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Expert Perspective: Q&A with a School-Based Occupational Therapist

Answers By Dana Kalksma, OTR/L

At SET Tech, we’re all about collaboration and listening to the community of parents and professionals who help children with handwriting and fine motor skills difficulties. For this article, we’ve asked Pediatric Occupational Therapist, Dana Kalksma OTR/L, about her experience in the school setting. Dana received her Master’s in Occupational Therapy from Columbia University and works at a school in the New England area. We dive into common handwriting issues, adaptive equipment and the influence of technology on her students. We hope you enjoy her thoughts as much as we did!

What is your current role as a school-based OT and what does your typical caseload look like?

“As an occupational therapist in a school setting, I work to support student success and participation in the classroom, hallway, recess, and during electives. I get many referrals for handwriting, organizational skills, and sensory processing. I work in three elementary schools, one middle school, and one high school with a direct caseload of around 75 students (and about another 40 students for consultation services). They certainly keep me busy! I work with an array of people ranging from students with ADHD, sensory processing disorder, Autism spectrum disorder, and Down syndrome.”

What are some of the common things you work on with your students?

“I work on fine motor skills with a majority of my students, which typically includes handwriting practice! The kids have a very busy and fast-paced school day and handwriting is not often a priority. I usually like to start my sessions with a gross motor, sensory motor, or body awareness activity such as an obstacle course. We then transition to fine motor skills training, which may include a craft, handwriting, or in-hand manipulation games.

Students are not always using their pincer grasp skills, which is the ability to use your index finger and thumb to pinch. This not only impacts their writing skills and pencil grasp patterns, but other important tasks including buttoning, manipulating coins, and shoe tying. Many sources say kids should be able to tie shoes around six years of age however I am working on shoe tying with students of all ages.”

In terms of handwriting and fine motor skills, what are some of the common problems you help them with?

“Many of my students have handwriting goals related to functional grasp patterns on their writing instrument, letter formation, letter sizing and spacing, and activity tolerance related to handwriting. Some of the underlying skills needed for handwriting include:

Hand and finger strength: I’m seeing many students who wrap their thumb around their pencil rather than stabilizing it on the pencil. Thumb wrapping means the student is looking for additional stability due to decreased hand strength. Concerns with wrapping the thumb around the pencil include not being able to use precise finger movements and fatigue on the forearm muscles when writing lengthier assignments. Other students will also start to hyper extend their index finger from too much pressure on the pencil.

Letter formation and pacing: As students are not always getting much handwriting practice, they do not always form letters in the top down approach. While a slower method may work for a period of time, students may have a hard time keeping up as the demands on writing assignments get more difficult. A lot of the students have difficulty pacing themselves through writing assignments, which impacts overall legibility.

Visual perceptual and visual motor integration skills: Many of my students demonstrate letter reversals. Typically, students will avoid writing letters “b” and “d” and will get into a habit of only writing those letters in capital.”

What kind of adaptive equipment do you use to address some of these issues?

“I try to address underlying skills before using adaptive devices as some students do not want to stand out with adaptive devices in the classroom and it is hard to monitor if devices are being carried over into the classroom environment. During therapy sessions, I try to promote functional grasp patterns during handwriting by having the students hold a small item in their hand or by using a pencil gripper to cue students where their fingers should be on the pencil. If their hand muscles fatigue during the writing assignment, I will place a slant board or binder under their wrist to promote stability.”

How do you feel tech has influenced the children you work with? What’s the good and what’s the not so good?

“Technology is so engaging for kids and they are often motivated to use it. Many students would choose to use an iPad rather than sit down for a handwriting assignment. Some students avoid handwriting assignments all together. It is also easier to allow a student to type or use speech to text options when handwriting gets too difficult or when students become too frustrated with handwriting.

Computers and iPads have also been a great resource for many students. Using functions such as speech-to-text and spell check are great for students with dyslexia, dysgraphia and cerebral palsy. Even simple features on a computer, such as adjusting the contrast, can help students significantly. Many parents have talked about how different apps have helped their children learn in ways they never thought possible.”

How do you use technology during your sessions?

"I originally purchased a tablet to use with my students as I thought it would be a lot more engaging for them to practice handwriting on the iPad rather than a piece of paper. I ended up not using it as much as I thought I would for a couple of reasons: The first being that much research shows the best way to improve handwriting skills is by actually handwriting (surprise, surprise). Another reason being that some students use the iPad as a reward in other areas throughout the school day, as well as in the home. The OT rooms typically have so many fun hands-on activities; I encourage my students to play during their reward/free time."

What are your thoughts on a tool like Hold It Write? Do you see this fitting into OT sessions, classrooms or at home?

“I love the idea of Hold It Write! Using a multi-sensory approach to learning is very important. Kids love technology and it is imperative to consider their interests and motivations during activities in order to engage them and make progress. Once kids develop a poor grasp pattern, inefficient writing style, or negative opinion on handwriting, their habits and ideas are hard to break. This technology can assist with skill establishment and skill maintenance. I only see my students 1-2x/week for 30-minute sessions and carry over of skills into other environments is something I worry about. I love that this technology can monitor progress and is easily accessible in the school and home environments!”


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