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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
involve extensive use of our hands. As we perform these
occupations we give little thought to the enormous
variety of actions our hands can do. A hand can be a
platform, a vise, or a hook. It can push and poke, pull
and twist, scratch or rub. It can hold a football, an
apple, or a raisin. It is the enabler of multiple tool uses.
A major task of childhood is the development of this
wide variety of hand actions. When a child’s hands are
not functioning well or if there is a delay in develop-
ment, the occupations of childhood are affected, such
as playing with objects, dressing, and using tools such
as spoons, scissors, or pencils. Remediation of the hand
is therefore a major focus of intervention.
Hand Function in the Child originally grew out of
the recognition that there was a significant gap in the
professional literature addressing the problems of hand
dysfunction in children, despite the importance of the
hand to the child’s development. It has been 10 years
since the first edition was published and it still remains
the only complete text covering this topic. This second
edition again reviews detailed information on the
neurological, structural, and developmental founda-
tions of hand function in children. We maintain the
focus on the hand as a tool for action and an organ of
accomplishment and highlight the complexity of skilled
hand use and the long developmental period needed
for its perfection. As many of the chapters review
information from rapidly changing fields of study, an
important purpose of the revised edition was to update
these chapters. Another purpose was to add chapters in
several areas of content that we felt to be important.
The content is presented in three parts. The first
part, “Foundation of Hand Skills,” provides informa-
tion on the anatomical, neurological, physiological, and
psychological aspects of hand function. This section
begins with an updated chapter on control within the
central nervous system that describes the mechanisms
that allow skilled use of the hand as it relates to hand-
object interaction. This is followed by a chapter on the
embryology, anatomy, kinesiology, and biomechanics
of the hand. The third chapter explores sensory control
and the way in which the control of grasp and lifting of
objects varies with differing sizes, shapes, and textures.
The next chapter examines the development and eval-
uation of the ability of infants and children to recognize
objects and object properties felt by the hand. The fifth
chapter updates the research on the role of vision in the
control of movements in the environment, and covers
the development of visual control in childhood. The
final chapter in Part I is new in this edition and high-
lights the cognitive processes required for the acquisi-
tion and performance of hand skills.
Part II, Development of Hand Skills, explores the
changes in hand skills that occur with age. The first
chapter on the early development of grasp, release, and
bimanual activities has been revised to present the con-
tent in the context of infant play from birth to 2 years.
The second chapter examines object manipulation from
birth throughout childhood. Chapter 9, on handedness
and its development, is new and includes an extensive
review of research on hand preference as well as on
the evaluation of hand preference. Chapter 10, on the
development of self-care activities in relation to the
development of hand skills, contains additional infor-
mation on current measures and on cultural influences.
The final chapter in Part II has a new, extensive review
of recent research on handwriting.
Therapeutic intervention is presented in Part III.
The chapters focus on the overall remediation of hand
skills, on the remediation of special problems, and on
specific areas of intervention. Chapters 12 and 15 have
been updated and revised. The remaining six chapters
in this section are new. Chapter 13 presents ideas on
how the engage the preschool child in hand activity and
to incorporate treatment activities into the classroom.
The next chapter reviews problems related to hand-
writing difficulties and presents formal and informal
assessments. Chapters 16, 17, and 18 focus on specific
areas of dysfunction and intervention. We chose a
review of research on the effectiveness of improving
hand function for the final chapter.
vii
viii Preface to the Second Edition
Our primary vision continues to be to present in a
single text current information on the neurological
foundations of hand skills, the development of hand
skills, and intervention for children with problems
related to hand skills. We hope that a comprehensive
review of the hand will provide an important resource
and clinical guide for students, practicing pediatric
therapists, and others who work with children.
ACKNOWLEDGMENTS
The editors wish first to acknowledge with gratitude
the time and expertise donated by the contributors to
this volume. These authors are highly regarded in their
respective fields, and we thank them for their insights
and the wealth of practical and theoretical under-
standing they bring through their chapters. We hope
that the diversity of ideas presented here will enrich the
reader’s understanding and appreciation of the im-
mense complexity and the multiple dimensions of the
human hand and particularly of its importance to daily
living from birth through adolescence.
This book is the culmination of the efforts of many
people who contributed ideas over an extended period
of time. The formal beginnings of the book occurred
during a series of workshops for occupational and
physical therapists funded by the Maternal and Child
Health Bureau, U.S. Department of Health and
Human Services, Department of Public Health. The
workshops were sponsored by the Occupational
Therapy and Physical Therapy Departments at the
University of Illinois at Chicago between 1988 and
1991. Several of the contributors to the first edition
participated in yearly task groups on the hand of the
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
the first edition by many professional colleagues and
their comments helped shape this second edition.
We would also like to acknowledge the help and
assistance of Kathy Falk, our editor at Elsevier, whose
support enhanced all the phases of the production of
this book by answering our questions and providing a
workable and timely schedule. Thanks also to Sarah
Wunderly, our production manager, and other Elsevier
staff for assisting in the final phase of our work.
Finally we want to recognize the families and
children we and our authors have known through our
professional practice and research for they have
contributed much to our current knowledge of hand
function in the child.
Anne Henderson
Charlane Pehoski
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
physical environment, both though the dexterous grasp
and manipulation of objects and as the enabler of
multiple tool functions. The enormous variety of actions
accomplished by our hands ranges from the practical to
the creative. The hand is incredibly versatile. It can be
a platform, a hook, or a vise. It can hold a football, a
hammer, or a needle. It can explore objects, express
emotion, or communicate language.
The hand is the subject of this book, most spe-
cifically the hand as a tool for action, as an organ of
accomplishment. The motor functions of the hand are
some of the most complex and advanced of all human
motor skills. Hand use is voluntary, under the control
of the conscious mind, and is regulated by feedback
from sensory organs. The complexity of skilled hand
use is shown by the long developmental period needed
for its perfection. The ability to manipulate objects with
the efficiency and precision of an adult continues to im-
prove throughout late childhood and early adolescence.
The plan for this book grew out of the recognition
that, although the treatment of hand dysfunction has
been a critical area of occupational therapy practice
since the beginning of the profession, for many years
the professional literature in pediatrics placed a greater
emphasis on the neurophysiology and development
of gross motor abilities than on manipulative skills. A
renewed attention to manipulative abilities, beginning
about 15 years ago, was spearheaded by the writings of
therapists such as Rhonda Erhart, Reggie Boehm, and
Charlotte Exner, and professional literature on the devel-
opmental treatment of hand skills has since increased.
During a similar period there has been increasing
research attention in the fields of neurophysiology and
psychology to the motor skills of the hand. Although
there are many unresolved issues about hand devel-
opment and dysfunction in childhood, it seemed timely
to review that which is currently known.
This book is intended for the professional and
student interested in the current research and treat-
ment of problems in children’s hand skills. The text is
organized around themes from neurobehavior and
development, drawing together information that is
pertinent to the understanding of dysfunction in the
hand in children and as a guidance to intervention.
Hand function is reviewed from the perspectives of
neurophysiology, neuropsychology, cognitive psychology,
developmental psychology, and therapeutic intervention.
The text is organized into three sections, each of
which presents several dimensions of hand function.
Section I includes chapters on the biologic and
psychologic foundations of hand function. The first
chapter describes the cortical control of skilled hand
use and identifies the properties of that control that are
different from the control of gross motor skills. The
second chapter presents the anatomic structure and
function of the hand facilitating the varied functions.
Two chapters on the sensory guidance of the hand
function follow, one on touch and proprioception and
the other on vision. The other two chapters in Section
I review knowledge from several branches of psy-
chology, including the perceptual functions of the hand
and the role of cognition in hand activity.
Section II focuses on development in both general
and specific areas of hand skill. Two chapters in this
section focus on the development of basic skills. The
first reviews research on the development of grasp,
release, and bimanual skills in infancy and the second
the development of object manipulation. Other
chapters cover specific and complex skill areas of
graphic skill and self-care and the development of hand
dominance.
ix
x Preface to the First Edition
Section III provides knowledge from selected
pediatric clinical practice areas. Two of the five chapters
describe dysfunction and treatment of special popula-
tions with cerebral palsy and Down syndrome. Another
chapter presents the principles and practice of the
remediation of hand skill problems, while a fourth
focuses on the specific area of teaching handwriting.
The remaining chapter identifies the many toys that are
the natural media for the treatment of hand dys-
function in children.
Despite the acceleration of research in the last
decade, the study of the development of hand use and
the treatment of hand dysfunction in children is still in
its infancy. It is our hope that assembling this
information on hand skills will stimulate interest in the
development of research programs that will increase the
body of knowledge about normal and deviant hand
skill development and the efficacy of intervention.
This text was written primarily for pediatric occu-
pational therapists and could serve as a graduate level
text or as a reference book in entry level education.
However, we anticipate that it will be of value for
anyone working with toddlers and children, including
preschool and elementary teachers, special educators,
early intervention providers, and other therapists.
Anne Henderson
Charlane Pehoski

CORTICAL CONTROL OF
HAND-OBJECT INTERACTION
Charlane Pehoski
CHAPTER OUTLINE
MOVING THE FINGERS INDEPENDENTLY: DIRECT
CORTICOSPINAL CONNECTIONS TO ALPHA
MOTOR NEURONS OF THE HAND AND PRIMARY
MOTOR CORTEX
Direct Corticospinal Connections to Alpha Motor
Neurons of Hand Muscles
Primary Motor Cortex
Use-Dependent Organization of the Primary Motor
Cortex
SENSORY GUIDANCE OF HAND MOVEMENTS:
PRIMARY SOMATOSENSORY CORTEX
Cortical Organization of the Somatosensory System
Use-Dependent Organization Within the Primary
Somatosensory Cortex
Role of Somatosensory Input in Grasp
Role of Somatosensory Cortex in Motor Learning
THE TRANSFORMATION OF VISUALLY OBSERVED
CHARACTERISTICS ABOUT OBJECTS INTO
APPROPRIATE HAND CONFIGURATIONS:
POSTERIOR PARIETAL LOBE AND VENTRAL
PREMOTOR CORTEX
Role of the Inferior Parietal Lobe in Preshaping of
the Hand
Role of the Ventral Premotor Cortex in Preshaping
of the Hand
Use-Dependent Organization of the Inferior Parietal
and Ventral Premotor Cortex
The Inferior Parietal Cortex and Tool Use
SUMMARY AND THERAPEUTIC IMPLICATIONS
Chapter 1
When I first met Katie she was 6 years old and was
having a great deal of difficulty managing the fine motor
tasks typical of most kindergarten children. She was
clumsy and had difficulty with such tasks as buttoning
and using tools. Her score on the Peabody Developmental
Fine Motor Scales was −2.33 standard deviations below
the mean for her age and her age equivalent score was
3 years 6 months. This is not an unusual profile for
children referred because of poor fine motor skills.
What was unique about Katie was that the source of
her difficulty was known. A benign tumor had been
removed from her right posterior parietal lobe when
she was 3 years old. Many of the difficulties she experi-
enced in hand–object interaction could be attributed to
the location of her lesion. For example, she was under-
responsive to tactile input and often used excess force
when holding objects. When asked to feel forms placed
in her hand without looking, she just grasped them and
did not explore them with her fingers. She had a great
deal of difficulty in tasks that required “in-hand manip-
ulation,” such as moving a small object from the palm
of the hand to the fingers. Objects often were dropped.
This chapter discusses the posterior parietal lobe and its
importance for hand–object interaction. However, this
is not the only important area; other cortical regions
are also explored.
The capacity to use the hand with skill in hand–
object interactions represents an evolutionary ability
characteristic of the behavior of higher primates. Three
fundamental prerequisites are necessary for this func-
tion: (a) the capacity for independent control over the
fingers, (b) a sophisticated somatosensory system to
guide finger movements, and (c) the ability to trans-
form sensory information concerning object properties
into appropriate hand configurations (Binkofski et al.,
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
includes the primary motor cortex, primary somato-
sensory cortex, parietal cortex (particularly the area
around the intraparietal sulcus), and premotor cortex
(particularly the ventral portion). That is not to say that
other motor structures, such as the supplementary
motor areas, cingulated motor areas, cerebellum, and
basal ganglion do not also serve important functions
(e.g., Ehrsson, Kuhtz-Buschbeck, & Forssberg, 2002;
Lemon, 1999; Schlaug, Knorr & Seitz, 1994), but rather
that the cortical regions mentioned previously seem
critically related to skilled action of the hand, partic-
ularly as it interacts with objects. This chapter reviews
each of the mentioned prerequisite skills and the cor-
tical areas important for their functions. The purpose of
this chapter is to better understand the problems of
children like Katie and provide evidence for the need to
encourage skilled hand use in these children.
MOVING THE FINGERS
INDEPENDENTLY: DIRECT
CORTICOSPINAL CONNECTIONS
TO ALPHA MOTOR NEURONS OF
THE HAND AND PRIMARY MOTOR
CORTEX
DIRECT CORTICOSPINAL CONNECTIONS TO
ALPHA MOTOR N EURONS OF HAND
M USCLES
As indicated, one prerequisite for skilled hand use is the
control over individual finger movements. This is true
even for a seemingly simple task such as picking up an
object using a precision grip.1 Try picking up a small
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
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
showed marked variation with respect to the precise
timing of their onset and time course of activity during
the task, resulting in the specificity of finger move-
1
This chapter uses the term “precision grip” when referring to the act
of picking up a small object between the index finger and thumb
because this is the term used in the neurophysiologic research that is
reviewed.
ments. This is in contrast to a power grip, in which all
the muscles are coactivated (Bennett & Lemon, 1996;
Muir, 1985). Even simple finger movements such as
this require hand muscles to work in a specific temporal
order and with varying amounts of force (Darian-
Smith, Burman, & Darian-Smith, 1999).
This ability to “fractionate,” or move the fingers
individually, is thought to result from the special contri-
bution of direct corticospinal connections primarily
from neurons in the motor cortex to the alpha motor
neuron of hand muscles in the ventral horn in the
spinal cord (see Lemon, 1993, for a review). The ven-
tral horn of the spinal cord is divided into two main
sections, an interneuron zone and the motor neuronal
pool or “final common pathway” to the muscle. The
motor neurons in the ventral horn are not randomly
distributed but are clustered into cell columns, a medial
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-
ities (Kuypers, 1981). Almost all descending motor
fibers first terminate in the interneuronal zone, so that
there is at least one interneuron between the descend-
ing motor fiber and motor neuron. An important
exception is the direct corticospinal fibers to alpha
motor neurons of the distal extremity (Figure 1-1).
This direct path is fast and thought to be important in
moving the hand with speed and skill. These special
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
small objects with precision (Long et al., 1970). Direct
corticospinal fibers seem to be a feature unique to
Corticospinal tract
Direct corticospinal input
Indirect corticospinal input
Interneuron zone
Muscle of distal
extremity
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
connections with a muscle through the interneuron. Also
shown is a fiber within the corticospinal tract that makes
a direct connection to a motor neuron of a distal limb
muscle.

primates and are particularly well developed in the most
dexterous primate species (Nakajima et al., 2000).
Lemon (1993) suggests that the direct corticospinal
projections allow motor commands to bypass spinal
mechanisms and break up synergies by direct access to
the motoneurons and the final common pathway. This
allows the flexibility of individual finger movements
with wrist actions appropriate to a given task.
PRIMARY MOTOR CORTEX
Although a large number of structures are involved in
the neural control of the hand, the importance of the
primary motor cortex for the execution of independent
finger movements is well established (Ehrsson et al.,
2002; Huntley & Jones, 1991) (Figure 1-2). Neurons
that are the source of the direct corticospinal connec-
tions are more numerous in the hand area of the
primary motor cortex than connections from other cor-
tical areas, such as the supplementary motor cortex
(Lemon et al., 2002; Maier et al., 2002). This area of
cortex is particularly well represented in nonhuman
primates by the ability to form a precision grip.
Damage to the motor cortex results in deficits in fine
manual coordination. Monkeys with lesions to this area
lose the ability to produce a precision grip and small
objects are picked up by the use of a more mass grasp
in which all the fingers work together (Fogassi et al.,
2001; Rouiller et al., 1998; Schieber & Poliakov, 1998).
Difficulty with independent finger movements can
also be seen in humans with lesions restricted to the
primary motor cortex or the corticospinal tract. Lang
and Schieber (2003) found that the fingers of the
affected hand in patients with damage to these areas
moved less independently than the fingers of the
uninvolved extremity or normal controls. This was par-
ticularly true for abduction and adduction of the fin-
Primary motor cortex
Central sulcus
Figure 1-2 Diagram of the primary motor cortex.
Cortical Control of Hand-Object Interaction • 5
gers. When EMG recordings were made of hand
muscles during abduction and adduction movements
of the fingers, activation of the first dorsal interosseous
of the normal hand was seen only when the person
moved the index finger. That is, the muscle’s response
was isolated and only related to the movement of this
one finger. In the disabled hand, this muscle was active
with thumb, index, and ring finger movements. The
authors concluded that cerebral areas and descending
pathways that are spared in humans may activate finger
muscles, but cannot fully compensate for the highly
selective control provided by the primary motor cortex.
The primary motor cortex has a particular relation-
ship to the hand. The cortical representation of muscles
involving the fingers occupies a larger area than those
concerned with shoulder movement (Paillard, 1993).
Hand muscles may also be more dependent on cortical
mechanisms. Turton and Lemon (1999) used trans-
cranial magnetic stimulation (TMS) to look at the
effects of stimulation of the primary motor cortex on
EMG output of the deltoid, biceps, and first dorsal
interosseous muscles when the participants contracted
each muscle. (TMS is a noninvasive way to stimulate
neurons in the motor cortex using a small coil placed
over the appropriate area of the head.) They found
that the EMG response to this additional facilitation
was significantly greater in the hand muscles than the
biceps, which was greater than in the deltoid. That is,
the “extra” input provided by the TMS through the
primary motor cortex was greatest in the hand muscles.
They suggest that this reflects a major difference in the
dependence on cortical mechanisms in hand muscles as
opposed to more proximal muscles. Therefore the hand
seems to have a privileged relationship with the primary
motor cortex.
USE-DEPENDENT ORGANIZATION OF THE
PRIMARY MOTOR CORTEX
One of the significant research findings in the last few
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 &
Jones, 1991; Sanes & Donoghue, 2000). Dynamically
6 Part I • Foundation of Hand Skills
changing patterns can be achieved by changing the
strength of these horizontal networks through use
(Butefisch, 2004). This is a requirement for motor
learning. The brain must have the ability to adapt to
new and changing circumstances, including both the
learning of new skills and recovery from injury (Jackson
& Lemon, 2001).
An example of a “use-dependent” change was demon-
strated by Karni et al. (1998). In this study, typical
adults practiced a finger sequence task daily for 5 weeks
(opposing the fingers of the nondominant hand to the
thumb in a specific order). The participants also were
given a second finger sequence that was not practiced
and served as a control for the study. Functional mag-
netic resonance imaging (fMRI) of the cerebral cortex
was done at the start of the experiment and then weekly
until the end of the experiment. The authors found
that in the initial images done before the experiment
began there were no differences between the cortical
representation of the experimental and control
sequences. At 3 weeks, when the experimental sequence
had been well learned, the area of motor cortex repre-
senting the experimental sequence had become larger.
Changes also have been seen using intracortical
microstimulation in monkeys, in which the neuronal
representative of movements in the distal forelimb area
of the primary motor cortex can be specifically mapped.
In one study the extent of the representation of the
hand was mapped and then the monkeys were trained
to pick up small food pellets from a food well (Nudo
et al., 1996). After training, intracortical microstimula-
tion of the primary motor cortex was done again and
the researchers found that the representation of the
movements used in the food retrieval task had
expanded. They also looked at the representation of
unpracticed wrist and forearm movements, and found
that the representation of these movements had con-
tracted. To demonstrate that these changes are
reversible and that the primary motor cortex changes
are based on use, the monkeys were then trained to
perform supination and pronation movements in a key
turning task. Intracortical microstimulation demon-
strated an expansion of the forelimb area and contrac-
tion of the digital representational zones. They also
found that movement combinations used in the acqui-
sition of these skilled motor tasks had come to be
represented in the same cortical territory.
Consequently, use of a particular motor pattern causes
structural reorganization in the primary motor cortex.
Actions that are practiced come to represent a larger
area of cortex and the muscle groups involved also
come to be represented together in what appear to be
functional groupings (Nudo et al., 1996); however, not
all “use” or practice may be as effective in driving these
changes. As discussed later, passive movements and
strength training appear to be less effective in driving
reorganization of the primary motor cortex.
Alternately, skill training or learning may be a par-
ticularly powerful force for reorganization.
With respect to passive movements, Lotze et al.
(2003) used fMRI to look at the effects of 30 minutes
of passive versus active wrist movement in typical
adults. They found that the accuracy of wrist move-
ments improved more with active movements and that
cortical reorganization as measured by fMRI also was
greater with active compared with passive movement.
In a clever experiment that looked at the effect of
strength training, Remple et al. (2001) trained one
group of rats to break increasingly larger bundles of
pasta with their forelimb and a second group to break
single strands of pasta. A control group that had no
training in either task also was included in the study.
After 30 days of training, the researchers found an
increase in the proportion of motor cortex occupied
by distal forelimb movements in both experimental
groups but not the control group. They concluded
that the development of skilled forelimb movements,
but not increased forelimb strength, is associated with
reorganization of forelimb areas in the primary motor
cortex.
The need for the animal to be engaged in a skilled
task or actually learn a task for significant changes in the
primary motor cortex to be observed also has been
reported. In two complementary studies, Nudo et al.
(1996) and, Plautz, Miliken, and Nudo (2000), the
researchers trained monkeys to retrieve food pellets
from food wells. In one group, the well was large and
therefore the task was fairly easy, so no skill or learning
was involved (Plautz et al., 2000) (Figure 1-3).
Another group of monkeys was required to use much
smaller food wells that required learning to retrieve the
food pellet (Nudo et al., 1996). Both groups used the
same fingers and were given the same number of pellets
to retrieve but only in the group of monkeys in which
the task required learning a new skill was there evidence
of modification of cortical maps. The authors
concluded that,
“Repetitive motor activity alone does not produce functional
reorganization of cortical maps. Instead we propose that motor
skill acquisition or motor learning is a prerequisite factor in
driving representational plasticity in the primary motor cortex”
(Plautz et al., 2000; p. 27).
Even adult patients who had reached a plateau in
their recovery after suffering a stroke showed an
increase in function (Taub & Morris, 2001) and expan-
sion of the cortical hand representation (Liepert et al.,
2000) after constraint induced movement therapy
(noninvolved extremity restrained to force use of the
involved extremity).

11.5mm 9.5mm 13.5mm 19.5mm 26mm
Figure 1-3 Depiction of a squirrel monkey performing a
large pellet retrieval task. Note the relative simplicity of
the task because of the size of the well compared with
the size of the animal’s hand. (Redrawn from Plautz E,
Miliken G, Nudo R [2000]. Effects of repetitive motor training
on movement representation in adult squirrel monkeys: Role
of use versus learning, Neurobiology of Learning and
Memory, 74:27–55.)
Use can change the organization of the primary
motor cortex, but disuse also can have an effect on
centers important to motor skills. Using kittens, Martin
et al. (2004) demonstrated that restricting the use of
one paw for the first 7 weeks after birth created perma-
nent changes both in the skill of that paw and the
morphology of the direct corticospinal connections
in the spinal cord. In another example, a group of
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-
lization splint that allowed passive but not active finger
flexion. After the splint was removed, the patients
complained of a temporary clumsiness of the hand that
could not be explained by stiffness of the fingers or
adhesions. In one patient, EMG studies were done
after splint removal and flexion of the fingers showed
increased cocontraction of the extensor muscles and
no full relaxation of this muscle was seen between sets
of movement. In four patients, positron emission
tomography (PET) was used to look at task-related
increases in cerebral blood flow as they flexed their
fingers. These scans were done immediately after the
splint was removed and again 6 to 10 weeks after
removal. They found that scans immediately after splint
removal demonstrated activation in the posterior
parietal lobe and cingulate sulcus. This was not seen in
the nonsurgical hand. The authors suggested that the
increase in parietal involvement (an area of tactile and
visual convergence discussed later in this chapter) may
Cortical Control of Hand-Object Interaction • 7
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
and direct corticospinal fibers to hand muscles. The
integrity of this cortical motor system is being tested
in part when a child is asked to tap his or her index
finger and thumb together as rapidly as possible or
quickly oppose the individual fingers to the thumb.
The speed with which these movements can be per-
formed increases with age (e.g., Denckla, 1974). Evans,
Harrison, and Stephens (1990) suggest that there is
a relationship between a child’s ability to perform rapid
finger movements and maturation of a cutaneo-
muscular reflex dependent on the corticospinal tract,
as well as the main sensory pathway. The results of
maturation in this system are demonstrated when an
infant of 9 to 10 months begins to use a precision grip
to pick up small objects (Siddiqui, 1995). It is apparent
that the hand needs to be used, particularly in skilled
tasks. This need for use also is seen for other cerebral
areas involved in control of the hand, particularly the
primary somatosensory cortex, which is discussed next.
SENSORY GUIDANCE OF HAND
MOVEMENTS: PRIMARY
SOMATOSENSORY CORTEX
The hand is both a motor and sensing organ and there
is a tight interplay between these two functions. The
delicate movements of the hand and fingers are needed
to “gather” sensory information, and those delicate
movements need sensory feedback to guide action,
particularly actions with objects. When objects are
handled they do not fall from the fingers, nor does
one use excessive force when picking things up. The
information needed for these activities is provided by
sensory feedback. The importance of this sensory infor-
mation is obvious when one removes a glove to gather
change from a pocket or when performing any delicate
activity with the hand. Figure 1-4 shows the attempts
of a woman with complete loss of sensation in her right
hand trying to crumple a piece of paper (Jeannerod,
8 Part I • Foundation of Hand Skills
RH LH
Figure 1-4 Schematic of a woman with a lesion in the
somatosensory cortex and superior parietal lobe
attempting to crumble a sheet of paper with her left
hand (LH) and involved right hand (RH). (Redrawn from
Jeannerod M, Michel M, Prablanc C [1984]. The control of
hand movements in a case of hemianaesthesia following a
parietal lesion. Brain, 107:899–920.)
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
understanding of the function of the primary somato-
sensory area is helpful to appreciate the complexity of
information processing within this area, particularly for
the hand.
Afferent fibers from the dorsal columns project
mainly to area 3b for cutaneous input and area 3a for
 Cortical Control of Hand-Object Interaction • 9

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
from an activity such as active flexion and extension
of the fingers) (Iwamura, 1998; Moore et al., 2000).
Area 3b sends information to area 1 and area 1 sends
information to area 2. Both areas then send informa-
tion to the parietal lobe (Inoue et al., 2004). Therefore
there is a serial or hierarchical processing of informa-
tion across this area (Ageranioti-Belanger & Chapman,
1992; Inoue et al., 2004; Iwamura, 1998; Iwamura
et al., 1985). One of the transformations in sensory
information that is seen as information is processed in
more posterior cortical regions is the response of a
single neuron to stimulation over wider areas of skin.
For example, there is an increase in the number of
multidigit receptive fields (the area from which stimu-
lation causes a single cortical neuron to fire) when pro-
gressing from area 3b, where 46% of neurons respond
to multiple sites; to area 1, where the percentage is
63%; to area 2, where 85% of neurons respond to
stimulation from multiple sites (Ageranioti-Belanger &
Chapman, 1992). That is, the discrete information that
first arises from the periphery appears to be combined
into progressively more functionally relevant networks.
In a study of neurons in area 2 of monkeys, Iwamura
et al. (1985) suggested that this convergence represents
skin surfaces that come in contact as the result of com-
mon behaviors of the animal. Like the primary motor
cortex, which tends to cluster muscles that have repeat-
edly worked together in interconnected networks, the
same appears to be true of sensory information
processed in the primary somatosensory cortex. Also
like the motor cortex, the organization of the sensory
cortex is dependent on use. Therefore these two areas
allow for a great deal of flexibility in how information
is organized to best serve a variety of functional
activities.
USE-DEPENDENT ORGANIZATION WITHIN
THE PRIMARY SOMATOSENSORY CORTEX
The primary sensory cortex is dynamic and changing.
This has led one researcher to suggest that at any given
time the details of the somatosensory cortex organ-
ization reflect the behavioral experience of the animal
(Recanzone et al., 1992). That is, the sensory represen-
tation of the extremities contracts or expands depend-
ing on the use or lack of use of a body part. In an
interesting study, Scheibel et al. (1990) did a post-
mortem examination of the dendritic complexity in
several areas of the cerebral cortex in 10 individuals.
The authors found a great deal of variability in the hand
area of the somatosensory cortex of these individuals
10 Part I • Foundation of Hand Skills
Central Sulcus
3a 3b 1 2
Primary
somatosensory
cortex
A auditory stimulus. These animals therefore received the
Central
sulcus
2 the stimulated portion of skin was mapped, both exper-
1 imental animals showed an increase in the represen-
B 3b
3a
Figure 1-6 A. Somatosensory cortex. B. Cross section
of somatosensory cortex showing Brodmann’s areas 3a,
3b, 1, and 2.
and felt that at least in some (e.g., former typist, appli-
ance repairman) these differences might be related to
the individual’s premorbid occupation. In a more recent
study, Hashimoto et al. (2004) used noninvasive tech-
niques to study the somatosensory cortex in string
players. They found an enlarged cortical representation
of the hand area in these individuals compared with
controls who did not play a string instrument.
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.
Using a behavioral task similar to the one used for
studying the changes in the motor cortex of monkeys,
animals were trained to pick up food pellets placed in
wells of varying diameters (Xerri et al., 1999). This
included large-diameter wells in which the pellets were
easy to retrieve, and smaller-diameter wells in which
retrieval was more difficult. The researchers found that
sensory neurons responsive to the specific finger sur-
faces that had been engaged in the small retrieval task
showed major representative changes within area 3b
of the somatosensory cortex that were not seen with
other finger surfaces. That is, changes reflected digital
surfaces that were necessary for object retrieval under
difficult task conditions or in which the animal had to
learn a skilled task.
In another study, Recanzone et al. (1992) trained
two groups of monkeys to place their hands on a mold
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
vibratory stimulus in a passive manner and were not
required to act on the input. When the area in the
primary sensory cortex of these animals that represents
tation of this skin area. However, the increase in the
animal who had been the passive recipient of the vibra-
tory stimulus was modest. The authors suggest that
attention influences cortical reorganization and that
stimulation alone is far less effective in driving cortical
reorganization than an active response to the stimulus.
In other words, being engaged in the activity and
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,
Ehrhardt, and Braun (2003) showed a 20% decrease in
two-point thresholds on the tip of the index finger and
a change in the cortical map of this finger after 3 hours
of intermittent, purely passive tactile stimulation to the
fingertip. Apparently passive input also can promote
organizational changes in the primary somatosensory
cortex along with some modest improvement in tactile
discrimination.
ROLE OF SOMATOSENSORY I NPUT IN G RASP
Tactile information from the fingers is necessary to
adjust the grip to the weight and friction of an object.
This is particularly true when picking up a small object
in the fingertips. Sensitive tactile receptors in the
fingertips are able to sense the “slip” of an object even
before this slip comes to conscious attention. Appro-
priate adjustments in the grip then can be automatically
made (Johansson & Westling 1984, 1987; Westling &
Johansson, 1984). If the friction between the finger
and objects is different for different fingers, these dif-
ferences are monitored separately (Edin, Wrestling, &
Johansson, 1992). That is, if one side of an object is
covered with silk and contacted by the index finger and

the other side of the object is covered with sandpaper
and contacted by the thumb, each finger adjusts to
the frictional conditions on its grip surface. Anesthesia
of the fingers results in an increase in the dropping
of objects (particularly small and slippery objects)
and the application of significantly greater grip forces
(Augurelle et al., 2003; Monzee, Lamarre & Smith,
2003; Westling & Johansson, 1984). The “just right
grip,” which includes just enough margin of safety so
the object will not be dropped, is lost. Anesthesia of the
fingers also appears to prevent the exact alignment of
the fingers on the object surface. Monzee, Lamarre,
and Smith (2003) found that although these misalign-
ments were too small to be visually apparent, they still
caused enough of a tangential force so that the meas-
ured grip forces were close to the slip point. Therefore
sensation from the fingers not only allows the appli-
cation of appropriate grip forces and adjustments to
small slips, this information also appears to help place-
ment of the fingers to the most appropriate position for
a secure grip.
Because accurate sensory information is necessary
for calibrating the “just right” grip force, children with
reduced sensation in the hand, such as Katie, might
have difficulty modulating grip and therefore manipu-
lating small objects. This reduction in sensation has
been found in children with cerebral palsy (see Eliasson,
this volume), as well as children with developmental
coordination disorders and attention deficit disorder
(Pereira et al., 2001). Differences in establishing the
“just right” grip also might be suspected in children
with Down syndrome who have been shown to have
impaired peripheral somatosensory function in the
upper extremity (Brandt, 1996; Brandt & Rosen, 1995).
Even in young children, the ability to adjust the grip
force to the “just right” level is problematic. Young
children, particularly those 4 years or younger, tend to
use significantly larger grip forces when compared with
adults (Forssberg et al., 1991). This may be one reason
why an in-hand manipulation task such as moving a
small peg from the palm to the fingers or turning a peg
over in the fingers is difficult for children 4 years of age
and younger (Pehoski, Henderson, & Tickel-Degnen,
1997a,b). This was a difficult task for Katie; she often
dropped the manipulated object.
ROLE OF SOMATOSENSORY CORTEX IN
MOTOR LEARNING
Area 2 in the primary sensory cortex is connected to
the primary motor cortex through corticocortical con-
nections (Asanuma & Pavlides, 1997). Sensory infor-
mation from the hand may be important to learn a new
motor skill but not to retain a skill already learned. For
Cortical Control of Hand-Object Interaction • 11
example, Pavlides, Miyashita, and Asanuma (1993) had
monkeys learn a new motor task, but with each of the
two hands subject to different conditions. In the first
condition, the somatosensory cortex to one hand was
lesioned. When the monkey had recovered from sur-
gery, both hands were trained to retrieve food pellets
falling at various velocities from a dispenser. The
authors found that the hand contralateral to the lesion
had difficulty learning the task and even when learned,
never achieved the skill of the “normal” hand. In the
second condition or experiment, the primary sensory
cortex to the “normal” hand was lesioned. Despite this
damage, the ability to perform the task with this hand
remained. The authors concluded, “The corticocortical
projections from the somatosensory to the motor cor-
tex play an important role in learning new motor skills,
but not in the execution of existing motor skills”
(Pavlides, Miyashita, & Asanuma, 1993, p. 733).
Practicing a task produces a vigorous circulation of
impulses among the peripheral sensory inputs, somato-
sensory cortex, and primary motor cortex (Asanuma &
Pavlides, 1997; Nadler, Harrison, & Stephens, 2000;
Stefan et al., 2000). This specific input from the pri-
mary somatosensory cortex to the motor cortex is said
to serve as a “teacher” (Asanuma & Pavlides, 1997).
The “teacher” informs the motor cortex of the results
of a movement so that eventually the exact combi-
nation and sequence of muscles needed for the task can
be selected.
Everyone has experienced clumsiness when learning
a new skill. The movements are not smooth and unnec-
essary movements (and therefore muscles) are used
when performing the task. As the task is practiced,
these unnecessary movements are eliminated and an
efficient, reproducible series of actions is seen.
Try this activity. Pick up a pencil with your preferred
hand with the fingers close to the eraser end rather than
the writing end. Now move your fingers up the pencil
shaft until they are in the proper position for writing.
Try the same activity with your nonpreferred hand. Did
you note a marked difference in the skill of this task
on the two sides? Was the nonpreferred side awkward
and clumsy? A possible interpretation of the study by
Asanuma and Pavlides (1997) is that practice is one of
the differences between the two hands in this task. The
nonpreferred hand has not had an opportunity for
sensory feedback to “teach” the motor cortex how to
do the task most efficiently.
It is not hard for people to understand how impor-
tant sensory feedback is to hand function. Everyone has
experienced the frustration of picking up a small object
from the table with a Band-Aid covering the distal pad
of one finger. Just think of how clumsy skilled motor
acts of the hand would be if this reduction in sensation
12 Part I • Foundation of Hand Skills
were experienced throughout the entire hand. One
would have difficulty moving the fingers with skill and
adjusting the hand to the “just right” grip so objects
are not dropped.2 There might even be some difficulty
learning a new motor task with the hands. Nonetheless
actual engagement with objects is more complicated
than just picking them up so they do not drop or
manipulating them within the hand. This is particularly
true for tool use. Preparation for grasp occurs even
before the object is touched and is based on the
observed characteristics of the object and the use that
will be made of the object. Consideration of the pos-
terior parietal lobe and connection with the premotor
cortex is covered next.
THE TRANSFORMATION OF
VISUALLY OBSERVED
CHARACTERISTICS ABOUT
OBJECTS INTO APPROPRIATE
HAND CONFIGURATIONS:
POSTERIOR PARIETAL LOBE AND
VENTRAL PREMOTOR CORTEX
Think for a moment what it would be like if one had
an excellent mechanism for the control of finger
movements and somatosensory feedback to guide the
movements but did not have a mechanism for selecting
the grasp appropriate for a particular object. There
would be a lot of trial and error. Movements would be
slow. A glass would be approached in the same way as
a fork. The hand would land on an object and then
“feel” for the appropriate grasp. One function that
would help would be vision. Up until now vision has
not been considered. The primary motor cortex has
limited access to direct visual information (Jeannerod
et al., 1995). Vision allows for the preparation of grasp
before contact; therefore the hand could be preshaped
to match objects of different shapes, sizes, and orien-
tation. Any final adjustments could be made by
somatosensory feedback on contact. This preshaping of
the hand is one of the functions provided by a posterior
parietal cortex–prefrontal lobe cortex circuit.
2
It should be noted that besides the neural mechanisms responsible
for the “just right” grip, there are other ways to increase the friction
at the finger–object interface, the oils or moisture of the fingers
themselves. Washing and drying the hands (Johansson & Westling,
1984) or the introduction of chemicals that reduce sweating of the
hands (Smith, Codoret, & St-Amour, 1997) cause an increase in the
grip force.
ROLE OF I NFERIOR PARIETAL LOBE IN
PRESHAPING OF THE HAND
Almost all interactions with objects start with a reach.
Reach is composed of two main parts, the transport of
the hand and the preparation of the hand for grasp (see
Rosblad, this volume). Each of these requires different
visual information about the object. Reach requires
the analysis of distance and direction. Preparation of
the hand for grasp requires the analysis of the object’s
shape, size, and orientation (Jeannerod et al., 1995).
Try this: Place two objects of different sizes on the
table, such as a paper clip and the box the paper clip
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
object, the fingers open to ready the hand for grasp,
and this opening is calibrated to the size of the object
to be grasped, although it is always a bit larger than the
object itself (Jeannerod, 1981).
Here is another activity. With one hand, hold a
pencil out in front of you and reach for it with the other
hand while the pencil is held in a vertical position and
then with the pencil in a horizontal position. Did you
rotate your forearm during the reach to accommodate
the difference in orientation of the pencil (e.g., “thumb
up” for the vertical position and “thumb down” for the
horizontal position)? Not only is the hand opening
“programmed” as a part of the reach, but forearm rota-
tion and wrist position also are part of the pattern of
the reach. All of this preparation ensures that a secure
grasp is achieved once contact with the object is made
(Jeannerod et al., 1995).
The ability to scale the hand opening and orient
the hand appropriately to an object is not seen in
young infants. Changes to the orientation of the wrist
or forearm to an object is seen at about 7 to 9 months
of age (Lockman, Ashmead, & Bushnell, 1984;
Morrongiello & Rocca, 1989; von Hofsten & Fazel-
Zandy, 1984; McCarthy et al., 2001) and adjusting the
opening of the hand to changes in an object’s size at
about 9 months of age (von Hofsten, 1979, 1991; von
Hofsten & Ronnquist, 1988).
The transformation of the visual image of an object
into an appropriate hand opening and orientation is
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
with those of the primary somatosensory cortex
(Debowy et al., 2001). The researchers found that the
neurons in the posterior parietal lobe were more active
during the approach stage as the hand was preshaped
and before the hand touched the object. Most of
the somatosensory neurons fired on contact with the

object. Contact appeared to be the transition point
from visually guided behavior to tactile guidance of the
action.
The posterior parietal lobe is composed of two parts,
the superior and inferior parietal lobes (Figure 1-7). It
is an important center for the integration of sensory
information, particularly somatosensory and visual
information. With respect to somatosensory input, this
area completes the hierarchical processing of this infor-
mation that started in the primary somatosensory cor-
tex. The superior parietal lobe receives information
from area 1 and more strongly from area 2 in the
primary somatosensory cortex (Hyvarinen, 1982). The
inferior parietal lobe’s sensory representation is more
complex than the superior parietal lobe because it not
only receives information from areas 1 and 2 and the
superior parietal lobe, it also receives a great deal of
information from the visual cortex; therefore this is
an area where visual and somatosensory information
converge (Hyvarinen, 1982; Mountcastle et al., 1975).
Within the inferior parietal lobe is an area that has
recently attracted much attention, the anterior intra-
parietal sulcus (see Figure 1-7). In this area are neurons
related to grasping that fire preferentially to the shape,
size, and orientation of objects (Sakata et al., 1995,
1999; Taira et al., 1990). Patients with lesions in this
area have no difficulty in reaching but hand shaping is
significantly disturbed and often there is no preshaping
of the hand at all (Binkofski et al., 1998). Monkeys
with reversible inactivation of this area also have diffi-
culty grasping. Grasping in these animals often is achieved
only after several corrections that rely on tactile feed-
back (Gallese et al., 1994). Binkofski et al. (1999)
found neurons in the intraparietal sulcus active (along
Central sulcus Primary
somatosensory
cortex
Superior
parietal
lobe
Intraparietal
sulcus
Inferior parietal lobe
Figure 1-7 Diagram of the intraparietal sulcus dividing
the superior parietal lobe and inferior parietal lobe.
Cortical Control of Hand-Object Interaction • 13
with the ventral premotor area, superior parietal lobe,
and secondary sensory cortex) when imaging studies
were done of typical adults manipulating complex
objects in their hands.
ROLE OF THE VENTRAL PREMOTOR CORTEX
IN PRESHAPING OF THE HAND
Registering information about an object’s size, shape,
and orientation is important, but the parietal lobe is
primarily a sensory area and this information must be
transferred from sensory to motor areas for use in
actual movement execution. The anterior interparietal
sulcus has corticocortical connections with the ventral
premotor area (Luppino et al., 1999) (Figure 1-8). The
“description” of the object is used here to select the
most appropriate grip.
Neurons in the ventral premotor cortex area of
monkeys, such as those in the anterior parietal sulcus,
are selective in the type of objects that cause them
to fire (Rizzolatti et al., 1988). In monkeys, many
neurons in this area can be classified by their action
(e.g., grasping, holding, tearing, or manipulating);
grasping neurons are most represented. Many also are
selective to the type of prehension used, such as a
precision grip, finger prehension, or whole hand pre-
hension. (These grips are the three most common grips
seen in monkeys [Fadiga & Craighero, 2003].) Some
neurons in this area are specific for different finger
configurations within a grip type. They are also selec-
tive to what part of the grip movement they fire. Some
discharge during the whole action with the object, others
during finger closure, and others after contact with the
object; therefore these neurons form a “vocabulary”
Primary motor
cortex
Ventral premotor Central sulcus
cortex
Figure 1-8 Diagram of ventral premotor area and
relationship to primary motor cortex.
14 Part I • Foundation of Hand Skills
of possible actions the hand can take on an object (see
Rizzolatti & Fadiga, 1998, for a review). This vocab-
ulary is related more to the goal of an action than to
individual movements (e.g., a specific neuron might fire
to “grasping” with the mouth and also with either
hand) (Rizzolatti et al., 1988; Rizzolatti & Fadiga,
1998).
The ventral premotor cortex is connected to the
primary motor cortex and from there to the direct
corticospinal fibers to hand muscles (Luppino et al.,
1999). What differentiates the primary motor cortex
from the ventral premotor cortex is that the latter
stores motor schemata that are goal directed, whereas
the primary motor area stores movements regardless
of the action or context in which they are used
(Rizzolatti & Fadiga, 1998). That is, the visual infor-
mation processed in the anterior intraparietal sulcus
about the three-dimensional characteristics of an object
is sent to the ventral premotor cortex for the selection
of grip and then to the motor cortex for sequencing of
the actual muscles to be used.
Neurons in the inferior premotor area are known to
facilitate neural action in the primary motor cortex.
Stimulation of a neuron in the hand area of the primary
motor cortex of monkeys causes changes in the EMG
reading from hand muscles, but stimulation of an
inferior premotor neuron or inferior parietal neuron
alone does not. If stimulation is first given to the
premotor cortex and then to the primary motor cortex,
the EMG hand muscle response is greater than when
the motor cortex is stimulated alone. The authors
indicate that this input might be part of the wider
control system that helps shape the pattern of activity
of different hand muscles for grasp of specific objects
(Shimazu et al., 2004).
If a small injection of an agent that temporarily
inactivates neurons is placed in the ventral premotor
cortex of monkeys, the results are similar to those seen
with inactivation of the anterior interparietal sulcus.
That is, the animal is able to use tactile feedback to
succeed in an appropriate grasp when preshaping of the
hand is absent, but only after contact with the object,
This is particularly true for small objects (Fogassi et al.,
2001). It is interesting that large lesions at this site also
produced problems with hand shaping of the ipsilateral
hand. Further, when monkeys with large lesions were
presented with raisins placed in a board with two rows
of six horizontally placed holes, the monkeys tended
to pick up the raisins in the right holes with the right
hand and those on the left with the left hand. They
also tended to remove the raisin first from the holes
ipsilateral to the injection site. When food was pre-
sented bilaterally, they always preferred the ipsilateral
presentation.
USE-DEPENDENT ORGANIZATION OF THE
I NFERIOR PARIETAL AND VENTRAL
PREMOTOR CORTEX
Although use-dependent changes have not been
directly studied in either the anterior intraparietal
sulcus or the ventral premotor area, it seems apparent
that these areas are influenced by use. As an example,
one of the most common types of grasping neurons
found in the ventral premotor cortex in monkeys are
those that respond to a precision grip, a grip formation
that is not seen in young infant monkeys, but is seen
with increasing regularity as monkeys get older (Lemon,
1993). Rizzolatti and Luppino (2001) suggest that the
matching between the visually observed characteristics
of an object and appropriate motor programs occurs
early in life and is accomplished through processes that
associate the intrinsic visual properties of the object with
the grips that are effective in interacting with them.
THE I NFERIOR PARIETAL CORTEX AND
TOOL USE
Hand positioning to pick up an object requires a
posture adapted to the features of the object (e.g., size,
shape), but picking up an object to actually use it also
requires that the grip anticipate what action will be
performed. Think about the difference in hand position
used when holding a pencil to punch a hole in a piece
of cardboard as opposed to picking up a pencil to write.
The posterior parietal lobe is implicated in this function.
Sirigu et al. (1995) describe a patient with a bilateral
lesion in the posterior parietal lobe who had normal
sensory and motor functions, yet had a great deal of
difficulty grasping tools. Figure 1-9 illustrates some
of the patient’s problems grasping common objects,
such as a nail clipper, spoon, and scissors. At home she
had difficulty using objects in such tasks as brushing
her teeth, locking her door, and cutting meat. What
was of particular interest in this patient was that if the
examiner corrected the patient’s grasp and the object
was placed in her hand appropriately, she could per-
form with normal movement kinematics. Further, if the
patient was asked to just grasp an object and not use it,
appropriate preshaping of the hand and wrist to the
object’s physical characteristics was seen. It was the
capacity to match the grasp to the object’s use that
seemed to be missing in this patient. Apparently the
posterior parietal cortex is important for this function.
Another feature of skilled tool use is that when the
hand uses a tool, the tool becomes an extension of the
hand. When one writes, one is not aware of the pen as
a tool separate from the hand. Rather, it is an integral
 Cortical Control of Hand-Object Interaction • 15

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.
It appears that the sense of the tool as an extension of
the hand has a neurologic correlate that includes the
tool into the body scheme of the hand.
Working with monkeys, Iriki, Tanaka, and Iwamura
(1996) pointed out that the visual receptive fields of
neurons within the anterior intraparietal sulcus changed
when the monkey used a rake to obtain food pellets
(Figure 1-10). Soon after the monkey began to use the
rake, the visual field was seen to change to not only
cover the area around the hand but also to include the
total length of the rake. This did not happen when the
animal only held the tool or just moved a stick back and
forth. That is, when the rake was used as a tool, the
rake and the body schema of the hand came to be
represented together. When imaging studies were done
of humans picking up a small object with tongs or with
just the fingers, the intraparietal sulcus was again
implicated in the tool use task (Inoue et al., 2001).
It appears that the anterior intraparietal sulcus is an
important area concerned with the preparation and
grasp of objects and may be particularly important for
tool use. This area has strong connections with the
ventral premotor area, which also appears to be impor-
tant for hand use. There is one other function of the
parietal lobe related to object interaction that should be
mentioned, the guidance of movements when explor-
ing an object manually. The term “tactile apraxia” has
been used to define a problem in this area (Pause et al.,
1989). In patients with tactile apraxia, exploratory
movements are described as slow and clumsy and may
consist of only squeezing the object (Binkofski et al.,
2001; Pause & Freund, 1989; Valenza et al., 2001).
This problem has been seen in a variety of parietal
lesions (Binkofski et al., 2001; Pause & Freund, 1989;
Valenza et al., 2001), including the primary somato-
sensory cortex (Motomura et al., 1990; Tomberg &
Desmedt, 1999). The problem does not appear to be
related to the severity of any somatosensory distur-
bances that might be present. That is, a patient with a
significant sensory loss may be better able to manipu-
late an object for identification than a patient with
better-preserved sensation (Pause et al., 1989; Valenza
et al., 2001). Problems moving her finger around
objects in a manual form identification task was one
area with which Katie had difficulty. She tended to just
16 Part I • Foundation of Hand Skills

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
parietal lobe is not only involved in the elaboration and
further processing of somatosensory information, but
also in the conception and generation of those motor
programs required to collect this information.” (Pause
et al., 1989, p. 1622).
SUMMARY AND THERAPEUTIC
IMPLICATIONS
This section reviews the covered information. The
primary motor cortex is critical to the ability to move
the fingers individually and speedily. Without this
input, hand movements are characterized by varying
degrees of muscle cocontraction so movements are
stiff, awkward, and slow. This ability to “fractionate”
movements of the hand is transmitted by the cortico-
spinal tract, particularly through direct corticospinal
connections to the motoneurons of hand muscles.
Through intracortical connections of the various hand
muscles in the primary motor cortex, movements used
together come to be represented together. When a
movement is performed, this action generates sensory
feedback. Discrete information related to the move-
ments is carried back to the primary sensory cortex by
the dorsal columns. This information can then be fed
back to the motor cortex via corticocortical connec-
tions so any necessary corrections of the movements
can be made. Through practice, the correct combina-
tion and timing of muscles can be perfected through
this mechanism. Once learned, feedback is much less
important. This is not to say that everyday, learned
movements are not dependent on sensory information.
The ability to pick up an object and hold it with just
enough force so that it is not dropped is dependent on
sensory input from the fingers. The exact placement of
the fingers on an object after grasp is also dependent on
sensory feedback.
Humans have an important cortical loop for the
control of skilled hand function and the interaction
with objects, the primary motor cortex and primary
sensory cortex connection (Figure 1-11). However,
the described actions are relatively simple and human
object use is not simple. The second cortical circuit
between the posterior parietal lobe (particularly the
anterior intraparietal sulcus) and the ventral premotor
area is important in the selection of the appropriate
grip patterns. As indicated, the inferior portion of the
posterior parietal lobe receives both somatosensory
information from the primary sensory cortex and visual
information from the visual cortex, resulting in com-
plex bimodal neurons (neurons that respond to both
somatosensory and visual information). Vision infor-
mation about an object provides information about
the object’s size, shape, and orientation. This allows the
hand to be preshaped to the object’s characteristics
before contact. This visual information is transferred to
the premotor area through corticocortical connections
in which the appropriate grip pattern is chosen. The
premotor area then sends this information to the pri-
mary motor cortex for the selection and timing of the
necessary muscles. This in turn results in sensory infor-
mation fed to the primary sensory cortex and back
to the motor cortex, completing the circuit (see Figure
1-11). The anterior intraparietal sulcus of the posterior
parietal lob also is important for incorporating the tool
into the body schema of the hand, therefore making
the tool an extension of the hand. It also should be
noted that there are hand skills that have not been
discussed in this chapter; many of these are covered in
 Cortical Control of Hand-Object Interaction • 17

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,
eye–hand coordination, and perceptual functions of
the hand).
This chapter has concentrated on the performance
of the hand in hand–object interaction, and has not
discussed the shoulder or postural support as back-
ground for these skilled movements. These are also
important aspects of hand function. For example,
Smith-Zuzovsky and Exner (2004) found that 6- and
7-year-old children who were positioned in furniture
that was fitted to their size did significantly better on a
test of in-hand manipulation than children using typical
classroom furniture. In most natural movements the
more proximal muscles provide the stability that allows
skilled actions of the hand. Thus the corticospinal
connections to proximal and distal muscles must coop-
erate (Turton & Lemon, 1999), but the roles of reach
and postural functions are different and therefore so are
the basic neural mechanisms that control them. The
primary role of posture and the shoulder in skilled hand
function is one of stability. If the shoulder lacks stability
for hand function or the postural muscles cannot
adequately support the trunk, then this needs to be
addressed through mechanisms to increase stability and
strength. Hand muscles also may need strengthening,
but remember that the primary roles of the hand are to
act, move, and perform with skill. If a child presents
with shoulder instability, poor trunk support, and poor
hand use, these should be worked on simultaneously.
The hand should not wait until some minimal level
of postural support is achieved. The choice of proper
positioning and creative selection of activities can make
it possible for the child to use his or her hands even
when postural support is poor.
As discussed, the cortical reorganization responsible
for skilled learning, particularly as it relates to hand–
object interaction, is use dependent. It is through use
that functional patterns of movement or the muscles
necessary for the action come to be represented togeth-
er. The same is true of patterns of somatosensory input.
Surfaces that are used together come to be represented
together. This happens through practice. Also as indi-
cated, this structural reorganization is best accom-
plished through tasks that require skill or the learning
of an activity. It also requires attention to the task.
Passive movements and strength training are much
less effective in driving this cortical reorganization.
Children with poor hand skills, like Katie, often avoid
or are so poor at fine motor tasks that they may actually
get less practice than their peers. Skill requires attention
to the activity and is facilitated when there is an interest
in the outcome. Children with poor hand skills may
need help to select and adapt to activities to meet their
level of performance and interest. The art of therapy is
being able to provide activities that challenge the child
within the scope of his or her abilities and elicit the
child’s enthusiastic cooperation.
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ANATOMY AND KINESIOLOGY
OF THE HAND
James W. Strickland
CHAPTER OUTLINE
EMBRYONIC DEVELOPMENT
ANATOMY OF THE FULLY DEVELOPED HAND
Osseous Structures
Joints
Muscles and Tendons
Nerve Supply
Skin and Subcutaneous Fascia
Functional Patterns
One cannot expect to adequately understand the devel-
opment and function of the hand and arm without
a solid working knowledge of the intricate anatomic
and kinesiologic relationships of the upper extremity,
including the embryonic growth stages through which
the extremity progresses. Only through comprehension
of the normal formation and anatomy of the human
hand can one adequately develop an appreciation for
the disturbance in function that accompanies injury,
disease, or dysfunction. It is appropriate, therefore
that an early chapter in a book devoted to development
of fine motor coordination be concerned with the
embryology, anatomy, kinesiology, and biomechanics
of the hand. Because it is impossible in this chapter
to review in great detail the enormous amount of
literature that has been written about these fields of
knowledge, readers are directed to the Suggested
Readings.
Chapter 2
EMBRYONIC DEVELOPMENT
Inspection of a normal newborn’s hands never ceases to
evoke awe and wonderment. The tiny nails punctuating
the ends of intricately formed fingers and opposable
thumbs, each delicately marked with familiar patterns
of joint wrinkles, immediately identify the newcomer as
human. All of the ingredients that eventually provide
an unbelievably extensive continuum of function from
exquisitely fine dexterity to great power are present in
the tiny waving arms and hands. However, the normal
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
weeks the webbed swellings of the three central digits
appear and are soon followed by the two border digits.
The metacarpals are present as cartilage, as are the prox-
imal phalanges of the index through small fingers.
Initially, each extremity is aligned longitudinally with
the body trunk, but at 7 weeks the arms rotate outward
and forward at the shoulder level to assume a hand-to-
face position with the flexor surface of the forearm and
hand turned inward toward the body and the extensor
surface turned outward. Elbows and wrists are slightly
flexed. Innervation of the limbs has already occurred
at this point, and vessels extend to the distal extremity.
Muscles, muscle groups, joint hollows, and digital cleav-
ages, including thumb differentiation, are also present
at 7 to 8 weeks. Webbing between the digits dimin-
ishes, and the fingers and thumb are independent of
each other by 8 weeks. Carpal bones are cartilaginous,
and the os centrale fuses to the scaphoid at 8 weeks.
21
22 Part I • Foundation of Hand Skills

For the remainder of gestation after 8 weeks, limb
changes primarily involve growth of already present
structures.
ANATOMY OF THE FULLY
DEVELOPED HAND
The anatomy of the hand must be approached in a
systematic fashion with individual consideration of the
osseous structures, joints, musculotendinous units, and
nerve supply. However, it is obvious that the systems
do not function independently, but that the integrated
presence of all these structures is necessary for normal
hand function. In presenting this material, this chapter
strays into the important mechanical and kinesiologic
considerations that result from the unique anatomic
arrangement of the hand.
OSSEOUS STRUCTURES
The unique arrangement and mobility of the bones of
the hand (Figure 2-1) provide a structural basis for its
enormous functional adaptability. The osseous skeleton
consists of eight carpal bones divided into two rows:
The proximal row articulates with the distal radius and
ulna (with the exception of the pisiform, which lies
palmar to and articulates with the triquetrum); the
distal four carpal bones in turn articulate with the five
metacarpals. Two phalanges complete the first ray, or
thumb unit, and three phalanges each comprise the
index, long, ring, and small fingers. These 27 bones,
together with the intricate arrangement of supportive
ligaments and contractile musculotendinous units, are
arranged to provide both mobility and stability to the
various joints of the hand. Although the exact anatomic
configuration of the bones of the hand need not be
memorized in detail, it is important that one should
develop knowledge of the position and names of the
carpal bones, metacarpals, and phalanges and an under-
standing of their kinesiologic patterns to proceed with
the management of many hand problems. The bones of
the hand are arranged in three arches (Figure 2-2), two
transversely oriented and one that is longitudinal. The
proximal transverse arch, the keystone of which is the
capitate, lies at the level of the distal part of the carpus
and is reasonably fixed, whereas the distal transverse
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
the second and third metacarpals, the index and long
fingers distally, and the central carpus proximally. The
longitudinal arch is completed by the individual digital
rays, and the mobility of the first, fourth, and fifth rays
around the second and third allows the palm to flatten
or cup itself to accommodate objects of various sizes
and shapes.
To a large extent the intrinsic muscles of the hand
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.)

Proximal
transverse Distal
arch transverse arch
Longitudinal
arch
A B
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-
tribute to severe disability and deformity. Flatt (1979,
1983, 1995) has pointed out that grasp is dependent
on the integrity of the mobile longitudinal arches
and when destruction at the carpometacarpal joint,
metacarpophalangeal joint, or proximal interphalangeal
joint interrupts the integrity of these arches, crippling
deformity may result.
JOINTS
The multiple complex articulations among the distal
radius and ulna, the eight carpal bones, and the
metacarpal bases comprise the wrist joint, whose prox-
imal position makes it the functional key to the motion
at the more distal hand joints of the hand. Functionally
the carpus transmits forces through the hand to the
forearm. The proximal carpal row consisting of the
scaphoid (navicular), lunate, and triquetrum articulates
distally with the trapezium, trapezoid, capitate, and
hamate; there is a complex motion pattern that relies
both on ligamentous and contact surface constraints.
The major ligaments of the wrist (Figure 2-3) are the
palmar and intracapsular ligaments. There are three
strong radial palmar ligaments: the radioscaphocapitate
or “sling” ligament, which supports the waist of the
scaphoid; the radiolunate ligament, which supports the
lunate; and the radioscapholunate ligament, which con-
nects the scapholunate articulation with the palmar
portion of the distal radius. This ligament functions
as a checkrein for scaphoid flexion and extension. The
ulnolunate ligament arises intra-articularly from the
triangular articular meniscus of the wrist joint and inserts
on the lunate and, to a lesser extent, the triquetrum.
The radial and ulnar collateral ligaments are capsular
ligaments, and V-shaped ligaments from the capitate to
Anatomy and Kinesiology of the Hand • 23
Distal transverse arch
Proximal transverse arch
the triquetrum and scaphoid have been termed the
deltoid ligaments. Dorsally, the radiocarpal ligament
connects the radius to the triquetrum and acts as a
dorsal sling for the lunate, maintaining the lunate in
apposition to the distal radius. Further dorsal carpal
support is provided by the dorsal intracarpal ligament.
These strong ligaments combine to provide carpal
stability while permitting the normal range of wrist
motion.
The distal ulna is covered with an articular cartilage
(Figure 2-3, C) over its most dorsal, palmar, and radial
aspects, where it articulates with the sigmoid or ulnar
notch of the radius. The triangular fibrocartilage com-
plex describes the ligamentous and cartilaginous struc-
ture that suspends the distal radius and ulnar carpus
from the distal ulna. Blumfield and Champoux (1984)
have indicated that the optimal functional wrist motion
to accomplish most activities of daily living is from 10°
of flexion to 35° of extension.
Taleisnik (1976a,b, 1985a,b, 1992) has emphasized
the importance of considering the wrist in terms of
longitudinal columns (Figure 2-4). The central, or flex-
ion extension, column consists of the lunate and the
entire distal carpal row; the lateral, or mobile, column
comprises the scaphoid alone; and the medial, or
rotation, column is made up of the triquetrum. Wrist
motion is produced by the muscles that attach to the
metacarpals, and the ligamentous control system pro-
vides stability only at the extremes of motion. The
distal carpal row of the carpal bones is firmly attached
to the hand and moves with it. Therefore during dorsi-
flexion the distal carpal row dorsiflexes, during palmar
flexion it palmar flexes, and during radial and ulnar
deviation it deviates radially or ulnarly. As the wrist
ranges from radial to ulnar deviation, the proximal carpal
row rotates in a dorsal direction, and a simultaneous
24 Part I • Foundation of Hand Skills

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
direction at the radiocarpal and midcarpal articulations.
This combined motion of the carpal rows has been
called the rotational shift of the carpus. It was once
taught that palmar flexion takes place to a greater
extent at the radiocarpal joint and secondarily in the
midcarpal joint, but because dorsiflexion occurs prima-
rily at the midcarpal joint and only secondarily at the
radiocarpal articulation, this now appears to be a sig-
nificant oversimplification. The complex carpal kine-
matics are beyond the scope of this chapter, and the
reader is referred to the works of Weber (1988),
Taleisnik (1985a,b), Lichtman and Alexander (1988),
and Cooney, Linscheid, and Dobyns (1998) to gain a
thorough understanding of this difficult subject.
The articulation between the base of the first
metacarpal and the trapezium (Figure 2-5) is a highly
mobile joint with a configuration thought to be similar
to that of a saddle. The base of the first metacarpal is
concave in the anteroposterior plane and convex in
the lateral plane, with a reciprocal concavity in the
lateral plane and an anteroposterior convexity on the
opposing surface of the trapezium. This arrangement
allows the positioning of the thumb in a wide arc of

Central
column
Medial Lateral
column column
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.)
Figure 2-5 Saddle-shaped carpometacarpal joint of the
thumb. A wide range of motion (arrows) is permitted by
the configuration of this joint. (From Fess EE, Gettle K,
Philips CA, et al. [2005]. Hand and upper extremity splinting.
St Louis, Mosby.)
motion (Figure 2-6), including flexion, palmar and radial
abduction, adduction, and opposition. The ligamen-
tous arrangement about this joint, while permitting the
wide circumduction, continues to provide stability at
the extremes of motion, allowing the thumb to be
brought into a variety of positions for pinch and grasp,
but maintaining its stability during these functions. The
articulations formed by the ulnar half of the hamate
and the fourth and fifth metacarpal bases allow a
modest amount of motion (15° at the fourth carpo-
metacarpal joint and 25° to 30° of flexion and exten-
sion at the fifth carpometacarpal joint). A resulting
“palmar descent” of these metacarpals occurs during
strong grasp.
The metacarpophalangeal joints of the fingers are
diarthrodial joints with motion permitted in three
Anatomy and Kinesiology of the Hand • 25
First metacarpal
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-
plex apparatus consisting of the joint capsule, collateral
ligaments, and the anterior fibrocartilage or palmar
plate (Figure 2-8). The capsule extends from the borders
of the base of the proximal phalanx proximally to the
head of the metacarpals beyond the cartilaginous joint
surface. The collateral ligaments, which reinforce the
capsule on each side of the metacarpophalangeal joints,
run from the dorsolateral side of the metacarpal head to
the palmar lateral side of the proximal phalanges. These
ligaments form two bundles, the more central of which
is called the cord portion of the collateral ligament and
inserts into the side of the proximal phalanx; the more
palmar portion joins the palmar plate and is termed the
accessory collateral ligament. These collateral ligaments
are somewhat loose with the metacarpophalangeal joint
in extension, allowing for considerable “play” in the
side-to-side motion of the digits (Figure 2-9). With the
metacarpophalangeal joints in full flexion, however,
the cam configuration of the metacarpal head tightens
the collateral ligaments and limits lateral mobility of the
digits. This alteration in tension becomes an important
factor in immobilization of the metacarpophalangeal
joints for any length of time, because the secondary
26 Part I • Foundation of Hand Skills

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,
which is of considerable functional importance in deli-
cate precision functions. There is considerable variation
in the range of motion present at the thumb metacar-
pophalangeal joints. The amount of motion varies from
as little as 30° to as much as 90°.
The digital interphalangeal joints are hinge joints
(see Figure 2-7) and, like the metacarpophalangeal
joints, have capsular and ligamentous enclosure. The
articular surface of the proximal phalangeal head is
convex in the anteroposterior plane with a depression
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
with an elevated ridge dividing two concave depres-
sions. A cord portion of the collateral ligament and an
accessory collateral ligament are present, and the
collateral ligaments run on each side of the joint from
the dorsolateral aspect of the proximal phalanx in a
palmar and lateral direction to insert into the distally
placed phalanx and its fibrocartilage plate (Figure 2-10).
A strong fibrocartilaginous (palmar) plate is also
present, and the collateral ligaments of the proximal
and distal interphalangeal joints are tightest with the
joints in near full extension.
The stability of the proximal interphalangeal joint is
ensured by a three-sided supporting cradle produced
by the junction of the palmar plate with the base of the
middle phalanx and the accessory collateral ligament
structures (see Figure 2-10). The confluence of liga-
ments is strongly anchored by proximal and lateral
extensions called the checkrein ligaments. This system
Cord
Collateral ligament
Accessory
Palmar plate
Checkrein ligaments
Checkrein Cord
Collateral ligament
ligaments Accessory
Palmar plate
Figure 2-10 Strong, three-sided ligamentous support
system of the proximal interphalangeal joint with cord
and accessory collateral ligaments and the
fibrocartilaginous plate, which is anchored proximally by
the checkrein ligamentous attachment. (From Fess EE,
Gettle K, Philips CA, et al. [2005]. Hand and upper extremity
splinting. St Louis, Mosby. Modified from Eaton RG [1971].
Joint injuries of the hand. Springfield, IL, Charles C Thomas.)
Anatomy and Kinesiology of the Hand • 27
has been described as a three-dimensional hinge that
results in remarkable palmar and lateral restraint.
A wide range of pathologic conditions may result
from the interruption of the supportive ligament sys-
tem of the intercarpal or digital joints. At the wrist
level, interruption of key radiocarpal or intercarpal liga-
ments may result in occult patterns of wrist instability
that are often difficult to diagnose and treat. In the
digits, disruption of the collateral ligaments or the
fibrocartilaginous palmar plates produces joint laxity or
deformity, which is more obvious.
M USCLES AND TENDONS
The muscles acting on the hand can be grouped as
extrinsic, when their muscle bellies are in the forearm,
or intrinsic, when the muscles originate distal to the
wrist joint. It is essential to thoroughly understand
both systems. Although their contributions to hand
function are distinctly different, the integrated function
of both systems is important to the satisfactory
performance of the hand in a wide variety of tasks. A
schematic representation of the origin and insertion of
the extrinsic flexor and extensor muscle tendon units of
the hand is provided in Figures 2-11 and 2-15. The
important nerve supply to each muscle group is
reviewed in these figures and again when discussing the
nerve supply to the upper extremity.
Extrinsic Muscles
The extrinsic flexor muscles (see Figure 2-11) of the
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,
palmaris, wrist flexors, and superficialis tendons arise
from the area about the medial epicondyle, the ulnar
collateral ligament of the elbow, and the medial aspect
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-
nates deep to the other muscles of the forearm from the
proximal two-thirds of the ulna on the palmar and
medial side. The deepest layer of the palmar forearm is
completed distally by the pronator quadratus muscle.
The flexor carpi radialis tendon inserts on the base of
the second metacarpal, whereas the flexor carpi ulnaris
inserts into both the pisiform and fifth metacarpal base.
The superficialis tendons lie superficial to the profun-
dus tendons as far as the digital bases, where they
bifurcate and wrap around the profundi and rejoin over
28 Part I • Foundation of Hand Skills

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.)

Composite
Deep
Figure 2-11—cont’d.
the distal half of the proximal phalanx as Camper’s
chiasma (Figure 2-12). The superficialis tendon again
splits for a dual insertion on the proximal half of the
middle phalanges. The profundi continue through
the superficialis decussation to insert on the base of
FDS FDP
FDP
Camper's chiasma FDS
Figure 2-12 Anatomy of the relationship among the
flexor digitorum superficialis (FDS), flexor digitorum
profundus (FDP), and the proximal portion of the flexor
tendon sheath. The superficialis tendon divides and
passes around the profundus tendon to reunite at
Camper’s chiasma. The tendon once again divides before
insertion on the base of the middle phalanx. (From Fess
EE, Gettle K, Philips CA, et al. [2005]. Hand and upper
extremity splinting. St Louis, Mosby.)
Anatomy and Kinesiology of the Hand • 29
Flexor digitorum profundus
Nerve: median—index and long
ulnar—ring and small
Action: flexion of distal
interphalangeal, proximal
interphalangeal, and
metacarpophalangeal
joints
Flexor pollicis longus
Nerve: median
Action: flexes
interphalangeal and
metacarpophalangeal
joints of thumb
the distal phalanx. The flexor pollicis longus inserts on
the base of the distal phalanx of the thumb.
At the wrist the nine long flexor tendons enter the
carpal tunnel beneath the protective roof of the deep
transverse carpal ligament in company with the median
nerve. In this canal the common profundus tendon to
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
profundus and superficialis tendons to the index, long,
ring, and small fingers and the flexor pollicis longus
to the thumb enter the individual flexor sheaths that
house them throughout the remainder of their digital
course. These sheaths with their predictable annular
pulley arrangement (Figure 2-14) serve not only as a
protective housing for the flexor tendons, but also
provide a smooth gliding surface by virtue of their
synovial lining and an efficient mechanism to hold the
tendons close to the digital bone and joints. There is an
increasing recognition that disruption of this valuable
30 Part I • Foundation of Hand Skills
Flexor digitorum
profundus
Digital flexor
sheath
Flexor digitorum
superficialis
Sheath of
flexor pollicis
longus
Hypothenar Median nerve
muscles
Thenar muscles
Ulnar artery
Ulnar nerve Transverse carpal
ligament
Radial artery
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
proximal portion of the sheath. (From Fess EE, Gettle K,
Philips CA, et al. [2005]. Hand and upper extremity splinting.
St Louis, Mosby.)
pulley system can produce substantial mechanical
alterations in digital function, resulting in imbalance
and deformity.
Extension of the wrist and fingers is produced by the
extrinsic extensor muscle tendon system, which consists
of the two radial wrist extensors, the extensor carpi
ulnaris, the extensor digitorum communis, extensor
indicis proprius, and the extensor digiti quinti proprius
(extensor digiti minimi) (Figure 2-15). These muscles
originate in common from the lateral epicondyle and
the lateral epicondylar ridge and from a small area
posterior to the radial notch of the ulna. The brachio-
radialis originates from the epicondylar line proximal to
the lateral epicondyle and, because it inserts on the
distal radius, it does not truly contribute to wrist or
digit motion. The extensor carpi radialis longus and
brevis insert proximally on the bases of the second and
third metacarpals, respectively, and the extensor carpi
ulnaris inserts on the base of the fifth metacarpal. The
long digital extensors terminate by insertions on the
bases of the middle phalanges after receiving and giving
fibers to the intrinsic tendons to form the lateral bands
that are destined to insert on the bases of the distal
phalanx. Digital extension, therefore results from a com-
bination of the contribution of both the extrinsic and
intrinsic extensor systems. The extensor pollicis longus
A-1
A-2
C-1 A-3 C-2 A-4 A-5
C-3
Figure 2-14 Components of the digital flexor sheath.
The sturdy annular pulleys (A) are important
biomechanically in guaranteeing the efficient digital
motion by keeping the tendons closely applied to the
phalanges. The thin pliable cruciate pulleys (C) permit the
flexor sheath to be flexible while maintaining its integrity.
(From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and
upper extremity splinting. St Louis, Mosby. Modified from
Doyle JR, Blythe W [1975]. American Academy of
Orthopaedic Surgeons: Symposium on tendon surgery in the
hand. St Louis, Mosby.)
and brevis tendons, together with the abductor pollicis
longus, originate from the dorsal forearm and, by
virtue of their respective insertions into the distal
phalanx, proximal phalanx, and first metacarpal of the
thumb, provide extension at all three levels. The exten-
sor pollicis longus approaches the thumb obliquely
around a small bony tubercle on the dorsal radius
(Lister’s tubercle) and therefore functions not only as
an extensor but as a strong secondary adductor of the
thumb. The extensor indicis proprius also originates
more distally than the extensor communis tendons
from an area near the origin of the thumb extensor and
long abductor. It lies on the ulnar aspect of the com-
munis tendon to the index finger and inserts with it
in the dorsal approaches of that digit. The extensor
digiti quinti proprius arises near the lateral epicondyle
to occupy a superficial position on the dorsum of the
forearm with its paired tendons lying on the fifth
metacarpal ulnar to the communis tendon to the fifth
finger. It inserts into the extensor apparatus of that
digit.
At the wrist, the extensor tendons are divided into
six dorsal compartments (Figure 2-16). The first com-
partment consists of the tendons of the abductor
pollicis longus and extensor pollicis brevis and the
second compartment houses the two radial wrist exten-
sors, the extensor carpi radialis longus and brevis. The
third compartment is composed of the tendon of the
extensor pollicis longus and the fourth compartment
allows passage of the four communis extensor tendons
and the extensor indicis proprius tendon. The extensor
 Anatomy and Kinesiology of the Hand • 31

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
compartment and the sixth houses the extensor carpi
ulnaris.
Intrinsic Muscles
The important intrinsic musculature of the hand can be
divided into muscles comprising the thenar eminence,
those comprising the hypothenar eminence, and the
remaining muscles between the two groups (Figure
2-17). The muscles of the thenar eminence consist of
the abductor pollicis brevis, the flexor pollicis brevis,
and the opponens pollicis, which originate in common
from the transverse carpal ligament and the scaphoid
and trapezium bones. The abductor brevis inserts into
the radial side of the proximal phalanx and the radial
wing tendon of the thumb, as does the flexor pollicis
brevis, whereas the opponens inserts into the whole
radial side of the first metacarpal.
32 Part I • Foundation of Hand Skills

Extensor pollicis brevis

Abductor pollicis Nerve: radial
longus Action: extension of
Nerve: radial metacarpophalangeal
Action: abduction of thumb joint of thumb

Figure 2-15—cont’d.

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
that is innervated by the median nerve and a deep
portion that arises from the ulnar side of the first
metacarpal and is often innervated by the ulnar nerve.
The hypothenar eminence in a similar manner is made
up of the abductor digiti quinti, the flexor digiti quinti
brevis, and the opponens digiti quinti, which originate
primarily from the pisiform bone and the pisohamate
ligament and insert into the joint capsule of the fifth
metacarpophalangeal joint, the ulnar side of the base of
the proximal phalanx of the fifth finger, and the ulnar
border of the aponeurosis of this digit. The strong
thenar musculature is responsible for the ability to posi-
tion the thumb in opposition so that it may meet the
adjacent digits for pinch and grasp functions, whereas
the hypothenar group allows a similar but less pro-
nounced rotation of the fifth metacarpal.
Of the seven interosseous muscles, four are consid-
ered in the dorsal group (Figure 2-18, B) and three as
palmar interossei (Figure 2-18, C). The four dorsal

Abductor pollicis brevis
Nerve: median
Action: abduction of thumb
Flexor pollicis brevis
Nerve: median—superficial
ulnar—deep
Action: flexion and rotation of thumb
Abductor digiti quinti
Nerve: ulnar
Action: abduction of small finger
(flexion of proximal phalanx, extension of
proximal and distal interphalangeal joints)
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.)
interossei originate from the adjacent sides of the
metacarpal bones and, because of their bipennate nature
with two individual muscle bellies, have separate inser-
tions into the tubercle and the lateral aspect of the
proximal phalanges and into the extensor expansion.
The more palmarly placed three palmar interossei
Anatomy and Kinesiology of the Hand • 33
Opponens pollicis
Nerve: median
Action: rotation of first
metacarpal toward palm
Adductor pollicis
Nerve: ulnar
Action: adduction
of thumb
Flexor digiti quinti brevis
Nerve: ulnar
Action: flexion of proximal phalanx
of small finger and forward
rotation of fifth metacarpal
Continued
(Figure 2-18, C) have similar insertions and origins and
are responsible for adducting the digits together, as
opposed to the spreading or abducting function of the
dorsal interossei. In addition, four lumbrical tendons
(Figure 2-19, A) arising from the radial side of the
palmar portion of the flexor digitorum profundus
34 Part I • Foundation of Hand Skills
Lumbricals
Nerve: median—index and long Composite
ulnar—ring and small
Action: supplements metacarpophalangeal
flexion and extension of proximal and
distal interphalangeal joints
Dorsal Dorsal interossei
interossei Nerve: ulnar
Action: spread of
index and ring fingers
away from long finger
Figure 2-17—cont’d.
tendons pass through their individual canals on the
radial side of the digits to provide an additional contri-
bution to the complex extensor assemblage of the
digits. The arrangement of the extensor mechanism,
including the transverse sagittal band fibers at the
metacarpophalangeal joint and the components of the
extensor hood mechanism that gain fibers from both
the extrinsic and intrinsic tendons, can be seen in
Figure 2-19, B, C.
An oversimplification of the function of the intrinsic
musculature in the digits would be that they provide
strong flexion at the metacarpophalangeal joints and
extension at the proximal and distal interphalangeal
joints. The lumbrical tendons, by virtue of their origin
from the flexor profundi and insertion into the digital
extensor mechanism, function as a governor between
the two systems, resulting in a loosening of the antago-
nistic profundus tendon during interphalangeal joint
All interossei
Nerve: ulnar
Action: flexion of
metacarpophalangeal
joints and extension of
proximal and distal
interphalangeal joints
Palmar Palmar interossei
interossei Nerve: ulnar
Action: adduction
of index, ring, and
fifth fingers
toward long finger
extension. The interossei are further responsible for
spreading and closing of the fingers and, together with
the extrinsic flexor and extensor tendons, are invaluable
to digital balance. A composite, well-integrated pattern
of digital flexion and extension is reliant on the smooth
performance of both systems; and a loss of intrinsic
function results in severe deformity.
Perhaps the most important intrinsic muscle, the
adductor pollicis (Figure 2-18, A), originates from
the third metacarpal and inserts on the ulnar side of the
base of the proximal phalanx of the thumb and into
the ulnar wing expansion of the extensor mechanism.
This muscle, by virtue of its strong adducting influence
on the thumb and its stabilizing effect on the first
metacarpophalangeal joint, functions together with the
first dorsal interosseous to provide strong pinch. The
adductor pollicis, deep head of the flexor pollicis brevis,
ulnar two lumbricals, and all interossei, as well as the
 Anatomy and Kinesiology of the Hand • 35

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
nerve. Loss of ulnar nerve function has a profound
influence on hand function.
Muscle Balance and Biomechanical
Considerations
When there is normal resting tone in the extrinsic and
intrinsic muscle groups of the forearm and hand, the
wrist and digital joints are maintained in a balanced
position. With the forearm midway between pronation
and supination, the wrist dorsiflexed, and the digits in
moderate flexion, the hand is in the optimum position
from which to function.
It may be seen that muscles are usually arranged
about joints in pairs so that each musculotendinous
unit has at least one antagonistic muscle to balance the
involved joint. To a large extent the wrist is the key
joint and has a strong influence on the long extrinsic
muscle performance at the digital level. Maximal digital
flexion strength is facilitated by dorsiflexion of the
wrist, which lessens the effective amplitude of the antag-
onistic extensor tendons while maximizing the con-
tractural force of the digital flexors. Conversely, a
posture of wrist flexion markedly weakens grasping
power.
At the digital level, metacarpophalangeal joint flex-
ion is a combination of extrinsic flexor power supple-
mented by the contribution of the intrinsic muscles,
whereas proximal interphalangeal joint extension
results from a combination of extrinsic extensor and
intrinsic muscle power. At the distal interphalangeal
joint the intrinsic muscles provide a majority of the
36 Part I • Foundation of Hand Skills

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
flexor digitorum profundus tendon.
The distance that a tendon moves when its muscle
contracts is defined as the amplitude of the tendon and
has been measured in numerous studies. In actuality
the effective amplitude of any muscle is limited by the
motion permitted by the joint or joints on which its
tendon acts. It has been suggested that the amplitude
of wrist movers (flexor carpi ulnaris, flexor carpi radialis,
extensor carpi radialis longus, extensor carpi radialis
brevis, and extensor carpi ulnaris) is approximately
30 millimeters with the amplitude of finger extensors
averaging 50 millimeters; the thumb flexor, 50 mm;
and the finger flexors 70 millimeters (Figure 2-20).
Although these amplitudes have been thought to be
important considerations when deciding on appro-
priate tendon transfers, Brand (1974, 1999) has shown
that the potential excursion of a given tendon such as
the extensor carpi radialis longus may be considerably
0 mm
3 mm
26 mm (S)
16 mm
23 mm (P)
16 mm (S)
17 mm (P)
44 mm
5 mm (P)
46 mm (S)
38 mm (P)
55 mm 88 mm (S)
85 mm (P)
Figure 2-20 Excursion of the flexor and extensor
tendons at various levels. The numbers on the dorsum of
the extended finger represent the excursion in
millimeters necessary at each level to bring all distal
joints from full flexion into full extension. The numbers
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
bring the finger from full extension to full flexion. (From
Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper
extremity splinting. St Louis, Mosby. Modified from Verdan C
[1979]. Tendon surgery of the hand. London, Churchill
Livingstone.)
Anatomy and Kinesiology of the Hand • 37
greater than the excursion that was necessary to
produce full motion of the joints on which it acted in
its original position.
Efforts have been made to determine the power of
individual forearm and hand muscles and a formula
based on the physiologic cross section is generally
accepted as the best method for determining this value.
The number of fibers in cross section determines the
absolute muscle power of a given muscle, whereas the
force of muscle action times the distance or amplitude
of a given muscle determines the work capacity of the
muscle. Therefore a large extrinsic muscle with rela-
tively long fibers such as the flexor digitorum profun-
dus is found to be capable of much more work than is
a muscle with shorter fibers such as a wrist extensor.
Table 2-1 is an indicator of the work capacities of the
various forearm muscles. It can be seen that the flexor
digitorum profundus and superficialis have a signifi-
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.
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-
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
greater is the angulatory effect created by the increased
length of the moment arm. Therefore a tendon posi-
tioned close to a given joint either by position of the
joint or by a restraining pulley has a much shorter
moment arm than a tendon that is allowed to displace
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
the muscle to turn a joint on its axis. It is determined
by multiplying the strength (tension) of the muscle by
the length of the moment arm. Again, it can be seen
that the distance of tendon displacement away from the
joint is the critical factor and that it does not matter
where the tendon insertion lies. The importance of the
various anatomic restraints of the extrinsic musculo-
tendinous units at the wrist and in the digits is mag-
nified by these mechanical factors.
N ERVE SUPPLY
In considering the nerve supply to the forearm, hand,
and wrist, understand that these nerves are a direct
continuation of the brachial plexus and that at least a
working knowledge of the multiple ramifications of the
38 Part I • Foundation of Hand Skills

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
the upper extremity. Injuries at either the spinal cord or
plexus level or to the major peripheral nerves in the
upper extremity result in a substantial functional
impairment for which splinting may be necessary.
The median, ulnar, and radial nerves, as well as the
terminal course of the musculocutaneous, are respon-
sible for the sensory and motor transmission to the
forearm, wrist, and hand. The superficial sensory distri-
bution is shared by the median, radial, and ulnar nerves
in a fairly constant pattern (Figure 2-22). This chapter
is concerned with the most frequent distribution of
these nerves, although it is acknowledged that
variations are common.
The palmar side of the hand from the thumb to a
line passed longitudinally from the tip of the ring finger
to the wrist receives sensory innervation from the
median nerve. The remainder of the palm, as well as the
ulnar half of the ring finger and the entire small finger,
receives sensory innervation from the ulnar nerve. On
the dorsal side, the ulnar nerve distribution again
includes the ulnar half of the dorsal hand and the ring
and small fingers, whereas the radial side is supplied by
the superficial branch of the radial nerve. Some inner-

Median
Ulnar
Radial
Ulnar
nerve
Median
A nerve
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
joints is supplied by the palmar digital nerves origi-
nating from the median nerve. The area around the
dorsum of the thumb over the metacarpophalangeal
joint is frequently supplied by the end branches of the
lateral antebrachial cutaneous nerve.
The extrinsic and intrinsic musculature of the fore-
arm and hand is supplied by the median, ulnar, and
radial nerves (Figure 2-23). The long wrist and digital
flexors, with the exception of the flexor carpi ulnaris
and the profundi to the ring and small fingers, are all
supplied by the median nerve. The pronators of the
forearm and the muscles of the thenar eminence, with
the exception of the deep head of the flexor pollicis
brevis and the adductor pollicis, which are innervated
by the ulnar nerve, are also supplied by the median
nerve. All muscles of the hypothenar eminence, all
interossei, the third and fourth lumbrical muscles, the
deep head of the flexor pollicis brevis, the adductor
pollicis brevis, as well as the flexor carpi ulnaris and the
ulnar-most two profundi, are supplied by the ulnar
nerve. The radial nerve supplies all long extensors of
the hand and wrist, as well as the long abductor and
short extensor of the thumb, the supinator, and the
brachioradialis of the forearm.
When considering sensibility, one should remember
that the hand is an extremely important organ for the
detection and transmission to the brain of information
relating to the size, weight, texture, and temperature of
objects with which it comes in contact. The types of
cutaneous sensation have been defined as touch, pain,
hot, and cold. Although most of the nervous tissue
Anatomy and Kinesiology of the Hand • 39
Median
Median
Radial
Superficial branch
of radial nerve
B
in the skin is found in the dermal network, smaller
branches course through the subcutaneous tissue fol-
lowing blood vessels. Several types of sensory receptors
have been described, and in most areas of the hand
there is an interweaving of nerve fibers that allows each
area to receive nerve input from several sources. In
addition, deep sensibility from nerve endings in mus-
cles and tendons is important in the recognition of
joint position.
The high interruption of the median nerve above
the elbow results in a paralysis of the flexor carpi
radialis, the flexor digitorum superficialis, the flexor
pollicis longus, the profundi to the index and long
fingers, and the lumbricals to the index and long fin-
gers. In addition, pronation is weakened as a result of
the loss of innervation of both the pronator teres and
quadratus muscles and, most importantly, the patient
loses the ability to oppose the thumb because of
paralysis of the median nerve-innervated thenar muscle
group. A more distal interruption of the median nerve
at the wrist level produces loss of opposition and both
lesions result in a critical impairment of sensation in the
important distribution of that nerve to the palmar
aspect of the thumb, index, long, and radial half of the
ring finger.
High ulnar nerve interruption produces paralysis
of the flexor carpi ulnaris, the flexor profundi and
lumbricals to the ring and small fingers and, most
importantly, the interossei, adductor pollicis brevis, and
deep head of the flexor pollicis brevis. The resulting
loss of the antagonistic flexion at the metacarpopha-
langeal joints of the ring and small fingers permits
40 Part I • Foundation of Hand Skills

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

Proper palmar
digital nerve
to fifth finger
Common digital
Motor (deep)
branch of ulnar
nerve to ring and nerve
small fingers
Ulnar nerve
B from the palmar aspect of the fingers, web areas, and
Figure 2-23 Distribution of the median (A) and ulnar
(B) nerves in the palm. (From Fess EE, Gettle K, Philips CA,
et al. [2005]. Hand and upper extremity splinting. St Louis,
Mosby.)
hyperextension at this level by the unopposed long
extensor tendons, often resulting in a claw deformity.
The loss of the strong adducting and stabilizing
influence of the adductor pollicis combined with the
paralysis of the first dorsal interosseous muscle results in
profound weakness of pinch and produces a collapse
deformity of the thumb, necessitating interphalangeal
joint hyperflexion for pinch (Froment’s sign). More
distal lesions of the ulnar nerve usually result in a
greater degree of claw deformity because of the sparing
of the profundi function of the ring and small fingers.
Sensory loss after ulnar nerve interruption involves the
palmar ring (ulnar half) and small fingers.
The palmar skin with its numerous small fibrous con-
nections to the underlying palmar aponeurosis is a
highly specialized, thickened structure with little
mobility. Numerous small blood vessels pass through
the underlying subcutaneous tissues into the dermis. In
contrast, the dorsal skin and subcutaneous tissue are
much looser with few anchoring fibers and a high
degree of mobility. Most of the lymphatic drainage
hypothenar and thenar eminences flows in lymph
channels on the dorsum of the hand. Clinical swelling,
which frequently accompanies injury or infection, is
usually a result of impaired lymph drainage.
The central, triangularly shaped palmar aponeurosis
(Figure 2-24) provides a semirigid barrier between the
palmar skin and the important underlying neuro-
vascular and tendon structures. It fuses medially and
laterally with the deep fascia covering the hypothenar
and thenar muscles, and fasciculi extending from this
thick fascial barrier extend to the proximal phalanges to
fuse with the tendon sheaths on the palmar, medial,
and lateral aspects. In the distal palm, septa from this
palmar fascia extend to the deep transverse metacarpal
ligaments forming the sides of the annular fibrous
canals, allowing for the passage of the ensheathed flexor
tendons and the lumbrical muscles and the neuro-
vascular bundles.
 Anatomy and Kinesiology of the Hand • 41

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.)
42 Part I • Foundation of Hand Skills

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

Figure 2-26 Strong power grip imparted primarily by
the thumb, ring, and small fingers around the hammer
handle with delicate precision tip grip employed to hold
the nail. (From Fess EE, Gettle K, Philips CA, et al. [2005].
Hand and upper extremity splinting. St Louis, Mosby.)
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
the large powerful forearm muscle groups is more
important to hand strength, the fine precision action
imparted by the intrinsic musculature gives the hand an
enormous variety of capabilities. Although one need

Figure 2-28 Power grip used to hold the squeeze
bottle with precision handling of the bottle top by the
opposite hand. (From Fess EE, Gettle K, Philips CA, et al.
[2005]. Hand and upper extremity splinting. St Louis,
Mosby.)
A Lippincott.
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.
B. Palmar grip. C. Lateral grip. (From Fess EE, Gettle K,
Philips CA, et al. [2005]. Hand and upper extremity splinting.
St Louis, Mosby. Modified from Flatt AE [1974]. The care of
the rheumatoid hand, 3rd ed. St Louis, Mosby.)
not specifically memorize the various patterns of pinch,
grasp, and combined hand functions, it is essential to
understand the underlying contribution of the various
muscle-tendon groups, both extrinsic and intrinsic, to
these activities.
ACKNOWLEDGMENTS
I am extremely grateful to Gary W. Schnitz for many of
the excellent illustrations used in this chapter. This
chapter has been edited by Elaine Ewing Fess, MS,
OTR, FAOTA, CHT for inclusion in this book. The
Anatomy and Kinesiology of the Hand • 43
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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Blumfield RH, Champoux JA (1984). A biomechanical
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Brand PW (1974). Biomechanics of tendon transfer.
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Flatt AE (1983). Care of the arthritic hand. St Louis, Mosby.
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Taleisnik J (1976a). Wrist anatomy, function, and injury.
American Academy of Orthopedic Surgeons’ Instructional
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Taleisnik J (1985a). The wrist. New York, Churchill
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Taleisnik J (1992). Soft tissue injuries of the wrist. In JW
Strickland, AR Rettig, editors: Hand injuries in athletes.
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Weber ER (1982). Concepts governing the rotational shift
of the intercalated segment of the carpus. Orthopedic
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Weber ER (1988). Physiologic bases for wrist function. In
D Lichtman, A Alexander, editors: The wrist and its
disorders. Philadelphia, WB Saunders.
SUGGESTED READINGS
Chase RA (1973). Atlas of hand surgery. Philadelphia, WB
Saunders.
Chase RA (1984). Atlas of hand surgery, vol. 2.
Philadelphia, WB Saunders.
Clemente CD (editor) (1990). Gray’s anatomy of the human
body, 14th ed. Philadelphia, Lea & Febiger.
Hollingshead HW (editor) (1982). Anatomy for surgeons,
vol 4. The back and limbs. New York, Harper & Row.
Kaplan EB (1965). Functional and surgical anatomy of the
hand, 2nd ed. Philadelphia, JB Lippincott.
Landsmere J (1976). Atlas of anatomy of the hand.
Edinburgh, Churchill Livingstone.
Mackin E, Callahan A, Skirven TM, Schneider L, Osterman
AL (editors) (2002). Hunter, Mackin, & Callahan’s
rehabilitation of the hand and upper extremity, 5th ed. St
Louis, Mosby.
Matsen FA, Fu FH, Hawkins RJ (1993). The shoulder: A
balance of mobility and stability, Rosemont, IL, American
Academy of Orthopedic Surgeons.
Morrey BF (2000). The elbow and its disorders, 3rd ed.
Philadelphia, WB Saunders.
Rasch P, Burke R (1990). Kinesiology and applied anatomy,
9th ed. Philadelphia, Lea & Febiger.
Rockwood CA, Matsen FA, Wirth MA, Lippitt SB (editors)
(2004). The shoulder, 3rd ed. Philadelphia, WB Saunders.
Zancolli E (1968). Structural and dynamic basis of hand
surgery. Philadelphia, JB Lippincott.

NORMAL AND IMPAIRED DEVELOPMENT
OF FORCE CONTROL IN PRECISION GRIP
Ann-Christin Eliasson
CHAPTER OUTLINE
DEVELOPMENT OF MOVEMENT CONTROL
THEORIES
LEARNED MOVEMENTS
AFFERENT INFORMATION
Proprioception
Touch
BASIC COORDINATION OF FORCES DURING
GRASPING
Development of Manipulatory Forces
DEVELOPMENT OF ANTICIPATORY CONTROL
Weight
Size
Friction
ORGANIZATION OF SENSORIMOTOR CONTROL
IMPAIRED FORCE CONTROL AND CLINICAL
IMPLICATIONS
Force Coordination
Anticipation of the Properties of Objects
Sensory Information Used for Force Control
SUMMARY
The hand is an effective tool that is used in many
different tasks of daily life. The successful performance
of manual skills in daily life depends on a complex
process incorporating several different aspects of a
person’s capability (Figure 3-1). The usefulness of the
hand is highly dependent on cognition because one has
to understand the value of using one’s hands for a
Chapter 3
meaningful purpose. Then the task to be performed has
to be encoded and translated into purposeful actions,
and these must be performed in the appropriate order.
In the last decade, considerable attention has been
given to the development of prehensile force control
during the manipulation of objects in both healthy
children and children with cerebral palsy (CP), as well
as attention deficit hyperactivity disorder (ADHD) and
other kinds of dysfunctions related to the central ner-
vous system (CNS). It is known that integration of
somatosensory information is crucial for the fine tuning
of motor commands, force regulation, and the build
up of memory strategies for grasping and manipulating
objects. Coordination of movements and somatosen-
sory control develop rapidly during the first years of
life. The refinement continues for many years, and
adult-like sensorimotor control is not attained until the
early teenage years. If somatosensory control is dys-
functional, a person is observed to be clumsy to a
greater or lesser degree. Furthermore, people’s percep-
tions have an effect on their performance of manual
skills because their sensory impressions should be trans-
lated into meaningful information even for the very
simplest of tasks. The perceptual system provides infor-
mation about the position of the hand in space, as well
as the position of the target, both of which are impor-
tant for goal-directed movement. Finally, the musculo-
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
movement, the contractile components of the muscles,
bones, and joints are the effectors of the planned move-
ment. Another cognitive aspect is motivation, which is
closely related to attention and concentration, and all
of which have an influence on the successful perform-
ance of manual skills. A reduced focus on a task almost
certainly limits the ability to learn. Thus self-efficacy
45
46 Part I • Foundation of Hand Skills
Motivation
Cognition
Task-comprehension
Attention
Task-focus
Hand use
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
skills is complex, this chapter discusses how the sensory
information received about an object is increasingly
well integrated with motor processing during develop-
ment, leading to smooth, coordinated movements of
the hand. This chapter also describes how impairment,
mainly arising from CP, but also from dysfunctions
such as those seen in children with ADHD and devel-
opmental coordination disorder (DCD) affects sensori-
motor control of the hand.
Dysfunction or impairment of the CNS almost
always affects hand function. There is a continuum of
decreasing hand function from being somewhat clumsy
to having severe impairment. It seems that the diag-
nosis is less important; it is the grade of impairment
or dysfunction that is crucial. Children with CP have
different degrees of impaired hand function. Some
children only have difficulty performing differentiated
finger movements or in-hand manipulation, whereas
others have severe impairments that make it impossible
even to grasp an object. Most children with ADHD
have fairly good hand function, but when DCD is
present also, the clumsiness is more apparent. Regard-
less of the degree of severity, decreased hand function
has an impact on children’s daily self-care or school
activities, and it affects their engagement in play or
leisure. The ability to analyze a child’s capacity to use
his or her hands and compare the child’s capabilities
with the complexity of the task is a prerequisite for
intervention planning. This chapter explains the under-
lying causes of the impairment or clumsiness apparent
in children with impairment or dysfunction in their
CNS. By understanding the mechanisms normally
responsible for controlling movements, intervention
that takes into consideration the mechanism control-
ling manual skills can be planned. Some examples of
this are given later in this chapter.
Sensorimotor system
Perception
Muscles and
skeletal system
DEVELOPMENT OF MOVEMENT
CONTROL THEORIES
At the beginning of this century, sensory stimuli were
thought to be responsible for the generation of move-
ments. This concept was based on studies by Mott
and Sherrington (1895) on deafferented monkeys. By
transecting the dorsal roots, researchers cut sensory
fibers and left the motor fibers intact. The complete
sensory loss resulted in permanent abolishment of
almost all voluntary movements, especially in the distal
segments. A model was proposed in which the move-
ments were generated by chain reflexes; the sensory
information from the first muscle contraction elicited
the subsequent spinal reflex.
This reflex origin of movement was disputed by
Brown (1911), who studied locomotion in spinal cats.
He suggested instead a central origin in which neuronal
networks could generate basic locomotor activity in the
absence of sensory information (half center model).
The task of the afferents was restricted to modifying
and compensating for ongoing movements. However,
it took quite a long time before this idea was con-
firmed. Nowadays there are several elegant studies that
indicate that innate neural networks control rhythmic
motor behavior in a variety of species such as locusts,
lampreys, and cats (Forssberg, Grillner, & Halbertsma,
1980; Forssberg et al., 1980; Grillner, Wallen, & Brodin,
1991; Wilson, 1964). Neural networks, called central
pattern generators (CPGs), consist of a group of inter-
neurons that interact in an organized manner to pro-
duce a motor act. Detailed knowledge of how one CPG
operates has been demonstrated in the lamprey, a prim-
itive vertebrate fish. The lamprey is especially suited for
such studies because the spinal cord survives in vitro for
several days, and neurons involved in the locomotor
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
swimming can be initiated by stimulation of specific
areas in the brainstem, sensory stimuli if some skin areas
are left innervated, and bath-applied excitatory amino
acids. Information about the networks also has been
used for computer simulation (Grillner et al., 1991).
The central origin of motor behavior has been fur-
ther demonstrated in other rhythmic movements, such
as mastication, swallowing, and respiration (Feldman &
Grillner, 1983; Lund & Olsson, 1983; Miller, 1972).
Swallowing occurs after the denervation of muscles
activated early in the sequence, indicating that the brain
sets the motor program for the whole motor act in
advance. However, this does not diminish the impor-
tance of afferent signals for modulation and learning
of movements. Movements are activated by efferent
signals from several higher levels of the CNS, which are
modulated by afferent signals from the sensory system
and by visual, auditory, and somatosensory information.
There are many reasons to believe that the human
nervous system is organized in the same way. Sponta-
neous movements in the human fetus appear from the
eighth gestational week, just after the first functional
synapses between neurons are developed. The move-
ments seem to be generated by neural networks, and
the afferents may not be needed for initiating the
movements but are used mainly to adjust and com-
pensate for disturbances (de Vries, Visser, & Pechtl,
1982; Okado, 1980, 1981). Innate motor programs,
such as breathing, sucking, and swallowing, function at
birth. The complex pattern of infant stepping also is
innate, but this program is immature in the newborn
and cannot be used for independent walking until the
child has learned to control and adjust the patterns to
external conditions. The system develops both through
practice and by the process of maturation, in which
connections with higher central and afferent sensory
input continue to be established. This is the concept
from which new therapeutic approaches are developed.
LEARNED MOVEMENTS
Voluntary movements in humans are complex. It is
difficult to demonstrate a simple fixed pattern from a
CPG, although skilled movements appear to depend on
a set of motor programs. According to Brooks (1986),
“Motor programs are a set of muscle commands that are
structured before the motor acts begin and that can be sent to the
muscles with the correct timing so that the entire sequence can be
carried out in the absence of peripheral feedback” (p. 7),
or, in other words, can follow an initial plan. In well-
learned, fast movements the trajectory exactly follows
this initial plan. The initiation and termination are
planned together, and the movements are almost
impossible to stop until completed. This is true, for
example, when throwing a ball and in more complex
actions, such as typing. Even continuous movements of
moderate speed, such as handling well-known objects,
are programmed but allow some amount of sensory
feedback. Both kinds of movements are called antic-
ipatory or feed-forward controlled movements, with
the characteristic bell-shaped, single-peaked velocity
profile (see later discussions).
Slow movements generally are not programmed,
allowing time for correction of the ongoing movement
by afferent signals, and demonstrated by a discon-
tinuous velocity profile (Brooks, 1986). The motor
programs are learned by practice when the afferent infor-
mation adjusts the ongoing movement and updates the
motor program for the final movement. The impor-
tance of sensory information is demonstrated by bird-
song learning in the European chaffinch. Normally, the
young birds are exposed to singing by their mothers
but do not start singing themselves until 10 months of
age. If the birds are not exposed to the adult song, they
produce only rudimentary sequences. If the birds are
exposed to adult song during the first 4 months of life
and then isolated from songs during the month after,
they start to sing properly. This indicates that auditory
experience is necessary for the motor program to be
fully developed. If the birds are deafened after 4 months
but before they start to sing, they sing in a very awk-
ward way. Deafening after they start to sing, however,
does not affect the song. This indicates that birds also
must compare the initial motor program for singing
with the actual song, that is, afferent information also
is necessary to be able to learn to use the program of
singing. The afferent information corrects the song and
updates the program, which could be used without
afferent feedback when the song was established
(Konishi, 1965; Nottebohm, 1970).
AFFERENT INFORMATION
The importance of afferent information is seen in
patients with large sensory fiber neuropathies, in which
the large afferent fibers generating proprioceptive and
tactile information degenerate. Unless these patients
see their limbs, they do not know their position and
cannot detect limb motion. When reaching toward a
target without seeing the moving hand, they make
large errors; if they look at the hand before reaching,
the hand comes closer to the target. This indicates that
these patients can compensate for the lack of somato-
sensory information visually and also use vision to
program the reaching in advance. Because the patients
cannot stop the movement precisely at the desired
48 Part I • Foundation of Hand Skills
target, information from various receptors in the skin is
essential for precise movements (Ghez et al., 1990).
Impaired sensation is also common in children with
hemiplegic CP and has to be taken into account when
planning treatment.
PROPRIOCEPTION
The proprioceptive system gives information about the
stationary position of the limbs (limb position sense)
and movements of the limb (kinesthesia). The latter
information is mediated from tendon organs and mus-
cle spindles and also from receptors in the skin, sensitive
to skin stretch. The tendon organ signals information
about the strength of muscle contraction, increased
signaling indicating increased tension. Signals from the
muscle spindle regulate the length of the muscle fibers.
The receptors are rather complicated and, despite inten-
sive research, their function is not fully understood. It
has been agreed, however, that the muscle spindle is
responsible for small changes in muscle contraction,
which may be important for force regulation during the
grasping act. There are muscle spindles in almost all
skeletal muscles, and they mediate information mainly
through 1a afferents to the spinal cord. The muscle
spindle also has efferent innervation to intrafusal mus-
cle fibers, in which the primary and secondary endings
set the sensitivity to the afferent signals. The different
contractions of intrafusal muscle fibers are probably
crucial for the information sent to the CNS. Alpha and
gamma motor neurons are co-activated by central
mechanisms to maintain the sensitivity of the muscle
spindles throughout the range of almost all move-
ments. There have been different models for the co-
activation of alpha and gamma motor neurons, but it
appears that descending commands activate both, as
demonstrated by Vallbo (1970) in studies of micro-
neurography. The afferent signals are used to update
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.
TOUCH
The tactile system is used to discriminate between
different surfaces and shapes and also provides sensory
input to the CNS, which regulates the force of the
muscles during grasping and holding of objects. Touch
transmits nerve impulses from mechanoreceptors to the
CNS via axons with different diameters. Large fibers
with a fast conduction rate mediate tactile sensation
from the skin, whereas thin fibers with a slow con-
duction rate mediate sensation of pain and tempera-
ture. The receptors mediating tactile sensation can be
classified on the basis of their receptive fields and
morphology: Two receptor types, Meissner and Pacini
corpuscles, are fast adapting; Meissner corpuscles have
small, sharply delineated sensory fields; and Pacini
corpuscles have large and diffuse sensory fields. Two
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
diffuse fields. Mechanoreceptors with small receptive
fields are suitable for fine spatial discrimination because
they have a high sensitivity over the entire field, whereas
mechanoreceptors with large receptive fields have a
central area of high sensitivity and decreased sensitivity
in the border of the receptive field. Because there are
about 17,000 tactile units in the hand and approxi-
mately 70% of them have small receptive fields, it can
be postulated that the tactile system of the hand is
highly developed to detect small movements and dis-
criminate among different surfaces (Johansson &
Vallbo, 1983).
People explore the surface of an object by manip-
ulation of the fingers. The difference between explor-
ing known and unknown surfaces is the speed of the
finger movements (Roland, Ericsson, & Widen, 1989).
A relevant movement for exploring the different sur-
faces of an object is by touch through digital manip-
ulation, whereas a more adequate way to explore the
shape is by rotation of the wrist and bimanual hand
activity. The fingertips are very sensitive to tactile infor-
mation, and tactile discrimination occurs early during
development. One-year-old children can recognize
dissimilar objects, and they are able to use the two
different exploratory maneuvers for objects differing in
texture or shape (Ruff, 1984). Newborn monkeys can
distinguish different textures by choosing the texture
that gives milk (Carlson, 1984). These examples indi-
cate that, despite an immature nervous system, there is
early interaction between somatosensory signals and
motor output.
BASIC COORDINATION OF FORCES
DURING GRASPING
During the last decade Johansson and Westling (1984,
1987, 1988, 1990) have studied grasping movement
to understand how somatosensory information is inte-
grated with motor control. In adults, movements of the
hand and fingers are precise and the forces of the
fingers well controlled. This is not an innate behavior;
in fact, these functions develop during early childhood
and may be dysfunctional if there is impairment in the
CNS (Eliasson & Gordon, 2000; Eliasson, Gordon, &
Forssberg, 1991, 1992, 1995; Forssberg et al., 1991,
1992, 1995, 1999; Gordon et al., 1992).
 Normal and Impaired Development of Force Control in Precision Grip • 49

Most grasping acts involve lifting and holding
objects, grasping with the fingers, and lifting with the
arm. The object seen in Figures 3-2 and 3-3 measures
grip force from each grip surface (thumb and index
finger), a combined vertical load force by strain-gauge
transducers, and vertical movement by a photoresistor
(Eliasson et al., 1991). With this instrument it has been
possible to define different phases of the lift and under-
stand how they are linked to produce smooth move-
ments. When grasping the instrument, there is a short
delay before the vertical load force starts to increase.
This preload phase is important for establishment of
the grasp. During the loading phase the grip and load
forces increase in parallel until the instrument starts to
move. The rates of grip and load forces have mainly
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.
50 Part I • Foundation of Hand Skills

the weight, size, and frictional character of the surface
of the object. After the loading phase there is a transi-
tion phase, in which the lift reaches the final position
and the forces are well adjusted to the current prop-
erties of the object. In the final static phase the object
is held in the air (Figure 3-4).
Tactile information triggers different motor com-
mands and links the different phases together. The
different types of receptors respond differently during
the lift, which has been demonstrated by microneu-
rography from single tactile units innervating the
glabrous skin of the fingers. Fast-adapting receptors
send bursts of impulses when first touching an object,
at the beginning of the loading phase and at lift-off but
are silent during the static phase. Slow-adapting recep-
tors send impulses continuously during the static phase
(Johansson & Vallbo, 1983). This ability makes it pos-
sible to handle small fragile objects without crushing
them. To investigate how separate components affect
the grasping act, the object has a slot in which blocks
of different weights may be inserted while the visual
appearance remains constant; the contact pads can be
covered with silk or sandpaper, each having different
frictional character, and the size can be adjusted by
boxes of different size attached to the instrument (see
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.)
 Normal and Impaired Development of Force Control in Precision Grip • 51

weight of the object at lift-off, indicating anticipatory

DEVELOPMENT OF MANIPULATORY FORCES
During the loading phase, just before the movement
starts, the grip and load forces are generated in parallel
for coordinated movements. This parallel increment of
both grip and load force increases with heavier objects,
resulting in prolonged latency until lift-off. If the
contact surface changes, the grip force increases more
for slippery materials compared with rough materials,
whereas the load force remains the same. Still the forces
increase in parallel but with different slope. This par-
allel force generation forms a lifting synergy to simplify
movements (Bernstein, 1967). It develops from the
second year when the pincer grasp is fully developed.
Smaller children cannot generate grip and load forces
in parallel; they initiate forces sequentially. This is
clearly seen in Figure 3-5; most of the grip force
increases before the onset of load force. The force rate
profile is irregular and has several peaks in young
children, whereas older children and adults perform
mainly a bell-shaped force rate profile, adjusted to the
controlled movements (Brooks, 1986; Forssberg et al.,
1991).
Small children also have more variation than adults
because they cannot repeatedly produce similar move-
ments. However, 1-year-old children can use tactile and
proprioceptive information to adjust the forces by
sensory feedback during the static phase. All phases are
prolonged, and the different phases are not triggered
elegantly as in adults (Forssberg et al., 1995). There is
an increased difference between thumb and finger
contact, probably because of an immature ability to
adjust the finger toward the object’s size (von Hofsten
& Ronnquist, 1988). This uncoordinated movement in
small children is likely attributable to immature motor
output and sensory processing. There is rapid devel-
opment until age 2. The refined coordination then
progressively develops until leveling out at ages 4 to 6
and continues gradually until the teenage years, when
the lifts are completely adult-like (see Figure 3-4)
(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.)
52 Part I • Foundation of Hand Skills

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,

friction, size, and haptic cues of the object (Gordon et
al., 1991a,b; Johansson & Westling, 1990).
WEIGHT
When the weight of the object is varied but the visual
appearance remains constant, adults typically scale the
grip and load force rates based on earlier experience of
the object’s weight. This is indicated by higher grip and
load force rates for heavier objects. The forces are
decreased at lift-off to harmonize with the weight of
the object. The anticipatory mechanism can be further
demonstrated when lifting an unexpectedly light
object. For example, if one lifts an unopened but empty
can of soda, the lift will probably be too high because a
heavier can is expected. However, this occurs only once
for the same can. Somatosensory information adjusts
the forces to the object’s actual weight during the static
phase and updates the internal representation of the
object for a smooth movement the next time the object
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
force rates, 2-year-old children start to scale the forces
toward different weights. It takes several years until
the anticipatory control of weight is fully developed.
Children between the ages of 6 and 8 are nearly adult-
like although the variation is still larger than in adults
(Figure 3-6). This indicates that anticipatory scaling
of forces occurs in conjunction with maturation of
coordinated movement (Forssberg et al., 1992).
SIZE
Anticipatory control also is predicted from visual infor-
mation about an object’s size (Gordon et al., 1991a,b).
When the object is kept proportional to the volume,
Acceleration (N/s2)
3
2
1
0
t
1-
2
2-
4
4-
6
6-
8 11 -1
5 ul
8- 11 Ad
B Age (yrs)
Figure 3-6 Influence of the 200- and 800-g weight
(400 g for 1- to 2-year-old children) in the constant lifting
series for peak grip force rate (A) and peak acceleration
(B). The means and standard error of means of the
individual means for each subject indicate the major
changes during development. (Modified from Forssberg H,
Kinoshita H, Eliasson AC, Johansson RS, Westling G [1992].
Development of human precision grip. II. Anticipatory control
of isometric forces targeted for object’s weight. Experimental
Brain Research, 90:393–398).
there are appropriately scaled forces toward the
expected weight relative to the volume. When only the
size of the object is co-varied and the weight is kept
constant, the employed grip force rate is higher for the
larger than the smaller object. However, adults and
older children perceive the small objects as heavier. This
indicates a dichotomy between the perceptual and
motor systems because of the size-to-weight illusion
(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
weight and a proper scaling of the motor output starts
to develop at 3 years. Children younger than 3 are
not able to control the motor output according to
size but do use a higher grip force rate for heavier
 Normal and Impaired Development of Force Control in Precision Grip • 53
objects. This suggests that the associative transforma-
tion between the object’s size and weight involves
additional demands of cortical processes, requiring fur-
ther cognitive development. In children 3 to 7 years of
age the difference between large and small objects is
greater than in adults. Older children seem capable of
reducing the effect if it is not purposeful for manip-
ulation, whereas younger children still strongly rely on
visual information (Gordon et al., 1992).
FRICTION
Tactile influence on the force coordination is available
on touching an object, contrary to weight influence,
which is not available until lift-off. Tactile information
from fingertips triggers prestructured motor com-
mands based on sensorimotor memories and adjusts
the force coordination based on the friction of the
contact surface. The employed grip forces are different
when one holds a slippery bottle than when holding a
tool covered with rubber, even if they have the same
weight. When contact pads on the test object are
altered by exchangeable contact surfaces of silk and
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
during the loading and static phases (Johansson &
Westling, 1987). These adjustments are important in
establishing an adequate safety margin, which prevents
one from dropping the object. The ratio between grip
and load force actually used, minus the slip ratio
necessary to prevent the object slipping out of the
hand, makes up the safety margin.
One-year-old children have a larger safety margin
than adults. Gradually, the safety margin decreases in
conjunction with increased coordination and less
variability during the first 5 years (Figure 3-7). Some
children of 18 months can scale the grip force based on
tactile information in the beginning of the lift. They
have a higher grip force for slippery materials than for
rough ones during consecutive lifts with the same
friction. Several years are necessary before children can
handle objects with different frictional surfaces in the
same elegant way as adults. Children younger than 6
years of age, sometimes up to 10 or 12 years, need
several lifts and a predictable order to adjust the grip
force to the current friction and form an internal
representation before setting the parameters of the
programmed motor output. The difference between
adaptation to weight and adaptation to friction is that
frictional conditions appear directly upon touching
the object, whereas weight information is likely more
crucial for anticipatory control because the weight is
not available until lift-off. Grip forces of high amplitude
Safety Margin
300
sp
si
250
200
Percent
150
100
50
0
t
1-
2
2-
3
3-
4
4-
5
5-
6 10 -1
5 ul
6- 11 Ad
Age (yrs)
Figure 3-7 The mean and standard deviation of
individual means of the safety margin for lifts with
sandpaper and silk plotted for different age groups. The
safety margin is expressed in percent of the slip ratio.
Significant differences are indicated by an asterisk
(p < 0.05). (Modified from Eliasson AC, Gordon AM,
Forssberg H [1995]. Tactile control of isometric finger
forces during grasping in children with cerebral palsy.
Developmental Medicine and Child Neurology, 37:72–84.)
are a useful compensatory strategy to avoid dropping
objects (Forssberg et al., 1995).
ORGANIZATION OF
SENSORIMOTOR CONTROL
These studies have enhanced our knowledge of the
mechanisms underlying sensorimotor integration and
anticipatory control in a grasping task. The model
implies that for this manipulatory act visual, tactile, and
proprioceptive information are integrated with memo-
ries of similar objects from previous manipulative expe-
rience. The appropriate muscles are then activated in
the proper sequence based on the internal memory
representation of the object, resulting in a well timed
and coordinated grasping and lifting act. The act
includes selection of motor programs that control ori-
entation of the hand and the subsequent limb trajec-
tories. These programs may be stored in sensorimotor
(procedural or implicit) memory and used in an uncon-
scious way, different from declarative (explicit) memory
that is used in conscious recall of facts, events, and
percepts (Squire, 1986) (see Chapter 6). The existence
of sensorimotor memory has been demonstrated by
disorders in higher brain function. It seems that net-
works involving cortical function, especially posterior
parietal cortex, are important for anticipation. Jeannerod
54 Part I • Foundation of Hand Skills
(1986) has described deficit in shaping the fingers
toward the size of the object in patients with damage to
the parietal area.
The maturation of control mechanisms for the
grasping movement continues throughout childhood.
All measured parameters rapidly develop during the
first years. Force coordination is poorly developed in 1-
year-old children; for example, they usually crush an ice
cream cone, whereas children of 2 years manage quite
well. There is a continuum of improvement of the
parallel generation of grip and load forces as well as
scaling of the forces toward the object’s different
weight and friction. In 4-year-old children the motor
output becomes less varied and more coordinated, in
conjunction with a decreased safety margin. Children
have more coordinated and adjusted movements and
are able, for example, to carry a kitten and handle
fragile objects. At that age there is even force scaling to
the size of the object. However, the appropriate antici-
patory scaling with acceleration of the lift to harmonize
with the weight of the object is not developed until 6
to 8 years of age. Even so, there are still large variations
in the ability to properly scale the forces according to
frictional demands. It is not until ages 10 to 12 that
scaling approaches adult levels. Efficient control of
finger movements continues to develop until adoles-
cence, when children can learn to play musical instru-
ments and develop good handwriting with accurate
speed. Obviously, there is parallel processing of cogni-
tive functions and sensorimotor control during normal
development.
The maturation processes probably occur at many
levels. Both the motor cortex and corticospinal tract
with monosynaptic connections are important for pre-
cision grip and are highly related to force generation.
In monkeys the monosynaptic projections to the spinal
cord are not fully developed until the end of the first
year (Lawrence & Hopkins, 1976). Myelination of the
axons and increased conduction rate of cortical motor
neuronal activity develop over several years and prob-
ably influence the temporal parameters of the lift
(Muller, Hornberg, & Lenard, 1991). Because many
areas of the brain are apparently involved in the grasp-
ing act, its full development obviously depends on
establishment of appropriate synaptic connections
between the cortex and all other areas associated with
the act. These maturation processes are shown by reor-
ganization of reflex responses with more efficient and
faster triggering, which continues until adolescence
(Evans, Harrison, & Stephens, 1990; Forssberg et al.,
1991; Issler & Stephens, 1983). There are cortical net-
works mediating monosynaptic corticospinal projec-
tions to the motor neurons controlling distal muscles
(Fetz & Cheney, 1980; Muir & Lemon, 1983), which
are active in fine manipulation and force regulation
(Smith, 1981; Wannier, Toltl, & Hepp-Reymond,
1986). There may exist subcortical motor centers and
even networks in the spinal cord important for storing
certain motor acts; for example, the C3-C4 proprio-
spinal system in cats can be used to mediate and update
cortical commands for visually guided reaching
(Alstermark et al., 1987). This provides several solu-
tions for a particular movement through a wide range
of central and peripheral inputs. During development
there may be reorganization of networks in the spinal
cord caused by increased descending control on pre-
motor neurons. The descending control may break up
the innate grasp reflex synergy allowing independent
finger movement and may form a grip/lift synergy
(Forssberg et al., 1991).
Learning motor activities proceeds by trial and error;
it is not really understood how the information from
subsequent lifts is stored in memory to result in effi-
cient programming. It is known that the anterior lobe
of the cerebellum is involved in force regulation before
a lift because the amplitude of the force is correlated
with activity in neurons in this region, which has cuta-
neous and muscle afferent inputs from the hand
(Espinoza & Smith, 1990). There are radical changes
in synaptic activity, reflected in regional cerebral blood
flow, during learning of motor sequence for finger
movements. In the initial part of learning there is
activation of the cortical areas, cerebellum, and struc-
tures providing information to those areas, namely the
anterior language area and somatosensory association
areas. As learning progresses, the activation in the lan-
guage areas of the cortex disappears, leaving a reduced
region in the somatosensory area, whereas different
motor structures and the cerebellum show consistent
increase in activity. This may mean that motor pro-
grams for motor sequence learning of finger move-
ments are established and can be produced in a
feed-forward strategy with less sensory information. It
appears that memories are not stored in a single cell or
in one particular cortical structure (Seitz et al., 1990).
IMPAIRED FORCE CONTROL AND
CLINICAL IMPLICATIONS
Clumsiness or impaired hand function may have dif-
ferent origins. The most common diagnoses of devel-
opmental disorders in children are ADHD, DCD, and
CP. Although of different origin, they are all associated
with more or less impaired force control during
grasping (Eliasson et al., 1991; Forssberg et al., 1999;
Pereira, Eliasson, & Forssberg, 2000). The dysfunction
 Normal and Impaired Development of Force Control in Precision Grip • 55
could be seen as a continuum, with clumsy children at
one end and severely impaired children with CP at the
other. Children with CP have disturbed hand function
because the primary or secondary lesions involve the
sensorimotor cortex and the corticospinal tract, both of
which have great implication for the performance of
precision grips and for independent finger movement
(Lawrence & Kuypers, 1968; Muir & Lemon, 1983)
(see also Pehoski, Chapter 1). These children are
known to be slow and weak with disturbed mobility of
their finger movements (Brown et al., 1987; Ingram,
1966). In addition, they have different degrees of
spasticity and tactile discrimination, especially those
children with hemiplegic CP (Brown et al., 1987;
Uvebrant, 1988). Little is known about the neural
mechanisms that cause the impaired motor behavior in
children with ADHD. The main problems are hyper-
activity and poor attention, as indicated by the name,
but about half of the children who have been diag-
nosed with ADHD also have motor problems (Barkley,
1990; Kadesjö & Gillberg, 1998). In particular, their
fine motor skills are diminished (Szatmari, Offord, &
Boyle, 1989; Whitmont & Clark, 1996), affecting, for
example, their handwriting and performance on other
highly skilled tasks (Doyle, Wallen, & Whitmont, 1995;
Raggio, 1999). DCD is characterized by minor motor
problems that occur as an isolated phenomenon in
some children (American Psychiatric Association,
1994), which is to say that the minor motor problems
appear without the symptoms attributable to ADHD
but also can be found in conjunction with ADHD.
These DCD children in the past were called “clumsy
children” or children with motor coordination prob-
lems. The cause of the dysfunction is unknown but the
group generally can be distinguished from typically
developed children from the results of a test like the
Movement ABC (Henderson & Sugden, 1992). As
indicated, dysfunctioning prehensile force control is
common to all children with ADHD, DCD, and CP.
FORCE COORDINATION
When making a lift, the temporal pattern is rarely
impaired in children with ADHD regardless of whether
or not the ADHD is accompanied by DCD (Pereira
et al., 2000); for children with CP, it is almost always
disturbed to some degree. In these children the differ-
ence in the time at which the first finger or thumb
makes contact with the object and the time at which
the second finger makes contact is larger than in typi-
cally developing children, indicating disturbed coordi-
nation of finger movement and shaping of the fingers
toward the size of the object, although there is a great
deal of variation within the group, from almost as good
as the average of the control group to severely impaired
(Eliasson et al., 1991; Forssberg et al., 1999). The
parallel grip and load force typical of normal develop-
ment rarely is seen. Instead, the forces increase sequen-
tially with the grip force increasing before the load
force (see Figure 3-5). Consequently, they do not
produce the force rates in mainly bell-shaped profiles,
but in stepwise, irregular, and extremely variable pro-
files (see Figure 3-4). However, this slow, sequential
initiation of movements is an adequate strategy pro-
viding security in a manipulative task in which the
coordination of force generation is not fully functional.
For both groups of children (ADHD and CP), the grip
force is larger and more unstable when performing a lift
than it is for controls, in addition to which there is
more variability between one lift and another (see
Figure 3-4) (Eliasson et al., 1991). This large variability
seems to be a characteristic of immaturity, as well as of
dysfunction and impairment. It means that the children
cannot repeat a task in the same way, or transfer the
experience of performing one task to the performance
of a similar one, making their performance unpre-
dictable or clumsy. The relation between the develop-
ment of force control and the severity of hand function
has been demonstrated previously (Forssberg et al.,
1999).
However, the slow performance commonly observed
in children with CP may be a good adaptation to their
impairment. An example of the usefulness of such slow
and sequential movement is evident when one con-
siders the impaired release of the grasp. When effi-
ciently putting down and releasing an object, including
toys, the object has to be lowered and placed on a
surface, not too quickly and not too slowly. This neces-
sitates a low velocity of the movement close to the
surface on which the object is to be placed (Figure
3-8). Then the force of the grasp ceases and the indi-
vidual fingers are removed quickly and almost simul-
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
contact with the table, making the movement abrupt.
Then it is hard for the child to decrease the force,
resulting in a prolonged movement phase during which
the fingers are released one at a time in an uncoor-
dinated manner (see Figure 3-8) (Eliasson & Gordon,
2000).
How can this knowledge be used in clinical practice?
The case of a 4-year-old girl with hemiplegia playing
with small plastic animals is one example. Every time
she tried to lift and then place the horse, it fell. It was
obvious that she was releasing the object too abruptly.
By giving a simple instruction, “Straighten your fingers
slowly,” she had the clue she needed to immediately
56 Part I • Foundation of Hand Skills

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-
plegic CP has impaired force coordination, the thera-
pist was able to give the girl precise information. The
therapist recognized that although she appeared to
be slow when replacing the horse, she was not slow
enough in the crucial part of the action—when she had
to loosen her grasp. That part had to be performed
even more slowly, and she was able to succeed by
increasing her awareness of that part of the movement
sequence.
Normally this behavior is performed in an uncon-
scious way (i.e., by implicit processes) (Gentile, 1998).
However, after a lesion has occurred in the CNS, it may
be necessary to use an explicit process, at least in the
early stage of learning. Knowledge about normal and
abnormal behavior and the ability to analyze the task
made it possible to give precise instructions. The idea
was to help the child to learn how her impaired nervous
system works and give her a strategy that could enable
her to perform this task successfully; then she might be
able to use the same strategy when releasing other
objects in different situations (Eliasson, 2005).
OF OBJECTS
During normal development small children are able to
scale the force that needs to be applied when gripping
an object even before the action starts, taking into
account the weight and friction, as well as the size of
the object. This happens even before the typical parallel
force coordination with the mainly bell-shaped force
rate profile is developed. Hardly any of the children
with CP who were aged 6 to 8 years, or the children
with ADHD plus DCD who were 9 to 15 years, scaled
the force amplitude appropriately for different weights,
whereas children with only ADHD anticipated the
weight fairly well (Eliasson et al., 1992; Pereira et al.,
2000). This indicates that a different type of dysfunc-
tion (diagnosis), at least on a group level, influences the
ability to scale the motor output. Although children
with ADHD plus DCD can apply an appropriate force
the first time they lifted a familiar object such as a
glass, or an unopened packet of milk, they cannot do
this efficiently with an unfamiliar object, when they
have only seen but not touched or lifted it (Pereira
 Normal and Impaired Development of Force Control in Precision Grip • 57
et al., 2000). Appropriate force involves anticipatory
scaling. That means that when heavier and larger
objects such as an unopened packet of milk are to be
lifted, the child increases the load force at a greater rate
during the initial lifts than when lifting smaller light
objects like the glass. Children with ADHD plus DCD
are able to build up a memory representation of the
object, although this is not as efficient as for typically
developed children and adults. This deficient control
was also demonstrated in a group of children with
hemiplegic CP who were unable to scale the force
output to match the weight of a previously lifted object
until they had lifted the object at least 15 times. This
has to be compared with the one or two times neces-
sary in age-matched peers (Gordon & Duff, 1999).
However, most participants with CP demonstrated
anticipatory scaling when lifting familiar objects,
which means that they are capable of learning by
practice, despite having a dysfunctional nervous system.
The question, then, is how this practice should be
planned and performed. An investigation was carried
out in another experiment in which children lifted
novel objects that varied in weight in either a blocked
series, with one weight being lifted several times, or a
random series in which different weights were ran-
domly assigned to be lifted (Duff & Gordon, 2003).
Blocked practice resulted in greater differentiation
of the force rates between objects during acquisition
than random practice. However, both types of practice
resulted in similar performance retention 24 hours
later. These findings suggest that children with hemi-
plegic CP are able to build up internal representations
that are used for anticipatory force scaling of novel
objects, and that practice is valuable, although it appears
that the type of practice schedule employed is not
important.
The importance of practice can be demonstrated by
adolescents with hemiplegic CP who were practicing
Frisbee golf using their hemiplegic hand. Being able to
throw a Frisbee as well as possible toward a target
requires the ability to plan the direction of the move-
ment, use a certain amount of force, and release the
grasp with exact timing. Playing Frisbee with a hemi-
plegic hand may seem crazy, but it was an activity
practiced at a 2-week, 5-day-a-week day camp in which
the adolescents were treated by Constraint Induced
Movement Therapy (Eliasson et al., 2003). The goal of
the Frisbee game was to traverse a 350-foot-long
course, at the end of which was a basket. The object of
the game was to use the fewest number of throws to
get the Frisbee in the basket. Nine adolescents prac-
ticed 30 minutes for 7 days during the day camp. All
adolescents improved at this game, and the number
of throws needed to get the Frisbee into its basket
decreased from the first to the last day of camp, from
20 (range 14 to 35) to 14 (range 12–18) (Eliasson et al.,
2003). It appears that it is possible to improve at
Frisbee golf, as well as to learn to scale the force output
during grasping applied to objects by practice, at least
for these groups of children with CP.
SENSORY I NFORMATION USED FOR
FORCE CONTROL
Sensory information is essential for prehensile force
control because it provides the nervous system with
information about different aspects of the physical
properties of objects in the immediate environment
and, as described, it is used for anticipatory scaling and
to adjust ongoing movements. Sensory impairments
have been described for children with hemiplegic CP
but have not been observed in children with diplegic
CP or ADHD (Uvebrant, 1988). In children with
hemiplegic CP, a decrease in two-point discrimination
and stereognosia occurs in 50% to 70% of children.
Processing of proprioceptive information also is
impaired. This can be seen during vibration of a
muscle, in which the muscle spindles are stimulated,
giving rise to an illusion of arm movement; this illusion
occurs in normal children, but only in 50% of children
with CP (Tardieu et al., 1984). However, there is an
unclear relationship between the perceived sensation of
this kind and the ability to adjust the force output to
match the physical properties of an object. All children
with CP who participated in earlier studies perceived
the difference between weight and frictional contact
surfaces of the object to be lifted although some of
them had decreased two-point discrimination and
stereognosis. That is, almost all of them have decreased
ability to transform sensory information into appro-
priate “settings” for a motor command. There was no
simple correlation between two-point discrimination
and ability to adjust the force output based on frictional
condition of the object (Eliasson et al., 1995). This
may indicate that two point discrimination needs to be
processed at a higher level in the central nervous system
than adjustment of forces for grasping.
The children with CP should be able to rely on
sensory feedback for grasping because, as mentioned,
their anticipatory control is impaired. Relying on sen-
sory feedback means that the forces increase in a
steplike manner, permitting sensory feedback, until lift-
off. This results in a prolonged loading phase for
heavier objects, but fairly well-adjusted forces taking
into account both the weight of the object and the
friction of the contact surfaces during the static phase
when the object is held still in the air (Eliasson et al.,
1992, 1995). Yet there is large variation in the grip
58 Part I • Foundation of Hand Skills
force applied during the isometric force coordination,
making the performance unpredictable and, of course,
inconvenient for daily life. This is a common feature
in the early development of all children, including chil-
dren with different diagnoses (Eliasson et al., 1991;
Brogren, Forssberg, & Hadders-Algra, 2001; Pereira et
al., 2000). A way of solving this problem is to increase
the safety margin to prevent objects from being dropped.
This compensatory behavior was obvious in all the
children with CP who were investigated. It is evidently
a successful compensatory strategy for those with
impaired sensory processing, lack of anticipatory con-
trol, and slow adaptation (Eliasson et al., 1995). How-
ever, it does make it difficult to handle fragile objects
because there is a danger that the object will be crushed,
and it also makes it difficult for children with CP to
handle heavy objects because, in this case, a high level
of force is needed and weakness is a common problem
in children with CP.
The question that needs to be addressed is: How
can children with sensory dysfunction learn to handle
objects as efficiently as possible? Sensory information
is crucial for the performance of precise movements.
Tactile information is the most important information
for discrete finger movements, whereas proprioception
is more important for reaching in different directions
and handling objects of different weights. Tasks in
which tactile information is crucial are, for example,
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
hold the object (an action requiring less sensory infor-
mation) with their impaired hand and manipulate
(requires efficient tactile regulation) with their domi-
nant hand (Krumlinde-Sundholm & Eliasson, 2002).
However, an important compensation for tactile
disturbance is to use visual information. Vision strongly
influences manipulatory actions and should not be
overlooked when attempts are made to gain a deeper
understanding of how the somatosensory systems
influence manipulatory actions. The ability to use visual
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
more or at least as much from upper limb surgery as
measured by a timed dexterity task than children with
intact sensibility (Figure 3-9) (Eliasson, Ekholm, &
Carlstedt, 1998). This probably has something to do
with the ability to “see the grasp” being performed
after surgery because before the surgery was per-
formed, the hand was pronated, the wrist was flexed,
and the thumb was in-palm, making it impossible to see
the grasping act as it was conducted. After surgery, in
contrast, the hand was more extended and supinated
Dexterity before and after surgery
140
120
100
Sec
80
60
40
20
0
Normal Impaired
Sensibility
Figure 3-9 Dexterity, in seconds when moving 10
cubes and placing them on the opposite side of a vertical
border on the table. Individual results of 11 subjects with
normal two-point discrimination (2PD) and 14 with
impaired 2PD before and after surgery. 2PD: 3 to 4 mm
was tested for in a randomized order, their fingers were
touched with a distinct but light touch with one or two
points, 10 times on each finger. Before examination, the
task was demonstrated for them to see and feel the
differences between one and two points on both hands.
Normal 2PD required at least eight correct answers on
two of three digits. The time decreased 14.5 s (md)
compared with 9 s (md) for children with normal
sensation. (Modified from Eliasson A.C, Ekholm C, Carlstedt T
[1998]. Hand function in children with cerebral palsy after
upper-limb tendon transfer and muscle. Developmental
Medicine in Child Neurology, 40:612–621.)
and the thumb was able to meet the fingers, making it
possible to use vision to compensate for impaired sensi-
bility. This may indicate that impaired sensation could
be an indication for surgery, at least from one per-
spective. This is opposite to what commonly is recom-
mended but has to be considered. One other important
way to compensate for lack of control that should not
be overlooked is to concentrate and pay deliberate
attention to the performance of the task. The compen-
satory strategies are crucial, but they often make the
children slower.
SUMMARY
Motor control—meaning how the CNS controls move-
ment—is complex, but by understanding the principles
of how movements are organized, it is possible to use
the knowledge that has been gained to plan interven-
tion. By using this perspective we can help children
to learn more about themselves and help them find
more efficient ways to use their possibilities rather than
focusing on the impaired or odd movement. An impor-
tant perspective to put across is that there is nothing
 Normal and Impaired Development of Force Control in Precision Grip • 59
wrong or right about a movement, rather, when there
is a task that needs to be performed, it can often be
done in a number of different ways. As therapists, we
can help them to learn themselves by adopting strate-
gies and ensuring that repetition consolidates improve-
ments. Thus, if knowledge of motor control is used
alongside the principles of motor learning, a new and
useful concept of treatment results. In addition, it
should be remembered that we do not know the rela-
tionship between the maturation of the CNS and the
performance of different tasks; however, we do know
that practice is necessary. Given this, it seems logical
that a less efficient nervous system needs more practice
than an appropriately functioning one.
It is also known that improvement in any task
strongly depends on motivation. Improvement induced
by motivation is shown nicely in a task measuring
pronation and supination of the hand: The children are
induced to increase their range of movement by hitting
a drum rather than by just performing the movement
(van der Weel, van der Meer, & Lee, 1991). For the
children concerned, it is the game itself that is the goal:
They are not interested in the specific movement of
arms and hands, and the therapist should remember
this. For success in skills, the therapist should encour-
age children to find tasks they are motivated to repeat
and learn, working on their possibilities rather than on
their limitations. We have to bear it in mind that the
task performance we see may look odd from a per-
spective of “normal” movements, but it may be a solu-
tion to a problem based on their way to handle their
impaired nervous system
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PERCEPTUAL FUNCTIONS OF THE HAND
Sharon A. Cermak
CHAPTER OUTLINE
DEVELOPMENT OF HAPTIC PERCEPTION
Haptic Perception in Infants
Haptic Perception in Children
Gender and Hand Differences in Haptic Recognition
and Haptic Accuracy
Summary and Implications for Practice
FUNCTIONS CONTRIBUTING TO HAPTIC
PERCEPTION
Role of Somatosensory Sensation in Haptic
Perception
Role of Manual Manipulation and Exploratory
Strategies in Haptic Perception
Role of Vision and Cognition in Haptic Perception
Summary and Implications for Practice
EVALUATION OF HAPTIC PERCEPTION IN INFANTS
AND CHILDREN
HAPTIC PERCEPTION IN CHILDREN WITH
DISORDERS
Prematurity
Mental Retardation
Brain Injury
Learning Disabilities and Related Disorders
Summary and Implications for Practice
SUMMARY
The hand has two closely related functions: It is both an
executive and a perceptual organ (Bushnell & Boudreau,
1998; Gibson, 1988; Hatwell, Streri, & Gentaz, 2003;
Lederman & Klatzky, 1998). As an executive organ it is
Chapter 4
used for carrying out everyday activities such as tying
shoes or buttoning. As a perceptual organ it seeks and
processes information such as when searching for a coin
in a pocket. The two functions of the hand are closely
intertwined. Rochat (1989) emphasized that
“from the origin of development, action is under some perceptual
or sensorimotor control and the picking up of perceptual infor-
mation is somehow inherent in any performed act” (p. 871).
However, when the hand performs a practical action,
its perceptual functioning is regulated by what is
needed to achieve this action, whereas when the hand
acts primarily as a perceptual system, its motor activity
is primarily exploratory and information seeking.
This chapter concerns the hand as a perceptual or
information-seeking organ. Focus is on active touch
(haptic perception) rather than passive touch. Passive
touch involves only the excitation of receptors in the
skin and underlying tissue;
“active touch involves the concomitant excitation of receptors in
the joints and tendons along with new and changing patterns in
the skin” (Gibson, 1962, p. 482).
Brazelton has suggested that, whereas
“passive touch may add to an infant’s ability to initiate and
maintain control, active touch … acts as an alerter and as
information. It helps the infant come to a receptive alert state
and begin to process information” (Rose, 1990, p. 316).
Haptic perception deals with the retrieval, analysis, and
interpretation of the tactile properties (e.g., size, shape,
texture) and identity of objects through manual and
in-hand manipulation (Bushnell & Boudreau, 1993;
Hatwell, 2003). The process of tactile scanning is com-
plex and includes the blending of feedback from tactile,
63
64 Part I • Foundation of Hand Skills
kinesthetic, and proprioceptive sensations. The tactile
spatial properties of objects are obtained through the
retrieval of information about the relationship of the
objects to the body and gravity during active manual
exploration.
The study of haptic perception has been closely
associated with the study of visual perception.
Researchers have attempted to gain insight into how
we use our visual and haptic senses to function by com-
paring the ability to match objects through the use of
vision and haptic manipulation. These studies typically
require the subject to match a standard (test) object to
a set of two or more comparison objects. If the subject
is asked to do an intramodal comparison, both the
standard and comparison objects are analyzed using
the same sensory modality (visual or haptic sense). If the
subject is asked to do an intermodal comparison, the
standard object is analyzed using one sense and the com-
parison object(s) are analyzed using the other sense. In
this chapter research methodology is specified as con-
taining intramodal or intermodal matching, whereas
the senses used appear in parentheses (standard com-
parison). For example, intermodal (haptic-visual)
matching means that the haptic sense was used to
analyze the standard or test object and the visual sense
was used to select from among the comparison objects.
The term multimodal exploration refers to the simul-
taneous use of the visual and haptic senses in object
investigation. In this chapter the review of intramodal
matching (matching using the same sensory system) is
limited to haptic-haptic matching in which the subject
feels the standard or test object and then feels several
comparison objects to find the match.
One goal of this chapter is to provide the reader with
an understanding of selected aspects of haptic
perception that may influence effective evaluation and
treatment of children with suspected and identified
impairments in haptic perception. Topics covered
include the development of haptic perception, func-
tions contributing to haptic perception, evaluation of
haptic perception in infants and children, and haptic
perception in children with neurologic disorders. The
adult literature has been included to the degree to
which it assists our understanding of the current status
of the pediatric research.
DEVELOPMENT OF HAPTIC
PERCEPTION
HAPTIC PERCEPTION IN I NFANTS
In the infant the hands and mouth are both potential
sources of haptic information. The mouth can be used
to gain information about the shape and substance of
objects (Ruff, 1989). Pecheux, Lepecq, and Salzarulo
(1988) found evidence suggesting intramodal (haptic-
haptic) recognition of shapes inserted into nipples by 2
months of age.
As the infant develops, the hands become a
perceptual system that increasingly participates in the
infant’s construction of knowledge (Bushnell &
Boudreau, 1998; Hatwell, 1987). Manipulation of an
object facilitates the learning of the object’s charac-
teristics. During exploratory play of the first year,
infants begin to learn about their environment, their
bodies, and how their actions can effect change
(Gibson, 1988). Current research has indicated that
haptic abilities are much more efficient in infants than
was thought in the past (Streri, 2003a). Use of the
habituation paradigm adapted from vision research has
shown that early intramodal (haptic-haptic) manual
exploration in infants provides consistent haptic dis-
crimination (Hatwell, 1987; Streri & Pecheux, 1986).
In this paradigm infants are given shapes to manually
explore with a screen preventing the infants from
seeing their hands. The amount of interest the infant
devotes to the object is measured by the amount of
time the object is grasped, and as the infant habituates,
he or she holds the object for shorter periods of time.
Using two pairs of shapes, Streri and Pecheux (1986)
observed a haptic habituation to a familiarized shape
and a reaction to novelty (longer holding) when a new
shape was presented to 4- and 5-month-old infants.
This was noted in infants as young as 2 to 3 months
(Streri, 1987). Streri and Pecheux (1986) reported that
infants required a longer period of time to habituate to
tactile stimuli than to visual stimuli and suggested that
this may be explained, in part, because information can
be obtained more quickly visually than tactually. In a
similar haptic habituation paradigm, 6- and 7-month-
old infants with severe visual impairments also were
found to show haptic integration for shape and texture
(Catherwood et al., 1998).
Research with infants also has shown that young
infants evidence intermodal integration. Rose, Gottfried,
and Bridger (1978) concluded that 6-month-old
infants could integrate visual and haptic perception as
evidenced by their ability to visually recognize a shape
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,
2004; Streri et al., 2004; Streri & Molina, 1993; Streri
& 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
opportunity for visual regard of the hands (Streri &
Spelke, 1988, 1989). One object presented was two
rings connected by a solid bar; the other object was
two rings connected by a string. The infants produced

different types of arm movements when holding the
different objects. The infants were shown visual
displays of two rings either connected or separated,
which were moving as they typically did while the
infants were holding them. The infants looked longest
at the rings that were dissimilar to those that they had
held. This was the expected response if the infants
perceived the similarities between the rings that they
held and moved and those that they saw moving. Streri
and Spelke (1988) concluded,
“infants evidently perceived connected or separated objects by
detecting the patterns of common or independent motion that
they themselves produced.” (p. 19).
They also noted that the infants held the objects for
relatively long periods, as much as five times as long as
they would have been expected to visually attend to an
object. Because these 4-month-old infants were so
competent at identifying objects tactually and visually,
Streri and colleagues (Streri, 2003a; Streri & Spelke,
1988) questioned Piaget’s theory that vision and touch
become integrated through haptic exploration of
objects and suggested that this ability may be present
without substantial experience in handling objects. In a
recent study of cross-modal recognition in newborns,
Streri and Gentaz (2004) have even suggested that
under some limited conditions, newborns have the
ability to extract shape in a tactile format and transfer it
to a visual format, independent of common experience.
Molina and Jouen (1998, 2001, 2003) also reported
that newborns can discriminate between rough and soft
textures and modify their grasping according to the
texture of the grasped object.
HAPTIC PERCEPTION IN C HILDREN
Much of the literature on haptic perception in children
deals with the recognition of common objects (e.g.,
comb, penny) and shapes (e.g., circle, square, diamond).
However, the hand also is used to gain information
about other object properties, such as texture, hardness,
size, weight, and spatial orientation. Each is discussed.
Recognition of Common Objects and Shapes
One of the most well-known studies on the develop-
ment of haptic perception in children is that of Piaget
and Inhelder (1948/1967). They presented a series of
solid (three-dimensional) common objects and card-
board cutouts of shapes (geometric figures and topo-
logic forms) to a group of 2- to 7-year-old children and
asked the children to feel each figure and then visually
select the figure from among a set of figure drawings.
The geometric figures used ranged from simple (e.g.,
circle, ellipse, square) to complex (e.g., star, cross,
semicircle). Topologic forms were shapes with irregular
Perceptual Functions of the Hand • 65
surfaces containing one or two holes or having open-
ings or closings on their outer edges. These authors
found that the ability of children to identify objects and
shapes by touch progressively improved with increased
age. Children 21⁄2 to 31⁄2 years of age were able to
correctly recognize common objects but were unable
to identify shapes. By 31⁄2 to 5 years of age children
developed the ability to match topologic forms.
Recognition of geometric figures emerged at 4 to 41⁄2
years with the ability to differentiate curvilinear (circle
and ellipse) from rectilinear (square and rectangle)
shapes. The ability to recognize geometric figures in
greater numbers and levels of complexity was shown to
progressively improve from 41⁄2 to 7 years of age.
Benton and Schultz (1949) also studied intermodal
(haptic-visual) matching of common objects in a group
of 156 3- to 5-year-old children and found that per-
formance progressively improved with age. Three-year-
old children typically were able to recognize 50% of the
items presented (mean 4.0 out of eight items). Four-
year-old children performed only slightly better than
children in the 3-year-old age group (mean = 4.5).
Near-perfect performance typically was found by 5 years
of age, with most children correctly recognizing at least
seven of the eight objects presented.
Hoop (1971a) also studied intermodal (haptic-
visual) matching at 31⁄2 to 51⁄2 years. Like Piaget and
Inhelder, Hoop found the identification of common
objects to be easier than the recognition of topologic
forms and geometric figures. There was little variation
in the ability of 31⁄2- to 51⁄2-year-old children to match
topologic forms (means ranging from 2.3 to 2.6 out of
a maximum score of 4). Miller (1971) reported a
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-haptic matching) presented shapes. Like Piaget
and Inhelder, Hoop found the recognition of topologic
forms through intermodal (haptic-visual) matching to
be easier than the identification of geometric figures.
However, this has not been a consistent finding
(Derevensky, 1979). Derevensky (1979) suggested that
listing shapes as topologic or geometric may be an
incorrect method of categorization, and suggested that
it may not be whether a shape is topologic or geometric
but the nature of the distinctive features that it contains
that contributes to task difficulty.
Another interesting finding was reported by
Abravanel (1972), who noted that, in a series of inter-
modal (haptic-visual matching conditions, it was easier
for 6- to 8-year-old children to identify solid (three-
dimensional) than flat (two-dimensional) geometric
figures. She attributed this to possible variation in the
usefulness of the manipulation strategies used by the
children in shape exploration. This topic is discussed in
depth in a later section of this chapter.
66 Part I • Foundation of Hand Skills
Recently, Bushnell and Baxt (1999) examined haptic
recognition of familiar versus unfamiliar objects. They
found that 5-year-old children more accurately
identified familiar than unfamiliar objects; however, this
varied as a function of whether the matching was
haptic-haptic or haptic-visual. For unfamiliar objects,
haptic-haptic matching was more accurate than haptic-
visual matching, whereas there was no difference for
familiar objects. Familiar objects were identified more
accurately than unfamiliar objects in a haptic-visual
matching task, but there was no difference as a function
of familiarity in the haptic-haptic matching task. A limi-
tation of the study is that a ceiling effect was reached
for familiar objects, with many participants achieving
maximum scores.
There is general agreement that the haptic percep-
tion of common objects is well developed by 5 years of
age, and the ability of children to select geometric
figures through intermodal (haptic-visual) matching
emerges at about 4 years of age (Abravanel, 1972;
Blank & Bridger, 1964; Hoop, 1971a; Micallef & May,
1979; Piaget & Inhelder, 1948/1967). Like the
finding of Piaget and Inhelder, all of these studies have
noted improvement in accuracy with increasing age.
Moreover, with increasing age, children change their
representation of objects from one based primarily on
global shape to one that incorporates a balance of
global shape and specific local parts (analytical mode)
(Berger & Hatwell, 1993, 1995; Morrongiello et al.,
1994). However, whereas some researchers reported
that young children primarily used global strategies to
categorize objects, others found that both children and
adults primarily used analytic modes (Schwarzer, Kufer,
& Willkening, 1999). Within this mode, Schwarzer
found a developmental sequence in the attribute chosen
for categorization of objects. They found that focusing
on surface texture decreased with age and focusing
on shape increased with age. Thus children preferred
substance-related attributes, especially surface texture,
whereas adults preferred the structure-related attrib-
utes, especially shape. This was consistent with Berger
and Hatwell (1993), who also found a preference for
surface texture as an analytic attribute.
Recognition of Texture, Size, and Weight
Unlike shape or orientation, length, or localization in
the environment, in which vision is superior to touch,
texture perception is often as good haptically as visually
(Gentaz & Hatwell, 2003). Haptic discrimination of
texture, size, and weight has been shown to improve
with increasing age in 4- to 9-year-old children (Gliner,
1967; Miller, 1986; Siegel & Vance, 1970). Gliner
further found rough textures to be easier to identify
than smooth textures, with third grade subjects
showing a lower threshold (greater sensitivity) to
texture stimuli than kindergarten subjects.
Intermodal (haptic-visual) discrimination of diameter
and length has been reported to emerge at 4 years and
continues to mature into adolescence, with variation in
diameter being easier to recognize than variation in
length (Abravanel, 1968a,b; Connolly & Jones, 1970;
Hulme et al., 1983). When analyzing length, children
found tasks requiring intramodal (vision or haptic)
discrimination easier than those requiring intermodal
(vision and haptic) discrimination for object com-
parison (Hulme et al., 1982, 1984).
Research comparing children’s preference for the use
of texture, size, and shape in object recognition suggests
that there may be a developmental progression in pref-
erential use of these sensory properties. Preference for
the use of texture over shape in object identification
during intramodal (haptic-haptic) matching tasks has
been found to occur in young children (4 to 5 years of
age) but not in older children (Berger & Hatwell, 1993,
1995; Gliner, 1967; Schwarzer et al., 1999; Siegel &
Barber, 1973; Siegel & Vance, 1970), although
Schwarzer and co-workers (1999) found that the
exploratory strategy varied as a function of the task
requirements and the feedback. Size has been shown to
be more difficult to discriminate than texture in children
4 and 8 years old (Miller, 1986). Gliner and co-workers
(1969) further found that the preference of kinder-
gartners for texture over shape in object identification in
an intramodal (haptic-haptic) matching task decreased as
the textured surfaces became more difficult to identify.
Preference for the use of shape over texture and size
during intramodal (haptic-haptic) matching of objects
was cited by Siegel and Vance (1970) and Gentaz and
Hatwell (2003) in kindergarten through third-grade
children. Adults preferred size or shape classification
(Gentaz & Hatwell, 2003).
Miller (1986) further found that variation in shape
interfered with accuracy in identification of texture
during intramodal (haptic-haptic) matching in 8-year-
old children but not in 4-year-old children. She con-
cluded that this might be because 4-year-old children
ignored shape cues when texture was available for use
in object discrimination. Thus it is possible that during
tasks requiring haptic discrimination, children might
use the sensory property that produced the strongest
distinctive features. As the ability to recognize shapes
improves with age, there might be increased preference
for the use of shape over other properties for object
identification because shape yields distinctive features
that are more useful in object recognition than texture
or size. If this hypothesis is correct, then the properties
selected for use in object recognition might be age and
task dependent. They might vary based on both the
degree to which the distinctive features provided by
the object were easy to identify and the developmental
level of haptic perception (e.g., texture, shape, size)
exhibited by the child being tested.

Recognition of the Spatial Orientation of Objects
Few studies have addressed the development of haptic
spatial orientation in children. Perceptual awareness
of the constancy of spatial location through the use of
vision and haptic exploration has been shown to
develop at an early age. Three-year-old children who
were blind were able to identify common objects after
180 degrees of object rotation (Landau, 1991).
Hatwell and Sayettat (1991) asked 4- to 7-year-old
children to reseat a doll at a table inside a doll house
after the child, the doll, the table, or the house was
rotated. Many of the 4-year-old children were able to
successfully reseat the doll in the initial location after
rotation using intramodal (visual or haptic) exploration.
An age-related increase in accuracy of doll placement
occurred between ages 4 and 6 years. The shape of the
table had no effect on task performance.
Children of 41⁄2 years in a study by Abravanel
(1968a) could visually recognize test objects facing up,
down, or rotated but had difficulty when intermodal
(haptic-visual) matching was necessary for task com-
pletion. Intermodal recognition of up-down was no
better than chance until 5 years of age, and the identifi-
cation of rotated figures was not possible until 6 years
of age. Pick, Klein, and Pick (1966) used intramodal
(visual-visual and haptic-haptic) matching tasks to
study children’s ability to differentiate the up-down
orientation of letter-like forms. They reported that the
task could be performed more easily through the use of
vision than touch. No relationship was found between
subjects’ ability to perform the task through the use of
vision versus touch, leading the authors to conclude
that perhaps the method used in coding and dis-
criminating spatial orientation is different for the two
sensory modalities. However, it is also possible that
some types of objects might just be better suited for
processing through one sensory system than the other.
For example, letter-like forms may represent a type of
object that is easily processed through the visual system
but not easily analyzed through the tactile system.
In a recent review of research examining processing
of spatial object properties and the oblique effect
(whether orientation is perceived more accurately in
the horizontal and vertical planes than the oblique
plane), investigators concluded that gravitational cues
play a role in the haptic perception of orientations in
blindfolded (sighted) adults and children (Gentaz &
Hatwell, 2003; Gentaz & Streri, 2004). This is similar
to the oblique effect found for orientation with vision.
G ENDER AND HAND DIFFERENCES IN HAPTIC
RECOGNITION AND HAPTIC ACCURACY
Several studies have examined whether boys and girls
perform differently in the accuracy of haptic perception
and whether one hand is more accurate than the other.
Perceptual Functions of the Hand • 67
Research generally has shown that boys and girls 3 to
14 years old display equal ability to recognize common
objects, shapes, and words through intramodal (haptic-
haptic) and intermodal (haptic-visual) matching
(Abravanel, 1970; Affleck & Joyce, 1979; Ayres, 1989;
Benton et al., 1983; Benton & Schultz, 1949; Bushnell
& Baxt, 1999; Cioffi & Kandel, 1979; Cronin, 1977;
Etaugh & Levy, 1981; Gliner, 1967; Klein &
Rosenfield, 1980; Kleinman, 1979; Witelson, 1976;
Wolff, 1972). Occasionally boys have been identified as
exhibiting greater skill than girls in the intramodal
(haptic-haptic) matching of objects by texture, size,
and shape (Gliner, 1967). In addition, Siegel and
Barber (1973) found boys to display a stronger pref-
erence than girls for the use of form over texture in the
intramodal (haptic-haptic) matching of shapes. Most
studies conducted on normal adults have shown there
to be no difference in the overall accuracy of haptic
perception between men and women (Cronin, 1977;
Kleinman, 1979; McGlone, 1980).
When handedness is examined, children often dis-
play greater left- than right-hand skill in some forms of
haptic perception (Hahn, 1987; Rose et al., 1998);
however, the strength and age of onset of this dif-
ference vary among studies (Streri, 2003c). The finding
of greater left- than right-hand skill on some tasks, par-
ticularly those requiring discrimination of meaningless
shapes, has been viewed as related to right hemisphere
superiority in the processing of spatial information
(e.g., Witelson, 1974, 1976). In a recent meta-analysis
of cerebral specialization of spatial abilities, Vogel,
Bowers, and Vogel (2003) found a right-hemisphere
preference when subjects were performing spatial
orientation and manual manipulation tasks. However,
because the age of onset of right–left hand differences
varied widely across studies, it is inappropriate to
interpret the presence or absence of a hand difference
for stereognosis as being related to the maturity of
hemispheric specialization for haptic perception in a
given child. Consistent evidence of a right–left hand
difference for stereognosis did not appear until
adolescence.
SUMMARY AND I MPLICATIONS FOR PRACTICE
The ability to distinguish the texture, shape, and
substance of objects through the use of intramodal
(haptic-haptic) and intermodal (haptic-visual and
visual-haptic) exploration develops over a long period.
It begins to emerge in early infancy and continues to
mature into adolescence.
Infants are amazingly adept at using haptic explora-
tion with the mouth and hands to learn about objects
in their environment. Early haptic discrimination using
the mouth is seen at 1 month of age or even earlier, and
haptic discrimination using the hands appears at 1 to
68 Part I • Foundation of Hand Skills
2 months of age. Intermodal transfer of information
between the haptic and visual senses begins at 4 to
6 months, although recent evidence suggests that even
newborns have limited ability. This means that by the
second half of the first year of life infants can explore an
object using the hand and then recognize the same
object as being similar or different using vision.
Haptic perception improves with increasing age.
Children find common objects easier to haptically
recognize than topologic forms, geometric figures, or
unfamiliar objects. At 21⁄2 years, children can identify
many common objects through use of the haptic sense.
Haptic recognition of common objects reaches full
maturity by about 5 years. Intramodal (haptic) and
intermodal (haptic and visual) identification of
topologic forms and geometric shapes emerges at 3 to
4 years and continues to develop throughout child-
hood. With increasing age children are able to match
forms or shapes having increasingly complex distinctive
features. They also are able to move from recognizing
only solid (three-dimensional) shapes to being able to
also distinguish flat (two-dimensional) figures. Haptic-
visual matching generally is better than visual-haptic
matching. Thus in developing a program to enhance
children’s haptic matching abilities it is best to start
with familiar objects, with haptic-visual matching
preceding visual-haptic matching.
Like adults, children show greater left than right
hand skill in some forms of haptic perception, possibly
reflecting specialization of the right hemisphere for the
processing of spatial information. However, the age at
which hand preference for haptic processing emerges
varies across studies. Although some authors suggest
that haptic perception may be better in boys than girls,
most studies have not found a difference.
The literature contains less information about the
development of sensory properties such as texture and
weight in childhood. It is known that children find
rough textures easier to match than smooth textures.
The development of texture discrimination improves
between 4 and 9 years, in part because tactile sensitivity
increases during this time span (Gliner, 1967). The
discrimination of diameter and length begins at about
4 years and continues into adolescence, with variation
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
that children can haptically identify objects as facing up,
down, or rotated.
Children’s ability to haptically analyze objects
having two or more tactile properties is limited. Rather
than analyzing several sensory properties simul-
taneously as adults do, children appear to select one
sensory property to use in object analysis. The sensory
property selected seems to be the one that is easiest for
the child to recognize, perhaps because it exhibits the
strongest distinctive features. For example, texture is
preferred to shape and size in young children, whereas
older children are more likely to match objects by shape
than texture. In addition, the coexistence of several
sensory properties in a given object can impair haptic
discrimination at some ages. This finding suggests that
haptic figure-ground may be an issue in haptic object
discrimination, a factor that needs to be considered in
the development of tests and training programs in
haptic perception.
We do not know whether the ability to distinguish
objects by shape, size, texture, or weight develops
sequentially or simultaneously. Research suggests that
children develop the ability to discriminate all of these
sensory properties, including texture, hardness, weight,
and temperature. Thus it is logical to conclude that we
should provide children with ample opportunity to
analyze objects having varying sensory properties.
When presenting activities designed to promote the
development of haptic perception, we should vary
objects by one sensory property and also offer objects
with a combination of sensory properties. If the child
has the opportunity to sort objects haptically in a
variety of ways, he or she is likely to identify or sort
objects using the sensory property that has the
strongest distinctive features or use exploratory pro-
cedures or strategies that are most well developed in his
or her repertoire. The sensory properties that the child
consistently avoids using may be those that are most
delayed and thus most in need of being addressed in
treatment. Because little is known about the develop-
ment of haptic figure-ground perception in children,
we do not know if the finding of impaired haptic
discrimination in multisensory haptic play activities is
normal or a sign of impairment. However, we can be
sensitive to the signs of haptic sensory overload in
children. It is possible that playing with toys having
several sensory properties may be disorganizing for
some infants and children. When problems are seen,
controlling the variety, as well as the quantity of sensory
experiences may be necessary to elicit optimum
performance during school and play activities.
FUNCTIONS CONTRIBUTING TO
HAPTIC PERCEPTION
Most haptic perception tasks are complex. Research
suggests that various factors contribute to haptic per-
ception, including somatosensory processing, manual
and in-hand manipulation, and vision and cognition.

ROLE OF SOMATOSENSORY SENSATION IN
HAPTIC PERCEPTION
Vierck (1978) proposed that sensory feedback
processed through the dorsal columns may guide
exploratory hand use. Although the firing of haptic
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-
tions among many central nervous system (CNS)
structures are involved in the process (Carpenter, 1991;
Goodwin & Wheat, 2004; Mountcastle, 1976). Recent
research examining neural substrates of tactile object
recognition using functional magnetic resonance
imaging (in adults) found that tactile object recog-
nition involved a complex network including parietal
and insular somatosensory association cortices, as well
as occipitotemporal visual areas, prefrontal, and medial
temporal supramodal areas, and medial and lateral
secondary motor cortices (Reed, Shoham, & Halgren,
2004). Disruption in communication anywhere within
this circuit logically could result in loss or impairment
of the ability to explore objects with the hands.
A synthesis of information derived from somato-
sensory receptors provides the hand with a dynamic
picture of the body and its orientation in space (body
scheme) (Gardner, 1988; Goodwin & Wheat, 2004).
This internal picture of the body is thought to be used
by CNS processes as a framework of the parameters of
real-world time and space (Brooks, 1986). Upon this
framework are scaled motor commands used in motor
programming and executing complex sequenced
movements. This internal picture of the body also is
thought to serve as a template for interpreting the spatial
properties of objects (Gibson, 1962). The precise detail
of this internal picture of the body decreases and its
spatial complexity increases with progressive afferent
processing in the CNS (Brooks, 1986).
Not only does somatosensory sensation contribute
to the development of body scheme needed for the
interpretation of the spatial properties of objects, but it
also appears to be necessary for regulating manual and
in-hand manipulation during active touch. Research
with children with spastic hemiplegia found that
deficient tactile sensitivity was strongly related to the
manual dexterity needed for exploration (Gordon &
Duff, 1999; Krumlinde-Sundholm & Eliasson, 2002).
The sensory control of hand movements is discussed in
Chapter 1. At present it seems sufficient to note that to
actively retrieve somatosensory sensation from the
environment during active touch the individual must
be able to make rapid and frequent changes in the
speed and sequencing of hand movements and regulate
force during object manipulation (Hollins & Goble,
1988; Johnson & Hsiao, 1992). These elements of fine
Perceptual Functions of the Hand • 69
motor coordination are thought to be related, in part,
to the processing of tactile, kinesthetic, and proprio-
ceptive sensations for their execution (Brooks, 1986;
Case-Smith, 1995; Case-Smith, Bigsby, & Clutter,
1998; Duque et al., 2003; Gordon & Duff, 1999;
Johansson & Westling, 1988, 1990).
ROLE OF MANUAL MANIPULATION AND
EXPLORATORY STRATEGIES IN HAPTIC
PERCEPTION
Manual exploration and in-hand manipulation are
critical for haptic perception and object recognition
(Lederman & Klatzky, 1998, p. 27). It has been
suggested that information from the motor commands
generating exploratory actions generates corollary
discharge or efferent copy and is involved in haptic
perception, although the mechanisms are not well
understood (Jeannerod, 1997).
Interest in the role of in-hand manipulation and
other forms of manual exploration in haptic perception
was precipitated by the work of Gibson (1962) on
active and passive touch. Using a set of geometric-
shaped cookie cutters, adult subjects either were
allowed to actively manipulate the cookie cutters or the
tactile stimuli were passively presented by the examiner
(cookie cutters pressed or pressed and turned in the
palm of the subject’s hand). The use of active touch
contributed to greater accuracy in intermodal (haptic-
visual) shape recognition than either of the passive
touch conditions, although pressing and turning the
cookie cutters in the subject’s hand (passive pressure
with movement) yielded higher scores than the isolated
use of passive pressure. Replication of Gibson’s study
with children yielded similar findings (Haron &
Henderson, 1985). Cronin (1977) also replicated
Gibson’s study but obtained somewhat different
results. She found that shape recognition by school-age
children and young adults did not differ between active
touch and passive touch (passive pressure with
movement) conditions when tactile stimulation was
restricted to the palm of the hand in all test conditions;
however, the isolated use of passive pressure (passive
pressure without movement) contributed to lower test
scores than either of the other two test conditions. In
addition, no difference between active touch and
passive touch (pressure with movement) was found for
the discrimination of texture and tactile maze learning
in adults (Lederman, 1981; Richardson, Wuillemin, &
MacKintosh, 1981). These findings suggest that it
might be movement of the object over the skin surface
that produces the tactile feedback needed for object
recognition. Although movement of the object in the
hand theoretically can be active or passive, it is most
70 Part I • Foundation of Hand Skills
commonly produced actively, through the use of
manual manipulation and exploratory strategies. This
raises the question of how the pattern of tactile feed-
back generated by variation in the pattern of manual
and in-hand manipulation affects the accuracy of object
identification. In recent years several researchers have
attempted to answer this question; their findings are
discussed in the following section. See Chapter 8 for a
detailed discussion of in-hand manipulation. Because
most of the research on this topic has been done on
adults, this section begins with a summary of the adult
research followed by a review of the pediatric literature.
Haptic Manipulation Strategies in Adults
In a series of studies, researchers (Klatzky, Lederman,
& Reed, 1987; Lederman & Klatzky, 1987, 1990,
1998) found that adults were highly systematic in the
manual exploration strategies they used. Adults
performed “a variety of stereotypical hand movement
patterns” (Lederman & Klatzky, 1998, p. 27), includ-
ing lateral motion, pressure, static contact, unsup-
ported holding, enclosure, and contour following, that
Lederman and Klatzky called “exploratory procedures
or EPs” (p. 27). These strategies were selected based
on the particular object property the adult desired
(e.g., hardness, texture, shape).
Early research on the influence of manipulation
strategies in object recognition was done by Davidson
in a series of studies comparing the ability of sighted
and congenitally blind subjects to recognize raised
curved edges. Davidson (1972) and Davidson and
Whitson (1974) found that when exploring concave,
convex, and straight edges, subjects chose to use three
manipulation strategies (gripping, pinching the edge,
and sweeping the fingers over the top edge). Gripping
(grasping the object in the hand) led to fewer errors in
identifying the form of the curved edges in both blind
and sighted subjects. Gripping was later found to be a
useful strategy for obtaining a general understanding
of the objects’ tactile properties (e.g., texture, weight,
shape) (Klatzky et al., 1987; Lederman & Klatzky,
1987). The method of gripping (called enclosure in
some studies) was modified to aid in differential
discrimination of size and shape. Subjects preferred to
grip with the whole hand when analyzing the size of
objects and grip, with effort, the edges of the object
using the fingers and palm when analyzing shape (Reed
& Klatzky, 1990). Although gripping provided subjects
with a general classification of object properties, other
strategies often were used when refined analysis was
needed.
Contour following (moving the fingers around the
edge of the object) was an optimum strategy for use in
haptic shape recognition (Lederman & Klatzky, 1987).
In a thorough analysis of strategies used in the
identification of geometric shapes, Kleinman and
Brodzinsky (1978) found that subjects preferred to use
a combination of manipulation strategies, including an
initial scanning of the standard and comparison objects.
This was followed by detailed simultaneous comparison
of the standard and comparison objects (congruent
feature comparison of analogous and mirror-image
features and contour following). The initial time spent
in scanning the objects was reduced as the shapes
became more complex. Locher and Simmons (1978)
found that haptic recognition of symmetric shapes was
more difficult than the recognition of asymmetric
shapes. Partial trace scanning (contour following along
portions of the shape) was common for asymmetric
shapes. More complex scanning strategies were used for
the identification of symmetric shapes (several
repetitions of partial and complete contour following).
In a subsequent study Simmons and Locher (1979)
found use of the trace scanning strategy (contour
following around the complete shape several times
using two fingers) to lead to greater accuracy in the
identification of asymmetric shapes and the simul-
taneous apprehension scanning strategy (smooth, con-
tinuous movement of thumb and index fingers of both
hands over opposite sides of the shape simultaneously)
to lead to greater accuracy in the identification of
symmetric shapes. The results of these studies suggest
that the isolated use of contour following may not
always be the most appropriate approach for use in the
identification of shapes. It may be necessary to change
manipulation strategies to adapt to variation in
symmetry of distinctive features and complexity of the
objects presented.
Lederman and Klatzky (1987) analyzed manipula-
tion strategies used for the identification of texture,
hardness, weight, volume, and temperature. They found
that the optimum manipulation strategy (which they
termed exploratory procedures) for use in object
identification differed for each tactile property (Table
4-1). Although contour following was necessary for
accurate recognition of shape, several approaches could
be used for the identification of most other tactile
properties (Box 4-1).
Preferred manipulation strategies remained unchanged
when subjects were asked to determine the gradations
of a given tactile property (texture, size, shape, and
hardness) and when they needed to simultaneously sort
pouches (fabric-covered shapes) by one to three of
these tactile properties (Klatzky, Lederman, & Reed,
1989; Lederman & Klatzky, 1987). Enclosure
(gripping) was commonly used for all tactile properties,
with lateral motion being used primarily for the
identification of texture, pressure being primarily used
for the identification of hardness, and contour
following being used primarily for the identification
 Perceptual Functions of the Hand • 71

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
72 Part I • Foundation of Hand Skills
serve both transport and support functions, bringing
the object alternately into the oral zone and the field of
view for exploration. Ruff (1989) described a dual role
of handling: the hands make information available to
the eyes as the object is manipulated at the same time
that the hands directly gather haptic information. In the
first role the hands are used to manipulate the object
and change the object’s location relative to the observer,
such as turning the object around to provide different
visual perspectives. In the second role the hands gather
haptic information about the object, such as by pressing
the object to determine its substance or rubbing a finger
across the object to determine its texture or shape.
Based on their developmental work, Bushnell and
Boudreau (1991, 1993, 1998) suggested that the
motoric capacities needed to perform exploratory pro-
cedures limit haptic perception in the young infant. In
conjunction with the early development of multimodal
exploration, the characteristics of object manipulation
change from 2 to 5 months. At 2 to 3 months the
infant’s manipulative behaviors are primarily limited to
grasping movements, potentially informing the infant
about the object’s substance, temperature, and size
(Bushnell & Boudreau, 1991, 1993). Although slight
finger movements are produced at 2 months, by 4 months
the occurrence of fingering behavior increases sig-
nificantly (Rochat, 1989). Because discrimination of
texture requires isolated finger movements, texture
discrimination does not begin until around 6 months
of age. Before this, when both hands are involved in
contacting an object, it is primarily for transporting the
object to the mouth. Rochat (1989) noted that in
young infants (2 to 4 months) bimanual coordination
is initially linked to the oral system. This observation
points to the importance of the mouth in the early
manifestation of bimanual action in the context of
object manipulation. The hand–mouth coordination
seen in the 2- to 4-month-old infant is later combined
with vision when behaviors such as fingering emerge.
To more thoroughly assess how infants use object
handling skills to gain information for recognition of
specific object qualities, Ruff (1984) studied 6-, 9-, and
12-month-old infants and assessed the various manip-
ulation strategies they used, including mouthing,
fingering, transferring, banging, and object rotation.
Fingering proliferated with increased age, particularly
with objects that varied in texture. Ruff suggested that
this fingering can be crucial for obtaining information
about small object details. Hand use for object rotation
also was noted to change, with all infants using a one-
handed rotation pattern, in which the arm or wrist
moves, but only older infants using two-handed object
rotations. Ruff suggested that two-handed rotation can
be particularly useful because with rotation the object
does not have some parts covered by the hand. She
suggested that infants who cannot adjust their handling
skills so they can finger objects rather than just hold
them and infants who cannot effectively use two hands
together may be limited in the complexity of infor-
mation about objects that they can readily gather.
Discrimination of shape does not occur until between
9 and 12 months when the infant learns to turn and
rotate an object in two hands (Ruff, 1989).
Given that adults use a flexible repertoire of
exploratory strategies and that certain actions may be
particularly useful for obtaining specific information
about objects, the question also has been asked how,
during development, young infants and children tailor
their actions to explore objects (Palmer, 1989).
Whereas earlier work has suggested that infants’ actions
were not clearly related to object attributes (McCall,
1974), current research has found that exploratory
action patterns are indeed influenced by object
characteristics and that the actions of the infant are
related in functional ways to the structure of the
environment (Gibson, 1988; Hatwell et al., 2003).
In a series of studies, Ruff (1980, 1984, 1989)
examined the effect of object characteristics on infant
manipulation strategies. In a study of 9- and 12-
month-olds, Ruff (1980) found that infants fingered
objects with surface texture more than they fingered
smooth blocks. Ruff (1984) investigated 6- to 12-
month-old infants’ manipulation of a range of objects
varying in color, shape, texture, and weight and found
that manual exploration was adapted to the visual and
the tactual properties of the object. When infants were
given objects that varied in shape, they rotated the
objects and transferred them from one hand to the
other hand; when objects had varying surface textures,
infants fingered the objects, often scratching their sur-
face. Weight change resulted in less looking and more
banging than did other changes in object charac-
teristics. In a more recent study Ruff (1989) found that
by 7 to 9 months infants banged hard objects more
than soft objects, banged more on hard surfaces than
on soft surfaces, and fingered textured objects more
than smooth objects. In a study of 12-month-old
infants’ haptic exploration and discrimination, Gibson
and Walker (1984) found that infants squeezed,
rubbed, and pressed a spongy object more than a rigid
object and banged the rigid object more than the
spongy one. The results of these studies suggest that
infants adjusted their manipulative behavior to the
characteristics of objects.
Palmer (1989) also found that infants 6, 9, and 12
months old tailored their actions to particular object
and table characteristics. Palmer recorded the manip-
ulative behavior of infants with 12 different objects of
varying rigidity, texture, shape, weight, and sound
potential using two different table surfaces (hard wood
 Perceptual Functions of the Hand • 73

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
use of both object properties and table surface
properties. For example, infants banged more on the
wood surface. Age differences in actions were also
noted. Palmer suggested that these differences may
reflect developing action economy (e.g., waving the
bell with a flick of the wrist rather than with the whole
arm swing seen in younger infants), new exploratory
systems (e.g., changing from mouthing to waving and
banging), and increasing fine motor control (e.g.,
finger individuation). Case-Smith and co-workers
(1998) examined 120 2- to 12-month-old infants and
also found that infants’ grasp and manipulation
strategies varied as a function of the objects’ haptic
attributes (size, shape, contour, movable parts) and the
child’s age. They found that objects with movable parts
elicited more varied and mature manipulation strategies
and suggested that objects with movable parts and
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).
Research suggests that even infants younger than
6 months detect an object’s perceptual features that
enable particular actions (affordances) for hand and
mouth. Rochat (1983, 1987) found that neonates
showed differential oral and manual responding to
objects varying in substance and texture. In a study of
3-month-old infants, Rochat (1989) noted that the
characteristics of manual manipulation and exploration
by the infant reflected some relation to the physical
properties and affordances of the object (Box 4-2).
Haptic Manipulation Strategies in Children
Research with children has focused primarily on
analysis of the role of manipulation strategies in the
development of haptic discrimination of shape and size
(length). Results of these studies suggest that there is a
4 to 5 years Exploration often remains
passive, with object being
grasped between palm and
middle fingers; crude manual
exploration begins; when
manual exploration is seen, it is
done in a global haphazard
manner, which includes probing
for distinctive features
5 to 6 years Systematic use of both hands
(palms and fingers) begins;
isolated analysis of distinctive
features without studying whole
form can be observed
6 to 7 years Use of systematic method of
exploration can be seen; contour
following is used
developmental progression in the acquisition of
manipulation strategies, with the accuracy of object
identification being related to the level of sophistication
of the haptic manipulation strategies (Abravanel,
1968b; Hatwell, 2003; Hoop, 1971b; Jennings, 1974;
Kleinman, 1979; Wolff, 1972; Zaporozhets, 1965,
1969). The description of the developmental pro-
gression of haptic discrimination of common objects
and shapes in Table 4-2 is a summary of the work
conducted by Piaget and Inhelder (1948/1967) and
Zaporozhets (1965, 1969). Whereas haptic strategies
of the 2- to 4-year-old child consist primarily of
grasping the object, by age 6 to 7 years systematic
exploration with contour following is noted.
Abravanel (1968b) provided a description of the
developmental progression in haptic manipulation of
size (length) that was strikingly similar to that identified
74 Part I • Foundation of Hand Skills
BOX 4-3 Examples of Manipulation
Strategies
If children want:
• To compare two objects for texture, they use a lateral
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,
they tend to embrace the object.
• To compare weight, they tend to hold the object in
their hand and lift it from the surface.
Hatwell Y (2003). Manual exploratory procedures in
children. In Y Hatwell, A Streri, E Gentaz (editors):
Touching for knowing (pp. 67–82). Philadelphia, John
Benjamins Publishing; Klatzky RL, Lederman SJ (2003).
The haptic identification of everyday life objects. In Y
Hatwell, A Streri, E Gentaz (editors): Touching for
knowing (pp. 105–122). Philadelphia, John Benjamins
Publishing; Klatzky RL, Lederman SJ, Metzger VA
(1985). Identifying objects by touch: An “expert system.”
Perception and Psychophysics, 37:299–302; Streri AF
(2003a). Manual exploration and haptic perception in
infants. In Y Hatwell, AF Streri, E Gentaz (editors):
Touching for knowing (pp. 51–66). Philadelphia, John
Benjamins.
for the analysis of common objects and shapes. She
found that the youngest children in her study (3 to
5 years) typically used the palm of the hand, grasping
and palpating the objects. By 5 years the children held
the ends of the bar used for evaluating length. From 5
through 8 years children used the whole hand (palm
with progressively increasing use of the fingers) for
manipulation of the bar and displayed a systematic
method of determining length. By 9 years, use of the
palm was no longer seen; the fingers and fingertips
were used for exploration.
Researchers have shown that the manipulation
strategy used by the child or adult varies as a function
of the information to extract (Box 4-3) (Hatwell,
2003; Klatzky & Lederman, 2003; Klatzky, Lederman,
& Metzger, 1985; Streri, 2003a).
In summary, the results of studies that address
analysis of strategies used in the recognition of com-
mon objects, shapes, and sizes, including lengths,
suggest that manipulation strategies become more
complex with increasing age, a maturational change
that seems to contribute to the accuracy of haptic
object recognition. The structural characteristics of the
test materials influence the time spent in haptic
exploration, perhaps because they contribute to task
difficulty or they affect the complexity of manipulation
strategies needed for object exploration. The effect of
object characteristics on the use of manipulation
strategies has been extensively addressed in infants, and
to a lesser extent in preschool and school-age children.
Infants use a variety of actions in exploring objects (see
Box 4-2). These actions vary as a function of the object
and surface characteristics; that is, they are influenced
by the perceptual affordances provided by the environ-
ment, as well as by the infants’ motor abilities.
ROLE OF VISION AND COGNITION IN
HAPTIC PERCEPTION
Vision
McLinden and McCall (2002) emphasize that most
skills and activities are performed with information
from multiple modalities simultaneously. They discuss
the role of vision in coordinating or integrating a wide
range of sensory information. Warren and Rossano
(1991) describe the important role that vision plays in
the development of haptic perception. Noting that
vision and touch are constant companions, Pears and
Jackson (2004) discuss how the brain dynamically
binds together visual and somatosensory information
to construct accurate representations of objects in
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
and fine haptic exploration early in development and
suggested that vision may serve as a potential organizer
of multimodal exploration and object manipulation in
infancy. This was based on research that indicated that
fingering starts to manifest itself in coordination with
vision. Refined object manipulation was more likely
to occur when infants simultaneously looked at and
manipulated objects. Thus it may be important for
infants to see their hands during manual object
manipulation. As further support of the role of vision as
an organizing factor of object manipulation, Rochat
(1989) cited developmental studies of congenitally
blind infants, who exhibited drastic delays in the use of
their hands as exploratory tools (Fraiberg, 1977). Even
though congenitally blind toddlers spontaneously
developed strategies such as object rotation (Landau,
1991), haptic exploration was primarily oral up to 3 to
4 years of age, much longer than was seen in sighted
infants. Thus the use of vision in object exploration
may be important for the development of haptic per-
ception. However, this is not to say that haptic percep-
tion cannot be developed in the absence of vision. For
example, Schellingerhout, Smitsman, and Van Galen
(1997, 1998) examined the haptic exploratory pro-
cedures of surface textures in eight infants, 8 to
24 months old, who were congenitally blind. They
found that younger infants showed a wide range of
exploratory strategies and older infants used these
strategies in a specific manner.

Hatwell (1990) suggested that even sighted children
between the ages of 3 months and 6 years have
difficulty using their hands for retrieving haptic
information independent of vision. She suggested that
the motor functions of young children’s hands were
primary, with the perceptual capabilities of the hands
rarely used except as an adjunct to motor functioning.
Hatwell noted that when vision was used, the hands
primarily operated under this system of control. Ruff
(1989) tempered this view by stating that it may be
that the visual system guides exploratory behavior in
the haptic system. In this sense, vision would not
exclude the contribution from the haptic system as put
forward by Hatwell (1987) but would constrain it.
Ruff (1989) suggested that there was an “initial
tightening of visual control over manipulation around
5 months of age [and] then the loosening of visual
control sometime after nine months” (p. 313).
Haptic manipulation with vision is important in the
early learning of object characteristics and has two
potential advantages. First, as infants look at an object
they are manipulating, they see the object from dif-
ferent points of view and can learn about its properties.
This is critical for the development of object recog-
nition so that the infant or child can recognize an
object in any orientation or in any context. Second, the
infant acquires tactile and kinesthetic information
about the object through active touch (Ruff, 1980,
1982; Streri, 1993, 2003a).
Ruff (1980) suggested that movement is particularly
important in helping infants to detect the properties of
an object that does not vary despite changes in the
object’s orientations. An important question is what
type of movement is necessary. For example, the infant
can produce different information about the object
through his or her own movements such as through
turning the head to look at the object, by moving the
body around the object, or by holding, manipulating,
and moving the object. Alternatively, the infant can get
different views of an object when a parent carries the
infant around the room, or when the object itself
moves, as in a mobile, or when a parent moves the
object, such as in the context of showing a toy to a
child. Ruff (1980) hypothesized that object trans-
formations that occur during movement allow for
detection of object characteristics that would not be
evident from observing a stationary object. She also
suggested that, although both watching object move-
ment and producing object movement were important
in learning about objects, producing movement could
yield the specific types of information sought and
therefore was a more efficient way of learning about
objects. The advantage to the individual doing the
moving is that infants learn to recognize objects in the
context of activity. Ruff (1980) found that 6-month-
Perceptual Functions of the Hand • 75
old infants learned structural differences in objects only
when they actually manipulated the objects; viewing
object movement did not result in the learning of
object characteristics. It should be emphasized that, in
the manipulation condition, the infants also visually
monitored their movements, thus obtaining tactile,
proprioceptive, and visual information. Ruff proposed
that the advantage of object manipulation may be in
the simultaneous use of visual and tactile integration in
learning about object qualities.
The heavy use of vision in object identification seen
in infants may continue into adulthood. Research com-
paring visual and haptic discrimination has shown visual
matching to be consistently superior to haptic and
intermodal (haptic-visual and visual-haptic) matching
(Garbin, 1988; Hatwell et al., 2003). This finding has
left the impression that vision may be more important
than haptic discrimination in object identification.
Nevertheless this may be an incorrect interpretation of
the research findings. Klatzky and co-workers (1985)
questioned this conclusion, stating that it might be
inappropriate to use objects that can be easily inter-
preted by the visual system when evaluating functions
of the tactile system. Rather than vision being superior
to haptic manipulation, it would probably be more
accurate to say that vision and somatosensory processing
both play supportive roles in object identification.
Although vision seems to be used by infants and young
children to guide exploratory hand use, its purpose may
not be to substitute for haptic perception but rather to
guide the development of haptic manipulation and
make the somatosensory input meaningful.
Cognition
The development of infants’ and young children’s
exploration of the environment is linked to their under-
standing and knowledge about the world (Bushnell &
Boudreau, 1998; McLinden & McCall, 2002). Because
cognition and vision are closely linked in haptic object
identification, it is difficult to categorize certain func-
tions, such as mental imagery, that involve both cog-
nition and vision. The ability to use cognitive strategies
(mental imagery and verbalization) to aid in haptic
object recognition develops during childhood. Piaget
and Inhelder (1948/1967) considered the ability to
distinguish objects through the use of touch to be an
external reflection of one’s capacity to transform tactile
properties of objects into visual images (integrate visual
and haptic information), although recently this view
has been questioned. This ability to use visual imagery
to improve haptic recognition and memory of objects
is thought to contribute to children’s ability to recog-
nize objects on tests of haptic perception and repro-
duce objects through drawing. In fact, research has
shown that adults with high spatial ability and skill in
76 Part I • Foundation of Hand Skills
mental imagery perform significantly better than
their less skilled peers on tests of haptic perception
(McCormick & Mouw, 1983).
Verbalization (labeling of the haptic properties of
objects) also has been found to aid in haptic object
identification. Bailes and Lambert (1986) compared
the ability of adults who were sighted and blind to
determine if four segments of a stimulus figure
matched a completed geometric design. The subjects
who were sighted were faster and more accurate than
the subjects who were blind. Adult subjects who used
verbalization had better haptic accuracy scores than sub-
jects who used a mixture of verbalization and mental
imagery. Subjects who solely used mental imagery dis-
played the lowest haptic accuracy scores. Thus in some
tasks, verbalization may be a more effective strategy
than mental imagery, although both may be beneficial.
The ability to use cognitive strategies (mental
imagery and verbalization) to aid in haptic object
recognition develops during childhood. Children 3 to
6 years of age often could not describe the strategies
that they used to aid in haptic object identification
(Blank & Bridger, 1964). By the fourth grade several
solely used verbalization or mental imagery, whereas
most relied on a mixture of verbalization and visual
imagery to aid in haptic object identification (Ford,
1973). Adults were evenly mixed in their isolated use of
verbalization and mental imagery, and combined use of
the two cognitive strategies (Bailes & Lambert, 1986).
Alexander, Johnson, and Schreiber (2002) examined
the effect of 4- to 9-year-old children’s domain-specific
knowledge on their performance in haptic comparison
task. Children with varying levels of knowledge about
dinosaurs haptically explored pairs of familiar
(dinosaur) and unfamiliar (sea creature) models and
were asked to state whether or not the pairs were
identical. Older children correctly identified more pairs
than younger children and explored models more
exhaustively. Although dinosaur knowledge did not
affect overall performance, it did affect the types of
explorations that to some extent resulted in increased
errors. Specifically, after exploring the first object,
children with high knowledge about dinosaurs tended
to form an initial hypothesis (e.g., based on one feature
such as the beak) and then sought evidence to confirm
this initial hypothesis by primarily exploring just the
beak of the possible matches. In doing this, they ignored
or failed to seek out evidence (e.g., exploring the
dinosaur’s feet) that did not confirm their hypothesis.
SUMMARY AND I MPLICATIONS FOR PRACTICE
Several functions contribute to the ability to perform
haptic perception tasks. Because an individual performs
poorly on tests of haptic perception does not mean that
somatosensory processing is impaired. Impairment in
somatosensory processing, vision, visual perception,
cognition, praxis, and any factor that may alter fine
motor coordination has the potential to lower per-
formance on tests of haptic perception. Determining
the reason for a child’s poor test performance is a
necessary prerequisite for effective treatment planning.
In the clinic we may be able to gain some insight
into the maturity of the somatosensory system by
observing the tendency of infants to mouth and
manipulate novel objects. Although infants use vision
extensively in object exploration, we should expect to
see a combination of visual and oral or manual
exploration during play in infancy.
Although research indicates that optimum per-
formance in haptic identification is seen when manual
manipulation is used for object identification, haptic
perception can be partially assessed without active
manipulation. Research has shown that placement of
the object in the palm of the hand and movement of
the object across the skin’s surface improves object
recognition. Thus the therapist can occlude the child’s
vision, move the object across the center of the palm,
and then ask the child to identify the object by visual
matching or verbal response. Analysis of the quality of
the haptic manipulation strategies used during test per-
formance also provides useful diagnostic information.
The preferred manual manipulation and exploratory
strategies of adults vary for objects with different tactile
properties. The manipulation strategy used affects the
accuracy of object identification. Research suggests that
the development of haptic manual manipulation and
exploratory strategies begins early in life, because
infants use specific manipulation strategies to explore
specific sensory properties. During childhood these
manipulation strategies grow in complexity with
increasing age. We do not know whether children with
problems in haptic perception and fine motor
coordination fail to use appropriate manipulation
strategies because they have difficulty in the selection or
execution of haptic manual manipulation and explor-
atory strategies. However, it is generally recognized
that the immature haptic manipulation strategies seen
in young children contribute to poor object recog-
nition (Abravanel, 1968b; Derevensky, 1979; Hatwell,
2003; Hoop, 1971b; Jennings, 1974; Wolff, 1972;
Zaporozhets, 1965, 1969).
Early haptic exploration in infancy is done with the
mouth. It is more than a year before mouthing is
primarily replaced by manual manipulation. We cannot
overemphasize the clinical importance of mouthing
objects in infancy. Mouthing of objects not only seems
to be important for decreasing oral hypersensitivity and
facilitating oral motor development, but it also appears
to be important for environmental learning and may

contribute to the early development of bilateral hand
use. Infants who exhibit little mouthing of objects
should be evaluated to determine the cause of the
delay. Even older children who exhibit tactile defensive-
ness and those with problems in haptic discrimination
should be encouraged to engage in oral and manual
exploration of objects. It takes creativity and close
interaction with parents to find socially acceptable ways
to encourage mouthing beyond infancy. Children also
can show a prolonged need for mouthing of objects. If
the behavior is caused by oral-tactile defensiveness or
poor haptic discrimination, then mouthing should be
encouraged. However, if the behavior is caused by
impaired visual-haptic integration or poor purposeful
use of objects, then treatment should be directed
toward pairing vision and oral-manual manipulation
during purposeful interaction with objects. A bigger
challenge is seen in children with multiple handicaps
and those who have severe impairment in motor
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.
Vision is paired with haptic exploration of the hands
throughout infancy and early childhood. Vision appears
to guide the development of haptic manipulation
strategies. It is not until later in life that vision and
somatosensory sensations appear to take on separate
but supportive roles in object identification and use.
The importance of vision in the development of
haptic manipulation is seen in blind infants. Whereas
typical infants begin to replace mouthing with manual
manipulation at about 4 months, blind infants continue
to identify objects orally, with mouthing the dominant
form of exploration until 3 or 4 years of age (Landau,
1991). Because vision appears to be necessary for the
development of haptic manual manipulation, the use of
haptic exploration with the hands should be specifically
taught to blind infants; we cannot assume that, because
the infant is not using vision, he or she will auto-
matically use the hands for environmental exploration.
Interplay between vision and haptic exploration
seems to be needed for environmental learning in
infancy and early childhood. Under the age of 5 or
6 years activities should be designed that pair vision and
touch in addition to using the haptic sense alone. The
identification of object features should be integrated in
these activities. An exception is seen in children who
overuse vision to guide hand use. For these children
vision should, at times, be removed from the play
activities to encourage the child to retrieve and use
haptic information.
Haptic object identification is made possible by
combining vision and cognition. The use of visual
imagery and verbalization helps improve haptic
Perceptual Functions of the Hand • 77
memory and discrimination. We cannot assume that
children will automatically learn cognitive strategies
to aid in haptic task performance. For children with
attention deficits, brain injury, and mental retardation,
the interpretation and use of haptic information might
be enhanced by teaching them to use cognitive strate-
gies such as mental imagery or verbalization techniques
during task performance. In addition, we know that
the ability to identify an object haptically proceeds not
only from extracting information from the stimulus
or object that is presented, but also by combining
“presented information with expectancies based on context or
previous experience” (Klatzky & Lederman, 2003),
called top-down processing. Thus providing a cue
such as “this is a fruit,” in advance of giving the child
an object to manipulate may result in improved
performance.
EVALUATION OF HAPTIC
PERCEPTION IN INFANTS AND
CHILDREN
Assessment of haptic perception can be considered
from the perspective of standardized versus nonstan-
dardized assessments and also analyzed according to
product/process dimensions. Most of the standardized
assessments examine the product; that is, the accuracy
of haptic perception, and the number of items the child
passed. Many of the nonstandardized assessments used
primarily for research purposes examine the process, or
the way the child approaches a task, and the effect of
the nature of the task on haptic style or strategy.
There are several standardized assessments to
evaluate accuracy of haptic perception The Miller
Assessment for Preschoolers (Miller, 1988) includes a
stereognosis item that uses common objects for the
younger (2- to 4-year-old) children and geometric
shape matching for older (3- to 5-year-old) children.
Although a specific score is not given for this item,
percentile equivalents can be determined from the
score sheet.
The Sensory Integration and Praxis Tests (SIPT)
(Ayres, 1989) make up a 17-test battery that assesses
aspects of sensory processing (visual, tactile, vestibular-
proprioceptive) and praxis. They are standardized on
children ages 4.0 to 8.11 years. This battery includes
several tests that tap aspects of haptic abilities. The
Manual Form Perception (MFP) test, which assesses
stereognosis, has two components. The first com-
ponent is a haptic-visual intermodal matching task in
78 Part I • Foundation of Hand Skills
which the child feels a geometric shape without the use
of vision and points to its visual counterpart from
among a set of choices. The second aspect of the test is
a haptic-haptic intramodal matching task in which the
child feels a geometric shape with one hand and
explores a set of five shapes to find its match with the
other hand. The MFP test is a complex task that, when
used in conjunction with the SIPT, contributes to
identification of various problems including haptic
perception, form and space perception deficit across
sensory systems, problems in visualization, and somato-
dyspraxia. The haptic-haptic matching component of
the test also reflects functional integration of the two
sides of the body (Ayres, 1989).
In the graphesthesia test (GRA) of the SIPT, the
examiner draws a design on the back of the child’s hand
and the child must reproduce that design with his or
her finger. This is not truly a haptic perception task
because the tactile input is received passively not
through active manipulation. Nevertheless it is similar
to many haptic perception tasks because the child needs
to interpret designs received through moving touch
applied to the hand and then signify knowledge of the
design by a motor response. As with tests of haptic
perception, fine motor coordination and motor
planning abilities are necessary for optimal test
performance (Ayres, 1989).
Another standardized test that includes aspects of
haptic perception is The Luria-Nebraska Neuropsycho-
logical Battery: Children’s Revision (Golden, 1987), a
149-item test battery designed to assess a broad range
of neuropsychological functions in children ages 8 to
12 years. There are 11 different scales, one of which
assesses tactile functions. The 16 items on this scale
assess tactile localization, tactile discrimination, inten-
sity, tactile spatial discrimination, direction of move-
ment, identification of traced shapes and numbers, and
identification of objects. The specific items on the
Tactile Function Scale that address aspects of haptic
perception include two items that assess stereognosis,
in which the examiner places an object (quarter, key,
paper clip, and eraser) in the child’s hand and the child
must name the object. If word-finding difficulties are
suspected, the examiner can place the four objects in
front of the child along with four other objects and ask
the child to point to the object he or she just felt. There
are also four items that are similar to the graphesthesia
test of the SIPT. In these items the child is required to
recognize a cross, triangle, and circle drawn on the
back of his or her wrist with a pencil. There are two
items in which a number is written on the back of the
wrist. In these items the child needs to know only that
a number was drawn and need not identify the specific
number. An overall score is provided for the Tactile
Function Scale. Although there is not a specific score
for the items assessing haptic perception, the examiner
can look at performance on these items. The Luria-
Nebraska Scales usually are administered by a
neuropsychologist and, like the Sensory Integration
and Praxis Tests, require special training. However, the
knowledgeable therapist can use results of this test to
aid in evaluation.
All the preceding tests examine accuracy of haptic
identification. The manipulation strategies used in
haptic exploration are not examined. At present there is
no standardized examination of exploratory strategies.
However, the work of Zaporozhets (see Table 4-2)
provides guidelines for the therapist wishing to
examine this area. If, for example, a therapist notes that
a 7-year-old child is using only grasping to examine
complex shapes, he or she can infer that this child is
using immature and inefficient strategies to gain
information about objects. Exner (1992) developed a
test to examine in-hand manipulation in children ages
18 months through 61⁄2 years. Although the emphasis
of this work is on the hand as a motor instrument used
to accomplish specific skilled fine motor tasks with
vision present, the process of adjusting objects within
the hand after grasp (in-hand manipulation) is critical
to enable effective haptic manipulation to gain
perceptual information about an object (Case-Smith &
Weintraub, 2002).
There are no standardized assessments to examine
haptic identification of the material properties of
objects such as weight, texture, or object features such
as length. Research has indicated that individuals use
different strategies to gain information about these
object characteristics. For example, if children are asked
to match objects on the basis of texture, they use lateral
motion; if they are asked to match objects on the basis
of hardness or firmness, they use pressure; if they have
to match on the basis of shape, they tend to use
contour following (Streri, 2003a). In working with
children with disabilities, we should examine whether
they vary the strategy used in exploring different object
properties as do typical children (McLinden, 2004;
McLinden & McCall, 2002). Although the typical
child does not need or receive specific training in how
to use the haptic sense, it may be necessary to explicitly
teach haptic manipulation strategies in children with
disorders (McLinden & McCall, 2002).
For therapists wishing to assess haptic abilities in
young infants, the best assessments at present are
observational qualitative assessments rather than
standardized testing, although it is important to use a
standard protocol to compare infants and see change in
haptic style over time. It has been reported in the
literature that from 6 to 12 months there is a decrease
in mouthing and an increase in fingering behavior
(Ruff, 1980; Streri, 2003a). Thus if at 12 months an

infant is bringing everything to the mouth, one could
identify a delay in the use of the hands for
manipulation. Similarly, Ruff (1980) noted that 9- and
12-month-old infants adjusted their behavior to the
characteristics of objects and more often fingered
textured objects with prominent surfaces than smooth
objects. Thus one could incorporate giving infants both
smooth blocks and blocks with textures and surfaces
and observing their response to these different objects.
The information on the role of manipulation in
haptic perception also provides guidance for evaluation.
Along with noting the frequency of mouthing and the
integration of vision and haptic senses in object explo-
ration in infancy and early childhood, note the manipu-
lation strategy used during performance on tests of
haptic perception. Because the identification of com-
mon objects matures by 5 to 6 years and can be accom-
plished with little to no haptic manipulation, common
objects may be useful only for assessing pre–school-age
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-
fication of geometric shapes to include the testing of
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
sensory properties encountered during daily activities.
Examination of whether children vary their strategy as
a function of the task demand provides information
about the type of information the child receives
through his or her haptic sense.
When assessing haptic perception in individuals with
multiple disabilities, such as visual impairment or visual
impairment plus other disabilities, McLinden (2004)
and McLinden and McCall (2002) caution against
relying only on norm-referenced assessments because
children with disabilities have different experiences and
often do not develop in the same sequence as typical
children. However, they recognize that there are no
assessments to assess haptic perception that are stan-
dardized for children with disabilities. They recom-
mend considering developmental assessments in
conjunction with criterion-referenced procedures and
process-oriented approaches, and emphasize that it is
critical to examine how children use their sense of
touch in naturalistic or functional situations. McLinden
(2004) recommends using an “adaptive tasks”
approach that identifies the child’s use of or response to
touch in daily activities. (See also the Scottish Sensory
Centre for a discussion of systematic ways to observe a
child’s response to touch for learning.)
Finally, in examining haptic perception, it is critical
to examine the child’s response or reaction to tactile
sensory input because this has a significant impact on
Perceptual Functions of the Hand • 79
the child’s willingness to explore objects through his or
her sense of touch. Children who show sensory defen-
siveness, such as may be seen in children who were
preterm as infants (Case-Smith, Butcher, & Reed,
1998), may be unwilling to use their hands to gain
information about the environment (Ayres, 1989).
Case-Smith (1991) reported that children with tactile
defensiveness and poor tactile discrimination demon-
strated less efficiency in in-hand manipulation tasks.
Response to touch can be assessed observationally
while administering standardized assessments of
somatosensory perception such as the SIPT, through
assessment of sensory processing using caregiver
questionnaires (Brown & Dunn, 2002a,b; Dunn,
1999) or through protocols designed for use with
children with disabilities (e.g., Assessing Communica-
tion Together) that suggest a structure for observing
response to touch (Bradley, 1991 as cited in McLinden
& McCall, 2002, p. 89).
HAPTIC PERCEPTION IN
CHILDREN WITH DISORDERS
PREMATURITY
The characteristics of touch most fully explored in the
infant are those related to social and emotional func-
tioning, and research on the perceptual role of touch
often proceeds separately from research on its social
role (Rose, 1990). Recently the specific role of tactile
stimulation has been examined, and numerous studies
have investigated whether the preterm infant will bene-
fit from changes in the quantity, quality, or patterning
of stimulation in the environment (Field, 2002, 2003).
The sensory organization and perceptual processing
characteristics of the preterm infant also have been
investigated. Rose and co-workers (Rose, Schmidt, &
Bridger, 1976; Rose et al., 1980) examined the infants’
responsivity to (passive) tactile stimulation and their
abilities to discriminate different intensities of such
stimulation. Infants were assessed at 40 weeks’ gesta-
tional age, and, while sleeping, they were touched with
plastic filaments of different intensities and their cardiac
and behavioral responses were examined. Results indi-
cated that preterm infants are significantly less respon-
sive to tactile stimulation than are full-term infants.
Rose, Gottfried, and Bridger (1978) also examined
differences between preterm and full-term infants at 1
year of age in an active touch multimodal (haptic and
visual) task using a habituation paradigm. Preterm
infants did not show any evidence of cross-modal
transfer, whereas full-term infants did show such
transfer. These results indicate that full-term infants are
80 Part I • Foundation of Hand Skills
able to gain knowledge about the shape of an object by
feeling it and mouthing it and that they are able to
make this information available to the visual system.
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
object they saw was the same object they were
exploring with their hand or mouth. Overall, preterm
infants were limited in acquiring information; they
showed evidence of difficulty perceiving passive touch
and effectively using active touch to explore their
world. Interestingly, lower-income full-term infants
also showed poorer haptic-visual integration than did
full-term middle-income infants. Recognition memory
also has been studied in premature infants (Rose, 1983;
Rose et al., 1988), who were found to have longer
initial exposures and less recovery with novelty,
indicating slower and perhaps less complete informa-
tion processing.
Poor haptic perception appears to be long lasting.
Two follow-up studies examined the long-term out-
comes of children who were born preterm. Somato-
sensory processing, including haptic perception, was
impaired when the children were examined at school
age (DeMaio-Feldman, 1994; Short et al., 2003).
Another research paradigm that has been found to
discriminate between high-risk infants and their typical
peers is manipulative exploration. Early studies of
exploratory behavior from a Piagetian perspective
documented decreased manipulation in premature
infants but interpreted the decreased action to be a
reflection of a disordered motor system that provided
inadequate or inaccurate information (Kopp, 1974).
Kopp examined the performance of premature and full-
term 8-month-old infants who were clumsy and non-
clumsy (based on reach and grasp). The coordinated
group of infants showed significantly more exploration
of objects, particularly more mouthing. The infants
with poor coordination used more large arm move-
ments and less object manipulation than the infants
with good coordination. Kopp discussed the value of
object manipulation in enhancing attention and
providing information to infants. However, she also
pointed out that infants with poor manipulation skills
may give extra attention to motor actions, leaving less
attention available for sensory or perceptual processing.
More recent studies have focused on the attentional
and organizational differences between preterm and
full-term infants because early focused attention reflects
active learning and predicts cognitive outcome (Lawson
& Ruff, 2004). Preterm infants exhibit shorter duration
of action and less directed information-seeking action.
High-risk infants have also been found to have less
organized action and attentional strategies in
exploratory manipulation of objects (Ruff, 1986; Ruff
et al., 1984). It is not clear whether this disorganization
is a purely motor phenomenon or relates to the ability
to perceive environmental affordances and act on them.
M ENTAL RETARDATION
Research conducted with individuals with mental
retardation provides insight into the relationship
between haptic perception and cognitive ability. Much
of the research examining the relationship among
cognitive abilities and haptic manipulation and motor
skill has been done with children with Down syndrome
(e.g., Brandt, 1996; Moss & Hogg, 1981). These
studies generally reported that children with Down
syndrome did not show as effective accommodation of
their hands to objects after grasp and did not use haptic
manipulation and exploratory strategies as readily as
typical children. However, it is difficult to directly
attribute these results to the child’s cognitive abilities
because many of these findings can be attributed to the
sensorimotor problems or other aspects of Down
syndrome (Exner, 1991). For example, Brandt and
Rosen (1995) found that children with Down syn-
drome demonstrated impaired peripheral somato-
sensory function (sensory nerve conduction velocities)
and suggested that this may contribute to poor tactual
perceptual performance. It is likely that, regardless of
the cause of the delay, impairment in the ability to
efficiently explore objects interferes with learning about
key object properties (Exner, 1991).
Jones and Robinson (1973) compared the per-
formance of a group of children with mental retar-
dation (mean IQ = 47) to an age-matched group
of children with normal intelligence. Accuracy of
intramodal (haptic-haptic) and intermodal (haptic-
visual) discrimination of meaningless shapes was poorer
for the children with mental retardation than for the
children with average intelligence. However, other
studies found that when children with mental retar-
dation and typical children were matched for mental
age, the between-group difference in accuracy of haptic
recognition disappeared (Derevensky, 1976, cited in
Derevensky, 1979; Jones & Robinson, 1973; Medinnus
& Johnson, 1966). In fact, two studies identified sub-
jects with mental retardation as performing better than
normal mental age-matched controls in intramodal
(haptic-haptic) and intermodal (haptic-visual) match-
ing tasks (Hermelin & O’Connor, 1961; Mackay &
Macmillan, 1968).
Because matching subjects for mental age eliminated
differences in haptic accuracy scores between children
with mental retardation and typical children, it can be
concluded that some aspects of higher cognitive proc-
essing are most likely necessary for task completion. In
addition to verbal intelligence, haptic strategies have

been found to affect test performance of individuals
with mental retardation. Subjects with mental retarda-
tion have been known to display immature manipula-
tion strategies during tests of haptic perception. The
sophistication of haptic manipulation strategies has
been shown to be closely related to cognitive ability
because manipulation strategies tended not to differ
between typical children and children with mental
retardation when subjects were matched for mental
age (Davidson, 1985; Davidson, Pine, & Wiles-
Kettenmann, 1980). An increase in sophistication of
manipulation strategies has been shown to occur in
close association with an increase in mental age within
the population with mental retardation (Davidson et
al., 1980). Evidence from research on children with
mental retardation who were blind and sighted and
age-matched controls suggests that experience may
contribute to improved manipulation and thus accuracy
of intramodal (haptic-haptic) matching in individuals
with mental retardation, but experience alone cannot
fully compensate for the effects of reduced cognitive
ability (Davidson, Appelle, & Pezzmenti, 1981). These
findings suggest that training can help improve the
sophistication of manipulation strategies in individuals
with mental retardation, but such improvement in hand
function may be only partially effective in improving
performance on tests of haptic perception.
BRAIN I NJURY
Impairments in tactile perception frequently have been
reported in children with a diagnosis such as cerebral
palsy that indicates a known brain injury (Bolanos et
al., 1989; Boll & Reitan, 1972; Cooper et al., 1995;
Duque et al., 2003; Krumlinde-Sundholm & Eliasson,
2002; Reitan, 1971; Solomons, 1957; Tachdjian &
Minear, 1958; Van Heest, House, & Putnam, 1993;
Yekutiel, Jariwala, & Stretch, 1994) and with traumatic
brain injury (Ayres, 1989). Stereognosis (haptic
identification of shapes or common objects) is often
cited among the tactile functions showing impairment.
Intermodal (visual-haptic) matching of shapes also
has been shown to be impaired in children with brain
injury (Birch & Lefford, 1964). Solomons (1957)
found that children with brain injury were also
impaired in the haptic discrimination of size and
texture, although they did not differ from typical
children in their ability to haptically match objects by
weight. Although Boll and Reitan (1972) cited no
problems in haptic shape recognition, they noted that
the children with brain injury performed poorly on a
complex tactile performance task that required shape
recognition for task completion. Rudel and Teuber
(1971) compared the ability of typical children and
children with brain injury to discriminate three-
Perceptual Functions of the Hand • 81
dimensional shapes through the use of intramodal
(haptic and visual) and intermodal (visual-haptic)
matching. Reduced performance in the group with
brain injury was seen only in the visual-visual and
visual-haptic matching conditions. These authors noted
that, unlike the typical controls, who tended to per-
form better on the test conditions that included the use
of vision than on the one requiring solely the use of
touch, the addition of visual cues did not seem to assist
the subjects with brain injury to improve their test
performance. This finding suggests that children with
brain injury may have a problem in visual perception or
visual-haptic integration. However, this conclusion
should be interpreted with caution because the mental
ages of the subjects in the group with brain injury were
11⁄2 to 2 years above that of the control group. It is
possible that, if the subjects were more equally matched
for mental age, greater impairment in haptic perception
might have been found within the group with brain
injury.
The studies reviewed frequently used children with a
mixture of diagnoses (e.g., cerebral palsy, encephalitis,
traumatic head injury). Thus it was not surprising to find
research that cited deficits in manual dexterity (e.g.,
finger tapping, grip strength, motor coordination) along
with dysfunction in tactile perception in the children
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
perform tests of haptic perception. The children with
brain injury with intact hand function were able to more
accurately match objects by shape, texture, and size than
the children with brain injury with fine motor impair-
ment. Studies also have reported that deficits in tactile
perception (including stereognosis) have been closely
associated with poor hand function in children with
cerebral palsy (Duque et al., 2003; Gordon & Duff,
1999; Tachdjian & Minear, 1958). In addition,
stereognosis has been identified as a good predictor of
upper-extremity surgical outcome within the population
with cerebral palsy (Goldner & Ferlic, 1966).
LEARNING DISABILITIES AND RELATED
DISORDERS
Impairment in tactile perception also has been cited in
children who display learning disabilities and related
disorders, conditions in which clearly identifiable brain
damage has not been found. Poor tactile and kines-
thetic perception has been found in children with
learning disabilities, language disorders, dyspraxia,
autism, and developmental Gerstmann syndrome
(Ayres, 1965, 1989; Harnadek & Rourke, 1994; Haron
& Henderson, 1985; Johnson et al., 1981; Kinnealey,
1989; Kinsbourne & Warrington, 1963; Lord &
82 Part I • Foundation of Hand Skills
Hulme, 1987; Spellacy & Barbara, 1978; Nyden et al.,
2004), with stereognosis among the tactile tests used in
some of these studies.
Impairment in motor coordination often has been
found to accompany poor tactile perception in children
with learning disabilities and related disorders. Johnson
and co-workers (1981) found children with language
disorders performed more poorly than a group of typical
children matched for age, IQ, and socioeconomic status
on tests of tactile perception (simultagnosia, graphesthesia,
and finger identification) and motor coordination
(hopping, finger opposition, diadochokinesis, and
putting coins in a box). Reports of children with
developmental Gerstmann syndrome have commonly
cited a pairing of impairment in finger identification
and constructional praxis (including poor handwriting
and difficulty drawing geometric shapes) (Benton &
Geschwind, 1970; Kinsbourne & Warrington, 1963;
PeBenito, 1987; Spellacy & Barbara, 1978). Case-
Smith (1995) studied 30 preschool children with
perceptual-motor problems and found that stereognosis
(Manual Form Perception test of SIPT) correlated with
Motor Accuracy, a test of fine-motor skill (r = 0.43).
Several other authors also have linked deficits in
somatosensory processing (including poor haptic
perception) to problems in motor planning (praxis)
(Ayres, 1965, 1969, 1971, 1972, 1977, 1989; Ayres,
Mailloux, & Wendler, 1987; Gubbay, 1975; Hulme
et al., 1982; Reeves & Cermak, 2002; Walton, Ellis, &
Court, 1962). However, it is not clear whether impaired
haptic perception contributes to poor motor planning,
poor motor planning contributes to difficulty in haptic
perception, or there is an ongoing interaction. There
has been little research specifically designed to identify
factors that may be contributing to impaired haptic
perception in children.
SUMMARY AND I MPLICATIONS FOR PRACTICE
The previous section provides evidence of the existence
of problems in haptic perception in children born
prematurely and those with a variety of disorders
associated with brain injury and learning disabilities.
Like much of the literature on haptic perception in
children previously discussed, most of the research on
haptic perception in children with disorders has been
limited to the study of haptic discrimination of shape.
The presence of problems in haptic discrimination of
shapes does not mean that a child also has equal impair-
ment in haptic discrimination of objects containing
other sensory properties (e.g., texture and weight).
Thus we cannot assume that because a child has problems
discriminating shapes he or she has global impairment
in haptic perception. Future research on children with
disabilities needs to be directed toward the analysis of
haptic recognition of objects having a variety of sensory
properties. Factors contributing to test performance
(e.g., in-hand manipulation and attention) also should
be addressed if we are to gain the information needed
for effective intervention.
It was interesting to note that the reduced
sophistication of manual and in-hand manipulation
strategies, seen with impairments in visual perception
and visual-haptic integration were cited as possible
contributing factors to poor haptic perception in all
the conditions reviewed. Although reduced cognitive
ability was considered only in children with mental
retardation, attention deficits or related cognitive proc-
essing problems were cited as possible contributing
factors to impairment in other populations.
SUMMARY
Haptic perception in infants and children has been
reviewed in depth in this chapter. It was the authors’
intent to provide an overview of the literature on the
topic, with emphasis on material relevant to the
evaluation and treatment of disorders in haptic
perception in children with suspected and identified
CNS dysfunction. The literature reviewed provides
insight into the development of haptic perception and
the identification of factors that may be contributing to
impairment in haptic perception in some children.
Haptic perception emerges in early infancy and con-
tinues to mature into adolescence. The infant initially
uses oral exploration to learn about objects. The hands
first transport objects to the mouth and later become a
primary tool for haptic object exploration. Manual
manipulation of objects begins with grasping and is
later replaced by more specific manipulation patterns
(e.g., fingering, banging) that are tailored to the
physical properties of the object. Manual manipulation
gradually replaces mouthing as the preferred method of
object exploration. This is followed by a long period of
development in which the accuracy of haptic object
recognition improves and the complexity of manual
manipulation and exploratory strategies increases.
The accuracy of haptic object recognition is related
to the choice of haptic manual manipulation and
exploratory strategies. Vision appears to guide the
development of manual manipulation and helps to
bring meaning to the haptic information being
retrieved by the hands. It is not until 6 years of age that
children can easily explore objects with the hands
without the assistance of vision. With time the hands
develop the ability to retrieve information from the
environment without the aid of vision, making it
possible for vision and haptic sensory processing to take

on separate supportive roles in daily function; however,
visual imagery continues to be used by many people to
aid in haptic object recognition.
Research suggests that the ability to use cognitive
strategies such as visual imagery and verbalization in
the cognitive processing of haptic information develops
with age. It appears to be related to intelligence, because
there is an association between mental age and the
accuracy of haptic object recognition.
Review of the literature on haptic perception in
children with disorders suggests that impairment in
somatosensory processing, manual and in-hand manip-
ulation, vision, visual perception, or cognition can con-
tribute to deficits in haptic perception.
Most of the tests currently used to assess haptic
perception measure the product, the number of objects
identified correctly. Yet process might be as important
as, or even more important than, product when using
the results of testing to guide treatment. Assessing the
process means considering the quality of manual
manipulation and exploratory strategies, along with the
degree to which vision and cognitive strategies are
being used in task performance.
Therapists should be aware that the tests available to
measure haptic perception in children assess only a seg-
ment of this function. Because a child shows impairment
in shape recognition on a test of stereognosis does not
mean that the same child will display problems in haptic
discrimination of other sensory properties (e.g.,
weight, texture). We should consider developing tests
of haptic perception that assess the breadth of haptic
sensory properties found in objects. We also should
develop tests that measure the process, as well as the
product of task performance. We should test haptic
discrimination of several sensory properties to deter-
mine the extent of dysfunction, and we should analyze
the process of task performance to determine the
reason for low test scores. We also should develop
treatment strategies that will translate into improve-
ment in the use of haptic perception in daily function.
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REACHING AND EYE-HAND
COORDINATION
Birgit Rösblad
CHAPTER OUTLINE
MATURE REACHING MOVEMENTS
Movement Speed
Transport and Grasp Phase
Role of Vision
Role of Proprioception
Integration of Sensory Information
DEVELOPMENT OF REACHING DURING INFANCY
Beginning to Master the Reach
Coordinating the Body Parts Involved in the
Reaching Movement
Movement Planning
Role of Sensory Information
Movement-to-Movement Variability
REACHING IN CHILDREN WITH MOTOR
IMPAIRMENTS
Movement Planning
Feedback Control of Reaching Movements
Adaptation of Reaching Movements
The Movements of the Arms Are Coupled in
Children with Hemiplegic Cerebral Palsy
Our hands are extremely important tools for us in our
everyday lives, and we are able to use them with grace
and skill. To do so we have to be able to bring them to
the right place at the right time. This can be illustrated
with the example of catching a ball. To catch the ball
successfully the hand has to be at the calculated
meeting point at exactly the right time. Moreover, it
must be prepared for the catch, with the fingers closing
Chapter 5
around the ball before the moment of contact, or we
will fail to catch it. In other types of goal-directed arm
movements the arm trajectory as such can be the goal,
as when painting or drawing, but in a reaching move-
ment the goal is to transport the hand to the target,
with precision in both time and space.
This chapter is organized in three parts: the first
deals with the mature reaching movement, the second
with the development of reaching in infancy, and the
third with reaching in children with motor disabilities.
MATURE REACHING MOVEMENTS
Reaching for an object means getting the hand from a
starting position to the goal, the object. In doing this,
the hand describes a trajectory. The word trajectory can
be used in different ways, but here refers to the path
taken by the hand as it moves toward a target and the
speed as it moves along the path. The reaching trajectory
has several characteristics that are discussed later.
MOVEMENT SPEED
If the velocity of the hand during a reaching movement
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
of velocity. In the last part of the reaching movement,
when the hand is close to the target, the velocity is
slow. This typical bell-shaped velocity curve is seen
when the reach is carried on with, as well as without,
visual feedback (Jeannerod, 1984; Morosso, 1981).
This indicates that the reaching movement is pro-
grammed in advance of movement onset to a high
degree.
89
90 Part I • Foundation of Hand Skills
cm/s cm/s2
140 1500
750
70
0 increased variability in the final limb position and thus
–750
0 Another way of viewing the reaching movement is to
0 200 400 600
ms
Figure 5-1 Kinematic profiles of the transport
component of a reaching movement. The heavy line
depicts the velocity of the wrist (cm) as a function of
time. This curve describes a single continuous movement
with a single peak of velocity. The two peaks connected
by the thin line depict the acceleration of the wrist (cm2)
as a function of time. The positive peak constitutes one
phase of acceleration and the negative peak one phase
of deceleration, together forming one movement unit.
(From Jeannerod M, et al. [1992]. Parallel visuomotor
processing in human prehension movements. In R Caminiti,
PB Johnson, Y Burnod [editors]: Control of arm movement in
space. New York, Springer-Verlag.)
If one considers the reaching movement in terms of
accelerations and decelerations, it can be divided into
movement units. One phase of acceleration followed
by a deceleration then can be said to constitute a
movement unit (Brooks, 1976; von Hofsten, 1979).
The movement paths within these movement units are
relatively straight, and movement direction is changed
in between units (von Hofsten, 1991). The number of
movement units comprising a movement can be viewed
as an index of its degree of programming. A movement
consisting of only one movement unit, such as that
depicted in Figure 5-1, then can be viewed as being
entirely programmed before movement onset. How-
ever, if the movement is composed of many movement
units, one can assume that it has been programmed
several times during execution. A reaching movement,
aimed at a stationary object, generally consists of one or
two movement units, with the first covering the main
part of movement duration.
The choice of movement speed is crucial for how
skillfully we manage to reach and grasp an object. A
movement cannot be both fast and precise. Uncon-
sciously we strive to optimize movement speed to suit
the activities we perform. When we reach out to pick a
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
Fitts’ law (1954). The minimum variance theory, put
forward by Harris and Wolpert (1998), might explain
this phenomenon. They argue that neuronal signals are
corrupted by “noise” that increases with the size of the
control signal. Therefore increased acceleration leads to
requires further corrective movements. This means that
moving very fast can be counterproductive.
TRANSPORT AND G RASP PHASE
look for its functional components. Two distinct and
coordinated movement components then can be
identified (Jeannerod, 1984). The first component is a
transportation phase, which brings the hand to the
target. In this part of the movement mainly the
proximal joints and muscles are involved. The second
component is a grasp phase in which the hand is shaped
in anticipation of contact with the object. This phase
involves mainly the distal joints and muscles. One also
can divide the visual information needed to successfully
grasp an object into two categories. For the transport
phase of the movement knowledge of the position of
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
phase, perception of the size and shape of the object is
needed (the object’s intrinsic properties). There is
evidence for independent planning of the two reaching
phases (Loukopoulos, Engelbrecht, & Berthier, 2001).
Although the grasp and transportation phase of the
reach are separately controlled, these two components
are coordinated so that the grasp phase starts during
the transportation phase.
To accomplish a smooth and coordinated grasp, the
fingers must initiate the grasp well before encountering
the object. Closing the hand too early or too late pre-
vents capturing or makes the grasp impossible or awk-
ward. During the transportation phase the fingers open
to a maximum grip aperture. After this maximum
opening the fingers start to close in anticipation of
contact with the object (Jeannerod, 1981). The control
strategy used by the central nervous system to co-
ordinate these components remains largely unknown.
However, it has been suggested recently that a simple
spatial relation, based on the size of finger opening in
relation to finger closing, might determine at what
point during the reach the maximum grip aperture will
occur (Mon-Williams & Tresilan, 2001).

The action we perform shapes our reaching or
grasping movement. A small object requires longer
reaching time than a larger object. The first part of the
movement trajectory seems to be unaffected by object
size, but for smaller objects extra movement time is
spent in the last part of the movement, after peak
acceleration. Moreover, the greater the precision
required, the earlier the hand will anticipate the
physical characteristics of the object (Marteniuk,
MacKenzie, & Athenes, 1990). The hand opens more
fully during the reach when reaching for a larger object,
and always more than necessary (von Hofsten &
Rönnquist, 1988). If the reach has to be carried out
with high speed, the grip aperture is larger. Opening
the hand more fully during a fast reach could be seen
as a way of making sure that the object is successfully
grasped despite the decreased movement accuracy
(Wing, Turton, & Fraser, 1986).
ROLE OF VISION
It is obvious that vision plays a very important role in
our ability to reach out for objects. One need only
imagine what it would be like to be blind to realize the
importance of vision to reaching. Vision is the sense
that provides us with information about the layout of
the environment, and when reaching for an object,
vision defines both the position and shape of the object.
Seeing the environment gives us an opportunity to
anticipate upcoming events and plan our movements in
an anticipatory fashion. One example of this is the way
we shape our hand before contact with an object. A
blind person reaching for an object does not have this
ability but has to touch the object first and then,
guided by haptic information, shape the hand for grasp.
If we cannot foresee upcoming events and plan our
movements ahead of time, our movements will be
uncoordinated of necessity.
Given that visual information is important both for
movement planning and execution, one may ask what
should be seen and when during the movement we
need that information. The answer to this seems to be
that full visual information is optimal. Several studies
show that we must be able to see the target both before
and during a movement or movement quality is reduced
(Berthier et al., 1996; Sarlegna et al., 2003). Moreover,
if we can see our hand as we move it toward the target,
movement accuracy and efficiency will be improved
(Connolly & Goodale, 1999; Sarlegna et al., 2004;
Saunders & Knill, 2003; Schenk, Mair, & Zihl, 2004).
The minimum delay needed for visual information
to affect the physical movement of the hand tradition-
ally has been thought to be around 200 msec (Keele &
Posner, 1968). Because many naturally occurring
reaching movements take around 500 msec to com-
Reaching and Eye-Hand Coordination • 91
plete, the assumption has been that only low-velocity
movements can be influenced by visual feedback. How-
ever, there is now considerable evidence that visual
feedback might be as fast as 160 to l00 msec, and that
we use online visual information to correct both slow
and fast movements (Alstermark et al., 1990; Martin &
Prablanc, 1992; Paulignan et al., 1991a,b; Saunders &
Knill, 2003).
Nevertheless, even if the movement is carried out
without visual feedback, the main features of the
reaching trajectory remain. One will still see the bell-
shaped velocity curve, as well as the coordination
between movement speed and anticipatory hand
shaping (Jeannerod, 1981). This indicates that to a
high degree the reaching movement is programmed in
advance of movement onset but can be modified
during execution when necessary—that is, when end-
point accuracy is needed or if we reach for a target that
moves in an unpredictable way.
ROLE OF PROPRIOCEPTION
We have receptors in our muscles, tendons, joints, and
skin that provide us with information about the
positions and movements of our body parts. This is
here termed proprioception, after Sherrington (1906).
Although it is relatively easy to find out how we can
move without vision or with degraded vision, proprio-
ceptive information cannot be manipulated as easily.
Instead, the research on the role of proprioception has
focused on animal experiments and patients with sen-
sory loss caused by diseases.
One line of research has used deafferented monkeys.
When their dorsal spinal roots are sectioned, the
monkeys are deprived of sensation from the upper
limbs but the motor nerves are unaffected. This tech-
nique was used in early experiments by Mott and
Sherrington (1895). They reported that the monkeys’
limbs became useless after such operations and that the
animals used their upper limbs only if forced to and
then in an awkward way. They concluded that afferent
information from the limbs was necessary for both
movement initiation and control. Similar results also
were reported by Lassek & Moyer (1953). However,
later experiments with deafferented monkeys reported
different results. Taub and Berman (1968) reported a
clear improvement in motor function after the initial
disability that resulted from the section of the nerves.
The animals were able to reach for and grasp objects
with a primitive pincer grip a few months after surgery.
Recovery of function also has been reported by Knapp
and co-workers (1963). Bossom and Ommaya (1968)
have pointed out that motor pathways can be damaged
easily during a rhizotomy and that this could be why the
degree of recovery of function varied between studies.
92 Part I • Foundation of Hand Skills
Despite the previous diversity in results, there are
also similarities. Several investigators have found that,
when forced to, the animals are able to use their
deafferented limb. Animals that had both forelimbs
deafferented regained function to a higher degree than
those with only one deafferented forelimb, who could
choose to use the normal hand. This latter effect has
been called learned nonuse by Taub and Berman
(1968) and was explained in terms of an inhibition of
the deafferented limb. However, if the animals that had
one limb deafferented were forced to use it because the
normal limb was restrained, they recovered function to
the same degree as the bilaterally deafferented animals
(Bossom, 1974; Knapp et al., 1963).
Yet another similarity among the reports is that the
deafferented monkeys were capable of both initiating
and carrying out motor acts, however uncoordinated.
Studies of humans with sensory deficits seem to con-
firm this. Gordon and Ghez (1992) described patients
with large-fiber sensory neuropathy in the following
way:
“These patients, although able to initiate and carry out complex
movement sequences, were severely impaired in most functional
activities. For example, none could drink water from a cup
without spilling.”
The experiments by Ghez and co-workers (1990)
provide us with important information about the role
of proprioception in reaching movements. They
studied the reaching movement in patients with
sensory loss caused by large-fiber neuropathy. Without
visual feedback the patients made large directional
errors from movement onset and also were unstable at
movement endpoint. When allowed to monitor the
movement visually, they were able to substitute for the
loss of proprioceptive information to some degree, and
performance improved. However, Ghez and co-
workers (1990) also studied the effect on movement
accuracy when the patients were able to look at the
limb before movement onset but not during the
ongoing movement and found that this also improved
function. This indicates that proprioception is not only
important for feedback during the ongoing movement
but also plays an important role for programming of
movements by providing the nervous system with
information about the current state of the body parts.
I NTEGRATION OF SENSORY I NFORMATION
When we reach for an object both vision and pro-
prioception provide information about hand position,
and this information must be integrated to generate
one single estimate of where the hand is in space (van
Beers, Wolphert, & Haggard, 2002). This means that
the visual and proprioceptive systems have to be in
correspondence with each other. One example of when
they are not integrated involves wearing a pair of
displacing prisms. If we then reach for an object, we
perceive the object at a location displaced from its
virtual position, and the reach is directed to this
erroneous position. However, reaching actively toward
the object several times rapidly reintegrates the visual
and proprioceptive systems, and within a few minutes
adaptation has occurred (Harris, 1965). This also can
be experienced when one puts on a pair of new glasses.
The distance to the ground seems to be changed, and
it takes some minutes of walking before the visual
system again is in agreement with the proprioceptive
system.
A recent study by van Beers and co-workers (2002)
suggests that the extent to which vision and proprio-
ception contribute to the control of reaching move-
ments depends on the task. The brain weighs the
information from each modality in a way that mini-
mizes the uncertainty in perceived position. This sug-
gests that we cannot say that one modality dominates
the other and that the situation is better described as a
flexible weighing of information from the modalities to
obtain movement precision.
DEVELOPMENT OF REACHING
DURING INFANCY
BEGINNING TO MASTER THE REACH
Observing a newborn baby’s arm movements, one might
perceive them as random, performed without meaning.
However, even at birth the infant is capable of move-
ments that require some degree of sensory motor inte-
gration. Von Hofsten (1982) placed 5-day-old infants
in a semireclining seat that gave good support to the
trunk and head but allowed free movement of the
arms. The infants were presented with a colorful tuft
that moved irregularly and slowly in front of them. The
infants’ arm movements were recorded with two video
cameras, making it possible to calculate the arm trajec-
tory in three-dimensional space. All infants noticed the
tuft and were able to follow it with eye and head
movements for varying periods. The infants’ forward
extended arm movements, as well as looking behavior,
were analyzed. When the infants were fixating the tuft,
they aimed their reaching movements closer to it than
when looking in another direction or closing their eyes.
Thus a child only a few days old already has a rudi-
mentary visual control of arm movements. Moreover,
when initiating an aimed movement toward a visually
fixated target, the infant must “know” where its arm is.

Because the neonate is fixating the target, the starting
position of the hand must be defined proprioceptively.
This indicates that the visual and proprioceptive spaces
are to some degree already connected in the newborn
infant. However, even though the infants aimed their
reaching movements closer to the object while fixating
on it, most of the time they did not touch it. Also, at
this early age, even if they did touch the object, they
were not capable of grasping it. Several months of
experience of its the own body and with the environ-
ment still remain before the infant starts to become
successful at reaching, at around 4 to 5 months of age
(Gesell & Ames, 1947).
COORDINATING THE BODY PARTS I NVOLVED
IN THE REACHING MOVEMENT
Before the infant can reach for and grasp an object he
or she must learn to coordinate the movements of the
shoulder, arm, and hand. This complicated task of
controlling movements over several joints, and accord-
ingly a great number of movement possibilities, has
been designated as the degrees of freedom problem
(Bernstein, 1967). One solution to this problem is to
reduce the degrees of freedom by keeping some of the
involved joints in a stiff position. This also seems to be
the strategy used by infants as they first start to reach
for objects. Berthier and colleagues (1999) found that
beginning reachers mainly use shoulder and torso rota-
tion to move the hand to the target, while the elbow is
kept in a stiff position. This reduces the complexity of
the movement and thus increases the infant’s chances
of successfully capturing the object. However, an obvious
limitation of this strategy is that it restricts the infant’s
possibility of placing the hand in an optimal position
for grasping.
Postural stability is yet another foundation for reaching
movements. Van der Fits and colleagues (1999), who
studied postural adjustments during arm movements in
infants, found that when infants first start to reach
successfully for objects the arm movements are
accompanied by a large amount of postural activity.
Already at this young age the pattern of activation
showed some resemblance to that seen in adults, with
an activation of the dorsal muscles before the ventral
and a top-down recruitment of muscles. With increasing
age the pattern of activation became more organized.
Yet another study demonstrating the linkage between
the development of posture and reaching was carried
out by Rochat (1992). When the infants started to
reach for objects, they tended to use both hands and
later in development acquired one-handed reach. A
successful object-oriented reach in a young infant is
symmetric and synergistic with the hands meeting in
Reaching and Eye-Hand Coordination • 93
midline. Older infants often display an asymmetric one-
hand reach. He reported that when infants first attained
the ability to sit without support they shifted toward
reaching more with one hand so that the other could
be used to maintain balance. Hopkins and Rönnqvist
(2002) studied reaching behavior in infants aged about
6 months who were not yet able to sit without support.
They compared the quality of the reaching movements
when the infants were provided with firm postural
support and when they were sitting in a commercially
available chair. That the firm postural support resulted
in a decrease in the number of movement units
indicates that this extra support improved the reaching
behavior. Clinical observations made by Grenier
(1981) also indicate that postural control is important
for coordinated arm movements and that if infants are
supported appropriately at the neck and trunk they can
perform coordinated arm movements at a much earlier
age than is typical.
Postural control does not only act by maintaining
balance after it has been perturbed. We also have the
ability to anticipate an upcoming situation that will
perturb our balance and prepare ourselves by means of
postural adjustments. There is some evidence that this
anticipatory mode of counteracting upcoming forces
on the body starts to operate during the first year of
life. Von Hofsten and Woollacott (1989) showed that
at 10 months of age children activated the muscles of
the trunk before making voluntary arm movements.
The integration between posture and voluntary control
is an important prerequisite for coordinated arm and
hand movements. Little is known of how children with
motor impairments can integrate voluntary movements
and posture, but it is possible that this is one con-
tributory factor in these children’s fine motor
disturbances.
MOVEMENT PLANNING
As discussed, the reaching movement can be analyzed
in terms of acceleration and deceleration. A phase of
acceleration followed by a phase of deceleration then
constitutes a movement unit. When the infants first
start to reach and grasp, at around 4 months of age, the
ability to plan the movement ahead of time is still poor.
As a consequence of this, the movement path is awk-
ward and crooked, and the trajectory consists of many
movement units. This changes after the infant has
practiced reaching for some time, and at around 1 year
of age the number of movement units has decreased
and the movement paths are straighter (Konczak &
Dichgans, 1997; von Hofsten, 1991) (Figure 5-2).
The ability to plan movements ahead of time, and
not only react to what has already happened, is funda-
mental for movement skill. One example when this is
94 Part I • Foundation of Hand Skills

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
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
the point where the hand and the object will meet
(Figure 5-3).
The ability for anticipatory control develops sub-
stantially during the first year of life. One example of
this is how the infant prepares the hand for the grasp.
An adult reaching for an object shapes the hand to fit
the properties of the object in anticipation of con-
tacting it. Von Hofsten and Rönnquist (1988) studied
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,
which indicates some anticipatory ability. However,
these young infants did not adjust their grip aperture to
match the object size, as did children at 9 months of
age. At 13 months of age the infants started to close
the hand earlier during the reach compared with the
younger children and were comparable to adults in this
respect. Infants 10 months of age also have been found
to shape their hand to fit different shapes of objects
before contact (Pieraut-Le Bonniec, 1990).
05:57:91
Figure 5-3 Two views of the performance of a well-
aimed reach by an infant who is 21 weeks of age. The
frame on the bottom is the start of the reach. The interval
between frames is 0.2 sec (digital clock reading in the
upper portion of each frame). The child is directing the
reach ahead of the object to the point at which the
object will be at the end of the reaching movement.
(From von Hofsten C [1980]. Predictive reaching for moving
objects by human infants. Journal of Experimental Child
Psychology, 30:369–382.)
When we as adults reach for an object the movement
trajectory is not only affected by the size and shape of
the object but also by what we intend to do with it after
we have picked it up. We reach more slowly for an
object that will be used in a precision task (e.g., fitting
a coin in a slot) than for an object that will be used in
a nonprecision task (e.g., throwing the coin in a
bucket). Claxton, Keen, and McCarty (2003) studied
10-month-old infants to see if they also had this ability
to plan a reaching movement in several segments. The
 Reaching and Eye-Hand Coordination • 95

infants were encouraged to reach for a ball and then
either throw it into a tub or fit it into a tube. Infants,
like adults, reached for the ball faster if they were going
to throw it as opposed to fit it into the tube. This shows
that infants have an ability to take several steps into
account when planning an activity. However, they did
not show the more sophisticated signs of movement
planning that adults do, such as a prolonged decelera-
tion phase when reaching for an object that will be used
in a precision task.
discussed in the preceding section suggest that young
infants are able to use proprioceptive information and
integrate it with visual information when reaching for
objects. A similar result was found when reaching was
studied in children 6, 7, and 8 years of age, in a
situation in which the amount of visual information was
varied. The children seemed to use visual information
for control of arm movements in a manner similar to
that of adults, although with less accuracy and speed
(Rösblad, 1998).

ROLE OF SENSORY I NFORMATION MOVEMENT-TO-MOVEMENT VARIABILITY

As discussed, visual information of the hands as well as
the goal is necessary for movement accuracy. However,
to a great extent we are able to replace visual infor-
mation with proprioceptive and tactual information if
the hand for some reason is out of sight or if we reach
in the dark. Clifton and colleagues (1994) have in a
series of studies investigated the ability in infants to
reach for objects in the dark They showed that 6- to
7-month-old infants could contact sounding objects
(Perris & Clifton, 1988) and that infants of 6 months
could successfully reach for glowing objects (Clifton et
al., 1994) and also reach for glowing objects that were
moving in the dark (Robin, Berthier, & Clifton, 1996).
For many years it has been assumed that young infants
are more dependent on visual information for control
of reaching movements than adults, and that their
ability to use proprioceptive information for movement
control is poor (Piaget, 1952). However, the studies
The infant has not yet learned the most efficient way
of performing a movement and is still exploring the
possibilities of its own body. Therefore he or she will
perform a specific task, such as reaching for a toy, with
significant movement-to-movement variability. In fact,
being able to perform a specific task in a consistent
manner is a prominent feature of movement skill.
Figure 5-4, A shows the superimposed movement
trajectories of a 1-year-old girl reaching for an object.
In Figure 5-4, B the same task is performed by an 11-
year-old boy. Although the little girl grasps the object
without difficulty, it is clear that she does not reach for
the object with the same skill as the older boy does.
Lhuisset and Proteau (2004), who studied reaching
movements in children 6, 8, and 10 years old, found
that although the children clearly planned the move-
ments ahead of time, the planning processes were still
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.)
96 Part I • Foundation of Hand Skills
REACHING IN CHILDREN WITH
MOTOR IMPAIRMENTS
We still have limited knowledge concerning the ability
to plan and control reaching movements in children
with motor impairments. However, the knowledge we
have from research carried out on normally developed
children and adults can be used when asking questions
about children with motor impairments. This section
provides examples from this line of research.
MOVEMENT PLANNING
A common finding in motor control research on
children with motor impairments is that the ability for
movement planning is impaired. One example of how
the ability to plan reaching movements can be impaired
comes from a study on reaching in children with
attention deficit hyperactivity disorder (ADHD)
(Eliasson, Rösblad, & Forssberg, 2004). To analyze the
kinematics of the arm movement we used a digitizing
tablet. The task for the children was to move a cursor
on a computer screen with a hand-held digitizer on the
tablet. Start and target positions on the screen were
always visible during the movement. The screen cursor,
however, could either be visible throughout the entire
movement or blanked at movement initiation. Analysis
showed that movement control was impaired in
children with ADHD and that their problems were
especially pronounced when the screen cursor was not
visible on the screen. Because the children could not
visually correct the movement when the screen cursor
was blanked, results indicate a poorer motor pro-
gramming in children with ADHD. Moreover, the
children with ADHD performed jerky movements with
higher peak accelerations than the control group of
children. As discussed earlier in this chapter, the choice
of movement speed is crucial for how skillfully we
manage to reach for and grasp an object. The children
with ADHD adopted higher movement speed com-
pared with the typically developed children but this
high speed was counterproductive and resulted in
increased movement endpoint errors and further
corrective movements.
Similar results also have been found when the con-
trol of reaching movements in children with develop-
mental coordination disorder (DCD) has been studied.
Van der Meulen and colleagues (1991a,b) tested the
ability in children with DCD to make precise arm
movements. In a first study, the task for the child was
to reach for a target as quickly and precisely as possible.
In a second study, the ability to track a target that
moved unpredictably was assessed. In both studies, the
children were tested in situations in which they did or
did not receive visual feedback of the moving arm.
Movement analysis indicated that the less efficient move-
ments of the children with DCD could be explained by
a less developed ability for anticipatory control.
FEEDBACK CONTROL OF REACHING
MOVEMENTS
Although it is a common finding that children with
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
with myelomeningocele (MMC) to control reaching
movements (Norrlin, Dahl, & Rösblad, 2004). As in
the study on children with ADHD discussed in the
preceding section, we used a digitizing tablet linked to
a computer. Results showed that the ability to program
reaching movements was similar in individuals with
MMC and a control group of children. In both groups
the velocity profiles were bell-shaped and also scaled
proportionally to target distances, indicating efficient
movement planning. The movement problems in the
MMC group seemed to be related to the execution
of the ongoing movement. The subjects with MMC
showed more problems when they were provided with
visual feedback during the entire movement, and thus
being given the opportunity to make visual corrections
of the trajectory. This suggests that the commonly
occurring visual perceptual problems in individuals
with MMC may contribute to their poor spatial move-
ment precision.
Kearney and Gentile (2002) performed a small but
interesting study, on prehension in young children with
Down syndrome. They compared the performance of
3-year-old children with Down syndrome (only three
children were included) with 2- and 3-year-old typically
developed children. The children with Down syndrome
scaled the peak velocity to movement distance, which
indicates ability for movement planning. However, they
differed from both groups of typically developed
children in that they performed the final part of the
reaching movement with reduced efficacy, which
indicates that these children mainly have problems with
feedback control of the reaching movement.
ADAPTATION OF REACHING MOVEMENTS
Our sensory motor system is highly adaptable. When
we use a computer mouse we get used to the specific
gain of that mouse and take this into account when we
program the movements of hand that will transfer the
mouse. If the gain of the mouse is changed we will
under- or overshoot the target on the computer screen,
but only a few times. The nervous system modifies the

programming of subsequent movements to prevent
errors and motor adaptation occurs rapidly. Motor
adaptation involves changes in the control of move-
ments and can be seen as short-term learning. In
everyday life we rapidly and frequently adapt our move-
ments to changing conditions, such as when we switch
to new cars with different transmission in the steering
system or simply when we switch to a light hammer
after having used a heavy one.
Again, using the described experimental setup with
a digitizing tablet linked to a computer, we investigated
the ability in subjects with MMC to adapt reaching
movements to a new visuomotor gain (Norrlin &
Rösblad, 2004). This was done by first letting the sub-
jects perform reaching movements at targets displayed
on a computer screen. After having performed a
number of trials (around 100) we changed the gain of
the mouse. Directly after this gain change both the
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
same accuracy as before the change. However, the
subjects with MMC needed considerably more time for
short-term learning to occur and they had still not fully
adapted after 30 trials with the new gain. However,
when an unexpected gain change back to the initial
condition was introduced after these 30 trials, both
groups undershot the target. This indicates that some
adaptation had occurred also in the children with
MMC. More knowledge about the capacity for motor
learning in children with motor impairments, as well as
knowledge about the best conditions for learning,
would be of great value when planning interventions.
THE MOVEMENTS OF THE ARMS ARE
COUPLED IN C HILDREN WITH H EMIPLEGIC
C EREBRAL PALSY
A specific problem faced by children with hemiplegic
cerebral palsy is that the movements of the arms and
hands often are coupled. If the child is engaged in
manual activities with one hand mirror movements
frequently can be observed in the other hand. Typically,
reaching movements in children with hemiplegia are
performed with lower velocity in the impaired arm than
in the unimpaired arm (Van Thiel & Steenbergen,
2001; Volman, Wijnroks, & Vermeer, 2002a,b).
However, symmetric movements of the arms tend to
improve the movement quality of the impaired hand,
measured as speed and smoothness, but restrict the
movements of the unimpaired hand, which adapts to
the impaired one and accordingly moves more slowly
(Utley & Sugden, 1998; Van Thiel & Steenbergen,
Reaching and Eye-Hand Coordination • 97
2001; Volman et al., 2002a). If the arms and hands are
to make asymmetric movements, the movement
control problems are amplified. A commonly occurring
situation is that we reach out for and grasp an object
with one hand while the other hand is occupied with
holding another object. The effect that the mirror
movements may have on the quality of reaching
movement is yet to be investigated.
When discussing results from studies of children
with motor impairments, we point out that the varia-
tion within one specific diagnostic group is large. The
movement problems within one diagnostic group
could not be explained by one specific factor; however,
the knowledge obtained from studies carried out on
both normally developed children and children with
motor impairments can provide us with knowledge
about which processes might be disturbed and what to
look for when assessing children.
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COGNITION AND MOTOR SKILLS
Ashwini K. Rao
“Perhaps the most incomprehensible thing about the world is that it is
comprehensible.”
Albert Einstein
CHAPTER OUTLINE
CASE SCENARIO
MOTOR SKILLS ARE ADAPTIVE
What Is the Overall Framework for Understanding
Movements?
INTRODUCTION TO COGNITIVE CONTRIBUTIONS TO
MOTOR SKILLS
COGNITIVE PROCESSES IN MOTOR SKILLS
Attention
Perception
Concept Formation (Knowledge)
Memory
SKILL ACQUISITION (LEARNING)
EPILOGUE: RELATIONSHIP BETWEEN COGNITIVE
AND MOTOR DEVELOPMENT
SUMMARY
Through the course of evolution, the importance of the
hand to the organism has increased tremendously. We
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
importance of hand skills in humans is reflected in an
increase in the area of the brain dedicated to hand
movement. In addition, cognitive capacity (broadly
defined as the collection and organization of informa-
tion into knowledge) has increased through the course
of evolution. This is also reflected in the increase in size
of frontal lobe structures in humans when compared
with nonhuman primates.
Chapter 6
Although the extent of brain structures has
increased along with our functional repertoire of hand
and cognitive skills, this in no way implies that there is
a simple cause-and-effect relationship between brain
and behavior. In fact, research on the neural control of
movement has shown that although specific areas of the
brain are involved in the control of hand movements,
the performance of movements in turn influences de-
velopment of the same neural structures. Thus struc-
ture (brain areas involved in hand control) and function
(behavioral repertoire of manipulative skills during
functional tasks) are intertwined and influence each
other through development.
Manipulation skills are some of the most complex
motor skills and require the coordination of many
systems. Within the motor system, manipulative skills
require the coordination of many different segments of
the body that allow for adapting the hand to grasp dif-
ferent objects and application of precise amounts of
force on objects that allow for successful manipulation
of objects during functional activity (Flanagan,
Haggard, & Wing, 1996). Coordination becomes even
more complicated when we consider the cognitive
components (e.g., memory, attention, perception) that
have to work in concert with the emerging motor skill.
CASE SCENARIO
Consider this simple scenario. Jimmy, a 2-year-old
typically developing child, is sitting at a table, reaching
out to grasp a glass full of water so as to bring it toward
his mouth. This simple functional act, one that is
carried out by children with seemingly effortless ease,
nevertheless is extremely complicated and poses several
challenges to a developing system such as Jimmy’s. This
101
102 Part I • Foundation of Hand Skills
task highlights the numerous processes that can be
categorized as cognitive-perceptual aspects of motor
control.
Even before beginning the movement of reaching
for the glass, Jimmy’s visual processes provide his
nervous system with tremendous information about
the glass: how far the glass is from him, where the glass
is placed on the table with reference to his body, the
shape of the glass, how much water is in the glass, the
consistency and estimated weight of the glass. The
responses to these questions constitute processes called
perception and representation. In addition to these
perceptual processes, the association of visual input
from the glass with symbols about objects provides
information that is stored as object knowledge, useful
for identification and classification. This information is
stored in memory, which can be retrieved at any time.
Furthermore, the size and apparent weight of the glass
determine whether Jimmy picks up the glass with one
or two hands. Such decision making is based on
memory of prior interactions with objects.
Once Jimmy grasps the glass, his visual and haptic
(tactile) processes provide his system with information
about the weight of the glass and how the movement
of bringing the glass to his mouth displaces the water
in the glass. As Jimmy repeats the process of grasping
glasses of various sizes, shapes, and weights, and
transporting the glass toward his mouth on different
occasions, his nervous system internalizes rules about
how his movement affects the liquid in the glass
through a process of trial and error. This process is
called learning and is an essential cognitive skill that
enables Jimmy not only to retain the knowledge of how
to grasp and lift a given glass, but also generalizes
(transfers) this skill to enable successful interactions
with various objects.
MOTOR SKILLS ARE ADAPTIVE
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
intentional, goal directed, organized, and adaptive.”
This description highlights a few important aspects of
motor skills that are particularly important for
manipulative skills:
1. The intentional nature of movement indicates a
process of planning, which involves cognitive
processes
2. The precise nature of movements indicates that
movement execution needs to fulfill constraints of
the task, and
3. Goal directed indicates that movements, in general,
are executed to accomplish a particular action.
There are instances in which the goal of the action
is a specific set of movements, as in a dance
performance. In this chapter, however, we are
concerned primarily with manipulative skills that are
executed to achieve an action goal (e.g., feeding,
object manipulation, writing).
WHAT IS THE OVERALL FRAMEWORK FOR
U NDERSTANDING MOVEMENTS?
Movements are one of the primary means by which
humans interact with the environment and act on the
environment. Thus an understanding of movement has
to take into consideration an understanding of the
nature of the environment in which movements take
place. Shumway-Cook and Woollacott (2001) have
suggested that movement emerges through an inter-
action of the performer (including biomechanical con-
straints of our musculoskeletal system), the task (which
can range from body stability to manipulation), and the
environment. According to Gentile (2000), the struc-
ture of a task determines the demands placed on the
performer. Given that different tasks pose different
challenges for the performer, it is imperative to begin
with an understanding of tasks. Gentile proposed an
analysis of tasks that categorized tasks based on their
functional role and the environmental context (Gentile,
1972). Based on the functional role, tasks can either
specify body orientation (which includes body stability
and body mobility) or manipulation of objects. With
reference to environmental context, tasks can be
categorized as those that are performed in closed
environments, which remain stable from trial to trial, or
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
pose, and also as a basis for evaluation and intervention
in clinical practice (Gentile, 1992, 2000).
INTRODUCTION TO COGNITIVE
CONTRIBUTIONS TO MOTOR
SKILLS
The importance of cognition in motor skill acquisition
and development is well established. However, the
reverse also has been proposed: that perceptual motor
activity is a mechanism for cognitive development.
However, the importance of cognition to motor skills
depends on the theoretical orientation that is used.

Some of the major theoretical orientations in the
literature are the Piagetian approach (Piaget, 1952),
the behaviorism approach of Skinner (1953), the eco-
logical approach of Gibson (1979) and more recently,
the information processing approach that has been
reformulated within the relatively new discipline of
cognitive neuroscience (Gentile, 2000; Thelen, 1995).
Each of these approaches is discussed briefly. For the
purpose of this chapter, the cognitive neuroscience
approach is used.
Piaget considered that motor activity was necessary
to the development of knowledge about the environ-
ment. Knowledge development was believed to be a
function of the interaction between neural structures
and the environment. According to Piaget, cognitive
functions develop through knowledge gained as a result
of action, which early in development is based on
innate reflexes (Piaget, 1952). Based on this approach
Piaget proposed a stage-like developmental process in
which new skills are learned based on skills previously
learned in development. For Piaget, infant motor
activity played a major role in cognitive development.
Object manipulation was believed to be critical for the
child’s learning about object properties. The manip-
ulation of objects is important as a way of facilitating
mental activity, which is believed to be the key for
learning object characteristics. Overall, in this approach,
cognitive-neural development is thought to play an
important role in development of skills, whereas factors
outside the performer (i.e., the environment) are not
emphasized.
This is in stark contrast with the behavioral approach,
pioneered by Skinner and his colleagues, which em-
phasized the role of reinforcement from the environ-
ment as a primary driving factor in development
(Skinner, 1953). Development, according to this
framework, occurs through the responses of the
performer and the reinforcement she or he receives
through the environment.
One approach that differed from these two
approaches was proposed by Gibson (1979). In this
approach action is not a precursor to perception. Rather,
perceptual information is actively sought through coor-
dinated systems of action, some of which are already
functioning in this capacity at birth. This approach
proposed that most of the information needed for the
control of motor skills was contained in the flow of
sensory afference (visual or haptic). Development was
thought to be a process whereby the performer learns
not so much to improve his or her movement skill per
se, but to learn to use the information contained in the
sensory flow. Although this approach explained some
of the behaviors seen during development, it did not
highlight the role of neural structures in the devel-
opmental process.
Cognition and Motor Skills • 103
The emerging approach in motor development is
one that developed out of the information processing
theories and current theories in motor control. Much
of this approach was influenced by Bernstein, a Russian
physiologist, who proposed that movements emerge
through the interaction among the performer, the
impact of movements made by the performer, and the
environment (Bernstein, 1967). Within motor devel-
opment, the application of this approach was pioneered
by Esther Thelen (1995). In this approach, movements
are proposed to emerge through the cooperative
interaction of many body parts and the environment,
rather than from a one-to-one mapping between neural
structures and movements. Because movements are
slightly different from trial to trial (even when the same
muscles are activated), Bernstein proposed that actions
were planned at a more abstract level. This is par-
ticularly true because it is impossible for the nervous
system to program all the force-related contextual
interactions ahead of time. Thelen (1995) argued that
cognition and motor skills emerge from a dynamic
process in which the performer learns the match among
herself, her movements, and the environment and how
the various component parts are coordinated to pro-
duce skillful movement. Thus early in the development
of a skill, a high degree of variability is seen in the
behavior. Rather than seen as an undesired outcome,
variability is seen as functional, and is exploited in
the generation of solutions. With development, the
macrostructure of the movement (the visible motor
output) becomes less variable and more stable, but this
stability arises as a result of maintaining variability at a
microstructural level, which refers to the forces gen-
erated and the patterns of muscular contraction
(Manoel Ede & Connolly, 1995).
With this framework in mind, we explore the dif-
ferent constituents of cognitive skill and their relation-
ship to motor skills. Although an attempt is made to
present the most pertinent and current literature on
infants and young children, at some points results from
adult studies are presented when little or no evidence is
available from the developmental literature.
COGNITIVE PROCESSES IN
MOTOR SKILLS
In this section, we discuss a few important components
of cognition critical to the successful generation of
motor skills. Attention, perception, concept formation,
memory, and learning are briefly discussed. Although
each component is discussed separately for clarity, one
should understand that in the development of motor
skills, many of these components interact with each
104 Part I • Foundation of Hand Skills
other and may assume differential importance depend-
ing on the demands of the task.
ATTENTION
Attention is a fundamental aspect of all human activity.
We are able to perceive stimuli and act on them better
when we attend to the stimulus of interest and ignore
extraneous stimuli. Our sensory systems receive a
tremendous amount of information. If we did not have
a mechanism to filter unwanted stimuli, we would
encounter sensory overload. At any given moment, we
are aware of only a few stimuli that are functionally
important to the task at hand, and our awareness is
limited by our capacity for processing information.
Thus functional attention is selective by definition.
Attention can be defined by examining its con-
stituent parts of arousal, capacity, and selectivity (Plude,
Enns, & Brodeur, 1994). Arousal refers to the momen-
tary level of excitation in the information processing
system that helps tune our cognitive systems to
optimally receive information. Capacity refers to the
actual capacity of our information processing system. It
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
resources so as to focus on certain stimuli and not
others.
Selective attention is a multidimensional process,
involving components of orienting, filtering, searching
and expecting (Plude et al., 1994). From an early age,
infants show preference for orienting their vision to
attend to certain stimuli while ignoring others (Maurer
& Lewis, 1991). In fact, neonates spend more time
attending to their mothers’ face than the faces of
strangers, even when other sensory cues, such as smell
and auditory cues, are excluded (Bushnell, Sai, &
Mullin, 1989). The orienting response is variable and
not developed early in life, presumably because the
neural structures that control such behavior (e.g., the
superior colliculus) are not fully developed. Neverthe-
less, the evidence suggests that infants demonstrate
beginning capabilities for selective orientation to
preferred stimuli.
Another aspect of selective attention is that infants
show a preference for novel stimuli rather than stimuli
that have been present in the environment. Most of us
have observed infants paying more attention to new
faces in comparison with familiar faces. This phenom-
enon is known as habituation and refers to the decrease
in the amount of visual attention (time spent on a
stimulus) devoted to more familiar stimuli (Bertenthal,
1996; Ruff, 1986). Ruff found that the amount of time
spent in examining novel stimuli decreases as the infant
becomes familiar with an object and suggests that the
time spent on novel stimuli may be influenced by the
arousal properties of the object.
Although infants have some capability in orienting
to stimuli, as shown in the preceding paragraphs, their
ability to devote attention resources to actively search
for objects of interest does not develop until early school
years (Cohen, 1981). Similarly, the skill of paying
attention to stimuli that has already been experienced
develops during the early school years. This phenom-
enon, known as priming, refers to the fact that we are
able to better attend to stimuli that has been presented
before, even if for a short period of time. Priming also
explains how certain stimuli are recalled easily because
of prior exposure (Plude et al., 1994).
To summarize, attention is a fundamental aspect of
cognitive skills that is related to perception and
memory. When we consciously attend to a sensory
stimulus, our perception is matched to information
stored in our memory (priming or recognition). Atten-
tion is an active process in which certain stimuli in the
environment are given preference over others depend-
ing on their perceived importance to the demands of
the task being performed.
PERCEPTION
Perceptual processes constitute an important part of
cognitive contributions to motor skills. Perception can
be defined as a process of collecting information from
the environment based on vision, touch, hearing, and
muscle and joint proprioceptors to construct an
internal representation of space and the body (Kandel,
2000). Thus our perception is created through an
active process of searching for and attending to stimuli
based on our sensory organs. All pertinent information
is then used in the construction of an internal
representation.
Historically, perception was thought to emerge from
a developmental process as infants and young children
developed their repertoire of sensorimotor behaviors
(Piaget, 1952). The current view, however, challenges
this notion and proposes that different sensory inputs
converge into a unified representation that precedes
thought and action (Marr, 1982). The emerging
framework from the cognitive neurosciences proposes
that there may be at least two independent and parallel
perceptual processes: one that is used in the recog-
nition of objects and the other used for the guidance of
movements (Goodale et al., 1994). Thus visual infor-
mation about an object in the environment is processed
by separate neural pathways and used for different
purposes (Bertenthal, 1996; Goodale & Westwood,
2004). The system for the identification of objects, also
called the ventral stream, is proposed to project from
the visual cortex to the temporal lobe. The system for

action, also called the dorsal stream, is proposed to
project from the visual areas to the posterior parietal
cortex. Although most of the evidence for this proposal
comes from neurophysiological studies from non-
human primates, neuropsychological studies in humans
with focal cortical lesions, and imaging studies in adults
(Goodale & Westwood, 2004), some authors have
proposed that such a dissociation may be present
during development (Johnson, 1990).
There are fundamental differences in these two
subsystems that support the notion that they operate
independently. First, the system for the guidance of
movement is proposed to work in a prospective manner
because actions are directed toward information
present at the time. Von Hofsten has argued that
actions occur through dynamic interactions between
an organism and the environment that occur in a
future-oriented manner (von Hofsten, 1993, 2004).
For example, in reaching for objects, infants begin to
crudely adjust the orientation of their hand to match
the orientation of the object even before grasping the
object of interest (von Hofsten & Fazel-Zandy, 1984).
Such adjustments are made in an anticipatory (pro-
spective) manner to maximize success at reaching
objects. This is in contrast with the system that is used
for object identification in which the information is
retrieved from a representation that is stored in
memory (Goodale et al., 1991, Goodale et al., 1994).
Second, the difference between these systems per-
tains to the manner in which the information is struc-
tured in the brain. All sensory information is structured
and represented in a format of coordinates called a
coordinate system. Although the information used for
perception and identification of objects is structured in
a coordinate system centered on the environment (or
world centered), information that is used for the guid-
ance of movement is structured in body coordinates
(Goodale & Westwood, 2004). This is because percep-
tion of objects requires that the observer be able to
identify object features correctly independent of his or
her position vis-à-vis the object. In contrast, sensory
information used for guidance of movement is structured
in body centered coordinates (Soechting & Flanders,
1992). This is because sensory information used for
movement ultimately has to be converted into patterns
of muscle activation that will move the arm to the
desired object. Because specification of movement
parameters ultimately has to match egocentric coordi-
nates of muscle action, it seems likely that such infor-
mation is stored in body-centered coordinates.
Third, these two systems also differ in terms of the
nature of conscious processing involved. The system
that deals with object perception and identification
processes visual information in a conscious manner
because the observer is required to actively attend to
Cognition and Motor Skills • 105
the stimulus. In contrast, the system that deals with
guidance of movement processes information sub-
consciously. We are not conscious about processing
sensory information when manipulating objects. Per-
haps the best evidence for this dissociation comes from
studies of patients with brain lesions who are unable to
perform conscious processing necessary in identifica-
tion of objects but nevertheless are able to reach out
and grasp them (Goodale et al., 1991). For instance,
patients with lesions of the ventral stream (pathways
from the primary visual cortex to the temporal lobe
structures) are unable to identify objects but are able to
reach out and grasp objects with problems. Patients
with lesions of the dorsal stream (the posterior parietal
cortex) show the opposite deficit: They are able to
identify objects but are unable to reach out and grasp
them (Goodale & Westwood, 2004).
Thus converging evidence from animal studies and
human lesion studies suggest that information for
perception and action are processed independently.
The system involved in perception perhaps develops
later as it involves conscious processing of knowledge
from memory, skills that develop as a child learns
language.
Perceptual-Motor Processes
We must perceive in order to move, but we must also
move in order to perceive.
(Gibson, 1979)
This statement, from one of the most influential
psychologists in the area of perception, highlights the
reciprocal relationship between perception and action.
According to Gibson (1979) perceptual systems have
adapted to use information pertinent to actions that
are readily available in the environment. For instance,
perceptual-motor systems use visual information avail-
able in the optic array, haptic information from hands
as they explore objects, and proprioceptive information
available from muscles and joints. Although move-
ments are adapted in response to perceptual processes,
the reverse is true as well. Such reciprocity was shown
in a study that tested crawling infants and recently
walking infants on their locomotion on two different
surfaces; a rigid and a pliable surface. Although crawling
infants did not differentiate between these two sur-
faces, recently walking infants changed their mode of
locomotion depending on the surface. They crawled on
the pliable surface and walked on the rigid one (Gibson
et al., 1987). More recently, it was shown that recently
walking infants adopt a more stable posture (sitting) as
they negotiate a surface with a downward incline,
whereas crawling infants did not adapt their posture
(Adolph, Eppler, & Gibson, 1993). These studies show
that perception (e.g., perceived stability of surface)
106 Part I • Foundation of Hand Skills
influences action and action in turn influences percep-
tion (e.g., newly walking infants differentiating among
surfaces).
Contrary to the proposals of early models of
perceptual-motor development (Piaget, 1952), goal-
directed behavior is observed very early in develop-
ment. Infants as young as 3 weeks old have been
observed to reach out and grasp stationary and moving
objects (von Hofsten, 1982). Neonates actively control
their gaze and look at faces that engage them in a
mutual gaze (Farroni et al., 2002), and visually track
moving objects within their first month (Bloch &
Carchon, 1992). Von Hofsten (1993) argues that behav-
iors that are explored in the womb (e.g., hand-to-
mouth behavior) may demonstrate an advantage after
birth. The evidence described in this section highlights
that infants are capable of goal-directed movements
based on visual information available in the environ-
ment (e.g., from a moving object). Although this
behavior is highly variable from trial to trial, and fragile
(it is not observed consistently), the existence of such
control provides evidence that our perceptual systems
are tuned to act on visual and haptic information from
a very early age. According to Thelen (Thelen, 1995;
Thelen & Corbetta, 1994), behavior is highly variable
when first expressed and is gradually adapted as a result
of a dynamic process of selection of the most appro-
priate coordinative structures that are specific to the
contextual demands of the task.
The contextual nature of perceptual-motor behavior,
in part, is dependent on the fact that motor skills are
not simply influenced by perceptual processes but also
by biomechanical and physiologic factors. For example,
although infants are able to reach for moving targets at
the age of 3 weeks, such behavior is contingent on the
stability of their head (von Hofsten, 1982). When
the head is not stabilized, goal-directed reaching is not
observed. In a now classic example of the contextual
nature of perceptual-motor behavior, Thelen and col-
leagues described the case of the “disappearing reflex”
(Thelen, 1995; Thelen, Fisher, & Ridley-Johnson,
1984). Infants are known to demonstrate a stepping
reflex when held upright with their feet on a supporting
surface. Within a few months, this “reflex” pattern
of movements is not seen. The traditional explanation
for the disappearance of this reflex was that the matur-
ing nervous system inhibited the reflex, a primitive
behavior. However, at the same time that the reflex dis-
appears, infants also demonstrate an increase in their
body mass. When such infants were held upright par-
tially submerged in water with their feet in contact with
a surface, the stepping reflex re-emerged, indicating
that the reflex “disappeared” primarily because of
increased weight and a biomechanically demanding
posture (Thelen et al., 1982; Thelen & Fisher, 1982)
rather than simply because of neuromaturational
factors.
CONCEPT FORMATION (KNOWLEDGE)
Concept formation refers to a higher-order mental
process that acts on information that has been per-
ceived through our sensory organs and encoded and
stored in memory. This process includes organization
of the information into conceptual categories and the
use of such knowledge in reasoning, problem solving,
goal selection, and planning. Through the process of
categorization, infants and young children begin to
form concepts about objects, people, and actions. For
instance, early in development, infants learn to
categorize faces as familiar and unfamiliar. As discussed
in an earlier section, infants are seen to spend more
time attending to faces that are familiar, such as the
mother (Bushnell et al., 1989). This indicates that
infants have already begun to categorize faces according
to their perceived familiarity.
Concepts (e.g., faces and objects) are units of mental
representation that assign certain perceptual features to
specific conceptual categories. Early in development,
we learn to differentiate between living and nonliving
objects, based on our ability to generate selfmotion.
This process becomes more complex as we learn to
differentiate subcategories within these categories of
living and nonliving objects. Knowledge organized into
such categories is encoded and stored in long-term
memory and retrieved during action.
Key elements of concept formation are the processes
of grouping and differentiation. Grouping involves the
clustering of information into larger units, a process
known as “chunking” (Gentile, 2000). Chunking helps
the system function more efficiently because the
performer has to attend to groups of information
rather than each piece of information separately. The
benefits of chunking perhaps can be seen best through
an example: Consider a child walking through his
classroom to his teacher. In performing this task, he
encounters numerous toys strewn across the floor, fur-
niture placed all over the room and a few peers running
around in the classroom. The process of chunking
allows the grouping of all stimuli into stationary and
moving objects; this way the child can perceive the
movement of his peers as a unit rather than attend to
the movement of each child individually. Grouping
reduces the attention demands of the task and allows
the child to allocate his attention to additional stimuli
(furniture) that are important.
Differentiation, on the other hand, refers to the
process through which performers perceive more detail
in an array of stimuli as they become more familiar with
it. To use the example cited in the preceding paragraph,

as the child begins to learn to walk, he will likely not
perceive the subtle differences in the speed of move-
ment of the moving objects in the environment. With
experience, he will learn to distinguish between stimuli
related to other children either walking or running.
Development of concepts and knowledge is extremely
useful for understanding the demands of the task and
goal completion. Early in the learning of a task, per-
formers should learn the relationship between move-
ment and the goal of the movement. Failure to
understand the goal of the task can lead to goal con-
fusion, which is commonly seen in elderly individuals
with memory disorders (Gentile, 2000). Specification
of the goal of the task has been shown to be critical in
improving the quality of movement (determined by
kinematic analysis) in unimpaired adults (Lin, Wu, &
Trombly, 1998; Wu et al., 1998) and individuals
recovering from a cerebrovascular accident (Wu et al.,
1998). Changing the goal of the task influences the
movement pattern selected. In a classic study
(Marteniuk et al., 1987) demonstrated that unimpaired
subjects reached for and grasped a disc differently
depending on whether the goal of the task was to place
the disc accurately in a container or to throw the disc.
Attention to the goal and knowledge of the relation-
ship between movement and its outcome (action) are
key components of concept formation pertaining to
hand skills.
In summary, concept formation is a conscious and
active process that categorizes sensory information
by associating it with conceptual categories. These
categories are stored in long-term memory and
retrieved in response to the demands of the task. As
stated earlier in the chapter, such information is
thought to be processed through ventral neural path-
ways projecting from the visual cortex to the temporal
cortex (Goodale, 1992).
M EMORY
Memory is the process by which knowledge is encoded,
stored, and retrieved (Milner, Squire, & Kandel, 1998).
The neurobiological pathways responsible for memory
are dependent on our sensory perceptual and attention
processes (discussed in the preceding sections) that
allow task-related information to be stored. Most models
of memory propose the existence of multiple systems
of memory, each devoted to a specific function
(Willingham, 1997). Memory can be classified in many
different ways: One is to classify it according to the
time scale of the operation. Thus we distinguish
between short-term (working) and long-term memory
systems.
Working memory is proposed to be a dedicated
system that holds information for short periods of time
Cognition and Motor Skills • 107
so that it can be manipulated during functional tasks.
According to Baddeley (2003), working memory is a
limited capacity system that supports thought processes
by providing an interface among perception, long-term
memory, and action. Working memory is proposed to
consist of at least three components: a central execu-
tive, and two storage loops; the phonological loop and
the visuospatial sketch pad. The central executive is
proposed to be the attention control system, which
regulates the function of the other two subsidiary
rehearsal systems. The central executive also serves as a
buffer that holds information temporarily. The phono-
logical loop contains a phonological store “which can
hold memory traces for a few seconds before they fade,
and an articulatory rehearsal process that is analogous
to sub-vocal speech” (Baddeley, 2003). The phono-
logical loop has a limited capacity that limits the amount
of information that can be held and manipulated at any
given time. Finally, the visuospatial sketch pad is also a
limited capacity rehearsal loop and mainly deals with
spatial information perceived through the visual system
(Baddeley, 1998). The function of the visuospatial loop
is to hold and manipulate visual spatial representations,
as seen in tasks that require mental rotation of images.
Most of the evidence supporting the model of
working memory comes from studies in unimpaired
adults and adults with focal cortical lesions. From a
developmental perspective, it seems likely that the
visuospatial sketch pad develops before the phono-
logical loop because the phonological loop is depen-
dent on language-based processes. Studies on the
development of working memory report age-related
differences in the speed with which words can be
articulated and differences in attention span (Hitch &
Towse, 1995). These age-related differences appear to
result from maturational factors (Cowan et al., 1999).
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
can be either explicit (or declarative) or implicit (pro-
cedural). Explicit memory is associated with conscious
awareness and the intention to recall information.
This form of memory typically is tested with recall or
recognition and underlies the memory for objects,
people, and events. Studies with infants have revealed
that they can retain memory for objects (as tested by
retention) across intervals of 1 to 3 months (Bahrick &
Pickens, 1995). Based on additional studies, Bahrick
and colleagues proposed that recent memories are
expressed as a visual preference for novelty, whereas
remote memories are expressed as a preference for
familiarity (Bahrick, Hernandez-Reif, & Pickens,
1997). However, younger children need greater num-
bers of prompts to recall memories compared with
older children.
108 Part I • Foundation of Hand Skills
Explicit memories are further divided into memories
for facts (semantic memory) and events (episodic
memory). Semantic memory is built up by associating
a stimulus with specific concepts. Thus a visual image of
an elephant associates features of the elephant (e.g., its
large size, large ears, tusks, and small tail) with the
conceptual category of “elephant.” This information is
then further associated with additional knowledge
about elephants that allows children to close their eyes
and recall an internal representation of an elephant.
Semantic memory is thought to be stored in a dis-
tributed fashion in the neocortex, including the medial
temporal areas that process verbal information and
occipital areas that process visual information. Episodic
memory, on the other hand, is concerned with the
temporal ordering of events. In children, this type of
memory is built up by associating events with what
happened during such events (Schneider, 2000).
Explicit memory is processed in four distinct phases.
The first phase is called the encoding phase, during
which new information is attended to and processed at
first encounter. All pertinent information in the
stimulus must be attended to for memory to be stored
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
interferes with this process prevents new and labile
information from being converted to long-term
memory. The third phase is storage, which refers to the
mechanism by which memories are retained over time.
Finally, the fourth phase is retrieval, which refers to the
process of recall of memories (Kandel, 2000).
Implicit memory, in contrast with explicit memory,
is concerned with storage and recall of information
without conscious awareness (Milner et al., 1998). This
kind of memory is also called procedural memory,
because it refers to knowledge about “how” a task is
performed, rather than “what” a task is. Implicit memory
does not depend on conscious processing of informa-
tion, builds slowly over time through repetition, and is
primarily expressed through performance rather than
through language (Kandel, 2000). Most of the early
evidence of the distinction between implicit and explicit
memories came from the study of individuals with focal
lesions of the medial temporal lobe. In one patient
(HM) most of the medial temporal lobes were removed
secondary to seizures. The surgical lesion left HM with
a memory deficit of explicit long-term memory,
particularly for facts and events that occurred after the
surgery and also a deficit of events that occurred
immediately before the surgery (retrograde amnesia).
Although he had a relatively intact short-term memory,
HM was unable to transfer information from short-
term to long-term memory (Milner et al., 1998).
Despite his devastating deficit in explicit (declarative)
memory, HM could learn new motor skills such as
mirror drawing (Milner, Corkin, & Teuber, 1968) or
novel patterns of arm movements (Shadmehr, Brandt,
& Corkin, 1998) comparable to age-matched unim-
paired subjects. Thus patients with temporal lobe
lesions are able to learn tasks that do not require con-
scious awareness and tasks that are procedural. These
studies have helped us understand that explicit and
implicit memories are independent systems, controlled
by different areas in the cortex (Milner et al., 1998).
For the developing child, it has been shown that
older children demonstrate an advantage for explicit
memories, whereas there is no specific age-related
difference in the formation of implicit memories. This
difference in the development of the two memory sys-
tems may result from the fact that sensory and per-
ceptual systems are developed early in life (as discussed
in the preceding section), whereas concept formation
(which is necessary for development of explicit
memories) continues to develop until the school years
(Bertenthal, 1996; Schneider, 2000).
SKILL ACQUISITION (LEARNING)
Learning is the process by which we acquire knowledge
about the world and ourselves. Skill can be defined as
consistently attaining an action goal with some
economy of effort (Gentile, 2000). Learning of motor
skills concerns a set of processes associated with practice
or experience, which leads to a relatively permanent
change in the ability of the performer to produce
movements (Shumway-Cook & Woollacott, 2001).
Box 6-1 highlights a few important concepts.
Learning is thought to progress in stages. Although
different models of learning have been proposed, most
models agree that different processes operate during
the early and late stages of learning. For the purpose of
this chapter, we discuss the two-stage model proposed
by Gentile (1992, 1998, 2000).
According to this model, in the early stages of
learning, the performer acquires the general concept of
the demands of the task and the movements that are
necessary to successfully achieve the goal. Part of this
process is to understand and attend to important
features of the action goal: This enables the performer
to focus on the regulatory features in the environment
and ignore the nonregulatory features. According to
Gentile (2000) the action goal concerns the function
of the task (whether the task requires manipulation or
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
capability for skilled action.
2. Learning results from practice or experience, rather
than being simply a function of neuromaturation.
Perhaps this concept is best highlighted by the fact that
infants practice tasks such as reaching (von Hofsten &
Fazel-Zandy, 1984) and locomotion (Adolph, 1997)
several hundred times in a day over a period of months
before they become skilled. This extended practice is
the basis for improvement of skill.
3. Learning is a process that cannot be observed directly
and typically is inferred from changes in behavior. As
discussed in the preceding sections, much of the
evidence on motor development has come from
detailed longitudinal observational studies in infants
and young children (Adolph, 1997; Thelen, 1995; von
Hofsten & Fazel-Zandy, 1984).
4. Learning produces changes that are relatively
the environment in which the action is taking place
(whether the environment is stationary or in motion).
Focus on the regulatory features necessitates selec-
tive attention to pertinent stimuli. During this process,
the performer’s system learns to differentiate the envi-
ronment (perceive greater detail in the sensory array)
and grouping of similar stimuli into chunks, a process
described earlier. During this phase, the child pays atten-
tion to the overall structure (shape or configuration) of
the movement. Thus in reaching for an object, a child
is aware of the orientation of her hand as it attempts to
approximate the orientation of the object for successful
grasp. Gentile (1992) terms this the topology or shape
structure of the movement. Although the performer is
aware of the topology, she or he is not aware of the
internal processes of parameter specification that specify
the timing of the movement components, the forces to
be imparted to the limbs, and so on. During this early
stage, based on the results of the movement, the child
receives feedback on the outcome of the movement.
This knowledge is then encoded and stored in memory
and helps the child learn the association between
movement patterns and their outcome. This process
enables children to repeat successful movements and
leads to the formation and refinement of internal
models (or representations) of the task.
Studies of infants learning to perform goal directed
reaching have demonstrated evidence for this notion.
Recording of the movement patterns of infants have
shown that early in learning, arm reaching movements
are extremely variable and the goal of reaching for and
grasping an object is not achieved consistently. How-
Cognition and Motor Skills • 109
permanent. This indicates that information acquired
through learning is stored in long-term memory, which
typically is retained over long periods of time.
5. Learning is task specific. A pattern of movement that
produces successful goal-directed interactions may not
be sufficient if there are changes in the environment or
in the morphology of the performer, as happens
continuously through development. Thus skill attained
under certain conditions can be generalized only to
other skills that share features with the original skill
learned. For instance, once a child learns to reach for
one stationary object, she or he can adapt this skill and
generalize it to successfully reach for stationary objects
of different shapes and sizes; however, this skill of
reaching for stationary objects does not necessarily
generalize to reaching for moving objects because such
a task poses different challenges to the system and
requires novel solutions.
ever, within a relatively short period of time, move-
ments converge to a consistent topology enabling the
child to achieve the goal more consistently (Konczak et
al., 1995; von Hofsten et al., 1984).
With refinement of the internal model, the abstract
representation of the movement and outcome becomes
independent of the actual environmental and bio-
mechanical constraints. For instance, in learning the
task of writing, a child acquires an internal model of
the task. In this case the movements of the hand (and
the forces applied) that produce the form (or topology)
of a letter. Once this model is learned, the child can
perform this task not only with the dominant hand, but
with the nondominant hand as well (although not as
efficiently because the nondominant hand is not as
skilled). The fact that we can produce the same action
using different effectors highlights the importance of
an internal model (abstraction) of the task that is
independent of the effectors.
Skill is refined during the later stages of learning.
Performance improves but at a much slower rate than
in the early stages of learning. In this phase improve-
ments occur in the efficiency of the movement: The
child is better able to predict the consequences of her
movement and better able to produce consistent move-
ments from one trial to the next. According to Gentile
(1998) this phase is characterized by changes that the
performer is not aware of. The changes pertain to the
parameter specification, and include improvements in
the timing of force generation of the segments involved
in the movement and the timing and amplitude of
muscle contractions that ultimately produce the
110 Part I • Foundation of Hand Skills
movements. In addition, movement sequences are
more efficiently blended together temporally so that
each sequence is not discernible from other sequences
of movement.
The evidence from recording of intersegmental
forces and patterns of muscle activation demonstrates
that improvements at this level of the system continues
over a much longer period of time (Konczak, Borutta,
& Dichgans, 1997). Although the topology of reaching
movement improves within the first few months,
improvements in the coordination of forces continue
until at least the third year. This underscores the fact
that consistency in the external features of movements
(e.g., topology) are contingent on internal features
(e.g., coordination of forces and muscle patterns) that
remain variable over a much longer period of time
(Manoel Ede & Connolly, 1995). It can be argued that
the variability in the coordination of forces allows the
system flexibility and generalizability.
In summary, learning is thought to progress
through two interdependent and parallel processes.
The early phase is characterized by establishment of a
mapping between the performer and the environment
that, with practice, quickly improves the overall shape
structure of the movement. The processing of infor-
mation during this phase is explicit in nature and leads
to the formation of an internal model of the task
(Gentile, 1998). Later in learning, movements are refined
at a micro level that is not observable in the behavior.
The processing of this information progresses without
conscious awareness on the part of the performer (i.e.,
implicitly). Because the improvements at this stage
concern coordination of the details of intersegmental
forces, the later stage of learning is extended over a
longer period of time (Gentile, 2000).
EPILOGUE: RELATIONSHIP
BETWEEN COGNITIVE AND
MOTOR DEVELOPMENT
Historically, motor development and cognitive devel-
opment have been studied separately and viewed as
somewhat independent of each other. It was also a
widely held belief that cognitive development occurred
over a longer period of time compared with motor
development. It is now apparent that motor skills,
particularly complex skills such as bimanual control and
some visuomotor skills, continue to develop until
adolescence. A recent development in the under-
standing of the relationship between cognitive and
motor development proposes that they are in fact
highly interrelated. This relationship is primarily
ascribed to the relationship between the prefrontal
cortex (which was thought to control cognitive skills)
and the cerebellum (which was thought to be involved
in movement), both of which are proposed to be involved
in cognitive and motor skills (Diamond, 2000).
Evidence for this proposal comes from imaging
studies during performance of motor or cognitive skills
and studies with patients with cortical and cerebellar
lesions. In terms of learning of motor skills, it has been
shown that both the prefrontal cortex and cerebellum
are activated: The activation shifts from the prefrontal
cortex to the cerebellum as the task is learned
(Shadmehr & Holcomb, 1997). Coactivation of the
prefrontal cortex and cerebellum also has been seen in
working memory tasks (Desmond, Gabrieli, & Glover,
1998; Smith & Jonides, 1997). According to Diamond
(2000), both the cerebellum and prefrontal cortex are
active under certain conditions; when the task is more
difficult, novel as opposed to familiar, unpredictable
as opposed to stable, and requires a quick response
(p. 45). Patients with lesions to the cerebellum demon-
strate deficits in a variety of cognitive tasks such as
working memory tasks administered through bedside
neuropsychological tests, set shifting tasks, and visuo-
spatial memory tasks (Schmahmann & Sherman 1998).
These deficits are presumably seen because of the inter-
connections between the prefrontal cortex and the
neocerebellum (Ghez & Thach, 2000).
Developmental evidence in support of this theory
has come from studies that have examined motor
problems in children with cognitive problems. Atten-
tion deficit hyperactive disorder (ADHD) is a syndrome
in which children demonstrate cognitive deficits,
including a short attention span. It is interesting to
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
with ADHD compared with unimpaired children
(Castellanos, 1997). Similar motor deficits are also
reported in children with dyslexia. In one study, it was
reported that children with dyslexia have problems
with motor tasks that require control of the timing of
movements, such as tapping a rhythm (Geuze &
Kalverboer, 1994). Because timing of movements is a
function attributed to the cerebellum (Ghez & Thach,
2000; Keele & Ivry, 1990), and given the connections
between the cerebellum and prefrontal cortex, it is not
surprising that children with dyslexia demonstrate motor
deficits. Children with autism also show deficits in motor
tasks, particularly in the execution of goal-directed
movements (Hughes, 1996). Although the motor deficit
in all these disorders is not the most significant, the
existence of these motor disorders highlights the close
relationship between cognitive and motor skills.

SUMMARY
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
by specific tasks. In addition to the control processes
underlying motor control, we have described many
components of cognitive skills that are important for
the development and execution of motor skills. Cog-
nitive development and motor development are closely
related and have a reciprocal relationship.
Hand function is critical in supporting cognitive
development because hand movements allow for inter-
actions with objects that in turn support the devel-
opment of knowledge about objects. Tool use with the
hands almost always requires cognitive skill to com-
prehend the means–end relationship of movement to
goal or outcome. In contrast with hand skills, gross
motor skills seem to require little cognitive develop-
ment for their emergence.
This chapter has covered a number of topics related
to the literature on the relationship between motor
skills and cognition. The past few years have seen a
fundamental shift in the way in which we understand
the relationship of cognitive and motor skills and our
understanding of development in general. The emerg-
ing paradigm proposes that movement skills are devel-
oped not only as a function of neuromaturation, but
also through the interaction of emergent movement
and cognitive skills with the environment. This new
paradigm
“emphasizes the multicausal, fluid, contextual and self-
organizing nature of developmental change, the unity of
perception, action and cognition, and the role of exploration
and selection in the emergence of new behavior” (Thelen, 1995).
For therapists interested in learning better ways to
teach children to learn or relearn cognitive and motor
skills, the new paradigm offers novel ways to assess and
plan interventions. For instance, different interventions
may be necessary to facilitate implicit versus explicit
learning. Although therapists can use conscious proc-
esses to facilitate explicit learning, the only way to
enhance implicit learning is to carefully structure the
environment and select tasks for optimal practice, and
provide timely feedback and structure ample oppor-
tunities for prolonged practice (Gentile, 1998). Thus
therapists not only have to keep the child in mind
during the assessment and intervention, but the envi-
ronment in which the skills are performed as well. As
we develop greater knowledge of the differential impact
of cognitive disability (e.g., attention, perceptual,
memory, conceptual) on the acquisition of motor skills,
Cognition and Motor Skills • 111
the challenge ahead will be to develop creative thera-
peutic solutions that enhance skill acquisition.
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HAND SKILL DEVELOPMENT IN THE
CONTEXT OF INFANTS’ PLAY:
BIRTH TO 2 YEARS
Jane Case-Smith
CHAPTER OUTLINE
DEVELOPMENTAL THEORIES AND CONCEPTS
A Neuromaturation Model
Individual Patterns in Hand Skill Development
Hand Skills Emerge Through the Interaction of
Systems
Perception as a Primary Influence on Hand Skill
Development
Development of Hand Skills for Functional
Outcomes
CONTEXTS FOR HAND SKILL DEVELOPMENT
SYSTEMS THAT CONTRIBUTE TO THE
DEVELOPMENT OF HAND SKILLS
Posture
Sensory Systems
DEVELOPMENT OF HAND SKILLS IN THE CONTEXT
OF INFANT PLAY ACTIVITIES
Play Activities: Birth to 12 Months
Prehension: Birth to 12 Months
Object Release: Birth to 12 Months
Bimanual Skills: Birth to 12 Months
Play Activities: 12 to 24 Months
Prehension: 12 to 24 Months
Object Release: 12 to 24 Months
Bimanual Skills: 12 to 24 Months
SUMMARY
Chapter 7
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
increasingly competent in exploring and playing with
objects. The young infant’s rudimentary grasp and
release patterns become precise patterns during the first
years of life. The purpose of this chapter is to describe
the infant’s development of grasp, release, and bi-
manual skills in the context of exploratory and func-
tional play. The first section describes developmental
theories and concepts helpful to understanding the
development of hand skills. The second and third
sections describe how contexts, posture, and sensory
function influence hand skill development The fourth
section describes the play activities and specific hand
skills that characterize the sequential stages of infant
development, birth to 2 years.
DEVELOPMENTAL THEORIES AND
CONCEPTS
A N EUROMATURATION MODEL
Early theories of motor development (Gesell, 1928;
Halverson, 1931, 1937; Shirley, 1931) emphasized the
importance of central nervous system control over
motor performance. Gesell documented an orderly
sequence of motor development, stage by stage, that
could be observed in every typically developing child.
The theory that maturation of skill and behavior resulted
from the maturation of the central nervous system
dominated understanding of motor development in the
117
118 Part II • Development of Hand Skills
1930s and 1940s. Based on neuronal maturation, grasp
and manipulation patterns develop in an orderly and
relatively invariant sequence. The sequence of reaching
and grasping patterns identified in the 1930s by Gesell
and Halverson continues to be referenced in develop-
mental motor tests in use today (Bayley Scales of Infant
Development) (Bayley, 1993).
The neuromaturation theory—that motor develop-
ment reflects central nervous system maturation—
emphasizes that early movements are involuntary
reflexes under the influence of subcortical brainstem
structures (Andre-Thomas, 1964; Gilfoyle, Grady, &
Moore, 1990; McGraw, 1943). Neonates’ reflexive
behaviors are automatic reactions to sensory stimula-
tion that result in neonates experiencing arm and hand
movements over which they later gain control. Reflexes
provide young infants with survival capabilities (e.g.,
sucking and rooting) and protective responses (e.g.,
avoiding response). Reflexes allow infants to experience
a complete range of movement and tactile propriocep-
tive input. Reflexes and reactions are modified through
interactions with the environment as infants assimilate
the sensory feedback from reflexive movements (Gilfoyle
et al., 1990). In the first 6 months they become integrated
into acquired or voluntary behaviors.
McGraw (1943) describes a typical progression of
maturation: (a) dominant reflexive responses, (b) inhi-
bition of reflexes, (c) transitional behaviors, and (d)
voluntary motor pattern and skill. This typical sequence
varies in the timing of onset and completion of each
phase but appears to be remarkably invariant in the
ordering of developmental motor patterns. When
cortical control begins to dominate over subcortical
control of hand movement, voluntary grasp emerges.
Transitional behaviors mark the period when reflexes
are inhibited and voluntary controlled movements begin
to develop (Twitchell, 1970). By 4 months the infant
grasps a visually located object.
A series of studies were completed from 1925 to
1940 to examine the neuromaturation model. These
descriptive studies documented the unfolding of
grasping patterns in the first year of life (Castner, 1932;
Halverson, 1931, 1932, 1937; Jones, 1926). Each
researcher investigated specific aspects of prehension
development. Jones (1926) was interested in when
infants begin to use their thumbs, recognizing the im-
portance of thumb movement to effective prehension.
He found thumb opposition to be present in all infants
by 9 months. Halverson examined visual control of
prehension, approach or reach, and grasping patterns.
He documented the emergence of visual attention and
visually guided grasp. Halverson reported active thumb
movement by 7 months and the beginning of fingertip
grasp by 9 months. Castner (1932) was primarily
interested in precision grasp of small objects (i.e., a
pellet). His study documented whole hand closure at
5 months, palmar grasp at 8 months, scissors grasp at
9 months, and pincer grasp at 12 months.
I NDIVIDUAL PATTERNS OF HAND SKILL
DEVELOPMENT
The design of these early studies of hand skill develop-
ment was cross-sectional; and therefore identified what
patterns infants demonstrate at specific ages, but not
how infants develop these skills. The purpose of the first
developmental studies was to document typical
development, without realizing that infants’ individual
differences might be more interesting and of equal
importance to examine. To learn how infants develop
and how developmental patterns differ among individual
infants requires longitudinal designs in which per-
formance patterns are observed over time.
In assuming a hierarchy of central nervous matura-
tion, the results in an invariant sequence of motor skills
development and neuromaturational theory limited
the thinking about how a child learns to act on the
environment. Current research models (Gibson &
Walker, 1984; Smith & Thelen, 2003; Thelen et al.,
1993) reveal that infants follow a general sequence of
motor milestones, but how they achieve skills is quite
individual and infants’ developmental trajectories
follow individual pathways. Beginning with Piaget
(1952), researchers have demonstrated that children
acquire skills through an interaction of their experience
and their innate abilities. The influence of the
environment on learning and development has become
an emphasis of child development research. Behavior
patterns are assumed to emerge from an organism–
environment coaction (Gottlieb, 1992).
This line of reasoning brought new understanding as
to how coordinated movements develop, emphasizing
the importance of sensory experience and feedback
through the hand’s surfaces (Bushnell & Boudreau,
1993; Newell & MacDonald, 1997; Rochat, 1987;
Ruff, 1984). For example, the first grasping patterns
of neonates are driven by sensory input to the palmar
surface. Throughout the first year infants’ actions
directly relate to sensory experiences, and movements
are adapted based on sensory feedback. Grasp and hold
patterns, which are first associated with proprioceptive-
tactile input, become grasp and manipulate patterns
guided by tactile, proprioceptive, and visual input
(Bushnell, 1985; McCall, 1974).
HAND SKILLS E MERGE THROUGH THE
I NTERACTION OF SYSTEMS
Recent research of hand skill development (e.g.,
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’
actions and performance emerge from the interaction
of many systems, both internal and external to the
child. Factors that influence hand skills include the
infant’s size, growth, biomechanical attributes, neuro-
logical maturation, perceptual abilities, sensation, and
cognition (Gordon & Forssberg, 1997; Manoel &
Connolly, 1998; Thelen, 1995; Thelen, Kelso, &
Fogel, 1987). Within individual infants, these factors
vary with time, activity, and environmental conditions.
An infant’s actions during the performance of a task,
then, are the results of the subsystems (e.g., motor,
sensory, perceptual, skeletal, psychologic) interacting
with each other and the environment. These individual
systems are interdependent and work together, such
that strengths in one system (e.g., visual) can support
limitations in another (e.g., kinesthetic). Which systems
are recruited for the tasks varies according to the
novelty of the activity and the degree to which the task
has become automatic. For example, reaching to pick
up a cup initially is guided by the visual system, but
after it is practiced and learned, reaching is guided
primarily by the kinesthetic system, with some direction
by the visual system. In contrast, grasping appears to
initially involve primarily somatosensory input, but
later also is guided by vision. Early grasping and
manipulation patterns that are guided by visual and
somatosensory input (e.g., play with a rattle) are later
guided by cognition and memory (e.g., handwriting).
The infant’s sensory–motor–biomechanical systems
self organize in a coordinated way to achieve the
infant’s goal. For example, when an infant reaches for
the toy, grasps it, brings it to midline in hand-to-hand
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
also learns that his actions cause environmental
consequences (e.g., shaking a toy makes a noise).
Gibson (1988) defines early action as both exploratory
(seeking information) and consequential (causing a
consequence). The infant’s actions are based on
affordances of the environment. Affordance defines the
fit between the child and her environment (Gibson,
1979, Gibson, 1988). The environment and objects in
it offer infants opportunities to explore and act. The
infant’s performance is based on not only what the
environment affords, but also her perceptual capability
to recognize those affordances. For example, most
infant toys provide opportunities for manipulation
because they have movable parts, rounded surfaces, and
easily fit into an infant’s hand. Individual finger move-
ments, thumb opposition, hand-to-hand transfer, and
eye–hand coordination are facilitated by the infant’s
perception of the physical characteristics of the toy and
his desire to explore those perceptual qualities. Case-
Smith, Bigsby, and Clutter (1998) found that toys with
movable parts afford higher-level skills than a cube or
pellet. The movable parts provide a variety of surfaces
for the infant to explore. The toy’s reciprocal action
gives feedback to finger movements and sustains the
infant’s attention. The perceptual-motor experience of
a toy with movable parts is much more interesting than
that of a cube (Figure 7-1).
The first actions of the infant directly relate to his
interest in acquiring perceptual and sensory infor-
mation (infants first explore objects with their eyes and
then hands). Through object manipulation, infants
develop haptic perception (i.e., an understanding of
objects’ shape, texture, and mass). Specific motor skills
are necessary to develop haptic perception. Researchers
(e.g., Bushnell & Boudreau, 1993; Lederman &
Figure 7-1 Movements are guided by object
affordances. Toys with movable parts elicit a variety of
grasping patterns.
120 Part II • Development of Hand Skills
Klatzky, 1987) have demonstrated that young infants
develop the hand skills that are necessary to explore an
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,
turn, and transfer objects with interesting shapes.
Bushnell and Boudreau (1993) noted that infants learn
to identify an object’s sensory qualities (e.g., texture,
consistency, contour) only when they develop the
motor skills to explore each different sensory quality.
Therefore an infant does not accurately discriminate
texture until she can explore texture by moving her
fingers back and forth. She also cannot discriminate
hardness until 6 months when she can tighten and
lessen her grip while holding an object (Bushnell &
Boudreau, 1991). Because configurable shape requires
that two hands are involved in exploring the object’s
surfaces, infants typically cannot accurately perceive
shape until 12 months.
DEVELOPMENT OF HAND SKILLS FOR
FUNCTIONAL OUTCOMES
Once infants learn to discern the perceptual qualities of
objects, they become interested in mastering objects
for functional purposes. Through their exploration of
objects and the environment, infants realize that they
have an effect on the environment and their actions
can produce functional outcomes. The outcomes that
motivate an infant may be social (e.g., mother’s smile)
or physical (e.g., a toy moves, makes a sound, falls
over). Functional tasks and outcomes begin to organize
the infant’s action (Gibson, 1988). Their actions are
intentional and goal driven (Manoel & Connolly,
1998). With this interest in functional outcomes, the
infant first attempts to use tools and relate objects to
each other (Lockman, 2000). By the end of the first
year, infants handle and manipulate objects according
to their functional purpose, and the goal of accom-
plishing a task guides the interaction (Connolly &
Dalgleish, 1989). One-year-old infants begin to use a
spoon and a cup to self feed. Infants at 14 months can
relate one object to another and use simple tools to
achieve a goal. By 2 years they learn to hold a comb, a
brush, and a marker and crudely apply them in appro-
priate tasks (Lockman, 2000; McCarty, Clifton, &
Collard, 2001).
How Are Functional Hand Skills Learned?
Infants generally go through three stages of learning to
acquire a new skill (Box 7-1) (Gibson, 1988; Manoel &
Connolly, 1998). The first stage involves exploratory
activity. As noted in the previous section, the first year
of life is primarily a period of sensory motor explora-
tion. Through exploration, an infant learns about
BOX 7-1 Three Stages of Learning to
Acquire a New Skill
1. Exploratory activity
Learn about objects and tasks
A variety of patterns and approaches tried
Lower levels of skills used
Focus on perceptual learning about the tasks to gain
information
2. Perceptual learning and feedback acquired from
previous tasks performed
Actions initially tried and ineffective are discarded
Continue to gain perceptual knowledge about the
task
Performance is variable, demonstrating higher and
lower levels of skill
3. Discovery of the “optimal solution” by selecting the
action pattern that will best achieve the goal
Pattern selected is comfortable, efficient, and
indicates increased self-organization
Demonstrates flexible consistency in performance
Tends to use a stable pattern for a task (e.g., stack
blocks), but can easily adapt the pattern
according to task’s requirement (e.g., with
larger blocks, heavier blocks)
High adaptability characterizes well-learned tasks
Mature movement patterns are characterized by
adaptable stability
Synergist movements (muscles and joints working
together) are softly assembled around the goal
of the task
Specific movement patterns are observed (e.g., a
tripod grasp)
Generalizes movement patterns to other tasks when
well learned for one task
objects and tasks. Most skill acquisition begins with
exploration, when a variety of patterns and approaches
are tried. New challenges tend to elicit lower levels of
skills because these more basic skills can be accessed
easily and require less energy and effort than higher-
level skills (Gilfoyle et al., 1990). By using lower-level
skills to explore a new task, the child can focus on
perceptual learning about the tasks to gain information
that will allow mastery with experience.
In the second phase of learning a task, the infant
uses the perceptual learning and feedback he acquired
from attempting to perform the task. Actions that were
initially tried and were ineffective are discarded. During
this phase, the infant continues to gain perceptual
knowledge about the task. Learning potential is high
when the task is perceptually interesting and the skill
demands are within the capability of the infant. At this
transitional phase, the infant’s performance is variable
in that he demonstrates higher and lower levels of skill.
For example, Connolly and Dalgleish (1989) found
considerable variability when infants first attempted to
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 121
use a spoon. McCarty, Clifton and Collard (1999)
noted that the transitional stage for spoon feeding is
between 14 and 19 months with an “optimal solution”
emerging by 19 months.
In the third phase of learning, an infant discovers the
“optimal solution” by selecting the action pattern that
will best achieve the goal. The pattern selected is
comfortable and efficient and indicates increased self-
organization. During this last stage of learning, the
child demonstrates flexible consistency in performance.
The infant tends to use a stable pattern for a task (e.g.,
stack blocks), but can easily adapt the pattern according
to the task’s requirement (e.g., with larger blocks,
heavier blocks). High adaptability characterizes a well-
learned task and mature movement patterns are charac-
terized by adaptable stability (Gordon & Forssberg,
1997; Thelen, 1995; Thelen et al., 1987). Synergistic
movements (muscles and joints working together) are
softly assembled around the goal of the task, allowing
the infant to adapt the pattern he has learned when
task variables change. Specific movement patterns are
observed in most children, such as a tripod grasp; once
a tripod grasp is well learned, it is easily adapted to pens
and pencils of different sizes and weights. When move-
ment patterns are well learned for one task and are
performed with flexible adaptability, the infant also
generalizes them to other tasks. McCarty and co-
workers (2001) demonstrated that infants who learned
to hold a spoon with a radial grasp consistently
generalized this pattern to other tools and tasks with
self-directed goals. By 14 months, the infants consis-
tently used a radial grasp on tools that were self-
directed (e.g., a hairbrush), recognizing it as the most
efficient grasp for using the tool.
A century of research on infant motor development
has provided a detailed description of the sequence of
hand skills development and a conceptual under-
standing of how infants develop hand skills. Knowledge
about the sequence allows therapists to identify infants
who may benefit from intervention and to establish
goals that reflect the next skill expected to emerge. The
theories that explain how infants develop hand skills
form the basis for intervention and educational
approaches. One recurring theme in human develop-
ment research, the relationship between skill develop-
ment and environmental context, is discussed in the
following section.
CONTEXTS FOR HAND SKILL
DEVELOPMENT
A child’s development is nested in his culture, family,
and community; these contexts determine his genetic
makeup and after birth provide his learning environ-
ment. Children develop skills through participation in
their family’s and community’s cultural practices.
Cultural practices are the routine activities common to
a community or people and reflect how they play,
recreate, and interact in social occasions.
The infant’s cultural, social, and physical contexts
expand greatly through the first 2 years of life. The
widening context affords the infant an increasing
variety of experiences, challenges, and opportunities. In
most cultures, the first 6 months of life are charac-
terized by closeness to the caregiver. Often children are
held and when they are positioned for play, they are
immobile for all practical purposes. The infant is quite
dependent at this point in life, not only to have his
basic needs met, but to bring play objects within reach.
In cultures with high interdependence and strong
appreciation of extended family, the infant may be con-
tinually held by a variety of family caregivers beyond
the parents. Hand skills may be practiced on the care-
giver’s lap by reaching for and grasping hair, jewelry, or
clothing items. First reach and grasp may be practiced
on the mother’s breast.
A family’s culture background influences the objects
made available to the infant. In some cultures, toys are
not valued or not available; as a result, young infants do
not experience these learning objects.
The contexts for play expand for infants after they
gain mobility (e.g., around 8 months). Because the
infant now can move to play objects, her sense of au-
tonomy increases and she has increasing choice about
play with objects. Once the infant is mobile, she is
unlikely to spend play time on her parents’ lap and is
more likely to play on the floor or in a seating device
with the caregiver nearby. Being able to move to a
location or object affords the infant greater variety
of play objects, enables the infant to develop self-
determinism, and expands the infant’s perception of
form, space, direction, and depth.
Cultural traditions influence how much the infant is
held, the space afforded to him or her for exploration,
and the complexity of the environment available. Infants
of families with low economic status may not have
appropriate spaces to explore and may be restricted for
safety reasons. Families of cultures that value infants’
exploration and play may have more toys and activities
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
development in girls. In contrast, boys whose families
had lower income demonstrated higher motor skills
than boys from more affluent families. Using a large
sample of different ethnic and economic groups, Bradley
and co-workers (2001) found that poverty per se did
not have a negative effect on infants’ motor develop-
122 Part II • Development of Hand Skills
ment; however, variables sometimes related to ethnicity
and economic status (i.e., availability of learning
materials and degree of parental responsiveness) did
relate to motor development.
A number of studies have found differences in hand
skill development when children from different cultures
are compared. In a study that examined motor per-
formance in Chinese and American children, American
children demonstrated higher scores in most gross
motor skills and Chinese children were higher in fine
motor skills (Chow, Henderson, & Barnett, 2001).
The authors suggest that Chinese children may not
have the same amount of space available for play and
exploration and Chinese parents also may not value
gross motor skill development as much as fine motor
skill because early proficiency with chopsticks and
writing implements is expected. Yim, Cho, and Lee
(2003) found that hand strength of children in Korea
was lower than in children from America and other
Western countries. Although these studies of Chinese
and Korean children examined older children (pre-
school and elementary ages), the results have implica-
tions for infants because hand skill and strength develop
incrementally from infancy.
Differences in caregiving practices across cultures
appear to affect infant skill development. When evaluated
using the Bayley Scales of Infant Development, 3- to
5-month old Brazilian infants were less skilled in grasping
and sitting than American infants (Santos, Gabbard, &
Goncalves, 2001). Santos and co-workers attributed
these differences to the tradition that Brazilian mothers
hold their infants almost constantly for the first 6
months. Because the infants are totally supported for
an extended period, their delay in hand skill develop-
ment may relate to delay in postural stability develop-
ment. These studies illustrate differences that have been
observed in different ethnic groups; however, these dif-
ferences have not been systematically studied in ethnic
groups that live in America, limiting generalizability to
children of different cultures who live in the United
States.
SYSTEMS THAT CONTRIBUTE
TO THE DEVELOPMENT OF
HAND SKILLS
Extensive research has demonstrated the importance
of posture and sensory function (i.e., visual, tactual,
proprioceptive) to the development of hand skills
(Bertenthal & von Hofsten, 1998; Thelen & Spencer,
1998; von Hofsten, 1986). The reciprocal influence of
sensory function was discussed in a previous section.
This section presents a developmental perspective of
the influence of posture and sensory functions.
POSTURE
The first stable posture of the infant is lying on his
back. Laying supine offers optimal stability; the infant
must reach against gravity, which constrains reach with
grasp. Because posture is unstable in the first months
after birth, the 2-month-old infant primarily demon-
strates asymmetric posturing, reinforced by the influ-
ence of the asymmetric tonic neck reflex (Gesell et al.,
1940). This asymmetric posture limits his or her visual
field and reinforces visual inspection of the hands
(Bower, 1974). To reach and grasp objects, infants
must maintain stable vision of the target as they lift
their arms. Thelen and Spencer (1998) found that head
control is critical to successful reaching. In their study
reaching did not emerge in any of the infant par-
ticipants until several weeks after good head control
emerged.
By 3 months, the infant has an emerging sense of
midline, and when supine brings the head to midline
and the hands toward midline. Symmetric weight
bearing in prone and increasing head control con-
tribute to establishing a sense of midline. Neck and
shoulder stability develops as a prerequisite for control
of reach and hand movements in space.
Symmetry is the predominant characteristic of the
infant’s posture between 4 and 6 months. Head and
hands come to midline, enabling a hands-together
posture and visual inspection of both hands. As a result,
the infant spends much of the time in hand-to-hand
play, first on the chest and then in space at the midline.
Head and trunk control and postural stability change
dramatically during this quartile. Thus the infant gains
important axial support for reach and use of hands in
space. Stability through the neck and shoulders helps
the infant gain control of the arms; therefore in sup-
ported positions he or she can hold her hands in space
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
reach by 4 months, when successful reaching emerges.
Therefore as reach and grasp emerge and later mature,
postural stability provides a base for these movements.
By 6 months, the infant demonstrates increased
postural control in the prone position, pushing onto
extended hands and shifting weight side to side. When
on elbows, the infant is able to lift one arm entirely
from the weight-bearing surface for reach to an object.
This complete lateral weight shift provides propriocep-
tive input through the hands across the palmar surface.
It also results in asymmetric sensory experiences. Prone
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 123
Figure 7-2 Prone position strengthens arms and hands.
Figure 7-3 Most 7-month-old infants sit independently.
positions help the infant strengthen arm and hand
musculature and provide tactile proprioceptive infor-
mation that appears important to the hand’s perceptual
development (Boehme, 1988) (Figure 7-2). Although
the increased postural control of the 6-month-old child
supports symmetric movements of the hands in space,
it does not appear adequate for skilled asymmetric or
unilateral movements.
In the following months, when trunk stability is
sufficient for independent sitting, the infant develops
an increased repertoire of arm and hand movements
that includes both symmetric and asymmetric patterns.
Gains in postural control allow the 7-month-old
child to sit independently (Figure 7-3). In the next
several months sitting becomes a favorite play position
because the hands are free to hold objects, and the
infant can control weight shift forward or to the sides
to obtain objects (Figure 7-4).
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
movement and the postural stability to allow for those
adjustments.
Infants at 7 and 8 months also assume the
quadruped position and begin to creep. The on-hands-
and-knees position results in frequent weight bearing
on the hands. This position tends to be dynamic and
mobile, thereby providing tactile and proprioceptive
input across the hand (Figure 7-5). The frequency of
play in prone position (in and out of quadruped)
strengthens the arms and hands. The infant shifts
weight across the hands in a diagonal direction while
moving from quadruped to side sitting (Boehme,
1988). Strengthening of the arms also occurs through
pulling to stand and through supporting himself while
erect (Figure 7-6).
Postural stability increases such that the 12-month-
old infant has greater control of arms in space while
sitting independently. The internal stability of the arm
allows the infant to prehend a small object using a
superior pincer grasp (i.e., use a pincer grasp without
124 Part II • Development of Hand Skills
Figure 7-5 Creeping on hands and knees provides
tactile and proprioceptive input to hands.
Figure 7-6 Practice of pull-to-stand helps to strengthen
arms.
stabilizing the arm on the surface). Postural stability is
an important factor in the development of an accurate
and well-directed reach (Corbetta & Thelen, 1996).
With increasing trunk stability and rotation the infant is
able to reach to the body’s contralateral side. Postural
stability also enables the child to reach overhead and
behind when sitting.
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
consistent form of mobility, upper extremity weight-
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
of the object it grasps, and control of release has not
been established (Figure 7-7).
The infant from birth through 3 months is often
prone lying and has frequent opportunities for tactile
or proprioceptive input to the hands and forearms. He
presses into a prone propped position with the head
erect, resulting in deep proprioceptive input to the
arms. Hand opening while weight bearing, prone-on-
elbows, provides specific tactile input to the palms.
Mouthing of the hand allows tactile exploration of the
hand and provides tactile or proprioceptive input to the
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 125
Figure 7-7 Hands conform to the object’s shape
Figure 7-8 Hands grasp at midline on his chest in 3-
month-old infant.
hand. When the infant is supine, the hands find each
other on the chest, clasping and engaging in mutual
fingering (Figure 7-8). These tactile or proprioceptive
experiences contribute to the development of grasp and
release patterns, as do the visual experiences that
contribute to the development of visually guided hand
movements.
Sensory experiences continue to be a primary basis
for movement in the 3- to 6-month-old infant. The
infant delights in the sensory world and begins to
integrate the information from more than one sensory
system. Rochat (1987) reported that infants this age
perceive hardness when compared with soft consis-
tencies. Bushnell and Boudreau (1993) concluded that
infants as young as 3 months can perceive hardness,
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.
They explore textures, rotate and transfer objects, and
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
evidence that an infant visually recognizes an object
that was previously held and tactually experienced but
not visualized. Sensory play at this time consists of
mouthing, hand-to-hand fingering, and intense visual
inspection.
The role of vision in guiding manipulation has an
increasingly important role after 6 months and then
throughout development (Bushnell & Boudreau,
1991). Whereas tactile input had primary influence on
grasp and manipulation, vision becomes a primary
sense for guiding the infant’s manipulation. McCall
(1974) reported an increase in manipulation with visual
regard at 81⁄2 months. Castner (1932) observed that
the duration of regard increased at 8 and 9 months, as
did the infant’s accuracy in reach and grasp of a pellet.
126 Part II • Development of Hand Skills
Figure 7-10 Infant at 8 months integrates visual and
tactile information from toy with movable parts.
Active mouthing decreases as manipulation with
visual regard increases in the second half of the first year
(McCall, 1974). This active mouthing appears to be
replaced with fingering. The increasing importance
of vision in manipulation complements rather than
diminishes the importance of the tactile system. The
infant is now able to integrate visual and tactile
information, using both senses simultaneously to learn
about the object’s properties (Corbetta & Mounoud,
1990; Ruff, 1984) (Figure 7-10). lntermodal transfer
of tactile and visual information (visual recognition of
an object after handling it without vision) becomes
possible at this age (Ruff & Kohler, 1978; Steele &
Pederson, 1977). Changes in discrimination of the
object’s weight and shape enable the 9- to 10-month-
old child to hold a cracker without crushing it and lift
an object with the appropriate amount of force.
At 12 months the infant continues to use vision as a
primary guide to object manipulation. The infant can
visually recognize the physical properties of the object
and act on it appropriately. For example, a 12-month-
old infant bangs and hits a rigid object and squeezes or
presses a spongy object (Bushnell & Boudreau, 1993;
Gibson & Walker, 1984). Fingering and hand-to-hand
manipulation become the primary modes for exploring
the sensory qualities of an object (Ruff, 1984) (Figure
7-11). Integration of senses continues and the infant
becomes increasingly able to recognize objects visually
that had been explored only through the tactile sense.
Infants learn anticipatory control; that is, they plan their
Figure 7-11 Infant at 12 months visually explores
object.
movements after visualizing the object. Anticipatory
control means that the infant opens his hand according
to the object’s size and shape before prehension.
Through their prehension experiences infants also
begin to anticipate the force necessary to grasp and lift
an object (Gordon & Forssberg, 1997; Johansson &
Westling, 1988).
In the second year of life, the infant becomes
interested in the functional use of objects and func-
tional goals become the prime motive for manipulation
(Gibson, 1988). The child continues to integrate visual,
tactile, and proprioceptive sensations by practicing per-
ceptual motor skills, demonstrating increased abilities
to use information from these sensory systems to
correct and refine movements. Thus increased precision
of movement results from increased perceptual ability,
as well as improved motor skill. The child can now
recognize the tactile and auditory properties of the
object through visual inspection and therefore
approaches an object with an appropriate response (i.e.,
shaking a rattle, squeezing a sponge, crumpling paper,
or using more force to lift a large object).
By 2 years of age, improved sensory discrimination
and integration enable the child to demonstrate increased
variety and control of perceptual-motor skills. The
24-month-old child is able to assimilate multimodal
sensory information and make appropriate adaptive
responses. Success in perceptual-motor skills such as
stringing beads and simple dressing tasks illustrates the
child’s ability to integrate and use sensory information.
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 127
DEVELOPMENT OF HAND SKILLS
IN THE CONTEXT OF INFANT PLAY
ACTIVITIES
PLAY ACTIVITIES: BIRTH TO 12 MONTHS
In the first months of life, infants delight in sensory
experiences of touch and movement. Infants exhibit
frequent generalized movements through which they
gather multisensory input that increases arousal and
attention. Play behaviors of young infants include
swiping movements to cause a mobile to move and
make sounds, or mouthing objects in perceptual explo-
ration. When general swiping movements cause a mobile
to move and make sounds, this sensory experience
reinforces that action and the infant swipes at the
mobile again. As noted in the previous section, visual
exploration, mouthing, and tactile reflexes appear to be
the infant’s primary methods for learning about the
environment (Bower, 1974; Gesell et al., 1940)
(Figure 7-12).
The 4- to 6-month-old infant continues to delight in
the sensory experiences of vision, touch, and move-
ment. One goal of generalized movements and
reactions appears to be creating sensory experiences. As
the infant scratches the weight-bearing surface of the
parent’s shoulder, this behavior seems to be auto-
matically reinforced by the tactile and proprioceptive
Figure 7-12 Mouthing at 4 months is a primary
method of object exploration.
input to the hand. He or she begins to actively explore
objects using specific movements to create sounds and
visual effects. By 6 months the infant can purposely roll
and initiate rolling to experience movement. Toys that
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-
tion (Piaget, 1952). Toys that are activated by generalized
responses continue to be preferred to those that require
specific, more localized responses; for example, a rattle
is preferred to a busy box requiring differentiated push,
pull, and press of fingers (McCall, 1974).
From 6 to 12 months, infants spend most of their
playtime in object exploration. Interest in and
awareness of the environment increases (as described in
the previous section). Visual and tactile exploration of
objects predominates. These exploratory behaviors are
characterized by a rich variety of manipulative skills.
Cause and effect are well established, and rather than
repeating the same actions on a toy, the infant tries new
strategies to create different reactions (Piaget, 1952).
Play involves imitation of actions observed, including
toy manipulation. The physical properties of the object
guide responses, because the infant does not yet under-
stand the specific functional uses of objects. The infant
begins to bang objects together and place one object in
proximity to another. These behaviors signal the advent
of tool usage and specific actions of one object in
relation to another (Bruner, 1970; Lockman, 2000).
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-
ation with active extension of the trunk or arms. The
neonate’s fisted hand is consistent with the overall
128 Part II • Development of Hand Skills

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.
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 129
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;
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
flexion and extension of the digits together. Scratching
also may occur on the caregiver’s clothing when
holding the infant upright against the shoulder. The
scratching motion allows the infant to practice the full
range of reciprocal finger flexion and extension.
Scratching also provides the infant with rich tactile
information about different textural surfaces.
Halverson (1931) observed rubbing of the hand on
the surface as an additional method for obtaining
tactile input in the infant at 16 to 28 weeks. As the
infant continues to use scratching, finger movements
become differentiated such that one or two fingers
move in isolation of the others. Halverson documented
pianoing or “raising and lowering of each finger
alternately” on the table in infants 16 to 24 weeks of
age. Pianoing appears to be an automatic movement
rather than a purposeful isolated motion of each digit.
As with other hand skills, isolated movements of the
fingers occur first in these automatic behaviors elicited
by the sensory stimulation of the hand resting on a flat
surface.
A palmar grasp is most frequently used by the
24-week-old infant. The palmar grasp is characterized
by a pronated hand and flexion of all fingers around the
object. The thumb may slide around the object passively
rather than actively holding it (see Figure 7-13).
Halverson suggested that when thumb opposition first
appears at 28 weeks, it is used only in association with
a palmar grasp. By 28 weeks the infant holds the object
in a radial palmar grasp (Gesell & Amatruda, 1947) or
what Halverson (1931) termed a superior palmar grasp.
The radial fingers and thumb press the cube against
the palm (Figure 7-14). Therefore when held in a
Figure 7-14 Radial palmar grasp.
supinated hand, the object can be brought to and put
into the mouth. The object can be banged against
another surface, and the object becomes accessible for
object transfer from hand to hand. The radial palmar
grasp is a hallmark in grasp maturation because the
infant now differentiates the sides of the hand, using
the ulnar side to provide stability for the grasping
movement and the radial side to prehend and hold the
object. This early pattern signifies the initial develop-
ment of radial fingers as the skill side of the hand.
Knobloch and Pasamanick (1974) emphasized the ver-
satility observed in manipulation patterns at 7 months:
“He grasps it, brings it to his mouth, withdraws it again
for inspection, restores it again for mouthing, transfers
it to the other hand, bangs it, contacts it with the free
hand, retransfers it, mouths it again, drops it, rescues it,
mouths it again” (p. 60).
Between 32 and 36 weeks the infant demonstrates
grasp of the object in the fingers rather than the palm,
and by 36 weeks the infant exhibits a radial digital grasp
(Gesell & Amatruda, 1947) or inferior forefinger grasp
(Halverson, 1931) (Figure 7-15). At this time the
infant can prehend a small object between the radial
fingers and thumb. With the object held distally in the
fingers (proximal to the finger pads), the infant can
adjust the object within the hand and as a result can use
the object for various purposes while holding it. The
adjustments allow for greater success in relating two
objects or in bringing the object to the mouth for
finger feeding. The movement of the object distally and
to the radial fingers gives the infant greater control of
the object and enables release control.
When the 36-week-old infant grasps a very small
object (pellet size), a scissors grasp is used. Gesell and
130 Part II • Development of Hand Skills
Figure 7-15 Radial digital grasp at 8 months.
Figure 7-16 Scissors grasp at 9 months.
Amatruda, as edited by Knobloch and Pasamanick
(1974), defined a scissors grasp as prehension of a small
object between the thumb and lateral border of the
index finger after a raking movement of the fingers.
The hand is stabilized on a surface during this grasp,
and the ulnar fingers are flexed to provide stability of
the thumb and radial finger movement (Figure 7-16).
Forefinger grasp (Halverson, 1931) or inferior
pincer grasp (Gesell & Amatruda, 1947) is observed at
40 weeks. This is a fingertip grasp in which the infant
stabilizes the forearm on the table as a base while
grasping the cube. The fingers that prehend the small
object are more extended than flexed. By 52 to 56 weeks
the infant prehends and holds the object between the
thumb and forefinger tip. Successful prehension using
a superior pincer grasp (Halverson, 1931; Illingworth,
1991) is achieved without the forearm stabilizing on
the surface. At this time the fingers adjust to the size
and weight of the object. The object is now in a
position that it can be used readily in a play activity or
as a tool. Because the infant no longer needs to stabilize
to grasp, he can easily prehend objects from a variety of
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
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.
Twitchell (1970) described an instinctive avoiding
response that is similar in nature to the instinctive grasp
response, in that it represents a transitional behavior
between reflexive and voluntary responses. The instinc-
tive avoiding response emerges between 12 and 20 weeks
of age. It is characterized by pronation and adduction
away from a stimulus on the hand’s ulnar border and
supination with abduction to stimulation of the hand’s
radial side. The instinctive avoiding reaction generally is
fully developed by 24 to 40 weeks of age (Twitchell,
1965, 1970). At this time the infant withdraws from
light contact stimulation, using a variety of hand move-
ments, including flexion, extension, abduction, adduc-
tion, and rotation. Avoiding reactions are seen more
frequently when the infant is irritable or when gener-
alized tactile defensiveness is present. The avoiding
response serves as an automatic mechanism to reinforce
hand opening and facilitate finger extension to balance
the effects of the grasp reflex. According to Gesell and
Amatruda (1947), release requires inhibition of the
flexor muscles with contraction of the extensors, which
is a more mature, later-developing neuromotor pattern.
More recent theories (Thelen et al., 1987, Thelen &
Smith, 1994) that recognize the interaction of systems
in development attribute initial hand opening to per-
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 131
ceptual and biomechanical influences. The hand may
first open with wrist flexion, which produces tension of
the finger extensors. The hand also may open to rub or
pat objects to perceive their sensory qualities (Bushnell
& Boudreau, 1993).
Purposeful Release
From 5 to 6 months the infant begins a transition from
reflexive to purposeful release. The infant demonstrates
release accidentally or involuntarily in association with
movements, tactile stimulation to the hand, or contact
with another surface. At 6 months release is observed
during mouthing and bimanual play. The infant brings
an object or finger food to the mouth with both hands
and may release one or both once the object is stabilized
in the mouth. When the infant holds an object with
two hands, one hand may fall from the object.
Meanwhile, the infant practices finger extension in
other activities. For example, extended fingers may be
observed in patting the bottle or toy (Figure 7-17).
Additional facilitation of finger extension in the 6- and
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
transferring it from one hand to the other. Initially
object transfer is achieved by holding the object at
midline with both hands and pulling it out of one hand
into the other. Therefore the release is actually a forced
withdrawal accomplished by the opposite hand. During
this same developmental period the infant releases an
object on a table surface or another resisting (Gesell &
Amatruda, 1947) or assisting (Ammon & Etzel, 1977)
surface. Release with the assistance of another surface
enables the child to roll the object from the fingers or
remove it from the hand by inhibiting finger flexion
(i.e., without active extension).
Between 40 and 44 weeks the infant demonstrates
purposeful release in the context of play (Illingworth,
1991; Knobloch & Pasamanick, 1974). This first active
Figure 7-17 Fingers extend as infant pats toy.
release is often accomplished by flinging the object—
combining elbow, wrist, and finger extension in a
synergistic, ballistic movement. The infant now pur-
posefully drops food and toys from his or her highchair
and takes great pleasure in practicing this newfound
skill. The object is released with the hand above the
table surface, using full finger and thumb extension.
Object-releasing activity is reinforced by the auditory
and visual consequence of dropping the object. This
new skill is also reinforced by the development of
object permanence and the infant’s interest in
observing objects disappear and reappear.
By 52 weeks the infant demonstrates greater
proficiency in releasing the object. With increasing con-
trol of finger extension, the infant begins to demon-
strate graded hand opening when releasing. At this
time she is practicing precision release for stacking one
block on another or placing a form in its form space.
Graded hand opening with controlled finger extension
is first observed with the proximal hand base and
forearm stabilized on a surface.
BIMANUAL SKILLS: BIRTH TO 12 MONTHS
Humans are essentially bimanual beings from birth and
most movement patterns of the arms and hands involve
combined movements of both. Fagard and Jacquet
(1996) indicated that bilateral arm movements are the
predominant pattern of upper extremity movement
throughout the first year of life. Two hand actions
generally follow prehension and although varied,
follow a developmental sequence. The sequence of
bimanual skills observed during infancy relates to the
infant’s postural, sensory, perceptual, and cognitive
development, as well as hand skill development.
Early Development of Bilateral Arm Movements
The neonate exhibits both asymmetric and symmetric
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.
Usually the hands join together at midline, and the
132 Part II • Development of Hand Skills
Figure 7-18 Symmetric arm movements at 4 months.
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
when transported to the mouth or may be captured
against a body part. These behaviors are reinforced by
the infant’s drive toward symmetric midline move-
ments at this age and the desire to experience oral
sensation. Lack of internal trunk stability at 4 months
also results in bringing both hands together around the
object for distal stability.
The 20-week-old infant tends to use the simul-
taneous approach described earlier, in which both
hands move toward the object at the same time. The
infant attempts to prehend the object using both hands
(Castner, 1932). Although the 5-month-old infant
reaches for the object with two hands, he uses only
one to grasp the object (Fagard & Peze, 1997). The
second hand may support the first after grasp is
achieved, and often both hands bring the object to the
mouth or hold it in space for visual inspection. Inter-
manual transfer has significantly increased (Rochat,
1989), although active purposeful release has not yet
developed. Compared with 2- and 3-month-olds, 4- and
5-month-old infants demonstrate significantly better
organized bimanual action with more holding and
fingering of objects, The bilateral fingering behavior
observed at this age has been described as grasping
the object with one hand and touching it or scanning
the object’s surface with the other (Ruff, 1984).
Transitional Bilateral Skills
Between 24 and 28 weeks the infant approaches the
cube most frequently with both hands, corralling it.
During this developmental period first a simultaneous,
then a successive bilateral approach is used. The infant
Figure 7-19 Unilateral approach to grasp object.
initiates movement in the second hand as the first hand
ends its approach (Castner, 1932).
Bilaterality versus unilaterality in approach seems to
be determined by the object’s size and the way it is
presented. The 7-month-old infant uses a bilateral
approach for large objects and a unilateral approach
for small objects (Fagard, 1998) (Figure 7-19). Other
authors suggest that approach is determined by the
external support provided for the infant’s proximal
stability during reach (Bushnell, 1985; Halverson,
1931). After grasping the object, the infant visually
inspects it or brings it to the mouth. She may transfer
it using the mouth as a stabilizer.
The 7-month-old infant uses primarily bilateral
movements for object manipulation (Goldfield &
Michel, 1986; Flament, as cited in Corbetta &
Mounoud, 1990). At this time the infant demonstrates
associated, rather than independent, bimanual move-
ments. Although the two hands act in concert, an
increasing variety of exploratory and manipulative
behaviors are observed (Figure 7-20). For example, the
infant uses an extended index finger to poke or probe
an object held in the other hand. This probing with
one hand while holding with the other is a primary
method of object exploration.
As mentioned, by 7 months the infant holds the
object in the radial digits and actively transfers it from
hand to hand, while visually and tactilely exploring it.
Active supination and isolated wrist movements enable
the infant to partially rotate or turn the object for visual
inspection. These isolated movements often are
mimicked by the other hand. Manipulation of the
object at this time is limited to transfers from hand to
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 133
Figure 7-20 Two hands explore in associated bimanual
movements.
Figure 7-21 A 7-month-old infant continues to mouth
toys.
hand or hand to mouth rather than within hand
manipulation. Mouthing remains an important part of
the infant’s exploration (Figure 7-21).
After 7 months of age, infants begin to play with two
toys at a time (Figure 7-22). The infant bangs two objects
together as the first indication of her capacity to associate
objects (Corbetta & Mounoud, 1990).
In the following weeks the infant adds to the
repertoire of bilateral movements. In addition to visual
inspection and hand-to-hand exchange, the infant
waves toys in the air and bangs them on the table
surface. By 9 months the striking change in manipula-
A
B
Figure 7-22 A, B. Infants can hold two objects
simultaneously by 7 months.
tion is not related to the development of any specific
skill, but to the expanded range of behaviors observed.
Now one hand holds the object and the second hand
manipulates the object. In “complementary bimanual
activities,” one hand positions the object and the other
manipulates parts of it (Bruner, 1970). Halverson
(1931) noted that 9-month-olds “exhibited all of the
following behaviors: transfer, visual inspection, release
and regain, bang it on the table, and hold it with both
hands.” By 9 months object rotation, primarily
achieved by transferring from hand to hand, allows the
infant to perceive the shapes of objects (Lederman &
134 Part II • Development of Hand Skills
Klatzky, 1987). This type of rotation is possible because
of increasing control of the radial digits and ability to
grade supination and pronation as the object moves
from hand to hand. This two-hand cooperation in
turning an object is evidence of beginning dissociation
of symmetric arm movements.
Near the end of the first year a change is observed in
the linkage between two-hand movement (Goldfield &
Michel, 1986). Whereas 7-month-old infants move their
hands in the same direction, 11-month-olds move them
in complementary directions. This change marks the
initiation of mature bimanual skills.
Coordinated Bimanual Skills
At 12 months the infant demonstrates significant
increases in both dexterity with one hand and
cooperative use of two hands together. Ruff (1984)
observed an increase in fingering by 12 months, which
she associated with an increase in the infant’s ability to
simultaneously assimilate tactile and visual information.
The two hands begin to demonstrate coordinated
asymmetric roles (Figure 7-23). These complementary
movements are observed as the infant simultaneously
holds two objects or an object and a container. A
typical bilateral pattern at this time is for one hand to
be active (generally the preferred hand) and one hand
to be passive or to support and stabilize the object
(e.g., one hand holds the container while the other
removes a block inside). Bruner (1970) studied the
success of infants in removing a toy from a toy box. He
found that before 12 months infants are rarely success-
ful in removing the object. Beginning at 12 months the
hands work in cooperation; for example, one hand
holds the bottle and the other unscrews the lid. These
complementary functions are flexile and adaptable,
enabling the hands to work together for functional
Figure 7-23 Play includes distinct yet complementary
movement of each hand.
purposes. Flexible bimanual skills that can combine in
numerous patterns, switching roles in a sequence of
movements, develop in the second and third year as the
child’s play repertoire expands.
PLAY ACTIVITIES: 12 TO 24 MONTHS
The 1-year-old infant has developed an understanding
of an object’s functional purpose, thereby attempting
to use objects for the function for which they are
intended. For the first time the infant’s repertoire of
manipulative skills increases, in accordance with
functional capabilities of the object more than its
sensory qualities. The infant pushes a truck, pulls a toy
dog on a string, lifts a telephone receiver to the ear,
rolls a ball, and lifts a brush to the hair. All of these
movements are based on emerging cognitive under-
standings, as functional play begins to predominate
over sensory play. The child’s interest in relating two
objects also results in more advanced unilateral and
bilateral skills. Endless repetitions of putting objects in
a container and placing one object next to another
create interesting results for the infant and at the same
time refine releasing skills. New skills in imitation are a
basis for developing additional manipulation skills as
the infant attempts new movements that he observes
others perform.
The child’s play between 18 and 24 months con-
tinues to focus on concrete, functional activities with
toys. Play sequences increase in length and complexity.
Symbolic play begins about the same time that
language develops, between 16 and 20 months. At first
the infant demonstrates self-play that is centered around
or directed toward the self (Belsky & Most, 1981). The
child’s play might consist of simulating eating,
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
lining up toys beside each other). These combined
actions show a play purpose that matches the various
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 135

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
136 Part II • Development of Hand Skills
Figure 7-27 Spoon feeding at 18 months.
in manipulation. Although the child continues to
explore objects to learn their sensory properties, she
also often “uses” objects for their specific function as
part of a purposeful play activity.
The 2-year-old child uses utensils with competency.
He now has sufficient control of crayon or pencil grasp
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
becomes more successful because the child does not
turn the spoon as it enters the mouth (Figure 7-27).
Spoon feeding and early drawing skills are made
possible by integration of sensory and perceptual
information into blended patterns of mobility and
stability. With improved perceptual-motor integration,
the child imitates a circular stroke, matches a form to a
form space, holds an object with appropriate pressure,
places and releases an object with accuracy, and
demonstrates beginning eye–hand coordination in ball
play. All of these skills indicate an increased ability to
integrate sensory experience and make accurate motor
responses or adaptations to those sensory inputs
(Connolly & Dalgleish, 1989).
PREHENSION: 12 TO 24 MONTHS
By 60 weeks prehension is deft and precise. The child
plans and uses grasping patterns that enable him or her
to act on the object after prehension (Gesell &
Amatruda, 1947). Fingertip grasp is used unless the
object is large and heavy or the situation is stressful for
the child (e.g., being off balance or hurried). The hand
is sufficiently differentiated to hold two cubes in one
hand (Knobloch & Pasamanick, 1974). The child can
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
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
of the object. These underlying hand skills enable the
child to perform a great variety of functional skills (e.g.,
self-feeding, using a spoon, scribbling with a crayon,
building a tower of three cubes, and turning pages of a
book). Practice of these skills leads to emergence of the
pretend play sequences that dominate by 3 and 4 years.
OBJECT RELEASE: 12 TO 24 MONTHS
The need to stabilize a proximal hand or arm part on a
surface to accomplish controlled release (e.g., release
cubes in a cup) continues through 18 months. In
particular, more precise release (e.g., of a small object)
requires the support of a stabilizing surface (Knobloch
& Pasamanick, 1974). Release of a cube in building a
three-cube tower is practiced, and, although generally
successful, alignment of the cubes is imprecise. Typically,
when stacking cubes or small blocks, the infant extends
the fingers all at one time, using more extension than is
necessary to actually release the object. The infant’s
release is graded rather than abrupt, and small wrist,
forearm, and finger movements are used to adjust the
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
most important contribution to the infant’s ability to
place one object on another is internal stability of the
arm while it is held in space, which allows the hands to
act independently.
By the end of the second year the child has well-
developed internal proximal stability and smooth
graded or incremental release patterns. He can open
the hand partially while carefully monitoring whether
the object is correctly placed. Therefore the infant is
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 137
now able to adapt and adjust the hand opening
according to the size, shape, and weight of the object.
Controlled release in the 2-year-old child enables him
to fit puzzle pieces into their form space, place small
objects in a container, turn pages of a book, stack
blocks, and manage a cup and feeding utensils. He can
construct a six-cube tower by precisely centering each
cube and slowly releasing it, using gradual extension of
his fingers. Object release continues to develop over the
next 3 years with significant increases in steadiness,
precision, dexterity, and speed.
BIMANUAL SKILLS: 12 TO 24 MONTHS
From 12 to 24 months the infant develops greater
control of bimanual skills with increasing complexity
and integration of motor patterns. Speed, accuracy, and
dexterity increase. Proximal arm movements become
dissociated from distal arm movements such that the
infant can hold the hands in space to manipulate objects.
He or she also can demonstrate controlled arm move-
ment while maintaining grasp of an object (Exner,
2005). Many of the child’s activities involve one hand
manipulating and the other stabilizing the object. For
example, the child begins to spoon feed while holding
the bowl, scribble with a marker while holding the
paper, bang with a toy hammer while stabilizing the
target toy.
Between 18 months and 2 years the child learns a
variety of bimanual skills that require control of simul-
taneous hand movements involving blended combina-
tions of alternating stability and mobility (Gilfoyle et
al., 1990). Stringing beads, pulling off shoes, and
unwrapping a piece of candy are examples of skills in
the repertoire of the 2-year-old that involve a sequence
of bimanual movements in which the child simul-
taneously controls arm and hand stabilization and
movement (Knobloch & Pasamanick, 1974). These
bimanual movements can be asymmetric and dis-
sociated when the activity requires that two hands act
together in different movements. Two-handed simul-
taneous movement also represents a developmental
step from the earlier pattern of one hand manipulating
and the other stabilizing. Cooperative and complemen-
tary bimanual movements continue to be added to the
child’s repertoire of fine motor skills throughout the
first decade of life. The complexity, speed, accuracy, and
precision of the skills increase with experience,
cognitive development, and neuromotor maturation.
Table 7-1 presents the developmental sequence of
grasp, release, and bimanual skills. Although the devel-
opmental ages for the listed skills vary, the sequence
of development tends to remain consistent across
children; therefore the months listed are estimated ages
when the described skills are achieved.
SUMMARY
The child’s play and the hand skills that enable that play
undergo tremendous developmental changes in the
first 2 years of life. Exploratory play skills evolve from
generalized movements that gather comprehensive
sensory input to specific exploration of the sensory
qualities of objects. After the first year of life, infants
exhibit functional play skills in which objects are used
as means toward a functional goal. Infants learn to use
tools as evidence of their expanding knowledge about
how objects relate and how tools can serve functional
goals. As play skills mature, the infant’s crude prehen-
sion patterns become precise grasping patterns that
enable skillful manipulation of objects. The child holds
objects first in the palm, then in the fingers, and finally
in the fingertips. As she holds objects more distally,
coordination of two hands together evolves, enabling
the child to achieve greater competence and skill in play
and interaction within the environment. This chapter
described how hand skills evolve from reflexive, stereo-
typical patterns into precise, well-controlled prehension
and manipulation patterns.
Current research has investigated how the infant
develops hand skills. Posture, sensory functions, and
perception appear to have essential roles in hand skill
development. The activities and environments that
surround the infant afford a multitude of manipulation
opportunities. Current explanatory models explain
how hand skills develop and elucidate what variables
influence an infant’s developmental trajectory. These
models emphasize the influence of contextual elements
in addition to biological foundations and have applica-
tion in early childhood intervention and education.
138 Part II • Development of Hand Skills

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
 Hand Skill Development in the Context of Infants’ Play: Birth to 2 Years • 139

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
140 Part II • Development of Hand Skills
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OBJECT MANIPULATION IN INFANTS
AND CHILDREN
Charlane Pehoski
CHAPTER OUTLINE
OBJECT MANIPULATION DURING INFANCY
Movements Used in Object Exploration by Infants
Exploratory Nature of Infant Object Manipulation
Object Exploration by the Mouth and Hand
Role of Vision in Infant Object Manipulation
Handling Multiple Objects
Summary and Therapeutic Implications
OBJECT MANIPULATION DURING THE TODDLER
YEARS
Beginning of In-Hand Manipulation
Control over Object Release
Complementary Two-Hand Use
Summary and Therapeutic Implications
OBJECT MANIPULATION IN THE PRESCHOOL AND
EARLY CHILDHOOD YEARS
Studies of In-Hand Manipulation
Role of Variability in Motor Skill Development
Factors Contributing to the Improvement of In-Hand
Manipulation Skills
Summary and Therapeutic Implications
OBJECT MANIPULATION IN OLDER CHILDREN
SUMMARY
The hand is a wonderful tool that has the exploration
and manipulation of objects as its primary purpose. The
development of the hand in the service of object ma-
nipulation follows a long course. It is one of the ways
Chapter 8
children experience success and the perception of com-
petence. Bruner (1973) pointed out that competence
includes not only social interaction but also mastery
over objects.
The theme of this chapter is how the child gradually
gains control over the hand to manipulate objects. Infancy
appears to be a time when reach is perfected and the
basic grasp patterns are developed. At first the infant
can manipulate objects only by grasping the object,
waving the arm, and moving the wrist because the
object is held in a power grip that fixes it in the hand
(Napier, 1956). Gaining the ability to transfer an object
hand to hand greatly expands the actions the infant can
produce with the object, but it is the appearance of a
precision grip (pad of radial fingers to pad of thumb)
that marks a major change in the eventual skills of the
hand. Landsmeer (1962) indicated that the purpose of
a precision grip is to “operate the object with precision
by means of the fingers.” The perfection of this skill
covers a long developmental period. Voluntary release
(e.g., releasing an object in a predetermined place) also
develops in late infancy and is an important component
to skilled object interaction. Like object release, many
of the basic components for skilled hand use are seen
during infancy, but their perfection takes many years.
As an example, the child must learn to control the
release of an object so he or she can place it with skill
and accuracy. In-hand manipulation skills, or the move-
ment of an object in the hand after grasp, are yet to be
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.
This chapter discusses what is known about the
development of these components. There are many
gaps in our understanding of these changes and how
they might impact on the child’s gradual mastery of the
143
144 Part II • Development of Hand Skills
physical world. Given the importance of object
manipulation to human behavior, it is interesting that
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
12 months old), toddler (1 to 2 years old), preschool/
early childhood (3 to 6 years old), and the older child.
In addition, themes that might help us understand the
direction skilled hand use is taking at each of these
stages are explored.
One last note: The hand is the tool of the mind. It
is the mind that directs and guides the hand in the
context of the child’s environment and culture. Object
exploration or manipulation is the result of our desire
to master the physical world. In infancy the basic drive
to explore the world is present and, although the
infant’s physical skills are limited, these skills are used to
gain information about object properties. It is probable
that this drive sets the stage for all future object
exploration and the continued drive toward mastery.
OBJECT MANIPULATION
DURING INFANCY
Manipulation implies that the movement of the object
is done to achieve some purpose or goal; that is, that
the individual is consciously engaged in the activity and
directing the action. By this definition, there was a time
when researchers would not have considered studying
object “manipulation” in the very young infant. Neo-
nates and young infants were considered to be primi-
tive beings dominated by reflexes that would gradually
be integrated so the infant could engage the world.
More recent research has been guided by the belief that
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
visually captured object (Bower, Broughton, & Moore,
1970; von Hofsten, 1982). Although this behavior has
been termed prereaching (Trevarthen, 1974) or pre-
functional (von Hofsten, 1982), it is voluntary and has
purposefulness not seen in more reflexive behaviors.
MOVEMENTS USED IN OBJECT EXPLORATION
BY I NFANTS
Humans are born with the drive to reach out and
explore the physical world. Even as a neonate, the infant
uses primitive motor skills to begin this process. Based
on the observation of infants from 1 month to about
10 to 12 months of age, Karniol (1989) proposed
10 stages in the early object exploration of the infant
BOX 8-1 Ten Stages in the Development of
Object Manipulation in Infancy
ONE TO THREE MONTHS
Stage 1: Rotation: An object is moved by twists of the
wrist.
Stage 2: Translation: There are movements of the arm
that change the location of an object by increasing or
decreasing the distance from self.
Stage 3: Vibration: There are repeated, rapid bending
motions of the arm as the object is held.
THREE TO FOUR MONTHS
Stage 4: Bilateral Hold: The object is held passively in
one hand as the other hand holds or does something
else to another object.
Stage 5: Two-handed Hold: A single object is held
with both hands.
Stage 6: Hand-to-Hand Transfer: An object held in
one hand is transferred to the other.
FIVE MONTHS
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
pulls at the hair).
SIX TO NINE MONTHS
Stage 8: There is coordinated action with two objects:
Manipulation of two objects, each held in a separate
hand, such as hitting two blocks together.
Stage 9: Deformations: The object is made to change
shape, such as tearing paper or pressing a toy to
make a sound.
Stage 10: Instrumental Sequential Actions: There is the
sequential use of two hands in obtaining a goal, as
demonstrated when the infant lifts a cup to obtain a
cube.
Data from Kamiol R (1989). The role of manual
manipulative stages in the infant’s acquisition of perceived
control over objects. Developmental Review, 9:222–225.
(Box 8-1). Three of these stages—rotation, translation,
and vibration—were related to the young infant less
than 4 months old. If an object was placed in the hand
of a 2- to 3-month-old infant, the earliest engagement
Karniol noted was that the infant would rotate or twist
the wrist, but only if the object happened to be visible
to the infant. If the hand was not visible, the object was
dropped. The next actions seen were translation move-
ments, or a deliberate effort to change the location of
an object by moving the arm toward or away from the
body. Often this involved bringing an object to the
mouth or was combined with rotation. Karniol believes
that these movements assist the infant in combining
changes in the retinal image of the object with proprio-
ceptive feedback from the arm. The third method of
engagement that Karniol observed in the very young

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
about 16 weeks of age.
Reach is becoming functional at 4 months of age;
the 4-month-old infant can also bring both hands
together to engage the object at midline. This ability
expands the action that can be taken on objects and is
a necessary first stage of “complementary two-hand
use” (Bruner, 1970). Midline behavior is facilitated by
changes in the general control of the arm and the body
itself. There is better balance in the trunk, as well as
neck flexors and extensors, so the head is held in mid-
line and the child can tuck the chin to better observe
the hands. By 4 months the child can also lie on his or
her back and bring the hands together up into the space
above the body (Bly, 1994). This ability to bring the
two hands together is used by the infant in exploring
objects.
At 3 to 4 months, Karniol (1989) adds bilateral hold
and two-handed hold to the list of options available to
the infant; that is, the infant can hold an object while
the other hand does something else or hold the object
using two hands. In a study of the object manipulation
and exploration of 2-, 3-, 4-, and 5-month-old infants,
Rochat (1989) saw an increase in mouthing in the 4-
to 5-month-old infants over the 2- to 3-month-old
infants, a behavior he found significantly associated with
two-handed grasp. Therefore two-hand support for an
object may assist the infant’s attempts to mouth objects,
increasing the likelihood that this form of exploration
will occur (Figure 8-1). Once midline engagement of
the hands is developed, manipulation also is assisted by
allowing one hand to hold and the other to explore the
surface of the object with the fingers. Rochat (1989)
also saw an increase in this fingering behavior in his
4-month-old subjects.
Further object exploration is possible around 5 to
6 months of age, when the infant is able to transfer an
object hand to hand. This is an important comple-
Object Manipulation in Infants and Children • 145
Figure 8-1 Mouthing of objects is assisted once an
infant is able to use two hands to support the object
(4-month-old infant).
mentary two-hand use stage. Karniol (1989) indicated
that, when this action is first seen, the infant often
rotates the wrist and bends the arm with the object in
one hand and then transfers it to the other hand and
repeats the action. In recording the infant’s exploratory
actions during a 90-second segment with a toy, Rochat
(1989) found that the 5-month-old infants in his study
transferred the toy a mean of three times, whereas the
2-, 3-, and 4-month-old infants transferred the toy a
mean of less than once per trial. Therefore like Karniol’s
infants, Rochat’s infants began to incorporate hand-to-
hand transfer into their exploratory play at about
5 months of age.
By 6 months of age infants have a variety of actions
at their disposal by which they can explore and manipu-
late objects. They can mouth, look, rotate, wave, bang,
finger (run the fingers over the surface of an object),
and transfer the object hand to hand. Nevertheless
grasp at this stage is still dominated by a power grip.
The thumb may be opposed to the fingers when
picking up an object such as a block (Halverson, 1931),
but when a smaller object is grasped, the fingers and
thumb work together so the object is raked into the
hand. By 9 to 10 months of age a major change occurs.
Infants can now isolate the movements of the index
finger and thumb from other movements of the hand
and fingers. They can poke with the index finger and
pick up a small object in a precision grip between the
radial fingers and thumb (Folio & Fewell, 2000). When
studying 6-, 9-, and 12-month-old infants, Ruff (1984)
found an increase in fingering behavior in the older
infants (running the fingers over the surface of an
object), a function she felt was facilitated by the
increased independence of the fingers and increased
146 Part II • Development of Hand Skills
Figure 8-2 Older infants can hold a cube with the
fingers acting independent of the palm. The object no
longer needs to be pressed into the palm but can be
held out on the finger surface (10-month-old infant).
coordination of the two hands. Grasp of an object, such
as a cube, has also changed; the cube can now be held
with the fingers acting independent of the palm, so the
object no longer needs to be pressed against the palm
but can be held out on the finger surface (Halverson,
1931) (Figure 8-2). The ability to move the object out
onto the finger surface, the development of a precision
grip, and the beginning of the differentiation of indi-
vidual fingers are critical to the further development of
skilled manipulation by the hand. Another important
development during this period is the beginning of
controlled release. As an example, it is also at about 9
to 10 months that infants can release a cube into a cup
(Folio & Fewell, 2000).
Therefore because infants’ exploratory actions
become more refined as they gain better control over
their motor abilities, the variety of actions that can be
taken on an object increases. Infants use these motor
skills to explore the properties of the objects they grasp.
That is, infants’ actions with objects are not purely
random but have the characteristics of true exploration.
EXPLORATORY NATURE OF I NFANT OBJECT
MANIPULATION
Although the neonate may be able to accomplish a
primitive form of reach, he or she does not yet have
voluntary control over the grasp of an object but will
hold an object placed in the hand. For the young infant
the mouth is also an instrument of grasp or exploration.
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
functional action”; that is, the hand and mouth are
tuned from the very beginning to actively explore an
object’s functional properties.
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
about object properties. Streri, Lhote, and Dutilleul
(2000) placed either a cylinder or an elongated prism in
the hands of neonates. After they had habituated to the
object (defined as holding time that decreased to one
third of the time on the first two trials or after nine
trials), the infant was either given the same or the oppo-
site object to hold. Holding time increased when the
infant was presented with the novel object. It appeared
that the infants were differentiating between the two
shapes and demonstrating at least a primitive form of
tactile discrimination. Neonates 3 days old can also
differentiate between objects that are smooth or have a
granular surface (Molina & Jouen, 1998, 2004). The
infants in these studies tended to use more pressure
when holding a smooth object and less pressure when
holding a granular object. Molina and Jouen (2004)
believe that neonates’ grip is an exploratory tool that
can be used to process object properties.
The object manipulation of the infant less than
4 months of age is necessarily limited because reach and
grasp are still quite primitive. Yet if an object is placed
in the infant’s hand or the infant happens to grasp an
object once in contact with it, some attempts to explore
the object’s characteristics appear to be present.
Older infants have more physical skills at their dis-
posal that are used to explore object properties. Steele
and Pederson (1977) looked at the difference in manip-
ulation with changes in object properties in 6-month-
old infants. They measured the amount of visual fixation
on the object, as well as the amount of manipulation.

Manipulation in this study was defined as any contact
between the infant’s hand and the object. No attempt
was made to further define the type of manipulation.
Familiar objects the infant had previously manipulated
and novel objects were used. The authors found an
increase in looking and manipulating with novel more
than familiar objects and also an increase in manipula-
tion to changes in shape and texture but not to color.
Of these two variables, texture elicited more manipula-
tive behavior from the infants than changes in shape.
The authors concluded, “the results indicate that an
object that presents different tactile sensations is neces-
ary to produce different manipulative behaviors.”
Ruff (1984) also looked at how infants responded to
different object characteristics. In this study, infants of
6, 9, and 12 months of age were presented with two
sets of blocks that varied in color and pattern; more
importantly, they also varied in surface texture and
shape. Of interest was the observation that the infants
tended to adjust their manipulative behavior to the
different physical characteristics of the objects; that is,
they mouthed and transferred the object more in the
shape series and did more fingering in the texture series
(e.g., blocks with bumps and depressions). In addition,
with increasing familiarity with an object, these explor-
atory actions on the object decreased. This included
looking, handling, rotating, transferring, and fingering.
One behavior, banging the object, did not decrease
over time. The author suggests that this activity may
represent a play behavior unrelated to object explor-
ation. This was also found by Ruff and co-workers
(1992), who further suggested that certain types of
mouthing might not be related to true object
exploration.
OBJECT EXPLORATION BY THE MOUTH
AND HAND
In early infancy object exploration by both the mouth
and hand is a major component in the infant’s inter-
action with objects, particularly the infant 7 months of
age and younger. Ruff and co-workers (1992) indicated
that, in their study, mouthing behavior peaked at about
7 months of age and comprised 27% of the time the
infant was engaged with an object. This fell to 17% for
11-month-old infants. Ruff (1984) suggested that the
decrease in mouthing might result from a better haptic
system becoming available in the hand.
Ruff and co-workers (1992) looked at the explor-
atory behavior of both the hands and the mouth in
5- to 11-month-old infants. They described what they
called active mouthing and distinguished this from
more general actions of objects in the mouth. Active
mouthing was defined as movements of the object in
the mouth by the hand (e.g., being turned in the
Object Manipulation in Infants and Children • 147
mouth) or when the mouth moved over the object.
The authors found a significant association between
active mouthing and then immediately looking at the
object, but not other forms of object–mouth inter-
action (e.g., just holding the object in the mouth).
After a bout of active mouthing the infant immediately
paused to look at the object. They hypothesized that
mouthing with looking might serve an exploratory or
information-gathering function. To study this further,
they presented infants with familiar and novel objects
and noted the forms of exploration used in the two
situations. They found that mouthing with looking and
manual actions such as turning the object, transferring
hand to hand, and fingering all declined as the infant
became familiar with the object but returned when the
infant was presented with a novel toy. Therefore they
suggest that these actions are truly exploratory and a
means of gathering information about objects. Other
actions, such as mouthing without looking, banging,
and waving, did not significantly decline in frequency as
the infants became familiar with the object, and they
indicate that these actions may serve some other
function.
ROLE OF VISION IN I NFANT OBJECT
MANIPULATION
Up to this point we have discussed changes in the
motor system that provide the infant with mechanisms
by which object manipulation and exploration can
happen. We have also indicated that even neonates
appear to use the motor skills available to them to
explore object characteristics. Also important to the
object exploration of infants is consideration of the role
vision plays in driving and supporting this behavior.
Blind infants are significantly delayed in their object
exploration when compared with sighted peers.
Fraiberg (1968) indicated that totally blind infants do
not spontaneously bring their hands to midline for
mutual fingering, as seen in the 4-month-old sighted
child. She argued “that there is good reason to believe
that the mutual fingering games and the organization
of the hands at midline are largely facilitated by vision
and that the tactile engagement of the fingers requires
simultaneous visual experience to insure its pleasurable
repetition.” She also indicated that the hands of the
totally blind infant do not explore objects, but serve
primarily to bring the object to the mouth.
Consequently it appears that, for the normally
sighted infant, vision is an important motivator that
leads the hand into space and serves to facilitate grasp
and manipulation. Even in neonates manual activity
appears to be directed by visual information. Molina
and Jouen (2001) presented 3- to 5-day-old neonates
with one of two objects. One object was smooth and
148 Part II • Development of Hand Skills
the other granular (same objects used in the studies
mentioned previously). In a pretest period one of
the objects was placed in the infant’s hand without the
infant being able to see the object. The time until the
object was dropped and the amount of pressure exerted
on the object were measured. After this pretest period
the object was placed back in the infant’s hand at the
same time a smooth or granular visual object was pre-
sented on the table in front of the infant. Therefore the
child was holding one object and looking at another
object that was either the same or a different texture than
the one being held. The holding time and pressure on
the held object were measured again. The visual object
was then removed and the holding time and pressure
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
matched increased but holding time remained the same
when the visual and tactile objects were mismatched.
Molina and Jouen (2001) feel the results indicate that
the infant is comparing the held object with the visual
object. If the infant finds differences between the tactile
and visual object, the process of comparison is stopped.
That is, holding time decreases because the “problem”
the child was given is solved. Alternately, as long as no
differences are observed between the tactile and visual
object, the process of comparison is ongoing and explo-
ration time is increased. Therefore the authors feel that
vision and touch are interconnected even at birth and
that neonates can make some comparisons across these
two modalities.
The role of vision also can be seen in older infants.
As indicated, Karniol (1989) found that when a 2-
month-old infant grasped an object, he or she would
rotate it but only if the hand could be seen. If the hand
was out of visual regard, the object would be dropped.
In his study of 2- to 5-month-old infants, Rochat
(1989) looked at what infants did first with an object.
Did they immediately bring it to the mouth or did they
first bring it to the eyes to look at it? (The infants were
all seated in slightly reclining infant seats.) He found
that at 2 to 3 months more than two thirds of the
infants first brought the object to the mouth. At 4 to 5
months the majority of the infants first brought the
object into the field of vision for inspection. This was
particularly true of the 5-month-old infants, in whom
visual exploration was used first in 90% of the sample.
Rochat (1989) also indicated that fingering of an
object by infants might be linked to vision. In one
study using 2-, 3-, 4-, and 5-month-old infants, the
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
manipulated objects in dark and light situations. The
dark situation was accomplished using an infrared light
and a video camera sensitive to this light. He found that
fingering was dramatically decreased in the dark situa-
tion, whereas the incidence of mouthing and hand-
to-hand transfer remained the same in the two
experimental conditions. The author indicated that
early fingering appears to be linked to vision and depends
on this modality. Alternately, mouthing appears to be
independent of vision, and in this study early hand-to-
hand transfer also did not seem to depend on vision.
Therefore it appears that, at least in younger infants,
vision is an integral part of the process of grasp and
manipulation, and in fact may be the early motivator for
object exploration and drive some of the more refined
manipulative actions, such as fingering of an object.
HANDLING M ULTIPLE OBJECTS
Effective object manipulation also requires that the
infant solve the problems of how to deal with more
than one object at a time. Bruner (1970) attempted to
look at what he called “taking possession of objects” by
presenting infants with a small toy and then presenting
a second toy to the same hand. If the infant did not
make an attempt to secure the second toy, it was then
held at midline. After two toys were grasped, the infant
was handed a third and fourth toy and the child’s
solution to this multiple object problem was observed.
Bruner found that 4- to 5-month-old infants had diffi-
culty managing two objects. Often, as the infant’s
attention was attracted to the second toy, the held toy
was dropped. The 6- to 8-month-old infants were able
to solve the two-toy problem by transferring the initial
toy to the other hand and then grasping the second toy.
Solving the problem of three objects required a dif-
ferent strategy that was not seen until 9 to 11 months;
that is, when offered the third object, the older infants
“stored” one of the objects he or she had been holding
on the table or lap. But half the infants of this age then
retrieved the stored object immediately. They did not
appear to be able to inhibit the drive to pick up what
they saw or could not delay this process. By 12 months
the infants had the solution of this problem well “in
hand.” They not only transferred the first object to the
other hand in anticipation of receiving the second
object, but also anticipated the third and fourth by
storing the toys in hand in the lap or the arm of the
chair. By 15 to 17 months the infants also stored by
handing objects to the parent or examiner. Therefore
by 12 months and older, infants have learned to deal
with several items at one time.
SUMMARY AND THERAPEUTIC I MPLICATIONS
As infants gain control over the movements of their
arms and hands, they also increase the options available
 Object Manipulation in Infants and Children • 149

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-
150 Part II • Development of Hand Skills
term infants (preterm infants’ age corrected for
prematurity). They found a significant decrease in the
incidence and amount of fingering, transfer, and
rotation of objects in the high-risk group compared
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
(<29 weeks’ gestation or <1000 g) until 5 years of age.
At 5 years, 64% of the children scored below 1 standard
deviation on the Peabody Developmental Fine Motor
Scales.
The quality of an infant’s object interaction can pro-
vide important observational information and assist in
providing caregivers with suggestions for an infant’s
continued development. Infants learn about their phys-
ical world through their manipulative actions. These
activities offer the infant an opportunity to experience
a sense of success and mastery and may provide ex-
periences on which later cognitive strategies can be
based. These experiences may not be readily available
to the physically handicapped infant, and this child
needs to be assisted through proper positioning and the
selection of appropriate toys.
Assistance has been shown to increase object engage-
ment in typically developing infants. Lobo, Galloway,
and Savelsbergh (2004) found an increase in the num-
ber of contacts made to a toy by 2- to 3-month-old
infants after 2 weeks of increased experience with toys.
In this study the infants either were manually assisted
in contacting an object at midline or the limb was
tethered to an overhead toy with a ribbon so that limb
movements moved the suspended toy.
In another study, Needham, Barrett, and Peterman
(2002) studied 3-month-old infants after an enrich-
ment experience that consisted of 12 to 14 parent-led
play sessions, each about 10 minutes in length. During
the sessions the infants wore mittens with Velcro
covering the palmar surface. They were then presented
with small toys that had the alternate side of a Velcro
strip attached to the toy. The study design also included
a group of infants whose parents were instructed to
follow their normal daily routine during the 2 weeks of
the study. After the 2 weeks, the infants in the experi-
mental condition produced more intentional swats at
objects than the infants in the control condition. They
also showed greater switching between visual and oral
exploration. The authors conclude, “Experiences
acting on objects may be a critical factor in increasing
infants’ engagement in objects and their object explora-
tion skills. Not only do infants explore objects more
after this experience, they employ more sophisticated
object exploration strategies that involve more co-
ordination between visual and oral exploration.”
Object exploration is an important part of develop-
ment, even for the very youngest infants. The more we
know about how typical infants interact with the objects
in their environment, the more effective we are in
encouraging this area of development in infants for
whom this is felt to be an area of concern.
OBJECT MANIPULATION DURING
THE TODDLER YEARS
Compared with those of the infant, the manipulative
skills of the toddler show great strides in development.
Unfortunately, we know this more from intuition than
actual research. Toddlers can do more than “grasp” an
object; they begin to manipulate the object in their
fingers and hands. Release of an object also has im-
proved, and these two skills allow the child to interact
effectively with smaller objects. It is also at this age that
children start to demonstrate complementary two-
hand use, greatly expanding their manipulative abilities.
Each of these areas is explored.
BEGINNING OF I N-HAND MANIPULATION
In discussing the fine motor abilities of the 12-month-
old child, Gesell and co-workers (1940) stated that the
child’s “prehensory patterns are approaching adult
facility … fine prehension is deft and direct.” That is,
the child has a neat pincer grasp and can use it with
skill. As indicated, this is an important achievement
for the child, but these prehensory patterns must be
changed to manipulatory patterns for true hand skill
to develop. As an example, 12-month-old infants can
pick up a small object such as a Cheerio very well, but
if provided with several Cheerios in the hand, their
manipulative skills are challenged. Young children
generally solve this problem by bringing the entire
hand to the mouth rather than moving the object
within the hand. Therefore one of the tasks in the next
few years is to take the “deft and direct” prehension
patterns they have learned and develop the capacity to
manipulate objects in the fingers and in the hand.
Exner (1990, 1992, 2001; see also Chapter 12) has
called this ability in-hand manipulation or the adjust-
ment of an object in the hand after grasp. The purpose
of these adjustments is to allow more efficient place-
ment of the object in the hand for use or voluntary
release. Three components of this skill have been
defined. One is the ability to move an object from the
fingers to the palm or the palm to the fingers (e.g.,
picking up a coin and placing it in the hand and then
moving the coin from the hand to the fingers for
placement in a bank or purse). Exner refers to these as
translation movements. Another component is the
ability to rotate the object in the pads of the fingers,

either through simple rotation, in which the object is
rolled or turned in the fingers, or more complex rota-
tion movements. In more complex rotation movements
the object is generally rotated at least 180º, and the
movement requires independent action of the fingers
and thumb. The third component is shift, or the move-
ment of an object in a linear direction on the finger
surface. The thumb often performs most of this move-
ment with reciprocal movements of the radial fingers
such as moving a pencil after it has been grasped so
the fingers are closer to the point (Exner, 1990). In
addition, these activities can also be accomplished while
another object is stabilized in the hand. An example of
a palm-to-finger movement with stabilization is when
several small objects are held in the hand and one of
them is moved to the fingers for placement, such as
when one of several Cheerios is moved from the palm
to the fingers for placement in the mouth. Children in
the toddler years are not yet adept at all components of
in-hand manipulation.
In her original pilot study, Exner (1990) looked at
the in-hand manipulation skills of 90 children 18 months
to 6 years 11 months old. The developmental trend in
these skills indicated that moving an object like a small
peg from the fingers to the palm for storage, then
moving it back out to the fingers, and simple rotation
were three of the easiest tasks and were accomplished
by at least half of the 18-month to 2-year-old children
in her study. Other tasks, such as the complex rotation
of a pen in the fingers so the point is in a position for
use, were more difficult and not accomplished until the
preschool years. Exner (1990) indicated that skills that
do not involve simultaneous stabilization of materials
during in-hand manipulation activities are easier than
those in which the child must control both sides of the
hand (ulnar side to hold and radial side to manipulate).
Exner (1992) also indicated that the amount of indi-
vidual finger movements necessary for a task may make
one component of in-hand manipulation more difficult
than another; that is, the ability to move an object such
as a peg from the fingers to the palm is a relatively easy
task because the fingers tend to work as a unit. How-
ever, rotating a pen in the fingers for use requires the
sequencing of individual movements among the radial
fingers and the thumb. Although the 12-month-old
child has the ability to isolate the index finger and can
use the index finger or radial fingers and thumb to pick
up a small object, there is reason to believe that further
isolation of finger movements is still difficult for the
child under 3 years of age.
As an example, Stutsman (1948) looked at the
ability of young children to make a fist and wiggle the
thumb without moving the fingers. She states that this
task “appears rather suddenly at 33 months.” Gesell
and co-workers (1940) also talked about the ability to
Object Manipulation in Infants and Children • 151
wiggle the thumb (or voluntarily isolate the movements
of the thumb) as being a skill observed in 2-year-old
children. The ability to move the fingers individually
seems to come later. When Stutsman (1948) asked young
children to oppose each finger to the thumb, she found
that this was possible for only three of the children she
observed who were between 30 and 36 months of age.
By 36 to 41 months, 35% of the children accomplished
the task, but it was not until 42 to 47 months that 50%
of the children were successful. It appears that isolated
movements of individual fingers are difficult for children
3 years of age and younger, and this may be a major
deterrent to the ability to accomplish deft and direct
manipulatory patterns of objects in the fingers.
Another factor that may limit the toddler’s in-hand
manipulation skills is the force of the grip used to hold
an object. When the grip strength was measured as
children and adults picked up a small object between
the thumb and index finger, children were observed to
use greater grip force than adults (Forssberg et al.,
1991; see also Chapter 3). This was particularly true for
children 5 years or younger. When the steps necessary
to prepare to lift a small object also were carefully
measured with instruments sensitive to changes not
observable to the eye, it was found that it took longer
for young children to prepare to lift the object.
Children 8 months (the youngest group of infants
studied) to 18 months old demonstrated a significantly
longer time from when the lead finger or thumb
touched the block to when the second finger or thumb
arrived. Small children also were noted to contact the
object several times before a stable grip was established,
and they also had a tendency to push down as they
were gripping. Forssberg et al. (1991) indicated that
this preparatory stage was three times longer in infants
under 10 months old and about twice as long in
children less than 3 years old.
Therefore if young children have difficulty isolating
finger movements, are slow in preparing for a grip (at
a micro level), and tend to grip objects harder in their
fingers than adults, then in-hand manipulation skills
that require the grasp and release of an object and the
coordination of these movements among different
fingers are quite difficult or impossible. This also is true
of older children with deficits or marked delays in these
areas. As an example, fasteners on clothes, particularly
buttons, require manipulation skills by the fingers. For
many children under 3 years of age, this is a difficult
task. Another task that requires isolated movements of
the fingers is the ability to move a pencil or writing im-
plement in a dynamic tripod grip. This is also difficult
for many children under 3 years of age (Rosenbloom
& Horton, 1971; Saida & Miyashita, 1979; Schneck
& Henderson, 1990). Despite these limitations, the
toddler is beginning to experiment with simple in-hand
152 Part II • Development of Hand Skills
manipulation tasks such as picking up and storing
several objects in the hand. These functions improve as
the child gains more control over the movement of
individual fingers and refines the force of grip.
CONTROL OVER OBJECT RELEASE
The child 12 months to 2 years of age is gaining con-
trol over the release of objects. This is an area that has
not been widely studied, even though Gesell and co-
workers (1940) state that release is “one of the most
difficult prehensile activities to master in early life.”
These authors point out that it is the inability to release
a cube properly that often causes the infant to fail when
attempting to build a two-block tower. Efficient object
release requires both the regulation of grip force with
the timing of the placement of the object so the object
is not “dropped” but precisely placed (Eliasson &
Gordon, 2000). At 2 years of age, the child can build a
tower of several blocks, but may press rather than place
the block, often with enough force that the structure
falls (Gesell et al., 1940). Gesell and co-workers (1940)
also note that, even at 3 years of age, the child may still
have difficulty with release on more delicate tasks. For
instance, the child may pull the lace out when the hand
is moved away while lacing shoes. Controlled release is
an important component of object manipulation. In
many in-hand manipulation tasks the object is grasped
and then repositioned by delicate grasp–release move-
ments of the fingers. The development of this ability,
particularly the ability to release without the need to
press down or use a supporting surface and to remove
the fingers from the object surface with correct timing,
is a valuable area for future research.
COMPLEMENTARY TWO-HAND USE
Complementary two-hand use is an important skill that
develops between 12 months and 2 years of age
(Bruner, 1970). As indicated in the previous section,
the infant’s ability to use two hands in the manipulation
of an object greatly expands the exploratory options
available. Nevertheless, being able to hold an object in
each hand, or even the ability to hold an object in one
hand while acting on this object or manipulating
another, does not take advantage of the potential skill
achieved when both hands are active at the same time.
This requires that the child be able to program or
motor plan different but complementary actions with
the two hands. This ability is more than just pro-
gramming a holding function for one hand and a doing
function for the other. It involves the monitoring of
active movements of both hands at the same time.
There is reason to suspect that this skill is not present
until 2 years of age. To look at the development of
complementary two-hand use, we now step back and
briefly look at the younger infant to observe the
transition to higher-level activities.
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
sliding, transparent lid to obtain a toy. Bruner found
that the 6- to 8-month-old infants in his study tended
to just bang or claw at the lid itself. In fact, this activity
often appeared to distract the infant from the toy, and
banging became the main activity of interest. He
indicated that this behavior also was common in 9- to
11-month-old infants. In addition, another common
behavior of infants of this age was to open and close the
lid, becoming distracted by this activity and not
attempting to retrieve the toy. Another behavior that
was seen in these younger infants was the opening of
the lid with one hand and then slipping the same hand
into the box with the other hand not participating at
all. At 12 to 14 months, the infants added another
approach to the solution of the problem; to raise the lid
with one or two hands and go after the toy with the
free hand but to let go of the lid during the retrieval
attempt. Even at 17 months, which was the oldest
group of infants studied, the activity was not yet well
mastered.
Ramsay and Weber (1986) used a similar task in
looking at this skill in 12- and 13-month-old infants
compared with 17- and 18-month-olds. They found
their infants to be a bit more competent than Bruner’s
(1970), which in part may have been related to differ-
ences in the testing apparatus. Ramsay and Weber also
had a box with a transparent lid, but this lid was hinged
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
provided the children with a clue as to how to solve the
problem. Ramsay and Weber state that in their study
use of only one hand was rare and seen only in the
younger age group. The most common method of
approach was to lift and hold the lid with one hand and
to retrieve the toy with the other hand. They found this
approach to be used an average of 50% of the time in
the 12- to 13-month-old children and 78% of the time
in the 17- to 19-month-old group. The younger children
also used a strategy in which both hands opened the lid,
and then one hand held as the other hand retrieved the
toy. This was seen an average of 37% of the time in the
younger group and only 12% of the time in the older
infants. Another strategy that was used almost equally
by both groups of infants was to lift the lid with one
hand, then transfer the hold of the lid to the free hand,
and retrieve the toy with the hand that originally
opened the lid (used 13% of the time by the younger
infants and 10% of the time by the older group).

Stutsman (1948) has commented on this function in
children. She states that the “inability to perform dif-
ferent movements with the two hands at the same time
seems to be characteristic of the child under 36 months
of age.” One of the tasks she presented to young
children was to give them a long string attached to a
toy that was lying on the floor. The child was instructed
to pull in the string to attempt to get the toy. Unsuc-
cessful attempts included walking over to pick up the
toy or only yanking the arm back to partially move the
toy forward. The problem was correctly solved only
when the child managed to pull in the string hand over
hand to obtain the toy. She found that 90% of the 30-
to 35-month-old children in the normative sample
were able to solve the problem, and 60% of the 24- to
29-month olds, but only 22% of the 18- to 23-month-
olds. Stutsman (1948) also lists scissor cutting as a
striking measure of bilateral hand use (Figure 8-4, A).
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.
Another task that requires complementary use of
two hands is bead stringing (Figure 8-4, B). Often
young children who are unsuccessful in this task seem
to have an idea of how to proceed but have difficulty
A because the activity often is not successful unless the
B when compared with adults. The subjects were asked to
Figure 8-4 (A) Scissor cutting, and (B) bead stringing
are two of the tasks that readily demonstrate a young
child’s ability to use both hands together in a task.
Object Manipulation in Infants and Children • 153
with the complementary two-hand aspect of the task.
They place the string correctly into the bead but then
do not seem to know how to transfer the activity
between the two hands to complete the task. Almost all
studies place the successful accomplishment of bead
stringing at 2 years of age (DuBose & Langley, 1977;
Folio & Fewell, 2000; Gesell et al., 1940). As an
example, in the Peabody Developmental Motor Scales
(Folio & Fewell, 1983), the ability of young children to
string three beads is examined. The authors found that
this task could be accomplished by only 16% of the 18-
to 23-month-old children in the normative sample, but
by 70% of the 24- to 29-month-old children, which
represents a significant change in behavior over a
relatively short time. It appears that something happens
that allows this task to be successfully completed. It is
probable that a major factor in this success is the
emergence of complementary two-hand use.
SUMMARY AND THERAPEUTIC I MPLICATIONS
The child at 12 months to 2 years of age has made
marked strides in the development of the control
necessary for refined object manipulation by the hand
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,
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
pick up boxes of varying size (0.08 to 24.2 cm) and
place them in another slightly larger box. The authors
found that young children and adults predominantly
154 Part II • Development of Hand Skills
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
should be considered when planning activities for small
children.
OBJECT MANIPULATION IN THE
PRESCHOOL AND EARLY
CHILDHOOD YEARS
Age 3 through 6 years appears to be a time when the
child is gaining control over the intrinsic movements of
the hand. One of the major changes seen during this
period is the continued emergence of in-hand manip-
ulation skills. This ability greatly expands the activities
the child can accomplish. For example, at 3 to 7 years
old the child learns to deal with the fasteners on clothes,
and cuts, pastes, and manipulates writing instruments.
These tasks require both cooperation between the two
hands and the ability to manipulate objects in the
fingers and hand.
STUDIES OF I N-HAND MANIPULATION
Buttoning is one of the representative manipulative
skills that has been studied during this age period.
Stutsman (1948) indicated that no child in her
normative sample who was under 23 months of age was
able to manage the button on a one-button strip, and
only 9% of 24- and 29-month-olds successfully com-
pleted this task. This is not surprising considering the
difficulty children of this age have in differentiating the
movements of individual fingers, as well as efficient use
of the two hands together. She found a major change
in the ability of 30- to 35-month-old children. In this
age group 72% of the sample was successful (Figure 8-5).
Despite the 30- to 35-month-old children’s ability to
perform the task, their efficiency or speed was markedly
different from that of older children. For example,
Stutsman found that it took an average of 170 seconds
for the children in her 30- to 35-month-old sample to
button two buttons, whereas 12 months later, at 42 to
Figure 8-5 Buttoning is a task that requires both
efficient use of the two hands together and the ability to
differentiate the movements of individual fingers. It is a
complex manipulative skill that is not accomplished well
until the preschool years.
47 months of age, the children completed the task in
34 seconds. Folio and Fewell (1983) found similar
results when they asked children to button and
unbutton one button in 20 seconds. Only 2% of the
normative sample at 30 to 35 months could accomplish
the task, whereas at 48 to 59 months 65% of the
children were successful. Therefore, despite the ability
of many 21⁄2-year-old children to accomplish buttoning,
the speed with which the activity is performed is so
slow as to preclude it from being functional. Are the
younger children slower because the basic movements
themselves are not as efficient, or are they using less
efficient methods than older children?
Pehoski, Henderson, and Tickle-Degnen (1997)
looked at this question using an in-hand manipulation
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
task). A group of adult subjects also was presented this
task to establish a standard against which the children’s
performance could be judged. All the children sampled
were able to accomplish the task, but the time they
took for completion and the methods they used to
perform this activity differed among the age groups.
The time for completion decreased with age, as did the
variability in time scores within an age group, but even
at 6 years 11 months the children were significantly
slower than the adults. Of the age groups of children
tested, the 3-year-olds were by far the slowest group
and differed significantly from the other age groups.
Perhaps of more interest was the finding that the
methods the children used to accomplish this task
differed. In the sample of normal adults, Pehoski and
co-workers (1997) found that all the subjects used the
same method to perform this task. Each of the adults
picked up the 10 pegs and rotated them using a series
of individual movements of the two radial fingers and
 Object Manipulation in Infants and Children • 155

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
were more varied, and often the children mixed the use
of more than one method in the repetitions of this task.
Many of the children were able to demonstrate use of
the adult method (Figure 8-6, A), but they also used
two other approaches when solving this problem. One
was to use an external surface against which the peg
was turned, such as holding the peg against the chest as
it was rotated (Figure 8-6, B). Inadvertent use of the
other hand also was considered as using an external
surface. (The children were instructed to hold a vertical
post with their nonpreferred hand in order to
encourage in-hand manipulation by one hand alone.)
The other method was to rotate the arm before picking
up the peg so that the peg was turned through the
derotation action of the arm, thereby excluding or
simplifying the need for individual finger movements
(Figure 8-6, C). Use of the adult method increased
with age, although even at 6 years this method was
used only 80% of the time.
Of interest was the marked change to an adult method
seen in 48- to 53-month-old children. The 3-year-olds
in the sample relied heavily on the use of an external
surface when turning the peg. This method was used
an average of 40% to 50% of the time by the two
youngest age groups. By 48 to 53 months this method
had fallen to 25%, and the predominant method used
was that of the adults (used 70% of the time). That is,
by 4 years of age the children were rotating the peg in
the fingers and used this method as the predominant
solution to the problem (Fig. 8-7).
ROLE OF VARIABILITY IN MOTOR SKILL
DEVELOPMENT
Variability in the methods or grasps used when
developing a new motor skill is a common finding in
children. It has been described in studies of infant reach
(Thelen et al., 1993), the placement of pegs in a hole by
12-month-olds (Moss & Hogg, 1983), the emergence
156 Part II • Development of Hand Skills
100.0
90.0
80.0
70.0
Percentage
60.0
50.0
40.0
30.0
20.0
10.0
0.0
3.0 3.6 4.0 4.6 5.0 5.6
Age
Adult
Internal
method rotation
Figure 8-7 Percentage of times each of three methods
was used when attempting a simple rotation task by
children 3.0 to 6.6 years of age. (From Pehoski C,
Henderson A, Tickle-Degnen L [1997]. In-hand manipulation
in young children: rotation of an object in the fingers.
American Journal of Occupational Therapy, 51:544–552.)
of self-feeding in toddlers (Connolly & Dalgleish,
1989), and the use of writing implements in 3- and
5-year-old children (Greer & Lockman, 1998). The
performance of adults on these same tasks is much
more stable. A dynamic systems approach to develop-
ment indicates that infants and children initially explore
different ways of accomplishing a task and that these
trials are based on the intrinsic dynamics of a particular
child (Thelen & Smith, 1994). These dynamics might
include such things as muscle tone, body dimensions,
and temperament. As children encounter their environ-
ment and explore different forms of an action for a
given task, they eventually settle on one form that is
most effective and efficient for them (Greer &
Lockman, 1998; Thelen & Smith, 1994). In this
dynamic systems theory of development, variability in
performance is viewed as a sign that the system is in
transition and working toward a more stable perform-
ance. Although the goal may be the same for each child
(e.g., to hold a spoon in a manner that allows food to
be brought efficiently to the mouth, hold a pen to
make a specific mark on a paper, or turn a peg over in
the fingers), the various methods the child uses as he or
she learns these skills depends on individual intrinsic
dynamics. Therefore variability is seen as a develop-
mental process that includes both physical change and
experience. Children who are having difficulty with this
process and are slow to develop a stable performance
may need more time or experience practicing a task.
They also may benefit from an attempt to analyze the
intrinsic factors that may be limiting them so that
changes or adaptations can be made to the implements
or methods used.
FACTORS CONTRIBUTING TO THE
I MPROVEMENT OF I N-HAND
MANIPULATION SKILLS
What are some of the physical aspects that change to
allow an increase in speed and a more consistent, adult
method of performance? The adult method of turning
over a peg using only one hand requires the differen-
tiation and change in performance between the two
6.0 6.6 Adult radial fingers and the thumb. As discussed, the ability
to differentiate the movements of the individual fingers
(e.g., the ability to sequentially oppose the fingers to
Surface or
other hand the thumb; Stutsman, 1948) seems to appear at about
42 to 47 months of age. Once present, there is a
gradual increase in the speed of these movements. As
an example, the Peabody Developmental Fine Motor
Scales (Folio & Fewell, 1983) looks at the ability of
children to oppose each finger to the thumb within
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
successful. The ability to isolate individual fingers of the
hand and perform this activity with speed appears to
be a requisite skill for efficient in-hand manipulation
activities and may be one of the reasons children 4 years
of age and older are better at in-hand manipulation
skills than are children 3 years old or younger.
Manipulating an object such as a peg in the fingers,
rotating a pencil so the tip is in the correct position to
write, and turning a small bead in the fingers to orient
the hole for stringing all require a grip that is firm
enough to keep the object from being dropped but
light enough to allow the object to be moved. In the
study by Forssberg and co-workers (1991), children
were noted to use significantly greater grip force than
adults when picking up a small object. In adults the
force of the grip is matched to the properties of an
object (e.g., its weight and frictional qualities), and
determining this force is related to tactile feedback
from the hand (Westling & Johansson, 1984). Adults
use just enough force to provide a small margin of
safety so the object does not slip out of the fingers. If
the adult’s fingers are anesthetized, eliminating the
tactile feedback that monitors the frictional conditions
between the object and the fingers, the ability to adjust
the grip force is compromised. Therefore tactile feed-
back is necessary for the successful accomplishment of
this skill. It is also interesting to note that Westling and
Johansson (1984) found that the adults in their study
with the greatest manual dexterity were also those who
employed the smallest safety margins.
Evans, Harrison, and Stephens (1990) have looked
at the maturation of cutaneous reflexes in children. To
do this they stimulated the cutaneous nerve of the

index finger and monitored the EMG response while
the first dorsal interosseous muscle was actively con-
tracting. The authors did not observe a full adultlike
EMG response until the early teen years. As an exam-
ple, the adult EMG response to digital nerve stimula-
tion has three components: an initial increase in muscle
electrical activity, followed by a decrease, and finally a
second, prominent increase. The last of these com-
ponents, called the E2 component, is felt to require the
integrity of the dorsal columns (tract carrying dis-
criminative somatosensory information to the cortex).
In the Evans and co-workers (1990) study, the E2
component was not seen until 4 years of age, and then
there was a gradual increase in the number of children
who demonstrated this aspect of the response until 12
years of age, when all children exhibited an E2 response.
Of further interest was the finding that children who
did not demonstrate an E2 component were more
likely to perform poorly on a test of rapid finger move-
ments; therefore the appearance of this component of
the cutaneous reflex response may be implicated in the
speed of finger movements.
SUMMARY AND THERAPEUTIC I MPLICATIONS
Children between the ages of 3 and 6 years are making
rapid improvement in their ability to manipulate
objects in the fingers and hand. This is still a difficult
task for many 3-year-old children, and an activity such
as buttoning is just beginning to be done with enough
speed to make the task functional. Other activities, such
as rotating a small object in the fingers, is still difficult
for the 3-year-old, and the child is likely to substitute
another method for the movements of the fingers (e.g.,
rotating the object against an external surface). The
fourth year of age may be a time of marked change in
these abilities, particularly the complex rotation of an
object in the fingers. Pehoski and co-workers (1997)
found that children at this age tend to switch from
using an external surface when rotating a small peg to
accomplishing the task with the fingers. Five- and six-
year-old children continue to show improvement in
these skills, although this improvement is not as
marked (e.g., the difference in improvement among
the 4-, 5-, and 6-year-old subjects is not statistically
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 &
Horton, 1971; Saida & Myashita, 1979; Schneck &
Henderson, 1990).
Of interest is that several other physical functions
also appear to be changing around 4 to 5 years of age.
As an example, Forssberg and co-workers (1991) found
that after 5 years there was no significant difference in
Object Manipulation in Infants and Children • 157
the grip force between a population of adults and
children when the subjects were asked to pick up a
small object between the index finger and thumb. As
indicated, the regulation of the grip force rate on this
task has been linked to tactile mechanisms. Evans and
co-workers (1990) found that an important compo-
nent of the cutaneous reflex is not present until 4 years
of age and that the appearance of this component may
be linked to the speed of sequential finger movements.
The strength of the grip force and the ability to
rapidly sequence the movements of the fingers are im-
portant components in the manipulation of an object in
the fingers or the hand. Vision can guide the hand to
the target, but tactile mechanisms guide the object in
the hand. Nature may well have a rule that says, “Use
whatever mechanisms you can to manipulate an object,
but whatever you do, don’t drop it!” This rule is
ensured by tactile mechanisms that detect even minor
slippage of a hand-held object and tell the motor
system to increase or adjust the grip (Johansson &
Westling, 1984). If these mechanisms are immature,
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
were asked to rotate a peg and replace it in the board,
dropping the peg was not a common finding. No child
dropped more than one of the 10 pegs, and approxi-
mately half the children dropped no pegs at all. When
working with children, a tendency for objects to be
dropped from the fingers should be noted. When this
is felt to be excessive, one possible area to consider is
the integrity of tactile motor mechanisms.
Another point to note when evaluating children is
that most tests for children in the preschool and early
childhood years do not include items that assess in-
hand manipulation skills. Therefore the evaluator may
wish to add tasks of this nature, particularly for the
child who is 4 years of age and older, so these skills can
be observed. As an example, first-grade children’s in-
hand manipulation skills are one of the factors that
differentiate good from poor handwriting (Cornhill &
Case-Smith, 1996); and the speed of rotation of small
pegs in a peg board in preschool children has been
shown to significantly correlate with a test of self-care
(Case-Smith, 1996).
OBJECT MANIPULATION IN
OLDER CHILDREN
Information about the object manipulation of older
children is limited. We do know that the speed of
movement and a decrease in variability of movement is
characteristic of older children. Finger movements get
158 Part II • Development of Hand Skills
faster from 6 to 12 years of age (Garvey et al., 2003),
as does the reaction time from the start signal for a
reach and the actual movement to reach (Kuhtz-
Buschbeck et al., 1998). Muller and Homberg (1992)
indicate that the maturation of the motor cortex and
corticospinal efferents is the main determinant of speed
in repetitive movements in children. They indicate that
the conduction times for afferent pathways reach adult
levels by the age of 5 to 7 years, and for efferent
pathways by 10 years (Muller & Homberg, 1992). In
reaching, the trajectory of the arm becomes smoother
and less variable (Schneiberg et al., 2002) with age. The
number of units per reach decline, so that by 12 years
only one acceleration-deceleration is seen (Kuhtz-
Buschbeck et al., 1998). Older children also are better
at adjusting the grip size to the size of an object; 4-
year-olds use a wider opening than do 12-year-olds
when grip opening is adjusted for hand size (Kuhtz-
Buschbeck et al., 1998). The coordination of the forces
necessary to lift an object from a surface and the force
in the fingers to hold the object during the lift also
improve with age (see Chapter 3).
Accuracy is improving, as is the timing of motor
acts. One form of timing has been called coincidence-
anticipation, or the ability to time a movement with
another moving object. Bard, Fleury, and Gagnon
(1990) suggest that this skill may improve linearly with
age until it levels off at around 15 years. However, the
authors also state that “further progress is sometimes
noticed beyond this age in tasks with high degrees
of stimulus uncertainty and motor response difficulty,
thus placing a greater burden on decision and motor
processes”.
Another area in the literature that indicates con-
tinued changes in older children is in complementary
two-hand use. As the child grows, the complexity of
bimanual task that can be completed expands, as well as
the efficiency between the two hands. Brumi (1972)
looked at the abilities of 5-, 8-, and 10-year-old children
to string beads, wind a string on a spool, and clap the
hands. The author found that the older children tended
to keep one hand stable while the other moved (e.g., in
winding the thread both hands did not rotate in mirror
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
hands. She suggests that improved interhemispheric
communication may assist this process.
We know that children get faster with age so that the
timing of movements improves. Variability decreases.
Reach is smoother. Bilateral hand skills also become
more complex and efficient. The adjustment of grasp
and the coordination of grasp and lift movements
improve. Many of these improvements are the result
of maturation in motor mechanisms combined with
environmental challenges that encourage children to
practice and advance their skills. Older children also
show improved judgment and better control over
impulsive behavior, which also improve the accuracy
and quality of skilled motor activities.
SUMMARY
Efficient object manipulation depends on several
factors. There is the necessity to be able to differentiate
the movement of individual fingers and to perform this
action with speed. Manipulation skills also depend on a
grip force that is firm enough to keep the object from
dropping, but loose enough so that the object can be
moved with ease. This ability apparently is dependent
on tactile mechanisms. In addition, an object also must
be released with skill and the appropriate timing. The
ability to use the hands together is important also. With-
out the ability to plan and use both hands together in
a complementary fashion, the function of the hands is
severely limited. Maturation in each of these abilities
assists the child’s mastery over objects and struggle
toward competence.
There is still much that is not known about the
developmental course and changes in development that
emerge as the child engages the objects in his or her
environment. We need more information on how normal
children develop manipulative skills. As an example, we
know very little about the beginning of in-hand manip-
ulation. There are no studies on the development of
controlled release, a process that probably follows
closely on how children grasp objects. The gradation of
pressure as a child picks up, puts down, and manip-
ulates objects deserves further study, as does the effect
of grasp force on higher-level skills, such as holding a
pen and writing. These are only a few of the areas
needing future research. Object interaction is an integral
part of human behavior, yet it is an area that has been
poorly studied. A more complete understanding of this
area of development would help both the evaluation
and treatment planning of children having difficulty in
achieving competency in object interaction.
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HANDEDNESS IN CHILDREN
Elke H. Kraus
CHAPTER OUTLINE
DEFINITION AND CLASSIFICATION OF
HANDEDNESS
Defining Handedness in Terms of Handedness
Dimensions
Classifying Handedness into Categories
Description of Left and Switched Handedness
PREVALENCE OF HANDEDNESS
ASSESSMENT OF HANDEDNESS
Tests for Hand Preference
Tests for Hand Performance
FACTORS DETERMINING AND INFLUENCING
HANDEDNESS
Neuroanatomical and Neurophysiological
Foundations of Handedness
Genetic Theories on Handedness
Pathological Influences on Handedness
Sociocultural and Environmental Influences
Concluding Remarks
THE DEVELOPMENT OF HANDEDNESS
Birth
4 Months
6 Months
8 Months
12 Months
18 Months
24 Months
2 to 6 Years
PEDIATRIC OCCUPATIONAL THERAPY AND
HANDEDNESS
Chapter 9
Assessment
Intervention Theory
Concluding Remarks
SUMMARY
Handedness can be defined as the consistent and more
proficient use of the preferred hand, compared with the
nonpreferred hand, in functional and skilled tasks
(Annett, 1985). Established handedness generally is
considered to be an important indicator of hemispheric
specialization and callosal myelination necessary for
development of motoric skills, language, and cognitive
processes (Annett, 1998; Bishop, 1990a,b). Conversely,
unestablished handedness, associated with develop-
mental delay or even pathologic conditions, sometimes
reflects inadequate hemispheric specialization (Coren,
1992; Gazzaniga, 1970). From a functional perspec-
tive, the establishment of handedness is critical for
successful occupational performance and development
of high manual skill levels (Hurlock, 1975; Mandell,
Nelson, & Cermak, 1984; Vasconcelos, 1993). It is
unlikely that a child will be able to develop optimal skill
if hands are changed during tasks such as drawing or
writing because the preferred hand will fail to specialize
to the necessary proficiency (Hurlock, 1975). Further-
more, evidence exists that motor and learning problems
frequently occur in children who learn to write with the
nonpreferred hand as a result of incorrect handedness
classification (Ardila et al., 1988; Bishop, 1990a;
Peters, 1990; Sattler, 1998, 2001, 2002). Occupational
therapists should understand and meet the special
needs of left-handed children, particularly in relation to
handwriting. In this context, the correct identification
of a child’s handedness, its promotion, and the devel-
opment of manual skill in children with unestablished
or left-handedness are necessary and important aspects
161
162 Part II • Development of Hand Skills
in pediatric occupational therapy (Mandell et al., 1984;
Sattler, 2001).
Children with unestablished handedness are fre-
quently referred to pediatric occupational therapy for
other reasons, and their inconsistent hand use is usually
noted informally during the process of assessment and
treatment. In a survey interviewing 51 occupational
therapists in Germany it was reported that overall 73%
of referred children between 4 and 7 years presented
with ambiguous hand use (Riedel, Künnemann, &
Kling, 2002).
However, handedness, particularly unestablished
handedness, has received little attention within occu-
pational therapy literature to date. Although the 1970s
and 1980s resulted in an abundance of handedness lit-
erature in the field of neuropsychology, this knowledge
was not comprehensively applied to, or incorporated
into, the occupational therapy frame of reference. Since
this time, research studies of handedness have been
much fewer, and particularly unestablished or mixed
handedness has received little attention in neuro-
psychology. Within the holistic definition of occupa-
tional performance, handedness should not be perceived
as an isolated unit within a hierarchy, but rather in
relation to other skills relating to occupational per-
formance in the wider sense. Unestablished handedness
in the developmental context is considered to be an
indicator of neuromaturational delay (Bishop, 1990a),
and the degree to which handedness is established may
indicate other forms of dysfunction or pathology (see
Factors Determining and Influencing Handedness).
Unestablished handedness may also coexist with other
behaviors such as avoidance of midline crossing and
poor bimanual motor coordination, which together
affect functional hand use (Ayres, 1972; Cermak,
Quintero, & Cohen, 1980; Dahl Reeves & Cermak,
2002). In addition, it is possible that one hand might
be prevented from gaining sufficient practice to
become adequately skilled in drawing and writing tasks.
Consequently, unestablished handedness is likely to
retard the development of highly integrated manual
skill and fine motor coordination that refine occupa-
tional performance.
This chapter presents an empirical, theoretical, and
developmental knowledge base for the establishment
and nature of handedness to provide therapists with a
more comprehensive basis for assessing and treating
children’s handedness. This knowledge base draws
from different approaches and is divided into six sec-
tions. First, the definition of handedness is presented,
differentiating between hand preference and hand
performance, and considerations for evaluating these
are reviewed. In addition, the process of classifying
handedness and the description of two particular types
of handedness conclude the first section. The prev-
alence of handedness, followed by the assessment of
handedness, comprise the second and third sections.
Fourth, various factors that determine and influence
handedness are presented as critical background infor-
mation, and fifth, the development of handedness is
outlined. In the final part of the chapter, handedness
is discussed in relation to pediatric occupational therapy
assessment and treatment.
DEFINITION AND CLASSIFICATION
OF HANDEDNESS
The definition of handedness in the literature is incon-
sistent and ambiguous. For the purpose of this chapter,
handedness is first defined in terms of dimensions of
handedness, followed by discussion on the classification
of handedness into categories, with particular emphasis
on consistency as an important classification factor. In
this context, left and switched handedness are described
in more detail. Figure 9-1 summarizes the aspects dis-
cussed in relation to the handedness definition.
DEFINING HANDEDNESS IN TERMS OF
HANDEDNESS DIMENSIONS
In the context of the many handedness definitions in
the literature, the term “handedness” refers to a
combination of hand preference and hand performance
(Annett, 1998) as two dimensions of handedness.
Hand preference has been defined as the tendency to
perform the majority of tasks with one hand rather
than the other (Nalçaçi et al., 2001). This does not
necessarily mean that the chosen hand is more efficient
(Porac & Coren, 1981). Moreover, hand preference
has been stipulated to be the spontaneous untrained
hand use as a measure of the inherent predisposition
to handedness (McManus & Bryden, 1992; Olsson &
Rett, 1989; Sakano, 1982; Sattler, 1998; Steenhuis
& Bryden, 1989; Steenhuis et al., 1990). Conversely,
hand performance is most aptly defined as the superior
proficiency of one hand over the other in tasks
requiring skill (Annett, 1970a). The innate motor ability
interacts with environmental demands and develops
with practice to varying extents of skill acquisition,
which may be independent of hand preference (Porac
& Coren, 1981).
The distinction between hand preference and hand
performance has been explored extensively (Annett,
1985; McManus & Bryden, 1992; Peters, 1996; Todor
& Doane, 1977). According to Annett (1985), the
inherently more skilful hand also becomes the preferred
one, whereas McManus and Bryden (1992) conclude
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.
164 Part II • Development of Hand Skills
ferent assessments were used in studies supporting the
preceding conclusions, which may be responsible for
the contradictory findings. A cause-and-effect relation-
ship between preference and performance is far from
clear, as Peters (1996) suggested when he asked
“Is it the predominance of inherent biases interacting with
environmental chance events, or is it the predominant environ-
mental influence interacting with weak inherent biases which
determines the final pattern of behaviour?” (p. 118).
To date there is no clear answer to this question.
The literature exploring hand preference and per-
formance and proficiency distributions displays a variety
of results in which some performance and preference
tasks yield large differences between the hands
(bimodal) and others do not (unimodal) (Annett,
1992; Borod, Caron, & Koff, 1984; Steenhuis, 1996).
For example, there is greater discrepancy between the
hands in handwriting proficiency than grip strength
(Provins & Magliaro, 1989). In addition, factors such as
practice or task nature may influence the magnitude of
the interhand performance differences (Annett, 1992).
It might be assumed that hand preference and hand
performance and proficiency should be virtually inter-
changeable (i.e., the preferred hand is also the more
skilled and proficient one and vice versa). However, the
correlation between hand preference and performance
has been shown to be weaker than expected. Porac and
Coren (1981) suggested that preference and per-
formance have a common underlying factor, because
their correlation, although not always strong, is still sig-
nificant. Furthermore, the correlations between pref-
erence and performance appear to be task dependent
(see Porac & Coren, 1981, for a review). Interestingly,
in some studies the correlation between preference and
performance became significantly weaker when the
sample was divided into left and right handers (Bryden
et al., 1994; Lake & Bryden, 1976; Tapley & Bryden,
1985), indicating different patterns of preference and
performance in the two groups. Furthermore, Peters
(1996) found that hand preference correlated more
strongly with performance in consistent handers than
inconsistent handers (see Classifying Handedness). The
discrepancy between preference and performance is also
likely to be compounded by incompatible assessments
in which hand preference often is assessed subjectively,
based on self-report or inventories, whereas hand per-
formance is evaluated more objectively through task
execution (Guiard & Ferrand, 1996).
The relatively low correlation between hand pref-
erence and hand performance indicates that hand func-
tion is multifaceted and multidimensional (Steenhuis,
1996). Numerous authors have attempted to identify
the factors determining hand preference and hand
performance, but so far no consensus on these factors
has been reached.
Hand Preference
Several authors have defined hand preference in terms
of types or components. Bryden (1982) proposed four
“types” of hand preference: actions that require skill
such as using a tool, reaching actions that do not
require any skill, power actions such as carrying a
suitcase (in which one is inclined to change hands
because of fatigue), and bimanual actions in which
both hands are involved. He found that hand
preference is most significant for tool use and bimanual
actions and least significant for power actions and
reaching (Bryden, 1982).
Healey, Liederman, and Geschwind (1986), and
Geschwind and Galaburda (1987) suggested that one
significant dimension of hand preference was deter-
mined by the musculature involved in task execution.
There is physiologic evidence that both the contra-
lateral and ipsilateral hemispheres control proximal arm
muscles via multisynaptic pathways, whereas distal con-
trol of the hand and fingers is executed by the contra-
lateral hemisphere via the corticospinal tract (Brinkman
& Kuypers, 1973; Glickstein & Buchbinder, 1998;
Haaxma & Kuypers, 1974; Peters, 1995). Support for
the distal–proximal distinction was found by several
authors who observed that fine manipulations per-
formed by distal musculature appear to be more
lateralized than gross motor tasks involving mainly
proximal musculature (Bryden, Bulman-Fleming, &
MacDonald, 1996; Peters & Pang, 1992). Other studies
only partially supported these findings, suggesting that
the musculature used seems to be task dependent
(Case-Smith, Fisher, & Bauer, 1989; Steenhuis &
Bryden, 1989). Whether and to what extent hand pref-
erence is influenced by proximal and distal musculature
is yet to be empirically established.
Steenhuis and Bryden (1989) proposed that the
position of an object in space (i.e., ipsilateral or contra-
lateral) influences preferred hand use, an observation
already made by Ayres (1972) years earlier. In addition,
Steenhuis and Bryden argued that hand preference
consists of two dimensions relating to skilled and
unskilled tasks. Similarly, Bishop (1990a) postulated
that when the two hands are equally skilled for a task,
either hand may be selected. As skill level differences
increase, so does the extent of preferred hand use.
Hand Performance
As with hand preference, various dimensions of hand
performance have been proposed. Some researchers
proposed that hand performance consists of two main
factors: strength, and a combination of speed and
accuracy or dexterity (Borod et al., 1984; Porac &
 Handedness in Children • 165

Coren, 1981). However, several authors found that
hand strength correlated only weakly with hand pref-
erence (Johnstone, Galin, & Herron, 1979; Provins &
Cunliffe, 1972; Satz, Achenbach, & Fennell, 1967).
Different hand performance factors identified by other
researchers through component analysis (Barnsley &
Rabinovitch, 1970) included reaction time, speed of
arm and finger movement, arm–hand steadiness, arm
movement steadiness, and aiming. All factors except
reaction time revealed a significant correlation with
hand preference (Barnsley & Rabinovitch, 1970).
Considerations for Evaluating Hand Preference
and Hand Performance
The divergent definitions in the literature demonstrate
the complex nature of handedness as a multidimensional
variable. Furthermore, although the multidimensional
concept of hand preference and hand performance
enables a more detailed understanding of handedness,
no consensus has been reached on the type, parameters,
and nature of the dimensions. This renders comparison
between studies difficult. To overcome this problem of
poor interstudy comparability, hand preference fre-
quently has been treated as a unidimensional variable
(Porac & Coren, 1981), in which all assessment items
are equally weighted and, in combination, reflect a
single dimension of preferred hand use.
Unidimensional hand preference assessments appear
accurate in determining the direction of hand pref-
erence (i.e., left or right), which can be obtained more
reliably than its degree (McMeekan & Lishman, 1975).
Provins (1997) and McManus (1984) believed that the
direction of hand preference has a genetic basis, where-
as the extent or degree of hand preference is subjected
to developmental and environmental factors. Further-
more, it has been argued that the degree of handedness
is a more important determinant of ability than the
direction of handedness, particularly when studying
individuals who lack a distinct hand preference (Annett,
1970b, 1998; Bradshaw & Nettleton, 1983; Swanson,
Kinsbourne, & Horn, 1980).
Occupational therapists should analyze handedness
both in terms of hand preference and hand per-
formance as two of its dimensions, because both are
subjected to different levels of training. To provide a
comprehensive context for a handedness assessment,
the genetic predisposition and environmental factors
determining and influencing the direction and degree
of handedness also should be considered (see Fig. 9-2
for an illustration of these handedness dimensions).
C LASSIFYING HANDEDNESS INTO CATEGORIES
The Process of Classification
In general, classification of handedness in the literature
appears to entail a nonspecific process that frequently
involves the creation of multiple categories, ranging
from three to five or more handedness groups, in which
“strong” or explicit handers are distinguished from
“weak” or moderate handers (Annett, 1985; Peters,
1996; Schachter, 2000). Clearly, the classification
method influences the incidence of left, right, and
mixed handers (Gudmundsson, 1993; see Bishop,
1990a, for a review). Rigal (1992) classified children
into left, right, and mixed handers, using a score of 70%
or above for established handers. These thresholds were
selected arbitrarily because no natural limits exist for
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).
166 Part II • Development of Hand Skills
often is varied to meet the researcher’s goals (Rigal,
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
(Annett, 1970b). Another method to classify handed-
ness is by means of a continuum. More specifically,
strength or the degree of preferred hand use frequently
has been measured as a percentage or continuous
variable.
Annett (1998) summarized the predicament asso-
ciated with classification as follows:
“The basic problem is that researchers treat a continuous
variable, degree of handedness, as if it were a simple binary one
(left or right). There are many ways of dividing a continuous
distribution to produce a discrete one and it is often unclear
precisely what was done. It is usual to find a statement of the
effect that ambidextrous individuals were either discarded or
counted with the left-handers, which appears to be a reasonable
way of dealing with a small number of cases. However, the
authors are usually confusing ambidexterity with mixed
handedness and the true size of the problem of mixed handedness
is simply not acknowledged. If some 33 percent of a sample
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-
tions could be made among mixed handers. She defined
eight classes of hand preference, with classes one and
eight consisting of “pure” right and left handers, respec-
tively, classes two, three, four, and five were mixed right
handers and classes six and seven mixed left handers.
Annett found that the degrees of hand preference
represented by the subgroups related reliably to
degrees of hand skill (hand performance) that was
assessed using a pegboard task.
Handedness Classification
Annett’s work has demonstrated the usefulness of using
categories of hand preference based on frequency
of use. However, in line with the present definition of
handedness consisting of both hand preference and
hand performance, handedness categories also can be
formulated in a broader sense, based on different types
or presentations. Several of these presentations have
been selected from various authors to provide a basis
for distinction (Box 9-1).
When a child presents with an unambiguous
preference for either the right or left hand, and when
this hand also demonstrates superior performance over
the other hand, he or she has established handedness
and is said to be right or left handed (Annett, 1998).
Conversely, when a child swaps hands during and
across tasks and thus presents with mixed handedness,
this is called unestablished handedness (Whittington &
BOX 9-1 Handedness Categories
Right or Left Handed. An unambiguous preference for
either the right or left hand. When this hand also
demonstrates superior performance over the other
hand, handedness has been established.
Unestablished Handedness. Hand swapping during
and across tasks, presenting with mixed handedness.
The term “unestablished” is used because children
are still in the process of developing.
Mixed Handers. Adults and older children showing a
similar presentation as unestablished handedness.
Switched Handers. When children are inherently left-
handed but learn to draw and write with the right
hand.
Pathologic Handedness. If there is evidence of prenatal,
perinatal, or postnatal trauma, and one hand is
significantly weaker and inferior compared with the
other hand but still shows some preference patterns.
Ambidextrous. Individuals show no performance dif-
ference between the hands and can draw or write
equally well with the left and right hands, although
performing in the average or above-average
normative range.
Richards, 1987), because children are still in the proc-
ess of developing. Adults and older children showing a
similar presentation are called mixed handers (Bishop,
1990a).
When children are inherently left handed but learn
to draw and write with the right hand, they are called
switched handers (Coren, 1992). The most obvious
difference between unestablished and switched
handedness is the clear transition from predominantly
left-handed use to right hand use because of socio-
cultural influences, mainly through pressure from
parents, grandparents, and teachers.
As discussed in the following, it is thought that hand
preference can be altered by neural insult, depending
on the locus and extent of lesion as well as timing
(Harris & Carlson, 1988; Liederman, 1983; Satz,
1972). If there is evidence of prenatal, perinatal, or
postnatal trauma, and one hand is significantly weaker
and inferior compared with the other hand but still
shows some preference patterns, it is likely that this
is a pathologic handedness presentation (Soper & Satz,
1984). Because the majority of people are right-
handed, pathologic left handers are far more frequent
than pathologic right handers.
Finally, ambidextrous individuals show no per-
formance difference between the hands and can draw
or write equally well with the left and right hands
(Annett, 1998), although performing in the average or
above-average normative range. This is extremely rare,
 Handedness in Children • 167

because performance is influenced and developed
through practice, and to be truly ambidextrous, both
hands have to be trained equally.
Consistency
The left/right/mixed classification, whether categorical
or continuous, has not been the only criterion for
grouping a sample population. Consistency in hand
use is another important means of categorization.
Although several studies have investigated handedness
consistency in relation to performance domains (e.g.,
consistency and intelligence; Kee, 1991), the definition
of consistency differs among the studies. Bishop
(1990a) stressed the importance of measuring con-
sistency within-tasks as a separate variable. She argued
that inconsistent or “ambiguous” hand use within a
single task (e.g., alternating right or left hand use for
throwing) might be more reflective of dysfunction than
a hand preference score. Consistency also can be
measured across tasks, whereby high consistency reflects
exclusive left or right hand performance (Peters, 1990,
1996; Peters & Servos, 1989). Thus an individual
might display inconsistency by using the left hand for
certain tasks and the right hand for others, resulting
in a low overall hand preference score, but show con-
sistency within-tasks by always using the same hand
for the same tasks. The across-task inconsistency and
within-task consistency correspond with Bishop’s
(1990a) mixed handedness described earlier. Figure 9-3
summarizes both types of consistency.
Peters (1996) found that right handers showed
greater strength in their preferred hand, but only
consistent (across-tasks) left handers showed superior
strength in their left hand, although inconsistent left
handers demonstrated a stronger right hand. Peters
proposed that the increased variability in left handers
compared with right handers might be substantially
influenced by inconsistent handers in the left handed
group. More specifically,
“Consistent left handers and right handers form extremes on the
performance spectrum, with inconsistent left handers being
intermediate in their performance. This suggests to us that the
distinction between consistent and inconsistent left handers is not
merely a matter of manual motor control and reaches deeper into
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.
168 Part II • Development of Hand Skills
Unfortunately, research studies frequently do not
differentiate between consistent and inconsistent
handers within or across tasks. This might be an im-
portant classification in identifying problems associated
with unestablished handedness, and therapists assessing
handedness should take this into account. Further-
more, therapists particularly should have an under-
standing of how left and switched handers differ from
right handers.
DESCRIPTION OF LEFT AND SWITCHED
HANDEDNESS
Left Handedness
Left handers have obscured the postulate of handed-
ness as a predictor of cerebral specialization (Bradshaw
& Nettleton, 1983; Bryden et al., 1996). Although
consistent left handers tend to perform much like right
handers (Amazeen et al., 1997; Peters, 1996), incon-
sistent left handers, or left handers in general as an
undifferentiated group, are not the mirror image of
right handers and show different and more hetero-
geneous behavior as a group (Bryden et al., 1996;
Dunaif-Harris, 1984).
Evidence suggests that left handers in general are
less strongly lateralized than right handers, and for this
reason they are more likely to present with variable
hand use (Bryden, 1982; Herron, 1980). Steenhuis
and Bryden (1989) proposed that in comparison to
right handers, left handers do not obtain lower
laterality scores from lacking strength of hand
preference in certain tasks (i.e., within-consistency),
but because they display greater across-tasks incon-
sistency of preference and perform some activities with
the nonpreferred hand.
Furthermore, left handers appear to reflect less
asymmetry and greater homogeneity of function
between the hemispheres (Butler, 1997; Kim, 1994;
Peters, 1985, 1987). For example, Peters (1985, 1987)
used a bimanual tapping task with adults to investigate
constraints in simultaneous bimanual task performance
related to handedness. He found that right handers
performed the bimanual tapping task better when the
preferred rather than the nonpreferred hand tapped
the more complex patterns. This lateralization effect
was not seen in left handers, who tapped the complex
pattern equally well with either hand. Other authors
have found a substantial number of left handers who
performed certain motor tasks better with their
nonpreferred hand (Satz et al., 1967).
Some authors suggested that the obvious behavioral
differences in left handers might be a result of different
neural and hemispheric organization (Beaumont,
1974; Hammond, 1990; Perelle & Ehrman, 1982;
Peters, 1990; Satz, 1980). Others have argued that dif-
ferences between left and right handers also might be
related to influencing factors such as physical environ-
ment and sociocultural milieu with a right handed
bias (Coren, 1992; Harris, 1990; Porac, Coren, &
Searleman, 1986; Sattler, 1998). It can be assumed that
variability in left handers is probably due to a com-
bination of these two factors.
Switched Handedness
The concept of switched left handedness has received
attention from several theorists (Collins, 1975, 1985;
Olsson & Rett, 1989; Peters, 1990; Porac, Rees, &
Buller, 1990; Sakano, 1982; Sattler, 1998, 2001;
Steenhuis, 1996). Payne (1987) investigated older
individuals and reported the incidence of switched left
handers to be 46%, although another study found that
89% of innate left handers in the age group between
65 and 74 years had been switched, compared with
26.6% aged 35 to 44 years (Galobardes, Bernstein, &
Morabia, 1999). The authors assigned the elevated
percentage of switched handedness to increased socio-
cultural pressure in previous generations. However, it
has been proposed that switched handers are not easily
detected with the conventional handedness measures
(Peters & Murphy, 1992; Sakano, 1982), so the
prevalence may well be higher than 8%, as proposed by
Porac and co-workers (1986).
Individuals with an innate predisposition for left
handedness are likely to present with a notable left-
handed preference during their early childhood years
(Fischl, 1986; Olsson & Rett, 1989; Sakano, 1982;
Sattler, 1998; Stutte, Schilling, & Weber, 1977).
Parents, other family members, and teachers may exert
social pressure on children to use their right hand for
certain unimanual tasks that are culturally and socially
important. Although there has been an increased
acceptance for left handedness over the last decades,
there is still evidence of existing right-biased social
pressures in Western societies reflected in language and
social customs (Collins, 1985; Harris, 1990; Porac et
al., 1990; Sattler, 1998). Olsson and Rett (1989)
suggest that some less strongly lateralized left-handed
individuals are likely to succumb even to subtle
pressures for right hand use, eventually resulting in
switched handedness for socially important tasks (e.g.,
drawing, eating with cutlery, cutting with right-handed
scissors). Untrained tasks, on the other hand, do not
receive the same amount of attention and thus tend
to be more resistant to environmental influence (Ida,
Mandal, & Bryden, 2000; Olsson & Rett, 1989). With
repetition and practice of task execution, the right
nondominant hand can become the preferred hand
for these untrained tasks (Fischl, 1986; Harris, 1990;
Richberg, 1987; Sakano, 1982; Sattler, 1998; Stutte
et al., 1977). However, switched handers are likely to

BOX 9-2 Some Problems Associated with
Switched Handedness
Decreased academic performance
Inferior bimanual coordination performance
Psychological abnormalities: Switching to the non-
dominant hand might have an unfavorable effect on
cortical functioning, and functional specialization of
the hemispheres may be altered through switching
handedness, which in turn might interfere with
interhemispheric communication processes
Primary problems: Memory deficit (i.e., recalling
learned material), concentration difficulty (i.e., tiring
quickly, poor endurance), learning difficulties (i.e.,
reading, spelling), position in space problems
(including poor left-right concept), speech deficit
(especially stammering), and fine motor problems
(e.g., handwriting)
Secondary problems: Poor self-esteem, insecurity,
social withdrawal, overcompensation with increased
effort, oppositional and provocative behavior (e.g.,
playing the clown, temper tantrums), bed wetting
and nail biting generally coexist with socioemotional
difficulties
continue preferring their left hand for many untrained
tasks and for the leading role in bimanual actions,
resulting in an incomplete shift of handedness (Olsson
& Rett, 1989; Porac, Rees, & Buller, 1990).
Only a few studies have addressed the consequences
of switched handedness (Box 9-2). They have found
decreased academic performance (Ardila et al., 1988;
Bryngelson & Clark, 1933; Clark, 1957), inferior bi-
manual coordination performance (Vaughn & Webster,
1989), and psychological abnormalities (Young &
Knapp, 1966). Based on a large number of case studies,
Sattler (1998, 2001, 2002) identified primary and sec-
ondary problems after switched handedness. Primary
problems included memory deficit (i.e., recalling
learned material), concentration difficulty (i.e., tiring
quickly, poor endurance), learning difficulties (i.e.,
reading and spelling), position in space problems
(including poor left-right concept), speech deficit
(especially stammering), and fine motor problems (e.g.,
handwriting). Interestingly, in numerous cases, these
problems decreased or even disappeared when indi-
viduals started to write with the inherently preferred
left hand, even as adults (Sattler, 1998, 2001, 2002).
Secondary problems associated with switching were
poor self-esteem, insecurity, social withdrawal, over-
compensation with increased effort, oppositional and
provocative behavior (e.g., playing the clown, temper
tantrums), bed wetting and nail biting, or general
socioemotional difficulties (Sattler, 1998, 2001, 2002).
Other authors have reported similar psychological
problems as Sattler (Friedmann, 1987; Richberg, 1987;
Handedness in Children • 169
Young & Knapp, 1966). These findings appear to indi-
cate that switching to the nondominant hand might
have an unfavorable effect on cortical functioning
(Sattler, 1998, 2001, 2002). Furthermore, it has been
speculated that functional specialization of the hemi-
spheres may be altered through switching handedness,
which in turn might interfere with interhemispheric
communication processes (Olsson & Rett, 1989;
Sattler, 1998, 2001).
Initially, many children with switched handedness
compensate effectively and their problems may not arise
until their performance is challenged as school pressure
and demands increase (Fischl, 1986; Olsson & Rett,
1989; Richberg, 1987; Sattler, 1998, 2001, 2002;
Stutte et al., 1977). The nature and extent of switching
effects also seem to vary greatly among individuals,
whereby some appear to adapt more easily to right
handedness with minimal problems, compared with
others who experience great difficulties (Friedmann,
1987; Harris, 1990; Sakano, 1982; Sattler, 1998, 2001,
2002). The enormous range of variation in the present-
ing problems (from minimal to multiple) observed in
switched handers poses a challenge in researching and
understanding the handedness behavior of these
individuals.
Today it is generally accepted that forcing or con-
verting left handers to become “right handers” should
be avoided (e.g., Richberg, 1987; Sattler, 2002). Even
Coren (1996), who appeared to favor pathologic
causes as an explanation for left handedness, argued
convincingly that forcing right handedness is not the
answer:
“Left-handedness is not a simple movement preference that has
developed into a habit. It probably reflects differences in the
patterns of neural circuitry in the brain” (p. 261).
Coren (1992) suggested that right hand training
only produces mixed handedness or modified left
handedness. It can be concluded that there is a general
consensus in the literature that switched handedness is
undesirable, and the importance of correct handedness
classification is evident. However, the lack of specific
empirical research into switched handedness and the
underlying neuropsychological processes to date limit
the conclusions that can be drawn on this group with
variable handedness.
PREVALENCE OF HANDEDNESS
The lack of coherent definitions, standard assessments,
and universal classification procedures for handedness
(Annett, 1998; Bishop, 1990a) makes accurate estima-
tion of the incidence of left, right, and unestablished
170 Part II • Development of Hand Skills
handedness difficult. As has been discussed, findings of
demographic studies have considered handedness as a
trinomial phenomenon in terms of left, right, and
“mixed” (unestablished) handers, whereby the cut-off
point for the latter group is quite arbitrary. One of the
more conservative estimates states that approximately
85% of the adult population are right handed, about
10% are left handed, and 5% show mixed handedness
(Coren & Porac, 1977). Other studies have provided
more specific distinctions between different handedness
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
right handers, and the remaining 23% demonstrate
ambiguous hand use. Annett (1998) made a distinction
between “ambidextrous” and “mixed” handers, in
which ambidextrous handers by definition have the
same level of skill in either hand, whereas “mixed”
handers use their left hand for some activities and their
right hand for other tasks. Annett (1998) reported only
0.3% of ambidextrous handers, but as many as 30% of
mixed handers, a figure supported by Amunts and co-
workers (2000).
Furthermore, the prevalence of left handedness has
been estimated to be 25% higher in males than females
(Heim & Watts, 1976; Seddon & McManus, 1993).
This gender difference may result from complex factors
leading to a differential expression of laterality in
females (McManus, 1991), greater testosterone levels
in utero (Geschwind & Galaburda, 1987), or a possible
genetic influence on handedness (McKeever, 2000).
However, other studies failed to find a significant
gender difference (Beaton & Mosley, 1984; Bishop,
1989; Bryden, 1977; Salmaso & Longoni, 1985). All
in all, there is a general consensus that among more
liberal societies, including most westernized and
Caucasian-based populations, 10% to 12% of
individuals are left handed (Ardila et al., 1989;
Connolly & Bishop, 1992; Ellis, Ellis, & Marshall,
1988; Harris, 1990; Nicholls, 1998).
Table 9-1 Summary of test-retest reliability of the Edinburgh Handedness Inventory
(McFarland & Anderson, 1980)
Pearson’s r
Item (p < .05)
1. Writing .95
2. Drawing .94
3. Throwing a ball .90
4. Using a toothbrush .87
5. Cutting with scissors .85
ASSESSMENT OF HANDEDNESS
This section provides a brief overview of general
assessments, as found in the handedness literature, that
appear to be useful and relevant to occupational
therapists. (Specific occupational therapy assessments
related to handedness are discussed further on under
Pediatric Occupational Therapy and Handedness,
Assessment.)
TESTS FOR HAND PREFERENCE
Hand preference assessments in the neuropsychology
domain typically consist of observing preferred hand
use across a variety of everyday tasks, some of which are
more skilled (e.g., writing and throwing) and some less
skilled (e.g., picking up items, opening containers)
(Ida et al., 2000; Steenhuis & Bryden, 1989). Some
authors state that only items with the highest test-retest
reliability should be included (e.g., Chapman &
Chapman, 1987; Raczkowski, Kalat, & Nebes, 1974),
whereas others question the validity of such items
because of the high training element involved in most
of the tasks included (e.g., Annett, 1998; Olsson &
Rett, 1989; Steenhuis & Bryden, 1989; Stutte et al.,
1977). In general, there appears to be no consensus on
superior test items for assessing hand preference, but a
mixture of both trained and untrained items appears to
be the best option.
One of the most frequently used tests is the stan-
dardized Edinburgh Handedness Inventory (EHI)
(Oldfield, 1971). The EHI consists of 10 items (Table
9-1), which include highly skilled and trained activities
such as writing and drawing, as well as less trained or
skilled ones, such as opening the lid of a box.
The EHI is a good choice for assessing hand pref-
erence for several reasons: It has been used extensively
(Annett, 1998; Schachter 2000), including with
children (Brito et al., 1992; Ross, Lipper, & Auld,
Pearson’s r
Item (p < .05)
6. Eating with a spoon .84
7. Striking a match .79
8. Sweeping with a broom .62
9. Using a knife for cutting .81
10. Opening the lid of a box .69

1992); has been standardized on several populations
(McMeekan & Lishman, 1975; Williams, 1986); and
has a high general reliability. These factors make it a
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,
there is evidence that the EHI is not sensitive to the
degree of hand preference; children between 3 and
5 years of age scored high on this test, at an age in
which the degree of handedness is still developing
(Kraus, 2003). It is possible that most of the EHI items
are lateralized early in life, thus displaying very similar
distributions for the different age groups. Further-
more, the EHI also failed to detect significant dif-
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
sensitive measures have been developed (see Kraus,
2003, Functional Hand Preference Tasks as an example
of a more sensitive measure). In the interim, the EHI
can be used with some caution in addition to hand
performance measures. In particular, it is useful to
distinguish between trained and untrained hand
preference tasks, and to draw comparisons between the
two preference groups.
TESTS FOR HAND PERFORMANCE
When assessing hand performance, note that superior
control of one hand may not necessarily indicate that it
is also the preferred hand. For example, if an innately
left-handed child learns and practices to use the right
hand for drawing and writing, it is possible that a
higher performance level in these tasks will be achieved
with the right hand, as case studies of such “switched
handers” have shown (Coren, 1992; Peters & Murphy,
1992; Sattler, 1998; Stutte et al., 1977). Thus
although activities such as tracing and dotting appear to
be suitable for assessing forms of trained performance
(i.e., hereafter called skill), hand performance should
also reflect the more inherent and innate proficiency
(hereafter called ability), which is relatively free of
training, to obtain a more coherent understanding of
the presenting variability in handedness.
In addition, speed is an important factor of hand
proficiency when considered in a multifactorial context
(Annett, 1985; Barnsley & Rabanovitch, 1970). More
specifically, speed and accuracy should be combined to
achieve an accurate measure of performance (Fitts,
1954). Thus, to conduct a comprehensive hand per-
formance test, the speed-accuracy combination should
be applied in hand performance Skill (i.e., trained) and
Ability (i.e., untrained) tasks (Box 9-3).
Handedness in Children • 171
Tests for Hand Performance in
BOX 9-3 Skill (i.e., Trained) and Ability
(i.e., Untrained) Tasks
SKILL:
Tracing and dotting: Can be performed in the context
of the Motor Accuracy Test (MAc; Ayres, 1989) and
the Hand Dominance Test (HDT; Steingrüber &
Lienert, 1971)
ABILITY:
Hammering (as a form of hand tapping) and tapping
(as a form of finger tapping): See Knickerbocker
(1980) for a timed hammering sample and Kraus
(2003) for a tapping adaptation.
Skill
Tracing, a proficiency task subject to training,
performed with the preferred and nonpreferred hands
can demonstrate the extent to which one hand has
acquired superior control as reflected in assessment
tasks (e.g., Ayres, 1989; Steingrüber & Lienert, 1971).
Similarly, several studies have employed timed dotting
as a skilled task to assess superior hand performance
(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
placing. Even though tracing and dotting require
different types of motor prerequisites, the level of both
tracing and dotting accuracy is closely related to the
learned task of drawing and writing (Annett, 1992a;
Steingruber, 1975; Tapley & Bryden, 1985), and they
can thus be considered to be trained and skilled tasks.
Tracing and dotting are two suitable skilled hand
performance tasks, and they can be performed in the
context of the Motor Accuracy Test (MAc; Ayres,
1989) test and the Hand Dominance Test (HDT;
Steingrüber & Lienert, 1971). The MAc
“emphasises accuracy or ‘steadiness’ of the visually directed hand
use of a pen and is specifically designed for comparison between
the more- and less-accurate hands” (Mandell, Nelson, &
Cermak, 1984, p. 115).
The MAc requires timed tracing of a butterfly-
shaped line on an A3 paper, first with the preferred
hand and then with the nonpreferred hand. The
standardized version of the HDT for children consists
of three parts: (a) a mazelike angled path for tracing;
(b) a path of irregularly spaced circles, 0.5 cm in
diameter for dotting; and (c) rows of equally spaced
adjacent squares, also for dotting. All three tasks have
to be attempted at maximum speed and precision
for 30 seconds. The distance of the traced path is
172 Part II • Development of Hand Skills
measured, and the number of successfully dotted circles
and squares is counted.
Both these standardized tests are suitable to assess
hand performance skill, but they have their limitations.
Kraus (2003) found that although the MAc perfor-
mance level increased significantly across all age groups,
the interhand differences on the test were not found to
be significantly different between 3- and 5-year-old
normal children. This might partly be a consequence
of revisions to the MAc, including adjustments to
decrease the difference between the hands (Smith,
1983). Although the MAc appears to be a valid tool for
assessing performance levels, the interhand differences
lack variability (Kraus, 2003), and thus sensitivity to
detect more subtle differences between the hands. This
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
the scoring of both the tracing and the dotting task do
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
the circle). Once again, these limitations have to be
considered until a more comprehensive assessment is
available (see, e.g., Kraus, 2003, for the Bear Tracing
Task and the Bead Dotting Task).
Ability
Tapping as a motor performance task to assess innate
motor ability is used most frequently in research to
distinguish manual asymmetry in rapid repetitive upper
extremity movements (McManus, Kemp, & Grant,
1986) as an innate and untrained task. Numerous
studies have shown that the preferred hand taps faster
than the nonpreferred hand (Peters, 1978, 1990;
Peters & Durding, 1979; Watter & Burns, 1995).
However, stipulations for tapping differ across studies,
with some employing hand tapping controlled from the
shoulder girdle (Peters, 1990) and others using finger
tapping with stabilization of the wrist (Watter & Burns,
1995). No studies were found that investigated the
difference or similarities between these two forms of
tapping (i.e., whether and to what extent distally
controlled tapping is indeed similar to proximally
controlled tapping/hammering). For this reason, it is
useful to include both hammering (as a form of hand
tapping) and tapping (as a form of finger tapping) as
tests to assess Ability hand performance. Knickerbocker
(1980) proposed a Timed Hammering Sample to
observe the
“presence or absence of established hand dominance” (p. 201).
For Knickerbocker’s test, a piece of carbon paper is
stapled face down between two sheets of paper and
secured to the table. The top paper features a circle
4 inches in diameter, and the child is presented with
a wooden hammer in the midline. The child is then
requested to hit as fast and hard as possible when the
stopwatch is activated. The number of hammer blows
in 15 seconds (or 20 or 30 seconds, depending on the
child’s age and abilities) is recorded. The two hands are
compared on the frequency of hammering blows and
the quality of the hammering executions (e.g., wild
uncontrolled movement, poor visual attention). The
same principles can be used for tapping, although some
adaptation should be made so that the wrist-generated
tapping also results in “blows” on carbon paper (see
Kraus, 2003, for a tapping adaptation as part of the
Ability Test).
FACTORS DETERMINING AND
INFLUENCING HANDEDNESS
For a comprehensive understanding of handedness,
one should have a knowledge base of factors that may
determine, or at least influence, the establishment of
handedness. Although empirical evidence concerning
the determining factors of handedness remains incon-
clusive, there is an abundance of information relating
to four different contexts: (a) neuroanatomical and
neurophysiological foundations, (b) genetic theories,
(c) pathological influences, and (d) sociocultural
influences. Therapists should draw on this knowledge
base when assessing and treating handedness in
children.
N EUROANATOMICAL AND
N EUROPHYSIOLOGICAL FOUNDATIONS
OF HANDEDNESS
Findings from scientific research link hemispheric
integration and callosal maturation to many higher
cognitive activities, such as complex problem solving,
visuomotor coordination, language skills, and social
competence, as well as handedness establishment
(Chiarello, 1980; Ettinger et al., 1972; Rourke, 1987;
Temple, Jeeves, & Vilarroya, 1990). When neuro-
scientists became aware of the functional asymmetry of
the brain, they regarded the two hemispheres as a left-
right dichotomy of “two minds, two consciousnesses”
(Gazzaniga, Bogen, & Sperry, 1962). It was assumed
that the left hemisphere was dominant and superior to
the right hemisphere, particularly for speech and praxis
(Gazzaniga et al., 1962; Luria, 1973; Sperry, 1974),
whereas the right (“lesser, inferior”) hemisphere
provided a general context to function in nonverbal,

emotional, and visuospatial domains (Hécaen &
Sauguet, 1971; Luria, 1973; see Beaton, 1985, for a
review).
Currently however, hemispheric “dominance” is
viewed as relative rather than absolute, whereby one
hemisphere is specialized only in relation to the other
(Ornstein, 1997). This bilateral concept of “asym-
metric but integrated” hemispheric roles assumes that
the hemispheres operate collaboratively on all tasks,
although showing flexibility in acquiring these roles
should the need arise (e.g., after brain damage)
(Deacon, 1997; Gazzaniga, 1995; Ornstein, 1997). In
addition to the emphasis on hemispheric role integra-
tion, there is continued support in the cortical
lateralization literature for specialized hemispheric
function and fundamental differences in information
processing (Galin, 1974; Pally, 1998; Tucker, 1981).
Based on this type of neurophysiological and
neuroanatomical research investigating hemispheric
lateralization and specialization, it has been suggested
that the two hands display asymmetric behavior because
they reflect the controlling contralateral hemispheres
(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
asymmetries are present in embryogenesis, and develop
into corresponding functional asymmetries in later life,
or whether anatomical asymmetries develop later as a
result of learned hand use and the interaction with the
environment (Hopkins & Rönnqvist, 1998). Environ-
mental influence appears to be evident in the develop-
ment of other brain structures associated with
handedness establishment, such as the corpus callosum.
For example, postnatal maturation of the corpus
callosum appears to be significantly influenced by expe-
rience, based on great variations in callosal size, irre-
spective of age and gender (Bleier, Houston, & Byne,
1986; Cowell et al., 1992). In addition, there is neuro-
anatomical evidence that the corpus callosum differs
with handedness, being approximately 11% larger in
left-handed and “ambidextrous” individuals than in
well-established right-handed individuals (Aboitiz et
al., 1992; Bleier et al., 1986; Witelson, 1985).
Gazzaniga (1970) stressed the importance of inter-
hemispheric communication for the establishment of
handedness. It has been proposed that the corpus
callosum, one of the last neurologic structures to
complete myelination (Farber & Knyazeva, 1991), is
instrumental in manual lateralization and specializa-
tion. Myelination of the corpus callosum is thought
to signal the emergence of hand preference, reflecting
hemispheric specialization of cortical function (Gazzaniga,
1970). In other words, the hand–cortex relationship
is considered to be a two-way process: More fre-
quent manipulation with the right hand increases the
Handedness in Children • 173
development of the left hemisphere, which in turn
reinforces right contralateral hand use until hand/brain
“dominance” is established (Gazzaniga, 1970).
Although it may not yet be clear to date which parts
of the brain are involved in handedness establishment,
it seems important not to restrict this process to specific
parts of the brain, such as the contralateral cortex.
Neuroscientific evidence has emerged indicating that
simple tasks tend to involve one hemisphere, whereas
effective solving of more complex tasks requires both
hemispheres and interhemispheric communication
(Weissman & Banich, 2000). These findings suggest
that, to an unknown extent, neurophysiologic involve-
ment might be task dependent. More specifically, some
authors have proposed that the task may determine
handedness (Steenhuis & Bryden, 1989). As proposed
in systems theory (Kelso et al., 1980), handedness
could be viewed as one aspect of the neuromotor
system interacting with the environment. Therefore it
is important to review other possible origins and
genetic, circumstantial, and environmental influences
of handedness in relation to its establishment.
G ENETIC THEORIES ON HANDEDNESS
Studies investigating familial handedness across genera-
tions have found support for a genetic aspect to handed-
ness. Hicks and Kinsbourne (1976) discovered that
there was a significant correlation between the handed-
ness of college students and their parents, but only if
the relationship was biological. A meta-analysis demon-
strated a 1 in 10 chance of having a left-handed off-
spring if both parents were right handed (Porac &
Coren, 1981). If one parent was left handed, partic-
ularly the mother, this ratio doubled to 2:10, and if
both parents were left handed, the chance of left
handedness further increased to 4:10 (Bryden et al.,
1996; McManus & Bryden, 1992; Porac & Coren,
1981). Other studies have found an even higher ratio
between left handers and their left-handed parents. For
example, Annett (1978, 1985, 1995) assessed the
difference in skill level between the hands rather than
preferred hand use, excluding parents who might have
been pathologic left handers. She found a 50%
prevalence of left-handed offspring from two left-
handed parents.
Several genetic theories have attempted to explain
the incidence of left handedness. Annett’s (1972, 1985,
1994, 1995) well-known right shift theory postulates
that handedness is influenced by an inherited factor
rather than being inherited directly. A single gene is
thought to be responsible for displacing handedness,
assumed to be a random or chance phenomenon,
toward the right (i.e., right shift). One allele causes
right handedness and another allele results in the
174 Part II • Development of Hand Skills
independent and random lateralization of manual
praxis. Those individuals homozygous for the random
factor have a 50% chance of being left or right handed.
Two factors influence the handedness outcome and
hemispheric specialization for speech: a genetic right
shift (RS+) factor, and a random congenital but
nongenetic factor that codes for speech representation
in the left hemisphere. Right handedness is linked to
left hemispheric speech representation, and thereby
determined by the genetic RS+ factor, whereas the
random factor implies that left handedness and left
hemispheric speech representation are not inherited.
According to Annett’s model, approximately 25% of
individuals presenting with atypical patterns of hemi-
spheric specialization (i.e., right and bilateral cerebral
speech representation) become left handers. However,
Annett argued that the right-biased cultural and
environmental influences increase the development of
right handedness, so that the incidence of left handers
is reduced to approximately 16%, which is congruent
with her prevalence studies based on hand skill (Annett,
1998). Furthermore, Annett has proposed that the
strength of handedness is inheritable, because some
individuals may be homozygous for the RS factor (i.e.,
RS++), displaying a stronger handedness than individ-
uals who are heterozygous (i.e., RS±). Annett’s model
has been criticized for lack of empiric support for the
50% frequency of both dominant and recessive alleles,
and the assumption that hand performance and hand
preference covary (Hopkins & Rönnqvist, 1998; Porac
& Coren, 1981).
Similarly to Annett, the authors McManus and
Bryden (1992) argued for a single gene with two alleles
indirectly determining handedness, namely Dextral (D)
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
of being left or right handed. Heterozygous individuals
(DC) received proposed “additivity,” having a 25%
chance of being left handed as opposed to a 75% chance
of becoming right handed. Unlike Annett, the authors
proposed that handedness and hemispheric specializa-
tion are coded independently of one another, and the
presence of a sex-linked moderator gene accounts for
the increased incidence of left handedness in males.
The central idea of the genetic models appears to be
similar. Approximately half of the population inherits
the potential to become either left or right handed, but
only a proportion of these individuals eventually present
as left handers. The genetic models could possibly
explain the variation in strength of handedness because
variable handers might include those individuals who
have an equal chance of being left or right handed.
However, twin studies have compounded the com-
plexities involved in the inheritance of handedness,
because monozygotic twins sharing identical genetic
make-up do not necessarily present with the same
handedness (Oberleke, 1996), and the incidence of
handedness discordance is as high as 25% (Carter-
Saltzman et al., 1976). Thus current genetic models
do not convincingly explain the reduced handedness
concordance in monozygotic twins (Stein, 1994), nor
is there certainty as to what proportion of people
should “genetically” be left handed, particularly if
the sociocultural and environmental factors reduce the
phenotypical presentation of left handers to an
unknown extent.
Nevertheless, the increase in ratios of left-handed
offspring from left-handed parents, including the
handedness concordance in 75% of identical twins,
suggests at least a genetic component to the handedness
phenomenon (Bryden et al., 1996). Furthermore, it
has been proposed that the “strength” of handedness is
inherited, with some individuals presenting with strong
left and right handedness, whereas others show greater
variation in their preferred hand use (Bryden, 1982;
Coren, 1992; Coren & Porac, 1980).
Recent findings also suggest that there is an X-linked
pattern of genetic influence on handedness (McKeever,
2000). However, to date no handedness gene or allele
has been identified that could ascertain the direction
and extent of handedness, and genetic theories thus
remain incomplete. The assumption that a genetic com-
position is responsible for the direction of handedness
permits left handedness to be a “normal” inherited trait
in a minority of people. At the same time, most genetic
theorists do not account for prenatal, perinatal, and
postnatal influences that may increase the incidence of
left handedness.
PATHOLOGIC I NFLUENCES ON HANDEDNESS
Models linking intrauterine influences and birth stress
with handedness appear to be based on the assumption
of a genetically predetermined right handedness in
humans. Generally, these models propose that left
handedness is a failure to become right handed and is
thereby rendered abnormal, “anomalous” (Geschwind
& Galaburda, 1985, 1987), or pathologic (see Harris
& Carlson, 1988, for a review on existing theories
relating to pathologic left handedness). The Geschwind-
Galaburda theory is the most prevalent and controversial
intrauterine model for the cause of left handedness. It
is based on the premise that anatomical asymmetries,
evidently already present in utero, result in functional
asymmetries (Geschwind & Levitsky, 1968). Geschwind
and Galaburda (1987) suggested that growth-retarding
influences of chemicals and hormones, particularly
testosterone, are most likely to affect the more
vulnerable left hemisphere because of its slower rate of

development. As a result, the anatomical brain asym-
metries are reduced and the hemispheres become more
symmetric, which leads to anomalous dominance with
equal chances of becoming left or right handed. The
authors proposed that left handedness results if the
right hemisphere becomes more specialized. In addi-
tion, variations in the chemical environment may cause
the variability typical of left handedness.
The testosterone hypothesis has been extensively
reviewed and questioned. Brain imaging studies have
supported the link between anatomical asymmetries in
language-related brain areas and hand preference (see
Foundas, Leonard, & Heilman, 1995; Steinmetz et al.,
1991, for a review). However, there are no longitudinal
studies to indicate if the observed anatomical asym-
metries in utero are related to corresponding functional
asymmetries in later life. Recent evidence also suggests
that brain symmetry appears to be triggered by trophic
changes in the right hemisphere rather than growth
retardation in the left hemisphere (Galaburda et al.,
1987; Habib, Touze, & Galaburda, 1990). Moreover,
if hormonal imbalances do exist, twins subjected to
identical intrauterine factors should present with
identical handedness, which is not necessarily the case
(Oberleke, 1996; Stein, 1994). In addition, males are
subjected to greater testosterone levels than females,
which, according to Geschwind and Galaburda (1987),
should result in a significantly higher incidence of
“atypical” handedness in males. However, as has been
noted, significant gender differences were found in
some prevalence studies but not others.
More recently, an increased incidence in left handed-
ness was revealed in male individuals who were exposed
to ultrasound in utero, which has been considered
another factor responsible for shifting inherent right
handedness to left handedness (Kieler et al., 1998).
However, intrauterine conditions do not appear to be
the only early influence on handedness development.
Just as abnormal prenatal intrauterine conditions may
affect the development of hemispheric specialization,
unfavorable perinatal and postnatal circumstances,
including birth-related stress, seem to have a similar or
even more prevailing effect (Coren, 1992).
Birth-related stress has been cited as one of the most
potent acquired influences on handedness outcome
(Bakan, Dibb, & Reed, 1973). It has been proposed
that the “dominant” hemisphere, which may not neces-
sarily be the left, is most likely to be affected by early
brain damage (Best, 1988). Goodman (1994) tested the
hypothesis of corresponding hemispheric and manual
dominance by investigating 463 children with hemi-
plegia in relation to familial handedness. Unexpectedly,
he found a highly significant correlation between right
hemiplegia and familial left handedness. Goodman
interpreted the results as evidence against the notion of
Handedness in Children • 175
a more vulnerable “dominant” hemisphere, and rather
in support of a more vulnerable left hemisphere.
Other evidence exists to support greater vulner-
ability of the left hemisphere, based on a higher ratio
of children with right hemiplegia (Uvebrandt, 1988).
Several reasons for the increased vulnerability of the
left hemisphere have been proposed. First, the blood
supply to the left hemisphere has less volume (Raichle,
1987). Second, the right hemisphere matures more
quickly and earlier than the left hemisphere, thus the
latter is more likely to be damaged (Jacobson, 1978),
being particularly vulnerable to intracranial focal lesions
and intracranial hemorrhage (Schuhmacher et al.,
1988). Third, the left hemisphere requires more blood
for metabolism and burns oxygen more quickly (Bakan,
1977). Fourth, the hormonal imbalances, especially
testosterone, appear to affect the left hemisphere more
strongly (Geschwind & Galaburda, 1987). In the case
of early neural insult affecting the left hemisphere, the
right hemisphere is thought to compensate by assuming
a more active role, resulting in pathologic left handed-
ness (Orsini & Satz, 1986; Rasmussen & Milner, 1977;
Soper & Satz, 1984).
Several prenatal, perinatal, and postnatal factors
related to the birth process have been associated with
an increased incidence of pathologic left handedness.
These factors include birth weight (O’Callaghan et al.,
1987), prematurity (Ross et al., 1987), difficult delivery
and induced birth (Colbourne et al., 1993), the mother’s
age (Coren, 1992), and smoking during pregnancy
(Bakan, 1991). It has been suggested that these factors
might later result in associated disorders such as
dyslexia (Eglington & Annett, 1994), attention deficit
disorder (ADD) (Gillberg & Rasmussen, 1982),
learning disability (Geschwind & Galaburda, 1984),
and intellectual disability (Fein et al., 1984). However,
some studies have failed to find support for an
association between left handedness and pathologic
conditions (Bishop, 1990). It has been argued that
the proposed elevated incidence of “pathologic” left
handedness is based almost exclusively on clinical
groups that consist of twice as many left handers as the
normal population (Perelle & Ehrman, 1982; Satz,
1972), and there is little evidence of an association
between left handedness and pathology in the general
population (Annett, 1992; Hardyck & Petrinovich,
1977; Satz, Soper, & Orsini, 1988).
Considering the evidence for a genetic versus intra-
uterine or birth-related stress basis for handedness, it is
generally accepted that left handedness consists of two
subgroups: familial (genetically based) and pathologic
(caused by brain damage). Distinguishing between
these two subgroups may produce different research
outcomes about comparisons between left and right
handers (Annett, 1985; Hécaen & Sauguet, 1971;
176 Part II • Development of Hand Skills
McKeever, 1981; Orsini & Satz, 1986). To date, there
is no agreement on the definition of pathologic left
handedness. There are those researchers who suggest
that pathologic left handedness appears to develop only
with substantial damage to the left hemisphere (Annett,
1985; McManus & Bryden, 1992; Satz et al., 1985), in
which case the incidence of pathologic left handedness
is relatively low. Conversely, other researchers propose
that pathologic left handedness is a result of relatively
minor neurologic trauma. In the latter case, at least half
of all left handers or even all left handers are thought
to demonstrate left handed behavior with a pathologic
origin (Coren, 1992). Taking an even more extreme
approach in the absence of strong genetic evidence
for left handedness, Bakan (1990) considered all left
handedness to stem from some form of pathology.
Hopkins and Rönnqvist (1998) emphasized that
strongly lateralized and unusually consistent hand pref-
erence during infancy, rather than fluctuating asym-
metry, may be indicative of underlying neuropathology.
It has been specifically suggested that poor perfor-
mance of the nonpreferred hand might be suggestive
of early brain damage (Bishop, 1984; Gillberg,
Waldenstrøm, & Rasmussen, 1984). This may affect
the left or right hand. There is indeed evidence for the
existence of “pathological right handers” (Kim et al.,
2001), referring to a group of familial left handers who
experience early right brain injury and consequently
develop right hand preference. However, the incidence
of pathologic right handers has been estimated to be
low because of the restricted number of familial left
handers (Satz, 1972, 1973).
Finally, if handedness is a manifestation of the extent
of interhemispheric communication via the corpus
callosum, clinical research should reflect a link between
variable handedness and callosal dysfunction. There is
evidence that dyslexia, which also has been linked to a
greater incidence of unestablished handedness (Satz &
Fletcher, 1987), appears to be related to poor hemi-
spheric lateralization (Galaburda, 1993; Satz, 1991),
and poor interhemispheric communication (Gladstone,
Best, & Davidson, 1989; Kerschner, 1983). However,
other studies have failed to find support for an associ-
ation between learning disabilities and unestablished
handedness (Bishop, 1990a,b). Also, magnetic resonance
imaging (MRI) of the corpus callosum did not reveal
differences in callosal size between dyslexic and normal
children (Larsen, Höien, & Ödegaard, 1992).
In summary, the proposition that unusual prenatal,
perinatal, and postnatal conditions influence the
cerebral lateralization process of the immature brain is
supported by empiric evidence. Although many of the
findings remain inconclusive, the impact of early
unfavorable conditions on hemispheric specialization
has not been disputed to date. However, intrauterine
models do not account for the increased incidence of
familial left handedness, suggesting a genetic compo-
nent. Furthermore, these models fail to consider socio-
cultural influences that are likely to cause an increased
occurrence of right handedness.
SOCIOCULTURAL AND E NVIRONMENTAL
I NFLUENCES
Genetic, intrauterine, and birth-related stress theories
have concentrated on predispositions and early factors
that could determine, influence, and change the handed-
ness outcome. However, handedness is undeveloped at
birth, and becomes established within the first 5 to
6 years of life (Tan, 1985). Although the direction of
handedness already may be apparent in infancy and is
considered to be stable by 5 years (McManus et al.,
1988), the degree and consistency of handedness are
subject to change, particularly up to the age of 9 years
(McManus et al., 1988; Goodall, 1984), 11 years
(Whittington & Richards, 1987), or even across the
entire life span (Porac & Coren, 1981). There is also
some evidence that handedness establishment takes
place earlier in right handers (i.e., by 5 years of age)
than left handers (i.e., by 9 years) (Mandell et al.,
1984). Environmental and cultural influences are likely
to have a significant effect on handedness, although
there is little empiric support for handedness as a sole
product of cultural influences. For example, children of
left-handed foster parents do not exhibit an increased
use of the left hand (Carter-Saltzman, 1980). Further-
more, in many societies it is far more likely that socio-
cultural influences restrain left handedness, forcing, or
at best encouraging, left handers to use their right hand
(Harris, 1990). One of the more extreme examples is
the account of Chinese children at Taiwanese schools,
in which the incidence of left-handed writing is only
0.7% (Teng et al., 1976). However, no evidence was
found that forced right-handed writing also resulted in
increased right hand use in other activities.
There is empiric support that the number of left
handers is significantly higher in younger individuals
than in older ones, both in cross-sectional and longi-
tudinal studies (Coren, 1992; Hugdahl et al., 1993;
Porac & Coren, 1981; Porac et al., 1986). Stricter
sociocultural pressures to use the right hand for socially
important tasks were imposed particularly on previous
generations, a phenomenon that has been described
in the “modification hypothesis” (Coren, 1992). This
hypothesis asserts that the existing right-handed bias in
the sociocultural and physical environments coerces left
handers to “switch” handedness to the right (Coren,
1992; Sakano, 1982). However, the modification
theory has only addressed switching of well-established
left handers. It is plausible that individuals with a mild

left-handed predisposition are most vulnerable to right-
biased sociocultural pressures. Therefore it is possible
that inherently mildly established left handers con-
stitute a proportion of unidentified switched handers
within the right-handed population.
CONCLUDING REMARKS
In summary, hand preference can be perceived as a
multicausal behavior that is influenced by a variety of
mechanisms, including genetic and nongenetic factors.
As Provins (1997) contended:
“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
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
pressure, other environmental influences or habit” (p. 556).
Although the origin and cause of manual lateraliz-
ation are still debatable, the prevalence of left and right
handedness appears to have existed fairly constantly
since prehistoric times (Bradshaw & Rogers, 1996;
Calvin, 1983; Corballis, 1983; Steele & Mays, 1995;
Toth, 1985) and across most human societies (Hardyck
& Petronovich, 1977; Harris, 1980, 1990; Peters,
1995). It could be concluded that handedness is a
unique human trait, displaying a wide variety of degrees
of presentation that are not yet well understood. In
contrast, the development of handedness has been well
documented since the 1940s, as reviewed in the
following section.
THE DEVELOPMENT OF
HANDEDNESS
Occupational therapists should have good understand-
ing of handedness development because this forms an
important basis for the intervention phase. Defining a
developmental process of a particular behavior in the
holistic context of occupational performance most
often requires the inclusion of related behaviors. This is
also the case with the development of handedness, in
which the hands tend to be used initially in the ipsi-
lateral hemispace before contralateral reaching with the
preferred hand is observed (Provine & Westerman,
1979; Pryde, Bryden, & Roy, 1999). Furthermore,
handedness is expressed both unimanually and bi-
manually (Hopkins & Rönnqvist, 1998). In particular,
Fagard (1998) argued that stabilization
“of unimanual handedness might be one of the factors
influencing the emergence of the capacity to use both hands in
Handedness in Children • 177
cooperation… Bimanual complementary movements often con-
sist of more than one step or action, in which each hand plays a
different role. The flexibility in shifting attention between hands
might therefore be one prerequisite for bimanual success”
(p. 125).
In a neurodevelopmental context it seems appro-
priate to follow the emergence of handedness in rela-
tion to midline crossing and bimanual coordination.
The different developmental stages are discussed in the
following, first in relation to handedness with reference
to the developmental stage of the corpus callosum, then
to midline crossing, and finally to bimanual coordination.
BIRTH
At birth, the corpus callosum is underdeveloped and
nonfunctional (Gazzaniga, 1970; Hewitt, 1962),
developing over the next 10 years at an unprecedented
rate compared with its later development. Movement
of the upper limbs has been described as uncontrolled
and reflexive, and is performed both symmetrically and
asymmetrically (Fagard, 1990, 1998), with the
presence of the asymmetrical tonic neck reflex (ATNR)
and the Moro reflex. These seemingly random move-
ments are closely linked to the lack of postural control
at this age. For example, when the head of a neonate is
stabilized externally, reaching is possible (Amiel-Tison
& Grenier, 1980). However, adequate postural control
is necessary to enable independent reaching by the
infant, so reaching does not occur spontaneously at this
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).
4 MONTHS
According to Gazzaniga (1980), each hemisphere
processes sensorimotor information independently of
the contralateral side. This activity might indicate that
the corpus callosum is starting to play a role in relaying
information from one hemisphere (e.g., visual field) to
the other (e.g., controlling contralateral motor perfor-
mance). Hand preference coincides with unilateral
swiping of either hand (Gesell & Ames, 1947) and a
decrease in the grasp reflex that is replaced with a crude
but voluntary grasp (Case-Smith, 1995). Provine and
Westerman (1979) found that this is the earliest time
that infants are able to cross the midline when one
hand is restrained (see also Murray, 1995, for a review).
Bimanual movements are symmetrical or mirrorlike
and simultaneous, resulting soon in bilateral body and
object exploration, and hand interplay in midline
(Fagard, 1990, 1998; Fagard & Pezé, 1997).
178 Part II • Development of Hand Skills
6 MONTHS
Gazzaniga (1980) proposed that the corpus callosum
first demonstrates increased myelination, reflected in
the emergence of unilateral reach. Alternating with the
bilateral development, a first (transient) preference for
unilateral, usually the right hand, use becomes apparent
(Gesell & Ames, 1947). As the infant’s postural control
develops in sitting, weight is borne on one arm for
pivoting, and the infant reaches with the other hand to
the contralateral side using trunk rotation (Case-Smith,
1995; Gilfoyle, Grady & Moore, 1990). No active
contralateral reaching has been recorded at this stage.
There is a definite shift toward bilaterality (Gesell &
Ames, 1947) from simultaneous to successive move-
ment (Castner, 1932). For example, the infant holds an
object in one hand and reaches with the other (White,
Castle, & Held, 1964), or movement is initiated with
one hand and completed with the other (Castner, 1932).
8 MONTHS
The emergence of a more radial palmar and then digital
grasp (Gesell & Amatruda, 1947) precedes a unilateral
phase whereby there is increased left hand use, followed
by a greater persistence of right hand use. Further
refinement of postural control is now evident (Case-
Smith, 1995; Gilfoyle et al., 1990), but no active
contralateral reaching has been recorded at this stage.
Infants start to hold two objects simultaneously in each
hand and combine this with a bimanual symmetric
action, such as banging (DeSchonen, 1977; Fagard,
1990, 1998; Fagard & Pezé, 1997).
12 MONTHS
As the corpus callosum continues to develop, the
emerging pincer grasp coincides with another phase of
more unilateral left hand performance, followed by a
phase of using either hand (Gesell & Ames, 1947).
Having achieved good postural control in sitting, the
infant is now able to reach into either contralateral
space using trunk rotation but without employing arm
support. However, this midline crossing occurs mainly
when one hand is occupied, not yet reflecting a
preferred hand. Ipsilateral reaching is still preferred
(Carlson & Harris, 1985; Case-Smith, 1995; Knobloch
& Pasamanick, 1974), although Bruner (1969)
suggested a diminished “midline barrier” at this stage.
The hands begin to work together in an increasingly
complementary fashion and coordinated asymmetric
roles (Goldfield & Michel, 1986), in which one hand is
more active, the other more passive. Bimanual hand
preference emerges after 9 to 10 months of age, involv-
ing temporal and spatial coordination and comple-
mentary action. Sequential rather than simultaneous
bimanual activity is performed (Fagard, 1998; Fagard
& Pezé, 1997).
18 MONTHS
Around this age, the left hemisphere develops more
rapidly than the right (Jacobson, 1978). The clear shift
toward unilateral hand use continues, alternating with
much bilateral activity, and inconsistent hand use is still
apparent (Gesell & Ames, 1947). Other researchers
have observed a clear hand preference in bimanual tasks
after 14 months (Michel, Ovrut, & Harkins, 1985;
Ramsey, Campos, & Fenson, 1979), concluding that
unimanual hand preference precedes bimanual hand
preference. More recently, Fagard and Marks (2000)
compared unimanual and bimanual tasks in relation to
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.
They deduced that hand preference is task related, and
that certain bimanual tasks might display greater asym-
metry than unimanual tasks in infancy. At this stage, the
first active contralateral reaching across the body is
observed (White et al., 1964), without one hand being
occupied or used for support. Children are now able
to combine stabilizing the object with one hand and
manipulating it with the other in an alternating manner
(Gilfoyle et al., 1990), which leads to more mature
bimanual coordination (Corbetta & Thelen, 1996;
White et al., 1964).
24 MONTHS
The corpus callosum appears to be functioning at a
basic level and inhibitory function is emerging (Farber
& Knyazeva, 1991). There appears to be a preference
for bimanual activity in which the preferred hand is
more active and the nonpreferred hand has a stabilizing
and assistive role (Fagard & Marks, 2000). At this stage,
most young children show a more definite preference
for the right hand (Gesell & Ames, 1947) because the
fingers and arms are increasingly dissociated for a large
variety of functional skills (Case-Smith, 1995). Stilwell
(1987) found that 2-year-old children actively cross the
midline, more so with their preferred hand. The hands
can now be used in all planes with good control
(Gilfoyle et al., 1990). Two-year-old children can also
perform a sequence of bimanual movements whereby
the arm and hand stabilization and movement are
controlled simultaneously (Knobloch & Pasamanick,
1974), such as holding a crayon and drawing, or
threading beads.

2 TO 6 YEARS
MRI studies have supported age-related increases in
cerebral white matter and myelination of the corpus
callosum in children and adolescents (DeBellis et al.,
2001; Giedd et al., 1999; Thompson et al., 2000).
There is evidence that callosal transfer is not optimal
until approximately 10 to 12 years (Yakovlev &
Lecours, 1967), and that subsequent sensorimotor and
cognitive development further increase the callosal
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
is a tendency toward unilateral activity (Gesell & Ames,
1947). This stage appears to be followed by another
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,
1947; Tan, 1985). At the age of 6 years children use
the preferred hand consistently to cross the body mid-
line (Stilwell, 1987). However, more complex tactile
tasks requiring crossed localization conditions demand
a higher level of interhemispheric transfer via the
corpus callosum (Fabbro, Libera, & Tavano, 2002).
Children aged 5 to 6 years make significantly more
errors than 10-year-olds (Quinn & Geffen, 1986).
Children are increasingly able to execute complex
activities requiring differentiated hand performance, in
which the asymmetrical and functional role differen-
tiation becomes more refined throughout childhood
(Fagard, 1990, 1998). Symmetrical in-phase coordina-
tion between the hands is evident at 5 years (Fagard,
1987), but inconsistent coordination patterns are still
observed in children between the ages of 6 and 10 years
(Haken, Kelso, & Bunz, 1985).
Unimanual action such as grasping might strengthen
the contralateral unilateral control system during
infancy (Fagard, 1998). This allows one hand to take
responsibility and lead, which in turn influences hand
preference and the dissociation between the hands.
Bimanual action, on the other hand, allows infants to
use both hands in succession until they are able to
coordinate their hands in an asymmetrical and simul-
taneous manner (Fagard, 1998). With maturation,
reaching and grasp extend to midline and then to the
contralateral space, possibly indicating a shift in
interhemispheric communication from extracallosal to
callosal control (Liederman, 1983). This contralateral
reaching or midline crossing has been defined as
“hand movements that approach and/or cross the centre
longitudinal axis of the body (the body midline)” (Stilwell,
1994).
Handedness in Children • 179
In summary, the development of handedness
appears to fluctuate between unimanual and bimanual
preferences that seem to be individually paced. Hand
function initially takes place only in ipsilateral and
midline spaces, and later extends to the contralateral
space. This developmental process supports the
neurophysiological basis for an intricate relationship
among hand preference, midline crossing, and biman-
ual coordination and appears to be closely linked to the
development of the corpus callosum.
PEDIATRIC OCCUPATIONAL
THERAPY AND HANDEDNESS
ASSESSMENT
Tests Used in Occupational Therapy
There is a lack of specific test procedures in occu-
pational therapy to assess handedness. The Mesker test
was designed specifically to assess writing handedness
for children at school entry (Mesker, 1972). This test
was used by occupational therapists in the United
Kingdom and involves simultaneous drawing with both
hands. However, findings from an evaluative study
indicate that hand preference could not be confirmed
definitely using the Mesker test (Warren & McKinlay,
1993).
Two assessments that include aspects of handedness
in children are frequently used in occupational therapy;
the Southern California Sensory Integration Tests
(SCSIT) (Ayres, 1980) and the Sensory Integration
and Praxis Tests (SIPT) battery (Ayres, 1989). Because
there is some evidence that
“limitations in development of unilateral hand preference may
be associated with poor functional integration of the two sides of
the body … [and] with diminished preferred-hand visuo-motor
coordination” (Ayres & Marr, 1991, p. 233),
there is an advantage of using the SCSIT or SIPT to
obtain a more holistic picture of handedness. The two
tests combine the assessment of preferred hand use,
hand performance, midline crossing, and bilateral
motor coordination, in addition to other behaviors
related to sensory integrative dysfunction. In the
SCSIT and SIPT, midline crossing is closely related to
preferred hand use: The therapist observes to what
extent the preferred hand is used for contralateral
reaching. In addition, hand performance is assessed in
both hands by means of a tracing task, with scores
180 Part II • Development of Hand Skills
incorporating both time and accuracy. However, note
that although the inclusion of handedness-related
information was initially aimed at detecting the extent
of hemispheric specialization (Ayres, 1980, 1989;
Murray, 1991), contemporary sensory integration is
primarily concerned with deficits in the central proc-
essing of tactile, proprioceptive, and vestibular sensa-
tions and the integration of these into adaptive
responses (Bundy & Murray, 2002; Windsor, Smith
Roley, & Szklut, 2001). Although the SCSIT and SIPT
test batteries still contain and use measures of preferred
hand use, motor accuracy for both left and right hands,
and a midline crossing measure, the purpose of these
measures is to obtain information on laterality estab-
lishment in general rather than handedness, because it is
considered to be an important component for detecting
bilateral integration and sequencing (BIS) deficits.
In both the SCSIT and SIPT, preferred hand use
(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-
vides an accurate reflection of hand preference, because
these tasks are subject to sociocultural influences (Ida,
Mandal, & Bryden, 2000). The inclusion of an
additional test with more opportunity to demonstrate
hand preference across a range of functional tasks is
thus necessary.
It seems evident that the multidimensional nature of
handedness requires a careful multifaceted assessment
in which hand preference, hand performance, con-
sistency, and interhand differences are recorded. In
addition, an assessment of bimanual coordination and
Performance Level
Below Border Average Handedness Aspect
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)
midline crossing contribute to a more functional
analysis of handedness, although background informa-
tion on early hand use, familial handedness, and
possible prenatal, perinatal, or postnatal trauma could
provide some context to the influences of handedness
establishment. A test battery addressing all of these
facets, the Handedness Profile, has been proposed by
Kraus (2003). The test battery includes a Handedness
Profile Chart, that summarizes both the extent of
interhand differences (ranging from explicit left L+,
moderate left L–, variable V, moderate right R–, to
explicit right R+ handedness), and performance levels
for six handedness aspects (Fig. 9-4). In addition, the
Handedness Profile features a Diagnostic Summary that
incorporates background information and qualitative
information on each of the handedness aspects to assist
the final diagnostic classification of the type of
presenting handedness.
I NTERVENTION THEORY
Unestablished Handedness
Occupational therapy intervention for unestablished
handedness has its roots in perceptual motor theory
(Keogh & Sugden, 1985; Kephart, 1971; Lerch,
Becker, & Nelson, 1974), sensorimotor principles
(Knickerbocker, 1980), and sensory integration (Ayres,
1972, 1989). Laterality has been defined by early
perceptual motor theorists as
“the internal awareness of the two sides of the body and their
difference” (Kephart, 1971, p. 88).
Inter-Hand Difference
L⫹ L⫺ V R⫺ R⫹

In this context, the development of laterality was
thought to underlie the establishment of handedness:
When a child is able to differentiate the two sides from
each other, one side becomes more “dominant.” The
emphasis in the perceptual motor approach is on the
establishment of laterality, and handedness is con-
sidered to be a by-product (Kephart, 1971). Although
some early sensorimotor training programs aimed at
improving body image and laterality have resulted in
increased contralateral reaching (Ball & Edgar, 1967;
Maloney, Ball, & Edgar, 1970), the broad definition of
laterality fails to specifically address handedness. Indeed,
handedness should not be considered synonymous with
laterality, because the correlation between handedness
and other modalities (foot, eye, and ear) is variable.
Footedness (as assessed through kicking) appears to be
most strongly related to handedness, with about 85% of
right handers and 80% of left handers using their right
and left feet, respectively (McManus, 2002). However,
clinical experience has indicated that one-leg standing
balance, another task used to assess the preferred leg,
does not appear to correlate strongly with kicking,
possibly because the nonkicking leg needs to acquire
good balance to support the kicking leg (Kraus, 2002,
personal observation). Eyedness has been assessed and it
was found that about 70% of people demonstrate right
eye preference and 30% left eye preference: Although
there is a correlation between eyedness and handedness,
it is rather weak (McManus, 2002). Finally, earedness
correlates even less with handedness, because only about
60% of people listen with the right ear and 40% show left
ear preference (McManus, 2002).
The importance of the lateralization of these
modalities remains controversial, particularly because
there is a lack of empirical evidence that they reflect
brain and language specialization more accurately than
handedness (Bryden et al., 1996). The concept of
“cross-dominance” (i.e., hand-, foot-, eye-, and ear-
dominance are not congruent) was introduced by
Orton (1925, 1937), who proposed that “cross-
dominance,” particularly between hand and eye pref-
erence, is associated with dysfunction such as dyslexia,
a theory supported by other early perceptual motor
theorists (Delacato, 1963; Harris, 1957; Rengsdorff,
1967). However, more recent research has challenged
these early theories, because no relationship was found
between them and a mixed or “crossed” dominance
profile and intelligence or achievements (Sulzbacher et
al., 1994). Other existing asymmetries or lateralities in
humans, such as arm folding, hand clasping, and leg
crossing, have been researched because they are not
subject to any learning. Luria (1973) and Sakono
(1982) suggested that these lateralities can denote
“latent left handedness,” which could explain why
some individuals were more likely to recover from
Handedness in Children • 181
aphasia after unilateral left hemisphere brain damage.
However, the supplied evidence is rather weak (Bryden
et al., 1996), and it has been suggested that these types
of lateralities are inherited genetically and not related to
brain lateralization (McManus, 2002).
Traditionally, clinicians have considered laterality to
be a sensorimotor-based phenomenon that becomes
established independently of the child’s knowledge of
left and right, and it is thought to be stabilized when
the child has acquired the left-right concept (Williams,
1983). This concept of laterality assumes hierarchical
functioning of the central nervous system, in which
laterality is deemed necessary for higher-level move-
ment efficiency, symbol recognition, and directionality
(Knickerbocker, 1980). Therapy promoting the estab-
lishment of handedness within the perceptual frame-
work aims to improved general body awareness, body
image, crossing the midline, and directionality
(Knickerbocker, 1980).
Adopting a similar bottom-up approach within a
sensory integrative frame of reference, Ayres (1972)
initially suggested that integration of proprioceptive
and vestibular sensations, as well as efficiency of inter-
hemispheric connections, were fundamental to good
bilateral integration and the establishment of a pre-
ferred hand in contralateral space. Since then, sensory
integration theory has refined these concepts or
expanded on Ayres’ propositions by linking theoretical
postulates to clinical practice and sensory integrative
therapy using case examples (Dahl Reeves & Cermak,
2002; Kimball, 1999; Koomar & Bundy, 1991, 2002;
Murray, 1991; Windsor et al., 2001). More specifically,
some authors suggested that the inclusion of trunk
rotation is important in developing bilateral integration
and crossing of the midline (Kimball, 1999; Koomar &
Bundy, 1991, 2002). These authors proposed that
employing these behaviors together in therapy might
assist in promoting the cerebral specialization necessary
for developing a skilled preferred hand.
Moreover, several authors have suggested the
inclusion of bilateral coordination and midline crossing
activities when treating unestablished handedness in
pediatric occupational therapy practice (Clancy &
Clark, 1990; Knickerbocker, 1980; Levine, 1991;
Stephens & Pratt, 1989; Whitehead, 1978; Wilson,
1994). In some instances mention is made to “remind”
a child to use the preferred hand when hand use is
inconsistent (Koomar & Bundy, 1991), although this
presupposes a certainty about the child‘s “correct”
handedness or hand dominance. Unfortunately, empirical
evidence is lacking to support the therapeutic effective-
ness using any of these treatment strategies in pro-
moting handedness establishment.
A sensorimotor and sensory integrative approach to
treatment of a 3- to 4-year-old child with unestablished
182 Part II • Development of Hand Skills
handedness seems appropriate, because an overall dev-
elopment of laterality may well assist in establishing
handedness. However, older children presenting with
unestablished handedness pose the greatest challenge,
particularly so if a decision on handedness is eminent
because of school entry. Based on the current handed-
ness knowledge discussed so far, assessment results
should be analyzed carefully before embarking on
clinical decision making. How do we know if a child is
inherently left or right handed? Are there other factors
to consider before making a final decision? What is the
most beneficial treatment for that child? In her doctoral
thesis, Kraus (2003) methodically evaluated existing
handedness measures, proposed several different
reasons why children could present with unestablished
handedness (or types of variable handedness), devised a
novel assessment battery and suggest treatment guide-
lines in the context of her Handedness Profile. This
process could be one way to deal with these questions,
but it extends beyond the scope of this chapter. In the
absence of evidence-based practice to substantiate
certain treatment approaches, differential handedness
assessment methods are crucial.
Switched Handedness
When addressing switched handedness flag a note of
caution. Although many of a child’s presenting
problems might be related to, or caused by, switched
handedness (Fischl, 1986; Friedman, 1987; Harris,
1990; Olsson & Rett, 1989; Richberg, 1987; Sattler,
1998; Stutte et al., 1977), “unswitching” might not be
favorable in every case because there appear to be cer-
tain preconditions for successful handedness retraining.
According to Sattler (1998), these preconditions
include the following: (a) full support for the retraining
process of parents and teachers; (b) a relatively stress-
free situation with flexible time constraints on writing,
and limited writing volume; (c) sufficient motivation of
the child; and (d) a skilled therapist experienced with
handedness issues. In addition, based on my own clinical
experience as an occupational therapist, average or
above-average motor performance level of the left
hand, regular occupational therapy sessions, monitor-
ing of progress, and regular follow-up (including close
contact with parents and teachers), also are necessary
for a successful handedness retraining outcome. Age
does not appear to be a major factor for successful
retraining because numerous case studies exist of adult
switched handers who have successfully retrained their
original or dominant handedness (Sattler, 1998). A
case study, based on the Handedness Profile (Kraus,
2003), illustrates the clinical decision making process
for a child with switched handedness (Box 9-4).
However, a note of caution: Until therapists are
more familiar with the dynamics and associated
problems of unestablished or variable handedness, they
should refrain from retraining handedness, unless they
receive professional supervision or have completed
special courses in this field.
Left Handedness
In most aspects, there are no differences between
treating left and right handed children in therapy,
because motor problems are common in both groups
and should be treated according to the same principles.
However, two intervention areas require specific atten-
tion for left handers: writing and those ADL activities
that involve utensils designed for right handers.
Writing
The act of writing from the left to the right is con-
ducive to right handers, who engage in a pulling
motion across the page whereby the written work is
clearly visible. Left handers have to adhere to the same
left-to-right direction in writing and thus should apply
a pushing motion that is more difficult to control.
Furthermore, if left handers employ the mirror image
hand position of right handers during writing, the left
hand obscures the written work, and if a fountain pen
is used, smudges it. The pushing action and visual
limitations seem to be the main reasons why many left
handers develop compensatory positions that often
result in an unfavorable, cramped writing grasp with
wrist flexion. Although the pushing action may be
more laborious when learning to write, this is no reason
to switch a left-handed child to right-handed writing,
because there is evidence that left handers are able to
develop the same writing speed as right handers
(Sattler, 2001). However, if a child learns to use a
hooked or clawed writing position through compensa-
tion, this is more likely to impede on the speed,
legibility, and ergonomics of writing.
In therapy it is thus crucial to establish the correct
writing pattern for left handers. The basic principles are
the same as in right handers:
• 90°-90°-90° position at hips, knees, and feet, with
table height two fingers above the adducted elbow;
good upright posture
• The upper arm only abducts slightly when the fore-
arm moves outward to the side, and the elbow does
not protrude sideways
• Lateral support of the ulnar side of the hand and
wrist extension
• Refined and relaxed tripod grip enabling intrinsic
finger movement
The following principles are specific to left-handed
writing:
• Paper or exercise book placed slightly toward the left
of the body midline with the left top corner slanted
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
Tim (6 years and 6 months old) presents with right-
handed writing. A history of early left hand use is
reported, and both father and sister are self-reported
switched left handers. There are indications of socio-
cultural pressure for right hand use, with Tim’s father
openly advocating the need to switch left handedness to
right handedness. There is a history of birth-related stress
and general mild developmental delay.
HANDEDNESS PROFILE
• Untrained hand preference tasks: More left than right
responses, below average performance, inconsistent
within and across tasks
• Trained hand preference tasks: Slightly more right than
left responses, below-average performance, inconsistent
across tasks mainly
• Hand performance ability: Significantly more right than
left responses, average performance
• Hand performance skill: Significantly more right than
left responses, below average performance
• Midline crossing: Crosses more frequently with the left
but overall avoids contralateral reaching
• Simple bimanual coordination (bimanual circle draw-
ing): Leads more with the left, average performance
• Overall classification: Variable left hander
DISCUSSION AND INTERPRETATION OF RESULTS
The handedness profile indicates both within-task and
across-task inconsistency, in which the left hand is used
more for untrained tasks (mild left) and the right slightly
more for trained tasks (variable right). There was no
• In general, wrist extension can be greater than in
right handers; that is, closer to maximum extension
(and not closer to neutral, as in right handers). This
allows the writing hand to be placed below the written
work and thereby ensures good visibility as well as a
functional and refined pencil grasp. In practice, wrist
extension might be closer to neutral when starting to
write from the left side, and may increase as the hand
moves toward midline.
Mirror writing or reversals is another interesting
aspect often observed with left-handed writing. There
seem to be two reasons for this. First, there appears to
be a natural tendency for a pulling motion during
drawing and writing, which, for left handers, extends
from right to left. Second, there is evidence that right
handers tend to process visual information in a left-to-
right direction, whereas left handers process in the
opposite right-to-left direction (Sattler, 1998). These
tendencies may result in reversals but do not necessarily
presuppose problems, unless the child also has visual
perceptual processing problems. It is a matter of prac-
tice and habit to adopt the left-to-right visuomotor
Handedness in Children • 183
incongruence between ability and skill, because the right
hand performed notably better than the left in both ability
and skill. For midline crossing the left hand was used more
for contralateral reaching than the right, although Tim
generally avoided crossing the midline. Ability was per-
formed in the average range with the right hand, which is
not unusual for left handers as a group. However, skill was
performed better with the right than with the left hand
but scored in the poor range. This might result from a
mild motor-based deficit, because both hands performed
in the subaverage or poor performance level range despite
the practice effect of the right hand. Bimanual coordina-
tion was scored in the average range with a stronger
left-handed lead. This, together with average ability per-
formance, suggests an absence of severe coordination
problems. In the light of sociocultural pressure for right
hand use, it can be assumed with reasonable confidence
that switched handedness is responsible for Tim’s variable
hand use.
CLINICAL DECISION MAKING
It appears that Tim’s motor and perceptual problems have
a developmental basis, and it is likely that these problems
are exacerbated by his switched handedness. However,
considering that his left hand performed in the subaverage
range for the “nonpreferred” hand, and given the “pro-
switching” attitude prevalent in his family, the option of
retraining handedness was rejected. Instead, a sensori-
motor program addressing his gross motor problems, and
a graded fine motor and graphomotor program appeared
more appropriate.
processing direction, but left-handed children might
thus undergo a more extensive phase of reversals and
mirror writing.
Activities of Daily Living
Although many activities of daily living (ADL) tasks can
be performed by left handers in a mirrorlike fashion to
right handers (e.g., brushing teeth, getting dressed,
doing buttons, tying laces), there are several ADL tasks
that involve utensils with a right-handed bias, or that
are performed in a right-hand-biased environment. These
include cutting with scissors and one-sided bladed
knives, pencil sharpeners, computer mice with clicks for
the right index finger, playing the piano (with the more
difficult part usually on the right), reading and using
measuring jugs, tightening of screws with a screw-
driver, and opening lids and taps with external wrist
rotation that usually require greater strength. Clearly,
there are differences in proficiency levels involved in
these tasks, and many left handers quite easily learn to
perform low-level skill tasks with their right hand. For
higher skill levels, such as cutting with scissors, it is
184 Part II • Development of Hand Skills
advisable to provide left-handed scissors. (Incidentally,
the so-called two-bladed scissors that are advertised for
both left and right handers may have a good cutting
action, but vision is obscured for left handers because
the scissor blades are assembled for right handers.) How-
ever, if a left-handed child has already taught herself or
himself to cut with good results with the right hand,
and if he or she resists changing to the left, this is
usually in order. If a left-handed child experiences
difficulties in other ADL tasks, there are several shops
for left handers advertised on the internet, in which
information on left handers is available and equipment
and utensils can be ordered (e.g., info@lefthander-
consulting.org; info@sinErgo.com).
CONCLUDING REMARKS
Considering the complexity of handedness, it seems
unlikely that there is one standard treatment approach
that could effectively enhance the establishment of
handedness, or that a certain combination of ap-
proaches is effective in all cases. Although the appro-
priateness and effectiveness of these treatment
approaches in addressing unestablished handedness has
still to be determined, it is proposed that the therapist
should be familiar with different types of intervention,
applying one or more approaches as deemed most
beneficial to each individual child. Furthermore, the
development of handedness, in relation to the develop-
ment of midline crossing and bimanual coordination,
provides valuable guidelines for therapy.
SUMMARY
This chapter has demonstrated that handedness is a
variable, complex, interactive, and multidimensional
phenomenon subject to hereditary, environmental, and
social influences. To understand and assess handedness
not only in this context but also in terms of function
within occupational performance, those behaviors
closely linked to handedness, function, and environment
(i.e., bimanual coordination and midline crossing)
should be assessed. The development, publication, and
standardization of a comprehensive handedness assess-
ment tool that satisfies these criteria is still pending, as
is the analysis of the results for clinical decision making.
A comprehensive assessment procedure is a crucial
research tool for investigating the nature of unestab-
lished, left and right handedness as well as the effec-
tiveness of different treatment approaches. It can be
concluded that handedness is a pediatric specialist area
in occupational therapy that is in need of much
empirical evidence and support.
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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
194 Part II • Development of Hand Skills
hand skills and other factors affecting the achievement
of particular skills.
IMPORTANCE OF INDEPENDENCE
IN SELF-CARE
Children of every society are expected to develop
independence in their performance of everyday living
skills and in most cultures independence is taken for
granted as children reach the appropriate maturational
levels. The universal expectation for competence in self-
care activities is the reason for the emphasis on their
acquisition in rehabilitation and education.
I MPORTANCE TO THE C HILD
A child’s control over the environment comes to a large
degree through mastery of daily activities (Amato &
Ochiltree, 1986). The ability to feed, dress, and care
for toileting needs significantly increases a child’s con-
trol over both home and school environments. For
example, a child who dresses himself or herself does not
have to depend on the convenience of the caregiver.
The child has more control of time, to be dressed with-
out waiting, or delay dressing a bit to complete an
interesting activity.
The ability to meet individual needs without seeking
help can result in feelings of efficacy and control
(White, 1959) and this is a most important con-
sideration in the development of basic self-care. Self-
dependence is an important developmental task in any
culture, the achievement of which wins cultural
approval, and cultural pressures are such that mastery
of a given task leads to satisfaction. Furthermore,
teaching self-care activities provides an opportunity for
caregivers to instill positive self-esteem in young
children.
The observation of emerging independence in a
child has been called “an early joy of parenthood”
(Coley & Procter, 1989, p. 260). In the United States
children are encouraged and praised for self-sufficiency,
with the result that most want to be independent and
feel a sense of pride in mastery (Gordon, 1992). Young
children often announce achievements such as tying a
bow or buckling a shoe to family and friends, often
wanting to demonstrate their new skill. When parents
actively encourage and teach children to care for them-
selves, they are fostering the development of compe-
tence (Maccoby, 1980). Furthermore, young children
demand independence: “I can do it myself.” This
insistence on self-sufficiency in performing activities
begins during the second year of life (Geppert &
Kuster, 1983) and has been related to the development
of volitional behavior (Bullock & Lutkenhaus, 1988).
Volition implies action in which the achievement of a
goal is seen as resulting from one’s own activity.
SELF-CARE IN DISABILITY
The timely achievement of abilities in self-care tasks is
important in the daily life of all children in the US
culture and the inability to perform a skill is a major
barrier to school and home living for children with
special needs. In the development of a child’s potential
“acquiring daily living skills may be as important as academic
qualifications” (Gordon, 1992, p. 97).
The degree of disability in self-care among children
with special needs varies with type and degree of
impairment both within and among disabilities. In a
London school district a survey conducted of special
needs children (primarily with cerebral palsy or
multiple handicaps) reported that about 65% needed
help in dressing and 25% in eating (Inglis, 1990). A
study of young adults with cerebral palsy also reported
a high degree of continuing dependence: Fewer than
half were independent in basic self-care (Senft et al.,
1990). As expected, these researchers found a greater
degree of dependence in persons with quadriplegia:
The majority of persons with hemiplegia were indepen-
dent. Another study of young persons with hemiplegic
cerebral palsy found most had achieved mastery in
self-care, including the bimanual activities, but some
expressed reluctance to perform them because the
adaptive method made them look different (Skold,
Josephson, & Eliasson, 2004).
Children with developmental coordination disorder
usually are evaluated for achievement in drawing, writing,
and schoolwork. Less attention has been given to their
self-care needs, but descriptive studies have shown that
their impaired motor abilities sometimes interfere with
eating and dressing independence (Gubbay, 1975;
May-Benson, Ingolia, & Koomar, 2002; Walton, Ellis,
& Court, 1962). The possible delay in self-care acquisi-
tion is now considered one criterion for diagnosis of
the disorder (American Psychiatric Association, 1994;
Cermak & Larkin, 2002).
Many disabilities of childhood interrupt the typical
sequence of independent performance in self-care skills.
Their importance in early childhood in the presence of
a disability sometimes is underestimated because infants
and preschool children are naturally dependent and
easy to tend. Parents may not be too concerned about
delays in activities such as dressing, but as a child grows
and siblings are born, extended dependency can add
significantly to the stress within a household (Wallander,
Pitt, & Mellins, 1990).

Research has demonstrated that life outcomes in
social and work situations of young adults with con-
genital handicaps appear to be related to their indepen-
dence in self-care. For example, Wacker and co-workers
(1983) reported that the variables most strongly related
to satisfaction with life outcomes were the individuals’
perception of their independence in self-care and
mobility. Christiansen (2000) has noted that being able
to conform to societal expectations for self-care is integral
to overall feelings of life satisfaction. Self-dependence
in everyday tasks is important to everyone, and no less
so for children whose achievement is interrupted by
disability
MEASUREMENT
NONSTANDARDIZED M EASURES
Since the early years of the profession, therapists have
been concerned with the assessment and treatment of
dysfunctional self-care performance. One of the first
known checklists of self-care performance was published
in 1935 (Wolf, 1969); since that time assessment of
function has been traditional in both occupational and
physical therapy. Assessment forms were published
from time to time in the early years, but more often
treatment settings designed forms to meet the needs of
their particular caseloads and treatment settings.
Developmentally oriented functional assessments
that incorporated information on child growth and
development came into use in the 1940s, and devel-
opmental scales that included basic self-care were
published a few years later. For example, an upper-
extremity motor development test that included age-
keyed items on feeding, dressing, and grooming, as
well as hand use, was developed at the New York State
Rehabilitation Hospital (Miller et al., 1955). Such
instruments used information on ages at which children
typically master skills, and grouped the skills by the age
at which achievement might be expected.
One of the reasons therapists have continued to con-
struct their own instruments is because of the need for
greater detail in planning treatment programs for dif-
ferent disabilities. Breakdown of self-care activities is
different for a child with a congenital amputation,
cerebral palsy, spina bifida, or mental retardation. Both
center-made and published scales are designed for day-
by-day guidance of intervention and are as detailed
as available knowledge allows. Some published non-
standardized instruments have been designed for
specific disability areas. For example, a comprehensive
tool for evaluating children’s self-sufficiency in self-care
activities was developed by the Occupational Therapy
Department at Children’s Hospital at Stanford,
Self-Care and Hand Skill • 195
California (Bleck & Nagle, 1975; Coley, 1978)
primarily for use in cerebral palsy patients.
Developmental scales providing standardized admin-
istration and some reliability of scoring also have been
published (Brigance, 1978; Vulpe, 1979). The estimated
ages at which the tasks and subtasks are accomplished
are derived from multiple sources that are identified in
the manuals. Sources include intelligence tests, devel-
opmental tests, and research studies. Because these tools
were intended as a guide for the sequential learning of
self-care and other developmental skills, they include
multiple steps in achievement. The purpose of these
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
assessment published by Vulpe has a particularly
detailed section on self-care.
Published and unpublished center-made measures
such as those described have been in wide use. The
advantage of center-made instruments is that they can
be designed for the needs of particular children in
particular settings. The disadvantage is that assessment
information cannot be generalized to other disabilities
or settings and the semiformal methods of adminis-
tration make it difficult to ensure reliability among
different therapists, even when a standardized method
of evaluating each item has been developed. Change
in a child’s skill or the lack thereof might reflect
differences between therapists rather than changes in
performance.
STANDARDIZED I NSTRUMENTS
Derived normative age information for developmental
scales is at best only fairly accurate, and the information
on individual children is descriptive only. Meaningful
overall scores are not obtainable because there is no
way of weighing individual items. Therefore they are
not appropriate for use in research or the documen-
tation of overall progress.
Two pediatric assessments designed for the func-
tional evaluation of children with disabilities and the
reliable documentation of change were developed and
standardized in the 1990s and are now in wide use in the
United States, as well as in other countries. They are
the Wee Functional Independence Measure (WeeFim)
(State University of New York at Buffalo, 1994) and
the Pediatric Evaluation of Disability Inventory (PEDI)
(Haley et al., 1992). Both include sections on basic
self-care and have been demonstrated to be valid and
reliable (Ottenbacher et al., 2000). The two instru-
ments are highly correlated (Ziviani et al., 2001): Each
has its advantages. The PEDI gives more depth of
information but the WeeFim is easier and faster to
administer.
196 Part II • Development of Hand Skills
The WeeFim evaluates functional independence of
children ranging in age from 6 months to 7 years and
is simple and fast to administer. Seven of the 18 items
are self-care and the scale yields a single score for the
level of independence in each of the domains of eating,
grooming, bathing, dressing upper body, dressing lower
body, and toileting. The instrument is being validated
in other countries; for example, in Japan (Liu et al.,
1998; Tsuji et al., 1999) and China (Wong et al.,
2002).
The PEDI evaluates self-care, mobility, and social
function in much greater detail than the WeeFim. The
items in basic self-care provide considerable informa-
tion on a child’s abilities and include the following
areas: eating different food textures; use of utensils; use
of drinking containers; tooth brushing; hair brushing;
nose care; hand washing; washing body and face;
pullover/front opening garment; fasteners, pants,
shoes/socks; and toileting tasks.
The PEDI has several strengths as a measurement
tool for children. It has been carefully standardized and
yields a total score that can be used to measure the
overall progress of children with disabilities. Age
expectations are given both for overall independence in
separate domains and individual items. The user can
select the level of expectation desired, such as the age
range at which 10%, 25%, 50%, 75%, or 90% of children
without disabilities demonstrate mastery. The PEDI
has been validated for use in other cultures, including
Puerto Rico (Gannotti & Cruz, 2001). Research has
shown that the PEDI can be used to document gain in
self-care (Dumas et al., 2001).
In summary, the selection of a measurement tool
needs to be based on the major purpose of the tool. If
multiple purposes are to be met, more than one tool
should be used. Possible purposes are (a) diagnostic-
remedial, that is, to provide a blueprint for selecting
and sequencing treatment activities; (b) description of
self-care performance for communication with parents
and professionals; (c) charting the acquisition of self-
care skills; and (d) evaluating the effects of treatment.
Both center-made and published but not standardized
evaluation instruments can be used for the first three
purposes; only standardized instruments are appropriate
for the fourth.
FACTORS IN THE ACQUISITION
OF SELF-CARE
Our knowledge of the factors that influence the devel-
opment of basic self-care is based more on common
knowledge derived from the experience of caregivers
than on research. However, most agree with the state-
ment made by Key and co-workers (1936) about
dressing; that learning is influenced by chronological
age, mental age, the child’s interest, the amount of
guidance given, and the type of clothing worn.
Whether or not these factors are supported by research,
social, psychological, and physical factors, as well as
gender and maturation, clearly play a part in skill
acquisition.
SOCIAL AND C ULTURAL I NFLUENCES
Gesell and Ilg (1943) considered the development of
feeding behavior in the infant to be a
“story of progressive self dependence combined with cultural
conformance” (p. 317).
The broad culture and expectations of the home and
preschool all determine the degree and timing of a
child’s mastery of basic self-care skills.
With the development and standardization of self-
care instruments in the United States, researchers in
other countries have conducted studies to determine
whether the measures can be used in their populations
(Gannotti & Cruz, 2001; Wong et al., 2002). Studies
also have provided information about differences
between countries in ages of self-care acquisition.
For example, younger Chinese children scored better
than U.S. children in self-care on the WeeFim (Wong
et al., 2002) and Puerto Rican children developed
some self-care skills later (Gannotti & Handwerker,
2002).
The timing of the mastery of self-care activities
depends on the expectations for the child and these
expectations differ among cultures. The U.S. culture
places high value on self-sufficiency, so that child-
rearing practices emphasize early independence. Many
other cultures place a higher value on family inter-
dependence, for example, in Puerto Rico child-rearing
practices include later teaching of skills such as self-
feeding (Gannotti & Handwerker, 2002).
An obvious cultural factor is in the difference in food
practices. In India food is eaten with the hand; in the
United States utensils are used, and in Asian countries
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,
which in turn requires less motor maturation than
chopsticks. The spoon is grasped in the fist and can be
carried to the mouth with the forearm pronated and
the arm abducted, but chopsticks require individuation
of the fingers and supination of the forearm. Another
difference is the way in which knives and forks are used.
In the United States, one scoops and spears with a fork
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
on the back of the fork, which is then carried to the
mouth with the left hand. These differences may
influence the sequence and timing of self-sufficiency in
self-feeding.
Differences in dressing styles must certainly influence
skill attainment. In some cultures children go naked
until they are toilet trained. In the United States the
emphasis on early self-sufficiency has led to inventions
in clothing style. For example, draw-down diapers
foster an earlier independence in going to the toilet,
and Velcro fasteners make the preschool child self-
sufficient in putting on shoes and outer clothing.
Individual families also influence the performance of
everyday skills. In this author’s experience in Mexico,
many families with maids did not permit children to use
spoons until they were able to do so without spilling;
bibs were not used beyond early infancy. Wong and co-
workers (2002) also reported that the presence of a
maid in the home led to later achievement of self-care.
Another example of family influence is on a child’s
tidiness in eating. Bott and co-workers (1928) won-
dered why a child who was above average on most
measures was so far below age expectations in eating.
On questioning the parents they discovered that,
because they thought the child was too young to eat
well, they had made no attempt to correct him. When
the expectations for the child were raised at home, his
score rose to age levels within 2 weeks. Such differences
in attitudes result in differences in the timing of the
child’s mastery of basic skills.
Two studies have investigated family factors
influencing competence in household tasks. A study by
Zill and Peterson (cited by Amato & Ochiltree, 1986)
found that the best predictor of performance on tasks
such as washing dishes without help was the frequency
of joint family activities. They also found that family
size was related to competence in such skills. Large
families may require more practical assistance from
their children in chores, and younger children are able
to learn from older children. The family variables found
by Amato and Ochiltree (1986) to foster the acquisi-
tion of practical skills were frequent interaction of
family members and the requirement that the children
take responsibility for chores.
In summary, cultural, class, and family 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
for eventual development of independence, but
behavior in childhood may signify cultural and parental
patterns rather than a child’s intrinsic abilities. Aware-
ness of such patterns is important in assessment and
goal setting.
Self-Care and Hand Skill • 197
SEX DIFFERENCES
Early literature reported several differences between
girls and boys in the age at which self-care skills are
acquired. Gesell and Ilg (1943) wrote that boys
demand independence in dressing at a younger age
than girls. Key and co-workers (1936) reported
tentative sex differences in dressing ability between 21⁄2
years and 41⁄2. Girls were more skillful than boys and
tended to dress faster, and the ability of boys generally
was more variable than that of girls. Sources of the
differences in the ages at which dressing skills are
achieved have been proposed. It has been thought that
girls dress themselves earlier than boys because their
wrists are more flexible, they are better coordinated,
and they wear simpler clothing (Coley, 1978; Gesell et
al., 1940; Key et al., 1936). A difference also has been
reported in the use of eating utensils in self-feeding
(Gesell & Ilg, 1943). Girls shifted to an adult grasp
earlier than boys, some as early as 3 years. Some boys,
on the other hand, continued to use a pronated grasp
at 8 years of age. Boys also were reported to sometimes
demand to feed themselves before they were competent
to do so.
One recent study has also shown a difference between
the sexes. In China, younger girls were reported to score
higher than boys on the self-care subscores of the
WeeFim (Wong et al., 2002). However, no sex differ-
ences in overall functional ability were found in research
in the United States on the PEDI (Haley et al., 1992).
MATURATION
Although culture and family expectations play a role, it
seems clear that the greatest factor in the achievement
of self-care skill in childhood is maturation. Certainly
Gesell and his associates thought so, and self-care items
are prominent in his developmental diagnosis (Gesell &
Amatruda, 1965). This supposition was borne out by
the research of Key and her associates (1936), who
found the correlation between dressing ability and
chronological age to be considerably higher than that
for mental age or any other factor. Furthermore, the
composite score of self-care, mobility, and social
functions of the PEDI showed high and significant
correlation with age but not with demographic
variables.
MASTERY MOTIVATION
The concept of mastery motivation has its roots in the
writings of Robert White (1959), who proposed that
the development of competence in young children
grew out of a pleasurable sense of efficacy when they
successfully manipulated objects. The toddler and
198 Part II • Development of Hand Skills
preschool years are important periods in this
development of goal-oriented behavior, and wanting to
be self-sufficient in the performance of early eating and
dressing skills is one expression of effectance or mastery
motivation (Bullock & Lutkenhaus, 1988; Geppert &
Kuster, 1983). Early anecdotal accounts of achieve-
ment in self-care performance indicated that interest,
self-reliance, and perseverance were important attributes.
Wagoner and Armstrong (1928) found success on a
buttoning task was correlated with teacher ratings of
perseverance. Key and her associates (1936) reported
that interest in dressing develops with ability in 2-year-
old children and that enjoyment increased as mastery
improved. However, at 3 years they found that interest
shifted to desire for approval and achievement and also
found wide differences among the children in the
development of self-reliance and the perseverance
needed for the performance of the more difficult tasks.
These findings were based on analysis of the children’s
comments while they were dressing.
Recent studies in mastery motivation have focused
on its relationship to many different child factors such
as cognition (Hauser-Cram et al., 2001) and parent
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
provide a challenge for the level of each child. A
longitudinal study of particular interest for this chapter
showed that children with disability who scored higher
levels of mastery motivation at 3 years of age achieved
greater independence in self-care at 10 years (Hauser-
Cram et al., 2001). These researchers found mastery
motivation to be important both for the development
of a child and for the well-being of the parent.
MOTOR FACTORS
Coley (1978) identified sequences of gross and fine
motor development leading to independence in self-
care tasks. Examples of necessary gross motor abilities
needed for dressing are reaching above the head or
behind the back while maintaining trunk stability. Self-
feeding requires head and mouth control, as well as
trunk stability. Coley identified steps in the motor
control leading to many individual self-care skills, and
they are discussed within each self-care domain. They
include bilateral skills, finger manipulation, and tool
skills. Children learn one-handed skills before bilateral
skills, and some skills are achieved later because of
the need for the two hands to work together. An early
example is holding a bowl with one hand while
scooping with the other. Children become functional
in the performance of skills during their preschool
years, but complete independence and adult levels of
speed and precision require a long developmental
period. One indication of the automatization of a skill
that occurs at about 4 years of age is when children can
feed and dress themselves while carrying on a
conversation (Hurlock, 1964; Klein, 1983).
Many self-care activities require the use of tools
(Castle, 1985). Tools are defined here as a means of
effecting change in other objects. The earliest self-care
tools are for eating: spoons, knives, forks, and cups.
Self-care in hygiene includes tools such as brushes,
combs, and washcloths. Dressing fasteners, zippers,
snaps, and buttons also can be considered tools. The
use of most tools is complex because it involves the
manipulation of one object relative to another, which
results in the change of state of one or both objects
(Parker & Gibson, 1977). The use of tools is goal
directed by definition and requires the understanding
of a means–end relationship. Even the use of a simple
tool such as a spoon requires both the understanding
of purpose and the motor skill to use it. However, as
children mature, their understanding often moves
ahead of their manipulative skill. In general, learning to
use tools is acquired later than self-care without tools.
CHRONOLOGY OF SELF-CARE
ACQUISITION
The following pages present developmental patterns
and the ranges of ages in which typical children learn
to care for their own daily needs. This information is
presented as a summary of what is currently known
about the chronology of the acquisition of skill in self-
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
acquisition of self-care skills to the development of
hand skills. The information that follows has been com-
piled from different sources to provide as much detailed
information as possible. The child’s attempts at perfor-
mance are included because they show an under-
standing of the task, and the practicing of subskills
reflects motor abilities. The developmental information
in the following discussion is organized into the do-
mains of eating, drinking, dressing, personal hygiene,
grooming, and simple household tasks. The items listed
in the charts are steps in the learning of self-care that
various authors have observed and reported. We have
no definitive information as to the universal consistency
of the sequences presented: They are based on reports
of ages at which children are usually self-sufficient in
discrete skills.
The area of research that has provided the most
information on the acquisition of specific self-care skills

over the years has been the area of development of
evaluation tools. Two such primary sources of infor-
mation were used to chart the general ages at which
skills are achieved. The first source is the PEDI (Haley
et al., 1992). As has been noted, this instrument includes
extensive sections on basic self-care and provides the
most reliable information available on the ages at which
many skills are achieved. The ages noted in the tables
from the PEDI indicate a group in which more than
75% of the children were reported to have achieved
independence.
The works of Gesell and his associates also were a
primary source. Data on the ages at which children
developed specific self-care skills were collected by many
different methods over many years. The results of most
of their observations were incorporated into overviews of
development (Gesell & Amatruda, 1965; Gesell & Ilg,
1943, 1946; Gesell et al., 1940). They were interested
in information that would assist in the diagnosis of
developmental delay and to that end selected different
sorts of behaviors expected at each age level. The
behaviors selected have provided information on the
acquisition of basic self-care skills for many years.
Several secondary sources also were used. Following
the lead of the Yale Developmental Clinic, self-care
items were and continue to be included in many
developmental evaluations. The primary and secondary
sources used for the tables were Coley (1978),
Brigance (1978), Vulpe (1979), Haley and co-workers
(1992), Gesell and Ilg (1943, 1946), and Key and co-
workers (1936).
It must be emphasized that the ages listed from
these sources are only approximate, are not necessarily
derived the same way, and reflect different levels of
expectations. As has been noted, family, social, and
cultural values influence expectations for independence
in self-care skills and these expectations result in
individual differences in skill acquisition. Furthermore,
it must be recognized that even within a homogeneous
group the age at which children master self-care skills is
highly variable. An important finding of the PEDI
research was that there is a wide age range, sometimes
as much as 3 to 4 years, over which individual children
achieve a particular skill. A recent study of the develop-
ment of feeding behaviors also found a wide range of
ages at which self-feeding skills occur (Carruth &
Skinner, 2002). The data in the following tables are
best interpreted as the age range at which many, but
not all, typical children in the United States perform
under optimum circumstances.
EATING
The progress of a child’s self-feeding behavior requires
both the acquisition of skill in the use of eating utensils
Self-Care and Hand Skill • 199
and conformity to cultural standards. In typically
picturesque speech, Gesell and Ilg (1943) described
this progression:
“At 36 weeks he can usually maintain a sustained hold on the
bottle. In another month he may hold it up and tilt it with the
skill of a cornetist. He can feed himself a cracker. At 40 weeks,
he also begins to finger feed, plucking small morsels. … He also
handles his spoon manfully [by 15 months] and begins to feed
himself in part, though not without spilling, for the spoon is a
complex tool and he has not acquired the postural orientations
and pre-perceptions necessary for dexterity. … At 2 years, he
inhibits the turning of the spoon as it enters the mouth and feeds
himself acceptably. … At 31⁄2 years he enjoys a Sunday breakfast
with the family. … At 5 years … he likes to eat away from home
especially at a restaurant. He is more a man of the world!”
(pp. 318–319).
Finger feeding and the use of a cup are early
accomplishments and the basic components of self-
feeding with a spoon—filling the spoon, carrying it to
the mouth without spilling, and removing food—are
well mastered by 3 years of age. However, self-feeding
takes concentration, and it is not until after the third or
fourth year that the skill is sufficiently automatic to
allow eating and talking at the same time (Hurlock,
1964). The 5-year-old is skillful but slow. Skill con-
tinues to improve, for it is not until 8 or 9 years of
age that the child has become deft and graceful
(Gesell & Ilg, 1946), and it is not until 10 years that
self-feeding is accomplished entirely independently,
with good control and attention to table manners
(Hurlock, 1964).
Finger Feeding
Self-feeding with the fingers begins in the second half
of the first year. Table 10-1 shows the development of
the skill, which parallels the infant’s acquisition of hand
skills. Initial feeding is of crackers held in the hand and
sometimes plastered against the mouth with the palm
and with the forearm supinated. As finger skill
develops, bite-size pieces of food are picked up and put
into the mouth with a pincer grasp. Even when spoon
use has become skillful, children prefer to use fingers
for discrete pieces of food such as peas or meat (Gesell
& Ilg, 1943).
Drinking from a Cup or Bottle
Independent drinking from a cup is an early developing
skill as long as safeguards are taken. The use of spout
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
drinking begins with the same bilateral whole hand
grasp used for the bottle and progresses to the dexterous
grip of one hand on the handle at 3 years of age.
200 Part II • Development of Hand Skills

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
Table 10-3 shows the chronology of the development
of the use of spoons, forks, and knives. The many years
necessary for learning to use utensils reflects the
complexity of their use, particularly the knife and fork
in cutting. The infant begins eating with a spoon held
in a fisted grasp, with the arm pronated and shoulder
abducted. The adult finger grip, with forearm supina-
tion and rotation as needed, requires more fine motor
control and dexterity (Haley et al., 1992) but does not
develop until approximately 3 years in girls (Gesell et
al., 1940); some boys continue to use a pronated
pattern at 8 years (Gesell & Ilg, 1946). The fisted grasp
appears again in the use of forks and knives in cutting.
It appears that the force needed for holding and cutting
requires the power of the whole hand and the necessary
power combined with the finger dexterity for cutting is
not developed until a child is about 10 years old.
Studies of Spoon Use
The spoon is the first tool used by most infants
(Connolly & Dalgleish, 1989). Several studies of spoon
use have been reported, two involving infants and one
preschool children. The earliest study was of nursery
school children’s eating behavior (Bott et al., 1928).
The eating behaviors included in the study were (a) the
proper use of utensils, (b) putting the proper portion of
food on a utensil, and (c) coordination, as indicated by
minimal spilling. They found improvement with age in
all these behaviors, but the behaviors differed as to
when they improved. The use and filling of the utensils
improved primarily between 2 and 3 years of age, but
spilling decreased more between 3 and 4 years.
A cinemagraphic study of infant eating behavior
conducted by Gesell and Ilg (1937) described both
prespoon activity and early spoon use. Preparation for
using the spoon began when a child was being fed.
Between 3 and 6 months of age the child watched the
spoon, and soon mouth opening began in anticipation
of the spoon reaching the mouth. Later, head move-
ments began with movement of the head toward the
spoon and then away as food was removed. Whereas
initially food was put in the mouth by the adult’s
manipulation of the spoon, the child later removed
food by lip compression. These movements of the head
and lips were considered to make later spoon manipu-
lation more effective.
Gesell and Ilg noted that even as simple a tool as a
spoon requires a sequence of perceptual and motor
acts. One act is the discriminative grasp of the spoon
handle. Infants first grasped the lower third of the
handle, later the middle to upper third, and finally the
end. Grasp was at first palmar, with the thumb wrapped
around the spoon, but later the thumb was placed
Self-Care and Hand Skill • 201
along the handle. The adult grasp usually was not seen
until 3 years of age. A second perceptual and motor act
is the filling of the spoon. At first the bowl of the spoon
is merely dipped in the dish, often with the spoon
handle perpendicular. Filling began with a rotary move-
ment toward the body, and it was not until 16 months
that children began filling the spoon by inserting its
point into the food. Lifting the spoon was at first
accomplished with the arm pronated, and often with
the bowl of the spoon tipping. By the end of the
second year children were lifting their elbows and
flexing their wrists. The insertion of the spoon into the
mouth also changed from the side into the mouth to
the point into the mouth.
The third study reported by Connolly and Dalgleish
(1989) confirmed many of the findings of Gesell and
Ilg. They conducted a comprehensive videotape study
on the longitudinal development of spoon use. The
research procedure was more formal, and the study
can serve as a model for the investigation of the learn-
ing of complex motor skills. The authors first presented
an analysis of spoon use that included both intentional
and operational aspects. The task was described as
entailing:
“… (a) an intention to eat, which involves the child’s motiva-
tion; (b) some knowledge about the properties of the spoon as an
implement with which to effect the transfer of food from dish to
mouth; (c) the ability to grasp and hold the spoon in a stable con-
figuration; (d) the loading of food onto the spoon; (e) carrying the
loaded spoon from dish to mouth; (f) controlling the orientation
of the spoon during this transfer to avoid spillage; and (g) emp-
tying the spoon and extracting it” (p. 897).
On the basis of this analysis, Connolly and Dalgleish
conducted a longitudinal videotape study of the devel-
opment in the operation of a spoon during the second
year of life. Among their descriptions was an analysis of
change in the action sequences from only two actions
to a complex sequence that included corrections. The
actions of putting a spoon in and out of a dish and
putting the spoon in and out of the mouth initially
were unconnected. Box 10-1 shows the progression
and change of action sequences in using the spoon.
This change in action sequences seems to indicate that
the child was learning skill both in the performance of
single actions and in the use of complex movement
sequences. Connolly and Dalgleish also report other
changes in motor actions, such as a smoothing of the
trajectory of the dish-to-mouth path, and the shifting
of the angle at which the spoon was placed from side
toward mouth, to point toward mouth. Children used
primarily a palmar grasp: the wrist, shoulder, and elbow
movements also were described.
202 Part II • Development of Hand Skills

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)


BOX 10-1 Progression of Action Sequences
in Using the Spoon
The first purposeful sequence was five steps:
1. Spoon to dish
2. Remove from dish
3. Lift to mouth
4. Put in mouth
5. Remove from mouth
Later, two more actions were added:
Filling the spoon
Removing food with lips
The final action sequence included 11 steps that
incorporated monitoring and correction through
repetition of sequences:
1. Control of spoon
2. Spoon to dish
3. Steady dish with other hand
4. Remove spoon from dish
5. Check to see if there is enough food on spoon (if
not, repeat 2 to 4)
6. Lift spoon
7. Put spoon in mouth
8. Empty spoon with lips
9. Remove from mouth
10. Check to see if spoon is empty (if not, repeat 7 to 9)
11. Pick up spilled food (repeat 6 to 8)
Connolly K, Dalgleish M (1989). The emergence of a
tool-using skill in infancy. Developmental Psychology,
25(6):894–912.
Serving and Preparing Food
A part of independence in eating is serving oneself and
preparing foods. Table 10-4 shows that by the time
children enter school they can take care of simple
preparation and self-service of food and drink. In
the preschool years children also begin to help with
simple household chores such as setting the table (3 to
4 years), putting away silverware (2 years), and wiping
up spills (3 years) (Gesell & Ilg, 1943).
One of the expectations of the nursery school
children studied by Bott and co-workers (1928) was
that their feeding area be cleaned up after they ate. At
the age of 2 the children left the table, chair, and floor
clean after eating in 45% of the observations. By the age
of 4 years the percentage had increased to 85%. This
change undoubtedly reflects the influence of nursery
school expectations, as well as maturation.
DRESSING
The development of self-care in dressing, undressing,
and managing fasteners also parallels and depends on
the development of hand skills. A fisted grasp is suffi-
cient for the tasks of removing hat and socks. Pulling
up pants requires more strength and bilateral coordina-
tion than pushing them down and kicking them off.
Self-Care and Hand Skill • 203
Individual finger function comes into play in loosening
laces, and full independence in dressing requires com-
plex finger manipulation of buttons and ties. The need
for finger dexterity and planning sequences underlies
the slow acquisition of management of fasteners.
Key and her associates (1936) studied the process of
learning to dress among 45 nursery school children,
ages 11⁄2 to 51⁄2 years. Overall dressing ability was highly
correlated with chronological age. They reported the
learning process to be continuous, increasingly dif-
ficult, and unstable, and that the most rapid period of
learning was between 11⁄2 years and 21⁄2 years. Overall
success rates increased over the ages studied as follows:
11⁄2 years, 40%; 2 years, 50%; 21⁄2 years, 80%; and 31⁄2
years to 51⁄2 years, 90%. Other authors also have
reported that dressing skills develop rapidly between
11⁄2 and 31⁄2 years (Gesell et al., 1940).
Self-help in putting on and removing clothes is
highly dependent on the type of clothing worn (Key et
al., 1936). The variability in the age of acquisition is
undoubtedly in part a result of the type of clothes
selected for children by their caregivers. Characteristics
of clothing that facilitate self-dressing include loose
tops with large neck openings and loose pants with
elastic tops and loose cuffs. The type and size of
fasteners should be appropriate for children and they
should be in reasonable locations (front or side). How-
ever, it should be noted that peer fashions may be
important even for young children and compromises
may be needed.
The overall development of dressing skill proceeds
from undressing, to dressing without fastening, to
managing fasteners. Taking off an item of clothing is
easier than putting it on because putting on clothing
is more complex both motorically and perceptually.
For example, socks slip off easily, but the coordination
between the two hands and between hands and feet
together are needed for putting socks on. Moreover,
the sock must be rotated correctly to match its heel to
the heel of the foot. Information on the chronology of
dressing is presented in four areas: antecedents of
dressing skills, undressing without fasteners, dressing
without fasteners, and managing fasteners.
Antecedents of Dressing Skills
Table 10-5 lists average ages at which children achieve
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
the ability to grasp. The early removal of hats and socks
is also hardly purposeful undressing because it is just as
likely to occur during dressing as undressing. Never-
theless, these actions demonstrate motor sequences
that will later be used purposefully.
Researchers have chronicled infant beginnings of
cooperation and assistance in dressing (Gesell & Ilg,
204 Part II • Development of Hand Skills

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)

 Self-Care and Hand Skill • 205

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)

206 Part II • Development of Hand Skills

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

 Self-Care and Hand Skill • 207

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)

208 Part II • Development of Hand Skills
needed. The last skills achieved are in the orientation of
the heel of the sock, the front and back of garments,
and, the most difficult, the distinguishing of left and
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-
clothes right side out, but it is not until 7 years that the
inside and outside of all clothes are discriminated
(Brigance, 1978).
In addition to these perceptual skills, self-care
dressing skills require complex motor planning. Gaddes
(1983) described the difficulty of some children with
learning disabilities in dressing as a lack of the tactile
and kinesthetic awareness essential to the task of
putting on one’s clothes, and commented that
“small children are usually unable to put on their clothes without
help … not because they lack the physical strength but because
they lack the necessary ideomotor image” (p. 109).
The hand skills needed are primarily whole-hand
grasp, a power grasp for pulling clothing on, and a high
level of bilateral skill. Hands must work smoothly and
in unison to pull socks up to full extension, pull on
boots, and pull up pants. Hands must work cooperatively
in holding a shirt or coat with one hand while finding
the armhole with the other.
Additional bilateral dressing skills have been
identified by Thornby and Krebs (1992). Their interest
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
(3 years 3 months to 4 years). The children with
amputations achieved these skills several years later than
most children.
A Study of Dressing
Key and her associates (1936) studied the ability of
children to put on the clothing that they wore to
nursery school and found wide differences in the ability
to put on separate garments. Overall, socks and leg
garments were found to be the easiest, followed by
upper body garments and dresses. Shoes, because of
their fasteners, were the most difficult. In addition to
looking at the overall ability to put on the garments,
the researchers recorded the success rate of separate
dressing units for each garment. These data provided
an index of the difficulty of the subskills needed for
successful performance. An analysis of the percentage
of success for each subskill at each age level shows the
relative difficulties of the components of putting on
shoes, socks, pull-down garments, dresses, and shirts.
This list excludes fasteners, and open-front and slipover
shirts were not differentiated. The order of difficulty
The Order of Difficulty in the
BOX 10-2 Ability of Children to Put on
Clothing
Put one leg in hole of pants
Pulled up pants
Shoe started on foot
Opened shoe for foot
Put head in neck hole of dress
Put on dress correctly front to back
Socks started over foot
Put foot in shoe with heel down
Pulled sock up on leg
Kept tongue out of shoe while donning
Put second leg in hole of pull-down garment
Pulled sock up on foot
Put pullover garment over head
Put first arm in dress hole
Adjusted dress when on
Put second arm in sleeve hole of dress
Shirt on correctly front to back
Adjusted pants when on
Put first arm in sleeve hole of T-shirt
Adjusted shirt when on
Put second arm in sleeve hole of T-shirt
Pants on correctly front to back
Adjusted heel of sock
Key CB, White MR, Honzik WP, Heiney AB, Erwin D
(1936). The process of learning to dress among nursery-
school children. Genetic Psychology Monographs,
18:67–163.
reported, based on the age group in which 50% or
more of the children succeeded in the task, is listed in
Box 10-2.
Note that a part of an individual motor skill, such as
putting on pants or socks, was easiest but complete
achievement was the hardest. The difficulty young
children have in dressing is a mix of a challenging per-
ceptual task, such as locating the front of a T-shirt or
the heel of a sock, and sometimes a complex motor act,
such as maneuvering an arm into a second dress hole.
Fasteners: Zippers, Snaps, Buttons, and Ties
Table 10-8 shows the range of average ages at which
children are able to fasten and unfasten their clothing.
Manipulating zippers, as long as it does not involve
hooking and unhooking a separating zipper, is the
easiest form of closure, whereas tying is the most
difficult. The feature all fasteners have in common is
the need for bilateral finger manipulation skills. Zippers
require precision grip and pinch strength. The bilateral
nature of this task is shown by the 3-year delay in skill
acquisition in children with unilateral below-elbow
amputations (Thornby & Krebs, 1992). Buttons
 Self-Care and Hand Skill • 209

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)

210 Part II • Development of Hand Skills
require precision grip with manipulation and with both
hands working cooperatively.
Strength is another component of the management
of fasteners. Snaps require considerable strength in the
fingers. Koch and Simenson (1992) examined func-
tional skills in spinal muscle atrophy. Children with 1⁄2-
to 2-lb pinch strength needed minimal help in dressing.
Children with less than 1⁄2-lb pinch strength had
trouble with tying and buttoning.
Managing fasteners is also a perceptual task,
particularly buttoning and tying. For both these tasks
vision is important for learning. It is only after
considerable skill has been developed that back buttons
and back bows can be accomplished, using touch and
kinesthesia alone.
Buttoning
The ability to button has been included in develop-
mental tests for many years, and it has been studied
more than other fastenings. The ability develops in
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
children to button buttons on a strip on a table.
Children under 2 years of age failed to button one
button, but by 21⁄2 to 3 years of age 72% of the children
succeeded, albeit slowly. However, Key and co-workers
(1936) reported that only 50% of their 3-year-old
children succeeded in buttoning their shirts or dresses,
and only 33% their pants.
Wagoner and Armstrong (1928) reported a study of
buttoning skill in 30 nursery school children between
the ages of 2 and 5 years. They standardized the task by
making jackets that were adjustable in size and which
had front and side buttons. The major findings were:
(a) children under 21⁄2 years seemed not to have the
motor control needed to button; from 21⁄2 to 5 years
speed of buttoning improved with age; (b) girls were
better than boys, but the researchers noted that this
result might have reflected an artifact of their sample;
and (c) side buttons were much more difficult than
front buttons; 25 children succeeded with the front
buttons, but only 15 completed the side buttons (the
authors noted that buttoning side buttons may require
a more complex type of motor adjustment than do
front buttons).
Wagoner and Armstrong also reported correlation
of buttoning speed with the Stanford-Binet Test
(r = .33), the Merrill-Palmer Performance Tests
(r = .62), and the Goodenough Drawing Test (r = .57).
Thus buttoning appeared to be more related to
performance tests than to intelligence. They also found
success in buttoning to be highly correlated (.83 to
.91) with teacher ratings on self-reliance, perseverance,
and care of details.
Learning to Tie Shoes
Shoe tying is an important and difficult developmental
task for children. Children perceive the relationship of
the loops and strings and learn the steps of looping,
winding, and pulling through but still may fail. The
most difficult aspect of shoe tying appears to be what
Maccoby and Bee (1965) in their study of form
copying termed the perception of attributes. Their
example was that children discriminate forms such as
diamonds but are unable to draw them because they do
not perceive the attributes of the form, such as the
relative size of lines and angles. Similarly, children do
not perceive the relative sizes of loops and strings; the
loop is too large and the bow fails. It is only when
children perceive these attributes of the lacing process
that they succeed. Learning to tie shoes is of special
importance to a child’s sense of competence. The
6-year-old child has a sense of achievement and
independence from adult help in the school
environment.
HYGIENE AND G ROOMING
Tables 10-9 and 10-10 present the sequences in which
hygiene and grooming skills are acquired by children.
The development of parts of the skills begins in early
childhood, but independence in most hygiene and
grooming skills is a middle childhood achievement.
Many hygiene and grooming tasks are bilateral.
Hands are rubbed together in washing; in drying,
towels are held alternately while drying each hand.
Applying toothpaste on a brush is a skilled bilateral
activity. This was shown by the delay in which children
with unilateral amputations were found to achieve this
task (Thornby & Krebs, 1992). The toothbrush is a
tool that requires a high level of skill, as wrist and hand
movements are complex in placing the brush and
brushing all the teeth. It is also a skill accomplished
without vision.
Independence in hair care is greatly influenced by
social factors, especially for girls. At about the time
when hair becomes manageable by the 4- to 7-year-old
child, independence is often delayed in girls by choice
of hairstyles (e.g., braids usually are a teenage accom-
plishment). Hair styling requires a complex manipula-
tion of many tools—brush, comb, pins, dryers—all of
which must be used without vision or with mirror
vision.
The ability to perform grooming and hygiene skills
develops far earlier than the acceptance of responsibility
for performing them. Grooming and hygiene skills are
particularly likely to be neglected by school-age
children. Note that the performance ages in the tables
reflect when a child can do a skill and not whether it is
done without supervision.
 Self-Care and Hand Skill • 211

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)
212 Part II • Development of Hand Skills

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-

Independence in the performance of the daily activities
of basic self-care requires the mastery of complex hand
skills that children learn over many years. The skills
have varying degrees of manipulative, perceptual, and
cognitive components and the action sequences are
learned through extensive practice until they become
automatic and efficient. We have some knowledge of
the usual ages at which the skills are mastered, but very
little knowledge of what Connolly and Dalgleish
(1989) called the general patterns of behavioral
change, which occur as children acquire specific self-
care skills.
Most of the studies of the development of self-care
skills cited in this chapter were conducted before 1940.
There are not many, and recent studies are even scarcer.
As noted by Amato and Ochiltree (1986), despite an
increasing interest in the development of competence
in childhood during the last decade, practical life skills
have been virtually ignored. Interest in the study of
children’s self-care skills over the years has been largely
stones, and most of our knowledge is of that kind. The
information in this chapter is a summary of what is
currently known about the chronology of skill acquisi-
tion and is presented as a possible source for finding
clues to the understanding of the process by which
skills are acquired.
Although the ages identified are approximate and
represent an unspecified average behavior, they provide
a tentative chronological order in which skills and
subskills develop. However, it must be remembered the
sequences of skill development that are suggested by
the information in the tables may be an artifact of the
use of group data. Of course, some of the steps in
learning are clearly acceptable; that is, a partial skill
precedes a complete skill and many of the sequences
have been repeatedly observed and verified by teachers,
parents, and therapists. However, individual differences
among children could result in different routes to
competence in an overall skill. Nevertheless, these over-
all sequences have value in that they provide infor-
mation that could be used in planning longitudinal

studies because they identify the age span in which skills
usually develop. Furthermore, they show general
patterns of behavioral change in the acquisition of self-
care that allows some generalizations about factors
affecting mastery.
HAND SKILLS IN SELF-CARE
The examination of the chronology of self-care acqui-
sition allows a preliminary, although fragmentary,
analysis of the relationship of the development of hand
use to the development of self-care. We do not know
when these self-care skills reach adult levels of efficiency
and precision, but clearly skill acquisition is a gradual
process that extends into the preteens. It appears that
aspects of hand skill acquisition over the years include
(a) finger manipulation and grip ability, (b) the use of
two hands in a complementary fashion, (c) the ability
to use the hands in varied positions with and without
vision, (d) the execution of increasingly complex action
sequences, and (e) the development of automaticity.
These hand skills have been discussed in the preceding
section in relation to specific skills and are summarized
in the following.
Grip Ability and Finger Manipulation
During the first year of life the infant develops whole
hand grip followed by the use of a finger grip with
some precision (see Chapter 7). As grips develop they
are used in self-care skills, first with the whole hand and
then with the fingers. Therefore the earliest self-care
actions are pulling at clothes and grasping food such as
a cracker with the whole hand. Finger feeding soon
follows the early emergence of pincer grasp. This whole
hand to pincer grip sequence occurs repeatedly as skills
develop. Examples in the young child include pro-
gression from a whole hand to a finger grip on a spoon
and from a whole hand grip pulling up pants to a
thumb and finger grip on socks. This progression of the
whole hand grip to pincer grip sequence is in part a
reflection of the interplay of power and precision in
grip as skill develops, as the infant has power in the
whole hand grip, but is slow to develop power in finger
grips. For example, a child lifts a cup or glass with one
hand before having the finger grip power needed for
lifting a cup by the handle. In cutting with a knife and
fork, a child first uses a fisted grip on both utensils to
exert the pressure needed. The power finger grips used
by adults for cutting are not achieved until the preteen
years.
The use of the fingers in a precision pincer grip is
used in dressing in the second year, but fasteners such
as buttons, shoe lacing, bow tying, and buckles, require
in-hand manipulation skills. In-hand manipulation
also is needed to position a spoon or toothbrush for
Self-Care and Hand Skill • 213
the appropriate finger grasp position. These skills begin
to develop in the third year but the combination of
precision and power in finger manipulation at the
highest level does not develop until a child is 8
years old.
Bilateral Hand Use
Most self-care skills are bilateral and the challenge
posed by these skills depends on their complexity. The
simple act of drinking from a bottle and then a cup held
in two hands is one of the first achievements of an
infant, and an infant is soon able to hold a dish while
spooning food. The order in which bilateral dressing
skills develop seems to depend on the added need for
power, whether hands work in unison or cooperate in
different functions, and the extent of the motor
sequencing involved. Undressing is easier with two
hands but requires less skill than does dressing.
Intermediate bilateral skills include pulling up pants,
holding a shoe open with the tongue out, and pulling
on boots. Manipulating buttons, buckles, and zippers is
more difficult because high precision is necessary and
the two hands work cooperatively but differently. The
greatest difficulty comes when the two hands must move
through different motor sequences, as in tying bows.
Position of the Hands
Two factors appear to influence a child’s ability to
perform a task with the hands someplace other than in
front of the body. Young children seem unable to
perform tasks such as buttoning without seeing their
hands, and performing with the hands in awkward
positions such as at the side of the body is difficult.
These two factors probably combine to delay learning
to manipulate back buttons until after the sixth year.
Executing Motor Sequences
As was noted in the discussion of spoon use, even the
early-developing task of self-feeding requires the
learning of a multiple sequence of actions. Through
analysis, therapists have identified the steps involved in
many dressing skills (Case-Smith, 2000), but the
sequence followed by typical children in learning par-
ticular dressing skills has not been studied. However, it
is to be expected that becoming self-sufficient in a skill
is in part a reflection of the number of action sequences
involved.
Automaticity
Self-care literature provides a clue to the development
of automaticity in skill performance. There appears to
be a delay following a child’s ability to perform a skill
in eating and dressing before the skill can be performed
while carrying on a conversation (Hurlock, 1964;
Klein, 1983). This suggests that an automatic level of
214 Part II • Development of Hand Skills
skill execution does not develop until several years after
a skill is first mastered.
Combined Motor Abilities
Examples of skills involving different facets of hand
manipulation have been given for illustrative purposes.
Nevertheless, clearly most of these facets occur in
combination. The highest level of self-care skill appears
to require some combination of bilateral sequencing
and complementary hand use, the combination of
power and precision in grip, the ability to perform hand
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
performance without vision, and is one of the last skills
learned.
PERCEPTUAL FACTORS IN SELF-CARE
The sequences of self-care acquisition also clearly
demonstrate the need for development of perceptual
skills. Perceptual skills are necessary for tool use,
ranging in difficulty for spoons, toothbrushes, and
combs. Perceptual factors are particularly evident in
dressing. Over several years children learn, in this order,
whether clothes are inside out or outside out, the
difference between front and back, and which is left or
right. Their ability to respond first to more obvious
cues is shown by this sequence, as well as by their ability
to locate a dress front by its decoration before the back
of a T-shirt by its label or the front of pants.
COGNITIVE AND PERSONALITY FACTORS
IN SELF-CARE
We have little data on the importance of cognitive and
personality factors in self-care acquisition, but the few
studies suggest that, for children whose intelligence is
within normal limits, the level of intelligence is less
important than the personality characteristics of per-
sistence and self-reliance. There is good reason to
believe that in typical children personal and social
characteristics are as important as perceptual and motor
maturation. Children are highly variable in the
chronological ages at which they acquire skills, and the
finding that a 3- to 4-year span may separate the earliest
and latest age at which typical children master a par-
ticular skill is a powerful indication that there are large
personal and situational differences among children.
We know very little about the sources of these
individual differences, but we can hypothesize that they
are multiple and include differences in problem-solving
abilities, persistence, and self-reliance. We also know
virtually nothing about the extent to which and in what
combinations these intrinsic factors influence the
maturation of self-care skills or how much is a function
of family and cultural variables. Many studies are
needed to understand the variables that have an impact
on the learning of self-care skills. The PEDI promises
to provide a rich resource for the determination of
which cultural, cognitive, motor, and personality fac-
tors have an impact. The interest in researching the
development of competence and volition will also hope-
fully include more attention to basic practical skills.
SUMMARY
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
children acquire self-sufficiency in daily activities can be
valuable in understanding the roadblocks for children
with physical or mental disability, and sequences of skill
acquisition can provide guidance in selecting the level
of skill at which to introduce training. However, the
acquisition of self-care in typical children provides only
a part of the picture needed for treatment planning. We
must learn how skills are learned in the presence of
different disabilities. We know that the presence of a
specific disability can change the sequence in which a
child will master self-care skills, but we have little infor-
mation about what that sequence is.
Most of our knowledge about the impact of dis-
ability on specific self-care skills comes from therapeutic
accounts. Several recent publications have provided
detailed task analyses of methods of dressing, eating,
and hygiene keyed to different impairments and
include multiple suggestions for adaptations. Some of
these are designed for children (e.g., Case Smith, 2000;
Shepard, 2001), and others for adults (e.g., Backman
& Christiansen, 2000; Holm, Rogers, & James, 1998;
Snell & Vogtle, 2000).
The tables also provide useful knowledge about the
acquisition of part skills. Typically children do not learn
a skill all at once. Rather they are encouraged to do
what they can long before they are developmentally
ready to master a skill. Parents of children with dis-
abilities should be encouraged to introduce part-skill
practice early and to set expectations that their child do
whatever he can. This will take more time but it will
contribute to the child’s sense of mastery and self-
esteem and provide practice of the motor skill. It would
be helpful to know more about the factors affecting
such a learning process and the differences and
similarities in the ways in which children with dis-
abilities learn complex skills.

The importance of self-care skill acquisition in a
typical child’s sense of efficacy and the parent–child
interaction around self-care issues should be investi-
gated. Furthermore, although we know that indepen-
dence in self-care is important to an individual’s quality
of life, disability sometimes is so severe that indepen-
dence cannot be achieved, and we know little about the
importance of partial independence to the individual or
of its meaning to an individual’s sense of mastery and
control. Research in self-care with both typical children
and children with disabilities has the potential for dis-
covering information that will be applicable to design-
ing rehabilitation programs.
Parents should be helped to understand the impor-
tance of the mastery of self-care skills to the child and
to give the child a sense of pride in this most mundane
of accomplishments. Time in the daily schedule is
needed for practice of self-care for all children. The
child with a disability has a different timetable for
mastery, but the same rules should apply. Time must be
scheduled for every child to master skills, and develop
the self-reliance and self-confidence that comes with
mastery.
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THE DEVELOPMENT OF
GRAPHOMOTOR SKILLS
Jenny Ziviani • Margaret Wallen
CHAPTER OUTLINE
GENERAL GRAPHOMOTOR COMPETENCY
Acquisition of Graphomotor Skills
Implement Grasp and Manipulation
DRAWING
The Nature of Drawing
Computers and Drawing
Drawing and Developmental Evaluation
HANDWRITING
Handwriting and Writing: Complementary Concepts
The Developmental Nature of Handwriting
Factors Contributing to Handwriting Performance
Computers and Handwriting
SUMMARY
This chapter provides information on the development
and execution of graphomotor skills, as a basis for
remediation. Concepts common to both drawing and
handwriting such as motor learning theory and grasps
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
outlining research that broadens our knowledge of the
development of drawing and handwriting and deepens
our understanding of the factors that are associated
with graphomotor difficulties.
Graphomotor skills comprise those conceptual and
perceptual-motor abilities necessary for drawing and
handwriting. Drawing is defined as the art of producing
a picture or plan with implements such as pencils, pens,
or crayons. Handwriting is the process of forming
Chapter 11
letters, figures, or other significant symbols, predomi-
nantly on paper. Both these activities can be used to
record experiences or thoughts, as well as communicate
these to others. Drawing and handwriting are com-
plex motor behaviors in which psychomotor, linguistic,
and biomechanical processes interact with matu-
rational, developmental, and learning processes (Smits-
Engelsman & Van Galen, 1997). The need to develop
proficiency in activities as fundamental as drawing and
handwriting may be questioned in relation to the
growing reliance on electronic communication devices.
It is the position of this chapter that graphomotor skills
represent more than a means of recording thoughts or
conveying experiences. Developmentally these skills
allow for experimentation and self-expression in the
way a child interacts with the environment. Further-
more they are a means by which children learn basic
tool use and are able to produce a product that is
socially recognized and rewarded. As such they form an
important part of the development of an individual.
GENERAL GRAPHOMOTOR
COMPETENCY
ACQUISITION OF G RAPHOMOTOR SKILLS
Children, when presented with tools for inscription,
readily smear paint, scribble with crayons, or draw. The
nature of the inscription varies depending on the
developmental status of individuals and their motor
learning in relation to prior exposure to graphomotor
experiences. In its most basic form simple inscription
with an implement onto a page can be understood as a
perceptual-motor act (van Galen, 1991). The learning
of a skilled task such as handwriting or drawing,
217
218 Part II • Development of Hand Skills

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-

tion because they can influence the adoption of appro-
priate remedial strategies.
The role of kinesthesia is frequently discussed in
relation to drawing and, particularly, handwriting.
Kinesthesis relates to the information received from
muscles, joints, and skin about body and limb position,
and the direction, extent, and velocity of movement
(Harris & Livesay, 1992; Sudsawad et al., 2002). An
impairment of kinesthesis may influence the refinement
of fine motor skills; children are not able to perceive
and therefore monitor and correct errors of movement,
particularly those of small amplitude, which are
observed in handwriting (Harris & Livesay, 1992).
Much of the work around kinesthesis in relation to
handwriting involves the Kinesthetic Sensitivity Test
(KST). This norm-referenced test consists of two sub-
tests: Kinesthetic Acuity and Kinesthetic Perception
and Memory. Each subtest has specific equipment that
was designed to eliminate the need for motor control,
thus allowing passive movement of children’s hands
and arms to determine kinesthetic ability. Laszlo and
Bairstow (1985a) developed the test to identify
kinesthetic deficits and reported that training children
using this test equipment resulted in improved drawing
skills in children with poor kinesthesis. However, the
relative importance of the role of kinesthesis in acqui-
sition of proficient handwriting remains unclear. This
subject is elaborated on in the review of handwriting
later in this chapter.
I MPLEMENT G RASP AND MANIPULATION
Brushes, crayons, pencils, felt-tip markers, and pens are
the primary tools used by children in their graphic
endeavors. These implements form an extension of the
hand, and their control and manipulation are impor-
tant in attaining skilled copying, drawing, and hand-
writing. Only through experimentation do children
become skilled in adapting to implements of different
weight, length, and graphic quality. Different grasps
may be adopted with a change in implement and task
to achieve an optimal outcome (Schwartz & Reilly,
1980; Thelen & Smith, 1994).
Grasps
Many children acquire a dynamic tripod grip by about
61⁄2 years of age as their means of implement manipula-
tion for drawing and handwriting. Children progress
through a range of precursor grips—palmar, incom-
plete tripod (or palmar supinate), and static tripod—
before adopting the dynamic tripod grip (Dennis &
Swinth, 2001; Rosenbloom & Horton, 1971; Saida &
Miyashita, 1979). Schneck and Henderson (1990)
propose a 10-grip scale to classify the developmental
range of grasps. Level 1, or the lowest level of the scale,
The Development of Graphomotor Skills • 219
describes a palmar grasp, whereas Level 10 describes
a dynamic tripod grasp. The scale is a “whole-
configuration system,” which means that all the com-
ponents of the grip can be described together rather
than evaluating various components of a grip separately.
Adoption of a scale such as this has the potential to
inform comparisons with and between children and
to contribute to a system of uniform terminology
(Windsor, 2000).
The dynamic tripod grasp, generally viewed as the
mature grasp, is one in which the writing implement is
grasped between the radial surface of the middle finger
and the pulp surface of the thumb and index finger,
with the thumb relatively opposed (Elliott & Connolly,
1984). However, not all children acquire or use this
grip. Research suggests that the dynamic tripod is used
by only 50% to 70% of children in a given sample
(Benbow, 1987; Blote & van der Heijden, 1988; Dennis
& Swinth, 2001; Schneck & Henderson, 1990). Other
grasps, such as the lateral tripod and quadripod, also
allow ulnar stability and controlled dynamic finger
movement, which are considered important for skilled
handwriting.
Diverse ways of categorizing variations in the
dynamic tripod grip have been used. Ziviani & Elkins
(1986) used a series of four nonexclusive categories
that described grips on the basis of the number of
fingers held on the shaft of the writing implement,
degree of forearm supination, hyperextension of the
distal interphalangeal joint of the index finger, and
thumb and index finger opposition. Sassoon, Nimmo-
Smith, and Wing (1986) used a classification of pen
holds that examined the position of digits on the pencil
shaft, their proximity to the writing tip, and the shape
of the digits. Furthermore, Sassoon described grips in
relation to the shaping of the hand, the positioning of
the upper body, and the specific orientation of the
writing paper. Neither Sassoon nor Ziviani’s studies
found writing speed was compromised by unconven-
tional pencil holds. Subsequent studies have confirmed
that grips affect neither legibility (Koziatek & Powell,
2003) nor the undertaking of long writing passages
(Dennis & Swinth, 2001). However, all these studies
have been undertaken with children without identified
disabilities, and have not taken into account the dynamic
aspect of adopted grips.
Schneck (1991) found that children who used
variants of the dynamic tripod grip also had impairment
of proprioceptive/kinesthetic finger awareness. Schneck
hypothesized that the grips may not themselves lead
to poor handwriting but, in conjunction with poor
proprioceptive and kinesthetic perception, might
contribute to poor handwriting performance. Research
that examined the impact of joint laxity has supported
this view (Summers, 2001). In Summers’ study, positive
220 Part II • Development of Hand Skills
but nonsignificant trends emerged between joint laxity
and the failure to develop a dynamic tripod grip in 55
7-year-old children.
Poorly established hand preference has been linked
to developmentally immature grips (Rosenbloom &
Horton, 1971; Schneck, 1989), but also can result
from insufficient prerequisite experience. Poor hand
preference is thought to impede the refinement of the
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-
dent on well-defined hand preference.
In a practical and clinical sense, therapists are con-
fronted by the issue of whether to assist children to
modify the grip they are using as part of an overall
strategy to facilitate an improvement in handwriting
performance. The following points may be worth
considering when this situation arises:
1. Mechanically the dynamic tripod grip offers a high
level of precision and control (Elliott & Connolly,
1984). The dynamic tripod grip should be encour-
aged when the child is young enough and has not
developed a fixed writing posture. In fact some have
argued that inadequate training in the use of a dynamic
tripod grip is one of the reasons it is not used by
greater numbers of children (Benbow, 1995).
2. Variations of the dynamic tripod grip do not, of
themselves, contribute to handwriting difficulties.
In typically developing students there appears to be
no difference in the speed or legibility of hand-
writing using the dynamic tripod versus atypical
dynamic grasps (Dennis & Swinth, 2001; Sassoon,
et al., 1986; Ziviani & Elkins, 1986). Differentia-
tion should be made, however, between a modified
version of the dynamic tripod grip and a grip that is
developmentally immature. The latter may be part
of a broader picture of developmental difficulty.
More research is necessary to determine if there is a
relationship between typical and atypical grasps and
legibility in children who are poor handwriters
(Schneck, 1991).
Writing Implements
A further issue related to implement manipulation is
the nature or type of writing tool used. Traditionally
young writers are given lead pencils with a larger than
normal lead and barrel for drawing and handwriting
instruction. This practice is based on the premise that it
is easier for their small hands to hold and manipulate a
larger barrel. However, studies have demonstrated that
the legibility of kindergarten children’s handwriting is
not associated with the tool used (Oehler et al., 2000).
The maturity of grasp employed, nevertheless, may
vary with the specific tool used (Yakimishyn & Magill-
Evans, 2002).
This section of the chapter outlined the processes
involved in acquiring proficient use of tools for drawing
and handwriting and about the grasps used when
manipulating these tools. The next section is about the
development of drawing ability.
DRAWING
THE NATURE OF DRAWING
When considering drawing, the simple copying of
shapes and figures should be differentiated from the
creation of pictures from memory or imagination. The
present discussion is concerned primarily with copying
skills (the perceptual-motor elements of drawing).
Certain characteristics are thought to distinguish
younger children’s drawings from those of adults.
Children’s drawings have been described as being
formula-like and depicting subjects as they are
perceived to be rather than how they look (Freeman,
1980). Apart from exceptional children (Selfe, 1985),
most children in their preschool and early school years
construct their drawings from simple geometric forms
and do not compose broad outlines that are then
detailed. Fenson (1985), in a detailed longitudinal
study of one child, found that a fundamental shift
occurred between 3 and 7 years of age in the structure
of drawing. The child moved from a constructional
style to the use of contoured forms.
The term constructional in this context relates to the
assembling of simple geometric forms into a pictorial
representation (e.g., the use of a circle for a face and a
rectangle for a body when drawing a person). The term
contoured, on the other hand, refers to the sketching
of an outline, which is subsequently detailed to achieve
the desired representation. Although no attempt is
made to explain why a shift might occur from the
former to the latter, it is postulated that the motivation
is a quest for realism. This quest, in conjunction with
greater skill in visually controlling actions and the
ability to plan spatially and execute actions, constitutes
the move from a juvenile to a more adult approach to
drawing. Obviously such assumptions require further
investigation.
There has been little advance on the seminal work of
authors such as Luquet (1927) and Kellogg (1969)
when considering the maturation of children’s draw-
ings. These authors considered that children between
the ages of 2 and 3 years make scribbling marks on
paper with no representational intent. The fascination
is thought to be more with the process of experimenta-
tion and exploration of media than with an intended
product. The drawing by a 21⁄2-year-old child in Figure
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
implement on paper. Only at the completion of these
marks is a border introduced as a way of demarcation.
Demarcating parts of a picture is argued to indicate the
beginning of an interpretive phase, which occurs
between the ages of 3 and 4 years. During this phase a
child begins to interpret a drawing, but generally only
after it has been produced. The representational intent
is not there at the outset. For example, Figure 11-3 was
drawn by a 31⁄2-year-old child. The task commenced
with the scribbling at the top of the page with no
apparent commitment as to the topic of the drawing.
At the completion of the task the child was asked to talk
about what had been drawn. The child nominated the
descriptions that have been inserted in print but only
after some reflection and consideration.
In the next stage (4 to 5 years) the nature of the
drawing is announced before its commencement, but
the coordination of individual elements remains diffi-
cult. At this stage children label and sign their drawings
(Devlin-Gascard, 1997). Words are incomplete and
letters are often reversed, but the comprehension of
symbol and meaning is observable. The drawing of a
ship by a 41⁄2-year-old boy in Figure 11-4 demonstrates
the use of word labels to describe the intent of the
drawing. In this case it was to inform the viewer that
the drawing was of the ship Oronsay, which had hit a
rock and was badly damaged.
The 6- to 7-year-old child is able to include all the
characteristics of objects being drawn as they are
known to him or her. This is not always consistent with
The Development of Graphomotor Skills • 221
the way they are in an adult reality. Figure 11-5 demon-
strates how a 6-year-old girl perceives her school. The
drawing is not a realistic representation but it does
contain features of her school and it highlights her
understanding of a friendly environment. Finally, from
around 8 years of age the child begins to take into
account visual perspective; object position and orienta-
tion also become more important. This shift represents
a progression from intellectual realism, in which the
child draws what he or she knows about a stimulus, to
a stage in which the drawing depicts what actually can
be seen (Laws & Lawrence, 2001). This shift also has
been associated with an increase in the amount of
attention given to the object being drawn (Sutton &
Rose, 1998), suggesting that realism is based on ability
to attend to detail.
The ability to produce and appreciate graphic per-
spective has received considerable attention (Freeman,
1980; Freeman, Eiser, & Sayers, 1977; Nicholls &
Kennedy, 1992; Toomela, 1999). Some authors see the
onset of perspective as evidence of cognitive maturation
(Reid & Sheffield, 1990), whereas others argue that it
is necessary to learn the rules about how to represent
something in true perspective (Hagen, 1985; Orde,
1997). This latter view is based on studies that found
little difference between the way in which children
handle the three-dimensional plane and the methods
adopted by adults. In both populations, individuals
who have no special artistic talent or training reproduce
the visual structures that they see in natural perspective
along a continuum from orthogonal (no diminishing
222 Part II • Development of Hand Skills

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).
 The Development of Graphomotor Skills • 223

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
(image size decreases as distance increases). As with
other skills that have learned elements, Messaris (1994)
argues that enhancement of depth perception might
lead to a more general stimulation of the capacity for
perceiving and thinking about three-dimensional space,
an important component of general intelligence.
Figure 11-6 demonstrates the use of foreground and
background, as well as three-dimensional perspective.
Some uniformity exists in the way certain objects are
drawn. Both convention and handedness have been
implicated in this uniformity (van Sommers, 1984).
For example, right-handed people tend to commence
the drawing of a free-standing circle at around the
12 o’clock position and invariably draw counter-
clockwise, whereas a little more than 60% of left-
handed people draw a circle in a clockwise direction.
Another interesting convention is the direction in
which profiles are facing. Most profiles of faces, for
instance, are drawn turned to the left, as are most cars.
Glasses are drawn with the lenses to the left, pencils
have points to the left, spoons and pipes have bowls to
the left. On the other hand, most flags are drawn flying
to the right, and cups and buckets have their handles to
the right. The foundations for these uniformities have
not been documented and neither have there been
224 Part II • Development of Hand Skills

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,
click, drag, and place have been used in this drawing. In
another example of freehand drawing (see Fig. 11-8), a
6-year-old girl demonstrates the use of click and drag
to create a self-portrait. There is scope for further
research in this domain to examine comparability
between the production of drawings using pencil and
paper and computer software.
DRAWING AND DEVELOPMENTAL
EVALUATION
Children’s drawing ability is incorporated into a number
of assessments of developmental status. The ability to
reproduce a straight line, a cross, and a circle, for
example, is used in a number of assessments as indicators
of developmental maturity (Bayley, 1993; Folio &
Fewell, 2000; Gesell, 1956; Griffiths, 1970). Further-
more one of the most widely used tests of visual-motor
integration, The Developmental Test of Visual Motor
Integration (VMI) (Beery, 1997) evaluates children’s
accuracy in reproducing shapes to determine their visual-
motor maturity. Some researchers have determined
ability in this assessment as being directly related to
subsequent handwriting skill (Oliver, 1990).
A number of studies have associated the ability to
draw a human form, such as found in the Goodenough
Draw-A-Man Test (Goodenough, 1926) with a range
of cognitive (Harris, 1963; Scott, 1981), behavioral
(Hartman, 1972; Pope-Grattan, Burnett, & Wolfe,
1976), and emotional (Fu, 1981; Roback, 1968) char-
acteristics in children. To date the findings from these
investigations remain inconclusive. Other issues related
to the perceptual-motor ability necessary to draw a
human form, the gender variability in drawings of this
nature, and the efficacy of drawing the self as opposed
to a male or female form have been investigated (Short-
DeGraff & Holan, 1992). Short-DeGraff and Holan
found that factors in preschool children’s self-drawing
were significantly and positively related to visual motor
skills as measured by the Test of Visual Motor Skills
(Gardner, 1986) but not with a measure of verbal
intelligence. Short-DeGraff and Holan also explored
alternatives to scoring the drawing to those originally
proposed by Goodenough. The high association between
their simplified scoring methods and Goodenough’s
more complex methods suggests that simplification
of scoring criteria is possible. Further research of the
scoring criteria, as well as extending the ages of chil-
dren under investigation, is warranted based on these
preliminary findings.
Obviously, for those children with motor impair-
ment (e.g., cerebral palsy, spina bifida) the quality of
drawings may be affected. The differences between
their drawings and those of children without disability
The Development of Graphomotor Skills • 225
should be considered within the context of the child’s
perceptual-motor limitations, cognitive impairment, and
possible environmental restrictions. Determining the
relative contribution of each factor is not easy. Unfor-
tunately, many assessments of developmental and cog-
nitive abilities rely, in part, on copying abilities, especially
for preschool children (Moore & Law, 1990).
An attempt has been made by Reid and Sheffield
(1990) to accommodate perceptual-motor limitations
when examining children’s drawings. These authors
adopted a cognitive-developmental model for the analysis
of drawings in children with myelomeningocele. Reid
and Sheffield argue that instead of attending to the
quality of drawings, which may be detrimentally
affected by motor disability, the subject matter and its
depiction should become the focus for determining
developmental maturity. They propose four complex
stages through which children pass in the development
of mature drawings. Perspective plays an important part
of their conceptualization of a mature drawing. Pre-
liminary observations suggest that Reid and Sheffield’s
stages and conceptualization of the content of drawings
are a useful analytic scheme for children with myelo-
meningocele. However, other experimenters argue
against the developmental significance of perspective
(Bremner & Batten, 1991; Hagen, 1985). Further
research to examine the potential clinical utility of Reid
and Sheffield’s (1990) findings, especially in the more
complex final stages of their model, is warranted.
A view of unique developmental progression in the
drawing ability of children with Down’s syndrome has
been advanced by Laws and Lawrence (2001). They
found preliminary evidence that the spatial charac-
teristics of drawings of children with Down’s syndrome
may follow an alternative route to those of children
without Down’s syndrome because of problems related
to motor planning, motor weakness, and aspects of
language development. Children with Down’s syn-
drome in their study did follow the expected develop-
mental, albeit delayed, trajectory of children in the
control group. Yet there were elements in the drawings
of children with Down’s syndrome that attested to
their ability to account for aspects such as spatial
relationships, although not in the same way as children
without Down’s syndrome. However, the two groups
were comparable with respect to drawing detail. The
authors of this study join others (Eames & Cox, 1994)
in advocating the use of measures sympathetic to
children with different developmental profiles.
This section has discussed the development of draw-
ing and the expectations of the composition of drawings
for typically developing children. It has shown the im-
portance of considering the different ways that children
with special needs may interact with writing imple-
ments and develop their drawing competence. The
226 Part II • Development of Hand Skills
following section focuses on a different graphomotor
skill, that of handwriting.
HANDWRITING
HANDWRITING AND WRITING:
COMPLEMENTARY CONCEPTS
There is an important differentiation, but also relation-
ship, between handwriting and writing. Handwriting
refers to the process of transcribing letters to form
words and words to form sentences. Writing, on the
other hand, is the composition and content of the
material that is handwritten. Proficient writing relies
on well-developed handwriting skills. Jones and
Christensen (1999), for instance, reported that
handwriting skills accounted for 50% of the variance in
the quality of writing content in a sample of 6- and 7-
year-old students. Both handwriting and writing are
complex abilities that are acquired hand-in-hand with
children’s acquisition of language. As with drawing, the
foundations for both handwriting and writing are the
integration of intrinsic and extrinsic factors. Extrinsic
factors involved in handwriting include instruction in
handwriting, the quality and extent of practice under-
taken, the requirements of the task, and the materials
used. Intrinsic abilities include orthographic coding,
orthographic-motor integration, visual-motor skills, fine
motor skills, cognition, linguistic skills, and motivation
(Tseng & Chow, 2000). Orthographic coding involves
developing a visual representation of letters and words,
knowledge of the process of forming each letter, a
verbal label for each letter, an accurate representation
of the letter’s form in memory and the ability to access
and retrieve this information from memory (Edwards,
2003; Jones & Christensen, 1999; Weintraub &
Graham, 2000). Orthographic-motor integration is the
way in which this letter knowledge can be motorically
transcribed to form letters and words on paper. Writers
who have poor orthographic coding and ortho-motor
integration, and thus need to attend to the mechanics
of handwriting (e.g., letter formation, spacing, align-
ment), have less attention and working memory that
can be directed to composing written work and spelling,
monitoring, and revision of the written work (Edwards,
2003; Swanson & Berninger, 1996).
Children’s competence in writing depends, in part,
on the mastery of handwriting (Graham, Harris, &
Fink, 2000). The ability to write legibly and in a timely
fashion is necessary for children to adequately docu-
ment their knowledge and learning. Children’s docu-
mentation is largely the basis on which their knowledge
acquisition is judged. Research has shown that lower
marks are ascribed to work that is less legible even
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
impede the ability to generate text that adequately
reflects their knowledge. Handwriting difficulties are a
significant problem for educationalists and occupa-
tional therapists. Berninger and co-workers (1997), for
instance, identified 202 (29%) at-risk writers out of 685
children screened and another study identified 24% of
children in a sample of 798 kindergarten and grade 1
children as having poor handwriting (Harris & Livesay,
1992). Further, a survey of grade 1 to 4 teachers re-
ported that 23% of children had handwriting difficulties
(Hammerschmidt & Sudsawad, 2004). Handwriting
proficiency remains a fundamental educational goal
despite the availability and uptake of computer
technology. The focus of this section is on under-
standing handwriting as a basis for intervention.
THE DEVELOPMENTAL NATURE OF
HANDWRITING
Several features of handwriting development are con-
sistent from both historical and cross-cultural perspec-
tives. At least some characteristics of handwriting are
likely to be common across cultures, language, and
written script (Yochman & Parush, 1998). For example,
there is a developmental progression of both speed and
legibility of handwriting with age and a relationship
between visuomotor skills and handwriting. Also girls
tend to write faster and more legibly than boys and more
boys than girls have handwriting difficulties. Further,
about 10% of a population is left handed but left handed-
ness is not associated with illegibility or slower speed
of handwriting. These relationships have been relatively
consistent in studies of handwriting of English,
Chinese, Hebrew, and Norwegian children (Graham,
1998; Karlsdottir, 1996; Tseng & Cermak, 1993;
Tseng & Chow, 2000; Yochman & Parush, 1998).
There are also consistent factors that seem to
operate in the development of written script over time:
The size of the writing diminishes; letter formation,
spacing, and horizontal alignment become more
accurate, simplified, and standardized; the handwriting
may become abbreviated; and cursive forms evolve with
curves replacing angles and ligatures joining letters
(van Sommers, 1991; Yochman & Parush, 1998).
Children personalize their own style of handwriting
as formal handwriting instruction diminishes. The
personalized style generally is faster and more efficient,
which may result in a deterioration of letter formation
at times. Personalized handwriting tends to become a
mix of manuscript and cursive letters, which develops

The First Nine Forms of the
Developmental Test of Visual
BOX 11-1
Motor Integration in Order of
Increasing Difficulty
1. Vertical line
2. Horizontal line
3. Circle
4. Cross
5. Right oblique line
6. Square
7. Left oblique line
8. Oblique cross
9. Triangle
Beery KE (1989). The Developmental Test of Visual-Motor
Integration, 3rd rev. Cleveland, OH, Modern Curriculum
Press.
because it is faster than exclusively manuscript or cur-
sive. Mixed handwriting that is predominantly cursive is
used relatively less frequently than other forms (cursive,
manuscript, or mixed but mostly manuscript). Despite
this, mixed handwriting that is mostly cursive tends to
yield more legible handwriting (Graham, 1998).
Integral to the issues of handwriting development
and understanding the developmental expectations for
handwriting is the question of when young children are
ready to begin handwriting instruction. A number of
factors may be considered here: perceptual readiness,
linguistic readiness, and the maturity of pencil control.
Beery (1989) argued that young children are not ready
to learn handwriting until they can correctly copy the
first nine forms of the VMI (Beery, 1989) (Box 11-1).
Kindergarten children who can copy these forms also
can copy significantly more letters (Daly, Kelly, &
Krauss, 2003; Weil & Cunningham Amundson, 1994)
and have better handwriting in grade 1 (Marr &
Cermak, 2002) than children who cannot achieve nine
forms. Daly demonstrated that 56% of children, when
tested in the first quarter of the kindergarten school
year, were able to copy these nine forms. This compares
with 88% who copied the nine forms in the middle of
the kindergarten school year in Weil and Cunningham
Amundson’s study. Thus if using the VMI as an indi-
cator of handwriting readiness, most typically develop-
ing kindergarten children should be ready to succeed
with handwriting instruction in the latter half of the
kindergarten school year.
As children develop the skill of handwriting, their
performance changes both qualitatively and quantita-
tively. Handwriting quality and quantity translate, respec-
tively, into legibility and speed. How do we judge if
either or both of these aspects are appropriate for the
The Development of Graphomotor Skills • 227
child’s chronologic or developmental level and what
factors constitute handwriting dysfunction? Handwrit-
ing difficulties become apparent when children write
too slowly to record sufficient quantities of work or
when the written work is difficult to read. For instance,
teachers report that failure to read student handwriting
was the most important criteria in determining whether
a child had handwriting difficulty (Hammerschmidt &
Sudsawad, 2004). Poor handwriters are more likely to
have inadequate closure and line quality of letters, poor
orientation to the writing line, poor spacing between
words and letters within words, and inconsistent sizing
of words and of letters within words (Malloy-Miller,
Polatajko, & Anstett, 1995).
Although children with handwriting difficulty should
be seen within their social and educational contexts,
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
letter formation (Ziviani & Elkins, 1984). Drawn from
a population of Australian schoolchildren, these data
support the assumption that letters become more accu-
rately formed, spacing becomes more consistent, size
diminishes (more particularly in girls), and handwriting
attains better horizontal alignment.
Information about developmental expectations and
the factors contributing to handwriting illegibility
provide a useful baseline measure for children exposed
to similar educational instruction. Ziviani, Hayes, and
Chant (1990) used the normative data discussed
previously to help specify the nature of difficulties
experienced by children with spina bifida who were able
to attend regular schools. Their findings indicated that
speed, horizontal alignment, and letter formation were
the handwriting characteristics most detrimentally
affected. Meanwhile, handwriting size fell within two
standard deviations of the normative means, and spacing
consistency often was better than in the normative
sample. Such findings are useful in delineating hand-
writing dysfunction to target intervention and not just
accepting a global disability.
Handwriting quality appears to be an elusive con-
cept to measure despite the development of both global
and detailed handwriting assessments. A review of fre-
quently used handwriting tools was written by Feder
and Majnemer (2003). A global measure such as the
Test of Legible Handwriting (TOLH) (Larsen &
Hammill, 1989) compares the individual’s performance
with a series of model specimens and the important
consideration in scoring is overall legibility (Feder &
Majnemer, 2003). However, researchers have sought
increasingly to break down handwriting samples into
their component parts and over the years a wide variety
of handwriting scales (Amundson, 1995; Phelps,
228 Part II • Development of Hand Skills
Stempel, & Speck, 1984; Reisman, 1993; Stott, Moyes,
& Henderson, 1985; Ziviani & Elkins, 1984) and
checklists (Alston, 1985) have been produced to reflect
this approach. Most of these tools identify characteris-
tics considered to contribute to handwriting legibility.
In general, the handwriting characteristics specified
in these detailed tools can be classified as giving form
(letter legibility and formation, size) or spatial align-
ment (space between letters and words, alignment with
lines) to handwriting. These tools provide a more com-
prehensive way of understanding legibility difficulties
than global handwriting assessments and offer a basis
for designing appropriate remedial interventions.
Graham, Weintraub, and Berninger (2001) reported
that several factors were significantly related to good
overall text legibility. These factors include letter
legibility, the absence of additional lines or strokes
attached to letters, correct within-letter proportions,
correct letter formation, and no rotations of letter
parts. There are other factors, arguably overlooked,
that relate to movement and that contribute to hand-
writing legibility (e.g., pressure while handwriting, fre-
quency of pen lifts). Of all the elements, individual
letter legibility (which incorporates letter formation,
proportion, and shaping, and letter identification out of
the context of a word) is considered the most impor-
tant to overall text legibility (Graham et al., 2001;
Mojet, 1991).
Handwriting speed is not necessarily related to
legibility; that is, handwriting speed is not predictive of
legibility and vice versa (Wann, 1987; Weintraub &
Graham, 1998). There is a trade-off, however, between
handwriting speed and legibility when children are
Table 11-1 Reported mean handwriting speed (letters per minute) by school grade
Author
Groff (1961)
Hamstra-Bletz & Blote (1990)
Phelps, Stempel, and Speck (1985)
Sassoon, Nimmo-Smith, and Wing (1986)
Wallen, Bonney, and Lennox (1996)
Ziviani and Elkins (1984)
specifically asked to write neatly or quickly. Children
asked to write neatly, for instance, do so at the expense
of speed; and children’s legibility decreases when asked
to write more quickly (Weintraub & Graham, 1998).
Authorities differ in terms of expected handwriting
speeds for children at various ages. A summary is
presented in Table 11-1. Most variation in handwriting
speed normative information may be attributed to
differing test instructions (“write normally” versus
“write fast”). In appraising handwriting speed tests and
their relevance to assessing handwriting speed, con-
sideration needs to be given to the nature of the text
being written (whether it is copied or self-generated),
the timing of data collection in the school year, and
variation in teaching practices. We know that the speed
of handwriting slows and that legibility and the quality
of letter formation decrease over a lengthy handwriting
sample in both good and poor handwriters (Dennis &
Swinth, 2001; Parush et al., 1998a). Fatigue affects
handwriting; therefore the length of text used to eval-
uate handwriting speed and legibility and its relation-
ship to everyday writing tasks needs to be considered.
Further work on tests of handwriting speed is
necessary to update and validate findings. Standardized
data used to evaluate handwriting ability and compare
performance with norms should reflect the child’s cul-
tural and educational environment. Teachers’ observa-
tions within a peer-appropriate context are critical when
deciding if a child’s performance is within develop-
mental expectations. Teachers are accurate in categoriz-
ing children with and without handwriting difficulties
when compared with a standardized assessment of
handwriting ability (Cornhill & Case-Smith, 1996).
School Grade
3 4 5 6 7
35.1 40.6 49.6
25 37 47 57 62
35 46 54 66
64
54.2 57.1 63.8 80.7 94.2
32.6 34.2 38.4 46.1 52.1

FACTORS CONTRIBUTING TO HANDWRITING
PERFORMANCE
Effective intervention can be planned when the factors
affecting an individual child’s ability to complete
legible and timely handwriting are clearly understood.
In addition to changes to handwriting legibility and
speed that occur over time in children’s handwriting,
various constraints to handwriting acquisition operate
at different stages of development. Berninger and
Rutberg (1992) suggest that neurodevelopmental con-
straints in orthographic coding, fine motor function,
and orthographic-motor integration are likely to inter-
fere with the rapid automatic production of written
language in younger children. Later, when most
children can automatically write the alphabet and spell
a set of functional words, the writing process is
more probably constrained by verbal working memory
and ability to generate the major units of written
language—the word, the sentence, or text-level struc-
tures. Once proficiency in generating units of language
is achieved, writing can be constrained by cognitive
processes such as planning, translating, and revising
when composing larger pieces of text.
For older children constraints may still be operating
at the neurodevelopmental or linguistic, as well as the
cognitive levels. Inefficiencies in the low-level neuro-
developmental processes early in handwriting acquisition
can contribute to future higher-level writing dis-
abilities, both directly (because production of written
material continues to be a problem) or indirectly
(because of an aversion to writing arising from early
frustration and failure) (Berninger et al., 1997). Some
of the major factors implicated in handwriting perfor-
mance follow.
Working Memory
Swanson and Berninger (1996) demonstrated that
individuals have a unique working memory. Working
memory is the ability to temporarily retain information
during the processing of other information. During
handwriting, orthographic codes are retrieved from
long-term memory and held in working memory while
the writer is developing the text (Weintraub & Graham,
2000). More processing functions are available for idea
generation, translation, and sequencing of ideas to text,
and revision of writing when aspects of handwriting
(including orthographic skills and even punctuation)
are automatic (Jones & Christensen, 1999). Further,
ideas that are held in working memory may be lost if a
child needs to focus attention on the mechanics of
forming a letter (Graham et al., 2001). Evidence for
this derives from studies that have shown a relationship
between orthographic-motor integration and written
expression and have demonstrated that writing (written
The Development of Graphomotor Skills • 229
expression) improved after intervention that specifically
targeted orthographic-motor integration by teaching
correct and automatic letter formation (Berninger et
al., 1997; Graham, Harris, & Fink, 2000; Jones &
Christensen, 1999). An essential educational goal is to
provide handwriting instruction that develops automatic,
fluent handwriting to free working memory for writing;
that is, generating ideas, monitoring, and revising con-
tent (Berninger et al., 1997).
Handwriting Instruction
Handwriting is heavily influenced by the nature of the
instruction received and the extent of practice under-
taken by the individual. In fact, the main factor that
influenced legibility in a study by Lamme and Ayris
(1983) was the great variability in handwriting instruc-
tion provided by the teachers involved in the study.
Handwriting probably receives insufficient emphasis in
school curricula: Teachers (62% of sample) reported
that they would like to spend more classroom time on
handwriting instruction (Hammerschmidt & Sudsawad,
2004). Berninger and co-workers (1997) surveyed
teachers who reported that students were becoming
less proficient at handwriting when they reached year 1
than students of previous years.
The importance of focused handwriting instruction
to both legible handwriting and writing has been
demonstrated in a number of studies (Berninger et al.,
1997; Graham et al., 2000; Jones & Christensen,
1999; Jongmans et al., 2003; Karlsdottir, 1996). Im-
portant components to include in handwriting instruc-
tion are listed in Box 11-2 (Berninger et al., 1997;
Graham et al., 2000; Hayes, 1982; Jones & Christensen,
1999). It seems that providing more types of cues or
perceptual prompting of letter formation may result in
better outcomes.
Adi-Japha and Freeman (2001) found that by 6
years of age children’s writing and drawing systems
were differentiated. Children as young as 3 years of age
produce different scribbles when asked to write their
name than those scribbles generated when drawing a
picture (Haney, 2002). Writing-specific cortical routes
emerge probably as a result of practicing handwriting.
Writing within a script context (e.g., words and letters
on a page) rather than writing within a picture context
produced more fluent handwriting (Adi-Japha &
Freeman, 2001). The importance of handwriting prac-
tice in early learners and thus a differentiation and
specialization of writing is reinforced by these findings.
Further, consideration needs to be given to the teach-
ing and practice of handwriting within writing specific
contexts; that is, using dedicated writing implements
and books, and reducing drawing conditions when the
aim is handwriting proficiency. Working within a script
context activates the writing system, and activation of
230 Part II • Development of Hand Skills
BOX 11-2 Important Components to Include
in Handwriting Instruction
• Copying model letters
• Visual directional cues provided by arrows
• Verbal prompting of letter formation (both instruc-
tor and self-verbal prompting)
• Copying from memory
• Reinforcing letter names and practice of letters with
a focus on committing these to memory
Berninger VW, Vaughan KB, Abbott RD, Abbott SP,
Rogan LW, Brooks A, Reed E, Graham S (1997).
Treatment of handwriting problems in beginning writers:
Transfer from handwriting to composition. Journal of
Educational Psychology, 89(4):652–656; Graham S, Harris
KR, Fink B (2000). Is handwriting causally related to
learning to write? Treatment of handwriting problems in
beginning writers. Journal of Educational Psychology,
92(4):620–633; Hayes D (1982). Handwriting practice:
The effects of perceptual prompts. Journal of Educational
Research, 75(31):169–172; Jones D, Christensen CA
(1999). Relationship between automaticity in handwriting
and students’ ability to generate written text. Journal of
Educational Psychology, 91(1):44–49.
the writing processing system separately from a drawing
context prepares for more accurate and automatic
handwriting output.
The outcomes of the studies that have focused on
developing orthographic skills and automatic hand-
writing have all been positive. The results suggest that
poor letter knowledge and orthographic skills are major
contributors to handwriting difficulties and are essential
to consider in handwriting intervention. Other studies
provide useful information to consider when planning
handwriting intervention. One study examining the
ability of children in years 1 to 3 to write manuscript
letters reported that some letters were more difficult to
form legibly (Graham et al., 2001). Overall these
letters, in descending order of difficulty, were q, z, u, j,
k. Fortunately some of these letters are not frequently
used in handwriting but may require more focus during
handwriting instruction and should be introduced only
after mastery of easier letters. Despite ongoing debate,
it seems that teaching slanted or elliptical manuscript
does not have advantages over traditional manuscript in
legibility outcomes or assisting the transition to cursive
handwriting (Graham, 1998). Karlsdottir (1996)
showed that handwriting quality of older (10-year-old)
students was significantly enhanced by reintroducing
each letter form with accompanying visual and verbal
cues. Thus one should consider these orthographic fac-
tors even in more mature writers. Older writers also tend
to personalize handwriting by mixing manuscript and
cursive text, among other things. Generally this is to
the advantage of both speed and legibility and need not
be discouraged.
Factors That Influence the Effectiveness of
Handwriting Instruction
Factors such as kinesthesis, fine motor skills, and visual
motor abilities are associated with handwriting devel-
opment and performance (Weintraub & Graham, 2000).
Researchers exploring these factors operate under the
assumption that they underlie handwriting performance
and that understanding their relationship with hand-
writing assists with developing and evaluating interven-
tion programs (Tseng & Cermak, 1993). Further factors,
such as posture while handwriting, paper positioning,
and stabilization of paper, as well as other ergonomic
factors, discriminate good and poor handwriters (Parush,
Levanon-Erez, & Weintraub, 1998b). Posture and sta-
bilization anomalies may result from similar mechanisms
to those that cause handwriting difficulties. It is not yet
known whether remediating kinesthesis, fine motor,
visual motor, ergonomic, and other factors improve
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
are expanded here. When an orthographic code is
mobilized from memory for handwriting, a motor
program is executed that encompasses manipulating
a writing implement to form letters and words
(Weintraub & Graham, 2000). Two aspects of motor
execution are examined in the literature, fine motor
skills (including in-hand manipulation) and abilities
related to kinesthesis.
Isolated and graded finger movements are necessary
to provide precise and rapid manipulation of a writing
tool for handwriting. On the basis of this premise, fine
motor skills and in-hand manipulation are frequently
assessed as part of a handwriting assessment. Fine motor
skills are assessed globally by tools such as the Peabody
Developmental Motor Scales—Fine Motor (Folio &
Fewell 2000). Fine motor skills incorporate the basic
patterns of reach, grasp and release, and the more com-
plex skills of in-hand manipulation and bilateral hand
use (Exner, 1989). In-hand manipulation, then, is an
essential component of dexterous hand function and
can be assessed separately using tools such as those de-
veloped by Exner (1993) or Case-Smith (1995). These
assessments include some of the defined features of
in-hand manipulations such as rotation (e.g., turning
an object over using the fingers of one hand) and
translation (e.g., using the fingers of one hand to move
objects in and out of the palm). In-hand manipulation
is assessed as its own entity in handwriting evaluation
because of a perceived relationship to pencil manipula-
tion. In reality the association between fine motor skills

or in-hand manipulation and pencil grip and hand-
writing speed and legibility has not been extensively
explored. Rubin and Henderson (1982) found that
children with poor handwriting did not have signifi-
cantly different scores from a group of good hand-
writers on the Test of Motor Impairment, but they did
have more variability of their scores. Tseng and Chow
(2000) on the other hand, found that Chinese hand-
writers, categorized as slow writers by their teachers,
had significantly lower scores on the Upper Limb
Speed and Dexterity subtest of the Bruininks-Oseretsky
Test of Motor Proficiency than normal speed hand-
writers. Cornhill and Case-Smith’s work (1996) pro-
vides us with some evidence that in-hand manipulation
is a significant predictor of handwriting legibility. Their
sample of year 1 students with handwriting difficulties
had significantly lower in-hand manipulation scores
than fellow students with good handwriting. Still we do
not know whether improving fine motor and in-hand
manipulation ability results in more legible or faster
handwriting.
Debate continues about the role of kinesthesis in
handwriting performance and the effectiveness of
kinesthetic training in improving handwriting. Laszlo
and Bairstow (1985b) have argued, based on their
work with the KST, that kinesthetic memory, more
than kinesthetic acuity, is primarily responsible for the
skilled performance of writers. Studies investigating the
proposed relationship between training children using
the testing equipment of the KST and handwriting
performance have reported contradictory findings and
have cast a shadow on the psychometric properties of
the KST (Hoare & Larkin, 1991; Lord & Hulme,
1987). Two of the stronger studies provide the best
evidence that the KST is not associated with hand-
writing. Copley and Ziviani (1990) found no significant
relationship between the KST and handwriting quality
when testing good and poor handwriters. A well-
designed randomized controlled trial evaluated hand-
writing outcomes after kinesthetic training on the KST
equipment (Sudsawad et al., 2002). There were no
significant between-group differences in these grade 1
children after kinesthetic training compared with a
sham intervention and no intervention. Previous studies
have evaluated kinesthetic training in children with
poor handwriting without identifying whether or not
they had kinesthetic difficulties. An important differ-
ence of Sudsawad’s study from previous ones is that
the children recruited were identified as having hand-
writing difficulty, as well as kinesthetic impairment
identified by the KST. The evidence suggests that kines-
thetic training using the KST equipment is not an
effective handwriting intervention.
Research on other aspects of somatosensory ability
and handwriting are inconclusive. Weintraub and Graham
The Development of Graphomotor Skills • 231
(2000) found that “finger function” was a strong pre-
dictor of good or poor handwriting ability. Rather than
reflecting strictly fine motor ability, the finger function
tasks contained largely proprioceptive and somato-
sensory ability. Yochman and Parush (1998), however,
found no correlation between kinesthesia-related tests
and handwriting performance.
Visual motor integration appears to be an important
factor in handwriting legibility. A great deal of research
supports the assumptions that (a) visual motor inte-
gration is correlated with handwriting performance in
good, as well as poor handwriters (Tseng & Chow,
2000; Tseng & Murray, 1994; Weil & Cunningham
Amundson, 1994); (b) visual motor abilities are weaker
in children with handwriting difficulties, across a wide
range of ages, compared with children without hand-
writing difficulties (Cornhill & Case-Smith, 1996; Daly,
Kelly, & Krauss, 2003; Rubin & Henderson, 1982;
Tseng & Chow, 2000; Tseng & Murray, 1994); and
(c) visual motor integration difficulties are a predictor
of handwriting legibility (Cornhill & Case-Smith, 1996;
Maeland, 1992; Tseng & Chow, 2000; Weintraub &
Graham, 2000; Yochman & Parush, 1998). Visual motor
integration may be particularly important in the acqui-
sition of handwriting because visual motor abilities are
used to acquire orthographic coding skills. Occupational
therapists tend to view visual motor integration as under-
lying handwriting dysfunction and intervene using visual
motor activities (Case-Smith, 2002). Despite this relative
abundance of evidence confirming the relationships
between visual motor integration and handwriting,
there is as yet no evidence that remediating visual
motor skills will result in enhanced handwriting output.
Handwriting intervention studies in the educational
and motor learning literature focus on developing
orthographic coding and using self-instruction methods
for enhancing handwriting legibility and writing ability
(Berninger et al., 1997; Graham et al., 2000; Hayes,
1982; Jones & Christensen, 1999; Jongmans et al., 2003;
Karlsdottir, 1996). These studies provide good evidence
that these approaches are effective in enhancing various
aspects of handwriting legibility and speed and also the
content of written work. Studies in occupational therapy
are fewer in number than studies in education. Typically
occupational therapy intervention studies integrate
multiple theoretical perspectives and offer broad-based
interventions encompassing biomechanical, multisensory,
visual motor, fine motor, and handwriting-specific inter-
ventions (Case-Smith, 2002; Lockhart & Law, 1994;
Peterson & Nelson, 2003). A range of outcomes which
are not always related to handwriting legibility, speed, and
content are evaluated. Two such broad-based studies
(including one randomized controlled trial) reported
significant improvement in handwriting; however, the
specific components of the intervention that contributed
232 Part II • Development of Hand Skills
to the outcomes are undetermined (Case-Smith, 2002;
Peterson & Nelson, 2003).
COMPUTERS AND HANDWRITING
Children with significant disability or those who con-
tinue to have handwriting difficulties even after inter-
vention may consider word processing as an alternative.
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
(e.g., word prediction); transfer of data among home,
school, and printers; the cognitive demands of man-
aging files, academic subjects, and the facilities of mul-
tiple software packages; the physical demands of the
task; and the suitability to the child. Further, it is
necessary to predict whether a child will actually achieve
quality written expression with adequate accuracy and
speed compared with handwriting.
Keyboarding, like handwriting, is a complex skill and
requires many hours of practice to achieve proficiency.
Learners of keyboarding should progress through
stages of learning the position of keys and the various
movement patterns necessary to achieve correct key
strokes. Proficiency, which relies largely on kinesthetic
feedback and little on visual feedback, may be achieved
with practice. It is interesting to contemplate whether
handwriting and keyboarding have similar underlying
abilities. If so, and if handwriting is a difficulty, then
these same underlying abilities also may affect the
development of proficiency at keyboarding. Studies
indicate that different components underlie hand-
writing and keyboarding accuracy in typically develop-
ing students (Preminger, Weiss, & Weintraub, 2004;
Rogers & Case-Smith, 2002). This information com-
bined with Barrera, Rule, and Diemart’s (2001) finding
that year 1 students wrote more words and sentences
using a keyboard than handwriting gives us more con-
fidence in using keyboarding as an option for children
with handwriting difficulties.
Word processing and word prediction software can
increase the legibility and spelling of written work in
children with learning and handwriting difficulties
(Handley-More et al., 2003). Studies do not concur as
to whether keyboard instruction can result in keyboard
speeds that are faster than handwriting (Rogers &
Case-Smith, 2002). Indeterminate hours are spent
learning and refining handwriting. The expectation
should be that substantial effort goes into ensuring that
the speed and accuracy of keyboarding is at least equi-
valent to handwriting to make it a viable alternative to
handwriting. The secondary complications of poor hand-
writing (e.g., compositional difficulties, avoidance of
handwriting, and loss of confidence) may be avoided if
children can be offered word processing as a viable
option to handwriting at an appropriate time (Rogers
& Case-Smith, 2002).
This review of handwriting has discussed hand-
writing development and factors associated with skilled
handwriting execution. The fact that handwriting under-
lies quality written output and thus that good hand-
writing instruction is essential has been emphasized.
SUMMARY
The process and products of children’s drawing and
handwriting have intrigued occupational therapists, as
well as others interested in child development, for a
number of years. It is clear from this chapter that,
although we now have certain structures in place to
understand the developmental transitions in children’s
drawings, there is still much to understand. The same
can be said for handwriting. There remain aspects of
drawing and handwriting acquisition that still tantalize;
this chapter concludes by pointing to some issues that
still beg investigation.
Drawing is an important developmental experience
for children. With the increasing use of computers by
younger and younger children, some of the pencil and
paper drawings with which we are most familiar are
being accomplished using a computer. Are we able to
translate our knowledge of paper-based outcomes to
those on the screen?
Preliminary research has indicated that handwriting
and keyboarding have differing underlying compo-
nents. Thus we are unlikely to be able to translate our
knowledge of handwriting directly to keyboarding. A
greater understanding of word processing, as an
alternative form of recording work, is necessary to
match it to the individual needs of students. Using a
motor learning framework, we understand that hand-
writing is a learned motor task requiring interplay
among the writer, the task, and the environment. A key
environmental factor in its acquisition is the quality of
instruction received and amount of practice under-
taken. However, even in the presence of adequate
instruction there are a multitude of factors pertinent to
an individual that may affect the child’s ability to
develop handwriting. The association between some
of these factors and handwriting has been better
researched than others. For example, we know there is
an association between visual motor integration and
handwriting. We are less certain of the relationship
between other factors such as kinesthesia and in-hand
manipulation and handwriting. Cognitive, linguistic,
and motivation factors also should inform research in
this field. We require a better understanding of the

relationship of all these factors to handwriting and
especially how these factors are manifesting in children
with poor handwriting. It may be that a breakdown in
any of these factors may impede a child’s acquisition of
handwriting. Determining their relative effect on
performance is essential if appropriate intervention is to
be designed.
Developing proficient handwriting requires children
to learn and apply a number of rules, as well as to
develop motor programs for the efficient execution of
script. We have established that the nature and extent
of instruction are highly influential in proficient
handwriting output. Part of handwriting instruction is
knowing how to form individual letters and join them
to manufacture words. One area that has not received
much attention in the literature is the influence of dif-
ferent scripts in the attainment of proficient hand-
writing. The relative merits of learning print (ball and
stick) and then moving on to learn cursive handwriting,
as opposed to starting with a simple modified cursive
script, also requires further investigation. Both
approaches, in fact, are currently used in school systems
throughout the world. We simply do not know which
is more effective in optimizing handwriting develop-
ment and outcomes.
Research in the area of implement grasp and
manipulation suggests that the type of grip being used
need not necessarily impede handwriting speed and
legibility (Dennis & Swinth, 2001; Koziatek & Powell,
2003). This suggests that the mechanism for execution
of handwriting is less important than the cognitive,
perceptual, and planning components. Research is
needed to clarify this relationship.
This review of the development of drawing and
handwriting shows a field dotted with light and shade.
Our knowledge of drawing and handwriting, grounded
in research and founded on principles of motor
learning, is the “light” we shed on our interactions with
children with handwriting difficulties. The “shade”
relates to areas in which knowledge is sparse. We
should continue to seek knowledge that will shed light
on the many “shaded” areas that currently exist in this
area and will enable us to provide evidence-based and
effective intervention for our clients.
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INTERVENTION FOR CHILDREN WITH
HAND SKILL PROBLEMS
Charlotte E. Exner
CHAPTER OUTLINE
FRAMEWORKS FOR INTERVENTION WITH
CHILDREN WHO HAVE HAND SKILL PROBLEMS
Impact of Hand Skill Problems on Children’s
Occupational Performance
Intervention Approaches: Modifications or
Adaptations and Motor Skill Remediation
Factors to Consider in Intervention Planning
GOAL SETTING FOR HAND SKILL INTERVENTION
Considerations in Setting Goals
Short-Term Goals for Hand Skill Intervention
RESEARCH RELATED TO HAND SKILL INTERVENTION
INTERVENTION STRATEGIES FOR HAND SKILL
PROBLEMS
Positioning of the Child and the Therapist
Tactile or Sensory Awareness or Discrimination
Tone and Postural or Proximal Control
Isolated Arm and Hand Movements
Grasp
Voluntary Release
In-Hand Manipulation
Bilateral Hand Skills
Integration of Skills into Occupational Performance
ADJUNCTS TO DIRECT INTERVENTION: SPLINTING,
CASTING, AND CONSTRAINT-INDUCED
MOVEMENT THERAPY
Splinting
Casting
Constraint-Induced Movement Therapy
SUMMARY
Chapter 12
FRAMEWORKS FOR
INTERVENTION WITH CHILDREN
WHO HAVE HAND SKILL
PROBLEMS
I MPACT OF HAND SKILL PROBLEMS ON
C HILDREN’S OCCUPATIONAL PERFORMANCE
Hand function has great significance for occupational
performance. The greater the difficulties with hand
function, the greater the impairment in skills that allow
for independence and participation in academic and
social activities. Children with hand function difficulties
usually are limited in their ability to effectively or effi-
ciently complete daily life skills and develop skills that
will support optimal occupational performance in the
future. In addition, for some children even subtle diffi-
culties with hand skills may affect their social participa-
tion because of limitations in ability to engage in activities
with their peers or messiness in task completion.
Fine motor skills have a major impact on children’s
school performance. McHale and Cermak (1992)
found that “all the classrooms observed [in their study]
had a high level of fine motor demands,” with fine
motor tasks being carried out for 30% to 60% of the
classroom day and the majority of these tasks involving
writing activities. In preschool settings, children must
be able to manage the classroom manipulatives,
including puzzles, scissors, crayons, blocks, pegs, and
beads. Elementary school-age children must be able to
manage the entire writing process, which includes
handling a pencil or pen effectively, using an eraser,
tearing and folding paper, putting paper into note-
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
have a high volume of written work, but they also take
courses that have labs (e.g., science, industrial arts,
home economics) that require the ability to handle
small materials with dexterity.
Children of all ages need effective hand function to
manage eating, dressing, hygiene care, and a variety of
other self-care activities independently in multiple envi-
ronments. Expectations for independence, and there-
fore proficient hand use, increase throughout adolescence.
Chapter 10 provides a thorough summary of the inter-
action of hand and self-care skills.
In response to the frequent difficulties that children
show and the impact of these difficulties on occu-
pational performance, pediatric occupational therapists
typically address children’s hand skills. Swart et al.
(1997) report that intervention for fine motor skills is
a top occupational therapy priority in working with
children. In their study of approximately 200 pediatric
occupational therapists, intervention for fine motor
issues was rated as very important or important by
100% of the therapists. Almost 100% of these therapists
reported that they consistently or often provide services
that address fine motor issues, and at least 90% reported
that addressing fine motor issues is unique or very unique
to the profession of occupational therapy.
I NTERVENTION APPROACHES:
MODIFICATIONS OR ADAPTATIONS AND
MOTOR SKILL REMEDIATION
A child’s hand function difficulties always must be
placed within the context of the child’s overall func-
tioning, needs, and priorities. Despite the significance
of hand skills to occupational performance and social
participation, the decision about intervention for hand
skill difficulties must be made with the child (when
feasible) and the family or other key individuals,
keeping in mind the child’s overall needs and priorities
and the likelihood of intervention having a significant
impact on the child’s functioning. For example, a child
may have multiple need areas for intervention, such as
academic skills, mental health issues, or language diffi-
culties. In addition, within the scope of responsibilities
of the occupational therapist, issues of hand function
may be of lesser priority than other areas, such as sen-
sory regulatory issues, acquisition of independence in
life skills, or psychosocial concerns.
Thus the occupational therapist participates with the
child, the family, and other team members in deter-
mining if and when intervention with a focus on hand
function issues is in the best interest of the child. Two
general types of intervention approaches may be con-
sidered in addressing hand function issues: adaptations
and direct intervention for the motor skill difficulty.
However, these two approaches may be blended and
both should be used with a consideration for applica-
bility to the child’s occupational tasks. The Occupa-
tional Therapy Practice Framework (2002) is helpful in
considering a variety of dimensions related to the
intervention approach.
Modifications and Adaptations for
Hand Skill Problems Within the Context of
Occupational Tasks
This type of intervention includes the use of alternative
strategies for accomplishing tasks, including the use of
adaptive equipment when necessary. Splinting is a
common adaptation used to support hand function in
children with moderate to severe disabilities. Although
direct intervention may not appear to be crucial when
adaptive strategies or splinting are selected as the
primary method of intervention, children often need
substantial intervention for these strategies to be used
successfully. Family members or teachers may need
ongoing guidance and the adaptive strategy or splint
may need modifications for function and optimal use.
The success of this type of intervention often is linked
to the follow-up provided to insure that the child and
others are using the strategy and are satisfied with the
adaptation and its applicability to the child’s daily life
task performance.
Motor Skill Remediation Within the Context of
Occupational Tasks
The therapist may work with the child to assist the child
in developing or improving specific hand skills such
as grasp, in-hand manipulation, or voluntary release.
Although the therapist may use the intervention time
to focus specifically on improvement of one or more of
the child’s hand skills, the skills being developed should
be immediately and directly linked to use of these hand
skills within the child’s daily life activities. Thus during
each session with a child, the therapist places high
priority on identification of helpful strategies that can
and will be used outside of the therapy session. These
strategies can include identifying ways in which adult
facilitation of the new skills will occur and ways in
which multiple repetitions of the skill can be elicited to
support proficiency, speed, and spontaneous skill use.
The decision about a focus of hand skill goals on
adaptation or motor skill remediation can vary over
time and for different skills, depending upon the child’s
needs and the degree of the child’s disability.
Vygotsky’s (1978) concept of the zone of proximal
development can be very useful in considering the most
appropriate approach for particular skill areas. This con-
cept focuses upon the amount of adult or peer assistance
or guidance needed to complete a skill. It suggests a

focus on the child’s abilities, rather than upon his or
her disabilities, as it considers the skills that are “close”
(i.e., within the “zone of proximal development”). The
“zone of proximal development” falls between those
skills that the child is able to do independently and
those that the child is unable to do, even with adult or
peer guidance or assistance. Clearly, even within the
“zone of proximal development,” some skills are nearer
to the “independent” end of the continuum, whereas
others are nearer to the “unable to complete” end of
the continuum.
When a child’s skills are not in the independent
category and not within the “zone of proximal devel-
opment,” yet the child needs a particular skill, adapta-
tion or compensation is necessary. For example, if the
child is unable to cut foods because of an inability to
hold a fork to stabilize food with a utensil in one hand
while cutting with a knife held in the other hand, an
adaptation is needed. Such an adaptation could include
using an adapted fork or knife, using a device to
stabilize the food, or having the food cut by another
person. In contrast, if the child is able to hold both
utensils and can bring both hands near midline but has
difficulty sustaining them at midline, intervention that
is focused on enhancing the child’s skills may be effec-
tive and an adaptation may not be necessary. Those
skills that require lesser degrees of adult (or therapist)
facilitation or assistance are clearly more likely to be
responsive to remediation. At times both an adaptation
and intervention for motor skill development may
be used.
FACTORS TO CONSIDER IN I NTERVENTION
PLANNING
The Relationship Between Proximal and Distal
Control
The developmental principle of proximal to distal
development often has been translated into a principle
for intervention. However, this principle, like many
principles of normal development, does not necessarily
relate well to intervention. Current research suggests
that the relationship between proximal functioning and
distal control is functional; it is not necessarily causal
(Case-Smith, Fisher, & Bauer, 1989). Although an
infant initially may appear to show greater control
proximally than distally, infants are developing both
proximal and distal control simultaneously. Distal con-
trol, however, does take longer to reach full refinement.
In fact, different neurologic tracts control proximal and
distal upper extremity functions (Lawrence & Kuypers,
1968a,b), with the corticospinal tracts being respon-
sible for distal functions, including well-controlled
forearm movements (Paillard, 1990) but not directly
Intervention for Children with Hand Skill Problems • 241
influencing proximal functions. Therefore intervention
for proximal control problems does not necessarily
result in improved distal control, unless the distal con-
trol problem results solely from difficulty placing and
holding the hand in space. Therefore as Pehoski (1992)
notes, distal control problems should be treated
specifically. This point is supported by a number of
single subject research studies conducted by Barnes
(1986, 1989a,b). She studied the effectiveness of upper
extremity weight bearing on hand function in children
with cerebral palsy (CP) and found that although some
upper extremity movement components improved,
grasp and release did not show significant changes;
therefore the proximal improvement did not yield distal
changes.
The Relationship Between Stability and Mobility
The use of motor skills relies on the interplay of
stability and mobility. Effective use of mobility of the
arm or the hand is based upon stability within the body
or the arm. Stability typically precedes the use of
mobility. For example, the child develops the ability to
grasp an object before being able to move the object by
the fingers.
Stability provided via seated positioning and its
effect on hand function has been addressed in some
studies. Noronha, Bundy, and Groll (1989); Seeger,
Caudrey, and O’Mara (1984); and Nwaobi (1987)
assessed positioning in children with cerebral palsy.
Smith-Zuzovsky and Exner (2004) found that the
quality of seated positioning had a significant impact
on typically developing, young school-age children’s
object manipulation skills. Children who were seated in
furniture more closely matched to their body size had
significantly higher scores on the In-Hand Manipula-
tion Test than did children who were seated in typical
classroom furniture that was too large.
The Relationship Between Sensory and
Motor Control
Children with various disabilities have been noted to
have impairments in tactile functioning in their hands
(Beckung, Steffenburg, & Uvebrant, 1997; Bumin &
Kayihan, 2001; Curry & Exner, 1988; Krumlinde-
Sundholm & Eliasson, 2002; Yekutiel, Jariwala, &
Stretch, 1994). Some children seem to have little aware-
ness that they have five digits on each hand; instead they
use all four fingers as a unit. They also seem to have little
awareness that they have different areas on the palms
of the hand. Skold, Josephsson, and Eliasson’s study
(2004) with individuals with hemiplegic cerebral palsy
corroborated the presence of sensory problems. Com-
ments from these young people revealed substantial
issues with sensory awareness of the more involved arm
and hand.
242 Part III • Therapeutic Intervention
Pehoski (2005) provides a summary of key literature
related to the importance of sensory functioning for
skilled hand use (see Chapter 1). Research by Gordon
and Duff (1999) illustrates the critical role of tactile
functioning on grasping and lifting objects in typical
children and adolescents and those with cerebral palsy
(see also Chapter 3). They state that
“the impairments in grasping in children with hemiplegic CP
are largely but not exclusively due to disturbed sensory
mechanisms which may have direct implications for therapeutic
intervention” (p. 586).
These findings are supported by Krumlinde-Sundholm
and Eliasson’s study (2002) in which specific types of
sensory problems were related to dexterity difficulties
in children with hemiplegic cerebral palsy. Case-Smith
(1991) found that children with both tactile discrimi-
nation problems and tactile defensiveness had signifi-
cantly poorer performance on in-hand manipulation
tasks than did other children. The individuals in the
Skold et al. (2004) study noted the negative effect of
their sensory problems on functional use of this arm
and hand.
The Child’s Attention and Cognitive Skills
The child’s attention and cognitive functioning have a
significant influence on goals and intervention strat-
egies for hand function difficulties. The child’s under-
standing of objects and their ability to be used with
other objects to accomplish tasks affects the child’s desire
to use the hands to make objects move and interact
with one another and the products of that manipula-
tion. Although children acquire some aspects of object
knowledge and their actual and potential relationships
through manipulating them, the child’s cognitive
functioning seems to drive (or at least set the stage for)
the acquisition of increasingly complex fine motor skills.
Therefore generally the child needs to understand the
goal of a hand function activity. If not, the child will
not have a context for use of the skills the therapist is
attempting to facilitate. For example, the child who
cannot attend to two objects simultaneously will not be
able to grasp two objects simultaneously and therefore
will not bang two objects together. This child is not able
to stabilize materials with one hand while manipulating
with the other.
Opportunities for Skill Repetition and Practice
Motor learning theory emphasizes that skills are acquired
using specific strategies and are refined through a great
deal of repetition and the transfer of skills to other tasks
(Croce & DePaepe, 1989). Exner and Henderson
(1995) provide an overview of motor learning relative
to hand skills in children. Opportunities for practice of
a new motor skill are extremely important in moving a
skill from the level of needing conscious attention in its
use to the level of spontaneous and automatic use.
For practice of a motor skill to occur, either it should
be a skill that the child will automatically repeat inde-
pendently or planned practice opportunities should be
created. Older children with sufficient cognitive skills
and motivation may be able to be provided with a list
of specific skills to practice. When providing a child
with this type of “homework” activity based upon
therapy recommendations, the child tends to do best if
given written instructions and a method of recording
(e.g., a chart) when he or she practiced the skill and for
how many times. Teachers or parents or other family
members also can support practice opportunities. How-
ever, realistic expectations of parents are critical, par-
ticularly because parenting a child with a disability has
numerous challenges. Cronin’s study (2004) illustrates
the stressors on mothers of children with develop-
mental and other health issues. A key theme of many
of these mothers is the challenge of managing daily
routines. Therefore meaningful opportunities for skill
practice are most likely to occur when the therapist
works with the family to enhance the child’s occupa-
tional performance or create opportunities for practice
of motor skills within the context of normal occupa-
tional routines.
Importance of Addressing the Child’s Interests
As Pehoski (1992) notes, hand skills and interest and
motivation are intimately related. A child’s interest in
an activity—an activity that has meaning and signifi-
cance for the child—is critical for the child to be fully
engaged in the intervention process. Hand skill inter-
vention cannot be done to a child; it must be done with
the child’s involvement in the activities and with the
child’s belief that he or she can be successful in accom-
plishing the activities presented. When a child engages
in an activity with little or no attention to the task or no
intrinsic investment in the activity, little improvement
and carryover into other occupational tasks are likely.
Erhardt (1992) also makes the point that in planning
intervention for eye-hand coordination, the therapist
must take into account the child’s intrinsic desire to play
and the child’s cognitive development because these
are the impetus for
“purposeful, goal-directed, eye-hand coordination behaviors”
(p. 23).
To address the issue of the role that motivation and
interest may have in therapy sessions, DeGangi et al.
(1993) conducted a study that focused on the child’s
active selection of activities used in the therapy session
versus therapist-selected activities. They compared

child-centered intervention, in which the adult
facilitates the child’s activities but the child selects the
activities from among those provided in a therapeutic
environment, with structured sensorimotor intervention
in which the adult directs the child’s activities. The child-
centered intervention seemed to result in more change
in the children’s fine motor skills, as measured by the
Peabody Fine Motor Scales, than the sensorimotor
program did, but the difference in gains between the
two approaches was not significant. DeGangi et al.
(1993) concluded that
“in practice, the therapy approaches used in this study may be
blended or sequenced one after the other for best results” and that
“this study provides preliminary evidence that children with
sensorimotor dysfunction benefit from approaches that elicit
adaptations to environmental and task demands through the use
of play and structured learning techniques as therapeutic
mediums” (pp. 782–783).
Case-Smith’s study (2000) of intervention for
preschool-age children also showed that play and peer
interaction are important factors in the outcome of
therapy for fine motor problems. In her study of
occupational therapy intervention for 44 children
across a school year, she found that in many cases
therapists used play and peer interaction activities
within therapy sessions that focused on fine motor
skills. The study findings support the conclusion that
“play activities and peer interaction [within therapy sessions]
were predictive of the fine motor/visual motor outcomes”
(p. 377).
Case-Smith notes that play activities are important in
children’s motivation and focused involvement with
activities and contribute to practice of skills in a variety
of meaningful situations.
The remainder of this chapter addresses structured
approaches for hand skill intervention, primarily
through or in conjunction with play and other occupa-
tional tasks of children. The importance of the environ-
ment also is stressed.
GOAL SETTING FOR HAND SKILL
INTERVENTION
CONSIDERATIONS IN SETTING GOALS
The assessment process used by the therapist with the
child and family has an impact on the framing of goals
and interventions. As stated in the Occupational Therapy
Practice Framework (2002)
Intervention for Children with Hand Skill Problems • 243
“‘engagement in occupation’ is viewed as the overarching out-
come of the occupational therapy process” (p. 615).
This focus emphasizes occupational performance as the
primary goal of intervention.
Weinstock-Zlotnick and Hinojosa (2004) describe
an approach to intervention that allows a focus on foun-
dational issues (often called a “bottom-up” approach),
as well as occupational performance (often called a
“top-down” approach). They note
“it is the ultimate goal of therapeutic intervention to encompass
both poles of the component-function continuum, wherein, both
the ‘top’ and ‘bottom’ of an individual’s functional limitations
are reached and successfully achieved or at least addressed”
(pp. 556–557).
Thus the most effective approach when a child
shows potential for motor skill improvement is to keep
the child’s occupational performance as the central
concern while addressing particular motor skills that
support the occupational performance. Generally,
progress in particular motor skill areas is important
only when the skills are or will be used within the
child’s daily activities.
For both occupational performance and motor skills,
consideration of the typical sequence of skill develop-
ment approach is important, but the developmental
sequence only rarely can be translated into or used as
the primary guide for intervention goals. For example,
in identifying development of a fingertip grasp or skill
in using palm to finger translation as a goal area, the
therapist should determine if the child has the develop-
mental readiness for the skill and also relate this motor
skill to specific occupational tasks that are develop-
mentally appropriate for the child, such as playing a
game with peers or handling money to purchase items
independently. Similarly, for example, increasing the
child’s ability to do palm to finger translation with
more objects has meaning only if the child needs to be
able to use a more complex level of hand skills. Deter-
mining the appropriateness of establishing a goal for a
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”
can be useful in designing an intervention plan with
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
which the child is still missing many prerequisites. Skills
not within reach may be skills that the child needs. If
so, adaptations or compensations may be needed to reach
these goals. When attempting to improve fine motor
skills, however, the child needs to have the prerequisite
244 Part III • Therapeutic Intervention
skills or be able to be facilitated in using a particular
fine motor skill before that skill is established as a goal.
Setting goals for hand skills intervention involves prior-
itizing the areas that should be addressed while deter-
mining those areas most likely to be responsive to
direct intervention and those that may need adaptation.
Collaborative goal setting with others is vital to the
success of the intervention program. Goal setting with
parent(s) and teachers (when appropriate) has been
recognized as a central consideration in intervention.
The child’s perspective on intervention also is impor-
tant. Although there is little documentation of the
role of the child in selecting intervention goals and
methods, Missiuna and Pollock (2000) found that
young school-age children were able to identify occu-
pational tasks with which they have difficulty and, based
upon this assessment, could choose occupational therapy
goals and priorities. Although these goals and priorities
may not necessarily converge completely with the
parent’s goals and priorities (Missiuna & Pollock,
2000), such collaborative goal setting with children as
young as possible is important for the intervention-
planning process.
SHORT-TERM GOALS FOR HAND SKILL
I NTERVENTION
Typical childhood occupational performance problems
that are likely to have a hand skills component, and
therefore are likely to be reflected in short-term goals,
include the following:
• Poor handwriting
• Difficulty managing materials in the classroom
• Limited constructive play skills
• Avoidance of play with peers
• “Messy” eating
• Slow dressing, with avoidance of fasteners
• Lack of independence in getting ready for school
• Difficulty with hygiene skills
The following represent examples of short-term goals
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
“bottom-up” or medical-model intervention) or with a
focus on the task that the child will be able to accom-
plish (more in keeping with a “top-down” or school or
home-based model of intervention). In either case, the
therapist addresses the occupational performance goals
with specific attention to facilitating improvement in
the child’s hand skills. Measurement of goal attainment
needs to consider both the child’s specific hand skills
and use of these skills within important occupational
performance areas. The challenge with adding specific
occupational tasks to the motor skill goals is that use of
the motor skills can appear narrower than actually
desired. The therapist typically focuses on the child’s
ability to generalize new motor skills across a range of
occupational tasks. Therefore when possible, meaning-
ful evaluation of the child’s effective use of new motor
skills includes a range of activities. Consistency of skill
use also needs to be a consideration in assessing inter-
vention effectiveness.
The goals listed in Box 12-1 have the motor skill
identified first, suggesting an emphasis on the motor
skill. For examples of goals that have occupational tasks
identified first with motor skills included as related to
these tasks, see Exner (2005).
RESEARCH RELATED TO HAND
SKILL INTERVENTION
A growing body of research evidence is lending support
to the value of intervention for hand skill problems in
children. Children with mild motor involvement such
as developmental coordination disorder or clumsiness
have shown improvement in various motor skills (Case-
Smith, 2000; Shoemaker et al., 2003), as well as children
with various degrees and types of cerebral palsy
(Barnes, 1986, 1989a,b; Bumin & Kayihan, 2001; Law
et al., 1997). The study by Stiller, Marcoux, and Olson
(2003) was less conclusive about test findings of im-
provement in hand skills, although parents and teachers
reported improvement in the children after inter-
vention. Although individual sessions of the therapist
and child appear to be the most common form of
intervention, studies by Case-Smith (2000) and Bumin
and Kayihan (2001) had positive findings associated
with small group intervention with children. This type
of intervention can support engagement in playful
activities, repetition of motor skills, and opportunities
for social skill development (Exner, 2005). In addition,
small group intervention can be more cost-effective
than individual interventions or allow for two or more
sessions for the same cost as an individual session.
INTERVENTION STRATEGIES FOR
HAND SKILL PROBLEMS
In planning an intervention session, the therapist con-
siders the specific hand skill goals while simultaneously
considering other goals for the child, the child’s interests
and abilities, and the child’s ability to participate in the
selection of materials or activities for the session. Each
session’s activities must be suited to the particular
child; activities that are particularly good for one child
may be of little interest to another. The child’s motiva-
tion to participate in the activities is an essential factor
to consider.

Sample Short-Term Goals for
Grasp, Voluntary Release,
BOX 12-1
In-Hand Manipulation, and
Bilateral Hand Skills
SAMPLE SHORT-TERM GOALS FOR GRASP
The child will:
• Use a power grasp on tools such as eating utensils,
toothbrush, hammer
• Modify use of a radial finger grasp according to
pressure requirements for small objects to pick up
and hold various finger foods
• Supinate the forearm slightly during approach and
maintain this during a radial finger grasp to allow for
visual monitoring of tasks such as putting items in a
cabinet, handling game board pieces, and opening
packages
• Use a full palmar grasp with wrist extension and
varying degrees of elbow flexion/extension while
completing dressing tasks
SAMPLE SHORT-TERM GOALS FOR VOLUNTARY
RELEASE
The child will:
• Release objects that are stabilized by a supporting
surface (e.g., a peg into a pegboard or a spoon into
a dishwasher container)
• Voluntarily release lightweight objects onto a flat sur-
face (e.g., a class paper into the teacher’s desk tray)
• Place an object within 1 inch of other objects with-
out disturbing these by using minimal finger exten-
sion (e.g., a glass on a table or a container in a
medicine cabinet)
• Release objects while maintaining the forearm in
midposition to allow for upright object placement
SAMPLE SHORT-TERM GOALS FOR IN-HAND
MANIPULATION
The child will:
• Use shift skills in handling fasteners on clothing
• Use shift skills in managing paper for cutting with
scissors
• Use translation and shift skills in handling money
• Use simple rotation (or complex rotation) to
position a crayon or pencil appropriately in the hand
• Use simple rotation to open and close bottles
• Use translation skills (with or without stabilization)
to finger feed effectively
SAMPLE SHORT-TERM GOALS FOR BILATERAL
HAND SKILLS
The child will:
• Carry objects with both hands (e.g., carry a bag of
groceries or a tray of food)
• Stabilize an object using grasp, while manipulating
with the other hand (e.g., grasp a crayon box while
putting crayons into it)
• Stabilize materials effectively with one hand while
manipulating with the other (e.g., stabilize paper
effectively with one hand while handwriting)
• Manipulate objects with both hands simultaneously
(e.g., shifting paper with the nonpreferred hand
while using scissors to cut with the other hand)
Intervention for Children with Hand Skill Problems • 245
In addition to a variety of nonmotor elements the
therapist considers in planning intervention, the
therapist usually attempts to select activities to address
a variety of motor factors that contribute to selected
hand skills. For example, when the focus is upon the
child being able to use a radial digital grasp pattern
with varying amounts of pressure, intervention may
address radial-ulnar dissociation within the hand, wrist
stability, ability to extend the fingers with the wrist in a
neutral position, ability to grade finger opening for an
object, ability to use a small range of finger flexion
(rather than full flexion), or ability to sustain inter-
phalangeal (IP) extension with metacarpal-phalangeal
(MP) flexion so as to grasp a flat object. The therapist
perhaps should prepare the child to work on these skills
by addressing other motor-related issues such as tone,
strength, cocontraction, and range of motion.
The amount of time for intervention not only
influences the number of different skills that may be
addressed, but also the number of practice oppor-
tunities. Within a session the therapist may focus on a
variety of hand skills or only one or two. The eight
areas outlined in the following may be addressed when
the therapist can work with the child directly for 45 to
60 minutes; the order of the suggested interventions is
such that skills can build on one another. Obviously
some areas are omitted or addressed only briefly when
a shorter session is used or when intervention is being
provided in a classroom setting or through consulta-
tion. However, the therapist always needs to consider
the intervention setting and its features (the environ-
ment), attempt to create a supportive physical environ-
ment, and develop or provide cognitive and social
supports for the child’s performance. In addition, the
child’s positioning and ways in which the skills may be
integrated into occupational performance must be con-
sidered for each intervention session. Box 12-2 lists a
typical sequence of areas that may be addressed within
an intervention session that focuses on hand skill
problems.
A Typical Sequence of Areas That
May Be Addressed Within an
BOX 12-2
Intervention Session That Focuses
on Hand Skill Problems
1. Positioning of the child and the therapist
2. Tone and postural/proximal control
3. Tactile/sensory awareness/discrimination
4. Isolated arm and hand movements
5. Grasp
6. Voluntary release
7. In-hand manipulation
8. Bilateral hand skills
9. Integration of skills into occupational performance
246 Part III • Therapeutic Intervention
In sessions that focus on improving the child’s hand
skills in one or more of these areas, the therapist’s role
is to:
• Address positioning for task engagement
• Select materials that allow for ease of handling
• Provide sufficient time for task completion
• Use (if appropriate) cuing for these hand skills
While promoting improved motor control, attention
also can be given to addressing tactile or proprioceptive
awareness and discrimination, as well as related per-
ceptual and cognitive, play, and social skills.
POSITIONING OF THE C HILD AND THE
THERAPIST
Positioning should be specifically selected to present
the type of postural support or challenge that the
therapist believes is most desirable for the hand skills
that will be addressed. In a specific session, it may be
appropriate to work on a particular skill first with the
child in a relatively non-demanding position, then work
on the same skill in a somewhat more posturally
demanding position. For other children, working with
them in the position in which they will be using the
hand skill(s) being emphasized is the better option.
The most commonly used position for intervention and
functional use of fine motor skills is sitting; standing is
the next most common body position for use of hand
skills. Supine, side lying, and prone may be used for
their therapeutic benefits, particularly with children
who have limited skills or need to improve proximal
stability.
For the child with very limited motor skills, the most
appropriate position for working on arm-hand skills
may be supported supine or supported side lying. In
these positions skills such as visually looking at the
hand(s), using a palmar grasp pattern, sustaining grasp
during arm movements, sustaining grasp with the wrist
in neutral extension, reaching followed by gross or
palmar grasp, and using crude voluntary release may be
addressed.
The prone on elbows or forearms position can be
useful for assisting children to develop selected hand
skills. If the child has some difficulty with stability,
emphasis may be placed on the child co-contracting at
90 degrees of elbow flexion, without pulling into more
flexion. Being able to sustain a position of 90 degrees
elbow flexion is helpful for effective hand use in most
tabletop activities; in addition, some standing activities
require that the forearm remain on or near the work
surface. To stabilize materials the nonpreferred hand
needs to exert pressure into elbow extension while
maintaining 90 degrees of elbow flexion. In addition,
forearm supination and grasp with the wrist in neutral
or slight extension may be addressed in this position.
For these hand skills to be carried out in the prone
position, activities that require a relatively small range
of movement must be used. Children usually can
use a wider range of movement in sitting or standing
positions.
Sitting at a table is often preferred over other posi-
tions for hand skill intervention. When a table is used,
it should be at or slightly above elbow height. Using a
lower table tends to facilitate upper trunk flexion, which
promotes humeral internal rotation. Using a higher
table places the child’s arms in abduction and internal
rotation. Internal rotation leads to use of elbow flexion,
pronation, and wrist flexion. A table at elbow height
makes it possible for the child to use humeral adduction
and slight external rotation, which make supination
and wrist extension easier to use.
Sitting in a chair without a table (or for some
children, sitting on the floor or on another surface) also
may be useful, particularly if the goal is to improve skill
in moving objects in space while maintaining a good-
quality grasp. When a table is not in front of the child,
the therapist often has more opportunity to do both
proximal and distal handling to facilitate the child’s
movements into external rotation, elbow extension,
supination, wrist extension, and finger flexion or
extension.
Standing is an important position to use when
working on some hand skills if the child has the
postural control to manage standing and hand use.
Generally, children find it easier to develop a degree of
proficiency when carrying out the skills in sitting, then
to begin using these skills in standing. Examples of skills
that may benefit from a sitting to standing progression
are buttoning, engaging the bottom of zippers,
brushing teeth, and handling money. For many of these
skills the child initially may find it easier to accomplish
the fine motor tasks while standing by leaning against a
surface to obtain some stability. Gradually the use of
this support surface may be decreased.
TACTILE OR SENSORY AWARENESS OR
DISCRIMINATION
Because a sensory problem, if present, is a major factor
in use of hand skills, attention to tactile or propriocep-
tion is a central element—and may be the major
focus—of a hand skill intervention program for many
children. For children with tactile defensiveness, the
therapist should begin intervention with a focus on
decreasing tactile defensiveness, because children with
tactile defensiveness are aversive to any other inter-
vention activities if they are intolerant to touch from
objects or the therapist. Activities involving firm pressure,
including weight bearing, pushing large objects with
the hands, and squeezing objects, can be useful in

Some Typical Activities Used for
BOX 12-3 Sensory Awareness and
Discrimination
1. Rubbing lotion on the fingers one at a time
2. Finding objects in beans, rice, or sand (graded
finger movements are used to get the grains of rice
or sand off the objects)
3. Pulling pieces of clay off a ball of clay
4. Pushing fingers into therapy putty or clay
5. Stretching rubber bands around the fingers
6. Playing games to identify objects held in the hand
dampening the over-responsiveness to light touch that
is common during grasp, release, and manipulation
activities.
For all children who have a program for hand skill
intervention, attention to tactile discrimination can
precede and also be incorporated into a variety of
activities designed to enhance hand skills. However,
when the child has significant tactile discrimination
problems, the therapist should make sensory issues a
key focus during an intervention session, rather than let
tactile input be only another dimension of the motor
activity as it can be for children with milder sensory
problems.
Typical activities used for sensory awareness and
discrimination are included in Box 12-3.
TONE AND POSTURAL OR PROXIMAL
CONTROL
Postural control is a significant consideration in inter-
vention with many children who have hand skill diffi-
culties. Head control, trunk control, prone skills, and
sitting skills often are problem areas for these children.
If the therapist has specific goals or the child needs
intervention to allow for more effective hand place-
ment in space, postural control needs to be addressed
next. Boehme (1988), Nichols (2005), and Exner
(2005) provide activity suggestions for this area.
Barnes’ studies (1986, 1989a,b) have provided some
empiric data in support of using upper extremity weight
bearing to improve hand function in children with
spastic cerebral palsy. In her single-subject studies she
found that extended-arm weight bearing increased the
children’s use of wrist extension for initiation of grasp
and during voluntary release. In her first study (1986),
she found that reach with an extended elbow also
increased after weight-bearing intervention. In a later
study (1989a), she did not find an increase in elbow
extension but did find an increase in index finger
extension during initiation of grasp. Supination and the
Intervention for Children with Hand Skill Problems • 247
quality of grasp did not improve as a result of the
weight-bearing intervention. Thus the components
that changed as a result of the weight-bearing interven-
tion were those inherent in the weight bearing itself.
These components are important for good-quality
hand function and should be emphasized. However,
intervention that specifically focuses on supination and
hand function is needed also. The focus of the re-
mainder of this chapter is primarily on using structured
activities and some degree of handling to address
children’s hand skill problems.
ISOLATED ARM AND HAND MOVEMENTS
Children often find it easier to work on a new move-
ment component (a) in isolation from other movement
components, (b) when not handling objects, or (c) when
handling well-stabilized objects as compared with using
the movement component within an activity that has
objects that are not stabilized.
For example, supination and pronation, wrist flexion
and extension, and MP flexion and extension with IP
extension may be addressed by playing a game with the
child in which the child is tapping the table, or his or
her leg, or a drum and is only using the desired upper
extremity motion. The therapist may assist the child to
stabilize a more proximal body part (e.g., the humerus
if using supination or pronation, the forearm if using
wrist extension or flexion, the dorsum of the hand if
using MP flexion or extension). The therapist also may
assist the child with actively using internal rotation,
pronation, and wrist flexion, because even children
who tend to hold their arms in these patterns have
functional difficulty using active internal rotation,
pronation, and wrist flexion. They need assistance in
developing control over the movements, as well as
assistance in holding in a more externally rotated or
extended or slightly supinated position.
Supination is a particularly difficult movement com-
ponent for children with abnormal tone. Even children
with only slightly low tone tend to stabilize in full
pronation when engaging in fine motor tasks. Full
pronation is functional for palmar grasp patterns, but
use of pronation when precision grasp patterns or
object manipulation are needed interferes significantly
with thumb mobility and distal finger control. Being
able to hold various degrees of supination is critical for
higher-level hand skills. Full supination is helpful in
performing activities, but the most important range of
supination for functional skill use is between full
pronation and midposition. The ability to hold at any
point within this range is important. During most skills
that involve controlled use of the radial fingers and
thumb, the forearm is in approximately 30 to 45 degrees
of supination.
248 Part III • Therapeutic Intervention
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
great deal of flexion. Supination can be observed as
babies bring their hands and toys to their mouths when
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
varying degrees of supination while weight shifting.
Gradually babies use more supination in sitting with
the elbows in about 90 degrees of flexion. For example,
by about 8 or 9 months of age, the normally devel-
oping baby can bang two objects together; this skill
illustrates at least two aspects of motor development
(and other areas of development as well): the ability to
use a finger surface grasp and the ability to hold at least
one forearm in midposition so that the surfaces of the
two blocks can come together. In another month or
so the baby is able to clap the hands together, thus
demonstrating the ability to sustain full finger exten-
sion with supination to midposition in both hands.
Babies also begin to use this range of supination (0 to
90 degrees) to carry out simple activities such as
holding a cup, finger feeding, and visually inspecting
objects they are holding. The baby now can reach with
supination to midposition. When the baby is reaching
laterally (using abduction), a greater degree of supina-
tion may be observed as compared with forward
reaching (using shoulder flexion).
Specific suggestions for enhancing supination, in
general order from least to most difficult, include the
following:
1. Encourage mouthing of toys (if age appropriate)
and finger feeding.
2. Facilitate supination with the forearm on a surface,
such as in weight bearing on the floor or on a mat
or while seated at a table. While the child is sitting,
the therapist may find it helpful to place an object
in the child’s hand with the child’s forearm
pronated, then use his or her hand to stabilize the
ulnar border of the child’s forearm so the child has
a surface to work against for the rotation (and so
that the child can see the object placed in the hand)
(Figure 12-1). This strategy also may be helpful if
Figure 12-1 Therapist facilitates the child’s use of
supination by providing stability at the ulnar border of the
child’s forearm and cues the child to look at the object in
the hand.
the child attempts to compensate for difficulty with
supination by using wrist hyperextension.
3. Encourage the use of 45 to 90 degrees of
supination followed by grasp of an object with the
elbow in 90 degrees of flexion, with at least the
elbow supported on a surface. The object should
be presented in a vertical orientation to facilitate the
use of forearm rotation. Some children respond
well to the verbal cue “keep your thumb up”
because this provides them with visual information
about the desired arm or hand position. The child
may be encouraged to sustain this position if he
or she must transport the object a short distance
before placing it into a container or board that
requires the forearm to be held in supination. An
example of this sequence is reaching and grasping
large birthday candles, then putting them into a
pretend cake. If the child can accomplish supination
to midposition with both hands, banging objects
together may be possible. He or she also may be
encouraged to hold large blocks or nesting cans by
putting one hand on either lateral side of the block
or can and stacking these. In this activity the child
is being asked to supinate, then initiate grasp and
maintain the supination while engaging in a simple
activity.
4. Encourage lateral reach followed by grasp. Most
children with limited use of supination find it easier
to combine humeral abduction with external
rotation and supination than to use humeral flexion
with external rotation and supination. Perhaps
objects initially should be presented laterally to the
child’s body to allow the child to use abduction but
to move out of internal rotation (and into external
rotation), which allows for the use of supination.
Objects may be presented low (relative to the
child’s body) initially and gradually raised higher

Figure 12-2 An object is presented laterally to the
child’s body and lower than shoulder height to facilitate
the use of external rotation and supination during
reaching.
(Figure 12-2). The therapist may find it possible to
gradually present objects diagonally to the child’s
body (in 60 degrees of horizontal abduction, then
45 degrees, then 30 degrees) to assist the child in
moving toward a more anterior reaching pattern.
5. Encourage forward reach using shoulder flexion
and some degree of external rotation. The object is
positioned in front of the child’s shoulder, not at mid-
line. The object may be placed anywhere between the
child’s leg (in sitting) and the shoulder, depending
on the child’s ability to control external rotation
and supination while completing the reach. With
increasing height of the object in front of the child’s
body, the child will have a greater tendency to sub-
stitute with shoulder elevation, humeral abduction,
and internal rotation. Positioning of the object at
the optimal height for the child and using slight
facilitation at the child’s elbow to help the child
initiate and complete the external rotation during
the reach may help the child to achieve the supina-
tion needed.
6. Encourage reach to midline, following the strategies
suggested for reaching in front of the shoulder.
7. Facilitate reach across midline, following the
strategies suggested for reaching in front of the
shoulder.
The therapist who is working with a child on
supination, as with any other skill, needs to be sensitive
to the child’s zone of proximal development in
determining the most appropriate level or levels for use
in intervention. The therapist may find it possible to
Intervention for Children with Hand Skill Problems • 249
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
child, the therapist should:
1. Assess the child’s current use of a wide variety of
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
affecting the child’s hand function, the more specific
can be the intervention. The therapist needs to deter-
mine if an opposed grasp pattern is possible for the
child, and if so, the sizes of objects with which it can be
used (e.g., larger, medium-size, or small and tiny ones).
Some children can functionally use an opposed grasp
pattern on larger objects but not on small or tiny ones
because of the lesser degree of stability that these
objects provide and the necessary index finger control.
For some children, use of the intrinsic muscles of the
hand is particularly difficult. These children may be able
to use the long finger flexors and extensors (e.g., a
palmar or hook grasp) but be unable to effectively use
the intrinsic muscles of the hand to allow for more
variety and function in grasp. Difficulty with intrinsic
muscle control may be particularly obvious if a child is
unable to hold a ball using a spherical grasp (which
requires the combination of long flexor activity with
dorsal interossei and lumbrical activity) or to hold a
piece of paper with a pattern of MP flexion and IP
extension (which requires use of the palmar interossei
and lumbricals). In addition, many children lack
adequate thumb stability for opposition; instead they
substitute with thumb adduction. Some children are
unable to activate any thumb abduction or opposition
as their thumbs are pulled into adduction by an over-
active adductor pollicis.
In addition to the outcome of an analysis of the
child’s functioning, information from an analysis of the
child’s functional needs should be considered in deter-
mining the types of grasp patterns to be emphasized in
250 Part III • Therapeutic Intervention
intervention. Some children have an adequate grasp
with the finger pads but are not able to effectively use
a full palmar grasp pattern for many dressing activities.
Some children have only a palmar grasp pattern and
thumb adduction, so they cannot pick up small or tiny
objects in a functional manner. Thus activities such as
finger feeding, cup drinking, and fastener use are nega-
tively affected. Grasp use within functional activities,
not only grasp on standardized test items, should be
assessed as a basis for intervention planning.
General Intervention Principles for Grasp
The following general principles are suggested for
intervention for grasp problems.
If fisting is a problem, voluntary hand opening needs
to be developed before setting any other goals for grasp. In
children who have limited ability to voluntarily open
their hands, the priority is voluntary hand opening and
being able to sustain some degree of finger extension
with arm movement (if this seems to be within their
zone of proximal development). For children whose
hands are held in a fisted position and who need
maximal assistance in obtaining and even briefly main-
taining hand opening, the goal of grasp intervention is
a greater degree of voluntary hand opening and, if
feasible, initiating and sustaining a palmar grasp pattern
with changing arm positions.
Upper extremity weight bearing may be used to
facilitate finger extension with wrist extension, but in
children who have marked fisting, weight bearing with
open hands perhaps should be used cautiously. Most of
the children with marked fisting do not have sufficient
length in their finger flexors to tolerate this position
without compromise in the finger positions used. In
this type of weight bearing the therapist must control
both the thumb, which typically is pulled into
adduction, and the fingers, which may pull up into a
boutonniere deformity position. Weight bearing on a
curved surface may be more effective than on a flat
surface, or the therapist may wish to consider use of a
weight-bearing splint or other device (Smelt, 1989).
Weight-bearing activities that do not ask the child to
assume full body weight may be more effective. An
example with the child in a sitting position is to assist
the child with hand opening, then move the arm into
an extended position so that the hand is placed on the
floor or to the side or front on a wall surface. This type
of position may allow for some degree of weight
bearing while minimizing the abnormal positioning of
the fingers and thumb that may occur in a full weight-
bearing position.
Rather than focusing specifically on hand opening,
encouraging a greater range of arm movements while
remaining as relaxed as possible may help the child to
open the hands and maintain them open. Tactile or
proprioceptive input to the child’s arms and hands can
be used directly with this technique. Emphasis on arm
movements often is most easily accomplished with the
child supine. In this position the child can be provided
with opportunities to see his or her hands and bring
both hands together, which are simple activities that
these children have had little opportunity to do. As the
child brings the hands together, the therapist can
encourage the use of supination with elbow flexion.
The child may be assisted with touching stuffed animals
with fisted hands, an activity that does not require that
the hands be open. Activities that encourage the child
to dissociate the two sides of the body may be
incorporated, such as having the child touch the stuffed
animal’s ear with one hand and his or her own ear with
the other hand. In this way one elbow is more extended
and the other is more flexed. The child may be
encouraged to assist with rubbing lotion on one arm
with the other hand to facilitate crossing midline and
hand contact on the body while the elbow position is
changing.
During these activities to promote active arm move-
ment, the child’s hand often begins to open or at least
becomes less fisted, and the therapist can begin activities
to encourage a full palmar grasp pattern and facilitate
changing arm positions while maintaining this grasp. If
the child’s fingers and thumb remain somewhat flexed,
techniques recommended by Boehme (1988) for
facilitating hand opening may be used.
Once the child has some degree of hand opening in
a supine position, it may be possible to change the child
to a sitting position and carry out similar activities. The
change in body positions often presents the next level
of challenge to the child. Partial or full weight bearing
may be added to reinforce the hand opening, if tolerated
by the child.
The stability of the child and of the objects used is
critical. The stability of the child, the surface on which
the object is presented, and the object itself are primary
considerations in planning intervention for grasp. This
principle is supported by the findings of Hirschel,
Pehoski, and Coryell (1990). In their study babies who
were beginning to develop control of a particular grasp
pattern were most successful when grasping from a very
firm surface and less successful from an unstable sur-
face. As the child improves in his or her ability to grasp
from a surface, the therapist can grade the activity by
providing less and less stability.
Object characteristics and orientation of objects
during presentation are important variables. The size,
shape, weight, texture, and slipperiness of the objects
selected for use in intervention must be given careful
consideration. Round objects, such as dowels, tend to
be held in a palmar grasp unless the child has good
stability in the fingers and thumb and can maintain a

grasp pattern by opposing the thumb to several finger
pads. Therefore many children can handle blocks and
other objects with straight sides more effectively than
they can handle round objects. Children who do not
have good internal stability in their hands should not
be expected to hold unstable objects (round, squishy,
or lightweight ones) with control in any pattern other
than a palmar grasp.
Grasp of small or tiny objects should not be a
priority for all children. An opposed grasp can be
introduced to the child with larger objects, particularly
if the child has sufficient hand expansion to accom-
modate the object. An opposed pattern is used to grasp
items such as a cup (a cylindrical grasp), a ball (a
spherical grasp), a telephone, and a large block. In
many of these opposed grasp patterns the thumb is
opposed to two, three, or all four fingers. Some
children with disabilities can be assisted in developing
skilled use of all types of opposed grasp patterns, as well
as the power grasp and the lateral pinch. Therefore the
pincer grasp need not be considered the highest level or
most important grasp. For many children less attention
should be paid to the pincer grasp and more attention
given to helping them develop a variety of functional
grasp patterns.
Supination and wrist stability almost always need
attention. Problems with supination tend to be evident
when the child needs to use grasp patterns that require
more precision, such as a three-jaw chuck (see Glossary),
a pincer, or a lateral pinch. These problems may be
addressed through use of the strategies suggested
under Isolated Arm and Hand Movements. Problems
with wrist stability must be addressed before or in con-
junction with specific interventions for grasp. Wrist
stability may be addressed through use of weight-
bearing techniques and through emphasis on devel-
oping a palmar grip (Boehme, 1988). Wrist extension
tends to be used more when holding objects in a full
palmar grip than in patterns with only the finger
surfaces or pads involved. The size of the object to be
used for a palmar grip perhaps should be explored with
the child; some children use more wrist extension with
small-diameter objects, whereas others use more wrist
extension with somewhat larger-diameter objects.
Emphasizing better-quality grasp without reach is
likely to be more successful than combining reach and
grasp. Grasp can be addressed in an intervention session
without asking the child to first reach, and then grasp.
When reaching before grasp, the child must preposition
the hand during movement of the arm, which is usually
moving against gravity. Generally, children show better
wrist, finger, and thumb prepositioning for grasp when
the object is presented close to the hand so that arm
movement is not needed simultaneously with hand
movement.
Intervention for Children with Hand Skill Problems • 251
Children benefit from developing skill in carrying
objects while maintaining quality of grasp before using
that grasp within an activity. Many children have
difficulty transporting an object while sustaining a
good-quality grasp pattern. The child can be assisted in
developing the ability to maintain a stable grasp pat-
tern, transport the object in space, and release it. After
this skill is developed, the child is more prepared to
initiate and use the grasp skill within a more challeng-
ing activity.
Inconsistency in performance is to be expected. As skills
are emerging, inconsistency in execution of the skills is
common; therefore consistency in performance is to be
expected. This clinical observation is supported by
empirical data on development of grasp patterns in
nondysfunctional infants. Hirschel et al. (1990) found
that normal 13- to 14-month-olds were consistent in
the pincer grasp pattern they used. However, 7- to 8-
month-olds and 10- to 11-month-olds tended to use a
variety of grasp patterns when attempting to obtain the
object.
Developing Radial Finger Grasp Patterns
The following strategies are useful for children who can
voluntarily grasp and release objects but who:
1. Lack good quality in one or more grasp patterns, or
2. Are not able to use grasp patterns involving distal
finger control.
These radial finger grasp patterns include a lateral
pinch or grasp with one or more fingers contacting the
object and thumb opposition. Further preparation of
the hand may be needed before using these strategies.
Objects selected should be appropriate for the grasp
pattern being addressed but also should be presented
within the context of an activity that the child finds
interesting. In the following sequence the emphasis is
first on assisting the child with grasping, although not
asking the child to reach. Objects initially are stabilized
well when presented, then gradually presented with less
external stability, in response to the child’s develop-
ment of internal stability. Gradually reach and grasp are
combined.
The therapist should assess the grasp patterns used
by the child at each of the levels to determine the best
place to begin therapeutic intervention. Not all children
should begin at the first level described in the following
sequence. In a session the therapist may find it useful to
move back and forth between two or three levels. For
example, the therapist may give three object presenta-
tions at level 2, then, finding that the child’s perfor-
mance has deteriorated slightly, give two or three
presentations at level 1, then give a few at level 2 again.
It then may be possible to give a few presentations at
level 3 before finishing that aspect of the session with
other object presentations at level 2.
252 Part III • Therapeutic Intervention
Figure 12-3 To promote use of an opposed grasp
pattern, the therapist stabilizes the dorsum of the child’s
forearm and presents an object held with her finger pads
directly to the child’s fingers.
Level 1: Grasp from therapist’s fingers. The child is in a
sitting position (usually in a chair) with the humerus
adducted and the forearm stabilized on his or her leg
or on the table surface. The child’s hand is in front
of the shoulder, not at midline. The therapist holds
the object in his or her fingers and places the object
just at the child’s fingers (Figure 12-3). The child
positions the hand for grasp, then grasps the object
and carries it a short distance before voluntary release.
The therapist notes the degree and quality of wrist
extension and finger and thumb positioning in the
grasp. If the child does not use sufficient wrist exten-
sion, the therapist may find it helpful to stabilize the
dorsum of the child’s forearm and to hold the object
just slightly higher for the next object presentation.
If the fingers are too flexed, other preparation of the
hand to decrease tone may be needed before the next
object presentation. If the quality of the pattern
appears good, the therapist will probably find it
helpful to give several other presentations in this
manner to ensure that the child can consistently
maintain this quality before moving to the next level.
Level 2: Grasp from palm of therapist’s hand. The child’s
arm and hand are positioned as in the first level. The
therapist positions the object in the palm of his or
her hand with the hand sufficiently cupped to
stabilize the object. Then he or she places this hand
just under the child’s hand. In this way the child is
required to position the hand for grasp and grasp the
object that is just slightly less stabilized than when it
was in the therapist’s fingers. Again the therapist
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-
ration of the hand for grasp. Hand preparation is
often better with the object in front of the shoulder
because this position allows slight supination to be
more easily used.
Level 5: Grasp from surface, near midline. The child
now begins to work on grasping at midline while
controlling the hand, forearm, and elbow position.
The child is still not expected to control the humerus
against gravity while initiating the grasp pattern. The
therapist needs to explore the best distance from the
child’s body for the object. Typically a distance that
incorporates 120 degrees or more of elbow extension
is helpful initially. Then this distance can be varied as
the child develops increasing skill.
Level 6: Grasp with object off surface. At this level the
child needs to control the humerus against gravity,
including the degree of external rotation used. At the
previously described levels, external rotation and
supination could be assisted by the surface. Now the
therapist’s positioning of the object can help the
child orient the arm into slight external rotation and
the forearm into slight supination (as described in
the section on supination). Again, distance from the
child’s body can be varied, as can positioning of the
object in front of the child’s shoulder or at midline.
Additional intervention strategies may be needed for
the child who is working on grasping and holding flat
objects by using MP flexion and IP extension of the
fingers and thumb opposition or adduction. Activities
that involve finger adduction with extension, such as
rolling out clay while keeping all fingers together and
straight, finger games that involve finger abduction and
adduction, squeezing balls of clay until they are flat by
using the thumb pad against the entire pad of the index
and middle fingers, shaking dice in the palm of the
hand by cupping the hand (curving the transverse
metacarpal arch and the carpal arch), and games or

Figure 12-4 Use of a thick, flat object may assist the
child in developing grasp with metacarpal-phalangeal
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
than a power grasp in which the ulnar fingers provide
stability for the handle and the radial fingers are more
extended so that they can reorient the tool as necessary
(Figures 12-5 and 12-6). Not all children with motor
disabilities are able to develop a power grasp, just as not
all children develop a pincer grasp. However, for those
children who have the potential to use a power grasp,
development of this skill enhances their ability to be
more effective and efficient with many daily life tasks.
Usually children who have some degree of instability in
their hands but have reasonable thumb opposition and
finger control in grasping stable objects can develop a
power grasp.
Facilitating the child’s use of radial-ulnar dissocia-
tion within the hand can be helpful in preparing him or
her for use of a power grasp. A useful strategy in this
skill development is to assist the child with retaining
one or more objects in the middle to ulnar side of the
palm with flexed ulnar fingers while having the child
use the radial finger(s) and thumb to grasp and release
objects. Initially the object held in the ulnar side of the
hand might be medium sized so that the degree of
Intervention for Children with Hand Skill Problems • 253
Figure 12-5 Young child demonstrates use of a palmar
grasp on a “tool.”
Figure 12-6 An older child demonstrates use of a
power grasp on a “tool.”
finger flexion necessary (and the degree of differen-
tiation in radial-ulnar finger positions) is less; gradually
the size of this object may be reduced. Similarly, the
size of the objects grasped with the radial fingers and
thumb may be decreased as the child’s proficiency
increases.
The therapist also may consider carefully selecting or
modifying the diameter and shape of objects to be held
with a power grasp. Tools with thin or rounded handles
are more difficult for the child to grasp well; children
with instability may grasp handles that are slightly
larger in diameter or have ridges or indentations more
effectively. Also the degree of power needed within the
activity should be graded because increased demands
for power tend to cause the child to move from a more
refined power grasp pattern to a palmar grasp pattern.
After grasping an object, the child may use the
object to complete a task (e.g., use a hammer to pound
a nail), use in-hand manipulation to adjust the object
after grasp (e.g., turn a key to fit it into a lock), or
254 Part III • Therapeutic Intervention
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-
tary release problems in children with involuntary move-
ment or tremors. However, instability also may negatively
affect voluntary release in children with low or high
tone who do not have excess movement. For effective
voluntary release the child needs to release where and
when he or she wants to do so. The arm is important
in transporting the hand to the location for release.
Holding the arm in a stable position during hand
opening contributes to accurate timing of the release.
Several strategies may be used with children who
have stability problems that affect voluntary release.
Upper extremity weight bearing, particularly on
extended arms, may help the child to develop improved
cocontraction at the scapulohumeral area, elbow, and
wrist. Reaching activities that involve touching a
desired target and holding that position for a few
seconds also may be helpful, particularly if the reaching
is done in a variety of planes of movement. For the
child who has marked instability or needs to function
despite some instability, teaching the child to stabilize
the arm against the body or on a surface before open-
ing the hand may be a helpful compensatory strategy.
Many of the stability problems that affect voluntary
release are related to problems with wrist stability
during finger extension; stabilizing in wrist extension
allows finger extension without using tenodesis action
and supports accuracy of release. Some children show
wrist flexion during elbow flexion, but they are able to
voluntarily release with the wrist in extension if the
elbow is extended. For these children, and even those
who have significant flexor tone at the wrist and fingers
when the elbow is flexed, an effective strategy can be to
facilitate releasing objects away from midline and with
the elbow extended. As with the strategy discussed for
Figure 12-7 Allowing for elbow extension by placing a
container on or near the floor may encourage use of
wrist and finger extension for voluntary release.
facilitating supination, humeral abduction and external
rotation may make it easier for the child to use elbow
extension and slight supination, which may in turn
allow voluntary release with wrist extension to occur.
Releasing into a container placed on the floor, or at
least lower than the seat of the child’s chair, also may
allow the child with high tone or little voluntary con-
trol to learn to take advantage of gravity or at least relax
the finger flexors (Figure 12-7). Gradually the con-
tainer used for release can be brought onto a table
surface (if initially down low), closer to the child’s body
(if initially further away from the body), and closer to
midline (if release initially in front of the shoulder or
lateral to the child’s body). However, these strategies
are unlikely to be beneficial for the child who can
release with adequate control at the shoulder, elbow,
and wrist but has difficulty grading finger extension.
In addressing problems of voluntary release caused
by poorly graded finger extension, the therapist should
consider the quality of the child’s grasp. Voluntary
release quality can be no better than the quality of the
grasp. However, the quality of voluntary release can
be poorer than the quality of grasp. Therefore when
the child holds an object in a palmar grasp, voluntary
release is initiated with full extension (or almost full
extension) of the fingers. If, on the other hand, the child
holds an object with the finger pads, he or she may
release with just slight finger extension or excessive
finger extension may be seen.
Because voluntary release quality depends so much
on grasp quality, the two skills often can be worked on

effectively within the same activity. Certainly the
therapist must address the quality of the child’s grasp in
intervention for voluntary release problems. For some
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
emphasis is on enhancing the use of intrinsic muscle
activity to allow for more control in grading both grasp
and release patterns. For children who have mild
problems, attention to forearm stabilization in a slight
degree of supination during voluntary release may help
them place objects with more accuracy and without
bumping other objects with their hands.
As children develop more control with voluntary
release, the therapist can gradually decrease object
weight, stability, or size, and the size of the area used
for object placement. A study by Gordon et al. (2003)
suggests the value of such strategies. They investigated
voluntary release skills in children without disabilities
and children with hemiplegic cerebral palsy. The children
released objects onto both stable and unstable surfaces
at two different speeds. Although the children with
cerebral palsy showed difficulties with coordinating the
force needed during release, they did demonstrate the
ability to both improve speed and accuracy with cuing
and under a condition in which greater accuracy was
needed. Because the children also showed subtle
difficulties in voluntary release with the hand that was
believed to be noninvolved, Gordon et al. suggest that
“practicing release tasks with the non-involved hand first or
practicing bimanual tasks may enhance performance” (p. 247).
They suggest that the therapist could vary the task
demands to address accuracy and speed separately and
then introduce activities to combine varying degrees of
accuracy at different speeds. Eliasson and Gordon’s
study (2000) provides some evidence for children with
hemiplegic cerebral palsy being able to improve their
grading of the grip forces necessary to allow for a more
accurate release.
In keeping with these suggestions, children with
mild motor control difficulties may benefit by using a
variety of sizes of objects, including small ones, and
objects that are less solid (paper balls rather than solid
rubber balls, cotton balls rather than paper balls).
Inexpensive toys, which tend to be lighter in weight
than sturdy high-quality toys, can be particularly useful.
Games in which the accuracy of placement is important
and obvious to the child can be selected or developed.
For example, some children’s game boards have large
areas for the game pieces, whereas others have small
areas. Activities that involve the child holding tweezers
to grasp and release objects may help the child focus on
graded pressure and graded release with a steady arm
Intervention for Children with Hand Skill Problems • 255
position. Also, the therapist can address precise grasp
with the child when using the tweezers and other small
materials.
I N-HAND MANIPULATION
In-hand manipulation skills seem to be the most com-
plex of all fine motor skills. In-hand manipulation
involves the adjustment of objects by movements of the
fingers so that the objects are more appropriately placed
within the hand for the task to be accomplished (Exner,
1990a, 1992). In-hand manipulation occurs within one
hand. Five basic types of in-hand manipulation skills
have been described (Box 12-4) (Exner, 1992).
Each of the in-hand manipulation skills may occur
with no other object in the hand at the time of the
manipulation or while the ulnar fingers are holding one
or more objects in the center or ulnar side of the palm
(Exner, 1990a, 1992). When other objects are held in
the hand during manipulation, the skill has the term
added “with stabilization.”
Although almost any child with a disability that affects
motor or sensory functioning has difficulty with in-
hand manipulation skills, not all of these children are
candidates for intervention for in-hand manipulation
problems. To be considered for intervention specifically
for in-hand manipulation problems, the child needs
to have:
• Index finger isolation
• Good skills in basic grasp and release patterns
including the ability to grasp a variety of objects and
to accommodate the hands to these objects effec-
tively. The child needs to be able to grasp objects at
least on the finger surface, not only use a palmar
grasp.
BOX 12-4 Five Basic Types of In-Hand
Manipulation Skills
1. Finger-to-palm translation: Movement of an object
from the fingers to the palm
2. Palm-to-finger translation: Movement of an object
from the palm to the finger pads
3. Shift: Slight adjustment of the object on or by the
finger pads
4. Simple rotation: Turning or rolling the object 90
degrees or less, with the fingers acting as a unit
5. Complex rotation: Turning an object over (turning
it 90 to 360 degrees) using isolated finger and
thumb movements
From Exner CE (1992). In-hand manipulation skills. In J
Case-Smith, C Pehoski, editors: Development of hand skills
in the child (pp. 35–45). Rockville, MD, The American
Occupational Therapy Association.
256 Part III • Therapeutic Intervention
Other skills that are useful include:
• Supination to at least midposition
• Thumb opposition
• Finger pad grasp patterns
• Radial-ulnar dissociation; this skill is important for
use of in-hand manipulation with stabilization of
other objects within the child’s hand.
In general, in-hand manipulation activities are realistic
only for children who have mild motor disabilities;
most children with moderate disabilities lack the ability
to use adequate grasp patterns and lack the associated
intrinsic muscle control to make in-hand manipulation
skills possible.
General Principles for Developing In-Hand
Manipulation Skills
The following are strategies that the therapist can use
in planning and implementing intervention for children
who have difficulty with in-hand manipulation.
Facilitate the use of the intrinsic muscles in grasp and
other hand functions. Many sensory activities (e.g.,
pulling clay) can be done in a manner that facilitates use
of the intrinsic muscles. Intrinsic muscle activity is
needed for in-hand manipulation and the grasp pattern
that is often used upon completion of object manipula-
tion. This grasp pattern reflects the child’s degree of
stability with the intrinsics; in-hand manipulation relies
on both mobility and stability of joints controlled by
the intrinsics. Emphasis on development and use of a
spherical grasp, a pattern that uses a combination of
long flexor activity and intrinsic activity and requires
cupping of the palm, also may be useful.
Encourage use of bilateral manipulation and skills
that substitute for in-hand manipulation. Infants
manipulate objects between the two hands (Ruff,
1984), and young children often use both hands to
turn objects over as well. They also spontaneously use
any supporting surface available to stabilize materials
during manipulation attempts. For example, young
children may use a table surface on which to turn a
puzzle piece, rather than picking up the puzzle piece
and turning it within the hand. Use of a supporting
surface during attempts at object manipulation allows
these skills to begin to emerge. However, as typical
children become more proficient with their skills,
bilateral manipulation and use of a supporting surface
are used less often and in-hand manipulation is used
more frequently. Thus substitution patterns can be
effective for handling many objects, but they are not
efficient, particularly when handling small or tiny
objects or when both hands should be manipulating
simultaneously (e.g., in shoe tying). Children who have
the potential to use in-hand manipulation can use
bilateral manipulation or surface support as a transitional
stage, whereas children who may not be able to develop
in-hand manipulation skills may use these alternative
strategies to successfully accomplish tasks.
Use small objects first with a new skill. Objects that are
small in relation to the child’s hand size are typically
easier for them to manipulate than are tiny or medium-
size objects. For example, children find nickels easier to
manipulate than dimes or silver dollars. Pegs that are
larger in diameter or length are more difficult to handle
than are pegs that are 1 to 11⁄2 inches long and 1⁄2 inch
in diameter. Tiny pegs are difficult to manipulate. In
addition, whereas 1-inch beads are easy to grasp, they
are more difficult for the child to manipulate than are
1
⁄2-inch beads. Therefore when introducing a new skill,
the therapist often finds it helpful to carefully select
small objects, so that the child can have sufficient finger
contact on the object during manipulation but does
not need to use all fingers to stabilize the object during
manipulation. As the child develops greater proficiency
in using a particular skill, the therapist can begin to vary
the size of the objects used by including larger and
smaller objects.
Use cues to facilitate the child’s use of in-hand manip-
ulation skills. Exner (1990b) studied the effectiveness
of cues in increasing 3- and 4-year-old children’s in-
hand manipulation skills. She found that, as a group,
the children improved significantly when given either
verbal cues to move the objects with the fingers or
demonstrations of the in-hand manipulation skills.
Although the children showed more improvement with
verbal cues for some skills and more improvement in
other skills with demonstrations, the use of palm-to-
finger translation with stabilization and rotation with
stabilization improved with both types of cues. How-
ever, not all children showed improved performance
with cues. As with other aspects of children’s hand
skills, the children’s zone of proximal development for
in-hand manipulation should be considered in setting
goals. In addition, the therapist needs to determine the
best mode for cuing for each child. During testing in
this study (Exner, 1990b) some children who were
provided with demonstrations (but not verbal cues)
seemed unsure of the aspect of the skill that they
should imitate. Therefore demonstration cues alone
may not be as helpful to the child as demonstration cues
with verbal cues. Other children may need only verbal
cues to remind them to try the skill with one hand.
Consider the sequence of skill difficulty. A general
sequence of in-hand manipulation skills has been devel-
oped (Exner, 2005) based on research by Exner (1990a);
Pehoski, Henderson, and Tickle-Degnen (1997a,b);
Humphrey, Jewell, and Rosenberger (1995); and Yim,
Cho, and Lee (2003). Children use finger-to-palm
translation earlier than other in-hand manipulation
skills. Palm-to-finger translation and simple rotation are
somewhat more difficult. Complex rotation is next in

terms of difficulty. Of the in-hand manipulation skills
without stabilization, shift is the most difficult, probably
because of its reliance on good-quality MP flexion
and adduction with IP extension. Generally, children
develop the ability to use an in-hand manipulation skill
with stabilization of other objects in the hand
simultaneously soon after they develop the ability to
use the same skill without stabilization. A list of sug-
gested intervention activities for each of the skill areas
is provided by Exner (2005).
Consequently in determining the type of in-hand
manipulation skills that will be the focus of intervention
for a child who has no skills in this area, the therapist
will probably find finger-to-palm translation the easiest
to help the child develop. Verbal cuing to the child to
“hide the object in your hand” may be helpful in
working on this skill. Pieces of dry cereal or coins are
good objects for the child to hide.
If the child is able to use finger-to-palm translation
with a variety of objects, the therapist may begin to
work on palm-to-finger translation and simple rotation.
For palm-to-finger translation the intervention strategy
that tends to be most effective is a backward shaping
approach. This is done by the therapist initially placing
the object on the volar surface of the child’s fingers at
approximately the distal IP (DIP) joint crease and (if
possible) asking the child to bring the object out to the
pads or tips of the fingers (Figure 12-8, A). For exam-
ple, a game piece may be placed on the child’s finger
surface, and the child asked to place the game piece on
a particular color square on the board. If verbal cuing
A B
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.
Intervention for Children with Hand Skill Problems • 257
is unlikely to be understood by the child, the therapist
needs to rely more heavily on the structuring of the
activity, for example, using a bank with a narrow slot or
a small container or a small surface that requires the
child to use a precision grasp (e.g., a pincer grasp) to be
successful with placement.
After the child is able to move objects well from the
DIP creases on the fingers, the object may be moved
closer to the proximal IP (PIP) crease but still kept on
the index or index and middle fingers (Figure 12-8, B).
Eventually it can be placed on the MP crease between
the index and middle fingers. Finally, objects may be
placed in the center of the palm (Figure 12-8, C).
Some children are able to work on bringing objects
from the ulnar side of the hand to the radial fingers and
thumb, a skill that is helpful for efficient hand use, par-
ticularly in the preferred hand. Common objects used
when working on palm-to-finger translation are small
pieces of food or dry cereal, small cookies, coins, game
pieces, small puzzle pieces, beads for stringing, paper
clips, caps for markers and pens, pegs, and small blocks.
Simple rotation skills often can be addressed early in
an in-hand manipulation skill intervention program.
Simple rotation tends to be “simple” because the fingers
move as a unit to partially turn the object. These skills
may be encouraged by placing an object on the distal
surface of the child’s fingers (the forearm is pronated)
and asking the child to make the object move into an
upright position. Slight stabilization of the child’s fore-
arm may help prevent the child’s use of forearm rota-
tion as a substitution for manipulation by the fingers.
C
258 Part III • Therapeutic Intervention

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
so that he or she is holding the marker more effectively
for writing or coloring.
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 paper and the fingers in a relatively extended position
on the underneath surface before expecting use of shift.
Index cards may be easier to use than paper, because the
cards are slightly thicker and sturdier than paper (but are
still easy to cut). They also are a good size for shifting
and cutting. As the child’s skill in shifting the index card
improves, larger and larger sizes of index cards may be
used. Eventually regular paper may be used.
Fully develop each skill before asking the child to
combine skills within an activity. Children seem to find
that using palm-to-finger translation immediately before
using either simple or complex rotation (e.g., moving a
key from the palm to the fingers, then turning it for
placement) is much more difficult than using simple or
complex rotation alone. Therefore children should be
assisted with developing palm-to-finger translation that
does not involve rotation of the object for placement
and simple and complex rotation without palm-to-
finger translation before asking for the combination of
these skills. When both skills are reasonably well devel-
oped, they may be combined for sequential use.
Fully develop a skill before asking the child to use
that skill with stabilization. Stabilizing other materials
in the hand while manipulating an object is quite diffi-
cult because it relies on good radial-ulnar dissociation
of movements and the ability to do the in-hand manip-
ulation skill with only the radial fingers (Figure 12-10).
Therefore the therapist should ensure that the child can
use the skill easily before asking the child to hold even
one object in the hand while manipulating.
Intervention for Children with Hand Skill Problems • 259
Figure 12-10 Child shows use of simple rotation with
stabilization by holding two objects in the hand. One
object is stabilized by the ulnar fingers, while the other
object is rotated slightly before stringing.
The easiest in-hand manipulation skill to use with
stabilization is finger-to-palm translation, because this
is only slightly more difficult than using this pattern
without stabilization. It requires the child to keep the
ulnar fingers flexed while grasping with the radial
fingers, and storing another object in the hand only
requires movement into finger flexion (which is easier
than moving into finger extension). This also seems to
be a skill that many young children develop spon-
taneously as they try to hold several pieces of cereal,
candy, or small crackers in their hands at one time.
After mastering finger-to-palm translation with
stabilization, most children seem to find it easier to
work on palm-to-finger translation with stabilization
than simple rotation with stabilization. However, the
therapist should explore these with the child, and then
select the easier skill to work on next. The size of the
object being held in the hand can be a factor in making
the skill seem easier or more difficult. If it is too small,
a great deal of ulnar flexion is needed, thus increasing
the requirement for radial-ulnar dissociation. If the
object is too large, the child may need to use the
middle finger to assist in the stabilization, but then will
not have this finger available for manipulation.
Children find it easier to hold one other object in the
hand than two or more. Initially they also find it easier
if the objects to be held are placed in the ulnar side of
the hand by the therapist. Later they may be asked to
pick up and move an object into the hand and hold it
there while manipulating another object with the radial
fingers.
260 Part III • Therapeutic Intervention
Children with mild disabilities may find it possible
to learn to use shift with stabilization and complex
rotation with stabilization, but many children find
these skills too difficult. If these skills seem possible, the
therapist may find that one skill is easier than the other
for the child to develop. Shift with stabilization is dif-
ficult because of the need to combine a flexion pattern
in the ulnar side of the hand with a more extended
pattern in the radial side. Thus holding a slightly larger
object in the ulnar side of the hand may be somewhat
easier when facilitating shift with the radial fingers and
thumb.
The size of the object being manipulated also is
particularly important for complex rotation, because
complex rotation generally is carried out by the index,
middle, and ring fingers. When stabilization of other
objects is necessary, the ring usually is not available to
assist in the rotation. Therefore smaller objects are
easier to use for complex rotation with stabilization
than are larger ones.
BILATERAL HAND SKILLS
As with other areas of hand skill development, an
understanding of normal development is helpful in
selecting goals and planning intervention for children
who have difficulties with bilateral hand skills. How-
ever, as in all areas of hand skill intervention planning,
the therapist should be guided by judgment about the
most important functional skills for the child now and
in the future.
Babies with normal development initially use gross
symmetric bilateral skills, such as holding objects with
two hands, clapping, and banging objects together. Then
they begin to stabilize objects with one hand while the
other is manipulating either by holding without grasp
(e.g., holding paper while coloring) or with grasp (e.g.,
holding a container during object placement). Later they
develop the ability to manipulate objects with both hands
simultaneously (e.g., stringing beads, tying a knot).
All children with motor control problems have dif-
ficulty with bilateral hand skills. Bilateral simultaneous
manipulation is a common problem; children with
motor disabilities generally cannot use effective in-hand
manipulation with one hand at a time, and certainly not
with two hands at one time. Many children with motor
control problems, even subtle problems, also have
difficulty stabilizing an object with one hand while
manipulating with the other hand. Problems may be
seen in stabilizing while grasping an object or stabi-
lizing without grasp. Children with marked asymmetry
in their arm-hand control also find gross symmetric
skills to be difficult, whereas children with milder
problems typically can use the more basic skills in this
category.
In bilateral hand skills, the issue of spontaneous use
is particularly significant. Fedrizzi et al. (2003) found
that children with cerebral palsy had substantial dif-
ficulties with spontaneous object handling in bilateral
tasks. They also tended to show little improvement in
these skills between the ages of approximately 2 years
and approximately 12 years.
Children with Moderate-to-Severe Motor
Involvement
The child who has significant asymmetry or significant
involvement bilaterally has difficulty with all three
categories of bilateral skills. Even most gross symmetric
skills require that the child be able to spontaneously
open both hands, sustain both hands open or in a grasp
position, and use supination to midposition. Although
gross bilateral skills may be used as part of an inter-
vention program to help prepare the child for other
activities, goals in the gross bilateral skill area may not
be the most appropriate. When the child has cognitive
skills that make independent performance of functional
tasks important, bilateral skills in stabilizing with and
without grasp become a much greater priority.
Initially the therapist may address either stabilizing
objects with or without grasp. Consideration needs to
be given to the type of stabilizing that seems to be
within the child’s zone of proximal development and
the most frequent needs of the child. For example,
when stabilizing with grasp, the ability to hold the fore-
arm of the stabilizing hand in supination to midposition
is important. Wrist extension to neutral is helpful in
stabilizing without grasp.
Stabilizing materials without grasp but with an open
hand may not be feasible for many children; however,
they may achieve sufficient dissociation between the
two sides of the body to be able to hold materials with
a fisted hand. An important component for this skill is
maintaining elbow flexion at approximately 90 degrees
so that stabilization with the hand on a surface is
possible. In stabilizing materials without grasp, some
children can initiate finger extension, but finger flexion
increases during the activity. In this case wrist flexion
becomes a greater problem than finger flexion and
interferes more with effectiveness of object stabiliza-
tion. Therefore often in initial intervention for the skill
of stabilizing without grasp, emphasis is on holding the
wrist in neutral extension rather than on finger exten-
sion. Activities in prone on forearms weight bearing
and in less stressful tabletop activities that involve
stabilizing materials are often introduced early in
intervention. At times the therapist may ask the child to
stabilize materials while the therapist does the
manipulation. For example, the child may hold his or
her hand on the paper while the therapist draws a
picture and asks the child to guess what is being drawn.

Gradually the child is asked to stabilize materials on the
surface while doing more with the manipulating hand.
Children with marked asymmetry usually need as
much attention to the less involved hand as to the more
involved hand. Even though the arm-hand with the
greater degree of disability seems more in need of
intervention, the hand with a mild disability needs to
be addressed specifically. The child with significant
asymmetry needs a skilled hand to accomplish tasks
unilaterally that other children may do bilaterally. The
less involved arm and hand have a greater degree of
potential for meaningful improvement in skill that will
enhance independent functioning than does the more
involved arm and hand. Thus intervention needs to
focus on both hands.
Bilateral simultaneous manipulation is rarely a goal
for children with moderate-to severe motor involve-
ment. Therefore for these children the focus needs to
be on developing or improving in-hand manipulation
in the hand with less involvement and adaptations or
compensatory strategies for dealing with other skills if
independence in these areas seems possible. The child’s
cognitive and perceptual skills influence decisions
about the motor skills that seem reasonable for the
child. As Skold, Josephsson, and Eliasson (2004) found
in their study of adolescents and young adults with
cerebral palsy, access to a variety of strategies for com-
pletion of functional activities is of great importance.
These individuals reported that although certain
strategies work under some circumstances, alternatives
are needed to meet different environmental demands.
Children with Mild Motor Involvement
Children with low tone and those with milder degrees
of asymmetry may be able to work on gross symmetric
skills and become functional with them. Therefore
setting goals in the area of gross symmetric bilateral
skills may be reasonable. Intervention for these problems
typically uses a graded approach for decreasing the size
of the objects used (e.g., the size of the ball to be
caught) or increasing precision or timing in the activity
(e.g., holding a stick with both hands to hit a stationary
target, then a slowly moving ball, then a quickly
moving ball) or increasing speed of performance.
Although children with mild involvement typically
need some intervention for gross symmetric bilateral
skills, they need more attention to skills involving
stabilizing with one hand while manipulating with the
other. Many times these children do not spontaneously
stabilize materials with one hand, yet with encourage-
ment or prompting they do so. Intervention depends
on the therapist’s assessment of the child’s reason(s) for
not spontaneously or consistently stabilizing materials.
Such reasons may include poor sensory awareness of
one upper extremity, poor ability to dissociate the two
Intervention for Children with Hand Skill Problems • 261
sides of the body so that the hands can assume different
functions, and the need to adduct or hyperextend one
upper extremity to assist with maintaining good pos-
tural control. In addition, as Skold et al. (2004) found
in their study, many adolescents and young adults with
hemiplegia do not use the more involved hand in bilat-
eral activities as they may wish to conceal the move-
ments of this hand. Intervention typically is directed, at
least in part, on the identified factors and the ability of
the individual to learn alternative strategies.
In intervention designed to facilitate spontaneous
stabilization of materials, the therapist may try (and
suggest to others) activities that definitely require the
use of one hand for stabilization. A highchair tray or a
slightly wobbly table may be useful, because materials
tend to be less stable on these surfaces than on others.
Inexpensive toys that are less sturdy than more
expensive ones may be helpful in encouraging the child
to use one hand to hold materials down. Simple toys
that can be put together without requiring manipula-
tion of objects in both hands can be appropriate, such
as a padlock that a key can be put into, markers with
caps to put on, and a box with a lid and objects to put
inside the box. Children who have good sitting balance
may be asked to sit in a chair (but not at a table) and
hold a cup or other small container with one hand
while putting objects in with the other hand. This type
of activity may be done while standing if the child has
good standing balance.
Children with mild or minimal motor involvement
may be able to work toward accomplishing bilateral
simultaneous manipulative tasks, such as buttoning
with both hands, tying a bow, and doing craft projects.
To do so, they need refined grasp patterns and the
ability to sustain these patterns, in-hand manipulation
skills with at least one hand and preferably both, and
skill in dissociating the movements on each side of the
body. For these children a graded progression of
activities that require stabilizing materials with a refined
grasp while using manipulation with the other hand,
and activities that require changing the hand that is
doing in-hand manipulation, may be useful. In these
activities children are usually more successful with more
stable materials such as blocks that fit together and
other building construction sets before having success
with unstable materials such as fabric with buttons and
shoelaces. Once the child is ready to try bilateral
manipulation with unstable materials, grading also may
be used. Large, then medium, then small buttons may
be tried; most children find it easier to button when the
buttons are low (in their visual field) and on their own
body or on another person’s body so the fabric is well
stabilized. Initially the fabric should overlap in the
correct direction for the child (right over left for girls,
left over right for boys) regardless of the placement of
262 Part III • Therapeutic Intervention
the item of clothing. Later this may be varied as well.
For lacing and tying, thicker (but not inflexible)
shoelaces that are just the right length need to be used
at first; then the thickness of the laces and their length
can gradually be decreased.
A study by Hung, Charles, and Gordon (2004)
yielded findings that are applicable to intervention for
these types of bilateral hand skills. They found that
children with hemiplegic cerebral palsy were able to
complete a task that involved the two hands completing
different activities and were able to alternate hands for
the two components of the activity. In this task neither
hand was necessary to execute fine control, and the task
was completed at two different speeds. Under the con-
dition in which greater speed was necessary, the children
showed enhanced coordination. Thus therapists may
wish to consider incorporating different degrees of
speed into activities, exploring the conditions that may
yield greater success for the child.
I NTEGRATION OF SKILLS INTO OCCUPATIONAL
PERFORMANCE
The child’s ability to generalize the skills emphasized in
intervention to other times of the day and other set-
tings is a crucial consideration in planning and imple-
menting intervention. At least some amount of each
session needs to be spent engaging the child in
activities that will be done in other situations. Unique
ways of modifying materials and object presentations
may work well in intervention with the therapist, but
parents and teachers often have difficulty presenting
materials in the same way as the therapist. Thus typical
ways of presenting materials also should be used, as
well as materials that the child has in the home or
school setting. If these strategies are not used, the child
will be asked to generalize a new skill to a new setting
with new materials without the therapist to provide
presentation in a unique way. Therapists expect skills to
be generalized, but this generalizability needs to be
supported by the therapist, not only with instructions
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
include the specific materials that we expect children to
practice with when they are in other settings. These
activities must be presented in ways that are reasonable
for children to do on their own or with adults who are
not therapists.
An example of an activity that is commonly used in
intervention but has little generalizability is a pegboard
set. A child is unlikely to have a basic pegboard at
home, and a pegboard is generally uninteresting to a
child so it is not used in free play. In addition, the child
is unlikely to have someone structure the presentation
of a peg to facilitate a finger pad grasp on the peg.
Therefore it is suggested that although placement of
pegs into a pegboard may be a reasonable activity for
the motor skill element of therapy, a pegboard set may
not be a good activity for engaging the child’s interest
or for carryover into real-life situations.
Involvement of parents or caretakers and teachers is
almost always necessary for a child to integrate new
skills into occupational tasks. This involvement needs
to be more than asking others to carry out specific skills
with the child. Parents and teachers
“may need to modify their expectations of the child’s performance
abilities” (Gilfoyle, Grady, & Moore, 1990, p. 259)
so the child is able to accomplish activities that are
appropriate. To support the child’s performance of
skills, the therapist must address the child’s environ-
ment, as well as the child’s ability to perform specific
skills (Gilfoyle et al., 1990).
ADJUNCTS TO DIRECT
INTERVENTION: SPLINTING,
CASTING, AND CONSTRAINT-
INDUCED MOVEMENT THERAPY
Using splinting or casting with children requires careful
attention to precautions associated with these devices.
Children may have less ability to report discomfort or
changes in tone or function associated with the splint
or other device, so preparation of the parent or guardian
for use of the device and key factors to observe is im-
portant. Initially, close monitoring of the child’s status
with the device is needed, thus leading to scheduling of
frequent check-up sessions with opportunities to gather
feedback from the parent or guardian and the child
about the device and its impact on the child’s arm or
hand, their comfort, and their functioning.
SPLINTING
Hand splinting can be an effective adjunct to direct
intervention for hand skills in children. Exner (2005)
provides information about splinting in children,
including a description of precautions and a summary
of the various types of splints and their rationale.
Additional information about splint types, and their
uses and construction is provided by Gabriel and
Duvall-Riley (2000) and Chapter 18. Research on the
use of splinting in children is limited. In a research
literature review analysis by Teplicky, Law, and Russell
(2002) on the use of upper extremity splinting and

casting with children, they identified a total of four
studies that addressed hand splinting. Only two of the
studies have been published since 1990. However, the
literature suggests reasonable effectiveness of splinting
for children with cerebral palsy, as all four of the studies
reported positive outcomes relative to some aspect of
upper extremity or hand control. Clearly this is an area
for further study.
Exner (2005) identified three broad categories of
hand splints. A static splint may be most commonly
used with children with the most severe disabilities.
This type of splint sustains the wrist or one or more
parts of the hand in a particular position. Static splints
may be provided to support more normal posturing of
the hand or prevent deformities. Some static splints
have been used to allow for upper extremity weight
bearing with a better hand position (Gabriel & Duvall-
Riley, 2000). Although children with moderate and
even mild motor involvement may be provided with a
static splint, they also may be provided with a dynamic
splint or other orthotic device. Dynamic splints are
designed to enhance the child’s movement at one or
more of the joints within the hand. Other devices that
are based on neurophysiologic principles for facilitating
or inhibiting muscle activity may be placed on the child’s
arm or hand. These devices may include the orthokinetic
cuff, which is designed to facilitate extensor muscle
activity and inhibit flexor muscle activity (Exner &
Bonder, 1983) and the MacKinnon splint (Exner &
Bonder, 1983; Flegle & Leibowitz, 1988; MacKinnon,
Sanderson, & Buchanan, 1975).
CASTING
Upper extremity casting for decreasing tone and
improving hand function has been used in intervention
with children with significant disabilities. Studies by
Yasukawa (1992); Law et al. (1991); Tona and Schneck
(1993); and Copley, Watson-Will, and Dent (1996)
have shown some empiric support for this approach. A
study by Law and associates (1997) used group experi-
mental methodology to study the effect of occupational
therapy treatment without casting to an intervention
program that included casting. In this study, the benefits
of including casting were not evident. Although
changes may occur in tone or range of motion as a
result of casting, changes in occupational performance
may not (Russell & Law, 2003).
CONSTRAINT-I NDUCED MOVEMENT THERAPY
Constraint-induced movement therapy and its applica-
bility to children have resulted in a number of research
studies in the past several years. This therapy is based
on the work by Taub, in which he identified the issue
Intervention for Children with Hand Skill Problems • 263
of “learned nonuse,” which refers to the lack of use of
a more-involved upper extremity. In this case, the
person has the ability to use the extremity to some
degree, but finds use difficult or less than successful, so
uses the arm even less. Thus skills are not developed to
the ability level possible. In constraint-induced move-
ment therapy, emphasis is placed on using the more
involved upper extremity exclusively for a period of
time; the less involved upper extremity is restrained via
a constraint.
Several single-subject studies (Crocker, MacKay-
Lyons, & McDonnell, 1997; DeLuca et al., 2003;
Glover et al., 2002) and small group comparison
studies (Taub et al., 2004; Willis et al., 2002) have
been conducted with children with cerebral palsy. The
children in these studies ranged from approximately 1
to 8 years of age and had a splint or a cast placed on the
less involved arm or hand for between 11 days (Glover
et al., 2002) and 4 weeks (Willis et al., 2002), with
3 weeks being the most common time period (Crocker
et al., 1997; DeLuca et al., 2003; Taub et al., 2004).
Most of the children had this arm in the cast or splint
while they were awake for 6 hours per day, except in the
Willis and associates study, in which the children had
the cast on their arms continuously for the month. The
intervention for the more involved arm varied across
the studies from several hours of highly specific inter-
vention per day (Taub et al., 2004) to routine visits to
occupational or physical therapy (Willis et al., 2002).
In all of the studies, the children showed substantial
change in functioning of the more involved upper ex-
tremity. Most studies reported continued improvement
up to 6 months after the intervention. Although wearing
the restraint was difficult periodically for some children
and families (Glover et al., 2002) and dropout occurred
in some studies (Crocker et al., 1997; Willis et al., 2002),
meaningful gains in occupational performance were
noted and valued by the families (Crocker et al., 1997;
DeLuca et al., 2003; Taub et al., 2004; Willis et al.,
2002). Clearly further research is needed on a number
of dimensions of this therapeutic technique, which
appears to have substantial promise.
SUMMARY
Intervention for children with hand skill problems is
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
more effectively fulfill desired roles. In approaching this
intervention, many factors must be considered. The
therapist—in collaboration with the child (whenever
feasible), parent or guardian, teacher, and significant
others—carefully assesses the child’s strengths and
264 Part III • Therapeutic Intervention
challenges and attempts to determine the major factors
interfering with his or her ability to be successful in a
variety of occupational tasks. If hand skill difficulties
play a role in limiting the child’s functioning, the
therapist seeks to delineate the problem areas and the
child’s potential for improvement in skills. Needs for
hand skills intervention must be balanced with other
types of priorities that could be addressed by the
therapist and the child’s other life needs and interests,
such as academic skills, social skills, and play. In this
process the therapist determines the child’s need for
direct intervention designed to improve hand skills and
the child’s need for any adaptations or compensatory
strategies to assist in accomplishing daily life tasks. The
child’s perceptual and cognitive functioning affect this
planning, because hand skills are intimately related to
the child’s perception of objects and space and his or
her desire to accomplish a meaningful end goal.
To assist in determining the child’s potential for
improvement from direct intervention for specific hand
skills, the therapist needs information that typically can-
not be derived solely from standardized tests of fine
motor skills. For realistic intervention designed to im-
prove the child’s hand skills the therapist must consider
the skills that are within reach for the child. Deter-
mining this range of skills within reach may be called
identifying the child’s “zone of proximal development.”
Hand skills intervention typically integrates a variety
of strategies, which depend upon the child’s overall
motor problems and skills, as well as the child’s
particular problems in hand function. Given the critical
role that tactile-proprioceptive perception play in the
use of hand skills, addressing this area may be an
important aspect of intervention. Physical handling to
enhance the child’s performance may be used with many
of the intervention strategies. Verbal cuing for the type
of motor action desired and verbal reinforcement for
performance of particular motor skills is appropriate for
almost all children. Repetition of actions is necessary
for building skill in new motor patterns, so games and
imaginative activities that engage the child’s interest
and sustain the child’s performance of the activities are
useful. Because hand skill activities must be done with
the child’s active participation and cannot be done to
the child, the child’s interest and motivation to engage
in the activities is very important.
Although children often respond well to initially
trying out new skills in a one-on-one situation with a
therapist, opportunities to practice and use skills in a
variety of settings and a variety of activities is an
important consideration. Therefore collaboration with
the child, the parents or caregivers, and teachers is
crucial in helping the child develop hand skills that can
be spontaneously used to enhance the child’s perfor-
mance in a variety of daily life skills.
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A FINE MOTOR PROGRAM FOR
PRESCHOOLERS
Carol Anne Myers*
CHAPTER OUTLINE
VERTICAL SURFACES
MANIPULATIVES
The Manipulatives Program
Fine Motor Planning
SCISSORS
DRAWING AND WRITING
Hand Preference
Activities to Help Develop Pencil Grasp and Control
WHAT MAKES THERAPY EFFECTIVE?
CASE STUDY
The activities and suggestions included in this chapter
were developed at the Newton Early Childhood Program
(formerly the Brookline-Newton Early Childhood
Collaborative) in the metropolitan area of Boston. The
program serves preschoolers from 3 through 5 years of
age with mild to severe special needs. This chapter
focuses primarily on activities that are used with chil-
dren who have mild to moderate special needs, but in
some cases they may be adapted for use with children
who have severe needs.
Occupational therapy (OT) services in the Newton
Early Childhood Program are provided to children
who attend integrated preschool classrooms (a com-
bination of typically developing children and children
who have with special needs), in substantially separate
*Taken in part from Myers CA (1992). Therapeutic fine-motor
activities for preschoolers. In J Case-Smith, C Pehoski, editors:
Development of hand skills in the child. Rockville, MD, American
Occupational Therapy Association.
Chapter 13
self-contained class-rooms, as well as to children who
attend community nursery schools. The children who
are in community nursery schools usually receive
related services such as speech and language, OT, and
physical therapy during their after-school hours. Many
of the children who receive OT services have learning
differences that may result in a learning disability diag-
nosis in later years, or mild to moderate sensory pro-
cessing difficulties. Some of the children who receive
OT, however, have no area of disability other than a
discrete weakness in fine motor skills. Although the
program is comprehensive in the types of OT inter-
vention that are provided, this chapter focuses on the
fine motor program, which refers both to the use of
manipulatives, as well as to prewriting skills such as the
use of scissors and drawing implements.
The theoretical rationale for the fine motor program
described in this chapter is based primarily on the work
of Mary Benbow, as gleaned from her workshops and
publications (see Chapter 15). Her perspective has
provided an invaluable foundation on which to base the
work of the program. Many of her ideas for fine motor
activities with older children have been adapted for the
work with preschool children.
The philosophy of the fine motor program is based
on the classic OT theory that intervention should
enhance the client’s ability to participate in his or her
“occupation,” which has
“long been recognized as a requirement for survival and, to
varying degrees, as a source of pleasure” (Hopkins & Smith,
1978).
The occupation of the preschool child is to be inde-
pendent and successful in all of the areas of the
classroom and playground, both with play activities as
well as with self-care. Specifically in respect to fine
267
268 Part III • Therapeutic Intervention
motor skills, the overall goal is for students to be able
to participate productively in classroom learning
centers such as the art area, manipulatives area, and
writing center. Young preschoolers work at mastering a
variety of manipulatives and simple art projects,
whereas older preschoolers develop the skills to
independently use complex, multistep manipulatives,
and to participate in multistep art projects as well as
prewriting tasks. Parents and teachers often
overemphasize prewriting activities for young pre-
schoolers, while short-changing them on the use of
manipulatives that will develop their overall hand func-
tion. This overemphasis on “academics” may have been
encouraged by the overall national trends toward
increased standardized testing of students of all ages.
Windsor (2000) stated that
“at the preschool level, tool use … and ‘whole body’ play in the
environment are preferred to practice with pencils, pens, and
tabletop exercises” (p. 19).
It is critical for parents of students in the program to
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.
To fully assist students in being functional and inde-
pendent with all of the classroom activities, therapists
either use materials that are similar to classroom mate-
rials, or they borrow materials from the classroom for
the OT sessions. This practice enhances the generaliza-
tion of skills learned during the OT sessions to the
classroom setting, and is particularly applicable in two
circumstances: (a) students who avoid fine motor areas
in the classroom because of low self-confidence, and
(b) students with fine motor planning difficulties.
Most of the children in the program who receive OT
services to address fine motor delays receive them once
weekly, for 30 minutes, in either an individual or small
group setting. The ideal arrangement is to schedule
sessions with pairs of children who have been carefully
matched by age and by specific needs. Case-Smith
(2000) found that
“occupational therapists’ use of play activities and peer
interaction were important predictors of [fine motor] skill levels
at the end of the year” (p. 379).
Pairing children for OT sessions provides structure as
well as peer support to encourage success with challeng-
ing activities. Having two students work together also
enhances the therapist’s ability to make the activities seem
like games rather than exercises. In a study examining
performance outcomes for OT that addressed fine
motor skills, Case-Smith (2000) noted that
“the most surprising finding [in the study] was that the
therapist’s use of play and peer interaction predicted the fine
motor outcomes and that among the intervention variables, play
and peer interaction were the only significant predictors”
(p. 378).
In addition to providing direct services to students,
the occupational therapists consult with parents and
classroom teachers. Once a child is comfortable with
the activities in the therapy settings (usually after 6 to
8 weeks), therapists typically provide recommendations
to the child’s classroom teachers and sometimes recom-
mend that the parents provide a modified home pro-
gram. Parents should not attempt to mimic the role of
the therapist or teacher; rather, parents provide appro-
priate materials and naturalistic, enjoyable opportu-
nities for the child to demonstrate and use at home the
skills that have been learned in therapy and school.
Surrounding the child with a team of people who are
familiar with the child’s strengths and weaknesses and
who understand the goals of the intervention program
greatly enhances the therapy process.
VERTICAL SURFACES
Vertical and slant board surfaces are an extremely
important part of the fine motor program. Benbow
(1995) emphasized the importance of working on a
vertical surface to encourage appropriate hand and
wrist position for fine motor and handwriting skills.
Both vertical and slant board surfaces correctly position
the wrist in extension, which supports thumb abduc-
tion so that the thumb can work skillfully with the
fingertips. Stable wrist extension and thumb opposition
also facilitate total arching of the hand for skillful
manipulation of objects. Therefore, providing a vertical
or slant board work surface is an important modifica-
tion that parents and teachers can incorporate as they
work or play with the child.
Activities performed above eye level on vertical or
near-vertical work surfaces such as floor and table easels
promote
“wrist stabilization in extension with precision finger skills”
(Benbow, 1995, p. 257),
as well as the development of arm and shoulder mus-
cles. Whenever possible, teachers are encouraged to
provide activity areas in which the children are working
upright (sitting, kneeling, or standing) with their arms
and hands moving against gravity at an easel or other
vertical work surface, rather than leaning over small
tables. When children work on a horizontal surface,

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).
5. Chalkboards: Use sidewalk chalk (wide-diameter
chalk) broken into 11⁄2- to 2-inch pieces for children
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-
brush with water to “magically” erase the design.
6. Geoboards (rubber band designs created on a grid
of nails).
7. Painting or drawing.
8. Ink stamping activities.
9. Pegboards, many different varieties (Lite Brite Cube
uses small pegs and by design is oriented on the
vertical).
they often place their wrists in neutral or flexion, which
does not promote skillful use of the intrinsic muscles.
Switching activities from a horizontal to a vertical
orientation can transform an ordinary or mediocre
activity into a powerful tool for encouraging fine motor
skill development.
Many activities can be oriented on the vertical by
placing the materials (e.g., geoboard) on the lower lip
of a tabletop easel. In the Newton Early Childhood
Program, children are expected to work regularly on
vertical work surfaces. With a minimal amount of modi-
fication and equipment expense, many activities can be
adapted easily for use on a vertical surface (Box 13-1).
It is beneficial for the shoulder, arm, wrist, and hand
development of all preschoolers to work on activities at
a vertical or near-vertical surface on a regular basis. For
older preschoolers who are working on representative
drawing and writing letters, students use a slant board
that is at an estimated angle of 20 degrees. A low-cost
way to provide multiple slant board surfaces in a
classroom is to place 3-inch three-ring binders at the
writing table; the ring side of the binder is placed
horizontally toward the middle of the table so that the
slope of the binder slants down toward the edge of
the table where the student is sitting. The students use
these slant board binders as drawing and writing sur-
faces. They are relatively inexpensive, and are easy for
teachers to store when the writing center is being used
A Fine Motor Program for Preschoolers • 269
Figure 13-1 Tripod grasp with extended wrist, and
forearm resting on the surface of a 20-degree slant
board.
for a different purpose. Parents also have used these
binders as slant boards at home, and often purchase a
three-hole zipper storage bag that can hold the child’s
markers inside the binder for traveling. A variety of
more sophisticated alternatives are available from many
sources, some of which are listed in the Appendix.
Because it is recommended that students use a slant
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
preschool students draw and write on the 20-degree
slant board instead of the vertical or near-vertical sur-
faces is because the 20-degree angle encourages students
to rest their hand and forearm on the work surface,
whereas the vertical and near-vertical surfaces do not.
With the older students, therapists are encouraging
the development of a tripod or quadrupod grasp, with
accompanying intrinsic muscle movements of the fingers
while drawing or writing, which means that the hand
and forearm must rest on the table (Figure 13-1).
Having parents and teachers provide a 20-degree slanted
work surface helps students to make the transition from
drawing with their hands off the table to drawing and
writing with their hands resting on the table, as ex-
pected. Although older students in elementary school
may have developed the appropriate mature writing
grasp, a slant board encourages the ideal posture—an
erect spine—while drawing or writing and enhances
students’ endurance for completing lengthy homework
assignments.
For therapists who are attempting to demonstrate
the value of vertical or slant board surfaces to parents
or teachers, it is helpful to ask children to perform a
task such as a pegboard or a drawing activity on a
horizontal surface, and then ask them to perform the
same activity on a vertical surface. The difference in the
child’s hand position and ability is often dramatically
evident in such a demonstration. Observing that
270 Part III • Therapeutic Intervention
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
pencil grasp, partially because children may be asked
to use writing utensils before their hands are ready for
that kind of refined activity. Benbow (1995) specifically
noted that boys tend to avoid fine motor activities in
lieu of computer games, while girls who practice with
writing implements at an early age
“without proper adult attention or supervision” may then
“adopt pencil grips that are inefficient or even harmful” (p. 255).
Benbow (1988) further noted that
“pencil postures ‘fixed’ early by repeated use at an intermediate
level of skill will later affect negatively on graphomotor perfor-
mance when speed and volume demands increase” (p. v).
Therefore children should be developing their hands
for a variety of activities in a variety of positions before
they are expected to draw or write with the proper grasp.
In preparation for writing, the hand progresses
through the following motor milestones (Benbow,
1995):
1. Development of wrist stabilization in extension to
support skilled finger movements.
2. Development of a stable open index finger-thumb
web space when performing skilled activities. The
open web space should have a circular shape. This
position is frequently compromised in children who
have hyperextension of the interphalangeal joint of
the thumb; rather than a circular web space; these
children form a “crescent moon” with a small open-
ing. The thumb is in a fixed position, thereby making
intrinsic muscle activity difficult (Figure 13-2).
Children with this problem must be monitored
carefully when they perform fine motor activities to
find those activities that encourage the use of the
thumb in a flexed position.
3. Development of palmar arches in the hand,
represented by a concave surface on the palm.
4. Development of an awareness of the “skill side” of
the hand; this means that the child consistently
orients skilled activities toward the thumb, index
Figure 13-2 Hyperextended thumb and compromised
web space on lace tip.
finger, and middle finger. These three fingers are
hereafter called the “skill fingers.”
5. Development of intrinsic muscle movement in the
fingers; this kind of fine muscle movement can be
seen when the ulnar side of the hand is stabilized on
the table while the fingers move a pencil to write, or
when the fingers make fine movements to thread a
needle. The intrinsic movements are best observed
in activities that require the tips of the thumb, index
finger, and middle finger to be touching while they
are performing small movements of midrange
flexion and extension of the metacarpal-phalangeal
(MCP) joints.
Many so-called “fine motor” activities involve the
use of the hands and fingers, but do not necessarily
elicit the fine motor movements of the intrinsic muscles
at the MCP joints. One example of an activity that
parents often cite as proof of their child’s fine motor
abilities is the use of a computer mouse. The use of a
mouse involves primarily the arm and shoulder muscles,
with slight flexion of the index finger for clicking the
mouse. (In cases in which the mouse has a scroll wheel,
the middle finger does use some intrinsic muscle move-
ment to scroll, although students usually point and click
more often than they scroll.) Although skilled use of a
mouse is difficult for children with overall upper extremity
motor control issues, many students with significantly
reduced fine motor skill with manipulatives are able to
successfully use a mouse. That is because the mouse
does not require the skilled use of the intrinsic muscles
of the skill fingers working together with an open
thumb-index finger web space; it falls short as a fine
motor activity. Adding insult to injury, instead of using
their hands to work a variety of real puzzles, many pre-
school students with poor fine motor skills work puzzles
on computer screens. Parents and teachers of children
who have poor fine motor skills are strongly encouraged
to limit the child’s time on the computer, and increase
the availability of a variety of concrete materials that
will encourage fine motor skill development.
 A Fine Motor Program for Preschoolers • 271

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.
272 Part III • Therapeutic Intervention
Another Wake Up Hands activity is “putting on
your [imaginary] power gloves,” which students can
either do for themselves or have done by an adult. To
put on the “gloves,” each finger is grasped at the
fingertip by the thumb and index finger of the other
hand, and gentle pressure is exerted as the thumb and
index finger slowly travel down to the base of the
finger. Each finger is stimulated in turn until all 10 are
complete, at which point the “gloves” have been put
on. This provides both tactile and proprioceptive stimu-
lation, and also provides a mental image of powerful
hands that is a good mindset for students preparing for
a fine motor task. It is, of course, a more powerful
sensation for an adult to provide the stimulation than
for the children to provide it for themselves, although
with a large group sometimes it is impossible for an
adult to get around to each child in a timely fashion.
Wake Up Hands with 4- and 5-year old children
often includes two components: the primarily sensory
component with the soft objects and varied textures,
and a higher-level demand such as finger plays. Many of
the students have difficulty isolating individual fingers,
and also with imitation and fine motor planning.
Carefully chosen finger plays tend to be motivating for
them, and observing students performing finger plays is
an excellent way to quickly learn a great deal about
their current level of hand development. Choose finger
plays that include developmentally appropriate finger
motions such as the following: forming a circle with the
thumb and index finger, isolating the index finger or
the thumb, or forming a cupped palm (see Appendix
for a good source of finger plays). Many young students
have difficulty forming a circle with their thumb and
index finger; the circle tends to be flattened rather than
round. These are often the same students who have dif-
ficulty forming an open thumb-index finger web space
with drawing implements. The finger plays provide an
additional way for students to practice using their fingers
in a variety of positions, and a way for the therapist to
visually gauge their progress. For students for whom
the combination of language and motor planning
demands is too high, therapists have them practice the
motor component of a finger play separately before
adding the language component.
Strong Hands
Although activities from any of the three components
of a therapy session may address multiple areas of
development, the rationale for labeling the activity is to
help students understand its primary goal. The use of
these specific terms has provided unexpected benefits,
particularly the use of the term “Strong Hands.” The
students with less than average hand grasp strength
are often the students who are least likely to take risks
with novel fine motor tasks. When “Strong Hands” is
presented as a regular activity, students quickly learn to
view their hands as strong. Verbal encouragement (e.g.,
“Look how strong you are. You made the rocket fly
across the table!”) helps students to believe that they
can become stronger through games and activities.
Students actually enter a session enthusiastically asking,
“What are we doing for Strong Hands today?”
When students have less than average hand grasp
strength, their parents and teachers are encouraged to
provide hand strengthening activities naturalistically
throughout the week. Therapists provide beneficial activ-
ities and attitude boosting encouragement, but children
should become stronger through daily activities that are
a natural part of their routine. A first step for many
teachers and parents is to discontinue the practice of
performing a task for the child if the child is not able to
perform it for himself or herself. Adults are asked to say,
“Let’s do it together” rather than “Let me help you.”
Even if the adult provides most of the power for the task,
having the child do even part of it helps to develop the
motor plan for the task and allows the child to use
whatever level of strength is available to assist. A
common example of this situation occurs in the class-
room when students bring a snack from home. Many of
the individually wrapped snacks that parents send in with
students, in fact, are challenging even for adults
to open. When necessary, adults open these containers
hand-over-hand with the students, both to assist them as
well as to gauge for themselves how difficult the task
really is. When students are empowered by participating
in the task from the start, they are much more likely to
perform the task independently in the future. Activities
to encourage hand strength are listed in Box 13-2.
In addition to these ideas, strength-based toys
including classroom building toys such as Duplos and
Bristle Blocks also are valuable. Furthermore, therapists
can use a variety of different containers to encourage
the development of both strength and skill. For
example, the OT clinic has a large collection of cookie
tin–style containers of varying resistance, and materials
often are placed inside the containers ahead of time.
One of the activities in the session is for the children to
open their own containers to see what materials will be
used for the next activity. In addition to cookie tin
containers, therapists use a variety of zipper containers,
screw-top jars of all sizes, Rubbermaid containers,
plastic lunch boxes, and many others to challenge
children’s hands in a variety of functional ways. Using
different kinds of containers, with the expectation that
what’s inside will be new or interesting each week, has
provided excellent motivation for students who were
previously reluctant to attempt opening containers on
their own. Hand-over-hand assistance is provided at
just the right level to encourage students to do as much
as they can by themselves.

BOX 13-2 Activities to Encourage Hand
Strength
1. Play Dough
a. Use a garlic press to make “spaghetti.”
b. Use rolling pins to make pretend cookies
(shoulder and arm strength).
c. Press cookie cutters into flattened play dough.
d. Find hidden objects such as pegs, marbles, or
toys.
Note: Crayola Model Magic or clay also can be used,
depending on how much resistance is desired.
Homemade play dough provides less resistance than
the commercial variety.
2. Water sprayers (e.g., those found in a drug store for
“spritzing” hair)
a. Spray water onto pictures drawn with markers to
make them “melt.” (Note: This activity works
best if the markers are relatively new and the
drawing has just been completed.)
b. Spray a mixture of water and food coloring to
color snow (in northern climates).
c. Spray plants or outdoor bushes.
d. Spray the walls while in the bathtub, with the
shower curtain partially closed.
3. Geoboards: This is a grid of nails or plastic points.
Use rubber bands of varying thicknesses to create
designs, or use nylon potholder loops for less resis-
tance. (Cotton cloth loops often are too thick to
successfully stay on the points.)
4. Newspapers: Tear newspapers to stuff a scarecrow or
other classroom project.
5. Wringing out sponges or washcloths (e.g., as part of
a clean-up activity, or in the bathtub).
6. Squeeze toys such as the Swinging Monkey and the
Flying Fist (see Appendix for sources).
Smart Hands
Smart Hands manipulative activities typically empha-
size multiple skills within one activity. For example,
using a wind-up toy encourages isolated use of the
thumb and index finger, but may also require a sig-
nificant amount of finger strength, depending on the
resistance of the particular wind-up toy and on the
shape of the winding knob or key. It is important for
therapists to be familiar enough with their manipula-
tives to know which ones are appropriate for 3-year-
olds, and which ones are more appropriate for 4- or
5-year-olds. Classroom teachers often need guidance
about this as well. Some of the classroom building
manipulatives require more eye-hand coordination
than is expected for the typical 3-year-old, and if
teachers expect and encourage students to participate
in a too-demanding activity, students may begin to feel
that they are not successful with manipulatives.
When referring specifically to in-hand manipulation,
Case-Smith (1995) stated that
A Fine Motor Program for Preschoolers • 273
“practice of a component skill (e.g., translation) may or may not
generalize into improved functional performance (e.g., ability
to button). Although task analysis demonstrates that a similar
movement pattern is necessary in object translation and but-
toning, the therapist cannot assume that in-hand manipulation
skill will generalize to the task” (pp. 773–774).
Therefore the therapists provide activities that are not
just “OT materials,” but also provide direct experience
with typical, age appropriate classroom manipulatives.
Although therapeutic activities that address the com-
ponent skills of a task are beneficial, for the most suc-
cessful transfer of learning and skills to the classroom
setting, preschool students need the concrete experience
of learning to use specific classroom manipulatives
within the OT session. Following is a list of some of the
most popular Smart Hands activities and manipulatives
used in the program:
1. Play dough (bilateral coordination, fine motor plan-
ning, skilled finger use): Play dough can provide
excellent strengthening activities for preschool stu-
dents, but also can be used to encourage the devel-
opment of skills. The following activities are used
with students who are ready for more skilled use of
play dough:
a. Drawing in flattened play dough using a peg,
b. Rolling play dough balls: There are three levels
of difficulty available for this activity: (a) using
one hand and rolling the play dough on the table,
(b) rolling the play dough between two hands in
the air, or (c) using the thumb, index finger, and
middle finger to roll a small ball, and
c. Using play dough to make representative objects
(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
make a snowman, drawing the facial features
and buttons using a small stick peg, and then
adding two stick pegs for the arms). As students
become more skilled in their ability to make a
variety of shapes, their ability to create complex
creations will increase. Another variation is to
use small toys with the play dough (e.g., small
plastic babies from the baby shower section of
a party store inspired students to make cribs,
playpens, diapers, and many other representative
objects from play dough to use with the babies).
2. Stringing/lacing activities (skilled grasp patterns,
eye-hand coordination, bilateral use of hands): Of
all the manipulative activities available to the stu-
dents, this has proved to be one of the most valuable.
Benbow (1995) stated that
“bead stringing is the classic preschool activity for developing
speed and dexterity in the alternate use of translation patterns”
(p. 260).
274 Part III • Therapeutic Intervention

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 &
Baubles”)
Figure 13-8 Eye bolts lacing activity.
forming tasks that involve more complex
sequencing, such as lacing cards.
3. Finger isolation activities (individual finger skill,
pincer grasp):
a. Hopping ants: Use the plastic ants from the
commercial game, Ants in Their Pants, and
encourage students to use an index finger to
make them jump. Once students have mastered
the basic finger movement, therapists can set up
a variety of items for the ants to jump over, or
targets at which they can jump.
b. Spinning tops: Therapists should provide a wide
array of tops for spinning, with the easiest tops
being those with a thick stem. Spinning tops
helps students isolate the thumb and index
finger, and also encourages a skilled finger
motion (similar to the finger-snapping motion).
A “stemless top” can be used for students who
A Fine Motor Program for Preschoolers • 275
Figure 13-9 Tops, including a stemless top (“optic top,”
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
paper towels or coffee filters. (Note: young 3-
year-olds with fine motor delays usually have
difficulty with the motor planning necessary for
this activity, so it is more often used with the
older preschoolers.)
e. Tissue paper pictures: The therapist gives the
children scraps of tissue paper, and asks them to
roll each piece into a small ball by using only the
skill fingers. The balls can be glued onto con-
struction paper to form a picture. Sometimes
the therapist can draw a general shape (e.g., a
pumpkin outline) and the children can make
enough tissue paper balls to fill up the outline.
f. Coins and buttons: Children can play a variety
of games with buttons and coins, including
using the skill fingers to insert them into a bank,
picking them up and arranging them as part of
a counting or matching game, making designs
with buttons on the table, sorting buttons
according to size, and so on. Teachers in the
276 Part III • Therapeutic Intervention
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
wooden pieces into a formboard, and they often
incorrectly assume that because they cannot phys-
ically insert the piece, their initial impulse about
where to place it must have been wrong. It is
particularly concerning when students correctly
surmise where to place a piece, but then assume
that their visual assessment was wrong because they
cannot insert the piece successfully. These students
are provided with puzzles well within their range of
ability from a visual perceptual aspect, and are
helped to develop the physical strategies for
inserting the pieces successfully. They work first
with wooden puzzles, and then eventually work on
inserting pieces to Lauri rubber puzzles, which
often are more challenging in terms of both finger
dexterity and fine motor planning. Puzzles with
small pegs on top of each piece are helpful for
developing thumb-index finger isolation.
5. Zoo Sticks (strength, motor planning, grasp): This
plastic toy has an animal at the top, with two long
tweezer tips extending from either side of the body.
The child grasps the middle of the tweezers and
squeezes to pick up small objects. The therapist
scatters cotton balls across the table, and the
animals “clean up the trash” by picking up the
cotton balls and transferring them to a container
placed in the middle of the table. (Cotton balls have
proved to be the most successful material for pre-
schoolers to pick up.) Students with less skilled
hands tend to use a fisted grasp on the shaft of the
tweezers, whereas more skilled students tend to use
only their skill fingers (Figure 13-10).
6. Wind-up toys (grasp, strength): Wind-up toys are
available in a variety of levels of resistance, as well as
with a variety of different kinds of knobs. The larger
the diameter of the knob, the easier it usually is for
students to turn. Some wind-up toys come with a
built-in key-shaped knob, which is typically the
easiest kind to wind. Therapists should be familiar
with the resistance levels of the various wind-up
Figure 13-10 Zoo sticks with cotton balls.
toys in their collection so they can provide the
appropriate level of challenge for a given student.
There is remarkable variety in the levels of resistance
among the different wind-up toys available. Wind-
up toys are particularly useful because the motor
plan for the winding motion is important for func-
tional tasks such as turning the volume knob on a
radio, or closing a screw-top jar.
7. Stickers: This activity is good for students who are
just learning to isolate the thumb and index finger
to pull a sticker from the backing, before the OT
session the therapists remove the background paper
surrounding the stickers so that it is easier for the
students to be able to determine the exact edge of
the stickers to pull them off independently. Students
begin with large-size stickers and transition to smaller
stickers. Eventually they can separate stickers from
the background paper with no difficulty. Therapists
can use a variety of stickers, including the colorful
circle stickers of various sizes (which do not have the
background paper) available at office supply stores.
8. Buttoning (grasp patterns, motor planning): For
therapists who have access to a sewing machine, a
simple homemade button game can be created
using interfacing sewn between two 4-inch square
pieces of fabric. Half of the sewn squares have a
buttonhole in the middle, and the other half have a
button sewn onto them. The game can be graded in
difficulty, based on the button size. Each set of two
sewn squares should have two matching buttons
associated with it; one button is sewn to the
matching cloth square and the other button is
loose. Children first practice putting the loose
button through the hole and pulling it out the
other side. Once they understand the concept of
putting the button through the hole, they use the
button that is sewn to the matching cloth square. At
least some of the buttons and buttonholes should

Figure 13-11 The button game.
be large, so that there is room for the therapist’s
fingers along with the child’s during the hand-over-
hand stage of teaching (Figure 13-11). Once
children can button and unbutton all of the square
sets in the button game, they are ready to button
and unbutton a variety of old cardigan sweaters
(with varying button sizes to grade the activity for
difficulty) that are stored in the OT clinic for that
purpose. It is surprising how motivating it is to
students to button and unbutton a “grown-up”
sweater. (Note: For practice with buttoning an adult
size cardigan, the sweater is placed on the table, not
worn by the student.) The sweaters also help stu-
dents to understand sequencing buttons on a gar-
ment. Eventually, students work on buttoning and
unbuttoning their own garments.
9. Bristle Blocks (strength, visual motor, motor plan-
ning): Although a wide variety of classroom-type
manipulatives are available, Bristle Blocks are one of
the most valuable because they are so versatile.
They are initially used as part of a strength-building
program, as they can be difficult for some students
to join and separate. Once students have mastered
the strength component of Bristle Blocks, they are
then able to build in a variety of ways. These blocks
provide more variety than Duplos, because they can
be used in both horizontal and vertical orientations.
They encourage the development of eye-hand
coordination, and can also be used to encourage the
development of representative building (e.g., stu-
dents can make a table, bed, house), which in turn
can facilitate many other areas of development
(e.g., visually copying from a model, language,
cooperative play).
Although all of these activities encourage the devel-
opment of the muscles needed for fine motor skills, the
A Fine Motor Program for Preschoolers • 277
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-
nificant hyperextensibility in their joints, however,
alternative grasp patterns may be necessary for them to
perform an activity successfully. Because of their joint
laxity, they often do not have a good physical foun-
dation in their fingers to support skilled grasp patterns
with small manipulatives. Children with hyper-
extensible fingers use the limits of their hyperextensible
joints to create grasp patterns that provide them with
the stability they need for motor tasks. By choosing
these alternative grasp patterns, however, they sacrifice
the ability to use fine, skilled movements because they
are choosing stability over skill.
Hyperextensible finger joints are not particularly
unusual, but they sometimes require that adults
working with a child help that child to be successful in
fine motor tasks through a variety of adaptations. For
example, the dexterity necessary in fine motor tasks
perhaps should be reduced until the child is better able
to sustain skilled grasp patterns with small objects.
Also, the child may use an adapted pencil grasp (rather
than the traditional “tripod grasp”) that provides both
stability and skill at the same time. Benbow (1995)
stated that
“the functional use of the hand depends more on joint stability
than joint mobility. Children adopt many ways to make their
hands work for them when they lack joint stability” (p. 267).
The therapist must know the limits of the child’s
hand skills well enough to know when to try to elicit a
more traditional skilled grasp with manipulatives, and
when to recognize that the child is using as skilled a
grasp as is physically possible for that child.
The preceding list of activities is meant to provide
enough examples so therapists will be guided in their
ongoing selection of a wide variety of therapeutic
activities and toys. Parents, teachers, and children con-
stantly contribute new activity ideas, and many of the
traditional preschool activities (e.g., gluing pasta and
278 Part III • Therapeutic Intervention
beans to make collages) provide the same kinds of
appropriate fine motor challenges as those listed in the
preceding list of Smart Hands activities and manipula-
tives. When therapists consult with teachers, it is
valuable to suggest new activities, but it is even more
valuable to point out those activities and toys already
available in the classroom that help children to develop
good hand skills. One particularly helpful way to
provide a workshop at a local nursery school is not only
to bring toys from the OT clinic, but also to select toys
from the school’s classrooms ahead of time so that their
merits can be pointed out to teachers. Incorporating
the school’s toys and materials into the workshop can
regenerate teachers’ interest in toys that previously
seemed humdrum.
FINE MOTOR PLANNING
Many preschool students who receive OT services have
a fine motor planning problem, which may or may not
be accompanied by immaturities in fine motor skills.
The students with more severe fine motor planning
difficulties tend to have a diagnosis of Pervasive
Developmental Disorder–Not Otherwise Specified
(PDD-NOS), or Autism Spectrum Disorder, whereas
the students with milder fine motor planning
difficulties may have no formal diagnosis at all. For all
students with motor planning difficulties, assistance in
the form of hand-over-hand help, visual modeling, pic-
ture sequence directions, and verbal cues should be
provided when unfamiliar fine motor tasks are pre-
sented. The assistance is faded as the student becomes
more independent with the task, with hand-over-hand
assistance being eliminated first. Once a student has
mastered the use of a specific manipulative or toy, a
similar manipulative or toy is introduced. This process
is repeated over time, with occasional repeated presen-
tation of the original manipulative or toy, so that the
student develops improved ability to generalize among
similar fine motor tasks.
One reason that therapists provide such a large
variety of activities within one activity domain (e.g.,
stringing tasks, wind-up toys, tops) is so that students
Roll the dough Push the cookie cutter
Figure 13-13 Step-by-step picture sequence directions for making play dough “cookies.”
with motor planning difficulties can sharpen their
ability to apply motor plans from one fine motor task to
a different one. For students with moderate to severe
motor planning difficulties, coordinating matching
materials between the classroom and OT clinic is
particularly critical. The classroom staff is instructed in
the physical or verbal cues that should be used with that
student, and cues fade in all settings as the students
make progress. Students with a milder level of fine
motor planning difficulty are able to quickly make
associations among similar tasks, and do not need the
daily repetition of the exact same motor tasks because
they are able to generalize much more easily from tasks
performed in the OT sessions to materials available in
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
materials available in the students’ classrooms so that
the OT activities will ultimately provide the students
with the skills they should successfully and indepen-
dently use with the fine motor materials at school.
It is often difficult for students with moderate to
severe motor planning difficulties to complete multi-
step art projects. Students in the self-contained class for
autism spectrum disorders complete the same therapist-
planned art project every single day for 1 week. The
repetition over 1 week’s time significantly increases
their independence by the end of the week. Because it
is difficult for these students to make generalizations,
even though the project is the same every day for a
week, it seems new enough each day so that it is still
interesting and challenging to them. They are able to
recognize their improved independence as they
complete the fifth and final version of the project. A
typical art project for this class might include a page
with three outlines of circles, accompanied by three
circle-shaped pieces of construction paper in red,
yellow, and green. The students must either follow a
visual model, picture sequence directions, or verbal
instructions to correctly glue the construction paper
circles to create a picture of a stoplight on the paper.
See Figure 13-13 for an example of step-by-step picture
sequence directions for a play dough activity.
Take the extra away Cookie on the pan

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
handle of the scissors should rest on the distal joint of
the thumb (Figure 13-14). The tips of the scissors
should be pointing away from the child, and the wrist
of the cutting hand should be in extension (Benbow,
1995). When cutting, movements of the fingers should
be in the intermediate range of excursion between very
flexed and very extended to use the intrinsic muscles to
their maximum benefit (Benbow, 1990a,b).
Many children hold scissors with the thumb and
index finger in the handles. This position does not
allow for proper control of the scissors, and does not
help develop the hand for fine motor skill. When
scissors are held in this manner, the scissors movements
are performed primarily by the larger muscles of the
forearm rather than primarily by the intrinsics
(Benbow, 1990a,b). Parents and teachers can make a
tremendous difference in a child’s hand development
simply by teaching the proper scissors grasp. It is
necessary to check throughout the year to be sure
children continue to use the correct grasp because in
the early stages of learning the habit can be lost.
The best scissors for children have sharp blades,
blunt tips, and small-holed handles. In recent years the
trend for children’s scissors has been for the handles to
be formed in such a way that they actually discourage
the use of the correct scissors grasp. Rather than have
children use scissors in their skill fingers, the design of
these scissors encourages children to place all four
fingers in the handles and keep their index finger on the
inside of the lower handle (Figure 13-15). The near-
Figure 13-14 Correct scissors grasp.
A Fine Motor Program for Preschoolers • 279
Figure 13-15 Incorrect scissors grasp, encouraged by a
less than desirable scissors design.
ubiquitous use of this style of children’s scissors can
make it difficult for therapists to reinforce the correct
scissors grasp in their students. The Children’s
Learning Scissors (available from several sources, see
Appendix) and, in rare cases, the Craft Scissors (a larger
version of the same scissors, used only for exceptionally
large preschoolers) are used exclusively in the Newton
Early Childhood Program for all preschoolers. The
therapists recommend that community nursery school
students who receive after-school OT services be pro-
vided with Children’s Learning Scissors for use at
home. Because many community nursery schools order
low-cost scissors in bulk from educational catalogues, it
has been challenging to convince them to purchase the
Children’s Learning Scissors, although some local
schools do use them. Therapists see a significant dif-
ference in scissors skills between students who use the
Children’s Learning Scissors with the correct grasp,
and students who use commercial scissors similar to
those pictured with an incorrect grasp.
Cutting with scissors is an excellent fine motor
activity, and scissors activities can be adapted to children
of varying skill levels. Three and one-half years of age is
the appropriate time for the majority of children to begin
learning scissors skills, because before this age most
children have not yet developed adequate separation of
the two sides of the hand to be able to isolate their skill
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-
vities for preschoolers is listed in Box 13-3. Many
280 Part III • Therapeutic Intervention
Hierarchy of Scissors Skills Used
BOX 13-3 for Planning Activities for
Preschoolers
Grade the scissors activities in this order:
1. Snip narrow strips of paper, approximately 1/2-inch
wide.
Teaching goals:
a. Learn to position scissors correctly on fingers.
b. Learn the cue, “thumbs up” while cutting (to
encourage a neutral forearm position, rather
than pronation).
The “confetti” cut by students can be saved in large,
clear plastic jars. Students are motivated to cut several
strips of paper at a time so they can add their paper to
the growing pile in the jar. Another activity at this level
of development might be to have the children “fringe”
the edge of a piece of paper.
2. Cut on pre-drawn lines on narrow strips of paper
(1/2-inch wide).
Teaching goal: Learning to “aim” and direct the
scissors when cutting.
3. Cut on pre-drawn lines on strips of paper 1 to
2 inches wide.
Teaching goals:
a. Students begin to develop repeated cutting
skills; this means that they do not close the
scissors all the way each time they cut, as they
did in the previous two stages of scissors skills.
b. Students learn to have the “helper hand” also be
“thumbs up” (i.e. wrist position in neutral)
while holding the paper for cutting at this stage.
(If the hand holding the paper is pronated, the
cutting hand tends to also pronate.)
4. Cut straight-line shapes such as squares and
triangles.
Teaching hints to provide to students:
a. Cut off excess paper as you go along.
b. Turn the paper, not the scissors.
c. Do not tear the paper when using scissors.
5. Cut rounded shapes.
Teaching hint: Keep the bulky side of the cutting
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-
sized”) markers for drawing and writing. Crayola
markers are the most widely used, because the stripe
near the writing point provides an excellent visual cue
to help children to remember where to place their
fingers. The diameter of the writing implement and its
effect on pencil grasp recently has been commented on
in the literature (Burton & Dancisak, 2000; Windsor,
2000), but a final conclusion about what diameter is
best has not yet been determined. However, it seems
that it might be useful for therapists to be flexible about
trying smaller-diameter implements in cases in which
preschoolers are having significant difficulty developing
a skilled grasp on large-diameter drawing implements.
Therapists in the Newton Early Childhood Program
rarely use crayons with the students who are receiving
OT services. This is because markers offer little resis-
tance to make a mark on paper, whereas crayons require
significant pressure. Crayons provide an unnecessary
challenge that makes it impossible for some students to
develop a skilled grasp with drawing implements. In
addition to large-diameter markers the therapists some-
times use large-diameter pencils, and paintbrushes of
various handle thicknesses. To encourage students to
hold close to the tip of the brush, the upper half of the
paintbrush handle can be cut off before use.
The normal sequence of development is that children
initially use a static grasp on a drawing implement, and
then progress to using a dynamic grasp (see tripod
grasp in Figure 13-16), with the hand and forearm
resting on the table. Because preschoolers are at a
malleable stage of fine motor development, and
because the preschoolers referred to the Newton Early
Childhood Program are considered to be at-risk, the
program therapists and teachers encourage children to
use either a tripod or quadrupod grasp. The quadrupod
grasp is similar to a tripod grasp, except that the ring
finger also is on the shaft of the drawing implement.
These open web space grasps also are used to perform
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
hyperextensible fingers. When the thumb is hyper-
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).
Using large-diameter markers with the slant board sur-
face encourages children to keep the thumb in flexion
while drawing or writing to facilitate a fully opened web
space posture.
Regardless of the less-skilled grasp variations that are
necessary to increase stability for some students,
therapists try to ensure that every single student uses
the skill fingers to hold and manipulate the drawing
implement, and that they are able to achieve a dynamic
grasp of some sort (with the drawing hand resting on
the table) by the time they enter kindergarten. In other
words, no student in the program “graduates” from
OT services while using any of the “primitive grasps”
discussed by Schneck and Henderson (1990), although
a number of students enter kindergarten using a static
rather than a dynamic grasp. The primitive grasps
include those in which the implement is held in the fist
like a hammer, the digital pronate grasp with only the
index finger extended (Figure 13-17), and others.
The integrated preschool classrooms are all provided
with developmentally appropriate drawing materials such
as large-diameter markers and slant board or vertical
drawing surfaces. The students’ grasp patterns with
drawing implements are monitored regularly by the
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
into his or her educational program, as well as the OT
program.
To help children learn how to hold a drawing
implement, they are asked to form a rounded circle
(often referred to in this practice as a “lobster claw”)
with their thumb and index finger. (Because the pro-
gram is located in New England, most of the students
A Fine Motor Program for Preschoolers • 281
Figure 13-17 Digital pronate grasp, with only the index
finger extended.
are familiar with lobsters.) The children are asked to
have the lobster hold the stripe at the base of the
Crayola marker, and all drawing or writing activities are
carried out on a 20-degree slant board.
Initially, children should be encouraged to begin a
drawing with the skilled grasp pattern, but not be
expected to use this grasp pattern for the entire
drawing. Once they develop the habit of initiating
drawings with the correct grasp, they typically develop
the endurance to use the skilled grasp for longer
periods each time until it eventually becomes their
preferred grasp. Some children quickly develop the
understanding of where to place their fingers, but may
keep the shaft of the marker under their palm in a
digital pronate grasp. With these children therapists
might place a sticker at the top of the marker as a visual
reminder: If the child cannot see the sticker they know
that they need to reposition the marker in their fingers.
When the child slips out of using the correct grasp,
instead of saying, “You need to fix your fingers on the
marker,” therapists can say, “Where’s the lobster?” This
whimsical way of pointing out that the marker is not
being held correctly seems to be palatable to children;
instead of correcting a mistake they are “finding the
lobster again.”
HAND PREFERENCE
The strongly academic nature of the kindergarten
curriculum in the surrounding community dictates that
students are more comfortable and successful in
kindergarten if they have developed adequate skill for
drawing, writing, and scissors use for at least one hand.
This means that it is useful to know which of a child’s
hands is significantly more skilled. For most students,
282 Part III • Therapeutic Intervention
the preferred hand is clearly evident. For the rest of the
students, preferred hand use is observed for a variety
of tasks, including but not limited to the following:
spinning tops, other one-handed manipulatives (not
including wind-up toys), pretend motions (e.g., “Show
me how you stir the soup,” “Show me how you brush
your teeth”), and use of a drawing implement. Parents
might be asked with which hand the child eats. Obtain-
ing a family history also can be useful; left handedness
may run in a family. Hand grasp strength testing is not
useful for this purpose because many people show
greater strength in their nonpreferred hand (Clerke &
Clerke, 2001). Noting the hand preference for scissors
is not always useful, because many left-handed people
skillfully use scissors with the right hand. Because the
turning motion for the knobs on wind-up toys is in a
right-handed skilled direction, many left-handed
children turn wind up toy knobs with the right hand.
Because many toys and tools in the everyday
environment are oriented toward right-handed people,
left-handed people typically develop a much greater
level of skill using the right hand than right-handed
people do with the left hand. It is perfectly functional
for students to seem “ambidextrous” for most manipu-
lative activities, but it is strongly preferable that in the
months before kindergarten, they develop a consistent
hand preference for writing and drawing, and a con-
sistent hand for scissors activities (not necessarily the
same hand). This is acceptable, as long as they are con-
sistent about the hand used for the specific type of task.
Children are not encouraged to use one hand more
than the other unless there is a significant and clear
difference in ability between the two hands. Most 41⁄2-
year-old children are able to recognize that difference,
and choose to use their more skilled hand on their own.
If the preferred hand and eye do not match, the child
might consistently use the preferred or more skilled
hand for drawing, writing, and scissors activities, but
lead with the nonpreferred hand (the one that cor-
responds to the preferred eye) for a variety of manipula-
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
(1999, 2000a,b), which is a series of three books
based on the three seasons of the school year. These
books are composed of reproducible activity pages
that, in addition to developmentally sequenced
tracing activities, also include simple drawing activ-
ities, mazes, easy dot-to-dot pictures, and many
other classroom activities related to the season.
Because all of the pages include at least a few small
pictures, these worksheets provide an excellent way
to also work on coloring skills.
2. S.O.S.: This version of S.O.S. is similar to the
original version, except that initials are not used in
the squares. The child and therapist each choose a
differently colored marker, and one person starts
the game by drawing a vertical or horizontal line
between two adjacent dots. The next person draws
a line between two dots, and the players keep taking
turns drawing lines in an attempt to finish a square.
The person who draws the fourth side of any square
is allowed to make a dot inside that square, thereby
marking it as his or hers. Once all the squares in a
grid are completed, each person counts his or her
dots and a winner is declared. This is an excellent
prewriting game for teaching pencil control,
starting and stopping ability (needed for printing
letters), and encouraging top-to-bottom and left-
to-right formation of writing strokes. It can also
encourage top-to-bottom and left-to-right sequenc-
ing when the therapist or teacher helps the child
organize his or her counting of the dots to deter-
mine the winner. Children can develop some
strategy skills as they begin to learn how to plan
their move so that their opponent’s next move will
not finish a square. S.O.S. grids can vary widely in
size, but a 16-dot grid seems to work best for most
preschoolers (Figure 13-18).
3. Drawing: Many students have difficulty not only
with the physical control of the pencil, but also with
the visual organization of drawings. It is beyond the
scope of this chapter to fully discuss visual percep-
tion and its relationship to making representative
Figure 13-18 (Left) Blank S.O.S. grid. (Right) S.O.S. grid
game in progress.

drawings, but a short summary of the learn-to-draw
program is provided. In this author’s experience,
interest in representative drawing typically begins
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
pencil; and can draw a vertical line, horizontal line,
and circle, they can begin playing representative
drawing games. These games follow a sequence of
using basic shapes to organize drawings. Preschool
children tend to see objects as being made up of
one or more basic shapes, rather than seeing the
outline (or contour) of the object (as older children
tend to do) (Ziviani, 1995). Therefore instead of
outlining the shape of a train they are drawing,
children tend to draw a rectangle for the train car
with circles underneath it for the wheels. The learn-
to-draw program begins with drawing circles, and
children modify their circles to become a variety
of different objects, such as a lollipop, pizza, or
balloon.
Once children are comfortable drawing circles,
and then making them into representations of real
objects, they are taught to draw squares and rec-
tangles. They are first shown how to draw the two
vertical lines, and then join them with two hori-
zontal lines. The children next draw squares or
rectangles and modify them to become something
representative (e.g., a square with lines on it can
become a gift with ribbon tied around it). They are
soon able to combine circles with squares or rec-
tangles to become trucks, trains, a radio with circu-
lar knobs, or a door with a doorknob. Eventually
they learn to draw triangles, which come last
because the ability to draw diagonal lines comes
later in development than vertical and horizontal
lines. The possibilities for combining the three basic
shapes are endless. A typical house drawing includes
all of the basic visual constructs, including a plus (to
encourage crossing the midline) for the window-
panes. Children who are provided with practice at
making the basic shapes, as well as guided oppor-
tunities to combine them into drawings, tend to
develop the skills and self-confidence to subse-
quently create a variety of drawings on their own.
4. Writing: Most children are able to write the letters
of their first name in capital letters, correctly
sequenced from left to right, by the time they enter
kindergarten. Many children begin learning to
write their first name between 4 and 5 years of age,
with girls often learning to write their name earlier.
At the latest, all students in the Newton Early
Childhood Program begin learning to write their
first name by January of their final year of
preschool.
A Fine Motor Program for Preschoolers • 283
Box 13-4 is a developmental hierarchy that
therapists can follow when teaching students to
write their name. Some students are able to start at
Developmental Hierarchy to
BOX 13-4 Follow When Teaching Students
to Write Their Name
1. For students with significantly decreased fine motor
skill and control, as well as some visual disorganiza-
tion, name stencils can be made using oak tag and
an Exacto knife. The students can trace the letters
error-free with the stencil until they can write their
names independently. Another good strategy for
early learners is to laminate a copy of their first
name, and then have the students practice by using
a marker to trace and erase multiple times over the
laminated example. Even at this early stage one
should teach students to use top-to-bottom and
left-to-right strokes.
2. The adult can write the student’s name using dots
for tracing and have the student trace over the dots.
Being very consistent about having them form the
letters the same (and correct) way every time helps
these students avoid having to reinvent their letter-
writing strategy every time they try to write their
names. For children with a long name, have them
learn the first few letters independently, and then
add on more letters. If they insist on writing their
entire name, have them do the first part indepen-
dently and then provide dots to trace for the rest of
the letters. For a student who is unable to visually
understand tracing a series of dots, write the name
in yellow marker and have the child trace over it.
For students who are unable to remember the direc-
tion for the strokes, make a brightly colored dot
with a different colored marker at the ends of each
line to be traced (therapists often use green for
“start,” and red for “stop”).
3. Once students can successfully trace their name in
dots, encourage them to begin to write the letters
independently. During this transition therapists
and teachers provide an oak tag strip with a visual
model of the name to copy. Large visual models
with at least 1-inch high letters work best with
preschoolers.
For 4-year-olds who have a name that begins with a
difficult letter such as “S” or “Z,” or letters with any
diagonal lines, it usually works best to have them trace
the fully written letter rather than just the dots, at least
at first. Students can be encouraged to make a “rain-
bow letter,” which means that they trace the already
written letter multiple times with several different
colors of markers so they can get additional practice
tracing a difficult letter. Eventually, the kinesthetic
memory helps them to write the letter independently,
even though those difficult letters may continue to be
challenging for them (from a developmental aspect),
depending on their current chronological age.
284 Part III • Therapeutic Intervention
Level 2, whereas others initially need the support of
the suggestions in Level 1. If a student is unable to
write his or her name independently by the end of
the final preschool year, he or she can use one of the
methods from Levels 1 or 2 from this list.
WHAT MAKES THERAPY
EFFECTIVE?
There are significant developmental differences between
young preschoolers (3 to 4 years) and older pre-
schoolers (41⁄2 to 5 years). Three-year-olds need activities
that are so intrinsically enjoyable and motivating that
they may not even be cognizant of how challenging the
activities are. In the sessions with younger children,
therapists might present eight or more activities within
a 30-minute session, as students’ attention spans are
shorter and they need a great deal of stimulation to
continue working on tasks that are difficult for them.
For most activities therapists try to find a level of
challenge that is only a small increment above the
students’ current level of performance, and always
include one or two activities that are within their
current level of performance so that the children can
experience a feeling of mastery.
The preschoolers rarely ask why they are attending
the OT sessions, and simply refer to these sessions as
“my afternoon school.” For students who are
particularly savvy, and who initially question why they
are participating, therapists encourage parents to say
something like, “You mentioned that the projects at
the art table at school are hard for you, and this [OT]
is a class that will help you learn ways to make it easier
and more fun for you.” All students, particularly those
for whom the initial evaluation was somewhat stressful,
typically demonstrate a tremendous sense of relief after
the first treatment session. They quickly recognize that
they will have a regular opportunity to participate in
fine motor activities that are at the correct level of
difficulty for them, which provides a huge boost to
their confidence. Furthermore, most of the students
are eager to learn the “tricks” that the therapists show
them, and the community preschool teachers typically
report that 1 to 2 months after beginning OT treat-
ment, the students’ attitude and behavior begin to
change significantly in the classroom. In particular, the
students tend to demonstrate increased risk-taking at
school by choosing manipulative activities they had
previously avoided, and they also come willingly (and
sometimes even spontaneously) to participate in class-
room art projects. The willingness to try is the most
important aspect of development that an occupational
therapist can encourage. Once children begin expe-
riencing an appropriate level of fine motor challenge on
a regular basis, their skill levels begin to improve and
they often begin to bring in projects from school or
from home to show the occupational therapist.
Progress toward treatment goals is made, therefore,
through an ongoing process that occurs throughout
the week, not just during a therapy session.
Most children have a desire to please adults, and many
children in the early stages of treatment find it easier to
cooperate with their therapist in the supportive clinic
environment to perform challenging fine motor activities
than with their parents or teachers. Therefore the occu-
pational therapist is often the first person that can entice
a child into attempting something difficult. The ability to
grade activities and task analyze them helps occupational
therapists to ensure successful experiences for students
the first time they try a new activity. Occupational thera-
pists have the ability to change the child’s attitude, which
may be the most important contribution therapists can
provide to help a child.
The child should establish a good working relation-
ship with the occupational therapist before activities are
introduced at home. Therefore fine motor “home-
work” usually is not assigned in the initial months of
therapy, and possibly not at all. Also, it is often difficult
for parents to adopt a low-pressure, encouraging
attitude, because of their close relationship with the
child. Sometimes the parent–child “fit” does not com-
fortably allow for a continuation of the therapy work at
home. Decisions about whether or not to provide home
activities are made individually for each child, depend-
ing on the unique family features of each specific case;
however, a few recommendations are typically made to
all parents.
In general, therapists ask parents to encourage their
children to participate in naturally occurring fine motor
activities at home, and they discourage home programs
that place parents in the position of being a “second
therapist.” This means that parents should make avail-
able an age-appropriate array of typical preschool
manipulative materials. For the very young students,
parents might be asked to put away the drawing and
writing materials so that the child spends most of his or
her time on manipulative activities. Parents also are dis-
couraged from allowing their children to spend a great
deal of time using a computer. Although many researchers
and professionals who work with children do not
recommend the use of a computer under 5 years of age
(and for some the lower limit is 7 years) (Meltz, 1998,
1999), many parents seem to have difficulty setting
limits on computer use with their preschoolers. Setting
a time limit (e.g., no greater than a specified amount of
time per day), and using a timer has been helpful for
many families. Fine motor activities that children can
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
strength and skill can be encouraged. Children can roll
out small amounts of dough with their own small
rolling pin, and cut cookies with cookie cutters. Sugar
sprinkles should be placed in a small bowl so that the
children have to pick them up with their fingertips to
decorate the cookies. Children also can participate in
tearing lettuce, pressing out pizza dough, pressing
toothpicks into cheese squares, and other kinds of food
preparation using their fingers.
2. Creating Wrapping Paper: Blank newsprint can be
taped to the wall and children can decorate it with ink
stamps, sponge painting, markers, or other materials.
The paper then can be used to wrap gifts for family
members or friends. Older preschoolers can learn to
use table tape dispensers (which require fine motor skill
and planning) to obtain tape for the package they are
helping to wrap.
3. Spray Bottles: These can be used in the bathtub or sink
at home, or to spray bushes and plants outside. Add a
Therapists try to help parents understand the
importance of using manipulatives rather than writing
utensils in promoting hand development. In particular,
parents are encouraged to look at commercial toys in
new ways. Many commercial toys “do it all” for the
child, particularly some of the electronic games. Other
toys, such as games with small parts, tiny blocks, and
miniature doll dishes, require skilled finger positions
and regulation of the intrinsic muscles that are needed
for skilled grasp and placement. Parents are asked to
evaluate their child’s toys and work toward a balance
between the toys that require minimal skill and those
that require more skill. Parents learn that although a
toy requires the use of the hands, it may call for wrist
and arm movements more than finger movements, and
therefore may not further the development of fine
motor skill. If parents wish, they are encouraged to
bring a child’s toy to an OT session so that the therapist
can use the toy with the child and provide feedback to
the parent about whether or not the level of difficulty is
A Fine Motor Program for Preschoolers • 285
small amount of food coloring when spraying snow.
Students usually begin by using two hands on the spray
bottle, and as they grow stronger they are able to use it
with just one hand.
4. Prewriting Activities: Parents are asked to provide
Children’s Learning Scissors (see Appendix) for either
the right or left hand, as needed, large diameter
markers, paper, and a 20-degree slant board drawing or
writing surface of some kind. Parents often purchase an
additional pair of these scissors for the child to use at
school.
5. Drawing and Writing Activities: Rather than have
preschoolers sit down for “work time” at home, if
a child chooses to draw at home, parents are asked to
include the drawing with a letter to a friend or relative.
If the child is learning to write his or her name, it can
be written on the card or letter. That way, the
functional use of drawing and writing is reinforced, and
the child is less likely to feel that the parent is trying to
act as a therapist or teacher.
appropriate for the child’s current developmental level.
The ability to analyze the components of both
therapeutic and day-to-day activities is one of the most
important skills of the occupational therapist. Although
it would be impractical to fully educate parents and
teachers in this skill, it is possible to teach them to
analyze fine motor activities well enough so that they
are truly part of a team with the therapist. An involved
parent can make important contributions to a child’s
progress, because once parents understand the con-
cepts behind fine motor development they are able to
see activities in a different way. The parents and teachers
feel empowered, and instead of feeling mystified or in
awe of the therapist’s special activities, they become
contributors in an ongoing process. This kind of
partnership strengthens mutual respect and enhances
the child’s progress. It cannot be overemphasized how
important it is for everyone to understand the sequence
of normal development, even if they are not taking an
active part in providing the activities.
286 Part III • Therapeutic Intervention
CASE STUDY
Tim became a student in an integrated preschool classroom
at the Newton Early Childhood Program in the middle of
winter, as he had just turned three years old and was eligible
for services from the public schools. He had been given a
diagnosis of PDD-NOS, with the primary referring con-
cerns including immaturities in his language development,
social skills, play skills, reduced eye contact, and apparent
unresponsiveness when he was called by name. Before
entering the program, Tim had been receiving services from
Early Intervention, including physical therapy, OT, speech
and language therapy, home visits, applied behavioral
analysis, floor time, and a center-based toddler group.
Specific difficulties noted by his two Early Intervention
occupational therapists included heightened sensitivity to
tactile inputs, avoidance of vestibular-based activities, over-
all low muscle tone, and immature fine motor skills.
When Tim became a student in the integrated classroom,
all of the preceding difficulties were noted, although he
presented as a student with significantly reduced attention
rather than as a student with PDD-NOS. The OT evalua-
tion that was completed during Tim’s first few weeks of
school indicated that although he had hyperextensibility in
his fingers and reduced fine motor skill (both eye–hand
coordination and grasp patterns), his most significant fine
motor problem was his difficulty intuiting motor plans for
using manipulatives. At that time Tim showed a preference
for his right hand, but used both hands fairly interchange-
ably, which is not unusual for a 3-year-old. When picking up
small objects, Tim tended to use a whole-hand pattern
(raking) rather than the expected pincer grasp. He would
even hold the tip of a lacing string in the palm of his hand
rather than with his fingertips. Tim also showed im-
maturities with puzzles and copying designs, so it was
recommended that visual perceptual skills also be included
in his educational and treatment plan. Tim was referred for
OT to address fine motor skills, visual perceptual skills, and
sensory integration difficulties.
The treatment notes from Tim’s first OT fine motor
session indicate that the session was only 15 minutes long,
which was the maximum length of time he was able to
participate in structured tabletop tasks. Only five activities
could be presented during that first session. Instead of using
a top with a stem for twirling, Tim used a stemless top that
simply required a brush of the hand to make it spin. He also
used the Flying Fist toy (the child squeezes the base to make
the top portion, the hand, pop off), at which point it
became clear that his overall hand strength also was reduced
for his age. His first stringing activity was placing the
medium rings (1⁄2-inch) onto gimp, which was difficult for
him. He did not spontaneously seem to understand that he
should place his fingers close to the tip of the gimp; rather,
he held far back on the gimp, which made it impossible for
the tip to be inserted into the ring. (Like Tim, many young
students need cues to hold close to the tip of the string.)
Two weeks later Tim could independently string the
1
⁄2-inch rings because he had learned the motor plan, but his
eye–hand coordination was still poor. Six weeks later Tim
was independently selecting his thumb and index finger to
hold the tip of a lacing string, and also was occasionally
placing his fingers at the tip of the string without reminders.
Tim was, however, unable to use his skill fingers when a new
activity, making small balls out of tissue paper, was
introduced. Rather, he used his entire hand to make the
small tissue balls. A few weeks later, the therapist introduced
pop beads in the shape of vehicles, and Tim was unable to
recognize the similarity between these pop beads and the
“regular” Fisher-Price pop beads that he had played with at
home. He needed full hand-over-hand assistance to be able
to use the vehicle pop beads. He was, however, able at that
point to string objects with a 1⁄8-inch hole, and his bilateral
coordination for this kind of task was becoming smoother.
A “spiral approach” for planning fine motor activities
continued for the next year, with activities that had been
mastered being replaced by similar but new ones, and as
those were mastered the original activities were cycled back
through the activities list to be sure Tim could still perform
the original task that had helped him form the motor plan.
Tim’s tolerance for tabletop work gradually increased so
that after 3 months of OT he could work with the occu-
pational therapist and one peer for 30 minutes, and his
ability to work at tabletop tasks in the classroom gradually
increased as well. Although his attention continued to be a
problem, his increased levels of skill, interest, and self-
confidence helped him to be able to focus for longer periods
of time in the classroom, where there were more
distractions than in the quiet, nondistractible, OT treatment
space.
Tim developed more skill in all the areas of fine motor
development, and he was retested at 4 years of age by the
occupational therapist a year after his first evaluation upon
entering the preschool program. During his first year in the
program, his preferred hand seemed to have become less
obvious. After initially appearing right-handed for a period
of time, he now appeared to be strongly left-handed. Later,
he began to again use his right hand more often. He
showed a consistent preference, however, for his left eye,
and his family had a strong history of left-handedness.
Although both hands tested below age level for hand grasp
strength, his right hand was significantly stronger than his
left. Testing indicated that Tim had some visual perceptual
skills that were within age limits, such as his puzzle skills and
design copying skills with marker and paper (e.g., vertical
line, horizontal line, circle). He continued to show im-
maturities in the area of hand grasp strength, however, and
as scissors activities and drawing activities had been
introduced by this time, immaturities with scissors skills and
grasp and control of large diameter markers were seen.
Tim’s finger hyperextensibility also contributed to his fine

CASE STUDY—CONT’D
motor immaturities. At that point his fine motor planning
difficulties were considered to be mild, although still
present. His ability to generalize motor plans among similar
manipulatives had significantly improved over his first year
of preschool.
With the use of a 20-degree slant board surface, large-
diameter markers (no crayons), and gentle but consistent
reminders about using the correct pencil grasp, Tim made
the transition to using a static tripod grasp, and finally
developed the beginnings of a mature tripod grasp as he
began to rest his hand on the table more consistently. Two
years after entering the program, at 5 years of age Tim
finally established the consistent use of his right hand for
drawing and scissors use. He would occasionally forget and
place scissors in his left hand, but after starting to cut he
would realize that the scissors were on the incorrect hand
and switch them on his own. With markers, he was con-
sistent about using his right hand. His ability to write his
name gradually changed from being an arm and wrist skill
with the letters filling up an entire page, to being a finger
skill. By February of that year, he was able to sign his
Valentines with the letters of his name only 1⁄2 inch high.
Tim worked his way through the more difficult levels of
the fine motor skills curriculum, including buttoning activ-
ities and multistep manipulatives. His hand grasp strength
continued to test at the level of a child approximately 1 year
younger than his chronological age of 5, although he was
able to open and close all of the containers expected for
a child his age, and could turn the knobs on even the
most resistive of the wind-up toys used in the treatment
sessions. Fine motor planning difficulties were rarely seen,
and when they appeared Tim was able to learn a new motor
task with only minimal verbal cueing, and no physical
assistance.
Interestingly, the primary area of difficulty for Tim
during the last few months before he entered kindergarten
was in the area of representative drawing. He had learned to
draw recognizable, visually organized drawings of people,
ACKNOWLEDGMENTS
I am grateful to Cindy Broder, OTR/L, for her kind
assistance with the editing of the initial draft of this
chapter, and for her encouragement throughout this
project, as well as for the past 19 years. I would also like
to thank my husband, Richard Myers, for his enthu-
siastic support of this project and his expert help with
proofreading.
A Fine Motor Program for Preschoolers • 287
but had not been able to create any other kinds of represen-
tative drawings on his own, particularly multiple component
drawings. He had difficulty forming a visual plan for a
drawing, although he could easily label all the components
that might belong in the drawing (his verbal skills had
reached age level by this time). He was able to draw a red
circle on the paper for an apple, but was not able to make
the drawing more complex by adding a stem or leaf, and
certainly not an entire tree. After Tim was helped to learn
how to draw basic shapes and incorporate them into
gradually more complex drawings, he was able to make a
small variety of multicomponent representative drawings by
the end of the year (5 years, 4 months of age). Many
students are able to learn these skills within the classroom
setting, with the occupational therapist working natural-
istically in the classroom, but in Tim’s case it was necessary
to remove him to a separate, nondistractible room for the
OT sessions for the second half of his last year of preschool.
Two typically developing peers were brought along as
models so the sessions would seem more like a regular
school tabletop activity.
By the end of the year, Tim had achieved nearly all of the
objectives on the Newton Early Childhood “Fine Motor
and Visual Perceptual Inventory for Children Entering
Kindergarten,” (Broder, 2004) with the only significant area
of weakness being that he still needed to improve his overall
control of drawing implements. (The pre-kindergarten
inventory can be found in Appendix 13 B.) His major areas
of improvement over the 21⁄2 years that he received OT
within an integrated preschool setting were in the establish-
ment of a consistent hand preference for writing and
cutting, improvements in fine motor planning, major
improvements in fine motor skills including cutting, and
good progress in pencil control, as well as visual motor
activities such as representative drawing and design copying.
It was recommended that Tim continue with OT services in
kindergarten, primarily to address his continued needs with
pencil control and representative drawing ability.
REFERENCES
Benbow M (1988). Loops and other groups, a kinesthetic
writing system. Tucson, AZ, Therapy Skill Builders.
Benbow M (1990a). A neurodevelopmental approach to
teaching handwriting. Lecture notes from a workshop
presented March 8, 1990.
Benbow M (1990b): Personal communication, April 16, 1990.
Benbow M (1995). Principles and practices of teaching
handwriting. In A Henderson, C Pehoski, editors: Hand
function in the child (pp. 255–281). St Louis, Mosby.
288 Part III • Therapeutic Intervention
Broder C (2004). Fine motor and visual perceptual
inventory for children entering kindergarten, unpublished
checklist.
Burton A, Dancisak M (2000). Grip form and graphomotor
control in preschool children. American Journal of
Occupational Therapy, 54(1):9–17.
Case-Smith J (1995). Clinical interpretation of
“Development of in-hand manipulation and relationship
with activities.” American Journal of Occupational
Therapy, 49(8):772–774.
Case-Smith J (2000). Effects of occupational therapy
services on fine motor and functional performance in
preschool children. American Journal of Occupational
Therapy, 54(4):372–380.
Case-Smith J, Pehoski C (1992). Development of hand skills
in the child. Rockville, MD, The American Occupational
Therapy Association.
Clerke A, Clerke J (2001). A literature review of the effect
of handedness on isometric grip strength differences of
the left and right hands. American Journal of
Occupational Therapy, 55(2):206–211.
Hopkins H, Smith H (1978). Willard and Spackman’s
occupational therapy, 5th ed. Philadelphia, Lippincott.
Meltz B (1999). Beware this screen, too. The Boston Globe,
p. F1, October 28.
Meltz B (1998). Computers, software can harm emotional,
social development. The Boston Globe, p. F1, October 1.
Schneck C, Battaglia C (1992). Developing scissors skills in
young children. In J Case-Smith, C Pehoski, editors:
Development of hand skills in the child (pp. 79–89).
Rockville, MD, The American Occupational Therapy
Association.
Schneck C, Henderson A (1990). Descriptive analysis of the
developmental progression of grip position for pencil and
crayon control in nondysfunctional children. American
Journal of Occupational Therapy, 44(10):893–900.
Spitz P (1999). Autumn activities: Apples apples everywhere.
Framingham, MA, Therapro.
Spitz P (2000a). Spring activities: Flowers flowers everywhere.
Framingham, MA, Therapro.
Spitz P (2000b). Winter activities: Snowflakes snowflakes
everywhere. Framingham, MA, Therapro.
Windsor M (2000). Clinical interpretation of “grip form
and graphomotor control in preschool children.”
American Journal of Occupational Therapy, 54(1):18–19.
Ziviani J (1995). The development of graphomotor skills.
In A Henderson, C Pehoski, editors: Hand function in
the child (pp. 184–193). St Louis, Mosby.

VERTICAL AND SLANT BOARD
SURFACES, AND A VARIETY OF
FINE MOTOR MANIPULATIVES,
INCLUDING CHILDREN’S
LEARNING SCISSORS
Therapro at www.theraproducts.com and OT Ideas at
www.otideas.com are both excellent sources of fine
motor materials. When a toy has been given a proper
name in this chapter, it signifies that the toy is available
under that specific name either on the website of one of
these two companies, or from a supplier who can be
located using that name with an internet search engine
such as Google. At the time of this writing, all of the
items mentioned in this chapter could be located
through one of these two methods. The Spitz activity
books (listed in the references) can be found on the
www.theraproducts.com website.
FINGER PLAYS
Finger Frolics, revised, by Cromwell, Hibner, and Faitel
(Partner Press, available online at www.ghbooks.com)
is a good source for finger plays on a variety of different
themes. Some of the most useful finger plays from this
Appendix 13A
book include “Wide Eyed Owl” (p. 60), “Here Is a Ball”
(p. 91), “A Good House” and “Different Homes”
(p. 19), “A Kitten” (p. 42), “Houses” and “Little
Birds” (p. 31), “My Little Garden” and “My Garden”
(p. 35), and “In the Apple Tree” (p. 22).
MEASURING HAND STRENGTH
The Martin Vigorimeter, which is used in the Newton
Early Childhood Program, is available from the follow-
ing source:
Albert Waeschle
11 Balena Close, Creekmoor Industrial Estate
Poole, Dorset BH17 7DX
United Kingdom
Fax: 011 44 1202 650022
Telephone (includes numbers necessary to dial
directly from the United States):
011 44 01202 601 177
Website: http://www.albertwaeschle.com
Preschool norms for hand grasp strength obtained
by using the Martin Vigorimeter can be found in this
resource:
Link L, Lukens S, Bush MA (1995). Spherical grip
strength in children 3 to 6 years of age. American
Journal of Occupational Therapy, 49(4):318–326.
289
290 Part III • Therapeutic Intervention

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

EVALUATION OF HANDWRITING
Scott D. Tomchek • Colleen M. Schneck
CHAPTER OUTLINE
PRE-EVALUATION DATA COLLECTION
Writing Samples
Interviews
Record Review
EVALUATION OF RELATED PERFORMANCE
COMPONENTS
Neuromuscular and Neurodevelopmental Status
Visual Perception
Motor Performance
Formulation of Written Language
Sensory Processing
ACTUAL EVALUATION OF HANDWRITING
PERFORMANCE
Domains of Handwriting
Legibility Components
Writing Speed
Ergonomic Factors
Keyboarding Performance
Commercially Available Assessment Tools
SUMMARY
Writing is a way to record information and events; a
tool for communication; and a means to project feel-
ings, thoughts, and ideas (Chu, 1997). Occupational
therapists are concerned with the occupational per-
formance of individuals in play, work, and self-care
activities. In childhood, a major occupation in the area
of work is handwriting (Amundson, 1992, 1995; Chu,
1997). It is often one of the first tasks taught to stu-
dents. Writing within learning tasks continues through-
out the academic careers of children and is used to take
Chapter 14
written tests, compose stories, take notes in class, copy
numbers for math computations, and communicate with
friends and family. Writing continues to be used through-
out their lives in the home and work place to write
checks, take messages, and communicate with others.
Learning to write legibly is a complex task of child-
hood and therefore it is not uncommon for problems
to arise during this learning process. Children may have
illegible script, difficulties with letter formulation, lack
the automaticity of writing, and therefore be unable to
keep pace with their peers. As a result, school
consequences of handwriting difficulties may be noted
(Amundson, 2001) and may include the following.
• A child may be assigned poorer marks for papers with
poorer legibility but not poorer content (Chase,
1986; Sweedler-Brown, 1992).
• A child’s slow handwriting speed may limit compo-
sition fluency and quality (Graham et al., 1997).
• A child may take a longer time to complete writing
tasks than peers (Graham, 1992).
• A child may avoid handwriting tasks because it
requires so much effort to produce text (Berninger,
Mizokawa, & Bragg, 1991).
When handwriting impairments that affect academic
performance are noted, children are often referred to
occupational therapists for evaluation and intervention
(Bonney, 1992; Case-Smith, 1996; McHale & Cermak,
1992; Reisman, 1991; Tseng & Cermak, 1993). The
occupational therapist is responsible for identifying
underlying motor, sensory, cognitive, or psychosocial
deficits that may interfere with the development of
legible handwriting (Amundson & Weil, 1996). The
process of evaluation is multifaceted with many
interrelated components. The purpose of this chapter is
to discuss the process of evaluation for handwriting
impairments and is grouped into three main compo-
nents: (a) pre-evaluation data collection, (b) evaluation
of related performance components that may be inter-
fering with handwriting, and (c) evaluation of the
actual process of handwriting.
291
292 Part III • Therapeutic Intervention
PRE-EVALUATION DATA
COLLECTION
Although discussed as separate assessment components
by several authors (Amundson, 1992, 2001; Amundson
& Weil, 1996), analysis of writing samples, interviews,
and record review comprise the pre-evaluation data
collection. Analysis of this information guides the
necessary components and sequence of evaluation
methods.
WRITING SAMPLES
Upon referral for handwriting problems, work samples
often are offered to substantiate the need for referral.
These samples should represent typical handwriting
performance of the child (not the worst examples) and
be analyzed to determine the types and magnitude of
the handwriting difficulties seen in the classroom
(Amundson, 2001). Comparing these samples to those
of peers also may be of benefit in determining the
magnitude of the difficulties, as well as gaining an
understanding of teacher expectations. Informal eval-
uation of the work samples for alignment, size, letter
formation, legibility, and slant may indicate need for
further evaluation.
I NTERVIEWS
Teachers and parents likely have valuable information
about the child that contributes to the assessment
process. Teachers can provide information about the
child’s unique academic strengths and weaknesses in
the classroom, as well as the specific curriculum of the
class. In addition, the teacher can describe the type
of script used (i.e., manuscript or cursive), the style of
script used (i.e., D’Nealian, Zaner-Bloser) and his or
her general expectations of the students for hand-
writing. Specific to the child referred for assessment,
the teacher can provide information on the place where
the child accomplishes writing, when difficulties occur,
what remediation techniques if any have been attempted,
and his or her feelings on why the handwriting diffi-
culties may be occurring. In addition, he or she can
provide insight on the child’s history of handwriting
instruction.
Cornhill and Case-Smith (1996) found that students
with poor handwriting, as identified by teacher report,
scored significantly lower on three assessments of sensori-
motor performance components (eye-hand coordina-
tion, visual motor integration, and in-hand manipulation)
than students with good handwriting. The authors also
found that scores on assessments of these performance
components could be used to predict scores in hand-
writing performance. This information can guide thera-
pists in their evaluation of children based on teacher
report of poor handwriting.
Two factors that teachers indicated most frequently
as important for handwriting to be acceptable were
correct letter formation, and directionality and proper
spacing (Hammerschmidt & Sudsawad, 2004). The
most important criteria that teachers used to determine
whether or not a student was having handwriting diffi-
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 was comparing student handwriting to class-
room peers (37%), followed by comparing student
handwriting to models in a book (35%). This awareness
can help structure the content of the occupational
therapy evaluation and ensure that occupational therapy
assessments produce results that are relevant to the
children’s handwriting function in the classroom.
The parents can provide insight on many of these
same factors as the child accomplishes handwriting in
the home. In addition, the parents can provide infor-
mation unknown to the teacher such as the attitudes
and interests of the child. This difference in perspective
may be useful in identifying the causes of handwriting
difficulties.
RECORD REVIEW
Reviewing the child’s educational file can provide infor-
mation on past academic performance and any special
services that may have been provided to the student.
Information obtained from the educational file may
reveal a pattern of educational difficulty or isolated
findings that may be useful in the assessment of hand-
writing difficulties. This review of information also may
require further interview of the teacher.
Through classroom observations, examination of
work samples, interviews, and record review a therapist
is able to identify related performance components and
administer assessments designed to determine whether
deficits in the identified components exist and to what
extent (Admundson & Weil, 1996).
EVALUATION OF RELATED
PERFORMANCE COMPONENTS
To assist in the process of identifying the cause(s) of
the handwriting impairments in a student, analysis of
the underlying performance components related to
handwriting require evaluation. Here, underlying sta-

bility, perceptual, sensorimotor, and written language
functions are assessed to determine their impact on
handwriting performance.
N EUROMUSCULAR AND
N EURODEVELOPMENTAL STATUS
A comprehensive neuromuscular assessment often
initiates the physical evaluation. Active and passive
range of motion limitations are noted and if present,
may limit in-hand or upper extremity mobility neces-
sary for handwriting. Muscle tone in the trunk and
extremities (both proximally and distally) also is eval-
uated. Strength often is assessed through structured
observation of antigravity postures and movements.
Specific muscle testing may be necessary in the hands
and upper extremities.
To supplement neuromuscular findings, a neuro-
developmental assessment may be conducted. The
neurodevelopmental assessment should include two
groups of automated responses as markers for motor
dysfunction. The first group of automated responses
to be evaluated is the primitive reflexes. These reflexes
appear during the late gestational period, are present at
birth, and normally are suppressed by higher cortical
function by approximately 6 months. Delayed integra-
tion of these reflexes has an impact on dissociated head
and extremity movements and thus affects motor per-
formance. For example, delayed integration of the
asymmetric tonic neck reflex may limit dissociated head
and upper extremity movement to the point of affect-
ing development of hand dominance and midline cross-
ing of the upper extremities. After evaluation of the
primitive reflexes, the second group of automated
responses to be evaluated is the postural reactions.
Righting, equilibrium, and protective reactions must be
evaluated. The coordination of these reactions into
functional balance often is observed during free play
and independent movements. Decreased functional
balance in sitting may limit independent arm move-
ment from trunk movement for writing. The child then
moves the trunk with the arm for writing or frequently
re-positions the paper as arm movement is needed.
Together, the tone, strength, reflex integration, and
balance development of a child serve as the foundation
for the development of stability and stable movement
patterns. If a child is posturally unstable she or he will
likely use compensatory movement patterns, which in
turn may affect motor control during handwriting
tasks. For example, a child who exhibits instability in
the upper trunk and shoulder may use a mid-guard
posture or stabilize at the shoulder to stabilize his or
her upper thoracic and cervical areas during hand-
writing. By doing so, the child’s fluidity and speed of
Evaluation of Handwriting • 293
movement will likely be compromised. In addition, the
child may fatigue quickly during handwriting tasks.
These neuromuscular and neurodevelopmental skills
serve as the foundation from which skilled mobility and
motor skill are built. Deficits identified in these areas
likely have an impact on performance of motor skill.
VISUAL PERCEPTION
Visual perception is the ability to use visual information
to recognize, recall, discriminate, and make meaning
out of what we see. Visual perceptual areas include the
visual receptive (acuity, convergence, tracking) and the
visual cognitive, which include visual discrimination,
visual memory, visual form constancy, visual spatial rela-
tion, visual sequential memory, visual figure ground,
and visual closure. Together, these perceptual skills
provide vital information that is used and relied on by
many other systems for optimal functioning. For
instance, when copying text from a blackboard, we use
visual figure ground to select the appropriate text on
the blackboard to copy, visual discrimination to differ-
entiate among letters, and visual memory and sequen-
tial memory to recall the text to be copied; therefore it
is important to distinguish visual perceptual problems
from motor problems.
Visual-perceptual skills, including visual-spatial
retrieval and left-right orientation, enable children to
distinguish visually among graphic forms and judge
their correctness (Solvik, 1975; Thomassen & Teulings,
1983). Tseng and Murray (1994) reported that the
143 children in their sample of children with illegible
handwriting had low scores on perceptual-motor
measures. Tseng and Chow (2002) found a significant
difference between slow and normal handwriters in
upper-limb coordination, visual memory, spatial rela-
tion, form constancy, visual sequential memory, figure-
ground, visual motor integration, and sustained
attention.
Clinical observations can be used to obtain some
informal information of perceptual abilities in children
who cannot participate in formal testing. Situations can
be devised to assess specific areas or a child’s work can
be evaluated. For instance, having a child find a certain
toy in a toy box can assess visual figure ground. Asking
a child to find or select an item he or she was shown
could be used to assess visual memory. Spatial relation
difficulties often can be seen when asking a child to
accomplish writing tasks, because drawings, letters, or
words may be rotated. In addition, alignment and
spacing may be a problem.
Visual discrimination difficulties may affect the child’s
handwriting in several ways and can be evaluated
through observation of the child during handwriting.
294 Part III • Therapeutic Intervention
For example, the child with poor form constancy may
not recognize errors in his or her own handwriting and
therefore not make corrections to errors. In addition,
the child may be unable to recognize letters or words
in different prints and therefore may have difficulty in
copying from a different type of print or handwriting.
The child also may show poor recognition of letters or
numbers of different sizes or in different environments.
If the child is unable to discriminate a letter, he or she
may show poor letter formation in handwriting.
Children with problems in visual attention may have
difficulty with the correct letter formation and can be
evaluated through observation of the child during
handwriting activities. Children with attention prob-
lems may exhibit difficulty with spelling, mechanics of
grammar, punctuation, capitalization, and the formula-
tion of a sequential flow of ideas necessary for written
communication. For the child to write spontaneously,
he or she must be able to revisualize letters and words
without visual cues. Therefore if the child has visual
memory problems, he or she may have difficulty recall-
ing the shape and formation of letters and numbers
(Schneck, 2001). Other problems that may be seen
when a child has visual memory problems include
missing small and capital letters within a sentence, the
same letter may be written in different ways on the
same page, and the inability to print the alphabet from
memory. The child’s legibility may be poor, and he or
she may need a model to write.
A child with visual spatial problems may show
reversal of letters such as the m, w, b, d, s, e, and z and
of the numbers 2, 3, 5, 6, 7, and 9. Children with
difficulty with discrimination of left from right may
have difficulty with the left-to-right progression or
writing words and sentences (Schneck, 2001). In addi-
tion, the child may demonstrate over-spacing or under-
spacing and have trouble keeping within the margins.
He or she may show inconsistency in letter size and
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-
tion and informal assessment can help to uncover
problems contributing to poor handwriting.
The formalized assessment of visual perceptual abili-
ties usually is reserved for children of school age and
older who have higher receptive language abilities, and
are able to comprehend the verbal instructions inherent
in these tests. Without receptive language abilities near
the 5-year level, testing will likely be invalid because the
instructions may be too abstract or not comprehended.
To maximize performance and obtain the most accu-
rate assessment of the individual perceptual areas,
adaptation or simplification of verbal instructions may
be necessary. For instance, when giving directions for
the visual spatial relations areas, instead of instructing
the child to “find the form that is going a different
way” or “find the form that is not the same as the
others,” the child will likely better understand the more
simple terms of “wrong” or “different.” Therefore a
request to find which one is wrong may produce
improved performance. Because we are assessing per-
ception and not receptive language abilities or vocabu-
lary, making these adaptations allows evaluation of the
focus area, visual perception. Tsurumi and Todd (1998)
have applied task analysis to the nonmotor tests of
visual perception. This information greatly assists the
therapist in analyzing the results of these tests. Care in
interpreting and reporting test results should be taken
because it is not always clear what visual perceptual
tests are measuring. Refer to Table 14-1 for a listing of
standardized assessments that may be used to assess
these visual perceptual areas. For valid test results it is
important to follow the standard instructions on stan-
dardized tests. If the standard procedures are not
followed it should be stated when reporting the results.
These visual-perceptual assessments assess nonmotor
perception, in that they do not require motor coor-
dination for the completion of testing. Instead, the
child can select his or her choice among the options by
saying the appropriate letter that corresponds to his or
her selection. Most children, however, point to their
response.
Deficits in these perceptual abilities may affect many
areas of development, especially fine and visual motor
development. The information taken in visually guides
our ability to reach to an object and the act of grasping
that object. During writing tasks, visual information
is used for spacing, alignment, and formation of all
drawings and letters. When deficits in these areas, or
in any areas that rely heavily on visual input for coordi-
nation, are detected, visual perceptual differences
should be identified through formal or informal
testing.
MOTOR PERFORMANCE
For the purpose of this section, assessment of motor
function is divided into the three broad areas of gross,
fine, and visual motor development. There is much
overlap between these areas of motor performance, in
that common performance components (i.e., muscle
tone, strength, coordination, visual motor integration)
serve as the foundation for skilled motor output. There
is also significant reliance between these motor skill
areas. For example, stability aspects of gross motor devel-
opment are vital in fine motor performance because
stability provides a solid foundation from which skilled
upper extremity usage is achieved. Both formal and
structured observation assessment is described here.
Some formalized assessments used to assess gross, fine,
 Evaluation of Handwriting • 295

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 figure ground
Visual closure

Test of Visual Perceptual Skills
Upper Limits (TVPS-UL)
Gardner, 1997 12–18 years Visual discrimination
Visual memory
Visual form constancy
Visual spatial relation
Visual sequential memory
Visual figure ground
Visual closure

and visual motor development are identified in Gross Motor Skill

Table 14-2.
When evaluating any component of motor per-
formance, not only are developmental milestones
noted, but also special attention is directed to the quali-
tative dimensions of the motor skill. Developmental
milestones provide evidence of what the child can and
cannot do relative to children of a comparable age. A
major goal of the assessment should be to determine
the source of an observed and documented deficiency,
that is, why the skill is problematic. Observations made
about the qualitative aspects of motor control often
pinpoint the area(s) of dysfunction and serve as the
foundation for intervention planning. In addition to
the value of direct observation of motor skill, obser-
vation of contextual aspects of motor skill also enhances
understanding of the source of developmental delays.
Gross motor development refers to movements that
require the use of large muscle groups. Ambulating,
running, jumping, climbing, and ball play are all con-
sidered gross motor skills. In neurodevelopmental
theory, the mobility necessary for these locomotor skills
is superimposed on stability. Consequently, the ability
to perform these skills, and the quality with which they
are performed, is dependant on the condition of the
child’s neuromuscular and neurodevelopmental status.
Often, the neuromuscular status assessment is consid-
ered one component of the child’s gross motor status.
Accordingly, gross motor includes both evaluation of
developmental milestones and observations about the
quality of the child’s movement patterns. Balance and
stability are measured and observed as the child per-
forms a number of motor tasks. These observations of
296 Part III • Therapeutic Intervention

Table 14-2 Standardized instruments used to assess gross, fine, and visual-motor skill

Instrument Author, Year Ages Areas Assessed

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-
ing of a child, illustrating the link between sensory and
motor responses.
Assessment of these gross motor areas often is
done within the context of play-based assessment or
strictly through observation. Having a child go
through a simple obstacle course, for instance, can pro-
vide a wealth of information about balance, strength,
and postural control. Further, within many clinic
settings or natural environments a child has the oppor-
tunity to explore his or her environment. In doing so,
the child likely ambulates, runs, jumps, or has to climb
steps. Situations also can be developed to observe catch
and throw abilities. Report of functioning during
higher-level bilateral motor tasks such as riding a bike
and swimming likely may be obtained from the
caregiver. As can be seen, throughout the evaluation,
both developmental milestones are assessed and the
quality with which they are accomplished is observed
and analyzed. Deficits in stability noted during gross
motor performance, especially trunk, shoulder, and
neck, may or may not be present when a child is seated
at a table to participate in handwriting tasks.
Fine Motor Skill
Fine motor development refers to movements that
require precise or fine motor actions and small muscles
and more sensory feedback. Grasp of objects, writing,
cutting tasks, and dexterity while accomplishing
clothing fasteners are all considered fine motor tasks.
When assessing fine motor skill it is again important to
note the impact of stability and postural awareness.

Stable positioning during fine and visual motor tasks
enhances optimal performance, whereas instability
diminishes fine coordination The importance of
addressing biomechanical factors, such as weak intrinsic
muscles of the hand, has been stressed (Peterson &
Nelson, 2003).
Fine motor skills are essential because accurately
formed letters can be produced only by the proper
timing and force control of coordinated arm, hand, and
finger movements (Alston & Taylor, 1987; Thomassen
& Tuelings, 1983). Children with illegible handwriting
scored lower on fine motor measures than children
with good handwriting (Tseng & Murray, 1994).
Berninger and Rutberg (1992) examined additional
variables and found that a fine motor task (sequentially
touching the thumb to the tip of each finger) had
the strongest correlation with handwriting. Levine,
Oberklaid, and Meltzer (1981) not only found that
72% of 26 children with “developmental output fail-
ure” had difficulty with fine motor tasks, they further
postulated that these children’s uncoordinated finger
movements and diminished pencil control accounted
for their slow, illegible handwriting.
Researchers have reported two general types of grip
assessment systems: component and whole configu-
ration. In component systems separate components of
the grip are evaluated (i.e., the position of each finger
and the thumb, the relative position of the grip along
the length of the implement, or the forearm position
relative to the table). In whole configuration systems,
all of the components of an observed grip are described
together. The grip is considered as a discrete behavior
and is labeled. Burton and Dancisak (2000) have
suggested that the use of Schneck and Henderson’s
(1990) 10-grip scale be used only for documenting the
grips of individual persons and changes in their grips. If
comparisons between persons are desired, then the
authors recommended Schneck’s (1991) five-level scale
be used. Tseng (1998) added three interdigital grasps
to this five-level scale in the primitive grasp category
and included the quadruped grasp as another mature
grasp for a total of 14 grasp patterns.
The task should be considered in the evaluation
process. For example, in a coloring task younger chil-
dren used a more mature grip to color the edge and
then colored the center with a less mature grip. Older
children slow down to color the edge and then con-
tinue with the same grip for the center of the object
(Schneck, 1991). Many children used less mature grips
when coloring spaces than when drawing. The most
common grip used for coloring was the static tripod
grasp, whereas for drawing it was the dynamic tripod
grasp (Schneck, 1991). Berninger and Rutberg (1992)
contended that finger function is the best predictor of
Evaluation of Handwriting • 297
handwriting dysfunction, in which fine motor skill
accounted for 52.5% of the variance in handwriting
speed. Solvik and Arntzen (1991) found that poor
coordination in the form of poor dissociation (exag-
gerated wrist and thumb movement) was inversely
correlated with writing speed.
In-hand manipulation can be assessed with trans-
lation and rotation tasks with the five small pegs and
pegboard from the Nine-Hole Peg test. Administration
and scoring procedures can be found in Case-Smith
(1996, 1998).
As in most assessments, initially the foundation skills
of an area are assessed. Many of these areas relating to
fine motor task performance are assessed though
observation. Table 14-3 outlines the pertinent areas
and specific questions that guide these structured
observations in fine motor evaluation of handwriting.
In conjunction with these observations, the atten-
tion of the evaluator can turn to evaluating the
functional application of these foundation skills. Here,
the child is asked to engage in purposeful tasks as a
means of identifying strengths, weaknesses, and devel-
opmental levels. If the child is unable to perform a
motor task, it is important to try to ascertain why,
because an inability to perform a motor task may stem
from one or several limitations including lack of
strength, deficient muscle control, dyspraxia, cognitive
limitations, or motivation. Determining the reason for
dysfunction allows for observation of hand dominance
and appropriate intervention planning.
Visual Motor Control
There is much overlap between fine and visual motor
skill, and often they are considered one entity. Visual
motor control refers to the ability to coordinate visual
information with motor output for visually guided
movements. Appropriate visual motor control is pred-
icated on intact visual localization and tracking abilities.
Visual motor control is used to string beads, cut on a
line, catch a ball, print within lines, and stay in the lines
when coloring a picture. Some individuals may demon-
strate better abilities for design copying items in tests
of visual motor integration, but have difficulty when
relating these abilities to handwriting. Therefore it is
important to assess each area separately (see hand-
writing assessment section that follows). Fundamental
to assessment is the recurrent theme of pinpointing
the location of the breakdown in task performance.
In the visual motor area, skills are dependent on ade-
quate attention, visual perception, motor control, and
motivation.
A number of researchers have documented a sig-
nificant relationship between visual motor skills and
handwriting performance (Cornhill & Case-Smith, 1996;
298 Part III • Therapeutic Intervention

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 &
Cermak, 1993; Tseng & Murray, 1994; Weil &
Amundson, 1994). The Test of Visual Motor Integra-
tion (VMI) has been supported in the literature as a
useful screening tool for handwriting abilities. Research
suggests that students are ready to engage in formal
handwriting instruction once they have mastered the
ability to copy the first nine forms on the VMI (Beery
& Butkenica, 1997; Daly, Kelley, & Krauss, 2003; Weil
& Amundson, 1994). The researchers have concluded
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-
gration was found to be the best predictor of legibility
for both American and Norwegian children (Solvik,
1995) and a group of Chinese school-aged children
(Tseng & Murray, 1994).
As can be seen by this discussion of assessment of
motor performance, much overlap and interdepend-
ence exist between the areas of motor development.
The ultimate goal of the process of motor assessment
is to identify the unique strengths and weaknesses of
the individual. Both formal and informal assessments
determine this vital information. Once skill levels are
identified, determining the etiology or source of the
documented skill deficiencies provides the basis for
program and intervention planning.
FORMULATION OF WRITTEN LANGUAGE
A written language assessment may be indicated during
a comprehensive assessment of handwriting, and espe-
cially when speed difficulties are noted. Here, the goal
is to determine if problems in written language (i.e.,
 Evaluation of Handwriting • 299

formulation) exist and if so, if they could be a factor

affecting handwriting rate. It stands to reason that a
child who spends more time in formulation of thoughts
and written communication will also likely take longer
to put those thoughts to paper.
Written language assessment usually is accomplished
by a speech language pathologist. Possible tools that
may be used to conduct a written language assessment
are summarized in Table 14-4.
SENSORY PROCESSING
Sensory processing is a broad term that refers to the
way in which the central and peripheral nervous
systems manage incoming sensory information from
the senses (Lane, Miller, & Hanft, 2000). Basically,
sensory processing refers to the sequence of events that
occurs as we take in and respond to environmental
stimulation. In the assessment of handwriting—in addi-

Table 14-4 Instruments to formally assess written language

Instrument Author, Year Ages Areas Assessed

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
Language (TEWL-2)
Test of Written Language 3
(TOWL-3)
Hresko, Herron, and 4–10 years Basic writing
Peak, 1996 Contextual writing
Hammil and Larsen, 7.6–17.11 years Spontaneous formats
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
300 Part III • Therapeutic Intervention
tion to visual perception—tactile-proprioceptive,
kinesthesia, and praxis aspects require specific atten-
tion. Most of these aspects are assessed through
structured observation during task performance and
are included in Table 14-3. Tactile-proprioceptive pro-
cessing is necessary to provide the child with infor-
mation used to grasp the pencil. Kinesthesia provides
the child with information that is used to gauge
pressure on the pencil and of the pencil on the paper
while writing or coloring. In addition, integration of
vision and kinesthesia guides the direction of a writing
tool. Children who have tactile-proprioceptive or
kinesthesia impairments may hold their pencil too
firmly or loosely or write with increased or decreased
pressure to paper, both of which can influence
endurance and quality of writing. Laszlo and Bairstow
(1984) proposed that kinesthetic feedback is essential
to handwriting development. They proposed that
kinesthetic information has two functions in the
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
kinesthetic information cannot be perceived or used,
efficient programming cannot occur. Levine (1987)
proposed that kinesthetic impairment in children might
lead to decreased speed of handwriting because of
either the excessive pressure needed for kinesthetic
feedback or the slower visual feedback used to substi-
tute for kinesthetic feedback. In addition, the child
who has tactile-proprioceptive or kinesthesia impair-
ment may continue to require visual monitoring of his
or her hand for handwriting tasks. A recent study
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).
Praxis refers to the planning and performance of a
motor movement or task, or a series of motor move-
ments or tasks. Impairments in praxis interfere with
letter formation and may be seen initially as initiation
deficits. The child may appear to form the letter
differently each time and act as if he or she had never
been taught proper formation. Further, praxis can
impair building words from letters and writing letters
or words on an automatic level.
Together, assessment of all of the discussed perfor-
mance components provides information for the
therapist to determine current developmental strengths
and weaknesses related to handwriting performance.
Noted deficits may serve as the foundation for noted
handwriting difficulties and are used to interpret the
findings of the actual assessment of handwriting
performance.
ACTUAL EVALUATION OF
HANDWRITING PERFORMANCE
The process of gathering information for a compre-
hensive handwriting evaluation has already largely been
completed through observations made during previous
testing. Specifically, observations about hand domi-
nance, midline crossing, grasp patterns to a pencil, the
firmness of that grasp, and the amount of pressure to
paper have all been made during the fine and visual
motor assessment. In addition, observations about
stability and compensatory movement patterns also
have been made. In this section, the focus is on the
actual process of handwriting. Initially the domains of
handwriting, legibility components, speed of writing,
and ergonomic factors are discussed as outlined by
Amundson (1992, 2001), followed by a discussion of
commercially available assessment tools.
DOMAINS OF HANDWRITING
Evaluating the various domains of handwriting allows
the therapist to identify which tasks the child is having
more difficulty with and address those tasks in the
intervention plan (Amundson, 1992). Handwriting
skills needed by students are included in Box 14-1.
LEGIBILITY COMPONENTS
Legibility deficits in handwriting are often the primary
reason for referral for handwriting problems. These
BOX 14-1 Handwriting Skills Needed
by Students
• Writing the alphabet and numbers from memory
requires that the student remembers letter/number
formation, their sequence, and maintains consistent
letter case (upper or lower).
• Copying. Both near-point (copying from a nearby
model) and far-point (copying from a distant model)
are used by students to take notes and communicate
information.
• Manuscript-to-cursive transition requires the student
to transcribe manuscript letters and words to cursive
letters and words and demands a mastery of both
letter forms.
• Dictation requires integration of both auditory
processing and motor responding.
• Composition is a high level task requiring both
written language and handwriting elements.

deficits may be caused by a number of components
and are assessed by analysis of a writing sample. Letter
formation is assessed initially to be sure letters are
properly formed and legible. Alignment of letters on a
line and in relation to each other is also assessed.
Spacing that needs to be addressed includes letters
within words, words within sentences, and the organi-
zation of the whole page. Another component to be
addressed is letter size, which refers to the size of letters
within writing guidelines and in relation to each other.
Together, all of these qualitative aspects of legibility
comprise the components of handwriting that are often
the visible evidence of handwriting impairment.
Informal evaluation also may include comparing the
child to his or her peers in terms of the completion of
a writing task during the allotted time and the amount
of work completed.
Common handwriting problems such as incorrect
letter formation, poor alignment, reversals, uneven size
of letters, irregular spacing between letters and words,
and slow motor speed (Alston & Taylor, 1987;
Johnson & Carlisle, 1996) do not necessarily arise from
identical underlying mechanisms. Careful observation
and evaluation are needed to determine the underlying
causes.
Two main approaches used in formal assessments to
rate handwriting legibility are rating of the legibility
components (i.e., slant, size, alignment) and rating of
global legibility (i.e., overall readability of writing sam-
ple). The assessment of legibility using ratings of legi-
bility components can be extremely time consuming
and may not provide a clear picture of the overall
readability of a child’s written work (Sudsawad et al.,
2001). Often, the components are judged against
standard templates, which may not be adaptable to
variations in handwriting style. Changes in these com-
ponents may or may not indicate whether the child’s
handwriting is easier or harder to read.
The readability of letters, words, and numerals is the
primary criterion that determines global legibility.
Evaluation of global legibility is quick and simple and
addresses the functional aspects of handwriting legi-
bility (Amundson, 1995). The evaluator is more con-
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
(Talbert-Johnson et al., 1991).
Examples of manuscript writing tests that rate
legibility components include The Children’s Hand-
writing Evaluation Scale for Manuscript Writing
(Phelps & Stempel, 1984) and the Minnesota
Handwriting Test (Reisman, 1993, 1999). The Eval-
uation Tool of Children’s Handwriting (Amundson,
1995) evaluates global legibility of manuscript writing.
Evaluation of Handwriting • 301
WRITING SPEED
Coupled with legibility, writing speed is a cornerstone
of functional handwriting (Amundson, 1995). In
general, speed of handwriting decreases as the com-
plexity of a task increases. Therefore speed of writing
needs to be addressed within each of the domains of
handwriting to determine the impact of the different
task demands. Although speed for copying tasks may be
adequate, slower handwriting speed for composition
task may indicate coexisting formulation deficits.
Slow handwriting speed affects functional perform-
ance because it prevents students from meeting time
constraints involved in schoolwork (Cermak, 1991;
Levine et al., 1981). Slow hand writers are different in
the way they process written information from normal
speed writers. Slow hand writers depend on visual
processing, whereas normal speed writers are motor
based (Tseng & Chow, 2002). Slow hand writers were
poorer as a group than children with normal-speed
hand writers in graphomotor output, level of per-
ceptual motor skills, and decreased attention (Tseng &
Chow, 2000). Rosenblum, Parush, and Weiss (2003)
using a computerized digital system found that non-
proficient 8- to 9-year-old handwriters required sig-
nificantly more time to perform handwriting tasks and
that their “in air” time, was especially longer as com-
pared to the proficient handwriters. “In air” time refers
to pauses, or temporary halts in the flow of writing
(Benbow, 1995; Kaminsky & Powers, 1981). The
researchers found this phenomenon not as a pause
but rather as a “motion tour” taking place in the air
between the writing of successive characters, segments,
letters, and words. It may be that the “in air” time
helps the student to prepare to execute subsequent
characters or character segments. This time may be
needed to parameratize the motor program or initiate
activity in the muscle groups needed to execute the
character. In addition, the researchers found that the
nonproficient hand writers’ handwriting speed was
slower and they wrote fewer characters per minute.
Formal assessments of handwriting speed are
included in Table 14-5.
E RGONOMIC FACTORS
The ergonomic factors affecting handwriting (e.g.,
writing posture, grip, stability) have been discussed
in the related performance components section, but
require further mention here. From the literature,
writing tools, paper, and surfaces appear to be impor-
tant factors in handwriting.
In assessing grip it is important to keep in mind the
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
Evaluation of Handwriting • 303
 304

Table 14-5 Instruments to assess handwriting—cont’d

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
Table 14-5 Instruments to assess handwriting—cont’d

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
Evaluation of Handwriting • 305
306 Part III • Therapeutic Intervention
Children used a less mature grasp in coloring than
drawing (Schneck, 1991). Young children aged 23 to
24 months used a more mature grasp when drawing
with a piece of crayon than with a pencil (Yakimishyn &
Magill-Evans, 2002). In addition, no difference in
grasp maturity was found when using a pencil com-
pared with a marker. Lastly, a more mature grasp was
demonstrated when drawing on the easel compared
with the table when using a crayon, not with a marker
or pencil. Krzesni (1971) found a significant increase in
writing performance with a felt pen. However, Lamme
and Aynis (1983) found that writing tools did not
affect legibility.
Several studies have extended the effects of writing
paper on handwriting performance. Lindsay and
McLennan (1983) and Weil and Amundson (1994)
reported that for beginning writers, lined paper may
add an element of confusion and compromise legibility.
Krzesni (1971) found the opposite is true for older
children; legibility improved with lined paper in 9-year-
old children. Halpin and Halpin (1976) compared
handwriting quality in kindergarten children with 1-
and 11/2-inch–spaced paper and found no difference.
KEYBOARDING PERFORMANCE
Sixth-grade students demonstrated low to moderate
correlation between keyboarding and handwriting per-
formance (Rogers & Case-Smith, 2002). This suggests
that these forms of written expression require distinctly
different skills. Most students who were slow at hand-
writing or had poor legibility increased the quantity
and overall legibility of the text they produced with a
keyboard. This suggests that it is important to assess
keyboarding in nonproficient writers because it may
simplify their text production. It may allow certain
children to concentrate on content and meaning when
composing and encourage them to engage in compo-
sitional writing.
COMMERCIALLY AVAILABLE
ASSESSMENT TOOLS
Several handwriting assessment tools are commercially
available. Although Table 14-5 provides a graphic sum-
mary of these instruments, Appendix 14A also provides
an in-depth analysis of each of the instruments that is
still currently available and summarizes some findings.
As can be seen by analyzing Appendix 14A, few
quality instruments specifically designed to assess hand-
writing are available. Selecting the most appropriate
instrument is dependent on the individual needs of the
evaluating therapist. In selecting a handwriting instru-
ment, therapists must not only consider a child’s area
of handwriting difficulty, but also the psychometric
properties of the instrument chosen. In the opinion of
the present authors, of the available instruments the
Minnesota Handwriting Assessment (MHA) (Reisman,
1999), Test of Handwriting Skills (THS) (Gardner,
1998), and Evaluation Tool of Children’s Handwriting
(ETCH) (Amundson, 1995) are the most useful. These
instruments could be used in any number of settings.
Each of these instruments provides for assessment of
both legibility and rate or speed aspects of handwriting.
All of the instruments also have in-depth scoring pro-
cedures that allow determination of the most common
legibility errors.
The MHA has the most limited scope in that it is an
assessment of near point copying only and can be used
for first and second graders only. The flexibility for the
assessment of both manuscript and D’Nealian script,
its short administration time, and its relatively short
scoring time make it attractive for clinical practice. A
categoric scoring summary on the MHA allows com-
parison to peers and can be used to determine the need
for intervention. Given these test constructs it is the
recommended instrument for first and second graders
experiencing difficulties with learning the writing
process.
For students older than second grade, the THS and
ETCH are the recommended instruments for use. Both
of these instruments allow for assessment of rate and
quality of writing within a number of handwriting
domains (e.g., copying, dictation, composition) and
have similar administration and scoring times. The
ETCH allows assessment of more domains of hand-
writing and, in addition, addresses sensorimotor aspects
of handwriting as part of the assessment. Given these
added benefits of the ETCH, it is the recommended
assessment for children in this age group. However,
one drawback to its use is its lack of normative data
(scoring results in a percentage of accuracy). Therefore
if normative data are necessary for eligibility or other
purposes, only the THS provides this information of
the two in this age group.
Of the other instruments, the Children’s Handwriting
Evaluation Scale (CHES) (Phelps & Stempel, 1984)
and Children’s Handwriting Evaluation Scale for
Manuscript Writing (CHES-M) (Phelps, 1987) were
validated approximately 15 years previously and on a
convenient sample of students in a school system in
Texas. In addition, test composition factors relating to
the scoring of quality and its resultant interpretation,
and the use of unlined paper cause concern. Given
these factors the overall value and validity of these two
instruments is questioned. Although the Handwriting
Speed Test (HST) (Wallen, Bonney, & Lennox,
1996a,b) may be useful if determining how a student’s
handwriting speed compares to others, its lack of
legibility scoring makes its uses limited. Further, given

its validation on a sample of students from Australia
only, the reliability and validity of finding are ques-
tioned also.
It is important to note that when comparing Table
14-5 to the instruments in this Appendix, two of
the instruments, the Denver Handwriting Analysis
(Anderson, 1983) and Test of Legible Handwriting
(Larsen & Hammill, 1989) are no longer commercially
available and therefore are not reviewed here. When
discussing the out-of-print status with the respective
publishers, both stated that there was little demand for
the instruments, which is interesting given the fact that
handwriting difficulties are a primary reason for referral
to occupational therapy. However, this supports the
findings of a recent investigation that found that stan-
dardized handwriting assessments were rarely employed
in assessment of handwriting (Feder, Majnmer, &
Synnes, 2000).
SUMMARY
As can be seen by this discussion, the assessment of
handwriting difficulty is a complex multifaceted
process. Administration of a formalized assessment of
handwriting alone does not provide the information
necessary to determine the root of the difficulty or
effectively plan a program. Stability, visual perception,
motor performance, written language, and sensory
processing aspects of development serve as the foun-
dations for developing the skill of handwriting. Thus
although administration of a formalized assessment of
handwriting can determine the nature of handwriting
difficulty demonstrated by a child, assessment of the
related performance components provides the basis for
determining the potential cause(s) of the impairments.
Identification of these causes allows appropriate
intervention planning to develop remediation of the
handwriting impairments.
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Reisman JE (1991). Poor handwriting: Who is referred?
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Therapy, 56:564–572.

HANDWRITING ASSESSMENT
INSTRUMENTS
MINNESOTA HANDWRITING
ASSESSMENT
AUTHOR, YEAR
Reisman, 1999
DESCRIPTION
The Minnesota Handwriting Assessment (MHA) is
used to assess manuscript and D’Nealian handwriting
in first and second graders who have knowledge of the
English language. The MHA assesses Rate for the whole
writing sample and five quality categories for each letter
of the sample: Legibility, Form, Alignment, Size, and
Spacing. Subjective quality ratings are collected and
yield interpretive cutoff scores within each category:
Performing like peers (top 75% of the final sample),
performing somewhat below peers (within the bottom
5% and 25% of the final sample), or performing well
below peers (bottom 5% of the final sample). It is recom-
mended that students performing somewhat below
peers should be monitored to determine if ongoing
instruction or practice is needed or whether the student
is demonstrating delayed development of underlying
hand skills. It is recommended that students perform-
ing in the well-below-peers category be referred for
comprehensive evaluation to determine the cause of
handwriting difficulties.
CONTENTS
What does the schedule try to measure? The MHA assesses
handwriting performance. Specifically measured are
Rate for the whole writing sample and five quality
Appendix 14A
categories (Legibility, Form, Alignment, Size, and
Spacing) for each letter of the sample.
Does it give a clinical diagnosis? No.
PURPOSE
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
the teacher’s subjective judgment of poor quality or
slow rate (Reisman, 1999). It is recommended that
interpretive ratings obtained after scoring the MHA be
used to guide the need for further assessment and the
intervention process.
ASSESSMENT COMPONENTS
Type of Assessment: Near-point copy assessment
Task(s): The student is required to copy from a printed
stimulus sheet onto lines below the words “the
brown jumped lazy fox quick dogs over.” The mixed
word order of the sentence is used to reduce the
speed and memory advantage of better readers by
requiring all students to refer to the stimulus items
word by word.
Paper Type: Supplied lined paper with center dotted
line
Pencil Type: Any size pencil typically used by the student
ADMINISTRATIVE /SCORING TIME
Administration: The test is timed for the first 21/2
minutes to obtain the Rate score and then, if
necessary, the students are given time to complete
the sample to allow for scoring the five quality
categories.
311
312 Part III • Therapeutic Intervention
Scoring: After some experience with the instrument (30
samples), scoring time ranges from 3 to 7 minutes.
From experience, scoring takes closer to 10 to 12
minutes.
PARTICIPANTS
Children: First and second graders
Developmental Level: Grade level
DERIVATION
Writing sample and scoring criteria were developed
from a pilot version, through literature review and field
testing with revision.
PUBLISHED MATERIAL
Author/Others: author (Reisman, 1993, 1999); others
(Peterson, 1999)
Usefulness: The MHA was designed to help meet the
needs of many school districts and special education
departments that require a handwriting assessment
to support the teacher’s subjective judgment of poor
quality or slow rate (Reisman, 1999).
Validated: On 2000 first- and second-grade students
from a nationwide sample (Reisman, 1993, 1999)
with cutoff scores determined after analysis. Content
validity was established in development.
Reliability: Interrater ranged from 0.77 to 0.88
(Pearson) for inexperienced raters and from 0.90 to
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
ranged from 64% to 86%. Test-retest reliability was
conducted in a related study (Peterson, 1999) with
at-risk students with correlations ranging from 0.60
to 0.89 (Internal Consistency Coefficient ICC).
Additional Statistical Analysis: A special group study
was conducted to examine first- and second-grade
students in regular education, special education, and
special education plus occupational therapy. Scores
on the MHA and Test of Visual Motor Skills (a
design copying visual motor control test) were
compared with correlations ranging from 0.37
(second grade) to 0.89 (occupational therapy).
OTHER DATA IN SCHEDULE /OTHER
I NFORMATION /COMMENTS
Is a helpful tool in discerning the types of handwriting
errors exhibited by first- and second-grade students.
Quality scoring for each letter provides a mechanism
for focusing treatment and evaluating progress. Its
short administration and scoring time make it advan-
tageous to clinical practice. Reliability findings may be
inflated because of use of Pearson for statistical analysis
(Ottenbacher & Tomchek, 1993, 1994).
REFERENCES
Ottenbacher KJ, Tomchek SD (1993). Reliability
analysis in therapeutic research: Practice and pro-
cedures. American Journal of Occupational Therapy,
47(1):10–16.
Ottenbacher KJ, Tomchek SD (1994). Measurement
error in method comparison studies: An empirical
examination. Archives of Physical Medicine &
Rehabilitation, 75(5):505–512.
Peterson CQ (1999). The effect of an occupational
therapy intervention handwriting in academically at-
risk first graders. Unpublished doctoral dissertation.
Cincinnati, The Union Institute Graduate School.
Reisman JE (1993). Development and reliability of the
research version of the Minnesota Handwriting Test.
Physical and Occupational Therapy in Pediatrics,
13:41–55.
Reisman JE (1999). Minnesota handwriting assessment.
Los Angeles, Psychological Corporation.
TEST OF HANDWRITING SKILLS
AUTHOR, YEAR
Gardner, 1998
DESCRIPTION
The Test of Handwriting Skills (THS) is used to assess
a child’s neurosensory integration ability in hand-
writing either manuscript or cursive and in upper and
lower case forms, and to measure the speed with which
a child handwrites from: writing from memory, upper
and lower case letters of the alphabet in sequence;
writing from dictation, upper and lower case letters of
the alphabet out of sequence; writing from dictation,
numbers out of numeric sequence; copying selected
letters from the alphabet; copying selected words; copy-
ing selected sentences; and writing from dictation
selected words. Although the purpose of the THS is to
measure how a child (ages 5 years, 0 months to 10
years, 11 months) can write letters, words, and num-
bers spontaneously, from dictation, or from copying, it
is also used to determine the speed by which a child can
produce letters spontaneously. Each of the 206 letters
in the sample is scored using a four-point scale. The
THS provides normative data in 3-month increments
for each subtest (standard scores, scaled scores, per-
centile ranks, and stanines).

CONTENTS
What does the schedule try to measure? The THS meas-
ures quality of handwriting in children. In addition
to the 206 scorable-language symbols, the THS,
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
from memory, and converting lower case letters to
upper case letters, and vice versa special features. The
THS, Cursive version (for children ages 8 years to 10
years 11 months) has in addition to the 206 scorable
letters, only one feature: speed of writing letters
spontaneously from memory.
Does it give a clinical diagnosis? No.
PURPOSE
The purpose of the THS is to measure how a child can
write letters, words, and numbers spontaneously, from
dictation, or from copying. It is also used to determine
the speed by which a child can produce letters spon-
taneously. These components of the assessment can
identify both the strengths and weaknesses of a child’s
handwriting that can be used to develop a remedial
program. The goal of remediation is to improve a
child’s legibility of letters, words, and numbers, along
with increasing speed of writing.
ASSESSMENT COMPONENTS
Type of Assessment: Spontaneous composition, dictation
and near-point copy assessment
Task(s): (a) Writing from memory, upper case letters of
the alphabet in sequence; (b) writing from memory,
lower case letters of the alphabet in sequence; (c)
writing from dictation, upper case letters of the
alphabet out of sequence; (d) writing from dictation,
lower case letters of the alphabet out of sequence; (e)
writing from dictation, numbers out of numerical
sequence; (f) copying selected upper case letters from
the alphabet; (g) copying selected lower case letters
from the alphabet; (h) copying selected words; (i)
copying selected sentences; and (j) writing from
dictation selected words.
Paper Type: Supplied unlined paper in test booklet
Pencil Type: Standard number 2 pencil
ADMINISTRATION /SCORING TIME
Administration: The test can be administered in 15 to
20 minutes.
Scoring: After some practice, scoring time ranges from
15 to 20 minutes. From experience, scoring takes all
of 20 minutes.
Evaluation of Handwriting • 313
PARTICIPANTS
Children: Ages 5 years, 0 months to 10 years 11
months
Developmental Level: Grade level
DERIVATION
Overall test developed based on literature review.
Words used in dictation components were determined
by a group of 15 teachers.
PUBLISHED MATERIAL
Author/Others: Author (Gardner, 1998); others
Usefulness: Quality and rate findings of the assessment
are used to identify both the strengths and
weaknesses of a child’s handwriting that can be used
to develop a remedial program.
Validated: On 839 children (Gardner, 1998) from a
nationwide sample with normative data determined
after analysis. Construct validity was in the moderate
range. Concurrent validity studies yielded positive
correlations with the TVMS-R, WRAT-3 (spelling
component), Bender, and VMI.
Reliability: Internal consistency was described as
“acceptable” with reliability coefficients ranging
from .51 to .78.
Additional Statistical Analysis: None
OTHER DATA IN SCHEDULE /OTHER
I NFORMATION /COMMENTS
Helpful tool in discerning the types of handwriting
errors exhibited by students. Cumbersome scoring and
lengthy administration may inhibit frequent use in clin-
ical practice. The use of unlined paper for this assess-
ment may facilitate further handwriting impairments in
that several studies have shown that children’s hand-
writing on unlined paper when compared with lined
paper is poorer in quality (Alston & Taylor, 1987;
Burnhill et al., 1983; Pasternicki, 1984).
REFERENCES
Alston J, Taylor J (1987). Handwriting: Theory,
research, and practice. Worcester, MA, Billings.
Burnhill P, Hartley J, Lindsay D (1983). Lined paper,
legibility and creativity. In J Hartley, editor: The
psychology of written communication. London, Kogan
Page.
Gardner M (1998). The test of handwriting skills:
manual. Hydesville, CA, Psychological and Educa-
tional Publications.
314 Part III • Therapeutic Intervention
Pasternicki JG (1984). Teaching handwriting: The
resolution of an issue. Support for Learning,
1:37–41.
CHILDREN’S HANDWRITING
EVALUATION SCALE
AUTHOR, YEAR
Phelps and Stempel (1984)
DESCRIPTION
The Children’s Handwriting Evaluation Scale (CHES)
is used to assess cursive handwriting in third through
eighth graders who have knowledge of the English
language. The CHES assesses Rate to copy the passage
(consisting of 197 letters) and five quality categories of
the sample: Form, Slant, Rhythm, Space, and General
Appearance. Rate and quality are evaluated independ-
ently on a five-point scale: very poor, poor, satisfactory,
good, and very good. Percentile ranges can be assigned
to correspond with rankings. In addition, percentile,
standard scores, T-scores, and stanines are provided for
Rate of writing for each grade.
CONTENTS
What does the schedule try to measure? The CHES
assesses handwriting performance. Specifically, Rate
for the whole writing sample and five quality cate-
gories (form, slant, rhythm, space, and general
appearance) for the whole sample are measured.
Does it give a clinical diagnosis? No.
PURPOSE
The main purpose is to assess the rate and quality of a
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
remediation process.
ASSESSMENT COMPONENTS
Type of Assessment: Near-point copy assessment
Task(s): The student is required to copy a passage from
a printed stimulus sheet directly below
Paper Type: Supplied unlined blank sheet with the
passage on top
Pencil Type: Number 2 pencil
ADMINISTRATIVE /SCORING TIME
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.
PARTICIPANTS
Children: Third through eighth graders
Developmental Level: Grade level
DERIVATION
No information identified.
PUBLISHED MATERIAL
Author/Others: Author (Phelps & Stempel, 1984);
others
Usefulness: Interpretive ratings obtained after scoring
the CHES should be used to guide need for further
assessment and the remediation process.
Validated: On 1365 third- through eighth-grade
students in Dallas County Schools (Phelps &
Stempel, 1984) with cutoff scores determined after
analysis. Content validity was established in devel-
opment (Phelps & Stempel, 1984).
Reliability: Interrater ranged from 0.88 to 0.95
(ICC).
Additional Statistical Analysis: The reasons for need
for remediation (performance below the 24th per-
centile) were studied with 9% needing remediation
for quality only, 13% for rate only, and 2% for both
rate and quality. In addition, rate scores for the CHES
were compared with rate scores for the American
Handwriting Scale (1957) (no longer available).
Findings showed that students in 1984 wrote at a
slower rate than in 1957 and that the AHS yielded
more letters of writing at all grade levels.
OTHER DATA IN SCHEDULE /OTHER
I NFORMATION /COMMENTS
Useful primarily for rate scoring in that the five-point
total quality scoring for whole sample lacks sensitivity
to define specific handwriting problems. The short time
to administer and score is a positive. Questionable
reliability and validity given the convenient sample
obtained from only Dallas County Schools. Validity of
findings are also questioned given the tool’s use of
unlined paper.

REFERENCE
Phelps J, Stempel L (1984). Children’s handwriting
evaluation scale. Dallas, TX, Scottish Rite Hospital
for Crippled Children.
CHILDREN’S HANDWRITING
EVALUATION SCALE FOR
MANUSCRIPT WRITING (CHES-M)
AUTHOR, YEAR
Phelps, 1987
DESCRIPTION
The CHES-M is used to assess manuscript handwriting
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
components in four main categories: Form, Rhythm,
Space and General Appearance. Rate and Quality are
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
to each constituent. When all are present, 100 points
are possible with 10 points deducted for each criterion
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
provided for a quality total score based on rating.
CONTENTS
What does the schedule try to measure? The CHES-M
assesses handwriting performance. Specifically, the
CHES-M measures Rate for the whole writing sam-
ple and four quality categories: Form (small letters
are uniform in height and proportion, tall letters
are higher than small and suitably proportioned
and aligned, correctly formed and recognizable out
of context, letters copied correctly); Space (space
between letters of a word uniform, space between
words adequate and uniform, right margin uncrowded,
space between lines uniform); Rhythm; and General
Appearance
Does it give a clinical diagnosis? No.
PURPOSE
The main purpose is to measure rate and quality of
manuscript handwriting. It is intended to provide a
Evaluation of Handwriting • 315
standard by which to monitor gradual improvement or
immediately define specific problem areas.
ASSESSMENT COMPONENTS
Type of Assessment: Near-point copy assessment
Task(s): The student is required to copy two sentences
(57 total letters) on a printed stimulus sheet directly
below.
Paper Type: Supplied unlined blank sheet with the
passage on top
Pencil Type: Number 2 pencil
ADMINISTRATIVE /SCORING TIME
Administration: The test is timed for 2 minutes. If the
student finishes before 2 minutes, he or she is asked
to start again.
Scoring: Scoring time ranges from 3 to 7 minutes.
PARTICIPANTS
Children: First and second graders
Developmental Level: Grade level
DERIVATION
Derived from the CHES with the same schools used for
norming purposes.
PUBLISHED MATERIAL
Author/Others: Author (Phelps, 1987); others
Usefulness: It is intended to provide a standard by
which to monitor gradual improvement or immedi-
ately define specific problem areas.
Validated: On 643 first- and second-grade students in
Dallas County Schools (Phelps & Stempel, 1984)
with cutoff scores determined after analysis. Content
validity was established in development.
Reliability: Interrater ranged from 0.85 to 0.93
(ICC).
Additional Statistical Analysis: None.
OTHER DATA IN SCHEDULE /OTHER
I NFORMATION /COMMENTS
Short administration and scoring time are benefits to
use in clinical practice. Significant questions relating
to reliability and validity given the convenient sample
obtained from only Dallas County Schools. Validity
of findings is also questioned given the tools use of
unlined paper.
316 Part III • Therapeutic Intervention
REFERENCE
Phelps J (1987). Children’s handwriting evaluation
scale for manuscript writing. Dallas, TX, Scottish Rite
Hospital for Crippled Children.
EVALUATION TOOL OF
CHILDREN’S HANDWRITING
AUTHOR, YEAR
Amundson, 1995
DESCRIPTION
The Evaluation Tool of Children’s Handwriting
(ETCH) is designed to evaluate manuscript (ETCH-
M) and cursive (ETCH-C) handwriting skills of chil-
dren in grades 1 through 6 who are experiencing
difficulty with written communication. The ETCH
contains seven cursive writing tasks and six manuscript
writing tasks, plus items addressing the child’s ability to
handle the writing tool and paper. The primary focus of
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
examines specific legibility components of a child’s
handwriting such as letter formation, spacing, size, and
alignment, as well as a variety of sensorimotor skills
related to the child’s handling of the writing tool and
paper. Subtest and ETCH total scores are calculated as
percentages on the basis of the number of readable
letters, words, and numbers against possible letters,
words, and numbers.
CONTENTS
What does the schedule try to measure? The ETCH
examines specific legibility components of a child’s
handwriting (manuscript or cursive) such as letter
formation, spacing, size, and alignment, as well as a
variety of sensorimotor skills related to the child’s
handling of the writing tool and paper. These com-
ponents are measured from spontaneous composi-
tion, dictation, near-point, and far-point copying
tasks.
Does it give a clinical diagnosis? No.
PURPOSE
The primary purpose of 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.
ASSESSMENT COMPONENTS
Type of Assessment: Spontaneous composition, dicta-
tion, near-point, and far-point copy assessment
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
copying a short sentence; (d) far-point copying a
short sentence; (e) manuscript-to-cursive transition a
short sentence; (f) dictation three nonsense words;
and (g) sentence composition. The ETCH-M con-
sists of all of the preceding subtests with the excep-
tion of manuscript-to-cursive transition.
Paper Type: Supplied lined paper in test booklet
Pencil Type: Standard number 2 pencil
ADMINISTRATIVE /SCORING TIME
Administration: The test can be administered in 15
to 30 minutes depending on the child’s age and
handwriting difficulties
Scoring: After some practice, scoring time ranges from
10 to 20 minutes. From experience, scoring takes all
of 20 minutes.
PARTICIPANTS
Children: Children in grades 1 through 6, ages 6 years,
0 months to 12 years, 5 months
Adults: Can be used to gather descriptive information
related to their functional handwriting performance.
Developmental Level: Grade level
DERIVATION
Writing sample and scoring criteria were developed
from a pilot version through literature review and field
testing with revision.
PUBLISHED MATERIAL
Author/Others: Author (Amundson, 1995); others
(Diekema, Deitz, & Amundson, 1998; Grace-
Frederick, 1998; Koziatek & Powell, 2002; Schneck,
1998; Sudsawad et al., 2001)
Usefulness: Useful in assessing a child’s legibility and
speed of handwriting in writing tasks that are similar
to those required of students in the classroom. This
is useful in analyzing underlying sensorimotor
functions of handwriting and assessing handwriting
quality to determine the need for intervention and
baseline for monitoring progress.
Validated: Although one construct validity study
(Grace-Frederick, 1998) showed agreement between
teacher ratings of poor handwriting and poor per-

formance on the ETCH, another study (Sudsawad et
al., 2001) reported that little agreement was noted
between teacher questionnaires of handwriting
difficulty and ETCH performance. The concurrent
validity coefficients were 0.61 for ETCH-C total
words and 0.65 for total letters and handwriting
grade.
Reliability: Interrater ranged from 0.64 to 0.94
(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
inexperienced raters and from 0.64 to 0.98 for expe-
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
0.71 (Pearson) for total numeral, letter and legibility,
with generally lower subtest coefficients (0.20 to 0.76).
Additional Statistical Analysis: None
OTHER DATA IN SCHEDULE /OTHER
I NFORMATION /COMMENTS
One of the more widely used instruments, although it
lacks normative data. Thorough manual and templates
eliminate the need for constant ordering of forms.
Useful in identifying the types of handwriting diffi-
culties a student may be having, as well as potential
underlying sensorimotor difficulties. It is cumbersome
scoring a negative. Reliability findings also are ques-
tioned given the use of the Pearson (Ottenbacher &
Tomchek, 1993, 1994).
REFERENCES
Amundson SJ (1995). The evaluation tool of children’s
handwriting (ETCH). Homer, AK, OT Kids.
Diekema SM, Deitz J, Amundson SJ (1998). Test-
retest reliability of the Evaluation Tool of Children’s
Handwriting, Manuscript. American Journal of
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.
Koziatek SM, Powell NJ (2002). A validity study of the
Evaluation Tool of Children’s Handwriting-Cursive.
American Journal of Occupational Therapy,
56:446–453.
Ottenbacher KJ, Tomchek SD (1994). Measurement
error in method comparison studies: An empirical
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-
dren’s Handwriting-Manuscript. American Journal
of Occupational Therapy, 52:256–258.
Evaluation of Handwriting • 317
Sudsawad P, Trombly CA, Henderson A, Tickle-Degnen
L (2001). The relationship between the Evaluation
Tool of Children’s Handwriting and teacher’s
perceptions of handwriting legibility. American
Journal of Occupational Therapy, 55:518–523.
HANDWRITING SPEED TEST
AUTHOR, YEAR
Wallen, Bonney, and Lennox (1996a,b)
DESCRIPTION
The Handwriting Speed Test (HST) is a standardized,
norm-referenced test of handwriting speed for children
and adolescents in grades 3 through 12. It is intended
to be used as one component of a multifaceted assess-
ment of handwriting. After a 3-minute trial of copying
the words “the quick brown fox jumps over the lazy
dog” as many times as they can, a letters per minute is
obtained and converted to a scaled score. The scaled
score can be used in determining the eligibility of stu-
dents for extra time or other assistance in examinations,
identifying children who require intervention for
handwriting speed difficulty, and evaluating the effects
of intervention on handwriting.
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.
PURPOSE
The HST was developed to provide an up-to-date and
objective means of evaluating the handwriting speed of
students presenting with handwriting difficulties.
ASSESSMENT COMPONENTS
Type of Assessment: Near-point copy assessment
Task(s): The student is asked to copy from a typed
Handwriting Sample Form onto lines below the
words “the quick brown fox jumps over the lazy
dog” as many times as they can in a 3-minute period.
Paper Type: Supplied lined paper with center dotted line
Pencil Type: Number 2
ADMINISTRATIVE /SCORING TIME
Administration: The test is timed for 3 minutes to
obtain the Rate score.
Scoring: Scoring time ranges from 3 to 5 minutes.
318 Part III • Therapeutic Intervention
PARTICIPANTS
Children: Third through twelfth graders
Adults: Young adult (high school aged)
Developmental Level: Can be used for children with
physical disabilities, learning disabilities, or specific
handwriting difficulties
DERIVATION
Writing sample and scoring criteria were developed
through literature review
PUBLISHED MATERIAL
Author/Others: Author (Wallen, Bonney, & Lennox,
1996a,b; Wallen & Mackay, 1999); others
Usefulness: The HST was designed to provide an up-to-
date and objective means of evaluating the hand-
writing speed of students presenting with handwriting
difficulties. The HST is a useful tool for determining
the eligibility of students for extra time or other
assistance in examinations, identifying children who
require intervention for handwriting speed difficulty,
evaluating the effect of intervention on handwriting,
and conducting research with handwriting speed as a
variable (Wallen et al., 1996b).
Validated: On 1292 third through twelfth grade
students from New South Wales, Australia schools
with normative data determined after analysis.
Content validity was established in development.
Reliability: Interrater ranges from 0.99 to 1.00 (ICC)
for each grade and an ICC of 1.00 for the whole
sample. Intrarater reliability ICC was 0.99 for the
whole sample and ranged from 0.99 to 1.00 for
various grades, teacher ratings, and genders of stu-
dents. Test-retest reliability correlations ranged from
0.717 to 0.916 (ICC) for the various grades and
speeds of hand writers.
Additional Statistical Analysis: None
OTHER DATA IN SCHEDULE /OTHER
I NFORMATION /COMMENTS
Its short administration and scoring time make it
advantageous to clinical practice if assessing rate of
handwriting in isolation. This is rarely the case;
therefore other instruments assessing both handwriting
quality and rate will likely see more use.
REFERENCES
Wallen M, Bonney M, Lennox L (1996a). The
handwriting speed test. Adelaide, Australia, Helios.
Wallen M, Bonney M, Lennox L (1996b). Interrater
reliability of the Handwriting Speed Test. Occu-
pational Therapy Journal of Research, 16:280–287.
Wallen M, Mackay S (1999). Test-retest, interrater, and
intrarater reliability and construct validity of the
Handwriting Speed Test in year 3 and year 6 stu-
dents. Physical and Occupational Therapy in Pediatrics,
19:29–42.
 Chapter 15
PRINCIPLES AND PRACTICES OF
TEACHING HANDWRITING
Mary Benbow

CHAPTER OUTLINE or pencil, requiring intricate fine motor skills. Because

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

319
320 Part III • Therapeutic Intervention
should enable most of these children to gain functional
writing skill.
In the current educational environment of “No
Child Left Behind,” school departments require that
children with widely different developmental levels
be taught together in integrated classrooms; therefore
handwriting instruction demands better investigation
and more attention. Professionals must concentrate
on related-skills necessary to ensure more consistent
success with this high-level skill. They must teach all
school children more efficiently, thoroughly, and
permanently.
All students, especially the great variety of children
who are subtly delayed, can benefit from develop-
mentally ordered physical, visual, kinesthetic, and fine
motor experiences. A clearer understanding of the con-
stellation of skills that enable one to write efficiently
must guide professionals in developing more systematic
ways to prepare children for handwriting, as well as
to teach handwriting. Occupational therapists are fre-
quently called on for motor evaluations, consultation,
and remediation for public school children. Nonfunc-
tional handwriting is the most common reason for
referral. For an evaluation to be useful for effective
curriculum implementation or intervention, profes-
sionals must understand the chain of motor skills that
enable a student to write comfortably, automatically,
and accurately.
The purpose of this chapter is to describe hand skills
that make children more adept at operating a pencil.
This chapter presents not only the optimal skills for the
way the hand should work to produce efficient hand-
writing, but also the problems that arise when motor
components for the skill are absent or less dexterous
motor patterns are used. Techniques to promote the
development of the foundation skills are presented,
along with remediation or compensation techniques
for related problems that arise. The final section on the
teaching and remediation of handwriting presents
the rationale and method for the kinesthetically based
instruction of cursive writing. It should be noted that
this chapter does not address language components such
as word finding, sentence formulation, punctuation,
and spelling, but is limited to the mechanical aspects of
writing and cognitive-associative mental processes.
Handwriting instruction in American schools typi-
cally begins with manuscript writing (printing) and
shifts to cursive writing in the third grade. The author’s
experience has been that the development of functional
handwriting can be fostered by an earlier introduction
to cursive script. Therefore the discussions of prewrit-
ing and writing skills emphasize cursive writing. The
cursive versus manuscript writing issue is discussed
more fully in a later section of this chapter.
DEVELOPMENTAL EXPERIENCES
THAT UNDERLIE SKILLED USE OF
THE HANDS
Since 1992 as fear about sudden infant death syndrome
(SIDS) became widespread, the “Back to Sleep
Campaign” was implemented to lower the risk of SIDS
(SIDS Task Force). Many anxious parents misinter-
preted this warning to mean their baby should never be
prone, even during daytime play periods.
While supine or semireclined in a variety of plastic
“exoskeletons” infant seats, the baby can barely raise
his or her head, much less bear weight on the upper
extremities and elongate and strengthen the cervical
spine. “Tummy Time” in prone posture facilitates head
lifting and neck strengthening, trunk stability, and
balance while weight bearing on the upper extremities.
Therefore lack of prone positioning during the baby’s
play periods lengthens the time it takes to master such
basic skills as lifting and holding the head, pivoting,
turning over, and sitting and crawling. Lack of weight
bearing on the hands may affect hand structures; under-
developed arch formation and stabilization, incomplete
expansion of the thumb-index web space for full
opposition, and skilled manipulation of tools. Skilled
use of tools (e.g., silverware, scissors, pencils) often lags
because of lack of full range of motion at the carpo-
metacarpal (CMC) joint of the thumb.
To be effective in promoting efficient graphic skills,
developmental therapists must address these unresolved
ergonomic factors (i.e., postural, tonal, stabilizing) in
addition to fine motor intervention. Graphomotor pro-
duction difficulties usually cluster under one or more of
the following classifications: (a) incomplete range of
motion and use of the proximal joints of the upper
extremity, (b) immature wrist and hand development
with clumsy distal manipulation skills, (c) insufficient
experience in eye-hand control, (d) incomplete bilateral
integration, (e) inadequate spatial analysis or synthesis
skills, and (f) reduced somatosensory input with failure
to develop kinesthesia.
U PPER EXTREMITY SUPPORT
The interaction of all joints of the upper extremity—
scapulothoracic, glenohumeral, elbow, and wrist—is
required for the development of dexterous hand skills.
Each component must be developed and move freely
into its mature patterns. In children experiencing
fine motor delays it is not uncommon to find the
shoulder joint slightly biased toward internal rotation,
adduction, or flexion; the elbow joint toward flexion or

pronation; and the wrist toward flexion and ulnar
deviation.
In addition to fluid range of motion, each upper
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,
he or she should include weight bearing, traction, and
compression activities for scapula, shoulder, and elbow
joint control. Specific proximal joint needs are most
naturally incorporated into therapeutic or adapted
physical education goals.
For example, jumping rope backward requires the
simultaneous involvement of all upper extremity joints
moving into their mature patterns. Because this activity
fully incorporates all upper extremity joints, it should
be included in developmental hand therapy programs
for children who show dysfunction or inefficiency in
proximal joints. A younger or less coordinated child
should first learn to turn one end of a long rope with a
partner using the dominant hand while a third child
jumps. The initial goal is to develop external rotation
in the shoulder on the dominant hand side followed
by full range of motion in the opposite shoulder. The
third step is for the child to swing a jump rope back-
ward over his or her head and step behind it when he
or she hears the rope strike the floor. Finally, the upper
and lower body should be coordinated in reverse rope
jumping.
The case of Zachary demonstrates the value of an
integrated upper extremity program for hand skill
development. This 6-year-old boy was referred to occu-
pational therapy for difficulties with printing and sloppy
paperwork. Initially a program of hand activities was
prescribed that specifically addressed the referral
request. Zachary faithfully practiced his prescribed pro-
gram. He made little progress because the hand
activities felt so unnatural and were so difficult. Client
resistance became a new and serious deterrent. After
assessing his upper extremities more thoroughly, the
therapist found some limitation of motion in external
rotation of the shoulders and incomplete supination
at the elbows. After a progressive program for upper
extremity range and stability, his hand skills followed
naturally and resistance to fine motor activities less-
ened. Zachary’s case is fairly typical. The often over-
looked component of proximal development proved to
be the key in unlocking distal skills.
WRIST AND HAND DEVELOPMENT
In addition to a developmentally based gross motor
program, early education curricula should stress devel-
oping the entire upper extremity with particular empha-
sis on the hands. The goals are listed in Box 15-1. The
Principles and Practices of Teaching Handwriting • 321
BOX 15-1 Early Education Curricula Goals
for Developing Upper Extremity
and Hands
1. To stabilize the wrist with fine manipulation of small
tools, objects, and writing implements
2. To open and stabilize the thumb-index web space
3. To increase and stabilize the arches of the hands
4. To separate the motor functions of the two sides of
the hand
5. To develop two aspects of precision handling,
precision translation and precision rotation
hand functions in Box 15-1 are fundamental for all
higher-level tool skills.
Stabilize the Wrist
Bunnell (1970) states that the wrist is the key joint of
the hand. Wrist limitations cannot be compensated
for by any other upper extremity joint. Because wrist
movements are inseparable from the hand as a single
physiologic unit, therapists should combine wrist and
hand activities. The position of the wrist influences the
tension of the extrinsic muscles. The origins of the
extrinsic muscles of the hand are in the forearm and
generally move the digits in gross flexion or extension
patterns. Extrinsic tendon length does not allow simul-
taneous maximal flexion or extension of the wrist and
fingers, so interplay is seen with wrist and finger
movements.
Long and co-workers (1970), using electromyog-
raphy found that intrinsic muscles (whose origins are in
the wrist and/or hand) guide and grade the multiple
intermediate finger and thumb patterns and control all
rotary movements of the thumb and metacarpopha-
langeal (MP) finger joints used in precision handling.
Tubiana (1981) pointed out that no single articulation
in the hand is an isolated mechanical entity. Instead,
each articulation functions as part of a group arranged
in kinetic chains. Each articulation depends on the
equilibrium of forces acting at its level, and this equilib-
rium is subject to the position of the immediate prox-
imal articulation. Mobile balance is realized through
the interdependence among the elements along its
osteoarticular chain. That interdependence includes
both passive and active components. The active com-
ponent is the dynamic balance between antagonistic
muscles. The main passive component is the restraining
action of ligaments and muscular viscoelasticity that
facilitates coordination of motion (Smith, 1974).
Therefore the wrist influences the position of the MP
joint, and the MP joint influences the position of the
proximal interphalangeal (PIP) joint, which in turn
322 Part III • Therapeutic Intervention
influences the distal interphalangeal (DIP) joint. These
anatomic principles provide ways to analyze, design,
and sequence hand activities that are more effective in
developing the constellations of motor patterns for fine
motor skills. A tool is an extension of the hand that uses
it. Developmental logic dictates that a hand must be
skilled before it can skillfully manipulate a tool as an
extension of the hand.
Activities that facilitate wrist stabilization in exten-
sion with precision finger skills can best be done on
vertical surfaces above eye level. Such positioning auto-
matically places the wrist into its optimal posture and
facilitates abduction of the thumb to work distally with
the fingertips. Working above eye level requires holding
the arms at a level at which their weight strengthens the
muscles and stabilizes the joints of the scapula and
shoulder. Enjoyable proximal joint activities include
painting on chalkboards with brushes dipped in water
or more colorful tempera painting on paper at an easel.
Many commercially available toys can be vertically
positioned to develop wrist stabilization with distal
finger skill. Magna Doodle, Etch-A-Sketch, pegboards,
and eye-hook boards can all be fastened onto a wall, set
in a chalk rail or on an easel ledge, and secured with an
elastic cord if necessary. The important part of each
activity is that it is performed above eye level.
Open and Stabilize the Thumb-Index Web Space
Muscle tightness on the flexor side of the wrist limits
range of motion into extension and reduces stabi-
lization of the wrist for distal digital manipulation. The
CMC joint located at the base of the thumb column
should fully rotate so the thumb pulp can be pronated
and positioned diametrically opposite each of the four
finger pulps. Incomplete abduction and rotation at
this mobile thumb joint result in a posture that cannot
be well stabilized for distal manipulation (Kapandji,
1982). A fully expanded web space between the thumb
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
digits II and III. The small degree of movement at
the fixed junctures allows stability without rigidity
(Tubiana, 1981). The mobile elements include the five
digits and the peripheral metacarpals of the thumb
and little finger. The mobile units of the thenar and
hypothenar eminences cup or arch the hand, providing
balanced isolated intrinsic activity within the hand.
Manipulating Chinese balls within the palm of the
hand is a rapid way to develop all three arches. The
balls should fit well within the cupped hand so that
the thumb can rotate them around within the hand.
Instruct the child to rotate the balls by moving the
thumb into the center of the palm (Fig. 15-1).
Activity sheets with circles to fill or shapes to circle
or outline before coloring can be designed for this pur-
pose. Activities can be graded by decreasing the size of
shapes as refinement of skill progresses distally. When
sheets or coloring book pages are secured in a vertical
orientation (fitted onto a vertically mounted clipboard
or taped up on a wall or easel), the oblique arch of
opposition can more easily manipulate the pencil or
marker. The most refined use of finger control with
crayons or markers is in outlining the shapes before
coloring them. The diamond coloring sheet shown in
Figure 15-2 requires dynamic finger skill to outline
followed by static finger skill to color in the shapes.
Primary school children are self-motivated to draw
and practice numbers and letters on the chalkboard
when their efforts on this surface yield satisfying results.
For one nursery school child, working on a vertical
surface magically transformed his clumsy attempts to
color at the table into performances that delighted him
and his teacher. It may be worth noting that the first
products of human use of an advanced tool, in the cave
paintings at Lascaux, France, are on a vertical surface
at or above eye level, as are many of the petroglyphs
made by Native Americans on the canyon walls of the
southwestern United States. Without knowing why,
these primitive tool users maximized shoulder stability,
Figure 15-1 Chinese balls to develop arches in the
hand. (Available from OT Ideas, Inc., copyright Mary Benbow)

Figure 15-2 Diamond coloring sheet. (Copyright Mary
Benbow.)
wrist and thumb postures, and visual and hand dexter-
ity for their expressive needs. Today skilled artists rarely
draw or paint on a horizontal surface.
Separate the Motor Functions of the Two Sides
of the Hand
Capener (1956) noted the coupling action of the two
ulnar digits (IV and V), which function together in
power grips and precision handling. In precision han-
dling, when the ulnar digits are flexed against the palm,
they provide stability to the MP arch while isolating
control of the radial digits for manipulation with the
thumb. Separation of the ulnar from the radial side of
the hand counterbalances the MP arch for higher-level
skills. Holding a heavier item, such as a teacup is
achieved by abduction and extension of digits IV and
V. The radial digits (II and III) can be isolated and
stabilized from the arched posture to perform their
function more securely with the opposed thumb.
The proper handling of scissors requires the sepa-
ration of the motor functions of the two sides of the
hand. The ulnar digits should be flexed and stabilized
against the palm. With the wrist stabilized in extension,
the child should place the distal joints of the thumb
and middle finger into the loops (oval loops stabilize
easier). The loops should be small enough to enable the
child to stabilize the handles at the DIP joints of the
long finger and the IP joint of the thumb. The index
finger should be placed against the shaft of the handle
to support the scissors in a vertical position and help to
close the blades. The ulnar digits (IV and V) should be
flexed and pressed against the palm to add stability to
the MP arch. If it is frustrating or difficult to remember
to flex and stabilize digits IV and V, then have the child
press a small flat sponge against the palm with the two
ulnar digits, as shown in Figure 15-3. This motoric
separation of the functions of the two sides of the hand
Principles and Practices of Teaching Handwriting • 323
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
practice simply opening and closing the blades. After
intended blade movements become rhythmic, intro-
duce tiny straws (which take almost no control from
the nondominant hand) to be cut into tiny segments.
Advance to oak tag or old playing cards, and finally to
paper, which requires the most skill. The nondominant
hand must hold the paper taut enough for cutting
without tearing.
Develop Two Aspects of Precision Handling:
Precision Rotation and Precision Translation
Precision handling requires full range of motion at the
CMC joint of the thumb so its pulp can be flexed and
placed diametrically opposite each of the finger pulps.
From this stable position the multiple variations of the
two precision handling skills, precision translation and
precision rotation, should be developed and refined.
Translation movements require that the thumb and
index or the thumb, index, and middle fingers move
in synchrony in a toward-the-palm or away-from-the-
palm pattern (Long et al., 1970). Needle threading
uses a translation-away pattern from the fully flexed
translation-toward the palm. Pulling a thread through
a needle is an example of translation toward the palm-
finger pattern.* Writing in a cursive hand requires rapid
alternation of toward and away translation patterns to
produce letter strokes.
Shifting a stiff piece of oak tag through the eye of
a yarn needle with the wrists stabilized against each
other is an effective way for an older child to practice,
speed up, and observe translation movements with the
skilled digits. Marks can be placed on the strip to
indicate increased length of movement as skill improves
(Fig. 15-4).
*The term precision translation is used by Long and co-workers
(1970) to describe the movement of an object toward and away from
the palm while the grip on the object is maintained. The term has
also been used to describe the shifting of a small object such as a piece
of lint from the fingertips into the palm.
324 Part III • Therapeutic Intervention
Figure 15-4 Needle threading or translation movement
activity. Work to increase distance and speed with the
skilled digits. (Copyright Mary Benbow.)
Bead stringing is the classic preschool activity for
developing speed and dexterity in the alternating use of
translation patterns. However, children who most need
to develop this skill often adopt an efficient substitute
system. They place the bead over the lacing tip rather
than inserting the tip through the bead. Eye-hook
lacing boards prevent this skill substitution and provide
a more motivating activity for young children (Fig.
15-5). Because children tend to be self-driven to stay
with this lacing board activity, it is effective and efficient
Figure 15-5 Threading board designed by author.
(Available from OT Ideas, Inc., copyright Mary Benbow.)
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
expanding the web space by joint mobilization and
progressive stretching may be indicated. Expansion of
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
index and middle fingers.
A simple activity to promote precision rotation is
rolling tiny balls (1/8-inch diameter) of clay or therapy
putty between the pulps of the thumb and index finger.
Another is playing tug-of-war with a small-diameter
object such as a coffee stirrer or plastic lace. Digital
rotation at the MP joints is necessary to shape the grip
snugly enough so the extrinsic muscles can effectively
provide strength for distal power pinch. Pinching a
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
role. For this reason many children with visual motor
problems should be advanced to cursive instruction as

soon as written work is required. The reduced demand
for visual motor integration yields more satisfactory
results. When using kinesthetic teaching strategies for
cursive training, visual control becomes secondary to
proprioceptive guidance during the first lesson. An
accomplished hand writer limits visual control to stay-
ing on the writing line, guiding retrace lines, properly
spacing between words, and serving as a neatness
checker of written work.
Most American schoolchildren learn to print their
names before entering kindergarten. A few children
master the whole alphabet. Imitating family members,
early education teachers, or educational television shows,
they rely heavily on visual control in drawing their
block letters. Close visual monitoring of the pencil
point is necessary for them to control stroke length
and angle, find the intersecting or joining points, and
inhibit pencil movement at the intended stopping
place.
In any mainstreamed primary classroom one can
observe many accommodations to insufficient eye-hand
skills. A child who has difficulty focusing when eye
alignment or extraocular control is deficient often adapts
by turning the head far to one side to isolate use of one
eye while diverting the other eye from the paper. The
child has unconsciously discovered that this head posi-
tion eliminates the second image. A child who has great
difficulty lowering and converging the eyes continues
to draw circles, write numbers and letters from bottom
to top, and fails to adopt the cultural pattern of top to
bottom stroking of letters and numbers.
In the early grades figure copying tests such as
the Developmental Test of Visual Motor Integration
(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
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
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
draw a continuous controlled line with his or her pencil
Principles and Practices of Teaching Handwriting • 325
along the middle of the yellow line. With the paper
positioned on the desk top so that the lines run from
top to bottom (slanted for better viewing), the child
is instructed to draw the first line from top to bottom
and the second line from bottom to top (Fig. 15-6).
Accuracy of control is noted as the child visually guides
the hand into upward and downward space. It is
insightful to ask which direction was easier for him or
her to complete.
If the child appears stressed while doing the pre-
ceding task on a desk top, a second sheet can be taped
on the wall or chalkboard in the vertical plane with the
middle of the sheet of paper positioned at eye level as
the child stands to work. This placement requires the
child to elevate and lower the eyes along the two lines.
If he or she does poorly on trial 1 (desk top) and better
on trial 2 (wall or chalkboard), it will be advantageous
for the child to stand while practicing numbers and
letters on the chalkboard or at an easel. The child’s
ability to control a pencil in these two directions is a
clear demonstration of the visual system’s guidance of
the hand for graphic skill training. Tracking comfort
and skill often clarifies the reason some children are
unable to conform to writing numbers and letters from
top to bottom.
Mature handwriting requires input from both foveal
and ambient vision. Inadequate integration of the two
visual systems is seen when the letters are fairly well
formed but the writing is irregular in size and spacing
and positioned poorly in relation to the writing line.
Top to bottom Bottom to top
Numbers 1-10
Name:
Figure 15-6 Form used to observe visual control of
pencil. (Copyright Mary Benbow.)
326 Part III • Therapeutic Intervention
This is seen in manuscript within words, as well as
between words. Spacing problems in cursive are usually
limited to spaces between words. The ambient system
is faulty in providing the spatial component as the hand
produces proper formations.
When poor efficiency in visual-motor orientation is
noted in the classroom, a child should be further eval-
uated by a physical educator because ball and game
skills are often impaired as well. Remediation for visual
scanning problems is not to be found in paper and
pencil activities but in vestibular-based visually demand-
ing gross motor activities. If the child has difficulty
tracking upward, include activities that require upward
gaze such as tossing a ball straight up and catching it at
chest level, gently tapping a ball suspended above eye
level, racket games, volleyball, and flying kites or air-
planes. Alternatively, if the child has difficulty tracking
downward, bouncing a ball and catching it at waist
level is advised. A line or pattern drawn on the floor or
sidewalk can make bouncing on a Hippity-Hop ball or
riding a scooter board or bicycle more interesting and
organizing. Activities demanding rapid movement and
visual guidance help integrate visual tracking with body
skills.
In cursive writing, problems in tracking downward
result in poorer control of the loops that descend below
the writing line (f, g, j, p, q, y, and z). Alternatively,
when children are stressed by elevating their eyes, they
may have more trouble controlling the upward moving
ascender strokes of tall letters (h, k, b, f, l, and t).
Suspect a near-point focusing insufficiency when a
child can produce a single stroke but is inaccurate in
retracing line segments. A therapist can detect a focus-
ing problem most easily on the retraced segments of
a, d, m, and t. When these visual motor errors are
seen consistently, a referral for a visual examination is
indicated.
BILATERAL I NTEGRATION
Bilateral integration and sequencing (BIS) dysfunction
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
this issue. The child is unable to change stroke direc-
tion in a continuous flow pattern. This is evidenced as
an inability to shift the right under-curving lead-in
stroke to the left when approaching the line top while
writing letters k, b, f, and l. Functional graphic motor
output remains far beyond the child’s reach. Unfor-
tunately, additional paper and pencil practice does not
solve these developmental issues.
A child who is not bilaterally integrated neglects
stabilizing the paper with the nondominant hand when
writing or coloring. Until the dominant hand assumes
a definite leadership role, the nondominant hand does
not sense and perform its assisting role. Instead of
cooperation between the two body sides, there is resid-
ual competition. Synkinesis (motor overflow) usually is
observable, which supports the finding of inadequate
central nervous system inhibition of the nondominant
hand as the dominant hand is being programmed by
the brain. When an older student must produce a
lengthy written assignment, it is visually helpful to draw
a pair of bold black margin lines about 1 inch from the
left side of the paper. The high-contrast lines alert his
or her peripheral vision and cue the child to stabilize
the paper with the nondominant hand while main-
taining left margin alignment. The nondominant hand
positioned on the edge of the paper helps to visually
define the writing area and promotes more balanced
sitting posture.
Directionality confusion is suspected when a child
continues to write wraparound letters after instructions
are given to stop at a specific point and retrace a letter
segment. When this wraparound pattern, as seen in the
letters a, d, g, q, and c, is the only immature pattern
noted, one can logically assume that the motor behav-
ior was generalized from self-taught incorrect forma-
tion of manuscript letters at an earlier stage. A typical
example is seen in Figure 15-7.
When a child with incomplete bilateral integration
draws horizontal or diagonal lines, a hesitation or jerk
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-
izing when the child draws diagonal lines. Typically the
child produces near-vertical lines for diagonals without
Figure 15-7 Example of the incorrect formation of the
wraparound letters a and g. (From Loops and other groups:
A kinesthetic writing system. Copyright 1990 by Harcourt
Assessment, Inc. Reproduced with permission. All rights
reserved.)

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
the writing of mirror-image letters or numerals. These
output errors are more commonly seen when a symbol
is produced in isolation. An evaluation of 900 middle
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
child should be taught the place to halt the pencil
progression and shift visual focus. The focal place is
usually where the stroke ends, as seen with directions
for capital D in Figure 15-9. The child must avoid
visually monitoring the pencil point where it recrosses
the visual midline to write these letters successfully.
An enigmatic problem associated with BIS dysfunc-
tion is seen in a child’s inability to change stroke direc-
tion in a continuous flow pattern. The child feels the
need to touch the top of the line and pause before
being able to shift line direction. When writing the
long ascenders of the loop letters (h, k, b, f, and l), it is
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
tall loop letters the change of direction is necessary to
prepare for the immediate down stroke once the line
top is touched. Changing directions in a continuous
flow pattern proves to be an intractable writing prob-
lem. To develop this sense of direction flow, the child
needs to bodily understand the verbal directions as
demonstrated by the instructor. The shifting direction
of the tall loop stroke is best taught through the
shoulder while writing in the air. Stress the inhibition
of the right ascending stroke where it shifts leftward
and up to the top of the line. Only when the child
Principles and Practices of Teaching Handwriting • 327
for for
Figure 15-9 Special instructions given to children
learning to write a capital D. (From Loops and other
groups: A kinesthetic writing system. Copyright 1990 by
Harcourt Assessment, Inc. Reproduced with permission. All
rights reserved.)
Figure 15-10 Illustration of the problem in changing
direction with a continuous flow pattern. (From Loops and
other groups: A kinesthetic writing system. Copyright 1990 by
Harcourt Assessment, Inc. Reproduced with permission. All
rights reserved.)
can master air writing with the shift of direction should
he or she attempt it on paper. Consistent repetition
is necessary for kinesthetic success. The difficulty of
changing stroke direction in a continuous flow pattern
also causes a problem in producing the alternating
swoop line used to top capital F and T.
SPATIAL ANALYSIS
Children with non–language learning disabilities
(NLD), which include difficulties with math, non-
phonetic spelling, and visualizing, usually lack strategies
to analyze geometric shapes, numbers, and letters.
These children require detailed letter analysis help to
learn to write. Small incremental steps (including start-
ing place, pencil progression, distance and speed at
which to move the pencil, and stopping point) must be
examined and explained and re-examined and re-
explained. Retraces, the point of intersection with lead-
in strokes, and instructions for the release stroke or
328 Part III • Therapeutic Intervention
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
when they are speed coached. All motor learning
requires that speed be matched to task difficulty and
the learner’s level of skill. A therapist can reduce learn-
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
instructions should include speed tips: The lead-in
strokes flow more naturally when done quickly; retraces
require some visual guidance, so slowing down is
advised; speed should be resumed for any single line
segment or release stroke that follows. These instruc-
tions seem most logical and are usually understood and
followed by most second graders. Speed coaching is
helpful for children who are struggling with any type of
gross or fine motor skill learning.
NLD children can learn cursive writing with their
peers when the entire class is given detailed visual and
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
learning. Subvocalizing the motor plan guides writing
hand movements. This practice should be continued
until the writing is faster than the verbalizing.
Writing instructors should be precise in their use of
the word “line.” It is confusing to the student to use
the same word to describe top and bottom lines and
the space between lines. Instructing the student to
make a letter “half a line high” only adds to his or her
confusion. If instructors consistently refer to the top
line, writing line, and dotted middle marker, they will
not confuse their students. The area between the lines
should always be called a space (or half space for letters
ascending only to the middle marker). It is also helpful
to the child if the writing line is darker than the top line
or colored for initial learning and practice sessions.
Using the designations writing line, top line, and mid-
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
strokes. If students are made aware of them, these
negative shapes can aid in determining whether the
letters are written correctly. For example, a triangle is
Figure 15-11 Showing negative shapes created
between writing lines and letter strokes. (From Loops and
other groups: A kinesthetic writing system. Copyright 1990 by
Harcourt Assessment, Inc. Reproduced with permission. All
rights reserved.)
created on the writing line by the lead-in stroke and
the lower rounded segment of the letters a and d (Fig.
15-11). Contrasting it with the smaller triangle made
on the right side of these letters before the release
stroke proves to be an intriguing challenge to the
novice for quality control. Readily identifiable negative
shapes can help the child recognize letter accuracy and
serve as a guide for self-correction. These visual cues
control for line contact as well. Producing the small
triangle at the bases of i, u, w, and t (Fig. 15-12)
prevents releasing the down stroke too soon for a good
connection or release unit.
KINESTHESIA
Writing is a motor skill and, as with other motor skills,
efficient writing depends on kinesthetic input. Motor
skills developed kinesthetically, such as riding a bike,
keyboarding, or handwriting, are most permanent. In
writing, an internal sensitivity that a letter movement
feels correct reduces a child’s need to visually monitor
the fingers or pencil point while moving along the line.
This security enhances speed in learning and confidence
in cursive writing. Kinesthetic writing naturally accel-
erates over time to functional speed without the reduc-
tion of performance quality seen with visually guided
writing. The visual system is far too slow and mechan-
ical to monitor the serial chain of finger movements
necessary for note taking much beyond mid third
grade. Advising a child to slow down (allowing time to
visually monitor the writing hand) temporarily results
Figure 15-12 Knowing that the triangle should be
small prevents a premature release of the down stroke.
(From Loops and other groups: A kinesthetic writing system.
Copyright 1990 by Harcourt Assessment, Inc. Reproduced
with permission. All rights reserved.)

in more legible paperwork. However, this remedy
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
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.
Kinesthetic skills usually intrigue young children.
Elementary kinesthetic activities can be done on desk
tops, at the blackboard, or in the gymnasium. A sample
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
Test of Visual Motor Integration are useful in predict-
ing the child’s potential ease or difficulty in learning
manuscript. Copy forms and manuscript letters require
analysis and synthesis of the forms to duplicate them
BOX 15-2 Sample Elementary Kinesthetic
Activities
1. Desk Top: Place an object (e.g., coin or cube)
anywhere on the desk surface within the arc of the
child’s reach. Withdraw the child’s hand to a resting
position and ask him or her to close the eyes and
reach directly to the object. Grade the activity by
having the child place the object with one hand and
retrieve it with the other.
2. Blackboard: Sports that have a spatial component
(e.g., baseball diamond, golf green) can be sketched
on the blackboard. After the child visually and
motorically senses the size and shape of the display,
have him or her close the eyes, visualize the display,
and draw with chalk a run from home plate for a
single, double, or home run (Fig. 15-13).
3. Gym: After gaining the feel of movement of pitching
like objects into a container, have the child close his
or her eyes and use kinesthetic sense to continue the
activity. The child should not alter orientation or
distance and the objects should be identical in
weight and size. The most challenging position for
this activity is seated on a one-legged stool.
Principles and Practices of Teaching Handwriting • 329
2nd
3rd 1st
Home
Plate
Figure 15-13 Chalkboard baseball. (Copyright Mary
Benbow.)
accurately. Skill in this area is less helpful in predicting
the ease a student will experience in learning cursive
writing.
A Production Consistency Sheet (Benbow et al.,
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
half sheet of unlined paper (51/2 × 81/2 inches). Each
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
using a fluid moving stroke(s) rather than a rigidly
controlled stroke(s). The four shapes should be drawn
in three evenly spaced rows of five figures. On com-
pletion of the fifteenth figure, the child is told to close
the eyes or avert the gaze and complete a fourth row
that looks like and is spaced like the rows above. The
quality of the first three rows reveals the child’s visual
motor control of horizontal, vertical, diagonal, or cir-
cular lines. The consistency of the fourth row is a
graphic demonstration of the child’s kinesthetic learn-
ing potential for both configuring and spacing. The
two examples selected in Figure 15-14 were drawn by
10-year-old boys who were classmates in a third-grade
classroom. Consistency in shape, size, and spacing is a
high indicator of potential for learning cursive writing.
In comparing these two samples, one can predict that
the child who drew Figure 15-14 A will learn to
write with less difficulty than the child who drew Figure
15-14 B.
330 Part III • Therapeutic Intervention
A Handwriting is the most frequently used, complex, and
B of 68 American children of the same age used this grip.
Figure 15-14 Production consistency of an average
writer (A) and a poor writer (B). (Copyright Mary Benbow.)
SUMMARY
Children who benefit from ongoing diagnostic hand-
writing training usually have identifiable problems in
one or more foundation skills. The first is gross and
fine motor readiness for cursive instruction. Output or
production problems can include difficulties with rapid
sequential movements (often noted in the child’s early
history as articulation problems), visual control,
bilateral integration, and spatial analysis and synthesis.
Feedback difficulties include inadequacies in visual and
kinesthetic reafferent systems.
Developmentally sequenced hand activities should
be a major fine motor focus in preschools and early
elementary education. Early educators should develop
the full potential of children’s hands for all skills
because the remediation of prewriting hand skills
greatly facilitates the learning of graphic skills. The
following sections turn to two specific aspects of hand-
writing training, pencil grip and kinesthetic writing.
HANDWRITING TRAINING:
PENCIL GRIP
Letter production skill can be influenced by the way
the writer grips a writing tool. This section includes a
description of pencil grips, a discussion of the limitation
imposed by maladaptive grips, and some remedial
strategies.
TRIPOD G RIP AND ALTERNATIVE G RIPS
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
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
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
tripod grips (three digits on the pencil shaft). This open
thumb web alternative to the normal tripod grip most
likely developed with premature use of pencils or low
joint stability in the hand. The fourth finger on the
shaft adds power for stroking, as well as a wider bridge
for stabilizing the pencil shaft. Many quadripod grips
do progress and become dynamic and fully functional.
The two slight disadvantages of this grip are (a) reduc-
tion in pencil point excursion, and (b) reduced stability
of the MP arch when the little finger is used alone
rather than being functionally coupled with the ring
finger.
A few children assume an adapted tripod grip
(Fig. 15-15) in which they stabilize their pencil within
the narrower web space between the middle and index
fingers. This is an effective adaptation when joint
stability is insufficient for controlled mobility. All of the
skilled muscles of the classic dynamic tripod manipulate
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
orthopedic writing problems.
Joint stability in the hand depends on ligaments and
fixed structures. Working with school children, one sees
evidence that the functional use of the hand depends
more on joint stability than joint mobility. Children
adopt unique ways to make their hands work for them

Figure 15-15 Adapted tripod grip. (Copyright Mary
Benbow.)
when they lack joint stability. If the MP joint of the
thumb is unstable, the web space will collapse when the
pulp of the thumb is used to stabilize a tool in the distal
fingertips or against another digit. In this case the child
will unknowingly substitute the two heads of the power-
ful adductor and the first dorsal interossei (internal
thenar muscles) for the three more highly skilled exter-
nal thenar muscles: abductor pollicis brevis, flexor pollicis
brevis, and opponens. The substitution of the internal
thenar muscles causes the thumb to supinate or rotate
away from the posture to allow pulp to pulp opposition
(Tubiana, 1984). When using a pen or pencil, the
individual wraps the thumb over or tucks the thumb
under the index finger to control the stroke. Either grip
provides a distal point of stability with the challenge to
devise a system to mobilize the pencil proximally. When
the web space is closed snugly over the pencil shaft, the
thumb MP joint support structures are stressed in an
outward direction, and the proprioceptive feedback
used to guide and grade fine motor muscles is reduced.
REMEDIATION OF PENCIL G RIP
In the development of motor skills there is evidence of
transfer between different forms of action. The preci-
sion grip once mastered and reliably used with a spoon
or fork begins to be used in drawing with a pencil.
Therefore the instructor or therapist should evaluate
the use of silverware before attempting to alter more
complex skills with marking or writing tools. Silverware
requires only stabilization of the shaft within the tripod
digits. A writing tool requires stabilization plus con-
trolled mobilization. If the child uses an immature
power grip on a spoon, the instructor should develop
Principles and Practices of Teaching Handwriting • 331
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.
Then a grip device can be an effective reminder to
maintain the advanced posture.
Reducing hyperflexion at the PIP joint or hyper-
extension at the DIP joint (Fig. 15-17) can be accom-
plished by taping or blocking PIP hyperflexion with a
tape support. With smaller, weaker, and less experi-
enced hands tape support is often an adequate support
to the extensor system. The surgical tape Microfoam
(3M, St Paul, MN) adds stability to the digit. Tactile
input from the taped finger is significantly increased so
any movement helps the child to sense where his or her
fingers are in space. A 1/8-inch wide strip of Microfoam
tape should be affixed to the middle dorsal aspect of
the index finger while the digit is positioned in full
extension. The distal end of the tape should be attached
to the nail and continue proximally over the DIP, PIP,
and MP joints to the mid-metacarpal level (Fig. 15-18).
The tape should be adjusted to give the joint(s) stability
without rigidity. Some children choose to use the tape
when a large amount of written work is necessary,
whereas others insist on wearing the tape most of
the day.
A newer device called a “Pencil Pal” (Fig. 15-19) is
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
to provide a higher stabilizing point for the pencil. This
shift in position of the shaft of the pencil reduces
hyperextension or “white knuckle” pain at the DIP
joint.
The ability to stabilize the CMC and MP joints of
the thumb is critical for tripod manipulation of objects
and tools. The IP joint cannot be a controlled mover if
the MP joint cannot provide a stable base of support.
This stability-mobility problem renders the hand most
dysfunctional, especially in the manipulation of color-
ing or writing tools. In younger children with short
fingers the “Pencil Grip” or external taping of the
332 Part III • Therapeutic Intervention

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
the distal interphalangeal joint and hyperflexion of the
proximal interphalangeal joint. (Copyright Mary Benbow.)
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
Benbow.)
posterior aspect of the thumb often is sufficient support
to make the thumb functional. Taping techniques out-
lined for the index finger can be applied to the thumb.
When the MP joint of the thumb is unstable because of
lax ligaments, a neoprene splint can support and pro-
tect the joint while writing.
Hand structures necessary for tool stabilization with
distal manipulation are shown in Box 15-3.
Principles and Practices of Teaching Handwriting • 333
Figure 15-19 Pencil Pal, which reduces the angle of
pencil and DIP hyperextension. (Available from OT Ideas,
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.
An “index grip”—a forearm, wrist, and pencil grip
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
is solidly stabilized on the writing surface. The pencil
shaft is cradled into the flexed index IP joints and
extends distally across the third, fourth, and occasion-
ally the fifth fingertips. The lead end of the pencil is
pointed toward the writer’s midline. Writing strokes
come from a combination of wrist flexion and MP fin-
ger extension with minimal thumb IP flexion. Because
the writer does not progressively slide the solidly
334 Part III • Therapeutic Intervention
Figure 15-20 Index grip adaptation to extreme laxity of
the metacarpal-phalangeal joint of the thumb. (Copyright
Mary Benbow.)
Figure 15-21 Neoprene thumb abduction splints. (Available from Benik Corp., www.benik.com; McKie,
www.mckiesplints.com; copyright Mary Benbow.)
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-
tion and provides stability at the hypermobile MP joint
when the thumb tip is positioned on the pencil shaft
(Fig. 15-21). Neoprene provides stability without the

rigidity of a thermoplastic device. Wrist-length neo-
prene gloves designed to provide thumb positioning
and stabilizing are commercially available in appealing
colors and multiple sizes.
School therapists, knowledgeable in developmental
hand functions, must use professional judgment to
determine if, how, and when adaptations, motor inter-
ventions, or outside stabilization will benefit the child.
The expectations of the child, teacher, and parents
must be fully appreciated and honestly incorporated
into the child’s educational plan. The therapist should
include recommendations for short-term trials and
offer periodic reassessments of their acceptability and
effectiveness.
Before intervening with an older student with an
inefficient grip, it is critical for the child to understand
why it is worth the effort to change. Pencil postures
that are not held within the pulps of the digits do not
lead to economy, convenience, or adequate feedback
for the proximal-distal axis. The simple flexor or exten-
sor synergy produces the fast writing needed once
output demand increases in middle school. An adducted
or closed web grip diminishes the proprioceptive feed-
back from the lumbricales of the skilled digits. The
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
his or her fingers. In addition, the child should be
aware that a hypermobile closed web grip predisposes
the joint to injury because of sustained co-contraction
(Pascarelli & Quilter, 1994).
The sequence demonstrated in Box 15-4 can make
the transition to a functional distal grip more successful
and less stressful.
Many persistent persons write satisfactorily with
poor grips. Many of these grips require the person to
develop skilled use of proximal joints, which lack the
precise control and speed of the distal joints. A pencil
held in a closed web grip by the adductor pollicis
cannot move far or use the rotary agility of the index
MP joint in producing rounded strokes. Curving and
rounding must be produced by more proximal joints
requiring supination at the elbow and external or inter-
nal rotation at the shoulder. Wrist and forearm exten-
sors must produce elongation of upstrokes, which is
efficiently done using a digital translation away pattern
and minimal wrist extension. A few writers use the
entire skilled side (radial) of the hand to clutch and
stabilize the pencil, and mobilize the pencil by extend-
ing and flexing the three joints of the power digits IV
and V. Writer’s cramps are often seen in people who
overuse their wrist in writing.
Principles and Practices of Teaching Handwriting • 335
BOX 15-4 Making the Transition to a
Functional Distal Grip More
Successful and Less Stressful
1. The instructor demonstrates placement of the pen-
cil positioned between the index and long fingers to
make large random patterns using only shoulder
and elbow movements.
2. The child imitates the pencil position and makes
large free flowing movements following this rigid
rule: No finger movements!! No letters!! No
numbers!!
3. After the child accommodates to the feel of the
pencil in the index/middle finger web space, the
child should draw anything he or she pleases.
4. Once the child is at ease with the new pencil posi-
tion, he or she should be encouraged to write large
isolated numbers and letters.
5. When the new grip becomes annoying, the child
should temporarily shift back to the former grip.
6. As soon as he or she feels ready, the child should
return to the adapted grip.
7. When a child is in control of the alternating time
shifting scheme, and experiences comfort and
success, he or she tends to use the adapted grip
more consistently.
KINESTHETIC APPROACH TO
TEACHING HANDWRITING
C URSIVE OR MANUSCRIPT WRITING
One of the difficulties facing anyone investigating
handwriting teaching and remediation issues is the lack
of longitudinal studies in the field. Studies of prepara-
tory skills, curriculum techniques, and timetables for
the consolidation of writing skill at an automatic level
are scarce. Tradition rather than scientific investigation
has guided the teaching of handwriting in America. For
example, there are no studies to substantiate the prac-
tice of using manuscript throughout kindergarten and
first and second grade. In fact there is considerable
evidence showing that such teaching may impede the
development of functional handwriting in some stu-
dents. Cursive instruction typically is introduced at the
beginning of grade 3 in most American school systems.
Several motor patterns adopted for printing and
reinforced by 3 to 5 years of use are often resistant to
change at age 8. In manuscript, children become accus-
tomed to having the paper square to the edge of the
desk in order to “write.” Later, slanting the paper to
the appropriate angle to accommodate the wrist for
diagonal down and up stroking in cursive is motorically
336 Part III • Therapeutic Intervention
disconcerting for many children. The D’Nealian manu-
script program is unique in that letters are practiced
with the paper positioned at an angle to take advantage
of the wrist flexors in down stroking. Interestingly, this
angling of the paper is beneficial only when the radial
side of the hand is used to guide the pencil to write.
However, this placement of the paper is usually
demanded of all children regardless of grip. In addi-
tion, the eye-hand pattern of top to bottom control of
vertical strokes needs to be shifted to bottom to top
under curving diagonals.
The strategy for gaining an understanding of ball
and stick manuscript letters requires whole-to-part
analysis followed by synthesis of the parts back into
wholes. For many children it is perplexing to alter the
process and analyze and integrate movement for the
whole letter formation necessary for cursive writing.
Again the D’Nealian manuscript program has been the
most successful in reducing segmentation of lines for
letter formations.
In more than 30 years of experience in the teaching
of handwriting, this author has found that second
grade is an optimal time for most children to learn
cursive handwriting. Student interest is high, and gen-
erally students have not yet developed faulty habits
of inventive cursive before formal instruction begins.
Training activities of combining letters into simple two-
and three-letter words to practice letter formations and
connector units are at a more appropriate cognitive
level for second-grade students. Initiating cursive writ-
ing instruction in the fall of second grade allows a full
year for students to stabilize this motor learning before
the higher volume of written work is demanded at the
third-grade level.
Curricula that use instructional techniques to accom-
modate for perceptual and motor delays and deficits
should enable nearly all children to advance to cursive
writing at an earlier age. In schools in which cursive
writing is introduced earlier and mastered kinesthet-
ically, there is less confusion with and substitution of
manuscript letters with cursive letters. Programming
ample time to master cursive writing reduces the num-
ber of children who revert to manuscript in middle
school when the output volume increases dramatically.
The most perplexing problem for parents, teachers,
and students themselves is how the student can have
excellent fine motor skills and horrible handwriting.
Levine (2003) explains that fine motor skills mainly
recruit the fingers to manage artwork, origami, or
airplane models, which are all navigated by the eyes.
Graphomotor functions take place over different neural
pathways and require rapid sequential movements
guided by ongoing sensory feedback from the digits.
The eyes are far too slow to monitor the movement of
the digits as they move at a functional speed. Levine’s
findings on the importance of sequential finger speed
to handwriting are supported by other handwriting
researchers.
Berninger and Rutberg (1992) evaluated children in
grades 1 to 3 using six finger tasks; two displacement
items, lifting and spreading, finger recognition, finger
localization, repeated tapping of thumb pad to index
pad, and rapid sequential touching of the thumb pulps
to the four finger pulps (5, 4, 3, 2, 5, 4, etc., a measure
of motor planning and rapid sequential movements).
The rapid, sequential touching to all four finger pulps
proved to be the only task that was reliable and valid for
assessing handwriting skill in young children.
Deuel (1995) found slow finger-tapping speed to
be significant in her dysgraphic subjects with motor
clumsiness. This was not significant in the language or
spatial problem students. In isolated cases, when finger
speed is significantly slow and sensory feedback from
the digits cannot be reinforced by taping, refining print-
ing skill may be the prudent solution to the student’s
needs. Early and thorough teaching of keyboarding
skills should be initiated as soon as practical in these
cases.
MOTOR PATTERNS IN C URSIVE WRITING
Motor output for cursive writing requires continuous
stroke patterns. For this reason cursive letter analysis
and instructions should be programmed to maximize
visualization of the whole. Mental formulation of the
plan with verbalization of the entire motor sequence
should be stressed. This elicits the child’s propriocep-
tive and kinesthetic sense, supporting the flow of the
whole letter.
Most published handwriting programs currently in
use employ a “copy-the-letter” scheme followed by
visually guided reproduction of the letter within divided
lines. Able or not, children are typically expected to
convert to cursive writing during the fall of third grade.
Many curricula introduce one or two alphabetically
sequenced lower case letters each week. Such slow pro-
gression means that the lower case letters are unavail-
able for classroom work for 3 or 4 months, and the
upper case letters still remain to be learned. Other
programs introduce the lower case and upper case of
the same letter in tandem. Shifting the unrelated motor
patterns for lead-in strokes that are necessary when
either alphabetical system is followed does not facilitate
efficient motor learning.
Grouping letters according to common movement
patterns reduces memory demands and motor diffi-
culties. After the initial session of introducing the
movement pattern, during which each child learns to
verbalize the pattern and produce it motorically,
additional letters in the group can be learned expedi-

tiously. The learning process is further hastened by
reinforcement as all of the letters within the cluster are
practiced together.
General instructions included in most handwriting
manuals are inadequate for children experiencing visual
motor difficulties, incomplete bilateral integration,
weak spatial analyzing ability, and attention or memory
problems. Specific compensations for their special needs
must be included with initial classroom instructions or
their classroom practice periods will not be productive.
In many schools the practice time is insufficient for
all but the most skilled students to achieve functional
output. Children are as frustrated by their handwriting
failures as are their parents and teachers. Those with
special needs, along with many who have simply not
received enough help or time to master this complex
motor task, resign themselves to poor handwriting or
simply revert to manuscript, which received far more
teaching time and reinforcement in the lower grades.
WHY TEACH WRITING KINESTHETICALLY?
Writing is a motor skill that requires competent motor
teaching and thoroughly reinforced motor learning.
Fitts (1964) believed the process of skill acquisition
falls into three stages. The first, the cognitive stage,
involves the initial encoding of the instructions for a
skill into a form sufficient for the learner to generate
the behavior to some crude approximation. He empha-
sized that rehearsal of information is necessary for the
execution of skill. The second, the associative stage,
involves smoothing out of the motor performance
with gradual detection and elimination of errors and
the dropping of verbal mediation. The third, the
autonomous stage, is one of gradual improvement that
may continue indefinitely.
One should distinguish these motor skill require-
ments for writing from other classroom learning.
Learning to write is different from learning to read. If
it were not, more good readers would be able to write
legibly. Learning to write is not a language skill,
although language skills are necessary to supply the
content of written production. Learning to write should
not be coupled with learning the alphabet. Learning to
write letters in alphabetical order is more likely to
enhance alphabetizing skills than handwriting skills. As
with all fine motor skills, a student must accept the fact
that the head learns to write faster than the hand.
By its nature a kinesthetic approach to handwriting
provides children with a clear, enjoyable progression
from (a) the placement of the letter within the three
half-space vertical units, to (b) the precise motor analy-
sis with verbal support of the motor plan, to (c) the
appropriate variations in speed, to (d) the practice with
eyes closed or averted, and finally to (e) the reinforcing
Principles and Practices of Teaching Handwriting • 337
or setting of motor and memory engrams at an auto-
matic level.
The product of visually guided, or drawn, writing
may be legible or even beautiful but is not functional
because its methodical execution is too slow and con-
suming of cognitive power. The motor activity of
writing must be fairly autonomous to free cognitive
power for composing and spelling. The human nervous
system can focus clearly on only one complex mental
task at a time. Related skills, such as writing, must be
sufficiently automatic to be carried out at an associative
skill level. It is beyond the ability of most persons to
compose a complex sentence and think about the way
each letter in each word is executed. This failure in skill
mastery is often the cause of a typical parent or teacher
complaint: “My brilliant child’s hand cannot keep pace
with his mind.”
KINESTHETIC TEACHING M ETHOD
Handwriting is a lateralized motor skill of the highest
order. When kinesthetic teaching techniques are incor-
porated from the beginning of handwriting instruction,
the child naturally develops a kinesthetic potential for
writing and other fine motor skills as well. The kines-
thetic method of teaching cursive writing presented in
Loops and Other Groups (Benbow, 1990) provides both
general and compensatory instructions that are nec-
essary for teaching in a mainstreamed classroom. It
enables learning-disabled students to progress with
their normal peers. Compensatory instructions and tips
are included for students with perceptual-motor delays
or deficits including difficulty with visually producing
diagonals, midline crossing interruptions, and fluctu-
ating motor memory for configurations.
The group names for letters relate to familiar objects
in a child’s environment and promote visualization of
the lead-in strokes (Fig. 15-22). The first letter in each
of the four groups must be mastered at the kinesthetic
level before the child is allowed to advance to the next
letter. As soon as any letter is mastered, instructions are
given for connecting it to itself or other previously
learned letters. The student’s awareness of and
repetition of the common motor patterns within each
group hasten mastery of the skill by reinforcing motor
learning of the entire group.
The author has conducted successful kinesthetic
writing programs by dividing the learning of lower
case letters into six teaching blocks for classroom use.
The blocks are rapidly but thoroughly taught in daily
30-minute sessions in 6 weeks during September and
October of second grade. The lower case letters are
consistently reinforced with daily practice and used
whenever possible (e.g., spelling tests when children
have learned the necessary letters) to reinforce and
338 Part III • Therapeutic Intervention
Clock Climbers
Kite Strings
Loop Group
Hills and Valleys
Figure 15-22 Letter group named to assist memory in
learning. (Copyright Mary Benbow.)
stabilize this new skill. It is estimated that 95% of the
letters on a page of writing are lower case, so stress is
put on mastery to the automatic level to ensure
functional writing speed.
During the fall, manuscript capitals are used in com-
bination with lower case cursive letters for all written
assignments. Cursive capitals are introduced after the
winter holiday vacation. This interval allows time for
lower case to become stabilized before the capitals are
introduced. This interim significantly reduces upper
case and lower case confusion in children with weak
memory for configuration.
KINESTHETIC REMEDIATION TECHNIQUES
Writing errors often tend to cluster and make a paper
look sloppy. With older students, correcting one or two
cluster errors is effective in producing an acceptable-
looking paper. Overall appearance often can be signifi-
cantly improved by improving one or two problem
areas. The three common cluster errors include the
seven drop-loop letters (f, g, j, p, q, y, and z), whose
loops are often huge, carelessly formed “sausages” that
interfere with the lower line of writing. The second
cluster is incomplete closure of the four round-over-
the-top letters in the “a” or clock climber group (a, d,
g, and q). The third cluster is failure to retrace letters
to the writing line before the release or connector
stroke. This failure places the connector unit too high
or too low to lead into the letter that follows it.
Cluster remediation often is more palatable for older
students to undertake. Group letter analysis and speed
coaching for segments to be produced quickly or slowly
offers new hope that is motivating for these often
discouraged students. With kinesthetic training, rein-
forcement, and moderate persistence most students
are self-motivated to improve their output quality and
increase their writing quantity as well.
Rule of the line or space between the writing and
top line should be compatible with the fineness or
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-
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
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-
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
ruled paper feels comfortable for their motor system.
An efficient way for the evaluator to detect well-
formed letters that have not been learned to the auto-
matic level is to look for connector breaks in the line at
the point where the lead-in stroke is initiated. Figure
15-24 shows breaks in writing the alphabet before
the letters f, j, r, and s. These breaks generally slow the
writer’s overall speed. The interruptions, or “think
breaks,” can also be detected within words, but a con-
nected cursive alphabet is the most thorough and
efficient way to assess the letters of the alphabet.
Specifically reinforcing the identified letters that follow
“think breaks” to the automatic level can often convert
nonfunctional output speed into functional skill.
Kinesthetic reinforcement of letters can increase
writing speed while maintaining quality in a child who
writes beautifully but has not developed functional
speed. After carefully re-examining the line progression
of any known letter and producing it with visual guid-
ance, the child should close his or her eyes, visualize the
letter, and write with fluidity on scrap paper 15 times
before checking the results. Once the initial letter
within a motor group is written reliably at an efficient
speed, the remaining letters of the group should be
brought up to speed one by one. A most popular time
to suggest for children to increase their speed in writing
is while watching television. The combination of
these two activities diverts visual monitoring from the
writing hand, and the student willingly extends practice
periods.
Seating Posture and Classroom Arrangement
Properly fitted furniture is indispensable if children are
to learn handwriting efficiently. If the chairs are too
high and the child’s heels do not touch the floor, he or
she will be unable to counterbalance for weight shift as
 Principles and Practices of Teaching Handwriting • 339

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
too high, the upper arm will be abducted too far to
control the fingers effectively. Figure 15-25 illustrates a
properly fitted student chair and desk for writing.
The child’s desk should face the chalkboard where
the teacher demonstrates the letters. There may be
subjects that can best be learned in cluster or circular
seating, but handwriting is not one of them.
Presentation of a Model
The instructor introduces the letter by producing
about a 15-inch model of it within the appropriate line
space(s) on the chalkboard. While demonstrating each
new letter, the instructor should recite each step of the
motor plan. Familiar objects in the student’s environ-
ment are used to aid the students in visualizing the
movement pattern as they motorically produce the
340 Part III • Therapeutic Intervention
Figure 15-25 Correct sitting posture for handwriting.
Knees and hips are flexed at 90 degrees and feet are flat
on the floor. The writing surface is 2 inches above the
student’s bent elbow. The top of the chair should be
slightly below the student’s shoulder blade. (From Loops
and other groups: A kinesthetic writing system. Copyright
1990 by Harcourt Assessment, Inc. Reproduced with
permission. All rights reserved.)
stroke progression. For example, the lead-in stroke
for the letter “a” should climb up and round over an
imaginary clock face between the 11 and 1 o’clock
positions and stop. The line reverses by retracing this
lead-in to 9 o’clock (Fig. 15-26).
Preparatory Exercises
Before using pencils and paper, children perform two
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
with the thumb to reinforce separation of the two sides
of the hand. For each exercise and each practice trial,
verbal directions should be voiced by the teacher and
the students.
The students should use the shoulder movements
and hand postures described previously to trace the
letter in the air. Simultaneously each student verbalizes
the motor plan while following the shape of the chalk-
board model. Each student in the class must demon-
strate the ability to verbalize the motor plan while
following the line of the letter model.
When secure in an understanding of the motor
sequence, each student closes the eyes and pictures the
letter to facilitate visualization of the movement pat-
tern. During the second exercise, students place their
elbows on the desk top to “write” using elbow and wrist
movements. Again, they must recite the motor plan as
they move their hands to pattern the visualized letter.
These preparatory exercises are important to the
initial learning of handwriting. The instructor is able to
determine which children are unable to visualize the
letter with eyes closed or averted from the model letter
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
what you tell it to do.” One should instruct children to
subvocalize the motor plan as they form each letter.
The instructor should be sure that the letter occupies
the proper space(s) in relation to the writing line and
middle marker.
After 10 trials, each student should circle all of the
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
own kinesthetic model.
When all children are confident in their ability to
write the letter with eyes open, they should close the
eyes to visualize and gain the feel of the smaller move-
ment pattern. Children who have tracking, converging,
or crossing the midline visual disorganization should
spend a major portion of their practice time with their
eyes closed or gaze averted to avoid visual interference.
SUMMARY
Kinesthetic handwriting training takes the drudgery
out of a task that is often difficult and time-consuming.
For all children and for their teachers, this provides
some benefit. For some children, kinesthetic training is
the single most effective tool for learning handwriting.
Children who benefit the most from kinesthetic
handwriting training usually have identifiable problems
in one or more general areas. Developmental gross and
fine motor foundation skills for cursive instruction may
be less than optimal. Output or production problems
may include difficulties with visual motor control.
Kinesthesia is the key to the lost science of hand-
writing. Properly understood, it is the basis for under-
standing handwriting problems and for preventing or
remediating them. Kinesthesia can be a curse or a
blessing. When a complex motor activity is scientifically
analyzed, appropriate foundation skills are set, teaching
steps are properly sequenced, and the skill is practiced
to the automatic level of performance, kinesthesia is a
lifelong blessing in the performance of that skill. On
the other hand, maladaptive kinesthetic patterns can be
 Principles and Practices of Teaching Handwriting • 341

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).
342 Part III • Therapeutic Intervention
The process that worked for Matisse is precisely the
kinesthetic learning that is most effective for training
children in handwriting. In cursive handwriting, as in
drawing from a model, if I don’t have it “in my fingers”
my work will be slow, crude, and unsightly. This approach
allows children to discover what the great artist described.
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AG Fisher, EA Murray, AC Bundy, editors: Sensory
integration, theory and practice. Philadelphia, FA Davis.
Beery KE (1997). Developmental test of visual motor
integration, VMI-4. Los Angeles, Psychological
Corporation.
Benbow M (1990). Loops and other groups: A kinesthetic
writing system. Tucson, AZ, Therapy Skill Builders, a
division of Communication Skill Builders, Inc.
Benbow M, Hanft B, Marsh D (1992). Handwriting in the
classroom: Improving written communication. The
American Occupational Therapy Association Self Study
Series. Rockville, MD, The American Occupational
Therapy Association Press.
Bernier R (1991). Matisse, Picasso, Miro: As I knew them.
New York, Alfred A. Knopf.
Berninger V, Rutberg J (1992). Relationship of finger speed
to beginning writing. Developmental Medicine and Child
Neurology, 34:198–215.
Bunnell S (1970). Surgery of the hand, 5th ed. Philadelphia,
JB Lippincott.
Capener N (1956). The hand in surgery. Journal of Bone
and Joint Surgery, 38B(I):128–140.
Deuel R (1995). Developmental dysgraphia and motor skills
disorders. Journal of Child Neurology, 1(10):S6–S8.
Fitts PM (1964). Perceptual motor skill learning. In AW
Melton, editor: Categories of human learning. New York,
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Kapandji IA (1982). The physiology of the joints. New York,
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Levine M (2003). The myth of laziness. New York, Simon &
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McGuinness D (1979). How schools discriminate against
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UPPER EXTREMITY INTERVENTION
IN CEREBRAL PALSY:
A NEURODEVELOPMENTAL
APPROACH
Laura K. Vogtle
CHAPTER OUTLINE
CEREBRAL PALSY
THE NEURODEVELOPMENTAL TREATMENT
APPROACH AND PEDIATRIC THERAPY
ROLE OF PERFORMANCE COMPONENTS ON
OCCUPATIONAL PERFORMANCE
THE RELATIONSHIP OF POSTURE TO UPPER
EXTREMITY FUNCTION
Postural Control in Typically Developing Children
Postural Control and Anticipatory Control in
Children with Cerebral Palsy
SENSATION AND ANTICIPATORY CONTROL IN HAND
FUNCTION
KINESIOLOGIC ASPECTS OF TRUNK AND ARM
FUNCTION
Typical Trunk and Upper Limb Interactions
Base of Support and Upper Limb Function
BIOMECHANICAL INTERACTIONS OF THE UPPER
LIMB IN CEREBRAL PALSY
Contrasts between Hypotonia and Hypertonia
TREATMENT APPROACHES: CONCEPTS OF
INHIBITION AND FACILITATION
Inhibitory Techniques
Facilitation Techniques
Combining Inhibition and Facilitation
Chapter 16
THE ASSESSMENT PROCESS
Physical Status of the Individual
TREATMENT PLANNING
THE INTERVENTION PROCESS
Neurodevelopmental Treatment and Hand Function
Efficacy of Neurodevelopmental Treatment
SUMMARY
CASE STUDY ONE: A CHILD WITH CEREBRAL PALSY
CASE STUDY TWO: A CHILD WITH LOW TONE
Therapists who treat children with developmental
delays, movement disorders, and tone abnormalities
such as those seen in cerebral palsy (CP) face significant
challenges in their efforts to provide efficacious inter-
ventions. Muscle tone and spasticity are impairments
seen in CP resulting from central nervous system
(CNS) damage that cannot be permanently changed by
means other than medication and surgery. However,
therapists can maintain and improve performance in
children with CP through their interventions and the
use of assistive technology. Clinicians can influence
client factors and modify environments that affect the
manifestation of muscle tone, its power, and the degree
to which it interferes with participation in occupation,
thus adding to the potential for client participation.
This chapter discusses the therapeutic management
of children with CP, focusing on the use of neuro-
developmental treatment (NDT) as an intervention.
343
344 Part III • Therapeutic Intervention
CEREBRAL PALSY
Cerebral palsy is a general term that describes a non-
progressive group of posture and movement disorders
diagnosed within the first 2 to 3 years of life (Koman,
Smith, & Shilt, 2004). The apparent causes of CP
come from a variety of sources, including maternal
infection, prematurity, multiple births, hypoxia asso-
ciated with birth trauma, and maternal bleeding from
premature placental separation, to mention a few
(Nelson & Grether, 1999). Although the insult to the
CNS is believed to be static, impairments seen with CP
include musculoskeletal concerns, muscle weakness,
spasticity, vision problems, cognitive limitations, and
seizures. Secondary conditions related to the various
primary impairments continue to evolve across the life
span and include muscle tightness and contracture,
joint abnormalities such as dysplasia and dislocation,
growth problems, pain, social isolation, and diminished
ability to participate in the community through occu-
pations such as education, work, and leisure. Evidence
suggests that loss of function seen in typical aging is
accelerated in CP, and that the secondary conditions
associated with CP become more common and more
severe with age (Andersson & Mattsson, 2001; Cathels
& Reddihough, 1993; Murphy, Molnar, & Lankasky,
2000; Turk et al., 1997).
The incidence of CP over the last 20 years, currently
estimated at 2 to 4 per 1000 children, appears to be
increasing. This change may result from many factors,
including improved documentation of the diagnosis in
countries around the world, improved care of prema-
ture and sick infants, or other unknown factors (Nelson
& Grether, 1999).
The movement disorders associated with CP include
spasticity, dyskinesia or dystonia, hypotonia, and ataxia.
Spasticity is the most frequently occurring disorder and
a mixture of various movement disorders are common.
The accepted distributions of movement impairment
include hemiplegia, diplegia, and quadriplegia (Dabney,
Lipton, & Miller, 1997).
Although improved care has resulted in typical life
spans for persons with less significant involvement,
those with severe quadriplegia and associated con-
ditions may die earlier (Hutton & Pharoah, 2002;
Strauss & Shavelle, 1998). Strauss, Cable, and Shavelle
(1999) carried out an epidemiologic review of a large
database targeting causes of death in CP. Their find-
ings found elevated death rates from cancer and heart
disease occurring at relatively young ages. Although
this study awaits replication and support from clini-
cal studies, the findings are provocative to say the
least.
THE NEURODEVELOPMENTAL
TREATMENT APPROACH AND
PEDIATRIC THERAPY
The intervention approach discussed in this chapter is
the neurodevelopmental treatment approach, or NDT,
originally called the Bobath approach. This paradigm
hypothesizes that abnormal tone and impairments of
movement and posture result from lesions in the CNS
and limit the development of function. Intervention is
aimed at minimizing these impairments and improving
functional outcomes as a result of problem-solving
among the clinician, client, and family to develop new
movement strategies and management of postural tone.
The original approach was developed by Berta and
Karel Bobath, a physiotherapist and physician, respec-
tively, who evolved the paradigm between late 1940
and 1990. Currently the instructors who teach the
technique and the national Neurodevelopmental Treat-
ment Association (NDTA) continue to expand and
update the treatment approach.
When Mrs. Bobath first began to practice as a physi-
cal therapist, therapeutic interventions for neuromus-
cular diagnoses were based on the stretching and
strengthening regimens used with the impairments left
after polio. Unhappy with the results of such treat-
ments, Mrs. Bobath documented observations from
her assessment and treatment of adults with paralysis
after stroke and children with CP. Dr. Bobath sup-
ported her ideas with information from the neuro-
physiologic scientists of the day, including the hierarchic
perspective of the CNS, the cephalad to caudal/proximal
to distal nature of human development, and the con-
cept that postural control evolved from primitive reflexes
(Howle, 2004). The Bobaths’ early work focused on
altering muscle tone and reflexes to enable the devel-
opment of more normal movements and followed the
normal developmental sequence in treatment. The
importance of the postural reflex mechanism was high-
lighted and primitive reflexes were seen as a first step in
the development of higher-level, skilled movements.
The persistence of these reflexes in conditions such as
CP originally was believed to block more skilled move-
ment, hence the concept of reflex-inhibiting postures
(RIPs), which were used to facilitate higher level
movements (Bobath, 1955).
Over time, Mrs. Bobath’s approach changed as she
documented her observations about the results of her
treatment. Although the concept of reflex inhibition,
even today, is seen by some as the substance of NDT,
Mrs. Bobath actually discarded this focus by 1964,
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
treatment approach continued to focus on develop-
ment of movement skills based on the normal devel-
opmental sequence until the lack of carryover outside
of individual sessions became apparent. The Bobaths
(1984) then acknowledged the importance of linking
treatment to the performance of functional tasks in
other settings, thus underscoring the importance of
motor learning on the part of the client.
Motor learning is defined as
“a set of processes associated with practice or experience leading
to relatively permanent changes in the capability for producing
skilled action.” (Shumway-Cook & Woollacutt, 2001, p. 27).
Shumway-Cook and Woollacutt distinguish between
motor learning and performance, citing changes in
motor performance as being temporary, whereas
permanent changes in skilled action result from true
motor learning. Clearly for children with CNS
dysfunction to change their occupational performance
outside of therapy intervention sessions, true motor
learning must take place. Current NDT treatment
recognizes the importance of motor learning to skilled
performance, and the necessity of practicing client-
designated activities in treatment for changes in
performance to occur.
Although the Bobaths themselves did not incor-
porate motor performance into their theory, the
Neurodevelopmental Treatment Association Theory
Committee, consisting of multidisciplinary NDT
instructors in the United States, began updating the
theoretic paradigm in the early 1990s to incorporate
current concepts with applicability to treatment of
persons with neurologic deficits. It was at this time that
theories such as dynamic systems theory and motor
learning were formally integrated into the theoretic
basis for the treatment approach (Howle, 2004). One
of the challenges for clinicians is the constant need to
keep their knowledge current with changes in
knowledge generated by science, a challenge the
NTDA has taken seriously, as evidenced by the work of
the NDTA Theory Committee.
ROLE OF PERFORMANCE
COMPONENTS ON
OCCUPATIONAL PERFORMANCE
Aspects of performance that therapists analyze when
planning treatment for children with CP are compo-
nents such as postural control, strength, muscle tone,
spasticity, range of motion, and the performance of the
activity or occupation designated as the goal of inter-
vention. Current studies provide a much clearer picture
of the role such impairments and movement disorders
have on performance skills. For example, Gordon and
Duff (1999b) studied the relationship between finger-
tip force regulation in grasp, spasticity, stereognosis,
two-point discrimination, manual dexterity, and per-
ception of pressure sensitivity. Their work demonstrated
a clear relationship among tactile perception, anticipa-
tory control (activation of sensory and muscular sys-
tems for a specified activity based on prior learning and
experience) (Shumway-Cook & Woollacutt, 2001) and
task performance; however, it also suggested that the
role of the other impairments in performance was
dependent on the aspects of the activity being performed.
They noted that spasticity appeared to affect the adjust-
ment of grip to object weight and to the length of time
between grasping and actually lifting an object, but it
did not have a relationship to anticipatory control.
The NDT approach emphasizes the importance
of postural control and anticipatory postural control,
both performance skills in the Occupational Therapy
Practice Framework (The American Occupational
Therapy Association [AOTA], 2002), to the outcomes
of therapy intervention, or areas of occupation. The
next section of this chapter discusses postural control
and its impact on upper limb function.
THE RELATIONSHIP OF POSTURE
TO UPPER EXTREMITY FUNCTION
One of the Bobaths’ contributions to management
of neuromuscular conditions was their understanding
that spasticity was not just an individual muscle phe-
nomenon, but actually affected posture and control of
upright position in space, a concept not previously
acknowledged. The emphasis on the postural reflex
mechanism as central to changes in other aspects of
motor performance was a principal factor in the Bobath
treatment approach, which underscored their belief
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-
op until postural control of head and trunk occurred,
defined as the postural regulation of the body’s posi-
tion in space for purposes of stability and orienta-
tion (Shumway-Cook & Woollacutt, 2001). Therapists
trained in the NDT approach through the 1980s
focused on altering postural tone passively, then on
facilitating active control in the head and trunk and
finally on development of control in the upper
and lower limbs. At the present time, NDT theory
346 Part III • Therapeutic Intervention
locates intervention for impairments such as postural
control within the desired occupational performance
outcome rather than as the primary treatment outcome.
POSTURAL CONTROL IN TYPICALLY
DEVELOPING C HILDREN
In typically developing children, postural control
evolves from the development of antigravity move-
ment, postural adjustment reactions, somatosensory
input, and experience, and is defined as maintenance of
body position in space (Nichols, 2001). Postural sway,
a component of postural control defined as “the move-
ment of the center of gravity within the base of support
in any upright position” refers to the constant move-
ment of the body when upright and occurs in a devel-
opmental sequence that matures around 13 years of age
(Nichols, 2001, p. 275). Another aspect of posture,
anticipatory postural control, defined as activation of
sensory and muscular systems for a specified activity
based on prior learning and experience, helps to pro-
vide efficient adjustments of the body to support use of
the limbs for various activities (Shumway-Cook &
Woollacutt, 2001).
All motor activities require some degree of postural
control, although those requirements vary depending
on the activity and the environment in which it is
performed. Bertenthal and Von Hofsten (1998) related
postural control to hand function, specifying that pos-
tural control is a necessary requirement for the devel-
opment of grasp and manipulation, and integration of
vision into hand function.
This constellation of postural control components
was not well delineated during the Bobaths’ time; how-
ever, the current premise that postural control and its
elements are necessary for successful motor perform-
ance supports some of the Bobaths’ ideas about the
interaction of the trunk and upper limbs. For example,
Bertenthal and Von Hofsten (1998) discussed the
importance of postural elements to both visual skill and
upper limb performance in tasks such as reach and
grasp, noting that
“. . . reaching for distal objects is necessarily a dynamic process
demanding mutual and reciprocal processing of the relevant
perceptions and actions” (p. 519).
Stapley, Pozzo, and Grishin (1998) studied the
interaction of anticipatory postural control and reach
in typical subjects. Their work suggested that the use of
anticipatory postural adjustments plays a role in activa-
tion of upper limb movement from a fixed base of
support before reach, as well as stabilizing the body
during reach.
POSTURAL CONTROL AND ANTICIPATORY
CONTROL IN C HILDREN WITH C EREBRAL
PALSY
In contrast to typical children and adults, children with
CP have difficulties with postural control and antici-
patory postural adjustments, as evidenced in a number
of studies. Liao and co-workers (2003) found signifi-
cantly worse postural control in sitting as demonstrated
on parameters of static and dynamic sway indices in
children with spastic CP when compared with typically
developing children. Roncesvalles, Woollacott, and
Burtner (2002) found that children with CP did not
demonstrate increased muscle response to changes in
platform perturbations, although typical children did.
They hypothesized this difference in ability to demon-
strate recovery of balance resulted from insufficient
contraction of agonist postural muscles.
Studies of anticipatory postural control demonstrate
differences in children with CP as well. Van der Heide
and co-workers (2004) found that children with CP
after prematurity have difficulty adapting or grading
postural adjustments to a variety of task-specific cir-
cumstances. Not unexpectedly, these difficulties were
worse in children with diplegia or quadriplegia than
in children with hemiplegia. A top-down sequence of
activation of postural muscles, particularly in the neck
extensors, was seen in their sample of children with CP,
which varied from the muscle activation sequence seen
in typical children. They noted that the gestational age
of the child was related to postural adjustment prob-
lems; the shorter the gestation, the greater the impact
on postural adjustment.
There are different theories about the interaction of
postural control and sensation and the role of anticipa-
tory postural control in upper limb function, including
the Dynamic Systems Approach and Neuronal Group
Selection Theory. Howle (2004) contrasted and com-
pared some of these theories as they relate to NDT.
Although these theories present different perspectives
on the topic of postural control and upper limb func-
tion, there is no question these elements of performance
are an important factor to be considered in movement
intervention, regardless of the theoretic perspective.
SENSATION AND ANTICIPATORY
CONTROL IN HAND FUNCTION
The Bobaths saw movement and sensation as complex,
interdependent aspects of human performance (Howle,
2004). They hypothesized that lack of movement
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 347
control affected the ability to perceive and process
sensation. Although the sequencing of sensation and
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
motor performance. Problems with sensory perception
and sensory processing affect performance in a number
of ways, including inability to detect and identify
incoming sensory information; difficulty interpreting
single sensory or multisensory input; problems with
modulation of sensory inputs to match changes in task
and environmental demands; and inability to match
sensory information with experience, memory and
specific tasks (Eliasson, Gordon, & Forssberg, 1995;
Gordon & Duff, 1999a; Gordon & Duff, 1999b;
Lesny et al., 1993; Yekutiel, Jariwala, & Stretch, 1994).
Impaired development of anticipatory control during
hand function also results from impaired sensation.
Eliasson and Gordon (2000) described anticipatory
control in object manipulation as
“internal representations or sensorimotor memories of the object
gained during previous manipulatory experience” (p. 233).
Researchers have carried out extensive studies over
recent years in an attempt to isolate the role of sen-
sation in prehensile and release functions in typical
adults and children (Forssberg et al., 1991; Kinoshita et
al., 1992; Eliasson, Johansson, & Westling, 1992). This
series of studies was followed by a body of research
looking at issues of vision, tactile sensation, spasticity,
and force generation in grasp and release. Comparisons
of these parameters in grasp and release between chil-
dren with CP and typical children also were performed
(Duff & Gordon, 2003; Eliasson & Gordon, 2000;
Eliasson et al., 2003; Gordon, Charles, & Duff, 1999;
Gordon & Duff, 1999a; Gordon & Forssberg, 1995).
This work has established that the grasp and release
of children with CP is impaired by deficits in tactile
perception and processing, difficulty with graded con-
trol resulting from balanced interactions between
muscle agonists and antagonists, and temporal control
of movement events (Eliasson & Gordon, 2000).
Temporal issues were cited again in the work of Gordon
and co-workers (2003), who found that release of
objects that varied in weight required more time in
children with CP than in typical children, especially
when accuracy and speed were necessary.
This discussion underscores the notion that motor
behaviors, sensory perception, and sensory processing
are inextricably linked, and that experience and prac-
tice with various motor behaviors helps to build
performance and anticipatory control in children with
CP. This is true for all aspects of motor performance,
including postural control, hand function, gait, and
speech.
KINESIOLOGIC ASPECTS OF
TRUNK AND ARM FUNCTION
The problems with postural control and upper limb
function seen in children with CP affect all aspects of
occupational performance. It is for this reason that
evaluation of posture, postural adjustments, and their
interactions with the upper limb particularly should be
part of a therapeutic assessment, as well as the status of
body structures.
TYPICAL TRUNK AND U PPER LIMB
I NTERACTIONS
The axial skeleton is the base upon which the limbs are
supported and from which they operate. The alignment
of the spine, pelvis, and ribs influences how both the
upper and lower limbs rest in space and how their
movements are used in the performance of various
activities. Remember that many of the muscles control-
ling the upper and lower limbs attach to the spine, rib
cage, and pelvis, and that the shoulder girdle moves
over the rib cage. The anatomical connections between
these musculoskeletal units are why mobility and stabil-
ity of the entire trunk are so important to movement of
the limbs (Neumann, 2002).
The pelvis provides support for the spine. Because
the lumbar spine interacts specifically with the pelvis in
virtually all movement sequences (e.g., forward flexion,
extension, rotation, lateral flexion), motor or joint
impairments in one or the other structure affect move-
ments in both areas. Similarly movements in any region
of the spine result in movements within the entire
spine, with the degree of the resulting motion decreas-
ing distally from the originating movement. Therefore
disruption of motion in one region of the spine affects
the entire spine, and by association, the position of the
head in space (Neumann, 2002).
In children with CP, both structures and movements
of the axial skeleton often are impaired, affecting both
posture and limb function. Such limitations in the bio-
mechanical interactions of the pelvis and spine are
concerns for therapy intervention in the child with CP.
The shoulder girdle is comprised of the scapulae,
clavicles, sternum, and glenohumeral joints. Just as
with the spine and pelvis, dysfunction at any one joint
of the complex affects movement at all of the other
joints. The shoulder, elbow, and forearm place and
sustain the wrist and hand in space for function.
348 Part III • Therapeutic Intervention
Arranging hair on the back of the head, clipping toe-
nails, bathing, and dressing are all examples of activities
that require the hand to be moved to a distance away
from the body. In typical movements, certain shoulder
complex functions are aided by actions of the spine. For
instance, rotation and flexion of the lumbar, thoracic,
and cervical spine extends the range of reach for items
high on a shelf or under a bed.
The rotary movements of the shoulder and forearm
are particularly important to skilled dexterous move-
ments within and between the hands, both at and away
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
be easily performed without humeral and forearm
rotation.
Finally, the complexity of wrist and hand movements
is significant and remarkable for the highly comple-
mentary nature of the interactions among various struc-
tures. Consider playing the piano and the configuration
of the wrist and fingers. During an octave stretch, the
wrist may be flexed to provide additional range of
movement in abduction and extension at the fingers.
When a chord is played, the wrist is extended to
provide power, stability, and control for the flexed
fingers. Knowledge of these kinds of interactions assists
the therapist to both understand and treat limitations
in occupational performance that involve the hands.
Awareness of the complex structures in the hand is
critical as well, including the carpal, metacarpal, pha-
langeal joints, and arches.
BASE OF SUPPORT AND U PPER
LIMB FUNCTION
Another biomechanical aspect of upper limb perform-
ance is the base of support generated for upper limb
function, basically the foundation of the head, trunk,
and limbs. Shumway-Cook and Woollacutt (2001)
define base of support as
“the area of the object in contact with the support surface”
(p. 164).
A wide base of support, such as the feet widely
separated in standing, provides stability for motor
functions, whereas a narrow base of support in sitting
and standing is more conducive to body mobility. One
also needs to consider the nature of the supporting
surface; some properties of various surfaces enhance
contact with body structures, such as beanbag chairs.
Age, the nature of the activity, and the environment are
other factors that affect the base of support incor-
porated by the individual.
In movement disorders such as CP, base of support
is affected by the movement disorder itself, structural
issues such as hip dislocation, and elements related to
the movement disorder such as limited postural con-
trol. Age, task constraints, and the physical environ-
ment mentioned previously should be considered when
carrying out assessments of performance in which base
of support is an issue. Interventions used to develop
more skilled action in NDT are designed to take into
consideration base of support and its impact on the
individual’s ability to perform upper limb functions.
BIOMECHANICAL INTERACTIONS
OF THE UPPER LIMB IN
CEREBRAL PALSY
Depending on muscle tone and distribution of motor
impairment in the individual with CP, there are
commonly fluctuations in movement control that affect
position of the spine and pelvis and postural adjustment
responses (Liao et al., 2003; Van der Heide et al.,
2004). These difficulties can be increased by tightness
in the soft tissue structures of the lower limbs, such as
the hamstrings and hip flexors (Reid, 1996). Such
problems in the axial structures influence purposeful
movements in the upper limbs of children with CP.
Posterior tilt of the pelvis and flexion of the lumbar
spine increase thoracic flexion and compromise actions
in the shoulder girdle and shoulder.
As discussed, changes in any aspect of shoulder
girdle function influence the entire shoulder girdle
complex (Neumann, 2002). Scapulohumeral rhythm is
commonly affected by increased thoracic flexion,
causing the scapula to rotate upward sooner in the
interaction of the two structures and sometimes lim-
iting the range of overhead action. Movements in the
frontal plane, such as humeral flexion and horizontal
adduction, seem to be difficult for children with CP,
resulting in the increased presence of humeral abduc-
tion and sometimes humeral extension. External rota-
tion of the humerus is affected by both increased
thoracic flexion and the resulting scapular abduction,
which biomechanically aligns the humerus into an
internally rotated posture. This configuration is most
often seen in children with spasticity; those who have
dyskinesia or dystonia may seek to control extraneous
movement in their upper limbs by holding their upper
limbs against their bodies in a practice called “fixing” or
stabilizing the upper limb (Nichols, 2001). This prac-
tice volitionally can limit their humeral motions
initially; however, if the practice persists, actual soft
tissue limitations can occur.
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 349
Movement of the body and limbs as a unit is a
characteristic seen in CP (Hadders-Algra et al., 1999).
Isolation of movement in the various segments of the
upper and lower limb is missing, causing a lack of dis-
association between the movement elements between
and within each limb. For instance, the motions used
in the shoulder girdle and humerus affect movement
components seen in the forearm and wrist. Humeral
abduction and internal rotation facilitate overuse of
forearm pronation and limit active supination needed
for efficient hand use, a common problem in children
with spastic CP. Active elbow and wrist extension is
often restricted by spasticity in the elbow and wrist
flexors, over time causing muscle tightness and con-
tracture. The predominance of flexion at the elbow and
wrist also affects the development of active intrinsic
muscle function in the hand, resulting in the use of
tenodesis interaction between the wrist and fingers and
the use of extrinsic finger flexors and extensors to con-
trol the digits. Types of grasp available, especially for
children with more severe impairments, are limited to
more primitive grasp sequences and lack of both power
and precision prehensions. Deformities of the web space
of the thumb and hypermobility in the metacarpo-
phalangeal (MCP) and distal interphalangeal joints of
the thumb are common.
These atypical interactions in the upper limb of
children with CP result in significant activity and
occupational limitations. Some authors hypothesize
that the movement alterations are actually an adaptive
function rather than true movement impairments
(Steenbergen, Hulstijn, & Dortmans, 2000). Whatever
the cause of the movement limitations, the manip-
ulative function needed to manage such items as
clothing fasteners, the ability to write, and use scissors,
is often either impaired or missing. Clinicians should
assess the child’s postural control and upper limb func-
tion as a whole to design interventions that enhance all
aspects of performance.
CONTRASTS BETWEEN HYPOTONIA
AND HYPERTONIA
The discussion to this point has addressed postural
control, anticipatory postural control, the relationship
of posture to upper limb function, and aspects of
atypical motor performance in children. Most of the
discussion has related to the child with spasticity and
increased tone. Muscle tone refers to the resistance a
muscle offers when lengthened (Shumway-Cook &
Woollacutt, 2001). This resistance is a result of both
neural factors (e.g., spasticity) and biomechanical fac-
tors (e.g., fibrosis, atrophy, changes in contractile prop-
erties of some muscle fibers).
Children with hypertonia have increased stiffness or
tone in their muscles, whereas children with hypotonia
have decreased resistance to lengthening and laxity of
both muscle and other soft tissue structures around
the joints. It is not uncommon to find children with
hypotonia in the trunk and hypertonia in the limbs, or
those with fluctuating tone, as well as children with
generalized hypotonia. The intervention approaches to
these variations in muscle tone differ in that children
with hypotonia use end range movements (activities
carried out by motions at the end of the available joint
range) and often have increased range of motion in
contrast to the limited active and passive mobility seen
with hypertonia. Children with underlying low tone
often use stabilizing or fixing of a body part (Nichols,
2001) to create stability, as well as a wide base of sup-
port in upright positions to create postural stability.
Body movements are characterized by straight plane
actions without a rotary component and limitations in
strength and endurance are common. In the upper
limb and hand, lack of graded, efficient movements
restrict refined functions such as precision grasp, inter-
digital interaction, and isolated digital control used
in complex manipulative sequences. The intervention
procedures differ somewhat, although the emphasis on
postural control as a necessary element of performance
remains unchanged.
TREATMENT APPROACHES:
CONCEPTS OF INHIBITION
AND FACILITATION
Three concepts underscore therapeutic handling (facili-
tating active movement by using a hands-on approach)
in the NDT treatment approach, key points of control,
inhibition, and facilitation. Key points of control refers
to specific hand placement by the therapist during
handling that allows direct influence or control over
the area and indirect control over other body structures
or functions proximal or distal to the key point. These
sources of control are used to either inhibit or facilitate
movement sequences and postural control. Proximal
key points include the pelvis, shoulder girdle, and trunk,
whereas distal key points are areas such as the elbow
and ankle. Inhibition is defined as
“the reduction of specific underlying impairments that interfere
with function” (Howle, 2004, p. 261).
In treatment, therapists use inhibition to limit the
ungraded force produced by spasticity, to balance
unequal power between antagonists and agonists, or to
350 Part III • Therapeutic Intervention
limit those movements that impair smooth coordinated
action. Facilitation consists of
“strategies employed in therapeutic handling that make a
posture or movement more likely to occur” (Howle, 2004, p.
260).
It is used to activate, grade and change various
movements, and should affect the direction, force and
availability of various movements.
Specific techniques are used for inhibition and facili-
tation (Box 16-1). These are discussed next.
I NHIBITORY TECHNIQUES
Inhibition is the primary tool used to manage abnormal
posture and tone. Specific “hands-on” inhibitory tech-
niques such as vibration, use of mobile surfaces,
location, position of structures within the treatment
environment, and use of various sensory stimuli and
speed of movement can all be used to minimize
impairments.
Vibration in NDT consists of placing the hand on a
body area and vibrating or oscillating the location
gently and consistently. Use of mechanical vibrators is
discouraged because of the noise and difficulty grading
the intensity of the vibration. This technique is best
used when a more global movement or gross motor
activity is being performed so as not to interfere with
performance. It is particularly useful when managing
trunk tone for vocalization or extending the range of
movement in the trunk or a limb. As with all inhibitory
techniques, one should withdraw the technique during
activity performance.
Prolonged stretch through weight bearing in both
upper and lower limbs is an inhibitory technique used
to elongate soft tissue structures and minimize flexion
BOX 16-1 Specific Techniques Used for
Inhibition and Facilitation
INHIBITORY TECHNIQUES
• Vibration
• Prolonged stretch
• Therapist guidance of movement
• Use of mobile surfaces
• Inhibition through activity
FACILITATION TECHNIQUES
• Deep pressure and joint approximation
• Weight bearing on both upper and lower limbs
• Vestibular input
• Environmental modifications
• Sensory modifications
• Combining inhibition and facilitation
or extension synergies in the limbs. It can be used to
increase range of movement and decrease tone in chil-
dren with spasticity, or in children with hypotonia or
athetosis who have decreased range caused by fixing
body parts to limit extraneous motion.
Therapist guidance of movement has applicability
for both inhibition and facilitation. For inhibition, the
therapist uses key points of control to limit ungraded
force in one muscle group while facilitating active
movement in the agonist or antagonist. It can be
particularly helpful in the case of hemiplegia, in which
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
circumstances, the therapist can inhibit asymmetry by
directing activities that are bilateral or symmetric in
nature, or by inhibiting symmetry of posture by using
treatment activities that require the limbs to be used
reciprocally.
Use of mobile surfaces has both inhibitory and facili-
tatory applications. Children who have increased trunk
extensor tone accompanied by lower limb extension
can be positioned on a mobile surface and the gentle
rocking movements of the surface used to inhibit tone
and relax the child. Over time, passively applied move-
ment on a mobile surface is shifted to the facilitation of
the child’s ability to use his or her own active motion
to manage tone increases.
Inhibition through activity is when the therapist
teaches the child or individual how to manage atypical
movements or increases in stiffness through specific
movement sequences. For example, in the child who
has increased tone in the flexors of the upper limb that
limits dressing or bathing, upper limb weight bearing
against a wall or the floor can help inhibit the flexion
posture, or bending from the waist and shaking the
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
increased participation.
FACILITATION TECHNIQUES
The use of key points of control combined with therapist
guided movement plays a big role in facilitation.
Remember that key points of control are body areas
from which the therapist facilitates or inhibits move-
ment. In facilitation, the goal might be to assist the
client to open a cupboard door using a more involved
upper limb while the unimpaired limb holds and then
places an item into the cupboard. The therapist could
use either the shoulder or elbow as a key point of
control to facilitate placement of the impaired arm
on the door handle, a task that the client cannot do
without prompts.
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 351
In this same example, tapping could be used along
the muscle belly of the elbow extensors to activate the
movement necessary to extend the arm to the door
handle. Tapping can be used alternatively with tactile
cues, which are a firm touch on the body part to indi-
cate that it needs to move. Tactile cues are a less
invasive form of facilitation, so moving back and forth
between the two techniques is one way to withdraw
input as the client is more able to perform the desired
activity with less assistance.
Deep pressure and joint approximation are facilitation
techniques to activate cocontraction around the joints.
The use of these techniques works best on low-toned
persons, but those with high tone often demonstrate
underlying low tone when their high tone is altered.
Sequencing deep pressure and joint approximation
after tone inhibition is a common practice to facilitate
better control and muscle activation.
Weight-bearing on both upper and lower limbs has
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
“locking” or hanging on the joints. However, if weight-
bearing is accompanied by weight-shifting (volitional or
assisted movement of body weight) and active move-
ment sequences, it can facilitate active movements in
various muscle groups. Weight-shifting refers to move-
ment of body weight through momentum of a body
part (Shumway-Cook & Woollacutt, 2001). Active
weight shift occurs in all volitional movement transi-
tions and is an important therapeutic tool in persons
with movement impairments resulting from neuro-
muscular disorders. In the upper limb, humeral flexion,
elbow extension and possible wrist and finger extension
can be facilitated by weight-shifting over weight-
bearing positions.
Vestibular input can be used to facilitate postural
control. Combinations of sensory-integrative tech-
niques can be incorporated, using swings or platforms
(Blanche, Botticelli, & Hallway, 1995). If the child is
not capable of sitting independently or sustaining
posture on such equipment, the therapist can sit on the
device with the child in his or her lap. A more desirable
option is to incorporate meaningful activities such as
dance with repeating rotary turns into the treatment
whenever possible.
Environmental modifications include arrangement of
physical, sensory, and even social aspects of the
environment to facilitate action. Pediatric therapists are
particularly good at such modifications. Arranging the
room so that items are placed strategically so as to
encourage active movement, use of surfaces that chal-
lenge the abilities of the child, and use of materials in
occupations that are meaningful to the child are all
ways to facilitate skilled action and successful perform-
ance. These same kinds of modifications can apply to
specific aspects of hand function as well. For instance,
using checkers instead of pennies to facilitate elements
of a precision prehension can ensure success for the
child and build the motor and sensory aspects of
activity demands.
Sensory modifications can be helpful too. Music that
is invigorating or calming can be used, singing, use of
high contrast, complex or simple visual backgrounds
are some ways to alter the sensory environment. Use of
social facilitation is another technique that has been
enhanced by inclusive practices in the classroom
(Kellegrew, 1996). Peer engagement and support can
serve to motivate and facilitate children in ways that
parents or therapists cannot achieve. Children’s desire
to be like their peers is a powerful force in facilitating
performance, especially in the achievement of activities
and occupations that the child wishes to perform to be
with friends.
COMBINING I NHIBITION AND FACILITATION
In almost any treatment session with children who have
CP, it is necessary to combine aspects of inhibition and
facilitation. This requires considerable skill on the part
of the clinician, especially in the case of active children.
By altering movements through the use of facilitation
or inhibition, the clinician causes the client to change
or adapt. This requires the clinician to quickly alter
hands-on input to continue to enhance the improve-
ment in the child. Ultimately the goal is to be able to
withdraw both kinds of techniques so that the child can
demonstrate motor learning and carryover of the skills
learned in therapy.
THE ASSESSMENT PROCESS
Assessment of the child with cerebral palsy can be
complex. Multiple aspects of performance should be
analyzed, including physical and sensory status, devel-
opmental status, postural control, and quality of
movement elements. The challenge for the clinician is
how to sort through these aspects of the client to see
which appear to be most critical to occupational per-
formance. Distribution and degree of movement
impairment also can be a guide. Children with mild
hemiplegia, for instance, may not need extensive physi-
cal assessment but based on research findings (Gordon
& Duff, 1999b) need assessment of tactile function.
Developmental and occupational assessments are
appropriate. A child with severe quadriplegia is more
likely to need physical status assessment (e.g., strength,
range of motion, spasticity) and less likely to need a full
developmental evaluation.
352 Part III • Therapeutic Intervention
Various assessments are discussed next, including
standardized tools whenever possible.
PHYSICAL STATUS OF THE I NDIVIDUAL
Range of motion and muscle strength are assessed
using standard goniometry and manual muscle testing.
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
makes this a relevant area to assess (Damiano, Vaughan,
& Abel, 1995; Darrah et al., 1999; Dodd, Taylor, &
Damiano, 2002).
Muscle tone is assessed through the use of tools that
are somewhat subjective, including the Ashworth Scale
(Bohannon & Smith, 1987). The Tardieu Scale’s use is
evolving; however, it requires more time and expertise
to achieve accurate results (Mackey et al., 2004). These
two scales assess increased tone but are not particularly
helpful with hypotonia. Existing tools to measure
decreased tone directly do not exist.
Assessment of sensation is a time-consuming process
that often is not carried out in children with CP in spite
of a body of research indicating tactile discrimination
deficits in children with CP, particularly hemiplegia and
quadriplegia (Duff & Gordon, 2003; Eliasson &
Gordon, 2000; Eliasson, Gordon, & Forssberg, 1995;
Gordon et al., 2003; Gordon, Charles, & Duff, 1999;
Gordon & Duff, 1999a). Gordon and Duff (1999b)
and Lesny and co-workers (1993) used a variety of
measures in their work that are recommended for
clinical practice, including tests of two-point discrimi-
nation, stereognosis, and deep pressure.
NDT emphasizes quality of movement. Existing
tools that assess quality of movement are limited.
Examples are the Gross Motor Performance Measure
(Boyce et al., 1995; Gowland et al., 1995; Thomas et
al., 2001), the Toddler and Infant Motor Evaluation
(TIME) (Miller & Roid, 1993; Rahlin, Rheault, &
Cech, 2003), and the Movement Assessment of Infants
(Hallan et al., 1993; Harris et al., 1984).
The limitations in standardized tools that assess
movement and posture are a concern for the NDT
treatment approach because the treatment emphasis is
on developing posture and movement. Researchers
have options available to them, but these are too expen-
sive and complex for the clinic. Nichols (2001) sug-
gested using indirect observation during assessment of
motor milestones, which is the best option available in
the clinic at present.
The success of any therapeutic intervention is
dependent on the therapist’s ability to analyze aspects
of performance and change over time. When one is
planning interventions that use an NDT treatment
approach, remember that the approach addresses pos-
ture and movement in the context of occupational
performance. This means that occupational perform-
ance needs to be assessed. Pediatric therapists have a
host of tools available to them in this realm, some of
which have a developmental or skill focus. The reader
should see Asher (1996) for a complete listing.
TREATMENT PLANNING
Planning appropriate interventions and documenting
outcomes are aspects of service provision that require
careful attention. Setting appropriate goals is the
cornerstone of treatment planning. As noted in the OT
Practice Framework, the occupations selected as out-
comes of intervention should be meaningful and
purposeful to the client and family; and successful
outcomes are more likely when occupations are incor-
porated into daily routines (AOTA, 2002). These
premises hold true for NDT intervention just as they
do for other treatment approaches.
Use of activity analysis and the principle of partial
participation are useful tools to help build specific skills
over time (Vogtle & Snell, 2004). Refer to Table 16-1
in Case Study 1 for one example of activity analysis that
is useful when planning NDT intervention. Sensory
and motor elements are delineated to assist the clinician
in organizing treatment and incorporating strengths of
the client. Partial participation, which enables clients to
complete steps of an activity that they are able to do
with the remaining steps completed by a caregiver, can
be planned satisfactorily through the use of this kind
of activity analysis (Vogtle & Snell, 2004). Breaking
an activity into steps also helps the clinician evaluate
treatment outcomes in a more systematic manner.
Another aspect of treatment planning that benefits
from activity analysis and partial participation is the
integration of accommodations into interventions. By
breaking an activity into steps and sorting out which
of those the client can do, modifications to promote
successful performance can be easily identified and used
in treatment. This has the extra benefit of giving the
clinician the opportunity to see if suggested modifica-
tions really work before asking families and educators
to make them.
Tables 16-2 and 16-4 in the Case Studies later in the
chapter give illustrations of how a clinician could use an
activity analysis to plan treatment. The tables include
columns for activity steps, movement components, and
facilitation techniques. Organizing treatment into this
kind of table can help the clinician develop a plan for
intervention that includes aspects of facilitation and
inhibition.
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 353
THE INTERVENTION PROCESS
Once assessment is complete and goals are established
by the family, child, and clinician, it is time to consider
how to provide treatment. The use of NDT techniques
means that the therapist needs to combine the client
factors to be addressed (e.g., tone, weakness, range
of motion, postural control issues) with performance
skills and activity demands of the goal while learning
and practicing identified activities or occupations. The
nature of the occupation selected as a goal in con-
junction with client factors dictates the degree of
postural control integrated into the intervention.
If the goal activity is focused on hand function, then
the level of postural control and adjustment factored
into the session depends on the planes in which the
hand function takes place and future postural control
goals. For instance, tying shoes occurs at some distance
from the body. Potentially there should be either more
work on posture involved in this kind of activity than if
the goal was handwriting, or the therapist should
develop postural supports necessary to allow the hands
to be free for the act of shoe-tying.
The base of support required by an activity during
intervention depends on the movement transitions
needed during performance, and on the degree of body
stability required by activity demands when adjusted by
client factors. For instance, a child with significant
quadriplegia may not be likely to use isolated trunk
control, so a wider base of support might be chosen
during hand function activities to contribute to the
child’s stability. A less involved child who is mobile and
has elements of active trunk control would be more
likely to benefit from working on a narrower base of
support. Base of support can be graded over time as
progress is seen. It is also important to remember if
the child is in supportive seating during the day, the
practice part of sessions needs to take place in the same
configuration.
Base of support can affect the degree of weight
shifting used in treatment. Large weight shifts obvi-
ously are important to movement transitions; however,
lesser degrees of weight shifting can play an important
role in upper extremity treatment. Sitting at a table
and cutting with scissors, for instance, usually incor-
porates subtler weight shifts. If the child reaches for
items set back from the edge of the table, an anterior
weight shift occurs. Similarly, reaching for items off to
the side results in a lateral weight shift. Using subtle
weight shifts assisted by key points of control when
working on table top activities and development of
fine motor skills can extend reach and assist with hand
placement, as well as inhibiting extensor tone in the
trunk.
Weight shifts can assist in inhibition of tone and
facilitate active trunk and upper limb function. Other
facilitation and inhibition techniques can be applied
during treatment of hand function as well. Gentle
vibration or oscillation on the trunk or limbs helps to
manage upper limb tone and use of the shoulder or
elbow as key points of control facilitates active move-
ments in the wrist and hand. Preparatory activities
using upper limb weight bearing prepare the hand for
more active hand function by inhibiting tone and
improving mobility of wrist and finger flexors. These
activities can take place with the child in sitting or
standing, not just in quadruped, positions in which
upper limb weight bearing often takes place in typical
children.
N EURODEVELOPMENTAL TREATMENT AND
HAND FUNCTION
There are children in whom the primary intervention
focus needs to be within the hand. Examples are
children with quadriplegic involvement in which the
most important goal is isolated index finger function to
access a computer or augmentative communication
device; a child with hemiplegic impairment who wants
to be able to hold a piece of paper in the impaired hand
so that cutting can be accomplished; or a young person
who wants to be able to manipulate a joystick to drive
a power chair.
In these kinds of examples, direct treatment of the
hand is necessary. Most of the inhibition and facilita-
tion techniques described earlier can be applied directly
to the hand. Vibration or oscillation at the wrist or
from the web space of the thumb minimizes tone in the
fingers; these techniques can be used as preparation
before performance or used during activities. Weight
bearing on the hand is a well-known NDT technique
for soft tissue stretch and tone management that is
underused in reciprocal hand interactions such as hand-
to-hand clapping games with another person, in which
hand contact is extended for the purpose of stretch,
deep pressure, or tone management. The degree of
wrist and finger extension involved in the activity can
be graded by the therapist depending on the desired
outcomes and the tolerance of the child.
Key points of control in the hand include the wrist,
longitudinal arch of the hand, MCP joint of the index
finger, thenar eminence, and web space of the thumb.
Obviously the use of key points of control has to be
carefully managed in such a small area as the hand,
which is when careful grading of activities comes into
play. For example, when isolated control of the index
finger is desired, the therapist may choose to use the
MCP joint as a key point of control. Activities that
might be used to facilitate sensorimotor experiences in
354 Part III • Therapeutic Intervention
this situation include pushing keys on a piano, com-
puter, or toy, pressing stickers onto a surface, making
fingerprints in play dough, extending the digit for
placement, removal of a ring, and so forth. Those
activities that entail pressure (e.g., play dough, pressing
keys, stickers) are situations in which weight shifts
across the pad of the digit provide alternating deep
pressure inputs into the interphalangeal (IP) joints, as
well as the MCP joint, a facilitatory technique.
The mobility of the carpals and metacarpals of the
hand contribute to the arch structures of the hand,
wrist flexion and extension, and radial to ulnar side
interactions within the hand. All of these elements also
play a role in grasp and manipulation between and
within the hands. Hypertonic CP commonly results in
a predominance of wrist and finger flexion combined
with ulnar deviation at the wrist—resulting in ulnar
prehensions. Maintaining mobility in the structures
of the hand mentioned earlier while facilitating active
movement and the ability to participate in chosen
occupations are focal concerns of NDT treatment.
Although the prevailing muscle tone in the hand is
increased with generalized hypertonia, hypermobility
in the IP joints of the fingers and thumbs is common,
as well as in the MCP and carpometacarpal joint of the
thumb. This combination of increased mobility and
fluctuating tone in the spastic hand presents challenges
for the therapist and the need to alternate strategies of
inhibition and facilitation frequently when working
within the hand.
Activity demands should be considered as part
of treatment as well. AOTA (2002) defines these
demands as
“. . . objects, space, social demands, sequencing or timing,
required actions, and required underlying body functions and
body structure needed to carry out the activity.” (p. 624).
Specific aspects of any activity are items that should
be considered in treatment, and amended or modified
when necessary to enable the client to have success in
performing the occupation. Nowhere is this more
important than when working within the hand. For
example, it is common for therapists to choose the
smallest possible items to develop skills such as tip-to-
tip prehension. Larger items offer the child better
control and incorporate the same movement sequences
used in precision prehension; as skill is gained, the
therapist can then move on to include small objects in
therapy.
Practicing occupations during treatment has been
emphasized in this chapter. There is a body of research
supporting the efficacy of activity practice in children
with cerebral palsy (Duff & Gordon, 2003; Taub et al.,
2004) and the importance of activity context on prac-
tice outcomes (Volman, Wijnroks, & Vermeer, 2002).
It is critical that the therapist spend significant time
having the client practice designated goals during the
session. The therapist can use inhibition and facilitation
in this process, but needs to withdraw such assistance
as the session moves on, remembering that ultimately
the child is expected to do the task without such
assistance.
E FFICACY OF N EURODEVELOPMENTAL
TREATMENT
Judgment about the efficacy of therapeutic interven-
tions should be based on careful examination of
published studies, either through systematic review or
meta-analysis. Such methods are limited by the limited
availability of high-quality studies. Two recent system-
atic reviews of NDT intervention have been carried
out (Brown & Burns, 2001; Butler & Darrah, 2001).
Butler and Darrah (2001) incorporated articles back
to 1973, whereas Brown and Burns (2001) included
those published since 1975. There were 21 studies in
the review by Butler and Darrah (2001) and 17 articles
in the review by Brown and Burns (2001). Both
reviews classified articles as one of five levels of evi-
dence. Brown and Burns (2001) used the Quality
Assessment of Randomized Clinical Trials scale created
by Jaded and co-workers (1996) to assign levels of
evidence, whereas Butler and Darrah (2001) used a
system developed by the American Academy of Cerebral
Palsy and Developmental Medicine (Butler & Darrah,
2001). Another unique feature of their review is their
incorporation of dimensions of disability reflective
of the National Center for Medical Rehabilitation
Research (NCMRR) model of disablement (Shumway-
Cook & Woollacutt, 2001) as one judgment of
outcome.
Both reviews cited numerous problems in attempt-
ing systematic study of NDT. Problems included
heterogeneity of the target population, lack of random-
ization, inadequate blinding of subjects, a wide range
of subject ages, use of a variety of clinical and stan-
dardized outcome measures, small sample size and
limited follow-up, interventions that included other
methods besides NDT, a range of duration and inten-
sity of treatments, and inconsistency of significance
across studies. Both studies concluded that the efficacy
of NDT could not be decided on the basis of the
studies reviewed, although Butler and Darrah noted
that studies published in the last 14 years had more
statistically significant results. In addition, both noted
that newer interventions based on more current
theories of motor learning and skill development exist
and appear to be generating more conclusive evidence
(Butler & Darrah, 2001). Butler and Darrah cited the
lack of association to any of the NCMRR dimensions
to which the various studies were compared. These
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 355
same authors suggest that the use of NDT as a control
intervention in studies comparing it to another treat-
ment would contribute to the body of existing evidence
about treatment efficacy for children with CP.
Since these two systematic reviews were published,
other publications about efficacy of NDT have been
published (Trahan & Malouin, 2002; Tsorlakis et al.,
2004). Trahan and Malouin’s research was a pilot study
analyzing the outcomes of an intermittent intensive
NDT intervention. Tsorlakis and co-workers (2004)
research was a carefully designed randomized clinical
trial comparing outcomes between two different dura-
tions of NDT treatment that attempted to avoid design
problems of earlier studies. Duration of intervention
has become a focus of studies because of the devel-
opment of constraint-induced therapy that provides
intensive duration of therapy over a relatively short
term (Taub et al., 2004).
CASE STUDY 1
A C HILD WITH C EREBRAL PALSY
Seven-year-old Jodie, who had spastic CP of quadriplegic
distribution, used a head-activated switch to work on the
computer, which meant scanning the keyboard rather than
being able to use direct selection of desired keys. Her
school therapists, teachers, and family wanted to explore
the possibility of hand activation of Jodie’s computer
access switch with the eventual goal of direct selection on
an alternative keyboard, which would be faster and more
productive. Although computer use in the context of the
school environment was the initial occupational goal,
success meant she would be able to access her home
computer with less assistance than she presently required.
TASK ASSESSMENT AND GOALS
Activity analysis of the process of pushing a switch (Table
16-1) and physical assessment of Jodie’s ability to push a
switch with her hand were carried out, along with an
assessment of performance components, activity demands,
and client factors in the OT Practice Framework (AOTA,
2002) and of performance components in Uniform
Terminology III (AOTA, 1994). Jodie demonstrated chal-
lenges in motor and process aspects of performance skills.
She maintained her head in an upright position for long
periods of time and used it to move her eyes when tracking
items. Efforts at arm and hand movement affected move-
ments of her head and trunk, resulting in dynamic tone
changes throughout her body manifested by increased
SUMMARY
This chapter has described the neurodevelopmental
treatment approach to pediatric intervention, and its
history, evolution, and current perspective. As reiter-
ated throughout the chapter, NDT is an intervention
focused on improving postural control and active
movement skills. The therapist bears the responsibility
for integrating this kind of approach into function and
practice of function. Carryover of movement changes
into function does not occur naturally, as once pro-
posed by the Bobaths. Although the efficacy of NDT
has yet to be demonstrated convincingly, more recent
studies are supportive and suggest that the shift to
integration of NDT with functional outcomes has
merit in the treatment of upper limb function in chil-
dren with CP.
extension in her torso, head, and neck, and by bilateral
rigid extension at the elbows and in the lower limbs. A
consistent lean to the left was noted, a trend made worse
by her attempts to use her hands. She could lift her arms
actively by flexing and elevating her shoulders to about 80
degrees but movement toward or away from the midline
to place her hands was difficult. There were soft tissue
restrictions in her shoulders, limiting the end range of
humeral flexion and abduction.
Jodie’s hands were most often fisted and wrists stiffly
extended. A right hand preference was noted. Jodie
reached for offered items directly in front of her body but
was unable to grasp an object volitionally or bring her
hands to her mouth. When a toy was placed in her hand,
she would hold it indefinitely using increased flexor tone
in the fingers of her hands but was unable to do anything
with it; there was no volitional release of objects and
efforts to do so resulted in head shaking in an effort to
release items from her hand. There was no isolation of
movement between limbs or within either limb.
Jodie could place her hand on a 5″ × 7″ switch placed
in front of her with difficulty, but could not consistently
depress and release the switch to use it for computer
access, nor could she remove her hand from the switch
once it was placed there.
The movement components she needed to activate
the switch for various aspects of the activity are noted in
356 Part III • Therapeutic Intervention

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
switch were felt to be appropriate because Jodie’s
volitional control of her elbow, wrist, and hand move-
ments was minimal, and the switch could be successfully
activated using these movements. In addition to move-
ments to activate and release the switch, she needed to be
able to organize and sequence these movements with
enough speed to push the switch in a timely fashion when
visually cued to do so by the scanning sequence. Thus
anticipatory control in her arm (remember that antic-
ipatory control was defined as activation of sensory and
muscular systems for a specified activity based on prior
learning and experience), postural control and adjustment
of her head, and active isolated movements of her right
upper limb were other aspects of performance needed for
motor control and learning so that she could initiate,
sustain, and terminate movements of the shoulder in
sequence to perform the activity.
TREATMENT PLAN
The organization of the treatment plan for Jodie is
detailed in this section and based on a school year with
weekly sessions. The treatment plan incorporates both
environmental and client factors, as well as practice of the
skill being developed during sessions and at home outside
of the therapy setting at school.
THERAPY GOALS
The goals found in Box 16-2 include long-term goals and
benchmarks as seen in an individualized educational plan
(IEP) write-up. Benchmarks were chosen that support the
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 357

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
switch switch using humeral flexion
and horizontal abduction.
Elbow extension
Tapping under the humerus to facilitate shoulder
flexion and elbow extension; tapping on the
medial border of the arm to facilitate horizontal
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
activation working from her wheelchair. Although Jodie
does have significant limitations in postural control, note
that postural elements are woven into the treatment but
are not identified as long-term goals.
THERAPY ENVIRONMENT
The therapist chose to intervene with Jodie in her class-
room. The first-grade classroom was broken up into areas,
meaning that there were times when floor space was avail-
able for therapy with Jodie out of her wheelchair. The
therapist brought a therapy bolster to use during sessions.
Being in the classroom meant that the same physical set-
up of the switch and computer was available for practice in
a real-life situation in which the therapist could observe
Jodie’s progress. Classmates were present, as was the case
during spelling class, and could be available to provide
encouragement if approved to do so by the classroom
teacher.
HANDS-ON TREATMENT
The therapist used four premises upon which to base her
treatment. First, tone increases seen in Jodie when she
attempts to use her upper limbs will be altered through
the use of work on a mobile surface (the bolster), facili-
tation of forward and lateral weight shifts when reaching
for her switch, and use of periodic rapid oscillations to the
upper limbs. Second, use of facilitatory tapping and active-
assisted hand placement on the switch will be used to help
Jodie activate shoulder movements for hand placement,
switch depression, and switch release (see Table 16-2).
Third, practice of the task will be used to ensure changes
in motor performance, motor learning of the skill being
developed, and switch activation for computer use. Fourth,
tactile enhancement and reinforcement will be used to
ensure that Jodie knows when her hand is and is not on
the switch to help build anticipatory control mechanisms
needed for successful task accomplishment.
358 Part III • Therapeutic Intervention
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
e. Jodie will maintain her accuracy at switch
activation through out the school day with
minimal fatigue
TREATMENT IMPLEMENTATION
In this section, sequencing within therapy sessions is
described, incorporating the physical environment, ther-
apy equipment, therapeutic facilitation, and practice
components.
Tone Management and Preparation for Activity
Jodie was removed from her wheelchair for the first 15 to
20 minutes of each 40-minute session. This enabled the
therapist to use weight shifts and techniques to modify the
dynamic muscle tone Jodie demonstrated whenever she
tried to use her upper limbs and gave her practice in use
of appropriate postural components. A bolster was used
because it enabled the therapist to use two planes of
motion: anterior/posterior movements and lateral move-
ments. Jodie was placed on the bolster, either on the far
end or straddling it, to enable the therapist to use the
movement of the bolster when addressing Jodie’s muscle
tone during activities and to facilitate her active weight
shifts while providing a wide base of support. These bol-
ster motions were activated by the therapist’s use of her
own lateral weight shifts and anterior or posterior body
movements.
At the same time, rapid oscillations of Jodie’s upper
limbs were used to help loosen her stiff arms in prepa-
ration for developing the active shoulder movements needed
to activate the switch (Figure 16-1). At this point, the
therapist had Jodie lean onto her upper limbs positioned
on the bolster to help inhibit tone and increase range in
her hands as preparation for switch activation.
Forward weight shifts accompanied the upper extrem-
ity weight bearing, passively accomplished at first by the
therapist leaning forward into Jodie’s torso and moving
her forward. The therapist facilitated the weight shift in
Figure 16-1 Jodie is seated on a bolster with the
therapist behind her. The therapist supports Jodie’s
arms at the elbow or slightly below, and moves them
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
extension on the part of the child.
this manner for the first few times, and then used decreas-
ing assistance as Jodie exhibited the ability to activate a
weight shift on her own.
Switch Activation
This skill was practiced first with Jodie still on the bolster.
Using the bolster allowed the therapist to facilitate weight
shifts and shoulder movements and inhibit hyperextension
of the trunk during efforts at movement. An adjustable
height table under which the bolster was slid helped to
support the switch. The switch position at first was put
further back on the table than needed to require an
exaggerated forward weight shift to counterbalance the
extensor thrust that occurred when Jodie tried to move.
Remember at this point that Jodie’s arms were resting on
the table surface at midline so she would not have to move
her shoulder high or far laterally to place her hand on the
switch. The switch surface could be enhanced with a num-
ber of different materials (e.g., carpet samples, various
fabrics) to heighten differences between the table and
switch surfaces.
When Jodie was asked to activate the switch, a series
of short taps under her humerus were used to activate
humeral flexion (Figure 16-2), then laterally to bring the
humerus to the switch, which was placed slightly off to the
side (Figure 16-3). Active assistance in placing her hand
was also used alternatively to help Jodie develop a sense of
what was needed to get to the switch; however, this only
occurred on alternate attempts rather than each time she
tried to touch the switch.
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 359
Figure 16-2 Jodie has been asked to activate the
switch but is demonstrating delayed response time. To
assist her, the therapist sweep taps on the dorsum of
her arm, moving from the elbow back toward the
shoulder. The purpose is to give tactile input so that
Jodie recognizes which body part needs to be moved.
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
the switch, the switch was attached to a device such as a
radio or fan, items that do not require a great deal of
accuracy for successful activation. Once Jodie had her
hand on the switch, a tap on either the volar surface of the
humerus or the forearm was used to facilitate activation.
An assisted weight shift posteriorly helped with switch
activation as well, but it needed to be carefully carried out
so that Jodie was not pulled backward. Active assistance
was used to press the switch, using the same careful
guidelines described earlier. A latch switch was used to
limit the amount of time the device is active, requiring
Jodie to lift her hand from the switch, then depress it
again to restart the device.
Releasing the switch was facilitated by incorporating
the same techniques used to facilitate placing Jodie’s hand
on the switch only in reverse order. Release of objects is a
more challenging task for children with CP, as indicated by
research in children with hemiplegia (Eliasson & Gordon,
2000; Gordon et al., 2003). Such studies have shown that
the temporal aspect of release is a particular problem,
which was the case for Jodie when releasing the switch.
SEQUENCING THE PLAN
The idea was to move Jodie forward in her treatment plan
as expeditiously as possible. To do this, she needed to
Figure 16-3 A continuation of sweep tapping is
used here; however, the direction has altered. The
switch is placed about 15 degrees off of midline and
Jodie needs to horizontally abduct her shoulder to hit
her target. While the palm of the therapist’s hand
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.
practice outside of her therapy sessions. Ideally this would
occur in both home and school settings, depending on the
family and time in the classroom. Another way to manage
more practice would be to increase the frequency and
duration of treatment sessions. Although this program was
developed around the traditional weekly model of therapy
frequency, research has demonstrated that massed or inten-
sive practice such as is used in constraint-induced para-
digms and other research has better outcomes for children
with CP (Duff & Gordon, 2003; Taub et al., 2004).
Another critical issue was communication between the
therapist and teacher. This assisted in documenting goals
and assuring that teacher, aide, and therapist were all using
similar techniques and the same equipment. If progress
was not seen in a short period of time (2 to 3 weeks), then
it would be necessary to re-evaluate the plan and adjust
intervention.
OUTCOME
It was soon apparent that the switch needed to be stabi-
lized on the surface; therefore a slightly inclined easel
surface with Dycem under the switch and easel were used
to provide stability. Masking tape was used on both home
and school table surfaces to mark where the easel went
to be sure that the location of the switch was consistent
over time.
360 Part III • Therapeutic Intervention
Jodie made rapid progress at placing her hand on the
switch. Accurate depression and release of the switch voli-
tionally in a timely fashion took another 2 to 3 months to
achieve with frequent dialogue among teachers, therapist,
and family. Jodie was motivated, which helped, and had
persistent encouragement from her classmates. Her switch
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.
She can hold her head up and sit for short periods of time
(3 to 5 minutes) when placed in supported sitting but
spends much of her day playing in prone or supine, or
propped in her infant seat. She can grasp objects with
either hand but does not use both hands together. Most
of her activity consists of mouthing objects and then drop-
ping them after briefly holding onto them. Her mother
reports her as being an irritable child who screams when
new stimuli come into the environment. The family would
like her to be able to play by herself for longer periods of
time and use both hands to play, to sit up longer so they
can play with her, to hold her cup and drink from it, and
for her to be less irritable. Box 16-3 contains examples of
goals for Lily. The goals of using her hands to hold a cup
will be used for demonstration purposes. Specifically the
goal will be for Lily to sit supported in her high chair and
lift her cup and drink when it is placed on a surface in front
of her. Table 16-3 shows an activity analysis of this goal,
which is used to plan the intervention.
PREPARATORY ACTIVITIES
The intervention was scheduled for Lily’s usual afternoon
snack time to locate the intervention in her usual daily
pattern of activities. Doing so offered demonstration time
and consistent feedback to the mother about Lily’s per-
formance and gave the therapist the opportunity to re-
evaluate Lily’s skills each week. Table 16-4 illustrates the
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
to 10 minutes. The therapist sat on a chair or sofa. Lily was
positioned on the therapist’s knees; she could either face
the therapist or face her mother with her back to the
therapist. Facing the therapist meant her base of support
was wider because she was straddling the therapist’s legs;
while facing her mother she was not straddling and the
base of support was narrower. Lily was supported at the
shoulders and the therapist gently bounced her using
day as fatigue set in, so the family limited her home
practice to weekends. At the end of 3 months, Jodie could
accurately complete a 10-word spelling assignment using
hand-activation of her switch in 30 minutes. Fatigue was
becoming less of a factor, so her teacher began to add
short assignments later in the day.
BOX 16-3 Long-Term and Short-Term
Goals for Lily
1. Lily will lift the cup from the surface to her
mouth
a. Lily will place both hands on the cup when it
is placed on the surface in front of her.
b. Lily will lift an almost empty cup off of the
surface briefly.
2. Lily will hold the cup when it is placed at her
mouth to take a drink.
a. Lily will place both hands on the cup while
mother provides over hand assistance.
b. Lily will spontaneously place her hands on
the cup held at her mouth for a few second.
c. Lily will hold an almost empty cup at her
mouth with minimal assistance from her
mother.
3. Lily will put the cup back on the surface after she
has drunk from it.
a. Lily will maintain her hands on the cup with
maximal assistance from her mother as her
mother returns it to the surface.
b. Lily will hold the cup briefly when she is
finished drinking and then place it.
4. Lily will lift the cup to her mouth, drink from it,
and return the cup to the surface.
plantar flexion and return from plantar flexion of her own
feet to provide bounces that were timed asymmetrically so
as not to be predictable. Firm downward pressure was
applied at the shoulders, with the therapist’s thumbs posi-
tioned over the heads of each humerus and the fingers
supporting the scapulae (Figure 16-4). Sound production
by Lily was encouraged to activate abdominal contraction
at the same time. This activity was sustained for 1 to 2
minutes, and then the therapist’s hand position was shifted
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 361

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
lumbar spine was for support, whereas the hand on the
abdomen was used to apply firm downward pressure to
continue activation of the abdominals.
A movement transition to produce coactivation of
trunk extensors and flexors followed. Lily was weight
shifted toward the arm of the chair with the key point of
control at the pelvis. The goal here was for Lily to put
both hands onto the chair arm, producing a bilateral upper
limb weight-bearing activity (Figure 16-5). The pelvis was
maintained in a straight plane position while the trunk
rotated over it, a position requiring cocontraction of abdom-
inals and trunk extensors. This activity was carried out
briefly, and then Lily was facilitated to turn to face her
mother with the therapist’s hands moved back to the
abdominals and lumbar spine and downward pressure
applied on the abdominals to activate a forward weight
shift. Her mother facilitated bilateral shoulder flexion by
holding her hands out to Lily. She did not pick up her
daughter until Lily reached out with both arms. The
362 Part III • Therapeutic Intervention

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;
surface; child’s arms possible components: humeral
activate at the sight abduction moves to humeral
of the cup adduction; elbows extend and
hands open
Deep pressure on the abdominals to facilitate
trunk and humeral movements toward midline;
humeri as key point of control to bring hands
together passively then as cue to do so actively;
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
adducted, elbows midway
between flexion and extension
and forearm midposition, fingers
flexing
Anterior weight shift to assist in reaching for and
grasping the cup; hands brought to the cup and
deep pressure on hands over the cup used to give
sensory feedback; approximation through the
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
vestibular input. More consistent use of rotary movements
during transitions provides the kind of vestibular input
children achieve themselves through active movements.
ACTIVITY PRACTICE OF DRINKING FROM THE CUP
Lily was placed in her child-sized chair. The therapist sat
behind the high chair and placed her hands on Lily’s
shoulders. The thumbs were placed along the proximal
aspect of the humerus and the fingers rested on the
abdomen. Her mother held a half-filled cup in front of
Lily but did not place it on the tray. The therapist used
pressure on the lateral border of the humeri to bring Lily’s
hands together and then slipped her hands up over the
proximal part of her arms to help Lily clap her hands
firmly several times. Her mother then placed the cup on
the tray, tapping it to get Lily’s attention and asking her to
take the cup. A subtle forward weight shift for the reach
was facilitated using the shoulders as a key point of
control. Her mother cued her verbally again and the
therapist waited briefly to see if Lily reached for the cup,
then helped place her hands on it. Firm pressure on the
shoulders was attempted to sustain Lily’s hands on the
cup. When unsuccessful, the therapist slid her hands down
over Lily’s hands (Figure 16-6). Once Lily sustained her
grasp of the cup, tapping under the proximal aspect of the
arm was used to facilitate lifting. As Lily became more
proficient at grasping, the therapist moved her hands back
up to the child’s shoulder to help facilitate lifting and
holding of the cup at the mouth. With further progress,
the therapist gradually withdrew her support, limiting the
cues needed to generate Lily’s participation.
The mother could facilitate this activity from in front of
Lily in a sitting position using the same key points and
sequence of activity. The preparatory activities were taught
to the mother as a game to be carried out at different
times during the day, as well as in preparation for feeding.
OUTCOMES
Lily actively resisted the movement transition sequence.
After attempting to use it before giving Lily her cup, the
therapist chose to discontinue this aspect of the inter-
 Upper Extremity Intervention in Cerebral Palsy: A Neurodevelopmental Approach • 363

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.
364 Part III • Therapeutic Intervention
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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
368 Part III • Therapeutic Intervention
(30%) followed by fractures (16%). The fingers were
the most commonly injured part of the hand, with
thumb injuries found in 19% of the cases and fingertip
injuries found in 21% of the cases (Fetter-Zarzeka &
Joseph, 2002; Damore et al., 2003). Most pediatric
hand and wrist injuries can be treated nonoperatively
with protective immobilization and activity modifica-
tion. However, cases that require surgical intervention
must be recognized early to avoid complications (Le &
Hentz, 2000).
The goal of this chapter is to provide basic infor-
mation to therapists to facilitate effective evaluation
and treatment for hand conditions occurring in pedi-
atric patients. This chapter covers the stages of wound
healing and evaluation considerations by age as the
baseline for making clinical decisions. Evaluation and
treatment suggestions for common traumatic and
congenital hand conditions in the child also are
included.
PHASES OF WOUND HEALING
Treatment and decision making during the healing
phase of wounds must be based on the stage of healing,
as well as on the age of the child. After injury, all tissues
undergo a similar process of repair. Injury to vascular
tissue initiates a series of responses collectively known
as “inflammation and repair.” Regeneration is possible
only in tissue that is capable of proliferation of the
remaining cells (normal tissue). Repair is the replace-
ment of destroyed tissue with scar tissue. Both regen-
eration and repair begin during inflammation with
phagocytosis of dead tissue cells. The ultimate goal of
these responses is to eliminate the pathologic or physi-
cal insult, replace the damaged tissue, promote regen-
eration, and thus restore function. Inflammation is the
first (acute) phase of healing. When unresolved, it may
go through two more stages:
Acute: Usually completed by day 6; normal healing.
Subacute: Reaction continues for up to 1 month, same
as acute stage on a cellular level. and is treated the
same clinically.
Chronic: Simultaneous progression of active inflamma-
tion, tissue destruction, and healing. It varies from
acute on a cellular level and lasts beyond 1 month.
Normal tissue is replaced by scar (Pryde, 2003).
The most common causes of an inflammatory
response are burns, fractures, cuts or crush injuries, and
soft-tissue injuries such as sprains, strains, or contu-
sions. Inflammation also can be caused by the presence
of foreign bodies, autoimmune diseases such as
rheumatoid arthritis or chemical agents (Pryde, 2003).
Healing requires increased metabolic activity. Blood
supply to the site of the lesion must remain increased
for continued oxygen, glucose, and protein supply.
Ischemia interferes with wound healing (Evans &
McAuliffe, 2002).
Although variations are reported in the literature,
tissue healing is most commonly summarized in three
phases.
PHASE I
Names: Inflammatory, Clot, Substrate, Lag, or
Exudates Phase
Duration: From Wounding Up to 6 Days
Phase I prepares the wound for healing by cleaning
up debris, foreign material, and any devitalized tissue
caused by the trauma. It has both vascular and cellular
responses. Initially there is vasoconstriction followed by
vasodilatation. A clot is formed to prevent bleeding and
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
inflammation.
Clinical Signs
Redness: Vasodilation
Swelling: Increase of interstitial fluid
Pain: Nerve ending stimulation
Heat: Increase in blood flow
Hematoma: Trapped red blood cells creating a clot
decrease functional ability
Clinical Implications
The extremity is swollen and painful. Thus effort must
be made to decrease edema, control pain, and maintain
a clean environment. All affected joints should be placed
in a functional position if possible. The functional
position is one in which the wrist is in neutral to 20
degrees of extension, the metacarpophalangeal joint
(MP) is in 60 to 70 degrees of flexion, the inter-
phalangeal joints (IPs) are extended, and the thumb is
in mid position between full abduction and full exten-
sion. Variations of this position depend on the injury.
This position must serve to both protect the wound
and to prepare the joint for future functional perform-
ance. Nonaffected joints should be free to move within
the constraints of the injury.
Physical agents can be used. An edematous hand in
the early phases of inflammation responds to cold to
help decrease the swelling. Cold constricts the vessels,
slowing down the active edema process; however, it is
rarely appropriate for the infant or toddler. For the
older child, physical agents must be selected carefully
to enhance healing. At later phase heat might be the
modality of choice for the same result. Heat dilates
the vessels. When the hand is placed in elevation with

slight pressure, the stationary edema is guided back
to the body. If used in Phase I, heat increases swelling.
A whirlpool may be used for debridement of open
wounds. The temperature of the water should be
tepid, and if possible the hand should be positioned at
heart level.
PHASE II
Names: Fibroblastic, Proliferative, or Latent
Stage
Duration: Variable, but Usually 5 to 21 Days, Can
Last Up to 6 Weeks
The purpose of this stage is to rebuild damaged struc-
tures, and cover and strengthen the wound. There is
migration and proliferation of vessels for tissue repair.
Primitive healing occurs. The wound begins contract-
ing from the outside in. This migration of cells is
limited by tension. Oxygen is needed for the healing
process. Four processes occur simultaneously in this
phase: epithelization, collagen production, wound con-
traction, and neovascularization.
Clinical Signs
Red granulation tissue
Beginning of wound contraction: Scars appear faster in
children than adults.
Moderate swelling may be present
Pain: Variable
Functional limitations
Clinical Implications
The clinical focus in Phase II is on decreasing scarring
and increasing mobility. Scar management is a chal-
lenge with children. If pressure garments are indicated,
the therapist may prefer to order a pressure garment
that covers more than just the hand to keep the gar-
ment on, and to allow even pressure throughout the
small body area. At the same time, motion must be
encouraged. With children, immobilization may extend
a week or two beyond the normal protocol if the repair
needs to be protected. Children regain motion rapidly
when presented with “play” situations after immobi-
lization. Balancing immobilization and mobility requires
individual decisions based on the child’s age and level
of maturity and severity of injury.
PHASE III
Names: Maturation, Scar Remodeling
Duration: End of Fibroplasia to 2 Years
In this phase, connective tissue matrix is remodeled.
Wound strength (tensile strength) may reach 50% of
normal by 4 to 6 weeks. Remodeling, which is a
Pediatric Hand Therapy • 369
balance between laying down collagen and getting rid
of debris (synthesis versus lysis), occurs in a balanced
fashion. However, when this balance is tipped, it may
become pathologic, which may result in the following:
• Contraction of the scar
• Hypertrophic scar: Within wound boundaries
• Keloid: Outside wound boundaries
Clinical Signs and Considerations
Scarring may affect function and aesthetics
Movement limitations may be present
Pain may continue to be problematic
Tensile strength (see below) of tissue is still increasing,
but remains below normal
Functional use of the extremity that is involved is
encouraged in activities of daily living (ADLs)
Contextual implications are considered in treatment
planning
Tensile Strength of Tissue
Tensile strength is the ability of a structure to withstand
a pulling force along its length or resistance to a tear.
Scar tissue is not as strong as the normal tissue it
replaces; however, the volume of the scar influences its
strength. Unfortunately, the more volume the scar has,
the stronger the scar and the less motion when the scar
crosses a joint. Tensile strength of the scar increases
with increased collagen and each phase of healing. As
mentioned, tensile strength reaches 50% of normal
strength of the skin by 6 weeks (Smith, 1992).
Clinical Implication
When healing reaches Phase III, the rehabilitation
program should concentrate on returning the child to
full play and activity. Therapeutic activities must stay
under the “breaking strength” of the scar, which is the
amount of force it takes to bring the wound apart.
How much tension one places on a wound varies with
each stage of healing, type of injury, and age (Mulder
& Brazinsky, 1995). Modalities such as splinting, physi-
cal agents, strengthening exercises, and other thera-
peutic interventions should focus on the functional
needs rather than the functional limitations of the
child.
Box 17-1 shows the three phases of wound healing.
EVALUATION OF THE CHILD WITH
A HAND INJURY
Evaluation of the child differs from that of the adult.
Specifically, the age of the child determines what the
“hand is expected to do.” The infant who does not yet
cross midline with hand performance differs from the
adolescent. A toddler who brings everything to the
370 Part III • Therapeutic Intervention
BOX 17-1 Phases of Wound Healing
PHASE I
Vasoconstriction
Vasodilation
Clot formation
Phagocytosis
PHASE II
Epithelization
Collagen production
Primitive wound contracture
Neovascularization (O2)
PHASE III
Maturation of scar
Collagen synthesis versus lysis
Collagen fiber orientation and wound strength
mouth differs from the teenager who can understand
and follow directions. Both evaluation and treatment
must reflect the age and developmental level of the
child, as well as the injury or condition of the hand.
Performance assessments such as dexterity tests cannot
be given to a newborn but can be administered in a
modified way to a toddler, and given in a standardized
way to an adolescent.
The goal of an evaluation is to determine the real-
istic functional abilities of the child at the initiation of
therapy and document progress. Realistic goals are set
by the child when possible, as well as by the parents or
guardians and therapist. The evaluation process must
be dynamic and flexible. Information about the child’s
ability to use the hand, pain level, and specific restric-
tion of motion may be gathered through play, general
observations, or specific assessments. Significant infor-
mation can be gathered from parental reports and
interviews. Creativity in encouraging a child to use an
injured hand is part of the challenge of a good eval-
uation. Photographs and videotaping for later specific
assessment of the child’s play patterns may be helpful.
In hand therapy, evaluation requires an initial deter-
mination of impairment level followed by its influence
on the functional levels as they apply to the child’s
developmental stage. The child’s hand performance
in life roles changes with growth. Shortridge (1989)
describes growth periods in estimated age levels that
must be considered during evaluation. After traumatic
injury or surgery the quality, speed, and direction of the
healing, as well as the age of the child, are considered.
With congenital differences, evaluations must be rele-
vant to realistic expectations for both the age and diag-
nosis. The specific assessments in a hand evaluation are
determined by the diagnosis, phase of healing, and age
of the child. While not losing sight of functional goals,
the therapist may wish to obtain information in the
following areas.
I NTERVIEW AND H ISTORY
When a child comes to therapy, a thorough review of
the child’s medical, family, emotional, educational, and
social history should be obtained from the family and
the child, when possible. Information from the doctor
should include precautions relevant to the healing of
the injury or surgery, as well as all relevant information
about the surgery and medical management. A pre-
scription from the doctor should be clear about the
expectations for function. If a child is referred for a
splint alone, information must be obtained about how
long the body part is to be immobilized.
HAND RANGE OF MOTION
Hand range of motion (ROM) is important for func-
tional activities such as picking up and manipulating
objects, as well as touching and feeling. Total upper
extremity ROM is important in reaching into the envi-
ronment. When measuring hand ROM, the therapist
also looks at total upper extremity movement, as well as
trunk and neck mobility. The hand is not separated
from the body in activity and therefore should not be
separated in evaluation.
When evaluating ROM in a hand injury or condi-
tion, close attention is given to tissue that obstructs the
motion. Ranges are reported, when possible, in several
ways so that the source of the limitation may be
identified. Passive range is the available motion intrinsic
to a joint when all extrinsic limitations are minimized.
If a tendon or scar is limiting the joint motion, place
the joint in a position of maximum biomechanical
advantage when measuring passive range so as to elimi-
nate the extrinsic factors (Figure 17-1). For example, if
the flexor tendons are tight, flex the wrist when meas-
uring passive MP motion.
Conversely, when measuring active motion, infor-
mation is gained about the extrinsic structure that may
be limiting joint motion. Active motion may be divided
into functional motion, the motion available when the
child is asked to make a fist or open the hand with no
limitations or instructions (Figure 17-2) versus blocked
motion, which refers to the motion available when
all proximal joints are put in neutral (biomechanical
advantage) to allow maximum force to be applied to
elicit the available motion of the joint being measured
(Figure 17-3).
For example, if measuring blocked proximal inter-
phalangeal (PIP) flexion in a child with a flexor tendon
injury, put the wrist and MPs in neutral and ask the
child to flex his or her fingers. This provides informa-

Figure 17-1 Passive range of motion (PROM).
Figure 17-2 Active range of motion (AROM).
tion about flexor tendon excursion. Placing the proxi-
mal joints in slight extension gives the flexors more
advantage. Always record where the proximal joint(s)
were placed during blocked measurements, so that
measurements can be repeated reliably. Finally, com-
pare all ranges to determine which structure is limiting
Pediatric Hand Therapy • 371
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
pulp of finger to pulp of thumb (Figure 17-5).
Functional Thumb Flexion: Ask the child to touch the
base of the small finger with the thumb, measure the
distance from the head of the 5th metacarpal to the
pulp of the thumb (Figure 17-6).
Functional Extension: Ask the child to extend the hand
against the table; measure the distance from the nail
to the table top (Figure 17-7).
372 Part III • Therapeutic Intervention
Figure 17-4 Functional flexion to the distal palmar
crease.
Figure 17-5 Functional opposition.
Newborns and Infants (Up to 12 Months)
ROM is assessed mainly through observation. The
therapist must pay close attention to the movement
in the whole upper extremity. The therapist looks for
shoulder movements, elbow range, and opening and
closing of the hand. The child is encouraged to move
through touch, sound, gentle handling, and reflex
stimulation such as the startle response. Movements
should be compared with the uninvolved side when
possible.
Figure 17-6 Functional thumb flexion to the base of
the fifth finger.
Figure 17-7 Functional extension to the table top.
Toddlers (12 to 48 Months)
ROM can be measured in the upper extremity, but it
is difficult in the hand itself. Motion is encouraged
through play. The child should be given objects that
range in size and weight to determine grasp and release
patterns. Sustained and volitional grasp should be
observed. Colorful objects or familiar designs are help-
ful. The child should be encouraged to place objects in
different locations so that reach and precision can be
examined. ROM at this age is documented more in
patterns of prehension and usage rather than degrees
of motion. For those situations in which handling of
 Pediatric Hand Therapy • 373

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-
don unit that is measured through manual muscle
testing, whereas functional strength is a measure of
muscles working together in a specific prehension
pattern and is measured with instruments such as a
dynamometer and pinch gauge. Functional measure-
ments are divided into grip and pinch strength (Figs.
17-8 and 17-9). They are divided further into varying
grip sizes and different pinch patterns. Most commonly
tested pinch patterns are key pinch, pencil or three jaw
chuck pinch, and pad to pad pinch. With the hand-
injured population, functional strength measurements
are the most common. Although a variety of tools
exist for measuring strength, the most common are a
dynamometer for grip strength and a pinch gauge for
pinch strength.
Newborn Through Early Childhood
Hand strength as a measure in and of itself is not
necessary for this age group. The therapist concentrates
on functional use of the hand in age-appropriate activi-
ties. For children past infancy, activities such as han-
dling toys, picking up utensils, and picking up objects
of different weights with one or two hands provide the
therapist with information on available strength for
the age-appropriate activities. Enticing a child to move
painful fingers is challenging. Young children like to
perform, so one effective method is videotaping the
child with the promise of watching his or her hands
move on tape. Specific questions related to functional
hand strength include the following: Does the child
have sustained grasp? Does the child demonstrate voli-
tional grasp?
374 Part III • Therapeutic Intervention
Middle Childhood to Adolescence
The older child’s strength can be measured with con-
ventional tools such as dynamometers and pinch
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.
When measuring hand grip in children, norms that
reflect the appropriate age group and comparable instru-
ments are used. Hager-Ross and Rosblad (2002) pro-
vide norms for children ages 4 to 16. They tested grip
strength in 530 children using the Grippit instrument.
They reported a parallel increase in grip strength for
both boys and girls until age 10, after which boys were
significantly stronger than girls. The study further sug-
gests a correlation between hand size, specifically hand
length, and strength. Right-handed children were sig-
nificantly stronger in their dominant hand than left-
handed children. Left-handed children did not show
any strength difference between the hands (Hager-Ross
& Rosblad, 2002). Bear-Lehman and co-workers (2002)
studied the relationship between grip size and strength
in children and also concluded that strength, grip, and
pinch increase with hand size, but they found no sig-
nificant difference between males and females or pre-
ferred hands. In an earlier study, Mathiowets, Wiemer,
and Federman (1986) reported dynamometer readings
from 471 typical children ages 6 to 19 years. They
reported pinch and grip strength increases with chrono-
logic age. Mathiowets and co-workers (1986) noted
possible instrument error after the study and concluded
that reported norms for subjects ages 14 to 19 may be
slightly lower than they should have been (Pratt et al.,
1989). These studies suggest a trend of increasing
strength with age and hand size. Caution should be
exercised in using these norms unless the test instru-
ments and conditions are the same.
Manual muscle testing may be used for specific
muscles for older children when indicated by the diag-
nosis. Large muscles, as well as the small muscles of the
hand, should be tested. When rating muscle strength,
the 0 to 5 scale may be used. Specific instructions are
available in the literature on how to perform manual
muscle testing (Aulicino, 2002).
0 = No evidence of contraction
1 = Trace of muscle contraction, no movement
2 = Complete ROM with gravity eliminated (poor)
3 = Complete ROM against gravity (fair)
4 = Complete ROM against gravity with some resist-
ance (good)
5 = Normal ROM against gravity with full resistance
Clinical Implication
Appropriate methods of obtaining hand strength
measurements vary according to the child’s age and
ability to participate. Functional measures are most
commonly used with hand injuries and conditions.
However, at times specific manual muscle testing is
indicated, especially with older children.
HAND DEXTERITY
Dexterity as a component of function is described
as the ability to manipulate objects with the hands.
Accuracy and speed are the parameters of measure-
ments for dexterity. Dexterity can be measured reliably
through established tests that have normative data on
the population tested. Dexterity may also be observed
when the child is picking up different size objects and
manipulating them (Aaron & Stegink Jansen, 2003).
Newborns and Infants
Hand dexterity in the newborn is confined to reflexive
opening and closing the hand and bringing the hands
to the mouth. Such motions are determined through
observation. In the newborn, stimulating reflexes such
as Moro or hand grasp gives the therapist information
on ROM and symmetry of movement patterns appro-
priate for this age.
Toddler
Dexterity is determined by watching the child manip-
ulate small objects. In-hand manipulation skills (moving
an object within the person’s hand) is noted at this age.
The therapist places a small object in the child’s hand
and asks that it be turned over or moved around in the
hand. Video recording of the manipulation comple-
ments the testing procedure.
Early Childhood
Observation remains a staple of the evaluation pro-
cedure for this age group. The therapist observes how
the child approaches small objects, which hand is used
in grasp, grasp and release patterns, and sizes of manip-
ulated objects. For more standardized testing, dexterity
tests such as the Functional Dexterity Test (FDT) may
be used. It is standardized for children ages 3 to 5 years
(Aaron & Stegink Jansen, 2003; Lee-Valkov et al., 2003).
For the age groups listed, the therapist observes for
the following information:
• Are tasks or activities performed unilaterally or
bilaterally?
• Is the hand being used spontaneously?
• Is there indication of dominance? (Note: Hand domi-
nance that appears too early may indicate a problem
with the nonpreferred side.)
Adolescence
Children in this age group have fine motor control and
dexterity that can be tested using available standardized
tests. Depending on what information the therapist

wants to obtain, the use of such standardized tests as
the Box and Block Test or the Minnesota Rate of
Manipulation may be used for information on dexterity
(Apfel & Carramza, 1992).
If information on ADLs is needed, specifically manip-
ulation of small objects such as buttoning or tying, the
Functional Dexterity Test (FDT) may be the test of
choice because it gives information on both dexterity
and function and can be administered in a short period
of time (Aaron & Stegink Jansen, 2003) (Figure 17-10).
Clinical Implications
Dexterity is a component of function that often is
overlooked in a hand evaluation. Dexterity information
is obtained by using standardized tests such as the FDT
or through observation.
WOUND, E DEMA, AND SCAR
When a child of any age has an acute injury, the thera-
pist must document the appearance of the hand at each
stage of healing. This includes describing the wound,
measuring the edema, and describing and measuring
the scar.
Describe the wound and take a picture when possible.
In the description of the wound, note such elements as:
1. Color
a. Red Wound: Normal granulating tissue
b. Yellow Wound: Wound covered by yellow fibrous
debris or viscous surface exudates
c. Black Wound: Wound covered with thick necrotic
tissue or eschar
2. Size. Measure the size of the wound. Draw the
actual size of the wound in the chart. Color in the
different colors that you see.
Figure 17-10 Functional dexterity test. (From Aaron DH,
Stegink Jansen CW [2003]. Development of the functional
dexterity test [FDT]: Construction, validity, reliability, and
normative data. Journal of Hand Therapy, 16[1]:12–21.)
Pediatric Hand Therapy • 375
3. Drainage. Note if there is any drainage. Use descrip-
tive words such as “minimal, moderate, or severe”
for the amount of drainage, and “bloody, sanguinous,
purulent, pus” for the quality of the drainage.
4. Odor. An unusual odor may suggest infection or
presence of foreign material.
5. Temperature. Compare the temperature of the hand
or part to the other side. Warm or hot may indicate
infection or inflammation, whereas cool or cold
may point to a vascular insufficiency.
6. Edema. Edema should be noted throughout the
healing process. Edema is measured with a tape
measure or volumeter. If the wound is open, the
tape measure must be sterile and the water in the
volumeter must be treated with a disinfectant.
When using a tape, landmarks are noted in the chart
for consistency of measurement. The skin should
not blanch when circumferential measurements are
taken with the tape. When using the volumeter
(a water displacement test), the hand is placed
straight-in so as not to displace more water than
necessary. The hand is lowered into the water until
the web space between the long and ring fingers
rests on the small peg at the bottom of the con-
tainer. The volumeter usually is used with large
edematous areas and with older children. Descrip-
tive words, such as “hard, mobile, brawny, or pitting,”
should be used for recording the type of edema.
7. Scar. Scar should be described as “soft, thick, raised,
indurated, hard, or reactive.” Depth, length, and
width of the scar should be measured and color and
vascularity should be noted. Sensitivity (or lack of)
of the scar should be recorded. Both a drawing and
a photograph of the scar should be taken if possible
(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
grasp a colorful object. Distraction is the best tactic for
this age group. The therapist’s observation skills are the
most valuable evaluation tools. A similar approach is
376 Part III • Therapeutic Intervention
helpful with children and adolescents. However, these
children may be able to provide more information with
use of such pain evaluation tools as the following:
1. Body Charts. The child points on a picture to where
it hurts; the therapist offers descriptive words to
help the child explain the nature of the pain
(Maurer & Jezek, 1992).
2. Visual Analog Scale (VAS). This is a vertical or
horizontal line of 10 cm with one end labeled “no
pain” and the other “terrible pain.” The therapist
asks the child the mark on the line the place that
best describes the amount of pain. A drawing of a
happy face on one end and a sad face on the other
also may be used.
3. Numeric Rating Scale (NRS). The child is asked to
pick a number between 0 (no pain) and 100 (lots of
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
reduce the validity of monitoring improvement over
time (e.g., the child might tend to keep picking the
number chosen previously rather than judge pain
objectively at that moment) (Maurer & Jezek, 1992).
4. Verbal Rating Scale (VRS). The child is asked to
pick from simple descriptive words that he or she
can identify with to describe the pain. Examples are
“lots of pain,” “some pain,” or “no pain” (Maurer
& Jezek, 1992).
5. Face Pain Scale-Revised (FPS-R). This is a pain meas-
urement scale that uses pictures representing facial
expressions to determine intensity. It is used for
children ages 4 to 16 (Hicks et al., 2001).
HAND SENSIBILITY
Normal hand function requires normal sensibility, as
well as mobility and strength. Sensibility should be
screened in all children who can reliably communicate
information about the sensitivity of the hand. On the
initial screening, the therapist asks if the affected hand
feels the same as the unaffected hand. The therapist
then asks the child to report if there are differences in
feelings between the two hands as the therapist strokes
both hands. With vision occluded, the therapist touches
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.
There are many creative ways to determine if the nerves
of the hand are viable. When this is not possible, infor-
mation must be gained through observing the child use
the hand and noting sympathetic functions such as skin
color and texture, temperature, sweating, nail changes,
or hair growth. This helps the therapist determine if
there is a nerve problem. Stereognosis and graphesthe-
sia are other forms of sensory screening in early child-
hood. The therapist asks the child to identify familiar
objects or symbols held in the hand or drawn on the
palm of the hand while the eyes are closed. Children
ages 6 and older should be able to undergo a complete
sensory evaluation if indicated by the initial screen.
Information on specific testing procedures is available
in the literature (Callahan, 2002).
Sensory testing can be divided into:
Threshold Tests: Tests that determine the minimum
stimulus perceived (e.g., pain, temperature, pressure),
such as the vibrometer and the Semmes-Weinstein
pressure aesthesiometer or pin prick.
Functional Tests: Tests that assess the usefulness of the
sensation, such as moving and static two-point dis-
crimination, touch localization, and the Moberg
Pick-Up Test (Callahan, 2002).
ACTIVITIES OF DAILY LIVING
The therapist must know normal expected levels of
independent function for each stage of development.
This knowledge is necessary to set treatment goals. The
therapist may have to develop realistic expectations of
“normal” for the child with congenital differences.
Expected levels of function are compared with what the
child is doing at the time of the evaluation. The stage
of healing needs to be taken into account, because
some children are temporarily immobilized in the early
stages of healing. For many this does not affect their
long-term function, whereas others may have perma-
nent impairment and must learn new adaptation skills.
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-
uation tool.
Clinical Implication
A thorough evaluation has a different meaning for each
diagnosis and age group. Many assessment tools are
available. Therapists must choose carefully and assure
that each evaluation looks at all components of func-
tion appropriate for the specific child, diagnosis, and
context. Evaluation is the road map for treatment and
progress.
TREATMENT OF TRAUMATIC
HAND INJURIES IN CHILDREN
Treatment of the pediatric population incorporates a
“playful” dimension. Couch, Deitz, and Kanny (1998)
reported on the role of play in preschool population.
They concluded that therapists must increase the
emphasis on play when evaluating or treating children.
 Pediatric Hand Therapy • 377

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
378 Part III • Therapeutic Intervention

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
 Pediatric Hand Therapy • 379

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:_________________________________

380 Part III • Therapeutic Intervention
In hand therapy, creative play helps the child participate
in his or her own therapy. Activities such as playing tic-
tac-toe in putty to increase pinch strength or playing
dice games or jacks to enhance and encourage prehen-
sion and dexterity engage the child while minimizing
the difficulty of using the injured hand. The therapist
provides a safe environment, encourages active partici-
pation, and offers age-appropriate activities. The thera-
pist must “get on the floor” to engage the child in fun
yet purposeful activity and seek to gain the child’s
permission to be touched. Through engagement in
play, the child is involved to the fullest extent in making
choices in the rehabilitation program. The parents or
guardians should be educated about how to use thera-
peutic play with the child. Treatment varies based on
the diagnosis.
Children are not small adults. They are more suscep-
tible to injury because they have a high power-to-
weight ratio and the neurologic mechanism necessary
for motor control is not yet fully developed. Children
do not assess risks in the same manner as adults. More
than half of the fractures seen in children are in the
upper limb (Graham & Hastings, 2000). It is rare to
see a young child with fractures. Often, these fractures
may be attributed to child abuse.
The growing skeleton differs from the mature skele-
ton. In the growing skeleton some fractures are man-
aged with less difficulty and for a shorter length of
time. Conversely, fractures that involve growth plates
may lead to long-term morbidity if treated incorrectly.
Mahabir and co-workers (2001) noted that the inci-
dence of hand fractures in children rose sharply after
the age of 9 and peaked at age 12. Sports activities were
the most common cause of fracture for both boys and
girls. The fifth metacarpal was the most commonly
fractured bone (21.1% of the total sample of 242 frac-
tures in their study), 60.2% were nonepiphyseal frac-
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
bones continue developing until maturation of the
pisiform, which occurs around the age of 9. The flexi-
bility that children enjoy, as well as the larger amount
of cartilage in their wrist, helps decrease the number of
injuries to the wrist compared with adults.
The most common wrist fracture is of the scaphoid,
usually seen in children older than 7 years of age
(Beatty et al., 1990). Participation in sports has increased
the incidence of wrist fractures. The immature skeleton
makes radiographic information difficult to read, and
thus diagnosis is challenging. Often children are sent to
therapy with a general diagnosis of “wrist pain.” The
child can be referred after a period of plaster immobi-
lization, or immediately after injury, generally for
splinting.
When a scaphoid fracture is found, it may not be
clear if a child has a fracture at the time of the initial
visit to the doctor. Typically, the child is placed in a
long arm spica cast for approximately 2 weeks (assum-
ing a scaphoid fracture). X-rays are repeated at that
time. If no fractures are determined to be present the
child starts therapy. If a fracture is present, casting con-
tinues until the fracture begins healing. This may be
6 weeks or more. The doctor determines when the
child can start therapy (Graham & Hastings, 2000)
(Figure 17-11).
Once the child is referred to therapy, the focus is on
protecting the wrist through splinting. Therapists must
assure that ROM of the affected and nonaffected joints
are maintained and that pain and edema are controlled.
The ultimate goal is to return the child to normal
activity.
Evaluation
Types of assessments performed are dictated by the age
and cooperation of the child, as well as the attitude
and willingness of the parents or guardians. A com-
Figure 17-11 Full arm cast.
 Pediatric Hand Therapy • 381

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.
382 Part III • Therapeutic Intervention
Figure 17-15 Thumb spica splint. (Courtesy of Kimberly
Goldie Staines.)
c. Splint wearing time is decreased as wrist pain
decreases and strength and ROM increase,
usually 3 to 6 weeks after injury. Often at this
stage the hard splint is changed to a soft splint
made by taping or neoprene if pain persists
(Figures 17-16 and 17-17).
Edema Control (Phase I)
If edema is present, the child is given a pressure
garment such as an elastic glove or wrap. The child and
parents or guardians are instructed in positioning the
limb in elevation, gentle motion, and retrograde mas-
sage. All activities should be at heart level or above (the
hand held higher than the elbow and at or above the
heart). If the swelling is severe, a “sandwich splint” may
be necessary initially (see Figure 17-30 later in this
chapter).
Figure 17-16 Taping of wrist to limit motion.
Figure 17-17 Neoprene wrist and thumb splint.
Exercise Activity (Phase II):
3 to 6 weeks after Injury
The child is encouraged to begin short arc ROM
exercises within his or her pain tolerance. This should
take the form of play. Initially, while the wrist is still
healing, no resistance is applied. The child is allowed
to “get to know the hand again.” Play can be with
bubbles or water (cool and elevated if swelling is
present). Other effective activities are games that require
grasp-release and reaching of light objects (e.g., work
on vertical surfaces, use stickers, felt boards, magnets).
Gentle exercises and activities are done through Phase
II of healing. Bilateral dexterity activities, such as
threading beads, may encourage use of an injured and
painful hand.
Strengthening (Phase III)
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-
dren can be treated effectively with a comprehensive

Figure 17-18 Use of putty for strengthening.
home program and only occasional visits to the thera-
pist for evaluation and update of home exercises.
FRACTURES AND DISLOCATIONS OF
THE DIGITS
The incidence of hand fractures rises dramatically after
the age of 8, with boys presenting more often than
girls with both fractures and dislocations. Phalangeal
fractures slightly outnumber metacarpal fractures.
Metacarpophalangeal joint dislocations are among the
most common of childhood injuries. Physeal injuries
may amount to 33% of the fractures seen. These frac-
tures are classified using the Salter-Harris classification,
with Salter-Harris II being the most common (Graham
& Hastings, 2000).
Most of these children are treated conservatively and
followed by the physician. Children who are referred
for therapy are the ones with complications such as
persistent pain, decreased ROM, or refusal to use the
hand. When a child comes to therapy, an accurate
description of the injury, how it happened, treatment
provided by the physician, and length of immobiliza-
tion should be available to the therapist.
Evaluation
1. Observe the child from afar. Watch him or her use
the hand. The way the child uses the hand provides
information on pain and usage patterns. Is he or she
protecting it or using it? Is the child using the
affected digit when using the hand? If the thumb
is involved, is there a grasp and release pattern? Is
there sustained grasp?
2. Determine the child’s demands on the hand under
normal conditions. Does he or she play sports or
participate in arts and crafts? Which is the dominant
hand? Interview the child (age dependent) and
Pediatric Hand Therapy • 383
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.
Usually grip strength that distributes the force
across all digits is easier to tolerate than pinch
strength with the affected digit. Strength informa-
tion also may be obtained by observing usage of the
hand. Is the child performing ADLs in the normal
and customary fashion?
8. What are the child’s and parents’ goals?
Treatment
The treatment is based on what is seen clinically at the
time of referral, because these children may be sent
to therapy at different points after injury. What stage of
healing is the injury? What were the results of the
evaluation?
General Splinting Considerations
The splinting goal is to keep the fracture stable until
healed.
1. Ligament Disruption or Dislocation. The splinting
goal is to align the finger and reduce the stress on
the affected structures. In certain conditions and
with certain age groups a hinged-type splint or one
that allows short arc ROM may be appropriate. Use
buddy splinting, which is taping the affected finger
to the adjacent one for stability at the onset if the
disruption is not significant. Otherwise buddy
splinting can be used for protection after 3 or 4
weeks of immobilization.
2. Phalanx Fracture or Displacement. These are most
common in border digits (Hastings & Simmons,
1984). Splinting usually includes the adjacent digit
and, depending on the age of the child, with or
without the wrist.
Common Digital Injuries and Their Treatment
Gamekeeper’s or Skier’s Thumb. This is an ulnar
collateral ligament tear or stretch. In the older child
this involves splinting the thumb MP with a hinged
splint allowing MP flexion-extension motion but
restricting radial deviation (thus protecting the ulnar
384 Part III • Therapeutic Intervention

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
Broken glass is a common cause of tendon injuries in
the young. Older children also can suffer tendon
injuries secondary to broken glass and sharp metal, as
well as through participation in sports and other activ-
ities. Often the cut is tidy, especially with broken glass.
The management of these injuries depends on the age,
understanding, and cooperation of the child (Favetto et
al., 2000).
Tendon healing has been a source of wonder and
research for many years. Clinicians must balance the
need of the tendon to heal with its need to glide.
Alternately, we know that if a tendon is immobilized it
will heal, but it will also adhere to the surrounding
tissue, and thus not glide. We know that if the tendon
is mobilized too fast or too hard, it will rupture. The
challenge in tendon management is to find a compro-
mise between protecting the blood supply and nutri-
tion to the healing tendon, while allowing gliding so
that the tendon will not adhere to the surrounding
tissue. The goal for tendon rehabilitation is to protect
the tendon through Phases I and II of healing (see
the following), while allowing some protection, below
breaking strength motion. This is particularly impor-
tant for flexor tendons, yet difficult to do with young
children. It is believed that children heal faster and with
fewer adhesions than adults (al-Quattan et al., 1993).
This information allows some creativity and deviation
from the adult tendon protocol in how to manage
these injuries postoperatively.
Conventional treatment protocols for adults have
been the traditional controlled protected motion for
both flexors and extensor injuries, and more recently
gentle protected active motion for flexor tendon injuries.
Rarely is an adult treated with complete immobilization
after flexor tendon injury; however, that might be the
treatment of choice for extensor tendons. With chil-
dren, it is common practice to immobilize the hand for
tendon injuries. With children under the age of 9, the
elbow is included with a long arm cast or splint. In an
interesting study, Friedrich and Baumel (2003) reported
good success using the modified Kleinert surgical repair
technique with early protected motion (see next sec-
tion) for children ages 9 months to 18 years who
suffered flexor tendon injuries. Their treatment tech-
nique varied from the traditional, which supports the
idea that creativity and individuality of protocol per
patient are advisable and possible (Friedrich & Baumel,
2003).
Tendon injuries are classified by zone of injury.
There are some variations in treatment protocol based
on the zone of injury, specifically for extensor tendons.
With flexors, however, many children are treated in the
same manner regardless of the zone.
Pediatric Hand Therapy • 385
Flexor Tendons
Immediately Postoperative (Phase I)
There are several accepted protocols for flexor tendon
repair. All tend to require 3 to 4 weeks of splinting,
with or without motion. The decision about which
protocol to follow is dictated by the surgeon’s choice of
suture style, as well as the age of the child and the
overall condition of the tendons and hand.
Young and unreliable children usually are placed in a
long arm splint or cast, placing the elbow in flexion (60
to 70 degrees), forearm in neutral, wrist in neutral or
with slight flexion (0 to 20 degrees), metacarpal joints
in flexion (60 to 70 degrees), and interphalangeal joints
in extension. This splint can be made intraoperatively
and then changed or adjusted in therapy on the second
or third day postoperatively. The patient is followed in
the clinic for splint checks and adjustments one to two
times weekly for 3 to 4 weeks.
The parents or guardians should be instructed in
all precautions about the child’s injury. They must
understand the importance of observing the fingers for
good color, thus assuring good circulation. They must
be instructed in edema prevention through elevation.
They also must understand the importance of encour-
aging the child to move the uninvolved joints such as
those not splinted. The splint may be removed to clean
the wounds or stitches. Great care must be taken not to
move the wrist and digits during dressing changes,
particularly if done by the parents or guardians. Some
elbow motion can be performed carefully when out of
the splint. Clinical visits include dressing changes and
gentle passive motion, of the elbow, wrist, and fingers,
in a protective manner by the therapist to protect repair
at all times (Penttengill & van Strien, 2002).
All reliable and older children may be treated like
adults and follow the early protective protocol of
Kleinert or Duran-Houser or the active motion pro-
tocols that are widely described in the literature
(Penttengill & van Strien, 2002).
The splint is fabricated and worn consistently for 4
weeks. In most cases, the child is splinted in a dorsal
blocking splint, with the wrist placed in neutral to 20
degrees of flexion, and metacarpals placed in 60 to 70
degrees of flexion by the dorsal hood. The fingers are
placed in extension in the hood for the early active
motion protocols and in rubber band traction for the
protective motion protocols.
For the protective motion protocol, a dorsal splint
is fabricated, placing the wrist in neutral and MPs in
70 degrees of flexion with rubber band traction on the
affected fingers or all fingers, depending on the sur-
geon’s preference and reliability of the child. The rub-
ber bands pull the fingers into the palm, creating a
fistlike appearance of the hand in the splint. The child
386 Part III • Therapeutic Intervention

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.

Figure 17-25 Early motion splint at rest.
Scar and edema management through pressure
and elevation is initiated for all patients. Pressure with
silicone gel or other sterile material can begin while
stitches are still in place.
Four Weeks Postoperative for All Protocols
(Phase II)
An initial evaluation is performed. Gentle active exer-
cises are initiated into flexion, with focus on full exten-
sion in a protected manner (i.e., full IP joint extension
with MP joints in flexion; full wrist extension with
digits flexed). The splint is worn protectively during the
day and at night. Precautions against full composite
extension (extending wrist and digits together in the
same movement) or resistive flexion are explained care-
fully. No blocked exercises are allowed. Dexterity activ-
ities and gentle ADLs are shown. The scar is managed
through pressure and stretch and by fabricating the
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
worn when the child is using the hand in normal
Pediatric Hand Therapy • 387
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
The literature suggests many different approaches to
treating tendon injuries in children and adults. Kayli
and co-workers (2003) evaluated results of early mobi-
lization of flexor tendon injuries in children ages 2 to
14, using above-elbow stabilization with a Duran-type
protocol. They reported favorable results with a mean
total active motion (0% to 100%) of 78.5%. They did
note that the age of the child and the presence of digital
nerve involvement affected the results (Kayli et al.,
2003). Fasching and co-workers (1998) looked at 90
severed digits in 38 children with the mean age of 4,
over a 4-year period. Children were all treated with the
Kleinert protocol. They had five cases of tenolysis and
one rupture. In the remainder of the cases they had
88% good results and 2% poor results, which they
assessed based on Buck-Gramcko’s classification. They
concluded that excellent results can be achieved with
experienced therapists and informed parents. Grobbelaar
and Hudson (1994) reported 82% excellent results
based on Lister’s criteria in their sample of 38 children
(average age 6.7 years). They had no tenolysis and
Figure 17-26 Blocking glove. (Courtesy of Kimberly
Goldie Staines.)
388 Part III • Therapeutic Intervention
three ruptures. They suggested better results when both
the FDP and FDS are repaired.
Friedrich and Baumel followed 173 cases of flexor
tendon injuries, ages 9 months to 18 years, over a 10-
year period. They concluded that early motion should
be initiated at any age, because of problems they saw
with immobilization, even in the young. Their protocol
follows a modified Kleinert routine, with a cast placed
in surgery either above the elbow or not, and the wrist
placed in 5 to 10 degrees of flexion and extended to the
MP joints. Digits are flexed by rubber band traction
that is routed through the palm. The initial goal is to
get full IP extension beginning on the first postoper-
ative day, with five to six exercises per day by the third
day. The goal is to achieve full flexion by 3 months.
Based on the Buck-Gramcko scale, they reported 95%
good results, with four cases of poor results (Friedrich
& Baumel, 2003) (Figure 17-27).
Ebinger and co-workers (2003) looked at two
groups of children with flexor tendon injuries. In group
A (children under 6 years of age), the postoperative
treatment consisted of immobilization for 3 weeks. In
group B (older children), early passive mobilization was
employed. Follow-up showed that the mobilization
Figure 17-27 Friedrich and Baumel casting for early
motion. (From Friedrich H, Baumel D [2003]. The treatment
of flexor tendon injuries in children. Handchir mikorchir
plastic chir, 35(6):347–352.)
group had good results compared with only average in
the immobilized group at 3 months postoperatively;
however, at 3.7 years postoperatively, both groups
showed good results.36
Clinical Implications
Flexor tendon protocols vary from immobilization to
protected motion to active motion. Long-term results
of studies do not show significant difference in the early
motion protocols; with the young, no study has shown
conclusively that early motion is preferred over
immobilization.
Extensor Tendons
Zones I and II injury distal to the PIP (known as
“mallet finger deformity”) is discussed in the fracture
section of this chapter. Treatment for a tendon avulsion
from the distal phalanx is the same as the treatment
described for mallet finger deformity.
The literature shows little or no difference in treat-
ing extensor tendons with early protected motion
rather than immobilization. Immobilization is the treat-
ment of choice in treating children of any age who
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
explained to the child, as well as the parents or guardians
about keeping the arm dry and clean, elevating the
extremity, and watching the color. The parents should

notify the doctor immediately if any discomfort or
unusual swelling is seen. Scarring and swelling are
addressed through pressure under the splint and
elevation.
Three to Four Weeks Postoperative Zones III to
VII (Phase II)
A baseline evaluation is done at this time. Edema is
measured, any scars are noted and described, and gentle
active ROM and dexterity are recorded. If there is sen-
sory involvement, a baseline sensory evaluation should
be performed. Particular attention is paid to any
adhesions along the tendon or to a lag. If a lag exists,
continued splinting for an additional 1 to 2 weeks may
be advised (Figure 17-28). Patients may begin active
range of motion (AROM) at this time; the exercises
should be carefully monitored for the first couple of
weeks so as not to strain the repair. Movements should
be in a tenodesis fashion; wrist extension with finger
flexion, wrist flexion with finger extension. The splint
may be adjusted or kept the same. It is used between
exercise sessions for protection and at night. The child
may use the hand for light ADLs and for bathing.
Precautions against resistive extension or composite
flexion (fisting with wrist flexion putting maximal strain
on the extensor mechanism) should be carefully
reviewed with the child and parents or guardians.
If the child can follow directions and has partici-
pating parents or guardians, and barring complications,
he or she can perform much of the therapy on a home
program basis and be followed in therapy once weekly.
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-
Figure 17-28 Extension lag.
Pediatric Hand Therapy • 389
vided. If a child is not progressing, then more frequent
visits to the therapist should be initiated.
Six Weeks to Eight Weeks Postoperative Zones III
to VII (Phase III)
The child may now use the hand in most of the ADLs.
Precautions against composite flexion until 8 weeks
postoperatively continue. Exercises that encourage active
extension, such as dowel or putty rolling, should be
used (Figure 17-29). Edema is a minimal problem by
this stage. The scar still needs attention. Splinting is
used for protection if a lag is present; otherwise it is
used as needed depending on the clinical manifestation.
Complete evaluation should be performed, looking at
all aspects of hand function.
Discussion
Little is available in the literature about extensor ten-
don management in the child. Most of the data are
based on adult populations. Protocols that are available
for adults certainly can be used for the older and reli-
able child. Evans (2002) suggested protocols for each
zone of injury, which may be appropriate to use under
certain circumstances with the pediatric population.
Clinical Implications
Extensor tendon injuries in children can be treated with
3 to 4 weeks of immobilization followed by a program
of gradual increase of motion and use. In treatment, all
efforts must be made to avoid an extension lag, includ-
ing increasing immobilization time if needed.
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 17-29 Rolling exercises to promote extension.
390 Part III • Therapeutic Intervention
are the most common, and children develop less stiff-
ness than adults when immobilized. Children are curi-
ous and thus put themselves at risk. Common causes
for hand burns are hot cups of coffee, hot water, irons,
and heaters. The mechanism of injury and the nature
of the burn agent dictate the severity of the burn.
Sunburn can produce a superficial burn, whereas hot
water produces a scalding injury that can be superficial
or deep. A flame may result in full thickness burns (de
Chaliain & Clarke, 2000; Greenhigh, 2000).
Burns occur initially when there is direct contact
with a thermal agent, causing injury to the cellular
elements and structural proteins. Subsequently, there
is delayed damage secondary to progressive dermal
ischemia. When a child is exposed to heat, both the
temperature and the time exposed to the heat deter-
mine the extent of tissue damage (de Chaliain and
Clarke, 2000).
Palmar burns in toddlers are increasingly more
common. Dunst and co-workers (2004) reported an
alarming increase in palmar burns associated with gas
fireplaces.
Burns have been classified in four degrees, although
commonly only three degrees are referred to, as seen in
Table 17-2.
Rehabilitation of the burned hand should begin
immediately after the child has been medically stabi-
lized because a 7- to 10-day delay may result in irre-
versible functional losses. The general goals of therapy
are to prevent deformity and maximize function (de
Chaliain & Clarke, 2000).
Intervention depends on the phase of healing.
Table 17-2 Classification of burn severity
Classification Depth of Penetration
First degree Superficial—epidermis level
Second degree Partial thickness—epidermis and
Superficial dermis level
Deep
Third degree Full thickness
Fourth degree Full thickness and more
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.
Phase I: Open Wound
The objective for treating a child in Phase I with an
open wound includes reducing edema, maintaining
digital circulation, limiting inflammation, and position-
ing and mobilizing the hand early. These are key
parameters to aid in the best chance for regaining
function (Clarke et al., 1990; McCauley, 2000).
Initial treatment of a hand burn must consider
wound care, the location of the burn, and the potential
deforming forces that will affect the healing.
Wound Care
Evaluation should consist of a description of the
wound, including the wound’s color, size, and depth,
as well as any exposed structures. Circumferential meas-
urements with a sterile measuring tape should be taken
for recording of edema. All blisters should be noted
and marked on a drawing of the hand. When possible a
picture should be taken of the wound.
Treatment should be coordinated with the burn
team and may consist of hydrotherapy (with the appro-
priate disinfectant agents) or wound cleansing directly
with dressing application and changes. Special care
should be given to any exposed tendons or bone. The
therapist’s role is to guide the team about positioning
the hand in the dressing. The goal of positioning is to
maintain burned structures on stretch while healing,
thus preparing for future functional use. Most com-
monly a resting splint is fabricated (see the following).
Edema and future scarring can be controlled with
pressure wrap over the dressing and splint immediately
after wounding.
Clinical Signs
Redness, pain, heals with no scarring (sunburn)
Blisters, moist, painful, heals in 2 to 4 weeks, or may
go to full thickness, scarring
Dermis destroyed, usually needs coverage, white or
black, dry, anesthetic
Deep destruction, to bone, needs flaps or grafts to
heal

Positioning
The goal of positioning the hand during the healing
phase is to maintain maximum potential for function.
Often the position of comfort is also the position of
potential contracture. Therefore positioning may not
always be comfortable, however it is essential for the
prevention of contractures. Positioning may be achieved
in many ways, the most common is through the use of
thermoplastic materials that are custom made for each
child. If these materials are not available, plaster, band-
ages, and other common items may be used.
The position that the hand and wrist are placed in
are determined by the location of the burns. The place-
ment of each joint in the hand, including the wrist,
must be such that the regenerating tissue regains maxi-
mum length and pliability. This position may at times
be in conflict with the “functional position” of the
hand. Positioning decisions need to be made for each
child with an exercise regimen that complements the
static positioning to maintain function. For example,
with palmar burns, the wrist is placed in 20 to 30
degrees of extension, with the MP joints in 30 to 40
degrees of flexion and IP joints in full extension. The
thumb should be positioned with maximal web stretch-
ing and in midposition between palmar and radial
abduction. Care must be taken not to stress the carpo-
metacarpal (CMC) joints. Support to the palmar arch
should be provided. The splint should be fabricated
on the volar side of the hand so that it puts pressure
on the healing wounds. This pressure aids in aligning
the collagen and reducing the potential for scarring.
However, this pressure must be distributed so as not to
cause point pressure areas, which can lead to tissue
necrosis.
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
of pressure on all circumferential burns, as well as
Pediatric Hand Therapy • 391
preventing the child from removing the splint (Ward et
al., 1998) (Figure 17-30).
Straps used to secure the splints should be wide and
placed diagonally, not circumferentially; when possible,
elastic wrap should be used so as not to compromise
circulation. Often, no straps are needed, because the
splint is incorporated into the total dressing and held in
place by bandages or elastic webbing. When using
elastic wrap, use no more than three wraps over one
area. Make sure even pressure is used. Leave the finger-
tips open so they can be seen to monitor color. Splints
should be worn continuously the first 5 days, removing
them for short periods to allow the child to exercise or
feed themselves. Thereafter, when edema has subsided
and tissue is starting to heal, splint wear time may vary
during the day, with continued night splinting used
until all scars have matured.
Scar and Edema Management
Scar and edema management should start immediately
after wounding. Pressure and elevation are the appro-
priate venues in the early phases of healing. Pressure
can be achieved through the use of elastic bandages.
Elevation can be accomplished through positioning in
bed on pillows or with the use of IV poles to “hang”
the hand. Attention must be given to the color of the
digits when pressure has been applied circumferentially
exposing the tips of the fingers, thus allowing visual
clues as to the circulatory viability. Children can be
advised to “wave” at everyone they see, with their hand
held high. When possible, extra pressure can be placed
in certain areas, such as the web spaces, with cotton,
bandages, or any other available sterile dressings
(Figure 17-31).
Figure 17-30 Sandwich splint for edema or scar.
(Courtesy of Kimberly Goldie Staines.)
392 Part III • Therapeutic Intervention
Figure 17-31 Circumference pressure wrapping for
burn scar. (From Serghiou M. In McCauley RL (2005):
Functional and aesthetic reconstruction of burned patients,
CRC Press.)
Exercise and Activities
Before initiating an exercise regimen, available active
and passive ROM as well as dexterity should be eval-
uated. This may require sterile instruments and tools.
In situations in which goniometric measurements are
difficult, the therapist should record functional meas-
ures. Although this is not as reliable as goniometric
measures specific to each joint, it does give some idea
of the child’s ability at that point in time. Ask questions
such as: Can the child touch the distal palmar crease
when asked to make a fist? Can the child extend the
fingers, touch each finger to the thumb in opposition,
or bring the thumb down to touch the base of the small
finger?
Exercise must be tailored to the age and compre-
hension of the child, as well as the depth of the burns.
In superficial burns, active ROM should be started
immediately with minimal limitations. For children with
deep burns, extreme care must be given to protect
structures that might have been affected, such as ten-
dons. If nerves are involved, the hand may be insensate,
and extreme attention must be given not to over-
exercise the part. To allow early motion, but also pro-
tect potential weakened structures, the ROM must be
done protectively. For example, if the extensor tendons
are exposed over the dorsum of the hand, composite
fisting must be avoided. ROM should be performed
one joint at a time or in a tenodesis manner. As an
example, the wrist should be extended when the child
is flexing the MCP joints with dorsal burns that expose
or affect the extensor tendons. Passive motion may be
applied, but with caution, so excess stress is not placed
on the tissue the therapist is holding or stretching. Care
should be given to maintaining the hand clean and
elevated during exercise session.
Whenever possible, the hand should be used in a
functional pattern because it assists the child in the
ADLs and exercise should be incorporated into active
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
outcomes, and steps to achieve these outcomes. In this
phase, education is primarily related to wound care,
dressing changes, positioning, pain management, and
limited activity. The parents or guardians are guided
through the rehabilitation process and included in all
therapy protocols. The importance of maintaining any
uncomfortable positions is emphasized. All precautions
are explained and reviewed. As indicated, the child is
encouraged to use the affected extremity in self-care as
much as possible.
Phases II and III: Closed Wound, Immature Scar
to Mature Scar
In Phases II and III, evaluation is more specific and
includes all aspects of hand function. It is performed
at regular intervals to record progress and modify
treatments. Wound care is discontinued.
Scar Management
The natural history of a burn scar is for tissue to
shorten and contract. The patterns of deformity are
well established. In managing the scar, the goal of
therapy is to both put pressure on the scar, as well as
to direct its orientation. In Phase II, when the scar
is immature, care must be taken not to disrupt the
healing by “shearing” the scar. Therefore efforts must
be made to minimize friction to the healing tissue, yet
at the same time apply pressure on it. Pressure can be
in the form of customized molds, gel sheets, foam, and
other types of materials that provide even pressure to
the scar. These pressure molds are secured with elastic
wrapping or splinting or both. Decisions are made
based on where the scar is and how extensive it is, as
well as the age and participation of the child. The
function of the hand must not be prevented by the
molds during the day. In some situations, there may be
a set of pressure molds for night time that differ from
the pressure wraps used during the day.
In Phase III, massage may be incorporated into the
scar management regimen. Creams may be used on a
lightly dampened hand to maintain moisture. Massage
without cream can be used with pressure to a particular
area to mobilize the scar. Also in the late phase a
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
tissue gains intrinsic strength, splinting during the day
can become more creative, addressing specific prob-
lems. Dynamic splints may be incorporated at this time
to encourage pull-through of the tendons, thus improv-
ing their excursion or to increase a joint’s ROM. At
night, positioning splints should be in place until ROM
is normal or any deformity has resolved (Figure 17-33).
Exercise and Activities
In Phase II the child is allowed to perform active ROM
in all planes. The child may now start with composite
motion, achieving gentle stretching of the scar while
exercising. For example, to achieve stretch or elonga-
tion of a dorsal scar, composite flexion with fisting and
wrist flexion should be done. Resistive exercises can be
performed only if they do not cause friction to the scar.
For example, if there is healing dorsal skin, use of putty
exercises for grip and pinch strength may be per-
formed, but not if there is a healing palmar scar. Passive
ROM is contraindicated in joints that have new healing
tissue so as to avoid friction. Dexterity and sensibility
should be tested and addressed as necessary.
In Phase III, both active and passive ROM as well
as strength should be addressed through play and
Figure 17-32 Custom ordered burn pressure wrap.
(Courtesy of Shrine Burns Hospital, Galveston, TX.)
Pediatric Hand Therapy • 393
Figure 17-33 Night position splint for burn hand. (From
Serghiou M. In McCauley RL (2005): Functional and
aesthetic reconstruction of burned patients, CRC Press.)
exercise. Intrinsic stretching, placing MPs in extension
while flexing the IPs, and intrinsic strengthening
should be incorporated. Tendon gliding, blocking
ROM, and other targeted exercises are employed as
indicated. Graded exercise activities should be incorpo-
rated that provide ROM, strengthening, dexterity, and
psychological stimulation. The activity should be
changed often to keep the child engaged.
Activities of Daily Living
In Phase II, the child should engage in light ADL, but
stay away from play or activities that could irritate the
scar. Equipment and tool modification should be pro-
vided to aid in independent function. This is based on
functional limitation and age. In Phase III, there are no
precautions—the child should engage in all ADLs he
or she can perform, with and without equipment as
dictated by the condition.
Skin care instruction should be given to the child
and parents, as well as education as to sun exposure 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
institutions. Sheridan and co-workers (1999) looked
at long-term results of acutely burned hands in 495
394 Part III • Therapeutic Intervention
children involving 698 injured hands, over a 10-year
period. These authors used ranging and splinting early
and throughout the treatment, with prompt sheet
autograft wound closure as soon as was practical, and
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
20% normal function in children who had deep struc-
ture involvement (e.g., tendon); however, 70% of
severely involved children were able to perform ADLs
(Sheridan et al., 1999).
Barillo and co-workers reported on a rehabilitation
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
MP joints with less than 70 degrees of flexion; and
active range and progressive resistance for alert patients
with MCP joint flexion of more than 70 degrees. Their
patients had an average of 220.6 degrees of motion at
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).
Roberts and co-workers (1993) reported on seven
patients’ hand strength that was followed by ROM,
compression therapy, and splinting. They showed that
although both grip and pinch strength improved at 6
weeks after injury, strength remained significantly less
than normal compared with the norm for age and sex
at 6 months. They concluded that although their find-
ings were lower than normal, this did not indicate poor
performance in ADLs.
Clinical Implications
Children with hand burns should be seen by a therapist
early for positioning and gentle motion. Splint design
should be dictated by burn location. Children should
be followed until the scar has matured, which could
take up to two years.
TREATMENT OF CONGENITAL
HAND DIFFERENCES
There has been a lack of generally accepted nomen-
clature for the problem in children with congenital
differences of the hand. They have been called upper
limb or congenital anomalies, malformations, or differ-
ences. In this chapter, the word differences is used to
describe this population. Further classification of con-
genital differences has been devised by the Interna-
tional Federation of Societies for Surgery of the Hand
(IFSSH) (Swanson, Swanson, & Tada, 1983). This
International Federation of
BOX 17-2 Societies for Surgery of the Hand
Classification of Congenital
Differences
I. Failure of formation
II. Failure of differentiation of parts
III. Duplication
IV. Overgrowth
V. Undergrowth
VI. Constriction ring syndrome
VII. Generalized abnormalities and syndromes
classification categorized the types of congenital
differences (Box 17-2).
The treatment of two of the most commonly seen
congenital differences, syndactyly and radial club hand,
are discussed.
SYNDACTYLY
Syndactyly falls under the “failure of differentiation”
classification. It is a fusing of adjacent fingers that can
be simple (involving only skin) to complex (in which
the bones of two digits are fused). Syndactyly is one of
the most common hand deformities. It is found in
males more than females, and is present in 50% of cases
bilaterally. Often syndactyly is associated with other
problems, such as polydactyly, clefting, symbrachy-
dactyly, or ring constriction. When these occur, surgery
and therapy should take these anomalies into account
when planning intervention. The goal of a syndactyly
surgical release is to create a functional hand with as
few surgical procedures as possible. Intervention can
be done as early as 6 months of age or even earlier,
especially in border fingers in which length discrepancy
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.,
2004). Island flap reconstruction in incomplete syn-
dactyly has been advocated by Brennen and Fogarty
(2004), in which skin and fat are rotated for coverage,
with good results, minimal scarring, and rare need for
follow-up skin grafting (Dao et al., 2004).
Postoperative Period: Phases I and II
The goal of therapy in the early phases of healing is
wound and edema management, followed by preven-
tion of scarring and creep (the distal progression of the
commissure), which may occur (Lourie, 1999).
The hand is elevated until edema is under control. A
dressing may be in place for up to 2 weeks and parents
 Pediatric Hand Therapy • 395

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
396 Part III • Therapeutic Intervention
pictures, as well as specific measurements of depth, size,
and color.
Clinical Implications
Children that have had syndactyly releases should be
seen in therapy for positioning and scar management
immediately postoperatively. AROM and functional
patterning should be initiated as soon as the grafts or
flaps are healed.
RADIAL C LUB HAND
Radial club hand belongs under category I of the
International Federation of Societies for Surgery of the
Hand, “failure of formation of the parts, longitudinal-
radial,” also known as radial ray deficiency or radial
dysplasia. It is a complex congenital difference of the
radial or preaxial border of the upper extremity. Radial
dysplasia may present with a spectrum of abnormalities,
varying in severity from a slight hypoplastic radius
and minor thumb hypoplasia to aplasia of the radius,
thumb, first metacarpal, scaphoid, trapezium, and all
related soft tissues. Bayne and Klug (1987) categorized
radial club hand into four categories, I through IV:
short radius, hypoplastic radius, partial absence of the
radius, and total absence of the radius, respectively. The
child presents with a shortened extremity and a hand
that is radially deviated at the distal end of a bowed
forearm (D’Arcangelo, Gupta, & Scheker, 2000)
(Figure 17-37).
Function
Functional limitations vary based on the severity of the
radial club hand, as well as the child’s age and adapta-
tion to the condition and environment. Clinicians must
be cautious not to assume functional limitations based
Figure 17-37 Radial club hand x-ray.
on the upper limb appearance alone, but rather on an
individualized ADL evaluation.
Impairment may be present in the elbow, with lim-
ited flexion. Wrist and finger motion is restricted sec-
ondary to the position of the hand, as well as to the
deforming forces of the flexors that pull the hand into
palmar displacement and radial deviation. With absence
of the thumb in many cases, pinch patterns are per-
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
wrist; this is a functional pattern for some. This action
may be helpful to the child, although it may not look
cosmetically appealing. The length discrepancy of the
limb can create some difficulty with bilateral activities.
Children with unilateral deficit adjust quite well and
thus have minimal functional loss compared with chil-
dren with bilateral involvement (Manske & McCarroll,
1998).
Evaluation of Radial Club Hand: Preoperative
and Postoperative
The preoperative evaluation should include assessment
of ROM of the elbow, wrist, and hand, noting the
position of the forearm, which is usually static. Specific
attention should be given to the amount of passive
range available in centering the hand on the ulna,
noting blanching of the skin and other signs of struc-
tural stress. A developmentally appropriate ADL assess-
ment should be done with particular emphasis on
self-care. Grasp and release patterns are recorded, look-
ing at the child’s ability to manipulate and move
objects of various sizes and weights. Children with an
absent thumb have creative new prehension patterns
that also should be recorded. The length of both
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
to record progress and be repeated at regular intervals.

Care must be given not to make surgical decisions
based on aesthetic pressure from the family that will
not improve the child’s function.
Postoperative evaluation differs slightly with the
type of surgery performed. Examples of common surgi-
cal procedures are Ilizarov placement and centralization
or pollicization for an absent or hypoplastic thumb. In
each situation, the evaluation should record the child’s
physical limitations (impairment level) and how they
affect their function.
Treatment of Radial Club Hand: Preoperative
and Postoperative
There are three options for addressing this condition:
no treatment, conservative treatment, or surgical cor-
rection. The primary goal of treatment is to improve
the overall function of the extremity. Cosmesis is a
secondary consideration.
Children with Type I or II of Bayne and Klug’s
classification can be treated conservatively, with treat-
ment starting a few days after birth. The child’s wrists
are passively stretched into a centralized position, and
the elbow is passively ranged. Parents or guardians are
instructed in stretching and ranging activities. In
between stretching, an above-elbow splint is applied,
placing the elbow in 90 degrees of flexion and the wrist
in a centralized position. If the soft tissues present with
particular tightness, a serial casting regimen can be
implemented. The cast should place the wrist in neutral
with the elbow in 90 degrees of flexion. The cast can be
changed a few days up to 2 weeks at a time. Once the
desired position is attained, splinting at night and
stretching by day should continue until bone maturity,
which occurs in adolescence (D’Arcangelo et al., 2000;
Manske & McCarroll, 1998).
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
Pediatric Hand Therapy • 397
be used to mimic wrist position before surgery. The
child can give his or her opinion of the wrist position.
Splinting for radial club hand can take many forms.
The author’s recommendation is a three-point pressure
design, with one point at the ulnar side of the proximal
forearm, the other on the ulnar side of the palm, with
the third point being in opposition right at the distal
end of the ulna, radial side (at the wrist). Depending on
the age of the child and condition of the elbow, the
splint design may be above the elbow, with the elbow
kept at 90 degrees of flexion, although the elbow is left
free when possible. If the thumb is present, it is also left
free (Figure 17-38).
Children and parents or guardians are educated
in ROM and stretching exercises of the elbow, wrist,
and digits. Shoulder active ROM also is included.
Digital flexion may be compromised because of the
limited excursion of the flexors. This can be improved
with positioning and exercise. Prolonged stretch may
be uncomfortable for the child; therefore parents or
guardians should be instructed carefully about keeping
the discomfort to a minimum and the importance of
the daily stretches (Fuller, 1999).
When a surgical correction is performed for central-
ization of the hand, the child generally is placed in a
cast. Once the cast is removed, a splint is made and
therapy can begin. However, first information should
be obtained about the surgical procedures, specifically
what tendons were transposed. Therapy generally com-
bines the following procedures:
1. Fabricating a splint, similar to the one described in
earlier, to maintain position until skeletal maturity is
achieved. Splint is adjusted on a regular basis.
2. Protecting and re-educating the transposed ten-
dons, usually flexor carpi ulnaris
Figure 17-38 Radial club hand splint.
398 Part III • Therapeutic Intervention
3. Increasing ROM once the child is cleared to move
the involved extremity
4. Re-education of prehension patterns and functional
tasks
5. Scar and edema management
6. Providing the child with appropriate assistive
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
encouraged with emphasis on elbow motion and digital
prehension. Bilateral activities are encouraged, as is
manipulation and grasp and release activities in a graded
manner. Play activities are encouraged.
External Fixation with an Ilizarov
Kessler (1989) introduced the Ilizarov, an external
fixator that gradually distracts the soft tissue, approxi-
mately 1 to 2 mm a day, slowly achieving a better wrist
position, with minimal to no neurovascular compro-
mise. The device is used preoperatively and may be on
the child’s hand for several weeks. During this period,
therapy should emphasize ROM of all uninvolved
joints. Because of the weight of the device, an excellent
medium for exercise is a therapeutic pool. The child
can move the shoulder and elbow with or without the
therapist’s assistance in the water, aiding the affected
arm with the non-affected one. Fingers can be stretched
with dynamic splinting that is fabricated on the Ilizarov.
Dynamic extension splinting can aid in reducing any
flexion contractures, as well as provide proprioceptive
input for flexor excursion. The hand can be supported
with a static night splint to maintain functional posi-
tioning of the digits (Figure 17-39).
Figure 17-39 Ilizarov for a radial club hand.
Clinical Implications
When treating a child with congenital differences, the
assessment should be based on the specific child and
his or her adaptation, rather than typical children of the
same age. Often children adapt beautifully to their
differences and minimal intervention is necessary.
SUMMARY
This chapter has provided a base line for the healing
process for common injuries or surgical interventions.
The process of evaluation also has been discussed, as
well as common treatment protocols. With each injury
or condition the actual treatment plan is individualized
to the specific child and his or her special situation
based on the evaluation. Knowledge of normal devel-
opment, normal healing, and good observation skills
may be the most valuable evaluation tools, especially
with infants and small children. Gaining the child’s
trust and helping him or her overcome fear is the first
step in therapy. After an injury or surgery, the child may
regress in development and adaptive skills. The parents
or guardians also may be fearful and confused as to
what is happening to the child. Each child presents
with unique qualities. When determining a treatment
plan, these qualities are considered, along with the
child’s home environment, diagnosis, and the type of
medical intervention received. Realistic functional goals
are then formulated that are specific to that child.
Children are resilient and bring new meaning to the
notion of “what is possible” rather than “impossible.”
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Roberts L, Alvarada MI, McElory K, Rutan RL, Dasai MH,
Herndon D, Robertson MC (1993). Longitudinal hand
grip and pinch strength recovery in the child with burns.
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Sheridan RL, Baryza MJ, Pessina MA, O’Neill KM, Cipullo
HM, Donela MB, et al. (1999). Acute hand burns in
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a 10-year experience with 698 injured hands. Annals of
Surgery, 229(4):558–564.
Shortridge SD (1989). The developmental process: Prenatal
to adolescence. In Occupational therapy for children. St
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40(5):363–367.
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Tribuzi, editors: Concepts in hand rehabilitation
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LRL Scheker, editors: The growing hand, diagnosis and
management of the upper extremity in children
(pp. 225–230). St Louis, Mosby.
Swanson AB, Swanson GD, Tada KA (1983). A
classification for congenital limb malformation. Journal of
Hand Surgery, 8(5):693–702.
Ward RS, Schnebly WA, Karvitz M, Warden GD, Saffle JR
(1998). Have you tried the sandwich splint? A method of
preventing hand deformities in children. Journal of Burn
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Trauma Surgery, 124(3):179–186.
 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
SPLINTING FOR PEDIATRIC ORTHOPEDIC
PROBLEMS
Fractures
Flexor Tendon Splinting in Children
Juvenile Arthritis
Brachial Plexus Injury and Peripheral Nerve Injury
child is to improve function. Of course there are other
primary reasons and secondary benefits such as to
improve joint range of motion, decrease joint stiffness
and contractures, improve hygiene, and modify behav-
ior. Dysfunction or deficits in the upper extremity
pediatric population can be divided into three major
groups: infants and children with congenital or birth
injuries that require splinting to prevent development
of deformity or correct existing deformities, children

401
402 Part III • Therapeutic Intervention
with congenital defect who have undergone corrective
surgery, and those who require treatment secondary
to pathology or trauma (Byron, 2002). Splinting and
postoperative protocols are more standardized for
orthopedic involved cases as compared to splinting and
protocols for neurological involvement. It is beyond
the scope of this chapter to cover the numerous splint
designs and fabrication instructions for multiple diag-
noses. Instead, an overview of splint decision making,
as well as splint ideas, is the focus.
It must be appreciated that the plasticity and imma-
turity of a child’s system allows gentle forces to both
promote developmental hand function, as well as poten-
tially result in harmful effects. It is important to realize
both the structural and developmental differences in a
child’s hand when splints are being applied. Develop-
mentally disabled children have not experienced nor-
mal hand function or weight bearing and consequently
lack the normal configuration of arches and grasping
patterns (Hogan & Uditsky, 1998). Therefore splints
should support the normal configurations, as well as
promote functional developmental grasp and release
patterns. Special care needs to be taken with the child
who is nonverbal because of age or disability who may
experience problems with decreased sensitivity, tactile
defensiveness, and splint pressure. The immature or
youthful lack of experience with normal motion and
function also requires observation, consideration, and
instruction for the child or parents.
SPLINTING PRINCIPLES
Mechanical principles used in splinting adults and chil-
dren are the same. Once the concepts of the anatomical
and mechanical principles are understood there is little
requirement for splint patterns. Applying the softened
splint material and positioning the hand and affected
joints in the desired and optimal biomechanical posi-
tion for the purpose the splint is intended are the keys
to effective splinting. Generally, the experienced thera-
pist uses less splint material without a pattern than a
novice splinter with a pattern because it takes both
perception of what the splint will do and what forces
the splint will exert, as well as the vision of how the
splint will accomplish this to be an effective and effi-
cient splint maker. The splint is used to place body
parts into the most beneficial position for the pre-
established goal with proper biomechanics considered
for the extremity, injury, and splint.
The mechanical principles that must be understood
and applied include force, pressure, torque, friction,
and shear stress. Obviously an entire chapter could be
dedicated to biomechanics and mechanical principles;
instead an overview of the important mechanical prin-
ciples as they relate to splinting is discussed. Fess and
co-workers (2005) were thorough in their discussion of
biomechanics of the hand and splint design, fabrica-
tion, and execution. It has long been considered the
“splinting bible”; any therapists contemplating splint
design should be aware of these principles (Fess et al.,
2005).
Some understanding of basic physics and mechanical
principles help with splint design, both from an effec-
tiveness and aesthetic standpoint, and can help the
splint look “cool,” an important aspect in convincing
children to wear one. It is critical to understand that
pressure is actually the force that is being applied by the
splint material, through gravity and dynamic tension,
multiplied by the area over which the force is being
distributed. In effect, splints covering a larger area dis-
perse force or load over a greater area and reduce pres-
sure and occurrence of skin breakdown. Also, the more
conforming the splint, the less room there is for friction
and pressure points to build. The rule of thumb in
maintaining the proper amount of pressure from the
splint material and straps is that the splint should cover
two-thirds of the length of the forearm or limb and one
half the circumference of the limb or body part. This
maximizes pressure distribution and splint stability and
minimizes pressure points and migration of the splint.
Wider splint straps also distribute pressure more evenly
than narrower straps. Common pressure points both
for splint material and strapping are included in this
sketch (Figure 18-1).
Another important principle in splinting is torque.
Torque is a rotational force and can be beneficial or
destructive. When applying torque it should be at 90
degrees to the segment being mobilized. Without the
correct line of pull in a dynamic situation, the skin
suffers with shear forces; the result is unnecessary pain,
unwanted torque on the joint, and possibly even skin
4 1
9
2 5
2
3
8
6
9
Figure 18-1 Areas prone to pressure because of splint
or strap force include: (1) dorsal metacarpals, especially
with dorsally based splints; (2) volar surface of
metacarpals and thumb at distal end of wrist cock-up
splints and C-bars; (3) volar surface of digits with resting
hand splints resulting from spasticity or contractures;
(4) dorsal surface of first phalanges and proximal
interphalangeal joints; (5) ulnar styloid; (6) thumb
metacarpal; (7) not shown, but center of the palm with
too much transverse arch in the palm; (8) base of the
thumb with vulnerable radial nerve; (9) proximal end of
the splint. (From Malik M [1985]. Manual on static hand
splinting. Pittsburgh, AREN.)

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
I or T to add strength to the structure. Flat beams are
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-
struct a splint, but basic mechanical and physics princi-
ples take one a long way in designing the optimal splint
for the child.
According to Fess and co-workers (2005), the gen-
eral principles of design that play an important role in
splint design must take individual patient factors, such
as age and intellect, into account. Also, one must con-
sider the high activity and energy level of a child; this
alone requires that splints must be durable, as well as
nontoxic and easily cleaned. The length of time the
splint is to be used is also a factor in design.
“In general the shorter the anticipated need of the splint, the
simpler its design, material type, and construction should be”
(Fess et al., 2005, p. 211).
Strive for simplicity and pleasing appearance. Some
patients have low “gadget tolerance” and are much
more accepting and compliant with a simple, cosmeti-
cally pleasing splint. Children also tend to be more
compliant if they are involved in helping to choose a
color or favorite sticker to decorate the splint. Allow for
optimum function of the extremity without needless
immobility of the uninvolved joint, unless it is neces-
sary to secure the splint to prevent removal. Children
are less likely to suffer stiff joints for a prolonged period
if proximal joints are used to stabilize or secure the
splint from removal by the child (Figure 18-2). Allow
for optimum sensation:
“Without sensation the hand is perceptively blind and
functionally limited . . . splint designs should leave as much of
the palmar tactile surface areas as free from occlusive material
as possible” (Fess et al., 2005, p. 213).
Splinting the Upper Extremity of a Child • 403
Figure 18-2 Splints should include proximal joints to
assist in splint stability and decrease the probability that
they will be removed.
Allow for efficient construction and fit. Plan design
to limit construction time and readjustment; some-
times prefabricated splints are the most reasonable,
especially when time and expenses are considered.
Provide for ease of application and removal. Independ-
ent donning and doffing of splints improve compliance;
caretakers of small children also need quick and
efficient means of fastening and unfastening splints for
application and removal. Consider the splint or exercise
regimen: It may be possible to have both flexion and
extension systems built into the same splint (Van Straten
& Sagi, 2000). Similarly, a long arm thumb spica may
be trimmed to a hand-based thumb spica as therapy
and healing progress. The cost factor also should be
considered at this point. Finally, the splint should be
safe from hard or sharp edges, as well as any attach-
ments or straps that may come off or be swallowed.
BENEFITS AND GOALS OF
SPLINTING
Establish the potential benefits and goals of splinting
(Box 18-1). Positioning is an important part of both
rest and active play. Because the upper extremities are
so vital to self-care, feeding, and sensory input, the
placement of the fingers, hands, wrists, and forearms is
crucial to development and life functions. Splinting
used for positioning is usually static, but also may have
a dynamic component. The goals for a positioning
splint are to mobilize joints, stretch soft tissues, reduce
contractures, provide stability or support at specific
joints, provide proper alignment, and prevent defor-
mity. As stated, the development of self-care and
404 Part III • Therapeutic Intervention
BOX 18-1 Potential Goals and Benefits
of Splinting
Position
Function
Hygiene
Protection and behavior
exploration in the child centers around the use of his
or her upper extremities. Other goals for a positional
splint include enabling or improving existing function,
augmenting the benefits of therapy, and substituting
for weak or absent muscles.
Functional splinting may be used to hold or adapt
eating or writing instruments, as well as to aid in the
management of assistive technology for environmental
controls or educational access. This may be attained
through isolation of a digit for pointing and touching a
keyboard or creating a flat palm to access a touch pad
for a fan or light switch. On the other hand, a custom
fabricated joy stick gripping splint may mean increased
independence of computer use or may improve
accuracy in controlling an electric wheelchair for a child
with a neurologically involved hand. Also, a hand-based
thumb spica splint may be the key to thumb control
that a child requires to manipulate clothing, fasteners,
or a pencil. Another potential goal is to improve or
prevent hygiene problems. This is usually more of an
issue with the neurologically involved hypertonic hand.
The difficulty of relaxing the hand to allow air flow and
hand washing can be assisted through splinting for
hand position, as well as protection of the palmar sur-
face. Finally, splinting goals can be to help modify or
prevent undesired behaviors that interfere with safety
or upper extremity use. This might include, but is not
limited to, elbow extension splinting to keep the hands
away from the mouth or necessary life support equip-
ment or medical equipment in use with the child. In
some cases splinting and behavior modification can be
tools to improve self-injurious behavior (Hogan &
Uditsky, 1998). Orthopedic or post trauma splinting is
discussed later in the chapter.
SPLINT SELECTION
THE PROBLEM-BASED SPLINT
SELECTION C HART
Hogan and Uditsky (1998) have developed a priority
rating form, as well as a splint selection flow chart
(Figure 18-3), which is helpful for determining the
priority of needs of the child. Table 18-1 is also helpful
and is an adaptation of another chart by the same
authors that lists the proper splint to fabricate for
specific needs.
Generally, the shotgun splinting approach of trying
to fix too many problems at once ends up not bene-
fiting any one problem well. For example, a child may
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
possible to achieve all of this through one splint with-
out causing undue pressure or constriction. Therefore
usually it is better to have splints for different functions.
The problem-based splinting chart is organized to
help plan splint selection around the child’s problem
and not diagnosis; look at the “problem” and not
just the diagnosis when deciding splint design. It is of
the utmost importance to observe the child’s pattern
of movement and grasp while playing or moving,
because children with abnormal tone adapt substitution
patterns that may be functional. A splint may limit
the functional movement and affect hand use in a
negative way. Problem solve first, and then create the
splint!
TYPE OF SPLINT: STATIC, SERIAL STATIC,
STATIC PROGRESSIVE, OR DYNAMIC?
Static splints are the most commonly made and one of
the most important splints. Static splinting is non-
articular, with no moving parts. It is basically an immo-
bilization or supportive splint, but may be used to
control mobilization or encourage mobilization by the
joints it is blocking or not blocking. Finger gutter, wrist
cock-up, thumb spica, and resting hand splints are
examples of static splints (Figure 18-4). Serial static
splints are static splints that are periodically remolded
and reapplied as the joint gains motion or the tissue
gains length. They are applied at the end range with the
joint stretched maximally. Serial casting is a good exam-
ple of this. It may be used to promote proximal interpha-
langeal (PIP) extension with flexion contractures
(Figure 18-5). A night time elbow extension splint may
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
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-
ping, hinges, screws, turnbuckles, and MERiT or Splint
Tuner components (Figure 18-6), without the use of
rubber bands and elastic materials, slowly changes the
resting length of soft tissue with the joint in a static,
stretched position over a prolonged amount of time
(Austin & Jacobs, 2003). Most often static-progressive
 Splinting the Upper Extremity of a Child • 405
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.)
406 Part III • Therapeutic Intervention

Table 18-1 Problem-based splint selection

 Splinting the Upper Extremity of a Child • 407

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.)
408 Part III • Therapeutic Intervention
Figure 18-4 Static splint: finger gutter.
Figure 18-5 Serial static splint. This splint can be
reapplied as the joints improve range of motion.
splinting is custom made, although some components
may be prefabricated and kits are available.
Dynamic splinting uses articulations and force
components to constantly put a dynamic pull on the
tight or healing tissue. Dynamic splinting uses the elas-
tic properties of the tissue, as well as the splint compo-
nents such as rubber bands, springs, or elastic cord, to
exert controlled mobilization (Figure 18-7). It may be
used conversely to strengthen or give proprioceptive
feedback when exercise is done against the line of pull
Figure 18-6 Static progressive splint. MERiT component
used to progress wrist extension.
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.
“. . . 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
much force? (2) Through what surface? (3) For how long? (4) To
what structure? (5) By what leverage? (6) Against what
reaction? (7) For what purpose? (8) Measured by what scale? (9)
Avoiding what harm? and (10) Warned by what signs?”
(Brand, 2002, pp. 1811-1817).
These principles seem simple; however, they make the
difference between a successful, well-designed dynamic
splint and a disaster that has potential to harm the
child.
 Splinting the Upper Extremity of a Child • 409

Inflammation Proliferative Remodeling

Immobilization
o Static
Mobilization
← o Dynamic
o Serial Static →
o Static Progressive →
Restriction
← o Static →
← o Dynamic →
Figure 18-8 Tissue is in constant change when healing,
always moving between stages. Observe tissue healing
and scar maturation when considering which type of
splint to use, and constantly re-evaluate tissue change
and splint effectiveness. (Modified from Jacobs M, Austin N
[2003]. Splinting the hand and upper extremity: Principles
and process. Philadelphia, Lippincott Williams & Wilkins.)
MATERIAL SELECTION FOR LOW
TEMPERATURE THERMOPLASTICS
A multitude of splint materials are on the market and it
would be difficult for anyone to fabricate all custom
designed splints with one material in one thickness.
The therapist will likely get the best splint for the
individual if thought is put into the choice of splint
material. Materials have six major qualities or handling
characteristics that affect splint fabrication including
drapability or conformity, stretch, memory, bonding,
rigidity, and handling or set time (Box 18-2).
Drapability or conformity is the degree at which
the material takes the shape of the contours below it.
High drapability or conformity material makes intimate
contact with the contours of the wrist, metacarpals, and
digits; on the other hand, it is easy to apply too much
pressure and get deep imprints that may cause pressure
and are not easily removed. Low drapability material
needs more handling to conform to the contours beneath
it. Overheated material also can result in too much
BOX 18-2 Splint Material Characteristics
Drapability and conformability
Stretch
Memory
Bondability
Rigidity
Working times and heating
Other
Thickness
Perforations
Color
drapability; therefore, watch heating time. A high
drapable material is Polyform; midrange materials are
Polyflex II, TailorSplint, and Orfit; and low drapable
materials are Synergy and Orthoplast. Highly drapable
materials should be handled in the horizontal plane to
prevent overstretching the material.
The ability to stretch or resist stretch without
buckling or loss of rigidity is another important charac-
teristic that usually runs parallel to the amount of
drapability a material has in it; the more drapability the
easier the stretch, and vice versa. Around contours such
as elbows and flexed metacarpals it is essential to have
stretch without loss of strength or shape; however, too
much drapability on a longer or larger splint can be
difficult to control. Novice splinters may wish to start
off with a midrange material such as Ezeform or Orfit.
Memory is the degree to which a material will
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
memory is helpful if high tone or tactile sensitivity is an
issue and the material may get “smushed” by a grasp
reflex. It is excellent if the goal is serial splinting or if
there will be a significant change in edema; however,
memory can be a problem if the material is taken off
the patient before it is fully cooled because it will shrink
and try to return to its original shape as it cools. This
in turn creates both a poor fit and edges that dig into
the skin.
Bondability, or the ability of the material to stick to
itself when heated, is another property that must be
weighed when choosing material. Material may have a
coating that resists bonding and is easy to “pop” apart
when cool. The coating may be left on and a damp
paper towel or lotion can be used to help prevent bond-
ing. Also, if bonding is desired for outrigger placement
or sealing around the thenar web space, the coating
can be removed with a solvent or scraped off with a
sharp instrument.
Rigidity is the relative amount of strength the mate-
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-
tures. Rigidity also can be added to less rigid materials
through contours, I- and T-beam supports, and
multiple layering.
Working time or setting time needs to be kept in
mind when working with a material. Thin materials
(1/16″) have a short working time and set quickly once
removed from the splint pan. Other materials depend-
ing on the heating time and temperature and material
qualities take up to 2 minutes to heat up and have 2 to
6 minutes of workable time before they set. Drying off
the splint material also extends the working time because
evaporation cools the material faster and less evenly.
410 Part III • Therapeutic Intervention
Each material also is made up of a different combina-
tion of plastic, rubber, and polymers and the qualities
also are influenced by the thickness of the material.
Materials come in 1/16″, 1/12″, 3/32″, and 1/8″ thickness.
Most finger-based splints are made from the thinnest
/16″ materials to help reduce bulk between the fingers
1
and they are strong enough to maintain the correct
position in a finger. Children’s hand or wrist splints can
be made from this material as well if spasticity is not an
issue. However, hand, wrist, and forearm splints should
be made from thicker materials so they will retain their
strength across the joint.
Other physical characteristics include the option of
perforations, as well as color. Many splinting materials
exist and new ones come on the market all the time. It
is a good learning experience to have your local sales
representative bring out or send you samples of the
various materials in different thicknesses. Different splint
property charts go into great detail about the materials,
but the best way to find out how they will respond to
your use of them is hands-on use. Play with the differ-
ent materials and make the same splint out of several
types and thicknesses of material. Use different
strapping materials as well and you will find out what
works best for the most common splint types you
make. If you work in a busy hand clinic you most likely
have several different types of materials in various
thicknesses because of the wide variety of hand and
upper extremity diagnoses seen. The school, itinerant,
or home health therapist may find that he or she is
making a similar type of splint for a similar age group
and may select a couple of all-around good splint mate-
rials to have on hand. Remember not to leave them in
the car! This is an expensive mistake for a traveling
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
established, and the biomechanics and pathology have
been understood and applied, the need for a pattern is
no longer essential. Make the splint material fit the
design and the child’s hand; do not try to make the
hand fit a preconceived pattern. Nearly all splints can be
started as a rectangle. Once the heated soft rectangle
of material has been placed on the hand or upper
extremity, it is much more apparent where to cut,
where to roll, and where not to cut. Too often the splint
material is cut before it is applied to the child and too
much material is already gone. Stretching to make up
for lack of material can weaken the splint design. Begin
by prepadding bony prominences, applying a stock-
inette (it may be wise to apply the padding on top
of the stockinette as in Figure 18-9), positioning the
child, and then applying the splint rectangle. With
proper positioning and the help of gravity, it is possible
to get good conformity and mark where the splint
needs to be cut away. Having a little extra material
beyond the conceived splint design can give the thera-
pist extra leverage to help hold joints for position while
the splint is being fabricated and it can be cut away
when the essential part of the splint is set and cooled.
Edge finishing is essential for comfort and safety, as well
as attachment and outrigger security, especially for the
infant and child. Attachments and straps should be
considered harmful if swallowed; therefore permanent
bonding or riveting may be needed. Commercially
designed patterns for the more common splints are
available and they can be shrunk in size with a copier
for a more child-friendly version. However, the propor-
tions of a child’s hand are not the same as those in an
adult; forearms may be too long or there may be no
allowance for the fat pads on the dorsum of an infant’s
hand and fingers. Remember to fit the splint to the
child’s needs and not the child to the splint pattern.
Figure 18-9 Prepadding the ulnar styloid and other
critical areas (e.g., around percutaneous pins) helps avoid
pressure areas.

SPLINTING FOR COMMON
PEDIATRIC HAND PROBELMS
THUMB IN PALM
Many times with infants and small children the best
splint is actually a strap or splint and strap combination
to gently control anatomical structures, especially the
thumb. Soft neoprene thumb straps that attach to a
wrist band are enough to allow improved thumb con-
trol and grasping patterns that are developmentally
appropriate. Also, elastomer or Adapt-It pellets can be
used as a soft base for strapping for an infant or small
child for soft control of a fisted hand or to maintain
the palmar arches within a splint (Figure 18-10). The
ThumbDuction strap is a soft prefabricated strap that
is available in pediatric sizes from 3-Point Products
(Figure 18-11).
A volar wrist cock-up or ulnar gutter splint with an
abduction thumb strap is a more rigid alternative if
there is spasticity in the wrist. The combination of a
rigid thumb “saddle” with a soft strap also helps posi-
tion the thumb (Figure 18-12). In older, neurologi-
cally involved children, thumb control is more difficult,
and thermoplastic splints are not as well tolerated if
they have not been initiated when the child was younger
and contractures less fixed.
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.
Splinting the Upper Extremity of a Child • 411
FISTED HAND
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
extremities. It may be appropriate to provide an anti-
spasticity cone or soft cone if the hand does not open
to explore or grasp in an age-appropriate pattern.
Infant splints are tiny, and fabricating these miniature
splints is an art in itself. It is perfectly fine to “cheat”
and fabricate on the opposite hand and “flip” the
splint, or look for a sibling or another similar-sized
infant on which to fabricate the splint. In the older
child the fisted hand can be a problem for function, as
well as hygiene. The least restrictive splint is always the
better choice; however, extra strapping or including
proximal joints may be necessary for splint security and
the prevention of splint distal migration.
For younger toddlers and pre-school-aged children,
weight bearing on their upper extremities requires wrist
and finger extension. A clamshell or bivalved splint
provides both wrist and hand control during weight-
bearing activity. Splint material plays a bigger part in
this splint than in others. Flexor tone and fisting can
immediately ruin a beautiful piece of soft Polyflex II by
turning it into a squashed-up clump of material when
applied to a sensitive or tactilely defensive hand. A
more rigid splint material with more memory, such as
412 Part III • Therapeutic Intervention

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-
rial to itself without instant bonding. The finished
splint also has fewer fingerprints and rough edges. It
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
or hand part of the splint that will be shaped for the
hand. This is a useful splint for supervised weight-
bearing activities. Because there is progression, the
dorsal part of the splint can be used alone with indi-
vidual finger strapping, which provides tactile and
kinesthetic input through the palm. With spasticity in
the upper extremities and hands, the position obtained
with the antispasticity ball or cone helps reduce tone
(Figure 18-13). In the most severe of hand contrac-
tures, in which the goal is to prevent skin breakdown
and maintain hygiene, the Freedom Finger Contracture
Orthosis or “carrot,” may be used (Figure 18-14).
There is now an inflatable version for progressive hand
opening.
WRIST FLEXION
The wrist is considered the “key” to the hand because
the hand is dependent on the wrist for correct place-
ment and stability to allow finger motion. It is crucial
that the wrist be controlled to allow the fingers and
thumb freedom. The optimal wrist position for finger
function is 25 to 30 degrees of wrist extension. To
allow maximum tactile input, dorsal splinting is pre-
ferred; however, pressure on a thin or bony wrist can
become uncomfortable and cause skin breakdown.
There are as many prefabricated and precut wrist splints
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 18-13 Antispasticity ball splint with both dorsal
and volar forearm. (Courtesy Sammons Preston Rolyan.)
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,
no matter how long it took to make it. Neoprene also
is effective if the problem is mild tone or hypotonicity.
In an older child with strong or fixed contractures, it is
not only painful, but useless to try to aggressively
obtain wrist extension. More subtle measures such as
static progressive splints or serial casting over a longer
period of time are better choices.
In general, the wrist cock-up splint is one of the
most common upper extremity splints you will make on
Splinting the Upper Extremity of a Child • 413
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
infant hinders hand-to-mouth exploration and self-
feeding. In an older child it may limit the ability to hold
a writing tool.
WRIST RADIAL DEVIATION
Sometimes this is a problem in young infants with
congenital anomalies. At times in radial “club” hand
there are other problems in the forearm. Soft splinting
of the infant, especially early on and during sleep, can
help bring the wrist to neutral. With the older infant
and toddler, a radially deviated wrist may not allow
weight bearing and is problematic for holding food,
toys, and writing instruments. Infants with milder cases
may respond well with a long thumb spica splint that
414 Part III • Therapeutic Intervention

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
EXTREMITIES
Weight bearing on extended arms is a developmental
milestone one looks for at 4 to 9 months of age because
it helps develop hand prehension skills. It is usually
not an issue in a young infant, but becomes more
important when the child begins moving and propping
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-
cates that after the application of an inhibitive weight-
bearing splint, tone changed minimally, fine motor
functional task changes were variable, and arm-hand
position improved. Subjective reports were given by
family and other caregivers; they stated that tone
decreased and function increased (Kinghorn & Roberts,
Figure 18-16 Thumb abduction supination splint
demonstrated here to aid in play activity.
1996). This suggests that function can be affected by
weight bearing. Similar splint designs have been
discussed for wrist flexion and fisted hand problems in
this chapter. (Figure 18-17).
I NDIVIDUAL FINGER CONTROL
Older children learning to point or operate environ-
mental controls or a keyboard may be dependent on
isolated finger extension. Pointing, for key pad or
keyboard selection, can mean a higher level of inde-
pendence and control. A soft neoprene splint can be
fabricated with mild tone, or the prefabricated finger
 Splinting the Upper Extremity of a Child • 415

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
good option (Figures 18-18 and 18-19). Thermoplastic
splinting may be more appropriate with greater tone.
Writing instrument or pointing stick grasp can be
assisted with splinting as well. For functional tasks such
as writing or coloring, the child’s normal pattern of
movement must be observed carefully because a splint
can easily limit the child rather than promote function.
SPLINTING FOR I NFANTS IN THE N EONATAL
I NTENSIVE CARE U NIT
population, and traditional therapeutic approaches may
not be adequate to prevent progressive deformity in the
hand of these critically ill infants.
“Medical instability, time constraints, lack of family partici-
pation in the therapeutic program, the complexity of the
treatment program, and fear of harming the infant are con-
siderations that may indicate the need for splinting as an
adjunctive therapeutic intervention. A number of factors are
particularly important in making splints for infants, including
splint alignment and padding, strap attachment, and thermo-
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,
416 Part III • Therapeutic Intervention
Figure 18-18 Index finger isolation splint in neoprene.
(Courtesy Benik Corp.)
Figure 18-19 Example of index finger isolation splint
designed to improve keyboard accuracy.
1988). First, the amount of time needed to perform an
adequate hand treatment program may be too much
for both staff and family in an NICU environment,
because both the number of critical infants and the life-
threatening nature of their condition make hand ther-
apy intervention lower on the priority scale in terms of
time. Second, the critical, medically unstable infant will
be stressed by increased handling and movement. The
infant must use the caloric input for survival and then
maturing and growing. Splinting provides positioning
without as much handling. Third, because of possible
unwillingness or inability by the family to participate in
the infant’s rehabilitation due to factors such as grief,
sibling and family issues, work schedule, and sometimes
transportation issues, splinting should be initiated early.
When establishing hand positioning and function from
the start through early intervention, these family com-
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
extremities require.
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
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
determine modification to the therapy program.
When choosing splint materials, keep in mind that
low temperature materials that are easily remodeled are
best. Remember that non-splint materials such as elas-
tomer can be used for positioning and may be better
tolerated. On the other hand, straps that are too thin or
too tight can cause severe edema. Write “Not Tight”
directly on the straps to help prevent family and staff
from overtightening (Anderson & Anderson, 1988).
Covering the entire splint with a sock or stockinette
also protects the infant from pulling off the strap or
splint and helps cushion the edges of the splint.
Splinting in the NICU is challenging and rewarding.
Attention to the needs of the critically ill infant and
overall therapy program brings the greatest benefit to
the infant. The team of physicians, therapists, parents
and family, nurses, and other medical staff combines to

provide the best therapeutic interventions in this most
complex situation.
SPLINTING FOR PEDIATRIC
ORTHOPEDIC PROBLEMS
Children generally recover much faster than adults
from orthopedic problems, and are less affected by the
amount of time spent immobilized. However, they are
much more active both during the immobilization
phase and after; therefore they often need protection
from their own activity level.
FRACTURES
Many nonoperative pediatric fractures are not even
seen by therapists because the patients are doing well
by the time they have their cast removal follow-up with
the orthopedic physician. Postoperative fractures, on
the other hand, may find their way to your clinic.
Percutanous pins and external fixators can be pro-
tected by splinting circumferentially with bivalved or
“clamshell” splinting. The zipper splint is an excellent
“after cast” splint because it is circumferential and rigid
(Figure 18-20).
Buddy taping or buddy strapping usually is effective
to encourage movement in a stiff finger after immo-
bilization. Taping stays on better, but parents or care-
givers should be instructed in how to apply it because
it does get dirty. Buddy straps are more easily removed
Figure 18-20 Zipper splint used after–forearm fracture
and postcast removal for support and protection.
Splinting the Upper Extremity of a Child • 417
for washing; the prefabricated 3-Point Products buddy
straps are soft and conforming. It can be cut down in
width for smaller hands.
FLEXOR TENDON SPLINTING IN C HILDREN
Flexor tendon injuries in children are most commonly
caused by sharp laceration (more than 50% from broken
glass) and up to 25% of tendon injuries are missed
(Osterman & Paksima, 2002). Controversy exists as to
the type of repair, material to be used, period and type
of immobilization, rehabilitation, use of tendon grafts,
and primary versus delayed repair. Cunningham and
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
postulated that the growth disturbance was related to
an absence of the mechanical force of flexion. The
treatment of postoperative flexor tendon repairs in
children is similar to the treatment in adults; however,
there are special considerations for the pediatric
population. Zone II flexor tendon repairs are the most
complicated and controversial tendon repair for chil-
dren because of multiple factors including the size of
the tendons, pulley system and digital nerve involve-
ment, age, and compliance with rehabilitation, and
postoperative protocols. In chapter 119 of Rehabilita-
tion of the Hand, the author states that the protocol for
children younger than 8 years is cast immobilization
from the humerus to the fingertips with the palm and
fingers open for exercise (elbow at 90 degrees, wrist at
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
high level of competence and should not be taken
lightly. This is another area in which therapist and
418 Part III • Therapeutic Intervention

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
subscapularis muscle. It may be released either at the
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-
tally still requires the same splinting approach. The
postoperative splint is fondly termed the “Statue of
Liberty” splint because it horizontally abducts and
externally rotates the shoulder, flexes the elbow, and
Figure 18-21 Static thumb carpal-metacarpal splint
used to stabilize thumb for strengthening activity; may be
used for handwriting activities as well.
Figure 18-23 Prefabricated anti-boutonnière splint.
(Courtesy North Coast Medical.)
holds the wrist and forearm in neutral. Postoperative
treatment protocols vary according to the surgeon’s
procedure, technique, and preferences.
Peripheral nerves can be damaged in a number of
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
to maintain flexor and extensor balance to prevent
contractures. Median nerve injury is the most com-
monly seen peripheral nerve injury in children resulting

from trauma (Birch et al., 2000). The radial nerve also
is often affected because of the intimate proximity to
the humerus. The case study at the end of this chapter
discusses the splinting approach and progress of a radial
nerve injury in a 4-year-old boy.
GENERAL CONSIDERATIONS IN
PEDIATRIC HAND SPLINTING
WEARING SCHEDULE FOR PEDIATRIC SPLINTS
The wearing schedules for splints depend on the diag-
nosis and rationale for the splint. As with adult splint-
ing, soft connective tissue responds better to low-load
prolonged stress (LLPS) than high-load brief stress
(HLBS). This has been documented time and again in
scientific papers, as well as clinical research for exercise
physiology and splint-wearing time (Austin & Jacobs,
2003; Gabriel, 1996; Hogan & Uditsky, 1998). Paul
Brand was one of the first to apply this to splinting. He
coined the term inevitability of gradualness. Dr. Brand
was a physician and missionary who worked to make a
difference in the quality of life of Indian children born
with club feet that were never treated and were limited
in mobility and social status by the time they became
adults. In treating these infants, he allowed the child to
nurse while seated in its mother’s lap as he gently
pulled the foot toward normal alignment. If the infant
looked up but continued sucking, that was where the
foot was casted; if the baby stopped sucking and started
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
of many of these infants. Flowers and Michlovitz (1988)
introduced the term total end range time (TERT)
through further research in this same area of soft tissue
adaptability. TERT is the frequency multiplied by the
duration when at end range. This also has evolved with
splinting to promote low-load prolonged stress. Three
factors play a role in deciding wearing schedules: fre-
quency, duration, and intensity of force. If the child
initially wears the splint 20 minutes three times a day,
the TERT is 60 minutes. If the intensity of force is too
low there is no advancement in joint motion; however,
it is necessary to allow the child and soft tissue to adapt
and accommodate to the splint and the stretch it is
providing. Slowly add to the wearing time by increasing
both the frequency and duration. It must be compat-
ible with the child’s and parents’ lifestyle and activities
that are appropriate. The Appendix to this chapter
includes a Splint Care Handout, which includes use,
wear, and care instructions, as well as precautions and
Splinting the Upper Extremity of a Child • 419
patient education in both English (Appendix 18A) and
Spanish (Appendix 18B). The older child or the parents
of younger children also should demonstrate inde-
pendent donning and doffing of the splint before
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
splinting, as well as decrease mouthing and chewing on
the splint.
COMPLICATIONS AND PRECAUTIONS
Most complications of splinting concern vascularity and
pressure. Symptoms of vascular insufficiency resulting
from constriction or pressure include unrelieved pain,
edema, blanching or discoloration, blistering, tingling
or numbness, no pulse, and temperature change of the
skin. Pericutaneus pins and wounds are precautions
but not contraindications for splinting. Splints and
straps should not put undue pressure on either pins or
wounds. Careful monitoring by parents or the older
child is important when pins or wounds are involved.
Not only should a splint be easy to don, but also it
must be difficult for the infant or young child to
remove. Fondly termed anti-Houdini techniques
have evolved with the need to keep children in their
splint. Toni Thompson describes two types of Houdini
children: Houdini Type I children remove the straps
and slip out of the splint; Houdini Type II children slip
out of the splint without removing any straps. Many of
the techniques may already be familiar, but they are all
worth mentioning (Box 18-3).
SUMMARY
In conclusion, when splinting the child, remember to
problem solve and prioritize the problems. The goals
of splinting vary and may be intended to promote
joint functional position or assist in holding an eating
or writing utensil. One must keep in mind the normal
configuration and architecture of the hand whether to
prevent contractures or help restore soft tissue length
after an injury. A well-designed splint should provide
the needed support or restriction without interfering
with normal exploration and movement patterns.
Children who have not experienced normal movement
patterns with grasp, release, or weight bearing may gain
new information from their environment with the use
of splints; however, sometimes the right answer is no
splint. Splinting is a science, as well as an art. Once
mastered, splinting is a great instrument to have in your
therapy toolbox when treating children. Enjoy the
journey.
 420 Part III • Therapeutic Intervention
BOX 18-3 Anti-Houdini Techniques
TYPE I: HOUDINIS WHO REMOVE THE STRAPS AND SLIP
OUT OF THE SPLINT
Figure 18-24, A: Wrap self-adhesive bandage (e.g.,
Coban) around the straps or entire forearm.
Figure 18-24, B: Wrap a 2′ length of 1/4 ″ loop Velcro
around the forearm and weave it under the
overlapping loops. When removal is attempted, it just
tightens.
Figure 18-24, C: Use a square metal ring or plastic
D-ring applied with sticky back Velcro to the proximal
end of the splint. Run the tail end of the Velcro
through it. When removal is attempted, the tail end
will not lift up.
Figure 18-24, D: Cut each strap 1″ longer than is needed
and Velcro together with sticky back hook tab that has
been made from doubling a piece of sticky back hook
on itself.
Figure 18-24, E: Make holes along the border of the
splint and use a regular or curly shoestring to tie the
splint on. Toddler shoestring holders can hold these
ties away from prying fingers and mouths. Also, the
strap is slipped through a slot that has been placed
near the edge of the splint, making strap removal
difficult.
Figure 18-24, F,G: Permanently attach one end of the
strap with a rivet or custom rivet using splint
material.
A B
Figure 18-24, H: An additional strap can be placed over
the forearm strap that attached to itself and will only
spin around the forearm, but needs to be removed to
take off other straps.
Figure 18-24, I: Covering the entire splint with a tube
sock or stockinette will make the straps more difficult
to reach.
TYPE II: HOUDINIS WHO SLIP OUT OF THE SPLINT
WITHOUT REMOVING ANY STRAPS
• Make sure borders of the splint are only one half of the
forearm thickness so that straps have the top of the
forearm to hold onto.
• Increase the curve or extension at the wrist as much as
tolerable for the goal of the splint design, as straighter
designs are easier to slip off.
• Figure 18-24, J: Fasten padding to the underside of the
straps to add friction to removal of the splint.
• Figure 18-2: More proximal joints may be immobilized
for securing the splint as well, even for a short period
while the child gets used to having the splint on.
• Mark Willey has also modified the typical thumb loop
splint by sewing on a click buckle clasp at the wrist.
• Figures 18-24, K, 18-25, 18-26: Do not forget the appeal
of the splint color or decoration. Fabricating a splint on
the child’s stuffed animal or doll can also encourage
positive results.
Figure 18-24 A–K, Anti-Houdini splinting. (See box
18-3 for legends.)
 Splinting the Upper Extremity of a Child • 421

Figure 18-24, cont’d

 422 Part III • Therapeutic Intervention

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.)
 Splinting the Upper Extremity of a Child • 423

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.
424 Part III • Therapeutic Intervention
A
Figure 18-29 A, Night splint decorated by patient. B, Night splint applied.
loops are made with a continuous loop of Thera-tubing in
the light yellow strength. The holes in the splint were
made with a Dremel tool with a round rotary blade.
Carlos’ mother was instructed in donning and doffing the
splint, as well as a daytime wearing schedule and in recog-
nizing problems with the splint. A resting hand night
splint also was fabricated because his mother stated his
hand stayed “fisted” at night (Figure 18-29).
On his next visit approximately 2 weeks later his wrist
and fingers appeared more balanced, with trace muscle
activity noted in the long extensors of the left wrist and
Figure 18-30 Second visit demonstrates maximum
effort for wrist and finger extension, improved muscle
balance, and less clawing.
B
digits (Figure 18-30). After approximately 2 more weeks,
his mother reported that Carlos had started holding light
objects in his left hand for play. At the 6-week visit the
wrist extensors were at a fair grade and some clawing was
still visible with wrist extension with effort (Figure 18-31).
At the final visit (20 weeks postoperative), Carlos was able
to use his left hand and wrist with full function, and the
radial nerve splint was discontinued (Figures 18-32 to
18-34). The night splint was advised to be worn for another
2 weeks, and thereafter only if Carlos was observed fisting
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.
 Splinting the Upper Extremity of a Child • 425

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.
426 Part III • Therapeutic Intervention
ACKNOWLEDGMENTS
Special thanks to Otto, Eric, Karl, Stefan, mom and
dad, Gloria Gogola, Trent Carlyle, Kimberly Staines,
Jean Polichino, Karen Lahvis, and the girls. Also, the
Spanish version of Appendix 18B is courtesy of A.
Galindo.
REFERENCES
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in the intensive care and special care nurseries. American
Journal of Occupational Therapy, 42(4):222–226.
Austin N, Jacobs M (2003) Splinting the hand and upper
extremity: Principles and process. Philadelphia, Lippincott
Williams & Wilkins.
Birch R, Chir F, Achan P (2000). Peripheral nerve repairs and
their results in children. Hand Clinics, 16(4):579–595.
Brand P (2002). The forces of dynamic splinting: Ten
questions before applying a dynamic splint to the
hand. In J Hunter, E Mackin, A Callahan, T Skirven,
L Schneider, L Osterman, editors: Rehabilitation of the
hand and upper extremity (pp. 1811–1817). St Louis,
Mosby.
Byron P (2002). Splinting the hand of a child. In J Hunter,
E Mackin, A Callahan, T Skirven, L Schneider, L
Osterman, editors: Rehabilitation of the hand and upper
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Cunningham MW, Yousif NJ, Matloub HS, et al. (1985).
Retardation of finger growth after injury to the flexor
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Fess EE (2002a). A history of splinting: To understand the
present, view the past. Journal of Hand Therapy,
15:97–132.
Fess EE (2002b). Principles and methods of splinting for
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Fess EE, Gettle K, Philips C, Janson J (2005). Hand and
upper extremity splinting: Principles & methods, 3rd ed.
St Louis, Mosby.
Flowers KR, Michlovitz SL (1988). Assessment and
management of loss of motion in orthopedic dysfunction.
In Postgraduate advances in physical therapy (pp 1-11).
Alexandria, VA: American Physical Therapy Association.
Gabriel L (1996). Splinting children who have
developmental disabilities. In B Coppard, H Lohman,
editors: Introduction to splinting: A critical thinking and
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Hogan L, Uditsky T, (1998) editors: Pediatric splinting:
Selection, fabrication, and clinical application of upper
extremity splints. San Antonio, TX, Therapy Skill Builders.
Kinghorn J, Roberts G (1996).The effect of an inhibitive
weight-bearing splint on tone and function: A single-case
study. American Journal of Occupational Therapy,
50(10):807–815.
Osterman L, Paksima N (2002). Flexor tendon injuries and
repair in children. In J Hunter, E Mackin, A Callahan, T
Skirven, L Schneider, L Osterman, editors: Rehabilitation
of the hand and upper extremity (pp. 1907–1913). St
Louis, Mosby.
Thompson T (2004). Strategies and techniques to enhance
wearing compliance of splints in pediatrics. Advance for
Occupational Therapy Practitioners, 17:14–15.
Van Straten O, Sagi A (2000). “Supersplint”: A new
dynamic combination splint for the burned hand. Journal
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SUGGESTED READING
Barnes KJ (1986). Improving prehension skills of children
with cerebral palsy: A clinical study. Occupational Therapy
Journal of Research, 6(4):227–239.
Bell-Krotoski J (2002). Plaster cylinder casting for
contractures of the interphalangeal joints. In J Hunter, E
Mackin, A Callahan, T Skirven, L Schneider, L Osterman,
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(pp. 1839–1845). St Louis, Mosby.
Brand P (1985) Clinical mechanics of the hand. St Louis,
Mosby.
Brand P (2002) Lessons from hot feet: A note on tissue
remodeling (1944), Correspondence from Dr. Brand to
Elaine Ewing Fess, MS, OTR, FAOTA, CHT about soft
tissue remodeling process. Journal of Hand Therapy:
Splinting Special Issue, 15:133–135.
Colditz J (2002) Anatomic considerations for splinting the
thumb. In J Hunter, E Mackin, A Callahan, T Skirven, L
Schneider, L Osterman, editors: Rehabilitation of the
hand and upper extremity (pp. 1858–1874). St Louis,
Mosby.
Colditz J (2002). Plaster of Paris: The forgotten hand
splinting material. Journal of Hand Therapy,
15(2):144–157.
Exner CE, Bonder BR (1983). Comparative effects of three
hand splints on bilateral hand use, grasp, and arm-hand
posture in hemiplegic children: A pilot study. The
Occupational Therapy Journal of Research, 3:75–92.
Fitoussi F, Mazda K, et al. (2000). Repair of the flexor
pollicis longus tendon in children. The Journal of Bone &
Joint Surgery, 82(8):1177–1180.
Glasgow C, Wilton J, Tooth L (2003). Optimal daily total
end range time for resolution in hand splinting. Journal
of Hand Therapy, 16(3):207–218.
Greenhalgh D (2000). Management of acute burn injuries
of the upper extremity in the pediatric population. Hand
Clinics, 16(2):175–186.
Keren O, Shnarch-Voda M, Barak D, Behroozi K (2003). A
therapeutic splint for hypertonic flexed elbow in upper
motor neuron diseased patients. Prosthetics and Orthotics
International, 27:63–68.
Lee M, LaStayo P, vonKersburg A (2003). A supination
splint worn distal to the elbow: A radiographic,
electromyographic, and retrospective report. Journal of
Hand Therapy, 16:190–198.
Lin SC, Huang TH, Lin CJ, Hsu HY, Chiu HY (1999). A
simple splinting method for correction of supple
congenital clasped thumbs in infants. Journal of Hand
Surgery (Br) 24(5):612 –614.
Lohman M (2001) Antispasticity splinting. In B Coppard,
H Lohman, editors: Introduction to splinting: A critical-
thinking & problem-solving approach (pp. 326–349). St
Louis, Mosby.
MacKinnon J, Sanderson E, Buchanan J (1975). The
MacKinnon splinting: A functional hand splint. Canadian
Journal of Occupational Therapy, 42(4):157–158.

Malik M (1985). Manual on static hand splinting.
Pittsburgh, AREN.
Press J, Wiesner S (1990). Prevention: Conditioning and
orthotics. Hand Injuries in Sports and Performing Arts,
6(3):383–392.
Schultz-Johnson K (2002). Static progressive splinting.
Journal of Hand Therapy, 15(2):163–178.
Shah M, Lopez J, et al. (2002). Dynamic splinting of
forearm rotational contracture after distal radius fracture.
Journal of Hand Surgery, 27A:456–463.
Sheridan R, Baryza M, Pessina M, et al. (1999). Acute hand
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.
Splinting the Upper Extremity of a Child • 427
Tomaino M (2001). Ligament reconstruction tendon
interposition arthroplasty for basal joint arthritis. Hand
Clinics, 17(2):207–221.
Willey M (2004). Modification to a pediatric thumb splint.
American Journal of Hand Therapy, 17(3):379–380.
Wilton J (2003). Casting, splinting, and physical and
occupational therapy of hand deformity and dysfunction
in cerebral palsy. Hand Clinics, 19:573–584.
Wu S (1991). A belly gutter splint for proximal
interphalangeal joint flexion contracture. American
Journal of Occupational Therapy, 45(9):839–843.
 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

EFFICACY OF INTERVENTIONS TO
ENHANCE HAND FUNCTION
Jane Case-Smith
CHAPTER OUTLINE
LEVELS OF RESEARCH EVIDENCE
CHILDREN WITH CEREBRAL PALSY
Weight Bearing on Hands
Neurodevelopmental Treatment
Casting and Splinting
Constraint-Induced Movement Therapy
Surgical and Medical Intervention
CHILDREN WITH DEVELOPMENTAL COORDINATION
DISORDER OR MILD DISABILITIES
Cognitive Orientation to Daily Occupational
Performance
Occupational Therapy Approaches with Preschool
Children
INTERVENTIONS TO IMPROVE HANDWRITING
Instructional Approaches
Occupational Therapy Approaches
SUMMARY
Occupational therapists have assumed leadership roles
in developing interventions to enhance children’s fine
motor skills. As leaders in the development of practice
models and strategies to improve hand function, occu-
pational therapists also have researched the effective-
ness of these interventions on children’s function. This
chapter describes occupational therapy (OT) and other
discipline research that has examined hand function
intervention outcomes and synthesizes current knowl-
edge on the effectiveness of these interventions.
Chapter 19
LEVELS OF RESEARCH EVIDENCE
The studies described in this chapter are categorized
according to their level of research evidence to assist
the reader in interpreting the importance of the find-
ings. Phillips and co-workers (1998) have categorized
research designs into five levels of research evidence
(Table 19-1). These categories have been adopted by
professional organizations that have synthesized research
reports into summaries of research evidence (Butler &
Darrah, 2001; Law, 2002). The levels of research evi-
dence define the confidence that professionals can place
in a study’s findings to be valid or true. Randomized
clinical trials (RCTs) are categorized as Level I research
evidence and have high rigor and validity. When a Level
I study produces positive effects, it provides strong
evidence that an intervention is effective. Randomization
increases the probability that samples are equal at the
beginning of the trial, and therefore, provide confidence
that if the samples differ after intervention, change is
related to the intervention. RCTs also use “blinding”
when testing, which means that both the researchers
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-
mental group.
In Level II research, an experimental group is com-
pared with a control or comparison group, but a con-
venience sample rather than randomized sample is
used. As a result, it cannot be assumed that the samples
are equal and the results can be influenced by initial
differences in the samples. One way to improve non-
randomized sampling is to use matched samples, ensuring
that the groups are equivalent for certain character-
istics. Small samples may be more equivalent if matched
433
434 Part III • Therapeutic Intervention

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

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.
 Efficacy of Interventions to Enhance Hand Function • 437

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
Authors Evidence Sample Intervention Measures Findings

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
438 Part III • Therapeutic Intervention

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
Authors Evidence Sample Intervention Measures Findings

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.
 Efficacy of Interventions to Enhance Hand Function • 439

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
Authors Evidence Sample Intervention Measures Findings

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
440 Part III • Therapeutic Intervention

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
Authors Evidence Sample Intervention Measures Findings

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
that hypertonicity is decreased with weight bearing,
allowing for improved active elbow, wrist, and finger
extension. In addition, the Barnes studies show improve-
ments in hand function. These findings have limited
validity and should be confirmed by more rigorous
study.
N EURODEVELOPMENTAL TREATMENT
The effectiveness of NDT has been researched for the
past 30 years. A number of these studies have used true
experimental designs (Level I); however, the majority
have used quasi-experimental and pre-experimental
designs (Levels II to IV) with small samples of conve-
nience. In 2001, an extensive review of NDT efficacy
research sponsored by the American Academy for
Cerebral Palsy and Developmental Medicine was pub-
lished in Developmental Medicine and Child Neurology.
In this comprehensive review, Butler and Darrah
(2001) synthesized the results of 21 studies. They
concluded that 86 of 101 results (from 21 studies)
were neutral or found an advantage for the comparison
group; only 15 results favored NDT.

“With the exception of immediate improvement in dynamic
range of motion, there was not consistent evidence that NDT
changed abnormal motoric responses, slowed or prevented
contractures or facilitated more normal motor development or
functional motor activities” (Butler & Darrah, 2001, p. 789).
A historic perspective of NDT research that included
hand function outcomes is helpful in understanding the
effects of this approach.
Two early studies, Carlsen (1975) and Scherzer,
Mike, and Ilson (1976) found positive results when
effects of NDT were compared with a contrasting
therapy. Carlsen reported greater gross motor improve-
ments in the NDT group, but fine motor improvement
did not differ when NDT was compared with func-
tional therapy. Scherzer and co-workers reported
improvement in physiologic function, but fine motor
skills were not specifically measured. Studies in the
1980s examined gross motor and social outcomes of
NDT with children with CP. These studies included
several clinical trials that did not support the benefits of
NDT (Hanzlik, 1989; Palmer et al., 1988).
Small Sample Studies and Short-Term Effects
A number of small sample or single subject studies have
examined the short-term effects of NDT. Because the
aims of NDT are to influence the child’s muscle tone
and improve the quality of movement, short-term
effects should be observed immediately after treatment.
One OT study by DeGangi, Hurley, and Linscheid
(1983) examined the short-term effects of NDT using
a single subject design with four subjects. Each child
received eight treatments consisting of 25 minutes of
NDT and 25 minutes of nonspecific play. The chil-
dren’s performance on specific goals was measured
from videotapes made immediately after NDT or play.
The repeated measures included postural tone, weight
shift and weight bearing, transition movements, and
functional skills. Consistent improvement after NDT or
play was not observed for any of the children. Although
this study validated use of qualitative measures of
movements, it did not validate the short-term effects
of NDT.
Lilly and Powell (1990) studied the effects of NDT
using two children with spastic diplegia, 27 and 32
months old. These authors applied play and NDT,
alternating the two interventions (Level III study). To
relate intervention effects to function, Lilly and Powell
measured components of dressing performance. Among
the measures was bilateral hand use. Performance did
not differ after play or NDT. The authors noted that
their results concurred with those of DeGangi and
colleagues (1993) in that neither study showed sig-
nificant differences between the effects of NDT and
those of play activity on functional activity.
Efficacy of Interventions to Enhance Hand Function • 441
DeGangi (1994) implemented a case study design
(level IV) to examine the short-term effects of NDT.
DeGangi was interested in the specific effects of NDT
and argued that measuring the immediate effects was
an important step before large clinical trials. She
believed that single subject designs were appropriate
and useful for examining NDT effects because individ-
ual children vary in their performance and their limita-
tions. DeGangi (1994) provided a detailed description
of the goals and the techniques used to reach those
goals. Successful performance on each goal as observed
by the parent and the therapist was counted across
observations. Of the three cases documented, one
focused on fine motor performance in a 6-year-old
child with right hemiparesis (the other cases focused on
other domains, such as feeding). The goals included
use of right hand as an assist to stabilize objects or
materials, improve visual motor skills, and bilateral
skills such as buttoning, zipping, and stringing beads.
After 8 weeks of twice-a-week hour-long NDT ses-
sions, the child’s performance improved but remained
inconsistent.
In another study that examined the short term
effects of NDT, Fetters and Kluzik (1996) compared
the effects of NDT with practice of reaching on eight
children with spastic CP. Each child received 5 days
of NDT and 5 days of practice. Kinematic analysis of
reach was used before and after each intervention to
measure smoothness and speed of reaching move-
ments. Although there were no difference between
NDT and practice of reaching, when intervention time
periods were combined and pre- and post-differences
analyzed, all children improved in reaching speed and
smoothness.
These short-term small sample studies do not
support positive effects of NDT when compared with
other interventions; that is, they found that NDT did
not result in greater positive effects than play or skill
practice. However, these Level III to IV studies should
not be considered conclusive; primarily, small sample
trials develop instrumentation and methodologies for
larger-scale studies.
Clinical Trials of Neurodevelopmental Treatment
In the past 20 years, clinical trials have investigated the
effects of OT using an NDT approach on hand function
outcomes. Two studies by Law and colleagues researched
the effects of NDT OT and casting on children with
CP. The first study (Law et al., 1991) used a 2 × 2
factorial design that examined the effectiveness of
intensive NDT and casting separately and combined.
The sample comprised 79 children (73 completed the
study; 18 months to 8 years) from three treatment
centers in Ontario, Canada. All children had CP that
included spasticity of wrist and hand. Children with
442 Part III • Therapeutic Intervention
fixed contractures or severe developmental disability
were excluded.
The intervention period was 6 months. Children
either received “intensive” NDT OT, defined as twice
a week (90 total sessions) with a 30-minute-per-day
home program or they received “regular” NDT occu-
pational therapy, defined as once a week (sometimes
less) with a 15-minute home program to be imple-
mented three times a week. Children who received
casting wore a bivalved inhibitive cast at least 4 hours a
day. The cast immobilized the wrist in extension and
did not include thumb or fingers. Details about the
treatment were not provided. The measures included
the Peabody Developmental Motor Scales-Fine Motor
(PDMS-FM), the Quality of Upper Extremity Skills
Test (QUEST), and range of motion of the wrist.
The children were randomized into one of four
groups: Intensive NDT plus casting, regular NDT plus
casting, intensive NDT, and regular NDT without cast-
ing. Measures were taken at 6 months to capture imme-
diate effects and 9 months to examine the long-term
effects. Although the design called for 48 NDT sessions
for the intensive NDT group, the mean number of
sessions was 29, which was almost three times higher
than the 11 sessions the regular NDT group received.
Hand function as assessed by the PDMS-FM did not
differ significantly among the groups at the 6- or 9-
month measure. However, using age equivalent scores
on the PDMS-FM, changes for all of the groups
appeared to be clinically significant (5.26 months at the
6-month measure and 6.33 months at the 9-month
measure). The qualitative measure of arm and hand
movements, the QUEST, was significantly different for
the children who wore casts with NDT when compared
with those who received NDT only. This difference was
more significant at 6 months (p = 0.03) than at 9
months (p = 0.10).
In a follow-up regression analysis, Law and co-
workers (1991) found that positive outcomes related to
parents’ estimate of their understanding, comfort, and
compliance with the home program and the age of the
child. Children who were younger and whose parents
estimated compliance as high had better outcomes.
This finding suggests that, when possible, therapists
should initiate therapy at young ages and encourage
parents’ participation in home programs. These
researchers concluded that casting with regular NDT
significantly improves the quality of upper extremity
movements. These effects are only partially sustained
over time.
Differences in the intensity of intervention did not
produce clinically or statistically significant differences
in performance. One consideration in interpreting
these results is that not all children in the intensive
therapy group attended intervention sessions according
to the design frequency. Intensive therapy may not be
practical for many families. The inclusion of casting
appears to be critical as only children who wore casts
demonstrated improved quality of movement.
Law and colleagues (1997) completed a second
study with similar goals. A primary difference was that
the sample was younger (18 months to 4 years). Other
than age, the criteria for the sample were the same. All
of the subjects had moderate to severe upper extremity
involvement with wrists held in a flexed position. The
children did not have significant cognitive impairments
as judged by their therapists. The final sample com-
prised 50 children who were randomized into two
groups. A crossover design was used, with each group
receiving a period of intensive NDT with casting and a
period of regular or functional OT with no casting. The
children were placed into one intervention for 4
months followed by a 2-month washout period, then
were placed in the other intervention for 4 months. In
the intensive therapy plus casting, the therapists used
NDT principles of facilitation and handling to improve
quality of movement. The casts were the same as in the
previous study. The functional OT program focused on
task analysis and facilitating skills needed for self-care,
feeding, and play. NDT was provided twice a week
for 45-minute sessions with a 30-minute daily home
program and functional OT was provided once a week
for 45 minutes. Outcomes were measured using the
PDMS-FM and the QUEST.
Law and others (1997) maintained detailed records
of therapist adherence to the treatment protocol,
child’s attendance, and parents’ report of implement-
ing the home program. The goals for therapy using
NDT were based on changing impairments and
improving quality of movement. The goals for func-
tional OT were more global and functional and included
improvement in self-care and play skills. Analysis of
their findings demonstrated no differences in PDMS-
FM scores when children received intensive NDT and
casting versus when they received functional occupa-
tional therapy. In addition, QUEST scores did not
differ by treatment as they had in the earlier study.
When differences between pre- and post-tests on the
PDMS-FM and QUEST for each group were exam-
ined, they were found to be both statistically and
clinically significant.
This study suggests that therapy designed to improve
functional goals is as effective as therapy designed to
improve quality of movement. How children achieve
the goal may not be as important as the goal achieve-
ment itself. In functional occupational therapy, the
therapist does not work to enhance motor components
(e.g., a missing motor skill such as thumb opposition or

active supination), unless it interferes with skill per-
formance. These critical foundational motor patterns
(e.g., object release or active supination) are addressed
in a functional context (e.g., drinking from a glass).
NDT emphasizes quality of movement and facilitating
normal patterns of movement; however, movements
are practiced in the context of functional activities.
Therefore, NDT and functional therapy may use the
same activity with different emphases and different
goals. This core similarity may produce similar out-
comes. In summary, functional OT and intensive NDT
both facilitated improved skills, and twice-a-week NDT
did not result in greater skill achievement than once-a-
week functional treatment.
CASTING AND SPLINTING
Upper Extremity Casting
Occupational therapists using NDT often advocate
methods for inhibiting abnormal muscle tone and
abnormal movement patterns. These inhibitory meth-
ods (e.g., positioning, casting, and splinting) are cou-
pled with handling to facilitate specific movement
patterns. They are sometimes applied to maintain inter-
vention effects such as increased ROM. Use of casting
and splinting as an adjunct to NDT has been examined.
Casting an extremity is believed to inhibit spasticity and
improve ROM because it holds the muscle in a
lengthened state. The inhibition is believed to be the
result of neutral warmth and constant pressure. Case
studies (Smith & Harris, 2002; Yasukawa, 1990) in
which upper-extremity casting is applied for a short
period of time (e.g., weeks) have reported improved
ROM and function. Smith and Harris applied a
bivalved inhibitive elbow cast to a 51/2-year-old with
spastic quadriparesis. They found that casting reduced
his elbow spasticity, increased facility in dressing, and
increased the child’s tolerance for weight bearing.
Yasukawa used a sequence of three phases of casting
with a 15-month-old infant who had spastic hemi-
paresis. In the first phase, the involved arm was serial-
casted for 4 weeks to improve ROM; then in a second
phase, the uninvolved arm was casted to encourage
active usage of the involved arm. In a third phase, a
bivalved cast was used at night. These casting methods
were applied over 11/2 years and resulted in increased
scapular stability, increased shoulder flexion, and
improved use of the involved arm during bilateral tasks.
Cruickshank and O’Neill (1990) applied two types
of casts and splints to an older child (11 years) with
spastic quadriparesis (Level IV study). When a plaster
cast was applied, elbow ROM improved. When a fiber-
glass cast combined with a plastic hand splint was
applied, elbow ROM decreased. The authors inter-
Efficacy of Interventions to Enhance Hand Function • 443
preted the latter negative findings to relate to problems
in stretching spastic muscles over three joints, to using
fiberglass, which is more pliable than plaster (therefore,
allowing some motion), or to lack of natural warmth in
fiberglass compared with plaster.
The effects of wearing a cast for 48 hours on quality
of movement, ROM, and strength in an 8-year-old
child were examined in a study by Tona and Schneck
(1993). The child’s performance was videotaped before
and after the cast was applied. Their findings demon-
strated a significant reduction in spasticity on the first
day that the cast was removed. However, in subsequent
days, spasticity returned to baseline levels. The authors
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
endure, the authors recommended that longer use of
casting be considered. For example, a bivalved cast can
be applied at night and periodically during the day.
In an Australian study, the effects of upper extremity
casting were studied using a sample of 11 children with
hemiparesis or quadriparesis CP, 5 to 18 years old
(Copley, Watson-Will, & Dent, 1996). The children
were casted 4 to 6 weeks and immediately after casting,
ROM increased and muscle tone decreased. An
intensive post-casting program was then implemented.
Six months post-casting, nine clients had maintained at
least 50% of initial gains in passive or active range. Tone
reduction was maintained in seven clients, and func-
tional goals were either fully or partially achieved by 10
clients (Copley et al., 1996).
In summary, in these Level IV studies, casting the
arm appears to reduce spasticity and improve ROM for
a short period. Long-term effects have not yet been
determined through research. Long term, regular use
of a bivalved cast may be needed to sustain the effects.
Reduction of spasticity does not necessarily imply
improved function, as the arm may remain weak or
coordination may remain poor despite improved ROM.
Functional outcomes, which were rarely measured in
the studies described, should become an emphasis in
future studies of casting effects.
Splinting
Splints have been designed to reduce hypertonicity
and improve function in children with CP. Exner and
Bonder (1983) evaluated three different splints on a
group of 12 children using a counterbalanced research
design. Each of the splints had significant positive
effects. The orthokinetic and MacKinnon splints demon-
strated a greater effect than the short opponens; how-
ever, the former are rarely used in practice today.
Although the short opponens was less effective in
improving grasping skill, at present it is commonly
444 Part III • Therapeutic Intervention
applied on children with CP. The short opponens splint
holds the thumb in opposition to the fingers and may
be made of neoprene or thermoplastic materials.
Reasons for its frequent use may relate to its appear-
ance, ease of use and comfort.
The effectiveness of the short opponens splint was
evaluated by Goodman and Bazyk (1991) using a 4-
year-old child with moderate spastic quadriparesis. The
volar splint of thermoplastic materials positioned the
thumb in opposition by supporting it at the thenar
eminence. Measures included active range of motion,
grip strength, and pinch strength, dexterity, and pre-
hension patterns. A 4-week baseline phase was followed
by a 4-week intervention phase in which the child wore
the splint for 3 hours in the morning and 3 hours in
the evening. Using visual analysis of graphed data,
improvements were reported in ROM, dexterity, and
quality of movement. Changes in strength were not
observed. Reid and Sochaniwskyj (1992) examined the
effects of a hand positioning splint on arm and hand
movements using a sample of 10 children with CP
(Level II study). Analysis in three dimensions of reach-
ing path length, movement latency, movement time,
average velocity, and movement units recorded no
significant differences when the splint was or was not
worn. Although group differences were not significant,
a number of the children demonstrated improved
performance on a visual motor test when wearing the
splint.
The research on splints and casts is inconclusive
given inconsistent results and weak research designs
(primarily Level IV). Despite lack of rigorous studies,
Teplicky, Law, and Russell (2002) concluded from a
review of the research on splinting and casting, that
casting consistently increases ROM. Whether or not
the increased ROM equates to improved function is
less clear. The effects of splinting are equivocal, with
limited evidence that splinting improves hand function.
In cerebral palsy, function is affected by limited
strength, abnormal muscle tone, impaired sensation,
difficulty in coordinating movements together, and in
some children, limited cognitive ability. Intervention
targeting one impairment may or may not improve
function given that multiple systems contribute to func-
tional performance (including sensory and cognitive).
To confirm the effects of casting and splinting, large
sample experimental design studies are needed.
CONSTRAINT-I NDUCED MOVEMENT THERAPY
The theory for constraint-induced (CI) movement
therapy is built on the concept of learned nonuse.
Learned nonuse is hypothesized to occur after neuro-
logic injury (DeLuca et al., 2003). After a neurologic
insult, when an individual attempts to move the
involved extremity and fails, he or she learns ways to
function using the uninvolved extremity and learns to
compensate using only one hand. With nonuse, the
ability of the involved extremity to move becomes per-
manently impaired and the sensorimotor cortex asso-
ciated with arm and hand movement actually shrinks.
In CI therapy, use of the nonaffected extremity is
restrained such that the individual is forced to use the
more affected extremity to accomplish functional tasks.
Researchers have defined how constraint-induced
movement therapy, which was developed for adults, has
been modified and used successfully with children
(Gordon, Charles, & Wolf, 2005). The approach involves
restraint of the noninvolved extremity using a sling,
sometimes a cast, and engaging the child in activities
with his or her involved arm 6 hours a day (for 10 or
more days). Generally groups of 2 to 3 children partici-
pate in therapist-led activities. Toys and activities are
selected that can be successfully completed with the
involved hand. The activities are graded from simple to
more complex and can include board games, card
games, manipulatives, puzzles, arts and crafts; each
elected to encourage repetition of hand movements
and skill building (Gordon et al, 2005). Families are
encouraged to engage the child in bimanual fine motor
activities at home (without the sling).
The original evidence for the effectiveness of CI
therapy was based on nonhuman primate research.
After positive results with primates, it was then used
with adults who had hemiparesis as a result of a cerebral
vascular accident (Taub et al., 1993) and was first
introduced for potential use with children in 1995
when Taub and Crago suggested that children may
benefit from this intervention. A series of case studies
and single subject designs were implemented in the late
1990s and early 2000s to investigate the effect of CI
therapy with children, and since 2003, two experi-
mental studies have been published.
Case Studies-Single Subject Designs
Crocker, MacKay-Lyons, and McDonnell (1997)
applied a single subject design (ABA) (Level III) to
investigate the efficacy of CI therapy (which they termed
forced use therapy) with two children with hemiparesis.
They specifically selected children who used their
involved arm as an assist and did not have major
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-
week study. After a 2-week baseline period, the less
involved arm was fitted with a custom resting splint
that was worn most of the waking hours for 3 weeks.
Measures were taken 2 weeks after CI therapy and 6
months later. One of the children did not comply with
wearing the splint; therefore, results for only one child

were reported. Specific movement patterns were counted
during a 15-minute play session. In addition, the
parents kept logs of how often the involved hand was
used in a finger feeding task. The results were graphed
for analysis. Significant improvements were found in
the use of the more involved hand for grasp and release,
sensory exploration, and push-pull. When all involved
hand movements were combined, they more than
doubled from baseline to 2 weeks after CI therapy. This
level of hand use was sustained at a 6-month follow-up
assessment.
Charles, Lavinder, and Gordon (2001) researched
the effect of CI therapy on three school-aged children
with hemiparesis. Each wore a cotton sling on the less
affected arm, whereas the researchers encouraged use
of the affected arm through play and functional activ-
ities 6 hours a day. After 14 days of CI therapy, the
three children demonstrated improved performance in
manual dexterity, sensory discrimination, and bilateral
coordination.
Two additional case studies of children using CI
therapy have been reported (DeLuca et al., 2003;
Pierce et al., 2002). DeLuca and co-workers reported a
case study of a 15-month-old girl who had incurred a
grade IV intraventricular hemorrhage and exhibited
right hemiparesis. For a 2-week period, the girl wore a
full arm bivalved cast on her unaffected arm except for
an occasional removal for cleaning and ranging. A
6-hour intervention was implemented daily by a grad-
uate student. In addition, the child received 4 hours
of physical therapy each week. During the 6 hours of
intervention, the child was encouraged to move her
affected arm and was reinforced with praise. Measures
given at the beginning and end of intervention
included the PDMS-FM, a test of pediatric motor
activity level (PMAL), and a Toddler Arm Use Test
(TAUT). The PMAL is a semistructured interview
administered every other day to the child’s primary
caregiver. It obtains systematic data about 22 arm–
hand functional activities. The TAUT is scored from a
videotape. Specific movements of the affected hand are
counted in 22 tasks/play activities. The PDMS-FM
scores improved significantly. The parents reported that
the child’s use of the involved arm improved from
“poor quality of use” to “moderate quality of use.”
Before intervention the child did not use her more
affected arm on any of the free choice tasks; after
intervention, she used the more affected arm sponta-
neously in 50% of the tasks.
A second intervention was implemented 5 months
after the first. The second period was carried out for 21
days and included 6 hours of intervention each day.
The focus of intervention was refinement of hand
movement to improve performance in play and func-
tional activities. Scores on the PMAL and TAUT again
Efficacy of Interventions to Enhance Hand Function • 445
improved. The participant used her more affected
extremity in 100% of free choice trials. In summary, this
child changed from no spontaneous use of her affected
arm and hand to regular and spontaneous use after the
second intervention. The authors suggest that short,
intensive periods of intervention should be considered
as an effective method for improving function.
Clinical Trials
Two randomized clinical trials of CI therapy have been
completed. Willis and others (2002) implemented a
study using 25 children with hemiparesis. A crossover
design was used. A plaster cast was applied to the
unaffected arm of the treatment group and was not
removed for 1 month. The control group received no
treatment. Fine motor skills of both groups were meas-
ured using the PDMS-FM before and after interven-
tion. At 6 months after the first intervention the
control group (N = 10) received the intervention and
the group previously casted served as a control. For the
first intervention period, changes in PDMS-FM scores
were significantly different, with gains by the inter-
vention group much higher than gains by the control
group. These changes were sustained when measured
6 months later. The second group (who began CI
therapy at 6 months) also made significant gains with
intervention. Parents globally reported improved use of
the affected arm. Several children did not tolerate the
casts and the parents asked that they be removed.
Taub and co-workers (2004) also completed a
randomized trial (Level I) using 18 children. The CI
therapy involved two components. The children in
the intervention group were casted and the cast was
bivalved for easy removal weekly. The intervention
group also received 6 hours of therapy each day, imple-
mented by occupational and physical therapists. Fine
motor and daily living skills were shaped using thera-
peutic principles. The two measures, PMAL and
TAUT, were reported earlier in the description of a case
study by these same authors.
The children who were casted improved significantly
on the parent interview (rating both the amount of use
and quality of use) and also improved significantly on
the TAUT. Follow-up evaluation (using the PMAL)
indicated that the gains were sustained over time. Taub
and colleagues (2004) concluded that the CI therapy
intervention produced “large improvement in the use
of the more affected extremity.” The children gained
9.3 new motor behaviors in a 3-week therapy period. A
critical therapeutic factor appears to be the concen-
trated extended nature of training conducted for many
hours daily over consecutive weeks. The authors discuss
the feasibility of concentrated doses of therapy. Because
6 hours of therapy each day is not reimbursed, not
practical for busy families, and not feasible for certain
446 Part III • Therapeutic Intervention
children, research studies using less intensive therapy
schedules are needed.
In summary, virtually all of the studies of CI therapy,
including two Level I studies, demonstrate its effec-
tiveness in promoting hand function in children with
hemiparesis. This therapy requires “forced,” intense
practice of the involved extremity in various functional
tasks. Most of the children appear to tolerate the
casting or splinting procedures; the primary limitation
appears to be in applying the intensive therapy schedule
of 4 to 6 hours per day. Such a schedule is difficult for
families and therapists alike, but may be feasible to
implement on a short-term basis.
SURGICAL AND M EDICAL I NTERVENTIONS
A number of surgical and medical procedures are
applied to decrease spasticity and improve function in
children with CP. Almost universally, these medical
procedures are followed by occupational and physical
therapy services (Dudgeon et al., 1994; Mittal et al.,
2002a). Although most often these procedures are
used to reduce lower extremity spasticity, they are
sometimes used to reduce upper extremity spasticity.
The effects of selective posterior rhizotomy, intrathecal
baclofen, and botulinum toxin on functional hand skills
in children with CP have been investigated using
cohort research designs (Level IV).
Selective Posterior Rhizotomy
This surgical procedure was originally designed to
reduce lower extremity spasticity in children with CP or
head injury. However, surgeons discovered that selec-
tive posterior rhizotomy (SPR) can have “suprasegmental
effect” (i.e., change above the segmental spinal cord
level of the cut nerve roots that affects upper extremity
spasticity and function). Several studies have measured
the effects of SPR on upper extremity and self-function
(Dudgeon et al., 1994; Loewen et al., 1998; Mittal et
al., 2002a,b). All of these studies are Level IV cohort
studies without a comparison group. Loewen and
others (1998) measured the effects of SPR on 37 chil-
dren (mean age = 4.1 years) in the United Kingdom.
The children were assessed using the QUEST and the
Functional Independence Measure for Children
(WeeFIM) before their surgery and 1 year after surgery.
During this year, the children continued to receive
their regular OT services. The mean improvement on
the QUEST was 3.2 (P = 0.001) and on the WeeFIM
was 11 (P = 0.001). These gains were clinically
significant according to the parents who validated them
in interviews. Dudgeon and co-workers (1994) also
analyzed changes in self-care of children with spastic
diplegia and quadriplegia after SPR. All children
received physical and occupational therapy during the
follow-up period. This sample of 29 children was
evaluated at 6 and 12 months after SPR. Self-care as
measured by the Pediatric Evaluation of Disability
Inventory (PEDI) improved in the children with
spastic diplegia, but not in the children with quadri-
paresis. In the latter population, upper extremity
function did not consistently improve.
Fine motor outcomes of SPR on children with
spastic CP were the focus of a Canadian study by Mittal
and co-workers (2002a). These researchers examined
the long-term effects of SPR using the PDMS-FM
before and after surgery, and then 1, 3, and 5 years after
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
occupational and physical therapy. OT was provided
once a week and focused on trunk control, positioning,
fine motor and self-care skills. The final sample com-
prised 45 of 70 eligible patients (41 in the second
study). After SPR, the children demonstrated statisti-
cally and clinically significant gains on both the PDMS
and the PEDI that were maintained at 3 and 5 years.
When the children were categorized according to the
severity of their disability, more mildly involved chil-
dren made greater gains. Self-care scores improved at 1
and 3 years, then stabilized between 3 and 5 years.
Therefore, Mittal and co-workers’ (2002a,b) results
support those of Loewen and colleagues (1998) that
important improvements in self-care are derived from
SPR, and children with milder disability make greater
gains after surgery. In contrast to Dudgeon and co-
workers (1994) fine motor skill also improved after
SPR. Steinbok (2001) reviewed published outcomes of
SDR for treatment of spastic CP. He concluded that
given moderate level evidence confirms significant
improvements in self-care and fine motor skills that
appear to be sustained over time.
Intrathecal Baclofen and Botulinum Toxin
In a descriptive report, Von Koch and others (2001)
compared SPR results to those obtained using intrathe-
cal baclofen. Intrathecal baclofen has a similar purpose
to SPR (i.e., to reduce spasticity). Instead of cutting
selective spinal nerves, baclofen is a synthetic gamma
aminobutyric acid (GABA) that reduces excitatory
synaptic transmission. This action on the spinal cord
relieves spasticity. Intrathecal baclofen is administered
using a permanent pump that is implanted into a sub-
cutaneous pocket in the anterior abdominal wall.
Although intrathecal baclofen is used most often to
reduce spasticity of the lower extremities, it can be used
to reduce spasticity of the upper extremities. Albright
and co-workers (2003) examined the effects of intrathe-
cal baclofen on 49 children. Spasticity was measured
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
increase in baclofen. Functional measures were not
used in this study and inclusion of OT as an adjunct to
baclofen was not reported.
Botulinum toxin (BOTOX) also has been used to
reduce spasticity in children with CP. BOTOX is injected
in muscles and produces a graded and reversible
relaxation of overactive muscles by blocking the release
of the neuromuscular transmitter acetylcholine. These
treatments have evolved over time and at present
higher doses are given and more muscles are injected.
BOTOX has been shown to reduce spasticity for 3 to 4
months. It is injected into specific muscles and only
works on those muscles. Neurosurgeons have indicated
that occupational and physical therapy after SPR is of
critical importance to achieve functional change, since
movements are less restricted now because of reduced
spasticity (Gaebler-Spira & Revivo, 2003). BOTOX
treatment is repeatable if it is successful. Wallen,
O’flaherty, and Waugh (2004) examined the functional
outcomes of BOTOX with a focus on upper extremity
movement. A convenience sample of 16 children with
CP (2 to 12 years old) were assessed at 2 weeks and 3
and 6 months after injections. During this period
regular OT was continued. In addition, electrical stim-
ulation of specific muscles was applied. The measures
included functional performance (Canadian Occupa-
tional Performance Measure), goal attainment scales,
an assessment of upper extremity function, ROM, and
a muscle tone scale. The children demonstrated sig-
nificant improvement in functional performance and on
their goals; however, upper extremity function and
ROM did not improve. Muscle tone was initially
reduced but returned to its original state by 6 months.
This study suggests that BOTOX can improve func-
tional skills, but may not improve upper extremity
movement as measured by a qualitative assessment.
SPR, intrathecal baclofen, and BOTOX effectively
reduce spasticity using different physiological mecha-
nisms. SPR results in a permanent change; in contrast,
the effects of intrathecal baclofen and BOTOX fade
over time and these medications must be readminis-
tered to continue to receive a benefit. Each treatment
has been shown to improve upper extremity function
and by extension to improve self-care. In the reviewed
studies, children received occupational and physical
therapy after the medical procedures. These rehabili-
tation services appear to be instrumental in helping
children make functional gains once muscle tone is
reduced and flexibility increased. However, few studies
have reported hand function improvement and more
substantial evidence is needed to support these treat-
ments and to recommend them with confidence as a
method for improving a child’s hand function.
Efficacy of Interventions to Enhance Hand Function • 447
CHILDREN WITH
DEVELOPMENTAL COORDINATION
DISORDER OR MILD DISABILITIES
Children with developmental coordination disorders
(DCDs) or dyspraxia form another group of children
who typically have delays in hand function and who
frequently receive OT services. Unlike children with
CP who have difficulty with basic movements such as
grasp and release, children with DCD generally have
functional movement patterns but have difficulty with
visual motor integration, bilateral coordination, rapid
alternating movements, sequences of movement, and
precise manipulation. This section describes efficacy
studies of children who have basic hand skills (i.e.,
reach, grasp, release) but demonstrate difficulties inte-
grating fine movements with sensory information to
perform the higher levels of visual motor skills, manip-
ulation, and bilateral coordination (Table 19-3). In
children with DCD (this term encompasses dyspraxia
for purpose of this chapter), daily living skills, such as
fastening buttons and zippers, tying shoelaces, and
handwriting are difficult to learn, may require excessive
time to perform, or may be poorly performed. A variety
of approaches have been used with children who have
DCD including cognitive orientation to daily occupa-
tional performance, sensorimotor interventions, and
practice of functional activities. This section describes
efficacy studies of OT approaches to DCD in which
hand function outcomes are a primary focus. Sensory
integration practice models are not described here, as
reviews of sensory integration efficacy have been pub-
lished elsewhere (Mulligan, 2003; Parham & Mailloux,
2005; Vargas & Camilli, 1999) and generally the aim of
sensory integration treatment is to enhance integration
of foundational perceptual-motor functions (e.g.,
motor planning, visual perception, bilateral integration,
and sequencing).
COGNITIVE ORIENTATION TO DAILY
OCCUPATIONAL PERFORMANCE
The originators of Cognitive Orientation to Daily
Occupational Performance (CO-OP) recognized that
cognition is important to the acquisition of occupa-
tional skills (Polatajko et al., 2001). In CO-OP, thera-
pists assist children in developing cognitive strategies to
improve their daily living skills. In contrast to many
other OT approaches that emphasize sensorimotor
activities and practice to gain skills, CO-OP uses a
verbal approach to help children solve problems. The
focus is to help the child learn to problem solve a motor
task and learn strategies for accomplishing a motor task
448 Part III • Therapeutic Intervention

Table 19-3 Research studies examining the efficacy of interventions to enhance hand
function in children with developmental coordination disorders

Level of
Authors Evidence Sample Intervention Measures Findings

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,
the child selects goals that he or she would like to
accomplish. The child’s performance is assessed and the
therapist determines what problems interfere with task
achievement (e.g., the child may have difficulty with
motivation, task knowledge, or performance). Then
the therapist and child together develop a plan or strat-
egy for accomplishing the task. Children are encour-
aged to talk their way through an activity. A number of
facilitating strategies can be introduced, including
altering body position, focusing on sensory aspects of
the task, and attending to specific parts of the task. The
child learns to self-evaluate so he or she can adapt the
strategy or revise it when applying it again. The goal is
that the child learns a strategy that results in success
and that he or she can use independently in another
situation.
The efficacy of CO-OP has been investigated in
small sample studies. Polatajko and others (2001)
reported a Level IV study of one aspect of CO-OP,
Verbal Self-Guidance. Ten children participated in 13
one-on-one sessions in which they were taught to use
verbal self-guidance to accomplish specific activities.
The children were taught to develop goals and strate-
gies to achieve specific activities. Most activities
involved multiple steps of sequenced bilateral manip-
ulation (e.g., making cookies, cutting, writing, key-
boarding). In addition, specific motor skills were assessed
using the Developmental Test of Visual Motor
Integration (VMI) and the Test of Motor Impairment
(TOMI). All of the children improved in the activities
that they had targeted and 9 of 10 met the performance
criteria established. Small changes in motor skills as
measured by the VMI and the TOMI were not statis-
tically significant. The effect size for the VMI was small
(d = 0.16) and for the TOMI was moderate (d = 0.62).
Given positive results from their pilot studies, Miller
and co-workers (2001) completed a randomized clini-

cal trial of CO-OP (Level I). Twenty children with
DCD, aged 7 to 12 years, were randomly assigned to
one of two groups, CO-OP or regular therapy. The
children had normal intelligence and the diagnosis of
DCD as determined by an occupational therapist. In
the 10 sessions of CO-OP, the children and therapist
established goals and developed strategies to reach
those goals. The therapists taught the children to use
self-talk and to develop strategies to solve motor
problems. Verbalization by both the child and the
therapist was used to guide performance. The contrast
group received regular therapy in which the therapist
instructed the child, and provided skills direction and
corrective instruction. The children who received CO-
OP made significantly greater gains on the Vineland
Adaptive Behavior Scale in the motor and daily living
skills domains. The CO-OP group also improved more
in upper extremity coordination as measured by the
Bruininks-Oseretsky Test of Motor Proficiency
(BOTMP) (p = 0.05) and in the visual motor integra-
tion as measured by the VMI (p = 0.065). (These posi-
tive findings were maintained when follow-up measures
were made 9 to 10 months afterward.) Replication of
these positive results with CO-OP appears to require
children who have normal range cognitive skills and can
use cognitive strategies to problem solve ways to
improve performance (Miller et al., 2001). By using
self-talk, the children may internalize strategies that
help them succeed in other similar tasks. It is not clear
what aspect of CO-OP leads to its success—the child’s
own development of a plan and strategy, learning to use
self-talk to guide his or her performance, or the process
of the child discovering strategies that solve a
performance problem.
OCCUPATIONAL THERAPY APPROACHES WITH
PRESCHOOL C HILDREN
Child-centered approaches have been used in inter-
ventions with preschool children. Preschool OT inter-
ventions tend to emphasize play occupations and social
interactions, in addition to focusing on development of
hand functions (Table 19-4). DeGangi and colleagues
(1993) focused on these outcomes in a Level II study
that compared child-centered therapy to structured
sensorimotor therapy. The child-centered therapy
emphasized the interaction between the therapist and
the child and focused on the child’s interests. The child
was allowed to explore and play with the therapist’s
guidance. The goal was to promote exploration, cre-
ativity, and organization and interaction skills. Struc-
tured sensorimotor therapy involved the therapist
giving the child specific instructions and directions and
Efficacy of Interventions to Enhance Hand Function • 449
teaching the child specific skills. The 12 children (3 to
6 years old) who participated had mild motor problems
such as DCD, motor delays, and sensory processing
disorders. Children with CP, major sensory impair-
ments, severe medical problems, or severe cognitive
delays were excluded. A crossover design was used,
such that 6 children received child-centered activity
and six received structured sensorimotor therapy for 8
weeks. They were assessed, and then the treatments
were reversed for 8 additional weeks.
Changes in hand function were measured using the
PDMS-FM age equivalent scores. After the child-cen-
tered therapy, children gained 6 months in fine motor
skills compared with 1.8 months gain during structured
sensorimotor therapy. These differences appear to be
clinically significant, but did not reach statistical sig-
nificance. The Degangi and co-workers’ (1993) and
Miller and associates’ (2001) studies support the impor-
tance of involving higher-level children in establishing
the goals and leading the activity and the critical nature
of involving the child in problem solving the task.
Engaging the child’s cognitive abilities by encouraging
discovery and problem solving (rather than simply fol-
lowing directions) seems to be important in the devel-
opment of fine motor skills. As stated by DeGangi and
co-workers (1993), fine motor skills depend on
“motivation and drive to seek and explore objects in the
environment. The process of experimenting with tools and
learning the function of objects through creative play may be key
components underlying hand function” (pp. 781–782).
The importance of play in therapy to children’s
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
months of intervention. The focus of the intervention
and the measurement was fine motor function. The
participants had delays in fine motor skills but no
specific diagnoses (e.g., CP, autism, mental retardation,
brain injury) and did not have severe sensory loss or
health problems. In-hand manipulation, eye–hand
coordination, visual motor integration, and fine motor
skills were measured. Functional skills using the PEDI
also were evaluated. After the 9 months of occupational
therapy, the participants made significant gains in all
fine motor measures. The number of therapy sessions
and the types of activities that the occupational thera-
pist implemented were recorded for each session. The
number of sessions and percentage of therapy activities
were used as predictors of the primary outcome vari-
ables. The two therapy activities that predicted the
outcomes were use of play and peer interaction. These
findings suggest that the therapist’s use of play and peer
450 Part III • Therapeutic Intervention

Table 19-4 Research studies examining the efficacy of interventions to enhance hand
function in preschool children with sensorimotor delays

Level of
Authors Evidence Sample Intervention Measures Findings

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
goals. This study supports the findings of DeGangi and
colleagues (1993) and Miller and co-workers (2001)
that incorporating play and social elements into therapy
session promotes children’s fine motor skills and hand
function. Play and social interaction may engage the
child’s attention, motivate the child to achieve higher
skills, or infuse emotions into certain activities, encour-
aging the child to repeat and remember them.
In another study examining the effect of OT on hand
skills of preschool children with mild delays, Dankert
and co-workers (2003) used a quasi-experimental

design (Level II). Three groups were compared, chil-
dren with delays who received OT, children without
delays who received OT, and children without delays
who served as a control group. The researchers posited
that visual motor skills are essential to school functions
such as handwriting; therefore an OT focus on visual
motor skills at the preschool age could serve as a
preventive measure for future problems with hand-
writing. The researchers’ hypothesis was that 1 year of
preschool OT services would promote gains in the
visual motor skills of children with fine motor delays
that would be comparable to gains made by children
without disabilities. Similar to the Case-Smith (2000)
study, regular OT services were provided (once a week
for 30 minutes) for 9 months. This level of service is
minimal when compared with other studies but is
comparable to typical levels of school-based OT serv-
ices. Children in all three groups made significant
improvements from the beginning to the end of the
year on the VMI test. The children who received OT
intervention gained 7 standard points on the VMI
compared with a 1-point gain by the group without
disabilities; however, this difference was not statistically
significant.
This study demonstrated positive effects of OT serv-
ices on visual motor skills development in preschool-
age children when measured over time, and these gains
were comparable to the progress made by children
without disabilities (who did not receive OT). Effect
sizes for the children who received OT were higher,
and the standard scores for the children with OT
services increased substantially more than they did in
the test standardization sample or the other groups in
the study.
Evidence from Case-Smith (2000) and Dankert
et al. (2003) supports the effectiveness of OT services
in improving children’s visual motor skills. Limitations
of these studies include lack of control and limited
description of the intervention and lack of fidelity
checks of the intervention. It was difficult to discern
the theoretic models that guided the therapists in
selecting and implementing intervention activities.
Examining the effects of 9 months of intervention
allows change to occur; however, long intervention
periods also allow extraneous variables to interfere with
the results, decreasing validity.
Studies of OT as it is typically implemented with
preschool children appear to effectively improve hand
skills. When quasi-experimental studies are examined,
hand skill outcomes of OT services are positive. These
studies have significant limitations in that samples of
convenience were used, fidelity measures of interven-
tion sessions were missing, and outcome measures
infrequently included children’s occupations. Future
research should address these limitations.
Efficacy of Interventions to Enhance Hand Function • 451
INTERVENTIONS TO IMPROVE
HANDWRITING
Handwriting is an important school and life function.
When handwriting is poor, the child may be penalized
with poor grades on school work and written assign-
ments. When handwriting is illegible, school achieve-
ment and self-esteem can be negatively affected
(Graham, Harris, & Fink, 2000; Jones & Christensen,
1999). Individual differences in handwriting skills and
handwriting fluency predict how much and how well
children compose and express ideas in writing (Graham
et al., 2000; Jones & Christensen, 1999). The pro-
duction of written text requires the coordination of
multiple skills. Visual motor integration appears to be
a fundamental prerequisite (Cornhill & Case-Smith,
1996; Tseng & Murray, 1994). Manipulation and
motor skills are also highly related to handwriting skills
(Cornhill & Case-Smith, 1996; Graham & Weintraub,
1996). Given its importance to children’s success in
school, a number of handwriting instructional approaches
and interventions have been developed (see Chapters
14 and 15). Handwriting interventions vary in their
theoretic model and the specific techniques and activ-
ities applied. In general, efficacy studies of handwriting
interventions have demonstrated significant effects.
This section reviews the experimental studies that have
examined the effects of educational and therapeutic
interventions designed to improve handwriting skills
(Table 19-5).
I NSTRUCTIONAL APPROACHES
Instructional approaches often follow behavioral prin-
ciples, providing structure for learning, instructing
children in practice of skills, and then providing feed-
back and reinforcement about the child’s performance.
Generally, these approaches involve guided practice.
Learning principles are followed but instruction gen-
erally does not consider individual differences among
children. Berninger and co-workers (1997) implemented
a comprehensive study of handwriting interventions
based on different instructional methods. A random-
ized experimental design was used with a sample of
144 first-grade children who were identified as being
at risk in handwriting. Five distinct instruction-based
interventions were implemented. The first was motoric
imitation in which the teachers modeled motoric acts
but were nonverbal. In the second instructional
approach visual cues were provided using numbered
arrows to cue the sequence of strokes. The third
instructional approach involved memory retrieval; the
children were required to cover letters and write them
from memory. The fourth instructional approach
452 Part III • Therapeutic Intervention

Table 19-5 Research studies examining the efficacy of interventions to enhance handwriting
in school-age children

Level of
Authors Evidence Sample Intervention Measures Findings

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
 Efficacy of Interventions to Enhance Hand Function • 453

Table 19-5 Research studies examining the efficacy of interventions to enhance handwriting
in school-age children—cont’d

Level of
Authors Evidence Sample Intervention Measures Findings

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
approach involved copying without any cueing from
the teachers. In each instructional method, the letter
was named twice on each teaching trial. In the control
condition, children received phonologic awareness
training with no practice of writing. The researchers
predicted that children’s performance after interven-
tion would vary with each of the different approaches
and that visual cueing and memory retrieval would
achieve the greatest handwriting automaticity. The
interventions were implemented over 24 20-minute
sessions held twice a week. Measures included hand-
writing legibility, handwriting automaticity, dictation
accuracy, writing fluency, and finger function. The
interventions produced significant improvement in all
handwriting assessments except the automaticity tasks
and quality of one writing task. Visual cuing with
memory retrieval was the most effective intervention
across measures. Composition fluency improved in
addition to handwriting legibility and improvements in
handwriting skills appeared to have a positive effect on
children’s ability to compose written text.
454 Part III • Therapeutic Intervention
Jones and Christensen (1999) also found that
handwriting instruction can improve both handwriting
and story writing (composition). This Level II
Australian study involved 19 6- and 7-year-olds who
demonstrated difficulty in handwriting speed and
accuracy. A matched group of children without diffi-
culties served as a control group. An 8-week inter-
vention (10 minutes per day) consisted of instruction in
letter formation with practice. The pre- and post-
assessments included writing speed and accuracy, hand-
writing formation, and a test of written expression. The
group that received intervention improved more than
the control group. In addition, the correlation between
handwriting speed/accuracy and written expression
was 0.73; that is, 53% of the variance in story writing
was accounted for by speed and accuracy in writing
letters. These researchers concluded that the interven-
tion was highly effective; in addition, it was cost
effective because the instruction required 10 minutes a
day and was implemented by parents. This study also
suggested that handwriting skill has an essential influ-
ence on composition in early elementary years.
Hayes (1982) implemented a study that appeared to
be the model for the Berninger et al. (1997) study.
Two groups were used, 45 children in kindergarten
and 45 in third grade. The children were randomly
assigned to one of five conditions: control, copying
with no prompting, visual demonstration with copying
practice, visual and verbal demonstration with copying,
and visual and verbal demonstration with the child
verbalizing during copying. The children received these
interventions for a single 20- to 25-minute session.
Despite the short period for intervention, an effect
resulted. Similar to the later findings of Berninger and
co-workers, the intervention that involved visual and
verbal demonstration with the child verbalizing while
copying was most effective and copying with no
prompting was least effective for both age groups.
Self-instruction is an approach to improving hand-
writing that actively involves the child in the learning
process. A number of researchers have examined the
effects of self-instruction (Blandford & Lloyd, 1987;
Graham, 1983; Kosiewicz, Hallahan, & Lloyd, 1981).
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.
The card had self-evaluation questions to emphasize
important aspects of correct handwriting. The students
were to read the card and fill in answers based on their
handwriting. Data were collected on correct letter
formation and spacing for 25 days. The boys demon-
strated improved handwriting (letter formation and
spacing) when using the card and after using the card.
Therefore, this method appears to yield a significant
effect with minimal teaching and can be implemented
with groups, as well as individuals. A larger study of
self-instruction was implemented in 2003 in the
Netherlands. Jongmans and others (2003) researched
the effects of a task-oriented intervention with self-
instruction on handwriting quality and speed in chil-
dren with significant handwriting problems. These
researchers completed two studies, one with 14 stu-
dents in regular education (7 with poor handwriting
[mean age = 7.9 years] and 7 with typical handwriting
[mean age = 8.6 years], all of whom received the
intervention) and a second with 36 students in special
education (18 who received the intervention [mean age
= 10.9 years] and 18 controls [mean age = 9.8 years]).
An assessment of handwriting quality was used before
and after the intervention. The children received 18
handwriting intervention sessions in the first study
and about 48 sessions (6 months twice a week) in the
second. The intervention used a self-instruction
method in which the child reflected on his performance
after each exercise. It consisted of multiple steps that
emphasized visual perception of the letters, motor
programming, repetition, and then practice of writing
words and sentences. The child self-corrected his work
at each step.
In the first study only descriptive results were
reported. All students with poor handwriting improved
and those with normal handwriting did not change. In
the second study, students who received intervention
improved significantly in handwriting quality and
improved more than students who did not receive
intervention. Speed did not change for either group.
Summarizing the significance of the effect, Jongsman
and co-workers (2003) reported that 72% of the
students changed from “dysgraphic” to “legible” after
the intervention.
This intervention is similar to the CO-OP inter-
vention (Polatajko et al., 2001) described in the pre-
vious section, in that the child directs the activity,
practices with self-guidance, and self-evaluates. Both
interventions draw on the child’s cognitive skills and
encourage active decision making and problem solving
to master a motor skill. Both interventions produced
strong, positive effects.
OCCUPATIONAL THERAPY APPROACHES
OT approaches to improve handwriting often combine
educational/instructional approaches with sensori-
motor interventions. In practice OT intervention is
individualized and based on analysis of the child’s
performance. Unique to OT is a deep understanding of
sensory and motor function, application of precise
assessment of sensory perception and sensorimotor skill
as it relates to handwriting, and implementation of
interventions that are specifically designed to improve

sensorimotor functions. Case-Smith (2002) examined
the effect of OT services provided in the school on
handwriting legibility and speed. A sample of students
in third, fourth, and fifth grades with poor handwriting
legibility (N = 29) received services throughout a
school year. A second sample of children in the same
grades (N = 9) had poor handwriting by report of their
teacher but did not receive OT services. The therapists
documented their intervention throughout the year. A
mean of 9 hours of direct services were provided and
about 30% of all sessions included follow-up consul-
tation with the teacher on the child’s behalf. The
students were assessed using visual motor, visual per-
ceptual, manipulation tests, the Evaluation Tool of
Children’s Handwriting (ETCH) and two sections of
the School Function Assessment (SFA). The students
who received intervention improved more than the
control group on in-hand manipulation and visual
motor control tests. They also improved more in letter
legibility, but not in handwriting speed. The improve-
ment in handwriting legibility appeared to be clinically
significant because two thirds of the sample moved
from illegible handwriting (<85% of legible letters
on the ETCH) to legible handwriting (>85% legible
letters). As mentioned, handwriting speed did not
improve, possibly because some of the students had
learned to write more carefully and slowly to improve
legibility.
Peterson and Nelson (2003) also investigated the
effects of OT intervention in a randomized clinical trial
of children with economic disadvantages. Their sample
consisted of 59 students in first grade, mean age =
7.1 years. They were assessed using the Minnesota
Handwriting Test (MHT) before and after a 10-week
intervention. Thirty children were randomly assigned
to the intervention group and subsequently received
20 sessions of OT (twice a week for 10 weeks). The
intervention was provided by OT students and each
session consisted of practicing heavy work and
sensorimotor activities, learning specific strategies to
improve letter formation and spacing, and practicing
handwriting.
The gain scores on the MHT were significantly
higher for the students who received OT. The effect
size for the intervention group was large (ranged from
0.64 to 1.3 for MHT subsections) and the control
group demonstrated no change. In follow-up analysis,
the students made strong gains in spacing, placing
letters on the line and using correct size; medium
effects resulted for legibility and use of correct form. As
in Case-Smith (2002), speed did not improve.
Both studies (Case-Smith, 2002; Peterson &
Nelson, 2003) demonstrated significant effects when
comprehensive OT services were applied. The inter-
ventions combined sensorimotor activities that included
Efficacy of Interventions to Enhance Hand Function • 455
heavy work with practice of isolated skills and holistic
practice of letter writing with feedback and reinforce-
ment. These studies provide evidence that holistic OT
improves handwriting but falls short of identifying the
differential effects of specific intervention approaches.
A study by Sudsawad and co-workers (2002) exam-
ined the effects of one aspect of a sensorimotor OT
approach, kinesthetic training. These researchers assumed
that kinesthesis can improve with training and that
improved kinesthesis would lead to more legible hand-
writing. A randomized blended three-group research
design was implemented. One group received kines-
thetic training, one handwriting practice, and one no
treatment. The measures were kinesthetic acuity,
kinesthetic perception and memory, and the ETCH.
The sample comprised 45 first-grade students with a
kinesthetic deficit and handwriting difficulties.
Kinesthetic training or handwriting practice was
provided 30 minutes per day for six consecutive school
days. Kinesthetic perception improved over time but
was not different among the groups. Scores on the
ETCH did not change between pre- and post-tests,
indicating that kinesthetic and handwriting interven-
tions had no effect on handwriting legibility or speed.
The teachers reported significant changes in hand-
writing for all three groups. The authors concluded
that their hypothesis that kinesthetic training would
lead to improvement in handwriting was not sup-
ported. Limitations included the short intervention
period (6 days) and small numbers in each group.
In summary, educational/instructional approaches
that use multiple sensory systems for cueing and feed-
back and that actively involve students have strong and
consistent effects on improving handwriting. Specific
instructional approaches with demonstrated effective-
ness are those that engage the student in goal setting
and reflection about performance, give visual and
verbal cues, and require memory retrieval during prac-
tice. Less effective approaches are those that involved
only copying, or only visual or verbal cueing. Instruc-
tion approaches appear most effective for improving
and writing quality and composition fluency, and least
effect for increasing speed.
OT approaches that are comprehensive, provide
multisensory input, and engage the child in activities
that reinforce multiple dimensions of handwriting
(e.g., motor planning, visual motor integration, small
muscle movement of the hand) effectively improve
handwriting legibility. There is no consistent evidence
that OT interventions improve handwriting speed.
Composition and writing quality have not yet been
assessed in OT studies, but should be considered given
its importance as primary outcomes of children’s writ-
ing skill. When a single component (i.e., kinesthesia) is
the emphasis of intervention, the effects are equivocal.
456 Part III • Therapeutic Intervention
As in the educational studies, use of a single learning
method that emphasizes a single sensory system does
not appear sufficient for effecting substantial improve-
ment in handwriting.
SUMMARY
Research evidence about treatment effects helps prac-
titioners make good clinical decisions, provides practi-
tioners with explicit information to give to families, and
helps practitioners justify treatment decisions to physi-
cians and other professionals. When levels of research
evidence are high and rigorous methods are used,
therapists can generalize the findings to their practice
with confidence. When levels of research evidence are
low, findings should be reported and applied with
caution because of inherent limitations. The majority of
studies on hand intervention effectiveness are Levels III
and IV and use small convenience samples. These
single-subject and case studies provide detailed infor-
mation about treatment outcomes for individuals, but
cannot be generalized beyond the characteristics of the
children who participated. Although case studies and
single subject design studies deepen understanding
of intervention effects, they do not provide definitive
information from which predictions about outcomes
can be made. In the past decade more rigorous (Level
I) randomized clinical trials have been completed,
providing more definitive findings and making impor-
tant contributions to the knowledge base for hand
function intervention outcomes.
The studies reviewed in this chapter examined vari-
ous levels of function and disability. Many hand inter-
vention studies have examined impairment level (body
structure and body function) outcomes. For example,
the studies of upper extremity weight bearing examined
ROM, muscle tone, and movement patterns (i.e.,
components of performance). Studies of casting also
emphasized ROM and muscle tone. Even studies of
comprehensive interventions (e.g., neurodevelop-
mental treatment) often used measures of arm and
hand movement rather than functional or occupational
measures. Impairment-level outcome measures leave
unanswered questions about if and how performance
and function changed given intervention effects.
Measures of function and occupation, in addition to
performance of specific skills, help to link interventions
to children’s daily lives and social roles. Researchers
(Butler & Darrah, 2001; Law & Baum, 2001) have
suggested that outcome studies routinely couple spe-
cific performance measures with holistic, comprehen-
sive assessment of function and occupation. Examples
of holistic assessments to be included are those that
measure functional goals (e.g., the Canadian Occupa-
tional Performance Measure), self-care and mobility
function (e.g., Pediatric Evaluation of Disability
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
association of measures of sensorimotor skill.
Specific studies reviewed in this chapter did use
functional and occupational assessments. For example,
Miller and co-workers’ (2001) study of cognitive orien-
tation to daily occupational performance implemented
the Canadian Occupational Performance measures,
the Vineland Adaptive Behavior Scale, the Bruininks-
Oseretsky Test of Motor Proficiency, and the Visual
Motor Integration test. These assessments examined
broad aspects of function and the child’s integration of
sensorimotor-perceptual-cognitive skills. The findings
that resulted answered questions about the children’s
occupations after intervention. Other studies that
examined the effects of holistic interventions (e.g.,
preschool OT services [Case-Smith, 2002]) demon-
strated the associations between children’s perform-
ance of basic skills and their functional outcomes.
Future hand intervention research should examine
children’s play and school outcomes to determine
effects on everyday life and children’s roles as students,
play partners, and family members.
Another limitation in interpreting the research liter-
ature is that the independent variable, the hand func-
tion intervention, is rarely described in detail in the
research report. As a result, it is not clear exactly what
intervention strategies were used and to what inter-
ventions the study results apply. In order to assure that
the intervention is true to its theoretic model and is
reliably applied across researchers and time, measures
of treatment fidelity are needed. Almost none of the
studies used checks on treatment fidelity; consequently,
the external validity of findings can be questioned, as
treatment protocols are easily and unintentionally altered
during implementation. Certain interventions (e.g.,
neurodevelopmental treatment) have been defined
differently over time (Howle, 2002); therefore, explicit
information about what intervention activities and
strategies were administered is provided in the research
report. Publications of standard or best practice inter-
vention models can be used to define interventions in
clinical trials.
A final limitation observed in many of the studies
was lack of long-term follow-up. Often studies imple-
mented a post-assessment immediately after inter-
vention, and did not follow children’s progress to
determine the long-term effects of intervention.
Outcomes of children’s occupations and roles as they
enter adolescence and adulthood have rarely been

assessed. This deficiency is not surprising given that
long-term follow-up of subjects requires substantial
resources and efforts of research teams. Although these
long-term projects have yet to be accomplished, the
preliminary data reported in this chapter can justify and
inform these large-scale projects. Professions focused
on hand intervention research are moving toward more
rigorous studies and designs that provide strong, valid
findings. To increase knowledge of hand intervention
effectiveness future research studies should:
1. Use randomized clinical trial designs with large
sample sizes.
2. Implement measures of occupation and function
that represent meaningful outcomes and quality of
life for children and families.
3. Implement methods to evaluate intervention
fidelity and ensure that interventions represent the
theoretic constructs from which they are derived.
4. Follow children over time to measure long-term
outcomes.
Summarizing the findings of research on interven-
tions to promote hand function is difficult at best,
given vast differences in study designs, samples, tech-
niques, and environmental contexts. This body of
research should be carefully read, critiqued, and digested.
When carefully analyzed, these studies offer explicit
guidance to practitioners who provide services to
children with delays in hand function and to scholars
who will take the next steps in research of intervention
outcomes.
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Adapted tripod grip: Grip where the pencil is
stabilized within the narrow web space between the
middle and index fingers when writing.
Affordances: The perceptual features of objects,
places, and events that enable particular functional
actions.
Anticipatory control: The programming of action
based on a mental representation of an object’s
properties that has developed through prior
experience. It involves the activation of sensory and
muscular systems for a specified activity that has been
learned.
Arches of the hand: The musculoskeletal structures
that allow the flattening and cupping of the hand.
The arches are the proximal transverse, distal
transverse, and longitudinal.
Attention: An active process in which certain stimuli
in the environment are given preference over other
stimuli depending on their perceived importance.
Automatization; autonomous phase: The stage of
a learned motor skill when the action is carried out
with minimal attention.
Base of support: The area of the body in contact
with the support surface; when more body area is in
contact with the surface, the base of support is wide;
when less body area is in contact with the surface, the
base of support is narrow.
Bilateral hold, cooperative: An action in which one
hand supports or stabilizes an object while the other
hand explores or manipulates it.
Bilateral or two-handed hold, symmetric:
Holding objects with the two hands acting in unison.
Bilateral simultaneous manipulation;
complementary two-hand use: An action in which
both hands are performing different but complementary
actions at the same time, as in bead stringing.
Central pattern generators: Neural networks that
interact in an organized manner to produce a motor
act.
Cognition: The collection and organization of
information into knowledge.
Glossary
Coincidence anticipation: A form of anticipatory
control in which movement coincides with an external
event, such as catching a ball.
Composite flexion: Fisting of the hand along with
flexion of the wrist, thereby putting maximal strain on
the extensor mechanism of the hand.
Concept formation (knowledge): Conscious and
active process that categorizes sensory information by
associating it with conceptual categories.
Constraint-induced movement: Immobilization of
the less involved upper extremity to require the child
to use the more involved extremity.
Constructional skill: The ability to perform the
sequences of movement involved in producing two-
or three-dimensional representations, as in drawing or
building.
Constructional style versus contoured style of
drawing: Refers to the execution of pictorial
representations by the assembly of simple forms as
opposed to beginning with a sketch of an outline.
Dexterity: Ability to manipulate objects with the
hands with accuracy and speed.
Disk grip (five-jaw chuck): A fingertip grip using
the pads of all the fingers and the thumb, as on the lid
of a jar.
Dissociation: Refers to the ability to carry out
precise, independent joint movements without
concurrent involuntary actions at other joints not
involved in the task.
Dorsal stream: Neural pathway that provides visual
information for the guidance of movement.
Dual motor systems: Refers to the differentiation
between central nervous system control of skilled
distal movements such as those of the hand and the
proximal movements of the limbs and trunk.
Dynamic splinting: Uses articulations and force
components to constantly put a dynamic pull on tight
or healing tissue; often incorporates rubber bands,
springs, or other materials to exert controlled
mobilization.
Dynamic tone: The muscle tone that occurs with
volitional movement.
461
462 • Glossary
Dynamic tripod grasp (pencil): Grasp in which the
pencil is stabilized against the side of the middle
finger by the pads of the thumb and index finger.
Writing includes localized movements of the fingers
and thumb as well as the wrist.
End range of movement: The distal range of
motion at a joint as opposed to movements that occur
in the middle of available range.
Executive function of the hand: The use of the
hand as a means of practical action on the
environment, during which perceptual function is
regulated by whatever is needed to achieve the action.
Explicit (declarative) memory: Conscious
awareness and intention to recall facts and events.
Extensor lag: Inability to extend the DIP joint of
the finger into full extension because of poor pull-
through of the terminal extensor tendon.
Eye–hand coordination: The integration of visual
perceptual information with the purposeful
movements of the hand and arm.
Feedback: Sensory information that arises from
movement.
Fine motor coordination: Use of small muscle
groups for precise movements, particularly in object
manipulation with the radial digits.
Finger differentiation or individuation: Controlled
individual or isolated finger movements.
Fixing: Volitional limitation of freedom to move at
various muscles and joints in order to produce
controlled movement in another body part.
Graphomotor skill: The conceptual and perceptual
motor abilities involved in drawing and writing.
Grasp phase of reaching: The phase of reaching for
an object in which the hand is shaped in anticipation
of the contact with the object.
Grip: The mechanical component of prehension; the
hand configuration on the object during grasp.
Grip force: The pressure exerted on an object in the
act of lifting and holding. In precision grasping, grip
force is matched to object qualities such as weight,
texture, and rigidity.
Hand preference: The consistent favoring of one
hand over the other in the performance of skillful acts.
Hand shaping: The adaptation of the hand arches
and the finger postures to the object’s size, shape, and
use in anticipation of grasp.
Handedness: Consistent and more proficient use of
the preferred hand. Its dimensions include hand
preference (the hand chosen more often) and hand
performance (the hand with superior ability).
Handwriting: The process of transcribing letters to
form words and words to form sentences;
differentiated from writing, which is the composition
and control of material that is handwritten.
Haptic perception: Recognition of objects and
object properties by the hand without the use of
vision.
Implicit (procedural) memory: Storage and recall
of information without conscious awareness.
Knowledge of how a task is done expressed through
performance.
Inferior or immature pincer grasp: A grasp
between adducted thumb and side of the index finger.
In-hand manipulation: The adjustment of a grasped
object within one hand while it is being held. Includes
translation, shift, and rotation with and without
stabilization.
In-hand manipulation with stabilization:
Manipulating one object with the fingers while
holding one or more additional objects within the
same hand.
Intermodal perception: The matching of objects or
shapes that are perceived by one sensory modality,
such as touch, to those which are perceived by a
different sensory modality, such as vision.
Intramodal perception: Matching objects or shapes
within a single sensory system, for example, matching
one object explored haptically to another also
explored haptically.
Kinesthesia: The conscious perception of the
excursion and direction of joint movement and of the
weight and resistance of objects.
Lateral tripod grasp (pencil): Grasp in which the
pencil is stabilized against the side of the middle
finger, with the index finger pad on the pencil, and
the thumb adducted with the thumb pad braced on
the side of the index finger. Writing includes localized
finger movements as well as wrist and arm
movements.
Learned non-use: When the more involved
extremity is not used, changes occur in the central
nervous system that reinforce the non-use of that
hand.
Memory: Process by which knowledge is encoded,
stored, and retrieved.
Mirror movements: Movements of the hands are
coupled, with the use of one hand the same
movements are observed in the second hand.
Motor functions of the two sides of the hand:
Refers to the differing functions of the ulnar (little
finger) side and the radial (thumb) side of the hand.
The primary function of the ulnar side of the hand is
to hold, whereas that of the radial side is to
manipulate.

Motor learning: A set of processes associated with
practice or experience leading to relatively permanent
changes in the capability for producing skilled
action.
Movement unit: Constituted by one phase of
acceleration of a limb followed by a deceleration. A
movement can consist of one or more movement
units.
Multimodal exploration: The simultaneous use of
more than one sensory system in object exploration.
Occupation performance: Performance of skills that
are essential for independent functioning in everyday
living.
Palmar grasp: A whole-hand grasp in which objects
are held against the palm of the hand by the fingers.
The thumb may be active or passive.
Palmar grasp (pencil): A grasp in which the pencil
is positioned across the palm and held in a fisted grip.
Pathologic handedness: Altered handedness
resulting from neural insult.
Perception: A process of collecting information from
the environment based on vision, touch, hearing, and
proprioception in order to construct an internal
representation of the environment and body.
Perceptual activity of the hand: Use of the hand as
a perceptual system, in which motor activity is
primarily exploratory and information seeking.
Perceptual-motor processes: The reciprocal
relationship between perception and action, wherein
movement adapts to perception and movement
influences perception.
Pincer grasp; pinch; fine prehension: The grasp of
an object with the index finger and thumb. Major
types include palmar pinch (pad of finger to pad of
thumb), tip pinch (using tips of both thumb and
finger), and lateral pinch (thumb holding object
against side of finger).
Postural control: The maintenance of body position
in space that evolves from the development of
antigravity movement, postural adjustment reactions,
and somatosensory input.
Power grip: A static grip applying force to an object
to immobilize it in the hand.
Praxis: The planning and execution of a motor
movement or a series of motor movements/tasks.
Precision grip: The grasp of an object with the
finger and thumb pads or tips. Precision grips may be
static but often allow movement of the object by or
within the fingers.
Precision handling: The dynamic or manipulative
characteristics of precision grip used for in-hand
manipulation and for the use of many tools.
Prehension: The voluntary act of grasping and
manipulating objects with the hand.
Glossary • 463
Preprogrammed movement/open loop
movement: A learned movement in which the entire
motor pattern is programmed before the movement is
initiated and which is not under sensory control
during execution.
Prereaching; prefunctional reach: The more
automatic movement of the very young infant’s
hand
toward an object before voluntary reach has developed.
Proprioception: Sensory information about positions
and movements of body parts from muscles, tendons,
joints, and skin. Limb position sense and kinesthesia
are forms of proprioception.
Quadripod grip (pencil): Grip in which the pencil is
held by three fingers and the thumb. May be static or
dynamic.
Radial digital grasp; inferior forefinger grasp:
Prehension of an object with the thumb, index, and
middle fingers but with the object held proximal to
the finger pads. Thumb may be in adduction or
opposition.
Radial palmar grasp: An immature grasp in which
the index and middle fingers and thumb press an
object into the palm.
Radial-ulnar dissociation; separation of the two
sides of the hand: The ability to perform holding
functions with the ulnar fingers while manipulating
objects with the thumb and radial fingers.
Reflexive grasp: The stereotypic closing of the hand
on an object in response to tactile or proprioceptive
information. Palmar grasp reflexes occur normally in
early infancy and may persist in children with brain
damage.
Reverse transverse grip; radial cross-palmar
grasp (pencil): An immature pencil grip with the
pencil positioned across the palm and the point
projecting from the thumb side of the hand. The
hand is fisted with the forearm fully pronated.
Rotation: An in-hand manipulation movement by
which an object is turned in the fingers. Simple
rotation involves turning or rolling the object 90
degrees or less with the fingers acting as a unit.
Complex rotation involves turning an object 90 to
360 degrees using isolated finger and thumb
movements.
Scissors grasp: The prehension of small objects
between the thumb and the lateral border of the
index finger.
Self-care activities: The basic daily living activities
of eating, dressing, bathing, and use of the toilet.
Sensory processing: The management of
incoming sensory information by the central nervous
system.
464 • Glossary
Shift: An in-hand manipulation movement where
there is slight adjustment of an object on or by the
finger pads.
Somatosensory: Refers to the tactile and
proprioceptive senses that contribute to the
perception of objects and events, as well as of the
body and limbs.
Spasticity: Velocity-dependent resistance to passive
movement.
Squeeze grasp: An immature grip in which an infant
presses an object against the palm with total finger
flexion. The thumb does not participate and force is
not modulated.
Stabilizing: Contraction of the muscles to fixate or
hold the body or a body part; also refers to the use of
external systems or devices to provide support when
an individual is unable to do so alone.
Static splint: An immobilization or supportive splint
that has no moving parts; serial static splints are
periodically remodeled as the joint gains motion;
static progressive splints use low load in a single
direction over a long period of time to mobilize soft
tissue at its end range.
Static tripod grasp (pencil): Grasp in which the
pencil is stabilized against the side of the middle
finger and held by the pads of the index finger and
thumb. The hand is moved as a unit by the wrist and
forearm in writing.
Stereognosis: The recognition of familiar objects
through touch.
Stiffness: A general term referring to difficulty
moving the limbs.
Switched handedness: Occurs when an inherently
left-handed child learns to draw and write with the
right hand because of sociocultural influences.
Tapping: A facilitation technique that is manually
applied and used to generate volitional movement at
individual muscles.
Three-jaw chuck: A power grip of the fingertips.
The object is held with the distal pads of the thumb,
index, and middle fingers.
Threshold tests: Tests that determine the minimal
stimulus a person can perceive (e.g., pain,
temperature, pressure).
Tone: The resistance a muscle offers to being
lengthened; abnormal tone is a result of both neural
factors (e.g., spasticity) and biomechanical factors
(e.g., fibrosis and atrophy), which cause changes in
contractile properties of some muscle fibers.
Total end range time: Term used in soft-tissue
adaptability that refers to the frequency of stretching
multiplied by the duration of the stretch at the end
range of a joint’s movement.
Trajectory: The path taken by the hand as it moves
toward a target and the speed at which it moves along
the path.
Translation: A form of in-hand manipulation by
which an object is moved in a linear direction between
the palm and the fingertips. Includes the movement
of an object from the palm of the hand to the
fingertips (palm-to-finger translation), and the
movement of an object from the fingertips to the
palm (finger-to-palm translation).
Transportation phase; transport: The phase of
reaching that brings the hand to the target or moves
an object through space.
Ventral stream: Neural pathway that provides visual
information for the recognition of objects.
Visual-motor integration: The coordination of
visual information with movement. The term is used
often to indicate the ability to copy geometric forms.
Volition: Action in which the achievement of a goal
is seen as resulting from one’s own activity.
Voluntary controlled release: Letting go of an
object in a specific place and with timing that is
appropriate for the specific task.
Weight shift: Volitional or assisted movement of
body weight which occurs with movement of a body
part.
Working memory: Short-term memory system that
holds information so that it can be manipulated
during tasks.
Zone of proximal development: A period of
developmental maturation in which particular skills
are within reach of a child.
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

Reaching (Continued)
movements
beginning stage, 92-93
coordinating body parts, 93
development during infancy, 92-95
integration of sensory information, 92
planning, 93-95
role of proprioception, 91-92
role of vision in, 91
sensory information, 95
speed, 89-90
transport and grasp phase, 90-91
variations, 95
and self-dressing, 205t
two main parts of, 12
Reflexes
control theories concerning, 46
Reflex-inhibiting postures (RIPs), 344-345
Regeneration
of tissue wounds, 368
Release; See object release
Repair
of tissue wounds, 368
Representation
definition of process, 102
Research evidence
on cerebral palsy, 435, 436t-440t
on hand function
in cerebral palsy patients, 436t-440t
on in-hand manipulation, 154-155
levels of, 433-434
summary of, 456-457
Retrieval phase
of explicit memory, 108
Reverse transverse grip, 463
Right handedness
consistent versus inconsistent, 168
definition of, 166b
Rotation skills, 257-259, 323, 324f, 463
S versus motor control, 241-242
Sandwich splints, 391f
Scaphoid
anatomical diagram of, 22f
description and position of, 22-23
fractures, 380-383
ligaments of, 23, 24f
Scar remodeling stage
of wound healing, 369, 370b
Scars
management of burn, 391-393
from radial club hand operations, 396-398
sandwich splints for, 391f
from syndactyly operations, 394-396
Scissors
illustration of cutting, 153f
motor functions of, 323
skill development
in preschoolers, 279-280
Scissors grasp, 463
Selective attention, 104
Selective posterior rhizotomy, 446
Self-care skills
acquisition of, 196-198
mastery motivation, 197-198
Index • 477
Self-care skills (Continued)
maturation, 197
motor factors, 198
sex differences, 197
social and cultural issues, 197-198
chronology of acquisition
activities of daily living, 212-214
cognitive and personality factors, 214
dressing and undressing, 203, 205t, 206, 207t, 208, 209t,
210
eating and drinking, 199, 200t
hand skills in, 193-214, 213-214
hygiene and grooming, 210, 211t-212t
self-feeding, 199, 200t
serving and preparing food, 203, 204t
utensil use, 201, 202t, 203b
definition of, 463
development of, 196-210, 211t-212t, 213-214
and fingers, hands and grip abilities, 213-214
and hand skill development, 193-214
independence in
in children, 194, 212-213
in the disabled, 194-195
measurement of
nonstandardized measures, 195
standardized measures, 195-196
perceptual factors in, 214
Self-dressing; See dressing skills
Self-feeding, 199, 200t, 201, 202t, 203, 204t
Semantic memory, 107-108
Sensorimotor control
organization of, 53-54
Sensorimotor cortex
firing of haptic neurons in, 69
and hand-object interactions, 3-4
Sensorimotor system
delay problems
research studies on, 450t
and hand ability in children, 46f
Sensory awareness
typical activities for, 247b
Sensory feedback
and grasp, 16
and haptic perception, 69
importance of
in motor learning, 11-12
Sensory information
and development of reaching skills, 95
gathered by hands and fingers, 7-9
and hand skill development
in infants, 119-120
integration of vision and proprioception, 92
processing
and handwriting, 299-300
and reaching, 92
used for force control, 57-58
Sensory Integration and Praxis Tests (SIPT), 77-78, 179-180
Sensory systems
impairments
with cerebral palsy, 346-347
importance of
in infant hand skill development, 124-126
Shift skills, 259, 463
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