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aminations at speci ed ages are cross-sectional assessments, which give little idea of the dynamics of behavioral development As already stated, temporal patterns of behavior reveal an extraordinary degree of variation in their emergence, increment, and decrement as well as marked variation from one individual to another The predictive value of developmental assessment has been the subject of a lively dispute Gesell took the position that careful observation of a large number of infants, with accurate recording of the age at which various skills are acquired, permits the establishment of norms or averages From such a framework one can determine the level of developmental attainment, expressed as the development quotient (DQ developmental age/chronological age), and thus ascertain whether any given child is superior, average, or inferior After examining 10,000 infants over a period of 40 years, Gesell concluded that attained growth is an indicator of past growth processes and a foreteller of growth yet to be achieved In other words, the DQ predicts potential attainment The other position taken by Anderson and others is that developmental attainments are of no real value in predicting the level of intelligence but are measures of completely different functions Illingworth and most clinicians, including the authors, have taken an intermediate position, that the developmental scale in early life is a useful source of information, but it must always be combined with a full clinical assessment When this is done, the clinician has a reasonably certain means of detecting mental retardation and other forms of neurologic impairment The trajectory of rapid growth and maturation continues in late childhood and adolescence, though at a slower pace than before Motor skills attain their maximal precision in the performances of athletes, artists, and musicians, whose peak development is at maturity (age 18 to 21) Intelligence and the capacity for re ective thought and the manipulation of mathematical symbols become possible only in adolescence and later Emotional control, precarious in the school age and all through adolescence, stabilizes in adulthood We tend to think of all these phenomena as being achieved through the stresses of human relations, which are conditioned and habituated by the powerful in uences of social approval In this extensive and pervasive interaction between the individual and the environment, which is the preoccupation of the child psychiatrist, it is well to remember that the processes of extrinsic and intrinsic organization can be separated only for the purpose of analytic discussion There is always interdependence rather than con ict between them.

As indicated above (and in Table 28-4), the wide variety and seemingly random movements displayed by the healthy neonate are from birth, and certainly within days, rmly organized into re exive-instinctual patterns called automatisms The most testable of the automatisms are blinking in response to light, tonic deviation of the eyes in response to labyrinthine stimulation (turning of the head), prehensile and sucking movements of the lips in response to labial contact, swallowing, avoidance movements of the head and neck, startle reaction (Moro response) in response to loud noise or dropping of the head into an extended position, grasp re exes, and support, stepping, and placing movements This repertoire of movements, as mentioned earlier, depends on re exes organized at the spinal and brainstem levels Only the placing reactions, ocular xation, and following movements (the latter are established by the third month) are thought to depend on emerging cortical connec-

Sorting Tab Sort Direction Sort By Advanced Tab Bind Display of Text/Attributes in Data Provider Result and in Value Help Bind Display of Text/Attributes in Data Provider Result and in Filter Values (dropdown boxes, text elements, and so on) TABLE 1-7

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tions, but even this is debatable In the neonatal period, when little of the cerebrum has begun to function, extensive cerebral lesions may cause no derangement of motor function and may pass unnoticed unless special methods of examination sensory evoked potentials, EEG, computed tomography (CT), and MRI are used Of clinically testable neurologic phenomena in the neonatal period, disturbances of ocular movement, seizures, tremulousness of the arms, impaired arousal reactions and muscular tone all of which relate essentially to upper brainstem and diencephalic mechanisms provide the most reliable clues to the presence of neurologic disease Prechtl and associates have documented the importance of disturbances of these neurologic functions at this early age as predictors of retarded development During early infancy, the motor system undergoes a variety of differentiations as visual-, auditory-, and tactile-motor mechanisms develop Bodily postures are modi ed to accommodate these complex sensorimotor acquisitions In the normal infant, these emerging motor differentiations and elaborations follow a time schedule prescribed by the maturation of neural connections Normalcy is expressed by the age at which each of these appear, as shown in Table 28-4 It is also evident from this table that re ex and instinctual motor activities are the most important means of evaluating early development Moreover, in the normally developing infant, some of these activities disappear as others appear For example, the grasp re ex, extension of the limbs without a exor phase, Moro response, tonic neck re exes, and crossed adduction in response to eliciting the knee jerk gradually become less prominent and are usually not elicitable by the sixth month The absence of these re exes in the rst few months of life and their persistence beyond this time indicate a defect in cerebral development, as described further on, under Delays in Motor Development By contrast, neck-righting re exes, support reactions, the Landau reaction (extending neck and legs when held prone), the parachute maneuver (page 505), and the pincer grasp, which are absent in the rst 6 months, begin to appear by the seventh to eighth months and are present in all normal infants by the twelfth month Since many functions that are classi ed as mental at a later period of life have a different anatomic basis than motor functions, it is not surprising that early motor achievements do not correlate closely with childhood intelligence The converse does not apply, however; delay in the acquisition of motor milestones often correlates with mental retardation In other words most mentally retarded children sit, stand, walk, and run at a later age than normal children, and deviations from this rule are exceptional In the period of early childhood, the re exive-instinctual activities are no longer of help in evaluating cerebral development, and one must turn to the examination of language functions and learned sensory and motor skills These are outlined in Tables 285 and 28-6 Quite apart from the early stage of motor development, one observes in later childhood and adolescence a remarkable variation in levels of muscular activity, strength, and coordination Motor acquisitions of later childhood such as hopping on one foot, kicking a ball, jumping over a line, walking gracefully, dancing, certain skills in sports are linked to age Ozeretzkii has combined these in a scale that often discloses arrests in motor development in the mentally retarded Also in later childhood, precocity in learning complex motor skills as well as skill in games and the development of an all-around interest in athletic activity become evident By adolescence, high individual physical achievement is well recognized At the other end of the spectrum are instances of motor.