Comprehension of handwriting development: Pen-grip kinetics in handwriting tasks and its relation to fine motor skills among school-age children

Evaluating handwriting in children with developmental coordination disorder (DCD): Temporal, spatial, pressure and grip-force measures

BACKGROUND

Writing involves complex sensorimotor and biomechanical processes that regulate pressure on the writing surface. Researchers analyze writing to understand kinetics and kinematics by evaluating temporal, spatial, and pressure aspects, yet discerning writing surface pressure and pen-grip force remains challenging.

AIMS

To compare handwriting kinetics (pen grip-force and surface pressure) and kinematics (temporal-spatial) of children with developmental coordination disorder (DCD) with those of typically developing (TD) children.

METHODS AND PROCEDURES

Twenty-seven children with DCD aged 7-12 years and 27 TD children matched by age and gender copied a 29-word passage onto a computerized tablet. Temporal, spatial and surface pressure as well as pen grip-force were measured with a tablet and a wearable device respectively.

OUTCOMES AND RESULTS

The DCD group displayed significantly longer total writing time, mean letter time, and greater letter height, width, variance, spacing, area, and erasures than the TD group. Although there were no significant between-group differences in the surface pressure or maintaining pressure, the DCD group displayed weaker grip-force, p = .01, with greater variance.

CONCLUSIONS AND IMPLICATIONS

The DCD group's weaker grip-force dynamics correlated with reduced legibility, form, and prolonged writing duration, revealing insights into handwriting mechanisms, particularly grip force, crucial for effective clinical interventions.

Participatory design and needs assessment for a pressure-sensitive pen and mobile application (SensoGrip) for children with handwriting problems

PURPOSE

Problems with handwriting are a common referral to occupational therapy in children and are often associated with inadequate pen grip and tip pressure. Technologies providing immediate feedback on applied forces are currently not available. Therefore, the aim was to identify user's perspectives on the optimal functionality of a pressure-sensitive pen with an integrated feedback system.

METHODS

To ensure that the product meets the requirements of the users, user needs of paediatric occupational therapists, elementary or special education teachers and children were collected in two focus groups and a children's workshops before starting the technical development process. Focus group transcripts were analyzed and rephrased as user stories to identify user-centred requirements. In a second step, user stories were merged and ranked regarding importance and feasibility.

RESULTS

120 user story requirements were generated from the focus groups and children's workshops, indicating requirements regarding design and functionality for the pen and mobile application. Visual feedback, appropriate size and weight, customizability, ease of settings and usability of the pen were pivotal.

CONCLUSIONS

This study comprehensively researched the requirements for a device that may facilitate children in adjusting their handwriting pressure and can guide further research and evaluation.

Evaluating the Experiences of Occupational Therapists and Children Using the SensoGrip Pressure-Sensitive Pen in a Handwriting Intervention: Multimethods Study

BACKGROUND

The acquisition of handwriting skills is essential for a child's academic success, self-confidence, and general school performance. Nevertheless, an estimated 5% to 27% of children face handwriting challenges, where the ability to modulate pressure on the pencil and lead on the paper is a key motor component.

OBJECTIVE

We aimed to investigate the experience with and usability of the SensoGrip system, a pressure-measuring pen system with personalized real-time feedback about pressure modulation, in a clinical setting with children and occupational therapists (OTs).

METHODS

A multimethods study was conducted, incorporating qualitative interviews and questionnaires with children, user diaries, focus group discussions, and a usability questionnaire with OTs, along with a questionnaire for parents.

RESULTS

The study involved OTs (n=8), children with handwriting difficulties (n=16), and their parents (n=16), each of whom used the SensoGrip system in up to 5 therapy sessions. OTs reported that the SensoGrip system helped to focus the child's awareness on handwriting pressure and to measure it objectively. The system received high acceptance and usability ratings from the OTs-usefulness: median score of 4 out of 7; ease of use and ease of learning: median score of 6 out of 7; and satisfaction: median score of 6 out of 7. Participants appreciated that it fosters pressure awareness and motivation to draw and write.

CONCLUSIONS

The SensoGrip pressure-sensing system with real-time feedback is a promising tool for pediatric occupational therapy. It supports children with handwriting difficulties to adjust their pressure application during the task. In the future, controlled quantitative trials are warranted to further examine the system's impact.

The relationship between motor performance and executive functioning in early childhood: A systematic review on motor demands embedded within executive function tasks

This systematic review examined to what extent response demands of executive functioning (EF) tasks influence the relationship between motor performance and EF in 2- to 6-year-old typically developing (TD) children and children with motor coordination difficulties (MCD). Eighteen of the included articles focused on TD children only and three also on children with MCD. EF tasks were subdivided based on the type of responses (i.e., motor or verbal). EF tasks requiring a motor response were subdivided into two levels (i.e., complex or simple). Results showed that the relationship between motor performance and EF in 2- to 6-year-old TD children and children with MCD was inconclusive with the strength of correlation coefficients for the most part varying from very weak to moderate. The type of EF task response did not influence the relationship between motor performance and EF. The review thus implies that other task demands than the type of EF task response need to be investigated to explain the inconsistent relationship between motor performance and EF, such as the complexity of the motor response of EF tasks, the complexity of the actual motor tasks, and additional processes (e.g., memory, intelligence, language comprehension).

Enhancing Handwriting Performance of Children with Developmental Coordination Disorder (DCD) Using Computerized Visual Feedback

Recent studies have analyzed the writing metrics of children with developmental coordination disorder (DCD) using computerized systems. To date, the use of computerized visual feedback to improve handwriting has not been investigated. This study aimed to examine the effects of computerized visual feedback on handwriting performance in time, spatial orientation, and pressure indices for children with DCD. Twenty-seven children aged 7 to 12 years with DCD assessed by the Movement Assessment Battery for Children and the Developmental Coordination Disorder Questionnaire received one weekly intervention session for 8 weeks, during which they twice copied an excerpt onto a tablet. Once, they received visual feedback where the writing color corresponded to the degree of pressure on the writing surface, and once they received no visual feedback. The two conditions were counterbalanced throughout the sessions. Pre-intervention sessions were compared with post-intervention sessions and with new texts for time, spatial orientation, and pressure measures. The findings revealed significantly decreased total and mean letter writing, in-air, and writing time and increased capacity in the visual feedback condition. In the spatial variables, a significant decrease in letter height variance was found. Pressure increased significantly throughout the intervention with visual feedback, whereas it decreased post-test in the writing task in both conditions and was maintained in the new text. Visual feedback intervention can increase the kinesthetic-haptic feedback required to regulate pressure during writing, promoting more efficient feedforward processes and improving output quality and capacity. The training effectiveness was transferable, and the intervention accessibility could increase student autonomy.

A novel tablet-based motor coordination test performs on par with the Beery VMI subtest and offers superior temporal metrics: findings from children with pediatric acute-onset neuropsychiatric syndrome

Neuropsychiatric and neurodevelopmental disorders are often associated with coordination problems. Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) constitutes a specific example of acute and complex symptomatology that includes difficulties with motor control. The present proof-of-concept study aimed at testing a new, bespoke tablet-based motor coordination test named SpaceSwipe, providing fine-grained measures that could be used to follow-up on symptoms evolution in PANS. This test enables computationally precise and objective metrics of motor coordination, taking into account both directional and spatial features continuously. We used SpaceSwipe to assess motor coordination in a group of children with PANS (n = 12, assessed on in total of 40 occasions) and compared it against the motor coordination subtest from the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) 6th edition, traditionally used to follow-up symptomatology. Using a bivariate linear regression, we found that 33 s of the directional offset from tracking a moving target in SpaceSwipe could predict the Beery VMI motor coordination (VMI MC) raw scores (mean absolute error: 1.75 points). Positive correlations between the predicted scores and the VMI MC scores were found for initial testing (r_adj = 0.87) and for repeated testing (r_adj = 0.79). With its short administration time and its close prediction to Beery VMI scores, this proof-of-concept study demonstrates the potential for SpaceSwipe as a patient-friendly tool for precise, objective assessment of motor coordination in children with neurodevelopmental or neuropsychiatric disorders.

Assessment of children's writing features: A pilot method study of pen-grip kinetics and writing surface pressure

The writing process is a complex task involving dexterous manipulation of the writing instrument by the hand digits and biomechanical ergonomic factors that contribute to handwriting efficiency and productivity. We describe a pilot study using an instrumented writing apparatus - a sensor (pen) and a digitized writing surface (tablet) - to measure the pen-grip kinetics (digit forces) and the pen pressure applied to the tablet during a writing task. Eight elementary school students with no handwriting difficulties copied a short story. The mean digit forces on the pen were compared with the mean pen pressure on the tablet at five interval points. Results revealed that the digit forces on the pen were significantly stronger than the pen pressure on the tablet. Results also showed significantly less digit-force variability throughout the writing task than the pen-pressure variability on the writing surface, which significantly lessened toward the end of the writing task. Information on these properties can broaden understanding of the elements that influence nonproficient handwriting in children with dysgraphia. Results also indicate the possible efficacy of a therapeutic tool for handwriting assessment and intervention using objective measurements during writing, warranting future studies with children with and without dysgraphia.

A Scoping Review of Grasp and Handwriting Performance in School-Age Children

OBJECTIVE

Handwriting is a critical functional skill that impacts academic participation and progress. Occupational therapists address components of grasp in their handwriting intervention as it is commonly assumed that grasp affects legibility, fluency, and endurance, yet research studies examining this relationship are limited.

METHOD

We used scoping review methodology to map existing research on grasp and handwriting performance in school-age children and to identify gaps in the literature.

RESULTS

Thirteen articles met search criteria and were categorized by grasp patterns and handwriting performance, and grasp force and handwriting performance. Findings suggest an inefficient grasp can lead to decreased handwriting legibility and fatigue. The current literature is inconclusive and several gaps were identified.

CONCLUSION

Additional studies should address research gaps through inclusion of children with special needs and interventions including lengthier handwriting tasks representative of a typical school day.

Association of children's toothbrushing and fine motor skills: a cross-sectional study

Fine motor skills (FMS) allow for the control and coordination of the distal musculature of hands and fingers, a skill required to brush teeth. The objective of this study was to investigate the association between FMS and toothbrushing efficacy. This cross-sectional study included 42 low-income Latino children aged 5 to 9 years from Pasto, Colombia. Toothbrushing efficacy was determined by the children's dental plaque Quigley-Hein Index (QH-I) mean-score difference from before and after toothbrushing. FMS were evaluated using the 5-15R parent evaluation, the spiral drawing Archimedes test, and a neurodevelopmental assessment of movements and prehension patterns during toothbrushing. A descriptive analysis was performed to assess the characteristics of FMS and children's toothbrushing, and a generalized linear model was used to determine associations between these skills and toothbrushing efficacy. Eighty-six percent of the children had at least one difficulty with FMS, and in 7%, they interfered with daily activities. Fourteen percent presented a moderate pattern in the Archimedes test, and 43% had inefficient prehension patterns. Toothbrushing reduced the QH-I by a mean of 1.45 (SD = 0.78-2.12) (p < 0.001). Toothbrushing efficacy was only significantly associated with age (mean-difference = -0.315, 95%CI: -0.481 to -0.148, p < 0.001). FMS and toothbrushing efficacy were not significantly associated. Other components of fine motor control should be analyzed to understand the kinetics of toothbrushing.

Pen-grip kinetics in children with and without handwriting difficulties

Introduction

Handwriting difficulty (HD) is a widely discussed issue. Previous researchers have revealed many valuable kinematics related to the handwriting performance. However, a clear understanding of the kinetics of handwriting performance in children with HD is still lacking. Therefore, this study investigated the writing performance of children with HD via a force acquisition pen (FAP), which detects the force applied from the digits and pen tip.

Methods

Data from 64 school-age children were divided into control (36 children without HD; mean age: 7.97 years) and HD (28 children with HD; mean age: 8.67 years) groups. The participants were asked to perform a tracing task using the FAP at their usual writing pace.

Results

Compared with the control group, the HD group had significantly less pen-tip force, an average amount of force (in-air) from all three digits, higher force variations (whole task) in the index finger, less force fluctuations with the index and middle fingers and a smaller force ratio.

Conclusion

The findings of this study suggest that an understanding of the handwriting kinetics and the role of digits in handwriting may be crucial for further planning strategies for handwriting training for children with HD.

Proximal and distal movement patterns during a graphomotor task in typically developing children and children with handwriting problems

BACKGROUND

Therapists specializing in handwriting difficulties in children often address motor problems including both proximal and distal movements in the upper extremity. Kinematic measures can be used to investigate various aspects of handwriting. This study examined differences in movement patterns in proximal and distal joints of the upper extremity during graphomotor tasks between typically developing children with and without handwriting problems. Additionally, it explored relationships between movement patterns, speed, and legibility of writing.

METHODS

Forty-one children, aged 7-11 years, were assessed with the Aleph Aleph Ktav Yad Hebrew Handwriting assessment and the Beery Test of Visual Motor Integration and, based on their scores, were divided into a research group (with handwriting difficulties) and a control group (without handwriting difficulties). Upper extremity joint movement patterns were analyzed with a motion capture system. Differences in the quality of shapes traced and copied on a graphics tablet positioned horizontally and vertically were compared. Between-group differences and relationships with speed and legibility were analyzed.

RESULTS

In both groups, there was greater movement in the distal compared to the proximal joints, greater movement when performing the task in a horizontal compared to a vertical plane, and greater movement when tracing than copying. Joint movements in the arm executed scaled-down versions of the shapes being drawn. While the amount of joint displacement was similar between groups, children in the research group showed greater dissimilarity between the drawn shape and the shape produced by the proximal joints. Finally, the drawing measure on the tablet was a significant predictor of legibility, speed of writing, visual motor integration and motor coordination, whereas the dissimilarity measure of joint movement was a significant predictor of speed of writing and motor coordination.

CONCLUSIONS

This study provides support for the role of the distal upper extremity joints in the writing process and some guidance to assist clinicians in devising treatment strategies for movement-related handwriting problems. While we observed differences in proximal joint movements between the children with and without handwriting difficulties, the extent to which they are responsible for the differences in drawing quality remains to be determined. Further studies should use a similar methodology to examine additional tasks such as drawing shapes of varying sizes.

Overpressure on fingertips prevents state estimation of the pen grip force and movement accuracy

We tested the hypothesis that the inability to move a pen accurately in a graphic task is partly due to a decrease of afferent somatosensory information resulting from overpressure on the tactile receptors of the fingers holding the pen. To disentangle the depressed somatosensory origin from an altered motor command, we compared a condition in which the participant actively produces pressure on the pen (active grip) with a condition in which pressure is passively applied (passive grip, no grip-related motor command). We expected that the response of the somatosensory cortex to electric stimulation of the wrist's tactile nerve (i.e., SEP) would be greater in the natural pen grip (baseline condition) than in the two overpressure conditions (actively or passively induced). Fifteen adults were required to trace a geometrical shape in the three grip conditions. The SEP amplitude was not significantly different between the baseline and both overpressure conditions. However, behavioral results showed that drawing accuracy is impaired when the pressure on the pen is increased (passively or actively). Cortical source analyses revealed that the activity of the superior parietal areas (SPL) increased in both overpressure conditions. Our findings suggest that the SPL is critical for sensorimotor integration, by maintaining an internal representation of pen holding. These cortical changes might witness the impaired updating of the finger-pen interaction force for such drawing actions under visual guidance.

Factors related to children's tooth-brushing at different ages: an application of the theory of planned behavior

Tooth-brushing is one of the most important health behaviors to teach children considering potentially serious ramifications of poor dental health. However, children's tooth-brushing behavior is affected by various developmental factors. The aim of this cross-sectional study was to investigate factors related to the tooth-brushing behavior of children adopting the Theory of Planned Behavior. A preliminary elicitation study with 33 primary school students identified underlying beliefs related to tooth-brushing intentions. This data was analysed, synthesized, and incorporated into the development of survey items for three age-appropriate, closed-ended questionnaires administered to 709 primary public school students. Path analyses using structural equation modelling were used to discover the structural relationships among the direct and indirect determinants of tooth-brushing behaviors, and path estimates and the model fit were calculated. Social recognition, peer influence, self-motivating strategies, and cognitive aspects of tooth-brushing were found to become more influential in facilitating behavioral intention with age. In the path models, the tooth-brushing behavioral intention was significantly related to perceived behavioral control rather than behavioral beliefs and normative beliefs. Subjective norms were found to become more significant as children matured. This result suggests that education to improve children's tooth-brushing behavior needs be appropriate to the developmental stage of children.

Fine motor deficits and attention deficit hyperactivity disorder in primary school children

Background

Many children with attention deficit hyperactivity disorder (ADHD) display motor deficiencies during their daily routine, which may have impact on their developmental course. Children with ADHD who experience motor deficiencies often display deficits in tasks requiring movements, such as handwriting.

Aim

This study investigated deficiencies in fine motor skills in primary school children with ADHD. The study further sought to establish whether ADHD subtypes differ in deficiencies of fine motor performance, recorded for both the dominant and non-dominant hands.

Methods

The Disruptive Behavior Disorders Rating Scale, completed by educators and parents, was used to screen for ADHD symptoms. Researchers confirmed the diagnosis of ADHD. Motor functioning was assessed using the Grooved Pegboard and Maze Coordination. The children diagnosed with ADHD were matched for age and gender with controls without ADHD. The sample consisted of an ADHD group (160) and control group (160) of primary school children from the Moletjie area.

Results

Children with ADHD (predominantly inattentive subtype) and ADHD (combined subtype) performed significantly more poorly than the control group on the Grooved Pegboard (p < 0.05) with both the dominant and non-dominant hand. No significant difference between the hyperactivity and impulsiveness subtype and the controls were found. There was no difference on the Maze Coordination Task (p > 0.05) between the ADHD subtypes and the controls.

Conclusion

Difficulties in fine motor skills are prevalent in children with ADHD, particularly in the ADHD-PI and ADHD-C. Problems are encountered in distal, complex, speeded tasks. The effect may lead to poor handwriting and academic performance.