Telehealth in Occupational Therapy Practice, Part 2:  Start Up Q & A

Telehealth in Occupational Therapy Practice, Part 2:  Start Up Q & A

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

 

 

 

 

Introduction

In Part 1 of this series, we discussed some of the legalities, competencies, and best practice research pertaining to telehealth as they relate to state laws, regulations, and licensing rules; competency issues; reimbursement matters, and professional standards and ethics.  There was a great deal of information offered as a starting point to your research on this service modality. This segment will be presented as an outline of the questions I am typically asked by peers in the field and will include my answers, as well as some additional sources for your research.

 

Questions and Answers

  1.  How did telehealth become a option as service delivery model in your Handwriting With Katherine practice?

The provision of services through technology in my private practice was actually born out of a suggestion from my husband.  After he retired, I wanted to continue the work I’d begun in my clinic but was torn between my professional passion and our dream to winter in a warmer climate.  His experience with teleconferencing as a business meeting model led him to suggest its use as a service delivery model that would allow me to enjoy both.  At the time, I was not familiar with the term “telehealth” and was unable to find information related to the delivery of professional services using technology such as Skype or FaceTime.  I was on my own, making my business decisions as well as those regarding best practices and ethics based on my education and previous experiences.  It wasn’t until a year later that I’d attend an AOTA Conference presentation that included Jana Cason, DHS, OTR/L, FAOTA,  who was considered the guru on this emerging delivery model.   And yet, after that presentation, I remained in unchartered territory since I’d learned that there existed very few guidelines or regulations addressing its use by occupational therapists.

2.  Please describe the start-up process for adding telehealth into your service options.

The start-up process was exciting as it provided a new environment of creativity within which to use my clinical reasoning and planning skills.  My previous experiences, both as a secondary education teacher and as a designer and presenter for training workshops, laid the foundation for building my service delivery model.  At the time, AOTA had not yet published their position paper on telehealth; but I offer it here as a reference because despite the lack of its valuable input at the time, the information included in it is the crux of how I built my delivery model best practice guidelines.

 

Ethical Considerations:  Informed Consent

Of course, the first items on my list were the ethical considerations regarding the delivery of services through technology. I had been corresponding with my clients’ parents through personal emails when they felt comfortable with that method.  There were some parents, of course, that preferred to discuss their child’s rehabilitative services on the phone or strictly in person.  Therefore, it was important to consider my approach to the parents whose children currently received services on site in my clinic and who would be involved in this change to a service that was restricted to technology.  In addition, the technologies I was considering (e.g., Skype, FaceTime, GoogleChat) and the electronic devices we would be using (desktop, laptop, and tablet computers) were not secure lines of communication.

The 2013 AOTA position paper on Telehealth (Table 1) states that the practitioner must “fully inform the client regarding the implications of a telehealth service delivery model versus an in-person service delivery model,” matching this guideline with Strategies for Ethical Practice that concern informing clients, their parents, spouses, and caregivers about the “benefits, risks, and potential outcomes of any intervention;” and/or “any reasonable alternatives to the proposed intervention. (Principle 3A)”

And this was what I did in those early days of planning.  In an effort to provide parents with the opportunity to review and completely understand this new development, I first discussed my consideration of a move to Arizona for four months that winter.  In this conversation, I included the introduction of a new service delivery option that would allow their children to continue to complete their rehabilitation plan under my care. (It is important to note here that our decision to winter in Arizona that year was based on the acceptance of this new service on the part of my clients’ parents.  My responsibility, of course, was to their children’s completion of their rehabilitation plans.)

During that conversation, I provided them with a written outline of my proposal for review at home with their spouses and children, giving them an opportunity to formulate questions for me.  I must say that I received an overwhelming acceptance to the idea even at this stage.  Most of the children had been working with me for a while and were happy and comfortable with my strategies.  That held a great deal of weight for the parents since I was offering specialized services in handwriting development skills that were difficult to obtain in other clinical or even school-based practices.

Next I obtained formal, written consent from the parents.  The 2013 AOTA position paper on Telehealth, Table 1, states that the practitioner will “obtain consent before administering any occupational therapy service, including evaluation, and ensure that recipients of service (or their legal representatives) are kept informed of the progress in meeting goals specified in the plan of intervention/care. (Principle 3B)”  In the consent form, I also outlined the additional responsibilities that would be theirs or another designated adult should they consent to this new service.  (These responsibilities will be discussed later in the article.) I was thrilled that each of my parents signed the consent and were looking forward to this new experience.

With the formal acceptance of the parents, I moved on to the challenge of creating my service delivery model. It’s difficult to imagine now but at the time there were no resources available on the internet to guide me through this.  I was doing it the old-fashioned way by building it from the ground up using ingenuity to devise the least complicated yet most effective mode of delivery.  Suffice it to say that in this day my methods may be considered unrefined; but they were effective and the process was exciting nonetheless.

 

Practitioner Competency

My main focus in this beginning stage was on my young clients (ages ranging from 5 to 16) and the effectiveness of the telehealth delivery model for engaging them and their parents as effectively as I had during an in-person session.  Skype and FaceTime were familiar to me; but I had not used them beyond chatting with friends or relatives and, even then, on a limited basis.  Even this level of experience with video technology had revealed that there occurred many glitches caused by slow internet speeds and older device capabilities, as well as difficulties connecting or maintaining the connection.  These types of technological interferences in a therapy session would most likely affect the engagement and experience of both the client and parent, as well as the clinical outcomes.  There was much to be learned about the different modes of audio technology that were available to my parents.  But the learning began with me.  So my husband and I set up practice sessions between my place in the clinic and his spot in the living room upstairs.  There soon came about many areas where the learning would be concentrated.

— Mastering the Technology:  Each video technology had its own Help Line. This information was recorded in a notebook placed next to my phone.  In the event of a glitch that couldn’t be solved in a timely manner, the session could be closed and rescheduled and I could call the Help Line to inquire about a solution.  This information could then be added to the notebook for use in similar situations.

The first and most critical aspect of an audio session proved to be the ability to link up and to receive and send both visual images and sound. This required my becoming familiar with the screen prompts and visual cues provided by each video technology.  This information went into the notebook as well to help prevent delays in the beginning of the session. It was important to become familiar with the tool that closes out the session both audibly and visually to ensure privacy after the session is ended.

We positioned my iMac such that the relevant clinical areas behind me would be visible to the clients and their parents. For example, the chalk board was an important tool in my work and therefore would need to be visible, as well as the floor space behind me that would allow me to demonstrate gross motor activities.

The computer positioning also addressed the location of my image on the screen of the receiving device. It was important for the clients and their parents to be able see both my face and my hands while keeping the chalkboard and floor space behind me remain visible.  My chair was the correct height to display my face well, but I needed to maintain my hands off the desk in order for them to be visible.

–Practicing the Service Delivery:  At this point, I engaged the services of one of my clients and her mother in completing practice therapy sessions. This proved to be an important step in the process.

—Organization:  I quickly realized that my session materials needed to be well organized and within reach during the session.  Where I could move about the clinic freely during an in-person session to retrieve items that I would use for therapy, this proved to be a visual distraction as I moved out of the camera’s range during a video session.

—Communication:  Engaging with the children and parents while maintaining the children’s attention were the next hurdles to practice. I would be utilizing the parents or caregivers in the role of assistants who would provide the hands-on interaction that was unavailable from my end.  Therefore, it would be necessary for me to communicate with both of them at the receiving end without causing confusion by talking too fast, talking over their voices, or not providing enough visual guidance.  Slow, deliberate speech patterns combined with visual demonstrations proved to be the best technique, as well as frequently asking for questions and feedback.

—Hands-Off Critical Thinking:  It quickly became apparent that the most important role I played on the screen was a natural one – a therapist. The same strategies that I utilized in the clinic to engage my clients remained the same ones I’d utilize in the session:  laughter, engaging in conversation, turning work into play, and providing time for client feedback and questions throughout the session.  But as I came to realize that this method of service delivery defined “hands-off” care, I began to understand how important all of my other senses would be now.  During our practice sessions, I honed my visual skills to avoid distraction and maintain eye contact with the parent’s movements as well as the reactions of the child in response to guided movement or the sensations provided during interaction with the tools.  In combination with my visual skills, I relied upon my vestibular skills to assist me in verbally guiding the child through gross motor and postural activities, relying of course on her verbal and vestibular responses as well.  But most important were my communication skills and my approach toward giving directions to both the parent and the child and offering feedback from a distance.

Finding the Right Space:  The area and environment you choose for providing your telehealth services should be considered very carefully.  These are some of the considerations that worked for me:

Be sure that the area respects patient privacy and confidentiality. It should have a door that closes securely; be in an area of the building that does not allow others to hear the conversations between you and your clients; and provides an environment that affords clear communication, free from noise and poor audibility. Place a sign on the door during your session to alert others that privacy is needed.

Limit the distractions behind you such as cluttered bookshelves, busy wallpaper, mirrors, or solar glare from a window behind or beside you.

Position your stored materials close by in a well-organized manner in case you need to retrieve a forgotten article or want to try a different activity in the session.

Be sure to have a comfortable seat and room to stretch your legs. Fidgeting can be distracting to the client and the parent or caregiver.

Be sure that any communication devices (e.g., land lines, computers, fax, or copy machines) are turned off or will not be needed by others during your session.  Silence phones and other computer equipment. And, of course, refrain from accepting any form of communication during your session.

 

Parent Engagement

At this point, I began working on parent engagement.  This facet was perhaps the most important one relative to the success of my service.  I would be relinquishing my cherished role as a hands-on therapist and entrusting it to my parents and caregivers.  This of course is what we’d see as an ideal transition from therapy to home programs; but most often I found that parents, no matter their dedication to their children’s rehabilitation efforts, felt more comfortable observing than interacting for most of the session.  This, of course, would not be an option and would definitely serve to enhance engagement of the parents.

–Defining the Parents’ Responsibilities:  My concern for the parents’ level of engagement in light of the increased responsibility they would be facing was a strong motivator for creating a well-organized system for communication between us during all phases of the sessions.  The success of the program relied a great deal on their understanding and acceptance of their roles, as well as my expectations before, during, and after the sessions; their sense of competence in their ability to perform that role and their confidence in my support toward their success; and their ability to sustain their placement in this role for the duration of their children’s rehabilitation plans.  Therefore, my delivery model structure was specific in defining the role of assistant that would ask them to

—become familiar with and maintain the video technology and device of their choice, including sharing Help numbers for the video technology with me;

—communicate with me before each session through emails to receive documents and a list of materials that would be needed for the session;

—provide a quiet and accessible treatment area that allowed both the child and myself to be seen and heard through their chosen device;

—plan and set up the treatment area prior to the session;

—review the session plans and gather materials prior to the session;

—scan and email their children’s competed homework before the season;

—provide guidance to their children through tactile or verbal cues during the session;

—interact with me during and after the session to allow for questions, feedback, and goal review; and

—spend time following the session to scan and email the work their children completed during that session.

I considered this transition from our interactions in an in-person session to one that relied on a shared responsibility for the success of the treatment session as a chance to review what my relationship might look like with the parents after the change.  I understood that maintaining our strong relationship was a key element in the level of their engagement.  They have taken on an important and unfamiliar role in their children’s therapy.  I took this opportunity to take an assessment of my responsibilities in this challenge and I came up with a few guidelines to help me:

—First of all, express appreciation for their taking on these additional responsibilities for the children’s therapy success.

—Practice long-distance patience for myself, the parents, and the children as we navigate this change together.

—Be understanding of the parents’ limitations and take note of their learning styles to help guide them in their role as an assistant.

—Give them support by listening to their feedback about their participation in the sessions and their management of the administrative duties. Take their suggestions when I can.

—Remember that “They are my hands” and that this change could not be completed successfully without them.

As you can see, the parents were now fully engrossed in the sessions as participants versus observers.   I was concerned about their perception of the telehealth service model’s effectiveness, although I was inclined to believe that this deeper level of engagement would reap benefits both in the accomplishment of home exercise programs and their sense of involvement.  But, in then end, I understood that the media would be the determining block in the structure I was building.  If it was a weak link, then the level of engagement would suffer on both ends.  And although I was going into this venture without a clear sense of the effectiveness of the media we would utilize, there was no precedent for me to consider in my decision.  I had to make the choice for myself and go forward with it.

Currently, similar concerns have risen regarding patient engagement and their perceptions of the effectiveness of telehealth as a service modality.  Professional service models that shoulder the client, or in my case the clients’ parents, with more responsibility while providing them with increased accessibility to the practitioner place the client/parent into a “self management” role.  A 2015 article reported that this element of patient care has been utilized “to guide higher-quality chronic illness management in primary care” resulting in “favorable health outcomes.”  It also reported that initiatives designed to increase the clients’ role in their medical care through technology “have led to reductions in hospital visits, decreased morbidity and mortality, and improvements in treatment adherence and quality of life associated with chronic diseases such as heart failure, ulcerative colitis, and asthma.” These results indicated that while costs were reduced with the introduction of technology, quality of care was not sacrificed.  As I noted with my clients’ parents, not everyone is familiar and/or comfortable with technology for medical purposes.  But according to this article, 79% of respondents in a 2010 study stated that they “were more likely to select a provider who allows them to conduct healthcare interactions online, on a mobile device, or at a self-service kiosk,” while additional study results showed that some respondents would pay for online services of this type.

It has also been noted that a poorly constructed telehealth environment could lead to confusion and frustration on the part of the clients and their caregivers.  WebPT reports that studies and accomplished program statistics have shown that “when done correctly, telehealth can strengthen the patient-provider relationship and better engage patients with their care — thus improving outcomes.” Positive results such as these were felt to be the result of the development of a strong healthcare team that shares information with patients that allows them to see what’s happening in their healthcare plan, assist in determining what needs to be done and in the development of a plan.  Programs that include clients in making their own health care decisions have seen improved compliance and in clinical outcomes over time.  WebPT also shared a recent study of knee and hip replacement patients at a hospital in Virginia that reported results indicating that “more than 90% of the participants said that telehealth improved their episode-of-care experiences, helped them better understand and set expectations, and improved their satisfaction with the care they received.”

At this point, I felt comfortable with the audio portion of the set-up and with my expectations and guidelines for the parents.  I was ready to move on to developing an efficient method for coordinating the mechanics of the sessions with the parents, such as the tools they would need on hand, and adapting therapy strategies I’d used in the clinic to facilitate the accessibility of those tools for the parents.

Therapy Tool Boxes:   Since I was familiar with the children for this first experience and had the luxury of working with them up until the day I left for Arizona, I had some fun crafting Tool Boxes for them as starter sets for their sessions. This is a strategy that I continued to use with new students using telehealth, mailing it to them after the evaluation.  Each was individually crafted, much the same as in an any individual rehabilitation plan, including simple and inexpensive items that would cover gross motor, visual motor, and fine motor skill areas, and a culmination activity that most likely would include handwriting.  Depending upon their ages and needs, the items might have included:

Gross Motor Warm-Up Materials:  Balloons, a small nerf ball, a visual list of yoga or core body exercises;

Vision Warm Up Materials:  Bubbles, whistles; small, soft ball with a string to use as a tether ball; cotton balls and straws;

Fine Motor Warm-Up Materials:  therapeutic putty, marbles with golf tees, a small selection of small snap together blocks, q-tips to use with water to trace; and

Culmination Activities:  paper and pencil activities or games that addressed the child’s specific handwriting development skill needs.

The items were stored in an inexpensive canvas bag that included a laminated list of its contents explaining which were to be retuned to me when I arrived back from Arizona, as well as a list of the paper copies of activities that I initially provided to give us a smooth start once we began the telehealth sessions.  This list also included inexpensive items that the parents might wish to purchase or might have on hand that would be useful in our sessions. These included items such as tweezers, scissors, small playing cards, and chalk and small chalkboard (which I provided to the initial children because I had them on hand and they could be returned when I came home).

In order to maintain consistency and reliability for some aspects of the handwriting development portions of our sessions, I provided copies of handwriting paper or activities designed on specific handwriting paper through email communication.  I also shared online resources that provided free downloadable copies of the handwriting paper we were using.

Session Outlines:  Effective parent engagement included keeping them well informed during every step of their involvement in their children’s telehealth experience.  Their success in meeting my expectation that they would provide guidance to their children and interact with me during the sessions would depend on my sharing information beforehand.  My responsibility would be to prepare an outline of each session’s activities and share it with them well in advance of the session.   I created a typical session outline that resembled my daily treatment plan organizer that could be filled in on the computer or by hand.  I emailed it to the parents about 3 days before the session, along with any activity sheets they would need for the session or for their home program.  The latter included instructions for the home work, which I would discuss with the parent before the end of the session.

 

Practitioner-Caregiver Competency

After the consent forms were signed and returned and the payment options explained and agreed upon, it was time to test the technology with each parent.  This was by far the second most important facet of the program development.  Each video technology worked in different ways and had its own tools for engagement.  This opportunity also gave us time to discuss some shared technology guidelines for times when the video equipment does not cooperate, such as an inability to connect, the screen freezing up, or unexpected internet shut downs.  We came up with a written plan to address:

–Who calls to reconnect?

–How much time is allowed for correcting the situation before considering the session canceled?

–What are the rescheduling options?

All in all, this part went smoothly and we were ready to begin our new adventure once I arrived in Arizona.

 

Client Engagement

The last step in my preparation process for the transition to telehealth addressed the children’s level of engagement.  In-person therapy sessions typically involve a lot of tactile, vestibular, auditory, and visual engagement between the therapist and the child.  While the auditory and visual engagement facets would continue to exist between us, I knew that they would be filtered by the long-distance impression of the video technology.  I would be relying on the parents to provide the tactile and vestibular input, for sure; but I recognized that their proximity to the children would override most of my input if I wasn’t creative.  I didn’t have difficulty adapting my therapeutic strategies for the screen and found in the end that I was able to conduct the same interactive activities as I’d done in the clinic.  But in my practice sessions conducted with my client and her parent before I left for Arizona, I found these simple guidelines worth noting:

–Ask the parent and child if they can hear and see you well enough and if there are any distractions that you need to address before you get started. This avoids hampering the child’s or parent’s engagement or creating disruption during the session to make changes.

–Ask the parent to keep the work area clear of all items except those which are going to be used in the activity.

–Provide the child with an opportunity to manipulate the materials, listen to your labels for them, discuss the directions and purpose for the activity, and ask questions or give feedback before starting.

–Speak slowly and provide instructions clearly. Sometimes a slight time delay in the transmission of information across the internet or phone lines can be distracting or result in the child misunderstanding your directions.

–In the case of long-distance conversations, it is even more important to ask the parent and/or child to repeat your directions in order to determine their level of understanding.

–If the family’s environment becomes noisy or the parent is interrupted during the session, be flexible and understanding. Have a plan to work on a simple fine or visual motor activity while the situation is resolved.  This helps to keep the child engaged and to prevent him or her from getting distracted. This works well if the parent is unprepared with disorganized or unavailable activity materials or the unavailability of downloaded materials. If this occurs often, you and the parent can discuss these events and options for remediation on the phone later.

–If the materials or downloaded items are not available, be creative and utilize previous activities or similar ones that include what is on hand and will meet the child’s needs.

–If the child gets fidgety or distracted, suggest a short break for a gross motor activity or to get a drink and/or non-messy snack that can be brought back to the therapy session.

We were ready to go!  For additional information about the process for setting up my telehealth practice you can download my handout from the 2014 AOTA National Conference by clicking on the picture below.  This will direct you to my Handwriting Development Skills Resources Page.  Scroll down until you see this picture there.

 

 

You can view a sample session from my clinic here:

 

 

3.  What types of services do you provide?

Let me begin with the types of services I provided specific to my private practice mission statement.  Handwriting With Katherine was created to meet the needs of an ever-growing population of children who were experiencing handwriting challenges that could not or were not being met through a structured, organized instruction program or with the benefit of an occupational therapy remedial plan.  The focus of my practice is to assess and remediate the underlying developmental skills that affect learning, in this case handwriting.  So although the end goal of my clients and their parents was to master handwriting skills, their rehabilitation plans addressed those developmental skills (gross motor, vision, fine motor, visual perceptual, sensory) that were identified in their initial assessment as the culprits standing in the way of their success.

Primarily, our work was done on an in-person basis at my clinic.  The live videoconferencing telehealth service model was later offered as a synchronous modality that allowed me to expand my services to meet both the needs of my clients and myself.  I found this to be an efficient way to conduct evaluations, provide treatment, and confer with parents while I was away and to provide services to clients who were unable to meet in the clinic.

A note about the conduction of an evaluation using the telehealth delivery model:  My initial telephone or in-person consultation with the parents is designed to determine if a handwriting development skills assessment is the appropriate starting point to address their concerns and their children’s needs.  The information gathered during this conversation would also assist me in deciding if a telehealth method of service delivery would be appropriate for the evaluation, if the parents desired this option.  The evaluation process that I conduct follows a standardized format that allows for the inclusion of specific adaptations during its presentation. In addition it utilizes basic, inexpensive items that were most often available to the parents or that I could mail to them inexpensively or email to them for downloading. This facilitated the evaluation through telehealth as I was able to utilize the parent as the assistant in providing the child with any tools and adaptations that were need during its administration.  The greatest drawback to this plan, however, was the additional time that the set up took in order to practice with the technology and ensure success with the session.  This was not my preferred method for conducting an evaluation and I would make every attempt to travel to the child’s home when possible.

For my service model, I chose “Live Videoconferencing,” though we now know that there are other modalities that serve additional client and practitioner needs.  There are a small number of sites that are addressing the pressing need to set standards and policies and to develop a framework for the delivery of telehealth services.  One such organization is the Center for Connected Health Policy (CCHP).  CCHP is a non-profit, private organization working toward the integration of “telehealth virtual technologies into the health care system through advancing sound policy based on objective research and informed practices.”   One of it’s major accomplishments was the research report they published that was the basis for the California Telehealth Advancement Act of 2011 (AB 415), which “allows all licensed health professionals to utilize telehealth, removes restrictions and barriers to providing telehealth, and expands the locations where telehealth can take place.”  Their site is a valuable resource for telehealth information, such as the definitions of the various technologies that encompass the telehealth service delivery model.

The CCHP page, “What is Telehealth?” provides definitions for and descriptions of the use of the 4 telehealth modalities.  The links in the left column of that page provide more extensive information about the modality, as well as their uses in various capacities.

Live Videoconferencing (Synchronous)

Store-and-Forward (Asynchronous)

Remote Patient Monitoring (RPM)

Mobile Health (mHealth)

 

4.  Based on your clinical experience, what are the pros and cons of providing services via telehealth?

Cons:  The excitement over this emerging service method as a solution for reducing costs and reaching clients in remote areas where services are not available has begun to push policymakers and state licensing boards to create definitions and regulations in an effort to set some type of standard that will allow healthcare professionals to include telehealth as a service model into their practices. For a number of years, the consideration of telehealth as an option sat in the background of the discussions that were taking place to improve healthcare delivery.  A small amount of groups and professionals were writing papers and delivering presentations designed to create awareness and garner interest in telehealth; but for the most part, those discussions led to the discovery that there was very little support by professional organizations or state licensing boards relative to our legal and ethical use of this model in our occupational therapy practices.  It was frustrating and confusing and often resulted in a reluctance by therapists to consider it.  Currently, we are finding more information on the internet, most importantly from AOTA, that provides definitions, guidelines, and ethical considerations based on our professional standards.  And that is fortunate.  However, I remain cautious about the rush on the part of therapists to become a telehealth provider.  My concerns include:

–Provider Competence: A current small internet search I conducted did not reveal an occupational therapy program that advertised telehealth as a course selection.  Of course, this is not conclusive but it does suggest that telehealth courses are not currently prevalent in occupational therapy curriculums, or at the least that colleges are not advertising them.  Using the key words “telehealth course,” the search did reveal a number of introductory training workshops designed to focus on various elements of telemedicine and telehealth offered by allied health, medical, and supplier organizations.  However, I was not able to locate a reference to an occupational therapy curriculum that included telehealth.  With the excitement and push for the advancement of this new delivery method, as well as the growing desire for therapists to enter into private contractual or private practice therapy enterprises, my concern is for the new graduates who are looking toward utilizing telehealth as a way to enter these job markets.  These concerns about educational needs for new endeavors were voiced as far in the past as 1998, by Mary Foto, in her AJOT article titled, “Competence and the Occupational Therapy Entrepreneur.”  The concern at the time was the increased desire for new graduates to want to assume a wider scope of responsibilities versus the once traditional goal of “entering into and becoming successful at hands-on clinical practice (p. 765)” relative to the question, “How will occupational therapy entrepreneurs be judged competent?”  Although her article discussed the “knowledge, skills, traits, and habits required of any occupational therapy practitioner contemplating a career as an entrepreneur (p. 765),” her thoughts relative to competency coincide with those being discussed here.  She states that:

“the American Occupational Therapy Association (AOTA) and its members are obligated to protect the health, safety, and welfare of the persons we serve. Certification – and recertification – is but one means of meeting this obligation. My views on this topic are based on three premises:

1. Assuring continuing competence is an obligation, not an option, so the question is how to assure the continuing competence of occupational therapy practitioners.

2. The assurance of continuing competence and quality of care is desirable not only for the protection of the public, but also for the protection and advancement of the occupational therapy profession and the protection and financial well-being of occupational therapy practitioners.

3. The manner in which we assure continuing competence must appropriately balance the needs and interests of all stakeholders including referral sources, clients, payers, and practitioners. A one-size-fits-all approach would be inconsistent with the diversity of occupational therapy practitioner roles and practice specialties found in our profession.

Foto addresses competency but sadly not entry-level education that would provide a baseline knowledge for introducing new therapists to, in her case, entrepreneurship.  However, her remarks relative to our obligation toward continued competence as well as competence in our progression toward a specialty area continue to reflect my concern about this recent transition into telehealth as an additional scope of our practices.  And although strictly speaking entrepreneurship and telehealth are not actually specialties but more delivery models, their use demands specialized knowledge, skills, traits, and habits that require competence.

Foto further writes on this topic:

“Just as occupational therapists move into certain roles over time, they also move from being general practitioners to being specialists. Thus, although the use of a general practice certification examination is appropriate to assure the competence of persons entering occupational therapy practice, it would be inappropriate to use this examination, which was designed to measure a broad range of knowledge, to determine the competence of those practicing a specialty. Just as competency assessment must take into consideration our occupational roles, it must also be relevant to one’s specialty area.

We must recognize that successfully passing a certification examination or recertification examination does nor assure competence. Demonstration of didactic knowledge should not be confused with consumer protection. Competence and consumer protection—whether entry level or continuing—must be viewed and measured within a broader framework. A certification examination and its criterion of successful passage set forth a minimal competence standard. Our profession’s Code of Ethics (AOTA, 1994a) sets forth the highest standard. In my view, competence is based on a body of knowledge and a set of skills that, when provided to consumers, are guided by our Code of Ethics, shaped by our profession’s values, and driven by our 10 standards of practice (AOTA, 1994b). A certification examination should address only one of these components of competent practice–knowledge. (p 769)”

My experience with the development and inclusion of a telehealth service into my practice at a time when guidelines and information resources were scant included those very concerns.  I was entering into unchartered territory in an environment where I was my sole judge of competency.  I had concerns about the quality and consistency of care provided using this method, as well as the outcomes that my clients would achieve with it.  In my case, however, I had been a member of therapy teams across the country in diverse environments for over 14 years.  These experiences culminated in the development of continued competence in the standards for continuing competence set by AOTA in the areas of:   Knowledge, Critical Reasoning, Interpersonal Abilities, Performance Skills, and Ethical Reasoning.   These skills form the knowledge base and core values “to perform current and future roles and responsibilities within the profession (p. 661).”   I was able to draw upon my trials and errors in each of those environments as well as my successes to form a plan and create a working model for using telehealth within my practice.  Competence in those areas takes time, practice, and patience.  AOTA defines continuing competence as “a dynamic, multidimensional process in which the occupational therapist and occupational therapy assistant develop and maintain the knowledge, performance skills, interpersonal abilities, critical reasoning, and ethical reasoning skills necessary to perform current and future roles and responsibilities within the profession (p. 661).”  My concern remains that new graduates will choose this intriguing and cost effective method of service delivery, without even an introduction to its benefits or contraindications in college or during formal training, only to find themselves entering the same unchartered territory as I did but lacking the awareness of that.

–Appropriate Environments:  My second concern is that of a general rush to assume that this delivery model will fit into any area of our profession and can be considered a suitable alternative for all treatments within a therapists’ practice.  AOTA clearly states in its 2013 paper titled, “Telehealth,” that although telehealth is supported as a service modality within each major practice area within occupational therapy, this is not an indication that it is appropriate for all situations.  The fact is that telehealth as a service modality “has potential” and should be utilized only after each case has been evaluated individually based on “the variability of client factors, activity demands, performance skills, performance patterns, and contexts and environments using clinical judgment, client’s informed choice, and professional standards of care (p. P S70)”

In the case of my business model, the majority of my clients’ needs could in theory be met with telehealth services.  However, it would not be appropriate for children with high sensory needs because hands-on treatment that addresses the child’s individual sensory needs is a vital factor in gathering information relative to his or her reactions and progress.  In my professional opinion, there could be no substitute for that.  This was not a concern for me, however, because I referred children whose needs centered around sensory issues to a clinician specializing in that area because mostly likely the focus on handwriting development needs would be more successful once the children had had success with a sensory plan.  In any case, I would be reluctant to offer services through the telehealth model to children who would benefit from my services but whose sensory needs ranked high in my handwriting development assessment.  In this case, as well as in most areas of our practice, our ability to use touch and to learn about our clients’ needs through tactile input is invaluable.  It’s one thing for my parents to provide hands-on techniques per my instructions, but it’s a whole other issue about their being able to understand and convey the tactile sensations they are receiving back from the children. While touch provides both the therapist and client with valuable information, touch also offers the therapist a unique learning experience that shapes his or her expertise.  And that comes only from experience and practice.  This is especially true for building competency in a new therapist.

Jana Cason, DHS, OTR/L, in her 2012 article, “Telehealth Opportunities in Occupational Therapy Through the Affordable Care Act,” shares insight into the aspects of the ACA that align with therapy roles supported by AOTA and provides research study results that support the use of telehealth in certain areas:  early intervention and school-based pediatric therapy; productive aging/health and wellness, mental health; rehabilitation, and disability, and participation.

Pros:  There are a number of situations that I consider excellent candidates for telehealth and look forward to its implementation within them as appropriate:

—providing services to communities that are underserved due to their remote location and/or lack of occupational therapists on site;

—offering services to clients who have difficulty meeting at a clinic due to financial or transportation constraints;

—assisting clients in the incorporation and use of assistive technology and adaptive techniques (e.g., caregivers serving a patient with dementia for Alzheimer’s Disease, parents of children who rely upon assistive technology to communicate or perform ADLs);

—assessing and assisting in the modification of home, work, or school environments to increase accessibility and level of independence;

—providing therapy designed to improve skills after clients return home post surgery or hospital visit to facilitate carryover to a functional environment;

—providing assessment and therapy designed to promote the creation and maintenance of healthily habits and routines.

Cason, in her 2012 article, concludes that, “by removing barriers to accessing care, including social stigma, travel, and socioeconomic and cultural issues, the use of telehealth as a service delivery model within occupational therapy leads to improved access to care and ameliorates the impact of personnel shortages in underserved areas (p. 132-133).”

An additional benefit of using the telehealth service delivery model in my practice was the opportunity for the enhanced experience it provided the parents as they were formally involved in the delivery of services.  This was the single-most positive outcome in that it resulted in improved participation and completion of the children’s home program, which is a key element of a rehabilitation program.

 

5. What has been the overall response from the clients (i.e. parents, children) you serve?

As I mentioned, the introduction of the program was met with an overwhelming positive response from both the initial parents and children.  The children were happy, of course, because they were entering into a new adventure with me! The parents were excited about continuing their children’s therapy with me and recognized the benefits of this service delivery method.  They dove into the project and worked with me to ensure its success throughout those initial 4 months.  I have to say that we encountered very few snags because of the many months that we’d taken planning the program and practicing with it.

Telehealth continued to be a service I offered when I traveled to Arizona in subsequent winters as well as when my clinic was open.  The parents who elected to utilize the program in lieu of in-person therapy did so because of transportation issues, scheduling barriers, or family responsibilities.  But when chosen, they viewed it as an interesting and appropriate method and one that they felt they could implement with a bit of planning and practice.

Although telehealth was offered as a service option in my business model, the decision to choose it for a child was decided on case-by-case basis. Whenever possible, I opted for an in-person evaluation and would consider the appropriate service delivery options for the child’s treatment strategy at that time.

In all instances, both the parents and I considered our relationship to be stronger because we had much more contact with each other while we managed the mechanics of the program.  I continued to request feedback from parents throughout the completion of the children’s rehabilitation plan and was often rewarded with ideas and suggestions for improving the program.

From my standpoint, I was very pleased with the continued engagement displayed by the parents as they maintained communication with me by email, downloaded materials in a timely manner, collected materials and set up the space before the session began, and worked with me throughout the session, limiting any absence away from the therapy set up.  This was time consuming for them and it added responsibility to their time at home.  Their sustained involvement humbled me as they became “my hands” and acted as my assistant.

 

6. What is the typical structure of an online session?

It was important to me that the services I provided through the telehealth delivery model were consistent in quality and efficiency with those that I offered in person.  Therefore, during the planning and creation of the project, I spent a considerable amount of time evaluating the impact that long-distance delivery would have on the length of my session; assessing the therapy tools and activities that would work well in this environment; determining strategies for providing adequate guidance to the parents for implementation of the therapeutic activities; and, finally, the feasibility of conducting an evaluation with this model.  When I’d determined that these facets could be accomplished, I designed my sessions in the same manner as an in-person session, with the exception of the additional 10-15 minutes of Parent Time.  During in-person sessions, the parents would typically sat in the therapy room with us and I would discuss progress and demonstrate activities for the home program during therapy.  Any discussions that addressed other areas of the children’s therapy were conducted on the telephone.  A typical telehealth session was conducted as follows:

—Gross Motor Warm-Up: 5-10 minutes (more if enhanced gross motor skills were a goal in the child’s remedial plan)

—Vision Warm-Up: 10-15 minutes

—Fine-Motor Warm Up: 15-20

—Culmination Activity: 15 minutes (This would be an activity that addressed handwriting at an appropriate skill level.)

—Parent Time: 10-15 minutes

I wrote an article that outlines a day in the life of an occupational therapist and you can see how my day usually went.  This day had one telehealth session in it.  It also includes a video of a portion of one of my sessions.

 

7. What recommendations or advice do you have for OT providers considering providing services via telehealth?

The start up of any project is an exciting and creative learning opportunity.  It is time consuming and frustrating at times.  But the most important part of any plan is the foundation upon which it is built.  Therefore, the time spent on the areas I’ve listed below will result in a greater possibility of success and a more rewarding start up and business experience.

—Spend time researching this delivery method.   Read every article you can find no matter the discipline it is directed toward in an effort to gather a diverse foundation of information and opinions.  Contact experts in the occupational therapy field, such as Jana Cason, DHS, OTR/L, FAOTA.  She has been very helpful to the many therapists I’ve sent her way.

—Determine if your practice area is an appropriate setting for the delivery of services with telehealth. Consult with other therapists in that area, asking for opinions and experiences with the modality.

—Determine your current level of competence within the area that you are considering for this delivery method. Take an honest assessment based upon your level of experience within that specific field and your level of comfort with the challenges that telehealth services can present.

—Consider courses that can offer an introduction to the general concept of telehealth or training courses that can address specific areas that may apply to your field.  Check with occupational therapy programs in your area to get information on any of their experiences with telehealth, courses they may offer, or resources that they can forward to you.

—Contact the licensing board in your home state and request copies of their guidelines and state regulations, if any exist, so that you can review them in detail, asking questions if you need clarification.

—Collect information regarding the laws, regulations, and board guidelines for any state in which your clients will reside if it is outside your home state. Be clear on these before you engage in the delivery of services to these clients.

—Spend time researching information about the start up of small businesses regardless of the focus of their services.  I cannot stress this enough.  For many of you, this will be your first entrepreneurial endeavor and you will want to gather information about business plans and mission statements.  It’s important to take the business management portion of a start-up company seriously no matter the size or scope of your practice. There are important decisions  to be made about registering your business, applying for local permits, and maintain legal compliance.  The Small Business Administration is a good pace to start, but there other online resources that can provide information about these and other business components such as accounting practices, business plans, and the legal requirements for working out of your home.

—Consider the time element inherent in providing telehealth services.  The professional that I had consulted that offered vision therapy services through a much more sophisticated modality than I was planning to use indicated quite clearly that this method of providing services would consume much more of my non-billable time than an in-person session. And I did, indeed, find that to be so.  The additional responsibilities that my parents would shoulder meant that my administration time would also be impacted by additional session preparation for items to sent to parents, preparing scanned items for the additional emailing required, receiving and printing items sent from the parents, and an additional accounting procedure to address long-distance parent payments.  As a small business owner, it is often not feasible to purchase sophisticated technologies or additional personnel for simplifying some of these aspects of the business.

 

8. How do you feel technology in general has been able to support your practice as an occupational therapist?

In my Handwriting With Katherine practice, I actually utilized very little technology before the introduction of telehealth as a service delivery model. And the latter was done solely out of necessity.  In my opinion and experience, the remediation of handwriting development skills are best addressed with a hands-on strategy, both for the therapist and the children. This type of specialized remediation benefits from the engagement of all of the senses, tactile in particular.  As far as using apps or electronic games in my sessions, I have chosen not to include them.  Although I appreciate them for what they are and the advantages they can offer children, I am happy with the results my clients make using hands-on activities such as board and card games, gross motor games, and paper-and-pencil activities. And I find I can tailor those activities to meet their needs much more effectively than I can with an electronic one.  It is funny, though, that in all my years of working with children on their handwriting skills, not one of them has asked me where the technology is.  Or their parents for that matter.

I recognize that some children will have needs that would best be addressed with adaptive technologies.  The mission statement of my business does not expand my practice to address adaptive technologies for those children whose needs go beyond the services offered in my practice. For those who would benefit and require adaptive strategies and equipment, I refer them to the experts in that area.  I have great respect for those who specialize in them.

 

Conclusion

Telehealth has the potential for becoming a useful service delivery method in occupational practice.  There is still much research to be done and guidelines to be written, however, and I am looking forward to what it may hold in the future.  I hope this series on telehealth has provided you with a starting point for considering this new service method.  As alway, that you for reading.  And I look forward to your comments.

 

 

Telehealth in Occupational Therapy Practice, Part 1: Legalities, Competencies, Best Practices

 

The Handwriting is Fun! Blog is published by and is the property of Handwriting With Katherine.

 

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

http://www.handwritingwithkatherine.com/handwriting-development-assessment-and-remediation-book.html

 

 

 

 

Pictures above that are the property of the author must provide a link back to this article or her website.

 

1 Disclaimer: This article is provided for informational and educational purposes only and is not a substitute for legal advice or the professional judgement of health care professionals in evaluating and treating patients. The author encourages the reader to review and verify the timeliness of information found on supporting links before it is used to make professional decisions. The author also encourages practitioners to check their state OT regulatory board/agency for the latest information about regulatory requirements regarding the provision of occupational therapy via telehealth.

2 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.

Telehealth in Occupational Therapy Practice, Part 1: Legalities, Competency, Best Practices

 

 

Telehealth Part 1:  Legalities, Competencies, and Best Practices

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

 

Introduction

Over the years, I have received a number of inquiries from occupational therapists about my experience with the telehealth service delivery model.  In the past 6 months, I have noticed an increase in these inquiries and realized that it would be an important area to address in an article.  My contacts with these wonderful therapists had piqued my interest in the area once again, so I went about searching the internet for new information and resources.  I will share what I’ve found with you in the first part of the article and then conclude in Part 2 with my experiences with telehealth; my thoughts and resources that address the benefits, drawbacks, and ethical concerns; as well as my impressions regarding the implications of these three areas in our practice.

 

Definition

Telehealth as a service model has marched to the forefront of the healthcare industry, with studies indicating that “an estimated 1.8 million health consumers [were expected] to take part in some form of telehealth….” by the end of 2017.  The various technological modalities listed under the telehealth umbrella have been proposed as the next generation of delivery service models to benefit both clients and practitioners.  In that light, it is important to understand the accurate interpretation of the term “telehealth.”  The Center for Connected Health Policy (CCHP) applies the term to “a collection of means or methods, not a special clinical service, to enhance care delivery and education.” It further clarifies that telehealth versus telemedicine  is “a more universal term for the current broad array of applications in the field” crossing most health disciplines and including consumer and professional education.

Telehealth has been defined by writers in the media in various ways.  For the purposes of this article, the AOTA and State of California definitions will be offered as references.  These were chosen because this article’s focus is on the delivery of occupational therapy services and the California state law definition provides a clear and specific model for interpreting this delivery model.  It is important to note, however, that the definition of telehealth varies among the states, with some states not addressing this mode of service delivery at all. This aspect will be discussed in detail further on in the article.

“AOTA defines telehealth as the application of evaluative, consultative, preventative, and therapeutic services delivered through telecommunication and information technologies.” Whereas, “telerehabilitation within the larger realm of telehealth is the application of telecommunication and information technologies for the delivery of rehabilitation services.”

“Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site.  Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.”  (Source as cited in referenced link:  CA Business and Professions Code Sec. 2290.5)

 

Laws, Regulations, and Licensing

In the same way that the state’s definitions of telehealth differ, so do their individual laws and regulations pertaining to licensing requirements, their laws regulating its use, and their rules for reimbursement for telehealth services. This section will address the regulating laws and licensing issues, while reimbursement will be reviewed in a separate section.

Although there are compilations provided by various agencies outlining licensing regulations among the states, it is important to contact the licensing board in the state where you are licensed to verify the current laws that apply to the use telehealth as a delivery model as well as the scope of those services that the law allows.  Each state and its board makes individual decisions on these issues.

Laws and Regulations:

  • For instance, Arizona provides both a legal definition of the delivery service models and a Regulation Telemedicine/Telehealth Definition:

AZ State Law Telemedicine/Telehealth Definition:

Under Arizona Statute, Public Health & Safety, “telemedicine means the practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the patient, including audio or video communications sent to a health care provider for diagnostic or treatment consultation.” (Source as cited in above link:  AZ Revised Statute Sec. 36-3601; link not available).

AZ Regulation Telemedicine/Telehealth Definition:

“Under State Administrative Code, Department of Insurance, Health Care Services Organization Oversight, ‘telemedicine means diagnostic, consultation, and treatment services that occur in the physical presence of an enrollee on a real-time basis through interactive audio, video, or data communication.”  (Source as cited in referenced link: AZ Admin. Code Sec. R20-6-1902

  • South Dakota also has both a legal definition and a regulation, however the latter provides a more limited scope for the use of the service models:

SD State Law Telemedicine/Telehealth Definition:

“ ‘Telehealth’ is a mode of delivering healthcare services that utilizes information and communication technologies to enable the diagnosis, consultation, treatment, education, care management and self-management of patients at a distance from health care providers.” (Source as cited in referenced link:  HB 1183 (2017)

SD Regulation Telemedicine/Telehealth Definition:

“ ‘Telehealth services’ is a home based health monitoring system used to collect and transmit an individual’s clinical data for monitoring and interpretation.”  (Source as cited in referenced link:  SD Regulation 67:40:18)

  • In the case of Montana, the state provides a detailed legal telemedicine/telehealth definition, but does not provide a regulation relative to the provision of those service modalities:

MT State Law Telemedicine/Telehealth Definition:

“Telemedicine means the use of interactive audio, video, or other telecommunications technology that is:

1. Used by a health care provider or health care facility to deliver health care services at a site other than the site where the patient is located; and

2. Delivered over a secure connection that complies with the requirements of HIPPA.

The term includes the use of electronic media for consultation relating to the health care diagnosis or treatment of a patient in real time or through the use of store-and-forward technology.

The term does not include the use of audio-only telephone, e-mail, or facsimile transmissions.   (Source as cited in above link:  MT Code Sec. 33-22-138)

 

Licensing Requirements:

In the case of licensure requirements, there is a great deal of variation among the states relative to the establishment of standards and regulations specific to occupational therapy and telehealth.   Some state licensing boards have established specific standards of practice for the delivery of services through telehealth modalities, while others have not addressed this despite the fact that their states provide definitions and regulations for telehealth/telemedicine.

For instance, Alaska has written a unique condition for occupational and physical therapists into their administrative code, as cited in this link.  This condition states that occupational and physical therapists “must be physically present in the state while performing telerehabilitation,” thereby preventing the use of telehealth as a service delivery model by their licensed practitioners residing outside of the state.

California’s occupational therapy regulations, as cited in that same link, contain another unique component stating that the therapist “must assess whether or not an in-person evaluation or intervention is necessary, and consider a number of specific factors outlined in the rule, before a telehealth visit can take place.” If it is determined to be more appropriate, then an OT or a COTA must be available in person.

An interesting addition to a Kentucky Board of Physical Therapy bill approved in March 2014 (as cited in the same link) “makes Kentucky the US state with the most detailed telehealth regulation related to physical therapy,” outlining the tasks that must be completed by the therapist during the initial and continuing treatment.

Some state boards simply cite AOTA’s 2013 position paper titled, “Telehealth,” as an acknowledgement that telehealth/telerehabilitation is an accepted service delivery model, while others have not yet taken a position on the issue.   It is vital, therefore, to verify the licensing regulations with your state’s board before embarking on a telehealth endeavor.  Members of AOTA can access this link for some information about each state’s licensing requirements.  However, it remains the practitioners’ responsibility to ensue that they are working under the provisions of the state licensing requirements in their home state and/or in the state in which the telehealth services are provided.

The licensing issue is complicated further because of the lack of a licensure compact affording occupational therapists the ability to practice outside their home state without obtaining a license for each additional state.  This is the reason that traveling therapists must obtain a license for each state in which they practice.  Interstate compacts are used as a measure to ensure cooperative action among states.  They are “contracts between two or more states creating an agreement on a particular issue, adopting a certain standard or cooperating on regional or national matters.” Although physical therapy has recently had such a compact approved in 10 states, thus beginning the rigorous process toward the creation of a Physical Therapy Compact Commission, occupational and speech therapy have not yet achieved this.

 

Reimbursement

The services provided in my practice were offered on a private-pay basis; therefore, I do not have first-hand knowledge of insurance reimbursement policies.  For information relative to reimbursement policies and the government programs, regulations, laws, and policies that are impacted or intersect with telehealth policy, I offer the following sources as a starting point in your search:

National Conference of State Legislatures

Center for Connected Health Policy:  State Laws and Reimbursement Policies

Center for Connected Health Policy: Government Regulations

 

Confidentiality

Confidentiality compliance as it relates to the 1996 Health Insurance Portability and Accountability Act (HIPPA) is a complicated and complex system to navigate.  It is important to contact government resources to discuss the HIPPA requirements as they pertain to individual practices.  I offer some resources as a starting point in your search:

Center for Connected Health Policy

Health Care Law Today

The following source includes a section on HIPPA but is also an excellent source for a wide range of questions related to telehealth:  “Telehealth Regulatory and Legal Considerations:  Frequently Asked Questions,” by Jana Cason, DHS, OTR/L, and Janice A. Brannon, MA.

 

Therapist Competency

The question of competency for the use of telehealth as a service delivery model addresses the therapists’ ability to utilize the technology inherent in its delivery.  The sudden increased interest in telehealth has placed technological knowledge and expertise at a higher premium as it will be the single most important facet for achieving success connected to the delivery method.  Technology disruption and failures can hamper outcomes, patient engagement, and therapist satisfaction, as well as the desired cost savings.  A thorough understanding of the mechanics, benefits, and limitations of the technology in play will be important skills in the use of telehealth for providing occupational therapy services.

A review of the literature, however, does not suggest that the profession as a whole, faculty nor therapists, has yet met the mark in this area.  The American Occupational Therapy Association Advisory Opinion for the Ethics Commission on Telehealth, under the section titled, “Provider Competence,” acknowledges the need for this understanding of technology in its statement,

“occupational therapy practitioners must be competent in the use of the technology to ensure effective service delivery, and the equipment or technology must be of sufficient quality and in dependable working order. Lapses in sound or picture transmission can impede the therapeutic encounter (Denton, 2003; Grosch, Gottlieb, & Cullum, 2011). To avoid disruption of services, facilities and private practitioners should have a sound plan of action in the event of equipment malfunction (Denton, 2003).”

In addition, under the section titled, “Quality Care and Adherence to Standards,” it states that “practitioners also must gain and maintain competency in the use of all relevant technology to provide safe and effective services (Brennan et al., 2010).”

However, while that same paper, under the section titled, “Quality Care and Adherence to Standards,” states that in the Ethics Code, Principle 1E, “occupational therapists and occupational therapy assistants are obligated to provide services within their level of competence and scope of practice,” and in Principle 1G that they are “to take responsibility for maintaining high standards and continuing competence in practice,” it also cites Principle 1F that “specifically refers to situations in which ‘generally recognized standards do not exist in emerging technology’ and directs therapists to take steps to ensure their own competence and weigh benefits of service provision with the potential for client harm.”   This acknowledgement that there lacks sufficient training in telehealth leaves therapists in a confusing bind relative to ethical considerations.

It also appears that the path toward competence with technology and telehealth are not being addressed by professional organizations or educational institutions; but instead left to the responsibility of the therapist.  The reference to this is presented in an AOTA paper titled, “Model Continuing Competence Guidelines for Occupational Therapists and Occupational Therapy Assistants: A Resource for State Regulatory Boards.”   In Chapter 02, Optional Provisions, Section 01., titled, “Continuing Competence Plan for Professional Development,” Subsection A clearly reflects this in its statement:

“It is the responsibility of each licensee to design and implement his or her own strategy for developing and demonstrating continuing competence. Each licensee has current and/or anticipated roles and responsibilities that require specific knowledge, attitude, abilities, and skills. It is incumbent upon each licensee to examine his or her unique responsibilities, assess his or her continuing competence needs related to these responsibilities, and develop and implement a plan to meet those needs.”

Further, in that same document, Chapter 02. Optional Provisions, the responsibility for assessing skills and determining needs are casually placed on the therapist within its description of the AOTA Continuing Competence Plan for Professional Development.  In this section it further states that the plan “encourages occupational therapists and occupational therapy assistants to examine each area of responsibility relative to their practice and perform a self-assessment of professional development strengths and needs in order to develop and implement an effective continuing competence plan for professional development.”  It is understandable to expect professionals to take responsibility for their own professional development and their continued competence in their fields.  However, with an emerging service model such as this that requires expertise in an area not typically addressed in current occupational therapy program curriculums, it would seem appropriate then that the educational institutions concerned would then enhance their programs to include both an understanding of the use of telehealth as a delivery model and of the technology it employs.

This may also be taking off at a slow pace as “only a fraction of OT faculty members across the nation has enough expertise in this area to adequately teach this subject matter to students. p. 3).”  Their confidence in their knowledge of technology and their limited experience with the telehealth modality seem to have faculty approaching course offerings with reluctance.  Results of a small study conducted at a medium-sized combined Bachelor’s of Science/Master’s of Science three-year occupational therapy programming an urban community demonstrated that this may not yet be happening. The results indicated that “faculty in this specific OT program lack the knowledge needed to fully evaluate and therefore make a decision about adopting this subject matter [telehealth as a service delivery model] into their course syllabi and fully integrate this topic into the program curriculum (p. 89).”  In addition, they voiced concerns about their lack of technological knowledge relative to “how to navigate the available technology; specifically what technology is available, how to set it up, and how to troubleshoot…. (p. 94).”

This raises concern about the level of competency that can be achieved by therapists in this time of rapidly growing interest in telehealth as an option for private practice, to provide care to underserved clients, and to reduce costs.

 

Best Practice Guidelines and Ethical Considerations

Telehealth as a service delivery method has been shown to be more convenient for patients, to have “the potential to cost-effectively meet the therapeutic needs of children living in rural areas,” to be effective in assessing “the functional mobility needs of clients being assessed for new wheeled mobility devices,” to be a feasible and accurate method for “conducting pre-admission orthopaedic occupational therapy home visits,” and to be a significant factor in reducing costs and improving health conditions. However, the questions surrounding client privacy and confidentiality, the quality of care and communication, the client’s or caregiver’s competency with technology, the effective engagement of the client, and client and practitioner satisfaction loom largely in the minds of those considering or entering into this emerging market. These are professional standards issues.  It is important to remember that the method of delivery does not dictate a professional’s standards.  AOTA clearly states that “The Standards of Practice for Occupational Therapy are requirements for occupational therapists and occupational therapy assistance for the delivery of occupational therapy services.”  Further, The American Occupational Therapy Association Advisory Opinion for the Ethics Commission on Telehealth, section “Quality Care and Adherence to Standards,” states that

the “determination for appropriateness of occupational therapy intervention using telehealth technology should be made on a case-by-case basis according to sound clinical reasoning and should be consistent with published professional standards (Brennan et al., 2010). That is, a decision to implement telehealth service delivery should be client-centered and based on advocating for recipients to attain needed services (Principle 4B of the Code) rather than on factors related to convenience or administrative directives.”

The advisory also notes that therapists should maintain current knowledge of laws and AOTA policies regarding the delivery of services and the reimbursement for services policies, as well as understand the benefits and drawbacks of offering this type of service to clients.

More specific guidelines are offered in an AOTA paper titled, “Telehealth.” This paper outlines the use of telehealth within occupational therapy and addresses tele-evaluation, teleintervention, telerehabilitation, teleconsultation, and telemonitoring services.  It further addresses practitioner qualifications and ethical considers, including a table detailing “Ethical Considerations and Strategies for Practice Using Telehealth Technologies.”  Finally it briefly covers legal and regulatory considerations and funding and reimbursement.

 

Conclusion of Part 1

There is much unchartered territory facing occupational therapists and health care professionals in general as we look to provide services through the telehealth modalities.  However, the journey can be exciting as we venture into it in these beginning stages.

Part 2 will share more resources, as well as my experiences with telehealth; my thoughts and resources that address the benefits, drawbacks, and ethical concerns; as well as my impressions regarding the implications of these three areas in our practice.

 

Telehealth in Occupational Therapy Practice, Part 2: Start Up Q & A

The Handwriting is Fun! Blog is published by and is the property of Handwriting With Katherine.

 

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

 

 

 

 

 

Pictures above that are the property of the author must provide a link back to this article or her website.

 

1 Disclaimer: This article is provided for informational and educational purposes only and is not a substitute for legal advice or the professional judgement of health care professionals in evaluating and treating patients. The author encourages the reader to review and verify the timeliness of information found on supporting links before it is used to make professional decisions. The author also encourages practitioners to check their state OT regulatory board/agency for the latest information about regulatory requirements regarding the provision of occupational therapy via telehealth.

 

2 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.

Handwriting Help for Floating Hands

Handwriting Help for Floating Hands

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

on the Handwriting is Fun! Blog

 

 

 

 

 

 

 

Just recently, I received an email from an occupational therapist that I’ve been working with for quite some time.  She had a question concerning an issue that is very familiar to me.  She wrote:

I have a couple of students whose hands “float” off the tabletop (ulnar side of hand is not in contact with tabletop).  They tend to write with shoulder/elbow movements.  If I make them keep their hand on table, they then use wrist rather that finger excursion movements.

What do you recommend to help correct this?? More wrist work??  Finger mobility excursion work??

I though I’d share our conversation and the ideas that I have found to work in this situation.

 

Planning is Important!

 

Our time with students is precious and there’s always so much to do.  I’ve found that a schedule of activities helps me to keep on task and accomplish the goals that we’ve set for that session.  Also, a written or visual schedule helps the student follow and understand what his or her work will be for that day.  In the case of “floating hands,” I typically follow a strict schedule of tasks that will help both me and the student recognize progress and to uncover continued needs.

 

 

  1. Begin the session with gross motor work.    Although the students are using their shoulders to manipulate the pencil and negotiate the task, that doesn’t mean that they have strong upper body and/or core strength.  In fact, it could mean the opposite.  It takes strong muscles in those areas to maintain the arm and wrist positioning needed for a fluid and legible handwriting style.  Writers who use their shoulders and elbows in this way often benefit from lots of upper body and core strengthening activities.  I’d suggest starting each session with 10-15 minutes of upper body workouts: wheelbarrow races; wall pushups; yoga exercises such as the the plank and the warrior; and floor pushups if they are strong enough.  I even work on arm wrestling at the table.  Of course, be careful – lots of these students can take you down on that one!

 

Yoga Exercises

 

 

 

  1. In the same session, I’d move on to vertical activities.  These can be completed on papers taped to the wall or white board (but not completed with marker on the whiteboard, please*), a window pane, or an easel.   The activities I provide include drawing, doodling, word search, crossword puzzles, coloring, tracing, or any type of activity that places the wrist in the slightly extended position that is preferable for handwriting at the desk.  I usually take my students through another 10-15 minutes of this, making sure that I explain why the wrist needs to be placed just so and why it is important not to lean on the forearm to steady oneself or to rest against the wall.  The arm and hand need to move fluidly as they do while producing handwritten work at the desk.  During this segment of the session, I will provide the students with a break periodically to give the upper extremity a rest.  For example, after each 5-minute span, I offer a break that might include playing an ongoing game such as Operation, blowing a cotton ball across the table or floor at a target, putty exercises, or any board game that interests the student.  The type of break offered would reflect the student’s needs at that time, taking into consideration whether a fine-motor, vision, or simple “fun” activity would best suit his or her needs.

 

An important note:   During the vertical activities, the students should have their wrists and forearms in light contact with the wall and paper, allowing them to glide across the paper with a fluid movement as they perform the task. (Be sure to attend to the non-dominant hand, as well, ensuring that it is placed appropriately on the wall and paper.)  To help with the correct positioning, I may add a very light weighted wrist band on each wrist, draw a highlighted line where their wrist should maintain contact, and/or place light pressure on their wrists with my index finger to guide and remind them.  It takes time – lots sometimes – so be patient.

*And it is also important to avoid using markers or pens for these initial stages.  Pencils provide important tactile feedback that gives the student an increased awareness of his or her hand placement using the appropriate writing tool, of a sense of pressure on the pencil, and a feel for the movement of the hand.

 

 

Graph Drawings (You can find more resources in the Needs and Strategies Tool Box included with my book.)
Wikki Stix Activity

 

 

 

 

 

 

 

 

 

 

 

 

The Cotton Ball Game helps build efficient visual skills.
Doodles and Drawings

 

 

 

 

 

 

 

 

 

 

 

 

  1. Next, I’d move on to a fine-motor activity.   Exercises that include wrist work and finger mobility are excellent choices.    But,  before I asked the student to do too much fine-motor work, I would take into consideration the level of finger and hand fatigue the student is experiencing after the vertical surface work that has been done.  If they are very fatigued, I’d alternate the sequence of the vertical work
    Fine Motor Activities From Dollar Tree

    and the fine-motor in different sessions.  For example, on Monday I’d do the fine-motor first, then go on to the vertical.  Then on Wednesday, I’d begin with vertical and then move on to fine-motor, increasing the amount gradually relative to the fatigue levels.  The reason I do this is because it makes it easier for me to assess the fine motor before and after using those muscles in the vertical position.  Then, when the fine-motor is improving, then I might keep that portion for after the vertical.  It sounds like that is contrary to the way we typically conduct a session, and it is.  But in the case of floaters, we are mostly working on keeping the wrist and forearm in the appropriate positions.  So, I alternate the order for the tasks to keep me informed about those particular needs.  Sometimes, the student doesn’t really need much fine-motor strengthening.  If he or she is not gripping the pencil too tightly or loosely, then the floating may simply be a case of upper body and core strength.

Putty exercises on a slightly vertical surface to enhance awareness of the appropriate wrist positioning. (Picture is the property of Handwriting With Katherine.)

 

  1. At the end of the session, I would transfer the vertical task requirements to desk work, explaining that the same wrist positioning and movement applies to handwritten work performed at the desk.  At first, it is best not to work on handwriting in this portion of the session.  Bring down the drawings, doodling, or coloring activities that the student was working on and have him or her practice on those.  This eliminates the need for the student to monitor his or her handwriting quality.  As the student progresses with the vertical activities, then handwriting can be introduced here in the final stages of the session.

 

Now, I would most definitely check sensory skills.  Sometimes students simply don’t like the feeling of having the side of their hand moving across the paper. In that case (which I’ve only come across rarely in children without other sensory needs), I begin their work on the vertical surface by adding a piece of felt or soft cloth layered on the bottom portion of the paper.   This provides a “gentler” surface that allows them to move their hands over that portion of the paper.  I gradually remove the amount of time this strategy is included in the task.  If they don’t like smooth surfaces, then I would put a fabric such as a softer burlap there that will provide some texture and scratchiness to the surface.

 

 

These are my tried and true suggestions.  But, I’m sure that you have your own strategies that have worked for you and your students.  Please share them with us so that we can all learn from your experiences.

 

 

 

 

The Handwriting is Fun! Blog is published by and is the property of Handwriting With Katherine.

 

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

 

 

 

 

 

 

 

Pictures above are the property of the author and their just must provide a link back to this article or her website.

Pictures that are the property of the photographers at Pixabay and their use should include the link provided with the photo to give proper credit to their owners.

Use of the bubble wand picture should include a link back to the blog author.

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.

 

Kindergarten Readiness Skills

 

As this school year begins, some children will be entering pre-school and beginning to learn kindergarten readiness skills.  The stakes are higher now for kindergarteners, with this grade becoming the “new first grade.”  What was once a time for honing socialization skills, understanding school behaviors, and becoming familiar with the use of school utensils, kindergarten is now a place to jump in with both feet to learn math, language, and all about their world! Therefore, it is important for parents to be knowledgeable about what will be expected of their children when they open those kindergarten doors.

As therapists and teachers, it is important for us to understand this as well and to have resources at hand to help guide parents.  The blog below, “10 Handy Helpers for Kindergarten Readiness,” is just that – a resource for professionals and parents to share.  It provides a bit of research findings relative to kindergarten readiness, a general list of skills that kindergarteners are expected to have to enhance their learning and growth, and a group of easy-to-implement and family-friendly activities that can help build those readiness skills.

I hope that you will find it helpful!  Just click on the little gal below to read the article!

As always, thank you for reading!

 

Kindergarten readiness skills can be developed at home with simple everyday tasks!

 

 

 

The Handwriting is Fun! Blog is published and is the property of Handwriting With Katherine.

 

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

 

 

 

 

 

Pictures are the property of the author and must provide a link back to this article or her website.  Those that provide a link to the originating source should include that link when they are shared.

Picture included with the link to the article is the property of Pixabay.

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.

 

 

 

 

 

 

 

 

 

 

 

 

Pencil Grasp Repair: Strategies 101

Pencil Grasp Repair:  Strategies 101

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

on the Handwriting is Fun! Blog

Research results indicate that “the number of children who experience handwriting difficulties can be upwards of 27% in the primary grades (Volman, van Schendel, & Jongmans, 2006, as cited in Collmer, 2016, xiii).  Experts have identified a current trend that may result in handwriting difficulties and an inefficient pencil grasp:  presenting toddlers and preschool children with pencils and pencil activities before their motor muscles are ready for this complex fine motor task. (Collmer, 2016, p. 28)   Proper development of the muscles of the hand, both intrinsic and extrinsic, assist the writer in maintaining his grasp without pain or fatigue, with grip strength correlating with handwriting legibility in typically developing children. (Collmer, 2016, p. 29)  As occupational therapists, we play a key role in alerting educational staff about the hazards of pushing children into forming inefficient handwriting habits.  However, what do we do when we are presented with a student who has been struggling with his handwriting skills for quite some time; and who now, at the age of 9, is attempting to keep up with his peers in handwritten assignments?  Where do we begin?

I recently received a note from a seasoned occupational therapist who was striving to provide the best services to her young client.  She wrote:

“I have recently begun working with a student who is 9 years 4 months old. He is quite inefficient in the classroom due to the speed at which he completes his classwork.  This is concerning to the team as he approaches 4th grade.  His OT Evaluation revealed that he continues to use a static tripod grasp for all of the handwriting tasks.  I am curious about your experience with the static to dynamic transition for handwriting.  I am wondering if you have any thoughts on why some children do not transition to a dynamic grasp.  My assumption in this scenario is the lack of transition is related to poor postural control. For some reason, this one is just throwing me off a bit more than others to see an nearly nine and a half year old doing writing assignments from his shoulder.”

I did agree with this therapist that a common reason for a static tripod grasp is poor postural support.  Taking that assumption a step further, inefficient posture can also be an adaptation for the underlying reasons for his inefficient pencil grasp.  Poor shoulder, arm, wrist, hand, and finger muscles may cause the writer to grip the pencil tightly, brace his arm and elbow against his body, and produce movements from the shoulder instead of fluidly moving his hand and arm across the page.  I was excited about helping this therapist and her young man and I dove right in with a suggestion or two.  Since I had not seen this student’s grasp, I provided a strategy that I felt would help in most cases, discussing it as a step-by-step process from which I’d typically work.  Of course, we’d work on more than one strategy in the list at a time, with those presented close together complementing each other.  Both she and I thought it would be a nice idea to share it with you, too!

Step-by-Step:  Proximal to Distal

At this age, I turn to a very basic assessment that looks at shoulder, arm, wrist, and finger strength.  If it is determined that the grasping problems result from strength issues, then I begin there.  Experience has shown me that most times it will be!  At the start, I tend to do very little handwriting practice or paying much attention to changing the child’s grip during handwriting tasks, as most likely that is like trying to get blood from a stone.  Often, there’s been lots of practice and there’s been tons of hours spent on tips and tricks to change his grasping pattern with little success.  The frustration meter at this point has been pegged out for everyone concerned.  I’ve found the most success comes from working strictly with strengthening activities designed to address the child’s particular areas of concern.

  1.  I’d begin by concentrating on palmar arches and separation of the two sides of the hand.  There are plenty of exercises and activities that concentrate on these skills and can be adapted to his developmental level, helping him to open his web space and attain flexibility in his fine motor movements.  It’s important to be sure that he can perform thumb opposition efficiently, as well.  If not, include activities for that in this step.  This sets the stage for the following strategies.
  1.  At the same time, I would work on shoulder stability with upper body exercises or yoga activities.  Select activities that allow you to monitor progress with repetitions or quality of production, such as the plank, wall pushups, and indoor volleyball between you and him.  Work on drawing, sketching a map, or visual perceptual copying tasks on a vertical surface (such as a wall or window or chalk board – no dry erase please!), working with his wrist extended to 20 degrees and about 10 degrees of ulnar deviation. You won’t have to be as vigilant on correcting his positioning if he is working on these types of vertical surfaces since they will most often position his wrist and arm correctly by default!
Working on wrist extension on a vertical surface before tackling the thumb positioning. One step at a time!
Designs with Wikki Stix on a vertical surface to promote optimal wrist extension.
  1.  When he begins to experience some progress with No. 1 above, I’d include some bilateral fine motor activities such as molding clay or those that include cutting or putting things together.  This will begin to include his wrist and fingers of his dominant hand with help from his non-dominant.  Be sure he is resting his arms and hands on the table at first.  If he is performing everything “in the air,” chances are he’s using his shoulders to brace himself and he is less likely to move his hands and arms fluidly across the table (even in small bits) during the task, which is the goal in handwriting tasks.  Be sure that during these tasks, you are reminding him of the postural “must do’s” that you have been working on so far – back slightly bent toward the table so that he can see his work, elbows on the table, knees in front, feet flat on the floor.  I have to confess, I’m not as strict with every part of this as I used to be.  If the posture is working for the task and the child is not experiencing discomfort due to it, then I let it go and move on to the other things I’m working on.  If the posture is hindering the task, I have the student remind me what he needs to fix.  It helps to have a sign on the wall or a note on the desk that he can refer to during the activity.
  1.  Along with this, I’d begin to include core exercises in his routine (No. 2) above.  Alternating toe touches, modified sit ups, or yoga poses such as rocking the boat are great ways to add abdominal muscle work that is quantifiable and allows the student to monitor his progress.  (There are quite a few examples of exercises in the downloads included with my book.)
My favorite set of yoga exercises!
  1.  After some more progress is achieved with 1 and 3 above, which will be demonstrated by less dependence on his shoulder for movement and increased flexibility in his arm and wrist,  I’d add fine motor exercises – not tasks or activities. Strictly the same types of exercises that we would do with adults in a rehabilitation setting.  (I’ve included a handout for putty exercises in my downloads for my book.) They are simple to demonstrate and easy for him and his parents to follow at home….and they work.  I am leaving this until he has some upper body improvement because, as you know, development is proximal to distal.  Once we can get him to stabilize his shoulder and begin to move his arm in tandem with his hand, then he can begin to include fine motor movements to tie it all together.  The exercises are static, however, and do not involve much arm movement.  I try to mix the exercises in with some of the other activities above to add movement.  For instance, I might have the student perform one upper body exercise and then move over to the table for a fine motor, sequencing like that until both sets of exercises are completed.  Or I like to have them play a dice game where each number is attached to an upper body or fine motor exercise.  The student checks off which ones he’s completed and we roll the dice until they’ve all been done.  This way, the arm is working as well as the fingers.  It works to enhance flexibility.  You can also have the student perform the exercises standing up when his fine motor skills begin to get stronger.  This allows him to move his arms without support.  But be sure he’s not using his shoulder to stabilize too much!
  1.  When the above strategies are moving close to his final goals for those skills, I’d move on to adding about 5-10 minutes at the end of the session to work on activities that include handwriting – slowly at first.  I begin with a reminder of the appropriate ways that the shoulder, arm, wrist, hand, and fingers work together toward efficient handwriting skills.  Handwriting program workbooks often have great visuals to remind students of the placement of these parts.  (I know Universal Publishing’s books have great ones.)  I keep a checklist on the desk where the student can self monitor his positioning.  We work with tasks such as copying spelling or vocabulary words from the board in therapy to take home for study.  Even if this is a repeat of what he’s done in class, the task completion is being monitored by you and the student can actively practice his self monitoring techniques for use at home or in the classroom.  I like to have them write down directions to their home or the park or movie theater, make a list of items that they will need for their next camping trip or for what they want for lunch, or draw a picture and write a short, short description of what is happening in it.  It depends on what the child likes to do for fun.

Be sure to continue to include upper body exercises in his program to keep the muscles toned and ready for fine-motor work.  Most children love to continue with the putty exercises, too.  And that’s good because the fingers continue to need work at this point.  If he tires of them, there are others on line that he can try that use other materials or exercise tools.  It’s up to you and him.

  1.  Finally, when all of this is working, I shift from exercises to activities that concentrate on handwriting mastery.  We remain on vertical surfaces at first, moving to the table bit-by-bit as the student demonstrates transference of the skills he developed in the exercises and small tasks to specific handwriting activities.  If the quality of my student’s letter formation and alignment are good, then I’d work on speed and accuracy.  (Otherwise, I’d begin with those basics.)  I have some speed and accuracy activities in my downloads for my book; but I put a really effective one on my blog that’s not in there.  Here’s the link:
Minute Mania: Turning Handwriting into a Functional Tool by Katherine J. Collmer, M.Ed., OTR/L, on the Handwriting is Fun! Blog

I would work very slowly with students such as this guy.  I know sometimes that frustrates teachers and parents who want to see results right away for grading purposes.  However, slow but sure wins the race!  Posture is a problem for them.  But most of the time, their posture is poor because they are using their shoulder to stabilize their arm; and their wrists, hands, and fingers are too weak to form and maintain an appropriate grasp.  It is important to remember, too, that a functional grasp is not necessarily a pretty one.  If the grasp isn’t the traditional dynamic tripod grasp but his fingers aren’t white with pressure and he isn’t complaining about pain or fatigue in the hand, then it just might be an appropriate grasp.  In this case, to address speed and accuracy I would assess his shoulder and back muscles to determine their need for strengthening.  Just for fun, I’ve included a blog I wrote on functional grasping patterns.  If you have purchased my book, you may recognize parts of it, as some of the information is included in there:

Should we worry about pencil grip? by Katherine J. Collmer, M.Ed., OTR/L, on the Handwriting is Fun! Blog

I am pretty consistent in the method of my delivery, moving from gross motor, to vision skills, to fine motor, then function in my sessions, as I’m sure you all do.  I didn’t include any vision in the above, but these skills could easily be addressed in both types of exercises.

I really enjoyed working with this therapist and am looking forward to hearing her feedback about her student’s progress toward handwriting mastery!

As always, thank you so much for reading and sharing my work!

The Handwriting is Fun! Blog is published by and is the property of Handwriting With Katherine.

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

Reference:

  1. Collmer, K.  Handwriting Development Assessment and Remediation:  A Practice Model for Occupational Therapists.  2016 ed. Waymart, PA:  Universal Publishing, 2016. Print.

Pictures are the property of the author and must provide a link back to this article or her website.  Those that provide a link to the originating source should include that link when they are shared.

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.

Another look at Eye-Care Professionals

Vision skills are essential foundations for literacy, as well as the mastery of play and life skills.  Early detection of vision problems can set the stage for enhanced learning potential and the discovery of life-threatening diseases.  There are different types of eye-care professionals, each committed to a particular facet of vision skills.  It is important to understand the roles they each play in your child’s overall eye health.

One of my most popular blogs describes the roles of eye-care professionals, as well as important information about vision skills.  I share it here with you again as a resource for parents, teachers, and therapists.  Just click on those beautiful eyes to read it!

A Vision and Eye-Care Professional Primer for Occupational Therapists

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

Pictures that are marked the property of the author must provide a link back to this article or her website. All others must provide a link to the originating source.

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.

 

 

Slow Down! Handwriting is not a race!

Keijj44 pixabaySlow Down! Handwriting is not a race!

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

on the Handwriting is Fun! Blog

I recently received an inquiry through my Handwriting With Katherine website regarding an aspect of handwriting that can be the final mastery challenge for many of my older students: handwriting speed.  My reader wrote:

“I have a 6th grade boy who writes crazy fast!  He wrote 99 letters/minute today.  According to the criteria I have, he should only need to be writing ~50 letters per minute for his age (11 years old).  And of course it looks very messy.”

This therapist indicated that the student produced “great precision and control when he slows down;” and while his grip was not considered anything “to be desired,” it was functional and did not affect his precision. His speed was affecting his ability to produce legible written work.  The therapist also inquired about the use of metronomes and music to assist in slowing her writer down.

Since I’m sure there are many therapists and teachers who have students who race through their written assignments, I thought I’d share my response to her. Here are some tips for helping students to get out of the handwriting race!

Editing Skills provide a foundation for appropriate speed.

Writing too fast can actually slow the writer down.  This can be both a good and a not-so-good thing.  In both cases, this is only true if students have been taught self-editing skills.  Self-monitoring their own work has been shown to increase the students’ sense of ownership and responsibility for their work (Thomson & Gilchrist, ed., p. 123).  They should understand the reasons for editing and have been instructed in the appropriate ways to incorporate editing skills as they are writing.  The foundation for self-editing is an important facet of a structured and guided handwriting instruction program.  In the early learning stages, they are taught to review their handwriting skills by going back to review a line of letter formation practice exercises as they complete each one.  As they become more proficient and begin to write words then sentences, they will train their eyes to recognize letter formation, alignment, and spacing errors as they are writing.  With these editing tools in hand, speedy writers will find themselves having to frequently

Self-editing skills (Photo property of Handwriting with Katherine)
Self-editing skills
(Photo property of Handwriting with Katherine)

erase and rewrite their work during its production.  As they recognize an error, they will attend to it and make the corrections.  So, editing can slow the pace of students’ handwriting.  This is a good thing if the writers are not producing so many errors that the time used in erasing and correcting hampers their ability to produce legible written work that accurately shares their knowledge in a timely manner.  This would indicate that the students have not yet mastered the foundational skills necessary for handwriting mastery.  In this case, it is important to return to practice or rehabilitation activities that will address letter formation, alignment, and spacing skills.  If the writers are producing sloppy work because of speed and not due to poor foundational skills, and their current level of self-editing has not assisted them in slowing down, then I suggest a fun game to help them to become “turtles.”  (Don’t let the name fool you. This game is appropriate for children in all grades.)

The Turtle Race.  For students who write very, very fast, I present an activity that is the opposite of my “Minute Mania” strategy.  (You can find many other excellent handwriting activities in my book, “Handwriting Development Assessment and Remediaiton:  A Process Model for Occupational Therpists.” )
Where in the “Minute Mania” strategy you ask the student to write very fast and worry about editing later, the “Turtle Race” is just the opposite.  Although I feel that metronomes and music can be effective timing tools, they do not present the functional basis for slowing down in a “fun and playful” way.*  I feel that this activity can do just that!

1. As with the “Minute Mania” strategy, you and the student can come up with a silly sentence (versus words) consisting of 5-8 words (perhaps more depending upon the age and handwriting skill of the student).

2. Present the sentence in typewritten format to prevent confusion over letter formations or handwriting style and cut the words into individual pieces of paper.

3. Place the individual words in sentence format above the student’s paper or taped on the board, depending on what type of task you are working on (near or distance copying).

4. Provide the student with these directions:

• Explain that the object of the game is to help him slow his handwriting speed in order to produce legible written work in a timely manner. Discuss self-editing strategies and how they are used to recognize and correct handwriting errors during the writing process.  (If the student is unfamiliar with these strategies – e.g., attention to detail and focusing on the letters produced versus his hand or pencil – take time to provide some

Makamuki0

instruction in them.)  Discuss the importance of correcting errors right away, so that during writing assignments he won’t have so many words to edit after his assignment is complete.  Explain that in the “Turtle Game,” he will correct his work during the writing process.  In addition, he will conduct a final edit of his work at the end of the game. At that time, he will create a score for the game by recording the number of words that he needed to rewrite during the final edit.  Finally, be sure that the student understands that the lowest score during final editing is the better one.

• Explain to the student that you will be pointing to each word in the order it appears in the sentence and that he will have a certain amount of time during each pointing to copy the word.  Emphasize that he cannot move on to the next word until you have pointed to it, so the student has LOTS of time to write it as neatly as he can and to edit his work.  You can decide on the amount of time you will allow for each word.  For example, 30 seconds per word for very fast writers will provide them with a sense that they have enough time to go slow; and that even though they may go fast, they will have to wait until the time is up until they can move on.

*You can enhance the students’ sense of timing by adding a metronome to the game, using its rhythmic sound and speed to help the writers’ slow down their handwriting speed.  Be sure to explain and demonstrate its purpose in the game and gradually remove it from the game to encourage carryover in a functional task.

• Be sure to let the student know that he should edit his work as it is written and not to wait until the end.

• Finally, remind the student that final editing will occur after the game; and for each word that includes an error, he will be asked to rewrite the word correctly and record the number of words that required rewriting. Remind him that the lowest score during final editing is the better one.  You can even make up a rubric for this if you want to so the student can monitor his own progress and take responsibility for it after each session.

5.  Now, students will most likely continue to write very fast at first even though you’ve given them time to work on each word.  This is a habit; and just like any other, it will need time to be replaced with a better one.  Don’t get discouraged.  Let them work it out as the game goes along.

6.  After the student has written the entire sentence, have him conduct the final edit and rewrite each word below the original, allowing the same amount of time you provided for each word during the original writing.  Have the student tell you what needs to be edited; and if he cannot find the errors, go ahead and discuss each word and/or letter formation with him.

7.  Have the student record his score on a score pad or your rubric.  Be sure to discuss his progress to help him understand the types of corrective actions that can help him improve his score.

8.  Then, run the “Turtle Race” again, with the same sentence, using the same time limits, and reminding the studentFotoShopTofs pixabay that he will want to beat his own score. Self-competition is a friendly, less stressful strategy for some students.  For others, healthy competition with another person can facilitate an understanding of speed and the motivation to slow down.

• If you are working with an individual student, you can add a more competitive component by including yourself in the game.  Both you and the student can write the words of the sentence sticking to the time limits.  By working alongside the student, you can demonstrate appropriate speed and timing, allowing him to get a sense of how fast he is writing compared with your speed.

• If you are working with more than one student at a time in your session or within a classroom setting, you can group the students and have them compete with each other by comparing scores.  This set-up can also provide students with an opportunity to model their speed after the slower writers.

Ideas for turning this strategy from practice into function.

• You can work with the student’s vocabulary or spelling lists.  Instead of providing a sentence format, simply flip over the words as they are presented in the “Minute Mania” game using a specific time limit for each word.

• Story-telling works well to incorporate writing skills into the session (which is the ultimate goal for handwriting mastery).  Have the student dictate a very short story to you, type it or write it on the board, and then conduct the game as originally presented.  As you point out the words, the student is actually recording his own original story.

Be Patient!  Sometimes the “Turtle Game” strategy very quickly accomplishes its goal of alerting students to the need to slow down.  Other times, it can take a while but then it clicks in.  Be patient – with yourself, the student, and the game.  There will always be a learning curve and it’s best to just let the learning take its course.  Remember, each student learns differently and that approaches to the game need to take those learning styles into account.

Be Prepared!  As an introductory preparation for this game, its best to begin with an activity that focuses on gross motor skills, especially those that include a visual component that requires diminished speed and precision.

• Let’s say for the little ones, the activity can be as simple as having them carry small objects across the room with a spoon to deposit into a small container.  This can work for older children, as well, if the props are appropriate.

• For older children, try a tether ball activity.  Hang a soft baseball-sized ball by a string from an overhead light or a ceiling tile at a height slightly above or at the students’ eye level.  Have your students stand about an arm’s length away, slightly less, and bat at it lightly.  Explain to them that the object is to have the ball cross just over their midline, back and forth just traveling from shoulder to shoulder.  Speed will need to be slower in order to maintain shoulder width and to keep the ball in control.  To help the students measure their speed, have them recite the alphabet slowly with each tap.  It also helps to enter into a conversation with the students, demonstrating speed by measuring the timing of your words.  As they converse with you, the students can model your speed.

I feel it’s very important to keep the functional aspect of therapy in the forefront of the student’s mind. Why do we need to write slow?  For the same reason we need to walk slowly with the spoon or tap the ball lightly – to maintain control and accuracy.  During the “Turtle Race,” discuss the reason why control and accuracy are important – many times!  It’s the ultimate object of the game, after all!  Enjoy!

The Handwriting is Fun! Blog is published and is the property of Handwriting With Katherine.

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

Reference:  Thomson, P., Gilchrist, P., ed. Dyslexia – A multidisciplinary approach. Stanley Thornes (Publishers) Ltd., United Kingdom, 1997.

Pictures that are marked the property of the author must provide a link back to this article or her website. All others must provide a link to the originating source.

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.

From Flapping to Function: A Parent’s Guide to Autism and Hand Skills – A book review

 

from-flapping-to-function-picture

 

From Flapping to Function:  A Parent’s Guide to Autism and Hand Skills – A book review

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

on the Handwriting is Fun! Blog

 

 

 

 

 

From Flapping to Function:  A Parent’s Guide to Autism and Hand Skills advances the work of Barbara Smith, M.S., OTR/L, on the development of hand skills to a broader level and will serve as a relevant and worthy resource to both her profession and parents worldwide.  Barbara’s landmark book, From Rattles to Writing:  A Parent’s Guide to Hand Skills, won the National Association of Parenting Publications Award in 2011 and proved to be a valuable guide to parents and occupational therapists alike.  In her continued drive to enhance family education, she has organized her newest contribution to serve as an excellent companion tool aimed toward understanding sensory processing disorders and their impact on hand skill development.

 

A journey through Barbara’s book reveals the caring and insightful manner in which she carries out her practice of occupational therapy.  She has transformed what can be a perplexing disorder into a concise and parent-friendly outline of facts and definitions, linking them to the development of hand skills, and most importantly, providing easy-to-implement strategies to enhance the development of those skills.  The concise introduction provides the basics in a clear and understandable breakdown of the medical definition of Autism Spectrum Disorder (ASD) including the other conditions that commonly occur with it.  Barbara provides a list of key acronyms that will serve as a guide throughout the book.  Part I dives right into the uniqueness of each individual with autism and defines the developmental factors that may impact their hand skills – sensory processing, functional vision and visual perception, and executive functioning.  This section focuses on Sensory Processing Disorder (SPD) and defines the symptoms of the disorder itself, as well as three primary SPD types:  sensory modulation, sensory-based motor, and sensory discrimination disorders.  Each disorder is discussed relative to its symptoms and impact on the development of hand skills and is matched to a multitude of strategies that have been found beneficial to enhance hand skill development.

 

Perhaps my favorite chapter of the book is “Chapter 3:  Functional Vision, Visual Perception, and Hand Skills.”   Barbara provides not only the essential information about vision and its link to learning but also the critical red flags that can alert parents to the need for a vision assessment conducted by a developmental optometrist.  The greatest asset of this chapter, however, is her link between the visual symptoms of ASD and the adaptations and activities that can stimulate the visual system.  Very well done!

 

In Chapter 4, Barbara discusses executive functioning skills and their link to hand skills, providing adaptations that encourage and provide the “just right challenge” for “Getting Things Done!”  One of the most critical and confusing aspects of any remedial program is the implementation of appropriate reinforcement strategies that will promote learning and generalization.  Barbara does an excellent job of explaining positive reinforcers that use movement and sensory input to produce the desired response while meeting the child’s needs.  Of course, the discussion of each type of reinforcement comes with its own list of possible interventions.

 

Part II focuses on Interventions and can best be described as the “go-to source” for teaching strategies.  The book stays true to the occupational therapy perspective of linking the strategies utilized in skill development to the eventual functionality of a skill, defining generalization with familiar examples. Barbara provides parents (and therapists, too) with approaches for self-regulation, methods for grading tasks, the concept of “The 80-20 Rule” used in education (you must read the book to find out!), the effective use of nonverbal directions and “success-only adaptations,” and the backward and forward chaining strategies for breaking tasks into steps.  Forever true to her Recycling Occupational Therapist’s mission, Barbara provides a treasure trove of activities that are created from items found in every home and that address the enhancement of skills in the most functional ways.  And for many of them, she includes pictures!

 

The most important element of any book is the reader’s ability to understand the content and to reflect on its meaning.  Barbara has achieved that goal by providing her readers with the opportunity to do that with Summary outlines at the end of each section.  These bulleted reviews reinforce the key facets of the chapter and ensure the readers’ understanding of what they have just read while they guide them toward the next section.

 

Once again, Barbara Smith has delved into her vast bank of experience, both professional and personal, to present us with a guide that will become frayed at the edges and littered with yellow highlights as we put it to use in our family and therapy lives.  Thank you, Barabara!

 

 

 

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 forCollmer Book addressing handwriting development needs. She can be contacted via her website, Handwriting With Katherine.

 

 

 

 

 

 

 

 

Pictures are the property of the Barbara A. Smith, MS, OTR/L and must provide a link back to this article, the link provided,  or her website.
 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.

10 Must-Haves in your Handwriting Tool Box

-----My OT Tool Box-----
——————-My OT Tool Box——————-

10 Must-Haves in your Handwriting Tool Box

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

on the Handwriting is Fun! blog

Helping students work on their handwriting development skills is fun and exciting!  And there are so many cool games, gadgets, toys, and widgets out there to gather up and hoard in our OT Tool Boxes.  Unfortunately, too much of a good thing leads to….well, too much of a good thing!  It’s often necessary to weed out the extraneous (no matter how many you were able to buy at The Dollar Store!) and pick out the tools that will serve the needs of your diverse groups of children in the most efficient manner.  Those are the gadgets and widgets that can be used in multiple ways to address a variety of developmental skills for children within a wide age range and who have many types of diagnoses.   Yes, it can be done!

My OT Tool Box has traveled with me from Maine to Maryland to Massachusetts and finally to Arizona.  It has held basically the same items for all these years, beginning in the days when I was new to the pediatric scene until these times when I’ve got the thought of retirement tucked away in the peaceful, relaxing spot in my mind.  I’m sure you have some type of box or bag that holds your treasured items, as well.  I thought I’d share my must-haves in the hopes that you will share yours, too!  Here goes!

My OT Tool Box

All of my sessions are organized in the same way:

  • Gross Motor Warm Ups
  • Vision Skill Warm Ups
  • Visual-Perception Work
  • Fine-Motor Work
  • Functional Handwriting Tasks.

So, I’ve organized my tool box outline in the same manner.

Gross Motor Warm-Ups:

  1. Balls and balloons are indispensable to me! A foam ball or two and a bag of balloons can carry us through balance and movement actions that
    In Toys and Games on Amazon.com
    In Toys and Games on Amazon.com

    also provide a touch of vision challenges.  Reaching, throwing, catching, kicking, and juggling are great ways to warm up the large muscles and to prepare the body’s core for fine motor work.  These are the muscles that help children sit appropriately and quietly while they work on handwritten assignments.

 

  1. Yoga – can you beat it for covering just about every muscle group need there is?  While balls and balloons provide action movements to wake up the muscles, yoga positions help the muscles pay attention to the commands directed at them.  Sitting with appropriate posture requires both strong and coordinated muscles.  And best yet, yoga is a double-duty activity.  Performing yoga exercises at the beginning of a session helps to prepare the large muscles, as well as the brain, for the precision work ahead.  Including yoga positions at the end of the session gives the large muscles time to reenergize with oxygen and provides the student with a cool down period before reentering the classroom.

Yoga

There are many free downloadable yoga charts on the internet with moves designed just for children.  It’s important to choose ones that provide easy-to-understand directions in case you want to include them in the student’s home program.

Vision Skills Warm-Ups:

  1. The Cotton Ball Game* has been a favored vision skill assessment and remediation tool for both me and my students for quite some time now. It’s a great way to warm up the eyes and the visual system for both close and distance work.  Blowing on a straw addresses divergence, or the ability of the eyes to move outward simultaneously and focus together on an object in the distance to produce a single picture.  This skill is especially helpful during copying-from-the board activities.  Convergence, or the ability of the eyes to move inward simultaneously during close work, is addressed by sucking on a straw.  Just a cotton ball or two and a few straws can be magically turned into target or carry games that address these important vision skills.
The Cotton Ball Game helps build efficient visual skills.
The Cotton Ball Game helps build efficient visual skills. (Photo is the property of Handwriting With Katherine.)
Cotton Ball Game
(Photo is the property of Handwriting With Katherine.)

Have your students create and produce a target as part of their fine-motor work and then use it in the next session to warm up their eyes in the Cotton Ball Game.  They can move the cotton ball along a track (created with masking tape) by blowing through the straw or carry it across the table toward the target by sucking on the straw to keep it stuck there.  Your students will love creating the track on the floor or a table, making intricate maze designs that will challenge their vision skills.

  1. Word Search Books (or free downloadable puzzles) come in very handy for vision skill warm-ups. It is important to prepare the eyes for fine motor work, especially scanning and tracking, to set the students up for achieving their personal best in your session.  These activities also serve double-duty as they can be included in your visual perception portion of the session!  If they are not completely finished during the session, they are simple to include in the students’ home programs.

Visual-Perceptual Work:

  1. Tangrams are terrific! I know that there a lot of expensive kits you can buy with plastic, colorful tangram pieces.  But, there are also free downloads that will provide you with tangram kits that you can cut out, ask the children to color them if you’d like, then laminate them to preserve them for use year after year.  I was fortunate to have purchased a Getting It Write **  book by LouAnne Audette and Anne Karson that provided a great group of tangrams (shown below).  The answer keys are separate and that helped me a great deal when BOTH the student and I were having trouble figuring the picture out.  Of course, I got to peek at the answer; they did not!  (But I did give them hints!)
Tangrams
(Photo is the property of Handwriting With Katherine.)

Tangrams work on visual closure, visual discrimination, and visual spatial relationships skills, while they enhance visual attention skills.

  1. Small playing cards are a dream tool to have on hand. Small ones help to develop fine motor skills and can work on so many visual-perceptual skills at the same time.
  • They can be used for memory games such as Concentration, where the cards are placed face down and then two are turned over to expose their faces.  If they are not a match, then they are turned over again and the next person reveals two more.  As the card faces are revealed, the object is to remember where you saw that one before and turn it over for a match!  Concentration games are wonderfully fun ways to enhance visual memory, visual attention, and visual discrimination skills.

how-to-play-concentration-1

  • Playing cards can be used for sequencing games such as those that teach math (1) to encourage the enhancement of visual attention and visual sequencing skills.  War, the ever popular two-person game, is great for visual attention and visual memory.  To change this game up a bit, I made small playing cards out of cardstock that each had a letter of the alphabet on them, then laminated them.  We played sequencing games and war by ranking the letters according to their placement in the alphabet.  Just think of all the ways you can then include handwriting practice in the game?  (Hint:  The student can write the letter or words that begin with the letter on his handwriting paper!)
  • My favorite small playing card game of all is The Number 10 Game!*  A long time ago, I found a small card game called that in a dollar-type store in Canada.  The cards had simple numbers on them from 1-10.  I still have those cards, although they are pretty worn out.  I wasn’t ever able to find the game again; so I use small playing cards now, removing the face cards and using just the number cards.  The goal is to find all the matches that add up to 10.  It’s simple to set up and a fun way to address both fine motor and visual-perceptual skills.  First the cards are set up in 4 rows with 4 cards in a row.  As the students make a match, those cards are put off to the side.  When there are no more matches in that set up, the removed cards are replaced to fill in the rows and the student continues to find more tens.  You can decrease the number of rows depending on your students’ strengths and needs.  If your students have difficulty with math concepts, post an addition chart by the table or next to the game so that they can reference it.  However, if your students are proficient in their addition skills, then you can set up the game as a race to beat their personal best.  Of course, I’ve played it with them as a race; but most often the scales are tipped unfairly – with them beating me every time!!!
Number 10 Game
(Photo is the property of Handwriting With Katherine.)

Fine-Motor Work:

  1. Putty, Always Putty!!! Therapeutic putty maintains a permanent place of honor in my tool box.  I don’t leave home without it.  Pegs, golf tees, marbles, tweezers, and coins are staples that come along for the ride, giving my students a fine-motor workout while they play.  Both the younger and older students enjoy creating objects out of the putty, rolling it out again, and setting their creative juices to work on it once more.  I do have a set of putty exercises* we work on, too, which often becomes part of their home programs.  For the more advanced students, I bring along clay especially for them so that they can warm up their fingers before beginning handwriting tasks.
Fine Motor Tools
(Photo is the property of Handwriting With Katherine.)
  1. My collection of fine-motor sundries make hand and finger warm-ups fun. Small sponge pieces, blocks, paper clips, and pegs match up with tweezers and tongs to exercise the arches of the hand and the fingers and wrist.  These pieces can be combined to outline the directional concepts of a letter formation, to place along the pathway of a maze, or to stack and create an object.  Pickup Sticks work the pincer grasp, shoulder and arm control, and visual attention and figure-ground discrimination skills.  Patience and critical thinking are added bonus skills that are touched on in this game!  Dice are wonderful tools to enhance in-hand manipulation skills.  They can be used during board games or activities that you design to address the handwriting development skills your students are working on.  For instance, you can play BINGO with them using the numbers they roll to determine what the students will write in the boxes.  In the example below, the die is rolled twice.  With the first roll, a 1 would indicate that the student would write a lower case “u.”  With the second roll, a 4 would indicate that the student would write that letter in the first box in the “G” column.  I always play along with the student so that we could compete to win.  The game would continue until the first person had BINGO!

Bingo Rules for Site

I’ve also used dice with the small playing cards, changing the Number 10 Game rules just a bit.  After the cards are set up, the student rolls the dice and selects the cards that add up to that number.  When all of those matches are made and the rows are filled in with additional cards again, the student rolls the dice again for a new number.  This adds to the suspense!

Functional Handwriting Tasks:

  1. I always carry a supply of postcards, sticky notes, children’s stationery, and lined and blank paper with me. The blank paper comes in handy for the younger children to draw a picture and then write a short story on handwriting paper describing what their picture shows me.  The older children can draw a directional map to guide me to their favorite place in town or a room diagram to show me what their living room or classroom looks like.  They label the items in their best handwriting and then write directions to the place or a provide a description of it.  To practice writing in small spaces, the students can write a postcard to a friend, their sister, or the teacher and hand deliver it; write the teacher or their parent a message on the sticky note; or write a recipe on an index card to share with me (they usually do this as part of their home program).  Handwriting practice that doesn’t look like handwriting practice.
  1. The most functional tool in my tool box doesn’t actually come with me to the session.  I often ask the students to bring in a homework or classwork assignment that addresses their particular handwriting need.  They will bring in their worksheets that include small, unlined spaces; book reports that are not quite completed; or math and spelling sheets.  These provide us with opportunities to work on spatial and editing skills, as well as discuss the areas that give them problems in class and at home.

Last but not least.

Other Tools
(Photo property of Handwriting With Katherine.)
Chalk Board
(Photo property of Handwriting With Katherine.)

I also carry a stash of supplies that will come in handy when the need presents itself.  A roll of blank paper and masking tape are two essentials to have on hand to practice letter formations skills (with drawings, doodles, mazes, or tracing) using large motor movements on a vertical surface.  Of course, sand paper, aluminum foil, and tissue paper are must haves for tactile feedback tools for pencil pressure.   I never leave home without my small chalkboard (have had this one for years!), tons of chalk, Q-tips, and a paper cup for water!  There is simply nothing that can replace these tools for the development of motor memory skills.  Writing the letters with chalk and then tracing over them with a Q-tip dipped in water is my all-time favorite disappearing act trick!  I usually have a bunch of construction paper on hand, too, to use as a substitute for the chalk board.  We write the letter in chalk on the paper and then trace it with the wet Q-tip.  (PS:  I never use white boards or markers.  Not enough tactile input to make the activity beneficial.  I like to get the most out of every minute the students are with me!)

So there you have it!

Well, I guess if you add up all of the individual pieces in my tool box, I wouldn’t be able to cash out in the “Around 15 items” checkout at the grocery store!  But, all in all, these are the tools I have been carting around for years.  I don’t know if they are the best ones; but I do know one thing.  Whenever I get overly creative and start to stuff boxes of toys and equipment into my trunk and lug them into the session, the children and I most often revert back to the old standbys!

Please let me and your fellow readers know “What’s in your tool box?”

And as always, thanks for reading and sharing my work!

*These activities, and many more, are included as downloadable handouts in my Handwriting Development Assessment and Remediation book.

**Updated 07/13/19:  It appears that the Getting It Write book is no longer available.

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

(1) https://topnotchteaching.com/math/math-card-games/
Pictures are the property of the author and must provide a link back to this article or her website.  If the photos are linked to another source, their use must provide a link to the originating source.
 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.

Handwriting: You can take it personal.

Betty Edwards Quote Handwriting
Quote from Betty Edwards: http://drawright.com

 

Handwriting:  You can take it personal.

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

on the Handwriting is Fun! Blog

 

 

 

 

 

The goal of a handwriting instruction program is to guide the writer toward an efficient handwriting style that is both fluid and legible.  Good penmanship is often defined by the level of proficiency the writer has achieved with the formations of letters, their proper placement on the lines and the paper, and the ability of the reader to interpret the intended message.  But how important is good penmanship?

 

From One Perspective

In a review of Tamara Plakins Thornton’s book, Handwriting in America:  A Cultural History, Dyas Lawson reveals the author’s interesting perspective of good penmanship.  It seems that Ms. Thornton had a “secret conviction that good penmanship does not matter, that if anything it Handwriting in America Thorntondenotes a person who is fearful or incapable of being in any way unusual.”  She goes on to say that the belief that one’s personality is reflected in his or her handwriting leads us to consider that a penmanship style that conflicts with the impression of “what teachers would call good handwriting,” one that conforms to the rules and looks like the formations printed in the instruction workbooks, would be the “mark of individuality” (as cited in Lawson, n.d., para. 3).  Yes, conformity is the standard of proficiency.   An effective handwriting instruction program demands a regimented curriculum and can indeed appear to be conducted in a “militaristic” fashion, as Lawson described the A. N. Palmer methods teachers used in their classes.  Lawson concedes, however, that although their practice began with the “issuing [of] commands: ‘Pens. Position. Circles’,” the teacher did “get results” (Lawson, n.d., para. 5).  I have always considered the process of learning and mastering the skill to write letters to lead to the discovery of a comfortable and personalized handwriting style with which to convey thoughts, feelings, and knowledge efficiently.  It seems strange somehow that an adult’s use of an individualized, nonconforming form of expression should be considered a weakness when it should be treated as a strength, a culmination of the years of practice and use of a handwriting style. If it’s legible, I consider it to be good penmanship.  Why are we still judged by our handwriting?   Perhaps the evolution of handwriting, the various places it has held in society, and its transition into a formal mode of communication has set the stage for this all-or-nothing standard for proficiency.

 

Some (a lot of) History

The birth of writing.  Not long ago, formal penmanship instruction was considered to be a valuable school subject, one that was taught with as much rigor as reading, math, and science.  But long before the introduction of standardized forms of handwriting that would serve as communication tools in every facet of life, cultures were concerned more about the basic need to exchange information to document their norms and histories. The earliest known form of communication presented in what we now call writing may have been cave paintings called pictographs and petroglyphs (paintings and incised pictures on stone, respectively) (Introduction to the History, n.d.).   Sumerian cuneiform, written with a reed stylus, and Egyptian hieroglyphics, carved in stone or painted on papyrus, as well as early Kanji Chinese letter forms, are considered to be the origins of writing, providing people with “a codified system of standard symbols:  the repetition of agreed-upon simple shapes to represent ideas” (History of Handwriting, n.d., p. 1).  The pictographs and ideographs (a combination of pictographs used to represent ideas) used in these methods of writing provided people within those cultures an opportunity to record their thoughts and creative ideas, as well as document their histories, discoveries, and theories (History of Handwriting, n.d.  p. 1) But not just any people.

 

These methods were specialized tools for communication comprised of many signs that took scribes years to master.  Originally, hieroglyphics were used to present religious writings and scribes were valued and highly respected, ranking at the top of the social chart.  Only those families with money could send their boys to school to learn this skill and those who were chosen to perform this task did not pay taxes, have to perform any military hieroglyphs pcdazero pixabayduties, or do manual labor.  (Egyptian Scribes, n.d., para. 2)  During the period before the invention of the printing press, handwriting skills were considered valuable rights that could enhance your life and prevent you from being “sent out into the fields to mow hay or to plow” (Saba, 2011, para. 6).  Scribes dedicated their lives to produce books and manuscripts in monasteries and it is thought that each monastery had its own style of handwriting (Saba, 2011).   Arnie Sanders, an associate professor of English at Goucher College in Baltimore, reveals that “The real purpose of writing was to propagate the word of God, and to regulate the worship of God.  That’s what kept handwriting alive, and why it was taught as a vocation” (as cited in Saba, 2011, para. 8).  As writing continued to maintain its status as an important religious documentation tool, it is felt that the demand of a more expeditious and legible script most likely led to the creation of the alphabet (Introduction to the History, n.d.).

 

The journey of the alphabet.  The Phoenicians developed a 22-letter phonetically-based alphabet that translated “ideographic writing to phonetic writing” (Introduction to the History, n.d., p. 8).  This spread to Greece, where it was transformed into an alphabet using 24 letters, including vowels.   This was later adopted by the Romans, who used 23 letter forms and additional consonants.  This alphabet consisted of only capital letters, with a more informal script developed later that “was the earliest sign of lowercase letter forms, with ascenders, descenders and ligatures between the letters” (History of Handwriting, n.d., p. 3) and would be used to record transactions and conduct correspondence.

The invention of the printing press and the creation of the “very delicate type faces with many flourishes and curliques in [their] script-like letters” (History of Handwriting, n.d., p. 4) resulted in the production of aesthetic looking documents.  The desire to emulate this style of print elevated the advantages of having an elegant handwriting style.  Those who possessed one enjoyed a higher social status.  It is felt that “it took the printing press to create a notion of handwriting as a sign of self,” (Atrubek, 2009, p. 3) slowly becoming a “form of self-expression when it ceased to be the primary mode of written communication.” (p. 4).

 

You are your handwriting.  At this point, handwriting had remained a somewhat personal skill, following prescribed alphabets but allowing for its presentation to be more class-based rather than conforming to a standardized format.  Clerks, engravers, ladies, and gentlemen all produced handwriting The Fountain Pen Network handwritingstyles that pointed to their individual stations in life.  During Colonial times, a handwritten document could readily identify the writer’s “social status, educational level, and relative importance in society” (Lawson, n.d., para. 8)  And although prominent figures in society, such as Benjamin Franklin, strongly supported good penmanship, only wealthy men were afforded the opportunity to learn it.  Encyclopedias and books included entries to illustrate appropriate writing equipment and grip, as well as the proper seated posture for writing (Makala, 2013, p. 8), and reference volumes were printed to educate clerks or tradesmen on the written transactions used in business (p. 10).   When training was finally offered to educate teachers as well as the general public on handwriting styles, it is evident that penmanship was considered a valuable and economically viable skill to sell.  Documentation recorded in 1849 indicates that “100 writing academies [were registered] in New Hampshire and 272 in Rhode Island” (Kaminski, n.d., (section “Understanding Edison’s Writing”).

During this time, penmanship instruction books for students were being developed to encourage the advancement of specific handwriting styles.  And handwriting styles became a topic of discussion among educators.  When public education was established and formal methods of handwriting instruction were being developed during the early 19th century, the leaders in handwriting instruction began to consideration the relative benefits of a “synthetic method [of] teaching” versus a “muscular-movement” method (Doughtery, 1917, p. 281).  This led to the debate over the importance of learning the individual stokes that formed a letter (synthetic) versus understanding the influence of the arms, hands, and fingers in the process of writing (muscular-movement). During the later years of that century, the elements of handwriting instruction that sparked concern in the minds of educators were not only the style of handwriting to teach and the method of instruction, but also the question of paper positioning and the desks that would facilitate its mastery.  (Doughtery, 1917)

 

Enter Mr. Spencer.  By the mid-19th century, those interested in developing an efficient handwriting system turned to a combination of the methods described above, with an emphasis on forearm movement included in the teaching of letter formations.  Platt Rogers Spencer, considered by some to be “the father of American handwriting,” (Atrubek, 2009, p. 3) designed what would become “the first accepted American standard for learningSpencerian Penmanship TheoryAndCopyBookSet Mott Media penmanship” (Introduction to the History, n.d., p. 22).  He built a chain of business schools to teach his script, believing that its mastery would “make someone refined, genteel, upstanding” (Handwriting is History, p. 3).  The Spencerian method was a form of cursive that included “ornate and sinuous” strokes (Cohen, 2012, para. 3) and was quickly adopted by schools and businesses.  Spencerian script was introduced and taught in schools from the 1860s to the 1920s (Handwriting is History, n.d.).  Also during this time, the creation of a public school grading system led to the creation of handwriting books designed to fit the developmental needs of the students in each grade (Doughtery, 1917).

 

At this time, some handwriting masters thought that “vertical writing,” or one produced without a slant, would be a preferable style “based on superior hygienic conditions” (Doughtery, 1917, p. 283).  I’m not quite clear about what Doughtery was referring to here; but I’m assuming that vertical writing produced in conjunction with vertical paper placement may have been felt to be more conducive to maintaining an upright body position to facilitate posture and to reduce eyestrain, for the author notes that neither of these were remedied by this handwriting practice.  She further notes that vertical writing “was found to be inefficient from the viewpoint of speed and legibility and so was abandoned” (p. 283) at the end of the 19th century.

 

Here comes the point!  The 20th century brought with it once again the demand for a style of writing that was more efficient in terms of speed and formation.   The Spencerian method was thought to be “too slow, ornamental, and inefficient,” (Makala, 2013, p. 14) requiring the writer to lift the pen off the page, sacrificing legibility for speed.  A. N. Palmer considered the Spencerian script to be less suited to the industrial age and created a “plain and rapid style” (Artubek, 2009, p. 3), the Palmer Method.   In the late 19th century, educators adopted his regimented program that utilized his strategy for teaching letter formations first on a chalk board using large arm movements and then gradually reducing the size of the letter formations until the appropriate size was achieved on paper (Lawson, n.d.).  (Sound familiar, OTs?)  Dyas Lawson sums up the significance of the implementation of this regimented format for handwriting instruction succinctly:

 

“As typewriting had mechanized office communication, Palmer turned individual writers into machines – the social importance ascribed to handwriting had again transmogrified from an integral indicator of character to a disconnected musculoskeletal function” (p. 5).

 

Lawson does concede, however, that Palmer did provide an efficient handwriting style that was uniform and legible.  The Palmer method was the “dominant tradition in American handwriting instruction from the 1890’s,” (Makala, 2013, p. 14) finally being unseated as the favored program in the mid-twentieth century.  At that time, educators felt it was more advantageous to teach manuscript first to initiate children into writing instruction sooner, followed by cursive when manuscript was mastered (Atrubek, 2009; Makala, 2013).

 

Penmanship Folder
Photo property of Handwriting With Katherine
----------------My dad's!---------------
———————–My dad’s!———————- Photo property of Handwriting With Katherine

 

 

 

 

 

 

 

 

 

 

 

But what does all of this history tell us about the relative importance of good penmanship and the relevance of an individual style of handwriting that defines us as a person and conveys our message in a way that no one else can?  What does Thornton’s conviction in her 1996 book say about the insidious decline of handwriting instruction – or the importance of it – in our schools, where once it was considered so very important that children stood at chalkboards day after day learning to master Palmer’s plain and rapid strokes?  What does the need for constant reaffirmation about the influence of learning handwriting formations on literacy development say about a culture that has prided itself as a leader in education, job growth, and innovation?  When at one point, we felt handwriting proficiency was so important that scribes dedicated their lives to learning it, when only the wealthy were afforded the skill, and when your handwriting could identify your station in society.  When, at a time not so long ago, those who valued handwriting feared that the typewriter threatened to take away the intimacy of self-expression that a handwritten document represented.  Was Thornton correct?  Is handwriting proficiency simply a way to shackle us to conformity?  Or is it a learning tool that guides us to literacy?  And a personalized mark that we leave as our legacy?

 

 

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 forCollmer Book addressing handwriting development needs. She can be contacted via her website, Handwriting With Katherine.

 

 

 

 

 

 

 

Pictures that are marked the property of the author must provide a link back to this article or her website.  All others must provide a link to the originating source.
 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.

 

References:
Atrubek. (2009, December 16). Handwriting is History. Pacific Standard. https://psmag.com/handwriting-is-history-9312bc557e07#.lwcwre79l
Cohen, J. (2012). A Brief History of Penmanship on National Handwriting Day [PDF]. New York: A&E Networks. http://www.history.com/news/a-brief-history-of-penmanship-on- national-handwriting-day
Dougherty, M. L. (1917). History of the Teaching of Handwriting in America. The Elementary School Journal, 18(4), 280-286. doi:10.1086/454610
Egyptian Scribes [HTML]. (n.d.). Dublin: History for Kids: Free history network for kids. http://www.historyforkids.net/egyptian-scribes.html
History of Handwriting: The development of handwriting and the modern alphabet [HTL]. (n.d.). Hood River: Letter. https://www.vletter.com/help/font-faq/history-of-handwriting.html
Introduction to the History of Handwriting Guideline for SAFDE Mambers [PDF]. (n.d.). Southeastern Association of Forensic Document Examiners. http://www.safde.org/hwhistory.pdf
Kaminski, D. (n.d.). The Varieties and Complexities of American Handwriting and Penmanship: Library Hand. David Kaminsky. retrieved on 27 July 2016 at http://scalar.usc.edu/works/handwriting/index
Lawson, D. A. (n.d.). Handwriting in America a cultural history, book review [HTML]. PaperPenalia. http://www.paperpenalia.com/history.html
Makala, J. (2013, October 13). “Born to please”: The Art of Handwriting Instruction [PDF]. Columbia: Thomas Cooper Library, University of South Carolina. library.sc.edu/spcoll/_current/Handwriting.pdf
Saba, M. (2011, August 26). Handwriting through the ages: An abridged history of English script [IRPT]. Atlanta: Cable News Network. http://www.cnn.com/2011/IREPORT/08/26/handwriting.history.irpt/

 

 

 

 

 

 

 

 

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