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 skills. Reflexes that initially developed to aid survival, become integrated into more refined movements as the child matures. Children tend to acquire these skills in an orderly fashion and within certain age brackets. This patter of skill acquisition is often referred to as 'Normal or Typical Development', and 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 acquistion of these skills is still considered 'normal' is wide (see WHO Study discussed later), 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 are outlined below.

Principles of Typical Development

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

Typical Development Global Patterns & Positions

0 - 2 MONTHS

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 breath  Slight increase of extensor muscles control head / neck  The baby is more alert, begins to respond to the environment  MORO Primitive Reflex Active  TACR Present  Gesture - Communication: Smile (6-12 weeks)
SUPINE	PRONE
Functional Achievement:   Slight movements in rotation of the head + lateral flexion of the trunk when trying to move the head, gesture, stared at the mother. Posture: Head Position: Hyperextension 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: Raise head less than 45°, baby push 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 covex) Pelvic Girdle: Pelvis in Anteversion Lower Limbs: Hip Joints in Flexion, Abduction and External Rotation

3 MONTHS

SYMMETRY (control of bilateral neck muscles) begins 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: Stare and makes visual tracking. Head control and maintain 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 vertebras elongate and dissociate. Upper Limbs: Scapulas in ADD, shoulders in 120 of FLEX, elbows 90º, hands open (not ulnar deviation). Trunk: Symmetric Pelvis: Slightly to retroversion. Lower Limbs: Triple flexion 90º of hips, knees and ankle. Ext ROT and ABD, feet in middle line. 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 the end of 3 months elbows in 90º of FLEX and in front of shoulders. Trunk: Beginning to gain range of lumbar extension because of the activity and alignment of the upper limb. Pelvic girdle and lower extremities: Beginning of pelvic extension, hips abducted and externally rotated, knees semi- Flex.

4 MONTHS	j
Development of Sagital Plane Strong symmetry, flexion and extension increased Beginning of Landau reaction in EXT.  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.	j
SUPINE	PRONE
Antigravity Movement: Is able to touch genitals and play with his/her clothes, with low limbs in FLEX. 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.

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 Aquisition

                                                                 Windows of Milestone Achievement in Months 

While motor milestones are undoubtable a useful way of monitoring a childs' 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 Organisation 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 above. It should also be noted that this study found that 4.3% of participants never exhibited the hands and knees crawling milestone.

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 cuases 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 symettrically 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 

Recent Related Research (from Pubmed)

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References

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