Development Milestones In

Children
Dr Farizan bt Ab Ghani

9/5/2022
Introduction
• First 6 years of life - greatest
growth and development
• Knowledge of normal growth
and development- essential
• Early detection of deviation-->
early intervention
Brain development begins at 25 days with patterning
events in the neural tube and ends with the mature
structure that is the center of thought and emotion.
Neural migration

- “hardware and wiring” for

sensory input, information
processing and motor output
Synaptogenesis

Ready to learn
• Making connections
is a neuron’s mission
• synapse
 Average brain weights (BW) at different times of development :

• AGE BW - Male (g) BW – Female (g) -

• Newborn 380 360
• 1 year 970 940
• 2 years 1,120 1,040
• 3 years 1,270 1,090
• 10-12 yrs 1,440 1,260
• 19-21 yrs 1,450 1,310
• 56-60 yrs 1,370 1,250
• 81-85 yrs 1,310 1,170
• Data from Dekaban, A.S. and Sadowsky, D.,
Changes in brain weights during the span of
human life: relation of brain weights to body
heights and body weights, Ann. Neurology,
4:345-356, 1978)
• 2 y.o - 4/5 size and weight of
adult’s brain
• 3 y.o – 1,000 trillion synapses
• Density of synapses remain high
1st decade
• Adolescence – half of all synapses
being discarded
 Critical periods of brain development

Prime time – synapses easily develop

Evidence via PET scan
• 1/12 : cortical/subcortical –sensory-motor
functions
• 2-3/12 :visual auditory stimulation
• 8/12 : frontal – emotional regulation and expression
CHILDREN DEVELOPMENT
• Changes of functions - influenced by genetic, emotional and social
environments
a) neurodevelopmental
b) cognitive
c) language
d) Psychosocial
e) emotional
 PRINCIPLES OF DEVELOPMENT
1. It is a CONTINUOUS process
2. SEQUENCE is the for all children, but
the RATE varies from child to child
3. Intimately related to the MATURATION of the
nervous system
4. GENERALIZED mass activity replaced by SPECIFIC
individual responses
5. PRIMITIVE reflexes have to be lost before the
VOLUNTARY movement is acquired
 REQUIREMENTS FOR SATISFACTORY
DEVELOPMENT
Nervous System
Well-formed & functioning

Opportunities Environment
to learn and act Appropriate and
adequate nutrition
at all stages

Challenges & Rewards

DEVELOPMENTAL DOMAINS

1. Gross Motor Skills

2. Fine Motor Skills
3. Receptive Language Skills
4. Expressive Language Skills
5. Personal-Social Skills
6. Cognitive/Adaptive Skills
MOTOR DEVELOPMENT

Dependent on brain maturity

Sequence : Gross: cephalocaudal
Fine : proximodistal
Weakest correlation to IQ
CEPHALOCAUDAL PATTERN OF DEVELOPMENT
Infancy
1mth Gradual development of head control

3mth Supine to sitting head lag still present

6 mth Feet to mouth.Plays with toes.
Weight bearing.
9mth Stable in sitting
12mon 1st independent steps
90% of children

sits independently 6-11 months

crawl 6-12 months
cruising 8-13 months
walk independently 18 months

Delay – lack of stimulation, left in cot,

baby walkers, neurological problems
Toddler and preschool

18 mon walk well, backwards

2yr runs well, kicking ball
3yr stand on 1 leg,jump,tricycle
4-5yr hops ,skips
response to music and rhythm
5 – 10 years
5 yr Stands on one leg
Hops. Jumps off step

7 yr Runs and climbs

9- 10 All skills performed more smoothly

and efficiently; competitive games
FINE MOTOR
VISION AND MANIPULATION
FINE MOTOR SKILLS

• Eye-hand coordination
• Proximodistal pattern
• Coordination of small muscles
• Related to self-help skills
• Upper extremity and manipulative hand abilities
 eat, dress and play
Infancy
1 mth Begins to fixate on nearby familiar
objects, mother’s face

3 mth Following with eyes.Holds objects

placed in hands momentarily

6mth Mature visual following and

convergence.No squint

9 mth Moves cover to see object.Index finger .

Toddler and preschool
12-18mon enjoys picture books,
picks small things,
stacks 2 cubes
18-24mon scribble, imitate vertical lines
turn pages singly
2-3 yr copies circle,recognise letters
3-4 yr 2 dimensional line drawing
4-5yr color pictures,draw people
5 – 10 years
5 yr Draws with dynamic tripod

7 yr Prints ,large irregular letters

9-10 Joined up, neat writing, bat and ball

games
 FINE MOTOR MILESTONES
Age Milestones Age Milestones
(mos) (yrs)
3 Hands open 2 Makes strokes
4 Midline play 3 Copy circle
5 Grasps, transfers 3½ Copy cross
6 Holds bottle 4 Copy square
9 Pincer grasp 5 Copy triangle
15 Imitate scribble 6 Copy diamond
18 Scribble 9 Copy cylinder
spontaneously
LANGUAGE DEVELOPMENT

Sequence : simple to complex

Correlates with IQ
Language delay a part of most
neurodevelopmental problems
 RECEPTIVE LANGUAGE
MILESTONES
Age Milestones Age Milestones
(mos) (mos)
1 Startles, 15 Points to 1 body part
Alerts to sound
4 Turns to noise and 18 Points to 2 body parts
voice
7 Responds to name 24 Follows 2-step commands
9 Responds to word 36 Identifies action in
“no” pictures
11 Follows 1-step com- 48 Knows 4 colors, address
mands with gestures
12 Follows 1-step com- 60 Follows 3-step commands
mands w/o gestures
 EXPRESSIVE LANGUAGE MILESTONES

Age Milestones Age Milestones

(mos) (yrs)
3 Vocalizes and coos 2 2-word phrases
6 Babbles 3 3-word sentence
Gives full name,age,sex
8 Says dada,mama 4 Repeats 3-word sentence
non-specifically Speech 100% intelligible
10 First words other 5 Uses past tense of eat,
than mama, dada run, go
12 Immature 6 Gives word for definition
jargon,second word
RULE OF THUMB:

Speech Intelligibility To
Non-Family Members

1 year old - 25%

2 years old - 50%
3 years old - 75%
4 years old - 100%
PSYCHOSOCIAL DEVELOPMENT

PERSONAL : performance of activities of daily

living
SOCIAL :interact, form & maintain relationships
 PERSONAL MILESTONES

Age Milestones Age Milestones

(mos) (yrs)
3 Opens mouth 2 Express need to go to
expectantly bathroom
Cooperates in dressing
6 Holds bottle, 3 Puts on shirt and shorts
Finger- feeds , feeds Dry by night, Use fork to
self cracker pierce
12 Drinks well from cup 4 Dresses without
Begins to hold supervision, Brush teeth
spoon with assistance

18 Feeds self with 5 Ties shoes

spoon
 SOCIAL MILESTONES
Age Milestones Age Milestones
(mos) (yrs)
3 Smiles responsively 2 Parallel play
6 Imitates actions 3 Likes to play “make-believe”
Demonstrates caution
9 Plays patty-cake, 4 Responds to instructions
peak-a boo Imitates tasks
12 Comes when called 5 Plays games with simple
by name rules ( tag, hide-and-seek)
18 Follows directions 6 Plays board games
related to routines
 COGNITIVE DEVELOPMENT

Learn, understand, solve problems

Verbal and non-verbal reasoning
Meet
Infants daily living
& toddlers demands
: Motor & language milestones
Pre-school child : Reasoning abilities
School-age child : Neuropsychological assessment
 COGNTIVE MILESTONES

Age (mos) Milestone

NB Identify mother’s voice and smell
3 Reach for dangling ring
6 Respond playfully to mirror
9 Object permanence
12 Understand spatial relationships
15 Make tower of 3 cubes, Insert 1 shape in FB
24 Tower of 7 cubes, 3 shapes in FB
36 Imitate bridge, tower of 10 cubes
48 Imitate gate, answers how many
WARNING
SIGNS !
18 months

• Does not understand simple command

• no meaningful words
• poor quality of relating to world
• unable to stand alone
• Unable walk independently
• do not explore objects
24 months
• play without meaning,stereotyped
• no 2 word combination
• less than 20 words
• not scribbling
30 months
• unintelligible speech, echolalia, jargon
• dribbling
• floppy mouth
• no phrases
36 months
• does not know 2 part command
• no sense of structure of stories
• less than 50 words
• chatter without meaning
• poor listening skills
• simple shapes - disorganised drawing
• no scribble
48 months
• no ‘why”, “what”
• no color concept
• poor memory for sounds, words,numbers
• poor social play
• self care skills disorganised
• holds face very close to books
60 months

• jumbled words, sentences

• marked articulation problems
• weak pencil skills
• very poor copying skills
• disjointed pictures
What to do ?

First detection

Health professionals

Rehabilitation

Hospitals Community
Immunization Developmental
Screening

Health and Safety

Nutrition
DEVELOPMENTAL SCREENING

 Part and parcel of a comprehensive health

program
 Objective: provide pre-symptomatic detection of
disability by examining children
 Subjects: Apparently healthy children
 Delineates the child’s abilities and compare it
to that of the “normal” child
 Output: profile of strengths and weaknesses
DEVELOPMENTAL MONITORING

 Screening with standardized instruments at every

health maintenance visit
 Getting current milestones
 Eliciting parental concerns
Main complaints
• Motor delay
• Speech delay
TWO IMPORTANT QUESTIONS:
• Specific areas or global?
Only developmantal delay or is there also developmental regression?
Developmental delay
• typically used to describe a child who does not seem to
be developing, or progressing at expected rates or
levels.
• may be delayed in several areas of development, or in a
single area.
Global developmental delay
( less than 5 years)
• Significant delay in 2 or more in the following domains:
• Gross/fine motor
• Speech/language
• Cognition
• Social/personal
• Activities of daily living
GLOBAL DELAY
• Cerebral malformations
• Chromosomal disturbances
• Intrauterine infections
• Perinatal disorders
• Progressive encephalopathies
Specific delays

• cognitive development - problem solving and memory

skills, as well as the ability to control one's behavior
and follow directions.
• motor development and body movements -sitting,
crawling, standing, walking and running, and hand
control.
• speech and language :
spoken sounds and words, repeating of sounds, child's
ability to understand language.

• social and self-help skills :

playing with peers, feeding, grooming, and toilet
training.
MOTOR DELAY
• Cerebral palsy
• Down’s syndrome
• peripheral neuromuscular d/o
• spinal d/o
 SPEECH DELAY
• Mental handicap
• Deafness
• Cleft palate
• palato-pharyngeal incompetence
• Neurological dysarthrias
• Dev . language d/o
• autism
• social and emotional deprivation
Clinical history
Ante and perinatal history
• Congenital infections – TORCHES
• Metabolic disease – maternal PKU
• Placental dysfunction – PIH, retroplacental
clots
• Birth trauma
• Perinatal asphyxia
Clinical history
Neonatal period
• CNS infections –meningitis, ventrculitis
• Intracranial bleed - HDN, prem
• Severe jaundice – ET
Subsequent health
• Infections, trauma, hypothyroidism
Social
Clinical examination
MEDICAL EXAMINATION
• Thorough- head to toe
• Growth parameters
• Dysmorphism
• Neurocutaneous stigmatas
• Signs of possible storage disorder
• CNS
Developmental assessment
• Screening and formal
• 4 aspects :
Gross motor
Vision and fine motor
Hearing and language
Social development
Denver Developmental screening test
Schedule of growing skills
 Flow chart for decision making for investigations for global developmental delay in young
children.

Renuka Mithyantha et al. Arch Dis Child 2017;102:1071-

1076

Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.
Investigations
Based on provisional diagnosis and differential diagnosis
• FBP- vaccuolation in WBC
• Metabolic screening :
Serum ammonia,lactate,pyruvate, aminoacid
chromatography, VBG
Urine – amino acid and organoacid
• LFT, CK
• CT/MRI brain
• Skeletal Xrays
• Genetic testing
Multidisciplinary assessment

• Opthalmologist/ optometrist
• Speech therapist
• Physiotherapist( gross motor)
• Occupational therapist( FM, ADL)
• Psychologist ( cognitive function)
MANAGEMENT
• Multidisciplinary
• Aim for early intervention
BENEFITS OF EARLY
IDENTIFICATION

1. Effect developmental change while the nervous

system is still malleable and responsive
2. Many causes of delay may be treated with
satisfactory results, if detected early enough
thus preventing further damage
3. Allows family members to feel that they are
doing all they can to assist the child
Developmental Screening

Early Recognition of
Developmental Delay

Early and Appropriate

Intervention

Help child achieve his

OPTIMAL POTENTIALS
Recommended reading and websites
• www.mypositiveparenting.org
• www.zerotothree.org
• www.childdevelopmentmedia.com
• Learning early by Dorothy Einon,Checkmarks book
• Teach your child by Dr Miriam Stoppard
THANK YOU