Developmental Assessment

For Residents and for MRCPCH

Exam

Dr. Varsha Atul Shah

Senior Consultant
Singapore General Hospital

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What the examiner is looking for:

A basic

knowledge of the main developmental milestones

An ability to summarise the findings quickly, and show some
understanding of assessment and management planning for children
with disability.
It is unlikely that you will be asked to carry out a global assessment on
any child except an infant (insufficient time). Usually you will be
asked to carry out only one of the motor or language assessment.
Fine motor assessment
Language assessment
Social skills/ Personal development assessment
Play with this child and describe
An ordered approach to assessment of behaviour
Gross motor assessment
Describe behaviour

Development station is 9 min

Any

child, with a developmental age of 6

months 5 years
Commonly preschooler

Causes of Developmental Delay

Delayed Motor
Development
central: cerebral palsy,
hemiplegia
peripheral lesions
visual impairment
affecting fine motor
systemic disorders:
hypothyroidism etc
environmental:
malnutrition, lack of
practice

Delayed Speech / Language Global Developmental

central: autism, global

learning difficulty
isolated speech delay
hearing loss
environmental:
malnutrition, lack of
practice

Delay
cerebral malformations
hypoxic ischemic
encephalopathy
chromosomal
abnormalities
TORCH infections
toxin exposure
metabolic causes

Usual lead in is Would you please

perform a language/Motor
assessment?
You

may or may not be told age of the

child?

Once

you know 18 months of

development backwards, including
time of appearance and incorporation of
primary reflexes, then you can fairly
interpret the findings

WIPE approach:
Wash/WIPE

Hands/Stethoscope with rub,

Introduce, Interact, Initiate, Inspect
Position yourself and baby and Play,
Examine, eyeball, engage, EEENT Eye- Eyeball whole Environment
and baby from head to toe, Examine-Use hands Ear-Hear Nose-Smell,
Throat-Talk
Begin

by introducing yourself to parents, hand rub etc. 1st only look

see, playand examine.
Inform examiner about your approach either:
live commentary or
summarize after full examination

General Inspection, Eyeball

1. Inspect for growth parameters e.g. FTT, syndromes, under

nutrition can have Developmental delay
2. Syndromic/Dysmorphic features e.g. Downs and other
Trisomy, Fragile X, Catch22,
3. Appearance of Ex premature infants(prominent forehead, pig
nose), correct the age. Obvious neurological anomalies like
floppy infants, posturing, hemiplegic posturing, and involuntary
movements.

Position child if infant:

If child is on mums lap(most of the time) can
do :
-1st vision and hearing,
-2nd Fine Motor,
-3rd language and personal social,
-4th Gross Motor examination
Do not separate for GM assessment.
Bigger kids can examine on chair.
Infants lie in bed-180 degree flip exam

TOOLS NEEDED:
1. Red yarn pom pom (4 cm diameter) with string and
dangling,
2. Bright color 12 cubes 2.5 cm,
3. Rattle with narrow handle
4. Raisins or cheerio's or honey stars or m and ms
5. Cup, spoon
6. A 4 size paper
7. Big size color pencils
7. Picture cards, multiple picture books (like bird, fish, dog,
bus, fruits etc) on same page,
8. Tennis ball
9. Small doll
10. Bell
11. Stickers, sweets for rewards

Vision
Always do vision before hearing.
Fixing and following pom pom ball. Distance 21
cm away.
Conjugated eye gaze(not rowing)/socially
modulated eye contact Check ability to pick up
hundreds and thousands, cubes are important.
Approached to toys
No rowing eye movement, No squint, No
nystagmus
Wearing glasses

Vision
Fix and follow wool ball(4cm) horizontally and
vertically 20 cm from eye level

Hearing: Distraction test

Use initial distraction with non noise making
stimulus in front of child
Always ask examiner to ring the bell at 20 cm
from both ears
Bell is brought towards ear from behind out
of range from visual fields 20 cm away from
ears.
Changes noted are facial expression,
vocalizing sounds, head turns.

Fine Motor:
Holds

rattles (3 months),
hand regards(4 mths),
palmer grasp objects(5 mths),
transfer cubes(7 mths),
Raisins for pincer grip(9 mths),
2.5 cm blocks for stacking,
2 cubes 15 months,
3 cubes(18 months)
6 cubes(21 months).
6 cubes, turn pages (2 yrs),
8 cubes (2.5 yrs),
9 cubes (3 years), beads, thread, putting on biro, plastic knife, and fork.
Comment on personal social interaction, language. Smiling, waving

Fine Motor: Pincer Grasp

Personal social Devt

Chronologically
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Focus on faces(4 weeks),

social smile(6 weeks),
excited with toys(4 months),
Castrate toys (5 months),
stranger anxiety, (6 months),
responds to No, imitates, (8 months),
clapping, bye bye, bang blocks (10 months),
peek boo(11 months),
picture books( 12 months),
kiss mirror (13 months),
points(15 months),
Body parts(21 months)

GROSS MOTOR:
HH

(16 weeks), Roll over,

Tripod (6 months),
Bear wt, bounces, lifts head(7 months) ,
sit well (8 months)
pull to sit and stand, crawl (10months),
Creep 11 months,
walk with support (1 year),
climb stairs with rail ,throw ball(18months),
walk upstairs(21 months)
up and down (2 years).

GROSS MOTOR: 180 degree flip

examination in infant < 8 months
and gait for > 1 year
Supine:

Note posture, abnormal ATNR, involuntary movements

with CP. paucity of movements for hemiplegia.

Pull

to sit: head lag. Sitting: Head and trunk control. Back is

straight or rounded.

Weight

bearing: scissoring, hypotonia, advanced weight bearing

(CP)
Ventral

suspension: Describe posture, low tone, increase

extensor tone.

Prone:

Observe ability to raise head, trunk above horizontal,

Primitive reflexes:
1. Sucking/Rooting :( 0-4,6mths),
2. Palmer grasp; (0-3 months).
3. Placing, stepping: (0-6weeks)
4. ATNR: 2-6 Months.
5. Landau: on ventral suspension, normally extend head, trunk,
and hip. Flex head and neck, response is flexion of hip, trunk.0-6
month).
6. Neck righting reflex: rotation of trunk 6mths-2 years.
7. Moro: 0-4 months.
8. Parachute: 6-12 months persist. Prone position, move
rapidly, face down. Will extend both upper limbs.

Speech and Language:

Cooing

( 2mths),
responds to human voice (4 mths),
Babbling (6mths),
Mamma, dada (9mths),
2 words plus mama, dada(12 mths),
Jargon, points (15mths),
10 words and says his name, points to 3 body parts, one
picture (18mths),
2-3 word phrase, name 3 objects, 4 body parts, says no
(2 yrs), know name, age sex
(2.5yrs), preposition, count 1-10, 2 colours
(3 yrs), name 3 colours, converses (4 years)

Gross Motor Milestones-1

Ball
1 year

18

months

2 years

2.5 years

Jumping

throws
ball 3 feet
throws
ball
without
falling
throws

ball
overhead
kicks ball

catches
ball into
body

Stairs

hops with 2

feet
jumps forward
4 feet

stand on tip
toes if shown

creeps up
stairs
walks up
stairs
creeps back
down stairs
2 steps up
& down

Walking

walks holding on
kneels & balances
walks well by 18
months

runs
walks around
carrying toy
starts & stops at
ease around
obstacles

Sitting

gets on to
furniture
and sits on
their own

Gross Motor Milestones-2

Ball
3 yrs

4 yrs

Jumping

Stairs

catches ball

with arms
extended

kicks forcefully
well

riding tricycle

stands on 1 foot
for 3 secs
walks on tip
toes
jumps down

2 steps up &
1 step down

stands on 1 foot
for 5 secs
hops with 1
foot
stands on tip
toes
jumps forward
30 feet

1 step up &
down

throws ball
underhand

5 yrs

bounces and
catches ball

stands on 1
foot for 10 secs
jumps across
line & over
string

Walking

Sitting

walk backwards &

sideways hauling a
large toy

sits with
ankles crossed

picks up object by
bending forward
with knees straight

sits with knees

crossed

skips with both

feet alternating

does 3 sit ups

Sequence of approach to gross motor assessment

Walk

jump /
hop climb
stairs throw
ball

Fine motor Milestones-1

# give the crayon of appropriate length to test maturity of pen grip

Formula for copying man: 3 + number of parts (paired parts are considered 1) , head O is excluded

1 yr

15 months

18 months

Cubes
mouthing
cubes
bangs cubes
together
picks cubes
with 1 hand
builds 2
cubes
builds 3
cubes

Pen

Cutting

builds 6
cubes

pen held in fist palmar grasp (1.5

- 2 yrs)

2.5 yrs

inferior pen grip

(2 - 2.5 yrs)

3 yrs

aligns 3
cubes
stack a train
builds 9
cubes
3 cube
pyramid
3 block
bridge

steadies paper
with other hand

Others
throws and cast
objects
place 1 correct
shapes in holes
puts pellets in &
out of cup/box
when shown

scribbles
thru & fro

hand preference
at 18 - 24 mths

Book / Pages
opens
book

2 yrs

Drawing

copies a

single line:
I then ---

copies O
copies +
(3 yo)

turns 2-3
pages at
the same
time
turns
pages
singly

makes a cut with

the scissors

cuts along a
line

no more casting
objects
place 2 correct
shapes in holes
place 3 correct
shapes in hole

removes screwed
lid from bottle

strings 4 beads
puts 10 pellets in a
bottle (3 yo)
laces 3 holds (3
yo)

Fine motor Milestones-2

Cubes

4 years

5 years

Pen

builds

10 -12
cubes
6 cube
pyramid
stack a
gate

6 years

Drawing

Book /
Pages

Cutting

Others

copies

cuts along
lines of O

buttons 1
button

colours neatly
within the lines
dynamic tripod
pen grip (4 - 5
years)

copies
writes
name
draws
house
draws 3
part man

cuts along
lines of

Folds paper
in
lengthwise
with edges
parallel

copies
,
draws 7
part
man

static tripod
pen grip (3 - 4
years)

Use of pencils/Crayons
Pencil Skills
Hand preference, functional grasp
Control, pressure, helper hand
Manipulation of writing tool ex. shift, rotation, etc.
Cutting Skills
Orientation, grasps accuracy
Helper hand use
Coloring Skills
Control, pressure, coverage, use of helper hand
Visual Motor
Printing(writing), drawing
Organization
Details of pictures, drawing lines & shapes

Pencil grip

Gesell's figures when use pencil

Gesell's blocks

Sequence of approach to fine

motor assessment
build blocks place shape in hole hold pen +
scribble, put pellets in bottle lace holes
Thread Beads cut paper buttons colors
in lines fold paper

Language Milestones
*1st ask the parent, what is the childs dominant language and any history of hearing loss

Length of sentences

1 yr

18
mon
ths

2 yrs
2.5
yrs

Words / Vocabulary
knows 2 - 3 words
says mama & pap
specifically (15 mths)
indicates needs by
pointing & vocalisations
(15 mths)

Pointing

enjoys nursery
rhymes &
attempts to sing
along

knows 10 - 20 words
jargons ++
echolalia
talks to self during play

2 -3 word
phrases
running
commentary
during play

20 - 50 words
ask: what & where
> 200 words
knows full name &
gender
uses pleural, nouns

1 body part
(15
months)
2 - 3 body
parts (18
mths)
5 body
parts
names 5
body
parts

Commands
follow 1 step commands
w/o gesture: give to
papa, come to mama

understands simple
instructions: come for
dinner, dont touch (15
mths)

follow 2 step commands

w/o gesture

Language Milestones-2
Length of
sentences
3 yrs

4 yrs

5 yrs

Words / Vocabulary

Pointing

Commands

3 word
phrases
correct
grammar,
preposition,
opposition
left, right
past, present

out counts from 1 - 10

asks: why

understood by
family

follows 3 step commands

complete
sentences

knows age

points to colours
route counts from 1 - 20 ,
1 - 2 counts from 1- 4
narrates long stories
knows address, month,
day, birthday
knows morn / afternoon
names 4 - 5 colours
ask : how

understood by
strangers

understands commands
with above and below

understands commands
with before and after

Personal social Milestones

1 yr

smiles
spontaneously
responds
differently to
strangers than to
familiar people
pays attention to
own name
responds to no
copies simple
actions of others

1 - 2 yr

recognises self in
mirror or pictures
refers to self by
name
plays by self,
initiates own play
imitate adult
behaviours in play
helps put things
away

2 - 3 yrs

feeds self cracker

holds cup with 2
hands, drinks
with assistance
holds out arms
and legs while
being dressed

uses spoon,
spilling little
drinks from cup
with 1 hand
unassisted
chews food
unzips large
zipper
indicates toilet
needs
removes shoes,
socks, pants,
sweater

3 - 4 yrs

plays near other

children
watches other
children, joins
briefly in their
play
defends own
possessions
beings to play
house
symbolically uses
objects, self in
play
participates in
simple group
activities
knows gender
identity

gets drink from

fountain or
faucet
independently
opens door by
turning handle
takes off coat
puts coat on with
assistance
washes & dries
hands w
assistance

joins in play with

other children, begins
to interact
shares toys, takes
turns with assistance
begins dramatic play,
acting out whole
scenes

4 - 5 yrs

pours well form

small pitcher
spreads soft butter
with knife
buttons &
unbuttons large
buttons
washes hands
independently
blows nose when
reminded
uses toilet
independently

5 - 6 yrs

plays &
interacts with
other
children
dramatic play
is closer to
reality:
attention paid
to detail,
time, space
plays dress
up
shows
interest in
exploring sex
differences

cuts easy
foods with a
knife
laces shoes

chooses own
friends
plays simple table
games
plays competitive
games
engages in
cooperative play
with other
children involving
group decisions,
role assignments,
fair play

dresses self
completely
ties bow
brushes teeth
independently
crosses streets
safely

Preverbal language
Point

to body parts
Point to pictures and identifies pictures by
pointing

Language assessment
Observe
Non-verbal communication: Eye gaze, eye contact
(describe length, frequency and pattern of eye contact),
modulation of facial expression pointing, body gesture,
body language, socially aware not aware
Receptive language/Comprehension: Following instructions
e.g.
Call him by name and see response
Ask what is your name, age, sex?
Ask labelling of body parts
Ask him to bring ball 1-3 steps
Ask to use on, down, under

Receptive language
Follows

instructions
Try 1 step than 2, 3 etc
See if he echoes questions
Responds to name

Expressive language
Expressive

language: production of
speech, voice quality, intonation, pitch,
volume
Tells his name, age, sex
Labels body parts, pictures

Types of pointing

Protodeclarative pointing: Child points indicate the desire to

share an experience with another person, e.g., a child pointing to
fish looks at you and than object and may look at again you.
Protodeclarative pointing, childs pointing requires joint attention,
or the ability to share experiences with others by attracting or
following their attention by looking or pointing

Types of pointing-2
Protoimperative pointing: points represent
desire for an object eg fish e.g., pointing to
fish or his needs like cookie, sweets, bread
etc. So pointing for needs.

Speech assessment-Quality
Articulation
Clarity
Pronunciation
Jargons
Apraxic
Dysfluency
Stuttering
Stammering

Assessment of language in older child

Language

Pre language skills

eye contact

facial expression, modulation

good attention span

imitation & compliance

joint attention

joint referencing (child shows you something)

Language skills - expressive & receptive

higher order language: idioms, sarcasms, bargaining

Problem with phonation

1. Can be due to hearing impairment
dropping & simplifying clusters of consonants

2. Check locally for any cleft palate / tongue tie

cleft difficulty in making CH, sounds

e.g. childish children eating chilies

rhinolalia look for cleft or catch 22

bob is a baby boy mob is a mamy moy

tongue tie difficulty making the L sounds

Spatial
Directions

1. Put the pencil behind your knees

2. Put the pencil between us but closer to you
3. Put the pencil above your ear
4. Touch the bottom of your chair
5. Put the pencil under this paper and put your hands on top of the paper

2 correct: 4 year level

3 - 4 correct: 5 year level
5 correct: 6 year level

Temporal
Directions

1. The boy saw the man who was carrying a red ball.
Q: who was carrying the red ball?
2. The girl who played with my friend came home late last night
Q: who came home late last night
3. The lady saw the man who was wearing a green hat
Q: who was wearing the green hat?
4. Before it got dark, the man went to the shop.
Q: when did the man go to the shop?
5. The baby ate the sweet after his mother called him.
Q: when did the baby eat the sweet?

1 - 2 correct: 4 year level

3 - 5 correct: 5- 6 year level

Understan
ding

I am going to tell you a story...

tailor the difficulty of the story to the age of the child

ask child to repeat the story back to you

ask child questions about the story

6 year old should be able to tell you the story

back with understanding and reasoning e.g.
why did the ice cream melt?

Others

Simple math (6- 7 yo)

Test fine motor test + hand writing
Compare big and small which circle is bigger?, compare long & short

Assessment of play
Can be divided into concrete play & pretend play
2 - 2.5 years: needs to play with object to
imagine it (symbolic play)
3 - 3.5 years: still require an object, but not so
much & more imaginative about it
4 - 4.5 years: able to play & imagine things out
of air
children with delay in symbolic play with have
delay in language - because language is a
sound symbol for the object

Assessment of play
Approach to steps in assessing play
1. looks what that? - point to a toy and see if there is
joint attention
2. do you wan to play with it? - bring the toy to the child
3. start playing & see if the child imitates you
4. add elements (pretend & fantasy) to the play - the doll
is hungry, shall we feed the doll some cake? the cat is
hungry how?, prompt the child to go on .. feed info when
the child needs otherwise watch
5. extension of play the child then continues the story
and says perhaps, the doll is full, its time to sleep

Assessment of play
Age
begins
18 mths

Type of play

Interaction of play

functional play

solitary play

2 yrs

imitative play

parallel play

2.5 yrs

pretend play

interactive play

3 yrs

fantasy / symbolic play

ASD
Conditi
on

Triad

Autism Qualitative impairments in

social communication and
interaction, together with
presence of restricted,
repetitive and stereotypic
behaviour, interests and
activities

Information

CHAT: Screening questionnaire for autism in children 18

- 36 months
does your child enjoy being bounced on your knee?
does your child take interest in other children?
does your child like climbing things like chairs?
does your child like playing peek-a-boo /hide & seek?
does your child pretend while playing?
does your child ever use his/her index finger to point
to ask for something?
does your child ever use his/her index finger to share
something interesting with you?
does your child play with small toys without
mouthing, fiddling, dropping them?
does your child ever bring objects to show you?

ASD
Neurodevelopmental disorders characterized by impairments
in three domains: Triad
1. Socialization
2. Communication
3. Behavior
Includes:
Autistic disorder
Asperger disorder
Rhetts disorder
Childhood Disintegrating disorder
Pervasive developmental disorder, not otherwise specified
(PDD-NOS)

ASD
Occurs

in ~1 in 150 to 1 in 500 children

Increasing incidence since 1970sdue to
increased awareness/changes in case
definition
MR /seizures common
Pathogenesis incompletely understood
Overwhelming evidence does not support
association with immunizations and
autism

Autistic disorderDSM-IV Criteria:

A total of six (or more) items from (1), (2),
and (3), with at least two from (1), and one
each from (2) and (3):

1. Qualitative impairment in social interaction, as

manifested by at least two of the following:
Marked

impairment in the use of multiple nonverbal

behaviors such as eye-to-eye gaze, facial expression,
body postures, and gestures to regulate social interaction

Failure

to develop peer relationships appropriate to

developmental level

A lack

of spontaneous seeking to share enjoyment,

interests, or achievements with other people (eg, by a lack
of showing, bringing, or pointing out objects of interest)

Lack

of social or emotional reciprocity

2. Qualitative impairments in communication as

manifested by at least one of the following:
Delay

in, or total lack of, the development of spoken language

(not accompanied by an attempt to compensate through
alternative modes of communication such as gesture or mime)

In

individuals with adequate speech, marked impairment in

the ability to initiate or sustain a conversation with others

Stereotyped

and repetitive use of language or idiosyncratic

language
Lack

of varied, spontaneous make-believe play or social

imitative play appropriate to developmental level

3. Restricted repetitive and stereotyped patterns

of behavior, interests, and activities
As manifested by at least one of the following:
Encompassing preoccupation with one or more stereotyped
and restricted patterns of interest that is abnormal either in
intensity or focus
Apparently

inflexible adherence to specific, non-functional

routines or rituals

Stereotyped

and repetitive motor mannerisms (eg, hand or

finger flapping or twisting, or complex whole-body
movements)

Persistent

preoccupation with parts of objects

ASD
Delays

or abnormal functioning in at least one

of the following areas, with onset before 3
years old:
(1) Poor social communication
(2) Poor social interaction
(3) Poor pretend play
(The

disturbance is not better accounted for by

Rett's Disorder or childhood disintegrative
disorder.

Diagnosis of Autism is a clinical one

Use

DSM-IV Criteria
Sometimes referral to ASD specialists for
definitive diagnosis
Diagnostic tools available:
Autism Behavior Checklist (ABC)
Gilliam Autism Rating Scale (GARS)
Autism Diagnostic Interview-Revised (ADI-R)
Childhood Autism Rating Scales (CARS)
Autism Diagnostic Observation ScheduleGeneric (ADOS-G)

Atypical Autism
Asperger disordersimilar to autism
No clinical significant delays in language
Higher levels of cognitive function
Greater interest in interpersonal social
activity
Specific DSM-IV Criteria for diagnosis
PDD-NOSused for individuals with some,
but not all, of the DSM-IV criteria for
autistic disorder

Rett Syndrome
Almost

exclusively females
Develop normally initially, then gradually
loose speech, purposeful hand use after 18
months of age
Deceleration in head growth
Mutations in MECP2 gene
Childhood disintegrating disorder
Regression in multiple areas of functioning
after two years of normal development

ADHD
Condition
ADHD

Examination

-Presence of hyperactivity,
inattention and impulsivity,
-Presenting prior to age 7,
-Of sufficient degree to
impairment social, academic or
occupational functioning,
-Present for 6 months across
2 environments

Information
Steps in History taking:
-exclude brain injury: hypoxia /
infections, ASD
-examine social setup: school, family,
teachers, seat in class
-perform diagnostic interviews as per
DMS IV manuals
-assess IQ, vision, hearing
-assess for OSA: might result in
ADHD
-assess for EEG: for absence seizures

GDD
GDD Chronic sick kids
GDD diagnosed when
usually have GDD
there are Child < 4 years
syndromic
of age with delays in
speech and language
look for a central cause
domain, and in at least 1
- Dysmorphic.
microcephaly
other developmental
domain
- IUI? - VP shunt, eyes,
hearing, cardiac
-ask parents about
murmur,
functional status at
hepatosplenomegaly
home
- CP? - gait, spasticity
of limbs
- storage disease hepatosplenomegaly,
eyes

Motor Delay
Motor
delay

comment on hand dominance e.g. in hemiplegia

bring out the inequality of bilateral hand dexterity by doing
threading & comment on it
In a child with neurological deficits offer that I want to do a proper
neurological examination, I am looking for dyskinetic CP.. etc
look for vision problems that can hinder fine motor dexterity - especially
if a young child is wearing spectacles
Comment that the child might have limitations due to ...., but
has functionally adapted to ..
ask parents about functional status at home

Mental Retardation (MR), cognitive

delay
a

state of functioning beginning in childhood characterized

by limitations in intelligence and adaptive skills
DSM-IV Criteria for MR:
Significant sub-average intellectual functioning
Adaptive functioning deficit or impairment
Onset before 18 years of age
Cognitive impairment requires IQ testing (accurate for ages
5 years)
Mild50 to 70 IQ ( 70 is 2 SD from normal100)
Moderate40 to 50
Severe20 to 40
Profound<20

Prognosis for MR
Depends on severity:
Mildcan be taught to read/write, live
independently and hold jobs as adults
Moderateprobably will not learn to
read/write, but may live/work in semiindependent supervised settings
Severe/profoundrequire substantial
lifelong support
Also dependent on etiology of MR and comorbid conditions

Learning difficulties
Achievement

substantially below
expected given the childs age,
intelligence and appropriate education

Dyspraxia/ developmental
coordination disorder
Motor

planning issues
with deficits in conceptualisation,
organisation and
execution of unfamiliar sequence of
movement, often affecting attention and
learning
Sensory integration disorder
Sensory defensiveness

Sensory integration
disorder
Sensory

defensiveness and
Modulation issues

Red flag signs of SLD

6 month -no response to sound
Deaf infants coo/laugh/squeak at @ normal age
then babble slightly later than then stop
babbling
1 yr no babbling, not localising sound
18
no meaningful words except ma/pa
month not pointing to wanted things
2 yr vocab < 20 words
no 2 word phrases
2.5 yr not understanding simple instructions
3 yr not understood by family
4 yr not understood by outside family
5 yr speech not clear, fluent, not complex
not understood

Important Milestones
Domains
Receptive language

Development
12 month

responding to their name

18 mth - 2 yrs

pointing to body parts, parents, pictures

following instructions
1 step: throw in the bin
2 step put this ball in box and bring shoes
-

mama & papa, pointing to what they want

linking words, naming 2 - cat, dog
repeats 3 word phrases
gives name & identifies colours
name colours, self, fluent
repeats 4 - 6 word phrases
eye contact
reciprocal play
pretend play
joint referencing, share interest

12 - 18 mths
2 yrs
Expressive language
(verbal & non verbal)

12 month
2 yo
3yo
4yo
5yo

Social Emotional
Self help
(ASD)

3 - 6 mth
18 - 24 mth

Gross motor

12 - 18 mths
2 yr
3 yr
4 yr
5 yr

walk
walk sideways 2 steps, kick a ball
stand on 1 foot, tiptoe 3 steps
stand on 1 foot for 1 secs, tiptoe 4 steps
hop 2 hops on 1 foots
stand on 1 foot for 5 secs

18 mths
2 yr
3 yr
4 yr
5 yr

scribbles / line
line / circle
circle / cross
copies square
copies triange

- to test for GDD

Fine motor
- to test for GDD

Offer to test hearing

Ask for f/h of delayed speech: more common in children with +ve f/h

3 blocks
6 blocks
9 blocks

In DCD:
The

single most common presenting concern

was speech and language (S&L) delay (30%).
The most common clinical developmental diagnosis
was autism spectrum disorder (ASD) (30%)
Global developmental delay (GDD)(10%)
ADHD(6%)
LD(4%)
Cognitive impairment(4%),
CP(3%)
Dyspraxia(2%)

Approach to Developmental Delay-1

Assess

if any medical problems like

Neurologic, myopathy, dystrophy etc
Genetic, syndromes particularly Fragile X,
Prader willi
Metabolic
Endocrine exclude Hypothyroidism for GDD
HIE, CP, IUI, ExPREM
Hearing loss
Vision loss, squint, lazy eye, astigmatism etc

Approach to Developmental Delay1,Medical Evaluation

Presence

of biologic risks or medical problems

associated with DD
Head circumference for micro/macrocephaly
Weight and height for growth deficiency
Dysmorphology (minor and major congenital
abnormalities)
Eye exam for poor tracking, strabismus, etc
Ear exam for recurrent/chronic OM
Abdomen for HSM (metabolic disease)
Skin for neurocutaneous lesions
Neurologic exam for reflexes, tone, symmetry, strength

Screening Tests:
Parents Evaluation

of Developmental Status (PEDS)

Ages and Stages Questionnaires (ASQ)
~15 minutes, by the parent
Generates a pass/fail score in four development
domains
Infant-Toddler Checklist for Language and
Communication
~5-10 minutes, by the parent
Identifies scores 1.25 SD below normal
Brigance Screens-II

Approach to Developmental Delay-2

Check

growth percentiles, macro or

microcephaly
FTT
Examine for Neurocutaneous syndromes
like caf au lait spots
Examine back for spina bifida occulta
Examine eye for squint, nystagmus,
cataract, clouding
Do Neurologic examination

Approach to Developmental Delay-3

Try

to differentiate UMN/LMN lesions

Examine abdomen for HSM
Otoscopy for wax, Otitis Media
Mouth for tongue tie, cleft, tongue
movement, gag

Approach to Developmental Delay-4

Do

Hearing test and Visual assessment with or

without sedation for all developmental delay
For GDD consider TFT
For hypotonia, GDD doe Muscle enzymes CK,
LDH and KIV aminoacidogram, metabolic
screen
For Genetic Karyotyping, FISH
Refer
Genetic/Neurologist/ENT/Eye/Endocrine as
needed

Evaluations-1
Formal

hearing testing (BAER)

Vision testing (full ophthalmologic exam)
Thyroid function testing (if no NBS, or
signs of thyroid disease)
Metabolic screening (if abnormal or no
NBS)
Neuroimaging (MRI vs CT)

Evaluations-2
Chromosomal/Cytogenetic

Testing (if

+family history)
Down Syndrome (karyotype), Fragile X
(FMR1), Rett Syndrome(MECP2), PraderWilli/Angelman (FISH)
EEG if suspected seizure
activity/encephalopathy (Landau-Kleffner)
CPK/Aldolase if abnormal muscle tone
(Muscular dystrophy)

Approach to Developmental Delay5,Children 0-36 monthsagencies

Refer

to EIPIC)
Multidisciplinary
Speech and Language Pathologist
Occupational and Physical Therapy
Social Worker
Psychological evaluation if needed
Focus on need for services rather than
diagnosis

Children 3-5 yearspreschool EIPIC/ICCP services

Continued

servicesmay be in or out of

classroom
Children older than 5 yearsreferrals
usually made through public school
system
Private evaluations/services are also
available

Children older than 5 year

Referrals

usually made to DCD therapist

Private evaluations/services are also
available
SPD
ICCP

At 6 years age-1
If assessment shows need of special school
Do IQ test for school placement
If going to mainstream, no need to do IQ test,
but can refer educational facilitator for
informing school special need officer (SNO)
regarding childs diagnosis and accommodation
needed
May need exemption from mOther Tongue
Extra Time in exam
Sitting in front of class, prompting, buddy

At 6 years age-2
If assessment shows mild delay and
potential to improve
Consider deferring primary 1
Inform MOE
Retain K2 (maximum 2 years retention
allowed)
Review KIV IQ test or Refer EF after 1
year
Inform EIPIC for extension for 1 year

Present the case as:

On

general inspection of this cute little /Race/ New born/infant/toddler, who

is well thrived, but would like to chart gender specific progressive
percentiles for Occipitofrontal circumference, length, and weight, he is not
syndromic, (no expremmie look), not floppy has good muscle tone moving
all limbs equally. No involuntary movements seen.
On examination of vision he had eye gaze, socially aware, he fixed followed
pompom ball, approached to toys, picked up raisins etc. On examination of
distraction hearing test , On personal social.., On language. On fine
motorOn gross motor..NN reflexes
or there is a huge scatter across the developmental ages of his different
abilities
In summary: this infant has DA of.GM FM. SL PS etc with
Developmental quotient at __%
I.Q= Mental age x 100

Chronological age