THE AUSTRALIAN

JOURNAL OF PHYSIOTHERAPY
VOLUME 8 DECEMBER, 1962 NUMBER 3

NORMAL AND ABNORMAL DEVELOPMENT IN BABIES

JOHN RENDLE-SHORT, M.D., M.R.C.P., D.C.H.

Professor of Child Health, University of Queensland

It has long been known that children's men­ The grasp reflex. If the examiner's finger
tal and physical development proceeds in an is rubbed across the baby's palm, he will
orderly fashion. Events such as smiling, grip the finger so hard that it is possible to
sitting, walking, and speaking occur in normal lift him off the couch by this means.
children at such precise ages that they are
often called the milestones of development. The tonic neck reflex. When a baby's head
Study of these development stages is of is turned to one side he extends the arm on
great importance from the point of view of that side and flexes the arm of the opposite
differential, or better, developmental diag­ side in the position of a fencer taking up
nosis, as deviation from the normal may have guard.
some significance and indicate mental re­
tardation, deafness or other illness. This can The walk i eflex. This reflex is less im­
only be appreciated if the normal sequence portant than the above. If the foot of a
of events is known and understood. newborn baby is placed flat on a table and
the baby moved forward and from side to
REFLEXES side he will bring up each foot as in walking.
He does not, of course, bear any weight.
There are four important reflexes which
should all be present in normal full-term CLASSIFICATION OF STAGES OF DEVELOPMENT
babies. They are poorly developed in pre­
mature babies and may be absent in babies All classifications are based on the original
who are acutely or chronically ill. Their work of Gesell and Amatruda (1947). A
significance lies not only in the fact of their modified version of the classification of
presence, but also in the age at which they Sheridan (1960) is used here.
disappear. If any of these reflexes can be
Gross Motor Development
elicited after the age of three months it is
possible that some neurological abnormality Gross motor development is assessed by
is present. placing the baby in various positions.

The Moro or staitle reflex. This is best Prone position. In the newborn, the pelvis
elicited by lifting the baby with one hand is high and the knees are drawn up under
under the back and another under the head. the abdomen. Later the legs extend at the
If the head is suddenly allowed to fall back­ hips and knees and the pelvis rests flat on
ward the Moro reflex should occur. This re­ the couch. At first the baby cannot raise
flex consists of a sudden throwing out of his head, but at the age of six weeks he can
the arms which are then brought together lift it momentarily from the couch. With
again as in an embrace. advancing age this power develops until the
104 T H E AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

child is able to hold the head up well and small objects unless he can see them. It
support himself, at first on his elbows and should be possible to tell that a child is
later on his straight arms. blind before the age of two to three months.
By this time the normal child follows with
Ventral suspension. When a newborn baby his eyes the movements of an adult near his
is held in the air with a hand under the ab­ cot. He is also starting to take notice and
domen supporting the body, his head hangs play with his own hands. A child usually
down, but the arms, and to a lesser extent smiles at a face. The blind child cannot see
the legs, are flexed. Within a few weeks the the face and so does not smile when an adult
baby is able to lift his head progressively looks at him, but will do so immediately if the
until it reaches 180° or above. The legs ex­ adult speaks or tickles him. By the age of
tend at the hips and knees. nine months the baby is playing well with
small objects which he picks up, transfers
Lying supine. If the baby is laid on his from one hand to the other and frequently
back and is then pulled by his arms into ends by putting in his mouth. At 15 months
the sitting position, his head at first flops he is ready for constructive play and will
backward. The older child voluntarily raises build a tower of two or three bricks.
his head at the same time.
Hearing and Speech
Sitting. When sitting, the baby's back is
uniformly rounded and the head is facing Even at} the age of one month a baby may
downwards. With the older child, the head be startled by a loud noise. By three months
for a time still wobbles from side to side if he may be quietened by a voice talking to
the baby is shaken, but the back is straighter. him and when happy will vocalize when he
By the age of 6 | months he should be able smiles. By six months there should be no
to sit momentarily with his hands forward doubt as to whether the infant can hear as
for support. Gradually the baby becomes he will turn immediately toward his mother's
more steady in the sitting position and by voice. Speech develops more slowly. A baby
11 months he can twist around to pick up makes "da-da", "ma-ma", "ba-ba" noises
an object from behind. When testing for from the age of nine months and these are
sitting, see that the baby is unsupported and often confused with speech. When question­
on a hard surface, otherwise he will appear ing the mother therefore it is essential to dis­
to be more advanced than he is. cover whether the words used are "with mean­
ing". That is to say "da-da" is said in the
Standing and walking. When held in the father's presence only. By 15 months the
standing position the infant is able to bear child is able to say two to three words well,
progressively more weight on his legs. By and by two years should be putting a few
seven months he can bear all his weight and words together in recognizable sentences.
soon after this will start to pull himself up
to the standing position. A few weeks later Social Behaviour and Play
he momentarily lets go of his support and The neonate spends most of his time sleep­
stands alone. The next stage, when he ing or sucking. When not doing either of
learns to walk around the playpen or furni­ these he is usually crying. The time spent on
ture, is called "cruising". By the age of the latter exercise gradually increases until
about 14 months the child can walk un­ by the age of eight weeks most normal babies
supported. At first he still has a wide base cry for about two hours out of the 24. At
and falls frequently, but gradually the walk three months the baby shows obvious pleasure
becomes more mature. when someone plays with him. By six months
he can grasp and play with toys and takes
Fine Motor Development and Vision pleasure in playing with his feet. He is
Fine movements are mainly performed by friendly with strangers but at nine months
the upper arms, particularly the hands. A may turn from them to bury his face in his
child obviously will not touch and pick up mother's shoulder. He should drink well from
 NORMAL AND ABNORMAL DEVELOPMENT IN BABIES 105

a cup and likes to hold a spoon although come retarded in development. The baby is
he cannot yet feed himself. Grasping comes particularly vulnerable between the ages of
long before letting go. A child can hold on seven months and five years, and at this
to the playpen when standing, or can show age should never be taken away from his
a toy to an adult, but he cannot let go in mother if it can be avoided. The deprived
order to sit down nor can he give the toy to child looks very like a mentally retarded
the adult. By 12 months, however, he has child, in fact, it may not be possible to dis­
acquired the act of letting go and practises tinguish between them. The best way to
it by frequently throwing objects to the floor make the diagnosis is to send the baby home
and watching them fall. At the age of 12 to his mother and watch the remarkable
months the baby will hold out his arm to transformation which takes place in the next
assist his mother to put his coat on. few weeks. The baby who previously lay
apathetically in his cot is now sitting up and
DEVELOPMENTAL DIAGNOSIS playing. Very often he is feeding better,
too, and for this reason has put on weight.
It is not possible to give an accurate es­
timate of what a child's intelligence will be The differentiation between mental retarda­
like in later years from a developmental tion, prematurity, severe illness and the de­
examination at six months, but it is usually privation syndrome may be made more diffi­
possible to prognosticate into which of four cult because two or more of these conditions
main intelligence groups the child will fall: may be operative at the same time. It is
an I.Q. of 100 or above, an LQ. between essential that the correct diagnosis be made,
75 and 100, an LQ. between 50 and 75 or an however, as the management of the case varies
I.Q. below 50. with the cause.

If all aspects of development are delayed,

Isolated Developmental Delay
the most probable reason is that the child
is mentally retarded. Sometimes a child's development is delayed
in one aspect only, for instance, speech. If
Three other conditions may also cause there are no other abnormal features a child
general retardation of development: may not start to speak until two or three
years of age and yet be quite normal. Isolated
Prematurity. If a baby has been born a delay in motor development, however, is more
month prematurely, he cannot be expected, likely to indicate some abnormality. For in­
at the age of three months, to do the things stance, a child might present with lateness in
that a full-term baby of three months should sitting. If other fields of development were
do. This factor of prematurity becomes of normal this could be due to a local lesion
less importance as the child grows older. such as a congenital dislocation of the hip
or a paraplegia.
Severe illness. A baby who has been
severely ill with, for instance an intestinal Mutiple Handicaps
obstruction, may be too weak to sit at the
expected age and too unhappy to smile or The greatest difficulty with developmental
vocalize. He may, therefore, appear to be diagnosis arises with multiple handicaps.
mentally retarded, but as he recovers it will Probably the commonest example of this is
be found that not only does he improve the combination of cerebral palsy and mental
physically, but also developmentally. In retardation. In the past this led to many mis-
time he will catch up with other children of diagnoses: in particular, severely athetoid
the same chronological age.
children were thought to be mentally retarded
The deprived child. However well a baby when in fact their intelligence was normal,
is looked after physically, if he is deprived It is important in these cases that all fields
of the love of his mother, he is liable to be­ of development should be considered and
106 T H E AUSTRALIAN JOURNAL OF PHYSIOTHERAPY

undue emphasis must not be placed on gross It is important, but often difficult, to recog­
motor development. Children with athetosis nize the degree of mental retardation in a
do not usually show the characteristic move­ child with cerebral palsy. The success of
ments until after the age of one year. Before treatment depends largely on the intelligence
this they may show hypotonia which causes of the child. A knowledge of developmental
retardation of motor development. Other diagnosis is of value in deciding how much
fields of development — speech, vision and of the child's handicap is due to the cerebral
social — should be normal, thus showing that palsy and how much to mental retardation.
the child is not mentally retarded.
DEVELOPMENTAL HISTORY AND EXAMINATION1
Considerable difficulty sometimes occurs if
there is a combination of athetosis and deaf­ Details of the ages at which the milestones should
ness. Here two different developmental fields be passed
are abnormal, and such a child might well be Milestones Aveiage Age
considered to be mentally retarded. Prone — knees under abdomen .... 0-2 w. only
Ventral suspension, head in same plane 6 w.
It is particularly in the treatment of cere­ Prone — legs largely extended 6 w.
bral palsy that accurate developmental diag­ Smiles in response _. .... 6 w.
nosis is essential. Every effort must be made Vocalizes with smile .... 8 w.
to discover the probable level of intelligence Supine —■ follow 180° with eyes 3 m.
of the child. At one time all children with Holds rattle for minutes when placed
cerebral palsy, or Little's disease as it was in hand ._„ ____ .... .... 3 m.
Hands loosely open .... .... 3 m.
then called, were considered to be mentally
Tonic neck reflex; grasp reflex 0-3 m. only
retarded. Then the pendulum swung in the
Hand regard .... .... .... .... 3-5 m. only
opposite direction and sometimes spastic
Prone — weight on forearms 4 m.
children were credited with too high an in­
Turns head to sound .... .... 4 m.
telligence and it was thought that most if not
Excited on seeing preparation of feed 4 m.
all could be greatly helped by treatment. It
Pull to sit, no head lag (some wobble
is now realized that only those who have
on swaying baby) .... 5 m.
sufficient intelligence to respond to and bene­ Goes for object and gets it _. 5 m.
fit by their training are worth treating. It is Rolls prone to supine .... 6 m.
in this sphere that developmental diagnosis Prone — weight on hands and extended
can be of particular value. arms __ .... .... 6 m.
Lifts head before pulled to sit (no
wobble when swayed in sitting
SUMMARY position) 6 m.
The development of a child proceeds in a Transfers __._ .... .... .... .... 61 m.
precise and regular manner. Chews solids — 6i m.
Rolls supine to prone .... ... .... 7 m.
Sits on floor for seconds, no support,
Knowledge of normal development enables no fall .... .... 7 m.
the examiner to appreciate when development Imitates noises, etc. __ .... 7 m.
is abnormal. Spontaneously lifts head up, when
supine .... „__ .... 7 m.
Generalized developmental retardation oc­ Sits, 10 seconds on floor or couch
{not bed), does not fall .... 7 m.
curs mainly in mental deficiency, prematurity,
Standing, full weight borne, supported 7 m.
severe physical illness and the deprived child.
Stands holding on to playpen or chair 9 m.
Progresses on abdomen 10 m.
Multiple handicaps may mimic mental re­ Index finger approach to object .... .... 10 m.
tardation if several spheres of development Pulls himself to standing position .... 10 m.
are affected such as the motor and hearing
spheres in an athetoid child with deafness. Modified fiom Illmgwoith (1960).
 NORMAL AND ABNORMAL DEVELOPMENT IN BABIES 107
Milestones Average Age Milestones Average Age
Bye-bye, Patacake 10 m. Dry by day 18 m.
Crawls (i.e., on knees and hands) 11 m. Words together (not imitation) 21-24 m.
One word with meaning 11 m. Dry by night 2 yrs.
Cruise (walks holding on to furniture) 12 m. Puts on shoes, socks, pants .— .... 2 yrs.
Gives toy (i.e., holds it out and parts Dresses fully apart from buttons 3 yrs.
with it) ._ .... .... .... .... .... 12 m.
Three words with meaning 12 m.
REFERENCES
Arms out for dress or coat; foot for shoe 12 m.
12-15 m. GESELL, A. and AMATRUDA, C. S., (1947), Develop-
Casting
mental Diagnosis. New York, Hoeber.
Walk without support 13 m.
ILLINGWORTH, R. S. (1960), Development of the
Slobbering .. 0-12 m. only Infant and Young Child. Edinburgh, Livingstone.
Picks up cup, drinks, puts it down, no SHERIDAN, M. D. (1960), The Developmental Pro-
help 15 m. gress of Infants and Young Children. London, Her
Asks mother for pottie 15-18 m. Majesty's Stationery Office.