Upper Limb and Fine Motor Difficulties

Child Development Service

Useful Management Information

  • Children under school age (i.e., infants to pre-prep), who do not have a diagnosis and do not require diagnostic formulation by a team.
  • Children with challenges in participating in activities, that is impacted by a developmental difficulty.
  • The following are not seen through CDS Occupational Therapy (OT):
    • Children who require OT for an acute medical issue or immediately post hospitalisation, or OT to prevent hospitalisation (e.g. therapy related to surgical procedures), should be referred to Gold Coast University Hospital (GCUH) OT.
    • Children with difficulties with development (including fine motor skills and upper limb use) post-oncology treatment should be referred to GCUH OT, who provide short term post-acute intervention (e.g. fine motor skills difficulties due to lack of experience/opportunity due to time in hospital, rather than a developmental delay).
    • Children who have orthopaedic concerns with upper limb such as trigger thumb or dactylies, should be referred to GCUH orthopaedics/plastics.
  • Other information for Referring Practitioners:
    • Children who have orthopaedic concerns with upper limb such as trigger thumb or dactylies should be referred to Orthopaedics .
    • Children with facial asymmetries should be referred to Paediatric Medicine .
    • If the question is of an acute medical diagnosis such as Cerebral Palsy, Erb Palsy, Brachial Plexus Injuries, then referral should go to Paediatric Medicine .
    • Children with asymmetry (use, or tone, or strength) in the lower limbs, trunk, or neck should be referred to Physiotherapy.

Clinician Resources:

Minimum Referral Criteria

Does your patient meet the minimum referral criteria?
Category 1 (appointment within 30 calendar days)
  • No category 1 criteria
Category 2 (appointment within 90 calendar days)
  • Asymmetry: Subtle, moderate and significant differences between use of, or tone, or strength between right and left sides of body, specifically upper limbs.
  • Decreased movement: Young infant who moves upper limbs less than expected (this is a gestalt observation usually noted by a Child Health Nurse) or doesn’t move fingers and thumb or limited range of movement not explained by a known orthopaedic or neurological abnormality.
  • Increased tone in upper limbs impacting on reach, grasp and movements required for play expected for age.
  • Pain associated with fine motor skills (e.g. related to hypermobility that isn’t due to acute neurological or medical deterioration).
  • Children less than 18 months of age that meet criteria for this referral reason.
  • Movement quality issues in the upper limb at any age (i.e. tremor, jerkiness, awkward looking grasps/holds, slow, shaky movements, stiffness, exaggerated opening or closing of hands).
  • Infants with significant difficulties reaching, grasping, and other upper limb movements required for play expected for their age.
    • Examples include:
      • 5-month-old who can’t maintain hold, or doesn’t attempt to reach for or grasp a toy presented
      • 6-month-old who has fisted hands, or is not reaching or grasping toys, or doesn’t reach for objects in midline, or can’t hold one object with two hands
      • 7-month-old who doesn’t use forearm or upper arm movement, or doesn’t reach to side for objects
      • 9-month-old who cannot transfer toys, or who cannot release a toy such as into carer’s hand
      • 18-month-old who has no container play (i.e. controlled release)
  • Severe fine motor skill delays impacting on participating in play or ADLs (e.g. feeding - using cutlery, and dressing – using fasteners).
    • Examples include:
      • 12-month-old who cannot finger feed or hold their own bottle/cup
      • 18-month-old who does not assist with dressing by moving limbs
      • 2-year-old who cannot spoon-feed independently
      • 4-year-old who cannot undress independently (where there has been opportunity provided to do so)
Category 3 (appointment within 365 calendar days)

Recommended to be seen within 90 - 180 calendar days

  • Severe delay in fine motor skills, impacting on participation in pre-academic tasks (e.g. use of pencil and scissors).
    Examples include:
    • 2-year-old who does not scribble (where there has been previous opportunity provided to develop this skill)
    • Pre-prep child who cannot cut along a line, hold scissors in a functional way, holds a pencil in an “awkward” grasp, controls the pencil with their wrist or whole arm, gets tired with drawing/colouring, holds a pencil in a fist grip, or can’t imitate vertical and horizontal lines, circle, cross (+)
  • Moderate developmental delay in fine motor skills, impacting on participation in pre-academic tasks, play or ADLs
    • 2 to 3-year-old who has difficulty manipulating small objects such as blocks
    • 4-year-old who does not draw recognisable pictures, colour within the lines (where there has been previous opportunity provided to develop this skill) or imitate a square
  • 3-year-old who can’t unscrew a lid from a jar (where there has been previous opportunity provided to develop this skill)

If your patient does not meet the minimum referral criteria

  • Assessment and management information may be found on a range of conditions at HealthPathways
  • If the patient does not meet the criteria for referral but the referring practitioner believes the patient requires specialist review, a clinical override may be requested:
    • Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
  • Please note that your referral may not be accepted or may be redirected to another service

Essential Referral Information

  • What activities the child can and cannot do (i.e. rather than simply saying ‘fine motor skills difficulties’)
  • Information on the frequency and duration of the specific difficulty (e.g. “pain in hand every time they draw, noticed 3 months ago and has worsened”).
  • Information on what investigations, if any, have been completed.

Additional Referral Information

  • Highly desirable information – may change triage category
    • Confirm the presence or absence of pain and/or fatigue when using hands
    • Provide reports from childcare/kindy in relation to the child’s performance in pre-academic skills
  • Desirable information – will assist at consultation
    • What strategies have already been tried to address fine motor and upper limb difficulties?
Last updated 7 December 2021

Send Referrals To

Smart Referrals

Preferred Method
About Smart Referrals

Secure Web Transfer

Send to: Gold Coast Child Community Health MO Account: GQ4215000TL HL EDI: qldcomch

Internal Referrals


(07) 5687 4497


Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215


(07) 5687 9141

Related HealthPathways

No directly related pathways found

Service Availability

Dr Francoise Butel
Medical Director Children's Community Health


Gold Coast University Hospital
Southport Health Precinct
Palm Beach Community Health Centre
Helensvale Community Health Centre
Upper Coomera Child Health
Early Years Centre Coomera Springs
Norfolk Village State School Health & Education Hub

If you would like to send a named referral, please address it to the specialist listed above, who will allocate a suitably qualified specialist to see the patient. Alternatively, you can view a full list of our specialists.

Child Safety

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