Hand Over Hand Prompting

Have you been hearing the talk lately about hand over hand prompting? Have you heard discussions surrounding this type of physical prompting and how it violates bodily autonomy and is not neurodiversity-affirming? I'm thrilled to share a thought-provoking discussion with Diamond Rashad, a passionate pediatric occupational therapist based in Georgia. Diamond's unique perspective stems from her own neurodivergent experiences and her dedication to fostering a supportive and understanding environment for her clients. Let's dive into her views on hand-over-hand prompting and why it’s crucial to reconsider this common practice.

Diamond Rashad, also known as A Dime of OT on Instagram, has been a pediatric occupational therapist for eight years. Her commitment to working with children feels like a full-circle moment as she navigates her own neurodivergence within a neurodiverse family. Beyond her professional life, Diamond cherishes her role as a full-time auntie and enjoys reading, especially thrillers and happy-ending romances, and spending time at the beach.

The Evolution of Hand Over Hand Prompting

Tara: I'm so excited to talk to you Diamond about hand over hand prompting and I saw you talking about it in a recent summit you presented at. I also noticed something posted that said people are learning and unlearning and it's helpful to have strategies in your toolbox. I love this so much, especially when it comes to something like hand over hand prompting with autistic children. Why is this something we need to unlearn?

Diamond: That’s a great question. We are all lifelong learners, and our understanding of best practices evolves over time. Hand over hand prompting, which I initially learned in school and through supervised practice, often focuses on compliance rather than connection. This method can violate a child's body autonomy, disregarding their right to control their own body and make choices.

Tara: Unlearning is really important, especially when we hear from people, autistic adults, and neurodivergent adults who are saying this was not the best way. I think we're starting to hear that more and more and we need to listen.

Diamond: A key part is listening to the client's needs and preferences and this is one of those needs. Hand over hand is placing your hand on top of a child's hand and guiding them or forcing them to engage with an object. So if you're trying to get them started with a puzzle, you're moving their hand on top of the puzzle piece, making them pick it up and put it where you want it to go, or doing half of the activity to get them started.

Tara: Thank you for defining that. We can all think of students or children who do not respond well to this kind of touch and pull away or become dysregulated. So what could we do instead of hand over hand prompting?

Practical Applications and Sensory Considerations

Diamond: There are several approaches. One is adjusting the environment or the task itself. For instance, if a child is sensitive to touch, you might use objects with extra texture or weight to provide the necessary sensory input without physical prompting. Understanding whether a child is overstimulated or understimulated can also guide you to modify activities accordingly. For instance, breaking tasks into smaller steps or incorporating movement can help regulate a child’s sensory needs.

If a child is having a hard time with sitting at the table and engaging in an activity, we can consider if they are regulated enough for this task. Are they overstimulated or are they understimulated? If they are overstimulated then I might lower the lights and use some natural lighting. Changing the sitting positioning to make it easier for them. I might break down the task so that they can get some movement in. They might need to jump on the trampoline or get some kind of sensory input before they engage with the task or combine the two together.

Underhand is a great tool that you can use also. Have their hand on top of yours so that they are in control of their bodies and they're in control of what action their body takes. Then they still get help from you on how to engage with the activity. Many kids are visual learners and the activity is visually not engaging or it's confusing. They don't know when to start, they don't know when to end, they're not sure how to navigate the activity.

Tara: Diamond, I loved all of those ideas that you gave.

Diamond: The strategies that are out there help us with starting the task and realizing that we can modify the environment instead of trying to modify the child. We have a model called person, environment, occupation. Occupation would be the task. What we want to focus on is how can we set up the environment and the task so that it is easier for the child to achieve it.

Consider a scenario where a child needs help with a puzzle. Instead of guiding their hand, you could provide a heavier puzzle piece. That would give sensory feedback. You could also place the pieces in a sensory bin to make the activity more engaging. Ensuring the child is regulated enough to engage in the task is crucial—sometimes, changing the setting or combining activities with physical movement can make a significant difference.

It's our job to build our toolkit so we can recognize where the barrier might be and what strategies might be a good fit for this child. How can I break down this task a little bit more so that it makes sense to them? If a child comes into a classroom and doesn't put their backpack away, instead of grabbing their hand and making them hold onto the handle and walking them over, think of what steps in the task do they not have the skills for yet.

Tara: That got me thinking that if you're doing hand over hand, making a child do something, it might be a clue that the activity is not at the right level for them yet. They could do a piece of it, like you're saying, break it down. They probably don't recognize the spot where their backpack is supposed to go. So could we start with a big bucket with a picture of their favorite character on it and show them to just plop it in there. They might not have the fine motor yet to get the loop over the hook and having a bucket gets them closer to that.

Diamond: That's exactly what I mean. And then once they've mastered that, you can even put the bucket inside their cubby. You know, you can break it down and work up to it.

Tara: I think sometimes people think, well I have to do hand over hand because they aren't doing this. I just love that idea of breaking it down into smaller pieces because that wouldn't require any hand over hand. You can start the bucket by the door wherever they usually drop it and make it closer to their cubby until it's in their cubby area.

The other thing I found for some kids is having the task or activity broken down into a visual schedule or visual sequence. Having visuals to break down the steps to washing hands might spur them to get going with it versus you taking their hand and putting it in the water.

Diamond: Yes, having a visual schedule that tells the order of things is a great idea!

Balancing Safety and Autonomy

Tara: How do you address safety concerns without compromising a child's autonomy?

Diamond: Safety is paramount. In situations where immediate action is required, such as preventing a child from running into the street, it is appropriate to use hand over hand. However, for learning tasks, modifying the environment and using tools like loop scissors can teach skills safely while respecting autonomy.

Multimodal communication is key. Even non-speaking children can express consent through actions like placing their hand in yours. It’s also vital to provide visual schedules and cues, breaking down tasks into manageable steps. Using visual supports, such as pictures or videos of familiar routines, can help children understand and engage with tasks without physical prompting.

Tara: Your insights are invaluable, Diamond. Breaking down tasks and considering a child's sensory needs can help avoid the need for hand over hand prompting and promote autonomy and engagement. Thank you for sharing your expertise with us.

Diamond: Thank you, Tara. It's been a pleasure discussing these important topics. Empowering children and respecting their autonomy are at the heart of effective therapy.

To connect with Diamond Rashad you can find her here:

Website: www.adimeinot.com

Instagram: www.instagram.com/adimeofot

You can watch the interview here:

Or if you prefer to listen to the podcast, click here

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At Home Hands On Activities for Parents of Young Children

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If you use visual supports in your classroom or home, you are going to want to sign up for this free Visual Supports Starter Set ASAP! Click here to have one sent to your inbox. Also, be sure to read more about visual supports and how they can help autistic children here.