TINY HANDS: An Overview of Fine Motor and Visual motor Assessment and Indicators for When to Refer Elizabeth Harris, MS OTR/L March 16, 2016
The Role of Occupational Therapy • Occupational therapy evaluations address: • developmental milestones including movement/strength/coordination • attention and follow simple instructions • participating in age appropriate daily routines • self-help skills (ability to eat, drink, wash, and dress) • sensory regulation/modulation • Occupations of infants and toddlers: • Eating, playing, social interaction
Occupational Therapy Evaluation • Evaluations Focus on: • Determining functional age • Assess muscle strength/tone/ROM • Assess visual skills • Assess Fine motor and Visual Motor coordination • Assess Gross motor coordination and motor control • Assess Feeding skills
Assessment of Upper Extremity, Neck, and Trunk Ages 0-18 months • Range of Motion and positioning • Active/Passive movement of the Upper Extremity • Joint and structural alignment of Upper Extremity including scapula and trunk • Muscle Tone • Hypertonicity- exhibiting excessive tone or tension • Hypotonicity- having less than normal tone or tension • Fluctuating Tone or dystonia- occurs when the muscle tone or tension is not consistent. Muscles will relax and contract involuntarily and will be too tight or too loose at times
Typical Development • Strength-Upper Extremity including hands, neck, and trunk • 1-2 months- Lifting head while prone • 2-4 months- pushing up through forearms, lifting head/chest 45 degrees • 6 months- push up through extended arms in prone; reaching while prone; maintaining quadruped; using UE’s for support in prop sitting and transitions (emerging) • 8-9 months- crawling/creeping; pulling up to standing; using UE’s for support in standing • 10 months and up- using hands/arms functionally
Fine Motor Coordination Fine Motor Skills by Age • Ages 0-3 months: • Grasping reflex-Tightly grasps objects placed in hand. • Holding onto rattles and shaking rattles • Brings hands to mouth • Ages 3-6 months: • Purposeful movements including reaching with both hands. • Open palms • Bring hands to midline
Fine Motor Continued • Ages 6-9 months • Transfer objects between hands • Exhibits Raking Grasp • Clasps hands • Ages 9-12 months • Points with index finger • Exhibits Neat Pincer Grasp • Ages 12-18 months • Stabilizes objects with one hand while working with opposite hand • Assembles simple formboards
Types of Grasps • Gross grasp • Palmer grasp (0-3 months)-When an object touches an infants palm, the infant's fingers will reflexively close around the object. • Raking grasp (4-5 months)- use all of their fingers as a whole to pull an object into their hand and often bend their wrist inward • Ulnar and radial grasp- use of each side of the hand and palm • Precision grasp • Pincer grasp (10-12 months)- full opposition of the pad of the thumb and the pad of the index finger to secure the object while using the pincer grasp
The Visual System The Visual System includes the following: • Eyes • Nerves that connect the eyes to the brain • Parts of the brain that process and interpret what we see primarily the occipital lobe.
Vision involves Two Processes • A person may have problems with one or both of the following processes: 1. Eye movement and taking in visual information into the brain 2. Processing and interpreting what you see
The Visual System The Vision Portion of the Brain functions by: • Coordinating the eyes to move together • Storing what we see in our memory • Allowing us to adjust how we move based on what we see
Eye Movement • The brainstem helps control eye movement. It directs the six muscles that keep the eyes moving together as you look up, down, right, and left
Processing and Interpreting • This is where the true "seeing" takes place. • Visual Perception or Visual Processing is interpreting what we see. This allows the brain to: • Distinguish colors • Follow patterns • Remember what is seen • Discriminate details • Determine directions and spatial relationships.
Visual Tracking • Visual Tracking is the ability to quickly and accurately look (fixate), visually follow a moving object (pursuit) and efficiently move our eyes so we can fixate on objects from point to point (saccades). • Typical development: • Eyes to Midline (1-3 months) • Eyes past Midline (2-3 months) • Eyes downward (2-3 months) • Eyes upward (2-3 months) • Eyes to 180 degrees (2-3 months) • Eyes without Head movement (4-6 months)
Eye Movement and Taking in Visual Information • Problems may include: • Muscle Weakness or Paralysis • Refraction Errors (i.e., nearsighted, farsighted, astigmatism) • Nystagmus (i.e., involuntary rhythmic oscillations)
Muscle Weakness of the Eye • Deficits may include: • Focusing on objects as they move (i.e., visual tracking) • Moving eyes smoothly from one object to the next (i.e., saccades) • Eye misalignment • Convergent: coordinated movement and focus of our eyes inward on close objects. • Divergent: coordinated movement of our eyes out away from each other and usually occurs when looking at an object moving further away • Hypertropia (strabismus): the visual axis of one eye is higher than the fellow fixating eye • Hypotropia: the visual axis lower than the fellow fixating eye.
Assessment of Visual Motor Coordination Visual motor coordination: effective and efficient communication between the eyes and the hands • 1-2 months • 6-7months • Extends 1 arm toward rattle • Tracking stationary and moving objects • Transferring objects between hands • 3-4 months • Touching small food pellets • Extends arms toward rattle (supine) • Banging toys together at midline • Approaching midline • Banging rattle on surface • 8-9 months • Poking using isolated fingers
Visual Motor Coordination Continued: • 10 months • 15-16 months • removing pegs from a pegboard • Stacking 2-3 blocks • 12-13 months • 17-18 months • Inverts containers • Places 2/3 simple shapes into formboard • Places small items into small containers • Places pegs • Places at least 1 shape into formboard • 14 months • Scribbling on paper
Self Help Skills Fine motor and visual motor skills setting the stage for progression of self help skills • Newborn: • State regulation before/during/after feeding • Oral motor skills- fluid loss, coordination (suck/swallow/breath) • 3-5 months: • Bringing hands to mouth • Regards bottle visually • Pats bottle and places hands on bottle • 6 months • Using raking grasp and begins feeding self
Self Help Skills continued • 9-12 months • Holds spoon; dips spoon and brings to mouth • Uses pincer grasp to self feed • 15 months • Begins to scoop food and empty contents in mouth Dressing • 15-18 months • Purposefully removes socks/assists with donning socks • Begins to zip/unzip large zipper
THANK YOU Any Questions?
References • American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain & process (3rd ed.). American Journal of Occupational Therapy, 68 (Suppl. 1), S1 – S48. http://dx.doi.org/10.5014/ajot.2014.682006 • Occupational Therapy for Children fifth edition by Jane Case-Smith • PDMS-2 Peabody Developmental Motor Scales Second Edition by M. Rhonda Folio and Rebecca R. Fewell • Hawaii Early Learning Profile by Furuno, et al.
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