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 3rd to 6th 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 NB-3m Sitting position NB-8m Prone position NB-9m Standing/Forw. Walking 9m-18m Running/Backw. Walking 2 yrs Balancing 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 0-6m NB primitive 1m primitive 2m starting to lose 3m voluntary on ulnar 4m hands together 5m palmar grasp 6m hand-mouth-hand; hand-to-hand

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

“Cognition” Social Development Problem solving Play Causality Language Development

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

Assessing cognitive development Play Age Play stage Piagetian stage <12m sensory-motor sensory-motor 12m-18m functional sensory-motor 18m-24m symbolic sensory-motor 2-5y imaginary/magical pre-operational 6y logical thinking concrete operation 11y + hypothetical 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 cries mom comes Early smiles mom responds 4m kicks crib mobile moves 8m pulls string gets ring 10m funny +response/repeats 24m winds key toy moves

Conversational speech probably starts with smiling

2 month old language

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

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