Alternatives to "hand over hand" support for handwriting!

Autonomy and agency.

Autonomy is the ability to make independent choices. 
Agency is the capacity to exert individual influence, be authentic and express one's self.

As we listen to Autistic adult voices; autonomy and agency allow individuals to make choices in their own way, including choices about their daily lives, communication methods, and environments, is essential. 

From this understanding, we are moving away from practices such as "hand over hand" (HOH) assistance. This is traditionally how we may help children by providing the physical assistance that they need by placing (often grasping strongly) to move the child's hand for them. This physical assistance in occupational therapy has been used to provide maximum support.  While some children do benefit from full physical assistance, we are now more conscious of autonomy, agency and consent. 

Occupational therapists consider what amount of support a child needs with various activities and how best to help them to achieve their goals.  We may consider the a "most to least" or "least to most" level of support (see "prompt hierarchy explained" for more information), environmental factors, forward or backward chaining (ie. first or last step taught first) among other factors. 

In handwriting, we consider what aspects the child needs assistance. This may include grasping a pencil, motor control of the pencil, making meaningful marks on the page, sequencing the steps to form letters, applying adequate pressure on the page, reducing strain, upper body/wrist and finger strength, fine motor skills, postural control, visual spatial awareness, attention, motivation and interest. 

"Hand over hand" assistance can actually inhibit learning with handwriting, as the child can be "limp" under the adult's hand, rely on the adult for the action and not develop their own grasp and control skills.  Grasp patterns develop with a child's ability to hold the pencil (or crayon or marker) themselves.  It requires them to make adjustments as needed and learn how to move their whole arm, before progressing to fine movements with their fingers. 

Visual motor learning on the page comes from understanding that scribble can become meaningful with lines, shapes, letters and numbers (read more "from scribble to writing").  Direction of movement develops with an understanding of how these marks on the page relate to the child's own body. 

Alternatives to "hand over hand" support.

1. Provide a variety of drawing and writing tools, including small pencils and broken crayons. 
Allow your child to experiment. Give them time to scribble, go outside of the lines when they colour in, "rip" the page when they apply too much pressure and sharpen their own pencils. 

We know that small pencils and broken crayons provide small surfaces for the child to hold onto. This means that they are more likely (but not always) to use a tripod grasp (thumb, index, third finger). 

This opportunity should be afforded to all children, even if they have started school are expected to write a significant amount.  For older children, you could also experiment with pencil shavings, gel pens, highlighters, styluses for tablets, charcoal and paintbrushes.

Further alternatives  to drawing and writing tools could include using q-tips (cotton buds), scratch art sticks, chalk, fabric markers and glass pens. 

2. Provide pencil grips early. 
Use pencil grips so that your child has physical, visual and sensory support on the pencil. Providing a pencil grip means that you will not need to position your child's fingers physcially so that they are holding the pencil. If they can't grip the grip, then there are other issues involved including poor fine motor skills (so work on these too). 

3. Multi-sensory approach.
Provide opportunities to learn motor patterns (read some ideas "multisensory approach to letter reversals").  This encourages the child to make the motor patterns themselves and therefore more likely to develop kinesthetic awareness independently. 

Draw and write in sand, on salt trays, chalk blocks, uncooked rice, in the air with a ribbon wand, on a person's back or hand, with playdough or putty.  Use toy cars to "drive", figurines to "dance" or animals to "do" the actions you need to work on.

These sensory experiences can also build fine  motor skills and hand strength. Include opportunities on a vertical surface (such as whiteboard) and you will also help to develop shoulder and wrist stability.  Providing multi-sensory experiences engages the child's mind and body together, making important neural connections in the brain.  They are also very motivating!

4. Modelled instruction (verbal and visual).
Watch and copy. This requires the child's ability to process the visual spatial information.  If they have the cognitive and phsycial abilities, modelled instruction can be very affective for learning the direction of movement. You could also use modified paper (eg. graph paper or sky, grass, ground) as further visual support, together with modelled instruction. 

5. Hand under hand.
Instead of moving the child’s hand from above, rest your hand gently under theirs. This allows them to feel your movement as a suggestion, but they still control their writing.

This not my preferred method. As an alternative, I developed "hand above hand". 

6. Hand above hand. 
Allow your child to grip the pencil (with or without a pencil grip).  Holding the pencil high while the child grasps low (towards the nib/point) means that I can provide graded support.  I can begin by helping more with the movement and then reduce the amount that I move the marker (or remove my hand entirely). The child uses their own hand to grasp the pencil so they work out the amount of force they need to grip it and the amount of pressure they need to apply to the page.  They "feel" the movement but they are  creating their own marks. 

If the child "lets go", they are not motivated to draw or write.  We need to address this first and I would suggest re-visiting the suggestions above! "Tool" use comes as an extension of the body to give us more refined movements (than animals who don't use tools). A child needs to develop body awareness and use of their own arms, hands and fingers before they can effective use tools (like pencils, scissors, cutlery). It is one of the reasons occupational therapists spend so much time on fine and gross motor skills, bilateral coordination (using both sides of the body in a coordinated way - read more here) and sensory regulation (we understand that there should be regulation before expectation - read more here). 

Exceptions!
There are always exceptions. Some children will require (with consent) physical guidance.  They may have uncontrolled body movements such as seen in some children with cerebral palsy.  Some children will request your assistance and ask that you show or help them. 

Physical assistance is not "bad". It is a consideration occupational therapists make as part of the intervention process.  Going back to the prompt hierarchy helps us to make informed decisions. 


So, I have to say that I tried to use AI to help me write this article but I abandoned it (in an attempt to give you more frequent content).  I'm not sorry that this is written from my own experience as an occupational therapist.  I have heard from many of you that you appreciate the irregular but authentic content. 

In writing this article, I could not find others recommending my concept of "hand above hand". Try it out and let me know how you go!

Until next time,

indy is a registered occupational therapist practising in Sydney, Australia.  She has two growing children who are a constant source of inspiration and learning.  Cindy loves working creatively to help children to reach their potential, finding opportunities in everyday living and making learning fun. She is also addicted to making printables (even when they take a long time to complete).  Cindy is the author of the Occupational Therapy blog Your Kids OT.  Read more articles from Your Kids OT at https://www.yourkidsot.com/blog

Cindy is a contributing author of the Functional Skills for Kids Therapy Team.  They have together published THE HANDWRITING BOOK, THE SCISSORS SKILLS BOOK and THE TOILETING BOOK.

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