The Handwriting Lady

At the AOTA Autism Specialty Conference I attended last week (there will definitely be more about the conference in a later blog), Winnie Dunn, an amazing OT and researcher, said in her keynote address, "Don't let yourselves be pigeonholed. We are more than just the Handwriting Ladies!" (Followed by a comic nod  to the 3 male OTs in attendance). This is very true. In the world of pediatric OT, we are so often linked with handwriting to the point where other related service professionals, teachers, parents (and if we're not careful even us as OTs!!) can forget or never realize in the first place that OTs do so much more than just helping the kids we treat improve their handwriting!

Why is it that pediatric OTs so frequently address handwriting that it has become possible to pigeonhole us as “the Handwriting Ladies”? Why is it that poor handwriting is the most common reason for OT referral in school aged children (and poor pre-writing skills in pre-school children)? I believe it is because of a paradox that is a very real part of school for kids. And that is that handwriting is an essential part of a child’s occupation of being a student (for those non-OTs who may be reading, an "occupation" refers to the things people do in their daily life that are of necessity and/or of meaning to them, for children being a student is one of the primary occupations they engage in).  Children are required to produce written work in basically every school subject, because writing is how they communicate what they know and have learned.  Unfortunately for children with special needs, handwriting is also one of the most complex tasks children are expected to perform. It seems automatic for those without a disability, but handwriting actually encompasses an extraordinary amount of body systems and underlying component skills, and if a child has issues with any one or combination of these skills it will very often manifest as poor handwriting.

[Here’s something that will probably blow the minds of the non-OT readers. Take a deep breath in....ok, readysetgo: In order to write successfully, first one needs to be able to sit in a chair. Just that involves a lot, such as having the core strength and postural control to stay upright in the chair against gravity. Then there are also a lot of visual elements to handwriting. There's visual acuity (being able to see and see clearly), occulomotor skills (such as being able to move one's eyes to visually scan from left to right and top to bottom), visual perception (which includes being able to interpret series of lines and curves as different and distinct letters), and visual-motor integration (which includes being able to write in between the lines). Another key component to handwriting is fine motor skills. One needs to be able to grasp a pencil appropriately, and manipulate it using very small movements. This involves having good control over the very small muscles of the wrist, hand and fingers in addition to strength and endurance of these muscles. Also, there's praxis (motor planning), which is the ability to plan and execute the specific movements required to form each letter consistently and correctly. Then there's other neurological components, such as the ability to sustain attention to task. There’s cognitive components such as memory--one needs to remember which set of lines and curves represent which letter. There's sensory processing components involved, such as being able to feel the pencil in one's hands and judging how much force to use on it, and having the ability to filter out excess sensory stimuli from the environment. And a partridge in a pear tree, lions and tigers and bears oh my!!! This is just to name SOME of the many components and skills involved in handwriting!!!] 

I am an occupational therapist, not a handwriting specialist. However, as OTs, we have the knowledge base to break down the task and determine exactly which components are posing a barrier to the student's success in handwriting, and then determine an appropriate intervention to help that student. The reason why OTs so often address handwriting is not so much the WHAT (the student writes poorly), but the WHY (ie poor fine motor coordination and endurance, poor visual perceptual skills, ect), and most importantly, HOW it is affecting the student’s ability to be successful in school.

Our jobs are to help our clients with any and all things that prevent success in their occupations. Although handwriting is a big part of the childhood occupation of being a student, it is not by any means the only part. As Winnie Dunn said, it is very important to make sure that we are recognized as more than just "the Handwriting Ladies," and I do make sure to do my best to advocate for the many other things we do as pediatric occupational therapists to other professionals and those outside the related service field. However, that being said, I am also excited to be, for 45 minutes every Friday, just that: The Handwriting Lady! On Fridays at the clinic I run a handwriting group for 5, 6 and 7 year olds. I was so happy to see them today, because we did not have group the last two Fridays due to being closed the day after Thanksgiving, and then me being away attending the aforementioned Autism Conference.

The group I run is based on the handwriting program Handwriting Without Tears. I took the course to become trained in the program this summer and I absolutely adore it! It was developed by an occupational therapist, Jan Olsen, and encompasses underlying skills that support handwriting success as well as using techniques that target the way children learn best--through multi-sensory, experiential learning, as backed up by years of research. It's also fun, motivating, and easily adaptable for kids with many different special needs. OTs understand that there is so much more to writing than pencil meets paper, which is why when children have handwriting issues we tend to be the ones called in. The kids in my group came to me with a variety of different challenges and were at varying developmental levels, but they all have shown remarkable success in group so far. This, in my humble and professional opinion, is because I'm using a program that's fun, motivational, developmentally appropriate and multi-sensory, and I can tailor each group's activity to meet the needs of each of the five children in the group. We sing songs, color with crayons, use play doh, write on chalkboards, do activities using our whole bodies, and exercise our fingers all before sitting down and practicing letters with a pencil and paper.

I know the importance of not being pigeonholed as "the Handwriting Lady," but for 45 minutes on Fridays that is exactly what I love to be......just with a very "OT" spin!

A lesson learned about assumptions

In my job, I work primarily in a private pediatric therapy practice with pre-school and school aged children in New York City in a clinic setting. Through the practice, I also contract to a secondary school and work with middle and high school aged children in the public school system two mornings per week. At this school, I treat a high school student who has “high functioning” autism. I will refer to this student Jason (not his real name). Jason is fascinated by the New York City public transportation system, particularly the subway system. In fact, the very first thing Jason said to me during our first occupational therapy session, after “hello” was, “Did you read the Subway Report Card that was published?” Then he proceeded to give me abundant detail about the best and worst lines and why each line ranked the way it did. He is forever giving me random subway statistics, such as which line is longest and which is shortest, or how many lines cross more than two boroughs. It is not uncommon for individuals with autism to fixate on a certain interest and develop an extensive knowledge base on this interest. It is also common for these individuals, who frequently have trouble understanding social cues and social protocol, to have difficulty understanding that others do not always share these the same interests, and may not be as excited to hear all about [subways, space, animals, ect].

With many of my teenagers at this school, I work on community mobility goals, especially with the students that are in the “basic” program (a program in which they do not receive a high school diploma from but an IEP diploma instead, the program focuses on life skills and functional skills as opposed to just academic skills). With many of my students who have these goals, we look at subway maps and talk about how to read them, and plan routes from point A to point B. This is not one of Jason's goals, but Jason always requests to look at subway maps in OT sessions. However, he has more knowledge about the subway system than most MTA workers probably do! He loves inventing “challenge problems” and will walk into sessions and ask things such as, “So today can we look at the subway map and can we try to figure out how to get from point A in Brooklyn to point B in the Bronx and pretend it’s a weekend, so line X runs a modified route and line Y doesn’t run, and there’s a snow storm and all elevated lines are not running?” Since looking at the subway map brings him so much joy, but is not therapeutic to address since it is a skill he already excels at, I came up with an idea. In therapy, I have been having Jason write down subway problems and answer keys for other students with whom I am working on community mobility with to figure out. This helps him work on his organizational skills, and the legibility of his handwriting, which are goals of his. This also helps him with social skills, because it is very hard for him to understand that not everyone understands the subway system as well as he does. I do let him write some “super duper challenge questions” that he really enjoys to figure out, but then I try to help him understand how to simplify things and create “beginner” questions that his peers may actually be able to do. Bingo! He gets to look at subway maps in OT, but I have made the exercise more functional for the skills he needs to work on. He feels so honored to have taken on this responsibility of creating subway problems for the kids I work on community mobility goals with. He loves to hear how the other kids are doing with the problems and continuing to create new ones. Jason has become my resident community mobility expert at the school.

After working with Jason twice per week for the last 2 months, one thing he told me served as a huge eye opener for me as a young therapist. For a young man who loves the subway system so much, and is so adept at theoretically navigating the subways, I incorrectly assumed that Jason was independent in community mobility, therefore it did not need to be an OT goal of his. Then, one day, I do not even remember exactly what we were talking about (as many of the conversations we try to have somehow end up relating back to the subway system), but he ended up mentioning something that shocked me. He told me that he cannot ride the subways by himself, and does not actually go anywhere in New York City on the subway without his mother! He revealed that the crowds on the subway and all the loud noises bother him too much and make him anxious, and he is afraid to go anywhere alone without his mother for this reason. A high functioning, bright teenager who is an expert on the subways, cannot ride the subway independently! Out of all my students at the school, I expected Jason to be the one who is most independent in community mobility because of his extensive subway knowledge and uncanny ability to quickly figure out how to travel between two points in New York City during any time of day or any unplanned circumstance. I felt so silly for assuming this, because I am aware that as OTs, we are taught to be masters of holistic thinking and task analysis. We learned in grad school how to think of all factors that are involved with everything our clients need to do on a daily basis. However, it just didn’t occur to me to ask him if he has any difficulty with community mobility because Jason spends so much time talking about it and demonstrating theoretical competence with it.

**Lightbulb moment!** There are a lot of generalizations here, but individuals with autism tend to have very strong visual/visual perceptual skills. Which is why PECS (a picture exchange communication system for kids with autism who have limited or no verbal abilities), picture schedules, pictures of each step of tasks, and pictorial social stories are so successful with individuals with autism. Also, individuals with autism tend to think very concretely and logically. So, it is not surprising that reading a subway map and quickly being able to determine even difficult routes is a breeze for Jason. Riding a subway is completely different! The sensory challenges of riding on a subway are monumental. (Why didn’t I originally consider this?? I spend most of my professional life addressing sensory challenges with the little kids at the clinic!) People with autism are frequently very auditorily defensive, meaning their brains process sound differently from people with typical neurology. Their brains have difficulty processing and interpreting auditory input, and as a result often everyday sounds that are noxious to most people can be overwhelming and even painful for those with autism. Additionally, people with autism often have difficulty processing input from other senses, such as the sense of movement (vestibular) and the sense of touch (tactile), and have a lot of sensory sensitivities. This is the case for Jason. Being on a subway is a very intense sensory experience for even people with typical neurology. The subway car starts and stops frequently, and dives underground and rises above ground quickly, in addition to sometimes making quick turns. The track can be bumpy. The car can sometimes vibrate and shake. There is gratuitous noise. The wheels screech. The doors ding. The conductor makes announcements. A booming computerized voice is constantly updating the passengers about the next stop, the current stop, to be mindful of the closing doors, to keep an eye on belongings. People talk to each other at loud volumes. On a crowded subway car you will be brushed against by many different people and their different textured coats and bags. For someone with autism who may have sensory processing difficulties and sensitivity to some sensory input such as auditory, vestibular and tactile input, it can be overwhelming and even traumatizing! No wonder Jason, despite his subway knowledge and navigational skills, cannot bring himself to ride the subway alone without the comfort of his mother!

This to me was a reminder about to never assume things, and to always consider all aspects of a task. Considering the environment, all skills required both cognitive and physical, and body systems required including sensory processing, is just as important as the actual steps of the task being performed. This goes down to the very core of what occupational therapy is, and we as OTs learned that in OT school ad nauseum. I learned that I should not have assumed independence in community mobility for Jason just because he is an expert in theoretically navigating the public transit system. There are so many more demands intrinsic to the task of riding the subway and factors that are part of Jason's neurological processes that are limiting Jason’s ability to be successful in this task. All these aspects need to be addressed that I originally did not fully consider. As OTs, we need to constantly remember, that more than any other person our clients work with, we are equipped with the skills to analyze all areas of every single task and occupation. Even though the goals on paper may say “will be able to determine the route between two points in New York City using the subway map to improve independence in community mobility skills,” there is so much more to riding a subway than that, and we are responsible for helping out clients find the tools to be successful and not just addressing the goals at face value.