Why So Many OT Referrals for Written Expression in the Schools?
As a practicing occupational therapist of 30 years, I have seen the number of referrals for O.T. in the public schools increase, especially in the area of written expression. Thirty years ago only the most severely handicapped children were serviced by O.T. Now O.T. services are provided to a much wider developmental range, and especially to children struggling with written expression. What has changed?
First, I think that the typical children of today do not come equipped with solid motor skills. It all begins when they are newborns and parents are instructed not to have their baby sleep on their stomachs, to lessen the possibility of S.I.D.S. Parents should be strongly encouraged to provide regular supervised tummy time with their infants. Tummy time positioning is the first step towards developing hand skills, as weight-bearing on the shoulders, forearms, wrist and hands is vital to developing a postural base for adequate fine motor skills.
Another contributing factor to immature motor skills is the lack of gross motor activity, in general, as many children spend more time with technology, instead of moving their bodies. Developing gross motor skills in a developmentally appropriate manner facilitates the foundation for fine motor skills. An excellent book, From Rattles to Writing, by Barbara A. Smith, OTR/L is a wealth of information on fun activities to encourage a mature foundation for fine motor skills and writing.
A third factor leading to immature fine motor skills is the change in demands made on preschool and kindergarten children. Many children, with immature motor skills, are expected to write, before they are developmentally ready leading to inefficient grasp patterns and frustration. Preschool and kindergarten should emphasize developmental practices, such as playing in the sand box, accessing playground equipment, playing dress-up, accessing sensory tables and learning social skills. This developmental theme is expressed in the poem, “All I Really Need To Know I Learned in Kindergarten, by Robert Fulghum. It is one of my favorites. When a writing tool is placed in a child’s hand, before he has developed the skilled side of his hand necessary for a pincer grasp, he will use an immature “death grip,” which will be inefficient and difficult to break as he matures. I say “he”, since boys develop their fine motor skills later than girls.
Once a child is in kindergarten and is expected to use a writing tool, there are several modifications which can be used to help overcome developmental limitations. Encouraging work on an upright surface, such as an easel, will promote wrist extension and the skilled side of the hand, leading to a pincer grasp. Sometimes, simply putting a 3 ring notebook in front of the child, to form a sloped surface, and clipping the paper to it, , will provide an adequate vertical surface. There are also a variety of pencil grips that can be employed. My favorite is the claw pencil grip, which has 3 suction cups to position the thumb, pointer and middle finger, which sustain a pincer grip. Writing tasks for the kindergarten child should also be brief, with movement breaks before and after the writing activity.
A final note regarding written expression difficulties relates to the actual mechanics of writing. It is very important that children receive regular handwriting instruction in the early years. I know that time is precious in the classroom; however, if children don’t receive regular instruction, some students will develop bad habits that will lead to inefficient writing later on. When an older child is trying to organize his or her thoughts to write, the mechanics should be automatic so the child can concentrate solely on the thought process. The same children that need regular instruction to develop efficient writing are most likely to struggle with organization of their thoughts later on.
Written expression is a complex process. I have highlighted a few issues that contribute to this process as these are some of the issues that frequently prompt an O.T. referral.
On a personal note, when my son was in kindergarten, his teacher greeted me one afternoon by saying, “I think you should take Tim to a psychiatrist; he ripped up his letter paper today.” I took off my Mom hat, and put on my O.T. hat, and helped his teacher make appropriate modifications, such as only asking for one or two good letters, after practicing in a multisensory format, and using an easel and a variety of writing tools. I will never forget that conversation, but we were able to turn things around and make letter formation fun. Yes, I did name my son Timothy…even with a last name of Buck!
This article is written by Mary Buck, M.S., OTR/L, who is a member of the McCoy Educational Consulting, LLC team. Learn more about Mary in the 'About Us' section of our website!