Pencil Grasp Repair: Strategies 101

Pencil Grasp Repair:  Strategies 101

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

on the Handwriting is Fun! Blog

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

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

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

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

Step-by-Step:  Proximal to Distal

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

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

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

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

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

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

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

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

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

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

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

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

Collmer Handwriting Development Assessment and Remediation

Reference:

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

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

Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.

Another Look at Pencil Grip

Pencil grip Pencil grip is the first visible sign of handwriting difficulties that can cause teachers and parents to ask for the assistance of an occupational therapist.  But, as important as an efficient pencil grip is to handwriting skills, it is not always the cause of handwriting needs. Research studies have concluded that an efficient pencil may not always look like one – although it is functional, nonetheless.  My article, “Should we worry about pencil grip?” shares important research conclusions and their implications for an occupational therapy assessment and remediation plan for handwriting development skills. Please share your feedback!

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

The Handwriting Book revealed!

Well, folks, today is the big day!  My new work, Handwriting Assessment and Remediation:  A Practice Model for Occupational Therapists, will be officially launched at the #AOTA16 Convention in Chicago!  I am honored to have worked with Universal Publishing toward sharing my book with you and look forward to chatting with my peers at Booth #5015 in the Expo Hall!    This is a very exciting time for me and, as always, I think you for reading and sharing my work.

If you could not make it to the convention this year, you can still pre-order my book by clicking on the picture below!

 

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

On my way to #AOTA16!

I’ll be boarding the plane bright and early today heading for Chicago and the 2016 AOTA Convention!  This will be a very exciting journey for me as I share my new book with my peers.  It will be an honor to discuss handwriting assessment and remediation and chat about the concerns and challenges we have all faced in this area of occupational therapy.  I look forward to meeting many of you at the Universal Publishing Booth #5015.  Please join me there!

 

Please stop by Booth 5015, AOTA in Chicago, to chat about my new book!

 

 

 

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.

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.

Should we worry about pencil grip?

“Should we worry about pencil grip?”

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

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

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

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

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

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

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

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

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

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

Photo is property of Handwriting With Katherine.

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

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

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

Collmer Handwriting Development Assessment and Remediation

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

References:

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