SCHOODLES Fourth Edition Assessment Guide

Table Of Contents

Introduction

Welcome to the fourth edition of SCHOODLES School Fine Motor Assessment! Therapists around the world have been using SCHOODLES for years, and with their input, we updated and improved this tool to make it one of the best assessments for school-based occupational therapists.

This assessment tool is a streamlined approach to evaluating a child’s fine motor skills related to school performance. SCHOODLES guides you through a series of tasks that allow you to use and build your observation skills and knowledge to make individualized decisions about a student’s educational needs.

This expanded, revised SCHOODLES fourth edition now includes a fine motor goal chart, school-environment observation checklist, teacher questionnaire, and updated information in nearly every task area. Please frequently check our website, www.SCHOODLES.com, for additional helpful information.

We designed this evaluation tool to be fun for kids and therapists. We hope you and your students find enjoyment in all you do together! - The SCHOODLES Team

This assessment guide is intended to be used as a companion to the student workbook. It was written to help guide therapists’ assessments of fine motor functions and underlying abilities needed to support skilled hand use. Procedures and techniques described in this text are to be used solely for observational purposes; they are not intended to diagnose any condition or disability. Therapists using this observation tool do so entirely at their own discretion. The SFMA is the sole property of SCHOODLES. All rights reserved. Only the workbook is intended to be reproduced for use with students. The assessment guide may not be copied without the authors’ expressed written consent.

© 2016 by Marie Frank OTR/L and Monica Fortunato OTR/L
How to use this Tool

SCHOODLES may be used as a screening tool, for an update of skills in preparation for yearly IEPs, or as a thorough assessment to determine need for services. It may be used alone to demonstrate need, or as a companion to standardized tools.

The therapist guide provides an explanation of each task. Approximate ages for skill attainment and further information about how to observe the skills are included in the skill table located in the supplemental materials section. The student’s ability to complete each activity should be viewed and described qualitatively as well as comparatively within his/her age group.

The assessment is divided into two groups of skills. The first group is comprised of classroom skills. These are easily observable activities in any classroom. They are found in the workbook portion of the assessment. The workbook is reproducible for use with your students. The activities are directly associated with school performance, and can be translated easily into measurable goals and objectives. The workbook tasks are in a developmental sequence. Go through each task until the child plateaus, then move on to the next task.

Classroom skills are the specific outcomes teachers look for in the classroom. If a child is having difficulty doing the workbook tasks, completing the supporting skills activities helps you understand why the child is struggling. Please note that not all activities are appropriate for each age level; for example, use the coloring task with children learning to control a writing tool. If the student currently produces somewhat-legible work, the coloring task is not necessary.

The second group of activities addresses supporting skills. These skills are needed to achieve quality fine motor outcomes. These skills also are in developmental order. One may assume that if a child plateaus on a particular skill, he most likely cannot achieve the next level of skill. Difficulty in supporting skills helps determine need for OT services and treatment focus areas.
Read through the entire therapist guide before you begin. As you become more familiar with the tool, you will discover your observation and reporting skills become more individualized and refined.

Add child-size scissors, three crayons (blue, red, and orange), a pencil, a small rubber mat for the puzzle, and a scarf or tissues to a pouch. This makes SCHOODLES a complete grab-and-go tool.
Teacher Collaboration

As a related service, occupational therapy can be a key contributor to a child’s classroom success. Collaborating with the classroom teacher is an important component to identify needs. By law, occupational therapy intervention must support classroom outcomes, and relate to goal and objective areas the team establishes.

Once a referral for an occupational therapy assessment is made, the next step is to gather information about why the student was referred. This helps focus our work and eliminate unnecessary testing.

Gather pertinent information from the teacher, the resource teacher, and the current occupational therapist. We recommend finding times when staff is not busy, such as in the morning before students arrive or just after school. It is most productive to interview the student's teacher in person. Send an email asking for a time to meet, and you might send a few questions so she can prepare. Prep time may be a good time to talk as well.

We have provided a few questions below to help begin the conversation. A more extensive questionnaire is included in the supplemental materials section.

Collaboration tips:
  • Never enter a room to engage a teacher in a conversation when class is in session or instruction is being given.
  • Explaining the role of a school therapist may help the teacher understand areas with which we can help. The form in the supplemental materials section assists with this explanation.
  • Focus on the teacher and the student. Although it might be tempting to impart helpful information at this point, it is much more important to listen and get a full picture of the student’s needs.
  • Whether we add the student to our caseloads or not, we can offer suggestions that fit the situation after putting thought into the issue. It is acceptable to tell the teacher you will get back to her after you reach a solution. When a therapist offers thoughtful suggestions, an awareness of areas in which occupational therapists have expertise increases in the school setting. Building awareness of occupational therapy may elicit more questions and more referrals, and increase impact in the school environment.
  • Understand as consultants, we should not overburden teachers with our ideas and suggestions. We will be better received if we offer to implement solutions in the classroom and frequently check back.
  • Building a team that works empowers every member of the team to support students and meet their educational needs.
Teacher questions

School-based occupational therapists work with children on a variety of tasks related to their education. Most common are fine motor tasks such as writing, coloring, cutting, and putting together projects. They also work with children who are having attention and behavioral problems related to poor sensory regulation. With more-involved children, they may work on positioning, computer access, and self-care skills such as feeding, toileting, and dressing.

(Student's name) has been referred for an occupational therapy assessment. Given the focus areas listed above, please describe his/her area(s) of need.

OR

In your view, how has the student progressed on the goals addressed by occupational therapy? What are his/her strengths in these areas? What are his/her current areas of need?

What is considered typical performance/expectations for other students in your class for the problem area(s) listed?

Which interventions have you tried, and which have worked?

Do you have any other comments/concerns you would like to share?

Classroom Skills

Classroom Observations

It is important to spend time in a child’s natural school environment as part of the evaluation process. Use the SCHOODLES observation checklist in the supplemental materials section while in the classroom, at PE, in the lunchroom, or on the playground. Be as unobtrusive as possible. The child does not need to know you are observing him; this allows you to glimpse how the child functions. Specifically look at that child’s participation in activities, and ability to follow directions; how much the student visually attends to what is going on; and the amount of movement a child exhibits (as compared to classmates).

Review a handwriting sample from the student’s typical work and view an art project. Comparing this work to the work of other students in the class provides useful information about the student's proficiency.

It also is very important to review any previous testing, medical history, and interventions other therapists have implemented.
Grasp and Hand Dominance

Although these two skills are supporting skills, we include them here because teachers and parents often refer to them. They are directly observable in the classroom. Therapists often lead reports with these two attributes of a child’s writing skills. If you see problems in these areas, complete the touch processing, proprioception, gross motor, and graphesthesia portions of this assessment.
Grasp

Beginning in kindergarten, it is expected children will write their names on their papers. Ask the child to write her name on the coloring page. Observe the child’s grasp while she is completing the writing/drawing activities in the workbook.

At three years of age, children use a wide variety of grasps to hold writing tools, but toward the end of that age, most children use a static tripod grasp. We start to see separation of the sides of the hand; however, the hand still typically moves as one unit.

By four years of age, the dynamic tripod grasp emerges, and movement begins to come from the finger joints. The thumb, index finger, and middle finger move independently of the stable ring finger and pinkie. Although this grasp is optimal, a variety of grasps are functional, and once established, should not be changed unless work quality is poor, too much pressure is on the child’s joints, or hand pain is present. (27)

Observe for hyper-extended joints, especially in the thumb and index finger. This could be a problem, as hyperextension can lead to pain and joint damage later in life. A wrapped thumb often indicates decreased tone or lack of stability within the hand. (20) Children may find stability with a thumb-wrap grasp, but it can cause discomfort when writing demands increase.

A quadripod grasp (three fingers and the thumb) often is seen in young children as well. This grasp or a wrapped-thumb grasp also can develop with premature use of pencils or low joint stability. Many quadripod grasps develop into more mature grasps. (20)

An adapted tripod grasp with the pencil placed between the index and middle fingers can be used as an alternative to a dynamic tripod grasp. This type of grasp may work well for children with decreased joint stability. When assessing pencil grasp, look at speed and legibility outcomes rather than focusing on the grasp itself. Teachers often mention that a student "holds his pencil funny." We should be focusing on outcomes and underlying reasons as to why a certain grasp is used. Having a child change an established grasp can decrease both speed and legibility, and increase frustration. Changing a grasp past about the age of six can be difficult, as muscle patterns already have set. If a less-optimal grasp is noted, make sure the grasp is the root of the problem before adding the stress of changing a child’s established grasp.

Note overall muscle tone, and check flexion and extension strength in hands and fingers as described in the supporting skills section. Manual muscle testing could reveal tone differences as well. Low-tone muscles quickly fatigue.
Grasp Observations

When observing a child as she writes, note where the movement of writing originates. Does the child have good control at the wrist and fingers, or does she move her entire arm as a unit? A student with a tripod grasp who originates movement at the shoulder may not demonstrate good control. (27) The hand must be stable before the fingers can be mobile and precise. It is important the child acquire the ability to sequence finger and wrist movements for letter formations. Flexion and extension of fingers produce vertical lines, and lateral wrist movements produce horizontal lines.

Once a child is able to put these two movements together, fluid drawing and writing can be mastered. If a child cannot combine wrist and finger movements, mobility originates from the elbow and shoulder. In this case, a child might increase pressure on the pencil to increase stability. (6)

A child sometimes may have trouble with processing sensory feedback from muscles and joints in her arms and hands. This might affect her ability to grade fine motor movements for writing tasks, and may be seen in a child who presses too hard or not hard enough when writing. (26) A child who writes very quickly may have stability or proprioceptive problems. The feeling of control sometimes is gained by moving quickly - although this typically decreases legibility. If you see problems in this area, complete the touch processing, proprioception, gross motor, and graphesthesia portions of this assessment.
Hand Dominance

Refer to Elke H. Kraus' chapter in Hand Function and the Child, Foundations for Remediation, Second Edition edited by Henderson and Pehoski for an excellent examination of research surrounding the issue of handedness.

Genetics, environmental demands, and pathologic conditions could influence handedness, but there is no conclusive evidence to support how preference or performance develops. Hand preference and performance are categorized the following ways (2):

  • 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, present with mixed handedness; the term "unestablished" is used because children still are in the processes of developing.
  • Switched handers: When children are inherently left-handed, but learn to draw and write with the right hand.
  • Pathological handedness: If there is evidence of prenatal, perinatal, or postnatal trauma, and one hand is significantly weaker and inferior compared to the other hand - but still shows some preference patterns.
  • Ambidextrous: Individuals show no performance difference between the hands, and can draw or write equally well with the left and right hands, performing in the average or above-average range.


  • At times, we meet children who were switched to use their right hands rather than their inherently dominant lefts. This happens much less than in the past, but it still occurs. There is evidence that children who are inherently left but switched to right exhibit problems in other areas of performance, such as concentration and memory; they do benefit from switching back to their preferred hands, even as adults. (17) One might detect an inherently left-handed child by observing untrained tasks such as door opening or hair combing.

    Describing handedness in terms of preference and performance may help clarify the issue. Hand preference is the tendency to perform the majority of tasks with one hand rather than the other, although it doesn't mean the chosen hand is more efficient. (2) Hand performance is the superior proficiency of one hand over the other in tasks requiring skill. (2) One hand may perform better than the other at certain tasks, even though it may not be dominant. For instance, one of the SFMA authors is right dominant, but deals cards with her left hand. Some researchers have suggested hand preference is established before the age of one but emerges at age four. (42)

    Given the literature reflects a complex list of variables in determining preferred hand use or handedness, and some literature is conflictive, we conclude that detailed observation of a child along with a caregiver interview should be done before "choosing" a hand for a child. Better still, allow the child to explore a variety of tools over time to see if a preferred hand emerges. Observe the child doing several two-handed activities, such as opening containers, pulling the cap off a marker, stringing beads, or cutting. It also is helpful to observe a child doing spontaneous activities, such as opening doors, picking up items, reaching for items, or batting at a balloon. Observe the child using other tools such as spoons and toothbrushes. Writing or drawing the same image with each hand may reveal clues about dominance.

    It may be useful to check for eye dominance. It is quick and easy to locate the dominant eye by having a child look through a tube or pinhole in paper. Present the tube or paper at the child’s midline. The eye the child typically uses denotes the dominant eye. This information might be useful in determining emergent handedness in a child who has yet to demonstrate a preferred hand. Eye and hand dominance typically occur on the same side of the body. (18)

    Do not take this information as conclusive evidence of handedness. Be aware of possible errors in clinical observations, to prevent the assignment of the "incorrect" hand as dominant.

    In general, by three years of age, one hand is preferred, although switching still is seen. Many children write with one hand and cut with the other. This is mixed-hand dominance; one hand develops strength, and the other develops precision. By age four, the non-dominant hand is rarely used for precision work; it is now the assisting hand, or "helper hand," for most activities that involve both hands working together. For a few children, solid hand dominance does not emerge until age eight or nine.

    Non-established dominance sometimes is seen in older children with developmental delays. (25) Ruth Rehbok states in an article titled "Crossing the Midline," “Children who appear to be able to use both hands are really struggling to establish a worker hand and a helper hand, and these children often end up with 2 unskilled hands. These students may benefit from doing lots of two-handed activities to help establish hand dominance and midline crossing.” (34)

    Gross motor skills also may be poorer in children with delayed hand dominance than in children who have a strong hand preference. They may be clumsy because of delayed kinesthetic/proprioceptive memory of skilled movements, and a decreased cumulative number of practice sessions with one hand. They may have decreased speed and accuracy in fine motor task completion. (34)

    If hand switching occurs, it is important to try to determine why it is happening. Does it appear to be a problem with hand fatigue? Is hand switching occurring randomly? Does it appear to be related to lack of hand dominance? Is the hand switching occurring at midline (starts writing/coloring and switches when he reaches the middle of his body)? Is the child supporting his body with his dominant side (trunk stability problems)?

Pre-writing Skills

Letter Recognition

Children can learn to recognize letters using writing activities, but it is helpful if they recognize letters before they write. Before you move on to pre-writing tasks, check to see if they recognize the capital letters of their names, and other random letters using the form included in the workbook.
Pre-Tracing

Ages 3 to 5

Hand-over-hand tracing can reveal information about a child’s emerging writing skills. At times, segments of letters of which the child has gained some understanding and control are expressed, even though the child may not be able to complete each entire letter. This sometimes is helpful with children with autism, or motor or cognitive delays. If the child recognizes letters but can’t duplicate them, try laying a hand on the child’s writing hand. Following along as she traces letters (particularly letters of her name) can pick up pre-writing/line control skills otherwise missed if the child is handed a tracing sheet. Parents often are pleased to hear some progress is being made with name writing. Use a highlighter to write capital letters of the child’s name, then "write" together.
When observing a student doing the tracing activity, note the following:

  • Can the student flow through designs and letters?
  • Can he keep his pencil on track?
  • What are the starting points?
  • How is he holding his pencil?

A 3.8- to 4.3-year-old should be able to trace simple shapes. (40)
Check muscle strength, tone, and eye-hand coordination if tracing abilities are poor. Make sure the child has his feet on a solid surface and the workspace is the correct height, creating a stable position. An unstable position can significantly affect the results of fine motor tasks.
Tracing

Ages 3 to 5 - Tracing is the ability to follow a path with a writing tool. It is a motor control task, and separates some of the memory skills of the task of writing. Tracing helps develop motor patterns, which in turn facilitate ease of letter and shape writing. Static tracing is tracing over a two-dimensional model. Dynamic tracing is tracing over a model that has been just drawn in front of the child. The workbook sample is an example of static tracing. You may want to try dynamic tracing to see if there is a difference in abilities. (40) Using a highlighter to draw shapes or write letters of the child’s name accomplishes this.


When observing a student doing the tracing activity, note the following:

  • Can the student flow through designs and letters?
  • Can he keep his pencil on track?
  • What are the starting points?
  • How is he holding his pencil?

A 3.8- to 4.3-year-old should be able to trace simple shapes. (40)

Check muscle strength, tone, and eye-hand coordination if tracing abilities are poor. Make sure the child has his feet on a solid surface and the workspace is the correct height, creating a stable position. An unstable position can significantly affect the results of fine motor tasks.
Design Imitation

Ages 3 to 5

Design imitation is the ability to imitate simple shapes after strokes are demonstrated. When doing this activity, use any writing tool, keeping in mind that whatever motivates the child is the best choice. This skill requires visual memory, although it takes less skill than design copy because the student is able to observe how the shape is formed by watching pencil strokes. Assess this skill by asking children to imitate your strokes, since most children love to imitate adults.
Design Copy

Ages 3 and older

The ability to copy designs is a precursor to writing letters. As the designs being copied increase in complexity, it increases the demand on the child. The ability to deconstruct shapes and letters in the mind's eye and reconstruct them on paper is necessary for completing written work. Students typically should be able to draw the following forms at the listed ages:
Horizontal and vertical lines, and circle by approximately age three (3)

  • Diagonal lines, "plus" sign, tracing, and mazes by approximately four years old; right-handed children begin drawing diagonal lines from right to left before left to right (22)
  • Letter "X," square, triangle, and some words by approximately age five
  • Diamonds by approximately six years old (3)

Look for starting points. All capital letters start at the top. All circle letters should be formed with a counterclockwise motion. Watch pencil strokes, crossing midline, spatial orientation of forms, and ability to easily change pencil direction when forming a square or triangle. If a child cannot copy the shapes, draw each shape to see if she can do so from imitation. If imitation is difficult, have the child trace over a shape you have drawn to see if she can demonstrate the motor control to trace. If she can trace but not draw from imitation, it probably indicates a developmental or visual perceptual delay. Further visual perceptual testing may be helpful.
Draw a Person

Ages 3 to 6

A child’s first experience with writing tools results in scribbling and an increased interest in making marks on paper. Meaning evolves from the realization that the marks on the paper can represent things. Children usually know what they are drawing before the items are recognizable to others. They often make marks, see something familiar in the drawing, and place a label on it. Later, children can crudely place body parts before they actually can draw them. A typically developing child is able to describe what he has drawn. By three years of age, approximations of a person emerge, often represented by a circle with two lines for legs. By age three-and-a-half, children often draw a head, face parts, legs, and arms, but no body. By age four, a child should be able to draw a recognizable person with at least four body parts. By five years of age, students typically can add detail to the head by drawing eyes, a nose, and a mouth. By age five-and-a-half, children can draw a person with at least six body parts. (3)

It also is important to look at the quality of the drawing:

  • Are the body parts proportional in size (spatial awareness)?
  • Are the parts correctly oriented to the person (body awareness of self)?
  • Is the person correctly oriented in space? It is not uncommon for a child to draw a person upside-down or even sideways. This skill involves the ability to correctly orient oneself to things in space.
  • Note where the drawing is placed on the paper. If the child has a hard time fitting the person on the page, or uses one tiny corner of the paper, it may indicate visual perceptual difficulties, which later may correlate with not knowing where to put answers on a worksheet.

Providing a partial drawing of a person and reference points, such as one eye or a mouth, to a child may help demonstrate an emerging understanding of the task.

Writing Skills

Handwriting



Ages 5 and older

Handwriting concerns are very common sources of referrals from school staff and parents. However, not all handwriting problems require OT intervention. Prior to testing a student, determine what kinds of interventions already were attempted. Sometimes, simple legibility instruction is all that is needed. If a student has poor handwriting, try to determine the reason for it. Is it a motor delay, a visual perceptual delay, a processing problem, or poor motor memory? Is it difficulty with organization? It is important to remember that overall legibility ultimately is more important than correct letter formation.

Although it may be helpful to make note of handwriting speed, SCHOODLES purposely does not offer time limits for handwriting tasks. The speed of completing written work varies with age. A child’s speed is relevant only if he is not able to keep up with his classmates. Many factors contribute to handwriting speed. These include strength, dexterity, motor planning, processing time, and distractibility. Try to determine underlying causes for decreased speed, and work on those areas during treatment sessions. Simply reducing the amount of work a student is required to complete may take care of the problem and increase a feeling of success.

While the child is writing, observe for starting points, letter formation, speed, ease of recall of individual letters and, most importantly, legibility. This also is a good time to observe if movements for letter and word formation are automated, or if the child has to think about each stroke. This is a motor planning task. Children in kindergarten and first grade rely on visual information to guide their movements to form letters. Internal feedback for letter formation comes at the end of first grade or the beginning of second grade. When this occurs, movements should smooth out, speed up, and become automated. At this time, vision often still guides placement, spacing, and sizing of letters. (26)

Most children can print their names at age five. By the end of kindergarten, most children can correctly sequence letter stroke patterns, but reversals are expected. Between ages six and seven, children improve basic writing legibility. The skill of being able to start at the top of a ruled line develops at age six. (36) Shortly after a child turns six, he should be able to print a minimum of three words (each with at least three letters), as well as the numbers 0 through 9, and the alphabet from memory. (3) By the end of their first-grade year, children can copy from the board. (36)

If a student is using cursive letters, take samples of printed work as well. If printing is easier and more legible, perhaps accommodations can be made for him to use printing as his primary means of completing written assignments.

Once a child has automated writing, it can be extremely difficult to change incorrect letter-formation habits. Only proceed with addressing letter-formation errors if it impacts speed or legibility.

Compare the handwriting sample with work in the student’s backpack and in the classroom.

While working through the handwriting task, watch for inconsistencies between the copied sample and the dictated, then the self-generated. If the copied sample is legible, and the dictated and/or the self-generated are not, the illegibility is not a motor problem. The task becomes more cognitively complex as we decrease supports. We then most likely have a visual memory or processing problem (learning disability). For a child to be able to write a sentence dictated to him, he must be able to visualize letter formations and construct words. For a child to be able to write from his own thoughts, he must be able to generate the thoughts, and visualize the letters or words without visual cues. (Adapted with permission from Jill Dalbaka OTR/L’s model.)
Instructions for the Handwriting Portion of Assessment

Find a starting point with the student. Complete each task until it becomes too challenging, then stop. As handwriting task requirements increase, writing quality may break down. The workbook task separates motor and cognitive abilities by asking the student to first copy a sentence, write a short sentence from dictation, and finally to write a sentence about the picture provided. Asking the child to make his letters the same size as the sea creature at the beginning of each line helps determine if the child has control of this aspect of his written work. ]

  • Ask the child to copy the sentence "I like jellyfish."
  • For dictation, use a simple sentence such as “My pet starfish is red.” For an older student, you might use “The quick brown fox jumps over the lazy dog.” The second sentence includes all twenty-six lower letters. Do not ask the student to write the letters independently if you use this sentence.
  • Finally, ask the student to self-generate content and write a sentence or two sentences describing the picture in the SCHOODLES workbook.

For a pre-K child, ask him to name the ten random letters from the SCHOODLES workbook page. Next, ask the student to write his name. Children typically are taught to write their names using capital letters first. Optional: For a student in the early grades, have her write the capital alphabet from memory. Most students have an easier time if they start with capital letters. If a student does not know how to write all the letters, encourage them to proceed with the letters they know. If a student is successful with the capital alphabet, move on to lowercase letters and the numbers 1 through 9. Check for start and sequence errors. Note any letters that are illegible or appear to be slowing down the student; they may not be automated yet.
Questions for students, related to handwriting:

  • Does your hand tire or hurt when you write for a long time
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  • Are you able to keep up when taking notes in class?
  • Are you able to copy from the board?
  • Are you able to complete handwritten assignments at about the same time as other students in your class?

Other School Skills

Coloring

Ages 3 to 8

Coloring is an important skill for developing the muscles in the hand to get them ready for writing. Coloring is a great way to practice grasp and increase strength, endurance, and control for fine motor activities.

Note on the SCHOODLES Clinical Observation form what type of coloring tool the student used (standard crayons, large crayons, markers, colored pencils, etc.).

A child who colors poorly often has difficulty anchoring his hands on the paper, and movement originates from the wrist, elbow, or shoulder. Placing a fun target on the paper for the student to rest his hand while coloring may fix the floating hand problem. (27)

Ideally, control for coloring should come from the fingertips. The paper should remain in position as the child colors. Children typically develop the ability to adjust hand movements to fill in empty spaces on their coloring pages. Frequent turning of the paper when coloring may indicate a delay in the child’s ability to change stroke directions while coloring, or it may just be a habit. Ask him not to turn the paper, and see if he is able to adjust to the challenge.

Fatigue sometimes is a factor when a child is coloring. Check hand strength and endurance. Watch for hand switching, and try to determine why switching occurs. Observe a student’s posture when coloring. Does she have to prop herself up or lean against the table/desk for stability? This could indicate poor trunk strength for sitting unsupported. Evaluate prone extension, supine flexion, and trunk rotation to test trunk strength and endurance.

In the student workbook, the coloring sample may be used for any age up to about that of students in second grade. Three- to four-year-olds should be able to color the ball, with a few excursions outside the lines. At this age, a child may demonstrate some variety in line direction when coloring, and may not anchor her hand on the paper.

Around the age of four, children typically can color pictures within 1/4 inch of the lines. (3) Four- to five-year-olds should be able to color the beak on the penguin, using an anchored hand and a variety of finger movements. Students ages five and older should have the control to color the dots on the necktie, using a tight, circular motion. If the child is able to color the dots on the necktie well, but has difficulty remaining within the lines of the ball, he may be having difficulty with grading muscle movements. This sometimes is seen in children with cerebral palsy, or those who possess lower tone and less stability than their peers. (26)

Observe the amount of pressure a student applies to the crayon. Children with decreased proprioceptive awareness often apply heavy pressure and occasionally tear the papers.

Another observation is the use of the helper hand to stabilize the paper. If the helper hand is lacking, the child may not have established bilateral coordination skills for some reason. Possibilities might include delay in integration of ATNR, cerebral palsy or something else pathological, or choice.

You also may use the coloring task to check multistep direction-following skills and memory. A prompt might be, “Color the ball blue, the beak orange, and the dots on the necktie red.” Pay attention to which direction is followed first, second, and third. Children sometimes follow the last direction they hear, and sometimes follow only the first.

To increase the possibility of success, give a visual cue by laying out the crayons as you say the colors. Ask the child to wait until you have given all the directions before he picks up a crayon. Note any difficulty following the sequence. Children who have delays often follow the last direction first. This is valuable information to share with your team. Please note this is not a motor planning task, but a check of the child’s ability to process several verbal directions.
Cutting


Ages 3 and older

Cutting is a complex skill that requires visual-motor control and bilateral coordination. Observing a child doing a cutting activity also gives us information about how he might coordinate movements for many other life tasks that require the use of two hands together, such as manipulating fasteners, opening containers, and operating electronic devices. Note the type of scissors used when assessing. Typically, we start with regular school scissors. Use loop scissors with children who are just beginning to learn to cut.

During cutting, the dominant hand must be able to stabilize the scissors; open and close the scissors with the thumb; and move the wrist to orient the scissors to paper. The stabilizer (non-dominant hand) must be able to hold the paper securely, and assist with orienting the paper to the scissors. The child must be able to look ahead of the cut and anticipate placement. A child also should be able to stop at the end point, instead of cutting off the edge of the paper. If a child does not stop at the end point, try to decipher whether it is poor motor control, or poor impulse control. This decision is based on the therapist’s clinical observations. A child may first learn how to hold scissors at eighteen to nineteen months. Initially, many children try to manipulate scissors using both hands to open and close the blades prior to learning to place their fingers in the loops. (8) In general, children start snipping between the ages of two and three. If children do not have the necessary shoulder, forearm, or wrist stabilization, or if the scissors are too big for their hands, they hold the scissors close to the knuckles of the hands rather than near the middle joints of the fingers. (8) This frequently is seen in children with decreased tone in their hands. Scissors cut most efficiently when held at 90 degrees to the paper. This requires forearm stability, as children must hold their hands with the thumbs up and their arms in mid-position between pronation (palms down) and supination (palms up). A child with decreased forearm stability may have a hard time keeping scissors at 90 degrees to the paper, which might cause bending and tearing of the paper. (8)

Control for cutting along straight lines occurs between the ages of three and four. A four- to five-year-old should be able to cut on curved lines, and cut out circles and squares. Between the ages of five and six, students should easily be able to cut out complex shapes. (27)

It may be helpful to ask the child to cut out a circle without any lines drawn (a blank piece of paper). This skill should be attained by approximately age five. If a student is unable to do this, you may want to do a more formal assessment of visual perceptual skills. Poor cutting skills may indicate a motor planning problem. More information about motor planning skills can be obtained through completing the supporting skill portions of this assessment.
Listed below are some observations related to a child’s cutting skills:

  • Observe which hand is used to hold the scissors. Is it the same hand that was used for writing (hand dominance)?
  • Can the child hold scissors with the wrist in a neutral position, with the thumb up?Most children use an awkward, thumb-down grasp when first learning to use scissors (developmental delay, weak hands or wrists, lack of experience).
  • Does the child fatigue when cutting? Does his wrist drop? Does he lose his grasp on the scissors and need to stop frequently? If so, check hand/arm strength. Make sure the scissors cuts easily.
  • Look for the quality of his cutting. Is it smooth or choppy (muscle grading, attention, attitude, control)?
  • Does the child visually attend to the paper when cutting, or is he distracted?
  • Does he have good visual-motor control for following along the line, and do both hands work together smoothly - one to hold the paper and one to manipulate the scissors (eye-hand coordination, bilateral control)?
  • Does the child have significant overflow when cutting (standing up, holding arms awkwardly in the air, sticking out the tongue)? If so, this could indicate his nervous system is not yet integrated.
  • To downgrade the cutting task, try loop scissors and/or widen and darken targets.(3)

Check the child’s skills against the approximate age references provided. If there are delays, treatment activities can focus on the underlying skills of strength, bilateral control, and trunk stability, which support hand mobility and precision.
Picture Assembly

Ages 3 to 8

This task was devised to gain insight into a child’s visual perceptual skills. Shortly after three years of age, a child typically can put together a simple three-piece puzzle. As a child nears four years, she should be able to assemble a four- to five-piece puzzle, and by age six, typically can put together a six- to twelve-piece interlocking puzzle. (3) Difficulty with the puzzle task may indicate the need to do further visual perceptual testing using standardized tests. It may be helpful to compare your outcomes with information gathered by your school psychologist regarding visual perception and cognitive ability levels. Compare assessment performance with the child’s typical classroom performance for art projects, assembly activities, and orientation of work on a page.

Typically, developing children easily can complete these two puzzles. We suggest laminating and cutting apart the puzzles for easy reuse. Store these pieces clipped in the pocket of your binder. Have the following available for each assessment:
  • laminated version of the three-piece puzzle
  • laminated version of the nine-piece puzzle
  • laminated, uncut version of both the three-piece and nine-piece puzzle
  • a rubberized mat to place the puzzle on so it does not slide around (not included in the tool)

Start by providing the three-piece puzzle. If the child cannot complete the puzzle, piece it together to show the student what it looks like. Then mix up the pieces and ask the student to put it back together. If she still has difficulty completing the puzzle, join two of the pieces and determine whether the child can orient the third, and note if/how much help she needs. Matching the colors on the pieces adds an extra visual cue, which may help her complete the puzzle. You can offer verbal guidance to use color. If she still is having difficulty, show her the uncut picture to use as a guide. Note any verbal, visual, or physical cues provided to the child.

If the child successfully completes the three-piece puzzle, provide the nine-piece puzzle. Follow the steps from the three-piece puzzle. Use verbal cues if necessary. Physical assistance may be required to help a student who is not able to complete the puzzle. Make sure the child feels successful at the end of the activity by helping her complete the puzzle if she is unable to by herself.

Supporting Skills

Vision Observations

Visual feedback is essential to children learning new fine motor tasks. As tasks become automated, the need to use the visual sense diminishes, and body sense takes over. Developed visual perceptual skills are an important component of skilled fine motor work. Use the puzzle task to provide some clues about a child’s visual perceptual abilities. A variety of standardized tests are available that may be used to further assess a student’s visual perceptual abilities.

Visual attention is the basis from which all other vision skills emerge. This may sound elementary, but it is not uncommon to see children not using their eyes and hands together. They may even be smiling at us while they color or draw, and have difficulty maintaining their attention on tasks in front of them. Fine motor tasks must be visually guided before they are automated through kinesthetic awareness of the moving body.

The American Optometric Association (AOA) recommends that beginning at six months of age, a doctor of optometry should conduct regular eye exams. According to the AOA, 60 percent of students identified as problem learners have undetected vision problems. (9) Taking the time to have a child read (or for younger students, identify a picture) at both close and far ranges may indicate any nearsightedness or farsightedness. An occupational therapist can make general vision observations, but a thorough eye exam might be suggested if problems are suspected. If a visual exam already is scheduled, place the assessment on hold until the results of that exam are known. Do not assess a child who is waiting to get glasses, as uncorrected vision problems may affect the testing results.

The AOA says every child needs to have the following vision skills for effective reading and learning:

  • Visual acuity: the ability to see clearly in the distance for viewing the classroom board, at an intermediate distance for the computer, and up close for reading a book.
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  • Eye focusing: the ability to quickly and accurately maintain clear vision as the distance from objects change, such as when looking from a chalkboard to a paper on the desk and back. Eye focusing allows the child to easily maintain clear vision over time, such as when reading a book or writing a report.
  • Eye tracking: the ability to keep the eyes on target when looking from one object to another, moving the eyes along a printed page, or following a moving object such as a thrown ball.
  • Eye teaming: the ability to coordinate and use both eyes together when moving the eyes along a printed page, and to be able to judge distances and see depth for class work and sports.
  • Eye-hand coordination: the ability to use visual information to monitor and direct the hands when drawing a picture or trying to hit a ball.
  • Visual perception: the ability to organize images on a printed page into letters, words and ideas, and to understand and remember what was read.
Visual Pursuits/Eye Tracking

It is important to check a child’s ability to follow a moving object with his eyes. This easily can be done during your occupational therapy assessment. Visual pursuit testing is appropriate for children five years and older. (38)

  1. Hold a small object of interest (we often use a pencil-top creature or colorful eraser) approximately 16 inches away from the child’s face.
  2. Do not give instructions as to whether moving the head is appropriate.
  3. Tell the child to watch the object as you move it, and to keep his eyes on the object.
  4. Move the object horizontally, vertically, diagonally (right to left and left to right), clockwise, and counterclockwise (two to three times for each movement).
  5. Observe range and accuracy of eye movement. (The goal for the child is smooth pursuit, without losing track of the object.) Observe short-term visual attention span and head movement.
  6. If the head moves with the eyes, try the exercise while asking the child to hold his head steady. Watch for the above.
  7. Note nystagmus (irregular movements) at ends of eye range or midline, convergence of eye gaze (eyes working together), or difficulty crossing midline. A jerk at midline indicates delayed bilateral integration. (38, 45)


A child approximately six years or older should be able to track with her eyes and easily follow an object for about sixty seconds without needing to turn her head. The eye movements should be sustained, smooth, and symmetrical. If the child's head has to move side to side while following the object, or if the child's eyes show jerking movements, excessive blinking, or have to refocus every few seconds, then we can infer the child has problems with visual tracking.

If a child cannot move his eyes independently from his head, causes may include possible immaturity in development, possible low muscle tone in trunk (the child needs the stability of neck and trunk to maintain smooth movements), possible torticollis, or stiff neck.

If a jerk at midline is seen, it may be helpful to complete the portions of this assessment that address crossing midline and bilateral integration. A detectable jump at midline could suggest midline-crossing problems, and may interfere with reading, as a child may often lose his place.
Saccadic Eye Movements (not included in this assessment)
Saccadic eye movements are needed for reading. Two tests are available that test saccadic movements in school-age children.

Developmental Eye Movement Test (DEM)
King-Devick Saccade Test (K-D)

According to the AOA’s Clinical Practice Guideline on Learning Related Vision Problems, these tests "simulate reading, using a rapid number-naming strategy in which numbers are placed in horizontal spatial arrays to be read in the left-to-right and top-down fashion of normal reading. The time to complete the task and the number of errors are the clinical outcomes. Presumably, slower and/or error prone performance would indicate poor saccadic eye movement control."
Eye-Hand Coordination



Coordination of eyes and hands together is imperative to skilled hand use. A gross observation of eye-hand coordination skills can be made using simple tools. Eye tracking, hand dominance, visual attention, crossing midline, timing, coordination, and possible neglect of one side of the body can be observed while doing this task.

Use a scarf, balloon, ball, bubbles, or tissue to make observations. These each have different properties and elicit different responses. If building rapport is a struggle, this one will break the ice. Kids love it! Just toss the scarf in the air and ask the child to catch it. Watch to see if the child turns her face away from the object as it gets close to her. Can she track the object through its entire course, or do her eyes dart off the object? Does she ready her hands in anticipation of catching the scarf? How is her timing? Can she catch the object with either side of her body, or does she fail to catch it if it is thrown to one side? Difficulty with this activity suggests target areas for intervention.
Visual Perception
In the absence of formal standardized testing, tentative statements may be made about visual perception based on classroom skills observations. Some examples are: difficulty with letter closure (visual closure); letter to line alignment; spacing between words (spatial orientation); puzzle assembly (figure ground, spatial orientation); organizing information on a page (visual orientation); difficulty recognizing letters in different fonts (visual form constancy); copying from the board (figure ground); or letter reversals (spatial orientation).

A child may not be able to recognize errors in his own letters (form constancy); may confuse capital and small letters (visual memory); may have difficulty printing the alphabet from memory; may have different letter formations within the same writing sample (visual memory); or may not be able to orient parts of an art project (visual sequencing, spatial orientation).

The puzzle task included in the workbook may help with observations regarding visual perceptual skills for younger children. Formal testing may be prudent for older children, or a check with the psychologist’s testing could provide insights.

Poor visual perceptual skills are a cognitive problem involving visual pathways in various locations in the brain, specifically the occipital, parietal, and temporal lobes. Other factors, cognition/developmental delay, poor memory, decreased attention, motivation, etc. may influence task outcomes, so avoid making definitive statements about visual perception without extensive investigation.

Visual perception can be tested somewhat directly using one or more of several standardized tests. Even with formal testing, take care with interpretation of the scores, as it is difficult to determine exactly what the tests measure. For example, if a child has challenges with receptive language, he may score low - but scores may not be providing information about visual perception. (21)

Tests one might include: (not included in this assessment)
  • Beery-Buktenica Developmental Test of Visual-Motor Integration - Sixth Edition, visual perception subtest (VMI-6)
  • Test of Visual Perceptual Skills - Third Edition (TVPS-3)
  • Developmental Test of Visual Perception - Third Edition (DVPT-3)


Several additional screening techniques may be used to evaluate vision problems. Further vision training prior to using these techniques is suggested. If problems are detected through screening of vision skills, a referral to an optometrist or behavioral/developmental optometrist may be warranted.
Knowledge of Right vs. Left
Right vs. left orientation skills contribute to a child's sense of visual spatial orientation. Right vs. left skills are very important as they relate to school tasks. They affect a student’s ability to determine where to begin writing, how to form letters, and where to place information on worksheets. Children should be able to identify right and left on their own bodies first, then on another person’s body, and finally in relation between objects. This is a tiered skill. If the child cannot do the first task, stop. She most likely will not be able to do the subsequent skills.

Five-year-olds may have been taught to identify a side based on a motor function; for example, “I use my right hand for writing.” Identifying right/left on oneself is a skill that should be well developed for a child between the ages of seven and eight. By age eight, children are developing directionality (an awareness of spatial positions of objects outside their bodies). Check this skill by placing three similar objects on the table. Use the phrases, “Pick up the object that is on the left,” or “the object to the right of the blue cube,” etc. Because of this developmental progression, letter reversals are common through first grade and into second grade. (36)

Hand and Arm Strength, Endurance, Coordination, and Tone

Muscle Testing

Having one’s hands on a moving child provides a dimension of understanding not otherwise gained by observation alone. This test is standardized for adults. Although it is not for children, a quick test of muscle strength of a child’s fingers, thumbs, wrists, elbows, and shoulders often reveals valuable information about proximal and distal strength needed to complete fine motor work. A few muscle groups are included in this set of tasks to get a general idea about strength while avoiding overtaxing the child.

Following directions is a component of this task, and may reveal information about body awareness, motor planning and processing, along with strength. A child as young as age four often can follow directions to complete each movement. Prior to that age, observations of the child participating in a variety of functional activities can provide information about strength. For example, connecting pop beads, pulling pop tubes, opening containers, or removing marker caps, and the ability to move across the floor and over obstacles suggests a child has sufficient strength to perform other fine motor tasks.

Children often need more than verbal directions; they need the therapist to demonstrate the positions (visual cuing). At times, therapists need to place the child’s arms and hands in the correct positions, or they may use imagery to help the child understand; for instance, "Put your arms out as if you were going to fly." It is important to note how easily the child follows directions and is able to assume positions, as it gives you information about coordination, motor planning, and body awareness.

Stabilize above the joint being tested, and apply pressure below the joint (see photos). Pressure should be applied and released gradually. The amount of resistance given should match the child’s size and weight. Experience with this type of testing increases confidence regarding the amount of pressure, and muscle grading.

Use of muscle grades are not necessary, as they most likely will be meaningless to most who read the report. However, noting whether the child "demonstrated adequate strength to support fine motor work," or "appears to have decreased muscle strength, which may interfere with the child’s ability to support skilled fine motor work" would be useful to others and help guide intervention.

Visual examination of the hands may reveal past injuries or structural differences not previously shared or known by parents or teachers. An observation of active range of motion may reveal asymmetry, and trigger an inquiry about previous injuries or musculoskeletal differences. A quick phone call to parents to review the child's medical history if it is not recorded in the child’s file may be helpful.

When performing manual muscle testing, first ask for permission to touch the child, and use simple directions such as those listed below. Muscle testing can be done standing or seated.

Children who are less stable, who need "grounding" because of behaviors, or who are low tone may benefit from being seated when muscle testing is done.



Shoulder Flexion: (Pictured above) “Put your arms out as if you are Frankenstein, and don’t let me push them down.”



Shoulder Abduction: (Pictured above) “Put your arms out as if you are going to fly, and don’t let me push them down."



Elbow Flexion: (Pictured above) “Show me how strong you are, and don’t let me pull your arms away from your body.”

Forearm Supination/Pronation: (No photo shown) Arm is hanging down next to the body, elbow bent to 90 degrees. Stabilize above the elbow, "test" just above the wrist, gently rotating the arm up or down. Say, “Turn your hands up to the sky. and don’t let me turn them over.” Then instruct, “Flip them over like pancakes, and don’t let me turn them back up to the sky.”



Wrist Extension/Flexion: (Pictured above) “Make your wrist look like this, and don’t let me push it down.”



Finger Flexion: (Pictured above) Make sure your fingernails are short. Say, “Wrap your fingers around mine, and don’t let me open them,” or “Squeeze tight! Don’t let me open your fingers!”

Finger Extension: (No photo shown) Support at the wrist, have the child extend her fingers, and very gently press down. “Straighten your fingers, and don’t let me push them down."


Thumb Flexion: (Pictured above) “Put your thumb in your palm, and don’t let me pull it away.”

Thumb Extension: (No photo shown) Support the hand, demonstrate a "thumbs up" and say, ”Put your thumb up, and don’t let me push it down.”



Finger opposition or pinch: (Pictured above) “Make your fingers look like mine, and don’t let me open them.”

More extensive hand- and arm-strength testing may be needed if significant weakness is observed in these brief evaluations. (5)

Make sure to note a child’s general muscle tone. Low-tone muscles are easy to passively manipulate because they are not contracting to resist the movement. Hyper-mobility in joints may be noted. When muscles possess ideal tone, they are contracted to a level that provides stability to the joints, even at rest. When slight force is applied, the muscles are able to resist immediately. If tone is high, active and passive range might be limited, as muscles constantly contract. (26)
Finger Coordination

Control of the intrinsic muscles of the hand is needed to be able to produce quality fine motor work. Observing tasks outlined here provide additional information about a child’s hand strength and coordination. Completion of the standard finger-touching task is an easy way to assess finger coordination. Have the student touch each finger to his thumb (both hands). Check for coordination, speed, use of vision for guidance, and motor planning.



Often, this is a task children have not done before. Novel motor tasks are useful when observing motor planning skills. Have the child repeat the finger touching on all fingers at least three times. Motor planning can break down with consecutive trials of unfamiliar tasks. Typical children easily complete this task by age four-and-a-half. (13)

If the child is unable to perform this task, downgrade by asking the child to make glasses (pictured above) and put them on. Demonstrate making circles with the index finger and thumb. If the web space is collapsed, and the child is unable to see you through his "glasses," you might infer low tone or poor coordination.

Poor performance on this task might suggest interventions and objectives involving finger plays. Around the age of three, typical children should be able to do simple finger plays while singing songs. (3)



Separation of the sides of the hand is needed to efficiently grasp a writing tool and use it with skill. Thumb, index and middle fingers are used for mobility (tripod grasp), and the ring finger and pinkie are tucked and used for stability. Asking students to make chickens (pictured to the right) with their fingers is a fun way to observe separation of the sides of the hand. Just show the child how to tuck in his ring finger and pinkie, and make beaks with the thumb, and pointer and middle fingers.



Making "butterflies" (pictured to the left) is another way to examine finger coordination and separation of the sides of the hand. Connect the index finger and thumb to make the body, and ask the child to "flap the butterfly’s wings." Watch for imitation and motor planning of this task.
Rotation, translation, shift, and squirreling

Another way to assess finger coordination and in-hand manipulation is to use a writing tool and few small items. These skills access many intrinsic and extrinsic muscles of the hand, especially those surrounding the MP joints.

1. Ask your student to inch his way up, or "walk," his fingers up and down a pencil, using his most skilled or dominant hand. This is shift.
2. Ask the student to rotate the pencil around in a circle in his hand. This is rotation.
3. Ask a student to move a small object from the palm of his hand to his fingertips, then back to his palm. This is translation.
4. Ask the student to pick up several small objects, one at a time, and move them to the palm of his hand. This is squirreling, a form of translation.

If a child tries to use both hands for these tasks, uses external support of a table, sets the object down and picks it up to move it, or has difficulty with movement or clumsiness, the child may have decreased finger coordination or decreased mobility.
Graphesthesia/Tactile Processing

It may be helpful to assess a child’s ability to process tactile information. Poor tactile awareness may interfere with a child’s ability to obtain adequate information from his hands to produce quality fine motor work. Ask the child to close his eyes, and with a pencil eraser, draw lines and basic shapes on the child’s palm. Use easily recognizable shapes such as a circle, square, or triangle, or easily recognizable letters such as “E,” “L” or “A.” Use the same letters or shapes on each hand to get a fair read of any difference in dominant vs. non-dominant hands. Move slowly so the child has time to process each shape. Use enough pressure so the child can process the input. Make sure the child knows what these shapes or letters are before you start, by pointing to them on paper and asking what they are. After drawing each shape, have him trace what he felt on his palm with the other hand.



Draw the letters and numbers so they are right side up for the child. If a child wants the shape repeated, erase his palm by rubbing your fingers across the palm a few times, then repeat. If a child cannot identify what you are drawing, let him watch you draw on his palm. If he then can identify the item, note that he can visually recognize the shape, but can’t process the tactile information. (5) Always show the child which shapes you have drawn to reduce feelings of failure if he can’t do it.
Gross Motor Skills

it may be very helpful to do a quick check of a child’s large motor skills. Muscle strength, tone, reflex development, motor planning proficiency, and vestibular function all contribute to performance in the classroom. These quick observations can informally assess a child’s quality of movement, and provide clues to address weaknesses in fine motor skill development. If difficulties with large motor skills are apparent, it may be helpful to include a physical therapist or adaptive physical education teacher on the child’s team.

Observe the child’s general muscle tone and fluidity of movement. These observations may be made by completing the following activities:

hopping (two- to three-year-old)
galloping (three- to four-year-old)
skipping (five- to six-year-old)
jumping jacks (seven-year-old)

Look for quality of each movement, speed of the child’s body responses, and motor planning proficiency. (32) These skills follow a developmental progression. If the child cannot perform the lower level skills, stop. Most likely, he will not be able to perform the next skill. It might be best not to continue, to reduce the possibility of feelings of failure. Observe direction following, coordination, and overall quality of movement.
Core Strength / Postural Control

Core strength is the basis for all refined movement. Children need proximal stability before they obtain distal mobility. Postural control impacts vision, oral motor skills, fine motor skills, and gross motor skills.

Postural control starts developing in the womb as babies are folded into flexed positions. The balance between flexion and extension continues to develop after birth as babies work in and out of different positions. Think of young babies needing to be swaddled to feel calm. This keeps them in a flexed position as they sleep, but as they wake, they move into more extended positions. If they are startled, they extend into the Moro reflex. Either through reflex maturation, natural movements against gravity, or caregiver positioning, they constantly work through flexion and extension.

Watching a baby develop sitting balance is the perfect way to begin to understand where skilled movement originates. At first, a baby is able to use extension to pick her head up off a caregiver's shoulder, barely working against gravity. Then she is able to lift her head off the floor in prone position, using capital extensors. This is quite a feat, as head size is large relative to body size in infants.

The unrefined movements of babies as they grade and practice sitting, reaching, and standing, demonstrates just how much work it is to balance muscle strength and coordination. All this work leads to refined movement of the entire body. The ballistic or jerky movements one observes as babies move eventually refine and smooth out over time. Nerve fibers are myelinated, muscle strength increases, and sensory/motor feedback loops are generated. A motor plan develops for each new skill.

At about four months of age, capital flexors are fully engaging, and we see a chin tuck when babies are moved from supine to a sitting position. Once babies have head control, postural control starts to develop from the shoulder girdle moving down to the hips. At first, babies need full support at the head, then at upper trunk, then down at the hips. Babies cannot use vision skills or hands efficiently as trunk control develops if they are not provided external stability.

Some children who were prematurely born develop strong extension patterns, as they missed the intense folding in the womb. These children sometimes have weak flexion patterns in the neck and trunk. Avoiding placing these babies in prone; not using walkers and jumpers sometimes is recommended to avoid promoting those patterns.

Weak chin tucks, poor head control, and unbalanced flexion/extension strength in the head and trunk may lead to poor vision skills, poor eye-hand control, poor oral motor skills, and poor endurance in seated positions.

Checking on this basic skill, and remediating weaknesses through intervention or adaptations might lead to improved outcomes in the classroom. It is critical to use prone extension, supine flexion, and plank positions in your assessments to examine postural control and strength.

Other researchers have quantified supine flexion and prone extension, and we offer those numbers here as a gross guide:

• Three- to four-year-olds should be able to hold for ten to fifteen seconds.
• Five- to six-year-olds should be able to hold for fifteen to twenty seconds.
• Older than six years old should be able to hold for fifteen to thirty seconds.

More important than the time it takes in each position is the observation of the child moving into, holding, and moving out of these positions. Watch for chin tuck, breath holding (a search for stability), scapula winging, shoulder girdle instability, head extension, and ease of maintaining each position. The level of effort is important to determine whether a child has proper postural stability and strength to support fine motor, oral motor, and visual work.






Check prone extension (airplane position, pictured above top) and supine flexion (egg, pictured above bottom) strength. The airplane position for children under six years old is done with arms at the sides of the body. Children age seven and older should hold their arms out in front of them.



The plank position (pictured above) uses flexion and extension simultaneously. Ask the child to assume the plank position on the elbows. The child should be able to hold the position for approximately ten seconds.

Watch to see if the child is having trouble getting into each position (motor planning/proprioception), or if he is too weak to maintain the position. Also watch for segmentation of the body (only able to lift arms or legs, not both). (25, 48)

Trunk instability and/or poor posture affect the quality (smooth vs. choppy) and accuracy of hand and arm movement. (32)

Weakness and instability in the trunk may decrease a child’s ability to remain comfortably seated on the floor or in a chair. If a child is moving a lot in seated positions, this may be a result of low tone or decreased strength. The child is continuously trying to "turn on" his muscles, which can be tiring and distracting. It also may cause a child to stabilize at the shoulder when writing, decreasing fluidity of movement and speed, and increasing the possibility of fatigue. (21) Doing "set-ups," either individually or as an entire class, to activate muscles can help reduce this problem as we work to improve strength. A quick yoga or Pilates break before seated work may improve fine motor outcomes.

This is a good time to check a child’s trunk rotation skills. To check trunk rotation, you might ask your student to swing a bat, or have him bring both hands together at midline and pretend he is an elephant swinging a trunk.

You also may test trunk rotation by standing behind the child, then asking him to take a ball from one side, and turn to pass the ball to you from the other side. Watch head, eye, and foot movements. Eyes and the head should follow the ball as it moves from one side to the other, then move to search for the ball coming from behind on the other side. Watch for loss of balance as the child readjusts to take the ball from the other side. Watch for feet repositioning rather than movement of the trunk. Watch for lack of movement in the trunk, and smooth movement around the core of the body. Try this with someone with no apparent difficulties to get a feel for intact rotation skills. In this task, we are looking at the interplay between the vestibular, visual, and proprioceptive systems. Decreased strength, poor ocular motor skills, or decreased CNS function may cause poor trunk rotation.
Crossing the Midline of the Body

Writing requires you to be able to cross the midline of your body. The beginning of crossing the midline happens at about eight months of age, when a baby passes a toy from one hand to the other. During crawling, midline crossing emerges, and is an important step in establishing this skill. (14)

Midline crossing appears to be an established behavior even in two-year-olds (10). Refinement occurs from ages three through age eight or nine. Between the ages of three and four, children should easily and smoothly cross one hand from one side of the body to the other. (10, 11, 30) Cognitive or motor delays may affect the acquisition age. It is somewhat difficult to accurately determine whether a child is crossing midline proficiently because of variables, such as trunk rotation compensations, location of the item to be retrieved left to right and its distance away from the body, and handedness.

Frequency of successful midline crossing decreases as object distance from midline increases, and improves as object distance moves closer to midline. For instance, a right-handed person reaches with the left hand if an object is placed far to the left, but retrieves it with the right if it is placed closer to midline. Children have a tendency to bring items closer to midline, and orient trunk, head, and hands to middle; this complicates our observations, but increases their success. Tasks involving two hands and crossing midline may elicit clearer results; for example, stacking cups, with one hand stabilizing the bottom cup.

Crossing the midline of the body has been associated with development of laterality in the brain, and the maturation of the corpus callosum. Developing hand dominance also is highly associated with midline crossing, and seems to develop along the same trajectory. (10)

A reduced ability to follow directions may hinder a student’s ability to demonstrate this skill. To create an observable situation, place preferred items, such as toys or food pieces, at various places near a seated child at clock points.

Lack of midline crossing while coloring or writing may be observed in a child who transfers her pencil from one side to the other as the tool passes the middle of her body. It also may be observed in the child who turns her body to avoid having her pencil cross the middle point of her body. (26) It is preferable to correct problems with crossing midline before age six. (34)

The Quantification of Hand Preference task (QHO) (16) is an informal measure that has been used in research to determine handedness, and to observe crossing midline. In this activity, place on a table stacks of three cards with pictures, or playing cards, in seven spatial locations (approximately 30 degrees apart) along a semi-circle, within the child's reach. Seat the child in the center of the semi-circle, then ask him to pick up a specific card and place it in a box located directly in front of him. (10, 16, 41) Do not cue as to which hand is to be used for the task. A child could be assumed to be successfully crossing midline if he uses a dominant hand on the contralateral side.



Another way to observe a child’s ability to cross midline is to demonstrate a sequence of five movements. Ask the child to do what you do.

1. Cross one ankle over the other ankle. 2. Cross one knee over the other knee. 3. Hands on ipsilateral knees cross over to touch contralateral knees. 4. Hands on ipsilateral shoulders cross over to touch contralateral shoulders. 5. Hands on ipsilateral ears cross over to touch contralateral ears.

The last movement requires the child to use body sense rather than vision to position his arms, thus increasing task difficulty, and providing another observation for proprioception related to maturity and experience. Visually guided movement may indicate decreased body sense. Expect skill to decrease as you move up the body. On average, a three-year-old crosses midline of his body using vision to guide him (28). By age five, most children should have no difficulties crossing the midlines of their bodies. (34)

Proprioception/Kinesthetic Awareness

Both of these terms relate to feedback and feed forward of information from and to our bodies through our sensory motor systems. Proprioception has been regarded as an unconscious sense. It provides information about the stationary position of body parts and movements. Kinesthesia is a conscious sense, and sometimes is considered a form of proprioception. It provides information about direction of joint movement, and the weight and resistance of objects. These two senses allow for imitation of motor action. If a student has poor proprioception and kinesthetic sense, he may have poor ability to plan and imitate or execute movements; may crash into other children or objects; and may not "sense" a writing tool appropriately in his hand, and apply too much or too little pressure.

Proprioception and kinesthetic sense allows us to initiate a movement, and move with quality. They provide us with an awareness of our body in space. Poorly graded movements, ballistic movements, and delayed movement (either processed slowly or executed slowly) may result from a deficit or delay in these two senses. Some children are unaware of where their body parts are in space. They primarily rely on visual information to tell them how and where to move. (35) Proprioception affects the timing of movements, and the amount of force used; thus it affects the ability to plan motor movements, move smoothly, position the body in relation to objects, and stabilize joints.

Observations of these skills may be done within the context of other tasks (use of vision to guide movements indicates reduced proprioceptive/kinesthetic sense) or directly, with some imitation exercises. Testing a child’s proprioception is a fairly straightforward task; however, the child should have good verbal-direction-following abilities to do this activity. Seat the child facing you. Ask him to close his eyes, and tell him you are going to move one of his arms, and you want him to move the other arm to the same place/position. Do a demonstration on yourself and let him move one of your arms, if needed to clarify the direction. Then move one arm to 90 degrees. Check to see if the child can imitate the posture with his other arm. Try several positions (elbow bent, arm above head, arm straight out with palm up, etc.) The child should be able to approximate each movement with the other side of his body while his vision is occluded. (44)

It also may be helpful to perform the Romberg Test, pictured below. Ask the child to stand with both feet together, with his eyes open. Have him do the same thing with his eyes closed. If the child has difficulty balancing, or demonstrates significant swaying with his eyes closed, poor proprioception is indicated. This means he is using his visual information to 'know' when his body is in space. It is not uncommon for a child to fall over when he closes his eyes. Be prepared to catch or assist a child who cannot maintain an upright position without his vision. Similar information may be gained from watching a child stand on one foot with eyes open, then eyes closed. Another way to test this sense is to ask the child to walk on a line on the floor, eyes open, heel to toe, then eyes closed, heel to toe, making sure to stand near him as he moves.

Practical observations of body sense skills can be made, such as noting grading of pencil pressure, flexion and extension tasks, galloping and skipping. Poor proprioception (body awareness) indicated the internal sensory feedback needed for accurate motor output is limited or delayed in its development. (29)



Identifying Body Parts

Ages 3 to 5

A good concept of self helps a child determine orientation of objects in the rest of his world. The "draw a person" task is a helpful indicator of parts-to-a-whole orientation. As part of the developmental process, a child learns to label his body parts. (17) Most children between the ages of eighteen to twenty-two months can identify at least three body parts. By the age of two, most children can identify six basic body parts, and they should understand the concepts of "out," "in," "up," "down," "on," and "under." By the age of three, children should be able to identify six body parts on a picture of a doll, and they should be able to add a body part to an incomplete drawing. Four- to five-year-olds should be able to identify most body parts and understand parts-to-a-whole concepts. They need these skills for puzzle assembly, block designs, and ultimately, letter formation and art project assembly. (27) If your student is not proficient in the English language, have the names of the body parts translated into his native language.

Self Care

Self Care

Assessing a child’s ability to manage and move through routine tasks helps complete the picture of his fine motor skill set. Ages for attainment of these skills vary widely, depending on a child’s culture, motivation, and exposure. Check with the child’s teacher or caregiver if you are not able to directly assess these tasks.
Dressing Skills

Ages are approximate and taken from Pratt, Allen, and Case-Smith’s Occupational Therapy for Children.

  • Removing socks: approximately two years old
  • Removing unfastened jackets, hat, and mittens: approximately two years old
  • Zipping an initiated zipper: approximately two-and-a-half years old
  • Putting on shoes: approximately two to three years old
  • Unbuttoning a large button: approximately three years old
  • Buttoning a large button: approximately four years old
  • Placing on socks: approximately three to four years old
  • Donning most clothing: approximately three years old
  • Snapping: approximately three to five years old
  • Initiating a zipper and zipping: approximately four years old
  • Places shoes on correct feet: approximately five years old
  • Tying shoes: approximately six years old
Feeding Skills

Children should be able to drink from an open cup by about twelve months. Children older than two years should easily be able to feed themselves using a spoon. They also should be able to use a pincer grasp to pick up food. Most children can open a twist-off lid, and open a zip-top bag by the age of three. (32)

A review of silverware use with parents may be helpful in determining readiness for writing. Before expecting stabilization and mobile finger use with a pencil, children should have a precision tripod grip with fork and spoon. (21)

General Observations

General Observations

Following Directions

Throughout this assessment, make note of a child’s general ability to follow directions - verbal, visual, and physical. Do you often need to repeat instructions, or can she take in the information and complete the activities after first instruction? Can the student follow multistep directions? When one direction is given, how many seconds does it take for the child to respond with an action?

Children who have delayed processing can take ten or more seconds to respond to a direction, either verbally or with an action. We can miss this delayed response problem if we don’t give silent wait time before we move on and assume they either didn’t hear or didn’t understand. Giving one direction at a time and using less words for these children are imperative to getting the best outcomes. It also is useful information when making recommendations to others.

We need to ask: Is the breakdown in direction-following because of poor ideation, poor auditory processing, a language barrier, decreased cognition, and/or poor motor planning skills?

Affect/Attitude/Arousal Level

Make some statements about how the student responded to being removed from his classroom setting. Did he enjoy the tasks? Was he focused? Distracted? What distracted him? Did he need breaks? Note any comments the child made that may be helpful to the team or delight parents. Did you frequently hear “I can’t”? How did the student transition back into the classroom?

Interests/Strengths

Make note of any interest areas the child shares. This helps you plan relevant treatment activities. Note personality strengths that might help increase effectiveness of interventions. Ask the student about his favorite and least favorite parts of the school day.

Overall Impression

Immediately following your evaluation is a good time to write a quick summary of your thoughts and insights, or note other tests you might want to perform. Write down any observations you did not have time to write while evaluating. For example:

  • Is this a child who has fine motor needs that relate to school performance? Would adding OT services to her plan help her?
  • Are there others who could work on these skills with the student, or does she require the unique skills of OT intervention?
  • Are there things you want to remember to share with the team?
  • Is this a child whose delay seems to stem from lack of experience?


It may be hard to determine need if a child seems to have quality movements, but cannot do specific tasks such as cutting. Ask a parent if the child has been exposed to tasks with which he is having challenges. Quite often, younger children with no school experience have not been given opportunities to use scissors or button clothing. If so, make a note to check with the team in a few months to see if classroom exposure has bolstered his skills.
Final Note
Final Note There we go! Although many tasks are included in this manual, discretion is left to the therapist as to which are appropriate for the child you are testing. We think you will see and learn new things about children and their fine motor delays as you conduct the assessment outlined here. Assessments should take no longer than thirty to forty-five minutes, and sometimes as little as twenty minutes. As always, we appreciate any feedback you care to provide. We want to make this the most useful tool available for school, private, and clinical therapists who work with children. We look forward to hearing from you!

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