Clinical Reasoning: A Critical Tool to Examine Data from a Traditional Handwriting Evaluation

Educators impart handwriting instruction as a component of literacy in the early school years. School occupational therapists share their expertise to support development of prerequisite skills needed for handwriting; promote efficient handwriting instruction; provide remediation when students experience difficulties in acquiring handwriting skills; and if required, recommend adaptations or accommodations to optimize a student’s participation in the educational environment. Handwriting difficulties continue to be one of the most frequent reasons teachers refer students for occupational therapy services (Benson, et al, 2016).

Informed by research (e.g., Cornhill and Case-Smith, 1996; Denton et al, 2006) occupational therapy interventions have addressed aspects such as development of a mature pencil grasp, sensorimotor function, and visual motor integration skills that were assumed to be the building blocks of competent handwriting. Evidence for the effectiveness of occupational therapy interventions to support handwriting function was studied extensively over the last two decades with some unanticipated results. For example, no evidence was identified for an effect on handwriting legibility outcomes with isolated activities addressing the components of visual perception, kinesthesis, or motor skill performance (Candler, 2019). Inconsistent results were found when the relationship between pencil grasp and handwriting performance was examined (e.g., Schneider et al, 2019; Dennis, J.L. & Swinth, 2001). When the effectiveness of sensorimotor approaches was compared to therapeutic practice approaches, the latter was found more effective in making a positive change in handwriting function (e.g., Denton et al, 2006; Zwicker and Hadwin, 2009). However, other research continues to support the influence of subskills such as visual perception on aspects of handwriting including speed and far point copying (Chang and Yu, 2017).

Considering such conflicting information, we, as occupational therapists, need to apply our clinical reasoning skills to analyze the therapeutic needs of individual children and determine which interventions we provide. This presentation will urge practitioners to think beyond quantified test results and examine aspects such as sensorimotor function, pencil grasp, and visual motor integration when addressing handwriting issues. We will scrutinize the information we glean from standardized tests (e.g., the Beery test of VMI) and observations (e.g., of pencil grasp) to resolve how this data can direct the interventions we recommend for specific children. The importance of progress monitoring to support further decision-making e.g., whether to offer interventions for improvement of handwriting skills, or to implement accommodations and adaptations to allow a student to demonstrate learning and participate in the academic environment, will be discussed.

Reiterating that handwriting is only one component of written expression, the importance of inter-professional collaboration between educators and occupational therapists will be reviewed. The presentation will emphasize a collaborative application of knowledge translated from research to optimize a student’s participation in the educational environment.