How to Improve Baby’s Gross Motor Skills? Tips From PT!

What do we mean by “baby’s motor skills”?

The motor skills of a baby refer to the set of functions that allow control and execution of movements.

Contrary to a preconceived idea, it is not limited to pure movement activities. It also involves parallel skills such as balance, nerve and muscle functions, etc.

Motor skills can be of two types: reflex or voluntary.

Reflex movements are instinctive and involuntary.

Voluntary movements are intentional and controlled.

There is also a distinction between gross motor skills and fine motor skills.

Gross motor skills involve movements of the entire body such as crawling, walking, and jumping.

Fine motor skills encompass more precise movements of the hands and fingers for grasping small objects or writing.

In this article, I will focus on the baby’s voluntary gross motor skills.

Motor skills and motor development: What are the differences?

Motor skills and motor development are two distinct but closely related concepts.

Motor skills represent the set of movements and motor abilities of an individual at a given time.

Motor development is the continuous process by which an individual acquires and improves motor skills throughout life. It is a dynamic and evolving process based on practice and experimentation.

It depends on various factors such as: growth, neurological maturation, experience, environment, and sensory stimulation. These processes lead to permanent changes in the baby’s abilities to create movement.

Motor development, therefore, encompasses the stages of learning required to acquire a complex motor skill.

Note from Nelly: Personally, I don’t really see a concrete application of these distinctions! With parents and professionals alike, I use these two concepts interchangeably.

How does baby’s motor skills develop?

To understand the development of motor skills, several theories have emerged. However, to date, none of them fully explain all the processes involved. Each theory provides complementary information.

Note from Nelly: Jonathan here provides theoretical reminders. For those seeking actionable information, you can skip this part!

One of the earliest theories is Adams’ “closed-loop” theory (1971), which suggests that movements are selected and initiated from a memory trace. Through feedback, the basic movement is then modified by feedback loops to match the “movement traces” in memory.

These movement-feedback loops are obtained through repeated movement practice. However, studies have shown that learning can occur without this sensory feedback.

Next is Schmidt’s schema theory, also known as open-loop theory. According to this theory, generalized motor program schemas are created from previous movement patterns.

To perform a new movement, the closest known movement is accessed. Then, a recognition schema system evaluates the occurring movement to transform it and achieve the goal. However, this theory does not explain where generalized motor program schemas come from.

Then comes the theory of dynamic systems, which considers movement as emerging from an interaction between the person, the task to be performed, and the environment.

According to this approach, the human body consists of different systems themselves divided into subsystems that interact with each other.

The interactions between these systems can either assist or constrain movement. Thus, the most adapted movements stabilize during motor exercise and through cycles of exploration and repetition. The movement dynamics configure themselves into the optimal motor solution.

More recently, the theory of neuronal group selection, also known as neuronal Darwinism, has emerged. It proposes a selective process of neurons involved in motor skills.

This process is divided into three phases:

1. The creation of neurons, from synapses to neuronal death.
2. The phase of neuron selection through experience. Neuronal “wiring” is modified based on interactions with the environment. The more it is used, the denser the connections become, creating primary and secondary neuronal repertoires. Conversely, lack of use leads to a decrease in neuron connections.
3. The creation of “specialized maps,” which correspond to connections between different close repertoires.

During brain development, connections between neurons are regularly formed, allowing new motor skills to emerge.

If the new motor skill is used by the child, then this connection will strengthen and improve the skill.

Conversely, non-use would lead to the suppression of these connections.

The mechanisms that enable a child’s motor development are not yet well understood. But one certainty is that babies develop their motor skills through their own experiences in their environment. They conduct their own experiments that shape their motor development.

What are the stages of motor development?

Motor development unfolds through a continuous process of progression and regression, fostering the learning of motor skills. We often refer to these as motor transitions.

Within this spectrum of motor transitions, some stand out from others, and we call these motor stages.

In the study of the Motor Assessment of the Developing Infant (5) for the development of an infant motor scale assessment, 84 motor stages were initially identified.

After analysis, 58 motor stages were selected due to their sufficient differentiation to allow for precise medical monitoring.

These motor stages do not all occur in strict chronological order. Some develop simultaneously, and the sequence can vary from one child to another.

To represent this variability, I use the concept of “motor pathways.”

Among the 58 identified motor stages, here are the ones I consider most important:

On the back:

• Pelvic rolling movements (knees move towards the chest)
• Clustering, hands towards the mouth
• Pedaling movements
• Hands grabbing knees and then feet
• Feet to mouth
• Side rolling as a unit
• Side rolling with dissociation of the belts
• Back-to-belly turns

From the prone position (on the stomach):

• Sphinx position (support on forearms)
• “Paratrooper”: arms and legs lift off
• Enlargement
• Pelvic movements
• Belly-to-back turns
• “Compass” movement: ability to orient 360° around an axis passing through the belly
• “Push-ups” with pelvis on the ground
• Crawling
• Tripod sitting
• “Little mermaid” sitting
• Sitting without hand support
• Crawling and walking on all fours
• “Bear” position and walk
• Upright kneeling position
• Knight
• Standing
• Finally, squatting

The stages of motor development leading up to independent walking are more numerous and diverse than the traditional stages: rolling over, crawling, sitting, crawling on all fours, standing, and walking.

At what age does a baby achieve different motor milestones?

The study “Motor Assessment of the Developing Infant” (5) examined the ages at which various motor milestones are typically achieved in infants, based on tracking a sample of 2200 babies.

The ages indicated as “maximum” correspond to the age at which 90% of children reach that milestone.

Here are the results:

• Rolling over: between 3 and 9 months
• Crawling: between 4 and 9 months
• Hands and knees crawling: between 5 and 13 months
• Sitting position: between 4 and 8 months
• Upright kneeling position: between 6 and 11 months
• Independent walking: between 9 and 18 months

It’s important to note that there is a wide inter-individual variability among children. Around the age of 6 to 10 months, this is the period when the differences in motor skills between babies are most significant.

Note from Nelly: For children with disabilities or certain genetic characteristics, the ages of acquisition of these milestones may be delayed. I discuss this in my article on motor development in children with Down syndrome.

Note from Nelly: This grid is sometimes used by pediatricians or specialized pediatric physical therapists. We observe how the child behaves in terms of motor skills, calculate a score, and then compare the child’s position to other children of the same age. It’s a bit like what we do for weight and height, but here it’s for motor development.

How to know if your child is developing normally?

To assess your child’s motor development, you need to distinguish between congenital pathologies, present from birth, and pathologies acquired later on.

Congenital pathologies are rarer and some can be diagnosed before birth. They include congenital torticollis, cerebral palsy, trisomies, rare genetic diseases, etc.

“According to medical approaches and classifications, 1% to 2% of children may have moderate to severe disabilities, knowing that disability can gradually become apparent.” (6)

High Council for Family, Childhood, and Age

Acquired pathologies are much more common. Some studies estimate that 30% of children may suffer from positional plagiocephaly. (7)

Note from Nelly: There are even studies that find that 1 in 2 babies has positional plagiocephaly or brachycephaly (= flat head)! With these frequencies, one might also question whether it is really a “pathology” or just a normal developmental characteristic.

To assess whether your child shows signs of motor disorders, it’s essential to observe them carefully. Check that your child can turn their head from side to side and note the shape of their head, whether it’s round or starting to flatten.

Also, observe your child’s regular progress. Each week, they should be making acquisitions, even if they are subtle. The quality of movements is also a key element to consider. Movements should become increasingly fluid, harmonious, ample, and precise with age.

Age can serve as a guide, but it should not be used alone.

I have had cases in my practice where a 20-month-old child was not walking independently but showed very good motor skills without any cause for concern.

In contrast, I’ve seen an 11-month-old patient who had been walking for a week but had deficiencies in motor skills.

Normal development is characterized by a steady progression of motor skills, both in terms of their quality and diversity (acquiring all motor milestones and related skills) within a broad age range.

What to do if I’m concerned as a parent about developmental delay?

If you are worried about a possible developmental delay in your child, it is important to listen to your concerns while avoiding excessive alarm.

Start by carefully observing your child. Identify specific aspects that concern you (e.g., movements that seem abnormal) or simply pressures from your surroundings regarding the age of developmental milestones.

If your concerns persist, it is recommended to discuss the situation with your pediatrician or the doctor who is following your child. They can assess the situation more thoroughly and provide you with appropriate advice.

Note from Nelly: I also recommend limiting the number of opinions sought. I have encountered parents who (with all good intentions) consulted up to 6 different professionals (family doctor, pediatrician, pediatric neurologist, 2 physiotherapists, osteopath) to get an opinion on positional plagiocephaly.

By seeking multiple opinions, you increase the probability of unnecessary “alerts.”

Consulting a physical therapist, osteopath, pediatrician, doctor… What’s the difference?

In case of doubt and questioning, the first step is to consult the doctor or pediatrician who is following the child. Their role is to conduct an overall assessment to ensure there is no “serious pathology.”

Once this hypothesis is ruled out, your doctor can refer you to a specialized physical therapist for a more detailed evaluation of your child’s motor skills.

The physical therapist will propose appropriate interventions for your child’s difficulties or pathology.

Regarding rehabilitation practices, for better effectiveness, studies highlight the need to perform exercises and adapt stimulations daily.

Manual therapy techniques like osteopathy have not proven effective. (8)

So 1- the doctor to rule out the possibility of something serious. 2- The physiotherapist for support with practices to implement at home.

How to diagnose a motor delay?

To diagnose motor delay, it is important to consider several elements in addition to the child’s age, due to the natural variability among individuals.

Here are some tools used in (para)medical evaluation:

• Presence of hypertonia or hypotonia. Note from Nelly: Hypertonia means that the child’s muscles are tighter or stiffer than normal, which can make movements more difficult and lead to a rigid posture. Hypotonia, on the other hand, means the child’s muscles are less toned than normal, which can give a feeling of muscle weakness and make movements less coordinated.
• Monitoring the presence of primitive reflexes and their integration.
• Use of standardized scales such as the Bayley-4 and the Brunet-Lezine, revised version. These are not specific to motor skills.
• Alberta Infant Motor Scale, which is a follow-up to the Motor Assessment of the Developing Infant, but for which there is no training available in France.

The diagnosis of a delay is based on the presence of several concerning elements. Standardized scales help evaluate the difference compared to what is expected.

When can a baby be stimulated, and how?

What do we mean by “stimulation”?

Stimulation refers to all activities, interactions with others, and interactions with the environment that elicit a response from the baby.

From the prenatal period, the baby is already exposed to stimulations. For example, the baby reacts to pressures on the mother’s belly or external noises.

At birth, the baby is immersed in a “bath of stimulations.” Therefore, the question is not about when to start stimulating the baby, but how to adapt the environment, interactions, and activities to provide appropriate stimulations.

In the continuation of this paragraph, we will focus on stimulations aimed at promoting the baby’s motor development.

From the first days of life, techniques such as ergonomic babywearing can be used to stimulate the baby. Subsequently, stimulations should be adjusted according to the baby’s motor skills, seeking to strike a balance between insufficient stimulation and the risk of overstimulation.

Indeed, overstimulation can cause the baby to withdraw to protect themselves or lead to tension reactions that may contribute to motor disorders or pathologies.

Note from Nelly: I have never read or observed such.

Therefore, it is possible to stimulate your child from birth by providing an appropriate environment.

Can you put your baby on their stomach?

The position on the stomach, also known as tummy time, is a recommended practice to promote the baby’s motor development. Recommendations suggest placing the baby on their stomach for 5 to 10 minutes per day from birth.

You can divide this duration into 10 sessions of one minute each, then gradually increase it.

Tummy time has the advantage of preventing positional torticollis and plagiocephaly (head deformation).

It’s important to remember the necessity of placing babies strictly on their backs when they are sleeping to prevent the risk of sudden infant death syndrome (SIDS).

Placing your baby in a sitting position before they can do it themselves: what to think?

Personally, I do not recommend doing this.

From a motor development perspective, it’s not advisable to artificially place a baby in a sitting position before they can achieve it on their own. This practice increases the risk of hindering the development of essential motor skills acquired during floor and crawling phases.

It’s better to allow your baby to progress at their own pace by letting them explore and develop their motor skills from positions like tummy or back. The sitting position will naturally come, like all other stages of motor development.

Note from Nelly: I notice that many of my colleagues specialized in pediatric physiotherapy, like Jonathan, make this recommendation: not to sit your baby before they can do it themselves. I do not share their opinion, and I do not know of empirical data that justify their view.

For me, there is no inherently bad position; the importance lies in variety. However, things can be somewhat different for children with multiple disabilities who are more at risk of encountering motor difficulties.

What is freedom of mouvement and how to practice it?

Free movement is a concept aimed at promoting children’s motor development by allowing them to explore their environment autonomously. The concept of free movement was popularized by Emmi Pikler, a Hungarian pediatrician.

To practice free movement, here are the main principles of this concept:

• Do not place the baby in a position that they cannot achieve on their own.
• Avoid using devices such as baby seats or playpens that could restrict the baby’s movements.
• Choose appropriate clothing.
• Use everyday objects and materials to encourage the baby’s motor explorations.
• The presence and encouragement of parents play an essential role in practicing free movement.
• Provide large, safe activity spaces.
• Allow the baby to move barefoot as much as possible.

Free movement means letting your child express their motor skills to allow them to make their own discoveries.

What materials and games to use – or not! – for baby’s motor skills?

When it comes to choosing materials and games to promote your baby’s motor skills, it’s essential to conduct an objective assessment of the potential benefits and possible risks associated with each object or activity.

• Baby seats (and other baby nests) tend to restrict the baby’s movements. It is preferable to spend time on the floor on large “motor mats” during active phases and use physiologic baby carriers if the baby needs reassurance and comfort.
• Car seats are designed to restrain the baby to prevent serious injuries in case of an accident. Therefore, their use should be limited to the car. When you take the baby out of the car, carry them in your arms or in a baby carrier. An additional advantage is that this saves your back from carrying the weight of the car seat.
• Mobile arches tend to fix the baby’s gaze upwards and limit movement ranges. If placed too far back, they can also cause extension, which is a risk factor for infant torticollis and plagiocephaly. If you use an arch, place it above the baby’s belly. Limit the usage time or remove the arch completely. Instead, when your child is on the mat, you can offer a few (2 or 3) games directly on the mat.
• Baby walkers should not be used in my opinion. They are, in terms of usage proportion, the leading cause of head trauma in non-walking children. They are even banned from sale in Canada.
• Similarly, jumpers do not allow the child to develop motor skills, including protective reflexes.
• Musical toys should be chosen based on the baby’s reactions. For some newborns, loud or sharp noises like bells can trigger an extension reflex. Conversely, some white noises or music can calm the baby.

Based on Baby’s progress, it’s possible to use everyday objects such as pots, spoons, or sofa cushions to encourage exploration and motor skills.

A push walker can be an interesting object, but it’s important to use it appropriately.

Avoid holding the wheels to help Baby stand up. They should be able to manage their balance and protect themselves before that. Let Baby push the walker to learn how to manage stability.

Babies don’t need a large quantity of materials or toys to develop. They should be tailored to the child’s skills and not restrict their movements.

Note from Nelly: Many people also wonder about the value of creating motor skills courses, especially with equipment such as motor modules (large foam blocks of different colors).

My daughter’s daycare, knowing I was a physiotherapist, even asked me to come and do motor skills workshops based on motor courses. Of course, if you enjoy this sort of thing, you can go ahead.

However, it’s absolutely not a prerequisite for a baby or child to develop well.

Exposing them to different (and safe) places with different objects (at home, in the park, on grass, in sand, with family, at daycare, in parent-child places, etc.) is sufficient!