The Effect of Pencil Grip On Handwriting

NOTE TO USERS
This reproduction is the best copy available.
UMI
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
The Pencil Grip 1
Touro College
School of Health Science
Department of Occupational Therapy
The effects of pencil grips on handwriting and tripod
grasp in children with learning disabilities
Author: Robin Akselrud, O.T.S
1055 East 28th Street
Brooklyn, NY 11210
Committee Members;
Thesis Chairperson: Tara Casimano, MHS, OTR/L, BCP
CajU /M l* lq AftfSj & *
Thesis Reader: Vanessa Giardina, MA, OTR/L
UMI Number: EP14497
INFORMATION TO USERS
The quality of this reproduction is dependent upon the quality of the copy
submitted. Broken or indistinct print, colored or poor quality illustrations and
photographs, print bleed-through, substandard margins, and improper
alignment can adversely affect reproduction.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if unauthorized
copyright material had to be removed, a note will indicate the deletion.
UMI
UMI Microform EP14497
Copyright 2005 by ProQuest Information and Learning Company.
All rights reserved. This microform edition is protected against
unauthorized copying under Title 17, United States Code.
ProQuest Information and Learning Company
300 North Zeeb Road
P.O. Box 1346
Ann Arbor, Ml 48106-1346
The Pencil Grip 2
Table of Contents
Chapter One.............................................. 9
Introduction............................................. 9
Purpose ........................................ 11
Methodology......................................... 11
Implications for Occupational Therapy ............... 13
Hypothesis.......................................... 13
Research Questions .................................. 13
Delimitations ....................................... 14
Definition of Terms................................... 15
Chapter Two 2 0
Literature Review................ 20
Computers vs. Handwriting ........................... 20
The History of Handwriting . ......................... 28
Anatomy and Kinesiology of the Hand................. 32
Previous research studies on the effects of pencil grips
.................................................... 35
Factors which may affect handwriting ................ 38
Kinesthesia......................................... 39
Motor Planning...................................... 40
Eye-Hand Coordination ............................... 41
Visual-Motor Integration ............................ 42
In-Hand Manipulation ................................ 43
Gender Differences . . 44
Finger Function ..................................... 45
Ergonomic Factors ................................... 47
Fatigue............................................. 4 8
Culture............................................. 4 9
Emotional Factors ................................... 50
Developmental progression of grip position....... 51
The Effects of Pencil Grip on Handwriting............ 54
Environmental Influences....................... 56
The Central Nervous System and Handwriting ........... 58
The Wold Sentence Copy Test......................... 7 0
Occupational Therapy Intervention ................... 70
Chapter Three.,....... 83
Methodology............................................. 83
Design format ......................................... 83
Subjects.............................................. 83
Experimental Environment .............................. 83
Procedure............................................. 83
Data Analysis......................................... 84
Chapter Four............................................ 8 6
Results................................................. 86
The Pencil Grip 3
Descriptives .......................................... 86
Descriptive of Test Scores............................. 87
Graph 1. . . ........................... *. 89
Graph 2.............................. 91
Graph 3................................................. 93
Graph 4................................................. 95
Testing of Hypothesis ................................. 96
Additional Findings ................................. 97
Chapter Five............................................ 98
Conclusion.............................................. 98
Major Findings........................................ 98
Sample 1 ...................................... 100
Sample 2 ....................................... 101
Other Contributing Factors...................... 103
Implication to Occupational Therapy.................. 104
Implications for future research...................... 105
Appendix 1............................................. 107
Appendix 2............................................ 108
Data for pre and post-test of the alphabet copy sheet... 108
Appendix 3........................................ 109
Data for first and second screenings of tripod grasp
strength............................................... 109
Appendix 4............................................. 110
Data for pre and post tests of The Wold Sentence Copy
Test (letters/minute)...... .... ...................... 110
Appendix 5............................................. Ill
Appendix 6..................... 112
Appendix 7............................................. 113
References........ ;.................................... 114
The Pencil Grip 4
Acknowledgements
Professor Tara Casimano and Vanessa Giardina, your
creativity, caring nature and drive to support evidence-
based practice are only a few characteristics which make
you both model practitioners in the OT field. Your
dedication to the field of Occupational Therapy inspires me
on a daily basis.
Professor Tara Casimano, for all your support and
guidance during the entire thesis process as well as
throughout my three years at Touro College. Your spirit,
enthusiasm and knowledge make you a wonderful professor and
practitioner. Thanks for all your assuring words and time
spent assisting me in seeing the thesis to fruition.
Vanessa Giardina, I am so grateful that we met when you
were my supervisor at Gatewaay. Your patience, persistence,
knowledge, ambition and love for the children you treat are
all attributes I can only hope to emulate as a therapist.
Thanks for taking time out of your schedule to work and
guide me with my research.
The Pencil Grip 5
Dedication
This thesis is dedicated to my wonderful, supportive
family, without whom I could not be where I am today.
In memory of my grandparents, Phillip and Esther Zuller
and Morris Spiegel who worked hard and strived to give
their families all that they could throughout their lives.
I hope I can follow in their ethical ways and in their
leadership abilities.
In memory of my Grandma Zuller, you were a model of a
functional mother, worker and member of your community. You
awaited my graduation with pride in your heart, even though
you were unable to live to see me get my degree, you
inspired me to work hard and I knew you were proud of me
the entire way.
To my Grandma Spiegel, thanks for all your support
throughout the past three years. Thank you for the
babysitting and love that you give Moshe Avi and me.
To my parents, who are my primary educators, I want to
thank you for your continued support over the past three
years. My list of thanks to you could go on and on, I hope
I continue to make you proud. Thank you and I love you.
To Ima and Abba, thank you for all your help through the
past three years. Your encouragement and support in
The Pencil Grip 6
pursuing my degree mean a lot to me. Thank you and I love
you.
To my siblings, Shlomie, Yudi- thanks for all the
photocopies and help, and Effie- thanks for keeping me "on
my toes" with all your questions.
I would like to thank Jackie for all her love and time
and for her advice("don't listen to the books"). Thank you.
I would like to thank my pal, Rayna for all her advice,
support and caring through the three years, I'm so happy we
met, friends forever!
Yossi- I love you and I am so happy that we made it
through this long journey together. All your cooking,
"babysitting" and support assisted me in reaching this
milestone in our lives. I can't wait to continue the
journey of life together with you and Moshe Avi.
Last, but definitely not least, I would like to thank
Moshe Avi for being the cutest, sweetest child anyone could
ask for. You deserve the credit too, because you took the
journey with me, you sat through Dr. Barry's four hour
lectures, anatomy lab and through the entire three years. I
love you and hope you're proud of your mommy, even though
OT moms can be neurotic at times.
The Pencil Grip 7
Abstract
The purpose of this study is to enhance the evidenced
based research in field of occupational therapy by
assessing whether pencil grip can improve the handwriting
and tripod grasp strength of school age children diagnosed
with learning disabilities. The subjects were twenty seven
children diagnosed with learning disabilities attending a
non-public school in NYC, NY. Children in the youngest
class of the school(ages 5-6 years old) completed a
handwriting sample consisting of copying letters of the
alphabet from a paper, and children ages 7-10 years old
were asked to complete the Wold Sentence Copy Test. The
principal investigator also recorded their tripod pinch
strength at this time. They were given a pencil grip and
asked to use it for two months. After the two month trial
the students completed a handwriting sample(ages 5-6 years
old), or the Wold Sentence Copy Test(ages 7-10 years old),
and their tripod pinch strength were re-assessed. Pinch
strength and handwriting were evaluated using the
standardized ranges for tripod pinch strength and by
evaluating their scores and evaluations with regard to the
Wold Sentence Copy Test. The- handwriting samples were
evaluated for spacing between words, spacing between lines
and size of letters and compared with their initial
The Pencil Grip 8
handwriting sample, using scoring criteria adapted from the
criteria of the Visual Motor Integration Test(Beery, 1982).
Results of the paired samples t-test were found to be
statistically significant(p<.05) with regard to tripod
grasp strength in participants ages 5-6 years of age.
Results of this analysis support the first hypothesis of
the study by demonstrating that children with learning
disabilities will demonstrate an increase in their tripod
grasp strength after using "The Pencil Grip" for two
months. The second hypothesis of this present study was
that students with learning disabilities will demonstrate
better handwriting with use of "The Pencil Grip", as
measured by the Wold Sentence Copy Test and the alphabet
copy sheet. Results of this analysis using a paired sample
t-test were found to be extremely significant(t(18)= .000)
with regard to the pre and post scores on the Wold Sentence
Copy Test.
The Pencil Grip 9
Chapter One
Introduction
Handwriting is a fundamental part of every child's
life, and it may become a skill, utilized throughout one's
lifespan. Although technology allows people to use
handwriting less than before, it is still commonly required
for numerous every day tasks such as taking notes, filling
out applications and making shopping lists. Even
professionals must continue to use handwriting in writing
notes, writing prescriptions, and leaving notes for staff.
Handwriting remains an essential skill, not easily replaced
through the life cycle.
Letters go astray, phone messages go unreturned,
students can't follow a professor's advice, and
instructions are misunderstood in everyday life all due to
poor handwriting. Handwriting can affect other people's
lives. If a Medical Doctor's(MD)handwriting is not legible
or poorly written, this can harm the individual and may
even lead to death (Horsham, 1997).
Despite technology, handwriting seems to be part of
every child's daily routine. Handwriting remains an
important functional task for children. Many children have
limitations in fine motor coordination skills, which
affects their various occupations, such as play and basic
The Pencil Grip 10
self-care (Parush, Levanon-Erez, & Weintraub 1998). These
children tend to have trouble with other tasks such as
tool-use, dressing, eating, constructive play and tabletop
games. School-aged children are often referred to OT for
help with their graphomotor skills and fine motor
abilities. One's capabilities in handwriting may have an
effect on occupational choice. As adults, writing illegibly
may inhibit their ability to convey their thoughts, affect
their chances for employment, damage their social
interactions, and affect their opportunity for higher
education.
Problem Statement
Children who have difficulty writing will continually
struggle in school. It is likely to take them longer to
complete tasks. Timed tasks such as tests become much more
difficult and anxiety producing. Self-esteem may be
damaged as they look around at others and see the ease with
which they complete the same task. Lack of self-esteem may
then impact on motivation and eventual success, because
they are unable to fully express their knowledge in written
form(Rubin and Henderson, 1982, Sassoon,1986).
Pencil grips are frequently used in therapy to
remediate handwriting, and their purchase is often
recommended to parents. In reality, there exists a paucity
The Pencil Grip 11
of research regarding the efficacy of pencil grips in
improving handwriting (Appleman & Lipman,2000). There is a
lack of data in terms of using pencil grip interventions
with learning disabled children. As a profession,
occupational therapists need evidenced based research to
support treatment efficacy.
Purpose
The purpose of this study is to enhance the evidenced
based research in the field of occupational therapy by
assessing whether pencil grip can improve the handwriting
and tripod grasp strength of school age children diagnosed
with learning disabilities. In addition, this study will
examine whether pencil grip usage improves the type of
grasp of the writing instrument. In particular, it will
examine the usage of the tripod grasp in writing. By
targeting grasp and legibility, this study will aid in
determining whether significant improvement can be attained
with the use of a pencil grip.
Methodology
Research in the area of handwriting suggests that one
of the causes of poor handwriting skills is the pencil
grasps utilized during writing. "The Pencil Grip" will be
used in this research study to decipher whether or not it
The Pencil Grip 12
will improve a child's tripod grasp and handwriting skills.
The subjects will consist of thirty children diagnosed with
learning disabilities attending a private school in NYC,
NY. Children in the youngest class of the school(ages 5-6
years old) will complete a handwriting sample consisting of
copying letters of the alphabet from a paper, and children
ages 7-10 years old will be asked to complete the Wold
Sentence Copy Test. The principal investigator will also
record their tripod pinch strength at this time. They will
be given a pencil grip and asked to use it for two months.
After the two month trial the students will complete a
handwriting sample(ages 5-6 years old), or the Wold
Sentence Copy Test(ages 7-10 years old), and their tripod
pinch strength will be re-assessed. Pinch strength and
handwriting will be evaluated using the standardized ranges
for tripod pinch strength and by evaluating their scores
and evaluations with regard to the Wold Sentence Copy Test.
The handwriting samples will be evaluated for spacing
between words, spacing between lines and size of letters
and compared with their initial handwriting sample, using
scoring criteria adapted from the criteria of the Visual
Motor Integration Test(Beery, 1982).
The Pencil Grip 13
Implications for Occupational Therapy
This study is important to the profession of
Occupational Therapy as it will enhance the amount of
information available on the effects of pencil grips on
handwriting and tripod pinch strength in children with
learning disabilities. This will provide occupational
therapists(OT)with the empirical data to support the use of
this type of assistive technology device.
Hypothesis
1. Students with learning disabilities will demonstrate an
increase in their tripod grasp strength when using
pencil grips for two months.
2. Students with learning disabilities will have better
handwriting with use of pencil grips, as measured by the
Wold Sentence Copy or the alphabet copy handwriting
sample, which asks the subjects to copy the first 14
letters of the alphabet.
Research Questions
1. Do students with learning disabilities have better
handwriting when using pencil grips?
2. Do students with learning disabilities have stronger
pinch strength after using a pencil grip for two
months?
The Pencil Grip 14
Limitations/Assumptions
1. Students will have been instructed properly on how to
write all the letters in the Wold Sentence Copy prior to
the study.
2. Students will have intact auditory processing needed to
understand the instructions.
3. Improvements in handwriting will be due to the
introduction of the pencil grip and not due to the effect
of maturation on handwriting performance.
4. Students will comply with using the pencil grips
Delimitations
1. The testing procedures are standardized, except for the
alphabet copy handwriting sample.
2. Writing is a task that the subjects are accustomed to,
since school-aged children know how to write and need to
on a daily basis.
3. They will be given the choice of the color of their
pencil grip, which may increase their motivation.
4. The environment is supportive to improving the lives of
children with learning disabilities, and therefore
teachers will reinforce and incorporate the pencil grips
into daily writing activities
The Pencil Grip 15
Definition of Terms
Abduction- A motion that causes the body part to move away
from midline(Nordin and Frankel,1989).
Activities of Daily Living(ADL)- Tasks which allow a person
to reach their own personal independence.(Pedretti, 1990)
For children these can include activities such as tying
their shoes, playing with other children and completing
their homework.
Adduction- A motion that moves the body part towards the
midline(Nordin and Frankel, 1989) .
Assistive Technology- "a broad range of devices, services,
strategies and practices that are conceived and applied to
ameliorate the problems faced by individuals who have
disabilities"(Cook and Hussey, 2002).
Brush grasp- pencil is held with fingers, eraser end of the
pencil is positioned against the palm, hand is pronated
with wrist movement present, whole arm movement, forearm
positioned in the air(Schneck and Henderson,1990).
Cross thumb grasp-"fingers fisted loosely into palm, pencil
held against index finger with thumb crossed over pencil
toward index finger, finger and wrist movement, forearm
positioned on table"(Gesell,1940).
Digital pronate grasp- pencil is held in a palmar grasp
with the index finger extended along the pencil toward the
The Pencil Grip 16
tip, arm is not supported on the table, full arm
movement(Morrison, 1978).
Distal- pertaining to the part farthest from the midline or
trunk(Batshaw,2002).
Engagement in Occupation- this term "recognizes the
commitment made to performance in occupation or activities
as the result of self-choice, motivation and meaning and
alludes to the objective and subjective aspects of being
involved in and carrying out occupations and activities
that are meaningful and purposeful to the person." (American
Journal of Occupational Therapy, 56, 609-639).
Ergonomics- "A scientific discipline devoted to the study
and analysis of human work, especially as it is affected by
individual anatomic, psychological, and other human
characteristics"(Mosby's Medical, Nursing and Allied Health
Dictionary, 1998, pg. 3134). For the purpose of this study,
this includes computer equipment, desk and furniture height
at school.
Extension- "Unbending of a joint whereby the angle between
the bones is increased"(Nordin and Frankel,1989).
Fatigue- a tired state caused by means of overexertion
(Webster, 1986).
The Pencil Grip 17
Fine-motor skills- may be interchanged with fine motor
coordination or hand skills. Refers to the hands ability to
attain and manipulate objects (Pedretti, 1990).
Flexion- "Bending of a joint whereby the angle between the
bones is decreased"(Nordin and Frankel,1989).
Grip strength- Refers to maximal grip force that is
produced in one isometric muscle contraction (Nwuga, 1975).
In-hand manipulation- Movement of an object within a
person's hand(Exner,1999), which includes shift,
translation and rotation(Pedretti,1990).
Instrumental activities of daily living(IADL)- Activities
that are oriented toward interacting with the environment
and that are often complex.(American Journal of
Occupational Therapy, 56, 609-639) For children this can
include painting, going to birthday parties and cleaning
their room.
Kinesthesia- A sense found in muscles,tendons and joints.
This allows a person to know that their joints are moving
and in which direction they are moving(Neistadt and
Crepeau,1998).
Lateral tripod grasp- "the pencil is stabilized against
radial side of third digit with index pulp on top of shaft
of pencil, thumb adducted and braced over or under anywhere
along the lateral border of the index finger, wrist
The Pencil Grip 18
slightly extended, fourth and fifth digits flexed to
stabilize metacarpophalangeal arch and third digit,
localized movement of digits of tripod and wrist movements
on tall and horizontal strokes, forearm resting on
table"(Schneck, 1987) .
Motor Planning- "the ability to carry out a skilled,
nonhabitual motor activity"(Neistadt and Crepeau,1998).
Occupation- "activites ..of everyday life, named,
organized, and given value and meaning by individuals and a
culture. Occupation is everything people do to occupy
themselves, including looking after themselves..enjoying
life..and contributing to the social and economic fabric of
their communities."(Law, Polatajko, Baptiste and Townsend,
1997).
Opposition- the movement by which the pad of the thumb is
brought to another digit pad(Moore and Dailey, 1999).
Palmar supinate grasp- pencil is positioned across the palm
projecting ulnarly, held with a fisted hand with wrist
slightly flexed and supinated away from midposition, full
arm movement(Ernhardt,1984).
Pencil Grasp- The relationship between arm, hand and finger
muscles and the position of fingers on the pencil
shaft(Case-Smith, Allen and Pratt, 1996).
The Pencil Grip 19
Posture- "attitude or position of the body"(Taber's
cyclopedic medical dictionary, 2001). For the purpose of
this study appropriate postural alignment, would include
the pelvis flexed at 90 degrees, the knees flexed at 90
degrees, elbows flexed at 90 degrees.
Prehension- movements which involve grasp of an
object(Case-Smith, 2001).
Proprioception- The ability to interpret reception of
stimuli produced within the organism that gives information
about the "position of one body part in relation to
another" (Neistadt and Crepeau, 1998).
Proximal- describing the part nearest the midline or
trunk(Batshaw,2001).
Radial cross palmar grasp-pencil is positioned across the
palm projecting radially, held with a fisted hand, forearm
pronated, full arm movement(Morrison, 1978).
Roles- A set of behaviors that have some socially agreed
upon function and for which there is an accepted code of
norms"(Christiansen and Baum, 1997) For the purpose of this
study, this includes the roles of children, such as
playing, drawing and dressing.
Web space- The transverse metacarpal ligament forms the
space of the floor. It extends dorsally between the fingers
and around the distal edge of the ligament (Lister, 1993).
The Pencil Grip 20
Chapter Two
Literature Review
Computers vs. Handwriting
Writing is a complex activity, which requires the use
and coordination of many skills simultaneously. Writing
requires organizing thoughts, choosing and recalling words,
forming letters, spacing letters and words, recalling
correct spellings, remembering and using rules of written
language, and managing time when writing a lengthy piece. A
child who has difficulty in these areas may have
difficulties producing written work. Rosa Hagin(1983)
stresses the significance of handwriting in the educational
setting by stating: "For pupils it represents the usual
medium by which they convey to their teachers the progress
they have made in learning what is being taught. Legible
writing is a tool for learning; poor writing is a barrier".
She also reported that illegible handwriting is a barrier
in mathematics and could possibly bias test grades.
Computers are now increasingly being recommended by
teachers, occupational therapists and other educators to
alleviate these problems, and to help students who are
learning disabled(Kelker, 1997). "Many forms of technology,
both "high" and "low" can help individuals with learning
The Pencil Grip 21
disabilities capitalize on their strengths and bypass or
compensate for their disabilities".(Lewis, 1998) As noted
in the Parent's Guide to the Individual Education
Plan(1997), which is designed and written for each student
based on individual needs, an accommodation that could be
made for a child with fine motor deficits could be the use
of word processing on a computer instead of writing.
Assistive technology is redefining what is possible for
individuals with a wide range of cognitive as well as
physical disabilities. Whether used at home, in the
classroom, workplace or community, computers are enabling
individuals with disabilities to be more independent, more
functional and self-confident.
Word processing can be a useful tool to address the
needs of children with occupational performance deficits
related to poor handwriting and poor legibility.(MacArthur,
1998) However, despite these advantages studies have shown
mixed results. Many studies have shown that there is no
substantial difference overall between writing by hand or
with a word processor. A study conducted by Handley-More
and colleagues in 2003 investigated whether OT intervention
that focused on teaching children use of word processing
was an effective means to improve written communication
skills or children with learning disabilities(LD) and
The Pencil Grip 22
handwriting problems. Three children in grades four and
five participated in the study. The children wrote stories
by hand, and then alternated between handwriting and use of
the word processor with and without word prediction. The
results of this study suggest that OT intervention
including word processing may facilitate written work by
improving legibility and spelling for some students with
LD. The success of technology varied depending on the
child's needs.(Handley-More,Deitz,Billingsley,Coggins,2003)
Computers are also being utilized by physicians and
healthcare professionals. In 197 6, when 200 handwriting
samples from physicians were compared to 500 handwriting
samples of other professionals, the result was that
physicians had less legible handwriting than did the other
professionals. A study by Kozak in 1994 showed that
handwritten notes took 11 seconds(46%) longer to read than
those notes that were typed, with slight differences in
comprehensibility favoring typewritten notes. Another study
in 1979 found that 16% of handwritten orders in a 500 bed
hospital were illegible, and 17% of notes had barely
legible handwriting. Poor handwriting by physicians leads
to misunderstandings by other health care professionals, as
well as patients and caretakers. Poor legibility of
prescriptions or diagnoses may provide incorrect care for
The Pencil Grip 23
patients. In the 1994 American Medical Association report,
it was noted that medication error secondary to
misinterpreted physician's prescriptions was the second
most common and expensive claim in 90,000 malpractice
claims over a 7 year period. To minimize this problem, more
physicians are now utilizing computers, and some
documentation is now computer-based. This may eliminate the
handwriting problem. Computers have been shown to improve
in-office messaging and appointment scheduling in primary
care settings. However, many older physicians feel uneasy
entering records on a computer, and cost is an obstacle as
well(Cabral, John David Y.,1997).
Charts would be much neater, each page could contain more
information than if it was handwritten and patients could
get their information printed out, so there may be better
compliance.
In recent times, critical opinion has appeared
concerning the use of computers by children and
adolescents, especially in education at the primary and
high school levels. Arguments in favor of early use of
computers discuss how computers improve both teaching and
student achievement, and give children the opportunity to
become more like adults. Those who share those opinions
feel that computer literacy should be taught as early as
The Pencil Grip 24
possible; otherwise students will fall behind. According to
this opinion computers make it possible to learn without
tensions and pressures and enhance imagination and
creativity. Opposing arguments discuss the lack of self-
discipline required when typing a letter, as opposed to
handwriting a letter. When handwriting a letter, the child
must exercise a tremendous amount of mental discipline.
When using a computer, the child does not need to pay much
attention to spelling or grammar, since by clicking on an
icon, the computer detects and corrects mistakes
made. (Setzer, 2003)
Another breakthrough in computers was on November 7,
2002, when Microsoft Hewlett-Packard and other computer
companies introduced the tablet PC. Instead of using a
keyboard to enter data, users are now able to write
directly on the screen with a stylus. This device allows
you to write on the screen just as you would on paper with
a pen. Its screen is simulated to look like lined paper as
well. This makes writing easier for some, and neater to
read. This invention may also be due to the fact that a
written letter is more sincere and personable than a typed
letter.(Magid,1998)
A research study was conducted to investigate the
difference in overall quality and length of creative
The Pencil Grip 25
writing papers, using a traditional paper-and pencil method
with those composed using word processing. Creative writing
compositions of thirty sixth graders using a pencil and
paper, with those written using a word processor. One month
later, the students wrote a second composition, switching
the writing approach they used earlier. Results revealed
that the overall quality of the composition showed no
difference between the two groups. Another variable that
was measured was the overall accuracy of the grammar in
composition, the results showed no significant difference
in this area between the groups. Number of sentences and
numbers of words per sentence differed significantly
between the groups. The compositions of the group using a
word processor were longer than those in the other group,
but the reading ease was not significantly different.
(Nicols, 1996)
Computers may be more innovative and easier for some,
but may lead to repetitive strain injuries (RSI) for
others. Some risk factors for RSI include over two hours of
computer use per day, high stress work, poor posture,
static loading(holding a mouse, while staring at a computer
monitor and improper workplace setup(keyboard too high,
monitor too low). Repetitive strain injuries stem from
intense computer work, poor work habits and poor posture.
The Pencil Grip 26
Since the introduction of computers, the costs of keyboard-
related repetitive strain injuries(lost work time, medical
bills, workers compensation) have increased rapidly. There
are multi-million dollar law suits against computer
manufacturers, such as IBM, Apple and others for RSI. The
standard QWERTY layout of keyboards tends to overwork the
weaker left hand, and certain fingers. Of increased
importance are factors such as: body posture, frequency of
breaks, stress levels, variety in the job, and the design
of the keyboard itself.(Magid, 1998)
The National Institute for Occupational Safety and
Health and the federal Occupational Safety and Health
Administration(OSHA) has started comprising a draft of the
state's first mandatory standards for ergonomic safety.
Fines for non-compliance could range from $7,000-$70,000
depending on the number of violations. In New York state,
Suffolk county was one of the first areas to establish
guidelines for workstation design, employee training and
appropriate break periods.(Magid, 1998)
Blue Cross of California, developed strategies to combat
the rise of RSI. The company started training and educating
managers and employees to recognize symptoms and dangers of
repetitive strain injuries, and what to do if they arise.
They were given instructions on how to set up their
The Pencil Grip 27
workstations, and after one year, the company's insurance
carrier gave them a 1 million dollar dividend because of
their reduced Workers' Compensation expenses. According to
Sambyal and Kleiner (2002) , the..scientists have been unable
to pinpoint exactly what aspects of work are causative
factors for repetitive strain injuries, and that there are
no scientific studies showing that keyboard use can cause
repetitive strain injuries.(Magid, 1998)
A study conducted by Thomas in 2 000, investigated the
effectiveness of an injury prevention group on cumulative
trauma disorders in a total of 30 employees. Eighteen
employees did not attend the prevention groups and thirteen
employees attended the groups. The employees were compared
using the Canadian Occupational Performance Measure(COPM).
The researchers found that overall, there were no
significant differences between the groups in terms of
performance, satisfaction or scores on the COPM. One
explanation may be that the employees had previous
knowledge of basic ergonomic principles.(Thomas, 2000)
A study by Shinn and Romaine(2000) investigated the need
for ergonomic intervention in a middle school in Deer Park,
NY. The students were educated on ergonomics with use of
computers, and were tested on the information, before and
after they received the information regarding ergonomics.
The Pencil Grip 28
Their low-baseline pre-test scores indicate that there is a
need for preventative education in the classroom.(Shinn and
Romaine, 2000)
A research study conducted by Horneffer and Jamison in
2002 examined the emotional effects of writing about
stressful situations. Ninety one college students who wrote
their feelings in journals for fifteen minutes on two
occasions were compared with a comparison group who did not
journalize. There were greater improvements in emotional
health for the group that journalized. These findings
suggest that journalizing thoughts and emotions using a
paper and pencil for short periods of time can increase a
person's mental health, which impacts on a person's
function and life roles.(Horneffer and Jamison, 2002)
The History of Handwriting
The history of writing and writing instruments which
humans have used to record their thoughts and feelings
started about 25,000 years ago. The caveman first invented
a hunting club, handy sharpened stone and a skinning and
killing tool. The latter of the three was adapted into the
first writing instrument. The caveman then scratched
pictures with a sharpened stone tool into the walls of
The Pencil Grip 29
their caves. These drawings depicted events of daily life
and events.
With some time, the record keepers designed systematized
symbols for the drawings. The symbols represented words and
sentences, and were easier and quicker to draw, as well as
universally recognized by most people. When clay was
discovered, this made portable records possible. With the
high volume and repetition in record keeping, pictographs
evolved. Pictographs are abstract figures representing
sounds in spoken communication. Between the time of 17 00
and 1500 B. C. in the Sinaitic world the alphabet replaced
pictographs. The Hebrew alphabet and writing started about
600 B. C., and at about 400 B. C. the Greek alphabet was
developed. Greek was the first script to be written in a
left to right format. This was followed by Byzantine and
Roman writing systems. At this time, all writing systems
had only uppercase letters, and when writing instruments
were refined for details, lowercase was introduced as well
around 600 A. D.(http://inventors.about.com)
The Greeks introduced the first means of writing using a
paper and pen. They used a writing stylus, which was made
of metal, bone or ivory, and used on wax-coated tablets.
Messages purely made by hand, which are the first examples
of handwriting originated in Greece. Cadmus, a Grecian
The Pencil Grip 30
scholar invented the written letter, sent from one person
to another.(http://inventors.about.com)
Another advancement was when the Chinese invented and
perfected "Indian Ink." The Chinese philosopher, Tien-
Lcheu invented this ink around 2 697 B. C., and it became
common at about 1200 B. C. In the early writings people
used different color inks which had ritual meanings
attached to each color.(http://inventors.about.com)
The Egyptians, Romans, Greeks and Hebrews utilized
papyrus as well as parchment papers. The "Prisse Papyrus",
one of the oldest samples of writing on papyrus dates back
to 2000 B. C. The Romans invented a reed pen which was used
with ink and parchment, made from hollow tubular-stems of
marsh grasses and bamboo plant. The Romans also converted
the bamboo stems into a primitive form of a fountain pen.
The writing fluid fills the stem, and squeezing the reed
forces the fluid to the tip. Around 400 A. D. an ink was
developed, that was a bluish-black, which was a composite
of iron-salts, nutgalls and gum, and remained around for
centuries. Wood fiber paper, invented in 105 A. D., in
China, came known in 7 00 A. D. and was brought to Spain in
711 A. D. by the Arabs. Paper was not frequently used in
The Pencil Grip 31
Europe until paper mills were established in the late 14th
century.(http://inventors.about.com)
The quill pen was the writing instrument that dominated
for the longest period of time(over one thousand years).
The quill pen, made from a bird feather was introduced
around 700 A. D. The preferred, stronger quills were those
that were taken from living birds during the spring from
the five outermost left wing feathers. The left wing was
favored over the right, since the feathers would curve
outward and away if used by a right- handed writer. Goose
feathers were used by most people, but swan feathers were
of a premium grade and more expensive. Crow feathers were
used to make fine lines, as well as the feathers of an
eagle, owl, hawk or turkey. Quill pens usually lasted for
about a week and then needed replacement. Another
disadvantage was that there was a lengthy preparation time
for their usage. A lead and a ruler were used to make
margins. European parchments also needed a lot of cleaning
and maintenance. People also needed a coal stove to dry the
ink quickly, and a special knife to sharpen the
quill.(http://inventors.about.com)
After the invention of the printing press with wooden
and metal letters by Johannes Gutenberg in 1436, plant-
The Pencil Grip 32
fiber paper became the common medium for writing. Articles
which were written by hand resembled printed letters, until
scholars decided to change the form of writing, by using
small and capital letters and by writing with more of a
slant and connecting letters. Slowly writing became
suitable to the speed that the new writing instruments
allowed.(http://inventors.about.com)
In 1495 A. D., Aldus Manutius of Venice invented cursive
handwriting(also known as the Italian "running hand"), with
Roman capitals and small letters. By the end of the 16th
century, the Roman capitals and Greek letters were
transformed into the twenty-six letter alphabet that we use
today. When better inks and paper were invented, writing
developed into an art form and an activity of daily living,
thus leading to the invention of the modern fountain
pen.(http://inventors.about.com)
Anatomy and Kinesiology of the Hand
Our hands give us a primary means of interacting with
the environment. The human hand has a detailed structure,
and therefore can engage in complex tasks. It is crucial
for one to examine the anatomy of the hand in order to
clearly understand writing legibility, grasp patterns and
writing difficulties.
The Pencil Grip 33
The human hand contains osseous structures, joints,
musculotendinous units and a nerve supply. The hand is made
up of 27 bones, 18 muscles and 14 phalangeal segments. The
thumb and fingers are important components of the hand.
Each finger contains one metacarpal and three phalanges.
The digits are unequal in their length, contributing to the
hand's functional capacities. The thumb is made up of one
metacarpal bone and two phalanges. The thumb significantly
enhances functional ability by it's ability to oppose the
pads of the fingers, needed for prehension and grasp. All
of these structures are required to work in unison for the
hand to function most efficiently and effectively.
Pathological conditions may result if these structures do
not work as a unit(Strickland,1995).
The extrinsic muscles of the hand and forearm provide
flexion and extension of the wrist and phalanges. During
grasp flexion of the MCP joints are necessary for obtaining
proper shape of the hand. Flexion of the wrist is
undesirable, because it decreases grip force. Digit
extension and flexion are a combination of efforts of the
extrinsic and intrinsic muscles. The extrinsic muscle
bellies are located in the forearm, and their tendons cross
over the wrist joint and insert onto the digits. Intrinsic
The Pencil Grip 34
muscle bellies are found in the hand, distal to the wrist
joint. The function of the intrinsic muscles, which
produces flexion of the proximal phalanx and extension of
the middle two phalanges is to contribute to precise finger
movements required for coordination. The thenar eminence is
made up of the opponens pollicis, flexor pollicis brevis,
adductor pollicis and abductor pollicis brevis. The thenar
eminence contributes to opposition of the thumb, which
allows for grasp and prehensile patterns. The hypothenar
eminence is made up of the abductor digiti minimi, flexor
digiti minimi, palmaris brevis and opponens digiti minimi.
These muscles assist in rotating the fifth digit during
grasp. Muscles of the central compartment consist of
lumbricals and dorsal and palmar interossei. The lumbricals
flex the MCP joints. The dorsal interossei produce finger
abduction, palmar interossei produce finger adduction. The
first dorsal interossei abducts the index finger, assisting
in properly positioning the hand for pinching
(Coppard,2001).
The small bones of the hand are arranged in three
arches, two transverse and one longitudinal, which are
important for a strong functional grasp. These three arches
give the hand the ability to flatten or cup itself in order
The Pencil Grip 35
to hold objects of various sizes and shapes. Collapse of
the arches may lead to severe disabilities and deformities.
The palmar skin attaches to the underlying palmar
aponeurosis which facilitates grasp (Coppard,2001).
Previous research studies on the effects of pencil grips
In 1983 Lamme and Ayris examined the legibility of 798
first graders using different writing tools( primary
pencil, #2 pencil, #2 pencil with a triangular pencil grip,
Zaner-Bloser pencil and a felt tip pen). This study
suggested that the triangular grip as well as the other
writing tools had no significant effects on children's
handwriting legibility(Case-Smith and Pehoski, 1992).
In 1981, Ziviani conducted a study exploring the use of
triangular pencil grips on the effect of different writing
utensils on motor accuracy during a writing task. She
compared the motor accuracy of 54 participants between ages
seven and eight years old during a handwriting task while
using a standard #2 pencil, a 1.5 cm thick #2 pencil and a
standard #2 pencil with a triangular grip, the study
concluded that the use of the triangular grip promoted use
of a dynamic tripod grasp, considered to be a mature
grasp(Schneck and Amundson, 1990).
The Pencil Grip 36
A study was conducted in 1999 to determine the
effectiveness of pencil grips by using electromyographical
(EMG)analysis. EMG refers to surface electromyographic
recording used to detect electrical activity signals from
skeletal muscles. Eighteen right-hand dominant
participants, ranging from ages 18 to 35 years old
participated in the study. The participants were asked to
complete a writing sample using three writing tools: a
standard #2 pencil with no grip, a standard #2 pencil with
a triangular grip, and a standard #2 pencil with a pear-
shaped grip. Data for each muscle were analyzed
individually, providing information on how each writing
tool affected the motor recruitment of each muscle. No
significant difference was found in the amount of motor
unit recruitment during the tasks using different pencil
grips. However, trends were noticed in the amount of muscle
activity between intrinsic and extrinsic hand muscles
tested. A smaller amount of activity was noted during the
use of the triangular grip for intrinsic muscles, first
dorsal interosseous and the abductor pollicus brevis,
indicating that the triangular grip may be more effective
for clients with intrinsic muscle weakness, while the least
amount of muscle activity was noted during the use of the
standardized pencil for the extrinsic muscles, extensor
The Pencil Grip 37
digitorum and finger flexors. The highest amount of muscle
activity was recorded with use of the pear-shaped grip for
three out of the four muscles, indicating that this type of
pencil grip may be more efficient in promoting a dynamic
tripod grasp. The researchers also observed that during the
writing trials, the pear-shaped grip consistently forced
the participants to modify their grasp pattern. They also
observed that the participants used the same grasp pattern
with both the standard pencil and with the triangular
shaped grip, demonstrating that the triangular grip does
not automatically elicit the use of the dynamic tripod
grasp.
In 2000, a study was conducted by Appleman and Lipman to
examine the affects of pencil grips on forty second grade
children. Participants were asked to use a stetro pencil
grip for one month to promote the dynamic tripod grasp. The
children were asked to copy a sentence written on the
board, and their pinch strength of their dominant hand was
tested. The children's fine motor coordination was also
evaluated using a likert scale(Miller,1993). After one
month, the students copied the same sentences from the
board, and pinch strength and fine motor coordination
skills were tested. The children did not use the pencil
The Pencil Grip 38
grips for one month and all three areas were reassessed
following the completion of one month. The study did not
find a correlation between use of a pencil grip, improved
pinch strength and fine motor coordination. This study did
find a significant correlation between the use of a pencil
grip and improved handwriting legibility. There was an
improvement in the subjects' handwriting legibility while
using the grips, however when they were asked not to use
them, their legibility decreased(Appleman & Lipman, 2000).
Factors which may affect handwriting
Tseng and Cermak(1993) stated that "handwriting is a
complex task, and various factors are related to skilled
handwriting." Therefore, an appreciation of the multiple
factors that contribute to handwriting acquisition is
important to providing effective remediation. A number of
studies have identified client factors associated with
handwriting(Tseng and Cermak, 1993;Tseng and Murray, 1994;
Weil and Cunningham Amundson, 1994). Kinesthesia, motor
planning as well as eye-hand coordination, visuomotor
integration and in-hand manipulation are among the
variables that have been researched(Cornhill and Case-
Smith, 1996).
The Pencil Grip 39
Kinesthesia
Benbow emphasized the importance of kinesthetic
perception and it's affect on handwriting, stating
"efficient writing depends on kinesthetic input."(Benbow,
1995). Because the somatosensory system provides us with
immediate and specific information about movement, this
feedback may be more important than visual input in
detecting errors in movement, and guiding precise
movements. In 1987 Levine hypothesized that children with
impaired kinesthetic function demonstrated pencil grips
that were awkward and inefficient. He also suggested that
slow writing may be a result of limitations in kinesthetic
function. Schneck supported these hypotheses and in 1991,
found that children who demonstrated immature grasping
patterns and poor handwriting also had limitations in
kinesthetic function. In a research study performed by
Ziviani, Hayes and Chant in 1990, kinesthesia, as measured
by the tactile subtests of the Southern California Sensory
Integration Test(SCSIT/Ayres,1972) was in fact related to
letter formation, and alignment in children diagnosed with
myelomeningocele. However, in 1994, Tseng and Murray found
that the opposite was true, kinesthesia measured by the
SCSIT was not a significant contributor to handwriting
legibility, showing no significant difference between
The Pencil Grip 40
children with good and poor handwriting(Cornhill and Case-
Smith, 1996).
Motor Planning
Levine(1987) felt that motor planning is important for
skilled motor acts such as handwriting. Ongoing motor
planning is required in order to form individual letters,
and to write complex sequences of letters. Motor planning
has an influence on a child's ability to plan, sequence and
form letters and ordering of letters in words. Motor
planning is required to execute unfamiliar movements,
therefore it should be important when a child is first
learning to write. When children display decreased
kinesthesia they may be limited in their ability to plan
and direct sequences of hand movements(Cornhill and Case-
Smith, 1996). In 1994, Tseng and Murray found that the best
predictor of handwriting legibility was a test of finger
praxis when distinguishing between good and poor
handwriters. In 1982, Rubin and Henderson conducted a
research study on the relationship between the Test of
Motor Impairment(Scott,Moyes and Henderson,1985) and
handwriting performance, evidenced by the relationship
between fine motor control and handwriting. Children with
poor handwriting were shown to not have poor fine motor
The Pencil Grip 41
skills, however there was a greater variability of scores
in the five subtests. Ziviani(1990) addressed handwriting
performance and it's relation to motor planning in children
diagnosed with spina bifida. As measured in the Motor
Accuracy Test, motor planning was not associated with
handwriting speed or legibility. In 1991, Tseng found that
the Finger Position Imitation Test was the best and only
significant predictor of legibility of poor writers(Tseng
and Cermak, 1993). Weintraub and Graham(2000) also suggest
that finger function made a significant contribution to the
prediction of handwriting status, when they had two groups
of fifth grade students, good and poor handwriters complete
an alphabet writing task, the Colorado Perceptual Speed
Test(Decker and DeFries,1981), Expressive Orthographic
Coding task(Berninger et al,1993),and several finger
functioning tasks, such as finger succession, finger
lifting and finger recognition.
Eye-Hand Coordination
Cornhill and Case-Smith(1996)described skillful use of
the hand under visual guidance as an integral part of
handwriting. Benbow(1995) states that "in manuscript
writing the hand's output depends almost entirely upon the
input and ongoing guidance of the visual system". In 1994,
The Pencil Grip 42
Tseng and Murray found a significant correlation between
scores on the Motor Accuracy Test and handwriting in
students in third to fifth grades. The scores showed a
significant difference between those identified as being
good and poor handwriters. Cornhill and Case- Smith(1996)
also suggest a moderate correlation between eye-hand
coordination and legibility. Eye-hand coordination skills
remain a fundamental component of handwriting.
Visual-Motor Integration
Visual-motor integration is defined as the ability to
copy geometric shapes(Beery, 1982). Beery suggests that the
first nine figures in the Developmental Test of Visual-
Motor Integration(VMI;Beery,1982)should be mastered before
a child learns how to write. In a study conducted by Sovik
in 1981, it was suggested that visuomotor integration was
the most significant predictor of handwriting performance
in a sample of American and Norwegian children ages 7-11
years old. In 1992, Maeland conducted a study of 59 fourth
grade students categorized as a)clumsy, b) non-clumsy and
dysgraphic, c) typically developing and found that
visuomotor integration, measured by the VMI was a
significant predictor of handwriting performance. In 1994,
Weil and Cunningham Amundson suggested that performance on
The Pencil Grip 43
the VMI was moderately correlated to writing legibility,
measured by the Scale of Children's Readiness in
Printing(SCRIPT);(Weil and Cunningham Amundson,1994).
Cornhill and Case-Smith(1996)also suggest a correlation
between visuomotor integration and handwriting legibility
as seen in the VMI scores of good and poor handwriters.
Graham and Weintraub(2000) found visuomotor integration to
be a significant contributor to the prediction of
handwriting status, using the VMI as a measure of
visuomotor skills.
In-Hand Manipulation
Writing requires that there be precise and rapid
manipulation of the writing tool. Relationships between in
hand manipulation and writing have been researched by not
conclusively determined(Cornhill and Case-Smith, 1996). In
1995 Humphrey and colleagues found a strong correlation
between coloring accuracy in a sample of children between
the ages of 2 and 7 years old and in-hand manipulation. In
1995, Case-Smith found a significant relationship between
scores on the MAC from preschool children with motor delays
and in-hand manipulation. Cornhill and Case-Smith (1996)
found a moderate to high correlation between in-hand
manipulation and handwriting, indicating that precise
The Pencil Grip 44
control of the fingers and thumb to move objects in and out
of the hand is associated with letter formation in regards
to handwriting.
Elementary school children typically spend about 50% of
the school day engaged in paper-and-pencil tasks(McHale and
Cermak, 1992). Many of these tasks are performed under time
constraints(Amundson and Weil, 1996). In 2000, Tseng and
Chow conducted a research study investigating differences
in perceptual-motor measures and sustained attention
between children with slow and normal handwriting speed and
examined the relationships between these factors. The
results show that slow handwriters performed poorer than
children with normal speed handwriting in the areas of
perceptual-motor skills, proficiencies and inattention. The
two groups were qualitatively different in the way they
processed the written information. The performance of the
slow handwriters depended mostly upon visual processing,
while the other group was motor-based. This suggests that
intervention for slow handwriters should focus on visual
processing, visual memory and visual-motor integration.
Gender Differences
Research shows that the handwriting of girls tends to be
better than the writing of boys using measures of
The Pencil Grip 45
legibility and quality(Ziviani and Elkins,1984). Rosenbloom
and Horton(1971), Goodgold(1983) and Schneck(1987)did not
find significant gender differences in their studies on
pencil grip. Saida and Myashita(1979) reported gender
differences only in a three-year old group in which girls
demonstrated more mature grasps earlier than boys. In 1990
Schneck and Henderson reported that boys and girls tend to
have different developmental progressions of pencil grip
for drawing and coloring. However, in 2000, Graham and
Weintraub found that gender did not make a significant
contribution to the prediction of handwriting status in
fifth grade students. Yakimishyn and Evans(2002) also found
that no combination of writing tool or surface worked
better in facilitating a more mature grasp for one gender
over the other.
Finger Function
Summers(2001) states that "pencil grasp contributes to
the competent use of the pencil because it influences the
degrees of movement available in the interphalangeal(IP)
joints of the index finger and thumb of the writing hand".
Fifty-five Austrailian primary school children, ages 7-8
years old participated in a study conducted by Summers in
2001 to determine if joint laxity in the distal IP joint of
The Pencil Grip 46
the index finger and the IP and metacarpophalangeal(MP)
joint of the thumb influenced the development of grasps
that deviate from the dynamic tripod grasp. Data collected
was the torque measurement of the degree of extension at
the distal interphalangeal(DIP) joint of the index finger,
IP and MP joints of the thumb, assessment of proprioceptive
kinesthetic awareness, analysis of pencil grasp used and
measurement of joint extension. Results show that the
relationship between joint laxity and pencil grasp were not
significant. However, there was an association between
index DIP laxity and DIP joint position, which supports the
hypothesis that laxity in the DIP will have an effect on
pencil grasp. Laxity in the thumb had a great influence on
the position of the thumb and the pencil grasp. Pencil
grasps which incorporated thumb opposition were used more
frequently when joint laxity was present. Lateral thumb
position was used more frequently with IP and MP joint
laxity. These results support the observations of
Benbow(1995) and Ziviani(1982), that when joint stability
in the thumb is insufficient to control mobility, a lateral
grasp is an effective biomechanical adaptation.
The Pencil Grip 47
Ergonomic Factors
Among other ergonomic factors which influence
handwriting, the writer's sitting posture is extremely
important(Yeats, 1997). When children lack trunk stability
due to decreased muscle tone they are unable to make
necessary adjustments, while focusing on fine motor
activities such as handwriting(Cunningham and Amundson,
1992). The position of the paper in the midline of the body
is also related to a student's writing. Parush, Levanon-
Erez and Weintraub conducted a study in 1998 which
investigated differences between children with good and
poor handwriting on ergonomic factors that underlie
handwriting(body and paper positioning, pencil grip and
pressure). One hundred and three students participated in
the study, ergonomic factors were assessed both in copying
and in dictation conditions using the Hebrew Handwriting
Evaluation(HHE);(Eraz,et al,1995). The results show that
children with poor handwriting have inferior pencil
positioning, paper positioning, body positioning,
stabilization of paper and consistency of pressure in
comparison to good handwriters. Factors that were not
significant between the good and poor handwriters were
pencil grip, consistency of pencil grip and pressure.
The Pencil Grip 48
Yeats(1997)also states that poorly adjusted school
furniture may affect the academic performance of students.
Fatigue
Tseng and Cermak(1993) suggest that poor pencil grip
could result in quicker fatigue, which affects speed and
legibility of handwriting. Benbow(1987) also postulated
that children who compensate for lack of kinesthetic
feedback while writing, by using visual guidance may become
fatigued. Parush and colleagues(1998) conducted a study
with two groups of children: good and poor handwriters,
identified by their classroom teacher. The children were
asked to write for fifteen minutes without a break, writing
consisting of the short text of the HHE, and a second text
from a third grade workbook. The results show that children
with good and poor handwriting have inferior performance
when writing long texts. The results indicate that when
writing for long periods of time, the children fatigue,
which effects speed, quality of letter formation and
different ergonomic factors that relate to all children.
There was a significant change in the child's posture, 41%
of good writers sat up straight when they began, and after
10 minutes of writing, only 18% sat up straight.
The Pencil Grip 49
In 2001 Dennis and Swinth conducted a study examining
the influence of pencil grasp on handwriting legibility
during both short and long writing tasks in fourth-grade
students who were typically developing. They observed a
significant difference in letter legibility scores on the
short and long writing tasks. The children's handwriting
was more legible on the short task than the longer task.
These results suggest that endurance may have influenced
legibility regardless of pencil grasp.
Culture
Tseng(1998) studied the progression of pencil grip in
Taiwanese children. He found that the percentage of
American children using primitive grips was twice that of
Taiwanese children, and 40% of the children in the two
oldest age groups utilized a lateral tripod grasp. This can
be attributed to many factors. Asian children usually use
chopsticks, which requires dexterous manipulations, similar
to the dynamic tripod grasp(Tseng, 1998). Another factor
may be the fact that children in Taiwan at the age of three
start engaging in pre-handwriting activities such as
tracing numbers with a pencil, and by the age of 5 they are
required to write numbers and symbols in a confined space.
The Chinese phonemic system, practiced by preschoolers in
The Pencil Grip 50
Taiwan is also composed of discrete strokes, unlike the
English writing system in which many letters have smoothly
rounded strokes.(Tseng, 1998)
Emotional Factors
Children diagnosed with specific learning difficulties
may have a history of failure with reading, spelling and/or
writing(Scott et al, 1987). Previous experiences with
failure may result in anxiety and/or frustration whenever a
challenging task needs to be performed. These emotions that
children with learning disabilities may have, may have an
impact on writing performance. The child may avoid
situations requiring use of this skill. Despite enormous
effort, these children may not have produced an
aesthetically pleasing product in their writing
experiences, yet they may have given much effort to the
task. Occupational Therapists must motivate these children
to be an active-participant in therapy addressing their
specific limitations in handwriting. The occupational
therapist use purposeful writing activities, such as
poetry, essay contests, letters, birthday cards and thank
you notes so that the emphasis is placed on the child's
feelings of success with their handwriting efforts(Clark-
Wentz, 1997). and The therapist shows an interest in the
The Pencil Grip 51
child's needs and therefore gains the trust of the child.
This results in motivation for the child to improve
themselves(Exner, 1992).
Developmental progression of grip position
Levine(1987) viewed handwriting as "the final common
pathway, the merger of multiple developmental functions."
One important aspect of handwriting with which Occupational
therapists are concerned is pencil grip. In order for
Occupational Therapists to understand and treat handwriting
difficulties it is important for them to know the normal
development of pencil grip in children without handwriting
difficulties. Research on the development of pencil grip
shows that there is a developmental progression, with
changes occurring until approximately 10 years of
age(Ziviani, 1983) .
In 1931, Halverson reported a progression from banging
movements of the arm to discrete and controlled finger
movements, as well as a progression from a young child's
fisted grip of a pencil to a fingertip grip. The fingertip
grip described by Halverson was termed the dynamic tripod
grasp by Wynn-Parry in 1966.(Schneck and Amundson,1990)
The Pencil Grip 52
In 1971 Rosenbloom and Horton studied the development of
the tripod grasp in children ages 1.6-7.0 years of age.
They described the pencil grip to develop in three
stages:a) palmar grasp with the index finger extended along
the pencil shaft, b) static tripod grasp, c) dynamic tripod
grasp.
In 1979 Saida and Myashita conducted a study in Japan,
with children ages 2.3-6.5 years of age, and described
pencil prehension as having four stages: a) palmar grasp,
b) any variety of transitional grasps preceding the tripod
grasp by the thumb and two radial digits, c) static tripod
grasp, d) dynamic tripod grasp.
In 1983 Ziviani studied finger posture and forearm
position in the dynamic tripod grasp and found that between
the ages of 7-14 years old the pad-to-pad opposition and
the number of fingers positioned on the pencil shaft did
not change. In children under 10.5 years of age, PIP
flexion was greater than 90 degrees, and after that age it
was less than 90 degrees. The degree of forearm pronation
also decreased from being greater than 45 degrees in
children under 9 years of age to less than 45 degrees
following that age.
The Pencil Grip 53
In 1990 Schneck and Henderson conducted a study
consisting of 320 nondysfunctional children ranging from 3-
6 years old, to investigate the developmental progression
in pencil and crayon grip. They observed all the grips
identified by Rosenbloom and Horton and Saida and Myashita,
as well as three other transitional grips: a) cross thumb
grasp, b) four fingers grasp, c) lateral tripod grasp. He
reports the grip postures in developmental order as
follows: radial cross palmar grasp, palmar supinate grasp,
digital pronate grasp, only index finger extended,brush
grasp, grasp with extended fingers, cross thumb grasp,
static tripod grasp, four fingers grasp, lateral tripod
grasp, and dynamic tripod grasp. They grouped the grasps
into categories, "primitive", "transitional" and "mature
grasps".
The children's grasps were recorded during two trials of
drawing and coloring tasks. The most common grip observed
at all age levels was the dynamic tripod grasp, however one
forth of the children in the higher age levels used the
lateral tripod grasp. The study concluded that children
three years of age can be expected to use primitive to
mature pencil grips. By age 4.5 children are expected to
use transitional or mature grips.
The Pencil Grip 54
Erhardt(1994) described a normal progression from
immature to mature grasp patterns that occur between 1-6
years of age. Children between ages 1-2 years old usually
grasp their pencils or crayons in a palmar-supinate grasp.
At around 2-3 years of age the digital pronate grasp
emerges, a static tripod grasp emerges at around 3-4 years
of age, and between the ages of 4-6 years the tripod grasp
emerges, as the child's fine motor coordination improves.
Because of this distal control Amundson and Weil(1996)
reported that it is generally considered by teachers and
occupational therapists to be the optimal grasp for
handwriting performance.
Tseng(1998) conducted a study to investigate
developmental progression of pencil grip in Taiwanese
children aged 2.5-6.4 years of age. Fourteen grip patterns
were observed, including the ten grips classified by
Schneck and Henderson(1990), and four more grips including:
three variations of the interdigital grip, and the
quadruped grip.
The Effects of Pencil Grip on Handwriting
Koziatek and Powell(2003) studied the affect that pencil
grip has on speed and legibility of fourth-grader's
handwriting. The children were 95 typically developing
The Pencil Grip 55
students and 6 students receiving special education. All
participants were asked to complete the Evaluation Tool of
Children's Handwriting- Cursive(ETCH-C;Amundson,1995).
Their findings found no significant differences in
legibility and speed scored among the four mature pencil
grips, which strengthens the argument that the dynamic
quadrupod, lateral tripod and lateral quadrupod grips
should be considered as mature grips equal in function to
the dynamic tripod grip.
In 1991, Schneck compared the grips of dysfunctional and
non-dysfunctional children to examine the effects of grip
on handwriting. The subjects were 60 first-grade children,
with no identified learning, physical or behavioral
problems, as reported by teachers and parents. The
components of grip were observed through a drawing task,
and rated using the 5-point rating system, developed by
Schneck in 1989. The results of the study suggest that
children with handwriting difficulties may demonstrate a
lower grip score on a drawing task than children without
handwriting problems. However, children who demonstrate
poor handwriting, but have good proprioceptive-kinesthetic
feedback demonstrate equal scores to those who had good
handwriting. This supports the suggestions of Sasson,
The Pencil Grip 56
Nimmo-Smith and Wing(1986), that although there may be a
greater number of students with atypical grips that have
poor handwriting, grips in itself are not a predictor of
poor handwriting.
Environmental Influences
In 1990, Carlson and Cunningham studied the effect of
pencil diameter on pencil management and performance of
pre-school children. The results were that there were no
differences in pencil management and graphomotor
performance when using a large or regular sized pencil(Weil
and Amundson, 1993)
In 2000, Oehler and her colleagues examined the effect
of pencil size and shape on the prewriting skills of
children in kindergarten. The Graphomotor Task Instrument
was used to test 126 children in kindergarten's pre-writing
skills using a triangular shaped pencil, a standard pencil
and a pencil with a large diameter. Results show that there
was no effect of pencil size or shape on the quality of the
children's handwriting. Sources which address handwriting
interventions for preschoolers suggest that the use of
special writing tools, such as a small piece of chalk, or
adapting the environment, by using a vertical surface
influences the use of tripod pencil grasp. The short length
The Pencil Grip 57
of a broken piece of chalk requires the child to hold it
with the tips of the thumb, index and middle fingers,
preventing use of a whole-hand or five-finger
grasp(Yakimishyn and Magill-Evans, 2002).
In 1992 Meyers suggested that vertical surfaces are
important for appropriate hand and wrist position for fine-
motor and handwriting activities. When a child works on a
vertical surface, the wrist is positioned in extension,
which in turn supports thumb abduction, and opposition
required for a tripod grasp(Strickland, 1995).
In 1990 Benbow also stated that wrist extension
facilitated balanced use of the intrinsic muscles of the
hand. In 2002, Yakimshyn and Evans assessed children
between the ages of 23-24 months of age, having them use a
primary marker, colored pencil, and a small piece of crayon
to draw on horizontal and vertical surfaces. The results
suggest that children will use a more mature grasp when
drawing on a vertical surface, compared with a horizontal
surface, but only using a crayon. (Yakimshyn and Evans, 2002)
Feldman and Fiedler(2001)investigated the effects of
broken and whole crayons on grasp development in children
ages 2.7-3.7 years of age. The children's grasps were
classified using the 10 developmental stages organized by
The Pencil Grip 58
Schneck and Henderson in 1990. Significant gains using the
adapted crayons were only made during the initial three
weeks of the experiment, with no improvements in grasp
maturity from that point on.
Burton and Dancisak(2000) also investigated the effect
of diameter on grip form and drawing accuracy. They had
children between ages 3-5 perform 20 trials of a precision
drawing task, using varying pencil diameters. They found
that varying the pencil diameter did not significantly
change the drawing accuracy.
The Central Nervous System and Handwriting
When a child presents with a motor deficit, such as poor
control of refined hand skills, knowledge about how the
brain controls these movements can be helpful in planning
therapeutic treatment plans, suggests Case-Smith and
Pehoski(1992)."Children with decreased tactile and
proprioceptive-kinesthetic feedback from their hands
continue to need visual monitoring in order to perform a
writing task." (Schneck,1990) If a child has decreased
tactile feedback, these pre-patterned movements may take
longer to develop, or may never develop. Therefore, demands
become more difficult as handwriting remains inefficient.
Structural changes in the hand allow it to be used as an
The Pencil Grip 59
instrument, and changes in the Central Nervous
System(CNS)support these functions. There are many factors
which affect a child's ability to grasp a pencil for
writing. Somatosensory input such as tactile,
proprioceptive and visual sensations are integrated during
the handwriting process.
Corticospinal and motor tracts
The corticospinal tract is believed to provide the
ability to perform movements including independent use of
separate muscles. Research shows that changes in hand
skills with age may be related to maturation of neural
structures(Case-Smith and Pehoski, 1992). Descending motor
tracts achieve most of their connections indirectly through
an interneuron space in the gray area of the spinal cord.
The corticospinal fibers make direct connections to motor
neurons. These connections are believed to provide the
ability to fractionate movements. The primary motor cortex
was found to have a particular role during the
fractionation of muscles required for discrete movements,
such as the movements of individual fingers, when
researchers recorded the discharge of neurons as well as
electromyography of the hand muscles in monkeys ask to
The Pencil Grip 60
squeeze using both precision and power grips(Case-
Smith, 1992).
The sensation of touch
Somatosensory inputs are gathered by the receptors and
processing takes place over the dorsal column medial
lemniscal(DCML) system and the pathways of the
anterolateral system(AL). Touch sensibility is divided into
tactile discrimination and light touch. Light touch refers
to a sense of contact with the skin. Tactile discrimination
is the perception of size and shape of objects(Gilman and
Newman,1996, pg 57). Mechanoreceptors located in muscles,
joints and skin mediate sensations of proprioception, touch
and tactile discrimination. Mechanoreceptors include muscle
spindles, Golgi tendon organs, Pacinian corpuscles as well
as free nerve endings in muscles tendons, ligaments, joint
capsules and skin(Gilman,1996,pg 58). Tactile receptors
include Meissner's corpuscles, Pacinian corpuscles,
Merkel's cells, Ruffini endings and free nerve endings.
Pacinian corpuscles are the largest sensory end organs in
the body, found in skin and connective tissue surrounding
bones and joints. These receptors transduce only high-
frequency components of touch sensations, detect vibration
and are unresponsive to sustained deformation of the skin.
The Pencil Grip 61
Mediation of superficial phasic touch sensations are
performed by the Meissner's corpuscles. These corpuscles
are located superficially in the epidermal-dermal junction.
Movement of hairs, which is detected by free nerve endings
located in hair follicles, conveys a sense of touch.
Merkel's disc is situated near the epidermal-dermal
junction. Each receptor contains a complex of specialized
cells. Stimulation of these cells, elicits a sensation of
light pressure. The Ruffini endings are located deep in the
dermis layer of the skin, more superficially than the
Pacinian corpuscle. The Ruffini ending is a stretch
receptor. They respond greatly to tactile stimulation of a
spatially confined area of the skin, and to skin stretch
outside the area of maximum sensitivity. Joint receptors
present as four types and are found in the joint capsule.
Type I are similar to Ruffini endings, type II to Pacinian
corpuscles, type III to golgi tendon organs, type IV to
free nerve endings(Cohen, 1999).
Sensory information occurs at the level of the cerebral
cortex. Located in the postcentral gyrus, in the parietal
lobe of the primary somatosensory cortex, which contains a
somatotopically organized sensory representation of the
body. Buried in the lateral sulcus, at the lateral part of
The Pencil Grip 62
the postcentral gyrus lies the secondary somatosensory
cortex, which is also somatotopically organized, but in a
different sequence than the primary somatosensory cortex.
Sensory information which is conveyed to these cortex by
the ventroposterior nuclei allow us to discriminate between
stimuli. The information about the stimuli are then
integrated to develop perceptions regarding the sensory
experience. Damage that occurs to the primary somatosensory
cortex results in contralateral loss of tactile
discrimination and stereognosis(Cohen,1999).
Tactile Pathways
An important part of the path which mediates
discriminative touch is the dorsal column pathway.
Receptors associated with this pathway respond to tactile
stimuli, vibratory, touch-pressure and proprioceptive
information. Inputs are transmitted over the axon to the
dorsal root ganglion. Without a synapse, the information is
then passed to dendrites which enter the spinal cord. The
main bundle of fibers travels from the spinal cord to the
dorsal column nuclei in the medulla, and synapses in the
medulla in the gracile and cuneate nuclei. After that
point, the fiber bundle decussates, and the pathway
continues through the reticular formation in the brainstem
The Pencil Grip 63
and then to the thalamus(VPL nucleus), as the medial
lemniscus. The thalamus receives the tactile input, and
projects the information to the primary and secondary
somatosensory cortex, and areas 5 and 7 of the posterior
parietal lobe(Bundy,2002). A clear definition of the
functions of this tract is elusive, despite the fact that
it's importance is known. This may in part be due to the
fact that the dorsal column is a conduit for a number of
descending and ascending pathways. The dorsal column is a
composite of many fibers that enter either from lower
levels or higher centers, however many fibers do not
contribute to the system that makes it's way to the dorsal
column nuclei(nucleus gracilis, nucleus cuneatus), thalamus
and cerebral cortex. The dorsal column is divided into the
fasciculus gracilis and fasciculus cuneatus. Axons entering
the spinal cord from the lower body shift medially, forming
the fasciculus gracilis. Axons entering the spinal cord
from the upper body remain lateral and form the fasciculus
cuneatus. The medial lemniscus terminates in the ventral
posterior lateral nucleus of the thalamus. Integrity of the
dorsal column appears necessary to produce precise and
refined movements. This is most evident for movements
involving fine-motor coordination of the upper extremities.
Research suggests that after a monkey suffered a lesion
The Pencil Grip 64
involving the fasciculus cuneatus, they were impaired in
their ability to use their fingers for fine grasps. The
anterolateral system makes a minor significant contribution
to perception of touch. Even if there is damage to the
dorsal column, a person may still be able to have tactile
sensation from the skin. This system orginates from axons
of sensory neurons in the spinal cord. The main ascending
sensory pathways in the ventrolateral quadrant are the
spinothalamic tract and the spinoreticular tract, which
convey pain, temperature and some light touch impulses to
the spinal cord. Some dorsal horn cells that receive light
touch information via large alpha and beta input convey
this information to the spinothalamic tract(Cohen,1999).
Proprioception
Proprioception includes the senses of static limb
position and kinesthesia and refers to "the sensory
processes involved in conscious appreciation of posture and
movement"(Cohen, PG #1999). Information regarding change in
muscle length and force arise from muscle spindles, Golgi
Tendon organs and joint proprioceptors. These receptors
provide the central nervous system with information
pertaining to static length of muscles, rate of changes in
length, and the force that muscles generate.
The Pencil Grip 65
Proprioceptive pathways
The pathways for proprioceptive input are different for
the upper and lower limbs. In the upper limb, the first-
order neurons enter the spinal cord, forming the dorsal
columns, where they ascend without synapsing in the dorsal
column medial lemniscal system and then to the medulla.
Some primary afferent fibers reach the medulla, some, known
as propriospinal fibers terminate at spinal levels. Other
fibers, which are second-order neurons terminate in the
dorsal column nuclei(Bundy, 2002).
Vision
We tend to rely most heavily on our visual system for
day-to-day function. "It is vision that helps us to
navigate in the world, to judge the speed and distance of
objects, to identify food, members of other species, and
familiar or unfamiliar members of our own species"(Zigmond,
et al.,1999, pg 821). Vision is utilized during the writing
process by all people, but is more heavily relied on by
children with other limitations, such as those with
perceptual or proprioceptive limitations. Vision receptors
are located in the neural retina. The rods and cones,are
photoreceptors which transduce light energy into electrical
energy, which can be transmitted to the central nervous
The Pencil Grip 66
system. Cones mediate color vision, and provide high
acuity, while rods are sensitive to light and enable vision
in dim light. Rods respond slowly, cones respond
rapidly(Bundy,2002).
Visual pathways
Axons from the retinal ganglion collect and form a
tract, known as the optic nerve. The optic chiasm is at the
point at which fibers from each side of the visual field
decussate, some fibers from the nasal retina of each eye
join the temporal fibers of the other eye. Each optic tract
carries signals from one half of the visual field. These
visual afferents continue as the optic tract. The optic
tract projects to the lateral geniculate nucleus(LGN),
which is caudal and lateral to the thalamus. Neurons in the
LGN, then project to the primary visual cortex, known as
area 17 in the occipital lobe(Brodmann's area). The optic
tract also sends a smaller projection to the superior
colliculus. The visual cortex sends processed signals back
to the colliculus. The three main sources from which the
spinal cord receives and integrates information from are
the optic tract, occipital cortex and the spinotectal
tract. Optic radiations and the calcarine sulcus of area 17
in the occipital lobe project from the pathways of LGN to
The Pencil Grip 67
the visual cortex. The radiations run posteriorly, through
Wernicke's area, lateral to the lateral ventricles. At the
lateral ventricles, fibers fan out and go posteriorly to
the visual cortex(Cohen, 1999).
Occupational Therapy Assessment of Handwriting
Poor handwriting is a primary reason for referral to
occupational therapy in a public school system(Clark-Wentz,
1997). Approximately 2.9 million students are currently
receiving special education services for learning
disabilities in the United States(SchwabLearning.org,
2003). "Occupational therapists view handwriting as a
functional activity, which when performed inadequately, may
affect an individual's satisfaction, creativity,
productivity and academic achievement"(Bonney, 1992).
Occupational therapists are empowered to evaluate and treat
children with handwriting problems in an professional
manner due to their extensive neuromuscular and
sensorimotor background, functional training experience as
well as knowledge of psychological and social behavior and
competence in analyzing complex activities(Cunnningham,
1992). "Handwriting difficulty may be experienced by
children with physical, sensory, intellectual or learning
disabilities, or by children with no other identified
The Pencil Grip 68
difficulty"(Penso, 1990). Difficulty with handwriting may
vary in severity, etiology and effect on occupational
performance. Not addressing the problems may lead to
reduced written work, performance anxiety, avoidance and
negative feelings (Sassoon, 1986). Management of
handwriting problems requires identification and
remediation of specific areas of difficulty(Bonney,1992).
Two approaches to assessment of handwriting have been
identified as the skill approach and the ability approach.
"The skill approach assumes that difficulty with skill
performance results from skill specific factors such as
inadequate experience, poor teaching or lack of appropriate
internal and external feedback." Therefore, assessments
focus on observation and measurement of skill performance.
The ability approach suggests that dysfunction in a child's
underlying abilities results in difficulty with skill
performance. Using this approach, assessments focus on
abilities such as visual-motor control.
A comprehensive evaluation includes information and data
that are gathered from classroom observations, discussions
with the teachers, parents and other team members and
formal and informal testing using evaluation instruments.
"The therapist's role is to determine underlying postural,
The Pencil Grip 69
motor, sensory integrative or perceptual deficits that
might interfere with development of legible
handwriting"(Stephens and Pratt, 1989). Upon evaluation of
handwriting dysfunction, the therapist may analyze four
main components to establish the child's baseline of
handwriting function. These components include a) domains
of handwriting, b) legibility components, c) writing speed,
and d) ergonomic factors(Amundson, 1992). Writing speed is
always measured by number of letters written per minute.
Speed and legibility of handwriting help determine whether
or not a child will meet the standards of the teacher and
curriculum where he/she will be placed(Rubin and Henderson,
1982) .
When choosing a tool to evaluate a student's
handwriting, the therapist should keep in mind the
characteristics and strengths and limitations of the
instrument. Several handwriting assessments are available
to occupational therapists. The most common ones utilized
include the Children's Handwriting Evaluation Scale(Phelps,
Stempel and Speck, 1984), The Children's Handwriting
Evaluation Scale-Manuscript(Phelps, Stempel, 1987), Denver
Handwriting Analysis(Anderson, 1983),Diagnosis and
Remediation of Handwriting Problems(Scott, Moyes and
The Pencil Grip 70
Henderson, 1985), and the Test of Legible
Handwriting(Larsen and Hammill, 1989).
The Wold Sentence Copy Test
The Wold Sentence Copy Test(Wold, 1970) is a
standardized visual motor test, which requires the student
to copy a printed sentence on the lower half of a sheet of
paper. The sentence is printed on the upper third of the
page. It is appropriate for evaluating children between 6-
10 years of age. The time required to copy the sentence is
recorded in seconds. The children are observed by the
evaluator for number of fixations, posture, pencil grip,
vocalizations, spacing of letters, concentration,
attention, fatigue, formation of letters and frustration
level during evaluation.
Occupational Therapy Intervention
Surveys from 900 school-based therapists across the
United States were analyzed by Chandler(1994), who found
that the most common reason for referral to occupational
therapy was handwriting problems(Case-Smith, 2002).
Therapists addressing handwriting difficulties in treatment
need to be sensitive to the child's needs due to
frustration or anxiety that may be due to the handwriting
The Pencil Grip 71
difficulties. The therapist must create an environment that
encourages a positive change in the child's behavior(Todd,
1993).
Occupational Therapy in mainstream schools is commonly
implemented with three models described by Dunn(1988) and
Mosey(1993) as: a) direct therapy, b) monitoring and c)
consultation. Direct service allows for consistent and
frequent practice essential to motor learning of
handwriting. Monitoring includes teaching, training and
supervising others who implement the intervention.
Consultation services are when an occupational therapist
provides expertise to support the operation of the school
system.(AOTA, 1989)
Occupational therapists may use several service
provision approaches when addressing the specific needs of
the child. The six service provision approaches described
by Mosey(1993) are as follows: a) Remedial approach which
emphasizes facilitating improvement in performance
components, i.e. perceptual training, b) Functional
approach, emphasizing facilitating mastery of tasks, i.e.
manual writing skills training, c) Compensatory approach,
emphasizing minimizing the effect of limitations in
performance components in areas of functional performance,
The Pencil Grip 72
i.e. using tape to indicate proper position of the paper on
a desk, d) Adaptive approach, emphasizing changing the
task, aspects of the environment to minimize limitations,
i.e. reducing the amount of a copying task, e) Management
approach, emphasizing minimizing of distressing or
disruptive feelings and behavior, in order to deal more
directly with primary problems, i.e. psychological support.
An intervention plan for handwriting should have a balance
between a variety of therapeutic approaches, such as
neuromuscular, acquisitional, sensorimotor, biomechanical
and motivational approaches(Case-Smith and Pehoski, 1992).
In a neuromuscular approach preparing the children's bodies
and upper extremities to write is critical. The
acquisitional approach focuses on practice, repetition,
feedback and reinforcement. The multisensory approach is
based on the theory that by varying sensory experiences,
the child's nervous system will integrate information more
efficiently, producing legible handwriting. The
biomechanical approach focuses on ergonomic factors
affecting handwriting. The motivational approach focuses on
developing a positive rapport with the student(Case-Smith
and Pehoski,1992). Occupational therapists are able to
analyze a child's pencil grasp, make suggestions on how to
The Pencil Grip 73
correct an immature grasp, and use clinical judgment in
designing treatment methods.
Occupational Therapy is process-oriented and education
is product-oriented, therefore, collaboration between the
teacher and therapist is essential in the evaluation and
intervention process(Chu,1997). A study was conducted by
Reisman in 1991, using a sample of 565 children in order to
investigate referrals made by teachers to Occupational
Therapy. A handwriting test was used to compare scores of
those who were referred and those who were not referred to
OT. The children were divided into four groups. The results
showed that the group of students in regular mainstreamed
classrooms with no special education had the highest
scores, and the group with mainstream students who spent
part of the day in special education classes, and received
OT intervention for poor handwriting had the lowest scores.
The study concluded that teachers were making appropriate
referrals for children with poor handwriting to have OT
intervention(Reisman, 1991).
Results from a research study by Daniel and Froude in
1998 were contradictory to the previous study. Handwriting
samples were gathered from 61 fifth and six grade children,
which showed a lack of reliability in the evaluation of
The Pencil Grip 74
handwriting quality between teachers and therapists. (Daniel
and Froude, 1998)
Several teaching methods have been developed to aid in
teaching handwriting to school-aged children. Two teaching
methods often utilized by occupational therapists are Loops
and Other Group, a kinesthetic teaching method designed to
teach cursive writing(Benbow,1990) and Handwriting Without
Tears, developed by Jan 01sen(1998).
Loops and Other Groups includes kinesthetic teaching
techniques to be included at the beginning of writing
instruction. The groups are separated into cursive style
letters that have common motor patterns. The letters are
taught one after another, to help the child master the
motor control needed for the group of letters(Benbow,1990).
Jan Olsen's Handwriting Without Tears can be used in
both regular and special education classrooms. The program
begins with pre-printing skills and progresses to cursive
writing. This program uses visual, tactile, auditory and
kinesthetic sensory systems to teach children how to write.
Olsen notes the importance of pencil grasp, pencil pressure
and proper sitting posture and proper paper
placement(Olsen, 1998).
The Pencil Grip 75
Several research studies have been conducted on the
effectiveness of handwriting interventions employed by
occupational therapists. A recent study conducted by Case-
Smith(2002) was designed to investigate the effects of
school-based occupational therapy services on student's
handwriting. Students 7-10 years of age with poor
handwriting legibility who received direct occupational
therapy services were compared with those who did not
receive services. Three subtests of the Developmental Test
of Visual Perception(DTVP; Hammill, Pearson and
Voress,1993) were administered to assess position in space,
figure ground perception and copying. The Bruininks-
Oseretsky Test of Motor Proficiency(BOTMP;Bruininks,1978)
subtests for visual-motor control and upper limb speed and
dexterity were also administered. In addition, in hand-
manipulation was measured using the nine-hole peg test.
Handwriting speed and legibility were measured with the
ETCH(Amundson, 1995). Two sections of the Student
Functional Assessment(SFA;Coster et al,1998) were completed
by the child's occupational therapist and teacher. The
study concluded that children in the intervention group
made significant improvements in visual-motor control, in
hand manipulation and position in space. A previous study
by Case-Smith in 1998 demonstrated improvements in in-hand
The Pencil Grip 76
manipulation and position in space by preschool children
receiving OT services compared to those that did not
receive services. This suggests that these skills may
consistently increase with OT intervention. The students
with intervention in the 2002 study by Case-Smith also made
significant gains in handwriting legibility, but increases
in speed were not significant. Scores on the SFA written
work scale also increased by 12 points. Fifteen out of 29
students with poor handwriting at the beginning of the
year(<85% total letter legibility) demonstrated good
legibility at the end of the school year(>90% total letter
legibility).
Peterson and Nelson(2003) investigated the effects of
Occupational Therapy intervention in a school setting. The
study examined printing skills in economically
disadvantaged first graders who were at risk both
academically and socially. Fifty nine first-grade children
participated in this study, and were given a pre-test and a
post-test which consisted of the Minnesota Handwriting
Test(MHT;Reisman,1999). The first five minutes of each
session included sensorimotor "heavy work", followed by 20
minutes focusing on motor planning, motor memory self
monitoring and learning of specific strategies to improve
The Pencil Grip 77
letter size, line use and spacing. Letters were practiced
using a variety of sensory modalities, pencil grasp was
explored in playful ways. The last five minutes of the
sessions focused primarily on practice of D'Nealian
handwriting. The results of the study concluded that the
intervention was effective in improving academic outcome of
printing, because of a significant increase in scores of
the MHT when comparing pre-test to post-test(Peterson &
Nelson, 2003).
Current trends in occupational therapy practice in
regards to handwriting were explored by Feder and
colleagues in 2000. Fifty Canadian occupational therapists
with a minimum of three years experience in pediatrics were
interviewed by phone. The survey that they completed was
designed by three occupational therapists and an
epidemiologist/neonatologist. The survey included three
parts: 1)demographic/general information, 2) specific
questions relating to assessment and treatment of
handwriting, and a section focused on the use of weights
for therapeutic intervention. Results revealed therapist
routinely (>90%) assessed gross/fine motor difficulties,
perceptual skills, quality of movement and motor planning
when a child was referred with fine motor or handwriting
The Pencil Grip 78
difficulties. A small portion of respondents assessed
cognition, language, environment, behavior, social-
emotional level, vision, keyboarding, soft signs,
functional performance or handwriting itself. Standardized
handwriting assessments were used by a 10% of respondents.
All therapists reported using an eclectic approach to
treating handwriting, with the sensorimotor approach most
frequently used(90%). Sixty eight percent of therapists
also responded positively to having used weights in
remediation of handwriting in their clinical practice. Most
therapists used weights for poor motor coordination,
tremor, low tone, poor postural stability or poor sensory
awareness. However it is important to note that there only
exists one single unrelated case report in pediatric
research literature in which weights were used with a
successful outcome to reduce self-injurious behaviors in a
10-year old child with severe developmental delays and
autistic features(Van Houten,1993). These leads us to
believe that there is a paucity of research addressing use
of weights, and that further research needs to be
conducted(Feder, Majnemer and Synnes, 2000).
A study by Lockhart and Law(1994) evaluated the
effectiveness of a multisensory writing program to improve
The Pencil Grip 79
cursive writing abilities of four children, with
sensorimotor difficulties in grades four, five and six.
Sessions consisted of tracing letters on a blackboard with
chalk, tracing letters on a rough surface with a marker,
forming letters in rice with a finger, copying letters on
paper over a rough surface followed by tracing and copying
letters on regularly lined paper. The children showed a
substantial trend in changes in visual analysis, however it
was not significant overall. One child had significant
changes in overall quality of handwriting. This study
suggest that there are effects of a multisensory program to
improve handwriting, however extent and scope are still
inclusive.(Lockhart and Law, 1994)
Woodward and Swinth(2002) sent out 313 school-based
occupational therapists, who were members of American
Occupational Therapy Association(AOTA)and who's primary
employment was in a school system. One hundred and ninety
eight surveys were returned and analyzed by the
researchers. The survey consisted of two parts, the first
was focused on demographic information, the second part
consisting of a list of 25 multisensory modalities and
activities and a Likert scale(1= never, 5= very often) to
rate the use of each intervention. The results demonstrate
The Pencil Grip 80
that using a multisensory approach to remediate handwriting
is important and is a frequent area of practice for school-
based occupational therapists as indicated by 92.1% of
respondents. The highest percentage of respondents work
with preschool-age to junior high school age students on
handwriting. This could possibly be explained by the theory
of neural plasticity, in which younger children benefit
greatly from therapy due to their rapidly developing and
changing nervous systems. Three of the modalities and
activities most often used by the respondents involved
adaptations to standard writing tools and surfaces, as well
as use of commercially available writing programs, such as
Handwriting Without Tears(Olsen, 1998). However, consensus
regarding the primary sensory systems targeted by
therapists was inclusive. Having a clear understanding of
the clinical reasoning for choosing different modalities
and activities may help with efficiency and effectiveness
of intervention focused on handwriting, which may in turn
affect the child's handwriting performance(Woodward and
Swinth, 2002).
Research was conducted in order to explore a handwriting
club, which utilizes sensory integration strategies to
improve handwriting. The students chosen were third and
The Pencil Grip 81
fourth grade boys who had handwriting and social skill
deficits. They were diagnosed as having a learning
disability, OHI or behavior disordered. The goals of the
club were to: a) improve student's cursive handwriting
skills, b) improve ability to work with peers in a loosely
structured, stimulating situation and c)help them identify
their own sensory needs and strategies to address those
needs. The group met twice a week for 8 months, with 30-
minute sessions. The sessions included gross motor
activities, fine-motor warm-ups and then handwriting
instruction using the Handwriting Without Tears
Program(Olsen,1998). The results indicated that the group
met it's set goals, and because of the children's success,
they felt more confident in their handwriting
abilities(Keller, 2001).
A study conducted by Sudsawad and colleagues in 2002
investigated the effect of kinesthetic training on first-
grade students ages 6-7 years old, who demonstrated
handwriting deficits and kinesthetic deficits. The children
were assigned to either a kinesthetic training group, a
handwriting practice group or a no treatment group. Each
child was given a pretest, a post-test and a follow-up
test, four weeks after the post-test. Each test consisted
The Pencil Grip 82
of the Kinesthetic Sensitivity Test(Laszlo and
Bairstow,1985), the ETCH and a teacher questionnaire.
Kinesthetic training was provided 30 minutes daily for 6
consecutive school days. The results suggest that
significant improvements were made in handwriting
legibility and kinesthesis as judged by teachers, however
no improvement was found as measured by the standardized
measurement tools. This study concludes that kinesthetic
training was not any more effective than handwriting
practice or no treatment.(Sudsawad, Trombly, Henderson and
Tickle-Degnen, 2002)
The Pencil Grip 83
Chapter Three
Methodology
Design format
The research was conducted utilizing a quasi-experimental
design. The purpose was to look at the effects of pencil
grips on the writing skills of school-aged children with
learning disabilities. The subjects were selected from a
group of children 5-10 years old. All children between the
ages of 5 and 10 years old whose parents/guardian completed
and returned consent forms participated.
Subj ects
A sample of children ages five to ten years of age from a
private school for children with learning disabilities in
NYC, NY. Thirty subjects participated in the study.
Experimental Environment
The study was done in a naturalistic environment, the
school library with minimal distractions. The teachers
helped in organization of the classes prior to the
beginning of the study.
Procedure
The subjects chosen for this study were school-aged
children with learning disabilities from The Gateway
School. The subjects were required to use "The Pencil Grip"
for two months, to promote the dynamic tripod grasp.
There were criteria for selection into the study. The
children selected were 1) children ages five to ten years
The Pencil Grip 84
old 2) had been diagnosed with a learning disability. All
students were able to participate, there were no exclusion
criteria, since all children in the school are diagnosed
with a learning disability. An occupational therapist,
currently working in the school monitored any difficulties
that arose during the two months of the study.
The children were asked to complete the Wold Sentence
Copy Test or handwriting sample(for children ages 5-6 years
old) administered by the principal investigator. The papers
were collected and analyzed for any handwriting
difficulties. The children's tripod grasp strength of their
dominant hand was measured. The children then received a
pencil grip, known as "The Pencil Grip" from the principal
investigator. Another pencil grip was mailed home to the
child's home so that they were able to use the grips at
home during writing activities. After two months, the
children were asked to complete a second Wold Sentence Copy
Test or handwriting sample, and their tripod pinch strength
was reevaluated. The children then choose whether or not
they would like to continue to use the pencil grips.
Data Analysis
A t-test was ran to determine the results of the study.
The one-tailed hypothesis will be proven if the mean scores
of the pre-tests are significantly less than the mean of
The Pencil Grip 85
the post-test scores on the alphabet copy sheet and Wold
Sentence Copy Test, this will demonstrate that "The Pencil
Grip" has an impact on handwriting. The means of the
subject's two tripod grasp strength readings were also
analyzed for significant improvements in tripod grasp
strength due to the use of "The Pencil Grip." The
children's responses towards use of the pencil grip will be
recorded.
The Pencil Grip 86
Chapter Four
Results
Descriptives
Thirty two elementary-school age children participated
in this study, after it was established that each
participant met the required criteria for inclusion. The
subjects in this study were students from a private school
for children with learning disabilities located in NYC, NY.
The subjects were required to return a consent form, signed
by their parent/ legal guardian in order to participate in
the study. The subjects were initially assessed at the end
of September 2003 and again in December 2003.In this quasi-
experimental study, the children's ages upon initial
assessment ranged from 5 years and 6 months to 9 years and
10 months of age. They represented a wide range of ethnic
backgrounds, mostly from the higher-level socioeconomic
class. The consent form provided permission to allow the
student to be assessed and to inform the parent/guardian
that the primary investigator will use the data collected
for a research study. Forty four consent forms were sent
out, 33 were returned signed by a parent/legal guardian.
Two students were excluded from the study after the initial
assessment, because their scores on the Wold Sentence Copy
The Pencil Grip 87
test were grade-appropriate or above grade level. Three
students were excluded due to numerous absences, and one
student was excluded because of his refusal to participate
in the assessment process. Of the 27 remaining students, 10
were girls and 17 were boys. Three of the students who
participated were left-handed,24 were right-handed.
Descriptive of Test Scores
The subjects' tripod grasp strength was measured using
a Jamar pinch gauge during the initial assessment, and a
second time after the two month trial was complete. On both
occasions, the subjects ages 5-6 years of age completed a
handwriting sample, the alphabet copy sheet, composed of
letters of the alphabet which the children copied into
spaces. Children ages 7-10 years of age completed the Wold
Sentence Copy Test on both occasions as well. The initial
tripod grasp readings for students ages 5-6 years of age
ranged from 4-9 pounds(mean= 6.63, standard deviation
=1.69). The second assessment of students ages 5-6 revealed
grasp readings ranging from 5-9 pounds(mean= 7.75, standard
deviation^ 1.58). The initial tripod grasp readings for
students ages 7-10 years ranged from 6-12 pounds(mean=
8.53, std. deviation= 1.35). The second readings for
students ages 7-10 years ranged from 8-13 pounds(mean=
The Pencil Grip 88
9.79, std. deviation= 1.48). These results are represented
in Graph 1.
G
r
a
s
p

s
t
r
e
n
g
t
h
Graph 1
The Pencil Grip 89
Ages 5-6
Ages 7-10
Pre-test Post-test
Initial and second readings of tripod grasp strength for
participants 5-6 and 7-10 years of age
The Pencil Grip 90
The initial time that it took for the students to complete
the alphabet copy sheet ranged from 1 minute to 2 minutes
and 18 seconds(mean= 1.67, std. deviation= .5084). To
complete the second, post-test trial of the alphabet copy
sheet, times ranged from 50 seconds to 1 minute and 59
seconds(mean= 1.0213, std. deviation= .5144). These results
are represented in Graph 2.
T
i
m
e
The Pencil Grip 91
Graph 2
2:24 -f
Ages 5-6
Pre-test Post-test
Time required to complete the alphabet copy sheet by
participants ages 5-6 years of age
The Pencil Grip 92
Initial scores on the alphabet copy sheet ranged from 40-64
points(mean= 54.75, std. deviation^ 8.05). Scores upon
completion of the second alphabet copy sheet ranged from
37-65 points (mean= 55.0, std. deviation= 9.2). These
results are represented in Graph 3.
A
l
p
h
a
b
e
t

s
c
o
r
e
s
The Pencil Grip 93
Graph 3
54.95
54.85
54.75
54.65
-.
>
Ages 5-6
Pre-test Post-test
Scores on the alphabet copy sheet by participants ages 5-6
years of age
The Pencil Grip 94
Pre-test scores on the Wold Sentence Copy test ranged from
5.64 letters/minute to 58.4 letters/minute (mean= 27.01,
std. deviation= 12.78). Post-test scores of the Wold
Sentence Copy Test ranged from 9.4 letters/minute to 56.4
letters/minute (mean= 30.87, std. deviation= 12.57). These
results are represented in Graph 4.
W
o
l
d

s
c
o
r
e
s
The Pencil Grip 95
Graph 4
31
30
29
28
27
26
25
Pre-test Post-test
Scores on the Wold Sentence Copy Test by participants ages
7-10 years of age
The Pencil Grip 96
Testing of Hypothesis
The first hypothesis stated that students with learning
grasp strength when using pencil grips for two months.
Results indicated no statistical significance (t(18)=.157,
p>.05) using a paired-samples t-test for the this
hypothesis with regard to subjects ages 7-10 years of age.
Results were found to be significant(t(7)=.048, p<.05)using
a paired samples t-test for subjects ages 5-6 years of age.
The second hypothesis was that students with learning
disabilities will have better handwriting with use of
pencil grips, as measured by the Wold Sentence Copy or the
alphabet copy handwriting sample, which asks the subjects
to copy the first 14 letters of the alphabet. Results of
the Wold Sentence Copy test were found to be significant
(t (18) = .000,p<.05)using a paired sample t-test. The amount
of time it took for students to complete the alphabet copy
sheet was not statistically significant (t(7)=.133, p>.05)
using a paired sample t-test. Scores on the alphabet copy
sheet were also found to be not statistically significant
(F=.081, p>.05). Results indicate an improvement in 63% of
the subjects' handwriting as evidence by the two trials of
the Wold Sentence Copy Test.
The Pencil Grip 97
Additional Findings
After conducting this research study, the principal
investigator asked the participants for their responses to
the use of the pencil grips. Sixty three percent of the
participants reported a positive response to the use of the
pencil grips, reporting that they would like to continue
using the grips in the future. Another finding was that 53%
of the participants produced handwriting samples with
improved legibility, when comparing the pre and post Wold
Sentence Copy tests.
The Pencil Grip 98
Chapter Five
Conclusion
Major Findings
Results of the paired samples t-test were found to be
statistically significant (p<.05) with regard to tripod
grasp strength in participants ages 5-6 years of age.
Results of this analysis support the first hypothesis of
the study by demonstrating that children with learning
grasp strength after using "The Pencil Grip" for two
months. These results don't support the results of a study
conducted by Appleman and Lipman(2000), in which tripod
grasp strength was not increased with use of pencil grips.
Although the results were not statistically significant
(p>.05) for students ages 7-10 years of age, there was a
slight increase in the mean tripod grasp strength between
the pre-test and post-test.
The second hypothesis of this present study was that
students with learning disabilities will demonstrate better
handwriting with use of the pencil grips, as measured by
the Wold Sentence Copy Test and the alphabet copy sheet.
Results of this analysis using a paired sample t-test were
found to be extremely significant(t(18)=.000) with regard
to the initial and secondary scores on the Wold Sentence
Copy Test. This proves the second hypothesis of this study,
The Pencil Grip 99
that improvements in handwriting are due to use of the
pencil grips. The mean scores on the alphabet copy sheet
were not found to be statistically significant, however
there was a slight increase in the mean scores for both
trials. As evident in the two alphabet copy test samples of
student #7, some students showed marked improvements in
letter formation and legibility after the two month trial
using "The Pencil Grip"(Samples 1 & 2).
Sample 1
The Pencil Grip 100
The Pencil Grip 101
Sample 2
The Pencil Grip 102
These results do not support the findings of Koziatek and
Powell(2003) that suggested that there was no significant
difference in speed scores on the ETCH-C(Amundson,1995)
among four mature pencil grips. The principal investigator
of the present study believes that these results did not
support the original hypothesis because of the younger
children's emphasis on finishing the handwriting sample
quickly, not dwelling on making the sample more legible.
The children were also eager to return to their classrooms,
and had just started learning how to write words in their
class when the principal investigator conducted this study.
Another factor that may had lead to these results is that
the alphabet copy test was developed by the principal
investigator, with little reliability and validity. This
assessment was not standardized, but adapted the scoring
criteria of the VMI(Beery, 1987) when establishing it's
scoring criteria, which is a limitation of this study. The
mean times for completion of the alphabet copy sheet
decreased slightly over the two trials, but was not found
to be statistically significant. These results are
consistant with Lamme and Ayris(1983) who suggested that
triangular grips and other writing tools had no significant
effect on handwriting legibility. These results are also
consistant with the conclusions drawn by Koziatek and
The Pencil Grip 103
Powell(2003), that no significant difference in legibility
was found among four mature pencil grips. Additional
findings were that 53% of the participants demonstrated
increased handwriting legibility, when comparing the two
Wold Sentence Copy Test samples. These results are
consistant with those of Appleman and Lipman(2000), who
found a significant correlation between the use of pencil
grips and improvements in handwriting legibility.
Other Contributing Factors
The principal investigator feels that a few factors may
have affected the pre and post scores on the Wold Sentence
Copy Test, the alphabet copy sheet and the initial and
secondary readings of tripod grasp strength. One factor
which may have affected the results of this study was the
testing environment. Although the principal investigator
made all efforts to keep the environment consistent during
pre and post tests, there were time-constraints, school
events and space constraints at times. Because the tests
and tripod readings were done in groups of two or three
students, there may have been competition between peers to
finish their samples first, not focusing on the legibility
of their writing. Some students were also easily distracted
by their peers, which decreased their time on task.
The Pencil Grip 104
Another factor that may have affected the results of
this study is that different teachers have different
classroom routines and rules. Some teachers handed out the
pencil grips to each child before each writing task, while
others left up to the student to not loose the grips and to
use them as they feel is appropriate. This may have led to
inconsistencies in this study with regard to compliance, as
some children in these such classes were extremely
compliant with use of the grips, others were not as
compliant and used the grips at their leisure.
Implication to Occupational Therapy
One area of treatment that an Occupational therapist
serving the pediatric population is constantly involved in
on a daily basis is handwriting. Many children demonstrate
difficulty with handwriting, specifically those diagnosed
with a learning disability. Many alternatives have been
introduced in the treatment of handwriting difficulties,
one being the provision of pencil grips. This study found
that "The Pencil Grip", a commercially available grip,
(purchased at www.pfot.com)significantly improved tripod
grasp strength in children ages 5-6 years of age. These
findings are significant, because the dynamic tripod grasp,
the mature, preferred grasp is facilitated with use of
"The Pencil Grip". This present study also revealed
The Pencil Grip 105
improvements in legibility with use of the grips. This can
ultimately enhance a student's handwriting performance.
Another key factor that was revealed during this study was
that 63% of the students enjoyed using the grips, which is
important for compliance with treatment of handwriting
difficulties. Occupational therapists can use these grips
as part of the treatment process, and provide them to the
child for home and school use. This may help children with
learning disabilities function as students in a school
setting and reach their highest potential.
Implications for future research
Many studies have been conducted regarding pencil grips
as treatment of handwriting difficulties, and many more
studies will be conducted on these topics. Future studies
can be conducted utilizing a random sample of students, or
a sample of students from a broad range of socioeconomic
backgrounds. A larger sample size of students would also
increase the validity of the study.
Another possible future research study can compare girl
and boy student's responses to use of the pencil grip. As
the principal investigator found trends in the responses of
the different genders toward the grips in this study.
Future studies on this topic can be conducted using a
standardized assessment as the pre and post test, and by
The Pencil Grip 106
choosing one specific age group as participants for the
study.
Other research studies on the efficacy of pencil grips as
treatment for handwriting difficulties can give an
assortment of different pencil grips to randomized students
and compare any significant changes in legibility,
responses to the grips and tripod grasp strength after
using the grips.
The Pencil Grip 107
Appendix 1
Scoring for Alphabet Copy Sheet
The handwriting sheet contains the first 14 letters of the
English alphabet, which the child is asked to copy into
boxes. The maximum score is 7 0 points. The child will
receive a maximum total of 5 points per box that meets the
following criteria:
1. over ^ of the letter copied is within 30' of vertical
2. there are intersecting lines where appropriate
3. the letter copied is recognizable to others
4. there is no directional confusion
5. the horizontal axis is within 170'-190'
The child can receive 1 point for each criteria met in
each box(total of 5 pts per box) If the child receives 5
points in all 14 boxes, they will receive the maximum
score, 70 points.
The Pencil Grip 108
Appendix 2
ALPHABET COPY SHEET
student time 1 time 2 score 1 score 2
1 1 0.5 64 58
2 1.45 1.04 55 64
3 2.2 0.45 56 54
4 1.14 0.43 63 65
5 1.24 1.04 60 61
6 2.04 1.56 52 50
7 2.08 1.56 40 51
8 2.18 1.59 48 37
Data for pre and post-test of the alphabet copy sheet
The Pencil Grip 109
Appendix 3
student tripod 1(lbs.) tripod 2(lbs.)
1 9 9
2 8 9
3 . 7 8
4 8 9
5 5 9
6 4 5
7 6 6
8 6 7
10 12 12
11 9 10
12 9 12
13 8 9
14 7 10
15 8 8
16 7 9
17 9 9
18 9 10
19 7 8
20 9 9
21 6 8
22 8 8
23 10 11
24 9 10
25 8 9
26 8 10
27 10 13
28 9 11
Data for first and second screenings of tripod grasp
strength
The Pencil Grip 110
Appendix 4
student Wold Sentence Copy 1 Wold Sentence Copy 2
10 5.64 9.4
11 21.1 36.7
12 12.24 11
13 18.9 17
14 19.64 23.2
15 28.6 41.3
16 18.4 24.4
17 39.5 44
18 35.9 33
19 33.8 27.5
20 20.2 22.2
21 18.1 20
22 19.1 34
23 25 31.4
24 27.5 31.4
25 24 30
26 40.7 46.5
27 46.5 47.1
28 58.4 56.4
Data for pre and post tests of The Wold Sentence Copy
Test(letters/minute)
The Pencil Grip 111
Appendix 5
IRB Approval Form
TOURO COLLEGE SCHOOL OF HEALTH SCIENCES
1700 Union Boulevard* Bay Shore, New York 11706 (631) 665-1600 Fax (631) 665-6902 e-mail: ieonardg@touro.edu
LEONARD B. GOLDSTEIN D.D.S., Ph.D.
CHAIRMAN, INSTITUTIONAL REVIEW BOARD
MEMORANDUM
To: Robin Akselrud
Principal Investigator
From: Leonard B. Goldstein, DDS, PhD
Chairperson, IRB
Date: September 25, 2003
Re: IRB #090301 The Effects of Pencil Grips on Handwriting and Tripod Grasp
Strength in Children with Learning Disabilities
The above referenced proposal has received expedited review and approval from the Institutional
Review Board under 45 CFR 46.103(b)(5).
APPROVAL DATE: September 25, 2003
RENEWAL DATE September 25, 2004
BE SURE TO NOTE: Any changes in your investigation that would effect the overall integrity
of your original IRB Submission would necessitate your filing an addendum that would
highlight the change(s).
Adverse events which occur during the course of this research study must be reported to the IRB
Office.
Please be advised that your research study may be audited periodically by the IRB Research
Conduct and Compliance Office.
The Pencil Grip 112
Appendix 6
Consent Form
Touro College School of Health Sciences
Dept, of Occupational Therapy
1700 Union Blvd.
Bay Shore, NY 11706
The Gateway School
236 Second Avenue
NYC, NY 10003
Dear Parents,
As a student in Touro Colleges Masters Occupational Therapy program, I had the
opportunity to spend six weeks observing the occupational therapy program and services
at The Gateway School last fall. I was welcomed into the warm environment of the
school, as well as well welcomed by the wonderful children. I am currently working on
my Masters thesis and decided that The Gateway School would be a great establishment
where I could conduct my research.
The nature of my project is to assess whether pencil grips, used by many children
effects handwriting and tripod grasp strength (the mature grasp needed for using a pencil)
in school-aged children with learning disabilities. What the study entails from the
students is to use a pencil grip for all writing activities for two months. The childrens
handwriting and tripod grasp strength will be assessed upon beginning the two month
trial and after its completion using standardized tools (Wold Sentence Copy Test, and
Pinch Meter to measure pinch strength). Upon completion of the study, the children will
be able to keep the pencil grips for further use if they wish. You may discontinue your
childs participation in the study at anytime during the trial. No child will be removed
from class or worked whh individually. As the principal investigator, I will be overseeing
the usage of the grips twice a month, and Vanessa Giardina, MA, OTR/L, the
Occupational Therapist currently working at the school will monitor the study daily. This
research will enhance the evidence-based practice in the field of Occupational Therapy.
The information gained from this project will provide us with valuable knowledge
regarding the effectiveness of pencil grips on handwriting legibility and tripod grasp
strength. The information that is collected from these measurements will be kept
confidential. If you have any questions, please contact me at (917)689-7925. Please sign
and return the form below, so that your child may participate.
Sincerely,
Robin Akselrud, OTS
Student Name:_____________________________________
I give permission for my child to participate in the research project regarding the effects
of pencil grips on handwriting and tripod grasp strength. I understand that all information
gathered will be kept confidential.
Parent/Guardian signature:_____________________________________
The Pencil Grip 1\
Appendix 7
The
Gateway
School
236 Second Avenue. New York, NY 10003. Tel. 212 777.5966
September 16,2003
Touro College School of Health Sciences
Institutional Review Board
1700 Union Boulevard
Bay Shore, NY 11706
I am pleased to have Robin Akselrud, OTS conducting a research study at The
Gateway School. The nature of her project is to assess whether pencil grips affect
handwriting and tripod grasp strength in children with learning disabilities. The study
entails that the students use a pencil grip for all their writing activities for two months.
The childrens handwriting and tripod grasp strength will be assessed upon beginning the
two-month trial and after its completion. No child will be removed from class or worked
with individually. All results will be kept confidential; numbers will be used instead of
names to ensure anonymity. A consent form from each childs parent or legal guardian
must be received, and verbal assent is required from the children prior to participation in
the study. As the principal investigator, Robin Akselrud, OTS will be overseeing the
usage of the grips twice a month, and Vanessa Giardina, MA, OTR/L will monitor the
study daily or as needed.
Dr. Davida Sherwood
Director
The Pencil Grip 114
References
Appleman, S. and Lipman,L.(2000).Effects of Pencil Grips,
pgs 7-14, Master's Thesis, Touro College: Bay Shore, NY
American Occupational Therapy Association.(1989).
Guidelines for Occupational therapy services in school
systems. Rockville,MD:Author.
Benbow, M. (1990).Loops and Other Groups. A Kinesthetic
Writing System.Tuscon:Therapy Skill Builders.
Benbow, M. (1995). Principles and practices of teaching
handwriting. In A. Henderson and C. Pehoski, Hand Function
in the Child: Foundations for Remediation, pgs 255-281. St.
Louis, MI:Mosby
Benbow, M.(1987)Sensory and motor measurements of dynamic
tripod skill. Unpublished master's thesis, Boston
University, 1987.
Bonney, M.(1992). Understanding and assessing handwriting
difficulty: Perspectives from the literature. The
Australian Journal of Occupational Therapy, 39(3), 7-15.
Bundy, A., Lane, S. L. and Murray, E. A. (2002) . Sensory
Integration Theory and Practice (2nd ed) . Pgs 35-67 F. A.
Davis Company, Philadelphia:PA.
The Pencil Grip 115
Burton, A,.W. and Dancisak,M.J.(2000). Grip form and
graphomotor control in preschool children. American Journal
of Occupational Therapy, 54(1), pgs 9-17.
Cabral, John David Y.(1997)Poor Physician Penmanship.
Journal of American Medical Association, 278(13), pgs 1116-
111
Case-Smith, J.(2002). Effectiveness of school-based
occupational therapy intervention on handwriting. American
Journal of Occupational Therapy,56(1), pgs 17-25.
Case-Smith, J.(1995). The relationships among sensorimotor
components, fine motor skill, and functional performance in
preschool children. American Journal of Occupational
Therapy, 49, pgs 645-652
Case-Smith, J. and Pehoski, C. (1992) . Development of Hand
Skills in The Child. American Occupational Therapy
Association, Bethesda, MD.
Chu, S. (1997). OT for Children with handwriting
difficulties: A framework for evaluation and treatment.
British Journal of Occupational Therapy, 60(12), pgs 514-
520.
Clark-Wentz, J.(1997). Improving Students' Handwriting. OT
Practice,2 (10) , pgs 29-31, 33.
The Pencil Grip 116
Cohen, H.(1999). Neuroscience for Rehabilitation(2nd ed) .pgs
93-193 Lippincott Williams and Wilkins, Philadelphia:PA
Cornhill, H., Case-Smith, J.(1996)Factors that relate to
good and poor handwriting. American Journal of Occupational
Therapy, vol 50(9), pgs732-739.
Cunningham Amundson, S. (1992). Handwriting: Evaluation and
intervention in school settings. In J. Case-Smith and C.
Daniel, M.E. and Froude, E.H.(1998). Reliability of
Occupational Therapist and Teacher Evaluations of the
Handwriting Quality of Grade 5 and 6 Primary School
Children. Austrailian Occupational Therapy Journal, 45(2),
pgs 48-58.
Denis,J.L. and Swinth,Y.(2001). Pencil grasp and children's
handwriting legibility during different length writing
tasks. American Journal of Occupational Therapy,55 (2), pgs
175-183.
Dunn, W.(1988). Models of occupational therapy service
provision in the school system. American Journal of
Occupational Therapy, 42 (11), pgs 718-722.
Exner, C. E.(1992) In hand manipulation skill. Development
of hand skills in children, pgs 35-45. AOTA: Rockville, MD
The Pencil Grip 117
Feder, K., Majnemer, A and Synnes, A. (2000) Handwriting:
Current trends in occupational therapy practice. Canadian
Journal of Occupational Therapy, 67(3), pgs 197-204.
Feldmam, A. and Fiedler, D.(2001). The relationahip between
pencil grasp pattern, pinch strength and the use of a
pencil grip on handwriting legibility in first-grade
children. Master's Thesis, Touro College
Gilman, S. and Newman, S. W.(1996). Essentials of Clinical
Neuroanatomy and Neurophysiology, (10th ed) . F.A. Davis
Company, Philadelphia:PA.
Horsham, and Cohen, Michael R.(1997). "Rit or wrong?".
Nursing, 21(9), pg 22.
Hagen,R.A.(1983). Write right or left:A practical approach
to handwriting. Journal of Learning Disabilities, 16(5) , pgs
266-271.
Horneffer, K. and Jamison, P(2002). The emotional effects
of writing about stressful experiences:An exploration of
moderators. Occupational Therapy in Healthcare,16 (2/3), pgs
77-89.
Handley-More, D., Deitz, J., Billingsley, F., Coggins,
T. (2003) . Facilitating written work using computer word
processing and word prediction. American Journal of
Occupational Therapy, 57(2), pgs 139-151.
The Pencil Grip 118
Humphry, R. Jewell, K. and Rosenberger, R. C. (1995) .
Development of in-hand manipulation and relationship with
activities. American Journal of Occupational Therapy, 49,
pgs 763-771.
Keller, M.(2001). Handwriting club:using sensory
integration strategies to improve handwriting. Intervention
in School and Clinic, 37(1), pg 9.
Koziatek,S.M. and Powell, N.J.(2003). Pencil grips,
legibility and speed of fourth grader's writing in cursive.
v
American Journal of Occupational Therapy,57(3), pgs 284-
288.
Levine, M.D.(1987). Developmental variation and learning
disorders. Cambridge, MA:Educators Publishing Service
Lewis, R.(1998). Assistive Technology and Learning
Disabilities:Today's realities and tommorow's promises,
Journal of Learning Disabilities,31 (1),pgs 16-28.
Lockhart,J. and Law, M.(1994). The effectiveness of a
multisensory writing programme for improving cursive
writing ability in children with sensorimotor difficulties.
Canadian Journal of Occupational Therapy,61(4), pgs 207-
213.
The Pencil Grip 119
MacArthur,C.A.(1998). Word processing with speech synthesis
and word prediction: Effects on the dialogue journal
writing of students with learning disabilities.Learning
Disability Quaterly,27,pgs 151-166.
Maeland, A. E.(1992). Handwriting and Perceptual Motor
Skills in clumsy, dysgraphic and normal children.
Perceptual and Motor Skills, 75, pgs 1207-1217.
Marr, D. and Cermak, S. (2002). Consistency of handwriting
in early elementary students. American Journal of
Occuptaional Therapy, 57(2), pgs 161-167.
McHale,K. and Cermak, S. (1992). Fine motor activities in
elementary school: Preliminary findings and provisional
implications for children with fine motor problems.
American Journal of Occupational Therapy, 46,pgs 898-903.
Nicols, Lois Mayer(1996). Pencil and Paper Versus Word
Processing: A Comparative Study of Creative Writing in the
Elementary School, Journal of Research on Computing in
Education,29(2), pg 159
Neistadt, M. E. & Crepeau, E. B. (1998) . Willard and
Spackman's Occupational Therapy(9th ed.).
Philadelphia:Lippincott.
The Pencil Grip 120
Oehler, E.,DeKrey, H, Eadrey, E., Fogo, J,Lewis, E,
Maher,C, Schilling, A(2000). The effect of pencil size on
the pre-writing skills of kindergartners. Physical and
Occupational Therapy in Pediatrics, 19 ( %) , pgs 53-60
Olsen, J.Z.,(1998). Handwriting Without Tears.Potomac, MD
Pehoski, Development of hand skills in the child, pgs 63-
78. Rockville, MD: AOTA
Parush,S., Erez, N. & Weintraub, N. (1998) . Ergonomic
factors influencing handwriting performance. WORK, 11, 295-
305.
Parush, S., Pindak, V, Hahn-Markowitz, J, Mazor-Karsenty,
T.(1998. Does fatigue influence children's handwriting
performance? WORK, 11(3), pgs 307-313
Peterson, C. Q. and Nelson, D.(2003). Effect of an
Occupational intervention on printing in children with
economic disadvantages. American Journal of Occupational
Therapy, 57(2), pgs 152-160.
Rubin, N. and Henderson, S. Two sides of the same coin:
Variations in teaching methods and failure to learn to
write. Special Education: Forward Trends, 9(4), 17-24
Reisman, J. E.(1991). Poor handwriting:Who is referred?
American Journal of Occupational Therapy, 45, pgs 849-852.
The Pencil Grip 121
Sambyal, A. and Kleiner, B. H.(2002). Developments
concerning repetitive stress injuries. Managerial Law, 44
(h) , pgs 45-50.
Sassoon, in Bonney, M. (1992) . Understanding and assessing
handwriting difficulty: Perspectives from the literature.
The Australian Journal of Occupational Therapy, 39(3) , pgs
7-15.
Schneck, C. M.(1991). Comparison of pencil-grip patterns in
first graders with good and poor writing skills. American
Journal of Occupational Therapy, 45 pgs 701-706.
Schneck, C.M. and Henderson, A. (1990) . Descriptive Analysis
of the Developmental Progression of grip position for
pencil and crayon control in nondysfunctional children.
American Journal Of Occupational Therapy, 44 (10) , pgs 893-
900.
Scott,D.H.,Henderson, S.E . and Moyes,F.A. (1987) . Diagnosis
and remediation of handwriting problems. Adapted physical
Activity Quaterly,4,pqs 137-147.
Seif, N. (1999) . The role of occupational therapy on hand
development. Master's Thesis, Touro College
The Pencil Grip 122
Shinn, J. and Romaine, K. A. (2000). The effectiveness of
ergonomic intervention in the classroom. Master's thesis,
Touro College
Strickman,J.W.(1995). Anatomy and Kinesiology of the hand.
In Henderson, A. and Pehoski, C.(Eds.) Hand function in the
Child: Foundations for Remediation(pgs 16-39). St.
Louis,MI:Mosby.
Sudsawad, P., Trombly,C. A., Henderson, A. and Tickle-
Degnen, L.(2002). Testing the effect of kinesthetic
training on handwriting performance in first-grade
students. American Journal of Occupational Therapy, 56(1),
pgs 26-33.
Summers, J. (2001) . Joint laxity in the index finger and
thumb and its relationship to pencil grasps used by
children. Australian Occupational Therapy Journal, 48(3),
pgs 132-141.
Taber's Cyclopedic Medical Dictionary, 19th ed. (2001). F. A.
Davis Company, Philadelphia:PA.
Thomas, K.(2000). Common office-work related injuries:
early identification and tracking of prevention efforts
using the Canadian Occupational Performance Measure.
Master's thesis, Colorado State University
The Pencil Grip 123
Tseng, M. H. and Cermak, S.A.(1993). The influence of
ergonomic factors and perceptual-motor abilities on
handwriting performance, American Journal of Occupational
Therapy,47 pgs 917-926
Tseng, M.H. and Chow, S.M.K.(2000)Perceptual-motor function
of school-age children with slow handwriting speed,
American Journal of Occupational Therapy, 54(1), pgs 83-
Tseng, M.,Murray, E. (1994). Differences in perceptual
motor measures in children with good and poor handwriting.
Occupational Therapy Journal of Research, 14, pgs 19-36.
Tseng, M. H.(1998). Development of pencil grip position in
preschool children. The Occupational Therapy Journal of
Research, 18(4), pgs 207-226.
Van Houten, R. (1993) . The use of wrist weights to reduce
self-injury maintained by sensory reinforecement. Journal
of Applied Behavioral Analysis, 26,pgs 197-203.
Weil, M.J. and Amundson, S.J.(1993)Annotated bibliography:
Biomechanical aspects of handwriting in the educational
setting. Physical and Occupational Therapy in Pediatrics,
13(2), pgs 57-66
Weil, M.J. and Amundson, S.J.(1994) Relationship between
visuomotor and handwriting skills of children in
The Pencil Grip 124
kindergarten. American Journal of Occupational Therapy,. 48,
(11) , pgs 982-988
Weintraub, N. and Graham, S.(2000)The contribution of
gender, orthographic, finger function, and visualmotor
processes to the prediction of handwriting status. The
Occupational Therapy Journal of Research,20(2), pgs 121-
141.
Wold, Robert(1970), Screening Tests to be used by the
Classroom Teacher,Novato,CA: Academic Therapy Publications
Woodward, S. and Swinth, Y. (2 002). Multisensory approach
to handwriting remediation:Perceptions of school-based
occupational therapists. American Journal of Occupational
Therapy, 56(3), pgs 305-312.
Yakimishyn, J.E. and Magill-Evans, J.(2002). American
Journal of Occuaptional Therapy,56 (5), pgs 564-572.
Zigmond, M. J., Bloom, F. E., Landic, S. C., Robers, J.L.
and Squire, L. R. (1999) .Fundamental Neuroscience. Academic
Press, Boston: MA.
Ziviani, J. and Elkins, J. (1984). An evaluation of
handwriting performance. Educational Review, 38, pgs 247-
257
The Pencil Grip 125
Kelker, Katherine, A. {1991) Developing an IEP.Parent's
Checklist for the IEP, retrieved May 9,2003 from:
escambia.K12.f1.us/adminoff/ese/ese.htm
Retrieved on May 9, 2003 from the World Wide Web:
http://www.Coping.org
Magid, Larry(1998). Retrieved on May 9, 2003 from the World
Wide Web: http://www.pcanswer.com/syndicate.html
Setzer, Valdemar W. (2003) , A Review of Arguments For the
Use of Computers in Elementary Education, Retrieved on
October 27, 2003 from the World Wide Web:
http://www.ime.usp.br/~vwsetzer
Retrieved May 1, 2003 from the World Wide Web:
http://inventors.about.com/library/weekly/aal0 0197.htm
LD Fast Facts, Retrieved on October 30,2003 from the World
Wide Web:
http: / /www. schwablearning.org/articles . asp?r=627&g=l

The Effect of Pencil Grip On Handwriting

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

The Effect of Pencil Grip On Handwriting

Transféré par

Droits d'auteur :

Formats disponibles

NOTE TO USERS

This reproduction is the best copy available.

Vous aimerez peut-être aussi