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Q. Why do some children avoid watching their hands or look at them only briefly?
A. Task analysis is necessary to discover the cause of poor visual monitoring of hands, since there are so many possible reasons. A child with a strong ATNR will be able to watch only the hand on the face side of the extended arm. If that hand attempts to bring an object to the mouth (finger food or a spoon), the elbow flexion will result in the head turning away. Treatment should aim to improve general midline orientation, symmetry, and bilaterality, which in turn will help integrate the obligatory reflexive pattern. In other cases, many children with multiple disabilities have poor grading of neck muscles for head control. They must maintain the head totally erect or it will flop into flexion. Thus, fixation on their hands or objects is usually fleeting. Long-term goals can include improving head control, but short-term intervention must provide environmental adaptations such as head support and appropriate positioning of objects so eyes can watch hands.

Q. Do children need to follow every step in normal development?
A. Actually, the developmental frame of reference is useful as a guide, not as a rigid course to follow. Many early components of hand development are certainly foundational skills essential for the natural unfolding of the maturation process. For example, weight-bearing in the prone position is crucial to establish integrity of the shoulder joint in preparation for accurate reaching, which places the hand in optimal position for grasp or manipulation.
On the other hand (no pun intended), a normal component such as the digital-pronate grasp may deteriorate into an atypical pattern in a child with distal spasticity whose wrist tends toward flexion and ulnar deviation. We would encourage different grasps that would not feed into the increased tone.

Q. What can we do about self-stimulating repetitive hand movements?
A. Normal infants go through stages of repetitive, reflexive movements such as scratching, clutching, tapping, etc. These patterns are gradually replaced by explorative, accommodative and discriminative movements linked to cognitive awareness and labeling of objects through language. The more mobile the developing child, the more opportunity that child has to seek and receive necessary tactile input. People with cognitive and/or mobility impairments still have strong needs for sensory input and motor output, but since the developmental process is interrupted, they get stuck using primitive patterns to satisfy those needs. Our intervention depends on the specific developmental levels and sensory motor needs of the individual. For example, a child with very low muscle tone and hands that have never accommodated (shaped) to a variety of objects may need manual assistance in exploring the sensory attributes, concurrently with learning the name and use of functional objects. An older child with cognitive delays and problematic self-stim behaviors may need a sensory diet that addresses ways of providing proprioceptive and vestibular input as well as tactile, through selected activities that are age-appropriate and functional, such as scrubbing, vacuuming, hammering, pushing a wheelbarrow, carrying groceries.

Adapted from: Erhardt, R.P. (June 9, 1997). Hand Function Series #1. Hand development: Answers to some common questions. ADVANCE for Occupational Therapists, 13(23) 12.

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