Motor Skills Concerns

Tummy time is an important position in early infancy that has been shown to impact gross motor skill development. You can read a recent article about it on our website. Again, I can't say for sure that lack of tummy time contributed at all to your son's lack of crawling, etc.

Walking at 16 months, although maybe later than some of his peers, is still considered within average. However, since you mention that he cannot yet assume a standing position without support and has trouble squatting down to pick things up, I am wondering if perhaps he has low muscle tone? Children with low muscle tone often achieve motor milestones later than average and in comparison to children with typical muscle tone, may feel "floppy" when carried or held. Low muscle tone can be assessed by a physical therapist or diagnosed by your son's pediatrician. I would also ask your pediatrician to check your son's hips (this is usually done at well baby visits) to rule out any problems.

As therapists we do tell families to use play equipment like walkers, exersaucers & bouncers in moderation, since these devices have been shown to not actually have any benefit in helping children to walk and often instead of developing a child's quadriceps muscles that they need for walking, they develop the calf muscles more and sometimes lead to toe walking. But, having said that, it would be hard to say if spending time in a walker on a ride on toy had any negative impact on your son's development.My recommendation would be to definitely call your local early intervention provider so the team can tell you if your son is demonstrating any developmental delays and if he is, he can begin physical therapy to work on these skills. This is a link I found for services in NC.

Torticollis should be diagnosed by your doctor and then a pysiotherapist should provide stretching exercises during therapy and can teach you some exercises you can also do at home. It is good that you are trying to position her on the opposite side for sleeping. You can also do things such as, positioning her chair during meals so that she has to turn to her non-preferred side to look at you and interact with you. Do the same if she is watching tv, etc. If you do not have a pysiotherapist in your area, you can review these stretching exercises for home use, but we strongly advise getting the advice of your child's doctor in getting an accurate diagnosis and seeking the guidance of a physiotherapist in performing these stretches to prevent injury.

You can gradually ease her into more time on her stomach, by playing with her as she lies on your chest facing you or getting down on the floor on a blanket with her. Try to build up her ability to play in this position for at least 5-10 minutes, 3-5 times per day. You can read a few of our articles on our website which tell you why tummy time is so important for young babies. And also check what is typical for her motor milestone development. Right now at age 5 months you want to focus more on the tummy time, rolling actively in both directions (stomach to back and back to stomach), as well as reaching for toys when she is on her stomach by being able to hold her chest up, pushing up on extended arms and reaching for a toy with one hand or the other. Here is an excellent source of information on how to encourage tummy time during play, carrying, diapering, etc.

I would also look into an early intervention evaluation from a physical therapist in your area so that she can start receiving therapy to help her progress in her motor skills. I was unable to locate a specific resource for early intervention/pediatric physical therapy in your area, however, perhaps if you contact someone at this website link they can point you in the right direction for resources available to you in the Toronto area.

You can ask you doctor about the possibility of this diagnosis on Friday and see if he recommends any specific referrals or testing to help get to the root of her problem.

Babies from 3-5 months still do a lot of hand to mouth with or without a toy, which is age appropriate. By the time a baby is 6-7 months old they can typically reach with control from a variety of positions (belly, back, sitting, sidelying), but right now your son's reaching may be more difficult in positions where he has less stability or support such as in his exersaucer or when on his belly. He may also still be using his fingers without his thumb to grasp, which is also ok for his age.

As far as standing, most babies by 5 months will briefly bear some weight on their legs and flex and extend their knees and by 6 months will bear weight for longer periods and bounce actively while requiring less support in this position. By the time a baby is 7-9 months they should be able to stand well with support against an object or with both hands held.

You can review our Gross Motor Development & Fine Motor Development sections at these links:

I wrote a few weeks ago about my son who shows no interest in reaching/grabbing for toys or         anything. He is very social, "talkative," full of smiles, and laughs. It almost seems like he is         bored with the toys and wants to connect to the person/people instead. My pediatrician said that everything         looks great and normal but seemed concerned when I brought this issue up. He doesn't reach for         his pacifier, my hair, or anything. She did say that it was very good that he is able to bring his         hands together at his midline and put them in his mouth. She referred us to early intervention         and we are just waiting on them to call and set up an appointment. I am literally going crazy         with anxiety while we wait. My question to you is, what could this mean? Sensory disorder,         developmental delay, autism? I know you can't diagnose him without seeing and interacting with         him, but I want to know if he is meeting every other milestone, what could no interesting in         reaching or grabbing for things mean? What possibilities are we looking at? I'm just trying         to prepare myself instead of drive myself crazy with anxiety.

I am sure it brings anxiety for you waiting for the early intervention team to show up to evaluate         your son, but be assured that this is the best possible thing you can do at this point to allay your         fears and help your son if he indeed needs help in any area of his development. Without knowing your         son, I am still apt to say that he may just need a little more time to develop his reaching skills         since he only just turned 5 months old on March 1. Most young babies still clearly prefer people and         faces over toys and believe it or not that is a good thing. If he did not look at your face and did not         show interest in people, I would be concerned. He may actually begin reaching for your face, hair or jewelry         before he begins reaching for toys. When the team arrives to assess your son, they may have a developmental         specialist or an OT and/or PT look at your son's fine motor/reaching skills. At age 5 months, we are mostly         looking at skills such as bringing his hand together at midline (which he is doing), bringing hands to         mouth (which he is doing) and bringing hands to mouth with a toy, which I think you said he will do if         you place the toy in his hand. I would also look for him to begin transferring a toy from hand to hand         by the 6th month. His hands should also be open most of the time and if they are sometimes fisted, they         should be very loosely fisted and not tight or with the thumb indwelling. Does he put his hands onto         the bottle at all when you feed him? I would not expect him to hold it yet, but ideally he should be         patting the bottle with one or both hands during feedings. Between 3-5 months babies are just         developing tactile awareness in their hands and learning how to use their hands and fingers. The         batting and swiping at toys comes way before the actual directed reach and clear grasp. The only other         thing I would suggest is that if you haven't done so, to have his vision screened since visual deficits         can be one reason a baby will not reach for things. The OT and/or PT on the early intervention team         will also assess his muscle tone and range of motion in his upper and lower extremities to make sure         he is not too loose or too tight which can prevent a child from being able to move in a typical pattern.         The team will only be able to tell you if he is showing a developmental delay in one of the areas of         development (Gross Motor, Fine Motor, Cognitive, Self-Help, Social, Communication), they cannot make a         specific diagnosis, but you can ask them about sensory issues if you are concerned about that.

You may want to try using wrist rattles, the little soft rattle toys that attach to a baby's wrist with         Velcro, this way the toy is on his one wrist and will encourage him to reach for it with his other hand and         he will not drop it. Then switch it to the other wrist and do the same. Also you can massage his hands and         fingers to improve his tactile awareness. If he is not reaching toward toys in his bouncy seat, try rolling         up small receiving blankets or towels and placing them behind his shoulders to bring his shoulders forward         which may help to bring his hand together and make it easier for him to reach toward the toys. You can also         do this on the floor if he is lying under a baby gym. Also, since many rattles these days are heavy, we suggest         using the connector rings that you use to hang toys on baby gyms, since these rings are small and light and the         right size for a baby's hands. Sometimes babies will hold or grasp a single connector ring before they are         able to grasp a heavier, larger rattle. You can also use textured books with your son, opening his palm and         guiding it across the page to feel the various textures or do this on the carpet or a pillow or blanket,         helping him feel different textures. Best of luck with his upcoming evaluation and let us know what the team         says. This link on our page talks a little bit about the process of early intervention and what to expect.

We are not sure what specific tests he might recommend for your daughter, but it could possibly be an MRI. Our suggestion would be to speak to your daughter's PT at school and she may be able to give you a better idea of why she recommends it and what tests she thinks the neurologist may perform. Seeing the neurologist can't hurt and it may give you piece of mind in ruling out other concerns. There are many children who have low muscle tone and no specific cause has been found, however other children have low muscle tone due to a specific diagnosis.

You can use a boppy pillow or a pile of regular pillows around her on the floor to encourage her to practice independent sitting. Place toys to her left and right sides and not always directly in front of her to encourage her to pivot and reach for things when she is on her belly and while sitting. After each diaper change you can work on helping her into a natural sitting position by (instead of just picking her straight up) by rolling her to her side, and placing on of your hands on her hip and your other hand on her opposite shoulder and rotating her up into a sitting position. This will help her to learn to achieve a sitting position on her own, and as she gets stronger she should be placing her hand on the floor and helping push herself upwards. You can also sit her on an exercise ball and gently bounce her, tipping her gently from side to side and encouraging her to "right" her body back into midline. This may help increase her core strength needed for more complex motor skills. You can lie her on her belly on a small playground ball and roll her forward encouraging her to place her hands on the floor and then rolling her back again into her knees. Limit her time spent in bouncy seats, exer-saucers, walkers, etc. A physical therapist will be able to give you many more suggestions on how to work on her motor skills during playtime. You can consult with your local Help Me Grow program, seek out a private physical therapist through your insurance or this is a link to early intervention services in your area: Clark County Board of MR & Developmental Disabilities: Early Intervention Services 2430 Van Buren Avenue, Springfield, OH 45505-2555 Phone: (937) 328-2680.

You can also sit him on your lap facing away from you, and sing a song, as you rock him side to side and gently apply some downward pressure to his knees (make sure his bare feet are flat on the floor under his knees-he should always be placed so his body is in alignment). You could also sit him on a small ball, small enough so his feet are flat on the floor when seated and do the same exercises, supporting him at the trunk/hips as needed. I would also mention your concerns to your pediatrician at his next well baby visit. Depending on the advice of your pediatrician, if you are still concerned about his motor skills and your son is not bearing weight and starting to bounce by around 9-10 months of age you may wish to have a physical therapy evaluation through your local Early Intervention provider: http://health.state.ga.us/programs/bcw/

You may want to refer to this recent "Ask A Therapist" question (I    copied and pasted it below), which details some ways to work on    independent walking skills (http://www.earlyinterventionsupport.com/commonquestions/asktherapist-development.aspx):

My daughter is 19 month old. She is not walking independently. She    is mostly walking by kneeling down but a couple times I have seen her    take a few steps but still reluctant to walk independently; otherwise    she holds my finger and walks. Hip x-rays were taken. All seems fine    according to her pediatrician. Otherwise, her vocabulary is great.    She knows a lot of words. Her memory is also great! Please let me    know what might be the reason.

Most children walk by age 18 months, but there are still plenty of    children who are late walkers who for some reason don't begin to    fully walk independently until closer to age two. Some of these    children are knee walkers or very fast crawlers and for them it seems    like "why walk when I can get there faster this way.

Some of these children are carried a lot by caregivers. I am glad    you checked with your pediatrician first and had your daughter's hips    checked. If she is walking with one hand held, that is a good sign    that she will soon take off on her own, she may just need to gain    that extra confidence to let go of your hand. I would recommend    carrying her as little as possible when at home and encouraging her    to walk pushing toys or holding your one finger as you mentioned. You    can also have her walk behind a large ball (like an exercise ball)    pushing it across the floor. You can try little tricks like dressing    her in overalls, so that you can hang onto the back straps of the    overalls while she walks (since you'll be behind her, she won't    notice as much when you are holding on or letting go) and much like    riding a bike "let go" when you feel she has her balance so that    hopefully she will take a few steps on her own. Some parents even    attach an extra little strap to the back of the overalls so they    don't have to bend down as far while their child is practicing    walking. You can also have her stand with her back to a couch so she    has her balance and then give her a small ball or stuffed toy to hold    so that she has to use both hands to carry it and encourage her to    come show the toy to you.

I would also suggest not using walkers or exersaucers with her    right now, or if you do, limit it to very short time periods since    she needs to develop strength and balance on her own. You can play    squatting games with her to help strengthen her quadriceps muscles    which she needs for walking, have her hold your hands and squat down    and then pop back up. If you continue to have concerns and your    daughter is not progressing with independent walking within the next    month I would suggest calling your local early intervention provider    for a physical therapy evaluation to rule out that any other factors    (such as low muscle tone) are contributing to her inability to walk    on her own.

Also check out our link for Gross Motor Skill Development for ages    9-12 months, as this section would also apply to a 14 month old    child: http://www.earlyinterventionsupport.com/development/grossmotor/9-12months.aspx

If you continue to have concerns, or your son is not yet pulling    to stand, cruising along furniture or walking with both hands held,    you may want to contact your local early intervention provider for a    physical therapy evaluation. This is a local link I found for your    area: http://www.southbaymentalhealth.com/families.html

I have copied and pasted below the answer to a similar question to    yours which we just answered on our website in recent weeks (http://www.earlyinterventionsupport.com/commonquestions/asktherapist-development.aspx 3rd question/answer on the page).

Most children walk by age 18 months, but there are still plenty of    children who are late walkers who for some reason don't begin to    fully walk independently until closer to age two. Some of these    children are knee walkers or very fast crawlers and for them it seems    like "why walk when I can get there faster this way?". Some of these    children are carried a lot by caregivers. I am glad you checked with    your pediatrician first and had your daughter's hips checked. If she    is walking with one hand held, that is a good sign that she will soon    take off on her own, she may just need to gain that extra confidence    to let go of your hand. I would recommend carrying her as little as    possible when at home and encouraging her to walk pushing toys or    holding your one finger as you mentioned. You can also have her walk    behind a large ball (like an exercise ball) pushing it across the    floor. You can try little tricks like dressing her in overalls, so    that you can hang onto the back straps of the overalls while she    walks (since you'll be behind her, she won't notice as much when you    are holding on or letting go) and much like riding a bike "let go"    when you feel she has her balance so that hopefully she will take a    few steps on her own.

Having said that, as therapists we look for babies to be pushing    up on extended forearms on their bellies by around 5-6 months,    rolling smoothly with coordination in both directions within the 6-9    month old period (you may read that most babies are rolling in both    directions by 5 months, but many babies still do this purely by    accident and not purposely at this age), and fully bearing weight on    feet and bouncing in a standing position by around 7-9 months (many    babies are just starting to bear weight on their feet around 5 months    of age). All babies develop at their own pace. I would encourage you    to mention these concerns to your pediatrician at your next well baby    visit so he can observe your daughter. Red flags would be if you feel    your baby's muscle tone feels too floppy or too stiff, or if she    prefers one side of her body over her other (such as keeping her head    turned to one side frequently or rolling to only one side). It is    great that you are doing tummy time with her, since this is indeed    the most important time for her to develop and practice the skills    you mentioned. It sounds like she has nice head control and neck    strength, so maybe she needs to develop more trunk/core strength. You    can encourage her to play with her feet when on her back, tucking a    blanket roll under her hips to help her raise her feet and place    rattle socks on her feet to entice her. You can encourage her to push    up on extended forearms by rolling up a small blanket and placing it    under her armpits so that her chest is now lifted and it makes it a    bit easier for her to place her forearms/hands on the floor.

Lay on the floor in front of her and entice her to push upwards    with mirrors and toys to reach toward. You can also place her on her    tummy over the lower part of your leg, knees bent under her in a sort    of kneeling position so her chest rests on your leg and encourage her    to put her hands down on the floor to bear weight on them. You can    facilitate rolling during play with her, gently guiding her at the    hip and opposite shoulder or simply tip the blanket by lifting a    corner to help her get the momentum to roll over. You can let her    play in a side-lying position (left and right sides) and then    practice rolling side to back or side to tummy. You can sit her on    your lower leg, straddling your leg, and gently lift her up and down    to encourage weight bearing on her feet. Also while in a sitting    position with her feet touching the floor you can very gently apply    pressure to her knees so that her feet feel the pressure of the floor    beneath her. Since babies learn new skills almost daily during these    early months you may want to give her another month to practice.    However, if you are very concerned right now, or if your pediatrician    has concerns or if you do not see anymore progress with these skills    by 6-6.5 months I would call your local early intervention provider    to have a free physical therapy evaluation completed to rule out any    concerns. Your local early intervention provider is: Montgomery    County Infants and Toddlers Program Administrative Office 51 Monroe    Street, Suite 1700 Rockville, MD 20850 Phone: 240 777-3997 Program    Director: Ronnie Biemans http://www.montgomeryschoolsmd.org/departments/infantstoddlers/

Some of these children are carried a lot by caregivers. I am glad    you checked with your pediatrician first and had your daughter's hips    checked. If she is walking with one hand held, that is a good sign    that she will soon take off on her own, she may just need to gain    that extra confidence to let go of your hand. I would recommend    carrying her as little as possible when at home and encouraging her    to walk pushing toys or holding your one finger as you mentioned. You    can also have her walk behind a large ball (like an exercise ball)    pushing it across the floor. You can try little tricks like dressing    her in overalls, so that you can hang onto the back straps of the    overalls while she walks (since you'll be behind her, she won't    notice as much when you are holding on or letting go) and much like    riding a bike "let go" when you feel she has her balance so that    hopefully she will take a few steps on her own. Some parents even    attach an extra little strap to the back of the overalls so they    don't have to bend down as far while their child is practicing    walking. You can also have her stand with her back to a couch so she    has her balance and then give her a small ball or stuffed toy to hold    so that she has to use both hands to carry it and encourage her to    come show the toy to you.

I would also suggest not using walkers or exersaucers with her    right now, or if you do, limit it to very short time periods since    she needs to develop strength and balance on her own. You can play    squatting games with her to help strengthen her quadriceps muscles    which she needs for walking, have her hold your hands and squat down    and then pop back up. If you continue to have concerns and your    daughter is not progressing with independent walking within the next    month I would suggest calling your local early intervention provider    for a physical therapy evaluation to rule out that any other factors    (such as low muscle tone) are contributing to her inability to walk    on her own. This is a link to a provider in your area: http://www.iceckids.org/html/icechome.htm

Once this is ruled out I would practice using a therapy ball or    large playground ball that is big enough that your son can stand in    front of it at about chest height. Make a game of singing and rolling    him forward with his belly on the ball and then back onto his feet.    Row, row, row your boat is a great song for that activity. He may    even enjoy just standing beside the big ball and patting it as a    game.

Since he already enjoys kneeling and playing in this position, you    can help him to assume a 1/2 kneel position by helping him shift his    weight and bringing one foot forward, which will be the position he    eventually use to pull to stand on his own. Often you can tempt    babies to try to pull to stand by placing some of their favorite toys    just out of reach on a low table or couch...if he gets to his knees,    push the toys a bit farther out of reach and help him assume the 1/2    kneel and boost him upwards so he can reach the toys. Make a game out    of it and practice it several times a day.

You can also sit him on your leg, with one of his legs on either    side of yours and raise him up and down encouraging him to press his    feet on the floor and stand as you raise him up with support.    Bouncing in this position can help him increase the strength in his    quad muscles that he needs for walking. Do not wear shoes on him, he    needs to feel the floor under his feet to develop these skills. Since    he is already pushing toys by knee walking, he will probably soon    begin to pull himself up on his own.

All babies develop at their own pace, but generally we look for    children to walk independently by around age 15-16 months, so your    son still has plenty of time for practicing these needed skills. If    you continue to have concerns and your son is still not weight    bearing on his feet within the next month I would recommend calling    your local early intervention provider to request a physical therapy    evaluation.

I am suggesting the OT evaluation since some children have sensory    issues which could be a reason your son does not like to bear weight    on his hands and knees and does not like his hands to be touched.    Does he have any sensitivity to his hands being messy when eating or    his face being wiped, etc? Has your son ever had his vision    evaluated? I would schedule a screening with your child's doctor to    rule out any problems related to his vision which could be another    reason he is hand gazing. Vision problems can also contribute to    delayed gross motor skills. You could also ask if your local early    intervention program provides functional vision evaluations.

Having said all that, I would continue to encourage floor play as    much as possible to increase his motor skills. Limit the use of    walkers, bouncers, etc so he can practice important skills on the    floor as much as possible. Crawling is a very important developmental    milestone, and can be encouraged by placing your son over your leg on    the floor, with his knees bent and hands bearing weight in front of    him, rock him back and forth and sing simple songs to make it fun.    You can also tape some large cans together or roll up several towels    to make a roll and place him over this roll in a hand/knee position.    Gently rock him back and forth so he is encouraged to bear weight on    both hands and knees. Place a mirror in front of him and place toys    to the left and right side, encouraging him to bear weight on one    hand while reaching for a toy with his other hand. You can also use a    small playground or exercise ball and place him belly down on there    and roll him back and forth bringing him forward to his hands and    then back to his knees or feet.

Work on transitional positions, such as encouraging him to go from    laying down to sitting by rotating his body, as well as going from    sitting to hand knee. Place the roll to his left or right side    (alternate) and help him rotate over into a hand-knee position. You    can use a small box turned upside-down as a table, and place your son    in a kneeling position beside the box for play to encourage weight    bearing on his knees. Make sure his heels are under his bottom (don't    allow him to sit in a "W" position with his bottom on the floor    between his legs) and help him pull up to a tall kneeling position.    When he is able to tolerate tall kneeling, you can help him move one    leg out into a half kneel position which he will need to pull up into    standing. Sometimes furniture in the house is simply too high for    little ones to pull up on, so use boxes, breakfast trays, lap desks    etc, whatever works best for your son's height. Ideally when he pulls    to stand the object you are using for a table should be about armpit    height or a bit lower.

Tummy time is the most important position for developing later motor skills. Typically between 4-5 months is when most babies do begin to push up a bit on extended arms lifting their chests off the floor. To encourage these skills lots of tummy time is important throughout your daughter's waking hours. You can roll up a small towel or receiving blanket under your daughter's armpits to raise her up a bit and encourage the weight bearing on her extended arms that you are looking for. You can also use a small soft wedge of foam for this same effect.

Always supervise tummy time play for young infants. Get down on your baby's level on the floor and face her so that she has the extra motivation to raise her head and look around and push upwards. You can also use a mirror & raise it up in front of her to encourage her to lift her head and chest. When using toys as a motivator, don't always put them directly in front of her, but to each side as well, moving toys farther away or holding them up higher to the left, right and center so she must look up to catch sight of them. Placing toys to the side encourages a baby to shift her weight and enhances her range of motion. To strengthen her neck, back and trunk muscles you can also carry her belly down in a sort of "football hold" by sliding your hand between her legs and under her tummy, you can support her head and neck with your other hand if needed and carry her close to your body for support.

Lying on your back with your baby on your stomach is another nice way to do tummy time without really thinking about it, she will want to look up to see your face as you talk/sing to her. You can also lie on your back with your knees bent, feet on floor and place your baby on your knees/lower legs facing you...hold her hands and encourage her to look up at you in this position. Daily tummy time is the best way to continue to strengthen all the muscles she will need for later more complex motor skills. If your daughter does not begin to bear weight on her hands and push up by 6 months you may want to seek a physical therapy evaluation through your local early intervention provider.

Once he is on all fours, I would use a toy that motivates him and encourage him to move toward it. Also, each time you change his diaper, roll him to his side and encourage him to push himself up into the sitting position. Try hard not to put him on the floor to play in a sitting position; instead, put him on his belly or back so he has to either work on crawling or getting to sit on his own. If you do these few things, he should accomplish moving to sit and crawling in no time. If he still doesn't seem to be gaining these skills, you can always discuss your concerns with your pediatrician.

If you choose to keep the exersaucer adjust it so that his feet can be flat. Often kids will stand or jump on their toes when in exersaucers causing their calf muscles to get tight and making it hard for them to stand on flat feet. Without seeing your child I can not be sure exactly why he is standing on his toes but I would suspect tight calves.

You can stretch his calf muscles by laying or sitting him on the floor or in your lap using toys to distract him-hold his knee straight with one hand and with the other bring "toes to nose." Stop and hold when you feel resistance. Try to hold at least 10 seconds, but if he tolerates it you can hold longer. Do not bounce his foot or push into the resistance. Be sure to keep his knee straight. Repeat (as tolerated) at least 3-5 times per foot and try to do this several times per day such as after diaper changes. After bath is also a great time to stretch as the warm water will help to loosen the muscles. Continue to reposition his feet so that they are flat when he is playing in standing. If the above suggestions do not seem to make an improvement in the next couple weeks then I would recommend looking into early intervention services in your area to get a physical therapy evaluation.