610

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Pediatrics:
Motor Development

Birth to 3

Home Study Course
By Joanne Bundonis, PT, PCS



January 2009

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2

Table of Contents
CCU Hours

Course instructions 3 (1)
Course objectives 4
Pre-test 5
Typical Motor Development 6
Newborn 7
Premature infant 8
One month 8
Two months 10
Three months 12 (2)
Four months 12
Five months 14
Six months 15
Seven months 17
Eight months 18
Nine months 19
Ten months 20
Eleven months 21
12 15 months 22
18 24 months 22
28 36 months 23

Areas of concern
0-3 months 26 (3)
4-6 months 28
7-8 months 29
9-12 months 30

Case study one 31
Case study two 33

Appendix Normal Development Table (4 pages) 35

References 38
Post test 39 (4)
Evaluation 44







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Course Instructions
Research has demonstrated that reading for comprehension for application to your therapy practice must
involve multiple steps. These steps involve much more than just reading the course material.
PTcourses.com and OTcourses.com recognize that different people read at different rates, therefore the
times below are an average estimate based on review of this course material by both therapists and
assistants. Recommended steps to complete the course and exam are outlined below:
1. Review these course instructions. (5 min)

2. Read the course description, and preview the course objectives. Highlight the main purpose of the
course and note anything with which you are unfamiliar. (5-15 min)

3. Review the chapter headings and subheadings in the table of contents. Look up any words that are
unfamiliar. (5-10 min)

4. Review the exam, and become familiar with the questions asked at the end of the course. This will
assist you to be observant and determine the important points in the course. Compare the questions
with the objectives. Answer any questions in the margin that you may think you know. (10-45 min)

5. Read the first sentence in each section to gain the overall big picture for each chapter. Preview charts
and illustrations, chapter summaries, and appendixes. Glance at the course references for authors,
sources, and dates of publication. (Time varies dependent on length of course: 10-60 min.)

6. Read the course material: Highlight important areas, and make notes in the margin, asking questions
of the writer, and looking up any terms that are unfamiliar. Relate the course material to the course
objectives, and note the location in the material where each objective was met. Make note in the margin
where you remember questions from the exam. Ask questions in the margin of the material that you may
not understand. Paraphrase each section. Think about the important points in each section. (Time varies
dependent on course. On average: 20-25 pages per hour for introductory course, 15-20 pages per hour
for intermediate course, 10-15 pages per hour for advanced course.)

7. Add your own opinions in the margins (Is the topic relevant? Has your experience been different? Is
this a topic or exercise you can use in your practice?) (10-15 min)

8. Complete the exam based on what you remember from the course. Look up answers to questions you
may not remember. Review your exam for accuracy. Be sure to answer each exam question. Blanks are
counted as incorrect. A minimum score of 70% is required for successful completion. (30 - 90 minutes
dependent on course, and therapists comprehension.)

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4
610 Pediatrics: Motor Development

Course Description
Motor Development (0 to 3): This course covers the sequence of normal development
from birth through the toddler years. It addresses points in development by month. It
covers areas of concern, by month, that may signal a later dysfunction. The course also
covers how motor development affects hand use, breathing and oral motor skills.
Strategies for children with neuromotor deficits are addressed.

AOTA Cat: 1
CEU Hours: 4 Instructional Level: Intermediate

Course Objectives

a. Understand the sequence of normal development from newborn through toddler
years.

b. Identify points in development where elongation prepares the body for later
activation.

c. List key points of development for each month.

d. Identify the benefits of physiological flexion for newborns.

e. Understand that normal development is variable.

f. Identify areas of concern in a developing child that may signal later dysfunction.

g. Identify characteristics of normal motor development.

h. Identify characteristics of abnormal motor development.

i. Understand how motor development affects some basic principles of hand use,
breathing, and oral motor skills.

j. Relate concepts of normal motor development to treatment strategies for children
with neuromotor deficits.





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PRE TEST

1. What position helps elongate the lateral trunk and tensor fascia latae?
a. Sidelying
b. Prone
c. Quadruped
d. Supine

2. What is the progression of weight shifting in quadruped?
(Mark order in which progression occurs from 1
st
through 4
th
)
_____ Rotation
_____ Counterrotation
_____ Anterior/Posterior
_____ Laterally

3. What must occur for a child to be able to cruise around a corner?
a. Get elongation on weight bearing side and rotation through trunk
b. Lateral flexion toward weight bearing side
c. Ability to stand without support.

4. Why do many children with neuromotor dysfunction retain a posture of thoracic
kyphosis, flattened lumber spine and a posterior pelvis?
a. Tight hip flexors
b. Poor positioning in wheelchairs
c. Limited exposure to dynamic standing
d. Inadequate development of extension mobility and motor control

5. Which posturing is usually indicative of a pathology in infants?
a. Cervical hyperextension, scapular adduction, lower back tightness, hip internal
rotation and adduction
b. Cervical flexion, hip external rotation and abduction
c. Cervical, hip and knee flexion, thoracic kyphosis and a posterior pelvis










6

Typical Motor Development
With new life comes wonder and beauty, an active dance creating balance,
fluidity and efficiency of movement in just a very short span of time. Normal
development has a distinct sequence with the ultimate goal of independent mobility. But
what makes this sequence so exciting to see unfold time and time again is that it can be so
variable. What is presented as a time frame of normal development shows what may
occur slightly before or slightly after a certain criteria of normal. Sometimes certain tasks
may not occur at all.
Normal development is made normal by the very fact that it is variable and that
there is a constant drive to progress. The normal developmental process does not
stagnate on one skill. There is an inherent desire to move and explore in the developing
human. The clearest way to truly see normal development is to break the process down
to its simplest form, in which the motor system is first elongated, preparing those muscles
to be most efficient for activation. The process of elongation, preparation and activation
begins simply with flexion and extension but is later more complicated by the balancing
and sustaining of muscle control to allow for more refined, coordinated movements
incorporating rotation and grading.
We as therapists are here to understand what normal development is comprised of
and how to use that understanding to help children with developmental delays gain what
may have been lost or missed during development.



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NEWBORN
A full term newborn enters this world dominated by flexion and with little
disassociation of all body parts. This physiological flexion truly sets the newborn up to
adjust to the new environment and to begin preparing for their monumentous task of
normal motor development. The baby is in physiological flexion for pure space
efficiency because of such compact quarters in utero. The soft tissue tightness is a
natural occurrence due to developing in such a flexed position. Physiological flexion
does offer the newborn a number of benefits as it is an organizing position which allows
the baby to establish an initial point for movement and control from which to develop. It
will limit or control the amount of extension within the system. Since the newborn has
no midline control, physiological flexion allows the baby to regulate, comfort and control
of his own body.
The baby does not have to move far out of flexion to gain sensory input and
begin to learn about his body and environment. At the same time, by returning to the
flexed position, the baby is able to regulate the input and movement he experiences,
because flexion will avoid overstimulation. The position of physiological flexion puts
consistent weight bearing on the head, upper chest and forearms with the lower body
higher than the shoulders, which initiates the cephalocaudal progression of normal
development. The ligamentous and soft tissue tightness associated with physiological
flexion helps the body in its remodeling process. The newborn's cries are usually very
nasally due to the compactness of the flexion and their perpendicular rib cage and sound
is usually movement induced.

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PREMATURE INFANTS
In premature infants, their development is based more on their gestational age;
therefore age should be corrected for preemies at least up to 18 months of age. A
premature infants lower extremities will appear tighter than a full term infants will.
This is because in utero the tautness in connective tissue develops from toe to head,
where motor development occurs from head to toe. A premature infant will usually
demonstrate physiological flexion at the appropriate gestational age, but the flexion will
not be as dramatic since the flexion has already been extended some. Since the preemie
does not get the same sensory stimulation from physiological flexion as a full term infant,
the preemie may have a stronger drive for tactile stimulation, which could be seen in the
use of hyperextension to seek out the needed tactile input. Therefore the benefits of
physiological flexion for the full term infant stated above are doubly important for
preemies.

ONE MONTH
The one-month-old infant remains dominated by physiological flexion, which
offers the baby its only stability source. Posturing includes rounded, internally rotated
shoulders, tight pectorals, elbows flexed and pronated with thumb in palm and wrists
flexed. The legs are flexed and adducted, ankles dorsiflexed and inverted, and pelvis
posteriorly tilted, which is the same position the legs are in utero. In supine there is
slightly less flexion than in prone due to effects of gravity. The baby has no active
control in midline or reciprocal inhibition with no grading, so movements are more
uncontrolled and uncoordinated. Everything appears to contract or relax together.
9
Random kicking helps the newborn begin to move out of flexion and adduction into more
external rotation.
There is more symmetry in prone than in supine for a newborn. In prone weight
is on the face and cheeks because of the high riding pelvis. It is an automatic reaction for
the infant to clear his airway and weight bear on the cheek. When prone, the baby is in
passive cervical extension, therefore, elongating the flexors preparing them for activation.
The baby will use cervical extension, initiating with rotation to clear the mouth, which is
the start of more asymmetry. Gravity will then facilitate the neck back into flexion, the
beginning of more dynamic cervical movement.
In supported sitting, the baby starts in a sacral sit with a posterior pelvis, but the
pelvis becomes perpendicular to the surface quickly. A head lag with pull to sit will be
more pronounced as physiological flexion and tightness decreases over the first month of
life. In supported standing, reflexive stepping and primary standing is noted, but between
11/2 and 2 months of age the presence of these reflexes will disappear (astasia abasia). A
majority of our sensory receptors are in the mouth and hands.
The one month olds positioning provides weight bearing on the face and since
the baby is in so much flexion the hands are near the mouth and they start to bring their
hands to their mouth. The weight bearing on the face also helps with oral motor
development. Infants are driven by visual and labyrinthine input, which are stimulated
by all their movements. They are beginning to get awareness of two sides due to
asymmetrical patterns. The baby is nearsighted with a focal point of about 7-10 inches
with better lateral vision and is able to track peripheral to midline but with jerky
movement.
10
The one-month-old will orient to sound by changing his body movement. The
grasping of objects is purely reflexive and the hand will open again with weight bearing.
This grasp and release pattern begins the development of finger extension. The baby is a
belly breather with ribs horizontal and rigid and a narrow tight chest. They also breathe
through the nose because of fat pads and large cheek and tongue size. As more
mylenization occurs the newborns increased tone and tightness will decrease and begin
to organize into more controlled movements.

TWO MONTHS
The two month old will appear low tone and asymmetrical because gravity is
beginning to work on the body with decreasing physiological flexion. The asymmetrical
tonic neck reflex (ATNR) is most dominant at two months, but is not obligatory.
Posturally the infant demonstrates decreased lower extremity flexion with increased
abduction and external rotation and less of a posterior pelvis. There will be increased
scapular adduction and shoulder abduction with the elbows now positioned behind the
shoulders in prone. They also have better active cervical extensor control with weight
shifting in prone.
Weight bearing is down to the upper chest pushing the spine into more extension
and further elongating the flexors. The baby is able to lift his head to 45 degrees but
cannot maintain it, allowing for the start of weight bearing through the arms. When
lifting his head it is still from a very asymmetrical position initiating the activation of
cervical extension and rotation. Normal babies from 2-3 months of age do not like the
prone position because it requires a lot of work and limits their freedom of movement. In
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supported sitting the baby will hold its head erect with elevated shoulders and head
bobbing. Visually the focal length is about 10 inches and he can see his hand, therefore
the ATNR allows the beginning of eye hand regard. Optical righting drives head lifting
and an upward gaze develops with extension. The baby begins using some facial
expressions, but vocalizations continue to be linked to movement.
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THREE MONTHS
A three-month-old is beginning to gain more symmetry and organization. He has
increased muscle tone. They have developed head control in supine and prone. The baby
has active extension control through the upper thoracic region and similar control of the
flexors, as well as the ability to hold his head in midline and turn side to side (rotation
requires control of the flexors and extensors). Posturally he is beginning to open up with
even less lower extremity flexion in both prone and supine with the pelvis going towards
more of an anterior tilt. Increased lower extremity external rotation and abduction allows
foot to lateral foot contact while kicking in supine.
In prone he is beginning to get control of scapular abduction and adduction with
the elbows in line with the shoulders. As the baby begins to weight shift he will shorten
the side to which he shifted because that is where there is control at this stage. Propping
on forearms elongates the shoulder abductors with increased extension. The baby will
also begin using bilateral upper extremities, i.e. bringing both hands to his body and
beginning to raise arms against gravity. In supported sitting the baby uses scapular
adduction to reinforce extension. The ribcage is coming down but is still elevated. In
prone, the weight is off the chest freeing the baby for more chest breathing.

FOUR MONTHS
At the fourth month, a normal child achieves symmetrical antigravity control and
begins to use bilateral upper extremities in weight bearing and function. Posturally, the
four months old legs are more in line with his lower body displaying increased extension
and decreased abduction and external rotation. His feet are more plantarflexed and push
13
off the supporting surface. There is also more anterior and posterior pelvic movement.
The baby is developing control of extension through the lumbar spine and flexion across
the thoracic spine. In prone, the elbows are further ahead of the shoulders with weight
shifted more posterior to the thighs. He is gaining more control of weight shifting with
increased shoulder cocontraction. With this increased weight shifting over the
abdominals, increased spitting up will be noted. The baby can actively rotate head and
upper body, getting some shoulder external rotation and the beginnings of
scapulohumeral disassociation.
Accidental rolling to sidelying is seen due to decreased control of weight shifting
in supine and prone. In order to reach in prone, the infant goes back in flat lying, the
reaching begins to elongate shoulder and latisimus muscles. This resorting to a more
stable and practiced position will continue throughout development when new tasks are
attempted.
In supine, the infant is able to flex hips and touch knees and lift upper arms off
the surface, demonstrating increased antigravity control. He can not lift his head off the
surface. The baby is able to sit with the back straight up to the thoracolumbar junction
and rounded at the lumbar spine. Forward protective extension begins on the forearms.
In several months, as control improves, protective extension is on extended arms.
In supported standing, the pelvis remains behind the shoulders due to a lack of hip
extension control. The four month old has almost full rib cage expansion, elongation of
the intercostals and more thoracic breathing, as seen in their longer vocalizations and the
beginning of separating sound production from body movement. The baby will hold
objects with an ulnar grasp and play by banging with mostly shoulder movement. In
14
order to grasp, the fingers and wrist will usually flex together. Hand to hand and foot to
foot play is also noted.

FIVE MONTHS
The fifth month is a very active time where the infant is gaining many important
pieces of development. Extension control will have developed across the hips and
flexion control across the abdominals as seen in the babys ability to lift the pelvis off the
floor in supine and with lots of swimming and rocking (forward and back and later
laterally) in extension and catching on arms in prone. The baby still does not have full
control and stabilization across the lower body and lower abdominals to be able to lift his
head in supine. But increased obliques control is noted with better grading of the upper
extremities and the ability to cross midline.
In supine the baby will have better arm and manipulative hand skills but in prone
there are more strength skills with less visual regard and hand use.
The baby is also able to reach in prone on elbows and weight bear on more extended
arms. Rolling begins to be more voluntary using flexion to roll from supine to prone and
extension to roll from prone to supine. Control with rolling will improve as weight
shifting and the balance of flexion and extension further develop. This voluntary desire
to move is the start of cognitive movement and motor planning. The five-month-old
tends to like sidelying because of his improved stability between flexion and extension in
the upper trunk. In sidelying, he begins to get lateral head righting, but he doesnt have
enough obliques to sustain the position. Sidelying is important to begin to round out the
15
rib cage and to get practice working in between flexion and extension. There will be
more symmetry and midline control with the decreased influence of the ATNR.
At five months, the baby has good head control with a chin tuck and uses prop
sitting with a wide base of support. In supported standing, the pelvis is behind the
shoulders with a wide base of support, accepting almost full weight bearing. The baby
begins to bounce getting proprioceptive, kinesthetic, and vestibular stimuli, usually with
hips and knees flexed. With more active abdominals and intercostals to stabilize the rib
cage, the baby uses more thoracic breathing, opening up the chest and allowing the
diaphragm to work more easily. Visually they are better able to separate eyes and hands,
also getting a more visually directed reach as the start of eye hand coordination. The
baby will be reaching with more elbow extension, using bilateral upper extremities, and a
palmar grasp. This swiping and reaching against gravity will help train the scapular
stabilizers.

SIX MONTHS
By six months extension control is through the hips and hip flexor control is
beginning, allowing for more centralization of weight, narrower base of support, and
more movement of the extremities. At five months, the baby is reaching for his feet with
flexion, abduction and external rotation of the legs. By six months he is reaching hands
to feet with decreased external rotation which helps to elongate the hamstrings, neck and
back extensors and develop better abdominal or flexion activation. Now at six months
the baby can lift his head in supine, showing more active control of the obliques and
lower abdominals.
16
Single leg movements can now be isolated showing the start of lower extremity
and pelvic disassociation, which will be important for later developmental transitions.
Now in prone, the baby can maintain weight bearing on extended arms and with pushing
back onto arms may slide backwards or even rock up onto hands and knees. This is the
first time the baby will raise his center of gravity off the floor and become aware of the
space behind him
The ability to weight bear on extended arms began with the elongation and
preparation of the scapular stabilizers during the fourth and fifth months of development.
Movements are becoming more advanced and refined as seen with more graded control,
rotation, and smoother movements in rolling. Also in sidelying increased refinement is
noted by the ability to stop and play, which demonstrates better oblique control and full
lateral head righting. Prone on extended arms is important to elongate the wrist flexors
and sidelying helps elongate the leg abductors.
By six months, the baby can sit erect without upper extremity support when
placed with more active anterior/posterior pelvic play. The anterior posterior pelvic
control is important to allow for reaching and weight shifting in sitting because it offers
the ability to use a narrower base of support and pivot over that base. The six-month-old
is able to sit without support and balance because he has gained active hip extension and
flexion in sitting, which was seen at five months in prone. In ring or propped sitting, the
baby will begin to play with toys in front of him by leaning forward, which will help
further elongate hamstrings, back, and hip external rotators. Increased hip extension
range of motion is also noted in supported standing, when bouncing with both hands held,
17
but most of the control in supported stand comes from the hip flexors and lower back
extensors.
He will have equilibrium responses in prone and supine and protective extension
forward. The protective extension response is dependent on the stability through the
trunk extensors so that the baby can get his arms out. Vocally the baby will use babbles,
intonation, graded pitch, and the integration of sound with body movement. By six
months, one will see more isolated finger movements and a radial palmar grasp.

SEVEN MONTHS
The seven-month-old in prone is beginning to move more through space, being
able to belly crawl and pivot in circles. Belly crawling begins using a reciprocal weight
shifting with lateral flexion at first and then later getting more rotation. Belly crawling
initially is reinforced by the amphibian reflex where weight shift to one side gets flexion
of the other. The reaching with abduction followed by moving the body over the arm in
belly crawling helps get lateral weight shift across the hands, distal stability with
proximal mobility, and disassociation of scapula and humerus.
More control is noted in sidelying with the ability to push up onto an extended
elbow, allowing for more elongation of the lateral trunk and tensor fascia latae and
activation of hip abductors into the surface. Also more activity is noted in sidelying with
moving top leg forward and back combining obliques/lower abdominals to hold the trunk
stable, while the hip flexes and extends. The baby will push back from prone into
quadruped and rock in quadruped. The rocking in quadruped is a good preparation for
creeping and helps develop stability around the hip joints.
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In quadruped, the weight is usually shifted more forward and the baby will fall
into an anterior pelvis until abdominal control develops. Then the pelvis will become
more neutral. If the abdominals stay weak and the pelvis anterior it will be more difficult
to transition and creep. The baby may attempt creeping or assume a plantigrade position
(bear stand).
The seven-month-old may get his first transition to sit by collapsing onto his
heels when pushing back in quadruped, leading to a heel or W-sit position. Transitions to
sit begin using an anterior/posterior movement progressing towards more lateral and then
with more rotation beginning first at the shoulders then the lower trunk. More weight
shifting in sitting with freer arms and equilibrium reactions will also be seen. The weight
shift of the trunk over an externally rotated leg in sitting then puts the leg into internal
rotation, which is similar to gait. The baby will pull to stand if his hands are held and
may attempt to take steps with support using a steppage gait. Orally the baby will use
finger feeding using the mouth to help release grasp, will be able to close lips on a spoon,
and separate voice from body movement. Seven-month-olds transfer objects from hand
to hand, use an inferior pincer grasp, and use surfaces to release objects, which is why
they are often throwing or dropping toys.

EIGHT MONTHS
In prone, the baby is beginning to transition to sit through sidelying and
progresses to using more rotation and lower extremity disassociation. By beginning to
play in between transitions he is developing the ability to grade transitions and use mid-
ranges. The infant is able to creep on all fours initially by moving ipsilateral sides then
19
reciprocally. Weight shifting in creeping begins with a lateral weight shift and then
rotation then counter-rotation (rotation toward unweighted side so upper body and lower
body move opposite) as the child develops more control. These rotational movements are
very important for gaining shoulder stability and mobility.
At seven months, the baby tends to weight bear with the shoulders internally
rotated and by eight months the shoulders are more externally rotated with greater weight
shifting across the hands. By holding a toy while creeping he is getting even more input
into the hand and developing the palmar arches.
In sitting the baby is able to rotate his trunk and at times shift through his base of
support getting elongation of the weight bearing side. The baby begins to transition from
sitting to quadruped by moving laterally, but needs more eccentric control to transition
back from quadruped to sitting. Kneeling and half kneeling occur as parts of transitions,
usually with upper extremity support for stability. The eight month old will begin to pull
up to stand at furniture using upper extremities to drag his legs behind together and later
getting one leg up in a very wide half kneel position. The baby will step with hands held
and climb on low surfaces all facilitating the alternating/diagonal weight shifts through
the trunk needed for later ambulation. More controlled oral skills are noted in the ability
to clear a spoon with his lips, a more graded chew, and eating mashed foods. His
developing a three-jaw-chuck grasp and now has a voluntary release.

NINE MONTHS
By nine months quadruped has been refined with the ability to transition to sitting
and back independently, with counter-rotation in creeping, and the ability to climb onto
20
furniture. Kneeling is seen more regularly but with little control using flexion of the hips
and ankles for stability. Nine months is when sitting truly becomes independent and
functional with hands free, good equilibrium, and the ability to move in and out and
pivot.
In standing, the baby will stabilize their lower body against a support to rotate his
upper body as control in upright develops he will rotate lower body while holding on
with his arms. Dynamically in supported standing, cruising will begin with lateral weight
shifting and a wide base of support. In standing while holding onto a support the baby
will practice squat to stand which helps develop knee and hip flexion grading and
strengthening. Although the baby can pull to stand, the transition to the floor is still with
a fall or plop due to limited eccentric control. Orally, increased independence and
control is seen in that he is able to finger feed, drink from a cup, and are able to separate
tongue movements from jaw movements.

TEN MONTHS
The tenth month is a period to perfect and refine more movements. Weight
shifting will begin to be initiated from the lower trunk in quadruped, cruising and sitting.
Equilibrium response will be seen in quadruped. Half kneeling is more mature with trunk
rotation and the foot more in front. Kneeling without upper extremity support will be
used. Cruising will be perfected with elongation of the weight bearing side and rotation
begins, as the child is able to get around corners or furniture. He will be able to walk with
one hand held, but may use scapular adduction for stability until he gets more control of
hip rotation. Hip rotation control will be played with in standing with upper extremity
21
support. The child has better eccentric control and fairly good strength through the legs
as seen in the ability to squat with one hand holding on. Ankle control and activation is
just beginning with increased plantarflexor use by coming up onto his toes, which will
also prepare and elongate the toe flexors. He will be able to grade release of objects and
isolate the index finger for poking.

ELEVEN MONTHS
For the normal child, the tenth through the twelfth months are about practicing
and perfecting a variety of movements, especially in standing and walking. The child
practices by combining many movement components to develop independence and
efficiency. Sidesitting is perfected with lateral trunk flexion and rotation. The baby will
creep with full rotation and cruise with one hand support, rotation, and elongation of the
weight bearing side. The baby will initiate bear walking in the plantigrade position.
Moving in the plantigrade position is important for development of gait because it utilizes
weight shifting in dorsiflexion and plantarflexion at ankles, with the legs disassociated
and trunk rotation against a stable shoulder. The child is able to stand alone using lower
extremity flexion, anterior pelvis and scapular adduction to stabilize. For new or
challenging fine motor tasks, the upper arms will be pulled in to get stability in the trunk
for distal work.







22
TWELVE TO FIFTEEN MONTHS
The child is able to stand independently and squat to pick up an object.
Independent steps begin as control around the hips and knees improve. Initial steps begin
with a wide base of support, hips and knees flexed, abduction and external rotation of the
hips, scapular adduction, anterior pelvis, lateral weight shifting and small steps. The
wide base of support with abduction and external rotation requires very little pelvic
movement. The high guard arm position of scapular adduction compensates for weak hip
extensors and helps throw weight posteriorly.
The squat to stand transition begins asymmetrically with abduction and external
rotation because a straight up and down would require a lot of hip and knee extension
force. This will later develop as the child gets better hip extension, abdominal control,
and increased pelvic mobility. The squatting also helps with progression of tibial torsion
alignment. The child is able to creep up stairs. He can say about five words.


EIGHTEEN TO TWENTY FOUR MONTHS
This is a time when the child will be driven by motor experiences; there may be a
slowing of development in other areas due to this desire to move. Walking skills improve
to include more lower body weight shifting and elongation of the abductors. By two
years old the childs gait will demonstrate decreased pelvic tilt, hip abduction and
external rotation, more knee flexion during foot strike, ankle dorsiflexion during swing,
plantarflexion at heel strike, and some reciprocal arm swinging. There is a preference
23
towards extension in standing at two years old predisposing most normal children to toe
walk for a short period.
As hip extension develops the child will begin stepping backwards. Standing
equilibrium responses are seen, but before equilibrium responses are fully developed one
will see more of a stagger response of moving the feet to maintain balance. Good pelvic
disassociation is necessary to begin walking up levels; the child can manage stairs with a
railing and non-alternating steps at this age. The child will also begin to use ride-on toys,
in which he usually starts by pushing backwards into extension because its easier than
pulling forward with flexion.

TWENTY-EIGHT TO THIRTY-SIX MONTHS
Gait will incorporate full counter-rotation at about 3 years of age. Children first
begin running as a fast walk, running with both feet off the ground occurs between 2-3
years of age. The ability to throw demonstrates upper extremity movement on an
extended trunk. The child can ride a tricycle and jump up and down. The child will
become toilet trained by around three years of age.






24

Characteristics of Normal Motor Control Development

Cephalic to Caudal
Proximal to Distal
Weight shift develops anterior/posterior to lateral to rotation
Muscle must elongate before you get activation
Develop concentric before eccentric control
Gain reciprocal inhibition then cocontraction then graded movement
Use bilateral movement before unilateral
Upper body control before lower
Return to more primitive patterns to reinforce learning of a new skill.
There is a gradation or stepping of control
Never perfect one skill before working on the next because the higher level work
helps develop other needed skills to perfect the prior.


There is a complexity and flow to normal development. The dependent infant is
building a framework towards being an independent functioning child through every
movement, a framework that begins with each movement out of flexion: elongating then
activating. He instinctively falls back on learned skills to build and refine new skills. As
was just outlined in the prior sections, normal human development has a clearly defined
process for muscle activation and development. The process begins with random
movements, followed by asymmetrical movements, bilateral symmetrical movements,
alternating movements, lateral flexion, and finally rotation.
Many children with neuromotor deficit do not gain the symmetrical control necessary
to develop the more graded control for lateral flexion or rotation. All babies learn to
move but as they move they learn to compensate for deficiencies. If these compensations
persist, we see deterioration in the process of normal development. If we break down
points of normal development we can begin to understand what components of normal
25
development get lost in children with neuromotor deficits or developmental delays. In
seeing where normal is lost, maybe we can use that to help the children learn more
functional and efficient movement patterns. There are also numerous standardized tests
available to assist in assessing gross motor development during the first year of life.
Some of those test include the Alberta Infant Motor Scales, Bayley Scale of Infant and
Toddler Development, Test of Infant Motor Performance, and the Peabody
developmental Motor Scales. Below we can begin to interpret signs of where normal
development may begin to skew.















26




Areas of Concern
ZERO - THREE MONTHS
In the first few months of a newborns life, it is difficult to identify motor
abnormalities, especially those that may be more subtle. But impairments in early
infancy will usually manifest themselves in the motor system. Good understanding of
what normal development and movements are helps distinguish areas of concern. A clear
red flag in a newborn is if there is a difference in tone on either side of the body. A baby
that is either hypoactive or hyperactive can also signal possibilities for impairment
because that child is having difficulty regulating himself to his new environment.
Newborns are very active with numerous random gross movements. One must look to see
if these movements are fluid, wax and wane, and if they incorporate rotation.
Newborns position their hands in a cortical thumb position with the thumb buried
in a fisted hand. This is a sign of an immature system and should decrease with
development. The crossed extension reflex pattern occurs when one side of the body is
stimulated and the other side responds (by touching the adductors of one leg it causes
flexion in that leg and extension and adduction in the opposite leg). If this is not present,
it may indicate brain damage or absence of the corpus collosum. Young infants may
begin to accidentally roll, but rolling is in one segment since the baby does not have
association of all movements and has limited spinal mobility. Segmental rolling becomes
27
a concern if it persists, as the child should be learning to roll more efficiently near the
fourth to fifth month.
The second month is characterized by asymmetry. The asymmetrical tonic neck
relfex (ATNR) is not obligatory in a normal infant, but one should suspect pathology if a
child does not use any other movement patterns or cannot break out of the ATNR
posture. In atypical infants, one may also see the ATNR accompanied by excessive
cervical hyperextension. Normal babies will hold or fix to provide stability so other areas
can be used or moved, as seen in a two month old elevating and blocking with the
scapulae to allow for head control. This becomes a concern or atypical if the baby
perseverates on one specific pattern. It is important to begin to get the opening of the
upper chest in prone. If this does not occur as in many children with neuromotor deficits
there will be a limitation in shoulder external rotation, scapular stability, and the use of
excessive extension later on.
Many children with neuromotor deficits retain the newborn spinal alignment of
thoracic kyphosis and a flattened lumbar spine. This is caused by the childs inadequate
development of extension mobility and motor control.
The third month is when the baby moves towards more symmetry. Concern
should be noted if there is a strong continuation of asymmetry with limited bilateral arm
movement. One never sees hip internal rotation positioning in normal development.
Cervical hyperextension with scapular adduction and lower back tightness, and hips
internally rotated and adducted may be indications of pathology. If head control appears
limited, the visual control should be further assessed as it can have a factor in the
development of head control. In prone if the baby is having difficulty with keeping his
28
elbows in line with his shoulders, this may indicate decreased development of shoulder
girdle strength and may lead to further problems in developing antigravity extension
control in prone. Children with lower extremity tone tend not to use a frog-legged posture
(flexion, abduction and external rotation) and do not activate hip extensors causing
decreased hip abduction range of motion in the future. Infants with low tone tend to get
stuck in the frog-legged posture and do not move out of it. This causes them to never
gain adequate strength of the trunk and hips to move dynamically with lateral or rotary
movements. As they get older, these children may demonstrate an increased gait angle
and excessive pronation.

FOUR SIX MONTHS
The fourth month is also a time where many changes are beginning, and it is
difficult to identify abnormalities at this age. Motor development is usually considered
pathological if there is perservation on a task or poverty of movements. In children with
neuromotor deficits, there will be an underdeveloped quality of symmetry in prone and
supine because they have not developed antigravity strength in the trunk flexors and
extensors. It will become easier for the developing infant with delays to substitute or
accommodate for immature patterns, especially if not challenged to attain higher level
skills.
In low tone babies, the position of lower extremity abduction and external rotation
will limit development because it causes an inability to shift weight down through the
lowers in prone and causes lumbar hyperextension. The infant that is not weight bearing
on upper extremities in prone by five months of age should be further assessed. As
29
rolling begins to develop, the baby will use extension to get to supine. However, but the
continuation and perservation of using extension to roll can limit the further development
of balance with the flexors and possibly affect visual control since extension incorporates
an upward visual gaze.
When a baby is using propped sitting, it should be a transition to more
independent sitting working to train the trunk extensors. If the baby becomes fixed in
propped sitting with no variety, there is reason for concern because it is a locked position
anatomically and does not allow the trunk to learn to work on its own. This limits
functional sitting and does not allow the arms to be free for play. Children with lower
extremity spasticity tend to crawl by dragging their legs behind them, denying the
development of hip extension and external rotation. Children who cannot bring their feet
to their mouth by 5-6 months are demonstrating decreased flexor control and decreased
extension mobility.

SEVEN & EIGHT MONTHS
The seven-month-old baby is very active against gravity, using a wide variety of
positions. A clear sign of motor developmental delay would be a seven month old with
little desire to move. Also there would be difficulties in prone or supine, inability to
weight bear on extended upper extremities, difficulty weight shifting over lower
extremities and inability to sit unsupported. An eight month old with neuromotor
dysfunction will have difficulty transitioning out of sit, movements will be stereotyped
and lack variety due to the childs decreased trunk, pelvic and femoral motor control.
Children with diplegia have difficulty with tall kneel because of a lack of balance
30
between the hip flexors and extensors and excessive extension at the lower back from the
increased tone around the pelvis.


NINE-TWELVE MONTHS
The inability to sit independently, creep in quadruped, climb, or stand in a
supported standing position by nine months old could be an indication of atypical motor
development. W-sitting is a normal sitting position when it is part of a variety of sitting
postures. Children who only use W-sitting tend to have poor pelvic and lower extremity
control and use the biomechanical stability of the W-sit to offer them stability. The
perseveration of the W-sit position can lead to tightness of the hip adductors, internal
rotators and flexors, and hamstrings. Difficulty with crawling and creeping may also be
due to limited pelvic femoral control and the babys inability to laterally weight shift and
disassociate the lower extremities. Subtle deficits may be seen in a childs inability to
weight shift or adjust posture when in supported stand.



Characteristics of Abnormal Motor Development

Perseveration on single movements or positions
Lack of variety of movements or positions
Use of stereotypical movements
Limited rotation
Compensatory or fixing patterns
Abnormal tone either hypo or hypertonia
Poor co-contraction and grading movements are all on or all off
Asymmetry

31








Case Study Examples

Case Study One

A three-year-old with a diagnosis of delayed development presents with
hypotonia. The child is able to sit independently, creep and assume a tall kneel position
without arm support. In lying, she maintains her legs widely abducted and externally
rotated (a frog legged position). In sitting, the child uses a wide base of support with legs
abducted and externally rotated. The child will stand with support but does not walk.
The child progresses through preschool to ambulate with a wide base of support,
hips excessively abducted and externally rotated. When walking she initially required
hand held support, as she could not weight shift over her wide base of support and she
lacked the lower extremity rotation control. As stability improves, her base narrows, but
she still remains externally rotated and abducted with poor weight shifting. Early in her
development this child did not shift her weight below her pelvis in prone, or begin to
activate her hip extensors and abductors in sidelying, prone, or sitting. This lack of
pelvic and lower abdominal control continued to affect her motor development in that she
did not gain the necessary cocontraction and eccentric control in her lower extremities to
allow for further progression of gait, squatting, and stairs. The lack of hip extension and
abduction torques at the hip joint have caused her hips to remain in a retroverted position.

32




What should be the focus of the therapy treatment?
Therapy sessions should focus on developing the hip extensors, abductors, and
abdominals. She would also benefit from activities to work on grading and eccentric
control of the lower extremities. Activities to further develop these skills may be
climbing over large objects, stairs, moving through half kneel and squat positions. She
could also work on resisted walking in all directions and partial transitions working on
grading of trunk and lower extremities.












33




Case Study Two
A girl diagnosed with spastic quadriplegia cerebral palsy, presents with low
postural tone and increased tone in all extremities. She demonstrates an underlying
athetoid component to her movements. Her sitting posture is extremely flexed with a
posterior pelvis and excessive thoracic kyphosis. She also has bilateral hamstring
contractures, which exacerbate this posturing. She requires full support to sit on the floor
and contact guard assistance to bench sit. She does not transition, but will attempt to
combat crawl on the floor pulling forward with flexion and not utilizing a prone pivot or
weight shift. She has maintained and further exaggerated much of a two month olds
flexed posturing with a posterior pelvis, kyphotic thoracic spine, forward head, and tight
pectorals.
This posture remains because this child has never gained the extension control
necessary to sustain an upright posture. As her extension control is lacking, she will
begin to compensate and fixate where she had biomechanical stability or tone, leading to
tight hamstrings, pectorals, hip flexors, latisimus dorsi, and elbow flexors.


34








What should be your focus of treatment?
In order for her to develop more effective sitting and transitional skills he must
gain extension control throughout the spine and hips. Activities in therapy would focus
on facilitation into extension and rotation, bilateral reaching activities especially
overhead, using an erect sitting posture while performing manual tasks, learning to push
off a surface instead of always pulling in.
During, the day positioning will be crucial for preventing further contractures and
allowing for better function. She should be given enough trunk support in sitting so she
does not need to fixate to just stay upright; this may free her hands, head and upper trunk
to be more active.







35
Appendix Normal Development
MONTHS SUPINE PRONE SITTING STANDING
1
a. Physiological
flexion
6. Head Rotated
k. Hands fisted,
Cortical thumb
b. Physiological
Flexion
Head turned to
side
Elongating
cervical
extensors
Rear Elevated
Most pressure
on head/face
Fully Rounded
Head lag with
pull to sit
Sacral sitting
Primary
Standing
Automatic
Walking/
Reflexive
stepping
2
Asymmetry of
extremities
Hand & head
regard
Head rotated
close to
shoulder
a. Shoulders more
abducted,
scapulae
adducted with
increased
weight through
upper chest and
arms
Frog legged
positioning
Extension
increases
through neck,
head lifted 45
degrees for
short periods
l. Head erect with
head bobbing
and elevated
shoulders in
supported sit
d. Astasia Abasia
3
e. Head to midline
f. Hands to body
g. Asymmetrical
head lifting
h. Increased
symmetry of
extremities
i. Decreased
flexion of the
extremities
Weight bearing
on forearms
Neck and trunk
extension
through upper
thoracic region
Head can be
lifted more
consistently
7. Slight increase
in extension
using scapular
adduction to
reinforce
extension
a. Knees do not
touch surface in
supported sit
b. Neck
hyperextends
c. Falls forward
when
unsupported

4
a. Head in midline
b. Hands to knees
c. Accidental
rolling to
sidelying
d. Lateral head
righting
e. Extension
control to
lumbar spine
Flexion to
thoracic region
a. Increased
elongation and
symmetry
b. Base of support
on hips and
thighs
c. Leg adduction
with knee
flexion
d. Weight shifts
with head
rotation
e. Weight bearing
on radial border
of forearms
a. Head in midline
with pull to sit
b. Cervical and
thoracic
extension
c. Ring sitting
with hip
external rotation
and support
d. Scapular
adduction
Supported stand
with pelvis
behind
shoulders











36

5


a. Feet to mouth
b. Increased
flexion against
gravity to
abdominals
c. Rolling using
flexion
d. Lateral head
righting in
sidelying


e. Weight bearing
on extended
arms
f. One arm
reaching
g. Rolling with
extension
h. Shoulder girdle
disassociation
with weight
shifting
i. Swimming
extension


j. No head lag
with pull to sit
k. Propped on
extended arms
l. Trunk erect
m. Lock elbows to
decrease
degrees of
freedom


Accepting
almost full
weight bearing
in supported
stand
Bouncing up
and down in
supported stand
6
a. Hands to feet
with head lifted
b. Rolls supine to
prone
c. Increased
shoulder girdle
control
d. Plays in
sidelying
e. Single leg
movements/
disassociation
f. Hands and
knees gaining
equilibrium
reactions
g. Able to laterally
flex and rotate

h. Sits with erect
spine
i. Forward
protective
reactions
j. Arms elevated
k. Unsupported
ring sitting with
a wide base of
support
Taking weight
with purposeful
responses
l. Knee and back
extension hips
flexed to
maintain
upright
m. Increased head
and trunk
control
7
a. Pivoting with
upper body
rotation
b. Symmetrical
upper extremity
movement
c. Able to weight
shift and rock in
quaduped
d. Belly Crawling
e. Lateral
protective
reactions
f. May push back
from quadruped
to a heel or W-
sit

Symmetrical leg
extension
e. Full weight
bearing on legs
with arm
support
8
7) Creeps for
mobility
Transitions
prone to sit
through
sidelying
8) Transitions
from sit to
quadruped more
laterally
9) Trunk rotation

10) Cruises
sideways and
reaches with
one hand
11) Pulls to stand
dragging legs
behind or with a
wide half kneel
12) Assumes tall
kneel
13) Rotates with
head first


















37
9
Counter-
rotation in
creeping

7) Independent
sitting
8) Sidesits and
Long sits
9) Transistions to
kneeling
10) Increased ability
to reach in sit

11) Cruises semi-
turned with
lateral weight
shifting
12) Increased hip
rotation and
decreased hip
flexion
13) Lowers self
with a plop
14) Pulls to stand
through half
kneel with
increased
rotation
10
Weight shifts
initiated
through lower
body
7) Cruises holding
with one hand
and elongation
to weight
bearing side
8) Symmetrically
lowers self to sit
9) Body fully
rotated away
from surface
10) Kneeling
without external
support
11) Walks one hand
held
11
Bear Walking

d. Varied sitting
postures and
transitions
e. Backward
protective
reactions
b. Sidesitting
f. Stands alone
g. Stable in half
kneel play
h. Lowers self
asymmetrically
12
10) Back props in
sitting
11) Independent
walking
12) Weight shifting
in standing
12-15
Creeps upstairs 13) Squat to stand








38
References

Bly, Lois. Motor Skills Acquisition in the First Year of Life. Therapy Skill Builders,
1994.

Cusick, Beverly. Progressive Casting and Splinting for Lower Extremities in Children
with Neuromotor Dysfunction, pages 3-96. Therapy Skill Builders, 1990.

Haywood, Kathleen, Getchell, Nancy. Life Span Motor Development. Human Kinetics,
2005.

Paul, Leslie. Course notes from NDT/Bobath 8-week course in the Treatment of Children
with Cerebral Palsy. Peapack, New Jersey, 2001.

Piek, Jan. Infant Motor Development: Normal & Abnormal Development. Human
Kinetics, 2006.

Shumway-Cook, Anne, Woollacott, Majorie H., Motor Control Translating Research
into Clinical Practice. Lippincott Williams & Wilkins, 2007.

Spittle, Alicia, Doyle, Lex, Boyd, Roslyn. A Systematic Review of Clinimetric
properties of neuromotor assessments for preterm infants during the first year of life.
Developmental Medicine and Child Neurology. Apr. 2008: 50(4): 254-266.

Staller, Jerry. Compiled from course notes from Typical and Atypical Motor
Development, New York University Developmental Disabilities Program, Fall 1997.

Tecklin, Jan Stephen. Pediatric Physical Therapy. Part I. Development. Lippincott
Williams & Wilkins, 2007.

















39

610 PEDIATRICS MOTOR DEV AGES 0-3
CERTIFICATION OF EXAMINATION

The individual submitting the request for continuing education credits should complete
this examination. No outside assistance is allowed. A 70% score is required before CEUs
may be awarded. I agree to complete this examination on my own as stated above. I am
completely responsible for the contents of this examination.
SIGNATURE _________________________________________

Name (Print)_________________________________ Date _____________________
Circle: PT PTA OT OTA
List each state you are licensed in and the license number for that state
1. State____________Lic # _____________ 2. State ___________ Lic # ___________
3. State ___________ Lic # ____________ 4. State ___________ Lic # ___________
Phone: _______________________ Email: ___________________________________
TO RECEIVE YOUR CERTIFICATE PROVIDE YOUR ADDRESS, FAX
OR EMAIL BELOW
___________________________________________________________

___________________________________________________________


SEND THIS COVER SHEET, THE ANSWER SHEET EXAM AND EVALUATION SHEET

MAIL TO: PTcourses or OTcourses, 6308 Circle Oak, Bulverde, TX 78163

OR FAX to 830-438-4573 or 801-457-2880

DO NOT SEND BY CERTIFIED MAIL - THIS ONLY DELAYS THE PROCESS

40
Pediatrics: Motor Dev (ages 0-3)
ANSWER SHEET

1. __________________________
__________________________
__________________________

2. A B C
3. A B C D
4. A B C D
5. A B C D
6. A B C
7. A B C D
8. _____ Rotation
_____ Counterrotation
_____ Anterior/Posterior
_____ Laterally
9. A B C
10. A B C D
11. A B C
12. A B C
13. A B C
14. A B C
15. A B C D
16. A B C D
17. A B C
18. A B C D
19. A B C D
20. A B C D E
21. A B C







41

Pediatrics: Motor Dev (ages 0-3)
Post Test

1. List three benefits of physiological flexion for newborns.




2. What position is crucial for premature infants?
a. Prone with head lower than heart
b. Physiological flexion
c. Held in a supported sit

3. In the first month, what area is becoming elongated in preparation for activity?
a. cervical flexors
b. hip flexors
c. pectorals
d.cervical extensors

4. What is the significant difference between the second and third month of
development?
a. Have gained independent sitting
b. Moving from more asymmetry towards more symmetry
c. Have gained elongation on the weight bearing side when weight shifted in prone
d. Elongation of tensor fascia latae

5. At which month of development does a child usually gain independent functional
sitting?
a. Five months
b. Nine Months
c. Twelve Months
d. Six Months

6. Why cant a five-month-old lift his head in supine?
a. The head is too big to lift against gravity.
b. Does not have good head control, cervical flexors still not fully active
c. Does not have enough lower abdominal and oblique control to stabilize lower
body.

7. What position helps elongate the lateral trunk and tensor fascia latae?

a. Sidelying b. Prone c .Quadruped d. Supine

42
8. What is the progression of weight shifting in quadruped?
(Mark order in which progression occurs from 1
st
through 4
th
)
_____ Rotation
_____ Counterrotation
_____ Anterior/Posterior
_____ Laterally

9. What must occur for a child to be able to cruise around a corner?
a. Get elongation on weight bearing side and rotation through trunk
b. Lateral flexion toward weight bearing side
c. Ability to stand without support.

10. Why do many children with neuromotor dysfunction retain a posture of thoracic
kyphosis, flattened lumber spine and a posterior pelvis?
a. Tight hip flexors
b. Poor positioning in wheelchairs
c. Limited exposure to dynamic standing
d. Inadequate development of extension mobility and motor control

11. Which posturing is usually indicative of a pathology in infants?
a. Cervical hyperextension, scapular adduction, lower back tightness, hip internal
rotation and adduction
b. Cervical flexion, hip external rotation and abduction
c. Cervical, hip and knee flexion, thoracic kyphosis and a posterior pelvis

12. If a child only uses W-sitting what may be a deficit in their motor control?
a. Limited hip internal rotation and adduction range of motion
b. Poor trunk flexion mobility
c. Poor pelvic and lower extremity mobility control

13. Which motor skill would be a concern if seen consistently in a baby?
a. A five month old who cannot bear weight on his upper extremities in prone.
b. A twelve month old who is not walking independently.
c. A two month old who does not exhibit an asymmetrical tonic neck reflex.

14. Which motor skill would be a concern if seen consistently in a baby?
a. A two-year-old who begins toe walking at times
b. A two to three month old baby who does not like the prone position.
c. A seven to eight month old who does not move out of sitting

15. Which is not a characteristic of abnormal motor development?
a. Increased muscle tone
b. Limited rotation control
c. Using a more primitive pattern when learning a new task
d. Using the same movement pattern to accomplish most tasks

43

16. A child of greater than 3 years old who remains in excessive external
rotation and abduction at the hips, walking with poor weight shifting has
not developed enough control of what areas?
a. Upper thoracic extensors
b. Pelvic region
c. Lower Abdominals
d. B & C

17. Which activity would be most appropriate for developing grading and
eccentric control of the lower extremities?
a. Partial transitions working on floor to stand
b. Seated bouncing on a therapy ball.
c. A static standing activity

18. What lack of control would cause a child over 3 years old to retain a 2
month old's flexed posturing (posterior pelvis, thoracic kyphosis, forward
head, and tight pectorals)?
a. Lack of distal hamstring activation
b. Limited flexion range of motion
c. Lack of extension control through the spine and hips
d. Limited scapular stability

19. Which activity would best focus on developing extension control through
the spine for the child in Case Study #2?
a. Bilateral overhead reaching with rotation
b. Stair training
c. Bike
d. Rolling

20. Infants who do not develop out of a frog-legged posture tend later in
childhood to present with:
a. Inadequate trunk and hip strength for lateral and rotary movements
b. Hip joint instability
c. Increased gait angle and excessive foot pronation
d. Tight adductors
e. A & C

21. Normal development is
a. Dependent only on genetics
b. Reliant mostly on primitive reflexes
c. Variable.




44
610 Course Evaluation Peds Motor Dev (0-3)

Please indicate your strong agreement (5) or disagreement (1) by
circling the appropriate number on the continuum from 5 to 1.

Circle: PT PTA OT OTA Date: _______________________


This self study was valuable to me because: (check all that apply)

_____I learned a new skill or approach to use in my practice.

_____I acquired one new and/or advanced skill that I can implement in my practice.

_____I gained knowledge upon which to base my decisions in my practice.

_____This self study doesnt apply to me on my job.

What information was the most valuable to you in this self study?


Other Comments:

5 - Strongly
Agree
4 - Agree 3 Neither
Agree / nor
Disagree
2 - Disagree 1 - Strongly
Disagree
1. The self-study met its stated objectives.
5 4 3 2 1
2. The self study content met my needs.
5 4 3 2 1
3. The author was knowledgeable in the content area.
5 4 3 2 1
4. Material was presented clearly.
5 4 3 2 1
5. Material was presented effectively.
5 4 3 2 1
6. Material was appropriate for stated title.
5 4 3 2 1
7. Examples were offered and discussed.
5 4 3 2 1
8. Content flowed logically.
5 4 3 2 1
9. Ample discussion of different areas was included.
5 4 3 2 1
10. Post test clearly reflected material.
5 4 3 2 1