When hypotonia is a forerunner of an extrapyramidal motor disorder (so-called double athetosis, another type of cerebral palsy), the first hint of abnormality may be opisthotonic posturing of the head and neck. However, involuntary choreic movements usually do not appear in the upper limbs before 5 to 6 months of age and often are so slight as to be overlooked. They worsen as the infant matures and by 12 months assume a more athetotic character, often combined with tremor. Tone in the affected limbs is by then increased but may be interrupted during passive manipulation.
Hypotonia may also be a prelude to a cerebellar motor defect. The ataxia becomes apparent when the infant makes the first reaching movements. Tremulous, irregular movements of the trunk and head are seen when the infant attempts to sit without support. Still later, as the infant attempts to stand, there is unsteadiness of the entire body.
In distinction to the gross deficits in motor development described earlier, there is a distinct group of young children who exhibit only mild abnormalities of muscle tone, clumsiness or unusual postures or rhythmic movements of the hands, tremor, and ataxia (“fine motor deficit”), or “developmental coordination disorders.” Such awkwardness in the somewhat older child is referred to as a “soft sign” and has been reviewed by Gubbay and colleagues in what they have called “the clumsy child.” Like speech delay and dyslexia, fine motor deficits of this sort are more frequent in males. Tirosh found that intranatal problems were more prevalent among children with fine motor deficits (compared to those with gross motor deficits), as were minor physical anomalies and seizures.
Systemic diseases in infancy pose special problems in evaluation of the motor system. The achievement of motor milestones is delayed by illnesses such as congenital heart disease (especially cyanotic forms), cystic fibrosis, renal and hepatic diseases, infections, and surgical procedures. Under such conditions one does well to deal with the immediate illnesses and defer pronouncements about the status of cerebral function. The brain proves to be simultaneously affected in 25 percent of patients with serious forms of congenital heart disease and an even higher proportion of patients with rubella and coxsackie B viral infections. In a disease such as cystic fibrosis, where the brain is not affected, it is advisable to depend more on the analysis of language development than on assessment of motor function, because muscular activity may be generally enfeebled.
Failure to see and to hear are the most important sensory defects affecting the infant and child. When both senses are affected, a severe cerebral defect is usually responsible; only at a later age, when the child is more testable, does it become apparent that the trouble is not with the peripheral sensory apparatus but with the central integrating mechanisms of the brain.
Failure of development of visual function is usually revealed by strabismus and by disorders of ocular movements, as described in Chap. 12. Any defect of the refractive apparatus or the acuity of the central visual pathways results in wandering, jerky movements of the eyes. The optic discs may be atrophic in such cases, but it should be pointed out that the discs in infants tend naturally to be paler than those of an older child. In congenital hypoplasia of the optic nerves, the nerve heads are extremely small. Defects in the retina and choroid are detectable by funduscopy. Faulty vision becomes increasingly apparent in older infants when the normal sequences of hand inspection and visuomanual coordination fail to emerge. Retention of pupillary light reflexes in a sightless child signifies a defect in the geniculocalcarine tracts or occipital lobes— conditions that may be confirmed by MRI and testing of visual evoked responses.