Handwriting assessment

Handwriting assessments are a vital component of any occupational therapy practice, specifically that of outpatient pediatrics, private practice, and school-based occupational therapy.

Occupational therapists observe and analyze all components of handwriting including cognition, fine motor skills, gross motor skills, sensory processing abilities, visual motor skills, and in-depth components of handwriting itself including legibility, formation, size, spacing, line use, fluidity, and orientation.

Handwriting is a critical developmental skill in children and the evaluation of handwriting is key for academic and social success, as well as fostering independence in daily skills.

Evaluation process

The evaluation of handwriting involves a series of steps including gaining the background and medical history of the client, skilled clinical observation, use of standardized assessments, and specific handwriting assessments, a fine motor assessment, a sensory processing assessment, and an analysis and a written report of the findings.

It is important to use appropriate assessments to identify areas of difficulty for handwriting. Some common handwriting assessments in occupational therapy practice can be found below.

Handwriting-specific assessments:

• Print Tool: It is from the Handwriting Without Tears curriculum and designed for children from preschool-6th grade. It evaluates a client’s ability to form capital and lowercase letters, numbers, and specific handwriting components such as memory, placement, size, orientation, sequence, and spacing. Samples of handwriting are also utilized.

• Evaluation tool of Children’s Handwriting (ETCH): The ETCH assesses a child's speed and legibility of handwriting in addition to the child's pencil management related to writing tasks commonly done in a classroom. ETCH activities include near-point and far-point copying, alphabet and numerical writing, dictation and sentence generation. It assesses pencil grasp, hand preference, legibility components, pencil pressure, manipulative skills with the writing tool, and classroom observations.

• Minnesota Handwriting Assessment: The handwriting skills of first and second-grade students are analyzed with the Minnesota Handwriting Assessment. It evaluates legibility, speed, letter formation as well as pencil grasp and provides a comprehensive analysis of handwriting skills.

• Test of Handwriting Skills-Revised (THS-R): The Test of Handwriting Skills-Revised is an untimed, clinical assessment of neurosensory integration skills in handwriting that includes cursive and manuscript that are often disrupted in students with learning difficulties. The THS-R provides a standardized assessment of children's handwriting ability for cursive and manuscript styles that can be used with any popular handwriting programs.

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Assessments Incorporating Fine Motor Skills:

• Beery-Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI): The purpose of the Beery VMI is to assess visual motor integration skills in ages 2-65+, with different booklets and assessments for specific ages including preschool ages, school-aged child, adolescents, adult, and elderly adult.

It also assesses cognition, coordination, dexterity, vision, perception, and infant and child development. The Beery VMI should not be exclusively utilized as an indicator for handwriting skills, however, should be utilized in conjunction with a handwriting-specific assessment.

• Bruininks-Oseretsky Test of Motor Proficiency (BOT-2): Assesses both fine and gross motor skills in children aged 4-11. It “assesses the motor proficiency of all children, ranging from those who are typically developing to those with mild to moderate motor control problems.” The BOT-2 should also be utilized in conjunction with a handwriting assessment to assess handwriting skills.

Fine motor skill areas:

Fine motor skills are a critical foundation for handwriting skill development.

Along with standardized assessments and handwriting assessments, occupational therapists will observe, evaluate, and assess key fine motor components including some of the following:

• Hand strength
• Hand dominance
• Fine motor coordination
• Pencil grasp and grasp patterns
• Fine motor dexterity
• Motor planning
• Seated posture
• Finger, joint, and wrist mobility
• Visual motor skills- size, spacing, and line use, and letter formation

Assessing letter formation and legibility, interpretation, and interventions:

Assessing letter formation and legibility in handwriting is a crucial aspect of a handwriting evaluation and has a significant impact on an individual's ability to communicate via written language.

To assess for formation and legibility, the therapist provides the assessments that allow the individual to write letters of the alphabet, and then the therapist will identify how the individual produces the letters specifically the sequence and stroke pattern, noticing errors, letter or number reversals, the alignment of letters, size, spacing between letters and sentences, and overall consistency.

In addition, it is vital to utilize the assessment’s scoring criteria to gather data and interpret results based on developmental norms. In addition, once data is gathered, considering the functional implications of the findings is key such as the impact on daily life, academic performance, social participation in school and work environments, is crucial for providing client-centered treatment and interventions, setting goals, and collaborating with other professionals.

Interventions and treatments for handwriting difficulties should be targeted on skills of need such as hand strength and grip strength, posture, coordination, utilizing multi-sensory and multi-modal approaches, visual-motor exercises, handwriting practice, and/or visual and verbal cues. It is vital to monitor progress and adjust strategies and treatment as necessary.

Developing and implementing individualized treatment strategies allows for effectively supporting clients to improve their handwriting and fine motor skills and overall achieve academic or work success, enhance social participation, and overall independence in daily life activities.

Future trends, technological considerations in handwriting assessment, and learning

In the age of technology in healthcare, it is essential to consider online assessment platforms, telehealth assessments, digital and interactive versions of handwriting assessments such as the print tool, and allow for treatment methods via digital apps, and electronic and interactive programs.

Furthermore, providing adaptations that meet the individualized needs of clients is important. These adaptations can be provided via online learning via digital handwriting worksheets, utilizing a digital pen/stylus, writing apps, and online writing platforms.

Some other considerations for therapists would include cultural competence, professional development, and ethical issues. Therapists need to be provided with and experience cultural competence training and create an open line of communication with clients regarding culture and diversity. Having cultural and diversity training is crucial to provide client-centered assessment, and treatment, as well as to be culturally responsive to meet the individualized needs of clients.

Professional development training via workshops, online or in-person seminars, and staying up to date with the latest research in handwriting assessment and treatment is critical for providing evidenced-based and client-centered care.

Furthermore, adhering to guidelines and HIPAA compliance regarding confidential assessment details is crucial for ethical practice in occupational therapy.

Overall, by providing cultural and diversity education, training, collaboration, and professional development, therapists can enhance their level of practice and overall contribute to the greater progress and treatment and meet the individualized needs of their clients.