“I need you to use your hand to help him make the writing stroke”. “Here let’s hold the piece like this”. “Put in”. “Take off”. “Student needed a full prompt to complete the activity successfully”.
These are common phrases I have utilized during my OT practice while performing hand over hand in activities.
I have recommended to my TAs, in the preschool classroom I support, to try hand over hand when working on prewriting skills.
Full prompting was utilized for my life skill students when we were working on new task boxes.
I would even use dependent prompting with my daughter when I was tired of picking up yogurt covered spoons on our rug.
I listened to an Occupational Therapy podcast called “Two Sides of the Spectrum” and it was so eye-opening to me. The host, Meg Proctor, was interviewing Sarah Selvaggi Hernandez, an Autistic Occupational Therapist. After listening, I did a lot of reflecting on my own practice and the therapist I wanted to be.
Definition
The Autism Society, Baltimore-Chesapeake division, defines hand over hands as
“A common teaching technique for children with autism, especially when using an ABA approach. It can be used to guide the student toward a correct response, or to help the student initiate a task, or allow the student to become “unstuck” when having difficulty transitioning from one step in a process to another.”
After having done my own research and reflection, I think we can do better than full prompting. I don’t believe that hand over hand should be a common teaching technique and I certainly do not believe that we have to use our body to help a child complete a task either.
This is why I do not use hand over hand in my practice:
Foundational Skills
I worked with an amazing OT, Brooke when I lived briefly out west. She stated “When we use hand over hand, we are missing something”. We essentially use full prompting because the student cannot complete the activity/the demand, independently.
This raises the following questions:
(1) What foundational skill does the child not possess?
(2) What skill is missing that inhibits their ability to complete the task independently?
(3) What environmental components might be making the task more difficult?
From the outside looking in, a prewriting task or a file folder task appear very black and white. It’s a solid, straightforward concept. But as educators and practitioners, we know that special education is very gray and is in a sense an “onion”. There are so many layers to tasks and lessons. We have to peel back these layers to find the core. The goal is to figure out how to get the student from Point A to Point B.
Task Analysis
In college, we would do an activity analysis where we would break activities up into smaller components. The goal is to look at what skills the activity focused on. This basic concept can be utilized for tasks. It is sort of overwhelming to break tasks down because the list always seems to get longer and longer. It is especially hard to do with a student you are unfamiliar with. Once you start building the relationship with that student, you see what their overall strengths and needs are. It is then easier to see a task through a new lens.
The Components of a Task Analysis
- Basic components of the present activity addressed
- Skills the child needs to have before the concepts of the activity can be met
- Types of instruction the child respond best to
- Child’s independence with task initiation
Task Initiation
If a child is struggling with independent task initiation, that is the first step we need to address. Task initiation is an internal response. We should never utilize hand over hand to start a task for a child or student.
As I further discuss below, when we demand a student start a task, by using our body to move theirs, we are not acknowledging their personal space. We are not respecting their body. By initiating a task for a student, we aren’t solving the problem. We need to find solutions to help a student feel ready to start.
The solutions might be addressing sensory input, or visual schedules, or using strength-based intervention/preferred topics/interests. It could also be working with the student to help them with the overall structure and schedule of your classroom, so the student understands the routine/what comes next.
Everyone has a right to say no, whether that is spoken verbally or not. I believe ‘no’ is always an option even when it is inconvenient for us as educators and makes things more difficult. Before I ramble further, I will summarize that task initiation as a giant Rubiks cube that needs to be solved and trialed before we can expect reliable data reflecting the student’s true abilities
Example
Let’s look at a student’s fine motor objective.
Objective: Student D will imitate developmentally appropriate pre-writing strokes (vertical, horizontal, circle) for increased graphomotor skills.
Typically what a session in the past would look like is I would review my student’s goal and objectives and then focus my session on ways to collect data for said objective. Firstly I would sit down and present the activity. Then I would model and see what they would complete independently and take the data. After that, I would model again and increase the prompting and take the data.
That is the data I would utilize on my progress reports.
In essence, though, that wasn’t fair to the student. I wasn’t giving them a fair shot. I wasn’t setting them up for success. The student needed increased prompting and the task modeled multiple times.
This showed me that he didn’t have the precursors for the activity. Compare it to reading. I was asking him to read at a level that did not meet his just-right challenge. He wasn’t able to be successful and thereby probably felt more frustrated.
I needed to break the components of the activity up. It is important to focus of the foundational skills to make sure they are established.
That’s not to say don’t take baseline data. Hand over hand is not needed to see that the student isn’t ready to complete the task independently.
Task Analysis Break Down
Let’s complete a task analysis on the pre-writing objective, remember we want to dissect the components; pull apart the outer layer!
When I look at that objective for student D, I know I need to work on task initiation. It is important to make sure he is able to start tasks independently. I should not resort in utilizing dependent prompting such as hand over hand.
I could also try different visuals and/or presenting my instructions in different formats. Whitney, for the Simply Special Blog Team, has a great article on different visual schedules that can be utilized .
It would be beneficial for me to work on that foundational grasp strength. When looking at developmental milestones, Grasp strength is a precursor for a functional grasp.
Reliable data will not be achieved by working on objectives that aren’t developmentally appropriate. A goal that is not appropriate leads to increased and dependent prompting. By utilizing hand over hand to help him make a horizontal stroke it is not benefiting him. If anything, that prompt is going to become a routine. He is going to start associating that tactile cue/prompt with the routine on how to perform the skill.
The big reason I do not utilize hand over hand in my practice is Autonomy.
Autonomy, I preach this terminology. I define autonomy as having the utmost say in regards to your body and your mind.
Regardless of age, race, sexual orientation, or medical diagnosis you have a right to your:
- Personal space/Body
- Thoughts
- Expression
In a previous blog, I talked about my youngest sister, Marina, who has Down syndrome. I strive to help her become independent and self-confident. I want her to be able to feel confident to tell someone no.
Personally, I am ashamed to say, that I did not correlate hand over hand and the overall concept of autonomy. I would use dependent prompting to work through my sessions. I would use hand over hand with my students who had limited verbal language. And also who weren’t proficient in their communication devices.
It is my belief that by using hand over hand, I was invading my students’ personal space. It leads into the question, if a student pulls away from this tactile prompt, what do you do? Do you respect their autonomy and release or do you firm your grip and finish the task? You might do this unconsciously. To further dive into the concept and to drive the point:
We are unconsciously sending the message: I can use my body to have you complete a task that I want you to complete.
We need to teach our students that they have a right to their bodies. The message we send them when they are young will carry with them through their adulthood. I know personally, I want my sister to know, her body is her choice. She has a right to her personal space.
Even though someone is seen as an authoritative figure, they do not have the right to touch her or use their body to gain their directive.
She has the RIGHT to stand up for herself just as each of us do.
When To Use Hand Over Hand
Let me be clear, there are times were hand over hand is appropriate, for instance, safety. If my young daughter and I are walking in the airport, and I am holding her hand, I am going to firm the pressure I am utilizing if she is pulling away. At a later time, I am going to address safety with her and why it is important to stay near me in a crowded unfamiliar place. I am going to use hand over hand to help with hygiene such as brushing teeth and I am going to work with her on how to independently establish healthy routines.
Alternatives
We can also provide tactile prompts that do not include guiding the hand and prolonged tactile reinforcing. For example, if I am helping with a cooking task in my life skill classroom, I can guide my student’s elbow to the mixing bowl if they are having difficulty with precision. If I am using a pinwheel with a preschool student with low muscle tone, and they are having difficulty making it spin, I can guide their triceps up so the pinwheel is near their mouth. If I am helping an older student, who elopes and has a visual impairment, I am going to guide them by the elbow when walking down the hall versus holding their hand. We can ensure safety, promote independence, and respect autonomy without using hand over hand.
Maya Angelou said, “When you know better, you do better” and I think that is my mantra as a practitioner. I want to continue learning and doing better. My professional goal is to utilize best practices and also help my students succeed and thrive, not only in the educational setting but also in their lives. I want to provide them with foundational skills that will benefit them after they are 21. Lastly, it is important for me to send a message to my students, from preschool to transitional programs, that I respect their autonomy.
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Mary Ellen Tenney says
Taylor! This is such an awesome post! I love the message and how articulate you are.
Taylor says
Hello Mary!
Thank you so much for your comment and for taking the time to read my blog!
Hope you are having a great day!
Taylor
Barb says
This was an excellent article. I never gave much thought to how controlling hand to hand can be. Teaching special individuals to understand their right to not be touched if it doesn’t feel right is much more important than correct formation of letters or grips. Thanks for offering new ideas to consider
Taylor says
Hello Barb!
Thank you so much for your comment and for taking the time to read my blog! I definitely agree, teaching autonomy is such an important life skill concept!
Hope you are having a good day!
Taylor
Meg Denton says
Thanks for this post Taylor! Hand under hand is fairly well known in the Deafblind community as a respectful way to assist and communicate with others. I have generalized this to my OT practice with the addition of increasing wait time. You did such a great job explaining the reasons why hand under hand is best practice.