motor mildstones

DOI: 10.1542/pir.31-7-2672010;31;267Pediatrics in Review

R. Jason Gerber, Timothy Wilks and Christine Erdie-LalenaDevelopmental Milestones: Motor Development

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Developmental Milestones: Motor DevelopmentR. Jason Gerber, MD,*

Timothy Wilks, MD,

Christine Erdie-Lalena,

MD

Author Disclosure

Drs Gerber, Wilks, and

Erdie-Lalena have

disclosed no financial

relationships relevant

to this article. This

commentary does not

contain a discussion

of an unapproved/

investigative use of a

commercial

product/device.

Objectives After completing this article, readers should be able to:1. Identify the milestones for gross and fine motor development.2. Recognize the child whose development falls outside of the expected range.3. Describe the sequences involved in gross and fine motor development.

This is the first of three articles on developmental milestones; the second and third articleswill appear in the September and November 2010 issues of Pediatrics in Review, respectively.

IntroductionInfancy and childhood are dynamic periods of growth and change. Neurodevelopmentaland physical growth proceed in a sequential and predictable pattern that is intrinsicallydetermined. Skills progress from cephalic to caudal; from proximal to distal; and fromgeneralized, stimulus-based reflexes to specific, goal-oriented reactions that becomeincreasingly precise. As one clinician has stated, infants [and children] are very orderly intheir ways; they actually behave [and develop] according to laws that can be explored,discovered, confirmed, reconfirmed, and celebrated. (1) By convention, these neuro-developmental laws or sequences often are described in terms of the traditional devel-opmental milestones.

Milestones provide a framework for observing and monitoring a child over time.According to recent American Academy of Pediatrics and Bright Futures guidelines,pediatricians should incorporate developmental surveillance at every health supervisionvisit. Surveillance involves analyzing the milestones in the context of a childs history,growth, and physical examination findings to recognize those who may be at risk fordevelopmental delay. A thorough understanding of the normal or typical sequence ofdevelopment in all domains (gross motor, fine motor, problem-solving, receptive lan-guage, expressive language, and social-emotional) allows the clinician to formulate acorrect overall impression of a childs true developmental status. However, it must beemphasized that even experienced pediatricians cannot rely solely on their knowledge ofthe milestones to identify children who have developmental concerns. Developmentalscreening using validated and standardized tools should occur at the 9-month, 18-month,and 30-month (or 24-month) health supervision visits or whenever surveillance uncoversa concern.

Although neurodevelopment follows a predictable course, it is important to understandthat intrinsic and extrinsic forces produce individual variation, making each childs devel-opmental path unique. Intrinsic influences include genetically determined attributes (eg,physical characteristics, temperament) as well as the childs overall state of wellness.Extrinsic influences during infancy and childhood originate primarily from the family.Parent and sibling personalities, the nurturing methods used by caregivers, the culturalenvironment, and the familys socioeconomic status with its effect on resources of time andmoney all play a role in the development of children. Developmental theory has, itself,developed as clinicians have tried to grapple with which influence is more predominant.

The focus of this series of articles is to help the clinician frame general concepts ofdevelopment according to the developmental streams rather than highlight developmental

*Major, USAF, Medical Corps, Developmental & Behavioral Pediatrics Fellow, Madigan Army Medical Center, Joint Base Lewis-McChord, Wash.LCDR, USN, Medical Corps; Developmental & Behavioral Pediatrics Fellow, Madigan Army Medical Center, Joint Base Lewis-McChord, Wash.Lt Col, USAF, Medical Corps, Program Director, Developmental & Behavioral Pediatrics Fellowship, Madigan Army MedicalCenter, Joint Base Lewis-McChord, Wash.

Article growth & development

Pediatrics in Review Vol.31 No.7 July 2010 267


Jos Roberto Fernndez Soto






abnormalities. The milestones cited are, on average,those at the 50th percentile for age. By understandingwhat is normal or typical, the clinician can appreciatemore keenly what is abnormal or delayed. This articleconcentrates on normal motor development, with a briefmention about specific red flags that should alert cli-nicians to potential motor developmental problems. Thesecond article in the series discusses cognitive and lan-guage development. The final article addresses the devel-opment of social-emotional skills. An all-inclusive tableof milestones is provided in this first article as a reference(Table 1) both in print and online; Table 1 appearsonline only in the September and November articles.

Gross Motor MilestonesThe ultimate goal of gross motor development is to gainindependent and volitional movement. During gesta-tion, primitive reflexes develop and persist for severalmonths after birth to prepare the infant for the acquisi-tion of specific skills. These brainstem and spinal reflexesare stereotypic movements generated in response to spe-cific sensory stimuli. Examples include theMoro (Fig. 1),asymmetric tonic neck (ATNR) (Fig. 2), and positivesupport reflexes (Fig. 3). As the central nervous systemmatures, the reflexes are inhibited to allow the infant tomake purposeful movements. For example, during thetime when the ATNR persists, an infant is unable to rollfrom back to front, bring the hands to midline, or reachfor objects. This reflex disappears between 4 and 6months of age, the same time that these skills begin toemerge. The Moro reflex interferes with head controland sitting equilibrium. As this reflex lessens and disap-pears by 6 months of age, the infant gains progressivestability in a seated position (Fig. 4).

In addition to primitive reflexes, postural reactions,such as righting and protection responses, also begin todevelop after birth. These reactions, mediated at themidbrain level, interact with each other and work towardthe establishment of normal head and body relationshipin space. Protective extension, for example, allows theinfant to catch him- or herself when falling forward,sideways, or backwards (Fig. 5). These reactions developbetween 6 and 9 months, the same time that an infantlearns to move into a seated position and then to handsand knees. Soon afterward, higher cortical centers medi-ate the development of equilibrium responses and permitthe infant to pull to stand by 9 months of age and beginwalking by 12 months. Additional equilibrium responsesdevelop during the second year after birth to allow formore complex bipedal movements, such as moving back-ward, running, and jumping.

During the first postnatal year, an infant thus movesfrom lying prone, to rolling over, to getting to hands andknees, and ultimately to coming to a seated position orpulling to stand (Fig. 6). Within the framework of Backto Sleep guidelines, infants must have age-appropriateand safe opportunities for tummy time to promote thedevelopment of these important prone-specific mile-stones. It is important to note that crawling is not aprerequisite to walking; pulling to stand is the skill infantsmust develop before they take their first steps. Theultimate goal of this timeframe is to develop skills thatallow for independent movement and freedom to use thehands to explore, manipulate, and learn from the envi-ronment.

Gross motor development in subsequent years con-sists of refinements in balance, coordination, speed, andstrength. The wide-based, slightly crouched, staccatogait of a 12-month-old evolves into a smooth, upright,and narrow-based style. The arms change from beingheld abducted and slightly elevated for balance to swing-ing in a reciprocal fashion as the gait reaches an adultpattern by age 3 years. Similarly, running develops soonafter walking, starting as a stiff-legged approximation andchanging into a well-coordinated movement that in-cludes rapid change of direction and speed by 18 monthsof age.

Simultaneous use of both arms or legs occurs aftersuccessful use of each limb independently. At age 2 years,a child can kick a ball, jump with two feet off the floor,and throw a big ball overhand.Milestones for succeedingages reflect progress in the length of time, number ofrepetitions, or the distance each task can be performedsuccessfully. By the time a child starts school, he or she isable to perform multiple complex gross motor taskssimultaneously (such as pedaling, maintaining balance,and steering while on a bicycle).

Fine Motor MilestonesFinemotor skills relate to the use of the upper extremitiesto engage and manipulate the environment. They arenecessary for a person to perform self-help tasks, to play,and to accomplish work. Like all developmental streams,fine motor milestones do not proceed in isolation butdepend on other areas of development, including grossmotor, cognitive, and visual perceptual skills. At first, theupper extremities play an important role in balance andmobility. Hands are used for support, first in the proneposition and then in sitting. Arms help with rolling over,then crawling, then pulling to stand. Infants begin to usetheir hands to explore, even when in the supine position.When gross motor skills have developed such that the

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Table 1. Developmental MilestonesAge Gross Motor Fine Motor Self-Help Problem-solving Social/Emotional Receptive Language Expressive Language

1 month Chin up inprone position

Turns head insupine position

Hands fistednear face

Sucks well Gazes at black-white objects

Follows face

Discriminatesmothers voice

Cries out ofdistress

Startles to voice/sound

Throaty noises

2 months Chest up inprone position

Head bobs whenheld in sittingposition

Hands unfisted50%

Retains rattleif placed inhand

Holds handstogether

Opens mouthat sight ofbreast orbottle

Visual threatpresent

Follows large,highlycontrastingobjects

Recognizesmother

Reciprocalsmiling:responds toadult voice andsmile

Alerts to voice/sound

Coos Social smile(6 weeks)

Vowel-like noises

3 months Props onforearms inprone position

Rolls to side

Hands unfisted50%

Inspectsfingers

Bats at objects

Brings handsto mouth

Reaches forface

Follows objectsin circle (insupineposition)

Regards toys

Expression ofdisgust (sourtaste, loudsound)

Visually followsperson who ismoving across aroom

Regards speaker Chuckles Vocalizes whentalked to

4 months Sits with trunksupport

No head lagwhen pulled tosit

Props on wrists Rolls front toback

Hands heldpredominatelyopen

Clutches atclothes

Reachespersistently

Plays withrattle

Briefly holdsonto breastor bottle

Mouths objects Stares longerat novel facesthan familiar

Shakes rattle Reaches forring/rattle

Smilesspontaneouslyat pleasurablesight/sound

Stops crying atparent voice

To and froalternatingvocalizations

Orients head indirection of avoice

Stops crying tosoothing voice

Laughs out loud Vocalizes whenalone

5 months Sits with pelvicsupport

Rolls back tofront

Anteriorprotection

Sits with armssupportingtrunk

Palmar graspscube

Transfersobjects: hand-mouth-hand

Holds handstogether

Reaches/graspsdangling ring

Gums/mouthspureed food

Turns head tolook fordropped spoon

Regards pelletor smallcracker

Recognizescaregivervisually

Formsattachmentrelationship tocaregiver

Begins torespond toname

Says Ah-goo Razzes, squeals Expresses angerwith soundsother than crying

6 months Sitsmomentarilypropped onhands

Pivots in prone In proneposition, bearsweight on 1hand

Transfershand-hand

Rakes pellet Takes secondcube and holdson to first

Reaches withone hand

Feeds selfcrackers

Places handson bottle

Touchesreflection andvocalizes

Removes clothon face

Bangs andshakes toys

Stranger anxiety(familiar versusunfamiliarpeople)

Stopsmomentarily tono

Gestures for up

Reduplicativebabble withconsonants

Listens, thenvocalizes whenadult stops

Smiles/vocalizesto mirror

7 months Bounces whenheld

Sits withoutsupport steadily

Lateralprotection

Puts arms outto sides forbalance

Radial-palmargrasp

Refusesexcess food

Exploresdifferentaspects of toy

Observes cubein each hand

Finds partiallyhidden object

Looks fromobject to parentand back whenwanting help(eg, with awind-up toy)

Looks towardfamiliar objectwhen named

Attends to music

Increasing varietyof syllables

8 months Gets into sittingposition

Commandocrawls

Pulls to sitting/kneelingposition

Bangs spoonafterdemonstration

Scissor graspof cube

Takes cube outof cup

Pulls out largepeg

Holds ownbottle

Finger feedsCheerios orstring beans

Seeks objectafter it fallssilently to thefloor

Lets parentsknow whenhappy versusupset

Engages in gazemonitoring:adult looksaway and childfollows adultglance with owneyes

Responds toCome here

Looks for familymembers,Wheresmama?. . . etc

Says Dada(nonspecific)

Echolalia (8 to 30months)

Shakes head forno

(continued)




Table 1. Developmental MilestonescontinuedAge Gross Motor Fine Motor Self-Help Problem-solving Social/Emotional Receptive Language Expressive Language

9 months Stands on feetand hands

Begins creeping Pulls to stand Bear walks (allfour limbsstraight)

Radial-digitalgrasp of cube

Bangs twocubes together

Bites, chewscookie

Inspects bell Rings bell Pulls string toobtain ring

Uses sounds toget attention

Separationanxiety

Follows a point,Oh look at . . .

Recognizesfamiliar peoplevisually

Enjoys gesturegames

Orients to namewell

Orients to bell

Says Mama(nonspecific)

Nonreduplicativebabble

Imitates sounds

10 months Creeps well Cruises aroundfurniture usingtwo hands

Stands with onehand held

Walks with twohands held

Clumsy releaseof cube

Inferior pincergrasp of pellet

Isolates indexfinger andpokes

Drinks fromcup held forchild

Uncovers toyunder cloth

Pokes at pelletin bottle

Tries to putcube in cup,but may not beable to let go

Experiences fear Lookspreferentiallywhen name iscalled

Enjoys peek-a-boo

Waves bye-byeback

Says Dada(specific)

Waves bye-bye

11 months Pivots in sittingposition

Cruises furnitureusing one hand

Stands for afew seconds

Walks with onehand held

Throws objects Stirs withspoon

Cooperateswith dressing

Finds toy undercup

Looks atpictures inbook

Gives objects toadult for actionafterdemonstration(lets adult knowhe or she needshelp)

Stops activitywhen told no

Bounces to music

Says first word Vocalizes to songs

12 months Stands wellwith arms high,legs splayed

Posteriorprotection

Independentsteps

Scribbles afterdemonstration

Fine pincergrasp of pellet

Holds crayon Attemptstower of twocubes

Finger feedspart of meal

Takes off hat

Rattles spoonin cup

Lifts box lid tofind toy

Shows objectsto parent toshare interest

Points to getdesired object(proto-imperativepointing)

Follows one-stepcommand withgesture

Recognizesnames of twoobjects and lookswhen named

Points to getdesired object(proto-imperativepointing)

Uses severalgestures withvocalizing (eg,waving, reaching)

13 months Walks witharms high andout (highguard)

Attempts torelease pelletin bottle

Drinks fromcup withsome spilling

Dangles ring bystring

Reaches aroundclear barrier toobtain object

Unwraps toy incloth

Shows desire toplease caregiver

Solitary play Functional play

Looksappropriatelywhen asked,Wheres theball?

Uses three words Immaturejargoning:inflection withoutreal words

14 months Stands withoutpulling up

Falls by collapse Walks well

Imitates backand forthscribble

Adds thirdcube to a two-cube tower

Puts round pegin and out ofhole

Removessocks/shoes

Chews well Puts spoon inmouth (turnsover)

Dumps pelletout of bottleafterdemonstration

Points at objectto expressinterest (proto-declarativepointing)

Purposefulexploration oftoys throughtrial and error

Follows one-stepcommandwithout gesture

Names one object Points at objectto expressinterest (proto-declarativepointing)

15 months Stoops to pickup toy

Creeps up stairs Runs stiff-legged

Walks carryingtoy

Climbs onfurniture

Builds three-to four-cubetower

Places 10cubes in cup

Releases pelletinto bottle

Uses spoonwith somespilling

Attempts tobrush ownhair

Fusses to bechanged

Turns pages inbook

Places circle insingle-shapepuzzle

Shows empathy(someone elsecries, child lookssad)

Hugs adult inreciprocation

Recognizeswithout ademonstrationthat a toyrequiresactivation;hands it toadult if cantoperate

Points to onebody part

Points to oneobject of threewhen named

Gets object fromanother roomupon demand

Uses three to fivewords

Mature jargoningwith real words

16 months Stands on onefoot with slightsupport

Walksbackwards

Walks up stairswith one handheld

Puts severalround pegs inboard withurging

Scribblesspontaneously

Picks up anddrinks fromcup

Fetches andcarriesobjects (sameroom)

Dumps pelletout withoutdemonstration

Finds toyobserved to behidden underlayers of covers

Places circle inform board

Kisses by touch-ing lips to skin

Periodicallyvisually relocatescaregiver

Self-conscious;embarrassedwhen aware ofpeople observing

Understandssimplecommands,Bring tomommy

Points to onepicture whennamed

Uses 5 to 10words

(continued)





18 months Creeps downstairs

Runs well Seats self insmall chair

Throws ballwhile standing

Makes four-cube tower

Crudelyimitatesvertical stroke

Removesgarment

Gets ontoadult chairunaided

Moves abouthousewithoutadult

Matches pairsof objects

Replaces circlein form boardafter it hasbeen turnedaround (usuallywith trial anderror)

Passes M-CHAT Engages inpretend playwith otherpeople (eg, teaparty, birthdayparty)

Begins to showshame (whendoes wrong)andpossessiveness

Points to two ofthree objectswhen named

Points to threebody parts

Points to self Understandsmine

Points to familiarpeople whennamed

Uses 10 to 25words

Uses giant words(all gone, stopthat)

Imitatesenvironmentalsounds (eg,animals)

Names one pictureon demand

20 months Squats in play Carries largeobject

Walksdownstairs withone hand held

Completesround pegboard withouturging

Makes five- tosix-cube tower

Completessquare pegboard

Places onlyedibles inmouth

Feeds selfwith spoonentire meal

Deduceslocation ofhidden object

Places squarein form board

Begins to havethoughts aboutfeelings

Engages in teaparty withstuffed animals

Kisses withpucker

Points to threepictures

Begins tounderstandher/him/me

Holophrases(Mommy? andpoints to keys,meaning: Theseare Mommyskeys.)

Two-wordcombinations

Answers requestswith no

22 months Walks up stairsholding rail,putting bothfeet on eachstep

Kicks ball withdemonstration

Walks with onefoot on walkingboard

Closes boxwith lid

Imitatesvertical line

Imitatescircularscribble

Uses spoonwell

Drinks fromcup well

Unzipszippers

Puts shoeson partway

Completesform board

Watches otherchildrenintensely

Begins to showdefiant behavior

Points to fourto five pictureswhen named

Points to five tosix body parts

Points to fourpieces ofclothing whennamed

Uses 25 to 50words

Asks for more Adds one to twowords/week

24 months Walks downstairs holdingrail, both feeton each step

Kicks ballwithoutdemonstration

Throwsoverhand

Makes asingle-linetrain ofcubes

Imitates circle Imitateshorizontal line

Opens doorusing knob

Sucksthrough astraw

Takes offclotheswithoutbuttons

Pulls offpants

Sorts objects Matchesobjects topictures

Shows use offamiliar objects

Parallel play Begins to maskemotions forsocial etiquette

Follows two-step command

Understandsme/you

Points to 5 to10 pictures

Two-word sentence(noun ! verb)

Telegraphic speech Uses 50! words 50% intelligibility Refers to self byname

Names threepictures

28 months Jumps frombottom stepwith one footleading

Walks on toesafterdemonstration

Walks backward10 steps

Strings largebeadsawkwardly

Unscrews jarlid

Turns paperpages (oftenseveral atonce)

Holds selfandverbalizestoilet needs

Pulls pantsup withassistance

Matchesshapes

Matches colors

Reduction inseparationanxiety

Understandsjust one

Repeats two digits Begins to usepronouns(I, me, you)

Names 10 to 15pictures

30 months Walks up stairswith rail,alternating feet

Jumps in place Stands withboth feet onbalance beam

Walks with onefoot on balancebeam

Makes eight-cube tower

Makes atrain ofcubes andincludes astack

Washeshands

Puts thingsaway

Brushes teethwithassistance

Replaces circlein form boardafter it hasbeen turnedaround (littleor no trial anderror)

Points to smalldetails inpictures

Imitates adultactivities (eg,sweeping,talking onphone)

Follows twoprepositions:put blockin . . . on box

Understandsactions words:playing . . .washing . . .blowing

Echolalia andjargoning gone

Names objects byuse

Refers to self withcorrect pronoun

Recites parts ofwell-known story/fills in words

33 months Walks swingingarms oppositeof legs(synchronousgait)

Makes 9- to10-cube tower

Puts six squarepegs inpegboard

Imitates cross

Toilet trained Puts on coatunassisted

Points to selfin photos

Points to bodyparts based onfunction(What do youhear with?)

Begins to taketurns

Tries to helpwith householdtasks

Understandsthreeprepositions

Understandsdirty, wet

Points to objectsby use: ridein . . . put onfeet . . . writewith

Gives first and lastname

Counts to 3 Begins to use pasttense

Enjoys being readto (short books)

(continued)





3 years Balances on onefoot for 3seconds

Goes up stairs,alternating feet,no rail

Pedals tricycle Walks heelto toe

Catches ballwith stiff arms

Copies circle Cuts with scissors:side-to-side(awkwardly)

Strings smallbeads well

Imitates bridge ofcubes

Independenteating

Pours liquid fromone container toanother

Puts on shoeswithout laces

Unbuttons

Draws a two- tothree-part person

Understands long/short, big/small,more/less

Knows own gender Knows own age Matches letters/numerals

Starts to sharewith/withoutprompt

Fears imaginarythings

Imaginative play Uses words todescribe whatsomeone else isthinking (Momthought I wasasleep)

Points to partsof pictures (noseof cow, door ofcar)

Names bodyparts withfunction

Understandsnegatives

Groups objects(foods, toys)

Uses 200! words Three-word sentences Uses pronounscorrectly

75% intelligibility Uses plurals Names body parts byuse

Asks to be read to

4 years Balances on onefoot 4 to 8seconds

Hops on onefoot two tothree times

Standing broadjump: 1 to2 feet

Gallops Throws balloverhand10 feet

Catchesbounced ball(412 yrs)

Copies square Ties single knot Cuts 5-inch circle Uses tongs totransfer

Writes part offirst name

Imitates gatewith cubes

Goes to toiletalone

Wipes after bowelmovement

Washes face/hands

Brushes teethalone

Buttons Uses fork well

Draws a four- tosix-part person

Can give amounts(usually less than 5)correctly

Simple analogies:- dad/boy:

mother/???- ice/cold: fire/

???- ceiling/up:

floor/??? Points to five to sixcolors

Points to letters/numerals whennamed

Rote counts to 4 Reads severalcommon signs/store names

Deception:interested intricking othersand concernedabout beingtricked by others

Has a preferredfriend

Labels happiness,sadness, fear,and anger in self

Group play

Follows three-step commands

Points to thingsthat are thesame versusdifferent

Names thingswhen actions aredescribed (eg,swims in water,you cut with it,its somethingyou read, it tellstime . . .)

Understandsadjectives: bushy,long, thin,pointed

Uses 300 to 1,000words

Tells stories 100% intelligibility Uses feeling words Uses words that tellabout time

5 years Walks downstairs with rail,alternating feet

Balances onone foot >8seconds

Hops on onefoot 15 times

Skips Running broadjump 2 to 3feet

Walks backwardheel-toe

Jumps backward

Copies triangle Puts paper clipon paper

Can use clothes-pins to transfersmall objects

Cuts with scissors Writes first name Builds stairs frommodel

Spreads withknife

Independentdressing

Bathesindependently

Draws an 8- to10-part person

Gives amounts(

infant is more stable in upright positions and can moveinto them easily, the hands are free for more purposefulexploration.

At birth, infants do not have any apparent voluntaryuse of their hands. They open and close them in responseto touch and other stimuli, but movement otherwise isdominated by a primitive grasp reflex. Because of this,infants spend the first 3 months after birth contactingobjects with their eyes rather than their hands, fixating onfaces and objects and then visually tracking objects.Gradually, they start to reach clumsily and bring theirhands together. As the primitive reflexes decrease, infantsbegin to prehend objects voluntarily, first using the en-tire palm toward the ulnar side (5 months) and thenpredominantly using the radial aspect of the palm(7 months). At the same time, infants learn to releaseobjects voluntarily. In the presence of a strong graspreflex, objects must be removed forcibly from an infantsgrasp or drop involuntarily from the hand. Voluntaryrelease is seen as the infant learns to transfer objects fromone hand to the other, first using the mouth as anintermediate stage (5 months) and then directly hand-to-hand (6 months).

Between 6 months and 12 months of age, the graspevolves to allow for prehension of objects of differentshapes and sizes (Fig. 7). The thumb becomes moreinvolved to grasp objects, using all four fingers againstthe thumb (a scissors grasp) at 8 months, and eventu-ally to just two fingers and thumb (radial digital grasp) at

9 months. A pincer grasp emerges as the ulnar fingers areinhibited while slightly extending and supinating thewrist. Voluntary release is awkward at first, with all fin-gers extended. By 10 months of age, infants can release acube into a container or drop things onto the floor.Object permanence reinforces the desire to practice thisskill over and over. Intrinsic muscle control develops toallow the isolation of the index finger, and infants willpoke their fingers into small holes for exploration. By 12months of age, most infants enjoy putting things intocontainers and dumping them out repeatedly. They alsocan pick up small pieces of food with a mature pincergrasp and bring them to their mouths.

As infants move into their second year, their masteryof the reach, grasp, and release allows them to start usingobjects as tools. Fine motor development becomes moreclosely associated with cognitive and adaptive develop-ment,with the infant knowing bothwhat he or shewants to

Figure 1. Moro reflex. This reflex occurs spontaneously toloud noises or by simply holding the supine infants hand andreleasing the hand suddenly. Classically, the reflex is elicitedwhile holding the infant supine, with the head droppedslightly backward. This produces sudden extension and abduc-tion of the upper extremities with hands open, followed byflexion of the upper extremities to midline (the startle reflex).

Figure 2. Asymmetric tonic neck reflex (ATNR). The sensorylimb of the ATNR involves proprioceptors in the cervicalvertebrae. With active or passive head rotation, the babyextends the arm and leg on the face side and flexes theextremities on the contralateral side (the fencer posture).There also is some subtle trunk curvature on the contralateralside produced by mild paraspinous muscle contraction.






















do and how he or she can accomplish it. Intrinsic musclerefinement allows for holding flat objects, such as crackersor cookies. By 15 months of age, voluntary release hasdeveloped further to enable stacking of three to four blocksand releasing small objects into containers. The child startsto adjust objects after grasping touse themproperly, such aspicking up a crayon and adjusting it to scribble spontane-ously (18 months of age) and adjusting a spoon to use itconsistently for eating (20 months of age).

In subsequent years, fine motor skills are refined fur-ther to draw, explore, problem-solve, create, and performself-help tasks. By age 2 years, children can create a six-block tower, feed themselves with a spoon and fork, re-

Figure 4. The declining intensity of primitive reflexes and theincreasing role of postural reactions represent at least permis-sive, and possibly necessary, conditions for the development ofdefinitive motor reactions. Reproduced with permission fromJohnson CP, Blasco PA. Infant growth and development.Pediatr Rev. 1997;18:225242.

Figure 5. Lateral protection. In the seated position, the childis pushed gently but rapidly to one side. The reaction is presentif the child puts out his or her hand to prevent a fall.

Figure 3. Positive support reflex. With support around thetrunk, the infant is suspended, then lowered to touch the feetgently on a flat surface. This produces reflex extension at thehips, knees, and ankles so the infant stands up, completely orpartially bearing weight. Mature weight-bearing lacks therigid quality of this primitive reflex.











move clothing, and grasp and turn a door knob. Theyhave sufficient control of a crayon to imitate both ver-tical and horizontal lines. In-hand manipulation skillspermit them to rotate objects, such as unscrewing asmall bottle cap or reorienting a puzzle piece beforeputting it in place. They are able to wash and dry theirhands. By 36 months of age, they can draw a circle, puton shoes, and stack 10 blocks. They make snips withscissors by alternating between full-finger extension and

flexion. Their grasp and in-hand ma-nipulation skills allow them to stringsmall beads and unbutton clothes.

At age 4 years, a palmar tripodgrasp allows for finer control of pencilmovements, and the child can copy across, a square, and some letters andnumerals and can draw a figure of aperson (the head and a few otherbody parts). Scissor skills have pro-gressed to permit the cutting of acircle. When a child reaches the ageof 5 years, he or she can dress and un-dress independently, brush the teethwell, and spread with a knife. Moreprecise in-hand manipulation skillsenable the child to cut a square withmature scissor movements (indepen-dent finger use) and to print his orher own name and copy a triangleusing a mature tripod pencil grasp(using the fingers to move the pencilrather than the forearm and wrist).

Developmental Red FlagsAs the clinician performs develop-mental surveillance, the absence ofcertain key milestones in a patientshould raise the level of concern.Table 2 lists the developmental redflags specific to the motor domain. Ifone of these red flags is discovered, amedical and more thorough devel-

opmental evaluation is warranted.Although reported in this article in isolation, motor

skills development overlaps significantly with the otherstreams of development.

Figure 6. Chronologic progression of gross motor development during the first 12postnatal months. Reproduced with permission from Johnson CP, Blasco PA. Infantgrowth and development. Pediatr Rev. 1997;18:224242.

Figure 7. Development of pincer grasp. Illustrations from the Erhardt developmentalprehension. In Erhardt RP. Developmental Hand Dysfunction: Theory Assessment, Treat-ment. 2nd ed. San Antonio, Tex: Therapy Skill Builders; 1994. Reprinted with permission.

Table 2. Motor Red FlagsAge Red Flag

4 months Lack of steady head controlwhile sitting

9 months Inability to sit18 months Inability to walk independently Summary

The development of motor skills is critical for a childto move independently and to interact with his or herenvironment meaningfully and usefully. Skills developin a cephalic-to-caudal progression and from proximalto distal. Thus, consistent head support occurs beforevoluntary control of arms and legs, and large musclecontrol of the upper arms occurs before small, intrinsicmuscle control in the hands.

Skills also progress from generalized responses tostimuli (primitive reflexes) to goal-oriented, purposefulactions with ever-increasing precision and dexterity.















References1. Lipsitt LP. Learning and emotion in infants. Pediatrics. 1998;102:12621267

Suggested ReadingAmerican Academy of Pediatrics Committee on Children with

Disabilities, Section on Developmental Behavioral Pediatrics;Bright Futures Steering Committee; Medical Home Initiativesfor Children with Special Needs Project Advisory Committee.Identifying infants and young children with developmental dis-orders in the medical home: an algorithm for developmentalsurveillance and screening. Pediatrics. 2006;118:405420

AAP Task Force on Infant Positioning and SIDS. Changing con-cepts of sudden infant death syndrome: implications for infant

sleeping environment and sleep position. Pediatrics. 2000;105:650656

Case-Smith J, Allen AS, Pratt PN, eds. Occupational Therapy forChildren. St. Louis, Mo: Mosby Year-Book, Inc; 1996

Fiorentino MR. Reflex Testing Methods for Evaluating CNS Devel-opment. Springfield, Ill: Charles C Thomas; 1973

Hagan JF, Shaw J, Ducan PM, eds. Bright Futures: Guidelines forHealth Supervision of Infants, Children, and Adolescents. 3rdedition. Elk Grove Village, Ill: American Academy of Pediatrics;2008

Johnson CP, Blasco PA. Infant growth and development. PediatrRev. 1997;18:224242

Sturner RA, Howard BJ. Preschool development 1: communicativeand motor aspects. Pediatr Rev. 1997;18:291301




PIR QuizQuiz also available online at http://pedsinreview.aappublications.org.

1. An 18-month-old girl is seen for a health supervision visit. Her mother has no concerns regarding herdaughters development. Her growth parameters are at the 25th percentile. She walks well, climbs onto hermothers lap, and whispers a few words to her mother. The best next step in the evaluation of this childsdevelopment is:

A. Full developmental surveillance.B. Further evaluation of language skills.C. Implementation of a developmental screening tool.D. Review of developmental milestones with the mother.E. Scheduling of a visit for full developmental assessment.

2. A 6-month-old infant is unable to roll from back to front or bring hands to midline. The most likely causeof this infants difficulty is:

A. Absence of lateral protection postural reaction.B. Absence of protective extension reaction.C. Persistence of asymmetric tonic neck reflex.D. Persistence of Moro reflex.E. Persistence of positive support reflex.

3. A 15-month-old typically developing girl is able to release cubes into a cup and has a mature fine pincergrasp. She most likely also is able to:

A. Build a tower of three blocks.B. Copy a vertical line.C. Feed herself with a spoon and fork.D. Put on her shoes.E. Turn a doorknob.

4. An 18-month-old typically developing boy can walk well and run. He most likely also is able to:

A. Jump with two feet off the ground.B. Kick a ball.C. Pedal a tricycle.D. Stoop and pick up a toy.E. Toe-walk.




DOI: 10.1542/pir.31-7-2672010;31;267Pediatrics in Review

R. Jason Gerber, Timothy Wilks and Christine Erdie-LalenaDevelopmental Milestones: Motor Development

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