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Chapter 15PRINCIPLES AND PRACTICES OFTEACHING HANDWRITING

Mary Benbow

CHAPTER OUTLINE

DEVELOPMENTAL EXPERIENCES THAT UNDERLIESKILLED USE OF THE HANDS

Upper Extremity Support

Wrist and Hand Development

Visual Control

Bilateral Integration

Spatial Analysis

Kinesthesia

Summary

HANDWRITING TRAINING: PENCIL GRIP

Tripod Grip and Alternative Grips

Remediation of Pencil Grip

KINESTHETIC APPROACH TO TEACHINGHANDWRITING

Cursive or Manuscript Writing

Motor Patterns in Cursive Writing

Why Teach Writing Kinesthetically?

Kinesthetic Teaching Method

Kinesthetic Remediation Techniques

SUMMARY

The use of tools was a major breakthrough in humanhistory, extending our ability to control our envi-ronment. The first tools were natural objects—sticks,stones, and bones—requiring gross motor skills such aspushing, striking, and throwing. It took thousands ofyears for humans to develop a tool as precise as a pen

or pencil, requiring intricate fine motor skills. Becausethe simplicity of a pencil often is taken for granted, it iseasy to overlook the complexity of its operation. In theopinion of this author, a pencil is more difficult to usethan the most powerful computer from a motor skillsperspective.

It is no wonder that children, their parents, and theirteachers are often frustrated with the results of earlyexperimentation with this advanced tool before the finemotor muscles are ready to function. Boys, whose finemotor development is typically behind that of girls(McGuinness, 1979), have greater difficulty managingwriting tools and tend to prefer simpler motor tools,such as computer keyboards, Nintendo games, and TVremote controls. Girls face a different problem. Manyof them begin to “write” as early as age 21/2, often with-out proper adult attention or supervision. Lacking suf-ficient hand development or guidance, they may adoptpencil grips that are inefficient or even harmful as theypursue their fascination with the letter shapes Big Birdshows them daily.

The overall management of handwriting training can be conceived as a kind of triage, in which somechildren (group A) learn to write well regardless of the method(s) of teaching. At the other extreme a few(group C) are unable to learn the skill no matter whatinterventions are employed to alleviate their difficulties.Most children (group B) fall between the two extremesand readily benefit from efficient teaching strategies.Therefore group B should receive the greatest concen-tration of effort from teachers, occupational therapists,and other professionals. It is simple to distinguishbetween groups A and B, but much more difficult toseparate group B from C. For this reason it seemedappropriate to develop teaching and treatment strate-gies around the combined needs of groups B and C.Appropriate compensatory or intervention strategies

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320 Part III • Therapeutic Intervention

should enable most of these children to gain functionalwriting skill.

In the current educational environment of “NoChild Left Behind,” school departments require thatchildren with widely different developmental levels be taught together in integrated classrooms; thereforehandwriting instruction demands better investigationand more attention. Professionals must concentrate on related-skills necessary to ensure more consistentsuccess with this high-level skill. They must teach allschool children more efficiently, thoroughly, andpermanently.

All students, especially the great variety of childrenwho are subtly delayed, can benefit from develop-mentally ordered physical, visual, kinesthetic, and finemotor experiences. A clearer understanding of the con-stellation of skills that enable one to write efficientlymust guide professionals in developing more systematicways to prepare children for handwriting, as well as to teach handwriting. Occupational therapists are fre-quently called on for motor evaluations, consultation,and remediation for public school children. Nonfunc-tional handwriting is the most common reason forreferral. For an evaluation to be useful for effectivecurriculum implementation or intervention, profes-sionals must understand the chain of motor skills thatenable a student to write comfortably, automatically,and accurately.

The purpose of this chapter is to describe hand skillsthat make children more adept at operating a pencil.This chapter presents not only the optimal skills for theway the hand should work to produce efficient hand-writing, but also the problems that arise when motorcomponents for the skill are absent or less dexterousmotor patterns are used. Techniques to promote thedevelopment of the foundation skills are presented,along with remediation or compensation techniques for related problems that arise. The final section on theteaching and remediation of handwriting presents the rationale and method for the kinesthetically basedinstruction of cursive writing. It should be noted thatthis chapter does not address language components suchas word finding, sentence formulation, punctuation,and spelling, but is limited to the mechanical aspects ofwriting and cognitive-associative mental processes.

Handwriting instruction in American schools typi-cally begins with manuscript writing (printing) andshifts to cursive writing in the third grade. The author’sexperience has been that the development of functionalhandwriting can be fostered by an earlier introductionto cursive script. Therefore the discussions of prewrit-ing and writing skills emphasize cursive writing. Thecursive versus manuscript writing issue is discussedmore fully in a later section of this chapter.

DEVELOPMENTAL EXPERIENCESTHAT UNDERLIE SKILLED USE OFTHE HANDS

Since 1992 as fear about sudden infant death syndrome(SIDS) became widespread, the “Back to SleepCampaign” was implemented to lower the risk of SIDS(SIDS Task Force). Many anxious parents misinter-preted this warning to mean their baby should never beprone, even during daytime play periods.

While supine or semireclined in a variety of plastic“exoskeletons” infant seats, the baby can barely raisehis or her head, much less bear weight on the upperextremities and elongate and strengthen the cervicalspine. “Tummy Time” in prone posture facilitates headlifting and neck strengthening, trunk stability, andbalance while weight bearing on the upper extremities.Therefore lack of prone positioning during the baby’splay periods lengthens the time it takes to master suchbasic skills as lifting and holding the head, pivoting,turning over, and sitting and crawling. Lack of weightbearing on the hands may affect hand structures; under-developed arch formation and stabilization, incompleteexpansion of the thumb-index web space for fullopposition, and skilled manipulation of tools. Skilleduse of tools (e.g., silverware, scissors, pencils) often lagsbecause of lack of full range of motion at the carpo-metacarpal (CMC) joint of the thumb.

To be effective in promoting efficient graphic skills,developmental therapists must address these unresolvedergonomic factors (i.e., postural, tonal, stabilizing) inaddition to fine motor intervention. Graphomotor pro-duction difficulties usually cluster under one or more ofthe following classifications: (a) incomplete range ofmotion and use of the proximal joints of the upperextremity, (b) immature wrist and hand developmentwith clumsy distal manipulation skills, (c) insufficientexperience in eye-hand control, (d) incomplete bilateralintegration, (e) inadequate spatial analysis or synthesisskills, and (f) reduced somatosensory input with failureto develop kinesthesia.

UPPER EXTREMITY SUPPORT

The interaction of all joints of the upper extremity—scapulothoracic, glenohumeral, elbow, and wrist—isrequired for the development of dexterous hand skills.Each component must be developed and move freelyinto its mature patterns. In children experiencing fine motor delays it is not uncommon to find theshoulder joint slightly biased toward internal rotation,adduction, or flexion; the elbow joint toward flexion or

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pronation; and the wrist toward flexion and ulnardeviation.

In addition to fluid range of motion, each upperextremity joint must provide a stable base of supportfor the control of the joint(s) distal to it. When atherapist finds functional limitations in proximal joints,he or she should include weight bearing, traction, andcompression activities for scapula, shoulder, and elbowjoint control. Specific proximal joint needs are mostnaturally incorporated into therapeutic or adaptedphysical education goals.

For example, jumping rope backward requires thesimultaneous involvement of all upper extremity jointsmoving into their mature patterns. Because this activityfully incorporates all upper extremity joints, it shouldbe included in developmental hand therapy programsfor children who show dysfunction or inefficiency inproximal joints. A younger or less coordinated childshould first learn to turn one end of a long rope with apartner using the dominant hand while a third childjumps. The initial goal is to develop external rotation in the shoulder on the dominant hand side followed by full range of motion in the opposite shoulder. Thethird step is for the child to swing a jump rope back-ward over his or her head and step behind it when heor she hears the rope strike the floor. Finally, the upperand lower body should be coordinated in reverse ropejumping.

The case of Zachary demonstrates the value of anintegrated upper extremity program for hand skilldevelopment. This 6-year-old boy was referred to occu-pational therapy for difficulties with printing and sloppypaperwork. Initially a program of hand activities wasprescribed that specifically addressed the referralrequest. Zachary faithfully practiced his prescribed pro-gram. He made little progress because the handactivities felt so unnatural and were so difficult. Clientresistance became a new and serious deterrent. Afterassessing his upper extremities more thoroughly, thetherapist found some limitation of motion in externalrotation of the shoulders and incomplete supination at the elbows. After a progressive program for upperextremity range and stability, his hand skills followednaturally and resistance to fine motor activities less-ened. Zachary’s case is fairly typical. The often over-looked component of proximal development proved tobe the key in unlocking distal skills.

WRIST AND HAND DEVELOPMENT

In addition to a developmentally based gross motorprogram, early education curricula should stress devel-oping the entire upper extremity with particular empha-sis on the hands. The goals are listed in Box 15-1. The

hand functions in Box 15-1 are fundamental for allhigher-level tool skills.

Stabilize the WristBunnell (1970) states that the wrist is the key joint ofthe hand. Wrist limitations cannot be compensated for by any other upper extremity joint. Because wristmovements are inseparable from the hand as a singlephysiologic unit, therapists should combine wrist andhand activities. The position of the wrist influences thetension of the extrinsic muscles. The origins of theextrinsic muscles of the hand are in the forearm andgenerally move the digits in gross flexion or extensionpatterns. Extrinsic tendon length does not allow simul-taneous maximal flexion or extension of the wrist andfingers, so interplay is seen with wrist and fingermovements.

Long and co-workers (1970), using electromyog-raphy found that intrinsic muscles (whose origins are inthe wrist and/or hand) guide and grade the multipleintermediate finger and thumb patterns and control allrotary movements of the thumb and metacarpopha-langeal (MP) finger joints used in precision handling.Tubiana (1981) pointed out that no single articulationin the hand is an isolated mechanical entity. Instead,each articulation functions as part of a group arrangedin kinetic chains. Each articulation depends on theequilibrium of forces acting at its level, and this equilib-rium is subject to the position of the immediate prox-imal articulation. Mobile balance is realized throughthe interdependence among the elements along itsosteoarticular chain. That interdependence includesboth passive and active components. The active com-ponent is the dynamic balance between antagonisticmuscles. The main passive component is the restrainingaction of ligaments and muscular viscoelasticity thatfacilitates coordination of motion (Smith, 1974).Therefore the wrist influences the position of the MPjoint, and the MP joint influences the position of theproximal interphalangeal (PIP) joint, which in turn

Principles and Practices of Teaching Handwriting • 321

BOX 15-1 Early Education Curricula Goalsfor Developing Upper Extremityand Hands

1. To stabilize the wrist with fine manipulation of smalltools, objects, and writing implements

2. To open and stabilize the thumb-index web space3. To increase and stabilize the arches of the hands4. To separate the motor functions of the two sides of

the hand5. To develop two aspects of precision handling,

precision translation and precision rotation

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influences the distal interphalangeal (DIP) joint. Theseanatomic principles provide ways to analyze, design,and sequence hand activities that are more effective indeveloping the constellations of motor patterns for finemotor skills. A tool is an extension of the hand that usesit. Developmental logic dictates that a hand must beskilled before it can skillfully manipulate a tool as anextension of the hand.

Activities that facilitate wrist stabilization in exten-sion with precision finger skills can best be done onvertical surfaces above eye level. Such positioning auto-matically places the wrist into its optimal posture andfacilitates abduction of the thumb to work distally withthe fingertips. Working above eye level requires holdingthe arms at a level at which their weight strengthens themuscles and stabilizes the joints of the scapula andshoulder. Enjoyable proximal joint activities includepainting on chalkboards with brushes dipped in wateror more colorful tempera painting on paper at an easel.Many commercially available toys can be verticallypositioned to develop wrist stabilization with distalfinger skill. Magna Doodle, Etch-A-Sketch, pegboards,and eye-hook boards can all be fastened onto a wall, setin a chalk rail or on an easel ledge, and secured with anelastic cord if necessary. The important part of eachactivity is that it is performed above eye level.

Open and Stabilize the Thumb-Index Web SpaceMuscle tightness on the flexor side of the wrist limitsrange of motion into extension and reduces stabi-lization of the wrist for distal digital manipulation. TheCMC joint located at the base of the thumb columnshould fully rotate so the thumb pulp can be pronatedand positioned diametrically opposite each of the fourfinger pulps. Incomplete abduction and rotation at this mobile thumb joint result in a posture that cannotbe well stabilized for distal manipulation (Kapandji,1982). A fully expanded web space between the thumband index finger allows dexterous digital manipulationleading to economy, variety, and convenience of move-ment because it requires minimum involvement of the upper extremity joints when moving a prehendedobject. Feedback from the intrinsic muscles regulatesgrip pressure on the shaft of the tool and providesongoing kinesthetic feedback to the nervous system forrapid automatic correction of motor programs. Whenthe hand is in a power grip with the fingers flexed, thereis a reduction in the firing of lumbricals, so the handloses much of its joint-balancing potential andproprioceptive guidance (Long et al., 1970).

Increase and Stabilize the Arches of the HandThe hand’s great adaptability depends on its fixed andmobile units. Fixed elements include the distal row ofcarpal bones and the central attached metacarpals todigits II and III. The small degree of movement at

the fixed junctures allows stability without rigidity(Tubiana, 1981). The mobile elements include the fivedigits and the peripheral metacarpals of the thumb and little finger. The mobile units of the thenar andhypothenar eminences cup or arch the hand, providingbalanced isolated intrinsic activity within the hand.

Manipulating Chinese balls within the palm of thehand is a rapid way to develop all three arches. Theballs should fit well within the cupped hand so that the thumb can rotate them around within the hand.Instruct the child to rotate the balls by moving thethumb into the center of the palm (Fig. 15-1).

Activity sheets with circles to fill or shapes to circleor outline before coloring can be designed for this pur-pose. Activities can be graded by decreasing the size ofshapes as refinement of skill progresses distally. Whensheets or coloring book pages are secured in a verticalorientation (fitted onto a vertically mounted clipboardor taped up on a wall or easel), the oblique arch ofopposition can more easily manipulate the pencil ormarker. The most refined use of finger control withcrayons or markers is in outlining the shapes beforecoloring them. The diamond coloring sheet shown inFigure 15-2 requires dynamic finger skill to outlinefollowed by static finger skill to color in the shapes.

Primary school children are self-motivated to drawand practice numbers and letters on the chalkboardwhen their efforts on this surface yield satisfying results.For one nursery school child, working on a verticalsurface magically transformed his clumsy attempts tocolor at the table into performances that delighted himand his teacher. It may be worth noting that the firstproducts of human use of an advanced tool, in the cavepaintings at Lascaux, France, are on a vertical surface at or above eye level, as are many of the petroglyphsmade by Native Americans on the canyon walls of thesouthwestern United States. Without knowing why,these primitive tool users maximized shoulder stability,


Figure 15-1 Chinese balls to develop arches in thehand. (Available from OT Ideas, Inc., copyright Mary Benbow)

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wrist and thumb postures, and visual and hand dexter-ity for their expressive needs. Today skilled artists rarelydraw or paint on a horizontal surface.

Separate the Motor Functions of the Two Sides of the HandCapener (1956) noted the coupling action of the twoulnar digits (IV and V), which function together inpower grips and precision handling. In precision han-dling, when the ulnar digits are flexed against the palm,they provide stability to the MP arch while isolatingcontrol of the radial digits for manipulation with thethumb. Separation of the ulnar from the radial side ofthe hand counterbalances the MP arch for higher-levelskills. Holding a heavier item, such as a teacup isachieved by abduction and extension of digits IV andV. The radial digits (II and III) can be isolated andstabilized from the arched posture to perform theirfunction more securely with the opposed thumb.

The proper handling of scissors requires the sepa-ration of the motor functions of the two sides of thehand. The ulnar digits should be flexed and stabilizedagainst the palm. With the wrist stabilized in extension,the child should place the distal joints of the thumb and middle finger into the loops (oval loops stabilizeeasier). The loops should be small enough to enable thechild to stabilize the handles at the DIP joints of thelong finger and the IP joint of the thumb. The indexfinger should be placed against the shaft of the handleto support the scissors in a vertical position and help toclose the blades. The ulnar digits (IV and V) should beflexed and pressed against the palm to add stability tothe MP arch. If it is frustrating or difficult to rememberto flex and stabilize digits IV and V, then have the childpress a small flat sponge against the palm with the twoulnar digits, as shown in Figure 15-3. This motoricseparation of the functions of the two sides of the hand

isolates control in the two radial digits to work incombination with the thumb. Initially a child shouldpractice simply opening and closing the blades. Afterintended blade movements become rhythmic, intro-duce tiny straws (which take almost no control fromthe nondominant hand) to be cut into tiny segments.Advance to oak tag or old playing cards, and finally topaper, which requires the most skill. The nondominanthand must hold the paper taut enough for cuttingwithout tearing.

Develop Two Aspects of Precision Handling:Precision Rotation and Precision TranslationPrecision handling requires full range of motion at theCMC joint of the thumb so its pulp can be flexed andplaced diametrically opposite each of the finger pulps.From this stable position the multiple variations of thetwo precision handling skills, precision translation andprecision rotation, should be developed and refined.Translation movements require that the thumb andindex or the thumb, index, and middle fingers move in synchrony in a toward-the-palm or away-from-the-palm pattern (Long et al., 1970). Needle threadinguses a translation-away pattern from the fully flexedtranslation-toward the palm. Pulling a thread througha needle is an example of translation toward the palm-finger pattern.* Writing in a cursive hand requires rapidalternation of toward and away translation patterns toproduce letter strokes.

Shifting a stiff piece of oak tag through the eye of a yarn needle with the wrists stabilized against eachother is an effective way for an older child to practice,speed up, and observe translation movements with theskilled digits. Marks can be placed on the strip toindicate increased length of movement as skill improves(Fig. 15-4).


Figure 15-2 Diamond coloring sheet. (Copyright MaryBenbow.)

Figure 15-3 Small hand scissors designed by authorshown with small sponge gripped by the ulnar digits.(Available from OT Ideas, Inc., copyright Mary Benbow.)

*The term precision translation is used by Long and co-workers(1970) to describe the movement of an object toward and away fromthe palm while the grip on the object is maintained. The term hasalso been used to describe the shifting of a small object such as a pieceof lint from the fingertips into the palm.

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Bead stringing is the classic preschool activity fordeveloping speed and dexterity in the alternating use oftranslation patterns. However, children who most needto develop this skill often adopt an efficient substitutesystem. They place the bead over the lacing tip ratherthan inserting the tip through the bead. Eye-hooklacing boards prevent this skill substitution and providea more motivating activity for young children (Fig. 15-5). Because children tend to be self-driven to staywith this lacing board activity, it is effective and efficient

in developing translation-toward and translation-awayfinger skills.

Precision rotation skill is used when strength demandis low, in activities such as opening and closing loos-ened tube caps or jar lids, turning knobs, and turningover small objects for inspection. When a child substi-tutes less efficient forearm rotation for digital rotation,an evaluation for range of motion and stabilization ofthe thumb is indicated.

The child must have functional range of motion atthe CMC joint to position the thumb diametricallyopposite the third digit. Snapping the fingers is a simplethumb-finger test for evaluation of range of motion atthe CMC joint. When there is incomplete separationbetween the thumb and index metacarpals, physicallyexpanding the web space by joint mobilization andprogressive stretching may be indicated. Expansion ofthe joint-supporting structures often can bring thethumb CMC joint into a position in which it can bestabilized for distal manipulation with the index orindex and middle fingers.

A simple activity to promote precision rotation isrolling tiny balls (1/8-inch diameter) of clay or therapyputty between the pulps of the thumb and index finger.Another is playing tug-of-war with a small-diameterobject such as a coffee stirrer or plastic lace. Digitalrotation at the MP joints is necessary to shape the gripsnugly enough so the extrinsic muscles can effectivelyprovide strength for distal power pinch. Pinching acoffee stirrer or plastic lace between the index andthumb pulps enhances position contact of the fingerpulps for strength.

An engrossing group activity is turning over a row of 25 pennies from heads to tails in a race againstclassmates or a stopwatch. A tiny moving picture typeflip-book or small deck of cards requires full CMCexpansion in the hand of a primary school child.Adequate range and stability at the CMC joint arenecessary for both card shuffling and distal dynamicpencil control. With middle school or high school–aged students, shuffling a standard size deck of cards isa challenging activity that promotes range of motionand stability at the thumb CMC joint. Tactile sensitivityof the thumb pulps needs to be refined to manage theintermixing of the cards from the two hands.

VISUAL CONTROL

Manuscript and cursive writing use vision differently inthe guidance of the pencil. In manuscript writing thehand’s output depends almost entirely upon the inputand ongoing guidance of the visual system. In cursivewriting the visual system should play a less significantrole. For this reason many children with visual motorproblems should be advanced to cursive instruction as


Figure 15-4 Needle threading or translation movementactivity. Work to increase distance and speed with theskilled digits. (Copyright Mary Benbow.)

Figure 15-5 Threading board designed by author.(Available from OT Ideas, Inc., copyright Mary Benbow.)

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soon as written work is required. The reduced demandfor visual motor integration yields more satisfactoryresults. When using kinesthetic teaching strategies forcursive training, visual control becomes secondary toproprioceptive guidance during the first lesson. Anaccomplished hand writer limits visual control to stay-ing on the writing line, guiding retrace lines, properlyspacing between words, and serving as a neatnesschecker of written work.

Most American schoolchildren learn to print theirnames before entering kindergarten. A few childrenmaster the whole alphabet. Imitating family members,early education teachers, or educational television shows,they rely heavily on visual control in drawing theirblock letters. Close visual monitoring of the pencilpoint is necessary for them to control stroke length and angle, find the intersecting or joining points, andinhibit pencil movement at the intended stoppingplace.

In any mainstreamed primary classroom one canobserve many accommodations to insufficient eye-handskills. A child who has difficulty focusing when eyealignment or extraocular control is deficient often adaptsby turning the head far to one side to isolate use of oneeye while diverting the other eye from the paper. Thechild has unconsciously discovered that this head posi-tion eliminates the second image. A child who has greatdifficulty lowering and converging the eyes continuesto draw circles, write numbers and letters from bottomto top, and fails to adopt the cultural pattern of top tobottom stroking of letters and numbers.

In the early grades figure copying tests such as the Developmental Test of Visual Motor Integration(Beery, 1997) are used to determine a child’s visualmotor integration age level. Beery cites multiple devel-opmental researchers who have explored the under-lying visual motor skills that determine a child’s potentialfor mastering manuscript formations. Beery states thatit is prudent to postpone formal pencil and paperwriting until at least such time as a child can easily copythe VMI Oblique Cross. The oblique cross requires thechild to cross the midline of the form using diagonalvisual guidance. This high-level perceptual motor skillis necessary to produce 10 of the manuscript letters.

An observation tool, the Observation of VisualMotor Orientation and Efficiency (Benbow, Hanft, &Marsh, 1992) can be a practical supplement to observevisual control of the hand as the eyes guide the pencilin upward and downward directions. To observe visualmotor efficiency in these two orientations, the instruc-tor should prepare an unlined sheet of paper (81/2 × 11inches) with two lines 1/8-inch wide and 11 inches long.Lines should be drawn with a yellow highlighter andspaced about 2 inches apart. The child is directed todraw a continuous controlled line with his or her pencil

along the middle of the yellow line. With the paperpositioned on the desk top so that the lines run fromtop to bottom (slanted for better viewing), the child is instructed to draw the first line from top to bottomand the second line from bottom to top (Fig. 15-6).Accuracy of control is noted as the child visually guidesthe hand into upward and downward space. It isinsightful to ask which direction was easier for him orher to complete.

If the child appears stressed while doing the pre-ceding task on a desk top, a second sheet can be tapedon the wall or chalkboard in the vertical plane with themiddle of the sheet of paper positioned at eye level asthe child stands to work. This placement requires thechild to elevate and lower the eyes along the two lines.If he or she does poorly on trial 1 (desk top) and betteron trial 2 (wall or chalkboard), it will be advantageousfor the child to stand while practicing numbers andletters on the chalkboard or at an easel. The child’sability to control a pencil in these two directions is aclear demonstration of the visual system’s guidance ofthe hand for graphic skill training. Tracking comfortand skill often clarifies the reason some children areunable to conform to writing numbers and letters fromtop to bottom.

Mature handwriting requires input from both fovealand ambient vision. Inadequate integration of the twovisual systems is seen when the letters are fairly wellformed but the writing is irregular in size and spacingand positioned poorly in relation to the writing line.


Top to bottom Bottom to top

Nam

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rs 1

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Figure 15-6 Form used to observe visual control ofpencil. (Copyright Mary Benbow.)

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This is seen in manuscript within words, as well asbetween words. Spacing problems in cursive are usuallylimited to spaces between words. The ambient systemis faulty in providing the spatial component as the handproduces proper formations.

When poor efficiency in visual-motor orientation isnoted in the classroom, a child should be further eval-uated by a physical educator because ball and gameskills are often impaired as well. Remediation for visualscanning problems is not to be found in paper andpencil activities but in vestibular-based visually demand-ing gross motor activities. If the child has difficultytracking upward, include activities that require upwardgaze such as tossing a ball straight up and catching it atchest level, gently tapping a ball suspended above eyelevel, racket games, volleyball, and flying kites or air-planes. Alternatively, if the child has difficulty trackingdownward, bouncing a ball and catching it at waistlevel is advised. A line or pattern drawn on the floor orsidewalk can make bouncing on a Hippity-Hop ball orriding a scooter board or bicycle more interesting andorganizing. Activities demanding rapid movement andvisual guidance help integrate visual tracking with bodyskills.

In cursive writing, problems in tracking downwardresult in poorer control of the loops that descend belowthe writing line (f, g, j, p, q, y, and z). Alternatively,when children are stressed by elevating their eyes, theymay have more trouble controlling the upward movingascender strokes of tall letters (h, k, b, f, l, and t).

Suspect a near-point focusing insufficiency when achild can produce a single stroke but is inaccurate inretracing line segments. A therapist can detect a focus-ing problem most easily on the retraced segments of a, d, m, and t. When these visual motor errors are seen consistently, a referral for a visual examination isindicated.

BILATERAL INTEGRATION

Bilateral integration and sequencing (BIS) dysfunctionis a common cause of motor delays or deficits (Ayres,1991). In addition to well-documented gross motordeficits (e.g., postural, equilibrium, and body side coor-dination), a child with BIS dysfunction is slow toestablish a good division of labor between the twohands. By the time most peers are performing well inthe graphic motor area, the child is still using the handsinterchangeably to do far less sophisticated activities.On paper and pencil tasks the child usually experiencesan interruption in crossing the visual midline and pro-duces reversals long after other classmates have resolvedthis issue. The child is unable to change stroke direc-tion in a continuous flow pattern. This is evidenced asan inability to shift the right under-curving lead-in

stroke to the left when approaching the line top whilewriting letters k, b, f, and l. Functional graphic motoroutput remains far beyond the child’s reach. Unfor-tunately, additional paper and pencil practice does notsolve these developmental issues.

A child who is not bilaterally integrated neglectsstabilizing the paper with the nondominant hand whenwriting or coloring. Until the dominant hand assumesa definite leadership role, the nondominant hand doesnot sense and perform its assisting role. Instead ofcooperation between the two body sides, there is resid-ual competition. Synkinesis (motor overflow) usually isobservable, which supports the finding of inadequatecentral nervous system inhibition of the nondominanthand as the dominant hand is being programmed bythe brain. When an older student must produce alengthy written assignment, it is visually helpful to drawa pair of bold black margin lines about 1 inch from theleft side of the paper. The high-contrast lines alert hisor her peripheral vision and cue the child to stabilizethe paper with the nondominant hand while main-taining left margin alignment. The nondominant handpositioned on the edge of the paper helps to visuallydefine the writing area and promotes more balancedsitting posture.

Directionality confusion is suspected when a childcontinues to write wraparound letters after instructionsare given to stop at a specific point and retrace a lettersegment. When this wraparound pattern, as seen in theletters a, d, g, q, and c, is the only immature patternnoted, one can logically assume that the motor behav-ior was generalized from self-taught incorrect forma-tion of manuscript letters at an earlier stage. A typicalexample is seen in Figure 15-7.

When a child with incomplete bilateral integrationdraws horizontal or diagonal lines, a hesitation or jerkis often seen along the pencil line in which the child’seyes crossed their midline while guiding the pencil.This interruption is even more visible and disorgan-izing when the child draws diagonal lines. Typically thechild produces near-vertical lines for diagonals without


Figure 15-7 Example of the incorrect formation of thewraparound letters a and g. (From Loops and other groups:A kinesthetic writing system. Copyright 1990 by HarcourtAssessment, Inc. Reproduced with permission. All rightsreserved.)

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being aware of it. The child’s cursive writing appears tobe near vertical as well. Vertical letters are more slowlyproduced because the wrist has to be repositioned toefficiently make the long diagonal down strokes.

A later sign of a problem with bilateral integration isthe writing of mirror-image letters or numerals. Theseoutput errors are more commonly seen when a symbolis produced in isolation. An evaluation of 900 middleschool writing samples revealed that the most typicalresidual reversals of letters in cursive writing werelimited to three left-moving capital letters: 3 for E, f forcapital J, and horizontally expanded reversed lower caseb for capital I (Fig. 15-8).

Averting the gaze is an effective accommodation towriting letters that reverse directions abruptly acrossthe visual midline. In writing capitals D, G, and S, thechild should be taught the place to halt the pencilprogression and shift visual focus. The focal place isusually where the stroke ends, as seen with directionsfor capital D in Figure 15-9. The child must avoidvisually monitoring the pencil point where it recrossesthe visual midline to write these letters successfully.

An enigmatic problem associated with BIS dysfunc-tion is seen in a child’s inability to change stroke direc-tion in a continuous flow pattern. The child feels theneed to touch the top of the line and pause beforebeing able to shift line direction. When writing thelong ascenders of the loop letters (h, k, b, f, and l), it isnearly impossible for these children to shift the flow ofthe right ascending lead-in stroke to the left whileapproaching the top of the line (Fig. 15-10). In thesetall loop letters the change of direction is necessary toprepare for the immediate down stroke once the linetop is touched. Changing directions in a continuousflow pattern proves to be an intractable writing prob-lem. To develop this sense of direction flow, the childneeds to bodily understand the verbal directions asdemonstrated by the instructor. The shifting directionof the tall loop stroke is best taught through theshoulder while writing in the air. Stress the inhibition of the right ascending stroke where it shifts leftwardand up to the top of the line. Only when the child

can master air writing with the shift of direction shouldhe or she attempt it on paper. Consistent repetition is necessary for kinesthetic success. The difficulty ofchanging stroke direction in a continuous flow patternalso causes a problem in producing the alternatingswoop line used to top capital F and T.

SPATIAL ANALYSIS

Children with non–language learning disabilities(NLD), which include difficulties with math, non-phonetic spelling, and visualizing, usually lack strategiesto analyze geometric shapes, numbers, and letters.These children require detailed letter analysis help tolearn to write. Small incremental steps (including start-ing place, pencil progression, distance and speed atwhich to move the pencil, and stopping point) must beexamined and explained and re-examined and re-explained. Retraces, the point of intersection with lead-in strokes, and instructions for the release stroke or


for for for

Figure 15-8 Typical reversal of capital cursive letters. (Copyright Mary Benbow.)

s

∗

Figure 15-9 Special instructions given to childrenlearning to write a capital D. (From Loops and othergroups: A kinesthetic writing system. Copyright 1990 byHarcourt Assessment, Inc. Reproduced with permission. Allrights reserved.)

for

Figure 15-10 Illustration of the problem in changingdirection with a continuous flow pattern. (From Loops andother groups: A kinesthetic writing system. Copyright 1990 byHarcourt Assessment, Inc. Reproduced with permission. Allrights reserved.)

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connector unit require a great deal of emphasis andrepetition. The instructor should point out and stressthe similarities of letter forms within the letter groupsor they will be missed. Visual and verbal images thatgive letters their identity are necessary to aid memoryand cue the lead-in stroke.

Children acquire functional writing more easilywhen they are speed coached. All motor learningrequires that speed be matched to task difficulty andthe learner’s level of skill. A therapist can reduce learn-ing time and trial-and-error frustration by explainingwhere the child should move the pencil slowly andquickly (Benbow, 1990). To hasten developing thissensitivity for all students in the room, initial letterinstructions should include speed tips: The lead-instrokes flow more naturally when done quickly; retracesrequire some visual guidance, so slowing down isadvised; speed should be resumed for any single linesegment or release stroke that follows. These instruc-tions seem most logical and are usually understood andfollowed by most second graders. Speed coaching ishelpful for children who are struggling with any type ofgross or fine motor skill learning.

NLD children can learn cursive writing with theirpeers when the entire class is given detailed visual andspatial analysis and verbal directions for writing eachnew letter. The relatively good language skills of NLDstudents should be called upon to support this motorlearning. Subvocalizing the motor plan guides writinghand movements. This practice should be continueduntil the writing is faster than the verbalizing.

Writing instructors should be precise in their use ofthe word “line.” It is confusing to the student to usethe same word to describe top and bottom lines andthe space between lines. Instructing the student tomake a letter “half a line high” only adds to his or herconfusion. If instructors consistently refer to the topline, writing line, and dotted middle marker, they willnot confuse their students. The area between the linesshould always be called a space (or half space for lettersascending only to the middle marker). It is also helpfulto the child if the writing line is darker than the top lineor colored for initial learning and practice sessions.Using the designations writing line, top line, and mid-dle marker, the instructor can easily describe what spacethe letter should fill. For example, all lower case cursiveletters lead in from the writing line and ascend to themiddle marker or top line. Seven letters descend to themiddle marker below the writing line. Only four lettersoccupy more than a whole space: lower case f, andcapitals J, Y, and Z.

Negative shapes are created between lines and letterstrokes. If students are made aware of them, thesenegative shapes can aid in determining whether theletters are written correctly. For example, a triangle is

created on the writing line by the lead-in stroke and the lower rounded segment of the letters a and d (Fig.15-11). Contrasting it with the smaller triangle madeon the right side of these letters before the releasestroke proves to be an intriguing challenge to thenovice for quality control. Readily identifiable negativeshapes can help the child recognize letter accuracy andserve as a guide for self-correction. These visual cuescontrol for line contact as well. Producing the smalltriangle at the bases of i, u, w, and t (Fig. 15-12)prevents releasing the down stroke too soon for a goodconnection or release unit.

KINESTHESIA

Writing is a motor skill and, as with other motor skills,efficient writing depends on kinesthetic input. Motorskills developed kinesthetically, such as riding a bike,keyboarding, or handwriting, are most permanent. Inwriting, an internal sensitivity that a letter movementfeels correct reduces a child’s need to visually monitorthe fingers or pencil point while moving along the line.This security enhances speed in learning and confidencein cursive writing. Kinesthetic writing naturally accel-erates over time to functional speed without the reduc-tion of performance quality seen with visually guidedwriting. The visual system is far too slow and mechan-ical to monitor the serial chain of finger movementsnecessary for note taking much beyond mid thirdgrade. Advising a child to slow down (allowing time tovisually monitor the writing hand) temporarily results


Figure 15-11 Showing negative shapes createdbetween writing lines and letter strokes. (From Loops andother groups: A kinesthetic writing system. Copyright 1990 byHarcourt Assessment, Inc. Reproduced with permission. Allrights reserved.)

not

Figure 15-12 Knowing that the triangle should besmall prevents a premature release of the down stroke.(From Loops and other groups: A kinesthetic writing system.Copyright 1990 by Harcourt Assessment, Inc. Reproducedwith permission. All rights reserved.)

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in more legible paperwork. However, this remedy fails in middle school and beyond, when greater speedis necessary in lecture settings. Therefore kinesthetictraining is important whether or not a child has a visualmotor or spatial problem. This is an area of trainingthat should be explored and further developed by earlyeducators.

Kinesthetic skill development is most beneficial forchildren experiencing visual motor deficits. Kinesthesiais an effective compensation for eye-hand coordinationdifficulties and can be a powerful builder of motorconfidence. Kinesthetic training enables these childrento bypass their problem area and become efficientwriters by concentrating on kinesthetic feedback. Ifdiminished kinesthesia is not enhanced, a child con-tinues an over-reliance on visual monitoring, with asubsequent slowness in the production of writing.Kinesthetic activities are an essential aspect of bothprewriting and writing programs.

Kinesthetic skills usually intrigue young children.Elementary kinesthetic activities can be done on desktops, at the blackboard, or in the gymnasium. A samplefor each location is demonstrated in Box 15-2.

As noted, kinesthetic writing should use limitedvisual motor control. Shape-copying tests such as theTest of Visual Motor Integration are useful in predict-ing the child’s potential ease or difficulty in learningmanuscript. Copy forms and manuscript letters requireanalysis and synthesis of the forms to duplicate them

accurately. Skill in this area is less helpful in predictingthe ease a student will experience in learning cursivewriting.

A Production Consistency Sheet (Benbow et al.,1992) can be used to informally observe a child’skinesthetic aptitude in repeating and spacing cursiveletters in words using the kinesthetic sense. Modelshapes are displayed in the upper left-hand comer of ahalf sheet of unlined paper (51/2 × 81/2 inches). Eachmodel is 1/2 inch high. The models include a square, acircle, a triangle, and a cursive capital A.

Instruct the students to duplicate the printed modelusing a fluid moving stroke(s) rather than a rigidlycontrolled stroke(s). The four shapes should be drawnin three evenly spaced rows of five figures. On com-pletion of the fifteenth figure, the child is told to closethe eyes or avert the gaze and complete a fourth rowthat looks like and is spaced like the rows above. Thequality of the first three rows reveals the child’s visualmotor control of horizontal, vertical, diagonal, or cir-cular lines. The consistency of the fourth row is agraphic demonstration of the child’s kinesthetic learn-ing potential for both configuring and spacing. Thetwo examples selected in Figure 15-14 were drawn by10-year-old boys who were classmates in a third-gradeclassroom. Consistency in shape, size, and spacing is ahigh indicator of potential for learning cursive writing.In comparing these two samples, one can predict thatthe child who drew Figure 15-14 A will learn to write with less difficulty than the child who drew Figure15-14 B.


BOX 15-2 Sample Elementary KinestheticActivities

1. Desk Top: Place an object (e.g., coin or cube)anywhere on the desk surface within the arc of thechild’s reach. Withdraw the child’s hand to a restingposition and ask him or her to close the eyes andreach directly to the object. Grade the activity byhaving the child place the object with one hand andretrieve it with the other.

2. Blackboard: Sports that have a spatial component(e.g., baseball diamond, golf green) can be sketchedon the blackboard. After the child visually andmotorically senses the size and shape of the display,have him or her close the eyes, visualize the display,and draw with chalk a run from home plate for asingle, double, or home run (Fig. 15-13).

3. Gym: After gaining the feel of movement of pitchinglike objects into a container, have the child close hisor her eyes and use kinesthetic sense to continue theactivity. The child should not alter orientation ordistance and the objects should be identical inweight and size. The most challenging position forthis activity is seated on a one-legged stool.

2nd

1st3rd

HomePlate

Figure 15-13 Chalkboard baseball. (Copyright MaryBenbow.)

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SUMMARY

Children who benefit from ongoing diagnostic hand-writing training usually have identifiable problems inone or more foundation skills. The first is gross and fine motor readiness for cursive instruction. Output orproduction problems can include difficulties with rapidsequential movements (often noted in the child’s earlyhistory as articulation problems), visual control,bilateral integration, and spatial analysis and synthesis.Feedback difficulties include inadequacies in visual andkinesthetic reafferent systems.

Developmentally sequenced hand activities shouldbe a major fine motor focus in preschools and earlyelementary education. Early educators should developthe full potential of children’s hands for all skillsbecause the remediation of prewriting hand skillsgreatly facilitates the learning of graphic skills. Thefollowing sections turn to two specific aspects of hand-writing training, pencil grip and kinesthetic writing.

HANDWRITING TRAINING:PENCIL GRIP

Letter production skill can be influenced by the way the writer grips a writing tool. This section includes a

description of pencil grips, a discussion of the limitationimposed by maladaptive grips, and some remedialstrategies.

TRIPOD GRIP AND ALTERNATIVE GRIPS

Handwriting is the most frequently used, complex, andlateralized skill used in education, yet little attention is paid to how, when, or where pencil practice bestenhances the development of this skill. Adults shouldnot assume that children somehow know the best wayto hold a pencil or that they will acquire the abilitythrough incidental experience. Rosenbloom andHorton (1971) found that 89 of 92 British childrenhad developed a dynamic tripod pencil skill by 72months, and Saida and Miyashita (1979) found that151 of 154 Japanese children had developed this skillby 72 months. In 1986 this author found that only 33of 68 American children of the same age used this grip.The other 35 children were managing in school withpencil grips that ranged from less efficient to maladroit.Any grip, efficient or inefficient, that has been usedover time becomes kinesthetically “locked in.” Animmature pencil grip that is kinesthetically locked incan inhibit a student’s ability to advance to a higherlevel even after hand development has progressed.

Among 7-year-old typical children in a Boston sub-urb, more quadripod grips (four digits—three fingersand the thumb—on the pencil shaft) were found thantripod grips (three digits on the pencil shaft). This openthumb web alternative to the normal tripod grip mostlikely developed with premature use of pencils or lowjoint stability in the hand. The fourth finger on theshaft adds power for stroking, as well as a wider bridgefor stabilizing the pencil shaft. Many quadripod gripsdo progress and become dynamic and fully functional.The two slight disadvantages of this grip are (a) reduc-tion in pencil point excursion, and (b) reduced stabilityof the MP arch when the little finger is used alonerather than being functionally coupled with the ringfinger.

A few children assume an adapted tripod grip (Fig. 15-15) in which they stabilize their pencil withinthe narrower web space between the middle and indexfingers. This is an effective adaptation when jointstability is insufficient for controlled mobility. All of theskilled muscles of the classic dynamic tripod manipulatethe pencil, and the MP joint of the thumb receives littleif any stress. This posture is the most readily acceptedalternate grip when a child or adult is having motor ororthopedic writing problems.

Joint stability in the hand depends on ligaments andfixed structures. Working with school children, one seesevidence that the functional use of the hand dependsmore on joint stability than joint mobility. Childrenadopt unique ways to make their hands work for them


Figure 15-14 Production consistency of an averagewriter (A) and a poor writer (B). (Copyright Mary Benbow.)

A

B

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when they lack joint stability. If the MP joint of thethumb is unstable, the web space will collapse when thepulp of the thumb is used to stabilize a tool in the distalfingertips or against another digit. In this case the childwill unknowingly substitute the two heads of the power-ful adductor and the first dorsal interossei (internalthenar muscles) for the three more highly skilled exter-nal thenar muscles: abductor pollicis brevis, flexor pollicisbrevis, and opponens. The substitution of the internalthenar muscles causes the thumb to supinate or rotateaway from the posture to allow pulp to pulp opposition(Tubiana, 1984). When using a pen or pencil, theindividual wraps the thumb over or tucks the thumbunder the index finger to control the stroke. Either gripprovides a distal point of stability with the challenge todevise a system to mobilize the pencil proximally. Whenthe web space is closed snugly over the pencil shaft, thethumb MP joint support structures are stressed in anoutward direction, and the proprioceptive feedbackused to guide and grade fine motor muscles is reduced.

REMEDIATION OF PENCIL GRIP

In the development of motor skills there is evidence oftransfer between different forms of action. The preci-sion grip once mastered and reliably used with a spoonor fork begins to be used in drawing with a pencil.Therefore the instructor or therapist should evaluatethe use of silverware before attempting to alter morecomplex skills with marking or writing tools. Silverwarerequires only stabilization of the shaft within the tripoddigits. A writing tool requires stabilization plus con-trolled mobilization. If the child uses an immaturepower grip on a spoon, the instructor should develop

this distal holding skill before advancing to writingtools.

A number of prosthetic devices (Fig. 15-16) havebeen developed to help position the digits for efficientdistal manipulation of writing tools. These devices aresculpted to position the distal aspects of the radial digitsinto an open thumb/index web posture. Providingwriting tools with positioning grips when preschoolchildren are first exploring pencil use is the most sensi-ble and effective use of these devices. Early implemen-tation of these devices should eliminate the struggle tocorrect the inefficient grip after it has been reinforcedand kinesthetically locked in.

Limited rotation within the index and long fingerMP joints and lack of an active transverse arch pushesthe fingertips distally beyond a pencil gripping device.Therapeutic techniques can increase the third degree offreedom (rotation) at the MP joint of the index fingers.Then a grip device can be an effective reminder tomaintain the advanced posture.

Reducing hyperflexion at the PIP joint or hyper-extension at the DIP joint (Fig. 15-17) can be accom-plished by taping or blocking PIP hyperflexion with atape support. With smaller, weaker, and less experi-enced hands tape support is often an adequate supportto the extensor system. The surgical tape Microfoam(3M, St Paul, MN) adds stability to the digit. Tactileinput from the taped finger is significantly increased soany movement helps the child to sense where his or herfingers are in space. A 1/8-inch wide strip of Microfoamtape should be affixed to the middle dorsal aspect of the index finger while the digit is positioned in fullextension. The distal end of the tape should be attachedto the nail and continue proximally over the DIP, PIP,and MP joints to the mid-metacarpal level (Fig. 15-18).The tape should be adjusted to give the joint(s) stabilitywithout rigidity. Some children choose to use the tapewhen a large amount of written work is necessary,whereas others insist on wearing the tape most of the day.

A newer device called a “Pencil Pal” (Fig. 15-19) ishelpful in reducing “white knuckle” pain caused byhyperflexion at the PIP joint and hyperextension at theDIP joint. The ring device is worn on the index fingerto provide a higher stabilizing point for the pencil. Thisshift in position of the shaft of the pencil reduceshyperextension or “white knuckle” pain at the DIPjoint.

The ability to stabilize the CMC and MP joints ofthe thumb is critical for tripod manipulation of objectsand tools. The IP joint cannot be a controlled mover ifthe MP joint cannot provide a stable base of support.This stability-mobility problem renders the hand mostdysfunctional, especially in the manipulation of color-ing or writing tools. In younger children with shortfingers the “Pencil Grip” or external taping of the


Figure 15-15 Adapted tripod grip. (Copyright MaryBenbow.)

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Figure 15-16 Prosthetic writing devices. From left toright: Start Right, Solo, Stetro, and the Pencil Grip.(Copyright Mary Benbow.)

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posterior aspect of the thumb often is sufficient supportto make the thumb functional. Taping techniques out-lined for the index finger can be applied to the thumb.When the MP joint of the thumb is unstable because oflax ligaments, a neoprene splint can support and pro-tect the joint while writing.

Hand structures necessary for tool stabilization withdistal manipulation are shown in Box 15-3.

An “index grip”—a forearm, wrist, and pencil gripadaptation to extreme laxity at the thumb MP joint—isillustrated in Figure 15-20. The forearm is maintained in mid-rotation between supination and pronation andis solidly stabilized on the writing surface. The pencilshaft is cradled into the flexed index IP joints andextends distally across the third, fourth, and occasion-ally the fifth fingertips. The lead end of the pencil ispointed toward the writer’s midline. Writing strokescome from a combination of wrist flexion and MP fin-ger extension with minimal thumb IP flexion. Becausethe writer does not progressively slide the solidly


Figure 15-17 Pencil grip, showing hyperextension ofthe distal interphalangeal joint and hyperflexion of theproximal interphalangeal joint. (Copyright Mary Benbow.)

Figure 15-18 Illustration of positioning of Microfoamsurgical tape on the back of the index finger to improvejoint awareness and add joint stability. (Copyright MaryBenbow.)

Figure 15-19 Pencil Pal, which reduces the angle ofpencil and DIP hyperextension. (Available from OT Ideas,Inc., copyright Mary Benbow.)

BOX 15-3 Hand Structures Necessary forTool Stabilization with DistalManipulation

1. An active metacarpophalangeal arch with threedegrees of freedom (flexion-extension, abduction-adduction, and rotation) at the metacarpal joints ofthe two radial digits.

2. Full range of motion at the carpometacarpal joint ofthe thumb. Full range is necessary to stabilize theopen thumb/index web space.

3. Motoric separation of the two sides of the hand.The ulnar side remains inactive to provide stabilityand shift skill to the radial digits as they workopposite the thumb.

4. Joint stability. Instability is a most prevalent findingcaused by lax ligaments. The writing hand mayrequire outside stabilization.

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stabilized forearm while writing, there is a need for theinterplay between thumb IP hyperextension and wristflexion. Writing into right space requires increasingflexion at the thumb IP joint and hyperextension at thewrist. When the wrist is fully hyperextended, a majorright shift of the forearm is necessary for the next posi-tion from which to write additional letters or words.

Because this “index grip” remains so nonfunctionalover time, it is prudent to intervene as early as possible.Generally, when the joint support structures and extrin-sic tendons cannot provide stability with the addedsupport of the tape, the therapist should explore theuse of a soft neoprene thumb abduction splint. Thisshort glove-type splint positions the thumb in abduc-tion and provides stability at the hypermobile MP jointwhen the thumb tip is positioned on the pencil shaft(Fig. 15-21). Neoprene provides stability without the


Figure 15-20 Index grip adaptation to extreme laxity ofthe metacarpal-phalangeal joint of the thumb. (CopyrightMary Benbow.)

Figure 15-21 Neoprene thumb abduction splints. (Available from Benik Corp., www.benik.com; McKie,www.mckiesplints.com; copyright Mary Benbow.)

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rigidity of a thermoplastic device. Wrist-length neo-prene gloves designed to provide thumb positioningand stabilizing are commercially available in appealingcolors and multiple sizes.

School therapists, knowledgeable in developmentalhand functions, must use professional judgment todetermine if, how, and when adaptations, motor inter-ventions, or outside stabilization will benefit the child.The expectations of the child, teacher, and parentsmust be fully appreciated and honestly incorporatedinto the child’s educational plan. The therapist shouldinclude recommendations for short-term trials andoffer periodic reassessments of their acceptability andeffectiveness.

Before intervening with an older student with aninefficient grip, it is critical for the child to understandwhy it is worth the effort to change. Pencil posturesthat are not held within the pulps of the digits do notlead to economy, convenience, or adequate feedbackfor the proximal-distal axis. The simple flexor or exten-sor synergy produces the fast writing needed onceoutput demand increases in middle school. An adductedor closed web grip diminishes the proprioceptive feed-back from the lumbricales of the skilled digits. Theluxury of the unconscious regulation of pressure of theshaft of the pencil or the downward pressure exertedagainst the writing surface will be reduced or lost.Without this feedback, the student needs to stop andrelease the grip on the pencil to shake the pain out ofhis or her fingers. In addition, the child should beaware that a hypermobile closed web grip predisposesthe joint to injury because of sustained co-contraction(Pascarelli & Quilter, 1994).

The sequence demonstrated in Box 15-4 can makethe transition to a functional distal grip more successfuland less stressful.

Many persistent persons write satisfactorily withpoor grips. Many of these grips require the person todevelop skilled use of proximal joints, which lack theprecise control and speed of the distal joints. A pencilheld in a closed web grip by the adductor polliciscannot move far or use the rotary agility of the indexMP joint in producing rounded strokes. Curving androunding must be produced by more proximal jointsrequiring supination at the elbow and external or inter-nal rotation at the shoulder. Wrist and forearm exten-sors must produce elongation of upstrokes, which isefficiently done using a digital translation away patternand minimal wrist extension. A few writers use theentire skilled side (radial) of the hand to clutch andstabilize the pencil, and mobilize the pencil by extend-ing and flexing the three joints of the power digits IVand V. Writer’s cramps are often seen in people whooveruse their wrist in writing.

KINESTHETIC APPROACH TOTEACHING HANDWRITING

CURSIVE OR MANUSCRIPT WRITING

One of the difficulties facing anyone investigatinghandwriting teaching and remediation issues is the lackof longitudinal studies in the field. Studies of prepara-tory skills, curriculum techniques, and timetables forthe consolidation of writing skill at an automatic levelare scarce. Tradition rather than scientific investigationhas guided the teaching of handwriting in America. Forexample, there are no studies to substantiate the prac-tice of using manuscript throughout kindergarten andfirst and second grade. In fact there is considerableevidence showing that such teaching may impede thedevelopment of functional handwriting in some stu-dents. Cursive instruction typically is introduced at thebeginning of grade 3 in most American school systems.

Several motor patterns adopted for printing andreinforced by 3 to 5 years of use are often resistant tochange at age 8. In manuscript, children become accus-tomed to having the paper square to the edge of thedesk in order to “write.” Later, slanting the paper tothe appropriate angle to accommodate the wrist fordiagonal down and up stroking in cursive is motorically


BOX 15-4 Making the Transition to aFunctional Distal Grip MoreSuccessful and Less Stressful

1. The instructor demonstrates placement of the pen-cil positioned between the index and long fingers tomake large random patterns using only shoulderand elbow movements.

2. The child imitates the pencil position and makeslarge free flowing movements following this rigidrule: No finger movements!! No letters!! Nonumbers!!

3. After the child accommodates to the feel of thepencil in the index/middle finger web space, thechild should draw anything he or she pleases.

4. Once the child is at ease with the new pencil posi-tion, he or she should be encouraged to write largeisolated numbers and letters.

5. When the new grip becomes annoying, the childshould temporarily shift back to the former grip.

6. As soon as he or she feels ready, the child shouldreturn to the adapted grip.

7. When a child is in control of the alternating timeshifting scheme, and experiences comfort andsuccess, he or she tends to use the adapted gripmore consistently.

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disconcerting for many children. The D’Nealian manu-script program is unique in that letters are practicedwith the paper positioned at an angle to take advantageof the wrist flexors in down stroking. Interestingly, thisangling of the paper is beneficial only when the radialside of the hand is used to guide the pencil to write.However, this placement of the paper is usuallydemanded of all children regardless of grip. In addi-tion, the eye-hand pattern of top to bottom control ofvertical strokes needs to be shifted to bottom to topunder curving diagonals.

The strategy for gaining an understanding of balland stick manuscript letters requires whole-to-partanalysis followed by synthesis of the parts back intowholes. For many children it is perplexing to alter theprocess and analyze and integrate movement for thewhole letter formation necessary for cursive writing.Again the D’Nealian manuscript program has been themost successful in reducing segmentation of lines forletter formations.

In more than 30 years of experience in the teachingof handwriting, this author has found that secondgrade is an optimal time for most children to learncursive handwriting. Student interest is high, and gen-erally students have not yet developed faulty habits of inventive cursive before formal instruction begins.Training activities of combining letters into simple two-and three-letter words to practice letter formations andconnector units are at a more appropriate cognitivelevel for second-grade students. Initiating cursive writ-ing instruction in the fall of second grade allows a fullyear for students to stabilize this motor learning beforethe higher volume of written work is demanded at thethird-grade level.

Curricula that use instructional techniques to accom-modate for perceptual and motor delays and deficitsshould enable nearly all children to advance to cursivewriting at an earlier age. In schools in which cursivewriting is introduced earlier and mastered kinesthet-ically, there is less confusion with and substitution ofmanuscript letters with cursive letters. Programmingample time to master cursive writing reduces the num-ber of children who revert to manuscript in middleschool when the output volume increases dramatically.

The most perplexing problem for parents, teachers,and students themselves is how the student can haveexcellent fine motor skills and horrible handwriting.Levine (2003) explains that fine motor skills mainlyrecruit the fingers to manage artwork, origami, orairplane models, which are all navigated by the eyes.Graphomotor functions take place over different neuralpathways and require rapid sequential movementsguided by ongoing sensory feedback from the digits.The eyes are far too slow to monitor the movement ofthe digits as they move at a functional speed. Levine’s

findings on the importance of sequential finger speedto handwriting are supported by other handwritingresearchers.

Berninger and Rutberg (1992) evaluated children ingrades 1 to 3 using six finger tasks; two displacementitems, lifting and spreading, finger recognition, fingerlocalization, repeated tapping of thumb pad to indexpad, and rapid sequential touching of the thumb pulpsto the four finger pulps (5, 4, 3, 2, 5, 4, etc., a measureof motor planning and rapid sequential movements).The rapid, sequential touching to all four finger pulpsproved to be the only task that was reliable and valid forassessing handwriting skill in young children.

Deuel (1995) found slow finger-tapping speed to be significant in her dysgraphic subjects with motorclumsiness. This was not significant in the language orspatial problem students. In isolated cases, when fingerspeed is significantly slow and sensory feedback fromthe digits cannot be reinforced by taping, refining print-ing skill may be the prudent solution to the student’sneeds. Early and thorough teaching of keyboardingskills should be initiated as soon as practical in thesecases.

MOTOR PATTERNS IN CURSIVE WRITING

Motor output for cursive writing requires continuousstroke patterns. For this reason cursive letter analysisand instructions should be programmed to maximizevisualization of the whole. Mental formulation of theplan with verbalization of the entire motor sequenceshould be stressed. This elicits the child’s propriocep-tive and kinesthetic sense, supporting the flow of thewhole letter.

Most published handwriting programs currently inuse employ a “copy-the-letter” scheme followed byvisually guided reproduction of the letter within dividedlines. Able or not, children are typically expected toconvert to cursive writing during the fall of third grade.Many curricula introduce one or two alphabeticallysequenced lower case letters each week. Such slow pro-gression means that the lower case letters are unavail-able for classroom work for 3 or 4 months, and theupper case letters still remain to be learned. Otherprograms introduce the lower case and upper case ofthe same letter in tandem. Shifting the unrelated motorpatterns for lead-in strokes that are necessary wheneither alphabetical system is followed does not facilitateefficient motor learning.

Grouping letters according to common movementpatterns reduces memory demands and motor diffi-culties. After the initial session of introducing themovement pattern, during which each child learns toverbalize the pattern and produce it motorically,additional letters in the group can be learned expedi-


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tiously. The learning process is further hastened byreinforcement as all of the letters within the cluster arepracticed together.

General instructions included in most handwritingmanuals are inadequate for children experiencing visualmotor difficulties, incomplete bilateral integration,weak spatial analyzing ability, and attention or memoryproblems. Specific compensations for their special needsmust be included with initial classroom instructions ortheir classroom practice periods will not be productive.In many schools the practice time is insufficient for all but the most skilled students to achieve functionaloutput. Children are as frustrated by their handwritingfailures as are their parents and teachers. Those withspecial needs, along with many who have simply notreceived enough help or time to master this complexmotor task, resign themselves to poor handwriting orsimply revert to manuscript, which received far moreteaching time and reinforcement in the lower grades.

WHY TEACH WRITING KINESTHETICALLY?Writing is a motor skill that requires competent motorteaching and thoroughly reinforced motor learning.Fitts (1964) believed the process of skill acquisitionfalls into three stages. The first, the cognitive stage,involves the initial encoding of the instructions for askill into a form sufficient for the learner to generatethe behavior to some crude approximation. He empha-sized that rehearsal of information is necessary for theexecution of skill. The second, the associative stage,involves smoothing out of the motor performance with gradual detection and elimination of errors andthe dropping of verbal mediation. The third, theautonomous stage, is one of gradual improvement thatmay continue indefinitely.

One should distinguish these motor skill require-ments for writing from other classroom learning.Learning to write is different from learning to read. Ifit were not, more good readers would be able to writelegibly. Learning to write is not a language skill,although language skills are necessary to supply thecontent of written production. Learning to write shouldnot be coupled with learning the alphabet. Learning towrite letters in alphabetical order is more likely toenhance alphabetizing skills than handwriting skills. Aswith all fine motor skills, a student must accept the factthat the head learns to write faster than the hand.

By its nature a kinesthetic approach to handwritingprovides children with a clear, enjoyable progressionfrom (a) the placement of the letter within the threehalf-space vertical units, to (b) the precise motor analy-sis with verbal support of the motor plan, to (c) theappropriate variations in speed, to (d) the practice witheyes closed or averted, and finally to (e) the reinforcing

or setting of motor and memory engrams at an auto-matic level.

The product of visually guided, or drawn, writingmay be legible or even beautiful but is not functionalbecause its methodical execution is too slow and con-suming of cognitive power. The motor activity ofwriting must be fairly autonomous to free cognitivepower for composing and spelling. The human nervoussystem can focus clearly on only one complex mentaltask at a time. Related skills, such as writing, must besufficiently automatic to be carried out at an associativeskill level. It is beyond the ability of most persons tocompose a complex sentence and think about the wayeach letter in each word is executed. This failure in skillmastery is often the cause of a typical parent or teachercomplaint: “My brilliant child’s hand cannot keep pacewith his mind.”

KINESTHETIC TEACHING METHOD

Handwriting is a lateralized motor skill of the highestorder. When kinesthetic teaching techniques are incor-porated from the beginning of handwriting instruction,the child naturally develops a kinesthetic potential forwriting and other fine motor skills as well. The kines-thetic method of teaching cursive writing presented inLoops and Other Groups (Benbow, 1990) provides bothgeneral and compensatory instructions that are nec-essary for teaching in a mainstreamed classroom. Itenables learning-disabled students to progress withtheir normal peers. Compensatory instructions and tipsare included for students with perceptual-motor delaysor deficits including difficulty with visually producingdiagonals, midline crossing interruptions, and fluctu-ating motor memory for configurations.

The group names for letters relate to familiar objectsin a child’s environment and promote visualization ofthe lead-in strokes (Fig. 15-22). The first letter in eachof the four groups must be mastered at the kinestheticlevel before the child is allowed to advance to the nextletter. As soon as any letter is mastered, instructions aregiven for connecting it to itself or other previouslylearned letters. The student’s awareness of andrepetition of the common motor patterns within eachgroup hasten mastery of the skill by reinforcing motorlearning of the entire group.

The author has conducted successful kinestheticwriting programs by dividing the learning of lower case letters into six teaching blocks for classroom use.The blocks are rapidly but thoroughly taught in daily30-minute sessions in 6 weeks during September andOctober of second grade. The lower case letters areconsistently reinforced with daily practice and usedwhenever possible (e.g., spelling tests when childrenhave learned the necessary letters) to reinforce and


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stabilize this new skill. It is estimated that 95% of theletters on a page of writing are lower case, so stress isput on mastery to the automatic level to ensurefunctional writing speed.

During the fall, manuscript capitals are used in com-bination with lower case cursive letters for all writtenassignments. Cursive capitals are introduced after thewinter holiday vacation. This interval allows time forlower case to become stabilized before the capitals areintroduced. This interim significantly reduces uppercase and lower case confusion in children with weakmemory for configuration.

KINESTHETIC REMEDIATION TECHNIQUES

Writing errors often tend to cluster and make a paperlook sloppy. With older students, correcting one or twocluster errors is effective in producing an acceptable-looking paper. Overall appearance often can be signifi-cantly improved by improving one or two problemareas. The three common cluster errors include theseven drop-loop letters (f, g, j, p, q, y, and z), whoseloops are often huge, carelessly formed “sausages” thatinterfere with the lower line of writing. The secondcluster is incomplete closure of the four round-over-the-top letters in the “a” or clock climber group (a, d,g, and q). The third cluster is failure to retrace lettersto the writing line before the release or connectorstroke. This failure places the connector unit too highor too low to lead into the letter that follows it.

Cluster remediation often is more palatable for olderstudents to undertake. Group letter analysis and speedcoaching for segments to be produced quickly or slowlyoffers new hope that is motivating for these oftendiscouraged students. With kinesthetic training, rein-forcement, and moderate persistence most students

are self-motivated to improve their output quality andincrease their writing quantity as well.

Rule of the line or space between the writing andtop line should be compatible with the fineness orbluntness of the writing pencil, pen or marker, anddistal digital excursion of the writing tool—not thegrade, age, or height of the writer. Line space of 1/2 inchor more naturally elicits movement from more proxi-mal, less skilled joints. Regardless of age, when finemotor muscles are to be trained for graphic skills, theletter, number, or symbol size to be learned must bewithin the excursion distance of the digits that manip-ulate the pencil. A distal control sheet (Fig. 15-23) canbe used to determine the ideal line rule for olderstudents. Accurate stroke excursion flows more natu-rally and shows better control when producing strokeswithin a compatibly ruled paper. Most learning dis-abled students and children with “fixed” grips producetheir best writing on 1/4-inch ruled paper. This narrowerruled paper feels comfortable for their motor system.

An efficient way for the evaluator to detect well-formed letters that have not been learned to the auto-matic level is to look for connector breaks in the line atthe point where the lead-in stroke is initiated. Figure15-24 shows breaks in writing the alphabet before the letters f, j, r, and s. These breaks generally slow thewriter’s overall speed. The interruptions, or “thinkbreaks,” can also be detected within words, but a con-nected cursive alphabet is the most thorough andefficient way to assess the letters of the alphabet.Specifically reinforcing the identified letters that follow“think breaks” to the automatic level can often convertnonfunctional output speed into functional skill.

Kinesthetic reinforcement of letters can increasewriting speed while maintaining quality in a child whowrites beautifully but has not developed functionalspeed. After carefully re-examining the line progressionof any known letter and producing it with visual guid-ance, the child should close his or her eyes, visualize theletter, and write with fluidity on scrap paper 15 timesbefore checking the results. Once the initial letterwithin a motor group is written reliably at an efficientspeed, the remaining letters of the group should bebrought up to speed one by one. A most popular timeto suggest for children to increase their speed in writingis while watching television. The combination of these two activities diverts visual monitoring from thewriting hand, and the student willingly extends practiceperiods.

Seating Posture and Classroom ArrangementProperly fitted furniture is indispensable if children areto learn handwriting efficiently. If the chairs are toohigh and the child’s heels do not touch the floor, he orshe will be unable to counterbalance for weight shift as


Clock Climbers

Kite Strings

Loop Group

Hills and Valleys

Figure 15-22 Letter group named to assist memory inlearning. (Copyright Mary Benbow.)

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the arm moves across the paper. If the desk surface istoo high, the upper arm will be abducted too far tocontrol the fingers effectively. Figure 15-25 illustrates aproperly fitted student chair and desk for writing.

The child’s desk should face the chalkboard wherethe teacher demonstrates the letters. There may besubjects that can best be learned in cluster or circularseating, but handwriting is not one of them.

Presentation of a ModelThe instructor introduces the letter by producingabout a 15-inch model of it within the appropriate linespace(s) on the chalkboard. While demonstrating eachnew letter, the instructor should recite each step of themotor plan. Familiar objects in the student’s environ-ment are used to aid the students in visualizing themovement pattern as they motorically produce the


Distal Finger ControlRest side of hand on desk. Use one stroke to circle left from top aroundto top within the donut.

Figure 15-23 Practice sheet for distal finger control. (From Loops and other groups: A kinesthetic writing system. Copyright1990 by Harcourt Assessment, Inc. Reproduced with permission. All rights reserved.)

Figure 15-24 “Think breaks” in writing. (Copyright Mary Benbow.)

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while verbalizing the motor plan. With a few additionalminutes of coaching, the students can be brought to a base level of skill before pencil and paper areintroduced.

Paper and PencilHalf-inch lined paper with a dotted middle marker ismost satisfactory for early cursive practice with visualguidance. Paper folded lengthwise in 4- or 5-inch stripskeeps the practice closer to the child’s midline where heor she has the most control. Using the newly learnedmotor plan, children complete 10 trials of the letter.They are told to “talk to your hand, and make it dowhat you tell it to do.” One should instruct children tosubvocalize the motor plan as they form each letter.The instructor should be sure that the letter occupiesthe proper space(s) in relation to the writing line andmiddle marker.

After 10 trials, each student should circle all of theletters that are correct. Among those circled theyshould select the one that is the best. After it is approvedby the instructor, they should write 20 more from theirown kinesthetic model.

When all children are confident in their ability towrite the letter with eyes open, they should close theeyes to visualize and gain the feel of the smaller move-ment pattern. Children who have tracking, converging,or crossing the midline visual disorganization shouldspend a major portion of their practice time with theireyes closed or gaze averted to avoid visual interference.

SUMMARY

Kinesthetic handwriting training takes the drudgeryout of a task that is often difficult and time-consuming.For all children and for their teachers, this providessome benefit. For some children, kinesthetic training isthe single most effective tool for learning handwriting.

Children who benefit the most from kinesthetichandwriting training usually have identifiable problemsin one or more general areas. Developmental gross andfine motor foundation skills for cursive instruction maybe less than optimal. Output or production problemsmay include difficulties with visual motor control.

Kinesthesia is the key to the lost science of hand-writing. Properly understood, it is the basis for under-standing handwriting problems and for preventing orremediating them. Kinesthesia can be a curse or ablessing. When a complex motor activity is scientificallyanalyzed, appropriate foundation skills are set, teachingsteps are properly sequenced, and the skill is practicedto the automatic level of performance, kinesthesia is alifelong blessing in the performance of that skill. Onthe other hand, maladaptive kinesthetic patterns can be


Figure 15-25 Correct sitting posture for handwriting.Knees and hips are flexed at 90 degrees and feet are flaton the floor. The writing surface is 2 inches above thestudent’s bent elbow. The top of the chair should beslightly below the student’s shoulder blade. (From Loopsand other groups: A kinesthetic writing system. Copyright1990 by Harcourt Assessment, Inc. Reproduced withpermission. All rights reserved.)

stroke progression. For example, the lead-in stroke for the letter “a” should climb up and round over animaginary clock face between the 11 and 1 o’clockpositions and stop. The line reverses by retracing thislead-in to 9 o’clock (Fig. 15-26).

Preparatory ExercisesBefore using pencils and paper, children perform twoexercises. In each exercise they are to use the handposture shown in Figure 15-27. Digits II and III areextended. Digits IV and V are flexed and held downwith the thumb to reinforce separation of the two sidesof the hand. For each exercise and each practice trial,verbal directions should be voiced by the teacher andthe students.

The students should use the shoulder movementsand hand postures described previously to trace theletter in the air. Simultaneously each student verbalizesthe motor plan while following the shape of the chalk-board model. Each student in the class must demon-strate the ability to verbalize the motor plan whilefollowing the line of the letter model.

When secure in an understanding of the motorsequence, each student closes the eyes and pictures theletter to facilitate visualization of the movement pat-tern. During the second exercise, students place theirelbows on the desk top to “write” using elbow and wristmovements. Again, they must recite the motor plan asthey move their hands to pattern the visualized letter.

These preparatory exercises are important to theinitial learning of handwriting. The instructor is able todetermine which children are unable to visualize theletter with eyes closed or averted from the model letter

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a curse. When a motor activity is haphazardly acquiredat an immature stage of development and reinforced tothe automatic level of performance, the kinestheticpattern can last a lifetime, blocking effective and effi-cient performance of the skill and frustrating anyattempts to modify it.

One of the world’s great artists, Henri Matisse, onceconfirmed the importance of kinesthetic learning(Bernier, 1991). A friend who visited him noticed asketch in white chalk on the back of his living roomdoor. Matisse explained,

“I had been working all morning [drawing] from the model. Iwanted to know if I had it in my fingers, so I had myselfblindfolded, and I walked to the door and drew” (p. 30).


Clock Climbers

Figure 15-26 Practice sheet for clock climber group (a, d, g, q, c). (From Loops and other groups: A kinesthetic writingsystem. Copyright 1990 by Harcourt Assessment, Inc. Reproduced with permission. All rights reserved.)

Figure 15-27 Hand posture used in preparatoryexercises. (From Loops and other groups: A kinestheticwriting system. Copyright 1990 by Harcourt Assessment, Inc.Reproduced with permission. All rights reserved.)

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The process that worked for Matisse is precisely thekinesthetic learning that is most effective for trainingchildren in handwriting. In cursive handwriting, as indrawing from a model, if I don’t have it “in my fingers”my work will be slow, crude, and unsightly. This approachallows children to discover what the great artist described.

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Beery KE (1997). Developmental test of visual motorintegration, VMI-4. Los Angeles, PsychologicalCorporation.

Benbow M (1990). Loops and other groups: A kinestheticwriting system. Tucson, AZ, Therapy Skill Builders, adivision of Communication Skill Builders, Inc.

Benbow M, Hanft B, Marsh D (1992). Handwriting in theclassroom: Improving written communication. TheAmerican Occupational Therapy Association Self StudySeries. Rockville, MD, The American OccupationalTherapy Association Press.

Bernier R (1991). Matisse, Picasso, Miro: As I knew them.New York, Alfred A. Knopf.

Berninger V, Rutberg J (1992). Relationship of finger speedto beginning writing. Developmental Medicine and ChildNeurology, 34:198–215.

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Fitts PM (1964). Perceptual motor skill learning. In AWMelton, editor: Categories of human learning. New York,Academic Press.

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McGuinness D (1979). How schools discriminate againstboys. Human Nature, Feb:82–88.

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Smith RJ (1974). Balance and kinetics of the fingers undernormal and pathological conditions. Clinical Orthopaedicsand Related Research, 104:92–111.

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