In this study, we set out to measure handwriting speed in JIA using the Detailed Assessment of Speed of Handwriting (DASH). We have shown that handwriting difficulties are common and for multidisciplinary teams, OT and PT handwriting assessments are feasible to perform in the outpatient setting.

Handwriting is a complex activity requiring extensive neuromuscular coordination. Children with arthritis in their hands or wrist may have pain, weakness or limited range of motion. Children experiencing pain can become fatigued and distracted. They may change how they grip a pencil / pen to limit or avoid the pain of stiff joints. Hoeksma and colleagues reported a high prevalence of hand- and wrist-related symptoms and impairments in a cohort of 121 school aged children with JIA and low disease activity with 54% reporting hand- and/or wrist-related problems at school [6]. Pain was the most reported symptom and considerably more children reported symptoms and impairments than had physical exam findings of active arthritis or disease damage [6]. Haberfehlner and colleagues described a cohort of 15 children with JIA and self-selected handwriting difficulties performing a 5-minute handwriting test. The children reported pain during handwriting and had significant decrease in the numbers of letters they wrote per minute during the test. [1] The presence of arthritis, and limitation in grip force and wrist range of motion did not correlate with handwriting output. [1]

Consistent with the literature, we found that our cohort of children with JIA had impairments in handwriting with low mean DASH scores. Our numbers were too small to explore relationships between disease activity and handwriting. The CHAQ-DI grip domain question “Is your child able to write or scribble with pen or pencil?” did not capture all the participants who had DASH scores below the 50th percentile. This may be due to small participant numbers and insensitivity of the CHAQ-DI for handwriting activities. We noticed a decrease in writing speed over time during the DASH free writing 10-minute task. The scoring for this is divided into 2-minute sections and scored in words per minute for the whole 10-minute period. Thus, we are unable to comment on whether the pattern of handwriting speed in our participants with JIA differs from the normative population.

Handwriting is important for school participation and achievement. Children master letter formation at a relatively early stage in their school learning, with handwriting fluency steadily developing until attaining automaticity. The capacity theory of writing proposes that as automaticity develops, the effort dedicated to the mechanics of handwriting is reduced, freeing capacity for planning, composing and editing content. [7] A study of the handwriting ability of 284 primary school children aged 8 to 9 years old found correlations between poor handwriting, lower cognitive and literacy scores, and a longer duration for handwriting tasks [8]. Handwriting is not only important in school aged children; Summers and colleagues report impairments in handwriting speed in university students limits fluency of thought communication and exam completion. [9]

Children and youth with JIA may benefit from support and accommodation in the classroom. In 2019, Chomistek and colleagues performed a cross-sectional survey of 98 children with JIA aged 8 to 17, to identify patient-reported school barriers. They found 30% reported difficulties writing and 20% percent had accommodations at school including computer or tablet access, extra time for tests, or modified gym. [10]

A recent qualitative study in 2021, explored the experience of teachers supporting children aged 7 to 11 years old with JIA. They describe four key themes to best support children with JIA; communicating (with child, parents, healthcare team); flexing and adapting (ability to provide individualized support to maximize inclusion); inclusion (mindful child is not seen as ‘different’); and learning and knowing (continuing education). [11] These findings highlight the importance of a team approach to ensuring a child’s success in school with the child, parents, teacher, and healthcare professionals working together. It is our usual practice to provide school accommodation letters for all our patients with JIA with individual recommendations as per our OT, PT, and medical assessment. Figure 2 shows an example of a school letter, highlighting the need for pacing and additional time for written work.