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ASSESSMENT

economic and social conditions facing the family) genetic factors


and acquired pathology. These factors affect:
rate of maturation (e.g. myelination of the nervous system)
quality of a developing skill
genetic potential and whether it is realized.

Paediatric developmental
assessment
Ajay Sharma

Warning signs of abnormal development


Sound knowledge of typical child development makes it possible
to recognize when development is going wrong. It is worth considering the common presentations, developmental red flags, and
less common but important scenarios:
delayed rate of development beyond accepted normal range of
variation in one or more developmental domains (e.g. echolalia repetitive imitation of speech still present by 3 years)
absolute failure to develop skills (e.g. no canonical babble
multi-syllable babble with intonation by 10 months)
disordered developmental sequence (e.g. hyperlexia advanced
reading coexisting with delayed language)
motor asymmetry
qualitative concerns about emerging skills and abilities
developmental regression loss/plateauing of skills.

Tony OSullivan
Gillian Baird

A child mental health assessment would not be complete without


giving some thought to the childs developmental progress, just as
a paediatric developmental assessment should include the emotional and mental health of the child and family. The differential
diagnosis of a childs behavioural signs and symptoms includes
the possibility of organic and developmental disorders. Conversely,
behavioural and emotional disorders are much more common in
disabled children than the general child population. Whereas physical disease may be identified by laboratory tests, developmental
markers help to identify the developmental disorders. The child
psychiatrists toolkit must include competency to assess a childs
development, and a working knowledge of typical developmental
ages or milestones and red flag alerts ages that indicate significant delay requiring a referral for further assessment.
Preschool children with behavioural concerns may be referred
either to the local child and adolescent mental health service
(CAMHS) or the child development service. Following initial
assessment, some children will require referral from one team
to the other. A close working relationship is therefore essential
between the child development team and the CAMHS.

The developmental examination


History-taking should cover family history, social and family
environment, and the pre-, peri- and postnatal history. The clinician
should enquire into the parents concerns and seek information from
others who know the child (e.g. teachers, health-care staff).
It used to be thought that parents were not particularly good
informants of their childrens development, but this was partly a
result of asking too detailed questions about the age of acquisition of particular skills. Asking open-ended questions and then
requesting examples elicits the most reliable history. All parents
are very good at remembering whether or not they had concerns
and, if so, what those concerns were. They are particularly good
at observing current behaviour if the right questions are asked.
Parents interpretation of what their child does may be incorrect
(e.g. he understands everything I say) but their observations
are usually accurate (e.g. he will fetch his shoes only if they are
visible). It is not only parents who find accurate estimates of
comprehension difficult; so do professionals, unless a specific test
is done.
The assessor should ask for the parents view of causation. If
the child has a development disorder, reassuring the parents about
unwarranted concerns that they may have been responsible (e.g.
a belief that autism could be caused by the mother going out to
work, or being depressed) can reduce or remove their guilt. It
is particularly important that developmental problems are not
wrongly attributed to causes that are plausible but improbable,
such as MMR immunization or obstetric intervention. A traumatic
event, such as the umbilical cord around the neck of the child
at birth or a forceps delivery, alone is an unlikely aetiology of a
neurodevelopmental disorder. Nevertheless, it is valuable to establish, from independent enquiry, the reason for obstetric intervention (e.g. foetal distress), the condition of the baby at birth (e.g.
Apgar score <5 at 5 or 10 minutes), and any history suggestive of
neonatal encephalopathy (e.g. neonatal fits). The childs current
general health and a history of serious illnesses may be relevant to
understanding current abnormalities of behaviour or learning.

Child development
Child development is a dynamic process. From birth to 5 years, the
typically developing child is transformed from a wholly dependent infant into a relatively independent child at school entry:
mobile, dexterous, communicative, sociable and able to look after
her/his basic needs directly or to seek assistance where necessary. Normal development varies enormously. It is determined
by a complex interplay between environmental factors (maternal
health antenatally, in utero conditions, the birth process, nutrition,

Ajay Sharma is a Consultant Community Paediatrician at the


Sheldon Childrens Centre, London, UK. His main area of work is
neurodevelopmental paediatrics. His research interests include autism
and developmental disorders.
Tony OSullivan is a Consultant Community Paediatrician at Priory Manor
Child Development Centre, London, UK. His special interests include
childhood neurodisability, autism and transitional services for young
disabled adults leaving school.
Gillian Baird is a Consultant Developmental Paediatrician at Guys
Hospital, London, UK. Her special interests include developmental
paediatrics and autistic spectrum disorders.

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ASSESSMENT

Developmental differences exist between boys and girls (e.g. boys


tend to lag behind in language). Boys are, on average, 1 month
delayed in early language development compared to girls, but the
difference accounts for less than 2% of the variation within the
sexes and across ages. Gestational age should be considered when
seeing a child under the age of 24 months, and correction should
be made when assessing age-appropriate attainments, especially
in the first postnatal year.

or severe developmental delay, plateauing or regression of development would also require further assessment and investigations.
Gross motor
Delay in achievement of the gross motor milestones (Figure 1) may
be an indicator of neurological abnormalities and is sometimes associated with a global developmental delay. Although the correlation
between gross motor skills and global developmental level is weak,
there is usually an impact on assessment of skills that depend on an
intact motor system for their expression. Evaluation and interpretation of test needs to be accommodated accordingly.
Developmental assessment involves establishing the childs
progress in the sequence of development and a qualitative description of the childs mobility. Clinical interpretation requires combining this information with the findings of physical examination.

Observation and interactive assessment


A suitable selection of toys should be made available before meeting the family and interacting with the child. These should be
appropriate for the age of the child and the domains of development to be assessed; for example:
copying behaviour (bell) and understanding of cause and effect
(pop-up animals toy)
definition by use (cup/spoon, doll/brush) and symbolic understanding (doll/teddy/tea set)
fine motor/eyehand (bricks, crayons/pencil/paper, soft ball,
form boards, puzzles)
language and play (books with single pictures and stories, range
of everyday toy objects, large and miniature world toys).
Materials for play should be separate from those required for systematic tests of developmental attainment. Some developmental
assessment schemes are practical, taking 1520 minutes, and easy
to learn, though each has drawbacks as well as strengths. Most
children function better when an adult interacts with them, but time
should be allowed for free play. The childs inability to organize
the environment and generate ideas on their own is significant and
may not be noticed if an adult is too helpful. The child may not be
able to focus attention, in which case s/he will flit from one object
to another, or very repetitive play may be noted. One of the cardinal
rules of developmental assessment is to look not only at what the
child does, but also how s/he does it. The quality of response should
therefore be monitored as well as the actual achievement.

Visual behaviour, eyehand coordination and problem solving


Progressive coordination of maturing vision with head, body and
fine motor movements and an increasing ability to comprehend
and solve problems can be observed through creating a range of
test situations such as manipulation and use of pellet, rings, bell,
cubes, crayon/pencil, form boards or puzzles. The use of a variety
of such interesting and non-threatening test situations also helps
to tease out the relative contributions of experience, emotional
factors, motor and cognitive abilities. Childrens achievements in
this domain represent the precursor to later non-verbal problemsolving abilities, correlate well with overall intellectual ability
and may provide early markers for learning, psychological and
psychiatric disorders.
Co-ordinated eye movements and eyehead co-ordination: the earliest developmental sequence starts with fixing gaze on the mothers
face, then to following a face with eyes only, and then being able
to co-ordinate eyehead movements to turn head to follow visually
(Figure 2). Any abnormality of early visual behaviour should prompt
an early referral for ophthalmological assessment.
Eyehand co-ordination: in this developmental sequence the
infant shows visual awareness of hands and becomes increasingly
refined in combining vision with hand movements for reaching,
grasping, exploring and releasing objects (Figure 3).

Developmental domains
Developmental milestones or norms are a way of describing development in a sequential manner. Delays in some developmental
sequences may indicate an underlying neurological, visual or hearing problem that requires an early referral for further assessment.
These are indicated below as red flag ages. Children with moderate

Object concepts and relationships: this developmental sequence


reflects infants growing understanding of the nature of objects,
their relatedness to each other and in space (visuo-spatial) combined with a refined grasp and release ability (Figure 4).

Gross motor milestones


Developmental milestone

Mean age
(months)

Limit age red


flag (months)

Eyehead co-ordination milestones

Hands open most of the time (not


fisted)

Developmental milestone

Good head control when sitting.


No head lag when pulled to sit

Visually alert, orients to face

Any delay

Visually follows face

Any delay

78

10

Any delay

1113

18

Co-ordinates eye movements


with head turning

Sits independently
Walks alone

Limit age red


flag (months)

PSYCHIATRY 4:6

Mean age
(months)

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ASSESSMENT

Cube model copying milestones

Eyehand co-ordination milestones


Developmental milestone

Developmental milestone

Mean age
(months)

Mean age
(months)

Horizontal alignment of bricks

24

3-cube bridge

33

4-cube train with a chimney

39

3 steps with 6 cubes

4854

Reaches out and grasps objects on table surface


with a raking grasp

4 steps with 10 cubes

60

Transfers from hand to hand

Explores with index finger

Picks up a pellet/raisin between thumb and finger

Picks up a string between thumb and finger

10

Can release in a container

10

Has mature grasp

12

Has precise release without pressing on surface

13

Builds towers of 2 cubes

13

Builds towers to 3 cubes

16

Turns pages of book one page at a time

24

Holds objects briefly when placed in hands without


visual regard

Visually examines own hand


Reaches out with a two-handed scoop

controlled circular scribble and soon imitate others hand movements to draw a line and later a circular shape before they are
able to copy a pre-drawn circle or other shapes. Children gradually
refine their grasp 50% of children by the age of 3 years and 80%
by 4 years have a good tripod grasp of pencil (Figure 6).
Language and communication
Identification of language impairment needs to combine information from parents, and observations/assessment. Parents
reporting of expressive language is improved by making lists of
spoken words or phrases. As children have good understanding
of daily family routines, their language comprehension is often
overestimated by parents.
Infants show preference to the mothers voice within the first
few days of birth, make responsive cooing sounds within the first
few months and play lap games by 6 months. At around 9 months
the infant begins to combine vocalizations and gestures to convey
wishes, feelings, purpose and experience to others. At this stage,
some infants may imitate the sounds of certain often-repeated
family words. This is followed by the development of speech and

Object concepts and relationships milestones


Developmental milestone

Mean age
(months)

Permanence of object: looks for hidden object

Cast: drops repeatedly enjoys sound and


attention

Cause and effect: presses or pushes to activate a toy

Meansend relationship: pulls toy placed out of


reach with a string

Relating two objects together

10

Relating objects: enjoys putting things in and out of


container

10

Simple posting games: round shapes


Matches simple shapes
Matches three shapes with good scanning

Drawing milestones
Developmental milestone
Shape copying

12
1618
24

Copying cube models: this sequence shows childrens desire and


ability to copy from models (combining the processes of encoding, decoding and executing) moving on from vertical alignment
to horizontal alignment to making two- and three-dimensional
models (Figure 5).

Makes a mark on paper

15

Scribble

18

Copies lines

24

Copies a circle

36 (90% by 42 months)

Copies a cross

42 (90% by 48 months)

Copies a square

48

Copies a triangle

60

Copies a diamond

6672

Drawing a person

Drawing: children initially start jabbing pencil on paper just as


they relate any other two objects together. This is followed by their
interest in making a mark on the paper and then making vigorous
uncontrolled scribble. By the end of the second year they can do

PSYCHIATRY 4:6

Mean age (months)

Figure with head, other parts,


no body

36 (80% by 45 months)

Figure with head, body, limbs

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ASSESSMENT

Play and social behaviour


Observation of play offers a unique opportunity to look at a number
of developmental sequences as they come together to create an
increasingly complex tapestry of play (Figure 8).

language understanding and expression with a considerable variation between children (Figure 7).

Language and communication milestones


Developmental milestone

Mean age
(months)

Range (months)

69

Development of attention
Children pass through a number of different developmental
stages as their attention and listening skills improve. Below are
the 6 main stages.
Stage 1 children at this stage are very distractible. Their attention is held momentarily by whatever is the dominant stimulus
(Year 1).
Stage 2 at this stage children can concentrate on a task of
their own choice. They have to ignore all other things in order to
focus on this one task. Children are very resistant to interference
by an adult (Year 2).
Stage 3 By now, children are beginning to allow an adult to
shift them from one task to another. Attention must still be fully
gained before changing focus (Year 3: single-channel attention).
Stage 4 Children now start to become able to control their
own focus of attention. They move gradually towards needing
to look at an adult only when the directions become difficult to
understand (Year 4: early integrated attention).
Stage 5 At this stage, children are usually entering school.
They can now perform an activity while listening to the teacher
giving directions (Year 5: mature integrated attention).
Stage 6 This is a mature stage where attention skills are flexible and sustained for lengthy periods.

Comprehension/receptive language
Understands no/bye
Recognizes own name

610

Understands familiar names

12

1015

Definition by use: using objects

by 15

Giving objects on request

by 15

Points to body parts on self/carer

15

1218

Points to body parts on doll

18

1521

Identifying objects on naming

by 24

Follows a 2-step command

24

1827

Functional understanding

30

2133

Understands prepositions (in/on)

24

1833

Understands prepositions (under)

30

2439

Understands action words


(e.g. eating, sleeping)

by 36

Understands simple negatives

36

3042

Understands comparatives

42

3648

Follows 2 instructions (4 ideas)

42

3648

Understands complex negatives

48

4260

Follows 3 instructions (6 ideas)

54

4866

Physical examination
The physical examination is generally left to the end of the assessment, as the child may become upset and this would interfere
with a subsequent developmental examination. The following key
guidelines should be observed.
Motor function determine whether the child has a motor
disorder or if any delay is part of global learning difficulty. Observe
movement patterns and posture during the appointment and developmental examination, when the child is walking, speaking and
handling material. This should give a good idea of the nature and
extent of any motor problem. Formal examination of tone, reflexes
and power is largely confirmatory.
Symmetry Compare the two sides of the body and determine
the childs hand preference. The motor skill, tone reflexes or limb
size may be significantly asymmetrical, suggesting hemisphere
dysfunction or other pathology.
Growth measure the head circumference, height and weight
and plot on a centile growth chart. Compare the consistency of
the parameters and assess the growth rate. If concerned about
the head size, it may be advisable to measure the parents head
circumference (familial inheritance is the usual reason for an
excessively large head, and there may be inherited reasons for
microcephaly).
Sight Examination of the optic discs and fundi will usually
not be possible, but it may be necessary to arrange this via the
ophthalmologist or paediatrician (e.g. for septo-optic dysplasia,
raised intra-cranial pressure).
Malformation look for dysmorphic features and congenital
malformations. They may suggest a particular syndrome or aetiol-

Expressive language and non-verbal communication


Jargon

12

1015

Syllabic and tuneful babble

69

Pointing to demand

Pointing to share interest

10

914

One word

12

1018

26 words

15

1221

720 words

21

1824

50+ words

24

1827

2 words joining

24

1830

200+ words

30

2436

34 words joining

30

2536

Speech usually understandable

30

3042

Question words

36

3042

Pronouns

42

3648

Uses conjunctions (and, but)

48

3654

Sentences of 5+ words

48

3654

Complex explanations and


sequences

54

4866

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ASSESSMENT

Developmental sequences involved in play


Cognitive play sequence
18 months

9 months
Object oriented
exploratory play
(maturing eyehand
co-ordination and
object concepts)

2430 months

Functional use of real


objects on self and
others (e.g. spoon,
brush)

Symbolic use of toys


(e.g. toy, tea set, doll)

34 years
Pretend or imaginative
play

Social play sequence


45 weeks

612 months

Social smile
(90% by 6 weeks)

Social anticipation
Lap games
(e.g. peek-a-boo,
pat-a-cake)

1015 months
Joint attention
Points to show

33.5 years
Social imitative play
(e.g. role play)

ogy (e.g. fetal alcohol syndrome).


Skin carefully examine the skin for pigmented and hypopigmented spots. Where there is significant developmental delay,
and especially with epilepsy, a Woods ultraviolet light examination should be performed (for ash-leaf skin patches in tuberous
sclerosis) or arranged.

Framework for evaluation of developmental delay and planning


investigations
Assessing developmental delay
It is helpful to consider moderate delay to be a developmental
level where the age equivalent for achieved milestones is between
two-thirds and half of chronological age (CA), and severe delay
where milestones are equivalent to 50% or less of CA (allowing
for prematurity up to 2 years). These examples are for ages commonly seen at referral for developmental concerns:
At 8 months:
moderate delay developmentally 45 months (e.g. not sitting
without support, not rolling, no single-syllable babble)
severe delay developmentally less than 4 months (e.g. not
lifting head).
At 2 years:
moderate delay developmentally 1218 months (e.g. no linkage of words, less than 10 words and not following simple commands)
severe delay developmentally less than 12 months (e.g. no
single words, not walking, no functional play, no joint attention).
At 3 years and 6 months:
moderate delay developmentally 2128 months (e.g. just
linking words, less than 50 words, minimal concepts, cannot
draw circle)
severe delay developmentally less than 21 months (e.g. single
words or less, simple commands, but no concepts).

Developmental diagnosis and management


The outcome of the examination is a profile of developmental
abilities and areas of difficulty, alongside the behavioural and
mental health assessment.
The combined picture may point to a specific developmental
delay or disorder (e.g. learning disability, autism).
Laboratory investigations may be indicated to look for specific
medical causation. This also applies to an analysis of behavioural
presentations.
Specific concerns may also require referral for specialist assessments (e.g. referral to speech and language therapy, occupational
therapy, physiotherapy, or the community paediatrician).
Close links between CAMHS and the child development team
aids such liaison greatly. The community paediatrician and the
whole child development team will be available to discuss concerns. Referral (e.g. for language assessment) can be very helpful
indeed for both family and psychiatrist.
Ongoing management may require shared care through partnership with one or more teams within the child development
service.
A clear management plan should be included in the assessment
report incorporating referrals and further investigations; plan for
who is to review and, where relevant, a named key worker for the
family.

PSYCHIATRY 4:6

Planning investigations
A differential diagnosis will be based on the results of the developmental assessment, and provides a set of hypotheses about
aetiology. Investigations are planned to test the most reasonable
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ASSESSMENT

Investigations that should be considered in moderate and severe developmental delay


8 months

24 months

42 months

moderate

severe

moderate

severe

moderate

severe

Chromosomes

Fragile X

CK (boys)

Urate

T4/TSH#

Plasma AAs#

Toxoplasma

CMV

FBC
Viral antibodies

Rubella
HIV

Needs to be considered on an individual basis

Urine

CMV

OAs$

MPS

Woods light

* Early in presentation, it is reasonable ro review progress for a short period (e.g. 3 months) and to do investigations as in
moderate column if moderate delay persists over time, with or without intervention.
# If neonatal results available, then use them. If not, repeat.
$ Urine organic acids if child shows moderate delay plus any feeding problems/vomiting.
CK, creatinine kinase; T4/TSH, thyroxine/thyroid stimulating hormone; AA, amino acids; FBC, full blood count; CMV,
cytomegalovirus; OA, organic acid; MPS, mucopolysaccharides.
Reproduced with permission from Talukdar K, OSullivan T. Extract from unpublished work, 2004.

hypotheses. The laboratory test most likely to yield positive results


is chromosomal analysis. Before finalizing the plan, consider:
what is the likelihood of the condition under investigation being
present?
do children with the condition under investigation present in
this way?
are there benefits from an early diagnosis: would it alter management and what bad outcomes would be prevented?
will the diagnosis improve the parents ability to plan and
cope?
The answers to these questions may not always be to hand but
their purpose is to focus investigation and to remain alert to the
possibility of over-investigating a child. However, there is also the
danger of under-investigating. If impairments are not detected
early then other disabilities may result, which may be a source
of resentment in parents when a late diagnosis is made, e.g. late
diagnosis of hearing loss associated with failure to develop oral
language adequately. Even more distressing is the scenario where a
delay in genetic diagnosis may have led to the parents going ahead
with a subsequent pregnancy, which they would have avoided had
they known that their delayed child had an autosomal or X-linked
recessive condition. A balance needs to be struck between these
two approaches the conservative and the aggressive when
investigating the child with developmental delay. A cause is more

PSYCHIATRY 4:6

likely to be found in a child presenting with severe developmental delay (80%) than in one with moderate developmental delay
(45%). It is beyond the scope of this chapter to discuss the causes
of developmental delay (termed mental retardation in the USA).
Figure 9 offers guidance on the planning of investigations for
developmental delay.

FURTHER READING
Baron-Cohen S, Wheelwright S, Cox A et al. The early identification of
autism: the Checklist for Autism in Toddlers (CHAT). J R Soc Med 2000;
93: 5215.
Bee H. The developing child. Boston, USA: Alleyn and Bacon, 2000.
Capute A J, Pasquale J A. Developmental disabilities in infancy and
childhood. Baltimore, USA: Paul H Brooks, 1996.
Egan D F. Developmental examination of preschool children. Oxford: Mac
Keith Press, 1990.
Frost M, Sharma A. From birth to five years Mary D Sheridan (Revised
and updated). London: Routledge, 1997.
Law J, ed. The early identification of language impairment in children.
London: Chapman Hall, 1992.
Salt A, Gringras P, Dorling J, Hartley L. Developmental delay. In: Moyer V
A, Elliott E, Davis R et al. eds. Evidence based paediatrics and child
health. BMJ 2000; 11724.

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