There are a few equipment and toy recommendations that every home-based pediatric OTR makes to a child’s parents: Play-Doh, puzzles, tunnels, …and a vertical easel. Found in every preschool, children from 18 months on can build their reach and proximal (upper body) control while coloring and scribbling on a vertical surface, rather than a tabletop.
But WHERE a child is directed to aim their stroke matters. Here is why:
Grasp and reach have a range of efficiency. I tell adults to imagine that they are writing on a whiteboard for a work presentation. Your boss is watching. Where will your writing/drawing be the most controlled? Everyone immediately knows. It is between your upper ribs and your forehead, within the width of your body or a few inches to either side. Beyond that range, you have less stability and control. Its an anatomy thing. If you are an OTR, you know why. If you are a parent, ask your child’s OTR for a physiology and ergonomics lesson.
Visual acuity (clarity of focus) is best in the center of your visual field (the view looking directly forward with your head centered). Looking at something placed in this range is called using your “central vision”. Your eyes see more accurately in that location, children can see an adult’s demonstration more clearly, and therefore they can copy models and movements more accurately. Kids with ASD like to use their peripheral (side) vision because it is cloudy, and the distortion is interesting to them. This is not good for accomplishing a visual-motor task or maintaining social eye contact, but they find this is a way to perform sensory self-stimulation and avoid the intensity of direct eye contact with others.
Young children have little self-awareness of how their environment impacts them. Until they fail. Then they think it is probably their fault. The self-centeredness that is completely normal in children gets turned around, and a child can feel that they are the problem. Telling children where to place their work on an easel gives them the chance to do their best work and feel great about it.
Children move on when a task is too hard, or when an adult doesn’t provide enough supportive strategies. Telling a child to try again, or telling them that their results weren’t too bad” isn’t nearly as helpful as starting them off where they have the best chance of success.
Using the non-dominant hand to support the body while standing is an important part of easel use. For kids with low muscle tone or hypermobility, it is very important. Standing to the side or draping the body on the surface to write are both poor choices that OTRs see a lot in kids with these issues. Make the easel a piece of therapy equipment and teach a child to place their non-coloring/painting hand on the side of the easel in the “yes zone”. Look at the picture of the older boy at the beginning of this post, then at the gentleman below. Note each person’s posture and try to embody it. Which posture provides more ease, more control?
Here is a graph of where an adult should place their demonstration on a page or board for optimal vision and motor control, and where adults should encourage a child to draw. “NO” and “YES” refer to the child’s optimal location for drawing or writing.
The exception is for height. A very tall child will need to draw higher on the chart, and a smaller child will only reach the lowest third of the easel. This should still allow them to use their central vision and optimal reach. If the easel doesn’t fit the child, place paper on a wall at the correct height.
One of my colleagues with a hypermobile third-grader told me this chair has been a great chair at school for her child. It hits a lot of my targets for a chair recommendation, so here it is: The Giantex chair.
Why do I like it so much?
It is a bit adaptable and sized for kids. No chair fits every child, but the more you can adjust a chair, the more likely you are to provide good supportive seating. This chair is a good balance of adaptability and affordability. My readers know I am not a fan of therapy balls as seating for homework. Here’s why: Should Hypermobile Kids Sit On Therapy Balls For Schoolwork?
It isn’t institutional. Teachers, parents, and especially kids, get turned off by chairs that look like medical equipment. This looks like a regular chair, but when adjusted correctly, it IS medical equipment, IMPO.
It’s affordable. The child I described got it paid for by her school district to use in her classroom, but this chair is within the budget of some families. They can have one at home for homework or meals. Most kids aren’t too eager to use a Tripp Trapp chair after 6 or 7. It’s untraditional looks bother them. This chair isn’t going to turn them off as easily.
This chair looks like it would last through some growth. I tell every parent that they only thing I can promise you is that your child will grow. Even the kids with genetic disorders that affect growth will grow larger eventually. This chair should fit kids from 8-12 years of age in most cases. The really small ones or the really tall ones? Maybe not, but the small ones will grow into it, and the tall kids probably fit into a smaller adult chair now or in the near future.
I had to look twice. A private client showed me the picture her 4 year-old made in his school OT session (not the picture above!). A picture decorated using a dot marker. He can copy a vertical cross and a circle using a pencil. I showed him how to draw a triangle in less than 4 minutes during that session. He is very risk-averse and is probably intellectually gifted. He has lots of sensory issues and mildly limited fine motor skills.
Why was he using a dot marker foranything?
I know his therapist isn’t very experienced, and I am sure the supplies budget isn’t huge. But neither are good excuses for using tools that don’t raise the skill level of a child that is so hesitant to be challenged. Those markers are great for toddlers under 2 or older children with motor skills under a 24-month level, especially kids with neurological or orthopedic issues that don’t allow them to easily grasp and control crayons. Dot markers get children excited to make a mark on paper (an 11-month fine motor skill) and can be the first step to holding a tool to develop early pre-writing.
They aren’t good at all to develop any kind of mature pencil grasp due to their large diameter and large tip. It would be like writing your name with a broom!
The ink tends to splatter with heavy quick contact with paper (fun to make a mess, but not therapeutic!), and doesn’t dry quickly enough. Repeated contact bleeds colors together, and it is hard to keep within the borders of a design unless the target is very large. I can assure you that the design above was done by an adult, an adult with some art training.
Dot markers aren’t building pre-writing skills for this child I treat. There are so many options for activities that do build skills in kids at his ability level. Their use can discourage a risk-averse child from working on pencil grasp. Whatever the activity it was that they were doing, unless he was swinging on his belly on a platform swing or going down a ramp on a scooter (I don’t think he was doing anything nearly that intense) while using a dot marker, there were other, better choices to make.
The child who stalls for time. Some kids want to run down the clock on their therapy session or on their homework time, and realize that erasing can help them do just that. The fun of rubbing the eraser on the paper exceeds the fun of struggling to write or struggling to answer a question.
The kid that gets upset when they make a mistake. Some children are oblivious, but some are distressed when they write poorly. So upset that they lose some of their focus and ability to listen to your suggestions/instructions.
The child who persistently traces over their original mistake. These kids were taught with a lot of tracing in pre-K and K, and their brains have been trained to trace. When they see the faint outline of their mistake, they have to struggle NOT to trace it. Oops.
What SHOULD you do?
These strategies assume that an adult is helping a child directly. You may not need to remain there for the entire homework assignment, but adult assistance is needed to get this train turned around:
Ask them to write the word again. You may need to fold the paper so that their mistake is not visible, but a correct model is visible. You may have to write a new visual model in the margins or above their work space.
Use Handwriting Without Tears pages. Their workbook pages are designed to be simple but offer visual models across the page, not just at the left margin.
Erase the mistake yourself. Adults can use more force and erase more effectively.
Make a copy (or 2) of your child’s homework so that you can ask them to start over again, but only if it is a short assignment. No one wants to rewrite a long page.
Provide more instruction before they begin their word or sentence. A reminder that certain letters are tricky or that they need to space words out How Do You Teach Word Spacing? can prevent errors.
All this is often visual noise to kids with sensory processing issues and ocular or visual-perceptual issues. These problems are sometimes subtle and appear to be behavioral. The kids who “hate to write”. The kids who look away when you are demonstrating how to write a letter or spell a word. The kids who cannot seem to remember where to start a letter, even after repeated practice. These children often do much better with HWT’s double-lined paper.
Let’s drill down into the design of this unique paper:
Double-lined paper provides just two lines; the baseline and the midline. Knowing where to start uppercase letters and tall lowercase letters is important, and this paper encourages practice and awareness while still giving some structure to writing.
There is a wide empty space between sets of lines. This is intentional; children have room to place the tails of lowercase “y” and “j”, for example, without blocking the uppercase or tall lowercase letters of the next line of writing. For many kids, not knowing what to do about crowding and spacing is a good reason to stop trying to write well, or sometimes even write at all.
This sturdy paper is pre-punched to be used in a 3-ring binder. The quality of the paper is very high, which means that it doesn’t tear easily when a child erases a mistake. Most schools provide the thinnest paper for teachers to use as handouts, creating the potential for a disaster when given to a child that struggles with grading their force on an eraser, or makes multiple errors in a word.
Brains get practice in sizing and proportion. Once kids have a pattern of letter formation, it is easier to accomplish without the extra midline. But so many kids need that “training wheel” effect much longer than scrolls recognize. Many kids need a day or two of double-lined paper use to start understanding the way a letter “h” is twice as tall as a letter “a” and the same size but aligned differently than the letter “y”. Of course, pointing it out is important, and so is working on other writing qualities such as letter and word spacing.
Kids write faster. Because they are guided to proportion and start letters correctly, they don’t waste time thinking about it or erasing incorrect letters. Again, this doesn’t mean their brain isn’t taking it all in. If that were true, we would start every kid on single-lined paper in preschool.
There are three line sizes, so you don’t have to abandon the double-lines when your kid enter middle school. I will admit that I wish the pre-k/K paper were thicker. But it is still fairly sturdy.
You can alternate using this paper with single-lined paper to see when to “take the training wheels off” and stop using double-lined paper. Kids should always have a chance to practice with standard paper, but when the choice is between fighting and crying, and quickly executing a homework assignment, it is no contest.
Many children resist doing their homework, but most kids say “Its so BORING!” not “My hand hurts too much”. If a child is complaining of pain, and they don’t have a joint disease such as JRA, the first thought is hypermobility. The good news is that there are a few fast fixes that can decrease or even eliminate hand pain.
It is rare that hypermobility in the hand is directly addressed at the preschool level unless it is generalized throughout the body or severely reduces pencil grasp. Many children have atypical grasp patterns when they cannot achieve the required stability for a standard pencil grasp. Children with mild instability and no other developmental issues may still be able to write legibly and even fast enough to complete assignments in the early grades. It is when the volume of work increases or the joint stability decreases that therapists get a request for service.
Here are a few strategies that can support hypermobile kids to write with less pain:
Use a tabletop easel. These can be foldable or static. They support not just the wrist and forearm, but also the shoulder and trunk. The angle of an easel both supports correct wrist positioning and decreases strain on the wrist and hand. Some easels come with clips that hold the paper, but they should be placed on an angle to mirror the natural arm position. This will require more table space, so be aware that the size of the easel could be an issue. Simple hack: use a three-ring binder as an easel.
Enlarge the width of the pencil shaft. My favorite pencils for grades 1+ (see photo above) have a standard #2 lead, but a wider shaft. Joint protection principles tell us that avoiding a closed joint position should lead to less strain on joints and supporting ligament structures. You could use some of the adaptive pens available, but I find kids reject these as looking strange. Of course, if you enlarge the shaft oo much you will find that it is more awkward, not less. Think of those novelty pencils you buy in gift stores on vacation. Cute but useless. Nobody really writes with anything that thick. Match the child’s hand size to the pencil.
Increase the texture of the pencil shaft for easier grip, less pain, and more endurance. Everyone has seen the rubbery grips you slip onto a pencil. You can slide 3-4 onto the entire shaft, or add some tape to create a non-slip surface. I have been adding kineseotape or Dycem to handles this year, with good results. You are battling grasp stability, but also fatigue. A hand that is tired is a hand that experiences more pain. Adding texture reduces the amount of force needed for proprioceptive registration (a fancy way of saying that kids need to squeeze to fully feel what is in their hand). Reducing force reduces pain and fatigue.
Teach pacing. Kids think that the faster they write, the faster they will be out of pain. Breaking up the work can have better results, but it isn’t natural for children to pace themselves. In fact, I have never seen a young child do so. You have to teach this to kids who likely will have joint instability throughout their school years. A schedule, a timer, organizing assignments and breaking them down into heavy writing choices and light writing choices all help.
Splinting can be a real option. Not a heavy plastic or metal splint (usually). A neoprene splint can be a lightweight supportive choice. These splints are comfortable and washable. These are affordable without insurance for most families, and your OT can help you decide if this is a worthwhile pursuit. They are durable but easily lost by younger children, so not all families send one to school. But the support is real, and kids that have been told for years to “fix your fingers” can feel relieved that they can now focus on writing and composing on the paper.
Looking for more assistance with hypermobility? My new e-book is coming out this summer, and it will address the issues of the early years (0-5). The series will continue with school age kids and teens. But you don’t have to wait; visit my website tranquil babies and request a consultation to discuss your child’s treatment plan and make a better plan that works for everyone…today!
My clients and colleagues know how much I love the original Water Wow books. They are reusable and mess-free fun for kids at home, at the doctor’s office, the restaurant and the plane ride. These bigger books are going to be even more fun for preschool kids and kindergarteners!
Here are some great reasons why I love these books:
They have more pages, and more pages means they keep kids busy (and happy) longer.
They offer more detail and more challenge. The graphics inspire critical thought (Is this a silly thing to find in the supermarket or not?) and the red lens that looks like a magnifying glass makes kids feel like Sherlock Holmes as they search for secret items.
There are mazes, hidden items and pages where kids can compare two almost-identical pictures and find the anomalies. It is more than just wiping water on a picture.
Like the originals, the pages dry quickly and can be used over and over. It seems like kids would get bored after the first run-through, but children can enjoy the “reveal” and the sensory play of water on a page for a long time after they have solved all the puzzles. If you are at 30K feet and your kid is getting restless, this could buy you a bit of time without having to resort to screens that they will insist on for the rest of the (expensive) trip. Genius.
Oh, and the pen is easy to grasp, and it develops a mature pencil grasp with repeated use. Yeah!