CHILD WITH DEVELOPMENTAL

DELAY

Sathyabama Ramachandram
Consultant Developmental Paediatrician
Hospital Pulau Pinang
Child Development
• Child development is a dynamic process.

• Normal development is determined by a

complex interplay between environmental
factors, genetic factors and acquired
pathology.
The Developmental Examination
• History taking: family history, social & family
environment, pre & postnatal history.

• Enquire into parental concerns.

• Seek information from others who know the

child (eg. teachers, health-care staff).
Observation & interactive assessment
• Suitable selection of toys made available
before meeting family & interacting with
child.

• Appropriate toys for the age of the child &

domains of development to be assessed.
How to observe/examine?

• Note qualitative information

How a task is done?

Rather than over-focused on success
or failure in specific task.
How to observe/examine?
• Non-verbal task gives information on
visual perception
fine and gross motor skills
cognitive skills
• Verbal tasks combine
social
speech-language, communication
cognitive skills
How to observe/examine?

• Structure setting to reduce distractions

• Give simple, active directions
• Use gestures where required to get
attention, for example, saying „listen‟ with a
gesture of listening with the ear.
Observation & interactive assessment
• Copying behaviour (bell). Cause & effect
(pop-up animal toys)
• Definition by use (cup/ spoon, doll/ brush
• Symbolic understanding (doll/ teddy/ tea set)
• Fine motor (bricks, crayons/pencil & paper,
soft ball, form boards, puzzles)
• Language and play (books with pictures &
stories, large and miniature toys)
Observation & interactive assessment
„Free Play‟
• Child‟s inability to organize the environment
& generate own ideas will be significant.
• May not be able to focus attention.
• Fleeting from one object to another or
repetitive play.

• Quality of response should be monitored

together with actual achievement.
Developmental Examination: Birth to 1 Year

• Gross motor
• Fine motor
• Speech language, communication
• Social
• Cognitive
Developmental Examination: Birth to 1 Year
Gross Motor Milestones
• Delay/disordered development marker for
motor disorders
• Motor abilities have weak correlation with
cognitive development
• Loss of primitive reflex by 3 months
• Appearance of supportive reflex by 4 months
• Improving postural control & stability in
cephalo-caudal direction
Examination/Observation Gross Motor

• Tone, movements and posture

head control, hands (open or fisted)
• Spine curvature, leg posture, weight bearing
• Supine, pull to sit, supported/ independent
sitting & standing, ventral suspension &
prone position (180* manoeuvre).
• Examine primary reflexes (Moro, grasp &
ATNR)
Developmental Examination: Birth to 1 Year
Developmental Examination: Birth to 1 Year
Fine Motor Development
• Coordination of vision with head movement
(6-8/52 weeks) & hand movement :
watches own hand or objects held in hands
(3-4/12)
• 2 handed reach replaced by single handed
reach (5-6/12)
• Exploration with index finger (8-9/12)
Developmental Examination: Birth to 1 Year

Fine Motor
• Maturing grasp: apposition of tips of fingers
with tip of thumb, palmar (6/12) pincer (9-
10/12) , finger tips (12/12)
• Release with open hands/pressure (10-
11/12); controlled release: puts 1 cube on
top of another (13/12)
Development of Grasp: Cube
Developmental Examination: Birth to 1 Year
Fine Motor examination
• Reaching, grasping, exploration
• Hand to hand transfer of a block placed in
front infant sitting supported
• Use a small object to prompt
• Encourage release of a block/toy in the
hand or container
• Placing one brick on another, indicating
mature release.
Visual Behaviour, eye-hand coordination &
problem solving
• Progressive coordination of maturing vision
with head, body & fine motor movements can
be observed through manipulation & use of
cubes, crayon, formboards etc

• Achievement in this domain represent the

precursor to later non-verbal problem solving
abilities, correlate well with intellectual ability .
Visual behavior eye & head co-ordination

• Earliest developmental sequence starts

with fixing gaze on the mother‟s face (1/12)
following face with eyes (2/12)
co-ordinate eye movement to head turning
(3/12)
• Any abnormality should prompt referral for
ophthalmology assessment.
Eye-hand coordination milestones
Eye-hand coordination milestones
Developmental Examination: Birth to 1 Year
• Speech, language & communication
• Observations made throughout examination
• Using common objects or toys
• Infants may respond better to caregiver
(asked to give simple directions for naming
or giving of objects)
Developmental Examination: Birth to
1 Year – Language development
• Receptive Language • Typical development
• Comprehension patterns
• Note response to • Selective attention to
speech sounds speech sounds
• Observe response to • Situational
naming common understanding: „No‟,
objects/simple respond to own name
directions 9/12, follows familiar
request 12-15/12
Developmental Examination: Birth to
1 Year - Language
• Expressive language

• Listen to spontaneous/imitated sounds in

response to being talked to
• Observe gestures
Developmental Examination: Birth to
1 Year - Language
• From preverbal communication to 1st word
• Cooing 8/52
• Squeals, yells, repeated vowels 4/12
• Multi-syllable babble (vowel-consonant) 8/12
• Jargon 9/12
• Consonant-vowel 12/12
• Single words other than Mama, Dada with
consistent meaning 12-13/12
Nonverbal Communication
Vocalization 3/12

Pointing to ask 9/12

Pointing to show 9-12/12

Conventional gestures eg waving 9-12/12

bye
Developmental Examination: Birth to 1 Year
Social
Social responsiveness
• Social smile
• Responds to social games & shows
anticipation
• Developing joint attention
• Becoming stranger aware : Reacting by
withdrawing or crying
• Social referencing : Checking back by looking
towards caregiver in new situations
Typical social development
Social smile 6-8 weeks
Anticipation to social games 6/12
Joint attention
Follows other‟s finger point to look at 8/12
an object
Uses finger & eye gaze to direct 9-12/12
others‟ attention to share interest

Stranger aware 6-8/12

Social referencing 12/12
Social Development
• History:
• How does your child respond when you
smile, play nursery games, peek-a-boo?
• How does your child get your attention?
• How does your child react to a stranger?
• Observe:
• Eye contact, gestures, response, turn
taking
Developmental Examination: Birth to 1 Year
Cognitive Development

• Observation of infant's cognitive abilities

are made during fine motor,
communication, play & social interaction
activities
• 4 main structured tasks are used
Developmental Examination: Birth to
1 Year - Cognitive
Physical rules and object relationships

• Offer 1 cube: reach, grasp, exploration,

hand-to-hand transfer (reach out to
grasp:5/12)
• Offer another cube: imitation of clicking of 2
cubes (12/12)
Developmental Examination: Birth to
1 Year - Cognitive
• Request for a cube back by putting open
hand out - note release
• Put an open container and encourage
releasing cube into it & taking it out (9-
15/12)
• Inserting pegs into holes (15 months)
Developmental Examination: Birth to
1 Year - Cognitive
• Cause & effect understanding and goal
directed actions

• Pop up or other action toys

• Place a toy out of reach with connected
string near child
• Check grasp of string & pulling string to get
toy
Developmental Examination: Birth to
1 Year - Cognitive
• Shake a bell (7/12)
• Using cause-&-effect toys (9/12)
• Pulling a toy with a string (9/12)
• Moving a car (12/12)

• Significant delay: No cause-and-effect play

by 12/12
Developmental Examination: Birth to
1 Year - Cognitive
• Object permanence

• Finding hidden toy (partially/ completely

covered with a cloth)
• Look for a partially hidden object: 6-8/12
• Search for toy which has been completely
hidden from view: 9-10/12
 Developmental Examination: Birth to
1 Year - Cognitive

• Categorisation

• Use common objects/toys on self/doll/mother

• At 10-12/12: infants use similar looking
objects/ toys in the same way eg moving toys
that look like a car.
Developmental Examination: Birth to
1 Year - Cognitive
• Show 'definition by use' (14/12)
• Eg using a hair brush to brush their hair

• Significant delay: not defining objects by

their use by 18/12
Developmental Examination: 1- 5 years
Gross Motor
• Beyond onset of walking at 12–13/12 main
purpose of motor examination is to detect
functional difficulties, impairment of
coordination, movement & balance
… rather than to ascertain the
developmental age of the child.

Sharma 2011
Developmental Examination: 1- 5 years
Gross Motor
• Arm & leg posture and coordination

12-18/12 arms held spread out rigidly

2 years, begin to move arms reciprocally
4 years arms by side, move reciprocally

• Toddlers walk with flat footed gait

• Heel toe gait emerges from 18/12
Developmental Examination: 1- 5 years
Gross Motor
• Running – 6 months after onset of walking
15-24 months
• Stand & walk on tip toe – 3 years
• Skipping – average 5 years
• Balance
Walking in a straight line by 3 years
Standing on 1 foot by 5 years
 Developmental Examination: 1- 5 years
• Non-verbal perceptual-cognitive development
• Fine motor, vision, cognition
• Influenced by visual perception, postural
balance & motor coordination.
• Handedness: appears from 2 years.
• Appearance before 12/12, will need further
evaluation
Pencil grasp
Non-verbal perceptual-cognitive development
1-5 years
Non-verbal perceptual-cognitive development
1-5 years

• Block (1- inch cube) construction tasks:

• Imitate a model
(child is shown how to do it)
• Copy a model
(child is shown a completed model)
Developmental Examination: 1- 5 years
Speech, Language & Communication

• Expressive
• Receptive (Comprehension)
• Speech Sound & Fluency
• 50% intelligible speech by 2 years
• Fully intelligible by 4 years
• Pragmatics
• 2 ½ - 3years can take turns in conversation
• 4 years, can converse skillfully
Developmental Examination: 1- 5 years
Speech, Language & Communication

• History:
• Does your child respond to your smile,
His/her name
“No”
Simple commands?
• What sounds does your child make in
response to you?
• Meaningful words?
 Developmental Examination: 1- 5 years
Speech, Language & Communication

• Understand familiar objects, family members?

• How does your child ask for things?
• Does he show things to you?
• Does he get your attention by pointing?

Note language spoken at home!

Developmental Examination: 1- 5
years – Expressive language
Developmental Examination: 1- 5 years
Speech, language & Communication
 Global developmental delay (GDD)
Delay in 2 ≥ domains of :
• gross/fine motor
• speech/language
• cognition
• social/personal and activities of daily living,
affecting children under the age of 5 years.

• Significant with deficit of at least 2 SD below age appropriate

mean on standardised assessment tests.
• Intellectual disability (ID): after 5 years when cognitive &
adaptive functions can be reliably tested.
History

• Significant family history, consanguinity

• Antenatal: maternal illness, ingestion of drugs,
alcohol, smoking.
• Birth: prematurity, perinatal asphyxia
• Postnatal: severe NNJ, hypoglycaemia or seizures
• Serious childhood infections, hospitalisation or
trauma
• Home environment, stimulation (environmental
deprivation)
Physical examination
• Head circumference, growth, dysmorphic
features, neurocutaneous markers
• Neurological abnormalities
• Full developmental assessment
• Observation of behaviour, social interaction &
play
Investigations
• Individualised based on clinical assessment.
• Presence of abnormal neurology, microcephaly, dysmorphism,
abnormal prenatal/ perinatal hx linked with higher yield.
• Visual & hearing assessment must be done.

Genetic tests
Molecular karyotyping
Specific tests: Fragile X (FMR1), Prader Willi or Angelman
syndrome
Array-based comparative genomic hybridisation (aCGH) as a
first-tier investigation - not readily available.
Refer to clinical geneticist when syndromic features are present.
Investigations
Metabolic & Biochemical
• Blood :
• Urea & electrolytes, Creatine Kinase, Thyroid Function
Test, Full Blood Count, Amino Acid, Acyl-carnitine Profile
• Urine:
• Organic Acid, Oligosaccharides, Creatine/GAA, Purine
and pyrimidine

MRI brain
• Higher yield when associated with microcephaly, non-
familial macrocephaly, rapid change in head
circumference, focal neurological signs or epilepsy.
EEG if history of seizures
 Management
Multidisciplinary approach
• Occupational therapy
• Speech therapist (if indicated)
• School placement : mainstream/inclusive/ integrated
class
• Extra training at government/private/NGO
intervention centres.
• Registration as Child with Special Needs
• Management of comorbidities
Thank you