Development Milestones PDF

Development Milestones Developmental milestones are markers of a child’s development from infancy on into childhood. They are used to help determine if a child is undergoing typical development versus if a child has delayed in a given area or over multiple areas in the process of aging development....

Development Milestones Developmental milestones are markers of a child’s development from infancy on into childhood. They are used to help determine if a child is undergoing typical development versus if a child has delayed in a given area or over multiple areas in the process of aging development. Milestones are categorized into social/emotional, gross and fine motor, language, and cognitive. This activity highlights the role of the interprofessional team in assessing developmental milestones. Objectives: Describe the common stages of development milestones. Identify the indications for assessing development milestones in infants and children. Explain the importance of diagnostic tests in regards to development milestones. Review one step the clinician can take to identify children with behavioral concerns. Introduction Developmental milestones are a set of goals or markers that a child is expected to achieve during maturation. They are categorized into 5 domains: gross motor, fine motor, language, cognitive, and social-emotional and behavioral. Understanding and identifying the developmental milestones can help the provider more adeptly recognize delayed development, facilitating earlier interventions and improving outcomes. Typical Milestones Six months: Stranger anxiety; Rolls over; begins to say consonants while babbling; brings things to mouth. Nine months: Separation anxiety; 'stands' on hands and feet, sits without support, crawls, pincer grasp; understands “no,” points with a finger, says “mama” or “baba;” plays “peek- a-boo.” Twelve months: Puts out arm or leg when dressed, cries when familiar people leave; stands well; responds to simple commands, makes gestures, puts things in a cup and removes them, bangs things together. Eighteen months: Engages in pretend play, kisses/hugs familiar people, walks alone, walks up steps, eats with utensils, says several individual words, points to one body part, scribbles with crayon, marker, or pen. Two years: Begins playing with other children, parallel play; stands on tiptoes, kicks a ball, throws a ball overhand; two to four-word sentences, points to things in a book, strangers can understand 50% of language; stacks four or more blocks, follows two-step instructions.  Three years: Dresses/undresses self, copies others, takes turns; walks up and downstairs with one foot per stair, runs easily; strangers can understand 75% of language; stacks six or more blocks, turns pages in a book, pushes buttons and turns knobs. Four years: Likes to play with others, more imaginative play; hops on one foot, can stand on one foot for two seconds, cuts with scissors; can recite a poem or sing songs, understands basic grammar; identifies some colors and numbers, draws a person with two to four body parts. Five years: Differentiates between real and pretend, wants to be like friends; can stand on one foot for 10 seconds, can somersault; easily understood by others, tells stories, uses future tense; counts to 10, draws a person with six body parts, prints some letters and numbers. Function The assessment of developmental disorders is guided by the processes of surveillance and screening: Surveillance: The process by which children who are at risk or who have developmental delay are identified. It is done at every well-child care visit, and it can be performed by using an age-appropriate checklist of milestone records. Special attention must be had at the 4 to 5-year visit prior to the start of school. Screening: The process by which asymptomatic children who may be at risk of developing a disorder are identified via standardized testing. Once a child screens positive, he or she should undergo a subsequent developmental-behavioral evaluation. The American Academy of Pediatrics recommends screening at ages 9, 18, and 30 months. Some of the tools used are the Denver Developmental Screening Test, Ages, and Stages Questionnaires. When evaluating a child, it is important to take into consideration the gestational age at birth, as premature infants have a higher risk of long-term neurodevelopmental disabilities. In order to assess the normal growth and development of an infant born premature, the clinician must adjust the chronological age to the appropriate gestational age, and adjust the milestones to the corrected gestational age. For example, a baby is born at 32 weeks, and they are 8 weeks premature based on a full-term baby born at 40 weeks gestation. One would expect this 32-week old baby to reach their milestones 2 months behind their chronological age. The implementation of both surveillance and screening enhances early identification, enabling more prompt intervention, which promotes improved outcomes.  Age Social/ Language/ Cognitive Movement/ Emotional Communicati Milestones Physical Milestones on (learning, Development Milestones thinking, Milestones problem- solving) 2 Calms down Makes sounds Watches you Holds head up months when spoken other than as you move; while on to or picked crying; reacts looks at a toy tummy; Moves up; looks at to loud sounds for several both arms and your face; seconds both legs; seems happy Opens hands to see you brie y when you walk up to her; smiles when you talk to or smile at her 4 Smiles on his Makes cooing If hungry, Holds head months own to get sounds (“ooo”, opens mouth steady without your attention; “aahh”); when he sees support when chuckles (not makes sounds breast or you are yet a full back when bottle; looks at holding him; laugh) when you talk to her hands with holds a toy you try to him; turns interest when you put make him head toward it in his hand; laugh; looks at the sound of uses his arm you, moves, your voice to swing at or makes toys; brings sounds to get hands to or keep your mouth; attention pushes up onto elbows- forearms when on tummy fl  6 Knows familiar Takes turns Puts things in Rolls from months people; likes making her mouth to tummy to to look at self sounds with explore them; back; ushes in a mirror; you; blows reaches to up with laughs “raspberries” grab a toy she straight arms (sticks tongue wants; closes when on out and lips to show tummy; leans blows); makes she doesn't on hands to squealing want more support noises food herself when sitting 9 Is shy, clingy, Makes a lot of Looks for Gets to a months or fearful different objects when sitting position around sounds like dropped out of by herself; strangers; “mamamama” sight (like his moves things shows several and spoon or toy); from one hand facial “bababababa”; bangs two to her other expressions, lifts arms up to things hand; uses like happy, be picked up together ngers to sad, angry, “rake” food and surprised; towards looks when himself; sits you call her without name; reacts support when you leave (looks, reaches for you, or cries); smiles or laughs when you play peek- a-boo fi  12 Plays games Waves “bye- Puts Pulls up to months with you, like bye”; calls a something in a stand; walks, pat-a-cake parent“mama” container, like holding on to or “dada” or a block in a furniture; another cup; looks for drinks from a special name; things he sees cup without a understands you hide, like lid, as you “no” (pauses a toy under a hold it; picks brie y or stops blanket things up when you say between it) thumb and pointer nger, like small bits of food fl fi  15 Copies other Tries to say Tries to use Takes a few months children while one or two things the steps on his playing, like words besides right way, like own; uses taking toys out “mama” or a phone, cup, ngers to feed of a container “dada,” like or book; herself some when another “ba” for ball or stacks at least food child does; “da” for dog; two small shows you an looks at a objects, like object she familiar object blocks likes; claps when you when excited; name it; hugs stuffed follows doll or other directions toy; shows given with you affection both a gesture (hugs, and words (for cuddles, or example, he kisses you) gives you a toy when you hold out your hand and say, “Give me the toy.”); points to ask for something or to get help fi  18 Moves away Tries to say Copies you Walks without months from you, but three or more doing chores, holding on to looks to make words besides like sweeping anyone or sure you are “mama” or with a broom; anything; close by; “dada”; follows plays with toys scribbles; points to show one-step in a simple drinks from a you something directions way, like cup without a interesting; without any pushing a toy lid and may puts hands gestures, like care spill out for you to giving you the sometimes; wash them; toy when you feeds himself looks at a few say, “Give it to with his pages in a me.” ngers; tries book with you; to use a helps you spoon; climbs dress him by on and off a pushing arm cough or chair through without help sleeve or lifting up foot fi 24 Notices when Points to Holds Kicks a ball; months others are hurt things in a something in runs; walks or upset, like book when one hand (not climbs) paushing or you ask, like while using up a few stairs looking sad “Where is the the other hand with or without when bear?”; says (for example, help; eats with someone is at least two holding a a spoon crying; looks words container and at your face to together, like taking the lid see how to “More milk,”; off); tries to react in a new points to at use switches, situation least two body knobs, or parts when buttons on a you ask him to toy; plays with show you; more than one uses more toy at the gestures than same time, just waving like putting toy and pointing, food on a toy like blowing a plate kiss or nodding yes 30 Plays next to Says about 50 Uses things to Uses hands to months other children words; says pretend, like twist things, and two or more feeding a like turning sometimes words block to a doll doorknobs or plays with together, with as if it were unscrewing them; shows one action food; shows lids; takes you what she word, like simple some clothes can do by “Doggie run”; problem- off by himself, saying, “Look names things solving skills, like loose at me!”; in a book like standing pants or an follows simple when you on a small open jacket; routines when point and ask, stool to reach jumps off the told, like “What is something; ground with helping to pick this?”; says follows two- both feet; up toys when words liek “I,” step turns book you say, “It's “me,” or “we” instructions pages, one at clean-up like “Put the a time, when time.” toy down and you read to close the her door.”; shows he knows at least one color, like pointing to a red crayon when you ask, “Which one is red?”  3 years Calms down Talks with you Draws a Strings items whithin 10 in circle, when together, like minutes after conversation you show him large beads or you leave her, using at least how; avoids macaroni; like at a two back-and- touching hot puts on some childcare drop forth objects, like a clothes by off; notices exchanges; stove, when himself, like other children asks “who,” you warn her loose pants or and joins them “what,” a jacket; uses to play “where,” or a fork “why” questions, like “Where is mommy/ daddy?”; says what action is happening in a picture or book when asked, like “running,” “eating,” or “playing”; says rst name, when asked; talks well enough for others to understand, most of the time fi  4 years Pretends to be Says Names a few Catches a something sentences colors of large ball most else during with four or items; tells of the time; play (teacher, more words; what comes serves herself superhero, says some next in a well- food or pours dog); asks to words from a known story; water, with go play with song, story, or draws a adult children if nursery person with supervision; none are rhyme; talks three or more unbuttons around, like about at least body parts some buttons; “Can I play one thing that holds crayon with Alex?”; happened or pencil comforts during her between others who day, like “I ngers and are hurt or played thumb (not a sad, like soccer.”; st) hugging a answers crying friend; simple avoids danger, questions like like not “what is a coat jumping from for?” or “What tall heights at is a crayon the for?” playground; likes to be a “helper”; changes behavior based on where she is (place of worship, library, playground) fi fi  5 years Follows rules Tells a story Counts to 10; Buttons some or takes turns she heard or names some buttons; hops when playing made up with numbers on one foot games with at least two between 1 other children; events (for and 5 when sings, dances, example, a you point to or acts for call was stuck them; uses you; does in a tree and a words about simple chores re ghter time, like at home, like saved it); “yesterday,” matching answers “tomorrow,” socks or simple “morning,” or clearing the questions “night”; pays table after about a book attention for 5 eating or story after to 10 minutes you read or during tell it to him; activities (for keeps a example, conversation during story going with time or more than making arts three back- and crafts -- and-forth but screen exchanges; time does not uses or count); writes recognizes some letters in simple rhymes her name; (bat-cat, ball- names some tall) letters when you point to them fi fi  Case Guide: Developmental Delay Developmental delay occurs when a child does not achieve developmental milestones in comparison to peers of the same age range. The degree of developmental delay can be further classi ed as mild (functional age < 33% below chronological age), moderate (functional age 34%–66% of chronological age) and severe (functional age < 66% of chronological age). A signi cant delay is de ned as performance that is two or more standard deviations below the mean on age-appropriate standardised norm-referenced testing (usually conducted in secondary or tertiary care settings). The delay can be in a single domain (i.e. isolated developmental delay) or more than one domain. A signi cant delay in two or more developmental domains a ecting children under the age of ve years is termed global developmental delay (GDD).(3) Other patterns of abnormal development include: developmental disorder; developmental arrest and regression; and developmental disability. In developmental disorders, development does not follow the normal pattern, such as in a child with autism who has language abilities but is unable to use it for social interaction and communication purposes. Developmental arrest and regression refers to a normal developmental phase in a child that is followed by a failure to develop new skills or even loss of previously acquired skills. Regression is an unequivocal red ag and warrants an urgent referral to a specialist for further assessment and management. Not all children with developmental delay will have a developmental disability, which refers to severe, lifelong impairment in areas of development that a ects learning, self-su ciency and adaptive skills. Developmental delays can be transient, such as during a phase of prolonged illness, or persistent. Variations in patterns of development Some children may not follow the normal pattern of development. These variants include ‘bottom shu ers’, who do not crawl but shu e around. These children tend to walk late and may be mildly hypotonic, especially in the lower limbs. Some ‘commando crawl’, while others do not go through the crawling phase at all. Children may exhibit variation in their rate of acquisition of language, social skills, play and behaviour, as they may follow a familial pattern (e.g. family history of speech delay) or be a ected by environmental in uences (e.g. not attending a preschool). There is a general belief that boys tend to acquire language later than girls, which has not been proven true.(4) Children coming from bilingual families may seem to have delayed acquisition of one language, but they eventually catch up in the absence of any risk factors. fi ffl fi fi fi ff fi ff ffl ffi fl ff fl Nevertheless, physicians should be aware of the red ags in the context of the child’s development when determining a further management plan. WHAT CAUSES DEVELOPMENTAL DELAY? Multiple causes or illnesses can contribute to developmental delay. The causes listed in Box 1 are not exhaustive but cover most of the common aetiologies. These can be broadly divided into four categories: prenatal; perinatal; postnatal; and other causes. fl  Studies evaluating the causes of GDD have indicated that in one-third of the cases, the cause can be established through history and examination alone, and in another one-third, through a thorough clinical evaluation prompting investigations. The remaining cases can be identi ed through investigations alone. WHAT CAN I DO IN MY PRACTICE? During each consultation, the primary care physician should encourage the parents to share any concerns they might have about their child’s development or behaviour, conduct an opportunistic evaluation (developmental surveillance) and ensure that the child has attended developmental screening at the prescribed touch points. Based on the consultation, a decision can be made to review again, refer further or discharge. For children presenting with mild developmental delay, in the absence of any red ags and no abnormality detected on clinical examination, parents can be advised about appropriate stimulation activities and a review conducted in three months’ time, especially if earlier milestones were achieved. For example, an 18-month-old child may present with concerns of expressive language delay, as he has only started saying a few single words with meaning. In the absence of any other concerns (e.g. the child has good eye contact and joint attention, with no behaviour concerns), advice on language stimulation activities could be given. In children presenting with signi cant developmental delays or with a history of regression in development, and those at risk for developmental delays, a prompt referral should be made to a developmental paediatrician. In cases where delays have been identi ed, but there is parental denial, consider arranging a follow-up appointment to conduct a more detailed developmental assessment. The functional impact of the child’s developmental delay should be explained to the parents. For example, if a child is identi ed with a ne motor delay, the possible impact on adaptive skills should be explored. When a consultation is pitched at the parental level of understanding, there is a better chance of acceptance. A lower referral threshold is advisable for children who are at high risk for developmental problems, such as preterm children (without follow-up), children with chronic medical conditions, and children in challenging circumstances (e.g. being in the care system or having a main caregiver with mental health problems). Primary care physicians should follow up with the parents at the next visit to ensure that the referral has been activated. fi fi fl fi fi fi Furthermore, consistent long-term emotional and practical support should be provided to the families of children with special needs. As this group is at high risk for caregiver stress, consider evaluating stress levels at each opportunistic visit, as well-being has an impact on their capability to look after their children.(11) The family can be referred to a Family Service Centre for further support if necessary. Other assessments and investigations include: Head-to-toe examination, including plotting the child’s weight, height and occipitofrontal circumference; Hearing assessment if there are concerns about hearing (e.g. poor response to name when called) and language delay; Vision assessment if the child (≥ 6 weeks) is not xing and following, has a history of frequent bumping into objects (for a mobile child), or may have delayed ne motor skills; and Full blood count (possible iron de ciency), bone mineral pro le and vitamin D levels (if rickets are suggested), thyroid function tests (especially for children with GDD and growth problems), urea levels and electrolyte levels. fi fi fi fi For preschoolers in Singapore, the two main Child Developmental Units (CDUs) are the Department of Child Development at KK Women’s and Children’s Hospital and the Child Development Unit at National University Hospital. If a child is referred to a CDU, a developmental assessment is conducted, and investigations are tailored based on the clinical evaluation. Apart from the aforementioned tests, these could include: genetic evaluation; creatine phosphokinase test; screening for inborn errors of metabolism; TORCH (toxoplasmosis, rubella cytomegalovirus, herpes simplex and HIV) screen; neuroimaging; and electroencephalography (Box 2).