Advanced Gross Motor Skills in Children

Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti and Jess Bell

Introduction

Childhood milestones are precise behaviours that identify typical stages of growth and development. Gross motor milestones involve the large muscles and typically occur within a specified range of time. Although there is a defined timeframe, it can vary as every child develops at their own pace. Expectations, cultural beliefs and practices can affect childrearing practices as they will provide different experiences and opportunities for each child within and between cultures.

Gross motor milestones occurs in a predictable pattern. Children develop top to bottom progressing upper body control before lower body. Each new skill is built on the previous skill acquisition. Crawling supersedes standing and standing supersedes walking. Upright advanced gross motor skills occur once the child is independent in sitting and is able to transition in and out of the sitting position.

Dependent Standing

Around 7 months, children are dependent in standing and walking requiring upper extremity support. The necessity for external support is due to their underdeveloped balance responses and poor anterior-posterior weightbearing alignment. Gait at this age is marked by a wide base of support with moderate abduction, hip external rotation and pronated feet. The amount of pronation correlates to the amount of abduction and external rotation of the hips. Children during this stage will walk with their hip and knees flexed.

Pull-to Stand

Between 7-8 months old, children begin to pull themselves up in their crib into a standing position. This movement is initiated by utilising the strength of their upper extremities. In this upright position, the child will hold onto the rails and bounce as they interact with their environment. During these early pull to stand experiences, the child has difficulty getting down as they are not adept at using eccentric control of the hip and knees to lower themself. Once tired, they will simply let go and drop down into sitting.

Tall-kneeling

By 10 months old, children pull themselves up to standing using a low table or sofa. At this stage, they rely mainly on their lower extremities to facilitate the motion with very little effort from the upper extremities. The upper extremities are used mainly for balance. They move into standing by moving from tall-kneeling (knee standing) to half-kneeling postures. They use these same postures to get back down to the floor.

To transition from tall kneeling to half-kneeling the child moves through the following steps:

• wide base of support
• shifts weight to one side
• elongates trunk on weight shifted side
• unweighted leg moves forward and places foot flat on floor into half-kneeling position
• uses hip and knee extensors to facilitate moving against gravity to standing position

The video below by Pediatric Physical Therapy Exercises demonstrates tall-kneeling to half-kneeling to stand:

With practice, these movements become quick and very controlled. Once the child is able to pull-to-stand, they will squat and play for long periods of time moving back and forth between furniture and the floor. As the child moves from squat-stand-squat, co-contraction of the ankle musculature occurs enhancing stability..

Cruising

Around 10 months old, children begin to step sideways holding furniture for support. This supported lateral movement is referred to as cruising, With this newfound mobility, the child is able to work their way along the furniture eventually reaching other pieces of furniture in an effort to navigate the room. Cruising gait exhibits less hip and knee flexion and better anterior-posterior alignment. Balance improves during this time as the takes opportunities to lifts one supported hand and rotate their body. They may even take 1-2 steps without upper extremity support. The child will eventually stand independently letting go of their upper extremity support.

Cruising facilitates the child's strength in their lower extremity musculature specifically the hip abductors/adductors and ankle evertors/invertors. During this stage, the plantar grasp reflex may still be present although considerably diminished. Complete resolution of the reflex is necessary for independent unsupported walking to develop.

Independent Ambulation

Between 10-15 months old, children begin to walk independently with the average age being 12 months.Initial ambulation is marked with various characteristics and progressesions as the child practices and gains experiences.

This video by Kids on the Move provides tips to encourage cruising:

Initial Gait

• hip and knees flexed
• abduction and external rotation of the hips
• wide base of support
• pronated feet
• no heel strike
• upper extremities in a high guard position
• abducted shoulders away from body (head height)
• elbows flexed
• hands up high
• circumduction of leg
• may see steppage gait or foot slap

Gait Progression 1

• upper extremities in mid guard position
• shoulder abducted out to side (close to shoulder height)
• elbows flexed
• hands just above waist and stabilised against the body
• fingers pointing upwards

Gait Progression 2

• upper extremities in shoulder extension and hang at child's side
• reciprocal arm swing
• increasing hip and knee extension
• decreased hip abduction
• decreased external rotation of the hip
• narrowing of base of support
• neutral pronation/supination of the feet
• heel strike, push off (around 2 years old)

** Children's gait continues to mature until the age of 7-9 years old. At this stage their gait resembles one of an adult.

**Children activate more motor units than adults suggesting less control and weaker muscles.

Gait Parameters

Gait parameters consisting of step and stride length, velocity and cadence will change as the child grows and matures.

The measurement from heel strike on one foot to heel strike on the opposite foot is referred to as step length. Stride, on the other hand is measured from heel strike on one lower extremity to heel strike on the same extremity. Stride length is roughly twice the step length. Velocity (distance covered over a specified amount of time) is correlated to the length of one's stride or step. Between the ages of 1-3, a child's velocity increases as their stride and step length increase.

During initial independent walking, the child spends very little time in single limb stance due to lack of strength and stability in their hips. This decreased stance time results in a high cadence (the number of steps per minute). As their strength and balance increase over time, the amount of time in single limb stance increases with a subsequent decrease in cadence.

Stairs

Many factors play a role in the ability of a toddler to negotiate stairs with opportunity being the main one. Some children do not have stairs in the home and therefore may not have the chance to practice this milestone. Those who do have stairs are more likely to ascend stairs at a younger age.

Initially stair climbing takes the form of both feet landing on each step. Alternating feet with stair climbing does not generally occur until the age of 3.. Upper extremity support changes as stair climbing progresses. Initially the child will be dependent on upper extremity support from a handrail or adult. As they progress, no upper extremity support will be required.

3-6 years old

• Running
  • true running: both feet are off the ground at the same time
  • immature running begins around 2 years old
  • true running occurs between 3-4 years old
• Jumping
  • once able to clear the floor with both feet simultaneously
  • around 3 years old
• Biking
  • have to coordinate both legs doing different activities
  • have to maintain trunk stability and control
  • around 3 years old
• Hoping
  • around 4 years old
• Galloping
  • around 4 years old
• Skipping
  • around 5-6 years old

Resources

• Learning to Stand
• Gross Motor Milestones in Infants 0-14 Months
• Development of Sitting