By Dr Lara Smith, MbChB (US), DCH (SA), FCPaed (SA), MMed (UCT)
Developmental milestones are behaviours or skills seen in infants and children as they grow and develop. The milestones are different for each age range, with a normal range in which a child may reach each milestone. It is important to remember that each child will progress at their own rate, in each skill area and it isn’t unusual for one area to be stronger, and hence develop faster, than another area.
Knowledge of the basic milestones in young children is important before one can establish if it is necessary to worry about a possible delay. Developmental monitoring or screening observes how your child changes over time and checks to see that your child meets the typical developmental milestones for playing, learning, speaking, behaving, and moving. It is used as a guide to a child’s developmental progress from infancy through to adolescence.
The four main areas of development that need to be assessed are:
1. movement skills (such as crawling and walking);
2. fine motor skills (such as drawing and stacking blocks);
3. speech and communication; and
4. personal-social development (this includes thinking, behaviour or emotional development, cognitive skills and self-help skills).
At your routine visits your paediatrician will ask questions and/ or use a checklist, together with observation, to ensure your child’s development is up to date. There are also guidelines in your baby’s clinic booklet (vaccination book) as well as reputable online guidelines, such as the WHO and CDC’s Developmental Milestones. If there are any concerns, a formal developmental assessment will be needed.
Screening tests, usually done at routine visits, only try to identify children who may have one or more problems. A screening test is not a diagnosis, but it may indicate that a child should be referred for formal developmental evaluation. The developmental tests available range from passive evaluation of an infant to more complex testing, particularly for older children and adolescents.
A developmental assessment is a structured lengthy, in-depth evaluation of the child’s skills and development and a comprehensive assessment to review the key areas of physical, social, emotional, moral, and intellectual ability. It provides a profile of a child’s strengths and weaknesses in all developmental areas. These tests are administered by trained professionals and may be used to determine if the child is in need of an early-intervention or treatment programme
Who is at risk?
High risk children include those with preterm births, complications around birth and certain syndromes and it is important that these children should have more frequent developmental monitoring and screening in all areas of development.
Why is it important to do developmental screening?
Developmental screening is particularly important for children under the age of three years, as the sooner problems are detected, the better the response to therapy will be. The screening identifies high risk individuals needing regular review or referral for further diagnostic evaluation.
Although early intervention is extremely important, intervention at any age can be helpful. It is best to get an evaluation early so that any needed interventions can get started. Most developmental delays are not serious and usually correct themselves.
Examples of disorders that could cause developmental delays
• Generalised developmental delay, isolated or part of another condition;
• Autism spectrum disorders;
• ADHD; • Cerebral palsy;
• Syndromes such as Trisomy 21 (Down syndrome) and Fragile X;
• Hearing problems; and
• Learning difficulties.
When should you worry
It is important to be vigilant and aware of normal milestones. If your child is not meeting the cut-off for achieving milestones, it is best to see your healthcare provider. In the early years children should have regular well-baby checks, where development is screened. As the child gets older the playschool or schoolteacher may well be the first person to realise that there are developmental delays.
There are many online tools available to help with normal developmental milestones, but the internet can often increase your stress levels if you try and diagnose problems on your own. Therefore, use the resources available to guide you for when you should seek further help. Milestones are a guide, not a rule.
Useful apps and checklists
• Milestone tracker (see the free app from the CDC at www.cdc.gov/ ncbddd/actearly/milestones-app.html)
• Your child’s Road-To-Health booklet includes broad milestones
• Online CDC checklists at www.cdc. gov/ncbddd/actearly/pdf/checklists/ all_checklists.pdf
• American Academy of Paediatrics at www.healthychildren.org/English/ MotorDelay/Pages/default.aspx
• Children’s league at www.tclny.org/ developmental-red-flags
If there are consistent delays, in other words there seems to be no “catch-up”, then you should seek help. Additionally, if two or more milestones are delayed it should prompt a visit to your doctor or clinic.
Any child who presents with regression must be seen sooner rather than later. This means your child has attained a milestone and then seems to have lost the skill again. This is typically found with speech and could be a sign of autism. However, there are a number of other causes, so before jumping to conclusions it is best to book an appointment with your paediatrician.
Warning signs at any age • Loss of skills;
• Lack of response to sounds or visual stimuli;
• Poor interaction with parents or siblings;
• No, or limited, eye contact;
• Obvious differences or preference for one side (left/right) in strength movement or tone; and
• Marked low tone (floppiness) or increased tone (stiffness).
Speech and language delay in toddlers are one of the most common forms of developmental delay. Early language development is often uneven and happens in spurts, so not all children follow the milestones exactly, often raising parental concerns.
Red flags for speech & communication include the following:
• No babbling by 9 months.
• No first words by 15 months.
• No consistent words by 18 months.
• No word combinations by 24 months.
• Slowing or loss of speech.
• Not showing an interest in communicating.
These could be problems relating to development only, but a hearing evaluation may be needed, to exclude a potential hearing loss.
Signs of an early motor delay (physical development) include:
• delayed rolling over, sitting, or walking; • poor head and neck control;
• muscle stiffness or floppiness;
• speech delay;
• swallowing difficulty;
• clumsiness; and
• muscle spasms.
Important to listen to your gut It remains important to remember that the vast majority of children showing a mild delay do not have a serious medical condition and there is no need to panic. In these cases, all that may be needed is to simply intensify the stimulation your child receives from the environment around him or her.
Play is an important part of development, so make time to do this with your child. And remember to show-and-tell during play. Start reading from an early age, and simply talking to your child is a great way to stimulate speech and communication. It is also during these times that you may detect a problem.
The bottom line for parents is that it remains important to listen to your gut. Rather than worrying about it being ‘silly’, it is better to talk to your doctor. Usually, the earlier a problem is addressed, the better the outcome.
Dr Lara Smith a paediatrician based in Claremont and works at Life Kingsbury Hospital. Her interests are in developmental problems and ADHD, but she also spends time doing general paediatrics and neonatology. She also particularly enjoys helping new parents with feeding problems and managing children with chronic conditions, but works with all ages of children, as each bring their own challenges and personalities. www.copperfieldchildcare.co.za