Exam 1: Infancy to Adolescence

International Classification of Functioning, Disability, Health (ICF)

1. Provide scientific basis for functional consequences of health conditions

2. Establish common language to improve communication amongst healthcare providers & general public

   1. Coding system for diagnosis, documentation, health info systems

3. Permit comparison of data across countries, healthcare, disciplines, services, time

4. Body structures/functions, activity & participation, environmental factors

OTPF-4

• Defines & guides practice/cornerstones of OT

• OT's foundational document defining domains (areas of occupation) and processes to support engagement and participation in meaningful activities.

• Articulates OT’s contributions to health & wellness through occupation

• How do we use occupation? How does that fit into OT & helping our clients gain/regain a state of health & wellness? Designed for internal & external audiences

Domain of OTPF-4 (5 parts)

1. Occupation: ADL, IADL, sleep/rest, work, play, leisure, education, social participation, health management

2. Performance patterns: habits, routines, roles, rituals

3. Performance skills: motor, process, social interaction

4. Client Factors: values, beliefs, spirituality; body function & structures

5. Contexts: personal & environmental

An OTR observes a child jump on 1 foot. Which of the 5 areas of OT domain are they most likely assessing?

Performance skills: Motor skills

OT Process

1. Evaluation: finding out what client wants & needs to do; determining what they can do & has done; identifying supports & barriers to health, wellbeing, participation

   1. Occupational profile & analysis of occupational performance, synthesis

2. Intervention: plan - identify goals & outcome measures, implement, review/re-evaluate

3. Outcomes: occupational performance, prevention, health & wellness, quality of life, participation, role competence, well-being, occupational justice; describe results clients can achieve through OT intervention

OT = Social & Medical Models of Disability

Recognize influence of environmental & social barriers on occupational participation

Social Model: context factors that create disability

Loss of function linked w/ health condition as an attribute of the social environment. Views disability as a socially created problem resulting from barriers in the environment & attitudes.

• EX: One injured with a spinal cord injury becomes disabled NOT by the injury itself, but because they can’t access local stores, public transport, etc.

Medical Model: factors intrinsic to individual as source of disability

Disability is a feature of the person that requires medical care, professionals “correct” the problem. Views disability as a problem of the person that requires treatment/correction

• Therapy clinicians identify impairments like weakness and develop strategies to improve one’s abilities or help them learn to compensate for the impairments (EX: One with a spinal cord injury is offered activities to strengthen muscles whilst being trained new ways to complete ADLs)

Infant Months: Trust VS Mistrust = Hope

• 0-3 mo: Early infancy

• 4-6 mo: Middle infancy

• 7-9 mo: Late infancy

• 10-12 mo: Transitional infancy

During infancy - 18 months, what’s the psychosocial crisis and virtue?

• Trust: Learn to develop sense of trust when basic physical & emotional needs consistently met by caregivers (feeding, comfort, affection, safety)

• Mistrust: difficulties w/ relationships & emotional regulation later in life

• Virtue: Hope

  • Building trust through consistent, nurturing engagement in daily routines = foundation for healthy emotional & social development, secure attachment

  • OTs can support routines, sensory regulation, co-occupation (shared activities between infant & caregiver)

Early infancy, 0-3 mo: Gross Motor Skills @ 0 months

• Fetal, flexed postures

• Primitive reflexes

Early infancy, 0-3 mo: Gross Motor Skills @ 3 months

• Lifting head in prone using antigravity extension

• Midline, symmetrical postures

• Hand to mouth: beginning of purposeful self-soothing & oral exploration

• Looking at hands

Neonatal Infant Reflex: Rooting Reflex (Integration: ~3 mo)

• Onset: Prenatal

• Interested in head-turning

• Stimulus: Stroke cheek

• Response: Turn head toward stimulus, opens mouth

• Purpose: Help locate breast/bottle for feeding

• Problem if persistent: Interferes with eating, speech, midline head control

Neonatal Infant Reflex: Suck-swallow (Integration: ~2-5 mo)

• Onset: Prenatal

• Stimulus: Touch to lips or inside mouth

• Response: Rhythmic sucking & swallowing

• Purpose: Intake of nutrition

• Problem if persistent: Neurological conditions, poor oral-motor control; difficulty transitioning to solids

Neonatal Infant Reflex: Moro (Integration: ~4-6 mo)

• Stimulus: Sudden head drop or loud noise

• Response: Arms extend/abduct, then flex inward

• Purpose: Protective/startle response

• Problem if persistent: Poor sensory regulation, emotional reactivity, poor balance

Neonatal Infant Reflex: Asymmetric Tonic Neck Reflex (Integration: ~4-6 mo) 

• Onset: At birth

• Stimulus: Turn head to 1 side

• Response: Arm/leg on face side extend, opposite limbs flex slowly

• Purpose: Hand-eye coordination development

• Problem if persistent: Difficulty with bilateral tasks, midline use, reading/writing, behaviors associated w/ ADHD

In the evaluation, the child demonstrates a retained ATNR. How would this present?

Rotation of the head to the right leads to extension of the right upper and right lower extremities

Neonatal Infant Reflex: Spinal Galant (Pre-natal onset, help get thru birth)

• Stimulus: Stroke alongside spine (prone)

• Response: Trunk curves toward stimulus

• Purpose: Aids trunk movement for crawling, walking, birthing

• Problem if persistent: Poor posture, fidgeting, bedwetting, attention issues

Neonatal Infant Reflex: Tonic Labyrinth Reflex (Integration: ~6 mo.; Onset: Birth)

• Stimulus: Change head in position (prone VS supine)

• Response:

  • Prone - body flexes

  • Supine - body extends

• Purpose: Develop muscle tone, posture, balance

• Problem if persistent: Poor head control, balance, delayed roll/sit, postural instability

Neonatal Infant Reflex: Palmar Grasp (Integration: ~4-6 mo.; Onset: Prenatal)

• Stimulus: Pressure on palm

• Response: Hand closes (grasp)

• Purpose: Preps for voluntary grasp

• Problem if persistent: Difficulty releasing objects, fine motor delays

When the OTR engaged the child by giving them a rattle to shake, they noticed that the child did not have a voluntary release of the object? Is this an expected behavior for a 12 month old child?

No, the palmar reflex is expected to integrate in late infancy (7-9 months)

Middle Infancy Milestones: 4-6 mo.

Anti-gravity behavior, postural control growth (holding head up in prone, bracing on 1 arm while reaching w/ the other)

• Rolling over: belly to back first; increases independence & exploration

• Hands to midline = brain lateralization, bilateral coordination

• Palmar grasp, raking: purposeful grasp

• Visually-guided reaching: reaching w/ intent

Middle & Late Infancy Milestones: 4-6 mo, 7-9 mo.

The Landau and Symmetrical Tonic Neck reflexes support?

• Crawling

• Postural balance

• Protective responses as infants master voluntary movement & operate upright against gravity

Middle & Late Infancy Reflex: Landau Reflex, Superman!

• When held in horizontal prone suspension, baby extends head, trunk, & limbs

• Supports: Anti-gravity posture, prone extension, trunk stability

• Prepares for: Active play in prone & facilitates extensor muscle tone

Middle & Late Infancy Reflex: Symmetrical Tonic Neck Reflex (STNR)

• Triggered by neck movement

• Neck Flexion (crawling): Arms flex, legs extend

• Neck Extension: Arms extend, legs flex

• Helps baby transition to independent sitting, begin quadruped positioning, dissociate upper & lower body to crawl

Integrated Reflexes

• Normal developmental process when reflexes are absorbed into more complex, voluntary actions

• Primitive, automatic movements are replaced by higher-level, voluntary control as the nervous system matures

Retained Reflexes

• Involuntary movements continue existing beyond the typical 3-9 months instead of integrating into more complex, voluntary movements

• Interferes with motor skills, learning, posture, sensory

How are reflexes different from righting reactions, equilibrium responses, & protective reactions?

• Reflexes are basic, automatic responses to stimuli that are present from birth and integrated by early infancy...

• Righting reactions, equilibrium responses, and protective reactions are more mature, voluntary-seeming postural reactions that emerge later and are maintained throughout life to help with balance and movement.

Middle Infancy, 4-6 mo: Labyrinthine Righting Reaction

• Helps infant orient head & body in space + maintain head-body alignment

• Vital for postural control & functional movement transitions (rolling, sit upright)

• Emerges around 2-3 months of age; integrates by 24 mo.

Middle Infancy, 4-6 mo: Equilibrium Reaction

• Maintain balance when body’s displaced by external force (being pushed)

• Trunk adjustments & protective arm/leg movements to maintain or regain posture

• Prep for standing, walking, fall prevention

Middle Infancy, 4-6 mo: Protective Response, Parachute RXN 🪂

Prevent injury from falls/loss of balance; safety mechanism.

• Forward protective extension: Baby reaches arms forward if falling face-first

• Lateral protective extension: arms extend sideways when tipping

• Backward protective extension: Arms extend behind to catch fall

Late Infancy: 7-9 mo, Motor Milestones “POP”

• Prehension: Thumb differentiation & voluntary release; palmar grasp integrated

• Oral: Manual self-feed, drink from sippy cup

• Posture & Mobility: Sitting unsupported, lie-to-sit, crawling, bears weight on feet

Important for play, eating, exploration, social participation

Late Infancy: 7-9 mo, Social & Cognitive Milestones “ACL”

• Attachment Behaviors: Protests separation, stranger anxiety (Ainsworth attachment & Erikson Trust vs Mistrust)

• Cognition: Object permanence (Piaget, Sensorimotor Stage - birth to 18 mo.) infants understand objects exist even out of sight

• Language: Reciprocal exchange & understand/respond to simple verbal cues

  • Knows familiar objects & words: Want milk!

  • Babbling, respond to words/sounds

Transitional Infancy, 10-12 mo, Milestones

• Communication: 1-4 word vocab. Intentional words to express needs/familiar items

• Motor skills - Walking

  • First steps (10-18 mo.)

  • Balance: leg strength, postural control

  • Standing: gross motor independence

  • Emerging pincer grasp

    • Use pads of thumb & index finger to pick up small objects like Cheerios

    • Self-feeding & fine motor precision

An OTR is evaluating an 18 month infant. When putting a toy in her hand, she grips it tightly but can’t let go to drop it in the bucket.

• This behavior indicates: reflex retention of the palmar grasp due to difficulty releasing objects and fine motor delays

• What occupation is disrupted: Play

• Is this typical performance given child’s age: NO, the child is 18 months and should have integrated this neonatal reflex at around 6 months

The OTR’s motor milestone checklist for a 10-12 month old included all of the following EXCEPT:

• First steps

• Standing Balance

• Rolling prone to supine (4-6 mo)

• Neat pincer grasp

Transitional Infancy: 10-12 mo, Developmental Sequence

• Timing & sequence of developmental milestone acquisition are used as key tools in assessing infants

  • Slow to acquire milestones = developmental delay

    • A 10-month-old infant is not yet crawling, but uses symmetrical rolling and shows normal muscle tone and posture.

    • This may be a motor delay, but development is otherwise typical.

  • Child demonstrates milestones out of sequence/qualitative differences in movement/behavior = abnormal development

    • A 10-month-old infant shows asymmetrical crawling, consistently using only one side of the body (e.g., left arm and left leg) and keeps the other side stiff or tucked.

    • This is a qualitative abnormality in movement, possibly indicating neuromotor dysfunction (e.g., early signs of cerebral palsy).

Toddlerhood (1-3 yrs): Theorists (6)

• Gesell: Maturational Theory

  • Growth follows predictable motor & behavioral milestones

• Piaget: Sensorimotor (Birth to 2 yrs) to Pre-operational (2-7 yrs)

  • Begin symbolic thinking & exploration thru play; centration/egocentrism

• Vygotsky: Sociocultural Cognitive Development

  • Social interaction, guided learning, ZPD: caregivers’ role in skill acquisition

• Ayres: Sensory Integration

  • Sensory processing key to motor planning & adaptive behavior

• Erikson: Autonomy VS Shame/Doubt (18 mo-3 yrs) = Will

  • Seek independence, testing boundaries & developing self-control

• Ainsworth: Attachment & Self-Regulation (Secure VS Insecure) = Early relationships

Toddlerhood (1-3 yrs): Gross Motor Milestones

• Early, 1-2 yrs: Runs, climbs on play equipment, throws & kicks ball

• Late, 2-3 yrs: Pedals a tricycle 

• Calibration: judges accurately

  • Force, speed, direction

  • Perceptual motor skills

• Postural Stability

  • Balance, alignment, static VS dynamic, body axis rotation

Early Toddlerhood (1-2 yrs): Fine Motor Milestones

• Uses tools

• Marks w/ crayon 

• Bimanual tasks 

• Turn book pages 📚 

Late Toddlerhood (2-3 yrs): Fine Motor Milestones

• Snips w/ scissors ✂ 

• Draws circle, traces

• Builds tower >4 blocks

• Strings beads

Toddlerhood (1-3 yrs): Visual Manual Skills

• Discriminative Touch: Using touch to identify texture, shape, weight, temperature, etc. to accurately judge the object touched.

• Haptic Perception: Combining touch and movement to understand objects without looking (uses discriminative touch plus memory of an object).

• Bimanual Coordination: Using both hands together for stabilizing and manipulating tasks.

• Precision Grasp: Refinement of fingertip grasp for small objects.

• Hand Preference: Emerging hand dominance, becoming more consistent.

Toddlerhood (1-3 yrs): Language, Early Toddler (19-24 mo) 💬

• Telegraphic speech: 2 word phrases “Lily tired”

• First sentence

• ~12 words

• Receptive (ability to understand) → expressive (ability to use words & sentences to communicate thoughts, needs, ideas)

Toddlerhood (1-3 yrs): Self-Care Skills

Adaptive skills, vary significantly by context

ADLs

• Independent eating (mostly) 🥣

• Assist in oral & toilet hygiene (imitate brushing teeth, may indicate need to go, attempts wiping) 🪥🚽

• Assist in dressing (remove loose clothing, help push arms thru sleeves/legs) 👕

IADLs

• Assist in household tasks (put away toys, mimic adult behaviors: wipe table) 🧸

Symbolic play is important in toddlerhood developmentally (emerges in 18-24 mo):

1. Language development: symbolic function

2. Decentering from self

3. Theory of Mind: enhances empathy & perspective-taking, understand others have different thoughts, beliefs

4. Engaging in roleplay helps children simulate & predict others’ mental states (ex: stick is magic wand)

Middle Childhood: 6-12 yrs, Overview

• Children gain a better sense of self & culture beyond home as they become active participants in school & community

• Increased independence & competence in ADLs and IADLs

  • Development of unique interests/personal expression through play/hobbies

  • Exploration of social world/virtual communities

  • Learn how to maneuver complex interpersonal and social worlds

• Risks: bullying, stress-related issues, potential sport injuries

  • Those w/ developmental differences face increased challenge as children learn to compare themself with peers

Middle Childhood: 6-12 yrs, Theorists

• Piaget - Concrete Operational Stage (7-11 yrs) 🥛

  • Organization & rational, logical thinking

  • Process environmental contexts logically

  • Begins to understand physics and conversation/classification/seriation (tall skinny and wide glass of water, same amount of water in both)

• Erikson - Industry VS Inferiority [5-13; Virtue = Competency] (engage in meaningful occupation OR suffer in feeling inferior to peers)

  • Peer comparison, motivation from accomplishments

  • Collaboration & teamwork develop

Middle Childhood: 6-12 yrs, Neurological Development 🧠

• Brain Development - Hemispheric specialization: dominance w/ various tasks

  • L: language & movement (Broca’s & Wernicke’s; rational & logical) 🗣

  • R: analyzing geometric shapes & elements (perceptual) ◼

• Corpus callosum myelination improves processing: fatty covering sheath enabling efficient communication

  • Frontal & prefrontal cortex supports flexibility, reasoning

Middle Childhood: 6-12 yrs, Sensory Development

• Visual acuity ~20/20 (see sharply unless visual deficit) 👀👓

• Auditory processing → language comprehension, sound localization; improved sensory filtering

  • Process language

  • Hear/repeat/recall words, phrase, sequence numbers

Middle Childhood: 6-12 yrs, Physical Motor Development

• Steady growth (2–3 in/year) 🤥

• Stronger bones/joints (increased injury risk); calibrate & refined balance & postural control, coordination, timing, bilateral coordination, movement; handwriting improves; hand dominance solidified (~7 yrs).

• Body composition

  1. Increased muscle and skeletal mass to support greater height & weight, but is less abler to withstand impact

  2. Refined balance and postural control; calibrate & refine movement (kick soccer ball) ⚽

• Fine motor skills: finger dexterity, bilateral coordination, speed and dexterity increase, hand preference and dominance (cut scissors, write, throw) ✂

Middle Childhood: 6-12 yrs, Cognition/Mental Functions

• Attention: greater focus, screens out distractions

• Memory: working memory expands (5–7 bits, 15–20 sec); long-term memory grows 🧠

• Perceptual: visual/auditory figure-ground, proprioception, stereognosis

• Cognitive monitoring: self-checking and persistence with tasks

• Cognitive maps: mental visualization and recall

• Spatial & temporal awareness: body schema, timing, planning 🤔

  • Body schema: internalized sense of how much space my body occupies and the space around my body. “Will I fit through this tight space with my bookbag on?”

  • Temporal awareness: Passage of time as it relates to planning, sequencing, and altering movements. “How much time will it take to finish this snack so I don’t miss the bus?” ⏰🚌

• Emotional function: self-regulation, self-concept, stress management (growth mindset important).

• Asynchronous development: uneven growth across domains is normal; risk of “learned helplessness” (Repeated failures at a task that is not aligned with the child’s skills/context may lead to low confidence and task avoidance).

Adolescence (12+ yrs): Overview

• Physical changes: brain maturation, increased physical development & need for sleep, puberty & sexuality, more complex motor & mental functions

• Activities & participation: ADLs & IADLs, relationships, school & work, leisure

• Prefrontal cortex HIGHLY connected w/ limbic system (emotions, memories) & striatal system (risk-taking)

• Health issues: environmental factors, EDs, substance abuse, depression, anxiety

• Romantic & family relationships

Adolescence (12+ yrs): Theorists (4)

• Piaget: Formal Operational Stage (12+ yrs)

  • High symbolic thought & representation, appears when individual has been exposed to complexity in cognitive challenges; scientific & physics understanding, cause/effect

• Erikson: Identity VS Role Confusion = Fidelity [13-21 yrs]

  • Importance of peer relations, separation from parents, tries out new roles, integration of previous resolutions

• Freud: Genital Stage - awakening of sexuality

• Resolution: sexual functioning, how adolescent relates to self & others

Gessel: Maturational Theory

• All children go through the same stages of development in the same sequence. Growth progresses in a pattern

• Each child moves through these stages at their own rate. Individual variation is normal.

• Equilibrium is followed by disequilibrium. Child can’t learn certain skills when their body and brain aren’t developed enough.

• Skill regression is built into normal development! A child can start to do something good but can do it bad; continuous growth.

• Established normative trends in motor, adaptive/cognitive, language, personal social behavior

A pediatric occupational therapist is evaluating a 12-month-old child referred for developmental delay. During the assessment, the therapist observes the child sitting independently, crawling, and beginning to pull to stand—but not yet walking. The parents express concern, as their friend’s child began walking at 10 months. The therapist explains that while some children walk earlier, others walk closer to 15 months. She assures the parents that the child is following a typical developmental sequence, and that individual variation in timing is normal. What theorist is this?

Gessel Maturational Theory

• All children go through the same stages of development in the same sequence

• Each child moves through these stages at their own rate

Piaget: Stages of Cognitive Development

• Children’s thinking becomes progressively more advanced

• Sensorimotor: birth to 18-24 months, object permanence, goal-directed action & cause-and-effect

• Pre-operational: 2-7 years, symbolic thought (language, drawings, pretend play; egocentrism)

• Concrete operational: 7-11 years, logical thought, conservation, physics, cause/effect

• Formal operational: 12+ yrs, scientific thinking

Polly is 10 months old and cries when her ball rolls behind the couch where she can’t see it. She smiles again immediately after you hand her the ball.

• Sensorimotor: birth to 18-24 months, object permanence

• When her ball rolls out of sight, she cries because she knows it exists but can’t get it.

• Object permanence: knowing objects continue existing when they can’t be directly observed or sensed

Vygotsky: Sociocultural Cognitive Development

• Learning is a social process driven by culture and social interaction, where children learn through guidance from more knowledgeable others

• Zone of Proximal Development: gap between what a learner can do without help and what they can achieve with guidance from a more knowledgeable person

• Scaffolding: Learns w/ specific assistance/support from others

• Private speech: talking to oneself; internalized mentally by 9

An OTR observes a 3 year old in daycare watching their teacher lace with beads to make a macaroni necklace using a 3 color pattern. The teacher lays out only 2 choices to help the child complete the pattern.

• Vygotsky, Sociocultural Cognitive Development

• Scaffolding: Learns w/ specific assistance/support from others

• Zone of Proximal Development: gap between what a learner can do without help and what they can achieve with guidance from a more knowledgeable person

Maslow: Hierarchy of Needs

Person acts according to priority of needs at any given point in time. If basic need like food is denied, person will be obsessed w/ satisfying that need; if it’s available, they can seek higher-level needs

• Self-actualization: Motivation to explore, play, learn; creativity & personal growth

• Self-esteem: confidence, self-worth, encouragement to take initiative and engage

• Love & Belonging: secure relationships w/ caregivers & peers

• Safety & Security: emotional & physical safety @ home & school

• Physiological Needs: sleep, nutrition, heath = foundation for attention & learning

Bandura: Social Learning Theory

• Learn through imitation/observation & modeling

  Modeling: Observe others seen as ‘models’

  • Attention to model

  • Retention of past experiences

  • Ability to reproduce response physically

  • Motivation to produce response

• Self-efficacy: one’s belief in ability to succeed in specific situations, influencing their motivation & performance

• Vicarious reinforcement: observing others be praised, then imitating behavior

Ayres: Sensory Integration

• The brain's ability to organize and interpret sensory input is essential for producing appropriate motor, behavioral, and learning responses.

• Sensory Processing: The brain’s ability to receive, organize, and interpret sensory information from the environment and the body.

• Key Sensory Systems:

  • Tactile: Touch and texture awareness

  • Vestibular: Balance, orientation

  • Proprioceptive: Body position-in-space, physical self awareness

  • Auditory: Sound processing

• Visual: Sight and spatial awareness

Ainsworth: Attachment & Self-Regulation

1. Securely attached: seek to maintain proximity w/ caregiver, reacts negatively when she leaves. Upon return, the infant goes to her immediately. When mom is present, infants leave to explore the room, referencing back to her visually/approaching at intervals to ensure she’s there.

2. Avoidant: don’t seek proximity to mom, when she returns, ignores her

3. Ambivalent: seek contact w/ mom and distressed when she leaves, but when she returns they may display anger and resist comfort

4. Disorganized-Disoriented: show inconsistent behavior often self-contradictory; LEAST securely attached infants

An OTR observes a child in daycare protest their parent leaving, remain upset and dysregulated for 3 hours, and avoid the parent’s embrace upon their return.

Ambivalent: Seek contact with parent and distressed when she leaves, but when she returns, displays anger & resists comfort

When evaluating social interaction skills, the OTR notes the child does not seem to notice or protest when both mom and dad both leave the room? What theorist and concept is guiding the OTR’s evaluation?

Ainsworth, attachment theory, avoidant

Erikson: 8 Stages of Psychosocial Development

Development is a series of conflicts/crises that must be resolved either in a positive or negative mode, determining future function

Infant - 18 months: Trust VS Mistrust; Hope

18 months - 3 years: Autonomy VS Shame/Doubt; Will

3-5 years: Initiative VS Guilt; Purpose

5-13 years: Industry VS Inferiority; Competency

13-21: Identity VS Confusion; Fidelity

21-39: Intimacy VS Isolation; Love

40-65: Generativity VS Stagnation; Care

65+: Integrity VS Despair; Wisdom

Preschool (3-5 yrs): Fine Motor Skills - Finger Dexterity, Translation

move object from palm of hand to fingertips & back to palm (paperclips)

Preschool (3-5 yrs): Fine Motor Skills

• Bimanual coordination: Stabilize paper to cut w/ scissors

• Oculomotor skills: eye movements and coordination needed for everyday tasks like reading, writing, and sports

Preschool (3-5 yrs): Fine Motor Skills - Graphomotor Skills

Conceptual/cognitive, visual perceptual, motor, somatosensory perception & perceptual motor skills in drawing & writing. At 5 yrs, can draw person w/ at least 6 body parts

• Trace: eye-hand coordination to trace directly over lines on paper

• Imitate: watch another draw a shape, then draw the shape

• Copy: draw shape next to an example of the same shape

• Create: draw intended shape without demonstration or sample to copy

Power Grasps (1 year)

Object pulled into hand, rests on thenar muscles

• Strong grip using partially flexed fingers and palm.

• Thumb opposes the fingers, stabilizing object

• All palmar surfaces (fingers and palm) involved in holding the object firmly.

• Wrist typically in a neutral or slightly flexed position to maximize force generated by the larger extrinsic muscles of forearm

• For holding or manipulating larger, heavier objects.

• Cylindrical (go into palm), spherical (hold ball), hook grips (hold cup)

Precision Grasps (1 year): 3 kinds

1. Lateral prehension/key pinch: pad-to-side, key grip (turn car key ignition)

2. Tripod grasp: 3 jaw chuck, use all 3 fingers together - pencil

3. Pincer grasp: fingertips press against each other

   1. Inferior/Crude: 8-9 mo. (use more pad, not as precise)

   2. Neat, superior, tip: 10-12 mo. (all the way @ thumb, like threading needle)

Precision Grasps (1 year): Overview

• Refinement period, all developed by 1 year age. Pre-school is for refinement, strengthening, coordination between 2 hands and practice.

• Unsupported hand and active wrist extension

• Thumb, index, and middle fingertips for fine control.

• Thumb is in opposition, creating a tip-to-tip or pad-to-pad pinch.

• Wrist usually in slight extension to optimize the use of the intrinsic hand muscles, allowing for delicate and precise movements.

• Used for manipulating small objects or tasks requiring dexterity, such as writing or buttoning.

• Pinch (key, disc), tripod (pencil), lumbrical

Pencil Grip: Pincer Grasp (10 mo)

• Uses the thumb and index finger tips to pick up small objects

• Important fine motor milestone, though not yet a pencil grasp.

Pencil Grip: Palmar Supinate (12-15 mo)

• Whole fist wraps around the crayon or pencil, with the thumb on top

• Forearm in Supination

• Arm moves as one unit to make marks on paper.

Pencil Grip: Digital Pronate (2-3 yrs)

• Fingers point down toward the paper, palm faces down in pronation

• All fingers grasp the pencil, with the index finger extended down the shaft

• Writing comes more from shoulder and elbow movement than fingers

Pencil Grip: Quadrupod (3-4 yrs)

• Pencil held between the thumb, index, and middle finger, with the ring finger providing extra support

• Increased control, though movement is still less refined.

Pencil Grip: Static Tripod Grasp (3-4 yrs)

• Pencil held with thumb, index, and middle fingers (three-point hold)

• Fingers placed correctly, but movement is from the wrist or arm rather than the fingers (“static”)

• Arm writing

Pencil Grip: Dynamic Tripod Grasp (5-6 yrs)

• Mature pencil grasp: pencil held with thumb, index, and middle fingers, while ring and little fingers rest in the palm

• Writing movement comes from small, coordinated finger movements instead of the whole arm

• MOST efficient grasp for handwriting!

• Open web space, 3 fingers, wrist in slight extension

• Pencil rests on DIP of middle finger

• Tip: Writing on a vertical surface puts wrist into extension (whiteboard)

Haptic Perception/Stereognosis 🪙

• Discriminative touch combined w/ active memory of touch, texture, shape, temperature, volume/size, hardness, weight that allows children to tell you they have a penny in hand

• Emergence of this parallels one of hand skills. Pairing of vision and touch sensations in brain lay foundation for development of haptic perception

• Haptic exploration begins at 2 months when baby brings hand to mouth

Fine Motor Skills: Pre-school

• Visual acuity: Ability to discern details when both person and target are static. Useful for reaching and grasping objects (basic hand skills needed in infancy + early preschool years)

  • Tested in standard eye exams, failure to correct issues hinder development of eye-hand coordination. As this develops, children experiment with hand movements and develop fine hand and eye control

  • Sharpness and clarity of your vision, typically tested by reading an eye chart from a specific distance. 20/20 = normal; clarity/sharpness of vision measured @ 20ft

• Visual discrimination: ability to distinguish specific features of an object like shape, size, color. Precedes a child's ability to copy those forms in drawing tasks.

• Visual scanning: short, rapid changes of fixation from 1 point in the visual field to another, used when searching for something and in reading

  • Rapid, jerky eye movements between 2 or more focal points

• Visual pursuits: primary eye movements used in vision (tracking); slow, smooth movements used as the gaze follows a moving object

  • Short, rapid changes of fixation from 1 point in the visual field to another

  • Smooth, steady eye movement that tracks a moving object

  • Follow a ball in flight

• Bimanual coordination

An OT is working w/ a preschooler on graphomotor skills. In the typical learning progression, which first step will the OTR have the child perform?

Trace: eye-hand coordination to trace directly over lines on paper

Lan is holding her pencil by wrapping all four fingers around one side and her thumb around the other. Further, you observe an open webspace with your wrist in neutral, as this grasp is a precursor to a tripod grasp. What type of grasp is this? At what stage is this a typical grasp?

Quadrupod grasp, 3-4 yrs

Why is play an important occupation developmentally?

Play is vital to learning & cognitive development; strong link between symbolic play & emergence of language. Enables children to operate within ZOPD. (Vygotsky, Sociocultural Cognitive Development)

• Pleasurable activity, nervous system development, primary tool for learning

• Adults can scaffold functional motor, social-emotional, language, executive functioning, math, self-regulation skills

• Builds social-emotional resilience, executive functioning in adaptive behaviors at home, improves language & math skills, builds safe, stable, nurturing relationships to prevent toxic stress

• Developmentally appropriate play w/ parents & peers promotes social-emotional, cognitive, language, self-regulation skills, and buffers against toxic stress

• Supports formation of safe, stable, nurturing relationships with all caregivers

• Enhances brain structure & function, promotes executive function (process of learning) to pursue goals & ignore distractions

Social Progression of Play

• Unoccupied (0-3 mo): Play with body, discover how it moves

• Solitary (0-2 yrs): play by oneself

• Onlooker (2 yrs): child watches others play, may talk about it but don’t join in (often 1^st type of social play)

• Parallel play (2+ yrs): children play side-by-side, near each other, sometimes copy/mimic actions without direct interaction

• Associative play (3-4 years): children play together & interact socially but without organized/cooperative efforts. Enjoy being w/ others, but focus more on social interaction than shared activity (jungle gym play, borrowing, showing toys)

• Cooperative play (4+ years): children actively work together w/ shared goals or roles, showing interest in each other and activity

You notice a child watching with interest as 2 other children play in the sand box. What category of the social progression of play is demonstrated here, and at what stage would you first expect to see this behavior?

Onlooker play (2 years): child watches others play, may talk about it but doesn’t join in (often 1st type of social play)

Play type progression (A Baddie Only Starts Playing Games) 💅

• Attunement: early social exchange (mutual gaze, facial expressions w/ caregivers) 🤰👶🏻

• Body play (0-3+): gross & fine motor movement; build strength, coordination, body awareness; active rough & tumble activity

• Object play, constructive (4 yrs): becomes more organized, with purposeful building and creation using materials like blocks, art supplies, or sand 🎨

• Symbolic (begins 18-24 mo, late preschool): use objects, actions, ideas to represent something else (use stick as magic wand) 🍌

• Pretense/sociodramatic: advanced symbolic play w/ role-taking & narrative; social interaction; playing family or doctor 🩺

• Games with rules: simple, self-created, or loosely structured at first—requiring turn-taking, shared understanding, and emotional regulation. 🥅

What type of play most closely correlates with language development? 🍌

Symbolic play - subbing 1 object for another (banana as phone), suspends reality, imagines what’s not present

• Language development

• De-centering from self

• Theory of mind: empathy & perspective taking

During an assessment, an OTR observes a child tying her shoes without assistance. What occupation is demonstrated here? At what stage does a child typically develop this skill (if culturally relevant)?

Occupation: ADL - dressing, 6-7 years old in middle childhood

A child is looking for the scissors in a messy drawer full of all types of art supplies. Which specific skill is required for this task? At what stage does this skill typically develop?

• Visual figure ground develops in middle childhood (6-12 years). Ability to discriminate between the object of focus and the other objects that are also in view, using visual skills such as attention, visual memory, and other components of visual perceptual skills

• Vital skill in reading, writing, learning, and retaining information 📖

• Performance skill - Process skills: Searches/locates scissors (task object). Gather related task objects into the same work space.

Neurodevelopment: Toddlers (1-3 yrs) 🧠

• Synaptic pruning begins in infancy, continues through childhood, refining neural connections by strengthening freq. used pathways & eliminating unused ones

• Hemispheric lateralization (big increase during this stage): specialization of R & L brain functions, w/ L side dominating language processing

• Myelination: enhances nerve signal speed, improving info processing, attention, cognition

Neurodevelopment: Pre-school (3-5 yrs) 🧠⬆

• 90% of adult size brain by 6 years; structural growth

• More lateralization; handedness. Left hemisphere (language, academics) grows more dominant. Hand preference typically emerges by age 4, and true dominance by age 7.

• Cerebellar-cortical connections growth, which supports refined motor control

• Musculoskeletal: muscle size, power, stamina

• Function: language, reasoning, calibration, fluidity, equilibrium, prehension

Neurodevelopment: Middle Childhood (6-12 yrs)

• Hemispheric specialization: hand dominance (5-7); L hemisphere: language, movement, logic; R: shapes, perceptual abilities

• Corpus callosum myelination: fatty covering sheath enabling efficient communication

• Frontal + Prefrontal cortex growth: cognition, mental flexibility, rational thinking, higher level thought

• Sensory development and refinement: inhibition, ability to focus, attention, memory, vision, kinesthetic function

  • Visual

  • Auditory

• Higher level cognitive functions

  • Cognitive monitoring: persist in school tasks, cognitive sequencing/persistence

  • Cognitive maps: mental representations in brain

  • Spatial awareness: aware of own body, cues of depth and distance, body schema (how much space does my body occupy, and how much space is around it)

  • Visual-figure ground

• Temporal awareness: passage of time in sequencing/altering movements (Do I have enough time to eat a snack before the bus comes?)

Neurodevelopment: Adolescence (12+ yrs)

• Brain & Nervous System Development - Prefrontal Cortex Maturation

  • Limbic system: emotions & memories

  • Striatal system: risk-taking; activated by rewarding/novel stimuli

    • Developing prefrontal cortex highly involved w/ striatal system & limbic system, causing motor accidents, substance abuse, high-risk physical activities often associated with teens

• Temporal discounting: common decision making pattern in adolescence that reflects immature executive functions; discounting potential long-term implications of a decision; focus on immediate rewards (accidental pregnancy, crime involvement, low educational achievement, drinking then realizing you must drive home

• Mental Function

  • Memory: semantic memory - memory of concept & word meanings

    • Teens gain more experience about world, learn new concepts thru application

  • Reasoning: metacognition - self-evaluate; higher order reasoning; still lack of reasoning skills as seen in adults (not accurate perception of risks VS benefits)

  • Judgement: striatal system more sensitive, which skews judgment & reasoning

• Motor control & flow, asynchronous skeletal growth

Pre-school Stage Occupations (3-5 yrs)

• Play: Symbolic and imaginative play. Social play with peers (cooperative, parallel, and associative play). Rough-and-tumble and gross motor play

• Self-Care (ADLs): Dress self completely, brush teeth, toilets independently, feeding, eating

  • IADLs

    • Cuts soft foods w/ knife

    • Sets table

    • Folds washcloths

    • Crosses street safely

• Education: pre-academic skills (color, cut, early writing), follow routines & class rules, attend/participate in group activities

• Social participation: interacting w/ peers and adults, develop communication & social problem-solving skills, learn to share, take turns, manage conflicts

• Rest & sleep: establishing consistent sleep routines, managing transitions like nap time

Kindergarten Readiness

• Motor/physical skills: gross motor control, fine motor skills to grasp tools, use utensils; perceptual-motor integration for early pre-writing tasks (color, cut); maintain postural stability & coordination

• Cognitive skills: understanding of basic ideas like colors, shapes, numbers, spatial relations, multi-step directions, problem-solving

• Adaptive skills: functional independence w/ age-appropriate ADLs and IADLs (toilet, dress, eating w/ basic manners, manage personal belongings); safety awareness in school environment (cross street, stay w/ group)

• Social/emotional skills: self and co-regulation (follow rules, manage emotions, recover from stress); sustain attention in stimulating, distracting areas (sensory processing, attachment patterns); skills for sharing & turn taking

• Communication skills: expressive, receptive, nonverbal to interact w/ peers and adults; ask for help, participate in group activities; good for peer relations, classroom participation, behavior regulation

Middle Childhood (6-12 yrs): Skills/Behaviors

• Bullying, stress-related issues, potential sport injuries, interpersonal relationships, social referencing

• Higher level cognitive functioning

Middle Childhood (6-12 yrs): Occupations

1. ADLs: independent in most by mid–middle childhood (e.g., shoe tying ~6–7).

2. IADLs: chores, money management (allowance, small jobs), digital literacy

3. Education: organization, exams, responsibility, identity, peer diversity

4. Play & Leisure: hobbies, sports, games (rule-making & rule-breaking, group play, conflict resolution).

5. Communication: adapt language to listener, maintain conversation, emotional expression.

6. Social Participation: independence from caregivers, peer importance, teamwork, role exploration, developing loyalty and values in friendships.

Adolescence (12+ yrs): Occupations

1. ADLs: hygiene refinement, appearance/attractiveness.

2. Community mobility: growing independence (driving, transport).

3. Identity formation: occupational identity, personal values.

4. Coping & resilience: adaptive vs. palliative coping; may involve “negative occupations” (substance use, disordered eating).

Adolescence (12+ yrs): Skills/Behaviors

• Coordinated + sophisticated flow and motor control

• More complex memory & reasoning, but reasoning & judgment still lacking

• Temporal discounting for immediate reward, risk-taking behaviors

• Reference group to form behaviors & habits, romantic and familial relationships, health issues (depression, EDs, substance abuse)

Autism Spectrum Disorder (ASD) 🧩

Challenges in social interaction, communication, and sensory processing.