One of the most common goals for initiating physical therapy services is walking. So much focus can be placed on getting a child to start walking that after it happens, parents can be overwhelmed with all the additional skills needed to take the next developmental steps. Once a child has combined all of the fundamental skills to allow for them to walk by themselves, there are many complementary skills and goals that allow the child to explore their environment independently. As a physical therapist, my goal, once a child has taken their first steps, is to progress the child to using walking as their primary means of mobility, and to do this they need to develop walking adaptability and transitional skills in and out of walking. After walking, important gross motor milestones include running, climbing stairs, jumping and standing on one foot.
Primary Mode of Mobility
A child's first steps are really just a series of falls forward and then catching themselves by putting one foot in front of the other. When a child first starts walking, they walk with their hands high in the air, called high guard, with a wide base of support and stiff steps -- all of these attributes to their walking pattern are related to finding more balance as a new walker. It is common for these to last for the first 6 months of walking, regardless of when they actually start walking. During this exploratory time, children will try out many different walking patterns, whether that be up on toes, feet turning in or feet turning out, as they develop more comfort and control with walking. The walking pattern progresses after 6-12 months, and a child will have a consistent heel strike, reciprocal arm swing and smaller base of support. This progression is seen as a child progresses from taking independent steps to using walking as their primary way of exploring their environment, with their muscles developing a more energy efficient pattern for walking. That increase of walking time is what helps the body become more efficient with walking. We do not expect a child to have a fully mature gait pattern, like you or me, until they are 7 years old, and that is mostly due to height.
Once a child is primarily walking, we then want the child to develop the ability to negotiate on their feet when the demands of the environment change. It is with the acquisition of negotiating changing environment and with various dual tasks that a child can safely play. Developing walking adaptability involves all of the following changes to the environment:
Obstacles can include stepping up and down onto different heights of surfaces, including stairs and transitions between carpets, and avoiding and negotiating around toys, furniture, and corners. Temporal refers to changes in speed with walking, including being able to change speeds of walking into running and then back to slower speeds. Terrain refers to uneven surfaces such as sand, grass, and hills. Ambient refers to the lighting of the environment, including negotiating areas that are bright or dark. Physical Load refers to being able to carry things while walking -- think doing loaded carries when you go to the gym. This can include carrying a toy or groceries, setting the table or wearing a backpack. Postural Transitions refer to moving our body around while walking and can include looking up, down, left or right, bending down to pick something up, squatting, and reaching overhead. Maneuvering in traffic refers to moving obstacles like avoiding siblings and traveling in busy environments, that involve backwards and lateral stepping. Cognitive dual task refers to the ability to think and walk and an easy way to work on this is with walking and talking with a child to encourage continued movement while talking, thus engaging multiple areas of the brain. Motor dual task refers back to adding a physical load to walking but can also include throwing, catching and kicking balls, and jumping.
Walking Transitional Skills
There are gross motor skills that develop in a similar time frame to walking that help to promote the independence needed for children to explore their environment on their feet. Balance reactions in sitting include equilibrium and protective reactions. Equilibrium reactions are being able to bring your body back to center when there is a perturbation within your center of gravity. Protective reactions include being able to catch themselves in all directions when a child's center of mass falls outside their base of support. Transitional skills like squatting and floor-to-stand transitions allow for children to get in and out of standing and to play with toys without completely getting off their feet. For a child who can only attain standing by pulling up at a surface, when he or she falls down when walking, they have to crawl over to a support surface to get back to walking, which slows a child down as a new walker, who may fall frequently as they get steady on their feet.
Gross Motor Milestones After Walking
Skills that begin to develop after walking include running, climbing stairs, jumping and standing on one foot. Walking has foundational skills that are necessary for each of these skills, which is why they happen after running. Additionally, all of these skills help to mature a walking pattern into an adult-like pattern due to strengthening, balance and coordination improvements.
18-20 months - runs stiffly 30 months – double leg clearance 42 months – appropriate running form
15-18 months – Walks up and down with hand 24-30 months – walks up and down without support 3-3.5 years old– up and down alternating steps
2 years old - Jumps down from step 3 years old– Jumps off floor with both feet 3-5 years old – hops on one foot
Standing on One Foot:
2.5 years old– 1-2 seconds 5 years old– 10 seconds without sway
While walking is an important developmental milestone, there are many skills that happen both in succession with a child starting to walk, along with skills that happen afterwards that could also be delayed if walking is delayed. Knowing the expected ages for these skills can give us a clue into the strength, balance and coordination of a child to know if, after walking, he or she is continuing to develop gross motor skills.