Process of Motor Development

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Process of motor development

Motor development typically occurs in an orderly sequence from head to trunk to handsto feet, from midline to extremities, and from gross to fine muscles. Stable posture

and sensory input facilitate controlled and refined movements and mobility (Martin,2002).

Motor development occurs:

Gross to fine- Motor skills progress from large muscle use (such as leg and armmovements for walking, pushing) to small muscle use (discrete hand movementsfor writing)

Head to toe- Cephalocaudal (see chart below) Center to extremities- Proximodistal (see chart below)


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Gross Motor Milestones

Atypical Motor Patterns

As noted earlier, motor development may be compromised if there is damage to thecentral nervous system, to the brain, or to sensory systems (Allen & Marotz, 1994).

Motor delays that are likely not explained by deafness or blindness include:

Favoring one hand before 12 months of age (due to weakness or difficulty usingboth hands)

Crossing midline to pick up a toy (children under 1 years should reach for

object with hand closest to the object rather than use the opposite hand,crossing over the midline)

Fisting of the hands beyond 46 months of age Persistent primitive reflexes beyond 46 months of age Log roll (rather than segmental roll) Muscle tone (low or high) Scissoring of the legs (when a child is picked up, the legs should be slightly

apart rather than crossing over each other) Conditions with deafness that "may" include motor involvement Inner ear malformations (cochlear dysplasia, mondini deformity)


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Reprinted with permission from Red flags for disabilities in children who aredeaf/hard of hearing by S.Wiley and M. P. Moeller. The ASHA Leader, 12(1),8-9, 28-29. Copyright 2007 by American Speech-Language-Hearing Association.


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PATHWAYS AWARENESS FOUNDATION.

Copyright 2006

Reflexes

Reflexes are involuntary responses to specific sensory stimulithat are generally tactile, proprioceptive, or vestibular in nature(Colangelo, 1999). Newborns' reflexive behaviors dominatemovement, allow for survival, and set the stage for earlyprimitive learning (Allen & Marotz, 1994).

Certain reflexes, such as swallowing, gagging, coughing, andyawning, remain present throughout a person's lifetime (Allen &Marotz, 1994). Other reflexes, however, begin to be integratedinto volitional motor responses by 4 months of age. For example,the reflexive grasp at birth becomes a voluntary grasp by 4months.

Motor Development and Movement,Carla J. Brown,Tanni L.Anthony,Susan Shier Lowry, Deborah D. Hatton


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The continued presence of primitive reflexes above the age of six to twelve monthsand the absence, or under development, of postural reflexes beyond three and a halfyears of age are reliable indicators of neurological dysfunction and immature postural,motor, and visual functioning.

A large majority of children with deafblindness have other disabilities as well, and mayhave aberrant reflexes that adversely affect posture and movement.

There are many primitive reflexes but we will consider three that significantly

affect posture and movement and are seen in many children with multiple

disabilities.

Moro Reflex: startle reflexes

Emerges at 9 weeks in utero and normally resolves at 2-4 months of life

The earliest form of "fight or flight"

Stimulus is sudden change in position

The response is extension of the arms and flexion of the legs as in a protectiveposture.


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Signs of aberrant or retained Moro reflex

Stimulus bound- can't ignore external stimuli

Chronic fatigue; constant hunger; weak immune systems due to over production ofstress hormones

Hyper-sensitive to change, light, sound or touch

Emotionally inappropriate, impulsive, unable to attend to tasks

Tonic Labyrinthine Reflex (TLR)

Emerges at birth and is resolved gradually from 6 weeks to 3 years

Position of flexion: the baby's legs are curled up and flexed into the fetal position

TLR stimulus is a change in head position (forward or backward)

TLR response is a change in muscle tone (flexion or extension)

Reflex is needed to help babies through the birth canal.


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Signs of aberrant or unresolved TLR reflex

When retained it can lead to spatial problems, motion sickness, poor posture, muscletone, and visual perception difficulties.

In supine position, the severely involved child is in stiff extension and cannot lift head,bring hands to midline or turn over.

In prone position, the child is in excessive flexion and may not be able to lift or turnthe head to clear the air passage. For example, a child sitting and lifting his headwould cause the body to hyper-extend, causing the child to slip right out of the chair.Good practice would be to get down on the child's level and address them eye to eye.This will help avoid posture and muscle tone change due to unresolved TLR reflex.

Asymmetrical Tonic Neck Reflex (ATNR)

ATNR reflex develops in utero and is strongest at 2 months of age; usually suppressedby 5-7 months of age.

The ATNR is stimulated by a rotation of the head left or right and is also refered to asthe "fencing" reflex because of the body position. The response is an extension of thelimbs on the same side of the body as the chin is facing; the limbs on the other side of

the body will curl or flex.


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Signs of aberrant or unresolved ATNR

Children with aberrant ATNR are stuck in the positioning until a head turn releasesthe reflex. With no motivation to turn their head, a deafblind child can be stuck in thisposition for a very long time.

Because in this position the muscle tone is different on both sides on the body, thestudent will have difficulty with bilateral skills (Balance, running, and jumping are allskills that require the balanced use of both sides of the body.)


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Development of postural control

"Postural control involves both stability and movement. Variousfactors influence the development of postural control.

Children with low postural tone (Hypotonia) have difficultymaintaining a secure posture in which to interact with theenvironment. They need a point of stability from which to move.For children with visual impairments, less movement leads todecreased practice of motor skills, which leads to a questionablefoundation on which to build more mature movement patterns.This, in turn, may result in developmental lags in movement(Norris et al., 1957), atypical movement patterns (Brown & Bour,1986), and decreased understanding of object and spatial

concepts (Warren, 1994).

Motor Development and Movement, Carla J. Brown,Tanni L.Anthony,Susan Shier Lowry, Deborah D. Hatton

Postural reactions

Postural reactions are automatic movements and adjustments inresponse to, or in anticipation of, changes of position in relationto the center of gravity. They allow individuals to maintain aposture against gravity while adjusting to movement (Alexanderet al., 1993). These reactions develop as the infant's centralnervous system (CNS) matures and reflexive behaviors areintegrated and provide the basis for postural stability upon whichmore mature movement is built (Alexander et al., 1993).


Derotational righting- usually appears at 4 to 5 months and involves the infant's bodyturning to follow the direction of the head when it turns, helping the child learn to rollover.

Parachute Response:This is a protective response. Beginning at about 5-6 months, if

the infant falls, he will extend his arms to try and catch himself.


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Propping- This response helps infants learn to sit.

Anterior propping response begins at 4-5 months and involves the infant extending hisarms when in sitting position to allow him to assume a tripod sitting position.

Lateral Propping appears at 6-7 months and causes him to extend his arm to the side ifhe is tilted.

Posterior propping causes him to extend his arms backwards if he is tilted backward.


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Goal-directed movement

Goal-directed movement refers to purposeful and self-initiated movement (Anthony,

1993). Goal directed movement is an important part of self-determination activities fora child with deafblindness. A child needs to learn through movement that he caninteract with his environment. He can move to accomplish a goal like finding a favoriteperson or toy. Self-initiated movement comes once a child with deafblindness has hadenough experience with movement that he feels safe to explore.

In order for a child to want to self-initiate movement, he must feel safe and must bemotivated to move and explore. To make exploration functional for a deafblind child,visual, tactile, and auditory information may need to be supplemented. It is importantto think about what information the child is missing due to his sensory impairment and

supplement the information in a motivational way.

Ideas for motivation include:

The use of objects meaningful for childrenfavorite toys,personal items, caregivers

Tactile reacquaintance with the object just prior to

removal for use as a motivator for movement


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Objects that make use of any residual vision and/or hearingthe child has

Immediate success assured by:

short distances

opportunity to use well-established motor skills

discreet assistance by the adult


Reaching

Reaching for a desired object is the beginning stage of goal directed movement. A childwith deafblindness will not have the natural opportunities to see and hear all theinteresting objects around him that motivate him to reach out and explore. Motivatinga child with deafblindness to explore beyond himself will take structured practicesessions with exploration. A communication partner introduces the child to objectsdirectly, models exploration of the objects with full or partial assistance, and allowstime to explore all the sensory qualities of the object. Familiar and motivating objectsshould then be used in functional ways over and over again. Is is vital to use a variety offamiliar and motivating sensory cues to entice the child to self-initiate reaching.

Movement transitions

A child with sensory impairment has a harder time masteringmovement transitions and rotational skills. Movement transitions

are the way in which a child moves his body from one position tothe next. For example: sitting to crawling or stooping to standing.

"Adelson and Fraiberg (1974) found that although children whowere blind were able to sit independently and stand within theage range of sighted children, they did not move into, out of, orforward from these positions at the same age as did sightedchildren. While Adelson and Fraiberg (1974) proposed that lackof vision as a motivator to move was a primary factor in changingpositions and moving out, Brown and Bour (1986) proposed that

the lack of crucial movement components (weight shift, rotation,postural reactions) was responsible for static positions and


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failure to move. Further, they proposed that facilitating activemovement transitions assists in the development of weight shift,rotation, and protective responses, which in turn lead toincreased mobility in rolling, crawling, and walking.

Also, quick, simple movement transition sequences can be builtinto common daily events such as:

Diaper changing: At each changing time, the caregiver places

the infant in prone first, then slowly rolls the infant to supineusing appropriate handling.

Picking up the infant: When picking up the infant from sitting,

the caregiver helps the infant to weight bear with both hands toone side, then to roll to all fours just before picking the infant

up.

Standing position play at sofa: Instead of placing the infant in

standing each time the infant wants to stand to play, place on allfours close to the sofa and help the infant reach up with onehand, move to kneel, then move through half-kneel to standing.


It is important to ask for, and follow, the guidance of the physical therapist and/oroccupational therapist when it comes to helping position a child during transitionalmovement. The child's health, bone health, muscle health and tone will all need to beconsidered by a professional in developing appropriate movement patterns.

*Click here to view video on movement transitions

Crawling

"Fraiberg and Freedman (1964) proposed that the act ofreaching out for an object in the all-fours position is the firstcomponent of crawling. Maida and McCune (1996) also identifiedthe ability to reach for an object while on all fours, as well as theability to move to or from the sitting position, to be the twomost critical precursors to crawling. In analyzing the componentsof movement needed to accomplish these skills, postural stability,with the center of gravity at the hips, which allows for lateral

weight shift to free one hand to reach forward, and trunkrotation appear to be critical components for crawling that


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children who are visually impaired may lack.

Some children with visual impairments demonstrate delays incrawling; others bypass crawling altogether (Adelson & Fraiberg,

1974; Trster et al., 1994). Infants and young children who areblind may have difficulty getting into and maintaining an all-fourscrawling position due to lack of postural stability in the shouldergirdle (Brown & Bour, 1986). Among children who are able tomaintain this position, the ability to shift weight and moveforward on all fours is sometimes absent (Brown & Bour, 1986;Fraiberg, 1968; Trster et al., 1994). As described earlier, thislack of postural stability may stem from the lack of activeexperience in the prone progression, the foundation for crawling(McGraw, 1966). The prone progression consists of: prone with

head elevated; prone with head and chest elevated; prone withsupport on forearms; prone with support on forearms andreaching; prone with extended-arm weight bearing; pivot inprone; and prone with pushing up to all fours (Bly, 1994).Experience and play in the prone progression are important fordeveloping the extensor muscles of the back, shifting children'scenter of gravity from the head and shoulders down to the hips(Bly, 1994)."

Motor Development and Movement, Carla J. Brown,Tanni L.

Anthony,Susan Shier Lowry, Deborah D. Hatton


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Walking

Cruising is an important functional activity to help children with sensory need to feelsafe, and gravitationally grounded before independant walking.

According to Lowry and Hatton (2002), an extended stage ofcruising may have the following benefits:

Cruising provides varied and repeated hands-on experienceswith common objects, landmarks, and surfaces, leading tobroader environmental concepts, a reinforced understanding ofobject permanence, and goal-directed movement.

Cruising provides opportunities to establish a beginning mental

map of the area, leading to more confidence and incentives formovement as independent walking emerges.

Cruising often provides the first means of independent upright

mobility well before children are posturally ready to walk.

Besides cruising around different obstacles, crawling up, down,over, and around obstacle such as foam mats, cushions, boxes, orhills will prepare a child for the depth changes and obstacles hewill experience walking.


A child with deafblindness who is walking independently will often still benefit from awalking aid such as an adapted cane, a push toy, stroller or shopping cart. Orientationand Mobility specialists can be consulted to help find what aids will be most functionalfor the child. The child can also be taught appropriate trailing techniques that will helpthe child feel grounded and receive the spacial information needed for goal directedmovement.


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Early Gross Motor Skills Intervention Ideas

Mindy Doyle McCall, physical therapist and JC Greeley, Orientation and MobilitySpecialist, Anchor Center for Blind Children, 2005

Motor skill milestones that a child with deafblindness may be currently working to master arelisted below along with ideas for functional intervention. It is important to consider how tobest use any residual vision and hearing the child has in order to motivate movement.

Birth to 4 months (There is no "norm." Ages are for typical reference only.)

Encourage Prone lying "tummy time"

*Click here for intervention ideas

4 to 6 Months (There is no "norm." Ages are for typical reference only.)

Encourage hand to foot play


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Encourage rolling


Encourage emerging visual tracking across midline


6 to 8 Months (There is no "norm." Ages are for typical reference only.)

Encourage mastery of rolling


Encourage the child to pull his legs up under his body


Encourage mastery of trunk control


8-12 months (There is no "norm." Ages are for typical reference only.)

Encourage exploration

*click here for intervention ideas

12-18 Months (There is no "norm." Ages are for typical reference only.)

Encourage crawling to standing transition



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Encourage rotation in transitional movement


Encourage spacial and body awareness


Encourage walking with support


18-20 Months (There is no "norm." Ages are for typical reference only.)

When walking, supported with one hand only


When child is taking steps independently

*click her for intervention ideas

Fine Motor Skill Development

Fine Motor Milestones

Fine motor skills generally refer to the purposeful and controlledmovements of the small muscles of the fingers and hands. These

movements are usually coordinated with the larger muscles ofthe arms and trunk for stability and with the eyes for eye-handcoordination. Children develop fine motor skills in a step by stepprogression. Development occurs at an uneven pace, with periodsof little progression.

These ages are approximate and may vary based on the child'sdevelopmental process.

Brings hands to mouth and watches the movements of his/her

hands (0 to 3 months)


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Reaches, grasps and brings hands to midline (3 to 6 months)

Transfers objects hand to hand ( 6 to 9 months)

Uses a neat, tip to tip pincer grasp on small, pellet-sized items(9 to 12 months)

Scribbles with a crayon using whole arm movements (12 to 18

months)

Snips paper with scissors (18 to 24 months)

Imitates a circle and vertical and horizontal lines (2 to 3 years)

Stacks five to seven small blocks (3 to 4 years)

Touches each finger to thumb (4 to 5 years)

Writes first name (5 to 6 years)

Tara Calder, OTR/L,TSBV

As a reminder, typical motor development moves from proximal to distal (trunk to armsand hands) and general to specific (large body movements to small body movements).Therefore, whole arm and hand movement occurs before discrete hand movements.Postural stability of the head, shoulders, and trunk are necessary for the finer controlof the hands.

The grasp reflex is evident at birth and occurs when a thin object is placed in theinfant's hand; the infant's fingers tightly curl around the object in response. Between1 and 4 months, the grasp reflex integrates into increasingly voluntary control of thehand. Over the course of the next 2 years, the infant's hand skills become more

precise and includes the ability to pick up smaller objects and to isolate fingers forspecific motions such as poking.

An early and necessary component of fine motor skills is that a child is aware of hishands and understands that hands can be used purposefully. Activities that providefirm proprioceptive input into the hands and that promote hand-to-hand play, hand-to-mouth play, and hand-to-foot play will facilitate an awareness of the hands and midlineorientation of the body.


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The first consideration, in preparing a child to participate in fine motor activities, is toestablish good positioning for the child. If the child is in a wheelchair the use of a laptray will help with the support and stability of the arms and shoulders during finemotor activities. Using the tray may also improve head control. If the child has use ofonly one extremity, clamp down paper or materials using a clipboard clamp screwed intothe lap tray. Velcro strips or tape may also help to stabilize these. Consulting with anoccupational therapist for the proper and most functional position for fine motor workwould be of great benefit.

The service provider will need to adapt for the child's visual and auditory needs. Some

visual and tactile adaptations for fine motor work could include:


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Texture on lines with puffy paint or Wikkisticks Use of high contrast materials (black on white, red on white, or yellow on black) Reduced complexity (line drawings vs. real pictures) Use of a light box The use of double lines, a thick marker or enlarged print Use of playdough to form letters The use of sand or textured paper in practicing writing

Fine Motor Activities To Encourage Pre-Braille Skills

Intervention Ideas by Debra Sewell, TSBVI

Although not all students with deafblindness will read Braille, these pre-braille skillscan be beneficial in that they strengthen hands and fingers, provide proprioceptive

feedback from the fine motor muscles (needed for motor planning), and increase bodyawareness and tactile sensitivity.


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Assistive Motor Devices

Functional movement is essential for a child with deafblindness to be able to developconcepts that the the world extends beyond what they can reach. Therefore, it is important toconsider the array of specialized mobility equipment which help the child have more

functional access within daily routines. These aides must be individualized to the child'svisual, auditory and motor needs. All equipment should be adapted by a licensedoccupational or physical therapist. Most equipment will need to be replaced or adjusted asthe child grows and his motor ability levels change. In fact, some equipment poses safetyand health concerns if it is not individualized for the child or is not functioning properly.

Positioning Equipment:

The goal of positioning equipment is to:

Keep children from developing more severe motor problems and/or deformities

Help the child to function as normally as possible


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Aid in respiration and digestion

Facilitate as much independent movement as possible

Minimize muscle tone issues by strengthening core muscles and relaxing spastic

muscles

Equipment commonly used for positioning:

Stationary positioning chair provides back support in sitting, ensuring shoulders areforward and the head is at midline.

Prone Stander provides support in varying angles from horizontal to vertical and is used forjoint compression (proprioceptive input), head control, and weight bearing.

Sidelyer provides a good position for encouraging children to bring and use their hands atmidline. It also is a good position to help break up excessive muscle tone. Use a motivatingobject, or model exploration of an object to encourage the child with deafblindness to use hishands at midline.

Orthoses:

Many children with deafblindness and tone issues use orthoses to help support joints in afunctional position. Some orthoses are used only occassionaly to support functionalmovement during a routine, while others are used daily to keep the joint properly aligned andto avoid malformation. Orthoses are professionally made and need to be monitored by theparent and the physical therapist. However, anyone working with the child can watch for anysign that the orthoses a renot fitting properly. These signs may include: redness, blisters or

sores, pain and discomfort, a change in movement pattern from the child, or signs ofmalfunction (cracked plastic, missing straps, missing screws). Any of these sign should bebrought to the immediate attention of the educator in charge, the parent, or occupational orphysical therapist.

Mobility Aids-


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The purpose of mobility aids is to:

encourage the child to move, explore and participate

increase the child's ability to travel as independently as possible

facilitate interaction with others

Some common mobility aids include:

Wheelchairs, strollers and scooters- Wheelchairs and scooters are individually adjustedto ensure proper fit, sitting alignment, and functional movement. Again, it is the role of theoccupational and physical therapist to adjust wheelchairs and recommend supports. Sensoryand cognitive function must be taken into consideration when determining if a motorize chairis an appropriate option. Most students with deafblindness who need wheelchair support willnot be using motorized scooters.

Canes and Walkers- The types of cane and walking aids can vary as much as theindividuality of the child being served. All service providers should work together inconsidering vision, hearing, other sensory (proprioceptive, vestibular), cognitive, and motorissues before deciding on a functional walking aid with the most potential benefit. It is onlythrough trial, and sometimes error, that the child's needs are best met.


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Scooter Boards-Scooter boards, if age appropriate, are a functional mobility aid that canbe used in either a prone or sitting position. Children with deafblindness who need fullphysical support and have limited arm movement can still use a scooter board while in asupported sitting position and using a switch for activation.

Adapted Mobility Devices- Many times the most efficient and inexpensive mobility solutionis "homemade." What can provide the best support while allowing the child to participate inhis world to the fullest extent possible, are ideas to consider when thinking about mobilitysolutions.


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Documents

Process of Motor Development