Directive Drawing: A Handwriting Tool

Author Jason Gonzales, OTR/L, discusses why drawing is the most consistent strategy he uses to improve a student’s fine motor skills, attention, and most importantly self-confidence. He finds that combining drawing, writing, and academics into the same activity aids in increasing these skills.

Directive Drawing: A Handwriting Tool

By Jason Gonzales, OTR/L

on the Handwriting is Fun! Blog


It is now my 19th year as a school-based occupational therapist. I have worked in five states, in at least 15 school districts, and I’ve lost count of how many schools. I have worked with children from the islands of Hawaii to the urban areas of New York City and have treated a variety of diagnosis including dysgraphia, autism, dyslexia, and ADHD. When asked during a job interview what materials I would need, my answer was always “pencil and paper.” And it wasn’t to practice copying the letters of the alphabet, but to draw. Drawing is the most consistent strategy that I use to improve a student’s fine motor skills, attention, and most importantly self-confidence. From my experience, handwriting needs are the most common reason why a student is referred for occupational therapy. The quality of the student’s handwriting can be impacted by a variety reasons including poor letter formation, line orientation, and spacing and size, possibly due to decreased fine motor strength, endurance, motor coordination, posture, motivation, or visual perceptual skills. Drawing can address all of these areas and it’s one of the easiest activities to grade based on a child’s abilities. And there is research to back this up.


Teachers are beginning to use drawing as a problem-solving tool with the feeling that the pictures students create

help them to keep track of information that is difficult to process and help them to “see concepts from a different perspective, giving [them] ideas on how to proceed with a problem. (1)” Considering that “drawing (scribbling, actually) is the first step in the development of the graphomotor skills necessary for handwriting mastery (2 p. 16)”, it makes sense to include it in a plan to enhance a student’s handwritten work. The process of creating a picture using colors, shapes, and elements correlates with the process of learning handwriting skills. Each process “combine(s) the arrangement of shapes, elements, and sometimes colors into a language that sends a message considered important to share with someone (2, p. 16).” In addition, art offers children with an opportunity to develop visual-motor and visual-perceptual skills that will benefit their handwriting practice.

A research study conducted by Fernandes, Wammes, and Meade (3) was designed to explore whether drawing the information that they were expected to learned enhanced the memory of undergraduate students. The findings revealed that:

• The students realized greater gains from drawing the information than from “other known mnemonic techniques, such as semantic elaboration, visualization, writing, and even tracing the to-be-remembered information (3 abstract)”.

• It was believed that “the benefit arises because drawing helps to create a more cohesive memory trace that better integrates visual, motor and semantic information. (Wammes quoted in 5)

• “Participants often recalled more than twice as many drawn than written words. (Wammes quoted in 5)”

• These benefits were realized across learning styles and artistic talent levels and included note taking as well as the understanding of complex concepts (3 shared in 4, p. 2-3).

The researchers believed that drawing provides an opportunity to take an active role in learning where we “must elaborate on its meaning and semantic features, engage in the actual hand movements needed for drawing (motor action), and visually inspect [the] created picture (pictorial processing) (3 as cited in 4, p. 2-3).”

And that appears to hold true for elementary school students as well. A study by Norris, Reichard, and Mokhtari titled, “The Influence of Drawing on Third Graders’ Writing Performance (6),” “compared the writing products of 60 third grade students who drew before writing a story on a self-selected topic (Experimental Group) with the writing products of 59 third grade students who simply wrote without drawing (Control Group).” The results showed that students who engaged first in a drawing activity,

• “tended to produce more words, sentences, and idea units, and their overall writing performance was higher;”
• “seemed to be much more enthusiastic about the visits from [the] researcher;”
• at times “independently drew about and composed extra stories, according to their teachers;” and
• demonstrated pleasure with writing experiences (6, p. 25).

In contrast, those students who were not afforded the opportunity to draw first before writing:

• were less enthusiastic about the writing task; and
• appeared to be “stymied completely after writing only a few lines,” seemingly “suffering from lack of confidence in their writing ability,”
• with some stopping their writing “well in advance of the required time limit (6, p. 25-26).”

Another significant finding was that these results were consistent for both boys and girls, regardless of group membership (6, p. 26).

(Click on The Grinch picture at the top of this article for a free downloadable resource containing these research results.)

Directive Drawing as a Tool

Armed with that research, we can now take a look at how drawing activities work with my students.

I typically use directive drawing activities which can be completed at a pace that allows the children to draw based on their capabilities, whether they can draw simple shapes or only prewriting strokes. It is important to know the children’s baseline so that you don’t overwhelm them. When a child is working on prewriting strokes or simple shapes, tracing or copying lines can be boring for both the child and the therapist. Incorporating the drawings into something functional, especially if it’s an interest of the child such as Pokemon or Thomas the Train, is an essential element in order to improve participation. Through directive drawing, I showed a 5-year-old child how to draw Optimus Prime using only squares. Using a variety of square sizes, the child was able to work on visual perceptual skills; spatial terminology such as next to, above, below; fine motor endurance; and pencil grasp. Once a drawing is complete, the children can work on coloring and/or handwriting. Usually children are pretty excited about their work. At that time, you can say “Let’s show your (teacher, mom, dad, etc.)! But first we want to (write your name, the name of the character, or a quick sentence on the bottom). Let’s make sure we write neatly so that they can read it.”

Drawing activities work on pencil grip and attention skills.
“Mickey” – This drawing was done by a first grader whose goal was to hold a pencil and participate in a pen-to-paper task for 8 seconds. He had difficulty writing his name, coloring, and drawing.
(Photo is the property of Jason Gonzales, OTR/L)

Directive drawing activities can work on attention and impulsivity.

For children who have difficulty focusing or attending to pen-to-paper activities, I can move them at a desired pace designed to slow them down because they have to wait until the next step. I have done whole class drawing activities in both general education classrooms and special education classrooms from kindergarten to high school. The most successful drawing activities are the ones that are interesting and have an element of surprise, such as not telling them what they are going to draw. This strategy improves the children’s attention to the task and decreases their impulsivity to move ahead. Watching a whole kindergarten classroom pick up their pencils to draw and put their pencils down waiting for the next step at the same time is a sight to be seen. Also, the students liked trying to guess what they were drawing.

Drawing activities can work on increasing attention skills, handwriting, and fine motor skills.
“Balthazar Bratt” was done by a 4th grade student whose goal was to improve fine motor skills, improve handwriting, and increase attention to tabletop activities. He was able to attend and complete this activity for 25 minutes.
(Photo is the property of Jason Gonzales, OTR/L)

Directive drawing activities can include academics which makes learning fun and interesting.

Here are some examples of how I was able to incorporate the students’ interests with their academics in a grades 2-3 special education class while working on their IEP goals.

This drawing activity included measuring and drawing lines with a ruler.
“Steve from Minecraft”
(Photo is the property of Jason Gonzales, OTR/L)

“Steve from Minecraft” was a math activity. The class was learning Perimeter and Area. I started the activity by handing students a ruler and a pencil, as well as a piece of paper that included only the square for his head and the lines for writing. The class practiced using a ruler to draw straight lines, coloring within the lines, copying the words “perimeter” and “area” from the board, and writing a sentence or two based on the character. They also had to use the ruler to calculate the area and perimeter of “Steve’s” head, arms, and legs.

Drawing activities can include literacy skills such as math.
Pig Activity
(Photo is the property of Jason Gonzales, OTR/L)

In another strategy, I was able to use the above “Pig” activity and modify it by adding math. In addition to the skills involved above, this activity also included working on scissor skills; coloring; generating sentences on a given topic; letter spacing, sizing, and line orientation.

Drawing activities are the most engaging activity that I have found that improves both handwriting and attention, but most importantly it boosts self-confidence.

When children are engaged and have self-confidence, they are open to learning. The best part about drawing is that it is subjective, which means that the drawing doesn’t have to be accurate as long as the student is satisfied. And who doesn’t like a Picasso-looking picture? Remember the purpose of the activity is not to draw perfectly but to learn the academic-related activity such as math, writing, and handwriting. So as parents, therapists, and teachers, it is essential that you provide positive feedback especially when that child is proud of his or her work. And when a child is not satisfied or appears frustrated that one eye is larger than the other eye, this is a good time to mention that that’s why Edward Nairne invented the eraser in 1770. It is also a good opportunity to work on visual perceptual skills and have the student identify the differences and determine how can they can be fixed.

Kids learn to draw before they write.

It’s their early form of telling stories and from my experience it can push a child towards or away from pen-to-paper activities. One thing to remember when working with children, especially when they are really young, is that our external words become their internal words. Give them the freedom to be creative and make mistakes; and most importantly provide them with positive feedback, because the bottom line is that they want you to be proud of them. When a child constantly hears that their drawing, writing, coloring, etc., isn’t good enough, they will believe it and start to disengage from those activities and even demonstrate task avoidance behaviors. I have found it much easier to increase self-confidence, attention, and fine motor skills when I combine drawing, writing, and academics into the same activity. And remember, it’s never too late to introduce drawing to your students or children.

Jason Gonzales has been practicing school based occupational therapy for 18 years. He graduated from the Ohio State University in 2001. Jason is married and has two kids and a chihuahua. He has worked in Hawaii, California, Massachusetts, New York, and New Jersey. He is the CEO and Co-Founder of Double Time Docs and founder of The Better Grip. He has been on several occupational therapy podcasts including OT Schoolhouse, OT4Lyfe, and Ontheaire.

All photos, with the exception of one, are the property of Jason Gonzales, OTR/L, and their use is prohibited without his permission. The photo of the children drawing is the property of the owner at the link provided; and if it is shared, his information should be included with the photo.


  1. “Building Your Child’s Problem Solving Tools: Drawing.” ExSTEMsions, June 24, 2019. Retrieved from
  2. Collmer, K. J. Handwriting Development Assessment and Remediation:  A Practice Model for Occupational Therapists.  2016 ed. Waymart, PA:  Universal Publishing, 2016. Print.
  3. Fernandes, M.A., Wammes, J.D., & Meade, M.E. (2018). The Surprisingly Powerful Influence of Drawing on Memory [Abstract]. Current Directions in Psychological Science, 27(5), 302-308. Retrieved from
  4. Terada, Y. (2019, March 14). The Science of Drawing and Memory. Want students to remember something? Ask them to draw it. Edutopia. Retrieved from
  5. Study International Staff (2016, April 26) University study finds drawing can improve memory. SI News. Retrieved from
  6. Norris, E. A., Reichard, C., & Mokhtari, K. (1997). The Influence of Drawing on Third Graders’ Writing Performance. Reading Horizons: A Journal of Literacy and Language Arts, 38 (1) September/October 1997, Article 2 (13-30) Retrieved from iss1/2

Vision: The Starting Point of Learning

Visual skills develop at their own pace. Skills like saccades and tracking are not yet fully developed in three- to five-year-old’s, making the “earlier is better” scholastic calendar challenging for every child.

Vision: The Starting Point of Learning

By Robert Constantine, OTR/L


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

“We worry about what a child will become tomorrow, yet we forget he is someone today. “

Stacia Fauscher

September is an exciting time for me. School programs are starting to get into their groove, setting up a fresh palate upon which students, teachers, parents, and therapists can create new adventures, paint exciting ideas, and draw up plans for a positive literacy experience. And this is the month that I like to share resources designed to guide educational staff toward helping their students work on the developmental skills they need today for literacy – and handwriting – success. I have an exciting schedule of informative posts lined up for us.

Today I’m presenting a guest post about a developmental skill I feel is perhaps the most important aspect of learning: vision skills. Robert Constantine, OTR/L, has dedicated his work’s mission toward educating therapists, teachers, and parents about the visual system in the interest of improving client outcomes. He has developed a presence in both the occupational therapy and the vision field through his continuing education courses and his social media platforms. Thank you, Robert, for joining our team and sharing this informative post and resource about vision skills and the importance of vision exams.

Vision: The Starting Point of Learning

I am excited to do a guest blog for Handwriting with Katherine. I am Robert Constantine, an occupational therapist since 1997 (no comments please!). I have spent a lot of time as a neuro and brain injury specialist where I developed an interested in vision and its relationship to function and therapy outcomes. In 2012, I had the unique opportunity to work in an optometry office, where I learned about the importance of eye movements and near vision focusing in school.

During my work in the optometry office, I learned two things very quickly:

  1. Vision affects everything we do. It is our furthest reaching sense and it gives us the most information about our environment.
  2. Eye movements and near vision focusing problems are holding back too many kids!

Now, I am on a mission to talk to as many therapists, teachers, and parents as possible about vision and share what I have learned! Here are some of the basics…

What is an age-appropriate vision expectation?

Academic standards continue to ask more of our youngest students. Reading and writing expectations for kindergarten students are common throughout our school systems, even as therapists continue to argue that these academic standards may not even be age appropriate. These tasks place a heavy demand on a child’s near vision skills. It is actually normal for children between 3 and 6 to be farsighted (hyperopia) making near vision tasks more challenging during this young age.

The age appropriate visual system

Visual skills develop at their own pace. Skills like saccades and tracking are not yet fully developed in three- to five-year-old’s, making the “earlier is better” scholastic calendar challenging for every child. Many parents are not getting eye exams for their children before they enter school for the first time, mistaking vision screenings by pediatricians or school nurses as sufficient evidence that their little one’s eyes are ready for the challenge of school. Eye exams are vital links for uncovering the hidden visual problems of our students. These problems can be the root cause for difficulty with learning and handwriting mastery. When it comes to eye exams, there are three lessons that are important for us to learn:

Lesson one: The complete eye exam

Only an optometrist or ophthalmologist has the skills to perform a complete eye exam that insures a child’s eyes are ready for school. In a child, a dilation is always part of the complete eye exam, not just to get a good look at the back of the eye but also to help tell how hard the eyes are working to keep things clear. The skilled eye doctor has no problem getting an accurate glasses prescription on any child, even when they are not verbal or do not know their letters, by using a procedure called retinoscopy.

For the school-based therapist, when a vision related learning problem is suspected, the Vision Therapy doctor may be able to help. These specially trained doctors offer services to improve eye movements and near vision focusing that could be at the root of poor academic performance. The College of Optometrists in Vision Development’s website shares important information about the 17 vision skills that impact learning and a link to help you locate a board certified optometrist near you who is qualified in vision development, vision therapy, and vision rehabilitation skills.

Lesson two: Eye Exam Frequency

The American Optometric Association (AOA) recommends that infants receive their first eye exam around 6 months of age to determine if an infant is at risk for eye or vision disorders. This exam is considered so important that the AOA, in cooperation with Infantsee, a public health program, provides an initial eye exam at no charge, no matter the parents’ financial status or access to medical care, for infants between the ages of 6-12 months. After this first exam, the next recommended exam is at 3 years old, or on a schedule determined by the child’s optometrist. Starting at school age (age 5), all children should have an annual eye exam. Just as their bodies are changing, so too are their eyes growing and changing.

Lesson three: 20/20 is not enough

Good acuity does not mean good vision. Vision is a dynamic process that includes the 17 skills mentioned above, two of which are the important binocular vision skills needed for handwriting mastery: near vision focusing and the ability of the eyes to move together accurately. When these skills are not well developed, a child may get headaches, see double, and even have behaviors that look like ADHD. Every pediatric eye exam should include an assessment of these binocular vision skills.

The Therapist’s Role

Just as visual skills begin to develop early on, an assessment of those skills should begin during those same years. The early intervention therapist is in the unique position to teach new parents about the importance of their child’s vision and the importance of eye exams. But many EI therapists have a difficult time finding the information they need to share with their parents. I have put together a group of tools for the early intervention therapist that includes a narrated power point discussing the development of vision from birth to 5 years old. It includes information to share with parents about eye exam frequency, an informational webpage on childhood vision pathologies with hyperlinks to explore the causes and prognosis of the most common problems, and a helpful glossary of vision related terms and more. This kit is a valuable collection of tools that can improve any therapist’s basic understanding of the visual system.

School Days!

Photo is the property of
Handwriting With Katherine

For school-based therapists, vision problems may be linked to many of your students’ handwriting and reading challenges. As you observe and assess their handwritten work, some initial symptoms of vision-related problems may appear as:

• poor letter spacing,
• “floating” letters that sit above or below the lines,
• different sized letters
• letter reversals
• poor far-near copying skills

Vision motor integration and visual perception problems that are uncovered during a handwriting assessment are, as the name implies, vision-related concerns. It is important to make sure the child completing these assessments has had an eye exam, as undiagnosed vision problems can affect the results.

I have some help for the school-based therapist, too. A vision toolkit for pediatric therapists with a narrated power point full of videos of treatment ideas, a narrated power point on my recipe for reversals, and lots more. There are also some easy strategies that can be employed during an initial assessment that can help you form a basic understanding of your students’ vision skills:

ASSESS EYE MOVEMENTS: Checking the tracking and saccade accuracy of your students will give you an idea of how well their eyes are working. A quick check of near point of convergence can tell you if they are seeing double when working up close.

HAVE A LOOK AT THEIR GLASSES. Are they dirty (yes…they are)? Do they slide down their nose when looking down to write? If so, they are losing the benefit of the glasses as the lenses are not in front of the eyes when they look up, causing possible copying errors.

ASK YOUR STUDENTS WHICH HAND IS THEIR LEFT AND WHICH IS RIGHT. Poor left-right awareness is frequently associated with letter reversals. Those children with laterization problems may also delay picking a dominant hand.

As therapists, we are also responsible for sharing the importance of vision with our teachers and parents. Every child needs an eye exam every year.

My Vision Platforms

Photo is the property of
Vision Rehab OT

My passion for spreading the word about vision has grown into the development of educational platforms where professionals can access resources easily and in a venue that is easy for them to use.

• I have a webpage at Vision Rehab OT where I share my blog, books, and wide array of courses.

• My Facebook group can be found at Vision Rehab OT .

• And for you visual learners, check out my YouTube Channel: Vision Rehab OT .

But that’s not all. I also conduct three live continuing education courses for PESI :

Visual Rehab After Neurological Events: Seeing the World Through New Eyes – All about assessing vision skills and treating vision problems associated with stroke, TBI, and concussion.

Innovative Vision Rehab Strategies for PTs, OTs, & SLPs: Don’t Let Vision Limit Your Patient’s Progress – For all of the therapists treating adult patients with eyes! This is about understanding vision and how it is affecting your patient outcomes.

Vision Techniques for Eye Movement Disorders Associated with Autism, ADHD, Dyslexia & Other Neurological Disorders: Hands-on Assessments and Treatments for Children and Adolescents – The pediatric course that I started presenting nearly three years ago. Its updated and lots of fun!!

You can always email me at with that “I have this one kid…” question. I like those challenges.

Thanks, Handwriting with Katherine, for helping me spread the word about the importance of vision.

Robert Constantine graduated from University of Alabama in Birmingham in 1997. He developed an interest in vision while working as the clinical specialist in brain injury for the West Florida Rehabilitation Institute, in Pensacola, Florida. He had an opportunity to work at an optometry office where he learned the techniques used in optometry to improve near vision focusing and ocular motor problems that affect academic performance. He continues to provide vision rehab services to both children and adults at the Pearl Nelson Center, working closely with several optometrists in his community. He has completed training in sports vision and was a member of the High-Performance Vision Associates, working with a team of optometrists assessing the visual skills of elite athletes. He has developed drag racing specific glasses in use by many NHRA drivers. He is also a member of the Neuro Optometric Rehab Association, having attended clinical level 1 and 2 trainings. Robert has lectured on binocular vision assessment and treatment for several years to thousands of therapists and teachers.

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.

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

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






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.



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





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



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.



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.



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 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.

Ordering the New Handwriting Book!

order button ArtsyBee pixabayMy new book, The Handwriting Development Assessment and Remediation:  A Practice Model for Occupational Therapists, will be offered for the first time in Chicago at the 2016 AOTA Conference.  It’s very exciting to be sharing my work with my peers!  But, I know that many of you will not be able to attend the conference, so I wanted to let you know that the book will be offered through a link here and on my website after the conference.  Please look for it!  And, as always, thank you for reading and sharing my work.



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 and understands the link between handwriting skills and writing.  She can be contacted via her website, Handwriting With Katherine.

Another look at Kinesthetic Learning and Pre-Handwriting Skills

Photo credit: renaln
Photo credit: renaln

Each year, as I work with students in elementary school, I continue to worry about their needs being the result of inadequate pre-handwriting skill training.  In short, that really simply means how well they learned to use their hands in play activities and kinesthetic learning.  Children learn to use their hands as tools to help them learn and grow from the moment they are born.  However, sometimes in this accelerated learning environment the we seem to be in now, children are being asked to attempt to learn skills that are far beyond their developmental capabilities.  With this in mind, I offer again my work to draw attention to the learning brain of the child.




Kinesthetic Learning and Pre-Handwriting Skills

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


Jean Piaget introduced the world to the learning brain of the child.  Through his systematic study of cognitive development, he discovered that children simply do not learn in the same way as adults.  According to his theory of cognitive child development, “children are born with a very basic mental structure … on which all subsequent learning and knowledge is based.

To read the entire article, click here.



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 and understands the link between handwriting skills and writing.  She can be contacted via her website, Handwriting With Katherine.
 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.
All photos are property of the owner of the site they are liked to and their use should always provide that link.

National Handwriting Week! How Does Vision Fit In?

IMG_5430National Handwriting Day is celebrated each year on January 23, John Hancock’s birthday (according to the Gregorian calendar), an American Revolutionary leader and first signer of the U.S. Declaration of Independence.  The Writing Instrument Manufacturers Association started this holiday in 1977 to acknowledge the history and influence of penmanship.  And we carry on this tradition today to increase awareness of the literacy benefits of mastering handwriting skills.


One of the most overlooked skills in the assessment of handwriting problems is the visual component.  Vision (which is comprised of 17 skills, only one of which is eyesight) can hinder a child’s educational progress by robbing him or her of the opportunity to form accurate perceptions of himself, the environment around him, and letter and numbers.  These misperceptions can lead to reading and writing challenges as well as problems with sports and activities of daily living.

With vision in mind, I am re-sharing this post that explains the vital need for having a child’s vision assessed and the important role vision has in learning.  And that includes handwriting.


Anatomy of the Eye Hot Air BalooningIn”sight” Into Handwriting Struggles







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 and understands the link between handwriting skills and writing.  She can be contacted via her website, Handwriting With Katherine.
 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.

The Core Strengthening Handbook: A book review

The Core Strengthening Handbook 2

The Core Strengthening Handbook:  A Book Review

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

A great deal of my energy on the internet focuses on reading and sharing the work of my peers and the many knowledgeable professionals in the therapy and educational fields.  My belief in the networking system that technology affords us encourages me to seek out their work and to offer it to others in an effort to support both the writers and the readers.  The realm of social media casts a brand new opportunity in our direction to learn and grow together in ways that were never before available to us.  My quest for knowledge and the responsibility I feel for sharing it freely has set my course as one of impartiality and equality, allowing me to turn so many brilliant people’s work around for others to see.  In the end, that means that I rarely accept promotional offers to review products and to advertise them on any of my platforms.  And when I do, I never accept compensation for the privilege.  Those are the times when a product comes along that I believe offers exceptional benefits for us as therapists, parents, and teachers.

I have just recently come across a publication that speaks in a very eloquent way to a facet of handwriting skill development that I consider to be the most important building block for success.  The Core Strengthening Handbook is a new resource offered by Lauren Drobnjak, BS, PT, and Claire Heffron, MS, OTR, from The Inspired Treehouse.  I feel that it will serve as a valuable resource for parents, teachers, and therapists and I think that you will agree.   Let me share a review of the book to help you get acquainted with what it has to offer.

But before we begin, I’d like to discuss briefly the vital connection that core body strengthening has with handwriting mastery.  Elementary school children spend 30-85% of their classroom time working at their desks, dedicating their visual and fine motor skills to close work that predominantly involves handwriting activities.  (1,2)   Close work places demands on the visual system to maintain efficient focusing, scanning, fixating, and accommodating skills for reading, writing, and copying from text or the board.  The eyes need to stabilize their positon while the head and body move.  Core muscle strength provides the platform for this to happen.  In addition, upper body control plays a key role in the development of an efficient pencil grasp and a fluid penmanship style that allows the hand to glide across the paper in a timely manner.  The core body muscles provide the stability for efficient eye and upper body positioning allowing the student to attend to the task at hand instead of having to expend cognitive and physical energy on maintaining an upright head and body position.  This is accomplished with the help of muscle strengthening and the development of the vestibular system and balance skills.  In a New York Times article, “The Unappreciated, Holding our Lives in Balance,” Dr. Daniel Merfeld, director of the Vestibular Physiology Lab at Massachusetts Eye and Ear Infirmary, described the Vestibular System’s job in a most interesting way:human-skeleton-johan-georg-heck

“Whenever we stand up and arrange our calves, thighs, torso and head into a stable, vertical configuration, we are unconsciously juggling six inverted pendulums, six mechanically independent units with masses above the pivot point – a feat that amounts to balancing six pencils on your palm simultaneously.”

The Vestibular System figures out where our head is relative to the floor and then tells the brain how to direct the muscles, joints, and ligaments in adjusting all of the masses and their pivot points to maintain our balance against gravity.  However, although an inefficient vestibular system can result in poor postural efficiency, its efficiency can also be limited due to inefficient core body strengthening.

The Core Strengthening Handbook

Lauren and Claire have designed their book to present the important message about core strengthening using developmental guidelines to instruct the reader about the muscles included in the body’s core and the progression of their development following typical gross motor milestones.  Their stated intent was to provide “a guide for supporting the development of core strength in children” and they have done that in an easy-to-understand resource for therapists, teachers, and parents.  They have acknowledged that the progression of a child’s gross motor development can be observed by his parents, who may often be the first to detect that their child is struggling with movement activities, as well as his teachers in their preschool through elementary grade classrooms.  The authors provide a well-written description of the journey a baby takes through tummy time, pulling to stand, and finally jumping using examples of observable movement patterns to help the reader visualize the muscles involved in the baby’s gross motor growth. For readers who are interested in the technical, Lauren and Claire share a brief description of the core muscles.

boy beach toys DariuszSankowski pixabayProbably one of the most important informational portions of the book is the section on “Why today’s kids aren’t as strong as they used to be.”  The authors discuss the importance of unstructured, spontaneous play in a child’s development of his core strength.  While they endorse the benefits of providing goal-directed activities to enhance core muscle strength, they recognize the importance of providing opportunities for children to have fun with simple playtime activities such as swinging, running, and climbing.  In an effort to encourage their readers to investigate the importance of play further, they have provided a link to an excellent article that shares a wealth of additional links and information.

The introductory chapter that begins their exciting list of core strengthening activities provides the reader with a better understanding of the behaviors that a child can exhibit when he is experiencing weak core muscles.  This is perhaps the most enticing method for gaining the attention of their audience and to compel them to buy their book!  When a parent or teacher understands that inefficient core muscle strength can result in poor posture, difficulty with transitional movements such as going from sitting to standing, challenges with dressing skills, and a poor pencil grasp, they will certainly want to learn more about how they can help their children with the fun and easy-to-use activities that follow!

The first impression I had when I began to investigate the book’s activities was that Lauren and Claire certainly know how to have fun!  They have provided a wide-range of strategies designed to engage the individual interests of the children as well as to facilitate their use in the home, classroom, or playground.  The activities range from those that include yoga, ball, and wedge components, which are the more advanced forms of core body strengthening work, through the easier to complete and more readily accessible everyday activities such as helping with chores or playing games on “all fours.”  Each strategy shares suggestions for grading the activity to match the child’s needs and for making the work fun for everyone.  The authors did not forget the babies!  They provide a group of playful activities that encourage tummy time and in turn engage the parent or caregiver in interaction with their child.

babies twins tummy time kangheungbo pixabay

My favorites?  Well, that was a difficult, for sure!  I lean toward selecting the Playground Ball Activities since they engage both the visual and the vestibular system in a very natural way.  But, who could not be interested in their Towel Activities!  I will definitely be including the Oblique Wake-Up Call in my next therapy session!  As far as assessment tools, I feel that their section on “Other Quick Core Strengthening Ideas” will come in handy the next time I’m working with a new client.  These six activities will tell me a great deal about his gross motor skills.

And did I mention that the book has pictures of the cutest children imaginable?  The Core Strengthening Handbook is certainly that – a handbook.  It is designed as both an informational resource as well as a quick reference for selecting activities that will work the core muscles.  If you have a moment, stop by The Inspired Treehouse and take a look at their site and this book.  I think you will be happy that you did!

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 and is the author of “Handwriting Development Assessment and Remediation:  A Practice Model for Occupational Therapists.”  She can be contacted via her website, Handwriting With Katherine.

 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.
Title photo is the property of  The Inspired Treehouse and should not be used without their expressed permission.  The human skeleton photo was published on the Figure Drawing Website  and its use should include the link to the author’s site.  All others are the property of the photographers at Pixabay.    Their use should include the link provided with the pictures.
(1) Marr, D., Cermak, S., Cohn, E.S., & Henderson, A. (2003) Fine motor activities in Head Start and kindergarten classrooms.  American Journal of Occupational Therapy, 57, 550-557.
(2) Mchale, K., and S. A. Cermak. “Fine Motor Activities in Elementary School: Preliminary Findings and Provisional Implications for Children With Fine Motor Problems.” American Journal of Occupational Therapy 46.10 (1992): 898-903. Web. 26 June 2015.

Handwriting and the non-dominant hand

hand sketch AlexandruPetre Pixabay

Handwriting and the non-dominant hand

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

Frank R. Wilson, in his renowned discussion of the evolution of the hand, poses the suggestion that bimanual tasks result in the development of a visual vocabulary.  He defines a “visual vocabulary” as one that is established as a result of a mysterious, nonverbal language.  This language can be witnessed in the arts, from jewelry making to writing, as each creator uses “internalized rules for combining materials and structural elements” to produce unique patterns of work.   These works of art take on a meaning for both the designer and viewer and become the personal stamp of the creator. (1)  In this sense, handwriting can be defined as a nonverbal language that results from the production of lines and shapes that are placed within spatial constraints according to predetermined directional and alignment rules.  They become words and sentences that take on a meaning that the writer conjures up in our minds to share thoughts, feelings, information, and knowledge.  Although Wilson describes handwriting as a task commonly considered to be a unilateral hand skill, (1) one that is considered by researchers to require only the “specific coordination between the finger and wrist movements” of one hand, (2) it appears that handwriting under the label of a visual vocabulary would then be considered a bimanual task.

The production of a visual vocabulary, in the arts and handwriting, depends on the ability of the hands to form a complementary partnership in their role as a vehicle for expression.  This partnership consists of a dominant and non-dominant hand that become one unit in the completion of bimanual tasks. Brain lateralization and the intercommunication between the two sides of the brain have been considered the foundational requisites that facilitate the establishment of a dominant hand and determine handedness in humans. However, the establishment of hand dominance remains a confusing and baffling human trait that scientists admit there is little known about its history or neurologic foundations.  The study of the evolution of handedness has taken anthropologists back to an examination of how the hands were used by our Stone Age predecessors to wield stones as hammers to create tools for building or cooking or to design weapons intended to kill game or to act as protection against predators.  Their studies revealed that the tool users would have divided the tasks of hammering or throwing into two distinct parts, utilizing one hand to steady the object to be hammered or to balance two hands machines pashminu Pixabaythe body against gravity in throwing and the other hand to perform the precise movements necessary to direct the stone toward a target with accuracy.  This division of labor has been labeled as the dominant and non-dominant hand movements.

Hand dominance** has been suggested to have been a “critical survival advantage” to hunters and gatherers as they engaged precision tasks within their competitive environments.  (1)  Given that precision tasks demand practice for mastery, their consistent use of one hand to perform and perfect an accurate aim-and-throw movement may have organized the brain-hand pathways and established a hand dominance.  Again, the baffling question remains:   Why did these early humans select the right versus the left hand for precision tasks?  While scientists have yet to uncover the answer to this conundrum, they have turned with equal wonder at the mystery of the perceived underdevelopment of the non-dominant hand.  Some ask the question, “Did it stagnate?  Was it ‘dumbed down’ somehow, in order to guarantee the emergence of a manual performance asymmetry?”  Or was the non-dominant upper limb intended to become specialized in a different way?  (1)   This latter view of the non-dominant hand suggests that the two hands are complementary, forming a whole that is dependent on the accurate production of the specified movements of both sides.  This is an enlightening perspective on the role of the non-dominant hand, for sure.

Dominant and non-dominant hands were once referred to as the “good” and “bad” hands, with the non-dominant hand being labeled as the “somewhat disabled one.” (1) The right hand was viewed as the “good” hand despite the occurrence of left-handedness in some children.  Left-handedness, in fact, was considered to be a deficit and children were strongly encouraged, sometimes forced, to ignore their tendency to use their left hand and to switch Left-Hand-vs-Right-Handinstead to their right hand for writing and drawing.  The argument and prejudice against left-handedness was promoted by the confusing fact that an overwhelming number of people were right-hand dominant.  In the end, regardless which hand became dominant, the non-dominant hand was believed to be an unequal force in the production of bimanual tasks.  It was considered to be inferior to the more precise hand.  As researchers began to investigate more closely the interaction of the hands in bimanual skills, they questioned this idea and considered instead the likelihood that they were interdependent.  Bimanual tasks, by definition, involve the use of both hands.  While some bimanual tasks can be accomplished with the use of one hand (as evidenced by the rehabilitation efforts of persons who have suffered from a stroke), most often the speed, fluidity, and accuracy of their production are compromised by the lack of a supporting hand.  In general, then, bimanual tasks demand the use of both hands for efficiency, as is seen in activities such as playing a musical instrument, golfing, tying our shoes, cutting our food, and handwriting.

Wilson describes handwriting as a task commonly considered to be unilateral hand skill, (1) one that is considered by researchers to require only the “specific coordination between the finger and wrist movements.” (2)  However, in light of the research that considers the two hands as partners in a task, an analysis of the the non-dominant hand in handwriting has revealed it to play “a complementary, though largely covert, role by continuously repositioning the paper in anticipation of pen movements.”  (3, qtd in 1)  In 1987, French psychologist Yves Guiard studied the complementary hand movements in handwriting relative to the idea that the physical characteristics of the movements of each hand,  as well as the sensory control mechanisms that supported those movements, were significantly different.  He proposed that their scaled movements were spatially and temporally divided into two categories.  In Guiard’s theory, the scale of the dominant hand’s movements is considered to be “micrometric,” or produced within a smaller space with slower speeds relative to the supporting hand.  Its performance is rehearsed and mostly internally driven or pre-programmed, directed by the development of motor patterns and the automatic reproduction of those patterns.  (1)   In contrast the movements of the non-

Photo: Property of Handwriting With Katherine
Photo: Property of Handwriting With Katherine

dominant hand in its role as the paper positioner are “macrometric.”   They are conducted to facilitate improvised adjustments using faster speeds within a larger context.  They are externally driven, being directed by the writing hand to set the spatial boundaries within which it can perform its skilled movements.  In effect, the non-dominant hand is supporting the precise movements of the dominant one by providing a stabilizing environment that allows for frequent alterations that are responsive to the movements of the skilled hand.  This perspective of the non-dominant hand elevates its significance in the production of handwritten work.  The actions of the supporting hand require controlled motor movements that can transition within a diverse range of “improvised hold and move sequences” that do not follow strict rules for patterns or rhythm.  These movements require sensory control mechanisms that can detect, analyze, and integrate visual perceptual information, such as spatial boundaries or paper angles, relative to the movements of the dominant hand.  The supporting role of the non-dominant hand demands flexibility to “conform its movements both to the behavior of an external object and to the actions of the other hand, to ensure that the object and the handheld tool will intercept at the intended time and place.”  (1)  Guiard discovered that these alterations are anticipated and initiated before the movements of the skilled hand take place, leading to his proposition that “there is a logical division of labor between the two hands that appears to govern the entire range of human bimanual activities.”  (1)

The precise, rehearsed, and preprogrammed facets of handwriting rely on the supportive role of the less-precise hand to guide the dominant one in producing the “collection of identical hash marks” (1) that create an individual penmanship style and comprise the visual vocabulary that delivers each writer’s personal message.  The supporting role of the non-dominant hand places handwriting among our most creative bimanual tasks.  In this light, an assessment of handwriting development skills would warrant an evaluation of the behaviors demonstrated by the supporting hand and rehabilitative efforts designed to develop it to its highest skill level.

**For more information about the developmental stages of hand dominance and the it plays in handwriting mastery, please read my article, “Hand Dominance – a key factor in handwriting success,” and my book, Handwriting Development Assessment and Remediation:  A Practice Model for Occupational Therapists,” which can be purchased on my website.

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 author of the book, Handwriting Development Assessment and Remediation:  A Practice Model for Occupational Therapists.  She can be contacted via her website, Handwriting With Katherine.  
 Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
Photos are the property of online sites or the photographers at Pixabay.    Their use should include the link provided with the pictures.  All other photographs are property of the author and are not to be used without her written permission.
(1) Wilson, Frank R. The Hand: How Its Use Shapes the Brain, Language, and Human Culture. New York: Pantheon, 1998. Print.
(2) H. Reinders-Messelink, M. Schoemaker, and L. Goeken, Kamps, W. “Handwriting and Fine Motor Problems After Acute Lymphoblastic Leukemia.” Handwriting and Drawing Research: Basic and Applied Issues. Amsterdam: IOS, 1996. 215-25. Print.
(3) Guiard, Yves. “Asymmetric Division of Labor in Human Skilled Bimanual Action.” Journal of Motor Behavior 19.4 (1987): 486-517. Web.

Hand Dominance – a key factor in handwriting success

Hand Dominance – a key factor in handwriting success

by Katherine J. Collmer, M.Ed., OTR/L

hand dominance iwanna pixabayHand dominance is a key factor in handwriting mastery.  Handwriting is a complex functional task that demands the hand to work efficiently with a tool.  This is accomplished through the hand’s intricate link with the brain.  Handwriting is considered to be the highest form of unilateral hand dexterity skill attained by the general population.  (1)   The establishment of hand dominance provides the child with a skilled hand for efficient pencil control to facilitate the learning of letter formations and line alignment as well as a stabilizing hand to monitor paper placement.

What is hand dominance or handedness?

Hand dominance is the term used to describe the hand a child is observed using spontaneously during skilled activities such as brushing his teeth, using scissors, or handwriting tasks.  It is the hand a child naturally prefers to use because it performs skilled tasks more efficiently, leaving the other hand to act as a stabilizer.  For example, a child who is right-hand dominant, or right-handed, will use his right hand to manipulate the scissors and his left hand to stabilize the paper during a cutting task.  The development of hand preference is a sign that the brain is maturating and that brain lateralization is occurring. Initial development of a preferred hand occurs from about the age of 4 months to the age of three to four, shifting from a reach that is convenient (such as using the right hand to pick up objects on the right side) to one that crosses the body’s midline.  Hand preference for the completion of unilateral tasks becomes more evident during this time with further bilateral differentiation occurring between 5 and 7 years.  Although children may continue to switch preferred hands at this stage for use with different fine-motor skilled activities, a fully established hand dominance presents itself between the ages of 6 and 9.

What are the behaviors associated with an Unestablished Hand Dominance?

Hand dominance is a foundational skill that promotes using the hands together efficiently during activities that involve more complex motor plans, motor accuracy, and greater skill.  These tasks include tying shoes, buttoning a coat, playing with interconnecting blocks, or handwriting.  Crossing

Little Boy Lacing his Shoes --- Image by © Royalty-Free/Corbis
Image by © Royalty-Free/Corbis

the midline and bilateral coordination are contributing foundational skills for the establishment of hand dominance and equally important in the performance of skilled tasks.  Difficulties in either of these skills can result in unilateral hand preference (using the right hand for performance on the right side and vice versa), difficulty with symmetrical bilateral hand skills such as catching a ball or holding an object with two hands, or competing dominance where the child switches hands during a fine-motor task.  It is also important to note that if a child who demonstrates a clear preference for one hand is observed switching between his dominant and non-dominant hand during skilled activities, muscle fatigue could be the underlying cause rather than difficulty with any of the above skills.

How can you determine the Establishment of Hand Dominance?

There are several ways to determine a child’s preferred hand and to determine the establishment of hand dominance.

Boy Playing with Building Blocks

  1. Observe the child participating in skilled fine-motor tasks such as brushing his teeth, buttoning his coat, drawing, playing with construction toys, or cutting paper.  Record the number of times that he uses a specific hand as the dominant one within each task, switches hands within the task, or uses only the hand located closest to the object when reaching for it (e.g., using the left hand solely to reach for items on the left side).
  1. Place items at the child’s midline on a table during a fine-motor play or functional activity.  Observe the use of a dominant hand or the switching of hands during the activity.
  1. Place items for use in activities such as puzzles, tangrams, or construction tasks in random positions on the table on the child’s left and right sides as well as in midline. Observe his use of a dominant hand, his switching hands, or the use of a unilateral reach as he completes the activity.

Activities that Promote the Development and Establishment of Hand Dominance.

After collecting observational data that reflects the child’s level of hand dominance, determine the hand that he appears to prefer.  Direct him to use that hand in activities that will reinforce it as the dominant hand.   If the child does not yet appear to have a preferred hand, begin with the foundational activities below to encourage the development of a dominant hand.  Progress to the activities that follow to enhance the underlying skills that promote the development and establishment of hand dominance.

Foundational Activities:

  1. Place objects for a task at the child’s midline. This provides him with the opportunity to select which hand to use and enhances the development of a dominant hand by lessening the chances to use the unilateral hand to avoid having to cross midline.
  1. Use auditory cues to direct the child’s reach across his body during play and functional tasks.  Positions items included in the activity randomly on the table on both sides of his midline.  Ask him to reach for them using the opposite hand.  For example, to direct him to reach across his midline to an object on his left, you might say, “Joey, please pick up the yellow marker with your right hand.”  This activity also promotes the development of crossing the midline and bilateral coordination skills as well as the understanding of directional concepts.
  1. Use auditory and visual cues to establish labels for his skilled and stabilizing hands. This helps him to understand how he uses his hands for fine-motor activities and supports their use as skilled or stabilizing hands.  For example, if the child has been observed to use his left hand predominantly during skilled tasks, you might verbally label his left as the “worker hand” and his right as the “helper hand.”  Demonstrate these labels as you and he complete tasks such as cutting, lacing, or construction play.  You may add a sticker to his worker hand to remind him of its role in the activity.
  1. Use auditory cues as reminders to continue to stay with one hand for the duration of a skilled activity.

Enhancement Activities:

Gross motor games.  Position balls or bean bags on the side of a child’s preferred hand and have him toss them at a target placed at his midline or on the opposite side of his body.  This activity promotes the development of hand dominance, as well as balance, bilateral coordination, visual attention, and crossing the midline skills.  Games of throw and catch (for example, baseball or bowling) and basketball (dribbling and throwing) also promote these skills.

Girl (6-8) Painting an Egg --- Image by © Royalty-Free/Corbis
Image by © Royalty-Free/Corbis

Fine motor activities.  The activities below promote the use of a dominant hand as well as the development of visual attention, crossing the midline, and bilateral coordination skills.

    • Drawing circles or lazy 8’s simultaneously on the left and right sides of a paper taped to the wall or on a chalkboard using a pencil or chalk in the hand on each side
    • Clapping games or games that tap knees and ankles on the opposite sides of the body
    • Tracing the non-dominant hand with the dominant
    • Drawing or coloring with the preferred hand.  The performance of this activity on a vertical surface will further enhance balance and visual attention.
    • Stacking blocks with the preferred hand
    • Activities that include stencils, rulers, or rubbing motions over textures using the dominant hand with the pencil or crayon and the other hand to stabilize the stencil, ruler, or paper.
    • Molding clay or putty using the dominant hand to pull and mold while the other stabilizes the clay or putty
    • Beading, lacing, and interlocking toys using the dominant hand to thread or position the interlocking toy while the other hand stabilizes the string, board, or opposite toy part.
    • Cutting and pasting using the dominant hand to perform the task and the other to stabilize the paper.
    • Construction activities with blocks, hammers, or screwdrivers using the dominant hand to perform and the other to stabilize during the task.
  • Opening containers using the preferred hand to turn or pull open the lid while the other hand stabilizes the container.

Academic activities.

  • Whole body writing (making large movements using the dominant hand) promotes the use of the dominant hand as well as the enhancement of motor movement planning skills.
  • Activities that include non-traditional materials such as finger paints, shaving cream, sand trays, or writing with water on the chalkboard or a piece of paper taped to the wall provide increased tactile input to promote the use of the dominant hand as well as the enhancement of motor movement skills.
  • Create letter formations by shaping them out of pipe cleaners or other tactile tools to promote the use of the dominant hand.
  • Writing or practicing letter formations with a pencil on a piece of paper over fine-grade sandpaper using the dominant hand for tool use and the non-dominant to stabilize the paper provides additional tactile input to promote the use of the dominant hand.
  • Tracing letter formations on a vertical surface using the dominant hand while the other hand positions and supports the paper also enhances visual attention skills.

Children who have not established a dominant hand may also be working with inefficient body image and spatial awareness skills.  It is important to observe the child in a diverse array of activities and provide a variety of opportunities to engage in bilateral tasks in order to determine the underlying  developmental skill needs.

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

Photos are the property of the  photographers at Pixabay or Royalty-Free/Corbis where indicated.    Their use should include the link or copyright provided with the pictures.

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.


  1. Yancosek, Kathleen E., and David R. Mullineaux. “Stability of Handwriting Performance following Injury-induced Hand-dominance Transfer in Adults: A Pilot Study.” The Journal of Rehabilitation Research and Development JRRD 48.1 (2011): 59. Web. 28 Oct. 2015.
  2. “Texas Child Care: Back Issues.” Texas Child Care: Back Issues. Texas Child Care Quarterly, n.d. Web. 30 Oct. 2015. <>.
  3. “Occupational Therapy for Children.” Occupational Therapy for Children. Occupational Therapy for Children, 08 Sept. 2015. Web. 30 Oct. 2015. <>.
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