Fine motor skills

Fine motor skills play an integral role in early childhood development and advance rapidly for independence in school and self-care activities. These skills refer to the small muscle actions that take place in our hands, wrists and arm that allow us to perform everyday tasks. Of course, these skills may vary across different cultures for example, when to use writing utensils, cutlery, or utensils used during feeding. We will discuss general fine motor development to provide a general idea of promoting fine motor skills in your unique situation. 

Infant and toddler fine motor skills activities

Fine motor skills can be observed as infants swipe their arms at a toy. These skills progress to using a purposeful reach for toys, bringing hands to midline, and using a symmetrical reach with both arms. Infants start using a “raking grasp”, picking up items like cereal with the ulnar (pinky) side of the hand. 

As their grasp matures, items can be held in the palm and eventually on the radial (thumb) side where they can grasp and control items in their fingertips. Other skills developed in infancy and toddlerhood include the development of palmar arches, wrist stability, bilateral hand use, intrinsic hand muscle development, and isolated finger control for holding different types of items.  

Fine motor skills activities to promote hand skills encourage play in various positions, combining postural control, with reaching, grasping, and releasing during play. Offer different textures to increase their sense of touch and allow them to help you in tasks such as pouring or stirring during meal preparation. 

By one year, children can assist with feeding and drinking tasks, using controlled reach, voluntary grasp/release, and appropriate pressure on items during feeding (not crushing food with hand). Other activities include encouragement of pointing to items of interest, stacking blocks and arranging simple puzzles. These tasks stimulate visual motor, cognitive and fine motor skills that unite to increase overall hand skills expected during the preschool years. 

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Preschool and early elementary fine motor skills activities 

By preschool, children can assist with precise dressing and feeding tasks such as buttoning and using utensils. Grasp has typically matured from a palmar grasp (holding an item in the palm with fingers wrapping around the item, to a radial grasp (using the thumb side of the hand with thumb opposition) and holding items with precision in the fingertips. Prewriting skills take center stage in preschool as children practice letter recognition, tracing shapes, copying lines, and tracing letters of their name. 

Prewriting strokes include vertical, horizontal, and diagonal lines, an “X” and a circle. If grasping difficulty persists, offer a variety of writing tools including a thicker writing utensil or a pencil grip, allowing the child to decide what they want to write with. For handwriting, a trusted strategy is to “trace-copy-generate” to master tracing a design before attempting to copy and subsequently generate the same design. 

By elementary school, children typically demonstrate a dynamic tripod grasp where the pencil is held at the fingertips, and pencil movement occurs using fingers and hands with precision. Scissor skills also become more prevalent as isolated finger control, hand strength, and bilateral hand skills develop. 

Activities to promote these skills include stacking blocks or stringing beads, pinching to turn pages in a book, increasing familiarity with using scissors and holding a writing utensil to draw or color. Activities to promote grasp include putting coins in a piggy bank, using tongs or tweezers to pick up items, and painting with cotton balls or cotton swabs. Activities to support scissor skills include practicing orienting scissors in the hand, using various scissor designs to cut snips, and cutting along bold lines on paper. Encourage the child to hold and move paper when cutting squiggly, zigzag, or simple shapes.

Late elementary and middle school fine motor skills activities

By late elementary and middle school, children can now demonstrate mature hand manipulation skills, requiring intrinsic hand strength and palmar arch control to complete their daily routine. In-hand manipulation are skills that translate items to or from palm and fingertips, shift items in our fingertips (managing a zipper) and rotate an item in our fingertips (opening a bottle top). Activities to stimulate hand manipulation include using fingertips to move coins to and from palm using fingertips, opening a bottle top, rotating a puzzle piece, and managing clothing fasteners.

 Children are also expected to be increasingly independent with computer skills including keyboarding. Keyboard skills typically require correct finger placement, visual motor integration, and fine motor dexterity. Visually, children need to shift their attention rapidly from the screen to the keyboard for successful typing. Modifications and assistive technology options may be available to assist with meeting the child at their unique needs to enhance participation in keyboarding activities. Among the technology options available are word prediction software, accessibility settings to adjust visuals, and voice-to-text options to assist with typing.

Activities such as playing an instrument can promote skills required for typing, bilateral hand use, and shifting visual attention, to enhance keyboarding skills. Drawing with a stencil promotes bilateral hand use and visual motor skills can be stimulated by tracing or copying designs, working on mazes, or folding origami.

High school and adult fine motor skills activities

By high school, into adult years, we can manipulate small, intricate items, manage fasteners required for dressing, manage various containers, and type or write legibly. Occupational therapists can help create a plan with clients who need additional support for fine motor skills activities for work modifications, ergonomic considerations, or energy conservation to maximize participation and independence. Many occupational therapists can visit clients on-site at work or school to make recommendations based on the client’s unique situation. 

General strategies and fine motor skills activities into adulthood include regular strengthening activities for the trunk, upper body and ensuring the seating position is optimal for writing and typing tasks. Other activities to promote independence include playing musical instruments, art activities, and athletics adapted to the client's needs to stimulate hand skills for independence.

Adapting fine motor skills activities for special populations

Untreated fine-motor impairment can lead to long-term difficulties managing items for self-care, and decreased independence. Generally, when customizing fine motor skills activities, therapists consider what is meaningful to the patient before making recommendations. 

Effective engagement in fine motor skills activities requires integration of several skills including sensory, vision, cognition, bilateral integration, coordination, and overall strength. Occupational therapists will use professional judgment to make appropriate modifications with the overall goal to increase independence.

Billing, best practices, mistakes to avoid with fine motor skills activities

Research is limited but consistent recommendations include promoting client engagement, use of client centered goals and ensuring the environment is optimal for participation. 

Fine motor activities can be billed as CPT 97530, Therapeutic Activity or CPT 97110, or Self-Care CPT 97535 depending on your activity parameters. Mistakes to avoid include not using client centered goals and not documenting a clear link from activity to improved participation and how activities will enhance participation.