By Peter Zakopcan, MSc., BSc., Dipl PT
Child development is always a mixture of internal and external factors. Inherited temperament, curiosity, but also optimal muscle tone plays an important role in an appropriate development. For example, children with lower muscle tone may struggle with sitting and crawling due to an early onset of fatigue and weak trunk muscles. On the other hand, the environment which was not encouraging child to move and explore own physical capabilities will inevitably impact quality of baby’s development.
Early detection of delays is extremely important especially when child experiences problems that may inhibit his or her natural development, quality of movement patterns or learning. If child has experienced traumatic delivery or complications related to prematurity there is a chance of developing some level of neurological dysfunction negatively affecting school performance and family dynamic during childhood and adolescence. Understandably, these complications do not automatically mean future disability, but up to 50% of preterm infants may later show motor disturbances and between 5 to 15% may suffer from Cerebral Palsy.
If parents have any concerns, they should contact a pediatric specialist- usually pediatrician or in complicated cases they may consider more specialized practitioner such as pediatric neurologist or pediatric orthopedic surgeon. Pediatric physiotherapist should be also capable of assessing child for developmental delays. However keep in mind that opinions may vary greatly from practitioner to practitioner. Therefore, if parents are not satisfied with explanation they should not hesitate to seek a second or third opinion.
Gross motor milestones parents should keep track of
There are certainly important gross motor milestones which parents should observe during child’s development. Their presence and quality differs based on the age of the child. However, child should never lose movement skills he or she once had.
It is completely normal for a newborn to keep asymmetrical posture on the back and tummy as long as there is no strong side preference without the ability to change it. Around the age of 6-8 weeks parents should notice satisfactory visual contact related to objects/ sounds, development of body symmetry and initiation of antigravity movements (head, arm or leg lift). Concerning would be if child sucks poorly, doesn’t respond to loud sounds or doesn’t focus and follow a nearby object moving side to side. Another issue could be a presence of strange or repetitive movements or parents’ perception of child being stiff or floppy. Children between the age of 3 and 5 months should be able to keep balanced position on tummy or back, reaching for the toy or crossing a midline with attempt to roll. We are usually concerned if by this age interaction with environment or parents is poor and motivation to move is very low. Child 6- 8 months should be able to roll over in both directions (front to back, back to front) and have relatively high support on extended arms during tummy time. It should experiment with sitting firstly with and then without hands’ support. There should be an improvement in fine motor skills linked to presence of raking and later pincer grip. Child should also react to people by making vowel sounds. Parents should be concerned if child still seems very stiff or floppy, struggles with basic motor patterns (rolling, tummy time, sitting) or shows no affection to people or interest in the surrounding environment.
Development gets even more complex between 9 to 12 months. Children should rock back and forth in all 4 position, crawl forward, get into sitting position and sit without support or even pull themselves to standing position and cruise around furniture. They should be able to move things smoothly from one hand to the other. Social and sensory development continues as they make a lot of different sounds like “mama” and “baba”. Concerning situation would be child’s inability to bear weight through legs, sit without help or dragging one side of body while crawling or walking. Generally speaking, any issues in previous developmental stages, presence of hereditary conditions such as increased ligament flexibility or disturbed muscle tone will contribute to decreased quality of gait. For example, the prolonged use of W sitting position strains unnecessarily hip and knee joints and it does not encourage appropriate development of core strength or rotation capabilities necessary for the efficient gait pattern.
There has been quite a discussion about the importance of crawling. Crawling can be perceived as a complex core strengthening exercise, but also as a facilitation of other motor and cognitive skills. It improves spatial awareness, problem solving strategies (choosing best pathways between obstacles) and control of speed and distance awareness. Therefore, skipping this important milestone may likely result (but not in all children) to disturbances of large and refined movements, balance or hand-eye-coordination. Furthermore, issues with low quality of crawling may later in life interfere with other activities such as running, jumping or writing.
When therapy would be required for children
An extensive number of studies suggest that early identification of children with developmental delay or in the risk of developing motor disability is crucial for providing the earliest support and intervention focused on their reduction. It is advisable to rely on comprehensive assessment of motor development with a high sensitivity in detecting small changes that may have important influence on child’s functional skills. It is crucial that none of the risk factors or signs of movement pathologies will be missed, neglected or ignored.
What to expect from physiotherapy
There are various types of pediatric physiotherapy interventions focused on the improvement or normalization of motor development. In general, physiotherapy should be initiated as soon as possible within the first 6 months of child’s life in order to maximize utilization of available potential for improvement. Quality of treatment is certainly more important than quantity and practical part of the session together with parental education should always be promoted. Physiotherapist with active participation of parents designs a treatment program adapted to actual level of child’s development, available skills, needs of the family and social environment. In addition, physiotherapist should have a sufficient psychological background to understand parents’ feelings and guide them efficiently through the treatment which can be lengthy and emotionally exhausting. The place where treatment is administered is not the factor affecting the quality of intervention. However, mastering treatment techniques and positions, handling, frequency and continuity of therapy are determinant factors in the intervention efficacy.
What activities should be encouraged at home?
Understandably, this would depend on child’s age and condition. In general, children up to 6 months should enjoy as much natural exercises as they can – tummy time or rolling. For example, tummy time allows babies to rock back and forth and helps them to get a better spatial perception for other movement patterns such as crawling. Later of course, activities such as creeping, transfers to and from sitting positions can be added. Parents may even create something like an obstacle course out of soft pillows and cushions for their babies to climb and crawl over to help them to build their self-confidence. For children between 1-2 years of age different forms of crawling should be encouraged (crawling backward, bear crawling) as well as walking on different surfaces (harder, softer, sand, grass…). Older children can fully utilize a potential of kids play areas whether indoor or outdoor and focus on more challenging postural situations such as balancing on unstable surfaces and climbing. Parents should be creative, but they need to take necessary precautions to keep their child safe and unharmed during these activities.
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