1), 49-69.
  17. Sudsawad, P., C. A. Trombly, A. Henderson, and L. Tickle-Degnen. “The Relationship Between the Evaluation Tool of Children’s Handwriting and Teachers’ Perceptions of Handwriting Legibility.” American Journal of Occupational Therapy 55.5 (2001): 518-23. Web. 7 Oct. 2015.
  18. Collmer, K.  Handwriting Development Assessment and Remediation:  A Practice Model for Occupational Therapists.  2016 ed. Waymart, PA:  Universal Publishing, 2016. Print.