Psychomotor Development of the Normal InfantPsychomotor Development of the Normal InfantOla Didrik Saugstad, MD, PhD, FRCPEProfessor of Pediatrics, University of Oslo

Student lecture 9th Semester

Recognisethe main aspects of normal psychomotor development such that the student is able to evaluate both gross motor and fine motor development

Goals of teaching:

Recognise a delayed motor development

Normal Psychomotor Development

Gross motor Fine motor Psychosocialhead control, raises chest grasps/releases focuses, smilesrolls over from stomach coordination between to back eye-head-arm talks, recognizes people crawls, walks pincer grip (thumb to index finger) reacts to own reflection

Psychomotor DevelopmentPsychomotor Development

Areas of Development

Gross motor control: head control, raises chest, rolls over from stomach to back, crawls, walksFine motor and vision: pincer grip (thumb to index finger) Coordination between eye-head-arm, grasps/releases, focuses Language and hearing: talks, hearing and auditory processing distinguish speech soundsSocial and daily living skills: Smiles, recognizes people, reacts to own reflection. Fine and motor skill enable imitative actions.Feeding, dressing, self-care, emotional regulation, play

From: MJ Robinson and DM Robertson: Practical PaediatricsChurchill Livingstone, 2003

Sphincter control - can it be taught?

1890-1910: No training1920-1930: Rigid training(In 1932 the US governement published ”Infant care” calling for training from 2-3 weeks after birth. ”Punishment” was used to promote sphincter control

1930-1940: permissive, the child decides1960 - :sphincter control is considered as a matter of neuromuscular maturation only - no effect of training

Can psychomotor development be accelerated?

SPHINCTER CONTROL

15-18 months: voluntary control of bladder

2 - 2 ½ years: can go to the bathroom, pull down his/her pants, sit down on the toilet without help needs help wiping

2 years: 50% of children are continent at night

5 years: 90% of children are continent at night

Sphincter control - can it be taught?

The Digo tribe in Eastern Africa actively train thesphincter control at a few weeks of age. Continence is expected at 4-6 months of age,its occurrence has been verified by field studies

The training is based on rewards, the siblings participate

Is this early sphincter control due to an accelerated psychomotoric development among the Digo people?

MV deVries & MR deVries Pediatrics 1977;60:170-177

- - a STATIC problem a STATIC problem (CP, mental retardation)(CP, mental retardation) - - a PROGRESSIVE condition a PROGRESSIVE condition (cerebral, degenerative, neoplastic or neuromuscular)(cerebral, degenerative, neoplastic or neuromuscular) - - an ACUTE process that leads to rapid deterioration an ACUTE process that leads to rapid deterioration (infections, trauma)(infections, trauma)

Psychomotor developmentPsychomotor development

One would like to know if the problem stems from:One would like to know if the problem stems from:

- the mother’s observations- the examiner’s findings

THE EXAMINATION

The assessment of development is based upon two fundamentalconditions:

For proper interpretation of these, knowledge of normal development from the neonatal period and onwards is essential

• fatigue• hunger• thirst• fear of strangers• mother’s concern

The child’s state at the time of examination must be The child’s state at the time of examination must be considered in the assessment of findingsconsidered in the assessment of findings

These conditions can affect the child’s manner

Normal ranges (approximately 25th to 90th centile)

Age Gross motor Fine motor/ Language/ Social and months_control and vision and hearing daily living skills

2-4 Head steady Follows objects Squeals with Smiles in sitting through 180o pleasure

5-8 Sits without Passes cube Turns to soft Feeds biscuit support hand to hand voice

9-14 stands with Neat pincer grip Mamma/dada Indicates needs support of raisin by gestures

12-16 Walks alone Stack of 2 cubes Three words Drinks from cup

15-24 Walks up Scribbles Points to one Removes garment steps spontaneously body part

From Robinson MJ, and Robertson DM Practical Paediatrics,2003

Warning signs to be concerned about – if child is not doing this

Age Gross motor Fine motor Language and Social andMonths control and vision hearing daily skills

3 Complete head Following with Searching for Smiling

lag eyes sounds with eyes

6 One hand Squint Head turn to Interest in preference, Moro soft voice people

9 Sitting with support Persistant hand Ba-ba,babble Awareness of regard strangers

12 Pulling to stand Pincer grasp Trying 1 or 2 words Constant Standing with support mouthing

18 Walking alone Play with blocks Six words Pointing at items casting toys Finger feeding

Or regression in skills, or at any age there is parental concern

From Robinson MJ, and Robertson DM Practical Paediatrics,2003

•2 months: response smiling•3 months: good eye contact•5 months: reaches for objects•10 months: sits unsupported•12 months pincer grip•18 months: walks unsupported•18 months : says single words with meaning•20 months: speaks in phrases

Some developmental ”limit ages”

Sit at latest 10 months

Psychomotor development

Absolute warning signs!!!

Walk at latest 18 months

Example 1: Deafness with delayed speechExample 2: Some children bottom-shuffle instead of crawling

There is normal variation in development

Another normal variation in development is when a child develops directly from sitting to walking, without crawling in-between the two.

Development can vary greatly in normal children. This often shows a hereditary pattern. One should, however, not assume that a delay in development is family related without excluding other possible reasons

This often runs in families and is often associated with other delays with, for example, sitting without support, and walking without support. This is a normal variation in development.

- The sequence of events varies with respect to duration and timing, but follows the same pattern

NORMAL DEVELOPMENT IN INFANCYNORMAL DEVELOPMENT IN INFANCY

- Development is continual from the time of conception to the time of complete maturity

- Development occurs in the cephalocaudal direction, such that head control and control of hands is obtained before walking

Main principles

-Individual primitive reflexes, must regress before the -corresponding voluntary movements can be attained

The automatic stepping reflex in newborns regresses and then usually disappears completely after just a few weeks

Grasp reflex disappears at 2-3 months

Parachute reflexesAppears 6-9 months of age

Locomotor (movement) developmentFrom lying down to the standing position

9 month: crawling

12 month:

early walking

Newborn

A. Ventral suspension

Examined by holding the child under the abdomen and chest

LOCOMOTOR (MOVEMENT) DEVELOPMENTLOCOMOTOR (MOVEMENT) DEVELOPMENT

Newborn: lacks head control6 weeks: briefly holds the head in the same plane as the body

Ventral suspension cont

8 weeks: lifts head over the horizontal plane of the body, able to maintain this position a while

Ventral suspension cont

Newborn: head can be moved from side to side, the pelvis is elevated and the knees drawn in under the stomach, often with automatic crawling. With increasing maturity, the pelvis is sunken, knees and hips become more extended

4 weeks: lifts head from the underlying mat4-6 weeks: pelvis still somewhat elevated, hips less extended

Lying prone cont

Prone position

12 weeks: head and shoulders held over the underlying mat with the face in a 90% plane in relation to the shoulders

Lying prone cont

6 months: chest and upper abdomen held over the underlying mat with the weight sup-ported by arms, extended elbows rolls over from lying prone to lying supine

Lying prone cont

12 months: starting to walk

9 months: crawling

7 months: rolls over from lying supine to prone, weight can be supported by one arm

9 months

C. From supine to Sitting

Traction: Examiner pulls the child upwards, pulling up by the hands, up to a sitting position

Newborn: marked head lag on pulling up, but as one nears the vertical position the head tips forward.

Traction contTraction cont

Head Control

4-6 weeks:back less humped over, better head control

The baby’s back is completely humped over, with a continual curve from the neck to the sacrum

Sitting contSitting cont

Sitting contSitting cont

26-28 weeks: the child sits with the support of hands in front

8 months:sits without the need for support

11 months: sits so stably that it is possible to turn around to pick up a toy from the underlying mat without losing balance

10 months: sits unsupported

Some developmental ”limit ages”

Walking

Newborn:in the upright position, falls together at the hips and knees

3 months: bears a good deal of weight in the legs6 months: bears most of own weight7 months: bears full bodyweight

8-9 months weeks:stands by holding on to furniture and the like, pulls himself/herself up to the standing position, but does not manage to again sit down

44 weeks: can lift one foot from the floor48 weeks: can walk while holding on to furniture52 weeks: can walk when holding hands with someone

13 months:walks without support, with wide-set gait and uneven steps, shoulders held abducted and elbows flexed

18 months: walks unsupported

Some developmental ”limit ages”

The grasp reflex of the hands persists until 8-12 weeks of age and is completely gone by 3-4 months of age (can persist in brain-damaged children and can surface in children with an activated brain-damage).

DEVELOPMENT OF MANIPULATIONDEVELOPMENT OF MANIPULATION

•4 weeks: hands are primarily closed

•8 weeks: hands are often open

•12 weeks: baby looks at objects as if he/she would like to grasp it, holds objects that are placed in the hands

•16 weeks: hands drawn to the midline while playing, reaches for objects but often misses, wants to play with and shake a rattle when placed in his/her hand

•20 weeks: grasps actively at objects – bringing it in towards his/her mouth, plays with his/her toes

Manipulation

Throughout the first 6 months, the complexity of the infant’s palmar grasp develops from a whole hand grasp from the ulnar side, becoming more refined, with a good pincer grip at 10 months of age.

40 weeks: the object is held between the thumb and first finger, the infant points at objects with the index finger (index approach) while he/she moves the hand to pick it up

24-32 weeks: radial grasp

5 months reaches for objects

Some developmental ”limit ages”

The speed of reaching after objects and grasping them increases successively with age

6 months: transfers objects from one hand to the other

40 weeks: releases grip of objects, learns to give an object to mom, puts objects away in baskets and takes them out again

FINE MOTOR AND VISION

Pincer grasp

•Development of manipulation is a better estimation of IQ than that of gross motor development. A good finger – thumb positioning and a certain “index approach” by 10 months of age almost entirely excludes the possibility of severe mental retardation

•Well-developed manipulation skills usually correlates to a high IQ

DEVELOPMENT OF PERCEPTION

Newborn: distinguishes patterns from one another. Stripes are preferred to gray colors. Faces are preferred to other images2 weeks: smiles during REM sleep6 wks-3mo: social smile – caused by happenings in the child’s surroundings smile develops to become an instrument for attention for the child12-24 weeks: looks at his/her hands (hand regard) while lying supine (also present in blind children) If this remains after the 24 weeks of age, it may be an indication of mental retardation20 weeks: smiles at his/her own reflection28 weeks: mimics his/her own reflection3 months: identifies/localises more precisely by turning his/her head in the direction of the sound

•2 months: response smiling•3 months: good eye contact•5 months: reaches for objects•10 months: sits unsupported•12 months pincer grip•18 months: walks unsupported•18 months : says single words with meaning•20 months: speaks in phrases

Some developmental ”limit ages”

HEARING AND SPEECH

DISTRACTION HEARING TEST

LANGUAGE DEVELOPMENT

Approx. 7 weeks: vocalisation12-16 weeks: “converses”, babbles with mother20 weeks: says, “a goo”28 weeks: says, “ba ha da”32 weeks: puts syllables together like, “dada”, puts together consonants 40 weeks: understands “no”44-48 weeks: words with meaning are said, though an understanding of the word comes first later12 months: 2 or 3 words with meaning15-18 months: “jargon” (own vocabulary)21-24 months: puts together two to three words like, “I”, “me”, “you”3 years: sentences