Fine Motor Control in Children

Fine motor skills are important to a child’s development. Not having these skills can interfere with school and home activities. It is important to understand the difference between fine motor skills and gross motor skills.

Fine motor skills are those skills that require smaller, more delicate movement; usually using the smaller motion with an emphasis on the coordination of those movements. Gross motor skills are those skills using the larger muscles in the body, those to run, jump and move about.

Concerns with a child’s fine motor skills can be treated by a therapist with a strong focus in the area of pediatric occupational therapy. A child with fine motor problems may become easily frustrated in school when having to copy things from the blackboard or in art class because he or she may have problems either writing neatly, staying within the lines when coloring or cutting out shapes.

A child’s motor planning and speed of movement can be greatly affected in cases of fine motor control development. Motor planning involves the visual detection of motion and errors in movements. For a child’s movement to be effective things must be timed adequately and fine motor skills require a certain amount of attention and concentration as well.

What is more important is the order in which certain movement is made to accomplish a task. Managing complex activity using smaller muscle groups may be compromised when dealing with fine motor skill problems. School-age children face more fine motor skill problems than most other age groups, making pediatric occupational therapy a very important step in the treatment of this problem.

Children with fine motor skill problems may present other behaviors as well. At times a child may have underlying issues that could be associated with fine motor skill problems. They may actually present problems with an articulation of words and sounds due to the fact that fine motor control has to do with tongue movement as well; being the tongue is a smaller muscle.

Fine motor control struggles can be due to sensory problems in the brain; the child may have an aversion to being touched and being introduced to new things. In these cases the child’s ability to behave and control their fine motor skills may be hampered by the overstimulation of the senses, causing frustration and clumsiness.

Children experiencing fine motor skill problems may present the following issues:

  • Clumsy pencil grasp (pincer grasp activities)
  • – Poor scissor skills (activities with scissors)
  • – Not able to grasp and release things in a controlled manner
  • – Cannot hold small objects or use tools such as pencils and scissors
  • – Dislikes completing mazes and dot to dots due to being easily frustrated with them
  • – Has problems copying from the blackboard in class

Ideas for Developing Fine Motor Skills

Below are a few activities you might find helpful to promote functional grasp patterns:

  • Squirt bottles can be used to promote the pincer grasp (pincer grasp activity ideas)
  • Bead stringing/lacing with the tip of the finger against thumb
  • Practice screw and unscrew lids
  • Activity ideas using bubble wrap to promote pincer grasp
  • Play dough can be used to promote the pincer grasp.
  • Tear pieces of construction paper into small pieces and paste the different colors of paper on a simple picture from a coloring book, or make your own design.
  • Use tongs/tweezers to pick up blocks/small objects.
  • Pennies into a piggy bank or slot cut in a plastic lid. Coins can also be put into slots cut in foam.
  • Working on a vertical surface, especially above eye level. Activities can be mounted on a clipboard or tapes to surface or chalkboard/easel. Examples: pegboards, Lite Brite, Etch-a-sketch( upside down), Magna Doodle, outlining, coloring, painting, writing.
  • Clothespins/pinching. Put letters on clothespins and spell words by clipping on edge of a shoe box. Use a clothespin to do finger “push-ups” by using the pads of the thumb and index finger to open a clothespin and count repetitions.

Pencil Grasp Patterns

The Dynamic Tripod Grasp

Pencil skills, and particularly handwriting, is a more complex skill than we often realize. A child’s ability to color within the lines, trace over a shape and draw simple pictures forms the building blocks for writing letters and words.

Mastery of these pencil skills focuses on the content of their writing rather than the mechanics of pencil, speed, and movement. However, given society’s emphasis on, and haste to commence, ‘academics’ earlier, we sometimes overlook the vital role these seemingly basic skills play in developing writing skills. Yet we expect children to demonstrate their knowledge on paper in order to assess their pace.

Handwriting is influenced by the development of appropriate sensorimotor, perceptual and cognitive skills.

One of the most common problems occupational therapists in the school are consulted about is improper pencil grasp.

While the most efficient way to hold a pencil is the dynamic tripod grasp many other patterns are commonly seen in children and it does not always require intervention or modification. In the dynamic tripod grasp, the pencil is held between the thumb and index finger, with the pencil resting on the middle finger.

There are a variety of reasons why children hold their pencils in patterns other than the dynamic tripod. One common reason is participating in a lot of writing before their hands are developmentally ready for this activity. This is becoming more and more common as parents try to start preparing children to school with writing activities at an earlier stage.

dynamic tripod grasp pencil hold for left hand figure
(dynamic tripod grasp for left-handed)
dynamic tripod grasp pencil hold for right hand figure
(dynamic tripod grasp for right-handed)

It is important to try to modify the pencil grasp as early as possible since many students seem to have developed bad habits even before entering kindergarten.

Adaptive Pencil Grips

Adaptive pencil grips may be helpful in teaching students to modify their grasp and are used to facilitate an optimal pencil grasp.

There are many different types of grips available. For a pencil grip to be effective, the student needs to be involved in choosing the grip and to understand the importance of using it.

Adaptive pencil grips in 2 different sizes

The most optimal position for writing includes the ankle, knee, and hip at right (90 degrees) angles with the forearms resting on the desk. The top of the desk should be approximately 2 inches above the elbows when the arms are at the student’s side.

Pencil Grasp Patterns

Functional Grasp Patterns

Tripod grasp with open web space: The pencil is held with the tip of the thumb and index finger and rests against the side of the third finger. The thumb and index finger form a circle.

Quadripod grasp with open web space: The pencil is held with the tip of the thumb, index finger, and third finger and rests against the side of the fourth finger. The thumb and index finger form a circle.

Adaptive tripod or D’Nealian grasp: The pencil is held between the index and third fingers with the tips of the thumb and index finger on the pencil. The pencil rests against the side of the third finger near its end.

Immature Grasp Patterns

Fisted grasp: The pencil is held in a fisted hand with the point of the pencil on the fifth finger side on the hand. This is typical of very young children.

Pronated grasp: The pencil is held diagonally within the hand with the tips of the thumb and index finger on the pencil. This is typical of children ages 2 to 3.

What is an efficient pencil grip?

“A pencil hold that provides speed, legibility is comfortable and will not cause harm to the joints of the hand over time. If a hold satisfies these criteria there is no need to change it” (Benrow 2002, cited: Foundation of Paediatric Practice for the Occupational Therapy Assistant, 2005)

Inefficient Grasp Patterns

Five finger grasp: The pencil is held with the tips of all five fingers. The movement when writing is primarily on the fifth finger side of the hand.

Thumb tuck grasp: The pencil is held in a tripod or Quadripod grasp but with the thumb tucked under the index finger.

Thumb wrap grasp: The pencil is held in a tripod or Quadripod grasp but with the thumb wrapped over the index finger.

Tripod grasp with closed web space: The pencil is held with the tip of the thumb and index finger and rests against the side of the third finger. The thumb is rotated toward the pencil, closing the web space.

Finger wrap or interdigital brace grasp: The index and third fingers wrap around the pencil. The thumb web space is completely closed.

Flexed wrist or hooked wrist: The pencil can be held in a variety of grasps with the wrist flexed or bent. This is more typically seen with left-hand writers but is also present in some right-hand writers.

Activities to Improve Pre-Writing Skills

The following list of activities can be used to improve pre-writing skills. Additional ideas can be found here.

  • Playing jump rope
  • Volleyball-type activities where hands, paddles, or rackets are in a palm-up position
  • Squirt bottles (activities using squirt bottles)
  • Slinky-shift back and forth with palm up
  • Bead stringing/lacing with the tip of the finger against thumb
  • Pouring from small pitcher to a specific level in the clear glass. Increase the size of the pitcher as strength increases.
  • Ich a pencil or chopstick positioned in tripod grasp toward and away from the palm. The shaft should rest in open web space.
  • Practice screw and unscrew lids
  • Pop bubble wrap
  • Play dough/silly putty activities
  • Use a turkey baster or nasal aspirator to blow cork or ping pong balls back and forth. These can also be used to squirt water to move floating object/toys.
  • Tier pieces of construction paper into small pieces and paste the different colors of paper on a simple picture from a coloring book, or make your own design.
  • Floor activities – large mural painting, floor puzzles, coloring when lying on the stomach on the floor.
  • Dot-dots, color by number, mazes.
  • Wheelbarrow walking-child’s hands are the large ones from Bed Bugs game or kitchen tongs.
  • Fingerplays/string games such as Cat’s Cradle.
  • Use tongs/tweezers to pick up blocks/small objects.
  • Pennies into piggyback or slot cut in the plastic lid. Coins can also be put into slots cut in foam.
  • Working on a vertical surface, especially above eye level. Activities can be mounted on a clipboard or tapes to surface or chalkboard/easel. Examples: pegboards, Lite Brite, Etch-a-sketch( upside down), Magna Doodle, outlining, coloring, painting, writing.
  • Clothespins/pinching. Put letters on clothespins and spell words by clipping on edge of a shoe box. Use a clothespin to do finger “push-ups” by using the pads of the thumb and index finger to open a clothespin and count repetitions.
  • Squirrel objects into the palm (pick up with index finger and thumb, move into palm without using the other hand)
  • Squeeze sponges to wash off the table, clean windows, shower, etc.

Causes and Treatment of Poor Fine Motor Control

The primary cause of fine motor control problems is a lack of or overabundance in muscle mass. A child having high muscle tone may make mistakes based on the over-activation of muscles, resulting in activities being sloppy or even clumsy in nature. A child having low muscle tone is quite common; a child with low muscle tone may struggle to maintain even the smallest control of a pencil or even scissors. Small feats like finger movement may prove to be an extreme effort for a child with low muscle tone.

It can be said that genetic and environmental factors can lead to fine motor skill problems. While pregnant, a mother exposed to alcohol and drugs can be a big factor in the development of a baby. Alcohol can directly affect the neurons in the brain. If a baby is born prematurely the connection of the neurons in the brain may be disturbed. The more premature a baby is the risk for this problem rises. Disturbing the connection of neurons can lead to difficulties with attention span and/or self-control in fine motor skill development. Even smoking has been known to have negative effects on motor skills.

Treatment with a pediatric occupational therapist can greatly improve a child’s fine motor skills with the right therapy geared to successful treatment of fine motor problems. The pediatric occupational therapist may try two approaches to the treatment of your child. The first is a relatively general approach dealing with the assessment of their sensory development. How a child moves and reacts to stimuli. Finding that underlying factor helps them form a second approach designed specifically for fine-tuning the way they perform more complex tasks using fine motor skills. Teaching them how to accomplish and fine-tune their skills can greatly improve motor function.

Being that no one method is successful for all patients a Pediatric Occupational Therapist may also treat a child in these areas:

  • Their finger strength, hand strength, hand position and stability
  • Overall pencil grip and control
  • Control of the wrist and forearm
  • Finger movement
  • The spatial organization of space and letter formation
  • Speed and dexterity
  • The isolated movement required for tweezers and scissors

It is necessary for parents to take an active role in their child’s treatment for the continuation of improvement outside of the pediatric occupational therapists’ office.

For at home improvement of fine motor skills the occupational therapist may suggest activities like drawing (sample activity), coloring and paper cutting art involving cutting out paper chains and making paper snowflakes. Drawing can improve how neatly the child can draw lines and shapes, improving the overall appearance of letters and shapes altogether; paired with coloring this helps the eyes determine where to stop by staying within the lines in shapes and forms. Tracking movement is one of the key factors in fine motor skills. There are also toys and games available that are geared for the improvement of fine motor skills.

Developing and improving fine motor skills can take a lot of time but with the proper guidance from a pediatric occupational therapist, you can make all the difference in the way your child learns and perceives life in general. Children with fine motor skill problems can suffer greatly in school and even social situations. Therefore it is important to identify any fine motor control issues and begin an occupation therapy program to help them develop these skills as quickly as possible.

Strategies to Improve Feeding at Home

Perspectives on sensory, texture, and environmental control factors: tips for picky eaters, feeding problems, and expanding your child’s diet.

Eating is a developmental process which changes over time as the child becomes more confident with his/her eating skills. Many children between the ages of two and three years old are picky eaters because they are going through a state of development where they fear new foods. This state may occur at a later stage in children with developmental delays. The fear of new foods generally improves during childhood. These changes in childhood are normal and most children balance their food selections and eat a nutritional diet over a period of time. Children with special needs sometimes are described as “picky eaters”, meaning they may have limited food selection, show anxiety or tantrums when presented with new foods, and/or require one or more foods be prepared in the same manner. Solving the feeding dilemma is not a quick fix.

Feeding Development: Texture Perspective

“Texture” refers to how smooth, lumpy, thick or thin the food is. This chart describes textures, examples of food, and the age the child generally is expected to handle a given texture:

0 – 13 monthsbreast/bottle
6 monthsthin pureesstage 1 Baby Food
7 monthsthick pureesstage 2 Baby Food
9 monthsmeltable hard solidsGraham crackers, Fruit Loops (foods which dissolve with spit only)
10 monthssoft cubesGerber Graduates fruits, boiled potatoes, bananas
11 monthssingle textured soft mechanicalmuffins, soft pasta, thin meats in small rectangles
12 monthsmixed texture soft mechanicalmacaroni and cheese, fries, spaghetti
16 monthshard mechanicalpretzel sticks, ritz crackers, chips

When working with your child with chewing and/or swallowing difficulties, there are a few general principles to keep in mind:

  • Often times, a child with swallowing problems is able to handle thicker foods and liquids best (e.g. applesauce in apple juice, yogurt, etc).
  • Chewable foods that maintain a solid mass are often easier to handle (e.g. banana, pancakes, etc).
  • Food with more than one consistency are more difficult to handle (e.g. soup with veggies/meat).

Feeding Development: Sensory Perspective

Children developmentally learn to accept new foods through their senses such as smell, touch, and taste. Providing children with experiences to learn each new food from its’ sight, smell, and texture often increases their tolerance and acceptance. Here are some guidelines and ideas to promote your child’s sensory development in feeding:

  • Activities for learning about new foods can be implemented either at the end of the meal or a separate scheduled time dedicated to “learning about new foods”
  • Graded sensory input (such as background visual and auditory stimuli) to fit the child’s level of sensitivity
  • Keep it fun without any coercion to explore a new food and maintain a positive and supportive attitude
  • Activities to “touch” new foods
  • Painting with food
  • Stamping with food
  • Stringing the food items onto yarn to make food jewelry
  • Activities to “smell” new foods
  • Placing a food item in the container and have your child smell it through the hole on the top then guess the item
  • Activities to “taste” new foods
  • Tasting a new food item begins with licking the item, then holding a small bite on the tongue, and finally chewing a small portion
  • Allow your child to spit out a new food item during the beginning of the exploration or have ice or water on hand for your child to use
  • Have your child to make a “teeth mark” on a food item
  • Invite your child to join the cooking process

Environmental Control Perspective for Picky Eaters

Environmental factors play a key role in developing and maintaining food aversions and problem eating. Environmental controls include scheduling meals, selecting an appropriate setting, creating a supportive climate, designing meals and portion sized, and addressing food jags.

Guidelines for creating the meal/snack schedule to help with consistency and predictable routines:

  • Write a schedule that is understandable and clear to the child
  • Use a timer to indicate when the next meal/snack will begin
  • Use a kitchen timer during the meal to set the pace and length of the meal
  • Make sure the mealtime schedule includes snacks
  • Offer the child at least one preferred food item at every meal and/or snack
  • Provide only water to the child between the scheduled meal/snack time to limit grazing

Mealtime setting should be a comfortable and supportive setting to help your child relax and focus on learning new skills to eat:

  • Eating and drinking should be done at the table for proper stability and posture
  • The child should sit in a chair with feet resting on the floor
  • The number of distractions at mealtimes should be kept to a minimum
  • Parents, siblings, and peers play an important role during the meal for socialization

Guidelines for creating a supportive mealtime environment for a child to feel supported, safe, nurtured, and trusted to explore new foods/skills:

  • Respect the child and do not invade his/her mouth without permission
  • Role–play and demonstrate eating techniques
  • Never discuss the child’s eating habits or how much he/she eats during the meal
  • Discuss the taste, texture, and smell of new foods

Portion size and food selection should be presented in a manner that allows a child to be successful.

  • Provide your child with an age-appropriate sized plate and utensils
  • It is better to start the meal with smaller portion sizes as it allows the child to see the results when taking a few small bites
  • A good rule of thumb for controlling portion size is to consider one tablespoon of each type of food for each year of the child’s age

Food selection should take into consideration the child’s age and eating habits. Keep in mind that new and exotic foods can be scary for your child.

  • Select only one menu for the entire family and include a variety of foods familiar to the picky eater as well as some new foods
  • Select foods that are child-friendly
  • Consider texture, color, and smell when introducing a new food
  • Include a piece of bread or roll with meals since child is often successful with this
  • Be flexible since the goal is for long-term changes it is ok to miss one balanced meal or not to always have the family eat the exact same meal

Food Jags refers to the insistence on the same food, serving utensils, or even the same setting over long periods of time. Guidelines for addressing food jags:

  • Create opportunities for structured flexibility and choice making allowing the child to have some choices (foods, dining ware etc) while maintaining the structure of the schedule and healthy choices
  • Do not cater to the child’s rigidity in wanting only the same foods. Make slight changes in the presentation such as changing the noodle shape for insistent mac-n-cheese eaters
  • Include the child in food preparation and presentation

Guidelines for implementing appropriate mealtime behaviors:

  • Resistant eaters often exhibit challenging behaviors during mealtimes due to their persistent food aversions. Be patient and take the time to extinguish challenging behaviors and replace with appropriate behaviors
  • Set up a routine for transitioning to the table
  • If the child exhibits noncompliance or tantrums during the meal, calmly remove them to a safe area away from the group
  • If the child throws food or destroys food, he must clean it up
  • Analyze your judgment about the child’s behavior in terms of cultural beliefs, messiness, and expectations

What is Occupational Therapy?

Occupational Therapy, often abbreviated as “OT“, is an applied science and health profession that provides skilled treatment to help individuals achieve and maintain independence in all facets of their lives. OT gives people the “skills for the job of living” necessary for independent and satisfying lives.

People who work in the Occupational Therapy field can be credentialed as Occupational Therapists or as Occupational Therapy Assistants (OTA).

The World Federation of Occupational Therapists provides the following definition of Occupational Therapy: “Occupational therapy is as a profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation.”

What does it take to be an OT?

An occupational therapist completes a 5 or 6-year post-baccalaureate occupational therapy degree. An occupational therapy assistant completes a 2-year associate degree program. Both must complete a supervised fieldwork program during their studies and pass a national certification exam (NBCOT).

Many states require continuing education courses to be taken to maintain licensing.

What kind of problems can OT treat?

Occupational therapy treats any physical or mental problem that interferes with a person’s ability to perform activities of daily living.

Therapy can be provided for anyone from young children to older adults. Some typical injuries or illnesses are: paralysis, injury to a hand, joint disease, injury that limits movement, cognitive impairments, inability to perform personal care tasks, activity of daily living (ADL), and many more.

What are the areas of practice for OTs in physical health?

  • Pediatric – in schools, community, inpatient hospital-based child OT.
  • Acute care hospitals
  • Inpatient rehabilitation – OTs help in recovery and adaptation for people with disabilities.
  • Rehabilitation centers – treating stroke (CVA), spinal cord injuries, head injuries.
  • Skilled nursing facilities
  • Home Health
  • Outpatient clinics
  • Specialist assessment centers
  • Assisted Living Facilities
  • Productive Aging
  • Mental Health

What is the Occupational Therapy process?

  • Referral
  • Information gathering
  • Initial assessment
  • Needs identification/problem formation
  • Goal setting
  • Action planning
  • Action
  • Ongoing assessment and revision of action
  • Outcome and outcome measurement
  • End of intervention or discharge
  • Review

What are the goals of Occupational Therapy?

Increasing function and independence in regards to physical disability and limitations to enable a person to perform the activities alone, with limited help, or with the use of devices. With occupational therapy treatment, a person can become more independent.

What kind of treatments are used in OT?

There are many ways to provide occupational therapy. Depending on the cause of the problem, each person is evaluated and a treatment plan is designed to fit his/her needs. The first step in treatment is an evaluation process by the therapist. This helps the therapist determine the best treatment plan and frequency of treatments.

Does insurance cover Occupational Therapy?

Most health insurance policies will cover occupational therapy.

Some insurance companies might have limits to the number of covered treatments in 1 calendar year.

Job Outlook for Occupational Therapists

Employment is expected to grow much faster than average. Occupational Therapy Job opportunities should be good especially for occupational therapists treating the elderly. [Source: bls.gov]

See Also

Wikipedia – Occupational Therapy
Wikipedia – Occupational Therapist
Occupational Outlook Handbook, 2010-11 Edition (Occupational Therapists)

How To Obtain Your Occupational Therapy Degree

Occupational therapy is a profession that deals with health and rehabilitation. These therapists work with a wide range of different people and assist in helping them achieve independence and boost productivity. Occupational therapists work with people of all ages to help with their physical, emotional, and social problems. The “occupation” used by these therapists include work and play, as well as self-care, to aid their clients.

Occupational therapy will help those struggling to achieve their goals of independence, prevent disability, and enhance their overall development and well-being. Needless to say, occupational therapy is a widely popular and important skill. If you’ve always wished to help those around you and are interested in new techniques in assisting others, occupational therapy may be for you.

Occupational Therapy vs. Physical Therapy

Many people may be confused as to the difference between occupational therapy and physical therapy. The requirements needed in order to obtain a degree in occupational therapy are different than those needed for physical therapy. However, both professions use similar therapy techniques on occasion but their goals are quite different.

There are many differences between the 2 professions.

Physical therapy is essentially all about helping someone regain physical mobility, including strength, balance and flexibility to name a few. Physical therapists work with people to improve their posture, regain strength after an accident or surgery, as well as help those who may have been born with a defect.

Occupational therapists help those with illness or a disability to learn how to take care of themselves and participate in meaningful activities. These activities may be driving, eating by themselves and even working. In addition to helping their clients re-engage in meaningful activities, occupational therapists work with the environment around their clients to ensure the person can have an easier time performing tasks that are important to them. One big difference between physical therapists and occupational therapists is that occupational therapy requires training with people who have mental or emotional disorders and illnesses.

Occupational Therapy as a Career

Occupational therapists work within a wide variety of settings and areas. These locations may include, but not be limited to, hospitals, schools, industry, community or private agencies, within homes, workplaces and outpatient clinics. As more people realize the profound benefits of occupational therapy, the locations in which it can be practiced grow.

The job outlook and salary is very decent for occupational therapists. Even after the job market contraction, occupational therapy is still booming. According to studies the need for occupational therapists isn’t going to die down anytime in the near future. Salaries for occupational therapy have risen as well. The median annual salary for an Occupational Therapist is $80,150 per the Bureau of Labor Statistics (as of May 2015). Naturally regional differences and setting differences will affect your salary. Additional information regarding OT salary ranges and salary outlook can be found here and here.

Becoming an Occupational Therapist

It is important to note the requirements you need to be a certified occupational therapist. Understanding the job duties and specific qualifications is vital in ensuring occupational therapy is the right career for you.

Career Requirements

Occupational therapists work with people who have been injured or disabled in some way that hinders their ability to live independently. These might be elderly people that want to be more active and independent or children who are struggling in school. Due to the nature of their work, occupational therapists work in a wide range of different areas.

In terms of educational requirements, occupational therapists must have at least a master’s degree. Their degree field must be in occupational therapy and they will need a state license to practice. Other important training to have includes CPR and BCLS. Personal skills to have includes excellence in communication and interactions with others and compassion as well as patience. Other useful skills include such things as writing.

Three Steps to Occupational Therapy Certification

Earning Your Bachelor’s Degree

Your first step in becoming certified to practice Occupational Therapy is to get your Bachelor’s degree. There are a few different choices for majors that will assist in becoming a certified occupational therapist. Some of these choices include anthropology, sociology, and psychology. You can choose a school that offers accelerated programs or even dual-degrees if possible. If you chose the right path you could obtain both your bachelor’s and master’s within only 5 years.

Earning Your Master’s

It takes roughly two years for a student to complete their Master’s degree after obtaining their Bachelor’s. Generally, potential occupational therapists will spend their year earning their Master’s degree learning about anatomy, patient care, and assistive technology in their field and social/medical conditions. During this time fieldwork is essential. This fieldwork can take place in nursing homes, rehab centers, schools or even private practices. It usually takes about 24 weeks on average to complete these field experiences.

Getting Your License

After receiving your degrees it’s time for the final third step in becoming certified to practice occupational therapy: becoming licensed in your state. These state licenses are a strict requirement. In order to receive this license you must have:

  •   Graduated from an accredited occupational therapy program
  •   Have complete necessary fieldwork
  •   Passed the NBCOT exam

After all of these requirements have been documented and passed you will be granted the OTR or Occupational Therapist Registered Credential. The OTR is mandatory to receive your license but voluntary thereafter. Many therapists choose to maintain this certificate actively by continuing their education.

You should check your local state requirements before applying to an OT program. Your state might have specific requirements that you should complete prior to becoming an OT. Additional state license information can be found here.

What is W Sitting Position?

W Sitting Position is a sitting position where the child sits on the bottom with both knees bent and feet pointing outwards. If viewed from above, you will notice the legs and body look like the letter W.

It is one of many sitting positions that most children move into and out of while playing.

Why Do Children Sit in the W Position?

W-Sitting Position
W-Sitting Position

As a child, you have more hip rotation, making it easier to move into a W sitting position. Children with weak core sometimes find W sitting more comfortable as it adds stability.

The W sitting position lets kids play in an upright position, without worrying about falling over or needing to balance as much.

At what age is a child most likely to sit in a W position?

Usually between 4 to 6, but you’ll also see it with younger and older kids.

Femoral anteversion, inward twisting of the thigh bone that causes the child’s knees and feet to turn inward, or have what is also known as a “pigeon-toed” appearance, tends to decrease after age 8. This reduces the likelihood a child will go into W sitting.

Why is it problematic for kids?

W-Sitting could lead to future orthopedic problems.

Crossed legs sitting, side-sitting, or sitting with your legs stretched out in front of you engages core strength. W Position does not challenge the muscles in your back and abdomen. These muscles are important for the development of fine and gross motor skills as well as maintaining balance and keeping an upright posture.

In a W sitting, a child cannot achieve active trunk rotation and cannot develop adequate balance because the child is not able to shift weight and rotate. This could result in delayed bilateral coordination skills.

When playing in other sitting postures, children develop the trunk control and rotation necessary for midline crossing (ability to reach across the midline of the body with the arms and legs crossing over to the opposite side) and separation of the two sides of the body. These skills are needed for a child to develop refined motor skills and hand dominance.

What type of issues could show up?

When W sitting becomes a habit and is done for continuous, prolonged periods, it can have long-ranging, negative health effects:

Criss-Corss applesause sitting
Criss-Cross Applesauce Sitting
  • Negatively impacting coordination, balance, and gross motor skills
  • Could lead to affecting the child’s ability to perform table-top activities such as writing
  • Create difficulties in the development of hand preference
  • Make it hard for a youngster to shift their weight from side to side.
  • Poor trunk rotation skills: in a W sitting position, the trunk muscles are not used as much to keep the body upright.
  • Limited core strength: W sitting position provides a wider base of support for the child which may be used to compensate for weak postural muscles

How to prevent W-sitting and What can you do?

Prevent it from becoming a habit. Be consistent and ask the child to change the sitting position. Praise the child’s posture when they are sitting in a different position.

Ask the child to sit in the “criss-cross applesauce” position.

If a child is unable to sit alone in any position other than a W, talk with a therapist about supportive seating or alternative positions such as prone and sidelying

Signs of Sensory-Motor Difficulties In Preschoolers

A child may demonstrate a few of the following behaviors without cause of concern. They may be suggestive of difficulty with sensory integration when they occur in meaningful clusters and interfere with daily activities and learning. Some of these signs may indicate problems in areas other than sensory integration.

General signs of sensory integration dysfunction:

  • Overly sensitive to touch, movement, sights, sounds, smells
  • Under-reactive to sensory stimulation
  • Activity level that is unusually high or low
  • Coordination problems
  • Speech, language, motor or academic delays despite normal intelligence
  • Poor organization of behavior (impulsive, lack of planning for a task such as a project, dressing, getting ready for dismissal)
  • Poor self-esteem (may appear lazy, unmotivated)

Specific signs of sensory integration dysfunction:

Gross Motor

  • Muscles feel stiff or floppy
  • Poor standing or sitting posture (e.g., rounded shoulders, slumps over tabletop, “melts” into the floor, people or other surfaces)
  • Delays in development skills such as one foot balance, jumping, hopping navigating stairs
  • Awkward gait; walks on toes, no arm swing
  • Clumsiness: falls easily; trips; bumps into things; drops things
  • Reluctant to participate in playground activities; difficulty learning new games or figuring out how to move body in relationship to new playground equipment
  • Seems weaker than others his/her age; fatigues easily

Fine Motor Difficulties

  • Delay in developing a hand preference
  • Immature, clumsy, or improper crayon grasp
  • Drops crayons and small pieces frequently
  • Difficulty coloring
  • Difficulty manipulating a scissors
  • Difficulty picking up small objects such as beads and pegs
  • May avoid difficult activities

Behavior Interfering With Function

  • Distractible
  • Short attention span
  • Restless
  • Impulsive
  • Accident prone
  • Hyperactive
  • Extremely slow worker
  • Forgetful
  • Difficulty following directions
  • Easily frustrated
  • Unable to cope with changes in routine
  • Frequent or unexplained outbursts or tantrums

Reacts to Tactile Input Differently (i.e., over or under responsive)

  • Tends to touch everything; craves self-initiated hugging and touching
  • Avoids touch from others, especially when unexpected (standing on line or near cubby, jostling in playground, circle time)
  • Dislikes water play, sand play, pasting, play dough or finger-painting
  • Tends to overdress (e.g., will not allow shirtsleeves pulled up)
  • Avoids crowds (e.g., story time, placement in the middle of a line, birthday party, unfamiliar multi-class activity)
  • Strong food preferences; avoids certain textures of food

Reacts to Vestibular (Movement) Input Differently

  • Craves movement activities such as swings and seesaws
  • Rocks back and forth more than other children, when seated
  • Jumps frequently; runs rather than walking calmly
  • May move around aimlessly
  • Difficulty staying seated at a table; constantly repositioning himself (falls off chair)
  • Fidgets constantly
  • Rejects movement activities; seems fearful of playground equipment
  • Fearful if feet are not on the ground

Reacts to Auditory Input Differently

  • Responds negatively to unexpected or loud noises (fire drill)
  • Difficulty paying attention when there is other noise; cannot ignore it
  • Fails to hear certain sounds
  • Hums constantly
  • Puts hands over ears, or asks you to do it for him/her