Fine motor skills include reach, grasp, carry, voluntary release, in-hand manipulation, and bilateral hand use. Definitions are

1. 
   

   Reach: Extension and movement of the arm for touching or taking hold of objects. Development progresses from swipe at object (2 months), to both hands, to midline and clasp (3 to 4 months), to unilateral arm reaching (4 to 5 months).

   
   
2. 
   

   Grasp: Hold or grip of an object with the hand.

   
   
   
   
   1. 
      

      Development progresses from reflexive grasp or an involuntary grasp (at birth), to ulnar palmar grasp (3 months), to palmar grasp (5 to 6 months), to radial palmar grasp (6 to 7 months), to radial digital grasp (8 months), to pincer or the holding of a small object against the tip of the index finger (12 months) (Table 45-1).

      
      
   2. 
      

      Grasping patterns vary based on object’s size and shape.

   
   
3. 
   

   Carry: Transportation of a handheld object from one place to another.

   
   
   
   
   1. 
      

      A combination of movements of the shoulder, body, and distal joints of the wrist and hand to hold the item.

      
      
   2. 
      

      Makes appropriate adjustments as necessary to maintain the holding of the item.

   
   
4. 
   

   Voluntary release: Intentional letting go of a handheld object at a specific time and place. Development progresses through sequence of five phases: no release (0 to 1 month.); involuntary release (1 to 4 months); two-stage transfer (5 to 6 months); one-stage transfer (6 to 7 months); and voluntary release (7 to 9 months).

   
   
   
   
   1. 
      

      Two-stage transfer: The child brings an object or finger food to the mouth with both hands and may release one or both once the object is stabilized in the mouth.

      
      
   2. 
      

      One-stage transfer: The child holds the object at midline with both hands and pulls it out of one hand and into the other. The release is, therefore, a forced withdrawal accomplished by the opposite hand.

      
      
   3. 
      

      The child begins the voluntary release by stabilizing his or her arm and/or hand on surface → releases without stabilizing → modulates force (demonstrates in stacking activities).

   
   
5. 
   

   In-hand manipulation: Adjustment of an object within one hand without the assistance of the other hand

   
   
   
   
   1. 
      

      The three in-hand manipulation skills are translation (finger-to-palm and palm-to-finger), shift, and rotation (simple and complex).

      
      
      
      
      • 
        

        Translation is to transfer an object from the fingertips to storage in the palm of the hand (finger-to-palm) or to retrieve objects from storage in the palm of the hand to fingertips for action (palm-to-finger).

        
        
      • 
        

        Shift is to move the fingers linearly on an object. An example is to move the fingers along the shaft of a pencil.

        
        
      • 
        

        Rotation is the movement of trolling a small object between the pads of the thumb and fingers (simple rotation) or using the thumb and fingers to turn an object end over end (complex rotation).

      
      
   2. 
      

      Requires the hand to perform two separate functions simultaneously. That is, the thumb, index, and middle finger perform manipulation skills while the fifth and ring finger side provides stabilization.

      
      
   3. 
      

      Poor in-hand manipulation skills are linked to clumsiness or poorer performance of functional activities.

   
   
6. 
   

   Bilateral hand use: Use of two hands together to accomplish an activity

   
   
   
   
   1. 
      

      Asymmetric movements (0 to 3 months) → symmetric movements → bimanual action (10 to 12 months).

      
      
   2. 
      

      By 12 to 18 months, infants use both hands for different functions. At 18 to 24 months, manipulation skills emerge. At the age of 2.5 years, the ability to use two different hands for two very different functions emerges.

Normal developmental sequence (Table 45-2)

The following chart provides the major fine motor activities that occur in different age ranges. This chart should only be used as a general guideline as some infants develop activities earlier or later than this chart may indicate.

1. 
   

   0 to 2 Months

   
   
   
   
   1. 
      

      Grasp reflex

      
      
   2. 
      

      Random arm movements

   
   
2. 
   

   2 to 3 Months

   
   
   
   
   1. 
      

      Reaches for (“swipes at”) objects inaccurately

      
      
   2. 
      

      Postural may be asymmetrical at this time

   
   
3. 
   

   3 to 5 Months

   
   
   
   
   1. 
      

      Clasps hands together often

      
      
   2. 
      

      Begins purposeful, visually directed reaching

      
      
   3. 
      

      Uses fingers in grasp without thumb involvement at 3 months

      
      
   4. 
      

      Progresses to symmetrical palmer grasp at 5 months

      
      
   5. 
      

      Begins to transfer objects from one hand to the other

   
   
4. 
   

   6 Months

   
   
   
   
   1. 
      

      Consistent palmar grasp

      
      
   2. 
      

      Consistent visually directed reach

      
      
   3. 
      

      Shakes and bangs toys to create auditory and visual effects

      
      
   4. 
      

      Finger feed bread sticks

   
   
5. 
   

   7 to 9 Months

   
   
   
   
   1. 
      

      Masters radial-palmar grasp (7 months)

      
      
   2. 
      

      Develops radial-digital grasp (8 months)

      
      
   3. 
      

      Points

      
      
   4. 
      

      Able to drop/release objects in space and into large container

   
   
6. 
   

   10 to 12 Months

   
   
   
   
   1. 
      

      Demonstrates three-jaw chuck grasp pattern (the pad of the thumb opposes against two fingers)

      
      
   2. 
      

      Pincer grasp with finger and thumb pads at 10 months

      
      
   3. 
      

      Finger-tip pinch developing at 12 months

      
      
   4. 
      

      Increased bimanual dexterity

      
      
   5. 
      

      Begins to supinate forearms to reach and grasp toys

      
      
   6. 
      

      Combines fine motor patterns into function

      
      
      
      
      • 
        

        Removes socks and unties shoes

        
        
      • 
        

        Imitates adult’s use of tools, such as combing hair

   
   
7. 
   

   12 to 18 Months

   
   
   
   
   1. 
      

      Holds crayon with whole hand, thumb up

      
      
   2. 
      

      Picks up and retains more than one small object in hand (in-hand manipulation)

      
      
   3. 
      

      Scribbles on paper

      
      
   4. 
      

      Role-differentiated hand use (ie, one hand stabilizes or holds the materials and the other manipulates them)

      
      
   5. 
      

      Hand preference begins to emerge

      
      
   6. 
      

      Uses a spoon by 18 months

      
      
   7. 
      

      Tries to play throw and catch with the ball

   
   
8. 
   

   2 to 3 Years

   
   
   
   
   1. 
      

      Draws and copies a vertical line

      
      
   2. 
      

      Strings large beads

      
      
   3. 
      

      Uses opposing hand and arm movements for highly differentiated activities (ie, snips paper with scissors, unbuttons large buttons)

      
      
   4. 
      

      Uses a fork by 2.5 years

      
      
   5. 
      

      Throws a ball forward and maintains balance

      
      
   6. 
      

      Identifies common objects by touch alone

   
   
9. 
   

   3 to 4 Years

   
   
   
   
   1. 
      

      Builds a tower of nine small blocks or more

      
      
   2. 
      

      Cuts on a line that is 6-in long or a circle

      
      
   3. 
      

      Strong preference for a lead/dominant hand may be evident, but switching continues

      
      
   4. 
      

      Strings small beads

   
   
10. 
    

    4 to 5 Years

    
    
    
    
    1. 
       

       Uses scissors to follow and cut both straight and curved lines

       
       
    2. 
       

       Manages buttons, zippers, and snaps completely

       
       
    3. 
       

       Draws and copies a cross

       
       
    4. 
       

       Cuts a square

       
       
    5. 
       

       Folds paper in half, making sure the edges meet

       
       
    6. 
       

       Hand dominance is typically established between 4 and 6 years, so a hand preference should be apparent and consistent

    
    
11. 
    

    5 to 6 Years

    
    
    
    
    1. 
       

       Dresses self independently

       
       
    2. 
       

       Cuts shapes and simple pictures with scissors

       
       
    3. 
       

       Uses an overhand throw to consistently hit a target 5 ft away

       
       
    4. 
       

       Uses a knife by the age of 6