Growth and development

Pregnancy is actually 280 days, or 40 weeks measured from the first

day of the last menstrual period,, divided into three trimesters.
The fetus develops over many months time, but the first few months
are the most critical.
All babys major organs begin forming in the early weeks of
pregnancy, some even before realizing pregnancy.
Therefore, mother's health, nutrition, and avoidance of harmful
substances are important even before pregnancy begins.
Anything mothers eat, drink, breathe, or touch can affect babys
development, especially in the very sensitive period beginning at
conception.

Introduction to Normal Growth and Development

They are two terms refer to continuous dynamic processes occurring from
conception to maturity and follow certain dynamic sequences.
-They are parallel to each other in normal child
-They are consistent, predictable and sequential

Growth
It is an increase of physical size of the whole body or organ of different
parts of the body.
It is an increase of the number and the size of each individual cell
The measuring scales are related to:
weight which is measured by Kg., gm or
Height Which is measured by Cm, Feet.

pound, Ounce.

Normal growth of young children

Regular measurements of child's height, weight and head circumference
and plotting them on a growth chart are a good way to see if the child is
growing normally.
Although many parents are preoccupied by where their child is on the
growth charts and often worry if their child is small or near the bottom of
the growth chart, it is child's rate of growth that is the most important factor
to consider when evaluating if child is growing and developing normally.
If child is following his growth curve, then he is likely growing normally

Growth chart

Keep in mind that some children can normally move up or down on

their growth curves when they are 6-18 months old.
As long as they are not actually losing weight, and they have no
other symptoms, such as persistent diarrhea, vomiting, poor appetite
or having frequent infections, then it may be normal to move down
on your growth percentiles.
Older children should stick to their growth curves fairly closely
though.

General guidelines for younger child growth rates:

The majority of babies born full-term ,
i.e. 40 weeks (280 days), weight from just over 2.6 to 3.8 kilos , and they
are between 48 - 53cm long, head circumference is between 34 40 cm.
Infants born before the completion of 37 weeks of gestation are
called premature.

Weight:

2 weeks
- regains birth weight and then gains about 1 1/2 - 2
pounds a month
3 months - gains about 1 pound a month
5 months - doubles birth weight
1 year
- triples birth weight and then gains about 1/2 pound a
month
2 years
- quadruples birth weight and then gains about 4-5
pounds a year
9-10 years - increased weight gain as puberty approaches, often
about 10 pounds a year

Height:

0-12 months - grows about 10 inches (25 cm).

1-2 years - grows about 5 inches (13 cm).
2-3 years - grows about 2 1/2 inches( 8 cm) a year.
Most children will double their birth height by 3-4 years of age.
3 years to puberty - grows about 2 inches (5cm) a year

Head Circumference:
03 Months - 2 centimeters a month
46 Months - 1 centimeters a month
612 Months - 1/2 centimeter a month
1 2 Years - 2 centimeters a year
Remember
that these are general guidelines though that the child may grow a little
more or a little less than this each year.

Factors Affecting Growth:

Mothers health during pregnancy.

Period of pregnancy.
Multiplication of labor.
Gender.
Nutritional factors.

Health status of the baby.

Development
-

It is a progressive increase in skill and capacity of function.

i.e increase of functional activity, indicates development
of millstones. (The ability to achieve specific function at certain age)

It is measured by specific scales that determines the different

age to achieve certain function.
e.g.:
The Denver Development Screening Test, Test form with 105 items.
Bruininks Oseretesky. Form for eight subtests.Test of Motor Proficiency.

The Denver Development Screening Test (DDST)

It includes 4 areas of development :
1.Personal social : the child ability to get along with people and to take
care of himself .
2. Fine motor adaptive : the child ability to see and use his hands to pick
up objects and to draw .
3. Language : the child ability to hear , to follow directions and to speak .
4. Gross motor : the child ability to sit , walk and jump .

It was performed on children from birth to 6 years .

It has 105 items and the scoring is as follow : P = pass , F = failure ,
R = refusal , N.O. = no opportunity .

Bruininks Oseretesky Test of Motor Proficiency (BOT)

It is designed to assess gross and fine motor functions in children

from 4.5 14.5 years . It included 8 subtests comprised of 46
separate items .
The subtests are running speed & agility , balance , bilateral coordination , strength (gross motor skills) , limb co-ordination
(gross and fine motor skills ) , response speed , visual motor
control , upper limb speed and dexterity ( fine motor skills) .

Development depends on the maturation of the C.N.S.

Mylination of C.N.S. Is complete by the end of the first year of age.
Mylination without skills Retardation
Skills without mylination no function

Patterns of development
1st pattern of development

A cephalocaudal direction or from head to tail. The head of the

fetus initially forms more completely than the body and limbs. Then
the trunk and limbs of the fetus develop. In following this pattern
after birth, the infant develops beginning head control before
learning to control the trunk or limbs functionally. Development
moves downward with the child learning to control the upper trunk
before the lower and using the eyes to engage the environment
before learning the skills to use the hands to grasp and manipulate.

2nd pattern of development.

From the center outward, or proximal to distal.

The fetus develops the spinal cord and trunk , as limb buds are
barely formed. As the fetus develops, the limb buds continue to grow
into fully formed limbs and the peripheral nerves form to provide
sensory data to the central nervous system, the brain.
The infant follows the same patter of proximal to distal development,
with the brain growth fastest in the first few years of life when the
development of more fine control of limbs is still emerging. As the
child grows, the movements of the limbs become more refined and
the child develops specific skills, such as throwing, writing. And
dancing

3rd Pattern of development

From general to the specific,or from simple to more complex.

As the fetus grows, undifferentiated cells migrate to specific location
in the fetus and take on specific roles (brain cells, skin, blood). In the
developing child, this pattern is also strong. The child learns general
skills first; for example, the child will cry to communicate. General
communication strategies are refined to specific language over time.
Limb movements start out as gross patterns that are directed by
reflexes, and mature into skilled movements that are functional for
life and safety such as running, jumping and climbing.

Stages of growth and development

Prenatal Stage:
About 40 weeks (280 days), From conception
to birth . Infants born before the completion of 37
weeks of gestation are called premature infants
Embryonic Stage: The first 8 weeks of gestation
Fetal Stage
: After 8 weeks of gestation to birth
Postnatal Stage:
Neonatal Stage
: From birth to 4 weeks of age
Infant Stage
: 4 weeks through 12 months of age
Toddler
: 13th months through 2 years of age
Early childhood
: From 2 years Through 6 years of age
Middle childhood : From 6 years Through 12 years of age
Adolescence
: From 12 years of age up to 18 years.

Normal newborn baby

Characters of full term baby:
1. Should be delivered at or near term (after 40 weeks of pregnancy)
2. Free from any congenital defects or obstetrical changes.
3. Healthy pink color.
4. His or her heart rate is 100 -140 beats / min.
5. Breaths spontaneously and cries lustily
6. Position in prone lying, with head turned one side and arms, legs are
flexed. (Flexion attitude).
7. On ventral suspension, no head control
(head lag)
8. Has a skeletal muscle tone.
muscle tone in both upper and lower extremities due to unmylination
of the pyramidal tract.
9. The fist of the hands are clenched and the thumb inside the palm

Parameters of development

Biological development is related to enzyme systems that stimulate

complex metabolic changes.
Psychological development refers to cognitive and effective
( emotional)
Social development provides child to live in community.
All the parameters of development affect one another.

Virginia Apgars method of evaluating newborn infant

Virginia Apgars method of evaluating newborn infant is now in standard use
to evaluate the newborn infant one minute after birth. Its useful to make serial
Apgar scores: the longer the score remains low, the worse the prognosis with
regard to mortality or neurological squeal.
score

Heart rate

Respiratory effort

100 - 140

Normal cry

100

No beat
obtained

Irregular and
shallow
Apnoea for more
than 60 sec

Total score:
8 10
37
02

Reflex
irritability

Reflex
irritability
Moderately
depressed
Absent

Good.
fair.
poor condition

Muscle tone

Colour

Good

Pink

Fair

Fair

Flaccid

Cyanotic

Major theories of normal growth and development

The developmental changes that occur from birth to adulthood were largely ignored
throughout much of history. Children were often viewed simply as small versions of adults
and little attention was paid to the many advances in cognitive abilities, language usage, and
physical growth. Interest in the field of child development began early in the 20th-century
and tended to focus on abnormal behavior.
The following are just a few of the many theories of child development that have been
proposed by theorists and researchers. More recent theories outline the developmental
stages of children and identify the typical ages at which these growth milestones occur.
Child developmental theories:
1. Psychoanalytic theories (Sigmund and Erik Erikson)
2. Social developmental theories (Bowlby)
3. Cognitive theories (Jean Piaget)
4. Behavioral theories (Pavlov)

Psychoanalytic Theories
Sigmund Freud:
The theories proposed by Sigmund Freud stressed the importance of childhood events and
experiences, but almost exclusively focus on mental disorders rather than normal
functioning.
According to Freud, child development is described as a series of 'psychosexual stages.' In
"Three Essays on Sexuality" (1915), Freud outlined these stages as oral, anal,, latency
period, and genital. Each stage involves the satisfaction of a specific desire and can later play
a role in adult personality.

Erik Erikson:
Theorist Erik Erikson also proposed a stage theory of development, but his theory
encompassed development throughout the human lifespan.
Erikson believed that each stage of development is focused on overcoming a conflict. Success
or failure in dealing with conflicts can impact overall functioning..

Behavioral Theories
Behavioral theories of development focus on how environmental interaction influences
behavior and are based upon the theories of theorists such as Watson, Pavlov, and Skinner.
These theories deal only with observable behaviors. Development is considered a reaction to
rewards, punishments, stimuli, and reinforcement.

Social Development Theories

There is a great deal of research on the social development of children.
John Bowbly proposed one of the earliest theories of social development. Bowlby believed
that early relationships with caregivers play a major role in child development and continue
to influence social relationships throughout life.

Cognitive theory:
Theorist Jean Piaget suggested that children think differently than adults and proposed a
stage theory of cognitive development. He was the first to note that children play an active
role in gaining knowledge of the world.

Piaget's Theory of Cognitive Development:

Jean Piaget believed that children go through a number of fixed stages on their way to
independent thinking.
His theory on cognitive development, though, is perhaps the most widely accepted and most
cited.

10

Piaget believed that all children will go through the following stages in order, the age ranges
are only a general guideline.
Each child matures in his own time, and even siblings don't do the same things at exactly the
same age.

Sensory Motor Stage:

Birth to 2 Years
An enormous amount of growth and development takes place in the first two years of life.
During that time span, children go from being completely helpless to walking, talking, and
to a degree, being able to make sense of the world around them.
One of the most important milestones that children achieve in their first few years,
according to Piaget, is their mastery of "object permanency," or the ability to understand
that even when a person or object is removed from their line of sight, it still exists.
Early on, children are only able to perceive things that are right in front of them, but as
they mature, they understand that if a ball rolls under a chair and they can no longer see
it, it still exists, under the chair.
This is an especially important understanding for children, helping them to have an
increased sense of safety and security since they can now grasp the fact that when mum
leaves the room, she hasn't disappeared, but will soon return.

Preoperational Stage:
2-7 Years
Once object permanency is achieved, children move onto this next stage, which is marked
by a number of advancements.
Language skills develop rapidly, allowing kids to better express themselves.
Also, children in the preoperational stage are egocentric, meaning that they believe that
everyone sees the world the way that they do, leaving no room for the perspectives of
others.

11

For example, a child will sometimes cover their eyes so that they cannot see someone and
make the assumption that the other person now cannot see them, either.
A major indicator of this stage is called conservation, or the ability to understand that
quantity does not change just because shape changes.
For example, if you were to pour the same quantity of liquid into two separate glasses, one
short and wide and the other tall and thin, younger children would insist that the taller
glass holds more.
Children who have mastered the concept of conservation would be able to understand that
the quantities are identical.
Piaget explained that the child's inability to yet grasp the concept is due to their capacity
to focus on only one aspect of a problem at a time (centration), their tendency to take
things at face value (appearance), and the fact that they see something only in its current
condition (state).
They cannot yet understand that the wider with of the short glass compensates for the
height of the taller one.

Concrete Operations Stage

7 to 11 Years
During the concrete operations stage, the centristic thought process is gradually replaced
by the ability to consider a number of factors simultaneously, giving them the ability to
solve increasingly complex problems.
Also, kids at this stage can now understand how to group like objects, even if they are not
identical.
For example, they are able to see that apples, oranges, cherries, and bananas are all types
of fruit; even they are not exactly the same.
Another important developmental advancement that occurs during this phase is seriation,
the ability to place things in order according to size.
Children who have a mastery of this concept are able to take jars of varying heights and
place them in order, tallest to shortest.
12

They still have some distinct limitations to their thinking process, however, especially when
it comes to applying concepts that they are unfamiliar with.
While their understanding of the things that they have direct access to is strong, kids this
age still have a tendency to lack understanding of things that they haven't personally seen,
touched, heard, tasted, or smelled.

Formal Operations Stage

11 and Beyond
In the final phase of cognitive development, children hold a much broader understanding
of the world around them and are able to think in abstract ways.
They are also able to hypothesizes possible outcomes to a given problem and then think of
ways in which to test their theories. Children in the formal operations stage learn to use
deductive reasoning to draw conclusions, which opens them up to a wider base of
knowledge than ever before.
An example might be as follows:
A bear is a mammal. All mammals have fur. Therefore, a bear has fur.

13

The first trimester

From conception through 12 weeks
The first trimester is a highly sensitive period in the development of the baby.
Harmful substances that are ingested can affect the normal growth and
development of the fetus.
Conception through the 10th week is referred to as the embryonic period.
This is the critical period of time when all of the major organs and structures
are forming.

From conception through 12 weeks

1) At 5th week:
The embryo is :
About one-half inch long
Weighs less than an ounce.
Its brain, heart, lungs, eyes, ears, arms, and legs are forming.
2) At 8th week:
The fingers are distinct
The beginnings of all essential external and internal structures are
present.
3) At 10th week:
the embryo is known as a fetus.
The face has a human profile and all of the major organs have formed.
It is now about 4 inches long and weighs about one ounce.
The heartbeat can now be heard with a Doppler stethoscope and can
also be easily seen on ultrasound examination.
The kidneys have begun to secrete urine, which partly makes up the
amniotic fluid
around the baby.
Teeth buds are present in the gums.

14

The Second trimester

From 13 weeks through 28 weeks.
The second trimester
is a period of rapid growth for the fetus.
Sexual differentiation is beginning to show.
By the 16th week:
it is about 6 inches long
weighs about 5 ounces.
It moves about, swallows amniotic fluid,
and has periods of sleep and wakefulness.

The third trimester

From 29 weeks until delivery
.
The final trimester marks the period of final growth.
During the last month of pregnancy: the baby can gain as much as half a
pound a week.
The average baby will weigh about 7 pounds,
The range at full term from 5 pounds up to over 9 pounds!
Fetal movement during this period of time is a good indicator of fetal well
being.

15

Stages of Motor Development In Infants and Young Children

Month One:
Gross Motor Skills

Fine Motor Skills

Can lift chin slihtly

Head lag in ventral suspension
Flexion attitude in prone
lying position

Hands fisted/reflexive grasp

Month Two
Gross Motor Skills

Fine Motor Skills

Wobbly head while sitting

Head Lag
Head lag when pull to sit

Swipes toys with hands

16

Three Month
Gross Motor Skill
Fine Motor Skill
Holds head steady in sitting
Hands open
Rolls back to side
Grasps/holds an object
Puts weight on arms while on tummy. Hands play at midline

Month Four
Gross Motor Skills
Fine Motor Skills
Sits on propped arms
Reaches with both arms/hands Rolls tummy to side
Brings fingers/hands in mo
No head lag seen when pulled
Squeeze grasp emerging
to sit

17

Month Five
Gross Motor Skills
Rolls tummy to back
Wiggles few feet forward
Pushes up with arms
while on belly
Sits propped on hands

Fine Motor Skills

Reaches with good aim
Puts objects/toys in mouth
Picks up spoon or cup by handle
Starts grabbing feet

Month Six
Gross Motor Skills
Sits briefly independently
Sits in a highchair
Rolls over both ways

Fine Motor Skills

Reaches precisely and grasps objects
Transfers toys from hand to hand
Bangs a cup on a table.

18

Month Seven
Gross Motor Skills
Sits unsupported~30 seconds
Rocks on all fours
Pivots in a circle while on tummy

Fine Motor Skills

Crosses midline when reaching
Uses whole hand to rake in objects
Thumb to finger grasp emerging

Month Eight
Gross Motor Skills
Transitions tummy to sit
Crawls forward
Reaches while on tummy

Fine Motor Skills

Bangs cubes together
Uses a three-fingered grasp

19

Month Nine
Gross Motor Skills
Transitions sit to tummy
Pulls to stand while holding on
Creeps on all fours
Stands while leaning on furniture

Fine Motor Skills

Uses thumb to index grasp (crude)
Crude release of objects
Drops toys and objects
Points index finger

Month Ten
Gross Motor Skills
Cruises along furniture
Stands unsupported briefly
Transfers from crawl to sit

Fine Motor Skills

Pokes with fingers
Uses thumb to index finger
grasp (precise)
Stacks objects

20

Month Eleven
Gross Motor Skills
Stands unsupported
Walks with hands held

Fine Motor Skills

Releases a cube at will
Removes pegs from a pegboard

Month Twelve
Gross Motor Skills
First independent steps
Stands unsupported~12 seconds
Assumes/maintains kneeling

Fine Motor Skills

Puts objects in a container
Releases an object precisely
Stacks two one-inch cubes

21

Months Twelve-Fifteen
Gross Motor Skills
Walks independently
Creeps/climbs stairs
Tries to climb out of highchair
Squats to play
Kneels
Stoops and recovers

Fine Motor Skills

Throws objects
Places rings on a peg
Makes marks with crayon
Holds large crayon in fisted grasp
Pulls large pop beads apart
Builds a 2 block tower

Months Fifteen-Eighteen
Gross Motor Skills
Walks in circles/backwards
Walks up stairs with help
Balance reactions in standing
Scribbles spontaneously
Tries to kick balls
Climbs on furniture
Pulls toy while walking

Fine Motor Skills

Directional scribble using crayons
Throws a ball
Builds a 3-block tower
Midlinhuse(1stabilizes/1manipulates)

22

Months Eighteen-Twenty-Four
Gross Motor Skills
Runs
Jumps in place/off a step
Pedals a tricycle
Kicks a stationary ball
Walks up stairs independently
Throws a ball overhand
toys forward

Fine Motor Skills

Unwraps things
Strings large, one-inch beads
Builds a 6-block tower
Holds crayon with thumb and
fingers
Turns 2-3 pages at a time
Imitates vertical stroke Propels ride-on

Months Twenty-Four-Thirty-Six(2-3 years old)

Gross Motor Skills
Hops on one foot
Walks up stairs alternating feet
Walks down stairs alternating feet
Walks backward
Balances on one foot briefly
Throws overhand at a target
Catches a rolled ball
Throws a small ball 2 feet
Rides a tricycle using pedals

Fine Motor Skills

Turns pages one at a time
Builds a 9 block tower
Strings small inch beads
Unscrews lid of a jar
Imitates horizontal line,
cross circle
Holds pencil in hand
instead of fist
Makes snips with scissors
Unbuttons
Places pegs in a pegboard

23

Gait development
The prerequisite for Gait development:

C.N.S. maturation.

Adequate motor control.

Adequate R.O.M.

Muscle strength.

Appropriate bone structure.

Intact sensation.

The development of a motor pattern in walking depends on a combination of neurological,

mechanical, cognitive, and perceptual factors.

Neurological factors
The basic neural organization and function used to excite locomotion is controlled
by a central pattern generator located either in the spinal cord or brain stem.
Descending neural input activates the central pattern generator, while descending
and peripheral input modify the output to adapt the execution of locomotion.
The central pattern generator organizes the activation and firing sequence of
muscles During Gait.

Mechanical factors

Rang of motion,

muscle strength,

bony structure of the lower limbs

affect the early pattern of walking.

24

NORMAL GAIT ANALYSIS

STANCE PHASE

SWING PHASE

heel strike
foot flat
mid stance
push off

initial swing
mid swing
terminal swing

Phases of gait
The stance phase of gait can be broken down into 5 sections
Heel Contact: Begins when the heel of the subject leg comes in
contact with the ground
Foot Flat:

Heel contact continues as the foot becomes flat

Mid-Stance: The subject leg then begins to move forward

Heel Off:

The heel begins to lift off of the ground

Toe Off:

The toe finally lifts off the ground

The swing phase of the gait can be broken down into 3 sections:
Toe Off:

Begins when the toe of the subject leg is lifted off

the ground

Mid-Swing:

Continues as the subject leg swings forward

Heel Contact: The heel of the subject leg makes contact with
the ground.

25

Determinants of walking
Step length:
The longitudinal distance between the two feet, it increases through out
childhood until growth is completed.
This parameter is closely related to change in height and leg length

Cadence:
The frequency of steps taken in a given amount of time (Steps / min), it gradually
decreases with age through out childhood. The most reduction between 1-2
years.

The duration of single limb in stance.

It is the length of time during which only one foot is on the ground during
the stance phase, if it increases, it implies a measure of increasing stability.

Walking velocity:
It is the rate of walking; it can be expressed as the product of step length
and cadence. It increases with age 1 to 7 years, but the rate of change
decreases from 4 to7.

The normal walking has five major attributes:

Stability in stance.

Sufficient foot clearance in swing.

Appropriate preposition of the foot for contact.

Adequate step length.

Energy conservation.

26

Gait development
From birth to 9 months:

Body fat of the infant rises from 12% to 25% of the body mass which causes
infant to be relatively weak, with increasing age and mobility , fat content
drops and muscle mass increases.

At this age the infant's gait is characterized by, supported walking, wide
abduction, external rotation, flexion hips and knees 35o, bow legs and an
everted heel position.

The postural control and development of the antigravity muscle strength are
important to develop independent ambulation.

Antigravity strength of hip flexors is built by kicking from supine position,

while hip extensor strength begins from activities in prone position.

The hip and knee extensors are built during rising from kneeling to standing
position.

By 8 months of age, the visual, proprioceptive and vestibular systems work

together to bring the central mass of the body (COG) back to a stable
position.

At age 12 months

The infant's center of body mass (COG) is closer to the head and upper
trunk, at the lower thoracic level, the ratio of body fat to muscle mass is still
high, The base of support is wide for both structural and stability reasons,
Medio-lateral stability is achieved, but antro-posterior stability is limited.

The ambulation characterized by wide base, increased hip and knee

flexion, full foot contact, initial contact in planter flexion, short stride length,
increased cadence and a relative foot drop in swing phase.
-Less

than

50%

of

children

demonstrate

heel

strike

commencement of walking. Instead, the child lands with a flat foot.

27

on

-their cadence (steps per minute) is very high, with a slow walking
speed and shortened step length, which is directly related to leg
length and age.
-95% of children can squat to play on the floor without support. The
ability to perform this task is present from the onset of walking.

At age of 18 months

Because of decreased abduction and improved stability, the base of

support is decreased, heel position remain everted, knee flexion begains to
emerge during initial stance phase as a heel strike develops, the duration of
stance phase remains prolonged and cadence is increased., the limb is straight
and the range of hip abduction is no longer excessive.
- heel strike is present in the majority of children. In this age group,
the arms are outstretched for balance.
- 80% of children can run . The difference between walking and
running is the presence of a period of "non-support", when neither
foot is in contact with the ground. However, at this age the running
---child has little control over walking speed or change in direction
and falls are frequent. By two years, 97% of children are able to run.

From 2-3 years

- The center of body mass is closer to lower limbs, base of Support is
narrower, hips and knees extension develop, heel eversion in weight bearing
can still observed but decreasing, heel strike is present with knee flexion
during early stance phase.
- 90% of children can 'walk on their tip-toes' .
However, walking on heels' is a more difficult task. Only 60% are able
to perform this activity by 2 years.

28

- 50% of children can hop for a distance of three metres. This

increases to 92% by five years.

From age 6-7 years

The gait patterns are fully mature, but time and distance variables continue
to vary with age and stature. The heel position is neutral by age 7 years, the
center of body mass is still higher than in the adult, at the level of 3rd lumber
vertebra.
By six to seven years the majority of children can hop on one leg or both .

29

Normal Hearing Development

Prenatal stimulation:
The human fetus possesses rudimentary hearing from 20 weeks of
gestation. This hearing will develop and mature during the remainder
of gestation. The fetus is able to hear sounds outside the mothers
body, although it is able to hear low-frequency sounds much better
than high-frequency sound.
Babies begin to hear in the last few months of pregnancy.
Thus, when an infant emerges into the world, they are well equipped
for hearing system, although some evidence exists that an infant's
sensory threshold is higher than that of an adult (i.e. a stimulus must
be louder to be heard by a newborn).
However, if a newborn child does not display the following , it may be a
sign of a hearing problem:
1.

Does not startle, move, cry or react in any way to unexpected loud noises.

2.

Does not awaken to loud noises.

3.

Does not turn his/her head in the direction of a parent's voice.

4.

Does not freely imitate sound.

Hearing at the first two important years:

The first two year is the time during which hearing develops in children. It is
important for parents to be able to recognize signs of a hearing problem as
early as possible and seek medical attention if there are any concerns.
Here is a guide of signs of normal hearing development by age through the
first 2 years of life:
30

From 1 to 3 Month:
During this period , babies love to hear their parents voices.
Babies seem to respond best to the female voice, the
one associated with comfort and food.
Besides voices, infants enjoy listening to music and
are fascinated by the routine sounds of life as well.

From 4-7 Month

A baby's hearing is crucial to speech development. During this period ,
most babies begin to understand the fundamentals of communication
through hearing and language. When younger, a baby understands
meaning through the tone of voice, but now the infant is beginning to
pick out the components of speech. Most infants at this age can hear and
understand the different sounds a parent makes and the way words form
sentences.
Normal Hearing development from 4 to 7 months will be as follow:
By 4 months of age a baby should:
Move or react when someone speaks or in response to any noise
Startle when there is a very loud noise
Startle to sudden or loud sounds. Begin to localize sounds with eyes or
head movements.

31

By 6 months:
Interest in different sounds. Experiment with making own sounds.
Seemingly recognise familiar voices.
By seven months a baby should:
Turn his/her head towards a voice or a noise(when a parent calls even
without being seen)
Stir or move in response to a noise or voice

Startle when there is a large sound.

By 9 months a baby should:

Turn his/her head to find out where a sound is coming from
Turn around if a parent is calling from behind
Stir or move in response to voice or any sound
Startle when there is a very loud noise.
9-12 months:
Babble. Begin to understand simple words such as "mommy" and
"bye-bye". Begin to follow simple instructions.
At 12 months a baby should:
Turn his/her head in all directions and show an interest in a person's
voice or a particular sound.
Repeat sounds that parents make.
Startle in response to a loud noise.
At 12-18 months:
Words begin to form from the babble. Can use around 20 words and
understand around 50 words.

32

At 2 years:
Can usually speak in simple sentences using a vocabulary of around
200-300 words. Enjoy being read to and can identify and name many
things in picture books.
At 3-4 years:
Use words and sentences to express needs, questions and feelings.
Vocabulary, pronunciation and understanding improve markedly
during these years.

33

Early speech and language milestones:

Newborns can localize a sound to their right or left side shortly after being
born and will turn their head or look in the direction of a sound. This works
best with loud noises when your baby is awake and alert, but they should
also be able to hear soft sounds. They can also begin to smile
spontaneously and in response to someone by 1 month. Infants learn to
recognize their parents by 1-2 1/2 months.
Infants can imitate speech sounds by 3-6 months.
Monosyllabic babbling, or making isolated sounds with vowels and
consonants (ba, da, ga, goo, etc) usually begins by 4-8 months.
Polysyllabic babbling, or repeating vowels and consonants (babababa,
lalalalala, etc) usually begins by 5-9 months.
Comprehending individual words (mommy, daddy, no) usually occurs by
6-10 months.
By 5-10 months, most infants can say mama/dada nonspecifically, using
the words as more than just a label for his parents.
Many infants can follow a one step command with a gesture (for
example, asking for an object and holding your hand out) by 6-9 months.
He should be able to follow a one step command without a gesture by 7-11
months.
The correct use of mama/dada as a label for a parent usually occurs by 712 months.
The first word (other than mama/dada) is usually spoken by 9-14 months.
By 10-15 months, he should be able to point to an object that he wants.
Your child will be able to say 4-6 words (other than mama/dada and names
of family members or pets) by 11-20 months.
He should be able to follow a two step command without a gesture by
14-21 months.
Two word combinations or sentences are used by 18-22 months and can
include phrases like 'Want milk', 'More juice', etc.
A vocabulary spurt leading to a 50+ word vocabulary occurs by 16-24
months.

Parents are usually the first ones to think that there is a problem with their child's
motor, social, and/or speech and language development, and this parental concern
should be enough to initiate furthur evaluation. In addition to a formal hearing test
(for children with speech delays), neurological exam (which will look at your
child's muscle tone, strenght, reflexes, coordination, etc), and developmental
assessment by their Pediatrician, children with developmental delays should be
referred to an early childhood intervention program (for children under 3), so
that an evaluation can be initiated and a treatment plan developed, including

34

physical therapy, occupational therapy and possible speech therapy. He may also
need a referal to a Pediatric Neurologist and/or a Developmental Pediatrician for
furthur evaluation and treatment.
In addition to the screening tests described above, your Pediatrician may be able to
calculate your child's motor quotient (MQ), which is his motor age (his age as
calculated by what milestones he has met) divided by his chronological age and
multiplied by 100. A motor quotient above 70 is considered normal, and between
50-70 is suspicious and requires furthur evaluation, although it is probably normal,
and below 50 is considered abnormal. For example, if your child is 12 months old
and has just begun to pull to a stand (motor age of 9 months, the age when most
children are pulling to a stand), his MQ would be (9/12)*100 or 75, which is
probably normal. On the other hand, if he has just begun to roll over (motor age of
5 months), then his MQ is (5/12)*100 or 42 and this is probably abnormal.

Normal Hearing Development in Children

Hearing: The first two important years
The first two year is the time during which
hearing develops in children. It is important
for parents to be able to recognize signs of a
hearing problem as early as possible and seek
medical attention if there are any concerns.
Here is a guide of signs of normal hearing
development by age through the first 2 years
of life:
By 4 months of age a baby should:
Move or react when someone speaks or in response to any
noise
Startle when there is a very loud noise
By seven months a baby should:
Turn his/her head towards a voice or a noise(when a parent
calls even without being seen)

35

 Stir or move in response to a noise or voice

Startle when there is a large sound
By 9 months a baby should:

Turn his/her head to find out where a sound is coming from

Turn around if a parent is calling from behind
Stir or move in response to voice or any sound
Startle when there is a very loud noise

At 12 months a baby should:

Turn his/her head in all directions and show an interest in a
person's voice or a particular sound
Repeat sounds that parents make
Startle in response to a loud noise
At 2 years of age a child should:
Be able to point out a part of his body when asked without
seeing that person's lips move
Be able to point to the right picture when asked(for
example: Where is the cat? Where is the bird?)
Be able to do simple tasks like give you one of his/her toys
when asked, without seeing that person's lips move.
:

36

VISUAL DEVELOPMENT

In the early months of life,

the visual system is still maturing; it is not fully developed at birth (and is even
less developed in the premature infant).
From birth to maturity,
The eye increases to three times its size at birth, and most of this growth is
complete by age 3
one third of the eye's growth in diameter is in the first year of life.

37

Some knowledge of normal visual development is necessary if abnormalities are

to be noted.
A premature infant:
The eyelids are not have fully separated;
The iris is not constrict or dilate; the aqueous drainage system may not be fully
functional.
The choroid lacks pigment.
Retinal blood vessels are immature.
Optic nerve fibers may not be myelinized;
There is still a pupillary membrane and/or a hyaloid system.
Lack of ability to control light entering the eye; visual system is not ready to
function.

At birth
The irises of infants may have a gray or bluish appearance; natural color
develops as pigment forms.
The eyes' pupils are not able to dilate fully yet.
The curvature of the lens is nearly spherical.
The retina (especially the macula) is not fully developed.
The infant is moderately farsighted and has some degree of astigmatism.
Functional implications: The newborn has poor fixation ability, a very limited
ability to discriminate color, limited visual fields, and an estimated visual
acuity of somewhere between 20/200 and 20/400.
:
By 1 month:
The infant can follow a slowly moving black and white target intermittently to
midline; he/she will blink at a light flash, may also intermittently follow faces
(usually with the eyes and head both moving together).
Acuity is still poor (in the 20/200 to 20/400 range), and ocular movements may
often be uncoordinated.
There is a preference for black and white designs.
By 2 months:

38

Brief fixation occurs sporadically, although ocular movements are still

uncoordinated there may be attention to objects up to 6' away.
The infant follows vertical movements better than horizontal , and is beginning
to be aware of colors (primarily red and yellow).
There is probably still a preference for black and white designs.
By 3 months:
Ocular movements are coordinated most of the time; attraction is to both black
and white and colored (yellow and red) targets.
The infant is capable of glancing at smaller targets (as small as 1"), and is
interested in faces; visual attention and visual searching begins.
The infant begins to associate visual stimuli and an event (e.g., the bottle and
feeding).
By 4 months:
"Hand regard" occurs; there is marked interest in the infant's own hands.
He/she is beginning to shift gaze, and reacts (usually smiles) to familiar faces.
He/she is able to follow a visual target the size of a finger puppet past midline,
and can track horizontally, vertically, and in a circle. Visual acuity may be in
the 20/200 to 20/300 range
By 5 months:
The infant is able to look at (visually examine) an object in his/her own hands;
ocular movement although still uncoordinated at times, is smoother.
The infant is visually aware of the environment ("explores" visually), and can
shift gaze from near to far easily; he/she can "study" objects visually at near
point, and can converge the eyes to do so; can fixate at 3.
Eye-hand coordination (reach) is usually achieved by now.
By 6 months:
Acuity is 20/200 or better, but eye movements are coordinated and smooth;
vision can be used efficiently at both near point and distance.
The child recognizes and differentiates faces , and can reach for and grasp a
visual target.
39

Hand movements are monitored visually; has visually directed reach." May be
interested in watching falling objects, and usually fixates on where the object
disappears.
Between 6 and 9 months:
Acuity improves rapidly (to near normal);
"explores" visually (examines objects in hands visually, and watches what is
going on around him/her).
Can transfer objects from hand to hand, and may be interested in geometric
patterns.

Between 9 months and a year:

The child can visually spot a small (2-3mm) object nearby;
Watches faces and tries to imitate expressions;
Searches for hidden objects after observing the "hiding;
Visually alert to new people, objects, surroundings;
Can differentiate between known and unfamiliar people; vision motivates and
monitors movement towards a desired object.
By 1 year:

Both near and distant acuities are good (in the 20/50 range); there may be
some mild farsightedness, but there is ability to focus, accommodate (shift
between far and near vision tasks), and the child has depth perception;

He/She can discriminate between simple geometric forms (circle, triangle,

square), scribbles with a crayon, and is visually interested in pictures.

Vision lures the child into the environment. Can track across a 180 degree
arc.

By 2 years:
40

Myelinization of the optic nerve is completed. There is vertical (upright)

orientation; all optical skills are smooth and well coordinated.

Acuity is 20/20 to 20/30 (normal).

The child can imitate movements, can match same objects by single
properties (color, shape), and can point to specific pictures in a book.

By 3 years:

Retinal tissue is mature.

The child can complete a simple form board correctly (based on visual
memory),

Can do simple puzzles, can draw a crude circle, and can put 1" things into
holes.

Social and Emotional Development

Social and emotional development means:
The development of emotional communication.
Understanding of self, ability to manage one's feelings .
Understanding and knowledge of other people.
Relationships, interpersonal skills and moral behavior.
Emotional Development Importance:
Emotions are central in all aspects of human activity.
They are vital to cognitive development because emotional reactions lead to
learning that is essential for survival.
It is also vital to social behavior because babies' emotional reactions like
crying, laughing and smiling affect others' interests in powerful ways.
Similarly the emotional reactions of others regulate children's social
behavior.
Much research indicates that emotions influence children's physical wellbeing.
Constant psychological stress in children is associated with various health
difficulties.
41

 Emotions are also important in the emergence of self-awareness.

Infants can not describe their feelings as adults do . So, they use emotions to
communicate.
In addition to facial expressions, some body movements also provide
information .
International studies have suggested that infants from various cultures show
almost the same facial expressions.
In the initial 2 years of life, babies and toddlers show basic emotions like
happiness, sadness, anger and fear.
Basic emotions are so universal that even non-human primates display them.

Beside basic emotions, human beings are capable of another set of emotions
called the self-conscious emotions.
As the name implies, these emotions include shame, pride, embarrassment,
guilt and envy.
Birth - 6 months:

Show signs of almost all basic emotions.

Smiles socially and laughs.
Express happiness more when interacting with familiar people.
Matches adults' emotional expressions while communicating face-to-face
Develops awareness of self as a knower and actor; like understanding that
self is separate from rest of the world.

42

7 12 months

Anger and fear increase, especially the case of anxiety.

They feel secure with caregiver and builds strong caregiver relationship.
Babies can detect the meaning of others emotional signals .
They feel much attached to familiar caregivers.

13 - 18 months
Can play with familiar adults and children.
Develops awareness of self as an object of knowledge and evaluation, like
understanding the psychological and social characteristics of self.
Understands that others' emotional reactions may differ from one's own.
Can start feeling empathy.

19 - 24 months

Display self conscious emotions but the intensity depends on monitoring

and encouragement of adults.
Adds more words in the vocabulary for talking about feelings.
Learns to tolerate absence of familiar caregiver.
Can use words to describe peer's behaviors.
Learns to use own name or personal pronouns to describe self.
Can sort others into categories based on age, sex, and other characteristics.

Starts to develop self control.

2 - 3 Years

43

Begins to develop self concept and self esteem.

Understands causes, effects and behavioral signs of basic emotions.
Learns to cooperate.
Empathy increases.

3 - 4 Years
Improves emotional self-regulation.
Decreases non-social activities and plays interactively more.
Forms first friendship.
Begins to prefer same-sex playmates.
Improves ability to interpret, predict and influence others' emotional
reactions.
Expresses empathy more by language.
Solves social problems better.
Knows many morally relevant rules and behaviors.

5 6 Years
Improves ability to interpret, predict and influence others' emotional
reactions.
Expresses empathy more by language.
Solves social problems better.
Knows many morally relevant rules and behaviors.

44

Denver II Developmental Screening Test Handout

DENVER II DEVELOPMENTAL SCREENING TEST
Handout Written by: Dr. Frances Murphy
The Denver II Developmental Screening Test is designed to be used with
apparently well children between birth and 6 years.
Objectives:
Study test and administration of test
Calculate and record age line
Identify portion of test which to begin
Identify pass/fail criteria
Rate childs behavior during test
Identify scores
Interpret test results
Not an IQ test 126 tasks/items:
1. Personal-Social: getting along with people and caring for personal needs
2. Fine Motor-Adaptive: eye-hand coordination, manipulation of small objects and
problem-solving
3. Language: hearing, understanding, and using language
4. Gross Motor: sitting, walking, jumping, and overall large muscle movement
Applications:
Provides an organized, clinical impression of a childs overall development
Alerts regarding the potential for developmental difficulties

45

 Provides comparisons with other children

Not recommended as a predictor of later development
Draw age line from top to bottom of page
Date of test ___ month ___ day ______ year
(Remember if you have
Date of birth ____ month ___ day ______ year
borrow, 30 days = month;
Difference
_________________________________
months = year)
equals exact age
____ months___ days______ years
In

to
12

each sector, administer

3 items nearest to and left of age line
all items on (intersecting) the age line
continue until 3 fails occur

Three trials are allowed to perform each item

After test, record Test Behavior Rating
Item Scoring:
P for PASS, the child successfully performs or the caregiver reports (as appropriate)
F for FAIL, the child does not successfully perform an item or the caregiver reports
so
N.O. for NO OPPORTUNITY (this is used on report items only)
R for REFUSAL, the child refuses to attempt item (cannot be used on report
items)

Interpretation:
Advanced
Normal
Caution
Delayed
No
Opportunity

Be Familiar with the Criteria

Instruct the child with the
words
from the manual
Observe the standards
indicated for P/F
Remember that 3 trials may
be given

46

Determine Results:
Normal: no delays and
maximum of 1 caution
Suspect: 2 or more cautions
and 1 or more delays

Developmental Delays
Parents are often have concerns about their children's development, especially when they
see other children of the same age who have already attained a milestone that their child
still hasn't met, causing them to think that their child is 'slow' or 'seems behind.' It is
important to keep in mind that for each milestone, there is a range of ages during which a
child will normally meet it. For example, some children may walk as early as 11 months,
while others may not walk until they are 15 months old, and it is still concerned normal.
Developmental milestones are determined by the average age at which children attain
each skill, therefore, statistically, about 3% of children will not meet them on time, but
only about 15-20% of these children will actually have abnormal development. The rest
will eventually develop normally over time, although a little later than expected.
Be sure to bring up any concerns that you have about your child's development with your
Pediatrician, especially if he seems to be losing milestones, or not doing things that he
was able to previously do.
A developmental delay occurs when your child has the delayed achievement of one or
more of his milestones. This may affect your child's speech and language, his fine and
gross motor skills, and/or his personal and social skills.

47

Your Pediatrician should screen for delays at your child's well child visits. This may
consist of simple questions to see what your child is able to do at different ages, or it may
include a formal screening test, such as the Denver II Developmental Screening Test. The
Denver test can look for delays in your child's social and personal skills, fine and gross
motor skills and language.
Developmental delays, especially if they involve a language delay which may be
secondary to a hearing loss, should be identified as early as possible.
A child with a global delay will have delays in all areas of development. It is usually
caused by a static (does not worsen with time) encephalopathy caused by a disorder
before or near the time or birth. Causes of global delays include prematurity, cerebral
malformations, chromosomal disorders, infections, and progressive (may worsen with
time) encephalopathies (metabolic diseases, hypothyroidism, neurocutaneous syndromes
(neurofibromatosis, tuberous sclerosis), Rett syndrome, and hydrocephalus). Testing to
look for the cause of a global developmental delay may include a head MRI.
Some signs that your infant may not be meeting his normal motor milestones include not
being able to bring his hands together by 4 months, not rolling over by 6 months,
having head lag when pulled to a sitting position after 6 months, not sitting by himself
without support by 8 months, not crawling by 12 months, and not walking by 15
months. Remember that mild delays in motor development can be normal, and there is a
range during which these milestones are usually met, so your child may not meet each
one at the same time as other children. Delayed motor
development, with normal language skills, can be caused by a neuromuscular disorder or
mild cerebral palsy.
A delay in fine motor skills in older children may be manifested by not being able to use
a spoon or fork, tie his shoes, button his clothes, write his name, draw shapes, color
inside the lines, or hold a pencil correctly at the age appropriate time, or by having poor
handwriting. A delay in gross motor skills in older children may include not being able
to ride a tricycle or bicycle, being clumsy, or not walking correctly.
The early speech and language milestones which are listed below include the upper
limit of when 75% of infants meet this milestone, so your child may still be developing
normally if he has not mastered a milestone by the age indicated. These milestones
should be used as a general guideline to help identify infants that are at risk for having
speech and language problems so that their development can be watched closely. Among
the screening tests available that your Pediatrician may perform are the Early Language
Milestone (ELM) Scale-2 and the Clinical Linguistic and Auditory Milestone Scale
(CLAMS). Delayed speech and language development can be caused by a
developmental language disorders (DLD), hearing loss, mental retardation and autism.
Early speech and language milestones:

48

Newborns can localize a sound to their right or left side shortly after being born
and will turn their head or look in the direction of a sound. This works best with
loud noises when your baby is awake and alert, but they should also be able to
hear soft sounds. They can also begin to smile spontaneously and in response to
someone by 1 month. Infants learn to recognize their parents by 1-2 1/2 months.
Infants can imitate speech sounds by 3-6 months.
Monosyllabic babbling, or making isolated sounds with vowels and consonants
(ba, da, ga, goo, etc) usually begins by 4-8 months.
Polysyllabic babbling, or repeating vowels and consonants (babababa, lalalalala,
etc) usually begins by 5-9 months.
Comprehending individual words (mommy, daddy, no) usually occurs by 6-10
months.
By 5-10 months, most infants can say mama/dada nonspecifically, using the
words as more than just a label for his parents.
Many infants can follow a one step command with a gesture (for example,
asking for an object and holding your hand out) by 6-9 months. He should be able
to follow a one step command without a gesture by 7-11 months.
The correct use of mama/dada as a label for a parent usually occurs by 7-12
months.
The first word (other than mama/dada) is usually spoken by 9-14 months.
By 10-15 months, he should be able to point to an object that he wants.
Your child will be able to say 4-6 words (other than mama/dada and names of
family members or pets) by 11-20 months.
He should be able to follow a two step command without a gesture by 14-21
months.
Two word combinations or sentences are used by 18-22 months and can include
phrases like 'Want milk', 'More juice', etc.
A vocabulary spurt leading to a 50+ word vocabulary occurs by 16-24 months.

Parents are usually the first ones to think that there is a problem with their child's motor,
social, and/or speech and language development, and this parental concern should be
enough to initiate furthur evaluation. In addition to a formal hearing test (for children
with speech delays), neurological exam (which will look at your child's muscle tone,
strenght, reflexes, coordination, etc), and developmental assessment by their Pediatrician,
children with developmental delays should be referred to an early childhood
intervention program (for children under 3), so that an evaluation can be initiated and a
treatment plan developed, including physical therapy, occupational therapy and possible
speech therapy. He may also need a referal to a Pediatric Neurologist and/or a
Developmental Pediatrician for furthur evaluation and treatment.
In addition to the screening tests described above, your Pediatrician may be able to
calculate your child's motor quotient (MQ), which is his motor age (his age as
calculated by what milestones he has met) divided by his chronological age and
multiplied by 100. A motor quotient above 70 is considered normal, and between 50-70 is
suspicious and requires furthur evaluation, although it is probably normal, and below 50
is considered abnormal. For example, if your child is 12 months old and has just begun to

49

pull to a stand (motor age of 9 months, the age when most children are pulling to a stand),
his MQ would be (9/12)*100 or 75, which is probably normal. On the other hand, if he
has just begun to roll over (motor age of 5 months), then his MQ is (5/12)*100 or 42 and
this is probably abnormal.

THE COMMON FACILITATORY AND INHIBITORY

TREATMENT TECHNIQUES
It is of great challenge for physical therapist to select methods most efficient for each
patient's needs. Appropriate selection of the treatment methods depends upon the
understanding of many aspects, such as:
1)
2)

The neuro-physiological bases of each method.

The biomechanical influencing of the treated body
part(s), segment(s), or body as a whole on the applied method, and the
mechanical effect of the intervention on the treated part.
3)
The nature of pathology and symptoms affecting the
patient's activity.
4)
The individual characters of each patient.
To initiate a movement response we should try to increase the neuronal activity
(it refers as facilitation) or to decrease the capacity to initiate a movement response
we should try to decrease the neuronal activity (it refers as inhibition)
The sensory stimulation technique can be used separately or grouped according to the
receptors activated, the nature of stimulation (intensity, duration and frequency) need
to be adjusted and readjusted to meet the individual needs of the patient.

50

The techniques commonly used are classified according to the type of sensory receptors
activated.
The common facilitatory techniques are:
1) Proprioceptive stimulation techniques.
2) Extroceptive stimulation techniques.
3) Vestibular stimulation techniques.
4) Special senses ( vision, hearing, smell and taste ) stimulation techniques.
5) Multi-sensory stimulation techniques.
6) Autonomic nervous system stimulation techniques.

Proprioceptive stimulation techniques:

a) Stretch: May be applied in three ways; quick, prolonged, and maintained
stretch.
Application of this technique may include tapping which is commonly
used in three forms; on tendon, on muscle belly and with the use of gravity.
It is used in preceding passive movement.
The quick stretch produce a relatively short lived contraction of the agonist
muscle and short lived inhibition of the antagonist muscle.
Prolonged and firm stretch produces inhibition of muscle responses which
may help in reducing hypertonus, e.g. Bobath's neuro-developmental
technique, inhibitory splinting and casting technique.
The maintained stretch, resistance can be applied manually or
mechanically or by using of gravity and body weight. Resistance facilitates
muscle contraction which is directly proportional to the amount of
resistance applied. Improving kinesthetic awareness and increasing strength
are another two benefits gained from resistance.
b) Vibration:May be applied in two ways; high and low frequency.

51

 The high frequency vibration is driven from vibratorthat optimally operates

at a frequency of 100 200 Hz and at amplitude of 1 2 mA. This type of
vibration produce facilitation of muscle contraction through what is known
as tonic vibration reflex. This facilitatory effect sustained for a brief time
after application. Therefore it can be used for stimulating muscles whose
primary function is one of tonic holding.
The low frequency stimulation 5 -50 Hz has an inhibitory effect on muscle
through its activation of spindle secondary endings and golgi tendon organs.
C) Approximation or compression of the joint surfaces:
facilitates posture extensors which are needed to stabilize the body.
Approximation can be applied slowly to inhibit muscle control or in jerky
manner to facilitate muscle control.
The application may be manually and/or by using weight bearing postures.
Joint awareness may be improved by approximation which will lead to
enhancing motor control.
d) A firm and moderate inhibitory pressure on tendons:
may result in inhibition of muscle control.
It can be applied manually and/or through devices such as splints.
Positioning may be used to achieve an inhibitory pressure, e.g. quadruped
position to inhibit the quadriceps muscle and the long finger flexors of the
hand.

Exteroceptive stimulation technique

a) Touch:
Is one of the simple ways of facilitation of muscle activity by eliciting the
phasic, protective withdrawal reflexes.
This reaction maintained for several seconds after discharge.
The location of the stimulus and its intensity play the important role in the
magnitude of reaction.
Application of the touch m can be manually using brief, light stroke, brief swipe
ice cube, noxious stimulus and/or light pinching.
b) Brushing:
As a therapeutic technique presented originally by Margeret Rood to
facilitate movement responses.
Application can be manually or by using battery-operated brush.
Skin overlying muscle can facilitate it and enhances static holding postural
extensors and will have immediate and long latency responses.
c) Icing for a long period:

52

(more than 20 min0 can inhibit muscle activity, postural tone (locally).
Application of the prolonged ice can be used clinically by four types; ice chips,
ice wraps, ice pack and immersion in cold water.

d) Neutral warmth:

It is one of the most common way to inhibit postural tone and muscle
activity.
It acts through stimulating the thermo receptors and activating of
parasympathetic responses.
Usually 10-20 minutes are sufficient period to produce effect.
The application may be by wrapping body part with towels, hot packs, tepid
baths and air splints.

e) Maintained touch:

It can be used to produce a general calming effect and generalized inhibition.

Firm manual contacts (pressure0 to midline abdomen, back are the common
used techniques.

f) Slow stroking:
It Is another technique used to produce a generalized calming effect by
activation of ANS.
It may be applied by using a flat hand over the paravertebral muscles from
cervical to sacral regions.
The generally calming effect can decrease muscle tone.
3-5 minutes are a sufficient period to produce effect.
g) Manual contact:

Itis one of the most success technique to facilitate motor control.

A manual direct firm contact over the desired muscles is the used technique.
Vestibular Stimulation Technique
The vestibular stimulation technique is a proprioceptive unique sensory system with
multi-sensory function.
According to the type of stimulus we can use the vestibular system to achieve many
treatment alternatives.
Total body inhibition can be achieved by slow rocking, slow anterior-posterior
movement, slow horizontal movement, slow vertical movement and slow linear
movement.
53

 Total body facilitation can be achieved by rolling patterns, a rocking pattern on elbows
and extended elbows and crawling.
Also spinning induces tonal responses and causes a strong facilitation of movement
through the overflow of impulses to higher centers.
A facilitation of postural extensors is another effect of vestibular stimulation if it is used
by a rapid way anterior-posterior or angular acceleration of the head and body while the
child in prone position.
The inverted position is commonly used now to achieve a total body inhibition, while it
may be used to increase to in certain extensors.

Special Senses Stimulation technique

Visual system:
May be used to produce a decrease or an increase in firing of sensory afferent fibers and
have an overall effect on CNS excitation.
Cool colors, a darkened room and monotone color schemes all tend to have an inhibitory
effect on muscle tone, a calming mood and generalized inhibitory response.
On the other hand a facilitatory effect can be gained by intermittent visual stimuli, bright
colors, bright light and a random color scheme.
If the sensory component of the tactile, proprioceptive or vestibular system has been lost or
severely damaged the visual stimulus may consider an effective alternative.

Auditory system stimulation :

As a treatment technique depends on the quality, quantity and effect of voice.
The therapist's voice can be considered a very important therapeutic tool to produce
a facilitatory or inhibitory response on muscle tone and activity.
The same effect may be gained by music.
Auditory biofeedback is a very important and famous therapeutic modality which
depends on intact auditory system.

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Olfactory system :
May be used as a treatment modality especially during feeding procedures.
Some odors such as vanilia and banana may be used to facilitate sucking movement.
Withdrawal patterns can be facilitated with ammonia and vineger.
Therapist should use olfactory system as a treatment technique under restricted
precautions because its arousal and emotional effect.

Multi-Sensory Treatment Techniques

Multi-Sensory Treatment Techniques is the most common type of procedures used by
therapists, who may concentrate on one target but more than one or two
sensorysystems will work simultaneously. For example, tapping is akind of
stimulation primarily can consider as a proprioceptive in origin but exteroceptive
sense will work automatically.
So facilitation of muscle activity will originate from two origins the proprioceptive
stimulus through the afferent activity within the muscle spindle and the
reflemechanism coming from the tactile receptors.
Another example, any exercise including head and body movements in space
The vestibular system and proprioceptive receptors will be fired simultaneously and
influencing the muscle activity.
Also, when therapist talk to the patient and demonstrate the exercise for him by any
means or correct his performance, this means are auditory, visual, vestibular, tactile
and proprioceptive stimulation working together.

Autonomic nervous system stimulation technique

Study of the interconnections between the ANS and CNS have lead the clinicians
and therapist to know viable treatment approaches that depend on both systems.
Both systems must react and work in integrated manner at appropriate intensities.
should- according to that differentiate between hypertonicity and disturb
movement created by emotional stresses which may lead to ANS reaction
versus disorders resulting from CNS damage.
There are four treatment procedures can be used to affect on movement and
muscle one throughout ANS reaction which normally produce a
parasympathetic response:
1)
2)
3)
4)
feet, peroneal area, and

Slow stroking over the paravertebral areas will cause inhibition.

Inverted tonic labyrinthine therapy.
Slow, smooth, passive movement within pain free range.
Maintained deep pressure on the abdomen, palms, soles of the

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skin rostral to the top lip may cause a reduction of tone or hyperactivity.

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