Developmental Assessment

Development is the progressive, orderly, acquisition of skills and abilities as a child grows.
It is influenced by genetic, neurological, physical, environmental and emotional factors.

Important points to note:-

1. Child must be co-operative, not tired, fretful, hungry nor sick.

2. Full allowance must be made for prematurity up to two years.

3. Take note of parental account of what child can/cannot do. If parent says the child
has a squint, there is a high chance that he has. Similarly, note comments on
abnormal gait, speech defects, etc.

4. Normal development is highly dependent on the integrity of child's hearing and

vision.

5. A normal pattern of speech and language development is essential for a normal

social, intellectual and emotional development.

6. Advanced motor development does not signify mental superiority,

manipulative skills are a more reliable guide, as well as interest in surrounding,
responsiveness, alertness and powers of concentration.

7. Always assess vision, hearing, language and social development in addition to

gross and fine motor skills.

8. Retardation may be global i.e. affecting all areas equally, or otherwise normal
except in specific areas e.g. speech (Always exclude deafness).

9. Always rule out hypothyroidism in all cases of global retardation.

Warning Signs

A. General

1. Head size out of proportion with length or crossing centile lines (too large or too
small).
2. Abnormal rates of growth in weight and height.
3. Congenital anomalies, odd facies, symmetrical defects of hands and feet.
4. Unusual hairs or hairline.
5. Persistence of primitive reflexes after 6 months of age.
6. Fisting or adducted thumb after the second month of age.
B. Gross Motor E. Psychosocial

5 mo Does not roll over 3 mo No social smile

8 mo Does not sit without support 6-8 mo Not laughing in playful situation
10 mo Does not stand while holding on 1 yr Hard to console, stiffens when
18 mo Not walking unaided approached
2 yr Not climbing up or down stairs 18 mo Not pointing to indicate wants
2 ½ yr Not jumping with both feet 2 yr Kicks, bites, and screams easily
3 yr Unable to stand on one foot and without provocation
momentarily Rocks back and forth.
4 yr Not hopping No eye contact.
5 yr Unable to walk a straight line 3-5 yr In constant motion.
back and forth or balance on one Resists discipline.
foot Does not play with other kids.

C. Fine Motor F. Cognitive

5 mo Unable to hold rattle 3 mo Not alert to mother

7 mo Unable to hold an object in each 9 mo No interest in peek-a-boo
hand 12 mo Does not search for hidden object
12 mo Absence of pincer grasp 18 mo No interest in cause-and-effect
15 mo Unable to put in or take out games
2 yr Not scribbling 2 yr Does not know categories
2 ½ yr Not turning a single page of a 3 yr Does not know own full name
book 4 yr Cannot pick shorter or longer of
3 yr Unable to draw a straight line two lines
4 yr Unable to copy a circle 4 ½ yr Cannot count sequentially
5 yr Unable to copy a cross 5 yr Does not know colours or any
letters
D. Language

6 mo Not babbling
9 mo Not saying “da” or “ba”
11 mo Not saying “dada” or “baba”
18 mo Has < 3 words with meaning
2 yr No two-word phrases
2 ½ yr Speech unintelligible to parents
3 yr Speech unintelligible to
strangers.
Gestures used instead of speech.
4 yr No ‘Why?’ or ‘What?’ questions.
Can’t tell a simple story.
Poor social play.
Poor word / sentence structures.
5 yr Still gets words, sentences or
ideas jumbled up.
Articulation problems
Hearing Assessment
Warning signs for hearing
 Child appears not to hear or
does not attempt to listen.
 Child by 12 months of age
does not respond to his name
or understand "No" or make
response to clue words like
"Shoe"
 Also those with warning signs
for speech / language delay
At Risk Groups
 Prematurity.
 Intrauterine Infection (TORCHES)
 Severe Neonatal jaundice
 Use of ototoxic drugs e.g. gentamicin.
 Meningitis, HIE
 Trauma.
 Chronic Secretory Otitis Media
 Family history of deafness (exclude Otitis media) -
at least 10 different genes are responsible for
deafness.
 Abnormal looking babies, abnormal external ears.

Normal Hearing

Newborn Sudden loud noise induces blinking, startle or cry.

Stilling to voice, change in breathing pattern
4 months Consistent head turning towards sound.
5-6 months Turns head to sound at level of ears.
7 months Turns to sound source below ear level
8 months Turns to sound source above ear level.
12 months Looks up to sound above head

Auditory Tests

7 - 9 months Distraction Tests. Baby held sitting facing forwards on mother's lap. A
toy is held in front by one team member to give visual distraction. Second
team member makes soft sounds 2-3 feet from either ear. The first team
member decides on the child’s response.

21mths - Voice Triggered Conditioning Test. Child conditioned to do a task

2 yr. when a sound is heard i.e. put a brick in the container. Voice sounds
or an audiometer are used.

> 18 mths Toy Tests. Child identifies toys when their names are spoken quietly.

4 yr. Pure tone audiometry. (Requires cooperation).

All ages Brainstem Auditory Evoked Response (BAER).

Visual Assessment
Warning signs for Poor Vision At risk
 Does not fix on face of mother while Prematurity.
feeding by 6 weeks. Small for Gestation.
 If the child's eyes wander from one corner Family history of cataract, retinoblastoma,
of the eye to the other after 6 weeks. squint.
 If leukocoria (white eye reflex) is noted at
any age.
 Child holds objects very close to eye.
 Squint in one of his eyes after 6 months of age.
 Strong objection to covering one eye (good eye), but not the other (bad eye).
 Blind mannerisms, abnormal head postures.

Development of Vision
When assessing vision in a young baby it is important to know the normal visual
attainment that can be expected at each age.

At birth Turn head towards source of light, follow face of mother if very
close, optokinetic nystagmus.

At 4 weeks Should follow light, dangling object < 90o, visual acuity 6/60 at this
stage.

8 weeks Fixation, convergence, focusing.

12 weeks Hand regard. Dangling object 180o. Visual acuity 6/18 - 6/12.

16 weeks Reach for any object in its view.

20 weeks Smile at mirror image.

8 months See Smartie or raisins, look for fallen toy.

10 months 100s and 1000s.

> 18 months Picture charts.

21mths/2 yr. Sheriden letters.

41mths/2-5yrs Snellen chart

NB. If vision improves when child reads through pinhole, refer to optician for
spectacles.
Corneal reflection test for squint
Refer funny looking eyes, abnormal eye movements/head posture.
Global Developmental Delay
History Consider
Consanguinity 1. Hypothyroidism
Pregnancy: Drugs, Alcohol or Illnesses. 2. Chromosomal anomaly e.g. Down or
Delivery: Premature or Birth Asphyxia Fragile X
Neonatal: Severe NNJ or Hypoglycaemia 3. Structural Brain Disorder
4. Cerebral Palsy
Family History 5. Congenital Infection
6. Specific Syndromes including tuberous
Do sclerosis or neurofibromatosis.
 Refer for eye and hearing test. 7. Inborn error of metabolism
 T4 / TSH 8. Postnatal causes like head injury,
 Chromosomal Analysis intracranial bleed, CNS infections.
 MRI brain 9. Muscular Dystrophies
(if not available, CT scan) 10. Autism
 KIV
o Other genetic studies if available (Methylation PCR for PWS / Angelman,
Subtelomeric rearrangements, Fragile X screen, MECP2) or get a genetic
consultation.
o Metabolic screen (VBG, serum lactate, ammonia, serum amino acids, urine
organic acids screen)
o Serum CPK in boys
o EEG if history suggestive of possible seizures

Isolated Speech Delay

History Consider
Congenital Rubella 1. Hearing Impairment
Perinatal Drugs 2. Familial or Genetic causes
Severe Neonatal Jaundice 3. Social Cultural Deprivation
Family History 4. IQ Low (Mental Retardation)
Ear Infection 5. Language Confusion
Ask for Quality and Quantity of speech 6. Autism
7. Hypothyroidism
Do
 Check ears and tonsils
 Distraction Test
 T4 / TSH
 Referral to ENT / Audiologist for formal hearing test
 Referral to Speech therapist
 KIV
o Chromosomal Analysis and other genetic testing.
o Metabolic screen
o EEG if there is language regression (Landau Kleffner syndrome)
Delayed Motor Development

Consider
1. Normal or Familial variation
2. Previous Chronic Illness
3. Cerebral Palsy
4. Neuromuscular Diseases e.g.
Duchenne Muscular Dystrophy
5. Orthopaedic Problems
6. Emotional Neglect

Learning Difficulties In School

Consider
1. Previous developmental delay
2. Medical Problems
 Hypothyroidism
 Iron deficiency anaemia
 Chronic lead poisoning
 Epilepsy (eg Absence Seizures)
3. Specific Learning Difficulty (Dyslexia)

References:-

1. RS. Illingworth. The Development of the Infant and Young Child.

2. Nelson’s Textbook of Pediatrics.
3. First LR, Palfrey JS. The infant or young child with developmental delay. NEJM 1994;330:478-483
4. Shevell M et al. Practice parameter: Evaluation of the child with global developmental delay.
Neurology 2003;60:367-380