Normal Development

Original Editor - The Open Physio project.

Top Contributors - Naomi O'Reilly, Siobhán Cullen, Tony Lowe, Rachael Lowe and Paule Morbois  

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. [1]

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) [2]

Typical Development Global Patterns & Positions

0 - 2 Months

You can download the Centres for Disease Control and Prevention 2 Month Milestone Checklist here

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) [2] [1]

 [3]

2 Month Milestone:

Makes Smoother Movements with Arms and Legs

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 [1]

3 Months

Symmetry Begins (Control of Bilateral Neck Muscles)

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 Position:

  • Symmetric

Pelvic Girdle:

  • Slightly Retroverted

Lower Limbs:

  • Flexion of Hips, Knees and Ankles to 90º with External Rotation and Abduction
  • Feet in Midline
  • 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 Position:

  • Beginning to gain range of lumbar extension because of the activity and alignment of the upper limb.

Pelvic Girdle:

  • Beginning of pelvic extension

Lower Limbs:

  • Hips abducted and externally rotated, knees semi- Flex.

4 Months

You can download the Centres for Disease Control and Prevention 4 Month Milestone Checklist here

Development of Sagital Plane

Strong symmetry, flexion and extension increased;

Beginning of Landau Reaction in Extension 

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

 [4]

Brings Hands to Mouth

SUPINE  PRONE

Antigravity Movement:

  • Is able to touch genitals and play with their clothes, with lower limbs in Flexion
  • 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 

5 Months

Good lateral weight transfer, symmetry enables coordination between both sides.

Increased Landau Reaction 

Swimming Position

Important manipulative strategies in supine.
SUPINE PRONE

Antigravity Movement:

Touches knees with hands, choosing to do it both hands at the same time or independence one from the other.

Grasp and manipulate in the midline staring the toy. Gripping still, from the ulnar side of the hand, with palmar flexion and supination to explore the toy with mouth

Antigravity Movement:

Chin tucked and chest elevated. Flexion and extension of knees, may play with feet together, lateral weight shift to wrap with the opposite hand. The infant may also push backward in this position.

Weightbearing:

Weight on hands, lower abdomen and thighs. Triangle base of support between nape elbow and thigh and face knee she use this base of support to liberate the face arm and wrap a toy with more stability. 

6 Months

You can download the Centers for Disease Control and Prevention 6 Month Milestone Checklist here

 [5]

Rolls Over in Both Directions

Front to Back, Back to Front

 [6]

When Standing, Supports Weight on Legs and Might Bounce

 [7]

Rocks Back and Forth, Sometimes Crawling Backward before Moving Forward

SUPINE PRONE PIVOTING

Antigravity Movement:

Eyes-feet-hands coordination, rolls from supine to prone. Movement initiated by shoulder, pelvis or head.

Posture during Rolling:

Head Position:

  • Lateral head righting when the baby reach lateral side.

Upper Limbs:

  • Base support arm is in 90° of FLEX, slight EXT ROT, elbow in flexion and pronation, hand open. Oscillate arm shoulder in ABD, elbow in semi-flexion and pronation, hand open. Scapulas dissociated one have weight bearing functions and the other a fasic movement to grasp a toy.

Trunk Position:

  • Elongated on weight bearing side.

Pelvic Girdle:

  • Dissociation of the hemipelvises start when the baby reaches the lateral side.
  • Transversal plane.

Lower Limbs:

  • The rolling start with triple flexion and finish with legs in extension.

Weightbearing in Rolling:

  • Shoulder, elbow, hemipelvis of the side that is rolling

Antigravity Movement

Swimming posture. Active weight shift to one side and grasp with the other hand.

Weightbearing:

Weight on one forearm or open hands, and distal thigh.

Posture:

Head Position:

  • Chin tuck and chest elevated,

Upper Limbs: 

  • Arms extended, shoulders coapted, hands open

Pelvic Girdle:

  • Extension

Lower Limbs:

  • Approaching neutral position

Weightbearing:

Weight on trunk, arms and hands

Posture:

Head Position:

  • Head at 90° legs abducted and externally rotated

Antigravity Movement Pivots:

  • Movements in arms and legs, lateral trunk flexion. Child use both arms and legs to pivot.

7 Months

Supporting legs on hands and knees (four legs)

Comando, Creeping

Lateral sitting

Can pass one object from one hand to the other

Can take one object in each hand

Answer to Name

Start Eating some Solid Food

SUPINE PRONE

Antigravity Movements:

  • Puts foot in mouth with hands 
  • Contact Eye - Hand - Feet - Mouth
  • Radial Gripping Digit

Antigravity Movements:

  • Begin to get in 4 legs
  • Begins to creep forward
  • Play in lateral support position

8 Months

  • In the 8th month is when all structures, bones and muscles, are prepared for the child can sit.
  • Immature crawling
  • Landau postural reaction complete
  • Stranger anxiety
  • Follows a falling object with eyes
  • Discover a hidden toy
  • Play Peek-a-boo
PRONE

Antigravity Movements:

  • Start of immature crawling
  • The child from lateral support, reach the sitting position alone
  • Can grip 3 toys at the same time

9 Months

You can download the Centers for Disease Control and Prevention 9 Month Milestone Checklist here.

Pulling with the arms can stand starting from a kneeling position. Will remain standing only a few seconds. 

Mature Crawling. 

Bisyllables “Papa”, Tata”

Waves “Bye, Bye” with hand

 [8]

Can get into Sitting Position

 [9]

Crawls

10 - 12 Months

You can download the Centers for Disease Control and Prevention 12 Month Milestone Checklist here

Makes side/lateral walking supported by hand on a table. Stands alone
 [10]

Pulls Up to Stand, Walks Holding on to Furniture

 [11]

May Take a Few Steps without Holding On

12 - 18 Months

You can download the Centers for Disease Control and Prevention 18 Month Milestone Checklist here

Walks Autonomously

Squat Position 

Moves from standing to squat and back to standing without any support

Tower of two bricks, put a chickpea into a plastic bottle, and eat with spoon

First Words. (Mama, Baba, Dada…)

Help in Dressing

 [12]

Walks Alone

 [13]

May Walk Up Steps and Run

 [14]

Pulls Toys While Walking

 [15]

Can Help Undress Herself

18 - 24 Months

You can download the Centers for Disease Control and Prevention 24 Month Milestone Checklist here

Runs, walking on toes and heels

Jumping on the same spot

Walk up and down stairs with handrail

Tower of 6 bricks, turn pages of a book

Bladder Control

 [16]

Begins to Run

 [17]

Makes or Copies Straight Lines and Circles

3 Years

You can download the Centers for Disease Control and Prevention 3 Year Milestone Checklist here

Pedal Tricycle

One Leg Standing

Uses Scissors

Uses Spoon and Fork

 [18]

Runs Easily

 [19]

Takes Turns in Games

5 Years

You can download the Centers for Disease Control and Prevention 5 Year Milestone Checklist here

Walk in a High Narrow Line 

 [20]

Stands on One Foot for 10 Seconds or Longer

 [21]

Hops; May be able to Skip


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

[22][23]

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

[22][23]

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

[23]

Age Ranges of Skill Aquisition

Six-gross-motor-milestones.jpg

                                                                 Windows of Milestone Achievement in Months [24]

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[24].

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[25]. This is demonstrated in the video below.

Age of Integration: 3-4 months


[26]


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[25]. Both this and the plantar grasp reflex are seen in the next video clip.

Age of Integration: 4 months[27]


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[27]

[28]

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[25]. This reflex is demonstrated in the clip below.

Age of Integration: 3-6 months[27]

[29] 


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[25]. This is demonstrated in the clip below.

Age of Integration: 6 months[27] 

[30]

Recent Related Research (from Pubmed)

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References

References will automatically be added here, see adding references tutorial.

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  2. 2.0 2.1 Stamer MH. Posture and movement of the child with cerebral palsy. 2015.
  3. Centers for Disease Control and Prevention - 2 Month Milestone: Makes smoother movements with arms and legs. Available from: https://www.youtube.com/watch?v=2O5OHu8jrtw [last accessed 13/08/16]
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  18. Centers for Disease Control and Prevention - 3 Year Milestone: Runs Easily. https://youtu.be/wkOOxsIrwgM [last accessed 13/08/16]
  19. Centers for Disease Control and Prevention - 3 Year Milestone: Takes Turns in Games. https://youtu.be/c9KtszF2_oc [last accessed 13/08/16]
  20. Centers for Disease Control and Prevention - 5 Year Milestone: Stands on One Foot for 10 Seconds or Longer. https://youtu.be/Ijp0BvoHTzA [last accessed 13/08/16]
  21. Centers for Disease Control and Prevention - 5 Year Milestone: Hops; MAy be able to Skip. https://youtu.be/-Pp08tBs0wU [last accessed 13/08/16]
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  24. 24.0 24.1 WHO Multicentre Growth Reference Study Group. ‘WHO Motor Development Study: Windows of achievement for six gross motor milestones’. Acta Paediatrica. 2006: Suppl 450; 86-95.
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  27. 27.0 27.1 27.2 27.3 Votroubek W. 2009. Pediatric Home Care for Nurses: A Family-Centred Approach. Ed. 3. Sudbury: Jones and Bartlett Pblishers Inc.
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  30. 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]