Visual-Motor

Motor skills are the movement skills that we learn throughout our lives.

There are two types of motor co-ordination, gross motor and fine motor. Gross motor skills refers to the ability of children to carry out activities that require large muscles or groups of muscles. These muscles need to act in a coordinated fashion to accomplish a movement or a series of movements. Examples of gross motor tasks include crawling, walking, running, throwing, jumping, standing on one leg and swimming.

Many children struggle with gross motor co-ordination. These children are commonly clumsy, they may bump into objects and other people and are generally unaware of the space their bodies occupy. Balance is crucial to the development of gross-motor skills. Children who struggle with balance may fall over more than expected especially when learning to walk. The child may be forced to hold onto objects or people, therefore a child who clings to their mothers side may not be shy but may have difficulty with their sense of balance. A useful analogy for adults to consider is to think of what it is like when we step onto land after being on a boat. It takes a while to reestablish our equilibrium, children who have difficulty with balance take longer to secure their equilibrium. These faulty balance perceptions will make any activity which requires balance harder. Learning to ride a bike may have been difficult. They may have difficulty maintaining their balance when seated at a desk, they may fall over when trying to kick a ball, are excessively prone to injuring themselves, have a fear of heights or are hesitant to climb on a jungle gym.

Fine motor skills consist of movements of small muscles (ie. hands, feet, and muscles of the head as in the tongue, lips, facial muscles) that act in an organized and subtle fashion to accomplish more difficult and delicate tasks. Fine motor skills are the basis of eye-hand coordination. Examples of fine motor activities include using the pincer grip to pick up small objects, writing, sewing, drawing, putting a puzzle together, imitating subtle facial gestures, pronouncing words (which involves coordination of the soft palate, tongue, lips), blowing bubbles, and whistling. Many children who have difficulties with their fine motor skills also have difficulties in articulating sounds or words. The child may resist eating with a fork or spoon owing to the poor dexterity in their fingers. Learning to tie shoelaces or do up buttons can take years to learn. The child may be unable to hold scissors or their pencil properly.

Figure 1. Eye hand co-ordination

When a child is born they are unable to move their body in a co-ordinated way, yet within a short period the child will acquire many new movement abilities. A few weeks after birth the child can lift their head. Within 3 months they can support their weight on their forearms and can grasp small objects with their hands. By 6 months they can sit unsupported, can roll over and pass an object from one hand to the other. By 8 months the child begins to creep on hands and knees and can grasp small objects between their fingers and thumb; and by 12 months they can generally walk.

Motor development proceeds in a cephalocaudal direction which means from head to foot. For example when a child is placed on their stomach on the floor the child is able to lift their head before they can lift their upper body. It also proceeds in a proximo-distal direction meaning that those muscles near the midline of the body become more functional than those further away. For example a child learns to catch a ball with their shoulders, upper arms and forearms before they learn to catch with their fingers. Gross motor skills such as throwing or kicking are acquired before fine motor skills such as using scissors or assembling a puzzle. The child is able to perform mass movements such as using large crayons to colour large spaces before they can do refined movements such as using small crayons to do intricate drawings.

Discussed below are some of the building blocks of motor functioning.

Muscular tone refers to the basic and constant ongoing contraction of the muscles. Tone may be normal, too low, or too high. Hypotonic (low tone) children have difficulty maintaining posture against gravity and prefer to sit, lie on the floor or lean against something. Young children may sit in a fashion that appears lazy, rather than sitting upright, they may sit in a slouching manner, leaning on the chair, with their head on top of the table, or they may lie down during activities as much as possible. Of course, this positioning can also be observed in older children and is often erroneously interpreted as a sign of lack of interest or even disrespect. Babies with hypotonic muscle tone appear floppy much like a rag doll.

By contrast, when muscular tone is hypertonic (too high), children appear stiff and do not move in a smooth and natural way. Youngsters may move somewhat like a puppet or a robot, and lack smooth natural movement when performing small motor tasks. Children with hypertonicity in the leg muscles may tend to walk on their tiptoes.

Basic muscle tone that is either too low or too high is one of the primary reasons for impaired motor skills. Hypotonic children must fight low muscle tone to carry out movements or activities, all the time expending energy to maintain their posture. Whereas hypertonic children may be more prone to making mistakes due to the overaction of their muscles.

Crawling is essential to the development of upper body strength and muscle tone since their arms are forced to support their weight, subsequently children who do not crawl or crawl inefficiently may demonstrate difficulty with muscle tone. Children with poor muscle tone may have problems with tactile discrimination otherwise known as finger agnosia. In other words the child has difficulty feeling the pencil in their fingers which affects their ability to control the pencil. As a result the child may hold the pencil with an awkward claw like grip and write with their wrist rather than their fingers, which causes their writing to be disorganised and messy. They may compensate for this difficulty by gripping the pencil so tightly that their hand cramps, which also causes them to apply too much pressure to the page. Copying, writing and drawing may be slow and arduous or they may avoid writing wherever possible.

The optimal pencil grip is known as the "tripod grip". This is where the pencil is supported by the thumb, index and middle fingers. The ring and little finger are bent and rest comfortably on the table.

Pencil grip also has a major influence on posture. If the pencil is held with a thumb wrap instead of with the points of the thumb, index and middle fingers, the point of the pencil cannot be seen, which forces the child to bring their head in at an angle to view their written material, which leads to an excessively close working distance.

When writing the paper should be placed parallel to the edge of the table. The paper should be tilted slightly. For children who are left-handed, the left corner of the paper should be higher. For right-handed children the right corner should be higher. The non-writing hand should be placed on the paper to minimise paper movement.

Below is a diagram of the optimal tripod grip for right and left handers.

Bilateral integration which is the ability to use both sides of the body simultaneously when performing an action is crucial to the development of both gross and fine motor skills. The more developed a child’s bilateral integration the more likely they are of developing a consistent dominant hand whether it be the left or right. Children can begin to show a preference for one hand as young as three years of age but it can take until 7 or 8 years of age to fully develop. Acquiring a dominant hand is crucial for gaining efficient everyday skills such as handwriting.

Bilateral integration begins when a baby begins to play with their hands (and sometimes feet) in front of their face. They will bring both hands up together and move them in similar ways at the same time. For example when an infant reaches for an object they will often reach with both arms at once even though only one hand will grasp the object. This first stage is called symmetrical bilateral integration where both sides of the body perform the same action at the same time. Older children practice this skill by jumping with both feet together, clapping their hands or when performing star jumps.

The next stage is called reciprocal bilateral integration, here one side of the body does the opposite to the other side and the child swaps actions in a back and forth manner. Crawling is the most basic form of reciprocal bilateral integration. Crawling involves the simultaneous movement of both sides of the body. ie. The right hand and left leg followed by the left hand and right leg. Children who do not crawl, crawl inefficiently or crawl for only short periods may have delays in the development of bilaterality. Similarly walking requires integration of the two sides of the body, we move one foot ahead of the other, while at the same time swinging the opposite arm as each foot comes forward, for example the right foot and the left arm, then the left foot and right arm. Marching, swimming and skipping are further examples of reciprocal bilateral integration.

These movements can be ipsilateral where the child learns to move one whole side of the body together (Ie. Moving the left arm and left leg together) or they can be contralateral where the child learns to move opposite sides of the body at the same time (ie. The right arm and left leg) .

Once the child has mastered this they are ready to develop asymmetric bilateral integration. This is a critical stage in the child’s motor development, its poor development will strongly influence the next two stages.

Asymmetric bilateral integration occurs when each side of the body learns to perform a different action, but both these actions are necessary for the task. This is more complex than the previous stages because the brain has to co-ordinate two different actions. An example of this is being able to pat your head whilst you rub your stomach. With proper development the left and right side should begin to enhance each other's function. Where a task calls for two hands one hand becomes the leading hand or the ‘doer’ and the non-preferred hand is the ‘helper’. For example in hammering the ‘helper’ hand holds the nail and the ‘doer’ does the hammering, when writing the right hand may stabilize a piece of paper while the left hand draws.

Getting dressed requires a great deal of asymmetric bilateral integration. This is no more evidence than in tying shoelaces. One hand creates a loop whilst the other hand wraps the lace around it. When putting on a shirt one hand holds the shirt whilst the hand is placed into the sleeve, similarly when doing up buttons one hand holds the shirt whilst the other hand pushes the button through the hole. When squeezing toothpaste onto a toothbrush the non-dominant hand must keep the toothbrush still whilst the dominant hand squeezes.

The fourth stage is called crossing the midline, which occurs at about 4 and a half years of age. This is the ability to perform a task with one hand in the space on the other side of the body. Putting an earring into your ear requires one hand to cross over the midline (an imaginary line that separates the two sides of the body). Children who did not develop adequate bilateral integration in the previous stages will often avoid crossing their midline. It appears almost as if they a wall down their middle dividing them in two. When the child draws or colours crayons on the left stay on the left and are manipulated by the left hand and vice versa. If the child wants something on their right to use on the left side, they will pick up the crayon in the right hand, then pass it to their other hand rather than cross over the midline of their body. If the midline wall persists it can affect many skills such as the child’s ability to reach across the front of themselves, which is what is required when we write. The midline division doesn’t always divide the whole body, sometimes the arms will cross but the eyes may hesitate or vice versa. The presence of a midline division in a child beginning school is a strong indicator of poorly developed integration between the two sides of the body.

Children with poor bilateral integration tend to use the hand closest to the object to pick it up. The child thus constantly alternates between hands which subsequently affects the development of a dominant side. For example if a child is predominantly right handed, but the crayon they want to use is sitting on the left side of the table, they may pick it up with the left hand and continue colouring in with the left hand. Proficiency at any task depends upon the time spent performing it, if both hands are taking turns both may be reasonably adept at performing a task but neither will become skillful considering also that most of these children have substantial gaps in their bilateral integration skills. To compound matters the left hand is not gaining experience at stabilizing. It is difficult to write if the paper is sliding around. The non-dominant hand should be keeping it still. As a result a child with cross dominance will likely have inaccurate and messy handwriting, due to poor pencil control of the more dominant hand and poor stabilisation by the non-dominant hand.

Gross and fine motor co-ordination requires a child to have adequate motor planning skills. Motor planning refers to the mental strategy a child uses to carry out a movement or an action. Most children develop some preconscious planning in the sequencing of movements, including how the body and limbs coordinate, the amount of strength required, and the necessary steps needed to achieve a specific goal. Learning to dance requires a high degree of motor planning, since the child must visualise each step. Most of the time in unaffected children, this function is achieved intuitively and without conscious planning. Children who demonstrate difficulties with motor planning may carry out actions using odd strategies. For example, trying to reach for something that is out of reach without first trying to move from a previous position. Another example is a child trying to get down from a chair without moving the trunk and preparing himself to go down and instead just letting himself fall. The child seemingly lacks the intuitive ability to plan how to effect a movement.

Sequencing skills are crucial to the development of motor co-ordination, which involves a set order of movements to achieve a desired goal. For example remembering the correct sequence of dance steps. Written letters require a set order of pencil strokes, therefore a child with sequencing difficulties may write letters with unusual starting and ending points.

Figure 2: The capital 'N' requires the following pencil strokes.

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