Developmental milestones

Background

• Developmental problems in young children are common.
• Up to 15% of children under 5 years may have difficulty in one or more developmental areas:
  • Speech and language
  • Motor development
  • Social-emotional development
  • Cognitive development
• More severe developmental delay is often detected early.
• Mild to moderate developmental problems may not be recognised until preschool or school.
• Australian Early Development Index data showed up to 24% of children starting school had developmental vulnerability in one or more areas.
• GPs are well placed to identify developmental concerns early because they have regular contact with children and families.

Normal development

• Child development usually follows predictable pathways.
• Milestones are useful, but there is wide normal variation.
• Delay in one milestone may not be clinically significant.
• Concern increases when:
  • Several milestones are delayed
  • Delay persists
  • Development is uneven across multiple domains
  • There is regression

Risk factors for developmental delay

Biological risk factors

• Prematurity
• Low birth weight
• Birth injury
• Vision impairment
• Hearing impairment
• Chronic illness

Environmental and family risk factors

• Low parental education
• Parental mental illness
• Social isolation
• Poverty
• Poor housing
• Poor-quality services
• Limited access to health or developmental services
• Multiple risk factors often cluster together, especially with poverty.

Methods of early detection

Parental concern

• Parents are often the first to notice developmental problems.
• Parental concerns should not be ignored.
• If parents are concerned, there is a reasonably high chance that formal assessment will identify a developmental or behavioural issue.
• However, absence of parental concern does not guarantee normal development.
• Parent recall of milestones can be inaccurate and biased toward “normal”.

Milestone checklists

• Useful as an aide-memoire.
• Can reassure parents when development matches expected milestones.
• Should not be used alone.
• Over-reliance may lead to over-identification of delay because normal development can be uneven.

Clinical judgement

• Clinical judgement is important but insufficient alone.
• Experience does not reliably improve detection of developmental delay.
• Studies showed clinicians may miss a significant proportion of children with developmental problems if relying only on clinical judgement.

Developmental screening tests

• Screening tools can help identify children at developmental risk.
• They are not diagnostic.
• They may miss children with problems due to limited sensitivity.
• They may also incorrectly identify normal children due to limited specificity.
• Development is dynamic, with spurts, plateaus and occasional regression, so a single screening snapshot may be misleading.

Developmental surveillance

• Broader and more useful than one-off developmental screening.
• A longitudinal process involving repeated, purposeful review.
• Aims to:
  • Detect developmental delay early
  • Identify risk factors
  • Support early intervention
  • Promote optimal child development
• Includes:
  • Asking about parental concerns
  • Observing the child’s behaviour and skills
  • Reviewing development over time
  • Providing age-appropriate advice to parents
  • Using formal screening tools when appropriate
• Every GP encounter with a child is an opportunity to assess developmental progress.

Parent questionnaires

• Parent questionnaires can improve accuracy of developmental assessment.
• The article discusses Parents’ Evaluation of Developmental Status — PEDS.
• PEDS:
  • Suitable from birth to 8 years
  • 10-item questionnaire
  • Can be completed before or during consultation
  • Takes only a few minutes
  • Helps identify children needing further assessment
  • Helps guide advice and follow-up

Common developmental screening tools

• Ages and Stages Questionnaire — ASQ
  • Parent-completed
  • Covers communication, gross motor, fine motor, problem-solving and personal-adaptive skills
  • Age range: 4–60 months
• Brigance Screens
  • Directly administered tool
  • Covers language, motor, general knowledge and personal-social skills
  • Age range: 0–90 months
• PEDS
  • Parent interview questionnaire
  • Screens for developmental and behavioural concerns
  • Age range: 0–8 years
  • Useful as a developmental surveillance tool

Assessment of suspected developmental delay

• Children suspected of developmental delay should be referred for formal developmental assessment.
• Assessment is often multidisciplinary.
• May involve:
  • Paediatrician
  • Psychologist
  • Speech pathologist
  • Occupational therapist
  • Physiotherapist
  • Neurologist
  • Ophthalmologist
  • Social worker
  • Geneticist
• Paediatrician may assess:
  • Developmental history
  • Physical examination
  • Neurological examination
  • Possible aetiology
  • Need for investigations
• Possible investigations:
  • Chromosomal
  • Biochemical/metabolic
  • Neurological
• Aim is to define:
  • Child’s strengths
  • Child’s weaknesses
  • Developmental profile
  • Ongoing risk factors
  • Individualised intervention plan

Red flags — refer early

Refer directly for formal assessment if any of the following are present:

• Developmental regression
  • Child is going backward in one or more areas of development.
• Extreme prematurity
  • Especially <28 weeks gestation
  • Or birth weight <1500 g
• Conditions associated with high risk of developmental delay
  • Chromosomal abnormalities
  • Significant hearing impairment
  • Significant vision impairment
  • Dysmorphic features
  • Abnormal neurological examination
• High clinical suspicion
  • Concerning GP observation
  • Failed screening test
  • Major psychosocial or family risk factors
• Major persistent parental concern
  • Even if GP observation appears normal
• Suspicion of autism

Red Flags Early Identification Guide

The guide is meant to be used as a conversation tool with parents/carers.

The guide is not just a checklist. It should help the clinician explore:

• Development
• Functional ability
• Participation in daily life
• Parent/carer concerns
• Whether the child needs monitoring, advice or referral

One red flag does not always mean referral

• A single red flag does not automatically mean the child has a developmental disorder.
• The important question is:

Is this red flag affecting the child’s everyday functioning or participation?

Consider functional impact

Assess how the concern affects daily life, such as:

• Feeding
• Sleeping
• Toileting
• Dressing
• Playing
• Communicating
• Moving around
• Social interaction
• Childcare/kindy/school participation
• Family functioning

Referral is more likely needed if the issue affects function, safety, independence, learning, participation or family coping.

Red flags are not milestones

• The guide uses wording such as:
  • “does not…”
  • “not able to…”

This is intentional.

• These statements highlight absence or delay of a skill at the outer boundary of the expected developmental range.
• So they are warning signs, not routine milestones.

Do not use it as a milestone screener

• The guide should not be used to check whether a child has achieved every normal developmental milestone.
• It is designed to identify concerning delays or missing skills that may need further assessment.
• Normal milestone charts describe what most children do at certain ages.
• Red flags describe what would be concerning if absent by a certain age.

Suggested approach

• Take a developmental history.
• Ask parents whether they think development is normal.
• Check milestones.
• Observe the child in the consultation room.
• Use toys, blocks, drawing materials, puzzles and books to observe:
  • Social interaction
  • Play
  • Fine motor skills
  • Communication
  • Problem-solving
• Perform physical examination.
• Include neurological examination.
• Assess vision and hearing.
• Formally elicit parental concerns, using PEDS if useful.
• Seek information from other professionals if available:
  • Maternal and child health nurse
  • Early childhood educators
  • Teachers
• Consider a formal developmental screening test.
• Provide guidance to parents on promoting health and development.
• Arrange review if developmental status is unclear.
• Refer early if developmental delay is identified or risk is high.

Key milestones

Communication and language

• Social smile: 6 weeks
• Cooing: 3 months
• Turns to voice: 4 months
• Babbling: 6–9 months
• “Mama/Dada” without meaning: 8–9 months
• “Mama/Dada” with meaning: 10–18 months
• Understands several words: 1 year
• Single words: 12–15 months
• Combines two words: 14–24 months
• 50-word vocabulary: 2 years
• Uses pronouns: 2 years

Motor and adaptive milestones

• Follows eyes past midline: 6 weeks
• Bears weight on legs with support: 3–7 months
• Sits with support: 4–6 months
• Sits without support: 5–8 months
• Crawls: 6–9 months
• Pulls to stand: 6–10 months
• Walks holding on: 7–13 months
• Drinks from cup: 10–15 months
• Waves goodbye: 8–12 months
• Climbs stairs: 14–20 months
• Scribbles: 1–2 years
• Uses spoon: 14–24 months
• Jumps on spot: 20–30 months
• Rides tricycle: 21–36 months
• Bowel control: 18 months–4 years
• Day bladder control: 8 months–4 years
• Clear hand preference: 2–5 years

Developmental milestones by age/range

Age / age range	Communication and language	Motor and adaptive
6 weeks	Social smile	Follows eyes past midline
3 months	Cooing	—
3–7 months	—	Bears weight on legs with support
4 months	Turns to voice	—
4–6 months	—	Sits with support
5–8 months	—	Sits without support
6–9 months	Babbling	Crawls
6–10 months	—	Pulls to stand
7–13 months	—	Walks holding on
8–9 months	“Mama/Dada” without meaning	—
8–12 months	—	Waves goodbye
10–15 months	—	Drinks from cup
10–18 months	“Mama/Dada” with meaning	—
12 months / 1 year	Understands several words	—
12–15 months	Single words	—
14–20 months	—	Climbs stairs
14–24 months	Combines two words	Uses spoon
18 months–4 years	—	Bowel control
20–30 months	—	Jumps on spot
21–36 months	—	Rides tricycle
2 years	50-word vocabulary; uses pronouns	—
1–2 years	—	Scribbles
8 months–4 years	—	Day bladder control
2–5 years	—	Clear hand preference

Main take-home points

• Developmental delay is common.
• Early detection matters because child development affects lifelong health, learning and wellbeing.
• Do not rely on milestones, screening tests or clinical judgement alone.
• Parental concern is important and should be taken seriously.
• Developmental surveillance is the preferred GP approach.
• Refer early when red flags are present.
• GP management should combine:
  • History
  • Parent concerns
  • Observation
  • Examination
  • Screening tools when needed
  • Review over time
  • Early referral when appropriate.

reference: https://www.racgp.org.au/getattachment/cbd88cc8-4203-4205-a1e8-f1e8c6e6441c/Is-my-child-normal.aspx