Posted in Eleanor Cawley, M.S., OTR/L

The Can of Worms is Open!-Building Blocks Missing

I am, in many ways, so grateful for this past year.  I have gone from a caterpillar to a butterfly, so to speak.  I have been so grateful for having the opportunity to collaborate with occupational therapists from all over the world and learn so much.  I am excited about the possibilities for learning from social media and currently sad to see the state it is in.

I was communicating with Katherine [Handwriting with Katherine] and we were discussing my last blog, ‘Does Backpack Safety Awareness go far Enough?’  I really just expressed a lot of my own opinions, but isn’t that one of the privileges of having a blog? In my opinion, one of the major issues, understanding the importance of developing all the blocks before constructing the building.  One of my pet projects, as if you didn’t know, is taking notes.  There is often a recommendation for assistive technology when what is really needed is more building blocks.  As occupational therapists know, good handwriting is built on quite a number of those building blocks; posture, visual perceptual/motor skills, functional pencil grip, enough muscle strength and endurance to maintain the writing task for as long as is needed, integration of primitive reflexes, etc.  All of these skills are building blocks that lead to good handwriting, and there are many more.

I am often amazed at how a student could come to me in the 7th grade with poor handwriting skills but missing vital building blocks.  The response often is to get him to take notes on the computer.  The first thing that comes to my mind is, “Well if he can’t take handwritten notes, what makes you think he can miraculously take notes on a keyboard?”  Posture, visual tracking, listening, responding to prompts, formatting the page, keyboarding, etc are all part of taking notes.   I am thinking of one student in particular, 12 years old, in OT since early intervention, who still did not have legible handwriting.  I observed this student in class and in the therapy room [or should I say therapy closet].  I was shocked beyond belief!  What I saw was the residual Asymmetric Tonic Neck Reflex [ATNR] in all its glory.  Of course, I could report my findings, but not make a recommendation to visit a neurologist [district policy].  Any way, this student exhibited classic signs of a residual ATNR.  He was right handed, but left foot and eye dominant.  He tested positive for an ATNR in quadruped. When hand writing, he sat on his left leg with his left arm flexed with his head tilted tilted slightly downward and turned to the right. Basically, reading with his left eye. Using a thumb wrap pencil grasp, he was able to write, but as he moved away from midline, he had difficulty retaining his grip on the pencil.  His grip was so tight, I could not pull the pencil from his hand without having him topple over.  He was so involved in maintaining control of his body that he failed to learn the listening skills, visual tracking skills, and all the other skills needed for effective note-taking.

Teachers have been complaining for years about his handwriting.  He was able to type with both elbows tight against his body but unable to type and read from copy placed to either side as any slight head turn would trigger the ATNR.  Any visual tracking to left or right of midline triggered the response. Was he aware of what was happening to him? Did anyone teach him different strategies? One of the first things that I did with him was to encourage him to write with the paper placed in landscape rather than portrait.  This way he was always writing at midline.   He was asked to sit further back in the classroom so that he did not have to turn his head to see the board.  He was asked to work this way as we continued to work on integrating the ATNR. Here is a link to Lisa Fass, OTR/L and her videos on using Yoga to integrate the ATNR   [Yoga Poses for Primitive Reflex Integration]. This student has made some progress in improving his handwriting and in integrating the ATNR.


Every baby is born with primitive reflexes which are often integrated in the first few months of life.   I chose this picture of the ATNR because it shows both the upper and lower extremity responses to head turning. As you can see, the arm and the leg on the side to which the head is turned are outstretched.  The opposite arm and leg are bent-a sword fighting position.    Some babies, when pushing down on the foot of bent leg and reaching with the arm on the same side, it can help the baby learn to roll from supine [on his or her back] to prone [on his or her tummy].  Again, this is why tummy time is so important to development.  Lisa’s video of integrating the ATNR is working in prone [tummy time].

Some therapist’s feel that once a child gets past the age of nine and the age of rapid changes in neuroplasticity, no amount of therapy will address integration of primitive reflexes.  So maybe the jury is still out on this one.  What I do know is this:  therapists working is school districts need more than a closet to address many of the needs of their students; good mats and equipment should be provided by the school district; therapists need to be able to spot all the signs for deficits in handwriting; therapists need to be able to make recommendations “from one parent to another” or “personally, I would…”  I am not sure how this went on for so long.  But it did and now this student is stuck in limbo with poor handwriting, just learning about why his handwriting is so poor and what he can do for himself.


I am an occupational therapist with 18 years of experience in the pediatric sector, much of that time as an independent contractor. I am very passionate about my work and my writing. My degrees include a Bachelor’s of Science in Health Sciences and a Master’s of Science in Occupational Therapy from Touro College. Since graduating as a non-traditional student, I have worked in a variety of settings throughout the life span but settled in the area of school-based therapy. My interests lie in the area of using technology to support independence and I often train students to use programming not only to monitor their own goal progress but also support educational, vocational and life skills. Another area of particular interest is documentation. As an independent contractor for many years, I feel that it is important to align methods of documenting goal progress with educators for greater consistency and understanding when writing for an IEP. It is better to plan a format for documentation used in the IEP, such as for assessment and goal progress and that a rubric, in many ways, fulfills the need for consistency in documentation across all domains. Combining my interest in technology and documentation, I use Microsoft OneNote to maintain all documentation. I create a digital notebook for each student or patient with any forms required uploaded as templates which can then be completed, and saved automatically. I strongly believe in student centered approach to therapy. Students must be active participants in developing goals and documenting progress. In order to help students understand their progress, I teach my students to develop electronic portfolios and to use spreadsheet programming with graphs to collect data and view progress, whenever possible.