Gross Motor versus Fine Motor Functions
Developmental, Individual differences, Relationship-based (DIR) Expert Training Leader and Occupational Therapist, Keith Landherr, is the founder and director of Little Buddies Pediatric Therapy, Inc. just outside of Vancouver, British Columbia. He is also a PhD student in the Fielding Graduate School’s Infant and Child Development Program. This week we discuss how parents are often focused on fine motor skills and how the development of gross motor skills are a pre-cursor to them. We talk about how Keith communicates the process with parents in order to foster an understanding and appreciation for the sometimes subtle, important work of the Occupational Therapist. It complements what was covered in my recent podcast with Occupational Therapist Maude Le Roux about going slower to move faster.
Parental Concerns versus Underlying Concerns
Keith shares that once a child demonstrates some gross motor skills such as kicking a ball, it’s usually a Behavioural Consultant or a grandparent who then asks about holding the spoon. Keith wants to look at the quality of the gross motor skill acquired first. It’s not just that you can run really quickly, but whether you can do that while you are being social in play. Is your gross motor integrated enough while you’re engaging in gross motor play? What does that look like? What needs more scaffolding so the child can continue to develop that before we sit them at a desk to practice holding a pen correctly? Often the fine motor function will mirror the gross motor function that comes first.
I echoed the example I gave in the Rubber Band podcast when I described my son’s progression from building a tower with huge, padded blocks in the sensory gym (i.e., gross motor) when he was younger to his building of LEGO today (i.e., fine motor). The struggle for Occupational Therapists, Keith explains, is that when children get referred for fine motor skills and the O.T. begins to work on some of the underlying issues, the parent feels that the fine motor is not being addressed. How does he help the parent understand what he’s trying to do in order to help the child in that way? Sometimes it’s just the ability for the O.T. to translate for the parent so it’s more digestible, Keith says, so they can feel secure on what he’s offering them.
Keith shared an email exchange (see the slides below) with a parent whose son was a client where the parent expressed concerns about Keith working on fine motor skills. It was a question that gave Keith the opportunity to really understand what the parent’s concerns were and to really address them and explain the purpose for the work they were doing at Little Buddies. The parent shared that their behavioural consultant was working on holding a pen for school preparation. This gave Keith a great cue to explain that while this is a great skill, if it doesn’t come from the ground up and is not a somatosensory learning experience, it’s not really going to be that useful for the child.
If we impose some sort of movement over what the child’s natural development looks like, we’re causing somatosensory confusion for a system that is experiencing a lack of integration. Somatosensory refers to the bottom-up learning and how one perceives all of the sensory information and how your brain organizes it to make use of it later. Looking at the diagram below, Keith explains, we know that the clients he works with, who are mostly on the autism spectrum, are not neurologically in the middle of the bell curve, are taking a sample of the information from the environment. Another way of saying this, he continues, is wondering how the other senses are fact-checking the information.
This now becomes your sensory input that your brain has made sense of, Keith continues. You encode this information and that becomes your perception. This efficient coding helps you select a better action, Keith says. Moving back to the email exchange with the parent, Keith then explains what he’s looking for when he’s playing with the child and how he’s scaffolding in order to get more asymmetrical responses to his movement so that the lateralization and crossing the midline are easier for the child. Keith wants to know how the child will move to look more comfortable, working from the bottom-up so the child can sense, process and perceive what’s happening in his body so it’s accurate enough for him to feel more comfortable. Keith said that this might be considered a soft skill and the principal might not like it, but it’s important.
The action–perception loop in active efficient coding. The sensory input is obtained by sampling input signals from the environment (e.g., via eye movements). A percept is formed by neural encoding, which drives the selection of actions and thereby, shapes the sampling process. Therefore, perception depends on both neural encoding and active input sampling. Classic efficient coding theories do not consider the active sampling component (orange).
We’re so happy with our son’s progress lately at Little Buddies. He seems to have overcome a lot of challenges in a short time with you.
Since his gross motor stuff is looking pretty good, we are wondering if it makes sense to start working on some more fine motor stuff? He is starting to independently brush his teeth, so that kind of motion might be something to work on. We’ve also been working on him taking his own shirt off before bed, so that could be something. And in the lead up to kindergarten, it would be great if he could hold a pen well (His BC is making good progress with this recently).
Happy to discuss further in person!
We can start to look at this and have him engage in more activities that require more hand manipulation.
His gross motor is looking better. I am trying to work on him having more asymmetrical responses to movement and for him to be more comfortable when moving. This will all help him in moving across his midline with greater ease.
We also are working on having him be more able to have higher-level language, to have conversations that are more spontaneous, and for him to engage in more group problem-solving.
We want him to do this while he is active/moving rather than him needing to stop everything to process the information while processing the environmental stimuli.
He has just started having these abilities so we want to solidify these skills and help him feel like he is the master of these skills.
This allows him to solidify his sensory processing skills including his visual processing skills.
When we know that his visual processing skills have improved enough for him to more easily engage in social gross motor skills, his tabletop tasks, including writing, will come more easily.
We then saw him hunch downward as he interacted with a boy with a sensory-seeking profile and watched him have visual processing difficulties that continued during a game of Funny Bunny.
When the discard pile turned into a mound, he couldn’t find the stack of cards in the play pile.
Thanks so much for this update Keith. Really appreciate the context for what’s going on with him at Little Buddies. My eyes are opening to the vastness of what you are thinking about with our son. Happy to hear he is coming into some new abilities (I’m sure this is kind of true all the time, but still happy to hear it).
Using Movement for Higher Level Processing Functions
Keith gave the example of being with this boy recently and having him lay in a lycra swing while Keith moved him from side-to-side. He also knows that the child has some visual processing issues going on. When the boy, who was staring at the ceiling, looked calm as if he could fall asleep, Keith brought him out and noticed that he was moving much more slowly and was more calm. His system was now able to process incoming information more effectively. Crossing the midline can be thought of as I described, where our arms cross over in a patty cake game, but Keith stressed that here, he was thinking about the input weight shifting from one leg to another while standing with the legs further apart, for example, with the midline going straight down the body, which also gives gross motor movement to provide the same effect.
Time for Absorbing New Learning
The boy also loves numbers so what was interesting is that when he came out of the swing, he went to a scale game where toys are balanced on the scale, mimicking things that his body was just trying to do. It was one of those priceless therapy moments, Keith shares. Keith could tell, or was hoping, that the child’s body was thinking about what the whole experience was about.
The child also tends to make up for the lack of movement in his life with his verbal skills, which went away as they saw the movement come on. For him to have that body experience was what they were looking for. It’s based on the science that is on the slide above, but the email explanation is more digestible: the goal is for him to have more spontaneous conversation that is less scripted and to be able to engage in more group problem-solving.
The boy was already making progress in these areas, so this was a way for Keith to cue the parent and demonstrate how they are scaffolding the child’s progress. Also, when someone was a fast mover in the environment, this child would hunch down preparing to fall because the visual information was affecting his ability to be stable, Keith explained. It was such a clear clue to Keith that he was losing his somatosensory connection in those moments when his fear comes up. He’s not able to process in that moment due to this fear that’s taken over. Keith says that when they see a lack of ease in the movement, it’s a clue that something in the environment is challenging the child. It happens to all of us, Keith says.
It reminded me of what Colette Ryan said in the last podcast about spoons in that once the child can feel more at ease in their movements, they have more spoons available for the language processing and spontaneous conversation. In a social situation, there’s a lot of environmental noise that comes in, Keith explains. When we can see that a child is interested in playing with another child, but it’s hard because the other child is moving too quickly, we can jump in and scaffold and also explain what’s happening to help the children figure it out for themselves as well.
Somebody’s music is noise to somebody else.
It’s also about solidifying his skills, Keith continues. You might spend two months working on something, which is not a long time in a child’s neurological development. It’s important also to stay on track with the skill set they’re working on before moving on to higher levels. Parents often want to rush ahead without realizing that it takes time to develop all of these skills. Keith said that sharing this story was so important to him because he wasn’t saying to the parent, “No, we’re working on this.” He was saying, “Yes, and here’s how we’re doing that…” Over the years, he’s gotten better at explaining the process to parents.
This child also loves games so he’s working on his fine motor skills as well such as precise reaching. All of these lovely social skills that he’s working on are doing the very things you’re looking for. The placing of the toys and precise reaching is helping quite a bit. That also helped Keith’s team discover that he had visual issues. The therapist thought he was cheating because he kept missing the dots on the board, skipping spots because he didn’t see them, so he couldn’t figure out where his eyes were to keep his place. Also when the cards were on the pile in the Funny Bunny game, and the cards were all over the place and you had to match the colour to the back of the card. The child had great difficulty with that.
As soon as Keith removed them, rather than saying, “You’re not looking in the right place“, the child was able to do it. Keith explained to his therapist that this information was more important than pointing it out to the child because children are often very aware when they can’t organize themselves to give us the outcome we’re looking for, and are sensitive to that. Rather than getting him anxious about it, they scaffolded his ability to continue to play. They don’t want to push the visual skill too hard on top of everything else he’s trying to process in that moment. Giving that information to the parent is more important than stopping everything to work on his scanning skills.
Working With Parents
Keith was happy with the parent’s response to his email exchange because sometimes he isn’t sure how the parents receive messages they send out. This parent gave Keith a gift of understanding. He communicated that he understood what Keith was explaining after Keith took the risk of explaining it all to him rather than just saying, “This is what we’re doing.” I suggested it was the OT equivalent of when people criticize Floortime by saying, “All you’re doing is playing.” Floortime, of course, is so much more, as is all of the work that OTs are doing when they appear not to be working on the skill that you want them to be working on. Here, we showed how a simple communication cleared it up any miscommunication for both parties.
If parents take anything from this (podcast) it’s, “How comfortable does your child look moving?” and when they feel comfortable moving then in some ways you’re taking the next step and we can scaffold them and provide different environmental changes to see what’s helping with that. If not, it’s taking a step back, and often when you take a step back and say, “Oh, we’re not going to do that“, the child goes and finds it themselves anyway and says, “I’m going to try it out on my own terms and figure it out” and says “Oh, I get why you did that.”
I gave Keith an example of how my son is struggling with counting the spaces on our Super Mario Game of Life board game. Keith suggests walking with his index and middle fingers across the board and then moving the player so that the hand narrows his visual field to where his fingers are, versus just pointing which is a redundant movement. Walking the fingers is more novel and works on sequencing, which also works on the midline of his hand, that mimics the midline of the body.
I also asked Keith about this tick-like movement my son makes as he walks with one of this legs. Keith says that this might be a readjustment for his sensory system to remind him to pay attention to his stepping and confidence in his movement. It’s something he’s found that works for him. What Keith would do is, first of all, is accept that this is what he does. What he might consider doing is being playful with funny walks. I suggested that I’ll get him to be the Mario Kart characters he loves and do a Bowser big burly monster walk, then a dainty Princess Peach walk, etc.
This week’s PRACTICE TIP:
This week let’s think about ways in which our children’s movement might seem laboured and wonder about some of the examples Keith gave for getting their movements to be more comfortable for them.
For example: If you have a lycra swing, work on the back-and-forth movement, do funny character walks as Keith suggested, have them move their fingers across the board game to count spaces when it’s their turn, or even kick a ball back and forth to each other slowly. You might try playing catch with balloons or rolling a ball back and forth to make sure your child can master these slower movements and coordination first.
Thank you to Keith for giving us such a rich explanation of the thought and planning that goes into the Occupational Therapist’s work when observing a child and how parents can gain a better understanding of how the Floortime OT is supporting the child’s development. I hope that you learned something valuable and will share it on Facebook or Twitter and feel free to share relevant experiences, questions, or comments in the Comments section below. Stay tuned for the next podcast in two weeks.
Until next week, here’s to choosing play and experiencing joy everyday!