Hand Strength, Handwriting, and Functional Skills in

Children With Autism

Michele L. Alaniz, Eleanor Galit, Corina Isabel Necesito,

Emily R. Rosario

MeSH TERMS OBJECTIVE. To establish hand strength development trends in children with autism and to investigate
 activities of daily living correlations between grip and pinch strength, components of handwriting, and functional activities in children
with and without autism.
 autistic disorder
METHOD. Fifty-one children were divided into two groups: typically developing children and children on
 hand strength
the autism spectrum. Each child completed testing for pinch and grip strength, handwriting legibility, pencil
 handwriting
control, and independence in functional activities.
 pinch strength
RESULTS. The children with autism followed the same strength development trends as the typically de-
veloping children. Grip strength correlated with pencil control in both groups and with handwriting legibility
in the typically developing children but not in the children with autism. Grip and pinch strength correlated
with independence with functional activities in both groups.
CONCLUSION. This study provides evidence that grip and pinch strength are important components in
developing pencil control, handwriting legibility, and independence with functional fine motor tasks.

Alaniz, M. L., Galit, E., Necesito, C. I., & Rosario, E. R. (2015). Hand strength, handwriting, and functional skills in children
with autism. American Journal of Occupational Therapy, 69, 6904220030. http://dx.doi.org/10.5014/ajot.2015.016022

Michele L. Alaniz, OTR/L, is Occupational Therapist

and Clinical Supervisor, Casa Colina Hospital and Centers
for Healthcare, Pomona, CA.
D ysgraphia and delays in functional living skills are well established in the
literature as impairments affecting children on the autism spectrum (Abu-
Dahab, Skidmore, Holm, Rogers, & Minshew, 2013; Frith, Morton, & Leslie,
Eleanor Galit, is Research Assistant, Casa Colina 1991; Fuentes, Mostofsky, & Bastian, 2009; Kushki, Chau, & Anagnostou,
Hospital and Centers for Healthcare, Pomona, CA. 2011). As part of the evaluation and treatment process, pinch and grip strength
are often measured (Engel-Yeger & Rosenblum, 2010; Ertem et al., 2005) be-
Corina Isabel Necesito, MS, OTR/L, is Occupational
Therapist, Casa Colina Hospital and Centers for
cause of the assumption of a correlation between strength and occupational
Healthcare, Pomona, CA. performance. Previous studies have established that children with autism have
weaker grip strength than typically developing children (Abu-Dahab et al., 2013;
Emily R. Rosario, PhD, is Director of Research
Hardan, Kilpatrick, Keshavan, & Minshew, 2003; Williams, Goldstein, &
Institute, Casa Colina Hospital and Centers for Healthcare,
Pomona, CA; erosario@casacolina.org Minshew, 2006). In this study, we sought to investigate the correlation between
grip and pinch strength and functional performance in typically developing
children and children on the autism spectrum. We also sought to establish de-
velopmental trends for pinch and grip strength in children with autism.

Strength and Handwriting

Pinch and grip strength may influence performance in a variety of childhood
tasks. The fine motor task that dominates a child’s school day is handwriting.
Children on the autism spectrum often have poor handwriting legibility
(Fuentes et al., 2009), which hinders their academic achievement (Cahill, 2009;
Feder & Majnemer, 2007). Handwriting is a complex task, and many underlying
skills contribute to the development of legible penmanship. Handwriting

The American Journal of Occupational Therapy 6904220030p1

remediation is as complex as the skill itself, and there is orders. Studies have established that children with autism
quite a bit of diversity in the activities included in a hand- often experience delays in achieving independence with
writing remediation program. daily living skills (Green & Carter, 2014; Jasmin et al.,
Most occupational therapy practitioners report using 2009; Liss et al., 2001) and that these delays correlate
an eclectic approach (Feder, Majnemer, & Synnes, 2000; with age, IQ, and language and sensorimotor skills. These
Woodward & Swinth, 2002) that blends sensory feed- studies did not assess hand strength to determine whether
back, direct handwriting instruction, and fine motor de- a link exists between delays in functional independence
velopment into a comprehensive handwriting intervention and grip and pinch strength.
(Case-Smith, 2002; Peterson & Nelson, 2003). Within
this eclectic approach, practitioners often include activities
Pinch and Grip Strength Norms and Trends
that target the development of pinch strength. In fact,
research supports the practice of measuring pinch strength Pinch and grip strength norms have been the subject of
as part of the evaluation process for dysgraphia (Engel-Yeger study for several decades. In the mid-1980s, researchers
& Rosenblum, 2010). Despite this common practice, began to use a standardized approach to gather strength
research does not provide consistent, reliable information on measurements that included a positioning protocol rec-
pinch strength norms for children, and no correlation ommended by the American Society of Hand Therapists
between pinch strength and handwriting legibility has (ASHT; Fess & Moran, 1981). The ASHT recom-
been established for children with disabilities. mended that the participant be seated with feet flat on the
Research instead has focused primarily on evaluating floor and a 90˚ bend in the hips, the shoulder adducted
the effectiveness of a variety of handwriting remediation and neutrally rotated, the elbow flexed to 90˚, the fore-
techniques (Denton, Cope, & Moser, 2006). Research has arm in neutral position, the wrist between 0˚ and 90˚ and
also focused on determining the relationship between ulnar deviation between 0˚ and 15˚, and the measurement
handwriting and underlying deficits such as grasp pattern tool supported by the examiner. They also recommend that
(Falk, Tam, Schwellnus, & Chau, 2010), eye–hand three consecutive trials be measured and the mean of the
coordination, visuomotor integration, and in-hand manip- three trials reported.
ulation (Case-Smith, 2002; Cornhill & Case-Smith, 1996; When examining the research from 1975 to 2014 to
Dennis & Swinth, 2001; Feder & Majnemer, 2007). How- determine pinch strength norms for children, we found
ever, little research has addressed the correlation between only six studies that included a reliable measurement tool;
pinch and grip strength and handwriting performance. followed the ASHT protocol; and gathered pertinent
Engel-Yeger and Rosenblum (2010) assessed the corre- information about gender, age, and hand dominance
lation between tripod pinch strength (palmar pinch) and (Bear-Lehman, Kafko, Mah, Mosquera, & Reilly, 2002;
dysgraphia and found that deterioration in tripod strength Butterfield, Lehnhard, Loovis, Coladarci, & Saucier,
was associated with a significant deterioration in hand- 2009; Mathiowetz, Wiemer, & Federman, 1986; Molenaar,
writing processes. The study sample, however, included Selles, Schreuders, Hovius, & Stam, 2008; Surrey
students with at least average intelligence and no neuro- et al., 2001; Yim, Cho, & Lee, 2003). Studies have firmly
logical or perceptual–motor problems. No research to established that grip and pinch strength increase with age
date has examined the association of pinch and grip (Ager, Olivett, & Johnson, 1984; Bear-Lehman et al.,
strength with handwriting in children with autism. 2002; Butterfield et al., 2009; De Smet & Decramer,
2006; Imrhan & Loo, 1989; Lee-Valkov, Aaron,
Eladoumikdachi, Thornby, & Netscher, 2003; Mathiowetz
Strength and Functional Activities et al., 1986; Molenaar et al., 2008; Surrey et al., 2001;
Whereas handwriting is an important childhood task in Yim et al., 2003). Evaluations of other trends in strength
the academic environment, self-care activities are an im- development have yielded inconsistent findings. The in-
portant childhood task in the home environment. Many fluence of hand dominance and gender on hand strength
self-care skills, such as manipulating fasteners, opening development is under debate.
packages, and tying shoes, require pinch strength and fine Research is almost completely silent on the topic of
motor control. Limited research has investigated the re- pinch and grip strength norms in children with disabilities.
lationship between pinch and grip strength and functional Broadhead (1975) indicated that students with dis-
performance. Li-Tsang (2003) found that dexterity, not abilities are able to generate statistically reliable scores.
hand strength, correlated with functional deficits and fine The grip scores for children with disabilities generally
motor delays in children with neurological motor dis- followed the same trends identified in the population as

6904220030p2 July/August 2015, Volume 69, Number 4

a whole; however, a standardized positioning protocol patient pediatric clinic in Southern California. Flyers were
and measurement tool with proven reliability were not posted at the clinic and given to parents of current clients.
used. Recent studies found that children with autism have In addition, clinicians recommended participation in the
lower grip strength than their typically developing peers study when they felt it was appropriate for their client.
(Abu-Dahab et al., 2013; Hardan et al., 2003; Kern et al., Typically developing participants were recruited using
2013; Williams et al., 2006). However, these studies do flyers and emails to hospital employees; therefore, the
not detail factors such as hand dominance and gender or sample of typically developing children was composed
include pinch measurements in the findings. Moreover, primarily of employees’ children. After approval from the
they do not report the positioning protocol followed institutional review board, full consent and assent were
when obtaining strength measurements. obtained for all children participating in the study. Par-
ticipants were divided into two groups for analysis: typically
developing children and children on the autism spectrum.
Research Questions
In this study, we evaluated the relationship between grip Instruments
and pinch strength and handwriting and independence Grip and pinch strength were measured using a Sammons
with functional activities in typically developing children Preston Jamar hand dynamometer and pinch meter (Pat-
and children on the autism spectrum. We also sought to terson Medical, Warrenville, IL). These instruments were
establish developmental trends for pinch and grip strength calibrated on an annual basis to ensure proper measurement.
in children with autism. This study sought to answer the The Beery–Buktenica Developmental Test of Visual–
following research questions: Motor Integration (VMI) Motor Coordination subtest was
• Does grip and pinch strength development in children used to assess pencil control (Beery & Beery, 2004). The
with autism follow the same trends as in typically de- VMI is a standardized test used for both research and
veloping children? clinical purposes in children aged 2–18 yr. The VMI has
• Does grip and pinch strength correlate with handwrit- been used extensively in the United States and other
ing legibility in typically developing children and chil- countries and demonstrates high psychometric properties
dren with autism? (test–retest reliability r 5 .92, Cronbach’s a 5 .86, con-
• Does grip and pinch strength correlate with pencil struct validity 5 .84; Beery & Beery, 2004). The Eval-
control in typically developing children and children
uation of Children’s Handwriting (ETCH; Amundson,
with autism?
1995) was used to measure handwriting legibility. The
• Does grip and pinch strength correlate with indepen-
ETCH has shown good test–retest reliability (r 5 .85–.90)
dence with functional activities in typically developing
and validity (r 5 .86; Diekema, Deitz, & Amundson,
children and children with autism?
1998; Feder & Majnemer, 2007).
A functional questionnaire was designed for this re-
Method search study based on activities children aged 4 yr and older
could complete. A total of 27 items in four domains
Participants assessed dressing, mealtime, grooming, and miscellaneous
Typically developing children (n 5 24) and children on activities. Caregivers rated their child’s independence in
the autism spectrum (as reported by a physician or parent; functional skills requiring pinch or grip strength (e.g.,
n 5 27), aged 4–10 yr old, were included in the study if opens a twist-off bottle top with closed seal, tears open
they were able to understand and follow directions and if a small snack, manipulates snaps) on a 5-point scale (4 5
they were able to complete the majority of the testing. independent, 3 5 completes with encouragement, 2 5 needs
Children who were unable to complete the majority of the minimal assistance, 1 5 needs maximum assistance, and
testing because of severe visual, cognitive, or motor im- 0 5 unable to complete).
pairments were excluded (2 children were excluded for this
reason). None of the participants in the autism group were Procedure
reported to have Rett syndrome or childhood disintegra- Participants were tested at the outpatient pediatric clinic.
tive disorder; children with pervasive developmental dis- Right and left grip and pinch strength were measured
order not otherwise specified were included. consecutively using the ASHT positioning protocol. Effort
Participants with autism were recruited from among and understanding were documented for each participant on
the clients currently receiving therapy services at an out- a 3-point scale (1 5 none, 2 5 poor, 3 5 average) during

The American Journal of Occupational Therapy 6904220030p3

the strength testing. Each participant was given three con- 66% male and 34% female; the participants with autism
secutive trials for grip strength and lateral, palmar, and tip were 78% male, however, and the typically developing
pinch strength. The VMI Motor Coordination subtest was participants were 54% male. These proportions are
administered to assess pencil control. Handwriting legibility consistent with those in the general population of both
was assessed with the ETCH, specifically the Upper Case, typically developing children and children with autism.
Lower Case, and Numbers subtests. Only participants age
6 yr and older participated in ETCH testing. The func- Grip and Pinch Strength
tional questionnaire was provided to participants’ caregivers In this study, the typically developing children and those
to complete. with autism showed increasing grip and pinch strength
Total testing took approximately 30 min to complete. with increasing age (Figure 1). Comparison of the slopes
Research assistants and experienced occupational therapists of the typically developing children and those with au-
administered all tests; research assistants had been trained by tism shows a trend toward differences, with the grip
occupational therapists and supervised until they established strength of children with autism showing greater vari-
proficiency with all test procedures. One research assistant ability as age increased. However, no significant differ-
completed the majority of testing. In all cases, the research ences are evident when comparing the slope or the means
assistants followed a 3-step training procedure. First, they by age (Table 1). We also found no significant association
observed an occupational therapist administering and among gender, hand dominance, and strength values.
scoring the assessments. Then they administered the In addition to examining the developmental trends in
assessments to the therapist until proficiency was established. hand strength, we assessed effort and understanding to de-
Once proficient with the therapist, assistants administered termine their impact on hand strength measurements. Effort
assessments to the participants while being assisted by the correlated with grip strength in the sample as a whole, F (1,
occupational therapist to ensure accuracy. Once competence 49) 5 6.7, p 5 .015, but not within the typically developing
was established in administering the assessments to the or autism groups. Similarly, direction comprehension corre-
participants, the assistants worked independently. All tests lated with grip strength in the sample as a whole, F(1, 49) 5
were scored by two assessors independent of each other. 4.6, p 5 .048, but not within the typically developing group;
Interrater agreement was 91%, and when scores differed, the however, it did correlate within the autism group (p 5 .04).
occupational therapist’s score was used.
Hand Strength and Pencil Control
Data Analysis
In the sample as a whole, grip strength correlated with pencil
Grip and pinch values were averaged from three con- control as measured by the VMI Motor Coordination
secutive trials. The mean of the three trials was used for subtest. Grip strength correlated with pencil control in the
analysis, with numbers rounded down if the score fell typically developing group, F(1, 22) 5 8.1, p 5 .008, and
between whole numbers. The coefficient of variation (CV) the autism group, F(1, 25) 5 7.9, p 5 .01. Pinch strength
was calculated to assess the variability of measurements for did not correlate with pencil control for the sample as
each child. If the CV was greater than 20%, the outlier was a whole or within the typically developing or autism groups.
removed. VMI raw scores were converted to T scores for
analysis, the functional skills assessment was represented Grip and Pinch Strength and Handwriting
as the percent of completed items demonstrating in- In participants who were able to complete the ETCH (n 5
dependence, and the ETCH scores were represented as 32, 63%), grip strength correlated with handwriting
a legibility percentage. Linear regressions were run to legibility using a mean percentage of legibility for Upper
evaluate relationships among strength, pencil control, Case, Lower Case, and Numbers, F(1, 30) 5 10.9, p 5
handwriting legibility, and functional abilities.
.002. Grip strength correlated with handwriting legibility
in the typically developing group (n 5 16), F(1, 14) 5
Results 6.1, p 5 .03, but not in the autism group (n 5 16),
F(1, 14) 5 3.2, p 5 .09; see Figure 2. Pinch strength did
Participants not correlate with handwriting in either group.
The mean age of the participants was 6 yr 9 mo (± 1.75
yr), and 90% of the participants were right handed. Of Grip and Pinch Strength and Functional Abilities
the 51 participants, 27 had been diagnosed with autism Grip strength and lateral, palmar, and tip pinch strength
and 24 were typically developing. Overall, the sample was correlated with functional activities when examining the

6904220030p4 July/August 2015, Volume 69, Number 4

Figure 1. (A) Grip strength and pinch strength—(B) tip, (C) lateral, and (D) palmar—increase with age.
Note. ASD 5 children with autism spectrum disorder; TD 5 typically developing children.
p
p < .05.

sample as a whole. When looking at the typically de- including handwriting legibility and functional tasks, in
veloping and autism groups separately, however, we ob- children with and without autism aged 4–10 yr. It also
served a significant relationship between only grip strength sought to establish grip and pinch strength trends in
and lateral pinch strength and functional activities (Figure children with autism. Children with autism followed the
3). The functional activities most significantly correlated same established developmental trends in strength as the
with grip strength included tears open a small snack, F(1, typically developing children, although their strength
49) 5 6.6, p 5 .02; opens twist-off bottle top with closed scores were lower than their typically developing peers in
seal, F(1, 49) 5 13.1, p 5 .004; cuts food with knife, all measurements. Grip strength correlated with pencil
F(1, 49) 5 5.2, p 5 .04; puts straw in juice box,
control in both groups and with handwriting legibility in
F(1, 49) 5 9.3, p 5 .01; takes cap off toothpaste, F(1, 49) 5
the typically developing children but not in the children
5.7, p 5 .038; squeezes toothpaste on toothbrush,
with autism. Grip and pinch strength correlated with in-
F (1, 49) 5 8.2, p 5 .01; turns key to unlock door,
dependence in functional activities in both groups.
F (1, 49) 5 8.7, p 5 .01; and turns doorknob to open
door, F(1, 49) 5 6.6, p 5 .02. Grip and Pinch Strength Trends
Our participants, including the children with autism,
Discussion followed the grip and pinch strength trends established in
This study investigated the correlation between grip and the literature (Ager et al., 1984; Bear-Lehman et al.,
pinch strength and proficiency in functional activities, 2002; Butterfield et al., 2009; De Smet & Decramer,

Table 1. Mean Grip and Pinch Strength in Pounds, by Age

Sample Size Grip Strength Tip Pinch Strength Lateral Pinch Strength Palmar Pinch Strength
Age Category TD ASD TD ASD TD ASD TD ASD TD ASD
4–6 yr 8 11 16.5 ± 1.2 13.3 ± 1.9 2.1 ± 0.3 1.2 ± 0.4 5.1 ± 0.6 3.8 ± 0.6 3.2 ± 0.6 2.5 ± 0.6
6–8 yr 10 11 21.1 ± 1.7 18.3 ± 1.7 5.0 ± 1.5 3.1 ± 1.6 6.5 ± 0.6 5.9 ± 0.6 5.7 ± 0.6 4.2 ± 0.7
8–10 yr 6 5 30.5 ± 1.4 22.6 ± 5 5.6 ± 0.9 4.0 ± 0.9 8.9 ± 0.6 8.1 ± 1.5 8.4 ± 1.2 7.5 ± 1.5
Note. ASD 5 children with autism spectrum disorder; TD 5 typically developing children.

The American Journal of Occupational Therapy 6904220030p5

 significant association between hand dominance and
pinch and grip strength (Ager et al., 1984; Bear-Lehman
et al., 2002; Butterfield et al., 2009; De Smet &
Decramer, 2006; Lee-Valkov et al., 2003; Mathiowetz
et al., 1986).
A finding unique to this study is the establishment of
new trends for children with autism. Our findings indicate
that no statistically significant difference exists in pinch
strength between typically developing children and chil-
dren with autism. We found a trend, however, toward
increased grip strength in the typically developing children
compared with the children with autism. The divergence
between the groups increased with age, indicating that the
gap between typically developing children and children
with autism widens as children grow older. A larger sample
Figure 2. Grip strength correlates with handwriting legibility:
Percentage of legibility as measured with the Evaluation of size is needed to more clearly define this relationship.
Children’s Handwriting (ETCH) significantly correlated with grip Also of note, we found that children with autism were
strength in typically developing children. less reliable in producing consistent scores across three
Note. ASD 5 children with autism spectrum disorder; TD 5 typically
developing children.
trials during the strength measurements; 43% of the
p
p < .05. children with autism, compared with 20% of the typically
developing children, had a CV greater than 20%. Char-
acteristics inherent in the autism diagnosis, such as com-
2006; Imrhan & Loo, 1989; Lee-Valkov et al., 2003; munication delays, social delays, and stereotypical behaviors,
Mathiowetz et al., 1986; Molenaar et al., 2008; Surrey likely interfered with the children’s ability to produce
et al., 2001; Yim et al., 2003). We found that children consistent results.
Both right and left grip strength correlated with
with and without autism grew stronger with age. In ad-
amount of effort in the sample as a whole; in other words,
dition, we did not observe a significant difference be-
the more effort put forth, the higher the grip strength
tween boys and girls in their pinch and grip strength
scores. However, effort did not correlate with strength in
scores; this finding is still debated in the literature (Ager the typically developing or autism groups individually.
et al., 1984; Bear-Lehman et al., 2002; De Smet & This finding may indicate that although the amount of
Decramer, 2006; Imrhan & Loo, 1989; Mathiowetz effort put forth during testing had an influence on strength
et al., 1986; Molenaar et al., 2008; Yim et al., 2003). Also scores, it was a minor influence.
unclear based on the current literature is the impact of Right and left grip strength also correlated with
hand dominance on strength in children. Our findings comprehension of testing directions in the sample as
were consistent with those of studies that found a non- a whole. For the typically developing group, however,

Figure 3. (A) Grip strength and (B) lateral pinch strength correlate with functional abilities.
Note. ASD 5 children with autism spectrum disorder; TD 5 typically developing children.
p
p < .05.

6904220030p6 July/August 2015, Volume 69, Number 4

direction comprehension did not correlate with strength; participants who were eligible to complete the ETCH
these children almost always seemed to understand the did so.
directions. In contrast, direction comprehension did Moreover, handwriting is a complex skill, and many
correlate with strength in the children with autism. Be- components influence handwriting development. Cog-
cause communication delays are intrinsic to the diagnosis nitive demands, visual–perceptual demands, and visual–
of autism, these children are particularly vulnerable to not motor integration, along with fine motor strength and
understanding directions, compromising their ability to development, all influence handwriting development.
reliably participate in strength testing (American Psychiatric Our findings indicate that although hand strength does
Association, 2000). influence handwriting legibility, other, more salient fac-
tors also influence legibility, making hand strength less
Correlations Between Functional Measures and critical in children with autism.
Hand Strength Finally, we examined the relationship between func-
Previous studies have established the correlation between tional abilities and grip and pinch strength. To do this, we
pencil control and handwriting legibility (Cornhill & developed a questionnaire for this research asking the
Case-Smith, 1996). Our study sought to establish a cor- parents to rate their child’s independence in a variety of fine
relation between hand strength and pencil control mea- motor functional tasks. In the sample as a whole, func-
sured using the VMI Motor Coordination subtest. For tional abilities correlated with lateral, palmar, and tip pinch
the sample as a whole, grip strength correlated with T strength in both the right and left hands. A variety of
scores on the VMI Motor Coordination subtest, in- correlations emerged in examining the groups separately.
dicating that the stronger the grip strength, the better the In the typically developing group, nondominant grip
pencil control. This correlation was observed in both the strength and dominant palmar pinch strength correlated
typically developing and autism groups. with independence in functional tasks. In the autism
Interestingly, pinch strength did not correlate with group, right and left grip strength, right and left lateral
pencil control. We hypothesize that this finding is at- pinch strength, and nondominant palmar pinch strength
tributable to the sensitivity of the instruments used to correlated with one another. To further define the func-
measure grip and pinch strength. We collected strength tional activities that more strongly correlated with grip and
data using a manual-read, rather than digital, dyna- pinch strength, we performed a discriminant analysis (see
mometer and pinch gauge. To maintain consistency Table 1). Grip and pinch strength were strongly correlated
throughout the research, if the measurement fell between with independence in functional activities in both groups.
whole numbers, the score was rounded down to the nearest
whole number. Pinch strength scores are particularly
susceptible to low sensitivity because the numbers are so
Study Limitations
small. Because we did observe a correlation between grip The primary limitation of this study is the sample size,
strength and pinch strength, however, pinch strength particularly when the sample is divided by sex, age, and
might also have correlated with pencil control were it not diagnosis. In addition, because only 78% of the children
for the limitations of the sample size and measurement with autism were able to complete the ETCH, the sample
sensitivity. size for this analysis was even further reduced. Although we
The relationship between strength and handwriting are able to draw some conclusions regarding trends and
legibility was assessed using the ETCH. In the sample as relationships, we are limited in making more specific
a whole, grip strength correlated with handwriting legibility. statements about gender differences and age-related
The typically developing children demonstrated a correla- changes. In addition, we believe that the pinch strength
tion between strength and legibility, a finding that agrees data were limited by the sensitivity of the measurement
with previous work in which a correlation was observed tool. Because we were not able to record values to a dec-
between tripod pinch strength and dysgraphia in typically imal place, our analysis of pinch strength was limited.
developing children (Engel-Yeger & Rosenblum, 2010). However, because the measurement tool we used is
However, the autism group did not demonstrate a cor- commonly used clinically, our pinch data carry some
relation between hand strength and handwriting legi- clinical validity. We were also limited in our interpretation
bility. Contributing to this finding may be the fact that of the relationship between grip strength and pencil
only 78% of our participants with autism who were control. Although children with visual impairments were
eligible to complete the ETCH were able to complete the excluded, we did not complete any visuoperceptual test-
ETCH testing, whereas 100% of the typically developing ing. Therefore, when examining the results regarding

The American Journal of Occupational Therapy 6904220030p7

pencil control, we were not able to rule out the possible Bear-Lehman, J., Kafko, M., Mah, L., Mosquera, L., & Reilly, B.
contribution of visuoperceptual deficits. (2002). An exploratory look at hand strength and hand size
among preschoolers. Journal of Hand Therapy, 15, 340–346.
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a minor influence on pinch and grip strength measure- 36, 279–283.
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Acknowledgments http://dx.doi.org/10.5014/ajot.55.2.175
Denton, P. L., Cope, S., & Moser, C. (2006). The effects of
The authors thank Dr. Loverso and the Casa Colina Board sensorimotor-based intervention versus therapeutic practice
of Directors, Cindy Sendor, the therapists in the children’s on improving handwriting performance in 6- to 11-year-
department (Lacy Wright, Sarah Yun, Kristin Horn, and old children. American Journal of Occupational Therapy, 60,
Yovana Guzman), and the Casa Colina Hospital and 16–27. http://dx.doi.org/10.5014/ajot.60.1.16
Centers for Healthcare Foundation for supporting this De Smet, L., & Decramer, A. (2006). Key pinch force in chil-
research. We also thank Brianna Bentley and Betsy Diaz dren. Journal of Pediatric Orthopaedics, Part B, 15, 426–427.
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