Charlotte OT Blog

In-hand skills typically emerge after 2 years of age, with the greatest number emerging between 2 and 2 ½ years of age. Simple in- hand skills are mastered by age 3.

• Translation
  • Finger to palm
  • Palm to finger
  • Manipulating a coin
• Shift
  • Occurs at finger tips, usually for fine adjustments
  • Moving pencil in fingers
• Rotation
  • Simple – turning a knob <180
  • Complex – turning an object >180 to 360

Sensory Processing is the method the nervous system uses to receive, organize, and understand sensory input.  It enables a person to respond to environmental demands based on the sensory information that is available. 

• Tactile, proprioceptive, kinesthetic
• Visual – receptive
• Visual cognitive
  • Form constancy
  • Visual discrimination
  • Position in space
• Vestibular

Neuromuscular capabilities must also be used.

• Muscle tone
• Strength
• Postural control
• Crossing midline
• Bilateral integration
• Laterality
• Praxis

Information adapted from Case-Smith (2004) textbook & Beery 1992

Occupational therapists look at how deficits in handwriting affect a child’s daily performance at home and school. The OT looks at 3 things:

1. the actual tasks of handwriting                                
2. school context                                             
3. the student’s abilities                                         

Handwriting development can be affected by many things including in-hand manipulation skills, sensory processing, neuromuscular control and cognition/understanding of handwriting concepts. There are 5 important prerequisite skills needed for handwriting and they include:

1. small muscle control
2. eye hand coordination
3. the ability to hold writing tools
4. the ability to form basic strokes (vertical, horizontal, diagonal lines and basic shapes)
5. letter perception (recognizing forms, different letters and being able to copy geometric forms

Pre-writing and handwriting

• Scribbles                                                                                                                          10-12mths
• Imitates hori./vert/cir. scribbles                                                                                      2 yrs  
• Copies hori./vert./ and circle                                                                                             3 yrs
• Copies cross, slanted lines, square, some letters & #s, own name (maybe)     4-5yrs
• Copies triangle, prints own name, most upper and lowercase letters                  5-6yrs      

Information adapted from Case-Smith (2004) textbook & Beery 1992

Developmental Checklist for the 1^st Year of Life: 11-12 months: Activities to Promote Skill Acquisition

Motor Skills:

• Give them objects to use in pull to stand
• Age appropriate utensils for self-feeding
• Small objects to refine pincer grasp
• Creeping/climbing around objects

Visual Skills:

• Most toys are appropriate at this age
• Continue to provide a variety of toys for exploration

Cognitive Skills:

• Playing with building blocks
• Simple puzzles (shapes)
• Simple direction activities
• Peek-a-boo

Developmental Checklist for the 1^st Year of Life: 11-12 months Expected Skills

***(Refer to “Developmental Reflexes in 1^st Year of Life” blogs for reflex descriptions)

Motor Skills:

• Walks while holding onto furniture
• Good pincer grasp (thumb and index finger)
• Stands up alone
• Climbs stairs
• Feeds with a spoon
• Pushes to stand from squat
• May start to take clothes off
• Squatting while standing
• Hands can perform dissociated tasks

Visual Skills:

• Vision is developed, refinement occurring during this time
• Refining visual acuity and depth perception
• Better at judging distances and more accurate at grasping/throwing objects
• Coordination vision with body movements
• Can reach for object while looking elsewhere

Cognitive Skills:

• Reasoning and speech developing
• Memory development
• Following simple directions
• Imitate word sounds and actions
• Reacts to “No”
• Protests
• Trial and error problem solving
• Cause and effect comes into thought process

As an Occupational Therapist at Child and Family Development, I regularly assess and treat a child's fine motor abilities, including pre-handwriting and handwriting skills.  This information is a useful summary of development.   

Developmental Sequence of 10 different grasps (according to Schneck and Henderson, 1990). Below is a range of grasps that may be demonstrated over time. Not all will be seen. By ages 5-6 you expect to see a hand dominance and want your child to be using a grasp similar to numbers 7-10, number 10 being the most wanted.

1. Radial cross palmar grasp: pencil positioned across palm projecting radially, held with fisted hand, forearm fully pronated, full arm movement

2. Palmar supinate grasp: pencil positioned across palm projecting ulnarly, held with fisted hand, wrist slightly flexed and supinated away from midposition, full arm movement

3. Digital pronate grasp, only index finger extended: pencil held in palmar grasp with index finger extended along pencil toward tip, arm not supported on table, full arm movement  

4. Brush grasp: pencil held with fingers with eraser end of pencil positioned against palm, hand pronated with wrist movement present, whole arm movement, forearm positioned in air

5. Grasp with extended fingers: pencil held with fingers, wrist straight and pronated with slight ulnar deviation, forearm moves as a unit 

6. Cross thumb grasp: fingers fisted loosely into palm, pencil help against index finger with thumb crossed over pencil toward index finger, finger and wrist movement, forearm positioned on table 

7. Static tripod grasp: pencils stabilized against radial side of third digit by thumb pulp with index pulp on top of shaft, thumb stabilized in full opposition, wrist slightly extended and hand moves as a unit, pencil rests in open webspace, forearm resting on table

8. Four finger grasp: pencil held with four fingers in opposition, wrist and finger movement, forearm positioned on table

9. Lateral tripod grasp: pencil stabilized against radial side of third digit with index pulp on top of shaft of pencil, thumb adducted and braced over or under anywhere along the lateral border of index finger, wrist slightly extended, fourth and fifth digits flexed to stabilize metacarpophalangeal arch and third digit, localized movement of digits of tripod and wrist movements on tall and horizontal strokes, forearm resting on table 

10. Dynamic tripod grasp: pencil stabilized against radial side of third digit by thumb pulp with index pulp on top of shaft of pencil, thumb stabilized in full opposition, wrist slightly extended, fourth and fifth digits flexed to stabilize the metacarpophalangeal arch and third digit, localized movement of digits of tripod and wrist movements on tall and horizontal strokes, forearm resting on table

Examples of Inefficient Pencil Grips:

Developmental Checklist for the 1^st Year of Life: 9-10 months: Activities to Promote Skill Acquisition

Motor Skills:

• Playing with cheerios and small pieces of food to work on inferior pincer grasp
• Obstacle courses in creeping path (work on moving through and around objects as well as problem solving)
• Toys with buttons and dials
• Push toys with wheels

Visual Skills:

• Most toys appropriate at this age to continue refining visual skills

Cognitive Skills:

• Singing songs and repeating phrases
• Playing hide and seek
• Playing with a variety of toys, looking at books and pictures

Developmental Checklist for the 1^st Year of Life: 9-10 months Expected Skills

***(Refer to “Developmental Reflexes in 1^st Year of Life” blogs for reflex descriptions)

Motor Skills:

• Great creeping skills, can turn while creeping (primary mode of locomotion)
• Can play in sitting with tilting forward and backward
• Pulls to standing with arms
• Climbs onto furniture & up stairs (but can’t get down)
• Cruises around furniture
• Supported walking, walking with 2 hands held at 9 months, with 1 hand held at 10 months
• Can lean over without falling
• Starts picking up small objects with thumb and index finger (inferior pincer grasp)
• More control in releasing objects from hands/grasp
• Drinks from a cup
• Points with 1 finger
• Clasps hands together

Visual Skills:

• Refining visual skills

Cognitive Skills:

• Attentive to objects, pictures in books, repetitive words
• Initiates new gestures and actions
• Understanding “no”
• Testing responses to behavior
• Object permanence (aware object is there although can not see or hear it)
• Space awareness
• Recognizing parents and calling for them (mama, dada)

Developmental Checklist for the 1^st Year of Life: 7-8 months: Activities to Promote Skill Acquisition

Motor Skills:

• To promote appropriate hand grasps provide building blocks, large puzzles, finger paints, cheerios, beads, buttons, zippers
• Place toy just out of reach to promote trunk rotation and reaching
• “Dancing” with baby helps promote leg function, strength, and coordination along with dissociation
• “Animal walking” helps promote body strength, posture and coordination
• Tall toys that can be pushed when walking to give support

Visual Skills:

• Play with baby in ways that use both eyes and both sides of their body
• Read books with large brightly colored pictures.
• Since vision is complete at this age, most toys are appropriate to continue refining vision

Cognitive Skills:

• Play peek-a-boo
• Creating obstacle course for them to crawl around (promote thinking and problem solving)
• Toys that make noise after specific actions to increase cause and effect and problem solving
• Reading books with details
• Pointing to parts of baby’s body and naming them (increasing awareness)

Developmental Checklist for the 1^st Year of Life: 7-8 months Expected Skills

***(Refer to “Developmental Reflexes in 1^st Year of Life” blogs for reflex descriptions)

Motor Skills:

• Begins some hand to hand transfer of objects/toys
• Active and controlled rolling from back to tummy
• Can sit independently with extended back and reach for objects
• Rocks in quadruped position (position on all fours like about to crawl)
• Creeping
• Kneeling and half-kneeling
• Sits in different positions
• Side to side cruising
• 3-jaw chuck grasp (thumb, index and middle fingers)

Visual Skills:

• In sitting position will look at hands, food, bottle
• Looks at and watches more distant objects
• Turns eyes inward while investigating hands or toys
• Eyes move with little head movements
• Looks at activities for longer period of time
• Begins to look for toys dropped in front of them
• Enjoys more complex designs and can distinguish colors
• Vision more complete at this age

Cognitive Skills:

• Object permanence good (understands objects are there even if they can’t see or hear them)
• Begins to think and problem solve
• Recognizes faces and objects
• Understands expressions
• Associates baby pictures with themselves
• Understand cause and effect
• Learn how things work by imitating what parent does
• Associates sound with pictures

Below is a chart summary of protective extension reflexes that begin to develop at in the 2nd half of the first year of life. These reflexes remain with the child after they have been fully integrated.  It describes what to do to elicit the reflex and what you should see your child do in response.

Protective Extension Reflexes

Developmental Checklist for the 1^st Year of Life: 5-6 months: Activities to Promote Skill Acquisition

Motor Skills:

• Teething rings
• Stackable toys
• Toys with buttons to push
• Plush toys
• Rattles
• Toys to crawl with

Visual Skills:

• Mirror
• Toys with lights and sounds
• Rattles
• Colorful toys- high contrast and bright colors

Cognitive Skills:

• Different shapes and textures of objects
• Blocks
• Beads
• Stackable rings
• Music
• Action/reaction toys & cause and effect toys (toys that respond to actions with fun rewards such as lights, sounds, music, etc)
• Peek-a-boo games

Developmental Checklist for the 1^st Year of Life: 5-6 months Expected Skills

***(Refer to “Developmental Reflexes in 1^st Year of Life” blogs for reflex descriptions)

Motor Skills:

• Rolls from lying on back to tummy (purposeful)
• Brings foot to mouth
• Props forward on hands while sitting
• Voluntary release of objects Head control established
• Trunk rotation
• First self-care skills- feeding self with bottle
• Quadruped at end of 6 months (propping on all fours like about to crawl)
• Radial palmar grasp & raking reach grasp (swiping to reach)
• Pivoting while lying on tummy
• Protective Extension forward present
• Symmetrical Tonic Neck Reflex

Visual Skills:

• Dissociation of head and eyes (eyes move independently from head)
• Can fixate eyes on object while another object is moving
• 20/20 vision by 6 months
• Able to release focus and relocate a target
• Increased eye-hand coordination
• Drawn to mirrors
• Tracking and localization in visual fields

Cognitive Skills:

• Object permanence beginning (ability to know that a toy is still there once removed from its visual field)
• Stereognosis (ability to determine objects by shape, size, weight)
• Seek stimulation on their own
• Explore by touching, shaking, and tasting objects
• Understand speech by tone of voice
• Imitate facial expressions
• Knows own name
• Recognizes face and own reflection

Below is a chart summary of righting reflexes that begin to develop at birth or after birth and take a couple of months to fully integrate. It describes what to do to elicit the reflex and what you should see your child do in response.

Developmental Checklist for the 1^st Year of Life: 3-4 months: Activities to Promote Skill Acquisition

Motor Skills:

• “Tummy time”- helps child bear weight and strengthen shoulder muscles
• Help sit with support
• Encourage rolling from lying on back to tummy
• Put toys to side to encourage reaching and sidelying
• Promote frog leg sitting (squatting on feet) to desensitize feet

Visual Skills:

• Mobiles over cribs
• Rattles
• Shiny or light reflective toys
• Colorful socks
• Practice tracking objects 180 degrees across midline
• Hold objects at different distances

Cognitive Skills:

• Sidelying position helps with dissociation
• Playing with toys that provide sensory feedback (i.e. rattles, chimes, music); hanging a mirror to look at
• Cause and effect games
• Exposure to objects of different sizes and textures
• Facial expressions
• Communication (talking, singing, reading books)
• Establish a routine (i.e. feeding, bathing, bedtime)

Developmental Checklist for the 1^st Year of Life: 3-4 months Expected Skills

***(Refer to “Developmental Reflexes in 1^st Year of Life” blogs for reflex descriptions)

Motor Skills:

• Brings hands to midline
• Raises head and chest while lying on tummy
• Starts voluntary movements, voluntary grasp
• Rolls from side to side (mostly accidental)
• Lies in sidelying position (on side)
• Reach and try to hold objects
• Can lay on tummy supporting self with elbows
• Raises head 90 degrees
• Maintains standing when hands are held

Visual Skills:

• Eyelid reflexes are integrated- to protect eyes
• Can track 180 degrees
• Can fixate on stationary target
• Can dissociate head and eye movements during tracking (eyes beginning to move independently from head)
• Downward gaze (allows to explore body with eyes)
• Can sustain midline convergence (bringing eyes to middle)

Cognitive Skills:

• Smile at reflection
• Show interest in sounds
• Learns from looking, holding, putting things in mouth
• Responds to familiar faces
• Purposeful, coordinated movements
• Dissociates right and left sides of body
• Integrates information from multiple sensory systems
• Repeats actions for pleasurable experiences

Developmental Checklist for the 1^st Year of Life: 0-2 months: Activities to Promote Skill Acquisition

Motor Skills:

• Place finger in baby’s palm on pinky finger side (Palmar Grasp Reflex)
• “Tummy Time” and place in non-constricted positions for free movement
• Lay child on side with support to increase body awareness
• Move legs in bicycle motion to strengthen muscles
• Give baby something to reach for and hold onto (finger toys such as rattles); toys that make noise or squeak when pressed will help the baby become more aware of what his/her hand is doing

Visual Skills:

• Hold and carry in different positions to see surroundings
• Use high contrast/black and white mobiles and toys
• Patchwork blankets with different textures/colors
• Rolling a colored ball in front from side-to-side when baby is on tummy (to increase eye movement)
• Mirror for baby to look at reflection (unbreakable)

Cognitive Skills:

• Hold and hug infant, especially during feeding
• Massage hands, feet, back, stomach (can do while changing baby)
• Speak to and sing to baby often
• Make eye contact
• Make facial expressions, especially smiling
• Give baby pacifier, blanket or soft object that is special to help baby calm and quiet self (increase self-soothing skills)

Developmental Checklist for the 1^st Year of Life: 0-2 months Expected Skills

Motor Skills:

• Grasp without voluntary release
• Palmar grasp present
• Can bring hands to mouth
• Rooting and sucking response present in response to food stimulus
• At 1 month, holding thumb inside palm, at 2 months, thumb is outside palm
• Spontaneous stepping when leaned forward while standing
• Asymmetrical Tonic Neck Reflex @ 1 month (strongest at 2 months)
• Movements are synergistically coupled (movements combined to be performed)
• Prefers fetal position

Visual Skills:

• Decreased vision, sees objects best at 9-12 inches distance
• Sees black/white and high contrast color
• At 1 month, eyes can focus on a face and are able to track objects from side to midline; can track past midline at 2 months
• Binocular vision begins at 2 months

Cognitive Skills:

• Developing interest in facial gaze (usually at mother)
• Responds to sound of voice at 1 month
• Responds to touch at 1 month
• Makes sounds and smiles at 2 months
• Responds to stimuli around them at 2 months
• Crying is major form of expression; quiets when picked up

Below is a chart summary of reflexes that begin to develop at birth and take a couple of months to fully integrate. It describes what to do to elicit the reflex and what you should see your child do in response.

One of my recent blogs reviewed The Williams and Shellenberger Engine Program that describes 3 different engine speeds: High, Just Right and Low.

The Just Right engine speed is the goal. 

Below are some activities a child can do to change their engine speeds to the Just Right alertness level from either high or low levels. Some activities can be used for both but the intensity and amount may vary.

Going from High to Just Right:

• Heavy work- pushing, pulling, lifting, carrying heavy objects

• Providing deep pressure- steam rolling- rolling over child’s body with foam bolsters or therapy balls, “squishing” child’s body between with pillows, blankets, etc; bear hugs

• Wearing a weighted vest

• Calming music while doing activities

• Slow rhythmic swinging

• Dim lights, calm music

• Obstacle course including heavy work tasks, propelling self on scooter board, going through tunnels

• Eating crunchy and/or chewy foods

• Petting a soft animal

• Playing in a ball pit (providing child with deep pressure)

• Wheelbarrow walking

• Yoga

• Brushing

• Jumping on trampoline at a steady pace

Going from Low to Just Right:

• Animal walks- Examples:

• Slither on the ground like a snake

• Jump up and down like a kangaroo or rabbit

• Run in place as fast as you can like a cheetah

• Crouch down and jump up like a frog

• Flap arms like a bird

• Keep both arms down stiff at your sides and waddle like a penguin

• Walk like a crab

• Run like a bear

• Playing follow the leader game- have them jump up and down, walk backwards, spin in circles, hop on one foot, etc

• Clapping game:

• Clap your hands

• Then clap fast, faster, fastest

• Then clap slow, slower, slowest

• Then clap high, high and fast, high and slow

• Then clap low, low and fast, low and slow

• Obstacle course- slides, jumping, fast swinging

• Jumping on trampoline to fast music

• Red light/Green light game, Simon Says game, Hot potato game

• Variety of swings in fast motions, changing from back and forth, side to side, & circular

• Knocking/kicking down bolsters

• Crunchy foods

• Jumping jacks, running in place

The website, www.alertprogram.com, offers more information.