Evaluation and Interventions to Develop Hand Skills

• Reach: extension and movement of the arm for grasping or placing objects

• Grasp: attainment of an object with the hand

• Carry: transportation of a hand-held object from one place to another

• Voluntary release: intentional letting go of a hand-held object at a specific time and place

• In-hand manipulation: adjustment of an object in the hand after grasp

• Bilateral hand use: use of two hands together to accomplish an activity

Visual Skills

Visual skills play a major role in the development of hand function.^10,77,142 Vision is particularly important for learning new motor skills. At about 4 months of age, infants begin to move their hands under visual control as they reach for an object and make differentiated finger movements. The visuomotor development required for accurate reach matures by approximately 6 months of age. The infant’s visual-motor coordination continues to refine, and by 9 months of age, the infant guides his or her hand movements using visual-somatosensory integration (i.e., these sensory inputs are combined and compared as the infant anticipates and plans movement). Vision is also important as the infant learns new fine motor skills or when an activity requires highly precise and accurate movements (e.g., stringing small beads or putting together a puzzle).

Somatosensory Functions

The relationship between somatosensory functions of the hands and hand skills is strong. Good hand skills are associated with intact somatosensory functioning; however, intact somatosensory functioning does not necessarily yield good hand skills. Huang, Gillespie, and Kuo found that adults with normal hand function had significant benefit from feedback that included both visual and haptic information to ensure consistency and rhythm while manipulating an object.⁷⁴

The role of somatosensory information and feedback is critical to development in many areas of children’s hand skills, particularly those involving isolated movements of the fingers and thumb. Typical infants develop the ability to match haptic perception (knowledge of objects gathered by means of active touch) of some three-dimensional objects with visual perception within the first 6 months of life. Bushnell and Boudreau reported that children as young as 2.5 years of age can identify common objects by touch alone and that children 5 years of age demonstrate good haptic recognition of unfamiliar objects.¹⁶ Many aspects of haptic perception, such as identification of three-dimensional common objects and perception of spatial orientation, are well developed by 6 years of age. The adolescent has fully developed the refinement of haptic perception and the ability to discriminate all aspects of object characteristics through touch.¹³²

The fingertips gather precise information about many types of object qualities. Children with impaired control of finger movement have limited access to somatosensory information, and/or the impaired control of finger movement may reflect their difficulties in perceiving and using sensory information. Initiating and sustaining grasp force requires tactile and proprioceptive input and integration.^60,64,78 The ability to hold objects in the hand (i.e., without dropping them) is related primarily to intact somatosensory functioning.⁶² Gordon and Duff also noted that tactile information is critical for anticipating the amount of force needed to grasp and lift an object.⁶⁴ Apparently a minimum amount of tactile awareness, as measured by two-point discrimination, is needed for functional development of these fine motor skills.

Somatosensory functioning is difficult to study in children, particularly in young children and those with disabilities. In testing, the performance of these children varies from one session to another, which further complicates the assessment process. Given that the link between somatosensory functioning and hand skills is a strong one, further investigation of the relationship between tactile functioning and various hand skills will support the development of new intervention approaches for these children.

Sensory Integration

The types of sensory integration problems most likely to influence hand use are sensory registration problems, tactile hypersensitivity, poor tactile discrimination, and dyspraxia. Children with poor sensory registration engage in few activities involving hand skills. The child with tactile hypersensitivity is likely to avoid contact with certain materials, thus limiting exposure to various objects. Motor-planning deficits and clumsiness are associated with poor tactile and proprioceptive functioning. Praxis problems based on poor tactile and proprioceptive processing are referred to as somatodyspraxia.⁴ Children with cerebral palsy can have sensory integration problems in addition to motor problems. Evidence of motor planning problems has been identified in children with cerebral palsy¹³⁰ as well as in children with other motor problems.

Visual Perception and Cognition

Perceptual development and cognitive development are difficult to isolate from each other, particularly as they relate to object-handling skills in children; for this reason, these areas are addressed together here. The development of hand skills allows for more complex interaction with objects, and perceptual and cognitive development allows the child to know the possibilities available for object use and interactions. Hand use and cognitive development seem to be particularly linked in infancy and very early childhood.³⁵

The child’s perception of object characteristics, movement speed required, and power needed affects his or her ability to effectively control objects.⁴⁴ The child acquires knowledge about objects through object manipulation. Early manual exploratory behavior plays an important role in the development of visual-spatial skills and learning about the environment.³⁴

During the first 6 months, the infant uses visual and tactile perception to guide fine motor development and begins to develop an awareness of object placement in space. In the second half of the first year, the infant adjusts the actions of the hand in response to object characteristics, such as size, shape, and surface qualities.²⁸ Ruff, McCarton, Kurtzber, and Vaughan emphasized the importance of object manipulation in infants between 6 and 12 months of age for learning object characteristics, because this learning was believed to be important for concept and language development.¹¹⁹ Infants demonstrate their perceptual and cognitive skills when reaching for objects. By 9 to 10 months of age, infants adapt their arm positions to horizontal versus vertical object presentations and shape their hands appropriately for convex and concave objects.

During the second year, infants learn to relate objects to one another with more accuracy and purpose. Before 18 months of age, infants modify their movement approach in anticipation of the weight of the object.^16,28

Rao discussed the interaction of cognition and hand skill development.¹¹⁴ Like perceptual development, cognitive development influences and is supported by the development of hand skills. For example, changes in attentional control and the development of problem-solving strategies are seen in the gradual improvement in infants’ ability to handle two objects simultaneously. Without this development in cognition, bilateral skills would not be possible. The infant must be able to attend to two objects simultaneously to be able to bang objects together, stabilize an object with one hand while manipulating with the other, and manipulate two or more objects simultaneously. Because attention and planning demands are greater for two-handed activities than for one-handed activities, bilateral skill development lags behind unilateral skill development.^16,28

Skeletal Integrity

The integrity of the hand’s joint and bone structures is an important consideration in hand function. Children with congenital hand anomalies may be missing one or more digits, a condition that significantly affects the variety of possible prehension patterns. Refined finger movements and in-hand manipulation skills may also be limited or absent. Severe congenital anomalies can affect bilateral hand use. Involvement of the thumb has a more significant effect on acquisition and use of hand skills than impairment of any other digit.

Joint range of motion (ROM) has a significant effect on the positioning of the arm for hand use and on reaching and carrying skills. Effective hand function also depends on adequate mobilization of distal muscle groups that control palmar arches. Limitations in range can occur as a result of abnormal joint structure, muscle weakness, or joint inflammation. Any of the problems that reduce range of motion are likely to affect a child’s ability to grasp larger objects or to flatten the hand to stabilize materials.

Muscle Function

Aspects of muscle functions include muscle power (strength), muscle tone, and muscle endurance. Sufficient strength is necessary to initiate all types of grasp patterns and to maintain these patterns during lifting and carrying. Children’s grasp strength gradually increases through the preschool years,^88,89 the elementary school years,¹⁵³ and adolescence.^93,126 This increase allows them to engage in activities with objects of increasing weight and to use greater resistance. Children with poor strength may be unable to initiate the finger extension or the thumb opposition pattern necessary before grasp. They also may not have the flexor control to hold a grasp pattern. Many children with diminished strength are unable to use patterns that rely on the intrinsic muscles for control and therefore are unable to use thumb opposition or metacarpophalangeal (MCP) joint flexion with interphalangeal (IP) joint extension. Children with fair strength may be able to initiate a grasp pattern but may be unable to lift an object against gravity while maintaining the grasp. Endurance during an activity can be a problem for children with mildly diminished strength, particularly in situations in which they must use a sustained grasp pattern or hold an object against resistance (e.g., during eating with utensils, coloring, handwriting, and scissors activities).

Tone in muscle groups affects the stability of parts of the arms and hands during activities and the types of movements possible. Damage to the CNS may cause tonal abnormalities, which can affect joint ROM and, in general, decrease speed of movement. Increased tone results in loss of ROM, whereas decreased tone results in exaggerated joint ROM and decreased stability. Children with fluctuating tone typically have full ROM but can maintain joint stability only at the extreme end of a joint position (full flexion or full extension). In addition, movements are less controlled and often are random or unrelated to the task.

Reach and Carry

Rosblad stated that “in a reaching movement, the goal is to transport the hand to the target, with precision in both time and space” (p. 81).¹¹⁷ Thus the development of reaching is described in terms of the changes that take place in the control and speed of the hand’s movement toward the object and the preparation of the hand for grasp.

Within the first several days of life, the neonate shows visual regard of objects close to him or her and activation of the arms in response to objects.¹⁴¹ Over the next few months the arms become more active and the infant swipes or bats at objects with the arm abducted at the shoulder. Reach with an extended arm is likely to occur between approximately 12 and 22 weeks of age.¹³⁶ Objects are rarely grasped and then only by accident. If grasped, they are released at random, generally in association with arm movements.

Gradually a midline orientation of the hands develops. Initially the hands are held close to the body. Soon, with an increased desire for visual regard of the hands and greater proximal arm stability, the child holds the hands further away to view them. This pattern precedes the onset of symmetric bilateral reaching, which usually occurs first in the supine and then in the sitting position. At this stage, the child initiates reach with humeral abduction, partial shoulder internal rotation, forearm pronation, and full finger extension.

As the infant shows increasing dissociation of the two body sides during movement, unilateral reaching begins. Abduction and internal rotation of the shoulder are less prominent in reach. The hand opens in preparation for grasping the object and is usually more open than necessary for the size of the object.

As scapular control and trunk stability mature, the infant begins to use shoulder flexion, slight external rotation, full elbow extension, forearm supination, and slight wrist extension during reaching. Active supination of the forearm is not seen until some external rotation is used to stabilize the humerus. In addition, well-controlled elbow extension evolves as the rotation elements are developing. Mature reach is usually seen with sustained trunk extension and a slight rotation of the trunk toward the object of interest. Over the next few years, the child refines this unilateral reaching pattern, increasing the accuracy of arm placement and the grading of finger extension as appropriate to the size of the object (Figure 10-1), as well as the timing of the various movement elements. To study the evolution of reaching behaviors after its primary development, Schneiberg, Sveistrup, McFadyen, McKinley, and Levin compared reaching behavior in typical 4- to 11-year-olds with that of adults.¹²¹ Developmental changes during this period include decreased trunk movement when objects are within arm’s length, enhanced smoothness, and decreased variability. With increasing age, arm movements were straighter and reaching patterns were more consistent.¹²¹ The quality of reach with grasp continues to mature until approximately 12 years of age, at which time the child prepares the hand with the optimal hand opening for the object size at the initiation of reach.⁸⁴ Before this age the child needs to use visual monitoring for accuracy in hand opening during reach.

Carrying (“moving” and “lifting”) involves a smooth combination of body movements accompanied by stabilization of an object in the hand. When carrying involves objects used in most occupational activities, small ranges of movements are used and adjusted in accordance with the demands of the activity. Co-contraction in the more distal joints of the wrist and hand often is present. The child must be able to hold the forearm stable while in any degree of rotation, and he or she must be able to modify the forearm and wrist positions during the carry so that the object remains in an optimal position. Similarly, the child must be able to use shoulder rotation movements simultaneously with shoulder flexion and abduction so that appropriate object orientation is maintained.

Grasp Patterns

In-Hand Manipulation Skills

Voluntary Release

Voluntary release, like grasp, depends on control of arm and finger movements. To place an object for release, the arm must move into position accurately and then stabilize as the fingers and thumb extend. Gordon, Lewis, Eliasson, and Duff refer to the two components of voluntary release as replacement and release.⁶³

Initially the infant does not voluntarily release an object; objects either drop involuntarily from the hand or must be forcibly removed from the hand. As the infant’s nondiscriminative responses to tactile and proprioceptive stimuli decrease and visual control and cognitive development increase, volitional control of release emerges. With increases in the mouthing of objects and bringing of both hands to midline and playing with them there, the infant begins to transfer objects from one hand to another. Initially the child stabilizes the object in the mouth during transfers or pulls it out of one hand with the other. Soon the infant begins to freely transfer the object from one hand to another. The receiving hand stabilizes the object, and the releasing hand is fully opened.

By 9 months of age, the infant begins to release objects without stabilizing then with the other hand. The arm is fairly extended during release. The infant exhibits increasing humeral control as he or she moves the arm to drop objects in different locations. The next step is the development of elbow stability in various positions, and the infant begins to release with the elbow in some degree of flexion. The child may stabilize the arm or hand on the surface during release. At about 1 year of age, the child can release objects with shoulder, elbow, and wrist stability; however, the MCP joints remain unstable during this pattern, therefore the infant continues to show excess finger extension (Figure 10-11, A). Gradually the child develops the ability to release objects into smaller containers (Figure 10-11, B) and to stack blocks (Figure 10-11, C). The release pattern is refined over the next few years until the child can release small objects with graded extension of the fingers, indicating control over the intrinsic hand muscles. These skills also illustrate the integration of perceptual, cognitive, and sensory skills with motor skills. For example, Eliasson and Gordon reported that typical children between 7 and 13 years of age demonstrate the ability to effectively modulate a decrease in force used to grasp a lighter object and a heavier object to allow for appropriate timing in voluntary release.⁴³

Bilateral Hand Use

As discussed previously, the normal infant progresses from asymmetry to symmetry to differentiated asymmetrical movements, which are used in bilateral hand activities. Asymmetry is a characteristic of movement patterns until almost 3 months of age. Symmetric patterns predominate between 3 and 10 months of age, when bilateral reach, grasp, and mouthing of the hands and objects are primary activities. Control of these movements originates proximally at the shoulders, allowing the hands to engage at midline. By 9 to 10 months of age, the infant can hold one object in each hand and bang them together (see Figure 10-9). This ability to hold an object in each hand at the same time is critical for further bilateral skill development. By 10 months of age, bimanual action is well differentiated, with one hand grasping the object and the other manipulating parts of it.⁵⁰ More complex bilateral skills depend on this ability.

Bimanual activity emerges first as reciprocal or alternating hand movements, then as simultaneous hand movements. By 17 to 18 months of age, infants frequently use role-differentiated strategies (i.e., one hand stabilizes or holds the materials and the other manipulates or activates them).¹¹³ For these skills to emerge, the infant must be able to dissociate the two sides of the body and begin to use the two hands simultaneously for different functions. Effective stabilization of materials also depends on adequate shoulder, elbow, and wrist stability.

Between 18 and 24 months of age, the child begins to develop skills that are precursors to simultaneous manipulation. Bilateral skill refinement depends heavily on continuing development of reach, grasp, release, and in-hand manipulation skills. Skills in visual-perceptual, cognitive, and motor areas become more integrated, leading to the child’s effective use of motor planning for task performance. The child demonstrates simultaneous manipulation at 2 to 3 years of age. The mature stage of bilateral hand use, which is the ability to use opposing hand and arm movements for highly differentiated activities (e.g., cutting with scissors), begins to emerge at about 2.5 years of age. The child applies and refines the patterns from each stage of bilateral hand use in a variety of activities throughout childhood.

Once a child is able to differentially use the two hands, the task becomes more significant in eliciting the particular strategy to be used to accomplish a task than the particular motor action. For example, Kunde and Weigelt explored the challenge presented by different types of bilateral manipulative tasks.⁸⁵ They found that when the goal of a manipulative task was to orient two objects similarly, speed and efficiency were better even if arm-hand movements needed to differ to accomplish the task than when objects were to be oriented differently but the movement of the two hands was the same. This supports the concept that the goal of a motor action is more important in selecting a movement strategy than is the ease of the motor action itself.

Ball-Throwing Skills

Ball-throwing skills reflect the child’s ability to use voluntary release skills. In throwing a small ball, the child must sequence and time movements throughout the entire upper extremity. The child must bring the arm into a starting position, then prepare for projection of the ball into space by moving the trunk with the scapulohumeral joint, stabilizing the shoulder while beginning to extend the elbow, stabilizing the elbow while moving the wrist from extension to a neutral position, and simultaneously forcefully extending the fingers and thumb.

Children progress through a series of skill levels before they can smoothly sequence these movements and project the ball to the desired location. By 2 years of age, the child should be able to throw a ball forward and maintain balance so that his or her body does not also move forward.¹²³ At this age the child uses extensor movements to fling the ball but is unable to sustain shoulder flexion during the toss.⁵⁵ The child can dissociate trunk and arm movement but cannot dissociate humeral and forearm movements. By 2.5 to 3 years of age, the child can aim the ball toward a target and project the ball approximately 3 feet forward. This ability to control the direction of the ball to some degree implies that the child can control the humerus so that the elbow is in front of the shoulder when the ball is released. Thus the shoulder has sufficient stability to support controlled elbow and finger movement. By 3.5 years of age, the child is able to throw the ball 5 to 7 feet toward a target with little deviation from a straight line.⁵⁵ To accomplish this accuracy, the child positions his or her elbow in front of the shoulder before the ball is released.

Further refinement of ball-throwing skills continues over the next few years. Distance and accuracy improve as the child gains scapulohumeral control, the ability to sustain the humerus above the shoulder, and the ability to control the timing of elbow, wrist, and finger extension. Thus at approximately 5 years of age, the child is able to use an overhand throw to hit a target 5 feet away fairly consistently. Children between 6 and 7 years of age are able to hit a target 12 feet away by using an overhand throw.⁵⁵ Underhand throws to contact a target are also possible in children 5 years of age or older. This skill requires the ability to move the humerus into flexion while sustaining full external rotation.

Tool Use

Connolly and Dalgleish defined a tool as “a device for working on something … tools serve as extensions of the limbs and enhance the efficiency with which skills are performed” (p. 895).²⁶ They defined tool use as “a purposeful, goal-directed form of complex object manipulation that involves the manipulation of the tool to change the position, condition or action of another object” (p. 895).²⁶ Tool-use skills are more complex than other hand skills, because the child must use a tool, rather than the hand, to act on objects.

The development of skill in using tools is critical to a variety of self-care, play and leisure, and school and work tasks. Skills in tool use for eating and play typically begin to emerge during the second year, after the child has mastered the basic skills of reach, grasp, and release. The skills emerge concurrently with in-hand manipulation skills, which are necessary for the progression of tool use skills beyond grasp and release proficiency. In-hand manipulation skills allow the tool to be adjusted in the hand after it has been grasped.

A key factor in the acquisition of tool-use skills is the high degree of interaction of these skills and cognitive development. Connolly and Dalgleish emphasized that an individual needs to know both what he or she wants to do (the intentional aspect of the task) and how he or she can accomplish it (the operational aspect of the task).²⁶ Both of these elements require development of the child’s cognitive skills and operational aspects of the child’s motor skills.

As with any new skill, when the child is developing tool use, the therapist sees inconsistencies in the child (even in the same session). The therapist is likely to record multiple strategies for children who are beginning to use a particular skill. Thus “inconsistency” in the strategy used to perform a skill should be considered an important stage in the skill-acquisition process. As skill acquisition progresses, practice allows the skill to progress from being performed with a high level of attention to being performed at a more automatic level. With such practice, performance becomes faster, more accurate, and smoother. Practice typically is necessary for a skill to become functional for execution in daily life tasks.

Researchers have studied the acquisition of children’s skills in the use of three tools: drawing and writing, scissoring, and eating. Of these, most of the research has focused on drawing and writing tool use (see Chapter 19 for a description of this type of tool use).

Schneck and Battaglia described the development of scissors skills in young children.¹²⁰ This skill emerges when the child first learns to place his or her fingers in the holes and to open and close the scissors. Early cutting is actually snipping, a process of closing the scissors on the paper with no movement of the paper and with no ability to repetitively open and close the scissors while flexing the shoulder and extending the elbow to move across the paper. Three-year-old children may use a pronated forearm position or a forearm-in-midposition placement,¹²⁰ or they may alternate between the two forearm positions. By 4 years of age, children typically hold both forearms in midposition for the cutting activity.

The Peabody Developmental Motor Scales has established the following typical sequence for scissors skills⁵⁵:

More complex cutting skills develop between 6 and 7 years of age. Other factors the therapist should consider when assessing a child’s skill in cutting include the width of the line to cut on, the size of the paper, the size of the design to be cut, and the complexity of the design.

The child’s grasp on the scissors changes over time. The thumb position in one hole remains consistent, but the finger positions change according to the child’s level of maturation and the type of scissors used.¹²⁰ In a mature grasp, which may not be achieved until after 6 years of age, the child has the middle finger in the lower hole of the handle, the ulnar two fingers flexed (inside or outside the lower hole, depending on its size), and the index finger positioned to stabilize the lower part of the scissors.^102,120

The general ages at which a child learns to use various utensils in eating are as follows: a spoon by 18 months of age, a fork by 2.5 years of age, and a knife by 6 years of age.⁷⁰ However, documentation regarding how these skills are acquired and how various components of movement interact to produce skill is limited. Connolly and Dalgleish conducted a longitudinal study on development of spoon use skills in infants between 11 and 23 months of age.²⁶ They analyzed videotapes of the infants’ grasp patterns on the spoon; the placement of the spoon in the hand; movements used in filling the spoon, bringing it to the mouth, clearing the spoon, and taking it out of the mouth; and visual monitoring of the pattern, timing, and use of the nonpreferred hand in the eating process. They found that the mean number of grasp patterns decreased between 11 and 17 months of age and that most infants 17 months of age or older showed a clear hand preference for eating. The infants used 10 different grasp patterns, but none of them used an adult pattern. The most commonly used pattern was a transverse palmar grasp with all four fingers flexed around the handle of the spoon. In the next two most commonly used patterns, the spoon handle was held within the fingers rather than in the palm. The 17- to 23-month-old infants used some degree of index finger extension to hold and orient the spoon. The infants became increasingly efficient in spoon use during this period, and exhibited improved visual monitoring of the process.

Another component in the development of tool use in children is the role of the assisting hand. In handwriting and coloring, the assisting hand plays an important role in stabilizing the paper. However, in using scissors and eating, the assisting hand is likely to be much more active. In cutting, this hand must hold the paper and orient it through rotation by moving in the same or the opposite direction as the hand with the scissors. In eating, the child’s assisting hand may be involved in a variety of activities, depending on the child’s age and the utensils used. Connolly and Dalgleish found that infants between 18 and 23 months of age showed significantly more involvement of the assisting hand in stabilizing a dish during spoon feeding than did infants between 12 and 17 months of age.²⁶ Learning to use a knife entails the child learning to stabilize food with a fork in one hand while using a knife for spreading or cutting.

Hand Preference

Hand preference, previously referred to more frequently as hand dominance, is a complex concept. In typical children hand preference evolves over a long period of time and gradually becomes more consistent, as do other expressions of motor functioning. Fagard and Lochman studied young children between the ages of 6 months and 48 months with a variety of tasks involving hand use.⁵¹ Greater variability was actually noted for less complex grasp activities. Activities and objects that elicited manipulative strategies were more likely to result in more consistent use of one hand for manipulation and the other for stabilization. Inconsistent use of one hand in a precision grasp task was noted in almost 20% of the infants under 12 months, but in none of the 2.5- to 3-year-old children, whereas about 60% of the children in this age group (and in the infants 6 to 24 months of age) were inconsistent in hand used for a simple grasp task. When one hand needed to be used as a stabilizer and one as a manipulator, 65% or more of the children over 18 months used the right hand as the manipulator. Inconsistency was noted in some children in the 2.5- to 3-year-old group but not in the 4-year-old group. Overall, Fagard and Lochman noted that the right hand was used more frequently than the left hand by infants and young children in every age group, even when it was not used consistently (on 80% or more of the trials).⁵¹

Hand preference continues to develop until at least 8 years of age, as illustrated in a study of a reaching activity that involved crossing the midline of the body. Carlier, Doyen, and Lamard found that with increasing age, children used the preferred hand with greater frequency to pick up cards in various locations, including crossing the midline with the preferred hand.¹⁸ As with other areas of hand skill development, some degree of variability and inconsistency is the typical pattern for infants and young children. It is worrisome and atypical when infants (less than 7 months) consistently use one hand, and these infants should be further evaluated for possible neurologic impairment.

Play

Although infants engage with people and objects through their visual and auditory senses, these are distant senses and do not readily bring the infant key information, which can be gained only through touch. Ruff described object handling with visual exploration as essential for an infant to learn object properties.¹¹⁸ The interaction of touching and looking helps enhance the infant’s ability to integrate sensory information and to learn that objects remain the same regardless of visual orientation. Typically this object handling in infants is called play because it is purposeful and done with pleasure.

With increasing age, until at least the early school years, a great deal of play depends on competence in fine motor skills. These skills are reflected in the child’s interest in activities such as cutting with scissors, dressing and undressing dolls, putting puzzles together, constructing with various types of building materials and model sets, participating in sand play, completing craft projects, and engaging in imaginary play with objects. Playing video games and using computers also require fine motor control. Some children may pursue play and leisure activities through organized groups such as the Girl Scouts or Boy Scouts and 4-H clubs, which tend to have projects requiring manual skills as a key component of their programs.

Activities of Daily Living

Activities of daily living also depend on the child’s ability to use all types of hand skills. According to Henderson, the specific skills needed for skill development in this area are “(1) finger manipulation and grip ability, (2) the use of two hands in a complementary fashion, (3) the ability to use the hands in varied positions with and without vision, (4) the execution of increasingly complex action sequences, and (5) the development of automaticity” (p. 213).⁷⁰ Case-Smith found that in-hand manipulation speed, grasp strength, motor accuracy, and tool handling were each significantly positively correlated with self-care skills in preschool-age children receiving occupational therapy services.²¹

Dressing skills involve complex grasp patterns and in-hand manipulation skills in the use of fasteners, but the ability to use all types of bilateral skills and a variety of grasp patterns is useful for putting on and removing shirts, shoes, socks, and pants. The ability to put on jewelry relies on the ability to use delicate grasp patterns and in-hand manipulation.

Bathing, showering, and other personal hygiene skills depend on the child’s increasing fine motor skills in handling slippery objects (e.g., soap). In addition, these skills are likely to be needed when an individual is in a standing position, such as when putting toothpaste on a toothbrush (Figure 10-12), brushing the teeth, shaving, or applying makeup. A high level of skill in tool use is needed for complex hygiene activities such as shaving, applying makeup, using tweezers, cutting nails, and styling hair (applying barrettes or rubber bands and using a curling iron, a brush, and a hair dryer).

Eating skills rely on refinement of the ability to use forearm control with a variety of grasp patterns and tools. The ability to use both hands together effectively is necessary for spreading and cutting with a knife, opening all types of containers, pouring liquids, and preparing food. In-hand manipulation skills are used to adjust eating utensils within the hand (Figure 10-13) and finger foods in the hand, to handle a napkin, and to manipulate the opening of packaged food and utensils.

In their studies of school-age children with developmental coordination disorder (DCD), Summers, Dawne, and Dewey¹³³ and Missiuna, Moll, King, King, and Law⁹⁹ illustrate the impact of hand skills on activities of daily living. Typically developing children 8 years of age and older are highly independent in an array of skills that rely on hand skill as well as postural control. In contrast, children with DCD demonstrated delayed development in dressing, personal hygiene, toileting, and independent eating skills. Older children who had DCD performed similarly to younger typical children. Parents provided cues, assistance, and substitutions for many of the needed skills far longer for their children with DCD than did parents of typically developing children.^99,133

School Functions

Independent functioning in the school environment requires effective fine motor skills. The preschool classroom provides children with a variety of manipulative activities, including the use of crayons, scissors, small building materials, and puzzles, as well as simple cooking and art projects. During kindergarten and the early elementary school years, children use fine motor skills most of the school day. McHale and Cermak found that 45 to 55% of the school day for first and second grade children is spent in fine motor activities. Fourth grade children spend approximately 30% of their school day participating in fine motor tasks.⁹⁴ The primary fine motor activities in all of these grades are paper-pencil tasks. Any writing activity includes preparing one’s paper, using an eraser, and getting writing tools in and out of a box. Other typical fine motor activities in children’s classrooms include cutting with scissors, folding paper, using paste and tape, carrying out simple science projects, assuming responsibility for managing one’s own snack and lunch items, and organizing and maintaining one’s desk. Children also need computer skills in most elementary classrooms.

Older children and adolescents need fine motor skills for science projects, vocational courses (e.g., woodworking, metal shop, and home economics), art classes, music classes (other than vocal music), managing a high volume of written work and notebooks, keyboarding, and maintaining a locker. Greater speed (e.g., in writing and keyboarding) and greater strength (e.g., for physical education and vocational courses) are required. Adolescents should be able to demonstrate consistent hand skills that they can execute quickly in a variety of situations.

Somatosensory Problems

Somatosensory problems can produce significant problems with hand function, even when motor control is good,¹⁰⁶ and poor hand skills can contribute to the child obtaining a limited amount of somatosensory information. Children with poor tactile discrimination receive less feedback about how their fingers move together and independently of one another. In addition, poor tactile discrimination has been found to be associated with difficulty anticipating the force needed in grasp, modulating the force needed for grasp, and transitioning from grasp to lift.⁶⁴

Children with cerebral palsy are very likely to have tactile discrimination problems as well as motor control problems. Several studies of tactile dysfunction in children with cerebral palsy were conducted in the 1950s and 1960s. These studies verified the presence of a variety of tactile discrimination problems in the hands of a high percentage of children with this disorder.^80,101,139 Recent studies of children with spastic hemiplegia have resulted in similar findings. Cooper, Majnemer, Rosenblatt, and Birnbaum found that eight of the nine children with spastic hemiplegia whom they tested had bilateral sensory deficits.²⁷ Yekutiel, Jariwala, and Stretch found that 51% of the 55 children with cerebral palsy whom they tested had sensory deficits on two-point discrimination and/or stereognosis.¹⁵² In a study of 25 children with spastic hemiplegia, Krumlinde-Sundholm and Eliasson found that 18 had impairment of the hemiplegic hand in two-point discrimination at 3 mm and more than half had difficulty with two-point discrimination at 7 mm.⁸³ For approximately one third of these children, tactile problems were noted in all five tests of tactile discrimination in the hemiplegic hand. A marked difference in stereognosis was seen between testing with common objects (11 children showed impairment) and testing with flat shapes (24 showed impairment). Arnould, Penta, and Thonnard also found deficits in stereognosis, proprioception, and perception of touch pressure in a large sample (approximately 100) of school-age and young adolescent children with cerebral palsy.² Some researchers have found that children with hemiplegia have deficits in the less (or non) involved upper extremity as well as the hemiplegic hand.²⁷

Although some researchers note that the degree of tactile problems is not always associated with the degree of motor impairment,^2,27 Krumlinde-Sundholm and Eliasson found strong relationships between impairment in sensation and dexterity in the more impaired hand of children with spastic hemiplegia (i.e., r = 0.60 to 0.71).⁸² They noted that bilateral hand skills were less associated with the level of tactile discrimination. Differences in these study findings may be associated with differences in tactile testing methodologies and sample sizes. Children with cerebral palsy tend to need more trials than nondisabled children to match tactile and proprioceptive information with force for grasp and lift of objects.³⁹

The use of sensory information about objects to plan movements also appears to be impaired in children with cerebral palsy, thus affecting their skill in object handling. In their study of children with cerebral palsy, Gordon et al. found that when children used their hand with motor impairment they did not effectively plan initiation of grasp with well-controlled finger spacing for the object (“anticipatory control”) relative to object weight, despite experience with the objects in the task.⁶¹ Of interest, however, is that when grasping objects with the other hand, they appeared to reflect knowledge of object weight that was learned by grasping with the involved hand. Thus, Gordon et al. stated that “the findings suggest that the impaired anticipatory control may be due to an inability to integrate the sensory information with the motor command in the involved hand… and that intact sensory information alone is not enough for anticipatory control, but instead it must be integrated with motor-related information” (p. 590).⁶¹

Children with milder problems also are at risk for somatosensory problems that affect hand skills. Case-Smith studied the relationship between both tactile hypersensitivity and tactile discrimination and in-hand manipulation skills in 50 children between 4 and 6 years of age.¹⁹ In this sample, which included 80% typical children, those having problems with either tactile defensiveness or decreased tactile discrimination showed no significant problems with performing the in-hand manipulation tasks presented. However, those who had both tactile discrimination problems and hypersensitivity had difficulty performing the in-hand manipulation tasks that were timed. Their performances were significantly less efficient than those of the children in the other groups.

Strategies and plans of action rely on knowledge of object properties that probably is gained through tactile and proprioceptive information. Children with DCD appear to have tactile problems, because they have difficulty with feed-forward strategies¹²⁷ and with planning for intentional actions that depend on the anticipation of force and timing.¹⁴⁸ Similarly Smyth and Mason found proprioception problems in a variety of tasks in children with DCD.¹²⁸

Learned Nonuse Phenomenon in Children with Hemiplegia

Sterr, Freivogel, and Schmalohr conducted a study to assess available use in the more involved arm-hand of a sample of 21 children, adolescents, and young adults with hemiplegia.¹³¹ Their research was based on several other studies with adults with learned nonuse as a result of strokes. They found that “the learned nonuse model predicts that even if the residual movement capacities of the hemiparetic arm should allow the person to carry out activities of daily living … that arm is not, in fact, used in the real-life situation” (p. 1727).¹³¹ The difference between these individuals’ available movement skills and the use of them in spontaneous situations was significant. The authors concluded that the limited use of the hemiplegic arm appeared to be due to learned nonuse.

Hand Skill Problems in Children and Adolescents with Various Developmental Difficulties

Children with a wide variety of developmental problems show significant difficulties in hand skills. Common developmental conditions that are reported to result in hand skill or fine motor problems include visual impairment/blindness, ADHD, autism spectrum disorders (ASD), and DCD.

Hand skill problems that reflect motor coordination difficulties have been identified in children with ASD^58,116,146 and with ADHD.^54,58,116 In a number of studies, the problems with motor coordination have been particularly linked to either the inattentive type of ADHD⁵⁴ or the combined type (both inattention and hyperactivity)¹¹⁵; less correlation has been documented with children who have ADHD-hyperactive type alone. Overall, problems with hand skills have been documented in these diagnostic categories in both large- and small-scale studies across a variety of ages of children, with a variety of test instruments. These problems have been corroborated by parent and teacher reports and reflect evidence for persistent coordination difficulties beyond childhood.⁵⁴

A study by Meyer and Sagvolden clarified the types of hand skill problems that may be noted in children with ADHD.⁹⁹ They compared typical South African children with a similar sample of children with ADHD relative to their skills in performing three fine motor tasks involving tool use, object manipulation, and finger tapping. Although the two groups did not differ on the repetitive tapping item, the children with ADHD were significantly slower and less accurate in performance on the more complex items involving object control. Children at the younger ages (6 to 9 years versus 10 to 13 years) appeared to have greater differences in the object manipulation task relative to their typical age-peers, but this may have been due to a ceiling effect on the measure used. The authors concluded that the combination of speed with demand for eye-hand coordination is very difficult for children with both hyperactivity and inattentiveness.

In clinical practice children with autism may be assumed to either not have specific hand skills problems¹¹² or have hand skill problems due to sensory avoidance of certain textures or materials or due to a limited repertoire of interests, which may interfere with the range and type of object manipulation activities. Some toddlers with autism have poorer fine motor skills than gross motor skills, but others may have similar performance in the two areas or poorer gross motor skills; all had at least some delay in motor skills.¹¹² Within the area of fine motor skills, the most common pattern identified was a delay in visual-motor integration and handling of objects.

In recent years, significant attention has been given to documenting the characteristics of children with developmental coordination disorder and to attempting to determine similarities and differences in the fine motor difficulties these children have relative to children with ASD¹⁵⁰ and ADHD.¹¹⁵ Flapper, Houwen, and Schoemaker found that approximately 60% of a sample of children with DCD had attention deficit disorders.⁵³ In a subset of 12 of the children they studied, the children differed significantly from typical children on the manual dexterity section of the Movement Assessment for Children, with 9 of the children having notable fine motor problems and 2 others having borderline performance. Their problems were reflected in increased errors and slower speed of performance. Piek et al. noted that attention difficulties may cause motor performance to be more variable, whereas difficulties with motor skill interfered with performance speed.¹¹⁰ One of the difficulties with motor skill may be related to poor control of force and torque using the finger tips.¹⁰⁴ The component of rotation/movement was more impaired in 7-, 9-, and 11-year-old children than was the component of pressure alone. Overall the typical 7-year-old children and the 9-year-olds with DCD had similar scores on the torque measure, while the force measure showed about a 1-year delay. The authors note that “impairments of torque control in children with DCD may result in a greater challenge in daily manipulative tasks” (p. 45)¹⁰⁴ because of the number of different digits that need to be controlled with relative force.

Differences in Developmental Trends between Children with and without Disabilities

Although information about normal development of hand skills can be useful to therapists in understanding difficulties with functioning and/or in guiding intervention planning, therapists also need to recognize that normal developmental sequences may not apply to children with some types of disabilities. For example, in a longitudinal study by Hanna et al., hand function in children with cerebral palsy generally improved in early childhood and then began to decline.⁶⁶ They found somewhat different patterns of development with children who had mild, moderate, and severe impairments and for children with hemiplegic cerebral palsy and with quadriplegic cerebral palsy. Hand skills increased more slowly in children with greater degrees of motor impairment. In general, the children with quadriplegic cerebral palsy showed more decrease in quality of functioning over time than did the children with hemiplegia. Overall the highest quality of functioning was found at the average age of 46 months, and the highest scores on the PDMS Fine Motor Scale were achieved at approximately 5 years of age.

Eliasson et al. also found a longer course of development of hand skills, but did not identify deterioration in the skills they tested over time.⁴² The children with cerebral palsy in their study were initially tested when they were between 6 and 8 years of age and retested 13 years later, assessing their hand skill dexterity and their ability to time finger movements for grasp and use a direct approach for grasp of objects. Overall they became faster in object manipulation both as measured on a standardized test and on a task involving grasp and lift. Thus, the children demonstrated increases in motor skill, including greater speed and increased consistency in movement, but appeared to have a longer course of development than in typical children (Research Note 10-1). The differences in findings between Hanna et al.⁶⁶ and Eliasson et al.⁴² may be related to use of different measures of hand function as well as different samples of children and may be influenced by intervention.

Similarly, it should be noted that individuals with DCD and other hand skill problems may continue to improve in performance over time, but problems with coordination persist that affect interactions with peers and have a negative impact on the children’s emotional well-being.⁹⁹ The time demands associated with slower performance or inability to accomplish tasks can make it extremely difficult or impossible to effectively engage in academic work.⁹⁹ Such problems with hand skill use for complex tasks are reported to persist at least through adolescence.⁵⁴

Screening for Hand Skill Problems

When a problem with occupational performance has been identified, the therapist needs to continue gathering information on the child’s performance of specific daily life activities. As part of this process, the therapist determines whether it is reasonable to carry out a full evaluation of fine motor and hand skill performance. This information must include data about the child’s age and general information about motor skills, cognitive and perceptual skills, sensory processing, social situation and skills, and emotional functioning, as well as contexts that affect the child. The therapist can obtain screening information from parents, teachers, the child, and other professionals or from reports of other professionals.

Observation of the skills noted in Table 10-1 can help determine what standardized test and further analysis should be pursued. These observations about the child’s quality of hand skills can supplement a standardized test. Some skills are inappropriate for younger children; an “X” designates the age group for which any activity may be used. When a skill emerges within a particular age group, ages are listed rather than an “X.” For block stacking, the number represents the number of blocks a child in that age group should be able to stack. The therapist can vary the materials used for some of the items so that he or she can assess many of these skills during mealtime, dressing, hygiene, or play activity. For all categories, except Bilateral Skills and Tool Use, the therapist should ask the child to perform the activities with both the right hand and with the left hand. Evaluation of both hands is important, because subtle difficulties may not be readily apparent. For example, Gordon, Lewis, Eliasson, and Duff found mild problems in the timing of voluntary release components in the noninvolved hand of children with hemiplegia.⁶³

Evaluation Content

A child with occupational performance problems who shows difficulties on screening for hand skills should be further evaluated so that the characteristics of the problem and the situations in which the child’s performance is optimal can be carefully delineated. When determining the child’s performance in the area of hand skills and potential reasons for any problems, the occupational therapist often uses a variety of standardized and nonstandardized assessments. All children should receive an assessment of hand skills in activities such as dressing, eating, hygiene skills, school activities, and play activities. Completion of a parent interview is helpful in determining persistent concerns and priorities. Wilson, Kaplan, Crawford, Campbell, and Dewey have developed a Developmental Coordination Disorder Questionnaire for parents.¹⁴⁷

Analysis of the identified hand skills problem involves administration of specific assessments or scales that define the basis of the problem and the extent of the impairment. A sample analysis of an occupational performance problem in the area of constructive play that is at least partly caused by hand skill difficulties is presented in Box 10-2. In this example the therapist has identified two main performance problems: lack of ability to manipulate materials after grasp and breakage of materials being handled (“manipulates” and “calibrates”¹). The therapist then attempts to determine how sensory functions, neuromusculoskeletal and movement-related functions, and mental functions contribute to this performance limitation. Muscle and movement functions associated with this problem may include difficulties with wrist and MCP joint stability, limited midrange movement control, lack of isolated finger movement, and excessive use of flexion. Based on evaluation findings and the therapist’s frames of reference, specific impairments are identified.

The following outline presents examples of tools and methods used in comprehensive evaluation to assess the underlying impairments associated with hand skill difficulties and delays.

Setting Goals

Several factors affect the types of goals developed in the area of hand skills and in other areas of the child’s functioning: the child’s occupational performance problems, the contexts in which the skills are needed, the types of problems in the hand skill area, the therapist’s frame of reference, and the setting in which services are to be provided. For some children, developmental sequences of skills influence the selection of goals, but for the child with a motor disability, other factors will affect the goals established and the strategies selected for intervention. These factors include the types of occupational performance skills the child needs, the complexity and severity of the child’s problems, and the human and nonhuman resources available to support the intervention program.

A child’s goals generally are developed through a process of child/adolescent, family, and professional collaboration. The Perceived Efficacy and Goal Setting System¹⁰⁰ is helpful in setting goals with children who are functioning at approximately the 6- to 9-year-old level.

Overall, the therapist must be realistic in the number and types of goals to recommend relative to other goals for the child. In addition, the therapist must consider hand skill goals that are feasible for the child to accomplish. Such goals may be limited for children with severe disabilities. In all cases the therapist must link hand skill goals to the child’s ability to engage in occupational activities more effectively. For some children the most appropriate focus of intervention is the development of skills in using adaptive equipment and strategies for accomplishing skills needed in activities of daily living. For children who show readiness to develop better quality or more complex hand skills, intervention can focus on acquisition of these skills. Factors to consider in planning intervention for hand skills problems are discussed in the following sections.

Considering Roles of the Occupational Therapy Assistant and Others in Intervention

Clearly the occupational therapist has a key role in evaluation, goal setting, and intervention planning for a child or adolescent with hand skill problems that are affecting functioning in daily life skills. However, others have a significant role as well. Typically not only is a parent/caregiver and/or a teacher involved in noting concerns relative to hand skills, but the child or adolescent, parent/caregiver, and other professionals need to identify their roles relative to intervention. In addition to parents/caregivers, teachers often have a key role. In fact, in some schools, the occupational therapist has predominantly a consultant role and the teacher is the primary interventionist.⁸ However, although teachers indicate a high level of receptivity to input and recommendations from the occupational therapist in helping children with hand skill difficulties, they may have limited knowledge of the role of the occupational therapist⁷⁶ and/or want a higher level of input than periodic consultation for these children.⁸

In general, teachers and parents/caregivers can be provided with specific activities (classroom or games or selected tasks that work well within daily living skills) that allow for repetition of skills that the child or adolescent is able to show with simple cuing or with particular materials. Thus, it is preferable for the occupational therapist to provide activities that allow for practice of skills, but not to expect these individuals to determine how to vary or adapt an activity to elicit a better response from the child or adolescent.

The occupational therapist and the occupational therapy assistant can be an excellent team in providing both direct and consultative intervention in the area of hand skills. When a child has complex problems and/or is highly inconsistent in performance, intervention by the occupational therapist who is continually assessing and modifying the intervention strategies is generally preferable. When a child has less variability or when the child is ready to make incremental gains in motor skills or to use motor skills within graded functional activities, often the occupational therapy assistant can provide highly appropriate intervention with grading of activities in response to changes in child performance.

Sequencing of Intervention Sessions

When the therapist provides direct services to improve hand and arm function, he or she usually carries out in the following sequence:

Not all children need all the steps in this sequence. In addition, intervention for all areas is rarely done in one session.

Preparation for Hand Skill Development

Many children require preparation of the total body in each treatment session before the therapist can begin intervention for specific hand skill problems. In addition to intervention to improve motor function, the therapist should pay specific attention to the child’s sensory functioning. The therapist can provide tactile and proprioceptive input to the arms and hands to enhance sensory awareness and discrimination. Lotion, toys, the child’s own clothing or, preferably, active movements of the child’s hands, with or without assistance, can provide stimuli. Children have greater tactile sensitivity when performing an activity that involves active touching rather than being touched.⁶⁷ The therapist should also encourage visual awareness of the hands with tactile and proprioceptive input.

Development of Hand Skills

The interventions described in this section apply and integrate four models of practice or frames of reference: neurodevelopmental treatment, developmental, motor learning, and biomechanical. Neurodevelopmental treatment frame of reference focuses on understanding and improving the child’s impairments in postural tone, postural control, and stability and mobility.¹²² The intervention activities focus on providing adequate support and helping the child develop dissociated and coordinated patterns of movement. Developmental theories give us a frame of reference to describe the sequences of skills that children develop (e.g., the progression from palmer grasp to a pincer grasp pattern). This frame of reference suggests that tasks should be presented in a sequential order and that children achieve increasingly more difficult skills in a specific developmental sequence.

When therapists use motor learning theory, they focus on how the child learns specific motor skills. The occupational therapist assists the child in acquiring motor skills through structure and feedback and provides him or her with structured practice to refine the skills. The therapist selects a specific type of practice and feedback based on the child’s level of performance and response to intervention. Sullivan, Kantak, and Burtner presented a clear example of research with children based on motor learning theory.¹³² In their study, different frequencies of feedback were provided during a task involving arm movements. The authors found that children use feedback in a manner different from that of adults and require longer periods of practice. Chapter 9 provides additional description of motor learning theory.

The biomechanical frame of reference is used primarily to assess and provide intervention activities that improve a child’s range of motion, strength, or endurance. Biomechanical approaches focus on postural alignment, joint stability and relationships, and musculoskeletal problems. Biomechanics helps the therapist understand the principles involved in tenodesis grasping patterns and the relationship of intrinsic and extrinsic muscle control for grasp and in-hand manipulation patterns.

When addressing hand skill development in children, the therapist must select activities that are interesting and appropriately challenging to the child. To support skill development, the therapist must be able to repeat these activities. Eliasson stated specifically that “practice or repetition is an important part of the learning process” (p. 50).⁴⁰ She defines learning as evidenced through “relatively consistent performance and retention of the task” (p. 50).⁴⁰ Therefore, eating activities and toys and games with many pieces can be particularly useful and enjoyable. Engaging in play while addressing hand skills can have important benefits, including motivating the child to engage in activities repeatedly and building his or her play repertoire.^29,137 Recent research suggests that the use of cognitive strategies to encourage awareness of elements of task performance may be helpful for enhancing the performance of children with developmental coordination disorders (Research Note 10-2).^17,98 Eliasson provides an excellent summary of a wide range of approaches to hand skill interventions for children with cerebral palsy, citing key research references as a basis for each of the approaches.