Chapter 10

SELF-CARE AND HAND SKILL

Anne Henderson

CHAPTER OUTLINE activities that are normal for an individual in good

health” (p. 7). Thus they considered self-care perfor-
IMPORTANCE OF INDEPENDENCE IN SELF-CARE mance to be a critical aspect of the health and well-
being of a child, and included the categories of eating,
Importance to the Child dressing, bathing, and toileting. These are the basic
Self-Care in Disability activities of self-care. They, with the inclusion of
MEASUREMENT grooming and hygiene, are the subject of this chapter.
We recognize the equal importance in the health of the
Nonstandardized Measures individual all the functional status activities identified in
Standardized Instruments this chapter as basic, as well as those identified as activ-
FACTORS IN THE ACQUISITION OF SELF-CARE ities of daily living (ADL) and independent activities of
daily living (IADL) skills or self-maintenance skills
Social and Cultural Influences (American Occupational Therapy Association, 1994).
Sex Differences However, it is independence in basic self-care that
Maturation usually is achieved in childhood. The child entering
school is expected to be toilet trained and self-sufficient
Mastery Motivation in eating, dressing, hygiene, and simple domestic tasks.
Motor Factors These self-care activities are among the first achieve-
CHRONOLOGY OF SELF-CARE ACQUISITION ments of childhood, and they provide independence,
social approval, and a sense of mastery for the child.
Eating This acquisition of self-care skills in childhood is
Dressing intricately involved with the development of motor
Hygiene and Grooming skill. The motor skills discussed in this chapter are
limited to those of the hand. We recognize that
DISCUSSION postural control is essential for all self-care and
Hand Skills in Self-Care oral–motor control is essential for eating and refer the
Perceptual Factors in Self-Care reader to several excellent discussions of their role in
basic self-care (Case-Smith, 2000; Shepard, 2001). The
Cognitive and Personality Factors in Self-Care reader must also incorporate the information in this
SUMMARY chapter into an overall framework of physical, mental,
and social development.
The purpose of this chapter is to review what is
The performance of self-care activities is so universal known about the development of self-care in relation to
that its relevance to all aspects of living is often over- the development of hand function. We begin with
looked. Eisen and co-workers (1980) in their Health comments on the importance of self-care, its measure-
Insurance Study conceptualized child health as including ment, and on factors such as culture and personality
physical, mental, and social health. They defined physi- that influence its development. We then present a de-
cal health in terms of functional status, which in turn velopmental overview of eating, dressing, and hygiene
was defined as the “capacity to perform a variety of and grooming behavior and end with a discussion of

193
194 Part II • Development of Hand Skills
hand skills and other factors affecting the achievement
of particular skills.
IMPORTANCE OF INDEPENDENCE
IN SELF-CARE
Children of every society are expected to develop
independence in their performance of everyday living
skills and in most cultures independence is taken for
granted as children reach the appropriate maturational
levels. The universal expectation for competence in self-
care activities is the reason for the emphasis on their
acquisition in rehabilitation and education.
I MPORTANCE TO THE C HILD
A child’s control over the environment comes to a large
degree through mastery of daily activities (Amato &
Ochiltree, 1986). The ability to feed, dress, and care
for toileting needs significantly increases a child’s con-
trol over both home and school environments. For
example, a child who dresses himself or herself does not
have to depend on the convenience of the caregiver.
The child has more control of time, to be dressed with-
out waiting, or delay dressing a bit to complete an
interesting activity.
The ability to meet individual needs without seeking
help can result in feelings of efficacy and control
(White, 1959) and this is a most important con-
sideration in the development of basic self-care. Self-
dependence is an important developmental task in any
culture, the achievement of which wins cultural
approval, and cultural pressures are such that mastery
of a given task leads to satisfaction. Furthermore,
teaching self-care activities provides an opportunity for
caregivers to instill positive self-esteem in young
children.
The observation of emerging independence in a
child has been called “an early joy of parenthood”
(Coley & Procter, 1989, p. 260). In the United States
children are encouraged and praised for self-sufficiency,
with the result that most want to be independent and
feel a sense of pride in mastery (Gordon, 1992). Young
children often announce achievements such as tying a
bow or buckling a shoe to family and friends, often
wanting to demonstrate their new skill. When parents
actively encourage and teach children to care for them-
selves, they are fostering the development of compe-
tence (Maccoby, 1980). Furthermore, young children
demand independence: “I can do it myself.” This
insistence on self-sufficiency in performing activities
begins during the second year of life (Geppert &
Kuster, 1983) and has been related to the development
of volitional behavior (Bullock & Lutkenhaus, 1988).
Volition implies action in which the achievement of a
goal is seen as resulting from one’s own activity.
SELF-CARE IN DISABILITY
The timely achievement of abilities in self-care tasks is
important in the daily life of all children in the US
culture and the inability to perform a skill is a major
barrier to school and home living for children with
special needs. In the development of a child’s potential
“acquiring daily living skills may be as important as academic
qualifications” (Gordon, 1992, p. 97).
The degree of disability in self-care among children
with special needs varies with type and degree of
impairment both within and among disabilities. In a
London school district a survey conducted of special
needs children (primarily with cerebral palsy or
multiple handicaps) reported that about 65% needed
help in dressing and 25% in eating (Inglis, 1990). A
study of young adults with cerebral palsy also reported
a high degree of continuing dependence: Fewer than
half were independent in basic self-care (Senft et al.,
1990). As expected, these researchers found a greater
degree of dependence in persons with quadriplegia:
The majority of persons with hemiplegia were indepen-
dent. Another study of young persons with hemiplegic
cerebral palsy found most had achieved mastery in
self-care, including the bimanual activities, but some
expressed reluctance to perform them because the
adaptive method made them look different (Skold,
Josephson, & Eliasson, 2004).
Children with developmental coordination disorder
usually are evaluated for achievement in drawing, writing,
and schoolwork. Less attention has been given to their
self-care needs, but descriptive studies have shown that
their impaired motor abilities sometimes interfere with
eating and dressing independence (Gubbay, 1975;
May-Benson, Ingolia, & Koomar, 2002; Walton, Ellis,
& Court, 1962). The possible delay in self-care acquisi-
tion is now considered one criterion for diagnosis of
the disorder (American Psychiatric Association, 1994;
Cermak & Larkin, 2002).
Many disabilities of childhood interrupt the typical
sequence of independent performance in self-care skills.
Their importance in early childhood in the presence of
a disability sometimes is underestimated because infants
and preschool children are naturally dependent and
easy to tend. Parents may not be too concerned about
delays in activities such as dressing, but as a child grows
and siblings are born, extended dependency can add
significantly to the stress within a household (Wallander,
Pitt, & Mellins, 1990).

Research has demonstrated that life outcomes in
social and work situations of young adults with con-
genital handicaps appear to be related to their indepen-
dence in self-care. For example, Wacker and co-workers
(1983) reported that the variables most strongly related
to satisfaction with life outcomes were the individuals’
perception of their independence in self-care and
mobility. Christiansen (2000) has noted that being able
to conform to societal expectations for self-care is integral
to overall feelings of life satisfaction. Self-dependence
in everyday tasks is important to everyone, and no less
so for children whose achievement is interrupted by
disability
MEASUREMENT
NONSTANDARDIZED M EASURES
Since the early years of the profession, therapists have
been concerned with the assessment and treatment of
dysfunctional self-care performance. One of the first
known checklists of self-care performance was published
in 1935 (Wolf, 1969); since that time assessment of
function has been traditional in both occupational and
physical therapy. Assessment forms were published
from time to time in the early years, but more often
treatment settings designed forms to meet the needs of
their particular caseloads and treatment settings.
Developmentally oriented functional assessments
that incorporated information on child growth and
development came into use in the 1940s, and devel-
opmental scales that included basic self-care were
published a few years later. For example, an upper-
extremity motor development test that included age-
keyed items on feeding, dressing, and grooming, as
well as hand use, was developed at the New York State
Rehabilitation Hospital (Miller et al., 1955). Such
instruments used information on ages at which children
typically master skills, and grouped the skills by the age
at which achievement might be expected.
One of the reasons therapists have continued to con-
struct their own instruments is because of the need for
greater detail in planning treatment programs for dif-
ferent disabilities. Breakdown of self-care activities is
different for a child with a congenital amputation,
cerebral palsy, spina bifida, or mental retardation. Both
center-made and published scales are designed for day-
by-day guidance of intervention and are as detailed
as available knowledge allows. Some published non-
standardized instruments have been designed for
specific disability areas. For example, a comprehensive
tool for evaluating children’s self-sufficiency in self-care
activities was developed by the Occupational Therapy
Department at Children’s Hospital at Stanford,
Self-Care and Hand Skill • 195
California (Bleck & Nagle, 1975; Coley, 1978)
primarily for use in cerebral palsy patients.
Developmental scales providing standardized admin-
istration and some reliability of scoring also have been
published (Brigance, 1978; Vulpe, 1979). The estimated
ages at which the tasks and subtasks are accomplished
are derived from multiple sources that are identified in
the manuals. Sources include intelligence tests, devel-
opmental tests, and research studies. Because these tools
were intended as a guide for the sequential learning of
self-care and other developmental skills, they include
multiple steps in achievement. The purpose of these
assessments is to provide an intervention guide and an
ongoing inventory of a child’s progress and achieve-
ments in all developmental areas. The developmental
assessment published by Vulpe has a particularly
detailed section on self-care.
Published and unpublished center-made measures
such as those described have been in wide use. The
advantage of center-made instruments is that they can
be designed for the needs of particular children in
particular settings. The disadvantage is that assessment
information cannot be generalized to other disabilities
or settings and the semiformal methods of adminis-
tration make it difficult to ensure reliability among
different therapists, even when a standardized method
of evaluating each item has been developed. Change
in a child’s skill or the lack thereof might reflect
differences between therapists rather than changes in
performance.
STANDARDIZED I NSTRUMENTS
Derived normative age information for developmental
scales is at best only fairly accurate, and the information
on individual children is descriptive only. Meaningful
overall scores are not obtainable because there is no
way of weighing individual items. Therefore they are
not appropriate for use in research or the documen-
tation of overall progress.
Two pediatric assessments designed for the func-
tional evaluation of children with disabilities and the
reliable documentation of change were developed and
standardized in the 1990s and are now in wide use in the
United States, as well as in other countries. They are
the Wee Functional Independence Measure (WeeFim)
(State University of New York at Buffalo, 1994) and
the Pediatric Evaluation of Disability Inventory (PEDI)
(Haley et al., 1992). Both include sections on basic
self-care and have been demonstrated to be valid and
reliable (Ottenbacher et al., 2000). The two instru-
ments are highly correlated (Ziviani et al., 2001): Each
has its advantages. The PEDI gives more depth of
information but the WeeFim is easier and faster to
administer.
196 Part II • Development of Hand Skills
The WeeFim evaluates functional independence of
children ranging in age from 6 months to 7 years and
is simple and fast to administer. Seven of the 18 items
are self-care and the scale yields a single score for the
level of independence in each of the domains of eating,
grooming, bathing, dressing upper body, dressing lower
body, and toileting. The instrument is being validated
in other countries; for example, in Japan (Liu et al.,
1998; Tsuji et al., 1999) and China (Wong et al.,
2002).
The PEDI evaluates self-care, mobility, and social
function in much greater detail than the WeeFim. The
items in basic self-care provide considerable informa-
tion on a child’s abilities and include the following
areas: eating different food textures; use of utensils; use
of drinking containers; tooth brushing; hair brushing;
nose care; hand washing; washing body and face;
pullover/front opening garment; fasteners, pants,
shoes/socks; and toileting tasks.
The PEDI has several strengths as a measurement
tool for children. It has been carefully standardized and
yields a total score that can be used to measure the
overall progress of children with disabilities. Age
expectations are given both for overall independence in
separate domains and individual items. The user can
select the level of expectation desired, such as the age
range at which 10%, 25%, 50%, 75%, or 90% of children
without disabilities demonstrate mastery. The PEDI
has been validated for use in other cultures, including
Puerto Rico (Gannotti & Cruz, 2001). Research has
shown that the PEDI can be used to document gain in
self-care (Dumas et al., 2001).
In summary, the selection of a measurement tool
needs to be based on the major purpose of the tool. If
multiple purposes are to be met, more than one tool
should be used. Possible purposes are (a) diagnostic-
remedial, that is, to provide a blueprint for selecting
and sequencing treatment activities; (b) description of
self-care performance for communication with parents
and professionals; (c) charting the acquisition of self-
care skills; and (d) evaluating the effects of treatment.
Both center-made and published but not standardized
evaluation instruments can be used for the first three
purposes; only standardized instruments are appropriate
for the fourth.
FACTORS IN THE ACQUISITION
OF SELF-CARE
Our knowledge of the factors that influence the devel-
opment of basic self-care is based more on common
knowledge derived from the experience of caregivers
than on research. However, most agree with the state-
ment made by Key and co-workers (1936) about
dressing; that learning is influenced by chronological
age, mental age, the child’s interest, the amount of
guidance given, and the type of clothing worn.
Whether or not these factors are supported by research,
social, psychological, and physical factors, as well as
gender and maturation, clearly play a part in skill
acquisition.
SOCIAL AND C ULTURAL I NFLUENCES
Gesell and Ilg (1943) considered the development of
feeding behavior in the infant to be a
“story of progressive self dependence combined with cultural
conformance” (p. 317).
The broad culture and expectations of the home and
preschool all determine the degree and timing of a
child’s mastery of basic self-care skills.
With the development and standardization of self-
care instruments in the United States, researchers in
other countries have conducted studies to determine
whether the measures can be used in their populations
(Gannotti & Cruz, 2001; Wong et al., 2002). Studies
also have provided information about differences
between countries in ages of self-care acquisition.
For example, younger Chinese children scored better
than U.S. children in self-care on the WeeFim (Wong
et al., 2002) and Puerto Rican children developed
some self-care skills later (Gannotti & Handwerker,
2002).
The timing of the mastery of self-care activities
depends on the expectations for the child and these
expectations differ among cultures. The U.S. culture
places high value on self-sufficiency, so that child-
rearing practices emphasize early independence. Many
other cultures place a higher value on family inter-
dependence, for example, in Puerto Rico child-rearing
practices include later teaching of skills such as self-
feeding (Gannotti & Handwerker, 2002).
An obvious cultural factor is in the difference in food
practices. In India food is eaten with the hand; in the
United States utensils are used, and in Asian countries
children use chopsticks. These three methods of self-
feeding require different hand skills. Hand feeding
requires less motor maturation than the use of a spoon,
which in turn requires less motor maturation than
chopsticks. The spoon is grasped in the fist and can be
carried to the mouth with the forearm pronated and
the arm abducted, but chopsticks require individuation
of the fingers and supination of the forearm. Another
difference is the way in which knives and forks are used.
In the United States, one scoops and spears with a fork
and cuts meat with the knife in the right hand, then

switches utensils to continue eating. In some European
countries the knife is used in the right hand to pile food
on the back of the fork, which is then carried to the
mouth with the left hand. These differences may
influence the sequence and timing of self-sufficiency in
self-feeding.
Differences in dressing styles must certainly influence
skill attainment. In some cultures children go naked
until they are toilet trained. In the United States the
emphasis on early self-sufficiency has led to inventions
in clothing style. For example, draw-down diapers
foster an earlier independence in going to the toilet,
and Velcro fasteners make the preschool child self-
sufficient in putting on shoes and outer clothing.
Individual families also influence the performance of
everyday skills. In this author’s experience in Mexico,
many families with maids did not permit children to use
spoons until they were able to do so without spilling;
bibs were not used beyond early infancy. Wong and co-
workers (2002) also reported that the presence of a
maid in the home led to later achievement of self-care.
Another example of family influence is on a child’s
tidiness in eating. Bott and co-workers (1928) won-
dered why a child who was above average on most
measures was so far below age expectations in eating.
On questioning the parents they discovered that,
because they thought the child was too young to eat
well, they had made no attempt to correct him. When
the expectations for the child were raised at home, his
score rose to age levels within 2 weeks. Such differences
in attitudes result in differences in the timing of the
child’s mastery of basic skills.
Two studies have investigated family factors
influencing competence in household tasks. A study by
Zill and Peterson (cited by Amato & Ochiltree, 1986)
found that the best predictor of performance on tasks
such as washing dishes without help was the frequency
of joint family activities. They also found that family
size was related to competence in such skills. Large
families may require more practical assistance from
their children in chores, and younger children are able
to learn from older children. The family variables found
by Amato and Ochiltree (1986) to foster the acquisi-
tion of practical skills were frequent interaction of
family members and the requirement that the children
take responsibility for chores.
In summary, cultural, class, and family variables
influence the timing of the acquisition of independence
in self-care in young children. For the most part
societal expectations do not vary in respect to the need
for eventual development of independence, but
behavior in childhood may signify cultural and parental
patterns rather than a child’s intrinsic abilities. Aware-
ness of such patterns is important in assessment and
goal setting.
Self-Care and Hand Skill • 197
SEX DIFFERENCES
Early literature reported several differences between
girls and boys in the age at which self-care skills are
acquired. Gesell and Ilg (1943) wrote that boys
demand independence in dressing at a younger age
than girls. Key and co-workers (1936) reported
tentative sex differences in dressing ability between 21⁄2
years and 41⁄2. Girls were more skillful than boys and
tended to dress faster, and the ability of boys generally
was more variable than that of girls. Sources of the
differences in the ages at which dressing skills are
achieved have been proposed. It has been thought that
girls dress themselves earlier than boys because their
wrists are more flexible, they are better coordinated,
and they wear simpler clothing (Coley, 1978; Gesell et
al., 1940; Key et al., 1936). A difference also has been
reported in the use of eating utensils in self-feeding
(Gesell & Ilg, 1943). Girls shifted to an adult grasp
earlier than boys, some as early as 3 years. Some boys,
on the other hand, continued to use a pronated grasp
at 8 years of age. Boys also were reported to sometimes
demand to feed themselves before they were competent
to do so.
One recent study has also shown a difference between
the sexes. In China, younger girls were reported to score
higher than boys on the self-care subscores of the
WeeFim (Wong et al., 2002). However, no sex differ-
ences in overall functional ability were found in research
in the United States on the PEDI (Haley et al., 1992).
MATURATION
Although culture and family expectations play a role, it
seems clear that the greatest factor in the achievement
of self-care skill in childhood is maturation. Certainly
Gesell and his associates thought so, and self-care items
are prominent in his developmental diagnosis (Gesell &
Amatruda, 1965). This supposition was borne out by
the research of Key and her associates (1936), who
found the correlation between dressing ability and
chronological age to be considerably higher than that
for mental age or any other factor. Furthermore, the
composite score of self-care, mobility, and social
functions of the PEDI showed high and significant
correlation with age but not with demographic
variables.
MASTERY MOTIVATION
The concept of mastery motivation has its roots in the
writings of Robert White (1959), who proposed that
the development of competence in young children
grew out of a pleasurable sense of efficacy when they
successfully manipulated objects. The toddler and
198 Part II • Development of Hand Skills
preschool years are important periods in this
development of goal-oriented behavior, and wanting to
be self-sufficient in the performance of early eating and
dressing skills is one expression of effectance or mastery
motivation (Bullock & Lutkenhaus, 1988; Geppert &
Kuster, 1983). Early anecdotal accounts of achieve-
ment in self-care performance indicated that interest,
self-reliance, and perseverance were important attributes.
Wagoner and Armstrong (1928) found success on a
buttoning task was correlated with teacher ratings of
perseverance. Key and her associates (1936) reported
that interest in dressing develops with ability in 2-year-
old children and that enjoyment increased as mastery
improved. However, at 3 years they found that interest
shifted to desire for approval and achievement and also
found wide differences among the children in the
development of self-reliance and the perseverance
needed for the performance of the more difficult tasks.
These findings were based on analysis of the children’s
comments while they were dressing.
Recent studies in mastery motivation have focused
on its relationship to many different child factors such
as cognition (Hauser-Cram et al., 2001) and parent
factors such as negative and positive maternal behaviors
(Kelley, Brownell, & Campbell, 2000). These recent
studies measure mastery motivation in a test situation,
usually with puzzles graded in difficulty so that they
provide a challenge for the level of each child. A
longitudinal study of particular interest for this chapter
showed that children with disability who scored higher
levels of mastery motivation at 3 years of age achieved
greater independence in self-care at 10 years (Hauser-
Cram et al., 2001). These researchers found mastery
motivation to be important both for the development
of a child and for the well-being of the parent.
MOTOR FACTORS
Coley (1978) identified sequences of gross and fine
motor development leading to independence in self-
care tasks. Examples of necessary gross motor abilities
needed for dressing are reaching above the head or
behind the back while maintaining trunk stability. Self-
feeding requires head and mouth control, as well as
trunk stability. Coley identified steps in the motor
control leading to many individual self-care skills, and
they are discussed within each self-care domain. They
include bilateral skills, finger manipulation, and tool
skills. Children learn one-handed skills before bilateral
skills, and some skills are achieved later because of
the need for the two hands to work together. An early
example is holding a bowl with one hand while
scooping with the other. Children become functional
in the performance of skills during their preschool
years, but complete independence and adult levels of
speed and precision require a long developmental
period. One indication of the automatization of a skill
that occurs at about 4 years of age is when children can
feed and dress themselves while carrying on a
conversation (Hurlock, 1964; Klein, 1983).
Many self-care activities require the use of tools
(Castle, 1985). Tools are defined here as a means of
effecting change in other objects. The earliest self-care
tools are for eating: spoons, knives, forks, and cups.
Self-care in hygiene includes tools such as brushes,
combs, and washcloths. Dressing fasteners, zippers,
snaps, and buttons also can be considered tools. The
use of most tools is complex because it involves the
manipulation of one object relative to another, which
results in the change of state of one or both objects
(Parker & Gibson, 1977). The use of tools is goal
directed by definition and requires the understanding
of a means–end relationship. Even the use of a simple
tool such as a spoon requires both the understanding
of purpose and the motor skill to use it. However, as
children mature, their understanding often moves
ahead of their manipulative skill. In general, learning to
use tools is acquired later than self-care without tools.
CHRONOLOGY OF SELF-CARE
ACQUISITION
The following pages present developmental patterns
and the ranges of ages in which typical children learn
to care for their own daily needs. This information is
presented as a summary of what is currently known
about the chronology of the acquisition of skill in self-
care as a source for the understanding of the process by
which skills are acquired. The immediate purpose is to
allow a preliminary analysis of the relationship of the
acquisition of self-care skills to the development of
hand skills. The information that follows has been com-
piled from different sources to provide as much detailed
information as possible. The child’s attempts at perfor-
mance are included because they show an under-
standing of the task, and the practicing of subskills
reflects motor abilities. The developmental information
in the following discussion is organized into the do-
mains of eating, drinking, dressing, personal hygiene,
grooming, and simple household tasks. The items listed
in the charts are steps in the learning of self-care that
various authors have observed and reported. We have
no definitive information as to the universal consistency
of the sequences presented: They are based on reports
of ages at which children are usually self-sufficient in
discrete skills.
The area of research that has provided the most
information on the acquisition of specific self-care skills

over the years has been the area of development of
evaluation tools. Two such primary sources of infor-
mation were used to chart the general ages at which
skills are achieved. The first source is the PEDI (Haley
et al., 1992). As has been noted, this instrument includes
extensive sections on basic self-care and provides the
most reliable information available on the ages at which
many skills are achieved. The ages noted in the tables
from the PEDI indicate a group in which more than
75% of the children were reported to have achieved
independence.
The works of Gesell and his associates also were a
primary source. Data on the ages at which children
developed specific self-care skills were collected by many
different methods over many years. The results of most
of their observations were incorporated into overviews of
development (Gesell & Amatruda, 1965; Gesell & Ilg,
1943, 1946; Gesell et al., 1940). They were interested
in information that would assist in the diagnosis of
developmental delay and to that end selected different
sorts of behaviors expected at each age level. The
behaviors selected have provided information on the
acquisition of basic self-care skills for many years.
Several secondary sources also were used. Following
the lead of the Yale Developmental Clinic, self-care
items were and continue to be included in many
developmental evaluations. The primary and secondary
sources used for the tables were Coley (1978),
Brigance (1978), Vulpe (1979), Haley and co-workers
(1992), Gesell and Ilg (1943, 1946), and Key and co-
workers (1936).
It must be emphasized that the ages listed from
these sources are only approximate, are not necessarily
derived the same way, and reflect different levels of
expectations. As has been noted, family, social, and
cultural values influence expectations for independence
in self-care skills and these expectations result in
individual differences in skill acquisition. Furthermore,
it must be recognized that even within a homogeneous
group the age at which children master self-care skills is
highly variable. An important finding of the PEDI
research was that there is a wide age range, sometimes
as much as 3 to 4 years, over which individual children
achieve a particular skill. A recent study of the develop-
ment of feeding behaviors also found a wide range of
ages at which self-feeding skills occur (Carruth &
Skinner, 2002). The data in the following tables are
best interpreted as the age range at which many, but
not all, typical children in the United States perform
under optimum circumstances.
EATING
The progress of a child’s self-feeding behavior requires
both the acquisition of skill in the use of eating utensils
Self-Care and Hand Skill • 199
and conformity to cultural standards. In typically
picturesque speech, Gesell and Ilg (1943) described
this progression:
“At 36 weeks he can usually maintain a sustained hold on the
bottle. In another month he may hold it up and tilt it with the
skill of a cornetist. He can feed himself a cracker. At 40 weeks,
he also begins to finger feed, plucking small morsels. … He also
handles his spoon manfully [by 15 months] and begins to feed
himself in part, though not without spilling, for the spoon is a
complex tool and he has not acquired the postural orientations
and pre-perceptions necessary for dexterity. … At 2 years, he
inhibits the turning of the spoon as it enters the mouth and feeds
himself acceptably. … At 31⁄2 years he enjoys a Sunday breakfast
with the family. … At 5 years … he likes to eat away from home
especially at a restaurant. He is more a man of the world!”
(pp. 318–319).
Finger feeding and the use of a cup are early
accomplishments and the basic components of self-
feeding with a spoon—filling the spoon, carrying it to
the mouth without spilling, and removing food—are
well mastered by 3 years of age. However, self-feeding
takes concentration, and it is not until after the third or
fourth year that the skill is sufficiently automatic to
allow eating and talking at the same time (Hurlock,
1964). The 5-year-old is skillful but slow. Skill con-
tinues to improve, for it is not until 8 or 9 years of
age that the child has become deft and graceful
(Gesell & Ilg, 1946), and it is not until 10 years that
self-feeding is accomplished entirely independently,
with good control and attention to table manners
(Hurlock, 1964).
Finger Feeding
Self-feeding with the fingers begins in the second half
of the first year. Table 10-1 shows the development of
the skill, which parallels the infant’s acquisition of hand
skills. Initial feeding is of crackers held in the hand and
sometimes plastered against the mouth with the palm
and with the forearm supinated. As finger skill
develops, bite-size pieces of food are picked up and put
into the mouth with a pincer grasp. Even when spoon
use has become skillful, children prefer to use fingers
for discrete pieces of food such as peas or meat (Gesell
& Ilg, 1943).
Drinking from a Cup or Bottle
Independent drinking from a cup is an early developing
skill as long as safeguards are taken. The use of spout
cups with lids allows a child to drink from a cup, as well
as a bottle in the second half of the first year of life.
Table 10-2 shows the progress of skill in drinking. Cup
drinking begins with the same bilateral whole hand
grasp used for the bottle and progresses to the dexterous
grip of one hand on the handle at 3 years of age.
200 Part II • Development of Hand Skills

Table 10-1 Eating finger foods

Skill Age Source

Picks up finger foods and eats 6 mo–1 yr Haley et al. (1992)

Feeds self cracker, whole hand grasp 6–7 mo Coley (1978)

Feeds self spilled bits from tray 9 mo Gesell and Ilg (1943)

Feeds self finger foods, pincer grasp 10 mo Coley (1978)

Finger feeds part of one meal 1 yr Gesell and Ilg (1943)

Takes bite-size pieces from plate, delicate grasp, 1 yr Coley (1978)

appropriate force, with demonstrated release

Table 10-2 Self-feeding: drinking from cup or bottle

Skill Age Source

Holds and drinks from bottle or spout cup with lid 6 mo–l yr Haley et al. (1992)

Tips bottle to drink 10 mo Gesell and Ilg (1943)

Lifts open cup to drink, some tipping 11⁄2–2 yr Haley et al. (1992)

Holds cup alone, hands pressed on side 1 yr Gesell and Ilg (1943)

Grasps with thumb and fingertips 1 yr 3 mo Gesell and Ilg (1943)

Holds cup and tilts by finger action 1 yr 3 mo Gesell and Ilg (1943)

Lifts open cup securely with two hands 11⁄2–2 yr Haley et al. (1992)

Lifts cup to mouth, drinks well, may drop 11⁄2 yr Coley (1978)

Holds cup well, lifts, drinks, replaces 1 yr 9 mo Coley (1978)

Holds cup or glass with one hand, free hand poised to help 2 yr Gesell and Ilg (1943)

Lifts open cup to drink with one hand 3–31⁄2 yr Haley et al. (1992)

Cup held by handle, drinks securely, one hand 3 yr Gesell and Ilg (1943)

Use of Utensils
Table 10-3 shows the chronology of the development
of the use of spoons, forks, and knives. The many years
necessary for learning to use utensils reflects the
complexity of their use, particularly the knife and fork
in cutting. The infant begins eating with a spoon held
in a fisted grasp, with the arm pronated and shoulder
abducted. The adult finger grip, with forearm supina-
tion and rotation as needed, requires more fine motor
control and dexterity (Haley et al., 1992) but does not
develop until approximately 3 years in girls (Gesell et
al., 1940); some boys continue to use a pronated
pattern at 8 years (Gesell & Ilg, 1946). The fisted grasp
appears again in the use of forks and knives in cutting.
It appears that the force needed for holding and cutting
requires the power of the whole hand and the necessary
power combined with the finger dexterity for cutting is
not developed until a child is about 10 years old.
Studies of Spoon Use
The spoon is the first tool used by most infants
(Connolly & Dalgleish, 1989). Several studies of spoon
use have been reported, two involving infants and one
preschool children. The earliest study was of nursery
school children’s eating behavior (Bott et al., 1928).
The eating behaviors included in the study were (a) the
proper use of utensils, (b) putting the proper portion of
food on a utensil, and (c) coordination, as indicated by
minimal spilling. They found improvement with age in
all these behaviors, but the behaviors differed as to
when they improved. The use and filling of the utensils
improved primarily between 2 and 3 years of age, but
spilling decreased more between 3 and 4 years.
A cinemagraphic study of infant eating behavior
conducted by Gesell and Ilg (1937) described both
prespoon activity and early spoon use. Preparation for
using the spoon began when a child was being fed.
Between 3 and 6 months of age the child watched the
spoon, and soon mouth opening began in anticipation
of the spoon reaching the mouth. Later, head move-
ments began with movement of the head toward the
spoon and then away as food was removed. Whereas
initially food was put in the mouth by the adult’s
manipulation of the spoon, the child later removed
food by lip compression. These movements of the head
and lips were considered to make later spoon manipu-
lation more effective.
Gesell and Ilg noted that even as simple a tool as a
spoon requires a sequence of perceptual and motor
acts. One act is the discriminative grasp of the spoon
handle. Infants first grasped the lower third of the
handle, later the middle to upper third, and finally the
end. Grasp was at first palmar, with the thumb wrapped
around the spoon, but later the thumb was placed
Self-Care and Hand Skill • 201
along the handle. The adult grasp usually was not seen
until 3 years of age. A second perceptual and motor act
is the filling of the spoon. At first the bowl of the spoon
is merely dipped in the dish, often with the spoon
handle perpendicular. Filling began with a rotary move-
ment toward the body, and it was not until 16 months
that children began filling the spoon by inserting its
point into the food. Lifting the spoon was at first
accomplished with the arm pronated, and often with
the bowl of the spoon tipping. By the end of the
second year children were lifting their elbows and
flexing their wrists. The insertion of the spoon into the
mouth also changed from the side into the mouth to
the point into the mouth.
The third study reported by Connolly and Dalgleish
(1989) confirmed many of the findings of Gesell and
Ilg. They conducted a comprehensive videotape study
on the longitudinal development of spoon use. The
research procedure was more formal, and the study
can serve as a model for the investigation of the learn-
ing of complex motor skills. The authors first presented
an analysis of spoon use that included both intentional
and operational aspects. The task was described as
entailing:
“… (a) an intention to eat, which involves the child’s motiva-
tion; (b) some knowledge about the properties of the spoon as an
implement with which to effect the transfer of food from dish to
mouth; (c) the ability to grasp and hold the spoon in a stable con-
figuration; (d) the loading of food onto the spoon; (e) carrying the
loaded spoon from dish to mouth; (f) controlling the orientation
of the spoon during this transfer to avoid spillage; and (g) emp-
tying the spoon and extracting it” (p. 897).
On the basis of this analysis, Connolly and Dalgleish
conducted a longitudinal videotape study of the devel-
opment in the operation of a spoon during the second
year of life. Among their descriptions was an analysis of
change in the action sequences from only two actions
to a complex sequence that included corrections. The
actions of putting a spoon in and out of a dish and
putting the spoon in and out of the mouth initially
were unconnected. Box 10-1 shows the progression
and change of action sequences in using the spoon.
This change in action sequences seems to indicate that
the child was learning skill both in the performance of
single actions and in the use of complex movement
sequences. Connolly and Dalgleish also report other
changes in motor actions, such as a smoothing of the
trajectory of the dish-to-mouth path, and the shifting
of the angle at which the spoon was placed from side
toward mouth, to point toward mouth. Children used
primarily a palmar grasp: the wrist, shoulder, and elbow
movements also were described.
202 Part II • Development of Hand Skills

Table 10-3 Self-feeding: use of utensils

Skill Age Source

SPOON
Grasps spoon in fist 10–11 mo Gesell and Ilg (1943)

Dips spoon in food, lifts to mouth 1 yr 3 mo Gesell and Ilg (1943)

Fisted grasp, pronated forearm, turns spoon 1 yr 3 mo Coley (1978)

Scoops food, lifts with spilling 11⁄2–2 yr Haley et al. (1992)

Fills spoon, turns in mouth, spilling 11⁄2 yr Coley (1978)

Spoon angled slightly toward mouth 11⁄2 yr Gesell and Ilg (1943)

Tilts spoon handle up as removes from mouth 11⁄2 yr Gesell and Ilg (1943)

Uses spoon well with minimal spilling 2–21⁄2 yr Ha1ey et al. (1992)

Point of spoon enters mouth 2 yr Gesell and Ilg (1943)

Inserts spoon into mouth without turning 2 yr Gesell and Ilg (1943)

Fills by pushing point of spoon into food 2 yr Gesell and Ilg (1943)

Grasps spoon with fingers (girls supinate) 3 yr Gesell and Ilg (1943)

Fills spoon by pushing point or rotating spoon 3 yr Gesell and Ilg (1943)

Holds spoon with fingers for solid foods 4 yr Coley (1978)

Eats liquids, spoon held with fingers, few spills 4–6 yr Coley (1978)

FORK
Spears and shovels food, little spilling 2–21⁄2 yr Ha1ey et al. (1992)

Fork held in fingers 41⁄2 yr Co1ey (1978)

KNIFE
Uses for spreading 5–51⁄2 yr Ha1ey et al. (1992)

Spreads with knife 6–7 yr Coley (1978)

Uses to cut soft foods (sandwich) 5–51⁄2 yr Ha1ey et al. (1992)

Cuts meat with knife 7–8 yr Coley (1978)

Uses utensils deftly and gracefully 8 yr Gesell and Ilg (1946)


BOX 10-1 Progression of Action Sequences
in Using the Spoon
The first purposeful sequence was five steps:
1. Spoon to dish
2. Remove from dish
3. Lift to mouth
4. Put in mouth
5. Remove from mouth
Later, two more actions were added:
Filling the spoon
Removing food with lips
The final action sequence included 11 steps that
incorporated monitoring and correction through
repetition of sequences:
1. Control of spoon
2. Spoon to dish
3. Steady dish with other hand
4. Remove spoon from dish
5. Check to see if there is enough food on spoon (if
not, repeat 2 to 4)
6. Lift spoon
7. Put spoon in mouth
8. Empty spoon with lips
9. Remove from mouth
10. Check to see if spoon is empty (if not, repeat 7 to 9)
11. Pick up spilled food (repeat 6 to 8)
Connolly K, Dalgleish M (1989). The emergence of a
tool-using skill in infancy. Developmental Psychology,
25(6):894–912.
Serving and Preparing Food
A part of independence in eating is serving oneself and
preparing foods. Table 10-4 shows that by the time
children enter school they can take care of simple
preparation and self-service of food and drink. In
the preschool years children also begin to help with
simple household chores such as setting the table (3 to
4 years), putting away silverware (2 years), and wiping
up spills (3 years) (Gesell & Ilg, 1943).
One of the expectations of the nursery school
children studied by Bott and co-workers (1928) was
that their feeding area be cleaned up after they ate. At
the age of 2 the children left the table, chair, and floor
clean after eating in 45% of the observations. By the age
of 4 years the percentage had increased to 85%. This
change undoubtedly reflects the influence of nursery
school expectations, as well as maturation.
DRESSING
The development of self-care in dressing, undressing,
and managing fasteners also parallels and depends on
the development of hand skills. A fisted grasp is suffi-
cient for the tasks of removing hat and socks. Pulling
up pants requires more strength and bilateral coordina-
tion than pushing them down and kicking them off.
Self-Care and Hand Skill • 203
Individual finger function comes into play in loosening
laces, and full independence in dressing requires com-
plex finger manipulation of buttons and ties. The need
for finger dexterity and planning sequences underlies
the slow acquisition of management of fasteners.
Key and her associates (1936) studied the process of
learning to dress among 45 nursery school children,
ages 11⁄2 to 51⁄2 years. Overall dressing ability was highly
correlated with chronological age. They reported the
learning process to be continuous, increasingly dif-
ficult, and unstable, and that the most rapid period of
learning was between 11⁄2 years and 21⁄2 years. Overall
success rates increased over the ages studied as follows:
11⁄2 years, 40%; 2 years, 50%; 21⁄2 years, 80%; and 31⁄2
years to 51⁄2 years, 90%. Other authors also have
reported that dressing skills develop rapidly between
11⁄2 and 31⁄2 years (Gesell et al., 1940).
Self-help in putting on and removing clothes is
highly dependent on the type of clothing worn (Key et
al., 1936). The variability in the age of acquisition is
undoubtedly in part a result of the type of clothes
selected for children by their caregivers. Characteristics
of clothing that facilitate self-dressing include loose
tops with large neck openings and loose pants with
elastic tops and loose cuffs. The type and size of
fasteners should be appropriate for children and they
should be in reasonable locations (front or side). How-
ever, it should be noted that peer fashions may be
important even for young children and compromises
may be needed.
The overall development of dressing skill proceeds
from undressing, to dressing without fastening, to
managing fasteners. Taking off an item of clothing is
easier than putting it on because putting on clothing
is more complex both motorically and perceptually.
For example, socks slip off easily, but the coordination
between the two hands and between hands and feet
together are needed for putting socks on. Moreover,
the sock must be rotated correctly to match its heel to
the heel of the foot. Information on the chronology of
dressing is presented in four areas: antecedents of
dressing skills, undressing without fasteners, dressing
without fasteners, and managing fasteners.
Antecedents of Dressing Skills
Table 10-5 lists average ages at which children achieve
abilities necessary for dressing. The earliest interaction
with clothing, such as clutching and pulling at clothing,
is meaningless in respect to self-care but demonstrates
the ability to grasp. The early removal of hats and socks
is also hardly purposeful undressing because it is just as
likely to occur during dressing as undressing. Never-
theless, these actions demonstrate motor sequences
that will later be used purposefully.
Researchers have chronicled infant beginnings of
cooperation and assistance in dressing (Gesell & Ilg,
204 Part II • Development of Hand Skills

Table 10-4 Serving and preparing food

Skill Age Source

PREPARES FOOD
Unwraps food 11⁄2–2 yr Vulpe (1979)

Opens jars 2 yr Gesell and Ilg (1943)

Fixes dry cereal 4–5 yr Vulpe (1979)

Serves self 4–5 yr Vulpe (1979)

Makes sandwich 7 yr Brigance (1978)

Prepares baked potato 8 yr Gesell and Ilg (1946)

PREPARES DRINKS
Pours from small pitcher 2–21⁄2 yr Vulpe (1979)

Obtains drink from tap 3–31⁄2 yr Gesell and Ilg (1943)

Pours from large pitcher or carton 4–41⁄2 yr Haley et al. (1992)

Carries glasses without spilling 6 yr Brigance (1978)

OTHER SKILLS
Uses napkin 4 yr Brigance (1978)

Sets table with help 21⁄2–3 yr Vulpe (1979)

Wipes up spills 3 yr Gesell and Ilg (1943)

Sets table without help 4–5 yr Vulpe (1979)

 Self-Care and Hand Skill • 205

Table 10-5 Antecedents of self-dressing skills

Skill Age Source

REACH AND GRASP

Clutches and pulls clothing Up to 3 mo Vulpe (1979)

Pulls off hat 6 mo Vulpe (1979)

Pulls off booties 6–9 mo Gesell and Ilg (1943)

Pulls off socks 9–10 mo Vulpe (1979)

COOPERATION
Passive (lies still) 3–6 mo Vulpe (1979)

Holds arm out 9 mo Coley (1978)

Lifts foot for shoe or pants 11⁄2–2 yr Haley et al. (1992)

Attempts skill

Tries to put on shoes 14–18 mo Vulpe (1979)

Tries to assist with fasteners 2–21⁄2 yr Haley et al. (1992)

Helps push down pants 2 yr Coley (1978)

Interested in lacing 21⁄2–3 yr Vulpe (1979)

TRUNK STABILITY
Reaches to toes 1 yr 4 mo Coley (1978)

Reaches above head bilaterally/unilaterally 2–5 yr Coley (1978)

Reaches behind back, hands together 3–6 yr Coley (1978)

Reaches behind head, hands together 4–6 yr Coley (1978)

206 Part II • Development of Hand Skills

1943). These early actions of pushing with arms or legs
are components of later self-dressing. Furthermore,
actions such as holding arms or legs out demonstrate
the child’s understanding of the dressing process.
Trying to assist (e.g., pulling at a zipper tab) may not
be functional but is important because it demonstrates
modeling behavior (Haley et al., 1992).
Undressing: Clothes Unfastened or Without
Fasteners
Table 10-6 identifies the sequences in which children
learn to take off their clothes. Complete independence
in undressing requires the release of fasteners, a skill
that does not develop until after 3 years of age (Coley,
1978). However, with assistance in unfastening, the
toddler can take off much clothing. Undressing requires
only simple perceptual skills; knowing front from
behind and left from right is unnecessary. Furthermore,
fewer action sequences are needed than for dressing
(Klein, 1983), and hand use requires little more than
gross grasp, pulling, and pushing. Interest in taking
clothes off begins in the first year; by 21/2 years most
children can and want to take off their clothes, and by
3 years undressing is done well and rapidly (Gesell &
I1g, 1943).
Dressing with Assistance on Fasteners
Table 10-7 1ists the sequences in which dressing skills
are acquired. The long 5-year developmental period is
to a great extent a reflection of the perceptual skills

Table 10-6 Undressing: clothes unfastened or without fasteners

Skill Age Source

HAT AND MITTENS

Pulls off hat appropriately, on request 11⁄2 yr Gesell and Ilg (1943)

Removes mittens 12–14 mo Coley (1978)

SOCKS AND SHOES

Removes socks on request 11⁄2–2 yr Haley et al. (1992)

Removes untied or unfastened shoes 11⁄2–2 yr Haley et al. (1992)

Unties and removes shoes 2–3 yr Coley (1978)

PANTS AND PULL-DOWN GARMENTS

Pushes off pants if soiled 1 yr Gesell and Ilg (1943)

Pushes down underpants or shorts 21–24 mo Gesell and Ilg (1943)

Removes elastic top on long pants, clearing over bottom 2–21⁄2 yr Haley et al. (1992)

SHIRTS, COATS, AND SWEATERS

Removes second arm from coat 1 yr Brigance (1978)

Removes unbuttoned coat 1 yr Brigance (1978)

Removes pullover garments, T-shirt, dress 21⁄2–3 yr Haley et al. (1992)

Assistance needed 3 yr Coley (1978)

Little assistance needed 4 yr Coley (1978)

 Self-Care and Hand Skill • 207

Table 10-7 Self-dressing: without fasteners

Skill Age Source

HAT
Puts on, may be backward 2 yr Gesell et al. (1940)

SOCKS
Puts on with help on heel orientation 3 yr Coley (1978)

Puts on heel correctly oriented 3–31⁄2 yr Haley et al. (1992)

Pulls socks to full extension 4 yr Key et al. (1936)

SHOES
Gets shoe on halfway 11⁄2 yr Gesell et al. (1940)

Puts on, may be on wrong feet 3–31⁄2 yr Haley et al. (1992)

If laces are loosened 2 yr Gesell et al. (1940)

Loosens laces and puts on 21⁄2 yr Vulpe (1979)

Puts on correct feet 41⁄2–5 yr Haley et al. (1992)

Puts on boots if loose fitting 3–4 yr Vulpe (1979)

Independent with Velcro fastenings 41⁄2–5 yr Haley et al. (1992)

COATS AND OPEN-FRONT SHIRTS

Finds large armholes 2 yr Coley (1978

Puts on coat with help 2 yr 9 mo Coley (1978)

Puts on open-front shirt 31⁄2–4 yr Haley et al. (1992)

Adjusts collar to neck 3 yr Key et al. (1936)

PULLOVER GARMENTS, T-SHIRTS, AND DRESSES

Puts head through hole 2 yr Key et al. (1936)

Puts on pullover garment 3–31⁄2 yr Haley et al. (1992)

Puts arm through hole 31⁄2 yr Key et al. (1936)

Pulls down over trunk 3 yr Key et al. (1936)

Distinguishes front and back, inside out 4 yr Coley (1978)

PANTS AND PULL-UP GARMENTS

Helps pull pants up 2 yr Gesell et al. (1940)

Tries to put on, two feet in one hole 2–21⁄2 yr Gesell et al. (1940)

Puts on if oriented verbally 3–31⁄2 yr Haley et al. (1992)

Orients correctly and puts on 4 yr Coley (1978)

Can turn right side out 4 yr Coley (1978)

208 Part II • Development of Hand Skills
needed. The last skills achieved are in the orientation of
the heel of the sock, the front and back of garments,
and, the most difficult, the distinguishing of left and
right shoes. Children know when their coat is right side
out when they are 3, but they have more difficulty with
other clothes. The 4- to 5-year-old gets the under-
clothes right side out, but it is not until 7 years that the
inside and outside of all clothes are discriminated
(Brigance, 1978).
In addition to these perceptual skills, self-care
dressing skills require complex motor planning. Gaddes
(1983) described the difficulty of some children with
learning disabilities in dressing as a lack of the tactile
and kinesthetic awareness essential to the task of
putting on one’s clothes, and commented that
“small children are usually unable to put on their clothes without
help … not because they lack the physical strength but because
they lack the necessary ideomotor image” (p. 109).
The hand skills needed are primarily whole-hand
grasp, a power grasp for pulling clothing on, and a high
level of bilateral skill. Hands must work smoothly and
in unison to pull socks up to full extension, pull on
boots, and pull up pants. Hands must work cooperatively
in holding a shirt or coat with one hand while finding
the armhole with the other.
Additional bilateral dressing skills have been
identified by Thornby and Krebs (1992). Their interest
was in expectations for independence for children with
unilateral below-elbow amputations. The skills identified
include grasping and pulling up trousers or skirt (21⁄2 to
3 years), and grasping clothing while zipping a zipper
(3 years 3 months to 4 years). The children with
amputations achieved these skills several years later than
most children.
A Study of Dressing
Key and her associates (1936) studied the ability of
children to put on the clothing that they wore to
nursery school and found wide differences in the ability
to put on separate garments. Overall, socks and leg
garments were found to be the easiest, followed by
upper body garments and dresses. Shoes, because of
their fasteners, were the most difficult. In addition to
looking at the overall ability to put on the garments,
the researchers recorded the success rate of separate
dressing units for each garment. These data provided
an index of the difficulty of the subskills needed for
successful performance. An analysis of the percentage
of success for each subskill at each age level shows the
relative difficulties of the components of putting on
shoes, socks, pull-down garments, dresses, and shirts.
This list excludes fasteners, and open-front and slipover
shirts were not differentiated. The order of difficulty
The Order of Difficulty in the
BOX 10-2 Ability of Children to Put on
Clothing
Put one leg in hole of pants
Pulled up pants
Shoe started on foot
Opened shoe for foot
Put head in neck hole of dress
Put on dress correctly front to back
Socks started over foot
Put foot in shoe with heel down
Pulled sock up on leg
Kept tongue out of shoe while donning
Put second leg in hole of pull-down garment
Pulled sock up on foot
Put pullover garment over head
Put first arm in dress hole
Adjusted dress when on
Put second arm in sleeve hole of dress
Shirt on correctly front to back
Adjusted pants when on
Put first arm in sleeve hole of T-shirt
Adjusted shirt when on
Put second arm in sleeve hole of T-shirt
Pants on correctly front to back
Adjusted heel of sock
Key CB, White MR, Honzik WP, Heiney AB, Erwin D
(1936). The process of learning to dress among nursery-
school children. Genetic Psychology Monographs,
18:67–163.
reported, based on the age group in which 50% or
more of the children succeeded in the task, is listed in
Box 10-2.
Note that a part of an individual motor skill, such as
putting on pants or socks, was easiest but complete
achievement was the hardest. The difficulty young
children have in dressing is a mix of a challenging per-
ceptual task, such as locating the front of a T-shirt or
the heel of a sock, and sometimes a complex motor act,
such as maneuvering an arm into a second dress hole.
Fasteners: Zippers, Snaps, Buttons, and Ties
Table 10-8 shows the range of average ages at which
children are able to fasten and unfasten their clothing.
Manipulating zippers, as long as it does not involve
hooking and unhooking a separating zipper, is the
easiest form of closure, whereas tying is the most
difficult. The feature all fasteners have in common is
the need for bilateral finger manipulation skills. Zippers
require precision grip and pinch strength. The bilateral
nature of this task is shown by the 3-year delay in skill
acquisition in children with unilateral below-elbow
amputations (Thornby & Krebs, 1992). Buttons
 Self-Care and Hand Skill • 209

Table 10-8 Fasteners: ties, buckles, Velcro, snaps, zippers, buttons

Skill Age Source

SHOES: LACE AND TIE

Unties shoe bow 11⁄2 yr Brigance (1978)

Pulls laces tight 21⁄2–3 yr Vulpe (1979)

Tries to lace, usually incorrectly 3 yr Coley (1978)

Laces shoes 4–5 yr Coley (1978)

Ties overhand knot 5 yr 3 mo Coley (1978)

1
Ties bow on shoes 6–6 ⁄2 yr Haley et al. (1992)

SASHES AND NECKTIES

Unties back sash of apron or dress 5 yr Coley (1978)

Ties front sash of apron or dress 6 yr Coley (1978)

Ties back sash of apron or dress 8 yr Coley (1978)

Ties necktie 10 yr Coley (1978)

BUCKLES
Unbuckles belt or shoe 3 yr 9 mo Coley (1978)

Buckles belt or shoe 4 yr Coley (1978)

Inserts belt in loops 41⁄2 yr Coley (1978)

VELCRO FASTENERS
Manages shoes with Velcro 41⁄2–5 yr Haley et al. (1992)

SNAPS
Unsnaps front snaps 1 yr Brigance (1978)

Unsnaps back snaps 3 yr Brigance (1978)

1
Snaps most snaps, front and side 3 ⁄2–4 yr Haley et al. (1992)

Snaps back snaps 6 yr Coley (1978)

ZIPPERS
Zips and unzips, lock tab 2–21⁄2 yr Haley et al. (1992)

Opens front separating zipper 31⁄2 yr Coley (1978)

Zips front separating zipper 41⁄2 yr Coley (1978)

Opens back zipper 4 yr 9 mo Coley (1978)

Closes back zipper 51⁄2 yr Coley (1978)

Zips, unzips, hooks, unhooks, separates zipper 51⁄2–6 yr Haley et al. (1992)

BUTTONS
Buttons one large front button 21⁄2 yr Coley (1978)

Unbuttons most front and side buttons 3 yr Coley (1978)

Buttons series of three buttons 31⁄2 yr Coley (1978)

Buttons and unbuttons most buttons 4–41⁄2 yr Haley et al. (1992)

Buttons back buttons 6 yr 3 mo Coley (1978)

210 Part II • Development of Hand Skills
require precision grip with manipulation and with both
hands working cooperatively.
Strength is another component of the management
of fasteners. Snaps require considerable strength in the
fingers. Koch and Simenson (1992) examined func-
tional skills in spinal muscle atrophy. Children with 1⁄2-
to 2-lb pinch strength needed minimal help in dressing.
Children with less than 1⁄2-lb pinch strength had
trouble with tying and buttoning.
Managing fasteners is also a perceptual task,
particularly buttoning and tying. For both these tasks
vision is important for learning. It is only after
considerable skill has been developed that back buttons
and back bows can be accomplished, using touch and
kinesthesia alone.
Buttoning
The ability to button has been included in develop-
mental tests for many years, and it has been studied
more than other fastenings. The ability develops in
preschool over 2 to 3 years of age, and achievement
depends in part on the location of the button.
Stutzman (1948) examined the ability of preschool
children to button buttons on a strip on a table.
Children under 2 years of age failed to button one
button, but by 21⁄2 to 3 years of age 72% of the children
succeeded, albeit slowly. However, Key and co-workers
(1936) reported that only 50% of their 3-year-old
children succeeded in buttoning their shirts or dresses,
and only 33% their pants.
Wagoner and Armstrong (1928) reported a study of
buttoning skill in 30 nursery school children between
the ages of 2 and 5 years. They standardized the task by
making jackets that were adjustable in size and which
had front and side buttons. The major findings were:
(a) children under 21⁄2 years seemed not to have the
motor control needed to button; from 21⁄2 to 5 years
speed of buttoning improved with age; (b) girls were
better than boys, but the researchers noted that this
result might have reflected an artifact of their sample;
and (c) side buttons were much more difficult than
front buttons; 25 children succeeded with the front
buttons, but only 15 completed the side buttons (the
authors noted that buttoning side buttons may require
a more complex type of motor adjustment than do
front buttons).
Wagoner and Armstrong also reported correlation
of buttoning speed with the Stanford-Binet Test
(r = .33), the Merrill-Palmer Performance Tests
(r = .62), and the Goodenough Drawing Test (r = .57).
Thus buttoning appeared to be more related to
performance tests than to intelligence. They also found
success in buttoning to be highly correlated (.83 to
.91) with teacher ratings on self-reliance, perseverance,
and care of details.
Learning to Tie Shoes
Shoe tying is an important and difficult developmental
task for children. Children perceive the relationship of
the loops and strings and learn the steps of looping,
winding, and pulling through but still may fail. The
most difficult aspect of shoe tying appears to be what
Maccoby and Bee (1965) in their study of form
copying termed the perception of attributes. Their
example was that children discriminate forms such as
diamonds but are unable to draw them because they do
not perceive the attributes of the form, such as the
relative size of lines and angles. Similarly, children do
not perceive the relative sizes of loops and strings; the
loop is too large and the bow fails. It is only when
children perceive these attributes of the lacing process
that they succeed. Learning to tie shoes is of special
importance to a child’s sense of competence. The
6-year-old child has a sense of achievement and
independence from adult help in the school
environment.
HYGIENE AND G ROOMING
Tables 10-9 and 10-10 present the sequences in which
hygiene and grooming skills are acquired by children.
The development of parts of the skills begins in early
childhood, but independence in most hygiene and
grooming skills is a middle childhood achievement.
Many hygiene and grooming tasks are bilateral.
Hands are rubbed together in washing; in drying,
towels are held alternately while drying each hand.
Applying toothpaste on a brush is a skilled bilateral
activity. This was shown by the delay in which children
with unilateral amputations were found to achieve this
task (Thornby & Krebs, 1992). The toothbrush is a
tool that requires a high level of skill, as wrist and hand
movements are complex in placing the brush and
brushing all the teeth. It is also a skill accomplished
without vision.
Independence in hair care is greatly influenced by
social factors, especially for girls. At about the time
when hair becomes manageable by the 4- to 7-year-old
child, independence is often delayed in girls by choice
of hairstyles (e.g., braids usually are a teenage accom-
plishment). Hair styling requires a complex manipula-
tion of many tools—brush, comb, pins, dryers—all of
which must be used without vision or with mirror
vision.
The ability to perform grooming and hygiene skills
develops far earlier than the acceptance of responsibility
for performing them. Grooming and hygiene skills are
particularly likely to be neglected by school-age
children. Note that the performance ages in the tables
reflect when a child can do a skill and not whether it is
done without supervision.
 Self-Care and Hand Skill • 211

Table 10-9 Hygiene

Skill Age Source

WASHING AND DRYING HANDS

Holds out hands to be washed 11⁄2–2 yr Haley et al. (1992)
1
Dries with help 1 ⁄2 yr Coley (1978)
Rubs hands together to clean 11⁄2–2 yr Haley et al. (1992)
Turns faucet on and off 21⁄2–3 yr Haley et al. (1992)
1
Dries hands thoroughly 3 ⁄2–4 yr Haley et al. (1992)
1
Dries without supervision 3 ⁄2 yr Coley (1978)
1
Washes hands thoroughly 3 ⁄2–4 yr Haley et al. (1992)
Washes without supervision 3 yr 9 mo Coley (1978)
Disposes of paper towel or replaces towel 4 yr Coley (1978)
Washes hands at appropriate time before meals 6 yr Coley (1978)

WASHING FACE
Washes and dries face thoroughly 51⁄2–6 yr Haley et al. (1992)
Without supervision 4 yr 9 mo Haley et al. (1992)
Washes ears 8–9 yr Haley et al. (1992)

BATHING BODY
Tries to wash body 11⁄2–2 yr Haley et al. (1992)
Bathes down front of body 3 yr Coley (1978)
1
Washes body well 3 ⁄2–4 yr Haley et al. (1992)
1
Soaps cloth and washes 4 ⁄2 yr Coley (1978)

TEETH BRUSHING
Opens mouth for teeth to be brushed 1–2 yr Haley et al. (1992)
Holds brush, approximates brushing 11⁄2–2 yr Haley et al. (1992)
Brushes teeth, not thoroughly 2–21⁄2 yr Haley et al. (1992)
1
Thoroughly brushes teeth 4 ⁄2–5 yr Haley et al. (1992)
1
Prepares brush, wets and applies paste 4 ⁄2–5 yr Haley et al. (1992)
Brushes routinely after meals 7 yr Coley (1978)

NOSE CARE
Allows wiping of nose 11⁄2–2 yr Haley et al. (1992)
1
Wipes on request 2–2 ⁄2 yr Haley et al. (1992)
1
Wipes without request 3–3 ⁄2 yr Haley et al. (1992)
Attempts to blow nose 11⁄2–2 yr Haley et al. (1992)
Blows and wipes alone 6–61⁄2 yr Haley et al. (1992)

TOILETING
Assists with clothing management 2–21⁄2 yr Haley et al. (1992)
1
Manages clothes before and after toileting 3–3 ⁄2 yr Haley et al. (1992)
1
Tries to wipe self after toileting 3–3 ⁄2 yr Haley et al. (1992)
1
Manages toilet seat, toilet paper, flushes 3–3 ⁄2 yr Haley et al. (1992)
1
Wipes self thoroughly 5 ⁄2–6 yr Haley et al. (1992)
Completely cares for self at toilet 5 yr Coley (1978)
212 Part II • Development of Hand Skills

Table 10-10 Grooming

Skill Age Source

HAIR
Holds head in position for combing 1–11⁄2 yr Haley et al. (1992)

Brings comb to hair 1–11⁄2 yr Haley et al. (1992)

Brushes or combs hair; combs with supervision 21⁄2–3 yr Haley et al. (1992)

Manages tangles and parts hair 7 yr Haley et al. (1992)

Combs using mirror to check style 7 yr Coley (1978)

Uses rollers, hair spray 12 yr Coley (1978)

OTHER GROOMING SKILLS

Shines shoes 7 yr Brigance (1978)

Uses deodorant daily 12 yr Coley (1978)

Scrubs fingernails with brush 51⁄2 yr Coley (1978)

Maintains clean nails, files, clips both hands 8 yr Coley (1978)

DISCUSSION limited to their use in identifying developmental mile-

Independence in the performance of the daily activities
of basic self-care requires the mastery of complex hand
skills that children learn over many years. The skills
have varying degrees of manipulative, perceptual, and
cognitive components and the action sequences are
learned through extensive practice until they become
automatic and efficient. We have some knowledge of
the usual ages at which the skills are mastered, but very
little knowledge of what Connolly and Dalgleish
(1989) called the general patterns of behavioral
change, which occur as children acquire specific self-
care skills.
Most of the studies of the development of self-care
skills cited in this chapter were conducted before 1940.
There are not many, and recent studies are even scarcer.
As noted by Amato and Ochiltree (1986), despite an
increasing interest in the development of competence
in childhood during the last decade, practical life skills
have been virtually ignored. Interest in the study of
children’s self-care skills over the years has been largely
stones, and most of our knowledge is of that kind. The
information in this chapter is a summary of what is
currently known about the chronology of skill acquisi-
tion and is presented as a possible source for finding
clues to the understanding of the process by which
skills are acquired.
Although the ages identified are approximate and
represent an unspecified average behavior, they provide
a tentative chronological order in which skills and
subskills develop. However, it must be remembered the
sequences of skill development that are suggested by
the information in the tables may be an artifact of the
use of group data. Of course, some of the steps in
learning are clearly acceptable; that is, a partial skill
precedes a complete skill and many of the sequences
have been repeatedly observed and verified by teachers,
parents, and therapists. However, individual differences
among children could result in different routes to
competence in an overall skill. Nevertheless, these over-
all sequences have value in that they provide infor-
mation that could be used in planning longitudinal

studies because they identify the age span in which skills
usually develop. Furthermore, they show general
patterns of behavioral change in the acquisition of self-
care that allows some generalizations about factors
affecting mastery.
HAND SKILLS IN SELF-CARE
The examination of the chronology of self-care acqui-
sition allows a preliminary, although fragmentary,
analysis of the relationship of the development of hand
use to the development of self-care. We do not know
when these self-care skills reach adult levels of efficiency
and precision, but clearly skill acquisition is a gradual
process that extends into the preteens. It appears that
aspects of hand skill acquisition over the years include
(a) finger manipulation and grip ability, (b) the use of
two hands in a complementary fashion, (c) the ability
to use the hands in varied positions with and without
vision, (d) the execution of increasingly complex action
sequences, and (e) the development of automaticity.
These hand skills have been discussed in the preceding
section in relation to specific skills and are summarized
in the following.
Grip Ability and Finger Manipulation
During the first year of life the infant develops whole
hand grip followed by the use of a finger grip with
some precision (see Chapter 7). As grips develop they
are used in self-care skills, first with the whole hand and
then with the fingers. Therefore the earliest self-care
actions are pulling at clothes and grasping food such as
a cracker with the whole hand. Finger feeding soon
follows the early emergence of pincer grasp. This whole
hand to pincer grip sequence occurs repeatedly as skills
develop. Examples in the young child include pro-
gression from a whole hand to a finger grip on a spoon
and from a whole hand grip pulling up pants to a
thumb and finger grip on socks. This progression of the
whole hand grip to pincer grip sequence is in part a
reflection of the interplay of power and precision in
grip as skill develops, as the infant has power in the
whole hand grip, but is slow to develop power in finger
grips. For example, a child lifts a cup or glass with one
hand before having the finger grip power needed for
lifting a cup by the handle. In cutting with a knife and
fork, a child first uses a fisted grip on both utensils to
exert the pressure needed. The power finger grips used
by adults for cutting are not achieved until the preteen
years.
The use of the fingers in a precision pincer grip is
used in dressing in the second year, but fasteners such
as buttons, shoe lacing, bow tying, and buckles, require
in-hand manipulation skills. In-hand manipulation
also is needed to position a spoon or toothbrush for
Self-Care and Hand Skill • 213
the appropriate finger grasp position. These skills begin
to develop in the third year but the combination of
precision and power in finger manipulation at the
highest level does not develop until a child is 8
years old.
Bilateral Hand Use
Most self-care skills are bilateral and the challenge
posed by these skills depends on their complexity. The
simple act of drinking from a bottle and then a cup held
in two hands is one of the first achievements of an
infant, and an infant is soon able to hold a dish while
spooning food. The order in which bilateral dressing
skills develop seems to depend on the added need for
power, whether hands work in unison or cooperate in
different functions, and the extent of the motor
sequencing involved. Undressing is easier with two
hands but requires less skill than does dressing.
Intermediate bilateral skills include pulling up pants,
holding a shoe open with the tongue out, and pulling
on boots. Manipulating buttons, buckles, and zippers is
more difficult because high precision is necessary and
the two hands work cooperatively but differently. The
greatest difficulty comes when the two hands must move
through different motor sequences, as in tying bows.
Position of the Hands
Two factors appear to influence a child’s ability to
perform a task with the hands someplace other than in
front of the body. Young children seem unable to
perform tasks such as buttoning without seeing their
hands, and performing with the hands in awkward
positions such as at the side of the body is difficult.
These two factors probably combine to delay learning
to manipulate back buttons until after the sixth year.
Executing Motor Sequences
As was noted in the discussion of spoon use, even the
early-developing task of self-feeding requires the
learning of a multiple sequence of actions. Through
analysis, therapists have identified the steps involved in
many dressing skills (Case-Smith, 2000), but the
sequence followed by typical children in learning par-
ticular dressing skills has not been studied. However, it
is to be expected that becoming self-sufficient in a skill
is in part a reflection of the number of action sequences
involved.
Automaticity
Self-care literature provides a clue to the development
of automaticity in skill performance. There appears to
be a delay following a child’s ability to perform a skill
in eating and dressing before the skill can be performed
while carrying on a conversation (Hurlock, 1964;
Klein, 1983). This suggests that an automatic level of
214 Part II • Development of Hand Skills
skill execution does not develop until several years after
a skill is first mastered.
Combined Motor Abilities
Examples of skills involving different facets of hand
manipulation have been given for illustrative purposes.
Nevertheless, clearly most of these facets occur in
combination. The highest level of self-care skill appears
to require some combination of bilateral sequencing
and complementary hand use, the combination of
power and precision in grip, the ability to perform hand
tasks with the hands behind the back or head, and the
ability to visualize what the hands are doing when they
are out of sight. Tying a necktie involves multiple com-
plex sequences, bilateral, complementary hand use, and
performance without vision, and is one of the last skills
learned.
PERCEPTUAL FACTORS IN SELF-CARE
The sequences of self-care acquisition also clearly
demonstrate the need for development of perceptual
skills. Perceptual skills are necessary for tool use,
ranging in difficulty for spoons, toothbrushes, and
combs. Perceptual factors are particularly evident in
dressing. Over several years children learn, in this order,
whether clothes are inside out or outside out, the
difference between front and back, and which is left or
right. Their ability to respond first to more obvious
cues is shown by this sequence, as well as by their ability
to locate a dress front by its decoration before the back
of a T-shirt by its label or the front of pants.
COGNITIVE AND PERSONALITY FACTORS
IN SELF-CARE
We have little data on the importance of cognitive and
personality factors in self-care acquisition, but the few
studies suggest that, for children whose intelligence is
within normal limits, the level of intelligence is less
important than the personality characteristics of per-
sistence and self-reliance. There is good reason to
believe that in typical children personal and social
characteristics are as important as perceptual and motor
maturation. Children are highly variable in the
chronological ages at which they acquire skills, and the
finding that a 3- to 4-year span may separate the earliest
and latest age at which typical children master a par-
ticular skill is a powerful indication that there are large
personal and situational differences among children.
We know very little about the sources of these
individual differences, but we can hypothesize that they
are multiple and include differences in problem-solving
abilities, persistence, and self-reliance. We also know
virtually nothing about the extent to which and in what
combinations these intrinsic factors influence the
maturation of self-care skills or how much is a function
of family and cultural variables. Many studies are
needed to understand the variables that have an impact
on the learning of self-care skills. The PEDI promises
to provide a rich resource for the determination of
which cultural, cognitive, motor, and personality fac-
tors have an impact. The interest in researching the
development of competence and volition will also hope-
fully include more attention to basic practical skills.
SUMMARY
This chapter has focused on how and when typical
children learn the separate skills and subskills of self-
care. Knowledge of the sequences in which typical
children acquire self-sufficiency in daily activities can be
valuable in understanding the roadblocks for children
with physical or mental disability, and sequences of skill
acquisition can provide guidance in selecting the level
of skill at which to introduce training. However, the
acquisition of self-care in typical children provides only
a part of the picture needed for treatment planning. We
must learn how skills are learned in the presence of
different disabilities. We know that the presence of a
specific disability can change the sequence in which a
child will master self-care skills, but we have little infor-
mation about what that sequence is.
Most of our knowledge about the impact of dis-
ability on specific self-care skills comes from therapeutic
accounts. Several recent publications have provided
detailed task analyses of methods of dressing, eating,
and hygiene keyed to different impairments and
include multiple suggestions for adaptations. Some of
these are designed for children (e.g., Case Smith, 2000;
Shepard, 2001), and others for adults (e.g., Backman
& Christiansen, 2000; Holm, Rogers, & James, 1998;
Snell & Vogtle, 2000).
The tables also provide useful knowledge about the
acquisition of part skills. Typically children do not learn
a skill all at once. Rather they are encouraged to do
what they can long before they are developmentally
ready to master a skill. Parents of children with dis-
abilities should be encouraged to introduce part-skill
practice early and to set expectations that their child do
whatever he can. This will take more time but it will
contribute to the child’s sense of mastery and self-
esteem and provide practice of the motor skill. It would
be helpful to know more about the factors affecting
such a learning process and the differences and
similarities in the ways in which children with dis-
abilities learn complex skills.

The importance of self-care skill acquisition in a
typical child’s sense of efficacy and the parent–child
interaction around self-care issues should be investi-
gated. Furthermore, although we know that indepen-
dence in self-care is important to an individual’s quality
of life, disability sometimes is so severe that indepen-
dence cannot be achieved, and we know little about the
importance of partial independence to the individual or
of its meaning to an individual’s sense of mastery and
control. Research in self-care with both typical children
and children with disabilities has the potential for dis-
covering information that will be applicable to design-
ing rehabilitation programs.
Parents should be helped to understand the impor-
tance of the mastery of self-care skills to the child and
to give the child a sense of pride in this most mundane
of accomplishments. Time in the daily schedule is
needed for practice of self-care for all children. The
child with a disability has a different timetable for
mastery, but the same rules should apply. Time must be
scheduled for every child to master skills, and develop
the self-reliance and self-confidence that comes with
mastery.
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