College or Bust? Understanding your college student’s mental health

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After months of preparation and the college essentials are jammed in the back of car, your high school grad is off to their first year of college.  You might be experiencing the swirl of emotions and expectations typical of a parent sending their child off on their first step toward adulthood. But what happens when your student doesn’t make it through their first year or even semester? According to some sources, 35 percent of first year college students will drop out during their first year.  The Bill and Melinda Gates foundation reports that a majority of these students drop out due to the cost of going to school. But what about the mental health of our first-year college students? According to the National Alliance on Mental Health, 50% of college students reported their mental health as below average or poor.

There is no doubt that the transition from high school to college is a difficult one. As therapists we are seeing clients who are struggling to make this transition. We work with others who have returned home experiencing feelings of shame and guilt for not performing to the real or perceived expectations of their family and friends. Students are left asking questions of themselves and working through the feelings on their own. Many times, parents are left with questions about how to help their children who are in uncharted college territory. I have turned to a seasoned colleague who has years of experience working with this exact population. Christine Triano is a licensed clinical social worker and the Director of Mental Health at the Center for Connection in Pasadena. Here is a question and answer session vis-à-vis parents of college-age students.


Christine, how can we know if our student is really struggling with mental health issues or if it’s just laziness or homesickness? 

Homesickness is a normal part of the college experience, and likely a feeling your child has already experienced at summer camp or travel away from family. It’s a hard feeling, but one that is also tolerable and should resolve with time and engagement with others and by participating in enjoyable activities.  

A mental health issue does not simply pass, but rather continues to come up and, untreated, likely worsen. One way to look at any issue is to ask, is this significantly impairing my child’s ability to function? Questions to assess this might include: Are they making it to class? Getting their work done on time? Maintaining a regular schedule? Getting enough sleep? Spending time with peers? How’s their self-care (e.g. hygiene, nutrition, personal chores)? Major challenges in any of these areas may signal that there is a mental health issue at play.

How do I prepare my student for the independence of college life?

There are two fundamental forms of preparedness for leaving home. The first is cultivating the skills necessary for independent living. I can’t tell you how many freshmen I met while working as a college mental health counselor who had never grocery shopped or done a load of laundry. Think about leaving home for the first time to live away from your family in a totally new setting, surrounded by strangers, including one or more you have to share a room with. Then add the academic pressures and logistical demands of mastering a college schedule. It’s a lot. Now, add the fact that you need to put money on your laundry card, make sure you have a bottle of Tide, and separate your whites from your colors. It is a small task that can become that one extra drop that makes a student’s bucket overflow. 

So, how to help your teen be better prepared in this regard? This one is relatively simple, but means starting now (or yesterday!). I strongly believe all kids should have chores. Even a 5-year-old can help set the table, or put their clothes in the hamper. Beginning in high school, I often share with parents that they are not helping their child grow by doing things for them they are capable of doing themselves. My own children, both teens themselves, have heard this time and again. Of course, there are exceptions. When my recent high school graduate was studying for finals, I happily threw in a couple of loads of laundry for him. But, in general, I think it’s great to look at this as adding tools to their self-care toolkit. This includes tasks like: laundry, changing their sheets, cleaning the bathroom, preparing some simple meals, and making a basic grocery store run. For older teens, making their own appointments for haircuts or the doctor is also great practice. If they drive, I would add basic car maintenance too. 

The second form of preparedness is more about emotional readiness. A Harris Poll of college freshmen found that a full 60% stated they wished they had gotten more help with emotional preparation for college, defined as “the ability to take care of oneself, adapt to new environments, control negative emotions or behavior and build positive relationships.”  Studies have shown us that such preparedness is a major factor for students’ success during their first year at college. I would also add that play and balance are major contributing factors for cultivating resilience.

At the Center for Connection, we often talk about the foundation for this kind of resilience in terms of having the ability to self-regulate. Anxiety, depression, panic, stress, isolation, or withdrawal, by contrast, are all forms of being in a state of dysregulation. One way to approach this is by asking yourself if you are scaffolding your child up toward greater resilience. This may mean encouraging them to email a teacher or to set up a meeting at school on their own, allowing them to plan how to spend their time when there are competing social and academic demands, and generally letting them experiment with taking risks (within reason) and possibly failing. In general, if you can standby with support and empathy, rather than intervening or otherwise performing those amazing contortions of body and spirit designed to prevent your child from experiencing disappointment, loss, or discomfort, then you are on the right path.

I know my student has mental health issues, what can I do to ensure he/she is safe and healthy at school?

College campuses are acutely aware that students are experiencing record-levels of mental health challenges, with counseling centers facing increasing, and in some settings, overwhelming demand for services. The fact is, almost one thirdof students meet criteria for an anxiety or depressive illness during their college experience and many do not get or seek the help they need. It’s important not to be afraid to explore what’s really going on. It’s not unusual for a young adult to try and work things out on their own, or to be reluctant to worry parents back home.  If you have concerns or a sense that your child is really struggling, start with some open-ended questions or maybe be sharing a memory of your own college experience when things were hard. Let them know that their well-being is more important than their GPA and that you are there to offer support, without judgment. If you suspect they feel overwhelmed, you may want to gently offer to investigate options on campus, such as “I know the counseling center is available to all students, would it be helpful if I checked into how you go about making an appointment?” Keeping your own fears and concerns in check is important here. Even with college-age students, as parents our emotional state still has a big impact on our kids. We can help by being mindful that our own worries don’t amplify our child’s distress.

My student just told me they want to take a year off, what should I do?

First, breathe. Then, investigate, without leaping to assumptions. If your child is coming to you with such a pronouncement, it very likely was not arrived at lightly or easy to share. Maybe they are just feeling overwhelmed and need to vent. In that case, it may be more a question of exploring what kinds of support they need that they may be lacking. If it’s more serious, the first step should be to assess whether your child is in crisis. If so, it’s always important to seek help immediately. There are lots of reasons students decide to take a break. In many other parts of the world, it’s common for young people to take a gap year before heading off to four-years of college. The reasons for this are many, including gaining life skills, seeing new places, discovering what they’re interested in, volunteering, earning some money, and learning more about themselves. 

I have worked with students who muscled through their first year or two of school, despite the growing burden of untreated, or undertreated, anxiety, depression, trauma or other mental health issues. In my experience of working with such young people, there is also often an element of confusion about their identity rooted in not having a sense of their authentic self. Teens today face enormous pressure, oftentimes internalized, to be “perfect.” I am regularly impressed by the drive I see in high-schoolers, juggling AP classes, sports, extra-curriculars and schedules that make me tired just to hear about. The one thing that can be missed in this drive to get into a good college or university, however, can be time to reflect on their true values, hopes, dreams, and passions. Once away at school, it can make it even harder to form meaningful connections with others when it’s hard to be yourself, or if you’re not even quite sure who that self is. 

All of these factors can lead to that call where the idea of taking a year off is proposed. Getting to the degree is important, but so is arriving at college graduation with the mental and emotional well-being, life skills, and maturity to succeed after college. Would your student benefit from a year to focus on cultivating these qualities? What are the options for your family, and how can you come to an agreement about what the year will look like? I’ve worked with students home for a semester or a year, some of whom have done intensive therapy for most of that time, others who combined treatment with getting a job or taking classes nearby, and yet others who created plans involving travel and volunteerism after a restorative period home. All schools have a procedure for requesting medical leave, which applies to mental as well as physical health. There are some details to work out, but with a simple request and sometimes a letter from a mental health professional, the process can be initiated to give your student the time they need to get well. 


Christine, you gave the readers great words of wisdom, anecdotes, and practical advice we can implement tonight! In some cases, the decision to go to college is expected and the discussion around the kitchen table usually focuses on tuition, deciding on a major, and where to live.  While bedding and books are essential parts of going to college, you can equip your child with a tool belt stocked with resilience, self-care, and self-advocacy tools to ease their transition into Independence University.  Experiment with giving your child space to be responsible for making an appointment, completing a chore, or advocating for themselves, and except some speed bumps along the way; mistakes and failures are moments of learning. By the way, the loads of laundry they bring home on the weekends are their way of saying, “I still need you.” — OMH

Introducing the Play Strong Institute...

The Center is excited to announce that we've expanded. Our new venture, The Play Strong Institute, will be run by Managing Director Georgie Wisen-Vicent and will open its doors September 1, 2018. 

Located at 1021 E. Walnut in Pasadena, California, the Institute is dedicated to providing continuing education and training to a new generation of play therapists, advancing study and research in play therapy and neuroscience, and enriching the lives of children and families through counseling that is highly integrated with the science of interpersonal neurobiology, trauma-informed care, play and the expressive arts. 

A MESSAGE FROM THE PLAY STRONG INSTITUTE

Our mission is to promote best practices in Child-Centered Play Therapy training with a focus on the brain and relationships for graduate students, pre-licensed and licensed professionals in counseling, psychology, social work, family therapy, and integrative mental health. We always incorporate the latest research on the developing mind, brain, and relationships working from a neurobiology framework in play therapy to better understand the needs of children who experience stress, anxiety, and trauma and help develop stronger emotional resilience. 

Because children are better at expressing emotions through their actions, the distinct advantage of play therapy is that children express their ideas and feelings through creativity and hands-on innovation. Research shows that our brains develop and get connected from the bottom up, so we begin with body movement and sensory experiences and allow children to make a natural progression to complex thinking, emotional awareness, and mature communication. In play therapy, children can share their life stories, form new connections and build confidence around previous challenges that have been difficult, uncomfortable, worrisome, confusing, or chaotic. A creatively attuned play therapist responds skillfully and effectively to clarify their needs, help them express their emotions, find new solutions, practice new skills, and rewire healthy brain connections in a way that feels most natural, comfortable, and yes, even fun and enjoyable to children!

Improving quality play therapy education and training for prospective play therapists and building competence in the neurorelational framework that respects the individual differences of children, teens and young adults are of particular importance to us. Our team of therapists, supervisors, and instructors has spent many years studying and practicing evidence-based, research-supported approaches in play therapy guided by the science of interpersonal neurobiology. We are very proud to share our knowledge, experience, and enthusiasm for teaching and working holistically with children and families. Join us in the movement to create stronger, healthier, more resilient kids through play!

Learn more!

Visit the Play Therapy Institute's website to learn more: https://www.thecenterforconnection.org/playstrong/

We have a new home for our interdisciplinary team!

We are very excited to have all of our brilliant CFC clinicians together under one roof! Our new office is located near the 210 freeway, right off the Madre Street exit, and we'll be open on Monday, July 23rd, 2018!

Our new offices will feature plenty of on-site parking, 6,000 square feet of office space, gorgeous mountain views, updated facilities, and more! It's also conveniently located near the Post Office, multiple restaurants, Target, and other shops.

We will close our California location by the end of July, and each team member's move-out date will vary. Our Walnut location will become a hub for play therapy. We will keep you updated as additional details become available! 

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 3030 E Colorado Blvd, Pasadena, CA 91107

3030 E Colorado Blvd, Pasadena, CA 91107

CFC Clinician Dr. Chon Featured on MotherSquad.com

Check out this powerful blog from CFC clinician, Dr. Esther Chon, which was featured on Mother Squad.com. Dr. Chon is a mom and a clinical psychologist with a specialty in Infant Mental Health and Maternal Mental Health. 

To quote Mother Squad, "Dr. Chon writes about the experience of having a picture in your head of what your baby will be like versus what the "real" baby is actually like. This process of grieving, accepting, and loving repeats itself throughout motherhood. Dr. Chon draws from her own experiences as a mom." 

We Now Offer the Safe and Sound Protocol

We are proud to announce that we now offer the Safe and Sound Protocol at the Center for Connection for kids who need help with regulating their emotions.

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Based on years of research by Dr. Stephen Porges, the Safe and Sound Protocol is a 5-day therapeutic listening program designed to help increase the social engagement system in children and adults while simultaneously calming the nervous system. We must be regulated and organized in order to understand language and engage socially with one another!

SSP is a great way to help children and adults move through major transitions (such as starting school, starting a new job, going on vacation) and prepare for participation in other therapeutic interventions. Visit the Integrated Listening System (iLs) website for more information.

Dr. Jamie Chaves, OTD, OTR/L, SWC at the Center for Connection, can now administer the SSP, which can only be done by a professional who has participated in the training. Interested participants will commit to five (5) consecutive days of listening to the 60-minute sessions (which can be broken up into two 30-minute sessions with a short break in between, if necessary). The cost of the 5-day intervention is $1,000.

Please contact Dr. Chaves directly for more information or to participate in the program.

Note that this intervention is not meant to replace other forms of therapy--it is designed to be used in an adjunctive manner.

Welcome to Our New Space!

The Center for Connection (CFC) recently added another office, 1021 E Walnut St., Suite 200, Pasadena, 91106, in order to accommodate our ever-growing staff and better serve our clients. With more space, more equipment, and more therapists come more opportunities, more potential for therapeutic progress, and more collaboration.

The educational therapy team now located at the Walnut office includes two part-time Educational Specialists, Tami Millard and Tiffanie Hoang, who are both seasoned educators working toward completion of requirements to become Educational Therapists, and Debra Hori, who is an experienced full-time Educational Therapist for CFC. In addition, Janel Umfress serves as a consultant to CFC for matters relating to educational therapy, school support, and speech/language pathology. We also have two full-time Occupational Therapists at the Walnut office, Dr. Jamie Chaves, and Justin Waring-Crane. Dr. Chaves has her state certification in feeding and swallowing.

At the center of the new space is our full sensory gym, rich in a variety of climbing components, swings, tactile experiences, chalkboard wall, and ample space to move around. Not to mention it is surrounded by windows to give a gorgeous view of the mountains and abundant natural light. Because the sensory gym serves as the central hub, our educational therapists and speech therapists can utilize the space in order to regulate clients before or during their sessions. This puts clients in a better state of mind for learning, allows them to be open to new challenges, and facilitates improved focus—all of which result in more productive sessions. Our occupational therapists find the new space to be more conducive to a sensory integration approach and the wide assortment of sensory-based activities allows them to tailor a “just right challenge” to children of many abilities and ages. Listed below are several of the most utilized pieces of equipment in our sensory gym and a brief description of how they might be used in therapy.

In addition, the Walnut space is equipped with a full kitchen that has ample space for feeding therapy. Kids can engage in making new food creations, constructing food houses and food faces, or simply having a picnic. The kitchen is quiet and exclusive so children can remain regulated and feel in control as they explore the world of new tastes, temperatures, and textures. 

Please stop by to see our new office!

Eating With All Your Senses: A Commentary about Picky Eating

By Dr. Jamie Chaves, OTD, OTR/L, SWC

Food is such an integral part of our society and a necessary component to our health. A well-balanced diet, including a variety of foods from each of the food groups (grains, dairy, fruits, vegetables, proteins), gives energy, boosts the immune system, helps with growth, and protects from certain diseases. But eating is more than just food. Mealtimes often dictate gatherings with family, friends, and colleagues. Gathering around a table facilitates conversations, laughter, and shared memories.

For a child who is a picky eater (defined as eating less than 20 foods), mealtimes are often a struggle for a variety of reasons: they must be distracted in order to eat, they must have their food prepared in a very specific way, restaurants do not offer the kind of food they like, the possibility of gagging or vomiting with any slight change of texture, sitting for a meal seems impossible, the entire process takes 45+ minutes, to name a few. Caregivers may hear phrases such as, “it’s not the kind I like”, “it looks funny”, “why does it smell so bad?”, “I’m not hungry”. Rather than turning the dinner table into a battlefield at the cost of precious calories, it is much easier to present the same 6 foods the child likes on a rotating basis while crossing fingers that each food stays in the rotation.

So why is it that some kids are such terribly picky eaters? Quite simply, it is more of a matter of “cannot”, not “will not”. Medical issues aside (e.g., reflux, hypertonia, hypotonia, food allergies/intolerances, pneumonia), sensory processing challenges oftentimes negatively impact the entire mealtime experience. People usually think about how food tastes and smells when eating, but the reality is that there are many more senses at play. If any one of the senses is not processing information about the food appropriately it can wreak havoc—the more often this happens the more the negative response is reinforced and the more the child will refuse to try anything new.

Understanding how a child’s sensory challenges are impacting eating is the first step in the journey to expanding a child’s diet. Once these sensory challenges are identified, then effective interventions, such as occupational therapy, can be initiated. It’s essential to realize that these eating problems won’t just magically disappear—early recognition of the need for therapeutic intervention is important. Here’s a breakdown of each sensory system and how it impacts the process of eating in order to help you identify possible sensory-related challenges in your picky eater.


The Vestibular System: [provides information about our balance, coordination, and relationship to gravity]

Most cultures sit to eat—whether in a chair, on the floor, or atop a stool. This alone is critical at mealtime in order to maintain a safe position and open airway. Our vestibular system helps to promote an upright seated posture with our head in a neutral position. Some children lack the postural stability to maintain a position in a chair or on the floor, while others lack the small postural adjustments not to fall out of the chair or off the stool. Some children crave movement so much they just cannot calm their body long enough to fully partake in a meal. This may result in “drive-by” eating, eating quickly, or leaning on someone nearby—none of which are very functional. 

In addition, the process of eating takes a lot of oral coordination. Our jaw moves in a rotary motion in order to transfer food from one side of our mouth to the other. Our tongue facilitates the movement of food in conjunction with the jaw movement, and then coordinates with the cheeks in order to produce a swallow. Children who have a difficult time with motor planning and coordination, as a result of decreased vestibular processing (and decreased proprioceptive processing), may present with immature chewing patterns that negatively impact the types of food that are safe for them to eat. Soft, pureed, or meltable foods are preferred because they dissolve easily with saliva without needing a mature chewing pattern. They might push their tongue out of their mouth to move food to the back of the mouth because coordinating tongue elevation with cheek compression is too challenging. Limiting their diet to certain foods is not a choice, it’s a necessity.


The Proprioceptive System: [provides information about our body position and muscle engagement]

Each bite we take requires us to evaluate how much pressure to exert from our jaw muscles—biting a carrot will take considerable more force than biting a banana. As we progress in our chewing and the food breaks down, we need less and less force from our jaws. If we want to hold a piece of food between our teeth, we must do so at exactly the right force so as not to drop it or crush it. These are all the proprioceptive system at work. Ever have that feeling that you put too much food in your mouth? Again, the proprioceptive system at work. We also need to avoid biting our tongue and cheeks when chewing, which means we need to know where they are at in relationship to our teeth. Some children overstuff their mouths because they enjoy the sensation they get from it; others may repeatedly bite their tongue during a meal. Biting a carrot might seem impossible for a child who is not consistently exerting enough force. All are signs that their proprioceptive system is not receiving or interpreting the input accurately.


The Tactile (Touch) System:

Our lips and tongues are loaded with touch receptors. They provide important information to the brain about the where our food is in our mouth, about the size of food, about the temperature of the food, and about the texture of the food. When we eat a messy ice cream cone, our lips detect that we need to lick the remains or wipe them with a napkin. As we chew, our tongue detects where the food is in our mouth. And when our tongue detects that a piece of food is small enough, then we can swallow it. We all have food temperatures and textures that are more favorable than others. However, in general, people have a wide range of hot, cold, warm, crunchy, chewy, smooth, mushy, chunky, meltable foods they eat. Some children become overwhelmed by the feeling of cold or hot food, so they wait until food is room temperature. Some children crave the calming sensation of munching on popcorn or chewing on granola bars. And some other children get completely overstimulated (at times to the point of gagging or vomiting) with mushy foods like mashed potatoes or cottage cheese, or foods that “pop” in their mouth like grapes or blueberries.  

When we eat a mixed-texture food, such as yogurt with granola, our tongue must differentiate between the hard granola that must be chewed and the smooth yogurt that must be swallowed. The tongue moves the granola in between the teeth to breakdown the granola into pieces that can be swallowed along with the yogurt. While this discrimination happens all the time subconsciously, there are some children who lack these discrimination skills for safe eating. Most of the time these children limit their diets to foods they can trust (including particular brands), investigate their food carefully before consuming, and/or only eat single-textured foods. They cannot trust their tongue’s tactile discrimination abilities so they employ their own safety mechanisms.


The Gustatory (Taste) System:

Food taste can be categorized as sweet, sour, bitter, salty, or umami (i.e. savory). Saliva helps to not only breakdown our food in order to be swallowed, but also increases the temperature of our food in order to release flavors from the chemicals in food. In general, the more taste buds one has, the more intense their taste experiences. Our taste buds continue to mature until the age of 16 years—so don’t be surprised if as an adult you now like tomatoes that you hated as a child. Bitter foods, like many vegetables, generally take more time to accept because of our biological design to avoid ingesting harmful substances. It is recommended that infants start with vegetable purees before fruit purees for that reason. Some children are understimulated by food, and seem bored or inattentive when eating, until flavors like curry, chili, lemon, vinegar, or saffron are added to their food. While other children respond to these flavors like someone washing out their mouth with soap; one blackberry in their smoothie can make it seem like they’re drinking lemon juice. Bland foods are safe and predictable. As a note, children who have a history of repeated ear infections may prefer more savory, fatty, creamy foods because a branch of a cranial nerve runs from the middle ear to the anterior and middle tongue thus impacting what tastes they experience.


The Olfactory (Smell) System:

Smells of certain foods evoke such strong memories that we can almost taste the food without even taking a bite: grandma’s fresh apple pie, dad’s homemade biscuits, Aunt Carron’s savory lasagna. That’s because about 80-90% of the taste of food can be attributed to its smell. Everyone knows the trick of plugging your nose when eating something off-putting in order to diminish the taste. This works because it blocks “retronasal olfaction” – a fancy name for the passage of air from the back of the oral cavity into the nasal passage—that enhances the smell of food when eating. Our brain identifies this smell as coming from our mouth (which it does) and therefore associates it to taste rather than smell. For some children it is the smell of food that elicits a gag reflex or avoidance of many flavorful foods; odorless foods are preferred because overstimulation does not occur. Other children crave smell and repeatedly bring their food to their nose in order to enhance its taste.  

NOTE: Children and adults who have anosmia (i.e. loss of smell) lack the cues from the olfactory system about the taste, and to a degree the texture, of food and may therefore activate their gag reflexes more quickly with unfamiliar foods.


The Visual System:

Presentation of food can make or break your mealtime experience. It sets up expectations for whether or not the food is fresh, and whether or not the food is cooked thoroughly (but not too thoroughly!). Eating with your eyes closed can dramatically change a meal because our visual system gives us a lot of information about our food before it even enters our mouth. We can see if there are croutons in our tomato bisque or whipped cream on top of our pancakes. How often do children decline trying a new food before they’ve tried it—just because of the way it looks? Some children cannot get past the visual cues from their food so they want it to look the same each time, they want to see the box or package it came from, they want to inspect each French fry to make sure it has no crispy parts, and/or they want to watch their food being prepared. The look of unfamiliar or undesired food triggers a part of the brain to become too overstimulated with the thought of how it might taste or feel in the mouth. That’s why repeated exposure of food (10-15 presentations!) is so important with children—familiarity is half the battle.


The Auditory (Sound) System:

Of the sensory systems with which we’re most familiar, this is often the least considered when it comes to eating. We generally do not attend to the sound of our food when we’re eating—probably because we’re busy attending to the conversation around the table. Some children cannot tolerate the sound of crunchy food as it’s being chewed because they have such extreme auditory sensitivity. This sensitivity may cause such dysregulation that the thought of eating evokes anxiety.

NOTE: Misophonia is a specific diagnosis associated with an extreme sensitivity to the sound of people chewing or smacking their lips, along with certain other sounds.

For those of you who weren’t counting, that’s seven senses that combine to make eating possible—3 to 5 times per day! Parents want their children to thrive in all areas, including participating in mealtime and eating a well-balanced diet. For children who are picky eaters, eating can be overstimulating, dysregulating, or disengaging. They may miss out or opt out of social opportunities around eating. Helping to address associated sensory processing challenges can open the doors to new mealtime experiences for the child and decrease the level of anxiety/stress/frustration at mealtime for the caregivers. If you have or know a child who is a picky eater (not due to medical issues), a comprehensive sensory evaluation by an occupational therapist certified in swallowing and feeding is recommended.

Why Dysgraphia (along with other forms of poor handwriting) is a Sensorimotor Problem

by Dr. Jamie Chaves, OTD, OTR/L, SWC

It is amazing that we can even write at all. Handwriting requires the integration of almost every sensory system in order to create a legible, organized product. When a breakdown occurs in any or several sensory systems, handwriting is generally negatively impacted. It is therefore important that when exploring the best therapeutic options for a child with dysgraphia or poor handwriting that a comprehensive sensorimotor occupational therapy evaluation be conducted. This includes exploring how a child responds to vestibular, proprioceptive, tactile, and visual inputs, as well as the child’s postural stability and praxis. (NOTE: postural stability and praxis essentially require the integration of the vestibular, proprioceptive, and tactile systems.) Here’s a glimpse at what needs to happen in order for handwriting to be successful.

Sitting upright in a chair: requires the integration of the vestibular, proprioceptive, and tactile systems in order to maintain postural stability and modulation of tactile input from the seat of the chair. “Proximal stability equals distal mobility” is a commonly used, and very foundational, catch phrase. This means that in order for us to effectively move our wrists and fingers we must first establish stability in our shoulders and core muscles. Children with poor postural stability (those who lean on other people or objects, prefer to lie down, have difficulty sitting in a chair) notoriously have poor handwriting. It is integral to all other aspects of handwriting, so I won’t continue to list it. Also, if a child is sensitive to tactile input and is sitting on a wooden chair or a chair with a textured seat, he or she may be too distracted by that feeling to stay attentive to writing.

Holding a pencil: requires modulation of tactile input from the writing tool on the fingers, discrimination of proprioceptive input to use the right amount of force, tactile discrimination and praxis to move each finger in a distinct position on the pencil, and vestibular discrimination to hold the pencil up against gravity. For children who don’t like the feeling of the pencil, grip the pencil too tightly (or loosely), position their fingers incorrectly on the pencil, or fatigue easily when holding a pencil, it is important to further investigate the corresponding sensory systems.

Manipulating a pencil: requires praxis to move the fingers apart from the rest of the hand and arm, discrimination of proprioceptive input to know how much pressure to use on the paper, and vestibular discrimination to know which direction to move the pencil. When we write our fingers do the majority of the work and must move on their own to be more efficient. Children who tire easily with handwriting may be engaging too many muscles to complete the task or may be pushing too hard on the paper. Or they may be using so much effort to isolate the movement of their fingers because their motor planning is off. Detecting up, down, forward, and backward is really important for moving the pencil in the direction needed to form shapes and letters.

Forming shapes and letters: requires praxis to remember the necessary motor pattern, body awareness (proprioceptive and vestibular integration) to understand laterality, visuo-vestibular integration so the eyes and hand can move in a coordinated manner, and visual modulation as to not get overwhelmed (or underwhelmed) with the visual input on the paper. As we progress in our handwriting skills we don’t even need to think about how to form each letter - it just happens because of praxis. When we learn a new symbol or form of writing we must concentrate more because our praxis is not yet automatic (this is what some children must do every time they write!). At the same time, being well acquainted with our body in relationship to itself must occur so we can understand our body in relationship to the writing tool being manipulated. This means we must consistently differentiate our right from our left (i.e., laterality) so we can differentiate letters facing right versus left. The visual and vestibular systems work very closely together to inform each other of where to keep our eyes oriented on the paper and where to form the letters. If these two systems are out of sync, which happens quite often in children with sensory processing disorder, then the head and eyes can have a difficult time remaining stable while the hand is moving. For children who get overwhelmed by visual input, the lines on the paper, amount of writing, or colors on the paper may be too much. Many children nowadays, however, have the opposite problem and are so underwhelmed with the mundane nature of gray pencil on white paper in contrast to fast-paced, colorful video screens.

It is important to mention several areas of visual-perceptual that also influence handwriting, such as visual attention, visual memory, visual spatial skills, and visual form. These are higher level cognitive processes that interpret visual information. While they can be assessed and addressed by an occupational therapist, they are not in and of themselves a sensory processing disorder. Similarly, occulomotor skills, such as visual tracking, visual saccades, and visual convergence can be screened by an occupational therapist to determine if a full evaluation by a developmental optometrist is warranted.  

There you have it. Now you can see why handwriting is such a complex process, and why dysgraphia cannot effectively be remediated by simply practicing writing over and over (although some practice is necessary). Educators, parents, and other professionals can have a profound role in recognizing handwriting problems early and recommending a comprehensive sensorimotor evaluation by an occupational therapist to get at the root of the issue.