Occupational therapy is a skilled therapy service designed to promote independence in activities of daily living and improve functional performance in a client’s roles and occupations (preferred or required tasks, not necessarily a client’s career). Occupational therapy practitioners address handwriting performance using developmental frameworks and holistic observations of a child’s global strengths and weaknesses. The role of an occupational therapist in improving handwriting is to target areas of concern, such as sizing, spacing, and letter formation, as well as adapt the task or tools or movement to promote mastery and successful use of strategies and adaptive methods (Graham & Harris, 2005).

Handwriting is a functional skill mastered by many at a young age. Handwriting is essential to many areas of life, such as academic progression, communication between friends or family, or generating a list. The importance of handwriting is stressed not only within the classroom, but in culture around us.

There are multiple facets of handwriting that contribute to the creation of a word or sentence; fine motor coordination or motor planning, strength, cognition, visual motor integration, and sensory processing:

  • Fine motor coordination is the coordination of hand skills, including utensil or object grasp, finger translation, manipulation of small objects, and dynamic movement of fingers and wrist. Grasp does not necessarily dictate poor legibility, but immature grasp patterns will lead to quicker fatigue and more difficulty with letter formation (Schwellnus et. al. 2012).

  • Strength refers not only to hand strength to hold a utensil properly, but also core and upper body strength to maintain proper positioning in a chair or writing surface for an extended period of time. Proximal body stability, such as the core, has a great effect on the distal body, hand and wrist, support and function.

  • Cognition is required for handwriting, as students not only have to focus on the formation of letters but also decide on the words they are writing. Students have to remember assignment requirements or dictated sentences, and the working memory for sentence generation frequently collides with the memory of handwriting strategies, creating slow printing and difficulty following directions (Case-Smith, J., Holland, T., & Bishop, B., 2011).

  • Visual Motor Integration is communication between the eyes and hands so that a person is able to write or draw. If coordination of visual systems is affected, this may have an impact on handwriting.

  • Sensory processing has an effect on handwriting because the information from the environment could positively or negatively influence the success of handwriting. Decreased proprioception, can influence pressure modulation on a utensil, leading to broken crayons or unreadable, lightly written words. Visual processing can impact the visual motor skills required for handwriting or become a distraction from the task at hand. Additionally, tactile, auditory, and praxis processing vary in children and may be impacting the attention to task and self-regulation during seated activities.

Through the use of standardized assessment, clinical observation, and caregiver interview, occupational therapists will identify problem areas that are negatively impacting handwriting. Also considered are other related functional skills that may be difficult (e.g. many children who struggle with handwriting also have difficulty with other fine motor tasks such as buttoning). Practitioners consider the future impact of handwriting, determining the appropriate way to develop and generalize this skill so that practicing now will lead to a permanent change in the capability to complete the skill successfully (Howe et. al. 2013).


Challenges with handwriting generally reflect difficulty in one or more skill areas; fine motor coordination, strength, cognition, and/or sensory processing. Occupational therapists are able to adapt and develop components of handwriting in order to achieve successful performance.

By: Bethany Domoto, MS, OTR/L, Occupational Therapist


Case-Smith, J., Holland, T., & Bishop, B. (2011). Effectiveness of an integrated handwriting program for first grade students: A pilot study. American Journal of Occupational Therapy, 65, 670-678.

Howe, T.-H., Rosten, K. L., Heu, C.-F., & Hinojosa, J. (2013) Assessing handwriting intervention effectiveness in elementary school students: A two group controlled study. American Journal of Occupational Therapy, 67 19-27.

Schwellnus, H., Carnahan, H., Kuhski, A., Polatajko, H., Missiuna, C., Chau, T. (2012). Effect of pencil grasp on the speed and legibility of handwriting in children. American Journal of Occupational Therapy, 66, 718-726.