Line Placement, Letter Size and Spacing

Line placement (alignment), letter size and spacing...are there any tricks to address working on these aspects of handwriting?  I do get asked this from time to time, so I will pass on some of the strategies that I use in individual sessions to paraprofessionals and teachers.

Of course, there are various types of papers that are helpful to assist with alignment by providing a visual guide (cue):

I use the yellow highlighted paper quite often, as it gives a nice visual cue for line placement and letter size (Bright Lines paper by Ellen Kinsinger, OTR).  The other paper in the picture has a blue line for the "sky" or the top line, and a green line for the "grass" or bottom line (Smart Start paper by Frog Street Press, Inc).

To work on letter size, I like to use graph paper-  I start with the larger size, and then decrease the size as we work on refining the skill.  You can also use graph paper to work on spacing between words when printing sentences (leave an open square between the words).  It is also helpful for lining up math problems.

For older kids, I like to work on decreasing letter size, spacing and writing within margins using RediSpace transitional notebook paper by Mead:

This is a strategy that I use on a chalkboard to work on pre writing/early writing skills:

It emphasizes top-down orientation (always start your letters at the top!), starting at a point and stopping at a point and staying within an area while making basic lines and a shape.  Working on a vertical plane is developmentally easier, and the resistance from the chalk board provides sensory feedback.

Here is an example of how a preschool teacher is making a visual cue on a student's work so that he starts to write his name within a given area:

Handwriting Without Tears also has it's own lined paper that alleviates the "3 lined paper" concept, and addressesses various other techniques and strategies for these same aspects of handwriting that you might want to check out here:  http://www.hwtears.com/hwt

Focus on Treatment

I recently spent 2 days in a workshop that was presented by Kristen Birkmeier, MSPT of Pediatric Therapy Training.  The training was sponsored by the facility that I work for and the hospital here in town.  The Pediatric Therapy Training website describes Kristin as "a renowned and highly respected pediatric clinician and educator who teaches national workshops focused on assessment and treatment of the infant and child with neuromotor dysfunction."   She truly is that and more!  I found her to be extremely knowledgable and I gained a lot of information regarding the treatment aspect of working with those with neuromotor dysfunction.  You can learn more about Kristin and Pediatric Therapy Training at Kristen's website here: http://pediatrictherapytraining.com/

There is a ton of information that I could share here, but the information is so extensive that it would be hard to do that.  So, I will share one very important thing that was the basic premise of the whole training session:

Treating the "Initial Triad":  which is head control, over an actively stable, well aligned shoulder girdle (this is the basis for head control), with the ability to take weight and shift weight over the upper extremities.

Maintaining range and mobility throughout the shoulder girdle and trunk, and addressing underlying weakness in these areas, is the basis for developing head control and UE function, as well as the refinement necessary for vision and oral motor control.  It also lends itself to achieving trunk control, balance, stability, distal control, which helps to improve fine motor skills, etc.  You get the picture...
Essentially, what is says to a therapist is that by focusing treatment on the "initial triad," all of the other things that you are hoping to achieve will start to fall into place.  What this says to a parent is that if your child does not have adequate mobility and strength throughout the shoulders and trunk, it will be difficult for your child to have adequate head and trunk control and to develop further refined skills.

As a parent, how can you work on this at home?

-Keep your child flexible and mobile.  Make sure that you maintain their joint ranges by stretching exercises.  Forward trunk flexion, trunk rotation to each side, and lateral rotation to each side.  If your child has cerebral palsy, ask their PT or OT to help you with learning how to passively range and have them guide you with a home program.
-Have your child weight bear through his/her forearms and extended arms.  If you have an infant or a child who is at that developmental level, spend time playing on their tummy.
-If your child is mobile:  climb.  Play on playground equipment.  Make an obstacle course that your child has to maneuver through and climb through and around, pull themselves up on.
-Engage in play and activities that can strengthen their "core" (trunk).
-See my previous posts, "Secrets to Good Handwriting" from 5/28/13 and "Postural Control and Shoulder Stability" from 6/3/13 for more information and specific activities.

Weak little hands?

I often get questions from parents and educators about how to go about improving hand strength in kids.  Kids have decreased hand strength for a variety of reasons-  low muscle tone, Down Syndrome, kids with small hands, cerebral palsy, etc.  Often times we notice weakness during self help tasks or fine motor tasks when we note that the child can't open containers, pull on mittens, shoes or boots, can't take marker caps off of markers or can't open and close a scissors.

There are over 25 muscles in the hand.  Development of higher-level manipulation skills require a good balance of strength and stability throughout the hand.  As a result, hand strength is another one of those issues to address with kids to improve their handwriting skills (see original post, "Secrets to Good Handwriting" from 5-28-13).

Activities used to strengthen the small muscles of the hands involve materials and tools that provide
resistance.  Here are some activities that we can engage kids in to address hand and finger strength:

-play with hole/shape punches and staplers
-pick up items using tongs, tweezers or clothespins:  aluminum foil balls, cotton balls, beads, small toys

-play with squirt guns, bulb syringes/squeezers, medicine dropper
-play dough -- squeeze, flatten with hands or a rolling pin, make cut outs by pushing cutters into the dough
-theraputty:  comes in various resistances.  Pull, push pegs into the putty, find hidden beads in putty, roll into long strips (“snakes”) and cut into pieces using a scissors

-cut with a scissors: vary the resistance of the paper by cutting through thicker paper
-popbeads, duplos, legos, bristle blocks
-squeeze stress balls and squeezy fidget toys
-pushing push pins into a bulletin board

Pushing push pins into a vertical board to make the first letter of my little friend's name.

-buttoning, snapping activities
-pop bubble wrap with fingers
-stirring things in a bowl that have varying resistances (pudding, brownie mix, etc)

In Hand Manipulation Skills

Once again I am expanding on the "Secrets to Good Handwriting" post from a few months back by addressing in hand manipulation skills.  Remember that developing all of the skills mentioned in that original post (dated 5-28-13) will positively affect your child's fine motor skills. Think of those skills mentioned as the building blocks of fine motor skills.

In Hand Manipulation Skills
In hand manipulation refers to the ability to shift objects within your hand using just the fingers.  Sometimes we do this when we are holding an object and looking at it, or shifting a small item in our hand to place it somewhere.  Being able to do this depends on mobility and coordinated movements at the base joints of your fingers (or, what is commonly referred to as your knuckles).  Kids who have difficulty with this are often dropping smaller items that they are handling.  Sometimes they use 2 hands together instead of just one hand for a task. You may also see that they will put an object down on the table top and then pick it up again because they are not able to orient the object just so.   Think about how often you use your own hand in this manner-  when you reach into your pocket and pull out a specific coin, when you push a push pin into a bulletin board, when you pick up a pencil and orient it with your fingers for writing.  I won’t go into all of the movements that are made possible by in hand manipulation.  I will just give you some ideas on how to address working on them with your child/students:

• Playing with playdough or clay-  make small items with it, pinch and roll small pieces into a ball
• String beads, play with lacing cards
• Place two pennies and two paper clips in palm of hand. Try to move one penny to fingertips and place on table without using other hand, then one paper clip, and so on.
• Place pennies or buttons into slots-  put coins into a piggy bank, cut a slit into into the plastic lid of a margarine container or a tennis ball and push the coins through the slit.
• Flip a pencil or coin over and over in fingertips
• Pegs and pegboards- if the pegs are smaller/thin, the child can hold a few pegs in their hand while placing each one into the board

• Hold a small plastic cup filled with water (the lid from liquid laundry detergent works well for this) upright in the tips of fingers. Turn the lid without spilling by turning it in fingertips.
• Save a used parmesan cheese container- push small pompoms into the small holes in the cover. Start by having 3 or 4 pompoms in the hand and have the child single each one out using their fingers for placement into the holes
• Push push pins into a bulletin board- lay a piece of paper with a simple design on it (such as the outline of a star) on the board and push the pins into the board along the outline of the shape