Category Archives: hand coordination

Boost Pincer Grasp With Tiny Containers

These days I am getting pretty…lazy.  My go-to items are designed so that children automatically  improve their grasp or their posture without my intervention.  I am  always searching for easy carryover strategies to share with parents too.  As with most things in life, easy is almost always better than complicated.

My recent fave piece of equipment to develop pincer grasp in toddlers and preschoolers is something you can pick up in your grocery store, but you are gonna use it quite differently from the manufacturer’s marketing plan….

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Remember these?

Enter the tiny party cup, AKA the disposable shot glass!  Yes, the one you used when you played “quarters” in school.  The very same.  These little cups work really well to teach toddlers to drink from an open cup, but they are also terrific containers to promote pincer grasp in young children.  Drop a few small snacks into these little cups and discourage them from dumping their snack onto the table instead of reaching inside with their fingers.

No matter how small your child’s fingers are, they will automatically attempt a tripod or pincer grasp to retrieve their treat.  You should’t have to say much of anything, but it never hurts to demonstrate how easy it is.  Make sure you eat your snack once you take it out of your cup.  After all, grownups deserve snacks too!

These little containers are much sturdier than paper cups.  This means that they can survive the grasp of a toddler who cannot grade their force well.  The cylindrical shape, with a slightly smaller base than top, naturally demands a refined grasp.  The cups have a bit of texture around the middle of the cup (at least mine do)  which gives some helpful tactile input to assist the non-dominant hand to maintain control during use.  They are top-shelf dishwasher safe and hand-washable, in case you feel strongly that disposables aren’t part of your scene.

Has your child mastered pincer grasp?  These little cups are fun to use in water and sand tables as well.  Mastery of pouring and scooping develops strong wrist and forearm control for utensil use and pre-writing with crayons.

For more ideas on developing grasp, take a look at Want Pincer Grasp Before Her First Birthday? Bet You’ll Be Surprised At What Moves (Hint) Build Hand Control! and Develop Pincer Grasp With Ziploc Bags.

 

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The Hypermobile Hand: More Than A Strength Problem

 

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I just received another referral for a kid with “weak’ hands.  Can’t hold a pencil correctly, can’t make a dark enough mark on paper when he writes or colors.  But his mom says he has quite a grip on an object when he doesn’t want to hand something over.  He plays soccer without problems and otherwise functions well in a regular classroom.  Could it be that hypermobility is his underlying problem?

Some children display problems with fine motor skills due to low muscle tone.  Many times, their low tone is significant enough to create poor joint alignment and stability, resulting in joint hypermobility as well as low muscle tone.  But kids can also have joint laxity with typical muscle tone.  Assessing the difference between tone, strength, alignment/stability and endurance is why you get an evaluation from a skilled therapist.  And even then, it can be tricky to determine etiology with the youngest children because they cannot follow your directions or answer questions.  Time to take out your detective hat and drill down into patient history and do a very complete assessment.

With older kids, both low tone and joint laxity can lead them over time to develop joint deformity and soft tissue damage.  Like a tire that you never rotated on your car, inappropriate wear and tear can create joint, ligament, tendon, and muscular imbalance problems that result in even worse alignment, less stability and endurance, and even pain.  And yes, weakness is often observed or reported, but it often is dependent on posture and task demands, rather than being consistent or specific to a nerve distribution or muscle/muscle group.

What does the classic hypermobile hand look like?  Here are some common presentations:

  • The small joints of the fingers and thumb look “swaybacked”, as the joint capsule is unstable and the tendons of the hand exert their pull without correct ligament support.  When they slide laterally and the joint is unable to move smoothly, people say that their fingers “lock” or they are diagnosed with “trigger finger”.
  • The arches of the hand aren’t supported, so the palm looks flat at rest.  By late preschool, the arches of the hand should be evident in both active and passive states.
  • The fleshy bases of the thumb and pinky ( the thenar and hypothenar eminences, for all you therapists out there) aren’t pronounced, due to the lack of support reducing normal muscle development during daily use.
  • Grasp and pinch patterns are immature and/or atypical.  A preschooler uses a fisted grasp to scribble, a grade-school child uses two hands to hold an object that should be held by one hand and uses a “hook” grasp on a pencil.
  • Grasp and pinch may start out looking great, and deteriorate with the need for force.  Or prehension begins looking poor and improves for a while, until fatigue sets in.  This bell-curve pattern of grasp control is often seen with kids that have poor proprioceptive discrimination.  As they use their hands they receive more input, but as fatigue sets in, they cannot maintain a mature grasp and good control.
  • The typical arches of the hand that create the “cupping” of the palm when pretending to scoop water from a stream, for example, will be somewhat flattened. Unless there is nerve damage, you won’t see the “claw hand” pattern or another atypical posture.
  • Fine grasp will often be accomplished with the thumb and third finger to achieve greater stability through the MCP (knuckle) joints and to avoid full opposition of the thumb.  Another common compensatory pattern is using digits II and III together to gain greater stability.  Some kids can even wrap one digit partially around another to do this.  Now that’s hypermobility!

Don’t forget that hypermobility creates poor sensory processing feedback loops.  Reduced proprioception and kinesthesia will result in issues when children try to grade force and control movement without compensations such as visual attention and decreased speed. This can result in kids being labeled clumsy or careless.

Looking for ideas to address the difficulties children face when they have hypermobility in their hands? Take a look at For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance and Does An Atypical Pencil Grasp Damage Joints or Support Function In Kids With Hypermobility?.  Depending on the age and skill level of the child, adaptations and education can be just as important as therapeutic exercise.  Your pediatric occupational therapist can help with more than pencil grasp; we are able to help with so many real-life issues!

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When Should You Begin To Teach Handwriting? (You May be Surprised!)

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The ability to bring two hands to midline and use fingertips to hold a block is a pre-writing skill!

Many formal handwriting programs begin at 4 years of age.  Handwriting Without Tears, Fundations, and others begin with children tracing letters and quickly progress to writing.  But the foundational skills for handwriting actually begin early.  Before your child’s first birthday.  Yes, that early.  And, believe it or not, that is when you could be teaching important skills that will eventually morph into handwriting.

No, I am not suggesting that we start teaching infants to write!  I have met a handful of very gifted children, some of whom could read before 4, but not one was writing letters before their first birthday.  The foundational skills for handwriting are grasp, reach, bilateral control, posture, ocular (eye) control and visual perception.  And every single one of these skills is developing before a child turns 1.

How do you develop these skills?  Play.  Play with small toys, play with big ones.  Play that requires a child to move.  Crawling through a tunnel and climbing over cushions to develop arm and hand control.  Play on their stomach and play standing at a table for posture and core stability.  Play that requires more than tapping a screen or pressing a button.  I love my tablet as much as the next person, but I was fortunate to grow up before it was invented.  I had something called “toys”.

If you sent me to teach occupational therapists in a developing country, I would bring a small bag of the best toys I know:  crayons, paper, scissors, LEGOs, balls of all sizes, and I would use some things that every home is likely to have:  small cups for scooping and emptying, scarves for peek-a-boo, and little pieces of food for self-feeding.  This is all you need.  Really.  Giving a child the chance to feed themselves, play in water and sand, build and scribble can do a lot to build foundational skills.

One thing that I forgot to mention as a foundational skill is……interest. Some kids are very interested in coloring.  Many are not.  Same with reading.  How do you get your child interested in writing?  You allow them access to tools, make the tools desirable, and show them that you enjoy coloring or writing.  When your infant reaches for your pen and you slide it away from them, they are showing you interest.  They can’t use a pen, but they can mess around with food puree on their high chair tray, drawing lines in the goo.  Prewriting at work.  When your toddler wants to eat the marker, remind them that these are for scribbling, and help them to make a masterpiece.  Every day.  Find fun materials.  I am a big fan of crayons instead of markers, but there are some sparkly crayons and some great markers and papers that don’t destroy your home while your child is learning to draw and write Color Wonder Paper Will Boost Creativity and Save Your Walls.

Not an artist?  No problem!  Fake it.  Just like you gleefully eat veggies even though you’d rather have cake, scribble and make something silly on paper.  Show how much fun it is.  You might find out that you are more creative than you thought, or that once you kill that critic in your head, you actually like to draw.

Child development experts bemoan the limited language skills of kids from families without books.  Philanthropists like Dolly Parton donate tons of books to poor families in the hopes that children will be read to and develop a love of reading.  Guess what?  Children need to have early experiences with writing and drawing as well.  The family that has no crayons, no markers, no paper and no interest in drawing or writing will not inspire their children.

Give the gift of “pre” prewriting to your child, and give them a head start today!

Looking for more information on handwriting and development?  Read Have More Fun When You Use Drawing To Develop Pre-Writing Skills and Why Dot-To-Dot Letter Practice Slows Down Writing Speed and Legibility.

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Which Improves Pencil Grasp Best: A Pencil Grip Or A Thicker Pencil?

 

kelli-tungay-324329A a pediatric occupational therapist, I am often asked to weigh in on this debate.  Not often enough, it seems.  There are a lot of kids out there using pencils with wonky grasp patterns because no one has made an effort to improve the way they hold a pencil, or they doubt that it matters.  Oops.  Although grasp isn’t often or evn usually the biggest issue with writing problems, a really poor grasp can reduce control and increase pain and fatigue.  Not every kid with poor pencil grasp is a hot mess.  Some of them just need good instruction and good materials.  For the others, it might be time to get an OT involved.

Kids that struggle with pencil grasp are often (in my opinion, too often) given a pencil grip and told to use it when they write. It may help, but it may not.  An yet, I will still hand out my favorite pencil grip if I think that it will build control and strength. The Pencil Grip That Strengthens Your Child’s Fingers As They Write.

I thought I would drill down into the ways that OTs think about the use of pencil grips, and present a few alternatives to reflexively sending kids home with a bit of plastic on the end of a pencil:

  • Change the pencil.  Triangular pencils give more sensory feedback during writing, and they offer a flat surface for finger pads.  Thick mechanical pencils still have a standard-thickness lead, but they also are easier to hold for some children.  Short pencils, including golf pencils, force more fingertip contact and can be helpful (but not if grasp is really weak or awkward).
  • Don’t jump into pencil use too early.  Until a child can manage a mature grasp, I try very hard to keep them using crayons when they are not yet in kindergarten.  I like the flip crayons from Learning Without Tears because they are so very small, but not all kids in kindergarten are ready for them.  I break a toddler crayon in two so that they get the benefits of a thick shaft but they will be unable to use a fisted grasp.
  • Like markers?  I only use them if they are the Pipsqueak markers from Crayola.  Nice thick, short shafts for little fingers.  Markers don’t give a child any resistance at all, so they don’t give enough sensory feedback or strengthening for my kids that need both.  And they make a mess most of the time.  I don’t have the time to scrub off markers.
  • Build strength and control with play.  Yes, fine motor play.  Totally outdated (just joking) but necessary.  I use the iCreate tablet stylus, bead stringing, therapy putty and lots of tiny toys like travel Connect Four games.  Even baking.     Utensil use counts too. How Using Utensils To Eat Prepares Your Child To Write    Children are spending less time with toys and more with tablets, so I insist that they use a tablet stylus with me in sessions.  They have no idea that the physical “drag” of the plastic point on the glass screen as they move objects around is creating resistance that helps their fingers get stronger.
  • Color with children, draw with children. A lot.  Coloring is less stressful to the risk-averse child who thinks he can’t write. Drawing simple shapes is directly applicable to writing letters and numbers.  Think “T” and a vertical cross, “A” and a volcano.  Watching an adult and listening to their narration, such as ” I am coloring around and around to fill in the balloon, since it is a circle shape”  is very helpful to young children who resist direct instruction.  The child that doesn’t naturally gravitate to coloring may need downloads of their fave character or stickers to add to the picture to make it exciting.  But the key is the adult interaction.

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For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance

 

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One of my most popular posts, Why “Hand-Over-Hand” Assistance Works Poorly With So Many Special Needs Children , explains how this common method of assisting children to hold and manipulate objects often results in rejection or even aversion.  This post tells you about my most successful strategy for kids with low muscle tone and limited sensory processing:  using graded resistance.

Why does making it harder to move work better?  Because if the child is actively trying to reach and grasp an object, you are providing more tactile, kinesthetic and proprioceptive information for their brain.  More information = better quality movement.  Your accurately graded resistance is doing what weighted/pressure vests, foot weights and SPIO suits do for the rest of their body.  Could you use a hand weight or weighted object?  Maybe, but little children have little hands with limited space to place a weight, and weights don’t distribute force evenly.  Did you take physics in school?  Then you know that gravity exerts a constant pressure in one direction.  Hands move in 3-D.  Oh, well.  So much for weighting things.

How do you know how much force to use?  Just enough to allow the child to move smoothly.  Its a dance in which you constantly monitor their effort and grade yours to allow movement to continue.

Where do you place the force?  That one is a little trickier.  It helps to have some knowledge of biomechanics, but I can tell you that it isn’t always on their hand.  Not because they won’t like it, but because it may not deliver the correct force. Often your force can be more proximal, meaning closer to the shoulder than the hand.  That would provide more information for the joints and muscles that stabilize the arm, steadying it so the hand can be guided accurately.   If a child has such a weak grasp that they cannot maintain a hold while pushing or pulling, you may be better off moving the object, not the hand,  while they hold the object, rather than holding their hand.

Still getting aversive responses from the child?  It may be because the child doesn’t want to engage in your activity, or they don’t realize that you are helping them.  They  may think that adults touch them to remove objects from their grasp or otherwise stop them from exploring.  Both can be true.  In that case, make sure that you are offering the child something that they want to do first.  Remember, we can’t force anyone to play.  The desire to engage has to come from them, or it isn’t play.  Its just adults making a kid do something that we think is good for them.

 

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One of the most amazing places I have ever seen:  Australia!

OXO for Kids: Great Tableware For Older Kids With Sensory and Motor Issues

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Does your child knock over her milk on a daily basis?  Do utensils seem to fly out of your son’s hands?  I treat kids with hypermobility, coordination and praxis issues, sensory discrimination limitations, etc.; they can all benefit from this terrific line of cups, dinnerware and utensils.

Yes, OXO, the same people that sell you measuring cups and mixing bowls: they have a line of children’s products.  Their baby and toddler items are great, but no 9 year-old wants to eat out of a “baby plate”.

OXO’s items for older kids don’t look or feel infantile.   The simple lines hide the great features that make them so useful to children with challenges:

  1. The plates and bowls have non-slip bases.  Those little nudges that have other dinnerware flipping over aren’t going to tip these items over so easily.
  2. The cups have a colorful grippy band that helps little hands hold on, and the strong visual cue helps kids place their hands in the right spot for maximal control.
  3. The utensils have a larger handle to provide more tactile, proprioceptive and kinesthetic input while eating.  Don’t know what that is?  Don’t worry!  It means that your child gets more multi-sensory information about what is in her hand so that it stays in her hand.
  4. The dinnerware and the cups can handle being dropped, but they have a bit more weight (thus more sensory feedback) than a paper plate/cup or thin plastic novelty items.
  5. There is nothing about this line that screams “adaptive equipment”.  Older kids are often very sensitive to being labeled as different, but they may need the benefits of good universal design.  Here it is!
  6. All of them are dishwasher-safe.  If you have a child with special needs, you really don’t want to be hand-washing dinnerware if you don’t have to.

For more information about mealtime strategies, please take a look at Which Spoon Is Best To Teach Grown-Up Grasp? and Teach Spoon Grip By Making It Fun And Sharing a Laugh With Your Child.

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Teach Utensil Grasp and Control…Without the Food!

Therapro has just published my latest guest post! There are some situations that almost require occupational therapists to separate mealtime from utensil manipulation, at least at the earliest stages.  Check out my post Teaching Utensil Use Outside of the Mealtime Experience to find out if your child or client would benefit from this approach!

If you haven’t already read this very popular post I wrote earlier, make learning to use utensils an opportunity to bond emotionally,  take the pressure of self-feeding off the table and help an avoidant child engage in food play with Teach Spoon Grip By Making It Fun And Sharing a Laugh With Your Child.

Therapro has been one of my go-to sources for quality therapy equipment for years.  Take the time to review their catalog online and explore their unique bowls, plates and utensils that can help children with developmental delays achieve independence in self-feeding.