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.   

The Relationship between Sensory Processing and Sleep

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

Sleep is a daily occupation in which all of us participate. Some better than others. When sleep is disrupted this is a red flag for occupational therapists, and should be for parents and other professionals as well. Sleep plays a critical role in restoration of brain cells, supporting brain plasticity, resting muscles and joints, and regulating our circadian rhythm. Poor sleep negatively impacts almost every area of functioning and development. Here’s a list of indicators of poor sleep patterns (for children and adolescents):

*Requires longer than 30-45 minutes to settle before preparing to falling asleep

*Takes longer than 15-20 minutes to fall asleep

*Requires someone present in the room, next to the bed, or lying in bed in order to fall asleep

*Restlessness or frequent changing of positions

*Getting up or waking up at night on a regular basis

*Inconsistent sleep patterns (e.g. sleeps 6 hours one night and 10 hours the next night)

*Gets less than 8 hours of sleep for 3-5 year olds or less than 7 hours of sleep for 6-13 year olds (numbers according to the National Sleep Foundation)

 

Poor sleep can be an indicator of sensory processing disorder (SPD) for myriad reasons. Different subtypes of SPD impact sleep differently. Sometimes the bedtime routine leading up to bedtime is dysregulating, which consequently impacts the quality of sleep. Sometimes the child is so overstimulated from the day that settling to sleep can be challenging. Sometimes the overstimulation from the day is so exhausting to your child that he wants to nap after school which disrupts his sleep at night. Sometimes the events of the day were so understimulating that the body was essentially in sleep mode all day long. It’s important to note that children with unaddressed sensory processing modulation disorder have a difficult time self-regulating because they do not yet have the strategies to do so. Therefore co-regulation, adaptive strategies, and use of external sensory inputs will be necessary until they can internalize the strategies provided by their occupational therapist. Don’t be quick to brush off requests or complaints from a child as “behavioral” or a means to “escape bedtime”.

If your child…                                        

·       Doesn’t like the feeling of pajamas (or other specific clothes)

o   He/She may be over-responsive to tactile input

o   Try sleeping naked, wearing a compression shirt to bed, or wearing an oversized t-shirt to bed

·       Doesn’t like the feeling of sheets

o   He/She may be over-responsive to tactile input

o   Try lycra sheets (“Skweezrs”), using a weighted blanket (7-10% of child’s body weight)

·       Gets upset when bathing or showering

o   He/She may be over-responsive to tactile input

o   Try bathing or showering in the morning, bathing or showering before dinner, switching from a shower to a bath

·       Wants to sleep next to someone

o   He/She may be seeking or under-responsive to proprioceptive input

o   Try moving the bed to a corner, buying a body pillow

·       Wants stuffed animals or pillows piled on top

o   He/She may be seeking or under-responsive to proprioceptive input

o   Try sleeping under or on top of a bean bag, using a weighted blanket (7-10% of child’s body weight)

·       Changes positions throughout the night

o   He/She may be seeking or under-responsive to vestibular or proprioceptive input OR over-responsive to tactile input (i.e. the movement is response to discomfort from pajamas/sheets)

o   Try moving the bed to a corner, sleeping under or on top of a bean bag, using a weighted blanket (7-10% of child’s body weight), lycra sheets (“Skweezrs”), wearing a compression shirt to bed, wearing an oversized t-shirt to bed

·       Falls out of the bed

o   He/She may be seeking or under-responsive to vestibular input

o   Try moving the bed to a corner, sleeping under or on top of a bean bag, using a weighted blanket (7-10% of child’s body weight)

·       Must have complete silence when falling asleep

o   He/She may be over-responsive to auditory input

o   Try using a sound machine or white noise machine, wearing noise-cancelling headphones

·       Dislikes the taste of toothpaste

o   He/She may be over-responsive to oral (taste/smell) input

o   Try brushing without toothpaste at night, using an electric toothbrush, flavored toothpaste (not peppermint or cinnamon)

·       Snacks right before bedtime

o   He/She may be seeking oral input

o   Try only giving chewy or crunchy foods before bedtime and/or at dinner

·       Uses a bottle at bedtime

o   He/She may be seeking oral input

o   Try giving a piece of candy to suck on when reading in bed, keeping a cup of water next to the bed, using an electric toothbrush

·       Looks around room when falling asleep

o   He/She may be seeking visual input

o   Try putting in a nightlight, hanging blue or green tube lights, using a moving fishtank toy

·       Complains the room is too bright (even with the lights off)

o   He/She may be over-responsive to visual input

o   Try facing the bed away from the windows, getting heavy curtains for the windows, using a sleep mask

Poor sleep may also exacerbate sensory processing to the point that child appears to have SPD. Think about a time you were tired in a meeting or presentation—what did you do? Oftentimes adults get up to move, swivel in the chair, bite nails, chew on a pen, drink or eat something, fidget with an object, doodle on the paper. All of these are sensory strategies to stay awake and alert. Now think about a time you didn’t sleep well—how did you function the next day? Did you get up more frequently from your desk? Did you have more difficulty multi-tasking or remembering details? Did you notice your tolerance of people around you dropped?

Consider a child who chronically sleeps poorly. Her tiredness may manifest by constantly jumping or skipping around in an attempt to stay awake. He could “zone out”. Chewing on his sweatshirt or nails may help him focus. She might be more reactive towards peers. His frustration tolerance might be limited or he might give up easily. Spinning in circle could give him more stimulation. Any strategy to say “wake up, body!” is likely. And anything that tests an already short fuse will lead to a “zero to sixty” response.

While all children are different in their sleep routine preferences there are a few things I regularly recommend.

1)     Eat dinner early—about 2 ½ hours before bedtime. This will allow for digestion.

2)     Play hard for about 45 minutes before you start the quiet bedtime routine.

3)     Transition to the calming routine by dimming the lights and playing classical instrumental music.

4)     Brush teeth. This is usually not a favorite for most kids, so doing it first will allow for the other activities to re-regulate him/her.

5)     Take a warm bath. Showers can be very stimulating because each stream can feel like a pin prick.

6)     Read 2-3 books together in bed.

7)     Sing 1-2 songs.

8)     Hug and kisses.

9)     Lights out.

It’s important to make slow changes to the bedtime routine and to try each strategy for 1-2 weeks before giving up. Change is hard so it may be met with initial resistance. Try to get your child involved as much as possible in making decisions, such as picking the color of the lycra sheets or deciding where the nightlight should be placed. No matter what, keep your sleep at the forefront of your conversations until you find a manageable solution!