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Typically developing children acquire motor skills at varying ages, and abnormal movements and motor control can occur in healthy children.1 Understanding the course of motor development is a core skill in pediatric medicine. Divergence from the expected developmental course and subacute loss of motor control are common reasons for referral to child neurologists. This chapter addresses the key points of the clinical approach to evaluation and management of children with problems with coordination, gait and balance, and eye movement control. These occur in 3 broad categories: clumsiness, acute ataxia, and chronic progressive ataxia. Neuroanatomically, the conditions discussed in this chapter involve the cerebellum and/or its afferent or efferent connections, in most cases. Ataxia is defined as an inability to generate a normal or expected voluntary movement trajectory that cannot be attributed to weakness or involuntary movements (eg, chorea, dystonia, myoclonus, tremor).2 In ataxia, the spatial pattern and/or timing of movements are affected. Clumsiness in this chapter refers to benign, nonprogressive difficulties with fine and gross motor function that are not due to a progressive neurologic disease. Key manifestations of cerebellar function/dysfunction are presented in Table 6–1.

Table 6–1.Selected symptoms and signs of cerebellar disorders.



A clumsy child is an otherwise healthy child who develops gait, balance, fine finger movements, and sometimes speech articulation along a developmental trajectory that is below the typical range. Determining what is benign clumsiness versus clumsiness due to an underlying neurologic disease can be challenging.3 The most important historical feature indicative of a serious neurologic problem is loss of well-established motor skills. However, degenerative diseases can also initially present with slower-than-expected skill acquisition. Therefore, vigilance and longitudinal clinical follow-up with serial examinations is important.


Parents may report tremor, particularly on awakening and during performance of fine motor tasks, and difficulty with tasks such as utensil use, drawing, or writing. Difficulties with cognition or emotional regulation are somewhat more common. Neurologic examination is critical. Benign clumsiness is often manifest primarily by slow, variable, inaccurate sequential ...

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