Article growth & development

Developmental Milestones: Motor Development

R. Jason Gerber, MD,*
Objectives After completing this article, readers should be able to:
Timothy Wilks, MD,†
Christine Erdie-Lalena, 1. Identify the milestones for gross and fine motor development.
MD ‡ 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 articles
Author Disclosure
will appear in the September and November 2010 issues of Pediatrics in Review, respectively.
Drs Gerber, Wilks, and
Erdie-Lalena have
disclosed no financial Introduction
relationships relevant Infancy and childhood are dynamic periods of growth and change. Neurodevelopmental
to this article. This and physical growth proceed in a sequential and predictable pattern that is intrinsically
determined. Skills progress from cephalic to caudal; from proximal to distal; and from
commentary does not
generalized, stimulus-based reflexes to specific, goal-oriented reactions that become
contain a discussion
increasingly precise. As one clinician has stated, “infants [and children] are very orderly in
of an unapproved/ their ways; they actually behave [and develop] according to laws that can be explored,
investigative use of a discovered, confirmed, reconfirmed, and celebrated.” (1) By convention, these neuro-
commercial developmental “laws” or sequences often are described in terms of the traditional devel-
product/device. 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 supervision
visit. 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 for
developmental delay. A thorough understanding of the normal or typical sequence of
development in all domains (gross motor, fine motor, problem-solving, receptive lan-
guage, expressive language, and social-emotional) allows the clinician to formulate a
correct overall impression of a child’s true developmental status. However, it must be
emphasized that even experienced pediatricians cannot rely solely on their knowledge of
the milestones to identify children who have developmental concerns. Developmental
screening 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 uncovers
a concern.
Although neurodevelopment follows a predictable course, it is important to understand
that 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 cultural
environment, and the family’s socioeconomic status with its effect on resources of time and
money 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 of
development 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 Medical
Center, Joint Base Lewis-McChord, Wash.

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growth & development motor development

abnormalities. The milestones cited are, on average, During the first postnatal year, an infant thus moves
those at the 50th percentile for age. By understanding from lying prone, to rolling over, to getting to hands and
what is “normal” or typical, the clinician can appreciate knees, and ultimately to coming to a seated position or
more keenly what is abnormal or delayed. This article pulling to stand (Fig. 6). Within the framework of Back
concentrates on normal motor development, with a brief to Sleep guidelines, infants must have age-appropriate
mention about specific “red flags” that should alert cli- and safe opportunities for “tummy time” to promote the
nicians to potential motor developmental problems. The development of these important prone-specific mile-
second article in the series discusses cognitive and lan- stones. It is important to note that crawling is not a
guage development. The final article addresses the devel- prerequisite to walking; pulling to stand is the skill infants
opment of social-emotional skills. An all-inclusive table must develop before they take their first steps. The
of milestones is provided in this first article as a reference ultimate goal of this timeframe is to develop skills that
(Table 1) both in print and online; Table 1 appears allow for independent movement and freedom to use the
online only in the September and November articles. hands to explore, manipulate, and learn from the envi-
ronment.
Gross Motor Milestones Gross motor development in subsequent years con-
The ultimate goal of gross motor development is to gain sists of refinements in balance, coordination, speed, and
independent and volitional movement. During gesta- strength. The wide-based, slightly crouched, staccato
tion, primitive reflexes develop and persist for several gait of a 12-month-old evolves into a smooth, upright,
months after birth to prepare the infant for the acquisi- and narrow-based style. The arms change from being
tion of specific skills. These brainstem and spinal reflexes held abducted and slightly elevated for balance to swing-
are stereotypic movements generated in response to spe- ing in a reciprocal fashion as the gait reaches an adult
cific sensory stimuli. Examples include the Moro (Fig. 1), pattern by age 3 years. Similarly, running develops soon
asymmetric tonic neck (ATNR) (Fig. 2), and positive after walking, starting as a stiff-legged approximation and
support reflexes (Fig. 3). As the central nervous system changing into a well-coordinated movement that in-
matures, the reflexes are inhibited to allow the infant to cludes rapid change of direction and speed by 18 months
make purposeful movements. For example, during the of age.
time when the ATNR persists, an infant is unable to roll Simultaneous use of both arms or legs occurs after
from back to front, bring the hands to midline, or reach successful use of each limb independently. At age 2 years,
for objects. This reflex disappears between 4 and 6 a child can kick a ball, jump with two feet off the floor,
months of age, the same time that these skills begin to and throw a big ball overhand. Milestones for succeeding
emerge. The Moro reflex interferes with head control ages reflect progress in the length of time, number of
and sitting equilibrium. As this reflex lessens and disap- repetitions, or the distance each task can be performed
pears by 6 months of age, the infant gains progressive successfully. By the time a child starts school, he or she is
stability in a seated position (Fig. 4). able to perform multiple complex gross motor tasks
In addition to primitive reflexes, postural reactions, simultaneously (such as pedaling, maintaining balance,
such as righting and protection responses, also begin to and steering while on a bicycle).
develop after birth. These reactions, mediated at the
midbrain level, interact with each other and work toward Fine Motor Milestones
the establishment of normal head and body relationship Fine motor skills relate to the use of the upper extremities
in space. Protective extension, for example, allows the to engage and manipulate the environment. They are
infant to catch him- or herself when falling forward, necessary for a person to perform self-help tasks, to play,
sideways, or backwards (Fig. 5). These reactions develop and to accomplish work. Like all developmental streams,
between 6 and 9 months, the same time that an infant fine motor milestones do not proceed in isolation but
learns to move into a seated position and then to hands depend on other areas of development, including gross
and knees. Soon afterward, higher cortical centers medi- motor, cognitive, and visual perceptual skills. At first, the
ate the development of equilibrium responses and permit upper extremities play an important role in balance and
the infant to pull to stand by 9 months of age and begin mobility. Hands are used for support, first in the prone
walking by 12 months. Additional equilibrium responses position and then in sitting. Arms help with rolling over,
develop during the second year after birth to allow for then crawling, then pulling to stand. Infants begin to use
more complex bipedal movements, such as moving back- their hands to explore, even when in the supine position.
ward, running, and jumping. When gross motor skills have developed such that the

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 growth & development motor development

Table 1. Developmental Milestones

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

1 month ● Chin up in ● Hands fisted ● Sucks well ● Gazes at black- ● Discriminates ● Startles to voice/ ● Throaty noises
prone position near face white objects mother’s voice sound
● Turns head in ● Follows face ● Cries out of
supine position distress
2 months ● Chest up in ● Hands unfisted ● Opens mouth ● Visual threat ● Reciprocal ● Alerts to voice/ ● Coos
prone position 50% at sight of present smiling: sound ● Social smile
● Head bobs when ● Retains rattle breast or ● Follows large, responds to (6 weeks)
held in sitting if placed in bottle highly adult voice and ● Vowel-like noises
position hand contrasting smile
● Holds hands objects
together ● Recognizes
mother
3 months ● Props on ● Hands unfisted ● Brings hands ● Reaches for ● Expression of ● Regards speaker ● Chuckles
forearms in 50% to mouth face disgust (sour ● Vocalizes when
prone position ● Inspects ● Follows objects taste, loud talked to
● Rolls to side fingers in circle (in sound)
● Bats at objects supine ● Visually follows
position) person who is
● Regards toys moving across a
room
4 months ● Sits with trunk ● Hands held ● Briefly holds ● Mouths objects ● Smiles ● Orients head in ● Laughs out loud
support predominately onto breast ● Stares longer spontaneously direction of a ● Vocalizes when
● No head lag open or bottle at novel faces at pleasurable voice alone
when pulled to ● Clutches at than familiar sight/sound ● Stops crying to
sit clothes ● Shakes rattle ● Stops crying at soothing voice
● Props on wrists ● Reaches ● Reaches for parent voice
● Rolls front to persistently ring/rattle ● To and fro
back ● Plays with alternating
rattle vocalizations
5 months ● Sits with pelvic ● Palmar grasps ● Gums/ ● Turns head to ● Recognizes ● Begins to ● Says “Ah-goo”
support cube mouths look for caregiver respond to ● Razzes, squeals
● Rolls back to ● Transfers pureed food dropped spoon visually name ● Expresses anger
front objects: hand- ● Regards pellet ● Forms with sounds
● Anterior mouth-hand or small attachment other than crying
protection ● Holds hands cracker relationship to
● Sits with arms together caregiver
supporting ● Reaches/grasps
trunk dangling ring
6 months ● Sits ● Transfers ● Feeds self ● Touches ● Stranger anxiety ● Stops ● Reduplicative
momentarily hand-hand crackers reflection and (familiar versus momentarily to babble with
propped on ● Rakes pellet ● Places hands vocalizes unfamiliar “no” consonants
hands ● Takes second on bottle ● Removes cloth people) ● Gestures for “up” ● Listens, then
● Pivots in prone cube and holds on face vocalizes when
● In prone on to first ● Bangs and adult stops
position, bears ● Reaches with shakes toys ● Smiles/vocalizes
weight on 1 one hand to mirror
hand
7 months ● Bounces when ● Radial-palmar ● Refuses ● Explores ● Looks from ● Looks toward ● Increasing variety
held grasp excess food different object to parent familiar object of syllables
● Sits without aspects of toy and back when when named
support steadily ● Observes cube wanting help ● Attends to music
● Lateral in each hand (eg, with a
protection ● Finds partially wind-up toy)
● Puts arms out hidden object
to sides for
balance
8 months ● Gets into sitting ● Bangs spoon ● Holds own ● Seeks object ● Lets parents ● Responds to ● Says “Dada”
position after bottle after it falls know when “Come here” (nonspecific)
● Commando demonstration ● Finger feeds silently to the happy versus ● Looks for family ● Echolalia (8 to 30
crawls ● Scissor grasp Cheerios® or floor upset members, months)
● Pulls to sitting/ of cube string beans ● Engages in gaze “Where’s ● Shakes head for
kneeling ● Takes cube out monitoring: mama?”. . . etc “no”
position of cup adult looks
● Pulls out large away and child
peg follows adult
glance with own
eyes
(continued)

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Table 1. Developmental Milestones—continued

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

9 months ● “Stands” on feet ● Radial-digital ● Bites, chews ● Inspects bell ● Uses sounds to ● Enjoys gesture ● Says “Mama”
and hands grasp of cube cookie ● Rings bell get attention games (nonspecific)
● Begins creeping ● Bangs two ● Pulls string to ● Separation ● Orients to name ● Nonreduplicative
● Pulls to stand cubes together obtain ring anxiety well babble
● Bear walks (all ● Follows a point, ● Orients to bell ● Imitates sounds
four limbs “Oh look at . . .”
straight) ● Recognizes
familiar people
visually
10 months ● Creeps well ● Clumsy release ● Drinks from ● Uncovers toy ● Experiences fear ● Enjoys peek-a- ● Says “Dada”
● Cruises around of cube cup held for under cloth ● Looks boo (specific)
furniture using ● Inferior pincer child ● Pokes at pellet preferentially ● Waves “bye-bye” ● Waves “bye-bye”
two hands grasp of pellet in bottle when name is back
● Stands with one ● Isolates index ● Tries to put called
hand held finger and cube in cup,
● Walks with two pokes but may not be
hands held able to let go
11 months ● Pivots in sitting ● Throws objects ● Cooperates ● Finds toy under ● Gives objects to ● Stops activity ● Says first word
position ● Stirs with with dressing cup adult for action when told “no” ● Vocalizes to songs
● Cruises furniture spoon ● Looks at after ● Bounces to music
using one hand pictures in demonstration
● Stands for a book (lets adult know
few seconds he or she needs
● Walks with one help)
hand held
12 months ● Stands well ● Scribbles after ● Finger feeds ● Rattles spoon ● Shows objects ● Follows one-step ● Points to get
with arms high, demonstration part of meal in cup to parent to command with desired object
legs splayed ● Fine pincer ● Takes off hat ● Lifts box lid to share interest gesture (proto-imperative
● Posterior grasp of pellet find toy ● Points to get ● Recognizes pointing)
protection ● Holds crayon desired object names of two ● Uses several
● Independent ● Attempts (proto- objects and looks gestures with
steps tower of two imperative when named vocalizing (eg,
cubes pointing) waving, reaching)
13 months ● Walks with ● Attempts to ● Drinks from ● Dangles ring by ● Shows desire to ● Looks ● Uses three words
arms high and release pellet cup with string please caregiver appropriately ● Immature
out (high in bottle some spilling ● Reaches around ● Solitary play when asked, jargoning:
guard) clear barrier to ● Functional play “Where’s the inflection without
obtain object ball?” real words
● Unwraps toy in
cloth
14 months ● Stands without ● Imitates back ● Removes ● Dumps pellet ● Points at object ● Follows one-step ● Names one object
pulling up and forth socks/shoes out of bottle to express command ● Points at object
● Falls by collapse scribble ● Chews well after interest (proto- without gesture to express
● Walks well ● Adds third ● Puts spoon in demonstration declarative interest (proto-
cube to a two- mouth (turns pointing) declarative
cube tower over) ● Purposeful pointing)
● Puts round peg exploration of
in and out of toys through
hole trial and error
15 months ● Stoops to pick ● Builds three- ● Uses spoon ● Turns pages in ● Shows empathy ● Points to one ● Uses three to five
up toy to four-cube with some book (someone else body part words
● Creeps up stairs tower spilling ● Places circle in cries, child looks ● Points to one ● Mature jargoning
● Runs stiff- ● Places 10 ● Attempts to single-shape sad) object of three with real words
legged cubes in cup brush own puzzle ● Hugs adult in when named
● Walks carrying ● Releases pellet hair reciprocation ● Gets object from
toy into bottle ● Fusses to be ● Recognizes another room
● Climbs on changed without a upon demand
furniture demonstration
that a toy
requires
activation;
hands it to
adult if can’t
operate
16 months ● Stands on one ● Puts several ● Picks up and ● Dumps pellet ● Kisses by touch- ● Understands ● Uses 5 to 10
foot with slight round pegs in drinks from out without ing lips to skin simple words
support board with cup demonstration ● Periodically commands,
● Walks urging ● Fetches and ● Finds toy visually relocates “Bring to
backwards ● Scribbles carries observed to be caregiver mommy”
● Walks up stairs spontaneously objects (same hidden under ● Self-conscious; ● Points to one
with one hand room) layers of covers embarrassed picture when
held ● Places circle in when aware of named
form board people observing
(continued)

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 growth & development motor development

Table 1. Developmental Milestones—continued

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

18 months ● Creeps down ● Makes four- ● Removes ● Matches pairs ● Passes M-CHAT ● Points to two of ● Uses 10 to 25
stairs cube tower garment of objects ● Engages in three objects words
● Runs well ● Crudely ● Gets onto ● Replaces circle pretend play when named ● Uses giant words
● Seats self in imitates adult chair in form board with other ● Points to three (all gone, stop
small chair vertical stroke unaided after it has people (eg, tea body parts that)
● Throws ball ● Moves about been turned party, birthday ● Points to self ● Imitates
while standing house around (usually party) ● Understands environmental
without with trial and ● Begins to show “mine” sounds (eg,
adult error) shame (when ● Points to familiar animals)
does wrong) people when ● Names one picture
and named on demand
possessiveness
20 months ● Squats in play ● Completes ● Places only ● Deduces ● Begins to have ● Points to three ● Holophrases
● Carries large round peg edibles in location of thoughts about pictures (“Mommy?” and
object board without mouth hidden object feelings ● Begins to points to keys,
● Walks urging ● Feeds self ● Places square ● Engages in tea understand meaning: “These
downstairs with ● Makes five- to with spoon in form board party with her/him/me are Mommy’s
one hand held six-cube tower entire meal stuffed animals keys.”)
● Completes ● Kisses with ● Two-word
square peg pucker combinations
board ● Answers requests
with “no”
22 months ● Walks up stairs ● Closes box ● Uses spoon ● Completes ● Watches other ● Points to four ● Uses 25 to 50
holding rail, with lid well form board children to five pictures words
putting both ● Imitates ● Drinks from intensely when named ● Asks for more
feet on each vertical line cup well ● Begins to show ● Points to five to ● Adds one to two
step ● Imitates ● Unzips defiant behavior six body parts words/week
● Kicks ball with circular zippers ● Points to four
demonstration scribble ● Puts shoes pieces of
● Walks with one on partway clothing when
foot on walking named
board
24 months ● Walks down ● Makes a ● Opens door ● Sorts objects ● Parallel play ● Follows two- ● Two-word sentence
stairs holding single-line using knob ● Matches ● Begins to mask step command (noun ⴙ verb)
rail, both feet “train” of ● Sucks objects to emotions for ● Understands ● Telegraphic speech
on each step cubes through a pictures social etiquette me/you ● Uses 50ⴙ words
● Kicks ball ● Imitates circle straw ● Shows use of ● Points to 5 to ● 50% intelligibility
without ● Imitates ● Takes off familiar objects 10 pictures ● Refers to self by
demonstration horizontal line clothes name
● Throws without ● Names three
overhand buttons pictures
● Pulls off
pants
28 months ● Jumps from ● Strings large ● Holds self ● Matches ● Reduction in ● Understands ● Repeats two digits
bottom step beads and shapes separation “just one” ● Begins to use
with one foot awkwardly verbalizes ● Matches colors anxiety pronouns
leading ● Unscrews jar toilet needs (I, me, you)
● Walks on toes lid ● Pulls pants ● Names 10 to 15
after ● Turns paper up with pictures
demonstration pages (often assistance
● Walks backward several at
10 steps once)
30 months ● Walks up stairs ● Makes eight- ● Washes ● Replaces circle ● Imitates adult ● Follows two ● Echolalia and
with rail, cube tower hands in form board activities (eg, prepositions: jargoning gone
alternating feet ● Makes a ● Puts things after it has sweeping, “put block ● Names objects by
● Jumps in place “train” of away been turned talking on in . . . on box” use
● Stands with cubes and ● Brushes teeth around (little phone) ● Understands ● Refers to self with
both feet on includes a with or no trial and actions words: correct pronoun
balance beam stack assistance error) “playing . . . ● Recites parts of
● Walks with one ● Points to small washing . . . well-known story/
foot on balance details in blowing” fills in words
beam pictures
33 months ● Walks swinging ● Makes 9- to ● Toilet trained ● Points to self ● Begins to take ● Understands ● Gives first and last
arms opposite 10-cube tower ● Puts on coat in photos turns three name
of legs ● Puts six square unassisted ● Points to body ● Tries to help prepositions ● Counts to 3
(synchronous pegs in parts based on with household ● Understands ● Begins to use past
gait) pegboard function tasks dirty, wet tense
● Imitates cross (“What do you ● Points to objects ● Enjoys being read
hear with?”) by use: “ride to (short books)
in . . . put on
feet . . . write
with”
(continued)

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Table 1. Developmental Milestones—continued

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

3 years ● Balances on one ● Copies circle ● Independent ● Draws a two- to ● Starts to share ● Points to parts ● Uses 200ⴙ words
foot for 3 ● Cuts with scissors: eating three-part person with/without of pictures (nose ● Three-word sentences
seconds side-to-side ● Pours liquid from ● Understands long/ prompt of cow, door of ● Uses pronouns
● Goes up stairs, (awkwardly) one container to short, big/small, ● Fears imaginary car) correctly
alternating feet, ● Strings small another more/less things ● Names body ● 75% intelligibility
no rail beads well ● Puts on shoes ● Knows own gender ● Imaginative play parts with ● Uses plurals
● Pedals tricycle ● Imitates bridge of without laces ● Knows own age ● Uses words to function ● Names body parts by
● Walks heel cubes ● Unbuttons ● Matches letters/ describe what ● Understands use
to toe numerals someone else is negatives ● Asks to be read to
● Catches ball thinking (“Mom ● Groups objects
with stiff arms thought I was (foods, toys)
asleep”)
4 years ● Balances on one ● Copies square ● Goes to toilet ● Draws a four- to ● Deception: ● Follows three- ● Uses 300 to 1,000
foot 4 to 8 ● Ties single knot alone six-part person interested in step commands words
seconds ● Cuts 5-inch circle ● Wipes after bowel ● Can give amounts “tricking” others ● Points to things ● Tells stories
● Hops on one ● Uses tongs to movement (usually less than 5) and concerned that are the ● 100% intelligibility
foot two to transfer ● Washes face/ correctly about being same versus ● Uses “feeling” words
three times ● Writes part of hands ● Simple analogies: tricked by others different ● Uses words that tell
● Standing broad first name ● Brushes teeth - dad/boy: ● Has a preferred ● Names things about time
jump: 1 to ● Imitates gate alone mother/??? friend when actions are
2 feet with cubes ● Buttons - ice/cold: fire/ ● Labels happiness, described (eg,
● Gallops ● Uses fork well ??? sadness, fear, swims in water,
● Throws ball - ceiling/up: and anger in self you cut with it,
overhand floor/??? ● Group play it’s something
10 feet ● Points to five to six you read, it tells
● Catches colors time . . .)
bounced ball ● Points to letters/ ● Understands
(41⁄2 yrs) numerals when adjectives: bushy,
named long, thin,
● Rote counts to 4 pointed
● “Reads” several
common signs/
store names
5 years ● Walks down ● Copies triangle ● Spreads with ● Draws an 8- to ● Has group of ● Knows right and ● Repeats six- to
stairs with rail, ● Puts paper clip knife 10-part person friends left on self eight-word sentence
alternating feet on paper ● Independent ● Gives amounts ● Apologizes for ● Points to ● Defines simple words
● Balances on ● Can use clothes- dressing (<10) mistakes different one in ● Uses 2,000 words
one foot >8 pins to transfer ● Bathes ● Identifies coins ● Responds a series ● Knows telephone
seconds small objects independently ● Names letters/ verbally to good ● Understands “er” number
● Hops on one ● Cuts with scissors numerals out of fortune of others endings (eg, ● Responds to “why”
foot 15 times ● Writes first name order batter, skater) questions
● Skips ● Builds stairs from ● Rote counts to 10 ● Understands ● Retells story with
● Running broad model ● Names 10 colors adjectives: busy, clear beginning,
jump 2 to 3 ● Uses letter names as long, thin, middle, end
feet sounds to invent pointed
● Walks backward spelling ● Enjoys rhyming
heel-toe ● Knows sounds of words and
● Jumps backward consonants and alliterations
short vowels by end ● Produces words
of kindergarten that rhyme
● Reads 25 words ● Points correctly
to “side,”
“middle,”
“corner”
6 years ● Tandem walks ● Builds stairs from ● Ties shoes ● Draws a 12- to ● Has best friend ● Asks what un- ● Repeats 8- to 10-
memory ● Combs hair 14-part person of same sex familiar words word sentences
● Draws diamond ● Looks both ways ● Number concepts ● Plays board mean ● Describes events in
● Writes first and at street to 20 games ● Can tell which order
last name ● Remembers to ● Simple addition/ ● Distinguishes words do not ● Knows days of the
● Creates and writes bring belongings subtraction fantasy from belong in a week
short sentences ● Understands seasons reality group ● 10,000 word
● Forms letters with ● Sounds out ● Wants to be like vocabulary
down-going and regularly spelled friends and
counterclockwise words please them
strokes ● Reads 250 words by ● Enjoys school
● Copies flag end of first grade

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

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 growth & development motor development

Figure 1. Moro reflex. This reflex occurs spontaneously to

loud noises or by simply holding the supine infant’s hand and
releasing the hand suddenly. Classically, the reflex is elicited
while holding the infant supine, with the head dropped
slightly backward. This produces sudden extension and abduc-
tion of the upper extremities with hands open, followed by
flexion of the upper extremities to midline (the “startle reflex”).

infant is more stable in upright positions and can move

into them easily, the hands are free for more purposeful
exploration.
At birth, infants do not have any apparent voluntary Figure 2. Asymmetric tonic neck reflex (ATNR). The sensory
use of their hands. They open and close them in response limb of the ATNR involves proprioceptors in the cervical
to touch and other stimuli, but movement otherwise is vertebrae. With active or passive head rotation, the baby
dominated by a primitive grasp reflex. Because of this, extends the arm and leg on the face side and flexes the
infants spend the first 3 months after birth “contacting” extremities on the contralateral side (the “fencer posture”).
objects with their eyes rather than their hands, fixating on There also is some subtle trunk curvature on the contralateral
faces and objects and then visually tracking objects. side produced by mild paraspinous muscle contraction.
Gradually, they start to reach clumsily and bring their
hands together. As the primitive reflexes decrease, infants 9 months. A pincer grasp emerges as the ulnar fingers are
begin to prehend objects voluntarily, first using the en- inhibited while slightly extending and supinating the
tire palm toward the ulnar side (5 months) and then wrist. Voluntary release is awkward at first, with all fin-
predominantly using the radial aspect of the palm gers extended. By 10 months of age, infants can release a
(7 months). At the same time, infants learn to release cube into a container or drop things onto the floor.
objects voluntarily. In the presence of a strong grasp Object permanence reinforces the desire to practice this
reflex, objects must be removed forcibly from an infant’s skill over and over. Intrinsic muscle control develops to
grasp or drop involuntarily from the hand. Voluntary allow the isolation of the index finger, and infants will
release is seen as the infant learns to transfer objects from poke their fingers into small holes for exploration. By 12
one hand to the other, first using the mouth as an months of age, most infants enjoy putting things into
intermediate stage (5 months) and then directly hand- containers and dumping them out repeatedly. They also
to-hand (6 months). can pick up small pieces of food with a mature pincer
Between 6 months and 12 months of age, the grasp grasp and bring them to their mouths.
evolves to allow for prehension of objects of different As infants move into their second year, their mastery
shapes and sizes (Fig. 7). The thumb becomes more of the reach, grasp, and release allows them to start using
involved to grasp objects, using all four fingers against objects as tools. Fine motor development becomes more
the thumb (a “scissors” grasp) at 8 months, and eventu- closely associated with cognitive and adaptive develop-
ally to just two fingers and thumb (radial digital grasp) at ment, with the infant knowing both what he or she wants to

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growth & development motor development

Figure 4. The declining intensity of primitive reflexes and the

increasing role of postural reactions represent at least permis-
sive, and possibly necessary, conditions for the development of
definitive motor reactions. Reproduced with permission from
Johnson CP, Blasco PA. Infant growth and development.
Pediatr Rev. 1997;18:225–242.

Figure 3. Positive support reflex. With support around the

trunk, the infant is suspended, then lowered to touch the feet
gently on a flat surface. This produces reflex extension at the
hips, knees, and ankles so the infant stands up, completely or
partially bearing weight. Mature weight-bearing lacks the
rigid quality of this primitive reflex.

do and how he or she can accomplish it. Intrinsic muscle

refinement allows for holding flat objects, such as crackers
or cookies. By 15 months of age, voluntary release has
developed further to enable stacking of three to four blocks
and releasing small objects into containers. The child starts
to adjust objects after grasping to use them properly, such as
picking up a crayon and adjusting it to scribble spontane-
ously (18 months of age) and adjusting a spoon to use it
consistently for eating (20 months of age).
In subsequent years, fine motor skills are refined fur-
ther to draw, explore, problem-solve, create, and perform Figure 5. Lateral protection. In the seated position, the child
self-help tasks. By age 2 years, children can create a six- is pushed gently but rapidly to one side. The reaction is present
block tower, feed themselves with a spoon and fork, re- if the child puts out his or her hand to prevent a fall.

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 growth & development motor development

flexion. Their grasp and in-hand ma-

nipulation skills allow them to string
small beads and unbutton clothes.
At age 4 years, a palmar tripod
grasp allows for finer control of pencil
movements, and the child can copy a
cross, a square, and some letters and
numerals and can draw a figure of a
person (the head and a few other
body parts). Scissor skills have pro-
gressed to permit the cutting of a
circle. When a child reaches the age
of 5 years, he or she can dress and un-
dress independently, brush the teeth
well, and spread with a knife. More
precise in-hand manipulation skills
enable the child to cut a square with
mature scissor movements (indepen-
Figure 6. Chronologic progression of gross motor development during the first 12 dent finger use) and to print his or
postnatal months. Reproduced with permission from Johnson CP, Blasco PA. Infant her own name and copy a triangle
growth and development. Pediatr Rev. 1997;18:224 –242. using a mature tripod pencil grasp
(using the fingers to move the pencil
rather than the forearm and wrist).

Developmental Red Flags

As the clinician performs develop-
mental surveillance, the absence of
certain key milestones in a patient
should raise the level of concern.
Figure 7. Development of pincer grasp. Illustrations from the Erhardt developmental Table 2 lists the developmental red
prehension. In Erhardt RP. Developmental Hand Dysfunction: Theory Assessment, Treat- flags specific to the motor domain. If
ment. 2nd ed. San Antonio, Tex: Therapy Skill Builders; 1994. Reprinted with permission. one of these red flags is discovered, a
medical and more thorough devel-
opmental evaluation is warranted.
Table 2. Motor Red Flags Although reported in this article in isolation, motor
skills development overlaps significantly with the other
Age Red Flag
streams of development.
4 months Lack of steady head control
while sitting
9 months Inability to sit
18 months Inability to walk independently
Summary
• The development of motor skills is critical for a child
move clothing, and grasp and turn a door knob. They to move independently and to interact with his or her
environment meaningfully and usefully. Skills develop
have sufficient control of a crayon to imitate both ver-
in a cephalic-to-caudal progression and from proximal
tical and horizontal lines. In-hand manipulation skills to distal. Thus, consistent head support occurs before
permit them to rotate objects, such as unscrewing a voluntary control of arms and legs, and large muscle
small bottle cap or reorienting a puzzle piece before control of the upper arms occurs before small, intrinsic
putting it in place. They are able to wash and dry their muscle control in the hands.
• Skills also progress from generalized responses to
hands. By 36 months of age, they can draw a circle, put
stimuli (primitive reflexes) to goal-oriented, purposeful
on shoes, and stack 10 blocks. They make snips with actions with ever-increasing precision and dexterity.
scissors by alternating between full-finger extension and

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growth & development motor development

References sleeping environment and sleep position. Pediatrics. 2000;105:

1. Lipsitt LP. Learning and emotion in infants. Pediatrics. 1998; 650 – 656
102:1262–1267 Case-Smith J, Allen AS, Pratt PN, eds. Occupational Therapy for
Children. St. Louis, Mo: Mosby Year-Book, Inc; 1996
Suggested Reading Fiorentino MR. Reflex Testing Methods for Evaluating CNS Devel-
American Academy of Pediatrics Committee on Children with opment. Springfield, Ill: Charles C Thomas; 1973
Disabilities, Section on Developmental Behavioral Pediatrics; Hagan JF, Shaw J, Ducan PM, eds. Bright Futures: Guidelines for
Bright Futures Steering Committee; Medical Home Initiatives Health Supervision of Infants, Children, and Adolescents. 3rd
for Children with Special Needs Project Advisory Committee. edition. Elk Grove Village, Ill: American Academy of Pediatrics;
Identifying infants and young children with developmental dis- 2008
orders in the medical home: an algorithm for developmental Johnson CP, Blasco PA. Infant growth and development. Pediatr
surveillance and screening. Pediatrics. 2006;118:405– 420 Rev. 1997;18:224 –242
AAP Task Force on Infant Positioning and SIDS. Changing con- Sturner RA, Howard BJ. Preschool development 1: communicative
cepts of sudden infant death syndrome: implications for infant and motor aspects. Pediatr Rev. 1997;18:291–301

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 growth & development motor development

PIR Quiz
Quiz 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 her
daughter’s development. Her growth parameters are at the 25th percentile. She walks well, climbs onto her
mother’s lap, and whispers a few words to her mother. The best next step in the evaluation of this child’s
development 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 cause
of 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 pincer
grasp. 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.

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 Developmental Milestones: Motor Development
R. Jason Gerber, Timothy Wilks and Christine Erdie-Lalena
Pediatrics in Review 2010;31;267
DOI: 10.1542/pir.31-7-267

Updated Information & including high resolution figures, can be found at:
Services http://pedsinreview.aappublications.org/content/31/7/267
References This article cites 5 articles, 5 of which you can access for free at:
http://pedsinreview.aappublications.org/content/31/7/267.full#ref-list
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 Developmental Milestones: Motor Development
R. Jason Gerber, Timothy Wilks and Christine Erdie-Lalena
Pediatrics in Review 2010;31;267
DOI: 10.1542/pir.31-7-267

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/31/7/267

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