Behavior - Shy
Infants at 12 months of age are often shy and have stranger anxiety. Most of the neurological exam can be performed with the child on his parent’s lap. The parent helps reassure the child and facilitates the exam. This infant is shy and frequently looks to his father for reassurance. The examiner uses toys to try to engage the child in play and overcome the shyness.
Behavior - Social and Language
Infants this age imitate activities, wave bye-bye, and play pat-a-cake. They can follow simple instructions especially if the desired action is demonstrated. They feed themselves finger foods. They usually have one or two meaningful words, usually mama and dada.
A colorful finger puppet is used to attract the infant’s attention and test extra ocular range of movement. For testing visual fields, a finger puppet is again used to get the infant to visually fixate, and then a dangling measuring tape is used to test peripheral vision.
Motor - Tone
Passive range of motion for both the upper and lower extremities is tested. Transforming the movements into a game makes the exam less threatening to the infant.
Motor/Reflexes - Deep Tendon Reflexes
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Motor/Reflexes - Plantar Reflex
At 12 months of age the toes can go up or down. Generally, they are down going. In this age group it's hard not to get withdrawal of the foot. An abnormality of the plantar reflex is most diagnostic if there is reproducible asymmetry.
Motor/Postural Reflexes - Parachute
The parachute is the last of the postural reflexes to develop. It usually appears at 8 to 9 months and certainly is present by 12 months of age. The reflex is elicited by turning the child up side down. The arms should come forward and the hands spread out to catch the fall. Asymmetry of the reflex is abnormal and may indicate paresis in the non-extended extremity.
Motor/Coordination - Pincer Grasp
Fine motor coordination of the hand progresses in a definite pattern. At 6-7 months the hand is used as a rake and objects are raked into the palm with the fingers. At 8-9 months the thumb and the radial fingers are used to grasp an object and smaller objects are picked up. At 10-12 months, the fine pincer grasp is developed. This enables an infant to pick up a small object between the distal thumb and index finger.
Both infants in this exam have developed a pincer grasp. The first infant uses the pincer grasp to feed himself a cheerio. The second infant demonstrates a pincer grasp by grabbing the tip of a measuring tape and pulling the tape out. The pincer grasp should be equal in either hand. Handedness does not develop until after 12 months of age. Early handedness and asymmetric fine motor skills are seen with a hemiparesis.
Motor/Coordination - Beads in the Cup
This test is a combination of understanding instructions, as demonstrated, and using a pincer grasp to place the small bead in a container.
Motor/Coordination - Play Ball
The infant plays the simple game of throw the ball. His throw is not an overhand throw which is seen in an 18 month old but rather a pushing away and dropping type of throw that is typical for this age.
Motor - Transition in and out of Sitting
As far as gross motor skills, the infant is able to get in and out of the sitting position with ease and creeps well.
Motor - Creeping
Crawling is a commando type of crawl which is an arm over arm propulsion forward with the trunk on the ground and legs dragging. Crawling is usually seen at 7 to 9 months. Creeping is crawling on hands and knees with the trunk off of the ground. Creeping is usually seen at 8 to 12 months.
Motor - Stoop and Recover
At one year, this infant has developed the ability to walk without support. Although still wobbly, he can stoop down to pick up an object and stand back up without falling. He can maintain his balance as he inspects and manipulates the toy. An infant usually develops the ability to stoop and recover at 11 to 14 months of age.
Motor/Gait - Stand, Walks with Support
The first infant demonstrates the ability to pull himself to a stand while holding on.
The second infant can stand, pull to a stand and cruise (not demonstrated because the baby is upset). Cruising is walking along a piece of furniture while holding on. It usually develops between 10 to 12 months. Along with cruising, the infant can take steps while holding on but he’s not ready to walk unsupported.
Motor/Gait - Toddler's Gait
Independent walking is achieved between 11 and 15 months of age. An infant is delayed if they aren't walking by 16 months. This 12 month old infant has a typical gait of an infant that has just learned to walk. He has a wide base, is unsteady, and toddles. His arms are held at near shoulder level in a high guard position. This is a protective position and probably aids in his balance. As he matures, his arms will come down to a low guard position, then into the usual associated arm movements seen with mature walking.
The first attempt to measure the head circumference is easy but the examiner reads the measurement as 50.6 cm, which is above the 98th percentile. Second attempt is much more difficult because the infant doesn't want the tape measure around his head. The measurement however is read as 47.7 cm, which is at the 50th percentile. A third attempt verifies that the 47.7 cm measurement is correct. Always take at least two measurements and save the head circumference to the last.