Development Assessment

Developmental Assessment
By Dr Nicholas Evans (ST1 Paediatrics)

Learning Objectives
• Describe which factors influence development
• List the 4 functional areas of development
• Understand the difference between median ages (milestones) and limit ages (red
flags)
• Have a structure for assessing development in children
• Consider which method of memorising milestones might work best for you
• Improve confidence in assessing the development of children through practice
Overview
6 weeks Levi
• The concept of ‘Development’
3-4 months Theo
• An approach to assessing development 6-8 months Sandy
• Developmental Characters (milestones) 10 months Tom
• Examples of common milestones 1 year Divya
• Video examples 18 months Emma
• Practice Assessing Development 2 years Terrance
3 years Charlie
• Briefly look at developmental limit ages (red flags)
4 years Floyd
NB: not covering developmental delay today

Development
• Is a continuum
• There are a range of ages which are considered normal to acquire a developmental skill.
• Therefore, it can be assessed by looking at:
• Median age (expect 50% of the population to have acquired a skill), which is typically used to denote the age of the ‘milestone’.
• Red Flags or Limit ages, which are either a particular worrying sign that requires onward assessment (in certain age groups) or an age
that would require onward assessment if a skill has not yet been acquired.
• Normal development can have variations

• ~80% children crawl before they walk
• While others (instead of crawling) bottom-shuffle, commando crawl or (rarely) go straight to walking.
• Is biopsychosocial
• As with factors that influence health, development is influenced by a huge variety of biopsychosocial factors:
• Internal: genetics, underlying disease or pathological insult.
• External: nutrition, home environment, social interaction etc
• Is adaptive and builds on previous achievement

• Development (just like physical growth) changes with changing circumstances and situations. Ongoing development
is also dependent on which milestones have previously been achieved.
Median age (50%) Limit Age
Walks alone
Age (months)
This shows the range of ages that you would This is a well known Public Health diagram, which illustrates the
commonly expect a child to be walking well socio-economic, cultural and environmental factors which
independently, and the limit age of 18 influence health. All of which are relevant to a Child’s health
months. (either directly or indirectly via parents) and development.
Approach to assessment of development
• In practice development is assessed through a combination of
• Observation
• History (asking parents)
• Testing through play
• There are 4 Functional areas of development
Gross Motor Fine Motor & Vision Social Behaviour & Play Speech, Language, Hearing
• When assessing development consider:

• Which Milestones do you expect for the child’s age (i.e. for that median age)?
• Which Milestones are you seeing?
• Any Red Flags (Limit Ages)? For the purpose of todays practice
assessments, we will be focusing
• Which areas are delayed? on these two
• Single, multiple, global (all)?
• Remember to correct for prematurity if < 2 years old (use corrected age as expected developmental age)
Developmental Milestones
• There are a huge number of skills in each functional area which can be used as developmental
milestones and, confusingly, there is some variations in the quoted ages for acquiring those milestones
depending on which sources you use.
• This can lead to the ‘heart sink’ moment some feel when trying to approach learning developmental
milestones.
• However, you don’t need to know every possible milestone for every area and age group!
• There are certain key and common milestones to learn (e.g. walking).
• However, for some age groups, it can be sensible to just try and learn one or a couple common milestones
for a functional area which you can test / ask about in an assessment.
• There are many different approaches to learning developmental milestones (some people like learning
a large table or lists), however, I have found trying to think about each age group as a ‘developmental
character’ with a certain set of skills or characteristics has helped me to remember them.
Developmental Characters
• These are our 9 developmental ‘Characters’
• Read through each one, paying attention to the examples in each functional area. 6 weeks Levi
• Along the way we see some examples and practice some assessments. 3-4 months Theo
6-8 months Sandy
• They are by no means exhaustive lists of milestones for each age group 10 months Tom
and can (and often are) divided into further sub groups (e.g. 3
1 year Divya
months, 6 months, 8-9 months, 2.5 years, 4.5 years).
18 months Emma
2 years Terrance
• Due to the variation in ages in certain sources, remember that
developmental age is an estimate based on your assessment. 3 years Charlie
4 years Floyd
• These characters are examples of some key and common milestones

for age groups, at a level of detail which should be appropriate for
your level.
6 Weeks – Levi
Raises head up 45 (when Fixes and follows Smiles (since birth – startles to
prone) sound)
3-4 months – Theo
Head Lag
Reaching
ooo, aaa,
hahahah
No Head lag (when held Reaches for toys (4 months) Coos, Laughs
sitting) Regards own hands (alone or when spoken to)
An Example of: Object Permanence
• We believe that the way in which children think goes through stages (Piaget’s Theory
of development)
• Initially (0-2yrs), knowledge is acquired from experience and sensory

interaction with the environment.
• During this stage, the idea of ‘Object Permanence’ develops.
• Watch a section of this video (until 0.54s)
https://youtu.be/35UfQjt8O_c?t=41
• Now watch a section of this video (until 0.42s)
https://youtu.be/rVqJacvywAQ?t=7
• This illustrates the concept of of object permanence (present in clip one, not present in
clip two), that a toy (object) still exists even when it is not seen. Peak-a-boo is another
example of this concept.
An Example of: Object Permanence
• We believe that the way in which children think goes through stages (Piaget’s Theory
of development)
• Initially (0-2yrs), knowledge is acquired from experience and sensory

interaction with the environment.
• During this stage, the idea of ‘Object Permanence’ develops.
• Watch a section of this video (until 0.54s)
https://youtu.be/35UfQjt8O_c?t=41
• Now watch a section of this video (until 0.42s)
https://youtu.be/rVqJacvywAQ?t=7
• This illustrates the concept of of object permanence (present in clip one, not present in
clip two), that a toy (object) still exists even when it is not seen. Peak-a-boo is another
example of this concept.
6-8 months – Sandy
babababa
lalalalalala
Sitting
Palmar Grasp
Sitting Palmar Grasp Puts food to mouth Multiple syllable babble
- rounded back 6 months Transfer between hands (7 Peak-a-boo (Object (non specific)
- straight back 8 months months) Permanence)
An Example of:
• Watch this video clip
• Do you know the name of the skill that is being
demonstrated?
An Example of: Cruising / Walking with support
• Do you know the name of the skill that is being
demonstrated?
• Walking with support (Cruising around Furniture)
10 months – Tom
Mama, Dada!
Pincer Grasp
Waves Bye
Cruises around furniture Pincer Grasp Waves Bye Mama, Dada specifically
(Shy strangers, separation
anxiety)
What developmental age is this child?
• Copy the table below onto some paper and then watch the video clip
on the next page.
• Write down the milestones you see the child displaying for each functional
area
• After the clip, think through the milestones you have seen and write
down your best estimate for the developmental age for this child.
• Make sure to commit an estimate to paper, this is just a practice to help
develop your skills!
Please watch Video 1
• What is your best estimate for the developmental age of this child?
• Which character do you think he is closest to?

• Levi (6 weeks)
• Theo (3-4 months)
• Sandy (6-8 months)
• Tom (10 months)
No Head Lag Fixes and follows Smiles Cooing
- 3-4 Months - 6 weeks - 6 weeks - 3-4 months
Sit with support but not Not quite reaching for toys
independently - <3-4 months
- <6 months
• Developmental age: around 3-4 months (Theo)

• Displayed all 6 week milestones and starting to show 3-4 month milestones
(although would perhaps expect better reaching for toys to be displayed)
• Can sit with support, but unable to independently <6 months
1 year – Divya Drink
Points
CUP
Walks
Walking (12-15 months) Points Drink with Cup ~3 words (other than
mama/dada) – Drink, No
18 months – Emma
Feeds with Spoon
Eyes
Scribble
Running
Run Scribble Feeds self with Spoon Can point to some parts of
Tower 3 body.
~10 words
An Example of:
• What type of play is happening here?
An Example of: Symbolic Play
• What type of play is happening here?
• This is an example of Symbolic (or Pretend) Play

• This child has seen these objects used for cleaning and is playing by
pretending to clean.
• Earlier examples of this type of play might include, feeding a teddy
or doll.
2 years – Terrance
Give me a
toy Plays feeding Doll
Jumping 6
Kicks Ball
Jump, Kick a ball Draw a LINE Symbolic Play (18-24 months) Simple phrases (2-3 words
Tower of 6 Dry during day /potty phrases)
(Train from blocks 2.5 years) trained (variable)
3 years – Charlie
Verbs
Age Years Old
Colours Today
Parallel Interactive
are doing or
action words
9
Stand 1 leg
Stand on 1 leg Draw a CIRCLE Parallel Play (2.5 years) then: 4 word sentences & joined
Tricycle Bridge from blocks Interactive Play -takes commands.
Tower of 9 turns, shares Verbs
Age, some Colours
4 years – Floyd Dress self Dry
Hop Catch
Rhyme, Count
Hop, Catch a Ball Draw a CROSS Dress Self Independently Counting, Rhymes
Up and down stairs (like Dry By Night More grammar (as per
adult) Imaginative play adult)
Draw a SQUARE (4.5 yrs)
Skip (5yrs) Draw a TRIANGLE (5 yrs)
• Copy the table below onto some paper and then watch the video clip
on the next page.
• Write down the milestones you see the child displaying for each functional
area
• After the clip, think through the milestones you have seen and write
down your best estimate for the developmental age for this child
• Make sure to commit an estimate to paper, this is just a practice to help
develop your skills!
• Please watch Video 2
• What is your best estimate for the developmental age of this child?
• Which developmental character do you think she is closest to?

• 6 weeks – Levi
• 3-4 months – Theo
• 6-8 months – Sandy
• 10 months – Tom
• 1 year – Divya
• 18 months – Emma
• 2 years – Terrance
• 3 years – Charlie
• 4 years Floyd
Jumps Draws a LINE Feeds self (spoon/fork) Colours
- 2 years - 2 years - 18 months - 3 years
Draws a CIRCLE Dry during the day
Stands on 1 leg - 3 years - 2 years 4 word sentences
- 3 years Can’t draw a CROSS Shares - 3 years
- <4 years - 3 years
Tower of > 9 Dry by night

- 3 years - 4 years
Imaginative play
- 4 years
• Developmental age: around 3 years

Developmental Red Flags – limit ages
8-10 wks Smile
7 months Babble
9 months Sit Unsupported
10 months
< 1 year Hand Preference
1 year Stand Alone Pincer Grip Look for dropped object Respond to Name
18 months Walk Alone Spoon feed self 6 words
2 years Run Scribble Symbolic Play (2.5 yrs) 2 word sentences

3 years Jump (two feet) Copy a line
4 years Dress Alone Name 4 colours
ANY AGE Unilateral Weakness Parental Concern Lack of eye contact or Parental Concern about
Eyesight emotional warmth hearing
ANY AGE: Loss of a previously acquired milestone (developmental regression)
Summary
• Development is a continuum with some known variations. It is influenced by bio-
psycho-social factors, what has already been learnt and changes in circumstances.
• The 4 functional areas of development are:
• Gross motor
• Fine motor and vision
• Social Behaviour and play
• Speech, language, Hearing
• Consider milestones, limit ages, which areas are delayed and correcting for
prematurity (latter if <2yrs).
• Try and remember common and key milestones in each functional area for each age
group (e.g. remembering a character or list/table for each age or functional area).
Learning Objectives
• Describe which factors influence development
• List the 4 functional areas of development
• Understand the difference between median ages (milestones) and limit ages (red
flags)
• Have a structure for assessing development in children
• Consider which method of memorising milestones might work best for you
• Improve confidence in assessing the development of children through practice
Next have a look at the Development Red Flags Quiz

References
• Lissauer, T. and Carroll, W., 2017. The Science Of Paediatrics.
• Lissauer, T. and Clayden, G., 2012. Illustrated Textbook Of Paediatrics. 4th ed. Elsevier.
• Tasker, R., Acerini, C. and McClure, R., n.d. Oxford Handbook Of Paediatrics. 2. ed.
• MRCPCH Clinical Exam Revision. 2020. Development Videos. [online] Available at:
<https://mrcpch.paediatrics.co.uk/development/development-videos/> [Accessed 14 April 2020].
• Geeky Medics. 2020. Developmental Milestones - OSCE Guide | Paediatrics | Geeky Medics.
[online] Available at: <https://geekymedics.com/developmental-milestones/> [Accessed 14 April
2020].
Many Thanks to:

• The children and parents who very kindly provided videos.
• Dr Emily Thuell and Dr Benita Morrissey for input and development.

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Developmental Assessment

By Dr Nicholas Evans (ST1 Paediatrics)

NB: not covering developmental delay today

• Normal development can have variations

• Is adaptive and builds on previous achievement

• There are 4 Functional areas of development

• When assessing development consider:

• These characters are examples of some key and common milestones

• Initially (0-2yrs), knowledge is acquired from experience and sensory

• Initially (0-2yrs), knowledge is acquired from experience and sensory

• Which character do you think he is closest to?

• Developmental age: around 3-4 months (Theo)

• This is an example of Symbolic (or Pretend) Play

• Which developmental character do you think she is closest to?

Tower of > 9 Dry by night

• Developmental age: around 3 years

2 years Run Scribble Symbolic Play (2.5 yrs) 2 word sentences

Next have a look at the Development Red Flags Quiz

Many Thanks to:

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