The development of visual and fine motor skills is foundational to infant and toddler participation and performance in meaningful occupations, specifically, self-help (self-feeding/eating, emotional regulation/self-soothing, dressing and undressing) and play (sensory-motor exploration, construction, imitation, dramatization) (American Occupational Therapy Association [AOTA], 2014; Case-Smith, 2006). Occupational therapy practitioners and scholars are interested in visual and fine motor development as a part of pediatric practice for children with disabilities or impairments and for those who may be at risk for disabilities or impairments.
Typical Developmental Sequence
An infant's fine motor skill development begins with visual tracking, which allows the infant to engage with the environment. Vision plays an increasingly important role throughout development as it acts as a primary sense to guide the infant's manipulation. As visual skills improve, the infant develops postural stability in sitting. This change frees up the upper extremities, resulting in improvements with reaching efficiency, and the child progresses from a reflexive palmar grasp, to a radial palmar grasp, and on to a pincer grasp. These advances in fine motor skills allow infants to interact with their environment, manipulate objects, self-feed finger foods, and play with simple toys (Case-Smith, 2006).
At 7 to 8 months, infants begin to voluntarily release objects from their hands, starting with an awkward and uncoordinated release and developing into a purposeful and accurate release. At 8 to 9 months, infants begin to show increased visual regard and accuracy of reach and grasp of small objects, fostering their ability to integrate visual and tactile information using both senses simultaneously. At approximately 12 months, infants use their visual system to recognize the physical properties of objects and act accordingly. Additionally, at this age, infants primarily use fingering and hand-to-hand manipulation during object exploration (Case-Smith, 2006).
At approximately 15 to 18 months, toddlers have improved spatial relations and visual perceptual skills that contribute to an improved ability to manipulate objects in hand (e.g., single-handed management of food, toys). This improvement contributes to the development of bilateral hand use (e.g., self-feeding, toys, simple clothing) (Case-Smith, 2006; Case-Smith & O'Brien, 2015). The typical developmental sequence of these skills is shown in Table 1.
Typical Development of Fine Motor Skills
As part of the occupational therapy process (AOTA, 2014; Polatajko, Craik, Davis, & Townsend, 2007; World Federation of Occupational Therapists, 2016), pediatric occupational therapists screen and evaluate these visual and fine motor skills among infants and toddlers through varying types of assessments. Specifically, occupational therapists may use standardized norm-referenced tests. (e.g., Bayley Scales of Infant and Toddler Development, third edition; Developmental Assessment of Young Children, second edition; Developmental Profile, third edition; Peabody Developmental Motor Scales, second edition); criterion-referenced tests (e.g., Hawaii Early Learning Profile); and structured (e.g., Revised Knox Play Scale) and unstructured clinical observations to identify strengths and deficits in occupational performance in infants and toddlers (Case-Smith & O'Brien, 2015).
Although these are commonly used types of assessments in pediatric practice (Bagatell, Hartmann, & Meriano, 2013; Piernik-Yoder & Beck, 2012), in most cases, the assessment procedures associated with these measures focus on the infant's ability to achieve specific visual and fine motor patterns in an isolated instance and do not record the frequency and duration of their use at various ages.
Research on Frequency and Duration of Visual and Fine Motor Development
Of the literature reviewed, only two studies used video capture methods to track the frequency and duration of developmental tasks and patterns of an infant's motor skills, visual gaze, and postural control. Specifically, Harbourne, Ryalls, and Stergiou (2014) used videography to focus on the interaction of development of sitting postural control and duration of gaze (which they termed look time) in both typically developing infants and infants with motor delays. The infants with motor delays had a longer mean look time across all stages of sitting compared with infants with typical development as well as an increase in mean look time from Stage 1 (able to prop sit for 30 seconds) to Stage 2 (able to sit without the use of hands for full postural support for at least 30 seconds) of sitting, but then look time significantly decreased in Stage 3 (able to sit for 5 minutes). Overall, the researchers found that look time decreased significantly in both groups (p < .001) as postural stability in a sitting position increased.
In another study that used similar methods, Sacrey, Karl, and Whishaw (2012) examined the coupling of visual attention and the reach-to-eat movement. Eight infants were filmed home by their parents. Videos were analyzed to track the infants' visual gaze, hand movement, and accuracy of those movements during self-feeding tasks. The authors found that the youngest infants (6–8 months) visually engaged the target well before initiating a reaching movement and continued to fixate on the target after it was grasped and as it was brought to the mouth. The data showed that the time spent on visual gaze decreased between 10 and 12 months of age as infants began to visually disengage the target as it was grasped (Sacrey et al., 2012). Not only did the infants spend less time visually engaging objects during reach and grasp but they also showed improved accuracy for grasping the object and placing it into the mouth, an improvement that can be partially attributed to the development of rotatory movement of the thumb and hand and precision grasping. This finding led the researchers to conclude that duration of gaze decreased as a result of improved motor skills and decreased need for visual monitoring of the task (Sacrey et al., 2012).
Exploration of the literature on infant development has yielded research methods that evaluate the duration of visual regard during visual and fine motor tasks that build a foundation for meaningful occupational development in young children (play, learning, self-help). However, there is limited focused research documenting the duration and frequency of visual and fine motor patterns among typical infants and toddlers. Adding to the literature will help pediatric occupational therapists to identify and track visual and fine motor patterns and subsequent skills through a temporal lens and establish foundational metrics for expectations for typically developing infants and toddlers.
The purpose of this study was to identify the trajectory of frequency and duration of visual and fine motor pattern use among typically developing infants and toddlers and explore the alignment of those patterns with the existing scholarship on typical development. The research questions were as follows: (1) What is the frequency of visual and fine motor patterns as observed through videorecorded interactions between caregivers and their infants and toddlers at 8 months, 12 months, and 16 months of age? (2) What is the duration of visual and fine motor patterns as observed through videorecorded interactions between caregivers and their infants and toddlers at 8 months, 12 months, and 16 months of age?
The medical center institutional review board at Eastern Carolina University approved the study, and the human subjects committee at Idaho State University provided exemption. All caregivers provided voluntary informed consent.
Data were obtained from a cohort of 16 caregiver-infant dyads who participated in a longitudinal research study of infants 6 to 18 months of age. For the current project, we evaluated data obtained at 8, 12, and 16 months of age, which consisted of 48 recordings lasting 20 minutes each. The study included (a) caregivers who had no significant history of prenatal or perinatal problems; (b) infants who were not at risk for developmental disorders; (c) families who primarily spoke English at home; (d) families who were able to travel to the laboratory monthly; and (e) families who did not expect to move from the area within 2 years of enrollment.
All families had reported yearly income of $50,000 to $100,000. Of the 16 infants, seven were boys and nine were girls. One girl was African American, one boy was Asian American (father of East Indian descent and mother of Vietnamese and Hawaiian descent), and one boy was Palestinian. The remaining infants were White.
Materials and procedures. Infants and caregivers came to the Infant Vocal Development Laboratory at Eastern Carolina University monthly for hour-long recordings. Caregivers were instructed to play and interact with their infants as they would typically do at home. To facilitate natural interaction, the laboratory was designed to simulate a home environment, with stuffed animals and age-appropriate toys.
Video and audio recordings. The laboratory was equipped with video and audio recording equipment. A team of three raters/researchers coded the middle 20 minutes of each free-play recording according to the fine motor integration coding scheme.
Coding scheme. The fine motor coding scheme was developed through a literature review that explored visual and fine motor integration (Case-Smith, 2006; Knox, 1997; Parks et al., 1994). From the literature, primary categories were identified and included visual exploration; object reach, retrieval, and release; simple and complex object manipulation; and unilateral and bilateral grasp. Twelve codes for developmental patterns were developed (Table 2).
A total of three raters (graduate research assistants in the master of occupational therapy program at Idaho State University) participated in multiple training sessions to gain competency with the Datavyu (Datavyu Team, 2014) software (an open-source video analysis tool) and the coding process. Coding occurred over several sessions with the primary investigator and the coders. The process of coding included viewing and reviewing video vignettes and assigning the identified codes. The visual and fine motor coding scheme across three raters attained intrarater reliability of 0.87 and interrater reliability of 0.85.
Data were exported from Datavyu, transformed, and analyzed with Microsoft Excel (2016). Descriptive statistics were calculated for the observed frequency and duration of visual and fine motor patterns. Statistical analysis consisted of calculating the mean and standard deviation for frequency and duration of the 16 subjects for each of the 12 coded patterns at each of the three age levels. These patterns were displayed as histograms to provide a visual representation for analysis.
Statistical analysis of the frequency and duration of the 12 developmental patterns is shown in Table 3 and Table 4 and graphically depicted in Figure 1 and Figure 2.
Fine/Visual Motor Descriptive Statistics for Frequency
Fine/Visual Motor Descriptive Statistics for Duration (Seconds)
Frequency of coded visual and fine motor patterns.
Duration of use of visual and fine motor skills.
Analysis of the average frequency for each age range shows a trend, with a spike in frequency at 16 months for each pattern with the exception of unilateral grasp left and bilateral hold symmetrical (Figure 1).
Figure 2 shows the duration of coded visual and fine motor patterns for each age group: 8 months, 12 months, and 16 months. Although the duration of skills such as unilateral grasp, simple object manipulation, and visual exploration peaked at 8 months, the duration of more complex skills such as complex object manipulation, bilateral grasp symmetrical, and bilateral grasp left/right followed a general upward trend through 16 months.
Visual and fine motor skills are believed to develop in a predictable, sequential order, and vision plays an important role in the development of fine motor skills (Case-Smith, 2006). Additionally, research suggests that caregiver-infant interaction facilitates developmentally appropriate play participation, promoting visual and fine motor integration (Daunhauer, Coster, Tickle-Degnen, & Cermak, 2007).
The results may be useful in providing current and future clinicians with a guide for expectations beyond skill acquisition, specifically, how frequently and how long typically developing infants and toddlers use those acquired skills as part of play-based and self-help occupations. Additionally, this study may sensitize pediatric therapists to the value of evaluating a repeated pattern of behavior during occupational performance in addition to documenting milestone achievement. By understanding trajectories of typical development among infants and toddlers, occupational therapy professionals can be better equipped to identify developmental delays and promote and encourage participation in occupations that facilitate these visual and fine motor patterns.
A variety of factors may have contributed to increases in the visual and fine motor activity of the infants and toddlers in this study. By 13 months, infants use upright ambulation as their main source of mobility, which may free their upper extremities and, along with an increase in fine motor development, allow for more interaction with a variety of objects (Case-Smith, 2006). The finding of an increase in visual and fine motor activity as the infants and toddlers in the cohort developed may be influenced by the acquisition of general mobility milestones.
The dominance of unilateral grasp right at 16 months could be the result of emerging hand preference in the toddlers or the placement and location of toys. The occupation of play participation and performance among young children involves routine engagement in activities and tasks such as maintaining toys, equipment, and materials and supplies appropriately (AOTA, 2014), all of which require foundational visual and fine motor integration skills. The infants became more efficient with object reach, and the average duration of visual and fine motor engagement decreased from 2.95 seconds at 8 months to 0.81 seconds at 16 months. Thus, there is a need to consider changes for cognition along with other factors when discussing the interaction of vision, posture, and motor development and the frequency and duration of these patterns. This cohort study supports these observations.
The findings provide a guide to development with a temporal perspective (duration and frequency) and describe visual and fine motor patterns as they occur in the natural context, in contrast with using standardized assessments that examine the ability to perform a behavior at a single moment in time. Increasing cognitive skills influence how children interact with the environment (Case-Smith & O'Brien, 2015). At 8 months, infants actively look for toys that are out of sight because they are beginning to understand object permanence (Case-Smith & O'Brien, 2015). At 12 months, they engage in more goal-directed behavior and try to determine the intended purpose of toys (Case-Smith & O'Brien, 2015). Occupational therapy professionals who work with infants and toddlers may benefit from understanding the frequency and duration of visual and fine motor patterns in children 0 to 3 years of age, thereby enabling proper timing for implementation of interventions that support play participation and performance and self-help skills.
The original intention in recording the videos was to document caregiver-infant interaction for an infant vocalization study by speech-language pathology researchers. Therefore, caregivers did not consistently facilitate play, multiple caregivers attended the sessions (e.g., mother, father, siblings, grandparents), and grasps may have been missed because the infants' hands were not always visible.
Generalizability of the findings may be influenced by cultural differences in play opportunity for children from varying socioeconomic backgrounds. A sample of 16 middle-class infants may not be representative of the greater population.
Recommendations for Future Research
Further research is needed on how grasp patterns develop over time in the same cohort of infants and toddlers. An additional area of study is the relationship between generational patterns such as changes in different play objects (traditional vs. electronic) and their effect on the development of fine motor skills/grasp patterns.
The results of this study demonstrate an approximation with the typical development trajectory for visual and fine motor skills among infants and toddlers. Additionally, the results provide a resource to help guide development from a temporal perspective.
- American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). Bethesda, MD: Author.
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- Case-Smith, J. (2006). Hand skill development in the context of infants' play: Birth to 2 years. In Henderson, A. & Pehoski, C. (Eds.), Hand function in the child: Foundations for remediation (2nd ed., pp. 117–142). St. Louis, MO: Mosby. doi:10.1016/B978-032303186-8.50010-1 [CrossRef]
- Case-Smith, J. & O'Brien, J. C. (Eds.). (2015). Occupational therapy for children and adolescents (7th ed.). St. Louis, MO: Mosby.
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- Daunhauer, L. A., Coster, W. J., Tickle-Degnen, L. & Cermak, S. A. (2007). Effects of caregiver-child interactions on play occupations among young children institutionalized in Eastern Europe. American Journal of Occupational Therapy, 61(4), 429–440. doi:10.5014/ajot.61.4.429 [CrossRef]
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- Sacrey, L. A., Karl, J. M. & Whishaw, I. Q. (2012). Development of visual and somatosensory attention of reach-to-eat movement in human infants aged 6 to 12 months. Experimental Brain Research, 223(1), 121–136. doi:10.1007/s00221-012-3246-x [CrossRef]
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Typical Development of Fine Motor Skills
|4||Grasp a visually located object||Reflexive release|
|5–6||Palmar grasp; typically reaches for objects with both hands, but grasps an object with one hand||Transition from reflexive to purposeful release; typically seen during mouthing and bimanual play|
|7||Radial palmar grasp to hold an object; may start to play with two toys at a time; uses bilateral grasp for larger objects||Releases an object when transferring it from one hand to the other; may forcefully pull the object out of one hand|
|8–9||Grasping an object in the fingers rather than the palm; begins to use radial digital grasp; scissor grasp for small objects; complementary bimanual activities; thumb opposition||-|
|10||Inferior pincer grasp||Purposeful release in the context of play; finds joy in dropping food/toys|
|12||Pincer grasp; superior pincer grasp without stabilizing the forearm; increased hand dexterity with one hand and cooperative use of two hands together||Greater control of finger extension that leads to greater proficiency in releasing the object|
|18||Precise pincer grasp||Increased control and precision in release|
|Visual exploration||Visually appraising or attending while engaging with an object or reaching for an object|
|Object reach||Getting a hand from a starting position to an object|
|Object retrieval||Obtaining and stabilizing an object|
|Object release||Releasing an object; person present takes the object|
|Complex object manipulation||Pulling, turning (to activate/manipulate; may be connected to another object), poking, tearing, dropping, picking up, throwing, inserting, pushing, carrying, opening, shutting|
|Simple object manipulation||Shaking, wiggling, rattling, touching, holding, tapping, rotating (turning around)|
|Unilateral grasp right||Holding an object with the right hand|
|Unilateral grasp left||Holding an object with the left hand|
|Bilateral grasp right||Transporting an object with the right hand as the primary stabilizer|
|Bilateral grasp left||Transporting an object with the left hand as the primary stabilizer|
|Bilateral hold, cooperative||Supporting or stabilizing an object with one hand while exploring or manipulating it with the other hand|
|Bilateral hold, symmetrical||Holding objects with both hands acting in unison|
Fine/Visual Motor Descriptive Statistics for Frequency
|Fine/visual motor patterns||8 months||12 months||16 months|
|Bilateral hold symmetrical||2.10||0.09||8.20||1.52||3.40||0.03|
|Bilateral hold cooperative||6.50||1.20||4.20||1.01||11.16||2.11|
|Bilateral grasp left||8.30||1.10||3.27||4.74||14.85||2.31|
|Bilateral grasp right||8.50||2.30||6.81||5.23||14.85||2.22|
|Unilateral grasp left||14.25||4.50||8.73||6.63||4.57||1.24|
|Unilateral grasp right||13.40||3.30||8.91||2.12||22.57||3.01|
|Simple object manipulation||4.25||1.24||6.99||3.24||10.28||1.22|
|Complex object manipulation||8.50||1.00||15.88||3.24||21.11||3.04|
Fine/Visual Motor Descriptive Statistics for Duration (Seconds)
|Fine/visual motor patterns||8 months||12 months||16 months|
|Bilateral hold symmetrical||15.01||1.22||48.53||4.93||59.63||2.93|
|Bilateral hold cooperative||17.47||4.31||50.21||9.61||48.97||4.82|
|Bilateral grasp left||10.87||3.35||16.03||4.73||25.65||2.15|
|Bilateral grasp right||10.58||3.94||15.72||5.32||22.18||1.23|
|Unilateral grasp left||21.89||4.73||20.33||15.85||20.11||7.11|
|Unilateral grasp right||46.80||3.24||31.11||2.33||21.86||2.22|
|Simple object manipulation||40.47||10.91||32.32||17.01||21.12||33.10|
|Complex object manipulation||3.89||12.12||42.43||12.82||60.86||14.70|