Typical Typical Childhood Growth & Childhood Growth & Development: Development:

Critical aspects for the Critical aspects for the PhysiotherapistPhysiotherapist

Robyn SmithRobyn SmithDepartment of PhysiotherapyDepartment of Physiotherapy

UFSUFS20122012

Objectives for this Objectives for this model:model:

After this module the learner should be able to:After this module the learner should be able to:

Define termDefine term typical development typical development Explain what is meant by the term Explain what is meant by the term “development”“development” Identify the Identify the goals of gross motor developmentgoals of gross motor development Recall the Recall the characteristics of typical developmentcharacteristics of typical development Identify Identify intrinsic and extrinsic factorsintrinsic and extrinsic factors that impact on childhood that impact on childhood

developmentdevelopment Explain the Explain the basic principlesbasic principles of the well known of the well known developmental developmental

theoriestheories Identify the main Identify the main areas of developmentareas of development Explain why Explain why physiotherapists need to be knowledgeablephysiotherapists need to be knowledgeable about about

normal developmentnormal development Explain the concept of Explain the concept of “developmental milestones”“developmental milestones” Explain the concept of Explain the concept of “developmental sequencing”“developmental sequencing” Recall important Recall important age related milestonesage related milestones Understand the Understand the components and sequencecomponents and sequence of development of motor of development of motor

controlcontrol

Typical DevelopmentTypical Development

Controversy around the use of Controversy around the use of the terms “normal” versus the terms “normal” versus “typical” when referring to “typical” when referring to developmentdevelopment

NormalNormal

Implies Implies conformityconformity to the to the human standard human standard rangerange

? What is the ? What is the standardstandard

TypicalTypical

Refers more to the Refers more to the specific qualities specific qualities of a group of a group e.g. e.g. humanshumans

More accepted More accepted termterm

What is What is “development” ?“development” ?

Process that:

– begins at conception,– and continues throughout life until death

Rate of change and growth is greatest in the first 2 years of life

Defining developmentDefining development

Increase in the complexity of structure and size. We grow physically in size and stature

Increase in the complexity function – human activity that becomes more organised and effective as a result of practice

Acquisition and refinement of skills in a specific sequence

Defining developmentDefining development

The human’s ability to learn, adapt, and cope with the world largely related to the child’s constant and dynamic interaction with the environment

normal developmental cascade or developmental sequence

Developmental cascade is characterised by milestones

Motor development occurs in a specific

sequence and timing

Intrinsic and extrinsic factors impact on the timing of,

and reaching of these milestones

Factors that may impact on a Factors that may impact on a child’s developmentchild’s development

Intrinsic factorsIntrinsic factors

PhysiologyPhysiology AnatomyAnatomy GeneticsGenetics Personality/Personality/

motiviationmotiviation Race/ethnicityRace/ethnicity Medical conditionsMedical conditions

Often cannot avoid Often cannot avoid internal factorsinternal factors

Extrinsic factorsExtrinsic factors

Inadequate bonding or Inadequate bonding or nurturing with nurturing with mother/caregivermother/caregiver

Opportunities to learn or Opportunities to learn or practicepractice

CultureCulture Environmental risksEnvironmental risks Parental and child-rearing Parental and child-rearing

practicespractices NutritionNutrition Socio-economic factorsSocio-economic factors TraumaTrauma

Often factors that can be Often factors that can be avoided or alteredavoided or altered

Some interesting facts Some interesting facts ….…. The child The child triples his birth weighttriples his birth weight in the first in the first

year of lifeyear of life Achieves Achieves 2/3 of his/her brain size2/3 of his/her brain size in the 1 in the 1stst 2- 2-

3 years3 years Progress from a completely dependent baby Progress from a completely dependent baby

to a verbal, to a verbal, independent independent being by 2-3 years.being by 2-3 years.

What are the What are the requirements for requirements for development in a baby?development in a baby? Stable Stable behaviouralbehavioural and and physiological physiological

statesstates Be able to Be able to interactinteract with the with the

environmentenvironment Spontaneous Spontaneous movementsmovements Gradual development of Gradual development of postural and postural and

antigravity controlantigravity control Balanced muscle activityBalanced muscle activity

The goal of gross The goal of gross motor development?motor development? Develop Develop antigravity controlantigravity control, ultimately , ultimately

allowing us as humans to move in an allowing us as humans to move in an erect erect postureposture ….. ….. walkwalk

Maintain Maintain our center of gravity over our our center of gravity over our basebase of support, initially in lower of support, initially in lower positions such as sitting and ultimately positions such as sitting and ultimately in standingin standing

Develop Develop isolated isolated and and dissociationdissociation of of movementmovement

What Characterises of What Characterises of typical development?typical development?

The following may be considered important The following may be considered important principles of development:principles of development:

Movement is initially more Movement is initially more reflexivereflexive after birth after birth as maturation occurs becomes more as maturation occurs becomes more complex complex andand volitionalvolitional

Movement is initially Movement is initially generalisedgeneralised and and becomes becomes more localisedmore localised

Developmental maturation was believed to Developmental maturation was believed to only develop in a only develop in a cephalo-caudal cephalo-caudal direction, but we now know that it develops in both directions at the same time.

Development is medial to lateral, trunk and head control develop before shoulder and pelvic girdle and then lastly limb control

What Characterises of What Characterises of typical development?typical development? Gross motor skillsGross motor skills develop develop before fine motor before fine motor

skillsskills Develop Develop flexor muscle tone before extensorflexor muscle tone before extensor

muscle tonemuscle tone Development of Development of antigravity extensionantigravity extension before before

antigravity flexionantigravity flexion Development is Development is proximal to distalproximal to distal

MobilityMobility then then stabilitystability, then , then mobility with mobility with stabilitystability and the development of and the development of skillsskills

Theories on motor Theories on motor developmentdevelopment

Many developmental theories exist

Only going to look at some of the important ones

No single theory can explain typical

development in its entirety

Many theories contain valuable

insights

Developmental Developmental theoriestheories Milestone approachMilestone approach (Illingsworth) –improved (Illingsworth) –improved

postural control postural control dependentdependent on the natural on the natural maturation process of the CNSmaturation process of the CNS. The . The order of order of development is samedevelopment is same for all children, for all children, rate rate varyvary. . characterised by characterised by milestonesmilestones

Neural maturation theory/ hierarchialNeural maturation theory/ hierarchial (Piaget, (Piaget, Gesell, Bayley)– Emphasis on the changes Gesell, Bayley)– Emphasis on the changes maturation in the CNSmaturation in the CNS which enables which enables development to proceed. Believed the CNS development to proceed. Believed the CNS driving force in development. Emphasised the driving force in development. Emphasised the normal normal developmental sequence developmental sequence common to common to all humans. all humans. naturenature

Developmental Developmental theoriestheories

Behavioural appraochBehavioural appraoch (Pavlov) – (Pavlov) – conditioning of a conditioning of a response response to specific stimuli. By to specific stimuli. By manipulating the manipulating the environmentenvironment create a response from an individual (used create a response from an individual (used in our therapy)in our therapy)

Dynamic systems theoryDynamic systems theory – – CNS CNS only one aspect, and the only one aspect, and the child’s child’s experience experience and interaction with his and interaction with his environmentenvironment (intrinsic and extrinsic factors) are critical to his (intrinsic and extrinsic factors) are critical to his development. development. No one No one system is more important than the other. Also system is more important than the other. Also sees the CVS, musculoskeletal sees the CVS, musculoskeletal and and peripheral nervous peripheral nervous systemsystem as important systems. as important systems.

FunctionalFunctional outcomes are the reason human’s perform outcomes are the reason human’s perform tasks. tasks.

nurturenurture

Developmental Developmental theoriestheories Latest and most widely accepted current theory on Latest and most widely accepted current theory on

developmentdevelopment

NB √ NB √ Neuronal group selection theoryNeuronal group selection theory

Suggests that the infant has an inherent Suggests that the infant has an inherent capacity for capacity for self generated activity, self generated activity, specific motor behaviour specific motor behaviour repertoiresrepertoires, ,

which are then which are then refined by experiencerefined by experience enabling the enabling the child to child to choose the most effective motor plan choose the most effective motor plan for the for the task at handtask at hand

Developmental Developmental theoriestheories

Theory also recognises the Theory also recognises the importanceimportance of: of:

opportunity for experienceopportunity for experience Environment extrinsic Environment extrinsic trial and error practicetrial and error practice varied practicevaried practice

interactive nature of all aspects of motor interactive nature of all aspects of motor control including sensory, cognitive and intrinsic control including sensory, cognitive and intrinsic perceptualperceptualbehavioral (personality)behavioral (personality)biomechanical aspectsbiomechanical aspects

Ability to learn and adapt to acquire new skillsAbility to learn and adapt to acquire new skills

Areas of Areas of DevelopmentDevelopment

Main areas of Main areas of development:development:

There areThere are 4 main areas of 4 main areas of developmentdevelopment that need to be that need to be assessedassessed

Gross motorGross motor Fine motorFine motor Speech and languageSpeech and language Socialization/ behaviourSocialization/ behaviour

As physiotherapists our focus As physiotherapists our focus is on is on gross motorgross motor development development

Have to now basics of other Have to now basics of other areas of development to be areas of development to be able to interpret information/ able to interpret information/ referrefer

Why must physiotherapists be Why must physiotherapists be knowledgeable regarding knowledgeable regarding

normal development?normal development? Provides a Provides a foundationfoundation for for

understandingunderstanding typical and typical and therefore atypical developmenttherefore atypical development

Serves as the basis for our Serves as the basis for our developmental/ neurological developmental/ neurological assessmentassessment

ScreeningScreening purposes purposes MonitorMonitor a child’s a child’s

developmental developmental progression progression or regressionor regression

InterpretInterpret developmental developmental findingsfindings

Aids us in Aids us in identifyingidentifying delays and/ or delays and/ or abnormalitiesabnormalities in development as in development as the earliest possible point in timethe earliest possible point in time

Why must physiotherapists be Why must physiotherapists be knowledgeable regarding knowledgeable regarding

normal development?normal development? Aids us in Aids us in planningplanning and and

executing our treatmentexecuting our treatment of of children, but children, but also also adultsadults with motor delays with motor delays or disturbances or disturbances NB !!!! NB !!!! developmental developmental sequencingsequencing

By being knowledgeable By being knowledgeable about the about the developmental developmental sequencesequence we can identify we can identify the the limitinglimiting componentscomponents and focus on them in and focus on them in treatment to aid the treatment to aid the developmental sequence.developmental sequence.

Milestones Milestones

What are What are developmental developmental milestones?milestones? Defined by Defined by IllingworthIllingworth in his milestone theory as in his milestone theory as

– Set of Set of functional skillsfunctional skills or or age-specific tasksage-specific tasks – that most children can do at a that most children can do at a certain age rangecertain age range

Milestone = Milestone = standardstandard for skill acquisitionfor skill acquisition

Defines the child’s Defines the child’s “developmental age”“developmental age”

NB norms are based for children of full gestational ageNB norms are based for children of full gestational age

Although each milestone has an age level, every child is Although each milestone has an age level, every child is unique, and the impact of intrinsic and extrinsic factors unique, and the impact of intrinsic and extrinsic factors may vary Therefore it is accepted that may vary Therefore it is accepted that standard standard deviation/variation of one month on either side is deviation/variation of one month on either side is allowed allowed

So where do I get So where do I get information on childhood information on childhood milestones?milestones? Many different milestone guidelines in table Many different milestone guidelines in table

and picture formatand picture format Internet – huge source of information Internet – huge source of information

regarding milestones availableregarding milestones available Peabody infant development chartsPeabody infant development charts

Developmental Screening testsDevelopmental Screening tests

Objective & quantifiable = gives a scoreObjective & quantifiable = gives a score Bayley scales III Bayley scales III Denver IIDenver II NDSNDS AIMSAIMS Bruininks-Oseretsky test of motor proficiencyBruininks-Oseretsky test of motor proficiency MABC MABC

START programme: checklists – START programme: checklists – not not quantifiablequantifiable

Milestones Milestones importance: to know importance: to know by heartby heart Head control in supine Head control in supine

(PTS) and in prone(PTS) and in prone Ventral suspensionVentral suspension Rolling Rolling SittingSitting

4 point kneeling /crawling4 point kneeling /crawling StandingStanding Pull to standPull to stand CruisingCruising WalkingWalking Running Running JumpingJumping GraspGrasp Vision Vision

5/125/12

5/125/12 6/126/12 Starts 6/12 arm support /well Starts 6/12 arm support /well

8/128/12 Start 7/12 well 9/12 Start 7/12 well 9/12 FWB 6/12 –holding on 10/12FWB 6/12 –holding on 10/12 7-9/127-9/12 10-12/1210-12/12 12-18/12 even 24/12 in cases12-18/12 even 24/12 in cases 24/1224/12 36/1236/12 7-9/127-9/12 6/126/12

Milestones vs. Milestones vs. developmental developmental sequencesequence Both are important components Both are important components to consider when to consider when

assessing and treating children with developmental assessing and treating children with developmental concernsconcerns

Developmental sequence refers to the Developmental sequence refers to the typical pattern or typical pattern or development of the components of movementdevelopment of the components of movement & & timing timing thereofthereof

Need to Need to understand the componentsunderstand the components and the and the sequencing sequencing of the componentsof the components in the developmental sequence in the developmental sequence

Whilst when looking at Whilst when looking at milestonesmilestones your are assessing the your are assessing the skills or tasksskills or tasks a child has achieved for his age a child has achieved for his age

References:References:

Images courtesy of GOOGLE (2009)Images courtesy of GOOGLE (2009) Growth and Development. In Coovadia, H.M. & Wittenberg, D.F. Growth and Development. In Coovadia, H.M. & Wittenberg, D.F.

(eds) in (eds) in Paediatrics and Child Health. A manual for health Paediatrics and Child Health. A manual for health professionals in developing countries. professionals in developing countries. 44thth ed. Oxford city Press: ed. Oxford city Press: Cape Town pp 21-40Cape Town pp 21-40

Van der Vyver, A.E. Normal Growth in Van der Vyver, A.E. Normal Growth in Paeditric doctors lectures for Paeditric doctors lectures for Physiotherapy students. Physiotherapy students. (Unpublished)(Unpublished)

Goldson, E. & Reynolds, A. Child development and Behaviour Hay, Goldson, E. & Reynolds, A. Child development and Behaviour Hay, W.W.; Myron, J. L.; Sondheimer, J.M. & Deterding, R.R. (eds). In W.W.; Myron, J. L.; Sondheimer, J.M. & Deterding, R.R. (eds). In current diagnosis and treatment in Paediatrics. 18th ed. McGraw-current diagnosis and treatment in Paediatrics. 18th ed. McGraw-Hill companies: NewYork pp65-101Hill companies: NewYork pp65-101

Aubert, E.J. Motor development in the normal child in Pediatric Aubert, E.J. Motor development in the normal child in Pediatric Physical Therapy. Tecklin, J.S. (Eds) in Pediatric Physical Therapy. Physical Therapy. Tecklin, J.S. (Eds) in Pediatric Physical Therapy. Lippincott, Williams & Wilkins. Baltimore pp17 -65Lippincott, Williams & Wilkins. Baltimore pp17 -65

Smith, R. 2009. Paediatric dictate, UFS (Unpublished).Smith, R. 2009. Paediatric dictate, UFS (Unpublished). Smith, R. 2009. Normal development (Unpublished)Smith, R. 2009. Normal development (Unpublished) Mosby Medical dictionary Mosby Medical dictionary