CHAPTER 17

WRITING AND PREWRITING SKILLS

Susan J. Amundson
KEYWORDS

Ease of writing
Functional written communication
Readability
Writing domains
Practice models
Writing intervention response

OBJECTIVES OF THE CHAPTER

1. describe the role of the occupational therapist in the evaluation and

intervention of children with writing difficulties
2. identify the factors contributing to the ease of writing in young children
3. examine 4 aspects of functional written communication including classroom
written tasks, legibility, speed, and ergonomic factors.
4. discuss student performance skills, client factors, performance patterns, and
the context that influences their participation in the writing process
5. Describe how writing fits into the educational writing process.
6. Develop compensatory and remedial strategies to improve student written
communication performance by focusing on current occupation and
occupational context.
7. examine the relationship of various pediatric occupational therapy practice
models and writing intervention programs.
8. appreciate the need for further evidence on the impact of occupational therapy
intervention on children's writing.

INTRODUCTION

Occupational therapy practitioners view children's occupations as activities of daily

living, education, work, play, and social participation. In the area of education, the
occupations of school-age children encompass academic tasks such as reading,
writing, calculations, and problem solving, as well as the
tasks non-academic and functional. Tasks
functional can include walk around the living room, the furniture and the
companions,
share school supplies with a peer, put a notebook in the closet, build a paper
balloon mache, and write words on paper - all of them
support the academic performance of the student in the classroom class. These
academic skills, functional abilities, and adaptive behaviors must evolve and
strengthen throughout the school years (Levine, 1994).
A common academic activity is writing, required as children and adolescents
compose theories, complete written exams, copy numbers to calculate, dictate
messages and phone numbers at home, and write messages to friends and family
members. Although it is easily demanded, writing is a complex process that requires
the synthesis and integration of memory, organization, problem solving, language
and reading skills, ideation and graphomotor function (Levita, 1994). The functional
task of handwriting supports the academic task of writing and allows students to
transport written information legibly and effectively while accomplishing written school
assignments appropriately. Once developed, these skills continue to be used
throughout adulthood, as individuals write checks, organize events on calendars,
write directions to the dentist's office, scribble grocery lists, and take notes, notes,
and messages for others.
Writing consumes the majority of the school day. McHale and Cermak (1992)
examined the amount of time devoted to fine motor activities and the type of fine
motor activities that school-age children are expected to perform in the classroom. In
their study of six classes consisting of two grades 2, 4, and 6 in middle-access public
schools, they found that 31 to 60% of the children's school day consisted of fine
motor activities. Of these fine motor tasks, 85% of the time consist of pencil-and-
paper tasks, indicating that students can possibly spend a quarter to half of their
classroom time engaging in pencil-and-paper tasks.
When boys and girls are experiencing difficulties in writing, problems arise in
following up on written tasks. Students with neurological impairments, learning
disabilities, attention deficits, and developmental disabilities often spend enormous
time and effort learning to write legibly (Amundson, 1992; Bergman & McLaughlin,
1988). School consequences of writing difficulties may include (1) assignment of
lower grades by teachers due to the written quality of papers with poor legibility but
not poor content (Chase, 1986; Seedler-Brown, 1992), (2) the slowness of students'
writing limits fluent composition and its quality (Graham, Berninger, Abbott, Abbott, &
Whitaker, 1997), (3) students take longer to complete their homework assignments
than their peers do ( Graham, 1992), (4) students have problems with taking notes in
class (Graham) and reading them later, (5) students fail to learn other higher-order
writing processes such as planning and grammar, and ( 6) avoidance of writing and
the development of writing (Berninger, Mizokawa and Bragg, 1991). Occupational
therapists are frequently called upon to evaluate writing when it interferes with a
student's performance on their written tasks. In fact, poor writing is one of the most
common reasons for allowing school-aged children to attend occupational therapy
(Chandler, 1994; Oliver, 1990; Reisman, 1991). The role of the occupational therapist
is to view student performance, in this case writing, focusing on student interaction,
the school environment, and the demands of the school occupation.
During the assessment and intervention process, the practitioner should remain
attentive to (1) the writing occupation, determining the writing domains (e.g. copying
or dictation) and which components (e.g. letter formation or spacing) are problematic
for the practitioner. student; (2) the school context (e.g., the curriculum or physical
classroom related to the child's performance); (3) the student's personal context
related to cultural, temporal, spiritual, and physical presentations; and (4) the
student's ability, experiences, and performance skills that are interfering with writing
production. Another role of the occupational therapist related to writing is the
assessment and intervention of children's prewriting and writing skills (Oliver, 1990),
particularly in preschool and kindergarten age.

THE WRITING PROCESS

The development of children's writing

Many children begin drawing and doodling soon after they are able to pick up a
writing tool. As children mature, they intentionally write meaningful messages, first
with drawings and then with scribbles, letter-like shapes, and rows of letters (McGee
& Richgels, 2000). The development of the child's writing process in the primary
grades includes not only the mechanical and perceptual processing of graphics, but
also the acquisition of child language and the learning of spelling and phonology
(Temple, Nathan, Temple, & Burris, 1993 ). Typically children's writing and reading
skills develop in a parallel process with each other (McGee & Richgels, 2000).
Consequently, if a young child is unable to recognize letters and understand that
these letters represent written language, the occupational therapist and educators
cannot expect the child to write.
As children develop, their scribbling and drawing evolve into writing (e.g., language
symbols) specific to their culture. Table 17-1 details the development of prewriting
and writing in children in the United States. The age levels of writing progression are
approximations, and variation in skill development is expected between each child.
For the acquisition of copy lyrics, very little information has been documented in the
literature. A study by Tan-Lin (1981) examined the sequential stage of letter
acquisition of 110 children between 3 and 5 years old. The children were observed
copying numbers, letters, words, and a sentence three times over a four-month
period. Their findings reveal the following sequential stages of prewriting and writing:
(1) controlled scribbling; (2) discrete lines, dots, or symbols; (3) straight or circular
lines, letters in the upper frame; and (5) letters in the lower frame, numbers, and
words.

TABLE 17-1 DEVELOPMENT OF PREWRITING AND WRITING IN YOUNG

CHILDREN
performance task
age level
doodle on paper 10-12
months
start horizontal, vertical, and circular marks on paper two years
a vertical line, a horizontal line, and a circle three years
4-5 years
copy a cross, right equal line, squares , straight line, left oblique cross,
some letters and numbers, and may be able to write your name
Copy the triangle, its name, copy letters in the upper and lower frame 5-6 years

Modified from Bayley, N. (1993) Bayley Infant Development Scale. (ED. Rev.). San Antonio, TX:
Psychological Corporation; Beery, K.E. (1982). Development of a visual-motor integration test.
Cleveland: Modern Curriculum Press; Tan-Lin, AS (1981) an investigation within the course of
development of the writing culture of preschool and kindergarten children. Dissertation Abstracts
International, 42, 4287 A; Weil, M. and Amundson, S.J. (1994). Relationship between visual motor
skills and children's writing in kindergarten. American Journal of Occupational Therapy, 48, 982-988.

Ease of writing

There is some controversy about when children are ready for formal writing
instruction. Different maturity ranges, environmental experiences, and interest levels
are factors that can influence children's early achievement and success in copying
letters. Some children may exhibit writing facility at the age of four while others may
be ready until the age of six (Lamme, Laszlo, & Bairstow, 1984). A number of authors
(Alston & Taylor, 1987; Donoghue, 1975; Lamme; Wright & Allen, 1975) have noted
the importance of mastering writing facility before beginning writing instruction. This
author states that children who are taught to write before they are ready may become
discouraged and develop poor writing habits that may be difficult to correct later.
The factors necessary for writing require the integrity of a number of sensory and
motor systems. Letter formation requires the integration of the perceptual, sensory,
visual, and motor systems. Sufficient fine motor coordination is also necessary to
form letters accurately (Alston & Taylor, 1987). Donaghue (1975) and Lamme (1979)
identified 6 prerequisite skills that children need before beginning writing instructions.
These are (1) small muscle development; (2) hand-eye coordination; (3) the ability to
maintain writing utensils or tools; (4) the ability to form basic shapes, such as circles
and lines; (5) letter perception including the ability to recognize shapes, similarities
and differences, infer the movements necessary for production of the shape, and
accurate verbal descriptions of what is seen; and (6) graphic language orientation,
which involves visual analysis of letters and words as well as left-right discrimination.
Other authors define the ease of writing on the basis of the child's ability to copy
geometric shapes. Beery (1992) and Benbow, Hanft, and Marsh (1992) suggested
that writing instruction should be postponed until the child is able to develop the first
nine figures of the Visual Motor Integration (VMI) Developmental Test (Beery, 1992,
1997). Nine o'clock
Figures are a vertical line, a horizontal line, a circle, a cross, a right oblique line, a
square, a left oblique line, an oblique cross, and a triangle.
A study by Weil and Amundson (1994) examined 59 typically developing
kindergarten children (age 54 to 64 months) and their abilities to copy letters as well
as geometric designs on the VMI. The results indicated that children who were able
to copy the first nine shapes of the test were able to copy more letters than those
who were not able to copy the first nine shapes, providing support for the views of
Beery (1992) and Benbow and others (1992).
Weil and Amundson (1994) also found that kindergarten children were on average
able to correctly copy 78% of the letters presented, despite having received no formal
writing instruction. Based on the results of this study, the authors conclude that most
typically developed kindergarten children should be ready for formal writing
instruction by the middle of the school year.
To develop writing ease skills in children, the occupational therapy practitioner must
incorporate activities into the therapy session or classroom. The selected activities
should promote the improvement of fine motor control and isolated finger
movements, promote prewriting skills, left-right discrimination, and improve
orientation to graphic language (Barchers, 1994; Benbow et al, 1992; Lamme, 1989 ;
Myers, 1992; Wright and Allen, 1985).
Some children with significant cognitive or physical impairments may not acquire
many of the prerequisites necessary for writing, and some are more successful in
written communication using a computer-based word processor and word prediction
program. Other children, despite the decline in prerequisites for writing, may be able
to learn to write their name with practice sessions. The occupational therapy
practitioner determines when it is appropriate for the child to work on skills and
prerequisites, functional writing skills, or both.
Activities are commonly used with young children to facilitate certain movements,
experiences, and perception for writing development (Table 17-2). Movements and
tasks to promote writing development should be used in the context of what is
meaningful and purposeful for the child.
TABLE 17-2 ACTIVITIES TO PROMOTE EASE OF WRITING

Areas of ease for the Selected activities

writing
Improve fine motor control and Roll ¼ to 1/8 inch balls between the pads of the
isolated finger movements thumb, index finger, and middle finger.
Pick up small objects with tweezers.
Grasp a bar using the opposition of the thumb to
each finger.
Open a tube of toothpaste with your thumb, index
finger, and middle finger.
Move a key from the palm to the pads.
Promote graphic skills Draw lines and copy shapes using cream, sand
or finger paint.
Draw lines and shapes to complete a story drawn
on a board.
Make and color drawings of people, houses,
trees, cars or animals.
Complete simple drawings and mazes.
Promote discrimination Play “Hokey-pokey”
Left Right Maneuver through obstacles focusing on right left
concept.
Connect dots on the board with right - left
directions.
Improve orientation in printed
language Label children's work based on the child's
description.
Promote the creation of books with the child's
favorite topics (special places, favorite foods)
Label common objects in the room.
Pencil grip progression

The development of young children's pencil grip follows a predictable course for
typically developed children but varies across cultures (Tseng, 1998). Children
commonly begin by holding the pencil with a primitive grip. The primitive grip is
characterized by holding the writing tool with one hand with the fingers extended, the
forearm pronated, and using the shoulder to move the pencil. Next, a more traditional
grip is seen with the pencil being held with the fingers flexed. Initially the forearm is
pronated (thumb side pointing down), but later the forearm is usually supinated.
Finally, the mature pencil grip is marked with the pencil stabilized on the distal
phalanges of the index, thumb, middle, and possibly the ring finger, the wrist slightly
extended and dynamic, and the forearm supinated resting on the table (Erhardt,
1982; Rosebloom and Horton, 1971; Schneck and Henderson, 1990, Tseng, 1998).
Traditionally, occupational therapy teachers and practitioners have emphasized the
importance of the dynamic tripod clamp (Rosebloom and Horton, 1971; Tseng and
Cermak, 1993). The dynamic tripod clamp appears when the writing implement rests
against the distal phalanx of the radial side of the middle finger while the thumb and
index finger control it (Rosebloom and Horton, 1971) (Figure 17-1). Recent studies
(Bergman, 1990; Dennis & Swintch, 2001; Koziatek & Powell, 2003; Schneck &
Henderson, 1990; Tseng, 1998; Ziviani & Elkins, 1984) have found that a variety of
pencil grip patterns exist among children and adolescents. typical adults. Mature
grips in addition to the dynamic tripod gripper are frequently seen, including the
lateral tripod, the dynamic quadripod, and the lateral quadripod. Schneck and
Henderson reported in their study of 320 normally developing children at the ages of
6.5 and 7 years, 90% of them had adopted a mature grasp, either dynamic tripod
(72.5%) or lateral tripod (22.5%). Outside the United States Tseng noted that lateral
tripod clamp (42.9%) occurs almost as frequently as dynamic tripod clamp (44.1%) in
typically developed Taiwanese children aged 5.5. at 6.4 years of age. In elementary
school children, the lateral and dynamic quadripod grippers have been identified as
mature and functional pencil grasps (Dennis and Swinth, Koziatek and Powell). Thus,
the lateral tripod clamp, the dynamic quadripod, and the lateral quadripod can be
considered acceptable options for the traditionally preferred dynamic tripod clamp
(see Figure 17-1).

Figure 17-1 Elementary school children using mature pencil grips. A, dynamic tripod,
B, lateral tripod; C, dynamic quadripod, and D, lateral quadripod.
WRITING EVALUATION

When a child with poor handwriting has been referred to occupational therapy,
methods for obtaining data for evaluation must be carefully selected and sequenced.
An individual evaluation is necessary since each child with writing dysfunction varies.
A comprehensive assessment of a child's writing includes (1) examination of samples
of written work; (2) discussion of the child's performance with the teacher, parent,
and other team members; (3) review of the child's clinical and educational records;
(4) direct observation of the child while writing in his or her natural environment
(school, home); (5) evaluation of the child's current writing performance; and (6)
assessment of performance skills suspected to interfere with writing.
Initially, student performance in the context of classroom standards should be the
focus (before standardized testing). Obtaining data and information from various
resources provides the therapist with a comprehensive picture of the child's written
communication. It also allows the therapist to examine the child's ability to perform
other functional school tasks, such as holding and manipulating school tools,
handling outdoor clothing quickly, and organizing school supplies. Although poor
writing is a commonly reported issue in the classroom, poor performance on other
school tasks may have been overlooked and should receive attention from the
occupational therapist and educational team.

Work samples

Often the referring person (parent or educator) approaches the occupational therapist
with the child's classwork or homework. Examples of written work may include
spelling lessons, math problems, a story. Ideally, these examples should represent
the child's typical writing performance. When reviewing a child's writing, a
comparison of peers' writing samples may also be required to understand classroom
standards and teacher expectations.

Interviews

Interviewing the child's parents, educators, and other team members serves as a
mechanism to build and obtain important data. Because teachers know how their
students are performing in class, they can provide information about student skills
and achievements, classroom standards and curriculum, and student interactions. An
example of questions that facilitate discussion between the teacher and the
occupational therapist is listed in Box 17-1. The educator can help by giving a picture
of the school student's abilities, behavior, and difficulties.

BOX 17-1
QUESTIONS TO FACILITATE DISCUSSION BETWEEN MEMBERS OF THE
EDUCATIONAL TEAM

1. What are the student's educational strengths and weaknesses?

2. What is your writing performance compared to peers?
3. What writing method (D'Nealian, Zaner-Bloser, Palmer, Italic) is being used and
what is the student's history with this method?
4. What are the learning standards or curriculum for your grade?
5. What seems to cause poor writing?
6. When did he do his best written work?
7. When does performance decrease?
8. What strategies for improvement have been discussed? Have they worked?
9. Is a portfolio available with the student's writing development and progress?
10. Are there other daily tasks (using scissors, engaging with peers, staying
organized) that concern the teacher?
Parents are also a valuable resource for occupational therapists; They provide a
different perspective of the child and the child's writing skills. Not only can they relate
the child's family, developmental, and medical background to the educational team,
they can share invaluable information about the child's interests, social competence,
and attitudes beyond learning and school.
Parents are considered members of the educational team, and provide important
perspectives that give the occupational therapist a comprehensive view of the child at
home and at school. Questions given to parents relate to the child and his or her
writing, to facilitate discussion may include the following: (1) do the parents expect
the child to complete writing assignments at home? (2) What is the child's response
to the writing task? (3) How is the child doing with his/her written assignments at
home and at school? And (4) what other written tasks are expected of the child at
home (e.g., correspondence with relatives, remembering phone messages)?

File review

Information relevant to the child's academic past, performance, special testing, or

receipt of special services can be found in the child's cumulative educational record.
Clinical or medical reports related to the child's education can be located in the
regular or special education files. The child's parents can share academic records
and reports to clinic- or hospital-based occupational therapists. This documentation
can lead to subsequent conversations between the child's parents and team
members.

Direct observation

Observing students during a writing activity is an essential step in the assessment

process (Figure 17-2). Referral of the child to an occupational therapist can be made
by parents or a teacher who has observed difficulties in the child with writing. Thus,
the occupational therapist needs to examine the child in his or her activity within the
classroom. Skilled observation by the examiner usually occurs in the child's
classroom and focuses on the child's task performance, attention to task, problem
solving, and behavior (Hanft & Place, 1996).
Figure 17-2 a girl completes her written homework at her desk

Practitioners should note the student's organizational skills, movement through the
classroom, interactions with teacher and peers, transition of activities, and overall
performance of other school tasks. The school context (classroom, lighting, noise
level, and means of instruction) as well as the current instruction of school personnel
must be considered in relation to student performance.
In addition to the structured protocol for direct observation, the occupational
therapist's questions may include the following:
1. Which writing tasks (for example, copying sentences from the board or composing
a story) are most problematic for the child?
2. What behaviors are manifested when the child requires writing? For example, do
you place your pencil on the other side of the desk to avoid writing?
3. Can the child participate in the writing task independently or does the child need
verbal and physical prompts from the teacher or educational assistant?

4. Are you easily distracted by visual and auditory stimuli during writing, such as the
delivery truck seen outside the school window?
5. Where does the child sit in the classroom?
6. What curriculum is being followed?
7. Where is the teacher located when giving assignment directions?

MEASURING WRITING PERFORMANCE

When evaluating the child's current writing task, the following areas need to be
examined: (1) writing proficiency, (2) legibility, (3) speed, and (4) ergonomic factors.
Whether the student writes in handwriting, cursive, or both, these four aspects will
assist the educational team and parents in discovering problem areas and
establishing a foundation for the function of writing. With an accurate and relevant
assessment of writing, the occupational therapist, the child's parents, and the
educational or clinical team will be able to establish specific goals and objectives for
the development of written communication.

Writing domains

Assessing the different domains of writing allows the occupational therapist to

determine which tasks the child may be having difficulty with and add those tasks to
the intervention plan. Writing tasks required of students and useful in planning the
intervention include:
• Write the alphabet in upper and lower case along with the numbers that the
child requires to remember the motor engram, form each letter and number,
sequence letters and numbers, and use consistent letters.
• Copying is the ability to reproduce numbers, letters, and words of a similar
pattern, whether handwritten to handwritten or cursive to cursive.
• Nearby copying is producing letters or words from a nearby model, commonly
on the same page or horizontal surface, for example when a student copies
the meaning of a word from a nearby dictionary.
• Copying from a vertical model distant to the writing surface is called far-point
copying, demonstrated by elementary students writing the words “Happy
Valentine's Day” on paper cards from words modeled by the teacher on the
board.
• More advanced than copying, the handwritten-to-cursive transition requires
mastery of both handwritten and cursive letterforms, as the child transcribes
handwritten letters and words into cursive letters and words. A high-level
writing task that combines auditory directions and motor response is dictation.
• Writing dictated words, names, addresses and phone numbers is a skill that
your child will need at home and at school.

• Composing is the child's generation of a sentence or paragraph,

demonstrated by writing a poem, a story, or a note to a friend. The
composition process uses the cognitive functions of planning, sentence
generation, and revision (Hayes & Flower, 1986); Thus, this writing task
involves the complex integration of linguistic, cognitive, organizational, and
sensorimotor skills.

Readability

Legibility is often assessed in terms of its components (letter formation, alignment,

spacing, size, and slant) (Alston, 1983; Amundson, 1995; Graham, Boyer-Shick, &
Tippers, 1989; Jackson, 1971; Ziviani & Elkins, 1984). However, the central point is
the ability to read them. It is of main importance when what is written by the child is
read by himself, his parents or teachers. In a writing assessment, both legibility and
reading ability should be assessed.
The influence of readability components on reading ability is significant (Graham et
al., 1989; Jackson, 1971). In letter formation, Alston (1983) identifies five
characteristics that impact legibility: (1) improper letter shapes; (2) poor tracking
between letters; (3) inadequate roundness of letters; (4) incomplete letter closures,
and (5) incorrect rises and falls in letters. Alignment or orientation refers to the place
within the text or lines. Spacing includes the dispersion of letters in words and words
in sentences (Larsen & Hammill, 1989) along with the organization of text on the
sheet of paper. Another component of legibility, size refers to the relationship of the
letters to the line and other letters. Finally, the uniformity or consistency of the slant
or angle of the text must be observed. Figure 17-3 illustrates errors in letter formation
and size in a child's cursive handwriting.

Figure 17-3 samples of cursive writing that exemplify inappropriate letter shapes and
size

Although the writing sample may be legible, one component of legibility (poor size)
may interfere with its appearance, with some components having more impact than
others. Graham et al. (1989) found that the letter formation, spacing, and neatness of
61 4th grade students with learning disabilities are significantly correlated with
legibility. Typically, legibility is determined by counting the number of readable letters
or words and dividing it by the total number of written letters or words. For example,
Figure 17-4 indicates the formula for determining percent readability. As reflected in
the figure, 8 words were written in the sample, however, only 4 could be read,
resulting in 50% legibility.

Figure 17-4 Handwriting legibility percentages calculated using a simple

mathematical formula.
Writing legibility percentages =
Total number of readable words = 4 = 50%
Total number of words written 8

Frequently, occupational therapy practitioners and educators want to determine what

percentage of readability is appropriate for students in specific grades. Additionally,
occupational therapists are interested in “cut-off” legibility percentages for good and
poor handwriting. The validity of the readability percentages is reported in 3 studies
with small samples.
Talbert-Johnson, Salva, Sweeney, and Cooper (1991) asked 15 elementary, middle,
and high school students with special needs to copy a short paragraph in cursive.
Through a lottery process, easy-to-read writing samples were scored between 95
and 100% legibility with a mean of 99%. Difficult-to-read writing samples were
measured at 60-90% legibility with a mean of 78%. Reisman (1991) indicated that 51
second grade students receiving occupational therapy intervention for writing
averaged a readability rate of 76% on a pilot version of the Minnesota Writing Test.
Recently, Graham, Berninger, Weintraub, and Shafer (1998), in their study of 900
children who typically developed in grades 1 to 9, found that handwriting legibility
shows a slight increase in the first four grades. Gains in readability were achieved in
the upper elementary grades and maintained through secondary school.
More recently, Koziatek and Powell (2002) investigated four writing tasks from the
Assessment Tool for Children's Cursive Writing (ETCH_C) with 101 fourth grade
children. They found that letter and word legibility scores from the ETCH_C were
able to rate and predict children's writing scores. The 75% readability level on the
ETCH_C can discriminate between satisfactory writing (grades A, B, C) and
unsatisfactory writing.
Although each of the aforementioned studies examines legibility ranges using
different measures, implications for occupational therapy practice suggest that the
range of 75 to 778% appears to discriminate between satisfactory and unsatisfactory
handwriting legibility. This range of readability percentages, however, is not the
reason why children require occupational therapy services. The legibility of a
student's writing can be 75% and still not be read. With compensatory strategies
recommended by the occupational therapy practitioner, this same child can convert
his or her writing into readable text. Thus, outside occupational therapy services will
not be needed. Determining appropriate therapeutic and educational services for
children involves an entire team, including the child's parents, and logically should
not depend solely on test results. Thus, the occupational therapist must be careful
and comprehensively assess the nature of the poor legibility in the child's handwriting
and make recommendations based on this process.

Writing speed.

The child's writing range, or the number of letters written per minute, as well as
legibility are two of the bases of functional writing (Amundson, 1995). Students take
longer to complete their written assignments and have difficulty taking notes in cases
(Graham, 1992), lose ideas for writing (McAvoy, 1996), and become frustrated when
their writing speed is slower than that of their peers. Writing speed typically
decreases when the amount or complexity of the written task increases (Rubin &
Henderson, 1982; Weintraub & Graham, 1998). Older students not only need an
adequate typing speed but they need to be able to adapt their speed in a pinch to an
appropriate speed. (Weintraub & Graham)
Differences in methodologies, subjects, and data collection have resulted in a variety
of bases for writing speed for typically developing children (Tseng & Cermak, 1991;
Ziviani & Elkins, 1984). Table 17-3 shows the writing speed in different studies and
the methodology used in each one. All studies show that children's writing speed
develops gradually, increasing successfully with each grade (Graham et al., 1998;
Hamstra-Bletz & Blote, 1990; Phelps & Stempel, 1987; Phelps, Stempel & Speck,
1984; Ziviani & Elkins, 1984; Ziviani & Watson-Will, 1998). However, the findings also
support that the increase in velocity may not be linear and is marked with several
peaks and plateaus. Wide ranges of writing speed are noted at each grade level.

TABLE 17-3 CHILDREN'S WRITING SPEED (LETTERS PER MINUTE)

Degree graham et Hamstra-Bletz & Phelps et al. Ziviani & Ziviani &
to the. (1998) Blote (1990) (1984) Elkins (1984) Watson-Will
Girls / (1998)
Children Girls /
Children
1 21 17 32
2 37 31 24 35 39 35
3 50 45 35 25 32 56 46
4 66 61 46 37 34 70 67
5 75 71 54 47 38 83 73
6 91 78 66 57 46 83 89
7 109 91 62 52 85 111
8 118 112 72
9 121 114
Graham, Berninger, Weintraub & Shafer (1998): Copy of a nearby paragraph for 1.5 minutes in the
child's preferred writing. Hamstra-Bletz & Blote (1990): Copy a nearby paragraph for 5 minutes.
Phelps, Stempel & Speck (1984); Phelps & Stempel (1987): copy 2 close sentences for 2 minutes.
Ziviani & Elkins (1984); Copy the phrase “Dog and cat” repeatedly for 2 minutes in the preferred script.
Ziviani & Watson-Will (1998): Copying “dog and cat” for 2 minutes in modern Australian writing.

Because of the wide range of writing speed, children's writing ranges need to be
considered individually within the classroom context. Teacher expectations and
classroom standards can influence children's writing speed. Thus, it is more
appropriate to compare the student's writing speed with the ranges of his or her
peers. Generally, writing speed is problematic when the student is unable to
complete written tasks in an appropriate manner. When students' written expression
skills (language, spelling) exceed the writing range, alternative forms (keyboarding,
word prediction programs) should be considered.

ergonomic factors

Writing posture, upper limb mobility stability, and pencil grip are all ergonomic factors
that should be analyzed while the child writes. Sitting posture in the classroom must
be observed. Does the child rest his head on his forearm or on the desk when
writing? Does the child fall out of his chair? Does the child stand next to the desk or
kneel on the chairs? Are the desk and chair appropriate heights?
Upper extremity stability and mobility refers to the stabilization of the shoulder,
shoulder, and wrist complex to allow the manual dexterity of manipulating the writing
instrument. Does the child write with full arm movements? What are the positions of
the trunk and arm while writing? Does the non-dominant hand stabilize the paper?
Does the child apply excessive pressure to the writing tool?
An ergonomic focus for most occupational therapy practitioners is how the child holds
the pencil itself or the grip on the pencil. Ziviani (1987) reinforced the different
variations in expected clamps. Poor writers tend to show a greater variety of atypical
tweezers than readable writers. Mature pencil grips include the dynamic tripod, the
lateral tripod, quadripod or dynamic, and lateral quadripod (Dennis & Swinth, 2001;
Koziatek & Powell, 2003; Schneck & Henderson, 1990; Tseng, 1998).
Unconventional pencil grips do not necessarily affect the speed or legibility of a
child's writing (Dennis & Swinth, 2001; TSeng & Cermak, 1993)

WRITING INSTRUMENTS

Standardized or formal tests are important to assess children's performance, provide

objective measures and quantitative scores, help monitor child progress, assist
professionals to communicate clearly, and generate advances in the field through
research. Numerous standardized writing instruments are commercially available.
Assessment tools commonly used by occupational therapists in the United States
include the Children's Handwriting Rating Scale (Phelps et al., 1984), the Children's
Handwriting Rating Scale (Phelps & Stempel, 1987), the Denver Writing Analysis
(Anderson, 1983), the Minnesota Writing Test (Reisman, 1999), the Children's
Writing Assessment Tool (Amundson, 1995), and the Writing Skills Test (Gardner,
1998). ).
Each of these assessment tools has several characteristics considering the writing
domains tested (copying far points, dictation), grade or age of the child (first or
second grade), writing tested (cursive), procedures for scoring written performance
( legibility of the manuscript), and scores obtained (percentiles). Typically the tests
measure legibility and writing speed. Procedures for scoring readability use
techniques ranging from global and subjective to detailed and specific. A description
and information on the writing instruments available to occupational therapists is
presented in Appendix 17-a. To select the tool, the occupational therapist must keep
in mind the characteristics of each instrument as well as its strengths, limitations,
considering data collection, reliability, validity, and other psychometric properties (see
Chapter 8). Descriptions and critiques of writing instruments by various authors
(Amundson, 1992; Daniels, 1988; Reisman, 1991; Tseng & Cermak, 1991) should be
considered when selecting appropriate programs. A shortcoming of most writing
instruments is the low credibility for measuring legibility due to the subjective nature
of determining the ability to read writing (Deikema, Deitz & Amundson, 1998). The
instrument chosen should cover the areas considered in the child's writing and
should allow for effective intervention planning between the occupational therapist,
the child's parents, and other members of the team.

Factors that restrict writing performance

To understand what elements may interfere with the child's ability to produce text, the
occupational therapist must consider the child's performance skills, client factors,
performance patterns, and contextual elements (American Occupational Therapy
Association, 2002). ). As occupational therapists build their clinical reasoning skills,
they are able to observe a child's difficulties with writing or seeing illegible writing and
identify factors that may interfere with the child's written communication. The
following example indicates how various factors can restrict a child's writing
performance. The complexity of these examples requires that occupational therapists
be able to analyze the interaction of factors that influence children's occupations
(writing).
Natasha, a nine-year-old girl with traumatic brain injury, has illegible handwriting
marked by open letters, poor use of lines, and many smudges. When his written
performance in the classroom was evaluated, the occupational therapist noted that
his performance skills, particularly his fine motor coordination, are limited.
Manipulation skills are poor and Natasha has difficulty moving her pencil from the
writing position to the erasing position, managing her sheet, and using her eraser.
When participating in classroom activities, the occupational therapist sees that
Natasha has a short attention span and impulsivity (client factors). Natasha has
difficulty maintaining her attention to desk work and the teacher's verbal instructions.
When the occupational therapist examined a story she had written during the day, it
was apparent that she had not incorporated the habit of writing the text on the lines of
the paper. By not adopting this pattern of performance, the text rose and fell on the
paper resulting in an illegible story. Finally, the occupational therapist was told that
Natasha used English as a second language due to recent immigration from the
United States. Consequently, the occupational therapy practitioner reasoned that his
cultural context could be affecting his overall performance in the classroom.
As with Natasha, it is common for children with poor handwriting to have a web of
factors that restrict their performance. The occupational therapist must identify each
factor from the others and its interaction with other patterns to understand its
influence on performance. For example, Natasha's client factors (short attention
spans, impulsivity) and cultural context (English as a second language) are related
and interact with each other to constrain her writing performance. Natasha's short
attention span not only diminishes her ability to learn to write but her ability to attend
to concepts including her second language, English. If she is unable to understand
the language symbols, words, and syntax of the English language, she will have
difficulty reading in English. Because reading and writing parallel the learning
process, Natasha's writing will be affected. Writing is more likely to improve once
effective compensatory and remedial techniques are implemented to improve their
attention span and knowledge of the use of the English language.

EDUCATOR'S PERSPECTIVE

Writing process

When educators talk about writing or the process of composing, they see a goal-
directed activity that uses the cognitive functions of planning, sentence generation,
and revision (Hayes & Flower, 1986). Actual text production occurs in sentence
generation, thus the child who needs to pay considerable attention to the mechanical
requirements of writing may interrupt higher-order writing processing, such as
planning or generating content. Most educators view the mechanical requirements of
writing as an integral basis of the writing process.

Writing instruction methods

Over the past decade, an educational debate has focused on teaching systematic
writing through commercially prepared or teacher-developed programs or learning
through a whole language approach. Whole language philosophy asserts that both
the substance (meaning) of writing and the form (mechanics) in writing are critical to
learning to write (Graham, 1992). Thus, when this method is used for children to
learn and master writing, the teacher gives advice and assigns practices on an
individual basis and according to needs. For example, the educator sees that a first
grade child has difficulty with the letter m while writing a story about monsters, he or
she can instruct the child by considering the correct formation of the letter m and
promoting traditional letter practice during the period. of story composition. In a
traditional writing instruction approach, students are introduced to letter formation
and practice with them outside the context of writing. For children with learning
disabilities and neurological impairments, regular practice in forming letters is
essential in the early stages of writing development, so writing should have a
meaningful context. The combination of systematic instruction and a whole language
approach to writing may be beneficial for this group of children (Graham).
In the United States, traditional writing instruction programs vary from district to
district and occasionally from grade to grade. It is common for occupational
therapists to receive a review of a child with poor handwriting who has never had
writing instruction! The most common methods include Palmer, Zaner-Bloser, Italic,
and D'Nealian (Alston & Taylor, 1987; Duvall, 1985; Thyrber, 1983). See Appendix
17-B for a list of writing curricula used in schools.
Unlike the United States, a few countries, such as the United Kingdom, New
Zealand, and Australia (Alston, 1991; Alston & Taylor; Jarman, 1990; Ziviani &
Watson-Will, 1998) have adopted national curricula for writing for improve the
standards of writing assessment and instruction within their school systems.

Handwritten and cursive style

A generally accepted sequence for writing instruction is handwriting used in grades 1

and 2, transitioning to cursive at the end of grade 2 and beginning of grade 3
(Barchers, 1994; Bergman & McLaughlin, 1988; Hagin, 1983). . The need for
handwriting can continue throughout life, as students label maps and posters,
teenagers fill out job or college applications, and adults fill out federal tax forms. In
high school, many students mix handwriting and cursive to form their own writing
style. To date, no research has decisively indicated the superiority of one script over
the other.
Both handwriting and cursive have complementary characteristics, which should be
considered when the occupational therapist, the child, his or her parents, and the
educational team are deciding which style will best serve the child.
The manuscript is supported for the following reasons:
1. Letter shapes are simpler and easier to learn.
2. It is close to the printing of textbooks and school manuals.
3. It is needed throughout adult life for documents and applications.
4. The beginning of handwriting is easier than cursive.
5. Handwritten letter formations are more developmentally appropriate than cursive
in young children.
6. Handwritten letters are easier to discriminate visually than cursive letters (Barbe,
Milone & Wasylyk, 1983; Bergman & McLaughlin, 1988; Graham & Miller, 1980;
Hagin, 1983)
Defenders of cursive writing say the following:
1. Italic movement patterns allow for faster and more automatic writing.
2. The inversion of individual letters and transposition of words is more difficult than
in handwriting.
3. A continuous, connected line enables the child to form words as units.
4. cursive is faster than handwriting.
5. Cursive allows the poor writer a new type of written format, which can be more
motivating at the maturational level of the child. (Armitage & Ratzlaff, 1985;
Bergman & McLaughlin, 1988; Graham & Miller, 1980; Hagin, 1983)

INTERVENTION IN WRITING

Planning

In school settings, if the referred child's educational team decides that functional
written communication is a priority of the child's educational program, the
occupational therapist can be instrumental in directing and guiding this aspect of the
program. Typically, the team uses compensatory or remedial approaches to
intervention or both to improve the child's written communication. Compensatory
strategies improve student participation in school with accommodations, adaptations,
and modifications to certain tasks, routines, and environments (Amundson, 1998;
Kemmis & Dunn, 1996; Swinth & Anson, 1998), while remedial strategies are used to
improve or establish the student's functional skills on a specific task.
When the team focuses on the task of written communication, generally both
compensatory and remedial strategies are commonly employed. For example,
Hunter, a second grader, who has illegible handwriting, about 60% of his written
letters are not legible, and his writing speed level is at the top of his class. While he
participates in an intensive multisensory writing remediation program, he needs
accommodations and strategies to help him be functional with his written
communication in the classroom. Consequently, your teacher may need to adjust the
time required to complete assignments, incorporate a greater number of oral reports
into assignments, or ask for a reasonable volume of work to be accomplished on
each assignment that may be different from that of your peers. The teacher and
occupational therapist can use other techniques to assist with legibility issues such
as word spacing, letter size, and placing text on lines.
Initially, the child, his or her parents, and the educational team need to reach a
consensus regarding the type of writing (cursive) and the method of writing
instruction (Zaner-Bloser) that appears to be advantageous for the child to use.
Specific intervention techniques must be generated and selected as well.
Consequently, the type, frequency, and duration of service with the service provider
(certified occupational therapy assistant) who works with a child with writing
disabilities must be determined within the planning.
Occasionally when children's writing is very slow and illegible, team members may
decide to incorporate computerized technology, such as a word processor or laptop.
Both students and the team, particularly occupational therapy practitioners, must
work hard to find the technological system that allows students efficiency in text
generation (Swinth & Anson, 1998). As with pencil and paper, the computer requires
adequate attention, motor control, sensory processing, visual functioning, and self-
regulation on the part of the student.
The computer is not a magical tool but one that allows the child to acquire word
processing and writing skills through planning, routine instruction, and practice. Two
studies of elementary students with learning disabilities (Lewis, Graves, Ashton, &
Kieley, 1998; MacArthr & Graham, 1987) indicated that writing was a faster mode of
text generation than typing, after several months of practice. . Word processing with
word prediction improved the readability and spelling of written assignments in two of
three children with learning disabilities in a simple design study (Handley-More,
Deitz, Billingsley, & Coggins, 2003). In this era of technology, it is important for all
students to develop typing skills as an additional academic foundation for computer
use in classrooms, workplaces, and homes. However, the surviving writing skills will
continue to be necessary throughout the student's adult life.

Practice models that guide the occupational therapist

The theories, strategies, and approaches of the occupational therapist may seem
unconventional to children, educators, parents, and other school personnel. Thus,
the occupational therapist must be able to (1) clearly articulate the intervention
techniques, activity modifications, and classroom accommodations that are being
used; (2) collaborate with the teacher and others to provide services in a less
restrictive environment; (3) implement therapeutic strategies to improve written
communication; (4) train others to work with children with writing problems; and (5)
closely monitor the child's progress and change aspects of the program to continue
improvement.
The central focus of the educational program is the improvement of student
performance in a particular occupation (written communication). The occupational
therapist's practice models or frames of reference contribute to the occupational
response including (1) neurodevelopmental, (2) acquisitive, (3) sensorimotor, (4)
biomechanical, and (5) psychosocial. Recognitions from occupational therapists in
the United States (Woodward & Swinth, 2002) and Canada (Feder, Majnemer, &
Synnes, 2000) indicate that the theoretical approach most applied to children in
writing intervention is multisensory (92%, United States United States) and
sensorimotor (90%, Canada). However, the use of several theoretical approaches
was found in writing intervention in Canada and in pediatric occupational therapy
literature.
When considering any intervention plan for writing, practitioners must take into
account the parameters of achievement of each practice model and the interaction
between them. The occupational therapist must be skilled in using one or more
models of practice and in teaching others to implement the strategies originating from
these models of practice. By considering the focus on the child's occupational
response to writing and applying various models of practice in the child's educational
program, the occupational therapy practitioner can provide a range of opportunities
for the child to learn and master the skills. of written communication.

Neurodevelopment

The theoretical approach to neurodevelopment is based on neurological principles

and normal development, focusing on the individual's ability to execute postural
responses and efficient movement patterns (Howle, 2002). This model of practice
provides an ideal orientation for the problems of children who have inadequate
neurodevelopmental organization exhibited in poor postural control, automatic
reactions, or limb control (Dutton, 1993a). Increased, decreased, or fluctuating
muscle tone, inadequate balance and righting responses, and poor proximal skills
can interfere with successful performance in fine motor activities (writing production
at home and at school).
Postural and limb preparation activities are an important component of the
comprehensive writing program for children with neuromuscular impairments and
sensory processing problems. For these children, preparing their bodies and hands
for writing becomes the preliminary ingredient of writing intervention before the
instructional program begins. Selecting preparatory activities to address each child's
specific deficits and carefully analyzing their response to your activities is critical in
the preparatory phase of the writing intervention program. The following paragraphs
in this section indicate activities for upper extremities and posture to get children's
bodies ready to write. These activities can be used in class or in therapy in the areas
of (1) modulating muscle tone, (2) promoting proximal joint stability, and (3)
improving hand function.
Postural preparation to modulate muscle tone may involve activities to increase,
decrease, or balance muscle tone. Traditional activities to increase tone include
jumping while sitting on a ball, and jumping on a mini trampoline. In the classroom,
activities to build tone and strength may include placing students' hands on the sides
of their chairs and swaying. They can maintain the position with arms extended to
rise above the chair. They can perform simple calisthenics, pushing above their
heads and shoulders with their hands while sitting in a chair (Amundson, 1998) or
pushing with their arms on a school chair (Figure 17-5).
Figure 17-5 a girl demonstrating arm push in her school chair
For children whose muscle tone needs to be reduced, conventional slow movements
can be achieved by sitting on a long hammock and moving it from side to side to the
rhythm of a poem that the child recites aloud. When writing in the classroom, the
child's postural tone can be reduced by sitting him in a rocking chair to the rhythm of
slow, rhythmic instrumental or vocal music, placing him in a seed chair, or
participating in a relaxing visual imagery exercise.
Children with poor handwriting often exhibit poor proximal stability and strength. To
promote co-contraction through the neck, shoulders, elbows, and wrists, young
children can enjoy walking like animals, such as a bear or horse. Older children may
prefer calisthenics such as pushing against the floor or against a wall, resistance
exercises with balls, partner exercises from a seated position on the floor, or yoga
poses that require weight maintenance on the upper extremities. Figure 17-6 shows
two children participating in a yoga position (London Bridge Pose) to prepare for
writing. Within the school environment, proximal stability can be promoted through
daily routines, such as cleaning the board and table, opening heavy doors, or moving
classroom furniture or physical education equipment.

Figure 17-6 2 children participating in a yoga game to get ready for writing
Alternative positions during writing can promote proximal stability. The prone position
requires maintaining weight on the forearms for writing, which increases proximal
joint stability and dissociation of the hand and fingers from the forearm.
When preparing to write, some children may benefit from developing more
coordinated synergies of the intrinsic and extrinsic muscles of the hand to improve
overall function. Typically, the hand needs to be stable and strong enough to provide
support for the fingers to manipulate tools. Hand strengthening activities in class
include carrying heavy bags, and participating in games such as Felicity The Cat
Scratch (Amundson, 1998). Prewriting, writing, and manipulation activities on vertical
surfaces can assist children by developing more stability of the wrist in extension to
facilitate balanced use of the intrinsic hand musculature (Benbow, 1990b). Activities
that require manipulation or adjustment of an object after placing it in the hand
(Exner, 1992) may be appropriate for children with writing deficits (see Chapter 10).
Translation by moving the writing instrument from the palm to the fingers of the hand,
“sticking” the instrument to the hand for proper grip, and rotating the pencil from the
writing position to the erasing position are necessary manipulation skills. for handling
the writing tool.
A study by Cornhill and Case-Smith (1996) on 48 first grade students demonstrated a
high or moderate correlation between writing skills and manipulation, especially
translation and complex rotation. Boehme (1998) suggested that the vertical
excursion of the line is produced by the flexion and extension movements of the
digits, while the horizontal excursion originates from the lateral movements of the
wrist. The balanced interaction of the intrinsic and extrinsic muscles of the hand is
the key to the fluid, dynamic and efficient movements necessary for writing.

Purchasing

Writing can be viewed as a complex motor skill that can be improved through
practice, repetition, feedback, and reinforcement (Hola, 1986, p. 70). The
instructional guide to writing is recommended by Graham and Mill (1980) to be (1)
taught directly; (2) implemented in short, daily injuries; (3) individualized; (4) planned
and modified according to evolution and performance data; and (5) overlearned and
used meaningfully by the child. When therapists and educators employ these
conditions in a positive, engaging, and dynamic learning environment, children are
more likely to become more readable and efficient writers. (Barchaers, 1994; Graham
& Miller; Milone & Wasylyk, 1981).
For occupational therapy practitioners, writing is a motor skill related to motor
learning theories that impacts the instructional process. Learning a new motor skill
has been described as a process through three phases: cognitive, associative and
autonomous (Fitts & Posner, 1967). First, in the cognitive phase, the child attempts to
understand the demands of the writing task and develops a cognitive strategy to
perform the necessary movements. Visual control of fine movements is important in
this phase. A child learning to write in this phase may have developed some
strategies for writing some of the easier handwritten letters such as o, l or t, but may
have difficulty with more complicated letters such as b, q or g.
In the associative phase, the child has learned the fundamentals of writing
performance and continues to adjust and refine skills. Proprioceptive feedback
becomes more important during this phase, where the importance of visual cues
decreases. For example, in the associative phase a child may have achieved
mastery in forming letters but is participating in improving the writing product by
learning to space words correctly, write letters within lines, or maintain a constant
size. continue to require practice, guidance, and self-monitoring strategies for writing
performance.
In the final, autonomous phase, the child can perform writing automatically with
minimal conscious attention. Performance variability is slight from day to day and the
child is able to detect and adjust small errors that may occur during the autonomous
phase (Schmidt, 1982). Once the child has achieved this level of writing, his or her
attention can be expanded to other high-level elements of writing (Graham, 1992) or
can be saved to relieve fatigue (Schmidt).
The implications and strategies of writing instruction and remediation evolve from
reviews of writing studies (Bergman & McLaughlin, 1988; Graham & Miller, 1980;
Peck, Askov, & Fairchild, 1980) as well as theories of motor learning (Magill, 1985).
Many writing intervention programs are commercially available (see Appendix 17-c
for a brief description of these programs; see Appendix 17-d for a list of Internet
resources). Each should contain a sequence of letter and number formations, along
with instructions. To date, no empirical evidence reveals that one commercial
program is more effective than another.
The intervention program sequence should focus on a structured progression of
introducing and teaching letters and numbers. Often letters with common
characteristics are introduced as a family, such as the lowercase letters e, i, t and l.
After the child masters these letters, he can immediately use them to write words that
combine them. Even if the intervention program is commercially available, each
program must be individualized according to the letters in which you have not
achieved mastery. Thus, the center of the child's program is to sequentially introduce
new letters and use them with the letters the child has mastered, excluding letters
that the child does not know or forms incorrectly, while reinforcing perceptual and
motor patterns (Ziviani, 1987). Combining acquired letters with blended letters allows
the child to write in a meaningful context. (Word and sentence formation). This
immediate reinforcement is more powerful and meaningful than writing strings of
letters repeatedly.
The instructional approach of writing intervention programs varies in that they tend to
combine sequential techniques including modeling, stimulation, copying,
composition, and self-monitoring (Amundson, 1992; Bergman & McLaughlin, 1988;
Milone & Wasylyk, 1987). When acquiring new letters, the child may need visual and
auditory cues. However, the service provider may remove these prompts based on
the child's progress. Then the child proceeds to copy the letters and words from
memory while they are dictated. Finally the child advances to generate letters and
words to practice. In each phase the child should expect to take responsibility for
correcting his or her own work, self-monitoring (Bergman & McLaughlin). Older
children may be referred to a checklist that considers spacing, size, alignment, and
letter shapes during self-assessment of their writing. However, young children may
need to verbally evaluate letter formation and overall appearance out loud.
Acquiring writing skills and applying them in school life means that the educational
team not only focuses on teaching letter formation, but also on the legibility and
speed of the student's writing. In addition to learning to form letters correctly, other
components of writing include spacing, size, and alignment. The spaces between
letters and words, placement of text on lines, and the size of letters often require
attention. An effective writing surface to help students with the placement and size of
text is a color-coded one. This sheet provides immediate visual cues for the child to
learn letter shapes, accompanied by auditory cues from the service provider. The
base of the line is red, the brown color represents the earth, the space between the
red and black line is green for grass, and the top is blue for the sky. For example, the
letter h must begin in heaven, descend and end on earth. This same scheme can be
applied to homework sheets, giving students strong prompts to learn how to place
letters and their size (Amundson, 1998) (Figure 17-7). Several strategies for
problems related to the components of readability, homework, and speed are listed in
Table 17-4.

Figure 17-7 Lined paper with diagrams to assist with font size and text placement.
 TABLE 17-4 STRATEGIES FOR WRITING PROBLEMS
Issues of the Potential Solutions
Writing
Spaces between letters
Use finger spacer on index finger
Use inked spacer on fingers by placing it on a pad
Teach the rule of not touching the letters
Spaces Use adhesive between words
Use a dot or dash (Morse code) between words
betweenon paper
Spaces
Use double line paper
Write on each line of the paper
Draw colored lines to mark (green is left, red is right)
Place he text
on the lines
Use graphic schemes on the lines
Provide lines with tactile cues to place letters
Remind students not to arrange letters like “popcorn.”
Letter and word size Use individual boxes for each letter
Name the letters with ascending indicators, without
indicators, and descendants, as “birds”,
and
Copy of points Highlight the text to be copied
nearby Teach the student to copy two or three letters at a time
Copy of points Enlarge the print to see better Start copying vertical models
distant Position the student in front of the board

Dictation Place an alphabet on the desk of the student who cannot

remember the letters
Dictate spelled words that contain multiple letters
Composition Be sure that students can form the letters from memory
Provide magnetic words to write poems or short stories

Speed

Allow students to start projects earlier

Photocopy math problems from the book to reduce copy
Shortlist a workload that may be different from your peers.
Modified from Amundson, S.J. (1998). TRICKS for written communication: Techniques to rebuild and
improve children's school skills. Homer, A.K.: O.T. KIDS.
Sensorimotor

The parameters for this model of practice, when applied by the occupational therapist
with children with writing disabilities, include the control of sensory input through
activities selected to promote the integration of sensory systems at the subcortical
level (Simon, 1993). By providing multiple sensory opportunities, the child's nervous
system can integrate information more efficiently to produce a satisfactory motor
response (legible letters). All sensory systems, including proprioceptive, tactile,
visual, auditory, olfactory and gustatory, can be added in a writing intervention
program, whichever is intended to promote learning. Incorporating a sensory-
integrative approach into writing intervention equates to the use of a variety of
sensory experiences, media, and instructional materials. Additionally, it provides new
and interesting materials for children to practice letter formation, which can keep
students motivated, excited, promoting student success in their learning. Children
with writing difficulties who have experienced frustrations with pencil and paper may
find writing instructions more enjoyable using this unique multi-sensory format.
Learning tools, writing surfaces, and writing positions are integral parts of the
sensorimotor approach. Examples of tools used include thicker pencils (regular,
changeable color), crayons (scented, glitter, glow in the dark), paintbrushes, Chinese
markers, vibrating pens, and chalk. Lamme and Ayris (1983) examined the effects of
different writing tools on readability. The results indicated that the type of tool does
not influence readability but the educators involved in the study reported that
children's attitudes toward writing were more positive when they could use different
tools. This suggests that children's feelings towards writing can be improved using a
variety of tools. Writing with chalk, grease pencils, or a resisted tool provides
additional proprioceptive stimulation to children, since greater pressure is required
than with traditional means, pencil and paper. Unconventional tools can be easily
incorporated into schoolwork.
Writing surfaces can be in a vertical, horizontal or angular plane. Vertical surfaces for
writing include the board, painting easels, and paper on the wall. These surfaces,
along with paper on inclined planes, facilitate a more mature grip on the writing tool
resulting in greater extension of writing and an open web space between the thumb
and fingers (Benbow et al., 1992). Figure 17-7 shows a girl working on her homework
which is taped to the refrigerator. A vertical orientation may decrease early writers'
directional confusion when learning letter formation (Hagin, 1983). In the vertical
plane up means above and down means below, as opposed to desk work where the
direction up means above the body and down means below the body. Remaining in
front of a board with the body in full extension and parallel to the writing surface can
promote internal stability of the trunk, increase the child's awareness, and provide
greater proprioceptive stimuli through the shoulder and arm and allow the hand to
move more independently or dissociated from the arm (Amundson, 1992).
Figure 17-8 a girl works on a homework assignment placed on a vertical surface
(kitchen)

Writing practice on a horizontal surface on the table or floor can be performed using
refrigerated bags partially filled with colored gel, sand, pudding, or hand lotion. The
tools can be modified by providing additional tactile and proprioceptive stimuli when
forming letters, numbers and words. Other writing activities can occur on textured
paper, nylon, or folders to provide proprioceptive stimulation.

Biomechanical

In the true sense, the biomechanical framework considers occupational performance

in terms of range of motion, strength, and endurance (Dutton, 1993b).
The discussion, however, focuses on the ergonomic factors of sitting posture, paper
position, pencil grip, writing instruments, and type of paper. Compensatory strategies
—including adaptive devices, procedural adaptations, and environmental
modifications to improve interaction and match children's abilities and the demands
of the writing task—are presented. This model emphasizes modifications to the
student's context rather than focusing on improving performance skills.
Sitting posture. Although upright and prone positions may be promoted as
alternative writing positions, students continue to spend much of their school day
sitting at a desk. The occupational therapist should add the student's sitting position
in the classroom. While writing, the student should be seated with feet firmly on the
ground, providing support for weight balance and postural adjustments (Benbow et
al., 1992). The table surface should be 2 inches above the bent elbows when the
child is sitting in the chair. In this position, the student can experience symmetry and
stability while performing written work. To ensure that the student is seated
appropriately the occupational therapist may recommend adjusting the height of
chairs and tables, providing necessary footrests for children, adding cushions, and
repositioning the desk facing the tabletop.
Paper position. The paper should be placed on the desk so that it is parallel to the
forearm of the writing hand when the forearm rests on the desk (Levine, 1991). This
angle of the paper allows the student to see their written work and avoid affecting
their writing. Right-handed students can place the edge of the paper 25 or 30° to the
left with the paper to the right of the midline of the body. A degree of 30 to 35° to the
right and the paper placed to the left of the midline are necessary for left-handed
students (Alston and Taylor, 1987). For the student with a left lateral grip on the
pencil, the paper should be placed in the same way as for right-handed students
(Benbow et al., 1992). The writing instrument is placed below the line and the non-
dominant hand should hold the paper (Alston and Taylor).
Pencil grip. Benbow defined the ideal grip as a dynamic tripod with an open web
space. With the net space open (forming a circle), the thumb, index finger and middle
finger achieve the greatest flexion, extension and rotation of the pencil (Benbow et al.
1992) during writing. Variations in clamps can make writing more difficult and less
functional (Tseng and Cermak, 1993). Educational team members may consider
modifying the students' gripper with the following conditions (1) writing results in
muscle tension and fatigue; (2) writing efficiency, such as letter formation or speed, is
impeded; (3) the child's inability to control and specify thumb movements form a
closed network space; (4) the child holds the pencil with a lot of pressure or presses
the pencil a lot on the paper, breaking the tip, the paper, and moving the hand
repeatedly (Benbow).
When attempting to modify a clamp pattern, the child's characteristics are an
important consideration. The occupational therapist should promote mature grasps in
young writers and recognize that success in modifying the gripper may be greater in
young children (Ziviani, 1987). Once the position of the clamp has been established,
it is very difficult to change it (Benbow, 1990). In fact, at the beginning of second
grade, changing a clamp pattern can be stressful and impossible (Benbow et al.
1992). The educational team needs to consider the child's acceptance of the new
clamp or adapted device before attempting to adopt it permanently.
A variety of devices and therapeutic strategies are available to assist the child in
positioning the fingers for better manipulation of the tool (Amundson, 1998). The
occupational therapist must know the function of the hand to determine which device
or technique is most appropriate for each individual. Triangular pencils, moldable,
can facilitate the tripod clamp. Muscle tension and fatigue when writing can be
decreased by using a wider pencil. To gain greater finger mobility, children can hold
a small eraser against their palms and ulnar fingers allowing for more dynamic
movement of the pencil. For older children with hand hypotonia, holding the pencil
between the red space of the index and middle fingers with the thumb in opposition
can give a viable grip (Benbow, 1990b). Other techniques to promote the delicate
balance between stability-mobility of the functional gripper include the use of external
supports such as a foam surgical support, ring splints (Benbow, 1995) and should be
used with knowledge of the anatomy and kinesiology of the hand. . A how band that
promotes the use of a relaxed writing position is shown in Figure 17-9.
Figure 17-9 an elastic band allows for a relaxed pencil position.

Writing tools. The type of instruments that children use must be considered. In
general, children should be allowed to choose from a variety of tools and parents and
teachers should help the child determine which one may be most useful and
comfortable. Traditionally, kindergarten and elementary classes have promoted the
use of a wide or beginner pencil to begin writing. Carlson and Cunningham (1990)
examined the tools used by preschoolers while drawing and writing. They found that
ease of writing is not promoted by the use of a wide pencil. This study suggests that
use of the beginner pencil is not guaranteed for all schoolchildren and some children
perform better with a No.2 pencil.
Paper. Various types of paper are available in the educational environment. Paper
without lines and paper with a middle line between the top and bottom lines are
commonly used in the lower grades. For most children, most research confirms that
lined paper improves handwriting legibility when compared to using unlined paper
(Pasternicki, 1987). Children start with a wide (1 inch) guide space. As writing
efficiency improves, usually in 3rd or 4th grade, the child begins to use medium-
spaced paper (Barchers, 1994). The occupational therapist and educator can allow
the student the opportunity to experiment with paper of different lines, sizes, and
textures to determine which offers the child the best medium for writing.

Psychosocial

The psychosocial approach used in child writing intervention generally focuses on

improving the student's self-control skills and social behavior. In the area of writing
this may mean that the child can produce a written text when an envelope is sent to
their residence knowing that the occupational therapist will use the envelope to send
the child a surprise. Receiving a surprise like a bookmark is a social reinforcement for
the child.
Sharing with the child the importance of writing and the reasons for the intervention,
as well as providing daily, meaningful and positive experiences using writing, can
lead to the child's behavior towards writing improving. Simple games at home and at
school, such as trique, can be played using the newly acquired letters, instead of Xs
and O. When a child presents a written and drawn Thanksgiving card (related to his
or her skill) at home, parents can provide social reinforcement. Additionally, teachers
can reward the child with poor writing with a special certificate for a school
assignment. By offering children choice, success, responsibility, and motivation within
an intervention program and natural environment, writing can be viewed and
practiced by children as a functional and socially valid skill.
Using a psychosocial approach, the occupational therapist can promote the child's
social competence within the framework of a writing intervention group. The use of
small groups as a service delivery model for school-based writing intervention is
often limited. Woodward and Smith (2002) found that school-based occupational
therapists infrequently use small groups in writing intervention (12.4%) when
compared to other types of services in school settings.
However, a successful group is a writing club of 4 to 6 students, who work on
improving writing, developing social skills, and monitoring their own work and
behavior (Amundson, 1998). Poor social functioning is common in children with
learning disabilities. Behaviors that interfere with social relationships include poor eye
contact, lack of physical approach, difficulty getting to know others, and lack of
awareness of verbal and nonverbal cues, to name a few (Williamson, 1994). The
service provider can provide group experiences and teach children necessary social
skills, such as regulating tone and volume of voice, accepting negative feedback,
maintaining personal space, and giving and accepting apologies (Williamson) while
engaging with the child. writing group.
In a writing club, for example, children stay in a prone position and practice forming
letters, each deciding the amount of personal space they need to feel comfortable, as
well as the amount of space they need to write. The practitioner can introduce both of
these space requirements, and can assist children in the problem-solving process.
Another example related to building social skills in a writing intervention group may
occur during a manipulation preparatory activity, such as a competitive game like
Kerplunk. As children remove the plastic cylinders from the cylinder, the occupational
therapy practitioner can reinforce the social skills of taking turns, regulating one's
own behavior within competition, and following the rules of a game.
Other strategies to promote children's social functioning within an intervention group
may require a proactive role of the occupational therapist. Giving a review of the
intervention session at the beginning of the period and clearly delineating the
beginning and end of activities can help children who have difficulty transitioning
activities between homework and class. Developing trust and a sense of
togetherness among children can be achieved by having a club or membership group
with a special name, logo or greeting (Williamson, 1993). Finally, the interventionist
must establish clear and reasonable rules and consequences and share them with
the group members and consistently manage the child's behavior. By building a
child's social skills within the group writing intervention framework, occupational
therapy practitioners help children become more socially competent with peers and
adults, as well as become more efficient and fluent in their writing.

Evidence of occupational therapy intervention in writing

Some children are good candidates for improving their current cursive or handwriting
through remediation. The occupational therapist and the child's team need to
consider compensatory strategies that allow the child with poor handwriting the
greatest opportunities to communicate in writing. Alternatives to writing include
keyboarding and word prediction, adapting and reducing the amount of writing
assignments, dictation, and having study buddies to help you with written expression.
In school settings, the educational team must determine the type of written
communication that is most functional for the child and develop a short-term (learn
essential handwritten words) and long-term (learn word processing) plan.
Although the field of occupational therapy assumes that occupational intervention
improves children's writing, the professional literature continues to have little control
over writing intervention studies. Two studies (Case-Smith, 2002; Peterson & Nelson,
2003) indicate, however, that occupational therapy intervention positively affects
students' writing. case Smith investigated 29 children who received occupational
therapy services and 9 who did not. The children were between 2nd and 4th grade.
The occupational therapy intervention focused on improving visual-motor skills and
writing practice. Occupational therapists reported using an eclectic model during
intervention sessions. After 8.8 hours of direct intervention, the intervention group
made significant gains in handwriting legibility compared to the control group.
Although speed was not significantly affected, students on average increased from
32 to 37 words per minute. The pretest and posttest were completed with the
Children's Writing Assessment Tool (Amundson, 1995).
In Peterson and Nelson's (2003) study, 59 first grade children from low
socioeconomic backgrounds participated. 30 children were randomly assigned to the
occupational therapy intervention group receiving 10 hours of intervention. The
control group (n=29) received regular academic writing instruction, children who
received writing intervention were based on the integration of theoretical
perspectives. Results indicated that children who received intervention reported a
significant increase in Minnesota Writing Test scores (Reisman, 1999) than those
who were in the control group.
Both studies (Case-Smith, 2002; Peterson & Nelson, 2003) provide evidence that
occupational therapy intervention significantly impacts children's writing; however,
both studies have limitations. A limitation in both is that the raters were not blinded to
the experimental conditions. Another limitation is that both writing instruments, the
Children's Writing Assessment Tool (Amundson, 1995) and the Minnesota Writing
Test (Reisman, 1999), have only good credibility. Finally, the sample size and the
specific geographic region limit the generalizability of the studies.

Service provision

Providing occupational therapy services to children with writing dysfunction should be

based primarily on the child's individual needs as determined by the medical or
educational team. More educational teams in school-based practice are using a
continuum of service delivery that allows for greater flexibility, fluidity, and
responsiveness to the child's individual needs (see Chapter 22).
For example, at the beginning of second grade, Tara, a girl with learning disabilities,
is evaluated by the occupational therapist for poor maintenance of manipulatives in
the classroom (glue, scissors, the computer mouse) and in writing. . After a
comprehensive occupational therapy evaluation, Tara's parents and educational
team decided to focus on helping her become a more efficient writer, with the
occupational therapist and teacher leading the intervention program.
The therapist and teacher developed strategies to be implemented in the classroom.
These strategies included placing Tara's desk in front of the board, reducing the
amount of written assignments, and giving her an alphabet placed on her desk at the
same angle as her writing paper (Figure 17-10).

Figure 17-10 An angled strip is placed on the student's desk.

The educator also asked the occupational therapist to help with fun exercises to do
with the class “ready to write” before their creative writing period. The occupational
therapist established a time with the teacher of 10 to 15 minutes per week (for 4
weeks) teaching the whole class manual dexterity games before a writing activity. He
also provided the teacher with written games so that the teacher could ask questions
and have a reference.
Due to the extremely poor legibility of Tara's handwriting, the team chose to place her
in an outside writing intervention group. This group has 25 minute sessions, 2 times a
week for 3 consecutive weeks. During the direct intervention period, the occupational
therapist assessed each child individually. She trained the teacher's assistant to
coordinate the writing group and add some individual problems. The occupational
therapist returned to the intervention once every 2 weeks to supervise the service
provider, monitor the children's progress, and modify the program when necessary. A
regular consultation period was established with the educator to evaluate Tara's
progress in the classroom, to formulate strategies according to the new situation
affecting her writing performance, and to write progress notes to her parents.
In Tara's case, during the first 4 weeks after the educational team met with the
occupational therapist, direct service was implemented, the teaching assistant was
trained, and the teacher was consulted. However, service provision was not set on a
schedule (2 25-minute sessions per week of direct therapy). Consequently, situated
within a continuum of service delivery, the occupational therapist was able to respond
to Tara's educational needs by initially working with the teacher, orchestrating an
external intervention program that another service provider could implement after the
training, and maintaining a regular contact with Tara and members of the educational
team, including her parents.
Most occupational therapists are comfortable providing individual or small group
sessions; However, some take on challenges when consulting or training and
supervising others to implement programs. Often, alternative service providers
(educators, educational assistants, volunteers, high school students, and parents)
are able to implement techniques and programs if the occupational therapist
assumes responsibility for organizing and monitoring the methods and programs
used. To do this the occupational therapy practitioner must model the service
provider role during training, clearly articulating the reason why the methods and
approaches are used in the program, and organizing the program so that the service
provider can use it. easily.
Supplying (1) program-specific oral and written directions; (2) a container, such as a
basketball, filled with materials for the writing intervention program (theraband,
manipulative games, sequenced writing lessons, and different writing tools); (3) data
management sheets; and (4) a system for providing reinforcements and rewards, the
program will be more user-friendly for the service provider. A program can increase
the pleasure of following the instructions given by the therapist. If the therapist
regularly observes the sessions implemented by the service provider, discusses the
reasons for using specific methods, reviews the child's progress and needs for
program change, the training can be beneficial for children receiving the intervention.
The training can benefit other children in the classroom who may have difficulty with
writing.

SUMMARY

Writing is an important academic occupation for children. Children with

neuromuscular impairments, learning disabilities, and developmental delays are often
referred to occupational therapy for writing problems. The role of the occupational
therapy practitioner includes assessing the functional performance of the child's
writing and prewriting skills, along with task demands and environmental
characteristics. The occupational therapist should assist the educational or clinical
team by determining and planning a comprehensive approach to promote the child's
functional communication.
Writing intervention programs must be comprehensive, incorporating therapeutic
activities and techniques from neurodevelopmental, acquisitive, sensory integration,
biomechanical, and psychosocial practice models within the child's natural
environment. Compensatory strategies must also be employed to provide the child
with successful and efficient means for functional written communication.

STUDY QUESTIONS

1. If a 5-year-old girl can't write her own name, is she ready for kindergarten, in
which the class will learn letters throughout the academic year? Give the
reason for your decision.
2. Why is it important for an occupational therapist to assess a child's
 manipulation or visual skills as the first step of an occupational therapy
assessment focused on writing performance?
3. Identify the practice models used and the reason for their selection when the
child engages in the following writing intervention activities:
a. Jade is building small figures. He is pressing the play dough on the table,
removing pieces of putty from his fingers, and making small balls with one
hand.
b. She is riding a crossbar while painting letters from the daily lesson with an
attached paintbrush during a tic-tac-toe letter game with Jesse.
4. Jamar is having difficulty placing italicized letters on the line, leaving spaces
between words, and using margins properly. What performance skills seem to
interfere with writing? What modifications and intervention techniques can be
considered?
5. What would be the advantages of implementing a writing intervention program
for the child within the classroom in a small group setting rather than in
individual therapy?

APPENDIX 17-A WRITING INSTRUMENTS

CHILDREN'S WRITING ASSESSMENT SCALE FOR HANDWRITTEN WRITING
(CHES-M)
Descriptions: This norm-referenced test examines the range and quality of children's
writing on a nearby dot copying task. Children's writing in grades 1 and 2 is examined
qualitatively for letter shape, spacing, rhythm, and overall appearance.
Authors: Joanne Phelps and Lynn Stempel (1987)
Publication: CHES
Information: 6031 St. Andrews Dallas, Tx 75205

CHILDREN'S WRITING ASSESSMENT SCALE (CHES-C) Descriptions: Reference

tool that assesses the cursive writing of children in grades three through eight. The
tasks consist of copying nearby points from short paragraphs. The presentation is
similar to the CHES-M
Authors: Joanne Phelps, Gail Speck and Lynn Stempel (1984)
Publication: CHES
Information: 6031 St. Andrews Dallas, Tx 75205

DENVER WRITING ANALYSIS

Description: Criterion-referenced tool that assesses third grade students' cursive
writing. Each of the following tasks is limited by grade: copying nearby points, writing
the alphabet from memory, copying far points, handwriting-crop transition, dictation.
Author: Peggy L. Anderson (1983)
Publication: Academic Therapy Publications
Information: 20 commercial Boulevard Novato, CA 97947-6191

ASSESSMENT TOOL FOR CHILDREN'S WRITING (ETCH)

Description: Criterion-referenced test that measures the legibility and speed of a first-
grade child's writing. Domains (handwriting and cursive) include writing the alphabet
of letters in the upper and lower frame, writing numbers, copying near and far points,
handwriting transition to cursive, dictation, and sentence composition.
Author: Susan J. Amundson, M.S.; TO (1995)
Publication: OT Kids, Inc.
Information: PO Box 1118 Homer, AK 99603

MINNESOTA WRITING TEST (MHT)

Description: Norm-referenced test that measures the quality and speed of
handwriting from a near-dot copying task. The models are in Zaner-Bloser or
D'Nealian for children in first and second grades.
Author: Judith Reisman, PhD, TO (1999)
Publication: Therapy Skills Builders
Information: Psychological Corporation
195000 Bulverde Road
San Antonio, TX 79259
(800) 872-1726

WRITING SKILLS TEST

Description: Standards-referenced test that examines handwriting and cursive writing
through dictation, copying nearby dots, and writing the alphabet from memory.
Normative data are given for children from 5 to 11 years old.
Author: Morrison F. Gardner (1998)
Publication. Psychological end Educational Publications, Inc.
Information: PO Box 520 Hydesville, CA 95547-0520

APPENDIX 17-B WRITING CURRICULUMS IN SCHOOLS

D'NEALIAN WRITING PROGRAM
Objective: handwritten, cursive
Author: Scott Foresman Co.

Salesman Addison Wesley Longsman

Division by Scott Foresman Adisson Wesley
1 Jacob Way
Reading, MA 01867
(800) 554-4411

ITALIC WRITING SERIES

Objective: handwritten, connected script
Author: B. Getty and I. Dubai
Seller: Postland State University
Continuing Education Press
PO Box 1394
Portland, OR 97207-1394
8800) 547-8887, ext. 4891
PALMER'S WRITING METHOD
Objective: Cursive, handwritten
Author: McGraw Hill
Seller: McGraw Hill
220 E. Danieldale Road
DeSoto, TX 75115
(800) 442-9685

ZANER-BLOSER WRITING
Objective: handwritten, cursive
Author: Zaner-Bloser
Seller: Zaner-Bloser
PO Box 16764
Columbus, OH 43216-6764
(800) 421-3018

APPENDIX 17-C WRITING INTERVENTION PROGRAMS

CALLIROBICS
Description: A program that links pencil and paper exercises to children's songs in
preparation for handwriting and cursive writing. Audio tapes of the program
accompany the student workbook and can be implemented individually or in groups.
Author: Liori Laufer
Seller: Therapo, Inc
225 Arlington Street
Framingham, MA 01702
(800) 257-5376 or 508-872-9494

BIG CHALLENGES FOR LITTLE ONES

Description: A developmental training program designed for children who recognize
most letters but have difficulty forming them. The target group is children from 5 to 9
years old, for handwritten, legible and spontaneous writing.
Author: B. Levine Rubell
Sold by: Therapy Skill Builders
PO Box 839954
San Antonio, TX 78283
(800) 211-8378

WRITE WITHOUT TEARS

Description: A series of manuals including general writing remediation in Writing
Without Tears, handwriting instruction in The Power of Writing and My Writing Book,
and cursive writing in Cursive Writing. Verbal and visual cues accompany the
lessons, and the writing of words and sentences is promoted throughout each
program.
Author: Janet Z. Olsen, O.T.
Seller: Handwriting without tears
8802 Quiet Stream Court
Potomac, MD 90854
(301) 983-8409

TIES AND OTHER GROUPS: A KINAESTHETIC WRITING SYSTEM Description:

This system was developed to enable second grade children to learn cursive letter
formations in 6 weeks. Students learn 4 letter patterns. Children visualize and
verbalize the movement patterns while experiencing the "feel" of the letter.
Author: Mary Benbow, MS, TO
Sold by: Therapy Skill Builders
PO Box 839954
San Antonio, TX 78283
(800) 211-8378

TRICKS FOR WRITTEN COMMUNICATION: TECHNIQUES FOR

REBUILD AND IMPROVE CHILDREN'S SCHOOL SKILLS Description: This
resource manual provides more than 400 remedial and compensatory strategies to
improve text production in the classroom. The center is students who experience
mechanical and organizational difficulties during writing.
Author: Susan Amundson, MS, TO
Seller: OT Kids, Inc.
PO Box 1118
Homer, AK 99603
(907) 235-0688

APPENDIX 17-D INTERNET RESOURCES: PREWRITING AND

WRITING
www.hwtears.com (Writing Without Tears products)
www.alaska.net/otkids (publications and information)
www.callirobics.com (callirobics prewriting program)
www.firststrokeshandwriting.com (program, methods, and ways of working)
www.handwritinghelpforkids.com (information and materials)
www.handwritinginterestgroup.org.uk (international group for the promotion of
children's writing)
www.idoonline.org (section on writing for children with learning disabilities)
www.peterson-handwriting.com (practical strategies and methods)