HELPING STUDENTS WITH FINE MOTOR &

SENSORY MOTOR DIFFICULTIES

Amy Elgin, OTR/L, BCP

Occupational Therapist

CAMCO
Physical & Occupational Therapy
 OBJECTIVES

• To have a basic understanding of hand skills and

development of fine motor skills
• To have a basic understanding of visual motor
development and impact on fine motor skills and
handwriting
• To understand the importance of proper positioning (desk,
chair, paper, etc.) for improved performance
• To describe proper pencil/tool grasps
• To utilize activities to develop: grip and pinch strength,
coloring within lines, pre-writing practice, printing within
lines, and spacing between letters and words
 HAND SKILLS
• Hand skills and fine motor skills are essential to
exploration and discovery of your environment

• Hands are the “tools” most often used to accomplish

work, play and daily living skills

• Hand skills are most readily developed and refined

via a combination of tactile/proprioceptive (touch)
input AND visual information (but can be done
without the visual component)
 HANDWRITING PREREQUISITES

• posture
• pencil grasp
• hand development
• finger muscles
• shoulder stability
• writing without watching
 POSITIONING
To promote good printing and cursive writing
skills, a student should be seated correctly. A
stable trunk will promote good arm control.
• proper chair size

• proper chair position

• proper desk size

• modifications

• positioning writing paper

• The three “P” s of handwriting

 UNDERSTANDING THE HAND
• There are two sides to the hand. The first is considered the
“mobile” side. It includes the thumb, index and middle finger.
These fingers move when you write. The other side is
considered the “stable” side. It includes the ring and pinky
finger. These two fingers generally are closed and resting on
the table during writing. The web space is the open area
between the thumb and the index finger. It is where the pencil
should rest during writing.
 REMEMBER…

• Good crayon and pencil grips should be actively and regularly

taught.
• Teach grips as soon as age 4 or whenever crayons are
introduced.
• Grips (good or bad) become automatic or habitual with
repetition.
• The older the student, the harder it is to change the pencil grip.
• Try to change grips if it hurts to write, or if the grip makes
writing inefficient.
• Use physical devices only if demonstration and practice
haven’t worked.
 HOW TO HELP
Always demonstrate proper finger position for students
(especially young children).

You may use devices as reminders. It’s best not to use pencil
grips in Kindergarten as children are just learning correct
grip and just starting to write. There are a lot of devices
available. Use what works for children (don’t feel limited to
the ones shown). If a device is used at school, parents should
be educated and the same device should be sent home. It’s
handy to have one at home and one at school.
 PENCIL AND TOOL GRASPS

• dynamic tripod grasp

• lateral tripod grasp
• preschool grasp
• scissors grasp
• knife grasp
• tweezers grasp
SUPINATE GRASP
PRONATE GRASP
STATIC TRIPOD
DYNAMIC TRIPOD
LATERAL GRASP
FISTED GRASP
ALL FINGERS EXTENDED
PRONATED PALMAR GRASP
 SUGGESTIONS FOR THE
CLASSROOM

“What can I do when a student has…”

• a poor pencil grasp

• poor scissor skills

• poor handwriting

• *handout*
SCISSOR GRASP (PRONATED, I.E.”THUMB DOWN”)
 FINGER MUSCLE “WARM-UPS”

• Fingertip push-ups
• Squeeze
• Translation
• Rotation
• Twirl
• Crawling
• Shake

*handout*
 TOYS FOR FINE MOTOR
DEVELOPMENT
• Please refer to handout for extensive samples of
toys to promote fine motor/hand development
THE 8 KEY COMPONTNTS OF HANDWRITING
1. Memory – Remembering & writing dictated letters and numbers
Quick and automatic recall of letters and numbers is very
important. Memory is essential for all independent
handwriting. Poor memory hurts production, speed, and
accuracy.

2. Orientation – Facing letters/numbers in the correct direction

Beginners may reverse a “few” letters and numbers. But with
good instruction, children can learn how to orient letters and
numbers correctly. Orientation errors are distracting; children
stop to think about which way the letters or numbers go.
Orientation errors cause spelling and legibility mistakes.
3. Placement – Putting letters and numbers on the
baseline

Placing letters and numbers on a line makes writing easier to

read. It is important for the flow of writing. Haphazard placement
makes printing appear immature, messy, or even illegible.

4. Size – How big or small a student chooses to write

Children need to be able to control their movements so their

writing isn’t too big for the current grade. Writing too large
causes problems with school papers, speed, and spacing.
5. Start – Where each letter or number begins
Good starting habits allow children to maintain neatness even
when they print quickly. Children who become messy when
they print quickly are typically children with incorrect starting
habits. They often start letters at the bottom.

6. Sequence – Order and stroke direction of the letter or

number parts
The ability to form letter or number parts correctly is acquired
through direct teaching and consistent practice. If children do
not form parts in the right sequence, speed and neatness are
affected.
7. Control – Neatness and proportion of letters and
numbers
Control does not usually require direct remediation. Problems
with control are almost always caused by poor habits. If the
student has an awkward pencil grip, control will be affected. If
the student has a problem with start or sequence, control will
be affected. As habits improve, so will the student's control.

8. Spacing – Amount of space between letters in words, and

between words in sentences
Spacing is important to the legibility and uniformity of
writing. Problems with spacing may be made worse by poorly
designed worksheets that do not give enough room for writing
 WHY CAN HANDWRITING BE SO
DIFFICULT?

Rather than give little children the overwhelming task of

learning 62 symbols (26 capitals, 26 lowercase and 10
basic number symbols), start with capitals! When
children learn to write their CAPITALS, they develop a
strong foundation for printing. They learn important
handwriting rules (such as a top to bottom, left to right
habit), proper letter formation, and solid visual memory of
their CAPITAL letters. Lowercase letters will be a breeze
to learn because of this foundation!
 CAPITAL LETTERS ARE EASIER

• All are the same height.

• All start at the same place - the top!
• All occupy the same vertical space.
• All are easy to recognize and identify
• (compare A B D G P Q with a b d g p q).
• They are big, bold and familiar.

ABCDEFGH
 LOWERCASE LETTERS ARE
MORE DIFFICULT

• Lowercase letters are not the same size.

• Lowercase letters are more difficult to recognize because
• of subtle differences (a b d g p q).
• Lowercase letters occupy three different vertical positions.
• Lowercase letters start in four different places. (b c e f m)

abcdefghijk
WHY DO YOU START YOUR LETTERS AT THE
TOP?

• Have you ever noticed how some children start their

letters? Sometimes they start them at the top and
sometimes they start them at the bottom. Does it really
matter? Yes, it does! The English language has
specific rules for reading and writing. We live in a top
to bottom and left right society.
• Developing good starting habits for printing is
essential to success. Did you know that there are
no capital or lowercase letters that start at the
bottom? All capital letters start at the same
place…at the TOP!

• Children who start their letters at the bottom are

usually slow or sloppy. By starting at the top,
you can be both fast and neat.
 SO WHY DO STUDENTS START THEIR
LETTERS INCORRECTLY?
• Introducing lines too soon can lead to problems.

• Using paper with too many lines can cause confusion

about where to start.

• Inappropriate letter practice/instruction

• Teaching both capital and lowercase letters together

can cause confusion about starting places.
HOW CAN YOU HELP CHILDREN?
• Demonstrate the correct formation of each letter several
times. Then, watch your children imitate before they
practice on their own.
• Look at the type of paper you are using; changing paper
can help.
• Look at your teaching materials; choose developmentally
appropriate letter practice.
• Teach only capital letters first. Remember, capital
letters have only one starting place...the TOP!

• Teach young children position words, like “top,

middle, bottom,” and demonstrate the meaning of
each. This will help your understand what you say
when you give directions for making letters.
 MEMORY

• Kindergarteners benefit from exposure to letters

and numbers by using a variety of materials and
approaches. Multisensory lessons engage
children in learning with hands-on and
developmentally appropriate materials.
 ORIENTATION

• Most kindergarteners have not yet mastered

directionality or the concept that letters and numbers
have a specific direction (whereas a doll facing left
or right is still the same doll).
• To correct reversals, take an easy approach. The
HWT Slate and Gray Block Paper give children a
frame of reference for directionality to correct
capital and number reversals.
• If children reverse many of their numbers, work on
them one at a time starting with the lowest number.
 PLACEMENT

• When learning to write, children need the

guidance of lines. However they can become
confused if they have to work with too many
types of lines on different assignments. To
succeed, beginning writers need to see active
modeling on lines and one consistent type of line
on which to write.
 SENTENCE SKILLS

• Kindergarteners can struggle with proper writing

conventions like capitalization and correct
spacing between letters and words.

• Ensure that all their workbooks and worksheets

provide enough room for writing. Landscape
orientation is best. Lines should be wide enough
to accommodate the larger writing of children
working at the kindergarten level.
 NAME
• Children love learning to write their names. Use
multisensory lessons to help them progress through
the stages of name writing as they learn proper
formation habits.

• Provide direct instruction of the letters in a child's

name using child friendly language for formation.

• Provide opportunities for children to practice name

writing in the classroom. Children will do well when
they can copy from good models that show the
progression of name writing skills.
 FORMATION

• Kindergarteners who have difficulty with

forming their letters may start at the bottom or
change the direction of the stroke while forming
a letter or number. Engage children with
multisensory activities that promote proper letter
formation practice.
 SIZE

• Some kindergartners may be writing too large

for their grade level. Have children engage in
developmentally appropriate, hands-on activities
that help them understand the concept of letter
size. Children at this age also need appropriate
resources for writing letters and numbers the
correct size.
 NEATNESS
• Children working at the kindergarten level may
demonstrate poor written work. Neatness takes time
and develops with daily instruction and practice
using well-designed materials.

• Neatness is related to correct formation habits and

motor skills. Children who are not neat may have
underlying formation problems or immature
physical development. Take time to look at their
formation habits and provide remediation as needed.
 SPEED
• Some children may be slow to complete tasks while
others are fast but messy. Writing speed is linked to
all the measurable skills of memory, orientation and
placement as well as formation skills. Children who
have to stop and think about what a letter looks like,
which direction it faces, how it's placed on a line,
and how to form it will be slow.

• Problems with speed can also be caused by other

concerns. Take time to investigate the problem and
provide appropriate remediation.
 POSTURE
• You must show young children how to prepare their
bodies for writing. Improve posture problems by
having the right furniture and adding movement to
improve alertness. Teach children how to sit and
place their hands for writing. Children this age need
explicit instruction and frequent movement breaks.

• To promote good posture check the furniture size.

The chair and desk should fit the child.
 PENCIL GRASP
• Children this age are excited to learn and have
flexible grip. Take advantage of their enthusiasm and
engage them with small writing tools that promote
proper grip development.
• Give children opportunities to practice proper finger
placement for grip Encourage children to drop and
then pick up their pencils correctly.
• Use writing tools that are the right size for little
hands and promote good grip. FLIP Crayons and
Pencils for Little Hands .
• Demonstrate grip.
 HELPER HAND
• Children working at the kindergarten level need to
be shown how to hold a piece of paper. Integrate
activities in everyday work that promote helper hand
skills.

• Make sure children are aware that they have a helper

hand and that they know its job--to hold the paper.
 VISUAL MOTOR CONTROL

• Definition
• Examples
• Overview of development
• Why difficulties may arise
• Classroom activities
• Modifications

*handout*
 TIPS FOR INDIVIDUALIZING AN
ACTIVITY
• Vary the level of intensity

• Vary the level of support

• Vary the materials used for the activity

• Incorporate practice into everyday activities

• Alternative strategies

• *handout*
 CLASSROOM ACTIVITIES
• Adaptations for weak pinch and grip strength

• Coloring within line boundaries

• Pre-writing activities – line copying

• Placement of letters within lines

• Spacing between letters and words

 PREPARE THE CLASSROOM

• Children ideally should be facing the chalkboard

when you’re demonstrating…your students will see,
hear, and pay attention better

• Keep board space clear

• Place the alphabet above the board and on desks

• When teaching one-on-one, be sure to place the

right-handed student on your right and the left-
handed student on your left.
LET’S ADDRESS SOME COMMON
CLASSROOM CONCERNS
 PENCIL GRASP
• The optimal pencil grasp is known as the "tripod grasp."
This is when the pencil is supported by the thumb, index,
and middle finger. The ring and little finger are bent and
rest comfortably on the palm. (You shouldn't worry about
a student's pencil grasp unless it is affecting their writing
or the student is experiencing pain/fatigue).

• Ideally it would be nice to teach every student how to hold

their pencil correctly from the start; however, some
children develop poor habits and you may need to try an
adaptive grip to help position their fingers.
• When using an adapted gripper, have the student only use
the adaptive grip for a short time each day. This will help
the student get accustomed to the feel of a new grasp. Too
much awkwardness may make the student resist change.

• Typically when trialing an adaptive gripper, you

should expect that the student’s handwriting will get
worse before it gets better as the student adjusts to the
gripper…IT WILL TAKE TIME AND PRACTICE.
 HOLDS PENCIL STRAIGHT UP IN THE AIR

• This is also known as the "Washington Monument" pencil

grasp. The student may be having a difficult time
separating the two sides of their hand. There is a mobile
side to the hand (the thumb, index, and middle finger) and
the stable side (the ring and pinky finger). You can try to
use the Handi-writer device purchased or “home made”
from your OT or you can use two rubber bands looped
together with one loop placed around the student's wrist
and one loop around the pencil. The eraser end of the
pencil should point toward the student’s shoulder.
 HOLDS PENCIL TOO CLOSE/TOO FAR AWAY FROM TIP

• Wrap a small rubber band or a piece of masking tape

around the area where the fingers should be placed.
This will remind the student where to hold the
pencil. When using a traditional pencil, you can
remind them to hold the pencil "where the paint
ends."
 MOVES ENTIRE ARM WHEN WRITING

• Have the student lay on the floor to write. This puts

weight on the arms and stabilizes them. You can also
have the student write on a vertical surface (like a
chalkboard or stable easel). This helps the student
put their wrist in a functional writing position and
also works on shoulder stability.
 STUDENT DOES NOT LEAVE
SPACES BETWEEN WORDS

• Use a stamp pad and have the student stamp their

fingerprint between each word.
• You can also place a small piece of candy or a sticker
between the words. Spacer sticks also work well.
• Use a “finger space” between each word
• Use a small popsicle stick or Q-tip as a visual reminder
until it becomes more habitual.
• Use a “spaceman” spacer between words
 PENCIL PRESSURE
Student Writes Too Hard
• This may be because the student has poor awareness of
finger placement and movement or poor control of the
smaller muscles of the hand. Sometimes correcting the
pencil grip may help this problem.
• Have the student practice coloring bunnies light gray,
medium gray, dark gray, and black to increase their
awareness of different degrees of pressure on the pencil.
• Try a mechanical pencil so the student will keep breaking.
• You can also has to learn to control the amount of
pressure used or the lead have the student place their paper
on a piece of Styrofoam or a computer mouse pad (if they
press too hard they will poke holes in their paper). Try
having the student write on a phone book.
 Student Writes Too Softly

• You can also try a weighted pencil to give the student

more awareness of the pencil.

• Sometimes correcting the pencil grasp can also help

with this problem.

• Have them write on a stack of papers, which

encourages them to use more pressure for their
writing to be seen.
 STUDENT DOESN'T STABILIZE PAPER WITH
OPPOSITE HAND
• If the student only has the physical use of one hand,
use a clipboard, slant board with clips or a piece of
tape to hold their paper in place.
• For other students try naming their helping hand
(non-dominant hand) and showing it how it has
other jobs to do. Students love when you talk to their
hand like it is a person.
• Have them hold their paper up on the wall or the
blackboard while writing, be/c if they don’t hold it,
it will fall to the floor.
 SENSORY SYSTEMS
• An Individual take in sensory information from
the environment and movement of the body, the
CNS processes/integrates these sensory inputs,
and the individual uses the sensory information to
organize his behavior

• Deficits in sensory integration results in deficits in

conceptual and motor learning
 SOME SENSORY BACKGROUND
INFORMATION
• The five main senses are: tactile (touch), auditory
(sound), visual (sight), gustatory (taste), and
olfactory (smell)

• Two additional senses which have significant

influence over our body systems are: vestibular
(movement and balance) and proprioception (joint
and muscle sense)
 VISUAL SYSTEM

• Motor skills

• Reading

• Safety and awareness

• Environmental navigation

• Motor planning
 AUDITORY SYSTEM

• Hearing

• Following directions

• Communication

• Safety and awareness

 GUSTATORY/OLFACTION

• Taste and smell

• Food preferences

• Pleasure
 TACTILE

• Touch

• Pain/temperature

• Discrimination

• FM skills

• Textures
 TACTILE DEFENSIVENESS
• The student lacks the ability to inhibit tactile
sensations and thus is overly focused on the input;
incoming tactile sensations are not modulated
correctly, resulting in the tactile input being viewed
as aversive

• Tactile defensiveness occurs when the dysfunctions

is with the protective component of the tactile
system
 TACTILE DEFENSIVENESS CAN IMPACT:
• The student's ability to engage in and tolerate self-
care activities (nails cut, teeth brushed, hair combed)
• The student's ability to eat certain
textures/temperatures (lumps in mashed potatoes,
crunchy, cold yogurt)
• The student's ability to sit near other students in
school (afraid of being brushed up against)
• The student's ability to utilize various school
materials (glue, finger paint, etc) which can affect
the student's tool use be/c he doesn’t want to hold
items and may only hold the item in his fingertips (=
poor grasp patterns)
 TACTILE DISCRIMINATION

• Tactile discrimination is the ability to understand

attributes of tactile sensations; includes determining
if the input is light touch vs. deep pressure,
pinpointing location of a touch, and understanding
properties of objects including size
 POOR TACTILE DISCRIMINATION CAN
RESULT IN:
• Difficulty interacting with toys effectively; the student
may not be able to control the force of his movement,
using too much or too little pressure
• Difficulty using touch alone to define/identify the
properties of an object, which means the student must
rely on the sense of vision
• Difficulty registering pain and localizing the point of
pain on his body
• Difficulty localizing where touch has occurred on his
body
• Poor in-hand manipulation skills because he is receiving
poor feedback in his hands; this results in poor pencil
grasp, scissor use, fastening buttons, etc.
 POOR TACTILE DISCRIMINATION CAN
RESULT IN:
• Difficulty interacting with toys effectively; the student
may not be able to control the force of his movement,
using too much or too little pressure
• Difficulty using touch alone to define/identify the
properties of an object, which means the student must
rely on the sense of vision
• Difficulty registering pain and localizing the point of
pain on his body
• Difficulty localizing where touch has occurred on his
body
• Poor in-hand manipulation skills because he is receiving
poor feedback in his hands; this results in poor pencil
grasp, scissor use, fastening buttons, etc.
 POOR VESTIBULAR PROCESSING CAN
RESULT IN:
• Low muscle tone

• Poor postural control and balance

• Gravitational insecurity

• Poor bilateral coordination

• Poor eye movements

 POOR PROPRIOCEPTIVE PROCESSING
MAY RESULT IN:
• The student having difficulty planning and
coordinating his movements; may appear to be very
clumsy/gawky

• The student may have low muscle tone; may have

difficulty “grading” his movements (may under or
overshoot his movements
 THE VESTIBULAR SYSTEM

• Receptors are located in the inner ear and respond to

changes in head position and movement
(acceleration/deceleration) ; these receptors also
respond to linear movement (up/down, side/side,
back/forth) and rotary movement (spinning)
• The vestibular system is responsible for providing
the body with information on the position of the
head and body in relation to the ground
 VESTIBULAR
• Head stability

• Postural control

• Muscle tone

• Body awareness

• Movement in space

• Auditory processing
 POOR VESTIBULAR PROCESSING CAN
RESULT IN:
•Low muscle tone

•Poor postural control and balance

•Gravitational insecurity

•Poor bilateral coordination

•Poor eye movements

 PROPRIOCEPTIVE SYSTEM

• Proprioception is the unconscious sense of body

movements
• Receptors are located in the muscles, muscle
tendons, and joints; they respond to movement and
gravity
• The function of the proprioceptive system is to
provide the body with information regarding where
the body is in space (external map) and also where
body parts are in relation to one another (internal
map)
• The proprioceptive system works very closely with
the tactile and vestibular systems
THE “HYPER”-RESPONSIVE STUDENT
• may have tactile defensiveness; may avoid or be
oversensitive to touch; avoid getting “messy”;
tags in clothing or certain textures may upset
them; specific items, textures, etc. may cause
them to gag when touched
• may be oversensitive to movement; avoid or
become upset with having feet leave the ground,
playground equipment, being picked up, car rides,
stairs, elevators/escalators
• may run around/move constantly, have difficulty
sitting still for any length of time
• may cover ears in cafeteria, on playground
• may pinch nose in cafeteria, around craft
materials, etc. due to smells
 THE “HYPO”-RESPONSIVE STUDENT

• may crave/seek touch; may constantly bump/crash

into people or things
• may appear very clumsy, due to the fact that he is
always running into objects or handle items
“roughly”/”grossly” rather that gently or with fine
motor skills
• may overstuff his/her mouth when eating secondary
being hypo-sensitive, does not realize how much
food is in his/her mouth
• may spin, jump, roll, run, bounce , rock/sway in an
effort to get sensory input into system and body
awareness/position-in-space
• may appear low-tone/hypotonic
 Amy Elgin, OTR/L, BCP
Occupational Therapist
Board Certified in Pediatrics
aelgin@camcoptot.com

Camco
Physical and Occupational Therapy
814-266-8833

Thank You!