Why We Choose Hand-Under-Hand Instead of Hand-Over-Hand

Aug 10

By Jessica Jordan, MS. OTR/L

What Is Hand-Under-Hand?

Hand-under-hand, yes, you heard that right. It’s a small shift with a big impact. While many providers are taught to use hand-over-hand assistance, this gentle reframe is one we deeply believe in here at SUNRISE Therapies.

So, what exactly do we mean by hand under hand? It’s the act of placing your hand beneath the individual’s hand, instead of on top of it. This subtle but powerful difference gives the person more control, dignity, and choice over their own movement. The guiding hand becomes supportive, not directive.

Everyone deserves autonomy over their body. This absolutely includes neurodivergent individuals and other high-risk populations, including young children and older adults.

Encouraging Autonomy in Therapy

When a child or client isn’t moving in the way we expect, it doesn’t permit us to take control of their body, unless they’ve given consent in some form.

For example, one of the clients I’m working with is currently learning to cut. He asks me to practice with him by using the scissors together. That invitation matters. We move through the task as a team, and hand-under-hand allows him to feel the motion, not just be forced through it.

Letting Go of Compliance-Based Strategies

Sometimes the task we’re asking an individual to do simply isn’t lining up with what their body can manage in that moment. When that happens, it’s easy to assume that they are refusing or “not trying,” but that’s rarely what is actually happening.
More often, it’s a sign that the task is landing just outside their current capacity—too many steps, too much sensory load, too much demand on their motor system.

This should be a moment for reflection, not reaction. This is a critical time to take a step back, slow down, and notice what is working and what isn’t working. It’s a signal that something about the task, the environment, or the level of support needs adjusting.

Another common reason hand-over-hand techniques are used is when a child “isn’t participating.” But before jumping to that conclusion, we need to pause and ask: Is the task itself meaningful to them? Is it interesting? Does it align with what matters to them or just what we think should matter? Is their apraxia or a motor loop hindering their ability to participate?

Especially for non-speaking individuals or those with apraxia, there’s often a dangerous assumption that lack of outward participation equals lack of understanding. But let’s be clear, it doesn’t. In fact, many of the individuals we support are incredibly intelligent and deeply aware. They may simply not be motivated by what we’re offering, or their bodies are not responding to that specific level of motor coaching that we are providing. That’s something we, as professionals and caregivers, need to respect or change.

So instead of assuming disinterest or defiance, let’s ask:

How can I adapt this task to make it more motivating?
What strengths or passions can we tap into?
Am I honoring this person’s autonomy or just pushing for compliance?
Can I use another level of prompting (i.e., motor coaching) to best support this individual?

This is an opportunity to ask questions that lead to connection and build trust.

Prioritizing Autonomy in Practice

Using hand-under-hand allows us to prioritize a person’s agency. It supports their ability to participate, explore, and engage on their own terms. Autonomy is a core principle of our profession and part of the Occupational Therapy Practice Framework. It’s not just an idea, it’s a guiding value that shapes how we show up in every session.

We talk about this a lot in our online courses for parents, caregivers, and OTs of autistic individuals, especially those with apraxia or unreliable speech. You’ll learn how to support your child or loved one using respectful, regulation informed strategies that go far beyond what most OTs are taught in school.

We hope all practitioners and caregivers supporting the neurodivergent community will begin to incorporate more autonomy first principles into their care.

Helpful Links

If you found this post helpful, you’ll love our therapy resources! Whether you’re a parent or therapist, our apraxia and autism courses are here to offer practical tools, compassionate guidance, and real-world strategies you can use every day.

👨‍👩‍👧‍👦 For Parents & Caregivers: Autism Training | Online Course for Parents and Caregivers

🧑‍🏫 For Therapists: Therapist Course for Apraxia and Autism | Mentorship for OTs and Therapists

🏥 Work With Us: In-Person Occupational Therapy (San Diego & Long Beach Areas) | Virtual Coaching