From the American Occupational Therapy Association: Occupational therapy practice framework: Domain and process, 2nd edition, Am J Occup Ther 62:625–683, 2008.

As children follow a developmental sequence within an individual performance skill, they are also developing other performance skills. For example, an 18-month-old toddler travels and explores independently, has a precise grasp, is beginning to use tools to solve problems, and demonstrates an understanding of the function of objects in play.

Infancy

Phillip is an active and happy 1-year-old boy. It is his first birthday party, and he is busy experimenting with his new toys. As family and friends watch, he attempts to sit on his push toy and make it move across the kitchen ﬂoor. When his older siblings offer help, he pushes them away because he wants to play alone.

Physiologic development

The newborn’s average weight at birth is 7 lb, 2 oz and the average length between 19 and 22 inches. The appearance of the newborn may be characterized by a covering comprising a layer of ﬂuid called vernix caseosa; a large, bumpy head; a ﬂat, “board” nose; reddish skin; puffy eyes; external breasts; and fine hair called lanugo covering the body.¹³ At 1 minute after birth, the newborn’s physiological status is tested using the Apgar scoring system, which rates each of the following five areas on a scale of 0 to 2: (1) color, (2) heart rate, (3) reﬂex irritability, (4) muscle tone, and (5) respiratory effort. The scores are computed at 1 and 5 minutes after birth. The closer the total score (sum of scores for the five areas) is to 10, the better is the condition of the newborn; scores of 6 or less indicate the need for intervention.¹²

The infant’s first 3 months of life are characterized by constant physiologic adaptations. Structural changes in the newborn’s circulatory system include the expansion of the lungs and increased efficiency of blood ﬂow to the heart. The developing central nervous system (CNS) participates in the body’s regulation of sleep, digestion, and temperature.¹⁰

Physical growth is dramatic—from birth to 6 months of age, infants experience a more rapid rate of growth than at any other time, except during gestation.¹⁹ During the first year, infants triple their body weight, and their height increases by 10 to 12 inches. Their body shape changes, and by 4 months the sizes of their heads and bodies are more proportionate. By 12 months, average infants weigh 21 to 22 lb and are 29 to 30 inches tall. During the second year of life, physical growth slows. By 24 months, an average toddler weighs about 27 lb and is 34 inches tall. The posture of toddlers is characterized by lordosis (forward curvature of the spine) and a protruding abdomen, which toddlers retain well into the third year.³³

At 4 months, sleep patterns begin to be regulated, and some infants may sleep through the night. By 8 months, the average infant sleeps 12 to 13 hours per day, but the range can vary from 9 to 18 hours per day. By 6 to 7 months, the average infant acquires the first tooth, a lower incisor. As a result, saliva production increases, which leads to drooling. At approximately 8 months, the upper central incisor teeth begin to surface, at 9 months the upper lateral incisors appear, and at 12 months the first lower molars are seen.²⁸

Motor development

Brazelton identified six behavioral states observed in the newborn: (1) deep sleep; (2) light sleep; (3) drowsy or semidozing; (4) alert, actively awake; (5) fussy; and (6) crying.⁹ The infant’s state should be noted when observing the way he or she responds to stimulation.¹³

Sensory skills

Newborns have vision at birth and can see objects best from about 8 inches away, which is the typical distance between the caregiver’s face and the infant’s.²⁹ By the first month of life, an infant shows a preference for patterns and can distinguish between colors. By 3 months, visual acuity develops enough to allow distinction between a picture of a face and a real face.¹⁰ By 12 months, the infant’s visual acuity is about 20/100 to 20/50.²⁴

Hearing is well developed in newborns and continues to improve as they grow. They tend to respond strongly to the mother’s voice.²⁵ During the first 2 months, infants respond to sound with random body movements. At 3 months, they move their eyes in the direction of sound.¹⁰ At 6 months, they localize sounds to the left and right.⁵

At birth, newborns are able to taste sweet, sour, and bitter substances. Between birth and 3 months, infants are able to differentiate between pleasant and noxious odors. They are very sensitive to touch, cold and heat, pain, and pressure; one of the most important stimuli for infants from birth to 3 months is skin contact and warmth.²⁷ Holding and swaddling the infant provide skin contact and maintain the infant’s body temperature.¹³

Gross motor skills

The newborn’s body is characterized by physiologic ﬂexion, a position of extremity and trunk ﬂexion.⁸ This ﬂexion tends to keep the infant in a compact position and provides a base of stability for random movements to occur. These movements are characterized by a motion called random burst, in which everything moves as a unit.¹ The newborn has numerous primitive reﬂexes, which are genetically transmitted survival mechanisms. These automatic responses to stimuli help the newborn adapt to the environment. Primitive reﬂexes are controlled by lower levels of the CNS. As higher levels of the CNS mature, higher systems inhibit the expression of primitive reﬂexes. As infants learn about the environment, primitive reﬂexes are integrated into their overall postural mechanism, with the more mature righting and equilibrium responses that dominate their movements.³⁴ Under stress, these reﬂexes may be partially present, but they are never obligatory in normal development. Some primitive reﬂexes are present at birth, whereas others emerge later in the infant’s development (Table 7-1).

TABLE 7-1

Reﬂexes and Reactions

NAME OF REFLEX OR REACTION	POSITION (P) STIMULUS (S)	POSITIVE RESPONSE	AGE SPAN: AGE OF ONSET OR INTEGRATION	LACK OF INTEGRATION OR ONSET
Rooting	P: Supine S: Light touch on side of face near mouth	Opens mouth and turns head in direction of touch.	Birth to 3 mo	Interferes with exploration of objects and head control
Sucking/swallowing	P: Supine S: Light touch on oral cavity	Closes mouth, sucks, and swallows.	Birth to 2–5 mo	Interferes with development of coordination of sucking, swallowing, and breathing
Moro’s	P: Supine, head at midline S: Dropping head, more than 30 degrees extended	Arms extend and hands open; then arms ﬂex and hands close; infant usually cries.	Birth to 4–6 mo	Interferes with head control, sitting equilibrium, and protective reactions
Palmar grasp	P: Supine S: Pressure on ulnar surface of palm	Fingers ﬂex.	Birth to 4–6 mo	Interferes with releasing objects
Plantar grasp	P: Supine S: Firm pressure on ball of foot	Toes grasp (ﬂexion).	Birth to 4–9 mo	Interferes with putting on shoes because of toe clawing, gait, and standing and walking problems (e.g., walking on toes)
Neonatal positive support—primary standing	P: Upright S: Being bounced several times on soles of feet (proprioceptive stimulus)	LE extensor tone increases, and plantar ﬂexion is present. Some hip and knee ﬂexion or genu recurvatum (hyperextension of the knee) may occur.	Birth to 1–2 mo	Interferes with walking patterns and leads to walking on toes
ATNR	P: Supine, arms and legs extended, head in midposition S: Head turned to one side	Arm and leg on face side extend; arm and leg on skull side ﬂex (or experience increased ﬂexor tone)	Birth to 4–6 mo	Interferes with reaching and grasping, bilateral hand use, and rolling
STNR	P: Quadruped position or over tester’s knees S: 1. Flexed head 2. Extended head	1. Arms ﬂex and legs extend (tone increases). 2. Arms extend and legs ﬂex (tone increases).	Birth to 4–6 mo	Interferes with reciprocal crawling (children “bunny hop” or move arms and then legs in quadruped position) and walking
TLR	P: 1. Supine, head in midposition, arms and legs extended 2. Prone S: Position (laying on ﬂoor); being moved into ﬂexion or extension	1. Extensor tone of neck UE, and LE increases when moved into ﬂexion. 2. Flexor tone of neck UE, and LE increases when moved into extension.	Birth to 4–6 mo	Interferes with turning on side, rolling over, going from lying to sitting position, and crawling; in older children, interferes with ability to “hold in supine ﬂexion” or assume a pivot prone position
Landau	P: Prone, held in space (suspension) supporting thorax S: Suspension (usually), also active or passive dorsiﬂexion of head	Hips and legs extend; UE extends and abducts. Elbows can ﬂex. (Typically used to determine overall development)	3–4 mo to 12–24 mo	Slows development of prone extension, sitting, and standing Early onset (1 mo); may indicate excessive tone or spasticity
Protective extension UE—Parachute, downward forward, sideways, backward	P: Prone, head in midposition, arms extend above S: Suspension by ankles and pelvis and sudden movement of head toward ﬂoor P: Seated S: Child pushed: 1. Forward 2. Left, right 3. Backward	Shoulders ﬂex and elbow and wrist extend (arms extend forward) to protect head; infant catches self in directions pushed: 1. Shoulder ﬂexes and abducts; elbow and wrist extend (arms extend forward). 2. Shoulder abducts, elbow and wrist extend (arms extend to side). 3. Shoulders, elbows, and wrists extend (arms extend backward) to protect head.	6-9 mo continues through life	Interferes with head protection when center of gravity displaced
Stagger LE—Forward, backward, sideways	P: Standing upright S: Displacement of body by pushing on shoulders and upper trunk: 1. Forward 2. Backward 3. Sideways	Infant takes one or more steps in direction of displacement. UEs often also have a protective reaction, with elbow, wrist, and fingers extending: 1. Shoulder ﬂexes. 2. Shoulder abducts and extends. 3. Shoulder abducts.	15–18 mo, continues throughout life	Interferes with ability to catch self when center of gravity displaced, causes trips and falls
Equilibrium—sitting	P: Seated, extremities relaxed S: Hand pulled to one side or shoulder pushed	Head righting: non–weight-bearing side—trunk ﬂexes; UE and LE abduct and internally rotate; and elbow, wrist, and fingers extend Head righting: weight-bearing side—trunk elongates; UE and LE externally rotate; and elbow, wrist, and fingers abduct and extend.	7–8 mo, continues throughout life	Interferes with ability to sit or maintain balance when reaching for objects or displacing center of gravity
Standing	P: Standing upright, extremities relaxed S: Body displaced by holding UE and pulling to side	Head righting: non–weight-bearing side—trunk ﬂexes; UE and LE abduct and internally rotate; and elbow, wrist, and fingers extend. Head righting: weight-bearing side—trunk elongates; UE and LE eternally rotate; and elbow, wrist, and fingers extend and abduct.	12–21 mo, continues throughout life	Interferes with ability to stand and walk and make transitional movements
Equilibrium or tilting—prone, supine	P: Prone or supine on a tilt board, extremities extended S: Board tilted to left or right	Head righting: non–weight-bearing side—trunk ﬂexes; UE and LE abduct; and elbow, wrist, hip, and knee externally rotate and extend. Head righting: weight-bearing side—UE and LE internally rotate and abduct and elbow, wrist, fingers, knee, and hip extend.	5–6 mo, continues throughout life	Interferes with ability to make transitional movements, sit, and creep

LE, lower extremity; UE, upper extremity; ATNR, asymmetrical tonic neck reﬂex; STNR, symmetrical tonic neck reﬂex; TLR, tonic labyrinthine reﬂex.

Adapted from Alexander R, Boehme R, Cupps B: Normal development of functional motor skills, Tucson, AR, 1993, Therapy Skill Builders; Bly L: Motor skills acquisition in the first year: An illustrated guide to normal development, Tucson, AR, 1994, Therapy Skill Builders; Fiorentino MR: Reﬂex testing methods for evaluating CNS development, ed 2, Springfield, IL, 1981, Charles C Thomas; Simon CJ, Daub MM: Human development across the life span. In Hopkins JL, Smith HD, editors: Willard and Spackman’s occupational therapy, ed 8, Philadelphia, 1993, Lippincott.

As shown in Table 7-2, infants’ gross motor skills become gradually more complex as they develop.¹^,⁸^,¹³ Infants begin to combine basic reﬂexive movements with higher cognitive and physiologic functioning to control these movements in the environment (Box 7-2). Between birth and 2 months, infants can turn their heads from side to side while in prone and supine positions. As physiologic ﬂexion diminishes, they appear more hypotonic (have less muscular and postural tone), and the movements of each side of their body appear asymmetrical. The asymmetrical tonic neck reﬂex (ATNR) holds infants’ heads to one side. By 4 months, they can raise and rotate their heads to look at their surroundings. In the supine position (on the back), 4-month-old infants begin to bring their hands to their knees and can deliberately roll from the supine position to the side. The increased head and trunk control observed at this age is the result of emerging righting reactions and better postural control (see Box 7-2). At 5 months, when pulled to a sitting position, infants can bring their heads forward without lagging. By 6 months, they can shift their weight to free extremities to reach for objects while in the prone position (on the stomach). In the supine position, 6-month-old infants can bring their feet to their mouths and are able to sit by themselves for short periods. At 7 to 8 months, they are able to push themselves from the prone position to the sitting position, roll over at will, and crawl on their stomachs. Between 6 and 9 months, infants develop upper extremity protective extension reactions that allow them to catch themselves when pushed off balance (Figure 7-1). From 7 to 21 months, they develop equilibrium reactions that allow them to maintain their center of gravity over their base of support; these reactions are critical for transitional movements patterns (i.e., movements from one position to another) and ambulation (see Box7-2; Figure 7-2). At 10 to 11 months, infants are practicing and enjoying creeping. By 12 months, they are learning to shift their weight and step to one side by cruising around furniture. At 13 or 14 months most infants take their first steps, and between 12 and 18 months they spend much of their time practicing motor skills by walking, jumping, running, and kicking. Mobility changes infants’ perceptions of their environment. A chair is a one-dimensional object in the eyes of a 6 month old; it is only when the infant can finally climb over, under, and around the chair that he or she discovers what a chair really is.¹⁸

BOX 7-2 Development of Coordinated Movement in Infancy

Extension → flexion → lateral flexion → rotation

Primitive reflexes

Primitive reﬂexes are automatic movements that are usually stimulated by sensory factors and performed without conscious volition. Primitive reﬂexes cause the first involuntary movements to occur and allow for extension movements to emerge. Primitive reflexes are controlled at the lower levels of the central nervous system. As the higher levels (cerebral hemispheres) mature, the expression of primitive reflexes is inhibited by these higher levels (i.e., they seem to disappear).

Righting reactions

Righting reactions are postural responses to changes of head and body positions. Righting reactions bring the head and trunk back into an upright position. These reactions involve movements called extension, ﬂexion, abduction, adduction, and lateral ﬂexion.

Equilibrium reactions

Equilibrium reactions are automatic, compensatory movements of the body parts that are used to maintain the center of gravity over the base of support when either the center of gravity or the supporting surface is displaced. These complex postural responses combine righting reactions with movements known as rotational and diagonal patterns. Essential for volitional movement and mobility, the use of righting reactions begins at 6 months and continues throughout life.

Protective extension responses

Protective extension responses are postural reactions that are used to stop a fall or to prevent injury when equilibrium reactions fail to do so. These responses involve straightening of the arms or legs toward a supporting surface. Essential for mobility, the use of protective extension reactions begins between 6 and 9 months and continues throughout life.

Adapted from Alexander R, Boehme R, Cupps B: Normal development of functional motor skills, Tucson, AR, 1993, Therapy Skill Builders; Bly L: Motor skills acquisition in the first year: An illustrated guide to normal development, Tucson, AR, 1994, Therapy Skills Builders: Florentino MR: Reflex testing methods for evaluating CNS development, ed 2, Springfield, IL, 1981, Charles C Thomas; Simon CJ, Daub MM: Human development across the life span. In Hopkins JL, Smith HD, editors: Willard and Spackman’s occupational therapy, ed 8, Philadelphia, 1993, Lippincott.

TABLE 7-2

Normal Development of Sensorimotor Skills

AGE	GROSS MOTOR COORDINATION	FINE MOTOR COORDINATION
BIRTH OR 37-40 WK OF GESTATION	Is dominated by physiologic ﬂexion Moves entire body into extension Turns head side to side (protective response) Keeps head mostly to side while in supine position	Visually regards objects and people Tends to fist and ﬂex hands across chest during feeding Displays strong grasp reﬂex but has no voluntary grasping abilities Has no voluntary release abilities
1–2 MO	Appears hypertonic as physiologicalal ﬂexion Practices extension and ﬂexion Continues to gain control of head Moves elbows forward toward shoulders while in prone position Has ATNR with head to side while in supine position When held in standing position, bears some weight on legs	Displays diminishing grasp reﬂex Involuntarily releases after holding them briefly has no voluntary release abilities
3–5 MO	Experiences fading of ATNR and grasp reflex Has more balance between extension and ﬂexion positions Has good head control (centered and upright) Supports self on extended arms while in prone position props self on forearms Brings hand to feet and feet to mouth while in supine position Props on arms with little support while seated Rolls from supine to prone position Bears some weight on legs when held proximally	Constantly brings hands to mouth Develops tactile awareness in hands Reaches more accurately usually with both hands Palmar grasp Begins transferring objects from hand to hand Does not have control of releasing objects may use mouth to assist
6 MO	Has complete head control Possesses equilibrium reactions Begins assuming quadruped position Rolls from prone to supine position Bounces while standing	Transfers objects from hand to hand while in supine position Shifts weight and reaches with one hand while in prone position Reaches with one hand and supports self with other while seated Reaches to be picked up Uses radial palmar grasp; begins to use thumb while grasping Shows visual interest in small objects rakes small objects Begins to hold objects in one hand
7–9 MO	Shifts weight and reaches while in quadruped position Creeps Develops extension, ﬂexion, and rotation movements, and increases number of activities that can be accomplished while seated May pull to standing position while holding on to support	Reaches with supination Uses index finger to poke objects Uses inferior scissors grasp to pick up small objects Use radial digital grasp to pick up cube Displays voluntary releases abilities
10–12 MO	Displays good coordination while creeping Pulls to standing position using legs only Cruises holding on to support with one hand Stands independently Begins to walk independently Displays equilibrium reactions while standing	Uses superior pincer grasp with fingertip and thumb Use 3-jaw chuck grasp Displays controlled release into large containers
13–18 MO	Walks alone Seldom falls Begins to go up and down stairs	Displays more precise grasping abilities Precisely releases objects into small containers
19–24 MO	Displays equilibrium reactions while walking Runs using a more narrow base support	Uses finger to palm translation of small objects
24–36 MO	Jumps in place*	Uses palm to finger and finger to palm translation of small objects Displays complex rotation of small objects Shifts small objects using palmar stabilization Scribbles Snips with scissors

ATNR, asymmetrical tonic neck reflex.

^*From this point on, skills learned during the first 24 months are further refined.

Adapted from Alexander R, Boehme R, Cupps B: Normal development of functional motor skills, Tucson, AR, 1993, Therapy Skill Builders; Case-Smith J, Shortridge SD: The developmental process: Prenatal to adolescence. In Case-Smith J, Allen AS, Pratt PN, editors: Occupational therapy for children, ed 3, St Louis, 1996, Mosby; Clark GF: Oral-motor and feeding issues. In Royeen CB, editor: AOTA self-study series: Classroom applications for school-based practice, Rockville, MD, 1993, American Occupational Therapy Association; Erhardt RP: Developmental hand dysfunction: Theory, assessment, and treatment, ed 2, Tucson, AR, 1994 Therapy Skill Builders.

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Jul 24, 2016 | Posted by admin in PEDIATRICS | Comments Off

Infancy

Physiologic development

Motor development

Sensory skills

Gross motor skills

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Fastest Obstetric, Gynecology and Pediatric Insight Engine

Development of occupational performance skills

Development of occupational performance skills

Infancy

Physiologic development

Motor development

Sensory skills

Gross motor skills

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