Message from Misti
We’re almost to summer - the pressures of school let up and the long days can feel endless. As we transition to this next season, I felt the need to address one of the most common issues pediatric occupational therapists are asked to address: hand function and pencil grasp. While handwriting skills are more often brought up as the concern, pencil grasp is one of the key indicators that tip off parents and teachers that something isn’t working correctly. While many reflexes affect fine motor skill development, the Robinson Hand Grasp Reflex is what brings power and maturation for dexterity to the hand. For the hand to mature and develop we need a functioning Tactile Sensory System to feel and discriminate where our hands come into contact with various surfaces. Even when our Hand Grasp Reflex and our Tactile System are maturing and intact, our hands need many different experiences to develop the skills necessary for controlled movement of a pencil. While books can/have been written on each of these topics, hopefully this blog post pulls together information that allows you to walk away understanding of the interplay of the three, and you can form activities for the children in your life that help with hand development.
Reflex Highlight: Robinson Hand Grasp
This reflex consists of securely gripping and holding an object with fingers flexed and thumb laying on top of the fingers. This grasp allows the hand to hold small to large objects. Once established, it leads to greater refinement of fine motor skills, controlled release of objects, and coordination. It allows the child to explore at midline and is instrumental in hand eye coordination. It also holds the protective meaning of “holding on for dear life” as many individuals hold their hands in this gripped fashion when emotionally distraught or feeling unable to “get a grip” on the current situation.
When not integrated a child will use too much pressure while holding a writing or eating utensil leading to finger and hand fatigue. They may use an immature or inefficient pencil grasp which makes controlling the pencil more difficult. This can lead to an avoidance of handwriting and other tasks which require fine motor engagement. Additionally, fine motor development in the hand corresponds significantly with the fine development of muscles in the face and mouth needed for speech and communication. Being sure this reflex is integrated is important for fine motor development, emotional resilience, and communication. If you are unsure, seek out assessment with a therapist who can address this reflex.
Sensory Connection: Tactile Sensitivity and Discrimination
Our tactile system is not just regulated to or hands, it covers our whole body to provide us with important information regarding our environment! There are 12 different types of tactile receptors located in varying depths of our skin and tissue. They transmit information such as hot, cold, smooth, rough, itchy, prickly, pain, pressure (light or deep), vibration, texture, and shape. They are categorized into 4 types: thermoreceptors, pain or nociceptors, proprioceptors, and mechanoreceptors. Some areas of our bodies have a lot of receptors per square inch of skin like our hands and around our mouth, while other areas have less which are more spread out like out back and trunk of our body. The more receptors in a small area the greater we can discriminate exactly what we are touching.
Sometimes a tactile system can be over responsive, with the receptors needing much less stimulation to be activated. This overstimulation of the nervous system can elicit feelings of pain or an uncomfortableness that can lead to nausea when severe. Touch processing is overwhelming for these individuals and leads to avoidance of activities and interaction. When required to engage with greater amounts of tactile information such as walking in a crowded hallway and bumping into people or completing an art project, the individual may have an over-reaction or a fight or flight response.
Other nervous systems are hypo-sensitive to tactile inputs, they need greater amounts of tactile input for the brain to recognize it. These individuals may not notice when they bump into something, may use too much pressure to hold items, or seek out extra pressure and touch everything all the time. Being under-responsive can lead to difficulty discriminating information, they may not feel when their clothes are twisted on their body, when their hands or face are dirty or if their nose is running.
As noted before, the hand has an enormous amount of tactile receptors in the skin. This helps us to manipulate objects of different sizes, textures, and weights with our hands. The information we gain from feeling the object allows the brain to plan how much pressure to use, which muscles should flex, and which should relax, and how the shape of the hand should form in relation to the object. This is so important as we learn to use tools such as crayons, pencils, spoons, forks, knives, scissors, snaps, buttons, zippers, and toothbrushes! The tactile system is key for development of hand and fine motor skills.
Skill Development: Pencil Grasp and Hand Skills Necessary for Handwriting
Even when the Hands Grasp Reflex is integrated and the tactile system is working properly, there are still hand skills that need to develop for children to hold a pencil and learn to write. The refined movements of the fingers, hand and wrist allow the precision needed for pencil control.
Starting with the gross Palmer grasp, a child typically develops through various stages to a tripod grip on a pencil. The more refined pencil grasps can be described as static or dynamic. The difference between them being the fingers in a static grasp stay still and the movement comes from the shoulder, forearm, or wrist. A dynamic grasp occurs when the fingers control the movement of the pencil and the shoulder, forearm and wrist are stabilized. While the tripod grasp pattern is important, research suggests there are other grasp patterns which are just as effective and efficient. Children should have an effective grasp pattern by the end of kindergarten. If a child entering 1st grade is still using a palmer, digital pronated, or digital grasp; evaluation and direct intervention should be considered.
Pencil grasp matures as the hand moves through specific skill development. These hand skills allow a grasp to be dynamic and the fingers to control the movement. Without these skills the hand will not be able to have the precision necessary for handwriting. If a child is struggling to hold and use a writing utensil, it is helpful to notice if they can do the following skills.
In hand manipulation: the ability to manipulate objects in the hand without support from the body or other hand. This skill may be of even greater importance than having a tripod grasp. It allows the pencil to be moved and positioned within the hand to adjust it for control. In hand manipulation consists of 3 types of movement: translation, shift and rotation.
Translation: using your fingers to move an item from your palm to your fingertips or fingertips to palm, like when you move coins from your palm to your fingertip to place in a vending machine.
Shift: using the pads of your fingers to move an object, like when moving a button through the hole or adjusting the pencil in your hand.
Rotation: rolling an object with the fingertips, like when turning a pencil over to use the eraser.
Separation of two sides of the hand: the ability to use the thumb, pointer and middle finger or the precision side of the hand independent from the ring and little finger or the power side of your hand. This is important for automatically tucking the ring and little finger into the palm while holding the pencil.
Endurance: using strength to hold the tool over time while maintaining an efficient grip. This includes being able to maintain fingers in flexed positions without collapsing or hyper extending joints. Without intrinsic hand strength an individual may experience fatigue or soreness over time while writing.
Wrist extension: while this is not technically a hand skill, wrist extension allows the hand to be placed optimally so all above hand skills can perform with ease. A lack of wrist extension indicates decreased strength in the upper extremity which needs to be addressed.
Activities To Develop Hand Skills and Grasp
Now that you understand the foundational skills for a functional pencil grasp, here are ways to promote stronger muscle strength and motor patterns that underly pencil grasp and handwriting without using a pencil.
Tongs, tweezers and clothespins: using all and any of these pinching tools helps strengthen the pattern of thumb opposition to fingers and the muscles of the thumb. Scale the activities by using different sizes of tools to match different sizes of objects to pick up and place with the tool. You can pick up and place blocks, use a tweezers with water beads, or a clothespin with colored pom poms.
Rolling and pinching playdough, clay or putty: These mediums are a fantastic for strengthening muscles and developing precision. While using tools with playdough is fun, interacting with playdough just by itself provides the hand with all the experiences needed to help develop a grasp.
Beading on strings or pipe cleaners: holding a string or pipe cleaner still with a thumb and forefinger while manipulating a small object on such as a bead, noodle, or Cheerio is great for practicing a pincer grip.
Lacing cards: like beading, lacing involves taking a string, ribbon or pipe cleaner through small holes on a form. Lacing activities can be scaled from easy shape boards available for preschool kiddos to sewing with a plastic needle on plastic canvas to create designs, or using craft foam and plastic lace to sew pieces together.
Sensory bins: filling a large bowl or bin with beans, rice, noodles, or other medium and then hiding objects in it offers lots of opportunities for hands to practice tactile discrimination. Although sensory bins are often associated with preschool ages children, many early elementary children still benefit from this important tactile medium when developing hand skills. For the elementary child hide cards with words to form sentences, letters for spelling words, or numbers to solve math fact cards.
Spray and Squirt Bottles: This gets a little messy and is best done in the context of cleaning up, or outside on a warm day. A favorite activity is to hang a balloon, spray a smile face on with shaving cream, then use a spray bottle of water to make the shaving cream melt off the face (best down out of doors where messes can be washed away)
Work on vertical surfaces: the use of an easel or taping your coloring page to a window or wall is a great way to encourage wrist, elbow, and shoulder stability. Use dry erase markers or window makers on windows to draw. Another great idea is to attach a flat Lego base to the wall and use Legos to make different marble runs. Arranging magnets on a refrigerator or drawing with chalk on a chalkboard offer a way to practice wrist extension while stabilizing the shoulder.
The Differentiatedkingergarten.com has a wonderful printable kit to make take home fine motor kits for practice. She also has several blogs with pintables and ideas for creating Morning workstations and bins that allow for fine motor practice. Although these activities are geared toward kindergarten, many 1st and 2nd graders have not had enough practice with these activities in their earlier years due to the pandemic and it is highly recommended that teachers and parents look at the ideas and try to incorporate them into the day if possible.
There are also many ways to work on improving pencil grasp and control without the pressure of handwriting as well.
Use broken or tiny crayons and little pencils: break crayons into small 1 inch size pieces, the small space forces just the thumb and index finger onto the crayon without the other fingers.
Rainbow circles: use colored pencils to fill in small circles on a page, staying inside the circles using small rotational movements.
Pencil control pages: there are many different pages to practice tracing small shapes, spirals and slim path following.
Mazes, dot to dots, and color by numbers: engaging control with games is a great way to practice grasp and control.
Magnadoodle: drawing on a magnadoodle is a fun way to practice pencil grasp without holding a pencil.
Ms. Olga of OT Closet has many videos to practice hands skills with pencils, coins and other simple materials. These are great 4-5 minute videos that an entire class can follow along with as warm up to handwriting practice.