WriteWays NO-TECH LOW-TECH HIGH-TECHTools for Teaching Students With Handwriting DifficultyBy:Jeane Zobel-LachiusaMargaret E. Pierce

Occupational therapists can choose from a growing number of tools for helping children with dysgraphia improve their written expression.

Dysgraphia (difficulty with handwriting) is a learning disability that affects how easily children acquire written language and how well they use written language to express their thoughts.1Despite the increasing use of computers in school and for everyday tasks, developing handwriting competency continues to be essential for success in school.2 Children spend 30% to 60% of their school day performing handwriting and other fine motor tasks3; therefore, children with poor written expression are at a distinct disadvantage for a majority of their school day.

Handwriting is necessary to successfully complete assignments, homework, and tests, including high-stakes tests for achieving in high school and getting into college.4 Additionally, legible handwriting is important in our society for communication tasks such as writing letters, taking phone messages, completing application forms, and writing checks.2

School professionals have witnessed first hand how inefficient or messy handwriting contributes to feelings of frustration and failure in children with handwriting difficulty. The handwriting of children with dysgraphia often does not adequately reflect their knowledge and cognitive ability. For example, an in-class essay from a sixth-grade student with dysgraphia might be short, with simple vocabulary and few descriptive details. Frequent erasures or words crossed out may make it difficult to read. The draft would not accurately reflect the student’s actual ability. Very often, the written products of students with dysgraphia contrast starkly with their verbal descriptions, which contain age-appropriate vocabulary and extensive details (for example, see Figures 1 and 2).

It is estimated that between 10% and 20% of school-age children have problems with handwriting.6 This number may be on the rise. As schools increasingly push academics down into kindergarten and preschool, less time is spent on developing the requisite sensory and motor foundation skills necessary for legible handwriting. This is expressed well by a quote from an elementary school principal in a recent New York Times interview:

Almost all our kids come into kindergarten able to recite their letters and their numbers. Some can even read. But in the last 5 years, I’ve seen a dramatic increase in the number of kids who don’t have the strength in their hands to wield scissors or do arts and crafts projects, which in turn prepares them for writing.7

School-based occupational therapy practitioners identify and support students with handwriting difficulty, which remains among the most common reasons for occupational therapy referrals.8 Clearly, fine motor delay and resultant difficulty with handwriting are important deficit areas for occupational therapy practitioners and teachers to be aware of and to address.

Recognizing Handwriting DifficultyThe first step in helping students with handwriting difficulty is to

identify and recognize the problem. Duell proposed three distinct diagnostic subtypes of developmental dysgraphia (disorder of written expression), each with a unique profile of symptoms and corresponding assessment suggestions.9 When an occupational therapist or teacher suspects that a student’s handwriting difficulties are disrupting his or her model of Dysgraphic subtypes (summarized in Figure 3) and corresponding assessments may be a helpful first step in identifying which dysgraphic subtype best describes the student’s profile.

Duell’s model describes students with dyslexic dysgraphia as having difficulties with reading and spelling that result in poor handwriting. These students typically have good motor control but lack the language skills to write fluently and legibly. They are focusing so much on spelling, grammar rules, and formulating their thoughts into words that they do not pay attention to the mechanics of writing. They may have difficulty forming letters correctly, and there may be frequent size, spacing, or alignment errors that interfere with legibility. These students can usually copy written text accurately, with relatively well-formed letters and words. However, their handwriting breaks down when composing text, due to the onerous demands of language formulation and spelling. For these students, composing text can be a slow and laborious process, and their drafts often contain many spelling and grammatical errors. Students with dyslexic dysgraphia can be distinguished by looking at their oral spelling (which will be poor), their drawing (which will be normal), and their finger tapping (touching thumb to each finger without looking, which will be normal).9,10

Students with motor dysgraphia exhibit poor handwriting stemming from “motor clumsiness”.9 These students are usually verbally adept, and they are skillful readers and spellers. However, students with motor dysgraphia exhibit slow and uncoordinated fine motor movements, which result in written work that is illegible or slowly produced. Students with motor dysgraphia can be distinguished by looking at their oral spelling (which will be good), their drawing (which will be messy), and their finger tapping (which will be abnormally slow).

The third subtype of dysgraphia is due to a deficit in understanding space. Students with spatial dysgraphia have been found to have deficits in spatial perception, which interferes with letter formation and drawing. These students display illegible handwriting in both spontaneous written text and copied text. However, fine motor tasks that do not draw on spatial perception (e.g., opening and closing containers) are preserved. Students with spatial dysgraphia can be distinguished by examining performance on oral spelling (which will be normal), drawing (which will be poor), and finger tapping (which will be normal).9

For students who are being evaluated for special education, a range of formal measures can be included inmthe multidisciplinary evaluation that will target spelling, spatial perception, and fine motor skills. There are also myriad informal measures that target these skills and can be used with general education students or students with disabilities who are not due for a re-evaluation. Some of these assessment options are presented in Figure 4. Whether formal or informal measures are used, therapists and teachers should focus on how the child’s spelling, drawing, and motor skills compare with those of children at the same developmental stage.

Supporting Handwriting DevelopmentAfter a student’s dysgraphic profile has been identified, occupational

therapists are in a better position to select and recommend instructional supports and strategies that are matched to the student’s needs. A useful way to categorize handwriting supports and strategies is to consider the level of technology involved.11 “No-tech” strategies do not require specialized equipment. “Lowtech” strategies involve materials that are easily found in most schools and classrooms. “High-tech” strategies involve specialized materials and typically require ordering and training to use.11

No-tech options include tools, supports, and techniques that can increase, maintain, or improve the functional capabilities of a child with dysgraphia without the use of equipment. Some examples include providing increased time for written tasks (e.g., providing an extra class period to complete an in-class essay) and decreasing length of written assignments (e.g., writing sentences with 10 spelling words rather than 20). For older students, no-tech strategies can ease the burden of taking notes during teacher presentations or class discussions. For example, the teacher might provide a hard copy of the lecture notes prior to the class for the student to follow along with and take supplemental notes on. Another no-tech option is arranging a peer to act as a notetaker. These options could benefit all students who are identified with any of the three subtypes of dysgraphia. An additional no-tech option to try for students with motor dysgraphia is

adjusting body position. These students would benefit from optimal body position in a well-fitting supported on the floor or an appropriately sized foot rest. The optimal body position rule of thumb is for hips and knees to be angled at 90° with forearms resting on the desk and shoulders in a neutral position (see Figure 5).

Low-tech options can increase, maintain, or improve the functional capabilities of a child with dysgraphia using commonly available materials. Low-tech options useful for some students with dyslexic dysgraphia include electronic aids such as a handheld, electronic dictionary or a tape recorder to tape lectures and/or record assignments. Other low-tech options benefiting students experiencing spatial dysgraphia include paper options such as graph paper for completing math problems. The lines on the graph paper encourage the student to write an vindividual number inside each space. This provides a visual boundary, which is useful for writing smaller and lining numbers up evenly. Paper options for children with spatial or motor dysgraphia include raised-lined paper (bought or made with glue so the lines can be felt), double-lined paper (Handwriting Without Tears materials), paper with broken midline (visual cue to size lower-case letters), and/or paper with colored lines (red is the bottom line or where to stop, and green is the top line or where to start). These paper options may assist a child by providing a visual and/or kinesthetic boundary or cue that helps to size letters more

evenly and prevent letters from “floating” above or “sinking” below the lines. Highlighting the bottom writing line with a colored highlighter may help some students with spatial dysgraphia pay better attention to it, thus improving letter alignment. If spacing between words is an issue for a student during copying tasks, the teacher can provide highlighted lines that are the same width as the word to be written, with spaces in between. Additionally, Popsicle stick spacers are a standard low-tech option to try as an alternative to using a finger as a spacer. Students enjoy decorating their own stick and can use Velcro to attach the stick to their desk when not in use.

Another low-tech option is to provide alternate writing tools or pencil grips, which “help position the digits for efficient distal manipulation of writing tools”.12 Similarly, positioning paper on an angled surface (such as an empty three-ring binder) promotes wrist extension that provides a biomechanical advantage for optimal finger mobility.12 When a student’s wrist is flexed, the finger flexor muscles and tendons are shortened, which prevents full, active mobility of the fingers. Positioning the wrist with approximately 30° of extension provides an optimal balance of finger and wrist flexors and extensors, allowing for the finger mobility necessary for writing.

High-tech options increase, maintain, or improve the functional capabilities of a child with any of the three types of dysgraphia through the use of specially designed tools. The general principle underlying high-tech assistive technology tools is that they allow the student to record written language while minimizing the physical demands of writing (motor dysgraphia). Additionally, some of the high-tech tools provide the needed support for improved writing useful for students identified with spatial or dyslexic dysgraphia. A commonly used high-tech tool involves using a laptop or a portable keyboard to write, such as a Neo 2 (formerly AlphaSmart; produced by Renaissance Learning). The portable keyboard option is successful for many students because of its ease of use. It easily fits into students’ backpacks and can used at their desks in class. Additionally, the Neo 2 provides a spell checker, custom dictionary, thesaurus, flexible font size, and specialized software options.

More recently, high-tech options have expanded to include computer software programs such as Solo 6 and Dragon Naturally Speaking. Solo 6 is a literacy suite of popular assistive technology accommodations, including a text reader (READ:Outloud), graphic organizer (DRAFT:Builder), talking word processor (WRITE:Outloud), and word prediction (CO:Writer). Each of these Solo 6 accommodations can be purchased and used separately or “bundled” together as the Solo 6 Literacy Suite (produced by Don Johnston).

Dragon Naturally Speaking 11 (produced by Nuance Communication) is another software package to assist with written output. Dragon is speech recognition software in which the computer program transcribes what the writer dictates. With Dragon Naturally Speaking, the student speaks into a microphone and watches the spoken words instantly appear in documents. Anything a student writes on the computer, from Facebook status updates to e-mail messages to word-processed documents, can be done using Dragon Naturally Speaking. This voice recognition software can help students who experience slow or difficult written output secondary to motor coordination difficulties. Students with dyslexic dysgraphia may also find these technologies useful because the software correctly spells their spoken text. However, because the software writes exactly what the student dictates, language-related errors will appear unless the text is edited. Additionally, although the software “learns” to read the child’s speech, the speech needs to be clear and loud enough to detect. This is sometimes difficult, especially with younger children. There are many organizations available to help teachers and practitioners stay current with assistive technology developments, including Closing the Gap (www.closingthegap.com), which provides a wealth of up-to-date information related to assistive technology through its resource directory, magazine, and annual international conference.

Selecting the Proper ToolsThe art of good teaching lies partly in selecting the most appropriate

instructional support for each student. This is especially true for students with deficits in handwriting, among whom the underlying vulnerabilities can be so varied. Students with different subtype of dysgraphia will benefit from different no-tech, low-tech, and high-tech instructional supports. These options are presented in Table 1

As with any intervention, therapists and teachers should monitor student progress. The authors have found an observation tool like the one presented in Table 2 to be an effective way to gather this data.

In documenting progress, practitioners might consider the following questions.

Do I see any changes in the child’s attitude about and interest in writing tasks?

How would I characterize the child’s satisfaction with the tool? Has there been a change in the neatness, fluency, length, or

complexity of composed text? Has there been a change in the neatness or fluency of the child’s

writing when copying text?

Final ThoughtsThe difficulties associated with dysgraphia present barriers and

prevent some students from reaching their potential and experiencing academic success. The field of occupational therapy has developed a range of notech, low-tech, and high-tech interventions that should be matched carefully to the student’s subtype of dysgraphia. As always, occupational therapy practitioners, special educators, and classroom teachers are encouraged to track the progress of their students with dysgraphia carefully to determine specific responses to these interventions.

References1. International Dyslexia Association. (2000). Just the facts: Dysgraphia. Retrieved February 9, 2011, from http://www.interdys.org/ewebedit pro5/upload/dysgraphia.pdf

2. Feder, K., & Majnermer, A. (2007). Handwriting development, competency, and intervention. Developmental Medicine & Child Neurology, 49, 312–317.3. McHale, K., & Cermak, S. (1992). Fine motor activities in elementary school: Preliminary findings and provisional implications for children with fine motor problems. American Journal of Occupational Therapy, 46, 898–903.4. Denton, P. L., Cope, S., & Moser, C. (2006). The effects of sensorimotor-based intervention versus therapeutic practice on improving handwriting performance in 6- to 11-year-old children. American Journal of Occupational Therapy, 60, 16–27.5. Graham, S., Harris, K. R., & Larsen, L. (2001). Prevention and intervention of writing difficulties for students with learning disabilities. Learning Disabilities Research & Practice, 16(2), 74–84.6. Preminger, F., Weiss, P., & Weintraub, N. (2004). Predicting occupational performance: Handwriting versus keyboarding. American Journal of Occupational Therapy, 58, 193–201.7. Tyre, P. (2010, February 10). Watch how you hold that crayon. Retrieved February 9, 2011, from http://www.nytimes.com/2010/02/25/ fashion/25Therapy.html8. Asher, A. (2006). Handwriting instruction in elementary schools. American Journal of Occupational Therapy, 60, 461–471.9. Deuel, R. K. (1995). Developmental dysgraphia and motor skills disorders. Journal of Child Neurology, 19(1), S6–S8.10. Reitan, R. (1993). Halstead–Reitan Neuropsychological Test Battery. Tucson, AZ: Reitan Neuropsychology Laboratory/Press.11. Katz, D., & Zobel-Lachiusa, J. (2001, November 1). Cultivating connections: A harvest of skills and knowledge. Workshop presentation at the Massachusetts Association of Occupational Therapy State Conference, Marlboro, MA.12. Benbow, M. (2006). Principles and practices of teaching handwriting. In A. Henderson & C.Pehoski (Eds.), Hand function in the child: Foundations for remediation (pp. 319–342). St. Louis, MO: Mosby.13. Wechsler, D. (2011). Wechsler Individual Achievement Test (3rd ed.). San Antonio, TX: Pearson.14. Larsen, S., Hammill, D., & Moats, L. (1999). Testof Written Spelling (4th ed.). San Antonio, TX: Pearson.15. Bear, D., Invernizzi, M., Templeton, S., & Johnston, F. (2011). Words their way: Word study for phonics, vocabulary, and spelling instruction (4th ed.). San Antonio, TX: Pearson.16. Granske, K. (1999). The Developmental Spelling Analysis: A measure of orthographic knowledge. Educational Assessment, 6, 141–171.17. Naglieri, J. (1988). Draw a Person: A quantitative drawing system. San Antonio, TX: Pearson.18. Beery, K., Buktenica, N., & Beery, N. (2010). Beery–Buktenica Developmental Test of Visual- Motor Integration (6th ed.). San Antonio, TX: Pearson.19. Bruininks, R., & Bruininks, B. (2006). Bruininks- Oseretsky Test of Motor Proficiency (2nd ed.). San Antonio, TX: Pearson.

Prepared By:

Jerik Kalvin A. BertuldoUST-OT Intern 2012