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Motor Development & Your Child

Have you ever wondered how to best monitor your child’s motor development, and what you can be doing at home to promote and support this aspect of your child’s development? Have you ever wondered why crawling is such an important milestone for your child to achieve? Did you know that particular sitting positions can give you clues about your child’s motor development?

Find these answers and more on my blog post interview with Peter Zakopcan, Pediatric Physiotherapist at the Osteopathic Health Center in Dubai.

Tell us a bit about yourself and why you chose this profession.

Well… I come from Slovakia where I have done my undergraduate physiotherapy training. I was always very curious about how the human body works and what was especially fascinating about physiotherapy was the fact that you do not need expensive equipment or a large team to make a significant difference in a patient’s life. It is your knowledge, logical reasoning and thinking outside the box which makes the real change.

Despite being more interested in sports or musculoskeletal issues, it occurred to me that better understanding of child’s development could be the key to better management of muscular imbalances in adulthood. Soon I attended my first two neurodevelopmental courses and that’s how my story as a pediatric physiotherapist began.

What kinds of cases do you see as a Pediatric Physiotherapist?

I deal mostly with cases related to prematurity, muscle tone disturbances, developmental delays, or other neurological issues. Another big group is infants with head or foot deformities and neck injuries after traumatic delivery. I also treat children with musculoskeletal or spinal problems such as scoliosis.

What does your job entail? How is it different to a Physical Therapist for adults?

Pediatric physiotherapy focuses on the specific needs of infants, children and adolescents. Early detection is extremely important especially when a child experiences problems that may inhibit his or her natural development, quality of movement patterns and learning. Understandably, pediatric physiotherapist should have an extensive knowledge about child’s physiological development, but also be able to design and practically implement therapeutic program in order to help children to improve their gross and fine motor skills.

The major difference in comparison to adult physical therapy is that pediatrics entails close cooperation with parents and their active involvement in the therapeutic process. Quality is more important than quantity and sessions that involve parental education should be always promoted. In addition, pediatric physiotherapist should have sufficient psychological background to understand parents’ feelings and guide them efficiently through the treatment which can be lengthy and emotionally exhausting. Therapist should not play “Mr. or Mrs. I know everything” as the perspective of the parents and their anxieties are an important consideration.

What kinds of other professionals do you have to work closely with?

I regularly collaborate with referring physicians such as pediatricians, neurologists, neonatologists and pediatric surgeons. Nevertheless, I also cooperate with other allied health professionals- physiotherapists, occupational therapists, speech therapists and orthotists. It is important for me to keep this spirit of multidisciplinary team work in order to deal with cases in a very complex and thorough way. However, this can be sometimes difficult as opinions may vary. Therefore, ability to compromise and find the most suitable solution for a child, parents and other involved parties is a crucial skill.

What are some of the gross motor milestones that one should keep track of? What are some red flags that one should investigate further?

There are certainly important gross motor milestones which we should observe during a child’s development. Understandably, they differ based on the age of the child. There are also many standardized forms of assessment that can vary. The following is a very short summary of expected milestones and probable concern areas:

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 we 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.

A child between the age of 3 and 5 months should be able to keep a balanced position on its tummy (bilateral elbow support) or back (symmetrical leg lift against the gravity). It uses hands and eyes together, such as 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. Additionally, poor performance during tummy time or with rolling may suggest developmental issues.

By the age of 6-8 months the child 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 hand support. There should be an improvement in fine motor skills linked to presence of raking and later pincer grip. Children at this age are curious about things and frequently seek to explore the environment. Child also reacts to people by making vowel sounds. We are generally concerned if child by this age 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 positions, crawl forward and get into a sitting position and sit without support. Many of them try to pull themselves to standing position and cruise around furniture. Fine motor skills improve significantly and 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 mama” and “baba baba”. They have favorite toys and look for things he/she sees you hide. Concerning situations would be a child’s inability to bear weight on legs or sitting without help and dragging one side of body while crawling or walking. Certainly, the child should not lose skills he/she once had.

What are the implications if a child skips the crawling milestone?

The importance of crawling lies in its complexity. It can be seen as a core or general 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, hand-eye-coordination or overall strength of back muscles. Furthermore, issues with quality of crawling may later in life interfere with other activities such as running, jumping, throwing a ball or writing. If your child shows signs of wanting to walk before they crawl or present some peculiar versions of crawling, encourage them to crawl as much as possible in a correct way. You may even need to get down on the floor and crawl with them!

What is a w-sitting position and what can this imply about a child’s motor development?

W-sitting position is characterized by children siting on their bottom with knees bent and feet positioned outside of their hips, which resembles the shape of W. We may often see it in children with lower muscle tone as no trunk rotation, weight shifting or righting reactions are necessary to assume or maintain W-sitting.

There has been quite a discussion about the real impact of this habitual position as we are lacking appropriate research. Nevertheless, children often get into this position while playing, but it should not be their preferred or long-term position because of associated risks. Prolonged use of W sitting unnecessarily strains hip and knee joints (increased risk with history of hip dysplasia). In addition, it does not encourage appropriate development of core strength, rotation capabilities and can even delay development of more mature movement patterns necessary for high-level skills.

If my child isn’t walking according to age appropriate norms, what could this indicate? What should I do?

There certainly would be reasons why such situation could be happening. Generally speaking, any issues in previous developmental stages, hereditary conditions such as increased ligament flexibility or disturbed muscle tone could contribute to decreased quality of gait. Thus, these factors should be thoroughly assessed by appropriate pediatric specialist before passing any judgment or suggesting possible solutions.

Can you talk a bit about flat head syndrome in babies (Plagiocephaly) – what causes it and what can be done about it?

Flat head syndrome, also known as Plagiocephaly is a condition characterized by an asymmetrical flattening of one side of the skull and is usually diagnosed between 1-4 months. Moderate to severe cases of plagiocephaly have a direct impact on facial development and facial symmetry. Severe deformity may also coexist with other developmental issues such as lower muscle tone, congenital hip dysplasia or cognitive impairment.

Progression of head deformity usually depends on intensity of side preference and risk factors such as restrictive intrauterine position before birth, prematurity, prolonged or complicated delivery with use of instruments ( forceps, suction cup), birth trauma (nerve injury, collar bone fracture) or shortening of neck muscles (Torticollis). The relationship between plagiocephaly and torticollis is slightly unusual as causality can go in either direction. Rare complication of plagiocephaly is Craniosynostosis or premature fusion of cranial sutures. This condition almost certainly requires surgical treatment due to possible impairment of neurodevelopmental and cognitive functioning.

Conservative treatment of plagiocephaly should start ASAP, the approach depends on the severity of the case. Outcomes of 12 months of conservative treatment are satisfactory in almost 70% of cases if the treatment routine was followed by the parents as their commitment to treatment program is vital. Therapy usually includes positioning, manual handling and specific stretching and strengthening exercises. Nevertheless, in severe cases Cranial Remolding Orthosis (CRO), which is like a hard helmet that the child has to wear, is the only option with the prospect of acceptable correction of head deformity. CRO is based on the principle of applied restriction on protruding parts of skull. Treatment ideally starts at the age of 5 months. The length of treatment depends of maturity of sutures, overall progress and compliance, but it rarely lasts longer than 6 months.

What is club-foot and how can it be diagnosed and treated?

Club foot, is a deformity in which the foot is twisted inward with the toes pointing down. It is more common in males and it may affect one or both feet. The exact cause of club foot is not known. It can be an abnormality of the tendons, ligaments or bones. However, if the foot is abnormally positioned in the uterus during pregnancy, it may also not grow into a normal shape, but this is not usually considered a "genuine" club foot deformity. Club foot can be also linked to conditions such as spina bifida or other neuromuscular diseases, but severity is significantly worse.

Club foot is usually diagnosed at birth or during pregnancy through ultrasound. A thorough physical examination should be later performed to rule out other spinal and muscular diseases. In addition, an X- ray may be needed to determine the position of the bones and detect possible abnormalities.

Treatment of this deformity is usually non-surgical including manipulation of the foot into a corrected position in combination with a cast, splint or in a milder cases a tape. Foot activation exercises can be also added to facilitate appropriate motor development. Special footwear or braces may be later required to ensure that acquired position will be preserved. In severe cases, surgical intervention may be performed to correct the position of tendons, ligaments, and joints, thus improving the foot function. Nevertheless, the earlier the treatment starts, the better the results.

How do I know if my child has difficulties with coordination, balance, or if they have reduced core strength?

Firstly, we need to distinguish between age groups. For children before 1 year of age difficulties in coordination could relate to otherwise benign motor delays, issues with lower muscle tone or in severe cases to neurological impairment. However, in older children who have no history of any severe issues, we may talk about clumsiness in their motor behavior (developmental dyspraxia). They usually have difficulties with learning new motor skills or performing everyday tasks that require higher-level of coordination (going down the stairs, catching a ball, etc.). In addition, they have a tendency to slouch, trip frequently and their dexterity (for example fastening buttons) may also be affected. Unfortunately, they often prefer sedentary activities like watching television as they do not feel so confident in front of their peers. Therefore, they should be frequently encouraged and helped to work on improvement of their balance and coordination.

In an ideal world, what activities from a motor perspective should I engage my child in?

Understandably, it would again depend on child’s age. In general, children up to 6 months should enjoy as much natural exercises as they can - tummy time or rolling. Tummy time allows babies to rock back and forth and helps them get a better perception for other movement patterns such as crawling. It also allows them to play with toys and explore their surroundings. Just always make sure the area is safe! Later of course, activities such as crawling, creeping, transfers to and from sitting positions can be added.

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.

What kinds of general advice do you have regarding toys and motor exposure that parents should consider?

Toys can be used to improve a child’s potential on every level including gross and fine motor skills or cognitive capabilities. Nevertheless, it is not the toy, but the way it is used which makes a difference. In a nutshell, toys should be able to create a motivation, a drive for a child to do something (usually what we want). Thus, we need to choose a toy which the child is interested in in a particular moment. Sometimes it can be a very sophisticated one, another time perhaps just an empty plastic bottle of water. Moreover, facilitation caused by a particular toy should be used for a child to practice more challenging movement patterns or refine its manual skills. For example, toys are one of the most exciting things to encourage your baby to roll or crawl. Make them curios and encourage them to chase the soft ball or a plastic car on the floor or through obstacles.

If my child does need to build motor skills, what are your guidelines regarding creating opportunities in the home environment to practice these skills?

Unfortunately, there are no standardized rules when it comes to exercising in a home environment. However, the highest priority is a child’s safety. Try to engage your child in a variety of activities always including some form of crawling, climbing or balance challenges. You may create something like an obstacle course out of soft pillows and cushions for your babies to climb and crawl over to help them to build their self-confidence. In addition, you may arrange suitable soft furniture or toys (cloth tunnel from IKEA) or use some hanging ropes fixed on a pull up bar to enhance the level of difficulty. Be creative, but make necessary precautions to keep your child unharmed.

What else do you think is vital for a parent to know regarding their child’s development from your perspective?

Child development is always a mixture of internal and external factors. Inherited temperament, curiosity, but also optimal muscle tone plays an important role in appropriate development. Nevertheless, if child has experienced traumatic delivery, complications related to prematurity or later the environment was not encouraging him or her to move and explore his own physical capabilities, the impact on quality of development will be inevitable. For example, children carried around most of the time can hardly develop full strength and coordination for perfect rolling or crawling. In addition, children with lower muscle tone may struggle with sitting and crawling due to an early onset of fatigue and weak trunk muscles.

If I’m concerned about my child’s development in the above areas mentioned, what should I do? How important is it to intervene early? Why?

If you have any concerns, you should contact a pediatric specialist- usually your pediatrician. In case your child has a history of prematurity or complicated birth you may consider more specialized practitioner such as pediatric neurologist or pediatric orthopedic surgeon. A pediatric physiotherapist is also capable of assessing your child for developmental delays. However, opinions may vary greatly from practitioner to practitioner. Therefore, if you are not satisfied with explanation do not hesitate to seek a second or third opinion. Also, seek the professionals who specialize in your targeted area of concern.