Child Development

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Introduction

As a child grows, they learn and acquire more refined gross and fine motor skills, as well as developing social and emotional skills. As the child matures, primitive reflexes that are initially developed to aid survival, become integrated into more refined movements. Children tend to acquire these skills in an orderly fashion and within certain age brackets. This pattern of skill acquisition, often referred to as "Typical Development", is used to monitor a child's developmental progress. In some cases late acquisition of these 'milestones' can indicate developmental delay. However, it must be remembered that the time span within which acquisition of these skills are still considered 'typical', are wide , and that some children may skip a milestone altogether. (eg. crawling)

The average age at which gross motor, fine motor and social skills are acquired is outlined below.

Principles of Typical Development

• Cranial to Caudal
• Proximal to Distal
• Flexion to Extension
• Asymmetry - Symmetry - Asymmetry
• Gross to Fine; Simple to Complex
• Global Patterns in 3 Planes (Frontal, Sagittal, Transverse) 

Typical Development Global Patterns & Positions

0 - 2 Months

You can download the Centers for Disease Control and Prevention 2 Month Milestone Checklist here.

Asymmetry and Flexion Period. Physiological Flexion. Mass Movements. Slight intentioned movements of the head in prone and supine.   In supine there are large movements of the upper limbs.  In prone activities are limited to the lifting and turning of the head to breathe.  Slight increase of extensor muscles control head / neck.   The baby is more alert, begins to respond to the environment.   MORO Primitive Reflex Active.  ATNR Present.  Gesture - Communication: Smile (6-12 weeks)	2 Month Milestone: Makes Smoother Movements with Arms and Legs.
SUPINE	PRONE
Functional Achievement:   Slight movements in rotation of the head + lateral flexion of the trunk when trying to move the head, gesture, stare at the mother. Posture: Head Position: Hyperextended and rotated. (Asymmetry) Trunk Position: Very active in frontal plane. Upper Limbs: Remain in Abduction and External Rotation. (Absorbed by Gravity) Hands in Ulnar Deviation although in 2 months. Thumb is not included any more in the hand. Pelvic Girdle: Pelvis in Anteversion. Lower Limbs: Remain more asymmetric and extension lying in the plain, not very active.	Functional Achievement: Raises head less than 45°, pushes the floor with the fists trying to lift head against gravity and against the resistance of spinal and hip that remain in flexion. Weightbearing: On cheek, hands, forearms and upper chest. Posture: Head Position: Baby uses the extension of upper trunk from an asymmetrical position to raise the head, uses upward gaze (eye extension) to assist the spinal extension. Eyes play a significant role in postural control. Upper Limbs: Shoulders in protraction, arms close to the body, elbows behind shoulders and in flexion. Trunk Position: Lumbar flexion and asymmetric in the frontal plane. (concave or convex) Pelvic Girdle: Pelvis in Anteversion. Lower Limbs: Hip Joints in Flexion, Abduction and External Rotation.

3 Months

Symmetry Begins. (Control of Bilateral Neck Muscles) Begins orientation to the midline of head. The Tonic Grasp Reflex is gone so can play with hands; hand-hand coordination and hand-eye coordination begins. Increase of Extension. TACR and MORO decreased or disappear. Increased visual control independent from the head also can do visual tracking of 180 degrees of rotation of head to follow an object.
SUPINE	PRONE
Functional or Antigravity Achievement: Stares and visual tracking. Head control and maintains in midline. Coordination between; hands-mouth, hand-hand and feet-feet these are up of the plane of support. Immature kicking. Posture: Head Position: Chin tuck, selective movement of rotation, not deviations in trunk or shoulders. Cervical vertebrae elongate and dissociate. Upper Limbs: Scapulas in ADD, shoulders in 120 of FLEX, elbows 90º, hands open (not ulnar deviation). Trunk Position: Symmetric Pelvic Girdle: Slightly Retroverted Lower Limbs: Flexion of Hips, Knees and Ankles to 90º with External Rotation and Abduction Feet in Midline Good synergy between Ventral and Dorsal Muscles	Antigravity Movement: Pushes against surface to raise head at least 45°. Chest elevated. Weightbearing: Symmetrically distributed on forearms (epitroclea and hands) and abdomen. Posture: Head Position: To 90º Upper Limbs: Shoulders abducted, elbows in line with shoulders, forearm support on immature extended arm support. At the end of 3 months elbows in 90º of FLEX and in front of shoulders. Trunk Position: Beginning to gain range of lumbar extension because of the activity and alignment of the upper limb. Pelvic Girdle: Beginning of pelvic extension Lower Limbs: Hips abducted and externally rotated, knees semi- flex.

4 Months

You can download the Centers for Disease Control and Prevention 4 Month Milestone Checklist here.

Development of Sagittal Plane. Strong symmetry, flexion and extension increased; Beginning of Landau Reaction in Extension. Strong synergy between flexor and extensor muscles of the neck, chin in more retraction. Begins gripping feature, can hold an object but loose it by chance.  Lateral rocking. Able to remove a blanket from the face with both hands	Brings Hands to Mouth
SUPINE	PRONE
Antigravity Movement: Is able to touch genitals and play with their clothes, with lower limbs in Flexion. Is able to pass to lateral position. (lateral rocking)	Weightbearing: Weight on forearms, hands and abdomen. Antigravity Movement: Free manipulation with both hands. Start lateral shifting of weight from one arm to another .

5 Months

Good lateral weight transfer, symmetry enables coordination between both sides. Increased Landau Reaction. Swimming Position. Important manipulative strategies in supine.
SUPINE	PRONE
Antigravity Movement: Touches knees with hands, choosing to do it both hands at the same time or independence one from the other. Grasp and manipulate in the midline staring the toy. Gripping still from the ulnar side of the hand, with palmar flexion and supination to explore the toy with mouth.	Antigravity Movement: Chin tucked and chest elevated. Flexion and extension of knees, may play with feet together, lateral weight shift to wrap with the opposite hand. The infant may also push backward in this position. Weightbearing: Weight on hands, lower abdomen and thighs. Triangle base of support between nape elbow and thigh and face knee. Uses this base of support to liberate the face arm and wrap a toy with more stability.

6 Months

You can download the Centers for Disease Control and Prevention 6 Month Milestone Checklist here.

Rolls Over in Both Directions Front to Back, Back to Front	When Standing, Supports Weight on Legs and Might Bounce	Rocks Back and Forth, Sometimes Crawling Backward before Moving Forward
SUPINE	PRONE	PIVOTING
Antigravity Movement: Eyes-feet-hands coordination, rolls from supine to prone. Movement initiated by shoulder, pelvis or head. Posture during Rolling: Head Position: Lateral head righting when the baby reaches to the lateral side. Upper Limbs: Base support arm is in 90° of FLEX, slight EXT ROT, elbow in flexion and pronation, hand open. Oscillate arm shoulder in ABD, elbow in semi-flexion and pronation, hand open. Scapulas dissociated: one has weight bearing functions and the other a basic movement to grasp a toy. Trunk Position: Elongated on weight bearing side. Pelvic Girdle: Dissociation of the hemipelvises start when the baby reaches the lateral side. Transversal plane. Lower Limbs: The rolling starts with triple flexion and finishes with legs in extension. Weightbearing in Rolling: Shoulder, elbow, hemipelvis of the side that is rolling	Antigravity Movement: Swimming posture. Active weight shift to one side and grasp with the other hand. Weightbearing: Weight on one forearm or open hands, and distal thigh. Posture: Head Position: Chin tuck and chest elevated. Upper Limbs:  Arms extended, shoulders coapted, hands open. Pelvic Girdle: Extension Lower Limbs: Approaching neutral position.	Weightbearing: Weight on trunk, arms and hands. Posture: Head Position: Head at 90° legs abducted and externally rotated. Antigravity Movement Pivots: Movements in arms and legs, lateral trunk flexion. Child use both arms and legs to pivot.

7 Months

Supporting legs on hands and knees (four legs) Comando creeping Lateral sitting Can pass one object from one hand to the other Can take one object in each hand Answers to name Starts eating some solid food
SUPINE	PRONE
Antigravity Movements: Puts foot in mouth with hands  Contact Eye - Hand - Feet - Mouth Radial Gripping Digit	Antigravity Movements: Begins to get in 4 point kneeling Begins to creep forward Play in lateral support position

8 Months

At 8th months, all structures, bones and muscles, are prepared for the child to sit. Immature crawling Landau postural reaction complete Stranger anxiety Follows a falling object with eyes Discover a hidden toy Play Peek-a-boo

PRONE

Antigravity Movements: Start of immature crawling From lateral support reaches the sitting position alone Can grip 3 toys at the same time

9 Months

You can download the Centers for Disease Control and Prevention 9 Month Milestone Checklist here.

Pulling with the arms can stand starting from a kneeling position. Will remain standing only a few seconds.  Mature Crawling.  Bisyllables “Papa”, Tata” Waves “Bye, Bye” with hand
Can get into Sitting Position.	Crawls.

10 - 12 Months

You can download the Centers for Disease Control and Prevention 12 Month Milestone Checklist here.

Makes side/lateral walking supported by hand on a table. Stands alone.

May Take a Few Steps without Holding On.

12 - 18 Months

You can download the Centers for Disease Control and Prevention 18 Month Milestone Checklist here.

Walks Autonomously. Squat Position. Moves from standing to squat and back to standing without any support. Can build a tower of two bricks, puts a chickpea into a plastic bottle, and eats with spoon. First Words (Mama, Baba, Dada…) Helps in Dressing.
Walks Alone.	May Walk Up Steps and Run.
Pulls Toys While Walking.	Can Help Undress Herself.

18 - 24 Months

You can download the Centers for Disease Control and Prevention 24 Month Milestone Checklist here.

Runs, walking on toes and heels. Jumping on the same spot. Walks up and down stairs with handrail. Tower of 6 bricks, turns pages of a book. Bladder Control.
Begins to Run.	Makes or Copies Straight Lines and Circles.

3 Years

You can download the Centers for Disease Control and Prevention 3 Year Milestone Checklist here.

Pedal Tricycle. One Leg Standing. Uses Scissors. Uses Spoon and Fork.
Runs Easily.		Takes Turns in Games.

5 Years

You can download the Centers for Disease Control and Prevention 5 Year Milestone Checklist here.

Walk in a High Narrow Line.

Stands on One Foot for 10 Seconds or Longer.

Hops; May be able to Skip.

Gross Motor Activities

Activity	Age
Lifts head to 45°	2/12
Props on forearms in prone	3/12
Rolls over	5/12
Prone on extended arms	6/12
Balance reactions	6/12
No Head lag	5/12
Sitting without support	6-8/12
Pulls to stand	8-9/12
Cruises	8-9/12
Crawls reciprocally	9/12
Stands alone	11/12
Walks alone	12/12
Runs	18-24/12
Walks up and down stairs with handrail	2 yrs
Pedals tricycle	3 yrs
Walks narrow line	5 yrs

Fine Motor Skills

Activity	Age
Follows objects with eyes	1-2/12
Grasps objects	4/12
Hand to hand transfers	5/12
Finger feeds	6/12
Objects into container	12/12
Builds 2 block tower	14/12
Helps with dressing	15/12
Builds 6-7 cube tower	2 yrs
Uses fork and spoon skilfully	2.5 yrs
Holds pencil with adult grasp	4 yrs
Colours inside lines	5 yrs

Social Skills

Activity/Interaction	Age
Smiles when stimulated	1/12
Vocalises to self	6/12
Plays peek-a-boo	8/12
Stranger anxiety	8/12
Drinks from cup	12/12
Uses spoon	13/12
2-6 words	15/12
Feeds self fully	2 yrs
Bladder and bowel control	2 yrs
Has 50+ words, understands 1000+	2 yrs
Undresses	2.5 yrs
Gramatically correct speech	4 yrs
Fluent	5 yrs

Age Ranges of Skill Acquisition

While motor milestones are undoubtedly a useful way of monitoring a child's development, it must be remembered that each child is different and will achieve the various milestones at different rates. There is a wide window for achievement of these milestones, during which achievement of the milestone is still considered to be in line with normal development. A study published by the World Health Organization in 2006 demonstrates just this. This study recorded the variations in milestone achievement in 816 children and generated windows during which achievements of these milestones is considered to be normal development, these are outlined in the table below. It should also be noted that this study found that 4.3% of participants never exhibited the hands and knees crawling milestone.

Windows of Milestone Achievement in Months

Primitive Reflexes

The primitive reflexes are movement patterns that can be involuntarily elicited in a newborn. They exist to enhance chances of survival. These reflexes should be integrated as the child's motor development matures. The persistence of these reflexes beyond the usual ages of integration is suggestive of ischemic brain injury. Below several of the primitive reflexes, their appearance and integration dates are discussed.

Rooting Reflex

The rooting reflex can be elicited by gently stroking the child's cheek. The reflex is intact if the child's response is to attempt to bring the object to their mouth. This is demonstrated in the video below.

Age of Integration: 3-4 months

Palmar Grasp

This reflex can be elicited by stimulating the palmar surface of the child's hand. The reflex is intact if the child reflexively grasps the object stimulating the palm. Both this and the plantar grasp reflex are seen in the next video clip.

Age of Integration: 4 Months

Plantar Grasp

This reflex is elicited by stimulating the plantar aspect of the child's foot, just below the toes. The reflex is intact if this causes toe flexion.

Age of Integration: 9 Months

Moro:

The Moro reflex is typically elicited by rapid extension of the child's neck. However it can also occur in response to loud noises. The reflex is intact if the child symmetrically and simultaneously abducts and extends the upper limbs, and extends the trunk. The upper limbs then immediately adduct. This reflex is demonstrated in the clip below.

Age of Integration: 3 - 6 Months

Asymmetrical Tonic Neck Reflex (ATNR)

This reflex is elicited by turning the child's head to one side. A normal response is seen if the baby's extensor tone increases on the side the head is facing, and flexor tone increases on the opposite side. This is demonstrated in the clip below.

Age of Integration: 6 Months 

Resources

• Child Development - UNICEF Parenting
• CDC’s Developmental Milestones