The “write” way

Melissa “Missy” Menzes is an occupational therapist and founder of Extra Credit! LLC. She is passionate about and highly successful at serving children in our community who have “fallen through the cracks” at school. Today she returns as our guest to give parents some insight and practical advice on supporting children with handwriting difficulties.
 

Handwriting help is, by far, the most common reason for referral at Extra Credit! LLC. I thought it might be helpful to address some of the most frequent questions we get with some developmental background and quick tips. The summer is a great time to work on these issues. For more specific help, a free handwriting screening, or formal assessment, contact missy@extracreditaustin.com.

Hand Use

Developmental Background: Bilaterality, or alternating hand use, occurs at 2–3 years. Lateral preference, or being able to use one side of the body more proficiently than the other, is usually achieved by age 3–4. Between 4 and 6 years, children develop more unilateral abilities. Developing a preference assists with directional concepts, brain hemisphere specialization, and refinement of manual skills. Hand dominance, or a strong consistency to use one hand during task-oriented activities, typically occurs between 6 and 7 years of age. By age 7–8 children should know left and right sides of their bodies well. Well-integrated dominance does not always occur until 8–9 years in many children. “Mixed Use/Dominance” is often due to lack of proximal stability or endurance, poor bilateral integration, and problems in manual dexterity. It is quite common with children who have learning disorders. True biological-based ambidexterity is quite rare and often has a genetic basis.

Quick Tips: Encourage awareness of both sides of the body and of directions by playing games like Hokey Pokey, Twister, Hop Scotch, and Simon Says. Have child pick the hand they want to use during a task and do not allow switching in the middle of the task. Place objects to either side of the body midline and spread out to encourage rotation of the trunk to help reaching across with the opposite hand. Sit on varying sides of a child and have them move around so that there is not unintended positional bias toward the child using one hand over the other. Put a watch or bracelet on the writing hand as a tactile cue, and use cognitive-recall strategies such as “I write with my right hand.” (Note: Left-handedness can bring a lot more challenges. I would recommend contacting us for support if you have a left-handed writer who is struggling and needs assistance.)

Pencil Grasp

Developmental Background: A fisted grasp is typical from 1–1.5 years. From age 2–3 a brush-style grasp is common; here, the arm is in the air and the pointer finger is extended toward the tip of the writing utensil. Next, typically a static (moving wrist, stationary fingers) pattern in opposition to the thumb is common and then a dynamic (moving fingers, stationary wrist) pattern with four fingers resting against the tool (quadropod). By 3.5 to 4 years, three fingers of stability are more common (tripod). A mature, efficient dynamic tripod grip is expected by 4.5 to 6 years of development. The dynamic tripod offers the best mechanical advantage for writing small and controlled letters for a long time. If a child has joint hypermobility or poor proximal stability, he or she will seek positions of best stability for comfort and endurance, but problems arise when this method causes pain, discomfort, fatigue, or joint deformity. Several specific developmental skills are needed before a mature grasp can be achieved. Research has proven that there are four grasp patterns that are considered functional for writing (static and dynamic tripod and quadropod grips). After around second grade or age 7, research says that a grasp pattern is locked in and cannot usually be successfully changed without external remedial supports (such as an adaptive pencil grip or tool).

Quick Tips: Using small pieces of crayons or chalk often encourages a three-finger grasp pattern. Drawing at vertical surfaces facilitates a wrist action called tenodesis that mimics the tripod grasp and improves wrist and shoulder proximal stability necessary for better distal fine motor control. Golf-sized pencils are better for kindergarten-sized hands. Squirt bottles, scissors, and climbing/hanging encourage opposition of the thumb and strengthen the hand arches. Fine motor activities with beads, bands, lacing, pinching, twisting, tool use, and manipulatives all improve strength and coordination useful in maturing grasp patterns. (Note: There are many commercial grips and a few tools that can help improve efficiency in an older child, but I would suggest working with an occupational therapist for best success with grip accommodation strategies. These options usually don’t work well unless done right, and sometimes a developmental hand program is needed before remedial options should be introduced.)

Reversals

Developmental Background: It’s not unusual or uncommon for preschoolers and kindergarteners to reverse several letters and numbers. By age 6, children should write capital and lowercase letters and numbers 1–9 with 85 percent correct orientation. By age 7, symbol accuracy should be 90 percent, and by age 8–9, 100 percent correct orientation is a suggested target. In many cases, reversals are either due to problems with spatial orientation, laterality, start, or sequencing of symbols. Children age 5–6 should identify their own left/right limbs with 75 percent accuracy. Children 7 and above should begin to identify what side objects are in relationship to each other, and typically by age 9 kids can understand lateral concepts on other people. When shown a mixture of reversed and correctly oriented symbols, children age 5 will typically make numerous mistakes identifying what is correct, but by ages 9–10 such recognition errors should be highly accurate.

Quick Tips: To reduce symbol reversals, teach correct start and sequence with a multisensory program (hear, see, feel, do big) and provide a visual letter template so that kids can compare work for editing. Worksheets and free writing without close facilitation are never encouraged because this is where young kids develop so many bad habits that go “unseen.” Kids often draw symbols in incorrect sequences or with inconsistent patterns and never get an appropriate motor memory of the correct formation, which is a necessary foundation to advancements in writing. Handwriting Without Tears uses several methods that help reduce reversals. Play “Mystery Letter” by drawing on the back or in the air or on something textured with the finger. Kids will recognize mistakes more quickly in these ways than in small works or in words. (Note: Sometimes reversals may indicate the need for additional screening. They can be symptoms of a visual or neuro-based condition.)

“Other”

Writing has a lot of important benefits, and no matter how much our society advances toward communicating with digital technology, the importance of legible and functional writing skills should never be overlooked. Kids should learn print and cursive and then focus on the one that suits his/her best before adding “flair.” I think it makes the most sense to begin with a solid foundation in print and then to add cursive. Some children do best with a vertical style, while a few others do better with a slanted one. Each child is different; there is no one way that is best for everyone.

When it comes to recommending a specific curriculum, I prefer Handwriting Without Tears because of its heavy emphasis on multisensory, kinesthetic, and developmentally appropriate instruction. I also like that the print, cursive, and keyboarding programs all reinforce each other. If done correctly, the kids should be working with fine motor manipulatives, grip, and learning formation through fun songs and games before even doing pencil-paper lessons. The double-lined paper is excellent for kids with visual-spatial-organization difficulties, and the workbooks reinforce early literacy and are not biased to the right-handed child.

I have been trained in several great programs and am certified in handwriting. As an occupational therapist, I naturally combine the best of all and give it my own spin. I always find success when something is fun, active, repetitive, meaningful, individualized, and the “just right” challenge.

Another major helper, as weird as it may sound, is music. More than anything else, I and my clients have truly been amazed by what sound therapy (even if purely home-based) can do for legibility. I’m not a sound engineer, but I have been trained in five different sound therapy approaches, and while they are each unique, the concepts and results are basically the same. Some programs are just a little more accessible or appropriate than others.

Lastly, when all else fails, I like to encourage exploration of assistive technology. With a few simple and modern supports, I have seen kids go from failing to passing homework assignments. Others have transitioned from hating writing to loving it. Who knows, maybe like one of my last kiddos, yours will be the next great author! The point is, sometimes a little support can go a long way, and it’s not about giving up; it’s about emphasizing strengths and leveling the playing field.

Melissa “Missy” Menzes, OTR
 

Teaching driving readiness to young teens

Missy Menzes, occupational therapist and founder of Extra Credit! LLC, is dedicated to helping school-aged kids and families dealing with “hidden disabilities” and learning differences. As program director of Driving Readiness for Teens (DRT) and a member of the Texas Teen Safe Driving Coalition (TTSDC), Missy is excited to be able to add a unique and valuable perspective to caregivers of potential drivers. She hopes to reach the central Texas community as part of her volunteer roles in the TTSDC’s Zero Teen Driving Fatality Initiative and others nationwide as a guest blogger for the Drive it Home™ project.
 

Community mobility is a necessary part of human independence and socialization. While most individuals can use public or private transportation, not everyone can or should drive. As a pediatric occupational therapist, one of the most important and unique roles that I have taken on is facilitating driving readiness potential for high-risk teens. Principles of my DRT therapy program and concepts of “driving fitness” are relevant to any parent raising a potential driver.

The first step of assessing readiness for driving is to notice how the child moves, sees, thinks, feels, and takes on general responsibilities. All of these attributes will, in some way, affect driving performance. Parents of middle school and even younger school-aged children should ask the question “Is my child coordinated, attentive, and adaptive?” Start addressing noted concerns in any ways you can on your own, and seek assistance for areas of need from qualified therapists or other professionals early on.

Pre-driving skills include coordinated use of extremities, quick/accurate visual & cognitive perceptual processing functions, and safe attention and reasoning abilities. A driver must be able to effectively filter and process incoming sensory stimulation while attending and responding to “most critical” information. One must also be knowledgeable about rules of the road, have good anticipation skills, and be capable of managing unexpected events as well as stressful situations.

My DRT therapy program activities vary among families to enhance the areas that we determine to be specifically problematic or at risk for their children. Students perform individualized home activities between sessions. These vary from simple postural and coordination exercises to more complex visual and cognitive processing games. I occasionally prescribe the use of cutting-edge technologies such as Drive Fit® or Interactive Metronome® at home. These modalities help build skills of noticing, prioritizing, and reacting to information both quickly and over time.

Once foundations for driving are well established, it’s time to proceed to pre-driving “passenger level” training activities. Most of my program recommendations at this stage are based on specialty training I received from Miriam Monahan of the Driver Rehabilitation Institute. If you have a child with unique needs, I highly recommend you work with an occupational therapist trained in American Occupational Therapy Association (AOTA) courses, if not a certified driving rehabilitation specialist.

For ideas to guide your own “backseat driver education” before permit time, my advice is to thoroughly check out driveithome.org from the National Safety Council. I have all my DRT participants reference Drive it Home™ because it offers free parent resources, including digital driving lessons, courses, programs, and videos. Parents can use this information as a way to initiate dialogue about teen driving risks and road safety, but much of it can also provide ways to approach aspects of driving earlier on with your children.

Every parent has the opportunity to help teens be better prepared for driving by addressing some readiness skills before permit time. You can ask them to put down their phone or tablet, stop thinking about what happened today and what’s to come, and stay focused on the road when a passenger. Teens could practice identifying cars in the blind spots with you, help navigate by providing directions, and notice general distractions or obstacles to avoid.

Of course, safety is always Priority Number One. If implementing this or any other type of parent-initiated readiness training is in any way distracting or emotional for you as a driver, don’t do it! There are other ways to practice pre-driving skills safely. From afar, one can safely observe traffic flow at a neighborhood intersection or community traffic signal. Individuals can also take note of driving behaviors while shopping somewhere busy. An important aspect of readiness is awareness that people break rules sometimes. A safe driving practice is to make sure the careless actions of others don’t cause you to have an accident.

Perhaps most importantly, caregivers should practice good habits for teens to follow. You know the big ones: buckle up, follow the road rules, always be a defensive driver, no texting or phone use (even over the speaker), only initiate use of navigational systems if necessary when the vehicle is in park, and keep your vehicle in good shape. There is really no good excuse to break these safety measures, but some habits can be difficult to curb.

Drivers should also avoid eating/drinking, listening to the radio/movies in the car, putting on/taking off things, reaching for objects, glancing at a phone or other device, or having distracting conversations/thoughts. These actions have led and can lead to serious accidents. It’s also important for drivers to keep emotions in check and practice time management. It’s never safe to drive under the negative influence of added stress or pressure.

I know that many of these tips can feel difficult if not impossible to follow at times. The important thing to remind yourself of is this cold, hard truth: driving is the number-one killer of teens. Teenagers cannot comprehend their levels of risk as inexperienced drivers and are more likely to engage in distracting behaviors. It is also much easier as a caregiver to set driving rules and say assertively to a teen, “You absolutely cannot _____ while in the car” if they can’t argue back to you, “But YOU do it, so why can’t I?!”

As seasoned drivers, we need to remind ourselves of how stressful the learning-to-drive process can be for everyone involved. As parents, we can start teaching kids early on, and they will (hopefully) listen to us, imitate us, and do as we say. More work ahead of time should mean less of it later on, and this will be especially useful when dealing with a teen who is hormonal, emotional, distracted, or stressed.

Thank you for reading, and I hope you have found this perspective and some of the suggested recommendations of value. It has been a pleasure acting as a guest blogger. Please use any of the tips I’ve provided here as loose guidelines. As a parent, you are ultimately the only one responsible for actions taken with your child. Driving is one of the most dangerous things that we regularly do, and this important privilege should never be taken lightly.

Drive safely!
“Ms. Missy,” OTR

P.S. To learn more about Extra Credit! LLC, visit www.extracreditaustin.com and like us on Facebook to receive informative postings. For more information about OT’s role in driving rehabilitation and community mobility, please check out AOTA and the Driver Rehab Institute.
 

Let’s be real people

Melissa Menzes, an occupational therapist and founder of Extra Credit! LLC, is whole-heartedly dedicated to helping school-aged kids and families dealing with “hidden disabilities.” She has been successful in best treating children for nearly 15 years and is excited to offer a new specialty OT/educational facility here in central Texas. She joins our blog by sharing some of her own experiences with overcoming neurological dysfunction and early learning challenges.

As a pediatric occupational therapist, I frequently get asked certain questions from concerned parents on their first or second visit with me. It is all too often that I hear “Will he outgrow this?” or “Can this be fixed?” The underlying sentiment seems to be “Will my child ever be normal?” My answers to these heartfelt questions generally start with something like “Maybe. Time will tell. With a little bit of intervention and lots of love, understanding, and support, I think your child is going to be just fine.”

But what is normal, anyway? “Normal” is just a setting on a washing machine. I’ve seen variations of this phrase on cards, books, and social media platforms, and I really like it. Openness about being “different” in our society is becoming the new normal, and I think this might be a really good thing. I mean, how boring would we be as a culture without diversity? Nobody’s perfect. That’s a fact. We just are who we are and that’s okay. Adversities help shape us and guide our life paths, dreams, and purposes.

I have accepted the fact that I’m not what my profession would call “neuro-typical,” but I’m me, and I like that. So do my friends, family, and clients! I know that I’m doing just fine (if not better) because of my personal differences and the related support and knowledge I’ve gained over time. I think it’s of value to share my brief story in case it might help a concerned parent dealing with the stress of a new diagnosis or the worry of an uncertain road ahead.
 

But who am I? I am, in part, a child therapist who is passionate about helping others with unique differences and struggles. It’s something that I happen to be quite good at. I think my focus on serving families dealing with “hidden” neurodevelopmental and learning issues is primarily shaped by personal experience with certain adversities and an overwhelming drive to overcome them.

Perhaps it started for me when I had to repeat second grade in a “move-at-your-own pace” sort of Individually Guided Education (IGE) School. As emotional as it was for me to be unexpectedly separated from many of my friends, academically I moved from the bottom to the top of the class. I worked my hardest to stay there for the rest of my education until successfully graduating with honors in college. Talents in art and athletics, along with a supportive family, helped me cope with the many challenges of schooling (which I kept well hidden) and eventually led me to find an amazing career in occupational therapy. It was OT that helped me learn more about my own unique and “hidden” differences and how to best manage them.

In the early 2000s, while attending an educational workshop on helping people with dyslexia, it was discovered that I had a severe form of perceptual processing disorder called Irlen Syndrome. In short, my brain has difficulty perceiving incoming visual information. The effects of this diagnosis and my eventual treatment were astounding for me. Put simply, it changed my world!

This experience encouraged me to be more open to identifying and managing other conditions that had long remained under the radar. My postgraduate Sensory Integration certification coursework and SPD trainings helped me better understand and handle my sensory over-responsiveness. More recently, I accepted some assistance from a psychologist and counselor for some mild anxiety and attention issues that surfaced while I was starting a business. It was wonderful to see that tools I was using every day to help “my kids” could also help me heal myself.

Most people don’t recognize that I have any of these challenges until I tell them. I think this is because I’ve learned how to manage them better over time and how to leverage my many strengths. I’m beginning to realize that it’s okay to be open about who I really am and how I am different—i.e., a real human being, imperfect and completely normal! It not only helps me heal through a feeling of self-acceptance but also provides some extra encouragement to families of children battling similar issues.

Part of my mission as a therapist is to help my clients see that we all have unique characteristics, none of which are “abnormal” or need to be “fixed” but that might need a little extra support, acceptance, and understanding. Everyone has at least one strength or talent. We all have a cool difference or quirk. Most of us are aware of a particular weakness or need, and every person needs a little help with something. This is normal.

I know that I have grown a lot in the face of some previously unseen adversity. I am writing now to tell you that I am happy and successful. Despite my weaknesses, I will continue to reach my goals and even perhaps some dreams because of my numerous strengths. I’d love to help support the next person or family to do the same.

To learn more about my specialty OT and developmental learning center, please check out Extra Credit! Brain & Body Programs for Kids and like us on Facebook to receive informative postings.

Keeping it weird in Austin,
“Ms. Missy”