Early Recognition of Developmental Delays in Children

David O. Childers, Jr., MD

Abstract: One of the mantras of General Pediatrics is that every patient contact is a chance to immunize. The same should be said regarding developmental surveillance. The American Academy of Pediatrics (AAP) considers developmental surveillance to be one of the key elements of every pediatric visit. In the July 2006 issue of Pediatrics, the AAP published guidelines for developmental surveillance in the General Pediatric Practice. In those guidelines, the AAP defined developmental surveillance as a flexible, longitudinal, continuous and cumulative process whereby knowledgeable health care professionals identify children who may have developmental problems. 1 Pediatricians and Family Physicians deal daily with the issue of behavior problems. Twenty percent of all children have a developmental problem, and 85% of developmental problems present as a behavioral issue. 2 It is, therefore, important for Pediatricians and Family Physicians to understand the typical pattern of development and to recognize the critical red flags of developmental problems.

may result in missing the child with the milder delays who can benefit the most from the available interventions.

Developmental Domains

There are multiple ways to look at development. Developmental domains were first described by Dr. Arnold Gesell. 3 The milestones in this article are primarily a compilation of the CAT/CLAMS 4 with additional milestones from Gesell, Bayley, Early Language Milestone Scale (ELMS) and clinical experience. Currently, I prefer to consider five separate (though related) developmental streams. These include:

Developmental Surveillance

Developmental surveillance may be the heart and soul of General Pediatrics. Each General Pediatrician is a Developmental Pediatrician. Screening instruments must be applied across time. A longitudinal and continuous surveillance is essential to identify mild developmental problems; the ones most amenable to interventional services. Applying a screening instrument once is a snapshot in time. Screening instruments by definition require a somewhat limited sensitivity. If too sensitive, the cost of further evaluation for large numbers of children can be prohibitive. Using a crayon, the exam table paper and six 1 square blocks (items which fit easily into a lab coat pocket), a clinician can obtain a rough developmental age of a child between 2 and 4 years of age using a table found in any edition of The Harriet Lane Handbook. This quick assessment is billable using CPT 96110. Children with moderate or severe developmental delays are obvious to the novice. No screening instrument is necessary to identify as developmentally delayed the 3-year-old who is not walking and/or talking. It is the mildly delayed child who may, but must not be, missed. Interventions for children with moderate to severe delays may not be particularly effective, but interventions for children with mild delays may dramatically alter a childs lifetime outcome. In looking at developmental surveillance, it is important to utilize a standardized instrument. While many of us in pediatrics feel we can eyeball a child and through our gestalt identify the children with delay, this is all too often not the case. The limited time in the exam room, the parents sense of their own childs abilities (babbling mama being equivalent to a specific mama in a mothers mind) are confounders which
Address Correspondence to: David O. Childers, Jr., MD. Florida Department of Health Emails: david_childers@doh.state.fl.us.

Gross Motor Visual-Spatial Problem Solving (visual cognition and fine motor) Adaptive (self-care and social) Expressive Language (including signs and other means of expression) Receptive Language (comprehension)

Each developmental stream has a pattern of typical development which derives from the Central Nervous System (CNS) maturation (myelination, neuronal arborization and neuronal apoptosis) in combination with appropriate environmental inputs. While it is true that each child develops at his/her own rate, it is also true that there are typical periods to obtain milestone development which children in a typical developmental pattern will reach. Children achieving milestones later than the typical expected range are delayed at some level.

Developmental Quotients

To understand development, it is first necessary to understand the Developmental Quotient. This is the rate of a childs development in one of the developmental domains. It is a simple equation: DQ = Developmental Age/Chronologic Age x 100% For example, if a 12-month-old child is accomplishing 6-month-old milestones, the developmental quotient (DQ) would be: Developmental Quotient = 6/12 x 100% = 50%. For most children, developmental rates are reasonably consistent across life, barring an atypical situation such as prematurity, sensory deficits, abuse or neglect.

Patterns of Developmental Delay

The three primary patterns of Developmental Delay are 1) General Delay; 2) Developmental Deviance; and 3) Developmental Dissociation. Following are explanations of each pattern.
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Developmental Delay: At least 3 of the 5 primary domains are delayed more than 70%. Developmental Deviance: In one of the 5 domains, milestones are accomplished in an atypical order. For example, a child pulls to a stand and walks but never sits or crawls. Or a child has a 15-20 word vocabulary but has never used a specific mama/dada. Developmental Dissociation: One of the developmental domains is disconnected from the other domains. For example, in Cerebral Palsy, the Gross Motor domain would be involved. In Autism, the Language domains are dissociated. It is also important to recognize whether the delay is acute, progressive or static.

6 months. The emergence of an Anterior Protective reflex is essential for this milestone. By 8 months an infant should be able to get into the sitting position independently. This requires the presence of the Lateral Protective reflex. The infant should also be able to get into a hand-knee position and begin rocking. At 9 months a child should initiate a reciprocal hand-knee crawl. By 10 months of age, pulling-to-stand should emerge, along with cruising with 2 hands. One-handed cruising should emerge by 11 months, and a few independent steps should come by 12 months. Independent ambulation is present by 13 months, and by 14 months hand-knee crawling should be extinguished. Toddlers should be able to climb up steps with a hand held only for support by 16 months and down steps by 18 months. At 21 months a child can climb steps with a rail for support and by 24 months can walk down steps, in a mark time fashion with a rail. Alternating feet going up steps emerges by 30 months, and by 3 years old a child can alternate feet going down steps, can pedal a tricycle and can balance on one foot for 5 seconds. The author suggests just remembering a saying he created: Three years: up 3 steps, down 3 steps, pedal a 3-wheel vehicle.

Developmental Milestones

Each child develops at their own rate. Developmental milestones are the longitudinal attainment of skills in a forward moving, logical progression based on the development of the CNS through cell apoptosis, neuronal arborization and myelinization. Each of the five developmental domains (Gross Motor, Visual-Spatial Problem Solving, Adaptive/Self-Care, Expressive Language and Receptive Language) has a predictable pattern of milestone attainment which occurs within a restricted window of time. As a child grows older, the windows expand somewhat. However, there remains a window which can be identified as falling in the typical range. Thus while each child does develop at their own rate, it is possible to determine if that rate is consistent with a typical or an atypical rate. 5,6

Visual-Spatial Problem Solving

Gross Motor Milestones

Of the five domains, Gross Motor is the least critical to long-term outcomes or survival. However, it is the one that parents frequently focus on first, and it is CNS derived. So we will look at it first. In order for typical rolling over to occur, the Asymmetric Tonic Neck Reflex (ATNR), also known as the fencer posture, must be integrated cortically. Rolling prone to supine (stomach to back) is anticipated by 4 months of age. This should be a segmental roll, not one based on an excessive Tonic-Labyrinthine Extensor primitive reflex (the pulling of the head up in prone leading to excessive arching of the back and the subsequent rolling in a flipping fashion based on tone.). Today, children frequently roll supine to prone first. This is due to the AAPs Back-to-Sleep campaign directed at decreasing the incidence of Sudden Infant Death Syndrome (SIDS). Unfortunately, many parents and health care providers fail to place children on their stomachs while awake (She doesnt like to be on her stomach). The infants arent being asked to push up on their forearms to see the world, and thus, they have delays in prone to supine rolling. (If you never hang from the pull- up bar, you never learn to do a pull up.) Supine-to-prone rolling should be present by 5 months. Children should sit, when placed, in a propped fashion by
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At birth the infant will preferentially focus on a human face and can track up to 15 either side of midline. It is important to keep in mind that infants have a fixed focal length of 9-13 inches, which is the general distance from a womans breast to her eyes. It is called the en face position and promotes infant focus during breast feeding. Evaluation of infant visual skills needs to be at an appropriate distance consistent with their focusing abilities. At 1 month infants can track 180 horizontally, from side to side. By 2 months the infant can track vertically 180, and by 3 months a child can track 360. Also at 3 months a child should be un-fisted 50% of the time and should have developed a Visual Threat reflex. By 4 months the infant should be un-fisted the majority of the time and should begin to reach out for and bat at items. At 5 months the infant should be grasping items intentionally and should begin mouthing objects. Infants have many more taste buds than adults, and mouthing is the principal method for exploring the world until a more sophisticated tactile exploration emerges at 14 months. By 6 months transferring objects between hands without using the mouth is present. Also at 6 months infants are attempting to pick up small items (e.g., Cheerios) with a midline rake (both radial and ulnar coordination without distinction). At 7 months there is a lateral (ulnar) grasp with the ulnar nerve integrating less upper motor neurons. By 8 months the infant is using the radial nerve with a 3 jaw chuk grasp. At 9 months there is an immature finger-thumb pincer and by 12 months a mature overhand pincer. At 6 months an infant will take one item, but if a second
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item is placed in the other hand, the initial item will be dropped. At 8 months, the infant can take one item in each hand. This is the same time the infant can get into a sitting position without assistance and has lateral protective reflexes. By 14 months an infant will be able to hold 3 or more items. At this point, the infant has a more sophisticated manner of exploring the world than by mouthing, and the oral exploration of items should end. At 9 months object permanence is present. Out of sight is no longer out of mind. An item dropped over the side of the table is then looked for by the child. This is where the infant begins the go fetch games that drive parents crazy. However, it is a good indicator of the beginnings of reciprocal social action and the understanding of cause and effect. At 16 months scribbling in imitation with a crayon is present, and by 24 months a childs scribbling should be able to distinguish between a scribble and a line. At 30 months circular scribbling should be present, and by 3 years of age a child should be able to intentionally draw a circle and build a 3 block bridge.7 The author suggests the saying: At 3 years old: draw a 360 and build a 3 block bridge.

the homunculus as myelinization is occurring. By 5 months the rear of the tongue and the soft palate are used to initiate the ah-goo sound. Then, in a very short time, the child is able to climb the inside of the mouth to the front of the tongue and produce a raspberry. Babbling then comes by 6 months of age. As the child climbs the mouth, the tip of the tongue leads to the dadada babble. Next, the child develops the ability to control the rear of the lips with bababa and papapa emerging. Finally, the child develops the ability to control the front of the lips with mamama and the ubiquitous infant cry of mamama, which is not related to the mother. In fact, none of these sounds has any relationship to the specific parents. Children are hard-wired to babble, but they are not born with a name for each parent. Rather we take the sounds the child makes and we assign the value to the sounds with mama becoming the mother and dada or papa becoming the father. By the typical pattern of development, moving up the oropharynx, it is easy to see by dada or papa comes before mama in every culture. By 8 months, the indeterminate babble is now a clipped nonspecific baba but still nonspecific to parents. However, by 10 months, mama and dada (or papa) should be specifically related to the individual parent and not used for anyone else. At 11 months infants should have a one word vocabulary in addition to names. This too is generally a babbled sound to which adults assign a value such as baba for bottle or ball. At 12 months there is a two word vocabulary, by 14 months a 3-5 word vocabulary and by 16 months a 5-7 word vocabulary. (Simplistically, this equates to 1 word at 11 months, 2 words at 12 months, 4 words at 14 months and 6 words at 16 months). Primarily these are still babbles which the toddler generates for which the meaning is determined by the adults with the child learning our definitions. Simultaneously, at 9 months children begin to communicate with gestures, initially with a gestured, open-handed reach for the object of desire beyond their reach. By 12 months this gesture matures into a Protodeclarative Point, which indicates the child now recognizes the parent has a different perspective from the child and can follow the childs point. This is also known as part of the development of the Theory of Mind. Sometime around 16 months a child has used up the variety of babbled sounds for words. At this point the toddler will move from generating a babble and learning the adult definition to actually learning new words directly from the adult. This is not dissimilar to buying a computer with some software installed (babbling) but then later downloading much cooler software from outside sources (leading adult words). At this point expressive language explodes exponentially. By 20 months there is a 20 word vocabulary. By 21 months, with a 30 word vocabulary, two word phrases emerge. This is not the hot-dog, thank you or stop it two-syllable
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Adaptive/Self-Care

Introduction of spoon feeding should be initiated by around 4 months, and introduction of a sippy cup by 6 months old. At 5 months infants should have a midline crunch, using the tongue to dissolve the food bolus against the roof of the mouth. By 7 months the infant should be able to lateralize the bolus to the side of the mouth to crush the bolus in the jaw with a lateral crunch. At 9 months a child should be able to sit and hold a bottle to drink without assistance. (Getting to sit and holding two items comes at 8 months.) By 12 months an infant should be able to assist with dressing, should be weaned and should be able to handle table foods (appropriately cut up). At 14 months infants should be able to self-feed with a spoon and by 18 months able to handle raw pieces of fruits and vegetables. At 21 months, playing with a zipper (up/down) should be present, and by 24 months using a fork as a fork (spearing the chicken nugget to get meat on a stick) should be present. At 30 months a child should be able to use a restroom (urination, not necessarily bowel movements) without any parental participation in the bathroom. Also, the toddler should be able to pull the pants all the way up, including the rear side. At 3 years old a child should be able to put tennis shoes on (not necessarily on the correct feet) and intentionally unbutton large buttons.

Expressive Language

The act of communicating ones thoughts is the essence of Expressive Language. It is not limited to speaking. At birth infants vocalize. By 3 months the manipulation of vocal cords results in cooing. Within a month, the vocal cord manipulation becomes more sophisticated with laughing. Speech production follows up the throat, climbing along
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memorized word but true two word phrases such as my ___ or more ___. By 2 years of age, with 50 words, there is two word syntax (verb-noun: want ___). Over the next 6 months the vocabulary will grow to 150 words by 30 months, and then within the next 6 months to a vocabulary of more than 500 words by 3 years of age. Thus, the progression is from 1 word at 11 months to 20 words by 20 months, 150 words by 30 months and 500 words by 36 months. Pronouns and 3 word phrases should be constant by 30 months, and by 3 years old nothing but 3-5 word sentences should be present. Good guidelines to remember are:
20 months: 2 years old: 3 years old: 20 word vocabulary 2 word sentences 3 word syntax, > 300 word vocabulary, 3 letter question (why)

gaze. Just as with the Expressive Language Protodeclarative Point, this is a component part of the Theory of Mind and indicates the toddlers ability to recognize other perspectives beyond his or her own. At 16 months there is a major shift. Just as with Expressive Language where an infant becomes able to download new words from the environment, at 16 months there is a magic developmental milestone for Receptive Language. At 16 months, an infant can be handed a spoon, a cup, a block or a toy (not a hat) and told to put it on your head (without any visual gesture or cue), and after the child has looked askance at the adult, he will place the object on the side of his head. This occurs even though the ability to identify body parts is not yet present. This ability to follow a novel command is a critical element to the emergence of comprehension. A command never heard before can be followed at this point. It is interesting to note that children with Autistic Spectrum Disorders are frequently delayed in these 16 month milestones in both the Expressive and Receptive Language areas. Coincidentally, it was the 15-18 month Measles, Mumps and Rubella vaccine (MMR) which initially bore the brunt of the blame for Autism. One of the best clinical pearls of my training was the admonition that the best use of the Peabody Picture Vocabulary Test is to take it and tell the child to put it on their head. 4 The naming of body parts emerge by 16-18 months as does the ability to begin to identify pictures. Additionally, echolalia, the ability to echo back words to adults, as a mechanism to develop a vocabulary from the environment, emerges by 18 months. This should not extend beyond 30 months when the childs vocabulary of 150 words and the ability to use 3-word phrases should supersede echoing. By 24 months children begin to follow two unrelated commands (Put the spoon on the table AND throw the ball on the floor). At 30 months a child can demonstrate an understanding of the concept of just one from a group. (Open hand with a request for Give me just one, and with the hand remaining open after receiving the one item, the child will not give more but rather will look at the examiner quizzically.)

Receptive Language

The most important developmental domain is Receptive Language. This is the basis for comprehension, attention, judgment, self-regulation and behavior. Arnold Capute, father of neurodevelopmental pediatrics, said many times, You will function in society at the level of your receptive language. By 6-8 weeks of age, infants manifest a reciprocal social smile, and can localize their mother in a room by voice. By 4 months of age infants localize others by voice. Using a bell for a Receptive Language evaluation is a language processing assessment, NOT a hearing test. A bell produces too many decibels to be a hearing test, and due to the arc of the metal bell, it produces multiple frequencies rather than a pure tone. At 5 months an infant will lateralize a bell in one plane. By 7 months the bell is lateralized in 2 planes, at a 90 angle, and by 9 months, infants localize a bell directly. Also at the 9 month level, infants are able to wave bye reciprocally. Consider that by 9 months infants have developed object permanence and can gesture for desires, the basis of interactive communication is then present. Many researchers are beginning to look at the introduction of sign language by 9 months for infants. The fact that vocal language emerges later may be due more to the rate of maturation of coordination of the oral musculature than to the rate of cognitive development. At 10 months of age an infant clearly understands the word no or another negative imperative. This can be tied to the emergence of a reciprocal hand-knee crawl by 9 months of age. Essentially, it takes only one month from the emergence of mobility to the understanding of a stop command. By 12 months an infant can follow a gestured give command, and by 14 months the gesture is not required. Toddlers can understand the verbal commands without the visual supports. (In clinic I look for the ability to follow a bring me command when out of sight since parents are not generally used to giving a command to a child without a visual cue.) Additionally, at 12 months a child develops a joint attention span. When an adult swivels a gaze saying, Oh, wow, look! even without a point, the toddler will follow the adults
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Developmental Red Flags

There are some key developmental red flags to alert physicians and parents to potential developmental delays. (see following charts)

Gross Motor Red Flags asymmetric movement persistent primitive reflexes beyond 6 months hyper/hypotonia hyper/hyporeflexia voluntary/dyskinetic movements

Visuomotor Problem Solving Red flags fisting beyond 4 months handedness before 1 year mouthing as primary means of exploration after 14 months inconsistent visual attention

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Speech and Language (EXPRESSIVE) Red flags lack of a protodeclarative point by 20 months rote non-related phrases after 24 months parents do not understand childs speech by 30 months

Child Find is the appropriate option, and, of course, a referral to a Developmental Pediatrician for a diagnostic evaluation should always be considered. These programs can be accessed through the following contact phone numbers: Early Steps (904-360-7022) and Child Find (904-348-7784).

Speech and Language (RECEPTIVE) Red flags inconsistent auditory attention lack of shared frames of reference by 20 months lack of joint attention span by 20 months echolalia after 30 months

Summary

What to Do When You Find Problems

Child development proceeds in a regular, structured and predictable pattern. Later more sophisticated skills build from earlier ones from a combination of genetics and environmental exposures. While every child does develop at their own rate there is a typical developmental profile against which children can be evaluated. In Pediatrics, the tincture of time is a valuable salve to be used for many conditions. But not in the developmental domains. If there is a suspicion of developmental problems (delays from the typical pattern in walking or talking), a more in-depth assessment is indicated. A referral for a no-cost evaluation by Early Intervention should be considered if the clinician is concerned about developmental patterns. (Call Early Intervention in Northeast Florida at 904-360-7022) The more severe developmental delays seldom escape detection. But these severe delays are seldom amenable to interventions. The milder delays; the ones we want to watch a little while longer, are the ones which can be most impacted by the alteration of the developmental environment. However, these are the ones for which the clinician needs to maintain a high index of suspicion and refer earlier rather than later to Early Intervention. Developmental rates are generally consistent across time. Interventions cannot alter this rate; however, interventions can impact motor patterns and the environmental exposure component of development. Intervention at the earliest possible time is not only good medicine, it may assist the child and family in identifying and managing problems in the most effective manner.
1. 2. American Academy of Pediatrics, Pediatrics Policy Statement: Pediatrics 2006;118: 405-420 Glascoe, Frances Page; Dworkin, Paul H. The Role of Parents in the Detection of Developmental and Behavioral Problems, Pediatrics 1995(6);127:829-836. Gesell, A. The Appraisal of Mental Growth Careers, Journal of Consulting & Clinical Psychology. 1939; 3(3):73-75. Voigt, Robert G. MD; Brown, Frank R. III PhD, MD; Fraley, J. Kennard MPH; et al. Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) and the Mental Developmental Index of the Bayley Scales of Infant Development, Clin Pediatr. 2003;42:427-432. Johnson, Chris P; Blasco, Peter A. Infant Growth and Development, Pediatrics in Review. 1997;7:224-241. Colson, Eve R; Dworkin Paul H. Toddler Development, Pediatrics in Review Aug.1997;7:255-259. Johnson, Kevin B., editor. The Harriet Lane Handbook: A Manual for Pediatric House Officers. Mosby; 1993;141.

In Pediatrics, the tincture of time and some comforting words are often all that is needed to deal with a lot of the ills which cross our thresholds. There are developmental lags which will not require intervention. These are generally of a very mild nature (DQ > 85%) and may not even rise to the level of concern for the parents. More significant delays, however, do require intervention, but all too often the physicians response to parental developmental concerns is: Hes a boy, theyre always a little slower. Her older sisters are talking for her. His father didnt talk until he was 3 years old and hes okay. Hes had several ear infections. Lets just watch it until the next visit. There is really nothing to be gained by watchful waiting. Rather, formal evaluation and appropriate interventions should be considered at the first real concern for developmental problems. Early Intervention Programs like Early Steps in Florida and Babies Cant Wait in Georgia are services mandated by Federal law. Under the Individuals with Disabilities Education Act (IDEA) these services must be made available to families at no cost to the family for children less than 36 months of age. These are eligibility determination programs. They are educational in nature rather than medical and are generally not a resource for the diagnosis of the underlying condition. They do, however, provide formal assessments of development, and for eligible children (DQ < 75 in any domain) they provide a service coordinator to the family and access to appropriate therapies with no family co-pays. Additionally, these programs provide access to an Early Intervention Specialist (sort of a Special Education teacher for children under 3 years of age) which is not available through any other resource. These services are provided in the home, the child care center or other natural environment requested by the family. An additional benefit of Early Intervention Plans (EIP) is the facilitation of the transition from the EIP to the school system on the third birthday. Even if the child is almost 3 years old, there is still benefit in a referral to EIP for this reason. Once a child has reached 3 years of age, a referral directly to
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References

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5. 6. 7.

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