Hand Functions in The Child 2006 PDF

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CONTRIBUTORS
Dorit Haenosh Aaron, MA, OTR, CHT, FAOTA Charlotte E. Exner, PhD, OTR/L, FAOTA
Coordinator Professor
Hand Therapy Fellowship Department of Occupational Therapy and
Department of Occupational Therapy Occupational Science
Texas Women’s University Dean
Houston, Texas College of Health Professions
Towson University
Mary Benbow, MS, OTR Towson, Maryland
Private Consultant and Lecturer
La Jolla, California Kimberly Brace Granhaug, OTR, CHT
Clinical Manager
Jane Case-Smith, EdD, OTR/L, FAOTA Sports Medicine and Rehabilitation
Professor Christus St. Catherine
Division of Occupational Therapy Katy, Texas
The Ohio State University
School of Allied Medical Professions Anne Henderson, PhD, OTR
Columbus, Ohio Professor Emeritus
Department of Occupational Therapy
Sharon A. Cermak, EdD, OTR/L, FAOTA Boston University/Sargent College of Allied
Professor of Occupational Therapy Health Professions
Department of Rehabilitation Sciences Boston, Massachusetts
Boston University, Sargent College;
Director of Occupational Therapy Training Elke H. Kraus, PhD, BSc.Occ.Ther., Dip.Ad.Ed
Leadership and Education in Neurodevelopment Professor of Occupational Therapy
Disabilities Alice-Saloman University of Applied Sciences
Children’s Hospital and University of Berlin, Germany
Massachusetts Medical Center
Boston, Massachusetts Carol Anne Myers, MS, OTR/L
Occupational Therapist
Ann-Christin Eliasson, PhD, OT Early Childhood Education Program
Associate Professor Newton Public Schools
Neuropsychiatric Research Unit Newton, Massachusetts
Institution of Woman and Child Health
Karolinska Institute Charlane Pehoski, ScD, OTR/L, FAOTA
Stockholm, Sweden Consultant
Eunice Kennedy Shriver Center
University of Massachusetts Medical School
Waltham, Massachusetts
v
vi Contributors
Ashwini K. Rao, EdD, OTR Scott D. Tomchek, MS, OTR/L

Assistant Professor of Clinical Physical Therapy Chief of Occupational Therapy
Program in Physical Therapy Child Evaluation Center
Department of Rehabilitation Medicine University of Louisville School of Medicine
Columbia University Department of Pediatrics
New York, New York Louisville, Kentucky
Birgit Rösblad, PhD, PT Laura K. Vogtle, PhD, OTR/L, ATP

Associate Professor Associate Professor
Community Medicine and Rehabilitation, Department of Occupational Therapy
Physiotherapy University of Alabama at Birmingham
University of Umeå Birmingham, Alabama
Umeå, Sweden
Margaret Wallen, MA, OT
Colleen M. Schneck, ScD, OTR/L, FAOTA Senior Occupational Therapist – Research
Professor and Post Professional Program Graduate Department of Occupational Therapy
Coordinator The Children’s Hospital at Westmead
Department of Occupational Therapy Westmead, New South Wales, Australia
Eastern Kentucky University
Richmond, Kentucky Jenny Ziviani, BAppScOT, BA, MEd, PhD
Associate Professor
James W. Strickland, MD School of Health and Rehabilitation Science
Clinical Professor The University of Queensland
Indiana University School of Medicine Queensland, Australia
Indianapolis, Indiana
PREFACE TO THE SECOND EDITION
The everyday occupations that most of us engage in of the hand. The third chapter explores sensory control
involve extensive use of our hands. As we perform these and the way in which the control of grasp and lifting of
occupations we give little thought to the enormous objects varies with differing sizes, shapes, and textures.
variety of actions our hands can do. A hand can be a The next chapter examines the development and eval-
platform, a vise, or a hook. It can push and poke, pull uation of the ability of infants and children to recognize
and twist, scratch or rub. It can hold a football, an objects and object properties felt by the hand. The fifth
apple, or a raisin. It is the enabler of multiple tool uses. chapter updates the research on the role of vision in the
A major task of childhood is the development of this control of movements in the environment, and covers
wide variety of hand actions. When a child’s hands are the development of visual control in childhood. The
not functioning well or if there is a delay in develop- final chapter in Part I is new in this edition and high-
ment, the occupations of childhood are affected, such lights the cognitive processes required for the acquisi-
as playing with objects, dressing, and using tools such tion and performance of hand skills.
as spoons, scissors, or pencils. Remediation of the hand Part II, Development of Hand Skills, explores the
is therefore a major focus of intervention. changes in hand skills that occur with age. The first
Hand Function in the Child originally grew out of chapter on the early development of grasp, release, and
the recognition that there was a significant gap in the bimanual activities has been revised to present the con-
professional literature addressing the problems of hand tent in the context of infant play from birth to 2 years.
dysfunction in children, despite the importance of the The second chapter examines object manipulation from
hand to the child’s development. It has been 10 years birth throughout childhood. Chapter 9, on handedness
since the first edition was published and it still remains and its development, is new and includes an extensive
the only complete text covering this topic. This second review of research on hand preference as well as on
edition again reviews detailed information on the the evaluation of hand preference. Chapter 10, on the
neurological, structural, and developmental founda- development of self-care activities in relation to the
tions of hand function in children. We maintain the development of hand skills, contains additional infor-
focus on the hand as a tool for action and an organ of mation on current measures and on cultural influences.
accomplishment and highlight the complexity of skilled The final chapter in Part II has a new, extensive review
hand use and the long developmental period needed of recent research on handwriting.
for its perfection. As many of the chapters review Therapeutic intervention is presented in Part III.
information from rapidly changing fields of study, an The chapters focus on the overall remediation of hand
important purpose of the revised edition was to update skills, on the remediation of special problems, and on
these chapters. Another purpose was to add chapters in specific areas of intervention. Chapters 12 and 15 have
several areas of content that we felt to be important. been updated and revised. The remaining six chapters
The content is presented in three parts. The first in this section are new. Chapter 13 presents ideas on
part, “Foundation of Hand Skills,” provides informa- how the engage the preschool child in hand activity and
tion on the anatomical, neurological, physiological, and to incorporate treatment activities into the classroom.
psychological aspects of hand function. This section The next chapter reviews problems related to hand-
begins with an updated chapter on control within the writing difficulties and presents formal and informal
central nervous system that describes the mechanisms assessments. Chapters 16, 17, and 18 focus on specific
that allow skilled use of the hand as it relates to hand- areas of dysfunction and intervention. We chose a
object interaction. This is followed by a chapter on the review of research on the effectiveness of improving
embryology, anatomy, kinesiology, and biomechanics hand function for the final chapter.
vii
viii Preface to the Second Edition
Our primary vision continues to be to present in a Health Bureau, U.S. Department of Health and
single text current information on the neurological Human Services, Department of Public Health. The
foundations of hand skills, the development of hand workshops were sponsored by the Occupational
skills, and intervention for children with problems Therapy and Physical Therapy Departments at the
related to hand skills. We hope that a comprehensive University of Illinois at Chicago between 1988 and
review of the hand will provide an important resource 1991. Several of the contributors to the first edition
and clinical guide for students, practicing pediatric participated in yearly task groups on the hand of the
therapists, and others who work with children. child, motivated by the need to share information in a
field where so little had previously been written. It was
from these meetings that the idea of a comprehensive
book on hand skills in children arose. The reception of
ACKNOWLEDGMENTS the first edition by many professional colleagues and
their comments helped shape this second edition.
The editors wish first to acknowledge with gratitude We would also like to acknowledge the help and
the time and expertise donated by the contributors to assistance of Kathy Falk, our editor at Elsevier, whose
this volume. These authors are highly regarded in their support enhanced all the phases of the production of
respective fields, and we thank them for their insights this book by answering our questions and providing a
and the wealth of practical and theoretical under- workable and timely schedule. Thanks also to Sarah
standing they bring through their chapters. We hope Wunderly, our production manager, and other Elsevier
that the diversity of ideas presented here will enrich the staff for assisting in the final phase of our work.
reader’s understanding and appreciation of the im- Finally we want to recognize the families and
mense complexity and the multiple dimensions of the children we and our authors have known through our
human hand and particularly of its importance to daily professional practice and research for they have
living from birth through adolescence. contributed much to our current knowledge of hand
This book is the culmination of the efforts of many function in the child.
people who contributed ideas over an extended period
of time. The formal beginnings of the book occurred Anne Henderson
during a series of workshops for occupational and Charlane Pehoski
physical therapists funded by the Maternal and Child
PREFACE TO THE FIRST EDITION
…[M]an though the use of his hands, as they are energized by mind and will, can
influence the state of his own health.
(Reilly, 1962, p.2)
The hand is our primary means of interaction with the opment and dysfunction in childhood, it seemed timely
physical environment, both though the dexterous grasp to review that which is currently known.
and manipulation of objects and as the enabler of This book is intended for the professional and
multiple tool functions. The enormous variety of actions student interested in the current research and treat-
accomplished by our hands ranges from the practical to ment of problems in children’s hand skills. The text is
the creative. The hand is incredibly versatile. It can be organized around themes from neurobehavior and
a platform, a hook, or a vise. It can hold a football, a development, drawing together information that is
hammer, or a needle. It can explore objects, express pertinent to the understanding of dysfunction in the
emotion, or communicate language. hand in children and as a guidance to intervention.
The hand is the subject of this book, most spe- Hand function is reviewed from the perspectives of
cifically the hand as a tool for action, as an organ of neurophysiology, neuropsychology, cognitive psychology,
accomplishment. The motor functions of the hand are developmental psychology, and therapeutic intervention.
some of the most complex and advanced of all human The text is organized into three sections, each of
motor skills. Hand use is voluntary, under the control which presents several dimensions of hand function.
of the conscious mind, and is regulated by feedback Section I includes chapters on the biologic and
from sensory organs. The complexity of skilled hand psychologic foundations of hand function. The first
use is shown by the long developmental period needed chapter describes the cortical control of skilled hand
for its perfection. The ability to manipulate objects with use and identifies the properties of that control that are
the efficiency and precision of an adult continues to im- different from the control of gross motor skills. The
prove throughout late childhood and early adolescence. second chapter presents the anatomic structure and
The plan for this book grew out of the recognition function of the hand facilitating the varied functions.
that, although the treatment of hand dysfunction has Two chapters on the sensory guidance of the hand
been a critical area of occupational therapy practice function follow, one on touch and proprioception and
since the beginning of the profession, for many years the other on vision. The other two chapters in Section
the professional literature in pediatrics placed a greater I review knowledge from several branches of psy-
emphasis on the neurophysiology and development chology, including the perceptual functions of the hand
of gross motor abilities than on manipulative skills. A and the role of cognition in hand activity.
renewed attention to manipulative abilities, beginning Section II focuses on development in both general
about 15 years ago, was spearheaded by the writings of and specific areas of hand skill. Two chapters in this
therapists such as Rhonda Erhart, Reggie Boehm, and section focus on the development of basic skills. The
Charlotte Exner, and professional literature on the devel- first reviews research on the development of grasp,
opmental treatment of hand skills has since increased. release, and bimanual skills in infancy and the second
During a similar period there has been increasing the development of object manipulation. Other
research attention in the fields of neurophysiology and chapters cover specific and complex skill areas of
psychology to the motor skills of the hand. Although graphic skill and self-care and the development of hand
there are many unresolved issues about hand devel- dominance.
ix
x Preface to the First Edition
Section III provides knowledge from selected information on hand skills will stimulate interest in the
pediatric clinical practice areas. Two of the five chapters development of research programs that will increase the
describe dysfunction and treatment of special popula- body of knowledge about normal and deviant hand
tions with cerebral palsy and Down syndrome. Another skill development and the efficacy of intervention.
chapter presents the principles and practice of the This text was written primarily for pediatric occu-
remediation of hand skill problems, while a fourth pational therapists and could serve as a graduate level
focuses on the specific area of teaching handwriting. text or as a reference book in entry level education.
The remaining chapter identifies the many toys that are However, we anticipate that it will be of value for
the natural media for the treatment of hand dys- anyone working with toddlers and children, including
function in children. preschool and elementary teachers, special educators,
Despite the acceleration of research in the last early intervention providers, and other therapists.
decade, the study of the development of hand use and
the treatment of hand dysfunction in children is still in Anne Henderson
its infancy. It is our hope that assembling this Charlane Pehoski
Chapter 1
CORTICAL CONTROL OF
HAND-OBJECT INTERACTION
Charlane Pehoski
CHAPTER OUTLINE When I first met Katie she was 6 years old and was
having a great deal of difficulty managing the fine motor
MOVING THE FINGERS INDEPENDENTLY: DIRECT tasks typical of most kindergarten children. She was
CORTICOSPINAL CONNECTIONS TO ALPHA clumsy and had difficulty with such tasks as buttoning
MOTOR NEURONS OF THE HAND AND PRIMARY and using tools. Her score on the Peabody Developmental
MOTOR CORTEX Fine Motor Scales was −2.33 standard deviations below
the mean for her age and her age equivalent score was
Direct Corticospinal Connections to Alpha Motor 3 years 6 months. This is not an unusual profile for
Neurons of Hand Muscles children referred because of poor fine motor skills.
Primary Motor Cortex What was unique about Katie was that the source of
Use-Dependent Organization of the Primary Motor her difficulty was known. A benign tumor had been
Cortex removed from her right posterior parietal lobe when
she was 3 years old. Many of the difficulties she experi-
SENSORY GUIDANCE OF HAND MOVEMENTS: enced in hand–object interaction could be attributed to
PRIMARY SOMATOSENSORY CORTEX the location of her lesion. For example, she was under-
Cortical Organization of the Somatosensory System responsive to tactile input and often used excess force
Use-Dependent Organization Within the Primary when holding objects. When asked to feel forms placed
Somatosensory Cortex in her hand without looking, she just grasped them and
did not explore them with her fingers. She had a great
Role of Somatosensory Input in Grasp deal of difficulty in tasks that required “in-hand manip-
Role of Somatosensory Cortex in Motor Learning ulation,” such as moving a small object from the palm
THE TRANSFORMATION OF VISUALLY OBSERVED of the hand to the fingers. Objects often were dropped.
CHARACTERISTICS ABOUT OBJECTS INTO This chapter discusses the posterior parietal lobe and its
APPROPRIATE HAND CONFIGURATIONS: importance for hand–object interaction. However, this
POSTERIOR PARIETAL LOBE AND VENTRAL is not the only important area; other cortical regions
PREMOTOR CORTEX are also explored.
The capacity to use the hand with skill in hand–
Role of the Inferior Parietal Lobe in Preshaping of object interactions represents an evolutionary ability
the Hand characteristic of the behavior of higher primates. Three
Role of the Ventral Premotor Cortex in Preshaping fundamental prerequisites are necessary for this func-
of the Hand tion: (a) the capacity for independent control over the
Use-Dependent Organization of the Inferior Parietal fingers, (b) a sophisticated somatosensory system to
and Ventral Premotor Cortex guide finger movements, and (c) the ability to trans-
form sensory information concerning object properties
The Inferior Parietal Cortex and Tool Use into appropriate hand configurations (Binkofski et al.,
SUMMARY AND THERAPEUTIC IMPLICATIONS 1999). Each of these prerequisites is served by separate
3
4 Part I • Foundation of Hand Skills
but interconnected areas of the cerebral cortex. This ments. This is in contrast to a power grip, in which all
includes the primary motor cortex, primary somato- the muscles are coactivated (Bennett & Lemon, 1996;
sensory cortex, parietal cortex (particularly the area Muir, 1985). Even simple finger movements such as
around the intraparietal sulcus), and premotor cortex this require hand muscles to work in a specific temporal
(particularly the ventral portion). That is not to say that order and with varying amounts of force (Darian-
other motor structures, such as the supplementary Smith, Burman, & Darian-Smith, 1999).
motor areas, cingulated motor areas, cerebellum, and This ability to “fractionate,” or move the fingers
basal ganglion do not also serve important functions individually, is thought to result from the special contri-
(e.g., Ehrsson, Kuhtz-Buschbeck, & Forssberg, 2002; bution of direct corticospinal connections primarily
Lemon, 1999; Schlaug, Knorr & Seitz, 1994), but rather from neurons in the motor cortex to the alpha motor
that the cortical regions mentioned previously seem neuron of hand muscles in the ventral horn in the
critically related to skilled action of the hand, partic- spinal cord (see Lemon, 1993, for a review). The ven-
ularly as it interacts with objects. This chapter reviews tral horn of the spinal cord is divided into two main
each of the mentioned prerequisite skills and the cor- sections, an interneuron zone and the motor neuronal
tical areas important for their functions. The purpose of pool or “final common pathway” to the muscle. The
this chapter is to better understand the problems of motor neurons in the ventral horn are not randomly
children like Katie and provide evidence for the need to distributed but are clustered into cell columns, a medial
encourage skilled hand use in these children. cell column that contains the motor neurons for the
trunk, shoulder girdle, and hips, and a lateral cell col-
umn that contains motor neurons for the distal extrem-
MOVING THE FINGERS ities (Kuypers, 1981). Almost all descending motor
fibers first terminate in the interneuronal zone, so that
INDEPENDENTLY: DIRECT there is at least one interneuron between the descend-
CORTICOSPINAL CONNECTIONS ing motor fiber and motor neuron. An important
exception is the direct corticospinal fibers to alpha
TO ALPHA MOTOR NEURONS OF motor neurons of the distal extremity (Figure 1-1).
THE HAND AND PRIMARY MOTOR This direct path is fast and thought to be important in
moving the hand with speed and skill. These special
CORTEX connections also are thought to be preferentially related
to the intrinsic hand muscles (Maier et al., 2002). The
intrinsic hand muscles provide the ability to handle
DIRECT CORTICOSPINAL CONNECTIONS TO small objects with precision (Long et al., 1970). Direct
ALPHA MOTOR N EURONS OF HAND corticospinal fibers seem to be a feature unique to
M USCLES
As indicated, one prerequisite for skilled hand use is the
Corticospinal tract
control over individual finger movements. This is true
even for a seemingly simple task such as picking up an Direct corticospinal input
object using a precision grip.1 Try picking up a small Indirect corticospinal input
object between your index finger and thumb. Pick it
up slowly enough so you can observe the action of
the fingers. Note the isolation of movement between
the index finger and thumb and the movement of the
Interneuron zone
remaining fingers as they get out of the way of the
action. If, during this task, your hand muscles had been
attached to an electromyograph (EMG) you would
have seen that the muscles necessary for this task
Muscle of distal
showed marked variation with respect to the precise extremity
timing of their onset and time course of activity during
the task, resulting in the specificity of finger move- Figure 1-1 Termination of the corticospinal tract in the
spinal cord. The diagram shows a single fiber that
synapses in the interneuronal zone and then makes
1
This chapter uses the term “precision grip” when referring to the act connections with a muscle through the interneuron. Also
of picking up a small object between the index finger and thumb shown is a fiber within the corticospinal tract that makes
because this is the term used in the neurophysiologic research that is a direct connection to a motor neuron of a distal limb
reviewed. muscle.
Cortical Control of Hand-Object Interaction • 5
primates and are particularly well developed in the most gers. When EMG recordings were made of hand
dexterous primate species (Nakajima et al., 2000). muscles during abduction and adduction movements
Lemon (1993) suggests that the direct corticospinal of the fingers, activation of the first dorsal interosseous
projections allow motor commands to bypass spinal of the normal hand was seen only when the person
mechanisms and break up synergies by direct access to moved the index finger. That is, the muscle’s response
the motoneurons and the final common pathway. This was isolated and only related to the movement of this
allows the flexibility of individual finger movements one finger. In the disabled hand, this muscle was active
with wrist actions appropriate to a given task. with thumb, index, and ring finger movements. The
authors concluded that cerebral areas and descending
pathways that are spared in humans may activate finger
PRIMARY MOTOR CORTEX muscles, but cannot fully compensate for the highly
Although a large number of structures are involved in selective control provided by the primary motor cortex.
the neural control of the hand, the importance of the The primary motor cortex has a particular relation-
primary motor cortex for the execution of independent ship to the hand. The cortical representation of muscles
finger movements is well established (Ehrsson et al., involving the fingers occupies a larger area than those
2002; Huntley & Jones, 1991) (Figure 1-2). Neurons concerned with shoulder movement (Paillard, 1993).
that are the source of the direct corticospinal connec- Hand muscles may also be more dependent on cortical
tions are more numerous in the hand area of the mechanisms. Turton and Lemon (1999) used trans-
primary motor cortex than connections from other cor- cranial magnetic stimulation (TMS) to look at the
tical areas, such as the supplementary motor cortex effects of stimulation of the primary motor cortex on
(Lemon et al., 2002; Maier et al., 2002). This area of EMG output of the deltoid, biceps, and first dorsal
cortex is particularly well represented in nonhuman interosseous muscles when the participants contracted
primates by the ability to form a precision grip. each muscle. (TMS is a noninvasive way to stimulate
Damage to the motor cortex results in deficits in fine neurons in the motor cortex using a small coil placed
manual coordination. Monkeys with lesions to this area over the appropriate area of the head.) They found
lose the ability to produce a precision grip and small that the EMG response to this additional facilitation
objects are picked up by the use of a more mass grasp was significantly greater in the hand muscles than the
in which all the fingers work together (Fogassi et al., biceps, which was greater than in the deltoid. That is,
2001; Rouiller et al., 1998; Schieber & Poliakov, 1998). the “extra” input provided by the TMS through the
Difficulty with independent finger movements can primary motor cortex was greatest in the hand muscles.
also be seen in humans with lesions restricted to the They suggest that this reflects a major difference in the
primary motor cortex or the corticospinal tract. Lang dependence on cortical mechanisms in hand muscles as
and Schieber (2003) found that the fingers of the opposed to more proximal muscles. Therefore the hand
affected hand in patients with damage to these areas seems to have a privileged relationship with the primary
moved less independently than the fingers of the motor cortex.
uninvolved extremity or normal controls. This was par-
ticularly true for abduction and adduction of the fin- USE-DEPENDENT ORGANIZATION OF THE
PRIMARY MOTOR CORTEX
Primary motor cortex One of the significant research findings in the last few
Central sulcus years is that the functional organization of the primary
motor cortex is dynamic and changes as a result of
use. “Use-dependent” changes have been seen in the
motor cortex of a wide variety of animals (e.g., Kleim
et al., 1996; Remple et al., 2001), including humans
(e.g., Classen et al., 1998; Pascual-Leone, Grafman,
& Hallett, 1994). What appears to happen is that the
representation of the “used” muscles expands or the
movements that are used together are represented
together (Nudo et al., 1996). There is not one repre-
sentation of the human hand in the motor cortex;
rather, multiple overlapping representations are func-
tionally connected through a horizontal network
between motor neurons (Butefisch, 2004; Huntley &
Figure 1-2 Diagram of the primary motor cortex. Jones, 1991; Sanes & Donoghue, 2000). Dynamically
changing patterns can be achieved by changing the strength training appear to be less effective in driving
strength of these horizontal networks through use reorganization of the primary motor cortex.
(Butefisch, 2004). This is a requirement for motor Alternately, skill training or learning may be a par-
learning. The brain must have the ability to adapt to ticularly powerful force for reorganization.
new and changing circumstances, including both the With respect to passive movements, Lotze et al.
learning of new skills and recovery from injury (Jackson (2003) used fMRI to look at the effects of 30 minutes
& Lemon, 2001). of passive versus active wrist movement in typical
An example of a “use-dependent” change was demon- adults. They found that the accuracy of wrist move-
strated by Karni et al. (1998). In this study, typical ments improved more with active movements and that
adults practiced a finger sequence task daily for 5 weeks cortical reorganization as measured by fMRI also was
(opposing the fingers of the nondominant hand to the greater with active compared with passive movement.
thumb in a specific order). The participants also were In a clever experiment that looked at the effect of
given a second finger sequence that was not practiced strength training, Remple et al. (2001) trained one
and served as a control for the study. Functional mag- group of rats to break increasingly larger bundles of
netic resonance imaging (fMRI) of the cerebral cortex pasta with their forelimb and a second group to break
was done at the start of the experiment and then weekly single strands of pasta. A control group that had no
until the end of the experiment. The authors found training in either task also was included in the study.
that in the initial images done before the experiment After 30 days of training, the researchers found an
began there were no differences between the cortical increase in the proportion of motor cortex occupied
representation of the experimental and control by distal forelimb movements in both experimental
sequences. At 3 weeks, when the experimental sequence groups but not the control group. They concluded
had been well learned, the area of motor cortex repre- that the development of skilled forelimb movements,
senting the experimental sequence had become larger. but not increased forelimb strength, is associated with
Changes also have been seen using intracortical reorganization of forelimb areas in the primary motor
microstimulation in monkeys, in which the neuronal cortex.
representative of movements in the distal forelimb area The need for the animal to be engaged in a skilled
of the primary motor cortex can be specifically mapped. task or actually learn a task for significant changes in the
In one study the extent of the representation of the primary motor cortex to be observed also has been
hand was mapped and then the monkeys were trained reported. In two complementary studies, Nudo et al.
to pick up small food pellets from a food well (Nudo (1996) and, Plautz, Miliken, and Nudo (2000), the
et al., 1996). After training, intracortical microstimula- researchers trained monkeys to retrieve food pellets
tion of the primary motor cortex was done again and from food wells. In one group, the well was large and
the researchers found that the representation of the therefore the task was fairly easy, so no skill or learning
movements used in the food retrieval task had was involved (Plautz et al., 2000) (Figure 1-3).
expanded. They also looked at the representation of Another group of monkeys was required to use much
unpracticed wrist and forearm movements, and found smaller food wells that required learning to retrieve the
that the representation of these movements had con- food pellet (Nudo et al., 1996). Both groups used the
tracted. To demonstrate that these changes are same fingers and were given the same number of pellets
reversible and that the primary motor cortex changes to retrieve but only in the group of monkeys in which
are based on use, the monkeys were then trained to the task required learning a new skill was there evidence
perform supination and pronation movements in a key of modification of cortical maps. The authors
turning task. Intracortical microstimulation demon- concluded that,
strated an expansion of the forelimb area and contrac-
“Repetitive motor activity alone does not produce functional
tion of the digital representational zones. They also
reorganization of cortical maps. Instead we propose that motor
found that movement combinations used in the acqui-
skill acquisition or motor learning is a prerequisite factor in
sition of these skilled motor tasks had come to be driving representational plasticity in the primary motor cortex”
represented in the same cortical territory. (Plautz et al., 2000; p. 27).
Consequently, use of a particular motor pattern causes
structural reorganization in the primary motor cortex. Even adult patients who had reached a plateau in
Actions that are practiced come to represent a larger their recovery after suffering a stroke showed an
area of cortex and the muscle groups involved also increase in function (Taub & Morris, 2001) and expan-
come to be represented together in what appear to be sion of the cortical hand representation (Liepert et al.,
functional groupings (Nudo et al., 1996); however, not 2000) after constraint induced movement therapy
all “use” or practice may be as effective in driving these (noninvolved extremity restrained to force use of the
changes. As discussed later, passive movements and involved extremity).
be related to an increased demand on body scheme

representation that is needed for instructing the
appropriate parts of the hand to move. The cingulate
may represent the recruitment of secondary motor
function for the execution of simple hand movements.
After the splint had been removed for several weeks, a
second scan showed movements related to the puta-
men, a subcortical structure. The authors indicated that
the shift from cortical to subcortical involvement may
indicate that movements have been relearned.
In summary, hand skill is possible because of the
ability to move the finger individually and with speed.
This ability is provided by the primary motor cortex
11.5mm 9.5mm 13.5mm 19.5mm 26mm and direct corticospinal fibers to hand muscles. The
integrity of this cortical motor system is being tested
Figure 1-3 Depiction of a squirrel monkey performing a in part when a child is asked to tap his or her index
large pellet retrieval task. Note the relative simplicity of finger and thumb together as rapidly as possible or
the task because of the size of the well compared with quickly oppose the individual fingers to the thumb.
the size of the animal’s hand. (Redrawn from Plautz E, The speed with which these movements can be per-
Miliken G, Nudo R [2000]. Effects of repetitive motor training formed increases with age (e.g., Denckla, 1974). Evans,
on movement representation in adult squirrel monkeys: Role
of use versus learning, Neurobiology of Learning and Harrison, and Stephens (1990) suggest that there is
Memory, 74:27–55.) a relationship between a child’s ability to perform rapid
finger movements and maturation of a cutaneo-
muscular reflex dependent on the corticospinal tract,
Use can change the organization of the primary as well as the main sensory pathway. The results of
motor cortex, but disuse also can have an effect on maturation in this system are demonstrated when an
centers important to motor skills. Using kittens, Martin infant of 9 to 10 months begins to use a precision grip
et al. (2004) demonstrated that restricting the use of to pick up small objects (Siddiqui, 1995). It is apparent
one paw for the first 7 weeks after birth created perma- that the hand needs to be used, particularly in skilled
nent changes both in the skill of that paw and the tasks. This need for use also is seen for other cerebral
morphology of the direct corticospinal connections areas involved in control of the hand, particularly the
in the spinal cord. In another example, a group of primary somatosensory cortex, which is discussed next.
researchers followed adults who had undergone sur-
gical treatment of the flexor tendons of the hand
(deJong et al., 2003). For 6 weeks after surgery, the
patients were required to wear a dynamic immobi- SENSORY GUIDANCE OF HAND
lization splint that allowed passive but not active finger
flexion. After the splint was removed, the patients
MOVEMENTS: PRIMARY
complained of a temporary clumsiness of the hand that SOMATOSENSORY CORTEX
could not be explained by stiffness of the fingers or
adhesions. In one patient, EMG studies were done The hand is both a motor and sensing organ and there
after splint removal and flexion of the fingers showed is a tight interplay between these two functions. The
increased cocontraction of the extensor muscles and delicate movements of the hand and fingers are needed
no full relaxation of this muscle was seen between sets to “gather” sensory information, and those delicate
of movement. In four patients, positron emission movements need sensory feedback to guide action,
tomography (PET) was used to look at task-related particularly actions with objects. When objects are
increases in cerebral blood flow as they flexed their handled they do not fall from the fingers, nor does
fingers. These scans were done immediately after the one use excessive force when picking things up. The
splint was removed and again 6 to 10 weeks after information needed for these activities is provided by
removal. They found that scans immediately after splint sensory feedback. The importance of this sensory infor-
removal demonstrated activation in the posterior mation is obvious when one removes a glove to gather
parietal lobe and cingulate sulcus. This was not seen in change from a pocket or when performing any delicate
the nonsurgical hand. The authors suggested that the activity with the hand. Figure 1-4 shows the attempts
increase in parietal involvement (an area of tactile and of a woman with complete loss of sensation in her right
visual convergence discussed later in this chapter) may hand trying to crumple a piece of paper (Jeannerod,
RH LH Michel, & Prablanc, 1984). Note the difficulty she has

in coordinating the fingers of her right hand. She was
reported to be able to reach for objects, eat normally,
and write (although with difficulty), all tasks she could
control using vision. Activities outside visual control,
such as combing hair or buttoning, were problematic,
as were activities that require the fingers to work
together as in the paper-crumbling task. No detectable
motor deficit, such as the ability to perform rapid
tapping of the index finger, was noted (i.e., motor
functions were intact). A computed tomography (CT)
scan found that this woman had a very large lesion
involving the somatosensory cortex and superior
parietal lobe (Jeannerod, Michel, & Prablanc, 1984).
(Note that this woman’s lesion extended beyond the
primary sensory cortex and probably contributed to the
severity of her disability).
Figure 1-5 shows similar disorganization of finger
movements in a monkey with a lesion in area 2 of
the somatosensory cortex (Hikosaka et al., 1985).
Brochier, Boudreau, and Smith (1999) also found a
loss of finger coordination and poor positioning of the
fingers when grasping objects in monkeys with
inactivation of the somatosensory cortex.
This section discusses the important roles sensory
information plays in skilled hand movements, including
the role it plays in motor learning.
CORTICAL ORGANIZATION OF THE

SOMATOSENSORY SYSTEM
The primary receiving area for somatosensory informa-
tion from the limbs is the area of cortex just behind the
central gyrus. This area generally is called the primary
somatosensory cortex (Figure 1-6). It is the major ter-
mination of the dorsal columns, which carries discrete
somatosensory information from the periphery. This
major tract has evolved in parallel with the corticospinal
tract, and like this system it reaches it highest level of
development in humans (Paillard, 1993). Information
carried in the dorsal columns can register even small
movements of joints and provide knowledge of the
exact location of stimulus on the skin. It was designed
to provide specific information about what is happen-
ing in the periphery.
In both monkeys (Sakata & Iwamura, 1978) and
humans (Moore et al., 2000) the primary somatosen-
sory cortex is composed of four areas, generally called
Brodmann’s areas 3a, 3b, 1, and 2 (see Figure 1-6). An
Figure 1-4 Schematic of a woman with a lesion in the
somatosensory cortex and superior parietal lobe understanding of the function of the primary somato-
attempting to crumble a sheet of paper with her left sensory area is helpful to appreciate the complexity of
hand (LH) and involved right hand (RH). (Redrawn from information processing within this area, particularly for
Jeannerod M, Michel M, Prablanc C [1984]. The control of the hand.
hand movements in a case of hemianaesthesia following a
Afferent fibers from the dorsal columns project
parietal lesion. Brain, 107:899–920.)
mainly to area 3b for cutaneous input and area 3a for
IPSI
CONTRA
Figure 1-5 Disruption of finger coordination after inactivation of area 2 in a monkey. The sequence of movements (left
to right) shows the animal’s attempts at picking up a piece of apple from a funnel. IPSI indicates the “normal” hand
ipsilateral to the inactivated region. CONTRA indicates the disorganized movements of the affected hand contralateral to
the inactivated region. (Redrawn from Hikosaka O, Tanaka M, Sakamoto M, Iwamura Y [1985]. Deficits in manipulative behaviors
induced by local injection of muscimol in the first somatosensory cortex of the conscious monkey. Brain Research,
325:375–380.)
deep, proprioceptive information (information arising mon behaviors of the animal. Like the primary motor
from an activity such as active flexion and extension cortex, which tends to cluster muscles that have repeat-
of the fingers) (Iwamura, 1998; Moore et al., 2000). edly worked together in interconnected networks, the
Area 3b sends information to area 1 and area 1 sends same appears to be true of sensory information
information to area 2. Both areas then send informa- processed in the primary somatosensory cortex. Also
tion to the parietal lobe (Inoue et al., 2004). Therefore like the motor cortex, the organization of the sensory
there is a serial or hierarchical processing of informa- cortex is dependent on use. Therefore these two areas
tion across this area (Ageranioti-Belanger & Chapman, allow for a great deal of flexibility in how information
1992; Inoue et al., 2004; Iwamura, 1998; Iwamura is organized to best serve a variety of functional
et al., 1985). One of the transformations in sensory activities.
information that is seen as information is processed in
more posterior cortical regions is the response of a USE-DEPENDENT ORGANIZATION WITHIN
single neuron to stimulation over wider areas of skin.
THE PRIMARY SOMATOSENSORY CORTEX
For example, there is an increase in the number of
multidigit receptive fields (the area from which stimu- The primary sensory cortex is dynamic and changing.
lation causes a single cortical neuron to fire) when pro- This has led one researcher to suggest that at any given
gressing from area 3b, where 46% of neurons respond time the details of the somatosensory cortex organ-
to multiple sites; to area 1, where the percentage is ization reflect the behavioral experience of the animal
63%; to area 2, where 85% of neurons respond to (Recanzone et al., 1992). That is, the sensory represen-
stimulation from multiple sites (Ageranioti-Belanger & tation of the extremities contracts or expands depend-
Chapman, 1992). That is, the discrete information that ing on the use or lack of use of a body part. In an
first arises from the periphery appears to be combined interesting study, Scheibel et al. (1990) did a post-
into progressively more functionally relevant networks. mortem examination of the dendritic complexity in
In a study of neurons in area 2 of monkeys, Iwamura several areas of the cerebral cortex in 10 individuals.
et al. (1985) suggested that this convergence represents The authors found a great deal of variability in the hand
skin surfaces that come in contact as the result of com- area of the somatosensory cortex of these individuals
Central Sulcus difficult task conditions or in which the animal had to

3a 3b 1 2
learn a skilled task.
In another study, Recanzone et al. (1992) trained
Primary
somatosensory two groups of monkeys to place their hands on a mold
cortex of the hand. The purpose of the mold was to keep the
hand in the same position so a vibratory stimulus could
be given to a small site on one of the fingers. One
group of animals was trained to lift the hand when they
perceived changes in the vibratory input. In other
words, these monkeys were to attend to and then make
an adaptive response to this tactile stimulus. Another
group of monkeys also received the vibratory stimulus
but were trained to lift the hand to changes in an
A auditory stimulus. These animals therefore received the
Central vibratory stimulus in a passive manner and were not
sulcus
required to act on the input. When the area in the
primary sensory cortex of these animals that represents
2 the stimulated portion of skin was mapped, both exper-
1 imental animals showed an increase in the represen-
tation of this skin area. However, the increase in the
B 3b animal who had been the passive recipient of the vibra-
tory stimulus was modest. The authors suggest that
attention influences cortical reorganization and that
3a
stimulation alone is far less effective in driving cortical
reorganization than an active response to the stimulus.
Figure 1-6 A. Somatosensory cortex. B. Cross section
In other words, being engaged in the activity and
of somatosensory cortex showing Brodmann’s areas 3a,
3b, 1, and 2. making an adaptive response based on sensory input
were the most efficient means of driving the cortical
changes seen in this study.
It also should be mentioned that in humans, Godde,
and felt that at least in some (e.g., former typist, appli- Ehrhardt, and Braun (2003) showed a 20% decrease in
ance repairman) these differences might be related to two-point thresholds on the tip of the index finger and
the individual’s premorbid occupation. In a more recent a change in the cortical map of this finger after 3 hours
study, Hashimoto et al. (2004) used noninvasive tech- of intermittent, purely passive tactile stimulation to the
niques to study the somatosensory cortex in string fingertip. Apparently passive input also can promote
players. They found an enlarged cortical representation organizational changes in the primary somatosensory
of the hand area in these individuals compared with cortex along with some modest improvement in tactile
controls who did not play a string instrument. discrimination.
Like the motor cortex, research seems to indicate
that skilled learning or attention to a task may be par-
ticularly effective in mediating these cortical changes.
ROLE OF SOMATOSENSORY I NPUT IN G RASP
Using a behavioral task similar to the one used for Tactile information from the fingers is necessary to
studying the changes in the motor cortex of monkeys, adjust the grip to the weight and friction of an object.
animals were trained to pick up food pellets placed in This is particularly true when picking up a small object
wells of varying diameters (Xerri et al., 1999). This in the fingertips. Sensitive tactile receptors in the
included large-diameter wells in which the pellets were fingertips are able to sense the “slip” of an object even
easy to retrieve, and smaller-diameter wells in which before this slip comes to conscious attention. Appro-
retrieval was more difficult. The researchers found that priate adjustments in the grip then can be automatically
sensory neurons responsive to the specific finger sur- made (Johansson & Westling 1984, 1987; Westling &
faces that had been engaged in the small retrieval task Johansson, 1984). If the friction between the finger
showed major representative changes within area 3b and objects is different for different fingers, these dif-
of the somatosensory cortex that were not seen with ferences are monitored separately (Edin, Wrestling, &
other finger surfaces. That is, changes reflected digital Johansson, 1992). That is, if one side of an object is
surfaces that were necessary for object retrieval under covered with silk and contacted by the index finger and
the other side of the object is covered with sandpaper example, Pavlides, Miyashita, and Asanuma (1993) had
and contacted by the thumb, each finger adjusts to monkeys learn a new motor task, but with each of the
the frictional conditions on its grip surface. Anesthesia two hands subject to different conditions. In the first
of the fingers results in an increase in the dropping condition, the somatosensory cortex to one hand was
of objects (particularly small and slippery objects) lesioned. When the monkey had recovered from sur-
and the application of significantly greater grip forces gery, both hands were trained to retrieve food pellets
(Augurelle et al., 2003; Monzee, Lamarre & Smith, falling at various velocities from a dispenser. The
2003; Westling & Johansson, 1984). The “just right authors found that the hand contralateral to the lesion
grip,” which includes just enough margin of safety so had difficulty learning the task and even when learned,
the object will not be dropped, is lost. Anesthesia of the never achieved the skill of the “normal” hand. In the
fingers also appears to prevent the exact alignment of second condition or experiment, the primary sensory
the fingers on the object surface. Monzee, Lamarre, cortex to the “normal” hand was lesioned. Despite this
and Smith (2003) found that although these misalign- damage, the ability to perform the task with this hand
ments were too small to be visually apparent, they still remained. The authors concluded, “The corticocortical
caused enough of a tangential force so that the meas- projections from the somatosensory to the motor cor-
ured grip forces were close to the slip point. Therefore tex play an important role in learning new motor skills,
sensation from the fingers not only allows the appli- but not in the execution of existing motor skills”
cation of appropriate grip forces and adjustments to (Pavlides, Miyashita, & Asanuma, 1993, p. 733).
small slips, this information also appears to help place- Practicing a task produces a vigorous circulation of
ment of the fingers to the most appropriate position for impulses among the peripheral sensory inputs, somato-
a secure grip. sensory cortex, and primary motor cortex (Asanuma &
Because accurate sensory information is necessary Pavlides, 1997; Nadler, Harrison, & Stephens, 2000;
for calibrating the “just right” grip force, children with Stefan et al., 2000). This specific input from the pri-
reduced sensation in the hand, such as Katie, might mary somatosensory cortex to the motor cortex is said
have difficulty modulating grip and therefore manipu- to serve as a “teacher” (Asanuma & Pavlides, 1997).
lating small objects. This reduction in sensation has The “teacher” informs the motor cortex of the results
been found in children with cerebral palsy (see Eliasson, of a movement so that eventually the exact combi-
this volume), as well as children with developmental nation and sequence of muscles needed for the task can
coordination disorders and attention deficit disorder be selected.
(Pereira et al., 2001). Differences in establishing the Everyone has experienced clumsiness when learning
“just right” grip also might be suspected in children a new skill. The movements are not smooth and unnec-
with Down syndrome who have been shown to have essary movements (and therefore muscles) are used
impaired peripheral somatosensory function in the when performing the task. As the task is practiced,
upper extremity (Brandt, 1996; Brandt & Rosen, 1995). these unnecessary movements are eliminated and an
Even in young children, the ability to adjust the grip efficient, reproducible series of actions is seen.
force to the “just right” level is problematic. Young Try this activity. Pick up a pencil with your preferred
children, particularly those 4 years or younger, tend to hand with the fingers close to the eraser end rather than
use significantly larger grip forces when compared with the writing end. Now move your fingers up the pencil
adults (Forssberg et al., 1991). This may be one reason shaft until they are in the proper position for writing.
why an in-hand manipulation task such as moving a Try the same activity with your nonpreferred hand. Did
small peg from the palm to the fingers or turning a peg you note a marked difference in the skill of this task
over in the fingers is difficult for children 4 years of age on the two sides? Was the nonpreferred side awkward
and younger (Pehoski, Henderson, & Tickel-Degnen, and clumsy? A possible interpretation of the study by
1997a,b). This was a difficult task for Katie; she often Asanuma and Pavlides (1997) is that practice is one of
dropped the manipulated object. the differences between the two hands in this task. The
nonpreferred hand has not had an opportunity for
ROLE OF SOMATOSENSORY CORTEX IN sensory feedback to “teach” the motor cortex how to
do the task most efficiently.
MOTOR LEARNING It is not hard for people to understand how impor-
Area 2 in the primary sensory cortex is connected to tant sensory feedback is to hand function. Everyone has
the primary motor cortex through corticocortical con- experienced the frustration of picking up a small object
nections (Asanuma & Pavlides, 1997). Sensory infor- from the table with a Band-Aid covering the distal pad
mation from the hand may be important to learn a new of one finger. Just think of how clumsy skilled motor
motor skill but not to retain a skill already learned. For acts of the hand would be if this reduction in sensation
were experienced throughout the entire hand. One ROLE OF I NFERIOR PARIETAL LOBE IN
would have difficulty moving the fingers with skill and
adjusting the hand to the “just right” grip so objects
PRESHAPING OF THE HAND
are not dropped.2 There might even be some difficulty Almost all interactions with objects start with a reach.
learning a new motor task with the hands. Nonetheless Reach is composed of two main parts, the transport of
actual engagement with objects is more complicated the hand and the preparation of the hand for grasp (see
than just picking them up so they do not drop or Rosblad, this volume). Each of these requires different
manipulating them within the hand. This is particularly visual information about the object. Reach requires
true for tool use. Preparation for grasp occurs even the analysis of distance and direction. Preparation of
before the object is touched and is based on the the hand for grasp requires the analysis of the object’s
observed characteristics of the object and the use that shape, size, and orientation (Jeannerod et al., 1995).
will be made of the object. Consideration of the pos- Try this: Place two objects of different sizes on the
terior parietal lobe and connection with the premotor table, such as a paper clip and the box the paper clip
cortex is covered next. comes in, then reach for each one. Note the difference
in the hand opening for the larger as opposed to the
smaller object. As the hand is brought toward the
THE TRANSFORMATION OF object, the fingers open to ready the hand for grasp,
VISUALLY OBSERVED and this opening is calibrated to the size of the object
to be grasped, although it is always a bit larger than the
CHARACTERISTICS ABOUT object itself (Jeannerod, 1981).
OBJECTS INTO APPROPRIATE Here is another activity. With one hand, hold a
pencil out in front of you and reach for it with the other
HAND CONFIGURATIONS: hand while the pencil is held in a vertical position and
POSTERIOR PARIETAL LOBE AND then with the pencil in a horizontal position. Did you
rotate your forearm during the reach to accommodate
VENTRAL PREMOTOR CORTEX the difference in orientation of the pencil (e.g., “thumb
up” for the vertical position and “thumb down” for the
Think for a moment what it would be like if one had horizontal position)? Not only is the hand opening
an excellent mechanism for the control of finger “programmed” as a part of the reach, but forearm rota-
movements and somatosensory feedback to guide the tion and wrist position also are part of the pattern of
movements but did not have a mechanism for selecting the reach. All of this preparation ensures that a secure
the grasp appropriate for a particular object. There grasp is achieved once contact with the object is made
would be a lot of trial and error. Movements would be (Jeannerod et al., 1995).
slow. A glass would be approached in the same way as The ability to scale the hand opening and orient
a fork. The hand would land on an object and then the hand appropriately to an object is not seen in
“feel” for the appropriate grasp. One function that young infants. Changes to the orientation of the wrist
would help would be vision. Up until now vision has or forearm to an object is seen at about 7 to 9 months
not been considered. The primary motor cortex has of age (Lockman, Ashmead, & Bushnell, 1984;
limited access to direct visual information (Jeannerod Morrongiello & Rocca, 1989; von Hofsten & Fazel-
et al., 1995). Vision allows for the preparation of grasp Zandy, 1984; McCarthy et al., 2001) and adjusting the
before contact; therefore the hand could be preshaped opening of the hand to changes in an object’s size at
to match objects of different shapes, sizes, and orien- about 9 months of age (von Hofsten, 1979, 1991; von
tation. Any final adjustments could be made by Hofsten & Ronnquist, 1988).
somatosensory feedback on contact. This preshaping of The transformation of the visual image of an object
the hand is one of the functions provided by a posterior into an appropriate hand opening and orientation is
parietal cortex–prefrontal lobe cortex circuit. processed in the posterior parietal lobe. In a study of
reach and grasp in monkeys, the timing of the firing of
neurons in the posterior parietal lobe was compared
2
It should be noted that besides the neural mechanisms responsible with those of the primary somatosensory cortex
for the “just right” grip, there are other ways to increase the friction (Debowy et al., 2001). The researchers found that the
at the finger–object interface, the oils or moisture of the fingers neurons in the posterior parietal lobe were more active
themselves. Washing and drying the hands (Johansson & Westling,
1984) or the introduction of chemicals that reduce sweating of the
during the approach stage as the hand was preshaped
hands (Smith, Codoret, & St-Amour, 1997) cause an increase in the and before the hand touched the object. Most of
grip force. the somatosensory neurons fired on contact with the
object. Contact appeared to be the transition point with the ventral premotor area, superior parietal lobe,
from visually guided behavior to tactile guidance of the and secondary sensory cortex) when imaging studies
action. were done of typical adults manipulating complex
The posterior parietal lobe is composed of two parts, objects in their hands.
the superior and inferior parietal lobes (Figure 1-7). It
is an important center for the integration of sensory ROLE OF THE VENTRAL PREMOTOR CORTEX
information, particularly somatosensory and visual
IN PRESHAPING OF THE HAND
information. With respect to somatosensory input, this
area completes the hierarchical processing of this infor- Registering information about an object’s size, shape,
mation that started in the primary somatosensory cor- and orientation is important, but the parietal lobe is
tex. The superior parietal lobe receives information primarily a sensory area and this information must be
from area 1 and more strongly from area 2 in the transferred from sensory to motor areas for use in
primary somatosensory cortex (Hyvarinen, 1982). The actual movement execution. The anterior interparietal
inferior parietal lobe’s sensory representation is more sulcus has corticocortical connections with the ventral
complex than the superior parietal lobe because it not premotor area (Luppino et al., 1999) (Figure 1-8). The
only receives information from areas 1 and 2 and the “description” of the object is used here to select the
superior parietal lobe, it also receives a great deal of most appropriate grip.
information from the visual cortex; therefore this is Neurons in the ventral premotor cortex area of
an area where visual and somatosensory information monkeys, such as those in the anterior parietal sulcus,
converge (Hyvarinen, 1982; Mountcastle et al., 1975). are selective in the type of objects that cause them
Within the inferior parietal lobe is an area that has to fire (Rizzolatti et al., 1988). In monkeys, many
recently attracted much attention, the anterior intra- neurons in this area can be classified by their action
parietal sulcus (see Figure 1-7). In this area are neurons (e.g., grasping, holding, tearing, or manipulating);
related to grasping that fire preferentially to the shape, grasping neurons are most represented. Many also are
size, and orientation of objects (Sakata et al., 1995, selective to the type of prehension used, such as a
1999; Taira et al., 1990). Patients with lesions in this precision grip, finger prehension, or whole hand pre-
area have no difficulty in reaching but hand shaping is hension. (These grips are the three most common grips
significantly disturbed and often there is no preshaping seen in monkeys [Fadiga & Craighero, 2003].) Some
of the hand at all (Binkofski et al., 1998). Monkeys neurons in this area are specific for different finger
with reversible inactivation of this area also have diffi- configurations within a grip type. They are also selec-
culty grasping. Grasping in these animals often is achieved tive to what part of the grip movement they fire. Some
only after several corrections that rely on tactile feed- discharge during the whole action with the object, others
back (Gallese et al., 1994). Binkofski et al. (1999) during finger closure, and others after contact with the
found neurons in the intraparietal sulcus active (along object; therefore these neurons form a “vocabulary”
Central sulcus Primary

Primary motor
somatosensory
cortex
cortex
Ventral premotor Central sulcus
Superior cortex
parietal
lobe
Intraparietal
sulcus
Inferior parietal lobe

Figure 1-7 Diagram of the intraparietal sulcus dividing Figure 1-8 Diagram of ventral premotor area and
the superior parietal lobe and inferior parietal lobe. relationship to primary motor cortex.
of possible actions the hand can take on an object (see

Rizzolatti & Fadiga, 1998, for a review). This vocab- USE-DEPENDENT ORGANIZATION OF THE
ulary is related more to the goal of an action than to I NFERIOR PARIETAL AND VENTRAL
individual movements (e.g., a specific neuron might fire
to “grasping” with the mouth and also with either
PREMOTOR CORTEX
hand) (Rizzolatti et al., 1988; Rizzolatti & Fadiga, Although use-dependent changes have not been
1998). directly studied in either the anterior intraparietal
The ventral premotor cortex is connected to the sulcus or the ventral premotor area, it seems apparent
primary motor cortex and from there to the direct that these areas are influenced by use. As an example,
corticospinal fibers to hand muscles (Luppino et al., one of the most common types of grasping neurons
1999). What differentiates the primary motor cortex found in the ventral premotor cortex in monkeys are
from the ventral premotor cortex is that the latter those that respond to a precision grip, a grip formation
stores motor schemata that are goal directed, whereas that is not seen in young infant monkeys, but is seen
the primary motor area stores movements regardless with increasing regularity as monkeys get older (Lemon,
of the action or context in which they are used 1993). Rizzolatti and Luppino (2001) suggest that the
(Rizzolatti & Fadiga, 1998). That is, the visual infor- matching between the visually observed characteristics
mation processed in the anterior intraparietal sulcus of an object and appropriate motor programs occurs
about the three-dimensional characteristics of an object early in life and is accomplished through processes that
is sent to the ventral premotor cortex for the selection associate the intrinsic visual properties of the object with
of grip and then to the motor cortex for sequencing of the grips that are effective in interacting with them.
the actual muscles to be used.
Neurons in the inferior premotor area are known to THE I NFERIOR PARIETAL CORTEX AND
facilitate neural action in the primary motor cortex.
Stimulation of a neuron in the hand area of the primary
TOOL USE
motor cortex of monkeys causes changes in the EMG Hand positioning to pick up an object requires a
reading from hand muscles, but stimulation of an posture adapted to the features of the object (e.g., size,
inferior premotor neuron or inferior parietal neuron shape), but picking up an object to actually use it also
alone does not. If stimulation is first given to the requires that the grip anticipate what action will be
premotor cortex and then to the primary motor cortex, performed. Think about the difference in hand position
the EMG hand muscle response is greater than when used when holding a pencil to punch a hole in a piece
the motor cortex is stimulated alone. The authors of cardboard as opposed to picking up a pencil to write.
indicate that this input might be part of the wider The posterior parietal lobe is implicated in this function.
control system that helps shape the pattern of activity Sirigu et al. (1995) describe a patient with a bilateral
of different hand muscles for grasp of specific objects lesion in the posterior parietal lobe who had normal
(Shimazu et al., 2004). sensory and motor functions, yet had a great deal of
If a small injection of an agent that temporarily difficulty grasping tools. Figure 1-9 illustrates some
inactivates neurons is placed in the ventral premotor of the patient’s problems grasping common objects,
cortex of monkeys, the results are similar to those seen such as a nail clipper, spoon, and scissors. At home she
with inactivation of the anterior interparietal sulcus. had difficulty using objects in such tasks as brushing
That is, the animal is able to use tactile feedback to her teeth, locking her door, and cutting meat. What
succeed in an appropriate grasp when preshaping of the was of particular interest in this patient was that if the
hand is absent, but only after contact with the object, examiner corrected the patient’s grasp and the object
This is particularly true for small objects (Fogassi et al., was placed in her hand appropriately, she could per-
2001). It is interesting that large lesions at this site also form with normal movement kinematics. Further, if the
produced problems with hand shaping of the ipsilateral patient was asked to just grasp an object and not use it,
hand. Further, when monkeys with large lesions were appropriate preshaping of the hand and wrist to the
presented with raisins placed in a board with two rows object’s physical characteristics was seen. It was the
of six horizontally placed holes, the monkeys tended capacity to match the grasp to the object’s use that
to pick up the raisins in the right holes with the right seemed to be missing in this patient. Apparently the
hand and those on the left with the left hand. They posterior parietal cortex is important for this function.
also tended to remove the raisin first from the holes Another feature of skilled tool use is that when the
ipsilateral to the injection site. When food was pre- hand uses a tool, the tool becomes an extension of the
sented bilaterally, they always preferred the ipsilateral hand. When one writes, one is not aware of the pen as
presentation. a tool separate from the hand. Rather, it is an integral
A B C
1 2
3 4
Figure 1-9 Spontaneous hand use of a woman with a bilateral disturbance of the posterior parietal lobe as she
attempts to use a: (A) lighter, (B) nail clipper, (C) soup spoon, and (D) scissors (successive attempts). (Redrawn from
Sirigu A, Cohen L, Duhamel J, Pillon B, Dubois B, Agid Y [1995]. A selective impairment of hand posture for object utilization in
apraxia. Cortex, 31:41–55.)
part of the automatic movements that create the letters. ventral premotor area, which also appears to be impor-
It appears that the sense of the tool as an extension of tant for hand use. There is one other function of the
the hand has a neurologic correlate that includes the parietal lobe related to object interaction that should be
tool into the body scheme of the hand. mentioned, the guidance of movements when explor-
Working with monkeys, Iriki, Tanaka, and Iwamura ing an object manually. The term “tactile apraxia” has
(1996) pointed out that the visual receptive fields of been used to define a problem in this area (Pause et al.,
neurons within the anterior intraparietal sulcus changed 1989). In patients with tactile apraxia, exploratory
when the monkey used a rake to obtain food pellets movements are described as slow and clumsy and may
(Figure 1-10). Soon after the monkey began to use the consist of only squeezing the object (Binkofski et al.,
rake, the visual field was seen to change to not only 2001; Pause & Freund, 1989; Valenza et al., 2001).
cover the area around the hand but also to include the This problem has been seen in a variety of parietal
total length of the rake. This did not happen when the lesions (Binkofski et al., 2001; Pause & Freund, 1989;
animal only held the tool or just moved a stick back and Valenza et al., 2001), including the primary somato-
forth. That is, when the rake was used as a tool, the sensory cortex (Motomura et al., 1990; Tomberg &
rake and the body schema of the hand came to be Desmedt, 1999). The problem does not appear to be
represented together. When imaging studies were done related to the severity of any somatosensory distur-
of humans picking up a small object with tongs or with bances that might be present. That is, a patient with a
just the fingers, the intraparietal sulcus was again significant sensory loss may be better able to manipu-
implicated in the tool use task (Inoue et al., 2001). late an object for identification than a patient with
It appears that the anterior intraparietal sulcus is an better-preserved sensation (Pause et al., 1989; Valenza
important area concerned with the preparation and et al., 2001). Problems moving her finger around
grasp of objects and may be particularly important for objects in a manual form identification task was one
tool use. This area has strong connections with the area with which Katie had difficulty. She tended to just
A B
table
Food dispenser
Figure 1-10 A. Monkey using a rake to obtain a food pellet that was dispensed out of its reach from a container. B.
Simple stick manipulation task in which the food pellet was delivered at a reachable distance as a reward for swinging
the stick. (Redrawn from Obayashi S, Suhara T, Kawabe K, Okauchi, Maeda J, Akine Y, Onoe H, Iriki A (2001): Functional brain
mapping of monkey tool use, Neuroimage 14: 853-861.)
hold the object. As one group of researchers said, “The enough force so that it is not dropped is dependent on
parietal lobe is not only involved in the elaboration and sensory input from the fingers. The exact placement of
further processing of somatosensory information, but the fingers on an object after grasp is also dependent on
also in the conception and generation of those motor sensory feedback.
programs required to collect this information.” (Pause Humans have an important cortical loop for the
et al., 1989, p. 1622). control of skilled hand function and the interaction
with objects, the primary motor cortex and primary
sensory cortex connection (Figure 1-11). However,
SUMMARY AND THERAPEUTIC the described actions are relatively simple and human
object use is not simple. The second cortical circuit
IMPLICATIONS between the posterior parietal lobe (particularly the
anterior intraparietal sulcus) and the ventral premotor
This section reviews the covered information. The area is important in the selection of the appropriate
primary motor cortex is critical to the ability to move grip patterns. As indicated, the inferior portion of the
the fingers individually and speedily. Without this posterior parietal lobe receives both somatosensory
input, hand movements are characterized by varying information from the primary sensory cortex and visual
degrees of muscle cocontraction so movements are information from the visual cortex, resulting in com-
stiff, awkward, and slow. This ability to “fractionate” plex bimodal neurons (neurons that respond to both
movements of the hand is transmitted by the cortico- somatosensory and visual information). Vision infor-
spinal tract, particularly through direct corticospinal mation about an object provides information about
connections to the motoneurons of hand muscles. the object’s size, shape, and orientation. This allows the
Through intracortical connections of the various hand hand to be preshaped to the object’s characteristics
muscles in the primary motor cortex, movements used before contact. This visual information is transferred to
together come to be represented together. When a the premotor area through corticocortical connections
movement is performed, this action generates sensory in which the appropriate grip pattern is chosen. The
feedback. Discrete information related to the move- premotor area then sends this information to the pri-
ments is carried back to the primary sensory cortex by mary motor cortex for the selection and timing of the
the dorsal columns. This information can then be fed necessary muscles. This in turn results in sensory infor-
back to the motor cortex via corticocortical connec- mation fed to the primary sensory cortex and back
tions so any necessary corrections of the movements to the motor cortex, completing the circuit (see Figure
can be made. Through practice, the correct combina- 1-11). The anterior intraparietal sulcus of the posterior
tion and timing of muscles can be perfected through parietal lob also is important for incorporating the tool
this mechanism. Once learned, feedback is much less into the body schema of the hand, therefore making
important. This is not to say that everyday, learned the tool an extension of the hand. It also should be
movements are not dependent on sensory information. noted that there are hand skills that have not been
The ability to pick up an object and hold it with just discussed in this chapter; many of these are covered in
4 1
4 3 2
3
1 2
Dorsal column
Corticospinal
tract
A B
Figure 1-11 A. Diagram of a somatosensory and a primary motor cortex circuit. (1) A message from the primary motor
cortex is sent to the muscles via the corticospinal tract; (2) sensory feedback is sent through the dorsal column as a
result of the movement (3) of sensory input to the primary somatosensory cortex; (4) sensory information is sent from
the primary sensory cortex to the primary motor cortex for any necessary correction of the movement. B. Diagram of
somatosensory, inferior parietal lobe, ventral premotor cortex, and motor cortex circuit. (1) Sensory information is sent to
the inferior parietal lobe; (2) visual information also is transferred to the inferior parietal lobe; (3) information from the
inferior parietal lobe is sent to the ventral premotor cortex; (4) the ventral premotor area transfers information to the
primary motor cortex and from there to the corticospinal tract.
other chapters of this book (e.g., handedness, reaching, As discussed, the cortical reorganization responsible
eye–hand coordination, and perceptual functions of for skilled learning, particularly as it relates to hand–
the hand). object interaction, is use dependent. It is through use
This chapter has concentrated on the performance that functional patterns of movement or the muscles
of the hand in hand–object interaction, and has not necessary for the action come to be represented togeth-
discussed the shoulder or postural support as back- er. The same is true of patterns of somatosensory input.
ground for these skilled movements. These are also Surfaces that are used together come to be represented
important aspects of hand function. For example, together. This happens through practice. Also as indi-
Smith-Zuzovsky and Exner (2004) found that 6- and cated, this structural reorganization is best accom-
7-year-old children who were positioned in furniture plished through tasks that require skill or the learning
that was fitted to their size did significantly better on a of an activity. It also requires attention to the task.
test of in-hand manipulation than children using typical Passive movements and strength training are much
classroom furniture. In most natural movements the less effective in driving this cortical reorganization.
more proximal muscles provide the stability that allows Children with poor hand skills, like Katie, often avoid
skilled actions of the hand. Thus the corticospinal or are so poor at fine motor tasks that they may actually
connections to proximal and distal muscles must coop- get less practice than their peers. Skill requires attention
erate (Turton & Lemon, 1999), but the roles of reach to the activity and is facilitated when there is an interest
and postural functions are different and therefore so are in the outcome. Children with poor hand skills may
the basic neural mechanisms that control them. The need help to select and adapt to activities to meet their
primary role of posture and the shoulder in skilled hand level of performance and interest. The art of therapy is
function is one of stability. If the shoulder lacks stability being able to provide activities that challenge the child
for hand function or the postural muscles cannot within the scope of his or her abilities and elicit the
adequately support the trunk, then this needs to be child’s enthusiastic cooperation.
addressed through mechanisms to increase stability and
strength. Hand muscles also may need strengthening,
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Chapter 2
ANATOMY AND KINESIOLOGY
OF THE HAND
James W. Strickland
CHAPTER OUTLINE EMBRYONIC DEVELOPMENT

EMBRYONIC DEVELOPMENT Inspection of a normal newborn’s hands never ceases to
ANATOMY OF THE FULLY DEVELOPED HAND evoke awe and wonderment. The tiny nails punctuating
the ends of intricately formed fingers and opposable
Osseous Structures thumbs, each delicately marked with familiar patterns
Joints of joint wrinkles, immediately identify the newcomer as
Muscles and Tendons human. All of the ingredients that eventually provide
an unbelievably extensive continuum of function from
Nerve Supply exquisitely fine dexterity to great power are present in
Skin and Subcutaneous Fascia the tiny waving arms and hands. However, the normal
Functional Patterns embryonic process through which the upper extrem-
ities develop is both predictable and consistent (Arey,
1980; Bora, 1986; Bunnell, 1944; Moore, 1982).
Upper limb buds are discernible at 4 weeks of gesta-
tion. The scapula, humerus, radius, and ulna are appar-
ent at 5 weeks as cartilage, and by 6 weeks upper arm,
forearm, and hand divisions are present. Also at 6
One cannot expect to adequately understand the devel- weeks the webbed swellings of the three central digits
opment and function of the hand and arm without appear and are soon followed by the two border digits.
a solid working knowledge of the intricate anatomic The metacarpals are present as cartilage, as are the prox-
and kinesiologic relationships of the upper extremity, imal phalanges of the index through small fingers.
including the embryonic growth stages through which Initially, each extremity is aligned longitudinally with
the extremity progresses. Only through comprehension the body trunk, but at 7 weeks the arms rotate outward
of the normal formation and anatomy of the human and forward at the shoulder level to assume a hand-to-
hand can one adequately develop an appreciation for face position with the flexor surface of the forearm and
the disturbance in function that accompanies injury, hand turned inward toward the body and the extensor
disease, or dysfunction. It is appropriate, therefore surface turned outward. Elbows and wrists are slightly
that an early chapter in a book devoted to development flexed. Innervation of the limbs has already occurred
of fine motor coordination be concerned with the at this point, and vessels extend to the distal extremity.
embryology, anatomy, kinesiology, and biomechanics Muscles, muscle groups, joint hollows, and digital cleav-
of the hand. Because it is impossible in this chapter ages, including thumb differentiation, are also present
to review in great detail the enormous amount of at 7 to 8 weeks. Webbing between the digits dimin-
literature that has been written about these fields of ishes, and the fingers and thumb are independent of
knowledge, readers are directed to the Suggested each other by 8 weeks. Carpal bones are cartilaginous,
Readings. and the os centrale fuses to the scaphoid at 8 weeks.
21
For the remainder of gestation after 8 weeks, limb metacarpals. Two phalanges complete the first ray, or
changes primarily involve growth of already present thumb unit, and three phalanges each comprise the
structures. index, long, ring, and small fingers. These 27 bones,
together with the intricate arrangement of supportive
ligaments and contractile musculotendinous units, are
ANATOMY OF THE FULLY arranged to provide both mobility and stability to the
various joints of the hand. Although the exact anatomic
DEVELOPED HAND configuration of the bones of the hand need not be
memorized in detail, it is important that one should
The anatomy of the hand must be approached in a develop knowledge of the position and names of the
systematic fashion with individual consideration of the carpal bones, metacarpals, and phalanges and an under-
osseous structures, joints, musculotendinous units, and standing of their kinesiologic patterns to proceed with
nerve supply. However, it is obvious that the systems the management of many hand problems. The bones of
do not function independently, but that the integrated the hand are arranged in three arches (Figure 2-2), two
presence of all these structures is necessary for normal transversely oriented and one that is longitudinal. The
hand function. In presenting this material, this chapter proximal transverse arch, the keystone of which is the
strays into the important mechanical and kinesiologic capitate, lies at the level of the distal part of the carpus
considerations that result from the unique anatomic and is reasonably fixed, whereas the distal transverse
arrangement of the hand. arch passing through the metacarpal heads is more
mobile. The two transverse arches are connected by the
rigid portion of the longitudinal arch consisting of
OSSEOUS STRUCTURES the second and third metacarpals, the index and long
The unique arrangement and mobility of the bones of fingers distally, and the central carpus proximally. The
the hand (Figure 2-1) provide a structural basis for its longitudinal arch is completed by the individual digital
enormous functional adaptability. The osseous skeleton rays, and the mobility of the first, fourth, and fifth rays
consists of eight carpal bones divided into two rows: around the second and third allows the palm to flatten
The proximal row articulates with the distal radius and or cup itself to accommodate objects of various sizes
ulna (with the exception of the pisiform, which lies and shapes.
palmar to and articulates with the triquetrum); the To a large extent the intrinsic muscles of the hand
distal four carpal bones in turn articulate with the five are responsible for changes in the configuration of the
Distal phalanx
Middle phalanx
Proximal phalanx
Metacarpal
Hamate Trapezoid
Capitate Hamate
Pisiform Trapezium
Triquetrum Scaphoid Triquetrum
A Lunate B
Figure 2-1 Bones of the right hand. A. Palmar surface. B. Dorsal surface. (From Fess EE, Gettle K, Philips CA, et al. [2005].
Hand and upper extremity splinting. St Louis, Mosby.)
Anatomy and Kinesiology of the Hand • 23
Distal transverse arch
Proximal
transverse Distal
arch transverse arch
Longitudinal
arch
A B Proximal transverse arch

Figure 2-2 A. Skeletal arches of the hand. The proximal transverse arch passes through the distal carpus; the distal
transverse arch, through the metacarpal heads. The longitudinal arch is made up of the four digital rays and the carpus
proximally. B. Proximal and distal transverse arches. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper
extremity splinting. St Louis, Mosby.)
osseous arches. Collapse in the arch system can con- the triquetrum and scaphoid have been termed the
tribute to severe disability and deformity. Flatt (1979, deltoid ligaments. Dorsally, the radiocarpal ligament
1983, 1995) has pointed out that grasp is dependent connects the radius to the triquetrum and acts as a
on the integrity of the mobile longitudinal arches dorsal sling for the lunate, maintaining the lunate in
and when destruction at the carpometacarpal joint, apposition to the distal radius. Further dorsal carpal
metacarpophalangeal joint, or proximal interphalangeal support is provided by the dorsal intracarpal ligament.
joint interrupts the integrity of these arches, crippling These strong ligaments combine to provide carpal
deformity may result. stability while permitting the normal range of wrist
motion.
The distal ulna is covered with an articular cartilage
JOINTS (Figure 2-3, C) over its most dorsal, palmar, and radial
The multiple complex articulations among the distal aspects, where it articulates with the sigmoid or ulnar
radius and ulna, the eight carpal bones, and the notch of the radius. The triangular fibrocartilage com-
metacarpal bases comprise the wrist joint, whose prox- plex describes the ligamentous and cartilaginous struc-
imal position makes it the functional key to the motion ture that suspends the distal radius and ulnar carpus
at the more distal hand joints of the hand. Functionally from the distal ulna. Blumfield and Champoux (1984)
the carpus transmits forces through the hand to the have indicated that the optimal functional wrist motion
forearm. The proximal carpal row consisting of the to accomplish most activities of daily living is from 10°
scaphoid (navicular), lunate, and triquetrum articulates of flexion to 35° of extension.
distally with the trapezium, trapezoid, capitate, and Taleisnik (1976a,b, 1985a,b, 1992) has emphasized
hamate; there is a complex motion pattern that relies the importance of considering the wrist in terms of
both on ligamentous and contact surface constraints. longitudinal columns (Figure 2-4). The central, or flex-
The major ligaments of the wrist (Figure 2-3) are the ion extension, column consists of the lunate and the
palmar and intracapsular ligaments. There are three entire distal carpal row; the lateral, or mobile, column
strong radial palmar ligaments: the radioscaphocapitate comprises the scaphoid alone; and the medial, or
or “sling” ligament, which supports the waist of the rotation, column is made up of the triquetrum. Wrist
scaphoid; the radiolunate ligament, which supports the motion is produced by the muscles that attach to the
lunate; and the radioscapholunate ligament, which con- metacarpals, and the ligamentous control system pro-
nects the scapholunate articulation with the palmar vides stability only at the extremes of motion. The
portion of the distal radius. This ligament functions distal carpal row of the carpal bones is firmly attached
as a checkrein for scaphoid flexion and extension. The to the hand and moves with it. Therefore during dorsi-
ulnolunate ligament arises intra-articularly from the flexion the distal carpal row dorsiflexes, during palmar
triangular articular meniscus of the wrist joint and inserts flexion it palmar flexes, and during radial and ulnar
on the lunate and, to a lesser extent, the triquetrum. deviation it deviates radially or ulnarly. As the wrist
The radial and ulnar collateral ligaments are capsular ranges from radial to ulnar deviation, the proximal carpal
ligaments, and V-shaped ligaments from the capitate to row rotates in a dorsal direction, and a simultaneous
Deltoid ligaments
Space of Poirier
Lunotriquetral ligament
Radioscaphocapitate
ligament
Vestigial ulnar
collateral ligament Scapholunate
ligament
Ulnocarpal Radial collateral

meniscus homologue ligament
Ulnolunate ligament Radiolunate

(ulnolunate-triquetral) ligament
(radiolunotriquetral)
Radioscapholunate
ligament
(ligament of Testut
and Kuenz)
A
C Td
H
Tm
P
Dorsal 1 Tq
intercarpal S
ligament L
7
Dorsal radiocarpal 4
ligament 2
(radiotriquetral)
3
5
6
B C
Figure 2-3 Ligamentous anatomy of the wrist. A. Palmar wrist ligaments. B. Dorsal wrist ligaments. C. Dorsal view of
the flexed wrist, including the triangular fibrocartilage. 1, Ulnar collateral ligament; 2, retinacular sheath; 3, tendon of
extensor carpi ulnaris; 4, ulnolunate ligament; 5, triangular fibrocartilage; 6, ulnocarpal meniscus homologue; 7, palmar
radioscaphoid lunate ligament. P, Pisiform; H, hamate; C, capitate; Td, trapezoid; Tm, trapezium; Tq, triquetrum; L, lunate;
S, scaphoid. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)
translocation of the proximal carpus occurs in a radial Taleisnik (1985a,b), Lichtman and Alexander (1988),
direction at the radiocarpal and midcarpal articulations. and Cooney, Linscheid, and Dobyns (1998) to gain a
This combined motion of the carpal rows has been thorough understanding of this difficult subject.
called the rotational shift of the carpus. It was once The articulation between the base of the first
taught that palmar flexion takes place to a greater metacarpal and the trapezium (Figure 2-5) is a highly
extent at the radiocarpal joint and secondarily in the mobile joint with a configuration thought to be similar
midcarpal joint, but because dorsiflexion occurs prima- to that of a saddle. The base of the first metacarpal is
rily at the midcarpal joint and only secondarily at the concave in the anteroposterior plane and convex in
radiocarpal articulation, this now appears to be a sig- the lateral plane, with a reciprocal concavity in the
nificant oversimplification. The complex carpal kine- lateral plane and an anteroposterior convexity on the
matics are beyond the scope of this chapter, and the opposing surface of the trapezium. This arrangement
reader is referred to the works of Weber (1988), allows the positioning of the thumb in a wide arc of
Central
column
Medial Lateral
column column
First metacarpal
Figure 2-4 Columnar carpus. The scaphoid is the

mobile or lateral column. The central, or flexion
extension, column comprises the lunate and the entire
distal carpal row. The medial, or rotational, column
comprises the triquetrum alone. (From Fess EE, Gettle K,
Philips CA, et al. [2005]. Hand and upper extremity splinting.
St Louis, Mosby.)
B
Figure 2-6 A. Multiple planes of motion (arrows) that
occur at the carpometacarpal joint of the thumb. B. The
thumb moves (arrow) from a position of adduction
against the second metacarpal to a position of palmar or
radial abduction away from the hand and fingers and can
then be rotated into positions of opposition and flexion.
(From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and
upper extremity splinting. St Louis, Mosby.)
planes and combinations thereof (Figure 2-7). The

cartilaginous surfaces of the metacarpal head and the
bases of the proximal phalanges are enclosed in a com-
Figure 2-5 Saddle-shaped carpometacarpal joint of the plex apparatus consisting of the joint capsule, collateral
thumb. A wide range of motion (arrows) is permitted by ligaments, and the anterior fibrocartilage or palmar
the configuration of this joint. (From Fess EE, Gettle K, plate (Figure 2-8). The capsule extends from the borders
Philips CA, et al. [2005]. Hand and upper extremity splinting. of the base of the proximal phalanx proximally to the
St Louis, Mosby.) head of the metacarpals beyond the cartilaginous joint
surface. The collateral ligaments, which reinforce the
capsule on each side of the metacarpophalangeal joints,
motion (Figure 2-6), including flexion, palmar and radial run from the dorsolateral side of the metacarpal head to
abduction, adduction, and opposition. The ligamen- the palmar lateral side of the proximal phalanges. These
tous arrangement about this joint, while permitting the ligaments form two bundles, the more central of which
wide circumduction, continues to provide stability at is called the cord portion of the collateral ligament and
the extremes of motion, allowing the thumb to be inserts into the side of the proximal phalanx; the more
brought into a variety of positions for pinch and grasp, palmar portion joins the palmar plate and is termed the
but maintaining its stability during these functions. The accessory collateral ligament. These collateral ligaments
articulations formed by the ulnar half of the hamate are somewhat loose with the metacarpophalangeal joint
and the fourth and fifth metacarpal bases allow a in extension, allowing for considerable “play” in the
modest amount of motion (15° at the fourth carpo- side-to-side motion of the digits (Figure 2-9). With the
metacarpal joint and 25° to 30° of flexion and exten- metacarpophalangeal joints in full flexion, however,
sion at the fifth carpometacarpal joint). A resulting the cam configuration of the metacarpal head tightens
“palmar descent” of these metacarpals occurs during the collateral ligaments and limits lateral mobility of the
strong grasp. digits. This alteration in tension becomes an important
The metacarpophalangeal joints of the fingers are factor in immobilization of the metacarpophalangeal
diarthrodial joints with motion permitted in three joints for any length of time, because the secondary
Collateral ligament
(loose in extension)
Hinge
(anteroposterior
motion)
Diarthrodial
(multiplane Palmar plate
motion)
Membranous portion
of palmar plate
(folds in flexion)
Figure 2-7 Joints of the phalanges. The diarthrodial

configuration of the metacarpophalangeal joint permits
motion in multiple planes, whereas the biconcave-convex Collateral ligament
(tight in flexion)
hinge configuration of the interphalangeal joints restricts
motion to the anteroposterior plane. (From Fess EE, Gettle
K, Philips CA, et al. [2005]. Hand and upper extremity
splinting. St Louis, Mosby.)
Cord portion of
collateral ligaments
Cord portion of
collateral ligaments Figure 2-9 At the metacarpophalangeal joint level, the
collateral ligaments are loose in extension but become
tightened in flexion. The proximal membranous portion
of the palmar plate moves proximally to accommodate
for flexion. (From Fess EE, Gettle K, Philips CA, et al. [2005].
Accessory collateral Hand and upper extremity splinting. St Louis, Mosby.
ligament Accessory collateral
Palmar ligaments Modified from Wynn Parry CB, et al. [1973]. Rehabilitation of
fibrocartilaginous Palmar the hand. London, Butterworth.)
plates fibrocartilaginous
plates
Figure 2-8 Ligamentous structures of the digital joints.
The collateral ligaments of the metacarpophalangeal and to the base of the proximal phalanx and loosely attached
interdigital joints are composed of a strong cord portion to the anterior surface of the neck of the metacarpal
with bony origin and insertion. The more palmarly placed by means of the joint capsule at the neck of the
accessory collateral ligaments originate from the proximal metacarpal. This arrangement allows the palmar plate
bone and insert into the palmar fibrocartilaginous plate.
The palmar plates have strong distal attachments to resist to slide proximally during metacarpophalangeal joint
extension forces. (From Fess EE, Gettle K, Philips CA, et al. flexion. The flexor tendons pass along a groove anterior
[2005]. Hand and upper extremity splinting. St Louis, to the plate. The palmar plates are connected by the
Mosby.) transverse intermetacarpal ligaments, which connect
each plate to its neighbor.
The metacarpophalangeal joint of the thumb differs
shortening of the lax collateral ligaments that may from the others in that the head of the first metacarpal
occur when these joints are immobilized in extension is flatter and its cartilaginous surface does not extend as
results in severe limitation of metacarpophalangeal joint far laterally or posteriorly. Two small sesamoid bones
flexion by these structures. are also adjacent to this joint, and the ligamentous
The palmar fibrocartilaginous plate on the palmar structure differs somewhat. A few degrees of abduction
side of the metacarpophalangeal joint is firmly attached and rotation are permitted by the ligament arrange-
ment of the metacarpophalangeal joint at the thumb, has been described as a three-dimensional hinge that
which is of considerable functional importance in deli- results in remarkable palmar and lateral restraint.
cate precision functions. There is considerable variation A wide range of pathologic conditions may result
in the range of motion present at the thumb metacar- from the interruption of the supportive ligament sys-
pophalangeal joints. The amount of motion varies from tem of the intercarpal or digital joints. At the wrist
as little as 30° to as much as 90°. level, interruption of key radiocarpal or intercarpal liga-
The digital interphalangeal joints are hinge joints ments may result in occult patterns of wrist instability
(see Figure 2-7) and, like the metacarpophalangeal that are often difficult to diagnose and treat. In the
joints, have capsular and ligamentous enclosure. The digits, disruption of the collateral ligaments or the
articular surface of the proximal phalangeal head is fibrocartilaginous palmar plates produces joint laxity or
convex in the anteroposterior plane with a depression deformity, which is more obvious.
in the middle between the two condyles, which artic-
ulates with the phalanx distal to it. The bases of the
middle and distal phalanges appear as a concave surface
M USCLES AND TENDONS
with an elevated ridge dividing two concave depres- The muscles acting on the hand can be grouped as
sions. A cord portion of the collateral ligament and an extrinsic, when their muscle bellies are in the forearm,
accessory collateral ligament are present, and the or intrinsic, when the muscles originate distal to the
collateral ligaments run on each side of the joint from wrist joint. It is essential to thoroughly understand
the dorsolateral aspect of the proximal phalanx in a both systems. Although their contributions to hand
palmar and lateral direction to insert into the distally function are distinctly different, the integrated function
placed phalanx and its fibrocartilage plate (Figure 2-10). of both systems is important to the satisfactory
A strong fibrocartilaginous (palmar) plate is also performance of the hand in a wide variety of tasks. A
present, and the collateral ligaments of the proximal schematic representation of the origin and insertion of
and distal interphalangeal joints are tightest with the the extrinsic flexor and extensor muscle tendon units of
joints in near full extension. the hand is provided in Figures 2-11 and 2-15. The
The stability of the proximal interphalangeal joint is important nerve supply to each muscle group is
ensured by a three-sided supporting cradle produced reviewed in these figures and again when discussing the
by the junction of the palmar plate with the base of the nerve supply to the upper extremity.
middle phalanx and the accessory collateral ligament
structures (see Figure 2-10). The confluence of liga- Extrinsic Muscles
ments is strongly anchored by proximal and lateral The extrinsic flexor muscles (see Figure 2-11) of the
extensions called the checkrein ligaments. This system forearm form a prominent mass on the medial side of
the upper part of the forearm: The most superficial
group comprises the pronator teres, the flexor carpi
radialis, the flexor carpi ulnaris, and the palmaris longus;
the intermediate group the flexor digitorum super-
ficialis; and the deep extrinsics the flexor digitorum
profundus and the flexor pollicis longus. The pronator,
Cord palmaris, wrist flexors, and superficialis tendons arise
Collateral ligament
Accessory from the area about the medial epicondyle, the ulnar
Palmar plate collateral ligament of the elbow, and the medial aspect
Checkrein ligaments of the coronoid process. The flexor pollicis longus
originates from the entire middle third of the palmar
surface of the radius and the adjacent interosseous
membrane, and the flexor digitorum profundus origi-
Checkrein Cord nates deep to the other muscles of the forearm from the
Collateral ligament
ligaments Accessory proximal two-thirds of the ulna on the palmar and
Palmar plate medial side. The deepest layer of the palmar forearm is
Figure 2-10 Strong, three-sided ligamentous support completed distally by the pronator quadratus muscle.
system of the proximal interphalangeal joint with cord The flexor carpi radialis tendon inserts on the base of
and accessory collateral ligaments and the the second metacarpal, whereas the flexor carpi ulnaris
fibrocartilaginous plate, which is anchored proximally by inserts into both the pisiform and fifth metacarpal base.
the checkrein ligamentous attachment. (From Fess EE,
Gettle K, Philips CA, et al. [2005]. Hand and upper extremity The superficialis tendons lie superficial to the profun-
splinting. St Louis, Mosby. Modified from Eaton RG [1971]. dus tendons as far as the digital bases, where they
Joint injuries of the hand. Springfield, IL, Charles C Thomas.) bifurcate and wrap around the profundi and rejoin over
Composite
Flexor digitorum superficialis

Nerve: median
Action: flexion of proximal
interphalangeal and
metacarpophalangeal
joints
Superficial
Palmaris longus Flexor carpi ulnaris

Nerve: ulnar Flexor carpi radialis
Nerve: median Nerve: median
Action: tension of Action: flexion of wrist;
ulnar deviation of Action: flexion of wrist;
palmar fascia radial deviation
hand
of hand
Flexor carpi ulnaris
Palmaris longus
Flexor carpi radialis
Pronator Pronator quadratus

quadratus Nerve: median
Action: forearm
pronation
Supinator
Pronator Supinator
teres Nerve: radial
Action: forearm
supination
Pronator teres Brachioradialis

Nerve: median Nerve: radial
Action: forearm Action: pronation or
Brachioradialis pronation supination, depending
Supination Pronation
on position of forearm
Figure 2-11 Extrinsic flexor muscles of the arm and hand. (Dark areas represent origins and insertions of muscles.)
(From Fess EE, Gettle K, Philips CA, et al. (2005). Hand and upper extremity splinting. St Louis, Mosby. Modified from Marble HC
[1960]. The hand, a manual and atlas for the general surgeon. Philadelphia, WB Saunders.)
Flexor digitorum profundus

Nerve: median—index and long
ulnar—ring and small
Action: flexion of distal
interphalangeal, proximal
interphalangeal, and
metacarpophalangeal
Composite joints
Deep Flexor pollicis longus

Nerve: median
Action: flexes
interphalangeal and
metacarpophalangeal
joints of thumb
Figure 2-11—cont’d.
the distal half of the proximal phalanx as Camper’s the distal phalanx. The flexor pollicis longus inserts on
chiasma (Figure 2-12). The superficialis tendon again the base of the distal phalanx of the thumb.
splits for a dual insertion on the proximal half of the At the wrist the nine long flexor tendons enter the
middle phalanges. The profundi continue through carpal tunnel beneath the protective roof of the deep
the superficialis decussation to insert on the base of transverse carpal ligament in company with the median
nerve. In this canal the common profundus tendon to
FDS FDP the long, ring, and small fingers divides into the indi-
vidual tendons that fan out distally and proceed toward
the distal phalanges of these digits (Figure 2-13). At
about the level of the distal palmar crease the paired
FDP profundus and superficialis tendons to the index, long,
ring, and small fingers and the flexor pollicis longus
Camper's chiasma FDS to the thumb enter the individual flexor sheaths that
Figure 2-12 Anatomy of the relationship among the house them throughout the remainder of their digital
flexor digitorum superficialis (FDS), flexor digitorum course. These sheaths with their predictable annular
profundus (FDP), and the proximal portion of the flexor pulley arrangement (Figure 2-14) serve not only as a
tendon sheath. The superficialis tendon divides and protective housing for the flexor tendons, but also
passes around the profundus tendon to reunite at provide a smooth gliding surface by virtue of their
Camper’s chiasma. The tendon once again divides before
insertion on the base of the middle phalanx. (From Fess synovial lining and an efficient mechanism to hold the
EE, Gettle K, Philips CA, et al. [2005]. Hand and upper tendons close to the digital bone and joints. There is an
extremity splinting. St Louis, Mosby.) increasing recognition that disruption of this valuable
Flexor digitorum A-1

profundus A-2
C-1 A-3 C-2 A-4 A-5
C-3
Digital flexor
sheath
Flexor digitorum
superficialis
Sheath of
flexor pollicis
longus Figure 2-14 Components of the digital flexor sheath.
The sturdy annular pulleys (A) are important
Hypothenar Median nerve biomechanically in guaranteeing the efficient digital
muscles
motion by keeping the tendons closely applied to the
Thenar muscles phalanges. The thin pliable cruciate pulleys (C) permit the
Ulnar artery flexor sheath to be flexible while maintaining its integrity.
Ulnar nerve Transverse carpal (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and
ligament upper extremity splinting. St Louis, Mosby. Modified from
Doyle JR, Blythe W [1975]. American Academy of
Radial artery Orthopaedic Surgeons: Symposium on tendon surgery in the
hand. St Louis, Mosby.)
Figure 2-13 Flexor tendons in the palm and digits.
Fibroosseous digital sheaths with their pulley
arrangement are shown, as is a division of the
superficialis tendon about the profundus in the and brevis tendons, together with the abductor pollicis
proximal portion of the sheath. (From Fess EE, Gettle K, longus, originate from the dorsal forearm and, by
Philips CA, et al. [2005]. Hand and upper extremity splinting.
virtue of their respective insertions into the distal
St Louis, Mosby.)
phalanx, proximal phalanx, and first metacarpal of the
thumb, provide extension at all three levels. The exten-
pulley system can produce substantial mechanical sor pollicis longus approaches the thumb obliquely
alterations in digital function, resulting in imbalance around a small bony tubercle on the dorsal radius
and deformity. (Lister’s tubercle) and therefore functions not only as
Extension of the wrist and fingers is produced by the an extensor but as a strong secondary adductor of the
extrinsic extensor muscle tendon system, which consists thumb. The extensor indicis proprius also originates
of the two radial wrist extensors, the extensor carpi more distally than the extensor communis tendons
ulnaris, the extensor digitorum communis, extensor from an area near the origin of the thumb extensor and
indicis proprius, and the extensor digiti quinti proprius long abductor. It lies on the ulnar aspect of the com-
(extensor digiti minimi) (Figure 2-15). These muscles munis tendon to the index finger and inserts with it
originate in common from the lateral epicondyle and in the dorsal approaches of that digit. The extensor
the lateral epicondylar ridge and from a small area digiti quinti proprius arises near the lateral epicondyle
posterior to the radial notch of the ulna. The brachio- to occupy a superficial position on the dorsum of the
radialis originates from the epicondylar line proximal to forearm with its paired tendons lying on the fifth
the lateral epicondyle and, because it inserts on the metacarpal ulnar to the communis tendon to the fifth
distal radius, it does not truly contribute to wrist or finger. It inserts into the extensor apparatus of that
digit motion. The extensor carpi radialis longus and digit.
brevis insert proximally on the bases of the second and At the wrist, the extensor tendons are divided into
third metacarpals, respectively, and the extensor carpi six dorsal compartments (Figure 2-16). The first com-
ulnaris inserts on the base of the fifth metacarpal. The partment consists of the tendons of the abductor
long digital extensors terminate by insertions on the pollicis longus and extensor pollicis brevis and the
bases of the middle phalanges after receiving and giving second compartment houses the two radial wrist exten-
fibers to the intrinsic tendons to form the lateral bands sors, the extensor carpi radialis longus and brevis. The
that are destined to insert on the bases of the distal third compartment is composed of the tendon of the
phalanx. Digital extension, therefore results from a com- extensor pollicis longus and the fourth compartment
bination of the contribution of both the extrinsic and allows passage of the four communis extensor tendons
intrinsic extensor systems. The extensor pollicis longus and the extensor indicis proprius tendon. The extensor
Extensor carpi
ulnaris
Extensor carpi radialis Nerve: radial
longus and brevis Action: extension of
Nerve: radial wrist and ulnar
Action: extension of deviation of hand
wrist and radial
deviation of hand
Extensor indicis
proprius
Nerve: radial
Action: extension of
index finger Composite
Extensor pollicis
longus Extensor digitorum
Nerve: radial communis and extensor
Action: extension of digiti quinti proprius
interphalangeal joint Nerve: radial
and metacarpophalangeal Action: extension of
joint of thumb fingers
Figure 2-15 Extrinsic extensor muscles of the forearm and hand. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand
and upper extremity splinting. St Louis, Mosby. Modified from Marble HC [1960]. The hand, a manual and atlas for the general
surgeon. Philadelphia, WB Saunders.) Continued
digiti quinti proprius travels through the fifth dorsal 2-17). The muscles of the thenar eminence consist of
compartment and the sixth houses the extensor carpi the abductor pollicis brevis, the flexor pollicis brevis,
ulnaris. and the opponens pollicis, which originate in common
from the transverse carpal ligament and the scaphoid
Intrinsic Muscles and trapezium bones. The abductor brevis inserts into
The important intrinsic musculature of the hand can be the radial side of the proximal phalanx and the radial
divided into muscles comprising the thenar eminence, wing tendon of the thumb, as does the flexor pollicis
those comprising the hypothenar eminence, and the brevis, whereas the opponens inserts into the whole
remaining muscles between the two groups (Figure radial side of the first metacarpal.
Extensor pollicis brevis

Abductor pollicis Nerve: radial
longus Action: extension of
Nerve: radial metacarpophalangeal
Action: abduction of thumb joint of thumb
First dorsal
interosseous
Extensor Extensor digitorum

indicis proprius communis
Extensor digiti quinti

Extensor proprius
pollicis brevis
Abductor digiti quinti
Extensor Extensor carpi ulnaris
pollicis longus
Extensor carpi 1 2 3 4 5 6
radialis
longus and brevis
Abductor
pollicis 2 3 4 5
longus
6
1
Figure 2-16 Arrangement of the extensor tendons in the compartments of the wrist.
The flexor pollicis brevis has a superficial portion the proximal phalanx of the fifth finger, and the ulnar
that is innervated by the median nerve and a deep border of the aponeurosis of this digit. The strong
portion that arises from the ulnar side of the first thenar musculature is responsible for the ability to posi-
metacarpal and is often innervated by the ulnar nerve. tion the thumb in opposition so that it may meet the
The hypothenar eminence in a similar manner is made adjacent digits for pinch and grasp functions, whereas
up of the abductor digiti quinti, the flexor digiti quinti the hypothenar group allows a similar but less pro-
brevis, and the opponens digiti quinti, which originate nounced rotation of the fifth metacarpal.
primarily from the pisiform bone and the pisohamate Of the seven interosseous muscles, four are consid-
ligament and insert into the joint capsule of the fifth ered in the dorsal group (Figure 2-18, B) and three as
metacarpophalangeal joint, the ulnar side of the base of palmar interossei (Figure 2-18, C). The four dorsal
Opponens pollicis
Abductor pollicis brevis
Nerve: median
Nerve: median
Action: rotation of first
Action: abduction of thumb
metacarpal toward palm
Flexor pollicis brevis Adductor pollicis

Nerve: median—superficial Nerve: ulnar
ulnar—deep Action: adduction
Action: flexion and rotation of thumb of thumb
Abductor digiti quinti Flexor digiti quinti brevis

Nerve: ulnar Nerve: ulnar
Action: abduction of small finger Action: flexion of proximal phalanx
(flexion of proximal phalanx, extension of of small finger and forward
proximal and distal interphalangeal joints) rotation of fifth metacarpal
Figure 2-17 Intrinsic muscles of the hand. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity
splinting. St Louis, Mosby. Modified from Marble HC [1960]. The hand, a manual and atlas for the general surgeon. Philadelphia,
WB Saunders.) Continued
interossei originate from the adjacent sides of the (Figure 2-18, C) have similar insertions and origins and
metacarpal bones and, because of their bipennate nature are responsible for adducting the digits together, as
with two individual muscle bellies, have separate inser- opposed to the spreading or abducting function of the
tions into the tubercle and the lateral aspect of the dorsal interossei. In addition, four lumbrical tendons
proximal phalanges and into the extensor expansion. (Figure 2-19, A) arising from the radial side of the
The more palmarly placed three palmar interossei palmar portion of the flexor digitorum profundus
Lumbricals
Nerve: median—index and long Composite All interossei
ulnar—ring and small Nerve: ulnar
Action: supplements metacarpophalangeal Action: flexion of
flexion and extension of proximal and metacarpophalangeal
distal interphalangeal joints joints and extension of
proximal and distal
interphalangeal joints
Dorsal Dorsal interossei Palmar Palmar interossei

interossei Nerve: ulnar interossei Nerve: ulnar
Action: spread of Action: adduction
index and ring fingers of index, ring, and
away from long finger fifth fingers
toward long finger
tendons pass through their individual canals on the extension. The interossei are further responsible for
radial side of the digits to provide an additional contri- spreading and closing of the fingers and, together with
bution to the complex extensor assemblage of the the extrinsic flexor and extensor tendons, are invaluable
digits. The arrangement of the extensor mechanism, to digital balance. A composite, well-integrated pattern
including the transverse sagittal band fibers at the of digital flexion and extension is reliant on the smooth
metacarpophalangeal joint and the components of the performance of both systems; and a loss of intrinsic
extensor hood mechanism that gain fibers from both function results in severe deformity.
the extrinsic and intrinsic tendons, can be seen in Perhaps the most important intrinsic muscle, the
Figure 2-19, B, C. adductor pollicis (Figure 2-18, A), originates from
An oversimplification of the function of the intrinsic the third metacarpal and inserts on the ulnar side of the
musculature in the digits would be that they provide base of the proximal phalanx of the thumb and into
strong flexion at the metacarpophalangeal joints and the ulnar wing expansion of the extensor mechanism.
extension at the proximal and distal interphalangeal This muscle, by virtue of its strong adducting influence
joints. The lumbrical tendons, by virtue of their origin on the thumb and its stabilizing effect on the first
from the flexor profundi and insertion into the digital metacarpophalangeal joint, functions together with the
extensor mechanism, function as a governor between first dorsal interosseous to provide strong pinch. The
the two systems, resulting in a loosening of the antago- adductor pollicis, deep head of the flexor pollicis brevis,
nistic profundus tendon during interphalangeal joint ulnar two lumbricals, and all interossei, as well as the
Adductor
pollicis
Abductor Opponens
pollicis brevis digiti quinti
Flexor pollicis Flexor digiti
brevis quinti
Transverse carpal
ligament Abductor digiti
Opponens quinti
pollicis
Flexor carpi
ulnaris
Pronator
Ulnar nerve
A quadratus
Dorsal Palmar
4 3 2 1 interossei
interossei
Abductor (1 to 3)
(1 to 4)
digiti 1 2
minimi 3
B C
Figure 2-18 Position and function of the intrinsic muscles of the hand.
hypothenar muscle group, are innervated by the ulnar involved joint. To a large extent the wrist is the key
nerve. Loss of ulnar nerve function has a profound joint and has a strong influence on the long extrinsic
influence on hand function. muscle performance at the digital level. Maximal digital
flexion strength is facilitated by dorsiflexion of the
Muscle Balance and Biomechanical wrist, which lessens the effective amplitude of the antag-
Considerations onistic extensor tendons while maximizing the con-
When there is normal resting tone in the extrinsic and tractural force of the digital flexors. Conversely, a
intrinsic muscle groups of the forearm and hand, the posture of wrist flexion markedly weakens grasping
wrist and digital joints are maintained in a balanced power.
position. With the forearm midway between pronation At the digital level, metacarpophalangeal joint flex-
and supination, the wrist dorsiflexed, and the digits in ion is a combination of extrinsic flexor power supple-
moderate flexion, the hand is in the optimum position mented by the contribution of the intrinsic muscles,
from which to function. whereas proximal interphalangeal joint extension
It may be seen that muscles are usually arranged results from a combination of extrinsic extensor and
about joints in pairs so that each musculotendinous intrinsic muscle power. At the distal interphalangeal
unit has at least one antagonistic muscle to balance the joint the intrinsic muscles provide a majority of the
Ulnar Radial
Triangular ligament
Lateral band
Slip of
long extensor
to lateral band
Dorsal extensor expansion
Sagittal bands
Lumbrical muscle
Long extensor tendon
Interosseous muscle
Long extensor tendon Sagittal bands

Dorsal extensor expansion
Interosseous muscle
Central slip of common extensor
Lateral band
Flexor profundus tendon

Lumbrical muscle
B Flexor digitorum superficialis
Long extensor tendon

Sagittal bands
Bony insertion of
interosseous tendon on
proximal phalanx
Distal movement of
extensor expansion
Interosseous Lumbrical muscle during flexion
muscle
Lateral band
C
Figure 2-19 A. Extensor mechanism of the digits. B, C. Distal movement of the extensor expansion with
metacarpophalangeal joint flexion is shown.
extensor power necessary to balance the antagonistic greater than the excursion that was necessary to
flexor digitorum profundus tendon. produce full motion of the joints on which it acted in
The distance that a tendon moves when its muscle its original position.
contracts is defined as the amplitude of the tendon and Efforts have been made to determine the power of
has been measured in numerous studies. In actuality individual forearm and hand muscles and a formula
the effective amplitude of any muscle is limited by the based on the physiologic cross section is generally
motion permitted by the joint or joints on which its accepted as the best method for determining this value.
tendon acts. It has been suggested that the amplitude The number of fibers in cross section determines the
of wrist movers (flexor carpi ulnaris, flexor carpi radialis, absolute muscle power of a given muscle, whereas the
extensor carpi radialis longus, extensor carpi radialis force of muscle action times the distance or amplitude
brevis, and extensor carpi ulnaris) is approximately of a given muscle determines the work capacity of the
30 millimeters with the amplitude of finger extensors muscle. Therefore a large extrinsic muscle with rela-
averaging 50 millimeters; the thumb flexor, 50 mm; tively long fibers such as the flexor digitorum profun-
and the finger flexors 70 millimeters (Figure 2-20). dus is found to be capable of much more work than is
Although these amplitudes have been thought to be a muscle with shorter fibers such as a wrist extensor.
important considerations when deciding on appro- Table 2-1 is an indicator of the work capacities of the
priate tendon transfers, Brand (1974, 1999) has shown various forearm muscles. It can be seen that the flexor
that the potential excursion of a given tendon such as digitorum profundus and superficialis have a signifi-
the extensor carpi radialis longus may be considerably cantly greater work capacity than do the remaining
extrinsic muscles. The abductor pollicis longus, pal-
maris longus, extensor pollicis longus, extensor carpi
radialis brevis, and flexor carpi radialis have less than
one fourth the capacity of these muscles.
0 mm Several mechanical considerations are important in
understanding the effect of a muscle on a given joint.
The moment arm of a particular muscle is the perpen-
3 mm dicular distance between the muscle or its tendon and
the axis of the joint. The greater the displacement of an
unrestrained tendon from the joint on which it acts, the
26 mm (S) greater is the angulatory effect created by the increased
16 mm
23 mm (P) length of the moment arm. Therefore a tendon posi-
tioned close to a given joint either by position of the
16 mm (S)
17 mm (P) joint or by a restraining pulley has a much shorter
moment arm than a tendon that is allowed to displace
44 mm away from the joint (Figure 2-21).
In simplifying the biomechanics of musculotendi-
nous function, Brand (1974, 1999) has emphasized
that the “moment” of a given muscle is the power of
5 mm (P)
46 mm (S) the muscle to turn a joint on its axis. It is determined
38 mm (P) by multiplying the strength (tension) of the muscle by
55 mm 88 mm (S) the length of the moment arm. Again, it can be seen
85 mm (P)
that the distance of tendon displacement away from the
joint is the critical factor and that it does not matter
Figure 2-20 Excursion of the flexor and extensor where the tendon insertion lies. The importance of the
tendons at various levels. The numbers on the dorsum of various anatomic restraints of the extrinsic musculo-
the extended finger represent the excursion in tendinous units at the wrist and in the digits is mag-
millimeters necessary at each level to bring all distal
joints from full flexion into full extension. The numbers nified by these mechanical factors.
shown by arrows on the palmar aspect of the flexed digit
represent the excursion in millimeters for the superficialis
(S) and the profundus (P) necessary at each level to N ERVE SUPPLY
bring the finger from full extension to full flexion. (From In considering the nerve supply to the forearm, hand,
Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper
extremity splinting. St Louis, Mosby. Modified from Verdan C and wrist, understand that these nerves are a direct
[1979]. Tendon surgery of the hand. London, Churchill continuation of the brachial plexus and that at least a
Livingstone.) working knowledge of the multiple ramifications of the
Normal
MA
Table 2-1 Work capacity of muscles A-4
C-1 A-3 C-2 C-3 A-5
A-2
Muscle Mkg IAPD
A PTE A-1
Flexor carpi radialis 0.8
A
M
Extensor carpi radialis longus 1.1 IAPD
PTE 90
Extensor carpi radialis brevis 0.9

B
Extensor carpi ulnaris 1.1 Abnormal
MA
1
Abductor pollicis longus 0.1 % 2 A-4
1
% 2 A-2 IAPD
C PTE
Flexor pollicis longus 1.2
A
M
Flexor digitorum profundus 4.5
IAPD
PTE 90
Flexor digitorum superficialis 4.8
D
Brachioradialis 1.9
Figure 2-21 Biomechanics of the finger flexor pulley
system. A. The arrangement of the annular and cruciate
Flexor carpi ulnaris 2.0 pulleys of the flexor tendon sheath. A, B, Normal
moment arm (MA), the intra-annular pulley distance
(IAPD) between the A-2 and A-4 pulleys, and the
Pronator teres 1.2 profundus tendon excursion (PTE), which occurs within
the intact digital fibroosseous canal as the proximal
interphalangeal joint is flexed to 90°. Annular pulleys:
Palmaris longus 0.1 A-1, A-2, A-3, A-4, and A-5; cruciate pulleys: C-I, C-2, C-3.
C, D, Biomechanical alteration resulting from excision of
Extensor pollicis longus 0.1 the distal half of the A-2 pulley together with the C-1,
A-3, C-2, and proximal portion of the A-4 pulley. The
moment arm is increased, and a greater profundus
Extensor digitorum communis 1.7 tendon excursion is necessary to produce 90° of flexion
because of the bowstringing that results from the loss of
From Von Lanz T, Wachsmuth W (1970). Praktische anatomie. pulley support. (From Fess EE, Gettle K, Philips CA, et al.
In JH Boyes, editor: Bunnell’s surgery of the hand, 5th ed. [2005]. Hand and upper extremity splinting. St Louis, Mosby.
Philadelphia, Lippincott. Modified from Strickland JW [1983]. Management of acute
flexor tendon injuries. Orthopaedic Clinics of North America,
vol 14. Philadelphia, WB Saunders.)
plexus is necessary if one is to fully appreciate the more

distal motor and sensory contributions of the nerves of these nerves, although it is acknowledged that
the upper extremity. Injuries at either the spinal cord or variations are common.
plexus level or to the major peripheral nerves in the The palmar side of the hand from the thumb to a
upper extremity result in a substantial functional line passed longitudinally from the tip of the ring finger
impairment for which splinting may be necessary. to the wrist receives sensory innervation from the
The median, ulnar, and radial nerves, as well as the median nerve. The remainder of the palm, as well as the
terminal course of the musculocutaneous, are respon- ulnar half of the ring finger and the entire small finger,
sible for the sensory and motor transmission to the receives sensory innervation from the ulnar nerve. On
forearm, wrist, and hand. The superficial sensory distri- the dorsal side, the ulnar nerve distribution again
bution is shared by the median, radial, and ulnar nerves includes the ulnar half of the dorsal hand and the ring
in a fairly constant pattern (Figure 2-22). This chapter and small fingers, whereas the radial side is supplied by
is concerned with the most frequent distribution of the superficial branch of the radial nerve. Some inner-
Median
Median
Median
Ulnar
Radial
Radial
Ulnar
nerve Superficial branch
of radial nerve
Median
A nerve B
Figure 2-22 Cutaneous distribution of the nerves of the hand. A. Palmar surface. B. Dorsal surface. (From Fess EE, Gettle
K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)
vation to an area distal to the proximal interphalangeal in the skin is found in the dermal network, smaller
joints is supplied by the palmar digital nerves origi- branches course through the subcutaneous tissue fol-
nating from the median nerve. The area around the lowing blood vessels. Several types of sensory receptors
dorsum of the thumb over the metacarpophalangeal have been described, and in most areas of the hand
joint is frequently supplied by the end branches of the there is an interweaving of nerve fibers that allows each
lateral antebrachial cutaneous nerve. area to receive nerve input from several sources. In
The extrinsic and intrinsic musculature of the fore- addition, deep sensibility from nerve endings in mus-
arm and hand is supplied by the median, ulnar, and cles and tendons is important in the recognition of
radial nerves (Figure 2-23). The long wrist and digital joint position.
flexors, with the exception of the flexor carpi ulnaris The high interruption of the median nerve above
and the profundi to the ring and small fingers, are all the elbow results in a paralysis of the flexor carpi
supplied by the median nerve. The pronators of the radialis, the flexor digitorum superficialis, the flexor
forearm and the muscles of the thenar eminence, with pollicis longus, the profundi to the index and long
the exception of the deep head of the flexor pollicis fingers, and the lumbricals to the index and long fin-
brevis and the adductor pollicis, which are innervated gers. In addition, pronation is weakened as a result of
by the ulnar nerve, are also supplied by the median the loss of innervation of both the pronator teres and
nerve. All muscles of the hypothenar eminence, all quadratus muscles and, most importantly, the patient
interossei, the third and fourth lumbrical muscles, the loses the ability to oppose the thumb because of
deep head of the flexor pollicis brevis, the adductor paralysis of the median nerve-innervated thenar muscle
pollicis brevis, as well as the flexor carpi ulnaris and the group. A more distal interruption of the median nerve
ulnar-most two profundi, are supplied by the ulnar at the wrist level produces loss of opposition and both
nerve. The radial nerve supplies all long extensors of lesions result in a critical impairment of sensation in the
the hand and wrist, as well as the long abductor and important distribution of that nerve to the palmar
short extensor of the thumb, the supinator, and the aspect of the thumb, index, long, and radial half of the
brachioradialis of the forearm. ring finger.
When considering sensibility, one should remember High ulnar nerve interruption produces paralysis
that the hand is an extremely important organ for the of the flexor carpi ulnaris, the flexor profundi and
detection and transmission to the brain of information lumbricals to the ring and small fingers and, most
relating to the size, weight, texture, and temperature of importantly, the interossei, adductor pollicis brevis, and
objects with which it comes in contact. The types of deep head of the flexor pollicis brevis. The resulting
cutaneous sensation have been defined as touch, pain, loss of the antagonistic flexion at the metacarpopha-
hot, and cold. Although most of the nervous tissue langeal joints of the ring and small fingers permits
Radial nerve lesions at or proximal to the elbow

result in a complete wrist drop and inability to extend
the fingers at the metacarpophalangeal joints. It should
Proper be remembered that paralysis of this nerve does not
palmar digital result in inability to extend the interphalangeal joints of
nerves
either the thumb or digits because of the contribution
to that function by the intrinsic muscles. The sensory
deficit over the dorsoradial aspect of the wrist and hand
Common resulting from radial nerve interruption is of much less
digital
nerves
significance than are lesions to nerves innervating the
palmar side.
Palmar nerves
to thumb Various combinations of paralyses involving more
than one nerve of the upper extremity are frequently
Motor (thenar)
branch of encountered; those of the median and ulnar nerve are
median nerve the most common. High lesions of these two nerves
Median nerve produce paralyses of both the extrinsic and intrinsic
muscle groups with total sensory loss over the palmar
A aspect of the hand. More distal combined median and
ulnar lesions have their effect primarily on the intrinsic
muscles, resulting in the most disabling deformities
with metacarpophalangeal hyperextension, interpha-
langeal flexion, and thumb collapse. An inefficient
pattern of digital flexion consisting of a slow distal-to-
proximal rolling grasp results from the loss of the
Proper palmar
digital nerves integrated intrinsic participation.
SKIN AND SUBCUTANEOUS FASCIA

The palmar skin with its numerous small fibrous con-
Proper palmar nections to the underlying palmar aponeurosis is a
digital nerve
to fifth finger highly specialized, thickened structure with little
Common digital
Motor (deep) mobility. Numerous small blood vessels pass through
branch of ulnar
nerve to ring and nerve
the underlying subcutaneous tissues into the dermis. In
small fingers contrast, the dorsal skin and subcutaneous tissue are
much looser with few anchoring fibers and a high
Ulnar nerve degree of mobility. Most of the lymphatic drainage
B from the palmar aspect of the fingers, web areas, and
Figure 2-23 Distribution of the median (A) and ulnar hypothenar and thenar eminences flows in lymph
(B) nerves in the palm. (From Fess EE, Gettle K, Philips CA, channels on the dorsum of the hand. Clinical swelling,
et al. [2005]. Hand and upper extremity splinting. St Louis, which frequently accompanies injury or infection, is
Mosby.)
usually a result of impaired lymph drainage.
The central, triangularly shaped palmar aponeurosis
hyperextension at this level by the unopposed long (Figure 2-24) provides a semirigid barrier between the
extensor tendons, often resulting in a claw deformity. palmar skin and the important underlying neuro-
The loss of the strong adducting and stabilizing vascular and tendon structures. It fuses medially and
influence of the adductor pollicis combined with the laterally with the deep fascia covering the hypothenar
paralysis of the first dorsal interosseous muscle results in and thenar muscles, and fasciculi extending from this
profound weakness of pinch and produces a collapse thick fascial barrier extend to the proximal phalanges to
deformity of the thumb, necessitating interphalangeal fuse with the tendon sheaths on the palmar, medial,
joint hyperflexion for pinch (Froment’s sign). More and lateral aspects. In the distal palm, septa from this
distal lesions of the ulnar nerve usually result in a palmar fascia extend to the deep transverse metacarpal
greater degree of claw deformity because of the sparing ligaments forming the sides of the annular fibrous
of the profundi function of the ring and small fingers. canals, allowing for the passage of the ensheathed flexor
Sensory loss after ulnar nerve interruption involves the tendons and the lumbrical muscles and the neuro-
palmar ring (ulnar half) and small fingers. vascular bundles.
As generally stated, power grip is a combination of

strong thumb flexion and adduction with the powerful
Palmar aponeurosis flexion of the ring and small fingers on the ulnar side of
(reflected) the hand. The radial half of the hand employing the
delicate tripod of pinch among the thumb, index, and
long fingers is responsible for more delicate precision
Flexor digitorum function.
superficialis
An analysis of hand functions requires that one
consider the thumb and the remainder of the hand as
two separate parts. Rotation of the thumb into an
opposing position is a requirement of almost any hand
function, whether it is strong grasp or delicate pinch.
Sheath of flexor
pollicis longus The wide range of motion permitted at the carpo-
metacarpal joint is extremely important in allowing the
Median nerve thumb to be correctly positioned. Stability at this joint
Ulnar
artery Thenar muscles is a requirement of almost all prehensile activities and is
Ulnar ensured by a unique ligamentous arrangement, which
nerve
Transverse allows mobility in the midposition and provides
carpal ligament stability at the extremes. As can be seen in Figure 2-25,
the thumb moves through a wide arc from the side of
Figure 2-24 Palmar aponeurosis reflected distally

reveals septa and underlying palmar anatomy.
Dorsally the deep fascia and extensor tendons fuse

to form the roof for the dorsal subaponeurotic space,
which, although not as thick as its palmar counterpart,
may prove restrictive to underlying fluid accumulations
or intrinsic muscle swelling.
FUNCTIONAL PATTERNS
The prehensile function of the hand depends on the
integrity of the kinetic chain of bones and joints extend-
ing from the wrist to the distal phalanges. Interruptions
of the transverse and longitudinal arch systems formed
by these structures always result in instability, defor-
mity, or functional loss at a more proximal or distal
level. Similarly, the balanced synergism–antagonism
relationship between the long extrinsic muscles and the
intrinsic muscles is a requisite for the composite func-
tions necessary for both power and precision functions
of the hand. It is essential to recognize that the hand
cannot function well without normal sensory input
from all areas.
Many attempts have been made to classify the differ-
ent patterns of hand function, and various types of
grasp and pinch have been described. Perhaps the Figure 2-25 Progressive alterations in precision grasp
more simplified analysis of power grasp and precision with changes in object size. Adaptation takes place
primarily at the carpometacarpal joint of the thumb and
handling as proposed by Napier (1955, 1956) and the metacarpophalangeal joints of the digits. (From Fess
refined by Flatt (1979, 1983, 1995) is the easiest to EE, Gettle K, Philips CA, et al. [2005]. Hand and upper
consider. extremity splinting. St Louis, Mosby.)
the index finger tip to the tip of the small finger, and
the adaptation that occurs between the thumb and
digits as progressively smaller objects are held occurs
primarily at the metacarpophalangeal joints of the digits
and the carpometacarpal joint of the thumb.
For power grip the wrist is in an extended position
that allows the extrinsic digital flexors to press the
object firmly against the palm while the thumb is closed
tightly around the object. The thumb, ring, and small
fingers are the most important participants in this
strong grasp function, and the importance of the ulnar
border digits cannot be minimized (Figure 2-26).
In precision grasp, wrist position is less important, A
and the thumb is opposed to the semiflexed fingers
with the intrinsic tendons providing most of the finger
movement. When the intrinsic muscles are paralyzed,
the balance of each finger is markedly disturbed. The
metacarpophalangeal joint loses its primary flexors, and
the interphalangeal joints lose the intrinsic contribu-
tion to extension. A dyskinetic finger flexion results in
which the metacarpophalangeal joints lag behind the
interphalangeal joints in flexion. When the hand is
closed on an object, only the fingertips make contact
rather than the uniform contact of the fingers, palm,
and thumb that occurs with normal grip (Figure 2-27).
Certain activities may require combinations of
power and precision grips, as seen in Figure 2-28.
Pinching between the thumb and either the index or
long finger is a further refinement of precision grip and B
may be classified as tip grip, palmar grip, or lateral grip Figure 2-27 A. Normal hand grasping a cylinder.
(Figure 2-29), depending on the portions of the pha- Uniform areas of palm and digital contact are shaded.
langes brought to bear on the object being handled. In B. Intrinsic minus (claw hand grasping the same
cylinder). The area of contact is limited to the fingertips
these functions the strong contracture of the adductor
and the metacarpal heads. (From Brand PW [1999]. Clinical
pollicis brings the thumb into contact against the tip or mechanics of the hand, 2nd ed. St Louis, Mosby.)
sides of the index or index and long fingers with digital
resistance imparted by the first and second dorsal

interossei.
The size of the object being handled dictates whether
large thumb and digital surfaces, as in palmar grip, or
smaller surfaces, as in lateral or tip grasp, are used. Flatt
(1972) has pointed out that the dual importance of
rotation and flexion of the thumb is often ignored in
the preparation of splints, which permit only tip grip
because the thumb cannot oppose the pulp of the
fingers to produce palmar grip.
The patterns of action of the normal hand depend
on the mobility of the skeletal arches, and alterations of
the configuration of these arches are produced by the
balanced function of the extrinsic and intrinsic muscles.
Whereas the extrinsic contribution resulting from
Figure 2-26 Strong power grip imparted primarily by the large powerful forearm muscle groups is more
the thumb, ring, and small fingers around the hammer
handle with delicate precision tip grip employed to hold important to hand strength, the fine precision action
the nail. (From Fess EE, Gettle K, Philips CA, et al. [2005]. imparted by the intrinsic musculature gives the hand an
Hand and upper extremity splinting. St Louis, Mosby.) enormous variety of capabilities. Although one need
original unabridged work may be found in Fess EE,

Gettle KS, Philips CA, Janson JR (2005). Hand and
upper extremity splinting: Principles and methods, 3rd
ed. St Louis, Mosby.
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anatomy: A review. American Journal of Anatomy,
159:245–260.
Bell-Krotoski J (1990). Light touch-deep pressure testing
using Semmes-Weinstein monofilaments. In J Hunter, L
Figure 2-28 Power grip used to hold the squeeze Schneider, E Mackin, A Callahan, editors. Rehabilitation
bottle with precision handling of the bottle top by the of the hand, 3rd ed. St Louis, Mosby.
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[2005]. Hand and upper extremity splinting. St Louis, study of normal functional wrist motion. Clinical
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Bora FW (1986). The pediatric upper extremity.
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Brand PW (1974). Biomechanics of tendon transfer.
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hand, 3rd ed. St Louis, Mosby.
Bunnell S (1944). Surgery of the hand. Philadelphia, JB
A Lippincott.
Cooney W, Linscheid R, Dobyns J (1998). The wrist
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Flatt AE (1972). Restoration of rheumatoid finger joint
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Flatt AE (1979). The care of minor hand injuries. St Louis,
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Flatt AE (1983). Care of the arthritic hand. St Louis, Mosby.
B Flatt AE (1995). The care of the arthritic hand, 5th ed. St
C Louis: Quality Medical Publishing.
Figure 2-29 Types of precision grip. A. Tip grip. Lichtman D, Alexander A (1988). The wrist and its
B. Palmar grip. C. Lateral grip. (From Fess EE, Gettle K, disorders. Philadelphia, WB Saunders.
Philips CA, et al. [2005]. Hand and upper extremity splinting. Long C, Conrad MS, Hall EA, Furler MS (1970). Intrinsic-
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the rheumatoid hand, 3rd ed. St Louis, Mosby.) precision handling. Journal of Bone & Joint Surgery,
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Moore KL (1982). The developing human: Clinically
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understand the underlying contribution of the various Napier J (1955). The form and function of the
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these activities. 89:362.
Napier JR (1956). The prehensile movements of the human
hand. Journal of Bone & Joint Surgery, 38B:902–913.
Taleisnik J (1976a). Wrist anatomy, function, and injury.
American Academy of Orthopedic Surgeons’ Instructional
ACKNOWLEDGMENTS Course Lectures, vol. 27. St Louis, Mosby.
Taleisnik J (1976b). The ligaments of the wrist. Journal of
I am extremely grateful to Gary W. Schnitz for many of Hand Surgery [America] 1:110–118.
Taleisnik J (1985a). The wrist. New York, Churchill
the excellent illustrations used in this chapter. This Livingstone.
chapter has been edited by Elaine Ewing Fess, MS, Taleisnik J (1985b). Carpal kinematics. In The wrist. New
OTR, FAOTA, CHT for inclusion in this book. The York, Churchill Livingstone.
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Philadelphia, WB Saunders. Landsmere J (1976). Atlas of anatomy of the hand.
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SUGGESTED READINGS Philadelphia, WB Saunders.
Rasch P, Burke R (1990). Kinesiology and applied anatomy,
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Chase RA (1984). Atlas of hand surgery, vol. 2. (2004). The shoulder, 3rd ed. Philadelphia, WB Saunders.
Philadelphia, WB Saunders. Zancolli E (1968). Structural and dynamic basis of hand
Clemente CD (editor) (1990). Gray’s anatomy of the human surgery. Philadelphia, JB Lippincott.
body, 14th ed. Philadelphia, Lea & Febiger.
Hollingshead HW (editor) (1982). Anatomy for surgeons,
vol 4. The back and limbs. New York, Harper & Row.
Chapter 3
NORMAL AND IMPAIRED DEVELOPMENT
OF FORCE CONTROL IN PRECISION GRIP
Ann-Christin Eliasson
CHAPTER OUTLINE meaningful purpose. Then the task to be performed has

to be encoded and translated into purposeful actions,
DEVELOPMENT OF MOVEMENT CONTROL and these must be performed in the appropriate order.
THEORIES In the last decade, considerable attention has been
given to the development of prehensile force control
LEARNED MOVEMENTS
during the manipulation of objects in both healthy
AFFERENT INFORMATION children and children with cerebral palsy (CP), as well
Proprioception as attention deficit hyperactivity disorder (ADHD) and
other kinds of dysfunctions related to the central ner-
Touch
vous system (CNS). It is known that integration of
BASIC COORDINATION OF FORCES DURING somatosensory information is crucial for the fine tuning
GRASPING of motor commands, force regulation, and the build
Development of Manipulatory Forces up of memory strategies for grasping and manipulating
objects. Coordination of movements and somatosen-
DEVELOPMENT OF ANTICIPATORY CONTROL
sory control develop rapidly during the first years of
Weight life. The refinement continues for many years, and
Size adult-like sensorimotor control is not attained until the
early teenage years. If somatosensory control is dys-
Friction
functional, a person is observed to be clumsy to a
ORGANIZATION OF SENSORIMOTOR CONTROL greater or lesser degree. Furthermore, people’s percep-
IMPAIRED FORCE CONTROL AND CLINICAL tions have an effect on their performance of manual
IMPLICATIONS skills because their sensory impressions should be trans-
lated into meaningful information even for the very
Force Coordination
simplest of tasks. The perceptual system provides infor-
Anticipation of the Properties of Objects mation about the position of the hand in space, as well
Sensory Information Used for Force Control as the position of the target, both of which are impor-
tant for goal-directed movement. Finally, the musculo-
SUMMARY
skeletal components are crucial for motor output.
Although any movement a person brings about is high-
ly dependent on how the CNS plans and organizes the
The hand is an effective tool that is used in many movement, the contractile components of the muscles,
different tasks of daily life. The successful performance bones, and joints are the effectors of the planned move-
of manual skills in daily life depends on a complex ment. Another cognitive aspect is motivation, which is
process incorporating several different aspects of a closely related to attention and concentration, and all
person’s capability (Figure 3-1). The usefulness of the of which have an influence on the successful perform-
hand is highly dependent on cognition because one has ance of manual skills. A reduced focus on a task almost
to understand the value of using one’s hands for a certainly limits the ability to learn. Thus self-efficacy
45
Motivation Sensorimotor system
Cognition
Task-comprehension
Attention Perception
Task-focus
Hand use
Muscles and
skeletal system
Self-efficacy
Figure 3-1 Descriptive illustration of components influencing children’s ability to use their hands. (From Eliasson AC
(2004). Improving the use of the hands in daily activities: aspects of the treatment of children with cerebral palsy. Physical and
Occupational Therapy in Pediatrics, 25:37–60.)
and body image have an impact on one’s ability to

perform tasks. Although the performance of manual
DEVELOPMENT OF MOVEMENT
skills is complex, this chapter discusses how the sensory CONTROL THEORIES
information received about an object is increasingly
well integrated with motor processing during develop- At the beginning of this century, sensory stimuli were
ment, leading to smooth, coordinated movements of thought to be responsible for the generation of move-
the hand. This chapter also describes how impairment, ments. This concept was based on studies by Mott
mainly arising from CP, but also from dysfunctions and Sherrington (1895) on deafferented monkeys. By
such as those seen in children with ADHD and devel- transecting the dorsal roots, researchers cut sensory
opmental coordination disorder (DCD) affects sensori- fibers and left the motor fibers intact. The complete
motor control of the hand. sensory loss resulted in permanent abolishment of
Dysfunction or impairment of the CNS almost almost all voluntary movements, especially in the distal
always affects hand function. There is a continuum of segments. A model was proposed in which the move-
decreasing hand function from being somewhat clumsy ments were generated by chain reflexes; the sensory
to having severe impairment. It seems that the diag- information from the first muscle contraction elicited
nosis is less important; it is the grade of impairment the subsequent spinal reflex.
or dysfunction that is crucial. Children with CP have This reflex origin of movement was disputed by
different degrees of impaired hand function. Some Brown (1911), who studied locomotion in spinal cats.
children only have difficulty performing differentiated He suggested instead a central origin in which neuronal
finger movements or in-hand manipulation, whereas networks could generate basic locomotor activity in the
others have severe impairments that make it impossible absence of sensory information (half center model).
even to grasp an object. Most children with ADHD The task of the afferents was restricted to modifying
have fairly good hand function, but when DCD is and compensating for ongoing movements. However,
present also, the clumsiness is more apparent. Regard- it took quite a long time before this idea was con-
less of the degree of severity, decreased hand function firmed. Nowadays there are several elegant studies that
has an impact on children’s daily self-care or school indicate that innate neural networks control rhythmic
activities, and it affects their engagement in play or motor behavior in a variety of species such as locusts,
leisure. The ability to analyze a child’s capacity to use lampreys, and cats (Forssberg, Grillner, & Halbertsma,
his or her hands and compare the child’s capabilities 1980; Forssberg et al., 1980; Grillner, Wallen, & Brodin,
with the complexity of the task is a prerequisite for 1991; Wilson, 1964). Neural networks, called central
intervention planning. This chapter explains the under- pattern generators (CPGs), consist of a group of inter-
lying causes of the impairment or clumsiness apparent neurons that interact in an organized manner to pro-
in children with impairment or dysfunction in their duce a motor act. Detailed knowledge of how one CPG
CNS. By understanding the mechanisms normally operates has been demonstrated in the lamprey, a prim-
responsible for controlling movements, intervention itive vertebrate fish. The lamprey is especially suited for
that takes into consideration the mechanism control- such studies because the spinal cord survives in vitro for
ling manual skills can be planned. Some examples of several days, and neurons involved in the locomotor
this are given later in this chapter. network for swimming are visible under the micro-
Normal and Impaired Development of Force Control in Precision Grip • 47
scope, which facilitates microelectrode recording. The planned together, and the movements are almost
swimming can be initiated by stimulation of specific impossible to stop until completed. This is true, for
areas in the brainstem, sensory stimuli if some skin areas example, when throwing a ball and in more complex
are left innervated, and bath-applied excitatory amino actions, such as typing. Even continuous movements of
acids. Information about the networks also has been moderate speed, such as handling well-known objects,
used for computer simulation (Grillner et al., 1991). are programmed but allow some amount of sensory
The central origin of motor behavior has been fur- feedback. Both kinds of movements are called antic-
ther demonstrated in other rhythmic movements, such ipatory or feed-forward controlled movements, with
as mastication, swallowing, and respiration (Feldman & the characteristic bell-shaped, single-peaked velocity
Grillner, 1983; Lund & Olsson, 1983; Miller, 1972). profile (see later discussions).
Swallowing occurs after the denervation of muscles Slow movements generally are not programmed,
activated early in the sequence, indicating that the brain allowing time for correction of the ongoing movement
sets the motor program for the whole motor act in by afferent signals, and demonstrated by a discon-
advance. However, this does not diminish the impor- tinuous velocity profile (Brooks, 1986). The motor
tance of afferent signals for modulation and learning programs are learned by practice when the afferent infor-
of movements. Movements are activated by efferent mation adjusts the ongoing movement and updates the
signals from several higher levels of the CNS, which are motor program for the final movement. The impor-
modulated by afferent signals from the sensory system tance of sensory information is demonstrated by bird-
and by visual, auditory, and somatosensory information. song learning in the European chaffinch. Normally, the
There are many reasons to believe that the human young birds are exposed to singing by their mothers
nervous system is organized in the same way. Sponta- but do not start singing themselves until 10 months of
neous movements in the human fetus appear from the age. If the birds are not exposed to the adult song, they
eighth gestational week, just after the first functional produce only rudimentary sequences. If the birds are
synapses between neurons are developed. The move- exposed to adult song during the first 4 months of life
ments seem to be generated by neural networks, and and then isolated from songs during the month after,
the afferents may not be needed for initiating the they start to sing properly. This indicates that auditory
movements but are used mainly to adjust and com- experience is necessary for the motor program to be
pensate for disturbances (de Vries, Visser, & Pechtl, fully developed. If the birds are deafened after 4 months
1982; Okado, 1980, 1981). Innate motor programs, but before they start to sing, they sing in a very awk-
such as breathing, sucking, and swallowing, function at ward way. Deafening after they start to sing, however,
birth. The complex pattern of infant stepping also is does not affect the song. This indicates that birds also
innate, but this program is immature in the newborn must compare the initial motor program for singing
and cannot be used for independent walking until the with the actual song, that is, afferent information also
child has learned to control and adjust the patterns to is necessary to be able to learn to use the program of
external conditions. The system develops both through singing. The afferent information corrects the song and
practice and by the process of maturation, in which updates the program, which could be used without
connections with higher central and afferent sensory afferent feedback when the song was established
input continue to be established. This is the concept (Konishi, 1965; Nottebohm, 1970).
from which new therapeutic approaches are developed.
AFFERENT INFORMATION
LEARNED MOVEMENTS
The importance of afferent information is seen in
Voluntary movements in humans are complex. It is patients with large sensory fiber neuropathies, in which
difficult to demonstrate a simple fixed pattern from a the large afferent fibers generating proprioceptive and
CPG, although skilled movements appear to depend on tactile information degenerate. Unless these patients
a set of motor programs. According to Brooks (1986), see their limbs, they do not know their position and
cannot detect limb motion. When reaching toward a
“Motor programs are a set of muscle commands that are
target without seeing the moving hand, they make
structured before the motor acts begin and that can be sent to the
large errors; if they look at the hand before reaching,
muscles with the correct timing so that the entire sequence can be
carried out in the absence of peripheral feedback” (p. 7), the hand comes closer to the target. This indicates that
these patients can compensate for the lack of somato-
or, in other words, can follow an initial plan. In well- sensory information visually and also use vision to
learned, fast movements the trajectory exactly follows program the reaching in advance. Because the patients
this initial plan. The initiation and termination are cannot stop the movement precisely at the desired
target, information from various receptors in the skin is morphology: Two receptor types, Meissner and Pacini
essential for precise movements (Ghez et al., 1990). corpuscles, are fast adapting; Meissner corpuscles have
Impaired sensation is also common in children with small, sharply delineated sensory fields; and Pacini
hemiplegic CP and has to be taken into account when corpuscles have large and diffuse sensory fields. Two
planning treatment. other types of receptors that are slow-adapting units are
Merkel corpuscles, with small and sharply delineated
sensory fields, and Ruffini corpuscles, with large and
PROPRIOCEPTION diffuse fields. Mechanoreceptors with small receptive
The proprioceptive system gives information about the fields are suitable for fine spatial discrimination because
stationary position of the limbs (limb position sense) they have a high sensitivity over the entire field, whereas
and movements of the limb (kinesthesia). The latter mechanoreceptors with large receptive fields have a
information is mediated from tendon organs and mus- central area of high sensitivity and decreased sensitivity
cle spindles and also from receptors in the skin, sensitive in the border of the receptive field. Because there are
to skin stretch. The tendon organ signals information about 17,000 tactile units in the hand and approxi-
about the strength of muscle contraction, increased mately 70% of them have small receptive fields, it can
signaling indicating increased tension. Signals from the be postulated that the tactile system of the hand is
muscle spindle regulate the length of the muscle fibers. highly developed to detect small movements and dis-
The receptors are rather complicated and, despite inten- criminate among different surfaces (Johansson &
sive research, their function is not fully understood. It Vallbo, 1983).
has been agreed, however, that the muscle spindle is People explore the surface of an object by manip-
responsible for small changes in muscle contraction, ulation of the fingers. The difference between explor-
which may be important for force regulation during the ing known and unknown surfaces is the speed of the
grasping act. There are muscle spindles in almost all finger movements (Roland, Ericsson, & Widen, 1989).
skeletal muscles, and they mediate information mainly A relevant movement for exploring the different sur-
through 1a afferents to the spinal cord. The muscle faces of an object is by touch through digital manip-
spindle also has efferent innervation to intrafusal mus- ulation, whereas a more adequate way to explore the
cle fibers, in which the primary and secondary endings shape is by rotation of the wrist and bimanual hand
set the sensitivity to the afferent signals. The different activity. The fingertips are very sensitive to tactile infor-
contractions of intrafusal muscle fibers are probably mation, and tactile discrimination occurs early during
crucial for the information sent to the CNS. Alpha and development. One-year-old children can recognize
gamma motor neurons are co-activated by central dissimilar objects, and they are able to use the two
mechanisms to maintain the sensitivity of the muscle different exploratory maneuvers for objects differing in
spindles throughout the range of almost all move- texture or shape (Ruff, 1984). Newborn monkeys can
ments. There have been different models for the co- distinguish different textures by choosing the texture
activation of alpha and gamma motor neurons, but it that gives milk (Carlson, 1984). These examples indi-
appears that descending commands activate both, as cate that, despite an immature nervous system, there is
demonstrated by Vallbo (1970) in studies of micro- early interaction between somatosensory signals and
neurography. The afferent signals are used to update motor output.
and correct the motor programs, and the information
can be used in a conscious way to give knowledge
about the limb movement and position in space. BASIC COORDINATION OF FORCES
TOUCH
DURING GRASPING
The tactile system is used to discriminate between During the last decade Johansson and Westling (1984,
different surfaces and shapes and also provides sensory 1987, 1988, 1990) have studied grasping movement
input to the CNS, which regulates the force of the to understand how somatosensory information is inte-
muscles during grasping and holding of objects. Touch grated with motor control. In adults, movements of the
transmits nerve impulses from mechanoreceptors to the hand and fingers are precise and the forces of the
CNS via axons with different diameters. Large fibers fingers well controlled. This is not an innate behavior;
with a fast conduction rate mediate tactile sensation in fact, these functions develop during early childhood
from the skin, whereas thin fibers with a slow con- and may be dysfunctional if there is impairment in the
duction rate mediate sensation of pain and tempera- CNS (Eliasson & Gordon, 2000; Eliasson, Gordon, &
ture. The receptors mediating tactile sensation can be Forssberg, 1991, 1992, 1995; Forssberg et al., 1991,
classified on the basis of their receptive fields and 1992, 1995, 1999; Gordon et al., 1992).
Most grasping acts involve lifting and holding stand how they are linked to produce smooth move-
objects, grasping with the fingers, and lifting with the ments. When grasping the instrument, there is a short
arm. The object seen in Figures 3-2 and 3-3 measures delay before the vertical load force starts to increase.
grip force from each grip surface (thumb and index This preload phase is important for establishment of
finger), a combined vertical load force by strain-gauge the grasp. During the loading phase the grip and load
transducers, and vertical movement by a photoresistor forces increase in parallel until the instrument starts to
(Eliasson et al., 1991). With this instrument it has been move. The rates of grip and load forces have mainly
possible to define different phases of the lift and under- bell-shaped profiles (see later discussion) adjusted to
Figure 3-2 Child lifting the experimental object.
Figure 3-3 Experimental instrument in which the grip surfaces are exchangeable and the weight can be covaried
without any visual changes.
the weight, size, and frictional character of the surface at the beginning of the loading phase and at lift-off but
of the object. After the loading phase there is a transi- are silent during the static phase. Slow-adapting recep-
tion phase, in which the lift reaches the final position tors send impulses continuously during the static phase
and the forces are well adjusted to the current prop- (Johansson & Vallbo, 1983). This ability makes it pos-
erties of the object. In the final static phase the object sible to handle small fragile objects without crushing
is held in the air (Figure 3-4). them. To investigate how separate components affect
Tactile information triggers different motor com- the grasping act, the object has a slot in which blocks
mands and links the different phases together. The of different weights may be inserted while the visual
different types of receptors respond differently during appearance remains constant; the contact pads can be
the lift, which has been demonstrated by microneu- covered with silk or sandpaper, each having different
rography from single tactile units innervating the frictional character, and the size can be adjusted by
glabrous skin of the fingers. Fast-adapting receptors boxes of different size attached to the instrument (see
send bursts of impulses when first touching an object, Figure 3-3).
1 Year 6 Years Adult
4N
Grip Force, N
Load Force, N 2N
Position, mm 40 mm
Grip Force 40 N/S

Rate, N/S
Cerebral Palsy
Grip Force 3N
Load Force 3N
Grip Force
Rate, N/S
40 N/S
0.2s
Figure 3-4 Superimposed traces of representative lifts performed at different ages and in three children with cerebral
palsy with various degree of severity. Grip force, load force, position, and grip force rate are shown as functions of time.
When lifting the object, the grip force starts to increase; then the grip force and load force increase until the object starts
to move. When the forces overcome gravity, the signal measuring position increases, followed by a static phase when the
object is held in the air. (Modified from Forssberg H, Eliasson AC, Kinoshita H, Johansson RS, Westling G [1991]. Development
of human precision grip. I. Basic coordination of force. Experimental Brain Research, 85:451–457; Forssberg H, Eliasson AC,
Redon-Zouiteni C, Mercuri C, Dubowitz L [1999]. Impaired grip-lift synergy in children with unilateral brain lesions. Brain,
122:1157–1168.)
weight of the object at lift-off, indicating anticipatory

DEVELOPMENT OF MANIPULATORY FORCES controlled movements (Brooks, 1986; Forssberg et al.,
During the loading phase, just before the movement 1991).
starts, the grip and load forces are generated in parallel Small children also have more variation than adults
for coordinated movements. This parallel increment of because they cannot repeatedly produce similar move-
both grip and load force increases with heavier objects, ments. However, 1-year-old children can use tactile and
resulting in prolonged latency until lift-off. If the proprioceptive information to adjust the forces by
contact surface changes, the grip force increases more sensory feedback during the static phase. All phases are
for slippery materials compared with rough materials, prolonged, and the different phases are not triggered
whereas the load force remains the same. Still the forces elegantly as in adults (Forssberg et al., 1995). There is
increase in parallel but with different slope. This par- an increased difference between thumb and finger
allel force generation forms a lifting synergy to simplify contact, probably because of an immature ability to
movements (Bernstein, 1967). It develops from the adjust the finger toward the object’s size (von Hofsten
second year when the pincer grasp is fully developed. & Ronnquist, 1988). This uncoordinated movement in
Smaller children cannot generate grip and load forces small children is likely attributable to immature motor
in parallel; they initiate forces sequentially. This is output and sensory processing. There is rapid devel-
clearly seen in Figure 3-5; most of the grip force opment until age 2. The refined coordination then
increases before the onset of load force. The force rate progressively develops until leveling out at ages 4 to 6
profile is irregular and has several peaks in young and continues gradually until the teenage years, when
children, whereas older children and adults perform the lifts are completely adult-like (see Figure 3-4)
mainly a bell-shaped force rate profile, adjusted to the (Forssberg et al., 1991).
Grip Force
2N
Load Force
2N 8 Months 2 Years Adult
4N
DIPLEGIA HEMIPLEGIA
Figure 3-5 Grip force during the preload and the loading phase (before lift-off) is plotted against load force in children
of different ages and children with cerebral palsy. Trials are superimposed for each subject. (Modified from Forssberg H,
Eliasson AC, Kinoshita, H, Johansson RS, Westling G [1991]. Development of human precision grip. I. Basic coordination of force.
Experimental Brain Research, 85:451–457; Eliasson AC, Gordon AM, Forssberg H [1991]. Basic coordination of manipulative
forces in children with cerebral palsy. Developmental Medicine and Child Neurology, 33:661–670.)
DEVELOPMENT OF ANTICIPATORY 200

800
CONTROL 100
Peak Grip Force Rate (N/s)

Anticipatory control of manipulation apparently 80
requires the nervous system to efficiently use sensory
information to integrate and store information for 60
internal representation or memory representation of
40
an object. This internal representation is necessary
to produce rapid and well-coordinated transitions
20
between the various movement phases because of a
long delay between motor command and sensory feed-
A 0
back. This is true for reaching, grasping, and lifting
movements, as well as for movement involving the
whole body. In the lifting task the motor output is
based on internal representation of the object’s prop- 4
erties learned by prior experience of the weight,
Acceleration (N/s2)
friction, size, and haptic cues of the object (Gordon et 3
al., 1991a,b; Johansson & Westling, 1990).
2
WEIGHT
When the weight of the object is varied but the visual 1
appearance remains constant, adults typically scale the
grip and load force rates based on earlier experience of 0
the object’s weight. This is indicated by higher grip and t
1-
2
2-
4
4-
6
6-
8 11 -1
5 ul
load force rates for heavier objects. The forces are 8- 11 Ad
decreased at lift-off to harmonize with the weight of
B Age (yrs)
the object. The anticipatory mechanism can be further
Figure 3-6 Influence of the 200- and 800-g weight
demonstrated when lifting an unexpectedly light
(400 g for 1- to 2-year-old children) in the constant lifting
object. For example, if one lifts an unopened but empty series for peak grip force rate (A) and peak acceleration
can of soda, the lift will probably be too high because a (B). The means and standard error of means of the
heavier can is expected. However, this occurs only once individual means for each subject indicate the major
for the same can. Somatosensory information adjusts changes during development. (Modified from Forssberg H,
Kinoshita H, Eliasson AC, Johansson RS, Westling G [1992].
the forces to the object’s actual weight during the static
Development of human precision grip. II. Anticipatory control
phase and updates the internal representation of the of isometric forces targeted for object’s weight. Experimental
object for a smooth movement the next time the object Brain Research, 90:393–398).
is lifted.
Children cannot handle this type of situation as
efficiently as adults. However, despite uncoordinated
force generation and large variation of grip and load there are appropriately scaled forces toward the
force rates, 2-year-old children start to scale the forces expected weight relative to the volume. When only the
toward different weights. It takes several years until size of the object is co-varied and the weight is kept
the anticipatory control of weight is fully developed. constant, the employed grip force rate is higher for the
Children between the ages of 6 and 8 are nearly adult- larger than the smaller object. However, adults and
like although the variation is still larger than in adults older children perceive the small objects as heavier. This
(Figure 3-6). This indicates that anticipatory scaling indicates a dichotomy between the perceptual and
of forces occurs in conjunction with maturation of motor systems because of the size-to-weight illusion
coordinated movement (Forssberg et al., 1992). (Charpentier, 1891). People predict a big object to be
heavier than a small one, yet this is not always true. This
understanding of the discrepancy between size and
SIZE weight and a proper scaling of the motor output starts
Anticipatory control also is predicted from visual infor- to develop at 3 years. Children younger than 3 are
mation about an object’s size (Gordon et al., 1991a,b). not able to control the motor output according to
When the object is kept proportional to the volume, size but do use a higher grip force rate for heavier
objects. This suggests that the associative transforma- Safety Margin

tion between the object’s size and weight involves 300
additional demands of cortical processes, requiring fur- sp
si
ther cognitive development. In children 3 to 7 years of 250
age the difference between large and small objects is
200
greater than in adults. Older children seem capable of
Percent
reducing the effect if it is not purposeful for manip- 150
ulation, whereas younger children still strongly rely on
visual information (Gordon et al., 1992). 100
50
FRICTION 0
Tactile influence on the force coordination is available t
1-
2
2-
3
3-
4
4-
5
5-
6 10 -1
5 ul
6- 11 Ad
on touching an object, contrary to weight influence,
which is not available until lift-off. Tactile information Age (yrs)
from fingertips triggers prestructured motor com- Figure 3-7 The mean and standard deviation of
mands based on sensorimotor memories and adjusts individual means of the safety margin for lifts with
the force coordination based on the friction of the sandpaper and silk plotted for different age groups. The
contact surface. The employed grip forces are different safety margin is expressed in percent of the slip ratio.
Significant differences are indicated by an asterisk
when one holds a slippery bottle than when holding a (p < 0.05). (Modified from Eliasson AC, Gordon AM,
tool covered with rubber, even if they have the same Forssberg H [1995]. Tactile control of isometric finger
weight. When contact pads on the test object are forces during grasping in children with cerebral palsy.
altered by exchangeable contact surfaces of silk and Developmental Medicine and Child Neurology, 37:72–84.)
sandpaper, the relationship between grip force and load
force is changed before lift-off. In adults there is an
initial adjustment to the new frictional condition
during the first 0.1 second and secondary adjustments are a useful compensatory strategy to avoid dropping
during the loading and static phases (Johansson & objects (Forssberg et al., 1995).
Westling, 1987). These adjustments are important in
establishing an adequate safety margin, which prevents
one from dropping the object. The ratio between grip ORGANIZATION OF
and load force actually used, minus the slip ratio
necessary to prevent the object slipping out of the SENSORIMOTOR CONTROL
hand, makes up the safety margin.
One-year-old children have a larger safety margin These studies have enhanced our knowledge of the
than adults. Gradually, the safety margin decreases in mechanisms underlying sensorimotor integration and
conjunction with increased coordination and less anticipatory control in a grasping task. The model
variability during the first 5 years (Figure 3-7). Some implies that for this manipulatory act visual, tactile, and
children of 18 months can scale the grip force based on proprioceptive information are integrated with memo-
tactile information in the beginning of the lift. They ries of similar objects from previous manipulative expe-
have a higher grip force for slippery materials than for rience. The appropriate muscles are then activated in
rough ones during consecutive lifts with the same the proper sequence based on the internal memory
friction. Several years are necessary before children can representation of the object, resulting in a well timed
handle objects with different frictional surfaces in the and coordinated grasping and lifting act. The act
same elegant way as adults. Children younger than 6 includes selection of motor programs that control ori-
years of age, sometimes up to 10 or 12 years, need entation of the hand and the subsequent limb trajec-
several lifts and a predictable order to adjust the grip tories. These programs may be stored in sensorimotor
force to the current friction and form an internal (procedural or implicit) memory and used in an uncon-
representation before setting the parameters of the scious way, different from declarative (explicit) memory
programmed motor output. The difference between that is used in conscious recall of facts, events, and
adaptation to weight and adaptation to friction is that percepts (Squire, 1986) (see Chapter 6). The existence
frictional conditions appear directly upon touching of sensorimotor memory has been demonstrated by
the object, whereas weight information is likely more disorders in higher brain function. It seems that net-
crucial for anticipatory control because the weight is works involving cortical function, especially posterior
not available until lift-off. Grip forces of high amplitude parietal cortex, are important for anticipation. Jeannerod
(1986) has described deficit in shaping the fingers are active in fine manipulation and force regulation
toward the size of the object in patients with damage to (Smith, 1981; Wannier, Toltl, & Hepp-Reymond,
the parietal area. 1986). There may exist subcortical motor centers and
The maturation of control mechanisms for the even networks in the spinal cord important for storing
grasping movement continues throughout childhood. certain motor acts; for example, the C3-C4 proprio-
All measured parameters rapidly develop during the spinal system in cats can be used to mediate and update
first years. Force coordination is poorly developed in 1- cortical commands for visually guided reaching
year-old children; for example, they usually crush an ice (Alstermark et al., 1987). This provides several solu-
cream cone, whereas children of 2 years manage quite tions for a particular movement through a wide range
well. There is a continuum of improvement of the of central and peripheral inputs. During development
parallel generation of grip and load forces as well as there may be reorganization of networks in the spinal
scaling of the forces toward the object’s different cord caused by increased descending control on pre-
weight and friction. In 4-year-old children the motor motor neurons. The descending control may break up
output becomes less varied and more coordinated, in the innate grasp reflex synergy allowing independent
conjunction with a decreased safety margin. Children finger movement and may form a grip/lift synergy
have more coordinated and adjusted movements and (Forssberg et al., 1991).
are able, for example, to carry a kitten and handle Learning motor activities proceeds by trial and error;
fragile objects. At that age there is even force scaling to it is not really understood how the information from
the size of the object. However, the appropriate antici- subsequent lifts is stored in memory to result in effi-
patory scaling with acceleration of the lift to harmonize cient programming. It is known that the anterior lobe
with the weight of the object is not developed until 6 of the cerebellum is involved in force regulation before
to 8 years of age. Even so, there are still large variations a lift because the amplitude of the force is correlated
in the ability to properly scale the forces according to with activity in neurons in this region, which has cuta-
frictional demands. It is not until ages 10 to 12 that neous and muscle afferent inputs from the hand
scaling approaches adult levels. Efficient control of (Espinoza & Smith, 1990). There are radical changes
finger movements continues to develop until adoles- in synaptic activity, reflected in regional cerebral blood
cence, when children can learn to play musical instru- flow, during learning of motor sequence for finger
ments and develop good handwriting with accurate movements. In the initial part of learning there is
speed. Obviously, there is parallel processing of cogni- activation of the cortical areas, cerebellum, and struc-
tive functions and sensorimotor control during normal tures providing information to those areas, namely the
development. anterior language area and somatosensory association
The maturation processes probably occur at many areas. As learning progresses, the activation in the lan-
levels. Both the motor cortex and corticospinal tract guage areas of the cortex disappears, leaving a reduced
with monosynaptic connections are important for pre- region in the somatosensory area, whereas different
cision grip and are highly related to force generation. motor structures and the cerebellum show consistent
In monkeys the monosynaptic projections to the spinal increase in activity. This may mean that motor pro-
cord are not fully developed until the end of the first grams for motor sequence learning of finger move-
year (Lawrence & Hopkins, 1976). Myelination of the ments are established and can be produced in a
axons and increased conduction rate of cortical motor feed-forward strategy with less sensory information. It
neuronal activity develop over several years and prob- appears that memories are not stored in a single cell or
ably influence the temporal parameters of the lift in one particular cortical structure (Seitz et al., 1990).
(Muller, Hornberg, & Lenard, 1991). Because many
areas of the brain are apparently involved in the grasp-
ing act, its full development obviously depends on IMPAIRED FORCE CONTROL AND
establishment of appropriate synaptic connections
between the cortex and all other areas associated with CLINICAL IMPLICATIONS
the act. These maturation processes are shown by reor-
ganization of reflex responses with more efficient and Clumsiness or impaired hand function may have dif-
faster triggering, which continues until adolescence ferent origins. The most common diagnoses of devel-
(Evans, Harrison, & Stephens, 1990; Forssberg et al., opmental disorders in children are ADHD, DCD, and
1991; Issler & Stephens, 1983). There are cortical net- CP. Although of different origin, they are all associated
works mediating monosynaptic corticospinal projec- with more or less impaired force control during
tions to the motor neurons controlling distal muscles grasping (Eliasson et al., 1991; Forssberg et al., 1999;
(Fetz & Cheney, 1980; Muir & Lemon, 1983), which Pereira, Eliasson, & Forssberg, 2000). The dysfunction
could be seen as a continuum, with clumsy children at as the average of the control group to severely impaired
one end and severely impaired children with CP at the (Eliasson et al., 1991; Forssberg et al., 1999). The
other. Children with CP have disturbed hand function parallel grip and load force typical of normal develop-
because the primary or secondary lesions involve the ment rarely is seen. Instead, the forces increase sequen-
sensorimotor cortex and the corticospinal tract, both of tially with the grip force increasing before the load
which have great implication for the performance of force (see Figure 3-5). Consequently, they do not
precision grips and for independent finger movement produce the force rates in mainly bell-shaped profiles,
(Lawrence & Kuypers, 1968; Muir & Lemon, 1983) but in stepwise, irregular, and extremely variable pro-
(see also Pehoski, Chapter 1). These children are files (see Figure 3-4). However, this slow, sequential
known to be slow and weak with disturbed mobility of initiation of movements is an adequate strategy pro-
their finger movements (Brown et al., 1987; Ingram, viding security in a manipulative task in which the
1966). In addition, they have different degrees of coordination of force generation is not fully functional.
spasticity and tactile discrimination, especially those For both groups of children (ADHD and CP), the grip
children with hemiplegic CP (Brown et al., 1987; force is larger and more unstable when performing a lift
Uvebrant, 1988). Little is known about the neural than it is for controls, in addition to which there is
mechanisms that cause the impaired motor behavior in more variability between one lift and another (see
children with ADHD. The main problems are hyper- Figure 3-4) (Eliasson et al., 1991). This large variability
activity and poor attention, as indicated by the name, seems to be a characteristic of immaturity, as well as of
but about half of the children who have been diag- dysfunction and impairment. It means that the children
nosed with ADHD also have motor problems (Barkley, cannot repeat a task in the same way, or transfer the
1990; Kadesjö & Gillberg, 1998). In particular, their experience of performing one task to the performance
fine motor skills are diminished (Szatmari, Offord, & of a similar one, making their performance unpre-
Boyle, 1989; Whitmont & Clark, 1996), affecting, for dictable or clumsy. The relation between the develop-
example, their handwriting and performance on other ment of force control and the severity of hand function
highly skilled tasks (Doyle, Wallen, & Whitmont, 1995; has been demonstrated previously (Forssberg et al.,
Raggio, 1999). DCD is characterized by minor motor 1999).
problems that occur as an isolated phenomenon in However, the slow performance commonly observed
some children (American Psychiatric Association, in children with CP may be a good adaptation to their
1994), which is to say that the minor motor problems impairment. An example of the usefulness of such slow
appear without the symptoms attributable to ADHD and sequential movement is evident when one con-
but also can be found in conjunction with ADHD. siders the impaired release of the grasp. When effi-
These DCD children in the past were called “clumsy ciently putting down and releasing an object, including
children” or children with motor coordination prob- toys, the object has to be lowered and placed on a
lems. The cause of the dysfunction is unknown but the surface, not too quickly and not too slowly. This neces-
group generally can be distinguished from typically sitates a low velocity of the movement close to the
developed children from the results of a test like the surface on which the object is to be placed (Figure
Movement ABC (Henderson & Sugden, 1992). As 3-8). Then the force of the grasp ceases and the indi-
indicated, dysfunctioning prehensile force control is vidual fingers are removed quickly and almost simul-
common to all children with ADHD, DCD, and CP. taneously. In a hemiplegic hand, a reversed pattern is
found: The placement is performed fairly quickly, and
the velocity of the movement is high upon making
FORCE COORDINATION contact with the table, making the movement abrupt.
When making a lift, the temporal pattern is rarely Then it is hard for the child to decrease the force,
impaired in children with ADHD regardless of whether resulting in a prolonged movement phase during which
or not the ADHD is accompanied by DCD (Pereira the fingers are released one at a time in an uncoor-
et al., 2000); for children with CP, it is almost always dinated manner (see Figure 3-8) (Eliasson & Gordon,
disturbed to some degree. In these children the differ- 2000).
ence in the time at which the first finger or thumb How can this knowledge be used in clinical practice?
makes contact with the object and the time at which The case of a 4-year-old girl with hemiplegia playing
the second finger makes contact is larger than in typi- with small plastic animals is one example. Every time
cally developing children, indicating disturbed coordi- she tried to lift and then place the horse, it fell. It was
nation of finger movement and shaping of the fingers obvious that she was releasing the object too abruptly.
toward the size of the object, although there is a great By giving a simple instruction, “Straighten your fingers
deal of variation within the group, from almost as good slowly,” she had the clue she needed to immediately
Control CP
T0 T1 T2T3 T0 T1 T2 T3
Grip force (ind)

6N
Grip force (th)
F4 F5
F6 F4 F5
Grip force rate F6
30 N/S
F3
F3
Load force
4N
Load force rate
60 N/S
Position F2
F2
60 mm
Velocity 50 mm/s
F1 F1
Acceleration 2 mm/s2
1 sec
Figure 3-8 Grip force from the index finger (ind) and thumb (th), grip force rate, load force, load force rate, vertical
position, velocity, and acceleration as a function of time for representative trials during object replacement and release for
one child in the control group and one child with hemiplegia. The grip and load force rates are shown using a ±20 point
numerical differentiation. Vertical lines indicate the initiation of vertical displacement (T0), object contact with the table
(T1), release of one digit (T2) and then the opposing digit (T3). The measured force parameters are shown by arrows
indicating peak velocity (F1), peak load force rate corresponding to table contact (F2), minimum grip force rate (F3), grip
force at replacement (F4), grip force at table contact (F5), and grip force at load force zero (F6) (dashed line in the right
traces). (Modified from Eliasson AC, Gordon AM [2000]. Impaired force coordination during object release in children with
hemiplegic cerebral palsy. Developmental Medicine in Child Neurology, 42:228–234.)
succeed. By analyzing her performance in the light of ANTICIPATION OF THE PROPERTIES

the knowledge that the hand of the child with hemi-
OF OBJECTS
plegic CP has impaired force coordination, the thera-
pist was able to give the girl precise information. The During normal development small children are able to
therapist recognized that although she appeared to scale the force that needs to be applied when gripping
be slow when replacing the horse, she was not slow an object even before the action starts, taking into
enough in the crucial part of the action—when she had account the weight and friction, as well as the size of
to loosen her grasp. That part had to be performed the object. This happens even before the typical parallel
even more slowly, and she was able to succeed by force coordination with the mainly bell-shaped force
increasing her awareness of that part of the movement rate profile is developed. Hardly any of the children
sequence. with CP who were aged 6 to 8 years, or the children
Normally this behavior is performed in an uncon- with ADHD plus DCD who were 9 to 15 years, scaled
scious way (i.e., by implicit processes) (Gentile, 1998). the force amplitude appropriately for different weights,
However, after a lesion has occurred in the CNS, it may whereas children with only ADHD anticipated the
be necessary to use an explicit process, at least in the weight fairly well (Eliasson et al., 1992; Pereira et al.,
early stage of learning. Knowledge about normal and 2000). This indicates that a different type of dysfunc-
abnormal behavior and the ability to analyze the task tion (diagnosis), at least on a group level, influences the
made it possible to give precise instructions. The idea ability to scale the motor output. Although children
was to help the child to learn how her impaired nervous with ADHD plus DCD can apply an appropriate force
system works and give her a strategy that could enable the first time they lifted a familiar object such as a
her to perform this task successfully; then she might be glass, or an unopened packet of milk, they cannot do
able to use the same strategy when releasing other this efficiently with an unfamiliar object, when they
objects in different situations (Eliasson, 2005). have only seen but not touched or lifted it (Pereira
et al., 2000). Appropriate force involves anticipatory decreased from the first to the last day of camp, from
scaling. That means that when heavier and larger 20 (range 14 to 35) to 14 (range 12–18) (Eliasson et al.,
objects such as an unopened packet of milk are to be 2003). It appears that it is possible to improve at
lifted, the child increases the load force at a greater rate Frisbee golf, as well as to learn to scale the force output
during the initial lifts than when lifting smaller light during grasping applied to objects by practice, at least
objects like the glass. Children with ADHD plus DCD for these groups of children with CP.
are able to build up a memory representation of the
object, although this is not as efficient as for typically SENSORY I NFORMATION USED FOR
developed children and adults. This deficient control
was also demonstrated in a group of children with
FORCE CONTROL
hemiplegic CP who were unable to scale the force Sensory information is essential for prehensile force
output to match the weight of a previously lifted object control because it provides the nervous system with
until they had lifted the object at least 15 times. This information about different aspects of the physical
has to be compared with the one or two times neces- properties of objects in the immediate environment
sary in age-matched peers (Gordon & Duff, 1999). and, as described, it is used for anticipatory scaling and
However, most participants with CP demonstrated to adjust ongoing movements. Sensory impairments
anticipatory scaling when lifting familiar objects, have been described for children with hemiplegic CP
which means that they are capable of learning by but have not been observed in children with diplegic
practice, despite having a dysfunctional nervous system. CP or ADHD (Uvebrant, 1988). In children with
The question, then, is how this practice should be hemiplegic CP, a decrease in two-point discrimination
planned and performed. An investigation was carried and stereognosia occurs in 50% to 70% of children.
out in another experiment in which children lifted Processing of proprioceptive information also is
novel objects that varied in weight in either a blocked impaired. This can be seen during vibration of a
series, with one weight being lifted several times, or a muscle, in which the muscle spindles are stimulated,
random series in which different weights were ran- giving rise to an illusion of arm movement; this illusion
domly assigned to be lifted (Duff & Gordon, 2003). occurs in normal children, but only in 50% of children
Blocked practice resulted in greater differentiation with CP (Tardieu et al., 1984). However, there is an
of the force rates between objects during acquisition unclear relationship between the perceived sensation of
than random practice. However, both types of practice this kind and the ability to adjust the force output to
resulted in similar performance retention 24 hours match the physical properties of an object. All children
later. These findings suggest that children with hemi- with CP who participated in earlier studies perceived
plegic CP are able to build up internal representations the difference between weight and frictional contact
that are used for anticipatory force scaling of novel surfaces of the object to be lifted although some of
objects, and that practice is valuable, although it appears them had decreased two-point discrimination and
that the type of practice schedule employed is not stereognosis. That is, almost all of them have decreased
important. ability to transform sensory information into appro-
The importance of practice can be demonstrated by priate “settings” for a motor command. There was no
adolescents with hemiplegic CP who were practicing simple correlation between two-point discrimination
Frisbee golf using their hemiplegic hand. Being able to and ability to adjust the force output based on frictional
throw a Frisbee as well as possible toward a target condition of the object (Eliasson et al., 1995). This
requires the ability to plan the direction of the move- may indicate that two point discrimination needs to be
ment, use a certain amount of force, and release the processed at a higher level in the central nervous system
grasp with exact timing. Playing Frisbee with a hemi- than adjustment of forces for grasping.
plegic hand may seem crazy, but it was an activity The children with CP should be able to rely on
practiced at a 2-week, 5-day-a-week day camp in which sensory feedback for grasping because, as mentioned,
the adolescents were treated by Constraint Induced their anticipatory control is impaired. Relying on sen-
Movement Therapy (Eliasson et al., 2003). The goal of sory feedback means that the forces increase in a
the Frisbee game was to traverse a 350-foot-long steplike manner, permitting sensory feedback, until lift-
course, at the end of which was a basket. The object of off. This results in a prolonged loading phase for
the game was to use the fewest number of throws to heavier objects, but fairly well-adjusted forces taking
get the Frisbee in the basket. Nine adolescents prac- into account both the weight of the object and the
ticed 30 minutes for 7 days during the day camp. All friction of the contact surfaces during the static phase
adolescents improved at this game, and the number when the object is held still in the air (Eliasson et al.,
of throws needed to get the Frisbee into its basket 1992, 1995). Yet there is large variation in the grip
force applied during the isometric force coordination, Dexterity before and after surgery
making the performance unpredictable and, of course, 140
inconvenient for daily life. This is a common feature
120
in the early development of all children, including chil-
dren with different diagnoses (Eliasson et al., 1991; 100
Brogren, Forssberg, & Hadders-Algra, 2001; Pereira et
Sec
80
al., 2000). A way of solving this problem is to increase
the safety margin to prevent objects from being dropped. 60
This compensatory behavior was obvious in all the 40
children with CP who were investigated. It is evidently
20
a successful compensatory strategy for those with
impaired sensory processing, lack of anticipatory con- 0
Normal Impaired
trol, and slow adaptation (Eliasson et al., 1995). How- Sensibility
ever, it does make it difficult to handle fragile objects
Figure 3-9 Dexterity, in seconds when moving 10
because there is a danger that the object will be crushed, cubes and placing them on the opposite side of a vertical
and it also makes it difficult for children with CP to border on the table. Individual results of 11 subjects with
handle heavy objects because, in this case, a high level normal two-point discrimination (2PD) and 14 with
of force is needed and weakness is a common problem impaired 2PD before and after surgery. 2PD: 3 to 4 mm
in children with CP. was tested for in a randomized order, their fingers were
touched with a distinct but light touch with one or two
The question that needs to be addressed is: How points, 10 times on each finger. Before examination, the
can children with sensory dysfunction learn to handle task was demonstrated for them to see and feel the
objects as efficiently as possible? Sensory information differences between one and two points on both hands.
is crucial for the performance of precise movements. Normal 2PD required at least eight correct answers on
Tactile information is the most important information two of three digits. The time decreased 14.5 s (md)
compared with 9 s (md) for children with normal
for discrete finger movements, whereas proprioception sensation. (Modified from Eliasson A.C, Ekholm C, Carlstedt T
is more important for reaching in different directions [1998]. Hand function in children with cerebral palsy after
and handling objects of different weights. Tasks in upper-limb tendon transfer and muscle. Developmental
which tactile information is crucial are, for example, Medicine in Child Neurology, 40:612–621.)
buttoning up a shirt, picking raspberries, and opening
a door with a key. For many bimanual tasks, having
intact sensibility in only one hand does not terribly
influence the task performance because people usually and the thumb was able to meet the fingers, making it
hold the object (an action requiring less sensory infor- possible to use vision to compensate for impaired sensi-
mation) with their impaired hand and manipulate bility. This may indicate that impaired sensation could
(requires efficient tactile regulation) with their domi- be an indication for surgery, at least from one per-
nant hand (Krumlinde-Sundholm & Eliasson, 2002). spective. This is opposite to what commonly is recom-
However, an important compensation for tactile mended but has to be considered. One other important
disturbance is to use visual information. Vision strongly way to compensate for lack of control that should not
influences manipulatory actions and should not be be overlooked is to concentrate and pay deliberate
overlooked when attempts are made to gain a deeper attention to the performance of the task. The compen-
understanding of how the somatosensory systems satory strategies are crucial, but they often make the
influence manipulatory actions. The ability to use visual children slower.
information as a form of compensation was seen when
the results of hand surgery were evaluated. Children
with CP and impaired sensibility tended to benefit SUMMARY
more or at least as much from upper limb surgery as
measured by a timed dexterity task than children with Motor control—meaning how the CNS controls move-
intact sensibility (Figure 3-9) (Eliasson, Ekholm, & ment—is complex, but by understanding the principles
Carlstedt, 1998). This probably has something to do of how movements are organized, it is possible to use
with the ability to “see the grasp” being performed the knowledge that has been gained to plan interven-
after surgery because before the surgery was per- tion. By using this perspective we can help children
formed, the hand was pronated, the wrist was flexed, to learn more about themselves and help them find
and the thumb was in-palm, making it impossible to see more efficient ways to use their possibilities rather than
the grasping act as it was conducted. After surgery, in focusing on the impaired or odd movement. An impor-
contrast, the hand was more extended and supinated tant perspective to put across is that there is nothing
wrong or right about a movement, rather, when there Neurology, 29:287–304.

is a task that needs to be performed, it can often be Brown TG (1911). The intrinsic factors in the act of
progression in the mammal. Proceedings of the Royal
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It is also known that improvement in any task children with hemiplegic cerebral palsy. Developmental
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daily activities: Aspects of the treatment of children with
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(van der Weel, van der Meer, & Lee, 1991). For the Clinical experience of constraint induced movement
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this. For success in skills, the therapist should encour- in children with cerebral palsy after upper-limb tendon
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and learn, working on their possibilities rather than on Neurology, 40:612–621.
Eliasson AC, Gordon AM (2000). Impaired force
their limitations. We have to bear it in mind that the coordination during object release in children with
task performance we see may look odd from a per- Hemiplegic Cerebral Palsy. Developmental Medicine and
spective of “normal” movements, but it may be a solu- Child Neurology, 42:228–234.
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anticipatory control of isometric forces during grasping by
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Chapter 4
PERCEPTUAL FUNCTIONS OF THE HAND
Sharon A. Cermak
CHAPTER OUTLINE used for carrying out everyday activities such as tying
shoes or buttoning. As a perceptual organ it seeks and
DEVELOPMENT OF HAPTIC PERCEPTION processes information such as when searching for a coin
Haptic Perception in Infants in a pocket. The two functions of the hand are closely
intertwined. Rochat (1989) emphasized that
Haptic Perception in Children
“from the origin of development, action is under some perceptual
Gender and Hand Differences in Haptic Recognition
or sensorimotor control and the picking up of perceptual infor-
and Haptic Accuracy
mation is somehow inherent in any performed act” (p. 871).
Summary and Implications for Practice
However, when the hand performs a practical action,
FUNCTIONS CONTRIBUTING TO HAPTIC its perceptual functioning is regulated by what is
PERCEPTION needed to achieve this action, whereas when the hand
Role of Somatosensory Sensation in Haptic acts primarily as a perceptual system, its motor activity
Perception is primarily exploratory and information seeking.
Role of Manual Manipulation and Exploratory This chapter concerns the hand as a perceptual or
Strategies in Haptic Perception information-seeking organ. Focus is on active touch
(haptic perception) rather than passive touch. Passive
Role of Vision and Cognition in Haptic Perception touch involves only the excitation of receptors in the
Summary and Implications for Practice skin and underlying tissue;
EVALUATION OF HAPTIC PERCEPTION IN INFANTS
AND CHILDREN “active touch involves the concomitant excitation of receptors in
the joints and tendons along with new and changing patterns in
HAPTIC PERCEPTION IN CHILDREN WITH the skin” (Gibson, 1962, p. 482).
DISORDERS
Prematurity Brazelton has suggested that, whereas
Mental Retardation
“passive touch may add to an infant’s ability to initiate and
Brain Injury maintain control, active touch … acts as an alerter and as
Learning Disabilities and Related Disorders information. It helps the infant come to a receptive alert state
and begin to process information” (Rose, 1990, p. 316).
Summary and Implications for Practice
SUMMARY Haptic perception deals with the retrieval, analysis, and
interpretation of the tactile properties (e.g., size, shape,
The hand has two closely related functions: It is both an texture) and identity of objects through manual and
executive and a perceptual organ (Bushnell & Boudreau, in-hand manipulation (Bushnell & Boudreau, 1993;
1998; Gibson, 1988; Hatwell, Streri, & Gentaz, 2003; Hatwell, 2003). The process of tactile scanning is com-
Lederman & Klatzky, 1998). As an executive organ it is plex and includes the blending of feedback from tactile,
63
kinesthetic, and proprioceptive sensations. The tactile objects (Ruff, 1989). Pecheux, Lepecq, and Salzarulo
spatial properties of objects are obtained through the (1988) found evidence suggesting intramodal (haptic-
retrieval of information about the relationship of the haptic) recognition of shapes inserted into nipples by 2
objects to the body and gravity during active manual months of age.
exploration. As the infant develops, the hands become a
The study of haptic perception has been closely perceptual system that increasingly participates in the
associated with the study of visual perception. infant’s construction of knowledge (Bushnell &
Researchers have attempted to gain insight into how Boudreau, 1998; Hatwell, 1987). Manipulation of an
we use our visual and haptic senses to function by com- object facilitates the learning of the object’s charac-
paring the ability to match objects through the use of teristics. During exploratory play of the first year,
vision and haptic manipulation. These studies typically infants begin to learn about their environment, their
require the subject to match a standard (test) object to bodies, and how their actions can effect change
a set of two or more comparison objects. If the subject (Gibson, 1988). Current research has indicated that
is asked to do an intramodal comparison, both the haptic abilities are much more efficient in infants than
standard and comparison objects are analyzed using was thought in the past (Streri, 2003a). Use of the
the same sensory modality (visual or haptic sense). If the habituation paradigm adapted from vision research has
subject is asked to do an intermodal comparison, the shown that early intramodal (haptic-haptic) manual
standard object is analyzed using one sense and the com- exploration in infants provides consistent haptic dis-
parison object(s) are analyzed using the other sense. In crimination (Hatwell, 1987; Streri & Pecheux, 1986).
this chapter research methodology is specified as con- In this paradigm infants are given shapes to manually
taining intramodal or intermodal matching, whereas explore with a screen preventing the infants from
the senses used appear in parentheses (standard com- seeing their hands. The amount of interest the infant
parison). For example, intermodal (haptic-visual) devotes to the object is measured by the amount of
matching means that the haptic sense was used to time the object is grasped, and as the infant habituates,
analyze the standard or test object and the visual sense he or she holds the object for shorter periods of time.
was used to select from among the comparison objects. Using two pairs of shapes, Streri and Pecheux (1986)
The term multimodal exploration refers to the simul- observed a haptic habituation to a familiarized shape
taneous use of the visual and haptic senses in object and a reaction to novelty (longer holding) when a new
investigation. In this chapter the review of intramodal shape was presented to 4- and 5-month-old infants.
matching (matching using the same sensory system) is This was noted in infants as young as 2 to 3 months
limited to haptic-haptic matching in which the subject (Streri, 1987). Streri and Pecheux (1986) reported that
feels the standard or test object and then feels several infants required a longer period of time to habituate to
comparison objects to find the match. tactile stimuli than to visual stimuli and suggested that
One goal of this chapter is to provide the reader with this may be explained, in part, because information can
an understanding of selected aspects of haptic be obtained more quickly visually than tactually. In a
perception that may influence effective evaluation and similar haptic habituation paradigm, 6- and 7-month-
treatment of children with suspected and identified old infants with severe visual impairments also were
impairments in haptic perception. Topics covered found to show haptic integration for shape and texture
include the development of haptic perception, func- (Catherwood et al., 1998).
tions contributing to haptic perception, evaluation of Research with infants also has shown that young
haptic perception in infants and children, and haptic infants evidence intermodal integration. Rose, Gottfried,
perception in children with neurologic disorders. The and Bridger (1978) concluded that 6-month-old
adult literature has been included to the degree to infants could integrate visual and haptic perception as
which it assists our understanding of the current status evidenced by their ability to visually recognize a shape
of the pediatric research. after only tactile contact with it. Streri and colleagues
completed a series of studies that supports even earlier
development of visual-haptic integration and haptic
object perception (Streri, 2003b; Streri & Gentaz,
DEVELOPMENT OF HAPTIC 2004; Streri et al., 2004; Streri & Molina, 1993; Streri
PERCEPTION & Spelke, 1988, 1989). For example, responses of
4- to 5-month-old infants to visual images of objects
were assessed after bilateral object handling without
HAPTIC PERCEPTION IN I NFANTS opportunity for visual regard of the hands (Streri &
In the infant the hands and mouth are both potential Spelke, 1988, 1989). One object presented was two
sources of haptic information. The mouth can be used rings connected by a solid bar; the other object was
to gain information about the shape and substance of two rings connected by a string. The infants produced
Perceptual Functions of the Hand • 65
different types of arm movements when holding the surfaces containing one or two holes or having open-
different objects. The infants were shown visual ings or closings on their outer edges. These authors
displays of two rings either connected or separated, found that the ability of children to identify objects and
which were moving as they typically did while the shapes by touch progressively improved with increased
infants were holding them. The infants looked longest age. Children 21⁄2 to 31⁄2 years of age were able to
at the rings that were dissimilar to those that they had correctly recognize common objects but were unable
held. This was the expected response if the infants to identify shapes. By 31⁄2 to 5 years of age children
perceived the similarities between the rings that they developed the ability to match topologic forms.
held and moved and those that they saw moving. Streri Recognition of geometric figures emerged at 4 to 41⁄2
and Spelke (1988) concluded, years with the ability to differentiate curvilinear (circle
and ellipse) from rectilinear (square and rectangle)
“infants evidently perceived connected or separated objects by shapes. The ability to recognize geometric figures in
detecting the patterns of common or independent motion that greater numbers and levels of complexity was shown to
they themselves produced.” (p. 19). progressively improve from 41⁄2 to 7 years of age.
Benton and Schultz (1949) also studied intermodal
They also noted that the infants held the objects for (haptic-visual) matching of common objects in a group
relatively long periods, as much as five times as long as of 156 3- to 5-year-old children and found that per-
they would have been expected to visually attend to an formance progressively improved with age. Three-year-
object. Because these 4-month-old infants were so old children typically were able to recognize 50% of the
competent at identifying objects tactually and visually, items presented (mean 4.0 out of eight items). Four-
Streri and colleagues (Streri, 2003a; Streri & Spelke, year-old children performed only slightly better than
1988) questioned Piaget’s theory that vision and touch children in the 3-year-old age group (mean = 4.5).
become integrated through haptic exploration of Near-perfect performance typically was found by 5 years
objects and suggested that this ability may be present of age, with most children correctly recognizing at least
without substantial experience in handling objects. In a seven of the eight objects presented.
recent study of cross-modal recognition in newborns, Hoop (1971a) also studied intermodal (haptic-
Streri and Gentaz (2004) have even suggested that visual) matching at 31⁄2 to 51⁄2 years. Like Piaget and
under some limited conditions, newborns have the Inhelder, Hoop found the identification of common
ability to extract shape in a tactile format and transfer it objects to be easier than the recognition of topologic
to a visual format, independent of common experience. forms and geometric figures. There was little variation
Molina and Jouen (1998, 2001, 2003) also reported in the ability of 31⁄2- to 51⁄2-year-old children to match
that newborns can discriminate between rough and soft topologic forms (means ranging from 2.3 to 2.6 out of
textures and modify their grasping according to the a maximum score of 4). Miller (1971) reported a
texture of the grasped object. similar finding. The 3- and 4-year-old children in her
study were able to identify fewer than half of the
intermodally (haptic-visual matching) and intramodally
HAPTIC PERCEPTION IN C HILDREN (haptic-haptic matching) presented shapes. Like Piaget
Much of the literature on haptic perception in children and Inhelder, Hoop found the recognition of topologic
deals with the recognition of common objects (e.g., forms through intermodal (haptic-visual) matching to
comb, penny) and shapes (e.g., circle, square, diamond). be easier than the identification of geometric figures.
However, the hand also is used to gain information However, this has not been a consistent finding
about other object properties, such as texture, hardness, (Derevensky, 1979). Derevensky (1979) suggested that
size, weight, and spatial orientation. Each is discussed. listing shapes as topologic or geometric may be an
incorrect method of categorization, and suggested that
Recognition of Common Objects and Shapes it may not be whether a shape is topologic or geometric
One of the most well-known studies on the develop- but the nature of the distinctive features that it contains
ment of haptic perception in children is that of Piaget that contributes to task difficulty.
and Inhelder (1948/1967). They presented a series of Another interesting finding was reported by
solid (three-dimensional) common objects and card- Abravanel (1972), who noted that, in a series of inter-
board cutouts of shapes (geometric figures and topo- modal (haptic-visual matching conditions, it was easier
logic forms) to a group of 2- to 7-year-old children and for 6- to 8-year-old children to identify solid (three-
asked the children to feel each figure and then visually dimensional) than flat (two-dimensional) geometric
select the figure from among a set of figure drawings. figures. She attributed this to possible variation in the
The geometric figures used ranged from simple (e.g., usefulness of the manipulation strategies used by the
circle, ellipse, square) to complex (e.g., star, cross, children in shape exploration. This topic is discussed in
semicircle). Topologic forms were shapes with irregular depth in a later section of this chapter.
Recently, Bushnell and Baxt (1999) examined haptic Intermodal (haptic-visual) discrimination of diameter
recognition of familiar versus unfamiliar objects. They and length has been reported to emerge at 4 years and
found that 5-year-old children more accurately continues to mature into adolescence, with variation in
identified familiar than unfamiliar objects; however, this diameter being easier to recognize than variation in
varied as a function of whether the matching was length (Abravanel, 1968a,b; Connolly & Jones, 1970;
haptic-haptic or haptic-visual. For unfamiliar objects, Hulme et al., 1983). When analyzing length, children
haptic-haptic matching was more accurate than haptic- found tasks requiring intramodal (vision or haptic)
visual matching, whereas there was no difference for discrimination easier than those requiring intermodal
familiar objects. Familiar objects were identified more (vision and haptic) discrimination for object com-
accurately than unfamiliar objects in a haptic-visual parison (Hulme et al., 1982, 1984).
matching task, but there was no difference as a function Research comparing children’s preference for the use
of familiarity in the haptic-haptic matching task. A limi- of texture, size, and shape in object recognition suggests
tation of the study is that a ceiling effect was reached that there may be a developmental progression in pref-
for familiar objects, with many participants achieving erential use of these sensory properties. Preference for
maximum scores. the use of texture over shape in object identification
There is general agreement that the haptic percep- during intramodal (haptic-haptic) matching tasks has
tion of common objects is well developed by 5 years of been found to occur in young children (4 to 5 years of
age, and the ability of children to select geometric age) but not in older children (Berger & Hatwell, 1993,
figures through intermodal (haptic-visual) matching 1995; Gliner, 1967; Schwarzer et al., 1999; Siegel &
emerges at about 4 years of age (Abravanel, 1972; Barber, 1973; Siegel & Vance, 1970), although
Blank & Bridger, 1964; Hoop, 1971a; Micallef & May, Schwarzer and co-workers (1999) found that the
1979; Piaget & Inhelder, 1948/1967). Like the exploratory strategy varied as a function of the task
finding of Piaget and Inhelder, all of these studies have requirements and the feedback. Size has been shown to
noted improvement in accuracy with increasing age. be more difficult to discriminate than texture in children
Moreover, with increasing age, children change their 4 and 8 years old (Miller, 1986). Gliner and co-workers
representation of objects from one based primarily on (1969) further found that the preference of kinder-
global shape to one that incorporates a balance of gartners for texture over shape in object identification in
global shape and specific local parts (analytical mode) an intramodal (haptic-haptic) matching task decreased as
(Berger & Hatwell, 1993, 1995; Morrongiello et al., the textured surfaces became more difficult to identify.
1994). However, whereas some researchers reported Preference for the use of shape over texture and size
that young children primarily used global strategies to during intramodal (haptic-haptic) matching of objects
categorize objects, others found that both children and was cited by Siegel and Vance (1970) and Gentaz and
adults primarily used analytic modes (Schwarzer, Kufer, Hatwell (2003) in kindergarten through third-grade
& Willkening, 1999). Within this mode, Schwarzer children. Adults preferred size or shape classification
found a developmental sequence in the attribute chosen (Gentaz & Hatwell, 2003).
for categorization of objects. They found that focusing Miller (1986) further found that variation in shape
on surface texture decreased with age and focusing interfered with accuracy in identification of texture
on shape increased with age. Thus children preferred during intramodal (haptic-haptic) matching in 8-year-
substance-related attributes, especially surface texture, old children but not in 4-year-old children. She con-
whereas adults preferred the structure-related attrib- cluded that this might be because 4-year-old children
utes, especially shape. This was consistent with Berger ignored shape cues when texture was available for use
and Hatwell (1993), who also found a preference for in object discrimination. Thus it is possible that during
surface texture as an analytic attribute. tasks requiring haptic discrimination, children might
use the sensory property that produced the strongest
Recognition of Texture, Size, and Weight distinctive features. As the ability to recognize shapes
Unlike shape or orientation, length, or localization in improves with age, there might be increased preference
the environment, in which vision is superior to touch, for the use of shape over other properties for object
texture perception is often as good haptically as visually identification because shape yields distinctive features
(Gentaz & Hatwell, 2003). Haptic discrimination of that are more useful in object recognition than texture
texture, size, and weight has been shown to improve or size. If this hypothesis is correct, then the properties
with increasing age in 4- to 9-year-old children (Gliner, selected for use in object recognition might be age and
1967; Miller, 1986; Siegel & Vance, 1970). Gliner task dependent. They might vary based on both the
further found rough textures to be easier to identify degree to which the distinctive features provided by
than smooth textures, with third grade subjects the object were easy to identify and the developmental
showing a lower threshold (greater sensitivity) to level of haptic perception (e.g., texture, shape, size)
texture stimuli than kindergarten subjects. exhibited by the child being tested.
Recognition of the Spatial Orientation of Objects Research generally has shown that boys and girls 3 to
Few studies have addressed the development of haptic 14 years old display equal ability to recognize common
spatial orientation in children. Perceptual awareness objects, shapes, and words through intramodal (haptic-
of the constancy of spatial location through the use of haptic) and intermodal (haptic-visual) matching
vision and haptic exploration has been shown to (Abravanel, 1970; Affleck & Joyce, 1979; Ayres, 1989;
develop at an early age. Three-year-old children who Benton et al., 1983; Benton & Schultz, 1949; Bushnell
were blind were able to identify common objects after & Baxt, 1999; Cioffi & Kandel, 1979; Cronin, 1977;
180 degrees of object rotation (Landau, 1991). Etaugh & Levy, 1981; Gliner, 1967; Klein &
Hatwell and Sayettat (1991) asked 4- to 7-year-old Rosenfield, 1980; Kleinman, 1979; Witelson, 1976;
children to reseat a doll at a table inside a doll house Wolff, 1972). Occasionally boys have been identified as
after the child, the doll, the table, or the house was exhibiting greater skill than girls in the intramodal
rotated. Many of the 4-year-old children were able to (haptic-haptic) matching of objects by texture, size,
successfully reseat the doll in the initial location after and shape (Gliner, 1967). In addition, Siegel and
rotation using intramodal (visual or haptic) exploration. Barber (1973) found boys to display a stronger pref-
An age-related increase in accuracy of doll placement erence than girls for the use of form over texture in the
occurred between ages 4 and 6 years. The shape of the intramodal (haptic-haptic) matching of shapes. Most
table had no effect on task performance. studies conducted on normal adults have shown there
Children of 41⁄2 years in a study by Abravanel to be no difference in the overall accuracy of haptic
(1968a) could visually recognize test objects facing up, perception between men and women (Cronin, 1977;
down, or rotated but had difficulty when intermodal Kleinman, 1979; McGlone, 1980).
(haptic-visual) matching was necessary for task com- When handedness is examined, children often dis-
pletion. Intermodal recognition of up-down was no play greater left- than right-hand skill in some forms of
better than chance until 5 years of age, and the identifi- haptic perception (Hahn, 1987; Rose et al., 1998);
cation of rotated figures was not possible until 6 years however, the strength and age of onset of this dif-
of age. Pick, Klein, and Pick (1966) used intramodal ference vary among studies (Streri, 2003c). The finding
(visual-visual and haptic-haptic) matching tasks to of greater left- than right-hand skill on some tasks, par-
study children’s ability to differentiate the up-down ticularly those requiring discrimination of meaningless
orientation of letter-like forms. They reported that the shapes, has been viewed as related to right hemisphere
task could be performed more easily through the use of superiority in the processing of spatial information
vision than touch. No relationship was found between (e.g., Witelson, 1974, 1976). In a recent meta-analysis
subjects’ ability to perform the task through the use of of cerebral specialization of spatial abilities, Vogel,
vision versus touch, leading the authors to conclude Bowers, and Vogel (2003) found a right-hemisphere
that perhaps the method used in coding and dis- preference when subjects were performing spatial
criminating spatial orientation is different for the two orientation and manual manipulation tasks. However,
sensory modalities. However, it is also possible that because the age of onset of right–left hand differences
some types of objects might just be better suited for varied widely across studies, it is inappropriate to
processing through one sensory system than the other. interpret the presence or absence of a hand difference
For example, letter-like forms may represent a type of for stereognosis as being related to the maturity of
object that is easily processed through the visual system hemispheric specialization for haptic perception in a
but not easily analyzed through the tactile system. given child. Consistent evidence of a right–left hand
In a recent review of research examining processing difference for stereognosis did not appear until
of spatial object properties and the oblique effect adolescence.
(whether orientation is perceived more accurately in
the horizontal and vertical planes than the oblique
plane), investigators concluded that gravitational cues
SUMMARY AND I MPLICATIONS FOR PRACTICE
play a role in the haptic perception of orientations in The ability to distinguish the texture, shape, and
blindfolded (sighted) adults and children (Gentaz & substance of objects through the use of intramodal
Hatwell, 2003; Gentaz & Streri, 2004). This is similar (haptic-haptic) and intermodal (haptic-visual and
to the oblique effect found for orientation with vision. visual-haptic) exploration develops over a long period.
It begins to emerge in early infancy and continues to
G ENDER AND HAND DIFFERENCES IN HAPTIC mature into adolescence.
Infants are amazingly adept at using haptic explora-
RECOGNITION AND HAPTIC ACCURACY tion with the mouth and hands to learn about objects
Several studies have examined whether boys and girls in their environment. Early haptic discrimination using
perform differently in the accuracy of haptic perception the mouth is seen at 1 month of age or even earlier, and
and whether one hand is more accurate than the other. haptic discrimination using the hands appears at 1 to
2 months of age. Intermodal transfer of information property selected seems to be the one that is easiest for
between the haptic and visual senses begins at 4 to the child to recognize, perhaps because it exhibits the
6 months, although recent evidence suggests that even strongest distinctive features. For example, texture is
newborns have limited ability. This means that by the preferred to shape and size in young children, whereas
second half of the first year of life infants can explore an older children are more likely to match objects by shape
object using the hand and then recognize the same than texture. In addition, the coexistence of several
object as being similar or different using vision. sensory properties in a given object can impair haptic
Haptic perception improves with increasing age. discrimination at some ages. This finding suggests that
Children find common objects easier to haptically haptic figure-ground may be an issue in haptic object
recognize than topologic forms, geometric figures, or discrimination, a factor that needs to be considered in
unfamiliar objects. At 21⁄2 years, children can identify the development of tests and training programs in
many common objects through use of the haptic sense. haptic perception.
Haptic recognition of common objects reaches full We do not know whether the ability to distinguish
maturity by about 5 years. Intramodal (haptic) and objects by shape, size, texture, or weight develops
intermodal (haptic and visual) identification of sequentially or simultaneously. Research suggests that
topologic forms and geometric shapes emerges at 3 to children develop the ability to discriminate all of these
4 years and continues to develop throughout child- sensory properties, including texture, hardness, weight,
hood. With increasing age children are able to match and temperature. Thus it is logical to conclude that we
forms or shapes having increasingly complex distinctive should provide children with ample opportunity to
features. They also are able to move from recognizing analyze objects having varying sensory properties.
only solid (three-dimensional) shapes to being able to When presenting activities designed to promote the
also distinguish flat (two-dimensional) figures. Haptic- development of haptic perception, we should vary
visual matching generally is better than visual-haptic objects by one sensory property and also offer objects
matching. Thus in developing a program to enhance with a combination of sensory properties. If the child
children’s haptic matching abilities it is best to start has the opportunity to sort objects haptically in a
with familiar objects, with haptic-visual matching variety of ways, he or she is likely to identify or sort
preceding visual-haptic matching. objects using the sensory property that has the
Like adults, children show greater left than right strongest distinctive features or use exploratory pro-
hand skill in some forms of haptic perception, possibly cedures or strategies that are most well developed in his
reflecting specialization of the right hemisphere for the or her repertoire. The sensory properties that the child
processing of spatial information. However, the age at consistently avoids using may be those that are most
which hand preference for haptic processing emerges delayed and thus most in need of being addressed in
varies across studies. Although some authors suggest treatment. Because little is known about the develop-
that haptic perception may be better in boys than girls, ment of haptic figure-ground perception in children,
most studies have not found a difference. we do not know if the finding of impaired haptic
The literature contains less information about the discrimination in multisensory haptic play activities is
development of sensory properties such as texture and normal or a sign of impairment. However, we can be
weight in childhood. It is known that children find sensitive to the signs of haptic sensory overload in
rough textures easier to match than smooth textures. children. It is possible that playing with toys having
The development of texture discrimination improves several sensory properties may be disorganizing for
between 4 and 9 years, in part because tactile sensitivity some infants and children. When problems are seen,
increases during this time span (Gliner, 1967). The controlling the variety, as well as the quantity of sensory
discrimination of diameter and length begins at about experiences may be necessary to elicit optimum
4 years and continues into adolescence, with variation performance during school and play activities.
in diameter being easier to recognize than variation in
length. Children as young as 3 to 4 years can recognize
the spatial orientation of an object when the child or
object has been rotated, but it is not until 5 to 6 years FUNCTIONS CONTRIBUTING TO
that children can haptically identify objects as facing up,
down, or rotated. HAPTIC PERCEPTION
Children’s ability to haptically analyze objects
having two or more tactile properties is limited. Rather Most haptic perception tasks are complex. Research
than analyzing several sensory properties simul- suggests that various factors contribute to haptic per-
taneously as adults do, children appear to select one ception, including somatosensory processing, manual
sensory property to use in object analysis. The sensory and in-hand manipulation, and vision and cognition.
ROLE OF SOMATOSENSORY SENSATION IN motor coordination are thought to be related, in part,

to the processing of tactile, kinesthetic, and proprio-
HAPTIC PERCEPTION ceptive sensations for their execution (Brooks, 1986;
Vierck (1978) proposed that sensory feedback Case-Smith, 1995; Case-Smith, Bigsby, & Clutter,
processed through the dorsal columns may guide 1998; Duque et al., 2003; Gordon & Duff, 1999;
exploratory hand use. Although the firing of haptic Johansson & Westling, 1988, 1990).
neurons in the sensorimotor cortex often is credited for
guiding exploratory hand use and contributing to the
ability to recognize objects by touch, synaptic connec- ROLE OF MANUAL MANIPULATION AND
tions among many central nervous system (CNS) EXPLORATORY STRATEGIES IN HAPTIC
structures are involved in the process (Carpenter, 1991;
Goodwin & Wheat, 2004; Mountcastle, 1976). Recent
PERCEPTION
research examining neural substrates of tactile object Manual exploration and in-hand manipulation are
recognition using functional magnetic resonance critical for haptic perception and object recognition
imaging (in adults) found that tactile object recog- (Lederman & Klatzky, 1998, p. 27). It has been
nition involved a complex network including parietal suggested that information from the motor commands
and insular somatosensory association cortices, as well generating exploratory actions generates corollary
as occipitotemporal visual areas, prefrontal, and medial discharge or efferent copy and is involved in haptic
temporal supramodal areas, and medial and lateral perception, although the mechanisms are not well
secondary motor cortices (Reed, Shoham, & Halgren, understood (Jeannerod, 1997).
2004). Disruption in communication anywhere within Interest in the role of in-hand manipulation and
this circuit logically could result in loss or impairment other forms of manual exploration in haptic perception
of the ability to explore objects with the hands. was precipitated by the work of Gibson (1962) on
A synthesis of information derived from somato- active and passive touch. Using a set of geometric-
sensory receptors provides the hand with a dynamic shaped cookie cutters, adult subjects either were
picture of the body and its orientation in space (body allowed to actively manipulate the cookie cutters or the
scheme) (Gardner, 1988; Goodwin & Wheat, 2004). tactile stimuli were passively presented by the examiner
This internal picture of the body is thought to be used (cookie cutters pressed or pressed and turned in the
by CNS processes as a framework of the parameters of palm of the subject’s hand). The use of active touch
real-world time and space (Brooks, 1986). Upon this contributed to greater accuracy in intermodal (haptic-
framework are scaled motor commands used in motor visual) shape recognition than either of the passive
programming and executing complex sequenced touch conditions, although pressing and turning the
movements. This internal picture of the body also is cookie cutters in the subject’s hand (passive pressure
thought to serve as a template for interpreting the spatial with movement) yielded higher scores than the isolated
properties of objects (Gibson, 1962). The precise detail use of passive pressure. Replication of Gibson’s study
of this internal picture of the body decreases and its with children yielded similar findings (Haron &
spatial complexity increases with progressive afferent Henderson, 1985). Cronin (1977) also replicated
processing in the CNS (Brooks, 1986). Gibson’s study but obtained somewhat different
Not only does somatosensory sensation contribute results. She found that shape recognition by school-age
to the development of body scheme needed for the children and young adults did not differ between active
interpretation of the spatial properties of objects, but it touch and passive touch (passive pressure with
also appears to be necessary for regulating manual and movement) conditions when tactile stimulation was
in-hand manipulation during active touch. Research restricted to the palm of the hand in all test conditions;
with children with spastic hemiplegia found that however, the isolated use of passive pressure (passive
deficient tactile sensitivity was strongly related to the pressure without movement) contributed to lower test
manual dexterity needed for exploration (Gordon & scores than either of the other two test conditions. In
Duff, 1999; Krumlinde-Sundholm & Eliasson, 2002). addition, no difference between active touch and
The sensory control of hand movements is discussed in passive touch (pressure with movement) was found for
Chapter 1. At present it seems sufficient to note that to the discrimination of texture and tactile maze learning
actively retrieve somatosensory sensation from the in adults (Lederman, 1981; Richardson, Wuillemin, &
environment during active touch the individual must MacKintosh, 1981). These findings suggest that it
be able to make rapid and frequent changes in the might be movement of the object over the skin surface
speed and sequencing of hand movements and regulate that produces the tactile feedback needed for object
force during object manipulation (Hollins & Goble, recognition. Although movement of the object in the
1988; Johnson & Hsiao, 1992). These elements of fine hand theoretically can be active or passive, it is most
commonly produced actively, through the use of identification of geometric shapes, Kleinman and
manual manipulation and exploratory strategies. This Brodzinsky (1978) found that subjects preferred to use
raises the question of how the pattern of tactile feed- a combination of manipulation strategies, including an
back generated by variation in the pattern of manual initial scanning of the standard and comparison objects.
and in-hand manipulation affects the accuracy of object This was followed by detailed simultaneous comparison
identification. In recent years several researchers have of the standard and comparison objects (congruent
attempted to answer this question; their findings are feature comparison of analogous and mirror-image
discussed in the following section. See Chapter 8 for a features and contour following). The initial time spent
detailed discussion of in-hand manipulation. Because in scanning the objects was reduced as the shapes
most of the research on this topic has been done on became more complex. Locher and Simmons (1978)
adults, this section begins with a summary of the adult found that haptic recognition of symmetric shapes was
research followed by a review of the pediatric literature. more difficult than the recognition of asymmetric
shapes. Partial trace scanning (contour following along
Haptic Manipulation Strategies in Adults portions of the shape) was common for asymmetric
In a series of studies, researchers (Klatzky, Lederman, shapes. More complex scanning strategies were used for
& Reed, 1987; Lederman & Klatzky, 1987, 1990, the identification of symmetric shapes (several
1998) found that adults were highly systematic in the repetitions of partial and complete contour following).
manual exploration strategies they used. Adults In a subsequent study Simmons and Locher (1979)
performed “a variety of stereotypical hand movement found use of the trace scanning strategy (contour
patterns” (Lederman & Klatzky, 1998, p. 27), includ- following around the complete shape several times
ing lateral motion, pressure, static contact, unsup- using two fingers) to lead to greater accuracy in the
ported holding, enclosure, and contour following, that identification of asymmetric shapes and the simul-
Lederman and Klatzky called “exploratory procedures taneous apprehension scanning strategy (smooth, con-
or EPs” (p. 27). These strategies were selected based tinuous movement of thumb and index fingers of both
on the particular object property the adult desired hands over opposite sides of the shape simultaneously)
(e.g., hardness, texture, shape). to lead to greater accuracy in the identification of
Early research on the influence of manipulation symmetric shapes. The results of these studies suggest
strategies in object recognition was done by Davidson that the isolated use of contour following may not
in a series of studies comparing the ability of sighted always be the most appropriate approach for use in the
and congenitally blind subjects to recognize raised identification of shapes. It may be necessary to change
curved edges. Davidson (1972) and Davidson and manipulation strategies to adapt to variation in
Whitson (1974) found that when exploring concave, symmetry of distinctive features and complexity of the
convex, and straight edges, subjects chose to use three objects presented.
manipulation strategies (gripping, pinching the edge, Lederman and Klatzky (1987) analyzed manipula-
and sweeping the fingers over the top edge). Gripping tion strategies used for the identification of texture,
(grasping the object in the hand) led to fewer errors in hardness, weight, volume, and temperature. They found
identifying the form of the curved edges in both blind that the optimum manipulation strategy (which they
and sighted subjects. Gripping was later found to be a termed exploratory procedures) for use in object
useful strategy for obtaining a general understanding identification differed for each tactile property (Table
of the objects’ tactile properties (e.g., texture, weight, 4-1). Although contour following was necessary for
shape) (Klatzky et al., 1987; Lederman & Klatzky, accurate recognition of shape, several approaches could
1987). The method of gripping (called enclosure in be used for the identification of most other tactile
some studies) was modified to aid in differential properties (Box 4-1).
discrimination of size and shape. Subjects preferred to Preferred manipulation strategies remained unchanged
grip with the whole hand when analyzing the size of when subjects were asked to determine the gradations
objects and grip, with effort, the edges of the object of a given tactile property (texture, size, shape, and
using the fingers and palm when analyzing shape (Reed hardness) and when they needed to simultaneously sort
& Klatzky, 1990). Although gripping provided subjects pouches (fabric-covered shapes) by one to three of
with a general classification of object properties, other these tactile properties (Klatzky, Lederman, & Reed,
strategies often were used when refined analysis was 1989; Lederman & Klatzky, 1987). Enclosure
needed. (gripping) was commonly used for all tactile properties,
Contour following (moving the fingers around the with lateral motion being used primarily for the
edge of the object) was an optimum strategy for use in identification of texture, pressure being primarily used
haptic shape recognition (Lederman & Klatzky, 1987). for the identification of hardness, and contour
In a thorough analysis of strategies used in the following being used primarily for the identification
analyze two tactile properties. Exploration time

Table 4-1 Haptic procedures associated decreased when subjects used lateral motion and
with acquiring knowledge about pressure to simultaneously discriminate texture and
objects hardness and when they used gripping (enclosure) to
simultaneously discriminate size and shape (Klatzky,
Object Dimension Exploratory Procedure Lederman, & Reed, 1989; Reed & Klatzky, 1990).
This finding suggests that adults may prefer manipula-
tion strategies that simultaneously explore multiple
SUBSTANCE
Texture Lateral motion sensory properties.
Hardness Pressure Not only do subjects select haptic manipulation
Temperature Static contact strategies based on the tactile properties of objects,
Weight Unsupported holding they also organize manipulation strategies into a
sequence. Lederman and Klatzky (1990) found haptic
exploration in adults consisted of a two-stage sequence.
STRUCTURE The first stage consisted of generalized exploration of
Weight Unsupported holding
the object using manipulation strategies such as
Volume Enclosure; contour following
Global shape Enclosure gripping (enclosure) or unsupported holding (object
Exact shape Contour following resting in the palm of the open hand), strategies that
provided awareness of the general tactile properties of
the object. This was followed by a second stage of
FUNCTION refined manipulation, in which the subject used more
Part motion Part motion test specialized manipulation strategies (e.g., contour
Specific function Function test following, lateral motion) to gain specific information
Data from Lederman SJ, Klatzky RL (1987). Hand movements:
about object characteristics. During the second stage
A window into haptic object recognition. Cognitive Psychology, the subject often alternated between different manip-
19:342–368. ulation strategies to guide the retrieval of information
about the object. In summary, results of research on
haptic manipulation and exploratory strategies provide
support for the hypothesis that the pattern of tactile
BOX 4-1 Most Effective Strategies Used for
feedback generated by variation in patterns of manual
Identification of Tactile Properties
manipulation during active touch contributes to the
(Other Than Recognition of Shape)
accuracy of object recognition. Adults select manip-
ulation strategies based on the tactile properties of the
1. Texture: lateral motion (moving the finger across object being explored. Furthermore, they combine and
the surface of the object) sequence the use of these manipulation strategies in
2. Hardness: pressure
situations in which conditions require the simultaneous
3. Weight: unsupported holding*
4. Volume: enclosure (gripping) or sequential analysis of several tactile properties. The
5. Temperature: static contact sophisticated haptic manipulation strategies seen in
adults develop throughout childhood.
*Jiggling while holding the object aided in the discrim-
ination of weight.
Brodie EE, Ross HE (1985). Jiggling a lifted weight does
Haptic Manipulation Strategies in Infants
aid discrimination. American Journal of Psychology, Haptic exploration begins in early infancy. Neonates
98:469–471. and young infants gain much information about objects
from action with their mouth. At 2 and 3 months
spontaneous interaction with a novel object starts with
of shape and size. When pouches needed to be an oral contact (Rochat, 1989). Ruff and co-workers
simultaneously sorted by two or three properties, the (1992) reported that oral exploration or mouthing
manipulation strategies were combined, with lateral increased until 7 months, and then decreased through
motion and pressure often being merged into a single 11 months in favor of manual manipulation. By 4 months,
finger movement. When the properties of texture and even though vision emerged as the initial modality of
shape needed to be analyzed, adults appeared to search exploration, infants continued to frequently bring the
for cues about texture before they searched for cues object to their mouth. Spontaneous behavior by infants
about the object’s shape (Lederman, Brown, & suggests increasing multimodal (visual and haptic)
Klatzky, 1988). Subjects showed a preference for organization of exploration, with vision playing a
manipulation strategies that could simultaneously growing role. According to Rochat (1989), the hands
serve both transport and support functions, bringing suggested that infants who cannot adjust their handling
the object alternately into the oral zone and the field of skills so they can finger objects rather than just hold
view for exploration. Ruff (1989) described a dual role them and infants who cannot effectively use two hands
of handling: the hands make information available to together may be limited in the complexity of infor-
the eyes as the object is manipulated at the same time mation about objects that they can readily gather.
that the hands directly gather haptic information. In the Discrimination of shape does not occur until between
first role the hands are used to manipulate the object 9 and 12 months when the infant learns to turn and
and change the object’s location relative to the observer, rotate an object in two hands (Ruff, 1989).
such as turning the object around to provide different Given that adults use a flexible repertoire of
visual perspectives. In the second role the hands gather exploratory strategies and that certain actions may be
haptic information about the object, such as by pressing particularly useful for obtaining specific information
the object to determine its substance or rubbing a finger about objects, the question also has been asked how,
across the object to determine its texture or shape. during development, young infants and children tailor
Based on their developmental work, Bushnell and their actions to explore objects (Palmer, 1989).
Boudreau (1991, 1993, 1998) suggested that the Whereas earlier work has suggested that infants’ actions
motoric capacities needed to perform exploratory pro- were not clearly related to object attributes (McCall,
cedures limit haptic perception in the young infant. In 1974), current research has found that exploratory
conjunction with the early development of multimodal action patterns are indeed influenced by object
exploration, the characteristics of object manipulation characteristics and that the actions of the infant are
change from 2 to 5 months. At 2 to 3 months the related in functional ways to the structure of the
infant’s manipulative behaviors are primarily limited to environment (Gibson, 1988; Hatwell et al., 2003).
grasping movements, potentially informing the infant In a series of studies, Ruff (1980, 1984, 1989)
about the object’s substance, temperature, and size examined the effect of object characteristics on infant
(Bushnell & Boudreau, 1991, 1993). Although slight manipulation strategies. In a study of 9- and 12-
finger movements are produced at 2 months, by 4 months month-olds, Ruff (1980) found that infants fingered
the occurrence of fingering behavior increases sig- objects with surface texture more than they fingered
nificantly (Rochat, 1989). Because discrimination of smooth blocks. Ruff (1984) investigated 6- to 12-
texture requires isolated finger movements, texture month-old infants’ manipulation of a range of objects
discrimination does not begin until around 6 months varying in color, shape, texture, and weight and found
of age. Before this, when both hands are involved in that manual exploration was adapted to the visual and
contacting an object, it is primarily for transporting the the tactual properties of the object. When infants were
object to the mouth. Rochat (1989) noted that in given objects that varied in shape, they rotated the
young infants (2 to 4 months) bimanual coordination objects and transferred them from one hand to the
is initially linked to the oral system. This observation other hand; when objects had varying surface textures,
points to the importance of the mouth in the early infants fingered the objects, often scratching their sur-
manifestation of bimanual action in the context of face. Weight change resulted in less looking and more
object manipulation. The hand–mouth coordination banging than did other changes in object charac-
seen in the 2- to 4-month-old infant is later combined teristics. In a more recent study Ruff (1989) found that
with vision when behaviors such as fingering emerge. by 7 to 9 months infants banged hard objects more
To more thoroughly assess how infants use object than soft objects, banged more on hard surfaces than
handling skills to gain information for recognition of on soft surfaces, and fingered textured objects more
specific object qualities, Ruff (1984) studied 6-, 9-, and than smooth objects. In a study of 12-month-old
12-month-old infants and assessed the various manip- infants’ haptic exploration and discrimination, Gibson
ulation strategies they used, including mouthing, and Walker (1984) found that infants squeezed,
fingering, transferring, banging, and object rotation. rubbed, and pressed a spongy object more than a rigid
Fingering proliferated with increased age, particularly object and banged the rigid object more than the
with objects that varied in texture. Ruff suggested that spongy one. The results of these studies suggest that
this fingering can be crucial for obtaining information infants adjusted their manipulative behavior to the
about small object details. Hand use for object rotation characteristics of objects.
also was noted to change, with all infants using a one- Palmer (1989) also found that infants 6, 9, and 12
handed rotation pattern, in which the arm or wrist months old tailored their actions to particular object
moves, but only older infants using two-handed object and table characteristics. Palmer recorded the manip-
rotations. Ruff suggested that two-handed rotation can ulative behavior of infants with 12 different objects of
be particularly useful because with rotation the object varying rigidity, texture, shape, weight, and sound
does not have some parts covered by the hand. She potential using two different table surfaces (hard wood
BOX 4-2 Actions Used by Infants in Object

Exploration Table 4-2 Developmental progression for
haptic discrimination of shapes
and objects
Grasping
Banging
Fingering
Age Range Haptic Strategy
Mouthing
Switching (hand to hand) 21⁄2 to 4 years Children may play with object
Squeezing (e.g., push), but there is no
Rubbing active manual exploration;
Pressing grasping or touching of object
Poking is seen with palm being still
Slapping when making contact with
Scooting object; by 3 to 6 years child
Dropping begins to make discoveries
about discriminative features
seemingly by chance
and foam covered). Results indicated that infants made 4 to 5 years Exploration often remains
use of both object properties and table surface passive, with object being
properties. For example, infants banged more on the grasped between palm and
wood surface. Age differences in actions were also middle fingers; crude manual
noted. Palmer suggested that these differences may exploration begins; when
manual exploration is seen, it is
reflect developing action economy (e.g., waving the
done in a global haphazard
bell with a flick of the wrist rather than with the whole manner, which includes probing
arm swing seen in younger infants), new exploratory for distinctive features
systems (e.g., changing from mouthing to waving and
banging), and increasing fine motor control (e.g.,
5 to 6 years Systematic use of both hands
finger individuation). Case-Smith and co-workers (palms and fingers) begins;
(1998) examined 120 2- to 12-month-old infants and isolated analysis of distinctive
also found that infants’ grasp and manipulation features without studying whole
strategies varied as a function of the objects’ haptic form can be observed
attributes (size, shape, contour, movable parts) and the
child’s age. They found that objects with movable parts 6 to 7 years Use of systematic method of
elicited more varied and mature manipulation strategies exploration can be seen; contour
and suggested that objects with movable parts and following is used
multidimensional surfaces “facilitate haptic develop-
ment and motor skill by affording the infant a variety of
surfaces to explore and by sustaining the infant’s
interest” (p. 108). developmental progression in the acquisition of
Research suggests that even infants younger than manipulation strategies, with the accuracy of object
6 months detect an object’s perceptual features that identification being related to the level of sophistication
enable particular actions (affordances) for hand and of the haptic manipulation strategies (Abravanel,
mouth. Rochat (1983, 1987) found that neonates 1968b; Hatwell, 2003; Hoop, 1971b; Jennings, 1974;
showed differential oral and manual responding to Kleinman, 1979; Wolff, 1972; Zaporozhets, 1965,
objects varying in substance and texture. In a study of 1969). The description of the developmental pro-
3-month-old infants, Rochat (1989) noted that the gression of haptic discrimination of common objects
characteristics of manual manipulation and exploration and shapes in Table 4-2 is a summary of the work
by the infant reflected some relation to the physical conducted by Piaget and Inhelder (1948/1967) and
properties and affordances of the object (Box 4-2). Zaporozhets (1965, 1969). Whereas haptic strategies
of the 2- to 4-year-old child consist primarily of
Haptic Manipulation Strategies in Children grasping the object, by age 6 to 7 years systematic
Research with children has focused primarily on exploration with contour following is noted.
analysis of the role of manipulation strategies in the Abravanel (1968b) provided a description of the
development of haptic discrimination of shape and size developmental progression in haptic manipulation of
(length). Results of these studies suggest that there is a size (length) that was strikingly similar to that identified
to a lesser extent in preschool and school-age children.

BOX 4-3 Examples of Manipulation
Infants use a variety of actions in exploring objects (see
Strategies
Box 4-2). These actions vary as a function of the object
and surface characteristics; that is, they are influenced
If children want: by the perceptual affordances provided by the environ-
• To compare two objects for texture, they use a lateral ment, as well as by the infants’ motor abilities.
motion, often with the index finger.
• To compare hardness, they use pressure.
• To examine temperature, they use static contact.
• To examine volume of three-dimensional objects, ROLE OF VISION AND COGNITION IN
they tend to embrace the object.
• To compare weight, they tend to hold the object in
HAPTIC PERCEPTION
their hand and lift it from the surface. Vision
McLinden and McCall (2002) emphasize that most
Hatwell Y (2003). Manual exploratory procedures in
children. In Y Hatwell, A Streri, E Gentaz (editors): skills and activities are performed with information
Touching for knowing (pp. 67–82). Philadelphia, John from multiple modalities simultaneously. They discuss
Benjamins Publishing; Klatzky RL, Lederman SJ (2003). the role of vision in coordinating or integrating a wide
The haptic identification of everyday life objects. In Y
Hatwell, A Streri, E Gentaz (editors): Touching for
range of sensory information. Warren and Rossano
knowing (pp. 105–122). Philadelphia, John Benjamins (1991) describe the important role that vision plays in
Publishing; Klatzky RL, Lederman SJ, Metzger VA the development of haptic perception. Noting that
(1985). Identifying objects by touch: An “expert system.” vision and touch are constant companions, Pears and
Perception and Psychophysics, 37:299–302; Streri AF
(2003a). Manual exploration and haptic perception in Jackson (2004) discuss how the brain dynamically
infants. In Y Hatwell, AF Streri, E Gentaz (editors): binds together visual and somatosensory information
Touching for knowing (pp. 51–66). Philadelphia, John to construct accurate representations of objects in
Benjamins. space, and emphasize the importance of this linkage for
acting on objects in the world around us.
Rochat (1989) noted a major link between vision
for the analysis of common objects and shapes. She and fine haptic exploration early in development and
found that the youngest children in her study (3 to suggested that vision may serve as a potential organizer
5 years) typically used the palm of the hand, grasping of multimodal exploration and object manipulation in
and palpating the objects. By 5 years the children held infancy. This was based on research that indicated that
the ends of the bar used for evaluating length. From 5 fingering starts to manifest itself in coordination with
through 8 years children used the whole hand (palm vision. Refined object manipulation was more likely
with progressively increasing use of the fingers) for to occur when infants simultaneously looked at and
manipulation of the bar and displayed a systematic manipulated objects. Thus it may be important for
method of determining length. By 9 years, use of the infants to see their hands during manual object
palm was no longer seen; the fingers and fingertips manipulation. As further support of the role of vision as
were used for exploration. an organizing factor of object manipulation, Rochat
Researchers have shown that the manipulation (1989) cited developmental studies of congenitally
strategy used by the child or adult varies as a function blind infants, who exhibited drastic delays in the use of
of the information to extract (Box 4-3) (Hatwell, their hands as exploratory tools (Fraiberg, 1977). Even
2003; Klatzky & Lederman, 2003; Klatzky, Lederman, though congenitally blind toddlers spontaneously
& Metzger, 1985; Streri, 2003a). developed strategies such as object rotation (Landau,
In summary, the results of studies that address 1991), haptic exploration was primarily oral up to 3 to
analysis of strategies used in the recognition of com- 4 years of age, much longer than was seen in sighted
mon objects, shapes, and sizes, including lengths, infants. Thus the use of vision in object exploration
suggest that manipulation strategies become more may be important for the development of haptic per-
complex with increasing age, a maturational change ception. However, this is not to say that haptic percep-
that seems to contribute to the accuracy of haptic tion cannot be developed in the absence of vision. For
object recognition. The structural characteristics of the example, Schellingerhout, Smitsman, and Van Galen
test materials influence the time spent in haptic (1997, 1998) examined the haptic exploratory pro-
exploration, perhaps because they contribute to task cedures of surface textures in eight infants, 8 to
difficulty or they affect the complexity of manipulation 24 months old, who were congenitally blind. They
strategies needed for object exploration. The effect of found that younger infants showed a wide range of
object characteristics on the use of manipulation exploratory strategies and older infants used these
strategies has been extensively addressed in infants, and strategies in a specific manner.
Hatwell (1990) suggested that even sighted children old infants learned structural differences in objects only
between the ages of 3 months and 6 years have when they actually manipulated the objects; viewing
difficulty using their hands for retrieving haptic object movement did not result in the learning of
information independent of vision. She suggested that object characteristics. It should be emphasized that, in
the motor functions of young children’s hands were the manipulation condition, the infants also visually
primary, with the perceptual capabilities of the hands monitored their movements, thus obtaining tactile,
rarely used except as an adjunct to motor functioning. proprioceptive, and visual information. Ruff proposed
Hatwell noted that when vision was used, the hands that the advantage of object manipulation may be in
primarily operated under this system of control. Ruff the simultaneous use of visual and tactile integration in
(1989) tempered this view by stating that it may be learning about object qualities.
that the visual system guides exploratory behavior in The heavy use of vision in object identification seen
the haptic system. In this sense, vision would not in infants may continue into adulthood. Research com-
exclude the contribution from the haptic system as put paring visual and haptic discrimination has shown visual
forward by Hatwell (1987) but would constrain it. matching to be consistently superior to haptic and
Ruff (1989) suggested that there was an “initial intermodal (haptic-visual and visual-haptic) matching
tightening of visual control over manipulation around (Garbin, 1988; Hatwell et al., 2003). This finding has
5 months of age [and] then the loosening of visual left the impression that vision may be more important
control sometime after nine months” (p. 313). than haptic discrimination in object identification.
Haptic manipulation with vision is important in the Nevertheless this may be an incorrect interpretation of
early learning of object characteristics and has two the research findings. Klatzky and co-workers (1985)
potential advantages. First, as infants look at an object questioned this conclusion, stating that it might be
they are manipulating, they see the object from dif- inappropriate to use objects that can be easily inter-
ferent points of view and can learn about its properties. preted by the visual system when evaluating functions
This is critical for the development of object recog- of the tactile system. Rather than vision being superior
nition so that the infant or child can recognize an to haptic manipulation, it would probably be more
object in any orientation or in any context. Second, the accurate to say that vision and somatosensory processing
infant acquires tactile and kinesthetic information both play supportive roles in object identification.
about the object through active touch (Ruff, 1980, Although vision seems to be used by infants and young
1982; Streri, 1993, 2003a). children to guide exploratory hand use, its purpose may
Ruff (1980) suggested that movement is particularly not be to substitute for haptic perception but rather to
important in helping infants to detect the properties of guide the development of haptic manipulation and
an object that does not vary despite changes in the make the somatosensory input meaningful.
object’s orientations. An important question is what
type of movement is necessary. For example, the infant Cognition
can produce different information about the object The development of infants’ and young children’s
through his or her own movements such as through exploration of the environment is linked to their under-
turning the head to look at the object, by moving the standing and knowledge about the world (Bushnell &
body around the object, or by holding, manipulating, Boudreau, 1998; McLinden & McCall, 2002). Because
and moving the object. Alternatively, the infant can get cognition and vision are closely linked in haptic object
different views of an object when a parent carries the identification, it is difficult to categorize certain func-
infant around the room, or when the object itself tions, such as mental imagery, that involve both cog-
moves, as in a mobile, or when a parent moves the nition and vision. The ability to use cognitive strategies
object, such as in the context of showing a toy to a (mental imagery and verbalization) to aid in haptic
child. Ruff (1980) hypothesized that object trans- object recognition develops during childhood. Piaget
formations that occur during movement allow for and Inhelder (1948/1967) considered the ability to
detection of object characteristics that would not be distinguish objects through the use of touch to be an
evident from observing a stationary object. She also external reflection of one’s capacity to transform tactile
suggested that, although both watching object move- properties of objects into visual images (integrate visual
ment and producing object movement were important and haptic information), although recently this view
in learning about objects, producing movement could has been questioned. This ability to use visual imagery
yield the specific types of information sought and to improve haptic recognition and memory of objects
therefore was a more efficient way of learning about is thought to contribute to children’s ability to recog-
objects. The advantage to the individual doing the nize objects on tests of haptic perception and repro-
moving is that infants learn to recognize objects in the duce objects through drawing. In fact, research has
context of activity. Ruff (1980) found that 6-month- shown that adults with high spatial ability and skill in
mental imagery perform significantly better than somatosensory processing is impaired. Impairment in
their less skilled peers on tests of haptic perception somatosensory processing, vision, visual perception,
(McCormick & Mouw, 1983). cognition, praxis, and any factor that may alter fine
Verbalization (labeling of the haptic properties of motor coordination has the potential to lower per-
objects) also has been found to aid in haptic object formance on tests of haptic perception. Determining
identification. Bailes and Lambert (1986) compared the reason for a child’s poor test performance is a
the ability of adults who were sighted and blind to necessary prerequisite for effective treatment planning.
determine if four segments of a stimulus figure In the clinic we may be able to gain some insight
matched a completed geometric design. The subjects into the maturity of the somatosensory system by
who were sighted were faster and more accurate than observing the tendency of infants to mouth and
the subjects who were blind. Adult subjects who used manipulate novel objects. Although infants use vision
verbalization had better haptic accuracy scores than sub- extensively in object exploration, we should expect to
jects who used a mixture of verbalization and mental see a combination of visual and oral or manual
imagery. Subjects who solely used mental imagery dis- exploration during play in infancy.
played the lowest haptic accuracy scores. Thus in some Although research indicates that optimum per-
tasks, verbalization may be a more effective strategy formance in haptic identification is seen when manual
than mental imagery, although both may be beneficial. manipulation is used for object identification, haptic
The ability to use cognitive strategies (mental perception can be partially assessed without active
imagery and verbalization) to aid in haptic object manipulation. Research has shown that placement of
recognition develops during childhood. Children 3 to the object in the palm of the hand and movement of
6 years of age often could not describe the strategies the object across the skin’s surface improves object
that they used to aid in haptic object identification recognition. Thus the therapist can occlude the child’s
(Blank & Bridger, 1964). By the fourth grade several vision, move the object across the center of the palm,
solely used verbalization or mental imagery, whereas and then ask the child to identify the object by visual
most relied on a mixture of verbalization and visual matching or verbal response. Analysis of the quality of
imagery to aid in haptic object identification (Ford, the haptic manipulation strategies used during test per-
1973). Adults were evenly mixed in their isolated use of formance also provides useful diagnostic information.
verbalization and mental imagery, and combined use of The preferred manual manipulation and exploratory
the two cognitive strategies (Bailes & Lambert, 1986). strategies of adults vary for objects with different tactile
Alexander, Johnson, and Schreiber (2002) examined properties. The manipulation strategy used affects the
the effect of 4- to 9-year-old children’s domain-specific accuracy of object identification. Research suggests that
knowledge on their performance in haptic comparison the development of haptic manual manipulation and
task. Children with varying levels of knowledge about exploratory strategies begins early in life, because
dinosaurs haptically explored pairs of familiar infants use specific manipulation strategies to explore
(dinosaur) and unfamiliar (sea creature) models and specific sensory properties. During childhood these
were asked to state whether or not the pairs were manipulation strategies grow in complexity with
identical. Older children correctly identified more pairs increasing age. We do not know whether children with
than younger children and explored models more problems in haptic perception and fine motor
exhaustively. Although dinosaur knowledge did not coordination fail to use appropriate manipulation
affect overall performance, it did affect the types of strategies because they have difficulty in the selection or
explorations that to some extent resulted in increased execution of haptic manual manipulation and explor-
errors. Specifically, after exploring the first object, atory strategies. However, it is generally recognized
children with high knowledge about dinosaurs tended that the immature haptic manipulation strategies seen
to form an initial hypothesis (e.g., based on one feature in young children contribute to poor object recog-
such as the beak) and then sought evidence to confirm nition (Abravanel, 1968b; Derevensky, 1979; Hatwell,
this initial hypothesis by primarily exploring just the 2003; Hoop, 1971b; Jennings, 1974; Wolff, 1972;
beak of the possible matches. In doing this, they ignored Zaporozhets, 1965, 1969).
or failed to seek out evidence (e.g., exploring the Early haptic exploration in infancy is done with the
dinosaur’s feet) that did not confirm their hypothesis. mouth. It is more than a year before mouthing is
primarily replaced by manual manipulation. We cannot
overemphasize the clinical importance of mouthing
SUMMARY AND I MPLICATIONS FOR PRACTICE objects in infancy. Mouthing of objects not only seems
Several functions contribute to the ability to perform to be important for decreasing oral hypersensitivity and
haptic perception tasks. Because an individual performs facilitating oral motor development, but it also appears
poorly on tests of haptic perception does not mean that to be important for environmental learning and may
contribute to the early development of bilateral hand memory and discrimination. We cannot assume that
use. Infants who exhibit little mouthing of objects children will automatically learn cognitive strategies
should be evaluated to determine the cause of the to aid in haptic task performance. For children with
delay. Even older children who exhibit tactile defensive- attention deficits, brain injury, and mental retardation,
ness and those with problems in haptic discrimination the interpretation and use of haptic information might
should be encouraged to engage in oral and manual be enhanced by teaching them to use cognitive strate-
exploration of objects. It takes creativity and close gies such as mental imagery or verbalization techniques
interaction with parents to find socially acceptable ways during task performance. In addition, we know that
to encourage mouthing beyond infancy. Children also the ability to identify an object haptically proceeds not
can show a prolonged need for mouthing of objects. If only from extracting information from the stimulus
the behavior is caused by oral-tactile defensiveness or or object that is presented, but also by combining
poor haptic discrimination, then mouthing should be
encouraged. However, if the behavior is caused by “presented information with expectancies based on context or
impaired visual-haptic integration or poor purposeful previous experience” (Klatzky & Lederman, 2003),
use of objects, then treatment should be directed
toward pairing vision and oral-manual manipulation called top-down processing. Thus providing a cue
during purposeful interaction with objects. A bigger such as “this is a fruit,” in advance of giving the child
challenge is seen in children with multiple handicaps an object to manipulate may result in improved
and those who have severe impairment in motor performance.
function. We should help these infants incorporate
mouthing of toys into daily play activities and find ways
to attach toys to clothing and position equipment so
that toys can easily reach the mouth. EVALUATION OF HAPTIC
Vision is paired with haptic exploration of the hands
throughout infancy and early childhood. Vision appears
PERCEPTION IN INFANTS AND
to guide the development of haptic manipulation CHILDREN
strategies. It is not until later in life that vision and
somatosensory sensations appear to take on separate Assessment of haptic perception can be considered
but supportive roles in object identification and use. from the perspective of standardized versus nonstan-
The importance of vision in the development of dardized assessments and also analyzed according to
haptic manipulation is seen in blind infants. Whereas product/process dimensions. Most of the standardized
typical infants begin to replace mouthing with manual assessments examine the product; that is, the accuracy
manipulation at about 4 months, blind infants continue of haptic perception, and the number of items the child
to identify objects orally, with mouthing the dominant passed. Many of the nonstandardized assessments used
form of exploration until 3 or 4 years of age (Landau, primarily for research purposes examine the process, or
1991). Because vision appears to be necessary for the the way the child approaches a task, and the effect of
development of haptic manual manipulation, the use of the nature of the task on haptic style or strategy.
haptic exploration with the hands should be specifically There are several standardized assessments to
taught to blind infants; we cannot assume that, because evaluate accuracy of haptic perception The Miller
the infant is not using vision, he or she will auto- Assessment for Preschoolers (Miller, 1988) includes a
matically use the hands for environmental exploration. stereognosis item that uses common objects for the
Interplay between vision and haptic exploration younger (2- to 4-year-old) children and geometric
seems to be needed for environmental learning in shape matching for older (3- to 5-year-old) children.
infancy and early childhood. Under the age of 5 or Although a specific score is not given for this item,
6 years activities should be designed that pair vision and percentile equivalents can be determined from the
touch in addition to using the haptic sense alone. The score sheet.
identification of object features should be integrated in The Sensory Integration and Praxis Tests (SIPT)
these activities. An exception is seen in children who (Ayres, 1989) make up a 17-test battery that assesses
overuse vision to guide hand use. For these children aspects of sensory processing (visual, tactile, vestibular-
vision should, at times, be removed from the play proprioceptive) and praxis. They are standardized on
activities to encourage the child to retrieve and use children ages 4.0 to 8.11 years. This battery includes
haptic information. several tests that tap aspects of haptic abilities. The
Haptic object identification is made possible by Manual Form Perception (MFP) test, which assesses
combining vision and cognition. The use of visual stereognosis, has two components. The first com-
imagery and verbalization helps improve haptic ponent is a haptic-visual intermodal matching task in
which the child feels a geometric shape without the use for the items assessing haptic perception, the examiner
of vision and points to its visual counterpart from can look at performance on these items. The Luria-
among a set of choices. The second aspect of the test is Nebraska Scales usually are administered by a
a haptic-haptic intramodal matching task in which the neuropsychologist and, like the Sensory Integration
child feels a geometric shape with one hand and and Praxis Tests, require special training. However, the
explores a set of five shapes to find its match with the knowledgeable therapist can use results of this test to
other hand. The MFP test is a complex task that, when aid in evaluation.
used in conjunction with the SIPT, contributes to All the preceding tests examine accuracy of haptic
identification of various problems including haptic identification. The manipulation strategies used in
perception, form and space perception deficit across haptic exploration are not examined. At present there is
sensory systems, problems in visualization, and somato- no standardized examination of exploratory strategies.
dyspraxia. The haptic-haptic matching component of However, the work of Zaporozhets (see Table 4-2)
the test also reflects functional integration of the two provides guidelines for the therapist wishing to
sides of the body (Ayres, 1989). examine this area. If, for example, a therapist notes that
In the graphesthesia test (GRA) of the SIPT, the a 7-year-old child is using only grasping to examine
examiner draws a design on the back of the child’s hand complex shapes, he or she can infer that this child is
and the child must reproduce that design with his or using immature and inefficient strategies to gain
her finger. This is not truly a haptic perception task information about objects. Exner (1992) developed a
because the tactile input is received passively not test to examine in-hand manipulation in children ages
through active manipulation. Nevertheless it is similar 18 months through 61⁄2 years. Although the emphasis
to many haptic perception tasks because the child needs of this work is on the hand as a motor instrument used
to interpret designs received through moving touch to accomplish specific skilled fine motor tasks with
applied to the hand and then signify knowledge of the vision present, the process of adjusting objects within
design by a motor response. As with tests of haptic the hand after grasp (in-hand manipulation) is critical
perception, fine motor coordination and motor to enable effective haptic manipulation to gain
planning abilities are necessary for optimal test perceptual information about an object (Case-Smith &
performance (Ayres, 1989). Weintraub, 2002).
Another standardized test that includes aspects of There are no standardized assessments to examine
haptic perception is The Luria-Nebraska Neuropsycho- haptic identification of the material properties of
logical Battery: Children’s Revision (Golden, 1987), a objects such as weight, texture, or object features such
149-item test battery designed to assess a broad range as length. Research has indicated that individuals use
of neuropsychological functions in children ages 8 to different strategies to gain information about these
12 years. There are 11 different scales, one of which object characteristics. For example, if children are asked
assesses tactile functions. The 16 items on this scale to match objects on the basis of texture, they use lateral
assess tactile localization, tactile discrimination, inten- motion; if they are asked to match objects on the basis
sity, tactile spatial discrimination, direction of move- of hardness or firmness, they use pressure; if they have
ment, identification of traced shapes and numbers, and to match on the basis of shape, they tend to use
identification of objects. The specific items on the contour following (Streri, 2003a). In working with
Tactile Function Scale that address aspects of haptic children with disabilities, we should examine whether
perception include two items that assess stereognosis, they vary the strategy used in exploring different object
in which the examiner places an object (quarter, key, properties as do typical children (McLinden, 2004;
paper clip, and eraser) in the child’s hand and the child McLinden & McCall, 2002). Although the typical
must name the object. If word-finding difficulties are child does not need or receive specific training in how
suspected, the examiner can place the four objects in to use the haptic sense, it may be necessary to explicitly
front of the child along with four other objects and ask teach haptic manipulation strategies in children with
the child to point to the object he or she just felt. There disorders (McLinden & McCall, 2002).
are also four items that are similar to the graphesthesia For therapists wishing to assess haptic abilities in
test of the SIPT. In these items the child is required to young infants, the best assessments at present are
recognize a cross, triangle, and circle drawn on the observational qualitative assessments rather than
back of his or her wrist with a pencil. There are two standardized testing, although it is important to use a
items in which a number is written on the back of the standard protocol to compare infants and see change in
wrist. In these items the child needs to know only that haptic style over time. It has been reported in the
a number was drawn and need not identify the specific literature that from 6 to 12 months there is a decrease
number. An overall score is provided for the Tactile in mouthing and an increase in fingering behavior
Function Scale. Although there is not a specific score (Ruff, 1980; Streri, 2003a). Thus if at 12 months an
infant is bringing everything to the mouth, one could the child’s willingness to explore objects through his or
identify a delay in the use of the hands for her sense of touch. Children who show sensory defen-
manipulation. Similarly, Ruff (1980) noted that 9- and siveness, such as may be seen in children who were
12-month-old infants adjusted their behavior to the preterm as infants (Case-Smith, Butcher, & Reed,
characteristics of objects and more often fingered 1998), may be unwilling to use their hands to gain
textured objects with prominent surfaces than smooth information about the environment (Ayres, 1989).
objects. Thus one could incorporate giving infants both Case-Smith (1991) reported that children with tactile
smooth blocks and blocks with textures and surfaces defensiveness and poor tactile discrimination demon-
and observing their response to these different objects. strated less efficiency in in-hand manipulation tasks.
The information on the role of manipulation in Response to touch can be assessed observationally
haptic perception also provides guidance for evaluation. while administering standardized assessments of
Along with noting the frequency of mouthing and the somatosensory perception such as the SIPT, through
integration of vision and haptic senses in object explo- assessment of sensory processing using caregiver
ration in infancy and early childhood, note the manipu- questionnaires (Brown & Dunn, 2002a,b; Dunn,
lation strategy used during performance on tests of 1999) or through protocols designed for use with
haptic perception. Because the identification of com- children with disabilities (e.g., Assessing Communica-
mon objects matures by 5 to 6 years and can be accom- tion Together) that suggest a structure for observing
plished with little to no haptic manipulation, common response to touch (Bradley, 1991 as cited in McLinden
objects may be useful only for assessing pre–school-age & McCall, 2002, p. 89).
children. Changes in the method of manipulation seen
during testing may be a better indication of change in
haptic perception than is change in the child’s accuracy
score. Expanding our assessment beyond the identi-
HAPTIC PERCEPTION IN
fication of geometric shapes to include the testing of CHILDREN WITH DISORDERS
other tactile properties allows us to look at the maturity
and flexibility of manipulation patterns and provides
insight into the child’s ability to recognize the scope of
PREMATURITY
sensory properties encountered during daily activities. The characteristics of touch most fully explored in the
Examination of whether children vary their strategy as infant are those related to social and emotional func-
a function of the task demand provides information tioning, and research on the perceptual role of touch
about the type of information the child receives often proceeds separately from research on its social
through his or her haptic sense. role (Rose, 1990). Recently the specific role of tactile
When assessing haptic perception in individuals with stimulation has been examined, and numerous studies
multiple disabilities, such as visual impairment or visual have investigated whether the preterm infant will bene-
impairment plus other disabilities, McLinden (2004) fit from changes in the quantity, quality, or patterning
and McLinden and McCall (2002) caution against of stimulation in the environment (Field, 2002, 2003).
relying only on norm-referenced assessments because The sensory organization and perceptual processing
children with disabilities have different experiences and characteristics of the preterm infant also have been
often do not develop in the same sequence as typical investigated. Rose and co-workers (Rose, Schmidt, &
children. However, they recognize that there are no Bridger, 1976; Rose et al., 1980) examined the infants’
assessments to assess haptic perception that are stan- responsivity to (passive) tactile stimulation and their
dardized for children with disabilities. They recom- abilities to discriminate different intensities of such
mend considering developmental assessments in stimulation. Infants were assessed at 40 weeks’ gesta-
conjunction with criterion-referenced procedures and tional age, and, while sleeping, they were touched with
process-oriented approaches, and emphasize that it is plastic filaments of different intensities and their cardiac
critical to examine how children use their sense of and behavioral responses were examined. Results indi-
touch in naturalistic or functional situations. McLinden cated that preterm infants are significantly less respon-
(2004) recommends using an “adaptive tasks” sive to tactile stimulation than are full-term infants.
approach that identifies the child’s use of or response to Rose, Gottfried, and Bridger (1978) also examined
touch in daily activities. (See also the Scottish Sensory differences between preterm and full-term infants at 1
Centre for a discussion of systematic ways to observe a year of age in an active touch multimodal (haptic and
child’s response to touch for learning.) visual) task using a habituation paradigm. Preterm
Finally, in examining haptic perception, it is critical infants did not show any evidence of cross-modal
to examine the child’s response or reaction to tactile transfer, whereas full-term infants did show such
sensory input because this has a significant impact on transfer. These results indicate that full-term infants are
able to gain knowledge about the shape of an object by et al., 1984). It is not clear whether this disorganization
feeling it and mouthing it and that they are able to is a purely motor phenomenon or relates to the ability
make this information available to the visual system. to perceive environmental affordances and act on them.
They were able to do this even after only 30 seconds of
handling or mouthing of the object. On the other
hand, preterm infants did not seem to know that the
M ENTAL RETARDATION
object they saw was the same object they were Research conducted with individuals with mental
exploring with their hand or mouth. Overall, preterm retardation provides insight into the relationship
infants were limited in acquiring information; they between haptic perception and cognitive ability. Much
showed evidence of difficulty perceiving passive touch of the research examining the relationship among
and effectively using active touch to explore their cognitive abilities and haptic manipulation and motor
world. Interestingly, lower-income full-term infants skill has been done with children with Down syndrome
also showed poorer haptic-visual integration than did (e.g., Brandt, 1996; Moss & Hogg, 1981). These
full-term middle-income infants. Recognition memory studies generally reported that children with Down
also has been studied in premature infants (Rose, 1983; syndrome did not show as effective accommodation of
Rose et al., 1988), who were found to have longer their hands to objects after grasp and did not use haptic
initial exposures and less recovery with novelty, manipulation and exploratory strategies as readily as
indicating slower and perhaps less complete informa- typical children. However, it is difficult to directly
tion processing. attribute these results to the child’s cognitive abilities
Poor haptic perception appears to be long lasting. because many of these findings can be attributed to the
Two follow-up studies examined the long-term out- sensorimotor problems or other aspects of Down
comes of children who were born preterm. Somato- syndrome (Exner, 1991). For example, Brandt and
sensory processing, including haptic perception, was Rosen (1995) found that children with Down syn-
impaired when the children were examined at school drome demonstrated impaired peripheral somato-
age (DeMaio-Feldman, 1994; Short et al., 2003). sensory function (sensory nerve conduction velocities)
Another research paradigm that has been found to and suggested that this may contribute to poor tactual
discriminate between high-risk infants and their typical perceptual performance. It is likely that, regardless of
peers is manipulative exploration. Early studies of the cause of the delay, impairment in the ability to
exploratory behavior from a Piagetian perspective efficiently explore objects interferes with learning about
documented decreased manipulation in premature key object properties (Exner, 1991).
infants but interpreted the decreased action to be a Jones and Robinson (1973) compared the per-
reflection of a disordered motor system that provided formance of a group of children with mental retar-
inadequate or inaccurate information (Kopp, 1974). dation (mean IQ = 47) to an age-matched group
Kopp examined the performance of premature and full- of children with normal intelligence. Accuracy of
term 8-month-old infants who were clumsy and non- intramodal (haptic-haptic) and intermodal (haptic-
clumsy (based on reach and grasp). The coordinated visual) discrimination of meaningless shapes was poorer
group of infants showed significantly more exploration for the children with mental retardation than for the
of objects, particularly more mouthing. The infants children with average intelligence. However, other
with poor coordination used more large arm move- studies found that when children with mental retar-
ments and less object manipulation than the infants dation and typical children were matched for mental
with good coordination. Kopp discussed the value of age, the between-group difference in accuracy of haptic
object manipulation in enhancing attention and recognition disappeared (Derevensky, 1976, cited in
providing information to infants. However, she also Derevensky, 1979; Jones & Robinson, 1973; Medinnus
pointed out that infants with poor manipulation skills & Johnson, 1966). In fact, two studies identified sub-
may give extra attention to motor actions, leaving less jects with mental retardation as performing better than
attention available for sensory or perceptual processing. normal mental age-matched controls in intramodal
More recent studies have focused on the attentional (haptic-haptic) and intermodal (haptic-visual) match-
and organizational differences between preterm and ing tasks (Hermelin & O’Connor, 1961; Mackay &
full-term infants because early focused attention reflects Macmillan, 1968).
active learning and predicts cognitive outcome (Lawson Because matching subjects for mental age eliminated
& Ruff, 2004). Preterm infants exhibit shorter duration differences in haptic accuracy scores between children
of action and less directed information-seeking action. with mental retardation and typical children, it can be
High-risk infants have also been found to have less concluded that some aspects of higher cognitive proc-
organized action and attentional strategies in essing are most likely necessary for task completion. In
exploratory manipulation of objects (Ruff, 1986; Ruff addition to verbal intelligence, haptic strategies have
been found to affect test performance of individuals dimensional shapes through the use of intramodal
with mental retardation. Subjects with mental retarda- (haptic and visual) and intermodal (visual-haptic)
tion have been known to display immature manipula- matching. Reduced performance in the group with
tion strategies during tests of haptic perception. The brain injury was seen only in the visual-visual and
sophistication of haptic manipulation strategies has visual-haptic matching conditions. These authors noted
been shown to be closely related to cognitive ability that, unlike the typical controls, who tended to per-
because manipulation strategies tended not to differ form better on the test conditions that included the use
between typical children and children with mental of vision than on the one requiring solely the use of
retardation when subjects were matched for mental touch, the addition of visual cues did not seem to assist
age (Davidson, 1985; Davidson, Pine, & Wiles- the subjects with brain injury to improve their test
Kettenmann, 1980). An increase in sophistication of performance. This finding suggests that children with
manipulation strategies has been shown to occur in brain injury may have a problem in visual perception or
close association with an increase in mental age within visual-haptic integration. However, this conclusion
the population with mental retardation (Davidson et should be interpreted with caution because the mental
al., 1980). Evidence from research on children with ages of the subjects in the group with brain injury were
mental retardation who were blind and sighted and 11⁄2 to 2 years above that of the control group. It is
age-matched controls suggests that experience may possible that, if the subjects were more equally matched
contribute to improved manipulation and thus accuracy for mental age, greater impairment in haptic perception
of intramodal (haptic-haptic) matching in individuals might have been found within the group with brain
with mental retardation, but experience alone cannot injury.
fully compensate for the effects of reduced cognitive The studies reviewed frequently used children with a
ability (Davidson, Appelle, & Pezzmenti, 1981). These mixture of diagnoses (e.g., cerebral palsy, encephalitis,
findings suggest that training can help improve the traumatic head injury). Thus it was not surprising to find
sophistication of manipulation strategies in individuals research that cited deficits in manual dexterity (e.g.,
with mental retardation, but such improvement in hand finger tapping, grip strength, motor coordination) along
function may be only partially effective in improving with dysfunction in tactile perception in the children
performance on tests of haptic perception. with brain injury (Boll & Reitan, 1972; Reitan, 1971).
Solomons (1957) compared the ability of children with
brain injury with and without fine motor impairment to
BRAIN I NJURY perform tests of haptic perception. The children with
Impairments in tactile perception frequently have been brain injury with intact hand function were able to more
reported in children with a diagnosis such as cerebral accurately match objects by shape, texture, and size than
palsy that indicates a known brain injury (Bolanos et the children with brain injury with fine motor impair-
al., 1989; Boll & Reitan, 1972; Cooper et al., 1995; ment. Studies also have reported that deficits in tactile
Duque et al., 2003; Krumlinde-Sundholm & Eliasson, perception (including stereognosis) have been closely
2002; Reitan, 1971; Solomons, 1957; Tachdjian & associated with poor hand function in children with
Minear, 1958; Van Heest, House, & Putnam, 1993; cerebral palsy (Duque et al., 2003; Gordon & Duff,
Yekutiel, Jariwala, & Stretch, 1994) and with traumatic 1999; Tachdjian & Minear, 1958). In addition,
brain injury (Ayres, 1989). Stereognosis (haptic stereognosis has been identified as a good predictor of
identification of shapes or common objects) is often upper-extremity surgical outcome within the population
cited among the tactile functions showing impairment. with cerebral palsy (Goldner & Ferlic, 1966).
Intermodal (visual-haptic) matching of shapes also
has been shown to be impaired in children with brain LEARNING DISABILITIES AND RELATED
injury (Birch & Lefford, 1964). Solomons (1957)
found that children with brain injury were also
DISORDERS
impaired in the haptic discrimination of size and Impairment in tactile perception also has been cited in
texture, although they did not differ from typical children who display learning disabilities and related
children in their ability to haptically match objects by disorders, conditions in which clearly identifiable brain
weight. Although Boll and Reitan (1972) cited no damage has not been found. Poor tactile and kines-
problems in haptic shape recognition, they noted that thetic perception has been found in children with
the children with brain injury performed poorly on a learning disabilities, language disorders, dyspraxia,
complex tactile performance task that required shape autism, and developmental Gerstmann syndrome
recognition for task completion. Rudel and Teuber (Ayres, 1965, 1989; Harnadek & Rourke, 1994; Haron
(1971) compared the ability of typical children and & Henderson, 1985; Johnson et al., 1981; Kinnealey,
children with brain injury to discriminate three- 1989; Kinsbourne & Warrington, 1963; Lord &
Hulme, 1987; Spellacy & Barbara, 1978; Nyden et al., haptic recognition of objects having a variety of sensory
2004), with stereognosis among the tactile tests used in properties. Factors contributing to test performance
some of these studies. (e.g., in-hand manipulation and attention) also should
Impairment in motor coordination often has been be addressed if we are to gain the information needed
found to accompany poor tactile perception in children for effective intervention.
with learning disabilities and related disorders. Johnson It was interesting to note that the reduced
and co-workers (1981) found children with language sophistication of manual and in-hand manipulation
disorders performed more poorly than a group of typical strategies, seen with impairments in visual perception
children matched for age, IQ, and socioeconomic status and visual-haptic integration were cited as possible
on tests of tactile perception (simultagnosia, graphesthesia, contributing factors to poor haptic perception in all
and finger identification) and motor coordination the conditions reviewed. Although reduced cognitive
(hopping, finger opposition, diadochokinesis, and ability was considered only in children with mental
putting coins in a box). Reports of children with retardation, attention deficits or related cognitive proc-
developmental Gerstmann syndrome have commonly essing problems were cited as possible contributing
cited a pairing of impairment in finger identification factors to impairment in other populations.
and constructional praxis (including poor handwriting
and difficulty drawing geometric shapes) (Benton &
Geschwind, 1970; Kinsbourne & Warrington, 1963;
PeBenito, 1987; Spellacy & Barbara, 1978). Case- SUMMARY
Smith (1995) studied 30 preschool children with
perceptual-motor problems and found that stereognosis Haptic perception in infants and children has been
(Manual Form Perception test of SIPT) correlated with reviewed in depth in this chapter. It was the authors’
Motor Accuracy, a test of fine-motor skill (r = 0.43). intent to provide an overview of the literature on the
Several other authors also have linked deficits in topic, with emphasis on material relevant to the
somatosensory processing (including poor haptic evaluation and treatment of disorders in haptic
perception) to problems in motor planning (praxis) perception in children with suspected and identified
(Ayres, 1965, 1969, 1971, 1972, 1977, 1989; Ayres, CNS dysfunction. The literature reviewed provides
Mailloux, & Wendler, 1987; Gubbay, 1975; Hulme insight into the development of haptic perception and
et al., 1982; Reeves & Cermak, 2002; Walton, Ellis, & the identification of factors that may be contributing to
Court, 1962). However, it is not clear whether impaired impairment in haptic perception in some children.
haptic perception contributes to poor motor planning, Haptic perception emerges in early infancy and con-
poor motor planning contributes to difficulty in haptic tinues to mature into adolescence. The infant initially
perception, or there is an ongoing interaction. There uses oral exploration to learn about objects. The hands
has been little research specifically designed to identify first transport objects to the mouth and later become a
factors that may be contributing to impaired haptic primary tool for haptic object exploration. Manual
perception in children. manipulation of objects begins with grasping and is
later replaced by more specific manipulation patterns
(e.g., fingering, banging) that are tailored to the
SUMMARY AND I MPLICATIONS FOR PRACTICE physical properties of the object. Manual manipulation
The previous section provides evidence of the existence gradually replaces mouthing as the preferred method of
of problems in haptic perception in children born object exploration. This is followed by a long period of
prematurely and those with a variety of disorders development in which the accuracy of haptic object
associated with brain injury and learning disabilities. recognition improves and the complexity of manual
Like much of the literature on haptic perception in manipulation and exploratory strategies increases.
children previously discussed, most of the research on The accuracy of haptic object recognition is related
haptic perception in children with disorders has been to the choice of haptic manual manipulation and
limited to the study of haptic discrimination of shape. exploratory strategies. Vision appears to guide the
The presence of problems in haptic discrimination of development of manual manipulation and helps to
shapes does not mean that a child also has equal impair- bring meaning to the haptic information being
ment in haptic discrimination of objects containing retrieved by the hands. It is not until 6 years of age that
other sensory properties (e.g., texture and weight). children can easily explore objects with the hands
Thus we cannot assume that because a child has problems without the assistance of vision. With time the hands
discriminating shapes he or she has global impairment develop the ability to retrieve information from the
in haptic perception. Future research on children with environment without the aid of vision, making it
disabilities needs to be directed toward the analysis of possible for vision and haptic sensory processing to take
on separate supportive roles in daily function; however, Affleck G, Joyce P (1979). Sex differences in the association
visual imagery continues to be used by many people to of cerebral hemispheric specialization of spatial function
with conservation task performance. Journal of Genetic
aid in haptic object recognition.
Psychology, 134:271–280.
Research suggests that the ability to use cognitive Alexander JM, Johnson KE, Schreiber JB (2002).
strategies such as visual imagery and verbalization in Knowledge is not everything: Analysis of children’s
the cognitive processing of haptic information develops performance on a haptic comparison task. Journal of
with age. It appears to be related to intelligence, because Experimental Child Psychology, 82:341–366.
Ayres AJ (1965). Patterns of perceptual motor dysfunction
there is an association between mental age and the
in children: A factor analytic study. Perceptual and Motor
accuracy of haptic object recognition. Skills, 20:335–358.
Review of the literature on haptic perception in Ayres AJ (1969). Deficits in sensory integration in
children with disorders suggests that impairment in educationally handicapped children. Journal of Learning
somatosensory processing, manual and in-hand manip- Disabilities, 26:13–18.
Ayres AJ (1971). Characteristics of types of sensory
ulation, vision, visual perception, or cognition can con-
integrative dysfunction. American Journal of
tribute to deficits in haptic perception. Occupational Therapy, 26:329–334.
Most of the tests currently used to assess haptic Ayres AJ (1972). Types of sensory integrative dysfunction
perception measure the product, the number of objects among disabled learners. American Journal of
identified correctly. Yet process might be as important Occupational Therapy, 26:13–18.
Ayres AJ (1977). Cluster analyses of measures of sensory
as, or even more important than, product when using
integration. American Journal of Occupational Therapy,
the results of testing to guide treatment. Assessing the 31:362–366.
process means considering the quality of manual Ayres AJ (1989). Sensory integration and praxis tests. Los
manipulation and exploratory strategies, along with the Angeles, Western Psychological Services.
degree to which vision and cognitive strategies are Ayres AJ, Mailloux ZK, Wendler CLW (1987).
Developmental dyspraxia: Is it a unitary function?
being used in task performance.
Occupational Therapy Journal of Research, 7:93–110.
Therapists should be aware that the tests available to Bailes SM, Lambert RM (1986). Cognitive aspects of haptic
measure haptic perception in children assess only a seg- form recognition by blind and sighted subjects. British
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Chapter 5
REACHING AND EYE-HAND
COORDINATION
Birgit Rösblad
CHAPTER OUTLINE around the ball before the moment of contact, or we

will fail to catch it. In other types of goal-directed arm
MATURE REACHING MOVEMENTS movements the arm trajectory as such can be the goal,
Movement Speed as when painting or drawing, but in a reaching move-
ment the goal is to transport the hand to the target,
Transport and Grasp Phase with precision in both time and space.
Role of Vision This chapter is organized in three parts: the first
Role of Proprioception deals with the mature reaching movement, the second
with the development of reaching in infancy, and the
Integration of Sensory Information third with reaching in children with motor disabilities.
DEVELOPMENT OF REACHING DURING INFANCY
Beginning to Master the Reach
Coordinating the Body Parts Involved in the MATURE REACHING MOVEMENTS
Reaching Movement
Movement Planning Reaching for an object means getting the hand from a
Role of Sensory Information starting position to the goal, the object. In doing this,
the hand describes a trajectory. The word trajectory can
Movement-to-Movement Variability be used in different ways, but here refers to the path
REACHING IN CHILDREN WITH MOTOR taken by the hand as it moves toward a target and the
IMPAIRMENTS speed as it moves along the path. The reaching trajectory
Movement Planning has several characteristics that are discussed later.
Feedback Control of Reaching Movements
Adaptation of Reaching Movements
MOVEMENT SPEED
The Movements of the Arms Are Coupled in If the velocity of the hand during a reaching movement
Children with Hemiplegic Cerebral Palsy is plotted versus time as in Figure 5-1, one can see that
the tangential velocity curve is bell shaped. The
reaching movement is continuous with one single peak
Our hands are extremely important tools for us in our of velocity. In the last part of the reaching movement,
everyday lives, and we are able to use them with grace when the hand is close to the target, the velocity is
and skill. To do so we have to be able to bring them to slow. This typical bell-shaped velocity curve is seen
the right place at the right time. This can be illustrated when the reach is carried on with, as well as without,
with the example of catching a ball. To catch the ball visual feedback (Jeannerod, 1984; Morosso, 1981).
successfully the hand has to be at the calculated This indicates that the reaching movement is pro-
meeting point at exactly the right time. Moreover, it grammed in advance of movement onset to a high
must be prepared for the catch, with the fingers closing degree.
89
cm/s cm/s2 the activities we perform. When we reach out to pick a

140 1500 blueberry, movement speed is lower compared with
that used in reaching for a ball we intend to throw. The
decrease of accuracy when speed increases has been
called the “speed-accuracy trade-off ” and is defined by
750 Fitts’ law (1954). The minimum variance theory, put
forward by Harris and Wolpert (1998), might explain
this phenomenon. They argue that neuronal signals are
70 corrupted by “noise” that increases with the size of the
control signal. Therefore increased acceleration leads to
0 increased variability in the final limb position and thus
requires further corrective movements. This means that
moving very fast can be counterproductive.
–750 TRANSPORT AND G RASP PHASE

0 Another way of viewing the reaching movement is to
0 200 400 600 look for its functional components. Two distinct and
ms coordinated movement components then can be
Figure 5-1 Kinematic profiles of the transport identified (Jeannerod, 1984). The first component is a
component of a reaching movement. The heavy line transportation phase, which brings the hand to the
depicts the velocity of the wrist (cm) as a function of
time. This curve describes a single continuous movement target. In this part of the movement mainly the
with a single peak of velocity. The two peaks connected proximal joints and muscles are involved. The second
by the thin line depict the acceleration of the wrist (cm2) component is a grasp phase in which the hand is shaped
as a function of time. The positive peak constitutes one in anticipation of contact with the object. This phase
phase of acceleration and the negative peak one phase involves mainly the distal joints and muscles. One also
of deceleration, together forming one movement unit.
(From Jeannerod M, et al. [1992]. Parallel visuomotor can divide the visual information needed to successfully
processing in human prehension movements. In R Caminiti, grasp an object into two categories. For the transport
PB Johnson, Y Burnod [editors]: Control of arm movement in phase of the movement knowledge of the position of
space. New York, Springer-Verlag.) the object in the room is needed (the object’s extrinsic
properties). With this information we can program the
direction and extent of the movement. For the grasp
If one considers the reaching movement in terms of phase, perception of the size and shape of the object is
accelerations and decelerations, it can be divided into needed (the object’s intrinsic properties). There is
movement units. One phase of acceleration followed evidence for independent planning of the two reaching
by a deceleration then can be said to constitute a phases (Loukopoulos, Engelbrecht, & Berthier, 2001).
movement unit (Brooks, 1976; von Hofsten, 1979). Although the grasp and transportation phase of the
The movement paths within these movement units are reach are separately controlled, these two components
relatively straight, and movement direction is changed are coordinated so that the grasp phase starts during
in between units (von Hofsten, 1991). The number of the transportation phase.
movement units comprising a movement can be viewed To accomplish a smooth and coordinated grasp, the
as an index of its degree of programming. A movement fingers must initiate the grasp well before encountering
consisting of only one movement unit, such as that the object. Closing the hand too early or too late pre-
depicted in Figure 5-1, then can be viewed as being vents capturing or makes the grasp impossible or awk-
entirely programmed before movement onset. How- ward. During the transportation phase the fingers open
ever, if the movement is composed of many movement to a maximum grip aperture. After this maximum
units, one can assume that it has been programmed opening the fingers start to close in anticipation of
several times during execution. A reaching movement, contact with the object (Jeannerod, 1981). The control
aimed at a stationary object, generally consists of one or strategy used by the central nervous system to co-
two movement units, with the first covering the main ordinate these components remains largely unknown.
part of movement duration. However, it has been suggested recently that a simple
The choice of movement speed is crucial for how spatial relation, based on the size of finger opening in
skillfully we manage to reach and grasp an object. A relation to finger closing, might determine at what
movement cannot be both fast and precise. Uncon- point during the reach the maximum grip aperture will
sciously we strive to optimize movement speed to suit occur (Mon-Williams & Tresilan, 2001).
Reaching and Eye-Hand Coordination • 91
The action we perform shapes our reaching or plete, the assumption has been that only low-velocity
grasping movement. A small object requires longer movements can be influenced by visual feedback. How-
reaching time than a larger object. The first part of the ever, there is now considerable evidence that visual
movement trajectory seems to be unaffected by object feedback might be as fast as 160 to l00 msec, and that
size, but for smaller objects extra movement time is we use online visual information to correct both slow
spent in the last part of the movement, after peak and fast movements (Alstermark et al., 1990; Martin &
acceleration. Moreover, the greater the precision Prablanc, 1992; Paulignan et al., 1991a,b; Saunders &
required, the earlier the hand will anticipate the Knill, 2003).
physical characteristics of the object (Marteniuk, Nevertheless, even if the movement is carried out
MacKenzie, & Athenes, 1990). The hand opens more without visual feedback, the main features of the
fully during the reach when reaching for a larger object, reaching trajectory remain. One will still see the bell-
and always more than necessary (von Hofsten & shaped velocity curve, as well as the coordination
Rönnquist, 1988). If the reach has to be carried out between movement speed and anticipatory hand
with high speed, the grip aperture is larger. Opening shaping (Jeannerod, 1981). This indicates that to a
the hand more fully during a fast reach could be seen high degree the reaching movement is programmed in
as a way of making sure that the object is successfully advance of movement onset but can be modified
grasped despite the decreased movement accuracy during execution when necessary—that is, when end-
(Wing, Turton, & Fraser, 1986). point accuracy is needed or if we reach for a target that
moves in an unpredictable way.
ROLE OF VISION
It is obvious that vision plays a very important role in
ROLE OF PROPRIOCEPTION
our ability to reach out for objects. One need only We have receptors in our muscles, tendons, joints, and
imagine what it would be like to be blind to realize the skin that provide us with information about the
importance of vision to reaching. Vision is the sense positions and movements of our body parts. This is
that provides us with information about the layout of here termed proprioception, after Sherrington (1906).
the environment, and when reaching for an object, Although it is relatively easy to find out how we can
vision defines both the position and shape of the object. move without vision or with degraded vision, proprio-
Seeing the environment gives us an opportunity to ceptive information cannot be manipulated as easily.
anticipate upcoming events and plan our movements in Instead, the research on the role of proprioception has
an anticipatory fashion. One example of this is the way focused on animal experiments and patients with sen-
we shape our hand before contact with an object. A sory loss caused by diseases.
blind person reaching for an object does not have this One line of research has used deafferented monkeys.
ability but has to touch the object first and then, When their dorsal spinal roots are sectioned, the
guided by haptic information, shape the hand for grasp. monkeys are deprived of sensation from the upper
If we cannot foresee upcoming events and plan our limbs but the motor nerves are unaffected. This tech-
movements ahead of time, our movements will be nique was used in early experiments by Mott and
uncoordinated of necessity. Sherrington (1895). They reported that the monkeys’
Given that visual information is important both for limbs became useless after such operations and that the
movement planning and execution, one may ask what animals used their upper limbs only if forced to and
should be seen and when during the movement we then in an awkward way. They concluded that afferent
need that information. The answer to this seems to be information from the limbs was necessary for both
that full visual information is optimal. Several studies movement initiation and control. Similar results also
show that we must be able to see the target both before were reported by Lassek & Moyer (1953). However,
and during a movement or movement quality is reduced later experiments with deafferented monkeys reported
(Berthier et al., 1996; Sarlegna et al., 2003). Moreover, different results. Taub and Berman (1968) reported a
if we can see our hand as we move it toward the target, clear improvement in motor function after the initial
movement accuracy and efficiency will be improved disability that resulted from the section of the nerves.
(Connolly & Goodale, 1999; Sarlegna et al., 2004; The animals were able to reach for and grasp objects
Saunders & Knill, 2003; Schenk, Mair, & Zihl, 2004). with a primitive pincer grip a few months after surgery.
The minimum delay needed for visual information Recovery of function also has been reported by Knapp
to affect the physical movement of the hand tradition- and co-workers (1963). Bossom and Ommaya (1968)
ally has been thought to be around 200 msec (Keele & have pointed out that motor pathways can be damaged
Posner, 1968). Because many naturally occurring easily during a rhizotomy and that this could be why the
reaching movements take around 500 msec to com- degree of recovery of function varied between studies.
Despite the previous diversity in results, there are the visual and proprioceptive systems have to be in
also similarities. Several investigators have found that, correspondence with each other. One example of when
when forced to, the animals are able to use their they are not integrated involves wearing a pair of
deafferented limb. Animals that had both forelimbs displacing prisms. If we then reach for an object, we
deafferented regained function to a higher degree than perceive the object at a location displaced from its
those with only one deafferented forelimb, who could virtual position, and the reach is directed to this
choose to use the normal hand. This latter effect has erroneous position. However, reaching actively toward
been called learned nonuse by Taub and Berman the object several times rapidly reintegrates the visual
(1968) and was explained in terms of an inhibition of and proprioceptive systems, and within a few minutes
the deafferented limb. However, if the animals that had adaptation has occurred (Harris, 1965). This also can
one limb deafferented were forced to use it because the be experienced when one puts on a pair of new glasses.
normal limb was restrained, they recovered function to The distance to the ground seems to be changed, and
the same degree as the bilaterally deafferented animals it takes some minutes of walking before the visual
(Bossom, 1974; Knapp et al., 1963). system again is in agreement with the proprioceptive
Yet another similarity among the reports is that the system.
deafferented monkeys were capable of both initiating A recent study by van Beers and co-workers (2002)
and carrying out motor acts, however uncoordinated. suggests that the extent to which vision and proprio-
Studies of humans with sensory deficits seem to conception contribute to the control of reaching move-
firm this. Gordon and Ghez (1992) described patients ments depends on the task. The brain weighs the
with large-fiber sensory neuropathy in the following information from each modality in a way that mini-
way: mizes the uncertainty in perceived position. This sug-
gests that we cannot say that one modality dominates
“These patients, although able to initiate and carry out complex the other and that the situation is better described as a
movement sequences, were severely impaired in most functional flexible weighing of information from the modalities to
activities. For example, none could drink water from a cup obtain movement precision.
without spilling.”
The experiments by Ghez and co-workers (1990)

provide us with important information about the role
DEVELOPMENT OF REACHING
of proprioception in reaching movements. They DURING INFANCY
studied the reaching movement in patients with
sensory loss caused by large-fiber neuropathy. Without
visual feedback the patients made large directional
BEGINNING TO MASTER THE REACH
errors from movement onset and also were unstable at Observing a newborn baby’s arm movements, one might
movement endpoint. When allowed to monitor the perceive them as random, performed without meaning.
movement visually, they were able to substitute for the However, even at birth the infant is capable of move-
loss of proprioceptive information to some degree, and ments that require some degree of sensory motor inte-
performance improved. However, Ghez and co- gration. Von Hofsten (1982) placed 5-day-old infants
workers (1990) also studied the effect on movement in a semireclining seat that gave good support to the
accuracy when the patients were able to look at the trunk and head but allowed free movement of the
limb before movement onset but not during the arms. The infants were presented with a colorful tuft
ongoing movement and found that this also improved that moved irregularly and slowly in front of them. The
function. This indicates that proprioception is not only infants’ arm movements were recorded with two video
important for feedback during the ongoing movement cameras, making it possible to calculate the arm trajec-
but also plays an important role for programming of tory in three-dimensional space. All infants noticed the
movements by providing the nervous system with tuft and were able to follow it with eye and head
information about the current state of the body parts. movements for varying periods. The infants’ forward
extended arm movements, as well as looking behavior,
were analyzed. When the infants were fixating the tuft,
I NTEGRATION OF SENSORY I NFORMATION they aimed their reaching movements closer to it than
When we reach for an object both vision and pro- when looking in another direction or closing their eyes.
prioception provide information about hand position, Thus a child only a few days old already has a rudi-
and this information must be integrated to generate mentary visual control of arm movements. Moreover,
one single estimate of where the hand is in space (van when initiating an aimed movement toward a visually
Beers, Wolphert, & Haggard, 2002). This means that fixated target, the infant must “know” where its arm is.
Because the neonate is fixating the target, the starting midline. Older infants often display an asymmetric one-
position of the hand must be defined proprioceptively. hand reach. He reported that when infants first attained
This indicates that the visual and proprioceptive spaces the ability to sit without support they shifted toward
are to some degree already connected in the newborn reaching more with one hand so that the other could
infant. However, even though the infants aimed their be used to maintain balance. Hopkins and Rönnqvist
reaching movements closer to the object while fixating (2002) studied reaching behavior in infants aged about
on it, most of the time they did not touch it. Also, at 6 months who were not yet able to sit without support.
this early age, even if they did touch the object, they They compared the quality of the reaching movements
were not capable of grasping it. Several months of when the infants were provided with firm postural
experience of its the own body and with the environ- support and when they were sitting in a commercially
ment still remain before the infant starts to become available chair. That the firm postural support resulted
successful at reaching, at around 4 to 5 months of age in a decrease in the number of movement units
(Gesell & Ames, 1947). indicates that this extra support improved the reaching
behavior. Clinical observations made by Grenier
(1981) also indicate that postural control is important
COORDINATING THE BODY PARTS I NVOLVED for coordinated arm movements and that if infants are
supported appropriately at the neck and trunk they can
IN THE REACHING MOVEMENT
perform coordinated arm movements at a much earlier
Before the infant can reach for and grasp an object he age than is typical.
or she must learn to coordinate the movements of the Postural control does not only act by maintaining
shoulder, arm, and hand. This complicated task of balance after it has been perturbed. We also have the
controlling movements over several joints, and accord- ability to anticipate an upcoming situation that will
ingly a great number of movement possibilities, has perturb our balance and prepare ourselves by means of
been designated as the degrees of freedom problem postural adjustments. There is some evidence that this
(Bernstein, 1967). One solution to this problem is to anticipatory mode of counteracting upcoming forces
reduce the degrees of freedom by keeping some of the on the body starts to operate during the first year of
involved joints in a stiff position. This also seems to be life. Von Hofsten and Woollacott (1989) showed that
the strategy used by infants as they first start to reach at 10 months of age children activated the muscles of
for objects. Berthier and colleagues (1999) found that the trunk before making voluntary arm movements.
beginning reachers mainly use shoulder and torso rota- The integration between posture and voluntary control
tion to move the hand to the target, while the elbow is is an important prerequisite for coordinated arm and
kept in a stiff position. This reduces the complexity of hand movements. Little is known of how children with
the movement and thus increases the infant’s chances motor impairments can integrate voluntary movements
of successfully capturing the object. However, an obvious and posture, but it is possible that this is one con-
limitation of this strategy is that it restricts the infant’s tributory factor in these children’s fine motor
possibility of placing the hand in an optimal position disturbances.
for grasping.
Postural stability is yet another foundation for reaching
movements. Van der Fits and colleagues (1999), who
MOVEMENT PLANNING
studied postural adjustments during arm movements in As discussed, the reaching movement can be analyzed
infants, found that when infants first start to reach in terms of acceleration and deceleration. A phase of
successfully for objects the arm movements are acceleration followed by a phase of deceleration then
accompanied by a large amount of postural activity. constitutes a movement unit. When the infants first
Already at this young age the pattern of activation start to reach and grasp, at around 4 months of age, the
showed some resemblance to that seen in adults, with ability to plan the movement ahead of time is still poor.
an activation of the dorsal muscles before the ventral As a consequence of this, the movement path is awk-
and a top-down recruitment of muscles. With increasing ward and crooked, and the trajectory consists of many
age the pattern of activation became more organized. movement units. This changes after the infant has
Yet another study demonstrating the linkage between practiced reaching for some time, and at around 1 year
the development of posture and reaching was carried of age the number of movement units has decreased
out by Rochat (1992). When the infants started to and the movement paths are straighter (Konczak &
reach for objects, they tended to use both hands and Dichgans, 1997; von Hofsten, 1991) (Figure 5-2).
later in development acquired one-handed reach. A The ability to plan movements ahead of time, and
successful object-oriented reach in a young infant is not only react to what has already happened, is funda-
symmetric and synergistic with the hands meeting in mental for movement skill. One example when this is
5 months 9 months
05:58:51
Vertical
Start
Horizontal
15 months 24 months Adult
05:58:31
10 cm
Start
Figure 5-2 Sagittal hand paths of one infant at four
different ages illustrating the progression toward
smoother and straighter movements. (From Konczak J,
Dichgans J (1997). The development toward stereotypic arm
kinematics during reaching in the first 3 years of life. 05:58:11
Experimental Brain Research, 117:346–354.)
obvious is when we catch a ball that is thrown to us.

To be able to do this we must predict the trajectory of
the moving object and reach for the meeting point.
Von Hofsten and Lindhagen (1979) found that at the
age children start to reach successfully for stationary 05:57:91
objects, they also can catch fast-moving ones. Eighteen-
week-old infants were found to be able to catch objects
that moved at 30 cm/sec. Most of the reaches were
aimed at the meeting point from movement onset. This
demonstrates an early emerging capacity for antici-
patory control of reaching movements. That is, the
infant does not reach toward where he or she first
sees the object, but rather appears to be anticipating Figure 5-3 Two views of the performance of a well-
the point where the hand and the object will meet aimed reach by an infant who is 21 weeks of age. The
(Figure 5-3). frame on the bottom is the start of the reach. The interval
The ability for anticipatory control develops sub- between frames is 0.2 sec (digital clock reading in the
stantially during the first year of life. One example of upper portion of each frame). The child is directing the
reach ahead of the object to the point at which the
this is how the infant prepares the hand for the grasp. object will be at the end of the reaching movement.
An adult reaching for an object shapes the hand to fit (From von Hofsten C [1980]. Predictive reaching for moving
the properties of the object in anticipation of con- objects by human infants. Journal of Experimental Child
tacting it. Von Hofsten and Rönnquist (1988) studied Psychology, 30:369–382.)
the shaping of grip aperture as infants reached for
objects. The 5- to 6-month-old children started to
close the hand before making contact with the object, When we as adults reach for an object the movement
which indicates some anticipatory ability. However, trajectory is not only affected by the size and shape of
these young infants did not adjust their grip aperture to the object but also by what we intend to do with it after
match the object size, as did children at 9 months of we have picked it up. We reach more slowly for an
age. At 13 months of age the infants started to close object that will be used in a precision task (e.g., fitting
the hand earlier during the reach compared with the a coin in a slot) than for an object that will be used in
younger children and were comparable to adults in this a nonprecision task (e.g., throwing the coin in a
respect. Infants 10 months of age also have been found bucket). Claxton, Keen, and McCarty (2003) studied
to shape their hand to fit different shapes of objects 10-month-old infants to see if they also had this ability
before contact (Pieraut-Le Bonniec, 1990). to plan a reaching movement in several segments. The
infants were encouraged to reach for a ball and then discussed in the preceding section suggest that young
either throw it into a tub or fit it into a tube. Infants, infants are able to use proprioceptive information and
like adults, reached for the ball faster if they were going integrate it with visual information when reaching for
to throw it as opposed to fit it into the tube. This shows objects. A similar result was found when reaching was
that infants have an ability to take several steps into studied in children 6, 7, and 8 years of age, in a
account when planning an activity. However, they did situation in which the amount of visual information was
not show the more sophisticated signs of movement varied. The children seemed to use visual information
planning that adults do, such as a prolonged decelera- for control of arm movements in a manner similar to
tion phase when reaching for an object that will be used that of adults, although with less accuracy and speed
in a precision task. (Rösblad, 1998).
ROLE OF SENSORY I NFORMATION MOVEMENT-TO-MOVEMENT VARIABILITY

As discussed, visual information of the hands as well as The infant has not yet learned the most efficient way
the goal is necessary for movement accuracy. However, of performing a movement and is still exploring the
to a great extent we are able to replace visual infor- possibilities of its own body. Therefore he or she will
mation with proprioceptive and tactual information if perform a specific task, such as reaching for a toy, with
the hand for some reason is out of sight or if we reach significant movement-to-movement variability. In fact,
in the dark. Clifton and colleagues (1994) have in a being able to perform a specific task in a consistent
series of studies investigated the ability in infants to manner is a prominent feature of movement skill.
reach for objects in the dark They showed that 6- to Figure 5-4, A shows the superimposed movement
7-month-old infants could contact sounding objects trajectories of a 1-year-old girl reaching for an object.
(Perris & Clifton, 1988) and that infants of 6 months In Figure 5-4, B the same task is performed by an 11-
could successfully reach for glowing objects (Clifton et year-old boy. Although the little girl grasps the object
al., 1994) and also reach for glowing objects that were without difficulty, it is clear that she does not reach for
moving in the dark (Robin, Berthier, & Clifton, 1996). the object with the same skill as the older boy does.
For many years it has been assumed that young infants Lhuisset and Proteau (2004), who studied reaching
are more dependent on visual information for control movements in children 6, 8, and 10 years old, found
of reaching movements than adults, and that their that although the children clearly planned the move-
ability to use proprioceptive information for movement ments ahead of time, the planning processes were still
control is poor (Piaget, 1952). However, the studies more variable than for adults.
500
500
400
400
Vel (mm/sec)
Vel (mm/sec)
300 300
200 200
100 100
0 0
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
A (sec) B (sec)
Figure 5-4 The figures show that a young child performs a specific movement with high variability, whereas an older
child has a more consistent movement pattern. A, Trajectory of the hand for a 12-month-old girl who is reaching
repeatedly for the same object. B, How an 11-year-old boy performs the same movement. (From Eliasson AC, Rösblad B
[2001]. Arm och handrörelser: Normal och avvikande utveckling. In E Beckung, E Brogren, B Rösblad [editors]: Sjukgymnastik för
barn och ungdom. Teori och tillämpning. Lund, Studentlitteratur.)
REACHING IN CHILDREN WITH did not receive visual feedback of the moving arm.
Movement analysis indicated that the less efficient move-
MOTOR IMPAIRMENTS ments of the children with DCD could be explained by
a less developed ability for anticipatory control.
We still have limited knowledge concerning the ability
to plan and control reaching movements in children
with motor impairments. However, the knowledge we FEEDBACK CONTROL OF REACHING
have from research carried out on normally developed
children and adults can be used when asking questions
MOVEMENTS
about children with motor impairments. This section Although it is a common finding that children with
provides examples from this line of research. motor impairments show signs of impaired ability for
movement planning, there are several exceptions to
this. We studied the ability of children and young adults
MOVEMENT PLANNING with myelomeningocele (MMC) to control reaching
A common finding in motor control research on movements (Norrlin, Dahl, & Rösblad, 2004). As in
children with motor impairments is that the ability for the study on children with ADHD discussed in the
movement planning is impaired. One example of how preceding section, we used a digitizing tablet linked to
the ability to plan reaching movements can be impaired a computer. Results showed that the ability to program
comes from a study on reaching in children with reaching movements was similar in individuals with
attention deficit hyperactivity disorder (ADHD) MMC and a control group of children. In both groups
(Eliasson, Rösblad, & Forssberg, 2004). To analyze the the velocity profiles were bell-shaped and also scaled
kinematics of the arm movement we used a digitizing proportionally to target distances, indicating efficient
tablet. The task for the children was to move a cursor movement planning. The movement problems in the
on a computer screen with a hand-held digitizer on the MMC group seemed to be related to the execution
tablet. Start and target positions on the screen were of the ongoing movement. The subjects with MMC
always visible during the movement. The screen cursor, showed more problems when they were provided with
however, could either be visible throughout the entire visual feedback during the entire movement, and thus
movement or blanked at movement initiation. Analysis being given the opportunity to make visual corrections
showed that movement control was impaired in of the trajectory. This suggests that the commonly
children with ADHD and that their problems were occurring visual perceptual problems in individuals
especially pronounced when the screen cursor was not with MMC may contribute to their poor spatial move-
visible on the screen. Because the children could not ment precision.
visually correct the movement when the screen cursor Kearney and Gentile (2002) performed a small but
was blanked, results indicate a poorer motor pro- interesting study, on prehension in young children with
gramming in children with ADHD. Moreover, the Down syndrome. They compared the performance of
children with ADHD performed jerky movements with 3-year-old children with Down syndrome (only three
higher peak accelerations than the control group of children were included) with 2- and 3-year-old typically
children. As discussed earlier in this chapter, the choice developed children. The children with Down syndrome
of movement speed is crucial for how skillfully we scaled the peak velocity to movement distance, which
manage to reach for and grasp an object. The children indicates ability for movement planning. However, they
with ADHD adopted higher movement speed com- differed from both groups of typically developed
pared with the typically developed children but this children in that they performed the final part of the
high speed was counterproductive and resulted in reaching movement with reduced efficacy, which
increased movement endpoint errors and further indicates that these children mainly have problems with
corrective movements. feedback control of the reaching movement.
Similar results also have been found when the con-
trol of reaching movements in children with develop-
mental coordination disorder (DCD) has been studied.
ADAPTATION OF REACHING MOVEMENTS
Van der Meulen and colleagues (1991a,b) tested the Our sensory motor system is highly adaptable. When
ability in children with DCD to make precise arm we use a computer mouse we get used to the specific
movements. In a first study, the task for the child was gain of that mouse and take this into account when we
to reach for a target as quickly and precisely as possible. program the movements of hand that will transfer the
In a second study, the ability to track a target that mouse. If the gain of the mouse is changed we will
moved unpredictably was assessed. In both studies, the under- or overshoot the target on the computer screen,
children were tested in situations in which they did or but only a few times. The nervous system modifies the
programming of subsequent movements to prevent 2001; Volman et al., 2002a). If the arms and hands are
errors and motor adaptation occurs rapidly. Motor to make asymmetric movements, the movement
adaptation involves changes in the control of move- control problems are amplified. A commonly occurring
ments and can be seen as short-term learning. In situation is that we reach out for and grasp an object
everyday life we rapidly and frequently adapt our move- with one hand while the other hand is occupied with
ments to changing conditions, such as when we switch holding another object. The effect that the mirror
to new cars with different transmission in the steering movements may have on the quality of reaching
system or simply when we switch to a light hammer movement is yet to be investigated.
after having used a heavy one. When discussing results from studies of children
Again, using the described experimental setup with with motor impairments, we point out that the varia-
a digitizing tablet linked to a computer, we investigated tion within one specific diagnostic group is large. The
the ability in subjects with MMC to adapt reaching movement problems within one diagnostic group
movements to a new visuomotor gain (Norrlin & could not be explained by one specific factor; however,
Rösblad, 2004). This was done by first letting the sub- the knowledge obtained from studies carried out on
jects perform reaching movements at targets displayed both normally developed children and children with
on a computer screen. After having performed a motor impairments can provide us with knowledge
number of trials (around 100) we changed the gain of about which processes might be disturbed and what to
the mouse. Directly after this gain change both the look for when assessing children.
children or youths with MMC and the typically devel-
oped children overshot the target. However, within a
few trials the control group of children had adapted to
the new condition and performed movements of the
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Chapter 6
COGNITION AND MOTOR SKILLS
Ashwini K. Rao
“Perhaps the most incomprehensible thing about the world is that it is

comprehensible.”
Albert Einstein
CHAPTER OUTLINE Although the extent of brain structures has

increased along with our functional repertoire of hand
CASE SCENARIO and cognitive skills, this in no way implies that there is
MOTOR SKILLS ARE ADAPTIVE a simple cause-and-effect relationship between brain
and behavior. In fact, research on the neural control of
What Is the Overall Framework for Understanding movement has shown that although specific areas of the
Movements? brain are involved in the control of hand movements,
INTRODUCTION TO COGNITIVE CONTRIBUTIONS TO the performance of movements in turn influences de-
MOTOR SKILLS velopment of the same neural structures. Thus struc-
COGNITIVE PROCESSES IN MOTOR SKILLS ture (brain areas involved in hand control) and function
(behavioral repertoire of manipulative skills during
Attention functional tasks) are intertwined and influence each
Perception other through development.
Concept Formation (Knowledge) Manipulation skills are some of the most complex
motor skills and require the coordination of many
Memory systems. Within the motor system, manipulative skills
SKILL ACQUISITION (LEARNING) require the coordination of many different segments of
EPILOGUE: RELATIONSHIP BETWEEN COGNITIVE the body that allow for adapting the hand to grasp dif-
AND MOTOR DEVELOPMENT ferent objects and application of precise amounts of
force on objects that allow for successful manipulation
SUMMARY of objects during functional activity (Flanagan,
Haggard, & Wing, 1996). Coordination becomes even
more complicated when we consider the cognitive
Through the course of evolution, the importance of the components (e.g., memory, attention, perception) that
hand to the organism has increased tremendously. We have to work in concert with the emerging motor skill.
use our hands to reach out and grasp and manipulate
objects, write and draw, make gestures, and create and
use tools. Thus our hands are not only used for manip-
ulation skills, but also for communication. The greater CASE SCENARIO
importance of hand skills in humans is reflected in an
increase in the area of the brain dedicated to hand Consider this simple scenario. Jimmy, a 2-year-old
movement. In addition, cognitive capacity (broadly typically developing child, is sitting at a table, reaching
defined as the collection and organization of informa- out to grasp a glass full of water so as to bring it toward
tion into knowledge) has increased through the course his mouth. This simple functional act, one that is
of evolution. This is also reflected in the increase in size carried out by children with seemingly effortless ease,
of frontal lobe structures in humans when compared nevertheless is extremely complicated and poses several
with nonhuman primates. challenges to a developing system such as Jimmy’s. This
101
task highlights the numerous processes that can be 3. Goal directed indicates that movements, in general,
categorized as cognitive-perceptual aspects of motor are executed to accomplish a particular action.
control. There are instances in which the goal of the action
Even before beginning the movement of reaching is a specific set of movements, as in a dance
for the glass, Jimmy’s visual processes provide his performance. In this chapter, however, we are
nervous system with tremendous information about concerned primarily with manipulative skills that are
the glass: how far the glass is from him, where the glass executed to achieve an action goal (e.g., feeding,
is placed on the table with reference to his body, the object manipulation, writing).
shape of the glass, how much water is in the glass, the
consistency and estimated weight of the glass. The WHAT IS THE OVERALL FRAMEWORK FOR
responses to these questions constitute processes called
perception and representation. In addition to these
U NDERSTANDING MOVEMENTS?
perceptual processes, the association of visual input Movements are one of the primary means by which
from the glass with symbols about objects provides humans interact with the environment and act on the
information that is stored as object knowledge, useful environment. Thus an understanding of movement has
for identification and classification. This information is to take into consideration an understanding of the
stored in memory, which can be retrieved at any time. nature of the environment in which movements take
Furthermore, the size and apparent weight of the glass place. Shumway-Cook and Woollacott (2001) have
determine whether Jimmy picks up the glass with one suggested that movement emerges through an inter-
or two hands. Such decision making is based on action of the performer (including biomechanical con-
memory of prior interactions with objects. straints of our musculoskeletal system), the task (which
Once Jimmy grasps the glass, his visual and haptic can range from body stability to manipulation), and the
(tactile) processes provide his system with information environment. According to Gentile (2000), the struc-
about the weight of the glass and how the movement ture of a task determines the demands placed on the
of bringing the glass to his mouth displaces the water performer. Given that different tasks pose different
in the glass. As Jimmy repeats the process of grasping challenges for the performer, it is imperative to begin
glasses of various sizes, shapes, and weights, and with an understanding of tasks. Gentile proposed an
transporting the glass toward his mouth on different analysis of tasks that categorized tasks based on their
occasions, his nervous system internalizes rules about functional role and the environmental context (Gentile,
how his movement affects the liquid in the glass 1972). Based on the functional role, tasks can either
through a process of trial and error. This process is specify body orientation (which includes body stability
called learning and is an essential cognitive skill that and body mobility) or manipulation of objects. With
enables Jimmy not only to retain the knowledge of how reference to environmental context, tasks can be
to grasp and lift a given glass, but also generalizes categorized as those that are performed in closed
(transfers) this skill to enable successful interactions environments, which remain stable from trial to trial, or
with various objects. those that are performed in open environments which
change from trial to trial. On the basis of this classifi-
cation, Gentile proposed a taxonomy of tasks that has
helped us understand tasks and the challenges they
MOTOR SKILLS ARE ADAPTIVE pose, and also as a basis for evaluation and intervention
in clinical practice (Gentile, 1992, 2000).
Motor skills are composed of discrete or sequential
movements that are organized in a precise manner to
achieve a specific action goal. Sugden and Keogh
(1990) described motor skills as “movements that are INTRODUCTION TO COGNITIVE
intentional, goal directed, organized, and adaptive.” CONTRIBUTIONS TO MOTOR
This description highlights a few important aspects of
motor skills that are particularly important for SKILLS
manipulative skills:
1. The intentional nature of movement indicates a The importance of cognition in motor skill acquisition
process of planning, which involves cognitive and development is well established. However, the
processes reverse also has been proposed: that perceptual motor
2. The precise nature of movements indicates that activity is a mechanism for cognitive development.
movement execution needs to fulfill constraints of However, the importance of cognition to motor skills
the task, and depends on the theoretical orientation that is used.
Cognition and Motor Skills • 103
Some of the major theoretical orientations in the The emerging approach in motor development is
literature are the Piagetian approach (Piaget, 1952), one that developed out of the information processing
the behaviorism approach of Skinner (1953), the eco- theories and current theories in motor control. Much
logical approach of Gibson (1979) and more recently, of this approach was influenced by Bernstein, a Russian
the information processing approach that has been physiologist, who proposed that movements emerge
reformulated within the relatively new discipline of through the interaction among the performer, the
cognitive neuroscience (Gentile, 2000; Thelen, 1995). impact of movements made by the performer, and the
Each of these approaches is discussed briefly. For the environment (Bernstein, 1967). Within motor devel-
purpose of this chapter, the cognitive neuroscience opment, the application of this approach was pioneered
approach is used. by Esther Thelen (1995). In this approach, movements
Piaget considered that motor activity was necessary are proposed to emerge through the cooperative
to the development of knowledge about the environ- interaction of many body parts and the environment,
ment. Knowledge development was believed to be a rather than from a one-to-one mapping between neural
function of the interaction between neural structures structures and movements. Because movements are
and the environment. According to Piaget, cognitive slightly different from trial to trial (even when the same
functions develop through knowledge gained as a result muscles are activated), Bernstein proposed that actions
of action, which early in development is based on were planned at a more abstract level. This is par-
innate reflexes (Piaget, 1952). Based on this approach ticularly true because it is impossible for the nervous
Piaget proposed a stage-like developmental process in system to program all the force-related contextual
which new skills are learned based on skills previously interactions ahead of time. Thelen (1995) argued that
learned in development. For Piaget, infant motor cognition and motor skills emerge from a dynamic
activity played a major role in cognitive development. process in which the performer learns the match among
Object manipulation was believed to be critical for the herself, her movements, and the environment and how
child’s learning about object properties. The manip- the various component parts are coordinated to pro-
ulation of objects is important as a way of facilitating duce skillful movement. Thus early in the development
mental activity, which is believed to be the key for of a skill, a high degree of variability is seen in the
learning object characteristics. Overall, in this approach, behavior. Rather than seen as an undesired outcome,
cognitive-neural development is thought to play an variability is seen as functional, and is exploited in
important role in development of skills, whereas factors the generation of solutions. With development, the
outside the performer (i.e., the environment) are not macrostructure of the movement (the visible motor
emphasized. output) becomes less variable and more stable, but this
This is in stark contrast with the behavioral approach, stability arises as a result of maintaining variability at a
pioneered by Skinner and his colleagues, which em- microstructural level, which refers to the forces gen-
phasized the role of reinforcement from the environ- erated and the patterns of muscular contraction
ment as a primary driving factor in development (Manoel Ede & Connolly, 1995).
(Skinner, 1953). Development, according to this With this framework in mind, we explore the dif-
framework, occurs through the responses of the ferent constituents of cognitive skill and their relation-
performer and the reinforcement she or he receives ship to motor skills. Although an attempt is made to
through the environment. present the most pertinent and current literature on
One approach that differed from these two infants and young children, at some points results from
approaches was proposed by Gibson (1979). In this adult studies are presented when little or no evidence is
approach action is not a precursor to perception. Rather, available from the developmental literature.
perceptual information is actively sought through coor-
dinated systems of action, some of which are already
functioning in this capacity at birth. This approach COGNITIVE PROCESSES IN
proposed that most of the information needed for the
control of motor skills was contained in the flow of MOTOR SKILLS
sensory afference (visual or haptic). Development was
thought to be a process whereby the performer learns In this section, we discuss a few important components
not so much to improve his or her movement skill per of cognition critical to the successful generation of
se, but to learn to use the information contained in the motor skills. Attention, perception, concept formation,
sensory flow. Although this approach explained some memory, and learning are briefly discussed. Although
of the behaviors seen during development, it did not each component is discussed separately for clarity, one
highlight the role of neural structures in the devel- should understand that in the development of motor
opmental process. skills, many of these components interact with each
other and may assume differential importance depend- time spent on novel stimuli may be influenced by the
ing on the demands of the task. arousal properties of the object.
Although infants have some capability in orienting
to stimuli, as shown in the preceding paragraphs, their
ATTENTION ability to devote attention resources to actively search
Attention is a fundamental aspect of all human activity. for objects of interest does not develop until early school
We are able to perceive stimuli and act on them better years (Cohen, 1981). Similarly, the skill of paying
when we attend to the stimulus of interest and ignore attention to stimuli that has already been experienced
extraneous stimuli. Our sensory systems receive a develops during the early school years. This phenom-
tremendous amount of information. If we did not have enon, known as priming, refers to the fact that we are
a mechanism to filter unwanted stimuli, we would able to better attend to stimuli that has been presented
encounter sensory overload. At any given moment, we before, even if for a short period of time. Priming also
are aware of only a few stimuli that are functionally explains how certain stimuli are recalled easily because
important to the task at hand, and our awareness is of prior exposure (Plude et al., 1994).
limited by our capacity for processing information. To summarize, attention is a fundamental aspect of
Thus functional attention is selective by definition. cognitive skills that is related to perception and
Attention can be defined by examining its con- memory. When we consciously attend to a sensory
stituent parts of arousal, capacity, and selectivity (Plude, stimulus, our perception is matched to information
Enns, & Brodeur, 1994). Arousal refers to the momen- stored in our memory (priming or recognition). Atten-
tary level of excitation in the information processing tion is an active process in which certain stimuli in the
system that helps tune our cognitive systems to environment are given preference over others depend-
optimally receive information. Capacity refers to the ing on their perceived importance to the demands of
actual capacity of our information processing system. It the task being performed.
is generally accepted that humans can process a certain
amount of information at any given moment. Finally,
selectivity refers to the ability of the system to allocate
PERCEPTION
resources so as to focus on certain stimuli and not Perceptual processes constitute an important part of
others. cognitive contributions to motor skills. Perception can
Selective attention is a multidimensional process, be defined as a process of collecting information from
involving components of orienting, filtering, searching the environment based on vision, touch, hearing, and
and expecting (Plude et al., 1994). From an early age, muscle and joint proprioceptors to construct an
infants show preference for orienting their vision to internal representation of space and the body (Kandel,
attend to certain stimuli while ignoring others (Maurer 2000). Thus our perception is created through an
& Lewis, 1991). In fact, neonates spend more time active process of searching for and attending to stimuli
attending to their mothers’ face than the faces of based on our sensory organs. All pertinent information
strangers, even when other sensory cues, such as smell is then used in the construction of an internal
and auditory cues, are excluded (Bushnell, Sai, & representation.
Mullin, 1989). The orienting response is variable and Historically, perception was thought to emerge from
not developed early in life, presumably because the a developmental process as infants and young children
neural structures that control such behavior (e.g., the developed their repertoire of sensorimotor behaviors
superior colliculus) are not fully developed. Neverthe- (Piaget, 1952). The current view, however, challenges
less, the evidence suggests that infants demonstrate this notion and proposes that different sensory inputs
beginning capabilities for selective orientation to converge into a unified representation that precedes
preferred stimuli. thought and action (Marr, 1982). The emerging
Another aspect of selective attention is that infants framework from the cognitive neurosciences proposes
show a preference for novel stimuli rather than stimuli that there may be at least two independent and parallel
that have been present in the environment. Most of us perceptual processes: one that is used in the recog-
have observed infants paying more attention to new nition of objects and the other used for the guidance of
faces in comparison with familiar faces. This phenom- movements (Goodale et al., 1994). Thus visual infor-
enon is known as habituation and refers to the decrease mation about an object in the environment is processed
in the amount of visual attention (time spent on a by separate neural pathways and used for different
stimulus) devoted to more familiar stimuli (Bertenthal, purposes (Bertenthal, 1996; Goodale & Westwood,
1996; Ruff, 1986). Ruff found that the amount of time 2004). The system for the identification of objects, also
spent in examining novel stimuli decreases as the infant called the ventral stream, is proposed to project from
becomes familiar with an object and suggests that the the visual cortex to the temporal lobe. The system for
action, also called the dorsal stream, is proposed to the stimulus. In contrast, the system that deals with
project from the visual areas to the posterior parietal guidance of movement processes information sub-
cortex. Although most of the evidence for this proposal consciously. We are not conscious about processing
comes from neurophysiological studies from non- sensory information when manipulating objects. Per-
human primates, neuropsychological studies in humans haps the best evidence for this dissociation comes from
with focal cortical lesions, and imaging studies in adults studies of patients with brain lesions who are unable to
(Goodale & Westwood, 2004), some authors have perform conscious processing necessary in identifica-
proposed that such a dissociation may be present tion of objects but nevertheless are able to reach out
during development (Johnson, 1990). and grasp them (Goodale et al., 1991). For instance,
There are fundamental differences in these two patients with lesions of the ventral stream (pathways
subsystems that support the notion that they operate from the primary visual cortex to the temporal lobe
independently. First, the system for the guidance of structures) are unable to identify objects but are able to
movement is proposed to work in a prospective manner reach out and grasp objects with problems. Patients
because actions are directed toward information with lesions of the dorsal stream (the posterior parietal
present at the time. Von Hofsten has argued that cortex) show the opposite deficit: They are able to
actions occur through dynamic interactions between identify objects but are unable to reach out and grasp
an organism and the environment that occur in a them (Goodale & Westwood, 2004).
future-oriented manner (von Hofsten, 1993, 2004). Thus converging evidence from animal studies and
For example, in reaching for objects, infants begin to human lesion studies suggest that information for
crudely adjust the orientation of their hand to match perception and action are processed independently.
the orientation of the object even before grasping the The system involved in perception perhaps develops
object of interest (von Hofsten & Fazel-Zandy, 1984). later as it involves conscious processing of knowledge
Such adjustments are made in an anticipatory (pro- from memory, skills that develop as a child learns
spective) manner to maximize success at reaching language.
objects. This is in contrast with the system that is used
for object identification in which the information is Perceptual-Motor Processes
retrieved from a representation that is stored in We must perceive in order to move, but we must also
memory (Goodale et al., 1991, Goodale et al., 1994). move in order to perceive.
Second, the difference between these systems per- (Gibson, 1979)
tains to the manner in which the information is struc-
tured in the brain. All sensory information is structured This statement, from one of the most influential
and represented in a format of coordinates called a psychologists in the area of perception, highlights the
coordinate system. Although the information used for reciprocal relationship between perception and action.
perception and identification of objects is structured in According to Gibson (1979) perceptual systems have
a coordinate system centered on the environment (or adapted to use information pertinent to actions that
world centered), information that is used for the guid- are readily available in the environment. For instance,
ance of movement is structured in body coordinates perceptual-motor systems use visual information avail-
(Goodale & Westwood, 2004). This is because percep- able in the optic array, haptic information from hands
tion of objects requires that the observer be able to as they explore objects, and proprioceptive information
identify object features correctly independent of his or available from muscles and joints. Although move-
her position vis-à-vis the object. In contrast, sensory ments are adapted in response to perceptual processes,
information used for guidance of movement is structured the reverse is true as well. Such reciprocity was shown
in body centered coordinates (Soechting & Flanders, in a study that tested crawling infants and recently
1992). This is because sensory information used for walking infants on their locomotion on two different
movement ultimately has to be converted into patterns surfaces; a rigid and a pliable surface. Although crawling
of muscle activation that will move the arm to the infants did not differentiate between these two sur-
desired object. Because specification of movement faces, recently walking infants changed their mode of
parameters ultimately has to match egocentric coordi- locomotion depending on the surface. They crawled on
nates of muscle action, it seems likely that such infor- the pliable surface and walked on the rigid one (Gibson
mation is stored in body-centered coordinates. et al., 1987). More recently, it was shown that recently
Third, these two systems also differ in terms of the walking infants adopt a more stable posture (sitting) as
nature of conscious processing involved. The system they negotiate a surface with a downward incline,
that deals with object perception and identification whereas crawling infants did not adapt their posture
processes visual information in a conscious manner (Adolph, Eppler, & Gibson, 1993). These studies show
because the observer is required to actively attend to that perception (e.g., perceived stability of surface)
influences action and action in turn influences percep- rather than simply because of neuromaturational
tion (e.g., newly walking infants differentiating among factors.
surfaces).
Contrary to the proposals of early models of
perceptual-motor development (Piaget, 1952), goal-
CONCEPT FORMATION (KNOWLEDGE)
directed behavior is observed very early in develop- Concept formation refers to a higher-order mental
ment. Infants as young as 3 weeks old have been process that acts on information that has been per-
observed to reach out and grasp stationary and moving ceived through our sensory organs and encoded and
objects (von Hofsten, 1982). Neonates actively control stored in memory. This process includes organization
their gaze and look at faces that engage them in a of the information into conceptual categories and the
mutual gaze (Farroni et al., 2002), and visually track use of such knowledge in reasoning, problem solving,
moving objects within their first month (Bloch & goal selection, and planning. Through the process of
Carchon, 1992). Von Hofsten (1993) argues that behav- categorization, infants and young children begin to
iors that are explored in the womb (e.g., hand-to- form concepts about objects, people, and actions. For
mouth behavior) may demonstrate an advantage after instance, early in development, infants learn to
birth. The evidence described in this section highlights categorize faces as familiar and unfamiliar. As discussed
that infants are capable of goal-directed movements in an earlier section, infants are seen to spend more
based on visual information available in the environ- time attending to faces that are familiar, such as the
ment (e.g., from a moving object). Although this mother (Bushnell et al., 1989). This indicates that
behavior is highly variable from trial to trial, and fragile infants have already begun to categorize faces according
(it is not observed consistently), the existence of such to their perceived familiarity.
control provides evidence that our perceptual systems Concepts (e.g., faces and objects) are units of mental
are tuned to act on visual and haptic information from representation that assign certain perceptual features to
a very early age. According to Thelen (Thelen, 1995; specific conceptual categories. Early in development,
Thelen & Corbetta, 1994), behavior is highly variable we learn to differentiate between living and nonliving
when first expressed and is gradually adapted as a result objects, based on our ability to generate selfmotion.
of a dynamic process of selection of the most appro- This process becomes more complex as we learn to
priate coordinative structures that are specific to the differentiate subcategories within these categories of
contextual demands of the task. living and nonliving objects. Knowledge organized into
The contextual nature of perceptual-motor behavior, such categories is encoded and stored in long-term
in part, is dependent on the fact that motor skills are memory and retrieved during action.
not simply influenced by perceptual processes but also Key elements of concept formation are the processes
by biomechanical and physiologic factors. For example, of grouping and differentiation. Grouping involves the
although infants are able to reach for moving targets at clustering of information into larger units, a process
the age of 3 weeks, such behavior is contingent on the known as “chunking” (Gentile, 2000). Chunking helps
stability of their head (von Hofsten, 1982). When the system function more efficiently because the
the head is not stabilized, goal-directed reaching is not performer has to attend to groups of information
observed. In a now classic example of the contextual rather than each piece of information separately. The
nature of perceptual-motor behavior, Thelen and col- benefits of chunking perhaps can be seen best through
leagues described the case of the “disappearing reflex” an example: Consider a child walking through his
(Thelen, 1995; Thelen, Fisher, & Ridley-Johnson, classroom to his teacher. In performing this task, he
1984). Infants are known to demonstrate a stepping encounters numerous toys strewn across the floor, fur-
reflex when held upright with their feet on a supporting niture placed all over the room and a few peers running
surface. Within a few months, this “reflex” pattern around in the classroom. The process of chunking
of movements is not seen. The traditional explanation allows the grouping of all stimuli into stationary and
for the disappearance of this reflex was that the matur- moving objects; this way the child can perceive the
ing nervous system inhibited the reflex, a primitive movement of his peers as a unit rather than attend to
behavior. However, at the same time that the reflex dis- the movement of each child individually. Grouping
appears, infants also demonstrate an increase in their reduces the attention demands of the task and allows
body mass. When such infants were held upright par- the child to allocate his attention to additional stimuli
tially submerged in water with their feet in contact with (furniture) that are important.
a surface, the stepping reflex re-emerged, indicating Differentiation, on the other hand, refers to the
that the reflex “disappeared” primarily because of process through which performers perceive more detail
increased weight and a biomechanically demanding in an array of stimuli as they become more familiar with
posture (Thelen et al., 1982; Thelen & Fisher, 1982) it. To use the example cited in the preceding paragraph,
as the child begins to learn to walk, he will likely not so that it can be manipulated during functional tasks.
perceive the subtle differences in the speed of move- According to Baddeley (2003), working memory is a
ment of the moving objects in the environment. With limited capacity system that supports thought processes
experience, he will learn to distinguish between stimuli by providing an interface among perception, long-term
related to other children either walking or running. memory, and action. Working memory is proposed to
Development of concepts and knowledge is extremely consist of at least three components: a central execu-
useful for understanding the demands of the task and tive, and two storage loops; the phonological loop and
goal completion. Early in the learning of a task, per- the visuospatial sketch pad. The central executive is
formers should learn the relationship between move- proposed to be the attention control system, which
ment and the goal of the movement. Failure to regulates the function of the other two subsidiary
understand the goal of the task can lead to goal con- rehearsal systems. The central executive also serves as a
fusion, which is commonly seen in elderly individuals buffer that holds information temporarily. The phono-
with memory disorders (Gentile, 2000). Specification logical loop contains a phonological store “which can
of the goal of the task has been shown to be critical in hold memory traces for a few seconds before they fade,
improving the quality of movement (determined by and an articulatory rehearsal process that is analogous
kinematic analysis) in unimpaired adults (Lin, Wu, & to sub-vocal speech” (Baddeley, 2003). The phono-
Trombly, 1998; Wu et al., 1998) and individuals logical loop has a limited capacity that limits the amount
recovering from a cerebrovascular accident (Wu et al., of information that can be held and manipulated at any
1998). Changing the goal of the task influences the given time. Finally, the visuospatial sketch pad is also a
movement pattern selected. In a classic study limited capacity rehearsal loop and mainly deals with
(Marteniuk et al., 1987) demonstrated that unimpaired spatial information perceived through the visual system
subjects reached for and grasped a disc differently (Baddeley, 1998). The function of the visuospatial loop
depending on whether the goal of the task was to place is to hold and manipulate visual spatial representations,
the disc accurately in a container or to throw the disc. as seen in tasks that require mental rotation of images.
Attention to the goal and knowledge of the relation- Most of the evidence supporting the model of
ship between movement and its outcome (action) are working memory comes from studies in unimpaired
key components of concept formation pertaining to adults and adults with focal cortical lesions. From a
hand skills. developmental perspective, it seems likely that the
In summary, concept formation is a conscious and visuospatial sketch pad develops before the phono-
active process that categorizes sensory information logical loop because the phonological loop is depen-
by associating it with conceptual categories. These dent on language-based processes. Studies on the
categories are stored in long-term memory and development of working memory report age-related
retrieved in response to the demands of the task. As differences in the speed with which words can be
stated earlier in the chapter, such information is articulated and differences in attention span (Hitch &
thought to be processed through ventral neural path- Towse, 1995). These age-related differences appear to
ways projecting from the visual cortex to the temporal result from maturational factors (Cowan et al., 1999).
cortex (Goodale, 1992). The other major classification that pertains to long-
term memory is based on how the information is stored
and recalled. According to this classification, memory
M EMORY can be either explicit (or declarative) or implicit (pro-
Memory is the process by which knowledge is encoded, cedural). Explicit memory is associated with conscious
stored, and retrieved (Milner, Squire, & Kandel, 1998). awareness and the intention to recall information.
The neurobiological pathways responsible for memory This form of memory typically is tested with recall or
are dependent on our sensory perceptual and attention recognition and underlies the memory for objects,
processes (discussed in the preceding sections) that people, and events. Studies with infants have revealed
allow task-related information to be stored. Most models that they can retain memory for objects (as tested by
of memory propose the existence of multiple systems retention) across intervals of 1 to 3 months (Bahrick &
of memory, each devoted to a specific function Pickens, 1995). Based on additional studies, Bahrick
(Willingham, 1997). Memory can be classified in many and colleagues proposed that recent memories are
different ways: One is to classify it according to the expressed as a visual preference for novelty, whereas
time scale of the operation. Thus we distinguish remote memories are expressed as a preference for
between short-term (working) and long-term memory familiarity (Bahrick, Hernandez-Reif, & Pickens,
systems. 1997). However, younger children need greater num-
Working memory is proposed to be a dedicated bers of prompts to recall memories compared with
system that holds information for short periods of time older children.
Explicit memories are further divided into memories term to long-term memory (Milner et al., 1998).
for facts (semantic memory) and events (episodic Despite his devastating deficit in explicit (declarative)
memory). Semantic memory is built up by associating memory, HM could learn new motor skills such as
a stimulus with specific concepts. Thus a visual image of mirror drawing (Milner, Corkin, & Teuber, 1968) or
an elephant associates features of the elephant (e.g., its novel patterns of arm movements (Shadmehr, Brandt,
large size, large ears, tusks, and small tail) with the & Corkin, 1998) comparable to age-matched unim-
conceptual category of “elephant.” This information is paired subjects. Thus patients with temporal lobe
then further associated with additional knowledge lesions are able to learn tasks that do not require con-
about elephants that allows children to close their eyes scious awareness and tasks that are procedural. These
and recall an internal representation of an elephant. studies have helped us understand that explicit and
Semantic memory is thought to be stored in a dis- implicit memories are independent systems, controlled
tributed fashion in the neocortex, including the medial by different areas in the cortex (Milner et al., 1998).
temporal areas that process verbal information and For the developing child, it has been shown that
occipital areas that process visual information. Episodic older children demonstrate an advantage for explicit
memory, on the other hand, is concerned with the memories, whereas there is no specific age-related
temporal ordering of events. In children, this type of difference in the formation of implicit memories. This
memory is built up by associating events with what difference in the development of the two memory sys-
happened during such events (Schneider, 2000). tems may result from the fact that sensory and per-
Explicit memory is processed in four distinct phases. ceptual systems are developed early in life (as discussed
The first phase is called the encoding phase, during in the preceding section), whereas concept formation
which new information is attended to and processed at (which is necessary for development of explicit
first encounter. All pertinent information in the memories) continues to develop until the school years
stimulus must be attended to for memory to be stored (Bertenthal, 1996; Schneider, 2000).
in long-term memory. A second phase is consolidation,
in which the new information is altered from a labile
state to a stable state for long-term storage. Consolida-
tion is a time-dependent process, and any event that SKILL ACQUISITION (LEARNING)
interferes with this process prevents new and labile
information from being converted to long-term Learning is the process by which we acquire knowledge
memory. The third phase is storage, which refers to the about the world and ourselves. Skill can be defined as
mechanism by which memories are retained over time. consistently attaining an action goal with some
Finally, the fourth phase is retrieval, which refers to the economy of effort (Gentile, 2000). Learning of motor
process of recall of memories (Kandel, 2000). skills concerns a set of processes associated with practice
Implicit memory, in contrast with explicit memory, or experience, which leads to a relatively permanent
is concerned with storage and recall of information change in the ability of the performer to produce
without conscious awareness (Milner et al., 1998). This movements (Shumway-Cook & Woollacott, 2001).
kind of memory is also called procedural memory, Box 6-1 highlights a few important concepts.
because it refers to knowledge about “how” a task is Learning is thought to progress in stages. Although
performed, rather than “what” a task is. Implicit memory different models of learning have been proposed, most
does not depend on conscious processing of informa- models agree that different processes operate during
tion, builds slowly over time through repetition, and is the early and late stages of learning. For the purpose of
primarily expressed through performance rather than this chapter, we discuss the two-stage model proposed
through language (Kandel, 2000). Most of the early by Gentile (1992, 1998, 2000).
evidence of the distinction between implicit and explicit According to this model, in the early stages of
memories came from the study of individuals with focal learning, the performer acquires the general concept of
lesions of the medial temporal lobe. In one patient the demands of the task and the movements that are
(HM) most of the medial temporal lobes were removed necessary to successfully achieve the goal. Part of this
secondary to seizures. The surgical lesion left HM with process is to understand and attend to important
a memory deficit of explicit long-term memory, features of the action goal: This enables the performer
particularly for facts and events that occurred after the to focus on the regulatory features in the environment
surgery and also a deficit of events that occurred and ignore the nonregulatory features. According to
immediately before the surgery (retrograde amnesia). Gentile (2000) the action goal concerns the function
Although he had a relatively intact short-term memory, of the task (whether the task requires manipulation or
HM was unable to transfer information from short- requires body orientation or both) and the nature of
BOX 6-1 Descriptions of Learning
1. Learning is a process whereby a child acquires the permanent. This indicates that information acquired
capability for skilled action. through learning is stored in long-term memory, which
2. Learning results from practice or experience, rather typically is retained over long periods of time.
than being simply a function of neuromaturation. 5. Learning is task specific. A pattern of movement that
Perhaps this concept is best highlighted by the fact that produces successful goal-directed interactions may not
infants practice tasks such as reaching (von Hofsten & be sufficient if there are changes in the environment or
Fazel-Zandy, 1984) and locomotion (Adolph, 1997) in the morphology of the performer, as happens
several hundred times in a day over a period of months continuously through development. Thus skill attained
before they become skilled. This extended practice is under certain conditions can be generalized only to
the basis for improvement of skill. other skills that share features with the original skill
3. Learning is a process that cannot be observed directly learned. For instance, once a child learns to reach for
and typically is inferred from changes in behavior. As one stationary object, she or he can adapt this skill and
discussed in the preceding sections, much of the generalize it to successfully reach for stationary objects
evidence on motor development has come from of different shapes and sizes; however, this skill of
detailed longitudinal observational studies in infants reaching for stationary objects does not necessarily
and young children (Adolph, 1997; Thelen, 1995; von generalize to reaching for moving objects because such
Hofsten & Fazel-Zandy, 1984). a task poses different challenges to the system and
4. Learning produces changes that are relatively requires novel solutions.
the environment in which the action is taking place ever, within a relatively short period of time, move-
(whether the environment is stationary or in motion). ments converge to a consistent topology enabling the
Focus on the regulatory features necessitates selec- child to achieve the goal more consistently (Konczak et
tive attention to pertinent stimuli. During this process, al., 1995; von Hofsten et al., 1984).
the performer’s system learns to differentiate the envi- With refinement of the internal model, the abstract
ronment (perceive greater detail in the sensory array) representation of the movement and outcome becomes
and grouping of similar stimuli into chunks, a process independent of the actual environmental and bio-
described earlier. During this phase, the child pays atten- mechanical constraints. For instance, in learning the
tion to the overall structure (shape or configuration) of task of writing, a child acquires an internal model of
the movement. Thus in reaching for an object, a child the task. In this case the movements of the hand (and
is aware of the orientation of her hand as it attempts to the forces applied) that produce the form (or topology)
approximate the orientation of the object for successful of a letter. Once this model is learned, the child can
grasp. Gentile (1992) terms this the topology or shape perform this task not only with the dominant hand, but
structure of the movement. Although the performer is with the nondominant hand as well (although not as
aware of the topology, she or he is not aware of the efficiently because the nondominant hand is not as
internal processes of parameter specification that specify skilled). The fact that we can produce the same action
the timing of the movement components, the forces to using different effectors highlights the importance of
be imparted to the limbs, and so on. During this early an internal model (abstraction) of the task that is
stage, based on the results of the movement, the child independent of the effectors.
receives feedback on the outcome of the movement. Skill is refined during the later stages of learning.
This knowledge is then encoded and stored in memory Performance improves but at a much slower rate than
and helps the child learn the association between in the early stages of learning. In this phase improve-
movement patterns and their outcome. This process ments occur in the efficiency of the movement: The
enables children to repeat successful movements and child is better able to predict the consequences of her
leads to the formation and refinement of internal movement and better able to produce consistent move-
models (or representations) of the task. ments from one trial to the next. According to Gentile
Studies of infants learning to perform goal directed (1998) this phase is characterized by changes that the
reaching have demonstrated evidence for this notion. performer is not aware of. The changes pertain to the
Recording of the movement patterns of infants have parameter specification, and include improvements in
shown that early in learning, arm reaching movements the timing of force generation of the segments involved
are extremely variable and the goal of reaching for and in the movement and the timing and amplitude of
grasping an object is not achieved consistently. How- muscle contractions that ultimately produce the
movements. In addition, movement sequences are ascribed to the relationship between the prefrontal
more efficiently blended together temporally so that cortex (which was thought to control cognitive skills)
each sequence is not discernible from other sequences and the cerebellum (which was thought to be involved
of movement. in movement), both of which are proposed to be involved
The evidence from recording of intersegmental in cognitive and motor skills (Diamond, 2000).
forces and patterns of muscle activation demonstrates Evidence for this proposal comes from imaging
that improvements at this level of the system continues studies during performance of motor or cognitive skills
over a much longer period of time (Konczak, Borutta, and studies with patients with cortical and cerebellar
& Dichgans, 1997). Although the topology of reaching lesions. In terms of learning of motor skills, it has been
movement improves within the first few months, shown that both the prefrontal cortex and cerebellum
improvements in the coordination of forces continue are activated: The activation shifts from the prefrontal
until at least the third year. This underscores the fact cortex to the cerebellum as the task is learned
that consistency in the external features of movements (Shadmehr & Holcomb, 1997). Coactivation of the
(e.g., topology) are contingent on internal features prefrontal cortex and cerebellum also has been seen in
(e.g., coordination of forces and muscle patterns) that working memory tasks (Desmond, Gabrieli, & Glover,
remain variable over a much longer period of time 1998; Smith & Jonides, 1997). According to Diamond
(Manoel Ede & Connolly, 1995). It can be argued that (2000), both the cerebellum and prefrontal cortex are
the variability in the coordination of forces allows the active under certain conditions; when the task is more
system flexibility and generalizability. difficult, novel as opposed to familiar, unpredictable
In summary, learning is thought to progress as opposed to stable, and requires a quick response
through two interdependent and parallel processes. (p. 45). Patients with lesions to the cerebellum demon-
The early phase is characterized by establishment of a strate deficits in a variety of cognitive tasks such as
mapping between the performer and the environment working memory tasks administered through bedside
that, with practice, quickly improves the overall shape neuropsychological tests, set shifting tasks, and visuo-
structure of the movement. The processing of infor- spatial memory tasks (Schmahmann & Sherman 1998).
mation during this phase is explicit in nature and leads These deficits are presumably seen because of the inter-
to the formation of an internal model of the task connections between the prefrontal cortex and the
(Gentile, 1998). Later in learning, movements are refined neocerebellum (Ghez & Thach, 2000).
at a micro level that is not observable in the behavior. Developmental evidence in support of this theory
The processing of this information progresses without has come from studies that have examined motor
conscious awareness on the part of the performer (i.e., problems in children with cognitive problems. Atten-
implicitly). Because the improvements at this stage tion deficit hyperactive disorder (ADHD) is a syndrome
concern coordination of the details of intersegmental in which children demonstrate cognitive deficits,
forces, the later stage of learning is extended over a including a short attention span. It is interesting to
longer period of time (Gentile, 2000). note that along with deficits in cognition, many
children with ADHD demonstrate motor deficits as
well (Kadesjo & Gillberg, 1998). This may be related
to a decreased size of the cerebellum in children
EPILOGUE: RELATIONSHIP with ADHD compared with unimpaired children
BETWEEN COGNITIVE AND (Castellanos, 1997). Similar motor deficits are also
reported in children with dyslexia. In one study, it was
MOTOR DEVELOPMENT reported that children with dyslexia have problems
with motor tasks that require control of the timing of
Historically, motor development and cognitive devel- movements, such as tapping a rhythm (Geuze &
opment have been studied separately and viewed as Kalverboer, 1994). Because timing of movements is a
somewhat independent of each other. It was also a function attributed to the cerebellum (Ghez & Thach,
widely held belief that cognitive development occurred 2000; Keele & Ivry, 1990), and given the connections
over a longer period of time compared with motor between the cerebellum and prefrontal cortex, it is not
development. It is now apparent that motor skills, surprising that children with dyslexia demonstrate motor
particularly complex skills such as bimanual control and deficits. Children with autism also show deficits in motor
some visuomotor skills, continue to develop until tasks, particularly in the execution of goal-directed
adolescence. A recent development in the under- movements (Hughes, 1996). Although the motor deficit
standing of the relationship between cognitive and in all these disorders is not the most significant, the
motor development proposes that they are in fact existence of these motor disorders highlights the close
highly interrelated. This relationship is primarily relationship between cognitive and motor skills.
the challenge ahead will be to develop creative thera-

SUMMARY peutic solutions that enhance skill acquisition.
In this chapter we have described motor skills as goal

oriented and made up of movements that are organized
to solve the spatial and temporal challenges presented
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Chapter 7
HAND SKILL DEVELOPMENT IN THE
CONTEXT OF INFANTS’ PLAY:
BIRTH TO 2 YEARS
Jane Case-Smith
CHAPTER OUTLINE The development of prehension and bimanual

coordination is essential to an infant’s ability to play
and explore. As hand skills mature, the infant becomes
DEVELOPMENTAL THEORIES AND CONCEPTS increasingly competent in exploring and playing with
A Neuromaturation Model objects. The young infant’s rudimentary grasp and
Individual Patterns in Hand Skill Development release patterns become precise patterns during the first
years of life. The purpose of this chapter is to describe
Hand Skills Emerge Through the Interaction of the infant’s development of grasp, release, and bi-
Systems manual skills in the context of exploratory and func-
Perception as a Primary Influence on Hand Skill tional play. The first section describes developmental
Development theories and concepts helpful to understanding the
Development of Hand Skills for Functional development of hand skills. The second and third
Outcomes sections describe how contexts, posture, and sensory
function influence hand skill development The fourth
CONTEXTS FOR HAND SKILL DEVELOPMENT section describes the play activities and specific hand
SYSTEMS THAT CONTRIBUTE TO THE skills that characterize the sequential stages of infant
DEVELOPMENT OF HAND SKILLS development, birth to 2 years.
Posture
Sensory Systems
DEVELOPMENT OF HAND SKILLS IN THE CONTEXT
DEVELOPMENTAL THEORIES AND
OF INFANT PLAY ACTIVITIES CONCEPTS
Play Activities: Birth to 12 Months
Prehension: Birth to 12 Months A N EUROMATURATION MODEL
Object Release: Birth to 12 Months Early theories of motor development (Gesell, 1928;
Bimanual Skills: Birth to 12 Months Halverson, 1931, 1937; Shirley, 1931) emphasized the
importance of central nervous system control over
Play Activities: 12 to 24 Months motor performance. Gesell documented an orderly
Prehension: 12 to 24 Months sequence of motor development, stage by stage, that
Object Release: 12 to 24 Months could be observed in every typically developing child.
The theory that maturation of skill and behavior resulted
Bimanual Skills: 12 to 24 Months from the maturation of the central nervous system
SUMMARY dominated understanding of motor development in the
117
118 Part II • Development of Hand Skills
1930s and 1940s. Based on neuronal maturation, grasp pellet). His study documented whole hand closure at
and manipulation patterns develop in an orderly and 5 months, palmar grasp at 8 months, scissors grasp at
relatively invariant sequence. The sequence of reaching 9 months, and pincer grasp at 12 months.
and grasping patterns identified in the 1930s by Gesell
and Halverson continues to be referenced in develop- I NDIVIDUAL PATTERNS OF HAND SKILL
mental motor tests in use today (Bayley Scales of Infant
Development) (Bayley, 1993).
DEVELOPMENT
The neuromaturation theory—that motor develop- The design of these early studies of hand skill develop-
ment reflects central nervous system maturation— ment was cross-sectional; and therefore identified what
emphasizes that early movements are involuntary patterns infants demonstrate at specific ages, but not
reflexes under the influence of subcortical brainstem how infants develop these skills. The purpose of the first
structures (Andre-Thomas, 1964; Gilfoyle, Grady, & developmental studies was to document typical
Moore, 1990; McGraw, 1943). Neonates’ reflexive development, without realizing that infants’ individual
behaviors are automatic reactions to sensory stimula- differences might be more interesting and of equal
tion that result in neonates experiencing arm and hand importance to examine. To learn how infants develop
movements over which they later gain control. Reflexes and how developmental patterns differ among individual
provide young infants with survival capabilities (e.g., infants requires longitudinal designs in which per-
sucking and rooting) and protective responses (e.g., formance patterns are observed over time.
avoiding response). Reflexes allow infants to experience In assuming a hierarchy of central nervous matura-
a complete range of movement and tactile proprioception, the results in an invariant sequence of motor skills
tive input. Reflexes and reactions are modified through development and neuromaturational theory limited
interactions with the environment as infants assimilate the thinking about how a child learns to act on the
the sensory feedback from reflexive movements (Gilfoyle environment. Current research models (Gibson &
et al., 1990). In the first 6 months they become integrated Walker, 1984; Smith & Thelen, 2003; Thelen et al.,
into acquired or voluntary behaviors. 1993) reveal that infants follow a general sequence of
McGraw (1943) describes a typical progression of motor milestones, but how they achieve skills is quite
maturation: (a) dominant reflexive responses, (b) inhi- individual and infants’ developmental trajectories
bition of reflexes, (c) transitional behaviors, and (d) follow individual pathways. Beginning with Piaget
voluntary motor pattern and skill. This typical sequence (1952), researchers have demonstrated that children
varies in the timing of onset and completion of each acquire skills through an interaction of their experience
phase but appears to be remarkably invariant in the and their innate abilities. The influence of the
ordering of developmental motor patterns. When environment on learning and development has become
cortical control begins to dominate over subcortical an emphasis of child development research. Behavior
control of hand movement, voluntary grasp emerges. patterns are assumed to emerge from an organism–
Transitional behaviors mark the period when reflexes environment coaction (Gottlieb, 1992).
are inhibited and voluntary controlled movements begin This line of reasoning brought new understanding as
to develop (Twitchell, 1970). By 4 months the infant to how coordinated movements develop, emphasizing
grasps a visually located object. the importance of sensory experience and feedback
A series of studies were completed from 1925 to through the hand’s surfaces (Bushnell & Boudreau,
1940 to examine the neuromaturation model. These 1993; Newell & MacDonald, 1997; Rochat, 1987;
descriptive studies documented the unfolding of Ruff, 1984). For example, the first grasping patterns
grasping patterns in the first year of life (Castner, 1932; of neonates are driven by sensory input to the palmar
Halverson, 1931, 1932, 1937; Jones, 1926). Each surface. Throughout the first year infants’ actions
researcher investigated specific aspects of prehension directly relate to sensory experiences, and movements
development. Jones (1926) was interested in when are adapted based on sensory feedback. Grasp and hold
infants begin to use their thumbs, recognizing the im- patterns, which are first associated with proprioceptive-
portance of thumb movement to effective prehension. tactile input, become grasp and manipulate patterns
He found thumb opposition to be present in all infants guided by tactile, proprioceptive, and visual input
by 9 months. Halverson examined visual control of (Bushnell, 1985; McCall, 1974).
prehension, approach or reach, and grasping patterns.
He documented the emergence of visual attention and HAND SKILLS E MERGE THROUGH THE
visually guided grasp. Halverson reported active thumb
movement by 7 months and the beginning of fingertip
I NTERACTION OF SYSTEMS
grasp by 9 months. Castner (1932) was primarily Recent research of hand skill development (e.g.,
interested in precision grasp of small objects (i.e., a Bushnell & Boudreau, 1991; Newell & MacDonald,
Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 119
1997; Thelen et al., 1993) has explored how infants’ Gibson (1988) defines early action as both exploratory
actions and performance emerge from the interaction (seeking information) and consequential (causing a
of many systems, both internal and external to the consequence). The infant’s actions are based on
child. Factors that influence hand skills include the affordances of the environment. Affordance defines the
infant’s size, growth, biomechanical attributes, neuro- fit between the child and her environment (Gibson,
logical maturation, perceptual abilities, sensation, and 1979, Gibson, 1988). The environment and objects in
cognition (Gordon & Forssberg, 1997; Manoel & it offer infants opportunities to explore and act. The
Connolly, 1998; Thelen, 1995; Thelen, Kelso, & infant’s performance is based on not only what the
Fogel, 1987). Within individual infants, these factors environment affords, but also her perceptual capability
vary with time, activity, and environmental conditions. to recognize those affordances. For example, most
An infant’s actions during the performance of a task, infant toys provide opportunities for manipulation
then, are the results of the subsystems (e.g., motor, because they have movable parts, rounded surfaces, and
sensory, perceptual, skeletal, psychologic) interacting easily fit into an infant’s hand. Individual finger move-
with each other and the environment. These individual ments, thumb opposition, hand-to-hand transfer, and
systems are interdependent and work together, such eye–hand coordination are facilitated by the infant’s
that strengths in one system (e.g., visual) can support perception of the physical characteristics of the toy and
limitations in another (e.g., kinesthetic). Which systems his desire to explore those perceptual qualities. Case-
are recruited for the tasks varies according to the Smith, Bigsby, and Clutter (1998) found that toys with
novelty of the activity and the degree to which the task movable parts afford higher-level skills than a cube or
has become automatic. For example, reaching to pick pellet. The movable parts provide a variety of surfaces
up a cup initially is guided by the visual system, but for the infant to explore. The toy’s reciprocal action
after it is practiced and learned, reaching is guided gives feedback to finger movements and sustains the
primarily by the kinesthetic system, with some direction infant’s attention. The perceptual-motor experience of
by the visual system. In contrast, grasping appears to a toy with movable parts is much more interesting than
initially involve primarily somatosensory input, but that of a cube (Figure 7-1).
later also is guided by vision. Early grasping and The first actions of the infant directly relate to his
manipulation patterns that are guided by visual and interest in acquiring perceptual and sensory infor-
somatosensory input (e.g., play with a rattle) are later mation (infants first explore objects with their eyes and
guided by cognition and memory (e.g., handwriting). then hands). Through object manipulation, infants
The infant’s sensory–motor–biomechanical systems develop haptic perception (i.e., an understanding of
self organize in a coordinated way to achieve the objects’ shape, texture, and mass). Specific motor skills
infant’s goal. For example, when an infant reaches for are necessary to develop haptic perception. Researchers
the toy, grasps it, brings it to midline in hand-to-hand (e.g., Bushnell & Boudreau, 1993; Lederman &
play, and then to the mouth, his attention is not on
planning each of these actions. Instead, the infant is
focused on assimilating the toy’s actions and perceptual
features, organizing his or her movement around that
goal. Therefore developmental outcomes reflect both
an infant’s self organization and the opportunities in
the environment.
PERCEPTION AS A PRIMARY I NFLUENCE ON

HAND SKILL DEVELOPMENT
A first influence on the young infant’s action and
movement is sensation. Through vision and touch the
infant is motivated to explore his environment and
objects within the environment. The infant’s percep-
tion of his environment informs action and then his
action provides feedback about performance. Initially
the infant’s goal is to explore the sensory attributes of
objects (e.g., learn their shape, texture, and consis-
tency) (Bushnell & Boudreau, 1993). Soon the infant Figure 7-1 Movements are guided by object
also learns that his actions cause environmental affordances. Toys with movable parts elicit a variety of
consequences (e.g., shaking a toy makes a noise). grasping patterns.
Klatzky, 1987) have demonstrated that young infants

BOX 7-1 Three Stages of Learning to
develop the hand skills that are necessary to explore an
Acquire a New Skill
object’s sensory qualities. For example, infants’ first
hand skills enable them to squeeze soft objects, run their
fingers back and forth over textured objects, rotate, 1. Exploratory activity
turn, and transfer objects with interesting shapes. Learn about objects and tasks
A variety of patterns and approaches tried
Bushnell and Boudreau (1993) noted that infants learn
Lower levels of skills used
to identify an object’s sensory qualities (e.g., texture, Focus on perceptual learning about the tasks to gain
consistency, contour) only when they develop the information
motor skills to explore each different sensory quality. 2. Perceptual learning and feedback acquired from
Therefore an infant does not accurately discriminate previous tasks performed
texture until she can explore texture by moving her Actions initially tried and ineffective are discarded
fingers back and forth. She also cannot discriminate Continue to gain perceptual knowledge about the
task
hardness until 6 months when she can tighten and
Performance is variable, demonstrating higher and
lessen her grip while holding an object (Bushnell & lower levels of skill
Boudreau, 1991). Because configurable shape requires 3. Discovery of the “optimal solution” by selecting the
that two hands are involved in exploring the object’s action pattern that will best achieve the goal
surfaces, infants typically cannot accurately perceive Pattern selected is comfortable, efficient, and
shape until 12 months. indicates increased self-organization
Demonstrates flexible consistency in performance
Tends to use a stable pattern for a task (e.g., stack
DEVELOPMENT OF HAND SKILLS FOR blocks), but can easily adapt the pattern
FUNCTIONAL OUTCOMES according to task’s requirement (e.g., with
larger blocks, heavier blocks)
Once infants learn to discern the perceptual qualities of High adaptability characterizes well-learned tasks
objects, they become interested in mastering objects Mature movement patterns are characterized by
for functional purposes. Through their exploration of adaptable stability
objects and the environment, infants realize that they Synergist movements (muscles and joints working
together) are softly assembled around the goal
have an effect on the environment and their actions
of the task
can produce functional outcomes. The outcomes that Specific movement patterns are observed (e.g., a
motivate an infant may be social (e.g., mother’s smile) tripod grasp)
or physical (e.g., a toy moves, makes a sound, falls Generalizes movement patterns to other tasks when
over). Functional tasks and outcomes begin to organize well learned for one task
the infant’s action (Gibson, 1988). Their actions are
intentional and goal driven (Manoel & Connolly,
1998). With this interest in functional outcomes, the objects and tasks. Most skill acquisition begins with
infant first attempts to use tools and relate objects to exploration, when a variety of patterns and approaches
each other (Lockman, 2000). By the end of the first are tried. New challenges tend to elicit lower levels of
year, infants handle and manipulate objects according skills because these more basic skills can be accessed
to their functional purpose, and the goal of accom- easily and require less energy and effort than higher-
plishing a task guides the interaction (Connolly & level skills (Gilfoyle et al., 1990). By using lower-level
Dalgleish, 1989). One-year-old infants begin to use a skills to explore a new task, the child can focus on
spoon and a cup to self feed. Infants at 14 months can perceptual learning about the tasks to gain information
relate one object to another and use simple tools to that will allow mastery with experience.
achieve a goal. By 2 years they learn to hold a comb, a In the second phase of learning a task, the infant
brush, and a marker and crudely apply them in appro- uses the perceptual learning and feedback he acquired
priate tasks (Lockman, 2000; McCarty, Clifton, & from attempting to perform the task. Actions that were
Collard, 2001). initially tried and were ineffective are discarded. During
this phase, the infant continues to gain perceptual
How Are Functional Hand Skills Learned? knowledge about the task. Learning potential is high
Infants generally go through three stages of learning to when the task is perceptually interesting and the skill
acquire a new skill (Box 7-1) (Gibson, 1988; Manoel & demands are within the capability of the infant. At this
Connolly, 1998). The first stage involves exploratory transitional phase, the infant’s performance is variable
activity. As noted in the previous section, the first year in that he demonstrates higher and lower levels of skill.
of life is primarily a period of sensory motor explora- For example, Connolly and Dalgleish (1989) found
tion. Through exploration, an infant learns about considerable variability when infants first attempted to
use a spoon. McCarty, Clifton and Collard (1999) makeup and after birth provide his learning environ-
noted that the transitional stage for spoon feeding is ment. Children develop skills through participation in
between 14 and 19 months with an “optimal solution” their family’s and community’s cultural practices.
emerging by 19 months. Cultural practices are the routine activities common to
In the third phase of learning, an infant discovers the a community or people and reflect how they play,
“optimal solution” by selecting the action pattern that recreate, and interact in social occasions.
will best achieve the goal. The pattern selected is The infant’s cultural, social, and physical contexts
comfortable and efficient and indicates increased self- expand greatly through the first 2 years of life. The
organization. During this last stage of learning, the widening context affords the infant an increasing
child demonstrates flexible consistency in performance. variety of experiences, challenges, and opportunities. In
The infant tends to use a stable pattern for a task (e.g., most cultures, the first 6 months of life are charac-
stack blocks), but can easily adapt the pattern according terized by closeness to the caregiver. Often children are
to the task’s requirement (e.g., with larger blocks, held and when they are positioned for play, they are
heavier blocks). High adaptability characterizes a well- immobile for all practical purposes. The infant is quite
learned task and mature movement patterns are charac- dependent at this point in life, not only to have his
terized by adaptable stability (Gordon & Forssberg, basic needs met, but to bring play objects within reach.
1997; Thelen, 1995; Thelen et al., 1987). Synergistic In cultures with high interdependence and strong
movements (muscles and joints working together) are appreciation of extended family, the infant may be con-
softly assembled around the goal of the task, allowing tinually held by a variety of family caregivers beyond
the infant to adapt the pattern he has learned when the parents. Hand skills may be practiced on the care-
task variables change. Specific movement patterns are giver’s lap by reaching for and grasping hair, jewelry, or
observed in most children, such as a tripod grasp; once clothing items. First reach and grasp may be practiced
a tripod grasp is well learned, it is easily adapted to pens on the mother’s breast.
and pencils of different sizes and weights. When move- A family’s culture background influences the objects
ment patterns are well learned for one task and are made available to the infant. In some cultures, toys are
performed with flexible adaptability, the infant also not valued or not available; as a result, young infants do
generalizes them to other tasks. McCarty and co- not experience these learning objects.
workers (2001) demonstrated that infants who learned The contexts for play expand for infants after they
to hold a spoon with a radial grasp consistently gain mobility (e.g., around 8 months). Because the
generalized this pattern to other tools and tasks with infant now can move to play objects, her sense of au-
self-directed goals. By 14 months, the infants consis- tonomy increases and she has increasing choice about
tently used a radial grasp on tools that were self- play with objects. Once the infant is mobile, she is
directed (e.g., a hairbrush), recognizing it as the most unlikely to spend play time on her parents’ lap and is
efficient grasp for using the tool. more likely to play on the floor or in a seating device
A century of research on infant motor development with the caregiver nearby. Being able to move to a
has provided a detailed description of the sequence of location or object affords the infant greater variety
hand skills development and a conceptual under- of play objects, enables the infant to develop self-
standing of how infants develop hand skills. Knowledge determinism, and expands the infant’s perception of
about the sequence allows therapists to identify infants form, space, direction, and depth.
who may benefit from intervention and to establish Cultural traditions influence how much the infant is
goals that reflect the next skill expected to emerge. The held, the space afforded to him or her for exploration,
theories that explain how infants develop hand skills and the complexity of the environment available. Infants
form the basis for intervention and educational of families with low economic status may not have
approaches. One recurring theme in human develop- appropriate spaces to explore and may be restricted for
ment research, the relationship between skill develop- safety reasons. Families of cultures that value infants’
ment and environmental context, is discussed in the exploration and play may have more toys and activities
following section. available. The effect of poverty on motor skills develop-
ment is equivocal. Peterson and Albers (2001) found
that poverty had a small negative effect on motor
CONTEXTS FOR HAND SKILL development in girls. In contrast, boys whose families
had lower income demonstrated higher motor skills
DEVELOPMENT than boys from more affluent families. Using a large
sample of different ethnic and economic groups, Bradley
A child’s development is nested in his culture, family, and co-workers (2001) found that poverty per se did
and community; these contexts determine his genetic not have a negative effect on infants’ motor develop-
ment; however, variables sometimes related to ethnicity This section presents a developmental perspective of
and economic status (i.e., availability of learning the influence of posture and sensory functions.
materials and degree of parental responsiveness) did
relate to motor development.
A number of studies have found differences in hand
POSTURE
skill development when children from different cultures The first stable posture of the infant is lying on his
are compared. In a study that examined motor per- back. Laying supine offers optimal stability; the infant
formance in Chinese and American children, American must reach against gravity, which constrains reach with
children demonstrated higher scores in most gross grasp. Because posture is unstable in the first months
motor skills and Chinese children were higher in fine after birth, the 2-month-old infant primarily demon-
motor skills (Chow, Henderson, & Barnett, 2001). strates asymmetric posturing, reinforced by the influ-
The authors suggest that Chinese children may not ence of the asymmetric tonic neck reflex (Gesell et al.,
have the same amount of space available for play and 1940). This asymmetric posture limits his or her visual
exploration and Chinese parents also may not value field and reinforces visual inspection of the hands
gross motor skill development as much as fine motor (Bower, 1974). To reach and grasp objects, infants
skill because early proficiency with chopsticks and must maintain stable vision of the target as they lift
writing implements is expected. Yim, Cho, and Lee their arms. Thelen and Spencer (1998) found that head
(2003) found that hand strength of children in Korea control is critical to successful reaching. In their study
was lower than in children from America and other reaching did not emerge in any of the infant par-
Western countries. Although these studies of Chinese ticipants until several weeks after good head control
and Korean children examined older children (pre- emerged.
school and elementary ages), the results have implica- By 3 months, the infant has an emerging sense of
tions for infants because hand skill and strength develop midline, and when supine brings the head to midline
incrementally from infancy. and the hands toward midline. Symmetric weight
Differences in caregiving practices across cultures bearing in prone and increasing head control con-
appear to affect infant skill development. When evaluated tribute to establishing a sense of midline. Neck and
using the Bayley Scales of Infant Development, 3- to shoulder stability develops as a prerequisite for control
5-month old Brazilian infants were less skilled in grasping of reach and hand movements in space.
and sitting than American infants (Santos, Gabbard, & Symmetry is the predominant characteristic of the
Goncalves, 2001). Santos and co-workers attributed infant’s posture between 4 and 6 months. Head and
these differences to the tradition that Brazilian mothers hands come to midline, enabling a hands-together
hold their infants almost constantly for the first 6 posture and visual inspection of both hands. As a result,
months. Because the infants are totally supported for the infant spends much of the time in hand-to-hand
an extended period, their delay in hand skill develop- play, first on the chest and then in space at the midline.
ment may relate to delay in postural stability develop- Head and trunk control and postural stability change
ment. These studies illustrate differences that have been dramatically during this quartile. Thus the infant gains
observed in different ethnic groups; however, these dif- important axial support for reach and use of hands in
ferences have not been systematically studied in ethnic space. Stability through the neck and shoulders helps
groups that live in America, limiting generalizability to the infant gain control of the arms; therefore in sup-
children of different cultures who live in the United ported positions he or she can hold her hands in space
States. while grasping an object. The movements of neck,
trunk, and arms appear to be coordinated early in life.
Van der Fits and Hadders-Algra (1998) found that
complex postural adjustments accompany the infant’s
SYSTEMS THAT CONTRIBUTE reach by 4 months, when successful reaching emerges.
TO THE DEVELOPMENT OF Therefore as reach and grasp emerge and later mature,
postural stability provides a base for these movements.
HAND SKILLS By 6 months, the infant demonstrates increased
postural control in the prone position, pushing onto
Extensive research has demonstrated the importance extended hands and shifting weight side to side. When
of posture and sensory function (i.e., visual, tactual, on elbows, the infant is able to lift one arm entirely
proprioceptive) to the development of hand skills from the weight-bearing surface for reach to an object.
(Bertenthal & von Hofsten, 1998; Thelen & Spencer, This complete lateral weight shift provides propriocep-
1998; von Hofsten, 1986). The reciprocal influence of tive input through the hands across the palmar surface.
sensory function was discussed in a previous section. It also results in asymmetric sensory experiences. Prone
Figure 7-2 Prone position strengthens arms and hands.
Figure 7-4 Hands are freed to hold objects.
Increased axial control seems to support the use of

one-hand reach and bimanual fingering (exploration)
of an object held at midline. Trunk rotation has devel-
oped in fully supported positions (i.e., rolling from
supine to prone and prone to supine) and begins to
develop in sitting positions. Related to these skills, the
infant demonstrates crossing the midline and begins to
use the hand in crossed lateral space. In a review of the
research literature, Bertenthal and von Hofsten (1998)
reported that reaching skills significantly improve
between 6 and 7 months of age. At this age, infants
become highly accurate in reaching for a moving
target, a task that requires rapid adjustments of arm
Figure 7-3 Most 7-month-old infants sit independently.
movement and the postural stability to allow for those
adjustments.
positions help the infant strengthen arm and hand Infants at 7 and 8 months also assume the
musculature and provide tactile proprioceptive infor- quadruped position and begin to creep. The on-hands-
mation that appears important to the hand’s perceptual and-knees position results in frequent weight bearing
development (Boehme, 1988) (Figure 7-2). Although on the hands. This position tends to be dynamic and
the increased postural control of the 6-month-old child mobile, thereby providing tactile and proprioceptive
supports symmetric movements of the hands in space, input across the hand (Figure 7-5). The frequency of
it does not appear adequate for skilled asymmetric or play in prone position (in and out of quadruped)
unilateral movements. strengthens the arms and hands. The infant shifts
In the following months, when trunk stability is weight across the hands in a diagonal direction while
sufficient for independent sitting, the infant develops moving from quadruped to side sitting (Boehme,
an increased repertoire of arm and hand movements 1988). Strengthening of the arms also occurs through
that includes both symmetric and asymmetric patterns. pulling to stand and through supporting himself while
Gains in postural control allow the 7-month-old erect (Figure 7-6).
child to sit independently (Figure 7-3). In the next Postural stability increases such that the 12-month-
several months sitting becomes a favorite play position old infant has greater control of arms in space while
because the hands are free to hold objects, and the sitting independently. The internal stability of the arm
infant can control weight shift forward or to the sides allows the infant to prehend a small object using a
to obtain objects (Figure 7-4). superior pincer grasp (i.e., use a pincer grasp without
Weight-bearing experiences continue to provide

heavy work for the upper extremities. Creeping usually
is the primary form of mobility. The infant may rise into
the hands-and-feet position (bear crawling), resulting
in heavy work for the arms. Fast creeping over a variety
of surfaces provides important tactual and propriocep-
tive input to the hands.
By 13 months the child’s balance and postural
stability are sufficient for upright ambulation. Trunk
rotation and pelvic stability are noted in smooth tran-
sitions from floor sitting to standing and from standing
to sitting. Postural control can now support hand ma-
nipulation with arms in space, as observed in stacking
blocks, placing objects in a container, and toy explo-
ration. Now that upright ambulation is the child’s
Figure 7-5 Creeping on hands and knees provides consistent form of mobility, upper extremity weight-
tactile and proprioceptive input to hands.
bearing experiences become limited and the hands no
longer are critical for support, resulting in increased
emphasis on their role in manipulation.
Postural control is excellent by 2 years as the child
begins to concentrate on speed, strength, balance, and
endurance. Postural stability of the child at 24 months
enables use of hands with control in all positions and
planes around the body. Although dexterity diminishes
when the child is in a less stable position (e.g., half
kneel), postural stability in typical sitting and standing
positions is sufficient for control of a great range of
manipulative skills.
SENSORY SYSTEMS
The sensory systems that most influence hand skill
development are visual, tactile, and proprioceptive. By
the third month the head is held at midline, which frees
the range of vision. During this same period the infant
learns to control eye movements, and visual inspection
becomes a key strategy for learning about the environ-
ment. Visual attention to specific events and objects
indicates the infant’s ability to focus and assimilate
important information from the environment (Bower,
1974; White, Castle, & Held, 1964). Although visual
attention becomes more discriminating (von Hofsten
& Rosander, 1996), hand skills remain primitive in that
the hand does not adapt to the specific sensory qualities
Figure 7-6 Practice of pull-to-stand helps to strengthen
of the object it grasps, and control of release has not
arms.
been established (Figure 7-7).
The infant from birth through 3 months is often
prone lying and has frequent opportunities for tactile
stabilizing the arm on the surface). Postural stability is or proprioceptive input to the hands and forearms. He
an important factor in the development of an accurate presses into a prone propped position with the head
and well-directed reach (Corbetta & Thelen, 1996). erect, resulting in deep proprioceptive input to the
With increasing trunk stability and rotation the infant is arms. Hand opening while weight bearing, prone-on-
able to reach to the body’s contralateral side. Postural elbows, provides specific tactile input to the palms.
stability also enables the child to reach overhead and Mouthing of the hand allows tactile exploration of the
behind when sitting. hand and provides tactile or proprioceptive input to the
Figure 7-7 Hands conform to the object’s shape
Figure 7-9 Infant at 4 months explores a toy with

hands and eyes.
size, and temperature. Mouthing and fingering behav-

iors increase significantly from 3 to 6 months,
increasing an infant’s perceptual learning (Ruff, 1984)
(Figure 7-9).
Fingering behaviors are associated with visual
inspection. At 4 and 5 months of age infants
increasingly make successive oral and visual contacts
with the object, thereby integrating information from
two different sensory systems. Beginning at 5 and
6 months, infants use both hands to explore objects.
Figure 7-8 Hands grasp at midline on his chest in 3- They explore textures, rotate and transfer objects, and
month-old infant. alternate looking with mouthing (Rochat, 1989). Ruff
and Kohler (1978) demonstrated that after 6-month-
old infants tactually explore objects, they tend to
visually prefer those objects. Their results provide
hand. When the infant is supine, the hands find each evidence that an infant visually recognizes an object
other on the chest, clasping and engaging in mutual that was previously held and tactually experienced but
fingering (Figure 7-8). These tactile or proprioceptive not visualized. Sensory play at this time consists of
experiences contribute to the development of grasp and mouthing, hand-to-hand fingering, and intense visual
release patterns, as do the visual experiences that inspection.
contribute to the development of visually guided hand The role of vision in guiding manipulation has an
movements. increasingly important role after 6 months and then
Sensory experiences continue to be a primary basis throughout development (Bushnell & Boudreau,
for movement in the 3- to 6-month-old infant. The 1991). Whereas tactile input had primary influence on
infant delights in the sensory world and begins to grasp and manipulation, vision becomes a primary
integrate the information from more than one sensory sense for guiding the infant’s manipulation. McCall
system. Rochat (1987) reported that infants this age (1974) reported an increase in manipulation with visual
perceive hardness when compared with soft consis- regard at 81⁄2 months. Castner (1932) observed that
tencies. Bushnell and Boudreau (1993) concluded that the duration of regard increased at 8 and 9 months, as
infants as young as 3 months can perceive hardness, did the infant’s accuracy in reach and grasp of a pellet.
Figure 7-11 Infant at 12 months visually explores

object.
Figure 7-10 Infant at 8 months integrates visual and
tactile information from toy with movable parts.
Active mouthing decreases as manipulation with movements after visualizing the object. Anticipatory
visual regard increases in the second half of the first year control means that the infant opens his hand according
(McCall, 1974). This active mouthing appears to be to the object’s size and shape before prehension.
replaced with fingering. The increasing importance Through their prehension experiences infants also
of vision in manipulation complements rather than begin to anticipate the force necessary to grasp and lift
diminishes the importance of the tactile system. The an object (Gordon & Forssberg, 1997; Johansson &
infant is now able to integrate visual and tactile Westling, 1988).
information, using both senses simultaneously to learn In the second year of life, the infant becomes
about the object’s properties (Corbetta & Mounoud, interested in the functional use of objects and func-
1990; Ruff, 1984) (Figure 7-10). lntermodal transfer tional goals become the prime motive for manipulation
of tactile and visual information (visual recognition of (Gibson, 1988). The child continues to integrate visual,
an object after handling it without vision) becomes tactile, and proprioceptive sensations by practicing per-
possible at this age (Ruff & Kohler, 1978; Steele & ceptual motor skills, demonstrating increased abilities
Pederson, 1977). Changes in discrimination of the to use information from these sensory systems to
object’s weight and shape enable the 9- to 10-month- correct and refine movements. Thus increased precision
old child to hold a cracker without crushing it and lift of movement results from increased perceptual ability,
an object with the appropriate amount of force. as well as improved motor skill. The child can now
At 12 months the infant continues to use vision as a recognize the tactile and auditory properties of the
primary guide to object manipulation. The infant can object through visual inspection and therefore
visually recognize the physical properties of the object approaches an object with an appropriate response (i.e.,
and act on it appropriately. For example, a 12-month- shaking a rattle, squeezing a sponge, crumpling paper,
old infant bangs and hits a rigid object and squeezes or or using more force to lift a large object).
presses a spongy object (Bushnell & Boudreau, 1993; By 2 years of age, improved sensory discrimination
Gibson & Walker, 1984). Fingering and hand-to-hand and integration enable the child to demonstrate increased
manipulation become the primary modes for exploring variety and control of perceptual-motor skills. The
the sensory qualities of an object (Ruff, 1984) (Figure 24-month-old child is able to assimilate multimodal
7-11). Integration of senses continues and the infant sensory information and make appropriate adaptive
becomes increasingly able to recognize objects visually responses. Success in perceptual-motor skills such as
that had been explored only through the tactile sense. stringing beads and simple dressing tasks illustrates the
Infants learn anticipatory control; that is, they plan their child’s ability to integrate and use sensory information.
input to the hand. He or she begins to actively explore

DEVELOPMENT OF HAND SKILLS objects using specific movements to create sounds and
IN THE CONTEXT OF INFANT PLAY visual effects. By 6 months the infant can purposely roll
and initiate rolling to experience movement. Toys that
ACTIVITIES react to simple movements are favorites in play. Rattles
are good examples, in that almost any movement pro-
duces a sound, reinforcing the infant’s play and explora-
PLAY ACTIVITIES: BIRTH TO 12 MONTHS tion (Piaget, 1952). Toys that are activated by generalized
In the first months of life, infants delight in sensory responses continue to be preferred to those that require
experiences of touch and movement. Infants exhibit specific, more localized responses; for example, a rattle
frequent generalized movements through which they is preferred to a busy box requiring differentiated push,
gather multisensory input that increases arousal and pull, and press of fingers (McCall, 1974).
attention. Play behaviors of young infants include From 6 to 12 months, infants spend most of their
swiping movements to cause a mobile to move and playtime in object exploration. Interest in and
make sounds, or mouthing objects in perceptual explo- awareness of the environment increases (as described in
ration. When general swiping movements cause a mobile the previous section). Visual and tactile exploration of
to move and make sounds, this sensory experience objects predominates. These exploratory behaviors are
reinforces that action and the infant swipes at the characterized by a rich variety of manipulative skills.
mobile again. As noted in the previous section, visual Cause and effect are well established, and rather than
exploration, mouthing, and tactile reflexes appear to be repeating the same actions on a toy, the infant tries new
the infant’s primary methods for learning about the strategies to create different reactions (Piaget, 1952).
environment (Bower, 1974; Gesell et al., 1940) Play involves imitation of actions observed, including
(Figure 7-12). toy manipulation. The physical properties of the object
The 4- to 6-month-old infant continues to delight in guide responses, because the infant does not yet under-
the sensory experiences of vision, touch, and move- stand the specific functional uses of objects. The infant
ment. One goal of generalized movements and begins to bang objects together and place one object in
reactions appears to be creating sensory experiences. As proximity to another. These behaviors signal the advent
the infant scratches the weight-bearing surface of the of tool usage and specific actions of one object in
parent’s shoulder, this behavior seems to be auto- relation to another (Bruner, 1970; Lockman, 2000).
matically reinforced by the tactile and proprioceptive In the first year, infants also engage in social play that
is focused on attachment, or bonding, to the primary
caregivers. Infants play social games with parents and
others to elicit responses. These may involve pat-a-
cake, squeezes, and kisses. Although infants at this age
engage readily with individuals other than family, they
require their parents’ presence as an emotional base and
return to them for occasional emotional refueling
before returning to play. Therefore an infant remains
near to caregivers, who assist in opening containers,
turning knobs, and providing physical assistance as the
infant investigates his environment (Pierce, 1997).
PREHENSION: BIRTH TO 12 MONTHS

The prehension skills that infants develop in their first
year of life serve their play goals and enable them to
explore and learn about the environment. As infants’
play transitions from sensory-driven to functional, hand
skills refine from generalized to precise patterns.
Primitive and Transitional Grasps

Newborns tightly flex their fingers around a flexed
thumb, only occasionally opening the hand in associ-
Figure 7-12 Mouthing at 4 months is a primary ation with active extension of the trunk or arms. The
method of object exploration. neonate’s fisted hand is consistent with the overall
predominance of physiologic flexor tone that domi- infant not only orients to the stimulus by adjusting his
nates upper- and lower-extremity movements. He or forearm but actually gropes for a tactile stimulus. Groping
she frequently brings the fisted hand to the mouth for the moving object that is touching the hand occurs
when prone, pulling the hands toward midline while without visual input and can be observed in the child
assuming an overall flexed position. The first reflexive who has visual impairment (Corbetta & Mounoud,
response of the arm and hand, termed the traction 1990). Therefore instinctive grasp includes following a
response, is demonstrated by the neonate when moving stimulus to secure it and then adjusting the
proprioceptive input or traction is applied to the arm. hand’s grasp to accomplish sustained holding of the
When the arm is pulled away from the body, synergistic object. Flexion of a single digit can be induced given
flexion of the fingers, wrist, elbow, and shoulder isolated tactile contact. The instinctive grasp is a transi-
results. As described by Twitchell (1970), stretch to the tional behavior between primitive (reflexive) and mature
flexor and adductor muscles of shoulder is a sufficient patterns of movement, as the fractionated movements
stimulus for eliciting this response. In the first couple of of the fingers and hand come under the infant’s volun-
weeks of life, the grasp reflex has not yet emerged. The tary control (Gilfoyle et al., 1990).
neonate may posture with fisted hands, but responses
to touch on the hands result in opening or partial Purposeful Grasp
opening. The transitional behaviors described previously lead to
It is not until the second to fourth week of life that the emergence of voluntary prehension (Gilfoyle et al.,
the infant automatically closes the fingers around an 1990). Between 4 and 6 months the infant develops
object (or adult’s finger) placed in his palm. This first control of grasp (Figure 7-13). Using both tactile and
grasp reflex requires that pressure (proprioception), as visual information, she becomes skillful in adjusting
well as tactile input be applied to the palm and is the hand to the object. The infant begins to use visual
accompanied by the traction response. A grasping input to prepare the hand for grasp by opening
reflex is not elicited in response to a visual stimulus. and shaping the hand before grasp according to the
By 4 weeks the grasp reflex can be elicited with a object’s size and shape (Corbetta & Mounoud, 1990;
contact stimulus to the palm or fingers. A moving Forssberg, 1998).
stimulus is most effective in producing this local grasp These beginning abilities to grasp, orient, and adjust
reaction, which is immediately followed by the traction the hand to objects based on tactile and visual infor-
response. By 8 weeks two distinct phases of the grasp mation signify the beginning of purposeful grasp. The
reflex are observed. The first is the catching phase, infant becomes capable of using a variety of grasping
which is an immediate flexion of the fingers and thumb. patterns that are selected based on the affordances of
In the second or holding phase the finger flexion is
sustained. This holding is intensified if the object is
lightly pulled. The traction response declines at this
time but can be elicited when the arm is pulled from
the body (Twitchell, 1970).
By 3 to 4 months of age a true grasp reflex has
developed and the traction response no longer auto-
matically accompanies this response, although dorsi-
flexion of the wrist continues to accompany the finger
flexion. When an object is placed in the hand and is
moved medially, the fingers flex in a sustaining grasp. A
palmar grasp is observed with the fingers flexing tightly
and pressing the object into the palm. Although in past
research an ulnar palmar grasp was documented to
emerge first, more recent research shows that the index
finger is active first and has a leading role in the first
grasping patterns (Lantz, Melen, & Forssberg, 1996).
The grasp reflex becomes diminished at 4 to 5 months
of age and fractionation of the grasp reflex begins
(Twitchell, 1970). One or two fingers flex in isolation
from the others, given specific stimulation of their volar
surfaces. At 5 to 6 months an instinctive grasp emerges,
which combines the fractionated grasp and the
orienting response (Twitchell, 1970). At this time the Figure 7-13 Palmar grasp at 6 months.
the objects and his or her playful intentions. Initially the

infant uses only a few grasping patterns and uses them
indiscriminately. As the infant gains experience and
matures, a variety of patterns can be observed.
At 20 weeks most infants touch, but do not grasp, a
cube placed before them. The infant who successfully
secures the cube does so by pulling it to the other hand
or the body and squeezing it against another surface.
Squeeze grasp develops by 20 to 24 weeks. The infant
presses the cube using total finger flexion against the
palm. Because his or her proprioceptive system and
motor control remain crudely developed, the cube is
squeezed tightly. Success in retaining the object is
limited by his or her ability to adjust the object within
the hand or differentiate finger movement. The thumb
does not actively participate in this grasp and tends to
lie in the palmar plane.
Finger and hand movements without object grasp
contribute to the development of grasp (Castner, 1932; Figure 7-14 Radial palmar grasp.
Halverson, 1931). The 4- to 5-month-old infant often
is observed scratching the supporting surface when
prone on elbows. The infant uses alternating finger supinated hand, the object can be brought to and put
flexion and extension of the digits together. Scratching into the mouth. The object can be banged against
also may occur on the caregiver’s clothing when another surface, and the object becomes accessible for
holding the infant upright against the shoulder. The object transfer from hand to hand. The radial palmar
scratching motion allows the infant to practice the full grasp is a hallmark in grasp maturation because the
range of reciprocal finger flexion and extension. infant now differentiates the sides of the hand, using
Scratching also provides the infant with rich tactile the ulnar side to provide stability for the grasping
information about different textural surfaces. movement and the radial side to prehend and hold the
Halverson (1931) observed rubbing of the hand on object. This early pattern signifies the initial develop-
the surface as an additional method for obtaining ment of radial fingers as the skill side of the hand.
tactile input in the infant at 16 to 28 weeks. As the Knobloch and Pasamanick (1974) emphasized the ver-
infant continues to use scratching, finger movements satility observed in manipulation patterns at 7 months:
become differentiated such that one or two fingers “He grasps it, brings it to his mouth, withdraws it again
move in isolation of the others. Halverson documented for inspection, restores it again for mouthing, transfers
pianoing or “raising and lowering of each finger it to the other hand, bangs it, contacts it with the free
alternately” on the table in infants 16 to 24 weeks of hand, retransfers it, mouths it again, drops it, rescues it,
age. Pianoing appears to be an automatic movement mouths it again” (p. 60).
rather than a purposeful isolated motion of each digit. Between 32 and 36 weeks the infant demonstrates
As with other hand skills, isolated movements of the grasp of the object in the fingers rather than the palm,
fingers occur first in these automatic behaviors elicited and by 36 weeks the infant exhibits a radial digital grasp
by the sensory stimulation of the hand resting on a flat (Gesell & Amatruda, 1947) or inferior forefinger grasp
surface. (Halverson, 1931) (Figure 7-15). At this time the
A palmar grasp is most frequently used by the infant can prehend a small object between the radial
24-week-old infant. The palmar grasp is characterized fingers and thumb. With the object held distally in the
by a pronated hand and flexion of all fingers around the fingers (proximal to the finger pads), the infant can
object. The thumb may slide around the object passively adjust the object within the hand and as a result can use
rather than actively holding it (see Figure 7-13). the object for various purposes while holding it. The
Halverson suggested that when thumb opposition first adjustments allow for greater success in relating two
appears at 28 weeks, it is used only in association with objects or in bringing the object to the mouth for
a palmar grasp. By 28 weeks the infant holds the object finger feeding. The movement of the object distally and
in a radial palmar grasp (Gesell & Amatruda, 1947) or to the radial fingers gives the infant greater control of
what Halverson (1931) termed a superior palmar grasp. the object and enables release control.
The radial fingers and thumb press the cube against When the 36-week-old infant grasps a very small
the palm (Figure 7-14). Therefore when held in a object (pellet size), a scissors grasp is used. Gesell and
surfaces, in and on other objects. He also can use the

index finger to turn or move the object before pre-
hension to increase success in grasp. Along with
increased accuracy in grasp at this time, by 1 year the
infant requires less time to prehend an object, displaces
the object less before grasp, and makes fewer adjust-
ments to secure the object firmly in the hand.
OBJECT RELEASE: BIRTH TO 12 MONTHS

Object release matures after early grasping patterns
are achieved. Release is an integral part of prehension
and manipulation, but involves extensor movement
patterns that follow a slightly different developmental
Figure 7-15 Radial digital grasp at 8 months. trajectory.
Automatic Release
As with grasp, the first object release observed is a
reflexive behavior. Finger extension is observed as the
neonate withdraws and abducts the fingers in response
to touch of the hand (Twitchell, 1970). This response,
termed the avoiding reaction, is usually only a slight
withdrawal of the neonate’s hand. By 3 weeks and
continuing to about 8 weeks, the avoiding response is
elicited easily. When the dorsum of the hand is
touched, the fingers abduct and extend. The hand also
may pronate to withdraw from a contact stimulus. This
response is elicited when the contact stimulus is lighter
and more quickly applied than the firm palmar
stimulation that elicits the grasp reflex.
Figure 7-16 Scissors grasp at 9 months. Twitchell (1970) described an instinctive avoiding
response that is similar in nature to the instinctive grasp
response, in that it represents a transitional behavior
Amatruda, as edited by Knobloch and Pasamanick between reflexive and voluntary responses. The instinc-
(1974), defined a scissors grasp as prehension of a small tive avoiding response emerges between 12 and 20 weeks
object between the thumb and lateral border of the of age. It is characterized by pronation and adduction
index finger after a raking movement of the fingers. away from a stimulus on the hand’s ulnar border and
The hand is stabilized on a surface during this grasp, supination with abduction to stimulation of the hand’s
and the ulnar fingers are flexed to provide stability of radial side. The instinctive avoiding reaction generally is
the thumb and radial finger movement (Figure 7-16). fully developed by 24 to 40 weeks of age (Twitchell,
Forefinger grasp (Halverson, 1931) or inferior 1965, 1970). At this time the infant withdraws from
pincer grasp (Gesell & Amatruda, 1947) is observed at light contact stimulation, using a variety of hand move-
40 weeks. This is a fingertip grasp in which the infant ments, including flexion, extension, abduction, adduc-
stabilizes the forearm on the table as a base while tion, and rotation. Avoiding reactions are seen more
grasping the cube. The fingers that prehend the small frequently when the infant is irritable or when gener-
object are more extended than flexed. By 52 to 56 weeks alized tactile defensiveness is present. The avoiding
the infant prehends and holds the object between the response serves as an automatic mechanism to reinforce
thumb and forefinger tip. Successful prehension using hand opening and facilitate finger extension to balance
a superior pincer grasp (Halverson, 1931; Illingworth, the effects of the grasp reflex. According to Gesell and
1991) is achieved without the forearm stabilizing on Amatruda (1947), release requires inhibition of the
the surface. At this time the fingers adjust to the size flexor muscles with contraction of the extensors, which
and weight of the object. The object is now in a is a more mature, later-developing neuromotor pattern.
position that it can be used readily in a play activity or More recent theories (Thelen et al., 1987, Thelen &
as a tool. Because the infant no longer needs to stabilize Smith, 1994) that recognize the interaction of systems
to grasp, he can easily prehend objects from a variety of in development attribute initial hand opening to per-
ceptual and biomechanical influences. The hand may release is often accomplished by flinging the object—
first open with wrist flexion, which produces tension of combining elbow, wrist, and finger extension in a
the finger extensors. The hand also may open to rub or synergistic, ballistic movement. The infant now pur-
pat objects to perceive their sensory qualities (Bushnell posefully drops food and toys from his or her highchair
& Boudreau, 1993). and takes great pleasure in practicing this newfound
skill. The object is released with the hand above the
Purposeful Release table surface, using full finger and thumb extension.
From 5 to 6 months the infant begins a transition from Object-releasing activity is reinforced by the auditory
reflexive to purposeful release. The infant demonstrates and visual consequence of dropping the object. This
release accidentally or involuntarily in association with new skill is also reinforced by the development of
movements, tactile stimulation to the hand, or contact object permanence and the infant’s interest in
with another surface. At 6 months release is observed observing objects disappear and reappear.
during mouthing and bimanual play. The infant brings By 52 weeks the infant demonstrates greater
an object or finger food to the mouth with both hands proficiency in releasing the object. With increasing con-
and may release one or both once the object is stabilized trol of finger extension, the infant begins to demon-
in the mouth. When the infant holds an object with strate graded hand opening when releasing. At this
two hands, one hand may fall from the object. time she is practicing precision release for stacking one
Meanwhile, the infant practices finger extension in block on another or placing a form in its form space.
other activities. For example, extended fingers may be Graded hand opening with controlled finger extension
observed in patting the bottle or toy (Figure 7-17). is first observed with the proximal hand base and
Additional facilitation of finger extension in the 6- and forearm stabilized on a surface.
7-month-old child (see Figure 7-2) also occurs in the
prone-on-hands position.
At 28 weeks, the child releases an object when
BIMANUAL SKILLS: BIRTH TO 12 MONTHS
transferring it from one hand to the other. Initially Humans are essentially bimanual beings from birth and
object transfer is achieved by holding the object at most movement patterns of the arms and hands involve
midline with both hands and pulling it out of one hand combined movements of both. Fagard and Jacquet
into the other. Therefore the release is actually a forced (1996) indicated that bilateral arm movements are the
withdrawal accomplished by the opposite hand. During predominant pattern of upper extremity movement
this same developmental period the infant releases an throughout the first year of life. Two hand actions
object on a table surface or another resisting (Gesell & generally follow prehension and although varied,
Amatruda, 1947) or assisting (Ammon & Etzel, 1977) follow a developmental sequence. The sequence of
surface. Release with the assistance of another surface bimanual skills observed during infancy relates to the
enables the child to roll the object from the fingers or infant’s postural, sensory, perceptual, and cognitive
remove it from the hand by inhibiting finger flexion development, as well as hand skill development.
(i.e., without active extension).
Between 40 and 44 weeks the infant demonstrates Early Development of Bilateral Arm Movements
purposeful release in the context of play (Illingworth, The neonate exhibits both asymmetric and symmetric
1991; Knobloch & Pasamanick, 1974). This first active limb movements. Some of these are associated with the
asymmetric tonic neck reflex; many appear to be ran-
dom. Smooth, alternating arm and leg movements are
most characteristic, with specific reflexive behaviors
elicited by specific tactile input. The first bimanual
reach toward an object may be observed at 2 months
(White et al., 1964), although swiping at objects tends
to be unilateral. By 3 months swiping increases and
hand-to-hand interplay, without an object, is observed
with hands clasped on the chest (see Fig 7-8). The
infant may involuntarily hold an object on the chest at
midline, resulting from the clasping of the hands
together. Most spontaneous arm and hand movements
appear to be simultaneous and symmetric.
At 16 weeks this symmetry continues to pre-
dominate, although one hand tends to lead the other.
Figure 7-17 Fingers extend as infant pats toy. Usually the hands join together at midline, and the
Figure 7-18 Symmetric arm movements at 4 months.
Figure 7-19 Unilateral approach to grasp object.

object is held between them (Figure 7-18). Almost
universally, once the object is prehended, the infant
brings it to the mouth or chest. The object may drop initiates movement in the second hand as the first hand
when transported to the mouth or may be captured ends its approach (Castner, 1932).
against a body part. These behaviors are reinforced by Bilaterality versus unilaterality in approach seems to
the infant’s drive toward symmetric midline move- be determined by the object’s size and the way it is
ments at this age and the desire to experience oral presented. The 7-month-old infant uses a bilateral
sensation. Lack of internal trunk stability at 4 months approach for large objects and a unilateral approach
also results in bringing both hands together around the for small objects (Fagard, 1998) (Figure 7-19). Other
object for distal stability. authors suggest that approach is determined by the
The 20-week-old infant tends to use the simul- external support provided for the infant’s proximal
taneous approach described earlier, in which both stability during reach (Bushnell, 1985; Halverson,
hands move toward the object at the same time. The 1931). After grasping the object, the infant visually
infant attempts to prehend the object using both hands inspects it or brings it to the mouth. She may transfer
(Castner, 1932). Although the 5-month-old infant it using the mouth as a stabilizer.
reaches for the object with two hands, he uses only The 7-month-old infant uses primarily bilateral
one to grasp the object (Fagard & Peze, 1997). The movements for object manipulation (Goldfield &
second hand may support the first after grasp is Michel, 1986; Flament, as cited in Corbetta &
achieved, and often both hands bring the object to the Mounoud, 1990). At this time the infant demonstrates
mouth or hold it in space for visual inspection. Inter- associated, rather than independent, bimanual move-
manual transfer has significantly increased (Rochat, ments. Although the two hands act in concert, an
1989), although active purposeful release has not yet increasing variety of exploratory and manipulative
developed. Compared with 2- and 3-month-olds, 4- and behaviors are observed (Figure 7-20). For example, the
5-month-old infants demonstrate significantly better infant uses an extended index finger to poke or probe
organized bimanual action with more holding and an object held in the other hand. This probing with
fingering of objects, The bilateral fingering behavior one hand while holding with the other is a primary
observed at this age has been described as grasping method of object exploration.
the object with one hand and touching it or scanning As mentioned, by 7 months the infant holds the
the object’s surface with the other (Ruff, 1984). object in the radial digits and actively transfers it from
hand to hand, while visually and tactilely exploring it.
Transitional Bilateral Skills Active supination and isolated wrist movements enable
Between 24 and 28 weeks the infant approaches the the infant to partially rotate or turn the object for visual
cube most frequently with both hands, corralling it. inspection. These isolated movements often are
During this developmental period first a simultaneous, mimicked by the other hand. Manipulation of the
then a successive bilateral approach is used. The infant object at this time is limited to transfers from hand to
A
Figure 7-20 Two hands explore in associated bimanual
movements.
B
Figure 7-21 A 7-month-old infant continues to mouth Figure 7-22 A, B. Infants can hold two objects
toys. simultaneously by 7 months.
hand or hand to mouth rather than within hand tion is not related to the development of any specific
manipulation. Mouthing remains an important part of skill, but to the expanded range of behaviors observed.
the infant’s exploration (Figure 7-21). Now one hand holds the object and the second hand
After 7 months of age, infants begin to play with two manipulates the object. In “complementary bimanual
toys at a time (Figure 7-22). The infant bangs two objects activities,” one hand positions the object and the other
together as the first indication of her capacity to associate manipulates parts of it (Bruner, 1970). Halverson
objects (Corbetta & Mounoud, 1990). (1931) noted that 9-month-olds “exhibited all of the
In the following weeks the infant adds to the following behaviors: transfer, visual inspection, release
repertoire of bilateral movements. In addition to visual and regain, bang it on the table, and hold it with both
inspection and hand-to-hand exchange, the infant hands.” By 9 months object rotation, primarily
waves toys in the air and bangs them on the table achieved by transferring from hand to hand, allows the
surface. By 9 months the striking change in manipula- infant to perceive the shapes of objects (Lederman &
Klatzky, 1987). This type of rotation is possible because purposes. Flexible bimanual skills that can combine in
of increasing control of the radial digits and ability to numerous patterns, switching roles in a sequence of
grade supination and pronation as the object moves movements, develop in the second and third year as the
from hand to hand. This two-hand cooperation in child’s play repertoire expands.
turning an object is evidence of beginning dissociation
of symmetric arm movements.
Near the end of the first year a change is observed in
PLAY ACTIVITIES: 12 TO 24 MONTHS
the linkage between two-hand movement (Goldfield & The 1-year-old infant has developed an understanding
Michel, 1986). Whereas 7-month-old infants move their of an object’s functional purpose, thereby attempting
hands in the same direction, 11-month-olds move them to use objects for the function for which they are
in complementary directions. This change marks the intended. For the first time the infant’s repertoire of
initiation of mature bimanual skills. manipulative skills increases, in accordance with
functional capabilities of the object more than its
Coordinated Bimanual Skills sensory qualities. The infant pushes a truck, pulls a toy
At 12 months the infant demonstrates significant dog on a string, lifts a telephone receiver to the ear,
increases in both dexterity with one hand and rolls a ball, and lifts a brush to the hair. All of these
cooperative use of two hands together. Ruff (1984) movements are based on emerging cognitive under-
observed an increase in fingering by 12 months, which standings, as functional play begins to predominate
she associated with an increase in the infant’s ability to over sensory play. The child’s interest in relating two
simultaneously assimilate tactile and visual information. objects also results in more advanced unilateral and
The two hands begin to demonstrate coordinated bilateral skills. Endless repetitions of putting objects in
asymmetric roles (Figure 7-23). These complementary a container and placing one object next to another
movements are observed as the infant simultaneously create interesting results for the infant and at the same
holds two objects or an object and a container. A time refine releasing skills. New skills in imitation are a
typical bilateral pattern at this time is for one hand to basis for developing additional manipulation skills as
be active (generally the preferred hand) and one hand the infant attempts new movements that he observes
to be passive or to support and stabilize the object others perform.
(e.g., one hand holds the container while the other The child’s play between 18 and 24 months con-
removes a block inside). Bruner (1970) studied the tinues to focus on concrete, functional activities with
success of infants in removing a toy from a toy box. He toys. Play sequences increase in length and complexity.
found that before 12 months infants are rarely success- Symbolic play begins about the same time that
ful in removing the object. Beginning at 12 months the language develops, between 16 and 20 months. At first
hands work in cooperation; for example, one hand the infant demonstrates self-play that is centered around
holds the bottle and the other unscrews the lid. These or directed toward the self (Belsky & Most, 1981). The
complementary functions are flexile and adaptable, child’s play might consist of simulating eating,
enabling the hands to work together for functional drinking, or sleeping. These self-directed actions signal
the beginning of pretend play (Piaget, 1952). The child
knows cause and effect and repeatedly makes the toy
telephone ring or the battery-powered doll squeal to
enjoy the effect of the initial action.
By 2 years, the child’s symbolic play becomes directed
to objects. This decentered play involves acting on dolls
or teddy bears, feeding them, putting them to bed,
combing their hair. The hand skills to perform such
actions are complex and require that a series of related
movements be linked together. These play activities are
thus an integrated combination of bimanual skills, most
of which require that one hand holds and the other acts
on the object.
By the end of the second year, play has expanded in
two important ways. First, the child begins to combine
actions into play sequences (e.g., he or she relates
objects to each other by stacking one on the other or
Figure 7-23 Play includes distinct yet complementary lining up toys beside each other). These combined
movement of each hand. actions show a play purpose that matches the various
Figure 7-24 Functional play with a toy car.
functions of the toy. Second, 2-year-old children now

direct actions away from themselves. The objects used Figure 7-25 Blended mobility and stability and use of
in play generally resemble real-life objects (Linder, isolated finger movements.
1993). The child places the doll in a toy bed and then
covers it. The child pretends to feed a stuffed animal or
drives toy cars through a toy garage. At 2 years of age,
play remains a central occupation of the child, who now
has an increased attention span and the ability to
combine multiple actions in play. The emergence of
symbolic or imaginary play with toys and objects offers
the first opportunities for the child to practice the skills
of daily living (Parham & Primeau, 1997; Reilly, 1974).
As the infant learns more about the capabilities and
affordances of objects, his play become more elaborate.
His manipulation skills match his need to open and com-
bine objects in novel ways, sometimes imitating parents
and peers and sometimes experimenting with object
properties. In general, the functional purpose of toys
determines the toddler’s response: dialing the phone,
turning the music box, unzipping a zipper, scribbling
with a crayon, or pushing a car (Figure 7-24).
With an increased interest in relating multiple Figure 7-26 Cup drinking as an example of
objects, the child fills a container with small objects, coordinated hand movements for a functional goal.
places one object on or next to another, and scoops
food with a spoon. These relational play activities often
require stabilizing the toy or object with one hand require new combinations of hand skills. Pushing,
while manipulating with the other. The child’s under- pulling, probing, rotating, and turning are combined
standing of cause and effect and object permanence into a new repertoire of play behaviors (Nicholich,
results in increased interest in switches, hinges, push 1977). With new understanding of tool use, the child
buttons, and pop-up toys. Switches require elaboration engages in play activities that require mobility of the
of the prehensile patterns developed and new combina- proximal arm and stability of the hand for grasping
tions of arm and hand movements. Most play activities the object (Exner, 2005). The functional use of some
now require bimanual skills, and the child is able to use objects, such as a cup, requires a series of combined
hands together simultaneously or reciprocally (Corbetta mobility and stability of the arm and hand (Figure
& Mounoud, 1990) (Figure 7-25). The child engages 7-26). The functional play that characterizes the child
in longer and more complex play sequences that at this age correlates with an increasing purposefulness
move different parts of the hand (i.e., the radial and

ulnar sides) independently and can control the action
of isolated fingers.
Gesell described the grasp of an 18-month-old child
as enveloping rather than manipulative. At this age
thumb opposition is good; however, the hand remains
primarily a prehender rather than a manipulator.
Exploration of the object requires both hands and
involves transferring and turning the object from one
hand to the other. At this time the infant is able to
adjust grasp to accommodate the weight and shape of
the object (Gordon & Forssberg, 1997). This enables
holding a cracker without crushing it. The infant has
increasing ability to differentiate the pressure used in
finger flexion, indicating increased tactile and proprio-
ceptive discrimination in addition to greater motor
Figure 7-27 Spoon feeding at 18 months. control.
The 24-month-old child demonstrates increasing
dissociation of the fingers, strength and control of the
hand’s arches, and sensitivity to the tactual properties
in manipulation. Although the child continues to of the object. These underlying hand skills enable the
explore objects to learn their sensory properties, she child to perform a great variety of functional skills (e.g.,
also often “uses” objects for their specific function as self-feeding, using a spoon, scribbling with a crayon,
part of a purposeful play activity. building a tower of three cubes, and turning pages of a
The 2-year-old child uses utensils with competency. book). Practice of these skills leads to emergence of the
He now has sufficient control of crayon or pencil grasp pretend play sequences that dominate by 3 and 4 years.
to make a vertical stroke. Most children insist on self-
feeding at this stage. Although early attempts to spoon
feed generally fail, the intent is clear. Self-feeding
OBJECT RELEASE: 12 TO 24 MONTHS
becomes more successful because the child does not The need to stabilize a proximal hand or arm part on a
turn the spoon as it enters the mouth (Figure 7-27). surface to accomplish controlled release (e.g., release
Spoon feeding and early drawing skills are made cubes in a cup) continues through 18 months. In
possible by integration of sensory and perceptual particular, more precise release (e.g., of a small object)
information into blended patterns of mobility and requires the support of a stabilizing surface (Knobloch
stability. With improved perceptual-motor integration, & Pasamanick, 1974). Release of a cube in building a
the child imitates a circular stroke, matches a form to a three-cube tower is practiced, and, although generally
form space, holds an object with appropriate pressure, successful, alignment of the cubes is imprecise. Typically,
places and releases an object with accuracy, and when stacking cubes or small blocks, the infant extends
demonstrates beginning eye–hand coordination in ball the fingers all at one time, using more extension than is
play. All of these skills indicate an increased ability to necessary to actually release the object. The infant’s
integrate sensory experience and make accurate motor release is graded rather than abrupt, and small wrist,
responses or adaptations to those sensory inputs forearm, and finger movements are used to adjust the
(Connolly & Dalgleish, 1989). positions of the cubes one on the other. Visual
inspection during release increases, such that the hand
can accurately place a cube or puzzle piece. Perhaps the
PREHENSION: 12 TO 24 MONTHS most important contribution to the infant’s ability to
By 60 weeks prehension is deft and precise. The child place one object on another is internal stability of the
plans and uses grasping patterns that enable him or her arm while it is held in space, which allows the hands to
to act on the object after prehension (Gesell & act independently.
Amatruda, 1947). Fingertip grasp is used unless the By the end of the second year the child has well-
object is large and heavy or the situation is stressful for developed internal proximal stability and smooth
the child (e.g., being off balance or hurried). The hand graded or incremental release patterns. He can open
is sufficiently differentiated to hold two cubes in one the hand partially while carefully monitoring whether
hand (Knobloch & Pasamanick, 1974). The child can the object is correctly placed. Therefore the infant is
now able to adapt and adjust the hand opening first decade of life. The complexity, speed, accuracy, and
according to the size, shape, and weight of the object. precision of the skills increase with experience,
Controlled release in the 2-year-old child enables him cognitive development, and neuromotor maturation.
to fit puzzle pieces into their form space, place small Table 7-1 presents the developmental sequence of
objects in a container, turn pages of a book, stack grasp, release, and bimanual skills. Although the devel-
blocks, and manage a cup and feeding utensils. He can opmental ages for the listed skills vary, the sequence
construct a six-cube tower by precisely centering each of development tends to remain consistent across
cube and slowly releasing it, using gradual extension of children; therefore the months listed are estimated ages
his fingers. Object release continues to develop over the when the described skills are achieved.
next 3 years with significant increases in steadiness,
precision, dexterity, and speed.
SUMMARY
BIMANUAL SKILLS: 12 TO 24 MONTHS
From 12 to 24 months the infant develops greater The child’s play and the hand skills that enable that play
control of bimanual skills with increasing complexity undergo tremendous developmental changes in the
and integration of motor patterns. Speed, accuracy, and first 2 years of life. Exploratory play skills evolve from
dexterity increase. Proximal arm movements become generalized movements that gather comprehensive
dissociated from distal arm movements such that the sensory input to specific exploration of the sensory
infant can hold the hands in space to manipulate objects. qualities of objects. After the first year of life, infants
He or she also can demonstrate controlled arm move- exhibit functional play skills in which objects are used
ment while maintaining grasp of an object (Exner, as means toward a functional goal. Infants learn to use
2005). Many of the child’s activities involve one hand tools as evidence of their expanding knowledge about
manipulating and the other stabilizing the object. For how objects relate and how tools can serve functional
example, the child begins to spoon feed while holding goals. As play skills mature, the infant’s crude prehen-
the bowl, scribble with a marker while holding the sion patterns become precise grasping patterns that
paper, bang with a toy hammer while stabilizing the enable skillful manipulation of objects. The child holds
target toy. objects first in the palm, then in the fingers, and finally
Between 18 months and 2 years the child learns a in the fingertips. As she holds objects more distally,
variety of bimanual skills that require control of simul- coordination of two hands together evolves, enabling
taneous hand movements involving blended combina- the child to achieve greater competence and skill in play
tions of alternating stability and mobility (Gilfoyle et and interaction within the environment. This chapter
al., 1990). Stringing beads, pulling off shoes, and described how hand skills evolve from reflexive, stereo-
unwrapping a piece of candy are examples of skills in typical patterns into precise, well-controlled prehension
the repertoire of the 2-year-old that involve a sequence and manipulation patterns.
of bimanual movements in which the child simul- Current research has investigated how the infant
taneously controls arm and hand stabilization and develops hand skills. Posture, sensory functions, and
movement (Knobloch & Pasamanick, 1974). These perception appear to have essential roles in hand skill
bimanual movements can be asymmetric and dis- development. The activities and environments that
sociated when the activity requires that two hands act surround the infant afford a multitude of manipulation
together in different movements. Two-handed simul- opportunities. Current explanatory models explain
taneous movement also represents a developmental how hand skills develop and elucidate what variables
step from the earlier pattern of one hand manipulating influence an infant’s developmental trajectory. These
and the other stabilizing. Cooperative and complemen- models emphasize the influence of contextual elements
tary bimanual movements continue to be added to the in addition to biological foundations and have applica-
child’s repertoire of fine motor skills throughout the tion in early childhood intervention and education.
Table 7-1 Development of grasp, release, and bimanual skills: birth through 24 months
Approximate Age Grasp Release Bimanual Skill
Neonate Traction response Avoiding reaction: hand Smooth, alternating arm

opens with tactile movements; reflexive arm
stimulus to hand’s responses to proprioceptive and
dorsum tactile input
1 months Grasp reflex: local grasp Avoiding reactions Asymmetry of arm reaction;
reaction, followed by continue reflexive arm responses to
traction response proprioceptive and tactile input
2 months Grasp reflex: catch and

holding phases
3 months Instinctive avoiding Hands held together on chest,

response; pronation and usually without object; symmetric,
adduction from stimulus simultaneous arm movement
on ulnar side, supination,
abduction from stimulus
on radial side
4 months True grasp reflex; Instinctive avoiding Objects held with both hands at
primitive squeeze of reactions continue; midline; symmetric, midline
fingers; diminished variety of hand movements
traction response; movements used to
orienting response avoid touch contact
5 months Instinctive grasp; Release involuntary or Two-hand reach, with unilateral

squeeze grasp, gropes accidental prehension; object transfer, hand
for tactile stimulus; to hand; bilateral holding and
adjusts hand to object fingering
6 months Palmar grasp; pronated Object accidentally Simultaneous, symmetric,

hand and flexion of all released in mouthing or bilateral approach with bimanual
fingers; adjusts hand bimanual play or unilateral prehension
using visual and
tactile information
7 months Radial palmar grasp; Purposeful release; Successive bilateral approach with
superior palmar grasp; transfer of object from unilateral prehension; bilateral
differentiation of ulnar one hand to the other; object manipulation; associated
and radial sides stable; release against a resisting bimanual movements
radial fingers hold object surface
8 months Radial digital grasp; Purposeful release with

inferior forefinger grasp; assistance or resistance
object held proximal against a surface
to finger pads; ulnar
side stable and radial
fingers hold object
Continued
Table 7-1 Cont’d
Approximate Age Grasp Release Bimanual Skill
9 months Scissors grasp; able to Object rotation by transferring it

hold small objects hand to hand; plays with two
toys, one in each hand, banging
together; dissociation of
symmetric arm movement
10 months Forefinger grasp; tip of Active release; flinging

thumb and forefinger of object by combining
used in grasp; grasping elbow, wrist, and
accuracy without finger extension; object
stabilization release above surface
11 months Complementary and cooperative

bimanual movement
12 months Superior pincer grasp; Beginning of controlled Coordinated, asymmetric

tip of thumb and release; remains imprecise movements; one hand stabilizes
forefinger used in grasp; and one hand manipulates
grasping accuracy
without stabilization
15 months Deft and precise grasp; Controlled release; Beginning of two-hand tool use;
a variety of grasps used increasing control when continues pattern of one hand
releasing stabilizing and one manipulating
18 months Increasing dissociation, Controlled release, Asymmetric, dissociated

strength, and perception increasing accuracy with bimanual skills; blended stability
enable child to use tools limited precision of and mobility; alternating
and manipulate objects placement; tends to sequences of two-hand
extend fingers all at movements
one time
24 months Greater precision and Increasing competence in

control of release; two-hand tool use; increasing
adjustment of hand complexity in movement
opening according to patterns; cooperation of
object’s size and shape two hands
Exner C (2005). The development of hand skills. In J Case-

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Chapter 8
OBJECT MANIPULATION IN INFANTS
AND CHILDREN
Charlane Pehoski
CHAPTER OUTLINE children experience success and the perception of com-

petence. Bruner (1973) pointed out that competence
OBJECT MANIPULATION DURING INFANCY includes not only social interaction but also mastery
Movements Used in Object Exploration by Infants over objects.
The theme of this chapter is how the child gradually
Exploratory Nature of Infant Object Manipulation gains control over the hand to manipulate objects. Infancy
Object Exploration by the Mouth and Hand appears to be a time when reach is perfected and the
Role of Vision in Infant Object Manipulation basic grasp patterns are developed. At first the infant
can manipulate objects only by grasping the object,
Handling Multiple Objects waving the arm, and moving the wrist because the
Summary and Therapeutic Implications object is held in a power grip that fixes it in the hand
OBJECT MANIPULATION DURING THE TODDLER (Napier, 1956). Gaining the ability to transfer an object
YEARS hand to hand greatly expands the actions the infant can
produce with the object, but it is the appearance of a
Beginning of In-Hand Manipulation precision grip (pad of radial fingers to pad of thumb)
Control over Object Release that marks a major change in the eventual skills of the
Complementary Two-Hand Use hand. Landsmeer (1962) indicated that the purpose of
a precision grip is to “operate the object with precision
Summary and Therapeutic Implications by means of the fingers.” The perfection of this skill
OBJECT MANIPULATION IN THE PRESCHOOL AND covers a long developmental period. Voluntary release
EARLY CHILDHOOD YEARS (e.g., releasing an object in a predetermined place) also
Studies of In-Hand Manipulation develops in late infancy and is an important component
to skilled object interaction. Like object release, many
Role of Variability in Motor Skill Development of the basic components for skilled hand use are seen
Factors Contributing to the Improvement of In-Hand during infancy, but their perfection takes many years.
Manipulation Skills As an example, the child must learn to control the
Summary and Therapeutic Implications release of an object so he or she can place it with skill
and accuracy. In-hand manipulation skills, or the move-
OBJECT MANIPULATION IN OLDER CHILDREN ment of an object in the hand after grasp, are yet to be
SUMMARY acquired, and although the infant has the rudiments of
two-hand use, the ability to plan the movements of
both hands at the same time is not yet present.
The hand is a wonderful tool that has the exploration This chapter discusses what is known about the
and manipulation of objects as its primary purpose. The development of these components. There are many
development of the hand in the service of object ma- gaps in our understanding of these changes and how
nipulation follows a long course. It is one of the ways they might impact on the child’s gradual mastery of the
143
physical world. Given the importance of object

BOX 8-1 Ten Stages in the Development of
manipulation to human behavior, it is interesting that
Object Manipulation in Infancy
so little study has been done on this motor skill. In
looking at what has been written, we divided the
children into four age groups: infancy (neonate to ONE TO THREE MONTHS
12 months old), toddler (1 to 2 years old), preschool/ Stage 1: Rotation: An object is moved by twists of the
wrist.
early childhood (3 to 6 years old), and the older child.
Stage 2: Translation: There are movements of the arm
In addition, themes that might help us understand the that change the location of an object by increasing or
direction skilled hand use is taking at each of these decreasing the distance from self.
stages are explored. Stage 3: Vibration: There are repeated, rapid bending
One last note: The hand is the tool of the mind. It motions of the arm as the object is held.
is the mind that directs and guides the hand in the THREE TO FOUR MONTHS
context of the child’s environment and culture. Object Stage 4: Bilateral Hold: The object is held passively in
exploration or manipulation is the result of our desire one hand as the other hand holds or does something
to master the physical world. In infancy the basic drive else to another object.
to explore the world is present and, although the Stage 5: Two-handed Hold: A single object is held
with both hands.
infant’s physical skills are limited, these skills are used to
Stage 6: Hand-to-Hand Transfer: An object held in
gain information about object properties. It is probable one hand is transferred to the other.
that this drive sets the stage for all future object
FIVE MONTHS
exploration and the continued drive toward mastery.
Stage 7: There is coordinated action with single object:
One hand holds the object stationary and the other
hand does something to it (e.g., strokes a doll or
OBJECT MANIPULATION pulls at the hair).
SIX TO NINE MONTHS
DURING INFANCY Stage 8: There is coordinated action with two objects:
Manipulation of two objects, each held in a separate
Manipulation implies that the movement of the object hand, such as hitting two blocks together.
is done to achieve some purpose or goal; that is, that Stage 9: Deformations: The object is made to change
the individual is consciously engaged in the activity and shape, such as tearing paper or pressing a toy to
make a sound.
directing the action. By this definition, there was a time
Stage 10: Instrumental Sequential Actions: There is the
when researchers would not have considered studying sequential use of two hands in obtaining a goal, as
object “manipulation” in the very young infant. Neo- demonstrated when the infant lifts a cup to obtain a
nates and young infants were considered to be primi- cube.
tive beings dominated by reflexes that would gradually
be integrated so the infant could engage the world. Data from Kamiol R (1989). The role of manual
manipulative stages in the infant’s acquisition of perceived
More recent research has been guided by the belief that control over objects. Developmental Review, 9:222–225.
infants are born curious and with a drive to explore
their universe (although admittedly within the limita-
tions of their physical capabilities). As an example, if
properly supported and alert, neonates reach toward a (Box 8-1). Three of these stages—rotation, translation,
visually captured object (Bower, Broughton, & Moore, and vibration—were related to the young infant less
1970; von Hofsten, 1982). Although this behavior has than 4 months old. If an object was placed in the hand
been termed prereaching (Trevarthen, 1974) or pre- of a 2- to 3-month-old infant, the earliest engagement
functional (von Hofsten, 1982), it is voluntary and has Karniol noted was that the infant would rotate or twist
purposefulness not seen in more reflexive behaviors. the wrist, but only if the object happened to be visible
to the infant. If the hand was not visible, the object was
MOVEMENTS USED IN OBJECT EXPLORATION dropped. The next actions seen were translation move-
ments, or a deliberate effort to change the location of
BY I NFANTS
an object by moving the arm toward or away from the
Humans are born with the drive to reach out and body. Often this involved bringing an object to the
explore the physical world. Even as a neonate, the infant mouth or was combined with rotation. Karniol believes
uses primitive motor skills to begin this process. Based that these movements assist the infant in combining
on the observation of infants from 1 month to about changes in the retinal image of the object with proprio-
10 to 12 months of age, Karniol (1989) proposed ceptive feedback from the arm. The third method of
10 stages in the early object exploration of the infant engagement that Karniol observed in the very young
Object Manipulation in Infants and Children • 145
infant was a movement she called vibration. She defined

this as rapid, periodic movements of an object by
repeated bending of the arm. If the object produced
noise, the motion might be maintained or be more
vigorous. If the object did not make noise, it might be
translated, rotated, and visually examined before being
dropped. Consequently it appears that the very young
infant will manipulate objects if they are placed in the
hand, but this manipulation is limited to movements of
the arm and wrist. As we will discuss later, grasp itself
can also provide information about object properties to
even very young infants.
Young infants also may use their feet for exploration.
Galloway and Thelen (2003) found that when infants
about 3 to 4 months old were given an opportunity to
contact a suspended toy with either their feet or their
hands, the infants were able to make contact with their
feet at about 12 weeks of age and with their hands at Figure 8-1 Mouthing of objects is assisted once an
about 16 weeks of age. infant is able to use two hands to support the object
Reach is becoming functional at 4 months of age; (4-month-old infant).
the 4-month-old infant can also bring both hands
together to engage the object at midline. This ability mentary two-hand use stage. Karniol (1989) indicated
expands the action that can be taken on objects and is that, when this action is first seen, the infant often
a necessary first stage of “complementary two-hand rotates the wrist and bends the arm with the object in
use” (Bruner, 1970). Midline behavior is facilitated by one hand and then transfers it to the other hand and
changes in the general control of the arm and the body repeats the action. In recording the infant’s exploratory
itself. There is better balance in the trunk, as well as actions during a 90-second segment with a toy, Rochat
neck flexors and extensors, so the head is held in mid- (1989) found that the 5-month-old infants in his study
line and the child can tuck the chin to better observe transferred the toy a mean of three times, whereas the
the hands. By 4 months the child can also lie on his or 2-, 3-, and 4-month-old infants transferred the toy a
her back and bring the hands together up into the space mean of less than once per trial. Therefore like Karniol’s
above the body (Bly, 1994). This ability to bring the infants, Rochat’s infants began to incorporate hand-to-
two hands together is used by the infant in exploring hand transfer into their exploratory play at about
objects. 5 months of age.
At 3 to 4 months, Karniol (1989) adds bilateral hold By 6 months of age infants have a variety of actions
and two-handed hold to the list of options available to at their disposal by which they can explore and manipu-
the infant; that is, the infant can hold an object while late objects. They can mouth, look, rotate, wave, bang,
the other hand does something else or hold the object finger (run the fingers over the surface of an object),
using two hands. In a study of the object manipulation and transfer the object hand to hand. Nevertheless
and exploration of 2-, 3-, 4-, and 5-month-old infants, grasp at this stage is still dominated by a power grip.
Rochat (1989) saw an increase in mouthing in the 4- The thumb may be opposed to the fingers when
to 5-month-old infants over the 2- to 3-month-old picking up an object such as a block (Halverson, 1931),
infants, a behavior he found significantly associated with but when a smaller object is grasped, the fingers and
two-handed grasp. Therefore two-hand support for an thumb work together so the object is raked into the
object may assist the infant’s attempts to mouth objects, hand. By 9 to 10 months of age a major change occurs.
increasing the likelihood that this form of exploration Infants can now isolate the movements of the index
will occur (Figure 8-1). Once midline engagement of finger and thumb from other movements of the hand
the hands is developed, manipulation also is assisted by and fingers. They can poke with the index finger and
allowing one hand to hold and the other to explore the pick up a small object in a precision grip between the
surface of the object with the fingers. Rochat (1989) radial fingers and thumb (Folio & Fewell, 2000). When
also saw an increase in this fingering behavior in his studying 6-, 9-, and 12-month-old infants, Ruff (1984)
4-month-old subjects. found an increase in fingering behavior in the older
Further object exploration is possible around 5 to infants (running the fingers over the surface of an
6 months of age, when the infant is able to transfer an object), a function she felt was facilitated by the
object hand to hand. This is an important comple- increased independence of the fingers and increased
Rochat (1987) looked at the neonate’s use of the hand

and mouth to explore or differentiate object properties.
He addressed this question by looking at the reaction
of neonates to a soft or rigid object placed in either the
mouth or the hand. Newborn infants (49 to 96 hours
of age) were presented with either a soft foam or rigid
plastic tube, which was placed in their hand for grasp or
in their mouth for sucking. The tubes were attached to
a transducer, which was able to monitor the amount
of pressure the infants applied to the two different
objects. When grasped with the hand, the hard object
was associated with significantly more squeezes than
the soft object. When it was placed in the mouth, the
reverse was seen. Obviously the infants were respond-
ing to differences in the flexibility of the object. The
author suggests that the hand appears to be more con-
cerned with the graspability of an object and the mouth
with suckability. He also states that this “supports the
idea of an early detection of what objects afford for
Figure 8-2 Older infants can hold a cube with the functional action”; that is, the hand and mouth are
fingers acting independent of the palm. The object no tuned from the very beginning to actively explore an
longer needs to be pressed into the palm but can be object’s functional properties.
held out on the finger surface (10-month-old infant).
More recent studies also have found that the grasp
of the neonate is not just a rigid reflex but rather a
movement that allows the infant to gather information
coordination of the two hands. Grasp of an object, such about object properties. Streri, Lhote, and Dutilleul
as a cube, has also changed; the cube can now be held (2000) placed either a cylinder or an elongated prism in
with the fingers acting independent of the palm, so the the hands of neonates. After they had habituated to the
object no longer needs to be pressed against the palm object (defined as holding time that decreased to one
but can be held out on the finger surface (Halverson, third of the time on the first two trials or after nine
1931) (Figure 8-2). The ability to move the object out trials), the infant was either given the same or the oppo-
onto the finger surface, the development of a precision site object to hold. Holding time increased when the
grip, and the beginning of the differentiation of indi- infant was presented with the novel object. It appeared
vidual fingers are critical to the further development of that the infants were differentiating between the two
skilled manipulation by the hand. Another important shapes and demonstrating at least a primitive form of
development during this period is the beginning of tactile discrimination. Neonates 3 days old can also
controlled release. As an example, it is also at about 9 differentiate between objects that are smooth or have a
to 10 months that infants can release a cube into a cup granular surface (Molina & Jouen, 1998, 2004). The
(Folio & Fewell, 2000). infants in these studies tended to use more pressure
Therefore because infants’ exploratory actions when holding a smooth object and less pressure when
become more refined as they gain better control over holding a granular object. Molina and Jouen (2004)
their motor abilities, the variety of actions that can be believe that neonates’ grip is an exploratory tool that
taken on an object increases. Infants use these motor can be used to process object properties.
skills to explore the properties of the objects they grasp. The object manipulation of the infant less than
That is, infants’ actions with objects are not purely 4 months of age is necessarily limited because reach and
random but have the characteristics of true exploration. grasp are still quite primitive. Yet if an object is placed
in the infant’s hand or the infant happens to grasp an
EXPLORATORY NATURE OF I NFANT OBJECT object once in contact with it, some attempts to explore
the object’s characteristics appear to be present.
MANIPULATION Older infants have more physical skills at their dis-
Although the neonate may be able to accomplish a posal that are used to explore object properties. Steele
primitive form of reach, he or she does not yet have and Pederson (1977) looked at the difference in manip-
voluntary control over the grasp of an object but will ulation with changes in object properties in 6-month-
hold an object placed in the hand. For the young infant old infants. They measured the amount of visual fixation
the mouth is also an instrument of grasp or exploration. on the object, as well as the amount of manipulation.
Manipulation in this study was defined as any contact mouth) or when the mouth moved over the object.
between the infant’s hand and the object. No attempt The authors found a significant association between
was made to further define the type of manipulation. active mouthing and then immediately looking at the
Familiar objects the infant had previously manipulated object, but not other forms of object–mouth inter-
and novel objects were used. The authors found an action (e.g., just holding the object in the mouth).
increase in looking and manipulating with novel more After a bout of active mouthing the infant immediately
than familiar objects and also an increase in manipula- paused to look at the object. They hypothesized that
tion to changes in shape and texture but not to color. mouthing with looking might serve an exploratory or
Of these two variables, texture elicited more manipula- information-gathering function. To study this further,
tive behavior from the infants than changes in shape. they presented infants with familiar and novel objects
The authors concluded, “the results indicate that an and noted the forms of exploration used in the two
object that presents different tactile sensations is neces- situations. They found that mouthing with looking and
ary to produce different manipulative behaviors.” manual actions such as turning the object, transferring
Ruff (1984) also looked at how infants responded to hand to hand, and fingering all declined as the infant
different object characteristics. In this study, infants of became familiar with the object but returned when the
6, 9, and 12 months of age were presented with two infant was presented with a novel toy. Therefore they
sets of blocks that varied in color and pattern; more suggest that these actions are truly exploratory and a
importantly, they also varied in surface texture and means of gathering information about objects. Other
shape. Of interest was the observation that the infants actions, such as mouthing without looking, banging,
tended to adjust their manipulative behavior to the and waving, did not significantly decline in frequency as
different physical characteristics of the objects; that is, the infants became familiar with the object, and they
they mouthed and transferred the object more in the indicate that these actions may serve some other
shape series and did more fingering in the texture series function.
(e.g., blocks with bumps and depressions). In addition,
with increasing familiarity with an object, these explor- ROLE OF VISION IN I NFANT OBJECT
atory actions on the object decreased. This included
looking, handling, rotating, transferring, and fingering.
MANIPULATION
One behavior, banging the object, did not decrease Up to this point we have discussed changes in the
over time. The author suggests that this activity may motor system that provide the infant with mechanisms
represent a play behavior unrelated to object explor- by which object manipulation and exploration can
ation. This was also found by Ruff and co-workers happen. We have also indicated that even neonates
(1992), who further suggested that certain types of appear to use the motor skills available to them to
mouthing might not be related to true object explore object characteristics. Also important to the
exploration. object exploration of infants is consideration of the role
vision plays in driving and supporting this behavior.
OBJECT EXPLORATION BY THE MOUTH Blind infants are significantly delayed in their object
exploration when compared with sighted peers.
AND HAND
Fraiberg (1968) indicated that totally blind infants do
In early infancy object exploration by both the mouth not spontaneously bring their hands to midline for
and hand is a major component in the infant’s inter- mutual fingering, as seen in the 4-month-old sighted
action with objects, particularly the infant 7 months of child. She argued “that there is good reason to believe
age and younger. Ruff and co-workers (1992) indicated that the mutual fingering games and the organization
that, in their study, mouthing behavior peaked at about of the hands at midline are largely facilitated by vision
7 months of age and comprised 27% of the time the and that the tactile engagement of the fingers requires
infant was engaged with an object. This fell to 17% for simultaneous visual experience to insure its pleasurable
11-month-old infants. Ruff (1984) suggested that the repetition.” She also indicated that the hands of the
decrease in mouthing might result from a better haptic totally blind infant do not explore objects, but serve
system becoming available in the hand. primarily to bring the object to the mouth.
Ruff and co-workers (1992) looked at the explor- Consequently it appears that, for the normally
atory behavior of both the hands and the mouth in sighted infant, vision is an important motivator that
5- to 11-month-old infants. They described what they leads the hand into space and serves to facilitate grasp
called active mouthing and distinguished this from and manipulation. Even in neonates manual activity
more general actions of objects in the mouth. Active appears to be directed by visual information. Molina
mouthing was defined as movements of the object in and Jouen (2001) presented 3- to 5-day-old neonates
the mouth by the hand (e.g., being turned in the with one of two objects. One object was smooth and
the other granular (same objects used in the studies and a video camera sensitive to this light. He found that
mentioned previously). In a pretest period one of fingering was dramatically decreased in the dark situa-
the objects was placed in the infant’s hand without the tion, whereas the incidence of mouthing and hand-
infant being able to see the object. The time until the to-hand transfer remained the same in the two
object was dropped and the amount of pressure exerted experimental conditions. The author indicated that
on the object were measured. After this pretest period early fingering appears to be linked to vision and depends
the object was placed back in the infant’s hand at the on this modality. Alternately, mouthing appears to be
same time a smooth or granular visual object was pre- independent of vision, and in this study early hand-to-
sented on the table in front of the infant. Therefore the hand transfer also did not seem to depend on vision.
child was holding one object and looking at another Therefore it appears that, at least in younger infants,
object that was either the same or a different texture than vision is an integral part of the process of grasp and
the one being held. The holding time and pressure on manipulation, and in fact may be the early motivator for
the held object were measured again. The visual object object exploration and drive some of the more refined
was then removed and the holding time and pressure manipulative actions, such as fingering of an object.
on the object that remained in the hand were mea-
sured. The authors found that the holding time when
the texture of the held object and the visual object
HANDLING M ULTIPLE OBJECTS
matched increased but holding time remained the same Effective object manipulation also requires that the
when the visual and tactile objects were mismatched. infant solve the problems of how to deal with more
Molina and Jouen (2001) feel the results indicate that than one object at a time. Bruner (1970) attempted to
the infant is comparing the held object with the visual look at what he called “taking possession of objects” by
object. If the infant finds differences between the tactile presenting infants with a small toy and then presenting
and visual object, the process of comparison is stopped. a second toy to the same hand. If the infant did not
That is, holding time decreases because the “problem” make an attempt to secure the second toy, it was then
the child was given is solved. Alternately, as long as no held at midline. After two toys were grasped, the infant
differences are observed between the tactile and visual was handed a third and fourth toy and the child’s
object, the process of comparison is ongoing and explo- solution to this multiple object problem was observed.
ration time is increased. Therefore the authors feel that Bruner found that 4- to 5-month-old infants had diffi-
vision and touch are interconnected even at birth and culty managing two objects. Often, as the infant’s
that neonates can make some comparisons across these attention was attracted to the second toy, the held toy
two modalities. was dropped. The 6- to 8-month-old infants were able
The role of vision also can be seen in older infants. to solve the two-toy problem by transferring the initial
As indicated, Karniol (1989) found that when a 2- toy to the other hand and then grasping the second toy.
month-old infant grasped an object, he or she would Solving the problem of three objects required a dif-
rotate it but only if the hand could be seen. If the hand ferent strategy that was not seen until 9 to 11 months;
was out of visual regard, the object would be dropped. that is, when offered the third object, the older infants
In his study of 2- to 5-month-old infants, Rochat “stored” one of the objects he or she had been holding
(1989) looked at what infants did first with an object. on the table or lap. But half the infants of this age then
Did they immediately bring it to the mouth or did they retrieved the stored object immediately. They did not
first bring it to the eyes to look at it? (The infants were appear to be able to inhibit the drive to pick up what
all seated in slightly reclining infant seats.) He found they saw or could not delay this process. By 12 months
that at 2 to 3 months more than two thirds of the the infants had the solution of this problem well “in
infants first brought the object to the mouth. At 4 to 5 hand.” They not only transferred the first object to the
months the majority of the infants first brought the other hand in anticipation of receiving the second
object into the field of vision for inspection. This was object, but also anticipated the third and fourth by
particularly true of the 5-month-old infants, in whom storing the toys in hand in the lap or the arm of the
visual exploration was used first in 90% of the sample. chair. By 15 to 17 months the infants also stored by
Rochat (1989) also indicated that fingering of an handing objects to the parent or examiner. Therefore
object by infants might be linked to vision. In one by 12 months and older, infants have learned to deal
study using 2-, 3-, 4-, and 5-month-old infants, the with several items at one time.
author found a significant interaction between fingering
and looking. To test this interaction further, he studied
a different set of 3-, 4-, and 5-month-old infants as they
SUMMARY AND THERAPEUTIC I MPLICATIONS
manipulated objects in dark and light situations. The As infants gain control over the movements of their
dark situation was accomplished using an infrared light arms and hands, they also increase the options available
to them for object exploration. In the very young

infant objects are fixed in the hand, and exploration is
limited to a power grip and movements of the arm and
wrist. An important expansion of the actions available
to infants comes when they can bring both hands
together and eventually transfer an object from one
hand to the other. The infant can now wave, bang,
mouth, transfer, rotate, and run fingers over an object’s
surface. The ability to manage more than one object at
a time is also an important aspect of object interaction,
and infants appear to gradually accomplish this skill
over the first 12 months of life. During this period
infants also develop two other extremely important
skills: Control over voluntary release or placement of an
object, and the ability to use a precision or refined
pincer grip. This latter skill is critical to the further
development of object manipulation by the hand. A
From a therapeutic point of view, one should note
that changes in object properties seem to elicit different
manipulative behaviors from infants. As an example,
changes in shape appear to generate more transferring
and rotation activities, and changes in texture more
fingering and possibly an increase in the duration of
manipulation (Figure 8-3). Often parents and others
who interact with infants see the infant’s mouthing,
turning, and handling of objects as random motions.
As indicated, however, at least some of these move-
ments appear to be meaningful attempts to explore
object properties. This is important information to
consider when evaluating and planning programs for a
child. Pointing out to parents or caregivers how the
infant changes manipulative strategies with changes in
object properties can help them appreciate the infant’s B
competencies and the importance of these actions to Figure 8-3 Changes in an object’s texture and surface
the infant’s learning. Providing the infant with a variety characteristics may increase higher-level manipulation
of objects that differ in shape and texture may well such as fingering. This figure shows two infants who are
facilitate this process. approximately 9 months old using finger movements to
explore (A) a yarn ball, or (B) bells attached to a toy.
In observing infants, it is also important to note when
they do not show the variety of exploratory behaviors
appropriate for their age. As indicated, waving, banging, score lower than term infants on eye–hand and fine
and some forms of mouthing may not serve the same motor items of developmental tests. Kopp (1976)
exploratory functions as activities such as transferring found preterm infants to differ significantly from full-
hand to hand, fingering, rotating, and active mouthing. term infants on the duration of exploratory activity. In
Ruff and co-workers (1984) state that another study this same author (1974) found a greater
percentage of preterm infants (age corrected for
“The infant who does not finger, rotate, and transfer objects very
much has less opportunity to learn about object properties. We prematurity) to be clumsy in object manipulation when
can speculate that the less infants learn about object properties compared with term infants (70% of the preterm infants
the less they will engage in categorization of objects. Any deficit and 19% of the term infants). The clumsy infants also
in categorization should affect early language development. In were noted to spend less time manually exploring
this way it is possible for manipulative exploration of objects to
objects and more time in visual exploration. Ruff and
contribute directly to an infant’s cognitive development”
(p. 1173). co-workers (1984) also studied the manipulative
abilities of preterm and term infants. They divided the
Several studies (Church et al., 1993; Goyen & Lui, preterm infants into high- and low-risk groups
2002; Ross, 1985; Ross, Lipper, & Auld, 1986; Thun- depending on the infants’ early medical history. They
Hohenstein et al., 1991) have found preterm infants to then compared these two groups to a group of full-
term infants (preterm infants’ age corrected for know about how typical infants interact with the objects
prematurity). They found a significant decrease in the in their environment, the more effective we are in
incidence and amount of fingering, transfer, and encouraging this area of development in infants for
rotation of objects in the high-risk group compared whom this is felt to be an area of concern.
with the two other infant groups. Apparently for some
infants, the delay in fine motor skills is long lasting.
Goyen and Lui (2002) followed 54 high-risk infants OBJECT MANIPULATION DURING
(<29 weeks’ gestation or <1000 g) until 5 years of age.
At 5 years, 64% of the children scored below 1 standard THE TODDLER YEARS
deviation on the Peabody Developmental Fine Motor
Scales. Compared with those of the infant, the manipulative
The quality of an infant’s object interaction can pro- skills of the toddler show great strides in development.
vide important observational information and assist in Unfortunately, we know this more from intuition than
providing caregivers with suggestions for an infant’s actual research. Toddlers can do more than “grasp” an
continued development. Infants learn about their phys- object; they begin to manipulate the object in their
ical world through their manipulative actions. These fingers and hands. Release of an object also has im-
activities offer the infant an opportunity to experience proved, and these two skills allow the child to interact
a sense of success and mastery and may provide ex- effectively with smaller objects. It is also at this age that
periences on which later cognitive strategies can be children start to demonstrate complementary two-
based. These experiences may not be readily available hand use, greatly expanding their manipulative abilities.
to the physically handicapped infant, and this child Each of these areas is explored.
needs to be assisted through proper positioning and the
selection of appropriate toys.
Assistance has been shown to increase object engage-
BEGINNING OF I N-HAND MANIPULATION
ment in typically developing infants. Lobo, Galloway, In discussing the fine motor abilities of the 12-month-
and Savelsbergh (2004) found an increase in the num- old child, Gesell and co-workers (1940) stated that the
ber of contacts made to a toy by 2- to 3-month-old child’s “prehensory patterns are approaching adult
infants after 2 weeks of increased experience with toys. facility … fine prehension is deft and direct.” That is,
In this study the infants either were manually assisted the child has a neat pincer grasp and can use it with
in contacting an object at midline or the limb was skill. As indicated, this is an important achievement
tethered to an overhead toy with a ribbon so that limb for the child, but these prehensory patterns must be
movements moved the suspended toy. changed to manipulatory patterns for true hand skill
In another study, Needham, Barrett, and Peterman to develop. As an example, 12-month-old infants can
(2002) studied 3-month-old infants after an enrich- pick up a small object such as a Cheerio very well, but
ment experience that consisted of 12 to 14 parent-led if provided with several Cheerios in the hand, their
play sessions, each about 10 minutes in length. During manipulative skills are challenged. Young children
the sessions the infants wore mittens with Velcro generally solve this problem by bringing the entire
covering the palmar surface. They were then presented hand to the mouth rather than moving the object
with small toys that had the alternate side of a Velcro within the hand. Therefore one of the tasks in the next
strip attached to the toy. The study design also included few years is to take the “deft and direct” prehension
a group of infants whose parents were instructed to patterns they have learned and develop the capacity to
follow their normal daily routine during the 2 weeks of manipulate objects in the fingers and in the hand.
the study. After the 2 weeks, the infants in the experi- Exner (1990, 1992, 2001; see also Chapter 12) has
mental condition produced more intentional swats at called this ability in-hand manipulation or the adjust-
objects than the infants in the control condition. They ment of an object in the hand after grasp. The purpose
also showed greater switching between visual and oral of these adjustments is to allow more efficient place-
exploration. The authors conclude, “Experiences ment of the object in the hand for use or voluntary
acting on objects may be a critical factor in increasing release. Three components of this skill have been
infants’ engagement in objects and their object explora- defined. One is the ability to move an object from the
tion skills. Not only do infants explore objects more fingers to the palm or the palm to the fingers (e.g.,
after this experience, they employ more sophisticated picking up a coin and placing it in the hand and then
object exploration strategies that involve more co- moving the coin from the hand to the fingers for
ordination between visual and oral exploration.” placement in a bank or purse). Exner refers to these as
Object exploration is an important part of develop- translation movements. Another component is the
ment, even for the very youngest infants. The more we ability to rotate the object in the pads of the fingers,
either through simple rotation, in which the object is wiggle the thumb (or voluntarily isolate the movements
rolled or turned in the fingers, or more complex rota- of the thumb) as being a skill observed in 2-year-old
tion movements. In more complex rotation movements children. The ability to move the fingers individually
the object is generally rotated at least 180º, and the seems to come later. When Stutsman (1948) asked young
movement requires independent action of the fingers children to oppose each finger to the thumb, she found
and thumb. The third component is shift, or the move- that this was possible for only three of the children she
ment of an object in a linear direction on the finger observed who were between 30 and 36 months of age.
surface. The thumb often performs most of this move- By 36 to 41 months, 35% of the children accomplished
ment with reciprocal movements of the radial fingers the task, but it was not until 42 to 47 months that 50%
such as moving a pencil after it has been grasped so of the children were successful. It appears that isolated
the fingers are closer to the point (Exner, 1990). In movements of individual fingers are difficult for children
addition, these activities can also be accomplished while 3 years of age and younger, and this may be a major
another object is stabilized in the hand. An example of deterrent to the ability to accomplish deft and direct
a palm-to-finger movement with stabilization is when manipulatory patterns of objects in the fingers.
several small objects are held in the hand and one of Another factor that may limit the toddler’s in-hand
them is moved to the fingers for placement, such as manipulation skills is the force of the grip used to hold
when one of several Cheerios is moved from the palm an object. When the grip strength was measured as
to the fingers for placement in the mouth. Children in children and adults picked up a small object between
the toddler years are not yet adept at all components of the thumb and index finger, children were observed to
in-hand manipulation. use greater grip force than adults (Forssberg et al.,
In her original pilot study, Exner (1990) looked at 1991; see also Chapter 3). This was particularly true for
the in-hand manipulation skills of 90 children 18 months children 5 years or younger. When the steps necessary
to 6 years 11 months old. The developmental trend in to prepare to lift a small object also were carefully
these skills indicated that moving an object like a small measured with instruments sensitive to changes not
peg from the fingers to the palm for storage, then observable to the eye, it was found that it took longer
moving it back out to the fingers, and simple rotation for young children to prepare to lift the object.
were three of the easiest tasks and were accomplished Children 8 months (the youngest group of infants
by at least half of the 18-month to 2-year-old children studied) to 18 months old demonstrated a significantly
in her study. Other tasks, such as the complex rotation longer time from when the lead finger or thumb
of a pen in the fingers so the point is in a position for touched the block to when the second finger or thumb
use, were more difficult and not accomplished until the arrived. Small children also were noted to contact the
preschool years. Exner (1990) indicated that skills that object several times before a stable grip was established,
do not involve simultaneous stabilization of materials and they also had a tendency to push down as they
during in-hand manipulation activities are easier than were gripping. Forssberg et al. (1991) indicated that
those in which the child must control both sides of the this preparatory stage was three times longer in infants
hand (ulnar side to hold and radial side to manipulate). under 10 months old and about twice as long in
Exner (1992) also indicated that the amount of indi- children less than 3 years old.
vidual finger movements necessary for a task may make Therefore if young children have difficulty isolating
one component of in-hand manipulation more difficult finger movements, are slow in preparing for a grip (at
than another; that is, the ability to move an object such a micro level), and tend to grip objects harder in their
as a peg from the fingers to the palm is a relatively easy fingers than adults, then in-hand manipulation skills
task because the fingers tend to work as a unit. How- that require the grasp and release of an object and the
ever, rotating a pen in the fingers for use requires the coordination of these movements among different
sequencing of individual movements among the radial fingers are quite difficult or impossible. This also is true
fingers and the thumb. Although the 12-month-old of older children with deficits or marked delays in these
child has the ability to isolate the index finger and can areas. As an example, fasteners on clothes, particularly
use the index finger or radial fingers and thumb to pick buttons, require manipulation skills by the fingers. For
up a small object, there is reason to believe that further many children under 3 years of age, this is a difficult
isolation of finger movements is still difficult for the task. Another task that requires isolated movements of
child under 3 years of age. the fingers is the ability to move a pencil or writing im-
As an example, Stutsman (1948) looked at the plement in a dynamic tripod grip. This is also difficult
ability of young children to make a fist and wiggle the for many children under 3 years of age (Rosenbloom
thumb without moving the fingers. She states that this & Horton, 1971; Saida & Miyashita, 1979; Schneck
task “appears rather suddenly at 33 months.” Gesell & Henderson, 1990). Despite these limitations, the
and co-workers (1940) also talked about the ability to toddler is beginning to experiment with simple in-hand
manipulation tasks such as picking up and storing complementary two-hand use, we now step back and
several objects in the hand. These functions improve as briefly look at the younger infant to observe the
the child gains more control over the movement of transition to higher-level activities.
individual fingers and refines the force of grip. Bruner (1970) studied the early acquisition of this
skill in infants 6 to 17 months of age. He presented the
infants with a box that required them to hold open a
CONTROL OVER OBJECT RELEASE sliding, transparent lid to obtain a toy. Bruner found
The child 12 months to 2 years of age is gaining con- that the 6- to 8-month-old infants in his study tended
trol over the release of objects. This is an area that has to just bang or claw at the lid itself. In fact, this activity
not been widely studied, even though Gesell and co- often appeared to distract the infant from the toy, and
workers (1940) state that release is “one of the most banging became the main activity of interest. He
difficult prehensile activities to master in early life.” indicated that this behavior also was common in 9- to
These authors point out that it is the inability to release 11-month-old infants. In addition, another common
a cube properly that often causes the infant to fail when behavior of infants of this age was to open and close the
attempting to build a two-block tower. Efficient object lid, becoming distracted by this activity and not
release requires both the regulation of grip force with attempting to retrieve the toy. Another behavior that
the timing of the placement of the object so the object was seen in these younger infants was the opening of
is not “dropped” but precisely placed (Eliasson & the lid with one hand and then slipping the same hand
Gordon, 2000). At 2 years of age, the child can build a into the box with the other hand not participating at
tower of several blocks, but may press rather than place all. At 12 to 14 months, the infants added another
the block, often with enough force that the structure approach to the solution of the problem; to raise the lid
falls (Gesell et al., 1940). Gesell and co-workers (1940) with one or two hands and go after the toy with the
also note that, even at 3 years of age, the child may still free hand but to let go of the lid during the retrieval
have difficulty with release on more delicate tasks. For attempt. Even at 17 months, which was the oldest
instance, the child may pull the lace out when the hand group of infants studied, the activity was not yet well
is moved away while lacing shoes. Controlled release is mastered.
an important component of object manipulation. In Ramsay and Weber (1986) used a similar task in
many in-hand manipulation tasks the object is grasped looking at this skill in 12- and 13-month-old infants
and then repositioned by delicate grasp–release move- compared with 17- and 18-month-olds. They found
ments of the fingers. The development of this ability, their infants to be a bit more competent than Bruner’s
particularly the ability to release without the need to (1970), which in part may have been related to differ-
press down or use a supporting surface and to remove ences in the testing apparatus. Ramsay and Weber also
the fingers from the object surface with correct timing, had a box with a transparent lid, but this lid was hinged
is a valuable area for future research. and lifted rather than pushed open. Another difference
was that the transparent lid in Ramsay and Weber’s
study was furnished with a white knob. This may have
COMPLEMENTARY TWO-HAND USE provided the children with a clue as to how to solve the
Complementary two-hand use is an important skill that problem. Ramsay and Weber state that in their study
develops between 12 months and 2 years of age use of only one hand was rare and seen only in the
(Bruner, 1970). As indicated in the previous section, younger age group. The most common method of
the infant’s ability to use two hands in the manipulation approach was to lift and hold the lid with one hand and
of an object greatly expands the exploratory options to retrieve the toy with the other hand. They found this
available. Nevertheless, being able to hold an object in approach to be used an average of 50% of the time in
each hand, or even the ability to hold an object in one the 12- to 13-month-old children and 78% of the time
hand while acting on this object or manipulating in the 17- to 19-month-old group. The younger children
another, does not take advantage of the potential skill also used a strategy in which both hands opened the lid,
achieved when both hands are active at the same time. and then one hand held as the other hand retrieved the
This requires that the child be able to program or toy. This was seen an average of 37% of the time in the
motor plan different but complementary actions with younger group and only 12% of the time in the older
the two hands. This ability is more than just pro- infants. Another strategy that was used almost equally
gramming a holding function for one hand and a doing by both groups of infants was to lift the lid with one
function for the other. It involves the monitoring of hand, then transfer the hold of the lid to the free hand,
active movements of both hands at the same time. and retrieve the toy with the hand that originally
There is reason to suspect that this skill is not present opened the lid (used 13% of the time by the younger
until 2 years of age. To look at the development of infants and 10% of the time by the older group).
Stutsman (1948) has commented on this function in with the complementary two-hand aspect of the task.
children. She states that the “inability to perform dif- They place the string correctly into the bead but then
ferent movements with the two hands at the same time do not seem to know how to transfer the activity
seems to be characteristic of the child under 36 months between the two hands to complete the task. Almost all
of age.” One of the tasks she presented to young studies place the successful accomplishment of bead
children was to give them a long string attached to a stringing at 2 years of age (DuBose & Langley, 1977;
toy that was lying on the floor. The child was instructed Folio & Fewell, 2000; Gesell et al., 1940). As an
to pull in the string to attempt to get the toy. Unsuc- example, in the Peabody Developmental Motor Scales
cessful attempts included walking over to pick up the (Folio & Fewell, 1983), the ability of young children to
toy or only yanking the arm back to partially move the string three beads is examined. The authors found that
toy forward. The problem was correctly solved only this task could be accomplished by only 16% of the 18-
when the child managed to pull in the string hand over to 23-month-old children in the normative sample, but
hand to obtain the toy. She found that 90% of the 30- by 70% of the 24- to 29-month-old children, which
to 35-month-old children in the normative sample represents a significant change in behavior over a
were able to solve the problem, and 60% of the 24- to relatively short time. It appears that something happens
29-month olds, but only 22% of the 18- to 23-month- that allows this task to be successfully completed. It is
olds. Stutsman (1948) also lists scissor cutting as a probable that a major factor in this success is the
striking measure of bilateral hand use (Figure 8-4, A). emergence of complementary two-hand use.
She suggests this skill is difficult for the child 24 to 29
months of age because he or she cannot yet sufficiently
differentiate movement of the two hands.
SUMMARY AND THERAPEUTIC I MPLICATIONS
Another task that requires complementary use of The child at 12 months to 2 years of age has made
two hands is bead stringing (Figure 8-4, B). Often marked strides in the development of the control
young children who are unsuccessful in this task seem necessary for refined object manipulation by the hand
to have an idea of how to proceed but have difficulty when compared with the infant. The child is beginning
to develop in-hand manipulation skills, which are
facilitated as the child gains increasing ability to isolate
the movements of individual fingers and when the force
of grasp is better controlled. The child also gains
marked control over the release of objects when com-
pared with the infant, and the child now uses both
hands together in a complementary fashion.
This is also a time when complementary two-hand
use is developing, and the child may enjoy the oppor-
tunity to practice these skills. Placing items in a purse
or bag necessitates interaction between the two hands,
A because the activity often is not successful unless the
holding hand is also active during the process. Bilateral
hand skills also make dressing oneself possible. Children
can now coordinate the use of two hands to pull up
their pants or put on a sock.
Object size needs to be considered. Exner (1990)
found that the manipulative abilities of small children
were affected by the size of the objects presented. She
found that, in general, tiny (1⁄2-inch peg) or medium
(1-inch cube) objects were more difficult to handle
than an object such as a key. Connolly (1973) also
found differences in children’s grip patterns based on
differences in object size. Newell et al. (1989) looked
specifically at the effect of object size in relation to hand
size in children 3 years 3 months to 5 years 4 months
B when compared with adults. The subjects were asked to
Figure 8-4 (A) Scissor cutting, and (B) bead stringing pick up boxes of varying size (0.08 to 24.2 cm) and
are two of the tasks that readily demonstrate a young place them in another slightly larger box. The authors
child’s ability to use both hands together in a task. found that young children and adults predominantly
use the same grip pattern when the object is scaled to

the size of the hand. Children at this age enjoy picking
up and manipulating small items and they appreciate
the opportunity to explore their ability to pick up and
hold several small objects in their hand as long as care
is taken that the objects cannot be swallowed (e.g., a
flat plastic disc that is 11⁄2 inches in diameter or larger
allows the small child to practice refined manipulation
movements, and yet the object cannot be swallowed if
placed in the mouth). Besides having large dolls or
trucks available to play with, the child also can be
furnished with small trucks and dolls that require more
delicate movements of the hand. Therefore object size Figure 8-5 Buttoning is a task that requires both
should be considered when planning activities for small efficient use of the two hands together and the ability to
children. differentiate the movements of individual fingers. It is a
complex manipulative skill that is not accomplished well
until the preschool years.
OBJECT MANIPULATION IN THE 47 months of age, the children completed the task in
PRESCHOOL AND EARLY 34 seconds. Folio and Fewell (1983) found similar
results when they asked children to button and
CHILDHOOD YEARS unbutton one button in 20 seconds. Only 2% of the
normative sample at 30 to 35 months could accomplish
Age 3 through 6 years appears to be a time when the the task, whereas at 48 to 59 months 65% of the
child is gaining control over the intrinsic movements of children were successful. Therefore, despite the ability
the hand. One of the major changes seen during this of many 21⁄2-year-old children to accomplish buttoning,
period is the continued emergence of in-hand manip- the speed with which the activity is performed is so
ulation skills. This ability greatly expands the activities slow as to preclude it from being functional. Are the
the child can accomplish. For example, at 3 to 7 years younger children slower because the basic movements
old the child learns to deal with the fasteners on clothes, themselves are not as efficient, or are they using less
and cuts, pastes, and manipulates writing instruments. efficient methods than older children?
These tasks require both cooperation between the two Pehoski, Henderson, and Tickle-Degnen (1997)
hands and the ability to manipulate objects in the looked at this question using an in-hand manipulation
fingers and hand. task. They asked 153 children between the ages of 3 years
and 6 years 11 months to turn over 10 small pegs in a
pegboard using only one hand (a complex rotation
STUDIES OF I N-HAND MANIPULATION task). A group of adult subjects also was presented this
Buttoning is one of the representative manipulative task to establish a standard against which the children’s
skills that has been studied during this age period. performance could be judged. All the children sampled
Stutsman (1948) indicated that no child in her were able to accomplish the task, but the time they
normative sample who was under 23 months of age was took for completion and the methods they used to
able to manage the button on a one-button strip, and perform this activity differed among the age groups.
only 9% of 24- and 29-month-olds successfully com- The time for completion decreased with age, as did the
pleted this task. This is not surprising considering the variability in time scores within an age group, but even
difficulty children of this age have in differentiating the at 6 years 11 months the children were significantly
movements of individual fingers, as well as efficient use slower than the adults. Of the age groups of children
of the two hands together. She found a major change tested, the 3-year-olds were by far the slowest group
in the ability of 30- to 35-month-old children. In this and differed significantly from the other age groups.
age group 72% of the sample was successful (Figure 8-5). Perhaps of more interest was the finding that the
Despite the 30- to 35-month-old children’s ability to methods the children used to accomplish this task
perform the task, their efficiency or speed was markedly differed. In the sample of normal adults, Pehoski and
different from that of older children. For example, co-workers (1997) found that all the subjects used the
Stutsman found that it took an average of 170 seconds same method to perform this task. Each of the adults
for the children in her 30- to 35-month-old sample to picked up the 10 pegs and rotated them using a series
button two buttons, whereas 12 months later, at 42 to of individual movements of the two radial fingers and
A C
Figure 8-6 In a study of in-hand manipulation in young

children, the children were asked to hold a dowel in their
nonpreferred hand to encourage activity in the dominant
or preferred hand as they turned over small pegs in a peg
board. Three methods were used to accomplish this task:
A, the method used by adults in which the pegs were
rotated in the fingers; B, use of an external surface to
support the peg as it was rotated (this was done most
often against the child’s chest); and C, rotating the arm,
and thereby excluding or simplifying the need for
individual finger movements. The adult method increased
B in use with age (see Fig. 8-7).
the thumb. The methods used by the sample of children Of interest was the marked change to an adult method
were more varied, and often the children mixed the use seen in 48- to 53-month-old children. The 3-year-olds
of more than one method in the repetitions of this task. in the sample relied heavily on the use of an external
Many of the children were able to demonstrate use of surface when turning the peg. This method was used
the adult method (Figure 8-6, A), but they also used an average of 40% to 50% of the time by the two
two other approaches when solving this problem. One youngest age groups. By 48 to 53 months this method
was to use an external surface against which the peg had fallen to 25%, and the predominant method used
was turned, such as holding the peg against the chest as was that of the adults (used 70% of the time). That is,
it was rotated (Figure 8-6, B). Inadvertent use of the by 4 years of age the children were rotating the peg in
other hand also was considered as using an external the fingers and used this method as the predominant
surface. (The children were instructed to hold a vertical solution to the problem (Fig. 8-7).
post with their nonpreferred hand in order to
encourage in-hand manipulation by one hand alone.) ROLE OF VARIABILITY IN MOTOR SKILL
The other method was to rotate the arm before picking
up the peg so that the peg was turned through the
DEVELOPMENT
derotation action of the arm, thereby excluding or Variability in the methods or grasps used when
simplifying the need for individual finger movements developing a new motor skill is a common finding in
(Figure 8-6, C). Use of the adult method increased children. It has been described in studies of infant reach
with age, although even at 6 years this method was (Thelen et al., 1993), the placement of pegs in a hole by
used only 80% of the time. 12-month-olds (Moss & Hogg, 1983), the emergence
100.0 FACTORS CONTRIBUTING TO THE

90.0
80.0
I MPROVEMENT OF I N-HAND
70.0 MANIPULATION SKILLS
Percentage
60.0
50.0 What are some of the physical aspects that change to
40.0 allow an increase in speed and a more consistent, adult
30.0 method of performance? The adult method of turning
20.0
10.0
over a peg using only one hand requires the differen-
0.0 tiation and change in performance between the two
3.0 3.6 4.0 4.6 5.0 5.6 6.0 6.6 Adult radial fingers and the thumb. As discussed, the ability
Age to differentiate the movements of the individual fingers
Adult
(e.g., the ability to sequentially oppose the fingers to
Internal Surface or
method rotation other hand the thumb; Stutsman, 1948) seems to appear at about
42 to 47 months of age. Once present, there is a
Figure 8-7 Percentage of times each of three methods gradual increase in the speed of these movements. As
was used when attempting a simple rotation task by
an example, the Peabody Developmental Fine Motor
children 3.0 to 6.6 years of age. (From Pehoski C,
Henderson A, Tickle-Degnen L [1997]. In-hand manipulation Scales (Folio & Fewell, 1983) looks at the ability of
in young children: rotation of an object in the fingers. children to oppose each finger to the thumb within
American Journal of Occupational Therapy, 51:544–552.) 5 seconds. It was found that this task could be accom-
plished by only 22% of the 42- to 47-month-old children,
but 72% of the 48- to 59-month-old children were
of self-feeding in toddlers (Connolly & Dalgleish, successful. The ability to isolate individual fingers of the
1989), and the use of writing implements in 3- and hand and perform this activity with speed appears to
5-year-old children (Greer & Lockman, 1998). The be a requisite skill for efficient in-hand manipulation
performance of adults on these same tasks is much activities and may be one of the reasons children 4 years
more stable. A dynamic systems approach to develop- of age and older are better at in-hand manipulation
ment indicates that infants and children initially explore skills than are children 3 years old or younger.
different ways of accomplishing a task and that these Manipulating an object such as a peg in the fingers,
trials are based on the intrinsic dynamics of a particular rotating a pencil so the tip is in the correct position to
child (Thelen & Smith, 1994). These dynamics might write, and turning a small bead in the fingers to orient
include such things as muscle tone, body dimensions, the hole for stringing all require a grip that is firm
and temperament. As children encounter their environ- enough to keep the object from being dropped but
ment and explore different forms of an action for a light enough to allow the object to be moved. In the
given task, they eventually settle on one form that is study by Forssberg and co-workers (1991), children
most effective and efficient for them (Greer & were noted to use significantly greater grip force than
Lockman, 1998; Thelen & Smith, 1994). In this adults when picking up a small object. In adults the
dynamic systems theory of development, variability in force of the grip is matched to the properties of an
performance is viewed as a sign that the system is in object (e.g., its weight and frictional qualities), and
transition and working toward a more stable perform- determining this force is related to tactile feedback
ance. Although the goal may be the same for each child from the hand (Westling & Johansson, 1984). Adults
(e.g., to hold a spoon in a manner that allows food to use just enough force to provide a small margin of
be brought efficiently to the mouth, hold a pen to safety so the object does not slip out of the fingers. If
make a specific mark on a paper, or turn a peg over in the adult’s fingers are anesthetized, eliminating the
the fingers), the various methods the child uses as he or tactile feedback that monitors the frictional conditions
she learns these skills depends on individual intrinsic between the object and the fingers, the ability to adjust
dynamics. Therefore variability is seen as a develop- the grip force is compromised. Therefore tactile feed-
mental process that includes both physical change and back is necessary for the successful accomplishment of
experience. Children who are having difficulty with this this skill. It is also interesting to note that Westling and
process and are slow to develop a stable performance Johansson (1984) found that the adults in their study
may need more time or experience practicing a task. with the greatest manual dexterity were also those who
They also may benefit from an attempt to analyze the employed the smallest safety margins.
intrinsic factors that may be limiting them so that Evans, Harrison, and Stephens (1990) have looked
changes or adaptations can be made to the implements at the maturation of cutaneous reflexes in children. To
or methods used. do this they stimulated the cutaneous nerve of the
index finger and monitored the EMG response while the grip force between a population of adults and
the first dorsal interosseous muscle was actively con- children when the subjects were asked to pick up a
tracting. The authors did not observe a full adultlike small object between the index finger and thumb. As
EMG response until the early teen years. As an exam- indicated, the regulation of the grip force rate on this
ple, the adult EMG response to digital nerve stimula- task has been linked to tactile mechanisms. Evans and
tion has three components: an initial increase in muscle co-workers (1990) found that an important compo-
electrical activity, followed by a decrease, and finally a nent of the cutaneous reflex is not present until 4 years
second, prominent increase. The last of these com- of age and that the appearance of this component may
ponents, called the E2 component, is felt to require the be linked to the speed of sequential finger movements.
integrity of the dorsal columns (tract carrying dis- The strength of the grip force and the ability to
criminative somatosensory information to the cortex). rapidly sequence the movements of the fingers are im-
In the Evans and co-workers (1990) study, the E2 portant components in the manipulation of an object in
component was not seen until 4 years of age, and then the fingers or the hand. Vision can guide the hand to
there was a gradual increase in the number of children the target, but tactile mechanisms guide the object in
who demonstrated this aspect of the response until 12 the hand. Nature may well have a rule that says, “Use
years of age, when all children exhibited an E2 response. whatever mechanisms you can to manipulate an object,
Of further interest was the finding that children who but whatever you do, don’t drop it!” This rule is
did not demonstrate an E2 component were more ensured by tactile mechanisms that detect even minor
likely to perform poorly on a test of rapid finger move- slippage of a hand-held object and tell the motor
ments; therefore the appearance of this component of system to increase or adjust the grip (Johansson &
the cutaneous reflex response may be implicated in the Westling, 1984). If these mechanisms are immature,
speed of finger movements. generally increasing the grip force or holding an object
more tightly is one way to compensate for this skill. In
Pehoski and co-workers’ study (1997), when children
SUMMARY AND THERAPEUTIC I MPLICATIONS were asked to rotate a peg and replace it in the board,
Children between the ages of 3 and 6 years are making dropping the peg was not a common finding. No child
rapid improvement in their ability to manipulate dropped more than one of the 10 pegs, and approxi-
objects in the fingers and hand. This is still a difficult mately half the children dropped no pegs at all. When
task for many 3-year-old children, and an activity such working with children, a tendency for objects to be
as buttoning is just beginning to be done with enough dropped from the fingers should be noted. When this
speed to make the task functional. Other activities, such is felt to be excessive, one possible area to consider is
as rotating a small object in the fingers, is still difficult the integrity of tactile motor mechanisms.
for the 3-year-old, and the child is likely to substitute Another point to note when evaluating children is
another method for the movements of the fingers (e.g., that most tests for children in the preschool and early
rotating the object against an external surface). The childhood years do not include items that assess in-
fourth year of age may be a time of marked change in hand manipulation skills. Therefore the evaluator may
these abilities, particularly the complex rotation of an wish to add tasks of this nature, particularly for the
object in the fingers. Pehoski and co-workers (1997) child who is 4 years of age and older, so these skills can
found that children at this age tend to switch from be observed. As an example, first-grade children’s in-
using an external surface when rotating a small peg to hand manipulation skills are one of the factors that
accomplishing the task with the fingers. Five- and six- differentiate good from poor handwriting (Cornhill &
year-old children continue to show improvement in Case-Smith, 1996); and the speed of rotation of small
these skills, although this improvement is not as pegs in a peg board in preschool children has been
marked (e.g., the difference in improvement among shown to significantly correlate with a test of self-care
the 4-, 5-, and 6-year-old subjects is not statistically (Case-Smith, 1996).
significant). The fourth to fifth year of age also is the
time when children are switching their pencil grip to
a dynamic tripod, or a grip that incorporates small,
intrinsic movement of the fingers (Rosenbloom &
OBJECT MANIPULATION IN
Horton, 1971; Saida & Myashita, 1979; Schneck & OLDER CHILDREN
Henderson, 1990).
Of interest is that several other physical functions Information about the object manipulation of older
also appear to be changing around 4 to 5 years of age. children is limited. We do know that the speed of
As an example, Forssberg and co-workers (1991) found movement and a decrease in variability of movement is
that after 5 years there was no significant difference in characteristic of older children. Finger movements get
faster from 6 to 12 years of age (Garvey et al., 2003), environmental challenges that encourage children to
as does the reaction time from the start signal for a practice and advance their skills. Older children also
reach and the actual movement to reach (Kuhtz- show improved judgment and better control over
Buschbeck et al., 1998). Muller and Homberg (1992) impulsive behavior, which also improve the accuracy
indicate that the maturation of the motor cortex and and quality of skilled motor activities.
corticospinal efferents is the main determinant of speed
in repetitive movements in children. They indicate that
the conduction times for afferent pathways reach adult SUMMARY
levels by the age of 5 to 7 years, and for efferent
pathways by 10 years (Muller & Homberg, 1992). In Efficient object manipulation depends on several
reaching, the trajectory of the arm becomes smoother factors. There is the necessity to be able to differentiate
and less variable (Schneiberg et al., 2002) with age. The the movement of individual fingers and to perform this
number of units per reach decline, so that by 12 years action with speed. Manipulation skills also depend on a
only one acceleration-deceleration is seen (Kuhtz- grip force that is firm enough to keep the object from
Buschbeck et al., 1998). Older children also are better dropping, but loose enough so that the object can be
at adjusting the grip size to the size of an object; 4- moved with ease. This ability apparently is dependent
year-olds use a wider opening than do 12-year-olds on tactile mechanisms. In addition, an object also must
when grip opening is adjusted for hand size (Kuhtz- be released with skill and the appropriate timing. The
Buschbeck et al., 1998). The coordination of the forces ability to use the hands together is important also. With-
necessary to lift an object from a surface and the force out the ability to plan and use both hands together in
in the fingers to hold the object during the lift also a complementary fashion, the function of the hands is
improve with age (see Chapter 3). severely limited. Maturation in each of these abilities
Accuracy is improving, as is the timing of motor assists the child’s mastery over objects and struggle
acts. One form of timing has been called coincidence- toward competence.
anticipation, or the ability to time a movement with There is still much that is not known about the
another moving object. Bard, Fleury, and Gagnon developmental course and changes in development that
(1990) suggest that this skill may improve linearly with emerge as the child engages the objects in his or her
age until it levels off at around 15 years. However, the environment. We need more information on how normal
authors also state that “further progress is sometimes children develop manipulative skills. As an example, we
noticed beyond this age in tasks with high degrees know very little about the beginning of in-hand manip-
of stimulus uncertainty and motor response difficulty, ulation. There are no studies on the development of
thus placing a greater burden on decision and motor controlled release, a process that probably follows
processes”. closely on how children grasp objects. The gradation of
Another area in the literature that indicates con- pressure as a child picks up, puts down, and manip-
tinued changes in older children is in complementary ulates objects deserves further study, as does the effect
two-hand use. As the child grows, the complexity of of grasp force on higher-level skills, such as holding a
bimanual task that can be completed expands, as well as pen and writing. These are only a few of the areas
the efficiency between the two hands. Brumi (1972) needing future research. Object interaction is an integral
looked at the abilities of 5-, 8-, and 10-year-old children part of human behavior, yet it is an area that has been
to string beads, wind a string on a spool, and clap the poorly studied. A more complete understanding of this
hands. The author found that the older children tended area of development would help both the evaluation
to keep one hand stable while the other moved (e.g., in and treatment planning of children having difficulty in
winding the thread both hands did not rotate in mirror achieving competency in object interaction.
image of each other). Fagard (1990) suggests that one
of the changes taking place in older children is an
increasing ability to do asymmetric tasks with the
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Chapter 9
HANDEDNESS IN CHILDREN
Elke H. Kraus
CHAPTER OUTLINE Assessment

Intervention Theory
DEFINITION AND CLASSIFICATION OF
HANDEDNESS Concluding Remarks
Defining Handedness in Terms of Handedness SUMMARY

Dimensions
Classifying Handedness into Categories
Description of Left and Switched Handedness Handedness can be defined as the consistent and more
proficient use of the preferred hand, compared with the
PREVALENCE OF HANDEDNESS nonpreferred hand, in functional and skilled tasks
ASSESSMENT OF HANDEDNESS (Annett, 1985). Established handedness generally is
Tests for Hand Preference considered to be an important indicator of hemispheric
specialization and callosal myelination necessary for
Tests for Hand Performance development of motoric skills, language, and cognitive
FACTORS DETERMINING AND INFLUENCING processes (Annett, 1998; Bishop, 1990a,b). Conversely,
HANDEDNESS unestablished handedness, associated with develop-
Neuroanatomical and Neurophysiological mental delay or even pathologic conditions, sometimes
Foundations of Handedness reflects inadequate hemispheric specialization (Coren,
1992; Gazzaniga, 1970). From a functional perspec-
Genetic Theories on Handedness tive, the establishment of handedness is critical for
Pathological Influences on Handedness successful occupational performance and development
Sociocultural and Environmental Influences of high manual skill levels (Hurlock, 1975; Mandell,
Nelson, & Cermak, 1984; Vasconcelos, 1993). It is
Concluding Remarks unlikely that a child will be able to develop optimal skill
THE DEVELOPMENT OF HANDEDNESS if hands are changed during tasks such as drawing or
Birth writing because the preferred hand will fail to specialize
to the necessary proficiency (Hurlock, 1975). Further-
4 Months more, evidence exists that motor and learning problems
6 Months frequently occur in children who learn to write with the
8 Months nonpreferred hand as a result of incorrect handedness
classification (Ardila et al., 1988; Bishop, 1990a;
12 Months Peters, 1990; Sattler, 1998, 2001, 2002). Occupational
18 Months therapists should understand and meet the special
24 Months needs of left-handed children, particularly in relation to
handwriting. In this context, the correct identification
2 to 6 Years of a child’s handedness, its promotion, and the devel-
PEDIATRIC OCCUPATIONAL THERAPY AND opment of manual skill in children with unestablished
HANDEDNESS or left-handedness are necessary and important aspects
161
in pediatric occupational therapy (Mandell et al., 1984; alence of handedness, followed by the assessment of
Sattler, 2001). handedness, comprise the second and third sections.
Children with unestablished handedness are fre- Fourth, various factors that determine and influence
quently referred to pediatric occupational therapy for handedness are presented as critical background infor-
other reasons, and their inconsistent hand use is usually mation, and fifth, the development of handedness is
noted informally during the process of assessment and outlined. In the final part of the chapter, handedness
treatment. In a survey interviewing 51 occupational is discussed in relation to pediatric occupational therapy
therapists in Germany it was reported that overall 73% assessment and treatment.
of referred children between 4 and 7 years presented
with ambiguous hand use (Riedel, Künnemann, &
Kling, 2002). DEFINITION AND CLASSIFICATION
However, handedness, particularly unestablished
handedness, has received little attention within occu- OF HANDEDNESS
pational therapy literature to date. Although the 1970s
and 1980s resulted in an abundance of handedness lit- The definition of handedness in the literature is incon-
erature in the field of neuropsychology, this knowledge sistent and ambiguous. For the purpose of this chapter,
was not comprehensively applied to, or incorporated handedness is first defined in terms of dimensions of
into, the occupational therapy frame of reference. Since handedness, followed by discussion on the classification
this time, research studies of handedness have been of handedness into categories, with particular emphasis
much fewer, and particularly unestablished or mixed on consistency as an important classification factor. In
handedness has received little attention in neuro- this context, left and switched handedness are described
psychology. Within the holistic definition of occupa- in more detail. Figure 9-1 summarizes the aspects dis-
tional performance, handedness should not be perceived cussed in relation to the handedness definition.
as an isolated unit within a hierarchy, but rather in
relation to other skills relating to occupational per- DEFINING HANDEDNESS IN TERMS OF
formance in the wider sense. Unestablished handedness
in the developmental context is considered to be an
HANDEDNESS DIMENSIONS
indicator of neuromaturational delay (Bishop, 1990a), In the context of the many handedness definitions in
and the degree to which handedness is established may the literature, the term “handedness” refers to a
indicate other forms of dysfunction or pathology (see combination of hand preference and hand performance
Factors Determining and Influencing Handedness). (Annett, 1998) as two dimensions of handedness.
Unestablished handedness may also coexist with other Hand preference has been defined as the tendency to
behaviors such as avoidance of midline crossing and perform the majority of tasks with one hand rather
poor bimanual motor coordination, which together than the other (Nalçaçi et al., 2001). This does not
affect functional hand use (Ayres, 1972; Cermak, necessarily mean that the chosen hand is more efficient
Quintero, & Cohen, 1980; Dahl Reeves & Cermak, (Porac & Coren, 1981). Moreover, hand preference
2002). In addition, it is possible that one hand might has been stipulated to be the spontaneous untrained
be prevented from gaining sufficient practice to hand use as a measure of the inherent predisposition
become adequately skilled in drawing and writing tasks. to handedness (McManus & Bryden, 1992; Olsson &
Consequently, unestablished handedness is likely to Rett, 1989; Sakano, 1982; Sattler, 1998; Steenhuis
retard the development of highly integrated manual & Bryden, 1989; Steenhuis et al., 1990). Conversely,
skill and fine motor coordination that refine occupa- hand performance is most aptly defined as the superior
tional performance. proficiency of one hand over the other in tasks
This chapter presents an empirical, theoretical, and requiring skill (Annett, 1970a). The innate motor ability
developmental knowledge base for the establishment interacts with environmental demands and develops
and nature of handedness to provide therapists with a with practice to varying extents of skill acquisition,
more comprehensive basis for assessing and treating which may be independent of hand preference (Porac
children’s handedness. This knowledge base draws & Coren, 1981).
from different approaches and is divided into six sec- The distinction between hand preference and hand
tions. First, the definition of handedness is presented, performance has been explored extensively (Annett,
differentiating between hand preference and hand 1985; McManus & Bryden, 1992; Peters, 1996; Todor
performance, and considerations for evaluating these & Doane, 1977). According to Annett (1985), the
are reviewed. In addition, the process of classifying inherently more skilful hand also becomes the preferred
handedness and the description of two particular types one, whereas McManus and Bryden (1992) conclude
of handedness conclude the first section. The prev- that preference precedes performance. Note that dif-
Handedness in Children • 163
Trained Untrained Trained Untrained
Hand Hand
preference performance
Dimensions of
handedness
Defining HANDEDNESS
Classifications of Consistency
handedness
Across tasks Within tasks
Continuous
Categories
spectrum
Explicit Explicit
left Mixed
right
Variable Unestablished Variable

left right
Switched Pathological
Figure 9-1 Summary of aspects related to the definition of handedness. Handedness can be defined both in terms of
dimensions and classification. An important distinction is made between hand preference and hand performance as two
dimensions of handedness, each with a trained and untrained aspect. Classifying handedness can be subject to observing
the consistency of hand preference during task execution (across and within tasks), but in essence handedness is viewed
across a continuous spectrum, ranging from explicitly left handed, to various extents of handedness variability, to explicitly
right handed. However, to draw comparisons for differences and similarities between different strengths of handedness, it
is useful to divide the continuum into categories: explicit left, mixed, and explicit right. The mixed category can be divided
further into variable left and right handers, and unestablished (switched and pathological) handers.
ferent assessments were used in studies supporting the performance, but so far no consensus on these factors
preceding conclusions, which may be responsible for has been reached.
the contradictory findings. A cause-and-effect relation-
ship between preference and performance is far from Hand Preference
clear, as Peters (1996) suggested when he asked Several authors have defined hand preference in terms
of types or components. Bryden (1982) proposed four
“Is it the predominance of inherent biases interacting with “types” of hand preference: actions that require skill
environmental chance events, or is it the predominant environ- such as using a tool, reaching actions that do not
mental influence interacting with weak inherent biases which require any skill, power actions such as carrying a
determines the final pattern of behaviour?” (p. 118). suitcase (in which one is inclined to change hands
because of fatigue), and bimanual actions in which
To date there is no clear answer to this question. both hands are involved. He found that hand
The literature exploring hand preference and per- preference is most significant for tool use and bimanual
formance and proficiency distributions displays a variety actions and least significant for power actions and
of results in which some performance and preference reaching (Bryden, 1982).
tasks yield large differences between the hands Healey, Liederman, and Geschwind (1986), and
(bimodal) and others do not (unimodal) (Annett, Geschwind and Galaburda (1987) suggested that one
1992; Borod, Caron, & Koff, 1984; Steenhuis, 1996). significant dimension of hand preference was deter-
For example, there is greater discrepancy between the mined by the musculature involved in task execution.
hands in handwriting proficiency than grip strength There is physiologic evidence that both the contra-
(Provins & Magliaro, 1989). In addition, factors such as lateral and ipsilateral hemispheres control proximal arm
practice or task nature may influence the magnitude of muscles via multisynaptic pathways, whereas distal con-
the interhand performance differences (Annett, 1992). trol of the hand and fingers is executed by the contra-
It might be assumed that hand preference and hand lateral hemisphere via the corticospinal tract (Brinkman
performance and proficiency should be virtually inter- & Kuypers, 1973; Glickstein & Buchbinder, 1998;
changeable (i.e., the preferred hand is also the more Haaxma & Kuypers, 1974; Peters, 1995). Support for
skilled and proficient one and vice versa). However, the the distal–proximal distinction was found by several
correlation between hand preference and performance authors who observed that fine manipulations per-
has been shown to be weaker than expected. Porac and formed by distal musculature appear to be more
Coren (1981) suggested that preference and per- lateralized than gross motor tasks involving mainly
formance have a common underlying factor, because proximal musculature (Bryden, Bulman-Fleming, &
their correlation, although not always strong, is still sig- MacDonald, 1996; Peters & Pang, 1992). Other studies
nificant. Furthermore, the correlations between pref- only partially supported these findings, suggesting that
erence and performance appear to be task dependent the musculature used seems to be task dependent
(see Porac & Coren, 1981, for a review). Interestingly, (Case-Smith, Fisher, & Bauer, 1989; Steenhuis &
in some studies the correlation between preference and Bryden, 1989). Whether and to what extent hand pref-
performance became significantly weaker when the erence is influenced by proximal and distal musculature
sample was divided into left and right handers (Bryden is yet to be empirically established.
et al., 1994; Lake & Bryden, 1976; Tapley & Bryden, Steenhuis and Bryden (1989) proposed that the
1985), indicating different patterns of preference and position of an object in space (i.e., ipsilateral or contra-
performance in the two groups. Furthermore, Peters lateral) influences preferred hand use, an observation
(1996) found that hand preference correlated more already made by Ayres (1972) years earlier. In addition,
strongly with performance in consistent handers than Steenhuis and Bryden argued that hand preference
inconsistent handers (see Classifying Handedness). The consists of two dimensions relating to skilled and
discrepancy between preference and performance is also unskilled tasks. Similarly, Bishop (1990a) postulated
likely to be compounded by incompatible assessments that when the two hands are equally skilled for a task,
in which hand preference often is assessed subjectively, either hand may be selected. As skill level differences
based on self-report or inventories, whereas hand per- increase, so does the extent of preferred hand use.
formance is evaluated more objectively through task
execution (Guiard & Ferrand, 1996). Hand Performance
The relatively low correlation between hand pref- As with hand preference, various dimensions of hand
erence and hand performance indicates that hand func- performance have been proposed. Some researchers
tion is multifaceted and multidimensional (Steenhuis, proposed that hand performance consists of two main
1996). Numerous authors have attempted to identify factors: strength, and a combination of speed and
the factors determining hand preference and hand accuracy or dexterity (Borod et al., 1984; Porac &
Coren, 1981). However, several authors found that to developmental and environmental factors. Further-
hand strength correlated only weakly with hand pref- more, it has been argued that the degree of handedness
erence (Johnstone, Galin, & Herron, 1979; Provins & is a more important determinant of ability than the
Cunliffe, 1972; Satz, Achenbach, & Fennell, 1967). direction of handedness, particularly when studying
Different hand performance factors identified by other individuals who lack a distinct hand preference (Annett,
researchers through component analysis (Barnsley & 1970b, 1998; Bradshaw & Nettleton, 1983; Swanson,
Rabinovitch, 1970) included reaction time, speed of Kinsbourne, & Horn, 1980).
arm and finger movement, arm–hand steadiness, arm Occupational therapists should analyze handedness
movement steadiness, and aiming. All factors except both in terms of hand preference and hand per-
reaction time revealed a significant correlation with formance as two of its dimensions, because both are
hand preference (Barnsley & Rabinovitch, 1970). subjected to different levels of training. To provide a
comprehensive context for a handedness assessment,
Considerations for Evaluating Hand Preference the genetic predisposition and environmental factors
and Hand Performance determining and influencing the direction and degree
The divergent definitions in the literature demonstrate of handedness also should be considered (see Fig. 9-2
the complex nature of handedness as a multidimensional for an illustration of these handedness dimensions).
variable. Furthermore, although the multidimensional
concept of hand preference and hand performance
enables a more detailed understanding of handedness,
C LASSIFYING HANDEDNESS INTO CATEGORIES
no consensus has been reached on the type, parameters, The Process of Classification
and nature of the dimensions. This renders comparison In general, classification of handedness in the literature
between studies difficult. To overcome this problem of appears to entail a nonspecific process that frequently
poor interstudy comparability, hand preference fre- involves the creation of multiple categories, ranging
quently has been treated as a unidimensional variable from three to five or more handedness groups, in which
(Porac & Coren, 1981), in which all assessment items “strong” or explicit handers are distinguished from
are equally weighted and, in combination, reflect a “weak” or moderate handers (Annett, 1985; Peters,
single dimension of preferred hand use. 1996; Schachter, 2000). Clearly, the classification
Unidimensional hand preference assessments appear method influences the incidence of left, right, and
accurate in determining the direction of hand pref- mixed handers (Gudmundsson, 1993; see Bishop,
erence (i.e., left or right), which can be obtained more 1990a, for a review). Rigal (1992) classified children
reliably than its degree (McMeekan & Lishman, 1975). into left, right, and mixed handers, using a score of 70%
Provins (1997) and McManus (1984) believed that the or above for established handers. These thresholds were
direction of hand preference has a genetic basis, where- selected arbitrarily because no natural limits exist for
as the extent or degree of hand preference is subjected the “mixed” category, and the range for mixed subjects
Untrained Handedness Untrained
Inherent
Hand predisposition
preference Hand
Functional task performance
performance, Speed, accuracy, dexterity,
including spontaneous proficiency, skill
hand use
Trained Environmental Trained

influence
Figure 9-2 Hand preference and hand performance as two dimensions of handedness. The two dimensions of
handedness, hand preference and hand performance, are both subject to genetically based predispositions and
environmental influences. The predisposition is revealed in tasks that are not trained or practiced in any way (e.g., for
hand preference: building with blocks, opening a small box; for hand performance: tapping, hammering for speed),
although the environmental influence is manifested in trained and practiced tasks (e.g., hand preference: brushing teeth,
eating with a spoon; hand performance: drawing, cutting).
often is varied to meet the researcher’s goals (Rigal,

BOX 9-1 Handedness Categories
1992). Others have defined left or right handedness
as being 100% consistent across all tasks, and any
variations from this standard were classified as mixed Right or Left Handed. An unambiguous preference for
(Annett, 1970b). Another method to classify handed- either the right or left hand. When this hand also
demonstrates superior performance over the other
ness is by means of a continuum. More specifically,
hand, handedness has been established.
strength or the degree of preferred hand use frequently Unestablished Handedness. Hand swapping during
has been measured as a percentage or continuous and across tasks, presenting with mixed handedness.
variable. The term “unestablished” is used because children
Annett (1998) summarized the predicament asso- are still in the process of developing.
ciated with classification as follows: Mixed Handers. Adults and older children showing a
similar presentation as unestablished handedness.
Switched Handers. When children are inherently left-
“The basic problem is that researchers treat a continuous
handed but learn to draw and write with the right
variable, degree of handedness, as if it were a simple binary one
hand.
(left or right). There are many ways of dividing a continuous
Pathologic Handedness. If there is evidence of prenatal,
distribution to produce a discrete one and it is often unclear perinatal, or postnatal trauma, and one hand is
precisely what was done. It is usual to find a statement of the significantly weaker and inferior compared with the
effect that ambidextrous individuals were either discarded or other hand but still shows some preference patterns.
counted with the left-handers, which appears to be a reasonable Ambidextrous. Individuals show no performance dif-
way of dealing with a small number of cases. However, the ference between the hands and can draw or write
authors are usually confusing ambidexterity with mixed equally well with the left and right hands, although
handedness and the true size of the problem of mixed handedness performing in the average or above-average
is simply not acknowledged. If some 33 percent of a sample normative range.
can be treated arbitrarily, inconsistency of findings is not
surprising” (p. 68).
In this light, Annett (1970b) derived a subgroup

classification to determine whether meaningful distinc- Richards, 1987), because children are still in the proc-
tions could be made among mixed handers. She defined ess of developing. Adults and older children showing a
eight classes of hand preference, with classes one and similar presentation are called mixed handers (Bishop,
eight consisting of “pure” right and left handers, respec- 1990a).
tively, classes two, three, four, and five were mixed right When children are inherently left handed but learn
handers and classes six and seven mixed left handers. to draw and write with the right hand, they are called
Annett found that the degrees of hand preference switched handers (Coren, 1992). The most obvious
represented by the subgroups related reliably to difference between unestablished and switched
degrees of hand skill (hand performance) that was handedness is the clear transition from predominantly
assessed using a pegboard task. left-handed use to right hand use because of socio-
cultural influences, mainly through pressure from
Handedness Classification parents, grandparents, and teachers.
Annett’s work has demonstrated the usefulness of using As discussed in the following, it is thought that hand
categories of hand preference based on frequency preference can be altered by neural insult, depending
of use. However, in line with the present definition of on the locus and extent of lesion as well as timing
handedness consisting of both hand preference and (Harris & Carlson, 1988; Liederman, 1983; Satz,
hand performance, handedness categories also can be 1972). If there is evidence of prenatal, perinatal, or
formulated in a broader sense, based on different types postnatal trauma, and one hand is significantly weaker
or presentations. Several of these presentations have and inferior compared with the other hand but still
been selected from various authors to provide a basis shows some preference patterns, it is likely that this
for distinction (Box 9-1). is a pathologic handedness presentation (Soper & Satz,
When a child presents with an unambiguous 1984). Because the majority of people are right-
preference for either the right or left hand, and when handed, pathologic left handers are far more frequent
this hand also demonstrates superior performance over than pathologic right handers.
the other hand, he or she has established handedness Finally, ambidextrous individuals show no per-
and is said to be right or left handed (Annett, 1998). formance difference between the hands and can draw
Conversely, when a child swaps hands during and or write equally well with the left and right hands
across tasks and thus presents with mixed handedness, (Annett, 1998), although performing in the average or
this is called unestablished handedness (Whittington & above-average normative range. This is extremely rare,
because performance is influenced and developed certain tasks and the right hand for others, resulting
through practice, and to be truly ambidextrous, both in a low overall hand preference score, but show con-
hands have to be trained equally. sistency within-tasks by always using the same hand
for the same tasks. The across-task inconsistency and
Consistency within-task consistency correspond with Bishop’s
The left/right/mixed classification, whether categorical (1990a) mixed handedness described earlier. Figure 9-3
or continuous, has not been the only criterion for summarizes both types of consistency.
grouping a sample population. Consistency in hand Peters (1996) found that right handers showed
use is another important means of categorization. greater strength in their preferred hand, but only
Although several studies have investigated handedness consistent (across-tasks) left handers showed superior
consistency in relation to performance domains (e.g., strength in their left hand, although inconsistent left
consistency and intelligence; Kee, 1991), the definition handers demonstrated a stronger right hand. Peters
of consistency differs among the studies. Bishop proposed that the increased variability in left handers
(1990a) stressed the importance of measuring con- compared with right handers might be substantially
sistency within-tasks as a separate variable. She argued influenced by inconsistent handers in the left handed
that inconsistent or “ambiguous” hand use within a group. More specifically,
single task (e.g., alternating right or left hand use for
throwing) might be more reflective of dysfunction than “Consistent left handers and right handers form extremes on the
a hand preference score. Consistency also can be performance spectrum, with inconsistent left handers being
measured across tasks, whereby high consistency reflects intermediate in their performance. This suggests to us that the
exclusive left or right hand performance (Peters, 1990, distinction between consistent and inconsistent left handers is not
1996; Peters & Servos, 1989). Thus an individual merely a matter of manual motor control and reaches deeper into
might display inconsistency by using the left hand for interhemispheric communication arrangements” (Peters, p. 118).
Task 1 Task 2 Task 3 Task 4

Writing Pointing Sewing Throwing
Across-tasks
1st Trial Left Left Left Left consistency
(Peters, 1996)
Uses left hand for all tasks
2nd Trial Left Right Left Right
Across-tasks
inconsistency
3rd Trial Left Right Right Right (Peters, 1996)
Uses left hand for some
and right hand for
other tasks
4th Trial Left Left Left Right
Within-tasks ambiguous
Within-tasks consistency hand use
(Bishop, 1990) (Bishop, 1990)
Always uses left hand for Sometimes uses left,
this task (writing) sometimes right
Figure 9-3 Summary of definitions for consistency. Within-tasks consistency displays consistent hand use within a
single task (e.g., constant use of one hand when executing a task repeatedly, such as throwing a ball). If the same hand
is not used during several executions of the same task, within-tasks inconsistency is demonstrated. Across-tasks
consistency reflects the same hand use across a range of different tasks, such as writing, throwing, and cutting. Across-
tasks inconsistency is displayed by using the left hand for some tasks and the right hand for others, irrespective of within-
tasks consistency.
Unfortunately, research studies frequently do not ferences between left and right handers also might be
differentiate between consistent and inconsistent related to influencing factors such as physical environ-
handers within or across tasks. This might be an im- ment and sociocultural milieu with a right handed
portant classification in identifying problems associated bias (Coren, 1992; Harris, 1990; Porac, Coren, &
with unestablished handedness, and therapists assessing Searleman, 1986; Sattler, 1998). It can be assumed that
handedness should take this into account. Further- variability in left handers is probably due to a com-
more, therapists particularly should have an under- bination of these two factors.
standing of how left and switched handers differ from
right handers. Switched Handedness
The concept of switched left handedness has received
DESCRIPTION OF LEFT AND SWITCHED attention from several theorists (Collins, 1975, 1985;
Olsson & Rett, 1989; Peters, 1990; Porac, Rees, &
HANDEDNESS Buller, 1990; Sakano, 1982; Sattler, 1998, 2001;
Left Handedness Steenhuis, 1996). Payne (1987) investigated older
Left handers have obscured the postulate of handed- individuals and reported the incidence of switched left
ness as a predictor of cerebral specialization (Bradshaw handers to be 46%, although another study found that
& Nettleton, 1983; Bryden et al., 1996). Although 89% of innate left handers in the age group between
consistent left handers tend to perform much like right 65 and 74 years had been switched, compared with
handers (Amazeen et al., 1997; Peters, 1996), incon- 26.6% aged 35 to 44 years (Galobardes, Bernstein, &
sistent left handers, or left handers in general as an Morabia, 1999). The authors assigned the elevated
undifferentiated group, are not the mirror image of percentage of switched handedness to increased socio-
right handers and show different and more hetero- cultural pressure in previous generations. However, it
geneous behavior as a group (Bryden et al., 1996; has been proposed that switched handers are not easily
Dunaif-Harris, 1984). detected with the conventional handedness measures
Evidence suggests that left handers in general are (Peters & Murphy, 1992; Sakano, 1982), so the
less strongly lateralized than right handers, and for this prevalence may well be higher than 8%, as proposed by
reason they are more likely to present with variable Porac and co-workers (1986).
hand use (Bryden, 1982; Herron, 1980). Steenhuis Individuals with an innate predisposition for left
and Bryden (1989) proposed that in comparison to handedness are likely to present with a notable left-
right handers, left handers do not obtain lower handed preference during their early childhood years
laterality scores from lacking strength of hand (Fischl, 1986; Olsson & Rett, 1989; Sakano, 1982;
preference in certain tasks (i.e., within-consistency), Sattler, 1998; Stutte, Schilling, & Weber, 1977).
but because they display greater across-tasks incon- Parents, other family members, and teachers may exert
sistency of preference and perform some activities with social pressure on children to use their right hand for
the nonpreferred hand. certain unimanual tasks that are culturally and socially
Furthermore, left handers appear to reflect less important. Although there has been an increased
asymmetry and greater homogeneity of function acceptance for left handedness over the last decades,
between the hemispheres (Butler, 1997; Kim, 1994; there is still evidence of existing right-biased social
Peters, 1985, 1987). For example, Peters (1985, 1987) pressures in Western societies reflected in language and
used a bimanual tapping task with adults to investigate social customs (Collins, 1985; Harris, 1990; Porac et
constraints in simultaneous bimanual task performance al., 1990; Sattler, 1998). Olsson and Rett (1989)
related to handedness. He found that right handers suggest that some less strongly lateralized left-handed
performed the bimanual tapping task better when the individuals are likely to succumb even to subtle
preferred rather than the nonpreferred hand tapped pressures for right hand use, eventually resulting in
the more complex patterns. This lateralization effect switched handedness for socially important tasks (e.g.,
was not seen in left handers, who tapped the complex drawing, eating with cutlery, cutting with right-handed
pattern equally well with either hand. Other authors scissors). Untrained tasks, on the other hand, do not
have found a substantial number of left handers who receive the same amount of attention and thus tend
performed certain motor tasks better with their to be more resistant to environmental influence (Ida,
nonpreferred hand (Satz et al., 1967). Mandal, & Bryden, 2000; Olsson & Rett, 1989). With
Some authors suggested that the obvious behavioral repetition and practice of task execution, the right
differences in left handers might be a result of different nondominant hand can become the preferred hand
neural and hemispheric organization (Beaumont, for these untrained tasks (Fischl, 1986; Harris, 1990;
1974; Hammond, 1990; Perelle & Ehrman, 1982; Richberg, 1987; Sakano, 1982; Sattler, 1998; Stutte
Peters, 1990; Satz, 1980). Others have argued that dif- et al., 1977). However, switched handers are likely to
Young & Knapp, 1966). These findings appear to indi-

BOX 9-2 Some Problems Associated with
cate that switching to the nondominant hand might
Switched Handedness
have an unfavorable effect on cortical functioning
(Sattler, 1998, 2001, 2002). Furthermore, it has been
Decreased academic performance speculated that functional specialization of the hemi-
Inferior bimanual coordination performance spheres may be altered through switching handedness,
Psychological abnormalities: Switching to the non-
which in turn might interfere with interhemispheric
dominant hand might have an unfavorable effect on
cortical functioning, and functional specialization of communication processes (Olsson & Rett, 1989;
the hemispheres may be altered through switching Sattler, 1998, 2001).
handedness, which in turn might interfere with Initially, many children with switched handedness
interhemispheric communication processes compensate effectively and their problems may not arise
Primary problems: Memory deficit (i.e., recalling until their performance is challenged as school pressure
learned material), concentration difficulty (i.e., tiring and demands increase (Fischl, 1986; Olsson & Rett,
quickly, poor endurance), learning difficulties (i.e.,
1989; Richberg, 1987; Sattler, 1998, 2001, 2002;
reading, spelling), position in space problems
(including poor left-right concept), speech deficit Stutte et al., 1977). The nature and extent of switching
(especially stammering), and fine motor problems effects also seem to vary greatly among individuals,
(e.g., handwriting) whereby some appear to adapt more easily to right
Secondary problems: Poor self-esteem, insecurity, handedness with minimal problems, compared with
social withdrawal, overcompensation with increased others who experience great difficulties (Friedmann,
effort, oppositional and provocative behavior (e.g., 1987; Harris, 1990; Sakano, 1982; Sattler, 1998, 2001,
playing the clown, temper tantrums), bed wetting
2002). The enormous range of variation in the present-
and nail biting generally coexist with socioemotional
difficulties ing problems (from minimal to multiple) observed in
switched handers poses a challenge in researching and
understanding the handedness behavior of these
continue preferring their left hand for many untrained individuals.
tasks and for the leading role in bimanual actions, Today it is generally accepted that forcing or con-
resulting in an incomplete shift of handedness (Olsson verting left handers to become “right handers” should
& Rett, 1989; Porac, Rees, & Buller, 1990). be avoided (e.g., Richberg, 1987; Sattler, 2002). Even
Only a few studies have addressed the consequences Coren (1996), who appeared to favor pathologic
of switched handedness (Box 9-2). They have found causes as an explanation for left handedness, argued
decreased academic performance (Ardila et al., 1988; convincingly that forcing right handedness is not the
Bryngelson & Clark, 1933; Clark, 1957), inferior bi- answer:
manual coordination performance (Vaughn & Webster,
1989), and psychological abnormalities (Young & “Left-handedness is not a simple movement preference that has
Knapp, 1966). Based on a large number of case studies, developed into a habit. It probably reflects differences in the
Sattler (1998, 2001, 2002) identified primary and sec- patterns of neural circuitry in the brain” (p. 261).
ondary problems after switched handedness. Primary
problems included memory deficit (i.e., recalling Coren (1992) suggested that right hand training
learned material), concentration difficulty (i.e., tiring only produces mixed handedness or modified left
quickly, poor endurance), learning difficulties (i.e., handedness. It can be concluded that there is a general
reading and spelling), position in space problems consensus in the literature that switched handedness is
(including poor left-right concept), speech deficit undesirable, and the importance of correct handedness
(especially stammering), and fine motor problems (e.g., classification is evident. However, the lack of specific
handwriting). Interestingly, in numerous cases, these empirical research into switched handedness and the
problems decreased or even disappeared when indi- underlying neuropsychological processes to date limit
viduals started to write with the inherently preferred the conclusions that can be drawn on this group with
left hand, even as adults (Sattler, 1998, 2001, 2002). variable handedness.
Secondary problems associated with switching were
poor self-esteem, insecurity, social withdrawal, over-
compensation with increased effort, oppositional and PREVALENCE OF HANDEDNESS
provocative behavior (e.g., playing the clown, temper
tantrums), bed wetting and nail biting, or general The lack of coherent definitions, standard assessments,
socioemotional difficulties (Sattler, 1998, 2001, 2002). and universal classification procedures for handedness
Other authors have reported similar psychological (Annett, 1998; Bishop, 1990a) makes accurate estima-
problems as Sattler (Friedmann, 1987; Richberg, 1987; tion of the incidence of left, right, and unestablished
handedness difficult. As has been discussed, findings of

demographic studies have considered handedness as a
ASSESSMENT OF HANDEDNESS
trinomial phenomenon in terms of left, right, and
“mixed” (unestablished) handers, whereby the cut-off This section provides a brief overview of general
point for the latter group is quite arbitrary. One of the assessments, as found in the handedness literature, that
more conservative estimates states that approximately appear to be useful and relevant to occupational
85% of the adult population are right handed, about therapists. (Specific occupational therapy assessments
10% are left handed, and 5% show mixed handedness related to handedness are discussed further on under
(Coren & Porac, 1977). Other studies have provided Pediatric Occupational Therapy and Handedness,
more specific distinctions between different handedness Assessment.)
groups. Coren (1992) differentiated between “strong”
and “weak” left or right handers, suggesting that 5%
present as strong left handers, 72% of people are strong
TESTS FOR HAND PREFERENCE
right handers, and the remaining 23% demonstrate Hand preference assessments in the neuropsychology
ambiguous hand use. Annett (1998) made a distinction domain typically consist of observing preferred hand
between “ambidextrous” and “mixed” handers, in use across a variety of everyday tasks, some of which are
which ambidextrous handers by definition have the more skilled (e.g., writing and throwing) and some less
same level of skill in either hand, whereas “mixed” skilled (e.g., picking up items, opening containers)
handers use their left hand for some activities and their (Ida et al., 2000; Steenhuis & Bryden, 1989). Some
right hand for other tasks. Annett (1998) reported only authors state that only items with the highest test-retest
0.3% of ambidextrous handers, but as many as 30% of reliability should be included (e.g., Chapman &
mixed handers, a figure supported by Amunts and co- Chapman, 1987; Raczkowski, Kalat, & Nebes, 1974),
workers (2000). whereas others question the validity of such items
Furthermore, the prevalence of left handedness has because of the high training element involved in most
been estimated to be 25% higher in males than females of the tasks included (e.g., Annett, 1998; Olsson &
(Heim & Watts, 1976; Seddon & McManus, 1993). Rett, 1989; Steenhuis & Bryden, 1989; Stutte et al.,
This gender difference may result from complex factors 1977). In general, there appears to be no consensus on
leading to a differential expression of laterality in superior test items for assessing hand preference, but a
females (McManus, 1991), greater testosterone levels mixture of both trained and untrained items appears to
in utero (Geschwind & Galaburda, 1987), or a possible be the best option.
genetic influence on handedness (McKeever, 2000). One of the most frequently used tests is the stan-
However, other studies failed to find a significant dardized Edinburgh Handedness Inventory (EHI)
gender difference (Beaton & Mosley, 1984; Bishop, (Oldfield, 1971). The EHI consists of 10 items (Table
1989; Bryden, 1977; Salmaso & Longoni, 1985). All 9-1), which include highly skilled and trained activities
in all, there is a general consensus that among more such as writing and drawing, as well as less trained or
liberal societies, including most westernized and skilled ones, such as opening the lid of a box.
Caucasian-based populations, 10% to 12% of The EHI is a good choice for assessing hand pref-
individuals are left handed (Ardila et al., 1989; erence for several reasons: It has been used extensively
Connolly & Bishop, 1992; Ellis, Ellis, & Marshall, (Annett, 1998; Schachter 2000), including with
1988; Harris, 1990; Nicholls, 1998). children (Brito et al., 1992; Ross, Lipper, & Auld,
Table 9-1 Summary of test-retest reliability of the Edinburgh Handedness Inventory

(McFarland & Anderson, 1980)
Pearson’s r Pearson’s r
Item (p < .05) Item (p < .05)
1. Writing .95 6. Eating with a spoon .84

2. Drawing .94 7. Striking a match .79
3. Throwing a ball .90 8. Sweeping with a broom .62
4. Using a toothbrush .87 9. Using a knife for cutting .81
5. Cutting with scissors .85 10. Opening the lid of a box .69
1992); has been standardized on several populations

Tests for Hand Performance in
(McMeekan & Lishman, 1975; Williams, 1986); and BOX 9-3 Skill (i.e., Trained) and Ability
has a high general reliability. These factors make it a
(i.e., Untrained) Tasks
superior test to other nonstandardized and less used
hand preference tests, such as the Harris Test (1958)
and Annett’s hand preference test (1976). However, SKILL:
there is evidence that the EHI is not sensitive to the Tracing and dotting: Can be performed in the context
of the Motor Accuracy Test (MAc; Ayres, 1989) and
degree of hand preference; children between 3 and
the Hand Dominance Test (HDT; Steingrüber &
5 years of age scored high on this test, at an age in Lienert, 1971)
which the degree of handedness is still developing
ABILITY:
(Kraus, 2003). It is possible that most of the EHI items
Hammering (as a form of hand tapping) and tapping
are lateralized early in life, thus displaying very similar (as a form of finger tapping): See Knickerbocker
distributions for the different age groups. Further- (1980) for a timed hammering sample and Kraus
more, the EHI also failed to detect significant dif- (2003) for a tapping adaptation.
ferences between the age groups (Brito et al., 1992;
Kraus, 2003).
All considered, it can be concluded that the EHI is
a useful tool for assessing hand preference until more Skill
sensitive measures have been developed (see Kraus, Tracing, a proficiency task subject to training,
2003, Functional Hand Preference Tasks as an example performed with the preferred and nonpreferred hands
of a more sensitive measure). In the interim, the EHI can demonstrate the extent to which one hand has
can be used with some caution in addition to hand acquired superior control as reflected in assessment
performance measures. In particular, it is useful to tasks (e.g., Ayres, 1989; Steingrüber & Lienert, 1971).
distinguish between trained and untrained hand Similarly, several studies have employed timed dotting
preference tasks, and to draw comparisons between the as a skilled task to assess superior hand performance
two preference groups. (e.g., Annett, 1992a; Carlier et al., 1993; Steingruber,
1975; Tapley & Bryden, 1985). Although tracing
requires continuous motor execution, dotting involves
control of rapidly alternating stop-start movements and
TESTS FOR HAND PERFORMANCE placing. Even though tracing and dotting require
When assessing hand performance, note that superior different types of motor prerequisites, the level of both
control of one hand may not necessarily indicate that it tracing and dotting accuracy is closely related to the
is also the preferred hand. For example, if an innately learned task of drawing and writing (Annett, 1992a;
left-handed child learns and practices to use the right Steingruber, 1975; Tapley & Bryden, 1985), and they
hand for drawing and writing, it is possible that a can thus be considered to be trained and skilled tasks.
higher performance level in these tasks will be achieved Tracing and dotting are two suitable skilled hand
with the right hand, as case studies of such “switched performance tasks, and they can be performed in the
handers” have shown (Coren, 1992; Peters & Murphy, context of the Motor Accuracy Test (MAc; Ayres,
1992; Sattler, 1998; Stutte et al., 1977). Thus 1989) test and the Hand Dominance Test (HDT;
although activities such as tracing and dotting appear to Steingrüber & Lienert, 1971). The MAc
be suitable for assessing forms of trained performance
“emphasises accuracy or ‘steadiness’ of the visually directed hand
(i.e., hereafter called skill), hand performance should
use of a pen and is specifically designed for comparison between
also reflect the more inherent and innate proficiency the more- and less-accurate hands” (Mandell, Nelson, &
(hereafter called ability), which is relatively free of Cermak, 1984, p. 115).
training, to obtain a more coherent understanding of
the presenting variability in handedness. The MAc requires timed tracing of a butterfly-
In addition, speed is an important factor of hand shaped line on an A3 paper, first with the preferred
proficiency when considered in a multifactorial context hand and then with the nonpreferred hand. The
(Annett, 1985; Barnsley & Rabanovitch, 1970). More standardized version of the HDT for children consists
specifically, speed and accuracy should be combined to of three parts: (a) a mazelike angled path for tracing;
achieve an accurate measure of performance (Fitts, (b) a path of irregularly spaced circles, 0.5 cm in
1954). Thus, to conduct a comprehensive hand per- diameter for dotting; and (c) rows of equally spaced
formance test, the speed-accuracy combination should adjacent squares, also for dotting. All three tasks have
be applied in hand performance Skill (i.e., trained) and to be attempted at maximum speed and precision
Ability (i.e., untrained) tasks (Box 9-3). for 30 seconds. The distance of the traced path is
measured, and the number of successfully dotted circles secured to the table. The top paper features a circle
and squares is counted. 4 inches in diameter, and the child is presented with
Both these standardized tests are suitable to assess a wooden hammer in the midline. The child is then
hand performance skill, but they have their limitations. requested to hit as fast and hard as possible when the
Kraus (2003) found that although the MAc perfor- stopwatch is activated. The number of hammer blows
mance level increased significantly across all age groups, in 15 seconds (or 20 or 30 seconds, depending on the
the interhand differences on the test were not found to child’s age and abilities) is recorded. The two hands are
be significantly different between 3- and 5-year-old compared on the frequency of hammering blows and
normal children. This might partly be a consequence the quality of the hammering executions (e.g., wild
of revisions to the MAc, including adjustments to uncontrolled movement, poor visual attention). The
decrease the difference between the hands (Smith, same principles can be used for tapping, although some
1983). Although the MAc appears to be a valid tool for adaptation should be made so that the wrist-generated
assessing performance levels, the interhand differences tapping also results in “blows” on carbon paper (see
lack variability (Kraus, 2003), and thus sensitivity to Kraus, 2003, for a tapping adaptation as part of the
detect more subtle differences between the hands. This Ability Test).
needs to be considered when using the MAc as a hand
performance measure. The HDT, on the other hand,
has some structural drawbacks: It has angled paths for
tracing, which encourages stop-start movements, and
FACTORS DETERMINING AND
the scoring of both the tracing and the dotting task do INFLUENCING HANDEDNESS
not take the quality of the child’s response into account
(i.e., a dot can also be a line as long as it is placed inside For a comprehensive understanding of handedness,
the circle). Once again, these limitations have to be one should have a knowledge base of factors that may
considered until a more comprehensive assessment is determine, or at least influence, the establishment of
available (see, e.g., Kraus, 2003, for the Bear Tracing handedness. Although empirical evidence concerning
Task and the Bead Dotting Task). the determining factors of handedness remains incon-
clusive, there is an abundance of information relating
Ability to four different contexts: (a) neuroanatomical and
Tapping as a motor performance task to assess innate neurophysiological foundations, (b) genetic theories,
motor ability is used most frequently in research to (c) pathological influences, and (d) sociocultural
distinguish manual asymmetry in rapid repetitive upper influences. Therapists should draw on this knowledge
extremity movements (McManus, Kemp, & Grant, base when assessing and treating handedness in
1986) as an innate and untrained task. Numerous children.
studies have shown that the preferred hand taps faster
than the nonpreferred hand (Peters, 1978, 1990;
Peters & Durding, 1979; Watter & Burns, 1995). N EUROANATOMICAL AND
However, stipulations for tapping differ across studies, N EUROPHYSIOLOGICAL FOUNDATIONS
with some employing hand tapping controlled from the
OF HANDEDNESS
shoulder girdle (Peters, 1990) and others using finger
tapping with stabilization of the wrist (Watter & Burns, Findings from scientific research link hemispheric
1995). No studies were found that investigated the integration and callosal maturation to many higher
difference or similarities between these two forms of cognitive activities, such as complex problem solving,
tapping (i.e., whether and to what extent distally visuomotor coordination, language skills, and social
controlled tapping is indeed similar to proximally competence, as well as handedness establishment
controlled tapping/hammering). For this reason, it is (Chiarello, 1980; Ettinger et al., 1972; Rourke, 1987;
useful to include both hammering (as a form of hand Temple, Jeeves, & Vilarroya, 1990). When neuro-
tapping) and tapping (as a form of finger tapping) as scientists became aware of the functional asymmetry of
tests to assess Ability hand performance. Knickerbocker the brain, they regarded the two hemispheres as a left-
(1980) proposed a Timed Hammering Sample to right dichotomy of “two minds, two consciousnesses”
observe the (Gazzaniga, Bogen, & Sperry, 1962). It was assumed
that the left hemisphere was dominant and superior to
“presence or absence of established hand dominance” (p. 201). the right hemisphere, particularly for speech and praxis
(Gazzaniga et al., 1962; Luria, 1973; Sperry, 1974),
For Knickerbocker’s test, a piece of carbon paper is whereas the right (“lesser, inferior”) hemisphere
stapled face down between two sheets of paper and provided a general context to function in nonverbal,
emotional, and visuospatial domains (Hécaen & development of the left hemisphere, which in turn
Sauguet, 1971; Luria, 1973; see Beaton, 1985, for a reinforces right contralateral hand use until hand/brain
review). “dominance” is established (Gazzaniga, 1970).
Currently however, hemispheric “dominance” is Although it may not yet be clear to date which parts
viewed as relative rather than absolute, whereby one of the brain are involved in handedness establishment,
hemisphere is specialized only in relation to the other it seems important not to restrict this process to specific
(Ornstein, 1997). This bilateral concept of “asym- parts of the brain, such as the contralateral cortex.
metric but integrated” hemispheric roles assumes that Neuroscientific evidence has emerged indicating that
the hemispheres operate collaboratively on all tasks, simple tasks tend to involve one hemisphere, whereas
although showing flexibility in acquiring these roles effective solving of more complex tasks requires both
should the need arise (e.g., after brain damage) hemispheres and interhemispheric communication
(Deacon, 1997; Gazzaniga, 1995; Ornstein, 1997). In (Weissman & Banich, 2000). These findings suggest
addition to the emphasis on hemispheric role integra- that, to an unknown extent, neurophysiologic involve-
tion, there is continued support in the cortical ment might be task dependent. More specifically, some
lateralization literature for specialized hemispheric authors have proposed that the task may determine
function and fundamental differences in information handedness (Steenhuis & Bryden, 1989). As proposed
processing (Galin, 1974; Pally, 1998; Tucker, 1981). in systems theory (Kelso et al., 1980), handedness
Based on this type of neurophysiological and could be viewed as one aspect of the neuromotor
neuroanatomical research investigating hemispheric system interacting with the environment. Therefore it
lateralization and specialization, it has been suggested is important to review other possible origins and
that the two hands display asymmetric behavior because genetic, circumstantial, and environmental influences
they reflect the controlling contralateral hemispheres of handedness in relation to its establishment.
(e.g., the left hand is superior in spatial tasks regardless
of handedness) (Carson, 1989; Ingram, 1975). How-
ever, there is a lack of evidence as to whether these
G ENETIC THEORIES ON HANDEDNESS
asymmetries are present in embryogenesis, and develop Studies investigating familial handedness across genera-
into corresponding functional asymmetries in later life, tions have found support for a genetic aspect to handed-
or whether anatomical asymmetries develop later as a ness. Hicks and Kinsbourne (1976) discovered that
result of learned hand use and the interaction with the there was a significant correlation between the handed-
environment (Hopkins & Rönnqvist, 1998). Environ- ness of college students and their parents, but only if
mental influence appears to be evident in the develop- the relationship was biological. A meta-analysis demon-
ment of other brain structures associated with strated a 1 in 10 chance of having a left-handed off-
handedness establishment, such as the corpus callosum. spring if both parents were right handed (Porac &
For example, postnatal maturation of the corpus Coren, 1981). If one parent was left handed, partic-
callosum appears to be significantly influenced by expe- ularly the mother, this ratio doubled to 2:10, and if
rience, based on great variations in callosal size, irre- both parents were left handed, the chance of left
spective of age and gender (Bleier, Houston, & Byne, handedness further increased to 4:10 (Bryden et al.,
1986; Cowell et al., 1992). In addition, there is neuro- 1996; McManus & Bryden, 1992; Porac & Coren,
anatomical evidence that the corpus callosum differs 1981). Other studies have found an even higher ratio
with handedness, being approximately 11% larger in between left handers and their left-handed parents. For
left-handed and “ambidextrous” individuals than in example, Annett (1978, 1985, 1995) assessed the
well-established right-handed individuals (Aboitiz et difference in skill level between the hands rather than
al., 1992; Bleier et al., 1986; Witelson, 1985). preferred hand use, excluding parents who might have
Gazzaniga (1970) stressed the importance of inter- been pathologic left handers. She found a 50%
hemispheric communication for the establishment of prevalence of left-handed offspring from two left-
handedness. It has been proposed that the corpus handed parents.
callosum, one of the last neurologic structures to Several genetic theories have attempted to explain
complete myelination (Farber & Knyazeva, 1991), is the incidence of left handedness. Annett’s (1972, 1985,
instrumental in manual lateralization and specializa- 1994, 1995) well-known right shift theory postulates
tion. Myelination of the corpus callosum is thought that handedness is influenced by an inherited factor
to signal the emergence of hand preference, reflecting rather than being inherited directly. A single gene is
hemispheric specialization of cortical function (Gazzaniga, thought to be responsible for displacing handedness,
1970). In other words, the hand–cortex relationship assumed to be a random or chance phenomenon,
is considered to be a two-way process: More fre- toward the right (i.e., right shift). One allele causes
quent manipulation with the right hand increases the right handedness and another allele results in the
independent and random lateralization of manual because monozygotic twins sharing identical genetic
praxis. Those individuals homozygous for the random make-up do not necessarily present with the same
factor have a 50% chance of being left or right handed. handedness (Oberleke, 1996), and the incidence of
Two factors influence the handedness outcome and handedness discordance is as high as 25% (Carter-
hemispheric specialization for speech: a genetic right Saltzman et al., 1976). Thus current genetic models
shift (RS+) factor, and a random congenital but do not convincingly explain the reduced handedness
nongenetic factor that codes for speech representation concordance in monozygotic twins (Stein, 1994), nor
in the left hemisphere. Right handedness is linked to is there certainty as to what proportion of people
left hemispheric speech representation, and thereby should “genetically” be left handed, particularly if
determined by the genetic RS+ factor, whereas the the sociocultural and environmental factors reduce the
random factor implies that left handedness and left phenotypical presentation of left handers to an
hemispheric speech representation are not inherited. unknown extent.
According to Annett’s model, approximately 25% of Nevertheless, the increase in ratios of left-handed
individuals presenting with atypical patterns of hemi- offspring from left-handed parents, including the
spheric specialization (i.e., right and bilateral cerebral handedness concordance in 75% of identical twins,
speech representation) become left handers. However, suggests at least a genetic component to the handedness
Annett argued that the right-biased cultural and phenomenon (Bryden et al., 1996). Furthermore, it
environmental influences increase the development of has been proposed that the “strength” of handedness is
right handedness, so that the incidence of left handers inherited, with some individuals presenting with strong
is reduced to approximately 16%, which is congruent left and right handedness, whereas others show greater
with her prevalence studies based on hand skill (Annett, variation in their preferred hand use (Bryden, 1982;
1998). Furthermore, Annett has proposed that the Coren, 1992; Coren & Porac, 1980).
strength of handedness is inheritable, because some Recent findings also suggest that there is an X-linked
individuals may be homozygous for the RS factor (i.e., pattern of genetic influence on handedness (McKeever,
RS++), displaying a stronger handedness than individ- 2000). However, to date no handedness gene or allele
uals who are heterozygous (i.e., RS±). Annett’s model has been identified that could ascertain the direction
has been criticized for lack of empiric support for the and extent of handedness, and genetic theories thus
50% frequency of both dominant and recessive alleles, remain incomplete. The assumption that a genetic com-
and the assumption that hand performance and hand position is responsible for the direction of handedness
preference covary (Hopkins & Rönnqvist, 1998; Porac permits left handedness to be a “normal” inherited trait
& Coren, 1981). in a minority of people. At the same time, most genetic
Similarly to Annett, the authors McManus and theorists do not account for prenatal, perinatal, and
Bryden (1992) argued for a single gene with two alleles postnatal influences that may increase the incidence of
indirectly determining handedness, namely Dextral (D) left handedness.
and Chance (C). Individuals with a Dextral-Dextral
(DD) genotype are right handed, whereas persons with
a Chance-Chance (CC) genotype have an equal chance
PATHOLOGIC I NFLUENCES ON HANDEDNESS
of being left or right handed. Heterozygous individuals Models linking intrauterine influences and birth stress
(DC) received proposed “additivity,” having a 25% with handedness appear to be based on the assumption
chance of being left handed as opposed to a 75% chance of a genetically predetermined right handedness in
of becoming right handed. Unlike Annett, the authors humans. Generally, these models propose that left
proposed that handedness and hemispheric specializa- handedness is a failure to become right handed and is
tion are coded independently of one another, and the thereby rendered abnormal, “anomalous” (Geschwind
presence of a sex-linked moderator gene accounts for & Galaburda, 1985, 1987), or pathologic (see Harris
the increased incidence of left handedness in males. & Carlson, 1988, for a review on existing theories
The central idea of the genetic models appears to be relating to pathologic left handedness). The Geschwind-
similar. Approximately half of the population inherits Galaburda theory is the most prevalent and controversial
the potential to become either left or right handed, but intrauterine model for the cause of left handedness. It
only a proportion of these individuals eventually present is based on the premise that anatomical asymmetries,
as left handers. The genetic models could possibly evidently already present in utero, result in functional
explain the variation in strength of handedness because asymmetries (Geschwind & Levitsky, 1968). Geschwind
variable handers might include those individuals who and Galaburda (1987) suggested that growth-retarding
have an equal chance of being left or right handed. influences of chemicals and hormones, particularly
However, twin studies have compounded the com- testosterone, are most likely to affect the more
plexities involved in the inheritance of handedness, vulnerable left hemisphere because of its slower rate of
development. As a result, the anatomical brain asym- a more vulnerable “dominant” hemisphere, and rather
metries are reduced and the hemispheres become more in support of a more vulnerable left hemisphere.
symmetric, which leads to anomalous dominance with Other evidence exists to support greater vulner-
equal chances of becoming left or right handed. The ability of the left hemisphere, based on a higher ratio
authors proposed that left handedness results if the of children with right hemiplegia (Uvebrandt, 1988).
right hemisphere becomes more specialized. In addi- Several reasons for the increased vulnerability of the
tion, variations in the chemical environment may cause left hemisphere have been proposed. First, the blood
the variability typical of left handedness. supply to the left hemisphere has less volume (Raichle,
The testosterone hypothesis has been extensively 1987). Second, the right hemisphere matures more
reviewed and questioned. Brain imaging studies have quickly and earlier than the left hemisphere, thus the
supported the link between anatomical asymmetries in latter is more likely to be damaged (Jacobson, 1978),
language-related brain areas and hand preference (see being particularly vulnerable to intracranial focal lesions
Foundas, Leonard, & Heilman, 1995; Steinmetz et al., and intracranial hemorrhage (Schuhmacher et al.,
1991, for a review). However, there are no longitudinal 1988). Third, the left hemisphere requires more blood
studies to indicate if the observed anatomical asym- for metabolism and burns oxygen more quickly (Bakan,
metries in utero are related to corresponding functional 1977). Fourth, the hormonal imbalances, especially
asymmetries in later life. Recent evidence also suggests testosterone, appear to affect the left hemisphere more
that brain symmetry appears to be triggered by trophic strongly (Geschwind & Galaburda, 1987). In the case
changes in the right hemisphere rather than growth of early neural insult affecting the left hemisphere, the
retardation in the left hemisphere (Galaburda et al., right hemisphere is thought to compensate by assuming
1987; Habib, Touze, & Galaburda, 1990). Moreover, a more active role, resulting in pathologic left handed-
if hormonal imbalances do exist, twins subjected to ness (Orsini & Satz, 1986; Rasmussen & Milner, 1977;
identical intrauterine factors should present with Soper & Satz, 1984).
identical handedness, which is not necessarily the case Several prenatal, perinatal, and postnatal factors
(Oberleke, 1996; Stein, 1994). In addition, males are related to the birth process have been associated with
subjected to greater testosterone levels than females, an increased incidence of pathologic left handedness.
which, according to Geschwind and Galaburda (1987), These factors include birth weight (O’Callaghan et al.,
should result in a significantly higher incidence of 1987), prematurity (Ross et al., 1987), difficult delivery
“atypical” handedness in males. However, as has been and induced birth (Colbourne et al., 1993), the mother’s
noted, significant gender differences were found in age (Coren, 1992), and smoking during pregnancy
some prevalence studies but not others. (Bakan, 1991). It has been suggested that these factors
More recently, an increased incidence in left handed- might later result in associated disorders such as
ness was revealed in male individuals who were exposed dyslexia (Eglington & Annett, 1994), attention deficit
to ultrasound in utero, which has been considered disorder (ADD) (Gillberg & Rasmussen, 1982),
another factor responsible for shifting inherent right learning disability (Geschwind & Galaburda, 1984),
handedness to left handedness (Kieler et al., 1998). and intellectual disability (Fein et al., 1984). However,
However, intrauterine conditions do not appear to be some studies have failed to find support for an
the only early influence on handedness development. association between left handedness and pathologic
Just as abnormal prenatal intrauterine conditions may conditions (Bishop, 1990). It has been argued that
affect the development of hemispheric specialization, the proposed elevated incidence of “pathologic” left
unfavorable perinatal and postnatal circumstances, handedness is based almost exclusively on clinical
including birth-related stress, seem to have a similar or groups that consist of twice as many left handers as the
even more prevailing effect (Coren, 1992). normal population (Perelle & Ehrman, 1982; Satz,
Birth-related stress has been cited as one of the most 1972), and there is little evidence of an association
potent acquired influences on handedness outcome between left handedness and pathology in the general
(Bakan, Dibb, & Reed, 1973). It has been proposed population (Annett, 1992; Hardyck & Petrinovich,
that the “dominant” hemisphere, which may not neces- 1977; Satz, Soper, & Orsini, 1988).
sarily be the left, is most likely to be affected by early Considering the evidence for a genetic versus intra-
brain damage (Best, 1988). Goodman (1994) tested the uterine or birth-related stress basis for handedness, it is
hypothesis of corresponding hemispheric and manual generally accepted that left handedness consists of two
dominance by investigating 463 children with hemi- subgroups: familial (genetically based) and pathologic
plegia in relation to familial handedness. Unexpectedly, (caused by brain damage). Distinguishing between
he found a highly significant correlation between right these two subgroups may produce different research
hemiplegia and familial left handedness. Goodman outcomes about comparisons between left and right
interpreted the results as evidence against the notion of handers (Annett, 1985; Hécaen & Sauguet, 1971;
McKeever, 1981; Orsini & Satz, 1986). To date, there models do not account for the increased incidence of
is no agreement on the definition of pathologic left familial left handedness, suggesting a genetic compo-
handedness. There are those researchers who suggest nent. Furthermore, these models fail to consider socio-
that pathologic left handedness appears to develop only cultural influences that are likely to cause an increased
with substantial damage to the left hemisphere (Annett, occurrence of right handedness.
1985; McManus & Bryden, 1992; Satz et al., 1985), in
which case the incidence of pathologic left handedness SOCIOCULTURAL AND E NVIRONMENTAL
is relatively low. Conversely, other researchers propose
that pathologic left handedness is a result of relatively
I NFLUENCES
minor neurologic trauma. In the latter case, at least half Genetic, intrauterine, and birth-related stress theories
of all left handers or even all left handers are thought have concentrated on predispositions and early factors
to demonstrate left handed behavior with a pathologic that could determine, influence, and change the handed-
origin (Coren, 1992). Taking an even more extreme ness outcome. However, handedness is undeveloped at
approach in the absence of strong genetic evidence birth, and becomes established within the first 5 to
for left handedness, Bakan (1990) considered all left 6 years of life (Tan, 1985). Although the direction of
handedness to stem from some form of pathology. handedness already may be apparent in infancy and is
Hopkins and Rönnqvist (1998) emphasized that considered to be stable by 5 years (McManus et al.,
strongly lateralized and unusually consistent hand pref- 1988), the degree and consistency of handedness are
erence during infancy, rather than fluctuating asym- subject to change, particularly up to the age of 9 years
metry, may be indicative of underlying neuropathology. (McManus et al., 1988; Goodall, 1984), 11 years
It has been specifically suggested that poor perfor- (Whittington & Richards, 1987), or even across the
mance of the nonpreferred hand might be suggestive entire life span (Porac & Coren, 1981). There is also
of early brain damage (Bishop, 1984; Gillberg, some evidence that handedness establishment takes
Waldenstrøm, & Rasmussen, 1984). This may affect place earlier in right handers (i.e., by 5 years of age)
the left or right hand. There is indeed evidence for the than left handers (i.e., by 9 years) (Mandell et al.,
existence of “pathological right handers” (Kim et al., 1984). Environmental and cultural influences are likely
2001), referring to a group of familial left handers who to have a significant effect on handedness, although
experience early right brain injury and consequently there is little empiric support for handedness as a sole
develop right hand preference. However, the incidence product of cultural influences. For example, children of
of pathologic right handers has been estimated to be left-handed foster parents do not exhibit an increased
low because of the restricted number of familial left use of the left hand (Carter-Saltzman, 1980). Further-
handers (Satz, 1972, 1973). more, in many societies it is far more likely that socio-
Finally, if handedness is a manifestation of the extent cultural influences restrain left handedness, forcing, or
of interhemispheric communication via the corpus at best encouraging, left handers to use their right hand
callosum, clinical research should reflect a link between (Harris, 1990). One of the more extreme examples is
variable handedness and callosal dysfunction. There is the account of Chinese children at Taiwanese schools,
evidence that dyslexia, which also has been linked to a in which the incidence of left-handed writing is only
greater incidence of unestablished handedness (Satz & 0.7% (Teng et al., 1976). However, no evidence was
Fletcher, 1987), appears to be related to poor hemi- found that forced right-handed writing also resulted in
spheric lateralization (Galaburda, 1993; Satz, 1991), increased right hand use in other activities.
and poor interhemispheric communication (Gladstone, There is empiric support that the number of left
Best, & Davidson, 1989; Kerschner, 1983). However, handers is significantly higher in younger individuals
other studies have failed to find support for an associ- than in older ones, both in cross-sectional and longi-
ation between learning disabilities and unestablished tudinal studies (Coren, 1992; Hugdahl et al., 1993;
handedness (Bishop, 1990a,b). Also, magnetic resonance Porac & Coren, 1981; Porac et al., 1986). Stricter
imaging (MRI) of the corpus callosum did not reveal sociocultural pressures to use the right hand for socially
differences in callosal size between dyslexic and normal important tasks were imposed particularly on previous
children (Larsen, Höien, & Ödegaard, 1992). generations, a phenomenon that has been described
In summary, the proposition that unusual prenatal, in the “modification hypothesis” (Coren, 1992). This
perinatal, and postnatal conditions influence the hypothesis asserts that the existing right-handed bias in
cerebral lateralization process of the immature brain is the sociocultural and physical environments coerces left
supported by empiric evidence. Although many of the handers to “switch” handedness to the right (Coren,
findings remain inconclusive, the impact of early 1992; Sakano, 1982). However, the modification
unfavorable conditions on hemispheric specialization theory has only addressed switching of well-established
has not been disputed to date. However, intrauterine left handers. It is plausible that individuals with a mild
left-handed predisposition are most vulnerable to right- cooperation… Bimanual complementary movements often con-
biased sociocultural pressures. Therefore it is possible sist of more than one step or action, in which each hand plays a
that inherently mildly established left handers con- different role. The flexibility in shifting attention between hands
stitute a proportion of unidentified switched handers might therefore be one prerequisite for bimanual success”
(p. 125).
within the right-handed population.
In a neurodevelopmental context it seems appro-

CONCLUDING REMARKS priate to follow the emergence of handedness in rela-
In summary, hand preference can be perceived as a tion to midline crossing and bimanual coordination.
multicausal behavior that is influenced by a variety of The different developmental stages are discussed in the
mechanisms, including genetic and nongenetic factors. following, first in relation to handedness with reference
As Provins (1997) contended: to the developmental stage of the corpus callosum, then
to midline crossing, and finally to bimanual coordination.
“what is genetically determined is a neural substrate that has
significantly increased its functional plasticity in the course of
evolution. … What is fine-tuned is the relative motor proficiency BIRTH
or skills achieved by the two sides in any given task according to
the use and the demands made on them as a result of social
At birth, the corpus callosum is underdeveloped and
pressure, other environmental influences or habit” (p. 556). nonfunctional (Gazzaniga, 1970; Hewitt, 1962),
developing over the next 10 years at an unprecedented
Although the origin and cause of manual lateraliz- rate compared with its later development. Movement
ation are still debatable, the prevalence of left and right of the upper limbs has been described as uncontrolled
handedness appears to have existed fairly constantly and reflexive, and is performed both symmetrically and
since prehistoric times (Bradshaw & Rogers, 1996; asymmetrically (Fagard, 1990, 1998), with the
Calvin, 1983; Corballis, 1983; Steele & Mays, 1995; presence of the asymmetrical tonic neck reflex (ATNR)
Toth, 1985) and across most human societies (Hardyck and the Moro reflex. These seemingly random move-
& Petronovich, 1977; Harris, 1980, 1990; Peters, ments are closely linked to the lack of postural control
1995). It could be concluded that handedness is a at this age. For example, when the head of a neonate is
unique human trait, displaying a wide variety of degrees stabilized externally, reaching is possible (Amiel-Tison
of presentation that are not yet well understood. In & Grenier, 1980). However, adequate postural control
contrast, the development of handedness has been well is necessary to enable independent reaching by the
documented since the 1940s, as reviewed in the infant, so reaching does not occur spontaneously at this
following section. age (Shumway-Cook & Woollacott, 2001). Further-
more, the infant is unable to cross the midline, even
when the body is fully supported and one limb is
restrained (Provine & Westerman, 1979).
THE DEVELOPMENT OF
HANDEDNESS 4 MONTHS
Occupational therapists should have good understand- According to Gazzaniga (1980), each hemisphere
ing of handedness development because this forms an processes sensorimotor information independently of
important basis for the intervention phase. Defining a the contralateral side. This activity might indicate that
developmental process of a particular behavior in the the corpus callosum is starting to play a role in relaying
holistic context of occupational performance most information from one hemisphere (e.g., visual field) to
often requires the inclusion of related behaviors. This is the other (e.g., controlling contralateral motor perfor-
also the case with the development of handedness, in mance). Hand preference coincides with unilateral
which the hands tend to be used initially in the ipsi- swiping of either hand (Gesell & Ames, 1947) and a
lateral hemispace before contralateral reaching with the decrease in the grasp reflex that is replaced with a crude
preferred hand is observed (Provine & Westerman, but voluntary grasp (Case-Smith, 1995). Provine and
1979; Pryde, Bryden, & Roy, 1999). Furthermore, Westerman (1979) found that this is the earliest time
handedness is expressed both unimanually and bi- that infants are able to cross the midline when one
manually (Hopkins & Rönnqvist, 1998). In particular, hand is restrained (see also Murray, 1995, for a review).
Fagard (1998) argued that stabilization Bimanual movements are symmetrical or mirrorlike
and simultaneous, resulting soon in bilateral body and
“of unimanual handedness might be one of the factors object exploration, and hand interplay in midline
influencing the emergence of the capacity to use both hands in (Fagard, 1990, 1998; Fagard & Pezé, 1997).
ing temporal and spatial coordination and comple-

6 MONTHS mentary action. Sequential rather than simultaneous
Gazzaniga (1980) proposed that the corpus callosum bimanual activity is performed (Fagard, 1998; Fagard
first demonstrates increased myelination, reflected in & Pezé, 1997).
the emergence of unilateral reach. Alternating with the
bilateral development, a first (transient) preference for
unilateral, usually the right hand, use becomes apparent
18 MONTHS
(Gesell & Ames, 1947). As the infant’s postural control Around this age, the left hemisphere develops more
develops in sitting, weight is borne on one arm for rapidly than the right (Jacobson, 1978). The clear shift
pivoting, and the infant reaches with the other hand to toward unilateral hand use continues, alternating with
the contralateral side using trunk rotation (Case-Smith, much bilateral activity, and inconsistent hand use is still
1995; Gilfoyle, Grady & Moore, 1990). No active apparent (Gesell & Ames, 1947). Other researchers
contralateral reaching has been recorded at this stage. have observed a clear hand preference in bimanual tasks
There is a definite shift toward bilaterality (Gesell & after 14 months (Michel, Ovrut, & Harkins, 1985;
Ames, 1947) from simultaneous to successive move- Ramsey, Campos, & Fenson, 1979), concluding that
ment (Castner, 1932). For example, the infant holds an unimanual hand preference precedes bimanual hand
object in one hand and reaches with the other (White, preference. More recently, Fagard and Marks (2000)
Castle, & Held, 1964), or movement is initiated with compared unimanual and bimanual tasks in relation to
one hand and completed with the other (Castner, 1932). hand preference in babies aged 18 to 36 months. They
found that bimanual tasks elicited a stronger role dif-
ferentiation than unimanual tasks even at 18 months.
8 MONTHS They deduced that hand preference is task related, and
The emergence of a more radial palmar and then digital that certain bimanual tasks might display greater asym-
grasp (Gesell & Amatruda, 1947) precedes a unilateral metry than unimanual tasks in infancy. At this stage, the
phase whereby there is increased left hand use, followed first active contralateral reaching across the body is
by a greater persistence of right hand use. Further observed (White et al., 1964), without one hand being
refinement of postural control is now evident (Case- occupied or used for support. Children are now able
Smith, 1995; Gilfoyle et al., 1990), but no active to combine stabilizing the object with one hand and
contralateral reaching has been recorded at this stage. manipulating it with the other in an alternating manner
Infants start to hold two objects simultaneously in each (Gilfoyle et al., 1990), which leads to more mature
hand and combine this with a bimanual symmetric bimanual coordination (Corbetta & Thelen, 1996;
action, such as banging (DeSchonen, 1977; Fagard, White et al., 1964).
1990, 1998; Fagard & Pezé, 1997).
24 MONTHS
12 MONTHS The corpus callosum appears to be functioning at a
As the corpus callosum continues to develop, the basic level and inhibitory function is emerging (Farber
emerging pincer grasp coincides with another phase of & Knyazeva, 1991). There appears to be a preference
more unilateral left hand performance, followed by a for bimanual activity in which the preferred hand is
phase of using either hand (Gesell & Ames, 1947). more active and the nonpreferred hand has a stabilizing
Having achieved good postural control in sitting, the and assistive role (Fagard & Marks, 2000). At this stage,
infant is now able to reach into either contralateral most young children show a more definite preference
space using trunk rotation but without employing arm for the right hand (Gesell & Ames, 1947) because the
support. However, this midline crossing occurs mainly fingers and arms are increasingly dissociated for a large
when one hand is occupied, not yet reflecting a variety of functional skills (Case-Smith, 1995). Stilwell
preferred hand. Ipsilateral reaching is still preferred (1987) found that 2-year-old children actively cross the
(Carlson & Harris, 1985; Case-Smith, 1995; Knobloch midline, more so with their preferred hand. The hands
& Pasamanick, 1974), although Bruner (1969) can now be used in all planes with good control
suggested a diminished “midline barrier” at this stage. (Gilfoyle et al., 1990). Two-year-old children can also
The hands begin to work together in an increasingly perform a sequence of bimanual movements whereby
complementary fashion and coordinated asymmetric the arm and hand stabilization and movement are
roles (Goldfield & Michel, 1986), in which one hand is controlled simultaneously (Knobloch & Pasamanick,
more active, the other more passive. Bimanual hand 1974), such as holding a crayon and drawing, or
preference emerges after 9 to 10 months of age, involv- threading beads.
In summary, the development of handedness

2 TO 6 YEARS appears to fluctuate between unimanual and bimanual
MRI studies have supported age-related increases in preferences that seem to be individually paced. Hand
cerebral white matter and myelination of the corpus function initially takes place only in ipsilateral and
callosum in children and adolescents (DeBellis et al., midline spaces, and later extends to the contralateral
2001; Giedd et al., 1999; Thompson et al., 2000). space. This developmental process supports the
There is evidence that callosal transfer is not optimal neurophysiological basis for an intricate relationship
until approximately 10 to 12 years (Yakovlev & among hand preference, midline crossing, and biman-
Lecours, 1967), and that subsequent sensorimotor and ual coordination and appears to be closely linked to the
cognitive development further increase the callosal development of the corpus callosum.
interconnections between the hemispheres up to
adulthood (Pujol et al., 1993).
By the third and fourth year, the direction of hand
preference is evident (McManus et al., 1988) and there PEDIATRIC OCCUPATIONAL
is a tendency toward unilateral activity (Gesell & Ames,
1947). This stage appears to be followed by another
THERAPY AND HANDEDNESS
period of well-differentiated bilaterality between 5 and
7 years of age. Hand preference becomes fully estab-
lished between 6 and 9 years of age (Gesell & Ames,
ASSESSMENT
1947; Tan, 1985). At the age of 6 years children use
the preferred hand consistently to cross the body mid- Tests Used in Occupational Therapy
line (Stilwell, 1987). However, more complex tactile There is a lack of specific test procedures in occu-
tasks requiring crossed localization conditions demand pational therapy to assess handedness. The Mesker test
a higher level of interhemispheric transfer via the was designed specifically to assess writing handedness
corpus callosum (Fabbro, Libera, & Tavano, 2002). for children at school entry (Mesker, 1972). This test
Children aged 5 to 6 years make significantly more was used by occupational therapists in the United
errors than 10-year-olds (Quinn & Geffen, 1986). Kingdom and involves simultaneous drawing with both
Children are increasingly able to execute complex hands. However, findings from an evaluative study
activities requiring differentiated hand performance, in indicate that hand preference could not be confirmed
which the asymmetrical and functional role differen- definitely using the Mesker test (Warren & McKinlay,
tiation becomes more refined throughout childhood 1993).
(Fagard, 1990, 1998). Symmetrical in-phase coordina- Two assessments that include aspects of handedness
tion between the hands is evident at 5 years (Fagard, in children are frequently used in occupational therapy;
1987), but inconsistent coordination patterns are still the Southern California Sensory Integration Tests
observed in children between the ages of 6 and 10 years (SCSIT) (Ayres, 1980) and the Sensory Integration
(Haken, Kelso, & Bunz, 1985). and Praxis Tests (SIPT) battery (Ayres, 1989). Because
Unimanual action such as grasping might strengthen there is some evidence that
the contralateral unilateral control system during
infancy (Fagard, 1998). This allows one hand to take “limitations in development of unilateral hand preference may
responsibility and lead, which in turn influences hand be associated with poor functional integration of the two sides of
preference and the dissociation between the hands. the body … [and] with diminished preferred-hand visuo-motor
Bimanual action, on the other hand, allows infants to coordination” (Ayres & Marr, 1991, p. 233),
use both hands in succession until they are able to
coordinate their hands in an asymmetrical and simul- there is an advantage of using the SCSIT or SIPT to
taneous manner (Fagard, 1998). With maturation, obtain a more holistic picture of handedness. The two
reaching and grasp extend to midline and then to the tests combine the assessment of preferred hand use,
contralateral space, possibly indicating a shift in hand performance, midline crossing, and bilateral
interhemispheric communication from extracallosal to motor coordination, in addition to other behaviors
callosal control (Liederman, 1983). This contralateral related to sensory integrative dysfunction. In the
reaching or midline crossing has been defined as SCSIT and SIPT, midline crossing is closely related to
preferred hand use: The therapist observes to what
“hand movements that approach and/or cross the centre extent the preferred hand is used for contralateral
longitudinal axis of the body (the body midline)” (Stilwell, reaching. In addition, hand performance is assessed in
1994). both hands by means of a tracing task, with scores
incorporating both time and accuracy. However, note midline crossing contribute to a more functional
that although the inclusion of handedness-related analysis of handedness, although background informa-
information was initially aimed at detecting the extent tion on early hand use, familial handedness, and
of hemispheric specialization (Ayres, 1980, 1989; possible prenatal, perinatal, or postnatal trauma could
Murray, 1991), contemporary sensory integration is provide some context to the influences of handedness
primarily concerned with deficits in the central proc- establishment. A test battery addressing all of these
essing of tactile, proprioceptive, and vestibular sensa- facets, the Handedness Profile, has been proposed by
tions and the integration of these into adaptive Kraus (2003). The test battery includes a Handedness
responses (Bundy & Murray, 2002; Windsor, Smith Profile Chart, that summarizes both the extent of
Roley, & Szklut, 2001). Although the SCSIT and SIPT interhand differences (ranging from explicit left L+,
test batteries still contain and use measures of preferred moderate left L–, variable V, moderate right R–, to
hand use, motor accuracy for both left and right hands, explicit right R+ handedness), and performance levels
and a midline crossing measure, the purpose of these for six handedness aspects (Fig. 9-4). In addition, the
measures is to obtain information on laterality estab- Handedness Profile features a Diagnostic Summary that
lishment in general rather than handedness, because it is incorporates background information and qualitative
considered to be an important component for detecting information on each of the handedness aspects to assist
bilateral integration and sequencing (BIS) deficits. the final diagnostic classification of the type of
In both the SCSIT and SIPT, preferred hand use presenting handedness.
(i.e., the measure of hand preference) is obtained by
first recording the hand that initially uses the pen to
draw. However, it is essential not to assume that a
highly trained task such as drawing and writing pro-
I NTERVENTION THEORY
vides an accurate reflection of hand preference, because Unestablished Handedness
these tasks are subject to sociocultural influences (Ida, Occupational therapy intervention for unestablished
Mandal, & Bryden, 2000). The inclusion of an handedness has its roots in perceptual motor theory
additional test with more opportunity to demonstrate (Keogh & Sugden, 1985; Kephart, 1971; Lerch,
hand preference across a range of functional tasks is Becker, & Nelson, 1974), sensorimotor principles
thus necessary. (Knickerbocker, 1980), and sensory integration (Ayres,
It seems evident that the multidimensional nature of 1972, 1989). Laterality has been defined by early
handedness requires a careful multifaceted assessment perceptual motor theorists as
in which hand preference, hand performance, con-
sistency, and interhand differences are recorded. In “the internal awareness of the two sides of the body and their
addition, an assessment of bimanual coordination and difference” (Kephart, 1971, p. 88).
Performance Level Inter-Hand Difference

Below Border Average Handedness Aspect L⫹ L⫺ V R⫺ R⫹
Untrained FHP
Trained FHP
Skill
Ability
Midline Crossing
Bimanual Coordination
Figure 9-4 Example of a handedness profile chart combining performance levels and interhand differences.
Note: FHP = Functional Hand Preference, L+ = explicit left handedness, L– = moderate left handedness, V = variable
handedness, R– = moderate right handedness, R+ explicit right handedness. This handedness profile is based on an
8-year-old boy with PDD who had left-handed tendencies but was encouraged at home and in therapy to use his right
hand. (Kraus, 2004)
In this context, the development of laterality was aphasia after unilateral left hemisphere brain damage.
thought to underlie the establishment of handedness: However, the supplied evidence is rather weak (Bryden
When a child is able to differentiate the two sides from et al., 1996), and it has been suggested that these types
each other, one side becomes more “dominant.” The of lateralities are inherited genetically and not related to
emphasis in the perceptual motor approach is on the brain lateralization (McManus, 2002).
establishment of laterality, and handedness is con- Traditionally, clinicians have considered laterality to
sidered to be a by-product (Kephart, 1971). Although be a sensorimotor-based phenomenon that becomes
some early sensorimotor training programs aimed at established independently of the child’s knowledge of
improving body image and laterality have resulted in left and right, and it is thought to be stabilized when
increased contralateral reaching (Ball & Edgar, 1967; the child has acquired the left-right concept (Williams,
Maloney, Ball, & Edgar, 1970), the broad definition of 1983). This concept of laterality assumes hierarchical
laterality fails to specifically address handedness. Indeed, functioning of the central nervous system, in which
handedness should not be considered synonymous with laterality is deemed necessary for higher-level move-
laterality, because the correlation between handedness ment efficiency, symbol recognition, and directionality
and other modalities (foot, eye, and ear) is variable. (Knickerbocker, 1980). Therapy promoting the estab-
Footedness (as assessed through kicking) appears to be lishment of handedness within the perceptual frame-
most strongly related to handedness, with about 85% of work aims to improved general body awareness, body
right handers and 80% of left handers using their right image, crossing the midline, and directionality
and left feet, respectively (McManus, 2002). However, (Knickerbocker, 1980).
clinical experience has indicated that one-leg standing Adopting a similar bottom-up approach within a
balance, another task used to assess the preferred leg, sensory integrative frame of reference, Ayres (1972)
does not appear to correlate strongly with kicking, initially suggested that integration of proprioceptive
possibly because the nonkicking leg needs to acquire and vestibular sensations, as well as efficiency of inter-
good balance to support the kicking leg (Kraus, 2002, hemispheric connections, were fundamental to good
personal observation). Eyedness has been assessed and it bilateral integration and the establishment of a pre-
was found that about 70% of people demonstrate right ferred hand in contralateral space. Since then, sensory
eye preference and 30% left eye preference: Although integration theory has refined these concepts or
there is a correlation between eyedness and handedness, expanded on Ayres’ propositions by linking theoretical
it is rather weak (McManus, 2002). Finally, earedness postulates to clinical practice and sensory integrative
correlates even less with handedness, because only about therapy using case examples (Dahl Reeves & Cermak,
60% of people listen with the right ear and 40% show left 2002; Kimball, 1999; Koomar & Bundy, 1991, 2002;
ear preference (McManus, 2002). Murray, 1991; Windsor et al., 2001). More specifically,
The importance of the lateralization of these some authors suggested that the inclusion of trunk
modalities remains controversial, particularly because rotation is important in developing bilateral integration
there is a lack of empirical evidence that they reflect and crossing of the midline (Kimball, 1999; Koomar &
brain and language specialization more accurately than Bundy, 1991, 2002). These authors proposed that
handedness (Bryden et al., 1996). The concept of employing these behaviors together in therapy might
“cross-dominance” (i.e., hand-, foot-, eye-, and ear- assist in promoting the cerebral specialization necessary
dominance are not congruent) was introduced by for developing a skilled preferred hand.
Orton (1925, 1937), who proposed that “cross- Moreover, several authors have suggested the
dominance,” particularly between hand and eye pref- inclusion of bilateral coordination and midline crossing
erence, is associated with dysfunction such as dyslexia, activities when treating unestablished handedness in
a theory supported by other early perceptual motor pediatric occupational therapy practice (Clancy &
theorists (Delacato, 1963; Harris, 1957; Rengsdorff, Clark, 1990; Knickerbocker, 1980; Levine, 1991;
1967). However, more recent research has challenged Stephens & Pratt, 1989; Whitehead, 1978; Wilson,
these early theories, because no relationship was found 1994). In some instances mention is made to “remind”
between them and a mixed or “crossed” dominance a child to use the preferred hand when hand use is
profile and intelligence or achievements (Sulzbacher et inconsistent (Koomar & Bundy, 1991), although this
al., 1994). Other existing asymmetries or lateralities in presupposes a certainty about the child‘s “correct”
humans, such as arm folding, hand clasping, and leg handedness or hand dominance. Unfortunately, empirical
crossing, have been researched because they are not evidence is lacking to support the therapeutic effective-
subject to any learning. Luria (1973) and Sakono ness using any of these treatment strategies in pro-
(1982) suggested that these lateralities can denote moting handedness establishment.
“latent left handedness,” which could explain why A sensorimotor and sensory integrative approach to
some individuals were more likely to recover from treatment of a 3- to 4-year-old child with unestablished
handedness seems appropriate, because an overall dev- problems of unestablished or variable handedness, they
elopment of laterality may well assist in establishing should refrain from retraining handedness, unless they
handedness. However, older children presenting with receive professional supervision or have completed
unestablished handedness pose the greatest challenge, special courses in this field.
particularly so if a decision on handedness is eminent
because of school entry. Based on the current handed- Left Handedness
ness knowledge discussed so far, assessment results In most aspects, there are no differences between
should be analyzed carefully before embarking on treating left and right handed children in therapy,
clinical decision making. How do we know if a child is because motor problems are common in both groups
inherently left or right handed? Are there other factors and should be treated according to the same principles.
to consider before making a final decision? What is the However, two intervention areas require specific atten-
most beneficial treatment for that child? In her doctoral tion for left handers: writing and those ADL activities
thesis, Kraus (2003) methodically evaluated existing that involve utensils designed for right handers.
handedness measures, proposed several different
reasons why children could present with unestablished Writing
handedness (or types of variable handedness), devised a The act of writing from the left to the right is con-
novel assessment battery and suggest treatment guide- ducive to right handers, who engage in a pulling
lines in the context of her Handedness Profile. This motion across the page whereby the written work is
process could be one way to deal with these questions, clearly visible. Left handers have to adhere to the same
but it extends beyond the scope of this chapter. In the left-to-right direction in writing and thus should apply
absence of evidence-based practice to substantiate a pushing motion that is more difficult to control.
certain treatment approaches, differential handedness Furthermore, if left handers employ the mirror image
assessment methods are crucial. hand position of right handers during writing, the left
hand obscures the written work, and if a fountain pen
Switched Handedness is used, smudges it. The pushing action and visual
When addressing switched handedness flag a note of limitations seem to be the main reasons why many left
caution. Although many of a child’s presenting handers develop compensatory positions that often
problems might be related to, or caused by, switched result in an unfavorable, cramped writing grasp with
handedness (Fischl, 1986; Friedman, 1987; Harris, wrist flexion. Although the pushing action may be
1990; Olsson & Rett, 1989; Richberg, 1987; Sattler, more laborious when learning to write, this is no reason
1998; Stutte et al., 1977), “unswitching” might not be to switch a left-handed child to right-handed writing,
favorable in every case because there appear to be cer- because there is evidence that left handers are able to
tain preconditions for successful handedness retraining. develop the same writing speed as right handers
According to Sattler (1998), these preconditions (Sattler, 2001). However, if a child learns to use a
include the following: (a) full support for the retraining hooked or clawed writing position through compensa-
process of parents and teachers; (b) a relatively stress- tion, this is more likely to impede on the speed,
free situation with flexible time constraints on writing, legibility, and ergonomics of writing.
and limited writing volume; (c) sufficient motivation of In therapy it is thus crucial to establish the correct
the child; and (d) a skilled therapist experienced with writing pattern for left handers. The basic principles are
handedness issues. In addition, based on my own clinical the same as in right handers:
experience as an occupational therapist, average or • 90°-90°-90° position at hips, knees, and feet, with
above-average motor performance level of the left table height two fingers above the adducted elbow;
hand, regular occupational therapy sessions, monitor- good upright posture
ing of progress, and regular follow-up (including close • The upper arm only abducts slightly when the fore-
contact with parents and teachers), also are necessary arm moves outward to the side, and the elbow does
for a successful handedness retraining outcome. Age not protrude sideways
does not appear to be a major factor for successful • Lateral support of the ulnar side of the hand and
retraining because numerous case studies exist of adult wrist extension
switched handers who have successfully retrained their • Refined and relaxed tripod grip enabling intrinsic
original or dominant handedness (Sattler, 1998). A finger movement
case study, based on the Handedness Profile (Kraus, The following principles are specific to left-handed
2003), illustrates the clinical decision making process writing:
for a child with switched handedness (Box 9-4). • Paper or exercise book placed slightly toward the left
However, a note of caution: Until therapists are of the body midline with the left top corner slanted
more familiar with the dynamics and associated between 20° and 40° up to the left
BOX 9-4 Case Presentation of “Tim” as an Example of Clinical Decision Making Based on
Background Information, the Handedness Profile (Kraus, 2003)
BACKGROUND INFORMATION incongruence between ability and skill, because the right
Tim (6 years and 6 months old) presents with right- hand performed notably better than the left in both ability
handed writing. A history of early left hand use is and skill. For midline crossing the left hand was used more
reported, and both father and sister are self-reported for contralateral reaching than the right, although Tim
switched left handers. There are indications of socio- generally avoided crossing the midline. Ability was per-
cultural pressure for right hand use, with Tim’s father formed in the average range with the right hand, which is
openly advocating the need to switch left handedness to not unusual for left handers as a group. However, skill was
right handedness. There is a history of birth-related stress performed better with the right than with the left hand
and general mild developmental delay. but scored in the poor range. This might result from a
mild motor-based deficit, because both hands performed
HANDEDNESS PROFILE
in the subaverage or poor performance level range despite
• Untrained hand preference tasks: More left than right
the practice effect of the right hand. Bimanual coordina-
responses, below average performance, inconsistent
tion was scored in the average range with a stronger
within and across tasks
left-handed lead. This, together with average ability per-
• Trained hand preference tasks: Slightly more right than
formance, suggests an absence of severe coordination
left responses, below-average performance, inconsistent
problems. In the light of sociocultural pressure for right
across tasks mainly
hand use, it can be assumed with reasonable confidence
• Hand performance ability: Significantly more right than
that switched handedness is responsible for Tim’s variable
left responses, average performance
hand use.
• Hand performance skill: Significantly more right than
left responses, below average performance CLINICAL DECISION MAKING
• Midline crossing: Crosses more frequently with the left It appears that Tim’s motor and perceptual problems have
but overall avoids contralateral reaching a developmental basis, and it is likely that these problems
• Simple bimanual coordination (bimanual circle draw- are exacerbated by his switched handedness. However,
ing): Leads more with the left, average performance considering that his left hand performed in the subaverage
• Overall classification: Variable left hander range for the “nonpreferred” hand, and given the “pro-
switching” attitude prevalent in his family, the option of
DISCUSSION AND INTERPRETATION OF RESULTS
retraining handedness was rejected. Instead, a sensori-
The handedness profile indicates both within-task and
motor program addressing his gross motor problems, and
across-task inconsistency, in which the left hand is used
a graded fine motor and graphomotor program appeared
more for untrained tasks (mild left) and the right slightly
more appropriate.
more for trained tasks (variable right). There was no
• In general, wrist extension can be greater than in processing direction, but left-handed children might
right handers; that is, closer to maximum extension thus undergo a more extensive phase of reversals and
(and not closer to neutral, as in right handers). This mirror writing.
allows the writing hand to be placed below the written
work and thereby ensures good visibility as well as a Activities of Daily Living
functional and refined pencil grasp. In practice, wrist Although many activities of daily living (ADL) tasks can
extension might be closer to neutral when starting to be performed by left handers in a mirrorlike fashion to
write from the left side, and may increase as the hand right handers (e.g., brushing teeth, getting dressed,
moves toward midline. doing buttons, tying laces), there are several ADL tasks
Mirror writing or reversals is another interesting that involve utensils with a right-handed bias, or that
aspect often observed with left-handed writing. There are performed in a right-hand-biased environment. These
seem to be two reasons for this. First, there appears to include cutting with scissors and one-sided bladed
be a natural tendency for a pulling motion during knives, pencil sharpeners, computer mice with clicks for
drawing and writing, which, for left handers, extends the right index finger, playing the piano (with the more
from right to left. Second, there is evidence that right difficult part usually on the right), reading and using
handers tend to process visual information in a left-to- measuring jugs, tightening of screws with a screw-
right direction, whereas left handers process in the driver, and opening lids and taps with external wrist
opposite right-to-left direction (Sattler, 1998). These rotation that usually require greater strength. Clearly,
tendencies may result in reversals but do not necessarily there are differences in proficiency levels involved in
presuppose problems, unless the child also has visual these tasks, and many left handers quite easily learn to
perceptual processing problems. It is a matter of prac- perform low-level skill tasks with their right hand. For
tice and habit to adopt the left-to-right visuomotor higher skill levels, such as cutting with scissors, it is
advisable to provide left-handed scissors. (Incidentally,

the so-called two-bladed scissors that are advertised for
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Chapter 10
SELF-CARE AND HAND SKILL
Anne Henderson
CHAPTER OUTLINE activities that are normal for an individual in good

health” (p. 7). Thus they considered self-care perfor-
IMPORTANCE OF INDEPENDENCE IN SELF-CARE mance to be a critical aspect of the health and well-
being of a child, and included the categories of eating,
Importance to the Child dressing, bathing, and toileting. These are the basic
Self-Care in Disability activities of self-care. They, with the inclusion of
MEASUREMENT grooming and hygiene, are the subject of this chapter.
We recognize the equal importance in the health of the
Nonstandardized Measures individual all the functional status activities identified in
Standardized Instruments this chapter as basic, as well as those identified as activ-
FACTORS IN THE ACQUISITION OF SELF-CARE ities of daily living (ADL) and independent activities of
daily living (IADL) skills or self-maintenance skills
Social and Cultural Influences (American Occupational Therapy Association, 1994).
Sex Differences However, it is independence in basic self-care that
Maturation usually is achieved in childhood. The child entering
school is expected to be toilet trained and self-sufficient
Mastery Motivation in eating, dressing, hygiene, and simple domestic tasks.
Motor Factors These self-care activities are among the first achieve-
CHRONOLOGY OF SELF-CARE ACQUISITION ments of childhood, and they provide independence,
social approval, and a sense of mastery for the child.
Eating This acquisition of self-care skills in childhood is
Dressing intricately involved with the development of motor
Hygiene and Grooming skill. The motor skills discussed in this chapter are
limited to those of the hand. We recognize that
DISCUSSION postural control is essential for all self-care and
Hand Skills in Self-Care oral–motor control is essential for eating and refer the
Perceptual Factors in Self-Care reader to several excellent discussions of their role in
basic self-care (Case-Smith, 2000; Shepard, 2001). The
Cognitive and Personality Factors in Self-Care reader must also incorporate the information in this
SUMMARY chapter into an overall framework of physical, mental,
and social development.
The purpose of this chapter is to review what is
The performance of self-care activities is so universal known about the development of self-care in relation to
that its relevance to all aspects of living is often over- the development of hand function. We begin with
looked. Eisen and co-workers (1980) in their Health comments on the importance of self-care, its measure-
Insurance Study conceptualized child health as including ment, and on factors such as culture and personality
physical, mental, and social health. They defined physi- that influence its development. We then present a de-
cal health in terms of functional status, which in turn velopmental overview of eating, dressing, and hygiene
was defined as the “capacity to perform a variety of and grooming behavior and end with a discussion of
193
hand skills and other factors affecting the achievement of volitional behavior (Bullock & Lutkenhaus, 1988).
of particular skills. Volition implies action in which the achievement of a
goal is seen as resulting from one’s own activity.
IMPORTANCE OF INDEPENDENCE SELF-CARE IN DISABILITY

IN SELF-CARE The timely achievement of abilities in self-care tasks is
important in the daily life of all children in the US
Children of every society are expected to develop culture and the inability to perform a skill is a major
independence in their performance of everyday living barrier to school and home living for children with
skills and in most cultures independence is taken for special needs. In the development of a child’s potential
granted as children reach the appropriate maturational
levels. The universal expectation for competence in self- “acquiring daily living skills may be as important as academic
care activities is the reason for the emphasis on their qualifications” (Gordon, 1992, p. 97).
acquisition in rehabilitation and education.
The degree of disability in self-care among children
with special needs varies with type and degree of
I MPORTANCE TO THE C HILD impairment both within and among disabilities. In a
A child’s control over the environment comes to a large London school district a survey conducted of special
degree through mastery of daily activities (Amato & needs children (primarily with cerebral palsy or
Ochiltree, 1986). The ability to feed, dress, and care multiple handicaps) reported that about 65% needed
for toileting needs significantly increases a child’s con- help in dressing and 25% in eating (Inglis, 1990). A
trol over both home and school environments. For study of young adults with cerebral palsy also reported
example, a child who dresses himself or herself does not a high degree of continuing dependence: Fewer than
have to depend on the convenience of the caregiver. half were independent in basic self-care (Senft et al.,
The child has more control of time, to be dressed with- 1990). As expected, these researchers found a greater
out waiting, or delay dressing a bit to complete an degree of dependence in persons with quadriplegia:
interesting activity. The majority of persons with hemiplegia were indepen-
The ability to meet individual needs without seeking dent. Another study of young persons with hemiplegic
help can result in feelings of efficacy and control cerebral palsy found most had achieved mastery in
(White, 1959) and this is a most important con- self-care, including the bimanual activities, but some
sideration in the development of basic self-care. Self- expressed reluctance to perform them because the
dependence is an important developmental task in any adaptive method made them look different (Skold,
culture, the achievement of which wins cultural Josephson, & Eliasson, 2004).
approval, and cultural pressures are such that mastery Children with developmental coordination disorder
of a given task leads to satisfaction. Furthermore, usually are evaluated for achievement in drawing, writing,
teaching self-care activities provides an opportunity for and schoolwork. Less attention has been given to their
caregivers to instill positive self-esteem in young self-care needs, but descriptive studies have shown that
children. their impaired motor abilities sometimes interfere with
The observation of emerging independence in a eating and dressing independence (Gubbay, 1975;
child has been called “an early joy of parenthood” May-Benson, Ingolia, & Koomar, 2002; Walton, Ellis,
(Coley & Procter, 1989, p. 260). In the United States & Court, 1962). The possible delay in self-care acquisi-
children are encouraged and praised for self-sufficiency, tion is now considered one criterion for diagnosis of
with the result that most want to be independent and the disorder (American Psychiatric Association, 1994;
feel a sense of pride in mastery (Gordon, 1992). Young Cermak & Larkin, 2002).
children often announce achievements such as tying a Many disabilities of childhood interrupt the typical
bow or buckling a shoe to family and friends, often sequence of independent performance in self-care skills.
wanting to demonstrate their new skill. When parents Their importance in early childhood in the presence of
actively encourage and teach children to care for them- a disability sometimes is underestimated because infants
selves, they are fostering the development of compe- and preschool children are naturally dependent and
tence (Maccoby, 1980). Furthermore, young children easy to tend. Parents may not be too concerned about
demand independence: “I can do it myself.” This delays in activities such as dressing, but as a child grows
insistence on self-sufficiency in performing activities and siblings are born, extended dependency can add
begins during the second year of life (Geppert & significantly to the stress within a household (Wallander,
Kuster, 1983) and has been related to the development Pitt, & Mellins, 1990).
Self-Care and Hand Skill • 195
Research has demonstrated that life outcomes in California (Bleck & Nagle, 1975; Coley, 1978)
social and work situations of young adults with con- primarily for use in cerebral palsy patients.
genital handicaps appear to be related to their indepen- Developmental scales providing standardized admin-
dence in self-care. For example, Wacker and co-workers istration and some reliability of scoring also have been
(1983) reported that the variables most strongly related published (Brigance, 1978; Vulpe, 1979). The estimated
to satisfaction with life outcomes were the individuals’ ages at which the tasks and subtasks are accomplished
perception of their independence in self-care and are derived from multiple sources that are identified in
mobility. Christiansen (2000) has noted that being able the manuals. Sources include intelligence tests, devel-
to conform to societal expectations for self-care is integral opmental tests, and research studies. Because these tools
to overall feelings of life satisfaction. Self-dependence were intended as a guide for the sequential learning of
in everyday tasks is important to everyone, and no less self-care and other developmental skills, they include
so for children whose achievement is interrupted by multiple steps in achievement. The purpose of these
disability assessments is to provide an intervention guide and an
ongoing inventory of a child’s progress and achieve-
ments in all developmental areas. The developmental
MEASUREMENT assessment published by Vulpe has a particularly
detailed section on self-care.
Published and unpublished center-made measures
NONSTANDARDIZED M EASURES such as those described have been in wide use. The
Since the early years of the profession, therapists have advantage of center-made instruments is that they can
been concerned with the assessment and treatment of be designed for the needs of particular children in
dysfunctional self-care performance. One of the first particular settings. The disadvantage is that assessment
known checklists of self-care performance was published information cannot be generalized to other disabilities
in 1935 (Wolf, 1969); since that time assessment of or settings and the semiformal methods of adminis-
function has been traditional in both occupational and tration make it difficult to ensure reliability among
physical therapy. Assessment forms were published different therapists, even when a standardized method
from time to time in the early years, but more often of evaluating each item has been developed. Change
treatment settings designed forms to meet the needs of in a child’s skill or the lack thereof might reflect
their particular caseloads and treatment settings. differences between therapists rather than changes in
Developmentally oriented functional assessments performance.
that incorporated information on child growth and
development came into use in the 1940s, and devel-
opmental scales that included basic self-care were
STANDARDIZED I NSTRUMENTS
published a few years later. For example, an upper- Derived normative age information for developmental
extremity motor development test that included age- scales is at best only fairly accurate, and the information
keyed items on feeding, dressing, and grooming, as on individual children is descriptive only. Meaningful
well as hand use, was developed at the New York State overall scores are not obtainable because there is no
Rehabilitation Hospital (Miller et al., 1955). Such way of weighing individual items. Therefore they are
instruments used information on ages at which children not appropriate for use in research or the documen-
typically master skills, and grouped the skills by the age tation of overall progress.
at which achievement might be expected. Two pediatric assessments designed for the func-
One of the reasons therapists have continued to con- tional evaluation of children with disabilities and the
struct their own instruments is because of the need for reliable documentation of change were developed and
greater detail in planning treatment programs for dif- standardized in the 1990s and are now in wide use in the
ferent disabilities. Breakdown of self-care activities is United States, as well as in other countries. They are
different for a child with a congenital amputation, the Wee Functional Independence Measure (WeeFim)
cerebral palsy, spina bifida, or mental retardation. Both (State University of New York at Buffalo, 1994) and
center-made and published scales are designed for day- the Pediatric Evaluation of Disability Inventory (PEDI)
by-day guidance of intervention and are as detailed (Haley et al., 1992). Both include sections on basic
as available knowledge allows. Some published non- self-care and have been demonstrated to be valid and
standardized instruments have been designed for reliable (Ottenbacher et al., 2000). The two instru-
specific disability areas. For example, a comprehensive ments are highly correlated (Ziviani et al., 2001): Each
tool for evaluating children’s self-sufficiency in self-care has its advantages. The PEDI gives more depth of
activities was developed by the Occupational Therapy information but the WeeFim is easier and faster to
Department at Children’s Hospital at Stanford, administer.
The WeeFim evaluates functional independence of ment made by Key and co-workers (1936) about
children ranging in age from 6 months to 7 years and dressing; that learning is influenced by chronological
is simple and fast to administer. Seven of the 18 items age, mental age, the child’s interest, the amount of
are self-care and the scale yields a single score for the guidance given, and the type of clothing worn.
level of independence in each of the domains of eating, Whether or not these factors are supported by research,
grooming, bathing, dressing upper body, dressing lower social, psychological, and physical factors, as well as
body, and toileting. The instrument is being validated gender and maturation, clearly play a part in skill
in other countries; for example, in Japan (Liu et al., acquisition.
1998; Tsuji et al., 1999) and China (Wong et al.,
2002).
The PEDI evaluates self-care, mobility, and social
SOCIAL AND C ULTURAL I NFLUENCES
function in much greater detail than the WeeFim. The Gesell and Ilg (1943) considered the development of
items in basic self-care provide considerable informa- feeding behavior in the infant to be a
tion on a child’s abilities and include the following
areas: eating different food textures; use of utensils; use “story of progressive self dependence combined with cultural
of drinking containers; tooth brushing; hair brushing; conformance” (p. 317).
nose care; hand washing; washing body and face;
pullover/front opening garment; fasteners, pants, The broad culture and expectations of the home and
shoes/socks; and toileting tasks. preschool all determine the degree and timing of a
The PEDI has several strengths as a measurement child’s mastery of basic self-care skills.
tool for children. It has been carefully standardized and With the development and standardization of self-
yields a total score that can be used to measure the care instruments in the United States, researchers in
overall progress of children with disabilities. Age other countries have conducted studies to determine
expectations are given both for overall independence in whether the measures can be used in their populations
separate domains and individual items. The user can (Gannotti & Cruz, 2001; Wong et al., 2002). Studies
select the level of expectation desired, such as the age also have provided information about differences
range at which 10%, 25%, 50%, 75%, or 90% of children between countries in ages of self-care acquisition.
without disabilities demonstrate mastery. The PEDI For example, younger Chinese children scored better
has been validated for use in other cultures, including than U.S. children in self-care on the WeeFim (Wong
Puerto Rico (Gannotti & Cruz, 2001). Research has et al., 2002) and Puerto Rican children developed
shown that the PEDI can be used to document gain in some self-care skills later (Gannotti & Handwerker,
self-care (Dumas et al., 2001). 2002).
In summary, the selection of a measurement tool The timing of the mastery of self-care activities
needs to be based on the major purpose of the tool. If depends on the expectations for the child and these
multiple purposes are to be met, more than one tool expectations differ among cultures. The U.S. culture
should be used. Possible purposes are (a) diagnostic- places high value on self-sufficiency, so that child-
remedial, that is, to provide a blueprint for selecting rearing practices emphasize early independence. Many
and sequencing treatment activities; (b) description of other cultures place a higher value on family inter-
self-care performance for communication with parents dependence, for example, in Puerto Rico child-rearing
and professionals; (c) charting the acquisition of self- practices include later teaching of skills such as self-
care skills; and (d) evaluating the effects of treatment. feeding (Gannotti & Handwerker, 2002).
Both center-made and published but not standardized An obvious cultural factor is in the difference in food
evaluation instruments can be used for the first three practices. In India food is eaten with the hand; in the
purposes; only standardized instruments are appropriate United States utensils are used, and in Asian countries
for the fourth. children use chopsticks. These three methods of self-
feeding require different hand skills. Hand feeding
requires less motor maturation than the use of a spoon,
FACTORS IN THE ACQUISITION which in turn requires less motor maturation than
chopsticks. The spoon is grasped in the fist and can be
OF SELF-CARE carried to the mouth with the forearm pronated and
the arm abducted, but chopsticks require individuation
Our knowledge of the factors that influence the devel- of the fingers and supination of the forearm. Another
opment of basic self-care is based more on common difference is the way in which knives and forks are used.
knowledge derived from the experience of caregivers In the United States, one scoops and spears with a fork
than on research. However, most agree with the state- and cuts meat with the knife in the right hand, then
switches utensils to continue eating. In some European

countries the knife is used in the right hand to pile food
SEX DIFFERENCES
on the back of the fork, which is then carried to the Early literature reported several differences between
mouth with the left hand. These differences may girls and boys in the age at which self-care skills are
influence the sequence and timing of self-sufficiency in acquired. Gesell and Ilg (1943) wrote that boys
self-feeding. demand independence in dressing at a younger age
Differences in dressing styles must certainly influence than girls. Key and co-workers (1936) reported
skill attainment. In some cultures children go naked tentative sex differences in dressing ability between 21⁄2
until they are toilet trained. In the United States the years and 41⁄2. Girls were more skillful than boys and
emphasis on early self-sufficiency has led to inventions tended to dress faster, and the ability of boys generally
in clothing style. For example, draw-down diapers was more variable than that of girls. Sources of the
foster an earlier independence in going to the toilet, differences in the ages at which dressing skills are
and Velcro fasteners make the preschool child self- achieved have been proposed. It has been thought that
sufficient in putting on shoes and outer clothing. girls dress themselves earlier than boys because their
Individual families also influence the performance of wrists are more flexible, they are better coordinated,
everyday skills. In this author’s experience in Mexico, and they wear simpler clothing (Coley, 1978; Gesell et
many families with maids did not permit children to use al., 1940; Key et al., 1936). A difference also has been
spoons until they were able to do so without spilling; reported in the use of eating utensils in self-feeding
bibs were not used beyond early infancy. Wong and co- (Gesell & Ilg, 1943). Girls shifted to an adult grasp
workers (2002) also reported that the presence of a earlier than boys, some as early as 3 years. Some boys,
maid in the home led to later achievement of self-care. on the other hand, continued to use a pronated grasp
Another example of family influence is on a child’s at 8 years of age. Boys also were reported to sometimes
tidiness in eating. Bott and co-workers (1928) won- demand to feed themselves before they were competent
dered why a child who was above average on most to do so.
measures was so far below age expectations in eating. One recent study has also shown a difference between
On questioning the parents they discovered that, the sexes. In China, younger girls were reported to score
because they thought the child was too young to eat higher than boys on the self-care subscores of the
well, they had made no attempt to correct him. When WeeFim (Wong et al., 2002). However, no sex differ-
the expectations for the child were raised at home, his ences in overall functional ability were found in research
score rose to age levels within 2 weeks. Such differences in the United States on the PEDI (Haley et al., 1992).
in attitudes result in differences in the timing of the
child’s mastery of basic skills.
Two studies have investigated family factors
MATURATION
influencing competence in household tasks. A study by Although culture and family expectations play a role, it
Zill and Peterson (cited by Amato & Ochiltree, 1986) seems clear that the greatest factor in the achievement
found that the best predictor of performance on tasks of self-care skill in childhood is maturation. Certainly
such as washing dishes without help was the frequency Gesell and his associates thought so, and self-care items
of joint family activities. They also found that family are prominent in his developmental diagnosis (Gesell &
size was related to competence in such skills. Large Amatruda, 1965). This supposition was borne out by
families may require more practical assistance from the research of Key and her associates (1936), who
their children in chores, and younger children are able found the correlation between dressing ability and
to learn from older children. The family variables found chronological age to be considerably higher than that
by Amato and Ochiltree (1986) to foster the acquisi- for mental age or any other factor. Furthermore, the
tion of practical skills were frequent interaction of composite score of self-care, mobility, and social
family members and the requirement that the children functions of the PEDI showed high and significant
take responsibility for chores. correlation with age but not with demographic
In summary, cultural, class, and family variables variables.
influence the timing of the acquisition of independence
in self-care in young children. For the most part
societal expectations do not vary in respect to the need
MASTERY MOTIVATION
for eventual development of independence, but The concept of mastery motivation has its roots in the
behavior in childhood may signify cultural and parental writings of Robert White (1959), who proposed that
patterns rather than a child’s intrinsic abilities. Aware- the development of competence in young children
ness of such patterns is important in assessment and grew out of a pleasurable sense of efficacy when they
goal setting. successfully manipulated objects. The toddler and
preschool years are important periods in this speed and precision require a long developmental
development of goal-oriented behavior, and wanting to period. One indication of the automatization of a skill
be self-sufficient in the performance of early eating and that occurs at about 4 years of age is when children can
dressing skills is one expression of effectance or mastery feed and dress themselves while carrying on a
motivation (Bullock & Lutkenhaus, 1988; Geppert & conversation (Hurlock, 1964; Klein, 1983).
Kuster, 1983). Early anecdotal accounts of achieve- Many self-care activities require the use of tools
ment in self-care performance indicated that interest, (Castle, 1985). Tools are defined here as a means of
self-reliance, and perseverance were important attributes. effecting change in other objects. The earliest self-care
Wagoner and Armstrong (1928) found success on a tools are for eating: spoons, knives, forks, and cups.
buttoning task was correlated with teacher ratings of Self-care in hygiene includes tools such as brushes,
perseverance. Key and her associates (1936) reported combs, and washcloths. Dressing fasteners, zippers,
that interest in dressing develops with ability in 2-year- snaps, and buttons also can be considered tools. The
old children and that enjoyment increased as mastery use of most tools is complex because it involves the
improved. However, at 3 years they found that interest manipulation of one object relative to another, which
shifted to desire for approval and achievement and also results in the change of state of one or both objects
found wide differences among the children in the (Parker & Gibson, 1977). The use of tools is goal
development of self-reliance and the perseverance directed by definition and requires the understanding
needed for the performance of the more difficult tasks. of a means–end relationship. Even the use of a simple
These findings were based on analysis of the children’s tool such as a spoon requires both the understanding
comments while they were dressing. of purpose and the motor skill to use it. However, as
Recent studies in mastery motivation have focused children mature, their understanding often moves
on its relationship to many different child factors such ahead of their manipulative skill. In general, learning to
as cognition (Hauser-Cram et al., 2001) and parent use tools is acquired later than self-care without tools.
factors such as negative and positive maternal behaviors
(Kelley, Brownell, & Campbell, 2000). These recent
studies measure mastery motivation in a test situation,
usually with puzzles graded in difficulty so that they
CHRONOLOGY OF SELF-CARE
provide a challenge for the level of each child. A ACQUISITION
longitudinal study of particular interest for this chapter
showed that children with disability who scored higher The following pages present developmental patterns
levels of mastery motivation at 3 years of age achieved and the ranges of ages in which typical children learn
greater independence in self-care at 10 years (Hauser- to care for their own daily needs. This information is
Cram et al., 2001). These researchers found mastery presented as a summary of what is currently known
motivation to be important both for the development about the chronology of the acquisition of skill in self-
of a child and for the well-being of the parent. care as a source for the understanding of the process by
which skills are acquired. The immediate purpose is to
allow a preliminary analysis of the relationship of the
MOTOR FACTORS acquisition of self-care skills to the development of
Coley (1978) identified sequences of gross and fine hand skills. The information that follows has been com-
motor development leading to independence in self- piled from different sources to provide as much detailed
care tasks. Examples of necessary gross motor abilities information as possible. The child’s attempts at perfor-
needed for dressing are reaching above the head or mance are included because they show an under-
behind the back while maintaining trunk stability. Self- standing of the task, and the practicing of subskills
feeding requires head and mouth control, as well as reflects motor abilities. The developmental information
trunk stability. Coley identified steps in the motor in the following discussion is organized into the do-
control leading to many individual self-care skills, and mains of eating, drinking, dressing, personal hygiene,
they are discussed within each self-care domain. They grooming, and simple household tasks. The items listed
include bilateral skills, finger manipulation, and tool in the charts are steps in the learning of self-care that
skills. Children learn one-handed skills before bilateral various authors have observed and reported. We have
skills, and some skills are achieved later because of no definitive information as to the universal consistency
the need for the two hands to work together. An early of the sequences presented: They are based on reports
example is holding a bowl with one hand while of ages at which children are usually self-sufficient in
scooping with the other. Children become functional discrete skills.
in the performance of skills during their preschool The area of research that has provided the most
years, but complete independence and adult levels of information on the acquisition of specific self-care skills
over the years has been the area of development of and conformity to cultural standards. In typically
evaluation tools. Two such primary sources of infor- picturesque speech, Gesell and Ilg (1943) described
mation were used to chart the general ages at which this progression:
skills are achieved. The first source is the PEDI (Haley
et al., 1992). As has been noted, this instrument includes “At 36 weeks he can usually maintain a sustained hold on the
extensive sections on basic self-care and provides the bottle. In another month he may hold it up and tilt it with the
most reliable information available on the ages at which skill of a cornetist. He can feed himself a cracker. At 40 weeks,
many skills are achieved. The ages noted in the tables he also begins to finger feed, plucking small morsels. … He also
handles his spoon manfully [by 15 months] and begins to feed
from the PEDI indicate a group in which more than
himself in part, though not without spilling, for the spoon is a
75% of the children were reported to have achieved
complex tool and he has not acquired the postural orientations
independence. and pre-perceptions necessary for dexterity. … At 2 years, he
The works of Gesell and his associates also were a inhibits the turning of the spoon as it enters the mouth and feeds
primary source. Data on the ages at which children himself acceptably. … At 31⁄2 years he enjoys a Sunday breakfast
developed specific self-care skills were collected by many with the family. … At 5 years … he likes to eat away from home
different methods over many years. The results of most especially at a restaurant. He is more a man of the world!”
of their observations were incorporated into overviews of (pp. 318–319).
development (Gesell & Amatruda, 1965; Gesell & Ilg,
1943, 1946; Gesell et al., 1940). They were interested Finger feeding and the use of a cup are early
in information that would assist in the diagnosis of accomplishments and the basic components of self-
developmental delay and to that end selected different feeding with a spoon—filling the spoon, carrying it to
sorts of behaviors expected at each age level. The the mouth without spilling, and removing food—are
behaviors selected have provided information on the well mastered by 3 years of age. However, self-feeding
acquisition of basic self-care skills for many years. takes concentration, and it is not until after the third or
Several secondary sources also were used. Following fourth year that the skill is sufficiently automatic to
the lead of the Yale Developmental Clinic, self-care allow eating and talking at the same time (Hurlock,
items were and continue to be included in many 1964). The 5-year-old is skillful but slow. Skill con-
developmental evaluations. The primary and secondary tinues to improve, for it is not until 8 or 9 years of
sources used for the tables were Coley (1978), age that the child has become deft and graceful
Brigance (1978), Vulpe (1979), Haley and co-workers (Gesell & Ilg, 1946), and it is not until 10 years that
(1992), Gesell and Ilg (1943, 1946), and Key and co- self-feeding is accomplished entirely independently,
workers (1936). with good control and attention to table manners
It must be emphasized that the ages listed from (Hurlock, 1964).
these sources are only approximate, are not necessarily
derived the same way, and reflect different levels of Finger Feeding
expectations. As has been noted, family, social, and Self-feeding with the fingers begins in the second half
cultural values influence expectations for independence of the first year. Table 10-1 shows the development of
in self-care skills and these expectations result in the skill, which parallels the infant’s acquisition of hand
individual differences in skill acquisition. Furthermore, skills. Initial feeding is of crackers held in the hand and
it must be recognized that even within a homogeneous sometimes plastered against the mouth with the palm
group the age at which children master self-care skills is and with the forearm supinated. As finger skill
highly variable. An important finding of the PEDI develops, bite-size pieces of food are picked up and put
research was that there is a wide age range, sometimes into the mouth with a pincer grasp. Even when spoon
as much as 3 to 4 years, over which individual children use has become skillful, children prefer to use fingers
achieve a particular skill. A recent study of the develop- for discrete pieces of food such as peas or meat (Gesell
ment of feeding behaviors also found a wide range of & Ilg, 1943).
ages at which self-feeding skills occur (Carruth &
Skinner, 2002). The data in the following tables are Drinking from a Cup or Bottle
best interpreted as the age range at which many, but Independent drinking from a cup is an early developing
not all, typical children in the United States perform skill as long as safeguards are taken. The use of spout
under optimum circumstances. cups with lids allows a child to drink from a cup, as well
as a bottle in the second half of the first year of life.
Table 10-2 shows the progress of skill in drinking. Cup
EATING drinking begins with the same bilateral whole hand
The progress of a child’s self-feeding behavior requires grasp used for the bottle and progresses to the dexterous
both the acquisition of skill in the use of eating utensils grip of one hand on the handle at 3 years of age.
Table 10-1 Eating finger foods
Skill Age Source
Picks up finger foods and eats 6 mo–1 yr Haley et al. (1992)
Feeds self cracker, whole hand grasp 6–7 mo Coley (1978)
Feeds self spilled bits from tray 9 mo Gesell and Ilg (1943)
Feeds self finger foods, pincer grasp 10 mo Coley (1978)
Finger feeds part of one meal 1 yr Gesell and Ilg (1943)
Takes bite-size pieces from plate, delicate grasp, 1 yr Coley (1978)

appropriate force, with demonstrated release
Table 10-2 Self-feeding: drinking from cup or bottle
Skill Age Source
Holds and drinks from bottle or spout cup with lid 6 mo–l yr Haley et al. (1992)
Tips bottle to drink 10 mo Gesell and Ilg (1943)
Lifts open cup to drink, some tipping 11⁄2–2 yr Haley et al. (1992)
Holds cup alone, hands pressed on side 1 yr Gesell and Ilg (1943)
Grasps with thumb and fingertips 1 yr 3 mo Gesell and Ilg (1943)
Holds cup and tilts by finger action 1 yr 3 mo Gesell and Ilg (1943)
Lifts open cup securely with two hands 11⁄2–2 yr Haley et al. (1992)
Lifts cup to mouth, drinks well, may drop 11⁄2 yr Coley (1978)
Holds cup well, lifts, drinks, replaces 1 yr 9 mo Coley (1978)
Holds cup or glass with one hand, free hand poised to help 2 yr Gesell and Ilg (1943)
Lifts open cup to drink with one hand 3–31⁄2 yr Haley et al. (1992)
Cup held by handle, drinks securely, one hand 3 yr Gesell and Ilg (1943)
Use of Utensils along the handle. The adult grasp usually was not seen
Table 10-3 shows the chronology of the development until 3 years of age. A second perceptual and motor act
of the use of spoons, forks, and knives. The many years is the filling of the spoon. At first the bowl of the spoon
necessary for learning to use utensils reflects the is merely dipped in the dish, often with the spoon
complexity of their use, particularly the knife and fork handle perpendicular. Filling began with a rotary move-
in cutting. The infant begins eating with a spoon held ment toward the body, and it was not until 16 months
in a fisted grasp, with the arm pronated and shoulder that children began filling the spoon by inserting its
abducted. The adult finger grip, with forearm supina- point into the food. Lifting the spoon was at first
tion and rotation as needed, requires more fine motor accomplished with the arm pronated, and often with
control and dexterity (Haley et al., 1992) but does not the bowl of the spoon tipping. By the end of the
develop until approximately 3 years in girls (Gesell et second year children were lifting their elbows and
al., 1940); some boys continue to use a pronated flexing their wrists. The insertion of the spoon into the
pattern at 8 years (Gesell & Ilg, 1946). The fisted grasp mouth also changed from the side into the mouth to
appears again in the use of forks and knives in cutting. the point into the mouth.
It appears that the force needed for holding and cutting The third study reported by Connolly and Dalgleish
requires the power of the whole hand and the necessary (1989) confirmed many of the findings of Gesell and
power combined with the finger dexterity for cutting is Ilg. They conducted a comprehensive videotape study
not developed until a child is about 10 years old. on the longitudinal development of spoon use. The
research procedure was more formal, and the study
Studies of Spoon Use can serve as a model for the investigation of the learn-
The spoon is the first tool used by most infants ing of complex motor skills. The authors first presented
(Connolly & Dalgleish, 1989). Several studies of spoon an analysis of spoon use that included both intentional
use have been reported, two involving infants and one and operational aspects. The task was described as
preschool children. The earliest study was of nursery entailing:
school children’s eating behavior (Bott et al., 1928).
The eating behaviors included in the study were (a) the “… (a) an intention to eat, which involves the child’s motiva-
proper use of utensils, (b) putting the proper portion of tion; (b) some knowledge about the properties of the spoon as an
food on a utensil, and (c) coordination, as indicated by implement with which to effect the transfer of food from dish to
minimal spilling. They found improvement with age in mouth; (c) the ability to grasp and hold the spoon in a stable con-
all these behaviors, but the behaviors differed as to figuration; (d) the loading of food onto the spoon; (e) carrying the
when they improved. The use and filling of the utensils loaded spoon from dish to mouth; (f) controlling the orientation
improved primarily between 2 and 3 years of age, but of the spoon during this transfer to avoid spillage; and (g) emp-
spilling decreased more between 3 and 4 years. tying the spoon and extracting it” (p. 897).
A cinemagraphic study of infant eating behavior
conducted by Gesell and Ilg (1937) described both On the basis of this analysis, Connolly and Dalgleish
prespoon activity and early spoon use. Preparation for conducted a longitudinal videotape study of the devel-
using the spoon began when a child was being fed. opment in the operation of a spoon during the second
Between 3 and 6 months of age the child watched the year of life. Among their descriptions was an analysis of
spoon, and soon mouth opening began in anticipation change in the action sequences from only two actions
of the spoon reaching the mouth. Later, head move- to a complex sequence that included corrections. The
ments began with movement of the head toward the actions of putting a spoon in and out of a dish and
spoon and then away as food was removed. Whereas putting the spoon in and out of the mouth initially
initially food was put in the mouth by the adult’s were unconnected. Box 10-1 shows the progression
manipulation of the spoon, the child later removed and change of action sequences in using the spoon.
food by lip compression. These movements of the head This change in action sequences seems to indicate that
and lips were considered to make later spoon manipu- the child was learning skill both in the performance of
lation more effective. single actions and in the use of complex movement
Gesell and Ilg noted that even as simple a tool as a sequences. Connolly and Dalgleish also report other
spoon requires a sequence of perceptual and motor changes in motor actions, such as a smoothing of the
acts. One act is the discriminative grasp of the spoon trajectory of the dish-to-mouth path, and the shifting
handle. Infants first grasped the lower third of the of the angle at which the spoon was placed from side
handle, later the middle to upper third, and finally the toward mouth, to point toward mouth. Children used
end. Grasp was at first palmar, with the thumb wrapped primarily a palmar grasp: the wrist, shoulder, and elbow
around the spoon, but later the thumb was placed movements also were described.
Table 10-3 Self-feeding: use of utensils
Skill Age Source
SPOON
Grasps spoon in fist 10–11 mo Gesell and Ilg (1943)
Dips spoon in food, lifts to mouth 1 yr 3 mo Gesell and Ilg (1943)
Fisted grasp, pronated forearm, turns spoon 1 yr 3 mo Coley (1978)
Scoops food, lifts with spilling 11⁄2–2 yr Haley et al. (1992)
Fills spoon, turns in mouth, spilling 11⁄2 yr Coley (1978)
Spoon angled slightly toward mouth 11⁄2 yr Gesell and Ilg (1943)
Tilts spoon handle up as removes from mouth 11⁄2 yr Gesell and Ilg (1943)
Uses spoon well with minimal spilling 2–21⁄2 yr Ha1ey et al. (1992)
Point of spoon enters mouth 2 yr Gesell and Ilg (1943)
Inserts spoon into mouth without turning 2 yr Gesell and Ilg (1943)
Fills by pushing point of spoon into food 2 yr Gesell and Ilg (1943)
Grasps spoon with fingers (girls supinate) 3 yr Gesell and Ilg (1943)
Fills spoon by pushing point or rotating spoon 3 yr Gesell and Ilg (1943)
Holds spoon with fingers for solid foods 4 yr Coley (1978)
Eats liquids, spoon held with fingers, few spills 4–6 yr Coley (1978)
FORK
Spears and shovels food, little spilling 2–21⁄2 yr Ha1ey et al. (1992)
Fork held in fingers 41⁄2 yr Co1ey (1978)
KNIFE
Uses for spreading 5–51⁄2 yr Ha1ey et al. (1992)
Spreads with knife 6–7 yr Coley (1978)
Uses to cut soft foods (sandwich) 5–51⁄2 yr Ha1ey et al. (1992)
Cuts meat with knife 7–8 yr Coley (1978)
Uses utensils deftly and gracefully 8 yr Gesell and Ilg (1946)

Individual finger function comes into play in loosening

BOX 10-1 Progression of Action Sequences
laces, and full independence in dressing requires com-
in Using the Spoon
plex finger manipulation of buttons and ties. The need
for finger dexterity and planning sequences underlies
The first purposeful sequence was five steps: the slow acquisition of management of fasteners.
1. Spoon to dish Key and her associates (1936) studied the process of
2. Remove from dish
learning to dress among 45 nursery school children,
3. Lift to mouth
4. Put in mouth ages 11⁄2 to 51⁄2 years. Overall dressing ability was highly
5. Remove from mouth correlated with chronological age. They reported the
Later, two more actions were added: learning process to be continuous, increasingly dif-
Filling the spoon ficult, and unstable, and that the most rapid period of
Removing food with lips learning was between 11⁄2 years and 21⁄2 years. Overall
The final action sequence included 11 steps that success rates increased over the ages studied as follows:
incorporated monitoring and correction through
11⁄2 years, 40%; 2 years, 50%; 21⁄2 years, 80%; and 31⁄2
repetition of sequences:
1. Control of spoon years to 51⁄2 years, 90%. Other authors also have
2. Spoon to dish reported that dressing skills develop rapidly between
3. Steady dish with other hand 11⁄2 and 31⁄2 years (Gesell et al., 1940).
4. Remove spoon from dish Self-help in putting on and removing clothes is
5. Check to see if there is enough food on spoon (if highly dependent on the type of clothing worn (Key et
not, repeat 2 to 4) al., 1936). The variability in the age of acquisition is
6. Lift spoon
undoubtedly in part a result of the type of clothes
7. Put spoon in mouth
8. Empty spoon with lips selected for children by their caregivers. Characteristics
9. Remove from mouth of clothing that facilitate self-dressing include loose
10. Check to see if spoon is empty (if not, repeat 7 to 9) tops with large neck openings and loose pants with
11. Pick up spilled food (repeat 6 to 8) elastic tops and loose cuffs. The type and size of
fasteners should be appropriate for children and they
Connolly K, Dalgleish M (1989). The emergence of a
tool-using skill in infancy. Developmental Psychology, should be in reasonable locations (front or side). How-
25(6):894–912. ever, it should be noted that peer fashions may be
important even for young children and compromises
may be needed.
Serving and Preparing Food The overall development of dressing skill proceeds
A part of independence in eating is serving oneself and from undressing, to dressing without fastening, to
preparing foods. Table 10-4 shows that by the time managing fasteners. Taking off an item of clothing is
children enter school they can take care of simple easier than putting it on because putting on clothing
preparation and self-service of food and drink. In is more complex both motorically and perceptually.
the preschool years children also begin to help with For example, socks slip off easily, but the coordination
simple household chores such as setting the table (3 to between the two hands and between hands and feet
4 years), putting away silverware (2 years), and wiping together are needed for putting socks on. Moreover,
up spills (3 years) (Gesell & Ilg, 1943). the sock must be rotated correctly to match its heel to
One of the expectations of the nursery school the heel of the foot. Information on the chronology of
children studied by Bott and co-workers (1928) was dressing is presented in four areas: antecedents of
that their feeding area be cleaned up after they ate. At dressing skills, undressing without fasteners, dressing
the age of 2 the children left the table, chair, and floor without fasteners, and managing fasteners.
clean after eating in 45% of the observations. By the age
of 4 years the percentage had increased to 85%. This Antecedents of Dressing Skills
change undoubtedly reflects the influence of nursery Table 10-5 lists average ages at which children achieve
school expectations, as well as maturation. abilities necessary for dressing. The earliest interaction
with clothing, such as clutching and pulling at clothing,
is meaningless in respect to self-care but demonstrates
DRESSING the ability to grasp. The early removal of hats and socks
The development of self-care in dressing, undressing, is also hardly purposeful undressing because it is just as
and managing fasteners also parallels and depends on likely to occur during dressing as undressing. Never-
the development of hand skills. A fisted grasp is suffi- theless, these actions demonstrate motor sequences
cient for the tasks of removing hat and socks. Pulling that will later be used purposefully.
up pants requires more strength and bilateral coordina- Researchers have chronicled infant beginnings of
tion than pushing them down and kicking them off. cooperation and assistance in dressing (Gesell & Ilg,
Table 10-4 Serving and preparing food
Skill Age Source
PREPARES FOOD
Unwraps food 11⁄2–2 yr Vulpe (1979)
Opens jars 2 yr Gesell and Ilg (1943)
Fixes dry cereal 4–5 yr Vulpe (1979)
Serves self 4–5 yr Vulpe (1979)
Makes sandwich 7 yr Brigance (1978)
Prepares baked potato 8 yr Gesell and Ilg (1946)
PREPARES DRINKS
Pours from small pitcher 2–21⁄2 yr Vulpe (1979)
Obtains drink from tap 3–31⁄2 yr Gesell and Ilg (1943)
Pours from large pitcher or carton 4–41⁄2 yr Haley et al. (1992)
Carries glasses without spilling 6 yr Brigance (1978)
OTHER SKILLS
Uses napkin 4 yr Brigance (1978)
Sets table with help 21⁄2–3 yr Vulpe (1979)
Wipes up spills 3 yr Gesell and Ilg (1943)
Sets table without help 4–5 yr Vulpe (1979)

Table 10-5 Antecedents of self-dressing skills
Skill Age Source
REACH AND GRASP

Clutches and pulls clothing Up to 3 mo Vulpe (1979)
Pulls off hat 6 mo Vulpe (1979)
Pulls off booties 6–9 mo Gesell and Ilg (1943)
Pulls off socks 9–10 mo Vulpe (1979)
COOPERATION
Passive (lies still) 3–6 mo Vulpe (1979)
Holds arm out 9 mo Coley (1978)
Lifts foot for shoe or pants 11⁄2–2 yr Haley et al. (1992)
Attempts skill
Tries to put on shoes 14–18 mo Vulpe (1979)
Tries to assist with fasteners 2–21⁄2 yr Haley et al. (1992)
Helps push down pants 2 yr Coley (1978)
Interested in lacing 21⁄2–3 yr Vulpe (1979)
TRUNK STABILITY
Reaches to toes 1 yr 4 mo Coley (1978)
Reaches above head bilaterally/unilaterally 2–5 yr Coley (1978)
Reaches behind back, hands together 3–6 yr Coley (1978)
Reaches behind head, hands together 4–6 yr Coley (1978)

1943). These early actions of pushing with arms or legs toddler can take off much clothing. Undressing requires
are components of later self-dressing. Furthermore, only simple perceptual skills; knowing front from
actions such as holding arms or legs out demonstrate behind and left from right is unnecessary. Furthermore,
the child’s understanding of the dressing process. fewer action sequences are needed than for dressing
Trying to assist (e.g., pulling at a zipper tab) may not (Klein, 1983), and hand use requires little more than
be functional but is important because it demonstrates gross grasp, pulling, and pushing. Interest in taking
modeling behavior (Haley et al., 1992). clothes off begins in the first year; by 21/2 years most
children can and want to take off their clothes, and by
Undressing: Clothes Unfastened or Without 3 years undressing is done well and rapidly (Gesell &
Fasteners I1g, 1943).
Table 10-6 identifies the sequences in which children
learn to take off their clothes. Complete independence Dressing with Assistance on Fasteners
in undressing requires the release of fasteners, a skill Table 10-7 1ists the sequences in which dressing skills
that does not develop until after 3 years of age (Coley, are acquired. The long 5-year developmental period is
1978). However, with assistance in unfastening, the to a great extent a reflection of the perceptual skills
Table 10-6 Undressing: clothes unfastened or without fasteners
Skill Age Source
HAT AND MITTENS

Pulls off hat appropriately, on request 11⁄2 yr Gesell and Ilg (1943)
Removes mittens 12–14 mo Coley (1978)
SOCKS AND SHOES

Removes socks on request 11⁄2–2 yr Haley et al. (1992)
Removes untied or unfastened shoes 11⁄2–2 yr Haley et al. (1992)
Unties and removes shoes 2–3 yr Coley (1978)
PANTS AND PULL-DOWN GARMENTS

Pushes off pants if soiled 1 yr Gesell and Ilg (1943)
Pushes down underpants or shorts 21–24 mo Gesell and Ilg (1943)
Removes elastic top on long pants, clearing over bottom 2–21⁄2 yr Haley et al. (1992)
SHIRTS, COATS, AND SWEATERS

Removes second arm from coat 1 yr Brigance (1978)
Removes unbuttoned coat 1 yr Brigance (1978)
Removes pullover garments, T-shirt, dress 21⁄2–3 yr Haley et al. (1992)
Assistance needed 3 yr Coley (1978)
Little assistance needed 4 yr Coley (1978)

Table 10-7 Self-dressing: without fasteners
Skill Age Source
HAT
Puts on, may be backward 2 yr Gesell et al. (1940)
SOCKS
Puts on with help on heel orientation 3 yr Coley (1978)
Puts on heel correctly oriented 3–31⁄2 yr Haley et al. (1992)
Pulls socks to full extension 4 yr Key et al. (1936)
SHOES
Gets shoe on halfway 11⁄2 yr Gesell et al. (1940)
Puts on, may be on wrong feet 3–31⁄2 yr Haley et al. (1992)
If laces are loosened 2 yr Gesell et al. (1940)
Loosens laces and puts on 21⁄2 yr Vulpe (1979)
Puts on correct feet 41⁄2–5 yr Haley et al. (1992)
Puts on boots if loose fitting 3–4 yr Vulpe (1979)
Independent with Velcro fastenings 41⁄2–5 yr Haley et al. (1992)
COATS AND OPEN-FRONT SHIRTS

Finds large armholes 2 yr Coley (1978
Puts on coat with help 2 yr 9 mo Coley (1978)
Puts on open-front shirt 31⁄2–4 yr Haley et al. (1992)
Adjusts collar to neck 3 yr Key et al. (1936)
PULLOVER GARMENTS, T-SHIRTS, AND DRESSES

Puts head through hole 2 yr Key et al. (1936)
Puts on pullover garment 3–31⁄2 yr Haley et al. (1992)
Puts arm through hole 31⁄2 yr Key et al. (1936)
Pulls down over trunk 3 yr Key et al. (1936)
Distinguishes front and back, inside out 4 yr Coley (1978)
PANTS AND PULL-UP GARMENTS

Helps pull pants up 2 yr Gesell et al. (1940)
Tries to put on, two feet in one hole 2–21⁄2 yr Gesell et al. (1940)
Puts on if oriented verbally 3–31⁄2 yr Haley et al. (1992)
Orients correctly and puts on 4 yr Coley (1978)
Can turn right side out 4 yr Coley (1978)

needed. The last skills achieved are in the orientation of

The Order of Difficulty in the
the heel of the sock, the front and back of garments,
BOX 10-2 Ability of Children to Put on
and, the most difficult, the distinguishing of left and
Clothing
right shoes. Children know when their coat is right side
out when they are 3, but they have more difficulty with
other clothes. The 4- to 5-year-old gets the under- Put one leg in hole of pants
clothes right side out, but it is not until 7 years that the Pulled up pants
Shoe started on foot
inside and outside of all clothes are discriminated
Opened shoe for foot
(Brigance, 1978). Put head in neck hole of dress
In addition to these perceptual skills, self-care Put on dress correctly front to back
dressing skills require complex motor planning. Gaddes Socks started over foot
(1983) described the difficulty of some children with Put foot in shoe with heel down
learning disabilities in dressing as a lack of the tactile Pulled sock up on leg
and kinesthetic awareness essential to the task of Kept tongue out of shoe while donning
Put second leg in hole of pull-down garment
putting on one’s clothes, and commented that
Pulled sock up on foot
Put pullover garment over head
“small children are usually unable to put on their clothes without Put first arm in dress hole
help … not because they lack the physical strength but because Adjusted dress when on
they lack the necessary ideomotor image” (p. 109). Put second arm in sleeve hole of dress
Shirt on correctly front to back
The hand skills needed are primarily whole-hand Adjusted pants when on
Put first arm in sleeve hole of T-shirt
grasp, a power grasp for pulling clothing on, and a high
Adjusted shirt when on
level of bilateral skill. Hands must work smoothly and Put second arm in sleeve hole of T-shirt
in unison to pull socks up to full extension, pull on Pants on correctly front to back
boots, and pull up pants. Hands must work cooperatively Adjusted heel of sock
in holding a shirt or coat with one hand while finding
the armhole with the other. Key CB, White MR, Honzik WP, Heiney AB, Erwin D
(1936). The process of learning to dress among nursery-
Additional bilateral dressing skills have been school children. Genetic Psychology Monographs,
identified by Thornby and Krebs (1992). Their interest 18:67–163.
was in expectations for independence for children with
unilateral below-elbow amputations. The skills identified
include grasping and pulling up trousers or skirt (21⁄2 to
3 years), and grasping clothing while zipping a zipper reported, based on the age group in which 50% or
(3 years 3 months to 4 years). The children with more of the children succeeded in the task, is listed in
amputations achieved these skills several years later than Box 10-2.
most children. Note that a part of an individual motor skill, such as
putting on pants or socks, was easiest but complete
A Study of Dressing achievement was the hardest. The difficulty young
Key and her associates (1936) studied the ability of children have in dressing is a mix of a challenging per-
children to put on the clothing that they wore to ceptual task, such as locating the front of a T-shirt or
nursery school and found wide differences in the ability the heel of a sock, and sometimes a complex motor act,
to put on separate garments. Overall, socks and leg such as maneuvering an arm into a second dress hole.
garments were found to be the easiest, followed by
upper body garments and dresses. Shoes, because of Fasteners: Zippers, Snaps, Buttons, and Ties
their fasteners, were the most difficult. In addition to Table 10-8 shows the range of average ages at which
looking at the overall ability to put on the garments, children are able to fasten and unfasten their clothing.
the researchers recorded the success rate of separate Manipulating zippers, as long as it does not involve
dressing units for each garment. These data provided hooking and unhooking a separating zipper, is the
an index of the difficulty of the subskills needed for easiest form of closure, whereas tying is the most
successful performance. An analysis of the percentage difficult. The feature all fasteners have in common is
of success for each subskill at each age level shows the the need for bilateral finger manipulation skills. Zippers
relative difficulties of the components of putting on require precision grip and pinch strength. The bilateral
shoes, socks, pull-down garments, dresses, and shirts. nature of this task is shown by the 3-year delay in skill
This list excludes fasteners, and open-front and slipover acquisition in children with unilateral below-elbow
shirts were not differentiated. The order of difficulty amputations (Thornby & Krebs, 1992). Buttons
Table 10-8 Fasteners: ties, buckles, Velcro, snaps, zippers, buttons
Skill Age Source
SHOES: LACE AND TIE

Unties shoe bow 11⁄2 yr Brigance (1978)
Pulls laces tight 21⁄2–3 yr Vulpe (1979)
Tries to lace, usually incorrectly 3 yr Coley (1978)
Laces shoes 4–5 yr Coley (1978)
Ties overhand knot 5 yr 3 mo Coley (1978)

1
Ties bow on shoes 6–6 ⁄2 yr Haley et al. (1992)
SASHES AND NECKTIES

Unties back sash of apron or dress 5 yr Coley (1978)
Ties front sash of apron or dress 6 yr Coley (1978)
Ties back sash of apron or dress 8 yr Coley (1978)
Ties necktie 10 yr Coley (1978)
BUCKLES
Unbuckles belt or shoe 3 yr 9 mo Coley (1978)
Buckles belt or shoe 4 yr Coley (1978)
Inserts belt in loops 41⁄2 yr Coley (1978)
VELCRO FASTENERS
Manages shoes with Velcro 41⁄2–5 yr Haley et al. (1992)
SNAPS
Unsnaps front snaps 1 yr Brigance (1978)
Unsnaps back snaps 3 yr Brigance (1978)

1
Snaps most snaps, front and side 3 ⁄2–4 yr Haley et al. (1992)
Snaps back snaps 6 yr Coley (1978)
ZIPPERS
Zips and unzips, lock tab 2–21⁄2 yr Haley et al. (1992)
Opens front separating zipper 31⁄2 yr Coley (1978)
Zips front separating zipper 41⁄2 yr Coley (1978)
Opens back zipper 4 yr 9 mo Coley (1978)
Closes back zipper 51⁄2 yr Coley (1978)
Zips, unzips, hooks, unhooks, separates zipper 51⁄2–6 yr Haley et al. (1992)
BUTTONS
Buttons one large front button 21⁄2 yr Coley (1978)
Unbuttons most front and side buttons 3 yr Coley (1978)
Buttons series of three buttons 31⁄2 yr Coley (1978)
Buttons and unbuttons most buttons 4–41⁄2 yr Haley et al. (1992)
Buttons back buttons 6 yr 3 mo Coley (1978)

require precision grip with manipulation and with both Learning to Tie Shoes
hands working cooperatively. Shoe tying is an important and difficult developmental
Strength is another component of the management task for children. Children perceive the relationship of
of fasteners. Snaps require considerable strength in the the loops and strings and learn the steps of looping,
fingers. Koch and Simenson (1992) examined func- winding, and pulling through but still may fail. The
tional skills in spinal muscle atrophy. Children with 1⁄2- most difficult aspect of shoe tying appears to be what
to 2-lb pinch strength needed minimal help in dressing. Maccoby and Bee (1965) in their study of form
Children with less than 1⁄2-lb pinch strength had copying termed the perception of attributes. Their
trouble with tying and buttoning. example was that children discriminate forms such as
Managing fasteners is also a perceptual task, diamonds but are unable to draw them because they do
particularly buttoning and tying. For both these tasks not perceive the attributes of the form, such as the
vision is important for learning. It is only after relative size of lines and angles. Similarly, children do
considerable skill has been developed that back buttons not perceive the relative sizes of loops and strings; the
and back bows can be accomplished, using touch and loop is too large and the bow fails. It is only when
kinesthesia alone. children perceive these attributes of the lacing process
that they succeed. Learning to tie shoes is of special
Buttoning importance to a child’s sense of competence. The
The ability to button has been included in develop- 6-year-old child has a sense of achievement and
mental tests for many years, and it has been studied independence from adult help in the school
more than other fastenings. The ability develops in environment.
preschool over 2 to 3 years of age, and achievement
depends in part on the location of the button.
Stutzman (1948) examined the ability of preschool
HYGIENE AND G ROOMING
children to button buttons on a strip on a table. Tables 10-9 and 10-10 present the sequences in which
Children under 2 years of age failed to button one hygiene and grooming skills are acquired by children.
button, but by 21⁄2 to 3 years of age 72% of the children The development of parts of the skills begins in early
succeeded, albeit slowly. However, Key and co-workers childhood, but independence in most hygiene and
(1936) reported that only 50% of their 3-year-old grooming skills is a middle childhood achievement.
children succeeded in buttoning their shirts or dresses, Many hygiene and grooming tasks are bilateral.
and only 33% their pants. Hands are rubbed together in washing; in drying,
Wagoner and Armstrong (1928) reported a study of towels are held alternately while drying each hand.
buttoning skill in 30 nursery school children between Applying toothpaste on a brush is a skilled bilateral
the ages of 2 and 5 years. They standardized the task by activity. This was shown by the delay in which children
making jackets that were adjustable in size and which with unilateral amputations were found to achieve this
had front and side buttons. The major findings were: task (Thornby & Krebs, 1992). The toothbrush is a
(a) children under 21⁄2 years seemed not to have the tool that requires a high level of skill, as wrist and hand
motor control needed to button; from 21⁄2 to 5 years movements are complex in placing the brush and
speed of buttoning improved with age; (b) girls were brushing all the teeth. It is also a skill accomplished
better than boys, but the researchers noted that this without vision.
result might have reflected an artifact of their sample; Independence in hair care is greatly influenced by
and (c) side buttons were much more difficult than social factors, especially for girls. At about the time
front buttons; 25 children succeeded with the front when hair becomes manageable by the 4- to 7-year-old
buttons, but only 15 completed the side buttons (the child, independence is often delayed in girls by choice
authors noted that buttoning side buttons may require of hairstyles (e.g., braids usually are a teenage accom-
a more complex type of motor adjustment than do plishment). Hair styling requires a complex manipula-
front buttons). tion of many tools—brush, comb, pins, dryers—all of
Wagoner and Armstrong also reported correlation which must be used without vision or with mirror
of buttoning speed with the Stanford-Binet Test vision.
(r = .33), the Merrill-Palmer Performance Tests The ability to perform grooming and hygiene skills
(r = .62), and the Goodenough Drawing Test (r = .57). develops far earlier than the acceptance of responsibility
Thus buttoning appeared to be more related to for performing them. Grooming and hygiene skills are
performance tests than to intelligence. They also found particularly likely to be neglected by school-age
success in buttoning to be highly correlated (.83 to children. Note that the performance ages in the tables
.91) with teacher ratings on self-reliance, perseverance, reflect when a child can do a skill and not whether it is
and care of details. done without supervision.
Table 10-9 Hygiene
Skill Age Source
WASHING AND DRYING HANDS

Holds out hands to be washed 11⁄2–2 yr Haley et al. (1992)
1
Dries with help 1 ⁄2 yr Coley (1978)
Rubs hands together to clean 11⁄2–2 yr Haley et al. (1992)
Turns faucet on and off 21⁄2–3 yr Haley et al. (1992)
1
Dries hands thoroughly 3 ⁄2–4 yr Haley et al. (1992)
1
Dries without supervision 3 ⁄2 yr Coley (1978)
1
Washes hands thoroughly 3 ⁄2–4 yr Haley et al. (1992)
Washes without supervision 3 yr 9 mo Coley (1978)
Disposes of paper towel or replaces towel 4 yr Coley (1978)
Washes hands at appropriate time before meals 6 yr Coley (1978)
WASHING FACE
Washes and dries face thoroughly 51⁄2–6 yr Haley et al. (1992)
Without supervision 4 yr 9 mo Haley et al. (1992)
Washes ears 8–9 yr Haley et al. (1992)
BATHING BODY
Tries to wash body 11⁄2–2 yr Haley et al. (1992)
Bathes down front of body 3 yr Coley (1978)
1
Washes body well 3 ⁄2–4 yr Haley et al. (1992)
1
Soaps cloth and washes 4 ⁄2 yr Coley (1978)
TEETH BRUSHING
Opens mouth for teeth to be brushed 1–2 yr Haley et al. (1992)
Holds brush, approximates brushing 11⁄2–2 yr Haley et al. (1992)
Brushes teeth, not thoroughly 2–21⁄2 yr Haley et al. (1992)
1
Thoroughly brushes teeth 4 ⁄2–5 yr Haley et al. (1992)
1
Prepares brush, wets and applies paste 4 ⁄2–5 yr Haley et al. (1992)
Brushes routinely after meals 7 yr Coley (1978)
NOSE CARE
Allows wiping of nose 11⁄2–2 yr Haley et al. (1992)
1
Wipes on request 2–2 ⁄2 yr Haley et al. (1992)
1
Wipes without request 3–3 ⁄2 yr Haley et al. (1992)
Attempts to blow nose 11⁄2–2 yr Haley et al. (1992)
Blows and wipes alone 6–61⁄2 yr Haley et al. (1992)
TOILETING
Assists with clothing management 2–21⁄2 yr Haley et al. (1992)
1
Manages clothes before and after toileting 3–3 ⁄2 yr Haley et al. (1992)
1
Tries to wipe self after toileting 3–3 ⁄2 yr Haley et al. (1992)
1
Manages toilet seat, toilet paper, flushes 3–3 ⁄2 yr Haley et al. (1992)
1
Wipes self thoroughly 5 ⁄2–6 yr Haley et al. (1992)
Completely cares for self at toilet 5 yr Coley (1978)
Table 10-10 Grooming
Skill Age Source
HAIR
Holds head in position for combing 1–11⁄2 yr Haley et al. (1992)
Brings comb to hair 1–11⁄2 yr Haley et al. (1992)
Brushes or combs hair; combs with supervision 21⁄2–3 yr Haley et al. (1992)
Manages tangles and parts hair 7 yr Haley et al. (1992)
Combs using mirror to check style 7 yr Coley (1978)
Uses rollers, hair spray 12 yr Coley (1978)
OTHER GROOMING SKILLS

Shines shoes 7 yr Brigance (1978)
Uses deodorant daily 12 yr Coley (1978)
Scrubs fingernails with brush 51⁄2 yr Coley (1978)
Maintains clean nails, files, clips both hands 8 yr Coley (1978)
DISCUSSION limited to their use in identifying developmental mile-

stones, and most of our knowledge is of that kind. The
Independence in the performance of the daily activities information in this chapter is a summary of what is
of basic self-care requires the mastery of complex hand currently known about the chronology of skill acquisi-
skills that children learn over many years. The skills tion and is presented as a possible source for finding
have varying degrees of manipulative, perceptual, and clues to the understanding of the process by which
cognitive components and the action sequences are skills are acquired.
learned through extensive practice until they become Although the ages identified are approximate and
automatic and efficient. We have some knowledge of represent an unspecified average behavior, they provide
the usual ages at which the skills are mastered, but very a tentative chronological order in which skills and
little knowledge of what Connolly and Dalgleish subskills develop. However, it must be remembered the
(1989) called the general patterns of behavioral sequences of skill development that are suggested by
change, which occur as children acquire specific self- the information in the tables may be an artifact of the
care skills. use of group data. Of course, some of the steps in
Most of the studies of the development of self-care learning are clearly acceptable; that is, a partial skill
skills cited in this chapter were conducted before 1940. precedes a complete skill and many of the sequences
There are not many, and recent studies are even scarcer. have been repeatedly observed and verified by teachers,
As noted by Amato and Ochiltree (1986), despite an parents, and therapists. However, individual differences
increasing interest in the development of competence among children could result in different routes to
in childhood during the last decade, practical life skills competence in an overall skill. Nevertheless, these over-
have been virtually ignored. Interest in the study of all sequences have value in that they provide infor-
children’s self-care skills over the years has been largely mation that could be used in planning longitudinal
studies because they identify the age span in which skills the appropriate finger grasp position. These skills begin
usually develop. Furthermore, they show general to develop in the third year but the combination of
patterns of behavioral change in the acquisition of self- precision and power in finger manipulation at the
care that allows some generalizations about factors highest level does not develop until a child is 8
affecting mastery. years old.
Bilateral Hand Use

HAND SKILLS IN SELF-CARE Most self-care skills are bilateral and the challenge
The examination of the chronology of self-care acqui- posed by these skills depends on their complexity. The
sition allows a preliminary, although fragmentary, simple act of drinking from a bottle and then a cup held
analysis of the relationship of the development of hand in two hands is one of the first achievements of an
use to the development of self-care. We do not know infant, and an infant is soon able to hold a dish while
when these self-care skills reach adult levels of efficiency spooning food. The order in which bilateral dressing
and precision, but clearly skill acquisition is a gradual skills develop seems to depend on the added need for
process that extends into the preteens. It appears that power, whether hands work in unison or cooperate in
aspects of hand skill acquisition over the years include different functions, and the extent of the motor
(a) finger manipulation and grip ability, (b) the use of sequencing involved. Undressing is easier with two
two hands in a complementary fashion, (c) the ability hands but requires less skill than does dressing.
to use the hands in varied positions with and without Intermediate bilateral skills include pulling up pants,
vision, (d) the execution of increasingly complex action holding a shoe open with the tongue out, and pulling
sequences, and (e) the development of automaticity. on boots. Manipulating buttons, buckles, and zippers is
These hand skills have been discussed in the preceding more difficult because high precision is necessary and
section in relation to specific skills and are summarized the two hands work cooperatively but differently. The
in the following. greatest difficulty comes when the two hands must move
through different motor sequences, as in tying bows.
Grip Ability and Finger Manipulation
During the first year of life the infant develops whole Position of the Hands
hand grip followed by the use of a finger grip with Two factors appear to influence a child’s ability to
some precision (see Chapter 7). As grips develop they perform a task with the hands someplace other than in
are used in self-care skills, first with the whole hand and front of the body. Young children seem unable to
then with the fingers. Therefore the earliest self-care perform tasks such as buttoning without seeing their
actions are pulling at clothes and grasping food such as hands, and performing with the hands in awkward
a cracker with the whole hand. Finger feeding soon positions such as at the side of the body is difficult.
follows the early emergence of pincer grasp. This whole These two factors probably combine to delay learning
hand to pincer grip sequence occurs repeatedly as skills to manipulate back buttons until after the sixth year.
develop. Examples in the young child include pro-
gression from a whole hand to a finger grip on a spoon Executing Motor Sequences
and from a whole hand grip pulling up pants to a As was noted in the discussion of spoon use, even the
thumb and finger grip on socks. This progression of the early-developing task of self-feeding requires the
whole hand grip to pincer grip sequence is in part a learning of a multiple sequence of actions. Through
reflection of the interplay of power and precision in analysis, therapists have identified the steps involved in
grip as skill develops, as the infant has power in the many dressing skills (Case-Smith, 2000), but the
whole hand grip, but is slow to develop power in finger sequence followed by typical children in learning par-
grips. For example, a child lifts a cup or glass with one ticular dressing skills has not been studied. However, it
hand before having the finger grip power needed for is to be expected that becoming self-sufficient in a skill
lifting a cup by the handle. In cutting with a knife and is in part a reflection of the number of action sequences
fork, a child first uses a fisted grip on both utensils to involved.
exert the pressure needed. The power finger grips used
by adults for cutting are not achieved until the preteen Automaticity
years. Self-care literature provides a clue to the development
The use of the fingers in a precision pincer grip is of automaticity in skill performance. There appears to
used in dressing in the second year, but fasteners such be a delay following a child’s ability to perform a skill
as buttons, shoe lacing, bow tying, and buckles, require in eating and dressing before the skill can be performed
in-hand manipulation skills. In-hand manipulation while carrying on a conversation (Hurlock, 1964;
also is needed to position a spoon or toothbrush for Klein, 1983). This suggests that an automatic level of
skill execution does not develop until several years after virtually nothing about the extent to which and in what
a skill is first mastered. combinations these intrinsic factors influence the
maturation of self-care skills or how much is a function
Combined Motor Abilities of family and cultural variables. Many studies are
Examples of skills involving different facets of hand needed to understand the variables that have an impact
manipulation have been given for illustrative purposes. on the learning of self-care skills. The PEDI promises
Nevertheless, clearly most of these facets occur in to provide a rich resource for the determination of
combination. The highest level of self-care skill appears which cultural, cognitive, motor, and personality fac-
to require some combination of bilateral sequencing tors have an impact. The interest in researching the
and complementary hand use, the combination of development of competence and volition will also hope-
power and precision in grip, the ability to perform hand fully include more attention to basic practical skills.
tasks with the hands behind the back or head, and the
ability to visualize what the hands are doing when they
are out of sight. Tying a necktie involves multiple com-
plex sequences, bilateral, complementary hand use, and SUMMARY
performance without vision, and is one of the last skills
learned. This chapter has focused on how and when typical
children learn the separate skills and subskills of self-
care. Knowledge of the sequences in which typical
PERCEPTUAL FACTORS IN SELF-CARE children acquire self-sufficiency in daily activities can be
The sequences of self-care acquisition also clearly valuable in understanding the roadblocks for children
demonstrate the need for development of perceptual with physical or mental disability, and sequences of skill
skills. Perceptual skills are necessary for tool use, acquisition can provide guidance in selecting the level
ranging in difficulty for spoons, toothbrushes, and of skill at which to introduce training. However, the
combs. Perceptual factors are particularly evident in acquisition of self-care in typical children provides only
dressing. Over several years children learn, in this order, a part of the picture needed for treatment planning. We
whether clothes are inside out or outside out, the must learn how skills are learned in the presence of
difference between front and back, and which is left or different disabilities. We know that the presence of a
right. Their ability to respond first to more obvious specific disability can change the sequence in which a
cues is shown by this sequence, as well as by their ability child will master self-care skills, but we have little infor-
to locate a dress front by its decoration before the back mation about what that sequence is.
of a T-shirt by its label or the front of pants. Most of our knowledge about the impact of dis-
ability on specific self-care skills comes from therapeutic
accounts. Several recent publications have provided
COGNITIVE AND PERSONALITY FACTORS detailed task analyses of methods of dressing, eating,
and hygiene keyed to different impairments and
IN SELF-CARE
include multiple suggestions for adaptations. Some of
We have little data on the importance of cognitive and these are designed for children (e.g., Case Smith, 2000;
personality factors in self-care acquisition, but the few Shepard, 2001), and others for adults (e.g., Backman
studies suggest that, for children whose intelligence is & Christiansen, 2000; Holm, Rogers, & James, 1998;
within normal limits, the level of intelligence is less Snell & Vogtle, 2000).
important than the personality characteristics of per- The tables also provide useful knowledge about the
sistence and self-reliance. There is good reason to acquisition of part skills. Typically children do not learn
believe that in typical children personal and social a skill all at once. Rather they are encouraged to do
characteristics are as important as perceptual and motor what they can long before they are developmentally
maturation. Children are highly variable in the ready to master a skill. Parents of children with dis-
chronological ages at which they acquire skills, and the abilities should be encouraged to introduce part-skill
finding that a 3- to 4-year span may separate the earliest practice early and to set expectations that their child do
and latest age at which typical children master a par- whatever he can. This will take more time but it will
ticular skill is a powerful indication that there are large contribute to the child’s sense of mastery and self-
personal and situational differences among children. esteem and provide practice of the motor skill. It would
We know very little about the sources of these be helpful to know more about the factors affecting
individual differences, but we can hypothesize that they such a learning process and the differences and
are multiple and include differences in problem-solving similarities in the ways in which children with dis-
abilities, persistence, and self-reliance. We also know abilities learn complex skills.
The importance of self-care skill acquisition in a Bethesda, MD, American Occupational Therapy
typical child’s sense of efficacy and the parent–child Association.
Castle K (1985). Toddlers and tools. Childhood Education,
interaction around self-care issues should be investi-
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dence in self-care is important to an individual’s quality disorder. Albany, NY, Delmar Thomson.
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dence cannot be achieved, and we know little about the Mallison T (2004). Impact of pediatric rehabilitation
services on children’s functional outcomes. American
importance of partial independence to the individual or
Journal of Occupational Therapy, 58:44–53.
of its meaning to an individual’s sense of mastery and Christiansen CH (2000). The social importance of self-care
control. Research in self-care with both typical children intervention. In C Christiansen, editor: Ways of living:
and children with disabilities has the potential for dis- Self-care strategies for special needs (pp. 1–11). Bethesda,
covering information that will be applicable to design- MD, American Occupational Therapy Association.
Coley IL (1978). Pediatric assessment of self-care activities.
ing rehabilitation programs.
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Physical Occupational Therapy in Pediatrics, 10(1):19–21.
Chapter 11
THE DEVELOPMENT OF
GRAPHOMOTOR SKILLS
Jenny Ziviani • Margaret Wallen
CHAPTER OUTLINE letters, figures, or other significant symbols, predomi-

nantly on paper. Both these activities can be used to
GENERAL GRAPHOMOTOR COMPETENCY record experiences or thoughts, as well as communicate
Acquisition of Graphomotor Skills these to others. Drawing and handwriting are com-
plex motor behaviors in which psychomotor, linguistic,
Implement Grasp and Manipulation and biomechanical processes interact with matu-
DRAWING rational, developmental, and learning processes (Smits-
The Nature of Drawing Engelsman & Van Galen, 1997). The need to develop
proficiency in activities as fundamental as drawing and
Computers and Drawing handwriting may be questioned in relation to the
Drawing and Developmental Evaluation growing reliance on electronic communication devices.
HANDWRITING It is the position of this chapter that graphomotor skills
represent more than a means of recording thoughts or
Handwriting and Writing: Complementary Concepts conveying experiences. Developmentally these skills
The Developmental Nature of Handwriting allow for experimentation and self-expression in the
Factors Contributing to Handwriting Performance way a child interacts with the environment. Further-
more they are a means by which children learn basic
Computers and Handwriting tool use and are able to produce a product that is
SUMMARY socially recognized and rewarded. As such they form an
important part of the development of an individual.
This chapter provides information on the development

and execution of graphomotor skills, as a basis for
remediation. Concepts common to both drawing and
GENERAL GRAPHOMOTOR
handwriting such as motor learning theory and grasps COMPETENCY
used with writing and drawing tools are discussed first.
Following are detailed sections on drawing and then
handwriting. The emphasis in these sections is on
ACQUISITION OF G RAPHOMOTOR SKILLS
outlining research that broadens our knowledge of the Children, when presented with tools for inscription,
development of drawing and handwriting and deepens readily smear paint, scribble with crayons, or draw. The
our understanding of the factors that are associated nature of the inscription varies depending on the
with graphomotor difficulties. developmental status of individuals and their motor
Graphomotor skills comprise those conceptual and learning in relation to prior exposure to graphomotor
perceptual-motor abilities necessary for drawing and experiences. In its most basic form simple inscription
handwriting. Drawing is defined as the art of producing with an implement onto a page can be understood as a
a picture or plan with implements such as pencils, pens, perceptual-motor act (van Galen, 1991). The learning
or crayons. Handwriting is the process of forming of a skilled task such as handwriting or drawing,
217
Individual Task used to modify and control subsequent handwriting. In

open-loop control systems there is no afferent feedback
• Sensory • Demands of and the central nervous system directs movement.
perception task (cognitive, Theorists have postulated that the acquisition of
• Cognition attentional,
• Motor control linguistic)
drawing and handwriting skills can be understood best
• Affective state • Nature of task within the framework of a closed-loop theory. That is,
• Motor planning (copied, afferent feedback is relied on to learn the skill. How-
• Biomechanical self-generated, ever, once learned, it is postulated that handwriting
considerations creative,
academic) moves into the domain of an open-loop skill (van der
• Speed and Meulen et al., 1991). This means that instead of
accuracy remaining dependent on vision and other sensory feed-
• Skilled back, the skilled writer is able to write so quickly that
manipulative task
there is no time to modify performance on the basis of
Skilled afferent feedback. Movements that are entrenched in
memory may predominate as handwriting becomes a
Handwriting proficient skill (Grossberg & Paine, 2000). In reality,
the environmental and task demands of handwriting
Environment
are diverse and dynamic and preprogrammed motor
• Writing materials acts are not adequate to respond to the changing
(implements, requirements of various handwriting tasks. Consequent-
paper) ly it is more likely that closed- and open-loop systems
• Furniture
• Ambient
work cooperatively, interacting with the various indi-
features vidual task and environmental factors to achieve hand-
(temperature, writing output (Mathiowetz & Bass-Haugen, 2002).
lighting, noise)
• Expectations of
others The Roles of Vision and Kinesthesis
• Exposure to Vision is essential to children learning to handwrite
instruction and as they plan, execute, and monitor their attempts.
practice Reliance on vision generally diminishes as skilled
Figure 11-1 Skilled handwriting demands interplay handwriting develops and feedback provided by the
among the individual, the task, and the environment. somatosensory system has greater influence in directing
skilled and precise movement (Cornhill & Case-Smith,
1996). However, the visual sense is thought to remain
however, involves an interplay among the individual, active in children who are experiencing difficulties in
task, and environment (Shumway-Cook & Woollacott, mastering handwriting. Wann (1987) found that good
2001). Figure 11-1 summarizes these with respect to and poor writers used different movement patterns when
handwriting (Jongmans et al., 2003; Shumway-Cook asked to reproduce letters and words. Wann recorded
& Woollacott, 2001). Each child’s individual capacity the performance of good and poor handwriters using an
to mesh the task and the environmental contributions xy digitizer, and movement patterns were categorized
to handwriting determines the extent to which effective according to their velocity and acceleration characteris-
handwriting will be acquired. tics. Poor handwriters used more patterns of movement
indicative of reliance on visual feedback as a major
Motor Learning source of environmental information during hand-
Handwriting and drawing have been conceptualized as writing. Although not suggesting that the more
learned motor tasks. Motor learning theorists explain proficient writers were not using visual feedback during
the control of coordinated movement in terms of open- letter production, Wann (1987) postulated that they
and closed-loop systems (Mathiowetz & Bass-Haugen, were probably less dependent on it as a means of con-
2002; McGill, 1998). The closed-loop system involves trol. He went on to point out that deprivation of visual
afferent feedback. In the case of handwriting, feedback feedback resulted in the deterioration of even the most
is received from the pressures exerted on the writing proficient writer’s performance. Other researchers (van
implement and the writing surface, from the senses of der Muelin et al., 1991) have supported the view of
touch and movement in the fingers, hand, and arm, Wann and suggest that children with difficulty in visual-
and from visually monitoring written work. This affer- motor control compensate by adopting a greater reliance
ent feedback is used to update the nervous system on visual monitoring and that this in turn results in
about the accuracy of the handwriting. The feedback is slower performance. These issues warrant greater atten-
The Development of Graphomotor Skills • 219
tion because they can influence the adoption of appro- describes a palmar grasp, whereas Level 10 describes
priate remedial strategies. a dynamic tripod grasp. The scale is a “whole-
The role of kinesthesia is frequently discussed in configuration system,” which means that all the com-
relation to drawing and, particularly, handwriting. ponents of the grip can be described together rather
Kinesthesis relates to the information received from than evaluating various components of a grip separately.
muscles, joints, and skin about body and limb position, Adoption of a scale such as this has the potential to
and the direction, extent, and velocity of movement inform comparisons with and between children and
(Harris & Livesay, 1992; Sudsawad et al., 2002). An to contribute to a system of uniform terminology
impairment of kinesthesis may influence the refinement (Windsor, 2000).
of fine motor skills; children are not able to perceive The dynamic tripod grasp, generally viewed as the
and therefore monitor and correct errors of movement, mature grasp, is one in which the writing implement is
particularly those of small amplitude, which are grasped between the radial surface of the middle finger
observed in handwriting (Harris & Livesay, 1992). and the pulp surface of the thumb and index finger,
Much of the work around kinesthesis in relation to with the thumb relatively opposed (Elliott & Connolly,
handwriting involves the Kinesthetic Sensitivity Test 1984). However, not all children acquire or use this
(KST). This norm-referenced test consists of two sub- grip. Research suggests that the dynamic tripod is used
tests: Kinesthetic Acuity and Kinesthetic Perception by only 50% to 70% of children in a given sample
and Memory. Each subtest has specific equipment that (Benbow, 1987; Blote & van der Heijden, 1988; Dennis
was designed to eliminate the need for motor control, & Swinth, 2001; Schneck & Henderson, 1990). Other
thus allowing passive movement of children’s hands grasps, such as the lateral tripod and quadripod, also
and arms to determine kinesthetic ability. Laszlo and allow ulnar stability and controlled dynamic finger
Bairstow (1985a) developed the test to identify movement, which are considered important for skilled
kinesthetic deficits and reported that training children handwriting.
using this test equipment resulted in improved drawing Diverse ways of categorizing variations in the
skills in children with poor kinesthesis. However, the dynamic tripod grip have been used. Ziviani & Elkins
relative importance of the role of kinesthesis in acqui- (1986) used a series of four nonexclusive categories
sition of proficient handwriting remains unclear. This that described grips on the basis of the number of
subject is elaborated on in the review of handwriting fingers held on the shaft of the writing implement,
later in this chapter. degree of forearm supination, hyperextension of the
distal interphalangeal joint of the index finger, and
thumb and index finger opposition. Sassoon, Nimmo-
I MPLEMENT G RASP AND MANIPULATION Smith, and Wing (1986) used a classification of pen
Brushes, crayons, pencils, felt-tip markers, and pens are holds that examined the position of digits on the pencil
the primary tools used by children in their graphic shaft, their proximity to the writing tip, and the shape
endeavors. These implements form an extension of the of the digits. Furthermore, Sassoon described grips in
hand, and their control and manipulation are impor- relation to the shaping of the hand, the positioning of
tant in attaining skilled copying, drawing, and hand- the upper body, and the specific orientation of the
writing. Only through experimentation do children writing paper. Neither Sassoon nor Ziviani’s studies
become skilled in adapting to implements of different found writing speed was compromised by unconven-
weight, length, and graphic quality. Different grasps tional pencil holds. Subsequent studies have confirmed
may be adopted with a change in implement and task that grips affect neither legibility (Koziatek & Powell,
to achieve an optimal outcome (Schwartz & Reilly, 2003) nor the undertaking of long writing passages
1980; Thelen & Smith, 1994). (Dennis & Swinth, 2001). However, all these studies
have been undertaken with children without identified
Grasps disabilities, and have not taken into account the dynamic
Many children acquire a dynamic tripod grip by about aspect of adopted grips.
61⁄2 years of age as their means of implement manipula- Schneck (1991) found that children who used
tion for drawing and handwriting. Children progress variants of the dynamic tripod grip also had impairment
through a range of precursor grips—palmar, incom- of proprioceptive/kinesthetic finger awareness. Schneck
plete tripod (or palmar supinate), and static tripod— hypothesized that the grips may not themselves lead
before adopting the dynamic tripod grip (Dennis & to poor handwriting but, in conjunction with poor
Swinth, 2001; Rosenbloom & Horton, 1971; Saida & proprioceptive and kinesthetic perception, might
Miyashita, 1979). Schneck and Henderson (1990) contribute to poor handwriting performance. Research
propose a 10-grip scale to classify the developmental that examined the impact of joint laxity has supported
range of grasps. Level 1, or the lowest level of the scale, this view (Summers, 2001). In Summers’ study, positive
but nonsignificant trends emerged between joint laxity This section of the chapter outlined the processes
and the failure to develop a dynamic tripod grip in 55 involved in acquiring proficient use of tools for drawing
7-year-old children. and handwriting and about the grasps used when
Poorly established hand preference has been linked manipulating these tools. The next section is about the
to developmentally immature grips (Rosenbloom & development of drawing ability.
Horton, 1971; Schneck, 1989), but also can result
from insufficient prerequisite experience. Poor hand
preference is thought to impede the refinement of the DRAWING
manipulative skills needed for good pencil control. This
view is consistent with Exner’s (1990) posit that the
development of in-hand manipulation skills is depen-
THE NATURE OF DRAWING
dent on well-defined hand preference. When considering drawing, the simple copying of
In a practical and clinical sense, therapists are con- shapes and figures should be differentiated from the
fronted by the issue of whether to assist children to creation of pictures from memory or imagination. The
modify the grip they are using as part of an overall present discussion is concerned primarily with copying
strategy to facilitate an improvement in handwriting skills (the perceptual-motor elements of drawing).
performance. The following points may be worth Certain characteristics are thought to distinguish
considering when this situation arises: younger children’s drawings from those of adults.
1. Mechanically the dynamic tripod grip offers a high Children’s drawings have been described as being
level of precision and control (Elliott & Connolly, formula-like and depicting subjects as they are
1984). The dynamic tripod grip should be encour- perceived to be rather than how they look (Freeman,
aged when the child is young enough and has not 1980). Apart from exceptional children (Selfe, 1985),
developed a fixed writing posture. In fact some have most children in their preschool and early school years
argued that inadequate training in the use of a dynamic construct their drawings from simple geometric forms
tripod grip is one of the reasons it is not used by and do not compose broad outlines that are then
greater numbers of children (Benbow, 1995). detailed. Fenson (1985), in a detailed longitudinal
2. Variations of the dynamic tripod grip do not, of study of one child, found that a fundamental shift
themselves, contribute to handwriting difficulties. occurred between 3 and 7 years of age in the structure
In typically developing students there appears to be of drawing. The child moved from a constructional
no difference in the speed or legibility of hand- style to the use of contoured forms.
writing using the dynamic tripod versus atypical The term constructional in this context relates to the
dynamic grasps (Dennis & Swinth, 2001; Sassoon, assembling of simple geometric forms into a pictorial
et al., 1986; Ziviani & Elkins, 1986). Differentia- representation (e.g., the use of a circle for a face and a
tion should be made, however, between a modified rectangle for a body when drawing a person). The term
version of the dynamic tripod grip and a grip that is contoured, on the other hand, refers to the sketching
developmentally immature. The latter may be part of an outline, which is subsequently detailed to achieve
of a broader picture of developmental difficulty. the desired representation. Although no attempt is
More research is necessary to determine if there is a made to explain why a shift might occur from the
relationship between typical and atypical grasps and former to the latter, it is postulated that the motivation
legibility in children who are poor handwriters is a quest for realism. This quest, in conjunction with
(Schneck, 1991). greater skill in visually controlling actions and the
ability to plan spatially and execute actions, constitutes
Writing Implements the move from a juvenile to a more adult approach to
A further issue related to implement manipulation is drawing. Obviously such assumptions require further
the nature or type of writing tool used. Traditionally investigation.
young writers are given lead pencils with a larger than There has been little advance on the seminal work of
normal lead and barrel for drawing and handwriting authors such as Luquet (1927) and Kellogg (1969)
instruction. This practice is based on the premise that it when considering the maturation of children’s draw-
is easier for their small hands to hold and manipulate a ings. These authors considered that children between
larger barrel. However, studies have demonstrated that the ages of 2 and 3 years make scribbling marks on
the legibility of kindergarten children’s handwriting is paper with no representational intent. The fascination
not associated with the tool used (Oehler et al., 2000). is thought to be more with the process of experimenta-
The maturity of grasp employed, nevertheless, may tion and exploration of media than with an intended
vary with the specific tool used (Yakimishyn & Magill- product. The drawing by a 21⁄2-year-old child in Figure
Evans, 2002). 11-2 demonstrates how repetitious marks (in this case
Figure 11-2 Scribbling marks with no representational intent (21⁄2-year-old boy).
circular) are employed in exploring the use of a drawing the way they are in an adult reality. Figure 11-5 demon-
implement on paper. Only at the completion of these strates how a 6-year-old girl perceives her school. The
marks is a border introduced as a way of demarcation. drawing is not a realistic representation but it does
Demarcating parts of a picture is argued to indicate the contain features of her school and it highlights her
beginning of an interpretive phase, which occurs understanding of a friendly environment. Finally, from
between the ages of 3 and 4 years. During this phase a around 8 years of age the child begins to take into
child begins to interpret a drawing, but generally only account visual perspective; object position and orienta-
after it has been produced. The representational intent tion also become more important. This shift represents
is not there at the outset. For example, Figure 11-3 was a progression from intellectual realism, in which the
drawn by a 31⁄2-year-old child. The task commenced child draws what he or she knows about a stimulus, to
with the scribbling at the top of the page with no a stage in which the drawing depicts what actually can
apparent commitment as to the topic of the drawing. be seen (Laws & Lawrence, 2001). This shift also has
At the completion of the task the child was asked to talk been associated with an increase in the amount of
about what had been drawn. The child nominated the attention given to the object being drawn (Sutton &
descriptions that have been inserted in print but only Rose, 1998), suggesting that realism is based on ability
after some reflection and consideration. to attend to detail.
In the next stage (4 to 5 years) the nature of the The ability to produce and appreciate graphic per-
drawing is announced before its commencement, but spective has received considerable attention (Freeman,
the coordination of individual elements remains diffi- 1980; Freeman, Eiser, & Sayers, 1977; Nicholls &
cult. At this stage children label and sign their drawings Kennedy, 1992; Toomela, 1999). Some authors see the
(Devlin-Gascard, 1997). Words are incomplete and onset of perspective as evidence of cognitive maturation
letters are often reversed, but the comprehension of (Reid & Sheffield, 1990), whereas others argue that it
symbol and meaning is observable. The drawing of a is necessary to learn the rules about how to represent
ship by a 41⁄2-year-old boy in Figure 11-4 demonstrates something in true perspective (Hagen, 1985; Orde,
the use of word labels to describe the intent of the 1997). This latter view is based on studies that found
drawing. In this case it was to inform the viewer that little difference between the way in which children
the drawing was of the ship Oronsay, which had hit a handle the three-dimensional plane and the methods
rock and was badly damaged. adopted by adults. In both populations, individuals
The 6- to 7-year-old child is able to include all the who have no special artistic talent or training reproduce
characteristics of objects being drawn as they are the visual structures that they see in natural perspective
known to him or her. This is not always consistent with along a continuum from orthogonal (no diminishing
Rain
Big tree
Horse float
Jeep
Horse 1 Baby in
back seat
Driver
Road
Figure 11-3 Beginning of interpretive phase. Naming occurs verbally at completion (31⁄2-year-old boy).
Figure 11-4 Labels incorporated into picture as a way of demonstrating intent (41⁄2-year-old boy).
Figure 11-5 Objects drawn as perceived, not necessarily realistically (6-year-old girl).
Figure 11-6 Use of foreground and background, as well as three-dimensional perspective (8-year-old boy).
projected size with increasing distance) to projective the drawing of a free-standing circle at around the
(image size decreases as distance increases). As with 12 o’clock position and invariably draw counter-
other skills that have learned elements, Messaris (1994) clockwise, whereas a little more than 60% of left-
argues that enhancement of depth perception might handed people draw a circle in a clockwise direction.
lead to a more general stimulation of the capacity for Another interesting convention is the direction in
perceiving and thinking about three-dimensional space, which profiles are facing. Most profiles of faces, for
an important component of general intelligence. instance, are drawn turned to the left, as are most cars.
Figure 11-6 demonstrates the use of foreground and Glasses are drawn with the lenses to the left, pencils
background, as well as three-dimensional perspective. have points to the left, spoons and pipes have bowls to
Some uniformity exists in the way certain objects are the left. On the other hand, most flags are drawn flying
drawn. Both convention and handedness have been to the right, and cups and buckets have their handles to
implicated in this uniformity (van Sommers, 1984). the right. The foundations for these uniformities have
For example, right-handed people tend to commence not been documented and neither have there been
any reports located that explore the impact of left

handedness on these tendencies.
Children maintain individuality in their drawings of
the most common objects even though they may have
constant access to other children’s drawings. When
children do adopt stereotyped formulas, they frequently
include their own versions alongside. The drawings of
one child over time may be very repetitious in the treat-
ment of the same subject material (van Sommers, 1984).
The logic is that flexibility of drawing is lost because of
the repetition of early drawing strategies. This is not
to say that children’s drawings never change but that
they evolve by gradually modifying existing drawing BUS A OW E N JENNY MARK
strategies, rather than by a revolutionary rethinking of
their basic representational strategy. Following this line Figure 11-7 Computer-generated drawing
demonstrating spatial realism (6-year-old boy).
of reasoning, innovation in drawing is thought to occur
late in the sequence of producing a drawing and not in
the initial strokes (van Sommers, 1984).
There has been some discussion in the literature
about the role of coloring-in and the development of
children’s graphic skills (Duncum, 1995). Debate
seems to surround the use of coloring-in as a means of
developing pencil control as opposed to being part of
artistic development. Coloring-in, or the use of pencils,
crayons, or other implements to provide a color fill
within a space defined by lines, is widely undertaken by
children and is promoted by teachers, parents, and
commercial enterprises (King, 1991). For example, it is
employed for the purpose of product promotion for
movies and by fast food outlets, and as a means of
keeping children occupied when they are on plane
trips. Further, proficiency of coloring-in is judged and
rewarded as part of promotional competitions for Figure 11-8 Computer-generated freehand drawing
various products. (6-year-old girl).
Distinction needs to be made about the use of
coloring-in that is predetermined by the presentation of
a figure and coloring-in that children choose to under- computer mouse is considered the most child-friendly
take after they have produced a drawing. The former, interface for accessing a wide range of software (Lane
which opponents call “dictated art” (Herberholz & & Ziviani, 1997). The mouse is used in a variety of
Hanson, 1985, p. 5), and place in the same category as ways depending on the nature of the program. The
paint-by-numbers, is thought to detract from apprecia- range of tasks required of a mouse to achieve the desired
tion of shapes and forms and their creation. Conversely, outcomes includes tracking, clicking, and dragging
when children color-in their own creations they are (Lane & Ziviani, 1999). As with drawing, producing
more highly motivated and better able to adhere to computer graphics makes varying demands on visual
the structures they create (Duncum, 1995). Jefferson motor control. There have been preliminary attempts
(1969) proposed that coloring-in per se can be used as to assess children’s skill proficiency using the mouse
a means of improving fine motor skills associated with (Lane & Denis, 2000) but little documented about the
handwriting. This proposition has not been researched; spontaneous attempts of children to draw using a
therefore the practice, although widely adopted, seems computer. Figures 11-7 and 11-8 are two examples of
to be based in convention more than research. how children use this medium. The picture in Figure
11-7, by a 6-year-old boy, demonstrates many of the
characteristics thought to manifest in pencil and paper
COMPUTERS AND DRAWING drawings at this age. There is evidence of spatial realism
The production of pictures by young children using the with respect to the placement of the bus in relation to
computer is now quite a common practice. The the road and the use of objects (i.e., helicopter) for
scenic representation. The mouse functions of tracking, should be considered within the context of the child’s
click, drag, and place have been used in this drawing. In perceptual-motor limitations, cognitive impairment, and
another example of freehand drawing (see Fig. 11-8), a possible environmental restrictions. Determining the
6-year-old girl demonstrates the use of click and drag relative contribution of each factor is not easy. Unfor-
to create a self-portrait. There is scope for further tunately, many assessments of developmental and cog-
research in this domain to examine comparability nitive abilities rely, in part, on copying abilities, especially
between the production of drawings using pencil and for preschool children (Moore & Law, 1990).
paper and computer software. An attempt has been made by Reid and Sheffield
(1990) to accommodate perceptual-motor limitations
DRAWING AND DEVELOPMENTAL when examining children’s drawings. These authors
adopted a cognitive-developmental model for the analysis
EVALUATION of drawings in children with myelomeningocele. Reid
Children’s drawing ability is incorporated into a number and Sheffield argue that instead of attending to the
of assessments of developmental status. The ability to quality of drawings, which may be detrimentally
reproduce a straight line, a cross, and a circle, for affected by motor disability, the subject matter and its
example, is used in a number of assessments as indicators depiction should become the focus for determining
of developmental maturity (Bayley, 1993; Folio & developmental maturity. They propose four complex
Fewell, 2000; Gesell, 1956; Griffiths, 1970). Further- stages through which children pass in the development
more one of the most widely used tests of visual-motor of mature drawings. Perspective plays an important part
integration, The Developmental Test of Visual Motor of their conceptualization of a mature drawing. Pre-
Integration (VMI) (Beery, 1997) evaluates children’s liminary observations suggest that Reid and Sheffield’s
accuracy in reproducing shapes to determine their visual- stages and conceptualization of the content of drawings
motor maturity. Some researchers have determined are a useful analytic scheme for children with myelo-
ability in this assessment as being directly related to meningocele. However, other experimenters argue
subsequent handwriting skill (Oliver, 1990). against the developmental significance of perspective
A number of studies have associated the ability to (Bremner & Batten, 1991; Hagen, 1985). Further
draw a human form, such as found in the Goodenough research to examine the potential clinical utility of Reid
Draw-A-Man Test (Goodenough, 1926) with a range and Sheffield’s (1990) findings, especially in the more
of cognitive (Harris, 1963; Scott, 1981), behavioral complex final stages of their model, is warranted.
(Hartman, 1972; Pope-Grattan, Burnett, & Wolfe, A view of unique developmental progression in the
1976), and emotional (Fu, 1981; Roback, 1968) char- drawing ability of children with Down’s syndrome has
acteristics in children. To date the findings from these been advanced by Laws and Lawrence (2001). They
investigations remain inconclusive. Other issues related found preliminary evidence that the spatial charac-
to the perceptual-motor ability necessary to draw a teristics of drawings of children with Down’s syndrome
human form, the gender variability in drawings of this may follow an alternative route to those of children
nature, and the efficacy of drawing the self as opposed without Down’s syndrome because of problems related
to a male or female form have been investigated (Short- to motor planning, motor weakness, and aspects of
DeGraff & Holan, 1992). Short-DeGraff and Holan language development. Children with Down’s syn-
found that factors in preschool children’s self-drawing drome in their study did follow the expected develop-
were significantly and positively related to visual motor mental, albeit delayed, trajectory of children in the
skills as measured by the Test of Visual Motor Skills control group. Yet there were elements in the drawings
(Gardner, 1986) but not with a measure of verbal of children with Down’s syndrome that attested to
intelligence. Short-DeGraff and Holan also explored their ability to account for aspects such as spatial
alternatives to scoring the drawing to those originally relationships, although not in the same way as children
proposed by Goodenough. The high association between without Down’s syndrome. However, the two groups
their simplified scoring methods and Goodenough’s were comparable with respect to drawing detail. The
more complex methods suggests that simplification authors of this study join others (Eames & Cox, 1994)
of scoring criteria is possible. Further research of the in advocating the use of measures sympathetic to
scoring criteria, as well as extending the ages of chil- children with different developmental profiles.
dren under investigation, is warranted based on these This section has discussed the development of draw-
preliminary findings. ing and the expectations of the composition of drawings
Obviously, for those children with motor impair- for typically developing children. It has shown the im-
ment (e.g., cerebral palsy, spina bifida) the quality of portance of considering the different ways that children
drawings may be affected. The differences between with special needs may interact with writing imple-
their drawings and those of children without disability ments and develop their drawing competence. The
following section focuses on a different graphomotor marks are ascribed to work that is less legible even
skill, that of handwriting. when the content is the same as more legible work
(Graham, Weintraub, & Berninger, 2001). Children
with handwriting difficulties may avoid writing, or the
effort involved in the process of handwriting may
HANDWRITING impede the ability to generate text that adequately
reflects their knowledge. Handwriting difficulties are a
HANDWRITING AND WRITING: significant problem for educationalists and occupa-
tional therapists. Berninger and co-workers (1997), for
COMPLEMENTARY CONCEPTS instance, identified 202 (29%) at-risk writers out of 685
There is an important differentiation, but also relation- children screened and another study identified 24% of
ship, between handwriting and writing. Handwriting children in a sample of 798 kindergarten and grade 1
refers to the process of transcribing letters to form children as having poor handwriting (Harris & Livesay,
words and words to form sentences. Writing, on the 1992). Further, a survey of grade 1 to 4 teachers re-
other hand, is the composition and content of the ported that 23% of children had handwriting difficulties
material that is handwritten. Proficient writing relies (Hammerschmidt & Sudsawad, 2004). Handwriting
on well-developed handwriting skills. Jones and proficiency remains a fundamental educational goal
Christensen (1999), for instance, reported that despite the availability and uptake of computer
handwriting skills accounted for 50% of the variance in technology. The focus of this section is on under-
the quality of writing content in a sample of 6- and 7- standing handwriting as a basis for intervention.
year-old students. Both handwriting and writing are
complex abilities that are acquired hand-in-hand with THE DEVELOPMENTAL NATURE OF
children’s acquisition of language. As with drawing, the
foundations for both handwriting and writing are the
HANDWRITING
integration of intrinsic and extrinsic factors. Extrinsic Several features of handwriting development are con-
factors involved in handwriting include instruction in sistent from both historical and cross-cultural perspec-
handwriting, the quality and extent of practice under- tives. At least some characteristics of handwriting are
taken, the requirements of the task, and the materials likely to be common across cultures, language, and
used. Intrinsic abilities include orthographic coding, written script (Yochman & Parush, 1998). For example,
orthographic-motor integration, visual-motor skills, fine there is a developmental progression of both speed and
motor skills, cognition, linguistic skills, and motivation legibility of handwriting with age and a relationship
(Tseng & Chow, 2000). Orthographic coding involves between visuomotor skills and handwriting. Also girls
developing a visual representation of letters and words, tend to write faster and more legibly than boys and more
knowledge of the process of forming each letter, a boys than girls have handwriting difficulties. Further,
verbal label for each letter, an accurate representation about 10% of a population is left handed but left handed-
of the letter’s form in memory and the ability to access ness is not associated with illegibility or slower speed
and retrieve this information from memory (Edwards, of handwriting. These relationships have been relatively
2003; Jones & Christensen, 1999; Weintraub & consistent in studies of handwriting of English,
Graham, 2000). Orthographic-motor integration is the Chinese, Hebrew, and Norwegian children (Graham,
way in which this letter knowledge can be motorically 1998; Karlsdottir, 1996; Tseng & Cermak, 1993;
transcribed to form letters and words on paper. Writers Tseng & Chow, 2000; Yochman & Parush, 1998).
who have poor orthographic coding and ortho-motor There are also consistent factors that seem to
integration, and thus need to attend to the mechanics operate in the development of written script over time:
of handwriting (e.g., letter formation, spacing, align- The size of the writing diminishes; letter formation,
ment), have less attention and working memory that spacing, and horizontal alignment become more
can be directed to composing written work and spelling, accurate, simplified, and standardized; the handwriting
monitoring, and revision of the written work (Edwards, may become abbreviated; and cursive forms evolve with
2003; Swanson & Berninger, 1996). curves replacing angles and ligatures joining letters
Children’s competence in writing depends, in part, (van Sommers, 1991; Yochman & Parush, 1998).
on the mastery of handwriting (Graham, Harris, & Children personalize their own style of handwriting
Fink, 2000). The ability to write legibly and in a timely as formal handwriting instruction diminishes. The
fashion is necessary for children to adequately docu- personalized style generally is faster and more efficient,
ment their knowledge and learning. Children’s docu- which may result in a deterioration of letter formation
mentation is largely the basis on which their knowledge at times. Personalized handwriting tends to become a
acquisition is judged. Research has shown that lower mix of manuscript and cursive letters, which develops
child’s chronologic or developmental level and what

The First Nine Forms of the
factors constitute handwriting dysfunction? Handwrit-
Developmental Test of Visual
BOX 11-1 ing difficulties become apparent when children write
Motor Integration in Order of
too slowly to record sufficient quantities of work or
Increasing Difficulty
when the written work is difficult to read. For instance,
teachers report that failure to read student handwriting
1. Vertical line was the most important criteria in determining whether
2. Horizontal line a child had handwriting difficulty (Hammerschmidt &
3. Circle
Sudsawad, 2004). Poor handwriters are more likely to
4. Cross
5. Right oblique line have inadequate closure and line quality of letters, poor
6. Square orientation to the writing line, poor spacing between
7. Left oblique line words and letters within words, and inconsistent sizing
8. Oblique cross of words and of letters within words (Malloy-Miller,
9. Triangle Polatajko, & Anstett, 1995).
Although children with handwriting difficulty should
Beery KE (1989). The Developmental Test of Visual-Motor
Integration, 3rd rev. Cleveland, OH, Modern Curriculum be seen within their social and educational contexts,
Press. general developmental expectations do exist. One study
documents the grade level expectations of children
between 7 and 14 years of age in terms of handwriting
size, horizontal alignment, spacing consistency, and
because it is faster than exclusively manuscript or cur- letter formation (Ziviani & Elkins, 1984). Drawn from
sive. Mixed handwriting that is predominantly cursive is a population of Australian schoolchildren, these data
used relatively less frequently than other forms (cursive, support the assumption that letters become more accu-
manuscript, or mixed but mostly manuscript). Despite rately formed, spacing becomes more consistent, size
this, mixed handwriting that is mostly cursive tends to diminishes (more particularly in girls), and handwriting
yield more legible handwriting (Graham, 1998). attains better horizontal alignment.
Integral to the issues of handwriting development Information about developmental expectations and
and understanding the developmental expectations for the factors contributing to handwriting illegibility
handwriting is the question of when young children are provide a useful baseline measure for children exposed
ready to begin handwriting instruction. A number of to similar educational instruction. Ziviani, Hayes, and
factors may be considered here: perceptual readiness, Chant (1990) used the normative data discussed
linguistic readiness, and the maturity of pencil control. previously to help specify the nature of difficulties
Beery (1989) argued that young children are not ready experienced by children with spina bifida who were able
to learn handwriting until they can correctly copy the to attend regular schools. Their findings indicated that
first nine forms of the VMI (Beery, 1989) (Box 11-1). speed, horizontal alignment, and letter formation were
Kindergarten children who can copy these forms also the handwriting characteristics most detrimentally
can copy significantly more letters (Daly, Kelly, & affected. Meanwhile, handwriting size fell within two
Krauss, 2003; Weil & Cunningham Amundson, 1994) standard deviations of the normative means, and spacing
and have better handwriting in grade 1 (Marr & consistency often was better than in the normative
Cermak, 2002) than children who cannot achieve nine sample. Such findings are useful in delineating hand-
forms. Daly demonstrated that 56% of children, when writing dysfunction to target intervention and not just
tested in the first quarter of the kindergarten school accepting a global disability.
year, were able to copy these nine forms. This compares Handwriting quality appears to be an elusive con-
with 88% who copied the nine forms in the middle of cept to measure despite the development of both global
the kindergarten school year in Weil and Cunningham and detailed handwriting assessments. A review of fre-
Amundson’s study. Thus if using the VMI as an indi- quently used handwriting tools was written by Feder
cator of handwriting readiness, most typically develop- and Majnemer (2003). A global measure such as the
ing kindergarten children should be ready to succeed Test of Legible Handwriting (TOLH) (Larsen &
with handwriting instruction in the latter half of the Hammill, 1989) compares the individual’s performance
kindergarten school year. with a series of model specimens and the important
As children develop the skill of handwriting, their consideration in scoring is overall legibility (Feder &
performance changes both qualitatively and quantita- Majnemer, 2003). However, researchers have sought
tively. Handwriting quality and quantity translate, respec- increasingly to break down handwriting samples into
tively, into legibility and speed. How do we judge if their component parts and over the years a wide variety
either or both of these aspects are appropriate for the of handwriting scales (Amundson, 1995; Phelps,
Stempel, & Speck, 1984; Reisman, 1993; Stott, Moyes, specifically asked to write neatly or quickly. Children
& Henderson, 1985; Ziviani & Elkins, 1984) and asked to write neatly, for instance, do so at the expense
checklists (Alston, 1985) have been produced to reflect of speed; and children’s legibility decreases when asked
this approach. Most of these tools identify characteris- to write more quickly (Weintraub & Graham, 1998).
tics considered to contribute to handwriting legibility. Authorities differ in terms of expected handwriting
In general, the handwriting characteristics specified speeds for children at various ages. A summary is
in these detailed tools can be classified as giving form presented in Table 11-1. Most variation in handwriting
(letter legibility and formation, size) or spatial align- speed normative information may be attributed to
ment (space between letters and words, alignment with differing test instructions (“write normally” versus
lines) to handwriting. These tools provide a more com- “write fast”). In appraising handwriting speed tests and
prehensive way of understanding legibility difficulties their relevance to assessing handwriting speed, con-
than global handwriting assessments and offer a basis sideration needs to be given to the nature of the text
for designing appropriate remedial interventions. being written (whether it is copied or self-generated),
Graham, Weintraub, and Berninger (2001) reported the timing of data collection in the school year, and
that several factors were significantly related to good variation in teaching practices. We know that the speed
overall text legibility. These factors include letter of handwriting slows and that legibility and the quality
legibility, the absence of additional lines or strokes of letter formation decrease over a lengthy handwriting
attached to letters, correct within-letter proportions, sample in both good and poor handwriters (Dennis &
correct letter formation, and no rotations of letter Swinth, 2001; Parush et al., 1998a). Fatigue affects
parts. There are other factors, arguably overlooked, handwriting; therefore the length of text used to eval-
that relate to movement and that contribute to hand- uate handwriting speed and legibility and its relation-
writing legibility (e.g., pressure while handwriting, fre- ship to everyday writing tasks needs to be considered.
quency of pen lifts). Of all the elements, individual Further work on tests of handwriting speed is
letter legibility (which incorporates letter formation, necessary to update and validate findings. Standardized
proportion, and shaping, and letter identification out of data used to evaluate handwriting ability and compare
the context of a word) is considered the most impor- performance with norms should reflect the child’s cul-
tant to overall text legibility (Graham et al., 2001; tural and educational environment. Teachers’ observa-
Mojet, 1991). tions within a peer-appropriate context are critical when
Handwriting speed is not necessarily related to deciding if a child’s performance is within develop-
legibility; that is, handwriting speed is not predictive of mental expectations. Teachers are accurate in categoriz-
legibility and vice versa (Wann, 1987; Weintraub & ing children with and without handwriting difficulties
Graham, 1998). There is a trade-off, however, between when compared with a standardized assessment of
handwriting speed and legibility when children are handwriting ability (Cornhill & Case-Smith, 1996).
Table 11-1 Reported mean handwriting speed (letters per minute) by school grade
School Grade
Author 3 4 5 6 7
Groff (1961) 35.1 40.6 49.6
Hamstra-Bletz & Blote (1990) 25 37 47 57 62
Phelps, Stempel, and Speck (1985) 35 46 54 66
Sassoon, Nimmo-Smith, and Wing (1986) 64
Wallen, Bonney, and Lennox (1996) 54.2 57.1 63.8 80.7 94.2
Ziviani and Elkins (1984) 32.6 34.2 38.4 46.1 52.1

FACTORS CONTRIBUTING TO HANDWRITING expression) improved after intervention that specifically

targeted orthographic-motor integration by teaching
PERFORMANCE correct and automatic letter formation (Berninger et
Effective intervention can be planned when the factors al., 1997; Graham, Harris, & Fink, 2000; Jones &
affecting an individual child’s ability to complete Christensen, 1999). An essential educational goal is to
legible and timely handwriting are clearly understood. provide handwriting instruction that develops automatic,
In addition to changes to handwriting legibility and fluent handwriting to free working memory for writing;
speed that occur over time in children’s handwriting, that is, generating ideas, monitoring, and revising con-
various constraints to handwriting acquisition operate tent (Berninger et al., 1997).
at different stages of development. Berninger and
Rutberg (1992) suggest that neurodevelopmental con- Handwriting Instruction
straints in orthographic coding, fine motor function, Handwriting is heavily influenced by the nature of the
and orthographic-motor integration are likely to inter- instruction received and the extent of practice under-
fere with the rapid automatic production of written taken by the individual. In fact, the main factor that
language in younger children. Later, when most influenced legibility in a study by Lamme and Ayris
children can automatically write the alphabet and spell (1983) was the great variability in handwriting instruc-
a set of functional words, the writing process is tion provided by the teachers involved in the study.
more probably constrained by verbal working memory Handwriting probably receives insufficient emphasis in
and ability to generate the major units of written school curricula: Teachers (62% of sample) reported
language—the word, the sentence, or text-level struc- that they would like to spend more classroom time on
tures. Once proficiency in generating units of language handwriting instruction (Hammerschmidt & Sudsawad,
is achieved, writing can be constrained by cognitive 2004). Berninger and co-workers (1997) surveyed
processes such as planning, translating, and revising teachers who reported that students were becoming
when composing larger pieces of text. less proficient at handwriting when they reached year 1
For older children constraints may still be operating than students of previous years.
at the neurodevelopmental or linguistic, as well as the The importance of focused handwriting instruction
cognitive levels. Inefficiencies in the low-level neuro- to both legible handwriting and writing has been
developmental processes early in handwriting acquisition demonstrated in a number of studies (Berninger et al.,
can contribute to future higher-level writing dis- 1997; Graham et al., 2000; Jones & Christensen,
abilities, both directly (because production of written 1999; Jongmans et al., 2003; Karlsdottir, 1996). Im-
material continues to be a problem) or indirectly portant components to include in handwriting instruc-
(because of an aversion to writing arising from early tion are listed in Box 11-2 (Berninger et al., 1997;
frustration and failure) (Berninger et al., 1997). Some Graham et al., 2000; Hayes, 1982; Jones & Christensen,
of the major factors implicated in handwriting perfor- 1999). It seems that providing more types of cues or
mance follow. perceptual prompting of letter formation may result in
better outcomes.
Working Memory Adi-Japha and Freeman (2001) found that by 6
Swanson and Berninger (1996) demonstrated that years of age children’s writing and drawing systems
individuals have a unique working memory. Working were differentiated. Children as young as 3 years of age
memory is the ability to temporarily retain information produce different scribbles when asked to write their
during the processing of other information. During name than those scribbles generated when drawing a
handwriting, orthographic codes are retrieved from picture (Haney, 2002). Writing-specific cortical routes
long-term memory and held in working memory while emerge probably as a result of practicing handwriting.
the writer is developing the text (Weintraub & Graham, Writing within a script context (e.g., words and letters
2000). More processing functions are available for idea on a page) rather than writing within a picture context
generation, translation, and sequencing of ideas to text, produced more fluent handwriting (Adi-Japha &
and revision of writing when aspects of handwriting Freeman, 2001). The importance of handwriting prac-
(including orthographic skills and even punctuation) tice in early learners and thus a differentiation and
are automatic (Jones & Christensen, 1999). Further, specialization of writing is reinforced by these findings.
ideas that are held in working memory may be lost if a Further, consideration needs to be given to the teach-
child needs to focus attention on the mechanics of ing and practice of handwriting within writing specific
forming a letter (Graham et al., 2001). Evidence for contexts; that is, using dedicated writing implements
this derives from studies that have shown a relationship and books, and reducing drawing conditions when the
between orthographic-motor integration and written aim is handwriting proficiency. Working within a script
expression and have demonstrated that writing (written context activates the writing system, and activation of
the advantage of both speed and legibility and need not

BOX 11-2 Important Components to Include
be discouraged.
in Handwriting Instruction
Factors That Influence the Effectiveness of
• Copying model letters Handwriting Instruction
• Visual directional cues provided by arrows Factors such as kinesthesis, fine motor skills, and visual
• Verbal prompting of letter formation (both instruc-
motor abilities are associated with handwriting devel-
tor and self-verbal prompting)
• Copying from memory opment and performance (Weintraub & Graham, 2000).
• Reinforcing letter names and practice of letters with Researchers exploring these factors operate under the
a focus on committing these to memory assumption that they underlie handwriting performance
and that understanding their relationship with hand-
Berninger VW, Vaughan KB, Abbott RD, Abbott SP, writing assists with developing and evaluating interven-
Rogan LW, Brooks A, Reed E, Graham S (1997).
Treatment of handwriting problems in beginning writers: tion programs (Tseng & Cermak, 1993). Further factors,
Transfer from handwriting to composition. Journal of such as posture while handwriting, paper positioning,
Educational Psychology, 89(4):652–656; Graham S, Harris and stabilization of paper, as well as other ergonomic
KR, Fink B (2000). Is handwriting causally related to
factors, discriminate good and poor handwriters (Parush,
learning to write? Treatment of handwriting problems in
beginning writers. Journal of Educational Psychology, Levanon-Erez, & Weintraub, 1998b). Posture and sta-
92(4):620–633; Hayes D (1982). Handwriting practice: bilization anomalies may result from similar mechanisms
The effects of perceptual prompts. Journal of Educational to those that cause handwriting difficulties. It is not yet
Research, 75(31):169–172; Jones D, Christensen CA
(1999). Relationship between automaticity in handwriting
known whether remediating kinesthesis, fine motor,
and students’ ability to generate written text. Journal of visual motor, ergonomic, and other factors improve
Educational Psychology, 91(1):44–49. handwriting output and writing outcomes.
Issues in relation to motor execution specific to
handwriting were introduced in the earlier section on
the processes of acquisition of graphomotor skills and
the writing processing system separately from a drawing are expanded here. When an orthographic code is
context prepares for more accurate and automatic mobilized from memory for handwriting, a motor
handwriting output. program is executed that encompasses manipulating
The outcomes of the studies that have focused on a writing implement to form letters and words
developing orthographic skills and automatic hand- (Weintraub & Graham, 2000). Two aspects of motor
writing have all been positive. The results suggest that execution are examined in the literature, fine motor
poor letter knowledge and orthographic skills are major skills (including in-hand manipulation) and abilities
contributors to handwriting difficulties and are essential related to kinesthesis.
to consider in handwriting intervention. Other studies Isolated and graded finger movements are necessary
provide useful information to consider when planning to provide precise and rapid manipulation of a writing
handwriting intervention. One study examining the tool for handwriting. On the basis of this premise, fine
ability of children in years 1 to 3 to write manuscript motor skills and in-hand manipulation are frequently
letters reported that some letters were more difficult to assessed as part of a handwriting assessment. Fine motor
form legibly (Graham et al., 2001). Overall these skills are assessed globally by tools such as the Peabody
letters, in descending order of difficulty, were q, z, u, j, Developmental Motor Scales—Fine Motor (Folio &
k. Fortunately some of these letters are not frequently Fewell 2000). Fine motor skills incorporate the basic
used in handwriting but may require more focus during patterns of reach, grasp and release, and the more com-
handwriting instruction and should be introduced only plex skills of in-hand manipulation and bilateral hand
after mastery of easier letters. Despite ongoing debate, use (Exner, 1989). In-hand manipulation, then, is an
it seems that teaching slanted or elliptical manuscript essential component of dexterous hand function and
does not have advantages over traditional manuscript in can be assessed separately using tools such as those de-
legibility outcomes or assisting the transition to cursive veloped by Exner (1993) or Case-Smith (1995). These
handwriting (Graham, 1998). Karlsdottir (1996) assessments include some of the defined features of
showed that handwriting quality of older (10-year-old) in-hand manipulations such as rotation (e.g., turning
students was significantly enhanced by reintroducing an object over using the fingers of one hand) and
each letter form with accompanying visual and verbal translation (e.g., using the fingers of one hand to move
cues. Thus one should consider these orthographic fac- objects in and out of the palm). In-hand manipulation
tors even in more mature writers. Older writers also tend is assessed as its own entity in handwriting evaluation
to personalize handwriting by mixing manuscript and because of a perceived relationship to pencil manipula-
cursive text, among other things. Generally this is to tion. In reality the association between fine motor skills
or in-hand manipulation and pencil grip and hand- (2000) found that “finger function” was a strong pre-
writing speed and legibility has not been extensively dictor of good or poor handwriting ability. Rather than
explored. Rubin and Henderson (1982) found that reflecting strictly fine motor ability, the finger function
children with poor handwriting did not have signifi- tasks contained largely proprioceptive and somato-
cantly different scores from a group of good hand- sensory ability. Yochman and Parush (1998), however,
writers on the Test of Motor Impairment, but they did found no correlation between kinesthesia-related tests
have more variability of their scores. Tseng and Chow and handwriting performance.
(2000) on the other hand, found that Chinese hand- Visual motor integration appears to be an important
writers, categorized as slow writers by their teachers, factor in handwriting legibility. A great deal of research
had significantly lower scores on the Upper Limb supports the assumptions that (a) visual motor inte-
Speed and Dexterity subtest of the Bruininks-Oseretsky gration is correlated with handwriting performance in
Test of Motor Proficiency than normal speed hand- good, as well as poor handwriters (Tseng & Chow,
writers. Cornhill and Case-Smith’s work (1996) pro- 2000; Tseng & Murray, 1994; Weil & Cunningham
vides us with some evidence that in-hand manipulation Amundson, 1994); (b) visual motor abilities are weaker
is a significant predictor of handwriting legibility. Their in children with handwriting difficulties, across a wide
sample of year 1 students with handwriting difficulties range of ages, compared with children without hand-
had significantly lower in-hand manipulation scores writing difficulties (Cornhill & Case-Smith, 1996; Daly,
than fellow students with good handwriting. Still we do Kelly, & Krauss, 2003; Rubin & Henderson, 1982;
not know whether improving fine motor and in-hand Tseng & Chow, 2000; Tseng & Murray, 1994); and
manipulation ability results in more legible or faster (c) visual motor integration difficulties are a predictor
handwriting. of handwriting legibility (Cornhill & Case-Smith, 1996;
Debate continues about the role of kinesthesis in Maeland, 1992; Tseng & Chow, 2000; Weintraub &
handwriting performance and the effectiveness of Graham, 2000; Yochman & Parush, 1998). Visual motor
kinesthetic training in improving handwriting. Laszlo integration may be particularly important in the acqui-
and Bairstow (1985b) have argued, based on their sition of handwriting because visual motor abilities are
work with the KST, that kinesthetic memory, more used to acquire orthographic coding skills. Occupational
than kinesthetic acuity, is primarily responsible for the therapists tend to view visual motor integration as under-
skilled performance of writers. Studies investigating the lying handwriting dysfunction and intervene using visual
proposed relationship between training children using motor activities (Case-Smith, 2002). Despite this relative
the testing equipment of the KST and handwriting abundance of evidence confirming the relationships
performance have reported contradictory findings and between visual motor integration and handwriting,
have cast a shadow on the psychometric properties of there is as yet no evidence that remediating visual
the KST (Hoare & Larkin, 1991; Lord & Hulme, motor skills will result in enhanced handwriting output.
1987). Two of the stronger studies provide the best Handwriting intervention studies in the educational
evidence that the KST is not associated with hand- and motor learning literature focus on developing
writing. Copley and Ziviani (1990) found no significant orthographic coding and using self-instruction methods
relationship between the KST and handwriting quality for enhancing handwriting legibility and writing ability
when testing good and poor handwriters. A well- (Berninger et al., 1997; Graham et al., 2000; Hayes,
designed randomized controlled trial evaluated hand- 1982; Jones & Christensen, 1999; Jongmans et al., 2003;
writing outcomes after kinesthetic training on the KST Karlsdottir, 1996). These studies provide good evidence
equipment (Sudsawad et al., 2002). There were no that these approaches are effective in enhancing various
significant between-group differences in these grade 1 aspects of handwriting legibility and speed and also the
children after kinesthetic training compared with a content of written work. Studies in occupational therapy
sham intervention and no intervention. Previous studies are fewer in number than studies in education. Typically
have evaluated kinesthetic training in children with occupational therapy intervention studies integrate
poor handwriting without identifying whether or not multiple theoretical perspectives and offer broad-based
they had kinesthetic difficulties. An important differ- interventions encompassing biomechanical, multisensory,
ence of Sudsawad’s study from previous ones is that visual motor, fine motor, and handwriting-specific inter-
the children recruited were identified as having hand- ventions (Case-Smith, 2002; Lockhart & Law, 1994;
writing difficulty, as well as kinesthetic impairment Peterson & Nelson, 2003). A range of outcomes which
identified by the KST. The evidence suggests that kines- are not always related to handwriting legibility, speed, and
thetic training using the KST equipment is not an content are evaluated. Two such broad-based studies
effective handwriting intervention. (including one randomized controlled trial) reported
Research on other aspects of somatosensory ability significant improvement in handwriting; however, the
and handwriting are inconclusive. Weintraub and Graham specific components of the intervention that contributed
to the outcomes are undetermined (Case-Smith, 2002; children can be offered word processing as a viable
Peterson & Nelson, 2003). option to handwriting at an appropriate time (Rogers
& Case-Smith, 2002).
This review of handwriting has discussed hand-
COMPUTERS AND HANDWRITING writing development and factors associated with skilled
Children with significant disability or those who con- handwriting execution. The fact that handwriting under-
tinue to have handwriting difficulties even after inter- lies quality written output and thus that good hand-
vention may consider word processing as an alternative. writing instruction is essential has been emphasized.
There are a multitude of factors to consider in deciding
whether keyboarding is an appropriate strategy for
children to adopt. Just some of these factors are the
keyboard configuration (e.g., laptop, PC); software SUMMARY
(e.g., word prediction); transfer of data among home,
school, and printers; the cognitive demands of man- The process and products of children’s drawing and
aging files, academic subjects, and the facilities of mul- handwriting have intrigued occupational therapists, as
tiple software packages; the physical demands of the well as others interested in child development, for a
task; and the suitability to the child. Further, it is number of years. It is clear from this chapter that,
necessary to predict whether a child will actually achieve although we now have certain structures in place to
quality written expression with adequate accuracy and understand the developmental transitions in children’s
speed compared with handwriting. drawings, there is still much to understand. The same
Keyboarding, like handwriting, is a complex skill and can be said for handwriting. There remain aspects of
requires many hours of practice to achieve proficiency. drawing and handwriting acquisition that still tantalize;
Learners of keyboarding should progress through this chapter concludes by pointing to some issues that
stages of learning the position of keys and the various still beg investigation.
movement patterns necessary to achieve correct key Drawing is an important developmental experience
strokes. Proficiency, which relies largely on kinesthetic for children. With the increasing use of computers by
feedback and little on visual feedback, may be achieved younger and younger children, some of the pencil and
with practice. It is interesting to contemplate whether paper drawings with which we are most familiar are
handwriting and keyboarding have similar underlying being accomplished using a computer. Are we able to
abilities. If so, and if handwriting is a difficulty, then translate our knowledge of paper-based outcomes to
these same underlying abilities also may affect the those on the screen?
development of proficiency at keyboarding. Studies Preliminary research has indicated that handwriting
indicate that different components underlie hand- and keyboarding have differing underlying compo-
writing and keyboarding accuracy in typically develop- nents. Thus we are unlikely to be able to translate our
ing students (Preminger, Weiss, & Weintraub, 2004; knowledge of handwriting directly to keyboarding. A
Rogers & Case-Smith, 2002). This information com- greater understanding of word processing, as an
bined with Barrera, Rule, and Diemart’s (2001) finding alternative form of recording work, is necessary to
that year 1 students wrote more words and sentences match it to the individual needs of students. Using a
using a keyboard than handwriting gives us more con- motor learning framework, we understand that hand-
fidence in using keyboarding as an option for children writing is a learned motor task requiring interplay
with handwriting difficulties. among the writer, the task, and the environment. A key
Word processing and word prediction software can environmental factor in its acquisition is the quality of
increase the legibility and spelling of written work in instruction received and amount of practice under-
children with learning and handwriting difficulties taken. However, even in the presence of adequate
(Handley-More et al., 2003). Studies do not concur as instruction there are a multitude of factors pertinent to
to whether keyboard instruction can result in keyboard an individual that may affect the child’s ability to
speeds that are faster than handwriting (Rogers & develop handwriting. The association between some
Case-Smith, 2002). Indeterminate hours are spent of these factors and handwriting has been better
learning and refining handwriting. The expectation researched than others. For example, we know there is
should be that substantial effort goes into ensuring that an association between visual motor integration and
the speed and accuracy of keyboarding is at least equi- handwriting. We are less certain of the relationship
valent to handwriting to make it a viable alternative to between other factors such as kinesthesia and in-hand
handwriting. The secondary complications of poor hand- manipulation and handwriting. Cognitive, linguistic,
writing (e.g., compositional difficulties, avoidance of and motivation factors also should inform research in
handwriting, and loss of confidence) may be avoided if this field. We require a better understanding of the
relationship of all these factors to handwriting and Barrera III MT, Rule AC, Diemart A (2001). The effect of
especially how these factors are manifesting in children writing with computers versus handwriting on the writing
achievement of first-graders. Information Technology in
with poor handwriting. It may be that a breakdown in
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Blote AW, van der Heijden PGM (1988). A follow-up
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Tseng MH, Chow SMK (2000). Perceptual-motor function Pediatrics, 18(3/4):53–65.
of school-age children with slow handwriting speed. Ziviani J, Elkins J (1984). An evaluation of handwriting
American Journal of Occupational Therapy, 54(1):83–88. performance. Educational Review, 36:251–261.
Tseng MH, Murray EA (1994). Differences in perceptual- Ziviani J, Elkins J (1986). Effect of pencil grip on
motor measures in children with good and poor handwriting speed and legibility. Educational Review,
handwriting. Occupational Therapy Journal of Research, 38:247–257.
14:19–36. Ziviani J, Hayes A, Chant D (1990). Handwriting: A
van der Meulen JHP, Denier van der Gon JJ, Gielem perceptual motor disturbance in children with
CCAM, Goosken RHJM, Willemse J (1991). Visuomotor myelomeningocele. Occupational Therapy Journal of
performance of normal and clumsy children. I. Fast goal- Research, 10:12–26.
Chapter 12
INTERVENTION FOR CHILDREN WITH
HAND SKILL PROBLEMS
Charlotte E. Exner
CHAPTER OUTLINE FRAMEWORKS FOR

FRAMEWORKS FOR INTERVENTION WITH
INTERVENTION WITH CHILDREN
CHILDREN WHO HAVE HAND SKILL PROBLEMS WHO HAVE HAND SKILL
Impact of Hand Skill Problems on Children’s PROBLEMS
Occupational Performance
Intervention Approaches: Modifications or
Adaptations and Motor Skill Remediation I MPACT OF HAND SKILL PROBLEMS ON
Factors to Consider in Intervention Planning C HILDREN’S OCCUPATIONAL PERFORMANCE
GOAL SETTING FOR HAND SKILL INTERVENTION
Hand function has great significance for occupational
Considerations in Setting Goals performance. The greater the difficulties with hand
Short-Term Goals for Hand Skill Intervention function, the greater the impairment in skills that allow
RESEARCH RELATED TO HAND SKILL INTERVENTION for independence and participation in academic and
social activities. Children with hand function difficulties
INTERVENTION STRATEGIES FOR HAND SKILL
usually are limited in their ability to effectively or effi-
PROBLEMS
ciently complete daily life skills and develop skills that
Positioning of the Child and the Therapist will support optimal occupational performance in the
Tactile or Sensory Awareness or Discrimination future. In addition, for some children even subtle diffi-
Tone and Postural or Proximal Control culties with hand skills may affect their social participa-
tion because of limitations in ability to engage in activities
Isolated Arm and Hand Movements
with their peers or messiness in task completion.
Grasp Fine motor skills have a major impact on children’s
Voluntary Release school performance. McHale and Cermak (1992)
In-Hand Manipulation found that “all the classrooms observed [in their study]
had a high level of fine motor demands,” with fine
Bilateral Hand Skills
motor tasks being carried out for 30% to 60% of the
Integration of Skills into Occupational Performance classroom day and the majority of these tasks involving
ADJUNCTS TO DIRECT INTERVENTION: SPLINTING, writing activities. In preschool settings, children must
CASTING, AND CONSTRAINT-INDUCED be able to manage the classroom manipulatives,
MOVEMENT THERAPY including puzzles, scissors, crayons, blocks, pegs, and
Splinting beads. Elementary school-age children must be able to
manage the entire writing process, which includes
Casting
handling a pencil or pen effectively, using an eraser,
Constraint-Induced Movement Therapy tearing and folding paper, putting paper into note-
SUMMARY books and folders, and doing art projects. As children
239
240 Part III • Therapeutic Intervention
reach middle school and high school age, they not only and direct intervention for the motor skill difficulty.
have a high volume of written work, but they also take However, these two approaches may be blended and
courses that have labs (e.g., science, industrial arts, both should be used with a consideration for applica-
home economics) that require the ability to handle bility to the child’s occupational tasks. The Occupa-
small materials with dexterity. tional Therapy Practice Framework (2002) is helpful in
Children of all ages need effective hand function to considering a variety of dimensions related to the
manage eating, dressing, hygiene care, and a variety of intervention approach.
other self-care activities independently in multiple envi-
ronments. Expectations for independence, and there- Modifications and Adaptations for
fore proficient hand use, increase throughout adolescence. Hand Skill Problems Within the Context of
Chapter 10 provides a thorough summary of the inter- Occupational Tasks
action of hand and self-care skills. This type of intervention includes the use of alternative
In response to the frequent difficulties that children strategies for accomplishing tasks, including the use of
show and the impact of these difficulties on occu- adaptive equipment when necessary. Splinting is a
pational performance, pediatric occupational therapists common adaptation used to support hand function in
typically address children’s hand skills. Swart et al. children with moderate to severe disabilities. Although
(1997) report that intervention for fine motor skills is direct intervention may not appear to be crucial when
a top occupational therapy priority in working with adaptive strategies or splinting are selected as the
children. In their study of approximately 200 pediatric primary method of intervention, children often need
occupational therapists, intervention for fine motor substantial intervention for these strategies to be used
issues was rated as very important or important by successfully. Family members or teachers may need
100% of the therapists. Almost 100% of these therapists ongoing guidance and the adaptive strategy or splint
reported that they consistently or often provide services may need modifications for function and optimal use.
that address fine motor issues, and at least 90% reported The success of this type of intervention often is linked
that addressing fine motor issues is unique or very unique to the follow-up provided to insure that the child and
to the profession of occupational therapy. others are using the strategy and are satisfied with the
adaptation and its applicability to the child’s daily life
task performance.
I NTERVENTION APPROACHES:
MODIFICATIONS OR ADAPTATIONS AND Motor Skill Remediation Within the Context of
Occupational Tasks
MOTOR SKILL REMEDIATION The therapist may work with the child to assist the child
A child’s hand function difficulties always must be in developing or improving specific hand skills such
placed within the context of the child’s overall func- as grasp, in-hand manipulation, or voluntary release.
tioning, needs, and priorities. Despite the significance Although the therapist may use the intervention time
of hand skills to occupational performance and social to focus specifically on improvement of one or more of
participation, the decision about intervention for hand the child’s hand skills, the skills being developed should
skill difficulties must be made with the child (when be immediately and directly linked to use of these hand
feasible) and the family or other key individuals, skills within the child’s daily life activities. Thus during
keeping in mind the child’s overall needs and priorities each session with a child, the therapist places high
and the likelihood of intervention having a significant priority on identification of helpful strategies that can
impact on the child’s functioning. For example, a child and will be used outside of the therapy session. These
may have multiple need areas for intervention, such as strategies can include identifying ways in which adult
academic skills, mental health issues, or language diffi- facilitation of the new skills will occur and ways in
culties. In addition, within the scope of responsibilities which multiple repetitions of the skill can be elicited to
of the occupational therapist, issues of hand function support proficiency, speed, and spontaneous skill use.
may be of lesser priority than other areas, such as sen- The decision about a focus of hand skill goals on
sory regulatory issues, acquisition of independence in adaptation or motor skill remediation can vary over
life skills, or psychosocial concerns. time and for different skills, depending upon the child’s
Thus the occupational therapist participates with the needs and the degree of the child’s disability.
child, the family, and other team members in deter- Vygotsky’s (1978) concept of the zone of proximal
mining if and when intervention with a focus on hand development can be very useful in considering the most
function issues is in the best interest of the child. Two appropriate approach for particular skill areas. This con-
general types of intervention approaches may be concept focuses upon the amount of adult or peer assistance
sidered in addressing hand function issues: adaptations or guidance needed to complete a skill. It suggests a
Intervention for Children with Hand Skill Problems • 241
focus on the child’s abilities, rather than upon his or influencing proximal functions. Therefore intervention
her disabilities, as it considers the skills that are “close” for proximal control problems does not necessarily
(i.e., within the “zone of proximal development”). The result in improved distal control, unless the distal con-
“zone of proximal development” falls between those trol problem results solely from difficulty placing and
skills that the child is able to do independently and holding the hand in space. Therefore as Pehoski (1992)
those that the child is unable to do, even with adult or notes, distal control problems should be treated
peer guidance or assistance. Clearly, even within the specifically. This point is supported by a number of
“zone of proximal development,” some skills are nearer single subject research studies conducted by Barnes
to the “independent” end of the continuum, whereas (1986, 1989a,b). She studied the effectiveness of upper
others are nearer to the “unable to complete” end of extremity weight bearing on hand function in children
the continuum. with cerebral palsy (CP) and found that although some
When a child’s skills are not in the independent upper extremity movement components improved,
category and not within the “zone of proximal devel- grasp and release did not show significant changes;
opment,” yet the child needs a particular skill, adapta- therefore the proximal improvement did not yield distal
tion or compensation is necessary. For example, if the changes.
child is unable to cut foods because of an inability to
hold a fork to stabilize food with a utensil in one hand The Relationship Between Stability and Mobility
while cutting with a knife held in the other hand, an The use of motor skills relies on the interplay of
adaptation is needed. Such an adaptation could include stability and mobility. Effective use of mobility of the
using an adapted fork or knife, using a device to arm or the hand is based upon stability within the body
stabilize the food, or having the food cut by another or the arm. Stability typically precedes the use of
person. In contrast, if the child is able to hold both mobility. For example, the child develops the ability to
utensils and can bring both hands near midline but has grasp an object before being able to move the object by
difficulty sustaining them at midline, intervention that the fingers.
is focused on enhancing the child’s skills may be effec- Stability provided via seated positioning and its
tive and an adaptation may not be necessary. Those effect on hand function has been addressed in some
skills that require lesser degrees of adult (or therapist) studies. Noronha, Bundy, and Groll (1989); Seeger,
facilitation or assistance are clearly more likely to be Caudrey, and O’Mara (1984); and Nwaobi (1987)
responsive to remediation. At times both an adaptation assessed positioning in children with cerebral palsy.
and intervention for motor skill development may Smith-Zuzovsky and Exner (2004) found that the
be used. quality of seated positioning had a significant impact
on typically developing, young school-age children’s
object manipulation skills. Children who were seated in
FACTORS TO CONSIDER IN I NTERVENTION furniture more closely matched to their body size had
PLANNING significantly higher scores on the In-Hand Manipula-
tion Test than did children who were seated in typical
The Relationship Between Proximal and Distal classroom furniture that was too large.
Control
The developmental principle of proximal to distal The Relationship Between Sensory and
development often has been translated into a principle Motor Control
for intervention. However, this principle, like many Children with various disabilities have been noted to
principles of normal development, does not necessarily have impairments in tactile functioning in their hands
relate well to intervention. Current research suggests (Beckung, Steffenburg, & Uvebrant, 1997; Bumin &
that the relationship between proximal functioning and Kayihan, 2001; Curry & Exner, 1988; Krumlinde-
distal control is functional; it is not necessarily causal Sundholm & Eliasson, 2002; Yekutiel, Jariwala, &
(Case-Smith, Fisher, & Bauer, 1989). Although an Stretch, 1994). Some children seem to have little aware-
infant initially may appear to show greater control ness that they have five digits on each hand; instead they
proximally than distally, infants are developing both use all four fingers as a unit. They also seem to have little
proximal and distal control simultaneously. Distal con- awareness that they have different areas on the palms
trol, however, does take longer to reach full refinement. of the hand. Skold, Josephsson, and Eliasson’s study
In fact, different neurologic tracts control proximal and (2004) with individuals with hemiplegic cerebral palsy
distal upper extremity functions (Lawrence & Kuypers, corroborated the presence of sensory problems. Com-
1968a,b), with the corticospinal tracts being respon- ments from these young people revealed substantial
sible for distal functions, including well-controlled issues with sensory awareness of the more involved arm
forearm movements (Paillard, 1990) but not directly and hand.
Pehoski (2005) provides a summary of key literature a new motor skill are extremely important in moving a
related to the importance of sensory functioning for skill from the level of needing conscious attention in its
skilled hand use (see Chapter 1). Research by Gordon use to the level of spontaneous and automatic use.
and Duff (1999) illustrates the critical role of tactile For practice of a motor skill to occur, either it should
functioning on grasping and lifting objects in typical be a skill that the child will automatically repeat inde-
children and adolescents and those with cerebral palsy pendently or planned practice opportunities should be
(see also Chapter 3). They state that created. Older children with sufficient cognitive skills
and motivation may be able to be provided with a list
“the impairments in grasping in children with hemiplegic CP of specific skills to practice. When providing a child
are largely but not exclusively due to disturbed sensory with this type of “homework” activity based upon
mechanisms which may have direct implications for therapeutic therapy recommendations, the child tends to do best if
intervention” (p. 586). given written instructions and a method of recording
(e.g., a chart) when he or she practiced the skill and for
These findings are supported by Krumlinde-Sundholm how many times. Teachers or parents or other family
and Eliasson’s study (2002) in which specific types of members also can support practice opportunities. How-
sensory problems were related to dexterity difficulties ever, realistic expectations of parents are critical, par-
in children with hemiplegic cerebral palsy. Case-Smith ticularly because parenting a child with a disability has
(1991) found that children with both tactile discrimi- numerous challenges. Cronin’s study (2004) illustrates
nation problems and tactile defensiveness had signifi- the stressors on mothers of children with develop-
cantly poorer performance on in-hand manipulation mental and other health issues. A key theme of many
tasks than did other children. The individuals in the of these mothers is the challenge of managing daily
Skold et al. (2004) study noted the negative effect of routines. Therefore meaningful opportunities for skill
their sensory problems on functional use of this arm practice are most likely to occur when the therapist
and hand. works with the family to enhance the child’s occupa-
tional performance or create opportunities for practice
The Child’s Attention and Cognitive Skills of motor skills within the context of normal occupa-
The child’s attention and cognitive functioning have a tional routines.
significant influence on goals and intervention strat-
egies for hand function difficulties. The child’s under- Importance of Addressing the Child’s Interests
standing of objects and their ability to be used with As Pehoski (1992) notes, hand skills and interest and
other objects to accomplish tasks affects the child’s desire motivation are intimately related. A child’s interest in
to use the hands to make objects move and interact an activity—an activity that has meaning and signifi-
with one another and the products of that manipula- cance for the child—is critical for the child to be fully
tion. Although children acquire some aspects of object engaged in the intervention process. Hand skill inter-
knowledge and their actual and potential relationships vention cannot be done to a child; it must be done with
through manipulating them, the child’s cognitive the child’s involvement in the activities and with the
functioning seems to drive (or at least set the stage for) child’s belief that he or she can be successful in accom-
the acquisition of increasingly complex fine motor skills. plishing the activities presented. When a child engages
Therefore generally the child needs to understand the in an activity with little or no attention to the task or no
goal of a hand function activity. If not, the child will intrinsic investment in the activity, little improvement
not have a context for use of the skills the therapist is and carryover into other occupational tasks are likely.
attempting to facilitate. For example, the child who Erhardt (1992) also makes the point that in planning
cannot attend to two objects simultaneously will not be intervention for eye-hand coordination, the therapist
able to grasp two objects simultaneously and therefore must take into account the child’s intrinsic desire to play
will not bang two objects together. This child is not able and the child’s cognitive development because these
to stabilize materials with one hand while manipulating are the impetus for
with the other.
“purposeful, goal-directed, eye-hand coordination behaviors”
Opportunities for Skill Repetition and Practice (p. 23).
Motor learning theory emphasizes that skills are acquired
using specific strategies and are refined through a great To address the issue of the role that motivation and
deal of repetition and the transfer of skills to other tasks interest may have in therapy sessions, DeGangi et al.
(Croce & DePaepe, 1989). Exner and Henderson (1993) conducted a study that focused on the child’s
(1995) provide an overview of motor learning relative active selection of activities used in the therapy session
to hand skills in children. Opportunities for practice of versus therapist-selected activities. They compared
child-centered intervention, in which the adult “‘engagement in occupation’ is viewed as the overarching out-
facilitates the child’s activities but the child selects the come of the occupational therapy process” (p. 615).
activities from among those provided in a therapeutic
environment, with structured sensorimotor intervention This focus emphasizes occupational performance as the
in which the adult directs the child’s activities. The child- primary goal of intervention.
centered intervention seemed to result in more change Weinstock-Zlotnick and Hinojosa (2004) describe
in the children’s fine motor skills, as measured by the an approach to intervention that allows a focus on foun-
Peabody Fine Motor Scales, than the sensorimotor dational issues (often called a “bottom-up” approach),
program did, but the difference in gains between the as well as occupational performance (often called a
two approaches was not significant. DeGangi et al. “top-down” approach). They note
(1993) concluded that
“it is the ultimate goal of therapeutic intervention to encompass
“in practice, the therapy approaches used in this study may be both poles of the component-function continuum, wherein, both
blended or sequenced one after the other for best results” and that the ‘top’ and ‘bottom’ of an individual’s functional limitations
“this study provides preliminary evidence that children with are reached and successfully achieved or at least addressed”
sensorimotor dysfunction benefit from approaches that elicit (pp. 556–557).
adaptations to environmental and task demands through the use
of play and structured learning techniques as therapeutic Thus the most effective approach when a child
mediums” (pp. 782–783). shows potential for motor skill improvement is to keep
the child’s occupational performance as the central
Case-Smith’s study (2000) of intervention for concern while addressing particular motor skills that
preschool-age children also showed that play and peer support the occupational performance. Generally,
interaction are important factors in the outcome of progress in particular motor skill areas is important
therapy for fine motor problems. In her study of only when the skills are or will be used within the
occupational therapy intervention for 44 children child’s daily activities.
across a school year, she found that in many cases For both occupational performance and motor skills,
therapists used play and peer interaction activities consideration of the typical sequence of skill develop-
within therapy sessions that focused on fine motor ment approach is important, but the developmental
skills. The study findings support the conclusion that sequence only rarely can be translated into or used as
the primary guide for intervention goals. For example,
“play activities and peer interaction [within therapy sessions] in identifying development of a fingertip grasp or skill
were predictive of the fine motor/visual motor outcomes” in using palm to finger translation as a goal area, the
(p. 377). therapist should determine if the child has the develop-
mental readiness for the skill and also relate this motor
Case-Smith notes that play activities are important in skill to specific occupational tasks that are develop-
children’s motivation and focused involvement with mentally appropriate for the child, such as playing a
activities and contribute to practice of skills in a variety game with peers or handling money to purchase items
of meaningful situations. independently. Similarly, for example, increasing the
The remainder of this chapter addresses structured child’s ability to do palm to finger translation with
approaches for hand skill intervention, primarily more objects has meaning only if the child needs to be
through or in conjunction with play and other occupa- able to use a more complex level of hand skills. Deter-
tional tasks of children. The importance of the environ- mining the appropriateness of establishing a goal for a
ment also is stressed. particular hand skill entails an understanding of the
child’s development in a number of areas, as well as his
or her environmental demands.
The concept of the “zone of proximal development”
GOAL SETTING FOR HAND SKILL can be useful in designing an intervention plan with
INTERVENTION goals that are realistic and achievable. Using this con-
cept, the therapist is interested in determining those
skills that are close or within reach, not the skills for
CONSIDERATIONS IN SETTING GOALS which the child is still missing many prerequisites. Skills
The assessment process used by the therapist with the not within reach may be skills that the child needs. If
child and family has an impact on the framing of goals so, adaptations or compensations may be needed to reach
and interventions. As stated in the Occupational Therapy these goals. When attempting to improve fine motor
Practice Framework (2002) skills, however, the child needs to have the prerequisite
skills or be able to be facilitated in using a particular ability to generalize new motor skills across a range of
fine motor skill before that skill is established as a goal. occupational tasks. Therefore when possible, meaning-
Setting goals for hand skills intervention involves prior- ful evaluation of the child’s effective use of new motor
itizing the areas that should be addressed while deter- skills includes a range of activities. Consistency of skill
mining those areas most likely to be responsive to use also needs to be a consideration in assessing inter-
direct intervention and those that may need adaptation. vention effectiveness.
Collaborative goal setting with others is vital to the The goals listed in Box 12-1 have the motor skill
success of the intervention program. Goal setting with identified first, suggesting an emphasis on the motor
parent(s) and teachers (when appropriate) has been skill. For examples of goals that have occupational tasks
recognized as a central consideration in intervention. identified first with motor skills included as related to
The child’s perspective on intervention also is impor- these tasks, see Exner (2005).
tant. Although there is little documentation of the
role of the child in selecting intervention goals and
methods, Missiuna and Pollock (2000) found that RESEARCH RELATED TO HAND
young school-age children were able to identify occu-
pational tasks with which they have difficulty and, based SKILL INTERVENTION
upon this assessment, could choose occupational therapy
goals and priorities. Although these goals and priorities A growing body of research evidence is lending support
may not necessarily converge completely with the to the value of intervention for hand skill problems in
parent’s goals and priorities (Missiuna & Pollock, children. Children with mild motor involvement such
2000), such collaborative goal setting with children as as developmental coordination disorder or clumsiness
young as possible is important for the intervention- have shown improvement in various motor skills (Case-
planning process. Smith, 2000; Shoemaker et al., 2003), as well as children
with various degrees and types of cerebral palsy
SHORT-TERM GOALS FOR HAND SKILL (Barnes, 1986, 1989a,b; Bumin & Kayihan, 2001; Law
et al., 1997). The study by Stiller, Marcoux, and Olson
I NTERVENTION (2003) was less conclusive about test findings of im-
Typical childhood occupational performance problems provement in hand skills, although parents and teachers
that are likely to have a hand skills component, and reported improvement in the children after inter-
therefore are likely to be reflected in short-term goals, vention. Although individual sessions of the therapist
include the following: and child appear to be the most common form of
• Poor handwriting intervention, studies by Case-Smith (2000) and Bumin
• Difficulty managing materials in the classroom and Kayihan (2001) had positive findings associated
• Limited constructive play skills with small group intervention with children. This type
• Avoidance of play with peers of intervention can support engagement in playful
• “Messy” eating activities, repetition of motor skills, and opportunities
• Slow dressing, with avoidance of fasteners for social skill development (Exner, 2005). In addition,
• Lack of independence in getting ready for school small group intervention can be more cost-effective
• Difficulty with hygiene skills than individual interventions or allow for two or more
The following represent examples of short-term goals sessions for the same cost as an individual session.
or objectives for intervention that are focused on reme-
diation of hand skill difficulties. They may be worded
with a focus on the motor skill (more in keeping with a INTERVENTION STRATEGIES FOR
“bottom-up” or medical-model intervention) or with a
focus on the task that the child will be able to accom- HAND SKILL PROBLEMS
plish (more in keeping with a “top-down” or school or
home-based model of intervention). In either case, the In planning an intervention session, the therapist con-
therapist addresses the occupational performance goals siders the specific hand skill goals while simultaneously
with specific attention to facilitating improvement in considering other goals for the child, the child’s interests
the child’s hand skills. Measurement of goal attainment and abilities, and the child’s ability to participate in the
needs to consider both the child’s specific hand skills selection of materials or activities for the session. Each
and use of these skills within important occupational session’s activities must be suited to the particular
performance areas. The challenge with adding specific child; activities that are particularly good for one child
occupational tasks to the motor skill goals is that use of may be of little interest to another. The child’s motiva-
the motor skills can appear narrower than actually tion to participate in the activities is an essential factor
desired. The therapist typically focuses on the child’s to consider.
In addition to a variety of nonmotor elements the

Sample Short-Term Goals for
therapist considers in planning intervention, the
Grasp, Voluntary Release,
BOX 12-1 therapist usually attempts to select activities to address
In-Hand Manipulation, and
a variety of motor factors that contribute to selected
Bilateral Hand Skills
hand skills. For example, when the focus is upon the
child being able to use a radial digital grasp pattern
SAMPLE SHORT-TERM GOALS FOR GRASP with varying amounts of pressure, intervention may
The child will: address radial-ulnar dissociation within the hand, wrist
• Use a power grasp on tools such as eating utensils,
stability, ability to extend the fingers with the wrist in a
toothbrush, hammer
• Modify use of a radial finger grasp according to neutral position, ability to grade finger opening for an
pressure requirements for small objects to pick up object, ability to use a small range of finger flexion
and hold various finger foods (rather than full flexion), or ability to sustain inter-
• Supinate the forearm slightly during approach and phalangeal (IP) extension with metacarpal-phalangeal
maintain this during a radial finger grasp to allow for (MP) flexion so as to grasp a flat object. The therapist
visual monitoring of tasks such as putting items in a perhaps should prepare the child to work on these skills
cabinet, handling game board pieces, and opening
by addressing other motor-related issues such as tone,
packages
• Use a full palmar grasp with wrist extension and strength, cocontraction, and range of motion.
varying degrees of elbow flexion/extension while The amount of time for intervention not only
completing dressing tasks influences the number of different skills that may be
SAMPLE SHORT-TERM GOALS FOR VOLUNTARY addressed, but also the number of practice oppor-
RELEASE tunities. Within a session the therapist may focus on a
The child will: variety of hand skills or only one or two. The eight
• Release objects that are stabilized by a supporting areas outlined in the following may be addressed when
surface (e.g., a peg into a pegboard or a spoon into the therapist can work with the child directly for 45 to
a dishwasher container) 60 minutes; the order of the suggested interventions is
• Voluntarily release lightweight objects onto a flat sur-
such that skills can build on one another. Obviously
face (e.g., a class paper into the teacher’s desk tray)
• Place an object within 1 inch of other objects with- some areas are omitted or addressed only briefly when
out disturbing these by using minimal finger exten- a shorter session is used or when intervention is being
sion (e.g., a glass on a table or a container in a provided in a classroom setting or through consulta-
medicine cabinet) tion. However, the therapist always needs to consider
• Release objects while maintaining the forearm in the intervention setting and its features (the environ-
midposition to allow for upright object placement ment), attempt to create a supportive physical environ-
SAMPLE SHORT-TERM GOALS FOR IN-HAND ment, and develop or provide cognitive and social
MANIPULATION supports for the child’s performance. In addition, the
The child will: child’s positioning and ways in which the skills may be
• Use shift skills in handling fasteners on clothing
integrated into occupational performance must be con-
• Use shift skills in managing paper for cutting with
scissors sidered for each intervention session. Box 12-2 lists a
• Use translation and shift skills in handling money typical sequence of areas that may be addressed within
• Use simple rotation (or complex rotation) to an intervention session that focuses on hand skill
position a crayon or pencil appropriately in the hand problems.
• Use simple rotation to open and close bottles
• Use translation skills (with or without stabilization)
to finger feed effectively A Typical Sequence of Areas That
SAMPLE SHORT-TERM GOALS FOR BILATERAL May Be Addressed Within an
HAND SKILLS BOX 12-2
Intervention Session That Focuses
The child will: on Hand Skill Problems
• Carry objects with both hands (e.g., carry a bag of
groceries or a tray of food)
• Stabilize an object using grasp, while manipulating 1. Positioning of the child and the therapist
with the other hand (e.g., grasp a crayon box while 2. Tone and postural/proximal control
putting crayons into it) 3. Tactile/sensory awareness/discrimination
• Stabilize materials effectively with one hand while 4. Isolated arm and hand movements
manipulating with the other (e.g., stabilize paper 5. Grasp
effectively with one hand while handwriting) 6. Voluntary release
• Manipulate objects with both hands simultaneously 7. In-hand manipulation
(e.g., shifting paper with the nonpreferred hand 8. Bilateral hand skills
while using scissors to cut with the other hand) 9. Integration of skills into occupational performance
In sessions that focus on improving the child’s hand For these hand skills to be carried out in the prone
skills in one or more of these areas, the therapist’s role position, activities that require a relatively small range
is to: of movement must be used. Children usually can
• Address positioning for task engagement use a wider range of movement in sitting or standing
• Select materials that allow for ease of handling positions.
• Provide sufficient time for task completion Sitting at a table is often preferred over other posi-
• Use (if appropriate) cuing for these hand skills tions for hand skill intervention. When a table is used,
While promoting improved motor control, attention it should be at or slightly above elbow height. Using a
also can be given to addressing tactile or proprioceptive lower table tends to facilitate upper trunk flexion, which
awareness and discrimination, as well as related per- promotes humeral internal rotation. Using a higher
ceptual and cognitive, play, and social skills. table places the child’s arms in abduction and internal
rotation. Internal rotation leads to use of elbow flexion,
POSITIONING OF THE C HILD AND THE pronation, and wrist flexion. A table at elbow height
makes it possible for the child to use humeral adduction
THERAPIST and slight external rotation, which make supination
Positioning should be specifically selected to present and wrist extension easier to use.
the type of postural support or challenge that the Sitting in a chair without a table (or for some
therapist believes is most desirable for the hand skills children, sitting on the floor or on another surface) also
that will be addressed. In a specific session, it may be may be useful, particularly if the goal is to improve skill
appropriate to work on a particular skill first with the in moving objects in space while maintaining a good-
child in a relatively non-demanding position, then work quality grasp. When a table is not in front of the child,
on the same skill in a somewhat more posturally the therapist often has more opportunity to do both
demanding position. For other children, working with proximal and distal handling to facilitate the child’s
them in the position in which they will be using the movements into external rotation, elbow extension,
hand skill(s) being emphasized is the better option. supination, wrist extension, and finger flexion or
The most commonly used position for intervention and extension.
functional use of fine motor skills is sitting; standing is Standing is an important position to use when
the next most common body position for use of hand working on some hand skills if the child has the
skills. Supine, side lying, and prone may be used for postural control to manage standing and hand use.
their therapeutic benefits, particularly with children Generally, children find it easier to develop a degree of
who have limited skills or need to improve proximal proficiency when carrying out the skills in sitting, then
stability. to begin using these skills in standing. Examples of skills
For the child with very limited motor skills, the most that may benefit from a sitting to standing progression
appropriate position for working on arm-hand skills are buttoning, engaging the bottom of zippers,
may be supported supine or supported side lying. In brushing teeth, and handling money. For many of these
these positions skills such as visually looking at the skills the child initially may find it easier to accomplish
hand(s), using a palmar grasp pattern, sustaining grasp the fine motor tasks while standing by leaning against a
during arm movements, sustaining grasp with the wrist surface to obtain some stability. Gradually the use of
in neutral extension, reaching followed by gross or this support surface may be decreased.
palmar grasp, and using crude voluntary release may be
addressed. TACTILE OR SENSORY AWARENESS OR
The prone on elbows or forearms position can be
useful for assisting children to develop selected hand
DISCRIMINATION
skills. If the child has some difficulty with stability, Because a sensory problem, if present, is a major factor
emphasis may be placed on the child co-contracting at in use of hand skills, attention to tactile or propriocep-
90 degrees of elbow flexion, without pulling into more tion is a central element—and may be the major
flexion. Being able to sustain a position of 90 degrees focus—of a hand skill intervention program for many
elbow flexion is helpful for effective hand use in most children. For children with tactile defensiveness, the
tabletop activities; in addition, some standing activities therapist should begin intervention with a focus on
require that the forearm remain on or near the work decreasing tactile defensiveness, because children with
surface. To stabilize materials the nonpreferred hand tactile defensiveness are aversive to any other inter-
needs to exert pressure into elbow extension while vention activities if they are intolerant to touch from
maintaining 90 degrees of elbow flexion. In addition, objects or the therapist. Activities involving firm pressure,
forearm supination and grasp with the wrist in neutral including weight bearing, pushing large objects with
or slight extension may be addressed in this position. the hands, and squeezing objects, can be useful in
quality of grasp did not improve as a result of the

Some Typical Activities Used for
weight-bearing intervention. Thus the components
BOX 12-3 Sensory Awareness and
that changed as a result of the weight-bearing interven-
Discrimination
tion were those inherent in the weight bearing itself.
These components are important for good-quality
1. Rubbing lotion on the fingers one at a time hand function and should be emphasized. However,
2. Finding objects in beans, rice, or sand (graded intervention that specifically focuses on supination and
finger movements are used to get the grains of rice
hand function is needed also. The focus of the re-
or sand off the objects)
3. Pulling pieces of clay off a ball of clay mainder of this chapter is primarily on using structured
4. Pushing fingers into therapy putty or clay activities and some degree of handling to address
5. Stretching rubber bands around the fingers children’s hand skill problems.
6. Playing games to identify objects held in the hand
ISOLATED ARM AND HAND MOVEMENTS

Children often find it easier to work on a new move-
dampening the over-responsiveness to light touch that ment component (a) in isolation from other movement
is common during grasp, release, and manipulation components, (b) when not handling objects, or (c) when
activities. handling well-stabilized objects as compared with using
For all children who have a program for hand skill the movement component within an activity that has
intervention, attention to tactile discrimination can objects that are not stabilized.
precede and also be incorporated into a variety of For example, supination and pronation, wrist flexion
activities designed to enhance hand skills. However, and extension, and MP flexion and extension with IP
when the child has significant tactile discrimination extension may be addressed by playing a game with the
problems, the therapist should make sensory issues a child in which the child is tapping the table, or his or
key focus during an intervention session, rather than let her leg, or a drum and is only using the desired upper
tactile input be only another dimension of the motor extremity motion. The therapist may assist the child to
activity as it can be for children with milder sensory stabilize a more proximal body part (e.g., the humerus
problems. if using supination or pronation, the forearm if using
Typical activities used for sensory awareness and wrist extension or flexion, the dorsum of the hand if
discrimination are included in Box 12-3. using MP flexion or extension). The therapist also may
assist the child with actively using internal rotation,
TONE AND POSTURAL OR PROXIMAL pronation, and wrist flexion, because even children
who tend to hold their arms in these patterns have
CONTROL functional difficulty using active internal rotation,
Postural control is a significant consideration in inter- pronation, and wrist flexion. They need assistance in
vention with many children who have hand skill diffi- developing control over the movements, as well as
culties. Head control, trunk control, prone skills, and assistance in holding in a more externally rotated or
sitting skills often are problem areas for these children. extended or slightly supinated position.
If the therapist has specific goals or the child needs Supination is a particularly difficult movement com-
intervention to allow for more effective hand place- ponent for children with abnormal tone. Even children
ment in space, postural control needs to be addressed with only slightly low tone tend to stabilize in full
next. Boehme (1988), Nichols (2005), and Exner pronation when engaging in fine motor tasks. Full
(2005) provide activity suggestions for this area. pronation is functional for palmar grasp patterns, but
Barnes’ studies (1986, 1989a,b) have provided some use of pronation when precision grasp patterns or
empiric data in support of using upper extremity weight object manipulation are needed interferes significantly
bearing to improve hand function in children with with thumb mobility and distal finger control. Being
spastic cerebral palsy. In her single-subject studies she able to hold various degrees of supination is critical for
found that extended-arm weight bearing increased the higher-level hand skills. Full supination is helpful in
children’s use of wrist extension for initiation of grasp performing activities, but the most important range of
and during voluntary release. In her first study (1986), supination for functional skill use is between full
she found that reach with an extended elbow also pronation and midposition. The ability to hold at any
increased after weight-bearing intervention. In a later point within this range is important. During most skills
study (1989a), she did not find an increase in elbow that involve controlled use of the radial fingers and
extension but did find an increase in index finger thumb, the forearm is in approximately 30 to 45 degrees
extension during initiation of grasp. Supination and the of supination.
Intervention to enhance use of supination can

include positions and activities in which supination is
easiest to use versus those in which it is more difficult
to use. Supination is easiest when the humerus is
adducted (close to the side of the trunk) and the elbow
is flexed. When the humerus is in 90 degrees of flexion
and the elbow is fully extended or when the humerus is
in full horizontal adduction and the elbow is extended
(as in crossing midline), supination is more difficult to
elicit.
Planning intervention for supination may use con-
cepts from the process that normal babies appear to use
in developing supination control. In normal develop-
ment, babies first use supination when the elbow is in a Figure 12-1 Therapist facilitates the child’s use of
great deal of flexion. Supination can be observed as supination by providing stability at the ulnar border of the
child’s forearm and cues the child to look at the object in
babies bring their hands and toys to their mouths when
the hand.
in supine, and in supported-sitting and prone-on-
forearms positions. In the latter position they also
begin to move the forearms from full pronation into the child attempts to compensate for difficulty with
varying degrees of supination while weight shifting. supination by using wrist hyperextension.
Gradually babies use more supination in sitting with 3. Encourage the use of 45 to 90 degrees of
the elbows in about 90 degrees of flexion. For example, supination followed by grasp of an object with the
by about 8 or 9 months of age, the normally devel- elbow in 90 degrees of flexion, with at least the
oping baby can bang two objects together; this skill elbow supported on a surface. The object should
illustrates at least two aspects of motor development be presented in a vertical orientation to facilitate the
(and other areas of development as well): the ability to use of forearm rotation. Some children respond
use a finger surface grasp and the ability to hold at least well to the verbal cue “keep your thumb up”
one forearm in midposition so that the surfaces of the because this provides them with visual information
two blocks can come together. In another month or about the desired arm or hand position. The child
so the baby is able to clap the hands together, thus may be encouraged to sustain this position if he
demonstrating the ability to sustain full finger exten- or she must transport the object a short distance
sion with supination to midposition in both hands. before placing it into a container or board that
Babies also begin to use this range of supination (0 to requires the forearm to be held in supination. An
90 degrees) to carry out simple activities such as example of this sequence is reaching and grasping
holding a cup, finger feeding, and visually inspecting large birthday candles, then putting them into a
objects they are holding. The baby now can reach with pretend cake. If the child can accomplish supination
supination to midposition. When the baby is reaching to midposition with both hands, banging objects
laterally (using abduction), a greater degree of supina- together may be possible. He or she also may be
tion may be observed as compared with forward encouraged to hold large blocks or nesting cans by
reaching (using shoulder flexion). putting one hand on either lateral side of the block
Specific suggestions for enhancing supination, in or can and stacking these. In this activity the child
general order from least to most difficult, include the is being asked to supinate, then initiate grasp and
following: maintain the supination while engaging in a simple
1. Encourage mouthing of toys (if age appropriate) activity.
and finger feeding. 4. Encourage lateral reach followed by grasp. Most
2. Facilitate supination with the forearm on a surface, children with limited use of supination find it easier
such as in weight bearing on the floor or on a mat to combine humeral abduction with external
or while seated at a table. While the child is sitting, rotation and supination than to use humeral flexion
the therapist may find it helpful to place an object with external rotation and supination. Perhaps
in the child’s hand with the child’s forearm objects initially should be presented laterally to the
pronated, then use his or her hand to stabilize the child’s body to allow the child to use abduction but
ulnar border of the child’s forearm so the child has to move out of internal rotation (and into external
a surface to work against for the rotation (and so rotation), which allows for the use of supination.
that the child can see the object placed in the hand) Objects may be presented low (relative to the
(Figure 12-1). This strategy also may be helpful if child’s body) initially and gradually raised higher
begin at one level, then to move up one or even two

levels for a few object presentations within a session.
When the child has difficulty maintaining skill at the
higher level, the therapist should move back down to a
lower-level skill. Most sessions consist of using two or
more levels, with the therapist helping the child to
develop greater competence at the lower level and to
explore a level that is slightly more challenging.
G RASP
In clinical practice, intervention for grasp problems
generally is interwoven with intervention for voluntary
release problems or in-hand manipulation problems.
However, to support clarity of intervention descrip-
tions, strategies for each of these skills are addressed
separately.
In preparation for addressing grasp skills with a
Figure 12-2 An object is presented laterally to the child, the therapist should:
child’s body and lower than shoulder height to facilitate 1. Assess the child’s current use of a wide variety of
the use of external rotation and supination during
reaching. grasp patterns, and
2. Determine the problem(s) most interfering with
one or more functional grasp patterns.
The more specific the analysis of the problems
(Figure 12-2). The therapist may find it possible to affecting the child’s hand function, the more specific
gradually present objects diagonally to the child’s can be the intervention. The therapist needs to deter-
body (in 60 degrees of horizontal abduction, then mine if an opposed grasp pattern is possible for the
45 degrees, then 30 degrees) to assist the child in child, and if so, the sizes of objects with which it can be
moving toward a more anterior reaching pattern. used (e.g., larger, medium-size, or small and tiny ones).
5. Encourage forward reach using shoulder flexion Some children can functionally use an opposed grasp
and some degree of external rotation. The object is pattern on larger objects but not on small or tiny ones
positioned in front of the child’s shoulder, not at mid- because of the lesser degree of stability that these
line. The object may be placed anywhere between the objects provide and the necessary index finger control.
child’s leg (in sitting) and the shoulder, depending For some children, use of the intrinsic muscles of the
on the child’s ability to control external rotation hand is particularly difficult. These children may be able
and supination while completing the reach. With to use the long finger flexors and extensors (e.g., a
increasing height of the object in front of the child’s palmar or hook grasp) but be unable to effectively use
body, the child will have a greater tendency to sub- the intrinsic muscles of the hand to allow for more
stitute with shoulder elevation, humeral abduction, variety and function in grasp. Difficulty with intrinsic
and internal rotation. Positioning of the object at muscle control may be particularly obvious if a child is
the optimal height for the child and using slight unable to hold a ball using a spherical grasp (which
facilitation at the child’s elbow to help the child requires the combination of long flexor activity with
initiate and complete the external rotation during dorsal interossei and lumbrical activity) or to hold a
the reach may help the child to achieve the supina- piece of paper with a pattern of MP flexion and IP
tion needed. extension (which requires use of the palmar interossei
6. Encourage reach to midline, following the strategies and lumbricals). In addition, many children lack
suggested for reaching in front of the shoulder. adequate thumb stability for opposition; instead they
7. Facilitate reach across midline, following the substitute with thumb adduction. Some children are
strategies suggested for reaching in front of the unable to activate any thumb abduction or opposition
shoulder. as their thumbs are pulled into adduction by an over-
The therapist who is working with a child on active adductor pollicis.
supination, as with any other skill, needs to be sensitive In addition to the outcome of an analysis of the
to the child’s zone of proximal development in child’s functioning, information from an analysis of the
determining the most appropriate level or levels for use child’s functional needs should be considered in deter-
in intervention. The therapist may find it possible to mining the types of grasp patterns to be emphasized in
intervention. Some children have an adequate grasp proprioceptive input to the child’s arms and hands can
with the finger pads but are not able to effectively use be used directly with this technique. Emphasis on arm
a full palmar grasp pattern for many dressing activities. movements often is most easily accomplished with the
Some children have only a palmar grasp pattern and child supine. In this position the child can be provided
thumb adduction, so they cannot pick up small or tiny with opportunities to see his or her hands and bring
objects in a functional manner. Thus activities such as both hands together, which are simple activities that
finger feeding, cup drinking, and fastener use are nega- these children have had little opportunity to do. As the
tively affected. Grasp use within functional activities, child brings the hands together, the therapist can
not only grasp on standardized test items, should be encourage the use of supination with elbow flexion.
assessed as a basis for intervention planning. The child may be assisted with touching stuffed animals
with fisted hands, an activity that does not require that
General Intervention Principles for Grasp the hands be open. Activities that encourage the child
The following general principles are suggested for to dissociate the two sides of the body may be
intervention for grasp problems. incorporated, such as having the child touch the stuffed
If fisting is a problem, voluntary hand opening needs animal’s ear with one hand and his or her own ear with
to be developed before setting any other goals for grasp. In the other hand. In this way one elbow is more extended
children who have limited ability to voluntarily open and the other is more flexed. The child may be
their hands, the priority is voluntary hand opening and encouraged to assist with rubbing lotion on one arm
being able to sustain some degree of finger extension with the other hand to facilitate crossing midline and
with arm movement (if this seems to be within their hand contact on the body while the elbow position is
zone of proximal development). For children whose changing.
hands are held in a fisted position and who need During these activities to promote active arm move-
maximal assistance in obtaining and even briefly main- ment, the child’s hand often begins to open or at least
taining hand opening, the goal of grasp intervention is becomes less fisted, and the therapist can begin activities
a greater degree of voluntary hand opening and, if to encourage a full palmar grasp pattern and facilitate
feasible, initiating and sustaining a palmar grasp pattern changing arm positions while maintaining this grasp. If
with changing arm positions. the child’s fingers and thumb remain somewhat flexed,
Upper extremity weight bearing may be used to techniques recommended by Boehme (1988) for
facilitate finger extension with wrist extension, but in facilitating hand opening may be used.
children who have marked fisting, weight bearing with Once the child has some degree of hand opening in
open hands perhaps should be used cautiously. Most of a supine position, it may be possible to change the child
the children with marked fisting do not have sufficient to a sitting position and carry out similar activities. The
length in their finger flexors to tolerate this position change in body positions often presents the next level
without compromise in the finger positions used. In of challenge to the child. Partial or full weight bearing
this type of weight bearing the therapist must control may be added to reinforce the hand opening, if tolerated
both the thumb, which typically is pulled into by the child.
adduction, and the fingers, which may pull up into a The stability of the child and of the objects used is
boutonniere deformity position. Weight bearing on a critical. The stability of the child, the surface on which
curved surface may be more effective than on a flat the object is presented, and the object itself are primary
surface, or the therapist may wish to consider use of a considerations in planning intervention for grasp. This
weight-bearing splint or other device (Smelt, 1989). principle is supported by the findings of Hirschel,
Weight-bearing activities that do not ask the child to Pehoski, and Coryell (1990). In their study babies who
assume full body weight may be more effective. An were beginning to develop control of a particular grasp
example with the child in a sitting position is to assist pattern were most successful when grasping from a very
the child with hand opening, then move the arm into firm surface and less successful from an unstable sur-
an extended position so that the hand is placed on the face. As the child improves in his or her ability to grasp
floor or to the side or front on a wall surface. This type from a surface, the therapist can grade the activity by
of position may allow for some degree of weight providing less and less stability.
bearing while minimizing the abnormal positioning of Object characteristics and orientation of objects
the fingers and thumb that may occur in a full weight- during presentation are important variables. The size,
bearing position. shape, weight, texture, and slipperiness of the objects
Rather than focusing specifically on hand opening, selected for use in intervention must be given careful
encouraging a greater range of arm movements while consideration. Round objects, such as dowels, tend to
remaining as relaxed as possible may help the child to be held in a palmar grasp unless the child has good
open the hands and maintain them open. Tactile or stability in the fingers and thumb and can maintain a
grasp pattern by opposing the thumb to several finger Children benefit from developing skill in carrying
pads. Therefore many children can handle blocks and objects while maintaining quality of grasp before using
other objects with straight sides more effectively than that grasp within an activity. Many children have
they can handle round objects. Children who do not difficulty transporting an object while sustaining a
have good internal stability in their hands should not good-quality grasp pattern. The child can be assisted in
be expected to hold unstable objects (round, squishy, developing the ability to maintain a stable grasp pat-
or lightweight ones) with control in any pattern other tern, transport the object in space, and release it. After
than a palmar grasp. this skill is developed, the child is more prepared to
Grasp of small or tiny objects should not be a initiate and use the grasp skill within a more challeng-
priority for all children. An opposed grasp can be ing activity.
introduced to the child with larger objects, particularly Inconsistency in performance is to be expected. As skills
if the child has sufficient hand expansion to accom- are emerging, inconsistency in execution of the skills is
modate the object. An opposed pattern is used to grasp common; therefore consistency in performance is to be
items such as a cup (a cylindrical grasp), a ball (a expected. This clinical observation is supported by
spherical grasp), a telephone, and a large block. In empirical data on development of grasp patterns in
many of these opposed grasp patterns the thumb is nondysfunctional infants. Hirschel et al. (1990) found
opposed to two, three, or all four fingers. Some that normal 13- to 14-month-olds were consistent in
children with disabilities can be assisted in developing the pincer grasp pattern they used. However, 7- to 8-
skilled use of all types of opposed grasp patterns, as well month-olds and 10- to 11-month-olds tended to use a
as the power grasp and the lateral pinch. Therefore the variety of grasp patterns when attempting to obtain the
pincer grasp need not be considered the highest level or object.
most important grasp. For many children less attention
should be paid to the pincer grasp and more attention Developing Radial Finger Grasp Patterns
given to helping them develop a variety of functional The following strategies are useful for children who can
grasp patterns. voluntarily grasp and release objects but who:
Supination and wrist stability almost always need 1. Lack good quality in one or more grasp patterns, or
attention. Problems with supination tend to be evident 2. Are not able to use grasp patterns involving distal
when the child needs to use grasp patterns that require finger control.
more precision, such as a three-jaw chuck (see Glossary), These radial finger grasp patterns include a lateral
a pincer, or a lateral pinch. These problems may be pinch or grasp with one or more fingers contacting the
addressed through use of the strategies suggested object and thumb opposition. Further preparation of
under Isolated Arm and Hand Movements. Problems the hand may be needed before using these strategies.
with wrist stability must be addressed before or in con- Objects selected should be appropriate for the grasp
junction with specific interventions for grasp. Wrist pattern being addressed but also should be presented
stability may be addressed through use of weight- within the context of an activity that the child finds
bearing techniques and through emphasis on devel- interesting. In the following sequence the emphasis is
oping a palmar grip (Boehme, 1988). Wrist extension first on assisting the child with grasping, although not
tends to be used more when holding objects in a full asking the child to reach. Objects initially are stabilized
palmar grip than in patterns with only the finger well when presented, then gradually presented with less
surfaces or pads involved. The size of the object to be external stability, in response to the child’s develop-
used for a palmar grip perhaps should be explored with ment of internal stability. Gradually reach and grasp are
the child; some children use more wrist extension with combined.
small-diameter objects, whereas others use more wrist The therapist should assess the grasp patterns used
extension with somewhat larger-diameter objects. by the child at each of the levels to determine the best
Emphasizing better-quality grasp without reach is place to begin therapeutic intervention. Not all children
likely to be more successful than combining reach and should begin at the first level described in the following
grasp. Grasp can be addressed in an intervention session sequence. In a session the therapist may find it useful to
without asking the child to first reach, and then grasp. move back and forth between two or three levels. For
When reaching before grasp, the child must preposition example, the therapist may give three object presenta-
the hand during movement of the arm, which is usually tions at level 2, then, finding that the child’s perfor-
moving against gravity. Generally, children show better mance has deteriorated slightly, give two or three
wrist, finger, and thumb prepositioning for grasp when presentations at level 1, then give a few at level 2 again.
the object is presented close to the hand so that arm It then may be possible to give a few presentations at
movement is not needed simultaneously with hand level 3 before finishing that aspect of the session with
movement. other object presentations at level 2.
notes the quality of the pattern used and determines

if other handling would be useful, if the child would
benefit more from greater repetitions at the preced-
ing level before trying this level again, or if this type
of presentation should be used again.
Level 3: Grasp from surface, near body with object in
front of shoulder, not midline. Now the object is
placed on the table surface, which provides it with
less stability than does the therapist’s hand. The
child’s arm position is similar to that used in the
previous two levels. The therapist may find it helpful
to place the object on a nonskid surface or stabilize
the object slightly with the fingers. The child needs
to control the positioning of the hand more in
preparation for grasp at this level.
Level 4: Grasp from surface, further from body with the
object in front of shoulder. At this level the child
begins to combine supported reaching with prepa-
Figure 12-3 To promote use of an opposed grasp
ration of the hand for grasp. Hand preparation is
pattern, the therapist stabilizes the dorsum of the child’s often better with the object in front of the shoulder
forearm and presents an object held with her finger pads because this position allows slight supination to be
directly to the child’s fingers. more easily used.
Level 5: Grasp from surface, near midline. The child
now begins to work on grasping at midline while
Level 1: Grasp from therapist’s fingers. The child is in a controlling the hand, forearm, and elbow position.
sitting position (usually in a chair) with the humerus The child is still not expected to control the humerus
adducted and the forearm stabilized on his or her leg against gravity while initiating the grasp pattern. The
or on the table surface. The child’s hand is in front therapist needs to explore the best distance from the
of the shoulder, not at midline. The therapist holds child’s body for the object. Typically a distance that
the object in his or her fingers and places the object incorporates 120 degrees or more of elbow extension
just at the child’s fingers (Figure 12-3). The child is helpful initially. Then this distance can be varied as
positions the hand for grasp, then grasps the object the child develops increasing skill.
and carries it a short distance before voluntary release. Level 6: Grasp with object off surface. At this level the
The therapist notes the degree and quality of wrist child needs to control the humerus against gravity,
extension and finger and thumb positioning in the including the degree of external rotation used. At the
grasp. If the child does not use sufficient wrist exten- previously described levels, external rotation and
sion, the therapist may find it helpful to stabilize the supination could be assisted by the surface. Now the
dorsum of the child’s forearm and to hold the object therapist’s positioning of the object can help the
just slightly higher for the next object presentation. child orient the arm into slight external rotation and
If the fingers are too flexed, other preparation of the the forearm into slight supination (as described in
hand to decrease tone may be needed before the next the section on supination). Again, distance from the
object presentation. If the quality of the pattern child’s body can be varied, as can positioning of the
appears good, the therapist will probably find it object in front of the child’s shoulder or at midline.
helpful to give several other presentations in this Additional intervention strategies may be needed for
manner to ensure that the child can consistently the child who is working on grasping and holding flat
maintain this quality before moving to the next level. objects by using MP flexion and IP extension of the
Level 2: Grasp from palm of therapist’s hand. The child’s fingers and thumb opposition or adduction. Activities
arm and hand are positioned as in the first level. The that involve finger adduction with extension, such as
therapist positions the object in the palm of his or rolling out clay while keeping all fingers together and
her hand with the hand sufficiently cupped to straight, finger games that involve finger abduction and
stabilize the object. Then he or she places this hand adduction, squeezing balls of clay until they are flat by
just under the child’s hand. In this way the child is using the thumb pad against the entire pad of the index
required to position the hand for grasp and grasp the and middle fingers, shaking dice in the palm of the
object that is just slightly less stabilized than when it hand by cupping the hand (curving the transverse
was in the therapist’s fingers. Again the therapist metacarpal arch and the carpal arch), and games or
Figure 12-4 Use of a thick, flat object may assist the Figure 12-5 Young child demonstrates use of a palmar
child in developing grasp with metacarpal-phalangeal grasp on a “tool.”
flexion and interphalangeal extension.
activities that involve holding thick flat objects may be

helpful (Figure 12-4). Verbal cues about the desired
pattern also may be useful in helping the child to
perform the desired pattern.
Developing a Power Grasp Pattern

The preceding strategies may be less helpful in
facilitating a power grasp than they are in facilitating
opposed grasp patterns. Children with poor stability in
their hands tend to use a palmar grasp on tools (e.g.,
knives, toothbrushes, hairbrushes, hammers) rather Figure 12-6 An older child demonstrates use of a
than a power grasp in which the ulnar fingers provide power grasp on a “tool.”
stability for the handle and the radial fingers are more
extended so that they can reorient the tool as necessary finger flexion necessary (and the degree of differen-
(Figures 12-5 and 12-6). Not all children with motor tiation in radial-ulnar finger positions) is less; gradually
disabilities are able to develop a power grasp, just as not the size of this object may be reduced. Similarly, the
all children develop a pincer grasp. However, for those size of the objects grasped with the radial fingers and
children who have the potential to use a power grasp, thumb may be decreased as the child’s proficiency
development of this skill enhances their ability to be increases.
more effective and efficient with many daily life tasks. The therapist also may consider carefully selecting or
Usually children who have some degree of instability in modifying the diameter and shape of objects to be held
their hands but have reasonable thumb opposition and with a power grasp. Tools with thin or rounded handles
finger control in grasping stable objects can develop a are more difficult for the child to grasp well; children
power grasp. with instability may grasp handles that are slightly
Facilitating the child’s use of radial-ulnar dissocia- larger in diameter or have ridges or indentations more
tion within the hand can be helpful in preparing him or effectively. Also the degree of power needed within the
her for use of a power grasp. A useful strategy in this activity should be graded because increased demands
skill development is to assist the child with retaining for power tend to cause the child to move from a more
one or more objects in the middle to ulnar side of the refined power grasp pattern to a palmar grasp pattern.
palm with flexed ulnar fingers while having the child After grasping an object, the child may use the
use the radial finger(s) and thumb to grasp and release object to complete a task (e.g., use a hammer to pound
objects. Initially the object held in the ulnar side of the a nail), use in-hand manipulation to adjust the object
hand might be medium sized so that the degree of after grasp (e.g., turn a key to fit it into a lock), or
voluntarily release the object (e.g., put coins into a

machine to buy a candy bar).
VOLUNTARY RELEASE
Motor control problems with voluntary release typically
result from three key areas of difficulty: (a) poor arm
stability; (b) increased flexor tone, which causes fisting
or difficulty with grasp using the finger surface; and
(c) lack of effective use of the intrinsics. In the latter
case, problems are seen in poor IP joint extension or
poor MP joint control. A typical pattern seen in poor-
quality voluntary release is MP joint extension with or
without IP joint extension. Problems with stability and
lack of extensor activity appropriately balanced with flexor
activity interfere with the effectiveness and efficiency of
voluntary release. Some children with these problems
resort to using tenodesis action by flexing at the wrist
to initiate the voluntary release (and may use the same
pattern to initiate grasp).
Arm instability is often a key contributor to volun- Figure 12-7 Allowing for elbow extension by placing a
tary release problems in children with involuntary move- container on or near the floor may encourage use of
ment or tremors. However, instability also may negatively wrist and finger extension for voluntary release.
affect voluntary release in children with low or high
tone who do not have excess movement. For effective facilitating supination, humeral abduction and external
voluntary release the child needs to release where and rotation may make it easier for the child to use elbow
when he or she wants to do so. The arm is important extension and slight supination, which may in turn
in transporting the hand to the location for release. allow voluntary release with wrist extension to occur.
Holding the arm in a stable position during hand Releasing into a container placed on the floor, or at
opening contributes to accurate timing of the release. least lower than the seat of the child’s chair, also may
Several strategies may be used with children who allow the child with high tone or little voluntary con-
have stability problems that affect voluntary release. trol to learn to take advantage of gravity or at least relax
Upper extremity weight bearing, particularly on the finger flexors (Figure 12-7). Gradually the con-
extended arms, may help the child to develop improved tainer used for release can be brought onto a table
cocontraction at the scapulohumeral area, elbow, and surface (if initially down low), closer to the child’s body
wrist. Reaching activities that involve touching a (if initially further away from the body), and closer to
desired target and holding that position for a few midline (if release initially in front of the shoulder or
seconds also may be helpful, particularly if the reaching lateral to the child’s body). However, these strategies
is done in a variety of planes of movement. For the are unlikely to be beneficial for the child who can
child who has marked instability or needs to function release with adequate control at the shoulder, elbow,
despite some instability, teaching the child to stabilize and wrist but has difficulty grading finger extension.
the arm against the body or on a surface before open- In addressing problems of voluntary release caused
ing the hand may be a helpful compensatory strategy. by poorly graded finger extension, the therapist should
Many of the stability problems that affect voluntary consider the quality of the child’s grasp. Voluntary
release are related to problems with wrist stability release quality can be no better than the quality of the
during finger extension; stabilizing in wrist extension grasp. However, the quality of voluntary release can
allows finger extension without using tenodesis action be poorer than the quality of grasp. Therefore when
and supports accuracy of release. Some children show the child holds an object in a palmar grasp, voluntary
wrist flexion during elbow flexion, but they are able to release is initiated with full extension (or almost full
voluntarily release with the wrist in extension if the extension) of the fingers. If, on the other hand, the child
elbow is extended. For these children, and even those holds an object with the finger pads, he or she may
who have significant flexor tone at the wrist and fingers release with just slight finger extension or excessive
when the elbow is flexed, an effective strategy can be to finger extension may be seen.
facilitate releasing objects away from midline and with Because voluntary release quality depends so much
the elbow extended. As with the strategy discussed for on grasp quality, the two skills often can be worked on
effectively within the same activity. Certainly the position. Also, the therapist can address precise grasp
therapist must address the quality of the child’s grasp in with the child when using the tweezers and other small
intervention for voluntary release problems. For some materials.
children the focus is on decreasing wrist and finger
flexor tone to allow for grasp on the finger surface
rather than in the palm. For other children the
I N-HAND MANIPULATION
emphasis is on enhancing the use of intrinsic muscle In-hand manipulation skills seem to be the most com-
activity to allow for more control in grading both grasp plex of all fine motor skills. In-hand manipulation
and release patterns. For children who have mild involves the adjustment of objects by movements of the
problems, attention to forearm stabilization in a slight fingers so that the objects are more appropriately placed
degree of supination during voluntary release may help within the hand for the task to be accomplished (Exner,
them place objects with more accuracy and without 1990a, 1992). In-hand manipulation occurs within one
bumping other objects with their hands. hand. Five basic types of in-hand manipulation skills
As children develop more control with voluntary have been described (Box 12-4) (Exner, 1992).
release, the therapist can gradually decrease object Each of the in-hand manipulation skills may occur
weight, stability, or size, and the size of the area used with no other object in the hand at the time of the
for object placement. A study by Gordon et al. (2003) manipulation or while the ulnar fingers are holding one
suggests the value of such strategies. They investigated or more objects in the center or ulnar side of the palm
voluntary release skills in children without disabilities (Exner, 1990a, 1992). When other objects are held in
and children with hemiplegic cerebral palsy. The children the hand during manipulation, the skill has the term
released objects onto both stable and unstable surfaces added “with stabilization.”
at two different speeds. Although the children with Although almost any child with a disability that affects
cerebral palsy showed difficulties with coordinating the motor or sensory functioning has difficulty with in-
force needed during release, they did demonstrate the hand manipulation skills, not all of these children are
ability to both improve speed and accuracy with cuing candidates for intervention for in-hand manipulation
and under a condition in which greater accuracy was problems. To be considered for intervention specifically
needed. Because the children also showed subtle for in-hand manipulation problems, the child needs
difficulties in voluntary release with the hand that was to have:
believed to be noninvolved, Gordon et al. suggest that • Index finger isolation
• Good skills in basic grasp and release patterns
“practicing release tasks with the non-involved hand first or including the ability to grasp a variety of objects and
practicing bimanual tasks may enhance performance” (p. 247). to accommodate the hands to these objects effec-
tively. The child needs to be able to grasp objects at
They suggest that the therapist could vary the task least on the finger surface, not only use a palmar
demands to address accuracy and speed separately and grasp.
then introduce activities to combine varying degrees of
accuracy at different speeds. Eliasson and Gordon’s
study (2000) provides some evidence for children with BOX 12-4 Five Basic Types of In-Hand
hemiplegic cerebral palsy being able to improve their Manipulation Skills
grading of the grip forces necessary to allow for a more
accurate release. 1. Finger-to-palm translation: Movement of an object
In keeping with these suggestions, children with from the fingers to the palm
mild motor control difficulties may benefit by using a 2. Palm-to-finger translation: Movement of an object
variety of sizes of objects, including small ones, and from the palm to the finger pads
objects that are less solid (paper balls rather than solid 3. Shift: Slight adjustment of the object on or by the
finger pads
rubber balls, cotton balls rather than paper balls).
4. Simple rotation: Turning or rolling the object 90
Inexpensive toys, which tend to be lighter in weight degrees or less, with the fingers acting as a unit
than sturdy high-quality toys, can be particularly useful. 5. Complex rotation: Turning an object over (turning
Games in which the accuracy of placement is important it 90 to 360 degrees) using isolated finger and
and obvious to the child can be selected or developed. thumb movements
For example, some children’s game boards have large
From Exner CE (1992). In-hand manipulation skills. In J
areas for the game pieces, whereas others have small Case-Smith, C Pehoski, editors: Development of hand skills
areas. Activities that involve the child holding tweezers in the child (pp. 35–45). Rockville, MD, The American
to grasp and release objects may help the child focus on Occupational Therapy Association.
graded pressure and graded release with a steady arm
Other skills that are useful include: in-hand manipulation skills may use these alternative
• Supination to at least midposition strategies to successfully accomplish tasks.
• Thumb opposition Use small objects first with a new skill. Objects that are
• Finger pad grasp patterns small in relation to the child’s hand size are typically
• Radial-ulnar dissociation; this skill is important for easier for them to manipulate than are tiny or medium-
use of in-hand manipulation with stabilization of size objects. For example, children find nickels easier to
other objects within the child’s hand. manipulate than dimes or silver dollars. Pegs that are
In general, in-hand manipulation activities are realistic larger in diameter or length are more difficult to handle
only for children who have mild motor disabilities; than are pegs that are 1 to 11⁄2 inches long and 1⁄2 inch
most children with moderate disabilities lack the ability in diameter. Tiny pegs are difficult to manipulate. In
to use adequate grasp patterns and lack the associated addition, whereas 1-inch beads are easy to grasp, they
intrinsic muscle control to make in-hand manipulation are more difficult for the child to manipulate than are
1
skills possible. ⁄2-inch beads. Therefore when introducing a new skill,
the therapist often finds it helpful to carefully select
General Principles for Developing In-Hand small objects, so that the child can have sufficient finger
Manipulation Skills contact on the object during manipulation but does
The following are strategies that the therapist can use not need to use all fingers to stabilize the object during
in planning and implementing intervention for children manipulation. As the child develops greater proficiency
who have difficulty with in-hand manipulation. in using a particular skill, the therapist can begin to vary
Facilitate the use of the intrinsic muscles in grasp and the size of the objects used by including larger and
other hand functions. Many sensory activities (e.g., smaller objects.
pulling clay) can be done in a manner that facilitates use Use cues to facilitate the child’s use of in-hand manip-
of the intrinsic muscles. Intrinsic muscle activity is ulation skills. Exner (1990b) studied the effectiveness
needed for in-hand manipulation and the grasp pattern of cues in increasing 3- and 4-year-old children’s in-
that is often used upon completion of object manipula- hand manipulation skills. She found that, as a group,
tion. This grasp pattern reflects the child’s degree of the children improved significantly when given either
stability with the intrinsics; in-hand manipulation relies verbal cues to move the objects with the fingers or
on both mobility and stability of joints controlled by demonstrations of the in-hand manipulation skills.
the intrinsics. Emphasis on development and use of a Although the children showed more improvement with
spherical grasp, a pattern that uses a combination of verbal cues for some skills and more improvement in
long flexor activity and intrinsic activity and requires other skills with demonstrations, the use of palm-to-
cupping of the palm, also may be useful. finger translation with stabilization and rotation with
Encourage use of bilateral manipulation and skills stabilization improved with both types of cues. How-
that substitute for in-hand manipulation. Infants ever, not all children showed improved performance
manipulate objects between the two hands (Ruff, with cues. As with other aspects of children’s hand
1984), and young children often use both hands to skills, the children’s zone of proximal development for
turn objects over as well. They also spontaneously use in-hand manipulation should be considered in setting
any supporting surface available to stabilize materials goals. In addition, the therapist needs to determine the
during manipulation attempts. For example, young best mode for cuing for each child. During testing in
children may use a table surface on which to turn a this study (Exner, 1990b) some children who were
puzzle piece, rather than picking up the puzzle piece provided with demonstrations (but not verbal cues)
and turning it within the hand. Use of a supporting seemed unsure of the aspect of the skill that they
surface during attempts at object manipulation allows should imitate. Therefore demonstration cues alone
these skills to begin to emerge. However, as typical may not be as helpful to the child as demonstration cues
children become more proficient with their skills, with verbal cues. Other children may need only verbal
bilateral manipulation and use of a supporting surface cues to remind them to try the skill with one hand.
are used less often and in-hand manipulation is used Consider the sequence of skill difficulty. A general
more frequently. Thus substitution patterns can be sequence of in-hand manipulation skills has been devel-
effective for handling many objects, but they are not oped (Exner, 2005) based on research by Exner (1990a);
efficient, particularly when handling small or tiny Pehoski, Henderson, and Tickle-Degnen (1997a,b);
objects or when both hands should be manipulating Humphrey, Jewell, and Rosenberger (1995); and Yim,
simultaneously (e.g., in shoe tying). Children who have Cho, and Lee (2003). Children use finger-to-palm
the potential to use in-hand manipulation can use translation earlier than other in-hand manipulation
bilateral manipulation or surface support as a transitional skills. Palm-to-finger translation and simple rotation are
stage, whereas children who may not be able to develop somewhat more difficult. Complex rotation is next in
terms of difficulty. Of the in-hand manipulation skills is unlikely to be understood by the child, the therapist
without stabilization, shift is the most difficult, probably needs to rely more heavily on the structuring of the
because of its reliance on good-quality MP flexion activity, for example, using a bank with a narrow slot or
and adduction with IP extension. Generally, children a small container or a small surface that requires the
develop the ability to use an in-hand manipulation skill child to use a precision grasp (e.g., a pincer grasp) to be
with stabilization of other objects in the hand successful with placement.
simultaneously soon after they develop the ability to After the child is able to move objects well from the
use the same skill without stabilization. A list of sug- DIP creases on the fingers, the object may be moved
gested intervention activities for each of the skill areas closer to the proximal IP (PIP) crease but still kept on
is provided by Exner (2005). the index or index and middle fingers (Figure 12-8, B).
Consequently in determining the type of in-hand Eventually it can be placed on the MP crease between
manipulation skills that will be the focus of intervention the index and middle fingers. Finally, objects may be
for a child who has no skills in this area, the therapist placed in the center of the palm (Figure 12-8, C).
will probably find finger-to-palm translation the easiest Some children are able to work on bringing objects
to help the child develop. Verbal cuing to the child to from the ulnar side of the hand to the radial fingers and
“hide the object in your hand” may be helpful in thumb, a skill that is helpful for efficient hand use, par-
working on this skill. Pieces of dry cereal or coins are ticularly in the preferred hand. Common objects used
good objects for the child to hide. when working on palm-to-finger translation are small
If the child is able to use finger-to-palm translation pieces of food or dry cereal, small cookies, coins, game
with a variety of objects, the therapist may begin to pieces, small puzzle pieces, beads for stringing, paper
work on palm-to-finger translation and simple rotation. clips, caps for markers and pens, pegs, and small blocks.
For palm-to-finger translation the intervention strategy Simple rotation skills often can be addressed early in
that tends to be most effective is a backward shaping an in-hand manipulation skill intervention program.
approach. This is done by the therapist initially placing Simple rotation tends to be “simple” because the fingers
the object on the volar surface of the child’s fingers at move as a unit to partially turn the object. These skills
approximately the distal IP (DIP) joint crease and (if may be encouraged by placing an object on the distal
possible) asking the child to bring the object out to the surface of the child’s fingers (the forearm is pronated)
pads or tips of the fingers (Figure 12-8, A). For exam- and asking the child to make the object move into an
ple, a game piece may be placed on the child’s finger upright position. Slight stabilization of the child’s fore-
surface, and the child asked to place the game piece on arm may help prevent the child’s use of forearm rota-
a particular color square on the board. If verbal cuing tion as a substitution for manipulation by the fingers.
A B C
Figure 12-8 A. Use of palm-to-finger translation may be encouraged by grading the activity. Initially the object is placed
on the distal surface of the child’s radial fingers. B. Gradually the object is placed more proximally on the child’s finger
surface. C. After success with more proximal placement, the child may be able to use palm-to-finger translation when the
therapist places the object in the palm of the child’s hand.
Although some supination is to be expected when

executing a simple rotation skill, the focus is upon
eliciting individual finger movements to produce the
movement.
Activities that may be useful for encouraging simple
rotation skills include unscrewing a bottle top, picking
up a pen, pencil, or marker that has been placed hori-
zontally on the surface with the writing end oriented
toward the ulnar side of the child’s preferred hand,
picking up pegs (or a similar object) from a surface and
putting them into a pegboard, and rolling clay between
the thumb and radial fingers. Again, the therapist may
find that demonstrations and visual cues are helpful in A
increasing the child’s understanding of what to do with
the materials. Physically assisting children is easier with
simple rotation skills than with translation skills. The
therapist may assist the child with rotation by placing
his or her fingers over the child’s fingers to facilitate the
necessary finger movements.
For complex rotation skills the therapist relies on
selection of materials that readily facilitate the use of
complex rotation supplemented by cues to the child.
Children should have the attention skills necessary to
focus well on verbal and demonstration cues for com-
plex rotation skills. The ability to respond to cues is
important because it is difficult for the therapist to
physically assist the child with these skills. Games and
imaginative play activities can be used for working on B
these skills, thus allowing for attention to other goals as
well, particularly those that address cognitive concepts
and visual perception. Materials that work well for
enhancing complex rotation include pegs that can be
placed upside down for the child to turn over, cubes
that have pictures on one or more sides and can be
turned to find the appropriate picture for a category of
pictures or a puzzle, a pencil with an eraser that can be
turned over to allow for its use and turned back for
writing again, markers with caps so the cap can be
placed in the child’s hand upside down before the child
places it on the marker, and toy people or figures that
can be inverted on a surface or in the child’s hand and
that should be rotated before placement (Figure 12-9).
When children are first working on complex
rotation, they tend to need a surface for support, both C
for their arms and the objects. Therefore it is easier for Figure 12-9 A. The child is forming a picture with a set
the child if the therapist places the object on a table of puzzle books. He is encouraged to find the side of the
surface. Soon, however, it is usually possible to place block that fits the design being constructed. The therapist
has placed the correct side of the block against the palm
the object in the child’s hand and encourage the child of his hand so that he must use complex rotation to find
to at least start the rotation before using a surface for it. B. Before using the in-hand manipulation skill of
support. Later the child can be asked to use the skill complex rotation, the child must use palm-to-finger
without depending on a supporting surface at all and translation to move the block toward the distal finger
completely finish the rotation before putting the object surface. In that process the block begins to be turned.
C. Having identified the correct side, the child shifts the
down. Once the child can do one complex rotation object out of the pads of the fingers before placement
with an object, the child may be encouraged to attempt with the other blocks. (From Case-Smith, J [2005].
repetitive rotations by turning the object over two Occupational Therapy for Children, 5th ed. St Louis, Mosby.)
times, then three times, and so on. Repetitive rotations

help to develop sustained stability with sustained mobility
(endurance), which is difficult for many children with
low tone.
Shift skills generally require the child to have more
sustained control of the fingers in IP extension;
therefore shift skills are difficult for children who are
unable to sustain this pattern. Some patterns of shift
tend to be easier than others. One shift movement
(e.g., moving a coin from the finger pads to the finger-
tips for placement) is easier than repetitive shift move-
ments (e.g., moving fingers around paper to allow for
cutting with scissors). In an intervention session
children may be encouraged to use single shift move-
ments, then gradually increase the number of shift
movements used. For example, the child who is
holding the fingers on a marker approximately 11⁄2
inches from the writing end may be asked to stretch the
fingers down toward the tip and then move the thumb Figure 12-10 Child shows use of simple rotation with
so that he or she is holding the marker more effectively stabilization by holding two objects in the hand. One
for writing or coloring. object is stabilized by the ulnar fingers, while the other
object is rotated slightly before stringing.
When the child can use a single shift movement, the
therapist can facilitate the use of shift skills to adjust
paper during cutting. The therapist should ensure that
the child can hold the paper with the thumb on top of The easiest in-hand manipulation skill to use with
the paper and the fingers in a relatively extended position stabilization is finger-to-palm translation, because this
on the underneath surface before expecting use of shift. is only slightly more difficult than using this pattern
Index cards may be easier to use than paper, because the without stabilization. It requires the child to keep the
cards are slightly thicker and sturdier than paper (but are ulnar fingers flexed while grasping with the radial
still easy to cut). They also are a good size for shifting fingers, and storing another object in the hand only
and cutting. As the child’s skill in shifting the index card requires movement into finger flexion (which is easier
improves, larger and larger sizes of index cards may be than moving into finger extension). This also seems to
used. Eventually regular paper may be used. be a skill that many young children develop spon-
Fully develop each skill before asking the child to taneously as they try to hold several pieces of cereal,
combine skills within an activity. Children seem to find candy, or small crackers in their hands at one time.
that using palm-to-finger translation immediately before After mastering finger-to-palm translation with
using either simple or complex rotation (e.g., moving a stabilization, most children seem to find it easier to
key from the palm to the fingers, then turning it for work on palm-to-finger translation with stabilization
placement) is much more difficult than using simple or than simple rotation with stabilization. However, the
complex rotation alone. Therefore children should be therapist should explore these with the child, and then
assisted with developing palm-to-finger translation that select the easier skill to work on next. The size of the
does not involve rotation of the object for placement object being held in the hand can be a factor in making
and simple and complex rotation without palm-to- the skill seem easier or more difficult. If it is too small,
finger translation before asking for the combination of a great deal of ulnar flexion is needed, thus increasing
these skills. When both skills are reasonably well devel- the requirement for radial-ulnar dissociation. If the
oped, they may be combined for sequential use. object is too large, the child may need to use the
Fully develop a skill before asking the child to use middle finger to assist in the stabilization, but then will
that skill with stabilization. Stabilizing other materials not have this finger available for manipulation.
in the hand while manipulating an object is quite diffi- Children find it easier to hold one other object in the
cult because it relies on good radial-ulnar dissociation hand than two or more. Initially they also find it easier
of movements and the ability to do the in-hand manip- if the objects to be held are placed in the ulnar side of
ulation skill with only the radial fingers (Figure 12-10). the hand by the therapist. Later they may be asked to
Therefore the therapist should ensure that the child can pick up and move an object into the hand and hold it
use the skill easily before asking the child to hold even there while manipulating another object with the radial
one object in the hand while manipulating. fingers.
Children with mild disabilities may find it possible In bilateral hand skills, the issue of spontaneous use
to learn to use shift with stabilization and complex is particularly significant. Fedrizzi et al. (2003) found
rotation with stabilization, but many children find that children with cerebral palsy had substantial dif-
these skills too difficult. If these skills seem possible, the ficulties with spontaneous object handling in bilateral
therapist may find that one skill is easier than the other tasks. They also tended to show little improvement in
for the child to develop. Shift with stabilization is dif- these skills between the ages of approximately 2 years
ficult because of the need to combine a flexion pattern and approximately 12 years.
in the ulnar side of the hand with a more extended
pattern in the radial side. Thus holding a slightly larger Children with Moderate-to-Severe Motor
object in the ulnar side of the hand may be somewhat Involvement
easier when facilitating shift with the radial fingers and The child who has significant asymmetry or significant
thumb. involvement bilaterally has difficulty with all three
The size of the object being manipulated also is categories of bilateral skills. Even most gross symmetric
particularly important for complex rotation, because skills require that the child be able to spontaneously
complex rotation generally is carried out by the index, open both hands, sustain both hands open or in a grasp
middle, and ring fingers. When stabilization of other position, and use supination to midposition. Although
objects is necessary, the ring usually is not available to gross bilateral skills may be used as part of an inter-
assist in the rotation. Therefore smaller objects are vention program to help prepare the child for other
easier to use for complex rotation with stabilization activities, goals in the gross bilateral skill area may not
than are larger ones. be the most appropriate. When the child has cognitive
skills that make independent performance of functional
tasks important, bilateral skills in stabilizing with and
BILATERAL HAND SKILLS without grasp become a much greater priority.
As with other areas of hand skill development, an Initially the therapist may address either stabilizing
understanding of normal development is helpful in objects with or without grasp. Consideration needs to
selecting goals and planning intervention for children be given to the type of stabilizing that seems to be
who have difficulties with bilateral hand skills. How- within the child’s zone of proximal development and
ever, as in all areas of hand skill intervention planning, the most frequent needs of the child. For example,
the therapist should be guided by judgment about the when stabilizing with grasp, the ability to hold the fore-
most important functional skills for the child now and arm of the stabilizing hand in supination to midposition
in the future. is important. Wrist extension to neutral is helpful in
Babies with normal development initially use gross stabilizing without grasp.
symmetric bilateral skills, such as holding objects with Stabilizing materials without grasp but with an open
two hands, clapping, and banging objects together. Then hand may not be feasible for many children; however,
they begin to stabilize objects with one hand while the they may achieve sufficient dissociation between the
other is manipulating either by holding without grasp two sides of the body to be able to hold materials with
(e.g., holding paper while coloring) or with grasp (e.g., a fisted hand. An important component for this skill is
holding a container during object placement). Later they maintaining elbow flexion at approximately 90 degrees
develop the ability to manipulate objects with both hands so that stabilization with the hand on a surface is
simultaneously (e.g., stringing beads, tying a knot). possible. In stabilizing materials without grasp, some
All children with motor control problems have dif- children can initiate finger extension, but finger flexion
ficulty with bilateral hand skills. Bilateral simultaneous increases during the activity. In this case wrist flexion
manipulation is a common problem; children with becomes a greater problem than finger flexion and
motor disabilities generally cannot use effective in-hand interferes more with effectiveness of object stabiliza-
manipulation with one hand at a time, and certainly not tion. Therefore often in initial intervention for the skill
with two hands at one time. Many children with motor of stabilizing without grasp, emphasis is on holding the
control problems, even subtle problems, also have wrist in neutral extension rather than on finger exten-
difficulty stabilizing an object with one hand while sion. Activities in prone on forearms weight bearing
manipulating with the other hand. Problems may be and in less stressful tabletop activities that involve
seen in stabilizing while grasping an object or stabi- stabilizing materials are often introduced early in
lizing without grasp. Children with marked asymmetry intervention. At times the therapist may ask the child to
in their arm-hand control also find gross symmetric stabilize materials while the therapist does the
skills to be difficult, whereas children with milder manipulation. For example, the child may hold his or
problems typically can use the more basic skills in this her hand on the paper while the therapist draws a
category. picture and asks the child to guess what is being drawn.
Gradually the child is asked to stabilize materials on the sides of the body so that the hands can assume different
surface while doing more with the manipulating hand. functions, and the need to adduct or hyperextend one
Children with marked asymmetry usually need as upper extremity to assist with maintaining good pos-
much attention to the less involved hand as to the more tural control. In addition, as Skold et al. (2004) found
involved hand. Even though the arm-hand with the in their study, many adolescents and young adults with
greater degree of disability seems more in need of hemiplegia do not use the more involved hand in bilat-
intervention, the hand with a mild disability needs to eral activities as they may wish to conceal the move-
be addressed specifically. The child with significant ments of this hand. Intervention typically is directed, at
asymmetry needs a skilled hand to accomplish tasks least in part, on the identified factors and the ability of
unilaterally that other children may do bilaterally. The the individual to learn alternative strategies.
less involved arm and hand have a greater degree of In intervention designed to facilitate spontaneous
potential for meaningful improvement in skill that will stabilization of materials, the therapist may try (and
enhance independent functioning than does the more suggest to others) activities that definitely require the
involved arm and hand. Thus intervention needs to use of one hand for stabilization. A highchair tray or a
focus on both hands. slightly wobbly table may be useful, because materials
Bilateral simultaneous manipulation is rarely a goal tend to be less stable on these surfaces than on others.
for children with moderate-to severe motor involve- Inexpensive toys that are less sturdy than more
ment. Therefore for these children the focus needs to expensive ones may be helpful in encouraging the child
be on developing or improving in-hand manipulation to use one hand to hold materials down. Simple toys
in the hand with less involvement and adaptations or that can be put together without requiring manipula-
compensatory strategies for dealing with other skills if tion of objects in both hands can be appropriate, such
independence in these areas seems possible. The child’s as a padlock that a key can be put into, markers with
cognitive and perceptual skills influence decisions caps to put on, and a box with a lid and objects to put
about the motor skills that seem reasonable for the inside the box. Children who have good sitting balance
child. As Skold, Josephsson, and Eliasson (2004) found may be asked to sit in a chair (but not at a table) and
in their study of adolescents and young adults with hold a cup or other small container with one hand
cerebral palsy, access to a variety of strategies for com- while putting objects in with the other hand. This type
pletion of functional activities is of great importance. of activity may be done while standing if the child has
These individuals reported that although certain good standing balance.
strategies work under some circumstances, alternatives Children with mild or minimal motor involvement
are needed to meet different environmental demands. may be able to work toward accomplishing bilateral
simultaneous manipulative tasks, such as buttoning
Children with Mild Motor Involvement with both hands, tying a bow, and doing craft projects.
Children with low tone and those with milder degrees To do so, they need refined grasp patterns and the
of asymmetry may be able to work on gross symmetric ability to sustain these patterns, in-hand manipulation
skills and become functional with them. Therefore skills with at least one hand and preferably both, and
setting goals in the area of gross symmetric bilateral skill in dissociating the movements on each side of the
skills may be reasonable. Intervention for these problems body. For these children a graded progression of
typically uses a graded approach for decreasing the size activities that require stabilizing materials with a refined
of the objects used (e.g., the size of the ball to be grasp while using manipulation with the other hand,
caught) or increasing precision or timing in the activity and activities that require changing the hand that is
(e.g., holding a stick with both hands to hit a stationary doing in-hand manipulation, may be useful. In these
target, then a slowly moving ball, then a quickly activities children are usually more successful with more
moving ball) or increasing speed of performance. stable materials such as blocks that fit together and
Although children with mild involvement typically other building construction sets before having success
need some intervention for gross symmetric bilateral with unstable materials such as fabric with buttons and
skills, they need more attention to skills involving shoelaces. Once the child is ready to try bilateral
stabilizing with one hand while manipulating with the manipulation with unstable materials, grading also may
other. Many times these children do not spontaneously be used. Large, then medium, then small buttons may
stabilize materials with one hand, yet with encourage- be tried; most children find it easier to button when the
ment or prompting they do so. Intervention depends buttons are low (in their visual field) and on their own
on the therapist’s assessment of the child’s reason(s) for body or on another person’s body so the fabric is well
not spontaneously or consistently stabilizing materials. stabilized. Initially the fabric should overlap in the
Such reasons may include poor sensory awareness of correct direction for the child (right over left for girls,
one upper extremity, poor ability to dissociate the two left over right for boys) regardless of the placement of
the item of clothing. Later this may be varied as well. of a peg to facilitate a finger pad grasp on the peg.
For lacing and tying, thicker (but not inflexible) Therefore it is suggested that although placement of
shoelaces that are just the right length need to be used pegs into a pegboard may be a reasonable activity for
at first; then the thickness of the laces and their length the motor skill element of therapy, a pegboard set may
can gradually be decreased. not be a good activity for engaging the child’s interest
A study by Hung, Charles, and Gordon (2004) or for carryover into real-life situations.
yielded findings that are applicable to intervention for Involvement of parents or caretakers and teachers is
these types of bilateral hand skills. They found that almost always necessary for a child to integrate new
children with hemiplegic cerebral palsy were able to skills into occupational tasks. This involvement needs
complete a task that involved the two hands completing to be more than asking others to carry out specific skills
different activities and were able to alternate hands for with the child. Parents and teachers
the two components of the activity. In this task neither
hand was necessary to execute fine control, and the task “may need to modify their expectations of the child’s performance
was completed at two different speeds. Under the con- abilities” (Gilfoyle, Grady, & Moore, 1990, p. 259)
dition in which greater speed was necessary, the children
showed enhanced coordination. Thus therapists may so the child is able to accomplish activities that are
wish to consider incorporating different degrees of appropriate. To support the child’s performance of
speed into activities, exploring the conditions that may skills, the therapist must address the child’s environ-
yield greater success for the child. ment, as well as the child’s ability to perform specific
skills (Gilfoyle et al., 1990).
I NTEGRATION OF SKILLS INTO OCCUPATIONAL
PERFORMANCE
ADJUNCTS TO DIRECT
The child’s ability to generalize the skills emphasized in
intervention to other times of the day and other set- INTERVENTION: SPLINTING,
tings is a crucial consideration in planning and imple- CASTING, AND CONSTRAINT-
menting intervention. At least some amount of each
session needs to be spent engaging the child in INDUCED MOVEMENT THERAPY
activities that will be done in other situations. Unique
ways of modifying materials and object presentations Using splinting or casting with children requires careful
may work well in intervention with the therapist, but attention to precautions associated with these devices.
parents and teachers often have difficulty presenting Children may have less ability to report discomfort or
materials in the same way as the therapist. Thus typical changes in tone or function associated with the splint
ways of presenting materials also should be used, as or other device, so preparation of the parent or guardian
well as materials that the child has in the home or for use of the device and key factors to observe is im-
school setting. If these strategies are not used, the child portant. Initially, close monitoring of the child’s status
will be asked to generalize a new skill to a new setting with the device is needed, thus leading to scheduling of
with new materials without the therapist to provide frequent check-up sessions with opportunities to gather
presentation in a unique way. Therapists expect skills to feedback from the parent or guardian and the child
be generalized, but this generalizability needs to be about the device and its impact on the child’s arm or
supported by the therapist, not only with instructions hand, their comfort, and their functioning.
and suggestions to the other key adults who will be
with the child, but also in the materials and activities
being used. Therefore intervention sessions need to
SPLINTING
include the specific materials that we expect children to Hand splinting can be an effective adjunct to direct
practice with when they are in other settings. These intervention for hand skills in children. Exner (2005)
activities must be presented in ways that are reasonable provides information about splinting in children,
for children to do on their own or with adults who are including a description of precautions and a summary
not therapists. of the various types of splints and their rationale.
An example of an activity that is commonly used in Additional information about splint types, and their
intervention but has little generalizability is a pegboard uses and construction is provided by Gabriel and
set. A child is unlikely to have a basic pegboard at Duvall-Riley (2000) and Chapter 18. Research on the
home, and a pegboard is generally uninteresting to a use of splinting in children is limited. In a research
child so it is not used in free play. In addition, the child literature review analysis by Teplicky, Law, and Russell
is unlikely to have someone structure the presentation (2002) on the use of upper extremity splinting and
casting with children, they identified a total of four of “learned nonuse,” which refers to the lack of use of
studies that addressed hand splinting. Only two of the a more-involved upper extremity. In this case, the
studies have been published since 1990. However, the person has the ability to use the extremity to some
literature suggests reasonable effectiveness of splinting degree, but finds use difficult or less than successful, so
for children with cerebral palsy, as all four of the studies uses the arm even less. Thus skills are not developed to
reported positive outcomes relative to some aspect of the ability level possible. In constraint-induced move-
upper extremity or hand control. Clearly this is an area ment therapy, emphasis is placed on using the more
for further study. involved upper extremity exclusively for a period of
Exner (2005) identified three broad categories of time; the less involved upper extremity is restrained via
hand splints. A static splint may be most commonly a constraint.
used with children with the most severe disabilities. Several single-subject studies (Crocker, MacKay-
This type of splint sustains the wrist or one or more Lyons, & McDonnell, 1997; DeLuca et al., 2003;
parts of the hand in a particular position. Static splints Glover et al., 2002) and small group comparison
may be provided to support more normal posturing of studies (Taub et al., 2004; Willis et al., 2002) have
the hand or prevent deformities. Some static splints been conducted with children with cerebral palsy. The
have been used to allow for upper extremity weight children in these studies ranged from approximately 1
bearing with a better hand position (Gabriel & Duvall- to 8 years of age and had a splint or a cast placed on the
Riley, 2000). Although children with moderate and less involved arm or hand for between 11 days (Glover
even mild motor involvement may be provided with a et al., 2002) and 4 weeks (Willis et al., 2002), with
static splint, they also may be provided with a dynamic 3 weeks being the most common time period (Crocker
splint or other orthotic device. Dynamic splints are et al., 1997; DeLuca et al., 2003; Taub et al., 2004).
designed to enhance the child’s movement at one or Most of the children had this arm in the cast or splint
more of the joints within the hand. Other devices that while they were awake for 6 hours per day, except in the
are based on neurophysiologic principles for facilitating Willis and associates study, in which the children had
or inhibiting muscle activity may be placed on the child’s the cast on their arms continuously for the month. The
arm or hand. These devices may include the orthokinetic intervention for the more involved arm varied across
cuff, which is designed to facilitate extensor muscle the studies from several hours of highly specific inter-
activity and inhibit flexor muscle activity (Exner & vention per day (Taub et al., 2004) to routine visits to
Bonder, 1983) and the MacKinnon splint (Exner & occupational or physical therapy (Willis et al., 2002).
Bonder, 1983; Flegle & Leibowitz, 1988; MacKinnon, In all of the studies, the children showed substantial
Sanderson, & Buchanan, 1975). change in functioning of the more involved upper ex-
tremity. Most studies reported continued improvement
up to 6 months after the intervention. Although wearing
CASTING the restraint was difficult periodically for some children
Upper extremity casting for decreasing tone and and families (Glover et al., 2002) and dropout occurred
improving hand function has been used in intervention in some studies (Crocker et al., 1997; Willis et al., 2002),
with children with significant disabilities. Studies by meaningful gains in occupational performance were
Yasukawa (1992); Law et al. (1991); Tona and Schneck noted and valued by the families (Crocker et al., 1997;
(1993); and Copley, Watson-Will, and Dent (1996) DeLuca et al., 2003; Taub et al., 2004; Willis et al.,
have shown some empiric support for this approach. A 2002). Clearly further research is needed on a number
study by Law and associates (1997) used group experi- of dimensions of this therapeutic technique, which
mental methodology to study the effect of occupational appears to have substantial promise.
therapy treatment without casting to an intervention
program that included casting. In this study, the benefits
of including casting were not evident. Although SUMMARY
changes may occur in tone or range of motion as a
result of casting, changes in occupational performance Intervention for children with hand skill problems is
may not (Russell & Law, 2003). guided by use of the occupational therapy framework,
in which the overarching factor is the child’s ability to
engage in occupational tasks with greater skill and thus
CONSTRAINT-I NDUCED MOVEMENT THERAPY more effectively fulfill desired roles. In approaching this
Constraint-induced movement therapy and its applica- intervention, many factors must be considered. The
bility to children have resulted in a number of research therapist—in collaboration with the child (whenever
studies in the past several years. This therapy is based feasible), parent or guardian, teacher, and significant
on the work by Taub, in which he identified the issue others—carefully assesses the child’s strengths and
challenges and attempts to determine the major factors

interfering with his or her ability to be successful in a
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Chapter 13
A FINE MOTOR PROGRAM FOR
PRESCHOOLERS
Carol Anne Myers*
CHAPTER OUTLINE self-contained class-rooms, as well as to children who

attend community nursery schools. The children who
VERTICAL SURFACES are in community nursery schools usually receive
MANIPULATIVES related services such as speech and language, OT, and
physical therapy during their after-school hours. Many
The Manipulatives Program of the children who receive OT services have learning
Fine Motor Planning differences that may result in a learning disability diag-
SCISSORS nosis in later years, or mild to moderate sensory pro-
cessing difficulties. Some of the children who receive
DRAWING AND WRITING OT, however, have no area of disability other than a
Hand Preference discrete weakness in fine motor skills. Although the
Activities to Help Develop Pencil Grasp and Control program is comprehensive in the types of OT inter-
vention that are provided, this chapter focuses on the
WHAT MAKES THERAPY EFFECTIVE? fine motor program, which refers both to the use of
CASE STUDY manipulatives, as well as to prewriting skills such as the
use of scissors and drawing implements.
The theoretical rationale for the fine motor program
The activities and suggestions included in this chapter described in this chapter is based primarily on the work
were developed at the Newton Early Childhood Program of Mary Benbow, as gleaned from her workshops and
(formerly the Brookline-Newton Early Childhood publications (see Chapter 15). Her perspective has
Collaborative) in the metropolitan area of Boston. The provided an invaluable foundation on which to base the
program serves preschoolers from 3 through 5 years of work of the program. Many of her ideas for fine motor
age with mild to severe special needs. This chapter activities with older children have been adapted for the
focuses primarily on activities that are used with chil- work with preschool children.
dren who have mild to moderate special needs, but in The philosophy of the fine motor program is based
some cases they may be adapted for use with children on the classic OT theory that intervention should
who have severe needs. enhance the client’s ability to participate in his or her
Occupational therapy (OT) services in the Newton “occupation,” which has
Early Childhood Program are provided to children
who attend integrated preschool classrooms (a com- “long been recognized as a requirement for survival and, to
bination of typically developing children and children varying degrees, as a source of pleasure” (Hopkins & Smith,
who have with special needs), in substantially separate 1978).
The occupation of the preschool child is to be inde-

*Taken in part from Myers CA (1992). Therapeutic fine-motor
pendent and successful in all of the areas of the
activities for preschoolers. In J Case-Smith, C Pehoski, editors:
Development of hand skills in the child. Rockville, MD, American classroom and playground, both with play activities as
Occupational Therapy Association. well as with self-care. Specifically in respect to fine
267
motor skills, the overall goal is for students to be able “the most surprising finding [in the study] was that the
to participate productively in classroom learning therapist’s use of play and peer interaction predicted the fine
centers such as the art area, manipulatives area, and motor outcomes and that among the intervention variables, play
and peer interaction were the only significant predictors”
writing center. Young preschoolers work at mastering a
(p. 378).
variety of manipulatives and simple art projects,
whereas older preschoolers develop the skills to
independently use complex, multistep manipulatives, In addition to providing direct services to students,
and to participate in multistep art projects as well as the occupational therapists consult with parents and
prewriting tasks. Parents and teachers often classroom teachers. Once a child is comfortable with
overemphasize prewriting activities for young pre- the activities in the therapy settings (usually after 6 to
schoolers, while short-changing them on the use of 8 weeks), therapists typically provide recommendations
manipulatives that will develop their overall hand func- to the child’s classroom teachers and sometimes recom-
tion. This overemphasis on “academics” may have been mend that the parents provide a modified home pro-
encouraged by the overall national trends toward gram. Parents should not attempt to mimic the role of
increased standardized testing of students of all ages. the therapist or teacher; rather, parents provide appro-
Windsor (2000) stated that priate materials and naturalistic, enjoyable opportu-
nities for the child to demonstrate and use at home the
“at the preschool level, tool use … and ‘whole body’ play in the skills that have been learned in therapy and school.
environment are preferred to practice with pencils, pens, and Surrounding the child with a team of people who are
tabletop exercises” (p. 19). familiar with the child’s strengths and weaknesses and
who understand the goals of the intervention program
It is critical for parents of students in the program to greatly enhances the therapy process.
understand that all aspects of hand development are
valuable, and that the provision of a rich variety of
manipulative materials will benefit all students as they
move toward developing prewriting skills. VERTICAL SURFACES
To fully assist students in being functional and inde-
pendent with all of the classroom activities, therapists Vertical and slant board surfaces are an extremely
either use materials that are similar to classroom mate- important part of the fine motor program. Benbow
rials, or they borrow materials from the classroom for (1995) emphasized the importance of working on a
the OT sessions. This practice enhances the generaliza- vertical surface to encourage appropriate hand and
tion of skills learned during the OT sessions to the wrist position for fine motor and handwriting skills.
classroom setting, and is particularly applicable in two Both vertical and slant board surfaces correctly position
circumstances: (a) students who avoid fine motor areas the wrist in extension, which supports thumb abduc-
in the classroom because of low self-confidence, and tion so that the thumb can work skillfully with the
(b) students with fine motor planning difficulties. fingertips. Stable wrist extension and thumb opposition
Most of the children in the program who receive OT also facilitate total arching of the hand for skillful
services to address fine motor delays receive them once manipulation of objects. Therefore, providing a vertical
weekly, for 30 minutes, in either an individual or small or slant board work surface is an important modifica-
group setting. The ideal arrangement is to schedule tion that parents and teachers can incorporate as they
sessions with pairs of children who have been carefully work or play with the child.
matched by age and by specific needs. Case-Smith Activities performed above eye level on vertical or
(2000) found that near-vertical work surfaces such as floor and table easels
promote
“occupational therapists’ use of play activities and peer
interaction were important predictors of [fine motor] skill levels “wrist stabilization in extension with precision finger skills”
at the end of the year” (p. 379). (Benbow, 1995, p. 257),
Pairing children for OT sessions provides structure as as well as the development of arm and shoulder mus-
well as peer support to encourage success with challeng- cles. Whenever possible, teachers are encouraged to
ing activities. Having two students work together also provide activity areas in which the children are working
enhances the therapist’s ability to make the activities seem upright (sitting, kneeling, or standing) with their arms
like games rather than exercises. In a study examining and hands moving against gravity at an easel or other
performance outcomes for OT that addressed fine vertical work surface, rather than leaning over small
motor skills, Case-Smith (2000) noted that tables. When children work on a horizontal surface,
A Fine Motor Program for Preschoolers • 269
BOX 13-1 Some Examples of Activities for

Use on a Vertical Surface
1. Making pictures with stickers.

2. Colorforms or Unisets (these activities provide
a board on which to arrange reusable plastic
“stickers,” and they are available in a wide variety of
themes and designs).
3. Feltboards or flannel boards, which permit the
placement of figures depicted in stories or scenes
created by the child.
4. Magnet letters or shapes on a magnet board
(available in story themes as well). Figure 13-1 Tripod grasp with extended wrist, and
5. Chalkboards: Use sidewalk chalk (wide-diameter forearm resting on the surface of a 20-degree slant
chalk) broken into 11⁄2- to 2-inch pieces for children board.
to hold with the tips of the thumb, index finger, and
middle finger. In one favorite activity, the child
draws a design with the chalk and then uses a paint- for a different purpose. Parents also have used these
brush with water to “magically” erase the design. binders as slant boards at home, and often purchase a
6. Geoboards (rubber band designs created on a grid three-hole zipper storage bag that can hold the child’s
of nails). markers inside the binder for traveling. A variety of
7. Painting or drawing.
more sophisticated alternatives are available from many
8. Ink stamping activities.
9. Pegboards, many different varieties (Lite Brite Cube sources, some of which are listed in the Appendix.
uses small pegs and by design is oriented on the Because it is recommended that students use a slant
vertical). board surface well beyond their preschool years, many
parents opt to purchase a more permanent work sur-
face, such as Write-Slant Boards, which provide a helpful
clip at the top to stabilize the paper. The reason older
they often place their wrists in neutral or flexion, which preschool students draw and write on the 20-degree
does not promote skillful use of the intrinsic muscles. slant board instead of the vertical or near-vertical sur-
Switching activities from a horizontal to a vertical faces is because the 20-degree angle encourages students
orientation can transform an ordinary or mediocre to rest their hand and forearm on the work surface,
activity into a powerful tool for encouraging fine motor whereas the vertical and near-vertical surfaces do not.
skill development. With the older students, therapists are encouraging
Many activities can be oriented on the vertical by the development of a tripod or quadrupod grasp, with
placing the materials (e.g., geoboard) on the lower lip accompanying intrinsic muscle movements of the fingers
of a tabletop easel. In the Newton Early Childhood while drawing or writing, which means that the hand
Program, children are expected to work regularly on and forearm must rest on the table (Figure 13-1).
vertical work surfaces. With a minimal amount of modi- Having parents and teachers provide a 20-degree slanted
fication and equipment expense, many activities can be work surface helps students to make the transition from
adapted easily for use on a vertical surface (Box 13-1). drawing with their hands off the table to drawing and
It is beneficial for the shoulder, arm, wrist, and hand writing with their hands resting on the table, as ex-
development of all preschoolers to work on activities at pected. Although older students in elementary school
a vertical or near-vertical surface on a regular basis. For may have developed the appropriate mature writing
older preschoolers who are working on representative grasp, a slant board encourages the ideal posture—an
drawing and writing letters, students use a slant board erect spine—while drawing or writing and enhances
that is at an estimated angle of 20 degrees. A low-cost students’ endurance for completing lengthy homework
way to provide multiple slant board surfaces in a assignments.
classroom is to place 3-inch three-ring binders at the For therapists who are attempting to demonstrate
writing table; the ring side of the binder is placed the value of vertical or slant board surfaces to parents
horizontally toward the middle of the table so that the or teachers, it is helpful to ask children to perform a
slope of the binder slants down toward the edge of task such as a pegboard or a drawing activity on a
the table where the student is sitting. The students use horizontal surface, and then ask them to perform the
these slant board binders as drawing and writing sur- same activity on a vertical surface. The difference in the
faces. They are relatively inexpensive, and are easy for child’s hand position and ability is often dramatically
teachers to store when the writing center is being used evident in such a demonstration. Observing that
difference first-hand helps parents and teachers to

understand why working on the vertical is so valuable.
Examples throughout this chapter illustrate how work-
ing on the vertical or slant board surface maximizes the
therapeutic benefit of the activities.
MANIPULATIVES
Young children, especially 3-year-olds, should spend
more time with fine motor manipulatives than writing
utensils. Sometimes parents and teachers feel that
young children should begin to “practice” with pencils
and markers, but this early practice may result in a poor Figure 13-2 Hyperextended thumb and compromised
pencil grasp, partially because children may be asked web space on lace tip.
to use writing utensils before their hands are ready for
that kind of refined activity. Benbow (1995) specifically finger, and middle finger. These three fingers are
noted that boys tend to avoid fine motor activities in hereafter called the “skill fingers.”
lieu of computer games, while girls who practice with 5. Development of intrinsic muscle movement in the
writing implements at an early age fingers; this kind of fine muscle movement can be
seen when the ulnar side of the hand is stabilized on
“without proper adult attention or supervision” may then the table while the fingers move a pencil to write, or
“adopt pencil grips that are inefficient or even harmful” (p. 255). when the fingers make fine movements to thread a
needle. The intrinsic movements are best observed
Benbow (1988) further noted that in activities that require the tips of the thumb, index
finger, and middle finger to be touching while they
“pencil postures ‘fixed’ early by repeated use at an intermediate are performing small movements of midrange
level of skill will later affect negatively on graphomotor perfor- flexion and extension of the metacarpal-phalangeal
mance when speed and volume demands increase” (p. v). (MCP) joints.
Many so-called “fine motor” activities involve the
Therefore children should be developing their hands use of the hands and fingers, but do not necessarily
for a variety of activities in a variety of positions before elicit the fine motor movements of the intrinsic muscles
they are expected to draw or write with the proper grasp. at the MCP joints. One example of an activity that
In preparation for writing, the hand progresses parents often cite as proof of their child’s fine motor
through the following motor milestones (Benbow, abilities is the use of a computer mouse. The use of a
1995): mouse involves primarily the arm and shoulder muscles,
1. Development of wrist stabilization in extension to with slight flexion of the index finger for clicking the
support skilled finger movements. mouse. (In cases in which the mouse has a scroll wheel,
2. Development of a stable open index finger-thumb the middle finger does use some intrinsic muscle move-
web space when performing skilled activities. The ment to scroll, although students usually point and click
open web space should have a circular shape. This more often than they scroll.) Although skilled use of a
position is frequently compromised in children who mouse is difficult for children with overall upper extremity
have hyperextension of the interphalangeal joint of motor control issues, many students with significantly
the thumb; rather than a circular web space; these reduced fine motor skill with manipulatives are able to
children form a “crescent moon” with a small open- successfully use a mouse. That is because the mouse
ing. The thumb is in a fixed position, thereby making does not require the skilled use of the intrinsic muscles
intrinsic muscle activity difficult (Figure 13-2). of the skill fingers working together with an open
Children with this problem must be monitored thumb-index finger web space; it falls short as a fine
carefully when they perform fine motor activities to motor activity. Adding insult to injury, instead of using
find those activities that encourage the use of the their hands to work a variety of real puzzles, many pre-
thumb in a flexed position. school students with poor fine motor skills work puzzles
3. Development of palmar arches in the hand, on computer screens. Parents and teachers of children
represented by a concave surface on the palm. who have poor fine motor skills are strongly encouraged
4. Development of an awareness of the “skill side” of to limit the child’s time on the computer, and increase
the hand; this means that the child consistently the availability of a variety of concrete materials that
orients skilled activities toward the thumb, index will encourage fine motor skill development.
THE MANIPULATIVES PROGRAM

The primary components of an OT session include
Wake Up Hands, Strong Hands, and Smart Hands.
Therapists’ regular use of these positive phrases is
powerful for students, who quickly learn to use them to
identify the attributes of their activities. Many of the
classroom teachers also provide Wake Up Hands
activities before beginning a fine motor or prewriting
tabletop activity with the older preschoolers.
Wake Up Hands
Wake Up Hands activities provide sensory stimulation
to the hands, including tactile stimulation as well as
proprioceptive/kinesthetic stimulation, resulting in
overall readiness for later activities. A wide variety of
soft objects, including gel-filled balls, rubber animals,
and countless other items are used during Wake Up
Hands. Activities include squeezing the objects, rolling Figure 13-3 Accordion tube toys (“rapper snappers”).
them on the table, rolling them all over the hands (with
each hand taking turns), grabbing them with the
thumb and index finger (pincer grasp), poking them
with either the thumb or index finger, and using them
isometrically by having both hands press the object.
Students also perform a variety of motions with their
hands such as clapping, rubbing, or shaking. A variety
of textures might be provided through materials such
as unscented lotion, powder (including dry Jell-O
powder), and fabrics from rough to smooth. The
therapists also provide rubber bands or elastic sewn
into circles of various sizes so that students can perform
a variety of pulling activities, one finger at a time.
Students seem to particularly enjoy placing the rubber
band in a way that “traps” their fingers, and they enjoy
moving their fingers against the resistance while pre- Figure 13-4 The “caterpillar pop” game using accordion
tending to escape from the rubber band trap. Thera- tube toys.
Band and Thera tubing also can be used for pulling and
stretching activities during Wake Up Hands.
One of the most popular Wake Up Hands activities learn how to position their feet effectively to brace
is the accordion tubes, sometimes called “rapper themselves. This activity can be repeated for several
snappers.” These tubes provide excellent resistance to minutes, as students select a new partner for each
finger, arm, and shoulder muscles when students caterpillar pop (Figure 13-4).
expand the tubes, and provide similar input when they All of the preceding materials are used for sensory
are manually contracted to become small again (Figure stimulation and also for basic practice with motor plan-
13-3). During a game, the tubes can be called cater- ning or imitation games. The therapist demonstrates
pillars; therapists ask students to pretend they are the movement, and the children imitate it. For example,
turning baby caterpillars into big ones, and then back the teacher or occupational therapist can bend the tube
into babies. For a whole-body motion that provides an into a variety of shapes, which the students must then
excellent motor break before a tabletop session, imitate with their own accordion tube. Representative
students pair up and connect their accordion tubes. shapes are best, such as an elephant’s trunk, telephone
They then make the caterpillars “pop” by pulling, tug receiver, window, or crown, so that the children can
of war style, on their respective tubes until the tubes concretely imagine a use for each new shape. After a
come apart with a large popping sound. From a safety few examples provided by an adult, students enjoy
perspective, be sure that the students have enough coming up with their own shapes to suggest. Mean-
space for this activity, as some of the smaller students while, all of the students’ fingers, hands, and arms are
literally fall backward from the momentum until they being stimulated in a positive, enjoyable way.
Another Wake Up Hands activity is “putting on presented as a regular activity, students quickly learn to
your [imaginary] power gloves,” which students can view their hands as strong. Verbal encouragement (e.g.,
either do for themselves or have done by an adult. To “Look how strong you are. You made the rocket fly
put on the “gloves,” each finger is grasped at the across the table!”) helps students to believe that they
fingertip by the thumb and index finger of the other can become stronger through games and activities.
hand, and gentle pressure is exerted as the thumb and Students actually enter a session enthusiastically asking,
index finger slowly travel down to the base of the “What are we doing for Strong Hands today?”
finger. Each finger is stimulated in turn until all 10 are When students have less than average hand grasp
complete, at which point the “gloves” have been put strength, their parents and teachers are encouraged to
on. This provides both tactile and proprioceptive stimu- provide hand strengthening activities naturalistically
lation, and also provides a mental image of powerful throughout the week. Therapists provide beneficial activ-
hands that is a good mindset for students preparing for ities and attitude boosting encouragement, but children
a fine motor task. It is, of course, a more powerful should become stronger through daily activities that are
sensation for an adult to provide the stimulation than a natural part of their routine. A first step for many
for the children to provide it for themselves, although teachers and parents is to discontinue the practice of
with a large group sometimes it is impossible for an performing a task for the child if the child is not able to
adult to get around to each child in a timely fashion. perform it for himself or herself. Adults are asked to say,
Wake Up Hands with 4- and 5-year old children “Let’s do it together” rather than “Let me help you.”
often includes two components: the primarily sensory Even if the adult provides most of the power for the task,
component with the soft objects and varied textures, having the child do even part of it helps to develop the
and a higher-level demand such as finger plays. Many of motor plan for the task and allows the child to use
the students have difficulty isolating individual fingers, whatever level of strength is available to assist. A
and also with imitation and fine motor planning. common example of this situation occurs in the class-
Carefully chosen finger plays tend to be motivating for room when students bring a snack from home. Many of
them, and observing students performing finger plays is the individually wrapped snacks that parents send in with
an excellent way to quickly learn a great deal about students, in fact, are challenging even for adults
their current level of hand development. Choose finger to open. When necessary, adults open these containers
plays that include developmentally appropriate finger hand-over-hand with the students, both to assist them as
motions such as the following: forming a circle with the well as to gauge for themselves how difficult the task
thumb and index finger, isolating the index finger or really is. When students are empowered by participating
the thumb, or forming a cupped palm (see Appendix in the task from the start, they are much more likely to
for a good source of finger plays). Many young students perform the task independently in the future. Activities
have difficulty forming a circle with their thumb and to encourage hand strength are listed in Box 13-2.
index finger; the circle tends to be flattened rather than In addition to these ideas, strength-based toys
round. These are often the same students who have dif- including classroom building toys such as Duplos and
ficulty forming an open thumb-index finger web space Bristle Blocks also are valuable. Furthermore, therapists
with drawing implements. The finger plays provide an can use a variety of different containers to encourage
additional way for students to practice using their fingers the development of both strength and skill. For
in a variety of positions, and a way for the therapist to example, the OT clinic has a large collection of cookie
visually gauge their progress. For students for whom tin–style containers of varying resistance, and materials
the combination of language and motor planning often are placed inside the containers ahead of time.
demands is too high, therapists have them practice the One of the activities in the session is for the children to
motor component of a finger play separately before open their own containers to see what materials will be
adding the language component. used for the next activity. In addition to cookie tin
containers, therapists use a variety of zipper containers,
Strong Hands screw-top jars of all sizes, Rubbermaid containers,
Although activities from any of the three components plastic lunch boxes, and many others to challenge
of a therapy session may address multiple areas of children’s hands in a variety of functional ways. Using
development, the rationale for labeling the activity is to different kinds of containers, with the expectation that
help students understand its primary goal. The use of what’s inside will be new or interesting each week, has
these specific terms has provided unexpected benefits, provided excellent motivation for students who were
particularly the use of the term “Strong Hands.” The previously reluctant to attempt opening containers on
students with less than average hand grasp strength their own. Hand-over-hand assistance is provided at
are often the students who are least likely to take risks just the right level to encourage students to do as much
with novel fine motor tasks. When “Strong Hands” is as they can by themselves.
“practice of a component skill (e.g., translation) may or may not

BOX 13-2 Activities to Encourage Hand generalize into improved functional performance (e.g., ability
Strength to button). Although task analysis demonstrates that a similar
movement pattern is necessary in object translation and but-
1. Play Dough toning, the therapist cannot assume that in-hand manipulation
a. Use a garlic press to make “spaghetti.” skill will generalize to the task” (pp. 773–774).
b. Use rolling pins to make pretend cookies
Therefore the therapists provide activities that are not
(shoulder and arm strength).
c. Press cookie cutters into flattened play dough. just “OT materials,” but also provide direct experience
d. Find hidden objects such as pegs, marbles, or with typical, age appropriate classroom manipulatives.
toys. Although therapeutic activities that address the com-
Note: Crayola Model Magic or clay also can be used, ponent skills of a task are beneficial, for the most suc-
depending on how much resistance is desired. cessful transfer of learning and skills to the classroom
Homemade play dough provides less resistance than setting, preschool students need the concrete experience
the commercial variety.
of learning to use specific classroom manipulatives
2. Water sprayers (e.g., those found in a drug store for
“spritzing” hair) within the OT session. Following is a list of some of the
a. Spray water onto pictures drawn with markers to most popular Smart Hands activities and manipulatives
make them “melt.” (Note: This activity works used in the program:
best if the markers are relatively new and the 1. Play dough (bilateral coordination, fine motor plan-
drawing has just been completed.) ning, skilled finger use): Play dough can provide
b. Spray a mixture of water and food coloring to excellent strengthening activities for preschool stu-
color snow (in northern climates).
dents, but also can be used to encourage the devel-
c. Spray plants or outdoor bushes.
d. Spray the walls while in the bathtub, with the opment of skills. The following activities are used
shower curtain partially closed. with students who are ready for more skilled use of
3. Geoboards: This is a grid of nails or plastic points. play dough:
Use rubber bands of varying thicknesses to create a. Drawing in flattened play dough using a peg,
designs, or use nylon potholder loops for less resis- b. Rolling play dough balls: There are three levels
tance. (Cotton cloth loops often are too thick to of difficulty available for this activity: (a) using
successfully stay on the points.)
one hand and rolling the play dough on the table,
4. Newspapers: Tear newspapers to stuff a scarecrow or
other classroom project. (b) rolling the play dough between two hands in
5. Wringing out sponges or washcloths (e.g., as part of the air, or (c) using the thumb, index finger, and
a clean-up activity, or in the bathtub). middle finger to roll a small ball, and
6. Squeeze toys such as the Swinging Monkey and the c. Using play dough to make representative objects
Flying Fist (see Appendix for sources). (e.g., rolling a “snake” form and decorating it
with different colors and sizes of pegs to create
a caterpillar; rolling balls and stacking them to
Smart Hands make a snowman, drawing the facial features
Smart Hands manipulative activities typically empha- and buttons using a small stick peg, and then
size multiple skills within one activity. For example, adding two stick pegs for the arms). As students
using a wind-up toy encourages isolated use of the become more skilled in their ability to make a
thumb and index finger, but may also require a sig- variety of shapes, their ability to create complex
nificant amount of finger strength, depending on the creations will increase. Another variation is to
resistance of the particular wind-up toy and on the use small toys with the play dough (e.g., small
shape of the winding knob or key. It is important for plastic babies from the baby shower section of
therapists to be familiar enough with their manipula- a party store inspired students to make cribs,
tives to know which ones are appropriate for 3-year- playpens, diapers, and many other representative
olds, and which ones are more appropriate for 4- or objects from play dough to use with the babies).
5-year-olds. Classroom teachers often need guidance 2. Stringing/lacing activities (skilled grasp patterns,
about this as well. Some of the classroom building eye-hand coordination, bilateral use of hands): Of
manipulatives require more eye-hand coordination all the manipulative activities available to the stu-
than is expected for the typical 3-year-old, and if dents, this has proved to be one of the most valuable.
teachers expect and encourage students to participate Benbow (1995) stated that
in a too-demanding activity, students may begin to feel
that they are not successful with manipulatives. “bead stringing is the classic preschool activity for developing
When referring specifically to in-hand manipulation, speed and dexterity in the alternate use of translation patterns”
Case-Smith (1995) stated that (p. 260).
There are students for whom learning the motor

plan for stringing objects is tremendously chal-
lenging, and they literally might spend many
months practicing this task to master the ability to
place just one large ring onto a 1⁄4-inch diameter
rope. The stringing activity that is selected depends
on the fine motor problem the therapist is trying to
address. For example, some students do not yet have
consistent object permanence, and if the objects
they are stringing are so large that they cannot see
the string emerge from the other side with just one
thrust, they will be unable to imagine how to con-
tinue the activity. Activities (a), (b), (d), and (e)
from the following list are best for these students.
Other students have difficulty with the eye-hand
coordination necessary to place the tip of the string
into the object. Activities (a) and (c) are good
starting activities for these students. Some students
have such difficulty using two hands together that Figure 13-5 One-quarter–inch rope with 11⁄4-inch rings
for lacing.
they benefit from stringing a series of eye bolts on
a wooden shape, because the therapist can help
stabilize the wooden shape with the eye bolts while
the student concentrates on placing the string tip
into the eye bolts. It is best for the student to also
hold onto the wooden shape along with the therapist,
as this enhances the development of bilateral co-
ordination. Three main factors, therefore, should
enter into the therapist’s decision about which
stringing activity is best for a student: (a) the size of
the hole in the object, (b) the length of the hard tip
on the string, and (c) the stability of the object
(e.g., is it fixed or does the child have to stabilize it
in the hand).
Following is a list of efficacious stringing and lacing
activities, in an estimated order of difficulty from
easiest to hardest:
a. Placing 11⁄4-inch rings on a 1⁄4-inch diameter
rope that has duct tape stabilizing the end of the Figure 13-6 Ideal Funtastic Frogs for lacing.
rope. (Note: Oversized rings can be obtained
either from a hardware store or manufacturers’
recyclables; they are not typically available in a e. Inserting a 1-inch hard cord tip through a series
toy store; see Figure 13-5). of eye bolts arranged on a wooden shape (use
b. Placing 1⁄2-inch rings onto gimp (because the pre-drilled wooden basket bottoms from a craft
gimp stays stiff and a pincer grasp is not store and grade the activity based on the size of
necessary). eye bolts placed into the holes; see Figure 13-8).
c. Stringing plastic frogs (Ideal Funtastic Frogs) f. Stringing small “pony” beads.
designed with a small hole on one side and a g. Stringing large wooden beads. The challenge
large hole on the other side (holes range in size with large beads is that several thrusting motions
from 1⁄8 inch to 1⁄2 inch, depending on which of of the skill fingers are necessary to move the
the three sizes of frogs are selected), with a cord string all the way through the bead, which is
that has a 2-inch long hard tip (the different size challenging for many students. Using the
holes allow this activity to be graded at several “thread the needle” motion to push a string
different levels; see Figure 13-6). through a large bead requires skilled intrinsic
d. Small rubber shapes (Lauri “Beads and Baubles”) muscle movements.
with a 3⁄16-inch hole and cord with a 1-inch hard h. Once students have mastered placing individual
tip (see Figure 13-7). objects onto strings, they then transition to per-
Figure 13-7 Rubber shapes for lacing (Lauri “Beads & Figure 13-9 Tops, including a stemless top (“optic top,”
Baubles”) upper left).
do not yet have the dexterity or motor planning

ability to use a top with a stem (see Figure
13-9; the top in the upper left of the picture is
the stemless top).
c. Geoboards: These are mentioned in the Strong
Hands section of this chapter, but they also
encourage isolated use of the thumb and index
finger or, sometimes, just the index finger to
stretch a rubber band down from a top point to
a bottom one. As the designs become more
complicated, this activity also helps develop fine
motor planning ability.
d. Eye droppers: Eye droppers can be used as a
table top activity, at a water table in the class-
room, or in the bathtub at home. Water can be
mixed with food coloring to make “dribble
pictures” by dripping the food coloring onto
Figure 13-8 Eye bolts lacing activity. paper towels or coffee filters. (Note: young 3-
year-olds with fine motor delays usually have
forming tasks that involve more complex difficulty with the motor planning necessary for
sequencing, such as lacing cards. this activity, so it is more often used with the
3. Finger isolation activities (individual finger skill, older preschoolers.)
pincer grasp): e. Tissue paper pictures: The therapist gives the
a. Hopping ants: Use the plastic ants from the children scraps of tissue paper, and asks them to
commercial game, Ants in Their Pants, and roll each piece into a small ball by using only the
encourage students to use an index finger to skill fingers. The balls can be glued onto con-
make them jump. Once students have mastered struction paper to form a picture. Sometimes
the basic finger movement, therapists can set up the therapist can draw a general shape (e.g., a
a variety of items for the ants to jump over, or pumpkin outline) and the children can make
targets at which they can jump. enough tissue paper balls to fill up the outline.
b. Spinning tops: Therapists should provide a wide f. Coins and buttons: Children can play a variety
array of tops for spinning, with the easiest tops of games with buttons and coins, including
being those with a thick stem. Spinning tops using the skill fingers to insert them into a bank,
helps students isolate the thumb and index picking them up and arranging them as part of
finger, and also encourages a skilled finger a counting or matching game, making designs
motion (similar to the finger-snapping motion). with buttons on the table, sorting buttons
A “stemless top” can be used for students who according to size, and so on. Teachers in the
preschool program often use button activities to

reinforce academic concepts while challenging
fine motor skills. To encourage the development
of finger dexterity, the buttons or coins must be
moved or turned over without bringing them to
the edge of the table. Large containers of mixed
buttons often are available at local fabric stores.
4. Puzzles (dexterity, fine motor planning, strength):
It is beyond the scope of this chapter to discuss the
visual perceptual aspects of puzzles, but in addition
to developing part-to-whole skills and other kinds
of visual matching (e.g., with formboard puzzles),
puzzles can encourage the development of fine
motor skills. Some students have such reduced
dexterity that it is challenging for them to insert
Figure 13-10 Zoo sticks with cotton balls.
wooden pieces into a formboard, and they often
incorrectly assume that because they cannot phys-
ically insert the piece, their initial impulse about toys in their collection so they can provide the
where to place it must have been wrong. It is appropriate level of challenge for a given student.
particularly concerning when students correctly There is remarkable variety in the levels of resistance
surmise where to place a piece, but then assume among the different wind-up toys available. Wind-
that their visual assessment was wrong because they up toys are particularly useful because the motor
cannot insert the piece successfully. These students plan for the winding motion is important for func-
are provided with puzzles well within their range of tional tasks such as turning the volume knob on a
ability from a visual perceptual aspect, and are radio, or closing a screw-top jar.
helped to develop the physical strategies for 7. Stickers: This activity is good for students who are
inserting the pieces successfully. They work first just learning to isolate the thumb and index finger
with wooden puzzles, and then eventually work on to pull a sticker from the backing, before the OT
inserting pieces to Lauri rubber puzzles, which session the therapists remove the background paper
often are more challenging in terms of both finger surrounding the stickers so that it is easier for the
dexterity and fine motor planning. Puzzles with students to be able to determine the exact edge of
small pegs on top of each piece are helpful for the stickers to pull them off independently. Students
developing thumb-index finger isolation. begin with large-size stickers and transition to smaller
5. Zoo Sticks (strength, motor planning, grasp): This stickers. Eventually they can separate stickers from
plastic toy has an animal at the top, with two long the background paper with no difficulty. Therapists
tweezer tips extending from either side of the body. can use a variety of stickers, including the colorful
The child grasps the middle of the tweezers and circle stickers of various sizes (which do not have the
squeezes to pick up small objects. The therapist background paper) available at office supply stores.
scatters cotton balls across the table, and the 8. Buttoning (grasp patterns, motor planning): For
animals “clean up the trash” by picking up the therapists who have access to a sewing machine, a
cotton balls and transferring them to a container simple homemade button game can be created
placed in the middle of the table. (Cotton balls have using interfacing sewn between two 4-inch square
proved to be the most successful material for pre- pieces of fabric. Half of the sewn squares have a
schoolers to pick up.) Students with less skilled buttonhole in the middle, and the other half have a
hands tend to use a fisted grasp on the shaft of the button sewn onto them. The game can be graded in
tweezers, whereas more skilled students tend to use difficulty, based on the button size. Each set of two
only their skill fingers (Figure 13-10). sewn squares should have two matching buttons
6. Wind-up toys (grasp, strength): Wind-up toys are associated with it; one button is sewn to the
available in a variety of levels of resistance, as well as matching cloth square and the other button is
with a variety of different kinds of knobs. The larger loose. Children first practice putting the loose
the diameter of the knob, the easier it usually is for button through the hole and pulling it out the
students to turn. Some wind-up toys come with a other side. Once they understand the concept of
built-in key-shaped knob, which is typically the putting the button through the hole, they use the
easiest kind to wind. Therapists should be familiar button that is sewn to the matching cloth square. At
with the resistance levels of the various wind-up least some of the buttons and buttonholes should
Figure 13-12 Lateral pinch grasp.
therapist needs to attend to how each child performs

them. A child with poor hand skill often finds a way to
use the less-skilled lateral pinch grasp, even in the best-
designed activity (Figure 13-12). For children with sig-
Figure 13-11 The button game. nificant hyperextensibility in their joints, however,
alternative grasp patterns may be necessary for them to
perform an activity successfully. Because of their joint
be large, so that there is room for the therapist’s laxity, they often do not have a good physical foun-
fingers along with the child’s during the hand-over- dation in their fingers to support skilled grasp patterns
hand stage of teaching (Figure 13-11). Once with small manipulatives. Children with hyper-
children can button and unbutton all of the square extensible fingers use the limits of their hyperextensible
sets in the button game, they are ready to button joints to create grasp patterns that provide them with
and unbutton a variety of old cardigan sweaters the stability they need for motor tasks. By choosing
(with varying button sizes to grade the activity for these alternative grasp patterns, however, they sacrifice
difficulty) that are stored in the OT clinic for that the ability to use fine, skilled movements because they
purpose. It is surprising how motivating it is to are choosing stability over skill.
students to button and unbutton a “grown-up” Hyperextensible finger joints are not particularly
sweater. (Note: For practice with buttoning an adult unusual, but they sometimes require that adults
size cardigan, the sweater is placed on the table, not working with a child help that child to be successful in
worn by the student.) The sweaters also help stu- fine motor tasks through a variety of adaptations. For
dents to understand sequencing buttons on a gar- example, the dexterity necessary in fine motor tasks
ment. Eventually, students work on buttoning and perhaps should be reduced until the child is better able
unbuttoning their own garments. to sustain skilled grasp patterns with small objects.
9. Bristle Blocks (strength, visual motor, motor plan- Also, the child may use an adapted pencil grasp (rather
ning): Although a wide variety of classroom-type than the traditional “tripod grasp”) that provides both
manipulatives are available, Bristle Blocks are one of stability and skill at the same time. Benbow (1995)
the most valuable because they are so versatile. stated that
They are initially used as part of a strength-building
program, as they can be difficult for some students “the functional use of the hand depends more on joint stability
to join and separate. Once students have mastered than joint mobility. Children adopt many ways to make their
the strength component of Bristle Blocks, they are hands work for them when they lack joint stability” (p. 267).
then able to build in a variety of ways. These blocks
provide more variety than Duplos, because they can The therapist must know the limits of the child’s
be used in both horizontal and vertical orientations. hand skills well enough to know when to try to elicit a
They encourage the development of eye-hand more traditional skilled grasp with manipulatives, and
coordination, and can also be used to encourage the when to recognize that the child is using as skilled a
development of representative building (e.g., stu- grasp as is physically possible for that child.
dents can make a table, bed, house), which in turn The preceding list of activities is meant to provide
can facilitate many other areas of development enough examples so therapists will be guided in their
(e.g., visually copying from a model, language, ongoing selection of a wide variety of therapeutic
cooperative play). activities and toys. Parents, teachers, and children con-
Although all of these activities encourage the devel- stantly contribute new activity ideas, and many of the
opment of the muscles needed for fine motor skills, the traditional preschool activities (e.g., gluing pasta and
beans to make collages) provide the same kinds of with motor planning difficulties can sharpen their
appropriate fine motor challenges as those listed in the ability to apply motor plans from one fine motor task to
preceding list of Smart Hands activities and manipula- a different one. For students with moderate to severe
tives. When therapists consult with teachers, it is motor planning difficulties, coordinating matching
valuable to suggest new activities, but it is even more materials between the classroom and OT clinic is
valuable to point out those activities and toys already particularly critical. The classroom staff is instructed in
available in the classroom that help children to develop the physical or verbal cues that should be used with that
good hand skills. One particularly helpful way to student, and cues fade in all settings as the students
provide a workshop at a local nursery school is not only make progress. Students with a milder level of fine
to bring toys from the OT clinic, but also to select toys motor planning difficulty are able to quickly make
from the school’s classrooms ahead of time so that their associations among similar tasks, and do not need the
merits can be pointed out to teachers. Incorporating daily repetition of the exact same motor tasks because
the school’s toys and materials into the workshop can they are able to generalize much more easily from tasks
regenerate teachers’ interest in toys that previously performed in the OT sessions to materials available in
seemed humdrum. the classroom. For students with fine motor planning
difficulties, however, it is especially critical for the
occupational therapist to be aware of the kinds of
FINE MOTOR PLANNING materials available in the students’ classrooms so that
Many preschool students who receive OT services have the OT activities will ultimately provide the students
a fine motor planning problem, which may or may not with the skills they should successfully and indepen-
be accompanied by immaturities in fine motor skills. dently use with the fine motor materials at school.
The students with more severe fine motor planning It is often difficult for students with moderate to
difficulties tend to have a diagnosis of Pervasive severe motor planning difficulties to complete multi-
Developmental Disorder–Not Otherwise Specified step art projects. Students in the self-contained class for
(PDD-NOS), or Autism Spectrum Disorder, whereas autism spectrum disorders complete the same therapist-
the students with milder fine motor planning planned art project every single day for 1 week. The
difficulties may have no formal diagnosis at all. For all repetition over 1 week’s time significantly increases
students with motor planning difficulties, assistance in their independence by the end of the week. Because it
the form of hand-over-hand help, visual modeling, pic- is difficult for these students to make generalizations,
ture sequence directions, and verbal cues should be even though the project is the same every day for a
provided when unfamiliar fine motor tasks are pre- week, it seems new enough each day so that it is still
sented. The assistance is faded as the student becomes interesting and challenging to them. They are able to
more independent with the task, with hand-over-hand recognize their improved independence as they
assistance being eliminated first. Once a student has complete the fifth and final version of the project. A
mastered the use of a specific manipulative or toy, a typical art project for this class might include a page
similar manipulative or toy is introduced. This process with three outlines of circles, accompanied by three
is repeated over time, with occasional repeated presen- circle-shaped pieces of construction paper in red,
tation of the original manipulative or toy, so that the yellow, and green. The students must either follow a
student develops improved ability to generalize among visual model, picture sequence directions, or verbal
similar fine motor tasks. instructions to correctly glue the construction paper
One reason that therapists provide such a large circles to create a picture of a stoplight on the paper.
variety of activities within one activity domain (e.g., See Figure 13-13 for an example of step-by-step picture
stringing tasks, wind-up toys, tops) is so that students sequence directions for a play dough activity.
Roll the dough Push the cookie cutter Take the extra away Cookie on the pan
Figure 13-13 Step-by-step picture sequence directions for making play dough “cookies.”
SCISSORS
When scissors are held correctly, and when they fit a
child’s hand well, cutting activities exercise the same
intrinsic muscles that are needed to manipulate a pencil
in a mature tripod grasp. The correct scissors position
is with the thumb and middle finger in the handles of
the scissors, the index finger on the outside of the
handle to stabilize, and fingers four and five curled into
the palm. The lower handle of the scissors should rest
on the distal joint of the middle finger, and the upper Figure 13-15 Incorrect scissors grasp, encouraged by a
handle of the scissors should rest on the distal joint of less than desirable scissors design.
the thumb (Figure 13-14). The tips of the scissors
should be pointing away from the child, and the wrist ubiquitous use of this style of children’s scissors can
of the cutting hand should be in extension (Benbow, make it difficult for therapists to reinforce the correct
1995). When cutting, movements of the fingers should scissors grasp in their students. The Children’s
be in the intermediate range of excursion between very Learning Scissors (available from several sources, see
flexed and very extended to use the intrinsic muscles to Appendix) and, in rare cases, the Craft Scissors (a larger
their maximum benefit (Benbow, 1990a,b). version of the same scissors, used only for exceptionally
Many children hold scissors with the thumb and large preschoolers) are used exclusively in the Newton
index finger in the handles. This position does not Early Childhood Program for all preschoolers. The
allow for proper control of the scissors, and does not therapists recommend that community nursery school
help develop the hand for fine motor skill. When students who receive after-school OT services be pro-
scissors are held in this manner, the scissors movements vided with Children’s Learning Scissors for use at
are performed primarily by the larger muscles of the home. Because many community nursery schools order
forearm rather than primarily by the intrinsics low-cost scissors in bulk from educational catalogues, it
(Benbow, 1990a,b). Parents and teachers can make a has been challenging to convince them to purchase the
tremendous difference in a child’s hand development Children’s Learning Scissors, although some local
simply by teaching the proper scissors grasp. It is schools do use them. Therapists see a significant dif-
necessary to check throughout the year to be sure ference in scissors skills between students who use the
children continue to use the correct grasp because in Children’s Learning Scissors with the correct grasp,
the early stages of learning the habit can be lost. and students who use commercial scissors similar to
The best scissors for children have sharp blades, those pictured with an incorrect grasp.
blunt tips, and small-holed handles. In recent years the Cutting with scissors is an excellent fine motor
trend for children’s scissors has been for the handles to activity, and scissors activities can be adapted to children
be formed in such a way that they actually discourage of varying skill levels. Three and one-half years of age is
the use of the correct scissors grasp. Rather than have the appropriate time for the majority of children to begin
children use scissors in their skill fingers, the design of learning scissors skills, because before this age most
these scissors encourages children to place all four children have not yet developed adequate separation of
fingers in the handles and keep their index finger on the the two sides of the hand to be able to isolate their skill
inside of the lower handle (Figure 13-15). The near- fingers adequately for skillful scissors use. Young 3-year-
olds tend to flex and extend the ring and little fingers
along with the other fingers while cutting, and do not
inhibit this movement of the nonscissors fingers until 3.6
to 3.11 years of age (Schneck & Battaglia, 1992). Also,
the hands of most early 3-year-old children are so small
that even the tiniest scissors available have handle holes
that are too large to allow for proper control with the
correct grasp. When the handle holes are too large,
children tend to place most or all of their fingers into the
handles, thereby learning the incorrect finger position
for skilled use of scissors.
A hierarchy of scissors skills used for planning acti-
Figure 13-14 Correct scissors grasp. vities for preschoolers is listed in Box 13-3. Many
sized”) markers for drawing and writing. Crayola

Hierarchy of Scissors Skills Used
markers are the most widely used, because the stripe
BOX 13-3 for Planning Activities for
near the writing point provides an excellent visual cue
Preschoolers
to help children to remember where to place their
fingers. The diameter of the writing implement and its
Grade the scissors activities in this order: effect on pencil grasp recently has been commented on
1. Snip narrow strips of paper, approximately 1/2-inch in the literature (Burton & Dancisak, 2000; Windsor,
wide.
2000), but a final conclusion about what diameter is
Teaching goals:
a. Learn to position scissors correctly on fingers. best has not yet been determined. However, it seems
b. Learn the cue, “thumbs up” while cutting (to that it might be useful for therapists to be flexible about
encourage a neutral forearm position, rather trying smaller-diameter implements in cases in which
than pronation). preschoolers are having significant difficulty developing
The “confetti” cut by students can be saved in large, a skilled grasp on large-diameter drawing implements.
clear plastic jars. Students are motivated to cut several Therapists in the Newton Early Childhood Program
strips of paper at a time so they can add their paper to
rarely use crayons with the students who are receiving
the growing pile in the jar. Another activity at this level
of development might be to have the children “fringe” OT services. This is because markers offer little resis-
the edge of a piece of paper. tance to make a mark on paper, whereas crayons require
2. Cut on pre-drawn lines on narrow strips of paper significant pressure. Crayons provide an unnecessary
(1/2-inch wide). challenge that makes it impossible for some students to
Teaching goal: Learning to “aim” and direct the develop a skilled grasp with drawing implements. In
scissors when cutting. addition to large-diameter markers the therapists some-
3. Cut on pre-drawn lines on strips of paper 1 to
times use large-diameter pencils, and paintbrushes of
2 inches wide.
Teaching goals: various handle thicknesses. To encourage students to
a. Students begin to develop repeated cutting hold close to the tip of the brush, the upper half of the
skills; this means that they do not close the paintbrush handle can be cut off before use.
scissors all the way each time they cut, as they The normal sequence of development is that children
did in the previous two stages of scissors skills. initially use a static grasp on a drawing implement, and
b. Students learn to have the “helper hand” also be then progress to using a dynamic grasp (see tripod
“thumbs up” (i.e. wrist position in neutral)
grasp in Figure 13-16), with the hand and forearm
while holding the paper for cutting at this stage.
(If the hand holding the paper is pronated, the resting on the table. Because preschoolers are at a
cutting hand tends to also pronate.) malleable stage of fine motor development, and
4. Cut straight-line shapes such as squares and because the preschoolers referred to the Newton Early
triangles. Childhood Program are considered to be at-risk, the
Teaching hints to provide to students: program therapists and teachers encourage children to
a. Cut off excess paper as you go along. use either a tripod or quadrupod grasp. The quadrupod
b. Turn the paper, not the scissors.
grasp is similar to a tripod grasp, except that the ring
c. Do not tear the paper when using scissors.
5. Cut rounded shapes. finger also is on the shaft of the drawing implement.
Teaching hint: Keep the bulky side of the cutting These open web space grasps also are used to perform
project in the noncutting hand.
children can accomplish the first three levels by the age

of 4, and then accomplish the last two levels between
4 and 5 years of age. (Note: Use card-weight or
construction-paper weight for all levels. Once students
have mastered cutting the heavier weight paper, they
can cut regular-weight paper.)
DRAWING AND WRITING

The preschoolers in the Newton Early Childhood
Program are provided with large-diameter (“primary- Figure 13-16 Tripod grasp.
common activities of daily living, such as buttoning

small buttons. Individual variations in pencil grasp may
occur as the children continue through later grades in
school, but hopefully those variations contain these
important components of the dynamic tripod grasp:
the open web space, precision translation, and precise
rotation of the fingers (Benbow, 1995).
Not all students are able to consistently use one of
these two commonly accepted skilled grasp patterns.
Some children, particularly those with hyperextensible
joints, do not ever achieve an “ideal” grasp with an
open web space. The children who typically need to use
a closed web space grasp are those who need additional
stability, which in the long run is more important than
mobility, as noted earlier in this chapter. The problem
of thumb interphalangeal hyperextension is a specific
example of a grasp frequently seen in preschoolers with Figure 13-17 Digital pronate grasp, with only the index
hyperextensible fingers. When the thumb is hyper- finger extended.
extended, it “fixes” the half-closed web space position
(providing stability) so that intrinsic muscle movement
is difficult to achieve (as seen earlier in Figure 13-2). are familiar with lobsters.) The children are asked to
Using large-diameter markers with the slant board sur- have the lobster hold the stripe at the base of the
face encourages children to keep the thumb in flexion Crayola marker, and all drawing or writing activities are
while drawing or writing to facilitate a fully opened web carried out on a 20-degree slant board.
space posture. Initially, children should be encouraged to begin a
Regardless of the less-skilled grasp variations that are drawing with the skilled grasp pattern, but not be
necessary to increase stability for some students, expected to use this grasp pattern for the entire
therapists try to ensure that every single student uses drawing. Once they develop the habit of initiating
the skill fingers to hold and manipulate the drawing drawings with the correct grasp, they typically develop
implement, and that they are able to achieve a dynamic the endurance to use the skilled grasp for longer
grasp of some sort (with the drawing hand resting on periods each time until it eventually becomes their
the table) by the time they enter kindergarten. In other preferred grasp. Some children quickly develop the
words, no student in the program “graduates” from understanding of where to place their fingers, but may
OT services while using any of the “primitive grasps” keep the shaft of the marker under their palm in a
discussed by Schneck and Henderson (1990), although digital pronate grasp. With these children therapists
a number of students enter kindergarten using a static might place a sticker at the top of the marker as a visual
rather than a dynamic grasp. The primitive grasps reminder: If the child cannot see the sticker they know
include those in which the implement is held in the fist that they need to reposition the marker in their fingers.
like a hammer, the digital pronate grasp with only the When the child slips out of using the correct grasp,
index finger extended (Figure 13-17), and others. instead of saying, “You need to fix your fingers on the
The integrated preschool classrooms are all provided marker,” therapists can say, “Where’s the lobster?” This
with developmentally appropriate drawing materials such whimsical way of pointing out that the marker is not
as large-diameter markers and slant board or vertical being held correctly seems to be palatable to children;
drawing surfaces. The students’ grasp patterns with instead of correcting a mistake they are “finding the
drawing implements are monitored regularly by the lobster again.”
teachers and therapists. If a child is approaching 4 years
of age and is not yet showing the appropriate develop-
ment of grasp patterns, direct guidance is incorporated
HAND PREFERENCE
into his or her educational program, as well as the OT The strongly academic nature of the kindergarten
program. curriculum in the surrounding community dictates that
To help children learn how to hold a drawing students are more comfortable and successful in
implement, they are asked to form a rounded circle kindergarten if they have developed adequate skill for
(often referred to in this practice as a “lobster claw”) drawing, writing, and scissors use for at least one hand.
with their thumb and index finger. (Because the pro- This means that it is useful to know which of a child’s
gram is located in New England, most of the students hands is significantly more skilled. For most students,
the preferred hand is clearly evident. For the rest of the based on the three seasons of the school year. These
students, preferred hand use is observed for a variety books are composed of reproducible activity pages
of tasks, including but not limited to the following: that, in addition to developmentally sequenced
spinning tops, other one-handed manipulatives (not tracing activities, also include simple drawing activ-
including wind-up toys), pretend motions (e.g., “Show ities, mazes, easy dot-to-dot pictures, and many
me how you stir the soup,” “Show me how you brush other classroom activities related to the season.
your teeth”), and use of a drawing implement. Parents Because all of the pages include at least a few small
might be asked with which hand the child eats. Obtain- pictures, these worksheets provide an excellent way
ing a family history also can be useful; left handedness to also work on coloring skills.
may run in a family. Hand grasp strength testing is not 2. S.O.S.: This version of S.O.S. is similar to the
useful for this purpose because many people show original version, except that initials are not used in
greater strength in their nonpreferred hand (Clerke & the squares. The child and therapist each choose a
Clerke, 2001). Noting the hand preference for scissors differently colored marker, and one person starts
is not always useful, because many left-handed people the game by drawing a vertical or horizontal line
skillfully use scissors with the right hand. Because the between two adjacent dots. The next person draws
turning motion for the knobs on wind-up toys is in a a line between two dots, and the players keep taking
right-handed skilled direction, many left-handed turns drawing lines in an attempt to finish a square.
children turn wind up toy knobs with the right hand. The person who draws the fourth side of any square
Because many toys and tools in the everyday is allowed to make a dot inside that square, thereby
environment are oriented toward right-handed people, marking it as his or hers. Once all the squares in a
left-handed people typically develop a much greater grid are completed, each person counts his or her
level of skill using the right hand than right-handed dots and a winner is declared. This is an excellent
people do with the left hand. It is perfectly functional prewriting game for teaching pencil control,
for students to seem “ambidextrous” for most manipu- starting and stopping ability (needed for printing
lative activities, but it is strongly preferable that in the letters), and encouraging top-to-bottom and left-
months before kindergarten, they develop a consistent to-right formation of writing strokes. It can also
hand preference for writing and drawing, and a con- encourage top-to-bottom and left-to-right sequenc-
sistent hand for scissors activities (not necessarily the ing when the therapist or teacher helps the child
same hand). This is acceptable, as long as they are con- organize his or her counting of the dots to deter-
sistent about the hand used for the specific type of task. mine the winner. Children can develop some
Children are not encouraged to use one hand more strategy skills as they begin to learn how to plan
than the other unless there is a significant and clear their move so that their opponent’s next move will
difference in ability between the two hands. Most 41⁄2- not finish a square. S.O.S. grids can vary widely in
year-old children are able to recognize that difference, size, but a 16-dot grid seems to work best for most
and choose to use their more skilled hand on their own. preschoolers (Figure 13-18).
If the preferred hand and eye do not match, the child 3. Drawing: Many students have difficulty not only
might consistently use the preferred or more skilled with the physical control of the pencil, but also with
hand for drawing, writing, and scissors activities, but the visual organization of drawings. It is beyond the
lead with the nonpreferred hand (the one that cor- scope of this chapter to fully discuss visual percep-
responds to the preferred eye) for a variety of manipulation and its relationship to making representative
tive activities. (See also Chapter 9 for more information
on handedness.)
ACTIVITIES TO H ELP DEVELOP PENCIL G RASP

AND CONTROL
1. Tracing: The act of carefully tracing a line, or the
outline of a drawing, often elicits a more skilled
grasp than the act of coloring the drawing. Children
are asked to perform a variety of tracing activities as
a therapeutic activity to enhance the development
of prewriting skills. One source for highly motivat-
ing preschool tracing sheets can be found in the
Prewriting Curriculum Enrichment Series by Spitz Figure 13-18 (Left) Blank S.O.S. grid. (Right) S.O.S. grid
(1999, 2000a,b), which is a series of three books game in progress.
drawings, but a short summary of the learn-to-draw Box 13-4 is a developmental hierarchy that
program is provided. In this author’s experience, therapists can follow when teaching students to
interest in representative drawing typically begins write their name. Some students are able to start at
by the age of 4 for girls, and between 41⁄2 and
5 years for boys. Once children have reached an
appropriate age; have at least minimal control of a Developmental Hierarchy to
pencil; and can draw a vertical line, horizontal line, BOX 13-4 Follow When Teaching Students
and circle, they can begin playing representative to Write Their Name
drawing games. These games follow a sequence of
using basic shapes to organize drawings. Preschool 1. For students with significantly decreased fine motor
children tend to see objects as being made up of skill and control, as well as some visual disorganiza-
one or more basic shapes, rather than seeing the tion, name stencils can be made using oak tag and
outline (or contour) of the object (as older children an Exacto knife. The students can trace the letters
tend to do) (Ziviani, 1995). Therefore instead of error-free with the stencil until they can write their
names independently. Another good strategy for
outlining the shape of a train they are drawing,
early learners is to laminate a copy of their first
children tend to draw a rectangle for the train car name, and then have the students practice by using
with circles underneath it for the wheels. The learn- a marker to trace and erase multiple times over the
to-draw program begins with drawing circles, and laminated example. Even at this early stage one
children modify their circles to become a variety should teach students to use top-to-bottom and
of different objects, such as a lollipop, pizza, or left-to-right strokes.
balloon. 2. The adult can write the student’s name using dots
for tracing and have the student trace over the dots.
Once children are comfortable drawing circles,
Being very consistent about having them form the
and then making them into representations of real letters the same (and correct) way every time helps
objects, they are taught to draw squares and rec- these students avoid having to reinvent their letter-
tangles. They are first shown how to draw the two writing strategy every time they try to write their
vertical lines, and then join them with two hori- names. For children with a long name, have them
zontal lines. The children next draw squares or learn the first few letters independently, and then
rectangles and modify them to become something add on more letters. If they insist on writing their
entire name, have them do the first part indepen-
representative (e.g., a square with lines on it can
dently and then provide dots to trace for the rest of
become a gift with ribbon tied around it). They are the letters. For a student who is unable to visually
soon able to combine circles with squares or rec- understand tracing a series of dots, write the name
tangles to become trucks, trains, a radio with circu- in yellow marker and have the child trace over it.
lar knobs, or a door with a doorknob. Eventually For students who are unable to remember the direc-
they learn to draw triangles, which come last tion for the strokes, make a brightly colored dot
because the ability to draw diagonal lines comes with a different colored marker at the ends of each
line to be traced (therapists often use green for
later in development than vertical and horizontal
“start,” and red for “stop”).
lines. The possibilities for combining the three basic 3. Once students can successfully trace their name in
shapes are endless. A typical house drawing includes dots, encourage them to begin to write the letters
all of the basic visual constructs, including a plus (to independently. During this transition therapists
encourage crossing the midline) for the window- and teachers provide an oak tag strip with a visual
panes. Children who are provided with practice at model of the name to copy. Large visual models
making the basic shapes, as well as guided oppor- with at least 1-inch high letters work best with
preschoolers.
tunities to combine them into drawings, tend to
For 4-year-olds who have a name that begins with a
develop the skills and self-confidence to subse- difficult letter such as “S” or “Z,” or letters with any
quently create a variety of drawings on their own. diagonal lines, it usually works best to have them trace
4. Writing: Most children are able to write the letters the fully written letter rather than just the dots, at least
of their first name in capital letters, correctly at first. Students can be encouraged to make a “rain-
sequenced from left to right, by the time they enter bow letter,” which means that they trace the already
kindergarten. Many children begin learning to written letter multiple times with several different
colors of markers so they can get additional practice
write their first name between 4 and 5 years of age,
tracing a difficult letter. Eventually, the kinesthetic
with girls often learning to write their name earlier. memory helps them to write the letter independently,
At the latest, all students in the Newton Early even though those difficult letters may continue to be
Childhood Program begin learning to write their challenging for them (from a developmental aspect),
first name by January of their final year of depending on their current chronological age.
preschool.
Level 2, whereas others initially need the support of riencing an appropriate level of fine motor challenge on
the suggestions in Level 1. If a student is unable to a regular basis, their skill levels begin to improve and
write his or her name independently by the end of they often begin to bring in projects from school or
the final preschool year, he or she can use one of the from home to show the occupational therapist.
methods from Levels 1 or 2 from this list. Progress toward treatment goals is made, therefore,
through an ongoing process that occurs throughout
the week, not just during a therapy session.
WHAT MAKES THERAPY Most children have a desire to please adults, and many
children in the early stages of treatment find it easier to
EFFECTIVE? cooperate with their therapist in the supportive clinic
environment to perform challenging fine motor activities
There are significant developmental differences between than with their parents or teachers. Therefore the occu-
young preschoolers (3 to 4 years) and older pre- pational therapist is often the first person that can entice
schoolers (41⁄2 to 5 years). Three-year-olds need activities a child into attempting something difficult. The ability to
that are so intrinsically enjoyable and motivating that grade activities and task analyze them helps occupational
they may not even be cognizant of how challenging the therapists to ensure successful experiences for students
activities are. In the sessions with younger children, the first time they try a new activity. Occupational thera-
therapists might present eight or more activities within pists have the ability to change the child’s attitude, which
a 30-minute session, as students’ attention spans are may be the most important contribution therapists can
shorter and they need a great deal of stimulation to provide to help a child.
continue working on tasks that are difficult for them. The child should establish a good working relation-
For most activities therapists try to find a level of ship with the occupational therapist before activities are
challenge that is only a small increment above the introduced at home. Therefore fine motor “home-
students’ current level of performance, and always work” usually is not assigned in the initial months of
include one or two activities that are within their therapy, and possibly not at all. Also, it is often difficult
current level of performance so that the children can for parents to adopt a low-pressure, encouraging
experience a feeling of mastery. attitude, because of their close relationship with the
The preschoolers rarely ask why they are attending child. Sometimes the parent–child “fit” does not com-
the OT sessions, and simply refer to these sessions as fortably allow for a continuation of the therapy work at
“my afternoon school.” For students who are home. Decisions about whether or not to provide home
particularly savvy, and who initially question why they activities are made individually for each child, depend-
are participating, therapists encourage parents to say ing on the unique family features of each specific case;
something like, “You mentioned that the projects at however, a few recommendations are typically made to
the art table at school are hard for you, and this [OT] all parents.
is a class that will help you learn ways to make it easier In general, therapists ask parents to encourage their
and more fun for you.” All students, particularly those children to participate in naturally occurring fine motor
for whom the initial evaluation was somewhat stressful, activities at home, and they discourage home programs
typically demonstrate a tremendous sense of relief after that place parents in the position of being a “second
the first treatment session. They quickly recognize that therapist.” This means that parents should make avail-
they will have a regular opportunity to participate in able an age-appropriate array of typical preschool
fine motor activities that are at the correct level of manipulative materials. For the very young students,
difficulty for them, which provides a huge boost to parents might be asked to put away the drawing and
their confidence. Furthermore, most of the students writing materials so that the child spends most of his or
are eager to learn the “tricks” that the therapists show her time on manipulative activities. Parents also are dis-
them, and the community preschool teachers typically couraged from allowing their children to spend a great
report that 1 to 2 months after beginning OT treat- deal of time using a computer. Although many researchers
ment, the students’ attitude and behavior begin to and professionals who work with children do not
change significantly in the classroom. In particular, the recommend the use of a computer under 5 years of age
students tend to demonstrate increased risk-taking at (and for some the lower limit is 7 years) (Meltz, 1998,
school by choosing manipulative activities they had 1999), many parents seem to have difficulty setting
previously avoided, and they also come willingly (and limits on computer use with their preschoolers. Setting
sometimes even spontaneously) to participate in class- a time limit (e.g., no greater than a specified amount of
room art projects. The willingness to try is the most time per day), and using a timer has been helpful for
important aspect of development that an occupational many families. Fine motor activities that children can
therapist can encourage. Once children begin expe- participate in at home are listed in Box 13-5.
BOX 13-5 Fine Motor Activities That Children Can Participate in at Home
1. Cooking Activities: When making cookies, both small amount of food coloring when spraying snow.
strength and skill can be encouraged. Children can roll Students usually begin by using two hands on the spray
out small amounts of dough with their own small bottle, and as they grow stronger they are able to use it
rolling pin, and cut cookies with cookie cutters. Sugar with just one hand.
sprinkles should be placed in a small bowl so that the 4. Prewriting Activities: Parents are asked to provide
children have to pick them up with their fingertips to Children’s Learning Scissors (see Appendix) for either
decorate the cookies. Children also can participate in the right or left hand, as needed, large diameter
tearing lettuce, pressing out pizza dough, pressing markers, paper, and a 20-degree slant board drawing or
toothpicks into cheese squares, and other kinds of food writing surface of some kind. Parents often purchase an
preparation using their fingers. additional pair of these scissors for the child to use at
2. Creating Wrapping Paper: Blank newsprint can be school.
taped to the wall and children can decorate it with ink 5. Drawing and Writing Activities: Rather than have
stamps, sponge painting, markers, or other materials. preschoolers sit down for “work time” at home, if
The paper then can be used to wrap gifts for family a child chooses to draw at home, parents are asked to
members or friends. Older preschoolers can learn to include the drawing with a letter to a friend or relative.
use table tape dispensers (which require fine motor skill If the child is learning to write his or her name, it can
and planning) to obtain tape for the package they are be written on the card or letter. That way, the
helping to wrap. functional use of drawing and writing is reinforced, and
3. Spray Bottles: These can be used in the bathtub or sink the child is less likely to feel that the parent is trying to
at home, or to spray bushes and plants outside. Add a act as a therapist or teacher.
Therapists try to help parents understand the appropriate for the child’s current developmental level.
importance of using manipulatives rather than writing The ability to analyze the components of both
utensils in promoting hand development. In particular, therapeutic and day-to-day activities is one of the most
parents are encouraged to look at commercial toys in important skills of the occupational therapist. Although
new ways. Many commercial toys “do it all” for the it would be impractical to fully educate parents and
child, particularly some of the electronic games. Other teachers in this skill, it is possible to teach them to
toys, such as games with small parts, tiny blocks, and analyze fine motor activities well enough so that they
miniature doll dishes, require skilled finger positions are truly part of a team with the therapist. An involved
and regulation of the intrinsic muscles that are needed parent can make important contributions to a child’s
for skilled grasp and placement. Parents are asked to progress, because once parents understand the con-
evaluate their child’s toys and work toward a balance cepts behind fine motor development they are able to
between the toys that require minimal skill and those see activities in a different way. The parents and teachers
that require more skill. Parents learn that although a feel empowered, and instead of feeling mystified or in
toy requires the use of the hands, it may call for wrist awe of the therapist’s special activities, they become
and arm movements more than finger movements, and contributors in an ongoing process. This kind of
therefore may not further the development of fine partnership strengthens mutual respect and enhances
motor skill. If parents wish, they are encouraged to the child’s progress. It cannot be overemphasized how
bring a child’s toy to an OT session so that the therapist important it is for everyone to understand the sequence
can use the toy with the child and provide feedback to of normal development, even if they are not taking an
the parent about whether or not the level of difficulty is active part in providing the activities.
CASE STUDY
Tim became a student in an integrated preschool classroom Two weeks later Tim could independently string the
1
at the Newton Early Childhood Program in the middle of ⁄2-inch rings because he had learned the motor plan, but his
winter, as he had just turned three years old and was eligible eye–hand coordination was still poor. Six weeks later Tim
for services from the public schools. He had been given a was independently selecting his thumb and index finger to
diagnosis of PDD-NOS, with the primary referring con- hold the tip of a lacing string, and also was occasionally
cerns including immaturities in his language development, placing his fingers at the tip of the string without reminders.
social skills, play skills, reduced eye contact, and apparent Tim was, however, unable to use his skill fingers when a new
unresponsiveness when he was called by name. Before activity, making small balls out of tissue paper, was
entering the program, Tim had been receiving services from introduced. Rather, he used his entire hand to make the
Early Intervention, including physical therapy, OT, speech small tissue balls. A few weeks later, the therapist introduced
and language therapy, home visits, applied behavioral pop beads in the shape of vehicles, and Tim was unable to
analysis, floor time, and a center-based toddler group. recognize the similarity between these pop beads and the
Specific difficulties noted by his two Early Intervention “regular” Fisher-Price pop beads that he had played with at
occupational therapists included heightened sensitivity to home. He needed full hand-over-hand assistance to be able
tactile inputs, avoidance of vestibular-based activities, over- to use the vehicle pop beads. He was, however, able at that
all low muscle tone, and immature fine motor skills. point to string objects with a 1⁄8-inch hole, and his bilateral
When Tim became a student in the integrated classroom, coordination for this kind of task was becoming smoother.
all of the preceding difficulties were noted, although he A “spiral approach” for planning fine motor activities
presented as a student with significantly reduced attention continued for the next year, with activities that had been
rather than as a student with PDD-NOS. The OT evalua- mastered being replaced by similar but new ones, and as
tion that was completed during Tim’s first few weeks of those were mastered the original activities were cycled back
school indicated that although he had hyperextensibility in through the activities list to be sure Tim could still perform
his fingers and reduced fine motor skill (both eye–hand the original task that had helped him form the motor plan.
coordination and grasp patterns), his most significant fine Tim’s tolerance for tabletop work gradually increased so
motor problem was his difficulty intuiting motor plans for that after 3 months of OT he could work with the occu-
using manipulatives. At that time Tim showed a preference pational therapist and one peer for 30 minutes, and his
for his right hand, but used both hands fairly interchange- ability to work at tabletop tasks in the classroom gradually
ably, which is not unusual for a 3-year-old. When picking up increased as well. Although his attention continued to be a
small objects, Tim tended to use a whole-hand pattern problem, his increased levels of skill, interest, and self-
(raking) rather than the expected pincer grasp. He would confidence helped him to be able to focus for longer periods
even hold the tip of a lacing string in the palm of his hand of time in the classroom, where there were more
rather than with his fingertips. Tim also showed im- distractions than in the quiet, nondistractible, OT treatment
maturities with puzzles and copying designs, so it was space.
recommended that visual perceptual skills also be included Tim developed more skill in all the areas of fine motor
in his educational and treatment plan. Tim was referred for development, and he was retested at 4 years of age by the
OT to address fine motor skills, visual perceptual skills, and occupational therapist a year after his first evaluation upon
sensory integration difficulties. entering the preschool program. During his first year in the
The treatment notes from Tim’s first OT fine motor program, his preferred hand seemed to have become less
session indicate that the session was only 15 minutes long, obvious. After initially appearing right-handed for a period
which was the maximum length of time he was able to of time, he now appeared to be strongly left-handed. Later,
participate in structured tabletop tasks. Only five activities he began to again use his right hand more often. He
could be presented during that first session. Instead of using showed a consistent preference, however, for his left eye,
a top with a stem for twirling, Tim used a stemless top that and his family had a strong history of left-handedness.
simply required a brush of the hand to make it spin. He also Although both hands tested below age level for hand grasp
used the Flying Fist toy (the child squeezes the base to make strength, his right hand was significantly stronger than his
the top portion, the hand, pop off), at which point it left. Testing indicated that Tim had some visual perceptual
became clear that his overall hand strength also was reduced skills that were within age limits, such as his puzzle skills and
for his age. His first stringing activity was placing the design copying skills with marker and paper (e.g., vertical
medium rings (1⁄2-inch) onto gimp, which was difficult for line, horizontal line, circle). He continued to show im-
him. He did not spontaneously seem to understand that he maturities in the area of hand grasp strength, however, and
should place his fingers close to the tip of the gimp; rather, as scissors activities and drawing activities had been
he held far back on the gimp, which made it impossible for introduced by this time, immaturities with scissors skills and
the tip to be inserted into the ring. (Like Tim, many young grasp and control of large diameter markers were seen.
students need cues to hold close to the tip of the string.) Tim’s finger hyperextensibility also contributed to his fine
CASE STUDY—CONT’D
motor immaturities. At that point his fine motor planning but had not been able to create any other kinds of represen-
difficulties were considered to be mild, although still tative drawings on his own, particularly multiple component
present. His ability to generalize motor plans among similar drawings. He had difficulty forming a visual plan for a
manipulatives had significantly improved over his first year drawing, although he could easily label all the components
of preschool. that might belong in the drawing (his verbal skills had
With the use of a 20-degree slant board surface, large- reached age level by this time). He was able to draw a red
diameter markers (no crayons), and gentle but consistent circle on the paper for an apple, but was not able to make
reminders about using the correct pencil grasp, Tim made the drawing more complex by adding a stem or leaf, and
the transition to using a static tripod grasp, and finally certainly not an entire tree. After Tim was helped to learn
developed the beginnings of a mature tripod grasp as he how to draw basic shapes and incorporate them into
began to rest his hand on the table more consistently. Two gradually more complex drawings, he was able to make a
years after entering the program, at 5 years of age Tim small variety of multicomponent representative drawings by
finally established the consistent use of his right hand for the end of the year (5 years, 4 months of age). Many
drawing and scissors use. He would occasionally forget and students are able to learn these skills within the classroom
place scissors in his left hand, but after starting to cut he setting, with the occupational therapist working natural-
would realize that the scissors were on the incorrect hand istically in the classroom, but in Tim’s case it was necessary
and switch them on his own. With markers, he was con- to remove him to a separate, nondistractible room for the
sistent about using his right hand. His ability to write his OT sessions for the second half of his last year of preschool.
name gradually changed from being an arm and wrist skill Two typically developing peers were brought along as
with the letters filling up an entire page, to being a finger models so the sessions would seem more like a regular
skill. By February of that year, he was able to sign his school tabletop activity.
Valentines with the letters of his name only 1⁄2 inch high. By the end of the year, Tim had achieved nearly all of the
Tim worked his way through the more difficult levels of objectives on the Newton Early Childhood “Fine Motor
the fine motor skills curriculum, including buttoning activ- and Visual Perceptual Inventory for Children Entering
ities and multistep manipulatives. His hand grasp strength Kindergarten,” (Broder, 2004) with the only significant area
continued to test at the level of a child approximately 1 year of weakness being that he still needed to improve his overall
younger than his chronological age of 5, although he was control of drawing implements. (The pre-kindergarten
able to open and close all of the containers expected for inventory can be found in Appendix 13 B.) His major areas
a child his age, and could turn the knobs on even the of improvement over the 21⁄2 years that he received OT
most resistive of the wind-up toys used in the treatment within an integrated preschool setting were in the establish-
sessions. Fine motor planning difficulties were rarely seen, ment of a consistent hand preference for writing and
and when they appeared Tim was able to learn a new motor cutting, improvements in fine motor planning, major
task with only minimal verbal cueing, and no physical improvements in fine motor skills including cutting, and
assistance. good progress in pencil control, as well as visual motor
Interestingly, the primary area of difficulty for Tim activities such as representative drawing and design copying.
during the last few months before he entered kindergarten It was recommended that Tim continue with OT services in
was in the area of representative drawing. He had learned to kindergarten, primarily to address his continued needs with
draw recognizable, visually organized drawings of people, pencil control and representative drawing ability.
ACKNOWLEDGMENTS REFERENCES
I am grateful to Cindy Broder, OTR/L, for her kind Benbow M (1988). Loops and other groups, a kinesthetic
writing system. Tucson, AZ, Therapy Skill Builders.
assistance with the editing of the initial draft of this Benbow M (1990a). A neurodevelopmental approach to
chapter, and for her encouragement throughout this teaching handwriting. Lecture notes from a workshop
project, as well as for the past 19 years. I would also like presented March 8, 1990.
to thank my husband, Richard Myers, for his enthu- Benbow M (1990b): Personal communication, April 16, 1990.
siastic support of this project and his expert help with Benbow M (1995). Principles and practices of teaching
handwriting. In A Henderson, C Pehoski, editors: Hand
proofreading. function in the child (pp. 255–281). St Louis, Mosby.
Broder C (2004). Fine motor and visual perceptual Meltz B (1998). Computers, software can harm emotional,
inventory for children entering kindergarten, unpublished social development. The Boston Globe, p. F1, October 1.
checklist. Schneck C, Battaglia C (1992). Developing scissors skills in
Burton A, Dancisak M (2000). Grip form and graphomotor young children. In J Case-Smith, C Pehoski, editors:
control in preschool children. American Journal of Development of hand skills in the child (pp. 79–89).
Occupational Therapy, 54(1):9–17. Rockville, MD, The American Occupational Therapy
Case-Smith J (1995). Clinical interpretation of Association.
“Development of in-hand manipulation and relationship Schneck C, Henderson A (1990). Descriptive analysis of the
with activities.” American Journal of Occupational developmental progression of grip position for pencil and
Therapy, 49(8):772–774. crayon control in nondysfunctional children. American
Case-Smith J (2000). Effects of occupational therapy Journal of Occupational Therapy, 44(10):893–900.
services on fine motor and functional performance in Spitz P (1999). Autumn activities: Apples apples everywhere.
preschool children. American Journal of Occupational Framingham, MA, Therapro.
Therapy, 54(4):372–380. Spitz P (2000a). Spring activities: Flowers flowers everywhere.
Case-Smith J, Pehoski C (1992). Development of hand skills Framingham, MA, Therapro.
in the child. Rockville, MD, The American Occupational Spitz P (2000b). Winter activities: Snowflakes snowflakes
Therapy Association. everywhere. Framingham, MA, Therapro.
Clerke A, Clerke J (2001). A literature review of the effect Windsor M (2000). Clinical interpretation of “grip form
of handedness on isometric grip strength differences of and graphomotor control in preschool children.”
the left and right hands. American Journal of American Journal of Occupational Therapy, 54(1):18–19.
Occupational Therapy, 55(2):206–211. Ziviani J (1995). The development of graphomotor skills.
Hopkins H, Smith H (1978). Willard and Spackman’s In A Henderson, C Pehoski, editors: Hand function in
occupational therapy, 5th ed. Philadelphia, Lippincott. the child (pp. 184–193). St Louis, Mosby.
Meltz B (1999). Beware this screen, too. The Boston Globe,
p. F1, October 28.
Appendix 13A
VERTICAL AND SLANT BOARD

SURFACES, AND A VARIETY OF book include “Wide Eyed Owl” (p. 60), “Here Is a Ball”
(p. 91), “A Good House” and “Different Homes”
FINE MOTOR MANIPULATIVES, (p. 19), “A Kitten” (p. 42), “Houses” and “Little
INCLUDING CHILDREN’S Birds” (p. 31), “My Little Garden” and “My Garden”
(p. 35), and “In the Apple Tree” (p. 22).
LEARNING SCISSORS
Therapro at www.theraproducts.com and OT Ideas at
www.otideas.com are both excellent sources of fine MEASURING HAND STRENGTH
motor materials. When a toy has been given a proper
name in this chapter, it signifies that the toy is available The Martin Vigorimeter, which is used in the Newton
under that specific name either on the website of one of Early Childhood Program, is available from the follow-
these two companies, or from a supplier who can be ing source:
located using that name with an internet search engine Albert Waeschle
such as Google. At the time of this writing, all of the 11 Balena Close, Creekmoor Industrial Estate
items mentioned in this chapter could be located Poole, Dorset BH17 7DX
through one of these two methods. The Spitz activity United Kingdom
books (listed in the references) can be found on the Fax: 011 44 1202 650022
www.theraproducts.com website. Telephone (includes numbers necessary to dial
directly from the United States):
011 44 01202 601 177
Website: http://www.albertwaeschle.com
FINGER PLAYS Preschool norms for hand grasp strength obtained
by using the Martin Vigorimeter can be found in this
Finger Frolics, revised, by Cromwell, Hibner, and Faitel resource:
(Partner Press, available online at www.ghbooks.com) Link L, Lukens S, Bush MA (1995). Spherical grip
is a good source for finger plays on a variety of different strength in children 3 to 6 years of age. American
themes. Some of the most useful finger plays from this Journal of Occupational Therapy, 49(4):318–326.
289
Appendix 13B
FINE MOTOR AND VISUAL PERCEPTUAL INVENTORY FOR CHILDREN
ENTERING KINDERGARTEN
Name of Child: _________________________________________________
Chronological Age: ____________________________ Date of Birth: ___________________
Date of Evaluation: ____________________________ Therapist: ______________________
______Skillfully uses a variety of multiple-step manipulatives (e.g., buttoning, wind-up toys, eye droppers).
______Laces using a skilled grasp.
______Builds a block tower of at least 10 one-inch blocks.
______Uses two hands together skillfully for bilateral activities.
______Demonstrates a clear right or left hand preference.
______Uses non-dominant hand appropriately as an assist (e.g., stabilizes paper while drawing).
______Holds primary-sized (large diameter) drawing implements with a skilled grasp.
______Draws and colors using skilled movement: forearm, wrist, fingers (most skilled).
______Draws or colors for five minutes with good endurance, pressure, speed, and accuracy.
______Draws a recognizable person with at least 8 body parts.
______Draws recognizable pictures with multiple components (e.g., a sun, tree, house).
______Copies horizontal and vertical lines, a plus, and a square.
______Copies right and left diagonal lines, and a triangle.
______Connects dots or completes simple mazes, and draws the lines with control.
______Prints letters of first name.
______Independently completes age-appropriate 5-10 piece interlocking puzzles.
______Positions preschool scissors on hand with skilled grasp, given one reminder.
______Cuts on a line smoothly and accurately, sustaining rhythm.
______Independently cuts out a square, triangle, and a circle shape, using appropriate strategies (e.g., turning
paper so that scissors stay pointing away from body).
3 = Achieved N = Needs further attention
Compiled by Cindy Broder, OTR/L, 2004

Newton Public Schools Early Childhood Program
290
Chapter 14
EVALUATION OF HANDWRITING
Scott D. Tomchek • Colleen M. Schneck
CHAPTER OUTLINE written tests, compose stories, take notes in class, copy
numbers for math computations, and communicate with
PRE-EVALUATION DATA COLLECTION friends and family. Writing continues to be used through-
out their lives in the home and work place to write
Writing Samples checks, take messages, and communicate with others.
Interviews Learning to write legibly is a complex task of child-
Record Review hood and therefore it is not uncommon for problems
to arise during this learning process. Children may have
EVALUATION OF RELATED PERFORMANCE illegible script, difficulties with letter formulation, lack
COMPONENTS the automaticity of writing, and therefore be unable to
Neuromuscular and Neurodevelopmental Status keep pace with their peers. As a result, school
Visual Perception consequences of handwriting difficulties may be noted
(Amundson, 2001) and may include the following.
Motor Performance • A child may be assigned poorer marks for papers with
Formulation of Written Language poorer legibility but not poorer content (Chase,
Sensory Processing 1986; Sweedler-Brown, 1992).
• A child’s slow handwriting speed may limit compo-
ACTUAL EVALUATION OF HANDWRITING sition fluency and quality (Graham et al., 1997).
PERFORMANCE • A child may take a longer time to complete writing
Domains of Handwriting tasks than peers (Graham, 1992).
Legibility Components • A child may avoid handwriting tasks because it
requires so much effort to produce text (Berninger,
Writing Speed Mizokawa, & Bragg, 1991).
Ergonomic Factors When handwriting impairments that affect academic
Keyboarding Performance performance are noted, children are often referred to
occupational therapists for evaluation and intervention
Commercially Available Assessment Tools (Bonney, 1992; Case-Smith, 1996; McHale & Cermak,
SUMMARY 1992; Reisman, 1991; Tseng & Cermak, 1993). The
occupational therapist is responsible for identifying
underlying motor, sensory, cognitive, or psychosocial
Writing is a way to record information and events; a deficits that may interfere with the development of
tool for communication; and a means to project feel- legible handwriting (Amundson & Weil, 1996). The
ings, thoughts, and ideas (Chu, 1997). Occupational process of evaluation is multifaceted with many
therapists are concerned with the occupational per- interrelated components. The purpose of this chapter is
formance of individuals in play, work, and self-care to discuss the process of evaluation for handwriting
activities. In childhood, a major occupation in the area impairments and is grouped into three main compo-
of work is handwriting (Amundson, 1992, 1995; Chu, nents: (a) pre-evaluation data collection, (b) evaluation
1997). It is often one of the first tasks taught to stu- of related performance components that may be inter-
dents. Writing within learning tasks continues through- fering with handwriting, and (c) evaluation of the
out the academic careers of children and is used to take actual process of handwriting.
291
PRE-EVALUATION DATA components could be used to predict scores in hand-

writing performance. This information can guide thera-
COLLECTION pists in their evaluation of children based on teacher
report of poor handwriting.
Although discussed as separate assessment components Two factors that teachers indicated most frequently
by several authors (Amundson, 1992, 2001; Amundson as important for handwriting to be acceptable were
& Weil, 1996), analysis of writing samples, interviews, correct letter formation, and directionality and proper
and record review comprise the pre-evaluation data spacing (Hammerschmidt & Sudsawad, 2004). The
collection. Analysis of this information guides the most important criteria that teachers used to determine
necessary components and sequence of evaluation whether or not a student was having handwriting diffi-
methods. culties was their not being able to read the student’s
writing. The majority of teachers answered that the
methods they used to evaluate their students’ hand-
WRITING SAMPLES writing was comparing student handwriting to class-
Upon referral for handwriting problems, work samples room peers (37%), followed by comparing student
often are offered to substantiate the need for referral. handwriting to models in a book (35%). This awareness
These samples should represent typical handwriting can help structure the content of the occupational
performance of the child (not the worst examples) and therapy evaluation and ensure that occupational therapy
be analyzed to determine the types and magnitude of assessments produce results that are relevant to the
the handwriting difficulties seen in the classroom children’s handwriting function in the classroom.
(Amundson, 2001). Comparing these samples to those The parents can provide insight on many of these
of peers also may be of benefit in determining the same factors as the child accomplishes handwriting in
magnitude of the difficulties, as well as gaining an the home. In addition, the parents can provide infor-
understanding of teacher expectations. Informal eval- mation unknown to the teacher such as the attitudes
uation of the work samples for alignment, size, letter and interests of the child. This difference in perspective
formation, legibility, and slant may indicate need for may be useful in identifying the causes of handwriting
further evaluation. difficulties.
I NTERVIEWS RECORD REVIEW

Teachers and parents likely have valuable information Reviewing the child’s educational file can provide infor-
about the child that contributes to the assessment mation on past academic performance and any special
process. Teachers can provide information about the services that may have been provided to the student.
child’s unique academic strengths and weaknesses in Information obtained from the educational file may
the classroom, as well as the specific curriculum of the reveal a pattern of educational difficulty or isolated
class. In addition, the teacher can describe the type findings that may be useful in the assessment of hand-
of script used (i.e., manuscript or cursive), the style of writing difficulties. This review of information also may
script used (i.e., D’Nealian, Zaner-Bloser) and his or require further interview of the teacher.
her general expectations of the students for hand- Through classroom observations, examination of
writing. Specific to the child referred for assessment, work samples, interviews, and record review a therapist
the teacher can provide information on the place where is able to identify related performance components and
the child accomplishes writing, when difficulties occur, administer assessments designed to determine whether
what remediation techniques if any have been attempted, deficits in the identified components exist and to what
and his or her feelings on why the handwriting diffi- extent (Admundson & Weil, 1996).
culties may be occurring. In addition, he or she can
provide insight on the child’s history of handwriting
instruction. EVALUATION OF RELATED
Cornhill and Case-Smith (1996) found that students
with poor handwriting, as identified by teacher report, PERFORMANCE COMPONENTS
scored significantly lower on three assessments of sensori-
motor performance components (eye-hand coordina- To assist in the process of identifying the cause(s) of
tion, visual motor integration, and in-hand manipulation) the handwriting impairments in a student, analysis of
than students with good handwriting. The authors also the underlying performance components related to
found that scores on assessments of these performance handwriting require evaluation. Here, underlying sta-
Evaluation of Handwriting • 293
bility, perceptual, sensorimotor, and written language movement will likely be compromised. In addition, the
functions are assessed to determine their impact on child may fatigue quickly during handwriting tasks.
handwriting performance. These neuromuscular and neurodevelopmental skills
serve as the foundation from which skilled mobility and
N EUROMUSCULAR AND motor skill are built. Deficits identified in these areas
likely have an impact on performance of motor skill.
N EURODEVELOPMENTAL STATUS
A comprehensive neuromuscular assessment often
initiates the physical evaluation. Active and passive
VISUAL PERCEPTION
range of motion limitations are noted and if present, Visual perception is the ability to use visual information
may limit in-hand or upper extremity mobility neces- to recognize, recall, discriminate, and make meaning
sary for handwriting. Muscle tone in the trunk and out of what we see. Visual perceptual areas include the
extremities (both proximally and distally) also is eval- visual receptive (acuity, convergence, tracking) and the
uated. Strength often is assessed through structured visual cognitive, which include visual discrimination,
observation of antigravity postures and movements. visual memory, visual form constancy, visual spatial rela-
Specific muscle testing may be necessary in the hands tion, visual sequential memory, visual figure ground,
and upper extremities. and visual closure. Together, these perceptual skills
To supplement neuromuscular findings, a neuro- provide vital information that is used and relied on by
developmental assessment may be conducted. The many other systems for optimal functioning. For
neurodevelopmental assessment should include two instance, when copying text from a blackboard, we use
groups of automated responses as markers for motor visual figure ground to select the appropriate text on
dysfunction. The first group of automated responses the blackboard to copy, visual discrimination to differ-
to be evaluated is the primitive reflexes. These reflexes entiate among letters, and visual memory and sequen-
appear during the late gestational period, are present at tial memory to recall the text to be copied; therefore it
birth, and normally are suppressed by higher cortical is important to distinguish visual perceptual problems
function by approximately 6 months. Delayed integra- from motor problems.
tion of these reflexes has an impact on dissociated head Visual-perceptual skills, including visual-spatial
and extremity movements and thus affects motor per- retrieval and left-right orientation, enable children to
formance. For example, delayed integration of the distinguish visually among graphic forms and judge
asymmetric tonic neck reflex may limit dissociated head their correctness (Solvik, 1975; Thomassen & Teulings,
and upper extremity movement to the point of affect- 1983). Tseng and Murray (1994) reported that the
ing development of hand dominance and midline cross- 143 children in their sample of children with illegible
ing of the upper extremities. After evaluation of the handwriting had low scores on perceptual-motor
primitive reflexes, the second group of automated measures. Tseng and Chow (2002) found a significant
responses to be evaluated is the postural reactions. difference between slow and normal handwriters in
Righting, equilibrium, and protective reactions must be upper-limb coordination, visual memory, spatial rela-
evaluated. The coordination of these reactions into tion, form constancy, visual sequential memory, figure-
functional balance often is observed during free play ground, visual motor integration, and sustained
and independent movements. Decreased functional attention.
balance in sitting may limit independent arm move- Clinical observations can be used to obtain some
ment from trunk movement for writing. The child then informal information of perceptual abilities in children
moves the trunk with the arm for writing or frequently who cannot participate in formal testing. Situations can
re-positions the paper as arm movement is needed. be devised to assess specific areas or a child’s work can
Together, the tone, strength, reflex integration, and be evaluated. For instance, having a child find a certain
balance development of a child serve as the foundation toy in a toy box can assess visual figure ground. Asking
for the development of stability and stable movement a child to find or select an item he or she was shown
patterns. If a child is posturally unstable she or he will could be used to assess visual memory. Spatial relation
likely use compensatory movement patterns, which in difficulties often can be seen when asking a child to
turn may affect motor control during handwriting accomplish writing tasks, because drawings, letters, or
tasks. For example, a child who exhibits instability in words may be rotated. In addition, alignment and
the upper trunk and shoulder may use a mid-guard spacing may be a problem.
posture or stabilize at the shoulder to stabilize his or Visual discrimination difficulties may affect the child’s
her upper thoracic and cervical areas during hand- handwriting in several ways and can be evaluated
writing. By doing so, the child’s fluidity and speed of through observation of the child during handwriting.
For example, the child with poor form constancy may the child to “find the form that is going a different
not recognize errors in his or her own handwriting and way” or “find the form that is not the same as the
therefore not make corrections to errors. In addition, others,” the child will likely better understand the more
the child may be unable to recognize letters or words simple terms of “wrong” or “different.” Therefore a
in different prints and therefore may have difficulty in request to find which one is wrong may produce
copying from a different type of print or handwriting. improved performance. Because we are assessing per-
The child also may show poor recognition of letters or ception and not receptive language abilities or vocabu-
numbers of different sizes or in different environments. lary, making these adaptations allows evaluation of the
If the child is unable to discriminate a letter, he or she focus area, visual perception. Tsurumi and Todd (1998)
may show poor letter formation in handwriting. have applied task analysis to the nonmotor tests of
Children with problems in visual attention may have visual perception. This information greatly assists the
difficulty with the correct letter formation and can be therapist in analyzing the results of these tests. Care in
evaluated through observation of the child during interpreting and reporting test results should be taken
handwriting activities. Children with attention prob- because it is not always clear what visual perceptual
lems may exhibit difficulty with spelling, mechanics of tests are measuring. Refer to Table 14-1 for a listing of
grammar, punctuation, capitalization, and the formula- standardized assessments that may be used to assess
tion of a sequential flow of ideas necessary for written these visual perceptual areas. For valid test results it is
communication. For the child to write spontaneously, important to follow the standard instructions on stan-
he or she must be able to revisualize letters and words dardized tests. If the standard procedures are not
without visual cues. Therefore if the child has visual followed it should be stated when reporting the results.
memory problems, he or she may have difficulty recall- These visual-perceptual assessments assess nonmotor
ing the shape and formation of letters and numbers perception, in that they do not require motor coor-
(Schneck, 2001). Other problems that may be seen dination for the completion of testing. Instead, the
when a child has visual memory problems include child can select his or her choice among the options by
missing small and capital letters within a sentence, the saying the appropriate letter that corresponds to his or
same letter may be written in different ways on the her selection. Most children, however, point to their
same page, and the inability to print the alphabet from response.
memory. The child’s legibility may be poor, and he or Deficits in these perceptual abilities may affect many
she may need a model to write. areas of development, especially fine and visual motor
A child with visual spatial problems may show development. The information taken in visually guides
reversal of letters such as the m, w, b, d, s, e, and z and our ability to reach to an object and the act of grasping
of the numbers 2, 3, 5, 6, 7, and 9. Children with that object. During writing tasks, visual information
difficulty with discrimination of left from right may is used for spacing, alignment, and formation of all
have difficulty with the left-to-right progression or drawings and letters. When deficits in these areas, or
writing words and sentences (Schneck, 2001). In addi- in any areas that rely heavily on visual input for coordi-
tion, the child may demonstrate over-spacing or under- nation, are detected, visual perceptual differences
spacing and have trouble keeping within the margins. should be identified through formal or informal
He or she may show inconsistency in letter size and testing.
may have difficulty with the placement of letters on a
line, or the ability to adapt letter sizes to the space
provided on the paper or worksheet. Careful observa-
MOTOR PERFORMANCE
tion and informal assessment can help to uncover For the purpose of this section, assessment of motor
problems contributing to poor handwriting. function is divided into the three broad areas of gross,
The formalized assessment of visual perceptual abili- fine, and visual motor development. There is much
ties usually is reserved for children of school age and overlap between these areas of motor performance, in
older who have higher receptive language abilities, and that common performance components (i.e., muscle
are able to comprehend the verbal instructions inherent tone, strength, coordination, visual motor integration)
in these tests. Without receptive language abilities near serve as the foundation for skilled motor output. There
the 5-year level, testing will likely be invalid because the is also significant reliance between these motor skill
instructions may be too abstract or not comprehended. areas. For example, stability aspects of gross motor devel-
To maximize performance and obtain the most accu- opment are vital in fine motor performance because
rate assessment of the individual perceptual areas, stability provides a solid foundation from which skilled
adaptation or simplification of verbal instructions may upper extremity usage is achieved. Both formal and
be necessary. For instance, when giving directions for structured observation assessment is described here.
the visual spatial relations areas, instead of instructing Some formalized assessments used to assess gross, fine,
Table 14-1 Instruments to assess visual perception
Instrument Author, Year Ages Areas Assessed
Developmental Test of Visual Hammill, Pearson, 4–9 years Eye-hand coordination

Perception, Second Edition and Voress, 1993 Spatial relations
(DVPT-2) Figure ground
Visual-motor speed
Copying
Position in space
Visual closure
Form constancy
Motor-Free Visual Perception Colarusso and Hammill, 4–11 years Visual discrimination
Test-Third Edition (MVPT-3) 2003 Visual memory
Visual spatial relations
Visual figure ground
Visual closure
Test of Visual Perceptual Gardner, 1995 4–12.11 years Visual discrimination

Skills-Revised (TVPS-R) Visual memory
Visual form constancy
Visual spatial relation
Visual sequential memory
Visual closure
Test of Visual Perceptual Skills Gardner, 1997 12–18 years Visual discrimination
Upper Limits (TVPS-UL) Visual memory
Visual form constancy
Visual spatial relation
Visual sequential memory
Visual closure
and visual motor development are identified in Gross Motor Skill

Table 14-2. Gross motor development refers to movements that
When evaluating any component of motor per- require the use of large muscle groups. Ambulating,
formance, not only are developmental milestones running, jumping, climbing, and ball play are all con-
noted, but also special attention is directed to the quali- sidered gross motor skills. In neurodevelopmental
tative dimensions of the motor skill. Developmental theory, the mobility necessary for these locomotor skills
milestones provide evidence of what the child can and is superimposed on stability. Consequently, the ability
cannot do relative to children of a comparable age. A to perform these skills, and the quality with which they
major goal of the assessment should be to determine are performed, is dependant on the condition of the
the source of an observed and documented deficiency, child’s neuromuscular and neurodevelopmental status.
that is, why the skill is problematic. Observations made Often, the neuromuscular status assessment is consid-
about the qualitative aspects of motor control often ered one component of the child’s gross motor status.
pinpoint the area(s) of dysfunction and serve as the Accordingly, gross motor includes both evaluation of
foundation for intervention planning. In addition to developmental milestones and observations about the
the value of direct observation of motor skill, obser- quality of the child’s movement patterns. Balance and
vation of contextual aspects of motor skill also enhances stability are measured and observed as the child per-
understanding of the source of developmental delays. forms a number of motor tasks. These observations of
Table 14-2 Standardized instruments used to assess gross, fine, and visual-motor skill
Peabody Developmental Folio and Fewell, 2000 Birth–83 months Gross motor:
Motor Scales-Second Edition Reflexes
(PDMS-2) Stationary
Locomotor
Object manipulation
Fine motor:
Grasping
Visual-motor integration
Toddler Infant Motor Miller and Roid, 1994 Birth–47 months Mobility
Evaluation (TIME) Motor organization
Stability
Functional performance
Social/emotional abilities
Bruininks-Oseretsky Test of Bruininks, 1978 4.5–14.5 years Gross motor:
Motor Proficiency Running speed and agility
Balance
Bilateral coordination
Strength
Upper-limb coordination
Fine motor:
Response speed
Visual-motor control
Upper-limb speed and
dexterity
Test of Gross Motor Ulrich, 2000 3–10 years Locomotor
Development, Second Object control
Edition (TGMD-2)
Test of Visual-Motor Gardner, 1995 3–13.11 years Visual motor control for
Skills-Revised (TVMS-R) design copying items
Test of Visual Motor Gardner, 1992 12–40 years Visual motor control for
Skills-Revised-Upper Limits design copying items
Developmental Test of Visual Beery and Buktenica, 2–15 years Visual motor control for
Motor Integration (VMI) 1997 design copying items
balance also have application to the vestibular process- caregiver. As can be seen, throughout the evaluation,
ing of a child, illustrating the link between sensory and both developmental milestones are assessed and the
motor responses. quality with which they are accomplished is observed
Assessment of these gross motor areas often is and analyzed. Deficits in stability noted during gross
done within the context of play-based assessment or motor performance, especially trunk, shoulder, and
strictly through observation. Having a child go neck, may or may not be present when a child is seated
through a simple obstacle course, for instance, can pro- at a table to participate in handwriting tasks.
vide a wealth of information about balance, strength,
and postural control. Further, within many clinic Fine Motor Skill
settings or natural environments a child has the oppor- Fine motor development refers to movements that
tunity to explore his or her environment. In doing so, require precise or fine motor actions and small muscles
the child likely ambulates, runs, jumps, or has to climb and more sensory feedback. Grasp of objects, writing,
steps. Situations also can be developed to observe catch cutting tasks, and dexterity while accomplishing
and throw abilities. Report of functioning during clothing fasteners are all considered fine motor tasks.
higher-level bilateral motor tasks such as riding a bike When assessing fine motor skill it is again important to
and swimming likely may be obtained from the note the impact of stability and postural awareness.
Stable positioning during fine and visual motor tasks handwriting dysfunction, in which fine motor skill
enhances optimal performance, whereas instability accounted for 52.5% of the variance in handwriting
diminishes fine coordination The importance of speed. Solvik and Arntzen (1991) found that poor
addressing biomechanical factors, such as weak intrinsic coordination in the form of poor dissociation (exag-
muscles of the hand, has been stressed (Peterson & gerated wrist and thumb movement) was inversely
Nelson, 2003). correlated with writing speed.
Fine motor skills are essential because accurately In-hand manipulation can be assessed with trans-
formed letters can be produced only by the proper lation and rotation tasks with the five small pegs and
timing and force control of coordinated arm, hand, and pegboard from the Nine-Hole Peg test. Administration
finger movements (Alston & Taylor, 1987; Thomassen and scoring procedures can be found in Case-Smith
& Tuelings, 1983). Children with illegible handwriting (1996, 1998).
scored lower on fine motor measures than children As in most assessments, initially the foundation skills
with good handwriting (Tseng & Murray, 1994). of an area are assessed. Many of these areas relating to
Berninger and Rutberg (1992) examined additional fine motor task performance are assessed though
variables and found that a fine motor task (sequentially observation. Table 14-3 outlines the pertinent areas
touching the thumb to the tip of each finger) had and specific questions that guide these structured
the strongest correlation with handwriting. Levine, observations in fine motor evaluation of handwriting.
Oberklaid, and Meltzer (1981) not only found that In conjunction with these observations, the atten-
72% of 26 children with “developmental output fail- tion of the evaluator can turn to evaluating the
ure” had difficulty with fine motor tasks, they further functional application of these foundation skills. Here,
postulated that these children’s uncoordinated finger the child is asked to engage in purposeful tasks as a
movements and diminished pencil control accounted means of identifying strengths, weaknesses, and devel-
for their slow, illegible handwriting. opmental levels. If the child is unable to perform a
Researchers have reported two general types of grip motor task, it is important to try to ascertain why,
assessment systems: component and whole configu- because an inability to perform a motor task may stem
ration. In component systems separate components of from one or several limitations including lack of
the grip are evaluated (i.e., the position of each finger strength, deficient muscle control, dyspraxia, cognitive
and the thumb, the relative position of the grip along limitations, or motivation. Determining the reason for
the length of the implement, or the forearm position dysfunction allows for observation of hand dominance
relative to the table). In whole configuration systems, and appropriate intervention planning.
all of the components of an observed grip are described
together. The grip is considered as a discrete behavior Visual Motor Control
and is labeled. Burton and Dancisak (2000) have There is much overlap between fine and visual motor
suggested that the use of Schneck and Henderson’s skill, and often they are considered one entity. Visual
(1990) 10-grip scale be used only for documenting the motor control refers to the ability to coordinate visual
grips of individual persons and changes in their grips. If information with motor output for visually guided
comparisons between persons are desired, then the movements. Appropriate visual motor control is pred-
authors recommended Schneck’s (1991) five-level scale icated on intact visual localization and tracking abilities.
be used. Tseng (1998) added three interdigital grasps Visual motor control is used to string beads, cut on a
to this five-level scale in the primitive grasp category line, catch a ball, print within lines, and stay in the lines
and included the quadruped grasp as another mature when coloring a picture. Some individuals may demon-
grasp for a total of 14 grasp patterns. strate better abilities for design copying items in tests
The task should be considered in the evaluation of visual motor integration, but have difficulty when
process. For example, in a coloring task younger chil- relating these abilities to handwriting. Therefore it is
dren used a more mature grip to color the edge and important to assess each area separately (see hand-
then colored the center with a less mature grip. Older writing assessment section that follows). Fundamental
children slow down to color the edge and then con- to assessment is the recurrent theme of pinpointing
tinue with the same grip for the center of the object the location of the breakdown in task performance.
(Schneck, 1991). Many children used less mature grips In the visual motor area, skills are dependent on ade-
when coloring spaces than when drawing. The most quate attention, visual perception, motor control, and
common grip used for coloring was the static tripod motivation.
grasp, whereas for drawing it was the dynamic tripod A number of researchers have documented a sig-
grasp (Schneck, 1991). Berninger and Rutberg (1992) nificant relationship between visual motor skills and
contended that finger function is the best predictor of handwriting performance (Cornhill & Case-Smith, 1996;
Table 14-3 Structured observations of fine-motor foundation skills
Foundation Area Specific Observations
Hand dominance Does the child demonstrate use of a dominant hand, mixed dominance, or no
dominance at all?
If the child has mixed or no dominance, does he or she avoid crossing the midline?
Grasp and prehension patterns Can the child isolate finger motions for prehension of smaller objects?
What grasp pattern does the child use to hold a pencil?
Does the child use this grasp statically or dynamically?
Does the child hold the pencil firmly?
Does the quality of the child’s grasp and prehension abilities differ when they are
just manipulating an object in comparison to when they are manipulating a tool for
use (i.e., hammer, pencil, ball)?
Does the child have adequate hand strength to hold onto objects?
Manipulation skill What is the quality of the child’s in-hand manipulation skill?
Can the child transition objects in his or her hand using transverse palmar (palm-
to-finger and finger-to-palm) motions, or does he or she stabilize the object and
regrasp?
Precision of interactions with Are tremors present?

objects Do the child’s movements appear ataxic?
Does the child use too much pressure when holding objects?
Does the child use too much pressure to paper when writing?
Does the child have a hard time damping their reach?
Task position and position of Does the child frequently shift his or her position while interacting with an object?
the child Does the child frequently turn or reposition a task?
If so, is he or she doing so to avoid midline crossing or for visual inspection?
Ergonomic factors What type of pencil does the child use?

What type of paper does the child write on?
Where is the paper positioned in relation to the child?
Daly, Kelley, & Krauss, 2003; Maeland, 1992; Tseng & As can be seen by this discussion of assessment of
Cermak, 1993; Tseng & Murray, 1994; Weil & motor performance, much overlap and interdepend-
Amundson, 1994). The Test of Visual Motor Integra- ence exist between the areas of motor development.
tion (VMI) has been supported in the literature as a The ultimate goal of the process of motor assessment
useful screening tool for handwriting abilities. Research is to identify the unique strengths and weaknesses of
suggests that students are ready to engage in formal the individual. Both formal and informal assessments
handwriting instruction once they have mastered the determine this vital information. Once skill levels are
ability to copy the first nine forms on the VMI (Beery identified, determining the etiology or source of the
& Butkenica, 1997; Daly, Kelley, & Krauss, 2003; Weil documented skill deficiencies provides the basis for
& Amundson, 1994). The researchers have concluded program and intervention planning.
that most children who are typically developing will be
ready for standard handwriting instruction in the later
part of their kindergarten year. Visual motor inte-
FORMULATION OF WRITTEN LANGUAGE
gration was found to be the best predictor of legibility A written language assessment may be indicated during
for both American and Norwegian children (Solvik, a comprehensive assessment of handwriting, and espe-
1995) and a group of Chinese school-aged children cially when speed difficulties are noted. Here, the goal
(Tseng & Murray, 1994). is to determine if problems in written language (i.e.,
formulation) exist and if so, if they could be a factor

affecting handwriting rate. It stands to reason that a
SENSORY PROCESSING
child who spends more time in formulation of thoughts Sensory processing is a broad term that refers to the
and written communication will also likely take longer way in which the central and peripheral nervous
to put those thoughts to paper. systems manage incoming sensory information from
Written language assessment usually is accomplished the senses (Lane, Miller, & Hanft, 2000). Basically,
by a speech language pathologist. Possible tools that sensory processing refers to the sequence of events that
may be used to conduct a written language assessment occurs as we take in and respond to environmental
are summarized in Table 14-4. stimulation. In the assessment of handwriting—in addi-
Table 14-4 Instruments to formally assess written language
Oral and Written Language Carrow-Woolfolk, 1995 3–21.11 years Use of conventions
Scales (OWLS) Use of linguistic forms
Communicate meaningfully
Test of Early Written Hresko, Herron, and 4–10 years Basic writing
Language (TEWL-2) Peak, 1996 Contextual writing
Test of Written Language 3 Hammil and Larsen, 7.6–17.11 years Spontaneous formats
(TOWL-3) 1996 Contextual conventions
Contextual language
Story construction
Contrived formats
Style
Spelling
Vocabulary
Logical sentences
Sentence combining
Test of Written Expression McGhee, Bryant, 6.6–14.11 years Ideation

(TOWE) Larson, and Rivera, Semantics
1995 Syntax
Capitalization
Punctuation
Spelling
Composition/essay
Written Language Assessment Grill and Kirwin, 1989 8–18 years General writing ability
Productivity
Word complexity
Readability
Written language
Writing Process Test Warden and Grades 2–12 Purpose/focus

Hutchinson, 1992 Audience
Vocabulary
Style/tone
Support/development
Organization
Sentence structure/variety
Grammar/usage
Capitalization
Spelling
tion to visual perception—tactile-proprioceptive,

kinesthesia, and praxis aspects require specific atten-
ACTUAL EVALUATION OF
tion. Most of these aspects are assessed through HANDWRITING PERFORMANCE
structured observation during task performance and
are included in Table 14-3. Tactile-proprioceptive pro- The process of gathering information for a compre-
cessing is necessary to provide the child with infor- hensive handwriting evaluation has already largely been
mation used to grasp the pencil. Kinesthesia provides completed through observations made during previous
the child with information that is used to gauge testing. Specifically, observations about hand domi-
pressure on the pencil and of the pencil on the paper nance, midline crossing, grasp patterns to a pencil, the
while writing or coloring. In addition, integration of firmness of that grasp, and the amount of pressure to
vision and kinesthesia guides the direction of a writing paper have all been made during the fine and visual
tool. Children who have tactile-proprioceptive or motor assessment. In addition, observations about
kinesthesia impairments may hold their pencil too stability and compensatory movement patterns also
firmly or loosely or write with increased or decreased have been made. In this section, the focus is on the
pressure to paper, both of which can influence actual process of handwriting. Initially the domains of
endurance and quality of writing. Laszlo and Bairstow handwriting, legibility components, speed of writing,
(1984) proposed that kinesthetic feedback is essential and ergonomic factors are discussed as outlined by
to handwriting development. They proposed that Amundson (1992, 2001), followed by a discussion of
kinesthetic information has two functions in the commercially available assessment tools.
performance and acquisition of handwriting: It pro-
vides ongoing error information, and it is stored in
memory to be recalled when the writing is repeated. If
DOMAINS OF HANDWRITING
kinesthetic information cannot be perceived or used, Evaluating the various domains of handwriting allows
efficient programming cannot occur. Levine (1987) the therapist to identify which tasks the child is having
proposed that kinesthetic impairment in children might more difficulty with and address those tasks in the
lead to decreased speed of handwriting because of intervention plan (Amundson, 1992). Handwriting
either the excessive pressure needed for kinesthetic skills needed by students are included in Box 14-1.
feedback or the slower visual feedback used to substi-
tute for kinesthetic feedback. In addition, the child
who has tactile-proprioceptive or kinesthesia impair-
LEGIBILITY COMPONENTS
ment may continue to require visual monitoring of his Legibility deficits in handwriting are often the primary
or her hand for handwriting tasks. A recent study reason for referral for handwriting problems. These
suggested that kinesthetic training did not improve
handwriting legibility or kinesthesis in children; there-
fore evaluation may not offer treatment options but
awareness of deficits in the child’s underlying compo-
nents (Sudsawad et al., 2002). BOX 14-1 Handwriting Skills Needed
Praxis refers to the planning and performance of a by Students
motor movement or task, or a series of motor move-
ments or tasks. Impairments in praxis interfere with • Writing the alphabet and numbers from memory
letter formation and may be seen initially as initiation requires that the student remembers letter/number
deficits. The child may appear to form the letter formation, their sequence, and maintains consistent
letter case (upper or lower).
differently each time and act as if he or she had never • Copying. Both near-point (copying from a nearby
been taught proper formation. Further, praxis can model) and far-point (copying from a distant model)
impair building words from letters and writing letters are used by students to take notes and communicate
or words on an automatic level. information.
Together, assessment of all of the discussed perfor- • Manuscript-to-cursive transition requires the student
mance components provides information for the to transcribe manuscript letters and words to cursive
therapist to determine current developmental strengths letters and words and demands a mastery of both
letter forms.
and weaknesses related to handwriting performance. • Dictation requires integration of both auditory
Noted deficits may serve as the foundation for noted processing and motor responding.
handwriting difficulties and are used to interpret the • Composition is a high level task requiring both
findings of the actual assessment of handwriting written language and handwriting elements.
performance.
deficits may be caused by a number of components

and are assessed by analysis of a writing sample. Letter
WRITING SPEED
formation is assessed initially to be sure letters are Coupled with legibility, writing speed is a cornerstone
properly formed and legible. Alignment of letters on a of functional handwriting (Amundson, 1995). In
line and in relation to each other is also assessed. general, speed of handwriting decreases as the com-
Spacing that needs to be addressed includes letters plexity of a task increases. Therefore speed of writing
within words, words within sentences, and the organi- needs to be addressed within each of the domains of
zation of the whole page. Another component to be handwriting to determine the impact of the different
addressed is letter size, which refers to the size of letters task demands. Although speed for copying tasks may be
within writing guidelines and in relation to each other. adequate, slower handwriting speed for composition
Together, all of these qualitative aspects of legibility task may indicate coexisting formulation deficits.
comprise the components of handwriting that are often Slow handwriting speed affects functional perform-
the visible evidence of handwriting impairment. ance because it prevents students from meeting time
Informal evaluation also may include comparing the constraints involved in schoolwork (Cermak, 1991;
child to his or her peers in terms of the completion of Levine et al., 1981). Slow hand writers are different in
a writing task during the allotted time and the amount the way they process written information from normal
of work completed. speed writers. Slow hand writers depend on visual
Common handwriting problems such as incorrect processing, whereas normal speed writers are motor
letter formation, poor alignment, reversals, uneven size based (Tseng & Chow, 2002). Slow hand writers were
of letters, irregular spacing between letters and words, poorer as a group than children with normal-speed
and slow motor speed (Alston & Taylor, 1987; hand writers in graphomotor output, level of per-
Johnson & Carlisle, 1996) do not necessarily arise from ceptual motor skills, and decreased attention (Tseng &
identical underlying mechanisms. Careful observation Chow, 2000). Rosenblum, Parush, and Weiss (2003)
and evaluation are needed to determine the underlying using a computerized digital system found that non-
causes. proficient 8- to 9-year-old handwriters required sig-
Two main approaches used in formal assessments to nificantly more time to perform handwriting tasks and
rate handwriting legibility are rating of the legibility that their “in air” time, was especially longer as com-
components (i.e., slant, size, alignment) and rating of pared to the proficient handwriters. “In air” time refers
global legibility (i.e., overall readability of writing sam- to pauses, or temporary halts in the flow of writing
ple). The assessment of legibility using ratings of legi- (Benbow, 1995; Kaminsky & Powers, 1981). The
bility components can be extremely time consuming researchers found this phenomenon not as a pause
and may not provide a clear picture of the overall but rather as a “motion tour” taking place in the air
readability of a child’s written work (Sudsawad et al., between the writing of successive characters, segments,
2001). Often, the components are judged against letters, and words. It may be that the “in air” time
standard templates, which may not be adaptable to helps the student to prepare to execute subsequent
variations in handwriting style. Changes in these com- characters or character segments. This time may be
ponents may or may not indicate whether the child’s needed to parameratize the motor program or initiate
handwriting is easier or harder to read. activity in the muscle groups needed to execute the
The readability of letters, words, and numerals is the character. In addition, the researchers found that the
primary criterion that determines global legibility. nonproficient hand writers’ handwriting speed was
Evaluation of global legibility is quick and simple and slower and they wrote fewer characters per minute.
addresses the functional aspects of handwriting legi- Formal assessments of handwriting speed are
bility (Amundson, 1995). The evaluator is more con- included in Table 14-5.
cerned with whether the handwriting can be read with
ease than with whether an exact correspondence exists
between a handwritten letter and the model letter
E RGONOMIC FACTORS
(Talbert-Johnson et al., 1991). The ergonomic factors affecting handwriting (e.g.,
Examples of manuscript writing tests that rate writing posture, grip, stability) have been discussed
legibility components include The Children’s Hand- in the related performance components section, but
writing Evaluation Scale for Manuscript Writing require further mention here. From the literature,
(Phelps & Stempel, 1984) and the Minnesota writing tools, paper, and surfaces appear to be impor-
Handwriting Test (Reisman, 1993, 1999). The Eval- tant factors in handwriting.
uation Tool of Children’s Handwriting (Amundson, In assessing grip it is important to keep in mind the
1995) evaluates global legibility of manuscript writing. effects of the task and writing tool on the grasp.
302
Table 14-5 Instruments to assess handwriting
Evaluation Tool of Children’s

Minnesota Test of Handwriting Skills Handwriting (ETCH)
Handwriting (THS) (Gardner, 1998) (Amundson, 1995) Children’s Handwriting
Assessment Evaluation Scale (CHES)
(MHA) THS– ETCH– (Phelps & Stempel,
(Reisman, 1999) Manuscript THS–Cursive Manuscript ETCH–Cursive 1984)
Age/grade Range: First and second 5–8.11 years 8–10.11 yrs Grades 1-6 Grades 1-6 Grades 3-8
grades
Part III • Therapeutic Intervention
Test Type:
Norm-referenced X X X X
Criterion-referenced X X
Script Assessed:
Manuscript X X X
Cursive X X X
Domains Tested:
Near-point copying X X X X X X
Far-point copying X X
Composition X X
Dictation X X X X
Upper or lower case X X X X
Manuscript to cursive X
Sensorimotor X X
Paper:
Lined X X X
Unlined X X X
Pencil: Size used by student No. 2 No. 2 No. 2 No. 2 No. 2

Table 14-5 Instruments to assess handwriting—cont’d
Evaluation Tool of Children’s

Minnesota Test of Handwriting Skills Handwriting (ETCH)
Handwriting (THS) (Gardner, 1998) (Amundson, 1995) Children’s Handwriting
Assessment Evaluation Scale (CHES)
(MHA) THS– ETCH– (Phelps & Stempel,
(Reisman, 1999) Manuscript THS–Cursive Manuscript ETCH–Cursive 1984)
Time:
Administration 2.5 minutes 15-20 minutes 15-20 minutes 15-30 minutes 15-30 minutes 2 minutes
Scoring 3-7 minutes 15-20 minutes 15-20 minutes 10-20 minutes 10-20 minutes 3-7 minutes
Assessed:
Rate X X X X X X
Quality (types) L, F, A, Sz, Sp Sp, A, Sz, F Sp, A, Sz, F F, Sp, Sz, A F, Sp, Sz, A F, Sl, R, Sp, Ap
Scores Yielded: Classification/Rating PR, Std, Sc, St PR, Std, Sc, St Percent Accurate Percent Accurate Std, PR
Reliability:
Interrater 0.77 to 0.88 for 0.64 to 0.94 for inexperienced Ranging from 0.88 to 0.95
inexperienced raters raters and from 0.63 to 0.91 for
and from .90 to .99 experienced raters
for experienced raters
Intrarater Ranged from 0.96 0.53 to 0.97 for inexperienced raters
to 1 and from 0.64 to 0.98 for experienced
raters
Test-retest 0.60 to 0.89 (ICC) Ranged 0.63 to 0.71 for total scores
Validated: 2000 first and On 839 children from a Items and scoring were developed On 1365 children from Dallas
second grade nationwide sample by literature review and field testing County Schools
students from a
nationwide sample
Available: Psychological Corp Psychological & Educational Pub OT Kids Author
Quality Rating Key: L=legibility, F=form, A=alignment, Sz=size, Sp=spacing, Sl=slant, R=rhythm, Ap=appearance
Scores Yielded Key: PR=percentile rank, Std=standard score, Sc=scaled score, St=stanine Continued
304
Handwriting Test of Legible

Denver Handwriting Speed Test Handwriting
CHES–Manuscript Analysis (Anderson, (Wallen et al, (Larsen & Chinese Speed Test
(Phelps, 1987) 1983) 1996a) Hammill, 1989) (Tseng, 1998)
Age/grade Range: First and second graders Grades 3-8 3-12 years 7-18.5 years Grades 2-6
Test Type:
Norm-referenced X X X X
Part III • Therapeutic Intervention
Criterion-referenced X
Script Assessed:
Manuscript X X X
Cursive X X X
Domains Tested:
Near-point copying X X X X
Far-point copying X
Composition X
Dictation X
Upper or lower case X
Manuscript to cursive X
Sensorimotor
Paper:
Lined X X
Unlined X
Pencil: No. 2 No. 2 No. 2 No. 2
Time:
Administration 2 minutes 3 minutes 3 minutes
Scoring 3-7 minutes 2 minutes 2 minutes
Handwriting Test of Legible

Denver Handwriting Speed Test Handwriting
CHES–Manuscript Analysis (Anderson, (Wallen et al, (Larsen & Chinese Speed Test
(Phelps, 1987) 1983) 1996a) Hammill, 1989) (Tseng, 1998)
Assessed:
Rate X X X X
Quality (types) F, Sp, R, Ap
Scores Yielded: Std, Pr Pr Std Std, Pr Std, Pr
Reliability:
Interrater Ranged from 0.85 Ranged from 0.99 Reported to be 0.95
to 0.93 to 1
Intrarater Ranged from 0.98

to 1
Test-retest Ranged from 0.71 Reported to be 0.98
to 0.92
Validated: On 643 Dallas County On 1292 Australian On 1525 Chinese

School students students students
Available: Author Out of print Helios Art & Book Out of print Author
Quality Rating Key: L=legibility, F=form, A=alignment, Sz=size, Sp=spacing, Sl=slant, R=rhythm, Ap=appearance
Scores Yielded Key: Pr=percentile rank, Std=standard score, Sc=scaled score, St=stanine
Children used a less mature grasp in coloring than properties of the instrument chosen. In the opinion of
drawing (Schneck, 1991). Young children aged 23 to the present authors, of the available instruments the
24 months used a more mature grasp when drawing Minnesota Handwriting Assessment (MHA) (Reisman,
with a piece of crayon than with a pencil (Yakimishyn & 1999), Test of Handwriting Skills (THS) (Gardner,
Magill-Evans, 2002). In addition, no difference in 1998), and Evaluation Tool of Children’s Handwriting
grasp maturity was found when using a pencil com- (ETCH) (Amundson, 1995) are the most useful. These
pared with a marker. Lastly, a more mature grasp was instruments could be used in any number of settings.
demonstrated when drawing on the easel compared Each of these instruments provides for assessment of
with the table when using a crayon, not with a marker both legibility and rate or speed aspects of handwriting.
or pencil. Krzesni (1971) found a significant increase in All of the instruments also have in-depth scoring pro-
writing performance with a felt pen. However, Lamme cedures that allow determination of the most common
and Aynis (1983) found that writing tools did not legibility errors.
affect legibility. The MHA has the most limited scope in that it is an
Several studies have extended the effects of writing assessment of near point copying only and can be used
paper on handwriting performance. Lindsay and for first and second graders only. The flexibility for the
McLennan (1983) and Weil and Amundson (1994) assessment of both manuscript and D’Nealian script,
reported that for beginning writers, lined paper may its short administration time, and its relatively short
add an element of confusion and compromise legibility. scoring time make it attractive for clinical practice. A
Krzesni (1971) found the opposite is true for older categoric scoring summary on the MHA allows com-
children; legibility improved with lined paper in 9-year- parison to peers and can be used to determine the need
old children. Halpin and Halpin (1976) compared for intervention. Given these test constructs it is the
handwriting quality in kindergarten children with 1- recommended instrument for first and second graders
and 11/2-inch–spaced paper and found no difference. experiencing difficulties with learning the writing
process.
For students older than second grade, the THS and
KEYBOARDING PERFORMANCE ETCH are the recommended instruments for use. Both
Sixth-grade students demonstrated low to moderate of these instruments allow for assessment of rate and
correlation between keyboarding and handwriting per- quality of writing within a number of handwriting
formance (Rogers & Case-Smith, 2002). This suggests domains (e.g., copying, dictation, composition) and
that these forms of written expression require distinctly have similar administration and scoring times. The
different skills. Most students who were slow at hand- ETCH allows assessment of more domains of hand-
writing or had poor legibility increased the quantity writing and, in addition, addresses sensorimotor aspects
and overall legibility of the text they produced with a of handwriting as part of the assessment. Given these
keyboard. This suggests that it is important to assess added benefits of the ETCH, it is the recommended
keyboarding in nonproficient writers because it may assessment for children in this age group. However,
simplify their text production. It may allow certain one drawback to its use is its lack of normative data
children to concentrate on content and meaning when (scoring results in a percentage of accuracy). Therefore
composing and encourage them to engage in compo- if normative data are necessary for eligibility or other
sitional writing. purposes, only the THS provides this information of
the two in this age group.
COMMERCIALLY AVAILABLE Of the other instruments, the Children’s Handwriting
Evaluation Scale (CHES) (Phelps & Stempel, 1984)
ASSESSMENT TOOLS and Children’s Handwriting Evaluation Scale for
Several handwriting assessment tools are commercially Manuscript Writing (CHES-M) (Phelps, 1987) were
available. Although Table 14-5 provides a graphic sum- validated approximately 15 years previously and on a
mary of these instruments, Appendix 14A also provides convenient sample of students in a school system in
an in-depth analysis of each of the instruments that is Texas. In addition, test composition factors relating to
still currently available and summarizes some findings. the scoring of quality and its resultant interpretation,
As can be seen by analyzing Appendix 14A, few and the use of unlined paper cause concern. Given
quality instruments specifically designed to assess hand- these factors the overall value and validity of these two
writing are available. Selecting the most appropriate instruments is questioned. Although the Handwriting
instrument is dependent on the individual needs of the Speed Test (HST) (Wallen, Bonney, & Lennox,
evaluating therapist. In selecting a handwriting instru- 1996a,b) may be useful if determining how a student’s
ment, therapists must not only consider a child’s area handwriting speed compares to others, its lack of
of handwriting difficulty, but also the psychometric legibility scoring makes its uses limited. Further, given
its validation on a sample of students from Australia Amundson SJ, Weil M (1996). Prewriting and handwriting
only, the reliability and validity of finding are ques- skills. In J Case-Smith, AS Allen, PN Pratt, editors:
Occupational therapy for children. St. Louis, Mosby.
tioned also. Anderson PL (983). Denver handwriting analysis. Novato,
It is important to note that when comparing Table CA, Academic Therapy Publications.
14-5 to the instruments in this Appendix, two of Benbow M (1995). Principles and practices of teaching
the instruments, the Denver Handwriting Analysis handwriting. In A Henderson, C Pehoski, editors: Hand
(Anderson, 1983) and Test of Legible Handwriting function in the child (pp. 255–281). St Louis, Mosby.
Berninger V, Mizokawa D, Bragg R. (1991). Theory-based
(Larsen & Hammill, 1989) are no longer commercially diagnosis and remediation of writing disabilities. Journal
available and therefore are not reviewed here. When of School Psychology, 29:57–97.
discussing the out-of-print status with the respective Berninger VW, Rutberg J (1992). Relationship of finger
publishers, both stated that there was little demand for function to beginning writing: Application to diagnosis of
the instruments, which is interesting given the fact that writing disability. Developmental Medicine and Child
handwriting difficulties are a primary reason for referral Beery KE, Butkenica NA (1997). Developmental Test of
to occupational therapy. However, this supports the Visual Motor Integration: Administration and Scoring
findings of a recent investigation that found that stan- Manual. Parsippany, NJ, Modern Curriculum Press.
dardized handwriting assessments were rarely employed Bonney M (1992). Understanding and assessing
in assessment of handwriting (Feder, Majnmer, & handwriting difficulty: Perspectives from the literature.
Australian Journal of Occupational Therapy, 39:7–15.
Synnes, 2000). Bruininks RH (1978). Bruininks-Oseretsky test of motor
proficiency examiner’s manual. Circle Pines, MN,
American Guidance Service.
Burton AW, Dancisak AW (2000). Grip form and
SUMMARY graphomotor control in preschool children. American
Journal of Occupational Therapy, 54:9–17.
Carrow-Woolfolk, E (1995). Oral and written language
As can be seen by this discussion, the assessment of scales. Circle Pines, MN, American Guidance Service.
handwriting difficulty is a complex multifaceted Case-Smith J (1996). Fine-motor outcomes in preschool
process. Administration of a formalized assessment of children who receive occupational therapy services.
handwriting alone does not provide the information American Journal of Occupational Therapy, 50:52–61.
Case-Smith J (1998). Fine motor and functional
necessary to determine the root of the difficulty or performance outcomes in preschool children. American
effectively plan a program. Stability, visual perception, Journal of Occupational Therapy, 52:788–796.
motor performance, written language, and sensory Cermak, S. (1991). Somatodyspraxia. In A Fisher, E
processing aspects of development serve as the foun- Murray, A Bundy (Eds.) Sensory integration: Theory and
dations for developing the skill of handwriting. Thus practice (pp. 138-170). Philadelphia, F.A. Davis.
Chase C (1986). Essay test scoring: Interaction of relevant
although administration of a formalized assessment of variables. Journal of Educational Measurement,
handwriting can determine the nature of handwriting 23:33–41.
difficulty demonstrated by a child, assessment of the Chu S (1997). Occupational therapy for children with
related performance components provides the basis for handwriting difficulties: A framework for evaluation and
determining the potential cause(s) of the impairments. treatment. British Journal of Occupational Therapy,
60:514–520.
Identification of these causes allows appropriate Colarusso RP, Hammill DD (2003). Motor-free visual
intervention planning to develop remediation of the perception test – third edition. Novato, CA, Academic
handwriting impairments. Therapy Publications.
Cornhill H, Case-Smith J (1996). Factors that relate to
good and poor handwriting. American Journal of
Occupational Therapy, 50:732–739.
Daly CJ, Kelley GT, Krauss A (2003). Relationship between
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on Exceptional Children, 25:1–14. disadvantages. American Journal of Occupational Therapy,
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Halpin G, Halpin G (1976). Special paper for beginning Crippled Children.
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Austin, TX, PRO-ED. handwriting and keyboarding performance of sixth-grade
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Appendix 14A
HANDWRITING ASSESSMENT
INSTRUMENTS
categories (Legibility, Form, Alignment, Size, and

MINNESOTA HANDWRITING Spacing) for each letter of the sample.
ASSESSMENT Does it give a clinical diagnosis? No.
AUTHOR, YEAR PURPOSE

Reisman, 1999 The MHA was designed to help meet the needs of
many school districts and special education depart-
ments that require a handwriting assessment to support
DESCRIPTION the teacher’s subjective judgment of poor quality or
The Minnesota Handwriting Assessment (MHA) is slow rate (Reisman, 1999). It is recommended that
used to assess manuscript and D’Nealian handwriting interpretive ratings obtained after scoring the MHA be
in first and second graders who have knowledge of the used to guide the need for further assessment and the
English language. The MHA assesses Rate for the whole intervention process.
writing sample and five quality categories for each letter
of the sample: Legibility, Form, Alignment, Size, and
Spacing. Subjective quality ratings are collected and
ASSESSMENT COMPONENTS
yield interpretive cutoff scores within each category: Type of Assessment: Near-point copy assessment
Performing like peers (top 75% of the final sample), Task(s): The student is required to copy from a printed
performing somewhat below peers (within the bottom stimulus sheet onto lines below the words “the
5% and 25% of the final sample), or performing well brown jumped lazy fox quick dogs over.” The mixed
below peers (bottom 5% of the final sample). It is recom- word order of the sentence is used to reduce the
mended that students performing somewhat below speed and memory advantage of better readers by
peers should be monitored to determine if ongoing requiring all students to refer to the stimulus items
instruction or practice is needed or whether the student word by word.
is demonstrating delayed development of underlying Paper Type: Supplied lined paper with center dotted
hand skills. It is recommended that students perform- line
ing in the well-below-peers category be referred for Pencil Type: Any size pencil typically used by the student
comprehensive evaluation to determine the cause of
handwriting difficulties. ADMINISTRATIVE /SCORING TIME
Administration: The test is timed for the first 21/2
CONTENTS minutes to obtain the Rate score and then, if
What does the schedule try to measure? The MHA assesses necessary, the students are given time to complete
handwriting performance. Specifically measured are the sample to allow for scoring the five quality
Rate for the whole writing sample and five quality categories.
311
Scoring: After some experience with the instrument (30 tageous to clinical practice. Reliability findings may be
samples), scoring time ranges from 3 to 7 minutes. inflated because of use of Pearson for statistical analysis
From experience, scoring takes closer to 10 to 12 (Ottenbacher & Tomchek, 1993, 1994).
minutes.
REFERENCES
PARTICIPANTS Ottenbacher KJ, Tomchek SD (1993). Reliability
Children: First and second graders analysis in therapeutic research: Practice and pro-
Developmental Level: Grade level cedures. American Journal of Occupational Therapy,
47(1):10–16.
Ottenbacher KJ, Tomchek SD (1994). Measurement
DERIVATION error in method comparison studies: An empirical
Writing sample and scoring criteria were developed examination. Archives of Physical Medicine &
from a pilot version, through literature review and field Rehabilitation, 75(5):505–512.
testing with revision. Peterson CQ (1999). The effect of an occupational
therapy intervention handwriting in academically at-
risk first graders. Unpublished doctoral dissertation.
PUBLISHED MATERIAL Cincinnati, The Union Institute Graduate School.
Author/Others: author (Reisman, 1993, 1999); others Reisman JE (1993). Development and reliability of the
(Peterson, 1999) research version of the Minnesota Handwriting Test.
Usefulness: The MHA was designed to help meet the Physical and Occupational Therapy in Pediatrics,
needs of many school districts and special education 13:41–55.
departments that require a handwriting assessment Reisman JE (1999). Minnesota handwriting assessment.
to support the teacher’s subjective judgment of poor Los Angeles, Psychological Corporation.
quality or slow rate (Reisman, 1999).
Validated: On 2000 first- and second-grade students
from a nationwide sample (Reisman, 1993, 1999) TEST OF HANDWRITING SKILLS
with cutoff scores determined after analysis. Content
validity was established in development.
Reliability: Interrater ranged from 0.77 to 0.88 AUTHOR, YEAR
(Pearson) for inexperienced raters and from 0.90 to Gardner, 1998
0.99 for experienced raters. Intrarater reliability (5-
to 7-day interval) ranged from 0.96 to 1. Test-retest
stability (5- to 7-day interval) for performance level
DESCRIPTION
ranged from 64% to 86%. Test-retest reliability was The Test of Handwriting Skills (THS) is used to assess
conducted in a related study (Peterson, 1999) with a child’s neurosensory integration ability in hand-
at-risk students with correlations ranging from 0.60 writing either manuscript or cursive and in upper and
to 0.89 (Internal Consistency Coefficient ICC). lower case forms, and to measure the speed with which
Additional Statistical Analysis: A special group study a child handwrites from: writing from memory, upper
was conducted to examine first- and second-grade and lower case letters of the alphabet in sequence;
students in regular education, special education, and writing from dictation, upper and lower case letters of
special education plus occupational therapy. Scores the alphabet out of sequence; writing from dictation,
on the MHA and Test of Visual Motor Skills (a numbers out of numeric sequence; copying selected
design copying visual motor control test) were letters from the alphabet; copying selected words; copy-
compared with correlations ranging from 0.37 ing selected sentences; and writing from dictation
(second grade) to 0.89 (occupational therapy). selected words. Although the purpose of the THS is to
measure how a child (ages 5 years, 0 months to 10
OTHER DATA IN SCHEDULE /OTHER years, 11 months) can write letters, words, and num-
bers spontaneously, from dictation, or from copying, it
I NFORMATION /COMMENTS is also used to determine the speed by which a child can
Is a helpful tool in discerning the types of handwriting produce letters spontaneously. Each of the 206 letters
errors exhibited by first- and second-grade students. in the sample is scored using a four-point scale. The
Quality scoring for each letter provides a mechanism THS provides normative data in 3-month increments
for focusing treatment and evaluating progress. Its for each subtest (standard scores, scaled scores, per-
short administration and scoring time make it advan- centile ranks, and stanines).
CONTENTS PARTICIPANTS
What does the schedule try to measure? The THS meas- Children: Ages 5 years, 0 months to 10 years 11
ures quality of handwriting in children. In addition months
to the 206 scorable-language symbols, the THS, Developmental Level: Grade level
Manuscript version (for children ages 5 years to 8
years 11 months) has reversal of letters, letters touch
one another, speed of writing letters spontaneously
DERIVATION
from memory, and converting lower case letters to Overall test developed based on literature review.
upper case letters, and vice versa special features. The Words used in dictation components were determined
THS, Cursive version (for children ages 8 years to 10 by a group of 15 teachers.
years 11 months) has in addition to the 206 scorable
letters, only one feature: speed of writing letters
spontaneously from memory.
PUBLISHED MATERIAL
Does it give a clinical diagnosis? No. Author/Others: Author (Gardner, 1998); others
Usefulness: Quality and rate findings of the assessment
are used to identify both the strengths and
PURPOSE weaknesses of a child’s handwriting that can be used
The purpose of the THS is to measure how a child can to develop a remedial program.
write letters, words, and numbers spontaneously, from Validated: On 839 children (Gardner, 1998) from a
dictation, or from copying. It is also used to determine nationwide sample with normative data determined
the speed by which a child can produce letters spon- after analysis. Construct validity was in the moderate
taneously. These components of the assessment can range. Concurrent validity studies yielded positive
identify both the strengths and weaknesses of a child’s correlations with the TVMS-R, WRAT-3 (spelling
handwriting that can be used to develop a remedial component), Bender, and VMI.
program. The goal of remediation is to improve a Reliability: Internal consistency was described as
child’s legibility of letters, words, and numbers, along “acceptable” with reliability coefficients ranging
with increasing speed of writing. from .51 to .78.
Additional Statistical Analysis: None
Type of Assessment: Spontaneous composition, dictation OTHER DATA IN SCHEDULE /OTHER
and near-point copy assessment
Task(s): (a) Writing from memory, upper case letters of
I NFORMATION /COMMENTS
the alphabet in sequence; (b) writing from memory, Helpful tool in discerning the types of handwriting
lower case letters of the alphabet in sequence; (c) errors exhibited by students. Cumbersome scoring and
writing from dictation, upper case letters of the lengthy administration may inhibit frequent use in clin-
alphabet out of sequence; (d) writing from dictation, ical practice. The use of unlined paper for this assess-
lower case letters of the alphabet out of sequence; (e) ment may facilitate further handwriting impairments in
writing from dictation, numbers out of numerical that several studies have shown that children’s hand-
sequence; (f) copying selected upper case letters from writing on unlined paper when compared with lined
the alphabet; (g) copying selected lower case letters paper is poorer in quality (Alston & Taylor, 1987;
from the alphabet; (h) copying selected words; (i) Burnhill et al., 1983; Pasternicki, 1984).
copying selected sentences; and (j) writing from
dictation selected words.
Paper Type: Supplied unlined paper in test booklet
REFERENCES
Pencil Type: Standard number 2 pencil Alston J, Taylor J (1987). Handwriting: Theory,
research, and practice. Worcester, MA, Billings.
Burnhill P, Hartley J, Lindsay D (1983). Lined paper,
ADMINISTRATION /SCORING TIME legibility and creativity. In J Hartley, editor: The
Administration: The test can be administered in 15 to psychology of written communication. London, Kogan
20 minutes. Page.
Scoring: After some practice, scoring time ranges from Gardner M (1998). The test of handwriting skills:
15 to 20 minutes. From experience, scoring takes all manual. Hydesville, CA, Psychological and Educa-
of 20 minutes. tional Publications.
Pasternicki JG (1984). Teaching handwriting: The

resolution of an issue. Support for Learning,
ADMINISTRATIVE /SCORING TIME
1:37–41. Administration: The test is timed for the first 2 minutes
to obtain the Rate score and then, if necessary, the
students are given time to complete the sample to
allow for scoring the quality categories.
Scoring: Scoring time ranges from 3 to 7 minutes.
CHILDREN’S HANDWRITING
EVALUATION SCALE PARTICIPANTS
Children: Third through eighth graders
AUTHOR, YEAR Developmental Level: Grade level
Phelps and Stempel (1984)
DERIVATION
DESCRIPTION No information identified.
The Children’s Handwriting Evaluation Scale (CHES)
is used to assess cursive handwriting in third through
eighth graders who have knowledge of the English
PUBLISHED MATERIAL
language. The CHES assesses Rate to copy the passage Author/Others: Author (Phelps & Stempel, 1984);
(consisting of 197 letters) and five quality categories of others
the sample: Form, Slant, Rhythm, Space, and General Usefulness: Interpretive ratings obtained after scoring
Appearance. Rate and quality are evaluated independ- the CHES should be used to guide need for further
ently on a five-point scale: very poor, poor, satisfactory, assessment and the remediation process.
good, and very good. Percentile ranges can be assigned Validated: On 1365 third- through eighth-grade
to correspond with rankings. In addition, percentile, students in Dallas County Schools (Phelps &
standard scores, T-scores, and stanines are provided for Stempel, 1984) with cutoff scores determined after
Rate of writing for each grade. analysis. Content validity was established in devel-
opment (Phelps & Stempel, 1984).
Reliability: Interrater ranged from 0.88 to 0.95
CONTENTS (ICC).
What does the schedule try to measure? The CHES Additional Statistical Analysis: The reasons for need
assesses handwriting performance. Specifically, Rate for remediation (performance below the 24th per-
for the whole writing sample and five quality cate- centile) were studied with 9% needing remediation
gories (form, slant, rhythm, space, and general for quality only, 13% for rate only, and 2% for both
appearance) for the whole sample are measured. rate and quality. In addition, rate scores for the CHES
Does it give a clinical diagnosis? No. were compared with rate scores for the American
Handwriting Scale (1957) (no longer available).
Findings showed that students in 1984 wrote at a
PURPOSE slower rate than in 1957 and that the AHS yielded
The main purpose is to assess the rate and quality of a more letters of writing at all grade levels.
student’s handwriting. It is recommended that inter-
pretive ratings obtained after scoring the CHES be
used to guide need for further assessment and the OTHER DATA IN SCHEDULE /OTHER
remediation process.
Useful primarily for rate scoring in that the five-point
ASSESSMENT COMPONENTS total quality scoring for whole sample lacks sensitivity
Type of Assessment: Near-point copy assessment to define specific handwriting problems. The short time
Task(s): The student is required to copy a passage from to administer and score is a positive. Questionable
a printed stimulus sheet directly below reliability and validity given the convenient sample
Paper Type: Supplied unlined blank sheet with the obtained from only Dallas County Schools. Validity of
passage on top findings are also questioned given the tool’s use of
Pencil Type: Number 2 pencil unlined paper.
standard by which to monitor gradual improvement or

REFERENCE immediately define specific problem areas.
Phelps J, Stempel L (1984). Children’s handwriting
evaluation scale. Dallas, TX, Scottish Rite Hospital
for Crippled Children.
Type of Assessment: Near-point copy assessment
Task(s): The student is required to copy two sentences
CHILDREN’S HANDWRITING (57 total letters) on a printed stimulus sheet directly
below.
EVALUATION SCALE FOR Paper Type: Supplied unlined blank sheet with the
MANUSCRIPT WRITING (CHES-M) passage on top
Pencil Type: Number 2 pencil
AUTHOR, YEAR
Phelps, 1987
Administration: The test is timed for 2 minutes. If the
student finishes before 2 minutes, he or she is asked
DESCRIPTION to start again.
The CHES-M is used to assess manuscript handwriting Scoring: Scoring time ranges from 3 to 7 minutes.
in first and second graders who have knowledge of the
English language. The CHES-M assesses Rate to copy
the sentences (consisting of 57 letters) and 10 quality
PARTICIPANTS
components in four main categories: Form, Rhythm, Children: First and second graders
Space and General Appearance. Rate and Quality are Developmental Level: Grade level
evaluated independently. Percentile ranks and standard
scores are provided for Rate of writing for each grade.
With respect to quality ratings, 10 points were assigned
DERIVATION
to each constituent. When all are present, 100 points Derived from the CHES with the same schools used for
are possible with 10 points deducted for each criterion norming purposes.
not met. Scores between 10 and 40 are considered
poor; between 50 and 70, satisfactory; and between 80
and 100 good. Percentile ranks and standard scores are
PUBLISHED MATERIAL
provided for a quality total score based on rating. Author/Others: Author (Phelps, 1987); others
Usefulness: It is intended to provide a standard by
which to monitor gradual improvement or immedi-
CONTENTS ately define specific problem areas.
What does the schedule try to measure? The CHES-M Validated: On 643 first- and second-grade students in
assesses handwriting performance. Specifically, the Dallas County Schools (Phelps & Stempel, 1984)
CHES-M measures Rate for the whole writing sam- with cutoff scores determined after analysis. Content
ple and four quality categories: Form (small letters validity was established in development.
are uniform in height and proportion, tall letters Reliability: Interrater ranged from 0.85 to 0.93
are higher than small and suitably proportioned (ICC).
and aligned, correctly formed and recognizable out Additional Statistical Analysis: None.
of context, letters copied correctly); Space (space
between letters of a word uniform, space between
words adequate and uniform, right margin uncrowded, OTHER DATA IN SCHEDULE /OTHER
space between lines uniform); Rhythm; and General
Appearance
Does it give a clinical diagnosis? No. Short administration and scoring time are benefits to
use in clinical practice. Significant questions relating
to reliability and validity given the convenient sample
PURPOSE obtained from only Dallas County Schools. Validity
The main purpose is to measure rate and quality of of findings is also questioned given the tools use of
manuscript handwriting. It is intended to provide a unlined paper.
REFERENCE ASSESSMENT COMPONENTS

Phelps J (1987). Children’s handwriting evaluation Type of Assessment: Spontaneous composition, dicta-
scale for manuscript writing. Dallas, TX, Scottish Rite tion, near-point, and far-point copy assessment
Hospital for Crippled Children. Task(s): The ETCH-C has the following tasks: (a)
writing from memory, upper and lower case letters of
the alphabet in sequence; (b) writing from memory,
the numbers 1 to 20 in sequence; (c) near-point
EVALUATION TOOL OF copying a short sentence; (d) far-point copying a
CHILDREN’S HANDWRITING short sentence; (e) manuscript-to-cursive transition a
short sentence; (f) dictation three nonsense words;
and (g) sentence composition. The ETCH-M con-
AUTHOR, YEAR sists of all of the preceding subtests with the excep-
Amundson, 1995 tion of manuscript-to-cursive transition.
Paper Type: Supplied lined paper in test booklet
Pencil Type: Standard number 2 pencil
DESCRIPTION
The Evaluation Tool of Children’s Handwriting
(ETCH) is designed to evaluate manuscript (ETCH-
M) and cursive (ETCH-C) handwriting skills of chil- Administration: The test can be administered in 15
dren in grades 1 through 6 who are experiencing to 30 minutes depending on the child’s age and
difficulty with written communication. The ETCH handwriting difficulties
contains seven cursive writing tasks and six manuscript Scoring: After some practice, scoring time ranges from
writing tasks, plus items addressing the child’s ability to 10 to 20 minutes. From experience, scoring takes all
handle the writing tool and paper. The primary focus of of 20 minutes.
the ETCH is to assess a child’s legibility and speed of
handwriting in writing tasks that are similar to those
required of students in the classroom. The ETCH also
PARTICIPANTS
examines specific legibility components of a child’s Children: Children in grades 1 through 6, ages 6 years,
handwriting such as letter formation, spacing, size, and 0 months to 12 years, 5 months
alignment, as well as a variety of sensorimotor skills Adults: Can be used to gather descriptive information
related to the child’s handling of the writing tool and related to their functional handwriting performance.
paper. Subtest and ETCH total scores are calculated as Developmental Level: Grade level
percentages on the basis of the number of readable
letters, words, and numbers against possible letters,
words, and numbers.
DERIVATION
Writing sample and scoring criteria were developed
from a pilot version through literature review and field
CONTENTS testing with revision.
What does the schedule try to measure? The ETCH
examines specific legibility components of a child’s
handwriting (manuscript or cursive) such as letter
PUBLISHED MATERIAL
formation, spacing, size, and alignment, as well as a Author/Others: Author (Amundson, 1995); others
variety of sensorimotor skills related to the child’s (Diekema, Deitz, & Amundson, 1998; Grace-
handling of the writing tool and paper. These com- Frederick, 1998; Koziatek & Powell, 2002; Schneck,
ponents are measured from spontaneous composi- 1998; Sudsawad et al., 2001)
tion, dictation, near-point, and far-point copying Usefulness: Useful in assessing a child’s legibility and
tasks. speed of handwriting in writing tasks that are similar
Does it give a clinical diagnosis? No. to those required of students in the classroom. This
is useful in analyzing underlying sensorimotor
functions of handwriting and assessing handwriting
PURPOSE quality to determine the need for intervention and
The primary purpose of the ETCH is to assess a child’s baseline for monitoring progress.
legibility and speed of handwriting in writing tasks Validated: Although one construct validity study
that are similar to those required of students in the (Grace-Frederick, 1998) showed agreement between
classroom. teacher ratings of poor handwriting and poor per-
formance on the ETCH, another study (Sudsawad et Sudsawad P, Trombly CA, Henderson A, Tickle-Degnen
al., 2001) reported that little agreement was noted L (2001). The relationship between the Evaluation
between teacher questionnaires of handwriting Tool of Children’s Handwriting and teacher’s
difficulty and ETCH performance. The concurrent perceptions of handwriting legibility. American
validity coefficients were 0.61 for ETCH-C total Journal of Occupational Therapy, 55:518–523.
words and 0.65 for total letters and handwriting
grade.
Reliability: Interrater ranged from 0.64 to 0.94 HANDWRITING SPEED TEST
(Pearson) for inexperienced raters and from 0.63 to
0.91 for experienced and inexperienced raters.
Intrarater reliability ranged from 0.53 to 0.97 for
AUTHOR, YEAR
inexperienced raters and from 0.64 to 0.98 for expe- Wallen, Bonney, and Lennox (1996a,b)
rienced and inexperienced raters. Test-retest relia-
bility was conducted in a related study (Diekema et
al., 1998) with correlations ranging from 0.63 to
DESCRIPTION
0.71 (Pearson) for total numeral, letter and legibility, The Handwriting Speed Test (HST) is a standardized,
with generally lower subtest coefficients (0.20 to 0.76). norm-referenced test of handwriting speed for children
Additional Statistical Analysis: None and adolescents in grades 3 through 12. It is intended
to be used as one component of a multifaceted assess-
OTHER DATA IN SCHEDULE /OTHER ment of handwriting. After a 3-minute trial of copying
the words “the quick brown fox jumps over the lazy
I NFORMATION /COMMENTS dog” as many times as they can, a letters per minute is
One of the more widely used instruments, although it obtained and converted to a scaled score. The scaled
lacks normative data. Thorough manual and templates score can be used in determining the eligibility of stu-
eliminate the need for constant ordering of forms. dents for extra time or other assistance in examinations,
Useful in identifying the types of handwriting diffi- identifying children who require intervention for
culties a student may be having, as well as potential handwriting speed difficulty, and evaluating the effects
underlying sensorimotor difficulties. It is cumbersome of intervention on handwriting.
scoring a negative. Reliability findings also are ques-
tioned given the use of the Pearson (Ottenbacher &
Tomchek, 1993, 1994).
CONTENTS
What does the schedule try to measure? Handwriting speed
for children and adolescents in grades 3 through 12.
Does it give a clinical diagnosis? No.
REFERENCES
Amundson SJ (1995). The evaluation tool of children’s
handwriting (ETCH). Homer, AK, OT Kids.
PURPOSE
Diekema SM, Deitz J, Amundson SJ (1998). Test- The HST was developed to provide an up-to-date and
retest reliability of the Evaluation Tool of Children’s objective means of evaluating the handwriting speed of
Handwriting, Manuscript. American Journal of students presenting with handwriting difficulties.
Occupational Therapy, 52:248–254
Grace-Frederick L. (1998). Printing, legibility, pencil
grasp, and the use of the ETCH-M. Boston, Boston
University, Unpublished master’s thesis. Type of Assessment: Near-point copy assessment
Koziatek SM, Powell NJ (2002). A validity study of the Task(s): The student is asked to copy from a typed
Evaluation Tool of Children’s Handwriting-Cursive. Handwriting Sample Form onto lines below the
American Journal of Occupational Therapy, words “the quick brown fox jumps over the lazy
56:446–453. dog” as many times as they can in a 3-minute period.
Ottenbacher KJ, Tomchek SD (1994). Measurement Paper Type: Supplied lined paper with center dotted line
error in method comparison studies: An empirical Pencil Type: Number 2
examination. Archives of Physical Medicine &
Rehabilitation, 75(5):505–512.
Schneck CM (1998). Clinical interpretation of Test-
Retest Reliability of the Evaluation Tool of Chil- Administration: The test is timed for 3 minutes to
dren’s Handwriting-Manuscript. American Journal obtain the Rate score.
of Occupational Therapy, 52:256–258. Scoring: Scoring time ranges from 3 to 5 minutes.
Reliability: Interrater ranges from 0.99 to 1.00 (ICC)

PARTICIPANTS for each grade and an ICC of 1.00 for the whole
Children: Third through twelfth graders sample. Intrarater reliability ICC was 0.99 for the
Adults: Young adult (high school aged) whole sample and ranged from 0.99 to 1.00 for
Developmental Level: Can be used for children with various grades, teacher ratings, and genders of stu-
physical disabilities, learning disabilities, or specific dents. Test-retest reliability correlations ranged from
handwriting difficulties 0.717 to 0.916 (ICC) for the various grades and
speeds of hand writers.
Additional Statistical Analysis: None
DERIVATION
Writing sample and scoring criteria were developed OTHER DATA IN SCHEDULE /OTHER
through literature review
Its short administration and scoring time make it
PUBLISHED MATERIAL advantageous to clinical practice if assessing rate of
Author/Others: Author (Wallen, Bonney, & Lennox, handwriting in isolation. This is rarely the case;
1996a,b; Wallen & Mackay, 1999); others therefore other instruments assessing both handwriting
Usefulness: The HST was designed to provide an up-to- quality and rate will likely see more use.
date and objective means of evaluating the hand-
writing speed of students presenting with handwriting
difficulties. The HST is a useful tool for determining
REFERENCES
the eligibility of students for extra time or other Wallen M, Bonney M, Lennox L (1996a). The
assistance in examinations, identifying children who handwriting speed test. Adelaide, Australia, Helios.
require intervention for handwriting speed difficulty, Wallen M, Bonney M, Lennox L (1996b). Interrater
evaluating the effect of intervention on handwriting, reliability of the Handwriting Speed Test. Occu-
and conducting research with handwriting speed as a pational Therapy Journal of Research, 16:280–287.
variable (Wallen et al., 1996b). Wallen M, Mackay S (1999). Test-retest, interrater, and
Validated: On 1292 third through twelfth grade intrarater reliability and construct validity of the
students from New South Wales, Australia schools Handwriting Speed Test in year 3 and year 6 stu-
with normative data determined after analysis. dents. Physical and Occupational Therapy in Pediatrics,
Content validity was established in development. 19:29–42.
Chapter 15
PRINCIPLES AND PRACTICES OF
TEACHING HANDWRITING
Mary Benbow
CHAPTER OUTLINE or pencil, requiring intricate fine motor skills. Because

the simplicity of a pencil often is taken for granted, it is
easy to overlook the complexity of its operation. In the
DEVELOPMENTAL EXPERIENCES THAT UNDERLIE opinion of this author, a pencil is more difficult to use
SKILLED USE OF THE HANDS than the most powerful computer from a motor skills
Upper Extremity Support perspective.
Wrist and Hand Development It is no wonder that children, their parents, and their
teachers are often frustrated with the results of early
Visual Control experimentation with this advanced tool before the fine
Bilateral Integration motor muscles are ready to function. Boys, whose fine
Spatial Analysis motor development is typically behind that of girls
(McGuinness, 1979), have greater difficulty managing
Kinesthesia writing tools and tend to prefer simpler motor tools,
Summary such as computer keyboards, Nintendo games, and TV
HANDWRITING TRAINING: PENCIL GRIP remote controls. Girls face a different problem. Many
of them begin to “write” as early as age 21/2, often with-
Tripod Grip and Alternative Grips out proper adult attention or supervision. Lacking suf-
Remediation of Pencil Grip ficient hand development or guidance, they may adopt
KINESTHETIC APPROACH TO TEACHING pencil grips that are inefficient or even harmful as they
HANDWRITING pursue their fascination with the letter shapes Big Bird
shows them daily.
Cursive or Manuscript Writing The overall management of handwriting training
Motor Patterns in Cursive Writing can be conceived as a kind of triage, in which some
Why Teach Writing Kinesthetically? children (group A) learn to write well regardless of
the method(s) of teaching. At the other extreme a few
Kinesthetic Teaching Method (group C) are unable to learn the skill no matter what
Kinesthetic Remediation Techniques interventions are employed to alleviate their difficulties.
SUMMARY Most children (group B) fall between the two extremes
and readily benefit from efficient teaching strategies.
Therefore group B should receive the greatest concen-
tration of effort from teachers, occupational therapists,
The use of tools was a major breakthrough in human and other professionals. It is simple to distinguish
history, extending our ability to control our envi- between groups A and B, but much more difficult to
ronment. The first tools were natural objects—sticks, separate group B from C. For this reason it seemed
stones, and bones—requiring gross motor skills such as appropriate to develop teaching and treatment strate-
pushing, striking, and throwing. It took thousands of gies around the combined needs of groups B and C.
years for humans to develop a tool as precise as a pen Appropriate compensatory or intervention strategies
319
should enable most of these children to gain functional

writing skill.
DEVELOPMENTAL EXPERIENCES
In the current educational environment of “No THAT UNDERLIE SKILLED USE OF
Child Left Behind,” school departments require that
children with widely different developmental levels
THE HANDS
be taught together in integrated classrooms; therefore
handwriting instruction demands better investigation Since 1992 as fear about sudden infant death syndrome
and more attention. Professionals must concentrate (SIDS) became widespread, the “Back to Sleep
on related-skills necessary to ensure more consistent Campaign” was implemented to lower the risk of SIDS
success with this high-level skill. They must teach all (SIDS Task Force). Many anxious parents misinter-
school children more efficiently, thoroughly, and preted this warning to mean their baby should never be
permanently. prone, even during daytime play periods.
All students, especially the great variety of children While supine or semireclined in a variety of plastic
who are subtly delayed, can benefit from develop- “exoskeletons” infant seats, the baby can barely raise
mentally ordered physical, visual, kinesthetic, and fine his or her head, much less bear weight on the upper
motor experiences. A clearer understanding of the con- extremities and elongate and strengthen the cervical
stellation of skills that enable one to write efficiently spine. “Tummy Time” in prone posture facilitates head
must guide professionals in developing more systematic lifting and neck strengthening, trunk stability, and
ways to prepare children for handwriting, as well as balance while weight bearing on the upper extremities.
to teach handwriting. Occupational therapists are fre- Therefore lack of prone positioning during the baby’s
quently called on for motor evaluations, consultation, play periods lengthens the time it takes to master such
and remediation for public school children. Nonfunc- basic skills as lifting and holding the head, pivoting,
tional handwriting is the most common reason for turning over, and sitting and crawling. Lack of weight
referral. For an evaluation to be useful for effective bearing on the hands may affect hand structures; under-
curriculum implementation or intervention, profes- developed arch formation and stabilization, incomplete
sionals must understand the chain of motor skills that expansion of the thumb-index web space for full
enable a student to write comfortably, automatically, opposition, and skilled manipulation of tools. Skilled
and accurately. use of tools (e.g., silverware, scissors, pencils) often lags
The purpose of this chapter is to describe hand skills because of lack of full range of motion at the carpo-
that make children more adept at operating a pencil. metacarpal (CMC) joint of the thumb.
This chapter presents not only the optimal skills for the To be effective in promoting efficient graphic skills,
way the hand should work to produce efficient hand- developmental therapists must address these unresolved
writing, but also the problems that arise when motor ergonomic factors (i.e., postural, tonal, stabilizing) in
components for the skill are absent or less dexterous addition to fine motor intervention. Graphomotor pro-
motor patterns are used. Techniques to promote the duction difficulties usually cluster under one or more of
development of the foundation skills are presented, the following classifications: (a) incomplete range of
along with remediation or compensation techniques motion and use of the proximal joints of the upper
for related problems that arise. The final section on the extremity, (b) immature wrist and hand development
teaching and remediation of handwriting presents with clumsy distal manipulation skills, (c) insufficient
the rationale and method for the kinesthetically based experience in eye-hand control, (d) incomplete bilateral
instruction of cursive writing. It should be noted that integration, (e) inadequate spatial analysis or synthesis
this chapter does not address language components such skills, and (f) reduced somatosensory input with failure
as word finding, sentence formulation, punctuation, to develop kinesthesia.
and spelling, but is limited to the mechanical aspects of
writing and cognitive-associative mental processes.
Handwriting instruction in American schools typi-
U PPER EXTREMITY SUPPORT
cally begins with manuscript writing (printing) and The interaction of all joints of the upper extremity—
shifts to cursive writing in the third grade. The author’s scapulothoracic, glenohumeral, elbow, and wrist—is
experience has been that the development of functional required for the development of dexterous hand skills.
handwriting can be fostered by an earlier introduction Each component must be developed and move freely
to cursive script. Therefore the discussions of prewrit- into its mature patterns. In children experiencing
ing and writing skills emphasize cursive writing. The fine motor delays it is not uncommon to find the
cursive versus manuscript writing issue is discussed shoulder joint slightly biased toward internal rotation,
more fully in a later section of this chapter. adduction, or flexion; the elbow joint toward flexion or
Principles and Practices of Teaching Handwriting • 321
pronation; and the wrist toward flexion and ulnar

BOX 15-1 Early Education Curricula Goals
deviation.
for Developing Upper Extremity
In addition to fluid range of motion, each upper
and Hands
extremity joint must provide a stable base of support
for the control of the joint(s) distal to it. When a
therapist finds functional limitations in proximal joints, 1. To stabilize the wrist with fine manipulation of small
tools, objects, and writing implements
he or she should include weight bearing, traction, and
2. To open and stabilize the thumb-index web space
compression activities for scapula, shoulder, and elbow 3. To increase and stabilize the arches of the hands
joint control. Specific proximal joint needs are most 4. To separate the motor functions of the two sides of
naturally incorporated into therapeutic or adapted the hand
physical education goals. 5. To develop two aspects of precision handling,
For example, jumping rope backward requires the precision translation and precision rotation
simultaneous involvement of all upper extremity joints
moving into their mature patterns. Because this activity
fully incorporates all upper extremity joints, it should hand functions in Box 15-1 are fundamental for all
be included in developmental hand therapy programs higher-level tool skills.
for children who show dysfunction or inefficiency in
proximal joints. A younger or less coordinated child Stabilize the Wrist
should first learn to turn one end of a long rope with a Bunnell (1970) states that the wrist is the key joint of
partner using the dominant hand while a third child the hand. Wrist limitations cannot be compensated
jumps. The initial goal is to develop external rotation for by any other upper extremity joint. Because wrist
in the shoulder on the dominant hand side followed movements are inseparable from the hand as a single
by full range of motion in the opposite shoulder. The physiologic unit, therapists should combine wrist and
third step is for the child to swing a jump rope back- hand activities. The position of the wrist influences the
ward over his or her head and step behind it when he tension of the extrinsic muscles. The origins of the
or she hears the rope strike the floor. Finally, the upper extrinsic muscles of the hand are in the forearm and
and lower body should be coordinated in reverse rope generally move the digits in gross flexion or extension
jumping. patterns. Extrinsic tendon length does not allow simul-
The case of Zachary demonstrates the value of an taneous maximal flexion or extension of the wrist and
integrated upper extremity program for hand skill fingers, so interplay is seen with wrist and finger
development. This 6-year-old boy was referred to occu- movements.
pational therapy for difficulties with printing and sloppy Long and co-workers (1970), using electromyog-
paperwork. Initially a program of hand activities was raphy found that intrinsic muscles (whose origins are in
prescribed that specifically addressed the referral the wrist and/or hand) guide and grade the multiple
request. Zachary faithfully practiced his prescribed pro- intermediate finger and thumb patterns and control all
gram. He made little progress because the hand rotary movements of the thumb and metacarpopha-
activities felt so unnatural and were so difficult. Client langeal (MP) finger joints used in precision handling.
resistance became a new and serious deterrent. After Tubiana (1981) pointed out that no single articulation
assessing his upper extremities more thoroughly, the in the hand is an isolated mechanical entity. Instead,
therapist found some limitation of motion in external each articulation functions as part of a group arranged
rotation of the shoulders and incomplete supination in kinetic chains. Each articulation depends on the
at the elbows. After a progressive program for upper equilibrium of forces acting at its level, and this equilib-
extremity range and stability, his hand skills followed rium is subject to the position of the immediate prox-
naturally and resistance to fine motor activities less- imal articulation. Mobile balance is realized through
ened. Zachary’s case is fairly typical. The often over- the interdependence among the elements along its
looked component of proximal development proved to osteoarticular chain. That interdependence includes
be the key in unlocking distal skills. both passive and active components. The active com-
ponent is the dynamic balance between antagonistic
muscles. The main passive component is the restraining
WRIST AND HAND DEVELOPMENT action of ligaments and muscular viscoelasticity that
In addition to a developmentally based gross motor facilitates coordination of motion (Smith, 1974).
program, early education curricula should stress devel- Therefore the wrist influences the position of the MP
oping the entire upper extremity with particular empha- joint, and the MP joint influences the position of the
sis on the hands. The goals are listed in Box 15-1. The proximal interphalangeal (PIP) joint, which in turn
influences the distal interphalangeal (DIP) joint. These the fixed junctures allows stability without rigidity
anatomic principles provide ways to analyze, design, (Tubiana, 1981). The mobile elements include the five
and sequence hand activities that are more effective in digits and the peripheral metacarpals of the thumb
developing the constellations of motor patterns for fine and little finger. The mobile units of the thenar and
motor skills. A tool is an extension of the hand that uses hypothenar eminences cup or arch the hand, providing
it. Developmental logic dictates that a hand must be balanced isolated intrinsic activity within the hand.
skilled before it can skillfully manipulate a tool as an Manipulating Chinese balls within the palm of the
extension of the hand. hand is a rapid way to develop all three arches. The
Activities that facilitate wrist stabilization in exten- balls should fit well within the cupped hand so that
sion with precision finger skills can best be done on the thumb can rotate them around within the hand.
vertical surfaces above eye level. Such positioning auto- Instruct the child to rotate the balls by moving the
matically places the wrist into its optimal posture and thumb into the center of the palm (Fig. 15-1).
facilitates abduction of the thumb to work distally with Activity sheets with circles to fill or shapes to circle
the fingertips. Working above eye level requires holding or outline before coloring can be designed for this pur-
the arms at a level at which their weight strengthens the pose. Activities can be graded by decreasing the size of
muscles and stabilizes the joints of the scapula and shapes as refinement of skill progresses distally. When
shoulder. Enjoyable proximal joint activities include sheets or coloring book pages are secured in a vertical
painting on chalkboards with brushes dipped in water orientation (fitted onto a vertically mounted clipboard
or more colorful tempera painting on paper at an easel. or taped up on a wall or easel), the oblique arch of
Many commercially available toys can be vertically opposition can more easily manipulate the pencil or
positioned to develop wrist stabilization with distal marker. The most refined use of finger control with
finger skill. Magna Doodle, Etch-A-Sketch, pegboards, crayons or markers is in outlining the shapes before
and eye-hook boards can all be fastened onto a wall, set coloring them. The diamond coloring sheet shown in
in a chalk rail or on an easel ledge, and secured with an Figure 15-2 requires dynamic finger skill to outline
elastic cord if necessary. The important part of each followed by static finger skill to color in the shapes.
activity is that it is performed above eye level. Primary school children are self-motivated to draw
and practice numbers and letters on the chalkboard
Open and Stabilize the Thumb-Index Web Space when their efforts on this surface yield satisfying results.
Muscle tightness on the flexor side of the wrist limits For one nursery school child, working on a vertical
range of motion into extension and reduces stabi- surface magically transformed his clumsy attempts to
lization of the wrist for distal digital manipulation. The color at the table into performances that delighted him
CMC joint located at the base of the thumb column and his teacher. It may be worth noting that the first
should fully rotate so the thumb pulp can be pronated products of human use of an advanced tool, in the cave
and positioned diametrically opposite each of the four paintings at Lascaux, France, are on a vertical surface
finger pulps. Incomplete abduction and rotation at at or above eye level, as are many of the petroglyphs
this mobile thumb joint result in a posture that cannot made by Native Americans on the canyon walls of the
be well stabilized for distal manipulation (Kapandji, southwestern United States. Without knowing why,
1982). A fully expanded web space between the thumb these primitive tool users maximized shoulder stability,
and index finger allows dexterous digital manipulation
leading to economy, variety, and convenience of move-
ment because it requires minimum involvement of
the upper extremity joints when moving a prehended
object. Feedback from the intrinsic muscles regulates
grip pressure on the shaft of the tool and provides
ongoing kinesthetic feedback to the nervous system for
rapid automatic correction of motor programs. When
the hand is in a power grip with the fingers flexed, there
is a reduction in the firing of lumbricals, so the hand
loses much of its joint-balancing potential and
proprioceptive guidance (Long et al., 1970).
Increase and Stabilize the Arches of the Hand

The hand’s great adaptability depends on its fixed and
mobile units. Fixed elements include the distal row of
carpal bones and the central attached metacarpals to Figure 15-1 Chinese balls to develop arches in the
digits II and III. The small degree of movement at hand. (Available from OT Ideas, Inc., copyright Mary Benbow)
Figure 15-3 Small hand scissors designed by author

shown with small sponge gripped by the ulnar digits.
(Available from OT Ideas, Inc., copyright Mary Benbow.)
isolates control in the two radial digits to work in

combination with the thumb. Initially a child should
Figure 15-2 Diamond coloring sheet. (Copyright Mary practice simply opening and closing the blades. After
Benbow.) intended blade movements become rhythmic, intro-
duce tiny straws (which take almost no control from
wrist and thumb postures, and visual and hand dexter- the nondominant hand) to be cut into tiny segments.
ity for their expressive needs. Today skilled artists rarely Advance to oak tag or old playing cards, and finally to
draw or paint on a horizontal surface. paper, which requires the most skill. The nondominant
hand must hold the paper taut enough for cutting
Separate the Motor Functions of the Two Sides without tearing.
of the Hand
Capener (1956) noted the coupling action of the two Develop Two Aspects of Precision Handling:
ulnar digits (IV and V), which function together in Precision Rotation and Precision Translation
power grips and precision handling. In precision han- Precision handling requires full range of motion at the
dling, when the ulnar digits are flexed against the palm, CMC joint of the thumb so its pulp can be flexed and
they provide stability to the MP arch while isolating placed diametrically opposite each of the finger pulps.
control of the radial digits for manipulation with the From this stable position the multiple variations of the
thumb. Separation of the ulnar from the radial side of two precision handling skills, precision translation and
the hand counterbalances the MP arch for higher-level precision rotation, should be developed and refined.
skills. Holding a heavier item, such as a teacup is Translation movements require that the thumb and
achieved by abduction and extension of digits IV and index or the thumb, index, and middle fingers move
V. The radial digits (II and III) can be isolated and in synchrony in a toward-the-palm or away-from-the-
stabilized from the arched posture to perform their palm pattern (Long et al., 1970). Needle threading
function more securely with the opposed thumb. uses a translation-away pattern from the fully flexed
The proper handling of scissors requires the sepa- translation-toward the palm. Pulling a thread through
ration of the motor functions of the two sides of the a needle is an example of translation toward the palm-
hand. The ulnar digits should be flexed and stabilized finger pattern.* Writing in a cursive hand requires rapid
against the palm. With the wrist stabilized in extension, alternation of toward and away translation patterns to
the child should place the distal joints of the thumb produce letter strokes.
and middle finger into the loops (oval loops stabilize Shifting a stiff piece of oak tag through the eye of
easier). The loops should be small enough to enable the a yarn needle with the wrists stabilized against each
child to stabilize the handles at the DIP joints of the other is an effective way for an older child to practice,
long finger and the IP joint of the thumb. The index speed up, and observe translation movements with the
finger should be placed against the shaft of the handle skilled digits. Marks can be placed on the strip to
to support the scissors in a vertical position and help to indicate increased length of movement as skill improves
close the blades. The ulnar digits (IV and V) should be (Fig. 15-4).
flexed and pressed against the palm to add stability to
the MP arch. If it is frustrating or difficult to remember
*The term precision translation is used by Long and co-workers
to flex and stabilize digits IV and V, then have the child
(1970) to describe the movement of an object toward and away from
press a small flat sponge against the palm with the two the palm while the grip on the object is maintained. The term has
ulnar digits, as shown in Figure 15-3. This motoric also been used to describe the shifting of a small object such as a piece
separation of the functions of the two sides of the hand of lint from the fingertips into the palm.
in developing translation-toward and translation-away

finger skills.
Precision rotation skill is used when strength demand
is low, in activities such as opening and closing loos-
ened tube caps or jar lids, turning knobs, and turning
over small objects for inspection. When a child substi-
tutes less efficient forearm rotation for digital rotation,
an evaluation for range of motion and stabilization of
the thumb is indicated.
The child must have functional range of motion at
the CMC joint to position the thumb diametrically
opposite the third digit. Snapping the fingers is a simple
thumb-finger test for evaluation of range of motion at
the CMC joint. When there is incomplete separation
between the thumb and index metacarpals, physically
Figure 15-4 Needle threading or translation movement expanding the web space by joint mobilization and
activity. Work to increase distance and speed with the progressive stretching may be indicated. Expansion of
skilled digits. (Copyright Mary Benbow.) the joint-supporting structures often can bring the
thumb CMC joint into a position in which it can be
stabilized for distal manipulation with the index or
Bead stringing is the classic preschool activity for index and middle fingers.
developing speed and dexterity in the alternating use of A simple activity to promote precision rotation is
translation patterns. However, children who most need rolling tiny balls (1/8-inch diameter) of clay or therapy
to develop this skill often adopt an efficient substitute putty between the pulps of the thumb and index finger.
system. They place the bead over the lacing tip rather Another is playing tug-of-war with a small-diameter
than inserting the tip through the bead. Eye-hook object such as a coffee stirrer or plastic lace. Digital
lacing boards prevent this skill substitution and provide rotation at the MP joints is necessary to shape the grip
a more motivating activity for young children (Fig. snugly enough so the extrinsic muscles can effectively
15-5). Because children tend to be self-driven to stay provide strength for distal power pinch. Pinching a
with this lacing board activity, it is effective and efficient coffee stirrer or plastic lace between the index and
thumb pulps enhances position contact of the finger
pulps for strength.
An engrossing group activity is turning over a row
of 25 pennies from heads to tails in a race against
classmates or a stopwatch. A tiny moving picture type
flip-book or small deck of cards requires full CMC
expansion in the hand of a primary school child.
Adequate range and stability at the CMC joint are
necessary for both card shuffling and distal dynamic
pencil control. With middle school or high school–
aged students, shuffling a standard size deck of cards is
a challenging activity that promotes range of motion
and stability at the thumb CMC joint. Tactile sensitivity
of the thumb pulps needs to be refined to manage the
intermixing of the cards from the two hands.
VISUAL CONTROL
Manuscript and cursive writing use vision differently in
the guidance of the pencil. In manuscript writing the
hand’s output depends almost entirely upon the input
and ongoing guidance of the visual system. In cursive
writing the visual system should play a less significant
Figure 15-5 Threading board designed by author. role. For this reason many children with visual motor
(Available from OT Ideas, Inc., copyright Mary Benbow.) problems should be advanced to cursive instruction as
soon as written work is required. The reduced demand along the middle of the yellow line. With the paper
for visual motor integration yields more satisfactory positioned on the desk top so that the lines run from
results. When using kinesthetic teaching strategies for top to bottom (slanted for better viewing), the child
cursive training, visual control becomes secondary to is instructed to draw the first line from top to bottom
proprioceptive guidance during the first lesson. An and the second line from bottom to top (Fig. 15-6).
accomplished hand writer limits visual control to stay- Accuracy of control is noted as the child visually guides
ing on the writing line, guiding retrace lines, properly the hand into upward and downward space. It is
spacing between words, and serving as a neatness insightful to ask which direction was easier for him or
checker of written work. her to complete.
Most American schoolchildren learn to print their If the child appears stressed while doing the pre-
names before entering kindergarten. A few children ceding task on a desk top, a second sheet can be taped
master the whole alphabet. Imitating family members, on the wall or chalkboard in the vertical plane with the
early education teachers, or educational television shows, middle of the sheet of paper positioned at eye level as
they rely heavily on visual control in drawing their the child stands to work. This placement requires the
block letters. Close visual monitoring of the pencil child to elevate and lower the eyes along the two lines.
point is necessary for them to control stroke length If he or she does poorly on trial 1 (desk top) and better
and angle, find the intersecting or joining points, and on trial 2 (wall or chalkboard), it will be advantageous
inhibit pencil movement at the intended stopping for the child to stand while practicing numbers and
place. letters on the chalkboard or at an easel. The child’s
In any mainstreamed primary classroom one can ability to control a pencil in these two directions is a
observe many accommodations to insufficient eye-hand clear demonstration of the visual system’s guidance of
skills. A child who has difficulty focusing when eye the hand for graphic skill training. Tracking comfort
alignment or extraocular control is deficient often adapts and skill often clarifies the reason some children are
by turning the head far to one side to isolate use of one unable to conform to writing numbers and letters from
eye while diverting the other eye from the paper. The top to bottom.
child has unconsciously discovered that this head posi- Mature handwriting requires input from both foveal
tion eliminates the second image. A child who has great and ambient vision. Inadequate integration of the two
difficulty lowering and converging the eyes continues visual systems is seen when the letters are fairly well
to draw circles, write numbers and letters from bottom formed but the writing is irregular in size and spacing
to top, and fails to adopt the cultural pattern of top to and positioned poorly in relation to the writing line.
bottom stroking of letters and numbers.
In the early grades figure copying tests such as
the Developmental Test of Visual Motor Integration Top to bottom Bottom to top
(Beery, 1997) are used to determine a child’s visual
motor integration age level. Beery cites multiple devel-
opmental researchers who have explored the under-
lying visual motor skills that determine a child’s potential
for mastering manuscript formations. Beery states that
it is prudent to postpone formal pencil and paper
writing until at least such time as a child can easily copy Numbers 1-10
the VMI Oblique Cross. The oblique cross requires the
child to cross the midline of the form using diagonal
visual guidance. This high-level perceptual motor skill
is necessary to produce 10 of the manuscript letters.
An observation tool, the Observation of Visual
Motor Orientation and Efficiency (Benbow, Hanft, &
Marsh, 1992) can be a practical supplement to observe
visual control of the hand as the eyes guide the pencil
in upward and downward directions. To observe visual
motor efficiency in these two orientations, the instruc-
tor should prepare an unlined sheet of paper (81/2 × 11
Name:
inches) with two lines 1/8-inch wide and 11 inches long.

Lines should be drawn with a yellow highlighter and
spaced about 2 inches apart. The child is directed to Figure 15-6 Form used to observe visual control of
draw a continuous controlled line with his or her pencil pencil. (Copyright Mary Benbow.)
This is seen in manuscript within words, as well as stroke to the left when approaching the line top while
between words. Spacing problems in cursive are usually writing letters k, b, f, and l. Functional graphic motor
limited to spaces between words. The ambient system output remains far beyond the child’s reach. Unfor-
is faulty in providing the spatial component as the hand tunately, additional paper and pencil practice does not
produces proper formations. solve these developmental issues.
When poor efficiency in visual-motor orientation is A child who is not bilaterally integrated neglects
noted in the classroom, a child should be further eval- stabilizing the paper with the nondominant hand when
uated by a physical educator because ball and game writing or coloring. Until the dominant hand assumes
skills are often impaired as well. Remediation for visual a definite leadership role, the nondominant hand does
scanning problems is not to be found in paper and not sense and perform its assisting role. Instead of
pencil activities but in vestibular-based visually demand- cooperation between the two body sides, there is resid-
ing gross motor activities. If the child has difficulty ual competition. Synkinesis (motor overflow) usually is
tracking upward, include activities that require upward observable, which supports the finding of inadequate
gaze such as tossing a ball straight up and catching it at central nervous system inhibition of the nondominant
chest level, gently tapping a ball suspended above eye hand as the dominant hand is being programmed by
level, racket games, volleyball, and flying kites or air- the brain. When an older student must produce a
planes. Alternatively, if the child has difficulty tracking lengthy written assignment, it is visually helpful to draw
downward, bouncing a ball and catching it at waist a pair of bold black margin lines about 1 inch from the
level is advised. A line or pattern drawn on the floor or left side of the paper. The high-contrast lines alert his
sidewalk can make bouncing on a Hippity-Hop ball or or her peripheral vision and cue the child to stabilize
riding a scooter board or bicycle more interesting and the paper with the nondominant hand while main-
organizing. Activities demanding rapid movement and taining left margin alignment. The nondominant hand
visual guidance help integrate visual tracking with body positioned on the edge of the paper helps to visually
skills. define the writing area and promotes more balanced
In cursive writing, problems in tracking downward sitting posture.
result in poorer control of the loops that descend below Directionality confusion is suspected when a child
the writing line (f, g, j, p, q, y, and z). Alternatively, continues to write wraparound letters after instructions
when children are stressed by elevating their eyes, they are given to stop at a specific point and retrace a letter
may have more trouble controlling the upward moving segment. When this wraparound pattern, as seen in the
ascender strokes of tall letters (h, k, b, f, l, and t). letters a, d, g, q, and c, is the only immature pattern
Suspect a near-point focusing insufficiency when a noted, one can logically assume that the motor behav-
child can produce a single stroke but is inaccurate in ior was generalized from self-taught incorrect forma-
retracing line segments. A therapist can detect a focus- tion of manuscript letters at an earlier stage. A typical
ing problem most easily on the retraced segments of example is seen in Figure 15-7.
a, d, m, and t. When these visual motor errors are When a child with incomplete bilateral integration
seen consistently, a referral for a visual examination is draws horizontal or diagonal lines, a hesitation or jerk
indicated. is often seen along the pencil line in which the child’s
eyes crossed their midline while guiding the pencil.
This interruption is even more visible and disorgan-
BILATERAL I NTEGRATION izing when the child draws diagonal lines. Typically the
Bilateral integration and sequencing (BIS) dysfunction child produces near-vertical lines for diagonals without
is a common cause of motor delays or deficits (Ayres,
1991). In addition to well-documented gross motor
deficits (e.g., postural, equilibrium, and body side coor-
dination), a child with BIS dysfunction is slow to
establish a good division of labor between the two
hands. By the time most peers are performing well in
the graphic motor area, the child is still using the hands
interchangeably to do far less sophisticated activities.
On paper and pencil tasks the child usually experiences
an interruption in crossing the visual midline and pro-
duces reversals long after other classmates have resolved Figure 15-7 Example of the incorrect formation of the
wraparound letters a and g. (From Loops and other groups:
this issue. The child is unable to change stroke direc- A kinesthetic writing system. Copyright 1990 by Harcourt
tion in a continuous flow pattern. This is evidenced as Assessment, Inc. Reproduced with permission. All rights
an inability to shift the right under-curving lead-in reserved.)
for for for
Figure 15-8 Typical reversal of capital cursive letters. (Copyright Mary Benbow.)
being aware of it. The child’s cursive writing appears to

be near vertical as well. Vertical letters are more slowly
produced because the wrist has to be repositioned to
efficiently make the long diagonal down strokes.
A later sign of a problem with bilateral integration is Figure 15-9 Special instructions given to children
the writing of mirror-image letters or numerals. These learning to write a capital D. (From Loops and other
output errors are more commonly seen when a symbol groups: A kinesthetic writing system. Copyright 1990 by
is produced in isolation. An evaluation of 900 middle Harcourt Assessment, Inc. Reproduced with permission. All
rights reserved.)
school writing samples revealed that the most typical
residual reversals of letters in cursive writing were
limited to three left-moving capital letters: 3 for E, f for
capital J, and horizontally expanded reversed lower case
b for capital I (Fig. 15-8).
Averting the gaze is an effective accommodation to
writing letters that reverse directions abruptly across
the visual midline. In writing capitals D, G, and S, the
Figure 15-10 Illustration of the problem in changing
child should be taught the place to halt the pencil direction with a continuous flow pattern. (From Loops and
progression and shift visual focus. The focal place is other groups: A kinesthetic writing system. Copyright 1990 by
usually where the stroke ends, as seen with directions Harcourt Assessment, Inc. Reproduced with permission. All
for capital D in Figure 15-9. The child must avoid rights reserved.)
visually monitoring the pencil point where it recrosses
the visual midline to write these letters successfully.
An enigmatic problem associated with BIS dysfunc- can master air writing with the shift of direction should
tion is seen in a child’s inability to change stroke direc- he or she attempt it on paper. Consistent repetition
tion in a continuous flow pattern. The child feels the is necessary for kinesthetic success. The difficulty of
need to touch the top of the line and pause before changing stroke direction in a continuous flow pattern
being able to shift line direction. When writing the also causes a problem in producing the alternating
long ascenders of the loop letters (h, k, b, f, and l), it is swoop line used to top capital F and T.
nearly impossible for these children to shift the flow of
the right ascending lead-in stroke to the left while
approaching the top of the line (Fig. 15-10). In these
SPATIAL ANALYSIS
tall loop letters the change of direction is necessary to Children with non–language learning disabilities
prepare for the immediate down stroke once the line (NLD), which include difficulties with math, non-
top is touched. Changing directions in a continuous phonetic spelling, and visualizing, usually lack strategies
flow pattern proves to be an intractable writing prob- to analyze geometric shapes, numbers, and letters.
lem. To develop this sense of direction flow, the child These children require detailed letter analysis help to
needs to bodily understand the verbal directions as learn to write. Small incremental steps (including start-
demonstrated by the instructor. The shifting direction ing place, pencil progression, distance and speed at
of the tall loop stroke is best taught through the which to move the pencil, and stopping point) must be
shoulder while writing in the air. Stress the inhibition examined and explained and re-examined and re-
of the right ascending stroke where it shifts leftward explained. Retraces, the point of intersection with lead-
and up to the top of the line. Only when the child in strokes, and instructions for the release stroke or
connector unit require a great deal of emphasis and

repetition. The instructor should point out and stress
the similarities of letter forms within the letter groups
or they will be missed. Visual and verbal images that
give letters their identity are necessary to aid memory
and cue the lead-in stroke.
Children acquire functional writing more easily Figure 15-11 Showing negative shapes created
when they are speed coached. All motor learning between writing lines and letter strokes. (From Loops and
requires that speed be matched to task difficulty and other groups: A kinesthetic writing system. Copyright 1990 by
Harcourt Assessment, Inc. Reproduced with permission. All
the learner’s level of skill. A therapist can reduce learn-
rights reserved.)
ing time and trial-and-error frustration by explaining
where the child should move the pencil slowly and
quickly (Benbow, 1990). To hasten developing this
sensitivity for all students in the room, initial letter created on the writing line by the lead-in stroke and
instructions should include speed tips: The lead-in the lower rounded segment of the letters a and d (Fig.
strokes flow more naturally when done quickly; retraces 15-11). Contrasting it with the smaller triangle made
require some visual guidance, so slowing down is on the right side of these letters before the release
advised; speed should be resumed for any single line stroke proves to be an intriguing challenge to the
segment or release stroke that follows. These instruc- novice for quality control. Readily identifiable negative
tions seem most logical and are usually understood and shapes can help the child recognize letter accuracy and
followed by most second graders. Speed coaching is serve as a guide for self-correction. These visual cues
helpful for children who are struggling with any type of control for line contact as well. Producing the small
gross or fine motor skill learning. triangle at the bases of i, u, w, and t (Fig. 15-12)
NLD children can learn cursive writing with their prevents releasing the down stroke too soon for a good
peers when the entire class is given detailed visual and connection or release unit.
spatial analysis and verbal directions for writing each
new letter. The relatively good language skills of NLD
students should be called upon to support this motor
KINESTHESIA
learning. Subvocalizing the motor plan guides writing Writing is a motor skill and, as with other motor skills,
hand movements. This practice should be continued efficient writing depends on kinesthetic input. Motor
until the writing is faster than the verbalizing. skills developed kinesthetically, such as riding a bike,
Writing instructors should be precise in their use of keyboarding, or handwriting, are most permanent. In
the word “line.” It is confusing to the student to use writing, an internal sensitivity that a letter movement
the same word to describe top and bottom lines and feels correct reduces a child’s need to visually monitor
the space between lines. Instructing the student to the fingers or pencil point while moving along the line.
make a letter “half a line high” only adds to his or her This security enhances speed in learning and confidence
confusion. If instructors consistently refer to the top in cursive writing. Kinesthetic writing naturally accel-
line, writing line, and dotted middle marker, they will erates over time to functional speed without the reduc-
not confuse their students. The area between the lines tion of performance quality seen with visually guided
should always be called a space (or half space for letters writing. The visual system is far too slow and mechan-
ascending only to the middle marker). It is also helpful ical to monitor the serial chain of finger movements
to the child if the writing line is darker than the top line necessary for note taking much beyond mid third
or colored for initial learning and practice sessions. grade. Advising a child to slow down (allowing time to
Using the designations writing line, top line, and mid- visually monitor the writing hand) temporarily results
dle marker, the instructor can easily describe what space
the letter should fill. For example, all lower case cursive
letters lead in from the writing line and ascend to the
middle marker or top line. Seven letters descend to the
middle marker below the writing line. Only four letters
occupy more than a whole space: lower case f, and
capitals J, Y, and Z.
Negative shapes are created between lines and letter Figure 15-12 Knowing that the triangle should be
small prevents a premature release of the down stroke.
strokes. If students are made aware of them, these (From Loops and other groups: A kinesthetic writing system.
negative shapes can aid in determining whether the Copyright 1990 by Harcourt Assessment, Inc. Reproduced
letters are written correctly. For example, a triangle is with permission. All rights reserved.)
in more legible paperwork. However, this remedy 2nd

fails in middle school and beyond, when greater speed
is necessary in lecture settings. Therefore kinesthetic
training is important whether or not a child has a visual
motor or spatial problem. This is an area of training
that should be explored and further developed by early
educators.
Kinesthetic skill development is most beneficial for
children experiencing visual motor deficits. Kinesthesia
is an effective compensation for eye-hand coordination 3rd 1st
difficulties and can be a powerful builder of motor
confidence. Kinesthetic training enables these children
to bypass their problem area and become efficient
writers by concentrating on kinesthetic feedback. If
diminished kinesthesia is not enhanced, a child con-
tinues an over-reliance on visual monitoring, with a
subsequent slowness in the production of writing.
Kinesthetic activities are an essential aspect of both
prewriting and writing programs. Home
Kinesthetic skills usually intrigue young children. Plate
Elementary kinesthetic activities can be done on desk Figure 15-13 Chalkboard baseball. (Copyright Mary
tops, at the blackboard, or in the gymnasium. A sample Benbow.)
for each location is demonstrated in Box 15-2.
As noted, kinesthetic writing should use limited
visual motor control. Shape-copying tests such as the accurately. Skill in this area is less helpful in predicting
Test of Visual Motor Integration are useful in predict- the ease a student will experience in learning cursive
ing the child’s potential ease or difficulty in learning writing.
manuscript. Copy forms and manuscript letters require A Production Consistency Sheet (Benbow et al.,
analysis and synthesis of the forms to duplicate them 1992) can be used to informally observe a child’s
kinesthetic aptitude in repeating and spacing cursive
letters in words using the kinesthetic sense. Model
shapes are displayed in the upper left-hand comer of a
BOX 15-2 Sample Elementary Kinesthetic half sheet of unlined paper (51/2 × 81/2 inches). Each
Activities model is 1/2 inch high. The models include a square, a
circle, a triangle, and a cursive capital A.
Instruct the students to duplicate the printed model
1. Desk Top: Place an object (e.g., coin or cube)
anywhere on the desk surface within the arc of the using a fluid moving stroke(s) rather than a rigidly
child’s reach. Withdraw the child’s hand to a resting controlled stroke(s). The four shapes should be drawn
position and ask him or her to close the eyes and in three evenly spaced rows of five figures. On com-
reach directly to the object. Grade the activity by pletion of the fifteenth figure, the child is told to close
having the child place the object with one hand and the eyes or avert the gaze and complete a fourth row
retrieve it with the other. that looks like and is spaced like the rows above. The
2. Blackboard: Sports that have a spatial component
quality of the first three rows reveals the child’s visual
(e.g., baseball diamond, golf green) can be sketched
on the blackboard. After the child visually and motor control of horizontal, vertical, diagonal, or cir-
motorically senses the size and shape of the display, cular lines. The consistency of the fourth row is a
have him or her close the eyes, visualize the display, graphic demonstration of the child’s kinesthetic learn-
and draw with chalk a run from home plate for a ing potential for both configuring and spacing. The
single, double, or home run (Fig. 15-13). two examples selected in Figure 15-14 were drawn by
3. Gym: After gaining the feel of movement of pitching 10-year-old boys who were classmates in a third-grade
like objects into a container, have the child close his
classroom. Consistency in shape, size, and spacing is a
or her eyes and use kinesthetic sense to continue the
activity. The child should not alter orientation or high indicator of potential for learning cursive writing.
distance and the objects should be identical in In comparing these two samples, one can predict that
weight and size. The most challenging position for the child who drew Figure 15-14 A will learn to
this activity is seated on a one-legged stool. write with less difficulty than the child who drew Figure
15-14 B.
description of pencil grips, a discussion of the limitation

imposed by maladaptive grips, and some remedial
strategies.
TRIPOD G RIP AND ALTERNATIVE G RIPS

A Handwriting is the most frequently used, complex, and
lateralized skill used in education, yet little attention
is paid to how, when, or where pencil practice best
enhances the development of this skill. Adults should
not assume that children somehow know the best way
to hold a pencil or that they will acquire the ability
through incidental experience. Rosenbloom and
Horton (1971) found that 89 of 92 British children
had developed a dynamic tripod pencil skill by 72
months, and Saida and Miyashita (1979) found that
151 of 154 Japanese children had developed this skill
by 72 months. In 1986 this author found that only 33
B of 68 American children of the same age used this grip.
The other 35 children were managing in school with
pencil grips that ranged from less efficient to maladroit.
Any grip, efficient or inefficient, that has been used
over time becomes kinesthetically “locked in.” An
immature pencil grip that is kinesthetically locked in
can inhibit a student’s ability to advance to a higher
Figure 15-14 Production consistency of an average
writer (A) and a poor writer (B). (Copyright Mary Benbow.) level even after hand development has progressed.
Among 7-year-old typical children in a Boston sub-
urb, more quadripod grips (four digits—three fingers
and the thumb—on the pencil shaft) were found than
SUMMARY tripod grips (three digits on the pencil shaft). This open
Children who benefit from ongoing diagnostic hand- thumb web alternative to the normal tripod grip most
writing training usually have identifiable problems in likely developed with premature use of pencils or low
one or more foundation skills. The first is gross and joint stability in the hand. The fourth finger on the
fine motor readiness for cursive instruction. Output or shaft adds power for stroking, as well as a wider bridge
production problems can include difficulties with rapid for stabilizing the pencil shaft. Many quadripod grips
sequential movements (often noted in the child’s early do progress and become dynamic and fully functional.
history as articulation problems), visual control, The two slight disadvantages of this grip are (a) reduc-
bilateral integration, and spatial analysis and synthesis. tion in pencil point excursion, and (b) reduced stability
Feedback difficulties include inadequacies in visual and of the MP arch when the little finger is used alone
kinesthetic reafferent systems. rather than being functionally coupled with the ring
Developmentally sequenced hand activities should finger.
be a major fine motor focus in preschools and early A few children assume an adapted tripod grip
elementary education. Early educators should develop (Fig. 15-15) in which they stabilize their pencil within
the full potential of children’s hands for all skills the narrower web space between the middle and index
because the remediation of prewriting hand skills fingers. This is an effective adaptation when joint
greatly facilitates the learning of graphic skills. The stability is insufficient for controlled mobility. All of the
following sections turn to two specific aspects of hand- skilled muscles of the classic dynamic tripod manipulate
writing training, pencil grip and kinesthetic writing. the pencil, and the MP joint of the thumb receives little
if any stress. This posture is the most readily accepted
alternate grip when a child or adult is having motor or
HANDWRITING TRAINING: orthopedic writing problems.
Joint stability in the hand depends on ligaments and
PENCIL GRIP fixed structures. Working with school children, one sees
evidence that the functional use of the hand depends
Letter production skill can be influenced by the way more on joint stability than joint mobility. Children
the writer grips a writing tool. This section includes a adopt unique ways to make their hands work for them
this distal holding skill before advancing to writing

tools.
A number of prosthetic devices (Fig. 15-16) have
been developed to help position the digits for efficient
distal manipulation of writing tools. These devices are
sculpted to position the distal aspects of the radial digits
into an open thumb/index web posture. Providing
writing tools with positioning grips when preschool
children are first exploring pencil use is the most sensi-
ble and effective use of these devices. Early implemen-
tation of these devices should eliminate the struggle to
correct the inefficient grip after it has been reinforced
and kinesthetically locked in.
Limited rotation within the index and long finger
MP joints and lack of an active transverse arch pushes
the fingertips distally beyond a pencil gripping device.
Therapeutic techniques can increase the third degree of
freedom (rotation) at the MP joint of the index fingers.
Figure 15-15 Adapted tripod grip. (Copyright Mary Then a grip device can be an effective reminder to
Benbow.) maintain the advanced posture.
Reducing hyperflexion at the PIP joint or hyper-
extension at the DIP joint (Fig. 15-17) can be accom-
when they lack joint stability. If the MP joint of the plished by taping or blocking PIP hyperflexion with a
thumb is unstable, the web space will collapse when the tape support. With smaller, weaker, and less experi-
pulp of the thumb is used to stabilize a tool in the distal enced hands tape support is often an adequate support
fingertips or against another digit. In this case the child to the extensor system. The surgical tape Microfoam
will unknowingly substitute the two heads of the power- (3M, St Paul, MN) adds stability to the digit. Tactile
ful adductor and the first dorsal interossei (internal input from the taped finger is significantly increased so
thenar muscles) for the three more highly skilled exter- any movement helps the child to sense where his or her
nal thenar muscles: abductor pollicis brevis, flexor pollicis fingers are in space. A 1/8-inch wide strip of Microfoam
brevis, and opponens. The substitution of the internal tape should be affixed to the middle dorsal aspect of
thenar muscles causes the thumb to supinate or rotate the index finger while the digit is positioned in full
away from the posture to allow pulp to pulp opposition extension. The distal end of the tape should be attached
(Tubiana, 1984). When using a pen or pencil, the to the nail and continue proximally over the DIP, PIP,
individual wraps the thumb over or tucks the thumb and MP joints to the mid-metacarpal level (Fig. 15-18).
under the index finger to control the stroke. Either grip The tape should be adjusted to give the joint(s) stability
provides a distal point of stability with the challenge to without rigidity. Some children choose to use the tape
devise a system to mobilize the pencil proximally. When when a large amount of written work is necessary,
the web space is closed snugly over the pencil shaft, the whereas others insist on wearing the tape most of
thumb MP joint support structures are stressed in an the day.
outward direction, and the proprioceptive feedback A newer device called a “Pencil Pal” (Fig. 15-19) is
used to guide and grade fine motor muscles is reduced. helpful in reducing “white knuckle” pain caused by
hyperflexion at the PIP joint and hyperextension at the
DIP joint. The ring device is worn on the index finger
REMEDIATION OF PENCIL G RIP to provide a higher stabilizing point for the pencil. This
In the development of motor skills there is evidence of shift in position of the shaft of the pencil reduces
transfer between different forms of action. The preci- hyperextension or “white knuckle” pain at the DIP
sion grip once mastered and reliably used with a spoon joint.
or fork begins to be used in drawing with a pencil. The ability to stabilize the CMC and MP joints of
Therefore the instructor or therapist should evaluate the thumb is critical for tripod manipulation of objects
the use of silverware before attempting to alter more and tools. The IP joint cannot be a controlled mover if
complex skills with marking or writing tools. Silverware the MP joint cannot provide a stable base of support.
requires only stabilization of the shaft within the tripod This stability-mobility problem renders the hand most
digits. A writing tool requires stabilization plus con- dysfunctional, especially in the manipulation of color-
trolled mobilization. If the child uses an immature ing or writing tools. In younger children with short
power grip on a spoon, the instructor should develop fingers the “Pencil Grip” or external taping of the
Figure 15-16 Prosthetic writing devices. From left to

right: Start Right, Solo, Stetro, and the Pencil Grip.
(Copyright Mary Benbow.)
Figure 15-17 Pencil grip, showing hyperextension of Figure 15-19 Pencil Pal, which reduces the angle of
the distal interphalangeal joint and hyperflexion of the pencil and DIP hyperextension. (Available from OT Ideas,
proximal interphalangeal joint. (Copyright Mary Benbow.) Inc., copyright Mary Benbow.)
BOX 15-3 Hand Structures Necessary for

Tool Stabilization with Distal
Manipulation
1. An active metacarpophalangeal arch with three

degrees of freedom (flexion-extension, abduction-
adduction, and rotation) at the metacarpal joints of
the two radial digits.
2. Full range of motion at the carpometacarpal joint of
the thumb. Full range is necessary to stabilize the
open thumb/index web space.
3. Motoric separation of the two sides of the hand.
The ulnar side remains inactive to provide stability
and shift skill to the radial digits as they work
opposite the thumb.
4. Joint stability. Instability is a most prevalent finding
caused by lax ligaments. The writing hand may
require outside stabilization.
Figure 15-18 Illustration of positioning of Microfoam

surgical tape on the back of the index finger to improve
joint awareness and add joint stability. (Copyright Mary An “index grip”—a forearm, wrist, and pencil grip
Benbow.)
adaptation to extreme laxity at the thumb MP joint—is
illustrated in Figure 15-20. The forearm is maintained
in mid-rotation between supination and pronation and
posterior aspect of the thumb often is sufficient support is solidly stabilized on the writing surface. The pencil
to make the thumb functional. Taping techniques out- shaft is cradled into the flexed index IP joints and
lined for the index finger can be applied to the thumb. extends distally across the third, fourth, and occasion-
When the MP joint of the thumb is unstable because of ally the fifth fingertips. The lead end of the pencil is
lax ligaments, a neoprene splint can support and pro- pointed toward the writer’s midline. Writing strokes
tect the joint while writing. come from a combination of wrist flexion and MP fin-
Hand structures necessary for tool stabilization with ger extension with minimal thumb IP flexion. Because
distal manipulation are shown in Box 15-3. the writer does not progressively slide the solidly
stabilized forearm while writing, there is a need for the

interplay between thumb IP hyperextension and wrist
flexion. Writing into right space requires increasing
flexion at the thumb IP joint and hyperextension at the
wrist. When the wrist is fully hyperextended, a major
right shift of the forearm is necessary for the next posi-
tion from which to write additional letters or words.
Because this “index grip” remains so nonfunctional
over time, it is prudent to intervene as early as possible.
Generally, when the joint support structures and extrin-
sic tendons cannot provide stability with the added
support of the tape, the therapist should explore the
use of a soft neoprene thumb abduction splint. This
short glove-type splint positions the thumb in abduc-
Figure 15-20 Index grip adaptation to extreme laxity of tion and provides stability at the hypermobile MP joint
the metacarpal-phalangeal joint of the thumb. (Copyright when the thumb tip is positioned on the pencil shaft
Mary Benbow.) (Fig. 15-21). Neoprene provides stability without the
Figure 15-21 Neoprene thumb abduction splints. (Available from Benik Corp., www.benik.com; McKie,
www.mckiesplints.com; copyright Mary Benbow.)
rigidity of a thermoplastic device. Wrist-length neo-

BOX 15-4 Making the Transition to a
prene gloves designed to provide thumb positioning
Functional Distal Grip More
and stabilizing are commercially available in appealing
Successful and Less Stressful
colors and multiple sizes.
School therapists, knowledgeable in developmental
hand functions, must use professional judgment to 1. The instructor demonstrates placement of the pen-
cil positioned between the index and long fingers to
determine if, how, and when adaptations, motor inter-
make large random patterns using only shoulder
ventions, or outside stabilization will benefit the child. and elbow movements.
The expectations of the child, teacher, and parents 2. The child imitates the pencil position and makes
must be fully appreciated and honestly incorporated large free flowing movements following this rigid
into the child’s educational plan. The therapist should rule: No finger movements!! No letters!! No
include recommendations for short-term trials and numbers!!
offer periodic reassessments of their acceptability and 3. After the child accommodates to the feel of the
pencil in the index/middle finger web space, the
effectiveness.
child should draw anything he or she pleases.
Before intervening with an older student with an 4. Once the child is at ease with the new pencil posi-
inefficient grip, it is critical for the child to understand tion, he or she should be encouraged to write large
why it is worth the effort to change. Pencil postures isolated numbers and letters.
that are not held within the pulps of the digits do not 5. When the new grip becomes annoying, the child
lead to economy, convenience, or adequate feedback should temporarily shift back to the former grip.
for the proximal-distal axis. The simple flexor or exten- 6. As soon as he or she feels ready, the child should
return to the adapted grip.
sor synergy produces the fast writing needed once
7. When a child is in control of the alternating time
output demand increases in middle school. An adducted shifting scheme, and experiences comfort and
or closed web grip diminishes the proprioceptive feed- success, he or she tends to use the adapted grip
back from the lumbricales of the skilled digits. The more consistently.
luxury of the unconscious regulation of pressure of the
shaft of the pencil or the downward pressure exerted
against the writing surface will be reduced or lost.
Without this feedback, the student needs to stop and
release the grip on the pencil to shake the pain out of
KINESTHETIC APPROACH TO
his or her fingers. In addition, the child should be TEACHING HANDWRITING
aware that a hypermobile closed web grip predisposes
the joint to injury because of sustained co-contraction
(Pascarelli & Quilter, 1994).
C URSIVE OR MANUSCRIPT WRITING
The sequence demonstrated in Box 15-4 can make One of the difficulties facing anyone investigating
the transition to a functional distal grip more successful handwriting teaching and remediation issues is the lack
and less stressful. of longitudinal studies in the field. Studies of prepara-
Many persistent persons write satisfactorily with tory skills, curriculum techniques, and timetables for
poor grips. Many of these grips require the person to the consolidation of writing skill at an automatic level
develop skilled use of proximal joints, which lack the are scarce. Tradition rather than scientific investigation
precise control and speed of the distal joints. A pencil has guided the teaching of handwriting in America. For
held in a closed web grip by the adductor pollicis example, there are no studies to substantiate the prac-
cannot move far or use the rotary agility of the index tice of using manuscript throughout kindergarten and
MP joint in producing rounded strokes. Curving and first and second grade. In fact there is considerable
rounding must be produced by more proximal joints evidence showing that such teaching may impede the
requiring supination at the elbow and external or inter- development of functional handwriting in some stu-
nal rotation at the shoulder. Wrist and forearm exten- dents. Cursive instruction typically is introduced at the
sors must produce elongation of upstrokes, which is beginning of grade 3 in most American school systems.
efficiently done using a digital translation away pattern Several motor patterns adopted for printing and
and minimal wrist extension. A few writers use the reinforced by 3 to 5 years of use are often resistant to
entire skilled side (radial) of the hand to clutch and change at age 8. In manuscript, children become accus-
stabilize the pencil, and mobilize the pencil by extend- tomed to having the paper square to the edge of the
ing and flexing the three joints of the power digits IV desk in order to “write.” Later, slanting the paper to
and V. Writer’s cramps are often seen in people who the appropriate angle to accommodate the wrist for
overuse their wrist in writing. diagonal down and up stroking in cursive is motorically
disconcerting for many children. The D’Nealian manu- findings on the importance of sequential finger speed
script program is unique in that letters are practiced to handwriting are supported by other handwriting
with the paper positioned at an angle to take advantage researchers.
of the wrist flexors in down stroking. Interestingly, this Berninger and Rutberg (1992) evaluated children in
angling of the paper is beneficial only when the radial grades 1 to 3 using six finger tasks; two displacement
side of the hand is used to guide the pencil to write. items, lifting and spreading, finger recognition, finger
However, this placement of the paper is usually localization, repeated tapping of thumb pad to index
demanded of all children regardless of grip. In addi- pad, and rapid sequential touching of the thumb pulps
tion, the eye-hand pattern of top to bottom control of to the four finger pulps (5, 4, 3, 2, 5, 4, etc., a measure
vertical strokes needs to be shifted to bottom to top of motor planning and rapid sequential movements).
under curving diagonals. The rapid, sequential touching to all four finger pulps
The strategy for gaining an understanding of ball proved to be the only task that was reliable and valid for
and stick manuscript letters requires whole-to-part assessing handwriting skill in young children.
analysis followed by synthesis of the parts back into Deuel (1995) found slow finger-tapping speed to
wholes. For many children it is perplexing to alter the be significant in her dysgraphic subjects with motor
process and analyze and integrate movement for the clumsiness. This was not significant in the language or
whole letter formation necessary for cursive writing. spatial problem students. In isolated cases, when finger
Again the D’Nealian manuscript program has been the speed is significantly slow and sensory feedback from
most successful in reducing segmentation of lines for the digits cannot be reinforced by taping, refining print-
letter formations. ing skill may be the prudent solution to the student’s
In more than 30 years of experience in the teaching needs. Early and thorough teaching of keyboarding
of handwriting, this author has found that second skills should be initiated as soon as practical in these
grade is an optimal time for most children to learn cases.
cursive handwriting. Student interest is high, and gen-
erally students have not yet developed faulty habits
of inventive cursive before formal instruction begins.
MOTOR PATTERNS IN C URSIVE WRITING
Training activities of combining letters into simple two- Motor output for cursive writing requires continuous
and three-letter words to practice letter formations and stroke patterns. For this reason cursive letter analysis
connector units are at a more appropriate cognitive and instructions should be programmed to maximize
level for second-grade students. Initiating cursive writ- visualization of the whole. Mental formulation of the
ing instruction in the fall of second grade allows a full plan with verbalization of the entire motor sequence
year for students to stabilize this motor learning before should be stressed. This elicits the child’s propriocep-
the higher volume of written work is demanded at the tive and kinesthetic sense, supporting the flow of the
third-grade level. whole letter.
Curricula that use instructional techniques to accom- Most published handwriting programs currently in
modate for perceptual and motor delays and deficits use employ a “copy-the-letter” scheme followed by
should enable nearly all children to advance to cursive visually guided reproduction of the letter within divided
writing at an earlier age. In schools in which cursive lines. Able or not, children are typically expected to
writing is introduced earlier and mastered kinesthet- convert to cursive writing during the fall of third grade.
ically, there is less confusion with and substitution of Many curricula introduce one or two alphabetically
manuscript letters with cursive letters. Programming sequenced lower case letters each week. Such slow pro-
ample time to master cursive writing reduces the num- gression means that the lower case letters are unavail-
ber of children who revert to manuscript in middle able for classroom work for 3 or 4 months, and the
school when the output volume increases dramatically. upper case letters still remain to be learned. Other
The most perplexing problem for parents, teachers, programs introduce the lower case and upper case of
and students themselves is how the student can have the same letter in tandem. Shifting the unrelated motor
excellent fine motor skills and horrible handwriting. patterns for lead-in strokes that are necessary when
Levine (2003) explains that fine motor skills mainly either alphabetical system is followed does not facilitate
recruit the fingers to manage artwork, origami, or efficient motor learning.
airplane models, which are all navigated by the eyes. Grouping letters according to common movement
Graphomotor functions take place over different neural patterns reduces memory demands and motor diffi-
pathways and require rapid sequential movements culties. After the initial session of introducing the
guided by ongoing sensory feedback from the digits. movement pattern, during which each child learns to
The eyes are far too slow to monitor the movement of verbalize the pattern and produce it motorically,
the digits as they move at a functional speed. Levine’s additional letters in the group can be learned expedi-
tiously. The learning process is further hastened by or setting of motor and memory engrams at an auto-
reinforcement as all of the letters within the cluster are matic level.
practiced together. The product of visually guided, or drawn, writing
General instructions included in most handwriting may be legible or even beautiful but is not functional
manuals are inadequate for children experiencing visual because its methodical execution is too slow and con-
motor difficulties, incomplete bilateral integration, suming of cognitive power. The motor activity of
weak spatial analyzing ability, and attention or memory writing must be fairly autonomous to free cognitive
problems. Specific compensations for their special needs power for composing and spelling. The human nervous
must be included with initial classroom instructions or system can focus clearly on only one complex mental
their classroom practice periods will not be productive. task at a time. Related skills, such as writing, must be
In many schools the practice time is insufficient for sufficiently automatic to be carried out at an associative
all but the most skilled students to achieve functional skill level. It is beyond the ability of most persons to
output. Children are as frustrated by their handwriting compose a complex sentence and think about the way
failures as are their parents and teachers. Those with each letter in each word is executed. This failure in skill
special needs, along with many who have simply not mastery is often the cause of a typical parent or teacher
received enough help or time to master this complex complaint: “My brilliant child’s hand cannot keep pace
motor task, resign themselves to poor handwriting or with his mind.”
simply revert to manuscript, which received far more
teaching time and reinforcement in the lower grades.
KINESTHETIC TEACHING M ETHOD
Handwriting is a lateralized motor skill of the highest
WHY TEACH WRITING KINESTHETICALLY? order. When kinesthetic teaching techniques are incor-
Writing is a motor skill that requires competent motor porated from the beginning of handwriting instruction,
teaching and thoroughly reinforced motor learning. the child naturally develops a kinesthetic potential for
Fitts (1964) believed the process of skill acquisition writing and other fine motor skills as well. The kines-
falls into three stages. The first, the cognitive stage, thetic method of teaching cursive writing presented in
involves the initial encoding of the instructions for a Loops and Other Groups (Benbow, 1990) provides both
skill into a form sufficient for the learner to generate general and compensatory instructions that are nec-
the behavior to some crude approximation. He empha- essary for teaching in a mainstreamed classroom. It
sized that rehearsal of information is necessary for the enables learning-disabled students to progress with
execution of skill. The second, the associative stage, their normal peers. Compensatory instructions and tips
involves smoothing out of the motor performance are included for students with perceptual-motor delays
with gradual detection and elimination of errors and or deficits including difficulty with visually producing
the dropping of verbal mediation. The third, the diagonals, midline crossing interruptions, and fluctu-
autonomous stage, is one of gradual improvement that ating motor memory for configurations.
may continue indefinitely. The group names for letters relate to familiar objects
One should distinguish these motor skill require- in a child’s environment and promote visualization of
ments for writing from other classroom learning. the lead-in strokes (Fig. 15-22). The first letter in each
Learning to write is different from learning to read. If of the four groups must be mastered at the kinesthetic
it were not, more good readers would be able to write level before the child is allowed to advance to the next
legibly. Learning to write is not a language skill, letter. As soon as any letter is mastered, instructions are
although language skills are necessary to supply the given for connecting it to itself or other previously
content of written production. Learning to write should learned letters. The student’s awareness of and
not be coupled with learning the alphabet. Learning to repetition of the common motor patterns within each
write letters in alphabetical order is more likely to group hasten mastery of the skill by reinforcing motor
enhance alphabetizing skills than handwriting skills. As learning of the entire group.
with all fine motor skills, a student must accept the fact The author has conducted successful kinesthetic
that the head learns to write faster than the hand. writing programs by dividing the learning of lower
By its nature a kinesthetic approach to handwriting case letters into six teaching blocks for classroom use.
provides children with a clear, enjoyable progression The blocks are rapidly but thoroughly taught in daily
from (a) the placement of the letter within the three 30-minute sessions in 6 weeks during September and
half-space vertical units, to (b) the precise motor analy- October of second grade. The lower case letters are
sis with verbal support of the motor plan, to (c) the consistently reinforced with daily practice and used
appropriate variations in speed, to (d) the practice with whenever possible (e.g., spelling tests when children
eyes closed or averted, and finally to (e) the reinforcing have learned the necessary letters) to reinforce and
are self-motivated to improve their output quality and

increase their writing quantity as well.
Clock Climbers
Rule of the line or space between the writing and
top line should be compatible with the fineness or
Kite Strings
bluntness of the writing pencil, pen or marker, and
distal digital excursion of the writing tool—not the
grade, age, or height of the writer. Line space of 1/2 inch
or more naturally elicits movement from more proxi-
Loop Group
mal, less skilled joints. Regardless of age, when fine
motor muscles are to be trained for graphic skills, the
letter, number, or symbol size to be learned must be
Hills and Valleys
within the excursion distance of the digits that manip-
ulate the pencil. A distal control sheet (Fig. 15-23) can
be used to determine the ideal line rule for older
students. Accurate stroke excursion flows more natu-
Figure 15-22 Letter group named to assist memory in
learning. (Copyright Mary Benbow.)
rally and shows better control when producing strokes
within a compatibly ruled paper. Most learning dis-
abled students and children with “fixed” grips produce
their best writing on 1/4-inch ruled paper. This narrower
stabilize this new skill. It is estimated that 95% of the ruled paper feels comfortable for their motor system.
letters on a page of writing are lower case, so stress is An efficient way for the evaluator to detect well-
put on mastery to the automatic level to ensure formed letters that have not been learned to the auto-
functional writing speed. matic level is to look for connector breaks in the line at
During the fall, manuscript capitals are used in com- the point where the lead-in stroke is initiated. Figure
bination with lower case cursive letters for all written 15-24 shows breaks in writing the alphabet before
assignments. Cursive capitals are introduced after the the letters f, j, r, and s. These breaks generally slow the
winter holiday vacation. This interval allows time for writer’s overall speed. The interruptions, or “think
lower case to become stabilized before the capitals are breaks,” can also be detected within words, but a con-
introduced. This interim significantly reduces upper nected cursive alphabet is the most thorough and
case and lower case confusion in children with weak efficient way to assess the letters of the alphabet.
memory for configuration. Specifically reinforcing the identified letters that follow
“think breaks” to the automatic level can often convert
nonfunctional output speed into functional skill.
KINESTHETIC REMEDIATION TECHNIQUES Kinesthetic reinforcement of letters can increase
Writing errors often tend to cluster and make a paper writing speed while maintaining quality in a child who
look sloppy. With older students, correcting one or two writes beautifully but has not developed functional
cluster errors is effective in producing an acceptable- speed. After carefully re-examining the line progression
looking paper. Overall appearance often can be signifi- of any known letter and producing it with visual guid-
cantly improved by improving one or two problem ance, the child should close his or her eyes, visualize the
areas. The three common cluster errors include the letter, and write with fluidity on scrap paper 15 times
seven drop-loop letters (f, g, j, p, q, y, and z), whose before checking the results. Once the initial letter
loops are often huge, carelessly formed “sausages” that within a motor group is written reliably at an efficient
interfere with the lower line of writing. The second speed, the remaining letters of the group should be
cluster is incomplete closure of the four round-over- brought up to speed one by one. A most popular time
the-top letters in the “a” or clock climber group (a, d, to suggest for children to increase their speed in writing
g, and q). The third cluster is failure to retrace letters is while watching television. The combination of
to the writing line before the release or connector these two activities diverts visual monitoring from the
stroke. This failure places the connector unit too high writing hand, and the student willingly extends practice
or too low to lead into the letter that follows it. periods.
Cluster remediation often is more palatable for older
students to undertake. Group letter analysis and speed Seating Posture and Classroom Arrangement
coaching for segments to be produced quickly or slowly Properly fitted furniture is indispensable if children are
offers new hope that is motivating for these often to learn handwriting efficiently. If the chairs are too
discouraged students. With kinesthetic training, rein- high and the child’s heels do not touch the floor, he or
forcement, and moderate persistence most students she will be unable to counterbalance for weight shift as
Figure 15-23 Practice sheet for distal finger control. (From Loops and other groups: A kinesthetic writing system. Copyright
1990 by Harcourt Assessment, Inc. Reproduced with permission. All rights reserved.)
Figure 15-24 “Think breaks” in writing. (Copyright Mary Benbow.)
the arm moves across the paper. If the desk surface is Presentation of a Model
too high, the upper arm will be abducted too far to The instructor introduces the letter by producing
control the fingers effectively. Figure 15-25 illustrates a about a 15-inch model of it within the appropriate line
properly fitted student chair and desk for writing. space(s) on the chalkboard. While demonstrating each
The child’s desk should face the chalkboard where new letter, the instructor should recite each step of the
the teacher demonstrates the letters. There may be motor plan. Familiar objects in the student’s environ-
subjects that can best be learned in cluster or circular ment are used to aid the students in visualizing the
seating, but handwriting is not one of them. movement pattern as they motorically produce the
while verbalizing the motor plan. With a few additional

minutes of coaching, the students can be brought to
a base level of skill before pencil and paper are
introduced.
Paper and Pencil

Half-inch lined paper with a dotted middle marker is
most satisfactory for early cursive practice with visual
guidance. Paper folded lengthwise in 4- or 5-inch strips
keeps the practice closer to the child’s midline where he
or she has the most control. Using the newly learned
motor plan, children complete 10 trials of the letter.
They are told to “talk to your hand, and make it do
Figure 15-25 Correct sitting posture for handwriting. what you tell it to do.” One should instruct children to
Knees and hips are flexed at 90 degrees and feet are flat
subvocalize the motor plan as they form each letter.
on the floor. The writing surface is 2 inches above the
student’s bent elbow. The top of the chair should be The instructor should be sure that the letter occupies
slightly below the student’s shoulder blade. (From Loops the proper space(s) in relation to the writing line and
and other groups: A kinesthetic writing system. Copyright middle marker.
1990 by Harcourt Assessment, Inc. Reproduced with After 10 trials, each student should circle all of the
permission. All rights reserved.)
letters that are correct. Among those circled they
should select the one that is the best. After it is approved
by the instructor, they should write 20 more from their
stroke progression. For example, the lead-in stroke own kinesthetic model.
for the letter “a” should climb up and round over an When all children are confident in their ability to
imaginary clock face between the 11 and 1 o’clock write the letter with eyes open, they should close the
positions and stop. The line reverses by retracing this eyes to visualize and gain the feel of the smaller move-
lead-in to 9 o’clock (Fig. 15-26). ment pattern. Children who have tracking, converging,
or crossing the midline visual disorganization should
Preparatory Exercises spend a major portion of their practice time with their
Before using pencils and paper, children perform two eyes closed or gaze averted to avoid visual interference.
exercises. In each exercise they are to use the hand
posture shown in Figure 15-27. Digits II and III are
extended. Digits IV and V are flexed and held down SUMMARY
with the thumb to reinforce separation of the two sides
of the hand. For each exercise and each practice trial, Kinesthetic handwriting training takes the drudgery
verbal directions should be voiced by the teacher and out of a task that is often difficult and time-consuming.
the students. For all children and for their teachers, this provides
The students should use the shoulder movements some benefit. For some children, kinesthetic training is
and hand postures described previously to trace the the single most effective tool for learning handwriting.
letter in the air. Simultaneously each student verbalizes Children who benefit the most from kinesthetic
the motor plan while following the shape of the chalk- handwriting training usually have identifiable problems
board model. Each student in the class must demon- in one or more general areas. Developmental gross and
strate the ability to verbalize the motor plan while fine motor foundation skills for cursive instruction may
following the line of the letter model. be less than optimal. Output or production problems
When secure in an understanding of the motor may include difficulties with visual motor control.
sequence, each student closes the eyes and pictures the Kinesthesia is the key to the lost science of hand-
letter to facilitate visualization of the movement pat- writing. Properly understood, it is the basis for under-
tern. During the second exercise, students place their standing handwriting problems and for preventing or
elbows on the desk top to “write” using elbow and wrist remediating them. Kinesthesia can be a curse or a
movements. Again, they must recite the motor plan as blessing. When a complex motor activity is scientifically
they move their hands to pattern the visualized letter. analyzed, appropriate foundation skills are set, teaching
These preparatory exercises are important to the steps are properly sequenced, and the skill is practiced
initial learning of handwriting. The instructor is able to to the automatic level of performance, kinesthesia is a
determine which children are unable to visualize the lifelong blessing in the performance of that skill. On
letter with eyes closed or averted from the model letter the other hand, maladaptive kinesthetic patterns can be
Clock Climbers
Figure 15-26 Practice sheet for clock climber group (a, d, g, q, c). (From Loops and other groups: A kinesthetic writing
system. Copyright 1990 by Harcourt Assessment, Inc. Reproduced with permission. All rights reserved.)
a curse. When a motor activity is haphazardly acquired

at an immature stage of development and reinforced to
the automatic level of performance, the kinesthetic
pattern can last a lifetime, blocking effective and effi-
cient performance of the skill and frustrating any
attempts to modify it.
One of the world’s great artists, Henri Matisse, once
confirmed the importance of kinesthetic learning
(Bernier, 1991). A friend who visited him noticed a
sketch in white chalk on the back of his living room
door. Matisse explained,
Figure 15-27 Hand posture used in preparatory
exercises. (From Loops and other groups: A kinesthetic “I had been working all morning [drawing] from the model. I
writing system. Copyright 1990 by Harcourt Assessment, Inc. wanted to know if I had it in my fingers, so I had myself
Reproduced with permission. All rights reserved.) blindfolded, and I walked to the door and drew” (p. 30).
The process that worked for Matisse is precisely the Bunnell S (1970). Surgery of the hand, 5th ed. Philadelphia,
kinesthetic learning that is most effective for training JB Lippincott.
Capener N (1956). The hand in surgery. Journal of Bone
children in handwriting. In cursive handwriting, as in
and Joint Surgery, 38B(I):128–140.
drawing from a model, if I don’t have it “in my fingers” Deuel R (1995). Developmental dysgraphia and motor skills
my work will be slow, crude, and unsightly. This approach disorders. Journal of Child Neurology, 1(10):S6–S8.
allows children to discover what the great artist described. Fitts PM (1964). Perceptual motor skill learning. In AW
Melton, editor: Categories of human learning. New York,
Academic Press.
Kapandji IA (1982). The physiology of the joints. New York,
REFERENCES Churchill Livingstone.
Levine M (2003). The myth of laziness. New York, Simon &
Schuster.
American Academy of Pediatrics Task Force on Infant Sleep Long C, Conrad MS, Hall EA, Furler MS (1970). Intrinsic-
Position and SIDS (2000). Changing concepts of sudden extrinsic muscle control of the hand in power and
infant death syndrome: Implications for infant sleeping precision handling. Journal of Bone and Joint Surgery,
environment and sleep position. Pediatrics, 105:650–656. 52A:853–867.
Ayres AJ (1991). Sensory integration and praxis tests. In McGuinness D (1979). How schools discriminate against
AG Fisher, EA Murray, AC Bundy, editors: Sensory boys. Human Nature, Feb:82–88.
integration, theory and practice. Philadelphia, FA Davis. Pascarelli E, Quilter D (1994). Repetitive strain injury. New
Beery KE (1997). Developmental test of visual motor York, Wiley.
integration, VMI-4. Los Angeles, Psychological Rosenbloom L, Horton ME (1971). The maturation of fine
Corporation. prehension in young children. Developmental Medicine
Benbow M (1990). Loops and other groups: A kinesthetic and Child Neurology, 13:3–8.
writing system. Tucson, AZ, Therapy Skill Builders, a Saida Y, Miyashita M (1979). Development of fine motor
division of Communication Skill Builders, Inc. skill in children: Manipulation of a pencil in young
Benbow M, Hanft B, Marsh D (1992). Handwriting in the children. Journal of Human Movement Studies,
classroom: Improving written communication. The 5:104–113.
American Occupational Therapy Association Self Study Smith RJ (1974). Balance and kinetics of the fingers under
Series. Rockville, MD, The American Occupational normal and pathological conditions. Clinical Orthopaedics
Therapy Association Press. and Related Research, 104:92–111.
Bernier R (1991). Matisse, Picasso, Miro: As I knew them. Tubiana R (1981). The hand, vol. 1. Philadelphia, WB
New York, Alfred A. Knopf. Saunders.
Berninger V, Rutberg J (1992). Relationship of finger speed Tubiana R (1984). Examination of the hand & upper limb.
to beginning writing. Developmental Medicine and Child Philadelphia, WB Saunders.
Chapter 16
UPPER EXTREMITY INTERVENTION
IN CEREBRAL PALSY:
A NEURODEVELOPMENTAL
APPROACH
Laura K. Vogtle
CHAPTER OUTLINE THE ASSESSMENT PROCESS

Physical Status of the Individual
CEREBRAL PALSY TREATMENT PLANNING
THE NEURODEVELOPMENTAL TREATMENT THE INTERVENTION PROCESS
APPROACH AND PEDIATRIC THERAPY
Neurodevelopmental Treatment and Hand Function
ROLE OF PERFORMANCE COMPONENTS ON
OCCUPATIONAL PERFORMANCE Efficacy of Neurodevelopmental Treatment
THE RELATIONSHIP OF POSTURE TO UPPER SUMMARY
EXTREMITY FUNCTION CASE STUDY ONE: A CHILD WITH CEREBRAL PALSY
Postural Control in Typically Developing Children CASE STUDY TWO: A CHILD WITH LOW TONE
Postural Control and Anticipatory Control in
Children with Cerebral Palsy Therapists who treat children with developmental
SENSATION AND ANTICIPATORY CONTROL IN HAND delays, movement disorders, and tone abnormalities
FUNCTION such as those seen in cerebral palsy (CP) face significant
KINESIOLOGIC ASPECTS OF TRUNK AND ARM challenges in their efforts to provide efficacious inter-
FUNCTION ventions. Muscle tone and spasticity are impairments
seen in CP resulting from central nervous system
Typical Trunk and Upper Limb Interactions (CNS) damage that cannot be permanently changed by
Base of Support and Upper Limb Function means other than medication and surgery. However,
BIOMECHANICAL INTERACTIONS OF THE UPPER therapists can maintain and improve performance in
LIMB IN CEREBRAL PALSY children with CP through their interventions and the
use of assistive technology. Clinicians can influence
Contrasts between Hypotonia and Hypertonia client factors and modify environments that affect the
TREATMENT APPROACHES: CONCEPTS OF manifestation of muscle tone, its power, and the degree
INHIBITION AND FACILITATION to which it interferes with participation in occupation,
Inhibitory Techniques thus adding to the potential for client participation.
This chapter discusses the therapeutic management
Facilitation Techniques of children with CP, focusing on the use of neuro-
Combining Inhibition and Facilitation developmental treatment (NDT) as an intervention.
343
CEREBRAL PALSY THE NEURODEVELOPMENTAL

TREATMENT APPROACH AND
Cerebral palsy is a general term that describes a non-
progressive group of posture and movement disorders PEDIATRIC THERAPY
diagnosed within the first 2 to 3 years of life (Koman,
Smith, & Shilt, 2004). The apparent causes of CP The intervention approach discussed in this chapter is
come from a variety of sources, including maternal the neurodevelopmental treatment approach, or NDT,
infection, prematurity, multiple births, hypoxia asso- originally called the Bobath approach. This paradigm
ciated with birth trauma, and maternal bleeding from hypothesizes that abnormal tone and impairments of
premature placental separation, to mention a few movement and posture result from lesions in the CNS
(Nelson & Grether, 1999). Although the insult to the and limit the development of function. Intervention is
CNS is believed to be static, impairments seen with CP aimed at minimizing these impairments and improving
include musculoskeletal concerns, muscle weakness, functional outcomes as a result of problem-solving
spasticity, vision problems, cognitive limitations, and among the clinician, client, and family to develop new
seizures. Secondary conditions related to the various movement strategies and management of postural tone.
primary impairments continue to evolve across the life The original approach was developed by Berta and
span and include muscle tightness and contracture, Karel Bobath, a physiotherapist and physician, respec-
joint abnormalities such as dysplasia and dislocation, tively, who evolved the paradigm between late 1940
growth problems, pain, social isolation, and diminished and 1990. Currently the instructors who teach the
ability to participate in the community through occu- technique and the national Neurodevelopmental Treat-
pations such as education, work, and leisure. Evidence ment Association (NDTA) continue to expand and
suggests that loss of function seen in typical aging is update the treatment approach.
accelerated in CP, and that the secondary conditions When Mrs. Bobath first began to practice as a physi-
associated with CP become more common and more cal therapist, therapeutic interventions for neuromus-
severe with age (Andersson & Mattsson, 2001; Cathels cular diagnoses were based on the stretching and
& Reddihough, 1993; Murphy, Molnar, & Lankasky, strengthening regimens used with the impairments left
2000; Turk et al., 1997). after polio. Unhappy with the results of such treat-
The incidence of CP over the last 20 years, currently ments, Mrs. Bobath documented observations from
estimated at 2 to 4 per 1000 children, appears to be her assessment and treatment of adults with paralysis
increasing. This change may result from many factors, after stroke and children with CP. Dr. Bobath sup-
including improved documentation of the diagnosis in ported her ideas with information from the neuro-
countries around the world, improved care of prema- physiologic scientists of the day, including the hierarchic
ture and sick infants, or other unknown factors (Nelson perspective of the CNS, the cephalad to caudal/proximal
& Grether, 1999). to distal nature of human development, and the con-
The movement disorders associated with CP include cept that postural control evolved from primitive reflexes
spasticity, dyskinesia or dystonia, hypotonia, and ataxia. (Howle, 2004). The Bobaths’ early work focused on
Spasticity is the most frequently occurring disorder and altering muscle tone and reflexes to enable the devel-
a mixture of various movement disorders are common. opment of more normal movements and followed the
The accepted distributions of movement impairment normal developmental sequence in treatment. The
include hemiplegia, diplegia, and quadriplegia (Dabney, importance of the postural reflex mechanism was high-
Lipton, & Miller, 1997). lighted and primitive reflexes were seen as a first step in
Although improved care has resulted in typical life the development of higher-level, skilled movements.
spans for persons with less significant involvement, The persistence of these reflexes in conditions such as
those with severe quadriplegia and associated con- CP originally was believed to block more skilled move-
ditions may die earlier (Hutton & Pharoah, 2002; ment, hence the concept of reflex-inhibiting postures
Strauss & Shavelle, 1998). Strauss, Cable, and Shavelle (RIPs), which were used to facilitate higher level
(1999) carried out an epidemiologic review of a large movements (Bobath, 1955).
database targeting causes of death in CP. Their find- Over time, Mrs. Bobath’s approach changed as she
ings found elevated death rates from cancer and heart documented her observations about the results of her
disease occurring at relatively young ages. Although treatment. Although the concept of reflex inhibition,
this study awaits replication and support from clini- even today, is seen by some as the substance of NDT,
cal studies, the findings are provocative to say the Mrs. Bobath actually discarded this focus by 1964,
least. moving on to the idea of “handling” or moving the
Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 345
child so as to generate active movement responses. The activity or occupation designated as the goal of inter-
treatment approach continued to focus on develop- vention. Current studies provide a much clearer picture
ment of movement skills based on the normal devel- of the role such impairments and movement disorders
opmental sequence until the lack of carryover outside have on performance skills. For example, Gordon and
of individual sessions became apparent. The Bobaths Duff (1999b) studied the relationship between finger-
(1984) then acknowledged the importance of linking tip force regulation in grasp, spasticity, stereognosis,
treatment to the performance of functional tasks in two-point discrimination, manual dexterity, and per-
other settings, thus underscoring the importance of ception of pressure sensitivity. Their work demonstrated
motor learning on the part of the client. a clear relationship among tactile perception, anticipa-
Motor learning is defined as tory control (activation of sensory and muscular sys-
tems for a specified activity based on prior learning and
“a set of processes associated with practice or experience leading experience) (Shumway-Cook & Woollacutt, 2001) and
to relatively permanent changes in the capability for producing task performance; however, it also suggested that the
skilled action.” (Shumway-Cook & Woollacutt, 2001, p. 27). role of the other impairments in performance was
dependent on the aspects of the activity being performed.
Shumway-Cook and Woollacutt distinguish between They noted that spasticity appeared to affect the adjust-
motor learning and performance, citing changes in ment of grip to object weight and to the length of time
motor performance as being temporary, whereas between grasping and actually lifting an object, but it
permanent changes in skilled action result from true did not have a relationship to anticipatory control.
motor learning. Clearly for children with CNS The NDT approach emphasizes the importance
dysfunction to change their occupational performance of postural control and anticipatory postural control,
outside of therapy intervention sessions, true motor both performance skills in the Occupational Therapy
learning must take place. Current NDT treatment Practice Framework (The American Occupational
recognizes the importance of motor learning to skilled Therapy Association [AOTA], 2002), to the outcomes
performance, and the necessity of practicing client- of therapy intervention, or areas of occupation. The
designated activities in treatment for changes in next section of this chapter discusses postural control
performance to occur. and its impact on upper limb function.
Although the Bobaths themselves did not incor-
porate motor performance into their theory, the
Neurodevelopmental Treatment Association Theory THE RELATIONSHIP OF POSTURE
Committee, consisting of multidisciplinary NDT
instructors in the United States, began updating the TO UPPER EXTREMITY FUNCTION
theoretic paradigm in the early 1990s to incorporate
current concepts with applicability to treatment of One of the Bobaths’ contributions to management
persons with neurologic deficits. It was at this time that of neuromuscular conditions was their understanding
theories such as dynamic systems theory and motor that spasticity was not just an individual muscle phe-
learning were formally integrated into the theoretic nomenon, but actually affected posture and control of
basis for the treatment approach (Howle, 2004). One upright position in space, a concept not previously
of the challenges for clinicians is the constant need to acknowledged. The emphasis on the postural reflex
keep their knowledge current with changes in mechanism as central to changes in other aspects of
knowledge generated by science, a challenge the motor performance was a principal factor in the Bobath
NTDA has taken seriously, as evidenced by the work of treatment approach, which underscored their belief
the NDTA Theory Committee. in the hierarchic, maturational principles of motor
development. The Bobaths believed that more distal
skills (e.g., reach, the ability to stand) could not devel-
ROLE OF PERFORMANCE op until postural control of head and trunk occurred,
COMPONENTS ON defined as the postural regulation of the body’s posi-
tion in space for purposes of stability and orienta-
OCCUPATIONAL PERFORMANCE tion (Shumway-Cook & Woollacutt, 2001). Therapists
trained in the NDT approach through the 1980s
Aspects of performance that therapists analyze when focused on altering postural tone passively, then on
planning treatment for children with CP are compo- facilitating active control in the head and trunk and
nents such as postural control, strength, muscle tone, finally on development of control in the upper
spasticity, range of motion, and the performance of the and lower limbs. At the present time, NDT theory
locates intervention for impairments such as postural POSTURAL CONTROL AND ANTICIPATORY
control within the desired occupational performance
outcome rather than as the primary treatment outcome. CONTROL IN C HILDREN WITH C EREBRAL
PALSY
POSTURAL CONTROL IN TYPICALLY
In contrast to typical children and adults, children with
DEVELOPING C HILDREN CP have difficulties with postural control and antici-
In typically developing children, postural control patory postural adjustments, as evidenced in a number
evolves from the development of antigravity move- of studies. Liao and co-workers (2003) found signifi-
ment, postural adjustment reactions, somatosensory cantly worse postural control in sitting as demonstrated
input, and experience, and is defined as maintenance of on parameters of static and dynamic sway indices in
body position in space (Nichols, 2001). Postural sway, children with spastic CP when compared with typically
a component of postural control defined as “the move- developing children. Roncesvalles, Woollacott, and
ment of the center of gravity within the base of support Burtner (2002) found that children with CP did not
in any upright position” refers to the constant move- demonstrate increased muscle response to changes in
ment of the body when upright and occurs in a devel- platform perturbations, although typical children did.
opmental sequence that matures around 13 years of age They hypothesized this difference in ability to demon-
(Nichols, 2001, p. 275). Another aspect of posture, strate recovery of balance resulted from insufficient
anticipatory postural control, defined as activation of contraction of agonist postural muscles.
sensory and muscular systems for a specified activity Studies of anticipatory postural control demonstrate
based on prior learning and experience, helps to pro- differences in children with CP as well. Van der Heide
vide efficient adjustments of the body to support use of and co-workers (2004) found that children with CP
the limbs for various activities (Shumway-Cook & after prematurity have difficulty adapting or grading
Woollacutt, 2001). postural adjustments to a variety of task-specific cir-
All motor activities require some degree of postural cumstances. Not unexpectedly, these difficulties were
control, although those requirements vary depending worse in children with diplegia or quadriplegia than
on the activity and the environment in which it is in children with hemiplegia. A top-down sequence of
performed. Bertenthal and Von Hofsten (1998) related activation of postural muscles, particularly in the neck
postural control to hand function, specifying that pos- extensors, was seen in their sample of children with CP,
tural control is a necessary requirement for the devel- which varied from the muscle activation sequence seen
opment of grasp and manipulation, and integration of in typical children. They noted that the gestational age
vision into hand function. of the child was related to postural adjustment prob-
This constellation of postural control components lems; the shorter the gestation, the greater the impact
was not well delineated during the Bobaths’ time; how- on postural adjustment.
ever, the current premise that postural control and its There are different theories about the interaction of
elements are necessary for successful motor perform- postural control and sensation and the role of anticipa-
ance supports some of the Bobaths’ ideas about the tory postural control in upper limb function, including
interaction of the trunk and upper limbs. For example, the Dynamic Systems Approach and Neuronal Group
Bertenthal and Von Hofsten (1998) discussed the Selection Theory. Howle (2004) contrasted and com-
importance of postural elements to both visual skill and pared some of these theories as they relate to NDT.
upper limb performance in tasks such as reach and Although these theories present different perspectives
grasp, noting that on the topic of postural control and upper limb func-
tion, there is no question these elements of performance
“. . . reaching for distal objects is necessarily a dynamic process are an important factor to be considered in movement
demanding mutual and reciprocal processing of the relevant intervention, regardless of the theoretic perspective.
perceptions and actions” (p. 519).
Stapley, Pozzo, and Grishin (1998) studied the SENSATION AND ANTICIPATORY
interaction of anticipatory postural control and reach
in typical subjects. Their work suggested that the use of CONTROL IN HAND FUNCTION
anticipatory postural adjustments plays a role in activa-
tion of upper limb movement from a fixed base of The Bobaths saw movement and sensation as complex,
support before reach, as well as stabilizing the body interdependent aspects of human performance (Howle,
during reach. 2004). They hypothesized that lack of movement
control affected the ability to perceive and process including postural control, hand function, gait, and
sensation. Although the sequencing of sensation and speech.
movement proposed by the Bobaths may be open to
question, there is no argument that persons with CNS
lesions do have sensory impairments that affect their KINESIOLOGIC ASPECTS OF
motor performance. Problems with sensory perception
and sensory processing affect performance in a number TRUNK AND ARM FUNCTION
of ways, including inability to detect and identify
incoming sensory information; difficulty interpreting The problems with postural control and upper limb
single sensory or multisensory input; problems with function seen in children with CP affect all aspects of
modulation of sensory inputs to match changes in task occupational performance. It is for this reason that
and environmental demands; and inability to match evaluation of posture, postural adjustments, and their
sensory information with experience, memory and interactions with the upper limb particularly should be
specific tasks (Eliasson, Gordon, & Forssberg, 1995; part of a therapeutic assessment, as well as the status of
Gordon & Duff, 1999a; Gordon & Duff, 1999b; body structures.
Lesny et al., 1993; Yekutiel, Jariwala, & Stretch, 1994).
Impaired development of anticipatory control during TYPICAL TRUNK AND U PPER LIMB
hand function also results from impaired sensation.
Eliasson and Gordon (2000) described anticipatory
I NTERACTIONS
control in object manipulation as The axial skeleton is the base upon which the limbs are
supported and from which they operate. The alignment
“internal representations or sensorimotor memories of the object of the spine, pelvis, and ribs influences how both the
gained during previous manipulatory experience” (p. 233). upper and lower limbs rest in space and how their
movements are used in the performance of various
Researchers have carried out extensive studies over activities. Remember that many of the muscles control-
recent years in an attempt to isolate the role of sen- ling the upper and lower limbs attach to the spine, rib
sation in prehensile and release functions in typical cage, and pelvis, and that the shoulder girdle moves
adults and children (Forssberg et al., 1991; Kinoshita et over the rib cage. The anatomical connections between
al., 1992; Eliasson, Johansson, & Westling, 1992). This these musculoskeletal units are why mobility and stabil-
series of studies was followed by a body of research ity of the entire trunk are so important to movement of
looking at issues of vision, tactile sensation, spasticity, the limbs (Neumann, 2002).
and force generation in grasp and release. Comparisons The pelvis provides support for the spine. Because
of these parameters in grasp and release between chil- the lumbar spine interacts specifically with the pelvis in
dren with CP and typical children also were performed virtually all movement sequences (e.g., forward flexion,
(Duff & Gordon, 2003; Eliasson & Gordon, 2000; extension, rotation, lateral flexion), motor or joint
Eliasson et al., 2003; Gordon, Charles, & Duff, 1999; impairments in one or the other structure affect move-
Gordon & Duff, 1999a; Gordon & Forssberg, 1995). ments in both areas. Similarly movements in any region
This work has established that the grasp and release of the spine result in movements within the entire
of children with CP is impaired by deficits in tactile spine, with the degree of the resulting motion decreas-
perception and processing, difficulty with graded con- ing distally from the originating movement. Therefore
trol resulting from balanced interactions between disruption of motion in one region of the spine affects
muscle agonists and antagonists, and temporal control the entire spine, and by association, the position of the
of movement events (Eliasson & Gordon, 2000). head in space (Neumann, 2002).
Temporal issues were cited again in the work of Gordon In children with CP, both structures and movements
and co-workers (2003), who found that release of of the axial skeleton often are impaired, affecting both
objects that varied in weight required more time in posture and limb function. Such limitations in the bio-
children with CP than in typical children, especially mechanical interactions of the pelvis and spine are
when accuracy and speed were necessary. concerns for therapy intervention in the child with CP.
This discussion underscores the notion that motor The shoulder girdle is comprised of the scapulae,
behaviors, sensory perception, and sensory processing clavicles, sternum, and glenohumeral joints. Just as
are inextricably linked, and that experience and prac- with the spine and pelvis, dysfunction at any one joint
tice with various motor behaviors helps to build of the complex affects movement at all of the other
performance and anticipatory control in children with joints. The shoulder, elbow, and forearm place and
CP. This is true for all aspects of motor performance, sustain the wrist and hand in space for function.
Arranging hair on the back of the head, clipping toe- In movement disorders such as CP, base of support
nails, bathing, and dressing are all examples of activities is affected by the movement disorder itself, structural
that require the hand to be moved to a distance away issues such as hip dislocation, and elements related to
from the body. In typical movements, certain shoulder the movement disorder such as limited postural con-
complex functions are aided by actions of the spine. For trol. Age, task constraints, and the physical environ-
instance, rotation and flexion of the lumbar, thoracic, ment mentioned previously should be considered when
and cervical spine extends the range of reach for items carrying out assessments of performance in which base
high on a shelf or under a bed. of support is an issue. Interventions used to develop
The rotary movements of the shoulder and forearm more skilled action in NDT are designed to take into
are particularly important to skilled dexterous move- consideration base of support and its impact on the
ments within and between the hands, both at and away individual’s ability to perform upper limb functions.
from midline. Removing post earrings, for example,
requires the palms of the hands to be facing each other
on one side of the body, an action that would not BIOMECHANICAL INTERACTIONS
be easily performed without humeral and forearm OF THE UPPER LIMB IN
rotation.
Finally, the complexity of wrist and hand movements CEREBRAL PALSY
is significant and remarkable for the highly comple-
mentary nature of the interactions among various struc- Depending on muscle tone and distribution of motor
tures. Consider playing the piano and the configuration impairment in the individual with CP, there are
of the wrist and fingers. During an octave stretch, the commonly fluctuations in movement control that affect
wrist may be flexed to provide additional range of position of the spine and pelvis and postural adjustment
movement in abduction and extension at the fingers. responses (Liao et al., 2003; Van der Heide et al.,
When a chord is played, the wrist is extended to 2004). These difficulties can be increased by tightness
provide power, stability, and control for the flexed in the soft tissue structures of the lower limbs, such as
fingers. Knowledge of these kinds of interactions assists the hamstrings and hip flexors (Reid, 1996). Such
the therapist to both understand and treat limitations problems in the axial structures influence purposeful
in occupational performance that involve the hands. movements in the upper limbs of children with CP.
Awareness of the complex structures in the hand is Posterior tilt of the pelvis and flexion of the lumbar
critical as well, including the carpal, metacarpal, pha- spine increase thoracic flexion and compromise actions
langeal joints, and arches. in the shoulder girdle and shoulder.
As discussed, changes in any aspect of shoulder
BASE OF SUPPORT AND U PPER girdle function influence the entire shoulder girdle
complex (Neumann, 2002). Scapulohumeral rhythm is
LIMB FUNCTION commonly affected by increased thoracic flexion,
Another biomechanical aspect of upper limb perform- causing the scapula to rotate upward sooner in the
ance is the base of support generated for upper limb interaction of the two structures and sometimes lim-
function, basically the foundation of the head, trunk, iting the range of overhead action. Movements in the
and limbs. Shumway-Cook and Woollacutt (2001) frontal plane, such as humeral flexion and horizontal
define base of support as adduction, seem to be difficult for children with CP,
resulting in the increased presence of humeral abduc-
“the area of the object in contact with the support surface” tion and sometimes humeral extension. External rota-
(p. 164). tion of the humerus is affected by both increased
thoracic flexion and the resulting scapular abduction,
A wide base of support, such as the feet widely which biomechanically aligns the humerus into an
separated in standing, provides stability for motor internally rotated posture. This configuration is most
functions, whereas a narrow base of support in sitting often seen in children with spasticity; those who have
and standing is more conducive to body mobility. One dyskinesia or dystonia may seek to control extraneous
also needs to consider the nature of the supporting movement in their upper limbs by holding their upper
surface; some properties of various surfaces enhance limbs against their bodies in a practice called “fixing” or
contact with body structures, such as beanbag chairs. stabilizing the upper limb (Nichols, 2001). This prac-
Age, the nature of the activity, and the environment are tice volitionally can limit their humeral motions
other factors that affect the base of support incor- initially; however, if the practice persists, actual soft
porated by the individual. tissue limitations can occur.
Movement of the body and limbs as a unit is a Children with hypertonia have increased stiffness or
characteristic seen in CP (Hadders-Algra et al., 1999). tone in their muscles, whereas children with hypotonia
Isolation of movement in the various segments of the have decreased resistance to lengthening and laxity of
upper and lower limb is missing, causing a lack of dis- both muscle and other soft tissue structures around
association between the movement elements between the joints. It is not uncommon to find children with
and within each limb. For instance, the motions used hypotonia in the trunk and hypertonia in the limbs, or
in the shoulder girdle and humerus affect movement those with fluctuating tone, as well as children with
components seen in the forearm and wrist. Humeral generalized hypotonia. The intervention approaches to
abduction and internal rotation facilitate overuse of these variations in muscle tone differ in that children
forearm pronation and limit active supination needed with hypotonia use end range movements (activities
for efficient hand use, a common problem in children carried out by motions at the end of the available joint
with spastic CP. Active elbow and wrist extension is range) and often have increased range of motion in
often restricted by spasticity in the elbow and wrist contrast to the limited active and passive mobility seen
flexors, over time causing muscle tightness and con- with hypertonia. Children with underlying low tone
tracture. The predominance of flexion at the elbow and often use stabilizing or fixing of a body part (Nichols,
wrist also affects the development of active intrinsic 2001) to create stability, as well as a wide base of sup-
muscle function in the hand, resulting in the use of port in upright positions to create postural stability.
tenodesis interaction between the wrist and fingers and Body movements are characterized by straight plane
the use of extrinsic finger flexors and extensors to con- actions without a rotary component and limitations in
trol the digits. Types of grasp available, especially for strength and endurance are common. In the upper
children with more severe impairments, are limited to limb and hand, lack of graded, efficient movements
more primitive grasp sequences and lack of both power restrict refined functions such as precision grasp, inter-
and precision prehensions. Deformities of the web space digital interaction, and isolated digital control used
of the thumb and hypermobility in the metacarpo- in complex manipulative sequences. The intervention
phalangeal (MCP) and distal interphalangeal joints of procedures differ somewhat, although the emphasis on
the thumb are common. postural control as a necessary element of performance
These atypical interactions in the upper limb of remains unchanged.
children with CP result in significant activity and
occupational limitations. Some authors hypothesize
that the movement alterations are actually an adaptive TREATMENT APPROACHES:
function rather than true movement impairments CONCEPTS OF INHIBITION
(Steenbergen, Hulstijn, & Dortmans, 2000). Whatever
the cause of the movement limitations, the manip- AND FACILITATION
ulative function needed to manage such items as
clothing fasteners, the ability to write, and use scissors, Three concepts underscore therapeutic handling (facili-
is often either impaired or missing. Clinicians should tating active movement by using a hands-on approach)
assess the child’s postural control and upper limb func- in the NDT treatment approach, key points of control,
tion as a whole to design interventions that enhance all inhibition, and facilitation. Key points of control refers
aspects of performance. to specific hand placement by the therapist during
handling that allows direct influence or control over
CONTRASTS BETWEEN HYPOTONIA the area and indirect control over other body structures
or functions proximal or distal to the key point. These
AND HYPERTONIA
sources of control are used to either inhibit or facilitate
The discussion to this point has addressed postural movement sequences and postural control. Proximal
control, anticipatory postural control, the relationship key points include the pelvis, shoulder girdle, and trunk,
of posture to upper limb function, and aspects of whereas distal key points are areas such as the elbow
atypical motor performance in children. Most of the and ankle. Inhibition is defined as
discussion has related to the child with spasticity and
increased tone. Muscle tone refers to the resistance a “the reduction of specific underlying impairments that interfere
muscle offers when lengthened (Shumway-Cook & with function” (Howle, 2004, p. 261).
Woollacutt, 2001). This resistance is a result of both
neural factors (e.g., spasticity) and biomechanical fac- In treatment, therapists use inhibition to limit the
tors (e.g., fibrosis, atrophy, changes in contractile prop- ungraded force produced by spasticity, to balance
erties of some muscle fibers). unequal power between antagonists and agonists, or to
limit those movements that impair smooth coordinated or extension synergies in the limbs. It can be used to
action. Facilitation consists of increase range of movement and decrease tone in chil-
dren with spasticity, or in children with hypotonia or
“strategies employed in therapeutic handling that make a athetosis who have decreased range caused by fixing
posture or movement more likely to occur” (Howle, 2004, p. body parts to limit extraneous motion.
260). Therapist guidance of movement has applicability
for both inhibition and facilitation. For inhibition, the
It is used to activate, grade and change various therapist uses key points of control to limit ungraded
movements, and should affect the direction, force and force in one muscle group while facilitating active
availability of various movements. movement in the agonist or antagonist. It can be
Specific techniques are used for inhibition and facili- particularly helpful in the case of hemiplegia, in which
tation (Box 16-1). These are discussed next. asymmetries exist, or in the cases of diplegia and
quadriplegia, in which symmetry of limb posture and
lack of dissociation of movement is a problem. In these
I NHIBITORY TECHNIQUES circumstances, the therapist can inhibit asymmetry by
Inhibition is the primary tool used to manage abnormal directing activities that are bilateral or symmetric in
posture and tone. Specific “hands-on” inhibitory tech- nature, or by inhibiting symmetry of posture by using
niques such as vibration, use of mobile surfaces, treatment activities that require the limbs to be used
location, position of structures within the treatment reciprocally.
environment, and use of various sensory stimuli and Use of mobile surfaces has both inhibitory and facili-
speed of movement can all be used to minimize tatory applications. Children who have increased trunk
impairments. extensor tone accompanied by lower limb extension
Vibration in NDT consists of placing the hand on a can be positioned on a mobile surface and the gentle
body area and vibrating or oscillating the location rocking movements of the surface used to inhibit tone
gently and consistently. Use of mechanical vibrators is and relax the child. Over time, passively applied move-
discouraged because of the noise and difficulty grading ment on a mobile surface is shifted to the facilitation of
the intensity of the vibration. This technique is best the child’s ability to use his or her own active motion
used when a more global movement or gross motor to manage tone increases.
activity is being performed so as not to interfere with Inhibition through activity is when the therapist
performance. It is particularly useful when managing teaches the child or individual how to manage atypical
trunk tone for vocalization or extending the range of movements or increases in stiffness through specific
movement in the trunk or a limb. As with all inhibitory movement sequences. For example, in the child who
techniques, one should withdraw the technique during has increased tone in the flexors of the upper limb that
activity performance. limits dressing or bathing, upper limb weight bearing
Prolonged stretch through weight bearing in both against a wall or the floor can help inhibit the flexion
upper and lower limbs is an inhibitory technique used posture, or bending from the waist and shaking the
to elongate soft tissue structures and minimize flexion arms in space can help reduce the stiffness. Whenever
possible, clients should be taught to use their own
movement over time for health promotion and
BOX 16-1 Specific Techniques Used for increased participation.
Inhibition and Facilitation
INHIBITORY TECHNIQUES
FACILITATION TECHNIQUES
• Vibration The use of key points of control combined with therapist
• Prolonged stretch guided movement plays a big role in facilitation.
• Therapist guidance of movement
Remember that key points of control are body areas
• Use of mobile surfaces
• Inhibition through activity from which the therapist facilitates or inhibits move-
ment. In facilitation, the goal might be to assist the
FACILITATION TECHNIQUES
client to open a cupboard door using a more involved
• Deep pressure and joint approximation
• Weight bearing on both upper and lower limbs upper limb while the unimpaired limb holds and then
• Vestibular input places an item into the cupboard. The therapist could
• Environmental modifications use either the shoulder or elbow as a key point of
• Sensory modifications control to facilitate placement of the impaired arm
• Combining inhibition and facilitation on the door handle, a task that the client cannot do
without prompts.
In this same example, tapping could be used along ance. These same kinds of modifications can apply to
the muscle belly of the elbow extensors to activate the specific aspects of hand function as well. For instance,
movement necessary to extend the arm to the door using checkers instead of pennies to facilitate elements
handle. Tapping can be used alternatively with tactile of a precision prehension can ensure success for the
cues, which are a firm touch on the body part to indi- child and build the motor and sensory aspects of
cate that it needs to move. Tactile cues are a less activity demands.
invasive form of facilitation, so moving back and forth Sensory modifications can be helpful too. Music that
between the two techniques is one way to withdraw is invigorating or calming can be used, singing, use of
input as the client is more able to perform the desired high contrast, complex or simple visual backgrounds
activity with less assistance. are some ways to alter the sensory environment. Use of
Deep pressure and joint approximation are facilitation social facilitation is another technique that has been
techniques to activate cocontraction around the joints. enhanced by inclusive practices in the classroom
The use of these techniques works best on low-toned (Kellegrew, 1996). Peer engagement and support can
persons, but those with high tone often demonstrate serve to motivate and facilitate children in ways that
underlying low tone when their high tone is altered. parents or therapists cannot achieve. Children’s desire
Sequencing deep pressure and joint approximation to be like their peers is a powerful force in facilitating
after tone inhibition is a common practice to facilitate performance, especially in the achievement of activities
better control and muscle activation. and occupations that the child wishes to perform to be
Weight-bearing on both upper and lower limbs has with friends.
properties of facilitation, as well as inhibition, depend-
ing on how it is applied. Static weight-bearing, espe-
cially for extended periods of time, can be achieved by
COMBINING I NHIBITION AND FACILITATION
“locking” or hanging on the joints. However, if weight- In almost any treatment session with children who have
bearing is accompanied by weight-shifting (volitional or CP, it is necessary to combine aspects of inhibition and
assisted movement of body weight) and active move- facilitation. This requires considerable skill on the part
ment sequences, it can facilitate active movements in of the clinician, especially in the case of active children.
various muscle groups. Weight-shifting refers to move- By altering movements through the use of facilitation
ment of body weight through momentum of a body or inhibition, the clinician causes the client to change
part (Shumway-Cook & Woollacutt, 2001). Active or adapt. This requires the clinician to quickly alter
weight shift occurs in all volitional movement transi- hands-on input to continue to enhance the improve-
tions and is an important therapeutic tool in persons ment in the child. Ultimately the goal is to be able to
with movement impairments resulting from neuro- withdraw both kinds of techniques so that the child can
muscular disorders. In the upper limb, humeral flexion, demonstrate motor learning and carryover of the skills
elbow extension and possible wrist and finger extension learned in therapy.
can be facilitated by weight-shifting over weight-
bearing positions.
Vestibular input can be used to facilitate postural THE ASSESSMENT PROCESS
control. Combinations of sensory-integrative tech-
niques can be incorporated, using swings or platforms Assessment of the child with cerebral palsy can be
(Blanche, Botticelli, & Hallway, 1995). If the child is complex. Multiple aspects of performance should be
not capable of sitting independently or sustaining analyzed, including physical and sensory status, devel-
posture on such equipment, the therapist can sit on the opmental status, postural control, and quality of
device with the child in his or her lap. A more desirable movement elements. The challenge for the clinician is
option is to incorporate meaningful activities such as how to sort through these aspects of the client to see
dance with repeating rotary turns into the treatment which appear to be most critical to occupational per-
whenever possible. formance. Distribution and degree of movement
Environmental modifications include arrangement of impairment also can be a guide. Children with mild
physical, sensory, and even social aspects of the hemiplegia, for instance, may not need extensive physi-
environment to facilitate action. Pediatric therapists are cal assessment but based on research findings (Gordon
particularly good at such modifications. Arranging the & Duff, 1999b) need assessment of tactile function.
room so that items are placed strategically so as to Developmental and occupational assessments are
encourage active movement, use of surfaces that chal- appropriate. A child with severe quadriplegia is more
lenge the abilities of the child, and use of materials in likely to need physical status assessment (e.g., strength,
occupations that are meaningful to the child are all range of motion, spasticity) and less likely to need a full
ways to facilitate skilled action and successful perform- developmental evaluation.
Various assessments are discussed next, including approach, remember that the approach addresses pos-
standardized tools whenever possible. ture and movement in the context of occupational
performance. This means that occupational perform-
ance needs to be assessed. Pediatric therapists have a
PHYSICAL STATUS OF THE I NDIVIDUAL host of tools available to them in this realm, some of
Range of motion and muscle strength are assessed which have a developmental or skill focus. The reader
using standard goniometry and manual muscle testing. should see Asher (1996) for a complete listing.
Argument existed for some years about whether accu-
rate evaluation of strength was possible in children with
muscle tone impairments, however, the existing litera-
ture on functional gain after strengthening programs TREATMENT PLANNING
makes this a relevant area to assess (Damiano, Vaughan,
& Abel, 1995; Darrah et al., 1999; Dodd, Taylor, & Planning appropriate interventions and documenting
Damiano, 2002). outcomes are aspects of service provision that require
Muscle tone is assessed through the use of tools that careful attention. Setting appropriate goals is the
are somewhat subjective, including the Ashworth Scale cornerstone of treatment planning. As noted in the OT
(Bohannon & Smith, 1987). The Tardieu Scale’s use is Practice Framework, the occupations selected as out-
evolving; however, it requires more time and expertise comes of intervention should be meaningful and
to achieve accurate results (Mackey et al., 2004). These purposeful to the client and family; and successful
two scales assess increased tone but are not particularly outcomes are more likely when occupations are incor-
helpful with hypotonia. Existing tools to measure porated into daily routines (AOTA, 2002). These
decreased tone directly do not exist. premises hold true for NDT intervention just as they
Assessment of sensation is a time-consuming process do for other treatment approaches.
that often is not carried out in children with CP in spite Use of activity analysis and the principle of partial
of a body of research indicating tactile discrimination participation are useful tools to help build specific skills
deficits in children with CP, particularly hemiplegia and over time (Vogtle & Snell, 2004). Refer to Table 16-1
quadriplegia (Duff & Gordon, 2003; Eliasson & in Case Study 1 for one example of activity analysis that
Gordon, 2000; Eliasson, Gordon, & Forssberg, 1995; is useful when planning NDT intervention. Sensory
Gordon et al., 2003; Gordon, Charles, & Duff, 1999; and motor elements are delineated to assist the clinician
Gordon & Duff, 1999a). Gordon and Duff (1999b) in organizing treatment and incorporating strengths of
and Lesny and co-workers (1993) used a variety of the client. Partial participation, which enables clients to
measures in their work that are recommended for complete steps of an activity that they are able to do
clinical practice, including tests of two-point discrimi- with the remaining steps completed by a caregiver, can
nation, stereognosis, and deep pressure. be planned satisfactorily through the use of this kind
NDT emphasizes quality of movement. Existing of activity analysis (Vogtle & Snell, 2004). Breaking
tools that assess quality of movement are limited. an activity into steps also helps the clinician evaluate
Examples are the Gross Motor Performance Measure treatment outcomes in a more systematic manner.
(Boyce et al., 1995; Gowland et al., 1995; Thomas et Another aspect of treatment planning that benefits
al., 2001), the Toddler and Infant Motor Evaluation from activity analysis and partial participation is the
(TIME) (Miller & Roid, 1993; Rahlin, Rheault, & integration of accommodations into interventions. By
Cech, 2003), and the Movement Assessment of Infants breaking an activity into steps and sorting out which
(Hallan et al., 1993; Harris et al., 1984). of those the client can do, modifications to promote
The limitations in standardized tools that assess successful performance can be easily identified and used
movement and posture are a concern for the NDT in treatment. This has the extra benefit of giving the
treatment approach because the treatment emphasis is clinician the opportunity to see if suggested modifica-
on developing posture and movement. Researchers tions really work before asking families and educators
have options available to them, but these are too expen- to make them.
sive and complex for the clinic. Nichols (2001) sug- Tables 16-2 and 16-4 in the Case Studies later in the
gested using indirect observation during assessment of chapter give illustrations of how a clinician could use an
motor milestones, which is the best option available in activity analysis to plan treatment. The tables include
the clinic at present. columns for activity steps, movement components, and
The success of any therapeutic intervention is facilitation techniques. Organizing treatment into this
dependent on the therapist’s ability to analyze aspects kind of table can help the clinician develop a plan for
of performance and change over time. When one is intervention that includes aspects of facilitation and
planning interventions that use an NDT treatment inhibition.
THE INTERVENTION PROCESS Weight shifts can assist in inhibition of tone and
facilitate active trunk and upper limb function. Other
facilitation and inhibition techniques can be applied
Once assessment is complete and goals are established during treatment of hand function as well. Gentle
by the family, child, and clinician, it is time to consider vibration or oscillation on the trunk or limbs helps to
how to provide treatment. The use of NDT techniques manage upper limb tone and use of the shoulder or
means that the therapist needs to combine the client elbow as key points of control facilitates active move-
factors to be addressed (e.g., tone, weakness, range ments in the wrist and hand. Preparatory activities
of motion, postural control issues) with performance using upper limb weight bearing prepare the hand for
skills and activity demands of the goal while learning more active hand function by inhibiting tone and
and practicing identified activities or occupations. The improving mobility of wrist and finger flexors. These
nature of the occupation selected as a goal in con- activities can take place with the child in sitting or
junction with client factors dictates the degree of standing, not just in quadruped, positions in which
postural control integrated into the intervention. upper limb weight bearing often takes place in typical
If the goal activity is focused on hand function, then children.
the level of postural control and adjustment factored
into the session depends on the planes in which the N EURODEVELOPMENTAL TREATMENT AND
hand function takes place and future postural control
goals. For instance, tying shoes occurs at some distance
HAND FUNCTION
from the body. Potentially there should be either more There are children in whom the primary intervention
work on posture involved in this kind of activity than if focus needs to be within the hand. Examples are
the goal was handwriting, or the therapist should children with quadriplegic involvement in which the
develop postural supports necessary to allow the hands most important goal is isolated index finger function to
to be free for the act of shoe-tying. access a computer or augmentative communication
The base of support required by an activity during device; a child with hemiplegic impairment who wants
intervention depends on the movement transitions to be able to hold a piece of paper in the impaired hand
needed during performance, and on the degree of body so that cutting can be accomplished; or a young person
stability required by activity demands when adjusted by who wants to be able to manipulate a joystick to drive
client factors. For instance, a child with significant a power chair.
quadriplegia may not be likely to use isolated trunk In these kinds of examples, direct treatment of the
control, so a wider base of support might be chosen hand is necessary. Most of the inhibition and facilita-
during hand function activities to contribute to the tion techniques described earlier can be applied directly
child’s stability. A less involved child who is mobile and to the hand. Vibration or oscillation at the wrist or
has elements of active trunk control would be more from the web space of the thumb minimizes tone in the
likely to benefit from working on a narrower base of fingers; these techniques can be used as preparation
support. Base of support can be graded over time as before performance or used during activities. Weight
progress is seen. It is also important to remember if bearing on the hand is a well-known NDT technique
the child is in supportive seating during the day, the for soft tissue stretch and tone management that is
practice part of sessions needs to take place in the same underused in reciprocal hand interactions such as hand-
configuration. to-hand clapping games with another person, in which
Base of support can affect the degree of weight hand contact is extended for the purpose of stretch,
shifting used in treatment. Large weight shifts obvi- deep pressure, or tone management. The degree of
ously are important to movement transitions; however, wrist and finger extension involved in the activity can
lesser degrees of weight shifting can play an important be graded by the therapist depending on the desired
role in upper extremity treatment. Sitting at a table outcomes and the tolerance of the child.
and cutting with scissors, for instance, usually incor- Key points of control in the hand include the wrist,
porates subtler weight shifts. If the child reaches for longitudinal arch of the hand, MCP joint of the index
items set back from the edge of the table, an anterior finger, thenar eminence, and web space of the thumb.
weight shift occurs. Similarly, reaching for items off to Obviously the use of key points of control has to be
the side results in a lateral weight shift. Using subtle carefully managed in such a small area as the hand,
weight shifts assisted by key points of control when which is when careful grading of activities comes into
working on table top activities and development of play. For example, when isolated control of the index
fine motor skills can extend reach and assist with hand finger is desired, the therapist may choose to use the
placement, as well as inhibiting extensor tone in the MCP joint as a key point of control. Activities that
trunk. might be used to facilitate sensorimotor experiences in
this situation include pushing keys on a piano, com- It is critical that the therapist spend significant time
puter, or toy, pressing stickers onto a surface, making having the client practice designated goals during the
fingerprints in play dough, extending the digit for session. The therapist can use inhibition and facilitation
placement, removal of a ring, and so forth. Those in this process, but needs to withdraw such assistance
activities that entail pressure (e.g., play dough, pressing as the session moves on, remembering that ultimately
keys, stickers) are situations in which weight shifts the child is expected to do the task without such
across the pad of the digit provide alternating deep assistance.
pressure inputs into the interphalangeal (IP) joints, as
well as the MCP joint, a facilitatory technique. E FFICACY OF N EURODEVELOPMENTAL
The mobility of the carpals and metacarpals of the
hand contribute to the arch structures of the hand,
TREATMENT
wrist flexion and extension, and radial to ulnar side Judgment about the efficacy of therapeutic interven-
interactions within the hand. All of these elements also tions should be based on careful examination of
play a role in grasp and manipulation between and published studies, either through systematic review or
within the hands. Hypertonic CP commonly results in meta-analysis. Such methods are limited by the limited
a predominance of wrist and finger flexion combined availability of high-quality studies. Two recent system-
with ulnar deviation at the wrist—resulting in ulnar atic reviews of NDT intervention have been carried
prehensions. Maintaining mobility in the structures out (Brown & Burns, 2001; Butler & Darrah, 2001).
of the hand mentioned earlier while facilitating active Butler and Darrah (2001) incorporated articles back
movement and the ability to participate in chosen to 1973, whereas Brown and Burns (2001) included
occupations are focal concerns of NDT treatment. those published since 1975. There were 21 studies in
Although the prevailing muscle tone in the hand is the review by Butler and Darrah (2001) and 17 articles
increased with generalized hypertonia, hypermobility in the review by Brown and Burns (2001). Both
in the IP joints of the fingers and thumbs is common, reviews classified articles as one of five levels of evi-
as well as in the MCP and carpometacarpal joint of the dence. Brown and Burns (2001) used the Quality
thumb. This combination of increased mobility and Assessment of Randomized Clinical Trials scale created
fluctuating tone in the spastic hand presents challenges by Jaded and co-workers (1996) to assign levels of
for the therapist and the need to alternate strategies of evidence, whereas Butler and Darrah (2001) used a
inhibition and facilitation frequently when working system developed by the American Academy of Cerebral
within the hand. Palsy and Developmental Medicine (Butler & Darrah,
Activity demands should be considered as part 2001). Another unique feature of their review is their
of treatment as well. AOTA (2002) defines these incorporation of dimensions of disability reflective
demands as of the National Center for Medical Rehabilitation
Research (NCMRR) model of disablement (Shumway-
“. . . objects, space, social demands, sequencing or timing, Cook & Woollacutt, 2001) as one judgment of
required actions, and required underlying body functions and outcome.
body structure needed to carry out the activity.” (p. 624). Both reviews cited numerous problems in attempt-
ing systematic study of NDT. Problems included
Specific aspects of any activity are items that should heterogeneity of the target population, lack of random-
be considered in treatment, and amended or modified ization, inadequate blinding of subjects, a wide range
when necessary to enable the client to have success in of subject ages, use of a variety of clinical and stan-
performing the occupation. Nowhere is this more dardized outcome measures, small sample size and
important than when working within the hand. For limited follow-up, interventions that included other
example, it is common for therapists to choose the methods besides NDT, a range of duration and inten-
smallest possible items to develop skills such as tip-to- sity of treatments, and inconsistency of significance
tip prehension. Larger items offer the child better across studies. Both studies concluded that the efficacy
control and incorporate the same movement sequences of NDT could not be decided on the basis of the
used in precision prehension; as skill is gained, the studies reviewed, although Butler and Darrah noted
therapist can then move on to include small objects in that studies published in the last 14 years had more
therapy. statistically significant results. In addition, both noted
Practicing occupations during treatment has been that newer interventions based on more current
emphasized in this chapter. There is a body of research theories of motor learning and skill development exist
supporting the efficacy of activity practice in children and appear to be generating more conclusive evidence
with cerebral palsy (Duff & Gordon, 2003; Taub et al., (Butler & Darrah, 2001). Butler and Darrah cited the
2004) and the importance of activity context on prac- lack of association to any of the NCMRR dimensions
tice outcomes (Volman, Wijnroks, & Vermeer, 2002). to which the various studies were compared. These
same authors suggest that the use of NDT as a control

intervention in studies comparing it to another treat-
SUMMARY
ment would contribute to the body of existing evidence
about treatment efficacy for children with CP. This chapter has described the neurodevelopmental
Since these two systematic reviews were published, treatment approach to pediatric intervention, and its
other publications about efficacy of NDT have been history, evolution, and current perspective. As reiter-
published (Trahan & Malouin, 2002; Tsorlakis et al., ated throughout the chapter, NDT is an intervention
2004). Trahan and Malouin’s research was a pilot study focused on improving postural control and active
analyzing the outcomes of an intermittent intensive movement skills. The therapist bears the responsibility
NDT intervention. Tsorlakis and co-workers (2004) for integrating this kind of approach into function and
research was a carefully designed randomized clinical practice of function. Carryover of movement changes
trial comparing outcomes between two different dura- into function does not occur naturally, as once pro-
tions of NDT treatment that attempted to avoid design posed by the Bobaths. Although the efficacy of NDT
problems of earlier studies. Duration of intervention has yet to be demonstrated convincingly, more recent
has become a focus of studies because of the devel- studies are supportive and suggest that the shift to
opment of constraint-induced therapy that provides integration of NDT with functional outcomes has
intensive duration of therapy over a relatively short merit in the treatment of upper limb function in chil-
term (Taub et al., 2004). dren with CP.
CASE STUDY 1
A C HILD WITH C EREBRAL PALSY
Seven-year-old Jodie, who had spastic CP of quadriplegic extension in her torso, head, and neck, and by bilateral
distribution, used a head-activated switch to work on the rigid extension at the elbows and in the lower limbs. A
computer, which meant scanning the keyboard rather than consistent lean to the left was noted, a trend made worse
being able to use direct selection of desired keys. Her by her attempts to use her hands. She could lift her arms
school therapists, teachers, and family wanted to explore actively by flexing and elevating her shoulders to about 80
the possibility of hand activation of Jodie’s computer degrees but movement toward or away from the midline
access switch with the eventual goal of direct selection on to place her hands was difficult. There were soft tissue
an alternative keyboard, which would be faster and more restrictions in her shoulders, limiting the end range of
productive. Although computer use in the context of the humeral flexion and abduction.
school environment was the initial occupational goal, Jodie’s hands were most often fisted and wrists stiffly
success meant she would be able to access her home extended. A right hand preference was noted. Jodie
computer with less assistance than she presently required. reached for offered items directly in front of her body but
was unable to grasp an object volitionally or bring her
TASK ASSESSMENT AND GOALS hands to her mouth. When a toy was placed in her hand,
Activity analysis of the process of pushing a switch (Table she would hold it indefinitely using increased flexor tone
16-1) and physical assessment of Jodie’s ability to push a in the fingers of her hands but was unable to do anything
switch with her hand were carried out, along with an with it; there was no volitional release of objects and
assessment of performance components, activity demands, efforts to do so resulted in head shaking in an effort to
and client factors in the OT Practice Framework (AOTA, release items from her hand. There was no isolation of
2002) and of performance components in Uniform movement between limbs or within either limb.
Terminology III (AOTA, 1994). Jodie demonstrated chal- Jodie could place her hand on a 5″ × 7″ switch placed
lenges in motor and process aspects of performance skills. in front of her with difficulty, but could not consistently
She maintained her head in an upright position for long depress and release the switch to use it for computer
periods of time and used it to move her eyes when tracking access, nor could she remove her hand from the switch
items. Efforts at arm and hand movement affected move- once it was placed there.
ments of her head and trunk, resulting in dynamic tone The movement components she needed to activate
changes throughout her body manifested by increased the switch for various aspects of the activity are noted in
Table 16-1 Activity analysis of activating/deactivating a switch for computer use
Step of Visual Auditory Movement Tactile

Activity Component Component Components* Component
Moves arm to Locates switch Lifts right arm toward Kinesthetic

switch the switch using feedback from
humeral flexion and the limb
horizontal abduction. moving
Elbow extension
Places hand on Sees switch and Humeral extension Jodie feels the
switch uses vision to activated to bring switch under
guide placement hand to switch her fisted
of hand on switch hand
Presses switch to Sees scanning Hears click as Humeral extension is Jodie feels the
activate array activate switch is activated used to push the pressure of the
when switch is switch switch on her
pressed hand increase
as she pushes
Releases pressure Uses vision to Hears click as Humeral flexion is Feels absence
on the switch guide her hand pressure is used to lift her hand of sensation as
lifting to release released and off the switch her hand clears
switch pressure switch deactivated the switch
Moves arm and Sees hand lift off Moves arm away from Feels table
rests hand on the of switch and the switch using surface under
surface away targets where humeral flexion and her hand and
from the switch hand is to rest horizontal adduction; arm when she
humeral extension is rests them on
used to lower arm to the table
the table surface
*Because the client has stiffly extended elbows, which become stiffer with efforts at movement, the choice made is to focus on
humeral movements to move her hand. Use of wrist flexion and extension also would be helpful; however, these movements are
not absolutely necessary to activate the switch.
Table 16-2. The use of these movements for activating the motor control and learning so that she could initiate,
switch were felt to be appropriate because Jodie’s sustain, and terminate movements of the shoulder in
volitional control of her elbow, wrist, and hand move- sequence to perform the activity.
ments was minimal, and the switch could be successfully
TREATMENT PLAN
activated using these movements. In addition to move-
The organization of the treatment plan for Jodie is
ments to activate and release the switch, she needed to be
detailed in this section and based on a school year with
able to organize and sequence these movements with
weekly sessions. The treatment plan incorporates both
enough speed to push the switch in a timely fashion when
environmental and client factors, as well as practice of the
visually cued to do so by the scanning sequence. Thus
skill being developed during sessions and at home outside
anticipatory control in her arm (remember that antic-
of the therapy setting at school.
ipatory control was defined as activation of sensory and
muscular systems for a specified activity based on prior THERAPY GOALS
learning and experience), postural control and adjustment The goals found in Box 16-2 include long-term goals and
of her head, and active isolated movements of her right benchmarks as seen in an individualized educational plan
upper limb were other aspects of performance needed for (IEP) write-up. Benchmarks were chosen that support the
Table 16-2 Facilitation and inhibition techniques to be used in Jodie’s treatment
Step of Activity Movement Component Facilitation/Inhibition Techniques
Moves arm to Lifts right arm toward the Tapping under the humerus to facilitate shoulder
switch switch using humeral flexion flexion and elbow extension; tapping on the
and horizontal abduction. medial border of the arm to facilitate horizontal
Elbow extension abduction; forward then lateral weight shift of
torso across the pelvis to facilitate arm
movement in a sagittal then lateral plane
Places hand on Humeral extension activated to Sweep tap across volar surface of the humerus;
switch bring hand to switch posterior weight shift of torso across the pelvis
to facilitate arm movement toward the switch
Presses switch to Humeral extension is used to Active assist from head of humerus or on the
activate push the switch forearm to facilitate pressure on hand to activate
switch; lateral weight shift of torso across the
pelvis to facilitate switch activation
Releases pressure on Humeral flexion is used to lift Tapping under the humerus to facilitate shoulder
the switch her hand off the switch flexion and elbow extension; tapping on the
medial border of the arm to facilitate horizontal
abduction; forward weight shift of torso across
the pelvis to facilitate arm movement in a
sagittal plane
Moves arm and rests Moves arm away from the switch Tapping under the humerus to facilitate shoulder
hand on the surface using humeral flexion and flexion and elbow extension; tapping on the
away from the horizontal adduction; humeral lateral border of the arm to facilitate horizontal
switch extension is used to lower arm to adduction; forward then medial weight shift of
the table surface torso across the pelvis to facilitate arm movement
in a sagittal then lateral plane
use of Jodie’s right upper extremity for single switch HANDS-ON TREATMENT
activation working from her wheelchair. Although Jodie The therapist used four premises upon which to base her
does have significant limitations in postural control, note treatment. First, tone increases seen in Jodie when she
that postural elements are woven into the treatment but attempts to use her upper limbs will be altered through
are not identified as long-term goals. the use of work on a mobile surface (the bolster), facili-
THERAPY ENVIRONMENT tation of forward and lateral weight shifts when reaching
The therapist chose to intervene with Jodie in her class- for her switch, and use of periodic rapid oscillations to the
room. The first-grade classroom was broken up into areas, upper limbs. Second, use of facilitatory tapping and active-
meaning that there were times when floor space was avail- assisted hand placement on the switch will be used to help
able for therapy with Jodie out of her wheelchair. The Jodie activate shoulder movements for hand placement,
therapist brought a therapy bolster to use during sessions. switch depression, and switch release (see Table 16-2).
Being in the classroom meant that the same physical set- Third, practice of the task will be used to ensure changes
up of the switch and computer was available for practice in in motor performance, motor learning of the skill being
a real-life situation in which the therapist could observe developed, and switch activation for computer use. Fourth,
Jodie’s progress. Classmates were present, as was the case tactile enhancement and reinforcement will be used to
during spelling class, and could be available to provide ensure that Jodie knows when her hand is and is not on
encouragement if approved to do so by the classroom the switch to help build anticipatory control mechanisms
teacher. needed for successful task accomplishment.
BOX 16-2 Long-Term Goal and

Benchmarks for Jodie
Jodie will be able to depress and release a 4 × 6

computer switch attached to a computer-scanning
program in order to participate in spelling tests with
her classmates
a. Jodie will be able to lift and place her hand
on the switch accurately 80% of the time.
b. Jodi will be able to depress the switch to
activate a simple on-off toy or object such as
a radio 90% of the time
c. Jodie will be able to depress and release the
switch to participate in a simple computer
game with 80% accuracy
d. Jodie will be able to activate the switch with
sufficient timing and accuracy to complete a
10-word spelling test within a 30-minute
period of time Figure 16-1 Jodie is seated on a bolster with the
e. Jodie will maintain her accuracy at switch therapist behind her. The therapist supports Jodie’s
activation through out the school day with arms at the elbow or slightly below, and moves them
minimal fatigue in a rapid alternating, up-and-down sequence to
reduce muscle tone. The hands can be clapped
against each other to assist. The therapist can move
the bolster side to side with her own body if needed,
and can lean forward to facilitate more trunk
TREATMENT IMPLEMENTATION extension on the part of the child.
In this section, sequencing within therapy sessions is
described, incorporating the physical environment, ther-
apy equipment, therapeutic facilitation, and practice
components. this manner for the first few times, and then used decreas-
Tone Management and Preparation for Activity ing assistance as Jodie exhibited the ability to activate a
Jodie was removed from her wheelchair for the first 15 to weight shift on her own.
20 minutes of each 40-minute session. This enabled the Switch Activation
therapist to use weight shifts and techniques to modify the This skill was practiced first with Jodie still on the bolster.
dynamic muscle tone Jodie demonstrated whenever she Using the bolster allowed the therapist to facilitate weight
tried to use her upper limbs and gave her practice in use shifts and shoulder movements and inhibit hyperextension
of appropriate postural components. A bolster was used of the trunk during efforts at movement. An adjustable
because it enabled the therapist to use two planes of height table under which the bolster was slid helped to
motion: anterior/posterior movements and lateral move- support the switch. The switch position at first was put
ments. Jodie was placed on the bolster, either on the far further back on the table than needed to require an
end or straddling it, to enable the therapist to use the exaggerated forward weight shift to counterbalance the
movement of the bolster when addressing Jodie’s muscle extensor thrust that occurred when Jodie tried to move.
tone during activities and to facilitate her active weight Remember at this point that Jodie’s arms were resting on
shifts while providing a wide base of support. These bol- the table surface at midline so she would not have to move
ster motions were activated by the therapist’s use of her her shoulder high or far laterally to place her hand on the
own lateral weight shifts and anterior or posterior body switch. The switch surface could be enhanced with a num-
movements. ber of different materials (e.g., carpet samples, various
At the same time, rapid oscillations of Jodie’s upper fabrics) to heighten differences between the table and
limbs were used to help loosen her stiff arms in prepa- switch surfaces.
ration for developing the active shoulder movements needed When Jodie was asked to activate the switch, a series
to activate the switch (Figure 16-1). At this point, the of short taps under her humerus were used to activate
therapist had Jodie lean onto her upper limbs positioned humeral flexion (Figure 16-2), then laterally to bring the
on the bolster to help inhibit tone and increase range in humerus to the switch, which was placed slightly off to the
her hands as preparation for switch activation. side (Figure 16-3). Active assistance in placing her hand
Forward weight shifts accompanied the upper extrem- was also used alternatively to help Jodie develop a sense of
ity weight bearing, passively accomplished at first by the what was needed to get to the switch; however, this only
therapist leaning forward into Jodie’s torso and moving occurred on alternate attempts rather than each time she
her forward. The therapist facilitated the weight shift in tried to touch the switch.
Figure 16-2 Jodie has been asked to activate the Figure 16-3 A continuation of sweep tapping is
switch but is demonstrating delayed response time. To used here; however, the direction has altered. The
assist her, the therapist sweep taps on the dorsum of switch is placed about 15 degrees off of midline and
her arm, moving from the elbow back toward the Jodie needs to horizontally abduct her shoulder to hit
shoulder. The purpose is to give tactile input so that her target. While the palm of the therapist’s hand
Jodie recognizes which body part needs to be moved. remains under Jodie’s arm, the tips of her fingers are
on the medial border of the arm and tap lightly to cue
the change in movement direction.
Placing her hand on the switch and activating the

switch were skills that were separated on the goal list but
not in treatment. At this early point in learning to activate practice outside of her therapy sessions. Ideally this would
the switch, the switch was attached to a device such as a occur in both home and school settings, depending on the
radio or fan, items that do not require a great deal of family and time in the classroom. Another way to manage
accuracy for successful activation. Once Jodie had her more practice would be to increase the frequency and
hand on the switch, a tap on either the volar surface of the duration of treatment sessions. Although this program was
humerus or the forearm was used to facilitate activation. developed around the traditional weekly model of therapy
An assisted weight shift posteriorly helped with switch frequency, research has demonstrated that massed or inten-
activation as well, but it needed to be carefully carried out sive practice such as is used in constraint-induced para-
so that Jodie was not pulled backward. Active assistance digms and other research has better outcomes for children
was used to press the switch, using the same careful with CP (Duff & Gordon, 2003; Taub et al., 2004).
guidelines described earlier. A latch switch was used to Another critical issue was communication between the
limit the amount of time the device is active, requiring therapist and teacher. This assisted in documenting goals
Jodie to lift her hand from the switch, then depress it and assuring that teacher, aide, and therapist were all using
again to restart the device. similar techniques and the same equipment. If progress
Releasing the switch was facilitated by incorporating was not seen in a short period of time (2 to 3 weeks), then
the same techniques used to facilitate placing Jodie’s hand it would be necessary to re-evaluate the plan and adjust
on the switch only in reverse order. Release of objects is a intervention.
more challenging task for children with CP, as indicated by
OUTCOME
research in children with hemiplegia (Eliasson & Gordon,
It was soon apparent that the switch needed to be stabi-
2000; Gordon et al., 2003). Such studies have shown that
lized on the surface; therefore a slightly inclined easel
the temporal aspect of release is a particular problem,
surface with Dycem under the switch and easel were used
which was the case for Jodie when releasing the switch.
to provide stability. Masking tape was used on both home
SEQUENCING THE PLAN and school table surfaces to mark where the easel went
The idea was to move Jodie forward in her treatment plan to be sure that the location of the switch was consistent
as expeditiously as possible. To do this, she needed to over time.
Jodie made rapid progress at placing her hand on the day as fatigue set in, so the family limited her home
switch. Accurate depression and release of the switch voli- practice to weekends. At the end of 3 months, Jodie could
tionally in a timely fashion took another 2 to 3 months to accurately complete a 10-word spelling assignment using
achieve with frequent dialogue among teachers, therapist, hand-activation of her switch in 30 minutes. Fatigue was
and family. Jodie was motivated, which helped, and had becoming less of a factor, so her teacher began to add
persistent encouragement from her classmates. Her switch short assignments later in the day.
activation accuracy initially deteriorated throughout the
CASE STUDY 2
A C HILD WITH LOW TONE
Two-and-a-half-year-old Lily has quadriplegic involvement

with low muscle tone and aimless movements of her limbs. BOX 16-3 Long-Term and Short-Term
She can hold her head up and sit for short periods of time Goals for Lily
(3 to 5 minutes) when placed in supported sitting but
spends much of her day playing in prone or supine, or
1. Lily will lift the cup from the surface to her
propped in her infant seat. She can grasp objects with
mouth
either hand but does not use both hands together. Most
a. Lily will place both hands on the cup when it
of her activity consists of mouthing objects and then drop-
is placed on the surface in front of her.
ping them after briefly holding onto them. Her mother
b. Lily will lift an almost empty cup off of the
reports her as being an irritable child who screams when
surface briefly.
new stimuli come into the environment. The family would
2. Lily will hold the cup when it is placed at her
like her to be able to play by herself for longer periods of
mouth to take a drink.
time and use both hands to play, to sit up longer so they
a. Lily will place both hands on the cup while
can play with her, to hold her cup and drink from it, and
mother provides over hand assistance.
for her to be less irritable. Box 16-3 contains examples of
b. Lily will spontaneously place her hands on
goals for Lily. The goals of using her hands to hold a cup
the cup held at her mouth for a few second.
will be used for demonstration purposes. Specifically the
c. Lily will hold an almost empty cup at her
goal will be for Lily to sit supported in her high chair and
mouth with minimal assistance from her
lift her cup and drink when it is placed on a surface in front
mother.
of her. Table 16-3 shows an activity analysis of this goal,
3. Lily will put the cup back on the surface after she
which is used to plan the intervention.
has drunk from it.
PREPARATORY ACTIVITIES a. Lily will maintain her hands on the cup with
The intervention was scheduled for Lily’s usual afternoon maximal assistance from her mother as her
snack time to locate the intervention in her usual daily mother returns it to the surface.
pattern of activities. Doing so offered demonstration time b. Lily will hold the cup briefly when she is
and consistent feedback to the mother about Lily’s per- finished drinking and then place it.
formance and gave the therapist the opportunity to re- 4. Lily will lift the cup to her mouth, drink from it,
evaluate Lily’s skills each week. Table 16-4 illustrates the and return the cup to the surface.
steps of the activity and the techniques to be incorporated
into the intervention session. Because Lily was anticipat-
ing the cup, she tended to be less tolerant of extensive
prefeeding activity, so preparatory work was limited to 5 plantar flexion and return from plantar flexion of her own
to 10 minutes. The therapist sat on a chair or sofa. Lily was feet to provide bounces that were timed asymmetrically so
positioned on the therapist’s knees; she could either face as not to be predictable. Firm downward pressure was
the therapist or face her mother with her back to the applied at the shoulders, with the therapist’s thumbs posi-
therapist. Facing the therapist meant her base of support tioned over the heads of each humerus and the fingers
was wider because she was straddling the therapist’s legs; supporting the scapulae (Figure 16-4). Sound production
while facing her mother she was not straddling and the by Lily was encouraged to activate abdominal contraction
base of support was narrower. Lily was supported at the at the same time. This activity was sustained for 1 to 2
shoulders and the therapist gently bounced her using minutes, and then the therapist’s hand position was shifted
Table 16-3 Activity analysis of drinking from a cup with two hands in supported sitting
Visual Auditory Movement Tactile

Step of Activity Component Component Components Component
Cup is placed on Sees cup Person handing Arms move toward Kinesthetic
surface; child’s approaching and the cup may make the cup; possible feedback from
arms activate at set on surface statement; cup components: humeral the limb
the sight of the makes sound as abduction moves to moving
cup it touches the humeral adduction;
table elbows extend and
hands open
Takes cup Sees the cup held Parent may make Hands grasp cup; Lily feels the
at midline statement humeri are adducted, cup on her
elbows midway hands; weight
between flexion and of the
extension and liquid gives
forearm midposition, proprioceptive
fingers flexing feedback
Raises cup to her Sees the cup Humeral movement Feels cup
mouth moving toward is flexion; elbows touch her
her face move into flexion; mouth; feels
fingers flexed weight of cup
on hands and
through
shoulders
Drinks from cup May look at Humeral and elbow Feels weight
others in the flexion used to lift of the cup in
room the cup to pour her hands,
liquid into the mouth and liquid in
the mouth
and throat
Brings cup back May look at cup Hears cup when it Humeri and elbows Feels cup hit
to surface and as she moves it hits the table extend the surface
releases it away from her and absence
mouth of tactile
feedback
on her hands
to Lily’s abdomen and lumbar spine. The hand on the maintained in a straight plane position while the trunk
lumbar spine was for support, whereas the hand on the rotated over it, a position requiring cocontraction of abdom-
abdomen was used to apply firm downward pressure to inals and trunk extensors. This activity was carried out
continue activation of the abdominals. briefly, and then Lily was facilitated to turn to face her
A movement transition to produce coactivation of mother with the therapist’s hands moved back to the
trunk extensors and flexors followed. Lily was weight abdominals and lumbar spine and downward pressure
shifted toward the arm of the chair with the key point of applied on the abdominals to activate a forward weight
control at the pelvis. The goal here was for Lily to put shift. Her mother facilitated bilateral shoulder flexion by
both hands onto the chair arm, producing a bilateral upper holding her hands out to Lily. She did not pick up her
limb weight-bearing activity (Figure 16-5). The pelvis was daughter until Lily reached out with both arms. The
Table 16-4 Facilitation and inhibition techniques to be used in Lily’s treatment
Step of Activity Movement Components Facilitation/Inhibition Techniques
Cup is placed on Arms move toward the cup; Deep pressure on the abdominals to facilitate
surface; child’s arms possible components: humeral trunk and humeral movements toward midline;
activate at the sight abduction moves to humeral humeri as key point of control to bring hands
of the cup adduction; elbows extend and together passively then as cue to do so actively;
hands open Hands clapped together to give sensory cue to
open hands and deep pressure feedback to palms
of hands.
Takes cup Hands grasp cup; humeri are Anterior weight shift to assist in reaching for and
adducted, elbows midway grasping the cup; hands brought to the cup and
between flexion and extension deep pressure on hands over the cup used to give
and forearm midposition, fingers sensory feedback; approximation through the
flexing trunk to facilitate co-contraction of abdominals
and extensors
Raises cup to her Humeral movement is flexion; Shoulders used as a key point of control to
mouth elbows move into flexion; sustain hands on the cup; ulnar side fingers used
fingers flexed to tap under the arms to facilitate forward flexion;
posterior weight shift used to facilitate arms
to lift.
Drinks from cup Humeral and elbow flexion used Posterior weight shift to facilitate neck flexors
to lift the cup to pour liquid and abdominals to hold with head and trunk
into the mouth extended while drinking; shoulders continue as
key point of control for entire upper limb
Brings cup back to Humeri and elbows extend Anterior weight shift to assist in reach of arms
surface and lets it to the tray; gentle vibration to facilitate fingers
drop letting go of the cup.
movement transitions described provided limited then helped place her hands on it. Firm pressure on the
vestibular input. More consistent use of rotary movements shoulders was attempted to sustain Lily’s hands on the
during transitions provides the kind of vestibular input cup. When unsuccessful, the therapist slid her hands down
children achieve themselves through active movements. over Lily’s hands (Figure 16-6). Once Lily sustained her
ACTIVITY PRACTICE OF DRINKING FROM THE CUP grasp of the cup, tapping under the proximal aspect of the
Lily was placed in her child-sized chair. The therapist sat arm was used to facilitate lifting. As Lily became more
behind the high chair and placed her hands on Lily’s proficient at grasping, the therapist moved her hands back
shoulders. The thumbs were placed along the proximal up to the child’s shoulder to help facilitate lifting and
aspect of the humerus and the fingers rested on the holding of the cup at the mouth. With further progress,
abdomen. Her mother held a half-filled cup in front of the therapist gradually withdrew her support, limiting the
Lily but did not place it on the tray. The therapist used cues needed to generate Lily’s participation.
pressure on the lateral border of the humeri to bring Lily’s The mother could facilitate this activity from in front of
hands together and then slipped her hands up over the Lily in a sitting position using the same key points and
proximal part of her arms to help Lily clap her hands sequence of activity. The preparatory activities were taught
firmly several times. Her mother then placed the cup on to the mother as a game to be carried out at different
the tray, tapping it to get Lily’s attention and asking her to times during the day, as well as in preparation for feeding.
take the cup. A subtle forward weight shift for the reach OUTCOMES
was facilitated using the shoulders as a key point of Lily actively resisted the movement transition sequence.
control. Her mother cued her verbally again and the After attempting to use it before giving Lily her cup, the
therapist waited briefly to see if Lily reached for the cup, therapist chose to discontinue this aspect of the inter-
Figure 16-4 Lily is positioned on the therapist’s

knees facing the therapist. She is supported at the
shoulders and the therapist is gently bouncing her,
using her own feet to provide the bounces. Firm
downward pressure is applied at the shoulders, with
the therapists’ thumbs positioned over the heads of
each humerus and the fingers supporting the
scapulae.
Figure 16-5 A movement transition to produce
coactivation of trunk extensors and flexors is illustrated
vention and worked on two-handed reach and grasp of the here. Lily’s weight is shifted toward the arm of the
cup only. Lily was able to reach and grasp with two hands chair with the therapist’s key point of control at the
successfully in several weeks. Her ability to keep two hands pelvis. The pelvis rotates slightly and one side lifts with
on the cup while bringing it to her mouth took another the weight shift while the trunk rotates over it. At the
month. Lily still refuses to grasp the cup on occasion when same time, Lily moves her hand to the arm of the
irritable. rocking chair to support herself, producing a weight-
bearing activity in conjunction with a movement
transition.
Figure 16-6 In this figure, the child is having

difficulty sustaining her grasp on the surface of the
cup. To cue her, the therapist places her hands over
Lily’s and applies gentle pressure over Lily’s wrists and
hands to support the cup and give her sensory
feedback about the task. As Lily becomes more
proficient, the therapist can slide her hands back up
the forearms to guide the movement while Lily
maintains her grip on the cup independently.
Duff S, Gordon A (2003). Learning of grasp control in

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Chapter 17
PEDIATRIC HAND THERAPY
Dorit Haenosh Aaron
CHAPTER OUTLINE torso, shoulder, elbow, wrist, and hand to accomplish

a task.
PHASES OF WOUND HEALING Scientific evidence on pediatric hand rehabilitation
is sparse. Thus this chapter is based primarily on the
Phase I author’s clinical experience. Additional information is
Phase II included when available.
Phase III Hand conditions are challenging in and of them-
selves. When they occur in a child, consideration must
EVALUATION OF THE CHILD WITH A HAND INJURY be given not only to the pathology, stages and rate of
Interview and History healing, and functional implications, but also to the
Hand Range of Motion stage of development. When treating a child attention
must be given to the child’s age, growth, maturity,
Hand Strength ability to participate in his or her own recovery, as well
Hand Dexterity as parental or guardian involvement. These additional
Wound, Edema, and Scare considerations make treating the child rewarding, as
well as challenging.
Pain The child’s hand differs from adults’ in that it is a
Hand Sensibility growing hand of a developing child. The growing hand
Activities of Daily Living changes rapidly in its physical size, manipulation skills,
strength, and control; as does the child’s ability to
TREATMENT OF TRAUMATIC HAND INJURIES IN follow directions and participate in rehabilitation.
CHILDREN Injuries to growth plates may affect the way the child’s
Wrist Pain and Wrist Fractures bone grows in length and direction. Fat pads may
Fractures and Dislocations of the Digits obscure swelling. Congenital differences may affect any
structure of the hand and thus influence function.
Tendon Injuries Therefore, when treating the child with a congenital
Thermal Hand Injuries in Children difference, determine what the child can do at present
TREATMENT OF CONGENITAL HAND DIFFERENCES and identify realistic expectations for the individual,
rather than focusing on what the child cannot do or
Syndactyly comparing the child to the general population.
Radial Club Hand In general, children have a better prognosis for
SUMMARY recovery from hand injuries than do adults. Stiffness is
less frequent, open wounds heal faster, remodeling of
angular deformities may occur, and nerve recovery after
Observing a child at play makes it easy to understand repair is significantly better than for adults (Davis &
why the hand is one of the most frequently injured Crick, 1988). Fetter-Zarzeka and Joseph (2002) exam-
body parts. Children must touch what they see and, if ined the etiologies of hand injuries in children and
the mind can conceive it, the hand will attempt it. The concluded that the most frequent injuries occurred
hand is the primary instrument of discovery. Although outdoors (47%), injuries occurred specifically from
discovery is a function of the mind, it involves the eyes, sports, and the most frequent injuries were lacerations
367
(30%) followed by fractures (16%). The fingers were for continued oxygen, glucose, and protein supply.
the most commonly injured part of the hand, with Ischemia interferes with wound healing (Evans &
thumb injuries found in 19% of the cases and fingertip McAuliffe, 2002).
injuries found in 21% of the cases (Fetter-Zarzeka & Although variations are reported in the literature,
Joseph, 2002; Damore et al., 2003). Most pediatric tissue healing is most commonly summarized in three
hand and wrist injuries can be treated nonoperatively phases.
with protective immobilization and activity modifica-
tion. However, cases that require surgical intervention
must be recognized early to avoid complications (Le & PHASE I
Hentz, 2000).
Names: Inflammatory, Clot, Substrate, Lag, or
The goal of this chapter is to provide basic infor-
Exudates Phase
mation to therapists to facilitate effective evaluation
and treatment for hand conditions occurring in pedi- Duration: From Wounding Up to 6 Days
atric patients. This chapter covers the stages of wound Phase I prepares the wound for healing by cleaning
healing and evaluation considerations by age as the up debris, foreign material, and any devitalized tissue
baseline for making clinical decisions. Evaluation and caused by the trauma. It has both vascular and cellular
treatment suggestions for common traumatic and responses. Initially there is vasoconstriction followed by
congenital hand conditions in the child also are vasodilatation. A clot is formed to prevent bleeding and
included. phagocytosis begins. The normal inflammatory phase
should be over in 5 to 6 days. However, a dirty wound,
in which the debris was not successfully cleaned up,
may develop into a subacute or chronic phase of
PHASES OF WOUND HEALING inflammation.
Treatment and decision making during the healing Clinical Signs

phase of wounds must be based on the stage of healing, Redness: Vasodilation
as well as on the age of the child. After injury, all tissues Swelling: Increase of interstitial fluid
undergo a similar process of repair. Injury to vascular Pain: Nerve ending stimulation
tissue initiates a series of responses collectively known Heat: Increase in blood flow
as “inflammation and repair.” Regeneration is possible Hematoma: Trapped red blood cells creating a clot
only in tissue that is capable of proliferation of the decrease functional ability
remaining cells (normal tissue). Repair is the replace-
ment of destroyed tissue with scar tissue. Both regen- Clinical Implications
eration and repair begin during inflammation with The extremity is swollen and painful. Thus effort must
phagocytosis of dead tissue cells. The ultimate goal of be made to decrease edema, control pain, and maintain
these responses is to eliminate the pathologic or physi- a clean environment. All affected joints should be placed
cal insult, replace the damaged tissue, promote regen- in a functional position if possible. The functional
eration, and thus restore function. Inflammation is the position is one in which the wrist is in neutral to 20
first (acute) phase of healing. When unresolved, it may degrees of extension, the metacarpophalangeal joint
go through two more stages: (MP) is in 60 to 70 degrees of flexion, the inter-
Acute: Usually completed by day 6; normal healing. phalangeal joints (IPs) are extended, and the thumb is
Subacute: Reaction continues for up to 1 month, same in mid position between full abduction and full exten-
as acute stage on a cellular level. and is treated the sion. Variations of this position depend on the injury.
same clinically. This position must serve to both protect the wound
Chronic: Simultaneous progression of active inflamma- and to prepare the joint for future functional perform-
tion, tissue destruction, and healing. It varies from ance. Nonaffected joints should be free to move within
acute on a cellular level and lasts beyond 1 month. the constraints of the injury.
Normal tissue is replaced by scar (Pryde, 2003). Physical agents can be used. An edematous hand in
The most common causes of an inflammatory the early phases of inflammation responds to cold to
response are burns, fractures, cuts or crush injuries, and help decrease the swelling. Cold constricts the vessels,
soft-tissue injuries such as sprains, strains, or contu- slowing down the active edema process; however, it is
sions. Inflammation also can be caused by the presence rarely appropriate for the infant or toddler. For the
of foreign bodies, autoimmune diseases such as older child, physical agents must be selected carefully
rheumatoid arthritis or chemical agents (Pryde, 2003). to enhance healing. At later phase heat might be the
Healing requires increased metabolic activity. Blood modality of choice for the same result. Heat dilates
supply to the site of the lesion must remain increased the vessels. When the hand is placed in elevation with
Pediatric Hand Therapy • 369
slight pressure, the stationary edema is guided back balance between laying down collagen and getting rid
to the body. If used in Phase I, heat increases swelling. of debris (synthesis versus lysis), occurs in a balanced
A whirlpool may be used for debridement of open fashion. However, when this balance is tipped, it may
wounds. The temperature of the water should be become pathologic, which may result in the following:
tepid, and if possible the hand should be positioned at • Contraction of the scar
heart level. • Hypertrophic scar: Within wound boundaries
• Keloid: Outside wound boundaries
PHASE II Clinical Signs and Considerations

Scarring may affect function and aesthetics
Names: Fibroblastic, Proliferative, or Latent Movement limitations may be present
Stage Pain may continue to be problematic
Duration: Variable, but Usually 5 to 21 Days, Can Tensile strength (see below) of tissue is still increasing,
Last Up to 6 Weeks but remains below normal
The purpose of this stage is to rebuild damaged struc- Functional use of the extremity that is involved is
tures, and cover and strengthen the wound. There is encouraged in activities of daily living (ADLs)
migration and proliferation of vessels for tissue repair. Contextual implications are considered in treatment
Primitive healing occurs. The wound begins contract- planning
ing from the outside in. This migration of cells is
limited by tension. Oxygen is needed for the healing Tensile Strength of Tissue
process. Four processes occur simultaneously in this Tensile strength is the ability of a structure to withstand
phase: epithelization, collagen production, wound con- a pulling force along its length or resistance to a tear.
traction, and neovascularization. Scar tissue is not as strong as the normal tissue it
replaces; however, the volume of the scar influences its
Clinical Signs strength. Unfortunately, the more volume the scar has,
Red granulation tissue the stronger the scar and the less motion when the scar
Beginning of wound contraction: Scars appear faster in crosses a joint. Tensile strength of the scar increases
children than adults. with increased collagen and each phase of healing. As
Moderate swelling may be present mentioned, tensile strength reaches 50% of normal
Pain: Variable strength of the skin by 6 weeks (Smith, 1992).
Functional limitations
Clinical Implication
Clinical Implications When healing reaches Phase III, the rehabilitation
The clinical focus in Phase II is on decreasing scarring program should concentrate on returning the child to
and increasing mobility. Scar management is a chal- full play and activity. Therapeutic activities must stay
lenge with children. If pressure garments are indicated, under the “breaking strength” of the scar, which is the
the therapist may prefer to order a pressure garment amount of force it takes to bring the wound apart.
that covers more than just the hand to keep the gar- How much tension one places on a wound varies with
ment on, and to allow even pressure throughout the each stage of healing, type of injury, and age (Mulder
small body area. At the same time, motion must be & Brazinsky, 1995). Modalities such as splinting, physi-
encouraged. With children, immobilization may extend cal agents, strengthening exercises, and other thera-
a week or two beyond the normal protocol if the repair peutic interventions should focus on the functional
needs to be protected. Children regain motion rapidly needs rather than the functional limitations of the
when presented with “play” situations after immobi- child.
lization. Balancing immobilization and mobility requires Box 17-1 shows the three phases of wound healing.
individual decisions based on the child’s age and level
of maturity and severity of injury.
EVALUATION OF THE CHILD WITH
PHASE III A HAND INJURY
Names: Maturation, Scar Remodeling Evaluation of the child differs from that of the adult.
Duration: End of Fibroplasia to 2 Years Specifically, the age of the child determines what the
In this phase, connective tissue matrix is remodeled. “hand is expected to do.” The infant who does not yet
Wound strength (tensile strength) may reach 50% of cross midline with hand performance differs from the
normal by 4 to 6 weeks. Remodeling, which is a adolescent. A toddler who brings everything to the
the therapist may wish to obtain information in the

BOX 17-1 Phases of Wound Healing
following areas.
PHASE I
Vasoconstriction I NTERVIEW AND H ISTORY
Vasodilation
Clot formation When a child comes to therapy, a thorough review of
Phagocytosis the child’s medical, family, emotional, educational, and
social history should be obtained from the family and
PHASE II
Epithelization the child, when possible. Information from the doctor
Collagen production should include precautions relevant to the healing of
Primitive wound contracture the injury or surgery, as well as all relevant information
Neovascularization (O2) about the surgery and medical management. A pre-
PHASE III scription from the doctor should be clear about the
Maturation of scar expectations for function. If a child is referred for a
Collagen synthesis versus lysis splint alone, information must be obtained about how
Collagen fiber orientation and wound strength long the body part is to be immobilized.
HAND RANGE OF MOTION

mouth differs from the teenager who can understand Hand range of motion (ROM) is important for func-
and follow directions. Both evaluation and treatment tional activities such as picking up and manipulating
must reflect the age and developmental level of the objects, as well as touching and feeling. Total upper
child, as well as the injury or condition of the hand. extremity ROM is important in reaching into the envi-
Performance assessments such as dexterity tests cannot ronment. When measuring hand ROM, the therapist
be given to a newborn but can be administered in a also looks at total upper extremity movement, as well as
modified way to a toddler, and given in a standardized trunk and neck mobility. The hand is not separated
way to an adolescent. from the body in activity and therefore should not be
The goal of an evaluation is to determine the real- separated in evaluation.
istic functional abilities of the child at the initiation of When evaluating ROM in a hand injury or condi-
therapy and document progress. Realistic goals are set tion, close attention is given to tissue that obstructs the
by the child when possible, as well as by the parents or motion. Ranges are reported, when possible, in several
guardians and therapist. The evaluation process must ways so that the source of the limitation may be
be dynamic and flexible. Information about the child’s identified. Passive range is the available motion intrinsic
ability to use the hand, pain level, and specific restric- to a joint when all extrinsic limitations are minimized.
tion of motion may be gathered through play, general If a tendon or scar is limiting the joint motion, place
observations, or specific assessments. Significant infor- the joint in a position of maximum biomechanical
mation can be gathered from parental reports and advantage when measuring passive range so as to elimi-
interviews. Creativity in encouraging a child to use an nate the extrinsic factors (Figure 17-1). For example, if
injured hand is part of the challenge of a good eval- the flexor tendons are tight, flex the wrist when meas-
uation. Photographs and videotaping for later specific uring passive MP motion.
assessment of the child’s play patterns may be helpful. Conversely, when measuring active motion, infor-
In hand therapy, evaluation requires an initial deter- mation is gained about the extrinsic structure that may
mination of impairment level followed by its influence be limiting joint motion. Active motion may be divided
on the functional levels as they apply to the child’s into functional motion, the motion available when the
developmental stage. The child’s hand performance child is asked to make a fist or open the hand with no
in life roles changes with growth. Shortridge (1989) limitations or instructions (Figure 17-2) versus blocked
describes growth periods in estimated age levels that motion, which refers to the motion available when
must be considered during evaluation. After traumatic all proximal joints are put in neutral (biomechanical
injury or surgery the quality, speed, and direction of the advantage) to allow maximum force to be applied to
healing, as well as the age of the child, are considered. elicit the available motion of the joint being measured
With congenital differences, evaluations must be rele- (Figure 17-3).
vant to realistic expectations for both the age and diag- For example, if measuring blocked proximal inter-
nosis. The specific assessments in a hand evaluation are phalangeal (PIP) flexion in a child with a flexor tendon
determined by the diagnosis, phase of healing, and age injury, put the wrist and MPs in neutral and ask the
of the child. While not losing sight of functional goals, child to flex his or her fingers. This provides informa-
Figure 17-1 Passive range of motion (PROM).
Figure 17-3 Blocked range of motion (BROM).
the motion. Reliability of ROM is based on repeatabil-

ity. The American Society of Hand Therapists (1992)
published a Clinical Assessment Recommendation
booklet that is an excellent resource for standardization
of measurements (Adams, Greene, & Topoozian, 1992).
Scheduling constraints and the child’s cooperation
at times may limit the therapist’s ability to take compre-
hensive measurements. On these occasions, functional
measurements can be recorded. These measurements
have poor reliability because they are difficult to repro-
duce consistently. However, they do give some func-
tional information about the use of the hand and thus
have value in some cases. Functional measurements
include:
Functional Flexion: (a) Ask the child to make a fist;
measure the distance from the pulp of the digit(s) to
the distal palmar crease (Figure 17-4); or (b) ask the
child to make a hook, bringing the tips of the fingers
to the palmar digital crease; measure that distance.
Functional Opposition: Ask the child to touch the tip of
each finger to the thumb; measure the distance from
Figure 17-2 Active range of motion (AROM).
pulp of finger to pulp of thumb (Figure 17-5).
Functional Thumb Flexion: Ask the child to touch the
tion about flexor tendon excursion. Placing the proxi- base of the small finger with the thumb, measure the
mal joints in slight extension gives the flexors more distance from the head of the 5th metacarpal to the
advantage. Always record where the proximal joint(s) pulp of the thumb (Figure 17-6).
were placed during blocked measurements, so that Functional Extension: Ask the child to extend the hand
measurements can be repeated reliably. Finally, com- against the table; measure the distance from the nail
pare all ranges to determine which structure is limiting to the table top (Figure 17-7).
Figure 17-6 Functional thumb flexion to the base of

the fifth finger.
Figure 17-4 Functional flexion to the distal palmar
crease.
Figure 17-7 Functional extension to the table top.
Figure 17-5 Functional opposition.
Toddlers (12 to 48 Months)

ROM can be measured in the upper extremity, but it
Newborns and Infants (Up to 12 Months) is difficult in the hand itself. Motion is encouraged
ROM is assessed mainly through observation. The through play. The child should be given objects that
therapist must pay close attention to the movement range in size and weight to determine grasp and release
in the whole upper extremity. The therapist looks for patterns. Sustained and volitional grasp should be
shoulder movements, elbow range, and opening and observed. Colorful objects or familiar designs are help-
closing of the hand. The child is encouraged to move ful. The child should be encouraged to place objects in
through touch, sound, gentle handling, and reflex different locations so that reach and precision can be
stimulation such as the startle response. Movements examined. ROM at this age is documented more in
should be compared with the uninvolved side when patterns of prehension and usage rather than degrees
possible. of motion. For those situations in which handling of
objects is not advised because of the stage of healing,

the therapist may encourage movement through reach
or gentle touch of sterile objects. Parents’ reports and
observations can be helpful with this age group.
Childhood (5 to 12 Years)
Measurement of specific range can be obtained at this
age, although it may be difficult. Observation of move-
ment patterns that are consistent with in-hand manipu-
lation that are present at this stage are helpful (Exner,
1992). The child can be asked to hold a spoon or turn
over a peg of a certain size in the hand, which provides
both functional and range information.
Adolescence (13 to 18 Years)

ROM in the adolescent and the older child can be Figure 17-8 Dynamometer used to measure grip
specific to joint and degrees of motion. Members of strength.
this age group can follow directions. Their hands are
large enough for goniometer placement and measure-
ment of individual joints.
Clinical Implication
ROM helps determine which structure is the source
of the limitation. This information comes from meas-
uring the difference between passive and active motion,
checking for unusual patterns such as intrinsic, web,
and ligamentous tightness. Active motion can be divided
into two types: (a) functional motion, motion the child
does on his or her own; and (b) blocked motion, motion
produced when the proximal joints are held in a posi-
tion that gives maximum advantage to the distal joint.
The difference between measurements tells the thera-
pist where the problem exists.
HAND STRENGTH Figure 17-9 Pinch gauge to measure pinch strength.

Hand strength is a function of the work of the muscles.
In measuring hand strength, we look at both specific
muscle strength and functional strength. Specific mus-
cle strength is the measurement of each muscle ten- Newborn Through Early Childhood
don unit that is measured through manual muscle Hand strength as a measure in and of itself is not
testing, whereas functional strength is a measure of necessary for this age group. The therapist concentrates
muscles working together in a specific prehension on functional use of the hand in age-appropriate activi-
pattern and is measured with instruments such as a ties. For children past infancy, activities such as han-
dynamometer and pinch gauge. Functional measure- dling toys, picking up utensils, and picking up objects
ments are divided into grip and pinch strength (Figs. of different weights with one or two hands provide the
17-8 and 17-9). They are divided further into varying therapist with information on available strength for
grip sizes and different pinch patterns. Most commonly the age-appropriate activities. Enticing a child to move
tested pinch patterns are key pinch, pencil or three jaw painful fingers is challenging. Young children like to
chuck pinch, and pad to pad pinch. With the hand- perform, so one effective method is videotaping the
injured population, functional strength measurements child with the promise of watching his or her hands
are the most common. Although a variety of tools move on tape. Specific questions related to functional
exist for measuring strength, the most common are a hand strength include the following: Does the child
dynamometer for grip strength and a pinch gauge for have sustained grasp? Does the child demonstrate voli-
pinch strength. tional grasp?
Middle Childhood to Adolescence commonly used with hand injuries and conditions.
The older child’s strength can be measured with con- However, at times specific manual muscle testing is
ventional tools such as dynamometers and pinch indicated, especially with older children.
gauges, or various available computerized instruments.
Strength goals in treatment should be consistent with
the demands for hand strength in the child’s life roles.
HAND DEXTERITY
When measuring hand grip in children, norms that Dexterity as a component of function is described
reflect the appropriate age group and comparable instru- as the ability to manipulate objects with the hands.
ments are used. Hager-Ross and Rosblad (2002) pro- Accuracy and speed are the parameters of measure-
vide norms for children ages 4 to 16. They tested grip ments for dexterity. Dexterity can be measured reliably
strength in 530 children using the Grippit instrument. through established tests that have normative data on
They reported a parallel increase in grip strength for the population tested. Dexterity may also be observed
both boys and girls until age 10, after which boys were when the child is picking up different size objects and
significantly stronger than girls. The study further sug- manipulating them (Aaron & Stegink Jansen, 2003).
gests a correlation between hand size, specifically hand
length, and strength. Right-handed children were sig- Newborns and Infants
nificantly stronger in their dominant hand than left- Hand dexterity in the newborn is confined to reflexive
handed children. Left-handed children did not show opening and closing the hand and bringing the hands
any strength difference between the hands (Hager-Ross to the mouth. Such motions are determined through
& Rosblad, 2002). Bear-Lehman and co-workers (2002) observation. In the newborn, stimulating reflexes such
studied the relationship between grip size and strength as Moro or hand grasp gives the therapist information
in children and also concluded that strength, grip, and on ROM and symmetry of movement patterns appro-
pinch increase with hand size, but they found no sig- priate for this age.
nificant difference between males and females or pre-
ferred hands. In an earlier study, Mathiowets, Wiemer, Toddler
and Federman (1986) reported dynamometer readings Dexterity is determined by watching the child manip-
from 471 typical children ages 6 to 19 years. They ulate small objects. In-hand manipulation skills (moving
reported pinch and grip strength increases with chrono- an object within the person’s hand) is noted at this age.
logic age. Mathiowets and co-workers (1986) noted The therapist places a small object in the child’s hand
possible instrument error after the study and concluded and asks that it be turned over or moved around in the
that reported norms for subjects ages 14 to 19 may be hand. Video recording of the manipulation comple-
slightly lower than they should have been (Pratt et al., ments the testing procedure.
1989). These studies suggest a trend of increasing
strength with age and hand size. Caution should be Early Childhood
exercised in using these norms unless the test instru- Observation remains a staple of the evaluation pro-
ments and conditions are the same. cedure for this age group. The therapist observes how
Manual muscle testing may be used for specific the child approaches small objects, which hand is used
muscles for older children when indicated by the diag- in grasp, grasp and release patterns, and sizes of manip-
nosis. Large muscles, as well as the small muscles of the ulated objects. For more standardized testing, dexterity
hand, should be tested. When rating muscle strength, tests such as the Functional Dexterity Test (FDT) may
the 0 to 5 scale may be used. Specific instructions are be used. It is standardized for children ages 3 to 5 years
available in the literature on how to perform manual (Aaron & Stegink Jansen, 2003; Lee-Valkov et al., 2003).
muscle testing (Aulicino, 2002). For the age groups listed, the therapist observes for
0 = No evidence of contraction the following information:
1 = Trace of muscle contraction, no movement • Are tasks or activities performed unilaterally or
2 = Complete ROM with gravity eliminated (poor) bilaterally?
3 = Complete ROM against gravity (fair) • Is the hand being used spontaneously?
4 = Complete ROM against gravity with some resist- • Is there indication of dominance? (Note: Hand domi-
ance (good) nance that appears too early may indicate a problem
5 = Normal ROM against gravity with full resistance with the nonpreferred side.)
Clinical Implication Adolescence

Appropriate methods of obtaining hand strength Children in this age group have fine motor control and
measurements vary according to the child’s age and dexterity that can be tested using available standardized
ability to participate. Functional measures are most tests. Depending on what information the therapist
wants to obtain, the use of such standardized tests as 3. Drainage. Note if there is any drainage. Use descrip-
the Box and Block Test or the Minnesota Rate of tive words such as “minimal, moderate, or severe”
Manipulation may be used for information on dexterity for the amount of drainage, and “bloody, sanguinous,
(Apfel & Carramza, 1992). purulent, pus” for the quality of the drainage.
If information on ADLs is needed, specifically manip- 4. Odor. An unusual odor may suggest infection or
ulation of small objects such as buttoning or tying, the presence of foreign material.
Functional Dexterity Test (FDT) may be the test of 5. Temperature. Compare the temperature of the hand
choice because it gives information on both dexterity or part to the other side. Warm or hot may indicate
and function and can be administered in a short period infection or inflammation, whereas cool or cold
of time (Aaron & Stegink Jansen, 2003) (Figure 17-10). may point to a vascular insufficiency.
6. Edema. Edema should be noted throughout the
Clinical Implications healing process. Edema is measured with a tape
Dexterity is a component of function that often is measure or volumeter. If the wound is open, the
overlooked in a hand evaluation. Dexterity information tape measure must be sterile and the water in the
is obtained by using standardized tests such as the FDT volumeter must be treated with a disinfectant.
or through observation. When using a tape, landmarks are noted in the chart
for consistency of measurement. The skin should
not blanch when circumferential measurements are
WOUND, E DEMA, AND SCAR taken with the tape. When using the volumeter
When a child of any age has an acute injury, the thera- (a water displacement test), the hand is placed
pist must document the appearance of the hand at each straight-in so as not to displace more water than
stage of healing. This includes describing the wound, necessary. The hand is lowered into the water until
measuring the edema, and describing and measuring the web space between the long and ring fingers
the scar. rests on the small peg at the bottom of the con-
Describe the wound and take a picture when possible. tainer. The volumeter usually is used with large
In the description of the wound, note such elements as: edematous areas and with older children. Descrip-
1. Color tive words, such as “hard, mobile, brawny, or pitting,”
a. Red Wound: Normal granulating tissue should be used for recording the type of edema.
b. Yellow Wound: Wound covered by yellow fibrous 7. Scar. Scar should be described as “soft, thick, raised,
debris or viscous surface exudates indurated, hard, or reactive.” Depth, length, and
c. Black Wound: Wound covered with thick necrotic width of the scar should be measured and color and
tissue or eschar vascularity should be noted. Sensitivity (or lack of)
2. Size. Measure the size of the wound. Draw the of the scar should be recorded. Both a drawing and
actual size of the wound in the chart. Color in the a photograph of the scar should be taken if possible
different colors that you see. (Baldwin, Weber, & Simon, 1992).
Clinical Implications
Open wounds, edema, and scar should be evaluated
and recorded on a regular basis. Photographs should be
taken when possible. The age of the child does not
change the evaluation procedure. However, in some
cases the evaluation process is challenging.
PAIN
Determining the level of a child’s pain is difficult at
best. Often, if the child hurts or perceives that some-
thing may hurt, a protective posture is assumed and the
child refuses to let anyone touch the hand. The thera-
pist must first differentiate between fear and true pain.
With newborns and toddlers, the initial approach is to
encourage the child to move the hand and perhaps
Figure 17-10 Functional dexterity test. (From Aaron DH,
Stegink Jansen CW [2003]. Development of the functional grasp a colorful object. Distraction is the best tactic for
dexterity test [FDT]: Construction, validity, reliability, and this age group. The therapist’s observation skills are the
normative data. Journal of Hand Therapy, 16[1]:12–21.) most valuable evaluation tools. A similar approach is
helpful with children and adolescents. However, these hood. The therapist asks the child to identify familiar
children may be able to provide more information with objects or symbols held in the hand or drawn on the
use of such pain evaluation tools as the following: palm of the hand while the eyes are closed. Children
1. Body Charts. The child points on a picture to where ages 6 and older should be able to undergo a complete
it hurts; the therapist offers descriptive words to sensory evaluation if indicated by the initial screen.
help the child explain the nature of the pain Information on specific testing procedures is available
(Maurer & Jezek, 1992). in the literature (Callahan, 2002).
2. Visual Analog Scale (VAS). This is a vertical or Sensory testing can be divided into:
horizontal line of 10 cm with one end labeled “no Threshold Tests: Tests that determine the minimum
pain” and the other “terrible pain.” The therapist stimulus perceived (e.g., pain, temperature, pressure),
asks the child the mark on the line the place that such as the vibrometer and the Semmes-Weinstein
best describes the amount of pain. A drawing of a pressure aesthesiometer or pin prick.
happy face on one end and a sad face on the other Functional Tests: Tests that assess the usefulness of the
also may be used. sensation, such as moving and static two-point dis-
3. Numeric Rating Scale (NRS). The child is asked to crimination, touch localization, and the Moberg
pick a number between 0 (no pain) and 100 (lots of Pick-Up Test (Callahan, 2002).
pain). Although there is high correlation between
the VAS and the NRS, children may remember the
number they assigned to their pain and thus may
ACTIVITIES OF DAILY LIVING
reduce the validity of monitoring improvement over The therapist must know normal expected levels of
time (e.g., the child might tend to keep picking the independent function for each stage of development.
number chosen previously rather than judge pain This knowledge is necessary to set treatment goals. The
objectively at that moment) (Maurer & Jezek, 1992). therapist may have to develop realistic expectations of
4. Verbal Rating Scale (VRS). The child is asked to “normal” for the child with congenital differences.
pick from simple descriptive words that he or she Expected levels of function are compared with what the
can identify with to describe the pain. Examples are child is doing at the time of the evaluation. The stage
“lots of pain,” “some pain,” or “no pain” (Maurer of healing needs to be taken into account, because
& Jezek, 1992). some children are temporarily immobilized in the early
5. Face Pain Scale-Revised (FPS-R). This is a pain meas- stages of healing. For many this does not affect their
urement scale that uses pictures representing facial long-term function, whereas others may have perma-
expressions to determine intensity. It is used for nent impairment and must learn new adaptation skills.
children ages 4 to 16 (Hicks et al., 2001). Goals are set based on expected outcomes. A baseline
ADL evaluation should be administered for each child.
Table 17-1 is an example of a functional hand eval-
HAND SENSIBILITY uation tool.
Normal hand function requires normal sensibility, as
well as mobility and strength. Sensibility should be Clinical Implication
screened in all children who can reliably communicate A thorough evaluation has a different meaning for each
information about the sensitivity of the hand. On the diagnosis and age group. Many assessment tools are
initial screening, the therapist asks if the affected hand available. Therapists must choose carefully and assure
feels the same as the unaffected hand. The therapist that each evaluation looks at all components of func-
then asks the child to report if there are differences in tion appropriate for the specific child, diagnosis, and
feelings between the two hands as the therapist strokes context. Evaluation is the road map for treatment and
both hands. With vision occluded, the therapist touches progress.
a finger and has the child tell what finger was touched.
The therapist moves the affected finger and asks the
child to mimic the movement with the other hand. TREATMENT OF TRAUMATIC
There are many creative ways to determine if the nerves
of the hand are viable. When this is not possible, infor- HAND INJURIES IN CHILDREN
mation must be gained through observing the child use
the hand and noting sympathetic functions such as skin Treatment of the pediatric population incorporates a
color and texture, temperature, sweating, nail changes, “playful” dimension. Couch, Deitz, and Kanny (1998)
or hair growth. This helps the therapist determine if reported on the role of play in preschool population.
there is a nerve problem. Stereognosis and graphesthe- They concluded that therapists must increase the
sia are other forms of sensory screening in early child- emphasis on play when evaluating or treating children.
Table 17-1 Hand therapy screening evaluation
FUNCTIONAL HAND EVALUATION

NAME___________________________ DOMINANCE_____ INVOLVED SIDE______ AGE____ DATE_______
HAND/WRIST EVALUATION
Strength R L Wrist/Hand Special Tests Right Left
Grip Intrinsic tightness (where?) + − + −
Key pinch Tight web spaces (where?)
Pencil pinch
Fingertip Index/middle Spontaneous use of hand

Ring/small Bilateral versus unilateral use
Dexterity Special hand posture

Describe
Functional Dexterity Test 19,20 Volitional release
Comment Sustained grasp

Functional reach to
Prehension Patterns Mouth

(Percent of normal) Back of neck
Fingertip pinch Small of back
Key pinch Hip
Pencil pinch (three jaw chuck) Other shoulder
Ball grasp Head
Cylindrical grasp Feet
Suitcase grasp Other
Other
Continued
Table 17-1 Hand therapy screening evaluation—cont’d
Girth (cm)
Wrist Manual muscle testing (0–5)
Palm (Proximal crease) Specify ms tested
Proximal phalanx
Middle phalanx
Distal phalanx
Volumeter Special descriptors of hand function
Other
ADL: Dependent/mod assist/

minimal assist/independent
List
Sensation 1. Pain (1 Norm to 2. Hypersensitivity

10 Painful) (1 Norm to 10 Sensitive)
Index
Middle
Ring
Small
Thumb
Palm
Tinels
Other
Comments
Order of Return
1. 30 CPS
2. Heavy moving touch
3. Heavy touch
4. Temperature
5. Position sense
6. Light moving touch
7. Light touch
8. 256 CPS
9. Moving 2-point
10. Static 2-point
A = Active
P = Passive
F = Functional
B = Blocked
Table 17-1 Hand therapy screening evaluation–cont’d
Range of Motion R L
WRIST
Palmar flexion
Dorsiflexion
Radial deviation
Ulnar deviation
Other
THUMB
Flexion MP
Extension MP
Flexion IP
Extension IP
Hyperextension IP
Palmar abduction
Radial extension (reposition)
Mid-position
Opposition (imp. rate)
Thumb to base 5th digit
Other description
Index Finger R L Ring Finger R L Opposition Thumb

to Fingertip (cm) R L
Flexion MP Flexion MP Index finger

Extension MP Extension MP Long finger
Deviation/rotation Deviation/rotation Ring finger
Flexion PIP Flexion PIP Small finger
Extension PIP Extension PIP
Flexion DIP Flexion DIP Fingertip to Palmar
Crease (cm)
Extension DIP Extension DIP Index finger
Other description: Other description: Long finger
Long Finger Small Finger Ring finger
Small Finger
Flexion MP Flexion MP Fingertip to Palmar

Extension MP Extension MP Digital Crease (cm)
Deviation/rotation Deviation/rotation Index finger
Flexion PIP Flexion PIP Long finger
Extension PIP Extension PIP Ring finger
Flexion DIP Flexion DIP Small finger
Extension DIP Extension DIP
Other description: Other description: Other description:
Goals (Parent/patient generated and rated 1 to 10 from least to most important):

1.
2.
3.
Therapist Signature: ________________________________ Date:_________________________________

In hand therapy, creative play helps the child participate bones continue developing until maturation of the
in his or her own therapy. Activities such as playing tic- pisiform, which occurs around the age of 9. The flexi-
tac-toe in putty to increase pinch strength or playing bility that children enjoy, as well as the larger amount
dice games or jacks to enhance and encourage prehen- of cartilage in their wrist, helps decrease the number of
sion and dexterity engage the child while minimizing injuries to the wrist compared with adults.
the difficulty of using the injured hand. The therapist The most common wrist fracture is of the scaphoid,
provides a safe environment, encourages active partici- usually seen in children older than 7 years of age
pation, and offers age-appropriate activities. The thera- (Beatty et al., 1990). Participation in sports has increased
pist must “get on the floor” to engage the child in fun the incidence of wrist fractures. The immature skeleton
yet purposeful activity and seek to gain the child’s makes radiographic information difficult to read, and
permission to be touched. Through engagement in thus diagnosis is challenging. Often children are sent to
play, the child is involved to the fullest extent in making therapy with a general diagnosis of “wrist pain.” The
choices in the rehabilitation program. The parents or child can be referred after a period of plaster immobi-
guardians should be educated about how to use thera- lization, or immediately after injury, generally for
peutic play with the child. Treatment varies based on splinting.
the diagnosis. When a scaphoid fracture is found, it may not be
Children are not small adults. They are more suscep- clear if a child has a fracture at the time of the initial
tible to injury because they have a high power-to- visit to the doctor. Typically, the child is placed in a
weight ratio and the neurologic mechanism necessary long arm spica cast for approximately 2 weeks (assum-
for motor control is not yet fully developed. Children ing a scaphoid fracture). X-rays are repeated at that
do not assess risks in the same manner as adults. More time. If no fractures are determined to be present the
than half of the fractures seen in children are in the child starts therapy. If a fracture is present, casting con-
upper limb (Graham & Hastings, 2000). It is rare to tinues until the fracture begins healing. This may be
see a young child with fractures. Often, these fractures 6 weeks or more. The doctor determines when the
may be attributed to child abuse. child can start therapy (Graham & Hastings, 2000)
The growing skeleton differs from the mature skele- (Figure 17-11).
ton. In the growing skeleton some fractures are man- Once the child is referred to therapy, the focus is on
aged with less difficulty and for a shorter length of protecting the wrist through splinting. Therapists must
time. Conversely, fractures that involve growth plates assure that ROM of the affected and nonaffected joints
may lead to long-term morbidity if treated incorrectly. are maintained and that pain and edema are controlled.
Mahabir and co-workers (2001) noted that the inci- The ultimate goal is to return the child to normal
dence of hand fractures in children rose sharply after activity.
the age of 9 and peaked at age 12. Sports activities were
the most common cause of fracture for both boys and Evaluation
girls. The fifth metacarpal was the most commonly Types of assessments performed are dictated by the age
fractured bone (21.1% of the total sample of 242 frac- and cooperation of the child, as well as the attitude
tures in their study), 60.2% were nonepiphyseal frac- and willingness of the parents or guardians. A com-
tures and 39.8% were epiphyseal fractures. Of these,
most (90.4%) were Salter-Harris type II (the fracture
goes through the physis and exits the metaphysic of
the bone). They reported that most fractures heal
within 2 to 3 weeks with excellent functional outcomes
(Mahabir et al., 2001). In another study, Zimmermann
and co-workers (2004) followed 220 children with
distal forearm fractures for 10 years. They concluded
that the younger the child at the time of injury, the
more favorable the results. Children who were 10 years
old or older at the time of a severe fracture had the
poorest results.
WRIST PAIN AND WRIST FRACTURES

At birth, the ossification of the carpus has not yet
begun. Through the first years, with the appearance of
the capitate at approximately 6 months, the carpus Figure 17-11 Full arm cast.
plete evaluation includes most of the following

components:
1. Observation from a distance to note if the child
uses or protects the hand. This provides infor-
mation about the level of pain or discomfort and
use patterns and information on the interaction
with the parents or guardians.
2. Interview with parents or guardians for informa-
tion on the child’s hand use patterns under normal
conditions, including handedness, participation in
sport activities, hobbies, and medical history.
3. Determination of pain level and positions of func-
tion and comfort.
4. Determination of the presence of edema.
5. Determination of sensory involvement (e.g., dis-
placed Salter-Harris Type II fractures of the distal Figure 17-13 Cock-up splint.
radius epiphysis may affect the median nerve)
(Binfield, Sott-Miknas, & Good, 1998).
6. Determination of degrees of pain-free ROM (e.g.,
shoulder, elbow, forearm, wrist, digits). stability and control. The young child with a short
7. Determination of dexterity and age-appropriate lever arm requires a splint that goes above the
manipulation skills. elbow to keep the splint in place (Figure 17-14).
8. Determination of ADL independence. 2. If a scaphoid fracture is present or suspected, the
9. If the child is in Phase III (see the following) of splint design includes the thumb (Figure 17-15).
the healing process, muscle strength may be The IP of the thumb can be free. For comfort the
assessed. splint is applied on the volar surface with dorsal
10. Additional interview with child and parents or support. The considerations listed in the preceding
guardians to determine their goals. apply as well.
a. Young or unreliable children need a splint that
Treatment includes the elbow to secure the splint and keep
it from coming off during play.
Fabricate Splint to Protect Wrist b. The splint is worn at night and during the day
1. Protect the wrist for comfort if there is no fracture. when the child is in school or otherwise out of
Use a simple volar wrist cock-up with the wrist in the immediate presence of a watchful adult. It
neutral to 20 degrees extension (Figures 17-12 and should be removed for supervised exercises and
17-13). A dorsal component can be added for extra light ADLs.
Figure 17-12 Cock-up splint. (Courtesy of Kimberly

Goldie Staines.) Figure 17-14 Above-elbow splint.
Figure 17-15 Thumb spica splint. (Courtesy of Kimberly Figure 17-17 Neoprene wrist and thumb splint.
Goldie Staines.)
Exercise Activity (Phase II):

c. Splint wearing time is decreased as wrist pain 3 to 6 weeks after Injury
decreases and strength and ROM increase, The child is encouraged to begin short arc ROM
usually 3 to 6 weeks after injury. Often at this exercises within his or her pain tolerance. This should
stage the hard splint is changed to a soft splint take the form of play. Initially, while the wrist is still
made by taping or neoprene if pain persists healing, no resistance is applied. The child is allowed
(Figures 17-16 and 17-17). to “get to know the hand again.” Play can be with
bubbles or water (cool and elevated if swelling is
Edema Control (Phase I) present). Other effective activities are games that require
If edema is present, the child is given a pressure grasp-release and reaching of light objects (e.g., work
garment such as an elastic glove or wrap. The child and on vertical surfaces, use stickers, felt boards, magnets).
parents or guardians are instructed in positioning the Gentle exercises and activities are done through Phase
limb in elevation, gentle motion, and retrograde mas- II of healing. Bilateral dexterity activities, such as
sage. All activities should be at heart level or above (the threading beads, may encourage use of an injured and
hand held higher than the elbow and at or above the painful hand.
heart). If the swelling is severe, a “sandwich splint” may
be necessary initially (see Figure 17-30 later in this Strengthening (Phase III)
chapter). The child begins strengthening the hand and wrist as
pain subsides and the fracture heals. There should be
“no pain with loading” such as when making a fist or
pushing off from floor or chair before beginning a
strengthening program. Strengthening is incorporated
into the child’s daily activities and play. Throwing balls
to encourage bilateral use or playing with putty is
effective for a strengthening program (Figure 17-18).
Education
Educating the parents or guardians on all precautions
about the child’s injury and what to expect with the
healing process is part of the treatment program. The
therapist assures that both parents or guardians and
child demonstrate understanding of the home pro-
gram, splint wear, and activities that can be harmful.
The home program includes pictures and written
instructions. The number of clinic visits varies with the
child and degree of impairment. However, many chil-
Figure 17-16 Taping of wrist to limit motion. dren can be treated effectively with a comprehensive
parents or guardians. Take a full history; include

activities, hobbies, and medical history.
3. Determine pain level. Determine the position of
function and comfort. What is the position of the
affected digit? Is there any deviation, angulation, or
rotation? Where? Is the digit stable? What position
exacerbates symptoms? (Shuaib, 1997).
4. Determine the presence of edema.
5. Determine the amount of pain-free ROM of the
digits and proximal and distal joints. Check ROM
of the entire extremity.
6. Check dexterity; determine appropriate manipu-
lation skills for the age of the child. Is he or she
using the affected digit?
7. Strength may be tested in Phase III of healing.
Figure 17-18 Use of putty for strengthening. Usually grip strength that distributes the force
across all digits is easier to tolerate than pinch
strength with the affected digit. Strength informa-
home program and only occasional visits to the thera- tion also may be obtained by observing usage of the
pist for evaluation and update of home exercises. hand. Is the child performing ADLs in the normal
and customary fashion?
FRACTURES AND DISLOCATIONS OF 8. What are the child’s and parents’ goals?
THE DIGITS
Treatment
The incidence of hand fractures rises dramatically after The treatment is based on what is seen clinically at the
the age of 8, with boys presenting more often than time of referral, because these children may be sent
girls with both fractures and dislocations. Phalangeal to therapy at different points after injury. What stage of
fractures slightly outnumber metacarpal fractures. healing is the injury? What were the results of the
Metacarpophalangeal joint dislocations are among the evaluation?
most common of childhood injuries. Physeal injuries
may amount to 33% of the fractures seen. These frac- General Splinting Considerations
tures are classified using the Salter-Harris classification, The splinting goal is to keep the fracture stable until
with Salter-Harris II being the most common (Graham healed.
& Hastings, 2000). 1. Ligament Disruption or Dislocation. The splinting
Most of these children are treated conservatively and goal is to align the finger and reduce the stress on
followed by the physician. Children who are referred the affected structures. In certain conditions and
for therapy are the ones with complications such as with certain age groups a hinged-type splint or one
persistent pain, decreased ROM, or refusal to use the that allows short arc ROM may be appropriate. Use
hand. When a child comes to therapy, an accurate buddy splinting, which is taping the affected finger
description of the injury, how it happened, treatment to the adjacent one for stability at the onset if the
provided by the physician, and length of immobiliza- disruption is not significant. Otherwise buddy
tion should be available to the therapist. splinting can be used for protection after 3 or 4
weeks of immobilization.
Evaluation 2. Phalanx Fracture or Displacement. These are most
1. Observe the child from afar. Watch him or her use common in border digits (Hastings & Simmons,
the hand. The way the child uses the hand provides 1984). Splinting usually includes the adjacent digit
information on pain and usage patterns. Is he or she and, depending on the age of the child, with or
protecting it or using it? Is the child using the without the wrist.
affected digit when using the hand? If the thumb
is involved, is there a grasp and release pattern? Is Common Digital Injuries and Their Treatment
there sustained grasp? Gamekeeper’s or Skier’s Thumb. This is an ulnar
2. Determine the child’s demands on the hand under collateral ligament tear or stretch. In the older child
normal conditions. Does he or she play sports or this involves splinting the thumb MP with a hinged
participate in arts and crafts? Which is the dominant splint allowing MP flexion-extension motion but
hand? Interview the child (age dependent) and restricting radial deviation (thus protecting the ulnar
collateral ligament from elongation). In the younger

child, a hand-based thumb spica splint is suggested.
Splint wear depends on healing and at what point the
child was referred. Usually the splint is worn for 6 to 8
weeks after injury. If there are no deforming forces and
the joint is stable, splinting can be discontinued except
for sports or other activities that may necessitate extra
protection.
When the splint is removed, the child and parents or
guardians are instructed in ROM exercises and protec-
tion of the hand during sports or play. Use of tape and
neoprene for added protection of the hand during
activities or sports is advised.
Proximal Interphalangeal (PIP) Joint Dorsal Figure 17-19 Mallet splint: lateral dorsal view.
Dislocation. This injury, although generally rare in
young children, is the most common PIP dislocation
in adolescent athletes. It usually is called “jammed
finger.” Many of these are reduced on the playing field.
They may have associated volar plate and collateral
ligament injuries.
Splinting for this condition may take the form of
buddy taping if the injury is mild, or complete rest with
the PIP joint in approximately 20 to 30 degrees of
flexion (to protect the volar plate). After a couple of
weeks of complete rest, if instability is noted, then a
dorsal blocking splint (a splint that allows PIP flexion
but blocks extension at −30 degrees) can be fabricated.
This type of splint allows the volar plate, which is
injured, to heal with no tension, while still allowing
short arc ROM. This can be in the form of a hinged
splint or a splint with “horse blinders” that serve to Figure 17-20 Mallet splint: volar view.
guide the motion. In some cases, protected early motion
in these splints is started immediately. If the PIP is
swollen, then edema control measures such as pressure volar surface of the affected digit. The hand can be
wrap and elevation may be necessary. When the pro- used in normal ADLs with the splint. The splint should
tective period is over, home exercise emphasizing com- be kept dry and changed every couple of days; check
posite flexion, as well as protected PIP extension, is the dorsal skin for breakdown. The tip of the finger
taught. The child and parents or guardians should be should be held in extension during the splint changes.
instructed in all precautions. For young or unreliable children, the PIP joint or PIP
Mallet Finger. This is a physeal fracture of the distal and MP joints should be included to secure the splint.
phalanx, with or without displacement. The fracture Watch for skin breakdown under the tape, especially
may be displaced by the pull of the extensor tendon with young children. The splint should be removed
insertion. Most of these fractures are treated closed after 6 weeks. If there is full extension, gentle short arc
(e.g., do not need surgical intervention) (Graham & of active ROM can begin, with night and PRN
Hastings, 2000). The finger should be splinted with a (whenever necessary) day splinting. If the DIP joint is
dorsal splint over the DIP joint. There should be no not extending actively, continue with continuous
hyperextension of the DIP joint in the splint, so as not splinting for two more weeks.
to blanche any of the dorsal skin and thus compromise After removal of the splint, watch for an extensor
circulation (Figs. 17-19 and 17-20).Tape should be lag, which is the inability to extend the DIP into full
used to secure the splint at the proximal edge going extension because of poor pull-through of the terminal
around the finger. A longitudinal strip of tape coming extensor tendon. This may last for up to 4 to 6 months.
from the volar to dorsal aspect of the finger should This may result from elongation of the tendon, which
secure the distal phalanx into the splint. A last piece of must stay in a shortened position to heal and function
tape is used horizontally around the finger’s distal properly. Provide the child and parents or guardians
phalanx. This splint allows good sensory input on the with home instructions and precautions.
TENDON I NJURIES Flexor Tendons

Broken glass is a common cause of tendon injuries in Immediately Postoperative (Phase I)
the young. Older children also can suffer tendon There are several accepted protocols for flexor tendon
injuries secondary to broken glass and sharp metal, as repair. All tend to require 3 to 4 weeks of splinting,
well as through participation in sports and other activ- with or without motion. The decision about which
ities. Often the cut is tidy, especially with broken glass. protocol to follow is dictated by the surgeon’s choice of
The management of these injuries depends on the age, suture style, as well as the age of the child and the
understanding, and cooperation of the child (Favetto et overall condition of the tendons and hand.
al., 2000). Young and unreliable children usually are placed in a
Tendon healing has been a source of wonder and long arm splint or cast, placing the elbow in flexion (60
research for many years. Clinicians must balance the to 70 degrees), forearm in neutral, wrist in neutral or
need of the tendon to heal with its need to glide. with slight flexion (0 to 20 degrees), metacarpal joints
Alternately, we know that if a tendon is immobilized it in flexion (60 to 70 degrees), and interphalangeal joints
will heal, but it will also adhere to the surrounding in extension. This splint can be made intraoperatively
tissue, and thus not glide. We know that if the tendon and then changed or adjusted in therapy on the second
is mobilized too fast or too hard, it will rupture. The or third day postoperatively. The patient is followed in
challenge in tendon management is to find a compro- the clinic for splint checks and adjustments one to two
mise between protecting the blood supply and nutri- times weekly for 3 to 4 weeks.
tion to the healing tendon, while allowing gliding so The parents or guardians should be instructed in
that the tendon will not adhere to the surrounding all precautions about the child’s injury. They must
tissue. The goal for tendon rehabilitation is to protect understand the importance of observing the fingers for
the tendon through Phases I and II of healing (see good color, thus assuring good circulation. They must
the following), while allowing some protection, below be instructed in edema prevention through elevation.
breaking strength motion. This is particularly impor- They also must understand the importance of encour-
tant for flexor tendons, yet difficult to do with young aging the child to move the uninvolved joints such as
children. It is believed that children heal faster and with those not splinted. The splint may be removed to clean
fewer adhesions than adults (al-Quattan et al., 1993). the wounds or stitches. Great care must be taken not to
This information allows some creativity and deviation move the wrist and digits during dressing changes,
from the adult tendon protocol in how to manage particularly if done by the parents or guardians. Some
these injuries postoperatively. elbow motion can be performed carefully when out of
Conventional treatment protocols for adults have the splint. Clinical visits include dressing changes and
been the traditional controlled protected motion for gentle passive motion, of the elbow, wrist, and fingers,
both flexors and extensor injuries, and more recently in a protective manner by the therapist to protect repair
gentle protected active motion for flexor tendon injuries. at all times (Penttengill & van Strien, 2002).
Rarely is an adult treated with complete immobilization All reliable and older children may be treated like
after flexor tendon injury; however, that might be the adults and follow the early protective protocol of
treatment of choice for extensor tendons. With chil- Kleinert or Duran-Houser or the active motion pro-
dren, it is common practice to immobilize the hand for tocols that are widely described in the literature
tendon injuries. With children under the age of 9, the (Penttengill & van Strien, 2002).
elbow is included with a long arm cast or splint. In an The splint is fabricated and worn consistently for 4
interesting study, Friedrich and Baumel (2003) reported weeks. In most cases, the child is splinted in a dorsal
good success using the modified Kleinert surgical repair blocking splint, with the wrist placed in neutral to 20
technique with early protected motion (see next sec- degrees of flexion, and metacarpals placed in 60 to 70
tion) for children ages 9 months to 18 years who degrees of flexion by the dorsal hood. The fingers are
suffered flexor tendon injuries. Their treatment tech- placed in extension in the hood for the early active
nique varied from the traditional, which supports the motion protocols and in rubber band traction for the
idea that creativity and individuality of protocol per protective motion protocols.
patient are advisable and possible (Friedrich & Baumel, For the protective motion protocol, a dorsal splint
2003). is fabricated, placing the wrist in neutral and MPs in
Tendon injuries are classified by zone of injury. 70 degrees of flexion with rubber band traction on the
There are some variations in treatment protocol based affected fingers or all fingers, depending on the sur-
on the zone of injury, specifically for extensor tendons. geon’s preference and reliability of the child. The rub-
With flexors, however, many children are treated in the ber bands pull the fingers into the palm, creating a
same manner regardless of the zone. fistlike appearance of the hand in the splint. The child
is shown how to release the tension on the rubber

bands so that he or she can achieve maximum extension
(full interphalangeal extension) into the dorsal hood,
allowing flexion through the pull of the rubber bands.
At night the fingers are released from the rubber
bands and secured in extension to the dorsal hood with
a wide strap. This, along with the protective daily
motion, is aimed at allowing some gliding of the flexor
tendons, as well as preventing PIP flexion contractures.
If the IPs of the fingers are not able to extend
completely (especially at the PIP joint level), a wedge is
placed on the dorsal aspect of the proximal phalanx
(P1) to encourage PIP extension. This can be accom-
plished with the use of a pencil or piece of foam (Figs.
17-21 to 17-23). Some children may be placed in the
dorsal hood as described above, with no rubber band Figure 17-22 Kleinert splint in flexion.
traction. These children follow the Duaran Houser
protocol of protected passive ROM (Penttingell & van
Strien, 2002).
Those following an early active motion protocol
go through a closely monitored program of tenodesis
exercises; specifically, wrist flexion with finger extension
followed by wrist extension with finger flexion. Also,
the therapist may place the digits into flexion and
instruct the child to “hold” them there with an iso-
metric contraction. These children should be followed
closely when they perform place and hold or tenodesis
exercises (Figs. 17-24 and 17-25).
The child should be followed in therapy no fewer
than two times a week for the protective motion
protocol, in which the therapist checks the splint and
the wounds or stitches, as well as performing passive
ROM when indicated, especially to DIP and PIP joints.
Nonaffected joints should be exercised on a regular Figure 17-23 Kleinert splint in night position.
basis. If an early active motion protocol is followed, the
child should be followed daily in therapy.
Figure 17-21 Kleinert splint in extension. Figure 17-24 Early motion splint, place, and hold.
activities. The design transfers the work load to the

long flexors and thus promotes gliding (Figure 17-26).
Resistive extension may be initiated and exercises
such as putty rolling can be introduced. Encourage the
child to use the hand in most of the ADLs, being
careful not to perform activities that require great
volitional strength. The child should engage in dexter-
ity activities that encourage differential gliding of the
FDS against the FDP. Edema and scar management are
addressed as necessary.
Splinting at this point is used based on clinical goals
such as proprioception to encourage pull-through or
positional to prevent or address deformities.
Discussion
Figure 17-25 Early motion splint at rest. The literature suggests many different approaches to
treating tendon injuries in children and adults. Kayli
and co-workers (2003) evaluated results of early mobi-
Scar and edema management through pressure lization of flexor tendon injuries in children ages 2 to
and elevation is initiated for all patients. Pressure with 14, using above-elbow stabilization with a Duran-type
silicone gel or other sterile material can begin while protocol. They reported favorable results with a mean
stitches are still in place. total active motion (0% to 100%) of 78.5%. They did
note that the age of the child and the presence of digital
Four Weeks Postoperative for All Protocols nerve involvement affected the results (Kayli et al.,
(Phase II) 2003). Fasching and co-workers (1998) looked at 90
An initial evaluation is performed. Gentle active exer- severed digits in 38 children with the mean age of 4,
cises are initiated into flexion, with focus on full exten- over a 4-year period. Children were all treated with the
sion in a protected manner (i.e., full IP joint extension Kleinert protocol. They had five cases of tenolysis and
with MP joints in flexion; full wrist extension with one rupture. In the remainder of the cases they had
digits flexed). The splint is worn protectively during the 88% good results and 2% poor results, which they
day and at night. Precautions against full composite assessed based on Buck-Gramcko’s classification. They
extension (extending wrist and digits together in the concluded that excellent results can be achieved with
same movement) or resistive flexion are explained care- experienced therapists and informed parents. Grobbelaar
fully. No blocked exercises are allowed. Dexterity activ- and Hudson (1994) reported 82% excellent results
ities and gentle ADLs are shown. The scar is managed based on Lister’s criteria in their sample of 38 children
through pressure and stretch and by fabricating the (average age 6.7 years). They had no tenolysis and
protective splint on the volar rather than the dorsal side
for added pressure to the scar. The wrist is placed in
slight extension in the splint.
Six Weeks Postoperative (Phase III)

Reevaluate status, including gross grip (pinch strength
evaluation usually is deffered until 8 weeks, when the
tendon is strong enough to withstand the strain).
Exercise can be upgraded to tendon gliding exercises
(allowing the flexor digitorum profundus [FDP] to
glide against the flexor digitorum superficialis [FDS])
and gentle blocking. When instructing in blocked exer-
cise (only advised if gliding is moderate to poor) tell the
child to only use 30% to 50% of his or her strength.
Blocked exercises are a common reason for tendon
rupture. If pull-through is poor, a blocking glove can
be fabricated, blocking the MPs at 0 to 20 degrees of
flexion and allowing full ROM of the IPs. This glove is Figure 17-26 Blocking glove. (Courtesy of Kimberly
worn when the child is using the hand in normal Goldie Staines.)
three ruptures. They suggested better results when both group had good results compared with only average in
the FDP and FDS are repaired. the immobilized group at 3 months postoperatively;
Friedrich and Baumel followed 173 cases of flexor however, at 3.7 years postoperatively, both groups
tendon injuries, ages 9 months to 18 years, over a 10- showed good results.36
year period. They concluded that early motion should
be initiated at any age, because of problems they saw Clinical Implications
with immobilization, even in the young. Their protocol Flexor tendon protocols vary from immobilization to
follows a modified Kleinert routine, with a cast placed protected motion to active motion. Long-term results
in surgery either above the elbow or not, and the wrist of studies do not show significant difference in the early
placed in 5 to 10 degrees of flexion and extended to the motion protocols; with the young, no study has shown
MP joints. Digits are flexed by rubber band traction conclusively that early motion is preferred over
that is routed through the palm. The initial goal is to immobilization.
get full IP extension beginning on the first postoper-
ative day, with five to six exercises per day by the third Extensor Tendons
day. The goal is to achieve full flexion by 3 months. Zones I and II injury distal to the PIP (known as
Based on the Buck-Gramcko scale, they reported 95% “mallet finger deformity”) is discussed in the fracture
good results, with four cases of poor results (Friedrich section of this chapter. Treatment for a tendon avulsion
& Baumel, 2003) (Figure 17-27). from the distal phalanx is the same as the treatment
Ebinger and co-workers (2003) looked at two described for mallet finger deformity.
groups of children with flexor tendon injuries. In group The literature shows little or no difference in treat-
A (children under 6 years of age), the postoperative ing extensor tendons with early protected motion
treatment consisted of immobilization for 3 weeks. In rather than immobilization. Immobilization is the treat-
group B (older children), early passive mobilization was ment of choice in treating children of any age who
employed. Follow-up showed that the mobilization suffer an extensor tendon injury.
Immediately Postoperative Zones III to VII

(Phase I)
Splint the child with an extensor tendon injury in a
protective splint that has both a dorsal and volar com-
ponent for better security and stability of the splint. For
Zone III injuries at the PIP level, a hand-based splint,
with the MPs at 20 to 40 degrees of flexion and the IPs
extended, is commonly used. The splint can go above
the wrist if it is feared that the child will not keep the
splint on. The splint should go above the elbow for
the young and unreliable child, with the elbow kept at
60 to 70 degrees of flexion; however, that is rare. For
all other zones, the forearm is neutral or pronated, the
wrist is in 30 to 45 degrees of extension, the MP joints
are kept at 30 to 60 degrees of flexion (depending on
the zone of injury), and the IPs are extended (including
the elbow if necessary to maintain the splint on the
child). The exact position depends on the stress on
the repair that can be determined intraoperatively and
communicated to the therapist.
The child should be followed in therapy at least two
times a week during the 3- to 4-week immobilization
phase. At each visit, the wound or stitches should be
cleaned, the dressing changed, gentle ROM should be
performed with all uninvolved joints, and protected
ROM may be performed with the involved joints
(patterns in extension only). Precautions should be
Figure 17-27 Friedrich and Baumel casting for early
motion. (From Friedrich H, Baumel D [2003]. The treatment explained to the child, as well as the parents or guardians
of flexor tendon injuries in children. Handchir mikorchir about keeping the arm dry and clean, elevating the
plastic chir, 35(6):347–352.) extremity, and watching the color. The parents should
notify the doctor immediately if any discomfort or vided. If a child is not progressing, then more frequent
unusual swelling is seen. Scarring and swelling are visits to the therapist should be initiated.
addressed through pressure under the splint and
elevation. Six Weeks to Eight Weeks Postoperative Zones III
to VII (Phase III)
Three to Four Weeks Postoperative Zones III to The child may now use the hand in most of the ADLs.
VII (Phase II) Precautions against composite flexion until 8 weeks
A baseline evaluation is done at this time. Edema is postoperatively continue. Exercises that encourage active
measured, any scars are noted and described, and gentle extension, such as dowel or putty rolling, should be
active ROM and dexterity are recorded. If there is sen- used (Figure 17-29). Edema is a minimal problem by
sory involvement, a baseline sensory evaluation should this stage. The scar still needs attention. Splinting is
be performed. Particular attention is paid to any used for protection if a lag is present; otherwise it is
adhesions along the tendon or to a lag. If a lag exists, used as needed depending on the clinical manifestation.
continued splinting for an additional 1 to 2 weeks may Complete evaluation should be performed, looking at
be advised (Figure 17-28). Patients may begin active all aspects of hand function.
range of motion (AROM) at this time; the exercises
should be carefully monitored for the first couple of Discussion
weeks so as not to strain the repair. Movements should Little is available in the literature about extensor ten-
be in a tenodesis fashion; wrist extension with finger don management in the child. Most of the data are
flexion, wrist flexion with finger extension. The splint based on adult populations. Protocols that are available
may be adjusted or kept the same. It is used between for adults certainly can be used for the older and reli-
exercise sessions for protection and at night. The child able child. Evans (2002) suggested protocols for each
may use the hand for light ADLs and for bathing. zone of injury, which may be appropriate to use under
Precautions against resistive extension or composite certain circumstances with the pediatric population.
flexion (fisting with wrist flexion putting maximal strain
on the extensor mechanism) should be carefully Clinical Implications
reviewed with the child and parents or guardians. Extensor tendon injuries in children can be treated with
If the child can follow directions and has partici- 3 to 4 weeks of immobilization followed by a program
pating parents or guardians, and barring complications, of gradual increase of motion and use. In treatment, all
he or she can perform much of the therapy on a home efforts must be made to avoid an extension lag, includ-
program basis and be followed in therapy once weekly. ing increasing immobilization time if needed.
The home program consists of exercises, and edema
and scar management. Home education about pre-
cautions and functional use of the hand also is pro-
THERMAL HAND I NJURIES IN C HILDREN
Burns in the upper extremity often occur in children.
Patterns of burn injuries in children differ from adults
because of children’s development, their physical and
psychological aspects, as well as how children get burned.
Clarke and co-workers (1990) claim that children are
different than adults in that burns caused by scalding
Figure 17-28 Extension lag. Figure 17-29 Rolling exercises to promote extension.
are the most common, and children develop less stiff- Phase I: Open Wound
ness than adults when immobilized. Children are curi- The objective for treating a child in Phase I with an
ous and thus put themselves at risk. Common causes open wound includes reducing edema, maintaining
for hand burns are hot cups of coffee, hot water, irons, digital circulation, limiting inflammation, and position-
and heaters. The mechanism of injury and the nature ing and mobilizing the hand early. These are key
of the burn agent dictate the severity of the burn. parameters to aid in the best chance for regaining
Sunburn can produce a superficial burn, whereas hot function (Clarke et al., 1990; McCauley, 2000).
water produces a scalding injury that can be superficial Initial treatment of a hand burn must consider
or deep. A flame may result in full thickness burns (de wound care, the location of the burn, and the potential
Chaliain & Clarke, 2000; Greenhigh, 2000). deforming forces that will affect the healing.
Burns occur initially when there is direct contact
with a thermal agent, causing injury to the cellular Wound Care
elements and structural proteins. Subsequently, there Evaluation should consist of a description of the
is delayed damage secondary to progressive dermal wound, including the wound’s color, size, and depth,
ischemia. When a child is exposed to heat, both the as well as any exposed structures. Circumferential meas-
temperature and the time exposed to the heat deter- urements with a sterile measuring tape should be taken
mine the extent of tissue damage (de Chaliain and for recording of edema. All blisters should be noted
Clarke, 2000). and marked on a drawing of the hand. When possible a
Palmar burns in toddlers are increasingly more picture should be taken of the wound.
common. Dunst and co-workers (2004) reported an Treatment should be coordinated with the burn
alarming increase in palmar burns associated with gas team and may consist of hydrotherapy (with the appro-
fireplaces. priate disinfectant agents) or wound cleansing directly
Burns have been classified in four degrees, although with dressing application and changes. Special care
commonly only three degrees are referred to, as seen in should be given to any exposed tendons or bone. The
Table 17-2. therapist’s role is to guide the team about positioning
Rehabilitation of the burned hand should begin the hand in the dressing. The goal of positioning is to
immediately after the child has been medically stabi- maintain burned structures on stretch while healing,
lized because a 7- to 10-day delay may result in irre- thus preparing for future functional use. Most com-
versible functional losses. The general goals of therapy monly a resting splint is fabricated (see the following).
are to prevent deformity and maximize function (de Edema and future scarring can be controlled with
Chaliain & Clarke, 2000). pressure wrap over the dressing and splint immediately
Intervention depends on the phase of healing. after wounding.
Table 17-2 Classification of burn severity
Classification Depth of Penetration Clinical Signs
First degree Superficial—epidermis level Redness, pain, heals with no scarring (sunburn)
Second degree Partial thickness—epidermis and Blisters, moist, painful, heals in 2 to 4 weeks, or may
Superficial dermis level go to full thickness, scarring
Deep
Third degree Full thickness Dermis destroyed, usually needs coverage, white or
black, dry, anesthetic
Fourth degree Full thickness and more Deep destruction, to bone, needs flaps or grafts to
heal
Modified from de Chaliain T, Clarke HM (2000). Thermal and chemical injuries. In A Gupta, SPJ Kay, LRL Scheker, editors: The
growing hand, diagnosis and management of the upper extremity in children (pp. 665–692). St Louis, Mosby.
Positioning preventing the child from removing the splint (Ward et

The goal of positioning the hand during the healing al., 1998) (Figure 17-30).
phase is to maintain maximum potential for function. Straps used to secure the splints should be wide and
Often the position of comfort is also the position of placed diagonally, not circumferentially; when possible,
potential contracture. Therefore positioning may not elastic wrap should be used so as not to compromise
always be comfortable, however it is essential for the circulation. Often, no straps are needed, because the
prevention of contractures. Positioning may be achieved splint is incorporated into the total dressing and held in
in many ways, the most common is through the use of place by bandages or elastic webbing. When using
thermoplastic materials that are custom made for each elastic wrap, use no more than three wraps over one
child. If these materials are not available, plaster, band- area. Make sure even pressure is used. Leave the finger-
ages, and other common items may be used. tips open so they can be seen to monitor color. Splints
The position that the hand and wrist are placed in should be worn continuously the first 5 days, removing
are determined by the location of the burns. The place- them for short periods to allow the child to exercise or
ment of each joint in the hand, including the wrist, feed themselves. Thereafter, when edema has subsided
must be such that the regenerating tissue regains maxi- and tissue is starting to heal, splint wear time may vary
mum length and pliability. This position may at times during the day, with continued night splinting used
be in conflict with the “functional position” of the until all scars have matured.
hand. Positioning decisions need to be made for each
child with an exercise regimen that complements the Scar and Edema Management
static positioning to maintain function. For example, Scar and edema management should start immediately
with palmar burns, the wrist is placed in 20 to 30 after wounding. Pressure and elevation are the appro-
degrees of extension, with the MP joints in 30 to 40 priate venues in the early phases of healing. Pressure
degrees of flexion and IP joints in full extension. The can be achieved through the use of elastic bandages.
thumb should be positioned with maximal web stretch- Elevation can be accomplished through positioning in
ing and in midposition between palmar and radial bed on pillows or with the use of IV poles to “hang”
abduction. Care must be taken not to stress the carpo- the hand. Attention must be given to the color of the
metacarpal (CMC) joints. Support to the palmar arch digits when pressure has been applied circumferentially
should be provided. The splint should be fabricated exposing the tips of the fingers, thus allowing visual
on the volar side of the hand so that it puts pressure clues as to the circulatory viability. Children can be
on the healing wounds. This pressure aids in aligning advised to “wave” at everyone they see, with their hand
the collagen and reducing the potential for scarring. held high. When possible, extra pressure can be placed
However, this pressure must be distributed so as not to in certain areas, such as the web spaces, with cotton,
cause point pressure areas, which can lead to tissue bandages, or any other available sterile dressings
necrosis. (Figure 17-31).
The hand with dorsal burns should be positioned
with the wrist in neutral, the MP joints in 70 degrees of
flexion, and the IP joints in extension or slight flexion.
The thumb should be positioned in palmar abduction
with maximum stretch of the dorsal web. The splint
should be placed dorsally when possible, thus providing
some pressure on the burned tissue. Variations to these
positions are done based on the location of the burns.
If the web spaces are affected, then the digits should be
placed in slight abduction. If both dorsal and volar
burns are present, then splinting must consider all areas
when deciding on the best position. Each child is dif-
ferent based on the age, burn pattern, and involve-
ment. Children younger than 4 years of age have a
small lever arm to stabilize a splint, and thus the splint
design perhaps should be above the elbow. The digits
perhaps should be positioned in full extension to gain
sufficient leverage. In some instances, a “sandwich”
splint design may be appropriate; it has the advantage Figure 17-30 Sandwich splint for edema or scar.
of pressure on all circumferential burns, as well as (Courtesy of Kimberly Goldie Staines.)
play. Using a whirlpool as a medium for ROM activities

and prehension exercises is an option. The therapist
must appreciate the patient’s pain level and tolerance
and the parents’ anxiety when prescribing exercises or
activities. As early as possible, the child must be taught
to exercise the entire upper extremity to prevent any
secondary stiffness of unaffected joints.
Education
The parents or guardians and the child should be pro-
vided with information about the diagnosis, expected
Figure 17-31 Circumference pressure wrapping for outcomes, and steps to achieve these outcomes. In this
burn scar. (From Serghiou M. In McCauley RL (2005): phase, education is primarily related to wound care,
Functional and aesthetic reconstruction of burned patients, dressing changes, positioning, pain management, and
CRC Press.) limited activity. The parents or guardians are guided
through the rehabilitation process and included in all
therapy protocols. The importance of maintaining any
Exercise and Activities uncomfortable positions is emphasized. All precautions
Before initiating an exercise regimen, available active are explained and reviewed. As indicated, the child is
and passive ROM as well as dexterity should be eval- encouraged to use the affected extremity in self-care as
uated. This may require sterile instruments and tools. much as possible.
In situations in which goniometric measurements are
difficult, the therapist should record functional meas- Phases II and III: Closed Wound, Immature Scar
ures. Although this is not as reliable as goniometric to Mature Scar
measures specific to each joint, it does give some idea In Phases II and III, evaluation is more specific and
of the child’s ability at that point in time. Ask questions includes all aspects of hand function. It is performed
such as: Can the child touch the distal palmar crease at regular intervals to record progress and modify
when asked to make a fist? Can the child extend the treatments. Wound care is discontinued.
fingers, touch each finger to the thumb in opposition,
or bring the thumb down to touch the base of the small Scar Management
finger? The natural history of a burn scar is for tissue to
Exercise must be tailored to the age and compre- shorten and contract. The patterns of deformity are
hension of the child, as well as the depth of the burns. well established. In managing the scar, the goal of
In superficial burns, active ROM should be started therapy is to both put pressure on the scar, as well as
immediately with minimal limitations. For children with to direct its orientation. In Phase II, when the scar
deep burns, extreme care must be given to protect is immature, care must be taken not to disrupt the
structures that might have been affected, such as ten- healing by “shearing” the scar. Therefore efforts must
dons. If nerves are involved, the hand may be insensate, be made to minimize friction to the healing tissue, yet
and extreme attention must be given not to over- at the same time apply pressure on it. Pressure can be
exercise the part. To allow early motion, but also pro- in the form of customized molds, gel sheets, foam, and
tect potential weakened structures, the ROM must be other types of materials that provide even pressure to
done protectively. For example, if the extensor tendons the scar. These pressure molds are secured with elastic
are exposed over the dorsum of the hand, composite wrapping or splinting or both. Decisions are made
fisting must be avoided. ROM should be performed based on where the scar is and how extensive it is, as
one joint at a time or in a tenodesis manner. As an well as the age and participation of the child. The
example, the wrist should be extended when the child function of the hand must not be prevented by the
is flexing the MCP joints with dorsal burns that expose molds during the day. In some situations, there may be
or affect the extensor tendons. Passive motion may be a set of pressure molds for night time that differ from
applied, but with caution, so excess stress is not placed the pressure wraps used during the day.
on the tissue the therapist is holding or stretching. Care In Phase III, massage may be incorporated into the
should be given to maintaining the hand clean and scar management regimen. Creams may be used on a
elevated during exercise session. lightly dampened hand to maintain moisture. Massage
Whenever possible, the hand should be used in a without cream can be used with pressure to a particular
functional pattern because it assists the child in the area to mobilize the scar. Also in the late phase a
ADLs and exercise should be incorporated into active pressure glove may be provided, which can be custom
made for the child commercially, in the clinic, or at

home (Figure 17-32). Care must be taken to apply
sufficient pressure to affect the scar, but not so much as
to cause vascular complications or restrict function.
Pressure wrapping should not exceed 25 to 30 mm Hg
to avoid vascular compromise. Pressure should be main-
tained at all times, except for bathing or changing gar-
ments. Pressure garments can be discontinued when
the scar has reached maturity; usually when the color
changes and the scar is less vascular. The scar may take
up to 2 years to mature.
Positioning
Positioning in Phase II is the same as in Phase I. As the Figure 17-33 Night position splint for burn hand. (From
tissue gains intrinsic strength, splinting during the day Serghiou M. In McCauley RL (2005): Functional and
can become more creative, addressing specific prob- aesthetic reconstruction of burned patients, CRC Press.)
lems. Dynamic splints may be incorporated at this time
to encourage pull-through of the tendons, thus improv- exercise. Intrinsic stretching, placing MPs in extension
ing their excursion or to increase a joint’s ROM. At while flexing the IPs, and intrinsic strengthening
night, positioning splints should be in place until ROM should be incorporated. Tendon gliding, blocking
is normal or any deformity has resolved (Figure 17-33). ROM, and other targeted exercises are employed as
indicated. Graded exercise activities should be incorpo-
Exercise and Activities rated that provide ROM, strengthening, dexterity, and
In Phase II the child is allowed to perform active ROM psychological stimulation. The activity should be
in all planes. The child may now start with composite changed often to keep the child engaged.
motion, achieving gentle stretching of the scar while
exercising. For example, to achieve stretch or elonga- Activities of Daily Living
tion of a dorsal scar, composite flexion with fisting and In Phase II, the child should engage in light ADL, but
wrist flexion should be done. Resistive exercises can be stay away from play or activities that could irritate the
performed only if they do not cause friction to the scar. scar. Equipment and tool modification should be pro-
For example, if there is healing dorsal skin, use of putty vided to aid in independent function. This is based on
exercises for grip and pinch strength may be per- functional limitation and age. In Phase III, there are no
formed, but not if there is a healing palmar scar. Passive precautions—the child should engage in all ADLs he
ROM is contraindicated in joints that have new healing or she can perform, with and without equipment as
tissue so as to avoid friction. Dexterity and sensibility dictated by the condition.
should be tested and addressed as necessary. Skin care instruction should be given to the child
In Phase III, both active and passive ROM as well and parents, as well as education as to sun exposure and
as strength should be addressed through play and other dangers that might damage the healing area.
General Comments
Treatment of a child with a burned hand must take into
account not only physiologic healing, but also psycho-
logical and emotional healing. The child’s treatment
plan should be formed with the consideration of the
child’s family situation, social situation, environment,
and available resources. Treatment varies with each
developmental stage and the individual response of the
child to his or her injury. Play should be incorporated
whenever possible. The experience of being burned is
frightening and painful to the child. Thus this must
be considered in the approach and design of the treat-
ment plan.
The literature suggests variation in care at different
Figure 17-32 Custom ordered burn pressure wrap. institutions. Sheridan and co-workers (1999) looked
(Courtesy of Shrine Burns Hospital, Galveston, TX.) at long-term results of acutely burned hands in 495
children involving 698 injured hands, over a 10-year

International Federation of
period. These authors used ranging and splinting early
BOX 17-2 Societies for Surgery of the Hand
and throughout the treatment, with prompt sheet
Classification of Congenital
autograft wound closure as soon as was practical, and
Differences
selective use of axial pin fixation and flaps for stability
and coverage. They reported normal function in 97% of
second-degree burns, 85% of third-degree burns, and I. Failure of formation
II. Failure of differentiation of parts
20% normal function in children who had deep struc-
III. Duplication
ture involvement (e.g., tendon); however, 70% of IV. Overgrowth
severely involved children were able to perform ADLs V. Undergrowth
(Sheridan et al., 1999). VI. Constriction ring syndrome
Barillo and co-workers reported on a rehabilitation VII. Generalized abnormalities and syndromes
protocol for MCP joints in which they used static
splinting alternating with continued passive motion
(CPM) 4 hours for sedated patients; and CPM alter-
nating with active ROM and night time splinting for classification categorized the types of congenital
MP joints with less than 70 degrees of flexion; and differences (Box 17-2).
active range and progressive resistance for alert patients The treatment of two of the most commonly seen
with MCP joint flexion of more than 70 degrees. Their congenital differences, syndactyly and radial club hand,
patients had an average of 220.6 degrees of motion at are discussed.
discharge and 229.9 at 3 months, with mean grip
strength of 60.8 pounds at discharge and 66 pounds at
3 months (Barillo et al., 1997).
SYNDACTYLY
Roberts and co-workers (1993) reported on seven Syndactyly falls under the “failure of differentiation”
patients’ hand strength that was followed by ROM, classification. It is a fusing of adjacent fingers that can
compression therapy, and splinting. They showed that be simple (involving only skin) to complex (in which
although both grip and pinch strength improved at 6 the bones of two digits are fused). Syndactyly is one of
weeks after injury, strength remained significantly less the most common hand deformities. It is found in
than normal compared with the norm for age and sex males more than females, and is present in 50% of cases
at 6 months. They concluded that although their find- bilaterally. Often syndactyly is associated with other
ings were lower than normal, this did not indicate poor problems, such as polydactyly, clefting, symbrachy-
performance in ADLs. dactyly, or ring constriction. When these occur, surgery
and therapy should take these anomalies into account
Clinical Implications when planning intervention. The goal of a syndactyly
Children with hand burns should be seen by a therapist surgical release is to create a functional hand with as
early for positioning and gentle motion. Splint design few surgical procedures as possible. Intervention can
should be dictated by burn location. Children should be done as early as 6 months of age or even earlier,
be followed until the scar has matured, which could especially in border fingers in which length discrepancy
take up to two years. is a concern. Full thickness skin graft is almost always
necessary for the soft tissue coverage after separation
and reconstruction (Smith & Laing, 2000; Dao et al.,
TREATMENT OF CONGENITAL 2004). Island flap reconstruction in incomplete syn-
dactyly has been advocated by Brennen and Fogarty
HAND DIFFERENCES (2004), in which skin and fat are rotated for coverage,
with good results, minimal scarring, and rare need for
There has been a lack of generally accepted nomen- follow-up skin grafting (Dao et al., 2004).
clature for the problem in children with congenital
differences of the hand. They have been called upper Postoperative Period: Phases I and II
limb or congenital anomalies, malformations, or differ- The goal of therapy in the early phases of healing is
ences. In this chapter, the word differences is used to wound and edema management, followed by preven-
describe this population. Further classification of con- tion of scarring and creep (the distal progression of the
genital differences has been devised by the Interna- commissure), which may occur (Lourie, 1999).
tional Federation of Societies for Surgery of the Hand The hand is elevated until edema is under control. A
(IFSSH) (Swanson, Swanson, & Tada, 1983). This dressing may be in place for up to 2 weeks and parents
are instructed to keep the dressing dry and clean. The

dressing maintains pressure on the grafts. Extra pres-
sure may be applied with wrapping or foam, as well
as a positional splint. The first dressing change may
be under anesthesia for the comfort of the child.
Compression is maintained at all times (Figs. 17-34
to 17-36).
At 2 to 4 weeks postoperatively when the wounds
are generally healed, pressure molds are made to com-
press the scar. These molds are held in place either by
an elastic wrap or a positional splint depending on the
clinical manifestation of the hand. Splints may be as
small as the scar mold, secured with straps, or as large
as a long arm splint to help maintain position in a
young or uncooperative child. Younger children have
fat around the hand, making splint stabilization and Figure 17-36 Syndactyly, complete wrap over pressure
pressure placement on the scar challenging. Splinting foam.
should be specific to each child, keeping in mind not

only where pressure is needed, but also positional issues
that may be present with the digits. Strapping should
be carefully placed to discourage rotational deformities
or flexion contractures. With good circulation in the
flap or grafts, gentle ROM may be initiated.
In addition, the child and parents or guardians are
educated about how to care for the wounds, change
the dressing if necessary, and maintain the hand to
prevent or minimize edema; also, the child is encour-
aged to wear his or her molds and splints.
Phase III
Scars may continue to heal for up to 12 months or
longer after injury. Attention should be given to scar
Figure 17-34 Syndactyly, after release. management for as long as there is active scarring. This
may take the form of night splinting with pressure
molds and day pressure wraps. These wraps can be
made in a variety of colors and can include just the
affected digit(s) or the whole hand. Always leave the tip
of the finger open to monitor circulation. With any
pressure application, the parents must be taught to
look at the color of the exposed tip to make sure the
wrap is not too tight (Fuller, 1999). Strengthening
exercises and desensitization activities should be
incorporated into the child’s home program, and the
use of the affected digits should be encouraged. In
some cases, sensory re-education should be included.
The child also should be encouraged to use the hand
in functional patterns; this can take the form of games
and ADLs, as well as playing with toys that facilitate
dexterity.
In each stage of healing an evaluation should be
done before the initiation of therapy, and at regular
Figure 17-35 Syndactyly, pressure foam. intervals thereafter. The scar can be monitored through
pictures, as well as specific measurements of depth, size, on the upper limb appearance alone, but rather on an
and color. individualized ADL evaluation.
Impairment may be present in the elbow, with lim-
Clinical Implications ited flexion. Wrist and finger motion is restricted sec-
Children that have had syndactyly releases should be ondary to the position of the hand, as well as to the
seen in therapy for positioning and scar management deforming forces of the flexors that pull the hand into
immediately postoperatively. AROM and functional palmar displacement and radial deviation. With absence
patterning should be initiated as soon as the grafts or of the thumb in many cases, pinch patterns are per-
flaps are healed. formed between the long fingers with the most range.
The child may use the hand against the forearm for
gross grasp, because of the significant deviation at the
RADIAL C LUB HAND wrist; this is a functional pattern for some. This action
Radial club hand belongs under category I of the may be helpful to the child, although it may not look
International Federation of Societies for Surgery of the cosmetically appealing. The length discrepancy of the
Hand, “failure of formation of the parts, longitudinal- limb can create some difficulty with bilateral activities.
radial,” also known as radial ray deficiency or radial Children with unilateral deficit adjust quite well and
dysplasia. It is a complex congenital difference of the thus have minimal functional loss compared with chil-
radial or preaxial border of the upper extremity. Radial dren with bilateral involvement (Manske & McCarroll,
dysplasia may present with a spectrum of abnormalities, 1998).
varying in severity from a slight hypoplastic radius
and minor thumb hypoplasia to aplasia of the radius, Evaluation of Radial Club Hand: Preoperative
thumb, first metacarpal, scaphoid, trapezium, and all and Postoperative
related soft tissues. Bayne and Klug (1987) categorized The preoperative evaluation should include assessment
radial club hand into four categories, I through IV: of ROM of the elbow, wrist, and hand, noting the
short radius, hypoplastic radius, partial absence of the position of the forearm, which is usually static. Specific
radius, and total absence of the radius, respectively. The attention should be given to the amount of passive
child presents with a shortened extremity and a hand range available in centering the hand on the ulna,
that is radially deviated at the distal end of a bowed noting blanching of the skin and other signs of struc-
forearm (D’Arcangelo, Gupta, & Scheker, 2000) tural stress. A developmentally appropriate ADL assess-
(Figure 17-37). ment should be done with particular emphasis on
self-care. Grasp and release patterns are recorded, look-
Function ing at the child’s ability to manipulate and move
Functional limitations vary based on the severity of the objects of various sizes and weights. Children with an
radial club hand, as well as the child’s age and adapta- absent thumb have creative new prehension patterns
tion to the condition and environment. Clinicians must that also should be recorded. The length of both
be cautious not to assume functional limitations based extremities is measured because length affects how far
the child can reach into the environment. When the
elbow is stiff in extension, the radial deviation of the
hand is often what allows the child to reach the mouth
and perineum for toilet care. The amount of deviation
needed for those functions should be recorded.
Careful notation of the child’s sensation, ability to
follow through with an activity, frustration level, and
parental or guardian’s participation assists the clinician
in treatment planning.
Evaluation of this population ideally should be pre-
operative, with the therapist contributing to the
surgical decisions. The therapist has an unusual oppor-
tunity to supply the surgical team with functional infor-
mation that can help in the algorithm of treatment.
Often, surgery is contraindicated if the child has adapted
to the condition. When surgery is appropriate, pre-
operative and postoperative evaluations should be done
Figure 17-37 Radial club hand x-ray. to record progress and be repeated at regular intervals.
Care must be given not to make surgical decisions be used to mimic wrist position before surgery. The
based on aesthetic pressure from the family that will child can give his or her opinion of the wrist position.
not improve the child’s function. Splinting for radial club hand can take many forms.
Postoperative evaluation differs slightly with the The author’s recommendation is a three-point pressure
type of surgery performed. Examples of common surgi- design, with one point at the ulnar side of the proximal
cal procedures are Ilizarov placement and centralization forearm, the other on the ulnar side of the palm, with
or pollicization for an absent or hypoplastic thumb. In the third point being in opposition right at the distal
each situation, the evaluation should record the child’s end of the ulna, radial side (at the wrist). Depending on
physical limitations (impairment level) and how they the age of the child and condition of the elbow, the
affect their function. splint design may be above the elbow, with the elbow
kept at 90 degrees of flexion, although the elbow is left
Treatment of Radial Club Hand: Preoperative free when possible. If the thumb is present, it is also left
and Postoperative free (Figure 17-38).
There are three options for addressing this condition: Children and parents or guardians are educated
no treatment, conservative treatment, or surgical cor- in ROM and stretching exercises of the elbow, wrist,
rection. The primary goal of treatment is to improve and digits. Shoulder active ROM also is included.
the overall function of the extremity. Cosmesis is a Digital flexion may be compromised because of the
secondary consideration. limited excursion of the flexors. This can be improved
Children with Type I or II of Bayne and Klug’s with positioning and exercise. Prolonged stretch may
classification can be treated conservatively, with treat- be uncomfortable for the child; therefore parents or
ment starting a few days after birth. The child’s wrists guardians should be instructed carefully about keeping
are passively stretched into a centralized position, and the discomfort to a minimum and the importance of
the elbow is passively ranged. Parents or guardians are the daily stretches (Fuller, 1999).
instructed in stretching and ranging activities. In When a surgical correction is performed for central-
between stretching, an above-elbow splint is applied, ization of the hand, the child generally is placed in a
placing the elbow in 90 degrees of flexion and the wrist cast. Once the cast is removed, a splint is made and
in a centralized position. If the soft tissues present with therapy can begin. However, first information should
particular tightness, a serial casting regimen can be be obtained about the surgical procedures, specifically
implemented. The cast should place the wrist in neutral what tendons were transposed. Therapy generally com-
with the elbow in 90 degrees of flexion. The cast can be bines the following procedures:
changed a few days up to 2 weeks at a time. Once the 1. Fabricating a splint, similar to the one described in
desired position is attained, splinting at night and earlier, to maintain position until skeletal maturity is
stretching by day should continue until bone maturity, achieved. Splint is adjusted on a regular basis.
which occurs in adolescence (D’Arcangelo et al., 2000; 2. Protecting and re-educating the transposed ten-
Manske & McCarroll, 1998). dons, usually flexor carpi ulnaris
Kennedy (1996) describes a neoprene wrist brace
designed for children as young as 3 weeks old. This
brace is designed to minimize pressure points and
disabling forces that are so common in these cases, by
reinforcing the ulnar and radial sides with thermo-
plastic material. The reinforcers can be serially adjusted
to achieve a neutral wrist. This study reports that
passive correction may be easier to obtain in babies, but
this brace also can be used successfully, in a serial
manner, with older children before surgery.
Infants also can be treated with taping, which is
easier to apply than a splint; however, caution must be
observed not to injure the skin.
Conservative treatment of older children is deter-
mined by their functional ability. With mild wrist devia-
tion, long-term splinting may help centralize the wrist;
however, the deforming forces will still be present and
thus usually some type of surgical intervention to
maintain the position may be warranted. Splinting can Figure 17-38 Radial club hand splint.
3. Increasing ROM once the child is cleared to move Clinical Implications

the involved extremity When treating a child with congenital differences, the
4. Re-education of prehension patterns and functional assessment should be based on the specific child and
tasks his or her adaptation, rather than typical children of the
5. Scar and edema management same age. Often children adapt beautifully to their
6. Providing the child with appropriate assistive differences and minimal intervention is necessary.
devices and adaptations
Starting with the initial visit to therapy, the child
is instructed in patterning for independent function
that is age appropriate. Adaptive use of the hand is
SUMMARY
encouraged with emphasis on elbow motion and digital
prehension. Bilateral activities are encouraged, as is This chapter has provided a base line for the healing
manipulation and grasp and release activities in a graded process for common injuries or surgical interventions.
manner. Play activities are encouraged. The process of evaluation also has been discussed, as
well as common treatment protocols. With each injury
External Fixation with an Ilizarov or condition the actual treatment plan is individualized
Kessler (1989) introduced the Ilizarov, an external to the specific child and his or her special situation
fixator that gradually distracts the soft tissue, approxi- based on the evaluation. Knowledge of normal devel-
mately 1 to 2 mm a day, slowly achieving a better wrist opment, normal healing, and good observation skills
position, with minimal to no neurovascular compro- may be the most valuable evaluation tools, especially
mise. The device is used preoperatively and may be on with infants and small children. Gaining the child’s
the child’s hand for several weeks. During this period, trust and helping him or her overcome fear is the first
therapy should emphasize ROM of all uninvolved step in therapy. After an injury or surgery, the child may
joints. Because of the weight of the device, an excellent regress in development and adaptive skills. The parents
medium for exercise is a therapeutic pool. The child or guardians also may be fearful and confused as to
can move the shoulder and elbow with or without the what is happening to the child. Each child presents
therapist’s assistance in the water, aiding the affected with unique qualities. When determining a treatment
arm with the non-affected one. Fingers can be stretched plan, these qualities are considered, along with the
with dynamic splinting that is fabricated on the Ilizarov. child’s home environment, diagnosis, and the type of
Dynamic extension splinting can aid in reducing any medical intervention received. Realistic functional goals
flexion contractures, as well as provide proprioceptive are then formulated that are specific to that child.
input for flexor excursion. The hand can be supported Children are resilient and bring new meaning to the
with a static night splint to maintain functional posi- notion of “what is possible” rather than “impossible.”
tioning of the digits (Figure 17-39).
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Chapter 18
SPLINTING THE UPPER EXTREMITY
OF A CHILD
Kimberly Brace Granhaug
CHAPTER OUTLINE GENERAL CONSIDERATIONS IN PEDIATRIC HAND

SPLINTING
SPLINTING PRINCIPLES Wearing Schedule for Pediatric Splints
Complications and Precautions
BENEFITS AND GOALS OF SPLINTING
SUMMARY
SPLINT SELECTION
CASE STUDY: A child with Radial Nerve Palsy
Problem-Based Splint Selection
APPENDICES
Type of Splint: Static, Serial Static, Static Progressive
or Dynamic? “Splinting is the intentional application of external loads to
Material Selection for Low Temperature specific anatomic structures to manipulate the internal reaction
Thermoplastics forces and thus enhance or restore function of the extremity”
(Austin, 2003, p. 59).
Splint Fabrication for the Child
SPLINTING FOR COMMON PEDIATRIC HAND Splinting is an ancient art. It has been practiced for
PROBLEMS thousands of years, as the Egyptians used twigs, reeds,
Thumb in Palm and vines for fracture stabilization (Fess, 2002a). There
are many tried and true splint designs; however,
Fisted Hand
Wrist Flexion “Of paramount importance is the understanding that there are
no rote splinting solutions to combating pathologic conditions of
Wrist Ulnar Deviation the hand. Splints must be individually created to meet the
Wrist Radial Deviation unique needs of each patient, as evidenced by designs that incor-
porate the variable factors of anatomy, physiology, kinesiology,
Supination and Pronation pathology, rehabilitation goals, occupation, and psychological
Weight Bearing on the Upper Extremities status” (Fess, 2002b, p. 1818).
Individual Finger Control The most important reason to apply a splint on a

Splinting Infants in the Neonatal Intensive Care Unit child is to improve function. Of course there are other
primary reasons and secondary benefits such as to
SPLINTING FOR PEDIATRIC ORTHOPEDIC
improve joint range of motion, decrease joint stiffness
PROBLEMS
and contractures, improve hygiene, and modify behav-
Fractures ior. Dysfunction or deficits in the upper extremity
Flexor Tendon Splinting in Children pediatric population can be divided into three major
groups: infants and children with congenital or birth
Juvenile Arthritis
injuries that require splinting to prevent development
Brachial Plexus Injury and Peripheral Nerve Injury of deformity or correct existing deformities, children
401
with congenital defect who have undergone corrective ciples as they relate to splinting is discussed. Fess and
surgery, and those who require treatment secondary co-workers (2005) were thorough in their discussion of
to pathology or trauma (Byron, 2002). Splinting and biomechanics of the hand and splint design, fabrica-
postoperative protocols are more standardized for tion, and execution. It has long been considered the
orthopedic involved cases as compared to splinting and “splinting bible”; any therapists contemplating splint
protocols for neurological involvement. It is beyond design should be aware of these principles (Fess et al.,
the scope of this chapter to cover the numerous splint 2005).
designs and fabrication instructions for multiple diag- Some understanding of basic physics and mechanical
noses. Instead, an overview of splint decision making, principles help with splint design, both from an effec-
as well as splint ideas, is the focus. tiveness and aesthetic standpoint, and can help the
It must be appreciated that the plasticity and imma- splint look “cool,” an important aspect in convincing
turity of a child’s system allows gentle forces to both children to wear one. It is critical to understand that
promote developmental hand function, as well as poten- pressure is actually the force that is being applied by the
tially result in harmful effects. It is important to realize splint material, through gravity and dynamic tension,
both the structural and developmental differences in a multiplied by the area over which the force is being
child’s hand when splints are being applied. Develop- distributed. In effect, splints covering a larger area dis-
mentally disabled children have not experienced nor- perse force or load over a greater area and reduce pres-
mal hand function or weight bearing and consequently sure and occurrence of skin breakdown. Also, the more
lack the normal configuration of arches and grasping conforming the splint, the less room there is for friction
patterns (Hogan & Uditsky, 1998). Therefore splints and pressure points to build. The rule of thumb in
should support the normal configurations, as well as maintaining the proper amount of pressure from the
promote functional developmental grasp and release splint material and straps is that the splint should cover
patterns. Special care needs to be taken with the child two-thirds of the length of the forearm or limb and one
who is nonverbal because of age or disability who may half the circumference of the limb or body part. This
experience problems with decreased sensitivity, tactile maximizes pressure distribution and splint stability and
defensiveness, and splint pressure. The immature or minimizes pressure points and migration of the splint.
youthful lack of experience with normal motion and Wider splint straps also distribute pressure more evenly
function also requires observation, consideration, and than narrower straps. Common pressure points both
instruction for the child or parents. for splint material and strapping are included in this
sketch (Figure 18-1).
Another important principle in splinting is torque.
SPLINTING PRINCIPLES Torque is a rotational force and can be beneficial or
destructive. When applying torque it should be at 90
Mechanical principles used in splinting adults and chil- degrees to the segment being mobilized. Without the
dren are the same. Once the concepts of the anatomical correct line of pull in a dynamic situation, the skin
and mechanical principles are understood there is little suffers with shear forces; the result is unnecessary pain,
requirement for splint patterns. Applying the softened unwanted torque on the joint, and possibly even skin
splint material and positioning the hand and affected
joints in the desired and optimal biomechanical posi- 4 1
tion for the purpose the splint is intended are the keys 9
to effective splinting. Generally, the experienced thera- 2 5

pist uses less splint material without a pattern than a 2
3
novice splinter with a pattern because it takes both 8
6
perception of what the splint will do and what forces 9
the splint will exert, as well as the vision of how the Figure 18-1 Areas prone to pressure because of splint
splint will accomplish this to be an effective and effi- or strap force include: (1) dorsal metacarpals, especially
cient splint maker. The splint is used to place body with dorsally based splints; (2) volar surface of
metacarpals and thumb at distal end of wrist cock-up
parts into the most beneficial position for the pre- splints and C-bars; (3) volar surface of digits with resting
established goal with proper biomechanics considered hand splints resulting from spasticity or contractures;
for the extremity, injury, and splint. (4) dorsal surface of first phalanges and proximal
The mechanical principles that must be understood interphalangeal joints; (5) ulnar styloid; (6) thumb
and applied include force, pressure, torque, friction, metacarpal; (7) not shown, but center of the palm with
too much transverse arch in the palm; (8) base of the
and shear stress. Obviously an entire chapter could be thumb with vulnerable radial nerve; (9) proximal end of
dedicated to biomechanics and mechanical principles; the splint. (From Malik M [1985]. Manual on static hand
instead an overview of the important mechanical prin- splinting. Pittsburgh, AREN.)
Splinting the Upper Extremity of a Child • 403
breakdown. Splints must be considered lever mecha-

nisms. Force applied in one area results in force and
pressure in another area, similar to a shovel. Pushing
down on the handle creates a force in the opposite
direction on the scooping end of the shovel. Similarly,
the force of wrist flexion can cause a short splint to dig
into the forearm, or a dorsally based splint to dig into
the metacarpals.
Use contours and curves to add strength to the
design of a splint. For example, a piece of flat sheet
metal wobbles and oscillates; yet can withstand heavy
loads when curved (e.g., a drainage gutter or car
fender). The same is true with forearm-based wrist
cock-up splints and outriggers. Curves add strength
and if used well in a design can also add to the aes-
thetics. Steel beams for buildings are in the shape of an Figure 18-2 Splints should include proximal joints to
I or T to add strength to the structure. Flat beams are assist in splint stability and decrease the probability that
they will be removed.
not nearly as strong for support. To build in strength
without adding several layers of splint material, add an
I- or T-shaped bar of splint material to the weak area.
It is not necessary to be a mechanical engineer to con- Allow for efficient construction and fit. Plan design
struct a splint, but basic mechanical and physics princi- to limit construction time and readjustment; some-
ples take one a long way in designing the optimal splint times prefabricated splints are the most reasonable,
for the child. especially when time and expenses are considered.
According to Fess and co-workers (2005), the gen- Provide for ease of application and removal. Independ-
eral principles of design that play an important role in ent donning and doffing of splints improve compliance;
splint design must take individual patient factors, such caretakers of small children also need quick and
as age and intellect, into account. Also, one must con- efficient means of fastening and unfastening splints for
sider the high activity and energy level of a child; this application and removal. Consider the splint or exercise
alone requires that splints must be durable, as well as regimen: It may be possible to have both flexion and
nontoxic and easily cleaned. The length of time the extension systems built into the same splint (Van Straten
splint is to be used is also a factor in design. & Sagi, 2000). Similarly, a long arm thumb spica may
be trimmed to a hand-based thumb spica as therapy
“In general the shorter the anticipated need of the splint, the and healing progress. The cost factor also should be
simpler its design, material type, and construction should be” considered at this point. Finally, the splint should be
(Fess et al., 2005, p. 211). safe from hard or sharp edges, as well as any attach-
ments or straps that may come off or be swallowed.
Strive for simplicity and pleasing appearance. Some
patients have low “gadget tolerance” and are much
more accepting and compliant with a simple, cosmeti- BENEFITS AND GOALS OF
cally pleasing splint. Children also tend to be more
compliant if they are involved in helping to choose a SPLINTING
color or favorite sticker to decorate the splint. Allow for
optimum function of the extremity without needless Establish the potential benefits and goals of splinting
immobility of the uninvolved joint, unless it is neces- (Box 18-1). Positioning is an important part of both
sary to secure the splint to prevent removal. Children rest and active play. Because the upper extremities are
are less likely to suffer stiff joints for a prolonged period so vital to self-care, feeding, and sensory input, the
if proximal joints are used to stabilize or secure the placement of the fingers, hands, wrists, and forearms is
splint from removal by the child (Figure 18-2). Allow crucial to development and life functions. Splinting
for optimum sensation: used for positioning is usually static, but also may have
a dynamic component. The goals for a positioning
“Without sensation the hand is perceptively blind and splint are to mobilize joints, stretch soft tissues, reduce
functionally limited . . . splint designs should leave as much of contractures, provide stability or support at specific
the palmar tactile surface areas as free from occlusive material joints, provide proper alignment, and prevent defor-
as possible” (Fess et al., 2005, p. 213). mity. As stated, the development of self-care and
priority of needs of the child. Table 18-1 is also helpful

BOX 18-1 Potential Goals and Benefits
and is an adaptation of another chart by the same
of Splinting
authors that lists the proper splint to fabricate for
specific needs.
Position Generally, the shotgun splinting approach of trying
Function to fix too many problems at once ends up not bene-
Hygiene
fiting any one problem well. For example, a child may
Protection and behavior
need to open the hand for weight bearing, abduct the
thumb for fine motor grasp, and pinch and extend
the wrist to improve hand biomechanics. It may not be
exploration in the child centers around the use of his possible to achieve all of this through one splint with-
or her upper extremities. Other goals for a positional out causing undue pressure or constriction. Therefore
splint include enabling or improving existing function, usually it is better to have splints for different functions.
augmenting the benefits of therapy, and substituting The problem-based splinting chart is organized to
for weak or absent muscles. help plan splint selection around the child’s problem
Functional splinting may be used to hold or adapt and not diagnosis; look at the “problem” and not
eating or writing instruments, as well as to aid in the just the diagnosis when deciding splint design. It is of
management of assistive technology for environmental the utmost importance to observe the child’s pattern
controls or educational access. This may be attained of movement and grasp while playing or moving,
through isolation of a digit for pointing and touching a because children with abnormal tone adapt substitution
keyboard or creating a flat palm to access a touch pad patterns that may be functional. A splint may limit
for a fan or light switch. On the other hand, a custom the functional movement and affect hand use in a
fabricated joy stick gripping splint may mean increased negative way. Problem solve first, and then create the
independence of computer use or may improve splint!
accuracy in controlling an electric wheelchair for a child
with a neurologically involved hand. Also, a hand-based TYPE OF SPLINT: STATIC, SERIAL STATIC,
thumb spica splint may be the key to thumb control
that a child requires to manipulate clothing, fasteners,
STATIC PROGRESSIVE, OR DYNAMIC?
or a pencil. Another potential goal is to improve or Static splints are the most commonly made and one of
prevent hygiene problems. This is usually more of an the most important splints. Static splinting is non-
issue with the neurologically involved hypertonic hand. articular, with no moving parts. It is basically an immo-
The difficulty of relaxing the hand to allow air flow and bilization or supportive splint, but may be used to
hand washing can be assisted through splinting for control mobilization or encourage mobilization by the
hand position, as well as protection of the palmar sur- joints it is blocking or not blocking. Finger gutter, wrist
face. Finally, splinting goals can be to help modify or cock-up, thumb spica, and resting hand splints are
prevent undesired behaviors that interfere with safety examples of static splints (Figure 18-4). Serial static
or upper extremity use. This might include, but is not splints are static splints that are periodically remolded
limited to, elbow extension splinting to keep the hands and reapplied as the joint gains motion or the tissue
away from the mouth or necessary life support equip- gains length. They are applied at the end range with the
ment or medical equipment in use with the child. In joint stretched maximally. Serial casting is a good exam-
some cases splinting and behavior modification can be ple of this. It may be used to promote proximal interpha-
tools to improve self-injurious behavior (Hogan & langeal (PIP) extension with flexion contractures
Uditsky, 1998). Orthopedic or post trauma splinting is (Figure 18-5). A night time elbow extension splint may
discussed later in the chapter. be used in the same way for an elbow flexion contrac-
ture. Static progressive splints use nonelastic compo-
nents with low load in a single direction over a long
SPLINT SELECTION period of time to mobilize soft tissue at its end range of
motion (ROM) so that it accommodates to the new
length. The use of nylon monofilament, inelastic strap-
THE PROBLEM-BASED SPLINT ping, hinges, screws, turnbuckles, and MERiT or Splint
Tuner components (Figure 18-6), without the use of
SELECTION C HART rubber bands and elastic materials, slowly changes the
Hogan and Uditsky (1998) have developed a priority resting length of soft tissue with the joint in a static,
rating form, as well as a splint selection flow chart stretched position over a prolonged amount of time
(Figure 18-3), which is helpful for determining the (Austin & Jacobs, 2003). Most often static-progressive
Figure 18-3 The Pediatric Splint Selection Flow Chart. (From: Hogan T & Uditsky T [1998]. Pediatric splinting: Selection, fabrication, and clinical
application of upper extremity splints. San Antonio, TX, Therapy Skill Builders. p. 20.)
Table 18-1 Problem-based splint selection

Table 18-1 Problem-based splint selection—cont’d
(Modified from: Hogan L & Uditsky T [1998]. Pediatric splinting: Selection, fabrication, and clinical application for upper extremity
splints. San Antonio, TX, Therapy Skill Builders. p. 31.)
Figure 18-6 Static progressive splint. MERiT component

used to progress wrist extension.
Figure 18-4 Static splint: finger gutter.
Figure 18-7 Dynamic splint. Used here as an exercise

splint to increase strength and proprioceptive input at the
distal interphalangeal joint after a flexor digitorum
profundus repair.
of the traction. Through the continuum of healing

there are basic guidelines for splint selection. Note that
joint, injury, or contracture fit into these categories;
however, it is a basic rule of thumb that may help you
decide what splint design the child needs. Constant
reassessment of tissue healing, joint motion, growth,
and splint fit are important to maximize the positive
aspects of the splint and minimize the negative effects
that are possible when applying a splint to the extremity
of a child (Figure 18-8). Paul Brand, a pioneer in hand
surgery and hand therapy, lists the 10 questions one
should ask before dynamic splints are made.
Figure 18-5 Serial static splint. This splint can be
reapplied as the joints improve range of motion. “. . . the first step is to define the object of the dynamic splint for
the specific hand we are treating and for the specific joint or
joints that we want to mobilize or modify. Then we should ask 10
questions in relation to the forces we propose to use: (1) How
splinting is custom made, although some components
much force? (2) Through what surface? (3) For how long? (4) To
may be prefabricated and kits are available.
what structure? (5) By what leverage? (6) Against what
Dynamic splinting uses articulations and force reaction? (7) For what purpose? (8) Measured by what scale? (9)
components to constantly put a dynamic pull on the Avoiding what harm? and (10) Warned by what signs?”
tight or healing tissue. Dynamic splinting uses the elas- (Brand, 2002, pp. 1811-1817).
tic properties of the tissue, as well as the splint compo-
nents such as rubber bands, springs, or elastic cord, to These principles seem simple; however, they make the
exert controlled mobilization (Figure 18-7). It may be difference between a successful, well-designed dynamic
used conversely to strengthen or give proprioceptive splint and a disaster that has potential to harm the
feedback when exercise is done against the line of pull child.
Inflammation Proliferative Remodeling

drapability; therefore, watch heating time. A high
drapable material is Polyform; midrange materials are
Immobilization Polyflex II, TailorSplint, and Orfit; and low drapable
o Static
materials are Synergy and Orthoplast. Highly drapable
Mobilization materials should be handled in the horizontal plane to
← o Dynamic prevent overstretching the material.
o Serial Static →
o Static Progressive → The ability to stretch or resist stretch without
buckling or loss of rigidity is another important charac-
Restriction teristic that usually runs parallel to the amount of
← o Static → drapability a material has in it; the more drapability the
← o Dynamic →
easier the stretch, and vice versa. Around contours such
as elbows and flexed metacarpals it is essential to have
Figure 18-8 Tissue is in constant change when healing, stretch without loss of strength or shape; however, too
always moving between stages. Observe tissue healing much drapability on a longer or larger splint can be
and scar maturation when considering which type of
splint to use, and constantly re-evaluate tissue change
difficult to control. Novice splinters may wish to start
and splint effectiveness. (Modified from Jacobs M, Austin N off with a midrange material such as Ezeform or Orfit.
[2003]. Splinting the hand and upper extremity: Principles Memory is the degree to which a material will
and process. Philadelphia, Lippincott Williams & Wilkins.) return to its original shape. Aquaplast has a high
memory. It can be molded and fixed and dropped in
the splint pan to return to its original shape. High
MATERIAL SELECTION FOR LOW memory is helpful if high tone or tactile sensitivity is an
issue and the material may get “smushed” by a grasp
TEMPERATURE THERMOPLASTICS reflex. It is excellent if the goal is serial splinting or if
A multitude of splint materials are on the market and it there will be a significant change in edema; however,
would be difficult for anyone to fabricate all custom memory can be a problem if the material is taken off
designed splints with one material in one thickness. the patient before it is fully cooled because it will shrink
The therapist will likely get the best splint for the and try to return to its original shape as it cools. This
individual if thought is put into the choice of splint in turn creates both a poor fit and edges that dig into
material. Materials have six major qualities or handling the skin.
characteristics that affect splint fabrication including Bondability, or the ability of the material to stick to
drapability or conformity, stretch, memory, bonding, itself when heated, is another property that must be
rigidity, and handling or set time (Box 18-2). weighed when choosing material. Material may have a
Drapability or conformity is the degree at which coating that resists bonding and is easy to “pop” apart
the material takes the shape of the contours below it. when cool. The coating may be left on and a damp
High drapability or conformity material makes intimate paper towel or lotion can be used to help prevent bond-
contact with the contours of the wrist, metacarpals, and ing. Also, if bonding is desired for outrigger placement
digits; on the other hand, it is easy to apply too much or sealing around the thenar web space, the coating
pressure and get deep imprints that may cause pressure can be removed with a solvent or scraped off with a
and are not easily removed. Low drapability material sharp instrument.
needs more handling to conform to the contours beneath Rigidity is the relative amount of strength the mate-
it. Overheated material also can result in too much rial has when cool. The higher the rigidity the more the
material resists passive bending and cracking. Higher
rigidity is suggested for spasticity or long-term contrac-
BOX 18-2 Splint Material Characteristics tures. Rigidity also can be added to less rigid materials
through contours, I- and T-beam supports, and
Drapability and conformability multiple layering.
Stretch Working time or setting time needs to be kept in
Memory mind when working with a material. Thin materials
Bondability (1/16″) have a short working time and set quickly once
Rigidity removed from the splint pan. Other materials depend-
Working times and heating
Other
ing on the heating time and temperature and material
Thickness qualities take up to 2 minutes to heat up and have 2 to
Perforations 6 minutes of workable time before they set. Drying off
Color the splint material also extends the working time because
evaporation cools the material faster and less evenly.
Each material also is made up of a different combina- no longer essential. Make the splint material fit the
tion of plastic, rubber, and polymers and the qualities design and the child’s hand; do not try to make the
also are influenced by the thickness of the material. hand fit a preconceived pattern. Nearly all splints can be
Materials come in 1/16″, 1/12″, 3/32″, and 1/8″ thickness. started as a rectangle. Once the heated soft rectangle
Most finger-based splints are made from the thinnest of material has been placed on the hand or upper
/16″ materials to help reduce bulk between the fingers
1
extremity, it is much more apparent where to cut,
and they are strong enough to maintain the correct where to roll, and where not to cut. Too often the splint
position in a finger. Children’s hand or wrist splints can material is cut before it is applied to the child and too
be made from this material as well if spasticity is not an much material is already gone. Stretching to make up
issue. However, hand, wrist, and forearm splints should for lack of material can weaken the splint design. Begin
be made from thicker materials so they will retain their by prepadding bony prominences, applying a stock-
strength across the joint. inette (it may be wise to apply the padding on top
Other physical characteristics include the option of of the stockinette as in Figure 18-9), positioning the
perforations, as well as color. Many splinting materials child, and then applying the splint rectangle. With
exist and new ones come on the market all the time. It proper positioning and the help of gravity, it is possible
is a good learning experience to have your local sales to get good conformity and mark where the splint
representative bring out or send you samples of the needs to be cut away. Having a little extra material
various materials in different thicknesses. Different splint beyond the conceived splint design can give the thera-
property charts go into great detail about the materials, pist extra leverage to help hold joints for position while
but the best way to find out how they will respond to the splint is being fabricated and it can be cut away
your use of them is hands-on use. Play with the differ- when the essential part of the splint is set and cooled.
ent materials and make the same splint out of several Edge finishing is essential for comfort and safety, as well
types and thicknesses of material. Use different as attachment and outrigger security, especially for the
strapping materials as well and you will find out what infant and child. Attachments and straps should be
works best for the most common splint types you considered harmful if swallowed; therefore permanent
make. If you work in a busy hand clinic you most likely bonding or riveting may be needed. Commercially
have several different types of materials in various designed patterns for the more common splints are
thicknesses because of the wide variety of hand and available and they can be shrunk in size with a copier
upper extremity diagnoses seen. The school, itinerant, for a more child-friendly version. However, the propor-
or home health therapist may find that he or she is tions of a child’s hand are not the same as those in an
making a similar type of splint for a similar age group adult; forearms may be too long or there may be no
and may select a couple of all-around good splint mate- allowance for the fat pads on the dorsum of an infant’s
rials to have on hand. Remember not to leave them in hand and fingers. Remember to fit the splint to the
the car! This is an expensive mistake for a traveling child’s needs and not the child to the splint pattern.
therapist, as the author learned from personal experi-
ence during one hot Texas summer. Soft splinting
materials also are splints by definition. This includes,
but is not limited to, Neoprene, Lycra, elastomer,
strapping, and taping. Combinations of conventional
splint and soft materials may be the best choice, depend-
ing on the specific needs of the child.
SPLINT FABRICATION FOR THE C HILD

Because of the generally short attention span of a child
with likely imperfect cooperation, time may be limited
to make patterns, fit, refit, apply strapping, and provide
adequate education. Reducing the child’s and parents’
anxiety through play can make the experience less of an
ordeal. Having some age-appropriate games and dis-
tractions at hand can help (often the siblings need
distraction). Realistically, once the goal(s) have been Figure 18-9 Prepadding the ulnar styloid and other
established, and the biomechanics and pathology have critical areas (e.g., around percutaneous pins) helps avoid
been understood and applied, the need for a pattern is pressure areas.
SPLINTING FOR COMMON FISTED HAND

PEDIATRIC HAND PROBELMS The fisted hand is difficult to distinguish in infants
because the palmar grasp reflex is strong. This is easier
to discern when looking at symmetry of the upper
THUMB IN PALM extremities. It may be appropriate to provide an anti-
Many times with infants and small children the best spasticity cone or soft cone if the hand does not open
splint is actually a strap or splint and strap combination to explore or grasp in an age-appropriate pattern.
to gently control anatomical structures, especially the Infant splints are tiny, and fabricating these miniature
thumb. Soft neoprene thumb straps that attach to a splints is an art in itself. It is perfectly fine to “cheat”
wrist band are enough to allow improved thumb con- and fabricate on the opposite hand and “flip” the
trol and grasping patterns that are developmentally splint, or look for a sibling or another similar-sized
appropriate. Also, elastomer or Adapt-It pellets can be infant on which to fabricate the splint. In the older
used as a soft base for strapping for an infant or small child the fisted hand can be a problem for function, as
child for soft control of a fisted hand or to maintain well as hygiene. The least restrictive splint is always the
the palmar arches within a splint (Figure 18-10). The better choice; however, extra strapping or including
ThumbDuction strap is a soft prefabricated strap that proximal joints may be necessary for splint security and
is available in pediatric sizes from 3-Point Products the prevention of splint distal migration.
(Figure 18-11). For younger toddlers and pre-school-aged children,
A volar wrist cock-up or ulnar gutter splint with an weight bearing on their upper extremities requires wrist
abduction thumb strap is a more rigid alternative if and finger extension. A clamshell or bivalved splint
there is spasticity in the wrist. The combination of a provides both wrist and hand control during weight-
rigid thumb “saddle” with a soft strap also helps posi- bearing activity. Splint material plays a bigger part in
tion the thumb (Figure 18-12). In older, neurologi- this splint than in others. Flexor tone and fisting can
cally involved children, thumb control is more difficult, immediately ruin a beautiful piece of soft Polyflex II by
and thermoplastic splints are not as well tolerated if turning it into a squashed-up clump of material when
they have not been initiated when the child was younger applied to a sensitive or tactilely defensive hand. A
and contractures less fixed. more rigid splint material with more memory, such as
Figure 18-10 A, Elastomer used as a splint base for a 2-month-old infant with fisted hand and thumb in palm.
Strapping is made of neoprene and is run through slits in the material. (Splint courtesy KG Staines, Hand Care of Houston.)
B, Adapt-It pellets used to form finger separation and control alignment within a resting splint.
A B
Figure 18-11 A, Fifteen-year-old child. with athetoid cerebral palsy demonstrating adducted thumb. B, ThumbDuction
strap on child to improve resting posture. C, ThumbDuction strap used to stabilize thumb carpometacarpal joint while
working on strengthening and manipulation activity.
Ezeform or Aquaplast, allows some touching of mate- Orthosis or “carrot,” may be used (Figure 18-14).
rial to itself without instant bonding. The finished There is now an inflatable version for progressive hand
splint also has fewer fingerprints and rough edges. It opening.
also may be easier to use precooled Thera-Band or Ace
wrap for a proximal “third hand” or to complete the
proximal forearm shape and then reheat only the distal
WRIST FLEXION
or hand part of the splint that will be shaped for the The wrist is considered the “key” to the hand because
hand. This is a useful splint for supervised weight- the hand is dependent on the wrist for correct place-
bearing activities. Because there is progression, the ment and stability to allow finger motion. It is crucial
dorsal part of the splint can be used alone with indi- that the wrist be controlled to allow the fingers and
vidual finger strapping, which provides tactile and thumb freedom. The optimal wrist position for finger
kinesthetic input through the palm. With spasticity in function is 25 to 30 degrees of wrist extension. To
the upper extremities and hands, the position obtained allow maximum tactile input, dorsal splinting is pre-
with the antispasticity ball or cone helps reduce tone ferred; however, pressure on a thin or bony wrist can
(Figure 18-13). In the most severe of hand contrac- become uncomfortable and cause skin breakdown.
tures, in which the goal is to prevent skin breakdown There are as many prefabricated and precut wrist splints
and maintain hygiene, the Freedom Finger Contracture as there are ideas for custom designs. If one splint
Figure 18-12 Thumb saddle splint with wrist strap used

for thumb postioning and carpometacarpal stabilization.
(Splint courtesy KG Staines, Hand Care of Houston.)
Figure 18-14 Fifteen-year-old child with variable flexor

tone, demonstrating use of the finger contracture orthosis
or “carrot” splint.
children, so learn to make a couple of types that suit

your population (Figure 18-15). Prefabricated splints
often are appropriate because they are time saving,
which results in monetary savings as well.
WRIST U LNAR DEVIATION

An ulnar gutter splint allows ulnar control and a free
palm and fingers for tactile input. As with other dorsal
wrist splints, one must prepad the ulnar styloid to pre-
vent pressure areas. This splint particularly may cause
pressure at the ulnar styloid with pronation and supina-
tion if not properly fitted. Neoprene also is effective if
the problem is mild tone or lack of tone, as with the
wrist flexion problem. Severe ulnar deviation in an
Figure 18-13 Antispasticity ball splint with both dorsal infant hinders hand-to-mouth exploration and self-
and volar forearm. (Courtesy Sammons Preston Rolyan.)
feeding. In an older child it may limit the ability to hold
a writing tool.
design does not work after careful planning, then try
another. This can be costly, but do not accept a splint
that does not fit well or perform its intended function,
WRIST RADIAL DEVIATION
no matter how long it took to make it. Neoprene also Sometimes this is a problem in young infants with
is effective if the problem is mild tone or hypotonicity. congenital anomalies. At times in radial “club” hand
In an older child with strong or fixed contractures, it is there are other problems in the forearm. Soft splinting
not only painful, but useless to try to aggressively of the infant, especially early on and during sleep, can
obtain wrist extension. More subtle measures such as help bring the wrist to neutral. With the older infant
static progressive splints or serial casting over a longer and toddler, a radially deviated wrist may not allow
period of time are better choices. weight bearing and is problematic for holding food,
In general, the wrist cock-up splint is one of the toys, and writing instruments. Infants with milder cases
most common upper extremity splints you will make on may respond well with a long thumb spica splint that
Figure 18-15 A, Wrist cock-up splint fabricated for post wrist trauma in a young girl. (Splint courtesy KG Staines, Hand
Care of Houston.) B, Prefabricated “cozy” wrist splint, with washable terry cover. The wrist support and hand rest can be
bent to fit.
is serially modified as wrist alignment improves. If

there are severe bony anomalies, then splinting is less
effective.
SUPINATION AND PRONATION

Limited supination often affects the ability to self-feed
and dress. This should be addressed early on. A soft
thumb abduction supination splint (TASS) may be
better tolerated than a traditional thermoplastic splint
(Figure 18-16). Limited pronation often affects the
ability to weight bear, write, and use a keyboard. The
thumb abduction pronation splint (TAPS) also is a
good gentle alternative.
WEIGHT BEARING ON THE U PPER Figure 18-16 Thumb abduction supination splint
demonstrated here to aid in play activity.
EXTREMITIES
Weight bearing on extended arms is a developmental
milestone one looks for at 4 to 9 months of age because 1996). This suggests that function can be affected by
it helps develop hand prehension skills. It is usually weight bearing. Similar splint designs have been
not an issue in a young infant, but becomes more discussed for wrist flexion and fisted hand problems in
important when the child begins moving and propping this chapter. (Figure 18-17).
on elbows in preparation to crawl.
A single case study on the upper extremity muscle
tone and function in a child with cerebral palsy indi-
I NDIVIDUAL FINGER CONTROL
cates that after the application of an inhibitive weight- Older children learning to point or operate environ-
bearing splint, tone changed minimally, fine motor mental controls or a keyboard may be dependent on
functional task changes were variable, and arm-hand isolated finger extension. Pointing, for key pad or
position improved. Subjective reports were given by keyboard selection, can mean a higher level of inde-
family and other caregivers; they stated that tone pendence and control. A soft neoprene splint can be
decreased and function increased (Kinghorn & Roberts, fabricated with mild tone, or the prefabricated finger
Figure 18-17 A, Four-year-old with athetoid cerebral palsy, unable to weight bear on open palm. B, Splint fabricated
to assist in supervised weight-bearing activities. Adapt-It pellets used to support the palmar arches while weight bearing.
C, Child in side sitting with weight-bearing splint on right hand.
isolation glove with computer keyboarding also is a population, and traditional therapeutic approaches may
good option (Figures 18-18 and 18-19). Thermoplastic not be adequate to prevent progressive deformity in the
splinting may be more appropriate with greater tone. hand of these critically ill infants.
Writing instrument or pointing stick grasp can be
assisted with splinting as well. For functional tasks such “Medical instability, time constraints, lack of family partici-
pation in the therapeutic program, the complexity of the
as writing or coloring, the child’s normal pattern of
treatment program, and fear of harming the infant are con-
movement must be observed carefully because a splint
siderations that may indicate the need for splinting as an
can easily limit the child rather than promote function. adjunctive therapeutic intervention. A number of factors are
particularly important in making splints for infants, including
SPLINTING FOR I NFANTS IN THE N EONATAL splint alignment and padding, strap attachment, and thermo-
I NTENSIVE CARE U NIT plastic malleability” (Anderson & Anderson, 1988).
Splinting preterm and critically ill infants in the neona- Besides progressive deformities that cannot be
tal intensive care unit (NICU) requires its own special handled solely by a hand treatment program, there are
skills compared with the full-term infant not in the five other indications for use of splinting in infants with
NICU. Hand dysfunction is seen frequently in this significant hand deformities (Anderson & Anderson,
plications will have less impact on the child. Fourth, the

treatment program may be too difficult for the family
or other staff to master. Interventions are determined
by severity and most often the more severe the injury,
the more time and mastery the intervention requires.
Sometimes clinicians are not able to teach the complex
interventions they have developed over years of practice
to family or staff, even with the use of guided practice,
pictures, and written instruction. Finally, fear can be
the limiting factor for splinting. The infant who is criti-
cally ill and on many life-supporting and -monitoring
machines is considered fragile; some family and staff
have a difficult time performing adequate therapy.
Splinting helps with positioning and adds the needed
hours of corrective intervention that the upper
Figure 18-18 Index finger isolation splint in neoprene. extremities require.
(Courtesy Benik Corp.) Static splinting or serial static splinting is likely to be
most beneficial in the NICU. Weak muscles and joints
may need protection and support to prevent further
deformity, and may only be necessary for a short term
if initiated early. The four most common splints used
by the authors include the resting hand, palmar cone,
wrist cock-up, and small finger antiabduction splints
(Anderson & Anderson, 1988). During the first 4
hours of splinting, check the skin hourly for irritation
and problems. Premature infants and sick neonates
often have diminished fat pads and are more vulnerable
to skin breakdown from pressure or force. After the
first 4 hours, initiate a wearing schedule of 4 hours on
and 1 hour off, keeping in mind that this is variable
considering the severity and type of problem, as well as
the infant’s reaction to the splint itself. Because of the
small size of an infant’s extremity, contours and fit are
Figure 18-19 Example of index finger isolation splint
designed to improve keyboard accuracy.
important. Poor alignment or edge irregularities can
produce severe problems quickly. Hand and arm exer-
cises may be performed between splinting times with
reassessment of the effectiveness of splinting to help
1988). First, the amount of time needed to perform an determine modification to the therapy program.
adequate hand treatment program may be too much When choosing splint materials, keep in mind that
for both staff and family in an NICU environment, low temperature materials that are easily remodeled are
because both the number of critical infants and the life- best. Remember that non-splint materials such as elas-
threatening nature of their condition make hand ther- tomer can be used for positioning and may be better
apy intervention lower on the priority scale in terms of tolerated. On the other hand, straps that are too thin or
time. Second, the critical, medically unstable infant will too tight can cause severe edema. Write “Not Tight”
be stressed by increased handling and movement. The directly on the straps to help prevent family and staff
infant must use the caloric input for survival and then from overtightening (Anderson & Anderson, 1988).
maturing and growing. Splinting provides positioning Covering the entire splint with a sock or stockinette
without as much handling. Third, because of possible also protects the infant from pulling off the strap or
unwillingness or inability by the family to participate in splint and helps cushion the edges of the splint.
the infant’s rehabilitation due to factors such as grief, Splinting in the NICU is challenging and rewarding.
sibling and family issues, work schedule, and sometimes Attention to the needs of the critically ill infant and
transportation issues, splinting should be initiated early. overall therapy program brings the greatest benefit to
When establishing hand positioning and function from the infant. The team of physicians, therapists, parents
the start through early intervention, these family com- and family, nurses, and other medical staff combines to
provide the best therapeutic interventions in this most for washing; the prefabricated 3-Point Products buddy
complex situation. straps are soft and conforming. It can be cut down in
width for smaller hands.
SPLINTING FOR PEDIATRIC FLEXOR TENDON SPLINTING IN C HILDREN

ORTHOPEDIC PROBLEMS Flexor tendon injuries in children are most commonly
caused by sharp laceration (more than 50% from broken
Children generally recover much faster than adults glass) and up to 25% of tendon injuries are missed
from orthopedic problems, and are less affected by the (Osterman & Paksima, 2002). Controversy exists as to
amount of time spent immobilized. However, they are the type of repair, material to be used, period and type
much more active both during the immobilization of immobilization, rehabilitation, use of tendon grafts,
phase and after; therefore they often need protection and primary versus delayed repair. Cunningham and
from their own activity level. co-workers (1985) reported on four cases in which
flexor tendon lacerations were not repaired, with sub-
sequent growth retardation of the injured fingers. They
FRACTURES postulated that the growth disturbance was related to
Many nonoperative pediatric fractures are not even an absence of the mechanical force of flexion. The
seen by therapists because the patients are doing well treatment of postoperative flexor tendon repairs in
by the time they have their cast removal follow-up with children is similar to the treatment in adults; however,
the orthopedic physician. Postoperative fractures, on there are special considerations for the pediatric
the other hand, may find their way to your clinic. population. Zone II flexor tendon repairs are the most
Percutanous pins and external fixators can be pro- complicated and controversial tendon repair for chil-
tected by splinting circumferentially with bivalved or dren because of multiple factors including the size of
“clamshell” splinting. The zipper splint is an excellent the tendons, pulley system and digital nerve involve-
“after cast” splint because it is circumferential and rigid ment, age, and compliance with rehabilitation, and
(Figure 18-20). postoperative protocols. In chapter 119 of Rehabilita-
Buddy taping or buddy strapping usually is effective tion of the Hand, the author states that the protocol for
to encourage movement in a stiff finger after immo- children younger than 8 years is cast immobilization
bilization. Taping stays on better, but parents or care- from the humerus to the fingertips with the palm and
givers should be instructed in how to apply it because fingers open for exercise (elbow at 90 degrees, wrist at
it does get dirty. Buddy straps are more easily removed 30 degrees of flexion, metacarpals at 70 to 80 degrees
of flexion, and interphalangeal joints at 0 degrees) for
4 weeks. Children older than 8 years are treated post-
operatively with the passive Duran program with
parental instruction (Osterman & Paksima, 2002). The
Duran program involves moving the joints and digits
passively each hour either with the uninjured hand or
by the parent. After 6 weeks of healing, the program
follows the adult protocol. Children more than 10
years old (depending on maturity) may be candidates
for the Kleinert protocol. This program uses rubber
band traction attached to the digits to passively pull the
digits into flexion so that the patient can actively extend
the digits up to the top of the splint on an hourly basis.
If using the traditional splinting procedures for the
Kleinert or Duran procedures, it is necessary to use a
dorsal blocking splint, which is applied from the proxi-
mal forearm to the finger tips and involves the injured
fingers, as well as at least one border digit. However, in
a child, including all the digits makes the program
more tolerable. Tendon repair rehabilitation requires a
Figure 18-20 Zipper splint used after–forearm fracture high level of competence and should not be taken
and postcast removal for support and protection. lightly. This is another area in which therapist and
surgeon benefit from working as a team to promote the

highest level of outcome possible.
J UVENILE ARTHRITIS
As with adult onset arthritis, the patient with juvenile
arthritis requires rest of inflamed joints and tissue.
Although there are many classifications of juvenile
arthritis, the joint problems and functional task prob-
lems are similar. Resting hand splints for night splinting
to rest the joints in the functional position is a good
preventive measure. Thumb carpometacarpal splints to
support the thumb are practical to prevent fatigue if the
hands are involved (Figure 18-21). Functional splints Figure 18-22 Prefabricated anti-swan neck splint.
(Courtesy North Coast Medical.)
for handwriting and computer keyboarding use also are
beneficial if the school-aged child will wear them in
front of peers. For swan neck (Figure 18-22) and
boutonnière (Figure 18-23) deformities, the same
splint design as that used in adults can be employed.
Proper alignment early on helps prevent joint contrac-
tures, which, when present, are more difficult to treat.
BRACHIAL PLEXUS I NJURY AND PERIPHERAL

N ERVE I NJURY
The treatment goals in brachial plexus injury and
peripheral nerve injury vary significantly if there has
been surgery to help balance musculature and regain
function. One of the more common procedures for
brachial plexus treatment in children is release of the Figure 18-23 Prefabricated anti-boutonnière splint.
subscapularis muscle. It may be released either at the (Courtesy North Coast Medical.)
origin at the inferior and anterior border of the scapula
(subscapular fossa) or at the insertion on the lesser
tubercle of the humerus. Releasing proximally or dis- holds the wrist and forearm in neutral. Postoperative
tally still requires the same splinting approach. The treatment protocols vary according to the surgeon’s
postoperative splint is fondly termed the “Statue of procedure, technique, and preferences.
Liberty” splint because it horizontally abducts and Peripheral nerves can be damaged in a number of
externally rotates the shoulder, flexes the elbow, and ways: (a) ischemia; (b) physical agents such as traction,
laceration, pressure, stretching, cold, and heat; (c)
infection and inflammatory processes; (d) ingestion of
drugs or metals; (e) infiltration by pressure from tumors;
and (f) the effects of systemic disease (Birch, Chir, &
Achan, 2000). Nerve damage is extremely variable.
Damage to part or an entire nerve can result from an
open or closed injury, or it may be a healthy nerve with
trauma or a more pathologic one with systemic illness.
If there has been surgery, splints are designed around
the postoperative protocols. Many times with children
with peripheral nerve injury the “wait and see” rather
than surgical exploration approach is taken if the nerve
injury is a result of compression or stretch. In the “wait
and see” period supportive splinting is recommended
Figure 18-21 Static thumb carpal-metacarpal splint to maintain flexor and extensor balance to prevent
used to stabilize thumb for strengthening activity; may be contractures. Median nerve injury is the most com-
used for handwriting activities as well. monly seen peripheral nerve injury in children resulting
from trauma (Birch et al., 2000). The radial nerve also patient education in both English (Appendix 18A) and
is often affected because of the intimate proximity to Spanish (Appendix 18B). The older child or the parents
the humerus. The case study at the end of this chapter of younger children also should demonstrate inde-
discusses the splinting approach and progress of a radial pendent donning and doffing of the splint before
nerve injury in a 4-year-old boy. leaving the clinic. Often, night splinting for positioning
may be more beneficial. Applying the splint while the
child is asleep may help to prevent resistance to
GENERAL CONSIDERATIONS IN splinting, as well as decrease mouthing and chewing on
the splint.
PEDIATRIC HAND SPLINTING
COMPLICATIONS AND PRECAUTIONS
WEARING SCHEDULE FOR PEDIATRIC SPLINTS Most complications of splinting concern vascularity and
The wearing schedules for splints depend on the diag- pressure. Symptoms of vascular insufficiency resulting
nosis and rationale for the splint. As with adult splint- from constriction or pressure include unrelieved pain,
ing, soft connective tissue responds better to low-load edema, blanching or discoloration, blistering, tingling
prolonged stress (LLPS) than high-load brief stress or numbness, no pulse, and temperature change of the
(HLBS). This has been documented time and again in skin. Pericutaneus pins and wounds are precautions
scientific papers, as well as clinical research for exercise but not contraindications for splinting. Splints and
physiology and splint-wearing time (Austin & Jacobs, straps should not put undue pressure on either pins or
2003; Gabriel, 1996; Hogan & Uditsky, 1998). Paul wounds. Careful monitoring by parents or the older
Brand was one of the first to apply this to splinting. He child is important when pins or wounds are involved.
coined the term inevitability of gradualness. Dr. Brand Not only should a splint be easy to don, but also it
was a physician and missionary who worked to make a must be difficult for the infant or young child to
difference in the quality of life of Indian children born remove. Fondly termed anti-Houdini techniques
with club feet that were never treated and were limited have evolved with the need to keep children in their
in mobility and social status by the time they became splint. Toni Thompson describes two types of Houdini
adults. In treating these infants, he allowed the child to children: Houdini Type I children remove the straps
nurse while seated in its mother’s lap as he gently and slip out of the splint; Houdini Type II children slip
pulled the foot toward normal alignment. If the infant out of the splint without removing any straps. Many of
looked up but continued sucking, that was where the the techniques may already be familiar, but they are all
foot was casted; if the baby stopped sucking and started worth mentioning (Box 18-3).
to cry, they had gone too far. This type of serial casting
was effective in remodeling soft tissue. Progress was
maximized without tearing tissue and the results of the
gentle but end-range stretching improved the outcome
SUMMARY
of many of these infants. Flowers and Michlovitz (1988)
introduced the term total end range time (TERT) In conclusion, when splinting the child, remember to
through further research in this same area of soft tissue problem solve and prioritize the problems. The goals
adaptability. TERT is the frequency multiplied by the of splinting vary and may be intended to promote
duration when at end range. This also has evolved with joint functional position or assist in holding an eating
splinting to promote low-load prolonged stress. Three or writing utensil. One must keep in mind the normal
factors play a role in deciding wearing schedules: fre- configuration and architecture of the hand whether to
quency, duration, and intensity of force. If the child prevent contractures or help restore soft tissue length
initially wears the splint 20 minutes three times a day, after an injury. A well-designed splint should provide
the TERT is 60 minutes. If the intensity of force is too the needed support or restriction without interfering
low there is no advancement in joint motion; however, with normal exploration and movement patterns.
it is necessary to allow the child and soft tissue to adapt Children who have not experienced normal movement
and accommodate to the splint and the stretch it is patterns with grasp, release, or weight bearing may gain
providing. Slowly add to the wearing time by increasing new information from their environment with the use
both the frequency and duration. It must be compat- of splints; however, sometimes the right answer is no
ible with the child’s and parents’ lifestyle and activities splint. Splinting is a science, as well as an art. Once
that are appropriate. The Appendix to this chapter mastered, splinting is a great instrument to have in your
includes a Splint Care Handout, which includes use, therapy toolbox when treating children. Enjoy the
wear, and care instructions, as well as precautions and journey.
BOX 18-3 Anti-Houdini Techniques
TYPE I: HOUDINIS WHO REMOVE THE STRAPS AND SLIP Figure 18-24, H: An additional strap can be placed over
OUT OF THE SPLINT the forearm strap that attached to itself and will only
Figure 18-24, A: Wrap self-adhesive bandage (e.g., spin around the forearm, but needs to be removed to
Coban) around the straps or entire forearm. take off other straps.
Figure 18-24, B: Wrap a 2′ length of 1/4 ″ loop Velcro Figure 18-24, I: Covering the entire splint with a tube
around the forearm and weave it under the sock or stockinette will make the straps more difficult
overlapping loops. When removal is attempted, it just to reach.
tightens.
Figure 18-24, C: Use a square metal ring or plastic TYPE II: HOUDINIS WHO SLIP OUT OF THE SPLINT
D-ring applied with sticky back Velcro to the proximal WITHOUT REMOVING ANY STRAPS
end of the splint. Run the tail end of the Velcro • Make sure borders of the splint are only one half of the
through it. When removal is attempted, the tail end forearm thickness so that straps have the top of the
will not lift up. forearm to hold onto.
Figure 18-24, D: Cut each strap 1″ longer than is needed • Increase the curve or extension at the wrist as much as
and Velcro together with sticky back hook tab that has tolerable for the goal of the splint design, as straighter
been made from doubling a piece of sticky back hook designs are easier to slip off.
on itself. • Figure 18-24, J: Fasten padding to the underside of the
Figure 18-24, E: Make holes along the border of the straps to add friction to removal of the splint.
splint and use a regular or curly shoestring to tie the • Figure 18-2: More proximal joints may be immobilized
splint on. Toddler shoestring holders can hold these for securing the splint as well, even for a short period
ties away from prying fingers and mouths. Also, the while the child gets used to having the splint on.
strap is slipped through a slot that has been placed • Mark Willey has also modified the typical thumb loop
near the edge of the splint, making strap removal splint by sewing on a click buckle clasp at the wrist.
difficult. • Figures 18-24, K, 18-25, 18-26: Do not forget the appeal
Figure 18-24, F,G: Permanently attach one end of the of the splint color or decoration. Fabricating a splint on
strap with a rivet or custom rivet using splint the child’s stuffed animal or doll can also encourage
material. positive results.
A B
Figure 18-24 A–K, Anti-Houdini splinting. (See box

18-3 for legends.)
Figure 18-24, cont’d

Figure 18-24, cont’d
Figure 18-25 Dorsal blocking splint designed to bring a Figure 18-26 Splinting can be fun and creative. (Splint
smile to a child’s face and improve wearing compliance. courtesy KG Staines, Hand Care of Houston.)
CASE STUDY
A C HILD WITH RADIAL N ERVE PALSY
Carlos is an active 4-year-old child who fell off the monkey

bars and sustained a Type III complete, displaced left
supracondylar humerus fracture. The fracture was closed
reduced and fixed with two K-wires under C-arm
guidance by an orthopedic surgeon the next day.
Progressive high radial nerve palsy was apparent when the
cast was removed at 4 weeks postoperatively. Carlos was
referred to therapy 3 months later. Initially he had no
active wrist extension and when digital extension was
attempted the unopposed long flexors created a “claw”
deformity (Figure 18-27). He was not using the extremity
to play, feed, or dress himself. The radial nerve splint was
fabricated to hold the wrist in extension and balance the
wrist and digital extensors with the strong flexors and still
allow full finger flexion and grasp, as well as sensory and Figure 18-27 Demonstrates maximum effort for
tactile input through the palm (Figure 18-28). This is a wrist and finger extension.
dorsal splint fabricated with 3/32″ Polyflex II. The finger
B
A
C
D
Figure 18-28 A, Volar view of radial nerve splint using Thera-tubing for digital support. B, Dorsal view of radial
nerve splint. C, Maximum extension effort with splint on. D, Maximum flexion effort with splint on.
A
B
Figure 18-29 A, Night splint decorated by patient. B, Night splint applied.
loops are made with a continuous loop of Thera-tubing in digits (Figure 18-30). After approximately 2 more weeks,
the light yellow strength. The holes in the splint were his mother reported that Carlos had started holding light
made with a Dremel tool with a round rotary blade. objects in his left hand for play. At the 6-week visit the
Carlos’ mother was instructed in donning and doffing the wrist extensors were at a fair grade and some clawing was
splint, as well as a daytime wearing schedule and in recog- still visible with wrist extension with effort (Figure 18-31).
nizing problems with the splint. A resting hand night At the final visit (20 weeks postoperative), Carlos was able
splint also was fabricated because his mother stated his to use his left hand and wrist with full function, and the
hand stayed “fisted” at night (Figure 18-29). radial nerve splint was discontinued (Figures 18-32 to
On his next visit approximately 2 weeks later his wrist 18-34). The night splint was advised to be worn for another
and fingers appeared more balanced, with trace muscle 2 weeks, and thereafter only if Carlos was observed fisting
activity noted in the long extensors of the left wrist and at night because of fatigue or overexertion.
Figure 18-31 After-visit demonstrating maximum

effort for wrist and finger extension. The patient
continues to improve wrist and finger control and uses
the hand for light play and activity.
Figure 18-30 Second visit demonstrates maximum
effort for wrist and finger extension, improved muscle
balance, and less clawing.
Figure 18-33 Final visit demonstrates normal control

with finger flexion and grip.
Figure 18-32 Final visit demonstrates good control

of wrist and finger extension.
Figure 18-34 Final visit demonstrates functional use of

hand for favorite activity with Yu-gi-oh cards.
Thompson T (2004). Strategies and techniques to enhance

ACKNOWLEDGMENTS wearing compliance of splints in pediatrics. Advance for
Occupational Therapy Practitioners, 17:14–15.
Special thanks to Otto, Eric, Karl, Stefan, mom and Van Straten O, Sagi A (2000). “Supersplint”: A new
dad, Gloria Gogola, Trent Carlyle, Kimberly Staines, dynamic combination splint for the burned hand. Journal
of Burn Care & Rehabilitation, 21(1):71–73.
Jean Polichino, Karen Lahvis, and the girls. Also, the
Spanish version of Appendix 18B is courtesy of A.
Galindo.
SUGGESTED READING
Barnes KJ (1986). Improving prehension skills of children
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Press J, Wiesner S (1990). Prevention: Conditioning and Clinics, 17(2):207–221.
orthotics. Hand Injuries in Sports and Performing Arts, Willey M (2004). Modification to a pediatric thumb splint.
6(3):383–392. American Journal of Hand Therapy, 17(3):379–380.
Schultz-Johnson K (2002). Static progressive splinting. Wilton J (2003). Casting, splinting, and physical and
Journal of Hand Therapy, 15(2):163–178. occupational therapy of hand deformity and dysfunction
Shah M, Lopez J, et al. (2002). Dynamic splinting of in cerebral palsy. Hand Clinics, 19:573–584.
forearm rotational contracture after distal radius fracture. Wu S (1991). A belly gutter splint for proximal
Journal of Hand Surgery, 27A:456–463. interphalangeal joint flexion contracture. American
Sheridan R, Baryza M, Pessina M, et al. (1999). Acute hand Journal of Occupational Therapy, 45(9):839–843.
burns in children: Management and long-term outcome
based on a 10-year experience with 698 injured hands.
Annals of Surgery, 229(4):558–556.
Appendix 18A
SPLINT INSTRUCTIONS
Name________________________________________________ Date__________________
Splint type_______________________ Goal of splint______________________
CARE OF YOUR SPLINT

1. Your splint is fabricated from heat-sensitive material.
a. Heat will melt your splint.
b. Do not leave your splint in or near a heat source.
c. Do not leave your splint in your car or truck.
2. Cleaning:
a. Clean with lukewarm water and soap unless padded.
b. Rubbing alcohol removes most ink and newsprint.
3. Cleaning the stockinette and straps:
a. Wash by hand or in a mesh bag in the machine.
b. Let them air dry. Do not put in dryer.
c. Trim ends of stockinette when they fray.
CARE OF YOUR SKIN
1. Stockinette is to help reduce irritation from the plastic, as well as to reduce the sweatiness underneath the splint. A tube
sock with the toe-end cutoff makes a good substitute.
2. Corn starch or light powder is recommended for excessive perspiration.
3. 20-Minute rule: If your skin remains red for more than 20 minutes after removing the splint it indicates too much
pressure from the splint. Please notify your therapist to schedule splint modification.
4. Problems with your splint that require immediate adjustment. Significant swelling, color, or temperature change, skin
irritation, increase in tingling, or numbness.
WEARING SCHEDULE
____ As needed for ADL, sports, leisure, or work activity
____ Day time _______times per day for _______minutes; increase to _____________
____ Night only
____ Full time except hygiene
____ Do not remove
The above instructions have been explained to me and I understand the use, wear, care, and precautions about my splint.
______________________________ ____________________________
Patient or Parent (if under 18) Therapist
429
Appendix 18B
CUIDADO DE LA FÉRULA
Nombre ______________________ Dato ________________ Férula ______________________
Las siguientes instrucciones se deben de aplicar para el cuidado y limpieza de su férula.

LIMPIEZA
1. Plástico (férula)
a. Limpie la férula con una toalla o esponja usando agua fria y jabón.
b. Limpie la férula con alcohol para quitar tinta o manchas de periódico.
c. Para manchas más difíciles use un detergente, por ejemplo, Lysol. Enjuague la férula muy bien antes de ponérsela
porque los químicos pueden irritar la piel.
2. Cintas de Velcro
a. Las cintas de Velcro se pueden lavar a mano o en la lavadora.
3. Telas
a. Lave a mano o remoje en jabón de lavar.
b. También se pueden poner dentro una funda o bolsa de lavandería y lavar en la lavadora.
EVITE CALOR
1. La férula esta fabricada de un material que reacciona a lo caliente. Demasiado calor puede cambiar la forma o deretir la
férula.
a. No deje la férula cerca de objetos calientes.
b. No deje la férula cerca de una ventana donde le pueda dar el sol.
c. No deje la férula en un carro (automóvil) especialmente durante los meses de verano.
CUIDADO DE LA PIEL
1. Debe de usar la tela para comodidad y protección contra irritación de la férula (plástico).
2. En caso de mucho sudor, use harina de maíz (maizena) para mantener la piel seca. Pongase la harina de maíz
directamente en la mano o brazo antes de ponerse la tela. También la puede poner la maizena directamente en la férula.
3. Observe la piel para sitios (partes) rojos al quitarse la férula. Sitios (partes) rojos que no se desaparecen en 15–20
minutos indican puntos de presión. Debe de llamar y hacer una cita con la terapista para que le modifiquen la férula.
Si tiene algún problema o alguna pregunta acerca de la férula, favor de llamar a su terapista.
_____ Duracion (uso) ____________________________________________________

_____ Dia ______________________________________________________________
_____ Noche ____________________________________________________________
_____ Tiempo completo excepto al banarse ____________________________________
Firma _____________________________________ Terapista _______________________________________
430
Appendix 18C
LIST OF VENDORS
1. Alimed Inc. 5. North Coast Medical

297 High Street 18305 Sutter Boulevard
Dedham, MA 02026-9135 Morgan Hill, CA 95037-2845
(800) 225-2610 (800) 821-9319
www.alimed.com www.ncmedical.com
2. Benik Corporation 6. Sammons Preston Rolyan

11871 Silverdale Way NW #107 4 Sammons Court
Silverdale, WA 98383 Bolingbrook, IL 60440-4995
(800) 442-8910 (800) 323-5547
www.benik.com www.sammonsprestonrolyan.com
3. DeRoyal/LMB 7. 3-Point Products

200 DeBusk Lane 1610 Pincay Court
Powell, TN 37849 Annapolis, MD 21401
(800) 541-3992 (888) 378-7763
www.deroyal.com www.3pointproducts.com
4. Joe Cool Company

9448 Lady Dove Lane
South Jordan, UT 84095
(800) 233-3556
www.joecoolco.com
431
Chapter 19
EFFICACY OF INTERVENTIONS TO
ENHANCE HAND FUNCTION
Jane Case-Smith
CHAPTER OUTLINE LEVELS OF RESEARCH EVIDENCE

LEVELS OF RESEARCH EVIDENCE The studies described in this chapter are categorized
CHILDREN WITH CEREBRAL PALSY according to their level of research evidence to assist
the reader in interpreting the importance of the find-
Weight Bearing on Hands ings. Phillips and co-workers (1998) have categorized
Neurodevelopmental Treatment research designs into five levels of research evidence
Casting and Splinting (Table 19-1). These categories have been adopted by
professional organizations that have synthesized research
Constraint-Induced Movement Therapy reports into summaries of research evidence (Butler &
Surgical and Medical Intervention Darrah, 2001; Law, 2002). The levels of research evi-
CHILDREN WITH DEVELOPMENTAL COORDINATION dence define the confidence that professionals can place
DISORDER OR MILD DISABILITIES in a study’s findings to be valid or true. Randomized
clinical trials (RCTs) are categorized as Level I research
Cognitive Orientation to Daily Occupational evidence and have high rigor and validity. When a Level
Performance I study produces positive effects, it provides strong
Occupational Therapy Approaches with Preschool evidence that an intervention is effective. Randomization
Children increases the probability that samples are equal at the
INTERVENTIONS TO IMPROVE HANDWRITING beginning of the trial, and therefore, provide confidence
that if the samples differ after intervention, change is
Instructional Approaches related to the intervention. RCTs also use “blinding”
Occupational Therapy Approaches when testing, which means that both the researchers
SUMMARY and the subjects are “blind” as to whether the subject
is in the experimental or the control group. Blinding is
not always possible in OT intervention, because, of
necessity, the subjects know that they are in the experi-
Occupational therapists have assumed leadership roles mental group.
in developing interventions to enhance children’s fine In Level II research, an experimental group is com-
motor skills. As leaders in the development of practice pared with a control or comparison group, but a con-
models and strategies to improve hand function, occu- venience sample rather than randomized sample is
pational therapists also have researched the effective- used. As a result, it cannot be assumed that the samples
ness of these interventions on children’s function. This are equal and the results can be influenced by initial
chapter describes occupational therapy (OT) and other differences in the samples. One way to improve non-
discipline research that has examined hand function randomized sampling is to use matched samples, ensuring
intervention outcomes and synthesizes current knowl- that the groups are equivalent for certain character-
edge on the effectiveness of these interventions. istics. Small samples may be more equivalent if matched
433
Table 19-1 Levels of research evidence
Level of Research Evidence Types of Research Design
I Randomized controlled trials

Randomized crossover designs
True experimental design
II Nonrandomized controlled trial

Prospective cohort study with control group
Quasi-experimental designs.
May include single subject when multiple baseline and
ABABA (alternating intervention and baseline)
III Cohort study with historical control group

Single subject ABA design
IV Before and after case series without control group

Descriptive case series or case reports
Pre-experimental designs.
V Expert opinion
Theories based on basic science. Adapted from Butler and Darrah (2001), Law (2002), and Phillips and co-workers (1998).
rather than randomized. Level II studies provide fair The first section of this chapter describes inter-
confidence in the validity of the findings, particularly if ventions for children with cerebral palsy (CP) who had
the sample size is large. moderate to severe hand function limitations. The
Level III studies refer to cohort studies that com- second section describes interventions for children with
pare existing patient groups who do or do not receive developmental coordination disorder and milder hand
the intervention. It also includes single subject designs function limitations. The third section describes
in which subjects are tested during baseline, interven- research of handwriting interventions. A summary dis-
tion and return to baseline or when subjects receive a cusses issues in research of hand skill interventions and
series of alternating interventions and are repeatedly future directions for research.
measured during the treatment phases. An important
aspect of these studies is that the subjects are evaluated
on a repeated basis for an extended time frame and they
serve as their own control (are measured when not
CHILDREN WITH
receiving intervention). Level III studies also include CEREBRAL PALSY
case control studies in which subjects are matched by
their outcomes. This type of study was not included in CP is a nonprogressive posture and movement disorder
the review of hand function interventions. that results from a brain lesion around the time of
Level IV studies are case series studies in which only birth. CP is a common disorder (2 in 1000) (Behrman,
one group (cohort) of subjects, all of whom receive Kleigman, & Jenson, 2000), and its clinical picture
the intervention, are assessed. A control or comparison varies greatly. Lifelong medical and functional prob-
group is not used. This level includes case studies. lems are associated with cerebral palsy and are well
These studies provide weak evidence, and minimal described in Chapter 16. Most individuals with CP
confidence in the findings. Level V research evidence have problems in hand function, characterized by weak-
refers to expert opinion, and is associated with low ness, spasticity, incomplete isolation of finger move-
confidence in the results. Level V evidence is not ments, and sensory impairments (Duff & Gordon,
discussed in this chapter. 2003). Bly (1983) explained that in children with CP,
Efficacy of Interventions to Enhance Hand Function • 435
movements often are primitive, asymmetric, and stereo- evidence) and a nonstandardized measure that required
typical patterns of flexion and extension. These move- some judgment as to what was observed. In a study
ment problems create functional performance difficulties similar to Barnes, Chakerian and Larson (1993) inves-
across most life skills. A number of intervention meth- tigated the effects of upper extremity weight-bearing
ods have been applied to remediate the motor problems on hand opening and prehension patterns. A 10-week
associated with CP (Table 19-2). Several approaches design with baseline, 2 to 5 weeks of treatment, and a
(e.g., neurodevelopmental treatment [NDT]) were period of no treatment (Level III evidence) was used
developed specifically for children and adults with CP. with 10 children with spastic cerebral palsy. The treat-
Other approaches (e.g., constraint-induced therapy) ment consisted of upper extremity weight bearing
were developed for other impairments and have been activities. Treatment effects were measured through
applied to the problem of CP. The research of inter- analyzing components of reach, grasp, and release
ventions to manage and improve function in children using videotapes of the children’s performance. In
with CP is equivocal and has not produced consensus addition, the weight-bearing surface of the hand was
on best practice. This section reviews studies of weight measured by tracing around the hand and calculating
bearing on hands, neurodevelopmental treatment, and the area of weight-bearing surface. Developmental level
constraint-induced movement therapy designed to of grasp and release were measured using a method
improve hand function in children with CP. It also similar to Barnes (1989a,b).
reviews studies on splinting and casting of the upper Hand surface area increased significantly from base-
extremity and specific medical and surgical approaches line to intervention, indicating more complete weight
used to improve arm and hand function. bearing and greater extension of elbow, wrist, and fin-
gers. Grasp and release improved overall but improve-
ments week to week were not significant. Reach did not
WEIGHT BEARING ON HANDS improve with weight bearing; no difference was found
Weight bearing on hands in individuals with CP is in the path of the hand toward the object (reach was
believed to improve hypertonicity and active range of not more direct or in active supination). They did
motion. Barnes (1989a,b) implemented two multiple- observe increased elbow, wrist, and finger extension,
baseline single subject design studies to examine the similar to the findings of Barnes.
effect of weight bearing on extended arms to the In 1996, Kinghorn and Roberts used a single sub-
development of prehension skills. Each study inves- ject design to investigate the effects of weight bearing
tigated three children with spastic CP who participated on decreasing upper extremity spasticity in a 20-
in weight-bearing exercises. In the first study, Barnes month-old boy. They theorized that weight bearing on
(1989a) implemented 8 weeks (about 19 to 20 ses- hands decreases spasticity by inhibiting motor neuron
sions) of weight-bearing intervention with three boys excitability and stretching connective tissues. They
(ages 4 to 6 years). Components of grasp, release, and were directly interested in increasing the hand’s
reach were measured during baseline and intervention. weight-bearing surface as evidence of increased range
These components were based on Erhardt’s hand of motion (ROM) and decreased finger flexor spas-
development assessment. All three boys made signifi- ticity. Kinghorn and Roberts designed a weight-bearing
cant improvement, although not always in both arms. splint similar to that of Smelt (1989), who reported
In the detailed analysis of graphed data, extensor move- a case study of a 17-month-old boy with left spastic
ments (i.e., release) appeared to improve more than hemiparesis using an inhibitive weight-bearing splint.
grasp for subject 1. In a second study, Barnes (1989b) This splint allows contact of maximal palmar surface
replicated these findings. Her second study also used when fingers have flexion contractures. Kinghorn and
three boys with spastic CP, who were slightly older (5 Roberts used an ABA design over 24 weeks, eight
years 9 months to 7 years 5 months). Using a multiple baseline, eight weight-bearing, and eight second base-
baseline design, intervention comprised four sessions of line. The hand weight-bearing area did not change with
weight-bearing activities per week for about 10 weeks. the treatment, arm position changed slightly, and func-
After the intervention, two subjects demonstrated clear tional activities did not improve. These results contra-
improvement in prehension and one did not. A sug- dicted Smelt, who found improvement in ROM,
gested reason for the lack of improvement in one boy weight-bearing surface of the hand, and function.
was difficulty in implementing the procedure because In summary, Level III and IV studies with small
of bilateral elbow contractures. samples have been used to examine the effects of
These studies demonstrated the positive effects of weight bearing on hands. The hypothesized effect of
weight bearing on hands. Limitations of the studies weight-bearing activities is decreased hypertonicity,
included use of AB single subject design (Level IV increased tendon length, improved ROM, and by exten-
Table 19-2 Research studies examining the efficacy of interventions to enhance hand
function in children with cerebral palsy (1985–2005)
Level of
Authors Evidence Sample Intervention Measures Findings
Barnes (1989a) Level IV N=3 Weight bearing on Erhardt’s Visual analysis.

AB single spastic cerebral extended arms; 19–20 assessment of Prehension
subject palsy (CP) sessions prehension skills improved
4–6 years in two subjects.
Barnes (1989b) Level IV N=3 Weight bearing on Erhardt’s Visual analysis;

AB single spastic CP extended arms; assessment of two of three
subject 5.9–7.5 years 4 sessions/wk for 10 wk prehension improved
Chakerian & Larson Level III N = 10, Upper extremity weight- Videotape of Hand surface
(1993) ABA cohort spastic CP bearing; 10 weeks with reach, grasp, increased.
design 2- to 5-week treatment release. Hand Reach did not
weight-bearing improve. Grasp
surface area and release
improved.
Kinghorn & Roberts Level IV N = 1, spastic Use of a weight-bearing Hand weight- Hand surface
(1996) ABA single quadriplegia splint; 8 wk baseline, bearing surface area and play
subject CP 8 wk treatment, 8 wk area; arms activities did
baseline position; two not improve.
play activities Arm position
did improve.
Lilly & Powell Level IV N=2 Alternating play and Analysis of No difference
(1990) ABAB spastic diplegia neurodevelopmental dressing in between play
27, 32 months treatment (NDT); shirt, socks, and NDT
12 wk, six sessions of jackets effects
NDT and six of play
DeGangi (1994) Level IV N = 3, one Individualized NDT For child with Substantial
case study spastic diplegia, techniques, 2/wk for hemiparesis: gains in all
one spastic 8 wks Posture, use of skill areas
quadriplegia, right hand,
one hemiparesis and bilateral
and visual
motor skills
Fetters & Kluzik Level III N = 8, spastic NDT for 35 minutes Upper Changes were
(1996) multiple quadriplegia for 5 days and practice extremity not significant
crossover 10–15 years for 5 days. movement for NDT
using kinematic alone; were
analysis significant for
treatments
combined.
Table 19-2 Research studies examining the efficacy of interventions to enhance hand
function in children with cerebral palsy (1985–2005)—cont’d
Level of
Law et al. (1991) Level I 79 children Intensive and regular PDMS-FM PDMS: not
randomized with spastic NDT with casting, QUEST significant;
clinical trial CP intensive and regular ROM of wrist QUEST, more
NDT alone for 6 improved for
months children who
wore casts
Law et al. (1997) Level I N = 50 spastic Intensive NDT with PDMS-FM No difference
crossover CP, with casting and regular QUEST among
with moderate- occupational therapy; treatment
washout severe UE 4 mo, 2 mo washout, types
impairment, 4 mo
18 months–
4 years
Cruickshank & Level IV N = 1, spastic Plaster cast, then Range of ROM

O’Neill (1990) case study quadriparesis, fiberglass cast with motion increased with
11 years splint (ROM) plaster cast
and decreased
with fiberglass
cast.
Copley, Watson- Level IV N = 11, Plaster cast for 4–6 ROM, muscle ROM
Will, & Dent cohort study, hemiplegic and weeks, followed by tone, progress increased and
(1996) pre- and post- quadriplegic post casting program on goals muscle tone
measures CP, 5–18 years decreased
immediately
after casting.
At 6-month
follow-up;
ROM
maintained;
some hand
function goals
achieved.
Tona & Schneck Level IV N = 1; CP, Plaster cast applied; Functional Reduced
(1993) ABA age = 8 years study for 11 days, cast activities; spasticity
worn for 48 hours modified immediately,
Ashworth but not long
Scale; resistive term.
movement
Goodman & Bazyk Level IV N = 1. Child wore a short ROM, grip ROM,
(1991) single moderate opponens splint, strength, dexterity,
subject spastic 6 h/day for 4 weeks dexterity, and quality of
AB quadriparesis, prehension movement
age = 4 years patterns improved;
strength did
not.
Continued
Level of
Reid & Level II N = 10, Children wore a hand Quality of No significant

Sochaniwskyj alternative children with position splint movement in differences
(1992). treatments CP with upper reaching, with or
extremity movement without the
involvement latency, time, splint
average
velocity, and
movement
units
Crocker, MacKay- Level III N = 2, Constraint-induced Analysis of play Use of involved

Lyons, & ABA hemiparesis; (CI) therapy, wore a session for hand doubled.
McDonnell (1997) ages = 2 and splint for 3 weeks, how often Improvements
3 years 2 weeks before and children used in grasp,
after were baseline, involved hand release, and
with 6-month follow-up sensory
exploration
were significant.
Charles, Lavinder, Level IV N = 3, CI therapy, wore a Manual Hand function

& Gordon (2001) AB design hemiparesis CP sling 6 h/day for dexterity, improved in
14 days strength 2 or 3 children;
sensory sensory
discrimination, discrimination
bilateral improved in all;
coordination coordination
of force
improved in 1.
DeLuca, Echols, Level IV N = 1, CI therapy, wore a PDMS-FM, All scores

Ramey, & Taub case study hemiparesis bivalved cast for 2 weeks DDST, improved
(2003) CP, age = Pediatric significantly
15 mo Motor Activity and used
Log, Toddler involved arm
Arm Use Test 100% in free
play.
Pierce, Daly, Level IV N = 1, CI therapy, plus Wolf Motor Scores

Gallagher, case study hemiparesis 62-hour sessions of Function Test, improved for
Gershkoff, & CP, age = OT/PT Assessment of the Wolf
Schaumburg (2002) 12 years Motor and Motor
Process Skill Function Test,
(AMPS); AMPS, and
8-month increased use
follow-up of involved
arm by self-
report.
Level of
Willis, Morello, Level I N = 25, CI therapy, cast was PDMS-FM, PDMS-FM

Davie, Rice, & randomized hemiparesis worn for 1 month, parent report improved
Bennett (2002) clinical trial; CP, ages = measured at 6 months, significantly,
crossover 1–8 years then crossover more in CI
design group than
control group;
21 of 22
parents
reported
improvement
at follow-up
Taub, Ramey, Level I N = 18, CI therapy; children Pediatric Large gains

DeLuca, & Echols randomized hemiparesis wore bivalved casts and motor activity with CI
(2004) clinical trial CP, ages = received 6 hours of level (PMAL) therapy, TAUT
7 mo to 8 yrs therapy for 21 days or Toddler Arm and PMAL
conventional therapy. Use Test improved
(TAUT) significantly.
Gains were
maintained at
3- and 6-
months
follow-up.
Dudgeon, Libby, Level IV N = 29, Selective dorsal Pediatric Children with

McLaughlin, Hays, pre- and spastic CP rhizotomy with Evaluation of diplegia
Bjornson, & post- postoperative physical Disability improved in
Roberts (1994) intervention and occupational Inventory functional
with therapy (PEDI); mobility and
follow-up reach and self-care on
coordination, the PEDI. Did
6- and 12- not improve in
month reach and
follow-up coordination.
Loewen, Steinbok, Level IV, N = 37, Selective dorsal Quality of Significant

Holsti, & MacKay pre- and spastic CP; rhizotomy Upper gains on both
(1998) post-surgery age mean = Extremity scales
with 4.1 yrs Skills Test
follow-up (QUEST),
WeeFIM, 1
year after
surgery
Mittal, Farmer, Level IV N = 57, 41 at Selective dorsal PEDI Self-care and

Al-Atassi, et al. pre- and 3 years, and rhizotomy mobility
(2002a) post-surgery 30 at 5 years, increased
with 3 and spastic CP, significantly
5 year 3–5 years at 3 and
follow-up maintained at
5 years.
Continued
Level of
Mittal, Farmer, Level IV N = 70 at Selective dorsal PDMS-FM Significant

Al-Atassi, et al. pre- and post-op, 45 rhizotomy gains at 3 years,
(2002b) post-surgery at 3 years and maintained at
with 25 at 5 years; 5 years
follow-up spastic CP, 3
to 7.4 years at
the time of
surgery
Albright, Gilmartin, Level IV 68 children Intrathecal baclofen Ashworth Spasticity

Swift, Krach, prospective with spastic scales for decreased
Ivanhoe, & case series CP, 73% were spasticity significantly
McLaughlin (2003) study with younger than and remained
no control, 16 years decreased for
3-month up to 10 years.
follow-up to
70 months
Wallen, O’flaherty, Level IV 16 children Botulinum toxin Canadian Improved on

& Waugh (2004) prospective with spastic (BOTOX) Occupational COPM, no
case series CP Performance change on the
study with Measure assessment of
no control, (COPM), limb function
3- and Goal or Child
6-month Attainment Health
follow-up Scale, Questionnaire,
Assessment of reduction of
limb function, muscle tone
Child Health that returned
Questionnaire, to baseline at
parent 6 months. No
questionnaire, change in
Modified ROM.
Ashworth
Scale, ROM
sion, increased hand function. The evidence suggests experimental designs (Level I); however, the majority
that hypertonicity is decreased with weight bearing, have used quasi-experimental and pre-experimental
allowing for improved active elbow, wrist, and finger designs (Levels II to IV) with small samples of conve-
extension. In addition, the Barnes studies show improve- nience. In 2001, an extensive review of NDT efficacy
ments in hand function. These findings have limited research sponsored by the American Academy for
validity and should be confirmed by more rigorous Cerebral Palsy and Developmental Medicine was pub-
study. lished in Developmental Medicine and Child Neurology.
In this comprehensive review, Butler and Darrah
(2001) synthesized the results of 21 studies. They
N EURODEVELOPMENTAL TREATMENT concluded that 86 of 101 results (from 21 studies)
The effectiveness of NDT has been researched for the were neutral or found an advantage for the comparison
past 30 years. A number of these studies have used true group; only 15 results favored NDT.
“With the exception of immediate improvement in dynamic DeGangi (1994) implemented a case study design
range of motion, there was not consistent evidence that NDT (level IV) to examine the short-term effects of NDT.
changed abnormal motoric responses, slowed or prevented DeGangi was interested in the specific effects of NDT
contractures or facilitated more normal motor development or
and argued that measuring the immediate effects was
functional motor activities” (Butler & Darrah, 2001, p. 789).
an important step before large clinical trials. She
believed that single subject designs were appropriate
A historic perspective of NDT research that included and useful for examining NDT effects because individ-
hand function outcomes is helpful in understanding the ual children vary in their performance and their limita-
effects of this approach. tions. DeGangi (1994) provided a detailed description
Two early studies, Carlsen (1975) and Scherzer, of the goals and the techniques used to reach those
Mike, and Ilson (1976) found positive results when goals. Successful performance on each goal as observed
effects of NDT were compared with a contrasting by the parent and the therapist was counted across
therapy. Carlsen reported greater gross motor improve- observations. Of the three cases documented, one
ments in the NDT group, but fine motor improvement focused on fine motor performance in a 6-year-old
did not differ when NDT was compared with func- child with right hemiparesis (the other cases focused on
tional therapy. Scherzer and co-workers reported other domains, such as feeding). The goals included
improvement in physiologic function, but fine motor use of right hand as an assist to stabilize objects or
skills were not specifically measured. Studies in the materials, improve visual motor skills, and bilateral
1980s examined gross motor and social outcomes of skills such as buttoning, zipping, and stringing beads.
NDT with children with CP. These studies included After 8 weeks of twice-a-week hour-long NDT ses-
several clinical trials that did not support the benefits of sions, the child’s performance improved but remained
NDT (Hanzlik, 1989; Palmer et al., 1988). inconsistent.
In another study that examined the short term
Small Sample Studies and Short-Term Effects effects of NDT, Fetters and Kluzik (1996) compared
A number of small sample or single subject studies have the effects of NDT with practice of reaching on eight
examined the short-term effects of NDT. Because the children with spastic CP. Each child received 5 days
aims of NDT are to influence the child’s muscle tone of NDT and 5 days of practice. Kinematic analysis of
and improve the quality of movement, short-term reach was used before and after each intervention to
effects should be observed immediately after treatment. measure smoothness and speed of reaching move-
One OT study by DeGangi, Hurley, and Linscheid ments. Although there were no difference between
(1983) examined the short-term effects of NDT using NDT and practice of reaching, when intervention time
a single subject design with four subjects. Each child periods were combined and pre- and post-differences
received eight treatments consisting of 25 minutes of analyzed, all children improved in reaching speed and
NDT and 25 minutes of nonspecific play. The chil- smoothness.
dren’s performance on specific goals was measured These short-term small sample studies do not
from videotapes made immediately after NDT or play. support positive effects of NDT when compared with
The repeated measures included postural tone, weight other interventions; that is, they found that NDT did
shift and weight bearing, transition movements, and not result in greater positive effects than play or skill
functional skills. Consistent improvement after NDT or practice. However, these Level III to IV studies should
play was not observed for any of the children. Although not be considered conclusive; primarily, small sample
this study validated use of qualitative measures of trials develop instrumentation and methodologies for
movements, it did not validate the short-term effects larger-scale studies.
of NDT.
Lilly and Powell (1990) studied the effects of NDT Clinical Trials of Neurodevelopmental Treatment
using two children with spastic diplegia, 27 and 32 In the past 20 years, clinical trials have investigated the
months old. These authors applied play and NDT, effects of OT using an NDT approach on hand function
alternating the two interventions (Level III study). To outcomes. Two studies by Law and colleagues researched
relate intervention effects to function, Lilly and Powell the effects of NDT OT and casting on children with
measured components of dressing performance. Among CP. The first study (Law et al., 1991) used a 2 × 2
the measures was bilateral hand use. Performance did factorial design that examined the effectiveness of
not differ after play or NDT. The authors noted that intensive NDT and casting separately and combined.
their results concurred with those of DeGangi and The sample comprised 79 children (73 completed the
colleagues (1993) in that neither study showed sig- study; 18 months to 8 years) from three treatment
nificant differences between the effects of NDT and centers in Ontario, Canada. All children had CP that
those of play activity on functional activity. included spasticity of wrist and hand. Children with
fixed contractures or severe developmental disability therapy group attended intervention sessions according
were excluded. to the design frequency. Intensive therapy may not be
The intervention period was 6 months. Children practical for many families. The inclusion of casting
either received “intensive” NDT OT, defined as twice appears to be critical as only children who wore casts
a week (90 total sessions) with a 30-minute-per-day demonstrated improved quality of movement.
home program or they received “regular” NDT occu- Law and colleagues (1997) completed a second
pational therapy, defined as once a week (sometimes study with similar goals. A primary difference was that
less) with a 15-minute home program to be imple- the sample was younger (18 months to 4 years). Other
mented three times a week. Children who received than age, the criteria for the sample were the same. All
casting wore a bivalved inhibitive cast at least 4 hours a of the subjects had moderate to severe upper extremity
day. The cast immobilized the wrist in extension and involvement with wrists held in a flexed position. The
did not include thumb or fingers. Details about the children did not have significant cognitive impairments
treatment were not provided. The measures included as judged by their therapists. The final sample com-
the Peabody Developmental Motor Scales-Fine Motor prised 50 children who were randomized into two
(PDMS-FM), the Quality of Upper Extremity Skills groups. A crossover design was used, with each group
Test (QUEST), and range of motion of the wrist. receiving a period of intensive NDT with casting and a
The children were randomized into one of four period of regular or functional OT with no casting. The
groups: Intensive NDT plus casting, regular NDT plus children were placed into one intervention for 4
casting, intensive NDT, and regular NDT without cast- months followed by a 2-month washout period, then
ing. Measures were taken at 6 months to capture imme- were placed in the other intervention for 4 months. In
diate effects and 9 months to examine the long-term the intensive therapy plus casting, the therapists used
effects. Although the design called for 48 NDT sessions NDT principles of facilitation and handling to improve
for the intensive NDT group, the mean number of quality of movement. The casts were the same as in the
sessions was 29, which was almost three times higher previous study. The functional OT program focused on
than the 11 sessions the regular NDT group received. task analysis and facilitating skills needed for self-care,
Hand function as assessed by the PDMS-FM did not feeding, and play. NDT was provided twice a week
differ significantly among the groups at the 6- or 9- for 45-minute sessions with a 30-minute daily home
month measure. However, using age equivalent scores program and functional OT was provided once a week
on the PDMS-FM, changes for all of the groups for 45 minutes. Outcomes were measured using the
appeared to be clinically significant (5.26 months at the PDMS-FM and the QUEST.
6-month measure and 6.33 months at the 9-month Law and others (1997) maintained detailed records
measure). The qualitative measure of arm and hand of therapist adherence to the treatment protocol,
movements, the QUEST, was significantly different for child’s attendance, and parents’ report of implement-
the children who wore casts with NDT when compared ing the home program. The goals for therapy using
with those who received NDT only. This difference was NDT were based on changing impairments and
more significant at 6 months (p = 0.03) than at 9 improving quality of movement. The goals for func-
months (p = 0.10). tional OT were more global and functional and included
In a follow-up regression analysis, Law and co- improvement in self-care and play skills. Analysis of
workers (1991) found that positive outcomes related to their findings demonstrated no differences in PDMS-
parents’ estimate of their understanding, comfort, and FM scores when children received intensive NDT and
compliance with the home program and the age of the casting versus when they received functional occupa-
child. Children who were younger and whose parents tional therapy. In addition, QUEST scores did not
estimated compliance as high had better outcomes. differ by treatment as they had in the earlier study.
This finding suggests that, when possible, therapists When differences between pre- and post-tests on the
should initiate therapy at young ages and encourage PDMS-FM and QUEST for each group were exam-
parents’ participation in home programs. These ined, they were found to be both statistically and
researchers concluded that casting with regular NDT clinically significant.
significantly improves the quality of upper extremity This study suggests that therapy designed to improve
movements. These effects are only partially sustained functional goals is as effective as therapy designed to
over time. improve quality of movement. How children achieve
Differences in the intensity of intervention did not the goal may not be as important as the goal achieve-
produce clinically or statistically significant differences ment itself. In functional occupational therapy, the
in performance. One consideration in interpreting therapist does not work to enhance motor components
these results is that not all children in the intensive (e.g., a missing motor skill such as thumb opposition or
active supination), unless it interferes with skill per- preted the latter negative findings to relate to problems
formance. These critical foundational motor patterns in stretching spastic muscles over three joints, to using
(e.g., object release or active supination) are addressed fiberglass, which is more pliable than plaster (therefore,
in a functional context (e.g., drinking from a glass). allowing some motion), or to lack of natural warmth in
NDT emphasizes quality of movement and facilitating fiberglass compared with plaster.
normal patterns of movement; however, movements The effects of wearing a cast for 48 hours on quality
are practiced in the context of functional activities. of movement, ROM, and strength in an 8-year-old
Therefore, NDT and functional therapy may use the child were examined in a study by Tona and Schneck
same activity with different emphases and different (1993). The child’s performance was videotaped before
goals. This core similarity may produce similar out- and after the cast was applied. Their findings demon-
comes. In summary, functional OT and intensive NDT strated a significant reduction in spasticity on the first
both facilitated improved skills, and twice-a-week NDT day that the cast was removed. However, in subsequent
did not result in greater skill achievement than once-a- days, spasticity returned to baseline levels. The authors
week functional treatment. concluded that casting does appear to inhibit spasticity
(as measured by passive resistance) when only applied
for 2 days. Because the significant effects did not
CASTING AND SPLINTING endure, the authors recommended that longer use of
Upper Extremity Casting casting be considered. For example, a bivalved cast can
Occupational therapists using NDT often advocate be applied at night and periodically during the day.
methods for inhibiting abnormal muscle tone and In an Australian study, the effects of upper extremity
abnormal movement patterns. These inhibitory meth- casting were studied using a sample of 11 children with
ods (e.g., positioning, casting, and splinting) are cou- hemiparesis or quadriparesis CP, 5 to 18 years old
pled with handling to facilitate specific movement (Copley, Watson-Will, & Dent, 1996). The children
patterns. They are sometimes applied to maintain inter- were casted 4 to 6 weeks and immediately after casting,
vention effects such as increased ROM. Use of casting ROM increased and muscle tone decreased. An
and splinting as an adjunct to NDT has been examined. intensive post-casting program was then implemented.
Casting an extremity is believed to inhibit spasticity and Six months post-casting, nine clients had maintained at
improve ROM because it holds the muscle in a least 50% of initial gains in passive or active range. Tone
lengthened state. The inhibition is believed to be the reduction was maintained in seven clients, and func-
result of neutral warmth and constant pressure. Case tional goals were either fully or partially achieved by 10
studies (Smith & Harris, 2002; Yasukawa, 1990) in clients (Copley et al., 1996).
which upper-extremity casting is applied for a short In summary, in these Level IV studies, casting the
period of time (e.g., weeks) have reported improved arm appears to reduce spasticity and improve ROM for
ROM and function. Smith and Harris applied a a short period. Long-term effects have not yet been
bivalved inhibitive elbow cast to a 51/2-year-old with determined through research. Long term, regular use
spastic quadriparesis. They found that casting reduced of a bivalved cast may be needed to sustain the effects.
his elbow spasticity, increased facility in dressing, and Reduction of spasticity does not necessarily imply
increased the child’s tolerance for weight bearing. improved function, as the arm may remain weak or
Yasukawa used a sequence of three phases of casting coordination may remain poor despite improved ROM.
with a 15-month-old infant who had spastic hemi- Functional outcomes, which were rarely measured in
paresis. In the first phase, the involved arm was serial- the studies described, should become an emphasis in
casted for 4 weeks to improve ROM; then in a second future studies of casting effects.
phase, the uninvolved arm was casted to encourage
active usage of the involved arm. In a third phase, a Splinting
bivalved cast was used at night. These casting methods Splints have been designed to reduce hypertonicity
were applied over 11/2 years and resulted in increased and improve function in children with CP. Exner and
scapular stability, increased shoulder flexion, and Bonder (1983) evaluated three different splints on a
improved use of the involved arm during bilateral tasks. group of 12 children using a counterbalanced research
Cruickshank and O’Neill (1990) applied two types design. Each of the splints had significant positive
of casts and splints to an older child (11 years) with effects. The orthokinetic and MacKinnon splints demon-
spastic quadriparesis (Level IV study). When a plaster strated a greater effect than the short opponens; how-
cast was applied, elbow ROM improved. When a fiber- ever, the former are rarely used in practice today.
glass cast combined with a plastic hand splint was Although the short opponens was less effective in
applied, elbow ROM decreased. The authors inter- improving grasping skill, at present it is commonly
applied on children with CP. The short opponens splint involved extremity and fails, he or she learns ways to
holds the thumb in opposition to the fingers and may function using the uninvolved extremity and learns to
be made of neoprene or thermoplastic materials. compensate using only one hand. With nonuse, the
Reasons for its frequent use may relate to its appear- ability of the involved extremity to move becomes per-
ance, ease of use and comfort. manently impaired and the sensorimotor cortex asso-
The effectiveness of the short opponens splint was ciated with arm and hand movement actually shrinks.
evaluated by Goodman and Bazyk (1991) using a 4- In CI therapy, use of the nonaffected extremity is
year-old child with moderate spastic quadriparesis. The restrained such that the individual is forced to use the
volar splint of thermoplastic materials positioned the more affected extremity to accomplish functional tasks.
thumb in opposition by supporting it at the thenar Researchers have defined how constraint-induced
eminence. Measures included active range of motion, movement therapy, which was developed for adults, has
grip strength, and pinch strength, dexterity, and pre- been modified and used successfully with children
hension patterns. A 4-week baseline phase was followed (Gordon, Charles, & Wolf, 2005). The approach involves
by a 4-week intervention phase in which the child wore restraint of the noninvolved extremity using a sling,
the splint for 3 hours in the morning and 3 hours in sometimes a cast, and engaging the child in activities
the evening. Using visual analysis of graphed data, with his or her involved arm 6 hours a day (for 10 or
improvements were reported in ROM, dexterity, and more days). Generally groups of 2 to 3 children partici-
quality of movement. Changes in strength were not pate in therapist-led activities. Toys and activities are
observed. Reid and Sochaniwskyj (1992) examined the selected that can be successfully completed with the
effects of a hand positioning splint on arm and hand involved hand. The activities are graded from simple to
movements using a sample of 10 children with CP more complex and can include board games, card
(Level II study). Analysis in three dimensions of reach- games, manipulatives, puzzles, arts and crafts; each
ing path length, movement latency, movement time, elected to encourage repetition of hand movements
average velocity, and movement units recorded no and skill building (Gordon et al, 2005). Families are
significant differences when the splint was or was not encouraged to engage the child in bimanual fine motor
worn. Although group differences were not significant, activities at home (without the sling).
a number of the children demonstrated improved The original evidence for the effectiveness of CI
performance on a visual motor test when wearing the therapy was based on nonhuman primate research.
splint. After positive results with primates, it was then used
The research on splints and casts is inconclusive with adults who had hemiparesis as a result of a cerebral
given inconsistent results and weak research designs vascular accident (Taub et al., 1993) and was first
(primarily Level IV). Despite lack of rigorous studies, introduced for potential use with children in 1995
Teplicky, Law, and Russell (2002) concluded from a when Taub and Crago suggested that children may
review of the research on splinting and casting, that benefit from this intervention. A series of case studies
casting consistently increases ROM. Whether or not and single subject designs were implemented in the late
the increased ROM equates to improved function is 1990s and early 2000s to investigate the effect of CI
less clear. The effects of splinting are equivocal, with therapy with children, and since 2003, two experi-
limited evidence that splinting improves hand function. mental studies have been published.
In cerebral palsy, function is affected by limited
strength, abnormal muscle tone, impaired sensation, Case Studies-Single Subject Designs
difficulty in coordinating movements together, and in Crocker, MacKay-Lyons, and McDonnell (1997)
some children, limited cognitive ability. Intervention applied a single subject design (ABA) (Level III) to
targeting one impairment may or may not improve investigate the efficacy of CI therapy (which they termed
function given that multiple systems contribute to func- forced use therapy) with two children with hemiparesis.
tional performance (including sensory and cognitive). They specifically selected children who used their
To confirm the effects of casting and splinting, large involved arm as an assist and did not have major
sample experimental design studies are needed. sensory deficits. The children who participated were 2
and 3 years old. They continued their regular once a
week occupational and physical therapy during the 7-
CONSTRAINT-I NDUCED MOVEMENT THERAPY week study. After a 2-week baseline period, the less
The theory for constraint-induced (CI) movement involved arm was fitted with a custom resting splint
therapy is built on the concept of learned nonuse. that was worn most of the waking hours for 3 weeks.
Learned nonuse is hypothesized to occur after neuro- Measures were taken 2 weeks after CI therapy and 6
logic injury (DeLuca et al., 2003). After a neurologic months later. One of the children did not comply with
insult, when an individual attempts to move the wearing the splint; therefore, results for only one child
were reported. Specific movement patterns were counted improved. The participant used her more affected
during a 15-minute play session. In addition, the extremity in 100% of free choice trials. In summary, this
parents kept logs of how often the involved hand was child changed from no spontaneous use of her affected
used in a finger feeding task. The results were graphed arm and hand to regular and spontaneous use after the
for analysis. Significant improvements were found in second intervention. The authors suggest that short,
the use of the more involved hand for grasp and release, intensive periods of intervention should be considered
sensory exploration, and push-pull. When all involved as an effective method for improving function.
hand movements were combined, they more than
doubled from baseline to 2 weeks after CI therapy. This Clinical Trials
level of hand use was sustained at a 6-month follow-up Two randomized clinical trials of CI therapy have been
assessment. completed. Willis and others (2002) implemented a
Charles, Lavinder, and Gordon (2001) researched study using 25 children with hemiparesis. A crossover
the effect of CI therapy on three school-aged children design was used. A plaster cast was applied to the
with hemiparesis. Each wore a cotton sling on the less unaffected arm of the treatment group and was not
affected arm, whereas the researchers encouraged use removed for 1 month. The control group received no
of the affected arm through play and functional activ- treatment. Fine motor skills of both groups were meas-
ities 6 hours a day. After 14 days of CI therapy, the ured using the PDMS-FM before and after interven-
three children demonstrated improved performance in tion. At 6 months after the first intervention the
manual dexterity, sensory discrimination, and bilateral control group (N = 10) received the intervention and
coordination. the group previously casted served as a control. For the
Two additional case studies of children using CI first intervention period, changes in PDMS-FM scores
therapy have been reported (DeLuca et al., 2003; were significantly different, with gains by the inter-
Pierce et al., 2002). DeLuca and co-workers reported a vention group much higher than gains by the control
case study of a 15-month-old girl who had incurred a group. These changes were sustained when measured
grade IV intraventricular hemorrhage and exhibited 6 months later. The second group (who began CI
right hemiparesis. For a 2-week period, the girl wore a therapy at 6 months) also made significant gains with
full arm bivalved cast on her unaffected arm except for intervention. Parents globally reported improved use of
an occasional removal for cleaning and ranging. A the affected arm. Several children did not tolerate the
6-hour intervention was implemented daily by a grad- casts and the parents asked that they be removed.
uate student. In addition, the child received 4 hours Taub and co-workers (2004) also completed a
of physical therapy each week. During the 6 hours of randomized trial (Level I) using 18 children. The CI
intervention, the child was encouraged to move her therapy involved two components. The children in
affected arm and was reinforced with praise. Measures the intervention group were casted and the cast was
given at the beginning and end of intervention bivalved for easy removal weekly. The intervention
included the PDMS-FM, a test of pediatric motor group also received 6 hours of therapy each day, imple-
activity level (PMAL), and a Toddler Arm Use Test mented by occupational and physical therapists. Fine
(TAUT). The PMAL is a semistructured interview motor and daily living skills were shaped using thera-
administered every other day to the child’s primary peutic principles. The two measures, PMAL and
caregiver. It obtains systematic data about 22 arm– TAUT, were reported earlier in the description of a case
hand functional activities. The TAUT is scored from a study by these same authors.
videotape. Specific movements of the affected hand are The children who were casted improved significantly
counted in 22 tasks/play activities. The PDMS-FM on the parent interview (rating both the amount of use
scores improved significantly. The parents reported that and quality of use) and also improved significantly on
the child’s use of the involved arm improved from the TAUT. Follow-up evaluation (using the PMAL)
“poor quality of use” to “moderate quality of use.” indicated that the gains were sustained over time. Taub
Before intervention the child did not use her more and colleagues (2004) concluded that the CI therapy
affected arm on any of the free choice tasks; after intervention produced “large improvement in the use
intervention, she used the more affected arm sponta- of the more affected extremity.” The children gained
neously in 50% of the tasks. 9.3 new motor behaviors in a 3-week therapy period. A
A second intervention was implemented 5 months critical therapeutic factor appears to be the concen-
after the first. The second period was carried out for 21 trated extended nature of training conducted for many
days and included 6 hours of intervention each day. hours daily over consecutive weeks. The authors discuss
The focus of intervention was refinement of hand the feasibility of concentrated doses of therapy. Because
movement to improve performance in play and func- 6 hours of therapy each day is not reimbursed, not
tional activities. Scores on the PMAL and TAUT again practical for busy families, and not feasible for certain
children, research studies using less intensive therapy follow-up period. This sample of 29 children was
schedules are needed. evaluated at 6 and 12 months after SPR. Self-care as
In summary, virtually all of the studies of CI therapy, measured by the Pediatric Evaluation of Disability
including two Level I studies, demonstrate its effec- Inventory (PEDI) improved in the children with
tiveness in promoting hand function in children with spastic diplegia, but not in the children with quadri-
hemiparesis. This therapy requires “forced,” intense paresis. In the latter population, upper extremity
practice of the involved extremity in various functional function did not consistently improve.
tasks. Most of the children appear to tolerate the Fine motor outcomes of SPR on children with
casting or splinting procedures; the primary limitation spastic CP were the focus of a Canadian study by Mittal
appears to be in applying the intensive therapy schedule and co-workers (2002a). These researchers examined
of 4 to 6 hours per day. Such a schedule is difficult for the long-term effects of SPR using the PDMS-FM
families and therapists alike, but may be feasible to before and after surgery, and then 1, 3, and 5 years after
implement on a short-term basis. surgery. In a second study, these researchers (Mittal et
al., 2002b) reported findings using the PEDI at these
same time frames. After surgery, the children received
SURGICAL AND M EDICAL I NTERVENTIONS occupational and physical therapy. OT was provided
A number of surgical and medical procedures are once a week and focused on trunk control, positioning,
applied to decrease spasticity and improve function in fine motor and self-care skills. The final sample com-
children with CP. Almost universally, these medical prised 45 of 70 eligible patients (41 in the second
procedures are followed by occupational and physical study). After SPR, the children demonstrated statisti-
therapy services (Dudgeon et al., 1994; Mittal et al., cally and clinically significant gains on both the PDMS
2002a). Although most often these procedures are and the PEDI that were maintained at 3 and 5 years.
used to reduce lower extremity spasticity, they are When the children were categorized according to the
sometimes used to reduce upper extremity spasticity. severity of their disability, more mildly involved chil-
The effects of selective posterior rhizotomy, intrathecal dren made greater gains. Self-care scores improved at 1
baclofen, and botulinum toxin on functional hand skills and 3 years, then stabilized between 3 and 5 years.
in children with CP have been investigated using Therefore, Mittal and co-workers’ (2002a,b) results
cohort research designs (Level IV). support those of Loewen and colleagues (1998) that
important improvements in self-care are derived from
Selective Posterior Rhizotomy SPR, and children with milder disability make greater
This surgical procedure was originally designed to gains after surgery. In contrast to Dudgeon and co-
reduce lower extremity spasticity in children with CP or workers (1994) fine motor skill also improved after
head injury. However, surgeons discovered that selec- SPR. Steinbok (2001) reviewed published outcomes of
tive posterior rhizotomy (SPR) can have “suprasegmental SDR for treatment of spastic CP. He concluded that
effect” (i.e., change above the segmental spinal cord given moderate level evidence confirms significant
level of the cut nerve roots that affects upper extremity improvements in self-care and fine motor skills that
spasticity and function). Several studies have measured appear to be sustained over time.
the effects of SPR on upper extremity and self-function
(Dudgeon et al., 1994; Loewen et al., 1998; Mittal et Intrathecal Baclofen and Botulinum Toxin
al., 2002a,b). All of these studies are Level IV cohort In a descriptive report, Von Koch and others (2001)
studies without a comparison group. Loewen and compared SPR results to those obtained using intrathe-
others (1998) measured the effects of SPR on 37 chil- cal baclofen. Intrathecal baclofen has a similar purpose
dren (mean age = 4.1 years) in the United Kingdom. to SPR (i.e., to reduce spasticity). Instead of cutting
The children were assessed using the QUEST and the selective spinal nerves, baclofen is a synthetic gamma
Functional Independence Measure for Children aminobutyric acid (GABA) that reduces excitatory
(WeeFIM) before their surgery and 1 year after surgery. synaptic transmission. This action on the spinal cord
During this year, the children continued to receive relieves spasticity. Intrathecal baclofen is administered
their regular OT services. The mean improvement on using a permanent pump that is implanted into a sub-
the QUEST was 3.2 (P = 0.001) and on the WeeFIM cutaneous pocket in the anterior abdominal wall.
was 11 (P = 0.001). These gains were clinically Although intrathecal baclofen is used most often to
significant according to the parents who validated them reduce spasticity of the lower extremities, it can be used
in interviews. Dudgeon and co-workers (1994) also to reduce spasticity of the upper extremities. Albright
analyzed changes in self-care of children with spastic and co-workers (2003) examined the effects of intrathe-
diplegia and quadriplegia after SPR. All children cal baclofen on 49 children. Spasticity was measured
received physical and occupational therapy during the every 3 months for 2 years using the Ashworth scales.
The reduction in spasticity was significant and was

maintained for up to 10 years without significant CHILDREN WITH
increase in baclofen. Functional measures were not
used in this study and inclusion of OT as an adjunct to
DEVELOPMENTAL COORDINATION
baclofen was not reported. DISORDER OR MILD DISABILITIES
Botulinum toxin (BOTOX) also has been used to
reduce spasticity in children with CP. BOTOX is injected Children with developmental coordination disorders
in muscles and produces a graded and reversible (DCDs) or dyspraxia form another group of children
relaxation of overactive muscles by blocking the release who typically have delays in hand function and who
of the neuromuscular transmitter acetylcholine. These frequently receive OT services. Unlike children with
treatments have evolved over time and at present CP who have difficulty with basic movements such as
higher doses are given and more muscles are injected. grasp and release, children with DCD generally have
BOTOX has been shown to reduce spasticity for 3 to 4 functional movement patterns but have difficulty with
months. It is injected into specific muscles and only visual motor integration, bilateral coordination, rapid
works on those muscles. Neurosurgeons have indicated alternating movements, sequences of movement, and
that occupational and physical therapy after SPR is of precise manipulation. This section describes efficacy
critical importance to achieve functional change, since studies of children who have basic hand skills (i.e.,
movements are less restricted now because of reduced reach, grasp, release) but demonstrate difficulties inte-
spasticity (Gaebler-Spira & Revivo, 2003). BOTOX grating fine movements with sensory information to
treatment is repeatable if it is successful. Wallen, perform the higher levels of visual motor skills, manip-
O’flaherty, and Waugh (2004) examined the functional ulation, and bilateral coordination (Table 19-3). In
outcomes of BOTOX with a focus on upper extremity children with DCD (this term encompasses dyspraxia
movement. A convenience sample of 16 children with for purpose of this chapter), daily living skills, such as
CP (2 to 12 years old) were assessed at 2 weeks and 3 fastening buttons and zippers, tying shoelaces, and
and 6 months after injections. During this period handwriting are difficult to learn, may require excessive
regular OT was continued. In addition, electrical stim- time to perform, or may be poorly performed. A variety
ulation of specific muscles was applied. The measures of approaches have been used with children who have
included functional performance (Canadian Occupa- DCD including cognitive orientation to daily occupa-
tional Performance Measure), goal attainment scales, tional performance, sensorimotor interventions, and
an assessment of upper extremity function, ROM, and practice of functional activities. This section describes
a muscle tone scale. The children demonstrated sig- efficacy studies of OT approaches to DCD in which
nificant improvement in functional performance and on hand function outcomes are a primary focus. Sensory
their goals; however, upper extremity function and integration practice models are not described here, as
ROM did not improve. Muscle tone was initially reviews of sensory integration efficacy have been pub-
reduced but returned to its original state by 6 months. lished elsewhere (Mulligan, 2003; Parham & Mailloux,
This study suggests that BOTOX can improve func- 2005; Vargas & Camilli, 1999) and generally the aim of
tional skills, but may not improve upper extremity sensory integration treatment is to enhance integration
movement as measured by a qualitative assessment. of foundational perceptual-motor functions (e.g.,
SPR, intrathecal baclofen, and BOTOX effectively motor planning, visual perception, bilateral integration,
reduce spasticity using different physiological mecha- and sequencing).
nisms. SPR results in a permanent change; in contrast,
the effects of intrathecal baclofen and BOTOX fade COGNITIVE ORIENTATION TO DAILY
over time and these medications must be readminis-
tered to continue to receive a benefit. Each treatment
OCCUPATIONAL PERFORMANCE
has been shown to improve upper extremity function The originators of Cognitive Orientation to Daily
and by extension to improve self-care. In the reviewed Occupational Performance (CO-OP) recognized that
studies, children received occupational and physical cognition is important to the acquisition of occupa-
therapy after the medical procedures. These rehabili- tional skills (Polatajko et al., 2001). In CO-OP, thera-
tation services appear to be instrumental in helping pists assist children in developing cognitive strategies to
children make functional gains once muscle tone is improve their daily living skills. In contrast to many
reduced and flexibility increased. However, few studies other OT approaches that emphasize sensorimotor
have reported hand function improvement and more activities and practice to gain skills, CO-OP uses a
substantial evidence is needed to support these treat- verbal approach to help children solve problems. The
ments and to recommend them with confidence as a focus is to help the child learn to problem solve a motor
method for improving a child’s hand function. task and learn strategies for accomplishing a motor task
function in children with developmental coordination disorders
Level of
Polatajko, Mandich, Level IV N = 13, Children were Functional Achieved 9 of 10

Miller & Macnab pre- and children with taught verbal goals; goals. VMI and
(2001) post- developmental self-guidance and Developmental TOMI were not
measures coordination to set goals Test of Visual statistically
with disorder Motor different.
intervention, Integration
no control (VMI),
Test of Motor
Impairment
(TOMI)
Miller, Polatajko, Level I N = 29, Cognitive COPM, COPM improved

Missiuna, Mandich, randomized developmental Orientation to Performance for both groups,
& Macnab (2001) clinical trial coordination Daily Occupational quality, but more for the
disorder. Age Performance Vineland CO-OP group.
mean = 9 yrs (CO-OP) for 10 Adaptive CO-OP also
sessions or Behavior Scales improved more in
“regular” (VABS), performance
OT approaches Bruininks- quality, and VABS
(control) for 10 Oseretsky Test Motor. Both
sessions. of Motor groups improved
Proficiency on the BOTMP
(BOTMP), and VMI.
Visual Motor
Integration
(VMI)
that can be generalized to other activities. In CO-OP, reported a Level IV study of one aspect of CO-OP,
the child selects goals that he or she would like to Verbal Self-Guidance. Ten children participated in 13
accomplish. The child’s performance is assessed and the one-on-one sessions in which they were taught to use
therapist determines what problems interfere with task verbal self-guidance to accomplish specific activities.
achievement (e.g., the child may have difficulty with The children were taught to develop goals and strate-
motivation, task knowledge, or performance). Then gies to achieve specific activities. Most activities
the therapist and child together develop a plan or strat- involved multiple steps of sequenced bilateral manip-
egy for accomplishing the task. Children are encour- ulation (e.g., making cookies, cutting, writing, key-
aged to talk their way through an activity. A number of boarding). In addition, specific motor skills were assessed
facilitating strategies can be introduced, including using the Developmental Test of Visual Motor
altering body position, focusing on sensory aspects of Integration (VMI) and the Test of Motor Impairment
the task, and attending to specific parts of the task. The (TOMI). All of the children improved in the activities
child learns to self-evaluate so he or she can adapt the that they had targeted and 9 of 10 met the performance
strategy or revise it when applying it again. The goal is criteria established. Small changes in motor skills as
that the child learns a strategy that results in success measured by the VMI and the TOMI were not statis-
and that he or she can use independently in another tically significant. The effect size for the VMI was small
situation. (d = 0.16) and for the TOMI was moderate (d = 0.62).
The efficacy of CO-OP has been investigated in Given positive results from their pilot studies, Miller
small sample studies. Polatajko and others (2001) and co-workers (2001) completed a randomized clini-
cal trial of CO-OP (Level I). Twenty children with teaching the child specific skills. The 12 children (3 to
DCD, aged 7 to 12 years, were randomly assigned to 6 years old) who participated had mild motor problems
one of two groups, CO-OP or regular therapy. The such as DCD, motor delays, and sensory processing
children had normal intelligence and the diagnosis of disorders. Children with CP, major sensory impair-
DCD as determined by an occupational therapist. In ments, severe medical problems, or severe cognitive
the 10 sessions of CO-OP, the children and therapist delays were excluded. A crossover design was used,
established goals and developed strategies to reach such that 6 children received child-centered activity
those goals. The therapists taught the children to use and six received structured sensorimotor therapy for 8
self-talk and to develop strategies to solve motor weeks. They were assessed, and then the treatments
problems. Verbalization by both the child and the were reversed for 8 additional weeks.
therapist was used to guide performance. The contrast Changes in hand function were measured using the
group received regular therapy in which the therapist PDMS-FM age equivalent scores. After the child-cen-
instructed the child, and provided skills direction and tered therapy, children gained 6 months in fine motor
corrective instruction. The children who received CO- skills compared with 1.8 months gain during structured
OP made significantly greater gains on the Vineland sensorimotor therapy. These differences appear to be
Adaptive Behavior Scale in the motor and daily living clinically significant, but did not reach statistical sig-
skills domains. The CO-OP group also improved more nificance. The Degangi and co-workers’ (1993) and
in upper extremity coordination as measured by the Miller and associates’ (2001) studies support the impor-
Bruininks-Oseretsky Test of Motor Proficiency tance of involving higher-level children in establishing
(BOTMP) (p = 0.05) and in the visual motor integra- the goals and leading the activity and the critical nature
tion as measured by the VMI (p = 0.065). (These posi- of involving the child in problem solving the task.
tive findings were maintained when follow-up measures Engaging the child’s cognitive abilities by encouraging
were made 9 to 10 months afterward.) Replication of discovery and problem solving (rather than simply fol-
these positive results with CO-OP appears to require lowing directions) seems to be important in the devel-
children who have normal range cognitive skills and can opment of fine motor skills. As stated by DeGangi and
use cognitive strategies to problem solve ways to co-workers (1993), fine motor skills depend on
improve performance (Miller et al., 2001). By using
self-talk, the children may internalize strategies that “motivation and drive to seek and explore objects in the
help them succeed in other similar tasks. It is not clear environment. The process of experimenting with tools and
what aspect of CO-OP leads to its success—the child’s learning the function of objects through creative play may be key
own development of a plan and strategy, learning to use components underlying hand function” (pp. 781–782).
self-talk to guide his or her performance, or the process
of the child discovering strategies that solve a The importance of play in therapy to children’s
performance problem. improvement in fine motor skills was also supported
by Case-Smith (2000). In this Level IV study, 44
preschool children were evaluated before and after 8
OCCUPATIONAL THERAPY APPROACHES WITH months of intervention. The focus of the intervention
and the measurement was fine motor function. The
PRESCHOOL C HILDREN participants had delays in fine motor skills but no
Child-centered approaches have been used in inter- specific diagnoses (e.g., CP, autism, mental retardation,
ventions with preschool children. Preschool OT inter- brain injury) and did not have severe sensory loss or
ventions tend to emphasize play occupations and social health problems. In-hand manipulation, eye–hand
interactions, in addition to focusing on development of coordination, visual motor integration, and fine motor
hand functions (Table 19-4). DeGangi and colleagues skills were measured. Functional skills using the PEDI
(1993) focused on these outcomes in a Level II study also were evaluated. After the 9 months of occupational
that compared child-centered therapy to structured therapy, the participants made significant gains in all
sensorimotor therapy. The child-centered therapy fine motor measures. The number of therapy sessions
emphasized the interaction between the therapist and and the types of activities that the occupational thera-
the child and focused on the child’s interests. The child pist implemented were recorded for each session. The
was allowed to explore and play with the therapist’s number of sessions and percentage of therapy activities
guidance. The goal was to promote exploration, cre- were used as predictors of the primary outcome vari-
ativity, and organization and interaction skills. Struc- ables. The two therapy activities that predicted the
tured sensorimotor therapy involved the therapist outcomes were use of play and peer interaction. These
giving the child specific instructions and directions and findings suggest that the therapist’s use of play and peer
function in preschool children with sensorimotor delays
Level of
DeGangi, Level II N = 12, Child-centered PDMS-FM Gain in fine motor

Wietlisbach, crossover developmental therapy sensory skills was higher
Goodin, & Scheiner using a delays, not emphasizing integrative for child-centered
(1993) sample of severe interaction and functioning, therapy; gain in
convenience disability; age structured behavior, sensory integrative
= 36–71 sensorimotor attention, play skills was higher
months therapy for 8 for structured
weeks with sensorimotor
crossover therapy; gross
motor skills
improved more
with structured
sensorimotor
therapy; no
definitive findings
for behavior,
attention, and play
Case-Smith (2000) Level IV N = 44, mild Occupational In-hand Improvements in

pre- and delays; ages therapy manipulation; all assessments;
post- = 4–6 years, emphasizing fine eye–hand interventions
intervention mean N = 57 motor function coordination using play and
measures of mo Visual social activities
one group perception were most
(DTVP); associated with
PDMS-FM visual motor and
visual motor fine motor gains
(DTVP);
function (PEDI)
Dankert, Davies, Level II N = 43, 12 Occupational (VMI) Children with

& Gavin (2003) quasi- with disabilities therapy for two Visual delays who
experiment; who received of three groups, Perception received
sample of OT, 16 typical 30 minutes of Motor occupational
convenience children in one-on-one and Coordination therapy improved
OT, and 15 30 minutes of in visual motor
typical children; group integration and
age = 3–6 years; intervention for visual perception,
mean = 53 children with but did not
months delays improve in motor
coordination more
than children
without disabilities.
interaction are important to achieving performance child’s attention, motivate the child to achieve higher
goals. This study supports the findings of DeGangi and skills, or infuse emotions into certain activities, encour-
colleagues (1993) and Miller and co-workers (2001) aging the child to repeat and remember them.
that incorporating play and social elements into therapy In another study examining the effect of OT on hand
session promotes children’s fine motor skills and hand skills of preschool children with mild delays, Dankert
function. Play and social interaction may engage the and co-workers (2003) used a quasi-experimental
design (Level II). Three groups were compared, chil-

dren with delays who received OT, children without
INTERVENTIONS TO IMPROVE
delays who received OT, and children without delays HANDWRITING
who served as a control group. The researchers posited
that visual motor skills are essential to school functions Handwriting is an important school and life function.
such as handwriting; therefore an OT focus on visual When handwriting is poor, the child may be penalized
motor skills at the preschool age could serve as a with poor grades on school work and written assign-
preventive measure for future problems with hand- ments. When handwriting is illegible, school achieve-
writing. The researchers’ hypothesis was that 1 year of ment and self-esteem can be negatively affected
preschool OT services would promote gains in the (Graham, Harris, & Fink, 2000; Jones & Christensen,
visual motor skills of children with fine motor delays 1999). Individual differences in handwriting skills and
that would be comparable to gains made by children handwriting fluency predict how much and how well
without disabilities. Similar to the Case-Smith (2000) children compose and express ideas in writing (Graham
study, regular OT services were provided (once a week et al., 2000; Jones & Christensen, 1999). The pro-
for 30 minutes) for 9 months. This level of service is duction of written text requires the coordination of
minimal when compared with other studies but is multiple skills. Visual motor integration appears to be
comparable to typical levels of school-based OT serv- a fundamental prerequisite (Cornhill & Case-Smith,
ices. Children in all three groups made significant 1996; Tseng & Murray, 1994). Manipulation and
improvements from the beginning to the end of the motor skills are also highly related to handwriting skills
year on the VMI test. The children who received OT (Cornhill & Case-Smith, 1996; Graham & Weintraub,
intervention gained 7 standard points on the VMI 1996). Given its importance to children’s success in
compared with a 1-point gain by the group without school, a number of handwriting instructional approaches
disabilities; however, this difference was not statistically and interventions have been developed (see Chapters
significant. 14 and 15). Handwriting interventions vary in their
This study demonstrated positive effects of OT serv- theoretic model and the specific techniques and activ-
ices on visual motor skills development in preschool- ities applied. In general, efficacy studies of handwriting
age children when measured over time, and these gains interventions have demonstrated significant effects.
were comparable to the progress made by children This section reviews the experimental studies that have
without disabilities (who did not receive OT). Effect examined the effects of educational and therapeutic
sizes for the children who received OT were higher, interventions designed to improve handwriting skills
and the standard scores for the children with OT (Table 19-5).
services increased substantially more than they did in
the test standardization sample or the other groups in
the study.
I NSTRUCTIONAL APPROACHES
Evidence from Case-Smith (2000) and Dankert Instructional approaches often follow behavioral prin-
et al. (2003) supports the effectiveness of OT services ciples, providing structure for learning, instructing
in improving children’s visual motor skills. Limitations children in practice of skills, and then providing feed-
of these studies include lack of control and limited back and reinforcement about the child’s performance.
description of the intervention and lack of fidelity Generally, these approaches involve guided practice.
checks of the intervention. It was difficult to discern Learning principles are followed but instruction gen-
the theoretic models that guided the therapists in erally does not consider individual differences among
selecting and implementing intervention activities. children. Berninger and co-workers (1997) implemented
Examining the effects of 9 months of intervention a comprehensive study of handwriting interventions
allows change to occur; however, long intervention based on different instructional methods. A random-
periods also allow extraneous variables to interfere with ized experimental design was used with a sample of
the results, decreasing validity. 144 first-grade children who were identified as being
Studies of OT as it is typically implemented with at risk in handwriting. Five distinct instruction-based
preschool children appear to effectively improve hand interventions were implemented. The first was motoric
skills. When quasi-experimental studies are examined, imitation in which the teachers modeled motoric acts
hand skill outcomes of OT services are positive. These but were nonverbal. In the second instructional
studies have significant limitations in that samples of approach visual cues were provided using numbered
convenience were used, fidelity measures of interven- arrows to cue the sequence of strokes. The third
tion sessions were missing, and outcome measures instructional approach involved memory retrieval; the
infrequently included children’s occupations. Future children were required to cover letters and write them
research should address these limitations. from memory. The fourth instructional approach
Table 19-5 Research studies examining the efficacy of interventions to enhance handwriting
in school-age children
Level of
Hayes (1982) Level I N = 45, in Five instructional Letter form The most effective
randomized kindergarten conditions: reproduction instructional
clinical trial and N = 45 in copying with no method was visual
third grade, prompting, visual and verbal
typical children demonstration demonstration
with copying, with the child
visual and verbal verbalizing. The
demonstration least effective
with the child method (other
verbalizing during than control) was
copying, control; copying only.
one single 25-
minute session
Blandford & Lloyd Level IV N = 2, learning Self-instruction Mean number The students
(1987) ABC single disabilities; procedures. of words wrote more and
subject ages = 10.6 Students used card written; quality the quality of their
and 11.4 to guide their of handwriting handwriting
handwriting and improved
to self-evaluate.
In the final phase,
the students did
not use the card
but were
instructed to
self-cue.
Berninger, Abbott, Level I N = 144, first- Instructional Handwriting All intervention

Vaughan, et al. randomized grade children approaches: motor legibility, resulted in
(1997) experimental at risk for imitation, visual automaticity, improvement in
design, handwriting cuing, memory dictation measures except
five-group problems retrieval, visual accuracy, automaticity.
comparison cuing and writing fluency, Visual cuing with
memory retrieval, and finger memory retrieval
copying without function was the most
cuing, control effective
group; 24 intervention.
20-minute
sessions were
provided
Jongmans, Level II N = 36 Motor learning Handwriting Handwriting

Linthorst-Bakker, quasi- children in principles are quality quality was
Westenberg, & experimental special taught; Self- significantly
Smits-Engelsman in which education, instruction and higher in children
(2003) controls 18 in each self-reflection on who received the
and group; mean handwriting instructional
intervention age = 9 yrs approach.
groups were
matched
Table 19-5 Research studies examining the efficacy of interventions to enhance handwriting
in school-age children—cont’d
Level of
Case-Smith (2002) Level II N = 38, 29 Occupational Visual motor Children who

quasi- who received therapy, 9 hours control; visual received
experimental occupational of direct services perception; intervention
therapy and 9 over 9 months in-hand improved more in
who did not; manipulation; in-hand
all with poor Evaluation Tool manipulation,
handwriting, of Children’s visual motor
third, fourth, Handwriting control, and letter
and fifth grades (ETCH) legibility. They did
not improve more
in handwriting
speed.
Peterson & Nelson Level I N = 59, Intervention Minnesota Children in

(2003) randomized children with group received Handwriting intervention
clinical trial economic occupational Test (MHT) scored higher on
disadvantages; therapy 2/wk for the MHT; specific
second grade; 10 wks. Control gains were in
mean age = group did not spacing, alignment,
7.1 yrs receive treatment. and correct size.
Speed did not
improve.
Sudsawad, Level I N = 45 One group Kinesthetic Scores on the

Trombly, randomized children with received acuity; ETCH did not
Henderson, & experimental kinesthetic kinesthetic kinesthetic change. Kinesthetic
Tickle-Degnen design with deficits and training; one perception and perception
(2002) three groups handwriting received memory; the improved for all
difficulties, first handwriting ETCH groups, but was
grade; 15 in practice; one not significantly
each of the received no more improved in
three groups treatment. any one group.
Treatment was The teachers
30 min/day for reported
6 days. significant changes
in handwriting for
all three groups.
combined visual cues and memory retrieval. The fifth sessions held twice a week. Measures included hand-
approach involved copying without any cueing from writing legibility, handwriting automaticity, dictation
the teachers. In each instructional method, the letter accuracy, writing fluency, and finger function. The
was named twice on each teaching trial. In the control interventions produced significant improvement in all
condition, children received phonologic awareness handwriting assessments except the automaticity tasks
training with no practice of writing. The researchers and quality of one writing task. Visual cuing with
predicted that children’s performance after interven- memory retrieval was the most effective intervention
tion would vary with each of the different approaches across measures. Composition fluency improved in
and that visual cueing and memory retrieval would addition to handwriting legibility and improvements in
achieve the greatest handwriting automaticity. The handwriting skills appeared to have a positive effect on
interventions were implemented over 24 20-minute children’s ability to compose written text.
Jones and Christensen (1999) also found that with groups, as well as individuals. A larger study of
handwriting instruction can improve both handwriting self-instruction was implemented in 2003 in the
and story writing (composition). This Level II Netherlands. Jongmans and others (2003) researched
Australian study involved 19 6- and 7-year-olds who the effects of a task-oriented intervention with self-
demonstrated difficulty in handwriting speed and instruction on handwriting quality and speed in chil-
accuracy. A matched group of children without diffi- dren with significant handwriting problems. These
culties served as a control group. An 8-week inter- researchers completed two studies, one with 14 stu-
vention (10 minutes per day) consisted of instruction in dents in regular education (7 with poor handwriting
letter formation with practice. The pre- and post- [mean age = 7.9 years] and 7 with typical handwriting
assessments included writing speed and accuracy, hand- [mean age = 8.6 years], all of whom received the
writing formation, and a test of written expression. The intervention) and a second with 36 students in special
group that received intervention improved more than education (18 who received the intervention [mean age
the control group. In addition, the correlation between = 10.9 years] and 18 controls [mean age = 9.8 years]).
handwriting speed/accuracy and written expression An assessment of handwriting quality was used before
was 0.73; that is, 53% of the variance in story writing and after the intervention. The children received 18
was accounted for by speed and accuracy in writing handwriting intervention sessions in the first study
letters. These researchers concluded that the interven- and about 48 sessions (6 months twice a week) in the
tion was highly effective; in addition, it was cost second. The intervention used a self-instruction
effective because the instruction required 10 minutes a method in which the child reflected on his performance
day and was implemented by parents. This study also after each exercise. It consisted of multiple steps that
suggested that handwriting skill has an essential influ- emphasized visual perception of the letters, motor
ence on composition in early elementary years. programming, repetition, and then practice of writing
Hayes (1982) implemented a study that appeared to words and sentences. The child self-corrected his work
be the model for the Berninger et al. (1997) study. at each step.
Two groups were used, 45 children in kindergarten In the first study only descriptive results were
and 45 in third grade. The children were randomly reported. All students with poor handwriting improved
assigned to one of five conditions: control, copying and those with normal handwriting did not change. In
with no prompting, visual demonstration with copying the second study, students who received intervention
practice, visual and verbal demonstration with copying, improved significantly in handwriting quality and
and visual and verbal demonstration with the child improved more than students who did not receive
verbalizing during copying. The children received these intervention. Speed did not change for either group.
interventions for a single 20- to 25-minute session. Summarizing the significance of the effect, Jongsman
Despite the short period for intervention, an effect and co-workers (2003) reported that 72% of the
resulted. Similar to the later findings of Berninger and students changed from “dysgraphic” to “legible” after
co-workers, the intervention that involved visual and the intervention.
verbal demonstration with the child verbalizing while This intervention is similar to the CO-OP inter-
copying was most effective and copying with no vention (Polatajko et al., 2001) described in the pre-
prompting was least effective for both age groups. vious section, in that the child directs the activity,
Self-instruction is an approach to improving hand- practices with self-guidance, and self-evaluates. Both
writing that actively involves the child in the learning interventions draw on the child’s cognitive skills and
process. A number of researchers have examined the encourage active decision making and problem solving
effects of self-instruction (Blandford & Lloyd, 1987; to master a motor skill. Both interventions produced
Graham, 1983; Kosiewicz, Hallahan, & Lloyd, 1981). strong, positive effects.
Blandford and Lloyd examined the effects of using a
written card that cued letter formation to guide two
fifth-grade boys’ handwriting during journal writing.
OCCUPATIONAL THERAPY APPROACHES
The card had self-evaluation questions to emphasize OT approaches to improve handwriting often combine
important aspects of correct handwriting. The students educational/instructional approaches with sensori-
were to read the card and fill in answers based on their motor interventions. In practice OT intervention is
handwriting. Data were collected on correct letter individualized and based on analysis of the child’s
formation and spacing for 25 days. The boys demon- performance. Unique to OT is a deep understanding of
strated improved handwriting (letter formation and sensory and motor function, application of precise
spacing) when using the card and after using the card. assessment of sensory perception and sensorimotor skill
Therefore, this method appears to yield a significant as it relates to handwriting, and implementation of
effect with minimal teaching and can be implemented interventions that are specifically designed to improve
sensorimotor functions. Case-Smith (2002) examined heavy work with practice of isolated skills and holistic
the effect of OT services provided in the school on practice of letter writing with feedback and reinforce-
handwriting legibility and speed. A sample of students ment. These studies provide evidence that holistic OT
in third, fourth, and fifth grades with poor handwriting improves handwriting but falls short of identifying the
legibility (N = 29) received services throughout a differential effects of specific intervention approaches.
school year. A second sample of children in the same A study by Sudsawad and co-workers (2002) exam-
grades (N = 9) had poor handwriting by report of their ined the effects of one aspect of a sensorimotor OT
teacher but did not receive OT services. The therapists approach, kinesthetic training. These researchers assumed
documented their intervention throughout the year. A that kinesthesis can improve with training and that
mean of 9 hours of direct services were provided and improved kinesthesis would lead to more legible hand-
about 30% of all sessions included follow-up consul- writing. A randomized blended three-group research
tation with the teacher on the child’s behalf. The design was implemented. One group received kines-
students were assessed using visual motor, visual per- thetic training, one handwriting practice, and one no
ceptual, manipulation tests, the Evaluation Tool of treatment. The measures were kinesthetic acuity,
Children’s Handwriting (ETCH) and two sections of kinesthetic perception and memory, and the ETCH.
the School Function Assessment (SFA). The students The sample comprised 45 first-grade students with a
who received intervention improved more than the kinesthetic deficit and handwriting difficulties.
control group on in-hand manipulation and visual Kinesthetic training or handwriting practice was
motor control tests. They also improved more in letter provided 30 minutes per day for six consecutive school
legibility, but not in handwriting speed. The improve- days. Kinesthetic perception improved over time but
ment in handwriting legibility appeared to be clinically was not different among the groups. Scores on the
significant because two thirds of the sample moved ETCH did not change between pre- and post-tests,
from illegible handwriting (<85% of legible letters indicating that kinesthetic and handwriting interven-
on the ETCH) to legible handwriting (>85% legible tions had no effect on handwriting legibility or speed.
letters). As mentioned, handwriting speed did not The teachers reported significant changes in hand-
improve, possibly because some of the students had writing for all three groups. The authors concluded
learned to write more carefully and slowly to improve that their hypothesis that kinesthetic training would
legibility. lead to improvement in handwriting was not sup-
Peterson and Nelson (2003) also investigated the ported. Limitations included the short intervention
effects of OT intervention in a randomized clinical trial period (6 days) and small numbers in each group.
of children with economic disadvantages. Their sample In summary, educational/instructional approaches
consisted of 59 students in first grade, mean age = that use multiple sensory systems for cueing and feed-
7.1 years. They were assessed using the Minnesota back and that actively involve students have strong and
Handwriting Test (MHT) before and after a 10-week consistent effects on improving handwriting. Specific
intervention. Thirty children were randomly assigned instructional approaches with demonstrated effective-
to the intervention group and subsequently received ness are those that engage the student in goal setting
20 sessions of OT (twice a week for 10 weeks). The and reflection about performance, give visual and
intervention was provided by OT students and each verbal cues, and require memory retrieval during prac-
session consisted of practicing heavy work and tice. Less effective approaches are those that involved
sensorimotor activities, learning specific strategies to only copying, or only visual or verbal cueing. Instruc-
improve letter formation and spacing, and practicing tion approaches appear most effective for improving
handwriting. and writing quality and composition fluency, and least
The gain scores on the MHT were significantly effect for increasing speed.
higher for the students who received OT. The effect OT approaches that are comprehensive, provide
size for the intervention group was large (ranged from multisensory input, and engage the child in activities
0.64 to 1.3 for MHT subsections) and the control that reinforce multiple dimensions of handwriting
group demonstrated no change. In follow-up analysis, (e.g., motor planning, visual motor integration, small
the students made strong gains in spacing, placing muscle movement of the hand) effectively improve
letters on the line and using correct size; medium handwriting legibility. There is no consistent evidence
effects resulted for legibility and use of correct form. As that OT interventions improve handwriting speed.
in Case-Smith (2002), speed did not improve. Composition and writing quality have not yet been
Both studies (Case-Smith, 2002; Peterson & assessed in OT studies, but should be considered given
Nelson, 2003) demonstrated significant effects when its importance as primary outcomes of children’s writ-
comprehensive OT services were applied. The inter- ing skill. When a single component (i.e., kinesthesia) is
ventions combined sensorimotor activities that included the emphasis of intervention, the effects are equivocal.
As in the educational studies, use of a single learning measure functional goals (e.g., the Canadian Occupa-
method that emphasizes a single sensory system does tional Performance Measure), self-care and mobility
not appear sufficient for effecting substantial improve- function (e.g., Pediatric Evaluation of Disability
ment in handwriting. Inventory), adaptive behavior (e.g., the Vineland
Adaptive Behavior Scales), or use of hands in play (e.g.,
the Toddler Arm Use Test). Measures of play skills,
playfulness, or quality of life also should be used in
SUMMARY association of measures of sensorimotor skill.
Specific studies reviewed in this chapter did use
Research evidence about treatment effects helps prac- functional and occupational assessments. For example,
titioners make good clinical decisions, provides practi- Miller and co-workers’ (2001) study of cognitive orien-
tioners with explicit information to give to families, and tation to daily occupational performance implemented
helps practitioners justify treatment decisions to physi- the Canadian Occupational Performance measures,
cians and other professionals. When levels of research the Vineland Adaptive Behavior Scale, the Bruininks-
evidence are high and rigorous methods are used, Oseretsky Test of Motor Proficiency, and the Visual
therapists can generalize the findings to their practice Motor Integration test. These assessments examined
with confidence. When levels of research evidence are broad aspects of function and the child’s integration of
low, findings should be reported and applied with sensorimotor-perceptual-cognitive skills. The findings
caution because of inherent limitations. The majority of that resulted answered questions about the children’s
studies on hand intervention effectiveness are Levels III occupations after intervention. Other studies that
and IV and use small convenience samples. These examined the effects of holistic interventions (e.g.,
single-subject and case studies provide detailed infor- preschool OT services [Case-Smith, 2002]) demon-
mation about treatment outcomes for individuals, but strated the associations between children’s perform-
cannot be generalized beyond the characteristics of the ance of basic skills and their functional outcomes.
children who participated. Although case studies and Future hand intervention research should examine
single subject design studies deepen understanding children’s play and school outcomes to determine
of intervention effects, they do not provide definitive effects on everyday life and children’s roles as students,
information from which predictions about outcomes play partners, and family members.
can be made. In the past decade more rigorous (Level Another limitation in interpreting the research liter-
I) randomized clinical trials have been completed, ature is that the independent variable, the hand func-
providing more definitive findings and making impor- tion intervention, is rarely described in detail in the
tant contributions to the knowledge base for hand research report. As a result, it is not clear exactly what
function intervention outcomes. intervention strategies were used and to what inter-
The studies reviewed in this chapter examined vari- ventions the study results apply. In order to assure that
ous levels of function and disability. Many hand inter- the intervention is true to its theoretic model and is
vention studies have examined impairment level (body reliably applied across researchers and time, measures
structure and body function) outcomes. For example, of treatment fidelity are needed. Almost none of the
the studies of upper extremity weight bearing examined studies used checks on treatment fidelity; consequently,
ROM, muscle tone, and movement patterns (i.e., the external validity of findings can be questioned, as
components of performance). Studies of casting also treatment protocols are easily and unintentionally altered
emphasized ROM and muscle tone. Even studies of during implementation. Certain interventions (e.g.,
comprehensive interventions (e.g., neurodevelop- neurodevelopmental treatment) have been defined
mental treatment) often used measures of arm and differently over time (Howle, 2002); therefore, explicit
hand movement rather than functional or occupational information about what intervention activities and
measures. Impairment-level outcome measures leave strategies were administered is provided in the research
unanswered questions about if and how performance report. Publications of standard or best practice inter-
and function changed given intervention effects. vention models can be used to define interventions in
Measures of function and occupation, in addition to clinical trials.
performance of specific skills, help to link interventions A final limitation observed in many of the studies
to children’s daily lives and social roles. Researchers was lack of long-term follow-up. Often studies imple-
(Butler & Darrah, 2001; Law & Baum, 2001) have mented a post-assessment immediately after inter-
suggested that outcome studies routinely couple spe- vention, and did not follow children’s progress to
cific performance measures with holistic, comprehen- determine the long-term effects of intervention.
sive assessment of function and occupation. Examples Outcomes of children’s occupations and roles as they
of holistic assessments to be included are those that enter adolescence and adulthood have rarely been
assessed. This deficiency is not surprising given that Butler C, Darrah J (2001). Effects of neurodevelopmental
long-term follow-up of subjects requires substantial treatment (NDT) for cerebral palsy: An AACPDM
evidence report. Developmental Medicine and Child
resources and efforts of research teams. Although these Neurology, 43:778–790.
long-term projects have yet to be accomplished, the Carlson, PN (1975 ). Comparison of two occupational
preliminary data reported in this chapter can justify and therapy approaches for treating the young cerebral-palsied
inform these large-scale projects. Professions focused child. American Journal of Occupational Therapy, 29:
on hand intervention research are moving toward more 267-272.
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rigorous studies and designs that provide strong, valid services on fine motor and functional performance in
findings. To increase knowledge of hand intervention preschool children. American Journal of Occupational
effectiveness future research studies should: Therapy, 54:372–380.
1. Use randomized clinical trial designs with large Case-Smith J (2002). Effectiveness of school-based
sample sizes. occupational therapy intervention on handwriting.
American Journal of Occupational Therapy, 56:17–25.
2. Implement measures of occupation and function Chakerian DL, Larson MA (1993). Effects of upper-
that represent meaningful outcomes and quality of extremity weight-bearing on hand-opening and
life for children and families. prehension patterns in children with cerebral palsy.
3. Implement methods to evaluate intervention Developmental Medicine and Child Neurology,
fidelity and ensure that interventions represent the 35:216–229.
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theoretic constructs from which they are derived. constraint induced therapy on hand function in children
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Summarizing the findings of research on interven- Copley J, Watson-Will A, Dent K (1996). Upper limb
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Australian Occupational Therapy Journal, 43:39–50.
given vast differences in study designs, samples, tech- Cornhill H, Case-Smith J (1996). Factors that relate to
niques, and environmental contexts. This body of good and poor handwriting. American Journal of
research should be carefully read, critiqued, and digested. Occupational Therapy, 50:732–739.
When carefully analyzed, these studies offer explicit Crocker MD, MacKay-Lyons M, McDonnell E (1997).
guidance to practitioners who provide services to Forced use of the upper extremity in cerebral palsy: A
single case design. American Journal of Occupational
children with delays in hand function and to scholars Therapy, 51:824–833.
who will take the next steps in research of intervention Cruickshank DA, O’Neill DL (1990). Case report – Upper
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quadriplegia. American Journal of Occupational Therapy,
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Glossary
Adapted tripod grip: Grip where the pencil is Coincidence anticipation: A form of anticipatory
stabilized within the narrow web space between the control in which movement coincides with an external
middle and index fingers when writing. event, such as catching a ball.
Affordances: The perceptual features of objects, Composite flexion: Fisting of the hand along with
places, and events that enable particular functional flexion of the wrist, thereby putting maximal strain on
actions. the extensor mechanism of the hand.
Anticipatory control: The programming of action Concept formation (knowledge): Conscious and
based on a mental representation of an object’s active process that categorizes sensory information by
properties that has developed through prior associating it with conceptual categories.
experience. It involves the activation of sensory and Constraint-induced movement: Immobilization of
muscular systems for a specified activity that has been the less involved upper extremity to require the child
learned. to use the more involved extremity.
Arches of the hand: The musculoskeletal structures Constructional skill: The ability to perform the
that allow the flattening and cupping of the hand. sequences of movement involved in producing two-
The arches are the proximal transverse, distal or three-dimensional representations, as in drawing or
transverse, and longitudinal. building.
Attention: An active process in which certain stimuli Constructional style versus contoured style of
in the environment are given preference over other drawing: Refers to the execution of pictorial
stimuli depending on their perceived importance. representations by the assembly of simple forms as
Automatization; autonomous phase: The stage of opposed to beginning with a sketch of an outline.
a learned motor skill when the action is carried out
with minimal attention. Dexterity: Ability to manipulate objects with the
hands with accuracy and speed.
Base of support: The area of the body in contact Disk grip (five-jaw chuck): A fingertip grip using
with the support surface; when more body area is in the pads of all the fingers and the thumb, as on the lid
contact with the surface, the base of support is wide; of a jar.
when less body area is in contact with the surface, the Dissociation: Refers to the ability to carry out
base of support is narrow. precise, independent joint movements without
Bilateral hold, cooperative: An action in which one concurrent involuntary actions at other joints not
hand supports or stabilizes an object while the other involved in the task.
hand explores or manipulates it. Dorsal stream: Neural pathway that provides visual
Bilateral or two-handed hold, symmetric: information for the guidance of movement.
Holding objects with the two hands acting in unison. Dual motor systems: Refers to the differentiation
Bilateral simultaneous manipulation; between central nervous system control of skilled
complementary two-hand use: An action in which distal movements such as those of the hand and the
both hands are performing different but complementary proximal movements of the limbs and trunk.
actions at the same time, as in bead stringing. Dynamic splinting: Uses articulations and force
components to constantly put a dynamic pull on tight
Central pattern generators: Neural networks that or healing tissue; often incorporates rubber bands,
interact in an organized manner to produce a motor springs, or other materials to exert controlled
act. mobilization.
Cognition: The collection and organization of Dynamic tone: The muscle tone that occurs with
information into knowledge. volitional movement.
461
462 • Glossary
Dynamic tripod grasp (pencil): Grasp in which the differentiated from writing, which is the composition
pencil is stabilized against the side of the middle and control of material that is handwritten.
finger by the pads of the thumb and index finger. Haptic perception: Recognition of objects and
Writing includes localized movements of the fingers object properties by the hand without the use of
and thumb as well as the wrist. vision.
End range of movement: The distal range of Implicit (procedural) memory: Storage and recall
motion at a joint as opposed to movements that occur of information without conscious awareness.
in the middle of available range. Knowledge of how a task is done expressed through
Executive function of the hand: The use of the performance.
hand as a means of practical action on the Inferior or immature pincer grasp: A grasp
environment, during which perceptual function is between adducted thumb and side of the index finger.
regulated by whatever is needed to achieve the action. In-hand manipulation: The adjustment of a grasped
Explicit (declarative) memory: Conscious object within one hand while it is being held. Includes
awareness and intention to recall facts and events. translation, shift, and rotation with and without
Extensor lag: Inability to extend the DIP joint of stabilization.
the finger into full extension because of poor pull- In-hand manipulation with stabilization:
through of the terminal extensor tendon. Manipulating one object with the fingers while
Eye–hand coordination: The integration of visual holding one or more additional objects within the
perceptual information with the purposeful same hand.
movements of the hand and arm. Intermodal perception: The matching of objects or
shapes that are perceived by one sensory modality,
Feedback: Sensory information that arises from such as touch, to those which are perceived by a
movement. different sensory modality, such as vision.
Fine motor coordination: Use of small muscle Intramodal perception: Matching objects or shapes
groups for precise movements, particularly in object within a single sensory system, for example, matching
manipulation with the radial digits. one object explored haptically to another also
Finger differentiation or individuation: Controlled explored haptically.
individual or isolated finger movements.
Fixing: Volitional limitation of freedom to move at Kinesthesia: The conscious perception of the
various muscles and joints in order to produce excursion and direction of joint movement and of the
controlled movement in another body part. weight and resistance of objects.
Graphomotor skill: The conceptual and perceptual Lateral tripod grasp (pencil): Grasp in which the
motor abilities involved in drawing and writing. pencil is stabilized against the side of the middle
Grasp phase of reaching: The phase of reaching for finger, with the index finger pad on the pencil, and
an object in which the hand is shaped in anticipation the thumb adducted with the thumb pad braced on
of the contact with the object. the side of the index finger. Writing includes localized
Grip: The mechanical component of prehension; the finger movements as well as wrist and arm
hand configuration on the object during grasp. movements.
Grip force: The pressure exerted on an object in the Learned non-use: When the more involved
act of lifting and holding. In precision grasping, grip extremity is not used, changes occur in the central
force is matched to object qualities such as weight, nervous system that reinforce the non-use of that
texture, and rigidity. hand.
Hand preference: The consistent favoring of one Memory: Process by which knowledge is encoded,
hand over the other in the performance of skillful acts. stored, and retrieved.
Hand shaping: The adaptation of the hand arches Mirror movements: Movements of the hands are
and the finger postures to the object’s size, shape, and coupled, with the use of one hand the same
use in anticipation of grasp. movements are observed in the second hand.
Handedness: Consistent and more proficient use of Motor functions of the two sides of the hand:
the preferred hand. Its dimensions include hand Refers to the differing functions of the ulnar (little
preference (the hand chosen more often) and hand finger) side and the radial (thumb) side of the hand.
performance (the hand with superior ability). The primary function of the ulnar side of the hand is
Handwriting: The process of transcribing letters to to hold, whereas that of the radial side is to
form words and words to form sentences; manipulate.
Glossary • 463
Motor learning: A set of processes associated with Preprogrammed movement/open loop

practice or experience leading to relatively permanent movement: A learned movement in which the entire
changes in the capability for producing skilled motor pattern is programmed before the movement is
action. initiated and which is not under sensory control
Movement unit: Constituted by one phase of during execution.
acceleration of a limb followed by a deceleration. A Prereaching; prefunctional reach: The more
movement can consist of one or more movement automatic movement of the very young infant’s
units. hand
Multimodal exploration: The simultaneous use of toward an object before voluntary reach has developed.
more than one sensory system in object exploration. Proprioception: Sensory information about positions
and movements of body parts from muscles, tendons,
Occupation performance: Performance of skills that joints, and skin. Limb position sense and kinesthesia
are essential for independent functioning in everyday are forms of proprioception.
living.
Quadripod grip (pencil): Grip in which the pencil is
Palmar grasp: A whole-hand grasp in which objects held by three fingers and the thumb. May be static or
are held against the palm of the hand by the fingers. dynamic.
The thumb may be active or passive.
Palmar grasp (pencil): A grasp in which the pencil Radial digital grasp; inferior forefinger grasp:
is positioned across the palm and held in a fisted grip. Prehension of an object with the thumb, index, and
Pathologic handedness: Altered handedness middle fingers but with the object held proximal to
resulting from neural insult. the finger pads. Thumb may be in adduction or
Perception: A process of collecting information from opposition.
the environment based on vision, touch, hearing, and Radial palmar grasp: An immature grasp in which
proprioception in order to construct an internal the index and middle fingers and thumb press an
representation of the environment and body. object into the palm.
Perceptual activity of the hand: Use of the hand as Radial-ulnar dissociation; separation of the two
a perceptual system, in which motor activity is sides of the hand: The ability to perform holding
primarily exploratory and information seeking. functions with the ulnar fingers while manipulating
Perceptual-motor processes: The reciprocal objects with the thumb and radial fingers.
relationship between perception and action, wherein Reflexive grasp: The stereotypic closing of the hand
movement adapts to perception and movement on an object in response to tactile or proprioceptive
influences perception. information. Palmar grasp reflexes occur normally in
Pincer grasp; pinch; fine prehension: The grasp of early infancy and may persist in children with brain
an object with the index finger and thumb. Major damage.
types include palmar pinch (pad of finger to pad of Reverse transverse grip; radial cross-palmar
thumb), tip pinch (using tips of both thumb and grasp (pencil): An immature pencil grip with the
finger), and lateral pinch (thumb holding object pencil positioned across the palm and the point
against side of finger). projecting from the thumb side of the hand. The
Postural control: The maintenance of body position hand is fisted with the forearm fully pronated.
in space that evolves from the development of Rotation: An in-hand manipulation movement by
antigravity movement, postural adjustment reactions, which an object is turned in the fingers. Simple
and somatosensory input. rotation involves turning or rolling the object 90
Power grip: A static grip applying force to an object degrees or less with the fingers acting as a unit.
to immobilize it in the hand. Complex rotation involves turning an object 90 to
Praxis: The planning and execution of a motor 360 degrees using isolated finger and thumb
movement or a series of motor movements/tasks. movements.
Precision grip: The grasp of an object with the
finger and thumb pads or tips. Precision grips may be Scissors grasp: The prehension of small objects
static but often allow movement of the object by or between the thumb and the lateral border of the
within the fingers. index finger.
Precision handling: The dynamic or manipulative Self-care activities: The basic daily living activities
characteristics of precision grip used for in-hand of eating, dressing, bathing, and use of the toilet.
manipulation and for the use of many tools. Sensory processing: The management of
Prehension: The voluntary act of grasping and incoming sensory information by the central nervous
manipulating objects with the hand. system.
464 • Glossary
Shift: An in-hand manipulation movement where Tone: The resistance a muscle offers to being
there is slight adjustment of an object on or by the lengthened; abnormal tone is a result of both neural
finger pads. factors (e.g., spasticity) and biomechanical factors
Somatosensory: Refers to the tactile and (e.g., fibrosis and atrophy), which cause changes in
proprioceptive senses that contribute to the contractile properties of some muscle fibers.
perception of objects and events, as well as of the Total end range time: Term used in soft-tissue
body and limbs. adaptability that refers to the frequency of stretching
Spasticity: Velocity-dependent resistance to passive multiplied by the duration of the stretch at the end
movement. range of a joint’s movement.
Squeeze grasp: An immature grip in which an infant Trajectory: The path taken by the hand as it moves
presses an object against the palm with total finger toward a target and the speed at which it moves along
flexion. The thumb does not participate and force is the path.
not modulated. Translation: A form of in-hand manipulation by
Stabilizing: Contraction of the muscles to fixate or which an object is moved in a linear direction between
hold the body or a body part; also refers to the use of the palm and the fingertips. Includes the movement
external systems or devices to provide support when of an object from the palm of the hand to the
an individual is unable to do so alone. fingertips (palm-to-finger translation), and the
Static splint: An immobilization or supportive splint movement of an object from the fingertips to the
that has no moving parts; serial static splints are palm (finger-to-palm translation).
periodically remodeled as the joint gains motion; Transportation phase; transport: The phase of
static progressive splints use low load in a single reaching that brings the hand to the target or moves
direction over a long period of time to mobilize soft an object through space.
tissue at its end range.
Static tripod grasp (pencil): Grasp in which the Ventral stream: Neural pathway that provides visual
pencil is stabilized against the side of the middle information for the recognition of objects.
finger and held by the pads of the index finger and Visual-motor integration: The coordination of
thumb. The hand is moved as a unit by the wrist and visual information with movement. The term is used
forearm in writing. often to indicate the ability to copy geometric forms.
Stereognosis: The recognition of familiar objects Volition: Action in which the achievement of a goal
through touch. is seen as resulting from one’s own activity.
Stiffness: A general term referring to difficulty Voluntary controlled release: Letting go of an
moving the limbs. object in a specific place and with timing that is
Switched handedness: Occurs when an inherently appropriate for the specific task.
left-handed child learns to draw and write with the
right hand because of sociocultural influences. Weight shift: Volitional or assisted movement of
body weight which occurs with movement of a body
Tapping: A facilitation technique that is manually part.
applied and used to generate volitional movement at Working memory: Short-term memory system that
individual muscles. holds information so that it can be manipulated
Three-jaw chuck: A power grip of the fingertips. during tasks.
The object is held with the distal pads of the thumb,
index, and middle fingers. Zone of proximal development: A period of
Threshold tests: Tests that determine the minimal developmental maturation in which particular skills
stimulus a person can perceive (e.g., pain, are within reach of a child.
temperature, pressure).
INDEX
A Anti-Houdini techniques, 419, 420b, 420f-422f

Arches
Abductor pollicis muscles, 31-34, 33f, 35f of the hands, 22, 23f, 461
Acceleration Arms
illustration of rates of, 56f embryonic development of, 21-22
Accordion tube toys, 271 extrinsic muscles
Active range of motion (AROM), 370, 371f, 373 and tendons of, 27, 28f-29f, 29-31, 32f
Activities of daily living (ADLs) functions of
for burn victims, 393 kinesiologic aspects of, 349-348
evaluation of isolated movements of, 247-249
following hand wounds, 376, 377t-379t Arousal, 104
handedness issues with, 183-184 Assessments
and self-care, 193-214 of cerebral palsy, 351-352
Adaptations of children’s drawings, 225-226
for hand skill problems, 240-241 of hand injuries
reaching activities of daily living, 376
and motor impairments, 96-97 hand dexterity, 374-375
Adapted tripod grip, 331f, 461 hand sensibilities, 376
Adductor pollicis muscles, 34-35 hand strength, 373-374
Adults interview and history, 370
drawing skills in, 220 pain, 375-376
haptic manipulation strategies in, 70-71 range of motion, 370-373
reaching movements by, 94-95 wounds, edema and scarring, 375
role of vision and cognition of handedness
in haptic perception, 74-76 by occupational therapists, 179-180
Afferent feedback, 47-48, 218 of handwriting skills, 291-307, 302t-305t, 311-318
Affordances, 461 of haptic perception
Alpha motor neurons in infants and children, 77-78
of hand muscles of self-care skills, 195-196, 197, 199
direct corticospinal connections to, 4-5 Attention
Ambidextrous definition of, 104, 461
definition of, 166b in motor skill, 242
Anatomy Attention deficit hyperactivity disorder (ADHD)
of the hand, 21-43 affecting reaching in children, 96
Anterior intraparietal sulcus impaired hand function with, 54-58
importance in movement, 16 prehensile force control in children with, 45-46
Anticipatory control Autism
development of, 52-53 and haptic perception, 81-82
during infancy, 94 Autism Spectrum Disorder, 278
in developmentally disabled children, 56-57 Avoiding reactions, 130
glossary definition of, 461
and learning, 47 B
Anticipatory postural control, 346
Anticipatory scaling, 57 Balance
development of
in infants, 122-124
and reaching, 93
Page numbers followed by f refer to figures; those followed by t refer Base of support, 461
to tables; and those followed by b refer to boxes. Bead stringing, 153f, 273-275, 324
465
466 • Index
Bilateral hold Case studies (Continued)

cooperative concerning low muscle tone, 360-363
definition of, 461 on preschool fine motor skill development, 285-286
Bilateral integration and sequencing (BIS) on radial nerve palsy
dysfunction, 326-327 and splinting, 423-425
Bilateral skills Casts; See also splinting
difficulties efficacy of
interventions for, 260-262 research studies on, 443-444
of manipulation, 256 Friedrich and Baumel, 388f
needed for hygiene and grooming, 210, 211t, 212t full arm, 380f
sample short-term goals for, 244, 245b as intervention adjunct, 263
and self-care, 213 “Caterpillar pop” game, 271
transitional, 131-134 Central nervous system (CNS)
Bimanual skills and haptic perception, 69
from birth to 12 months, 131-134 and prehensile force control, 45-46
coordination of, 134 Central pattern generators, 461
developmental sequence of Cerebral cortex
birth through 24 months, 138t-139t and hand-object interactions, 3-4
and hand preference, 164 Cerebral palsy (CP)
Blocked range of motion (BROM), 370, 371f, 373 affecting drawing abilities, 225
Blocking gloves, 387f affecting grip force, 11, 54-58
Bobath approach, 343, 344-347 anticipatory and postural control with, 346
Body charts assessment process, 351-352
to identify pain, 376 biomechanical interactions
Bones of upper limbs with, 348-349
anatomical diagram of hand, 22f causes of, 344
embryonic development of, 21-22 definition of, 344, 434-435
Botulinum toxin (BOTOX), 447 hemiplegic
Boutonniere deformities reaching problems with, 97
splinting, 418f hypertonia versus hypotonia, 349
Brachial plexus injuries, 418 impaired hand function with, 54-58
Brain injuries impairments seen with, 344
and haptic perception problems, 81 lift capacity of children with, 50f
Bristle blocks, 272, 277 neurodevelopmental treatment (NDT)
Brodmann’s areas, 8-9, 10f case study, 355-359
Bruininks-Oseretsky Test, 231, 449 description of, 343-363
Buddy taping, 417 research studies, 440-443
Burns prehensile force control in children with, 45-46
in children research studies on, 435, 436t-440t
classification of severity, 392-394, 390t treatment planning, 352, 357t, 361t
closed wound scarring phase of, 392-394 Checkrein ligaments, 27
open wound phase of, 390-392 Children
patterns of, 389-390 anticipatory control development in, 52-53
management of scars, 391-393 with cerebral palsy (See cerebral palsy (CP))
Buttoning, 154, 208, 209t, 210, 273, 275-276, 276-277 drawing skills in, 220-221, 222f, 223-224
graphomotor skill acquisition in, 217-220
C grasping coordination of, 48-51
hand therapy in, 367-398
Callosal dysfunction, 176 congenital problems, 394-398
Capacity evaluation of, 369-376, 377t-379t
definition of, 104 introduction to, 367-368
Capitate phases of wound healing, 368-369, 370b
anatomical diagram of, 22f thermal injuries, 389-394
description and position of, 22-23 traumatic injury treatment, 376, 380-394
ligaments of, 23, 24f handedness in
Carpal bones assessment of, 170-172
diagram illustrating, 22f classification of, 165-168
embryonic development of, 21-22 definition of, 161, 162, 163f, 164
Carpometacarpal joints development of, 177-179
anatomy of, 23, 24, 25f factors influencing, 172-177
and handwriting, 322 flow chart illustrating, 163f
Carpus, 23, 24f, 25f introduction to, 161-162
Case studies left and switch, 168-169
on cognition and motor skills, 101-102 and pediatric occupational therapy, 179-184
concerning cerebral palsy prevalence of, 169-170
and neurodevelopmental treatment (NDT), 355-359 haptic manipulation strategies in, 73-74, 76-77
Index • 467
Children (Continued) Congenital hand differences

haptic perception development in, 65-67 radial club hand, 396-398
illustration of hand ability in, 46f syndactyly, 394-396
interventions Consolidation phase
for hand skill problems, 239-264 of explicit memory, 108
with motor impairments Constraint-induced (CI) movement therapy
reaching/coordination problems in, 96-97 definition of, 461
object manipulation development in, 154-158 description of, 263
prehensile force control development in, 45-46 research and case studies on, 444-446
preschoolers Constructional skills, 461
fine motor program for, 267-287, 289-291 Contoured drawing, 220, 461
role of vision and cognition Cooperation
in haptic perception, 74-76 and self-dressing, 205t
using sensory information Coordination
for reaching, 95 development of, 45, 46f
Children’s Handwriting Evaluation Scale (CHES), 302t-305t, eye-hand and reaching, 89-97
314-315 force
Chinese speed test, 304t-305t in grasping and lifting, 55-56
“Chunking,” 106, 108 during grasping, 48-51
Clot formation, 368-369, 370b by infants
Clumsiness when reaching, 93
causes of Corpus callosum, 176, 177-179
in children, 54-58 Corticospinal tract
Cock-up splints, 381f connections to alpha motor neurons, 4-5
Cognition Culture
definition of, 461 and hand skill development, 121-122
development of, 45, 110 and handedness, 176-177
factors in self-care, 214 and handwriting, 226-227
and hand ability in children, 46f and self-care skill development, 196-197
importance of Cursive writing
for motor skill acquisition, 102-103 kinesthetic approach to teaching, 335-336
and motor skills motor patterns in, 3
adaptation, 102 teaching, 328-329
attention and perception, 104-105
case scenario, 101-102 D
concept formation, 106-107
importance in acquisition of, 102-103 Decision making
memory, 107-108 concerning hand actions, 102
perceptual-motor processes, 105-106 Deep pressure
processes of, 103-108 and joint approximation, 351
problems Denver Handwriting Analysis, 304t-305t
with cerebral palsy, 344 Development
role in haptic perception, 74-76, 77 process of, 102-103
Cognitive neuroscience approach stages of object manipulation, 143, 144-146, 144b
to cognition and motor skill development, 103 theories
Cognitive Orientation to Daily Occupational Performance for hand and motor skills, 117-121
(CO-OP), 447-449 Developmental coordination disorder (DCD)
Cognitive skills; See cognition affecting sensorimotor control in hands, 54-58
Coincidence anticipation, 461 efficacy and research studies, 447, 448t, 449
Collagen, 368-369, 370b impaired hand function with, 54-58
Collateral ligaments self-care skill difficulties in, 194-195
accessory, 25, 26f Developmental disabled children
cord portion of, 25, 26f reaching skills impaired in, 96-97
splinting of, 383-384 self-care skill difficulties in, 194-195
Columnar carpus, 23, 25f Developmental Gerstmann syndrome
Communication and haptic perception, 81-82
using hands, 101 Developmental Test of Visual Motor Integration (VMI), 325,
writing, 291 448-449
Complementary two-hand use, 152-153, Dexterity
158 and bead stringing, 273-275
Composite flexion, 461 diagram illustrating, 58f
Computers glossary definition of, 461
and drawing, 224-225 of hands
and handwriting, 232 and function, 374-375
Concept formation Differentiation, 106, 108
definition of, 461 Digital cleavage
description of, 106-107 embryonic development of, 21-22
468 • Index
Digital interphalangeal joints, 26f, 27 Ecological approach

Digital pronate grasp, 281f to cognition and motor skill development, 103
Digits Edema
anatomical diagram of, 22f description of, 375
description and position of, 22-23 management of burn, 391-392
embryonic development of, 21-22 sandwich splints for, 391f
fractures and dislocations of, 383-384 Edinburgh Handedness Inventory (EHI)
ligaments of, 23, 24f, 25, 26f description of, 170-171
muscles and tendons of, 33-34, 36f reliability of, 170t
Disabilities Elbows
affecting drawing abilities, 225 casting and splinting, 380f, 381f
and keyboarding, 232 embryonic development of, 21-22
Disk grip, 461 Encoding phase
Dissociation, 461 of explicit memory, 108
Distal finger control End range of movement, 462
practice sheet for, 339f Episodic memory, 107-108
Distal grips, 335b Epithelization, 368-369, 370b
Distal phalanges Ergonomics
anatomical diagram of, 22f affecting handwriting, 298t, 301, 306
description and position of, 22-23 Ethnicity; See culture
ligaments of, 23, 24f Evaluation Tool of Children’s Handwriting (ETCH), 302t-
Distal transverse arch 303t, 316-317
anatomical diagram of, 23f Evaluations
description of, 22 of hand injuries
Diversity; See culture activities of daily living, 376
Dorsal interossei muscles, 32-34, 35f hand dexterity, 374-375
Dorsal stream, 104-105, 461 hand sensibilities, 376
Down syndrome hand strength, 373-374
affecting drawing abilities, 225 interview and history, 370
affecting grip force, 11 pain, 375-376
and haptic perception, 80-81 range of motion, 370-375
reaching skills affected by, 96 wound, edema and scarring, 375
Drawing; See also graphomotor skills of handwriting
and computers, 224-225 actual performance, 300-301, 302t-305t, 306
definition of, 217 fine motor skill, 296-297
development in preschoolers, 280-284 gross motor skill, 295-296
and developmental evaluation, 225-226 keyboarding performance, 306-307
instruction and practice, 229-232 motor performance, 294-295
motor learning theories, 218 neuromuscular and neurodevelopmental status, 293
nature of, 220-221, 222f, 223-224 pre-evaluation data collection, 292
and pencil grasp, 282-283 related performance components, 292-300
phases of, 221, 222f visual motor control, 297-298
role of vision and kinesthesis in, 218-219 visual perception components, 293-294
tools, 280-281 of haptic perception
Dressing skills in infants and children, 77-78
antecedents of, 203, 205t Executive function
with fasteners, 208, 209t, 210 of the hand, 462
learning Explicit memory, 107, 462
and hand skill development, 203, 205t, 206, 207t, 208, Exploration
209t, 210 and haptic perception, 69-74
order of difficulty, 208b by infants, 73b
undressing, 206t movements used in object, 144-147
without fasteners, 206, 207t and object dimensions, 71t
Drinking, 199, 200t Extensor lag, 462
Dual motor systems, 461 Extensor pollicis muscles
Dynamic grasp, 280-281 of hand, 31-35, 32f
Dynamic muscle tone, 461 Extensor tendons
Dynamic splinting, 408, 461 injuries to, 388-389
Dynamic tone, 461 Extrinsic muscles
Dynamic tripod grip, 210-220, 462 and tendons
Dyspraxia of hands, 27, 28f-29f, 29-31, 32f
and haptic perception, 81-82 Eyedness, 181
Eye-hand coordination
E definition of, 462
interventions to improve, 242-243
Earedness, 181 play activities to improve, 273-275
Eating, 199, 200t, 201, 202t, 203, 204t and reaching, 89-97
Index • 469
F Fractures
of fingers, 383-384
Face pain scale-revised (FPS-R) splinting for, 417
to measure pain, 376 of wrist, 380-383
Facilitation Friction
case study techniques of, 352, 357t, 362t of objects
definition of, 350 and anticipatory control, 53
techniques of, 350-351 Friedrich and Baumel casts, 388f
Fasteners, 208, 209t, 210 Full arm casts, 380f
Feedback, 462 Functional range of motion, 370-371, 372f, 375
Feed-forward controlled movements, 47
Feeding; See self-feeding G
Fibroblastic stage
of wound healing, 369 Gamekeeper’s thumb, 383-384
Fine motor coordination, 462 Gender
Fine motor skills and haptic perception, 67
activities that help children learn, 285b and self-care skills, 197
case study on preschoolers, 285-286 Geoboards, 272, 275
emphasis on Gestation, 21-22
in different cultures, 121-122 Glossary, 461-464
evaluating handwriting, 296-297, 298t Graphesthesia test (GRA), 78
goals for preschoolers, 267-268 Graphomotor skills; See also drawing; handwriting
and handwriting instruction, 230-231 acquisition of, 217-220
instruments to assess, 296t motor learning, 218
learning on vertical surfaces, 268-269 definition of, 217, 462
planning, 278 development of, 217-233
problems in children, 239-262 drawing, 220-226
and visual perceptual inventory grasping and manipulating tools, 219-220
for preschoolers, 290-291 handwriting, 226-232
Finger feeding, 199, 200t role of vision and kinesthesis in, 218-219
Finger plays, 289 ergonomic factors, 298t, 301, 306, 320
Fingers; See also digits; phalanges writing implements, 220
biomechanics of flexor pulley system, 38f Grasp; See also grip
embryonic development of, 21-22 and anticipatory control, 53
force coordination in, 55-56 basic coordination of forces during, 48-51
fractures and dislocations of, 383-384 case scenario concerning, 101-102
and in-hand manipulation skills, 255-260 developmental sequence of
isolation activities, 275 birth through 24 months, 138t-139t
movements of, 4-5 experiments involving, 48-51
in older children, 157-158 illustration of normal, 42f
sensory function, 7-9 importance of postural control in, 346
and tactile system, 48-54 by infants
and vision systems that influence, 122-126
and object manipulation, 147-148, 149f interventions
Fisted hands for problems with, 249-251
problems with, 250 mass, 5
splinting for, 406t and object manipulation
Fixing, 462 in infants and children, 143-158
Flexor pollicis muscles, 31-34, 33f, 35f and osseous arches, 23
Flexor tendons power
injuries to, 385-388 functional patterns of, 41-43
splinting, 417-418 precision, 41-43
Food; See also self-feeding preparation and vision, 11-13, 16
and learning to self-feed, 199, 200t, 201, 202t, 203, 204t in preschoolers
serving and preparing, 203, 204t for drawing/ writing, 280-281
Footedness, 181 primitive and transitional, 127-128
Force coordination purposeful, 128-130
in grasping and lifting, 55-56 radial finger patterns, 251-253
Forearms role of somatosensory cortex in, 10-11
embryonic development of, 21-22 sample short-term goals for, 244, 245b
muscles of, 31f of scissors, 279
nerves associated with tendons and muscles of, 28f-29f, 31f, and self-dressing, 205t
32f, 33f, 37-40 and sensorimotor control, 53-54
power of muscles in, 37, 38t and sensory feedback, 16
“Fractionate,” 4, 16 strength and “Strong Hands,” 273, 274b
470 • Index
Grasp (Continued) Hand skills (Continued)

and tripod grips, 219-220 functional in infants, 120-121
variability in, 155-157 grasp, release and bimanual development
Grasp phase birth through 24 months, 138t-139t
definition of, 462 learning stages, 120-121
of reaching, 90-91 object manipulation, 143-158
Grip; See also grasp and the primary motor cortex, 5-7
affecting handwriting, 298t, 301, 306 problems in children
assessment systems, 297 goal setting, 243-244, 245b
in children with cerebral palsy, 11 impact on occupational performance, 239-240
definition of, 462 intervention approaches, 240-241
force development, 51 intervention planning factors, 241-243
interventions for problems with, 249-251 intervention strategies, 244-262
power research, 244
description of, 41 splints, casts and constraints, 262-263
functional patterns of, 41-43 and self-care, 193-214
precision Hand strength
functional patterns of, 41-43 in infants, 375
precision versus power, 4-5 measuring of, 289
and preshaping hand, 12-14 in middle childhood to adolescence, 374
role of somatosensory cortex in, 10-11 Hand therapy
tripod, 219-220 pediatric, 367-398
Grip force congenital problems, 394-398
coordination of, 55-56 evaluation of, 369-376, 377t-379t
definition of, 462 introduction to, 367-368
development of, 51 phases of wound healing, 368-369, 370b
and friction, 53 thermal injuries, 389-394
illustration of, 50f traumatic injury treatment, 376, 380-394
illustration of rates of, 56f Handedness
Grooming categories of, 165-166, 166b
developing self-care skills in, 210, 211t, 212t in children
Gross motor skills assessment of, 170-172
emphasis on classification of, 165-168
in different cultures, 121-122 definition of, 161, 162, 163f, 164
evaluation of development of, 177-179
for handwriting analysis, 295-296 factors influencing, 172-177
Grouping, 106, 108 flow chart illustrating, 163f
introduction to, 161-162
H left and switch, 168-169
and pediatric occupational therapy, 179-184
Hamate prevalence of, 169-170
anatomical diagram of, 22f consistency of, 167-168
description and position of, 22-23 definition of, 462
ligaments of, 23, 24f development of
Hammering, 42f, 171b, 172 from 2 years to age 6, 179
Hand muscles; See also muscles from birth to 24 months, 177-178
direct corticospinal connections and drawing, 223-224
to alpha motor neurons, 4-5 and haptic perception, 67-68
and the primary motor cortex, 5 intervention theories
Hand performance for left, 182-184
definition of, 162 for switched, 182
versus hand preference, 162, 163f, 164-165 for unestablished, 180-182
skill and ability tests for, 171-172 in preschoolers, 281-282
Hand preference; See also handedness theories concerning establishment of
definition of, 162, 462 genetic, 173-174
four components of, 164 intrauterine influences, 174-176
versus hand performance, 162, 163f, 164-165 neuroanatomical and neurophysical, 172-173
linked to immature grips, 220 pathologic, 174-176
in preschoolers, 281-282 sociocultural and environmental, 176-177
tests for, 170-171 Handedness profile charts, 180f, 183b
Hand skills Hand-eye coordination; See eye-hand coordination
complementary two-hand use, 152-153 Hand-object interactions
development of cortical control of, 3-17
importance of posture and senses in, 122-126 skills in
and infant play, 117-137, 138t-139t prerequisites for, 3-4
Index • 471
Hands Handwriting (Continued)

anatomy and kinesiology of, 22-43 bilateral integration, 326-327
clumsiness or impaired function of kenesthetic approach to, 335-341
in children, 54-58 kinesthesia, 328-330
diagram illustrating bones of, 22f pencil grip, 330-331, 332f, 333-335
embryonic development of, 21-22 spatial analysis, 327-328
extrinsic muscles training groups, 319
and tendons of, 27, 28f-29f, 29-31, 32f upper extremity support, 320-321
functional patterns of, 41-43 visual control, 324-325
isolated movements of, 247-249 wrist and hand development, 321-324
joints and ligaments of, 23-27 tests for assessing, 302t-305t, 311-318
movements of versus writing, 226
sensory function, 7-9 writing tools, 220
summary and therapeutic implications, 16 Handwriting Speed Test, 304t-305t, 317-318
muscles and tendons of, 27, 28f-29f, 29-37 Haptic perception
nerves associated with, 28f-29f, 31f, 32f, 33f, 37-40 accuracy, 67
osseous structures of, 22-23 definition of, 63-64, 462
perceptual functions of, 63-83 (See also haptic perception) development in children, 65-67
power of muscles in, 37, 38t development in infants, 64-65
preference (See handedness) disorders of, 79-80
preshaping of, 12-14, 16 evaluation of
role of inferior parietal lobe in, 12-13 in infants and children, 77-78
research studies functions contributing to, 68-77
on effects of cerebral palsy, 436t-440t manual manipulation and exploration
sensation and anticipatory control in, 346-349 in adults, 70-71
sensibility of, 376 in children, 73-74
skin and subcutaneous fascia, 40, 41f in infants, 71-73
systems that contribute to abilities of, 46f strategies, 69-74
Handwriting and recognizing objects and shapes, 65-67
consequences of bad, 291 role of somatosensory sensation in, 69
definition of, 217, 462 summary and implications for practice, 67-68, 82
development in preschoolers, 280-284 of texture, size and weight, 66
developmental progression of, 226-229 visual, 65-66
diagram illustrating skilled, 218f Healing
ergonomic factors, 298t, 301 phases of wound, 368-369, 370b
evaluation of Hemiplegic cerebral palsy
actual performance, 300-301, 302t-305t, 306 coupled movements with, 97
fine motor skill, 296-297 High load brief stress (HLBS), 419
gross motor skill, 295-296 Holding skills
keyboarding performance, 306-307 bilateral, 133
motor performance, 294-295 Hygiene
neuromuscular and neurodevelopmental status, 293 developing self-care skills in, 210, 211t, 212t
pre-evaluation data collection, 292 Hypertonia
related performance components, 292-300 versus hypotonia, 349
visual motor control, 297-298 Hypotonia
visual perception components, 293-294 versus hypertonia, 349
handedness actions involved in, 182-183
implement grasp and manipulation, 219-220 I
instruction and practice, 229-232
interventions to improve Ilizarov, 396
efficacy studies on, 451, 452t-453t, 454-456 Imaginary play, 125
kinesthetic approach to teaching, 335-340 Implicit memory, 107, 462
learning on vertical surfaces, 268-269 Independence
legibility of, 226-228, 300-301 in self-care skills
tests for assessing, 302t-305t, 311-318 cultural and social factors, 196-197
manipulatives program before learning, 270-278 and disabilities, 194-195
motor learning theories, 218 importance to children, 194
performance factors, 229-232 maturation and motivation, 197-198
prosthetic devices, 331, 332f motor factors, 198
quality of, 227-228 sex difference, 197
reported mean speed, 228t Independent activities of daily living (IADLs)
role of vision and kinesthesis in, 218-219 and self-care, 193-214
and skilled tool use, 14-16 Index finger
speed of, 226-228, 301 embryonic development of, 21-22
tests for assessing, 302t-305t, 311-318 grip force rates, 56f
teaching principles and practices, 319-342 splints, 416f
472 • Index
Index grip, 333, 334f Interventions (Continued)

Infants goal setting, 243-244, 245b
bimanual skills in, 131-134 impact on occupational performance, 239-240
contexts of learning, 121-122 intervention approaches, 240-241
development of reaching skills, 92-95 intervention planning factors, 241-243
hand skill development in intervention strategies, 244-262
contexts for, 121-122 research, 244
in play context, 117-137, 127-137, 138t-139t splints, casts and constraints, 262-263
systems that contribute to, 122-127 for handedness, 180-184
theories of, 117-121 to improve handwriting
haptic manipulation strategies in, 71-73, 76-77 efficacy studies on, 451, 452t-453t, 454
haptic perception development in, 64-65 muscle tone and posture, 247
learning skills in, 108-110 positioning, 246
measuring pain in, 375-376 surgical and medical, 446-447
neonatal typical problem areas, 245b
splints, 415-417 Intraparietal sulcus
object manipulation diagram illustrating, 13f
stages of, 143, 144-150, 144b Intrathecal baclofen, 446-447
object release in, 130-131, 136-137 Intrinsic hand muscles
play activities and alpha motor neurons, 4-5
12-24 months, 134-136 and tendons, 31-35
birth to 12 months, 127-129
and posture, 122-124 J
preterm
haptic perception disorders in, 79-80 Joint capsules, 25, 26f
reaching movements by, 94-95 Joints
role of vision and cognition deep pressure, 351
in haptic perception, 74-76 embryonic development of, 21-22
sensory progression in, 124-126 metacarpophalangeal, 23, 25, 26-28
Inferior parietal cortex of phalanges, 23, 24f, 25, 26f
and tool use, 14-16 stability and mobility
“use-dependent” organization of, 14 and hand function, 277
Inferior parietal lobes Juvenile arthritis
diagram illustrating, 13f splinting, 418
functions of
and hand movements, 12-13 K
role in preshaping of hand, 12-13
Inferior pincer grasp, 462 Key points of control
Inflammation with cerebral palsy, 350
clinical signs and implications of, 368-369 in neurodevelopmental treatment (NDT), 349, 353-354
stage of, 368 Keyboarding, 232, 306-307
In-hand manipulation Kinesiology
assessment of, 297 of the hand, 21-43
definition of, 150, 462 Kinesthesia
five basic types of, 255b definition of, 219, 462
general principles for developing, 256-260 and proprioception, 48
important factors influencing, 156-157 role in graphomotor skills, 218-219
intervention strategies, 255-260 and teaching handwriting, 230-231, 328-330, 329b,
sample short-term goals for, 244, 245b 335-340
sequence of difficulty, 256-257 Kinesthetic Sensitivity Test (KST), 219, 231
and “Smart Hands” activities, 273 Kinesthetic teaching techniques, 335-340
studies of, 154-155 Kleinert splints, 385, 386f
Inhibition Knickerbocker’s test, 171b, 172
case study techniques of, 352, 357t, 362t Knowledge
definition of, 349 components of, 106-107
techniques of, 350 and memory, 107
Intermodal perception, 462
Interpretive phase L
of drawing, 221, 222f
Interventions Lacing activities, 273-275
for cerebral palsy Language disorders
neurodevelopmental treatment (NDT), 353-354 and haptic perception, 81-82
to enhance hand function Lateral tripod grasp, 462
efficacy of, 433-457 Learned movements
grasp levels, 251-253 description of, 47
for hand skill problems in children Learned non-use, 462
Index • 473
Learning Manipulation (Continued)

definition of process of, 102, 108-110 “Strong Hands” and “Smart Hands,” 272-278
descriptions of, 109b and tripod grips, 219-220
dressing skills, 203, 205t, 206, 207t, 208, 209t, 210 Manual Form Perception (MFP) test, 77-78
and sensorimotor control, 53-54 Manuscript writing
stages of versus cursive, 324-326
in infants, 120-121 kinesthetic approach to teaching, 335-336
to write name, 283b Mastery motivation, 197-198
Learning disabilities Mastication, 47
and haptic perception, 81-82 Matin Vigorimeter, 289
Left handedness Maturation stage
consistent versus inconsistent, 168 of wound healing, 369
definition of, 166b Mechanoreceptors
intervention theories for, 182-184 and touch, 48
Letters Meissner corpuscles, 48
presenting models for, 339-340 Memory
Lifting definition of, 107, 462
and anticipatory control, 53 storing information in, 102
coordination of forces during, 48-51 working
performed at different ages, 50f and handwriting performance, 229
Ligaments Mental retardation; See also Down syndrome
checkrein, 27 and haptic perception, 80-81
collateral, 25, 26f Metacarpals
of digital joints, 25, 26f anatomical diagram of, 22f
splinting, 383 description and position of, 22-23
of wrist, 23, 24f embryonic development of, 21-22
Limb position sense ligaments of, 23, 24f
and proprioception, 48 Metacarpophalangeal joints, 23, 25, 26-28
Load force collateral ligaments of, 25f, 26
illustration of, 50f Middle phalanges
illustration of rates of, 56f anatomical diagram of, 22f
Loading phase description and position of, 22-23
and manipulation force development, 51 ligaments of, 23, 24f
Longitudinal arch Miller Assessment for Preschoolers, 77
anatomical diagram of, 23f Minnesota Handwriting Assessment (MHA), 302t-303t, 306,
description of, 22 311-312
Low load prolonged stress (LLPS), 419 Mirror movements, 462
Lunate Mixed handers
anatomical diagram of, 22f definition of, 166b
description and position of, 22-23 Mobility
ligaments of, 23, 24f versus stability, 241
Motivation
M and hand ability in children, 46f
to improve hand skills, 45-46
Mallet finger, 384 and interests
Manipulation; See also in-hand manipulation; object of children to learn, 242-243
manipulation mastery, 197-198
and anticipatory control, 52-53 Motor control
bilateral, 260-262 summary of, 58-59
complexity of, 101 Motor impairments
definition of, 144, 147 affecting drawing abilities, 225
examples of strategies of affecting reaching skills, 96
by children, 74b Motor learning
force development, 51 definition of, 347, 463
general principles for developing in-hand, 256-260 development of
grip and finger in infant play context, 117-137, 138t-139t
and self-care, 213 and kinesthetic teaching techniques, 335-340
important aspects of, 102 role of somatosensory cortex in, 11-12
by infants theory of, 242
systems that influence, 122-126 Motor programs
in-hand definition of, 47
intervention strategies, 255-260 Motor skills
versus prehension, 150 affected by brain injuries, 81
during preschool training, 270-278 and cognition
role of in haptic perception in, 69-70 adaptation, 102
and sensorimotor control, 53-54 attention and perception, 104-105
474 • Index
Motor skills (Continued) Muscles

case scenario, 101-102 balance and biomechanical considerations, 35, 37
concept formation, 106-107 embryonic development of, 21-22
importance in acquisition of, 102-103 extrinsic
memory, 107-108 of hands and arms, 27, 28f-29f, 29-31, 32f
perceptual-motor processes, 105-106 and hand ability in children, 46f
processes of, 103-108 intrinsic
definition of, 102 of hands, 31-35
development of and proprioception, 48
versus cognitive skill development, 110 tendon movement with, 37
in infant play context, 117-137, 138t-139t weakness
role of somatosensory cortex in, 11-12 with cerebral palsy, 344
variability in, 155-157 work capacity of, 37, 38t
and evaluating handwriting, 294-295 Myelomeningocele (MMC)
goal setting interventions, 243-244, 245b affecting drawing abilities, 225
important aspects of, 102 affecting reaching movements, 96
and kinesthetic teaching techniques, 335-340
repetition and practice, 242 N
and self-care, 193-214
Mouth Needle threading, 323, 324f
two hands and exploration with, 145f Neonatal infants
used for object exploration, 146, 147-149 haptic perception disorders in, 79-80
Movements splints, 415-417
acceleration and deceleration phases of, 93-95 Neoprene thumb abduction splints, 334f, 335
and anticipatory control, 53 Neovascularization, 368-369, 370b
components of, 102 Nerves
constraint-induced (CI) therapy associated with tendons and muscles
description of, 263 of hand, wrist and forearm, 28f-29f, 31f, 32f, 33f
research and case studies on, 444-446 injuries to
control theories, 46-47 splinting approach, 418, 423-425
development of supply of
in small children, 51 to forearm, hand, and wrist, 37-40
disorders of Neurodevelopmental Treatment Association (NDTA), 344-347
cerebral palsy, 344 Neurodevelopmental treatment (NDT)
goal directed, 102 for cerebral palsy, 343-363
in infants case studies, 355-359, 360-363
and hand skill development, 117-121 efficacy of, 354-355
isolated hand and arm, 247-249 research studies on, 440-443
learned facilitation techniques, 350-351
description of, 47 inhibition, 349-350
mature reaching intervention process
integration of sensory information, 92 for cerebral palsy, 353
role of proprioception, 91-92 key points of control, 349, 353-354
role of vision in, 91 planning treatment, 352, 357t, 361t
speed, 89-90 and postural control, 347-346
transport and grasp phase, 90-91 role of sensation and anticipatory control in, 346-349
reaching Neuromaturation model
beginning stage, 92-93 of motor development, 117-118
coordinating body parts, 93 Newborns; See infants
development during infancy, 92-95 Newton Early Childhood Program, 267, 280, 283, 285-286,
planning, 93-95 289, 290-291
sensory information, 95 Nine-Hole Peg test, 297
variations, 95 Non-language learning disabilities (NLD), 327-328
summary of object manipulation, 148-149 Numeric rating scale (NRS)
theories of, 102-103 to measure pain, 376
units, 463
used in object exploration, 144-146 O
Multimodal exploration
definition of, 64, 463 Object manipulation; See also manipulation
Muscle tone and anticipatory control, 346-349
assessment of and haptic perception, 69-74
in cerebral palsy patients, 352 in infants and children, 143-158
definition of, 349 of multiple objects, 148
neurodevelopmental approach to, 347 in older children, 157-158
case study, 360-363 in preschool and early childhood years, 154-157
Index • 475
Object manipulation (Continued) Passive range of motion (PROM), 370, 371f, 375
role of vision in infant, 147-148 Pathologic handedness
during toddler years, 150-154 definition of, 166b, 463
summary of, 153-156 Peabody Developmental Fine Motor Scales, 3, 150, 243
Object release Pediatric Evaluation of Disability Inventory (PEDI), 195-196,
from 12 to 24 months, 136-137 197, 199
from birth to 12 months, 130-131 Pencil grips
control of improper, 319
by toddlers, 152 remediation, 331, 333f
developmental sequence of training, 330-335
birth through 24 months, 138t-139t “Pencil Pal,” 331, 333f
Objects Perception
characteristics of definition of, 104, 463
and grasp interventions, 250-251 definition of process, 102
familiar versus unfamiliar, 56-57 and hand ability in children, 46f
and hand interaction importance in hand skill development, 119-120
cortical control of, 3-17 in motor skills, 104-105
handling of multiple, 148 and self-care, 214
infant exploration actions, 73b Perceptual skills; See perception
in-hand manipulation of, 256-260 Perceptual-motor processes, 105-106, 463
manipulation (See also object manipulation) Peripheral nerves
and exploration, 144-147 injuries to
and haptic perception, 69-74 splinting approach, 418, 423-425
in infants and children, 143-158 Personality
release of (See also object release) factors in self-care, 214
in infants, 130-131, 136-137 Pervasive Developmental Disorder- Not Otherwise Specified
spatial orientation of, 67 (PDD-NOS), 278
substance, structure and function of, 71t Phagocytosis, 368-369, 370b
transporting, 251 Phalanges; See also digits; fingers
weight, size and friction of embryonic development of, 21-22
and anticipatory control, 52-53 fractures and dislocations of, 383-384
Observation of Visual Motor Orientation and Efficiency, 325 joints of, 23, 24f, 25, 26f
Occupational therapy Physical health
approaches to handwriting functional definition of, 193
efficacy research on, 454-456 Piagetian approach
approaches with preschoolers to cognition and motor skill development, 103
research studies, 449-450, 451t, 453-454 Pincer grasps, 463
cerebral palsy research, 436t-440t Pisiform
effective sessions for preschoolers, 284-285 anatomical diagram of, 22f
fine motor program for preschoolers, 267-287, 289-291 description and position of, 22-23
goal setting, 243-244, 245b ligaments of, 23, 24f
interventions Play
to enhance hand function, 433-457 activities
for hand skill problems, 239-264 and child motivation, 242-243
pediatric and fine motor development, 267-268
and handedness, 179-184 imaginary or symbolic, 125
role of performance in infants
when treating cerebral palsy, 347 from 12 to 24 months, 134-136
Opponens pollicis muscles, 31-34, 33f, 35f from birth to 12 months, 127-129
Osseous arches for preschoolers, 271-272
of the hands, 22, 23f “Smart Hands,” 272-278
“Strong Hands,” 273, 274b
P therapy
research on efficacy of, 449
Pacini corpuscles, 48 Play dough, 273, 278f
Pain Positioning
with cerebral palsy, 344 and grip force, 50f
with fractures of hand
in wrists, 380-383 during burn healing phase, 391, 393
of hand wounds, 375-376 and self-care, 213
measurement tools, 376 and splinting, 403-404
Palmar aponeurosis, 40, 41f using vertical surfaces, 268-269
Palmar grasps, 128-130, 256-258, 463 Posterior parietal lobes
Palmar interossei muscles, 32-34, 35f importance for hand-object interactions, 3-4
Parietal cortex two parts of, 13
and hand-object interactions, 3-4 Postural control, 463
476 • Index
Postural sway, 346 Pronation

Posture interventions to improve, 247-249
affected by cerebral palsy, 344 splints, 414
affecting handwriting, 298t, 301, 306 Proprioception
anticipatory, 346 definition of, 463
and hand skill difficulties, 247 description of, 48
and handwriting instruction, 230-231 role in reaching, 91-92
importance of Proprioceptive systems
in infant hand skill development, 122-124 influencing hand skill development
in reaching, 93 in infants, 124-126
inhibition and facilitation techniques, 349-351 Prosthetic devices
and kinesthetic teaching techniques, 338, 341f for handwriting, 331, 332f
reflex-inhibiting, 344-347 Proximal interphalangeal (PIP) joints
relationship to upper extremity function description of, 23
and cerebral palsy, 347-346 dorsal dislocation of, 384
Power Proximal phalanges
and hand preference, 164 anatomical diagram of, 22f
Power grip description and position of, 22-23
definition of, 463 embryonic development of, 21-22
description of, 41 ligaments of, 23, 24f
development of, 253-254 Proximal to distal development, 241
Praxis, 463 Proximal transverse arch
Precision grip anatomical diagram of, 23f
alteration with object sizes, 41f description of, 22
definition of, 463 Purposeful release, 131
development of, 143 Puzzles, 276
normal and impaired development
of force control in, 45-59 Q
versus power grip, 4-5
types of, 43f Quadrupodgrasp, 280-281
Precision handling
definition of, 463 R
and handwriting, 323, 324f
Preference; See hand preference; handedness Radial digital grasp, 251-253, 463
Prehensile force control Radial nerve palsy
in children with central nervous system disorders, 45-46 case study
sensory information used for, 57-58 on splinting, 423-425
Prehension skills Radial palmar grasp, 463
from 12 to 24 months, 136 Radial-ulnar dissociation, 253, 463
from birth to 12 months, 127-130 Range of motion (ROM)
definition of, 463 assessment of
patterns of in cerebral palsy patients, 352
versus manipulator patterns, 150 in children and adolescents, 375
Premotor cortex of hands
and hand-object interactions, 3-4 following wounds or injuries, 370-375
Preschoolers; See also children in infants, 372
fine motor program for, 267-287, 289-291 neurodevelopmental approach to, 347
fine motor skills in in toddlers, 372-373
and visual perceptual inventory, 290-291 types of, 370-373
object manipulation in, 154-157 upper extremity
occupational therapy research studies, 449-450, 451t, 453- and handwriting, 321, 324
454 “Rapper snappers,” 271
scissors skills in, 279-280 Reaching
Primary motor cortex and anticipatory control, 53, 94
diagram of, 5f case scenario concerning, 101-102
role in hand movements, 5-7 definition of, 89
summary and therapeutic implications, 16 and eye-hand coordination, 89-97
“use-dependent” organization of, 5-7 and hand preference, 164
Primary sensory cortex importance of postural control in, 346
connections to, 16, 17f in infancy, 143
Primary somatosensory cortex; See somatosensory cortex and motor impairments
Priming adaptations, 96-97
definition of, 104 in children, 96-97
Primitive grasps, 128-130 with hemiplegic cerebral palsy, 97
Primitive wound contracture, 368-369, 370b planning and feedback control, 96
Production Consistency Sheet, 329, 330f
Index • 477
Reaching (Continued) Self-care skills (Continued)

movements maturation, 197
beginning stage, 92-93 motor factors, 198
coordinating body parts, 93 sex differences, 197
development during infancy, 92-95 social and cultural issues, 197-198
integration of sensory information, 92 chronology of acquisition
planning, 93-95 activities of daily living, 212-214
role of proprioception, 91-92 cognitive and personality factors, 214
role of vision in, 91 dressing and undressing, 203, 205t, 206, 207t, 208, 209t,
sensory information, 95 210
speed, 89-90 eating and drinking, 199, 200t
transport and grasp phase, 90-91 hand skills in, 193-214, 213-214
variations, 95 hygiene and grooming, 210, 211t-212t
and self-dressing, 205t self-feeding, 199, 200t
two main parts of, 12 serving and preparing food, 203, 204t
Reflexes utensil use, 201, 202t, 203b
control theories concerning, 46 definition of, 463
Reflex-inhibiting postures (RIPs), 344-345 development of, 196-210, 211t-212t, 213-214
Regeneration and fingers, hands and grip abilities, 213-214
of tissue wounds, 368 and hand skill development, 193-214
Release; See object release independence in
Repair in children, 194, 212-213
of tissue wounds, 368 in the disabled, 194-195
Representation measurement of
definition of process, 102 nonstandardized measures, 195
Research evidence standardized measures, 195-196
on cerebral palsy, 435, 436t-440t perceptual factors in, 214
on hand function Self-dressing; See dressing skills
in cerebral palsy patients, 436t-440t Self-feeding, 199, 200t, 201, 202t, 203, 204t
on in-hand manipulation, 154-155 Semantic memory, 107-108
levels of, 433-434 Sensorimotor control
summary of, 456-457 organization of, 53-54
Retrieval phase Sensorimotor cortex
of explicit memory, 108 firing of haptic neurons in, 69
Reverse transverse grip, 463 and hand-object interactions, 3-4
Right handedness Sensorimotor system
consistent versus inconsistent, 168 delay problems
definition of, 166b research studies on, 450t
Rotation skills, 257-259, 323, 324f, 463 and hand ability in children, 46f
Sensory awareness
S versus motor control, 241-242
typical activities for, 247b
Sandwich splints, 391f Sensory feedback
Scaphoid and grasp, 16
anatomical diagram of, 22f and haptic perception, 69
description and position of, 22-23 importance of
fractures, 380-383 in motor learning, 11-12
ligaments of, 23, 24f Sensory information
Scar remodeling stage and development of reaching skills, 95
of wound healing, 369, 370b gathered by hands and fingers, 7-9
Scars and hand skill development
management of burn, 391-393 in infants, 119-120
from radial club hand operations, 396-398 integration of vision and proprioception, 92
sandwich splints for, 391f processing
from syndactyly operations, 394-396 and handwriting, 299-300
Scissors and reaching, 92
illustration of cutting, 153f used for force control, 57-58
motor functions of, 323 Sensory Integration and Praxis Tests (SIPT), 77-78, 179-180
skill development Sensory systems
in preschoolers, 279-280 impairments
Scissors grasp, 463 with cerebral palsy, 346-347
Selective attention, 104 importance of
Selective posterior rhizotomy, 446 in infant hand skill development, 124-126
Self-care skills Shift skills, 259, 463
acquisition of, 196-198
mastery motivation, 197-198
478 • Index
Shoes Splinting (Continued)

learning to tie, 209t, 210 fabrication for children, 410
and haptic perception, 63 history of, 401-402
Size as intervention adjunct, 262-263
haptic perception of, 66 material characteristics, 409-410
of objects for orthopedic problems, 407t, 417-419
and anticipatory control, 52 patient care instructions, 429-430
Skier’s thumb, 383-384 principles of, 402-403
Skilled hand movements; See also movements selection of, 404, 405f, 406t-407t, 408-410
role of sensory information in, 8-9 types of, 404, 405f, 406t-407t, 408
Skilled tasks Splints; See also splinting
versus unskilled, 164 finger and thumb, 383-384
Skills Kleinert, 385, 386f
acquisition of, 108-110 for mallet finger, 384f
definition of, 108 neoprene, 334f, 335, 382f
Skin for tendon injuries, 385-389
of hands, 40, 41f vendors, 431
“Smart Hands,” 272-278 wearing schedules and precautions, 419
Social isolation for wrist and elbow injuries, 380-382
with cerebral palsy, 344 Squeeze grasp, 464
Somatosensory cortex Stability
circuit of, 17f affecting handwriting, 298t, 301, 306
and hand skills, 7-9 definition of, 464
and hand-object interactions, 3-4 and grasp, 250
illustration of, 10f importance of wrist
role in grasp, 10-11 in handwriting, 321-323
role in motor learning, 11-12 of materials
role in sensory function, 7-9 and grasp, 259f, 260-262
“use-dependent” organization within, 9-10 versus mobility, 241
Somatosensory sensation and self-dressing, 205t
role in haptic perception, 69 Stabilization; See stability
Somatosensory system Static splinting, 404, 464
cortical organization of, 8-9 Static tripod grasp, 464
definition of, 463 Stereognosis, 464
feedback Stickers, 276
and graphomotor skills, 218-219 Stiffness, 464
S.O.S. grids, 282 Storage phase
Southern California Sensory Integration Tests (SCSIT), 179- of explicit memory, 108
180 Stringing activities, 273-275
Spasticity “Strong Hands,” 272
with cerebral palsy, 344 Subcutaneous fascia
biomechanics of, 350-349 of hands, 40, 41f
definition of, 464 Superior parietal lobes
neurodevelopmental approach to, 345-346 diagram illustrating, 13f
surgical and medical interventions, 446-447 effect of lesions in, 8f
Spatial analysis functions of
in handwriting, 327-328 and hand movements, 12-13
Spina bifida Supination
affecting drawing abilities, 225 interventions to improve, 247-249, 251
Spinal cord splints, 414
ventral horn divisions of, 4-5 Swallowing
Splinting; See also splints and movements, 47
anti-Houdini techniques, 420b, 418f-420f, 419 Swan neck deformities
benefits of, 402-403 splinting, 418f
case study on radial nerve palsy, 423-425 Switched handedness
common problems requiring definition of, 166b, 464
finger control, 414-415, 416f intervention theories for, 182
fisted hand, 411-412 problems associated with, 169b
neonatal intensive care, 415-417 theories concerning, 168-169
supination and pronation, 414 Symbolic play, 125
thumb in palm, 411 Syndactyly, 394-396
weight bearing, 414, 415f
wrist flexion, 412-413 T
wrist ulnar and radial deviation, 413-414
efficacy of Tactile apraxia, 15
research studies on, 443-444 Tactile cues, 351
Index • 479
Tactile perception Thumbs

and brain injury, 81 embryonic development of, 21-22
impairments grip force rates, 56f
and learning disabilities, 81-82 metacarpophalangeal joint of, 26-27
Tactile scanning, 63 Ties, 208, 209t, 210
Tactile system Tissue
awareness or discrimination, 246-247 burn scarring of, 391-394
definition of, 48 regeneration of wounds, 368
and friction, 53 Toddlers; See also children
identifying properties, 71b complementary two-hand use by, 152-153
importance of measuring pain in, 375-376
in grasping and holding, 48-54 object manipulation by, 150-154
influencing hand skill development summary and therapeutic implications
in infants, 124-126 of object manipulation skills, 153-156
and motor control, 241-242 Toileting, 210, 211t
and object recognition, 69 Tone; See muscle tone
Tapping, 171b, 172, 351, 464 Tools
Teaching definition of, 198
approaches to handwriting features of skilled use of, 14-16
efficacy studies, 451, 452t-453t, 454 handwriting, 220
principles and practices of handwriting, 319-342 history of, 319
bilateral integration, 326-327 power grasps on, 253-254
kinesthetic approach to, 335-341 role of inferior parietal cortex in use of, 14-16
kinesthesia, 328-330 and self-care activities, 198-210, 211t-212t
pencil grip, 330-331, 332f, 333-335 skills with
spatial analysis, 327-328 and hand preference, 164
training groups, 319 stabilization of
upper extremity support, 320-321 hand structures needed for, 333b
visual control, 324-325 Total end range time (TERT), 419, 464
wrist and hand development, 321-324 Touch; See also tactile system
to write name, 283b importance of
Tendons in grasping and holding, 48
balance and biomechanical considerations, 35, 37 Toys
extrinsic “Smart Hand,” 272-278
of hands and arms, 27, 28f-29f, 29-31, 32f types of
injuries to hand, 385-389 for fine motor skill development, 271-278
and intrinsic muscles Tracing, 171b, 172, 282
of hands, 31-35 Trajectory
movement with muscle contraction, 37 definition of, 89
and proprioception, 48 of reaching, 91
Tensile strength Translation, 464
and wound healing, 369 Transport phase
Test of Handwriting Skills (THS), 302t-303t, 312-313 of reaching, 90-91, 464
Test of Legible Handwriting, 304t-305t Trapezium
Test of Motor Impairment (TOMI), 231, 448-449 anatomical diagram of, 22f
Tests description and position of, 22-23
for assessing handwriting, 302t-305t ligaments of, 23, 24f
Texture Trapezoid
haptic perception of, 66 anatomical diagram of, 22f
identifying, 71b description and position of, 22-23
The Development Test of Visual-Motor Integration, 227b ligaments of, 23, 24f
The Luria-Nebraska Neuropsychological Battery, 78 Tripod grip
Therapeutic interventions; See interventions adapted, 331f
Thermal hand injuries description of, 219-220
in children illustration of, 269f, 280f
classification of severity, 392-394, 390t training children in, 330-331
closed wound scarring phase of, 392-394 Triquetrum
open wound phase of, 390-392 anatomical diagram of, 22f
patterns of, 389-390 description and position of, 22-23
“Think breaks,” 339f ligaments of, 23, 24f
Three-jaw chuck, 464 Trunk
Threshold tests, 464 functions of
Thumb in palm, 406t, 411 kinesiologic aspects of, 347-350
Thumb spica splints, 382f stability of
Thumb-index web space, 322 and self-dressing, 205t
480 • Index
U Visual motor integration (VMI), 227, 231, 325, 448-449, 451,

452t-453t, 454
Unestablished handedness Visual perceptual inventory
definition of, 166b and fine motor skills
intervention theories for, 180-182 for preschoolers, 290-291
Upper extremities Visual-motor skills
casting instruments to assess, 296t
research on efficacy of, 443-444 Visual-perceptual skills
constraint therapy, 263 evaluation of, 293-294
embryonic development of, 21-22 instruments to assess, 295t
interventions for cerebral palsy Volition, 464
a neurodevelopmental treatment approach, 343-363 Voluntary release
motor development tests, 195 definition of, 464
splinting, 401-419, 420f-422f difficulties
case study, 423-425 intervention strategies, 254-255
and teaching handwriting, 320-321 sample short-term goals for, 244, 245b
and voluntary release, 254
Upper limbs W
biomechanical interactions of
in cerebral palsy patients 350-349 “Wake Up Hands,” 271-272
functions of Wee Functional Independence Measure (WeeFim), 195-196
kinesiologic aspects of, 347-350 Weight
“Use-dependent” organization bearing
of inferior parietal and ventral premotor cortex, 14 splints, 414
within somatosensory cortex, 9-10 on upper and lower limbs, 351
Utensils; See also tools haptic perception of, 66
learning progression for using, 201, 202t, 203b of objects
and anticipatory control, 52
V shifting, 351, 464
Wind-up toys, 276
Vasoconstriction, 368-369, 370b Work capacity
Vasodilation, 368-369, 370b of muscles, 37, 38t
Velocity Working memory, 229, 464
illustration of rates of, 56f Wounds
Ventral premotor cortex burns
diagram illustrating, 13f classification of severity, 392-394, 390t
role in preshaping hand, 13-14 closed wound scarring phase of, 392-394
“use-dependent” organization of, 14 open wound phase of, 390-392
Ventral stream, 104, 464 patterns of, 389-390
Verbal rating scale (VRS) caused by congenital differences, 394-398
to measure pain, 376 characteristics of, 375
Vertical surfaces phases of healing, 368-369, 370b
examples of activities for, 269b Wrists
materials and suppliers, 289 embryonic development of, 21-22
teaching hand/wrist positions using, 268-269 fractures in, 380-383
Vestibular input, 351 joints of, 23, 24f
Vibration, 144-145, 350, 353 nerves associated with tendons and muscles of, 28f-29f, 31f,
Vision 32f, 33f, 37-40
and grasp preparation, 12-13, 16 stabilizing of
influencing hand skill development importance for handwriting, 321-322
in infants, 119-120, 124-126 supination and stability of, 251
and manuscript versus cursive writing, 324-326 and teaching handwriting, 321-324
problems ulnar and radial deviation, 413-414
with cerebral palsy, 344 using vertical surfaces when training, 268-269
role of Writing; See graphomotor skills; handwriting
in graphomotor skills, 218-219 Written language assessments, 298-299
in haptic perception, 65-67, 74-75, 77
in object manipulation, 147-148 Z
in reaching, 91
Visual analog scale (VAS) Zippers, 208, 209t, 210
to measure pain, 376 Zone of proximal development, 240-241, 243, 464
Visual motor control Zoo sticks, 276
evaluation of, 297-298
in handwriting, 324-326

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MOSBY

11830 Westline Industrial Drive

HAND FUNCTION IN THE CHILD: FOUNDATIONS FOR ISBN-13: 978-0323-03186-8

The Publ isher

International Standard Book Number 13 978-0323-03186-8

Publishing Director: Linda Duncan

Ashwini K. Rao, EdD, OTR Scott D. Tomchek, MS, OTR/L

Birgit Rösblad, PhD, PT Laura K. Vogtle, PhD, OTR/L, ATP

be related to an increased demand on body scheme

RH LH Michel, & Prablanc, 1984). Note the difﬁculty she has

CORTICAL ORGANIZATION OF THE

Central Sulcus difﬁcult task conditions or in which the animal had to

Central sulcus Primary

Inferior parietal lobe

of possible actions the hand can take on an object (see

CHAPTER OUTLINE EMBRYONIC DEVELOPMENT

Distal transverse arch

A B Proximal transverse arch

Ulnocarpal Radial collateral

Ulnolunate ligament Radiolunate

Figure 2-4 Columnar carpus. The scaphoid is the

planes and combinations thereof (Figure 2-7). The

Figure 2-7 Joints of the phalanges. The diarthrodial

Flexor digitorum superficialis

Palmaris longus Flexor carpi ulnaris

Pronator Pronator quadratus

Pronator teres Brachioradialis

Flexor digitorum profundus

Deep Flexor pollicis longus

Flexor digitorum A-1

Extensor pollicis brevis

Extensor Extensor digitorum

Extensor digiti quinti

Flexor pollicis brevis Adductor pollicis

Abductor digiti quinti Flexor digiti quinti brevis

Dorsal Dorsal interossei Palmar Palmar interossei

Long extensor tendon

Long extensor tendon Sagittal bands

Flexor profundus tendon

Long extensor tendon

Flexor carpi radialis 0.8

Extensor carpi radialis brevis 0.9

plexus is necessary if one is to fully appreciate the more

Radial nerve lesions at or proximal to the elbow

SKIN AND SUBCUTANEOUS FASCIA

As generally stated, power grip is a combination of

Figure 2-24 Palmar aponeurosis reflected distally

Dorsally the deep fascia and extensor tendons fuse

resistance imparted by the ﬁrst and second dorsal

original unabridged work may be found in Fess EE,

CHAPTER OUTLINE meaningful purpose. Then the task to be performed has

Motivation Sensorimotor system

and body image have an impact on one’s ability to

Figure 3-2 Child lifting the experimental object.

1 Year 6 Years Adult

Grip Force 40 N/S

weight of the object at lift-off, indicating anticipatory

DEVELOPMENT OF ANTICIPATORY 200

Peak Grip Force Rate (N/s)