Child Development
== 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 pattern of skill acquisition is often referred to as 'Normal 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 e.g. crawling. The average age at which gross motor, fine motor and social skills are acquired are outlined below. == Principals of Normal 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) == Normal Global Movement Patterns and Positions == {| width="100%" border="1" cellpadding="1" cellspacing="1" |- ! scope="col" colspan="2" | 0 - 2 Month |- | colspan="2" | *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, while 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 very present *Gesture-Communication: Smile (6-12 weeks). |- | align="center" | SUPINE | width="50%" align="center" | PRONE |- | align="left" valign="top" | Functional Achievement: Slight movements in rotation of the head with lateral flexion of the trunk when trying to move the head, gesture, stares at the mother.
Posture: *Head Position: Hyperextension and rotated (Asymmetry) *Upper Limbs: Abduction and External Rotation (absorbed by Gravity), Hands in ulnar deviation although at 2 months thumb is not included any more in the hand. *Trunk Position: Very active in frontal plane. *Lower Limbs: more asymmetrical and extension lying in the frontal plain, not very active. *Pelvic Girdle: Pelvis in anteversion
| width="50%" | 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.
Weight Bearing: 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 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) *Lower Extremities: Hip joints in flexion, abduction and external rotation. *Pelvic Girdle: Pelvis in Anteversion |}
{| width="100%" border="1" cellpadding="1" cellspacing="1" |- | colspan="2" align="center" | 3 Months |- | colspan="2" | *Symmetry (Control of Bilateral Neck Muscles) begins *Begins orientation to Midline of Head Position *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, can do visual tracking of 180 degrees of rotation of head to follow an object |- | width="50%" | 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, no deviations in trunk or shoulders. Cervical vertebras elongate and dissociate. *Upper LImbs: Scapulas Adducted, Shoulders in 120 of Flexion, Elbows 90º, Hands Open (No Ulnar Deviation) *Trunk Position: Symmetrical *Lower Limbs: Flexion 90º at Hips, Knees and Ankles. External Rotation and Abduction with Feet in Mid Line. Good synergy between ventral and dorsal muscles.
*Pelvic Girdle: Pelvis Slightly Retroverted | align="left" valign="top" | Antigravity Movement: Pushes against surface to raise head at least 45°, chest elevated.
Weight bearing: 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 Flexion and in front of shoulders. *Trunk Position: Beginning to gain range of lumbar extension because of the activity and alignment of the upper limb. *Lower LImbs: Hips Abducted and Externally Rotated, Knees Semi- Flexed *Pelvic Girdle: Beginning of Pelvic Extension |} {| width="100%" border="1" cellpadding="1" cellspacing="1" |- ! scope="col" colspan="2" | 4 Months |- | colspan="2" | *Development of Sagital Plane movement *Strong Symmetry, Flexion and Extension Increased *Beginning of Landau Reaction in Eextension *Strong synergy between Flexor and Extensor Muscles of the Neck, Chin in more retraction. *Begins gripping, can hold an object but loose it by chance. *Lateral Rocking *Able to remove a blanket from the face with both hands. |- | align="center" | SUPINE | align="center" | PRONE |- | align="left" valign="top" | Antigravity Movement: Is able to touch genitals and play with his/her clothes, with low limbs in Flexion. Is able to move to lateral position (lateral rocking). | width="50%" align="left" valign="top" | Weight Bearing: Weight on forearms, hands and abdomen
Antigravity Movement: Free manipulation with both hands. Start lateral shifting of weight from one arm to another.
|} {| width="100%" border="1" cellpadding="1" cellspacing="1" |- ! scope="col" colspan="2" | 5 Months |- | Good lateral weight transfer, symmetry enables coordination between both sides.
Increased reaction Landau
Swimming position
Important manipulative strategies in supine.
| |- | | |} == Gross Motor Activities == {| class="FCK__ShowTableBorders" |- | Activity | align="center" | Age |- | Lifts head to 45° | align="center" | 2/12 |- | Props on forearms in prone | align="center" | 3/12 |- | Rolls over | align="center" | 5/12 |- | No Head Lag | align="center" | 5/12 |- | Prone on extended arms | align="center" | 6/12 |- | Balance reactions | align="center" | 6/12 |- | Sitting without support | align="center" | 6-8/12 |- | Pulls to stand | align="center" | 8-9/12 |- | Cruises | align="center" | 8-9/12 |- | Crawls reciprocally | align="center" | 9/12 |- | Stands alone | align="center" | 11/12 |- | Walks alone | align="center" | 12/12 |- | Runs | align="center" | 18-24/12 |- | Walks up and down stairs with handrail | align="center" | 2 yrs |- | Pedals tricycle | align="center" | 3 yrs |- | Walks narrow line | align="center" | 5 yrs |} [1][2] == Fine Motor Skills == {| |- | Activity
| align="center" | Age |- | Follows objects with eyes | align="center" | 1-2/12 |- | Grasps objects | align="center" | 4/12 |- | Hand to hand transfers | align="center" | 5/12 |- | Finger feeds | align="center" | 6/12 |- | Objects into container | align="center" | 12/12 |- | Builds 2 block tower | align="center" | 14/12 |- | Helps with dressing | align="center" | 15/12 |- | Builds 6-7 cube tower | align="center" | 2 yrs |- | Uses fork and spoon skilfully | align="center" | 2.5 yrs |- | Holds pencil with adult grasp | align="center" | 4 yrs |- | Colours inside lines | align="center" | 5 yrs |} [1][2] == Social Skills == {| |- | Activity/Interaction | align="center" | Age |- | Smiles when stimulated | align="center" | 1/12 |- | Vocalises to self | align="center" | 6/12 |- | Plays peek-a-boo | align="center" | 8/12 |- | Stranger anxiety | align="center" | 8/12 |- | Drinks from cup | align="center" | 12/12 |- | Uses spoon | align="center" | 13/12 |- | 2-6 words | align="center" | 15/12 |- | Feeds self fully | align="center" | 2 yrs |- | Bladder and bowel control | align="center" | 2 yrs |- | Has 50+ words, understands 1000+ | align="center" | 2 yrs |- | Undresses | align="center" | 2.5 yrs |- | Gramatically correct speech | align="center" | 4 yrs |- | Fluent | align="center" | 5 yrs |} [2] == Age Ranges of Skill Aquisition ==
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[3]. == 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[4]. This is demonstrated in the video below. Age of Integration: 3-4 months
[5]
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[4]. Both this and the plantar grasp reflex are seen in the next video clip. Age of Integration: 4 months[6]
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 [6]
[7]
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[4]. This reflex is demonstrated in the clip below. Age of Integration: 3-6 months[6]
[8]
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[4]. This is demonstrated in the clip below. Age of Integration: 6 months[6]
[9] == Recent Related Research (from Pubmed) ==
== References == References will automatically be added here, see adding references tutorial.
- ↑ 1.0 1.1 Bly L. Motor skills acquisition in the first year: An illustrated guide to normal development. ed. 1. Great Britain: Elsevier Science & Technology books, 1998.
- ↑ 2.0 2.1 2.2 Sheridan M. D. Sharma A. and Cockerill H. From birth to five years. ed. 3. London: Routledge, 2008.
- ↑ WHO Multicentre Growth Reference Study Group.‘WHO Motor Development Study: Windows of achievement for six gross motor milestones’. Acta Paediatrica. 2006
- ↑ 4.0 4.1 4.2 4.3 Zitelli BJ, McIntire SC and Nowalk AJ. 2012. Zitelli and Davis' Atlas of Pediatric Physical Diagnosis. Ed. 6. Philadelphia: Elsevier
- ↑ onlinemedicalvideo. Physical exam-Newborn Normal: Primitive reflexes-suck, root. Available from: http://www.youtube.com/watch?v=_Vs7_aHfOy8 [last accessed: 17/06/13]
- ↑ 6.0 6.1 6.2 6.3 Votroubek W. 2009. Pediatric Home Care for Nurses: A Family-Centred Approach. Ed. 3. Sudbury: Jones and Bartlett Pblishers Inc.
- ↑ onlinemedicalvideo. Physical exam-Newborn normal: Primitive reflexes-grasp. Available from: http://www.youtube.com/watch?v=BF1j1PXRq-I [last accessed: 17/06/13]
- ↑ Onlnemedicalvideo. Physical exam-Newborn normal:primitive reflexes-moro. Available from: http://www.youtube.com/watch?v=7oD6set72lo [last accessed: 17/06/13]
- ↑ Dr. Prodigious. Primitive Reflexes, Asymettric Tonic Neck-3 months-Infant clinical exam (MRCP. Available from: http://www.youtube.com/watch?v=uXsb7bxTc5g)[last accessed: 17/06/13]
