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Pediatrics:

Motor Development

Birth to 3

Home Study Course By Joanne Bundonis, PT, PCS

January 2009

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Table of Contents CCU Hours

Course instructions 3 (1)

Course objectives 4

Pre-test 5

Typical Motor Development 6

Newborn 7

Premature infant 8

One month 8

Two months 10

Three months 12 (2)

Four months 12

Five months 14

Six months 15

Seven months 17

Eight months 18

Nine months 19

Ten months 20

Eleven months 21

12 – 15 months 22

18 – 24 months 22

28 – 36 months 23

Areas of concern

0-3 months 26 (3)

4-6 months 28

7-8 months 29

9-12 months 30

Case study one 31

Case study two 33

Appendix – Normal Development Table (4 pages) 35

References 38

Post test 39 (4)

Evaluation 44

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Course Instructions

Research has demonstrated that reading for comprehension for application to your therapy practice must

involve multiple steps. These steps involve much more than just reading the course material.

PTcourses.com and OTcourses.com recognize that different people read at different rates, therefore the

times below are an average estimate based on review of this course material by both therapists and

assistants. Recommended steps to complete the course and exam are outlined below:

1. Review these course instructions. (5 min) 2. Read the course description, and preview the course objectives. Highlight the main purpose of the course and note anything with which you are unfamiliar. (5-15 min) 3. Review the chapter headings and subheadings in the table of contents. Look up any words that are unfamiliar. (5-10 min) 4. Review the exam, and become familiar with the questions asked at the end of the course. This will assist you to be observant and determine the important points in the course. Compare the questions with the objectives. Answer any questions in the margin that you may think you know. (10-45 min) 5. Read the first sentence in each section to gain the overall big picture for each chapter. Preview charts and illustrations, chapter summaries, and appendixes. Glance at the course references for authors, sources, and dates of publication. (Time varies dependent on length of course: 10-60 min.) 6. Read the course material: Highlight important areas, and make notes in the margin, asking questions of the writer, and looking up any terms that are unfamiliar. Relate the course material to the course objectives, and note the location in the material where each objective was met. Make note in the margin where you remember questions from the exam. Ask questions in the margin of the material that you may not understand. Paraphrase each section. Think about the important points in each section. (Time varies dependent on course. On average: 20-25 pages per hour for introductory course, 15-20 pages per hour for intermediate course, 10-15 pages per hour for advanced course.) 7. Add your own opinions in the margins (Is the topic relevant? Has your experience been different? Is this a topic or exercise you can use in your practice?) (10-15 min) 8. Complete the exam based on what you remember from the course. Look up answers to questions you may not remember. Review your exam for accuracy. Be sure to answer each exam question. Blanks are counted as incorrect. A minimum score of 70% is required for successful completion. (30 - 90 minutes dependent on course, and therapist’s comprehension.) 9. Complete the evaluation. This is required in order to receive your Certificate. Make constructive suggestions in the comment section. Add topics for courses you would like to see addressed in future courses. We value your responses and suggestions. We upgrade our procedures and course materials based on your responses. (5-10 minutes) 10. After successful completion of the exam and evaluation, your Certificate of Completion will be mailed to you. If you take your exam online, you may print your Certificate immediately after finishing the evaluation. Certificates may also be emailed upon request. If you have any questions about your examination or your Certificate of Completion, please call us toll free at 866-257-1074 during normal business hours M-F, 9-5 CST. We may also be reached by email at info@PTcourses.com or info@OTcourses.com.

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610 Pediatrics: Motor Development

Course Description

Motor Development (0 to 3): This course covers the sequence of normal development

from birth through the toddler years. It addresses points in development by month. It

covers areas of concern, by month, that may signal a later dysfunction. The course also

covers how motor development affects hand use, breathing and oral motor skills.

Strategies for children with neuromotor deficits are addressed.

AOTA Cat: 1

CEU Hours: 4 Instructional Level: Intermediate

Course Objectives

a. Understand the sequence of normal development from newborn through toddler

years.

b. Identify points in development where elongation prepares the body for later

activation.

c. List key points of development for each month.

d. Identify the benefits of physiological flexion for newborns.

e. Understand that normal development is variable.

f. Identify areas of concern in a developing child that may signal later dysfunction.

g. Identify characteristics of normal motor development.

h. Identify characteristics of abnormal motor development.

i. Understand how motor development affects some basic principles of hand use,

breathing, and oral motor skills.

j. Relate concepts of normal motor development to treatment strategies for children

with neuromotor deficits.

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PRE TEST

1. What position helps elongate the lateral trunk and tensor fascia latae?

a. Sidelying

b. Prone

c. Quadruped

d. Supine

2. What is the progression of weight shifting in quadruped?

(Mark order in which progression occurs from 1st through 4

th)

_____ Rotation

_____ Counterrotation

_____ Anterior/Posterior

_____ Laterally

3. What must occur for a child to be able to cruise around a corner?

a. Get elongation on weight bearing side and rotation through trunk

b. Lateral flexion toward weight bearing side

c. Ability to stand without support.

4. Why do many children with neuromotor dysfunction retain a posture of thoracic

kyphosis, flattened lumber spine and a posterior pelvis?

a. Tight hip flexors

b. Poor positioning in wheelchairs

c. Limited exposure to dynamic standing

d. Inadequate development of extension mobility and motor control

5. Which posturing is usually indicative of a pathology in infants?

a. Cervical hyperextension, scapular adduction, lower back tightness, hip internal

rotation and adduction

b. Cervical flexion, hip external rotation and abduction

c. Cervical, hip and knee flexion, thoracic kyphosis and a posterior pelvis

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Typical Motor Development

With new life comes wonder and beauty, an active dance creating balance,

fluidity and efficiency of movement in just a very short span of time. Normal

development has a distinct sequence with the ultimate goal of independent mobility. But

what makes this sequence so exciting to see unfold time and time again is that it can be so

variable. What is presented as a time frame of normal development shows what may

occur slightly before or slightly after a certain criteria of normal. Sometimes certain tasks

may not occur at all.

Normal development is made normal by the very fact that it is variable and that

there is a constant drive to progress. The normal developmental process does not

stagnate on one skill. There is an inherent desire to move and explore in the developing

human. The clearest way to truly see normal development is to break the process down

to its simplest form, in which the motor system is first elongated, preparing those muscles

to be most efficient for activation. The process of elongation, preparation and activation

begins simply with flexion and extension but is later more complicated by the balancing

and sustaining of muscle control to allow for more refined, coordinated movements

incorporating rotation and grading.

We as therapists are here to understand what normal development is comprised of

and how to use that understanding to help children with developmental delays gain what

may have been lost or missed during development.

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NEWBORN

A full term newborn enters this world dominated by flexion and with little

disassociation of all body parts. This physiological flexion truly sets the newborn up to

adjust to the new environment and to begin preparing for their monumentous task of

normal motor development. The baby is in physiological flexion for pure space

efficiency because of such compact quarters in utero. The soft tissue tightness is a

natural occurrence due to developing in such a flexed position. Physiological flexion

does offer the newborn a number of benefits as it is an organizing position which allows

the baby to establish an initial point for movement and control from which to develop. It

will limit or control the amount of extension within the system. Since the newborn has

no midline control, physiological flexion allows the baby to regulate, comfort and control

of his own body.

The baby does not have to move far out of flexion to gain sensory input and

begin to learn about his body and environment. At the same time, by returning to the

flexed position, the baby is able to regulate the input and movement he experiences,

because flexion will avoid overstimulation. The position of physiological flexion puts

consistent weight bearing on the head, upper chest and forearms with the lower body

higher than the shoulders, which initiates the cephalocaudal progression of normal

development. The ligamentous and soft tissue tightness associated with physiological

flexion helps the body in its remodeling process. The newborn's cries are usually very

nasally due to the compactness of the flexion and their perpendicular rib cage and sound

is usually movement induced.

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PREMATURE INFANTS

In premature infants, their development is based more on their gestational age;

therefore age should be corrected for preemies at least up to 18 months of age. A

premature infant’s lower extremities will appear tighter than a full term infant’s will.

This is because in utero the tautness in connective tissue develops from toe to head,

where motor development occurs from head to toe. A premature infant will usually

demonstrate physiological flexion at the appropriate gestational age, but the flexion will

not be as dramatic since the flexion has already been extended some. Since the preemie

does not get the same sensory stimulation from physiological flexion as a full term infant,

the preemie may have a stronger drive for tactile stimulation, which could be seen in the

use of hyperextension to seek out the needed tactile input. Therefore the benefits of

physiological flexion for the full term infant stated above are doubly important for

preemies.

ONE MONTH

The one-month-old infant remains dominated by physiological flexion, which

offers the baby its only stability source. Posturing includes rounded, internally rotated

shoulders, tight pectorals, elbows flexed and pronated with thumb in palm and wrists

flexed. The legs are flexed and adducted, ankles dorsiflexed and inverted, and pelvis

posteriorly tilted, which is the same position the legs are in utero. In supine there is

slightly less flexion than in prone due to effects of gravity. The baby has no active

control in midline or reciprocal inhibition with no grading, so movements are more

uncontrolled and uncoordinated. Everything appears to contract or relax together.

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Random kicking helps the newborn begin to move out of flexion and adduction into more

external rotation.

There is more symmetry in prone than in supine for a newborn. In prone weight

is on the face and cheeks because of the high riding pelvis. It is an automatic reaction for

the infant to clear his airway and weight bear on the cheek. When prone, the baby is in

passive cervical extension, therefore, elongating the flexors preparing them for activation.

The baby will use cervical extension, initiating with rotation to clear the mouth, which is

the start of more asymmetry. Gravity will then facilitate the neck back into flexion, the

beginning of more dynamic cervical movement.

In supported sitting, the baby starts in a sacral sit with a posterior pelvis, but the

pelvis becomes perpendicular to the surface quickly. A head lag with pull to sit will be

more pronounced as physiological flexion and tightness decreases over the first month of

life. In supported standing, reflexive stepping and primary standing is noted, but between

11/2 and 2 months of age the presence of these reflexes will disappear (astasia abasia). A

majority of our sensory receptors are in the mouth and hands.

The one month old’s positioning provides weight bearing on the face and since

the baby is in so much flexion the hands are near the mouth and they start to bring their

hands to their mouth. The weight bearing on the face also helps with oral motor

development. Infants are driven by visual and labyrinthine input, which are stimulated

by all their movements. They are beginning to get awareness of two sides due to

asymmetrical patterns. The baby is nearsighted with a focal point of about 7-10 inches

with better lateral vision and is able to track peripheral to midline but with jerky

movement.

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The one-month-old will orient to sound by changing his body movement. The

grasping of objects is purely reflexive and the hand will open again with weight bearing.

This grasp and release pattern begins the development of finger extension. The baby is a

belly breather with ribs horizontal and rigid and a narrow tight chest. They also breathe

through the nose because of fat pads and large cheek and tongue size. As more

mylenization occurs the newborn’s increased tone and tightness will decrease and begin

to organize into more controlled movements.

TWO MONTHS

The two month old will appear low tone and asymmetrical because gravity is

beginning to work on the body with decreasing physiological flexion. The asymmetrical

tonic neck reflex (ATNR) is most dominant at two months, but is not obligatory.

Posturally the infant demonstrates decreased lower extremity flexion with increased

abduction and external rotation and less of a posterior pelvis. There will be increased

scapular adduction and shoulder abduction with the elbows now positioned behind the

shoulders in prone. They also have better active cervical extensor control with weight

shifting in prone.

Weight bearing is down to the upper chest pushing the spine into more extension

and further elongating the flexors. The baby is able to lift his head to 45 degrees but

cannot maintain it, allowing for the start of weight bearing through the arms. When

lifting his head it is still from a very asymmetrical position initiating the activation of

cervical extension and rotation. Normal babies from 2-3 months of age do not like the

prone position because it requires a lot of work and limits their freedom of movement. In

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supported sitting the baby will hold its head erect with elevated shoulders and head

bobbing. Visually the focal length is about 10 inches and he can see his hand, therefore

the ATNR allows the beginning of eye hand regard. Optical righting drives head lifting

and an upward gaze develops with extension. The baby begins using some facial

expressions, but vocalizations continue to be linked to movement.

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THREE MONTHS

A three-month-old is beginning to gain more symmetry and organization. He has

increased muscle tone. They have developed head control in supine and prone. The baby

has active extension control through the upper thoracic region and similar control of the

flexors, as well as the ability to hold his head in midline and turn side to side (rotation

requires control of the flexors and extensors). Posturally he is beginning to open up with

even less lower extremity flexion in both prone and supine with the pelvis going towards

more of an anterior tilt. Increased lower extremity external rotation and abduction allows

foot to lateral foot contact while kicking in supine.

In prone he is beginning to get control of scapular abduction and adduction with

the elbows in line with the shoulders. As the baby begins to weight shift he will shorten

the side to which he shifted because that is where there is control at this stage. Propping

on forearms elongates the shoulder abductors with increased extension. The baby will

also begin using bilateral upper extremities, i.e. bringing both hands to his body and

beginning to raise arms against gravity. In supported sitting the baby uses scapular

adduction to reinforce extension. The ribcage is coming down but is still elevated. In

prone, the weight is off the chest freeing the baby for more chest breathing.

FOUR MONTHS

At the fourth month, a normal child achieves symmetrical antigravity control and

begins to use bilateral upper extremities in weight bearing and function. Posturally, the

four month’s old legs are more in line with his lower body displaying increased extension

and decreased abduction and external rotation. His feet are more plantarflexed and push

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off the supporting surface. There is also more anterior and posterior pelvic movement.

The baby is developing control of extension through the lumbar spine and flexion across

the thoracic spine. In prone, the elbows are further ahead of the shoulders with weight

shifted more posterior to the thighs. He is gaining more control of weight shifting with

increased shoulder cocontraction. With this increased weight shifting over the

abdominals, increased spitting up will be noted. The baby can actively rotate head and

upper body, getting some shoulder external rotation and the beginnings of

scapulohumeral disassociation.

Accidental rolling to sidelying is seen due to decreased control of weight shifting

in supine and prone. In order to reach in prone, the infant goes back in flat lying, the

reaching begins to elongate shoulder and latisimus muscles. This resorting to a more

stable and practiced position will continue throughout development when new tasks are

attempted.

In supine, the infant is able to flex hips and touch knees and lift upper arms off

the surface, demonstrating increased antigravity control. He can not lift his head off the

surface. The baby is able to sit with the back straight up to the thoracolumbar junction

and rounded at the lumbar spine. Forward protective extension begins on the forearms.

In several months, as control improves, protective extension is on extended arms.

In supported standing, the pelvis remains behind the shoulders due to a lack of hip

extension control. The four month old has almost full rib cage expansion, elongation of

the intercostals and more thoracic breathing, as seen in their longer vocalizations and the

beginning of separating sound production from body movement. The baby will hold

objects with an ulnar grasp and play by banging with mostly shoulder movement. In

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order to grasp, the fingers and wrist will usually flex together. Hand to hand and foot to

foot play is also noted.

FIVE MONTHS

The fifth month is a very active time where the infant is gaining many important

pieces of development. Extension control will have developed across the hips and

flexion control across the abdominals as seen in the baby’s ability to lift the pelvis off the

floor in supine and with lots of swimming and rocking (forward and back and later

laterally) in extension and catching on arms in prone. The baby still does not have full

control and stabilization across the lower body and lower abdominals to be able to lift his

head in supine. But increased obliques control is noted with better grading of the upper

extremities and the ability to cross midline.

In supine the baby will have better arm and manipulative hand skills but in prone

there are more strength skills with less visual regard and hand use.

The baby is also able to reach in prone on elbows and weight bear on more extended

arms. Rolling begins to be more voluntary using flexion to roll from supine to prone and

extension to roll from prone to supine. Control with rolling will improve as weight

shifting and the balance of flexion and extension further develop. This voluntary desire

to move is the start of cognitive movement and motor planning. The five-month-old

tends to like sidelying because of his improved stability between flexion and extension in

the upper trunk. In sidelying, he begins to get lateral head righting, but he doesn’t have

enough obliques to sustain the position. Sidelying is important to begin to round out the

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rib cage and to get practice working in between flexion and extension. There will be

more symmetry and midline control with the decreased influence of the ATNR.

At five months, the baby has good head control with a chin tuck and uses prop

sitting with a wide base of support. In supported standing, the pelvis is behind the

shoulders with a wide base of support, accepting almost full weight bearing. The baby

begins to bounce getting proprioceptive, kinesthetic, and vestibular stimuli, usually with

hips and knees flexed. With more active abdominals and intercostals to stabilize the rib

cage, the baby uses more thoracic breathing, opening up the chest and allowing the

diaphragm to work more easily. Visually they are better able to separate eyes and hands,

also getting a more visually directed reach as the start of eye hand coordination. The

baby will be reaching with more elbow extension, using bilateral upper extremities, and a

palmar grasp. This swiping and reaching against gravity will help train the scapular

stabilizers.

SIX MONTHS

By six months extension control is through the hips and hip flexor control is

beginning, allowing for more centralization of weight, narrower base of support, and

more movement of the extremities. At five months, the baby is reaching for his feet with

flexion, abduction and external rotation of the legs. By six months he is reaching hands

to feet with decreased external rotation which helps to elongate the hamstrings, neck and

back extensors and develop better abdominal or flexion activation. Now at six months

the baby can lift his head in supine, showing more active control of the obliques and

lower abdominals.

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Single leg movements can now be isolated showing the start of lower extremity

and pelvic disassociation, which will be important for later developmental transitions.

Now in prone, the baby can maintain weight bearing on extended arms and with pushing

back onto arms may slide backwards or even rock up onto hands and knees. This is the

first time the baby will raise his center of gravity off the floor and become aware of the

space behind him

The ability to weight bear on extended arms began with the elongation and

preparation of the scapular stabilizers during the fourth and fifth months of development.

Movements are becoming more advanced and refined as seen with more graded control,

rotation, and smoother movements in rolling. Also in sidelying increased refinement is

noted by the ability to stop and play, which demonstrates better oblique control and full

lateral head righting. Prone on extended arms is important to elongate the wrist flexors

and sidelying helps elongate the leg abductors.

By six months, the baby can sit erect without upper extremity support when

placed with more active anterior/posterior pelvic play. The anterior posterior pelvic

control is important to allow for reaching and weight shifting in sitting because it offers

the ability to use a narrower base of support and pivot over that base. The six-month-old

is able to sit without support and balance because he has gained active hip extension and

flexion in sitting, which was seen at five months in prone. In ring or propped sitting, the

baby will begin to play with toys in front of him by leaning forward, which will help

further elongate hamstrings, back, and hip external rotators. Increased hip extension

range of motion is also noted in supported standing, when bouncing with both hands held,

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but most of the control in supported stand comes from the hip flexors and lower back

extensors.

He will have equilibrium responses in prone and supine and protective extension

forward. The protective extension response is dependent on the stability through the

trunk extensors so that the baby can get his arms out. Vocally the baby will use babbles,

intonation, graded pitch, and the integration of sound with body movement. By six

months, one will see more isolated finger movements and a radial palmar grasp.

SEVEN MONTHS

The seven-month-old in prone is beginning to move more through space, being

able to belly crawl and pivot in circles. Belly crawling begins using a reciprocal weight

shifting with lateral flexion at first and then later getting more rotation. Belly crawling

initially is reinforced by the amphibian reflex where weight shift to one side gets flexion

of the other. The reaching with abduction followed by moving the body over the arm in

belly crawling helps get lateral weight shift across the hands, distal stability with

proximal mobility, and disassociation of scapula and humerus.

More control is noted in sidelying with the ability to push up onto an extended

elbow, allowing for more elongation of the lateral trunk and tensor fascia latae and

activation of hip abductors into the surface. Also more activity is noted in sidelying with

moving top leg forward and back combining obliques/lower abdominals to hold the trunk

stable, while the hip flexes and extends. The baby will push back from prone into

quadruped and rock in quadruped. The rocking in quadruped is a good preparation for

creeping and helps develop stability around the hip joints.

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In quadruped, the weight is usually shifted more forward and the baby will fall

into an anterior pelvis until abdominal control develops. Then the pelvis will become

more neutral. If the abdominals stay weak and the pelvis anterior it will be more difficult

to transition and creep. The baby may attempt creeping or assume a plantigrade position

(bear stand).

The seven-month-old may get his first transition to sit by collapsing onto his

heels when pushing back in quadruped, leading to a heel or W-sit position. Transitions to

sit begin using an anterior/posterior movement progressing towards more lateral and then

with more rotation beginning first at the shoulders then the lower trunk. More weight

shifting in sitting with freer arms and equilibrium reactions will also be seen. The weight

shift of the trunk over an externally rotated leg in sitting then puts the leg into internal

rotation, which is similar to gait. The baby will pull to stand if his hands are held and

may attempt to take steps with support using a steppage gait. Orally the baby will use

finger feeding using the mouth to help release grasp, will be able to close lips on a spoon,

and separate voice from body movement. Seven-month-olds transfer objects from hand

to hand, use an inferior pincer grasp, and use surfaces to release objects, which is why

they are often throwing or dropping toys.

EIGHT MONTHS

In prone, the baby is beginning to transition to sit through sidelying and

progresses to using more rotation and lower extremity disassociation. By beginning to

play in between transitions he is developing the ability to grade transitions and use mid-

ranges. The infant is able to creep on all fours initially by moving ipsilateral sides then

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reciprocally. Weight shifting in creeping begins with a lateral weight shift and then

rotation then counter-rotation (rotation toward unweighted side so upper body and lower

body move opposite) as the child develops more control. These rotational movements are

very important for gaining shoulder stability and mobility.

At seven months, the baby tends to weight bear with the shoulders internally

rotated and by eight months the shoulders are more externally rotated with greater weight

shifting across the hands. By holding a toy while creeping he is getting even more input

into the hand and developing the palmar arches.

In sitting the baby is able to rotate his trunk and at times shift through his base of

support getting elongation of the weight bearing side. The baby begins to transition from

sitting to quadruped by moving laterally, but needs more eccentric control to transition

back from quadruped to sitting. Kneeling and half kneeling occur as parts of transitions,

usually with upper extremity support for stability. The eight month old will begin to pull

up to stand at furniture using upper extremities to drag his legs behind together and later

getting one leg up in a very wide half kneel position. The baby will step with hands held

and climb on low surfaces all facilitating the alternating/diagonal weight shifts through

the trunk needed for later ambulation. More controlled oral skills are noted in the ability

to clear a spoon with his lips, a more graded chew, and eating mashed foods. His

developing a three-jaw-chuck grasp and now has a voluntary release.

NINE MONTHS

By nine months quadruped has been refined with the ability to transition to sitting

and back independently, with counter-rotation in creeping, and the ability to climb onto

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furniture. Kneeling is seen more regularly but with little control using flexion of the hips

and ankles for stability. Nine months is when sitting truly becomes independent and

functional with hands free, good equilibrium, and the ability to move in and out and

pivot.

In standing, the baby will stabilize their lower body against a support to rotate his

upper body as control in upright develops he will rotate lower body while holding on

with his arms. Dynamically in supported standing, cruising will begin with lateral weight

shifting and a wide base of support. In standing while holding onto a support the baby

will practice squat to stand which helps develop knee and hip flexion grading and

strengthening. Although the baby can pull to stand, the transition to the floor is still with

a fall or plop due to limited eccentric control. Orally, increased independence and

control is seen in that he is able to finger feed, drink from a cup, and are able to separate

tongue movements from jaw movements.

TEN MONTHS

The tenth month is a period to perfect and refine more movements. Weight

shifting will begin to be initiated from the lower trunk in quadruped, cruising and sitting.

Equilibrium response will be seen in quadruped. Half kneeling is more mature with trunk

rotation and the foot more in front. Kneeling without upper extremity support will be

used. Cruising will be perfected with elongation of the weight bearing side and rotation

begins, as the child is able to get around corners or furniture. He will be able to walk with

one hand held, but may use scapular adduction for stability until he gets more control of

hip rotation. Hip rotation control will be played with in standing with upper extremity

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support. The child has better eccentric control and fairly good strength through the legs

as seen in the ability to squat with one hand holding on. Ankle control and activation is

just beginning with increased plantarflexor use by coming up onto his toes, which will

also prepare and elongate the toe flexors. He will be able to grade release of objects and

isolate the index finger for poking.

ELEVEN MONTHS

For the normal child, the tenth through the twelfth months are about practicing

and perfecting a variety of movements, especially in standing and walking. The child

practices by combining many movement components to develop independence and

efficiency. Sidesitting is perfected with lateral trunk flexion and rotation. The baby will

creep with full rotation and cruise with one hand support, rotation, and elongation of the

weight bearing side. The baby will initiate bear walking in the plantigrade position.

Moving in the plantigrade position is important for development of gait because it utilizes

weight shifting in dorsiflexion and plantarflexion at ankles, with the legs disassociated

and trunk rotation against a stable shoulder. The child is able to stand alone using lower

extremity flexion, anterior pelvis and scapular adduction to stabilize. For new or

challenging fine motor tasks, the upper arms will be pulled in to get stability in the trunk

for distal work.

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TWELVE TO FIFTEEN MONTHS

The child is able to stand independently and squat to pick up an object.

Independent steps begin as control around the hips and knees improve. Initial steps begin

with a wide base of support, hips and knees flexed, abduction and external rotation of the

hips, scapular adduction, anterior pelvis, lateral weight shifting and small steps. The

wide base of support with abduction and external rotation requires very little pelvic

movement. The high guard arm position of scapular adduction compensates for weak hip

extensors and helps throw weight posteriorly.

The squat to stand transition begins asymmetrically with abduction and external

rotation because a straight up and down would require a lot of hip and knee extension

force. This will later develop as the child gets better hip extension, abdominal control,

and increased pelvic mobility. The squatting also helps with progression of tibial torsion

alignment. The child is able to creep up stairs. He can say about five words.

EIGHTEEN TO TWENTY FOUR MONTHS

This is a time when the child will be driven by motor experiences; there may be a

slowing of development in other areas due to this desire to move. Walking skills improve

to include more lower body weight shifting and elongation of the abductors. By two

years old the child’s gait will demonstrate decreased pelvic tilt, hip abduction and

external rotation, more knee flexion during foot strike, ankle dorsiflexion during swing,

plantarflexion at heel strike, and some reciprocal arm swinging. There is a preference

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towards extension in standing at two years old predisposing most normal children to toe

walk for a short period.

As hip extension develops the child will begin stepping backwards. Standing

equilibrium responses are seen, but before equilibrium responses are fully developed one

will see more of a stagger response of moving the feet to maintain balance. Good pelvic

disassociation is necessary to begin walking up levels; the child can manage stairs with a

railing and non-alternating steps at this age. The child will also begin to use ride-on toys,

in which he usually starts by pushing backwards into extension because it’s easier than

pulling forward with flexion.

TWENTY-EIGHT TO THIRTY-SIX MONTHS

Gait will incorporate full counter-rotation at about 3 years of age. Children first

begin running as a fast walk, running with both feet off the ground occurs between 2-3

years of age. The ability to throw demonstrates upper extremity movement on an

extended trunk. The child can ride a tricycle and jump up and down. The child will

become toilet trained by around three years of age.

24

Characteristics of Normal Motor Control Development

Cephalic to Caudal

Proximal to Distal

Weight shift develops anterior/posterior to lateral to rotation

Muscle must elongate before you get activation

Develop concentric before eccentric control

Gain reciprocal inhibition then cocontraction then graded movement

Use bilateral movement before unilateral

Upper body control before lower

Return to more primitive patterns to reinforce learning of a new skill.

There is a gradation or stepping of control

Never perfect one skill before working on the next because the higher level work

helps develop other needed skills to perfect the prior.

There is a complexity and flow to normal development. The dependent infant is

building a framework towards being an independent functioning child through every

movement, a framework that begins with each movement out of flexion: elongating then

activating. He instinctively falls back on learned skills to build and refine new skills. As

was just outlined in the prior sections, normal human development has a clearly defined

process for muscle activation and development. The process begins with random

movements, followed by asymmetrical movements, bilateral symmetrical movements,

alternating movements, lateral flexion, and finally rotation.

Many children with neuromotor deficit do not gain the symmetrical control necessary

to develop the more graded control for lateral flexion or rotation. All babies learn to

move but as they move they learn to compensate for deficiencies. If these compensations

persist, we see deterioration in the process of normal development. If we break down

points of normal development we can begin to understand what components of normal

25

development get lost in children with neuromotor deficits or developmental delays. In

seeing where “normal” is lost, maybe we can use that to help the children learn more

functional and efficient movement patterns. There are also numerous standardized tests

available to assist in assessing gross motor development during the first year of life.

Some of those test include the Alberta Infant Motor Scales, Bayley Scale of Infant and

Toddler Development, Test of Infant Motor Performance, and the Peabody

developmental Motor Scales. Below we can begin to interpret signs of where normal

development may begin to skew.

26

Areas of Concern

ZERO - THREE MONTHS

In the first few months of a newborn’s life, it is difficult to identify motor

abnormalities, especially those that may be more subtle. But impairments in early

infancy will usually manifest themselves in the motor system. Good understanding of

what normal development and movements are helps distinguish areas of concern. A clear

red flag in a newborn is if there is a difference in tone on either side of the body. A baby

that is either hypoactive or hyperactive can also signal possibilities for impairment

because that child is having difficulty regulating himself to his new environment.

Newborns are very active with numerous random gross movements. One must look to see

if these movements are fluid, wax and wane, and if they incorporate rotation.

Newborns position their hands in a cortical thumb position with the thumb buried

in a fisted hand. This is a sign of an immature system and should decrease with

development. The crossed extension reflex pattern occurs when one side of the body is

stimulated and the other side responds (by touching the adductors of one leg it causes

flexion in that leg and extension and adduction in the opposite leg). If this is not present,

it may indicate brain damage or absence of the corpus collosum. Young infants may

begin to accidentally roll, but rolling is in one segment since the baby does not have

association of all movements and has limited spinal mobility. Segmental rolling becomes

27

a concern if it persists, as the child should be learning to roll more efficiently near the

fourth to fifth month.

The second month is characterized by asymmetry. The asymmetrical tonic neck

relfex (ATNR) is not obligatory in a normal infant, but one should suspect pathology if a

child does not use any other movement patterns or cannot break out of the ATNR

posture. In atypical infants, one may also see the ATNR accompanied by excessive

cervical hyperextension. Normal babies will hold or fix to provide stability so other areas

can be used or moved, as seen in a two month old elevating and blocking with the

scapulae to allow for head control. This becomes a concern or atypical if the baby

perseverates on one specific pattern. It is important to begin to get the opening of the

upper chest in prone. If this does not occur as in many children with neuromotor deficits

there will be a limitation in shoulder external rotation, scapular stability, and the use of

excessive extension later on.

Many children with neuromotor deficits retain the newborn spinal alignment of

thoracic kyphosis and a flattened lumbar spine. This is caused by the child’s inadequate

development of extension mobility and motor control.

The third month is when the baby moves towards more symmetry. Concern

should be noted if there is a strong continuation of asymmetry with limited bilateral arm

movement. One never sees hip internal rotation positioning in normal development.

Cervical hyperextension with scapular adduction and lower back tightness, and hips

internally rotated and adducted may be indications of pathology. If head control appears

limited, the visual control should be further assessed as it can have a factor in the

development of head control. In prone if the baby is having difficulty with keeping his

28

elbows in line with his shoulders, this may indicate decreased development of shoulder

girdle strength and may lead to further problems in developing antigravity extension

control in prone. Children with lower extremity tone tend not to use a frog-legged posture

(flexion, abduction and external rotation) and do not activate hip extensors causing

decreased hip abduction range of motion in the future. Infants with low tone tend to get

stuck in the frog-legged posture and do not move out of it. This causes them to never

gain adequate strength of the trunk and hips to move dynamically with lateral or rotary

movements. As they get older, these children may demonstrate an increased gait angle

and excessive pronation.

FOUR – SIX MONTHS

The fourth month is also a time where many changes are beginning, and it is

difficult to identify abnormalities at this age. Motor development is usually considered

pathological if there is perservation on a task or poverty of movements. In children with

neuromotor deficits, there will be an underdeveloped quality of symmetry in prone and

supine because they have not developed antigravity strength in the trunk flexors and

extensors. It will become easier for the developing infant with delays to substitute or

accommodate for immature patterns, especially if not challenged to attain higher level

skills.

In low tone babies, the position of lower extremity abduction and external rotation

will limit development because it causes an inability to shift weight down through the

lowers in prone and causes lumbar hyperextension. The infant that is not weight bearing

on upper extremities in prone by five months of age should be further assessed. As

29

rolling begins to develop, the baby will use extension to get to supine. However, but the

continuation and perservation of using extension to roll can limit the further development

of balance with the flexors and possibly affect visual control since extension incorporates

an upward visual gaze.

When a baby is using propped sitting, it should be a transition to more

independent sitting working to train the trunk extensors. If the baby becomes fixed in

propped sitting with no variety, there is reason for concern because it is a locked position

anatomically and does not allow the trunk to learn to work on its own. This limits

functional sitting and does not allow the arms to be free for play. Children with lower

extremity spasticity tend to crawl by dragging their legs behind them, denying the

development of hip extension and external rotation. Children who cannot bring their feet

to their mouth by 5-6 months are demonstrating decreased flexor control and decreased

extension mobility.

SEVEN & EIGHT MONTHS

The seven-month-old baby is very active against gravity, using a wide variety of

positions. A clear sign of motor developmental delay would be a seven month old with

little desire to move. Also there would be difficulties in prone or supine, inability to

weight bear on extended upper extremities, difficulty weight shifting over lower

extremities and inability to sit unsupported. An eight month old with neuromotor

dysfunction will have difficulty transitioning out of sit, movements will be stereotyped

and lack variety due to the child’s decreased trunk, pelvic and femoral motor control.

Children with diplegia have difficulty with tall kneel because of a lack of balance

30

between the hip flexors and extensors and excessive extension at the lower back from the

increased tone around the pelvis.

NINE-TWELVE MONTHS

The inability to sit independently, creep in quadruped, climb, or stand in a

supported standing position by nine months old could be an indication of atypical motor

development. W-sitting is a normal sitting position when it is part of a variety of sitting

postures. Children who only use W-sitting tend to have poor pelvic and lower extremity

control and use the biomechanical stability of the W-sit to offer them stability. The

perseveration of the W-sit position can lead to tightness of the hip adductors, internal

rotators and flexors, and hamstrings. Difficulty with crawling and creeping may also be

due to limited pelvic femoral control and the baby’s inability to laterally weight shift and

disassociate the lower extremities. Subtle deficits may be seen in a child’s inability to

weight shift or adjust posture when in supported stand.

Characteristics of Abnormal Motor Development

Perseveration on single movements or positions

Lack of variety of movements or positions

Use of stereotypical movements

Limited rotation

Compensatory or fixing patterns

Abnormal tone either hypo or hypertonia

Poor co-contraction and grading movements are all on or all off

Asymmetry

31

Case Study Examples

Case Study One

A three-year-old with a diagnosis of delayed development presents with

hypotonia. The child is able to sit independently, creep and assume a tall kneel position

without arm support. In lying, she maintains her legs widely abducted and externally

rotated (a frog legged position). In sitting, the child uses a wide base of support with legs

abducted and externally rotated. The child will stand with support but does not walk.

The child progresses through preschool to ambulate with a wide base of support,

hips excessively abducted and externally rotated. When walking she initially required

hand held support, as she could not weight shift over her wide base of support and she

lacked the lower extremity rotation control. As stability improves, her base narrows, but

she still remains externally rotated and abducted with poor weight shifting. Early in her

development this child did not shift her weight below her pelvis in prone, or begin to

activate her hip extensors and abductors in sidelying, prone, or sitting. This lack of

pelvic and lower abdominal control continued to affect her motor development in that she

did not gain the necessary cocontraction and eccentric control in her lower extremities to

allow for further progression of gait, squatting, and stairs. The lack of hip extension and

abduction torques at the hip joint have caused her hips to remain in a retroverted position.

32

What should be the focus of the therapy treatment?

Therapy sessions should focus on developing the hip extensors, abductors, and

abdominals. She would also benefit from activities to work on grading and eccentric

control of the lower extremities. Activities to further develop these skills may be

climbing over large objects, stairs, moving through half kneel and squat positions. She

could also work on resisted walking in all directions and partial transitions working on

grading of trunk and lower extremities.

33

Case Study Two

A girl diagnosed with spastic quadriplegia cerebral palsy, presents with low

postural tone and increased tone in all extremities. She demonstrates an underlying

athetoid component to her movements. Her sitting posture is extremely flexed with a

posterior pelvis and excessive thoracic kyphosis. She also has bilateral hamstring

contractures, which exacerbate this posturing. She requires full support to sit on the floor

and contact guard assistance to bench sit. She does not transition, but will attempt to

combat crawl on the floor pulling forward with flexion and not utilizing a prone pivot or

weight shift. She has maintained and further exaggerated much of a two month olds

flexed posturing with a posterior pelvis, kyphotic thoracic spine, forward head, and tight

pectorals.

This posture remains because this child has never gained the extension control

necessary to sustain an upright posture. As her extension control is lacking, she will

begin to compensate and fixate where she had biomechanical stability or tone, leading to

tight hamstrings, pectorals, hip flexors, latisimus dorsi, and elbow flexors.

34

What should be your focus of treatment?

In order for her to develop more effective sitting and transitional skills he must

gain extension control throughout the spine and hips. Activities in therapy would focus

on facilitation into extension and rotation, bilateral reaching activities especially

overhead, using an erect sitting posture while performing manual tasks, learning to push

off a surface instead of always pulling in.

During, the day positioning will be crucial for preventing further contractures and

allowing for better function. She should be given enough trunk support in sitting so she

does not need to fixate to just stay upright; this may free her hands, head and upper trunk

to be more active.

35

Appendix – Normal Development

MONTHS SUPINE PRONE SITTING STANDING

1 a. Physiological

flexion

6. Head Rotated

k. Hands fisted,

Cortical thumb

b. Physiological

Flexion

Head turned to

side

Elongating

cervical

extensors

Rear Elevated

Most pressure

on head/face

Fully Rounded

Head lag with

pull to sit

Sacral sitting

Primary

Standing

Automatic

Walking/

Reflexive

stepping

2 Asymmetry of

extremities

Hand & head

regard

Head rotated

close to

shoulder

a. Shoulders more

abducted,

scapulae

adducted with

increased

weight through

upper chest and

arms

Frog legged

positioning

Extension

increases

through neck,

head lifted 45

degrees for

short periods

l. Head erect with

head bobbing

and elevated

shoulders in

supported sit

d. Astasia Abasia

3 e. Head to midline

f. Hands to body

g. Asymmetrical

head lifting

h. Increased

symmetry of

extremities

i. Decreased

flexion of the

extremities

Weight bearing

on forearms

Neck and trunk

extension

through upper

thoracic region

Head can be

lifted more

consistently

7. Slight increase

in extension

using scapular

adduction to

reinforce

extension

a. Knees do not

touch surface in

supported sit

b. Neck

hyperextends

c. Falls forward

when

unsupported

4 a. Head in midline

b. Hands to knees

c. Accidental

rolling to

sidelying

d. Lateral head

righting

e. Extension

control to

lumbar spine

Flexion to

thoracic region

a. Increased

elongation and

symmetry

b. Base of support

on hips and

thighs

c. Leg adduction

with knee

flexion

d. Weight shifts

with head

rotation

e. Weight bearing

on radial border

of forearms

a. Head in midline

with pull to sit

b. Cervical and

thoracic

extension

c. Ring sitting

with hip

external rotation

and support

d. Scapular

adduction

Supported stand

with pelvis

behind

shoulders

36

5

a. Feet to mouth

b. Increased

flexion against

gravity to

abdominals

c. Rolling using

flexion

d. Lateral head

righting in

sidelying

e. Weight bearing

on extended

arms

f. One arm

reaching

g. Rolling with

extension

h. Shoulder girdle

disassociation

with weight

shifting

i. Swimming

extension

j. No head lag

with pull to sit

k. Propped on

extended arms

l. Trunk erect

m. Lock elbows to

decrease

degrees of

freedom

Accepting

almost full

weight bearing

in supported

stand

Bouncing up

and down in

supported stand

6 a. Hands to feet

with head lifted

b. Rolls supine to

prone

c. Increased

shoulder girdle

control

d. Plays in

sidelying

e. Single leg

movements/

disassociation

f. Hands and

knees gaining

equilibrium

reactions

g. Able to laterally

flex and rotate

h. Sits with erect

spine

i. Forward

protective

reactions

j. Arms elevated

k. Unsupported

ring sitting with

a wide base of

support

Taking weight

with purposeful

responses

l. Knee and back

extension hips

flexed to

maintain

upright

m. Increased head

and trunk

control

7 a. Pivoting with

upper body

rotation

b. Symmetrical

upper extremity

movement

c. Able to weight

shift and rock in

quaduped

d. Belly Crawling

e. Lateral

protective

reactions

f. May push back

from quadruped

to a heel or W-

sit

Symmetrical leg

extension

e. Full weight

bearing on legs

with arm

support

8 7) Creeps for

mobility

Transitions

prone to sit

through

sidelying

8) Transitions

from sit to

quadruped more

laterally

9) Trunk rotation

10) Cruises

sideways and

reaches with

one hand

11) Pulls to stand

dragging legs

behind or with a

wide half kneel

12) Assumes tall

kneel

13) Rotates with

head first

37

9 Counter-

rotation in

creeping

7) Independent

sitting

8) Sidesits and

Long sits

9) Transistions to

kneeling

10) Increased ability

to reach in sit

11) Cruises semi-

turned with

lateral weight

shifting

12) Increased hip

rotation and

decreased hip

flexion

13) Lowers self

with a plop

14) Pulls to stand

through half

kneel with

increased

rotation

10 Weight shifts

initiated

through lower

body

7) Cruises holding

with one hand

and elongation

to weight

bearing side

8) Symmetrically

lowers self to sit

9) Body fully

rotated away

from surface

10) Kneeling

without external

support

11) Walks one hand

held

11 Bear Walking

d. Varied sitting

postures and

transitions

e. Backward

protective

reactions

b. Sidesitting

f. Stands alone

g. Stable in half

kneel play

h. Lowers self

asymmetrically

12 10) Back props in

sitting

11) Independent

walking

12) Weight shifting

in standing

12-15 Creeps upstairs 13) Squat to stand

38

References

Bly, Lois. Motor Skills Acquisition in the First Year of Life. Therapy Skill Builders,

1994.

Cusick, Beverly. Progressive Casting and Splinting for Lower Extremities in Children

with Neuromotor Dysfunction, pages 3-96. Therapy Skill Builders, 1990.

Haywood, Kathleen, Getchell, Nancy. Life Span Motor Development. Human Kinetics,

2005.

Paul, Leslie. Course notes from NDT/Bobath 8-week course in the Treatment of Children

with Cerebral Palsy. Peapack, New Jersey, 2001.

Piek, Jan. Infant Motor Development: Normal & Abnormal Development. Human

Kinetics, 2006.

Shumway-Cook, Anne, Woollacott, Majorie H., Motor Control Translating Research

into Clinical Practice. Lippincott Williams & Wilkins, 2007.

Spittle, Alicia, Doyle, Lex, Boyd, Roslyn. A Systematic Review of Clinimetric

properties of neuromotor assessments for preterm infants during the first year of life.

Developmental Medicine and Child Neurology. Apr. 2008: 50(4): 254-266.

Staller, Jerry. Compiled from course notes from Typical and Atypical Motor

Development, New York University Developmental Disabilities Program, Fall 1997.

Tecklin, Jan Stephen. Pediatric Physical Therapy. Part I. Development. Lippincott

Williams & Wilkins, 2007.

39

610 PEDIATRICS MOTOR DEV– AGES 0-3

CERTIFICATION OF EXAMINATION

The individual submitting the request for continuing education credits should complete

this examination. No outside assistance is allowed. A 70% score is required before CEUs

may be awarded. I agree to complete this examination on my own as stated above. I am

completely responsible for the contents of this examination.

SIGNATURE _________________________________________

Name (Print)_________________________________ Date _____________________

Circle: PT PTA OT OTA

List each state you are licensed in and the license number for that state

1. State____________Lic # _____________ 2. State ___________ Lic # ___________

3. State ___________ Lic # ____________ 4. State ___________ Lic # ___________

Phone: _______________________ Email: ___________________________________

TO RECEIVE YOUR CERTIFICATE PROVIDE YOUR ADDRESS, FAX

OR EMAIL BELOW

___________________________________________________________

___________________________________________________________

SEND THIS COVER SHEET, THE ANSWER SHEET EXAM AND EVALUATION SHEET

MAIL TO: PTcourses or OTcourses, 6308 Circle Oak, Bulverde, TX 78163

OR FAX to 830-438-4573 or 801-457-2880

DO NOT SEND BY CERTIFIED MAIL - THIS ONLY DELAYS THE PROCESS

40

Pediatrics: Motor Dev (ages 0-3) ANSWER SHEET

1. __________________________

__________________________

__________________________

2. A B C

3. A B C D

4. A B C D

5. A B C D

6. A B C

7. A B C D

8. _____ Rotation

_____ Counterrotation

_____ Anterior/Posterior

_____ Laterally

9. A B C

10. A B C D

11. A B C

12. A B C

13. A B C

14. A B C

15. A B C D

16. A B C D

17. A B C

18. A B C D

19. A B C D

20. A B C D E

21. A B C

41

Pediatrics: Motor Dev (ages 0-3)

Post Test

1. List three benefits of physiological flexion for newborns.

2. What position is crucial for premature infants?

a. Prone with head lower than heart

b. Physiological flexion

c. Held in a supported sit

3. In the first month, what area is becoming elongated in preparation for activity?

a. cervical flexors

b. hip flexors

c. pectorals

d.cervical extensors

4. What is the significant difference between the second and third month of

development?

a. Have gained independent sitting

b. Moving from more asymmetry towards more symmetry

c. Have gained elongation on the weight bearing side when weight shifted in prone

d. Elongation of tensor fascia latae

5. At which month of development does a child usually gain independent functional

sitting?

a. Five months

b. Nine Months

c. Twelve Months

d. Six Months

6. Why can’t a five-month-old lift his head in supine?

a. The head is too big to lift against gravity.

b. Does not have good head control, cervical flexors still not fully active

c. Does not have enough lower abdominal and oblique control to stabilize lower

body.

7. What position helps elongate the lateral trunk and tensor fascia latae?

a. Sidelying b. Prone c .Quadruped d. Supine

42

8. What is the progression of weight shifting in quadruped?

(Mark order in which progression occurs from 1st through 4

th)

_____ Rotation

_____ Counterrotation

_____ Anterior/Posterior

_____ Laterally

9. What must occur for a child to be able to cruise around a corner?

a. Get elongation on weight bearing side and rotation through trunk

b. Lateral flexion toward weight bearing side

c. Ability to stand without support.

10. Why do many children with neuromotor dysfunction retain a posture of thoracic

kyphosis, flattened lumber spine and a posterior pelvis?

a. Tight hip flexors

b. Poor positioning in wheelchairs

c. Limited exposure to dynamic standing

d. Inadequate development of extension mobility and motor control

11. Which posturing is usually indicative of a pathology in infants?

a. Cervical hyperextension, scapular adduction, lower back tightness, hip internal

rotation and adduction

b. Cervical flexion, hip external rotation and abduction

c. Cervical, hip and knee flexion, thoracic kyphosis and a posterior pelvis

12. If a child only uses W-sitting what may be a deficit in their motor control?

a. Limited hip internal rotation and adduction range of motion

b. Poor trunk flexion mobility

c. Poor pelvic and lower extremity mobility control

13. Which motor skill would be a concern if seen consistently in a baby?

a. A five month old who cannot bear weight on his upper extremities in prone.

b. A twelve month old who is not walking independently.

c. A two month old who does not exhibit an asymmetrical tonic neck reflex.

14. Which motor skill would be a concern if seen consistently in a baby?

a. A two-year-old who begins toe walking at times

b. A two to three month old baby who does not like the prone position.

c. A seven to eight month old who does not move out of sitting

15. Which is not a characteristic of abnormal motor development?

a. Increased muscle tone

b. Limited rotation control

c. Using a more primitive pattern when learning a new task

d. Using the same movement pattern to accomplish most tasks

43

16. A child of greater than 3 years old who remains in excessive external

rotation and abduction at the hips, walking with poor weight shifting has

not developed enough control of what areas?

a. Upper thoracic extensors

b. Pelvic region

c. Lower Abdominals

d. B & C

17. Which activity would be most appropriate for developing grading and

eccentric control of the lower extremities?

a. Partial transitions working on floor to stand

b. Seated bouncing on a therapy ball.

c. A static standing activity

18. What lack of control would cause a child over 3 years old to retain a 2

month old's flexed posturing (posterior pelvis, thoracic kyphosis, forward

head, and tight pectorals)?

a. Lack of distal hamstring activation

b. Limited flexion range of motion

c. Lack of extension control through the spine and hips

d. Limited scapular stability

19. Which activity would best focus on developing extension control through

the spine for the child in Case Study #2?

a. Bilateral overhead reaching with rotation

b. Stair training

c. Bike

d. Rolling

20. Infants who do not develop out of a frog-legged posture tend later in

childhood to present with:

a. Inadequate trunk and hip strength for lateral and rotary movements

b. Hip joint instability

c. Increased gait angle and excessive foot pronation

d. Tight adductors

e. A & C

21. Normal development is

a. Dependent only on genetics

b. Reliant mostly on primitive reflexes

c. Variable.

44

610 Course Evaluation – Peds Motor Dev (0-3)

Please indicate your strong agreement (5) or disagreement (1) by

circling the appropriate number on the continuum from 5 to 1.

Circle: PT PTA OT OTA Date: _______________________

This self study was valuable to me because: (check all that apply)

_____I learned a new skill or approach to use in my practice.

_____I acquired one new and/or advanced skill that I can implement in my practice.

_____I gained knowledge upon which to base my decisions in my practice.

_____This self study doesn’t apply to me on my job.

What information was the most valuable to you in this self study?

Other Comments:

5 - Strongly

Agree

4 - Agree 3 – Neither

Agree / nor

Disagree

2 - Disagree 1 - Strongly

Disagree

1. The self-study met its stated objectives.

5 4 3 2 1

2. The self study content met my needs.

5 4 3 2 1

3. The author was knowledgeable in the content area.

5 4 3 2 1

4. Material was presented clearly.

5 4 3 2 1

5. Material was presented effectively.

5 4 3 2 1

6. Material was appropriate for stated title.

5 4 3 2 1

7. Examples were offered and discussed.

5 4 3 2 1

8. Content flowed logically.

5 4 3 2 1

9. Ample discussion of different areas was included.

5 4 3 2 1

10. Post test clearly reflected material.

5 4 3 2 1