T
he term in-hand manipulation refers to move-
The Zone of Proximal
Development in In-
Hand Manipulation
Skills of
Nondysfunctional 3-
and 4-Year-Old Children
Charlotte E. Exner
Key Words: child development. hand
functions and skills evaluation. motor skills
The purpose of this study was to assess the influence
of verbal and visual cues on 28 nondysfunctional 3-
and 4-year-old children's performance of in-hand
mampulation skills. During the uncued version of
the test (pretest), the children were presented with
play activities known to elicit in-hand manipula-
tion skills in young children but were given no cues
for specific manipulative skill use. Within 1 week of
the pretest, after the children were randomly as-
Signed to groups, a posttest was given in which the
children were provided with verbal or visual cues.
The results indicate that both visual and verbal cues
were effective in increasing the groups' test scores,
but no Significant differences were found based on
the type of cue provided. Approximately 30% of the
children in the study showed marked improvement
on the posttest scores, whereas the others showed lit-
tle change. The children who had lower pretest
scores showed greater score increases on the posttest
than did the children who scored somewhat higher
initially. The use of an uncued test followed by a
cued test may be an effective method for the identi-
fication of those children who are most likely to
show improvement in these manipulation skills with
intervention. This study's findings lend tentative
support to Vygotsky's (1978) zone ofproximal devel-
opment theory and extends the application of his
work into the domain offine motor skills.
CharlO[te E. Exner, MS, OTR, FAOTA, is Assistam Professor,
Occupational Therapy Depanment, Towson State Univer·
sity, Towson, MD 21204.
This arlicle was accepted for puhlicalioll./anuar)' 24, 1990.
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ment of an object within a person's hand
(Exner, 1989). The person may be shifting ob-
jects on the surface of the fingers or among the
fingers, rotating objects between the fingers, movins
objects from palm to fingers (palm-to-finger transla-
tion), or moving objects from fingers to palm (finger-
to-palm translation) (Exner, 1989). A person may
perform these movements while no other object is in
the hand or while simultaneously stabilizing another
object or objects in the hand. This type of stabilization
is usually accomplished with the ulnar fingers, while
the radial fingers produce the manipulation. The abil-
ity to perform these skills is essential to the perfor-
mance of refined, skilled fine motor tasks. Many daily
living tasks that involve the use of tools and the han-
dling of small materials require these skills in addi-
tion to refined grasp, release, and bilateral hand use.
Children with problems using in-hand manipula-
tion skills are often able to effectively perform the
basic skills of reach, grasp, and release but remain
clumsy, slow, and inefficient in performing fine
motor tasks. These children are also delayed in ac-
quiring specific fine motor skills, such as using pen-
cils or crayons for writing and coloring; using scissors;
tying; buttoning; and engaging in complex construc-
tive, manipulative play. They may continue to use two
hands to manipulate materials when one hand would
be more efficient and may drop materials often. Some
children resort to forcefully pushing and pulling ma-
terials when they have difficulty with manipulation,
which can result in such materials being broken or
crushed.
Literature Review
Despite the significance of in-hand manipulation
skills to the performance of many daily living tasks, no
tests of hand function for children or adults include an
assessment of specific manipulation skills. The Bri-
gance Diagnostic Inventory of Early Development
(Brigance, 1978), the Denver Developmental Screen-
ing Test (Frankenberg, Dodds, & Fandal, 1970), the
Early Intervention Developmental Profile (Schafer &
Moersch, 1977), and the Hawaii Early Learning Profile
(Furuno et aI., 1979) are all standardized develop-
mental tests that assess fine motor skills in young
children. On each of these tests, the evaluator notes
whether the child has acqUired a particular develop-
mental skill and performs it in a normal manner. No
qualitative assessment of fine motor skills is included.
The fine motor skills covered in the tests are reach,
grasp, and release, with manipulation addressed by
items such as the child's using crayons, stringing
beads, and opening containers. The Fine Motor scale
of the Peabody Developmental Motor Scales (Folio &
Fewell, 1983) includes many items that require the
Octoher 19.90, Volume 44, Number 10
 child to manipulate small materials. Two categories
on this test-eye-hand coordination and manual
dexterity-specifically tap manipulative skills. The
eye-hand coordination section has some items that
involve tool use (e.g., marker, scissors), and the man-
ual dexterity section has items that primarily assess
speed of manipulation of materials. No qualitative as-
sessment of the child's performance is made, how-
ever, and no reference to any specific in-hand manip-
ulation skills is provided.
The Bruininks-Oseretsky Test of Motor Profi-
ciency (Bruininks, 1978) contains a subtest that spe-
cifically addresses the speed and dexterity of fine
motor skills. Items are scored exclusively on time to
completion, number of marks made with a pencil, or
number of objects placed in a specific amount of time;
quality of performance is not assessed. In addition,
this test is not standardized for children under the age
of 4Y2 years and therefore would not be appropriate
for use with younger preschool children. In contrast,
the Erhardt Developmental Prehension Assessment
(Erhardt, 1982) does include assessment of the qual-
ity of fine motor skills and is designed for use with
children who have developmental problems. This test
assesses reach, grasp, and release of objects but not
manipulation skills.
The present study is part of a larger project to
develop a standardized instrument for use by occupa-
tional therapists in the evaluation of in-hand manipu-
lation skills in preschool and young school-age chil·
dren who have or are at risk for haVing fine motor
problems. The test will be designed to assess the
quality of children's manipulative skills in typical
childhood activities.
I made an initial investigation in this area using
an instrument suitable for research purposes only
(Exner, 1986). Children were presented with mate-
rials, and their spontaneous skills in manipulating the
materials were recorded. The only verbal cues pro·
vided for the first 20 test items indicated the desired
end product of the manipulation, such as "Can you
put a.ll of these pegs into the board'" "Put this key
into the lock," or "Can you hold all of these blocks in
one hand"" For the last two items, the child was asked
to do the task using one hand only. No demonstra-
tions of methods for task completion were prOVided
This method was successful in eliciting spontaneous
behaviors but may not have elicited the children's
best manipulative skills. Verbal or visual cuing for any
particular item, however, may affect a child's perfor-
mance on subsequent test items.
Lyons (I984) discussed the importance of using
concepts presented by Vygotsky, a Russian psycholo-
gist, in the occupational therapy assessment of chil-
dren. Vygorsky (978) introduced the phrase zOlle of
prOXimal development to indicate the range of skills
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that the child could not yet use independently but that
he or she could use when interacting with an adult or
a more competent peer. Vygotsky emphasized the
importance of social interaction in learning. He stated
that the child gradually internalizes the ability to use
skills observed during social interactions; at this
point, the child can function independently regarding
these skills by using information gained during col-
laborative problem solving.
The assessment of children's functioning typi-
cally relies on standardized tests that proVide little
information that is useful in a determination of how
the child has developed or his or her potential for
future development; these tests assess only the child's
independent problem solVing (Vygotsky, 1978)
Lyons 0984, 1987) stressed the importance of the use
of the assessment process to determine a child's zone
of proXimal development and the use of this informa-
tion in treatment planning. Facilitation of the devel-
opment of those emerging skills that are within the
child's zone of prOXimal development is an appro-
priate focus of intervention (Vygotsky, 1978)
Besides assessment of children's independent
functioning with standardized tests, methods by
which the therapist can elicit a child's zone of proxi-
mal development in a skill area may be developed
(Lyons, 1984). These methods may be used with stan-
dardized tests The therapist can first administer a
standardized test to a child, then readminister some
items that the child did not successfully complete
while proViding the child with one or more types of
assistance (Lyons, 1986). This assistance may be in
the form of altered test methods, verbal cues, or visual
cues (ie., demonstration) (Lyons, 1986)
Lyons (1987) used Vygotsky's (1978) principles
in a recent study of block construction tasks with 3-
and 4·year-olcl children She tried to determine ifvar-
ious types of verbal cues given to the children before
each task would affect the children's accuracy in the
block construction. The three verbal cues used did
not affect these children's performances. The verbal
cues that were given after the completion of each
structure, which asked the child to evaluate the fin-
ished product, however, did result in some children
modifying their structures to be more like the model
proVided. The older children were much more re-
sponsive to these cues. The resu Its of this study sug'
gest that instructions used in standardized tests
should be carefully assessed to determine if they actu-
ally serve a useful purpose or if they proVide more or
less assistance to the child than intended. The assess-
ment of test instructions, therefore, seems to be an
important aspect of the development of any standard-
ized test.
The zone of proximal development was used by
Vygotsky (1978) to refer to attentional and perceptual
885
 processes in addition to higher levels of cognitive
functioning. Lyons 0984, 1987) similarly referred to
its use in the cognitive domain Clinical experience
with nondysfunctional children and children with
sensorimotor disabilities suggests that the concept
also can be applied to sensorimotor skills, particularly
regarding some aspects of fine motor skills.
Because I am designing the Test of In- Hand Ma-
nipulation so as to provide information to the thera-
pist about the quality and efficiency of a child's skills
in this area, administration of the test without adult
assistance or guidance is important. This process
allows the therapist to identify those skills that the
child could use independently and spontaneously.
Another purpose of this test, however, will be to assist
therapists in determining appropriate goals for the
children they treat, which is accomplished in part
through a determination of the child's zone of proxi-
mal development in in-hand manipulation skills.
Areas in which the child shows improved functioning
with cues may be those that can most likely be en-
hanced with therapy or by suggestions to others who
work with the child. The present study, therefore, as-
sessed the responsivity of nondysfunctional pre-
school children to typical types of cues that could
be given on this test. The overall purpose was to as-
sess the influence of two types of cues on preschool
children's performance of in-hand manipulation
activities.
Hypotheses
The hypotheses tested in this study were as follows:
1. Preschool children's scores on the Test of In-
Hand Manipulation Skills will be significantly
better when they are proVided with cues than
when they are not provided with cues.
2. Visual cues will be more effective than verbal
cues in enhancing in-hand manipulation test
scores in 3- and 4-0Id-children.
3. Specific types of in-hand manipulation skills
will be more easily facilitated by cues than
other skills in young children
4. Three-year-olds and 4-year-olds and boys and
girls will show different levels of responsivity
to cues.
Method
Subjects
Twenty-eight children participated in the study.
Twelve children were between the ages of 3 years 0
months and 3 years 11 months, and 16 chiJdren were
between the ages of 4 years 0 months and 4 years 11
months. The mean age of the subjects was 48.86
months (SD = 5.66 months). Of the 3-year-olds, there
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were 5 boys and 7 girls. Nine were White and 3 were
Black. Of the 4-year-olds, there were 8 boys and 8
girls. Ten were White, 4 were Black, and 2 were cate-
gorized as Other (i.e., races other than White or
Black) All of the 4-year-olds and 10 of the 3-year-olds
attended the Council Day Care Program or the pre-
kindergarten program at Lida Lee Tall School at Tow-
son State University in Towson, Maryland. All of these
children were reported by their teachers to have nor-
mal cognitive and motor development. The two addi-
tional children in the 3-year-old group were obtained
through personal contacts. These children's mothers
reported no concerns with their children's develop-
ment. Both children were performing appropriately
in their preschool programs.
The mean age of the visual cue group was 48.79
months (SD = 5.96 months); of the verbal cue group,
4893 months (SD = 5 58 months). Each group had six
3-year-olds and eight 4-year-olds. The verbal cue
group had 7 boys and 7 girls; the visual cue group, 6
boys and 8 girls.
Instrument
The instrument used in this study was based on an
earlier version of the instrument that I used in the
pilot study (Exner, 1986). Most of the items selected
for inclusion on this test were those that most 3- and
4 -year-old children in the pilot study were able to
accomplish using in-hand manipulation skills; some
of the items were selected because only the 5- and
6-year-old children were able to accomplish them
using in-hand manipulation skills. All items were
completed by the 3- to 4-year-old children in the ear-
lier study, although they may not have used in-hand
manipulation skills to accomplish them. Thus, the
children could perceive that they were successful
with the tasks presented even if they did not meet the
scoring criteria. In addition, the items selected were
those that the children found to be interesting
and fun.
Five sets of materials were presented in this
study: (a) nickels and a bank, (b) small pegs and a
pegboard, (c) markers and paper, (d) clay (to form
into a ball), and (e) small erasers that fit into plastic
containers with lids. These materials were selected to
elicit the follOWing in-hand manipulation skills: (a)
finger-to-palm and palm-to-finger translation, with
and without simultaneous stabilization of materials in
the hand; (b) shift, with and without stabilization of
another object in the hand; and (c) rotation, with and
without stabilization of another object in the hand.
This process resulted in eight categories of in-hand
manipulation skills. Each category was tested by one
or more of the activities for a total of 26 items. Each
item was repeated three times in the test. The items
October 1990, Volume 44, Number 10
 were scored according to whether a particular in· hand
manipulation skill was present or absent, Thus, the
maximum total in-hand manipulation score possible
was 78, Maximum scores for the various types of in-
hand manipulation skills ranged from 3 to 12,
The test had three sets of instructions, In the un-
cued (pretest) version, each child was told the end
product for the task, but not the process to use in
accomplishing the task, for example, "Put the money
in the bank, one at a time," "Can you hold three pegs
in your hand at one time?" or "Put the pegs in the
board with this hand," Only for forming the clay ball
was the child told not to use the table surface or the
other hand,
The instructions used in the uncued version of
the test were also used in the cued (posttest) version,
The verbal and visual cues were proVided for the first
trial on each item, On the second and third trials, each
child was asked, "Do you remember how I told/
showed you to do this?" For the visual cues, I said,
"Watch how I do this and see if you can do it like I did
it." An attempt was made to ensure that the child was
visually attending during the demonstrations, Only
one demonstration was provided per item, For the
verbal cues, I emphasized to the children that they
should move the materials with their fingers and not
use their other hand or their body to help move the
object. Instructions were specific to the particular ma-
terials and the skills being tapped, Again, an effort was
made to ensure that the child was attending to me
when the cues were given,
Procedure
Before the stUdy was begun, I trained an undergradu-
ate occupational therapy student to provide interrater
agreement dara, Terminology for in-hand manipula-
tion skills was reviewed, and four test administrations
with nondysfunctional 5-year-old children were con-
ducted, Discussion occurred both during and after
these test administrations to resolve differences in
scoring, No discussion took place during or after the
test administrations in the actual stUdy, The student
collected interrater agreement data for 28 (50%) of
the test administrations, Fifteen of these occurred
during uncued tests; 13, during cued versions of the
test. Seven of the scored cued versions were verbal;
the remaining six tests were visual. The overall agree-
ment between the two raters was 91%,
Two versions of the test were administered to
each child, During the pretest, all children received
the uncued version, Two to 7 days later, each child
was administered either the verbally cued or the vi-
sually cued version of the test. Equal numbers of 3-
and 4-year-old children were randomly assigned to
each group, An attempt was made to have equal num-
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bel'S of boys and girls in each group as well. Due to
the limited number of subjects available in this age
range for the study, a group that received no cuing on
the second test administration could not be formed,
The children were tested in a small room adja·
cent to their classrooms, This room was equipped
with a child-sized table and chairs, Each child was
tested individually, with no other children present.
The testing environment was quiet and familiar to the
children, The two children who were not attending
programs at Towson State University were tested in
their homes with the testing environment as similar to
the other children's test situation as possible, All chil-
dren in programs at Towson State University were
tested in the morning for both tests; the two children
tested in their homes were tested in the late afternoon
or early evening for both tests,
I sat facing the child for all test items, Materials
were presented to the child's preferred hand, The first
four sets of materials were presented to the child with
the table positioned in front of him or her. The last set
of materials, the erasers in the plastic containers, was
presented with the table at the child's left side, This
positioning was used so that the table surface would
be available but not too accessible to the child as he or
she took the eraser toys apart or put them together.
Without such positioning, children have been found
to consistently use the table surface rather than in-
hand manipulation skills for this task
All of the children cooperated With the testing
and demonstrated an active interest in the materials
presented, Each test took 15 to 20 min, The children
were quite willing to participate in the retesting and
attended well to the visual and verbal instructions
proVided, All of the children successfully completed
all the of the items presented, even if they did not use
in-hand manipulation skills,
The Wilcoxon signed rank tests were used to as-
sess differences between the uncued and cued test
data for each group, This nonparametric statistical
procedure was used due to the small sample size, An
independent-groups t test was used to test the differ-
ence between the mean scores of the verbally cued
and Visually cued groups on the pretest and posttest. A
two-way analysis of variance (ANOVA) was used to
assess the effects of age and type of cuing and sex and
type of cuing on the mean scores of the groups,
Results
Table 1 shows a comparison of the various in-hand
manipulation skills used in the uncued and cued
groups, For each skill area, the mean scores increased
in the cued version of the test for both the Visually
cued and the verbally cued groups, Both groups
showed significant changes in palm-to-finger transla-
887
 Table 1
Statistics for Items in the In-Hand Manipulation Test (N = 28)
Verbally Cued Group en = 14) Visually Cued Group en = 14)
Test Skill Uncued Cued p Un cued Cued p
Finger-to-palm translation
withoul stabiEzation
M 8_714 9786 ns 8286 9857 .014
SD 2.867 2577 2.016 1.875
Range 1-12 2-12 4-11 7-12
Finger-to-palm translation
with stabilization
M 7_786 8286 ns 7_786 8500 ns
SD 1718 1437 1.888 0941
Range 4-9 4-9 2-9 6-9
Palm-to-finger translation
without stabilization
M 7321 9714 _002 7.357 8.143 ns
SD 2499 1899 2437 2627
Range 2-11 6-12 3-12 3-12
Palm-to-finger translation
with stabilization
M 6500 9786 _014 6143 9286 .001
SD 4.071 1986 3009 2867
Range 1-12 6-12 0-11 2-12
Shift without stabilization
M 4.214 4786 ns 3000 4286 023
SD 2694 2723 2353 2813
Range 0-8 0-9 0-7 0-9
Shift with stabilization
M 2.500 2_786 ns 2643 2857 ns
SD 0941 0579 0745 0363
Range 0-3 1-3 1-3 2-3
Rotation without
stabilization
M 5_714 7786 023 5_571 6143 ns
SD 2431 3534 3275 3159
Range 0-9 2-12 0-12 1-12
Rotation with stabilization
M 2643 5_571 .002 2500 4_286 .004
SD 2134 2409 2029 2234
Range 0-6 1-9 0-6 LJ-9
Drops
M 1571 2571 ns 1500 2429 ns
SD 1697 1910 1345 1989
Range 0-6 0-6 0-5 0-6
Total'
M 45429 58500 001 43286 53357 002
SD 14119 11044 11.841 12_112
Range 23-64 34-73 28-71 36-76
Note_ ns = not significant.
, Out of a possible 78 pOints.

tion with stabilization (p <05) and rotation with sta­
bilization (p < _01) In addition, the verbally cued
group showed significant changes in palm-to-finger
translation without stabilization (p < .01) and rotation
without stabilization (p < .05) _ The Visually cued
group showed significant changes in finger-to-palm
translation without stabilization (p < .05) and shift
without stabilization (p < .05). The mean number of
times that the children dropped what they were hold·
ing-termed drops-increased (not significantly) for
both the visually cued and verbally cued versions of
the test, but no child had more than six drops during
either test. The mean number of drops was similar for
both groups of children.
Table 2 shows descriptive data from each of the
three trials for the two groups. Significant differences
(p < .01) were found for both groups between Trials 1
and 2 of the uncued and the cued tests. The differ­
ences in Trial 3 for both groups approached, but did
not reach, statistical significance at the p < .05 level.
When post hoc comparisons were made among scores
for different trials within each group for the uncued
test, the only significant difference (p < .05) was
found between Trials 1 and 3 for the verbally cued
group. On the cued test, no significant differences
occurred among trials for the verbally cued group.
The Visually cued group showed significant differ­
ences between Trials 1 and 2 (p < .05) and between

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 Table 2 Table 3
Comparisons of Trials Within Each Test (N = 28) Age X Sex Uncued (Pretest) and Cued (Posttest)
Test Comparisons (N = 28)
Verbally Cued Group Visually Cued Group
(n=14) (n=14) 3·Year·Olds 4-Year-Olds Total
Trial Uncued Cued p Uncued Cued p Uncueu Cued Uncued Cued Uncued Cued
---_.
Trial I Boys
M 14286 19,857 001 14500 17643 ,011 M 40200 53200 42125 54750 41385 54154
SD 4375 3.394 4363 4162 SD 12153 10.426 13442 15.908 12474 13582
Range 7-20 12-24 8-22 10-25 Girls
Trial 2 M 42286 52000 51.000 62250 46733 57467
M 15000 19,286 003 14429 19214 001 SD 12.540 9292 12750 12843 13134 9956
SD 5.129 4232 4219 4.282 TOlal
Range 7-23 10-25 10-24 11-26 M 41417 52500 46562 58500 44250 55929
Trial 3 SD 11859 9327 13461 12.843 12883 11671
M 15929 19.357 054 14357 16500 054
SD 5663 3815 4361 4570
Range 7-23 12-25 7-25 11-25
---_.
Note, TOla I posSible poinls per tria I = 26 Diflerences between boys and girls were greater at
age 4 years than at age 3 years on both the uncued anel
cued tests The 4-year-old girls had the highest mean
Trials 2 and 3 (p < .01) on the cued version of the test. scores on both tests, whereas the 4-year-old boys, 3-
For this group, the highest score was on Trial 2; the year-old boys, and 3-year-old girls scored similarly on
lowest was on Trial 3. the uncued and cued tests. A two-way ANOYA for Age
The verbally and visuaUy cued groups were as· X Group (visual or verbal test cues) and Sex X Group
sessed with an independent-groups t test to ensure resulted in no significant effects.
that there were no significant differences between the Further analysis of the influence of pretest scores
groups before the two types of instruction were pro- on posttest scores was done by plotting the difference
vided for the second test. This obtained t value was scores for each age group. This resulted in the group-
0.3898; the obtained t value for difference between ing of subjects into two categories-those who
groups following visual or verbal instructions was showed substantial change on the posttest (posttest
1.174 (critical value for t = 2056, dI= 26, p =05) score less than 10 points over pretest score) and those
(see Table 1) The verbally cued group's mean total who did not (posttest score 0 to 10 points greClter than
score increased by 13 points; the visually cued pretest score). For both the 3-year-old and 4-year-old
group's score increased by 10 points, Figure 1 illus- children, those who had lower mean scores on the
trates the pattern of scores for the cued and uncued uncued version, on the average, showed more im-
tests. A normal distribution of scores was expected for provement on the cued version of the test (see Table
both sets of data, 4). The groups did overlap, however, such that a few
Table 3 shows the Age X Sex scores for the un- children who initially had low scores did not show
cued anu cued tests as a whole. In both age groups, substantial score gains.
the boys had slightly lower scores th~ln the girls, and
the 3-year-olds had lower scores than the 4-year-olds. Discussion
The interrater agreement data indiclte that the test
was scored consistently and that this consistency can
- - Uncued Test
9 ,.. ---Cued Test
8 / '" Table 4
~ 7
:g 6
---.---.'--..,
/
.... ,, Influence of Uncued Test Scores on Cued Test Scores
..c /
/
,, by Age Group (N = 28)
o 5
'0 4
"
,,' '.
P<lint Change Between Cued <lnd
lIncued TeSlS
~ 3 /" "
/ Age Group <0 to 10 Points >10 Points
2 / . _ - - -------
1 / 5ve:lrokb
Me:\I1 preteSI score ~86 3U
20-29 30-39 40-49 50-59 60-69 70-78 Hang<: of pr('teSl scores 35--')7 23-.jJ
No. of chi IJren 7 5
Total Test Scores ~,\·e<l[·olds
Me<lll prCleS! scon:' 512 38.8
Range of pretest scores 2')-71 3l-47
Figure 1. Total scores of the children for the uncued (pretest)
No. of childn:1l 10 6
and cued (posHest) versions of the In-Hand Manipulation Test

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 be attained with relatively brief training of an occupa-
tional therapy student Agreement levels in the .90
range suggest that the test items can be scored with
reasonable ease with a group of nondysfunctional 3-
and 4-0Id-children.
Cuing appeared to produce a significant increase
in the overall scores of the 3- and 4-year-old children.
The group results suggest, however, that the type of
cuing provided in this study did not influence the
children's performances, similar to Lyons' (1987)
finding with the same age group in which variations of
verbal cues were used. The present study suggests
that visual demonstrations may not influence chil-
dren's performance more than verbal cues. A combi-
nation of visual and verbal cues that direct the child's
attention to the specific component to be imitated
may be more effective than either type of cue alone.
Although, overall, no significant difference in
skills was elicited with the two types of cues, the pat-
terns of scores for the three trials across the two
groups did vary. The children who were provided
with verbal cues had essentially the same mean score
across all three trials. The verbal cues appeared to
help the children focus on what they should not do as
well as what they should do.
In contrast, some of the children who were given
visual cues were unsure of what they should try to
replicate. They appeared to monitor several facets of
my actions, but they did not change their manipula-
tion of the object significantly. This group's mean
scores for the three trials varied more than did the
score's of the verbal group. The children seemed to
try to replicate my performance on the first trial but
were not consistently successful. On the second trial,
they often appeared more skillful. On the third trial,
however, this group of children showed fewer in-
hand manipulation skills overall.
Although the 4-year-olds had somewhat higher
mean scores than did the 3-year-olds on both the un-
cued and cued versions of the test, these differences
were not statistically significant. Additionally, the 3-
year-aids and 4-year-olds did not score in a manner
that would indicate differential responsivity to cues.
The 4-year-old girls were found to have the highest
mean scores. Possibly, the small number of 3-year-
aids affected these findings. In addition, the instru-
ment used in this study did not allow for rating of the
quality or efficiency of the in-hand manipulation
skills used or how closely the skill approximated the
criterion for the item. Instead, it assessed the pres-
ence or absence of a skill. Generally, the 4-year-olds
appeared to be more proficient with the skills and to
use more fingertip control in executing them, but this
was not reflected in the test scores.
The study findings lend support to the use of
Vygotsky's (1978) theory of the zone of prOXimal de-
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velopment with the assessment for fine motor skills.
Although approXimately 60.7% of the children in the
study showed only small increases in test scores (if
any at all) with the cues, the remaining children
showed substantial improvement in performance.
The children who had the most improvement in test
scores appeared to have more advanced in-hand ma-
nipulation skills within their zone of prOXimal devel-
opment. Those children with lower scores on the
pretest, in general, were those who seemed most re-
sponsive to the testing cues.
Some increase in scores might have occurred re-
gardless of cuing; I did not assess this possibility be-
cause a control group could not be included in the
study. Despite this study limitation, however, several
factors suggest that the retaking of the test was not the
primary reason for the overall increases in scores from
pretest to posttest. First, 11 of the 28 children showed
substantial increases in scores, but the other children
showed less marked improvement; thus, not all chil-
dren were significantly influenced by the cues. Sec-
ond, drops increased during the cued tests, thus sug-
gesting that the children were trying new skills. Ob-
servations during testing and comments by the
children indicated that many were attempting to vary
their performance in response to the cues proVided
and that the skills they were asked to perform were
ones that they had not used preViously. Third, the data
suggest that some skills, such as palm-to-finger trans-
lation with stabilization and rotation with stabilization
as well as other patterns involVing stabilization,
changed more with cues than did other in-hand ma-
nipulation patterns.
Recommendations
The present study suggests several avenues for further
study. The Test of In-Hand Manipulation needs fur-
ther development, including item analysis and deter-
mination of internal and test-retest reliability. Until
these phases of instrument development are com-
plete, the results obtained in the present study should
be viewed cautiously and should not be considered as
directly supporting Vygotsky's (1978) theory.
This study does support the feasibility of one's
use of the concept of the zone of proximal develop-
ment in designing an instrument for determining the
skills for which a child shows obvious readiness and
those that are still quite difficult. Perhaps scores could
be increased further with the use of a combination of
visual and verbal cues. We may eventually be able to
use cuing as part of formal testing procedures to
identify those children who may be particularly re-
sponsive to intervention. Further study of changes in
different in-hand manipulation skills when cues are
provided is also warranted.
October 1990, votume 44, Number 10
 Conclusion
The findings of this study suggest support for study of
the extension of Vygotsky's (1978) zone of proximal
development concept into the domain of fine motor
skills. Visual and verbal cues were both effective in
increasing many of the 3- and 4-year-old children's
test scores, but no significant differences were found
between the two types of cues in promoting the chil-
dren's performance. Approximately 30% of the chil-
dren in this study showed substantial improvement in
their posttest scores over their pretest scores, sug-
gesting that these children have a large zone of prOXi-
mal development for in-hand manipulation skills.
This method of assessment-provision of an uncued
test followed by a cued test within 1 week of the
uncued test-seemed to be effective in determining
those children for whom improvement in these ma-
nipulation skills is most likely. Improvement of such
skills is important to the occupational therapist be-
cause it may contribure to the child's ability [Q per-
form various fine mowr skills with greater efficiency
and effectiveness. Further study is needed to assess
the validity and reliability of the instrumem used in
this study. ..t.
Acknowledgments
I thank Joanne Parrott for her collection and assessment of
the interrater reliability data and the program staff and chil-
dren of the Council Day Care Program of Towson State
University, Towson, Maryland; the prekindergarten class of
the Uda Lee Tall School at Towson State University; and the
other chi ldren who participated in this study.
This study was done in partial fulfillment of the re-
quirements of the docLOral program in Education-Hum:m
Development at the University of Maryland. College Park.
Tbe Americall.!oumal o/Occupational Tberapy
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