From early infancy through toddlerhood and into early childhood, skills develop in predictable and sequential patterns. This development of motor, thinking, communication, coordination, and social skills is watched with delight by friends and families, and monitored by health care providers.
There is no exact timetable for development. There is a range of time during which milestones are expected to emerge. Parents often worry that their baby is not rolling over or crawling when she should, simply because they hear stories from other parents about when their babies did these things. These developmental variations are rarely of any concern.
But sometimes development does not occur as expected, and milestones are achieved slowly or not at all. So how can parents know what is a normal delay, and what suggests a more serious developmental issue?
How can parents know what is a normal delay, and what suggests a more serious developmental issue?
The report urges early and repeated screening for children to identify potential concerns in order to begin appropriate treatment as early as possible.
Delays are common in these milestones, and the report makes clear that many, if not most, resolve as the child grows and matures.
Movements like crawling, walking, and standing involve the large muscle groups. Delays are common in these milestones, and the report makes clear that many, if not most, resolve as the child grows and matures. Sometimes, however, motor delays can be a sign of a condition that leads to permanent disability, such as cerebral palsy, or another underlying neuromuscular disorder.
Parents and pediatricians should discuss development at every well child visit. Children should also be formally screened by their health care providers at 9-, 18-, 30-, and 48-months for developmental milestones to be sure that they have acquired the expected skills.
- By nine months the infant should roll to both sides, sit well without support, use each side of their body symmetrically (they aren’t right- or left-handed yet), and should be able to grasp and transfer objects from one hand to the other.
- By 18 months, the toddler should sit, stand and walk independently and grasp and manipulate small objects
- By thirty months, most motor delays will have already been identified. However, progressive neuromuscular disorders may begin to emerge and the child may lose some of the gross and fine motor skills that they had previously attained.
- By forty-eight months the child should have early elementary school skills such as knowing the names of some colors, being able to play board or card games or understanding “same” and “different”.
Children should be screened more frequently if the child has known risk factors for delay, such as premature birth, severe illness or meninigitis early in life; or their medical providers, parents, or caregivers have concerns based on their observations of the child. In these cases, when concerns are raised by parents or those involved in the child’s care, education, or health, the AAP recommends that monitoring should continue throughout later childhood.
Pediatricians doing routine screening of motor development need to
- Pay attention to parents’ concerns about their child’s development;
- Keep an accurate and ongoing record of the child's developmental history as well as their own observations, process and findings.
- Identify risk and protective factors (such as prenatal and neonatal history) that may affect motor development such as cerebral palsy or other neuromuscular condition.
The results of such a skills assessment are scored and compared with same-aged peers to determine whether the child is following normal patterns and sequences of development.
“Handedness” is not normal before about a year and a half, and if present before than that, may be a sign of weakness of lack of coordination on one side of the body.
For example, if a child is suspected of having cerebral palsy, an MRI to look at the brain may be ordered. If a child has low tone or muscle weakness, tests to rule out muscular dystrophy or hypothyroidism may be advised. When a child has a constellation of features including muscular delay, abnormal physical appearance, or abnormalities in their internal organs, a genetic syndrome may be suspected and chromosomal testing may be suggested. Test results will help guide diagnosis and further referral for management and intervention.
One child may take her first steps at age 9 months, while another may not walk until 15 months but both are within the range of normal.
If the examination reveals a motor delay, but evidence does not suggest any specific tests, it's likely you will be asked to return for close follow up to help your provider determine how the condition is evolving over time. Children with motor delays should also be referred to early intervention or special education resources to receive appropriate diagnostic and therapeutic interventions to address their delays.
Sometimes parents may not know what to look for or what observations to report to their baby’s doctor. The AAP offers the following questions to help elicit the major elements of the motor history.
- Is there anything your child is not doing that you think he or she should be able to do?
- Is there anything your child is doing that you are concerned about?
- Is there anything your child used to be able to do that he or she can no longer do?
- Is there anything other children your child’s age can do that are difficult for your child?
Parents should also be sure that their child’s health care provider is aware of any conditions that give them increased vulnerability for developmental delay. These might include premature delivery, health problems during the neonatal period, family history, lead poisoning, and significant early childhood illness such as meningitis.
If your provider recommends a “wait and see ” approach, it is up to you to make sure he or she revisits their concerns at each subsequent visit.
Parents also need to be messengers who bring concerns of others who observe and interact with their child, such as baby sitters, family members, and teachers, to the attention of the care provider.
If your provider recommends a “wait and see” approach, it is up to you to make sure they revisit their concerns at each subsequent visit to be certain that the developmental issue is appropriately pursued. Parents should bring new or growing concerns back to the provider when necessary. When their child is identified as being delayed, parents must take on the added role of advocates, so their child receives the services to which he or she is entitled.
As mentioned at the beginning, it is important to recognize that although development is predictable and sequential, children achieve milestones at different rates and there is a range of ages during which new skills are expected to emerge and solidify. Thus one child may take her first steps at age 9 months, while another may not walk until 15 months but both are within the range of normal. Parents often compare their children to peers and siblings and may be come concerned about differences.
It is well-documented that early intervention for delays in development can make a difference in the ultimate potential that a child and family achieve Taking steps to support development and intervene with any serious delays during critical periods of brain and muscle development are key to achieving the best possible outcome.
Parents and providers can use the guidelines offered in this AAP Clinical Report to better track and document children's motor development and to take appropriate steps to address any delays that may arise.