APPROACH TO

DEVELOPMENTAL
DELAY
 Objectives

◦ Introduction: definitions, Transient and Persistent
developmental delays
◦ Developmental milestones: normal for age,
warning signs.
◦ Etiology: causes of global developmental delay, high
risk children
◦ Approach to a Child with Developmental Delay:
History, Physical exm, Invistigations, Screening
 

Introduction
 What is child
development?

◦Child development refers to how a
child becomes able to do more
complex things as they get older.
◦Growth only refers to the child
getting bigger in size.
 What is developmental
delay?

◦ Developmental Delay is when a child does
not reach their developmental milestones at the
expected times.
◦It is an ongoingmajor orminor delay in the processof
development.
◦Delay can occur in one or many areas—for
example, gross or fine motor, language, social,
or thinking skills.
◦ Developmental delay is not uncommon and
occurs in 2-3% of all children. (~)
◦The term developmental delay is often used
until the exact nature and cause of the delay is
known.
◦The significance of the delay is often only
determined by observing the child’s
development over time.
 Transient developmental
delay

◦ Some children have a transient delay in their
development.
◦ For example, some extremely premature babies may
show a delay in the area of sitting, crawling and
walking but then progress on at a normal rate.
◦ Other causes of transient delay may be related to
physical illness and prolonged hospitalization,
immaturity, family stress or lack of opportunities to
learn.
 Persistent developmental
delay

◦ If the delay in development persists it is usually related to
problems in one or more of the following areas:
 understanding and learning
 moving
 communication
 hearing
 seeing.
◦ An assessment is often needed to determine what area or
areas are affected.
◦ Disorders which cause persistent developmental delay are often
termed developmental disabilities.
 Developmental
disability

◦ Developmental disability is estimated to occur in 5-10% of
the population with enormous psychological, emotional, and
economic impact on the affected individuals and society.
◦ Studies have shown that developmentally delayed children who
are recognized at an early age receive more developmental
optimization and greater gains than those who are identified
later in life.
◦ Early recognition of children with developmental problems is
therefore important.
◦ There are several disabilities in the classification of
developmental delay:
 Disability Description

Gross motor delay Significant delay in fine or gross motor skills

with no impairment in other developmental
areas
Developmental language disorders Significant delay in receptive and/or expressive
language skills with no delay in other
developmental domains

Global developmental delay Significant delay in two or more developmental

streams as measured by appropriate
standardized screening tests. This term is
reserved for children less than 5 years of age

Cerebral palsy Early-onset non-progressive motor

impairment with associated abnormalities in
muscle tone

Hearing sensory impairment A reduction in the ability to hear sound, ranging

from slight to complete deafness
 Disability Description
Visual sensory impairment An optically or medically diagnosable condition
in the eye(s) or visual system that affects the
development and normal use of vision, ranging
from slight to complete blindness

Learning disabilities Significantly lowered individual achievement

than predicted by intellectual ability as
measured by standardized psycho-educational
tests assessing reading, mathematics, or written
expression

Pervasive developmental delay (PPD) / Impairments in social skills, communication

Autism skills and restrictive / repetitive patterns of
behavior
 
DEVELOPMENTAL
MILESTONES
 What are developmental
milestones?

◦ Developmental milestones are a set of functional
skills or age-specific tasks that most children can do
at a certain age range.
◦ A pediatrician uses milestones to help check how a
child is developing.
◦ Although each milestone has an age level, the actual
age when a normally developing child reaches that
milestone can vary quite a bit. Every child is unique!
◦ CDC’s milestone checklists
In these categories…

◦ Gross motor: using large groups of muscles to sit, stand, walk,
run, etc., keeping balance, and changing positions.
◦ Fine motor: using hands to be able to eat, draw, dress, play,
write, and do many other things.
◦ Language: speaking, using body language and gestures,
communicating, and understanding what others say.
◦ Cognitive: Thinking skills: including learning, understanding,
problem-solving, reasoning, and remembering.
◦ Social: Interacting with others, having relationships with
family, friends, and teachers, cooperating, and responding to the
feelings of others.
 1
month 
• Makes jerky, quivering arm thrusts
• Brings hands within range of eyes and
mouth
Movement • Moves head from side to side while
lying on stomach
Milestones • Head flops backward if unsupported
• Keeps hands in tight fists
• Strong reflex movements
 1
month 
• Focuses 8 to 12 inches (20.3 to 30.4 cm)
away
• Eyes wander and occasionally cross
Visual and • Prefers black-and-white or high-contrast
Hearing patterns
• Prefers the human face to all other patterns
Milestones • Hearing is fully mature
• Recognizes some sounds
• May turn toward familiar sounds and voices
 1
month 
• Prefers sweet smells
• Avoids bitter or acidic smells
Smell and • Recognizes the scent of his own
Touch mother’s breastmilk
Milestones • Prefers soft to coarse sensations
• Dislikes rough or abrupt
handling
 3
months 
• Raises head and chest when lying on stomach
• Supports upper body with arms when lying on
stomach
• Stretches legs out and kicks when lying on stomach
Movement or back
• Opens and shuts hands
Milestones • Pushes down on legs when feet are placed on a firm
surface
• Brings hand to mouth
• Takes swipes at dangling objects with hands
• Grasps and shakes hand toys
 3
months 
• Watches faces intently
• Follows moving objects
• Recognizes familiar objects and people at a
Visual and distance
Hearing • Starts using hands and eyes in coordination
• Smiles at the sound of your voice
Milestones • Begins to babble
• Begins to imitate some sounds
• Turns head toward direction of sound
 3
months 
• Begins to develop a social smile
• Enjoys playing with other people
Social and and may cry when playing stops
Emotional • Becomes more communicative and
expressive with face and body
Milestones • Imitates some movements and
facial expressions
 7
months 
• Rolls both ways (front to back, back
to front)
• Sits with, and then without, support
Movement of her hands
• Supports her whole weight on her legs
Milestones • Reaches with one hand
• Transfers object from hand to hand
• Uses raking grasp (not pincer)
 7
months 
• Develops full color
vision
Visual • Distance vision matures
Milestones
• Ability to track moving
objects improves
 7
months 
• Responds to own name
• Begins to respond to ―no‖
• Distinguishes emotions by tone of
Language voice
Milestones • Responds to sound by making sounds
• Uses voice to express joy and
displeasure
• Babbles chains of consonants
 7
months 
• Finds partially hidden
object
Cognitive • Explores with hands and
Milestones mouth
• Struggles to get objects
that are out of reach
 7
months 
• Enjoys social play
Social and • Interested in mirror images
Emotional • Responds to other people’s
Milestones expressions of emotion
and appears joyful often
 12
months 
• Gets to sitting position without assistance
• Crawls forward on belly by pulling with arms and
pushing with legs
• Assumes hands-and-knees position
• Creeps on hands and knees supporting trunk on hands
Movement and knees
• Gets from sitting to crawling or prone (lying on
Milestones stomach) position
• Pulls self up to stand
• Walks holding on to furniture
• Stands momentarily without support
• May walk two or three steps without support
 12
months 
• Uses pincer grasp
Milestones • Bangs two cubes together
• Puts objects into container
In Hand • Takes objects out of container
and Finger • Lets objects go voluntarily
Skills • Pokes with index finger
• Tries to imitate scribbling
 12
months 
• Pays increasing attention to speech
• Responds to simple verbal requests
• Responds to ―no‖
Language • Uses simple gestures, such as shaking
head for ―no‖
Milestones • Babbles with inflection
• Says ―dada‖ and ―mama‖
• Uses exclamations, such as ―oh-oh!‖
• Tries to imitate words
 12
months 
• Explores objects in many different ways
(shaking, banging, throwing, dropping)
• Finds hidden objects easily
Cognitive • Looks at correct picture when the
image is named
Milestones • Imitates gestures
• Begins to use objects correctly (drinking
from cup, brushing hair, dialing phone,
listening to receiver)
 12
months 
• Shy or anxious with strangers
• Cries when mother or father leaves
• Enjoys imitating people in play
• Shows specific preferences for certain people and toys
Social and • Tests parental responses to his actions during feedings (What do
you do when he refuses a food?)
Emotional • Tests parental responses to his behavior (What do you do if he
cries after you leave the room?)
Milestones • May be fearful in some situations
• Prefers mother and/or regular caregiver over all others
• Repeats sounds or gestures for attention
• Finger-feeds himself
• Extends arm or leg to help when being dressed
 2
years 
• Walks alone
• Pulls toys behind her while walking
• Carries large toy or several toys while walking
• Begins to run
Movement • Stands on tiptoe
•
milestones •
Kicks a ball
Climbs onto and down from furniture
unassisted
• Walks up and down stairs holding on to
support
 2
years 
• Scribbles spontaneously
Milestones • Turns over container to pour
out contents
in hand • Builds tower of four blocks or
and finger more
skills • Might use one hand more
frequently than the other
 2
years 
• Points to object or picture when it’s named for him
• Recognizes names of familiar people, objects, and
body parts
• Says several single words (by fifteen to eighteen
Language months)
• Uses simple phrases (by eighteen to twenty-four
milestones months)
• Uses two- to four-word sentences
• Follows simple instructions
• Repeats words overheard in conversation
 2
years 
• Finds objects even when
hidden under two or
Cognitive three covers
milestones • Begins to sort by shapes
and colors
• Begins make-believe play
 2
years 
• Imitates behavior of others, especially adults
and older children
• Increasingly aware of herself as separate from
Social and others
• Increasingly enthusiastic about company of
emotional other children
• Demonstrates increasing independence
milestones • Begins to show defiant behavior
• Increasing episodes of separation anxiety
toward midyear, then they fade
 3-4
years 
• Hops and stands on one foot up to five
seconds
• Goes upstairs and downstairs without
Movement support
• Kicks ball forward
milestones • Throws ball overhand
• Catches bounced ball most of the time
• Moves forward and backward with agility
 3-4
years 
• Copies square shapes
Milestones • Draws a person with two to
four body parts
in hand • Uses scissors
and finger • Draws circles and squares
skills • Begins to copy some capital
letters
 3-4
years 
• Understands the concepts of ―same‖
and ―different‖
• Has mastered some basic rules of
Language grammar
• Speaks in sentences of five to six words
milestones • Speaks clearly enough for strangers to
understand
• Tells stories
 3-4
years 
• Correctly names some colors
• Understands the concept of counting and may
know a few numbers
• Approaches problems from a single point of
Cognitive view
• Begins to have a clearer sense of time
milestones • Follows three-part commands
• Recalls parts of a story
• Understands the concept of same/different
• Engages in fantasy play
 3-4
years 
• Interested in new experiences
• Cooperates with other children
• Plays ―Mom‖ or ―Dad‖
Social and • Increasingly inventive in fantasy play
• Dresses and undresses
emotional • Negotiates solutions to conflicts
• More independent
milestones • Imagines that many unfamiliar images may be ―monsters‖
• Views self as a whole person involving body, mind, and
feelings
• Often cannot distinguish between fantasy and reality
 4-5
years 
• Stands on one foot for
ten seconds or longer
Movement • Hops, somersaults
milestones
• Swings, climbs
• May be able to skip
 4-5
years 
• Copies triangle and other geometric
Milestones patterns
• Draws person with body
in hand • Prints some letters
and finger • Dresses and undresses without assistance
• Uses fork, spoon, and (sometimes) a table
skills knife
• Usually cares for own toilet needs
 4-5
years 
• Recalls part of a story
• Speaks sentences of more
Language than five words
milestones • Uses future tense
• Tells longer stories
• Says name and address
 4-5
years 
• Can count ten or more objects
• Correctly names at least four
colors
Cognitive • Better understands the concept of
milestones time
• Knows about things used every
day in the home (money, food,
appliances)
 4-5
years 
• Wants to please friends
• Wants to be like her friends
• More likely to agree to rules
Social and • Likes to sing, dance, and act
• Shows more independence and may even visit
emotional a next-door neighbor by herself
• Aware of sexuality
milestones • Able to distinguish fantasy from reality
• Sometimes demanding, sometimes eagerly
cooperative
 What are the
Warning signs of
a physical
developmental
delay ?
 Newborn to 2
months

after 2 months, doesn't hold his head up when you pick
him up from lying on his back
after 2 months, still feels particularly stiff or floppy

after 2 months, overextends his back and neck (as if

he's pushing away from you) when cradled in your arms
after 2 or 3 months, stiffens, crosses, or "scissors" his
legs when you pick him up by the trunk
 3 to 6
months

by 3 or 4 months, doesn't grasp or reach for toys

by 3 or 4 months, can't support his head well by

4 months, isn't bringing objects to his mouth

by 4 months, doesn't push down with his legs when his feet are
placed on a firm surface
after 4 months, still has Moro reflex (when he falls backward or is startled, he throws
out his arms and legs, extends his neck, and then quickly brings his arms back
together and begins to cry)
 3 to 6
months

after 5 or 6 months, still has the asymmetrical tonic neck reflex (when
his head turns to one side, his arm on that side will straighten, with the
opposite arm bent up as if he's holding a fencing sword)
by 6 months, can't sit with help

after 6 months, reaches out with only one hand while keeping the other
fisted

doesn't roll over in either direction (back to front or front to back) by 5

or 6 months
 7 to 9
months

at 7 months, has poor head control when pulled to a sitting
position
at 7 months, is unable to get objects into his mouth

at 7 months, is not reaching for objects

by 7 months, doesn't bear some weight on his legs

by 9 months, can't sit independently

 9 to 12
months

after 10 months, crawls in a lopsided manner, pushing
off with one hand and leg while dragging the
opposite hand and leg
at 12 months, is not crawling

at 12 months, can't stand with support

 13 to 24
months

by 18 months, can't walk

after several months of walking, doesn't walk

confidently or consistently walks on toes

after his second birthday, is growing less than 2

inches per year (get more on a normal growth rate)
 36
months

falls frequently or is unable to use the
stairs
drools persistently

can't manipulate small objects

 

ETIOLOGY
 Why is finding a cause
important?

◦ Establishing a cause has many benefits for the child and family and improves
overall quality of life:
◦ The family gains understanding of the condition, including prognostic information.
◦ Lessens parental blame.
◦ Ameliorates or prevents co-morbidity by identifying factors likely to cause secondary
disability that are potentially preventable e.g. surveillance of other systems such as
vision and hearing.
◦ Appropriate genetic counselling about recurrence risk for future children and the
wider family.
◦ Accessing more support (e.g. within education services and specific syndrome support
groups).
◦ To address concerns about possible causes e.g. events during pregnancy or delivery.
◦ Potential treatment for a few conditions.
 Causes of Global
Developmental  Delay
◦ Global developmental delay can be the presenting feature of a
huge number of neurodevelopmental disorders (from learning
disability to neuromuscular disorders).
◦ It is not possible to provide an exhaustive list.
◦ Careful evaluation and investigation can reveal a cause in 50-70%
of cases.
◦ This leaves a large minority where the cause is not determined.
◦ It is still useful to investigate globally delayed development
whatever the age of the child (occasionally older children with
significant disability may not have been investigated adequately)
 Environmental Factors that May
Place a Child at Risk

◦ Living in families that are at lower socioeconomic levels;
◦ Living in families with varied cultural backgrounds;
◦ Living in families classified as dysfunctional;
◦ Being born to teenage mothers or mothers more than forty years old;
◦ Growing up in homes where English is not the primary language spoken:
(racism?)
◦ Being exposed prenatally to viruses, drugs, or alcohol;
◦ Being born into families with other children who have developmental
delays;
◦ Being born to mothers who were malnourished during pregnancy;
◦ Being born to mothers who have diabetes, thyroid disorders, syphilis, or
other viral infections.
 
OUR
APPROACH
 An Approach to a Child with
Developmental Delay

◦ A child’s development is a dynamic process, and assessment at any point
in time is merely a snap shot of the bigger picture and should be
interpreted in the context of the child’s history from conception to the
present.
◦ While a child may appear to have normal development for the first twelve
months of life, a deviation in the course of the child’s development in
subsequent years is indicative of an underlying disability.
◦ It is important to keep this in mind as you assess a child, and to keep
reassessing children in subsequent office visits.
◦ Developmental assessment involves three aspects: screening,
surveillance, and definitive diagnostic assessment.
 Developmental
Assessment

◦ Developmental screening is identifying children who may need more comprehensive
evaluation. It is a brief assessment procedure designed to identify children who should
receive more intensive diagnosis or assessment. This is accomplished in the pediatrician’s
office through thorough history taking + / - the use of screening tools such as the Denver
or Bayley Scales of infant development.
◦ Developmental surveillance is a continuous process whereby the child is followed over
time to pick up on subtle deficiencies in the child’s developmental trajectory. The
components of developmental surveillance include eliciting and attending to parental
concerns, obtaining a relevant developmental history, observing the child’s development
in the office and referring for further assessment of development by other relevant
professionals such as OT/PT for motor developmental concerns or hearing tests for
concerns with language acquisition.
◦ Diagnostic assessment is performed on a child who has been identified as having a
potential problem. This step requires extensive involvement of various team players such
as a psychologist, educator, social worker, developmental pediatrician, geneticist, and/or
other medical professionals.
 History

◦ To perform a developmental assessment, a detailed history
from conception to the present is required to assess
developmental level.
◦ Knowing the appropriate milestones is key to this
assessment.
◦ Any signs of developmental regression should be regarded as
a medical emergency and an urgent medical workup is
indicated.
◦ An underlying etiology for developmental delay should be
sought through attention to the following clues on history:
 Prenatal
History 
◦Complications
◦Prenatal diagnoses made (eg. Down
Syndrome)
◦Infections (eg. TORCH)
◦Exposures (eg. Fetal Alcohol Syndrome)
 Obstetrical
History
◦Complications
◦APGAR scores
◦Infections
◦Seizures
Past medical history and
medications

◦Ototoxic antibiotics eg. Gentamicin
◦Frequent ear infections may lead to
effusions affecting hearing
 Behavior since
birth 
◦Behavioral disturbances – aggression, self
injury, defiance, inattention, anxiety,
depression, sleep disturbances, stereotypic
behaviors, poor social skills, hyperactivity,
difficult temperaments
 Family
History 
◦Relatives with developmental delay,
genetic abnormalities, syndromes
◦Consanguinity
 Screening
Tools 
◦ There are various screening instruments used for
assessing developmental.
◦ The Denver II assesses gross motor, fine motor,
adaptive and social skills.
◦ It is designed for children between the ages of 0 and
6.
◦ Similar tools are the ―Ages and Stages‖
questionnaires and the Bayley infant development
scales.
 Physical
Examination

◦A thorough physical examination is important
in the assessment of a developmentally
delayed child.
◦Characteristic findings on physical exam may
provide clues as to the cause of the
developmental delay.
 Neurological
Exam
◦ Cranial nerves
◦ Specific vision tests: red reflex, normal fundi,
response to visual stimuli, field of vision
◦ Specific auditory tests: response to auditory stimuli
◦ Receptive or expressive language delay
◦ Abnormal speech (eg. articulation)
◦ Persistently present Babinski response (older than 2
years of age)
 Neurological
Exam
◦ Hyper- or Hypotonia
◦ Sensory
◦ Motor strength
◦ Gait
◦ Deep tendon reflexes
◦ Primitive reflexes – Moro, Gallant
◦ Postural reflexes – propping response
 

MANAGEMENT
◦ Beginning as early as birth and continuing through age 3
years, any child with a known disability, significant delay, or
condition with a high risk for disability (eg, Down syndrome)
is entitled to early intervention services that provide
developmental therapies intended to improve performance in
one of the developmental spheres.
◦ These can include traditional therapies, such as physical
therapy, occupation therapy, and speech-language therapy, as
well as broader services such as special instruction,
counseling, and family training.
◦ Many programs provide for parent training or home-
based therapy to allow for generalization of skills
learned.
◦ For children 3 years and older and continuing into
the school-age years, the child with disabilities is
entitled to an individualized, free, and appropriate
education along with related therapy services.
◦ Specific medical treatments targeted towards a child’s related
medical conditions should also begin with diagnosis.
◦ For example, along with receiving physical therapy and other
early intervention services, the child with cerebral palsy
should be considered for medical treatment of tone
abnormalities with oral agents, intramuscular botulinum
toxin, or intrathecal baclofen.
◦ The child with behavior disorders accompanying a
communication or intellectual disability is a candidate for
psychopharmacologic treatments, such as stimulants for
ADHD and risperidone for aggression.
 Resourc
es 
◦ Nelson Textbook of Pediatrics, 19th Edition.
◦ http://www.med.umich.edu/yourchild/topics/devmile.htm
◦ http://www.med.umich.edu/yourchild/topics/devdel.htm
◦ http://www.healthychildren.org/English/ages-stages/baby/Pages/default.aspx
◦ http://www.babycenter.com/0_warning-signs-of-a-physical-developmental-delay_6720.bc
◦ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791071/
◦ Center of Disease Control’s checklist of developmental milestones.
◦ The Royal Children's Hospital Melbourne; developmental delay: an information guide to parents.
◦ Developmental Delay – Causes and Investigation, Angharad V Walters
◦ http://learnpediatrics.com/body-systems/nervous-syste/basics-to-the-approach-of-
developmental-delay/
◦ http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_
management/P3
THANK YOU
The End