Pediatric Occupational Therapy
Development, sensory integration, and intervention strategies for children
Table of Contents
1. Developmental Milestones
Gross Motor Milestones
| Age | Gross Motor Skills |
|---|---|
| 0-3 months | Lifts head in prone, physiological flexion |
| 4-6 months | Rolls over, props on forearms, sits with support |
| 6-9 months | Sits independently, pivots in prone, begins crawling |
| 9-12 months | Pulls to stand, cruises, may take first steps |
| 12-18 months | Walks independently, begins running, climbs stairs with help |
| 2 years | Runs, kicks ball, walks up/down stairs two feet per step |
| 3 years | Pedals tricycle, walks stairs alternating feet, jumps |
| 4 years | Hops on one foot, skips, throws overhand |
| 5 years | Skips, catches ball, tandem walks |
Fine Motor Milestones
| Age | Fine Motor Skills |
|---|---|
| 0-3 months | Hands fisted, reflexive grasp, regards hands |
| 4-6 months | Palmar grasp, transfers objects hand to hand, reaches |
| 6-9 months | Radial-palmar grasp, raking grasp, inferior pincer |
| 9-12 months | Superior (neat) pincer grasp, pokes with index finger |
| 12-18 months | Controlled release, builds 2-3 block tower, scribbles |
| 2 years | Imitates vertical stroke, builds 6-block tower, turns pages |
| 3 years | Copies circle, snips with scissors, strings beads |
| 4 years | Copies cross and square, cuts on line, buttons/zips |
| 5 years | Copies triangle, prints name, ties shoes |
Key Memory Aid: Shape Copying Sequence
Circle (3) → Cross (4) → Square (4.5) → Triangle (5) → Diamond (6-7)
Remember: "Children Cross Squares To Diamonds"
2. Reflex Development
Primitive Reflexes
| Reflex | Stimulus | Response | Integration |
|---|---|---|---|
| ATNR | Head turned to side | Fencing posture (face arm extends, skull arm flexes) | 4-6 months |
| STNR | Head flexion/extension | Flex head = arms flex, legs extend; vice versa | 8-12 months |
| TLR | Head position in space | Prone = flexion; Supine = extension | 6 months |
| Moro | Sudden head drop | Arms abduct/extend then adduct ("embrace") | 4-6 months |
| Palmar Grasp | Pressure in palm | Finger flexion | 4-6 months |
| Rooting | Stroke cheek | Head turns toward stimulus | 3-4 months |
| Galant | Stroke lateral spine | Trunk curves toward stimulus | 2 months |
| Plantar Grasp | Pressure on ball of foot | Toe flexion | 9-10 months |
Postural/Righting Reactions
Righting Reactions
- Head righting: Maintains head upright in space
- Neck righting (NOB): Body follows head rotation
- Body righting (BOB): Segmental rotation emerges
- Labyrinthine righting: Head position via vestibular
- Optical righting: Visual head orientation
Equilibrium Reactions
- Protective extension: Arms reach to catch self
- Tilting reactions: Body curves against gravity
- Emerge prone (6mo) → supine → sitting → quadruped → standing
- Persist throughout life
Clinical Significance of Retained Reflexes
- Retained ATNR: Difficulty with midline crossing, handwriting, bilateral coordination
- Retained STNR: Poor sitting posture, w-sitting, difficulty copying from board
- Retained Moro: Hypersensitivity, anxiety, sensory processing issues
- Retained TLR: Poor posture, motion sickness, balance problems
3. Sensory Integration
Developer: A. Jean Ayres, PhD, OTR (1972)
Definition: The neurological process of organizing sensations from the body and environment for use in daily life
The Sensory Systems
Vestibular
Movement and position in space
- Located in inner ear
- Detects head position
- Affects balance, posture
- Influences muscle tone
- Modulates alertness
Proprioception
Body awareness in space
- Receptors in muscles, joints
- Senses position and force
- Motor planning
- Body scheme
- Calming/organizing effect
Tactile
Touch discrimination
- Receptors in skin
- Protective (light touch)
- Discriminative (deep)
- Stereognosis
- Emotional security
Sensory Processing Patterns
| Pattern | Description | Behaviors |
|---|---|---|
| Sensory Seeking | High threshold + active | Craves input, constantly moving, mouths objects |
| Low Registration | High threshold + passive | Seems unaware, misses cues, slow to respond |
| Sensory Sensitivity | Low threshold + passive | Notices everything, easily distracted |
| Sensory Avoiding | Low threshold + active | Withdraws, covers ears, picky eater |
SI Dysfunction Types
Sensory Modulation Disorder
- Over-responsivity: Fight/flight to ordinary input
- Under-responsivity: Doesn't notice/respond
- Sensory seeking: Craves intense input
Sensory Discrimination Disorder
- Difficulty interpreting qualities of stimuli
- Can't tell differences (hot/cold, rough/smooth)
- Poor stereognosis or proprioception
Sensory-Based Motor Disorder
- Dyspraxia: Difficulty with motor planning and sequencing new movements
- Postural disorder: Poor posture, low tone, decreased stability
SI Intervention Principles
- Just Right Challenge: Activity is challenging but achievable
- Adaptive Response: Child produces purposeful response to sensory input
- Active Engagement: Child is actively involved and self-directed
- Child-Directed: Follows child's lead within therapeutic structure
- Inner Drive: Uses child's intrinsic motivation
4. Fine Motor Development
Grasp Development Sequence
| Age | Grasp Type | Description |
|---|---|---|
| 0-3 mo | Reflexive grasp | Automatic; stimulus-driven |
| 3-4 mo | Ulnar-palmar | Object against palm, held by pinky side |
| 5-6 mo | Palmar grasp | Object pressed into palm, all fingers |
| 6-7 mo | Radial-palmar | Thumb side involved, more refined |
| 7-8 mo | Radial-digital | Fingertips + thumb, object in space |
| 8-9 mo | Inferior pincer | Thumb pad to side of index finger |
| 10-12 mo | Superior pincer (neat) | Thumb tip to index fingertip |
Pencil Grasp Development
1-2 years
Palmar-Supinate
Fisted grip, arm movement
2-3 years
Digital-Pronate
Fingers hold, wrist pronated
3.5-4 years
Static Tripod
3-point hold, wrist movement
4.5-6 years
Dynamic Tripod
Finger movement, mature grasp
In-Hand Manipulation Skills
Translation
Moving object between fingers and palm
- Finger-to-palm (picking up coins)
- Palm-to-finger (moving coin to fingertips)
Shift
Linear movement at fingertips
- Adjusting paper position
- Moving pencil up/down
Rotation
Turning object at fingertips
- Simple rotation (< 90°)
- Complex rotation (> 90°; flipping pencil)
5. Handwriting & School Skills
Prerequisites for Handwriting
- Postural control: Stable sitting posture
- Shoulder stability: Proximal stability for distal mobility
- Forearm support: Wrist extension
- Grip strength: Adequate force
- Mature pencil grasp: Dynamic tripod
- In-hand manipulation: Position adjustments
- Visual-motor integration: Eye-hand coordination
- Bilateral coordination: Paper stabilization
Pre-Writing Strokes Sequence
- Vertical line (|): 2 years - imitates; 3 years - copies
- Horizontal line (—): 2.5 years - imitates; 3 years - copies
- Circle (O): 2.5 years - imitates; 3 years - copies
- Cross (+): 3.5 years - imitates; 4 years - copies
- Right oblique (/)
- Square: 4-4.5 years
- Left oblique (\)
- X: 5 years
- Triangle: 5 years
- Diamond: 6-7 years
Common Handwriting Problems
| Problem | Possible Causes | Interventions |
|---|---|---|
| Illegibility | Poor VMI, motor planning | Pre-writing activities, letter formation practice |
| Too much pressure | Poor proprioception, decreased awareness | Pencil grips, carbonless paper, heavy work |
| Too little pressure | Weak grip, low tone | Strengthening, vertical surfaces, resistance |
| Slow speed | Motor planning, automaticity | Practice, keyboarding alternative |
| Letter reversals | Visual perception, directionality (normal until 7-8) | Multisensory approach, verbal cues |
Scissor Skill Development
- 2 years: Snips (random cuts)
- 2.5 years: Cuts across paper (fringe cuts)
- 3 years: Cuts forward on line (within 1/2 inch)
- 3.5 years: Cuts circle
- 4 years: Cuts square
- 4.5 years: Cuts triangle
- 5-6 years: Cuts complex shapes
6. Feeding & Oral Motor
Feeding Milestones
| Age | Feeding Skills |
|---|---|
| 0-4 months | Liquid diet; suck-swallow-breathe coordination |
| 4-6 months | Begin purees; tongue thrust diminishes; opens mouth for spoon |
| 6-9 months | Mashed foods; munching pattern; holds bottle; finger feeds |
| 9-12 months | Soft solids; diagonal jaw movement; drinks from cup with help |
| 12-18 months | Coarsely chopped foods; rotary chew emerges; uses spoon with spilling |
| 18-24 months | Most textures; mature rotary chew; uses spoon well; holds cup independently |
| 2-3 years | All foods; uses fork; pours from pitcher |
| 4-5 years | Uses knife to spread; independent dining skills |
Oral Motor Patterns
Sucking (Suckling → Mature Suck)
- Suckling: In-out tongue, rhythmic (newborn)
- Mature suck: Up-down tongue, stronger (6 mo)
- Straw drinking by 2 years
Chewing Development
- Munching: Up-down jaw (6-9 mo)
- Diagonal rotary: Lateral + vertical (9-24 mo)
- Circular rotary: Mature pattern (24+ mo)
Feeding Problem Red Flags
- Coughing/choking during or after meals
- Wet, gurgly voice quality after eating
- Recurrent respiratory infections
- Drooling beyond 2 years
- Extreme food selectivity (< 20 foods)
- Weight loss or poor growth
- Meals lasting > 30 minutes routinely
Feeding Intervention Strategies
- Proper positioning (90-90-90 position)
- Appropriate utensil selection
- Food texture modification
- Oral motor exercises
- Environmental modifications
- Food chaining for picky eaters
- SOS Approach to Feeding
- Sensory-based strategies
- Behavioral approaches
- Parent/caregiver education
7. Play Development
Parten's Social Play Stages
| Stage | Age | Description |
|---|---|---|
| Unoccupied | 0-2 | Random movements, observing |
| Solitary | 0-2 | Plays alone, unaware of others |
| Onlooker | 2 | Watches others play |
| Parallel | 2-3 | Plays beside others, not with |
| Associative | 3-4 | Plays with others, no organization |
| Cooperative | 4+ | Organized, shared goals, roles |
Types of Play
Exploratory/Sensorimotor
0-2 years
- Mouthing, banging, shaking
- Cause-and-effect discovery
- Repetitive actions
Constructive Play
2+ years
- Building, creating
- Blocks, Legos, puzzles
- Goal-directed product
Symbolic/Pretend Play
18 mo - 7 years
- Object substitution (banana = phone)
- Role playing
- Fantasy/imagination
Games with Rules
6+ years
- Structured games
- Following rules
- Turn-taking, competition
Play as OT Intervention
- Play is the primary occupation of childhood
- Play can be used AS therapy (means) or the goal OF therapy (end)
- Intrinsically motivated and child-directed
- Develops motor, cognitive, social, and emotional skills
- Adapt play materials and environment to promote participation
8. Pediatric Assessments
Developmental Assessments
| Assessment | Age Range | What It Measures |
|---|---|---|
| Bayley-4 | 1-42 months | Cognitive, language, motor, social-emotional, adaptive |
| PDMS-2 | Birth-5 years | Gross motor, fine motor (reflexes, stationary, locomotion, grasping, VMI) |
| BOT-2 | 4-21 years | Fine motor precision, integration, dexterity; gross motor |
| HELP (Hawaii) | 0-3 years | Curriculum-based; all developmental domains |
Sensory Processing Assessments
Sensory Profile 2
- Caregiver questionnaire
- Birth-14 years (different versions)
- Identifies sensory patterns
- School companion available
SIPT (Sensory Integration and Praxis Tests)
- Performance-based
- 4-8:11 years
- 17 subtests
- Requires certification
Visual-Motor & Perception Tests
| Assessment | Age | Focus |
|---|---|---|
| Beery VMI | 2-100 years | Visual-motor integration (copying shapes) |
| TVPS-4 | 5-21 years | Visual perception (motor-free) |
| DTVP-3 | 4-12 years | Motor-reduced and motor-enhanced visual perception |
| MVPT-4 | 4-80+ years | Motor-free visual perception |
Functional Assessments
PEDI-CAT
Birth-20 years
Daily activities, mobility, social/cognitive, responsibility
WeeFIM
6 mo-7 years
Self-care, mobility, cognition; level of assistance
SFA
K-6th grade
School function: participation, task supports, activity performance
Key Takeaways for the Board Exam
- ✓Pincer grasp: Inferior 8-9 mo; Superior/neat 10-12 mo
- ✓Shape copying: Circle 3, Cross 4, Square 4.5, Triangle 5, Diamond 6-7
- ✓ATNR integration: 4-6 months; retention affects midline crossing
- ✓Parallel play: 2-3 years (plays beside, not with)
- ✓Sensory seeking: High threshold + active response strategy
- ✓Dynamic tripod grasp: Mature pencil grasp by 4.5-6 years
- ✓Rotary chew: Diagonal 9-24 mo; Circular/mature 24+ mo
- ✓BOT-2: 4-21 years; comprehensive motor assessment