neurodevelopmental screening.pptx

Neurodevelopmental Screening
– Development And Reflexes
By:
Dr. Baljeet Kaur

DEVELOPMENT
• Development is defined as a natural process of acquiring skills
ranging from simple to complex .
• It is a continuous process preceding stage by stage in an orderly
sequence despite individual variations. An increasingly complex
behavior unfolds as nervous system matures .
• Concept of growth deals with maturational changes that are
physically measurable like increase in height and weight of individual .

PRINCIPLES OF DEVELOPMENT
• Development is sequential and predictable. (the rate of skill
acquisition varies among children and depends on cultural , social,
personal contexts)
• Maturation & experience affects development. Maturation is the
innate (natural process) of growth & experience is the result of
interaction with the environment.
• Therefore maturation, experience, arousal state and motivation have
an impact on child's development .
• Development involve changes in biological , psychosocial and social
system .

Development progresses in order of three
basic sequence:
• cephlad to caudal
• proximal to distal
• gross to fine development

PERIODS OF DEVELOPMENT
PRENATAL PERIOD
PERINATAL PERIOD
POSTNATAL PERIOD
post natal period has several stages.
 Neonatal period : from birth to first 28 days
 Infancy : upto 1 year
 Toddler : upto 3 years
 Preschool : 3-5 years
 School : 6- 12 years

GROSS MOTOR DEVELOPMENT
• 3-4 months
Can raise head when pulled to sitting position
• 4 months
Rolls from back to side
• 5 months
Rolls from back to front
• 6 months
Can raise chest and upper part of abdomen (when on stomach)
• 7 months
Can bear weight on one hand while exploring with the other hand (when on
stomach)
• 6-7 months
Sits alone

• 8-10 months
Crawls
• 10-11 months
Cruises around furniture
• 9-12 months
Reaches actively for toy (when in sitting position)
• 11-12 months
Pulls to a standing position
• 15 months
Walks alone well
Squats and stands back up
Walks up and down steps holding hand

• 18 months
Can run, though falls easily
• 2 years
Walks and runs fairly well
Can jump with both feet
Can climb stairs without support
Can kick a ball
• 3 years
Can balance on one foot for a few seconds
Can broad jump 10-24 inches
Can catch a large ball

• By 4 years
Can run, jump and climb well, is beginning to skip
Hops proficiently on one foot
Catches a ball reliably
Can ride a tricycle
Begins somersaults
• By 5 years
Can skip on alternate feet and jump rope
Beginning to skate and swim
Climbing well

GROSS MOTOR SKILLS
AGE SKILL
PRONE POSITION
0- 2 mon Turns head side to side, Lifts head momentarily,
Bends hips with bottom in air.
3- 4 mon Lifts head & sustain in midline, rotates head
freely when up, able to bear weight on forearms
5- 6 mon Attempts to shift weight on forearm & reaches
foreward, equilibrium reactions are present.
7- 8 mon Pivots in prone position &moves from prone
position to sit.
9 - 12 mon On hands & knees lifts arm & opposite leg,
crawls reciprocally, rises to upright
kneeling with hand support & walks on
hands & feet .

12 – 24 mon Crawls upstairs
Half kneels upright with no support
kneel walks forwards
rises to stand with no support
SUPINE POSITION
0- 3 mon Head held to one side & slowly able to turn
head from side to side
3 – 4 mon Holds head in midline, chin is tucked in, legs
come together, lower back flattens
4 – 5 mon Head lag is gone when pulled to sitting
Bridges hips into extention , reaches up ,
across body ,

5 – 6 mon Lifts head independently , brings feet to mouth
brings hands to feet , able to reach for toy with
one or both hands,
7 – 8 mon Equilibrium reactions are present .head turns is
isolated from trunk
9-12 mon Pulls self to sitting & dislikes supine position
ROLLING
3 – 4 mon Rolls from prone position to side accidentally
because of poor control of weight shift
Rolls from supine position to side
5 – 6 mon Rolls from prone position to supine position
6 – 14 mon Rolls segmentally with roll initiated by head ,
shoulder & hips .

CREEPING
7 mon Creeps foreward on belly
7 – 10 mon Reciprocal creep
10 – 11 mon Creeps on hands & feet
11 – 12 mon Creeps well with abducted lower limbs

SITTING
0 – 3 mon (held in sitting ) Head bobs in sitting, back is rounded
hips are apart turned out & bent
3 – 4 mon (held in sitting ) Head is steady , chin tucks , sits with
less support , hips are bent &
shoulder are in front of hips
5 – 6 mon( supports self in sitting position )
Sits alone momentarily , increased
extension in back , sits by propping
on arms , wide base , protective
responses are present when falling
5-10 mon ( sits alone ) sits alone steadily , initially with wide base of
support & able to play with toys in sitting
position
6-11 mon gets to sitting position from prone position

7-8 mon equilibrium reactions are present
able to rotate upper body while lower body
remains stationary , protective responses are
present when falling to side .
8-10 mon sits well without support, legs are close &
knees are straight
9-18 mon rises from supine position by first rolling
over stomach then pushing up in 4 point
position
10-12 mon protective extention backwards , able to
move in & out of sitting position into other
position

11-12 mon Trunk control & eqbm responses are fully
developed in sitting position
11-24 mon + Rises from supine by first rolling to side then
pushing into sitting position
STANDING
0 – 3 mon When held in standing takes some weight on legs
2 - 3 mon When held in standing legs may give way
3 – 4 mon Bears some weight on legs when held pelvis &
hips are behind shoulder , legs are apart
5 – 10 mon Stands when holding on to furniture
6 - 12 mon Pulls to standing position at furniture
8 – 9 mon Rotates trunk over lower extremities, pulls to
standing position by kneeling & half kneeling
9 – 13 mon Pulls to standing position with legs only ,

no longer needs arms , stands alone momentarily
12 mon Equilibrium reactions are present in standing.
WALKING
8 mon cruises sideways
8 – 18 mon walks with two hands held
9 – 10 mon cruises around furniture turning slightly in
intended direction
9- 17 mon takes independent steps , falls easily
10 – 14 mon walking :stoops & recover in play
11 mon walks with one hand held
15 mon able to start & stop in walking
18 mon seldom falls & runs stiffly with eyes on ground
19- 24 mon displays eqbm reactions while walking

runs with narrow base of support
24 – 36 mon Jumps in place, pedals tricycle
walks upstairs & downstairs alternating feet
3 – 4 years Stands on preferred leg
Hops on preferred leg
Heel to toe walk
4 – 5 years Balances on one leg , 10 seconds
Walks on narrow straight line
Walks between 8 inches parallel bar
Backward heel to toe walk

FINE MOTOR SKILLS
AGE SKILLS
GRASP
0-3 mon Hands are predominantly closed
2-7 mon Object is cluched between little & ring finger & palm
4-6 mon Hands are predominantly open , ulnar palmar grasp
develops object is held from ulnar side with flexion of
fingers & thumb abducted
6 – 7 mon Radial palmar grasp develops ,object held in palm by
finger & thumb opposed
8 mon Objects are held with opposed thumb & fingertips
space is visible between palm & object , scissor
grasp i.e a P shaped object can be gripped
9-10 mon Inferior pincer grip develops, object is grasped by

pad of index finger& thumb . Infant is able to extend
index finger keeping others closed i.e point out.
12 mon Fine pincer grip develops.
RELEASE
0-1 mon No release , grasp reflex is strong
1 – 4 mon Involuntary release
4 -- 8mon Transfer object from hand to hand
5 - 6mon Drops object reflexly , voluntary release only when
held by mouth & other hand
7 mon Release only when hand is pressed against a surface
8 mon Release above a surface with wrist flexion
9-10 mon Release into a container with wrist straight
12–15 mon Precise , controlled release into small container with
wrist extended

By 3 months a child develops eye to eye contact , fixes eyes on light , eyes
follow object to midline then past midline upto 180 degrees ,down &
then up eye movements
During 3-5 months visual exploration of environment & visually directed
reach begins , by 7 months moves head to see objects eyes converge
and focus , continues to mouth every thing , hand to mouth movement
with object . By 12 months looks for fallen objects ( permanence of
objects )&mouthing of object stops and starts building a tower of 2
cubes , drinks alone from a cup & often spills .

SPEECH DEVELOPMENT
• 6 weeks- cooing i.e chance movement of vocal cords produces simple sounds
, first sounds are vowel, first consonant is b .
• 3-4 months- babbling develops repetition of simple vowels & consonant
sound.
• 6-12 months- lallation i.e accidental repetition of what has been heard .
• 8-9 months child utters monosyllable words ( ma, da) & by 10-11mon utters 2
syllables .
• 9-10 months- conscious imitation of sound called Echolalia.
• 18 months- expressive jargons :meaningful utterances that sound like
sentences with pauses & able to name pictures.
• 2 year- child utters his own name, uses personal pronouns like mine
• 3 years- can count objects & uses pleural words.
• 4-5 years- a child uses prepositions, complex sentences.

VISUAL DEVELOPMENT
 New born have vision at birth & can see objects from about 8 inches
away.
By first 10 days doll`s eye phenomena is present.
By 2-4 weeks brief eye following upto 45 degrees ,
by 8-10 weeks definite regard of rattle is there & eyes start following
upto 90 degrees & can distinguish between colors .
By 12 weeks can look around & recognizes parents .
By 16 weeks visual fields are developed upto 180 degrees and eye hand
coordination starts .

SCREENING
• Take history from parents/caregiver about
• Pre-natal causes
• Peri-natal causes
• Post-natal causes
• APGAR Score
• For checking grimace, a cannula is inserted into the nose just to stimulate a
sneezing response, 0- no response, 1- grimace( child will make faces), 2-
sneezing response.
• Respiration is checked by the ability to cry as it involved deep breathing, 0-
no cry, 1 – weak cry, 2 – loud cry.
• APGAR score is always compared for 1st, 2nd and 5th min after the child is
born.

Reflex Testing In Infants And Pediatric Patients
• Primitive reflexes
• These are normally seen during the developmental maturity of the
child, they integrate with gradual growth and development.
• They form the basis for all normal movements which the child has to
perform later in life. E.g plantar reflex is imp for walking.
• Some of these reflexes may not appear, but if the reflexes do not
integrate with time then that is an abnormal finding.

There are five levels of reflex control
• Automatic reflexes- lowest level of control & present when the child is
born.
• Spinal reflexes
• Brain stem reflexes- also known as tonic reflexes
• Mid brain reflexes
• Cortical reflexes- highest level of control

AUTOMATIC REFLEXES
• Moro’s reflex
• Landeau reflex
• Gallant’s reflex
• Parachute reflex

MORO’S REFLEX
• Position- supine/reclining
• Stimulus- drop the child backwards from reclining and hold before the child
touches the plinth.
• Response – U/L will go into extension, abduction followed by flexion and
adduction as if trying to grasp and hold onto something.
• Presence - birth
• Integration- 3-4 months
• Significance- it is a protective response, and shows the integrity of neural
pathways of upper limb. If there is asymmetrical response on both arms
then it suggests that there might be brachial plexus injury (during birth).
• Note: it should be assessed as a last reflex as the child starts crying after
this.

LANDEAU REFLEX
• Position- prone position Or ventral suspension.
• Stimulus- active or passive neck extension.
• Response – hyperextension of spine along with lower limb, such that a curve
is present.
• Presence – after 3 months and peaks at 6 months
• Significance- protective in nature and prevents the head from striking with the
ground when prone.

GALLANT’S REFLEX OR GALLANT’S TRUNK INCURVATUM REFLEX
• Position- ventral suspension.
• Stimulus- give a stroke on paraspinal muscles starting from 12 rib to same
side iliac crest.
• Response – bending or curving of the trunk towards the side of stimulus.
• Presence – from birth
• Significance- this reflex helps in the development of trunk control. If it
doesn’t integrate on time and persists for long then it can lead to scoliosis.
• Note: This reflex is seen preserved in athetoid variety of cerebral palsy
patients.

PARACHUTE’S REFLEX
• Position- prone position on plinth
• Stimulus- lift the child from prone by holding from pelvis or ankle suddenly.
• Response – upper limbs will go into quick extension to prevent the head from
striking the ground.
• Presence – after 6 months form birth
• Integration- doesn't integrate and persists throughout life.
• Significance- protective in nature

SPINAL CORD LEVEL REFLEXES
• Flexor withdrawal
• Extensor thrust
• Crossed extensor thrust
• Palmar grasp
• Plantar grasp
• Sucking reflex & Rooting reflex
• Reflex stepping/Primitive walking

FLEXOR WITHDRAWAL
• Position- supine
• Stimulus- stroking the foot on the dorsal aspect.
• Response – flexion and withdrawal (uncontrollable) of the same lower limb.
• Presence – 28 weeks of gestation. (this reflex is one of the reasons why
mother start feeling kicks of the baby by 7 months).
• Integration- 2 months
• Significance- protective in nature, also shows the integrity of spinal cord
connections.

EXTENSOR THRUST
• Position- supine with one leg flexed and one extended
• Stimulus- stroking the foot on the dorsal aspect of the flexed leg
• Response – uncontrolled extension of the flexed lower limb with dorsiflexion
of the foot.
• Presence – 28 weeks of gestation.
• Significance- protective in nature, also shows the integrity of spinal cord
connections.

CROSSED EXTENSOR THRUST
• Position- supine with one leg flexed and one extended
• Stimulus- stroking the foot on the dorsal aspect of the EXTENDED leg.
• Response – uncontrolled extension of the flexed lower limb with
dorsiflexion of the foot.
• Presence – 28 weeks of gestation.
• Significance - the interconnections of spinal cord are well formed.

PALMAR GRASP also known as ulnar palmar grasp
• Position- supine or any comfortable position
• Stimulus- give a little stroke with mild pressure with one finger on the ulnar
side of the palm.
• Response – the child will grasp the finger by making a fist.
• Presence – by birth
• Significance – if this reflex is not present and doesn't integrate on time then
the hand functions like grasp and prehensions will not be developed
properly.

PLANTAR GRASP
• Stimulus- give a stroke on the lateral side of the foot. This reflex stimulates
even when anything touches the lateral border of foot.
• Response – there will be clawing of the toes.
• Integration- 9-10 months (when the child starts standing with support)
• Significance – A negative or diminished reflex during early infancy is often a
sensitive indicator of spasticity. Infants with athetoid type cerebral palsy
exhibit an extremely strong retention of the reflex, and infants with mental
retardation also exhibit a tendency toward prolonged retention of the reflex.

SUCKING REFLEX
• Stimulus- touch your clean little finger on the lips or gums of the patient.
• Response – there will be reflex sucking
• Integration- 3-6 months (when the child starts doing sucking with a
voluntary effort and not as a reflex)
• Significance – important for feeding and development of oral musculature.

ROOTING REFLEX
• Stimulus- give a stroke from angle of mouth towards the ear of the same
side.
• Response – turning of head towards the side of stimulus
• Significance – indicates development and isolation of jaw muscles. If chewing
doesn’t come by the end of 7 months then it suggests abnormality. This is
also seen in mental subnormality.

PRIMITIVE WALKING
• Position- keep the child in supported standing by holding from armpits/axilla
• Stimulus- touch the dorsal aspect of the footof the child on the edge of a
table.
• Response – the child flexes the leg and tries to walk on it.
• Significance – it shows the integrity of spinal cord.

BRAINSTEM LEVEL REFLEXES/TONIC REFLEXES
• ATNR- Asymmetric Tonic Neck Reflex
• STNR – Symmetric Tonic Neck Reflex
• TLR – Tonic Labyrinthine Reflex
• Positive and Negative Supporting Reactions

ATNR- Asymmetric Tonic Neck Reflex
• Position- Supine
• Stimulus- turn the neck to one side i.e lateral rotation
• Response – extension of the limbs on face side/jaw side and flexion of
the limb on occiput side.
• Presence – 2 months
• Significance- this reflex helps in reducing tone in patients who have
increased tone. As this reflex integrates it allows the child to cross the
body’s midline for hand activities. Also this reflex must integrate by 4
months because after that eye hand coordination develops and if the
reflex will be persisting beyond 4 months then it will interfere with proper
development of eye hand coordination.

STNR- Symmetric Tonic Neck Reflex
• Position- prone ventral suspension/quadriped
• Stimulus-therapist move patient’s neck into flexion and then extension
• Response – flexion flexion of U/L & extension of L/L
extension extension of U/L & extension/flexion of L/L.
• Presence – 4 months
• Significance- this reflex separates the upper and lower halves of the
body. This reflex has to integrate for crawling to develop. And if it doesn’t
integrate then the child will slide the bottom and move.

TLR- tonic labyrinthine reflex
• Position- supine & prone
• Stimulus- position itself is a stimulus – supine & prone
• Response – supine  increases the extensor tone
prone increases the flexor tone
• Significance- this reflex helps in balance and postural control. And it must
integrate in time otherwise it will interfere with neck control and trunk
control.

Positive And Negative Supporting Reactions
• Position- child should be held in erect position holding from the axilla.
• Stimulus- bounce the child up and down in lap such that the sole of the foot
touches the therapist lap.
• Response – the tone in the lower limbs increase and all the muscles(specially
extensor group of muscles) will co-contract turning the legs into rigid pillars.
This response is considered as a positive supporting reaction.
- same stimulus is given and doesn’t produce contraction of leg
muscles and legs remain flexed that is considered as a negative
supporting reaction.
Presence – by birth
• Significance- this reflex helps in balance and postural control by developing
extensor tone and strength in anti gravity muscles.

MIDBRAIN REFLEXES/ RIGHTING
REFLEXES(REACTIONS)
• NOB – neck righting acting on body
• BOB – body righting acting on body
• LR – labyrinthine head righting reactions
• BOH – Body righting acting on head
• OR – optical righting reflex

NOB- Neck Righting Acting on Body Reactions
• Position- supine & prone
• Stimulus- turn (rotate) the head of the baby to one side
• Response – the body will follow the head and will turn towards the same
side as the head is rotated.
• Presence – 4- 6 months
• Integration- 5 years
• Significance- The reflex uses a combination of visual system inputs,
vestibular inputs, and somatosensory inputs to make postural adjustments
when the body becomes displaced from its normal vertical/erect position.

BOB- Body Righting Acting on Body
• Position- hook lying
• Stimulus- turn (rotate) the upper half of the body Or turn the lower half of
the body
• Response – if upper half of the body is rotated then lower half of the body
will follow and rotate to the same direction. And if lower half of the body
is rotated then upper half of the body will rotate and follow.
• Presence – 4- 6 months
vestibular inputs, and somatosensory inputs to make postural
adjustments when the body becomes displaced from its normal
vertical/erect position.

LB- Labyrinthine Head Righting Reaction
• Position- hold the baby in supine in your hands
• Stimulus- vision occluded, tip the body in all directions.
• Response – head orients to vertical position with mouth horizontal.
• Presence – birth to 2 months
• Integration- persists lifetime
• Significance- The reflex uses a combination of vestibular inputs, and
somatosensory inputs but not visual inputs to make postural adjustments
when the body becomes displaced from its normal vertical/erect position.

BOH- Body Righting Acting on Head
• Position- place in prone or supine.
• Stimulus- position acts as stimulus.
vestibular inputs, and somatosensory inputs to make postural
adjustments when the body becomes displaced from its normal
vertical/erect position.

OR – Optical Righting Reaction
• Position- hold the baby in supine in your hands
• Stimulus- tip the body in all directions.
• Significance- The reflex uses a combination of visual inputs, vestibular
inputs, and somatosensory inputs to make postural adjustments when the
body becomes displaced from its normal vertical/erect position.

CORTICAL REFLEXES/EQUILIBRIUM REACTION
• Protective extension
• Equilibrium reaction (tilting)
• Equilibrium reaction (postural fixation)

Protective extension
• Position- can be checked in standing or sitting
• Stimulus- displace COG out of the BOS (give perturbations with medium
force)
• Response – extremities extend for support & will protect the body from
falling.
• Presence – arms- 4-6months
legs – 6-9 months
• Significance- as the name suggests it is a protective response when the
body faces an external force this reflex helps maintain balance.

Equilibrium Reaction (Tilting)
• Stimulus- displace COG by tilting or moving the support surface
• Response – curvature of the trunk towards the upwards side of the support
surface with extension and abduction of the extremities of that side
• Presence – gradually develops in all positions: prone supine sitting
quadruped standing (12-21 months)
• Significance- it is a protective response when the body faces an external
force this reflex helps maintain balance.

Equilibrium Reaction (Postural Fixation)
• Stimulus- displace COG out of the BOS (give perturbations with greater force)
• Response – curvature of the trunk towards the force with extension and
abduction of the extremities on the side to which force was applied.
• Presence – gradually develops in all positions
• Significance- it is a protective response when the body faces an external
force this reflex helps maintain balance.

neurodevelopmental screening.pptx

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