developmental milestones

DOI: 10.1542/pir.31-7-2672010;31;267Pediatrics in Review

R. Jason Gerber, Timothy Wilks and Christine Erdie-LalenaDevelopmental Milestones: Motor Development

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Developmental Milestones: Motor DevelopmentR. Jason Gerber, MD,*

Timothy Wilks, MD,†

Christine Erdie-Lalena,

MD‡

Author Disclosure

Drs Gerber, Wilks, and

Erdie-Lalena have

disclosed no financial

relationships relevant

to this article. This

commentary does not

contain a discussion

of an unapproved/

investigative use of a

commercial

product/device.

Objectives After completing this article, readers should be able to:

1. Identify the milestones for gross and fine motor development.2. Recognize the child whose development falls outside of the expected range.3. Describe the sequences involved in gross and fine motor development.

This is the first of three articles on developmental milestones; the second and third articleswill appear in the September and November 2010 issues of Pediatrics in Review, respectively.

IntroductionInfancy and childhood are dynamic periods of growth and change. Neurodevelopmentaland physical growth proceed in a sequential and predictable pattern that is intrinsicallydetermined. Skills progress from cephalic to caudal; from proximal to distal; and fromgeneralized, stimulus-based reflexes to specific, goal-oriented reactions that becomeincreasingly precise. As one clinician has stated, “infants [and children] are very orderly intheir ways; they actually behave [and develop] according to laws that can be explored,discovered, confirmed, reconfirmed, and celebrated.” (1) By convention, these neuro-developmental “laws” or sequences often are described in terms of the traditional devel-opmental milestones.

Milestones provide a framework for observing and monitoring a child over time.According to recent American Academy of Pediatrics and Bright Futures guidelines,pediatricians should incorporate developmental surveillance at every health supervisionvisit. Surveillance involves analyzing the milestones in the context of a child’s history,growth, and physical examination findings to recognize those who may be at risk fordevelopmental delay. A thorough understanding of the normal or typical sequence ofdevelopment in all domains (gross motor, fine motor, problem-solving, receptive lan-guage, expressive language, and social-emotional) allows the clinician to formulate acorrect overall impression of a child’s true developmental status. However, it must beemphasized that even experienced pediatricians cannot rely solely on their knowledge ofthe milestones to identify children who have developmental concerns. Developmentalscreening using validated and standardized tools should occur at the 9-month, 18-month,and 30-month (or 24-month) health supervision visits or whenever surveillance uncoversa concern.

Although neurodevelopment follows a predictable course, it is important to understandthat intrinsic and extrinsic forces produce individual variation, making each child’s devel-opmental path unique. Intrinsic influences include genetically determined attributes (eg,physical characteristics, temperament) as well as the child’s overall state of wellness.Extrinsic influences during infancy and childhood originate primarily from the family.Parent and sibling personalities, the nurturing methods used by caregivers, the culturalenvironment, and the family’s socioeconomic status with its effect on resources of time andmoney all play a role in the development of children. Developmental theory has, itself,developed as clinicians have tried to grapple with which influence is more predominant.

The focus of this series of articles is to help the clinician frame general concepts ofdevelopment according to the developmental streams rather than highlight developmental

*Major, USAF, Medical Corps, Developmental & Behavioral Pediatrics Fellow, Madigan Army Medical Center, Joint Base Lewis-McChord, Wash.†LCDR, USN, Medical Corps; Developmental & Behavioral Pediatrics Fellow, Madigan Army Medical Center, Joint Base Lewis-McChord, Wash.‡Lt Col, USAF, Medical Corps, Program Director, Developmental & Behavioral Pediatrics Fellowship, Madigan Army MedicalCenter, Joint Base Lewis-McChord, Wash.

Article growth & development

Pediatrics in Review Vol.31 No.7 July 2010 267



abnormalities. The milestones cited are, on average,those at the 50th percentile for age. By understandingwhat is “normal” or typical, the clinician can appreciatemore keenly what is abnormal or delayed. This articleconcentrates on normal motor development, with a briefmention about specific “red flags” that should alert cli-nicians to potential motor developmental problems. Thesecond article in the series discusses cognitive and lan-guage development. The final article addresses the devel-opment of social-emotional skills. An all-inclusive tableof milestones is provided in this first article as a reference(Table 1) both in print and online; Table 1 appearsonline only in the September and November articles.

Gross Motor MilestonesThe ultimate goal of gross motor development is to gainindependent and volitional movement. During gesta-tion, primitive reflexes develop and persist for severalmonths after birth to prepare the infant for the acquisi-tion of specific skills. These brainstem and spinal reflexesare stereotypic movements generated in response to spe-cific sensory stimuli. Examples include the Moro (Fig. 1),asymmetric tonic neck (ATNR) (Fig. 2), and positivesupport reflexes (Fig. 3). As the central nervous systemmatures, the reflexes are inhibited to allow the infant tomake purposeful movements. For example, during thetime when the ATNR persists, an infant is unable to rollfrom back to front, bring the hands to midline, or reachfor objects. This reflex disappears between 4 and 6months of age, the same time that these skills begin toemerge. The Moro reflex interferes with head controland sitting equilibrium. As this reflex lessens and disap-pears by 6 months of age, the infant gains progressivestability in a seated position (Fig. 4).

In addition to primitive reflexes, postural reactions,such as righting and protection responses, also begin todevelop after birth. These reactions, mediated at themidbrain level, interact with each other and work towardthe establishment of normal head and body relationshipin space. Protective extension, for example, allows theinfant to catch him- or herself when falling forward,sideways, or backwards (Fig. 5). These reactions developbetween 6 and 9 months, the same time that an infantlearns to move into a seated position and then to handsand knees. Soon afterward, higher cortical centers medi-ate the development of equilibrium responses and permitthe infant to pull to stand by 9 months of age and beginwalking by 12 months. Additional equilibrium responsesdevelop during the second year after birth to allow formore complex bipedal movements, such as moving back-ward, running, and jumping.

During the first postnatal year, an infant thus movesfrom lying prone, to rolling over, to getting to hands andknees, and ultimately to coming to a seated position orpulling to stand (Fig. 6). Within the framework of Backto Sleep guidelines, infants must have age-appropriateand safe opportunities for “tummy time” to promote thedevelopment of these important prone-specific mile-stones. It is important to note that crawling is not aprerequisite to walking; pulling to stand is the skill infantsmust develop before they take their first steps. Theultimate goal of this timeframe is to develop skills thatallow for independent movement and freedom to use thehands to explore, manipulate, and learn from the envi-ronment.

Gross motor development in subsequent years con-sists of refinements in balance, coordination, speed, andstrength. The wide-based, slightly crouched, staccatogait of a 12-month-old evolves into a smooth, upright,and narrow-based style. The arms change from beingheld abducted and slightly elevated for balance to swing-ing in a reciprocal fashion as the gait reaches an adultpattern by age 3 years. Similarly, running develops soonafter walking, starting as a stiff-legged approximation andchanging into a well-coordinated movement that in-cludes rapid change of direction and speed by 18 monthsof age.

Simultaneous use of both arms or legs occurs aftersuccessful use of each limb independently. At age 2 years,a child can kick a ball, jump with two feet off the floor,and throw a big ball overhand. Milestones for succeedingages reflect progress in the length of time, number ofrepetitions, or the distance each task can be performedsuccessfully. By the time a child starts school, he or she isable to perform multiple complex gross motor taskssimultaneously (such as pedaling, maintaining balance,and steering while on a bicycle).

Fine Motor MilestonesFine motor skills relate to the use of the upper extremitiesto engage and manipulate the environment. They arenecessary for a person to perform self-help tasks, to play,and to accomplish work. Like all developmental streams,fine motor milestones do not proceed in isolation butdepend on other areas of development, including grossmotor, cognitive, and visual perceptual skills. At first, theupper extremities play an important role in balance andmobility. Hands are used for support, first in the proneposition and then in sitting. Arms help with rolling over,then crawling, then pulling to stand. Infants begin to usetheir hands to explore, even when in the supine position.When gross motor skills have developed such that the

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268 Pediatrics in Review Vol.31 No.7 July 2010



Table 1. Developmental MilestonesAge Gross Motor Fine Motor Self-Help Problem-solving Social/Emotional Receptive Language Expressive Language

1 month ● Chin up inprone position

● Turns head insupine position

● Hands fistednear face

● Sucks well ● Gazes at black-white objects

● Follows face

● Discriminatesmother’s voice

● Cries out ofdistress

● Startles to voice/sound

● Throaty noises

2 months ● Chest up inprone position

● Head bobs whenheld in sittingposition

● Hands unfisted50%

● Retains rattleif placed inhand

● Holds handstogether

● Opens mouthat sight ofbreast orbottle

● Visual threatpresent

● Follows large,highlycontrastingobjects

● Recognizesmother

● Reciprocalsmiling:responds toadult voice andsmile

● Alerts to voice/sound

● Coos● Social smile

(6 weeks)● Vowel-like noises

3 months ● Props onforearms inprone position

● Rolls to side

● Hands unfisted50%

● Inspectsfingers

● Bats at objects

● Brings handsto mouth

● Reaches forface

● Follows objectsin circle (insupineposition)

● Regards toys

● Expression ofdisgust (sourtaste, loudsound)

● Visually followsperson who ismoving across aroom

● Regards speaker ● Chuckles● Vocalizes when

talked to

4 months ● Sits with trunksupport

● No head lagwhen pulled tosit

● Props on wrists● Rolls front to

back

● Hands heldpredominatelyopen

● Clutches atclothes

● Reachespersistently

● Plays withrattle

● Briefly holdsonto breastor bottle

● Mouths objects● Stares longer

at novel facesthan familiar

● Shakes rattle● Reaches for

ring/rattle

● Smilesspontaneouslyat pleasurablesight/sound

● Stops crying atparent voice

● To and froalternatingvocalizations

● Orients head indirection of avoice

● Stops crying tosoothing voice

● Laughs out loud● Vocalizes when

alone

5 months ● Sits with pelvicsupport

● Rolls back tofront

● Anteriorprotection

● Sits with armssupportingtrunk

● Palmar graspscube

● Transfersobjects: hand-mouth-hand

● Holds handstogether

● Reaches/graspsdangling ring

● Gums/mouthspureed food

● Turns head tolook fordropped spoon

● Regards pelletor smallcracker

● Recognizescaregivervisually

● Formsattachmentrelationship tocaregiver

● Begins torespond toname

● Says “Ah-goo”● Razzes, squeals● Expresses anger

with soundsother than crying

6 months ● Sitsmomentarilypropped onhands

● Pivots in prone● In prone

position, bearsweight on 1hand

● Transfershand-hand

● Rakes pellet● Takes second

cube and holdson to first

● Reaches withone hand

● Feeds selfcrackers

● Places handson bottle

● Touchesreflection andvocalizes

● Removes clothon face

● Bangs andshakes toys

● Stranger anxiety(familiar versusunfamiliarpeople)

● Stopsmomentarily to“no”

● Gestures for “up”

● Reduplicativebabble withconsonants

● Listens, thenvocalizes whenadult stops

● Smiles/vocalizesto mirror

7 months ● Bounces whenheld

● Sits withoutsupport steadily

● Lateralprotection

● Puts arms outto sides forbalance

● Radial-palmargrasp

● Refusesexcess food

● Exploresdifferentaspects of toy

● Observes cubein each hand

● Finds partiallyhidden object

● Looks fromobject to parentand back whenwanting help(eg, with awind-up toy)

● Looks towardfamiliar objectwhen named

● Attends to music

● Increasing varietyof syllables

8 months ● Gets into sittingposition

● Commandocrawls

● Pulls to sitting/kneelingposition

● Bangs spoonafterdemonstration

● Scissor graspof cube

● Takes cube outof cup

● Pulls out largepeg

● Holds ownbottle

● Finger feedsCheerios® orstring beans

● Seeks objectafter it fallssilently to thefloor

● Lets parentsknow whenhappy versusupset

● Engages in gazemonitoring:adult looksaway and childfollows adultglance with owneyes

● Responds to“Come here”

● Looks for familymembers,“Where’smama?”. . . etc

● Says “Dada”(nonspecific)

● Echolalia (8 to 30months)

● Shakes head for“no”

(continued)





Table 1. Developmental Milestones—continued

Age Gross Motor Fine Motor Self-Help Problem-solving Social/Emotional Receptive Language Expressive Language

9 months ● “Stands” on feetand hands

● Begins creeping● Pulls to stand● Bear walks (all

four limbsstraight)

● Radial-digitalgrasp of cube

● Bangs twocubes together

● Bites, chewscookie

● Inspects bell● Rings bell● Pulls string to

obtain ring

● Uses sounds toget attention

● Separationanxiety

● Follows a point,“Oh look at . . .”

● Recognizesfamiliar peoplevisually

● Enjoys gesturegames

● Orients to namewell

● Orients to bell

● Says “Mama”(nonspecific)

● Nonreduplicativebabble

● Imitates sounds

10 months ● Creeps well● Cruises around

furniture usingtwo hands

● Stands with onehand held

● Walks with twohands held

● Clumsy releaseof cube

● Inferior pincergrasp of pellet

● Isolates indexfinger andpokes

● Drinks fromcup held forchild

● Uncovers toyunder cloth

● Pokes at pelletin bottle

● Tries to putcube in cup,but may not beable to let go

● Experiences fear● Looks

preferentiallywhen name iscalled

● Enjoys peek-a-boo

● Waves “bye-bye”back

● Says “Dada”(specific)

● Waves “bye-bye”

11 months ● Pivots in sittingposition

● Cruises furnitureusing one hand

● Stands for afew seconds

● Walks with onehand held

● Throws objects● Stirs with

spoon

● Cooperateswith dressing

● Finds toy undercup

● Looks atpictures inbook

● Gives objects toadult for actionafterdemonstration(lets adult knowhe or she needshelp)

● Stops activitywhen told “no”

● Bounces to music

● Says first word● Vocalizes to songs

12 months ● Stands wellwith arms high,legs splayed

● Posteriorprotection

● Independentsteps

● Scribbles afterdemonstration

● Fine pincergrasp of pellet

● Holds crayon● Attempts

tower of twocubes

● Finger feedspart of meal

● Takes off hat

● Rattles spoonin cup

● Lifts box lid tofind toy

● Shows objectsto parent toshare interest

● Points to getdesired object(proto-imperativepointing)

● Follows one-stepcommand withgesture

● Recognizesnames of twoobjects and lookswhen named

● Points to getdesired object(proto-imperativepointing)

● Uses severalgestures withvocalizing (eg,waving, reaching)

13 months ● Walks witharms high andout (highguard)

● Attempts torelease pelletin bottle

● Drinks fromcup withsome spilling

● Dangles ring bystring

● Reaches aroundclear barrier toobtain object

● Unwraps toy incloth

● Shows desire toplease caregiver

● Solitary play● Functional play

● Looksappropriatelywhen asked,“Where’s theball?”

● Uses three words● Immature

jargoning:inflection withoutreal words

14 months ● Stands withoutpulling up

● Falls by collapse● Walks well

● Imitates backand forthscribble

● Adds thirdcube to a two-cube tower

● Puts round pegin and out ofhole

● Removessocks/shoes

● Chews well● Puts spoon in

mouth (turnsover)

● Dumps pelletout of bottleafterdemonstration

● Points at objectto expressinterest (proto-declarativepointing)

● Purposefulexploration oftoys throughtrial and error

● Follows one-stepcommandwithout gesture

● Names one object● Points at object

to expressinterest (proto-declarativepointing)

15 months ● Stoops to pickup toy

● Creeps up stairs● Runs stiff-

legged● Walks carrying

toy● Climbs on

furniture

● Builds three-to four-cubetower

● Places 10cubes in cup

● Releases pelletinto bottle

● Uses spoonwith somespilling

● Attempts tobrush ownhair

● Fusses to bechanged

● Turns pages inbook

● Places circle insingle-shapepuzzle

● Shows empathy(someone elsecries, child lookssad)

● Hugs adult inreciprocation

● Recognizeswithout ademonstrationthat a toyrequiresactivation;hands it toadult if can’toperate

● Points to onebody part

● Points to oneobject of threewhen named

● Gets object fromanother roomupon demand

● Uses three to fivewords

● Mature jargoningwith real words

16 months ● Stands on onefoot with slightsupport

● Walksbackwards

● Walks up stairswith one handheld

● Puts severalround pegs inboard withurging

● Scribblesspontaneously

● Picks up anddrinks fromcup

● Fetches andcarriesobjects (sameroom)

● Dumps pelletout withoutdemonstration

● Finds toyobserved to behidden underlayers of covers

● Places circle inform board

● Kisses by touch-ing lips to skin

● Periodicallyvisually relocatescaregiver

● Self-conscious;embarrassedwhen aware ofpeople observing

● Understandssimplecommands,“Bring tomommy”

● Points to onepicture whennamed

● Uses 5 to 10words

(continued)







18 months ● Creeps downstairs

● Runs well● Seats self in

small chair● Throws ball

while standing

● Makes four-cube tower

● Crudelyimitatesvertical stroke

● Removesgarment

● Gets ontoadult chairunaided

● Moves abouthousewithoutadult

● Matches pairsof objects

● Replaces circlein form boardafter it hasbeen turnedaround (usuallywith trial anderror)

● Passes M-CHAT● Engages in

pretend playwith otherpeople (eg, teaparty, birthdayparty)

● Begins to showshame (whendoes wrong)andpossessiveness

● Points to two ofthree objectswhen named

● Points to threebody parts

● Points to self● Understands

“mine”● Points to familiar

people whennamed


● Uses giant words(all gone, stopthat)

● Imitatesenvironmentalsounds (eg,animals)

● Names one pictureon demand

20 months ● Squats in play● Carries large

object● Walks

downstairs withone hand held

● Completesround pegboard withouturging

● Makes five- tosix-cube tower

● Completessquare pegboard

● Places onlyedibles inmouth

● Feeds selfwith spoonentire meal

● Deduceslocation ofhidden object

● Places squarein form board

● Begins to havethoughts aboutfeelings

● Engages in teaparty withstuffed animals

● Kisses withpucker

● Points to threepictures

● Begins tounderstandher/him/me

● Holophrases(“Mommy?” andpoints to keys,meaning: “Theseare Mommy’skeys.”)

● Two-wordcombinations

● Answers requestswith “no”

22 months ● Walks up stairsholding rail,putting bothfeet on eachstep

● Kicks ball withdemonstration

● Walks with onefoot on walkingboard

● Closes boxwith lid

● Imitatesvertical line

● Imitatescircularscribble

● Uses spoonwell

● Drinks fromcup well

● Unzipszippers

● Puts shoeson partway

● Completesform board

● Watches otherchildrenintensely

● Begins to showdefiant behavior

● Points to fourto five pictureswhen named

● Points to five tosix body parts

● Points to fourpieces ofclothing whennamed


● Asks for more● Adds one to two

words/week

24 months ● Walks downstairs holdingrail, both feeton each step

● Kicks ballwithoutdemonstration

● Throwsoverhand

● Makes asingle-line“train” ofcubes

● Imitates circle● Imitates

horizontal line

● Opens doorusing knob

● Sucksthrough astraw

● Takes offclotheswithoutbuttons

● Pulls offpants

● Sorts objects● Matches

objects topictures

● Shows use offamiliar objects

● Parallel play● Begins to mask

emotions forsocial etiquette

● Follows two-step command

● Understandsme/you

● Points to 5 to10 pictures

● Two-word sentence(noun � verb)

● Telegraphic speech● Uses 50� words● 50% intelligibility● Refers to self by

name● Names three

pictures

28 months ● Jumps frombottom stepwith one footleading

● Walks on toesafterdemonstration

● Walks backward10 steps

● Strings largebeadsawkwardly

● Unscrews jarlid

● Turns paperpages (oftenseveral atonce)

● Holds selfandverbalizestoilet needs

● Pulls pantsup withassistance

● Matchesshapes

● Matches colors

● Reduction inseparationanxiety

● Understands“just one”

● Repeats two digits● Begins to use

pronouns(I, me, you)

● Names 10 to 15pictures

30 months ● Walks up stairswith rail,alternating feet

● Jumps in place● Stands with

both feet onbalance beam

● Walks with onefoot on balancebeam

● Makes eight-cube tower

● Makes a“train” ofcubes andincludes astack

● Washeshands

● Puts thingsaway

● Brushes teethwithassistance

● Replaces circlein form boardafter it hasbeen turnedaround (littleor no trial anderror)

● Points to smalldetails inpictures

● Imitates adultactivities (eg,sweeping,talking onphone)

● Follows twoprepositions:“put blockin . . . on box”

● Understandsactions words:“playing . . .washing . . .blowing”

● Echolalia andjargoning gone

● Names objects byuse

● Refers to self withcorrect pronoun

● Recites parts ofwell-known story/fills in words

33 months ● Walks swingingarms oppositeof legs(synchronousgait)

● Makes 9- to10-cube tower

● Puts six squarepegs inpegboard

● Imitates cross

● Toilet trained● Puts on coat

unassisted

● Points to selfin photos

● Points to bodyparts based onfunction(“What do youhear with?”)

● Begins to taketurns

● Tries to helpwith householdtasks

● Understandsthreeprepositions

● Understandsdirty, wet

● Points to objectsby use: “ridein . . . put onfeet . . . writewith”

● Gives first and lastname

● Counts to 3● Begins to use past

tense● Enjoys being read

to (short books)

(continued)







3 years ● Balances on onefoot for 3seconds

● Goes up stairs,alternating feet,no rail

● Pedals tricycle● Walks heel

to toe● Catches ball

with stiff arms

● Copies circle● Cuts with scissors:

side-to-side(awkwardly)

● Strings smallbeads well

● Imitates bridge ofcubes

● Independenteating

● Pours liquid fromone container toanother

● Puts on shoeswithout laces

● Unbuttons

● Draws a two- tothree-part person

● Understands long/short, big/small,more/less

● Knows own gender● Knows own age● Matches letters/

numerals

● Starts to sharewith/withoutprompt

● Fears imaginarythings

● Imaginative play● Uses words to

describe whatsomeone else isthinking (“Momthought I wasasleep”)

● Points to partsof pictures (noseof cow, door ofcar)

● Names bodyparts withfunction

● Understandsnegatives

● Groups objects(foods, toys)

● Uses 200� words● Three-word sentences● Uses pronouns

correctly● 75% intelligibility● Uses plurals● Names body parts by

use● Asks to be read to

4 years ● Balances on onefoot 4 to 8seconds

● Hops on onefoot two tothree times

● Standing broadjump: 1 to2 feet

● Gallops● Throws ball

overhand10 feet

● Catchesbounced ball(41⁄2 yrs)

● Copies square● Ties single knot● Cuts 5-inch circle● Uses tongs to

transfer● Writes part of

first name● Imitates gate

with cubes

● Goes to toiletalone

● Wipes after bowelmovement

● Washes face/hands

● Brushes teethalone

● Buttons● Uses fork well

● Draws a four- tosix-part person

● Can give amounts(usually less than 5)correctly

● Simple analogies:- dad/boy:

mother/???- ice/cold: fire/

???- ceiling/up:

floor/???● Points to five to six

colors● Points to letters/

numerals whennamed

● Rote counts to 4● “Reads” several

common signs/store names

● Deception:interested in“tricking” othersand concernedabout beingtricked by others

● Has a preferredfriend

● Labels happiness,sadness, fear,and anger in self

● Group play

● Follows three-step commands

● Points to thingsthat are thesame versusdifferent

● Names thingswhen actions aredescribed (eg,swims in water,you cut with it,it’s somethingyou read, it tellstime . . .)

● Understandsadjectives: bushy,long, thin,pointed

● Uses 300 to 1,000words

● Tells stories● 100% intelligibility● Uses “feeling” words● Uses words that tell

about time

5 years ● Walks downstairs with rail,alternating feet

● Balances onone foot >8seconds

● Hops on onefoot 15 times

● Skips● Running broad

jump 2 to 3feet

● Walks backwardheel-toe

● Jumps backward

● Copies triangle● Puts paper clip

on paper● Can use clothes-

pins to transfersmall objects

● Cuts with scissors● Writes first name● Builds stairs from

model

● Spreads withknife

● Independentdressing

● Bathesindependently

● Draws an 8- to10-part person

● Gives amounts(<10)

● Identifies coins● Names letters/

numerals out oforder

● Rote counts to 10● Names 10 colors● Uses letter names as

sounds to inventspelling

● Knows sounds ofconsonants andshort vowels by endof kindergarten

● Reads 25 words

● Has group offriends

● Apologizes formistakes

● Respondsverbally to goodfortune of others

● Knows right andleft on self

● Points todifferent one ina series

● Understands “er”endings (eg,batter, skater)

● Understandsadjectives: busy,long, thin,pointed

● Enjoys rhymingwords andalliterations

● Produces wordsthat rhyme

● Points correctlyto “side,”“middle,”“corner”

● Repeats six- toeight-word sentence

● Defines simple words● Uses 2,000 words● Knows telephone

number● Responds to “why”

questions● Retells story with

clear beginning,middle, end

6 years ● Tandem walks ● Builds stairs frommemory

● Draws diamond● Writes first and

last name● Creates and writes

short sentences● Forms letters with

down-going andcounterclockwisestrokes

● Copies flag

● Ties shoes● Combs hair● Looks both ways

at street● Remembers to

bring belongings

● Draws a 12- to14-part person

● Number conceptsto 20

● Simple addition/subtraction

● Understands seasons● Sounds out

regularly spelledwords

● Reads 250 words byend of first grade

● Has best friendof same sex

● Plays boardgames

● Distinguishesfantasy fromreality

● Wants to be likefriends andplease them

● Enjoys school

● Asks what un-familiar wordsmean

● Can tell whichwords do notbelong in agroup

● Repeats 8- to 10-word sentences

● Describes events inorder

● Knows days of theweek

● 10,000 wordvocabulary

Copyright 2007 by Chris Johnson, MD, AAP Council on Children with Disabilities. Adapted by the authors with permission and contributions from FrancesPage Glascoe, PhD, and Nicholas Robertshaw, authors of PEDS:Developmental Milestones; Franklin Trimm, MD, Vice Chair of Pediatrics, USA/APAEducation Committee; the Centers for Disease Control and Prevention “Act Early” initiative; the National Institute for Literacy/Reach Out and Read; andthe Inventory of Early Development by Albert Brigance published by Curriculum Associates, Inc. Permission is granted to reproduce these pages on thecondition that they are only used as a guide to typical development and not as a substitute for standardized validated screening for developmental problems.





infant is more stable in upright positions and can moveinto them easily, the hands are free for more purposefulexploration.

At birth, infants do not have any apparent voluntaryuse of their hands. They open and close them in responseto touch and other stimuli, but movement otherwise isdominated by a primitive grasp reflex. Because of this,infants spend the first 3 months after birth “contacting”objects with their eyes rather than their hands, fixating onfaces and objects and then visually tracking objects.Gradually, they start to reach clumsily and bring theirhands together. As the primitive reflexes decrease, infantsbegin to prehend objects voluntarily, first using the en-tire palm toward the ulnar side (5 months) and thenpredominantly using the radial aspect of the palm(7 months). At the same time, infants learn to releaseobjects voluntarily. In the presence of a strong graspreflex, objects must be removed forcibly from an infant’sgrasp or drop involuntarily from the hand. Voluntaryrelease is seen as the infant learns to transfer objects fromone hand to the other, first using the mouth as anintermediate stage (5 months) and then directly hand-to-hand (6 months).

Between 6 months and 12 months of age, the graspevolves to allow for prehension of objects of differentshapes and sizes (Fig. 7). The thumb becomes moreinvolved to grasp objects, using all four fingers againstthe thumb (a “scissors” grasp) at 8 months, and eventu-ally to just two fingers and thumb (radial digital grasp) at

9 months. A pincer grasp emerges as the ulnar fingers areinhibited while slightly extending and supinating thewrist. Voluntary release is awkward at first, with all fin-gers extended. By 10 months of age, infants can release acube into a container or drop things onto the floor.Object permanence reinforces the desire to practice thisskill over and over. Intrinsic muscle control develops toallow the isolation of the index finger, and infants willpoke their fingers into small holes for exploration. By 12months of age, most infants enjoy putting things intocontainers and dumping them out repeatedly. They alsocan pick up small pieces of food with a mature pincergrasp and bring them to their mouths.

As infants move into their second year, their masteryof the reach, grasp, and release allows them to start usingobjects as tools. Fine motor development becomes moreclosely associated with cognitive and adaptive develop-ment, with the infant knowing both what he or she wants to

Figure 1. Moro reflex. This reflex occurs spontaneously toloud noises or by simply holding the supine infant’s hand andreleasing the hand suddenly. Classically, the reflex is elicitedwhile holding the infant supine, with the head droppedslightly backward. This produces sudden extension and abduc-tion of the upper extremities with hands open, followed byflexion of the upper extremities to midline (the “startle reflex”).

Figure 2. Asymmetric tonic neck reflex (ATNR). The sensorylimb of the ATNR involves proprioceptors in the cervicalvertebrae. With active or passive head rotation, the babyextends the arm and leg on the face side and flexes theextremities on the contralateral side (the “fencer posture”).There also is some subtle trunk curvature on the contralateralside produced by mild paraspinous muscle contraction.





do and how he or she can accomplish it. Intrinsic musclerefinement allows for holding flat objects, such as crackersor cookies. By 15 months of age, voluntary release hasdeveloped further to enable stacking of three to four blocksand releasing small objects into containers. The child startsto adjust objects after grasping to use them properly, such aspicking up a crayon and adjusting it to scribble spontane-ously (18 months of age) and adjusting a spoon to use itconsistently for eating (20 months of age).

In subsequent years, fine motor skills are refined fur-ther to draw, explore, problem-solve, create, and performself-help tasks. By age 2 years, children can create a six-block tower, feed themselves with a spoon and fork, re-

Figure 4. The declining intensity of primitive reflexes and theincreasing role of postural reactions represent at least permis-sive, and possibly necessary, conditions for the development ofdefinitive motor reactions. Reproduced with permission fromJohnson CP, Blasco PA. Infant growth and development.Pediatr Rev. 1997;18:225–242.

Figure 5. Lateral protection. In the seated position, the childis pushed gently but rapidly to one side. The reaction is presentif the child puts out his or her hand to prevent a fall.

Figure 3. Positive support reflex. With support around thetrunk, the infant is suspended, then lowered to touch the feetgently on a flat surface. This produces reflex extension at thehips, knees, and ankles so the infant stands up, completely orpartially bearing weight. Mature weight-bearing lacks therigid quality of this primitive reflex.





move clothing, and grasp and turn a door knob. Theyhave sufficient control of a crayon to imitate both ver-tical and horizontal lines. In-hand manipulation skillspermit them to rotate objects, such as unscrewing asmall bottle cap or reorienting a puzzle piece beforeputting it in place. They are able to wash and dry theirhands. By 36 months of age, they can draw a circle, puton shoes, and stack 10 blocks. They make snips withscissors by alternating between full-finger extension and

flexion. Their grasp and in-hand ma-nipulation skills allow them to stringsmall beads and unbutton clothes.

At age 4 years, a palmar tripodgrasp allows for finer control of pencilmovements, and the child can copy across, a square, and some letters andnumerals and can draw a figure of aperson (the head and a few otherbody parts). Scissor skills have pro-gressed to permit the cutting of acircle. When a child reaches the ageof 5 years, he or she can dress and un-dress independently, brush the teethwell, and spread with a knife. Moreprecise in-hand manipulation skillsenable the child to cut a square withmature scissor movements (indepen-dent finger use) and to print his orher own name and copy a triangleusing a mature tripod pencil grasp(using the fingers to move the pencilrather than the forearm and wrist).

Developmental Red FlagsAs the clinician performs develop-mental surveillance, the absence ofcertain key milestones in a patientshould raise the level of concern.Table 2 lists the developmental redflags specific to the motor domain. Ifone of these red flags is discovered, amedical and more thorough devel-

opmental evaluation is warranted.Although reported in this article in isolation, motor

skills development overlaps significantly with the otherstreams of development.

Figure 6. Chronologic progression of gross motor development during the first 12postnatal months. Reproduced with permission from Johnson CP, Blasco PA. Infantgrowth and development. Pediatr Rev. 1997;18:224–242.

Figure 7. Development of pincer grasp. Illustrations from the Erhardt developmentalprehension. In Erhardt RP. Developmental Hand Dysfunction: Theory Assessment, Treat-ment. 2nd ed. San Antonio, Tex: Therapy Skill Builders; 1994. Reprinted with permission.

Table 2. Motor Red FlagsAge Red Flag

4 months Lack of steady head controlwhile sitting

9 months Inability to sit18 months Inability to walk independently Summary

• The development of motor skills is critical for a childto move independently and to interact with his or herenvironment meaningfully and usefully. Skills developin a cephalic-to-caudal progression and from proximalto distal. Thus, consistent head support occurs beforevoluntary control of arms and legs, and large musclecontrol of the upper arms occurs before small, intrinsicmuscle control in the hands.

• Skills also progress from generalized responses tostimuli (primitive reflexes) to goal-oriented, purposefulactions with ever-increasing precision and dexterity.





References1. Lipsitt LP. Learning and emotion in infants. Pediatrics. 1998;102:1262–1267

Suggested ReadingAmerican Academy of Pediatrics Committee on Children with

Disabilities, Section on Developmental Behavioral Pediatrics;Bright Futures Steering Committee; Medical Home Initiativesfor Children with Special Needs Project Advisory Committee.Identifying infants and young children with developmental dis-orders in the medical home: an algorithm for developmentalsurveillance and screening. Pediatrics. 2006;118:405–420

AAP Task Force on Infant Positioning and SIDS. Changing con-cepts of sudden infant death syndrome: implications for infant

sleeping environment and sleep position. Pediatrics. 2000;105:650–656

Case-Smith J, Allen AS, Pratt PN, eds. Occupational Therapy forChildren. St. Louis, Mo: Mosby Year-Book, Inc; 1996

Fiorentino MR. Reflex Testing Methods for Evaluating CNS Devel-opment. Springfield, Ill: Charles C Thomas; 1973

Hagan JF, Shaw J, Ducan PM, eds. Bright Futures: Guidelines forHealth Supervision of Infants, Children, and Adolescents. 3rdedition. Elk Grove Village, Ill: American Academy of Pediatrics;2008

Johnson CP, Blasco PA. Infant growth and development. PediatrRev. 1997;18:224–242

Sturner RA, Howard BJ. Preschool development 1: communicativeand motor aspects. Pediatr Rev. 1997;18:291–301





PIR QuizQuiz also available online at http://pedsinreview.aappublications.org.

1. An 18-month-old girl is seen for a health supervision visit. Her mother has no concerns regarding herdaughter’s development. Her growth parameters are at the 25th percentile. She walks well, climbs onto hermother’s lap, and whispers a few words to her mother. The best next step in the evaluation of this child’sdevelopment is:

A. Full developmental surveillance.B. Further evaluation of language skills.C. Implementation of a developmental screening tool.D. Review of developmental milestones with the mother.E. Scheduling of a visit for full developmental assessment.

2. A 6-month-old infant is unable to roll from back to front or bring hands to midline. The most likely causeof this infant’s difficulty is:

A. Absence of lateral protection postural reaction.B. Absence of protective extension reaction.C. Persistence of asymmetric tonic neck reflex.D. Persistence of Moro reflex.E. Persistence of positive support reflex.

3. A 15-month-old typically developing girl is able to release cubes into a cup and has a mature fine pincergrasp. She most likely also is able to:

A. Build a tower of three blocks.B. Copy a vertical line.C. Feed herself with a spoon and fork.D. Put on her shoes.E. Turn a doorknob.

4. An 18-month-old typically developing boy can walk well and run. He most likely also is able to:

A. Jump with two feet off the ground.B. Kick a ball.C. Pedal a tricycle.D. Stoop and pick up a toy.E. Toe-walk.





DOI: 10.1542/pir.31-7-2672010;31;267Pediatrics in Review

R. Jason Gerber, Timothy Wilks and Christine Erdie-LalenaDevelopmental Milestones: Motor Development

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