Building Blocks for Fine Motor Success
04/28/2015 by Christine Moller, M.S., OTR/L
As discussed in our previous blog, “Handwriting and Your Child," strong handwriting—and fine motor skills in general—requires sufficient development of certain foundational skills: strength, hand arches, finger dexterity, and eye-hand coordination. Just as support beams are necessary to hold up a ceiling, these “building blocks" support higher-level hand skills. If your child’s fine motor skills are below age-level expectations, it’s a safe bet that at least one of these foundational skills are underdeveloped as well. Below is an explanation of each of these essential skills as well as descriptions of exercises and activities you can do at home with your child to strengthen any skills that are underdeveloped.

STRENGTH
Core and Upper Body Strength
A strong core provides stability of the trunk and pelvis, which is necessary to sit with good posture and balance (called postural control). Strong shoulder muscles provide stability of the shoulder girdle. Without this base of support, the smaller muscles in our arms and hands can’t move with precision during fine motor activities. For example, imagine sitting in a chair and attempting to thread a needle in the air in front of you, which takes precise finger movement. If you mimic this movement, you will notice how stable your trunk and shoulders need to be in order to allow for the precise movement of your forearms and fingers. If you lacked this stability, your trunk and shoulders would be constantly making subtle postural adjustments just to keep you upright in the chair, and you would never be able to get the thread through the needle.

What to Look For
Signs of a weak core include slumped sitting posture with rounded shoulders and back, fatiguing quickly when working at a table, holding head in hands when sitting at the table, inability to sit up from the floor without rolling over or using arms, and a decreased ability to perform the exercises below. In addition, children with poor upper body strength—and thus poor shoulder stability—have difficulty performing fine motor tasks in space, such as turning pages in a book, stringing beads, or putting together linking toys. Instead, they need to lean their arms or hands against a table or floor in order to gain stability when performing these tasks.

Exercises to Strengthen
• Push ups
• Sit ups
• Wheelbarrow walking
• Animal walks: Crab walking, Bear Walking, Caterpillar Walking
• Hang from Monkey Bars
• Play games (or watch TV) while lying on belly, propped up on elbows
• Play games such as catch in “tall kneel" (not sitting on feet) or “half kneel" (one foot on the ground)
• Army Crawl under tables, chairs, benches, etc.
• Pull a laundry basket filled with toys across a room using rope (tie rope to the handle of the laundry basket)

Hand and Finger Strength
Hand and finger strength allows us to grasp and hold items securely. For children, this means being able to hold a pencil correctly, play with and manipulate toys, hang on monkey bars, climb rock walls, snap their pants, and cut their food.

What to Look For
Children with decreased hand and finger strength will have difficulty holding a pencil with any space between the pencil and their fingers; that is they will hold it too tightly. They need help cutting food, pulling the Velcro open on shoes, snapping pants, and opening lids on Play-Doh or other containers well past when their peers require help.

Exercises to Strengthen
• Manipulate Play-Doh or Therapy Putty (hide small items like coins or beads in the putty and have your child search for the “treasure;" form into “pancakes" and “logs;" stretch into long “snakes" and then cut into strips)
• Pick up small items with tongs, tweezers, or strawberry hullers
• Make art using eye droppers to place various colors of water on paper
• Play with construction toys: Legos, Zoobs, Bristle Blocks, Pop Beads
• Clothespin games (use the pad of thumb and index finger to squeeze open)
• Spray water from a spray bottle or other squirt toys
• Play with wind up toys
• Crumple small pieces of tissue paper with fingertips and glue to make artwork
• Pop bubble wrap
• Play with hole punchers
• Play with squeeze toys such as foam or rubber balls

HAND ARCHES
There are several arches in the palms of the hands that allow us to pick up and manipulate items of different sizes and shapes. These arches create the shallow “cup" shape our palms resemble when at rest. (People with poorly developed hand arches—as well as decreased tone and muscle strength in the hand—have a palm that looks flat when at rest.) Crawling helps to develop these arches and is one of the reasons crawling is an important stage in a toddler’s development.

What to Look For
Have your child hold her hand, palm up, in front of her with elbow bent. When relaxed, the fingers should curl up and the palm should make a shallow cup shape. A palm that is very flat when relaxed has decreased arches.

Exercises to Strengthen
• Any activity in which a child applies weight through the hands such as:
• Animal walks such as crab walking or bear walking
• Wheelbarrow walking
• Practice yoga poses such as “plank" or “table"
• Crawl through tunnels or obstacle courses
• Propel scooter board with hands while lying on belly
• Lie on belly over pillows or a bolster and hold self up on hands while playing a game, completing a puzzle, etc.
• Hold and manipulate toys (see Hand and Finger Strength)
• Squeeze rubber or foam squeeze balls

HAND DEXTERITY

What to Look For
Hand dexterity refers to the skill of using the hands and fingers for precise, controlled movement. Our hand dexterity allows us to push, pull, hold, and manipulate items with our hands and fingers. One of the reasons we have finger dexterity is that in toddlerhood, we develop separation of the sides of the hand: that is, we learn to separately use the precision (thumb side) of the hand and the power (pinkie) side of the hand. For example, when picking up a pencil, we hold it with three fingers, with our ring and pinkie finger tucked into the palm. We are using the precision side of the hand. When hammering nails, we hold the hammer with the power (pinkie) side of the hand, only using our thumb to stabilize the hammer. Infants have not yet developed this separation. An infant will pick up small pieces of cereal or a block using their whole hand, raking it in with all five fingers to grasp it. As children mature, they develop three very important skills that all contribute to hand dexterity: a pincer grasp, finger isolation, and in-hand manipulation skills.
Pincer Grasp
The pincer grasp refers to the ability to pick up small items such as cereal or pennies using the tip of the thumb and index finger. Infants developing this grasp will use their thumb against the side of the index finger, or place their thumb against the middle of their index finger. By the age of one, most toddlers have developed a neat, tip-to-tip pincer grasp.

What to Look For
Place small items such as Cheerios in front of your child and watch how he picks them up. If older than one, he should pick them up with a neat pincer grasp. If he uses his thumb and middle finger, this is a sign of decreased dexterity and hand strength. If he places his thumb against the side of his index finger or doesn’t use the tip of his index finger, his grasp is immature if older than 12 months.

Exercises to Strengthen
Practice picking up small items with a pincer grasp. Pinching resistive items, such as clothespins, are especially helpful for strengthening this grasp. Talk to your child about her pincer grasp, calling it by name (you can say “use your pincers" or “your pinchers") and praise her for using the correct grasp. This will bring attention to the grasp and help your child begin to self-correct. When working with children under the age of three, watch them carefully to make sure they don’t place small items in their mouths.
• Practice sealing Ziploc bags
• Place pennies in a piggybank
• Play Hi-Ho Cheerio! or other games with small pieces that should be picked up with a pincer grasp
• Link small pop beads
• Peel stamps or stickers
• Roll small pieces of Play-Doh between the pincer fingers to form into small logs or ball shapes
• Squeeze bag clips or clothespins with a pincer grasp; you can place the clothespins around the edge of a paper plate, along a string, or on a piece of fabric
• Practice using a correct pincer grasp when snacking on Cheerios or small toddler snacks; provide one at a time if needed

Finger Isolation
Finger isolation refers to the ability to move the fingers independently of each other. Infants move all of their fingers together as a unit, and over time, develop the ability to move them individually. This is very important in order to perform many fine motor skills such as handwriting, lacing, and pointing.

What to Look For
Your child should be able to isolate the index finger (as we do when pointing) at the age of one. Performing the “thumbs up" position usually develops around age two. A two-year-old can usually also isolate two fingers (index and middle) to show they are two years old. Likewise, a three-year-old can typically isolate three fingers (index, middle, and ring) to express he is three. Isolation of the middle, ring, and pinkie fingers develops in early childhood.

Exercises to Strengthen
• Point to objects around the room and pictures in a book (if needed, help your child isolate her index finger by holding the other fingers against her palm)
• Play with finger puppets
• Practice making signs us as “thumbs up," “thumbs down," “A-OK," “one," “two," “three," and “four"
• Play finger games such as The Itsy Bitsy Spider and Where is Thumbkin?
• Finger paint
• Use index finger to trace shapes and letters, or “draw" shapes in pudding, shaving cream or paint
• Practice buttoning, snapping, and zipping
• Touch the pad of the thumb to the pad of each other finger. (Tell your child to have her thumb say “hello" to her index, middle, ring, and pinkie finger. This is called opposition.)
• Practice touching keys on a keyboard, piano, or calculator using different fingers
• Using a tennis ball or other small ball, have your child “walk" the ball up one leg, across her tummy, and down the other leg using only the fingers of one hand

In-Hand Manipulation Skills
In-hand manipulation is the ability to move and precisely place objects in one hand without the use of the other hand. There are several types of in-hand manipulation: translation is the movement of objects from the palm to the fingertips and from the fingertips to the palm. Rotation is rotating an object using the fingertips, such as rotating a pencil from the writing position to the erasing position. Shift is moving the position of an object using the fingertips, such as picking up a pencil towards the top and using the fingertips to shift the pencil up until you are holding it nearer to the point.

What to Look For
Children who have difficulty with in-hand manipulation skills need to use both hands to perform these skills. For example, to erase a letter they have written they will hand the pencil to their “helper hand" while rotating it to the erasing side and then hand it back to the dominant hand. During translations, children will use both hands, drop items, or stabilize their hand against a tabletop or their body.

Exercises to Strengthen
• Practice! Pick up pennies one at a time from a table using a pincer grasp and translate them to the palm. Once the total number of pennies is contained in the palm, bring them back out to the fingertips one at a time and place them in a piggy bank or other container such as the holes in an egg crate or ice cube tray without using the other hand or dropping any pennies. You can also practice this skill with small rocks, pieces of candy, dry beans, or other small disc shapes. As a general guideline, children around the age of 3 should be able to manipulate at least one penny, 5 year olds should be able to manipulate 2-5 and an 8 year old should be able to manipulate 10. For older children, play games such as Travel Connect Four, translating up to 10 pieces at a time while playing the game.
• For school-age children, practice rotating a pencil from writing to erasing (hold their “helper hand" down to keep them from using it when erasing homework).
• For school-age children, practice moving the fingers up a pencil until they can touch the eraser and then down the pencil until they can touch the point.

EYE-HAND COORDINATION (Visual Motor Skills)
Often referred to as visual motor skills by occupational therapists, eye-hand coordination is the controlled movement of the hands guided by the eyes. (The eyes control our visual attention so that the hands can achieve a skill.) Eye-hand coordination affects a multitude of skill sets including drawing, writing, cutting, tying shoes, lacing, building with blocks, completing puzzles, throwing, catching, kicking, batting and dribbling a ball, to name a few.

What to Look For
Children with difficulties in this area often appear clumsy and uncoordinated. Often, deficits in this area are first noticed when the child begins to learn to write his name or cut a line in school and these activities seem more challenging than they do for peers. Or, parents notice the problem when their child begins taking an early sport or gym class and his abilities seem strikingly inferior to his peers.

Usually, children with visual motor deficits have normal eyesight (known as visual acuity). However, it is a good idea to take your child for an eye exam to make sure there are no underlying visual problems. Keep in mind that more often, children’s visual acuity is fine, but the coordination of their eye muscles—known as ocular motor skills—is delayed. A child with decreased ocular motor skills will follow a moving target (such as a fingertip) by moving her whole head instead of just her eyes, or lose his place often when reading and need to use his finger to compensate. These skills can be assessed by a developmental optometrist and worked on by developmental optometrists and occupational therapists. Often, however, the visual system as a whole is intact and the problem lies in how the visual and motor systems communicate.

Exercises to Strengthen
Like most things, eye-hand coordination can be improved with practice. When practicing a particular skill isn’t helping, the skill should be broken down into smaller steps; each component part should be taught and practiced before attempting to put the parts together. For example, if a child is having difficulty navigating a hopscotch board, rote practice of an entire board may not be enough to learn the skill. The skill can be broken down into first practicing repeatedly jumping forward with two feet, then repeatedly hopping forward on one foot, then jumping with two feet along marked squares, then hopping on one foot along marked squares, then jumping from two feet to one foot, then jumping from one foot to two feet. After all of these skills are mastered, the board as a whole can be attempted. Simplifying a higher-level skill can also help. For example, practice batting a ball using a beach ball or playground ball before attempting a Wiffle ball or baseball. First practice stringing beads with larger beads and a pipe cleaner, which is stiffer and easier to manage than string.
• Have your child lie on his belly, holding a tennis ball. Roll a large ball (such as large playground ball or therapy ball) across the floor in front of your child. The object of the game is for your child to roll the tennis ball and hit the larger ball as it passes.
• Have your child place straws, pipe cleaners or toothpicks through the small holes of a clean, empty spice jar.
• Line paper cups with colored masking tape at different levels. Have your child pour water from a pitcher or bottle into the cups up to the line.
• Roll two socks into a ball. Practice throwing them into laundry baskets placed in various positions around the room. This is a good way to practice throwing when indoors.
• Tie a length of string through a Wiffle ball and suspend (you can hang it from a branch of a tree or playground equipment as long as your child has enough room). Have your child practice hitting the ball with a pole or bat. For a thicker bat, cut the bottoms off two empty soda bottles and tape together with masking tape. The child can practice batting by holding the bat with two hands and facing the ball. Have the child try to hit the ball to a rhythm (such as you clapping in time). Or, practice traditional batting as performed in baseball.
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