Why “Hand-Over-Hand” Assistance Works Poorly With So Many Special Needs Children

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This method of teaching fine motor skills has never worked well for me in Early Intervention.  In my professional experience, it has been a popular technique for many special educators.  But they aren’t always getting the results they want.  Very often, the scenario is as follows:  I get a call from a concerned parent, telling me that the teacher is wondering if their child has sensory aversion, since he or she resists the teachers’ touch during sessions.

Sometimes that is indeed the case.  More of the time it is not.  The true reason why “hand-over-hand” assistance is not accepted or working well is a little more complicated.  Here are the two situations in which sensory aversion is not the biggest problem, but there are less obvious reasons for the failure of this method of training:

  1. Children with low muscle tone.  Holding a child’s hand and guiding them, even moving their hand and arm, limits the necessary proprioceptive and kinesthetic information that is required for a child to learn effective hand control.  The tactile sensation and the imposed movement from an adult’s hand masks this subtle information.  The brain cannot process and learn if it isn’t receiving correct and useful information. Children with low tone are automatically placed in the category of “sensory processing issues” due to the diminished proprioceptive and kinesthetic information resulting from low tone  Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children.  Using hand-over-hand assist is creating more tactile input but less muscle and joint input!  One strategy that works for me is using the weight of my hand to create “drag”; I am giving the child more proprioceptive/kinesthetic information as the child moves intentionally to accomplish a task.  It cannot be too much drag, restricting their movements, and it cannot be too little movement or contact, which the brain interprets as offensive light touch.  And it has to follow their general movement, not passively bringing a child’s hand to the toy.  This takes practice to learn, and it helps if you are good at perceiving your own subtle movements.  Think Feldenkrais or Tai Chi.
  2. Children with cognitive and/or communication delays.  A child that doesn’t realize that “hand-over-hand’ assistance is intended to help them perform a task, or a child that doesn’t want to perform that task, will almost always resist the physical contact of an adult.  Imagine if the person sitting next to you suddenly grabbed your partially paralyzed hand and pulled  it off the table.  You would jerk it back.  If you knew that a spider was crawling toward your hand, you would be grateful, not resentful.  It’s dependent on your awareness of the person’s intent, and your agreement that this is the way you want assistance to move your hand!!   If a child is unaware or uninterested, it makes sense for them to resist physical intervention.  So many globally-delayed children are handled all day long without their full awareness or even their consent.  They may have no interest in stacking blocks or scribbling.  There are other ways to assist them.  Creativity and excellent observations of a child’s motivation to move are the keys to improving their participation.

What CAN you do to help these kids?  What about kids who are truly aversive to being touched?

My approach to reducing tactile aversion is fairly simple:  touch needs to begin in areas that the child can accept, paired with emotional warmth and paced by the child but structured by the adult.  Remember:  light moving touches neurologically perceived to be alerting, firm and static touch is modulating to the nervous system.  Grade your touch accordingly.  If you cannot, ask your OT to show you how this is done.

For children that are avoiding contact because they don’t understand why you are holding and placing their hand on a toy, play has to begin without an object and with lots of demonstration.  Yes, it looks like you aren’t doing anything.  That’s because you are doing preparatory activities.  A child that wants a toy, wants to hold a toy, and wants to manipulate a toy may be more open to your assistance.  You may have to spend some time at this stage.  Children need to re-learn habitual responses.  Don’t give up, but ask for help from your OT if no change in a child’s responses is observed.

What else can you do?  Use more force, not less, to give them more sensory-based information about what their hand is doing.  Read For Kids With Sensory and Motor Issues, Add Resistance Instead of Hand-Over-Hand Assistance to understand how to use this strategy instead of hand-over-hand helping.

I hope this clarifies why I rarely use traditional H-O-H with my clients.  It can work, but usually it works better with older special needs children, special needs children with fair to good receptive language, and children without sensory processing issues.  Unfortunately, that population is rarely on my Early Intervention caseload!

Looking for more information about how to help a special needs child at school?  Check out Help Your Special Needs Toddler Make The Transition To School Routines and Is is Sensory Or Is It Behavior? Before 3, The Answer Is Usually “Yes!” for some ideas that really work!

 

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