Motor skills

What are gross motor skills?

Gross motor skills are the large movements your child makes with their arms, legs, feet and their body as a whole.

In the early, pre-nursery years these are assessed by the timescale in which gross motor milestones are reached. These milestones include independent rolling, sitting, crawling, standing and walking/ cruising. It is important to note that this is a fluid scale and not all skills will happen one after the other. For example, some children may be able to stand but not yet sit independently but will develop sitting following standing.

There’s a lot of variation in the time it takes for children to achieve these goals, but they usually have them by the age of two. Sometimes additional factors such as bottom shuffling or increased joint mobility may cause a slight delay in the achievement of these skills. In the case of more complex neuro-disability physiotherapy input may be needed to help children achieve these milestones.

Gross motor skills can be challenging for children for a number of reasons:

• lack of experience or practise
• difficulty coordinating the two sides of the body (bilateral integration)
• reduced balance caused by poor core stability
• difficulty planning and organising themselves to follow instruction
• limited spatial awareness skills
• lack of motivation to perform the required tasks.

How can you help with gross motor skills?

General tips:

• regular practise (five to 10 minutes each day) will help your child improve their skills

• encourage your child by giving praise and encouragement for their efforts and success
• start easily and gradually make tasks more difficult
• make it fun.

Tips for practising new skills

• consistency – practice new tasks in the same place with the same materials

• repetition – repeat the task over days and weeks with consistency
• demonstration – demonstrate the task to the child regularly
• use both verbal instruction and demonstration together
• even if you are only changing or extending the task slightly assume your child is learning the whole task again from the beginning
• praise all efforts.

When to refer

It is important that children are given adequate opportunity in which to explore, develop and challenge themselves to gain gross motor skills. However, in some circumstances it is important to seek physiotherapist advice and input.  These circumstances include:

• significant developmental delay

• concerns regarding muscle tone (muscles or joints feeling or appearing much stiffer or weaker than expected)
• significant reduction in the ability to balance, particularly when walking
• restriction in movements or joint range
• asymmetrical movement or apparent rigidity in the limbs when performing gross motor tasks

What are fine motor skills?

Fine motor skills refer to a child’s ability to use their hands and fingers accurately while carrying out everyday tasks. These include tasks such as grasping objects, handwriting, cutting with scissors, typing shoes laces, fastening a button and picking up a small toy brick. These skills are needed for self-care and participation in activities at school and at home.

An infant will initially hold objects within the palm of their hands after being raked into the palm by the fingers. They will then develop on to picking up and holding objects in a pincer grasp. The development of grasp is influenced by a child’s growing interest in objects and desire to hold them.

The pincer grasp is defined as a grasp that uses the pads then tips of the index finger and thumb to pick up and grasp objects. As a baby masters self-feeding you will notice this grasp in how they pick up smaller pieces of food such as circle cereal with their fingers instead of the palm of their hand. For babies this is an important milestone in fine motor development. The pincer grasp represents the coordination of brain and muscles that’s necessary to help them gain increasing independence.

A baby will typically develop this skill between the ages of nine and 10 months, although this can vary as children develop at different rates.

The pincer grasp is an essential grasp to develop as it allows for more refined control which is essential as a child is learning to master important tasks such as holding a pen/pencil, using cutlery, fastening a button and zip.

Is your child is doing any of the following?

• finding it difficult to pick up small items and manipulating them
• avoiding or not interested in using their fingers to do fiddly tasks
• preferring physical activity (again to avoid sit down tasks)
• much more interested in watching the TV or iPad/tablet than doing construction play and craft
• not interested in pencil or scissors skills
• preferring to tell you what to do rather than do the ‘fiddly finger’ task themselves
• waiting for you to dress them or clean their teeth rather than trying themselves.

If so, your child will need some opportunities to join in activities throughout the day that help develop their fine motor skills.

If so, explore the tabs on this page to find activities to help with:

• developing your child’s fine motor skills
• using thera-putty to strengthen and improve fine motor skills
• learning how to apply the right amount of pressure for fine motor tasks (see grading force activities).

Occupational therapists work closely with early years settings and schools to support the East Sussex local offer which include a universal offered programme of intervention including Jump Ahead.

Helpful strategies and activities to support fine motor skills

Fine motor skills refer to the use of small muscles or muscle groups, particularly in the hands and fingers, to perform precise skilled tasks, including writing skills. Refined fine motor skills stem from solid sensory and motor foundations. Adequate muscle and joint stability, especially in the neck, trunk, and extremities, are required for good hand use.

The strategies and activities listed below can be practised in order to develop fine motor skills.

Helpful strategies

• establish a good posture when sitting at a table (for example table and chair at the correct height, achieving 90° angles at the knee, pelvis and feet, encourage bottom at the back of the chair)

• grade activities according to ability (large items will be easier to handle than small).
• break down tasks by giving instructions stage by stage
• pre-prepare parts of the task if the total task is very complex
• use equipment to make tasks easier (such as non-slip matting, pen grips, triangular pencils)
• practice large movements to develop motor planning and kinaesthetic awareness before attempting refined smaller movements such as those needed for writing
• give physical prompts, if necessary (such as physically directing hands through a movement).

Activities

Play dough

Practice kneading, rolling, pinching, poking, squashing, moulding into shapes and cutting the play dough using pizza cutters.

Therapy putty activities help develop hand strength, finger dexterity and fine motor skills.

Threading

Practice threading beads of different colours, shapes and sizes on to a shoelace. Try different objects (such as macaroni, straws, cotton reels, Hula Hoops, Cheerios, etc.)

Practice threading a shoe lace through a lacing card. In addition to commercially available cards or wooden sets, try laminating a favourite image and hole punching around the border.

Pegs

Play games using clothes pegs.
Peg pictures, clothes or cards on to a line.
Race to see who can put pegs on the sides of an ice cream container and remove them the fastest.
Try making a long chain of pegs.
Time how long it takes to remove pegs placed all over the body such as a trouser hem, sleeves and knees.

Hand play
(stretching elastic, popping bubbles, squeezing, tweezers)

Practice the hand actions while singing action songs such as Incy Wincy Spider, Five Fat Sausages, Peter Pointer and Twinkle, Twinkle Little Star.

Playing church and steeple, hand clapping games, shadow puppets and finger puppets.

Use a narrow necked bottle and practice picking up peas using the thumb and index finger one at a time. Post them into the bottle. Try using the thumb and the middle finger, ring finger, and then little finger (very tricky).

Make a tennis ball man by cutting a slit into a tennis ball (mouth) and adding googly eyes, hair, nose, etc. Practice feeding him a selection of small items (such as beads) to develop pincer grasp, in-hand manipulation and bilateral skills.

Screw up paper into balls of different sizes. Increase the challenge by using one hand at a time (this will help develop hand manipulation and strength). Use the balls for:

• throwing at targets (such as a bucket).

• flicking – competition to see how far the balls can be flicked
• finger football – with palm face down on a table, extend index finger to kick the ball into a goal across the table (use two items such as salt/pepper pots).

Play hand games with an elastic band:

• pass the band – pass the band along all fingers of one hand (for example pass from thumb to index finger, then through each fingers alternately).
• stretch – cup hands with fingertips together. Place the band around the fingertips and practice opening and shutting fingers against resistance. Then practice one finger at a time.

Use tweezers to move small objects of different textures into a pot for example sweets, raisins, popcorn, rice, pasta, cotton wool, paper or play dough. Have races to improve speed. Use the tweezers to make towers with small blocks.

Have fun popping bubble wrap between thumb and first finger.

Blow bubbles and practice popping them by poking them with different fingers, grasping them, flipping them and hitting them.

Pen and paper play

• try drawing, colouring, stencils and tracing using pens, pencils, crayons and chalks
• use a ruler to join the dots in dot-to-dots
• practice mazes of varying degrees of difficulty. Try to stay within the lines.

Practice punching holes with a hole punch.
Practice using a stapler.

Try to make a long chain from paper clips.

Coin games

Try some of these games with coins.
Posting – practice posting coins into a money box or a tub with a slot cut in the lid.
Coin turn – race to rapidly turn over a line of coins.
Finger flip – with hands flat on the table, lay a coin on each finger nail. Try to flip a coin one finger at a time.
Coin store – try to pick up as many coins as possible with one hand and keep them stored in the palm.
Creeping coin – practice moving a coin from the fingertips to the palm and back again.

Construction games

Use large or small construction with toy bricks, Lego, Duplo, Mechano, sticky bricks or any other activity that requires putting together and pulling apart pieces.

Practice screwing nuts and bolts together.

Cooking

Encourage your child to join in cooking activities as these involve using the hands in many different ways such as opening and closing containers, rolling dough or using cookie cutters.

Craft activities

Art projects – activities that involve colouring, painting, printing, cutting, gluing and assembling (such as cards, collages, puzzles, masks, calendars, etc.)
Finger painting – using paint, cornflour, porridge, ink, etc.
Crayon rubbings – over leaves, string, coins etc.
Ripping paper – ripping paper with the thumb and index/middle fingers, and then using glue to make collages or papier mache.
Cutting with scissors – practicing using scissors to cut around pictures, templates, and through different textures (such as cotton, straws, clay, etc.)
Modelling – with clay, plasticine or pipe cleaners.
Paper folding – making paper planes, simple origami, paper weaving, paper chains, etc.

Commercial games

There are lots of commercial games available that help develop fine motor skills.

Some examples include: Board games, Connect Four, Jenga, Monkey Business, Dominoes, pick-up-sticks, shape sorters, puzzles, peg boards, cards, etc.

Grading force activities (to support writing)

Grading force refers to the amount of pressure a child applies to objects including pens and pencils when writing. Some children apply too much force so may frequently break toys, pencil leads or erase so hard that the paper rips. Other children do not apply enough force to objects and this causing them to write too lightly for example.

Helpful strategies

• establish a good posture when sitting at a table (for example table and chair at the correct height, achieving 90° angles at the knee, pelvis and feet, encourage bottom at the back of the chair)
• grade activities according to ability
• pre-prepare parts of the task if the total task is complex
• break down tasks by giving instructions stage by stage
• give physical prompts and hand over hand support, if necessary (for example when encouraging a good pen grip).

Activities

J Colouring different shades with the same pencil. Creating a colour by number is a really good way to encourage children to make different tones with their colouring pencil causing them to adjust the amount of pressure being applied to the pencil.

J Crayon rubbings: Place a sheet of paper over the top of a textured object such as a leaf, stencil (can be made with string on cardboard) and tree bark. Then rubbing hard with a crayon over the top to reveal the pattern.

J Use golf tees in putty, Playdoh, cork board or polystyrene and get the child to balance marbles on each one.

J Throwing and catching games using different weighted objects such as balloon, bean bag, bouncy ball, football or teddy bear.

J Practice setting up domino rallies.

J Use sticker books or stickers getting the child to peel the stickers off of the paper.

J Have a pompom puff race. Using a pipette and a pompom, race to see who can blow it across the line first.

J Explore different types of pens including vibrating pens and squiggle wiggle pens.

J Complete some heavy muscle work prior to completing writing tasks. For example, wall push ups, chair push ups, pulling a weighted suitcase or tug of war.

J Use a single-handed hole puncher on different thicknesses of paper such as tissue paper, paper, card or laminate.

J Ghost writing game – write a message to a friendly ghost and then erase it. If the words written are unable to be read by the other player, the writer wins.

J Place sticky tack, putty or Playdoh around the pen or pencil and challenge the child to not leave deep finger marks while completing a writing or drawing activity.

J Practice writing on different delicate papers including tissue paper, toilet roll or kitchen roll.

J Playing balloon volleyball.

J Play balloon tennis with paper plates as bats.

J Explore a mixture of cornflour and water – you can add food colouring and glitters if you like. Try applying different pressures to it with your fingers to see what effect it has.

J Try writing on different coarse sand paper.

When to refer

It is important that you and your child’s education setting build opportunities into the day to practice fine motor skills. It helps to use toys your child finds motivating as this encourages them to join in. However you might find:

• your child continues to have difficulties despite doing the suggested activities

• your child’s difficulties are having an impact on how they join in everyday tasks.

If this is the case they may need a specialist assessment from an occupational therapist.

If you want more information about referral, follow the links below. Remember you can phone and speak to a therapist on our Therapy One Point: 0300 123 2650 if you need to discuss a possible referral.

What is developmental co-ordination disorder?

Developmental co-ordination disorder (DCD) is a motor skills disorder that affects five to six per cent of all school-aged children. DCD can also be referred to as dyspraxia. It causes a child to perform less well than expected in daily activities for their age, and appear to move clumsily.

There is usually a history of delayed early developmental milestones of crawling, walking, self-feeding and dressing in young children with DCD. Drawing, writing and performance in sports are also usually behind what is expected for their age.

Although signs of the condition are present from an early age, children vary widely in their rate of development. This means a definite diagnosis of DCD does not usually happen until a child with the condition is five years old or older.

DCD is thought to be around three or four times more common in boys than girls and the condition sometimes runs in families. (NHS website)

The developmental co-ordination disorder pathway

Your paediatrician, GP, school or you, might refer your child to us. It is very difficult to diagnose a child under the age of five so we tend to see children from six years and up in line with international guidelines.

Your child may be referred because you or another professional, for example a teacher or therapist, is concerned about your child’s motor skills.

Children and young people should have completed four terms of a motor skills programme called Jump Ahead (or similar) in school before referral is considered. This is because some children’s motor skills improve with this programme, meaning they don’t need further assessment.

If the referral shows that your child has significant motor skill difficulties which are impacting on their ability to complete everyday tasks such as handwriting, tying shoelaces or using a knife and fork, they will be invited for an assessment.

The assessment will take place face-to-face in clinic, home or school. A standardised motor assessment will be used to assess their motor skills. This assessment will be carried out by and occupational therapist and/or a physiotherapist.

The assessment will involve gathering information from other agencies who know your child, such as school.

Therapists cannot diagnose developmental co-ordination disorder. If we have evidence that your child may meet the criteria for diagnosis following assessment we will link with community paediatrics. They will then make a final diagnosis.

What we can do for you?

If your child has completed the Jump Ahead programme in school and are continuing to experience motor difficulties which are impacting on their daily lives we can see them for an assessment.

After the assessment we will write a report that will summarise what we found out and make recommendations.

We will link with the paediatricians to support a formal diagnosis of DCD.

Depending on your child’s presentation we may offer:

• a school visit
• a home visit
• some therapy sessions
• a home or school programme

These may be carried out by an integrated therapy assistant, an occupational or physiotherapist.

Helpful links

• The NHS website offers an overview of DCD (NHS.uk)
• The Can Child Centre in Canada offers the latest information and research (Canchild)

Case studies 

Nathan is a nine-year-old boy. He was referred by his parents because they were concerned that despite input in school he was struggling with handwriting. Nathan had never learned to ride a bike or scooter. He found it difficult to organise himself to get up and ready in the morning and often forgot to bring his water bottle or jumper home from school.

Nathan came to clinic for an assessment with his mother. We assessed the quality of his handwriting and how he completed daily tasks like cutting up food with a knife and fork. He took part in a standardised motor assessment that told us that his motor skills were below the fifth percentile for his age, indicating he had significant motor difficulties.

Nathan’s teachers reported that Nathan was a bright boy but that he sometimes found it hard to concentrate in class and he struggled to get his great ideas down on paper in the time he was given.

Nathan was referred to community paediatrics at the Scott Unit for further assessment and diagnosis.

We worked with teaching staff at Nathan’s school to educate the teachers about DCD with a special focus on how this affected Nathan. We advised that Nathan should be sat at the front of the class near his teacher. This meant he could regularly check in with him to make sure he knew what was happening. Nathan found a different pen helped his writing and he started to type long pieces on a laptop. He was given extra time in exams.

Nathan was given a home exercise programme to help build up his tummy, shoulder and arm muscles. We encouraged him to continue swimming lessons and joining in Jump Ahead sessions in school.

The occupational therapist saw Nathan to work on some of his goals, including bike riding using an evidence-based practice cognitive approach.

The following websites all have information about sports and disability

• Active Sussex – Inclusive sports Active Sussex
• Defiant sports Welcome to Defiant Sports – Connecting Through Sport
• Cerebral Palsy Sport
• Active alliance / disability inclusion sport (over 40 different leaflets)
• Scope / Disability sports
• Paralympic information
• NHS Sports and activities

Non-fee-paying schools in East Sussex can also access the Healthy Schools Programme. Please see here for further information Healthy schools programme | East Sussex (eastsussexchildren.nhs.uk)