Process of motor development

Motor development typically occurs in an orderly sequence from head to trunk to hands to 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 arm movements for walking, pushing) to small muscle use (discrete hand movements for writing) Head to toe- Cephalocaudal (see chart below) Center to extremities- Proximodistal (see chart below)

Gross Motor Milestones

Atypical Motor Patterns

As noted earlier, motor development may be compromised if there is damage to the central 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 using both 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)

Reprinted with permission from Red flags for disabilities in children who are deaf/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.

PATHWAYS AWARENESS FOUNDATION. Copyright 2006 Reflexes

Reflexes are involuntary responses to specific sensory stimuli that are generally tactile, proprioceptive, or vestibular in nature (Colangelo, 1999). Newborns' reflexive behaviors dominate movement, allow for survival, and set the stage for early primitive learning (Allen & Marotz, 1994). Certain reflexes, such as swallowing, gagging, coughing, and yawning, remain present throughout a person's lifetime (Allen & Marotz, 1994). Other reflexes, however, begin to be integrated into volitional motor responses by 4 months of age. For example, the reflexive grasp at birth becomes a voluntary grasp by 4 months.

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

The continued presence of primitive reflexes above the age of six to twelve months and the absence, or under development, of postural reflexes beyond three and a half years 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 may have 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 protective posture.

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 of stress 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.

Signs of aberrant or unresolved TLR reflex When retained it can lead to spatial problems, motion sickness, poor posture, muscle tone, 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 turn the head to clear the air passage. For example, a child sitting and lifting his head would 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 suppressed by 5-7 months of age. The ATNR is stimulated by a rotation of the head left or right and is also refered to as the "fencing" reflex because of the body position. The response is an extension of the limbs 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.

Signs of aberrant or unresolved ATNR Children with aberrant ATNR are stuck in the positioning until a head turn releases the reflex. With no motivation to turn their head, a deafblind child can be stuck in this position for a very long time. Because in this position the muscle tone is different on both sides on the body, the student will have difficulty with bilateral skills (Balance, running, and jumping are all skills that require the balanced use of both sides of the body.)

Development of postural control

"Postural control involves both stability and movement. Various factors influence the development of postural control. Children with low postural tone (Hypotonia) have difficulty maintaining a secure posture in which to interact with the environment. They need a point of stability from which to move. For children with visual impairments, less movement leads to decreased practice of motor skills, which leads to a questionable foundation 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 in response to, or in anticipation of, changes of position in relation to the center of gravity. They allow individuals to maintain a posture against gravity while adjusting to movement (Alexander et al., 1993). These reactions develop as the infant's central nervous system (CNS) matures and reflexive behaviors are integrated and provide the basis for postural stability upon which more mature movement is built (Alexander et al., 1993). Motor Development and Movement, Carla J. Brown,Tanni L. Anthony,Susan Shier Lowry, Deborah D. Hatton

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

Propping- This response helps infants learn to sit. Anterior propping response begins at 4-5 months and involves the infant extending his arms 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 if he is tilted. Posterior propping causes him to extend his arms backwards if he is tilted backward.

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 for a child with deafblindness. A child needs to learn through movement that he can interact with his environment. He can move to accomplish a goal like finding a favorite person or toy. Self-initiated movement comes once a child with deafblindness has had enough 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 be motivated to move and explore. To make exploration functional for a deafblind child, visual, tactile, and auditory information may need to be supplemented. It is important to 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

Objects that make use of any residual vision and/or hearing the child has Immediate success assured by: short distances opportunity to use well-established motor skills discreet assistance by the adult

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

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

Movement transitions
A child with sensory impairment has a harder time mastering movement transitions and rotational skills. Movement transitions are the way in which a child moves his body from one position to the next. For example: sitting to crawling or stooping to standing. "Adelson and Fraiberg (1974) found that although children who were blind were able to sit independently and stand within the age range of sighted children, they did not move into, out of, or forward from these positions at the same age as did sighted children. While Adelson and Fraiberg (1974) proposed that lack of vision as a motivator to move was a primary factor in changing positions 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

failure to move. Further, they proposed that facilitating active movement transitions assists in the development of weight shift, rotation, and protective responses, which in turn lead to increased mobility in rolling, crawling, and walking. Also, quick, simple movement transition sequences can be built into 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 supine using appropriate handling. Picking up the infant: When picking up the infant from sitting, the caregiver helps the infant to weight bear with both hands to one 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 all fours close to the sofa and help the infant reach up with one hand, move to kneel, then move through half-kneel to standing. Motor Development and Movement, Carla J. Brown,Tanni L. Anthony,Susan Shier Lowry, Deborah D. Hatton

It is important to ask for, and follow, the guidance of the physical therapist and/or occupational therapist when it comes to helping position a child during transitional movement. The child's health, bone health, muscle health and tone will all need to be considered 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 of reaching out for an object in the all-fours position is the first component of crawling. Maida and McCune (1996) also identified the ability to reach for an object while on all fours, as well as the ability to move to or from the sitting position, to be the two most critical precursors to crawling. In analyzing the components of 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 trunk rotation appear to be critical components for crawling that

children who are visually impaired may lack. Some children with visual impairments demonstrate delays in crawling; others bypass crawling altogether (Adelson & Fraiberg, 1974; Trster et al., 1994). Infants and young children who are blind may have difficulty getting into and maintaining an all-fours crawling position due to lack of postural stability in the shoulder girdle (Brown & Bour, 1986). Among children who are able to maintain this position, the ability to shift weight and move forward on all fours is sometimes absent (Brown & Bour, 1986; Fraiberg, 1968; Trster et al., 1994). As described earlier, this lack of postural stability may stem from the lack of active experience 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 with support on forearms; prone with support on forearms and reaching; prone with extended-arm weight bearing; pivot in prone; and prone with pushing up to all fours (Bly, 1994). Experience and play in the prone progression are important for developing the extensor muscles of the back, shifting children's center 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

Walking
Cruising is an important functional activity to help children with sensory need to feel safe, and gravitationally grounded before independant walking. According to Lowry and Hatton (2002), an extended stage of cruising may have the following benefits: Cruising provides varied and repeated hands-on experiences with common objects, landmarks, and surfaces, leading to broader environmental concepts, a reinforced understanding of object permanence, and goal-directed movement. Cruising provides opportunities to establish a beginning mental map of the area, leading to more confidence and incentives for movement 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, or hills will prepare a child for the depth changes and obstacles he will experience walking. Motor Development and Movement, Carla J. Brown,Tanni L. Anthony,Susan Shier Lowry, Deborah D. Hatton A child with deafblindness who is walking independently will often still benefit from a walking aid such as an adapted cane, a push toy, stroller or shopping cart. Orientation and Mobility specialists can be consulted to help find what aids will be most functional for the child. The child can also be taught appropriate trailing techniques that will help the child feel grounded and receive the spacial information needed for goal directed movement.

Early Gross Motor Skills Intervention Ideas

Mindy Doyle McCall, physical therapist and JC Greeley, Orientation and Mobility Specialist, Anchor Center for Blind Children, 2005 Motor skill milestones that a child with deafblindness may be currently working to master are listed below along with ideas for functional intervention. It is important to consider how to best 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

*Click here for intervention ideas

Encourage rolling

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Encourage emerging visual tracking across midline

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

Encourage mastery of rolling

*Click here for intervention ideas

Encourage the child to pull his legs up under his body

*Click here for intervention ideas

Encourage mastery of trunk control

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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

*Click here for intervention ideas

Encourage rotation in transitional movement

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Encourage spacial and body awareness

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Encourage walking with support

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

When walking, supported with one hand only

*Click here for intervention ideas

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 controlled movements of the small muscles of the fingers and hands. These movements are usually coordinated with the larger muscles of the arms and trunk for stability and with the eyes for eye-hand coordination. Children develop fine motor skills in a step by step progression. Development occurs at an uneven pace, with periods of little progression. These ages are approximate and may vary based on the child's developmental process. Brings hands to mouth and watches the movements of his/her hands (0 to 3 months)

 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 arms and 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 control of the hands. The grasp reflex is evident at birth and occurs when a thin object is placed in the infant's hand; the infant's fingers tightly curl around the object in response. Between 1 and 4 months, the grasp reflex integrates into increasingly voluntary control of the hand. 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 for specific motions such as poking. An early and necessary component of fine motor skills is that a child is aware of his hands and understands that hands can be used purposefully. Activities that provide firm proprioceptive input into the hands and that promote hand-to-hand play, hand-tomouth play, and hand-to-foot play will facilitate an awareness of the hands and midline orientation of the body.

The first consideration, in preparing a child to participate in fine motor activities, is to establish good positioning for the child. If the child is in a wheelchair the use of a lap tray will help with the support and stability of the arms and shoulders during fine motor activities. Using the tray may also improve head control. If the child has use of only one extremity, clamp down paper or materials using a clipboard clamp screwed into the lap tray. Velcro strips or tape may also help to stabilize these. Consulting with an occupational therapist for the proper and most functional position for fine motor work would 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:

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 skills can be beneficial in that they strengthen hands and fingers, provide proprioceptive feedback from the fine motor muscles (needed for motor planning), and increase body awareness and tactile sensitivity.

Assistive Motor Devices

Functional movement is essential for a child with deafblindness to be able to develop concepts that the the world extends beyond what they can reach. Therefore, it is important to consider 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's visual, auditory and motor needs. All equipment should be adapted by a licensed occupational or physical therapist. Most equipment will need to be replaced or adjusted as the child grows and his motor ability levels change. In fact, some equipment poses safety and 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

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 are forward and the head is at midline. Prone Stander provides support in varying angles from horizontal to vertical and is used for joint compression (proprioceptive input), head control, and weight bearing. Sidelyer provides a good position for encouraging children to bring and use their hands at midline. It also is a good position to help break up excessive muscle tone. Use a motivating object, or model exploration of an object to encourage the child with deafblindness to use his hands at midline.

Orthoses:
Many children with deafblindness and tone issues use orthoses to help support joints in a functional position. Some orthoses are used only occassionaly to support functional movement during a routine, while others are used daily to keep the joint properly aligned and to avoid malformation. Orthoses are professionally made and need to be monitored by the parent and the physical therapist. However, anyone working with the child can watch for any sign 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 of malfunction (cracked plastic, missing straps, missing screws). Any of these sign should be brought to the immediate attention of the educator in charge, the parent, or occupational or physical therapist.

Mobility Aids-

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 adjusted to ensure proper fit, sitting alignment, and functional movement. Again, it is the role of the occupational and physical therapist to adjust wheelchairs and recommend supports. Sensory and cognitive function must be taken into consideration when determining if a motorize chair is an appropriate option. Most students with deafblindness who need wheelchair support will not be using motorized scooters.

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

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

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