Guidelines for Best Practices in Determining Eligibility Based on Children’s Physical Development

The goal of these Guidelines is to support Birth-to-3 staff and families in their team decisionmaking regarding a child’s eligibility and need for intervention based on physical development. In Wisconsin, physical development is defined as follows:

Physical development, including hearing and vision, as evidenced by gross motor and fine motor coordination, tactility, health and growth. [HFS 90.08 (7)(c)2]

Evaluation considerations for the areas of Gross Motor Development and Fine Motor Development will be addressed separately. Vision is addressed in the Fine Motor section. Hearing is addressed in the Communication section.

Motor Development

In the first three years of life a child typically learns to move effectively to reach, sit, crawl, walk, run, climb and jump. Ideally, movement is smooth, easy, coordinated, purposeful, graded and fun. Efficient motor control is characterized by variability and adaptability. Multiple factors influence motor progress, most obviously neurological and orthopedic integrity, but also general health and medical history, nutrition and feeding, metabolism and energy level, behavior and temperament. Motor skills are an end in and of themselves, but also critically support development in other domains. Cognitively, an infant needs to explore their environment and manipulate toy and non-toy objects alike. Emotionally, a toddler needs to earn greater autonomy (and learn self control). Socially, a preschooler needs to engage with friends, even if they are not able to fully “keep up with peers” in all situations.

These Guidelines highlight the components of evaluation and follow the process in a thematic manner. Additional considerations are noted as well. Appendix 1 provides milestones for gross motor development from birth to age three. Appendix 2 lists approximate lower extremity range of motion which would be expected in a 2 year old. Appendix 3 lists some evaluation tools with brief comments. Appendix 4 offers considerations when evaluating children less than 4 months adjusted age (a period when most assessment tools lack discernment and we must rely more on professional judgment). Appendix 5 contains information on muscle tone and various presentations. Appendix 6 is a reference on early reflexes and their integration.

Physical Development

Gross Motor

Components to evaluate

• Milestones and history (e.g., age at sitting, creeping, walking; recent changes/ rate of development; inhibiting factors such as illnesses)
• Function (across environments)
• Gross motor developmental level (as determined on standardized testing)
• Underlying strengths and impairments
• Temperamental considerations (e.g., motor-driven, observer, cautious, fearful)
• Potential equipment needs (positioning devices, mobility aides, orthotics, etc.)
• Environmental strengths and concerns

If gross motor development is an area of concern, evaluation includes:

• Ongoing conversation with parents and caregivers regarding their child’s
  • function and safety across environments (including frequency and pattern of falls),
  • overall health and activity level,
  • temperament and personality factors,
  • performance during the evaluation compared to their typical behavior.
  • Also elicit not-easily-observed information and
  • confirm that all concerns are being addressed.
• Clinical observation of the child’s
  • mobility (method, quality and functionality),
  • static posture (weight bearing alignment, sitting posture, etc.),
  • dynamic posture (transitions, walking on line, walking on tip toes, etc.),
  • gait pattern and any deviations and
  • overall quality of movement
• Administration of an evaluation tool for baseline and eligibility requirements. Some commonly used evaluation tools are listed in Appendix 3. As most assessment tools lack sensitivity with newborns – will “miss” children who later “develop” motor delays -- clinical judgment is even more essential (see also Appendix 4).
• Physical examination, including:
  • range of motion (please see Appendix 2 for approximate ranges)
  • muscle tone (please see Appendix 5 for comments on muscle tone)
  • clonus
  • balance reactions (speed, effectiveness, maturity)
  • tolerance to vestibular stimulation (e.g., swing, spin, toss in air)

Defer to the end any procedures which are likely to upset a particular child.

It is essential to rule out significant impairments, particularly if the child may not be seen again by a motor specialist. A thorough physical exam will assess atypical muscle tone, genu recurvatum or excessive calcaneal valgus in weight-bearing, clonus, heel cord or hamstring contracture, limited hip abduction (possible hip dysplasia), or weak or latent trunk balance reactions.

• Supplemental testing (as needed to identify underlying impairments):
  • balance challenge (e.g., step over obstacle, walk on pillow, recovery from perturbation, stance on rocker board, etc.)
  • strength indicators (e.g., ease of stair climbing, steadiness in squat, jumping, sustaining tip toes with or without hand support, etc.)
  • motor planning (e.g., novel fine motor task, climbing off couch, down stairs or off kitchen chair, complex fine motor task, etc.)
  • eye-hand/eye-foot coordination (e.g., catch, throw, kick; walk on a line, etc.)
  • respiration (e.g., pattern of chest expansion, sternal depression, rib flare, etc.)
• Trial intervention for purposes of assessment and planning (if appropriate and time permits).
• Closing Conversation with family to
  • Invite caregiver questions
  • Communicate initial impressions and findings
  • Provide home activity suggestions as appropriate
  • Foreshadow next steps (test scoring and analysis of findings, consultation with other professionals, phone call from service coordinator, written report mailed to family, meeting to determine eligibility, possible development of IFSP)

AFTER THE EVALUATION

• Reflect. Score and analyze test results.
• Consult with professional references and supports as needed.
• Synthesize findings and write report in family-friendly language.
• Participate in Eligibility Meeting and Individualized Family Service Planning.

If gross motor development is not an area of concern, it may be appropriate to gather information about the child’s gross motor abilities by using these methods:

• Checklist (e.g., Hawaii Early Learning Profile – Gross Motor strand)
• Screening (e.g., Denver 2, Bayley Screener)
• Parent Interview and Observation
• Play-Based Assessment

Acknowledgments

Special thanks to Victoria Moerchen, PT, Ph.D., Jennifer Bowen, OTR, Pam Erlanger, OTR, Lynne Herrli, PT, Janet Sternat, PT, Cyndy Smith, PT, Mary Locast, OTR, and the pediatric team at Middleton Rehab Clinic for their insights, feedback, resources and substantive input.

Selected References

Alexander, R., Boehme, R., & Cupps, B. (1993). Normal Development of Functional Motor Skills. Tuscon, Arizona: Therapy Skill Builders.

Cusick, B. (1990). Progressive Casting and Splinting for Lower Extremity Deformities in Children with Neuromotor Dysfunction. Tuscon, Arizona: Therapy Skill Builders.

Damiano, D.L., & Abel, M.F. (1998). Functional outcomes of strength training in spastic cerebral palsy. Archives of physical medicine and rehabilitation, 79(2): 119-125.

Dubowitz, Victor, (1980). The Floppy Infant, 2nd ed. England: Levanham Press Inc.

Jacobson, Richard D., (1998). Approach to the Child with Weakness or Clumsiness. Pediatric Clinics of North America 45 (1). W. B. Saunders Company

http://medicine.ucsd.edu/peds/Pediatric%20Links/Links/Neurology.htm

Moerchen, Victoria, PhD, P.T. 2003. Personal communication.

Appendix 1

Early Milestones in Gross Motor Development

Variable onset. Temperamental factors play large role in emergence. Quality is more telling than timing. Very early rolling may fade with loss of tonic neck reflex

Milestones	Ages	Comments
Rolling	3-6 months
Sitting	5-8 months	Gradual emergence. Posture is revealing, as well as maturity of balance reactions
“Creeping” (hands and knees)	8-9 months	By some accounts, 10-15 % of “typically developing” children do not creep. There are many benefits to creeping.
Pull to Standing	8-10 months	Usually emerges right after creeping.
Cruising	10-12 months	Important precursor activity for walking.
Walking	9-15 months	If child begins walking late (after 14-15 months) expect a more mature early gait pattern with less “toddling” quality, fewer falls, more rapid competence on uneven surfaces.
Crawl up stairs*	9-12 months	Dependent on opportunity to practice.
Climb safely off of couch*	10-16 months	Unwillingness may be indicative of difficulty with motor planning, body awareness, and/or visuo-perceptual delays. Visuo-perceptual experience with creeping should be considered.
Walk stairs* - 2 hand assist	18 months	Both hands held or one hand held and one on rail, “marking time” / “step to” pattern (i.e., placing both feet on each step).
Run	18-24 months	Technically involves “flight” (both feet off the ground at once). Functionally can be defined as when the child is “hard to catch.”
Walk stairs* - independent	24 months	Holding rail with one hand, marking time.
Jump	22-26 months	Both feet must leave the ground together.
Walk stairs* - maturing	36 months	Without holding onto support and marking time OR holding rail with one hand and using reciprocal pattern (one foot on each step).

* Items which are more experience-dependent in their emergence.

Adapted from Hawaii Early Learning Profile, Furuno, S., et al (1995) with practitioner input.

Appendix 2

Selected Lower Extremity Range of Motion (ROM) Table

Lower Extremity Range of Motion	Approximate range for 2-year-old	Comments
Hamstring length test, measured in supine with hip flexed at 90 degrees and contra-lateral thigh in relaxed extension: Extend knee up toward 180 degrees. Measure end range (R2), expressed often as a negative. Note angle of first catch (R1) if there is spasticity.	Neutral to -20 degrees of full knee extension	Hamstring length less than -20 degrees (e.g., -30 degrees) can be considered limited. Excessive hip range is consistent with low muscle tone, although a precaution is to flex hip only to 90 degrees in Thomas position to avoid overstressing SI joint.
Hip Abduction (supine)	60 degrees	90 degrees is possible for a child with low tone/ joint laxity. Limited range may indicate hip dysplasia.
Hip External Rotation (supine, 90/90 knee/hip)	80 degrees	Supine testing is not consistent with prone testing of ER and IR, which is used for clinical assessment of hip torsion.
Hip Internal Rotation (supine)	30-45 degrees	Greater range may be a sign of habitual “W” sitting (with resultant soft tissue changes).
Ankle Dorsiflexion (in subtalar neutral)	15-30 degrees	25-45 degrees in 1 year old reduces to 10-20 degrees by about 5 years. Range of 45 degrees or more can be considered increased. Less than 10 degrees may impact balance and gait.

Estimated ranges were primarily compiled from practitioner findings, most often non-goniometric.

Reference was also made to Progressive Casting and Splinting for Lower Extremity Deformities in Children with Neuromotor Dysfunction, 1990, by Beverly Cusick, which should be consulted for more definitive joint ranges by age as well as postural and gait parameters.

Appendix 3

Considerations when evaluating children less than 4 months (adjusted) age:

• Family Concerns
• Diagnoses, conditions, complications, pertinent family history
• History of care in the NICU with oxygen supplementation
• Known neurological conditions (such as intraventricular hemorrhage, periventricular leucomalasia, etc)
• Failure to Thrive (poor suck, fatigue with feeding, difficulty with coordination of breathing, sucking, swallowing)
• Tube feedings beyond NICU period
• History of frequent seizures, particularly if uncontrolled
• Difficulty with self-regulation (highly arousable, easily upset and difficult to calm, extremely sleepy well past first month, frequent hiccups)
• Stiff: body seems tight with clothing and diaper changes, straightens and holds legs stiffly, does not conform body to adult when being held, arms do not explore own body
• Floppy: feels “like a sack of flour”, legs “frogged” in supine in first month of life, arms flop out to sides, seems passive to gravity
• Does not move arms and legs after 1 month of age (as when excited during play or interaction with adults and siblings)
• Does not show emerging head control*
• Lacks visual engagement (holding eye gaze and social smiling) by 4 months of age (Moerchen, PhD, P.T. (2003) Personal communication).

Development of early head control

• A newborn lifts and turns head part way in prone.
• A baby holds head erect briefly in supported sitting, not steady but bobs and lifts head in prone 45 degrees by end of second month.
• And, when held upright at three months, the baby maintains the head in a vertical position and, if tipped forward or back, the baby extends or flexes the head and neck accordingly. In the fourth month, lateral flexion occurs when the baby is tilted to the side. By five months, when pulled to a sitting position, the baby flexes and lifts the head, tucking the chin.

Alexander, Rona, Boehme, Regi and Cupps, Barbara. (1993). Normal Development of Functional Motor Skills, Therapy Skill Builders.

Appendix 4

Evaluation tool (examples)	May be appropriate for:	Comments:
Alberta Infant Motor Scale (AIMS)	Pre-walkers, under 16 months	Fast, observational gross motor tool. Assess in prone, supine, sit and stand W.B. Saunders Company
Peabody Developmental Motor Scales, second edition - Gross Motor (PDMS2 - GM)	Child with divergent Gross and Fine Motor skills	Separation of 4 GM sub-tests aids analysis, although each subtest is not equally sensitive for every age group. Riverside Publishing
Bayley Scales of Infant Development, 2nd ed. (BSID-2)	General motor delays suspected	3rd edition now available. Psychological Corporation
Toddler Infant Motor Protocol (TIMP)*	Preemies; for kids at risk for cerebral palsy	Newer test. Infant Motor Performance Scales, LLC
Gross Motor Function Measure (GMFM)**	Children with cerebral palsy.	Valid and sensitive measure of progress. GMFM Score sheets & Gross Motor Functional Classification System for Cerebral Palsy (GMFCS) available at no cost http://www.fhs.mcmaster.ca/canchild/

• Note: the TIMP used “high risk” and “low risk” infants for standardization, rather than typically developing children. As a result, the TIMP recommends children who score .5 standard deviation below the mean be considered delayed (the 1.3 standard deviation cutoff in HFS 90 is not appropriate; clinical judgment can be cited and evidence of atypical development carefully documented).

Appendix 5

MUSCLE TONE

Low Muscle Tone/Hypotonia

Tone is tension or resistance to movement of resting muscles. Reduced tone cannot be described. It can only be experienced. There is not a precise dividing line between abnormally reduced tone and normal tone. The examiner must place the individual patient along a spectrum defined by his or her own experience. Examination of many normal children is essential in defining this spectrum.

Hypotonia is usually assessed by passive manipulation of the arms or legs, which can be made into a game with younger children. Other maneuvers that assess tone include pulling the child from supine to sitting (traction response); holding the child vertically with the hands underneath the arms; holding the child in ventral suspension (tummy down). The child’s response to these maneuvers depends not only on passive tone, but also on the strength generated by their proximal limb girdle and trunk muscles. Weakness and hypotonia are different aspects of motor control that should not be used interchangeably.” (Jacobson, 1998)

Descriptors/ definition of low muscle tone:

• Decreased resistance to passive elongation of a muscle
• Excessive joint laxity
• Atypical postures

A child with low muscle tone could present as follows. This “constellation of findings” is presented in the order characteristics might be observed during the evaluation:

• parents and teachers describe the child as “clumsy” or “weak”
• history of delayed milestones, falls
• open mouth appearance; drooling in absence of illness or teething, decreased facial expressiveness
• sitting posture: rounded back; sacral sitting; habitual or exclusive “W” sitting; leaning against support such as couch; propping on hands in sit
• creeping posture, speed and pattern: knees wide apart, lordotic (not using abdominals against gravity to raise/”flatten” spine), hands turned (fingers pointing inward), slower speed , difficulty creeping over obstacles such as an adult leg (all of these signs are typical for approximately first two months of creeping)
• standing posture: wide base of support, “toe out”, locked or hyper-extended knees
• immature gait: persistent side-to-side toddle (“Trendelenberg”)
• immature run: persistent high arm guard position; slow speed, decreased trunk rotation with reciprocal arm swing (for age), compensatory “hip swivel” (due to posture/ alignment), inconsistent foot placement
• delayed balance, excessive falls for age
• ineffective protective extension (as evidenced by bumps, bruises on face) due to arm or neck weakness or slow reaction
• use of momentum, leverage, other compensatory movement strategies
• specific muscular weakness (e.g. inability to rise onto tiptoes or poor eccentric quadriceps control with stair descent)
• phasic but not tonic muscular contraction (e.g., no sustained tiptoe standing)
• pronounced specialization of sides (i.e., right side mobile side, left side stability side)
• avoidance of static postures (e.g., refuses to attempt single limb stance or walking on line)
• lower extremity alignment: pronated feet (arches more collapsed than typical baby flat feet), calcaneal valgus (ankle rolling in), toe out (particularly if from forefoot)
• poor head control (significant head lag when pulled to sit after 4 months of age, inadequate head control when moved about)
• slow, immature, ineffective balance reactions in trunk (as seen when tipped in space when sitting on theraball or therapist’s knees, point of control at pelvis)
• “slip through” when held around trunk at armpits (usually more significant central hypotonia)
• poor tolerance to vestibular stimulation possible
• low tone when child relaxed and legs or arms passively moved
• crepitus
• calf muscle bulk feels “squishy”
• joint laxity
• increased range of motion (common pattern: hip abduction and ankle dorsiflexion, often also hip flexion, finger extension)
• may have decreased hamstring range (due to guarding with hamstrings in sitting and/ or “W” sitting)
• may develop decreased ankle dorsiflexion (due to lack of use of dorsiflexion range with chronic “toe out” position)
• decreased endurance and activity level (observed and reported)
• decreased vocalization/ breath support/ length of utterance
• poor motor planning (due to decreased body awareness or lack of practice)
• fine motor may be a strength or grasp patterns may be delayed (inaccurate reach, unrefined pincer grasp, opposition of thumb with middle or more lateral fingers, use of straight instead of rounded fingers to utilize stability of end ranges)
• delayed self-help skills such as removing socks (due to need to prop with a hand in sitting, inability to reach forward using flexion control trunk rotation, weakness of grasp)
• behavioral adaptations to avoid demands (screaming, tantrums, tears, excessive need by child to control activity or how they are moved)
• persistent self-direction toward sedentary, fine motor activities.

Physical therapy prognosis (expectations about rate and course of development) is based on the child’s diagnosis (the etiology of their condition) even more than on the child’s presentation. To illustrate this, at a given testing point, two children with hypotonia may have similar test scores and age at milestones. However we would anticipate a child with anemia to progress more rapidly after receiving iron supplements than a child with Down Syndrome, whose standardized scores might diverge further from the norm over time even with intervention.

Low Muscle Tone: Consideration of Underlying Issues (differential diagnosis)

• Metabolic low tone: child with low energy level and poor endurance (possible anemia or Carnitine deficiency, often unknown etiology)
• Respiratory low tone: chronic respiratory illnesses, nasal discharge, energy fluctuates with health
• Sensori-neural low tone: good energy level, may have poor body awareness or poor motor planning (e.g., Idiopathic; Autism spectrum; Down Syndrome)

High Muscle Tone/Hypertonia

Many of the underlying impairments and functional limitations listed above for low muscle tone may also describe aspects of a child with high muscle tone. For a child with increased tone, in addition to spasticity or rigidity, the “constellation of findings” could include:

• parents describe the child as “tight”; caregivers note difficulty opening legs for diaper changes baby may feel “different” when held or legs are moved
• history of delayed milestones, possibly quite significantly delayed
• “reflexive” (persistent asymmetrical tonic neck reflex (ATNR), symmetrical tonic neck reflex (STNR), reverts to reflexive postures when stressed or surprised)
• appearance of excessive effort with of without movement
• lack of isolated muscle control (synergistic patterns)
• atypical movement patterns (e.g., commando crawl by pulling with forearms, legs dragged behind)
• atypical gait pattern, such as “crouched gait” (may increase over time with decreasing range of motion or increasing balance demands) or “scissoring gait” (a very significant finding which may be present even with early assisted walking)
• asymmetric gait features, such as unilateral hip hike, leg circumduction, medial heel whip, inadequate toe clearance (as in spastic diplegia)
• toe walking due to muscle tone (vs. idiopathic toe walking)
• persistent high arm guard with gait, decreased “freedom” for arms to move
• lack of protective extension due to arm guard postured, tight biceps, disadvantaged/ inhibited/weak triceps
• decreased speed with attempt to run, “bouncy” quality
• generally poor balance and coordination due to lack of dynamic and graded muscle control;
• lack of variety with movement (as with climbing or descending stairs)
• decreased trunk rotation (log roll, lack of rotation with reach in sitting)
• pull-to-sit sign: child’s hips do not bend easily with this maneuver so their bottom slides toward you or child goes straight to standing (may be early indicator of diplegia or, if transient, just a phase where the child wants to get on their feet)
• “stiff” trunk when held and swung
• decreased range of motion, particularly tight hamstrings and shortened heelcords
• sternal depression or emerging pectus excavatum (due to excessive reliance on rectus abdominus and lack of dynamic abdominal oblique control)
• fisted or overly-flexed hands (beyond 4-6 months)
• poor control with release (may put hand in container when releasing object, may have poor control of directionality when tossing a small ball)
• lack of reaching across midline and bimanual coordination (due to arm guard posture, decreased trunk rotation)
• “retracted” lips with or without drooling or,
• “forced” quality to vocalizations
• Weakness, or the inability to generate force, will be a significant underlying impairment for children with hypertonia. This is true even if parents report feeling that their child is unusually strong, such as if it is hard to bend their child’s legs for diaper changes or if there seems to be precocious weightbearing. See also the research of Damiano in support of strength training for children with cerebral palsy.

Appendix 6

Newborn Reflexes

Infantile reflexes are tested and observed by the medical team to evaluate neurological function and development. Absent or abnormal reflexes in an infant, persistence of a reflex past the age where the reflex is normally lost, or redevelopment of an infantile reflex in an older child or adult may suggest significant neurological problems.

As a newborn and young infant, most of your baby's development and physical reactions will be determined by primitive reflexes. For example, if you brush your newborn's cheek, he will likely turns his head (rooting reflex), which helps him to find a breast or bottle for a feeding. Or if you place a nipple in his mouth, as it touches the roof of his mouth, it will cause him to begin sucking (sucking reflex).

There are many of other types of reflexes, most of which are present at birth, including the Moro or startle reflex, walking or stepping, tonic neck reflex and the palmar and plantar grasp. It is not always easy to demonstrate these reflexes and not all babies do them all of the time, so don't be surprised if you or your Pediatrician can't trigger all of the reflexes. More important, is your baby's overall growth and development. Absent, asymmetric or persistent reflexes might be a sign of a neurological problem, though, and need further evaluation.

Moro Reflex

Also called the startle reflex, the Moro is usually triggered if your baby is startled by a loud noise or if his head falls backward or quickly changes position. Your baby's response to the moro will include spreading his arms and legs out widely and extending his neck. He will then quickly bring his arms back together and cry. The Moro reflex is usually present at birth and disappears by 3-6 months.

Grasp

This reflex is shown by placing your finger or an object into your baby's open palm, which will cause a reflex grasp or grip. If you try to pull away, the grip will get even stronger. In addition to the palmar grasp, there is also a plantar grasp, which is elicited by stroking the bottom of his foot, which will cause it to flex and his toes to curl. The palmar and plantar grasps usually disappear by 5-6 months and 9-12 months respectively.

Stepping/Walking

Most parents are surprised by this reflex. If you hold your baby under his arms, support his head, and allow his feet to touch a flat surface, he will appear to take steps and walk. This reflex usually disappears by 2-3 months, until it reappears as he learns to walk at around 10-15 months.

Positive Support Reflex

Like the stepping reflex, if you hold your baby under his arms, support his head, and allow his feet to bounce on a flat surface, he will extend (straighten) his legs for about 20-30 seconds to support himself, before he flexes his legs again and goes to a sitting position. This reflex usually disappears by 2-4 months, until it becomes a more mature reflex in which there is a sustained extension of the legs and support of his body by about 6 months.

Tonic Neck Reflex

A postural reaction, the asymmetric tonic neck reflex, or fencer response, is present at birth. To elicit this reflex, while your baby is lying on his back, turn his head to one side, which should cause the arm and leg on the side that he is looking toward to extend or straighten, while his other arm and leg will flex. This reflex usually disappears by 4-9 months.*

Galant Reflex

If your baby is on his stomach and you stroke neck to the spinal cord (paravertebral area) on his middle to lower back, it will cause his back to curve towards the side that you are stroking. This reflex is present at birth and disappears by 3-6 months.

Infants also have reflexive postural reactions that usually begin later in the first year of life. These postural reactions include:

Derotational Righting

This reaction usually appears by 4-5 months, and involves your infant's body turning to follow the direction of his head when it turns, helping him learn to roll over.

Parachute Response

This is a protective response that protects your infant if he falls. Beginning at about 5-6 months, if an infant falls, he will extend his arms to try and 'catch' himself.

Propping

Beginning at different ages, the propping responses help your child learn to sit. The first is the anterior propping response, which begins at 4-5 months, and involves your infant extending his arms when he is held in a sitting position, allowing him to assume a tripod position. Next, lateral propping, appearing at 6-7 months, causes him to extend his arm to the side if he is tilted. Lastly, posterior propping, causing him to extend his arms backwards if he is titled backward. It is also important that the reflexes are symmetric, meaning that they are the same on both sides of the body. An asymmetric Moro reflex, for example, might mean that your baby has weakness on one side of his body.

Edited from MedlinePlus, a service of NLM and NIH:
www.nlm.nih.gov/medlineplus/ency/article/003292.htm