fine-motor,occupational-therapy

and

$tax_query = array(
	'relation' => 'AND',
	array(
		'taxonomy'         => 'attachment_category',
		'terms'            => array( 'fine-motor', 'occupational-therapy' ),
		'field'            => 'slug',
		'operator'         => 'AND',
		'include_children' => false,
	),
	array(
		'taxonomy'         => 'attachment_tag',
		'terms'            => 'active',
		'field'            => 'slug',
		'operator'         => 'AND',
	),
	array(
		'taxonomy'         => 'attachment_category',
		'terms'            => 'handwriting',
		'field'            => 'slug',
		'operator'         => 'NOT IN',
		'include_children' => false,
	),
);