Developmental Milestones & Red Flags

1. Developmental Milestones & Red Flags Kathryn R. Oubre, M.D. 3/13/08

2. Gross Motor DevelopmentEarly Reflex Patterns Moro: disappears by 4 months Asymmetrical tonic neck reflex: appears at 2-4 wks; disappears by 6 months

3. Primitive Reflexes & Protective Equilibrium Responses

4. Postural Reactions • Head righting: infant’s ability to keep the head vertical despite a tilt of the body • Protective equilibrium response: if child pushed laterally, flexes trunk toward the force to regain center of gravity while one arm extends to protect against falling (lateral propping) • Parachute response: outstretch of both arms and legs when the body is abruptly moved head first in a downward direction

5. Head control • Neonates- minimal control of neck flexors • 5-6 months: infant anticipates direction of movement of the pull-to-sit maneuver and flexes neck before the shoulders begin to lift • Red flag: Be concerned if there is no head control by 4 months! Look what I can do, Mom!

6. Posture in Prone Position Newborn lies tightly flexed with the pelvis high and the knees under the abdomen 3-4 months: keeps the pelvis flat and lifts head & shoulders

7. “My neonate rolled off the bed!” • 3-4 months • Rolls prone-to-supine • 5-6 months • Rolls supine-to-prone • Because of new “Back to Sleep” program, supine-to-prone may preceed prone-to- supine

8. Time for the “Exersaucer” 4 months: pushes with feet when in standing position

9. Development of Sitting Posture • 1-2 mo: head held up intermittently, but lacking trunk control • 2-3 mo: raises head & shoulders well; lacks control of thoracolumbar area • 3-4 mo: need support in lumbar area to sit • 5-6 mo: holds head erect and spine straight • 8 mo: gets into sitting position • Be concerned if a child does not sit without support by 7 months! 6 months old sits alone, props on hands

10. Watch out! I’m mobile now! 5-6 mo: commando crawl 9-10 mo: cruising 6-9 mo: creeping 11.7 mo: median age of walking 3 steps alone; range: 9-17 mo

11. Complex Gross Motor Patterns • 13 ½ mo: walking well • 15 mo: stoops to floor and recovers independently • 18 mo: stairs with hand held; runs • 22 ½ mo: throws ball overhead • Be concerned if a child is not walking by 15 mo or running by 24 mo

12. Complex Gross Motor Patterns • 2 y/o: • Runs well • Kicks ball • Jumps with 2 feet off floor • Removes clothing • 3 y/o: • can balance on one foot for 1 second • Broad jumps • Pedals tricycle

13. Complex Gross Motor Patterns • 4 years • Hops • Balances on one foot for 20 seconds • 5 years • Can catch • Skips alternating feet • Dresses & undresses • 6 years • Rides bicycle without training wheels

14. Fine Motor Development Reflexive palmar grasp- disappears at 1 month 2-3 mo: midline hand play & Sucking on thumb/finger 4-5 mo: use hands as entire units to draw objects toward them Be concerned if a child does not have open grasp & midline activity by 4 mo or reaching by 6 mo

15. Learning to Use Our Hands • 4 months • Reaches for objects • 6 months • Rake • Transfers objects hand to hand • 9 months • Feeds self with fingers • Holds two objects one at a time; bangs together • Pat-a-cake in imitation • Immature pincer

16. Learning to Use Our Hands • 12 months • Neat pincer • 2 years • Washes and dries hands • 3 years • Helps in dressing (unbuttons clothes, puts on shoes)

17. Fine Motor Tasks: Blocks • 18 months • 2 cube tower • 24 months • 6 cube tower • 3 years • 10 cube tower • Bridge

18. Fine Motor Tasks • 15 months- imitates/scribbles spontaneously • 2 years- imitates vertical/circular strokes • 3 years- copies circle • 4 years- copies cross • 5 years- copies square • 6 years- copies triangle Be concerned if a child shows hand preference in the first year of life

19. Drawing a Person • 4 y/o includes eyes, nose, mouth, hair, and legs • Receives one point for each of the following features: two eyes, two ears, a nose, etc. • Each point converts to the value of ¼ year added to a base age of 3 years

20. Cognitive Development • 4-8 mo: early object permanence • track objects visually through vertical fall • search for partially hidden toy • explore toys by mouthing, shaking, banging • When mouthing of toys persists as predominant mode of exploration after 12-18 mo, assessment of cognitive function is warranted • Term newborn • Fixes on faces 9-12 in from the face • Tracks objects horizontally at least 30

21. Cognitive Development 9-12 mo • Object permanence: awareness that objects continue to exist even when no longer visible 1 y/o: aware that different objects have different purposes (comb to hair) 15 m/o: mature means-end reasoning (ex: turns knob on mobile to make it play) 18 m/o: can deduce location of an object even if they haven’t seen it hidden from view; symbolic thinking; discipline starts to become an issue; imitates household tasks

22. Cognitive Development • 2nd year of life: pretend play • Preschoolers- think that # and quantity vary with appearance • School age children- increased logic but limited by hypothetical/abstract • Adolescents- extend logical principles to increasingly diverse problems

23. Language Milestones

24. Language Milestones

25. Language Milestones

26. Language Red Flags • Failure to orient to sound or absent babbling may indicate a hearing deficit • Get a hearing test on any child who does not have a single word by 15 mo or several single words by 18 mo • Lack of protodeclarative pointing or pointing for naming may indicate a pervasive devt d/o • Refer any child who is not combining words and at least 50% intelligible by 2 y/o for a hearing and speech assessment

27. Delays in Development of Intelligibility • Lack of intelligible speech by age 3 • Frequent omission of initial consonants after age 4 • Continued substitution of very easy sounds for harder ones after age 5 • Persistent articulation errors after age 7 • Stuttering/rapid speech beyond age 4 If any of these delays persists for 6 months or more, a referral should be initiated

28. Social Development: Responsivity • Neonates- fix visually on faces in preference to other sights • Evident during the first few days of life • Responsive smile develops soon thereafter • Social smile- innate; appears at 4-6 w/o • Smiling appears in infants from all cultures at about the same time Be concerned if a child does not focus on Mom’s face at 1st visit or have a social smile by 8 w/o

29. Development of Attachment • First 6 mo: indiscriminate in their social behavior • By 6-8 mo, know that parents exist when out of sight; stranger awareness • Stranger anxiety- may occur in infants who haven’t had routine care from other caregivers • Infants who have developed a secure attachment to their parents show signs of recognition and pleasure when reunited with them • Explore at greater distances from parents; return for verbal encouragement/eye contact/hug

30. Development of Social Play Up to 3 y/o: Parallel play 2 y/o: symbolic play 3y/o: -cooperative play -pretend play -impulse control 4-5 y/o: -peer play -domestic role playing -dress-up -imaginary friends

31. Red Flags • Be concerned if a child does not show pride in accomplishments by 12 m/o or social relatedness by 15-18 m/o • Be concerned if a child has excessive temper tantrums, hyperactivity, or persistent poor transitions at 24 m/o

32. Development of Sense of Self • 6-9 m/o: emerging identity- displays interest in their own mirror images • 1-2 y/o: feeds self, manages cup (by 15 mo) & spoon (by 18 m/o); enjoys own accomplisments (claps for self); discipline becomes a challenge • 18 m/o visit: talk about toilet training • 2-3 y/o: increased independence in verbal abilities; increased awareness of body sensations; modest skills in clothing self; begin toilet training