Delayed Development
Principles of Development
• Development is a continuous process from conception to maturity.
• The rate of development may vary in an individual child, but the sequence
of development is same in all children
• The development always proceeds in cephalocaudal direction. A child will
learn first to hold his head, followed by sitting & then walking. This sequence
from head to toe will always remain the same, though the age at which
each milestone is achieved may differ.
• Development is related to maturation, myelination of the nervous system. The
normal development need an intact anatomical & functionally normal central
nervous system (CNS).
Anatomical CNS malformations like anecephaly, meningomyelocele are
commonly associated with developmental problems.
H/o hypoxic ischemic encephalopathy, CNS infection, kernicterus,
hypoglycemia or any other metabolic cause may have delayed
development. Such insult during first 5 years of life (while brain is
growing) may play an important role in its development.
• Persistent primitive reflexes beyond the age at which they should have
disappeared, indicates abnormal development. e.g. Moro’s reflex disappears
by 3 months of age, but presence of Moro’s reflex at 7 month of age is
suggestive of abnormal development.
• Development in one field may not be parallel to that in other fields & this is
termed as developmental dissociation. It helps to decide anatomical
localization of the pathology.
• Developmental delay should be differentiated from developmental regression
in which there is loss of mile stones which already child had achieved.
Domains of Development
• Gross Motor.
• Fine Motor.
• Language (speech & hearing).
• Personal & social milestones.
Important Gross Motor milestones
Age Milestone
3 months Head control (Neck Holding)
5 months Rolling over (turning from supine to prone & prone to
supine)
6 months Sitting with support
7 months Sitting without support
9 – 10 months Standing with support
12- 13 months Standing to rise & walking without support
18 months Running
2 years Climbing up stair using two feet per step. Kicking a ball
2.5 years Jumping
3 years Riding a tricycle, standing on one leg momentarily
4 years Hopping on one foot. Climbing up & down stairs with
one foot per step.
5 years Skipping & jumping
Important Fine motor milestones
Age Milestones
6 weeks Follows face in midline & turns head towards moving object
4 months Reaches for toy or red ring or rattle in front with both
hands
6 months Reaches for objects by one hand only (palmar grasp)
7 months Transfers objects from one hand to another
9 months Pincer grasp (picks up a pellet with thumb & index finger)
12 months Throwing the object away
15 months Able to feed himself with spoon without spilling
18 months Builds tower of three cubes & scribbles
2 years Vertical & circular strokes
3 years Copies a circle
4 years Copies a square & cross
5 years Draws a triangle
Important Personal & Social development
Age Milestones
4 weeks Alert to sound
2 months Social smile
3 months Recognizes mother
6 months Smiles at reflection in the mirror
9 months Waves ‘Bye Bye’
12 months Plays simple ball games
15 – 18 months Holds spoon & feeds without spilling
18 – 24 months Copies parents tasks
3 years Shares toys & knows name & gender. Dry by night
4 years Attends the toilet alone
5 years Helps in house hold works, dresses & undresses
Important Language mile stone development
Age Milestones
4 weeks Turns head to sound
3 months Vocalize & cooing sounds
6 months Speaks monosyllables (ma, ba)
7 – 8 months Turns to soft sound out to sight
9 months Speaks bi syllabus (mama, baba)
12 months Two words with meaning
18 months Ten to fifteen words with meaning. Shows two parts of body
2 years Uses 2- 3 words to make phrases
3 years Speaks in sentences, tells short stories
Red Flag Signs for Developmental Delay
• Gross motor delay
Tone abnormalities: Hypertonia, Hypotonia, Dystonia.
Asymmetry.
Dysmorphism.
Persistent primitive reflexes.
Abnormal DTR, clonus.
Hand preference in < 18 months.
Abnormal gait.
• Fine Motor delay
Immature grasp till 1 year of age.
Poor manipulation of objects till 1 year of age.
Excessive clumsiness after 2 years.
Assistance in dressing beyond 3 years.
Difficulty in buttoning the shirt by 4 - 5 years.
• Speech Delay
No babbling: 12 months.
No single words: 16 months.
No 2 word phrases: 24 months.
Regression of language skills at any age.
Loss of social skills.
• Cognitive delay
Difficulty in following simple instructions.
Difficulty in learning new skills.
Poor expressive language.
Behavioral problems.
Poor self help & increased dependency.
• After performing developmental assessment as per standard methods, if there
is abnormal development, identify if there is delay, deviation or dissociation.
Global developmental delay is identified if the developmental quotient
(DQ) is < 70 in one or more domains.
Deviation is identified, if the child develops skill out of the usual
sequence. e.g. hand preference by 12 months. This is characteristics of
cerebral palsy. Check for other markers of cerebral palsy.
Dissociation is identified if the development is different in different
developmental spheres. e.g. autism.
Conditions mimicking developmental delay
• Transient tone abnormalities.
• Less environmental stimulation.
• Vision & hearing loss.
• Epilepsy.
• Autism.
• Child with chronic illness.
• Severe Acute malnutrition.
• Muscular disorders.
• Neurodegenerative disorders.
• SOL of brain.
• Hydrocephalus.
• Metabolic disorders.
• Genetic syndromes.
Marker for cerebral palsy in infancy
• Acquire handedness before age of 1 year.
• Cross midline to pick up a toy.
• Persistent fisting after 4 months of age.
• Long roll rather than segmental roll.
• Leg scissoring when picked up.
• Persistent primitive reflexes.
Causes of Global Developmental Delay
• Prenatal
Genetic - Chromosomal defects,
Acquired: Maternal infections, nutritional deficiencies, fetal alcohol
syndrome, maternal substance abuse.
• Perinatal
Hypoxic Ischemic Encephalopathy.
Infections.
Stroke.
Hypoglycemia.
Metabolic disturbances.
• Postnatal
Infections leading to meningoencephalitis.
Kernicterus.
Trauma.
Stroke.
Severe malnutrition.
Psychosocial deprivation.
Dr. Baldev S. Prajapati
M.D. (Ped); D. Ped. Gold Medalist
FIAP,MNAMS.
HOD & Professor,
GCS Medical College, Hospital And
Research Centre, Ahmedabad