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Snell, R. (1997). Gross motor development in infants with multiple disabilities. In D. Chen (Ed.). Effective practices in early intervention. Infants whose multiple disabilities include visual impairment and hearing loss (pp.167-176). Northridge, CA: California State University, Northridge, Department of Special Education (ERIC Document Reproduction Service No. ED 406-795).

GROSS MOTOR DEVELOPMENT IN INFANTS WITH MULTIPLE IMPAIRMENTS

by Rita Snell, MA, RPT

Typical development

A typical infant tends to follow a known developmental progression that starts at birth. As the infant grows and his central nervous system matures, the gross motor skills develop in a head to foot progression (Gesell, 1940). First, at about two months of age, the infant will learn to hold his head up in attempt to look at the world around him. As he begins to notice light and sounds, the curious infant will look from side to side, developing strength and coordination in the neck and upper back muscles. At three to four months an infant will often roll over for the first time while desperately trying to reach for a favorite toy that is just beyond reach. Around six months of age, when placed in a sitting position, the infant keeps himself balanced by propping himself up with both arms. Within a month or two, he is able to get into and out of the sitting position without any help, and use both hands to explore a toy. On the floor he can scoot across the room on his tummy, and later get up on his hands and knees to crawl. Generally by a year of age, the infant has figured out how to pull up to stand, cruise along the furniture, and maybe even attempt a few steps alone, until he is finally walking, climbing, and getting into everything (McGraw, 1943; Gesell, 1945).

Effects of disabilities

When an infant is developmentally delayed or neurologically impaired, these motor skills are often delayed, and do not develop easily. Gross motor skills occur in a typical sequence. However, these skills can only occur as the infant develops the balance, coordination and postural control needed to move his body about in space (Shumway-Cook & Woollacott, 1985). An infant's desire to reach out and explore his surroundings is the primary motivator that eventually leads to gross motor development. When an infant's disabilities interfere with what he is able to see and hear, or impair his overall motor functioning, then an infant will not follow the developmental sequence as we know it (Teplin, 1983).

As a parent or early interventionist of a special needs infant, you may already be working with a physical or occupational therapist. Starting with a detailed assessment of your baby, they have probably established a specific program for you to follow. If so, please consider any precautions or specific instructions they have suggested. The activities presented in this chapter are general ways in which you can interact with your infant, while encouraging progress in gross motor development. Although each developmental level builds on a previously developed skill, the infant experiments with many movements at the same time, which are preparing him for higher levels of activity (Gesell, 1949). Playing with your infant and making it possible for him to explore his surroundings is very helpful for the baby's development. The extent to which each infant will progress depends on the type of impairment and the amount of neurological damage that is present.

In this chapter I will cover the various gross motor skills from head control through walking. First we will examine how these skills occur in normal development, then we can look at ways to adapt the environment as well as our interactions with an infant who has multiple disabilities to encourage these developmental skills. Each of these activities will allow the infant to experience normal movement to increase the likelihood that typical movement patterns will develop.

In each of the following areas, I have provided a variety of ways to play with your infant, and facilitate developmental milestones. Since infants are motivated initially through their senses, you can choose the most appropriate activity that meets the auditory, visual or physical needs of each infant.

Head control

Head control is the first movement that a baby achieves, and is necessary to attain other movement skills such as sitting, crawling, and walking (Illingworth, 1983). Head control requires strength and coordination of the muscles which flex (bend) and extend (straighten) the neck. Infants are born with a flexion pattern throughout their neck and bodies, and will develop extension by repeatedly attempting to lift their head and turn it from side to side. A baby will develop head control in 3 major positions; prone (on tummy), supine (on back), and in sitting, as the infant learns to raise, turn and maintain his head in the upright position. A baby is generally motivated to turn his head in attempt to see an object, or to locate a near by sound. A newborn can distinguish colors, focus on a human face, and follow the movement of the face across his visual field (Miranda, Hack, & Fantz, 1977). When a child has a visual and hearing impairment, there are other ways to encourage head control and exploration.

Place baby on floor, lying on his back or stomach:

An important way to develop head control in an infant is in the pull-to-sit position. Place the baby on his back, either on the floor in front of you, or on your lap. Place both of your hands behind his shoulders, providing only as much support as he requires, so that his head does not drop back. If the baby's neck is very weak, you can place your hands behind his head rather than his shoulders initially, and move your hands down to his shoulders as his head control improves. Slowly raise him up towards you, as you bring him from the supine to the sitting position. As his neck and trunk muscles get stronger, you can do this activity by holding the baby's hands, and gently pulling him up into sitting. This can only be done when the infant shows the ability to bring his own head forward, and uses his shoulders to help you pull him up into sitting.

Shake a rattle, or place a musical toy to each side, encouraging head turning

Use flashlight or brightly colored object to encourage baby's eyes to focus in midline, then slowly move light from side to side, allowing the infant opportunity to turn head as he follows the light.

Gently stroke side of baby's cheek with your fingers, and with a variety of soft textures (plush toys, washcloth) to encourage head turning to each side.

Approach and talk to your baby from both sides to encourage turning in both directions. If an infant has the tendency to look toward one side, make an effort to feed and play with your baby primarily from the opposite side.

Position yourself directly in front of baby, and use your voice, a musical toy, or brightly colored object to encourage him to raise head up.

If your infant shows no ability to raise head up or turn from side to side, place your hand gently on his forehead, and move him through these positions while providing visual or auditory stimulation.

Head control in sitting:

Have infant sitting on your lap, facing you. With your hands behind his shoulders, gently move him from side to side, as well as forward and back. Move slowly, allowing him time to respond by keeping his head upright.

Playing in front of a mirror is a perfect way to work on head control. Sit on floor in front of mirror, with baby positioned on your lap, facing the mirror. Gently rock him side to side, and forward and back, allowing him opportunity to maintain head upright.

Rolling

The ability to roll smoothly from back to stomach, or stomach to back requires some degree of head control, and a rotation movement that occurs along the trunk of the body, between the hips and the shoulders. Rolling is the first movement that allows a baby to change his position, and usually develops between 4 and 5 months of age (Caplan, 1978). An infant with abnormal muscle tone may have difficulty with this movement. Spasticity can cause stiffness through the trunk, interfering with a coordinated rolling movement. A baby who is weak or floppy may not be able to begin the movement, as rolling requires enough strength to move against gravity.

As with head control, a baby is generally motivated to roll when an object of interest is off to one side, and he is determined to get to it. An infant with visual and auditory impairments can be encouraged to roll by providing him with brightly colored objects, musical toys, or your voice introduced from the side. If a baby is physically unable to roll, you can help him roll so he can experience this pattern of movement. A child who is visually impaired generally prefers being on his back, and will often learn to roll from his stomach to his back to avoid being on his stomach (Fraiberg, 1971). It is important for these infants to spend some time on their stomach, however, as many skills are developed when a child plays in this position. The prone position allows the baby to develop weight shift to each side, weight bearing through both arms and shoulders as he begins to prop on his forearms (Hanson & Harris, 1986), and trunk rotation as the baby reaches for a toy in front of him.

Rolling from stomach to back

Place infant on the floor, lying on his stomach:

While baby is on his stomach, be sure his head is turned toward one side. Slightly tuck his opposite shoulder under him. Place a rattle or brightly colored toy in front of baby, where he can easily see it. Slowly raise it above where he is lying, encouraging him to follow it while turning his head, and shifting his weight over towards the tucked shoulder. The baby will then be in a position to roll over onto his back as he continues to follow the toy. If he stops following the toy or sound, bring it back to where he can easily see or hear it, and continue again from there. If baby gets stuck anywhere along the way, gently grasp the baby's top leg and help him to complete the rolling movement. Switch off doing this to both sides.

If the baby displays abnormal muscle tone, spasticity may interfere with rolling from stomach to back. You can physically assist the infant with rolling to help teach him this movement. Place the baby on his stomach, and as he looks toward one side, you can tuck his opposite arm slightly under him. Gently grasp the leg on the side toward where he is facing, holding near the hip and the knee. Bend that leg up slightly, and help him to roll over onto his back. This can be repeated to both sides.

If a visually impaired infant does not like the prone position, you can use pillows and wedge shapes to help him prop in that position, so that he can develop head and trunk control in his extensor muscles.

Rolling from Back to Stomach

Place infant on the floor, lying on his back:

Present a rattle or brightly colored toy in front of baby. As he focuses on the toy, move it off to one side, and slightly above the level of his head. As baby follows the object, he will be encouraged to roll toward his side, facing the toy. If baby is unable to complete the movement, gently grasp his leg on the side opposite the toy, and assist him to roll onto his side, then over to his stomach.

Place brightly colored or musical toy to one side, and slightly above the level of baby's head. Gently grasp baby's leg on side opposite toy, and rotate that leg across baby's body, moving him onto his side. Assist infant to reach up toward toy, and continue to roll him onto his side, then over to his stomach, as he completes the rolling movement.

If baby cannot see or hear a toy, you can place him on his back, and gently move him through this position so that he can repeatedly experience this rolling movement.

Sitting

The ability to maintain a sitting position requires a baby to have developed equilibrium reactions and protective responses in the forward, backward, and side to side directions (Bobath, 1964). If a baby has difficulty with maintaining balance, his equilibrium reactions can often be improved by playing with him in the sitting position, and challenging his balance in all directions. If a baby has muscle tightness in his legs, or weakness in his neck or trunk muscles, sitting will be more difficult for the baby. Initially a baby sits by propping forward with both hands in front of him. As his balance and upright posture improve, he maintains the sitting position by placing a hand to one side or the other as needed to keep himself sitting upright. Eventually the baby can hold himself in a good sitting position without the use of his hands for balance.

Developing the sitting position:

Place baby on the floor in a sitting position, and seat yourself behind him to provide support as needed. Place toy or familiar object on floor in front of infant to encourage him to prop forward on both hands. If baby cannot put both hands on the floor, you can help by placing both of his hands on floor, and gently placing your hands over his to give him the sensation of taking some weight through his hands and arms. While your hands are still over his, rock him forward over his hands several times to help facilitate this propping position.

Once the infant can prop forward, you can begin to encourage side to side balance. Place a toy or familiar object off to one side, and slightly in front of the baby. Assist him to support his weight on the hand near the toy, as he reaches with the opposite hand. As you switch sides with this activity, the baby will have the opportunity to develop weight bearing and protective responses to each side.

If the infant falls to the side while in the sitting position, you can teach him to use his hands for balance. Start by placing one of his hands out to the side. Gently shift him off balance to that side, so that he needs to use that arm to maintain sitting balance. Switch off doing this to both sides. As the baby's arm supports his weight in this off-balance position, he will be learning how his arms can support him. The baby will begin responding by putting his arms out automatically as he leans to one side, until eventually he can maintain the sitting position without the use of his arms.

The visually impaired infant generally develops sitting around the same time as a sighted infant. It is common for them to be slower learning to get in and out of the sitting position. Try to provide a reason for the baby to get out of sitting, such as a musical toy just out of his reach.

There are many opportunities throughout the day to practice sitting with your infant. Each time you change a diaper or dress your infant, encourage them to assist in coming to sit by rolling toward one side, and pushing up into sitting with that arm.

Pull to stand, cruising and walking

Once an infant develops strength, coordination, and balance to move about freely on the floor, he will begin to pull up to stand and discover ways to explore things that were previously out of his reach (Bly, 1980). As a baby pulls to his feet and stands, he gains further strength and control in his trunk and leg muscles. Soon he develops enough strength and balance to "cruise" along furniture, as he sidesteps to reach a new destination. This sidestepping teaches the weight shift your baby will need to take steps forward in walking.

When an infant has increased muscle tone, the stiffness through the legs and possibly the trunk may interfere with pulling to stand, and maintaining the upright position. Often the spasticity will make both legs move stiffly together and cause the baby to weight bear up on his toes. When this happens, the baby will benefit from activities that encourage the legs to work separately, and help maintain the feet flat on the floor. Adaptive equipment is sometimes needed to assist your baby with walking, such as special braces or a walker. These would be recommended by your therapist or orthopedist, and they will be able to instruct you in the proper use of any adaptive equipment that is necessary.

A visually impaired infant will often be delayed in walking, as he may feel insecure in the upright position. Very little of his body is supported once he is up on his feet, and he may prefer being on the floor until closer to 18 months of age (Fewell, 1983). Once he does show some interest in walking, he will need to be encouraged to move toward musical or noisy objects, or a familiar voice that is slightly out of his reach. It is also normal for the visually impaired infant to keep his feet further apart for a longer time, as he is understandably more unsure of himself without the visual input, and this will allow him to feel more balanced and secure during the first few months of walking.

Pull to Stand:

Once your baby gets around well on the floor, he will probably begin to play in the "tall kneel" position, where he is up on both knees, and usually holding onto a surface such as a couch or low table. If your infant is unable to assume this position, you can place him in this kneeling position, where he can support himself against a couch or low table or chair. Position yourself behind him, with your hands at his hips. Gently shift him over to one side, which places most of his weight on that leg, and very little weight on the opposite leg. This will allow him to pick up the leg he is not weight bearing on, and bring it up, so that he is in a half kneel position. From here, he can pull himself all the way up to stand, or you can assist him up into a standing position by keeping your hands at his hips, and shifting his weight slightly forward over his feet, and upward.

Position yourself seated on the floor, near a low table or couch. Place baby on your lap, facing away from you. Place a toy of interest, or a snack on the low table, and with your hands at his hips, shift his weight forward over his feet, and help him to assume the standing position. As he develops more strength and trunk control, allow him to do more of the work in pulling up to a standing position

.

Once your baby is in the standing position, you can help improve his standing balance by gently shifting his weight from side to side, and encouraging him to support his weight on each leg, as you rock him to each side. Place your hands at his hips as you shift his weight from side to side, so that his arms are free to help him balance.

Cruising:

Once in the standing position at a couch or low table, you can help encourage cruising, or sidestepping by placing a toy of interest or a snack a short distance out of baby's reach. With your hands at his hips, shift baby's weight off the leg nearest the toy, allowing him time to take a step with that leg. Now shift his weight over that leg, so he can take a step with the opposite leg, which will bring the legs together again. As you repeat this, he will be able to side step to one side. You can then repeat this in the other direction, to strengthen the muscles of both legs.

To help strengthen your baby's trunk and hip muscles so that he is able to cruise along furniture, have him stand on your lap while you are sitting on the couch or a chair. Hold both of your baby's hands, and gently move your legs up and down, one at a time, so that he will be shifting his weight from one side to the other. If he needs more support, place your hands at his hips to do this activity.

Walking:

Have baby push a small chair, box, or push toy with a handle that is made for this purpose. Stand behind your infant, and give support with your hands at his hips, as you move the object just a few inches in front of your baby. Allow him the time to shift his weight forward, and take a step, as he moves toward the object he is pushing. Repeat this, continuing to move object just a few steps at a time, so baby has a chance to balance himself as he moves forward over alternating legs.

Position yourself on the floor behind baby while he is in a standing position. Place your hands at his hips, so that his arms are free to help him balance. Move yourself along behind your baby as you help him shift his weight from one leg to the other, allowing him to move forward in a walking pattern. As his balance and upright posture improve, offer him less support.

Try to make walking a purposeful activity for your baby, and encourage him to be up on his feet as you need to move from one room to another. When it is bath time, for example, assist him into an upright position, and use the technique described above to help him weight shift, and take steps forward into the bathroom.

Summary

All the play activities discussed here are presented in a way to help you understand normal development and movement patterns that your infant can benefit from. Once you understand the various ways to help your baby, you can begin to incorporate these ideas into everyday play that will be fun for both you and your baby. Most of the activities can be done on your lap as you sit on the floor or the couch, or even across your chest as you play on the floor with your infant. Just carrying your baby from room to room during the day can be an opportunity to help your baby develop head control if you provide only the support he needs, and allow him to assist with holding his head and trunk upright. If he tends to look primarily to one side, carry him in a way that he must look to the opposite side to see you.

Having your infant stand on your lap, supported at the shoulders or hips, or even standing him next to you while you sit on the couch is a great opportunity to encourage upright posture, weight shift, and equilibrium in standing. Introducing toys and food from different sides encourages head control and trunk rotation that is needed in all of your baby's motor skills.

Dressing is an excellent opportunity to work on balance and weight shift if you have your baby stand to put on his pants, and sitting at the edge of the couch or your lap to put on his shoes and socks.

Gross motor development is an important area to develop in your infant, as it will allow him the opportunity to be mobile, and to interact with his surroundings. It is exciting to see the changes in your baby's overall growth and learning as he gains control over his movement and his motor abilities.

References

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Bobath, K. & Bobath, B. (1964). The facilitation of normal postural reactions and movements in the treatment of cerebral palsy. Physiotherapy, 50, 246-252.

Butterworth, G. & Hicks, L. (1977). Visual proprioception and postural stability in infancy. A developmental study. Perception, 6, 255-262.

Campbell, P.H. (1985) Assessment of posture and movement in children with severe movement dysfunction. Akron, OH.: Children's Hospital Medical Center.

Caplan, F. (1978). The first twelve months of life. New York: Bantam Books.

Fewell, R.R. (1993). Working with sensorily impaired children. Rockville, MD: Aspen.

Fraiberg, S. (1971). Intervention in infancy: A program for blind infants. Journal of the American Academy of Child Psychiatry, 10, 381-405.

Gesell, A. (1940). The first five years of life. New York: Harper.

Gesell, A. (1945). The embryology of behavior. New York: Harper

Hanson, M.J. & Harris, S.R. (1986). Teaching the young child with motor delays. Austin, TX: PRO-ED.

Illingworth, R.S. (1983). The development of the infant and young child: normal and abnormal. New York: Churchill Livingstone.

Mc Graw, M.B. (1943). Neuromuscular maturation of the human infant. New York: Hafner.

Miranda, S.B., Hack, M., & Frantz, R.L. (1977). Neonatal pattern vision: A predictor of future mental performance? Journal of Pediatrics, 91, 642-647.

Shumway-Cook, A. & Woollacott, M.H. (1985). The growth of stability: Postural control from a developmental perspective. Journal of Motor Behavior, 17, 131-147.

Teplin, S.W. (1983). Development of blind infants and children with retrolental fibroplasia: Implications for physicians. Pediatrics, 71, 6-12

Resource list

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