O.n T.ues Day

Play and hand skills – 0 to 12 months

It is a child’s "job" or "occupation" to play! The great benefit of play is that it is fun whilst developing physical coordination, emotional maturity, social skills to interact with other children, and self-confidence to try new experiences and explore new environments.

Some children can have difficulties with play and learning. This can be because of conditions that affect development,  an injury or perhaps differences in individual learning styles and needs. If a child’s play and ability to learn is affected, then their independence, health and how they feel about themselves will be impacted. Our job as Occupational Therapists is to help children to live more independently to improve their capacity to continue to play and learn.

A significant aspect of play involves hand skills or fine motor skills. These skills refer to the coordinated use of the small muscles in the hands and fingers to complete precise and accurate motions such as touching, reaching and grasping.  These motions not only enable exploration of the child’s world but also the facilitation of key developmental areas that include imaginative play, social interaction and communication.  In order for Occupational Therapists to support a child in developing the next stage of skills, it is important to know how skills are developed!

The development of hand skills:

At around three months of age, children can hold small toys placed into their hands, explore their own hands, bring their hands/toys to the mouth, and reach and swipe out at dangling toys.

At around six months of age, children begin to grasp objects within their reach using their whole hand. They can start to hold onto toys for longer, explore toys using their mouth and reach for toys using both hands. It is also around this age that children start to learn to sit on their own freeing their hands to play with toys. 

At around nine months of age, children begin to pass toys from one hand to another, hold toys between their fingers and thumb, hold a toy in each hand and purposely let go of toys onto a surface such as their highchair tray. 

At around twelve months of age, children start to point at toys using their index finger, pick up small objects using their fingers and thumb and place objects in open containers or an adult's hand.

How understanding developmental milestones shape therapy strategies:

There is a lot of talk about developmental milestones and the ages that we might expect to see these skills emerge. For children with neurological conditions and injuries, the timestamp for these milestones is not our main focus, rather it is the identification of what skill stage the child is currently at. From there, therapy will aim to consolidate those skills so that it is used in their everyday repertoire and strategies and toys are selected to help progress to the next stage. The approach to achieving these skills (the type of therapy) and the dosage (how frequently it needs to be practiced) is where research comes in. Research tells us how to and how much so that you get the “most bang for your buck”.

Here are some helpful strategies to select toys for each stage of development: 

Early fine motor skills  

• Open ended toys. This refers to toys that have no predefined structure to the play pattern. The experience is entirely child-led to enable “error free” exploration.
• Play simple games and recite nursery rhymes with timed physical actions to develop anticipation and response taking. 
• Turn taking vocalisation games and imitating the noise the child makes. 
• Read books where you can make the noises that match the pictures. This is super fun! Choose books with high contrast pictures and a small number of words. Look out for books with different texture feels.
• Musical toys.
• Toys that light up on touch and movement 

Developing more precise fine motor skills 

• Play hide and seek games.
• Play stacking games (go from larger size blocks to smaller size ones).
• Play memory retrieval games where you hide an object under a choice of 2-3 boxes so that the child needs to lift the cup to find the object.
• Provide textures to explore.
• Container play e.g. place objects in boxes for the child to retrieve 

Play and hand skills – Toddler years

Play is an important part of a child’s early development. Playing helps children learn and develop by discovering and exploring the world around them. Discovery is dependent on opportunities for ‘trial and error’ to understand what works and what doesn’t and this is very commonly seen when babies transition into toddlers. 

Toddlers are very busy and inquisitive at this stage of development and they thrive on interactions and exploration of their environment. Every child is different and there is a big range of ‘normal’ in children’s development. As therapists we aim to facilitate and encourage this natural curiosity and provide strategies to further develop these essential skills to promote independence, participation in daily activities and improve their capacity to play and learn.

The three areas that therapists can focus on during this developmental stage are fine motor skills, play and social interactions/communication.   

The development of hand skills:

After mastering skills such as reaching and grasping a toy, the next step is to refine and develop more precise and controlled movements that allow children to complete more complex tasks. This may include using a fork or spoon, putting pen to paper and isolating fingers to point to an object they desire. This stage of development sees children begin to use both hands in a more coordinated way to push, pull, turn, stack toys and pull them apart and build them up again. During this stage, we see progression from using the whole hand to grasp or using a ‘raking’ motion, to a pincer grasp using the thumb and index finger to pick up small items with accuracy. 

The development of play and social skills:

Toddlers are experimenting, thinking, solving problems and learning all the time. Play is vital for a toddler’s cognitive development, because it’s one of the main ways toddlers explore the world. Through exploration and experimentation, toddlers develop the ability to think, understand, communicate, make memories, imagine and work out what might happen next. Imaginative play, role playing and turn taking are all vital components of this stage of learning. 

The development of communication skills:

These early years are the optimal time for children to experience both expressive (communicating needs and wants) and receptive (understanding basic conversation) communication opportunities. Toddlers communicate using a combination of sounds, gestures, and facial expressions. Reading with children at this stage on a regular basis is such an effective way to foster these opportunities. Books provide great opportunities to ask toddlers to point to objects on a page, imitate words and later progress towards “who/what/where” questions..  

How understanding developmental milestones shape therapy strategies:

There is a lot of talk about developmental milestones and the ages that we might expect to see these skills emerge. For children with neurological conditions and injuries, the timestamp for these milestones is not our main focus, rather it is the identification of what skill stage the child is currently at. From there, therapy will aim to consolidate those skills so that it is used in their everyday repertoire and strategies and toys are selected to help progress to the next stage. The approach to achieving these skills (the type of therapy) and the dosage (how frequently it needs to be practiced) is where research comes in. Research tells us how to and how much so that you get the “most bang for your buck”.

Here are some helpful strategies to select toys for each stage of development: 

Strategies to develop these skills  

• Play stacking games (go from larger size blocks to smaller size ones and varying shapes) to work on hand eye coordination. 
• Stacking and pulling apart duplo. Depending on the child’s age, pulling the duplo apart with both hands might be easier to achieve than stacking the duplo. The ability to stack duplo will come as more skills develop.  
• Provide opportunities to pick up small items such as sultanas or blueberries and encourage children to do this using their index finger and thumb. 
• Table top activities such as drawing, sticker books, play dough and puzzles are great ways to strengthen the small muscles of the hand, practice movement in a controlled way as well as work on hand eye coordination. 
• Sing songs together that have repetitive lines and actions whilst providing opportunities for children to finish sentences or missing words of the song. Songs also provide great opportunities to incorporate actions such as clapping and use two hands together.
• Read books with interesting and various objects to point to on the page as well as asking questions to provoke responses.   

School readiness skills (3 to 5 years)

School readiness refers to a child’s readiness to make a smooth and successful transition into more formal schooling whether that be pre school, kindergarten, or an early learning centre. These include social, language, play, self care and hand skills which, when well established, make learning easier for the child, teacher and parent. 

Hand skills

We start to see children build on their foundation hand skills and begin to use their hands and fingers in a more skilful and coordinated way. This can be observed in activities when using a pencil to draw basic shapes such as a cross, circle or straight lines, when using scissors to cut along a straight line, or even using a spoon or fork to feed themselves. 

We also start to see children favouring one hand over the other for skilled parts of an activity. For example, when writing or drawing the preferred hand holds and uses the pencil whilst the other hand supports the paper. It is, however, common at this stage for children to swap hands and a real preference isn’t typically fully established at this point. 

Some activities to promote hand skill development include:

• Encourage children to put pen to paper using a range of interesting textas, crayons, coloured pencils and different paper. 
• Use various mediums such as drawing in sand or foam to provide a sensorimotor experience.
• Drawing and completing activities on a vertical surface such as drawing on blackboard or white board, placing magnets on the fridge, or painting at an easel.
• Continue to develop fine motor skills through fun activities such as art and crafts, building blocks, and using pegs or tweezers to pick up small objects such as pom poms. 
• Manipulating playdough helps to strengthen the small muscles of the hand, develop control and improve dexterity which are skills required for handwriting and cutting. Try some of the following play-doh activities with your child:
• Roll into balls or long logs using two hands
• Pinch small sections using the thumb and index finger
• Squeeze in the palm of the hand
• Poke holes using the index finger 
• Add essential oils to the dough to make it more of a sensory experience

Play and social skills

At this age children are very social and interested in the world around them. They are moving on from playing alongside other children to interacting with their peers. This requires many different skills such as turn taking, emotional regulation (ability to perceive and control emotions), reading social cues (such as body language and facial expressions) and attending to an activity. 

Reading with your child is a great way to promote communication. Encourage your child to tell their own story based on the pictures of a book, ask lots of open ended questions such as “who/what/where/when” throughout the story or even create your own storybook with your child. 

Communication

Communication at this age is very important as children are rapidly expanding their receptive communication (understanding who/what/where questions, understanding basic concepts such as big/little and on/under) and their expressive communication (which is communicating their needs, wants, thoughts and ideas). Children also begin to form more complex sentences, and their language becomes clearer and easier to understand, particularly for those outside of their immediate family. This may occur verbally, through key word sign, or low/hi tech communication devices. 

Turn taking games support the development of both play and communication, and can  be practiced using fun games such as blowing bubbles, stacking blocks, bowling and simple board games. 

This age group is all about gaining more independence and acquiring skills that allow optimal engagement and participation in school-based activities

Fine motor skills

Fine motor skills develop naturally as your child gains the ability to control and coordinate their body. As fine motor skills continue to develop, children gain more independence in activities such as feeding and dressing. Some important fine motor skills include:

• Strengthening the muscles hands 
• Developing wrist stability 
• Separation of the two sides of the hand.
• Using 2 hands together in a coordinated way 

Keep in mind that some children might develop fine motor skills earlier or later than others, but incorporating fun activities into their daily routine can help improve their fine motor skills. 

Some activities may include:

• Encourage children to hold the paper with one hand and cut or draw with the other
• Beading and threading activities
• Allow your child to assist with meal preparation, like stirring, kneading, or pouring ingredients
• Put together a puzzle as a family
• Finger painting/ using spray bottle to paint on a vertical surface 
• Place objects in a container and have your child remove them with tweezers
• Construction based activities such as lego
• Cutting basic shapes
• Practicing writing and cutting with play dough

Some strategies to help cutting skills include:

• Using thicker paper
• Trialling various types of scissors
• Encouraging a “thumbs up” position from the very beginning
• Place something between their trunk and elbow to reduce excess movement and provide stability

Handwriting skills

Children develop handwriting ability at very different rates, and the development is ongoing throughout childhood. This is because handwriting is a very complex task that requires coordination of the small muscles of the hand, coordination of your vision and hand movements, and also a cognitive aspect to understand letters of the alphabet, writing from left to right and top to bottom. Handwriting is  a tricky task for some children but it is a skill used at school to complete homework and assignments, and in every day tasks such writing a card or filling in forms.

Children start to use a more mature and dynamic pen grip using the thumb and index finger, with the wrist positioned slightly backwards (extension), and the forearm comfortably on the table. This sees movement initiated from the wrist and fingers as opposed to the elbow and shoulder that we tend to see earlier on in development. Children start to grasp letter formation, start to write their name and the alphabet.

Some strategies to support handwriting in the classroom include:

• Highlight dotted thirds to indicate top and bottom  
• Building the grip of a pen to support grasp 
• Use of an angle board to support the position of the wrist and hand.