What Are Fine Motor Problems that I Should Refer To an Occupational Therapist?

Patient Presentation
A 5-year-old male came to clinic with his mother for his health supervision visit. She stated that he was doing well but that the child care provider says that he doesn’t want to do coloring or writing activities very much. Both have noted that he seems to tire quickly in these activities and just kind of lays on the table or squirms in his chair. His mother also says that he seems to turn his hand around while holding a crayon or pencil and doesn’t seem entirely comfortable with it. The past medical history and review of systems are negative. The family history shows that his father needed some speech therapy as a child for dysarticulation.

The pertinent physical exam shows a smiling boy with normal vital signs and growth parameters. His physical examination is normal including his neurological examination. His writing on the chalkboard shows immaturely formed letters and shapes. He is able to form squares, crosses and triangles but they have a shaky appearance. When asked to draw on the board, he holds the chalk in an awkward position, somewhere between a fisted grip and a proper tripod position. When a formal Denver Developmental Screening Test was performed he was normal in all areas.

The diagnosis of a possible writing problem was made and the child was referred to an occupational therapist (OT). The OT found a mild hypotonia in the upper extremities and an abnormal grip, and began intervening with him. She began working with him to increase his strength using PlayDoh®, playing with a peg board and picking small objects with tweezers, tongs and other similar items. The OT and the school personnel were working collaboratively to improve his fine motor skills. At his last appointment he was making good progress on opening up the space between his thumb and fingers to increase the webspace, but he needed an adaptive pencil grip at that time. Therapy was ongoing.

Fine motor movements affect almost everything we do on a daily basis such as moving and manipulating tools and objects, preparing and eating meals, personal hygiene, communicating through writing and typing, counting change, opening doors, etc.

Occupational therapists (OTs) are highly skilled professionals who assist children and families in some of the most important activities of life. OTs may work in hospitals, clinics, schools, rehabilitations centers and other locations, and a master’s degree is needed for an entry level position. Pediatric occupational therapists consider the wide range of developmental attainment for children. Depending on the problem, they may also need to consider rehabilitation needs if skills are lost through disease or accident in a child. OTs also work in areas of mental health including substance abuse, eating disorders and depression. OTs often work in interprofessional teams because most problems do not occur in isolation. For example, a child may be having difficulty writing because of general hypotonia or decreased physical stamina, and therefore the child may not be able to get into a proper truncal body posture or keep it there to be able to support the writing. An OT is qualified to treat these problems but may recommend co-treatment with a qualified physical therapist also. It is especially important for the OT to partner with the family and others to adapt/modify fine motor activities for the child while the strengthening and grasp therapy is getting started, i.e. finding ways for the child to be successful in spite of the fine motor problems.

Self care tasks (e.g. clothing management before/after toileting, difficulty with fasteners, cutting foods, etc) can be difficult to assess in a medical clinic setting. Noticing if the child has difficulty taking off or putting on clothing at the visit, or even asks for help for a developmentally appropriate task may indicate a more global fine motor problem. Dyskinetic or awkward movement patterns could be coordination problem or weak grasp, but could also be sensory in nature. An OT can be valuable in assessing these problems.

While there are many checklists that both parents and healthcare providers can use to screen children for developmental problems, it is important to note that it is not just the presence or absence of the skills which may be of concern (i.e. a quantitative measure), but concerns about how the skills are carried out should also be noted (i.e. a qualitative measure). For example, a child with mild hypotonia or decreased stamina slumping over the work or putting their body into different postures such as hooking their legs around the chair legs. In these cases, this may be the child’s way of trying to hold up their body to be able to produce the work. On the checklist, the child would pass, but it is the way in which the child does the task which is of concern. Medical personnel (e.g. doctors, nurses, etc.) tend to have more training in screening to determine IF the skill is performed, and less about HOW it is performed. For this reason, even skilled medical professionals can miss less obvious developmental problems. It is often useful to refer a child for an evaluation by an OT if there are concerns by family members, caretakers or other personnel about how a child performs a task.

Learning Point
Medical personnel should screen children for developmental delays at each health supervison visit.
Normal fine motor skills attainment in the first 5 years of life is by noted below along with areas of concern that should be considered for further evaluation and possible referral to an OT.

  • End of 12 Months (1 Year)
    • Uses pincer grasp
    • Bangs two objects together
    • Puts objects into container
    • Takes objects out of container
    • Lets objects go voluntarily
    • Pokes with index finger
      • Developmental Concerns During 0-12 months
        • 3.5 months – persistence of grasp reflex
        • 4-5 months – unable to hold rattle
        • 7 months – unable to hold an object in each hand
        • 10-11 months – absence of pincer grasp
      • Developmental Concerns During 13-24 Months
        • 15 months – unable to put in or take out object, does not seem to know the function of common household objects (brush, telephone, bell, fork, spoon)
        • 20 months – unable to remove socks/gloves by self
  • End of 24 Months (2 Years)
    • Scribbles on his or her own (generally with a fisted pencil grip)
    • Turns over container to pour out contents
    • Builds tower of four blocks or more
    • Might use one hand more often than the other
    • Fingers move independently of each other often
      • Developmental Concerns During 25-36 Months
        • 24 months – unable to stack 5 blocks or not scribbling
        • 30 months – not turning single page of book
        • 36 Months – unable to stack 8 blocks, draw straight line, cannot grasp a crayon between thumb and fingers, has difficulty scribbling, cannot stack four blocks
  • End of 36 Months (3 Years)
    • Makes up-and-down, side-to-side, and circular lines with pencil or crayon (pronated pencil grip – fingers pointed toward the end of the writing instrument)
    • Snips paper with scissors
    • Turns book pages one at a time
    • Builds a tower of more than six blocks
    • Holds a pencil in writing position
    • Screws and unscrews jar lids, nuts, and bolts
    • Turns rotating handles
      • Developmental Concerns During 37-48 Months
        • 48 Months – unable to stack 6-8 blocks, cannot copy circle
        • During this time period – seems uncomfortable holding crayons
  • End of 48 Months (4 Years)
    • Copies square shapes (generally with a tripod pencil grip)
    • Draws a person with two to four body parts
    • Uses scissors
    • Draws circles and squares
    • Will try to color within the lines but with limited success
    • Begins to copy some capital letters
    • Scissoring is more efficient with forward motion and following a simple S curve on the paper
      • Developmental Concerns During 49-60 Months
        • 54 months – unable to copy square
        • During this time period – has trouble taking off clothing, cannot brush teeth efficiently, cannot wash and dry hands
  • End of 60 Months (5 Years)
    • Copies triangle and other shapes
    • Colors usually well within the lines
    • Draws person with body
    • Prints some letters
    • Dresses and undresses without help
    • Uses fork, spoon, and (sometimes) a table knife
    • Usually cares for own toilet needs
    • Hand dominance should be fairly well established and totally established by 72 months
    • Can cut out a square

Children who are performing writing-type tasks should have the ankles, knees and hips at 90 degree angles. The forearms should rest on the desk/table top. The height of the desk/table top is 2 inches above the elbows when the elbows are held at the child’s side. There are a variety of pencil grasp patterns (including developmental ones that are perfectly normal – see To Learn More Below), but the emphasis should be on a functional grasp. The tripod grasp with open web-space is a common one where the writing utensil is “… held with the tip of the thumb and index finger and rests against the side of the third finger. The thumb and index finger form a circle.” There are variations of this including the adaptive tripod and quadripod grasp. For children who have difficulties with consistently creating a functional grasp, adaptive pencil grips may be utilized.

Questions for Further Discussion
1. Where are OT services provided locally?
2. What problems do children with writing problems show in elementary school?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Learning Disorders and Muscle Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

OTility.com. Pencil Grasp Patterns and Pre-Writing Skills.
Available from the Internet at http://www.otility.com/articles/Pencil-Grasp-Patterns.aspx (cited 5/17/10).

Skillbuildersonline.com. Fine Motor Develoment 0-6 Years.
Available from the Internet at http://www.skillbuildersonline.com/SBA/Description.asp?ID=2 (cited 5/19/10).

Occupational Outlook Handbook. Occupational Therapists. Bureau of Labor Statistics. 11th edit. Available from the Internet at http://www.bls.gov/oco/ocos078.htm (rev. 12/17/2009, cited 5/17/10).

Bright Futures. Developmental Milestones Age 2, Ages 3-4 years, Age 4-5 years.
Available from the Internet at http://www.aap.org/healthtopics/stages.cfm (rev. 3/17/10, cited 5/17/10).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Larissa Treat, MOT, OTR/L