Toddlers who have recently learned to walk fall a lot. Karen Adolph counted the number of times toddlers fall per hour: 12- to 19-month-olds averaged 2,368 steps and 17 falls.
Falls will usually decrease over time and with experience and most toddlers and young children fall infrequently.
"After walking onset, natural locomotion improved dramatically: Infants took more steps, traveled farther distances, and fell less. Walking was distributed in short bouts with variable paths—frequently too short or irregular to qualify as periodic gait. Nonetheless, measures of periodic gait and of natural locomotion were correlated, which indicates that better walkers spontaneously walk more and fall less. Immense amounts of time-distributed, variable practice constitute the natural practice regimen for learning to walk." Adolph et al 2012
However, there are a group of young children who continue to fall frequently, most often when they are moving at speed, encounter obstacles and rough, uneven or slippery support surfaces.
Factors that contribute to frequent falls in young children
Child does not pay attention to the environment
Looking where one is going is essential for adapting one's actions to accommodate support surface characteristics, obstacles up ahead, people and animals moving about. Visual attention includes knowing what to pay attention, and selecting and interpreting this information with respect to present goals.
Picking up information, and keeping it in mind as the task unfolds also requires good working memory.
Adapting actions to the characteristics of the environment
One of the important abilities toddlers need to acquire when they first start to walk independently is being able to interpret available visual information about the surfaces, objects and people in the environment to make decisions about what is possible. What does the environment allow (referred to as affordances)?
Can I jump down from this chair, or is it too high. Can I step across the gap, or is it too wide? Can I step up onto this step, or is it better to use my hands and climb up?
Karent Adolph's research on toddlers negotiating cliffs, narrow bridges and steep slopes beautifully illustrates how toddlers learn to about what sorts of terrains are safe and unsafe through experience. Is this safe: how infants learn about cliffs, gaps and slopes.
Ability to negotiate obstacles: stepping over, across, down and up.
Children acquire the task specific balance, coordination and strength needed for stepping up, down and over obstacles through experience. Repeated practice allows the child to adapt their actions to the demands of the task, develop the coordination and strength needed for performing the task and use anticipatory and adaptive adjustments to maintain balance and stabilize the trunk.
Read more: Balance is task specific
Difficulties with coordination (DCD)
Many children with movement difficulties have an underlying an coordination disorder (such as developmental coordination disorder) which affects the variability of their gait patterns and ability to control the COM and makes them more susceptible to trip and falls.
"The gait pattern of children with DCD was characterised by wider steps, elevated variability in the time spent in double support and stride time and greater medio-lateral velocity and acceleration compared to their peers. An elevated variability in medio-lateral acceleration was also seen in the young but not the older children with DCD. In addition, the young children showed a greater variability in velocity and acceleration in all three directions compared to the older children. The data suggest that the high incidence of trips and falls seen in children with DCD may be due to differences in the control of the CoM. " (Wilmut et al 2016)
Weakness and fatigue
Walking on uneven ground, running,stopping and making sudden changes in direction and negotiating obstacles all require the rapid increases in muscle force in the lower extremities to accommodate the acceleration and deceleration of the center of mass (COM) and to support the body weight.
The ability to generate a rapid increase in muscle force (muscle power) depends on the force generating capacity of the LE muscles as well as the ability to rapidly recruit motor units simultaneously (motor learning component of muscle strength and power).
Children with LE muscle weakness will fall more frequently when they are fatigued and the muscles are less able to generate the forces needed for supporting the body.
Generalized joint hypermobility (GJH)
Children with GJH have less inherent stability of the musculoskeletal system, with associated weakness, sometime limited ROM of hip adduction, which affect their ability to balance on one leg, a tendency to hyperextend their knees and poor foot alignment and ankle balance responses. All of these factors can contribute to frequent tripping and falling.
More about GJH How joint hypermobility affects infant development Joint hypermobility and Ehlers Danlos
Suggested Assessment and Intervention Plan
1 Identify the circumstances that lead to falls
When and under what circumstances does the child fall? Are falls related to moving around in a busy environments, moving at speed, making sudden stops and turns, negotiating obstacles, not paying attention, fatigue?
2 Observe the child moving about in different natural environments
Does the child pay attention to the environment? Does he avoid obstacles? Does he adapt his actions to the characteristics of the terrain (slope, stiffness, gaps, steps, roughness) and so on.
Observation in natural environments associated with the child's daily routines provides insight into the relationship between the child's attention and motor abilities and the physical and social environment.
3 Assessment and analysis of locomotor task performance
Task oriented assessment provides information about the child's ability to perform specific locomotor tasks, and an analysis of task performance gives information about factors that contribute to, or constrain success: visual pickup, adaptation to the physical environment, impact of the social environment, functional muscle strength and power, coordination, balance responses.
Read more: Toddler learning to step up: how experience and context influence motor planning
4 Identify general, everyday function goals
In collaboration with th child's parents and teachers, decide on a few measurable, every-day-function goals for intervention.
What is it that the child should be able to do in his natural environment that he cannot do presently?
- Walk across the classroom without bumping into people and furniture.
- Walk across the playground without falling more than twice during one recess.
- Walk 20 meters along a rough path in the park without falling
5 Select tasks to work on
Based on the assessment of locomotor tasks, select tasks that need work and will contribute to achieving the identified functional goals.
Read more: Checklist of Gross Motor Tasks
6 Implement a task oriented training intervention program
Task training, to be effective needs regular training sessions, and and such must involve the parents in implementing a home program. This is best achieved if parents are involved in figuring out:
- How to practice a task using resources in the home environment;
- How to adapt the task to allow the child to succeed;
- How to make the training session fun;How to provide immediate rewards to keep the child enaged and on task.
TOMT 0-3 Toddler Training Guide
For TOMT 0-3 Subscribers
Activities for training locomotor tasks
Adolph KE, Cole WG, Komati M, Garciaguirre JS, Badaly D, Lingeman JM, Chan GL, Sotsky RB. How do you learn to walk? Thousands of steps and dozens of falls per day. Psychol Sci. 2012;23(11):1387-94. doi: 10.1177/0956797612446346. Epub 2012 Oct 19. PubMed PMID: 23085640; PubMed Central PMCID: PMC3591461.
Franchak JM, van der Zalm DJ, Adolph KE. Learning by doing: action performance facilitates affordance perception. Vision Res. 2010 Dec;50(24):2758-65. doi: 10.1016/j.visres.2010.09.019. Epub 2010 Sep 19. PubMed PMID: 20858512; PubMed Central PMCID: PMC3013505.
Gentle J, Barnett AL, Wilmut K. Adaptations to walking on an uneven terrain for individuals with and without Developmental Coordination Disorder. Hum Mov Sci. 2016 Oct;49:346-53. doi: 10.1016/j.humov.2016.08.010. Epub 2016 Sep 1. PubMed PMID: 27591489.
Wilmut K, Du W, Barnett AL. (2016) Gait patterns in children with Developmental Coordination Disorder. Exp Brain Res. 2016 Jun;234(6):1747-55. doi: 10.1007/s00221-016-4592-x. Epub 2016 Feb 15. PubMed PMID: 26879769.