Normal Developmental Milestones

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

2. 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.

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

4. 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

5. Development Occurs in a Cephalocaudal Direction

7. 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

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

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

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

12. Gross motor development“Locomotion”

13. Locomotion begins with head control

14. 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 +

15. Ventral suspension

16. Head control

17. 2 month head control

18. 4 month head, arm control

19. 6 month head, arm, trunk control

20. 8 month head, arm, trunk, leg control

21. 9 month pulls up to stand

22. 12 month old locomotion

23. 2 year old Running Backward Walking

24. 3 year old Balance

25. “Manipulation”Fine Motor Development

26. 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

27. 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

28. “Cognition” Social Development Problem solving Play Causality Language Development

29. Assessing cognitive developmentProblem 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

30. Assessing cognitive developmentPlay 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

31. 12-month 18-monthFunctional Play

32. 18-month 24-monthSymbolic Play

33. 2-5 yearImaginary/Magical Play

34. 6 year oldLogical Thinking

35. 11 years +Hypothetical thinking

36. Assessing cognitive developmentCausality 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

37. Conversational speech probably starts with smiling

38. 2 month old language

39. 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

40. 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

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

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

43. Bonding

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

45. Newborn “Personality”

46. 4 month old “Personality”

47. 9-month old“Personality”

48. 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

49. 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