Postural Control as Prerequisites of Handwriting for Children with
Spastic Cerebral Palsy
Riksma Akhlan, Endang Rochyadi and Sunardi Sunardi
Special Education Program, Universitas Pendidikan Indonesia, Jl. Dr. Setiabudhi No. 229 Bandung, Indonesia
Keywords: Cerebral Palsy, Control Posture, Handwriting Readiness, Psycho Rehabilitative Intervention Program.
Abstract: Children with cerebral palsy shows wide range syndromes of brain disorder related with the motor skills
function in activity, physical, and balance limitations. This study reports postural control which includes
body awareness in sitting position and movement of hand and arms in handwriting readiness for children
with spastic cerebral palsy. A psycho rehabilitative approach was used as an intervention program to
improve the child’s basic motor skills. Experiment was conducted in a single subject research with spastic
cerebral palsy at age of 6 years old. Pre-test and post-test were designed to see intervention effect on
stability in stroking the line and quantity of the stroked lines. Results showed improvement in stability of
stroking the lines after six session of intervention. However, the quantity of the stroked line did not meet the
expected number. In conclusion the postural control using psycho rehabilitative intervention approach affect
handwriting readiness. Further research is needed to define other factors that may be contributed to the
ability of making a number of expected lines when the stability has actually achieved. This psycho
rehabilitative approach also need to be further conducted in a classroom setting with a longer period of time
and a more subject included.
1 INTRODUCTION
All activities in live involve motor skills function.
Postural control and stability are the prerequisites in
doing movement task functionally (Hong, 2002).
Inability to control posture will significantly have
effect on motor skills function achievement (Hong,
2002; Santos et al., 2010; Shumway and Woollacott,
2012; Saether et al., 2013). Children with cerebral
palsy are enduring brain disorder syndromes related
to the motor skills function (Miller, 2007),
movement development, posture and balance, which
are causing restriction in their activity. These
disorders are non-progressive and happen during
infant or baby. As a result, some approaches like
stimulation, motor skills intervention and
rehabilitation become an inseparable part of the
children life. There are abilities that need to be
trained, such as ability to maintain a current physical
condition, delay contracture and reduce stiffness
(Gilinsky and Smith, 2005; McClinton, 2007).
Intervention towards postural control is also
significant in preparing special function (Hong,
2002).
However, not all activities in stimulation
program can improve its physical activity (van Wely
et al., 2014). Thus, conceptual construction in
controlling motor system, motor learning (Howe et
al., 2013) and stimulation of development strategy in
improving daily function are of importance.
The first research objectives are to observe the
ability of children with Cerebral palsy spastic
hemipleg in stroking lines and drawing lines as
prerequisite in handwriting abilities. The second
objective is to determine whether the given
intervention could improve the prerequisite
handwriting abilities in both striking lines and
drawing circle. This determines of prerequisites
abilities is important before we could teach / give a
handwriting lesson to the children. The ability in
stroking lines is in line with stability in movement
execution that requires muscle strength and posture
control. This research was conducted by combining
few approaches, i.e. the psycho rehabilitative
approach as an intervention and the stimulation
children activity as an active participant using
instruction. The instruction was given to lead the
child’s understanding of postural control and body
awareness on doing basic motor skills in arm hand
Akhlan, R., Rochyadi, E. and Sunardi, S.
Postural Control as Prerequisites of Handwriting for Children with Spastic Cerebral Palsy.
In 1st International Conference on Educational Sciences (ICES 2017), pages 1027-1033
ISBN: 978-989-758-314-8
Copyright © 2017 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
1027

skilled movement and sitting position stability.
Those skills are the prerequisites in handwriting.
Writing is an essential activity for children and a
challenge to majority of students, especially those
who have motor skills dysfunction. Writing ability is
one of the academic tasks that has function to
remember, to process information and to
communicate thought and ideas (Naider-Steinhart
and Katz-Leurer, 2007). Writing is a complex
motoric activity. It requires a number of prerequisite
skills, such as good postural control (Donica et al.,
2013). It needs motoric planning and hand mastery,
which is quite dominantly (Benbow et al., 1992).
The activity requires visual discrimination,
perception organization (Tükel and Eliasson, 2011)
and cognition (Feder and Majnemer, 2007). It also
involves language processing (Kurtz, 2008) and
executive functions (Hooper et al., 2002; St Clair-
Thompson and Gathercole, 2006). Writing is more
comfortable when position and posture are in the
sitting position with the head postural control
(Wandel, 2000), rather than in the standing position
(Howe et al., 2013). Perceptually good sitting
posture is a straight posture that developed three
dimension of space and distance awareness.
Comprehension about surrounding will get better
when the head, eyes and ears are in a straight
position, as well as social interactions that are
mostly conducted in a straight position.
As not all activities in stimulation program can
improve physical activity, the construction needs to
be focused on special needs of each child based on
its required development. In Japan, stimulation and
intervention program named as dohsa-hou is one of
a psycho rehabilitative intervention approaches. This
approach has been used in helping children to
understand themselves in executing their motoric
activity (Naruse, 1997; Dadkhah and Harizuka,
2002; Konno, 2016). In South Australia, conductive
education has been used to support children and
adults with physical and multiple disabilities, with
assumption that motor disorders are learning
disabilities. Conductive education involves the role
of class leader known as conductor, teaching
strategies known as rhythmic intention, task series
and described equipment, and the structured
program. (Bourke-Taylor et al., 2007) describes the
importance of the group setting, the impact on
motivation, and the development of self-efficacy
within each child in this type of education. Other
combination programs, such as a sensory motor
program that combined with an occupational therapy
treatment have shown a significant changed in
component function for improving handwriting
readiness skills (Oliver, 1990). A different method
on teaching handwriting with instruction or
instructional condition has also been able to show an
enhanced legibility and fluency in better writing
performance (Santangelo and Graham, 2016).
However, those mentioned research were solely
conducted in its own approach.
2 METHODS
Experiment was conducted with a single subject
research using the A/B design which purposively
chosen. This experiment was taken place in Centre
of Assessment and Intervention for Children with
Special Needs, Universitas Pendidikan Indonesia,
Bandung, from February to August 2015. Individual
analysis was assessed to a 6 years old child with
spastic cerebral palsy at the first grade of Special
School. Participant assessment was directed by a
pretest-posttest design. The pre-test was defining a
baseline of the child’s handwriting readiness. Six
times pre-test was conducted until the child showed
a consistent handwriting readiness skills before it
was given a psycho rehabilitative intervention.
Intervention of postural control on body
awareness in sitting position, hand and arms
movement using psycho rehabilitative approach was
given in six sessions within 4 hours per week
through learning process and playing activity where
child as an active participation. The skills were
including (1) positioning the upper extremity and
postural head control, (2) reach, (3) grasp, (4) hold,
(5) release, (6) manipulate, (7) push/pull/shove, (8)
displace/Lift, (9) fixate as described in Lemmens
(2014) (10) pelvic stability, and (11) leg and foot
positioning as described in Wendel (2000).
During six session of intervention, the child was
given a series of stroking line intervention sheet as
presented in Figure 1. Five different sheets were
given to the child gradually in proportion to the
child’s ability in stroking the lines. The more
progress the child made, the more complex sheet
was given to the child. At the beginning of the
session, the child was only given the sheet number 1
(Figure 1). This work on sheet number 1 was
continued at the session two. At the session three,
the child was started to work on sheet number 2 and
number 3 (Figure 1). At the session four, five and
six, the child was gradually working on sheets
number 3, 4 and 5 (Figure 1), respectively.
In each session, the intervention of postural
control given to the child was focused on its motor
skills that affect handwriting readiness as described
ICES 2017 - 1st International Conference on Educational Sciences
1028

in Donica et al. (2013). The handwriting readiness
was assessed by indicators in stability to stroke a
line and the expected quantity of the stroked line as
exampled in previous research (Tükel and Eliasson,
2011; van Hartingsveldt et al., 2011; Santangelo and
Graham, 2016).
Figure 1: A series of stroking line intervention sheet.
3 RESULTS AND DISCUSSION
The pre-test was aimed to measure the child’s
handwriting skills in making a stroke line with
stability and to quantify the stroked-lines that was
made in six repeatable times. The result showed that
the child was not able to make a stroke line and
stability was not evident when making the stroked
lines. The child was able to hold a utensil, i.e. a pen,
but did not have enough strength to make a stroked
line with its pen. Thus, psycho rehabilitative
intervention was introduced to improve child’s basic
motor skills. This intervention was conducted in six
sessions to stimulate the ability in making stroke
lines.
At first session of intervention, the child showed
an ability to hold the writing utensil. The child was
given an intervention in acknowledging the most
comfortable utensil to be used in making stroked
line, and was encouraged to have enough strength to
push the utensil into the paper. Stability and the
expected quantity of the stroked line were not shown
in this session. At second session of intervention,
stability was started to appear when the child stroked
a straight line in sheet number 1 (Figure 2. First and
Second Session sheet number 1). However, the
quantity of the stroked line was not fulfilled
assessment criteria.
Figure 2: First and Second Session sheet number 1.
Improve child’s motor skills started to show at
the third session of intervention. Here, the child has
found comfort in holding the pen and was able to
stroke the line consistently. It was able to thickening
the points of the straight line in the sheet number 3,
but it struggled to make a circle in the sheet number
2 and sheet number 3 (Figure 3. Third Session sheet
number 2 and Figure 4. Third Session sheet number
3). From stability perspective, the child has made
improvement in stroking a straight line. The stroke
lines were not jagged sharply in distant-wise. They
also closely stroke to the targeted line. The end
result of the stroking lines was started to match the
targeted line.
Figure 3: Third Session, Sheet number 1.
Postural Control as Prerequisites of Handwriting for Children with Spastic Cerebral Palsy
1029

Figure 4: Third Session, sheet number 3.
At the forth session intervention, the ability to
stroke a line in a circle shape was started to show.
However, the line was not in a full circle. The
constant stability in the straight line showed by the
minimal jagged when stroking the line and when it
was achieved 50% of the stroked line targeted
quantity (Figure 5. Fourth Session sheet number 3).
Figure 5: Fourth Session sheet number 3.
At the fifth session, stability of intervention in
stroking the lines has fulfilled all required target.
However, the quantity of the stroked lines was not
achieved as expected. It was still about 50%
achievement (Figure 6. Fifth Session sheet number 4
and Figure 7. Fifth Session sheet number 5).
Figure 6: Fifth Session sheet number 4.
ICES 2017 - 1st International Conference on Educational Sciences
1030

Figure 7: Fifth Session sheet number 5.
At the last intervention, stability was continue
fulfilling the target. However, the quantity of the
stroked lines was still not achieved as required at
more than 75% (Figure 8. Sixth session sheet
number 5)
Figure 8: Sixth Session sheet number 5.
The summary of this result is presented in Table
1. Progress Score Handwriting Readiness.
Table 1: Progress Score Handwritting Readiness.
Postural Control as Prerequisites of Handwriting for Children with Spastic Cerebral Palsy
1031

Handwritting readiness indicators are : (a)
stability in stroking a line, and (b) a quantity of the
stroked line.
Stability score means: (1) stroking line at any
place and not as shaped as the targeted shape, (2)
stroking the line with jagged sharply and shaped as
the targeted shape, (3) stroking the line without
jagged, line as straight as the targeted shape, and
stroke in no distance or close to the target.
Quantity score means: (1) making a straight
stroke line and circling 20 % of the targeted shape,
(2) making a straight stroke line and circling 50% of
the targeted shape, (3) making a straight stroke line
and circling more than 80% of The targeted shape.
4 CONCLUSIONS AND
RECOMMENDATION
Writing readiness in children with cerebral palsy is
really depend on their postural control skills, i.e. the
ability to understand body awareness, the ability to
plan movement and the ability to function in their
activity. Intervention with the psycho rehabilitative
approach has been proven in helping children with
spastic cerebral palsy. It helped organizing the
stability of stroking the lines and enabling to achieve
the required-quantity of the stroked-lines. However,
stability in stroking the lines were not hand in hand
with the produced line numbers. A further research
is needed to observe whether there were other
factors influencing postural control. The complexity
of making different types of stroking lines (e.g.
making a combination of vertical and horizontal
stroking lines and circle at one assignment) may
possibly influence the ability of the children in
producing certain numbers of the stroking lines. It
was also possible that the child was experiencing
tiredness when they were making more complex
stroking lines. Psycho rehabilitative intervention has
also functioned in keeping the movement of muscles
and joints, this shows in the progress of stability in
stroking lines. The function of motor skill activity
could keep maintained. To make sure that the motor
skills activity was functioned, the research needs to
be observed in a longer period of time. A thorough
observation would also be necessity in the
development of children with cerebral palsy.
Combining a rehabilitation approach with the ability
in postural control was a strategy in helping children
with cerebral palsy in conducting certain motor
skills activity. By way of a will power and effort
from the child, children with cerebral palsy can no
longer be a passive recipient of the therapy but an
active participant in learning process.
REFERENCES
Benbow, M., Hanft, B. E., Marsh, D., 1992. Handwriting
in the classroom: Improving written communication,
American Occupational Therapy Association.
Rockville.
Bourke-Taylor, H., O'shea, R., Gaebler-Spira, D., 2007.
Conductive education: A functional skills program for
children with cerebral palsy. Physical and
Occupational Therapy in pediatrics. 27(1), 45-62.
Dadkhah, A., Harizuka, S., 2002. The application of a
Japanese psychological rehabilitation method in Iran.
Journal of Rehabilitation Psychology. 30, 9-13.
Donica, D. K., Goins, A., Wagner, L., 2013. Effectiveness
of handwriting readiness programs on postural control,
hand control, and letter and number formation in head
start classrooms. Journal of Occupational Therapy,
Schools, and Early Intervention. 6(2), 81-93.
Feder, K. P., Majnemer, A., 2007. Handwriting
development, competency, and
intervention. Developmental Medicine and Child
Neurology. 49(4), 312-317.
Gilinsky, G., Smith, C., 2005. New wheelchair or new
solutions?. Rehab Management. 19(1), 34-36.
Hong, C., 2002. Positioning for children with learning
disabilities. British Journal of Therapy and
Rehabilitation. 9, 443-446.
Hooper, S. R., Swartz, C. W., Wakely, M. B., de Kruif, R.
E., Montgomery, J. W., 2002. Executive functions in
elementary school children with and without problems
in written expression. Journal of Learning
Disabilities. 35(1), 57-68.
Howe, T. H., Roston, K. L., Sheu, C. F., and Hinojosa, J.
2013. Assessing handwriting intervention
effectiveness in elementary school students: A two-
group controlled study. American Journal of
Occupational Therapy. 67(1), 19-26.
Konno, Y., 2016. Psychotherapeutic Approach of Dohsa-
hou in Japan. The Jappanese Association of Special
education, Journal of Special Education Researche.
5(1), 11-17.
Kurtz, L. A., 2008. Understanding motor skills in children
with dyspraxia, ADHD, autism and other learning
disabilities. A good to improving coordination. Jessica
Kingsley Publisher. London, Philadelphia. pp 95-112.
McClinton, D. H., 2007. Seating and positioning systems
provide pediatric patient with clinical, environmental
benefits. Care Management. 13(2), 23-27.
Miller, F., 2007. Physical Therapy of Cerebral Palsy,
Springer. USA.
Naider-Steinhart, S., Katz-Leurer, M., 2007. Analysis of
proximal and distal muscle activity during handwriting
tasks. American Journal of Occupational Therapy.
61(4), 392-398.
ICES 2017 - 1st International Conference on Educational Sciences
1032

Naruse, G., 1997. The clinical Dohsa-hou for cerebral
palsied person. The Journal Rehabilitation
Psychology. 25, 1-7.
Oliver, C. E., 1990. A sensorimotor program for
improving writing readiness skills in elementary-age
children. American Journal of Occupational Therapy.
44(2), 111-116.
Santangelo, T., Graham, S., 2016. A comprehensive meta-
analysis of handwriting instruction. Educational
Psychology Review. 28(2), 225-265.
Saether, R., Helbostad, J. L., Riphagen, I. I., Vik, T., 2013.
Clinical tools to assess balance in children and adults
with cerebral palsy: A systematic review.
Developmental Medicine and Child Neurology.
55(11), 988-999.
Santos, M. J., Kanekar, N., Aruin, A. S., 2010. The role of
anticipatory postural adjustments in compensatory
control of posture: 1. Electromyographic analysis.
Journal of Electromyography and Kinesiology. 20(3),
388-397.
Shumway-Cook A., Woollacott M. H., 2012. Normal
postural control. In: motor control: Translating
research into clinical practice, Lippincott Williams
and Wilkins. Baltimore,
4th
edition. pp. 161–94.
St Clair-Thompson, H. L., Gathercole, S. E., 2006.
Executive functions and achievements in school:
Shifting, updating, inhibition, and working memory.
The Quarterly Journal of Experimental Psychology.
59(4), 745-759.
Tükel, K. Ş., Eliasson, A. C., 2011. Development of
handwriting skill in children with unilateral cerebral
palsy (CP). Disability and Rehabilitation. 33(21-22),
2084-2091.
Van Hartingsveldt, M. J., de Groot, I. J., Aarts, P.,
Nijhuis-van, S. M. W., 2011. Standardized tests of
handwriting readiness: A systematic review of the
literature. Developmental Medicine and Child
Neurology. 53(6), 506-515.
Van Wely, L., Balemans, A. C., Becher, J. G., Dallmeijer,
A. J., 2014. Physical activity stimulation program for
children with cerebral palsy did not improve physical
activity: A randomised trial. Journal of
Physiotherapy. 60(1), 40-49.
Wandel, J. A., 2000. Positioning and handling, Pediatric
Skills for Occupational Therapy Assistants, Mosby.
London.
Postural Control as Prerequisites of Handwriting for Children with Spastic Cerebral Palsy
1033