Kathryn R. Oubre, M.D. 3/13/08

Moro: disappears by 4 months Asymmetrical tonic neck reflex: appears at 2-4 wks; disappears by 6 months

ReflexAppearanceDisappearance Hand graspBirth3 months Crossed adductorBirth7 months Toe graspBirth8-15 months Head righting4-6 monthsPersists voluntarily Protective equilibrium 4-6 monthsPersists voluntarily Parachute8-9 monthsPersists voluntarily

 Head righting: infant’s ability to keep the head vertical despite a tilt of the body  Protective equilibrium response: if child pushed laterally, flexes trunk toward the force to regain center of gravity while one arm extends to protect against falling (lateral propping)  Parachute response: outstretch of both arms and legs when the body is abruptly moved head first in a downward direction

 Neonates- minimal control of neck flexors  5-6 months: infant anticipates direction of movement of the pull- to-sit maneuver and flexes neck before the shoulders begin to lift  Red flag: Be concerned if there is no head control by 4 months! Look what I can do, Mom!

Newborn lies tightly flexed with the pelvis high and the knees under the abdomen 3-4 months: keeps the pelvis flat and lifts head & shoulders

 3-4 months ◦ Rolls prone-to-supine  5-6 months ◦ Rolls supine-to-prone ◦ Because of new “Back to Sleep” program, supine-to-prone may preceed prone-to- supine

4 months: pushes with feet when in standing position

 1-2 mo: head held up intermittently, but lacking trunk control  2-3 mo: raises head & shoulders well; lacks control of thoracolumbar area  3-4 mo: need support in lumbar area to sit  5-6 mo: holds head erect and spine straight  8 mo: gets into sitting position  Be concerned if a child does not sit without support by 7 months! 6 months old sits alone, props on hands

5-6 mo: commando crawl 6-9 mo: creeping 9-10 mo: cruising 11.7 mo: median age of walking 3 steps alone; range: 9-17 mo

 13 ½ mo: walking well  15 mo: stoops to floor and recovers independently  18 mo: stairs with hand held; runs  22 ½ mo: throws ball overhead  Be concerned if a child is not walking by 15 mo or running by 24 mo

 2 y/o: ◦ Runs well ◦ Kicks ball ◦ Jumps with 2 feet off floor ◦ Removes clothing  3 y/o: ◦ can balance on one foot for 1 second ◦ Broad jumps ◦ Pedals tricycle

 4 years ◦ Hops ◦ Balances on one foot for 20 seconds  5 years ◦ Can catch ◦ Skips alternating feet ◦ Dresses & undresses  6 years ◦ Rides bicycle without training wheels

Reflexive palmar grasp- disappears at 1 month 2-3 mo: midline hand play & Sucking on thumb/finger 4-5 mo: use hands as entire units to draw objects toward them Be concerned if a child does not have open grasp & midline activity by 4 mo or reaching by 6 mo

 4 months ◦ Reaches for objects  6 months ◦ Rake ◦ Transfers objects hand to hand  9 months ◦ Feeds self with fingers ◦ Holds two objects one at a time; bangs together ◦ Pat-a-cake in imitation ◦ Immature pincer

12 months Neat pincer 2 years Washes and dries hands 3 years Helps in dressing (unbuttons clothes, puts on shoes)

 18 months ◦ 2 cube tower  24 months ◦ 6 cube tower  3 years ◦ 10 cube tower ◦ Bridge

 15 months- imitates/scribbles spontaneously  2 years- imitates vertical/circular strokes  3 years- copies circle  4 years- copies cross  5 years- copies square  6 years- copies triangle Be concerned if a child shows hand preference in the first year of life

 4 y/o includes eyes, nose, mouth, hair, and legs  Receives one point for each of the following features: two eyes, two ears, a nose, etc.  Each point converts to the value of ¼ year added to a base age of 3 years

 Term newborn ◦ Fixes on faces 9-12 in from the face ◦ Tracks objects horizontally at least 30   4-8 mo: early object permanence ◦ track objects visually through vertical fall ◦ search for partially hidden toy ◦ explore toys by mouthing, shaking, banging  When mouthing of toys persists as predominant mode of exploration after mo, assessment of cognitive function is warranted

9-12 mo  Object permanence: awareness that objects continue to exist even when no longer visible 1 y/o: aware that different objects have different purposes (comb to hair) 15 m/o: mature means-end reasoning (ex: turns knob on mobile to make it play) 18 m/o: can deduce location of an object even if they haven’t seen it hidden from view; symbolic thinking; discipline starts to become an issue; imitates household tasks

 2 nd year of life: pretend play  Preschoolers- think that # and quantity vary with appearance  School age children- increased logic but limited by hypothetical/abstract  Adolescents- extend logical principles to increasingly diverse problems

Age RangeReceptive SkillExpressive Skill 0-1 ½ moStartles/widens eyes to sound Variation in crying (hunger, pain) 1 ½ - 4 moQuiets to voice, blinks eyes to sound musical sounds; coos; participates in reciprocal exchange 4 mo: laughs/squeals 4-9 moTurns head to sound; raises arms with “up” and when adult reaches Babbles consonant; repeats self-initiated sounds 9 mo: mama/dada non- specific 9-12 moResponds to “no”, waves bye-bye, claps; turns to own name Uses symbolic gestures & jargon; repeats parent- initiated sounds 12 mo: mama/dada c meaning

Age RangeReceptive SkillExpressive Skill mo Points to 3 body parts Understands 50 wds Follows 1 step command c gesture (throw ball) Uses wds to express needs; wds by 18 mo; wds mix c jargon, echolalia 18 mo-2 y/o Points to pics when asked “show me”; dist. you from me; understands soon, in, on, under Telegraphic 2 wd sentences (go byebye, up daddy); 50+ wds; “I, me, mine” 2 y/o: 50% intelligible 30 moFollows 2 step commands; can identify objects by use 2 ½ wd sentence; adjectives/adverbs; asks ?’s; asks adults to repeat actions 3 yo Knows several colors; past/future; today vs not today; knows what to do c basic needs; knows meaning simple adjective 75% intelligible; pronouns/plurals/negative s; 3-4 wd sentences; tells full name/age/gender

Age RangeReceptive SkillExpressive Skill 3 ½ y/oCan answer “do you have a doggie?” etc. Can relate experiences in sequential order; say nursery rhyme; ask permission 4 y/oUnderstands same vs different; follow 3 step commands Tells story; past tense; counts to 3; names primary colors; many ?’s; 100% intelligible 5 y/oUnderstands what we do with eyes/ears; diff. in textures; if, when, why; L and R Mature sentence structure & form; asks defn. specific wds; serious inquiries; “I don’t know”

 Failure to orient to sound or absent babbling may indicate a hearing deficit  Get a hearing test on any child who does not have a single word by 15 mo or several single words by 18 mo  Lack of protodeclarative pointing or pointing for naming may indicate a pervasive devt d/o  Refer any child who is not combining words and at least 50% intelligible by 2 y/o for a hearing and speech assessment

 Lack of intelligible speech by age 3  Frequent omission of initial consonants after age 4  Continued substitution of very easy sounds for harder ones after age 5  Persistent articulation errors after age 7  Stuttering/rapid speech beyond age 4 If any of these delays persists for 6 months or more, a referral should be initiated

 Neonates- fix visually on faces in preference to other sights ◦ Evident during the first few days of life  Responsive smile develops soon thereafter  Social smile- innate; appears at 4-6 w/o  Smiling appears in infants from all cultures at about the same time Be concerned if a child does not focus on Mom’s face at 1 st visit or have a social smile by 8 w/o

 First 6 mo: indiscriminate in their social behavior  By 6-8 mo, know that parents exist when out of sight; stranger awareness ◦ Stranger anxiety- may occur in infants who haven’t had routine care from other caregivers  Infants who have developed a secure attachment to their parents show signs of recognition and pleasure when reunited with them ◦ Explore at greater distances from parents; return for verbal encouragement/eye contact/hug

Up to 3 y/o: Parallel play 2 y/o: symbolic play 3y/o: -cooperative play -pretend play -impulse control 4-5 y/o: -peer play -domestic role playing -dress-up -imaginary friends

◦ Be concerned if a child does not show pride in accomplishments by 12 m/o or social relatedness by m/o ◦ Be concerned if a child has excessive temper tantrums, hyperactivity, or persistent poor transitions at 24 m/o

 6-9 m/o: emerging identity- displays interest in their own mirror images  1-2 y/o: feeds self, manages cup (by 15 mo) & spoon (by 18 m/o); enjoys own accomplisments (claps for self); discipline becomes a challenge ◦ 18 m/o visit: talk about toilet training  2-3 y/o: increased independence in verbal abilities; increased awareness of body sensations; modest skills in clothing self; begin toilet training