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.
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.
National 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.
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.
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 the 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 instead 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-
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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
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
by Katherine J. Collmer, M.Ed., OTR/L
Hand 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
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.
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).
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.
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:
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.
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.
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.
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.
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
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.
References:
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.
“Texas Child Care: Back Issues.” Texas Child Care: Back Issues. Texas Child Care Quarterly, n.d. Web. 30 Oct. 2015. <http://www.childcarequarterly.com/spring07_story3.html>.
“Occupational Therapy for Children.” Occupational Therapy for Children. Occupational Therapy for Children, 08 Sept. 2015. Web. 30 Oct. 2015. <http://www.occupationaltherapychildren.com.au/blog/dominance-hand-dominance/>.
Children who experience difficulty with the mastery of handwriting skills are often struggling with crossing their body midline. During the performance of handwriting tasks, the arm, hand, and eyes travel from the writer’s left side to his right, crossing the body’s center many times. Letter formations also rely upon the writer’s ability to cross from left to right to cross a “t” or produce an “x.” A developmental skill need that limits the fluid movement across midline prevents a child from mastering the basic facets of handwriting mastery.
What is Crossing the Midline?
Crossing the midline is a bilateral skill demonstrated by the ability to spontaneously move one hand, foot, or eye into the space of the other hand, foot, or eye. This happens when we sit cross-legged on the floor, scratch our elbow, read or write from left to right, draw a horizontal line from one side of the paper to the other, or connect intersecting lines to draw a cross without switching hands. Crossing the midline is a coordinated movement that is developed as a child experiences activities that include cross-lateral motions, such as reaching across the body to retrieve a toy. These movements help to build pathways in the brain that facilitate the development of various motor and cognitive skills involved in completing self-care tasks, participating in sports, reading, and writing.
Crossing the midline is an integral skill related to bilateral coordination. Bilateral coordination is defined as the ability to use both sides of the body together in a coordinated, controlled, and organized manner during tasks that require the use of one hand to stabilize and the other to perform simultaneously. These activities include crawling or climbing stairs, catching or throwing a ball, manipulating clothing fasteners, tying shoes, stringing beads, cutting, and handwriting. In addition to the foundational skills of eye-hand coordination and muscular strength, the development of bilateral coordination is dependent upon an accurate body awareness. This perceptual skill represents the ability to know where the body and its parts are positioned in space without using vision allowing for the spontaneous and efficient completion of tasks. The development of bilateral coordination indicates that both sides of the brain are communicating effectively in the sharing of information. The development of a “helper” and a “worker” hand to facilitate bilateral movements is a sign that the brain is maturating and that brain lateralization is occurring. The lateralization process is strongly correlated with the ability to cross midline.
Brain lateralization is defined by the ongoing process that is thought to begin in the prenatal period and continue throughout early childhood. The cerebrum consists of two hemispheres (or halves) that specialize in different functions which control different areas of the body. The left hemisphere controls the right side of the body and contains the centers for the understanding and use of language (listening, reading, speaking, and writing), memory for spoken and written language, analysis of information in detail, and motor control of the right side of the body. The right hemisphere controls the motor movements of the left side of the body and contains the centers for processing visual-spatial information, comprehending and remembering things you see and do, and using pieces of information to form a complete picture. The two halves are connected by a band of fibers called the corpus callosum which plays an important role in integrating their respective functions. Lateralization becomes specialized to serve particular functions and involves a preference for using one hand or side of the body more than another. Hand dominance is a result of brain lateralization. (1, p. 176-7)
What are the behaviors that indicate difficulty with Bilateral Coordination and Crossing the Midline Skills?
Children who have difficulty with these skills may display decreased coordination and motor control, tend to avoid crossing their midline by using alternate hands for performing tasks on each side of their body, and have difficulty establishing hand dominance. These children may appear to be ambidextrous because they use both hands alternately during and among tasks. However, they may actually be doing that because they have two unskilled hands. In addition, children who experience problems with crossing the midline can have difficulty with higher level skills such as reading and writing as they both involve left-to-right eye and hand movements. This may be observed as stopping in the middle of the page to blink or rub their eyes, losing their place frequently during close work tasks, being unable to master letter formations that include diagonal lines, or stopping in the middle of the page to switch hands during handwriting assignments. For children who have an inaccurate sense of body awareness, they may appear clumsy and cautious with movement especially when it involves having their feet of the ground. They may seek or avoid deep sensory input or have difficulty coordinating both sides of their body to complete bilateral activities of daily living. These behaviors also can result from inefficient eye-hand coordination and muscular strength.
What are some activities to promote the development of Crossing the Midline Skills?
The activities listed below are some examples of easy-to-implement tasks or games that will enhance the underlying skills that promote the development of crossing the midline skills.
For younger children:
Obstacle course activities performed inside or outside that encourage crawling and climbing using verbal commands for directional concepts such as over and under, back and front, and up and down promote gross- and fine-motor muscle strengthening, the understanding of directional concepts, body awareness, and bilateral coordination skills.
Floor games such as bean bag toss or ball rolling can be designed to encourage crossing the midline by having children catch or stop the bean bag or ball on the sides of their body versus the middle (e.g., using the right hand to perform the task on the left and vice versa). Have the child call out the side of his body where he has caught or stopped the object. These activities encourage body awareness, balance skill development, and midline crossing as the child reaches with one or both hands across the body to perform the task and identifies the sides of his body.
Sitting or standing games such as bean bag toss can encourage the child to reach for and pick up an object on the opposite side of the body and throw it at a target on the reverse side (e.g., picking up a bean bag located on the left side with the right hand and then throwing it at a target on the right side and vice versa.) Provide verbal directions to direct which hand the child will use or have him call out which hand he intends to use before he begins each toss. This activity encourages balance, midline crossing, and visual attention skills.
Push and pull toys or activities that are performed at midline such as pop beads, connecting blocks, lacing, hand exercises (pushing palms together at chest level), or rolling putty into a long snake encourage bilateral coordination, crossing the midline, and upper extremity muscle strengthening skills.
Pretending to drive a car using a ball promotes midline crossing as the child holds the ball in both hands and turns it like a steering wheel by crossing his arms over each other as he drives. This can be adapted for children who have sufficient upper extremity strength by having them perform the activity without the ball. This activity promotes upper extremity muscle strengthening, bilateral coordination, and crossing the midline skills.
Clapping and popping bubbles performed in either sitting or standing can encourage engagement in the left, center, and right space in front of the child. This activity promotes visual attention, bilateral coordination, midline crossing, and upper extremity muscle strengthening skills.
Keeping time to music by clapping hands, alternating clapping hands and patting knees, tapping sticks together, or marching in place promote crossing the midline skills. These activities as well as playing games that include following directions such as Simons Says or Hokey Pokey promote balance, body awareness, bilateral coordination, and visual attention skills.
Batting a balloon back and forth in sitting or standing promotes balance, visual attention, and crossing the midline skills.
Upper extremity exercises performed in either sitting or standing can promote midline crossing skill development. Exercises can include touching toes with the opposite hand, performing windmills above the head or windshield washers in front of the body (crossing arms back and forth over each other), tapping opposite shoulders with the hands, hugging the body, or swinging lowered arms back and forth slowly across and behind the body. Provide verbal directions or have the child call out the directions for each hand or side being addressed. These activities promote balance, body awareness, bilateral coordination, crossing the midline, visual attention, and upper extremity muscle strengthening skills.
Large arm movement activities in the air that cross from the child’s left side to his right side and reverse, such as drawing large crosses or figure 8’s (an 8 turned on its side or the infinity symbol) promote midline crossing development. Activities that include practice for letter formation strokes (circle, up/down, or left/right strokes) can be adapted to address midline skills by first producing the letter on the left side, then in the middle, and finally on the right side using the child’s preferred hand. Large arm movements in the air promote balance, upper extremity muscle strengthening, bilateral coordination, and midline crossing skills as well as visualization skills for automatic motor memory patterns.
Large movement activities performed on the floor on a large piece of paper or on a sidewalk can encourage crossing the midline. Have the child trace large crosses or figure 8’s (drawn on their side) using different colors of chalk to create rainbow tracings, drive a toy car through a figure eight driveway, or complete a large simple maze with chalk or colored pencils. These activities promote visual attention, bilateral coordination, and crossing the midline skills as well as upper extremity muscle strengthening with crawling and movement on all four’s. The use of chalk provides tactile input to promote handedness and writing/drawing tool control.
Tracing activities on a vertical surface that use large arm movements that cross from the child’s left side to his right side and reverse, such as drawing large crosses or figure 8’s (drawn on their side), driving a small car through a roadway system, completing a simple maze, or drawing lines on which to practice letter strokes. These activities promote bilateral coordination and crossing the midline skills. In addition, activities that are performed on a vertical surface promote upper extremity muscle strengthening and visual attention skills.
For older children: While some of the activities listed below were also listed for younger children, they can be enhanced for the older ones by increasing the challenges with time or speed elements or the inclusion of academic tasks.
Large arm movement activities in the air that cross from the child’s left side to his right side and reverse, such as drawing large crosses or figure 8’s (an 8 turned on its side or the infinity symbol) promote midline crossing skills. This activity can include practicing letter formations or spelling words in the air using his preferred hand, first on the left side, then in the middle, and finally on the right side. Large arm movements in the air promote upper extremity muscle strengthening, bilateral coordination, midline crossing skill as well as visualization skills for automatic motor memory patterns.
Large movement activities that combine arm and leg movements such as drawing or writing on a large piece of paper or a sidewalk promote crossing the body midline. Have the child trace large crosses or figure 8’s using different colors of chalk to create rainbow tracings, use a pencil to “drive” through a figure 8 pathway, copy a drawing, or complete a large maze with chalk or colored pencils. These activities promote visual attention, bilateral coordination, and crossing the midline skills as well as upper extremity muscle strength with crawling and movement on all four’s. The use of chalk provides tactile input to promote handedness and writing/drawing tool control.
Tracing activities on a vertical surface that provide large arm movements that cross from the child’s left side to his right side promotes midline crossing. These activities can include copying a drawing, completing an age-appropriate maze or word search, or drawing lines on which to practice spelling words. These activities promote bilateral coordination as well. In addition, activities that are performed on a vertical surface promote upper extremity muscle strengthening and visual attention skills.
Keeping time to music by clapping hands, alternating clapping hands and patting knees, tapping sticks together, or marching in place promote balance, body awareness, bilateral coordination, and visual attention skills.
Batting a balloon back and forth in sitting or standing promotes balance, visual attention, and crossing the midline skills. Using a balloon instead of a ball increases the challenge and enhances the development of these skills. Adding a verbal task such as reciting the alphabet or answering questions further increases the activity’s challenge.
Upper extremity exercises performed in sitting or standing can include touching toes with the opposite hand, crossing the right hand to touch the raised left knee and alternating sides in a rhythmic fashion, jumping jacks, or running in place with exaggerated arm movements. These activities promote balance, body awareness, bilateral coordination, crossing the midline, visual attention, and upper extremity muscle strengthening skills. Adding small, light weights or a verbal task, such as reciting the directions aloud during the task will further enhance development of visual attention, crossing the midline, and bilateral coordination skills.
Ball toss, catch, or kick games in standing or sitting promote visual attention, body awareness, balance, midline crossing, and upper extremity strengthening skills.
Construction toys and crafts that encourage the use of two hands to construct a product promote bilateral coordination, crossing the midline, fine motor strengthening, and visual attention skills.
Board or card games such as strategy games or solitaire can encourage visual scanning from left-to-right. These activities, as well as most board or card games, promote visual attention, bilateral coordination, and crossing the midline skills.
Mazes, word search, hidden picture, and tangrams performed on a vertical or horizontal surface promote visual attention and crossing the midline skills. Activities performed on a vertical surface promote upper extremity strengthening skills.
Yoga postures. These activities promote body awareness, balance, bilateral coordination, crossing the midline, visual attention, and muscle strengthening skills.
Playing sports or tug-of-war. These activities promote balance, visual attention, bilateral coordination, crossing the midline, and muscle strengthening skills.
Crossing the midline skills are developmental and should appear by the age of 3-4 years. This article is meant to provide information about its development and the symptoms that indicate a need in this area. If you find that your child has not achieved this milestone by the age of 4, it would be wise to consult with his or her pediatrician to determine if there is an actual need that would benefit from intervention.
(Blog edited May 2018.)
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
Photos are the property of the photographers at Pixabay where indicated. 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.
Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
References:
Shaffer, David R., and Katherine Kipp. Developmental Psychology: Childhood and Adolescence. 9th ed. Belmont, CA: Wadsworth, 2013. Print.
Edwards, Marissa, M.S., OTR/L. “Help Your Child Develop the “Crossing the Midline” Skill.” Nspt4kids.com. North Shore Pediatric Therapy, 18 Apr. 2011. Web. 28 Oct. 2015. <http://nspt4kids.com/parenting/help-your-child-develop-the-crossing-the-midline-skill/>.
“What Is Brain Lateralization?” Nspt4kids.com. North Shore Pediatric Therapy, n.d. Web. 28 Oct. 2015. <http://nspt4kids.com/healthtopics-and-conditions-database/brain-lateralization/>.
Dyspraxia, most concisely described, is a learning difficulty that “possesses the most interesting ‘melting pot’ mix of physical and mental characteristics.” (Patrick 2015 p. 11) Once called a “disorder of sensory integration by Jean Ayes in 1972 and then labeled as “Clumsy Child Syndrome” in 1975, dyspraxia continues to be a confusing condition to classify. The terms “Dyspraxia” and “Developmental Coordination Disorder” are commonly used interchangeably, however, it is felt by some professionals that they are not the same condition. Dyspraxia is defined by the Dyspraxia Foundation USA as “a neurological disorder throughout the brain” that often comes with a variety of comorbidities, the most common [of these being] Developmental Co-ordination Disorder (also known as DCD). (“1 in 10 Odds”) The UK branch further explains that “while DCD is often regarded as an umbrella term to cover motor coordination difficulties, dyspraxia refers to those people who have additional problems planning, organising and carrying out movements in the right order in everyday situations” and can also experience difficulties with “articulation and speech, perception and thought.” (“What is Dyspraxia,” Section “What is Dyspraxia?”) Alison Patrick, in her book “The Dyspraxic Learner,” stresses that “the significant role that the mind plays in this condition cannot be underestimated.” (Patrick 2015 p. 17)
Developmental Dyspraxia, the term more commonly used to describe the developmental problems observed in children who are clumsy, describes the condition as “a failure to learn or perform voluntary motor activities despite adequate strength, sensation, attention, and volition (Missiuna & Polatajko, p. 620)” It is felt that the term was chosen as a result of the belief that a link existed between apraxia and dyspraxia. Due to the lack of empirical data that shows a causative link between apraxia – the condition that involves “the loss of ability to perform previously acquired movements” most commonly observed in adults who have experienced a cerebrovascular accident resulting in brain damage – and the problems of children who have the symptoms described above, the condition is often labeled simply as “Dyspraxia.” (Missiuna & Polatajko 1995 p. 620) The roots of this confusion over labelling stem from two facts: first, that there is no internationally agreed upon definition for the term “dyspraxia” and second, that the DSM-V does not list it among diagnosable conditions. Instead, it is felt that dyspraxia would most suitably fall under the new reclassification of “Neurodevelopmental Disorders-Motor,” as some consider it a developmental coordination disorder (“Highlights of Changes”). Steinman, et. al. make a further distinction that developmental dyspraxia should be considered in terms of praxis “rather than a diagnostic label” and referred to instead as “a specific neurologic sign of impaired execution of skilled learned movements. (p. 5)” The authors stress that it can exist in children who demonstrate no other signs of neurological impairments, as well as in conjunction with other neurodevelopmental disorders such as autism and language disorders. After all the discussions have been heard, it is not difficult to imagine a more fitting label than “the hidden handicap.” (Udoh & Okoro 2013, Kirby 1999)
It is difficult to estimate exactly how many children are affected by DCD/Dyspraxia due to the lack of an official diagnosis and consistent use of behavioral information to identify them. However, 2009 study results out of the UK “suggested that up to one in every 20 children between seven and eight years of age may be affected by the condition to some degree. It is felt that the disorder occurs three or four times more in boys than girls and that the condition “sometimes runs in families.” (Developmental Co-ordination, Section “Who is affected).
Despite the confusion, understanding developmental dyspraxia remains an important concern for occupational therapists who are often presented with referrals for children who have handwriting difficulties, problems with self-care management, and social isolation that results from their clumsiness and uncoordinated behaviors (Missiuna & Polatajko 1995). Without a clear definition for dyspraxia nor a diagnosis that outlines the symptoms associated with it, our assessment will be based upon our knowledge of the condition itself. Children who present with these school-, home-, and socially based needs will appear physically capable, will not have intellectual needs, and often will not have any identifiable disease or medical condition. Since dyspraxia is a developmental condition, it can present itself in the early years as children meet the prescribed developmental gross-motor milestones late and experience difficulty with fine-motor activities of daily living, such as tying their shoes or fastening buttons, very much like developmental coordination disorder. From an occupational therapy standpoint, then, dyspraxia and the behaviors associated with it must be differentiated from those same behaviors that exist with a motor coordination condition. Dyspraxia, in our practice area, is not viewed as a primary problem in motor coordination and the child must present with difficulties with ideation and planning to be regarded as dyspraxic from our point of view. (9) Rather than be the result of a problem with motor execution, dyspraxic behaviors are felt to be a difficulty in formulating a plan of action, the problem presenting itself as the inability to efficiently plan and carry out skilled non-habitual motor acts in the correct sequence. Although children with dyspraxia may have difficulty learning a new task, once they are able to master the skills that it demands, they can use those skills to repeat the task. (9) Their ability to use their skill development in the mastery of other similar activities is limited, however, as they are not able to effectively plan and execute new motor actions or generalize motor actions in a new situation. (9) From an occupational therapy standpoint, the child with dyspraxia will present with the following behaviors (10) that can be fall into four categories: (7)
Dyspraxic BehaviorsCategories of Dyspraxia
The appearance of “clumsiness” stems from their difficulty in transitioning from one body position to another, their poor discrimination of tactile input, an overall difficulty in relating their bodies to physical objects and space, and challenges with imitating actions or perceiving the direction of movement. They are slower to develop both gross- and fine-motor skills and are often referred to occupational therapy for these reasons, particularly handwriting. They may tend to prefer talking rather than performing and will often avoid new tasks altogether. Their social behaviors result from their becoming frustrated with new situations because they are unable to approach these activities in an organized manner. The culmination of these symptoms and behaviors can be low self-esteem or self-concept. (9)
Patten, in her newsletter article, “Dyspraxia from an Occupational Therapy Perspective,” suggests a battery of standardized assessments that will assist in the assessment process. Goodgold-Edwards and Cermak, (10) stress that we must also have an understanding of the motor, sensory integrative, and cognitive and conceptual components of movement as we observe the children in both standardized testing environments and the performance of everyday activities. Treatment strategies we select can include sensory integrative, perceptual motor, sensorimotor, cognitive goal-directed, and compensatory skill development approaches. (9) These will most likely be combined in a remedial plan that addresses each child’s individual needs and will include skill areas such as rule learning as it applies to motor planning and motor learning; planning for managing movements as they occur that include goal-directed activities with performance expectations; the use of tasks that have a clear, functional identification within the practicing environment; the inclusion of cognitive strategies that allow for the child’s learning abilities and styles; and, perhaps most importantly, will be fun as well as challenging. (10) Of course, the complex nature of dyspraxia and the multiple needs that a child may experience will necessitate the development of a team approach. (7)
The implications of dyspraxic behaviors for the school-based occupational therapist are that we must consider the “whole child” in our development of a remedial plan or recommendations for adaptations. Although the child may have been referred to therapy because of handwriting difficulties, it is vital that we look below the surface and develop the overall picture of his behaviors, from home, to school, to the playground, and the community. With or without an official diagnosis, dyspraxia exists and will continue to present itself in our therapy rooms and clinics.
Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine
Photos are the property of Handwriting With Katherine and are not to be used in any fashion except as links to the appropriate blog or the Handwriting With Katherine website without the expressed, written permission of Katherine Collmer. Those photos that include a link to the Pixabay site should be used only if they include the link to the photographer’s page that is provided with them.
Patrick, Alison. “Introduction and Chapters 1 and 2.” The Dyspraxic Learner: Strategies for Success. 2015 ed. London: Jessica Kingsley Pub., 2015. 11-54. Print.
“1 in 10 Odds Are That You Know Someone With Dyspraxia.” Dyspraxia Foundation USA. Dyspraxia Foundation USA, n.d. Web. 08 Oct. 2015. <http://www.dyspraxiausa.org/>.
“What is Dyspraxia?” Dyspraxia Foundation.org.uk. Dyspraxia Foundation UK, n.d. Web. 8 Oct. 2015. <https://www.dyspraxiafoundation.org.uk/about-dyspraxia/>.
Missiuna, C., and H. Polatajko. “Developmental Dyspraxia by Any Other Name: Are They All Just Clumsy Children?” American Journal of Occupational Therapy 49.7 (1995): 619-27. Web. 8 Oct. 2015.
“Highlights of Changes From DSM-IV to DSM-5.” Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013): n. pag. DSM5.org. American Psychiatric Publishing. Web. 8 Oct. 2015. <http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf>.
Steinman, K. J., S. H. Mostofsky, and M. B. Denckla. “Toward a Narrower, More Pragmatic View of Developmental Dyspraxia.” Journal of Child Neurology 25.1 (2009): 71-81. Web. 8 Oct. 2015.
Udoh, Nsisong A., and Cornelius C. Okoro. “Developmental DyspraxiaâImplications for the Child, Family and School.” International Journal of Academic Research in Progressive Education and Development IJARPED 2.4 (2013): 200-14. Web. 9 Oct. 2015.Caroline Lacey. London:
Patten, Natasha, Bcc OT. Dyspraxia from an Occupational Therapy Perspective (n.d.): n. pag. Dyspraxia Foundation.org.uk. Dyspraxia Foundation UK. Web. 8 Oct. 2015. <http://dyspraxiafoundation.org.uk/wp-content/uploads/2013/10/dyspraxia_and_Occupational_Therapy.pdf>.
Goodgold-Edwards, S. A., and S. A. Cermak. “Integrating Motor Control and Motor Learning Concepts With Neuropsychological Perspectives on Apraxia and Developmental Dyspraxia.” American Journal of Occupational Therapy 44.5 (1990): 431-39. Web. 8 Oct. 2015.
“Developmental Co-ordination Disorder (dyspraxia) in Children .” NHS Choices. National Health Services UK, n.d. Web. 09 Oct. 2015. <http://www.nhs.uk/Conditions/Dyspraxia-(childhood)/Pages/Introduction.aspx>.
A Vision and Eye-Care Professional Primer for Occupational Therapists
by Katherine J. Collmer, M.Ed., OTR/L
Vision Facts to Guide Assessment and Treatment:
The visual sense is the primary way in which we understand what we see. It is “our most far-reaching sense” and the one through which we obtain 75-85 percent of what we learn about ourselves and the world around us. (1, p. 3) Vision as a term is most often confused with that of eyesight. However, the terms are not interchangeable.
Eyesight consists of our level of visual acuity and our ability to recognize contrasts. It is a measure of our distance vision and does not effectively determine the efficiency of our near vision skills. It is also an indicator of eye health.
Vision is comprised of 17 skills, one of which is eyesight. (2) The measure of 20/20 eyesight and a healthy medical condition of the eyes does not entail the complexity of the visual system. “In addition to clear vision, an individual must have the ability to use his or her eyes for extended periods of time without discomfort, be able to analyze and interpret the incoming information, and be able to respond to what is being seen.” (1, p. 6)
The Visual Brain
Vision does not occur in the eyes but in the brain. The eyes are actually a part of the brain and act as the sensory receptors that collect light and transmit it to the visual brain (3) to “form a model of our world, to identify objects and events, to attach meaning and significance to them, and to establish their causal relations” for the ultimate production of adaptive behavior. The visual brain is influenced by the brain’s visual pathways and includes the vision that is used for action and that which is utilized for perception. (4) Neurons devoted to visual processing in the brain account for about 30 percent of the cortex with millions of optic nerve fibers carrying information from the retina to these areas. In contrast, touch and hearing are represented by 8 and 3 percent of the brain’s cortex, respectively, with each auditory nerve carrying 30,000 signals. (5)
Models of vision have been developed that emphasize vision as a learned process and one that organizes and manipulates space. It is the sensory system through which we understand the information collected through our other senses. It a movement pattern and is developed through the use of our motor skills, much like walking and talking. Vision provides the brain with accurate translation of the information collected through our eyesight. (1, p. 6) Therefore, vision plays a key role in learning and can influence the quality of learning through visual efficiency and visual information processing. Visual efficiency comprises the process of visual acuity and refractive error, accommodation, vergence, and ocular motility. Visual information Processing involves the higher level brain functions that include the non-motor aspects of visual perception and cognition, and their integration with motor, auditory, language, and attention systems. Deficits in either of these aspects of vision can result in some form of learning problem. Proper diagnosis of learning related vision problems therefore requires comprehensive evaluation of visual efficiency and visual information processing skills. (6)
Undetected vision problems can affect a child’s ability to learn in school by interfering with his ability to see clearly, interpret what he sees, and use his eyes to guide movement. Although vision screenings are performed by pediatricians and school nurses, their tests are designed to assess for visual acuity and do not reflect how well the eyes focus up close, track, or work together. Occupational therapists are in a key position to detect the common signs and symptoms that indicate a potential vision problem in these areas and that may be the cause of a reading, learning, or motor performance need. An efficient OT evaluation will include a vision screening that checks visual acuity, eye teaming, eye movement control, and visual motor integration. Therefore, it is important to understand and recognize the five most common symptoms that can identify a person is in need of a vision assessment by a developmental optometrist.
Frequent loss of place when reading
Slopping handwriting
Eye fatigue or headaches after reading
Avoidance of close work
Attention problems (7)
In addition, it is important for occupational therapists to inform parents and teachers about the importance of early detection of vision-related problems by sharing visual behavior checklists (8) and resources about vision assessments (9) and vision therapy (2). Equally as important as recognizing early symptoms and sharing information about visual problems, occupational therapists should have a solid understanding about the areas of expertise for those professionals who specialize in eye care.
Eye-Care Professionals Guide
Maintaining eye and vision health relies upon regularly scheduled assessments that can alert us and our doctors to the presence of eye diseases and vision disorders. The early detection of these conditions depends upon the selection of the appropriate eye-care professional to address these specialized areas. There are four areas of expertise and levels of training that define the providers that address eye and vision health. (The following was adapted from References 10, 11, and 12.)
Ophthalmologists (MD) are medical or osteopathic doctors who have completed college and at least eight years of additional medical training. They are licensed to practice medicine and surgery and specialize in the diagnosis and treatment of eye disease. Ophthalmologists diagnose and treat all eye diseases, perform eye surgery, and prescribe and fit eyeglasses and contact lenses to correct vision problems. In general, they use medical and surgical methods to treat eyes diseases and vision disorders.
Optometrists (OD) are Doctors of Optometry and the primary health care professionals for the eye. Optometrists complete a pre-professional undergraduate education at a college or university followed by four years of professional education at a college of optometry. Following graduation, optometrists have the option to complete a one-year residency for additional training in a specific area of practice. They are licensed to examine, treat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures. They are trained to perform eye exams, prescribe and dispense corrective lenses, detect certain eye abnormalities, and prescribe mediation for certain eye diseases.
Developmental Optometrists (FCOVD) provide vision care based on the principle that vision can be developed and changed. They are health care professionals who obtain board certification from the College of Optometrists in Vision Development (COVD) to provide specialized services in behavioral and developmental vision care, vision therapy, and vision rehabilitations. Developmental Optometrists specialize in the treatment of functional vision problems, including difficulties with binocular vision, eye movements, and depth perception, as well as visual deficits following brain injuries and are skilled in the use of lenses, prisms, and optometric vision therapy. They perform functional vision tests to determine underlying vision deficits.
Opticians are technicians trained to design, verify, and fit eyeglass lenses and frames, contact lenses, and other eyesight correction devices. They provide services through prescriptions supplied by ophthalmologists or optometrists.
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
Photos are the property of the photographers at Pixabay or authors on specific online sites. Their use should include the link provided with the pictures.
References:
Scheiman, Mitchell. Understanding and Managing Vision Deficits a Guide for Occupational Therapists. 3rd ed. Thorofare, NJ: Slack, 2011. Print.
“Vital Visual Skills -.” COVD.org. College of Optometrists in Vision Development (COVD), n.d. Web. 26 Oct. 2015. <http://www.covd.org/?page=Visual_Skills>.
Hubel, David H. “Eye, Brain, and Vision.” Eye, Brain, and Vision. David Hubel, n.d. Web. 24 June 2015. <http://hubel.med.harvard.edu/book/b8.htm>. Text Publication: Henry Holt and Company, May 15, 1995
Milner, A.. David, and Melvyn A. Goodall. “The Visual Brain in Action.” Assc.org. The Association for the Scientific Study of Consciousness, n.d. Web. 26 Oct. 2015. <http://www.theassc.org/files/assc/2367.pdf>.
Grady, Denise. “The Vision Thing: Mainly in the Brain.” Discover Magazine. Discover Magazine, 01 June 1993. Web. 26 Oct. 2015. <http://discovermagazine.com/1993/jun/thevisionthingma227>.
Garcia, Ralph P., O.D., Steven B. Nicholson, O.D., Leonard J. Press, O.D., Mitchell M. Scheiman, O.D., and Harold A. Solan, O.D. “Optometric Management of Learning-Related Vision Problems, 2nd Edition.” Clin Exp Optometry Clinical and Experimental Optometry 89.6 (2006): 403-04. Aha.org. American Optometric Association, 2008. Web. 26 Oct. 2015. <http://www.aoa.org/documents/optometrists/CPG-20.pdf>.
Hong, Carole L., OD, FCOVD. “Vision Screenings & When to Refer for a Developmental Vision Evaluation: What Every OTR Should Know.” PediaStaff. PediaStaff, Inc., 26 May 2011. Web. 26 Oct. 2015. <http://www.pediastaff.com/blog/qa-ask-the-expert-vision-screenings-when-to-refer-for-a-developmental-vision-evaluation-what-every-otr-should-know-3592>.
Collmer, Katherine J., M. Ed., OTR/L. “Resources for Handwriting/Writing Development.” Handwriting With Katherine. Katherine J. Collmer, M.Ed., OTR/L, n.d. Web. 26 Oct. 2015. <http://www.handwritingwithkatherine.com/resources.html>.
“InfantSEE: A Public Health Program for Infants | Helping Infants to Establish a Lifetime of Healthy Vision.” InfantSEE. Optometry Cares – The American Optometric Association, n.d. Web. 26 Oct. 2015. <http://www.infantsee.org/>. InfantSEE®, a public health program, managed by Optometry Cares® – the AOA Foundation, is designed to ensure that eye and vision care becomes an essential part of infant wellness care to improve a child’s quality of life.
Mischio, Greg. “What’s the Difference between Optometrist vs. Ophthalmologist?” Vision Therapy Center. Vision Therapy Center, 14 Nov. 2011. Web. 26 Oct. 2015. <http://www.thevisiontherapycenter.com/discovering-vision-therapy/bid/75509/What-s-the-difference-between-optometrist-vs-ophthalmologist>.
“Difference between an Ophthalmologist, Optometrist and Optician.” Difference between an Ophthalmologist, Optometrist and Optician — AAPOS. American Association for Pediatric Ophthalmology and Strabismus, n.d. Web. 26 Oct. 2015. <http://www.aapos.org/terms/conditions/132>.
“About COVD.” COVD. College of Optometrists in Vision Development (COVD), n.d. Web. 26 Oct. 2015. <http://www.covd.org/?page=About_Us>.
Growth Mindsets: Their Implications in Pediatric Occupational Therapy
by Katherine J. Collmer, M.Ed., OTR/L
What is the element in therapy that transforms a goal from one focused upon performance to that which targets learning? What facet of our service approach drives motivation and addresses or prevents the client’s sense of “learned helplessness?” At what point do we, as therapists, influence the mindset of our clients and facilitate their growth in rehabilitation?
These questions lie at the foundation of our own growth as a profession as the health care reform initiatives align with our long-held principles of client-centered treatment. But, just as we are beginning to understand that the medical community is catching up to our perspective, we are equally becoming aware that a client-centered practice framework can produce outcomes that reflect the “shift toward value-based-reimbursement” and “challenge(s) occupational practitioners to demonstrate their unique contributions” (1) to healthcare. In turn, the quality of a framework that stresses the importance of individuality, holism, and a sense of self and one that values the development of both the individual and a client-therapist relationship is contingent in part on the (client’s) experience of care and his perspective of his involvement in the process. Toward that end, research and discussions have been directed toward the development of a “working alliance” and a stable relationship that foster a positive rapport with our clients and serves as a means for active participation in their service plans. (2)
Active participation implies motivation. And motivation suggests a belief that one can succeed in his attempts to learn and grow and to achieve his personal potential. Our ability to motivate our clients demands a certain awareness of the ways in which people are motivated and how their responses to failures can provoke either a helpless response or the determination to master new things and conquer challenges. Carol Dweck, author of Mindset: The New Psychology of Success, conducted research to uncover the factors that motivate and direct a learner’s pattern of success or failure. She concluded that children who were guided toward persisting in the face of challenges and encouraged to believe that failures were due to their lack of trying versus a lack of ability developed “mastery-oriented patterns.” (3) Their “attributions” toward success and failure reflected their judgments about the causes of events and behavior, as well as the recognition of the consequences of those attributions, and drove them to strive for learning versus performance. There is an important difference between performance-oriented and learning-focused goals. Dweck noted that performance goals focus upon demonstrating the ability to do something while learning-focused goals encourages the increase of ability. The difference lies in one being static and fixed and the other dynamic and malleable. The success of client-centered therapy relies upon the participant believing that he has the ability to increase his ability. It is based upon a growth mindset.
Fostering a Growth Mindset in a Therapeutic Environment
Mindset is defined as “a fixed mental attitude or disposition that predetermines a person’s responses to and interpretations of situations.” It is a frame-of-mind, a perspective, and a set of behaviorisms that become an inclination or a habit. According to the prominent dictionaries, a habit is a recurrent and often unconscious behavior that is acquired through frequent repetition and becomes an established disposition of the mind or character. Therefore, habits can be developed as well as broken. Fostering a growth mindset in our pediatric therapy sessions is a viable and applicable target in a client-centered service delivery model. The same assumptions about success relative to a child’s level of academic achievement can be applied to a pediatric client’s success toward therapy goals. A research team reviewed the literature that studied the “noncognitive factors” involved in student learning. These included both their Academic Behaviors, such as going to class, completing homework, active classroom engagement, and studying, and their levels of Academic Perseverance, labeled as tenacity or stick-to-it-ness. They both were determined to be indicators of how likely a child was to continue to pursue academic goals despite challenges. (4) The results of the review suggested that “one of the best levers for increasing students’ perseverance and improving their academic behaviors (was) by supporting the development of Academic Mindsets.”
The key mindsets that the research team defined as those associated with increased perseverance, better academic behaviors, and higher grades can be applied to our therapy services.
Belonging to a learning community. Our therapy sessions revolve around learning (or unlearning) habits and behaviors that will enhance a child’s opportunity for success. Our willingness to build a rapport that fosters trust and develops into a working alliance that encourages communication, and in the end becomes a stable relationship that incorporates the child’s opinions and ideas into the rehabilitation process, encourages a sense of belonging in the therapy environment. (2)
Belief in the likelihood of success. Studies have shown that self-efficacy was a strong determinant of success among similar-ability students. A child’s sense of his ability to succeed is “malleable” and can be influenced by feedback on performance and ability, as well as the provision of training and assistance with setting goals. (4) The core components of client-centered care (respect, collaboration, communication, support, and inclusion) and the part that hope and self-perception play in an occupational practice (1) foster the building of self-efficacy. It is our role as occupational therapists to help our clients to “celebrate” their willingness to take risks, to allow themselves to fail, and to learn from those failures. (5)
Belief that abilities and intelligence can grow with effort. Carol Dweck considers students with a growth mindset to believe that “the brain is like a muscle” that gets stronger with use. (6, qtd in 4) They are motivated by mastery and enjoy challenging themselves with new ideas and learning opportunities. (4) It is our role as therapy practitioners to provide the “just-right challenges” that will build brain muscle and encourage our clients to believe that they can learn and grow despite their personal challenges.
Belief in a sense of meaning and value surrounding the work. As we continue to interpret and make meaning of our experiences, our brains are looking for connections in order to process new information and ideas. (4) Tasks and information that do not represent meaning nor constitute any value to our clients will fall short of the mark and limit their potential for success. Purposeful activities are planned and directed tasks that are key to planning an occupational therapy program, while meaningful activities are those that achieve the program goals through an intrinsic motivation for the patient. (7) It is our role as therapists to offer our clients activities that are both purposeful and meaningful and that will bring them back to therapy to build the sense of belonging and self-efficacy that results from a mastery mindset.
Fostering a learning mindset in therapy begins with the principles laid out in the client-centered approach to our occupational practice that build rapport, a working alliance, and a stable relationship, no matter the age of client.
Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine
Mroz, Tracy M., Jennifer S. Pitonyak, Donald Fogelberg, and Natalie E. Leland. “Client Centeredness and Health Reform: Key Issues for Occupational Therapy.” Am J Occup Ther American Journal of Occupational Therapy 69.5 (2015): 1-8. Web. 3 Oct. 2015.
Collmer, Katherine J., M.Ed., OTR/L. “Client-centered Practice in Pediatrics.” Handwriting Is Fun! Blog. Handwriting With Katherine, 29 Sept. 2015. Web. 3 Oct. 2015. <http://blog.handwritingwithkatherine.com/client-centered-practice-in-pediatrics/>.
Farrington, Camille A. “Academic Mindsets as a Critical Component of Deeper Learning.” Hewlett Foundation News. William and Flora Hewlett Foundation, n.d. Web. 03 Oct. 2015. <http://www.hewlett.org/library/grantee-publication/academic-mindsets-critical-component-deeper-learning>.
Schwartz, Katrina. “What’s Your Learning Disposition? How to Foster Students’ Mindsets.” MindShift. KQED News, 25 Mar. 2014. Web. 03 Oct. 2015. <http://ww2.kqed.org/mindshift/2014/03/25/whats-your-learning-disposition-how-to-foster-students-mindsets/>.
Dweck, Carol S. Mindset: The New Psychology of Success. S.l.: Random House, 2008. Print.
This summer, I was honored and humbled by the thoughtfulness of eight inspiring and knowledgeable Occupational Therapists who so lovingly shared their time and expertise with my readers on the Handwriting is Fun! Blog. Their willingness to jump in and give me a hand when I needed it most won’t ever be forgotten, for sure.
Most importantly, however, their words of wisdom in the 10 blogs they shared will help so many readers for years to come.
In that light, I wanted to take a moment to thank them personally and to share their work with you once again. And, as always, thank you to my readers. You are the foundation upon which the success of the Handwriting is Fun! Blog is built.
Thank you so much
Spaghetti and Meatball Spacing by Jaime Spencer, MA, OTR/L, Miss Jaime OT
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.
For the month of September, the Handwriting is Fun! Blog will be sharing insights about the role of Occupational Therapy in the classroom. In recent years, the role of OT, in general, has been changing with the waves of healthcare and education reforms. Despite a certain amount of turmoil and confusion where those changes may have thrown us a curve ball, most often they have provided us with an opportunity to make a difference in an area in which we’ve longed to see an improvement. Client involvement is an excellent example of a concept that can turn the tide in school-based and pediatric practice. Although this concept is relatively new in pediatrics, it remains an important one to embrace as we enter this new generation of healthcare and education perspectives. In that light, this week’s article focuses upon the concepts that define a client-centered therapeutic approach and the implications for its use in all facets of occupational therapy, including pediatrics and in the schools.
Client-centered practice in pediatrics.
by Katherine J. Collmer, M.Ed., OTR/L
The rehabilitation process and client-centered practice: Defined
The rehabilitation process can be defined as a “reiterative, active, educational, problem solving process focused on a patient’s behavior (disability)” that uses assessment, goal setting, intervention, and evaluation tools to achieve its objectives. The objective of the rehabilitation process includes maximizing the client’s participation in his or her environment and to minimize the effects of pain and distress on the client and client families. (1) In recent years, the approach to rehabilitation has moved from a “predominantly medical one to one in which psychological and sociocultural aspects are equally important.” This has resulted in transforming the rehabilitation process into a client-centered practice where the personal perspectives and backgrounds of the client are becoming increasingly important.
The process of rehabilitation is complex (1) and works within a structure that demands the collaboration of a multi-disciplinary team who works toward client-specific goals and encourages involvement of the individual and his or her family. (2) In the past, this group included professionals from the medial, therapeutic, and ancillary staff of the hospital, school, clinic, or facility where the client was receiving services. Family members and caregivers in the adult environment were invited to participate in team meetings, training, and decision making events along with the client. The client’s level of participation in the process rested on his or her capacity for understanding the choices and for making decisions. A child-centered rehabilitation process, however, typically includes the professionals on the team and the family members responsible for the child’s wellbeing. The child most often serves in an “invisible role” on the team appearing for the assessment and therapeutic interventions but rarely for events that would determine his or her goals for therapy. The move toward a client-centered practice has not completely turned the corner into pediatrics.
The rehabilitation process in the pediatric practice remains the same regardless of the arena within which it is carried out. The provision of therapy in the clinic or hospital, the home or the school, begins and ends with the same tools as it seeks to achieve the highest level of independence for the clients. Our clients are young, ranging from birth to around 18 years of age, and present with a wide range of strengths and needs. They are all individuals and deserve strategies for care that respect them as such.
In that light, the process of their care in any environment should include them in what has been described as a “working alliance.” This relationship “is formed as individuals collaborate with one another to develop common goals and as they develop a sense of shared responsibility for working on tasks that are involved in achieving those goals.” (Bordin, E.S., 1979, qtd. in 4) The development and maintenance of rapport, mutual respect, and collaboration between therapists and their clients have been linked to the therapeutic relationship that fosters client participation in their own rehabilitation. (4) Client participation has been considered a focal point in occupational therapy and is reflected in the professional standards established by the American Occupational Therapy Association. They clearly state that occupational therapists will collaborate with the client in the assessment of his or her skills and during the development and implementation of the intervention plan. (5)
However, results of a 1995 study of the participation of adult patients in their rehabilitation process conducted by Northen et al. (5, quoted in 6) determined that the “maximum potential of client-centered practice was not realized throughout the treatment process.” This was linked primarily to inconsistencies in the use of structured methods for encouraging client participation in the initial process as well as during the ongoing rehabilitation process. Given the lack of data available that tracks client involvement in the pediatric practice, it is of value to discuss the implications of client-centered rehabilitation with children.
Client-centered therapy and its implications for pediatric outcomes.
Client-centered therapy implies that the person for whom the services are designed will actively and willingly participate in the rehabilitation process and includes both a “behavioral” and a “motivational” component on his part. In the case of student “involvement,” this translates to the “amount of physical and psychological energy” that he devotes to the learning experience. This involvement can be measured in both quantitative and qualitative terms using testing and the observation of functional use of skills. The student achieves both functional and personal development through his participation in this working alliance. And the effectiveness of that alliance rests upon “the capacity of (the practitioner) to increase student involvement. (8)
Success of a client-centered occupational therapy practice depends upon two principal components, as outlined by Maitra and Erway, in their article “Perception of Client-Centered Practice in Occupational Therapists and Their Clients:”
The desire and ability of the clients to take part in the decision-making process, and
The desire and ability of the occupational therapists to include clients in the decision-making process. (6)
These two components rely upon the development and implementation of a team-based strategy that is designed to enhance both client and therapist involvement in the client-centered process. This type of strategy is based upon three factors for success: rapport, a working reliance, and a stable relationship.
The development of rapport, a working alliance, and a stable working relationship requires “an ongoing communication process that involves the exchange of information.” (4)*
Rapport. Children rely on trust within each of their daily interactions with teachers, therapists, and school personnel. Trust in a therapeutic partnership begins with the gathering and sharing of information about the client and the therapist, the demonstration of “cooperative intent” during the initial stages of the alliance, and the regulation of the student’s involvement in decision-making events. Trust is built during informal discussions about activities that each enjoys, challenges they have faced, and goals for the future. It continues to develop when each understands that the other can be flexible and accept changes in plans or challenges that push comfortable boundaries. And, most importantly, trust is built when the therapist recognizes the student’s need to have less distraction or increased interaction in order to be successful.
Working Alliance. As the rapport continues to develop, the therapist and client begin to focus on the goals and tasks that will define the student’s therapy. Eleanor Cawley, MS., OTR/L, in her book, The Student Interview, stresses that the use of effective communication techniques can produce benefits that improve diagnosis and outcomes, treatment adherence, (and) patient satisfaction….” (9) She refers to communication strategies that build a working alliance as avenues of exchange that can help students to build “a sense of self and of personal identity.” While her information targets the adolescent population, students of any age will experience a sense of belonging and importance when the therapy plan is shared with them and decision making involves them at an age-appropriate level.
Perhaps one of the most significant facets of the development of rapport and a working alliance is the therapist’s and the student’s combined response to the success or failure of a therapy technique. Tickle-Degnen, in her AJOT article, “Client-Centered Practice, Therapeutic Relationship, and the Use of Research Evidence,” (4) suggests the use of a recording tool** that documents the goals of the treatment and whether or not the task or strategy is accomplishing them. In addition, in an effort to enhance the working relationship, she suggests that “occupational therapists should incorporate client satisfaction and frustration ratings” into this recording tool. Children can easily express their feelings of frustration with a task, as well as their sense that it is beneficial. The working alliance is a “living relationship” that continues to expand and contract as it becomes a stable working relationship.
Stable Relationship. This phase of the client-centered therapeutic process has been described as the place where the “hard work of therapy begins” and one where the challenges and changes that provide opportunities for growth and skill in therapy can also “enhance the probability of ‘errors’ during interaction (and) threaten the continuation of the relationship.” (4) Communication and student engagement become an even more significant set of tools during this phase as these changes and challenges will require intrinsic motivation on the part of the student. While student engagement is considered to be among the better predictors of learning and personal development, (12 qtd. in 10) with positive links to critical thinking and grades, (11) it has also been identified as an important tool that allows our young clients to express their priorities, goals, and impressions of therapy. A stable relationship that fosters rapport and a working alliance relies upon the therapist’s ability to work alongside students in an effort to maintain an “authoritative” position that “gains control through interaction with the student and incorporates the student’s opinions and ideas” into the rehabilitation process. Ultimately, this results in a “Student-Therapist Partnership.” (9)
Barriers to implementing a client-centered practice. Research has unveiled 4 significant barriers to implementing a client-centered practice that can be reflected in every therapeutic environment:
We, as the service provider have control over our knowledge base and our feelings of comfort or insecurity that surround the implementation of a client-centered approach to therapy. We can influence a student’s intrinsic motivation by attending to the development of rapport, a working alliance, and a stable working relationship and by adapting the process to meet his particular learning, cognitive, and physical needs. We can influence the environment with the demonstration of success within our personal practice of client-centered therapy and with discussions about the benefits for increasing a client’s sense of worth and self-efficacy.
Conclusions.
A client-centered approach to therapy is not a new concept. The term was coined by Carl Rogers, an American humanistic psychologist, in his 1939 book, The clinical treatment of the problem child. In it he stresses the importance of “individuality, holism, sense of self, the influence of the environment, values development, actualization, and goal-directed behavior” in both the individual’s overall development and the development of the client-therapist relationship. (15, qtd. in 14) The Philosophical Base of Occupational Therapy (16) defines “participation in a meaningful occupation (as) a determinant of health.” It stresses the same concepts of therapy as Rogers, describing the environment, intrinsic individual factors, occupational contexts, and inherent characteristics of the activity as significant factors to consider as we develop a focus and outcome expectations to encourage and enhance our clients’ engagement in meaningful occupations. Children, our students and clients, deserve the opportunity to use “occupation” as a change agent, as well as an individual means to achieve their goals, and to experience a client-centered therapeutic approach as a means for active participation in their service plan.
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.
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*The information in this section was adapted from Reference No. 4.
**Student Self-Assessments have been identified as tools that facilitate the collection of information relative to a student’s perception of his skill strengths and needs, his participation in therapy, and the value of the therapeutic interventions included in his rehabilitation plan. Each self-assessment instrument should be reviewed prior to administration to measure its benefits and limitations for the audience for whom it is intended. (13, 14)
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