SCREENING FOR ABNORMAL CHILD DEVELOPMENT

Low Poh Sim

Contents
• Areas of child development
• Normal developmental patterns in the first 5 years
• Who is at risk of abnormal development
• When to refer for further assessment

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Bulletin 14; May 2000
MITA (P) No: 251/06/2000
The following four different areas of child development proceed in a normal child in an
integrated manner.
1. Gross motor development
2. Vision and fine motor development
3. Hearing and speech
4. Social behaviour and play

Gross motor development

The ability to move through these developmental steps smoothly depends among other
things on the normal muscle tone, strength and coordination. The expected norms of
gross motor development are outlined in Table 1.

Fine motor development

It is important to realise that fine manipulative precision is dependent not only on the
development of hand skills but also on normal vision. Reaching for an object, bringing
an object to mouth, transfer of the object from hand to hand, development of the pincer
grasp occurs in sequence as shown in Table 1.

Hearing and Speech

Delays in language development are more common than delays in other domains of
development. Cognitive deficit is the most common reason for language delay. The
development of speech is closely associated with the ability to hear. All children who
have delayed language development should undergo hearing testing to rule out hearing
loss. The child's behaviour around others is an important observation to make. A child
who is hyperactive but not purposeful in what he does has broader functional disturbance
of his brain of which lack of language development is just a feature. A child who is
behaving as though in a world of his own with lack of ability to relate to others and
avoiding eye contact may be autistic.

Table 2 is a check-list of language milestones for the first 5 years of life. A clinical
approach to a child with delayed speech development is shown on alogarithm 1.

Social Behaviour and Play

Infants triple their birth weight at about 12 months i.e. they put on an average of 12.5-
15g/day from 5-12 months.
During the preschool years, children are rapidly developing patterns of social behaviour.
Table 3 summarises the early social behaviour of a child.
Who is at risk?

In general, allowance need to be made for prematurity, social and environmental

factors that may result in lack of opportunities in attainment of milestones.

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Bulletin 14; May 2000
MITA (P) No: 251/06/2000
Those at risk for delay in gross and fine motor skills are
• children with problems of tone, power, coordination
• children with joint and ligament abnormalities
• children with mental retardation
• children with multiple disabilities
• children with problems with balance (gross motor skill)
• children with visual impairment (fine motor skill)

Those at risk for delay in language development are

• children with mental retardation
• children with cerebral palsy
• children with deafness
• children with autism
• children with multiple disabilities

Those at risk for abnormal social development are

• children with mental retardation
• children with autism
• children with hyperactivity

When to refer for further assessment

1. Mother's suspicion that her child is not seeing, hearing, moving his limbs or
taking notice like other children of his age is to be taken for evaluation very
seriously.

2. Gross motor developmental signs

a. A child rolling over before 3 months of age may have stiff limbs.
b. Poor head control by 5 months.
c. Persistent toe walking.

3. Fine motor developmental signs

a. Hands that are persistently fisted at 3 months of age
b. Fixed hand preference before the age of 18 months may indicate
weakness of the less preferred hand.

4. Possible visual impairment

a. Visual inattention
b. Inability to visually fixate and to follow moving objects

5. Possible deafness
a. Unresponsiveness to sound stimuli
b. Delayed development of vocalisation or speech
c. Absence of babbling at 6 months
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Bulletin 14; May 2000
MITA (P) No: 251/06/2000
 6. Abnormal speech development
a. Lack of spoken words by 18 months
b. Persistence of echolalia at 2-2½ years

7. Abnormal social development

a. Lack of interest in people or playthings
b. Gaze avoidance

Algorithm 1: Clinical Approach to Delayed Speech Development

Delayed Speech

Global Isolated Developmental

Developmental Speech Speech
Delay Delay Delay

Exclude Good speech Poor social interaction

Mental retardation comprehension with with other people
Multiple disabilities face seen
Cerebral palsy
Good expressive
Makes noise,
pantomime
echolalic
Poor reaction to sounds

Exclude ExcludeAutistic
Deafness Spectrum
Disorders

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MITA (P) No: 251/06/2000
TABLE 1. MOTOR DEVELOPMENT IN THE FIRST FIVE YEARS OF AGE
Age Gross Motor Skills Fine Motor Skills

1 mo Lying on tummy, head up Hands tightly fisted

3 mo Good head control. Hands unfisted

Lying on tummy, head up and rests on
forearms

6 mo Rolls over Reaches for object, puts object to mouth, may be

Sits with support, propping up with own able to transfer object hand to hand
hands
Bears weight in legs when supported to
stand

9 mo Commando crawls Grasp a cube with palm, rakes objects with

Sits without support, gets into sitting fingers into palm
position Immature pincer grasp
Pulls to stand
12 mo Crawls Pokes / points with index finger
Stands alone Claps hands
Walks with one hand held / cruises / Waves
independent steps

18 mo Walks well alone Precise release of a pellet into small container

Climbs on furniture Builds tower of up to 4 cubes
Walks backwards Scribbles spontaneously
Throws a ball while standing Beginning to show hand preference

24 mo Walks up / down stairs with hand held or Builds tower of 6 cubes

holding to rail Imitates vertical stroke
Jumps in place Turns pages singly, enjoys picture books
Kicks ball / throws ball over hand
2½ yrs Runs well Imitates horizontal line and circle
Jumps with 2 feet together from low step
3 yrs Walks alone upstairs with alternating feet Copies circle. Imitates cross
Walks downstairs 2 feet to a step Draws man with head and 1 or 2 other parts
Rides tricycle Matches 2 or 3 primary colours
Stands momentarily on one foot Cuts with scissors

4 yrs Walks or runs up and down stairs, one Holds and uses pencil with good control (like
foot to step adult)
Throws, catches, bounces and kicks a Draws a man with head, legs, trunk, arm and
ball fingers
Matches and names primary colours correctly

5 yrs Skips, hops Copies square and triangle

Skilful in climbing, sliding and swinging Writes a few letters spontaneously

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Bulletin 14; May 2000
MITA (P) No: 251/06/2000
TABLE 2. DEVELOPMENT OF LANGUAGE SKILLS DURING THE FIRST 5
YEARS OF LIFE
Age Receptive Expressive Warning Signs

1 mo Alert to sound Cries No response to

sounds ?deaf

2 mo Looks at speaker Social smile, coos, vocalises

4 mo Cries discriminately (hunger, pain)

Laughs, says “ah-goo”
Listens and vocalises in response

6 mo Laterally localises source of Babbles "baba, gaga" Absent babbling

sound indicates possible
hearing deficit

8 mo Plays peek-a-boo Mimics sounds

10 mo Comprehends "no" Dada/Mama appropriately Inability to localise

Answers to name Waves Bye-bye sound may indicate
hearing loss

12 mo Looks at familiar family First word

member when named Imitates simple sounds
Follows commands like "give Immature jargoning
me"

14 mo Looks appropriately when 2 to 3 words

asked "Where is (familiar
object)?"
Follows command without
gesture

18 mo Points to 3 body parts 10-25 words

Points to self Including thank you, let's go, I want
Carries out simple instructions Names one picture on command

24 mo Points to 4-6 pictures 50+ words Non-communicative

Carries out 2-step commands
Understands me/you
2½ yrs
2-3 word sentences (noun-verb) speech (echoing,
Refers to self by name repeating by rote
Uses "I", "you", "me" memory) may
indicate autism
Knows full name Stuttering common

3 yrs Listens to stories, knows Gives full name, sex and may be
nursery rhymes age
Carries out simple conversations
Asks many questions
4 yrs Enjoys jokes Sings nursery rhymes
Listens to stories Tells imaginative stories
Count by rote up to 20

5 yrs Enjoys riddles Speaks fluently

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MITA (P) No: 251/06/2000
TABLE 3. DEVELOPMENT OF SOCIAL BEHAVIOUR AND PLAY IN THE
FIRST FIVE YEARS OF AGE
Age Behaviour

5-6 wks Social smile

Stops crying when picked up or spoken to
Responsive vocalisation

3 mo Gazes on mother's face when feeding

Smiles, coos, excited movements to familiar situations like feeding or bathing

6 mo Grasps small toys

Takes everything to mouth
Shakes rattle for sound
May begin to show anxiety with strangers

9 mo Distinguishes strangers from familiars

Claps
Plays peek-a-boo

12 mo Holds and drinks from a cup

Takes toys to mouth less often
Helps with dressing
Stops drooling
Gives toys to adults on request
Waves bye bye

18 mo Holds cup between both hands, drinks with little spilling

Takes off shoes, socks
No longer takes toys to mouth
Stills wets, may have bowel control
Imitates simple daily activities such as feeding dolls

2 yrs Spoon feeds self with messing

Indicates toilet needs
Usually dry through day
Very curious, demanding for attention and easily frustrated
Rebellious, temper tantrums
3 yrs Feed self without spilling much
Washes and dries hands and face
Dry by day and night
Puts on pants, shoes and socks but cannot button
Understands sharing
Active in make belief play

4 yrs Towel dry after a bath

Brushes teeth
Dresses completely, distinguishes front from back
Understands turn-taking

5 yrs Bathes or showers without assistance

Understands rules for games
Understands meaning of clock-time

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Bulletin 14; May 2000
MITA (P) No: 251/06/2000