Tag Archives: handwriting

When Writing Hurts: The Hypermobile Hand

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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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

For more information on hypermobility, read The Hypermobile Hand: More Than A Strength Problem and For Kids With Hypermobility, “Listen To Your Body” Doesn’t Teach Them To Pace Themselves. Here’s What Really Helps.

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!

The Hypermobile Hand: More Than A Strength Problem

 

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I just received another referral for a kid with “weak’ hands.  Can’t hold a pencil correctly, can’t make a dark enough mark on paper when he writes or colors.  But his mom says he has quite a grip on an object when he doesn’t want to hand something over.  He plays soccer without problems and otherwise functions well in a regular classroom.  Could it be that hypermobility is his underlying problem?

Some children display problems with fine motor skills due to low muscle tone.  Many times, their low tone is significant enough to create poor joint alignment and stability, resulting in joint hypermobility as well as low muscle tone.  But kids can also have joint laxity with typical muscle tone.  Assessing the difference between tone, strength, alignment/stability and endurance is why you get an evaluation from a skilled therapist.  And even then, it can be tricky to determine etiology with the youngest children because they cannot follow your directions or answer questions.  Time to take out your detective hat and drill down into patient history and do a very complete assessment.

With older kids, both low tone and joint laxity can lead them over time to develop joint deformity and soft tissue damage.  Like a tire that you never rotated on your car, inappropriate wear and tear can create joint, ligament, tendon, and muscular imbalance problems that result in even worse alignment, less stability and endurance, and even pain.  And yes, weakness is often observed or reported, but it often is dependent on posture and task demands, rather than being consistent or specific to a nerve distribution or muscle/muscle group.

What does the classic hypermobile hand look like?  Here are some common presentations:

  • The small joints of the fingers and thumb look “swaybacked”, as the joint capsule is unstable and the tendons of the hand exert their pull without correct ligament support.  When they slide laterally and the joint is unable to move smoothly, people say that their fingers “lock” or they are diagnosed with “trigger finger”.
  • The arches of the hand aren’t supported, so the palm looks flat at rest.  By late preschool, the arches of the hand should be evident in both active and passive states.
  • The fleshy bases of the thumb and pinky ( the thenar and hypothenar eminences, for all you therapists out there) aren’t pronounced, due to the lack of support reducing normal muscle development during daily use.
  • Grasp and pinch patterns are immature and/or atypical.  A preschooler uses a fisted grasp to scribble, a grade-school child uses two hands to hold an object that should be held by one hand and uses a “hook” grasp on a pencil.
  • Grasp and pinch may start out looking great, and deteriorate with the need for force.  Or prehension begins looking poor and improves for a while, until fatigue sets in.  This bell-curve pattern of grasp control is often seen with kids that have poor proprioceptive discrimination.  As they use their hands they receive more input, but as fatigue sets in, they cannot maintain a mature grasp and good control.
  • The typical arches of the hand that create the “cupping” of the palm when pretending to scoop water from a stream, for example, will be somewhat flattened. Unless there is nerve damage, you won’t see the “claw hand” pattern or another atypical posture.
  • Fine grasp will often be accomplished with the thumb and third finger to achieve greater stability through the MCP (knuckle) joints and to avoid full opposition of the thumb.  Another common compensatory pattern is using digits II and III together to gain greater stability.  Some kids can even wrap one digit partially around another to do this.  Now that’s hypermobility!

Don’t forget that hypermobility creates poor sensory processing feedback loops.  Reduced proprioception and kinesthesia will result in issues when children try to grade force and control movement without compensations such as visual attention and decreased speed. This can result in kids being labeled clumsy or careless.  For more on handwriting and hypermobility, read When Writing Hurts: The Hypermobile Hand

In terms of treatment, the standard strategies of strengthening and adapting equipment will be important, but I also teach joint protection to kids and parents, energy conservation and I do K-taping to hands.  It is more adaptable than splinting, parents can learn to do a taping protocol at home, and it provides the necessary proprioceptive input for learning that most splinting simply cannot deliver.  For more details on taping kids with hypermobility related to EDS, read Can You K-Tape Kids With Ehlers-Danlos and Other Connective Tissue Disorders?

Looking for more ideas to address the difficulties children face when they have hypermobility in their hands?

I wrote an e-book for you!

The JointSmart Child:  Living and Thriving With Hypermobility Volume One: /The Early Years is my newest book, and it answers many of the questions parents of young hypermobile kids have every day!  Filled with strategies to build control, independence and safety, it guides families in the use of seating, picking out utensils for meals, even how to make the bath and bedtime safer and easier.  It is available on Amazon.com for digital download.  The book is designed to make parents feel empowered and to help children live happier and easier lives!

 

Take a look at For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance and Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility?.  Depending on the age and skill level of the child, adaptations and education can be just as important as therapeutic exercise.  Your pediatric occupational therapist can help with more than pencil grasp; we are able to help with so many real-life issues!  For toys that support a child’s grasp and control, check out Playing With Toy Food Builds Hand Skills…Faster! and DUPLO Train Set Is Affordable Safe Fun!; both of these toys are easy to hold and easy to manipulate, but allow creativity and fun while developing coordination and control.

 

Do you need help with toilet training?  My e-book will give you the support to make this less of a struggle!  Read The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived! and find out what parents have to say about the only manual on the market to address potty training and low tone.

 

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The Elf on the Shelf Could Get Your Child to Write a Letter to Santa!

 

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Write to Santa, but KEEP the note since the elf brings it to the North Pole…and then back to your home!

‘Tis the season, and Elf On The Shelf is back for more fun!  Some parents adore the concept and cannot wait to move that little elf around the house every night, and others mock him and his expanding merchandising.  Now that he is getting kids to write and draw, and parents will be able to save the heartfelt message as an ornament, I’m in with the Elf!  Not familiar with the Elf story?  Read Elf on the Shelf Controversy: Let’s Try Positive Gossiping to Santa.  Used as an encouragement and not a punishment or a threat, I am OK with this holiday tradition.

You use the paper and materials in the kit to write and bake-off a letter into an ornament that the elf “shows” to Santa on his nightly trip, and then he “returns” it to your tree.  The kit includes a storybook, materials to write, bake and hang your ornament.

As a pediatric occupational therapist, I wanted to share a few ideas that could make this more fun and a bit less stressful for children that struggle with handwriting, learning and attention issues:

  • The set includes 8 special sheets of paper that will get baked off in the oven to create an ornament, but I would encourage everyone to have their child refine their message and practice writing/drawing the note on regular paper before putting it on the special sheets.  Use these sheets as a template so that your child is aware that they can’t write more than a few lines at most.  There is no way to erase on the special sheets, and although some errors are charming, a child can be heartbroken if they think that they are sending a messy message.
  • I would encourage parents to consider copying the message so that kids have a sample to copy, rather than free writing.  Copying is an easier task in the developmental progression of handwriting, and reduces the stress for success on kids.  Nobody needs stress when making a special request to Old Saint Nick.
  • Younger kids, or kids with strong fears of failure or anxiety in general can draw or decorate a parent’s writing.  As long as they are involved, I don’t think it has to be all or nothing.  Many of my most avoidant clients get excited when I tell them that they just have to draw a sun (circle with rays) or some grass (short vertical lines that start at the top and descend to a baseline) to a picutre that I am drawing, and I  will take care of all the hard stuff.  Sometimes they even decide that they want to draw much more than they were planning to contribute.
  • Encourage your child to make the letters and designs a bit large, since they will shrink with the baking process.  Most young children cannot comprehend this step and will assume that the finished product will come out of the oven the same size that it was when it went in.  Tiny details may not be visible, tiny letters may be illegible.  Make a sample if possible for children that need proof of everything before they believe you.
  • If you know that your child may be impulsive or has such significant struggles with design, handwriting, or decision-making that you will need more than 8 sheets to create one final project, buy two kits.  The holidays are challenging enough without a fun activity ending without even one finished ornament.  If things go well and you don’t need the extra box, you have something that can be a wonderful gift for another family this season!

If you use this kit with your child this Christmas season, please write a comment and let my readers know how it worked out for you!

 

 

Make Handwriting Fun While Getting Ready For The New School Year

Here in the US, kids are getting ready to go back to school.  And most of them haven’t been writing much in the last 6-8 weeks.  At the kindergarten level, some children will have forgotten any lowercase letters they knew in the spring.  At the 1-2 grade levels, it is not uncommon for kids to forget how to form letters, where to place them on the baseline, and how to use simple punctuation.   Teachers sometimes need to use the first 1-2 weeks for review alone.

What if they didn’t need to review?  What if your child was ready to hit the ground running (and writing)?  There is nothing like seeing a confident kid sit down to crush her homework instead of struggling through it.  For all those writers who worked hard last year and are a little nervous to pick up a pencil again, here are some ideas that help getting back to writing fun and easy:

  1. Get good materials.  Kids are just like adults.  We like new, cool stuff.  So do they.  I recommend using the best eraser (Problems With Handwriting? You Need The Best Eraser ) and either the small Learning Without Tears (they changed their name!!!)  pencils for kindergarteners, or the Papermate 1.3mm lead mechanical pencils for older kids.  Take a look at my post on these useful pencils Great Mechanical Pencils Can Improve Your Child’s Handwriting Skills
  2. Use fun workbooks like Madlibs and games like Hangman.  Make up games that you think your kids will find funny.  Try the Junior version of Madlibs for grades 2-3, and the regular one for the higher grades.  There are themes for every kid, trust me.  Something will be funny.  Do them together with your child, have a contest for silliest madlib, send them to relatives that can appreciate this humor, etc.
  3. Target any errors made in writing their first and family name first.  Those errors will be repeated over and over in the first few days of school if you do not focus on them.  Time to make this a priority.
  4. Figure out where the gaps are, and hit the low-hanging fruit next.  Why?  Because that builds confidence.  Look for simple errors with easy-to-write or frequently written letters.  Think “a”, “e”, and “t”.  Doesn’t even have to be letters; could be numbers.  Kids need to feel like they can hit singles, and then they will try harder for doubles and triples.  Forgive the baseball reference; I saw a ton of stickers and vanity plates today.   Apparently all of my neighbors are big baseball fans!

There are only a few weeks of summer left, but if you make a small effort,  it can mean a lot to a child’s first weeks of school!

Child Writing Too Lightly on Paper? It Might Not Be Hand Strength Holding Him Back

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If your child barely makes a mark when he scribbles or writes, most adults assume that grasp is an issue. Today’s post suggests that something else could be the real reason for those faint lines.

Limitations in postural and bilateral control contribute far more to lack of pressure when writing  than most parents and teachers realize.  For every child in occupational therapy that is struggling to achieve good grasp, I see three whose poor sitting posture and inability to get a stable midline orientation are the real issues.

Think about it for a minute:  if you sat with your non-dominant (not the writing hand) hand off to the side and you shifted your body weight backward in your chair, how would you be able to use sufficient force on a pencil or a crayon?  Try this right now.  Really.  You would have to focus on pressing harder while you write and hope your paper doesn’t slip around.  That would require your awareness and some assessment of your performance.  Children don’t do “awareness and assessment” very well.  That ability comes from frontal lobe functions that aren’t fully developed in young children.  But they can learn where to place their “helper hand”, and that sitting straight and shifting forward is the correct way to sit when you scribble or write.

If a child has sensory processing or neuromuscular issues such as cerebral palsy, Ehlers-Danlos Syndrome or Down Syndrome, achieving adequate postural stability may take some effort on the part of the therapists and the teacher.  Well worth it, in my experience.  There are easy hacks that help kids; good equipment and good seating that won’t cost a fortune or inconvenience the class.  Every child can learn that posture is important for writing.  But the adults have to learn it first.  Kids take their cues from what adults appear to value, and if they figure out that they are allowed to slump or lean, they almost always will.

I am doing a lecture on pre-writing next week, and I intend to make this point, even though the emphasis of my lecture is on the use of fun drawing activities to prepare children to write and read.  Why?  Because it may be the only time these preschool teachers hear from a pediatric occupational therapist this year, and I want to make a difference.  Understanding the importance of postural control in pre-writing and handwriting could help struggling kids, and make decent writers into stars!

 

For more information, take a look at For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance and Better Posture and More Legible Writing With A “Helper Hand”.

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Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility?

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An adaptive grasp pattern for the hypermobile child

As a pediatric OT, I am often asked to assess and teach proper pencil grasp.  Once you start looking, you see a lot of interesting patterns out there.  When a child clearly has low muscle tone and/or hypermobile joints, the question of what to do about an atypical pencil grasp used to puzzle me.  I could spend weeks, or even months, teaching positioning and developing hand strength in a child, only to find that they simply couldn’t alter their grasp while writing.

Now I triage grasp issues by determining if it is a problem for the child now or in the future.  An atypical pencil grasp can be an acceptable functional compensation or it can be a contributor to later joint damage.  What’s the difference?  You have to know a bit about hand anatomy and function, how to adapt activities, and how to assess the ergonomics of writing.

Children aren’t aware of most of the problems that low tone and/or hypermobility create when they hold a pencil.  They just want to create. The effects of their unique physiology often results in grasp patterns that cause parents pain just to observe; fingers twisted around the shaft of the pencil, thumb joints bent backward, etc.  The kids aren’t usually complaining; their lack of sensory receptor firing at the joints and muscles gives them no clues to the strain they are inducing.  None.  Occasionally children will complain of muscular fatigue or pain after writing a few paragraphs or completing an art project.  For the most part, they are unconcerned and unaware of what is really going on.  For a more detailed explanation, please check out Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children,

Do these funny grasp patterns reduce legibility?  Only sometimes.  There are atypical grasp patterns that are good choices for children with hypermobility.  One is to place the shaft of the pencil directly between the index and third finger, and allow the thumb to support the side of the pencil.  The knuckle joints of those fingers provide more stability than the standard tripod grasp.  This grasp pattern is illustrated at the beginning of this post.

I allow preschoolers who need to keep more than 3 fingers on the shaft of the pencil to do so, and wait to see what happens as they develop more overall hand control.  This is especially beneficial for the child with sensory discrimination issues or joint hypermobility.  Forcing a tripod grip isn’t always in their best interest now or for the future.

What can be done?  My favorite method to help children with low tone or hypermobility is to look at the problem with both a wide-angle lens and with targeted analysis.  I think about changing overall posture, altering any and all equipment, and examine the mechanics of movement.

Does handwriting instruction matter?  I think so.  The best writing program teaches children quickly, so that they don’t have to write 100 “A”s to learn how to write.   The only program I use is Handwriting Without Tears.  The high-quality materials and the developmental progression make learning easier and faster.  Read KickStart Kindergarten: Get Your Child Ready for Kindergarten Writing The Easy Way! to see some sample pages and understand how this particular book can work for ages 4-8.

Wondering if there are issues beyond writing that your OT can address?  Check out Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children and Three Ways To Reduce W-Sitting (And Why It Matters) for more information.

Atypical pencil grasp can be a problem, but it can also be a solution to a child who is struggling to write and draw in school.  If you have concerns, ask your OT to evaluate and explore the issue this week!

Looking for more information on raising a child who is dealing with hypermobility?  I wrote the e-book you need!

The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years is filled with practical strategies to help parents build safety, skill, and independence.  Written in easy-to-understand language and designed with chapter summaries that help busy parents find the answers they need, this book is unique in the world of special needs resources!  Read   to learn more and find out how to order it today!

 

Why Dot-To-Dot Letter Practice Slows Down Writing Speed and Legibility

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These beach umbrellas look like a dot-to-dot picture!

Most workbooks feature dot-to-dot practice for writing letters.  They shouldn’t.  Why?  The answer is obvious if you know how to teach handwriting.  The biggest problem is that so few people understand how children learn to write, and what gets in their way.

There are 3 stages of learning:  imitating an adult, copying printed materials, and independently writing a letter.  When the first stage of instruction is too short, poorly attended to (imagine a distracting preschool room) or nonexistent (“go practice at the writing table during your free period”), children end up drawing their letters, unaware of how letters are correctly constructed.  Dot-to-dot worksheets encourage drawing letters. They do a very poor job of teaching correct formation and a good job of encouraging bad habits in handwriting.

Dot-to-dot worksheets, even the ones with a starting dot or arrow, cannot be followed correctly by most very young children.  They look at the letter “a” in the same way I look at a Chinese character or a hieroglyph.  I could probably copy it, but I have no idea which lines make a single stroke, which to write first, second and third, and no sense that it should be similar to other characters.  Children really don’t follow a tiny arrow or understand that numbering the strokes means that a tiny number two at the top means “This is your second stroke”.  Older children do, but they aren’t the ones laboring over the dot-to-dot letter pages.  There is a better way.

To make my point clear, look at the letters that Handwriting Without Tears calls the “magic c letters”:  c, o, a, d, and g.  By the way, are you wondering why “q” isn’t in the group, since it is formed in a similar manner?  They add “q” later in instruction, due to the potential confusion with “g”,which is a more commonly used letter in English.  I have seen a single child write the letter “c” made starting at the baseline and curving up, then make the letter “o” correctly by first writing a “c”, and then write letters “a”, “g” and “d”  by drawing circles and adding straight or curved lines.

This method of letter formation never looks neat once children have to write full sentences with some speed.  It can’t look good, as the pencil control required to write well with these strategies is too challenging for young children once they have to write more than a few letters.  Ooops! Where did they come up with all those different methods of writing letters that should be made by starting with the letter “c” and then continuing to form the specific letter?   They figured it out for themselves, since no one was watching!

The “Magic C” approach is brilliant because it is simple to recall and it creates control and automaticity, two hallmarks of legible handwriting.  Dot-to-dot writing leads children down a path riddled with possible bad habits.  Want a terrific HWT book for your preschool child that is advanced, or your struggling kindergartener?  Check out KickStart Kindergarten: Get Your Child Ready for Kindergarten Writing The Easy Way!.

So are dot-to-dot pictures a terrible idea?  Not at all.  I love the way children have to control pencil strokes and visually scan the page for the connecting number or letter.  They are great visual-motor fun.   There are complex dot-to-dot pictures with over 200 dots that really challenge kindergarteners who can count.  Just don’t teach letters this way!