Sure, with my first born I was in a panic when she wasn’t the first to take on a new milestone, but by my second – eh. Of course after I became a more “calm” mama, then I would hear how not meeting those coveted skills such as crawling, talking, etc. could be signs of larger problems that could be solved only with early treatment all translating to one thing: panic. Breezy Mama turned to Milestone Mom – a.k.a. Occupational Therapist Nancy Silverman-Konigsberg — to discuss what it can mean when a child doesn’t have a new skill according to their developmental age (and find out when issues such as biting and hitting can be indicative of Autism, PDD, Asperger’s Syndrome and Rett Syndrome), when it’s okay to relax and when it’s time to freak out, er, um, take action.
Babies are born with millions of neurons and synapses that connect them. These connections carry vital information that ultimately determines knowledge, function and ability. Research has shown that there is actually a window of opportunity to keep these connections open. The best example I ever heard was that of a baby girl who was born with a cataract that impaired her vision. It had to be removed by 3 months or she would never see with that eye. There was no damage to the eye. But without vision, her brain couldn’t “learn” how to use the eye.
Milestones need to be reached within a specific time frame. Not all development is as crucial as the eye, but missed milestones generally mean that the child’s full potential will not be realized. In some cases the difference between achievement and potential may not be significant, but in other cases it can be problematic. That’s why it is important to give a baby or toddler a push if they seem to be lagging. Movement and experience are tied in to all aspects of development. They affect all skills: cognitive, gross motor, visual motor, perceptual and fine motor.
When a child is not meeting one or more of their milestones, the caregiver should be aware of global issues. It is possible that the baby might need help with a particular skill, but it is more likely that the lack of skill development suggests a broader problem.
Picking Up Objects
By 6 months of age, a baby should be able to pick up small items like cheerios or a raisin with what is called a raking grasp. That is, they use all their fingers like a rake and scrape the object to their thumb in an effort to pick it up. Some babies can already use a pincer grasp at this age. That is, they can pick up a raisin between their thumb and index finger. But it is not unusual for the pincer grasp to emerge as late as 12 months. The pincer grasp plays an important role in development. It is the skill that will allow the baby to eventually button, zip, tie laces and most importantly, write.
There are a lot of activities and exercises that can help with pincer grasp development. One of my favorites is to use coins. All babies love playing with change. Playing tug of war with the coin is a good activity. Because the surface area is small, it forces the baby to hold on with fewer fingers. You give them the coin and tell them not to let go. Then you take a small section of the coin and tug gently. Increase the tug and see if the baby holds on tighter. That is the goal. The resistance of the tug helps improve hand strength. Another good activity is to place a mound of Play-doh or therapy putty on the table. Have the baby stick their fingers in the mound and have them pull the mound toward them by pulling with their fingers. Or, get a dowel stick and insert the tip deep into the mound. Have the baby grasp the stick and drag the dough/putty toward the edge of the table. Before the age of 12 – 15 months, it is hard to get babies to do pincer grasp specific exercises. That’s why weight bearing activities such as crawling are so important. The weight bearing helps with hand development.
Crawling, as stated above, is another very important milestone. It generally emerges around 6-8 months of age. If a baby does not engage in a lot of tummy time, however, the time frame can run later. As a matter of fact, many babies who sleep on their backs and are not encouraged to spend time on their tummies can miss this milestone. It is important to encourage crawling even if the baby prefers to avoid it. Crawling has many benefits for the developing baby. It helps with spatial relationships and it helps provide weight bearing into the hand and up to the shoulders. The weight bearing helps prepare for fine motor task and for handwriting. In fact, it is very beneficial to the development of the hand arches. The hand arches are defined by the lines we see in the palm of the hand. There is a direct relationship between the arches and fine motor skills.
If a baby isn’t crawling, there are a lot of components to look at. Can the baby sustain the “all fours” position if placed that way, or do they collapse to the floor? Do they just not like being put in that position? Can they move reciprocally (alternating sides)?
In my experience, the usual reasons a baby doesn’t crawl are because of low tone, insufficient strength, and joint laxity. Sometimes it is a combination of all three. There are many other reasons as well. Children who fall in the Spectrum disorder category often dislike the sensory aspect of crawling. And children with neurological and muscle disorders also may not crawl. In the absence of a specific diagnosis, lack of crawling is generally for the first reasons cited.
The treatment to promote crawling usually focuses on improving strength and postural stability. It also includes placing the baby on their tummy for play time. If the parent/caregiver feels confident, there are a number of exercises they can do with their baby. My blog, Milestone Mom has a few video demonstrations and lots of written instructions on how to do the strengthening exercise. If they don’t feel confident, the pediatrician can write a prescription for therapy.
Talking is another huge milestone that parents and caregivers are concerned about if it doesn’t happen on “schedule”. Like crawling, there are many factors that have to be considered if a baby doesn’t start talking. In general, babies can start talking at about 12 months. That is, they know a few words. If a baby is not saying anything by 18 months, a parent or caregiver should start to take notice. Many children do not talk until 2 or later, so there is no reason yet to be alarmed. Boys tend to talk later than girls anyway. At 18 months, however, the caregiver wants to rule out problems. The most obvious thing to check is hearing. It is easy to assess at home without running to a specialist. By a year and a half, most children can follow a simple directive – or respond to a question. If you say, “Bring me the ball” and the child gets the ball, you know that hearing isn’t an issue. So the next thing you want to check out, and it can be accomplished while you are checking hearing, is receptive language. Many children understand language before they speak it. If you say “bring me the ball” and they bring the ball, then you know that their receptive language is intact. That leaves expressive language. Some aspects of gross motor development can cause delayed speech. Children that are motor driven (crawling, walking, jumping) often speak later than their peers. It is not uncommon for a child to stop talking when they are learning to walk. Researchers theorize that focused development can preclude the emergence of other skills. And truthfully, some children decide to talk when they are good and ready. One mom whose daughter I treated bumped into me a few years after her therapy ended. She said she needed to get in touch with her speech therapist. I asked why. She said, “She did a great job teaching her to talk. Now I want her to teach her how to be quiet!”
If a parent is concerned about late speech, it is best to seek an evaluation by a licensed speech therapist. In addition to working on both receptive and expressive language, the therapist can help with lip closure, formation of sounds, and oral motor skills.
As an occupational therapist, it is my job to help children master skills that are going to enable them to perform activities of daily (ADL’s). For children, ADL’s include playing, eating, feeding and self-care such as dressing and undressing. Although I have treated almost every diagnosis imaginable, I mostly treated babies and children who just needed a little push. More and more, babies are spending time in exersaucers, jumpers and bouncers. They are not getting enough tummy time and weight bearing. The outcome is that many babies skills are emerging later and they are not optimizing their potential. It really is important for them to progress through the developmental milestones and achieve them on time. Believe it or not, missed milestones or delayed milestones can have a profound effect later on. If a child does not have good postural stability and good fine motor development, it can affect school performance. Poor spatial and visual motor development also becomes problematic once the child reaches school age. In order to sit at a desk, focus and perform table top activities such as note taking, over the length of the school day, a child needs to have well developed, intact skills.
Behavior is another area that can be addressed by the occupational therapist. With toddlers and young children, it is often hard to determine what is normal development and what is a problem behavior. Because toddlers are self-centered, they do not yet understand sharing and other social interactions. So it is not uncommon to see hitting, biting, and kicking. Many children use these behaviors as communication to indicate frustration, anger or fatigue. The best thing to do when you witness one of these behaviors, is to firmly say “no hitting”, or “no biting”, or no to whatever they were seen doing. You can take them out of the situation if possible, or separate them from the child they were engaged with. By age two, you can also try a very short time-out (less than 2 minutes) if they persist. What you don’t want to do is give the matter your attention. When you start talking to your child about the issue, they are rewarded by your attention. Children crave attention, albeit positive or negative. You can however, reinforce the “no biting” rule prior to the next similar situation. Before going into the daycare, classroom or play center, remind your child that biting, hitting or pushing is not allowed.
If these behaviors have progressed to the point of being habitual, your child may need to be evaluated by an early childhood specialist. Children who fall on the spectrum can often exhibit these behaviors. The spectrum includes a number of disorders: autism, PDD, Asperger’s Syndrome and Rett Syndrome. Also, children who have ADHD, oppositional –defiant disorder (ODD), Tourette’s syndrome and conduct disorder present with these behaviors. It is very important to evaluate and determine the cause of the behaviors prior to treatment. Depending on the condition, the treatment protocol can vary. Many children who are on the Autism spectrum crave sensory feedback and will bite or hit because of the sensory component. Children with ADHD type issues can have impulse control problems, and poor internal regulation. They can also crave various types of sensory stimulation.
Time invested in promoting all the developmental milestones pays off later on. As a baby and toddler develop, experience and interaction with the environment fosters good physical and cognitive development. It is important to address that window of opportunity, and make the effort to ensure that the opportunity is not missed.
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For a large part of my working experience, I went home to homes and treated children in their own environment. It gave me the opportunity to meet and develop relationships with family members and to learn about the families attitudes and ambitions for their child. The one thing all families wanted was for their child to reach 100% of their potential.
For contact information, visit Nancy’s site Milestone Mom — click here.
To learn about her id bracelet and service visit: www.kidsafeconnection.com.