Normal Developmental Milestones An emphasis on anticipatory guidance

Normal Developmental Milestones An emphasis on anticipatory guidance Ana Malinow, MD

Why we should teach parents about development Parents who understand their child’s developmental state, are more likely to have appropriate expectations. Having appropriate expectations makes for a healthier relationship between parent and child. Healthier relationships facilitate development.

Objectives • • • Principles of development Primitive Reflexes “Locomotion”: Gross Motor “Manipulation”: Fine Motor “Cognitive”: Language and Social Behavior and Personality

Principles of Development • A continuous process • Sequence of development is the same, rate of development varies • Not parallel • Related to CNS maturation • Involuntary movements give way to voluntary responses • Occurs in cephalocaudal and proximal to distal • Progresses from dependence to independence

Development Occurs in a Cephalocaudal Direction

Development begins in utero Age Responses/Reflexes 8 ½ wks tactile stimuli (reflex arc laid down) 12 wks sucking 24 wks sound 26 wks rhythmic breathing movements/ controls body temperature 30 wks pupilary light reflex 35 wks grasp/spontaneous orientation to light

All primitive reflexes develop during gestation and disappear by the 3 rd to 6 th month after birth

Primitive reflexes • Tonic labyrinthine reflex • Asymmetric tonic neck reflex • Positive support reflex

Declining intensity of primitive reflexes and increasing role of definitive motor actions

Gross motor development “Locomotion”

Locomotion begins with head control

Assessing Locomotion • • • Ventral suspension Sitting position Prone position Standing/Forw. Walking Running/Backw. Walking Balancing NB-3 m NB-8 m NB-9 m 9 m-18 m 2 yrs 3 yrs +

Ventral suspension

Head control

2 month head control

4 month head, arm control

6 month head, arm, trunk control

8 month head, arm, trunk, leg control

9 month pulls up to stand

12 month old locomotion

2 year old Running Backward Walking

3 year old Balance

“Manipulation” Fine Motor Development

Manipulation: Assessing the pincer grasp from 0 -6 m • • NB 1 m 2 m 3 m 4 m 5 m 6 m primitive starting to lose voluntary on ulnar hands together palmar grasp hand-mouth-hand; hand-to-hand

Manipulation: Assessing the pincer grasp 7 -12 m • 7 m • 8 m • 9 m • 10 m • 12 m • >12 m thenar side, raking 1 block in each hand radial-digital grasp; inferior pincer index finger isolation fine pincer letting go, stacking

“Cognition” Social Development Problem solving Play Causality Language Development

Assessing cognitive development Problem solving • • • NB 4 -6 wks 2 m 3 m 5 m 6 m 7 m 8 m 9 m 10 m visual exploration smiles, fixes, follows imitates mouth movements anticipates feeds object permanence looks to floor when toy dropped grabs 2 nd cube, drops first seeks object after fall (silent) uncovers hidden object under cloth isolates index finger

Assessing cognitive development Play Age <12 m 12 m-18 m 18 m-24 m 2 -5 y 6 y 11 y + Play stage sensory-motor functional symbolic imaginary/magical logical thinking hypothetical Piagetian stage sensory-motor pre-operational concrete operation formal operational

12 -month 18 -month Functional Play

18 -month 24 -month Symbolic Play

2 -5 year Imaginary/Magical Play

6 year old Logical Thinking

11 years + Hypothetical thinking

Assessing cognitive development Causality Age Cause Effect Early 4 m 8 m 10 m 24 m cries smiles kicks crib pulls string funny winds key mom comes mom responds mobile moves gets ring +response/repeats toy moves

Conversational speech probably starts with smiling

2 month old language

Assessing cognitive development: Language Age Milestone 4 -6 wks 2 m 3 m 4 m 6 m 7 m 8 m 12 m smiles vocalizes with vowels vocalizes with consonants squeals syllables non-specific combinations imitates sounds, understands “no” 1 -3 words

Assessing language Age Expressive Receptive Jargon Sentence L. Intelligible 12 m 1 -3 100 Y none 18 m 10 -25 ID body Y giant words holophrases 2 y 50 Pts. Body N 2 words 25 -50% 3 y 500 Prepositions N 3 -4 words 75% 4 y 5 def. Comparisons N 4 -5 words 100% 5 y 7 def. N 100% 6 y masters rules of grammar

Behavior • • One-way or two-way interactions Prenatal factors Bonding/attachment CNS maturation Match Schedule Language Instincts

Behavior -continued • Cognitive, gross and fine motor development • Illness, separation, feeding issues • Birth order, family size • Secondary attachments • Environment • Gender identification

Bonding

Personality • • Factors that influence behavior Create behavior Through adaptability and flexibility Produce personality/social behavior

Newborn “Personality”

4 month old “Personality”

9 -month old “Personality”

Other “Personality” Landmarks • 2 -year old independence/dependence • 3 -year old master of impulse control, sharing, wants to please, guilt • 7 -year old ability to see another’s point of view • Adolescence begins identity formation (idealistic) • Adulthood completion of identity formation

Conclusion • • • Development is a continuous process Sequence is always the same, rate varies Development does not run parallel Intimate relationship with CNS Generalized activity gives way to voluntary activity • Cephalocaudal development • Dependence to independence