Developmental Delay and

Warning Signs
 OUTLINE
1) Introduction
2) Normal development
• Each field of development
• Pattern of development
3) Developmental delay
• Stage, sequence, global/specific
• Chronological and Developmental age
4) Warning signs
Early brain development and its influence on life
Use it- or Lose it!
Introduction
 Child Development
• Child development is a dynamic process

• Normal development is determined by a

complex interplay between environmental
factors, genetic factors and acquired
pathology.
 Normal Development
4 areas / fields
• Gross motor
• Vision and fine motor
• Hearing, speech and language
• Social, emotional and behavioural
Gross motor examination: Birth to 1year
Significant Delay Age

Fisting of hands >3/12

Poor head control 4/12

Persistence of primary reflexes >6/12

Persistence of flexor hypertonia in the LLs (Popliteal angle >9/12

<150⁰)

Unable to sit independently with straight spine 10/12

Not walking 18/12

Fine Motor Development
 Fine motor is part of non-verbal
perceptual-cognitive development
Drawing
• Scribble to-and-fro: 15-18months
• Circular scribble: 2years
• Draw a man
• Copy shapes
• Grasp of crayon/pencil: 3 (50%)-4years (80%)

Handedness appears from 2-4years. Appearance

before 12months, prompt neurological
examination
Crayon or Pencil Grasp
 Gross Motor
• Delay in achievement of the gross motor
milestones may be an indicator of neurological
abnormalities and is sometimes associated
with a global developmental delay
 Possible Diagnosis
• Central causes
• Peripheral causes
• Orthopaedic causes
• Global developmental delay
Observation of language development:
Birth to one year
Non verbal communication:
• Vocalisation 3months
• Pointing to ask 9months
• Pointing to show 9-12months
• Conventional gestures eg. Wave goodbye,
blow a kiss 9-12months
 Expression
• Have a conversation with the child: school/
playtime
• Look at the picture and tell me what is
happening (describing narrative: 41/2- 5
years)
• Describe common objects/ concepts:'What is
a key/ friend?' (defining words: 52 months)
 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.
 Cognitive Play sequence

9 months
Object
18 months
oriented
Functional use 24- 30 months 3- 4 years
exploration
of real objects Symbolic use Pretend or
play (maturing
on self and of toys (eg. Toy, imaginative
eye- hand
others (eg. tea set, doll) play
coordination
spoon, brush)
and object
concepts)
 Social play sequence

6- 12 months
Social
4- 5 weeks 3- 3.5 years
anticipation 10- 15 months
Social smile Joint attention Social imitative
Lap games play (eg. role
(90% by 6 Points to show
(eg. peek- a- play)
weeks)
boo, pat- a
cake)
 Development of Attention
• Stage I- extreme distractibility. Attention shifts
from one object/ person/ event to another. Their
attention is held momentarily by whatever is the
dominant stimulus (Year 1)
• Stage 2- children can concentrate on a task of
their own choice. They are v. resistant to
interference by an adult (Year 2)
• Stage 3- can shift their full attention to speaker
and back to task with adult support. (Year 3:
‘single-chained attention’)
 Development of Attention
• Stage 4- Children begin to become able to
control focus of attention. Looks at an adult
only when the directions become difficult to
understand (Year 4: early ‘integrated
attention’)
• Stage 5- Can integrate verbal commands
related to a task. Attention span still short.
(Year 5: mature ‘integrated attention’)
KNOW THE NORMAL!!
 Reassuring signs of developmental
progress
Gross motor
• Walking by 10-14months
• Climbing by 2years
• Throwing / kicking a ball by 2.5years
• Pedalling a tricycle by 3years
• Hopping by 4years
• Skipping by 6years
 Reassuring signs of developmental
progress
Fine motor
• Stacking 3-4 blocks by 18months
• Completing simple form boards by 2years
• Threading beads by 3years
• Folding/Cutting a piece of paper by 3.5years
• Copying geometric shapes by 4years
• Printing legibly by 6years
 Reassuring signs of developmental
progress
Speech and language
• Speaking single words by 12months
• Word combinations by 2years
• Making clear, simple sentences, interested in
books abd stories by 3years
• Making clear conversation by 3-4years
• Reading by 5-6years
 Reassuring signs of developmental
progress
Social
• Dressing by 2years
• Self-feeding using cutlery by 3years
• Toilet-trained by day at 3years
• Playing cooperatively in groups
by 3.5years
• Playing team games by 7years
 Warning signs of development
Gross motor
• Head lag >4months
• Persistent hand fisting >6months
• Not walking >18months
 Warning signs of development
Fine motor
• Motor asymmetry: Hand dominance before
18months
 Warning signs of development
Speech and language
• Echolalia- repetitive imitation of speech- still
present by 3 years.
• Absolute failure to develop skills (eg multi-
syllable babble with intonation by 10 months)
 Developmental assessment tools
Screening
• Stycar developmental sequences

• Ages and Stages Questionnaires (ASQ)

• Denver

• Peds
 Assessment tools
• Bayley
How About School Children?
 Common presentations that signal
learning difficulties
Speech or language difficulties

Academic difficulties
•Reading
•Writing, spelling
•Arithmetic often not in isolation
•‘Slow learner’

Behaviour
•Poor self-regulation
•Socially disconnected child
•ADD/ADHD phenotype