Pediatricsi: Developmental Milestones: Motor Development R. Jason Gerber, Timothy Wilks and Christine Erdie-Lalena Pediatr. Rev. 2010;31;267-277 DOI: 10.1542/pit.31-7-267 ‘The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.eappublications.org/cgi/content/full/3 1/7/267 Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Iinois, 60007. Copyright © 2010 by the American Academy of Peaiatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347. ‘American Academy of Pediatrics & DEDICATED TO THE HEALTH OF ALL CHILDREN” Dowaloaded from itp://pedsinreview.aappublications org, Provided by LSU Medical Center on October 12, 2010Article growth & ceveoom Jason Gerber, MD,” Timothy Wilks, MO," Christine Exe-Latena, mot ‘uthor Disclosure Des Gerber, Wilks, and Erdie-Lalena have dlislosed no financial tclationshis relevant, to this atte. This commentary does not contain a discussion of an unapproved invesigative se of commercial produt/eviee Objectives after completing this article, readers should be able to: 1. Identify the milestones for gross and fine motor development. 2, Recognize the child whose development falls outside of the expected range, ‘3. Deserbe the sequences involved in gross and fine motor development. This is the frst of three articles on developmental milestones; the second and third ortcles will oppear in the September and November 2070 issues of Pediatis in Review, respectively. Introduction Infancy and childhood are:dynamie periods of growth and change. Neurodevelopmental and physical growth proceed in a sequential and predictable pattern that is intrinsically determined. Skills progress from cephalic to caudal; from proximal to distal; and from generalized, stimulus based reflexes to specific, goal-oriented reactions that become increasingly precise. As one clinician has stated, “infants [and children] are very orderly in their ways; they actually behave [and develop] according co laws that can be explored, discovered, confirmed, reconfirmed, and celebrated.” (1) By convention, these neuro developmental “laws” or sequences often are described in terms of the traditional devel- Milestones provide a framework for observing and monitoring a child over time. According to recent American Academy of Pediatrics and Bright Fusures guidelines, pediatricians should incorporate developmental surveillance at every health supervision, visit, Surveillance involves analyzing the milestones in the context of a child’s history, growth, and physical examination findings to recognize those who may be at tisk for developmental delay. A thorough understanding of the normal or typical sequence of development in all domains (gross motor, fine motor, problem-solving, receptive lan- guage, expressive language, and social-emotional) allows the clinician to formulate a correct overall impression of a chill’s rue developmental status. However, it must be ‘emphasized that even experienced pediatricians cannot rely solely on their knowledge of the milestones to identify children who have developmental concerns. Developmental screcning using validated and standardized tools should oceurat the 9-month, 18-month, and 30-month (or 24-month) health supervision visits or whenever surveillance uncovers 2 concern, Although neurodevelopment follows a predictable course, itis important ro understand, thar intrinsic and extrinsic forces produce individual variation, making each child's devel- ‘opmental path unigue. Inetinsic influences include genetically determined artribures (eg, physical characteristics, temperament) as well as the cbild’s overall state of wellness. Extrinsic influences during infancy and childhood originate primarily from the family. Parent and sibling personalities, the nurturing methods used by caregivers, the eulearal ‘environment, and the family’s socioeconomic status with its effect on resources of ime and ‘money all play a role in the development of children. Developmental cheory has, itself, developed as clinicians have tied to grapple with which influence is move predominant. ‘The focus of this series of article is to help the clinician frame general concepts of development according to the developmental streams rather than highlight developmental rt NCOR USN etl Cons Delpmenta & Betavrs Peas Flin, Madigan Amy Mei Center, et ase Lei eons vith 6 CSA, Mata Cops, Fat Dis eter, int se eth, ae eee Behl Pete Fellow, Mason Ay Mee Downloaded fom hppedsinreview pplication: or. Provided by LSU Medical CEES BERET, 3a" °° 27growth & development motor development abnormalities. The milestones cited are, on average, those at the 50th percentile for age. By understanding ‘what is “normal” or typical, the clinician can appreciate more keenly what is abnormal or delayed. This article concentrates on normal motor development, with a brie? ‘mention about specific “red flags” that should alert clt- nicians to potential motor developmental problems. The second article in the series discusses cognitive and lan- ‘guage development, The final article addresses the devel- ‘opment of social-cmorional skills, An all-inclusive table ‘of milestones is provided in this fist article asa reference (Table 1) both in print and online; Table 1 appears ‘online only in the September and November antics. Gross Motor Milestones ‘The ultimate goal of gross motor developments to gain independent and volitional movement. During. gesta- tion, primitive reflexes develop and persist for several ‘months after birth to prepare the infant for the acquisi- tion of specific sis. These brainstem and spinal reflexes sare stereotypi movements generated in response to spe- cific sensory stimuli, Examples include che Moro (Fig), asymmetric tonic neck (ATNR) (Fig. 2), and positive support reflexes (Fig, 3). As the central nervous system matures, the reflexes are inhibited to allow the infant to make purposeful movements. For example, during the time when the ATTNR persist, an infantis unable to roll from back to front, bring the hands to midline, or seach for objects. This reflex disappears between # and 6 months of age, the same time that these skills begin to emerge. The Moro reflex interferes with head control and sitting equilibrium. As this reflex lessens and dis pears by 6 months of age, the infant gains progressive stability in a seated postion (Fig. 4) In addition to primitive reflexes, postural reactions, such as righting and protection responses, aso begin £0 develop after birth, These teactions, mediated at the midbrain eve, interact with each other and work coward the establishment of normal head and body relationship in space. Protective extension, for example, allows the infant to catch him- or herself when falling forward, sideways, or backwards (Fig. 8). These reactions develop beeween 6 and 9 months, the same time that an infant Jears to move into a seated position and then to hands and knees, Soon afterward, higher cortical centers medi- ate the development of equilibrium responses and permit the infant co pul co stand by 9 months of age and begin walking by 12 months. Addisional equilibrium responses develop during the second year ater birth to allow for more complex bipedal movements, such as moving back- ward, running, and jumping Daring the fist postnatal year, an infanc thus moves from lying prone, to rolling ove, to getting to hands and kes, and ultimately to coming to a seated positon or polling to stand (Fig. 6). Within che framework of Back to Sleep guidelines, infants must have age-appropriate and safe opporcuities for “tammy time” to promote the development of these important prone-specific mile stones. It is important to aote that cravling is not a prerequisite co walking; pling to stand is che sillinfants must develop before they take their fre step. The ultimate goal of this timeframe is t0 develop skills that allow for independent movement and freedom to use the hands to explore, manipulate, and leaen from the eni- ronment, Gross motor development in subsequent years con: sins of refinements in balance, coordination, speed, and stecngth. The wide-based, slightly crouched, staccato ‘git ofa 12-month-old evolves into a smoot, upright, and navrow-based style. The arms change feom being hnld abdcted and slightly clvated for balance to swing- ing in reciprocal fashion as dhe gait reaches an adalt pattorn by age 3 years. Similarly, running develops soon afer walking, starting 2s a stiff legged approximation and changing into a wellcoordinated movement that ia- cludes rapid change of dreetion and speed by 18 months of age Simultaneous use of both arms or legs occurs after successful use ofeach limb independently. Atage 2 years a child can kick a ball, jump with two feet off the floor, and throw big ball oveshand. Milescones for succeeding ages reflect progress in the length of ine, number of repetitions, or the distance each task can be perfoomed successfally By the time child starts school, he or she is able to perform multiple complex gross mocor casks simultaneous (such as pedaling, maintaining balance, and steering while on a bicycle). Fine Motor Milestones Fine motor sills relate to the use ofthe upper extremities to engage and manipulate the environment, They are nccessary for a person to perform self-help tasks to play, and to accomplish work, Like all developmental streams, fine motor milestones do not proceed in isolation but depend on other areas of development, including gross motor, cognitive, and visual perceptual sills. At frst, the "upper excremities play an important role in balance and mobility. Flands are used for support, firs in che prone position and then in sitting, Arms help with rolling over, then crawling, then pulling to stand. Infants begin to use their hands to explore, even when in the supine position When gross motor skills have developed such that che 268 Pes alSaded ffom bil/pedsinreview-aappublicationsorg. Provided by LSU Medical Center on October 12, 2010rave 1. Developmental Milestones ae 3 month 2 months aimonihs 4 mets Siete ess Meroe + chinup in «Tei eas in sine pesion + Gestupin leet, es when ‘eld sting aston =p oo Rene «Sis wih vane ‘inp = Ne ead tog ‘when pulled to 3 1 Pos on wits 1 fal wont oe Sis th pve + habe to front Laer 5 months 2 wont ‘8 months otecion + Sewn ams ‘Supporting ane 2st momentary Popped en Fane isin prone S Inprone poston, bees hee Baines whe! ea + Sie without + Gate tng pate + Eas Rios necting ¥, pel Fre Motor Sete Pltlen-saving Monde ited» Susts well Gunes aback near tose wae shee ods wie « : ie vate ced hand «+ Hd hands together ans nied Ea + rgpets tinge = BIE objects Hands eld preminately pen, Gites at stots eaehes peor ays with rate Pama ge enging tig = Trane. ane + Rakes pete Takes Secon cae and ales onto het « Reathes with fre hand ' Radar & sp = Bangs soon ater demonstration « + SSisor sep gain + Taher ebe it ep + Fula ge ro ‘Opens mouth © Vial rest stagieot eee + Plows ge toaie "ht ae + etogies rene Bins nah Rene ot tomar te 1+ Flow ees ee ta Sane pester) + Rese top Biel hoe» touts bjs nto bret Stronger srbatle stove faces an tar « Siete 1 Reaches tr rae Sins" 6 Tis ead to routs tae ce eed rope soon + Fogel coder Fecis set + Tous fears” reerion and Foe fonds wean one « Rapes cts + Bangs and sats tp fis By ce food” Set sc of toy + Disowe at inch nd Perec Has own Sexe been Ren, fees ey te Grasse er” ny teas Sodalfimotionl Dict mone + Geaue Se + Redo ropa to ete + ein of Saget Ger ‘ast, ud aur) Vital fone peson whois fot a + Sree =pontaneouly pleural Sohusound Stone eng at rent lee + fesnd to sitemating vocalizations 4 Resor waa + Bins chess ‘ean to crave + feage ase Srraer Lai tr beet fo perent Sra back hen ering > with 3 ah Lets pens ‘ow when happy verses ‘hay and eh far ste ‘nee with eve Bes eh devel rent motor development Receptive Language Expesive Language 1 States to ole! « That noses Bane Alerts to weice) + Coos pind 1 Soca mate (eves) 1 Vole noses 1 Rinsho « Cakes 1 Moca when hed Ores headin» Laughs ot lou Gian ofa + Voctics when wos alone + Sop cig to seating vate Begineio 000 Soy Anat Tepmeto ¢ Resta cone 1 presen witsounds ‘ther ten rg + Stops «+ Redpltive openly to bate fo fesorans + Gesture for up» tier then cals when eles + Smeets tomer 1 Kale toa the a ettnees ‘sponds to. + Says "Dade ‘Come ee” epee) 1 Look for fay» Exes (10 20 renter, rant) Siheres + Shakes ead for rrami.ctc at (continued) Downloaded from btp://pedsinreview aappublications org. Provided by LSU Medical Centar Gn October 13, orb" "7‘motor development tase 1. Developmental Milestones—continued Age ess Motor ‘Fine Motor Seep ——_‘Frelen-sohingSxelEmatonl Receptive Language Exes Lineue 3 mans ‘eee sfuipild + iovone sonal + Usable + Eimesotie + Sn Ma snd ands yup arabe "come atenton * gone co i Ribsting to» Suntan» Brent tonne + Soret Be She ye Eee Bey {Beery cSkenen + Beime 28 eee Sin ones dais meinen amass come wren eetarmeeie Rete sesh cies eee eee eee rere ae BES ey OY EEE Te ora Rilo Sagie eee se =. = ene. sinooe «ag Terai» Gas lr «moc» ys go pear, Serie 7 Ske eng * Gp ‘But orstor "mre on $ Vols tens eg a Bag Pe eee recy ee Bee ay so Saat it eee Ea = eR a ge fa et a Set CEMA erin pent pesaee reset pg et ee en Seo, ieee eee Bee eee Sov ae ee | ee See hoe ee mee pete, Ea, ae = an See ES ans oa, Sacer Smee Mee Soogier ieaetete eee vie eee en RE eee ee ee aed Sartore Fontinl pny Mies te taetion watt ane = BS se Vine ite ape MR ce» Kam sw te sess mae ma ten aN 2 ieee ne Bibi ak + Gewec, te Mette — mithetgeire "Weare cea ee Boece ae eee es eee SS ame ++ Puts round peg foration of e sen viogont + Mlaner “Ugmre slepnet «Bain «fuuinor «Ut tete wor fefeureie "wit sene "took * Eomeare the” boy art os Sg Se en Ee, Bee Tere Ere Eee eee teas even abe chet Be ee Eo Ree ae See Wien Seale | Sec eat, dee i ae ‘elt, Teer eg cre re cmt rn epg uae feotwmaralgtodpectie armthon “gute. og ipeteaca | gle woes cae ie ee Ee eee ae = SS 2 eee ee See Sak et ee ee ee a eee See ee cee ae ae fe See ae = tay cere Seu Soe oso 770 Peas nbsuded Hat hl pedsinreview cappublicationsorg. Provided by LSU Medical Center on October 12, 2010tavte 1. Developmental Milestones—conti Ie 20 monty, 22 ment, 24 months 20 many 38 mints ‘re Matar So iin well Bea ‘al St «Teal ‘ie ang «= Seuts in ply + Gr kre cue + Vine owns wit ‘ne hand bel yas op a Faden ay itn beth Revon ech ep + os oat in enoratston + Wake th ee featonwaling tod + Was dow Stay cake cre kesui® Bow Ehotnain inom onan jumps ot eat, “aE Saas Eee oie ere. Reese Se Piss me Gametvonous re Netor Mate ore ‘ae tower + Gee vert ke + Comets ones 8 Hh + Make fc to Save owe + Compe rae ae vate sti ne ore rier pa Makes 2 fingete Slee ot ‘te: 1 fires ccte Sitter erat oe 1 Mates okt cist 2 Mo Seber = hase Sle, Renee sk che nae “Moves sot hes oa + fags er itis froth + Rte ice Ue an ig + Bil en save ee + Motes Epes Opes oer Sige feet hts ae (etalon tote meds + ier shame = Wines 1 Tae in pata? ued Proenting + Mae pas + fs ce aint say ‘et lan trot ce eto ‘mar es Mas + Males clas places ce inform ours ter te teen mee oud (ie a al and Font sal Settee ficwre a frit 19 inp grown & develop Secafimctoral rts MCAT 1 Etaesin Sone "sare oe” sae. fel + Engages in tex ry ith Beted orm + Hen pace 4 Wath ote ‘niger merely 1 Hegre show (eet tar oat aia in Seuratan act + nttes att seine sve. ‘hago hor + Dei tae Mote eceptieLnaione ints ot of yee wen mn ont tee ‘oa pa. Pom set estes + Pot rite ‘ple when 1 otto thee "antes eine ses ce ie oe i + Folows ton Step cores + Sera Tinea se topecre: Vode at ne + Flow ve Face thereon bt « Gisad Sines vonings. Sowa «oer a + Unload ae ae oohe motor development xpreie Lng + Uses 101025. Tee Sie wn (lene ia mes Sour amy Names ee pete — feneaiee se oe seins ay Boe als es sone aT Weslo noe Thess 1 Tonner sentence Gon + vt) seat, eee = een i Scam lie (ne ve) + Manes Oe 18 cures + Foose st cain ce RES eft ef with fone onan 1 Ret prt of weiter So fills in words i ves fet aot (creme Dowload rom iip./pedsnview appblconsor. Provided by LSU Medical CEES CEE, S88owt & develapmsot motor development tos Sisto pectin yee ier es es hee Re eee Seat cere en Elen Gee mene fetta. Goh Tear Rays «Roc Soar Uasor onethe« eae ee so hinge goes Epsane + Gels erere age, ee ee EE HE twa Boe EE Bees Ser Re’ ee, Sear Hite Be HES ESE Bn Eee, Be ree GSS ee ee Sa we A a yee ta age spt Big ether iste” Sad» Ee Ree ee eee ee eae tee Een Gillen ic, : preset ae TEE 1 Bbnten Se & + Rings beware Eyeame Tandem walls + ud tas fom » Ts shoe Pemory s Conth ae + Draws amond + Tacs bth nes We fine ant" stavest. Fesname Renee to + Geste wits” ts Bros «Fos eters th doweaang ond ‘coro soe = ops eg ‘abte 1. Developmental Milestones—continued Praershirg Sodaletnat ‘Stato nue «Fast parte Frese Linguine Express Language Serer waren’ eerie par en aie stincrterdiny) fowl enurswst + ln penne See: Eetagay 2a ay Reng «Belen ots eat Semen Vere yee eo ee ave ee eN Renee Cet hiya Saige «Ss a ‘ano + beeen + Flos dee = e300 1080 Soetioe fee, * Gorm, * Us + Gana amusing” ats « fons to tangs + Tel tre, {Ghaty em tn 8). ad enmcemed Sucre the 100% tity fret Houten. Somes Uses eng weds 1 Siete ralesles: en by oes afaent + Uses mcs ttl wadhoy« Has pfewed «Hames ines "soul Une matey? * elena tenon star re = Bg Se « pps, = clinghp: — Srdanger sf yr ut tn, Soot. Grouppay. Resametang eine of ts ya rag ls fort Yes) 1 Pin to ees + Unterance umes when gests buy, ames Ite pee Sorensge en an to“! Ha an of 4 Koos wit dnd «Repent int Nene) CHRO | cabernet one sence s Ghemeunts + Apolsin fer + Fate ‘ele wats (io! ets!" Gioeat nein © Une 508 mode + Hens coke, ‘uci Fesponds 2 ong teepoe ‘aly god « Unset“ Nise sumer eo feces" sexo Nees 0 as esr besiing, oy aS ae + Rr amas of aoe Se = Ret as eds - opm iie peated « tt ee wesioe "Mascot Se, > et Hee, Rams Reems Sete Ss -Elinome SE + Shle ain) —« Betingustes “ts donc «Kos days ofthe ee an Be Elo Eee ee te Sey Be eat Bin "Sabet sae ‘Ci 200 Ci Jno) AAY Cb dn i ESA Aa i pam nd co Pe age Gisker, Fab, an Neils Nobetolray, than of PEDsPrypeisl Alter sda Tom, 1D, Vice Chis of Feasts, USA/ATA Eesti Cmte the Cre fr Dia Con nd Pav “hr Ear et Se Rane Inne Eira Out aR and the leven of Ey Delon by Alen Drgancepublane by Celi Awa, Te: Pesan ated epee ese paso te ‘odilon tae thy aaah wed ss gto mpl dene opment nd na 2 miso snared vale ets er decpncn pete: 12 ren tron hi podsinceview sappublications.org. Provided by LSU Medial Center on Oxtober 12, 2010Figure 1. Moro reflex. This reflex occurs spontaneously to Joud noise or by simply holding the supine infant’ hand and releasing the hand suddenly. Classically, the reflex is elcted while holding the infant supine, with the head dropped slightly backward. This produces sudden extension and abduce tion of the upper extremities with hands open, followed by flexion of the upper extremities to midline (the "startle reflex). infant is more stable in upright positions and can move into them easly, the hands are fee for more purposefel exploration. ‘AC birth, infants do not have any apparent voluntary use oftheir hands. They open and close them in response to touch and other stimali, but movement otherwise is dominated by a primitive grasp reflex. Because of this, nfants spend the frst 3 months after birth “concacting™ objects with their eyes rather than theirhands, fxating on. faces and objects and then visually tracking objects. Gradually, they start to reach clumsily and bring their hhands together. As the primitive reflexes decrease, infants begin to prehend objects voluntarily, first using the en- tire palm toward the ulnar side (5 months) and then predominantly using the radial aspect of the palm (7 months). At the same time, infants learn ro release bjects vohuntaeily. In the presence of a strong grasp reflex, objects must be removed forcibly from an infant’s grasp or drop involuntarily from the hand. Voluntary release is seen asthe infant leams to transfer objects from fone hand (0 the other, fst using the mouth as an intermediate stage (5 months) and then directly hand- torhand (6 month) Between 6 months and 12 months of age, the grasp evolves to allow for prehension of objects of different shapes and sizes (Fig. 7). The thumb becomes more involved to grasp objects, using all four fingers against the thumb (a “scissors” grasp) at 8 months, and eventu- ally to just two fingers and thumb (radial digital grasp) at growth # development moter development igore 2. Asymmetric tonie neck reflex (ATNR). The sensory limb of the ATNR involves proprioceptors in the cervical vertebrae. With ative or passive head rotation, the baby fextends the arm and leg on the face side and flexes the extremities on the contralateral side (the "fencer posture"), ‘There aso is some subtle trunk curvature on the contralateral side produced by mild parespinous muscle contraction. ‘9 months. A pincer grasp emerges 2s the ulnar fingers are inhibited while slightly extending and supinating the wrist. Voluntary release is awleward at first, with all fin ‘gers extended. By 10 months of age, infants can release a ‘cube into a container or drop things onto the Moor. ‘Object permanence reinforces the desire to practice this skill over and over. Intinsic muscle control develops to allow the isolation of the index finger, and infants will ppoke their fingers into small holes for exploration. By 12 months of age, most infants enjoy putting things into containers and dumping them out repeatedly. They also can pick up small pieces of food with a mature pincer grasp and bring them to their mouths As infants move into their second year, their mastery of the reach, grasp, and release allows them to stare using objects as tools. Fine motor development becomes more closely associated with cognitive and adaptive develop: ‘ment, with che infantknowing both whathe or she wantsto Downloaded from ppedsineviewaappublictonsog. Provided hy LSU Mel Ci? Sa OEE tid" 2?e deopment motor development 1e 3. Positive support reflex. With support around the trunk, the infantis suspended, then lowered to touch the fect gently ona fat surface. This produces reflex extension at the hips knees, and ankles so the Infant stands up, completely or partially bearing weight. Mature weight-bearing lacks the rigid quality of this primitive reflex. do and how he or she can accomplish i. Intrinsic muscle refinement allows for holding fat objects, such as crackers or cookies. By 15 months of age, voluntary release has developed further to enable stacking of three to four blocks and releasing sal objects into containers, The child stares toadjustobjecs after grasping to use them properly, suchas picking up a erayon and adjusting it to seribble spontane ‘ously (18 months of agc) and adjusting a spoon to use it consistently for eating (20 manths of ag) In subsequent years, fine motor skills are refined far- ther to draw, explore, problem-solve, create, and perform selélielp tasks, By age 2 years, children can create a six- block tower, feed themselves with a spoon and fork, ec rosa, ‘igure, The desing intensity of primitive reflexes and the ineressing role of postutal reactions represent at lest permis= sve, and possibly necessary, conditions forthe development of ‘definitive motor reactions. Reproduced with permission from Johnson CP, Blasco PA. Infant growth and development, Pediatr Rev. 1997:18:225-242. is pushed gently but rapidly to one side. The reaction Is present ifthe child puts out bis of her hand to prevent a fll 774 Pes vlad Hom hiipl/pedsinreview aappublications org. Provided by LSU Medical Center on October 12, 2010sow & development mater development flexion. Their grasp and in-hand ma- nipalation skills allow them co sting small beads and unbutron clothes, At age 4 years, a palmar tripod raspallows for finer conteolofpencil ‘movements and the child ean copy cross, a squate, and some leters and ‘numerals and can dra a figure of person (the head and a few other body pars). Scisor sills have pro- agressed wo permit the cutting of a circle. When a child reaches the age (of S yeas, cor she can dress and un ciressindependendy, brash the teeth well, and spread with a knife. More precise invhand manipulation skills enable the child to cut a square with ‘mature scissor movements (indepen- igure 6. Chronoogie progession of gross motor development during the frst 12 dent finger use) and to print his or postnatal’ months, Reproduced with permision trom Johnson CP, Blasco PA. Infant her own name and copy a triangle using a mature tripod pencil grasp (Casing the fingers to move the pencil Fmoshi — Smonihe —G mons Smonihs Irons omosihs 12 monihe rather than the forearm and wis) Developmental Red Flags As the clinician performs develop mental survelane, the absence of certain key nlestones in a patent should rae the level of concem, Tigue 7, Development of pincer grap lsvations fom the Everdt developmental Table 2 lis the developmental red prehension In thardt RP. Developmental Hand Dysfurtion: Theory Assessment Treat= flags speci to the moto domain IF ment, 2nd ed. San Antonio, Tex: Therapy Skill Builders; 1994, Reprinted with permission. taote 2, Motor Red Flags ‘Age Red Flag A months Lack of steady head contol ‘while siting 9 months Inability to st 18 months Inability to walk independent move clothing, and grasp and turn a door knob. They have sufficient control of @ crayon to imicate both ver~ tical and horizontal fines. In-hand manipulation stills permit them to rotate objects, such as unscrewing a small bottle cap or reorienting a puzzle piece before putting it in place. They are able to wash and dry their hands. By 36 months of age, they can draw a circle, put fon shoes, and stack 10 blocks. ‘They make snips with scissors by alternating between fallfinger extension and ‘Downloaded som hitp//pedsinreview aappublications.og. Provided by LSU Medical CSnia ch cone of these red flagsis discovered, a medical and more thorough deve- ‘opmental evaluation is warranted. Although reported in this article in isolation, motor skills development overlaps significantly with the other streams of development. Summary ‘The development af motor sls is ertcal fora cid ‘to move independently and to interact with his or her ‘evvironment meaningfully and usefully. Skils develop in 9 cephalicto-caudal progression and from proximal to Hist. Thus, consistent head support occurs before ‘voluntary control of arms and legs, and large muscle ‘conte ofthe Upper arms occurs before small nine nucle contrat in the hands, Sls also progress from generalized responses to stimuli (primi reflexes) to goal-oriented, puroseful ‘actions with ever-ineressing pression and dexterity, cober'13, Bb" 775References 1. Lipsie LP. Learoing and emotion ia inns. Pediatrics. 19985, 102:1262-1267 Suggested Reading American Academy of Pediatees Commitee on Clie with Disbiltes, Section on Developmenal Behavior Peds ‘ght Futrs Steering Commitee; Medical Home Titaves for Children with Special Needs Project Advisory Conmitce eating infants and young ckren with developmental i conde inthe medical home: an algorithm for developmental sarlanes and srening, Pest 20063118:405-420 AAP Task Force on Tafinc Positioning and STDS, Changing con cepts of siden infne death syndrome: implication for nfink Sleeping environment ani sleep poston, Pediaerie: 2000105: 650-656, (CaseSmith J, Allen AS, Pate PN, eds. Occupmonal Therapy fir ‘Ghildren, St. Lous, Mo: Mosby Yeae-Book, In; 1996 Fiorentino MR. Reflee Tesing Mabe for Evaluating CNS Der epoentSpingld, I: Chavles C Thomas; 1973. Hagan JF, Shaw J, Ducan PM, els. Bright Burur: Guilin ir Health Superviio of Infos, Oildren, and AMeecense Sd ‘dion, Elk Grove Vilage, Ile American Academy of Pediatrics; ‘one Johnson CP, Blssco PA. Infne gronth and develops Rev, 1997;18224-242 Scumer RA, Howard BJ. Preschool development I: communicative and motor aspects. Piney Rev. 1997318:291-301 Pediatr SSwaldaded Ivor hip://pedsineview.aappublications.org. Provided by LSU Medical Center on October 12, 2010south 6 development ator development PIR Quiz (Quiz also available online at hitppedsirevew.aappublcatons.org. 1. An 18-month-old girl is seen for a health supervision visit. Her mother has no concerns regarding her daughter's development. Her growth parameters are at the 26th percentile. She walks well, climbs onto her mother’s lap, and whispers a few words to her mother. The best next step in the evaluation of this child's development is: ‘A. Full developmental surveillance. B. Further evaluation of language skills C Implementation of a developmental sereening toa. 1. Review of developmental milestones with the mother, E, Scheduling of a visit for full developmental assessment. 2. A G-month-old infant is unable to roll from back to front or bring hands to midline. The most likely cause of this infant's difficulty ist ‘A, Absence of lateral protection postural reaction. B. Absence of protective extension reaction. . Persistence of asymmetric toni¢ neck reflex. D. Persistence of Moro reflex. E, Persistence of positive support reflex. 3. A 15-month-old typically developing grasp. She most likely also is able to: ‘A. Build a tower of three blocks. B. Copy 2 vertical line. ©. Feed herself with @ spoon and fork. 1. Put on her shoes. E, Tura doorknob. able to release cubes into 2 cup and has a matuee fine pincer 4, An 18-month-old typically developing boy can walk well and run. He most likely also is able t A hump with wo fet off he ground Kicks ball © Pedal a teycle 1, Stoop and pick up a toy. , Tocewalk, Ea ‘Downloaded from http:/pedsinreview.aappublications org. Provided by LSU Medical Center on Uciober 13, 2010”Developmental Milestones: Motor Development R. Jason Gerber, Timothy Wilks and Christine Erdie-Lalena Pediatr. Rev. 2010;31;267-277 DOI: 10.1542/pir.31-7-267 Updated Information including high-resolution figures, can be found at: & Services http:/pedsinreview aappublications.org/cgi/content/fulV/31/7/267 Related Articles A related article has been published: hnttp:/pedsinreview aappublications org/egieontent/full31/9/364 Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at http://pedsinreview aappublications.orgimise/Permissions.shirnl Reprints Information about ordering reprints can be found online: http://pedsinreview aappublications.org/mise/reprints.shtmal American Academy of Pediatrics DEDICATED TO THE HEALTH OF ALL CHILDREN" SE Downloaded from htip://pedsinreview aappublications org. Provided by LSU Medical Center on October 12, 2010