Math Learning Disabilities

By: Kate Garnett (1998) While children with disorders in mathematics are specifically included under the definition of Learning Disabilities, seldom do math learning difficulties cause children to be referred for evaluation. In many school systems, special education services are provided almost exclusively on the basis of children's reading disabilities. Even after being identified as learning disabled (LD), few children are provided substantive assessment and remediation of their arithmetic difficulties. This relative neglect might lead parents and teachers to believe that arithmetic learning problems are not very common, or perhaps not very serious. However, approximately 6% of school-age children have significant math deficits and among students classified as learning disabled, arithmetic difficulties are as pervasive as reading problems. This does not mean that all reading disabilities are accompanied by arithmetic learning problems, but it does mean that math deficits are widespread and in need of equivalent attention and concern. Evidence from learning disabled adults belies the social myth that it is okay to be rotten at math. The effects of math failure throughout years of schooling, coupled with math illiteracy in adult life, can seriously handicap both daily living and vocational prospects. In today's world, mathematical knowledge, reasoning, and skills are no less important than reading ability .

Different types of math learning problems

As with students' reading disabilities, when math difficulties are present, they range from mild to severe. There is also evidence that children manifest different types of disabilities in math. Unfortunately, research attempting to classify these has yet to be validated or widely accepted, so caution is required when considering descriptions of differing degrees of math disability. Still, it seems evident that students do experience not only differing intensities of math dilemmas, but also different types, which require diverse classroom emphases, adaptations and sometimes even divergent methods.

Mastering basic number facts

Many learning disabled students have persistent trouble "memorizing" basic number facts in all four operations, despite adequate understanding and great effort expended trying to do so. Instead of readily knowing that 5+7=12, or that 4x6=24, these children continue laboriously over years to count fingers, pencil marks or scribbled circles and seem unable to develop efficient memory strategies on their own. For some, this represents their only notable math learning difficulty and, in such cases, it is crucial not to hold them back "until they know their facts." Rather, they should be allowed to use a pocket-size facts chart in order to proceed to more complex computation, applications, and

problem-solving. As the students demonstrate speed and reliability in knowing a number fact, it can be removed from a personal chart. Addition and multiplication charts also can be used for subtraction and division respectively. For specific use as a basic fact reference, a portable chart (back-pocket-size, for older students) is preferable to an electronic calculator. Having the full set of answers in view is valuable, as is finding the same answer in the same location each time since where something is can help in recalling what it is. Also, by blackening over each fact that has been mastered, overreliance on the chart is discouraged and motivation to learn another one is increased. For those students who have difficulty locating answers at the vertical/horizontal intersections, it helps to use cutout cardboard in a backward L-shape. Several curriculum materials offer specific methods to help teach mastering of basic arithmetic facts. The important assumption behind these materials is that the concepts of quantities and operations are already firmly established in the student's understanding. This means that the student can readily show and explain what a problem means using objects, pencil marks, etc. Suggestions from these teaching approaches include:

Interactive and intensive practice with motivational materials such as games attentiveness during practice is as crucial as time spent Distributed practice, meaning much practice in small doses for example, two 15-minute sessions per day, rather than an hour session every other day Small numbers of facts per group to be mastered at one time and then, frequent practice with mixed groups Emphasis is on "reverses," or "turnarounds" (e.g., 4 + 5/5 + 4, 6x7/7x6) In vertical. horizontal, and oral formats Student self-charting of progress having students keep track of how many and which facts are mastered and how many more there are to go Instruction, not just practice Teaching thinking strategies from one fact to another (e.g., doubles facts, 5 + 5, 6 + 6, etc. and then double-plus-one facts, 5 + 6, 6 + 7, etc.).

(For details of these thinking strategies, see Garnett, Frank & Fleischner, 1983, Thornton.1978; or Stern, 1987).

Arithmetic weakness/math talent

Some learning disabled students have an excellent grasp of math concepts, but are inconsistent in calculating. They are reliably unreliable at paying attention to the operational sign, at borrowing or carrying appropriately, and at sequencing the steps in complex operations. These same students also may experience difficulty mastering basic number facts. Interestingly, some of the students with these difficulties may be remedial math students during the elementary years when computational accuracy is heavily stressed, but can go on to join honors classes in higher math where their conceptual prowess is called for. Clearly, these students should not be tracked into low level secondary math classes where they will only

continue to demonstrate these careless errors and inconsistent computational skills while being denied access to higher-level math of which they are capable. Because there is much more to mathematics than right-answer reliable calculating, it is important to access the broad scope of math abilities and not judge intelligence or understanding by observing only weak lower level skills. Often a delicate balance must be struck in working with learning disabled math students which include: a. Acknowledging their computational weaknesses b. Maintaining persistent effort at strengthening inconsistent skills; c. Sharing a partnership with the student to develop self-monitoring systems and ingenious compensations; and at the same time, providing the full, enriched scope of math teaching.

The written symbol system and concrete materials

Many younger children who have difficulty with elementary math actually bring to school a strong foundation of informal math understanding. They encounter trouble in connecting this knowledge base to the more formal procedures, language, and symbolic notation system of school math. The collision of their informal skills with school math is like a tuneful, rhythmic child experiencing written music as something different from what he/she already can do. In fact, it is quite a complex feat to map the new world of written -math symbols onto the known world of quantities, actions and, at the same time to learn the peculiar language we use to talk about arithmetic. Students need many repeated experiences and many varieties of concrete materials to make these connections strong and stable. Teachers often compound difficulties at this stage of learning by asking students to match pictured groups with number sentences before they have had sufficient experience relating varieties of physical representations with the various ways we string together math symbols, and the different ways we refer to these things in words. The fact that concrete materials can be moved, held, and physically grouped and separated makes them much more vivid teaching tools than pictorial representations. Because pictures are semiabstract symbols, if introduced too early, they easily confuse the delicate connections being formed between existing concepts, the new language of math, and the formal world of written number problems. In this same regard, it is important to remember that structured concrete materials are beneficial at the concept development stage for math topics at all grade levels. There is research evidence that students who use concrete materials actually develop more precise and more comprehensive mental representations, often show more motivation and on-task behavior, may better understand mathematical ideas, and may better apply these to life situations. Structured, concrete materials have been profitably used to develop concepts and to clarify early number relations, place value, computation, fractions, decimals, measurement, geometry, money, percentage, number bases story problems, probability and statistics), and even algebra. Of course, different kinds of concrete materials are suited to different teaching purposes (see appendix for selected listing of materials and distributors). Materials do not teach by themselves; they work together with teacher guidance and student interactions, as well as with repeated demonstrations and explanations by both teachers and students.

Often students' confusion about the conventions of written math notation are sustained by the practice of using workbooks and ditto pages filled with problems to be solved. In these formats, students learn to act as problem answerers rather than demonstrators of math ideas. Students who show particular difficulty ordering math symbols in the conventional vertical, horizontal, and multi-step algorithms need much experience translating from one form to another. For example, teachers can provide answered addition problems with a double box next to each for translating these into the two related subtraction problems. Teachers can also dictate problems (with or without answers) for students to translate into pictorial form, then vertical notation, then horizontal notation. It can be helpful to structure pages with boxes for each of these different forms. Students also can work in pairs translating answered problems into two or more different ways to read them (e.g., 20 x 56 - 1120 can be read twenty times fifty- six equals one thousand, one hundred and twenty or twenty multiplied by fifty-six is one thousand, one hundred, twenty). Or, again in pairs, students can be provided with answered problems each on an individual card; they alternate in their demonstration, or proof, of each example using materials (e.g., bundled sticks for carrying problems). To add zest, some of the problems can be answered incorrectly and a goal can be to find the "bad eggs." Each of these suggestions is intended to move youngsters out of the rut of thinking of math as getting right answers or giving up. They help create a frame of mind that connects understanding with symbolic representation, while attaching the appropriate language variations.

The language of math

Some LD students are particularly hampered by the language aspects of math, resulting in confusion about terminology, difficulty following verbal explanations, and/or weak verbal skills for monitoring the steps of complex calculations. Teachers can help by slowing down the pace of their delivery, maintaining normal timing of phrases, and giving information in discrete segments. Such slowed down "chunking" of verbal information is important when asking questions, giving directions, presenting concepts, and offering explanations. Equally important is frequently asking students to verbalize what they are doing. Too often, math time is filled either with teacher explanation or with silent written practice. Students with language confusions need to demonstrate with concrete materials and explain what they are doing at all ages and all levels of math work, not just in the earliest grades. Having students regularly "play teacher" can be not only enjoyable but also necessary for learning the complexities of the language of math. Also, understanding for all children tends to be more complete when they are required to explain, elaborate, or defend their position to others; the burden of having to explain often acts as the extra push needed to connect and integrate their knowledge in crucial ways. Typically, children with language deficits react to math problems on the page as signals to do something, rather than as meaningful sentences that need to be read for understanding. It is almost as though they specifically avoid verbalizing. Both younger and older students need to develop the habit of reading or saying problems before and/or after computing them. By

attending to the simple steps of self-verbalizing, they can monitor more of their attentional slips and careless errors. Therefore, teachers should encourage these students to:

Stop after each answer, Read aloud the problem and the answer, and Listen to myself and ask, "Does that make sense?"

For youngsters with language weakness, this may take repeated teacher modeling, patient reminding and much practice using a cue card as a visual reminder.

Visual-spatial aspects of math

A small number of LD students have disturbances in visual-spatial-motor organization, which may result in weak or lacking understanding of concepts, very poor "number sense," specific difficulty with pictorial representations and/or poorly controlled handwriting and confused arrangements of numerals and signs on the page. Students with profoundly impaired conceptual understanding often have substantial perceptual-motor deficits and are presumed to have right hemisphere dysfunction. This small subgroup may well require a very heavy emphasis on precise and clear verbal descriptions. They seem to benefit from substituting verbal constructions for the intuitive/spatial/relational understanding they lack. Pictorial examples or diagrammatic explanations can thoroughly confuse them, so these should not be used when trying to teach or clarify concepts. In fact, this subgroup is specifically in need of remediation in the area of picture interpretation, diagram and graph reading, and nonverbal social cues. To develop an understanding of math concepts, it may be useful to make repeated use of concrete teaching materials (e.g., Stern blocks, Cuisenaire rods), with conscientious attention to developing stable verbal renditions of each quantity (e.g., 5), relationship (e.g., 5 is less than 7), and action (e.g., 5+2=7). Since understanding visual relationships and organization is difficult for these students, it is important to anchor verbal constructions in repeated experiences with structured materials that can be felt, seen, and moved around as they are talked about. For example, they may be better able to learn to identify triangles by holding a triangular block and saying to themselves, "A triangle has three sides. When we draw it, it has three connected lines." For example, a college freshman who had this deficit could not "see" what a triangle was without saying this to herself when she looked at different figures or attempted to draw a triangle. The goal for these students is to construct a strong verbal model for quantities and their relationships in place of the visual-spatial mental representation that most people develop. Consistent descriptive verbalizations also need to become firmly established in regard to when to apply math procedures and how to carry out the steps of written computation. Great patience and verbal repetition are required to make small incremental steps. It is important to recognize that average, bright, and even very bright youngsters can have the severe visual-spatial organization deficits that make developing simple math concepts extremely difficult. When such deficits are accompanied by strong verbal skills, there is a tendency to disbelieve the impaired area of functioning. Thus, parents and teachers can spend years growling,

"She's just not tryingShe doesn't play attentionShe must have a math phobiaIt's probably an emotional problem." Because other accompanying weaknesses usually include a poor sense of body in space, difficulty reading the nonverbal social signals of gesture and face, and often nightmarish disorganization in the world of "things," it can be easy to mistake the problem for a constellation of emotional symptoms. Misreading the problems in this way delays the appropriate work that is needed both in mathematics and the other areas.

In summary
Math learning difficulties are common, significant, and worthy of serious instructional attention in both regular and special education classes. Students may respond to repeated failure with withdrawal of effort, lowered self-esteem, and avoidance behaviors. In addition, significant math deficits can have serious consequences on the management of everyday life as well as on job prospects and promotion. Math learning problems range from mild to severe and manifest themselves in a variety of ways. Most common are difficulties with efficient recall of basic arithmetic facts and reliability in written computation. When these problems are accompanied by a strong conceptual grasp of mathematical and spatial relations, it is important not to bog the student down by focusing only on remediating computation. While important to work on, such efforts should not deny a full math education to otherwise capable students. Language disabilities, even subtle ones, can interfere with math learning. In particular, many LD students have a tendency to avoid verbalizing in math activities, a tendency often exacerbated by the way math is typically taught in America. Developing their habits of verbalizing math examples and procedures can greatly help in removing obstacles to success in mainstream math settings. Many children experience difficulty bridging informal math knowledge to formal school math. To build these connections takes time, experiences, and carefully guided instruction. The use of structured, concrete materials is important to securing these links, not only in the early elementary grades, but also during concept development stages of higher-level math. Some students need particular emphasis on the translating between different written forms, different ways of reading these, and various representations (with objects or drawings) of what they mean. An extremely handicapping, though less common math disability, derives from significant visual-spatial-motor disorganization. The formation of foundation math concepts is impaired in this small subgroup of students. Methods to compensate include avoiding the use of pictures or graphics for conveying concepts, constructing verbal versions of math ideas, and using concrete materials as anchors. The organizational and social problems that accompany this math disability are also in need of long-term appropriate remedial attention in order to support successful life adjustment in adulthood. In sum, as special educators, there is much we can and need to do in this area that calls for so much greater attention than we have typically provided.

About the author

Dr. Garnett received her doctorate from Teachers College, Columbia University. Over the last 18 years Dr. Garnett has been on the faculty of the Department of Special Education, Hunter College, CUNY where she directs the masters program in Learning Disorders. She is currently with The Edison Project, where she is the architect of their Responsible Inclusion/Special Edison Support. References Garnett, Ph.D., Kate. "Math Learning Disabilities." Division for Learning Disabilities Journal of CEC (1998).

Handwriting Club: Using Sensory Integration Strategies to Improve Handwriting

By: Melissa Keller (2001) Handwriting was a subject that I didn't believe I had time to teach. As a teacher of students with behavior disorders and learning disabilities, I felt more responsible for teaching the basic skills. I did not have time to "do" handwriting. Then last year another teacher in my building told me about the Handwriting Club she had conducted at a school where she previously taught. The club met for a few weeks with the teacher and the occupational therapist (OT) and incorporated sensory activities with handwriting instruction. I was interested because I had begun working on some sensory integration activities using the How Does Your Engine Run? program with my students with behavior disorders. Handwriting Club sounded like a great way to combine sensory integration and handwriting. In Sensory Integration and the Child, A. Jean Ayres, PhD, OTR, FAOTA, wrote, Sensory integration is the organization of sensation for use. Our senses give us information about the physical conditions around us. Sensations flow into the brain like streams flowing into a lake. Countless bits of sensory information enter our brain at every moment, not only from our eyes and ears, but also from every place in our bodies. The brain must organize all of these sensations if a person is to move and learn and behave normally. The brain locates, sorts, and orders sensations somewhat as a traffic policeman directs moving cars. When sensations flow in a well-organized or integrated manner, the brain can use those sensations to form perceptions, behaviors, and learning. When the flow of sensations is disorganized, life can be like a rush-hour traffic jam.

The seven sensory systems that deliver this flow of information are:
1. 2. 3. 4. 5. 6. 7. tactile vestibular proprioceptive olfactory visual auditory, and gustatory

Ayres described the sensory inputs and end products in her chart entitled, "The Senses, Integration of Their Inputs, and Their End Products." The integration of the auditory and vestibular senses results in speech and language. The integration of vestibular and proprioceptive senses results in eye movements, posture, balance, muscle tone, and gravitational security. Body perception, coordination of two sides of the body, motor planning, activity level, attention span, and emotional stability result from the integration of vestibular, proprioceptive, and tactile senses. The vestibular, proprioceptive, tactile, and visual senses result in eye-hand coordination, visual perception, and purposeful activity. All of the senses together are required for the end products concentration, organization, self-esteem, self-control, self-confidence, academic learning, abstract thought and reasoning, and specialization of each side of the body and the brain (Ayres, 1979). Handwriting is a very complex skill that requires many of these systems to work well together. Dobbie and Askov described the processes necessary for handwriting:

visual, auditory, and visuomotor perception; gross and fine motor coordination; directionality; sequencing skills; recall; letter knowledge; tool hold; lines; sitting and paper position; cursive script; tracing and copying; joining letters; self-evaluation; and numerals.

Our district OT found that students with difficulties in sensory processing, sensory awareness, and/or perceptual skills usually have handwriting problems. For example, a student with proprioceptive problems may hold the pencil too tight and push too hard while writing. Our premise for the Handwriting Club was that combining sensory activities with direct instruction in handwriting would be an effective way to address both areas.

Handwriting club format

The students we chose for the Handwriting Club were all third- and fourth-grade boys who had handwriting and social skill deficits. They had special education labels of learning disabilities, other health impaired (Attention Deficit/Hyperactivity Disorder), or behavior disordered. Our goals were to

improve students' cursive handwriting skills, improve their abilities to work with peers in a somewhat loosely structured and stimulating situation, and help teach them to identify some of their own individual sensory needs and strategies in order to address those needs.

Most club meetings followed the same basic format. We designed Handwriting Club activities to address all seven of the sensory areas, but we didn't have the students engage in every activity at every club meeting. Our first club meeting was an informational one to tell the students about the club and our goals. Because these were all students who hated writing, they were not enthusiastic about a club just for writing. We made participation voluntary, however, and described the club so that it sounded somewhat like a privilege. The students were responsible for designing the club rules, which they wrote and we saved as a preintervention writing sample. We also made a chart of the rules to post at each meeting. The biggest selling point for the boys was choosing a name for the club and designing a logo for the T-shirts they would get after they had proven themselves to be serious Handwriting Club members. All of our candidates agreed to join the club. They voted to call themselves "The Pythons" and agreed on the logo for their shirts. We met twice a week from October through early May. Each club meeting usually lasted 30 minutes, which really wasn't quite long enough. Forty-five minutes would have been ideal. We started each meeting with some gross motor activities, such as jumping jacks, yoga poses, or chair push-ups, to warm up. Next, the students did fine motor warm-ups, like squeezing a foam ball or shaping clay, before one of the teachers introduced the letter to be taught. We used the "Handwriting Without Tears" system as recommended by our OT. It uses only two writing lines, which is visually less complicated for students. This is helpful for students with figure-ground deficits. It also uses a vertical (not slanted) writing style for cursive handwriting. Some research has supported that using the vertical style aids significantly in the legibility of students' handwriting. The students then participated in a variety of guided practice activities before finally writing in the actual handwriting book. They were relieved to discover that the Handwriting Club consisted of 20 to 25 minutes of "other" activities and only about 5 to 10 minutes of real paper and pencil work. The final stage of the club meeting entailed independent practice or homework (see Figure 1).

Typical Club Session Format and Sample Activities 1. Gross Motor Warm-up Activities (5 minutes) o Do jumping jacks o Do crab walk o Perform push ups on floor o Chair push-ups 1. Seated student places hands on either side of chair next to thighs. 2. Straightens arms and lifts bottom off the chair o Balance on one leg with eyes closed o Walk toe-to-heel on a masking tape line on the floor 2. Fine Motor Warm-up Activities (5-10 minutes) o Rub hands together o Squeeze tennis balls o Rub hands in circles on the carpet o Play with Wikki Stix o Build with small Lego blocks o String small beads o Roll clay between fingers o "Walk" fingers up and down the pencil 3. Letter Introduction (2-3 minutes) 1. The teacher models writing the letter on the board and describes the steps. 2. The students imitate by writing in the air using large arm movements and repeating steps aloud. 3. The students then continue to say the steps while writing on the table with pointer finger. 4. Guided Practice Activities (10 minutes) o Write on board (white or chalk) while wearing wrist weights. o Write on another student's back and have him or her guess the letter. o Write with: Color change markers Scented markers Magna Doodle Battery-operated pens Paint Chalk on sidewalk Finger paint Pudding Shaving cream o Write in: Clay tray Salt, rice, or sand tray 5. Semi-independent Practice (5-10 minutes) o Students write in their handwriting books with teachers monitoring 6. Independent Practice Homework 7. Additional Activities o Writing for a purpose (i.e., make holiday cards or write thank-you notes)

Figure 1. Typical handwriting club activities. Choose 2 to 3 activities from 1, 2, and 4; complete all steps from 3, 5, and 6.

Social skills
Social skills were addressed as the situations demanded. The guided practice activities were set up as "stations," which required students to rotate through and take turns. One adult was at each station to provide assistance. Some equipment was highly desired, such as the Wiggle Pen (a battery-operated pen that rapidly vibrates when activated). Students had to learn to delay access to it and also to not keep using it longer than appropriate. Students had to be able to use exciting materials, like shaving cream, without getting out of control (students squirt it on their desk areas, smooth it out, and use their index fingers to practice forming letters). They also had to learn to participate in activities that they didn't want to do at times (some of them didn't like the gross motor activities). They needed to be able to ask appropriately for what they wanted or needed from teachers and peers. (Several of the students had typically acted out under such circumstances in the past.) One rule was that only students who could follow directions were able to be Handwriting Club participants. Noncompliant students were sent to the other resource classroom. This was not a punitive action. These particular students were always asked to leave with great empathy from the adults because we genuinely realized (and let the student know) that the demands of the Handwriting Club at that time were "too much" for the student and that he would probably get in trouble if he stayed in the room during the activities. Students were encouraged to return as soon as they had regained control of themselves. T-shirts were not given out until we had several successful (in which no one had to leave the room) club meetings. That was motivating for the boys; we told them that the shirts were only for the very serious handwriters and that we had to make sure that no one was going to drop out before we awarded T-shirts to the group.

Handwriting strategies physical strategies

It is important for students to learn correct posture when writing. Chair height should be adjusted to fit the desk or table height. The table or desk should be at the student's chest level, and elbows should be able to rest comfortably on top. The student needs to have his or her back against the back of the chair and feet on the floor. Knees, hips, and ankles should be at a 90-degree angle. Some chair legs were fitted with tennis balls (make a 3-inch slice in the ball and squeeze to slide over chair leg) on catty-corner legs to allow the chairs to rock slightly. Padded seats were placed on some chairs. Occasionally students were allowed to take turns sitting on a large therapy ball instead of a chair. These strategies address the theory that rocking and swaying are calming activities. A slant board was also available for students who chose to use it.

External stimulants

Relaxation music was sometimes played in the background to help integrate the auditory system, and self-talk during writing practice was also used as an auditory system strategy. Dobbie and Askov (1995) found that students trained with perceptual prompts and verbalization of stroke sequence perform better than students who simply copy models. Using scented markers while practicing may help students to remember the letter formation because the olfactory system has neuronal connections to the memory system. The students especially enjoyed the gustatory system activities. We provided hard candy, gum, Twizzlers, and straws to have students assess if keeping their mouths busy helped concentration. Tear Jerkers, Pop Rocks, and Warheads were used to provide extremes in oral sensations. Kranowitz (1998) recommended chewing and sucking activities as calming or organizational sensory activities. Equipment that helps with proprioception are wrist weights, Wiggle Pens, and a weighted pencil holder. Some students needed help with their tripod grasp. Pencils were marked with dots to indicate where the fingers should be placed, or sometimes commercial pencil grippers were used. Balancing exercises were used to integrate the vestibular system. Most other activities used were designed for integration of the visual and tactile sensory systems (see Figure 1). Some students found that using Right Line paper, which has raised green lines, was helpful. It is ideal for helping students stay within the lines because it provides both visual and tactile cues.

Conclusion
I now realize that handwriting is a more important skill than I had previously believed. Our students' inability to communicate legibly puts them at a disadvantage in several ways. Unreadable academic assignments, even though they may be accurate, often result in poorer grades due to negative teacher bias. Employers are also biased against job applications that are messy and illegible. Finally, personal handwritten correspondence will be a struggle for these students. 1 found that it is not realistic and productive to take the time to teach this skill directly. Research has not been clear in supporting sensory integration. The activities are hypothesized to work through influencing brain organization and, consequently, result in brain change. Brain change is not directly observable, so it is difficult to conclude that a sensory activity has changed the brain simply because a child performed the activity. Instead, it could perhaps be inferred that a change has occurred if a directly observable change has occurred in the child's performance. We are certainly unable to conclude that we made significant brain changes in these students; however, there were obvious differences in performance that may have resulted at least in part from the sensory integration activities. The Handwriting Club met the goals that we set. The students did improve their cursive writing skills, social skills were practiced and improved upon at each club meeting, and the students learned which sensory activities seemed to help them focus and self-regulate themselves. Additionally, because of their success, they felt more confident in their handwriting abilities. Melissa Keller, MS, is a behavior specialist for the Gardner Edgerton school district in Gardner, Kansas. She earned her MS from the University of Kansas and has begun work in the special education doctoral program. She wants to give special thanks to her Handwriting Club co-teacher

Anna Friend, who first thought of the idea, and also to occupational therapist Lisa Mayer for her assistance. References Melissa Keller Intervention in School and Clinic, Vol. 37, No. 1, September 2001 (pp. 9-12)