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Psychomotor Development of the Normal Infant

Psychomotor Development of the Normal Infant. Ola Didrik Saugstad, MD, PhD, FRCPE Professor of Pediatrics, University of Oslo. Student lecture 9th Semester. Normal Psychomotor Development. Goals of teaching:. Recognise the main aspects of normal psychomotor

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Psychomotor Development of the Normal Infant

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  1. Psychomotor Development of the Normal Infant Ola Didrik Saugstad, MD, PhD, FRCPE Professor of Pediatrics, University of Oslo Student lecture 9th Semester

  2. Normal Psychomotor Development Goals of teaching: • Recognisethe main aspects of normal psychomotor development such that the student is able to evaluate both gross motor and fine motor development · Recognise a delayed motor development

  3. Psychomotor Development Gross motor Fine motor Psychosocial head control, raises chest grasps/releases focuses, smiles rolls over from stomach coordination between to back eye-head-arm talks, recognizes people crawls, walks pincer grip (thumb to index finger) reacts to own reflection

  4. Areas of Development Gross motor control:head control, raises chest, rolls over from stomach to back, crawls, walks Fine motor and vision: pincer grip (thumb to index finger) Coordination between eye-head-arm, grasps/releases, focuses Language and hearing:talks, hearing and auditory processing distinguish speech sounds Social and daily living skills:Smiles,recognizes people, reacts to own reflection. Fine and motor skill enable imitative actions. Feeding, dressing, self-care, emotional regulation, play From: MJ Robinson and DM Robertson: Practical Paediatrics Churchill Livingstone, 2003

  5. Sphincter control - can it be taught? 1890-1910: No training 1920-1930: Rigid training (In 1932 the US governement published ”Infant care” calling for training from 2-3 weeks after birth. ”Punishment” was used to promote sphincter control 1930-1940: permissive, the child decides 1960 - :sphincter control is considered as a matter of neuromuscular maturation only - no effect of training Can psychomotor development be accelerated?

  6. SPHINCTER CONTROL • 15-18 months: voluntary control of bladder • 2 - 2 ½ years: can go to the bathroom, pull down his/her pants, • sit down on the toilet without help needs help wiping • 2 years: 50% of children are continent at night • 5 years: 90% of children are continent at night

  7. Sphincter control - can it be taught? The Digo tribe in Eastern Africa actively train the sphincter control at a few weeks of age. Continence is expected at 4-6 months of age, its occurrence has been verified by field studies The training is based on rewards, the siblings participate Is this early sphincter control due to an accelerated psychomotoric development among the Digo people? MV deVries & MR deVries Pediatrics 1977;60:170-177

  8. Psychomotor development One would like to know if the problem stems from: - a STATIC problem (CP, mental retardation) - a PROGRESSIVE condition (cerebral, degenerative, neoplastic or neuromuscular) - an ACUTE process that leads to rapid deterioration (infections, trauma)

  9. THE EXAMINATION The assessment of development is based upon two fundamental conditions: -the mother’s observations - the examiner’s findings For proper interpretation of these, knowledge of normal development from the neonatal period and onwards is essential

  10. The child’s state at the time of examination must be considered in the assessment of findings • fatigue • hunger • thirst • fear of strangers • mother’s concern These conditions can affect the child’s manner

  11. Normal ranges (approximately 25th to 90th centile) Age Gross motor Fine motor/ Language/ Social and months_control and vision and hearing daily living skills 2-4Head steady Follows objects Squeals with Smiles in sitting through 180o pleasure 5-8 Sits without Passes cube Turns to soft Feeds biscuit support hand to hand voice 9-14 stands with Neat pincer grip Mamma/dada Indicates needs support of raisin by gestures 12-16 Walks alone Stack of 2 cubes Three words Drinks from cup 15-24 Walks up Scribbles Points to one Removes garment steps spontaneously body part From Robinson MJ, and Robertson DM Practical Paediatrics,2003

  12. Warning signs to be concerned about – if child is not doing this From Robinson MJ, and Robertson DM Practical Paediatrics,2003 Age Gross motor Fine motor Language and Social and Months control and vision hearing daily skills 3Complete head Following with Searching for Smiling lag eyes sounds with eyes 6One hand Squint Head turn to Interest in preference, Moro soft voice people • Sitting with support Persistant hand Ba-ba,babble Awareness of • regard strangers 12Pulling to stand Pincer grasp Trying 1 or 2 words Constant Standing with supportmouthing • Walking alone Play with blocks Six words Pointing at items • casting toys Finger feeding Or regression in skills, or at any age there is parental concern

  13. Some developmental ”limit ages” • 2 months: response smiling • 3 months: good eye contact • 5 months: reaches for objects • 10 months: sits unsupported • 12 months pincer grip • 18 months: walks unsupported • 18 months : says single words with meaning • 20 months: speaks in phrases

  14. Psychomotor development Absolute warning signs!!! Sit at latest 10 months Walk at latest 18 months

  15. There is normal variation in development Development can vary greatly in normal children. This often shows a hereditary pattern. One should, however, not assume that a delay in development is family related without excluding other possible reasons Example 1: Deafness with delayed speech Example 2: Some children bottom-shuffle instead of crawling • This often runs in families and is often associated with other delays • with, for example, sitting without support, and walking without • support. This is a normal variation in development. Another normal variation in development is when a child develops directly from sitting to walking, without crawling in-between the two.

  16. NORMAL DEVELOPMENT IN INFANCY Main principles • - Development is continual from the time of conception to the • time of complete maturity • - The sequence of events varies with respect to duration and • timing, but follows the same pattern • - Development occurs in the cephalocaudal direction, • such that head control and control of hands is obtained before • walking

  17. Individual primitive reflexes, must regress before the • corresponding voluntary movements can be attained Grasp reflex disappears at 2-3 months • The automatic stepping reflex • in newborns regresses and • then usually disappears • completely after just a few weeks

  18. Parachute reflexesAppears 6-9 months of age

  19. Locomotor (movement) developmentFrom lying down to the standing position 9 month: crawling Newborn 12 month: early walking

  20. LOCOMOTOR (MOVEMENT) DEVELOPMENT • A. Ventral suspension • Examined by holding the child under the abdomen and chest

  21. Ventral suspension cont 6 weeks: briefly holds the head in the same plane as the body • Newborn: lacks head control

  22. Ventral suspension cont • 8 weeks: lifts head over the horizontal plane of the body, able • to maintain this position a while

  23. Lying prone cont • Newborn: head can be moved from side to side, the pelvis is • elevated and the knees drawn in under the stomach, often with • automatic crawling. With increasing maturity, the pelvis is sunken, • knees and hips become more extended • 4 weeks: lifts head from the underlying mat • 4-6 weeks: pelvis still somewhat elevated, hips less extended

  24. Prone position

  25. Lying prone cont • 12 weeks: head and shoulders held over the underlying mat • with the face in a 90% plane in relation to the shoulders

  26. 6 months: chest and • upper abdomen held • over the underlying mat • with the weight sup- • ported by arms, extended • elbows rolls over from • lying prone to lying supine Lying prone cont • 7 months: rolls over from • lying supine to prone, • weight can be supported • by one arm • 9 months: crawling 12 months: starting to walk

  27. 9 months

  28. C. From supine to Sitting

  29. Traction: Examiner pulls the child upwards, pulling up by the • hands, up to a sitting position • Newborn: marked head lag on pulling up, but as one nears the • vertical position the head tips forward.

  30. Traction cont

  31. Head Control

  32. Sitting cont • The baby’s back is completely • humped over, with a continual • curve from the neck to the sacrum 4-6 weeks:back less humped over, better head control

  33. Sitting cont

  34. 26-28 weeks: the child sits with the support of hands in front 8 months:sits without the need for support • 11 months: sits so stably • that it is possible to turn • around to pick up a toy • from the underlying mat • without losing balance

  35. Some developmental ”limit ages” 10 months: sits unsupported

  36. Walking

  37. Newborn: • in the upright position, falls together at the hips and knees

  38. 3 months: bears a good deal of weight in the legs • 6 months: bears most of own weight • 7 months: bears full bodyweight

  39. 8-9 months weeks: • stands by holding on to furniture and the like, • pulls himself/herself up to the standing position, but does not • manage to again sit down

  40. 44 weeks: can lift one foot from the floor • 48 weeks: can walk while holding on to furniture • 52 weeks: can walk when holding hands with someone

  41. 13 months:walks without support, with wide-set gait and uneven • steps, shoulders held abducted and elbows flexed

  42. Some developmental ”limit ages” 18 months: walks unsupported

  43. DEVELOPMENT OF MANIPULATION • The grasp reflex of the hands persists until • 8-12 weeks of age and is completely gone by • 3-4 months of age (can persist in brain- • damaged children and can surface in children with an activated • brain-damage).

  44. Manipulation • 4 weeks: hands are primarily closed • 8 weeks: hands are often open • 12 weeks: baby looks at objects as if he/she would like to grasp it, • holds objects that are placed in the hands • 16 weeks: hands drawn to the midline while playing, reaches for • objects but often misses, wants to play with and shake a rattle • when placed in his/her hand • 20 weeks: grasps actively at objects – bringing it in towards • his/her mouth, plays with his/her toes

  45. Throughout the first 6 months, the complexity of the infant’s palmar • grasp develops from a whole hand grasp from the ulnar side, • becoming more refined, with a good pincer grip at 10 months of age. • 24-32 weeks: radial grasp • 40 weeks: the object • is held between the • thumb and first finger, • the infant points at • objects with the index • finger (index approach) • while he/she moves • the hand to pick it up

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