Normal development
Reham Ibrahim Abdelmageed
Associate professor of pediatrics
Ain Shams University
Learning objectives
Understand the principles of development
Recognize factors affecting development
Understand developmental milestones for children from birth to age 5
Identify “red flags” or delays to watch for in children who are not meeting
developmental milestones
To understand how to assess development
Recognize causes of developmental delays
Development is a continuous process from
Principles conception to maturity
Development refers to a progressive increase
of in skills and capacity of function
Children tend to acquire such skills in a
Developme sequential pattern and within certain age
ranges; this is the so-called typical or normal
nt
development, but the rate of development
varies from child to child
Development is intimately related to the
maturation of the central nervous system
Certain primitive reflexes, like the grasp reflex
and walking reflex, have to be lost before the
appropriate milestone is achieved
Principles of
Development
Development proceeds in
cephalocaudal and proximodistal
directions
Cephalocaudal direction: the child
gains control of the head first,
then the trunk, and then the legs
Control of limbs in a proximodistal
direction where hand use is learnt
before finger control
Developmental milestones
are set of functional skills or
age-specific tasks that most
children can do at a certain age
range
Principles of A pediatrician uses milestones
to help ckeck how a child is
Developmen developing
t
Every child is unique !
Principles of Development
Developmental delay
occurs when a child does
Specific
not reach typical
Global developmental developmental delay
developmental
delay, delay in two or (motor or
milestones at the
more domains speech&language), delay
expected age compared
in single domain
to peers from the same
population.
Factors affecting Development
Genetic Perinatal Psychosocial &
factors Environmental
Factors
• Chromosomal • Factors
Prematurity,
abnormalities • Quality of parent-
birth asphyxia.
(e.g., Down • jaundice/ child interaction,
syndrome, stimulation, and
kernicterus
Fragile X) • bonding
Complications
• inborn errors of • Socioeconomic
of labor and
metabolism Postnatal status
Prenatal factors delivery.
Biological Factors • Neglect, abuse
• Maternal health: • Maternal depression
• Nutrition
malnutrition,
infections (e.g., (malnutrition,
rubella, CMV), iron and iodine
chronic illnesses. deficiency)
• • Infections
Teratogens:
alcohol, drugs, (meningitis,
radiation, toxins. encephalitis)
• • Chronic diseases
Placental
• Trauma or
insufficiency,
intrauterine acquired brain
injury
o Gross motor
o Fine motor
Developmental o Social
domains o Speech
Gross motor skills
At birth: Flexed posture& head lag
Gross motor skills
At 2 months: Raises head & chest when lying prone
At 4-5 months: Head support (no head lag)
Gross motor skills
At 5-6 months: Sits with support
At 6-7 months: Sits without support (straight back) & rolls over (prone to s
Supine)
Gross motor skills
At 7-8 months: Crawls
At 9-10 months: Creeps
Gross motor skills
At 9 months: Stands holding onto objects
At 12 months: Walks with one hand held
Gross motor skills
At 13-15 months: walks unsupported
At 18 months: Runs
Goes upstairs with support
Gross motor skills
At 24 months: Goes up & down stairs with two feet per step
Kick a ball
At 2.5 yrs : Jumps with both feet in place
Gross motor skills
At 3 yrs:
-Goes up & down stairs with alternating feet
-Ride a tricycle
-Stands on one foot briefly
Gross motor skills
At 4 yrs: Hops (on one foot)
At 5 yrs: Skips (on one foot)
Gross motor milestones (0-5
years)
Age Milestone
2 months Raises head & chest when lying prone
4-5 months Head support
5-6 months Sits with support
6-7 months Sits without support
7-8 months Crawls
9 months Creeps, standing holding onto objects
12 months Walks with one hand held
13-15 months walks unsupported
18 months: Runs, goes upstairs with support
24 months: Goes up & down stairs with two feet per step, kicks a ball
2.5 yrs Jumps with both feet in place
3 yrs Goes up & down stairs with alternating feet, rides a tricycle, and stands on one foot
briefly
4 yrs Hops on one foot
5yrs Skips on one foot
Fine motor skills
At 2 months: follows objects to midline.
At 4 months: Grasp a rattle
At 5-6 months: Reach for objects, grasp large objects, and mouth
At 6-7 months: Transfers objects from hand to hand
Fine motor skills
At 9 months: Finger food, immature pincer grasp
At 12 months: Mature pincer grasp
Fine motor skills
At 15 months: Uses a cup well, builds a tower of two blocks
At 18 months: build a tower of three blocks
At 2 yrs: Uses spoon and fork well, builds a tower of six blocks, and
draws a vertical line
At 2.5 yrs: builds a tower of eight blocks, and draws a horizontal
line
Fine motor skills
At 3 yrs: Put on shoes and socks, copy circle
Build a Tower of 9 cubes, and build a bridge
At 4 yrs: Dresses self except for tying, copy cross and square
Build a Tower of 12 cubes
At 5 yrs: Ties shoe lace and knows right and left and prints letters
Build a Tower of 15 cubes, copy triangle
Fine motor milestones (0-5
years)
Age Milestone
2 months follows objects to midline
4 months Grasp a rattle
5-6 months Reach for objects, grasp large objects, and mouth
6-7 months Transfers objects from hand to hand
9 months Finger food, immature pincer grasp
12 months Mature pincer grasp
13-15 months Uses a cup well, builds a tower of two blocks
18 months: build a tower of three blocks
24 months: Uses spoon and fork well, builds a tower of six blocks, and draws a vertical line
2.5 yrs builds a tower of eight blocks, and draws a horizontal line
3 yrs Put on shoes and socks, copy circle
Build a Tower of 9 cubes, and build a bridge
4 yrs Dresses self except for tying, copy cross and square
Build a Tower of 12 cubes
5yrs Ties shoe lace and knows right and left and prints letters
Build a Tower of 15 cubes, copy triangle
Social skills
At 2 months: Social smile
Follow things with eyes and turn to sound
At 4 months: Recognizes mother by facies
At 5-6 months: Recognizes family
At 6-7 months: Recognizes a stranger, stranger anxiety at 9
months
At 8-9 months: Responds to his name
Social skills
At 9 months: Enjoys peek-a-boo
Waving “bye-bye”
At 12 months: Points to get desired objects
At 15 months: Showing affection by
hugging, kissing, and cuddling familiar
people.
At 18 months: Imitating or copying parents’
tasks
One-step commands
Pretend (symbolic) play
At 2-3 yrs: Two- to three-step commands
Simple games, parallel playing
Social skills
At 4 yrs: Group playing
share toys
At 5 yrs: Choose friends
Plays competitive games
with rules (hide and seek)
Social skills development (0-5
years)
Age Milestone
2 months Social smile , follow things with eyes and turn to sound
4 months Recognizes mother by facies
5-6 months Recognizes family
6-7 months Recognizes a stranger
9 months stranger anxiety
Responds to his name
Enjoys peek-a-boo
Waving “bye-bye”
12 months Points to get desired objects
15 months Showing affection by hugging, kissing, and cuddling familiar people.
18 months: Imitating or copying parents’ tasks, One-step commands, Pretend (symbolic) play
24 months: Two-step commands
Simple games, parallel playing
3 yrs Two- to three-step commands
Simple games, parallel playing
4 yrs Group playing, share toys
5yrs Choose friends, Plays competitive games with rules (hide and seek)
Speech skills
At 2 months: Makes sounds other than crying
At 4 months: Coos (vowel sounds, oooo, aaah)
At 6 months: Babbles (repetitive consonant-vowel
sounds, e.g., “ba-ba”)
At 9-10 months: Says nonspecific “mama/dada”
At 12 months: says mama/dada (specific)
At 15 months: Says 3–6 words
Speech skills
At 18-24 months: Says 2-word phrases
At 2-2.5 yrs: Say 3-word phrases
At 3 yrs: Give name, age, sex
3-4-word sentences
At 4yrs: Tell a story, past tense
Identifies several colours, counts 1-10
At 5yrs: Language becomes complex (6-8 word
sentence)
Uses future tense
Defines simple words
Speech and Language milestones(0-5
years)
Age Milestone
2 months Makes sounds other than crying
4 months Coos (vowel sounds, oooo, aaah)
6 months Babbles (repetitive consonant-vowel sounds, e.g., “ba-ba”)
9-10months Says nonspecific “mama/dada”
12 months says mama/dada (specific)
15 months Says 3–6 words
18 -24 months: Says 2-word phrases
2-2.5 yrs: Say 3-word phrases
3 yrs Give name, age, sex
3-4-word sentences
4 yrs Tell a story, past tense
Identifies several colours, counts 1-10
5yrs Language becomes complex (6-8 word sentence)
Uses future tense
Defines simple words
Developmental Red Flags (0-5
years)
Age Red flag
2 months Can not raise head when prone, Does not alert to voice
4 months Can’t hold head steady, Doesn’t coo or make sounds, Lack of smiling
6 months Not starting to babble, Not reaching for & grasping toys, Not holding head with control in supported
sitting
9 months Not sitting independently/without support, Not moving(e.g., creeping, crawling), Not using two-part
babble (e.g., bubu, dada)
12 months Does not notice someone new, Does not feed self finger foods, does not respond to his name
15 months Does not use words such as mama/dada, no pincer grasp
18 months: Lacks interest in playing and interacting with others, not able to understand short requests, Not able
to walk independently
2yrs: When playing with toys tend to bang, drop, or throw them rather than use them for their purpose,
not putting words together, and are not able to walk up and down stairs, holding on
3 yrs Not able to run or jump, not using simple sentences, no interest in pretend play or interacting with
other children
4 yrs Speech is difficult to understand, not able to draw lines and circles
5yrs Play is different than their friends. Difficulty telling a parent what is wrong
What is the purpose of a
developmental assessment?
• Identify children who may be at risk for
developmental delays or disabilities
• Determine the child’s strengths and
weaknesses
• Develop a plan to help the child reach
their full potential
• Monitor the child’s progress over time
How to assess
development?
History • Antenatal, natal, and
postnatal events
taking • Family history relevant to
development
• Social history (Main
caregiver(s) spoken language
at home, medical
illnesses (especially mental
wellness) in the family, recent
stressors, domestic violence,
financial difficulty, any past or
current concerns of child
abuse/neglect
• Medications
Whether or not parents have
concerns
Developmental Right questions
history Age-specific questions
Details should be asked in
younger children aged up to 3
years of age
Check doubtful reply
• Growth parameters (weight,
height, occipitofrontal
circumference)
• Dysmorphism
Physical • Neurocutaneous stigmata
• Systemic examination
examination • Full neurological
examination (tone, reflexes, gait,
cranial nerves, cerebellar)
• Behavioural observations during
consult
• Hearing and vision assessment
Developmental Evaluation
Should be done in a place free of distractions
Playful mood with mother around
Adequate time to make the child and family comfortable
Infant or child in a good temper
Should not be hungry, tired, ill, irritated, have had convulsions
prior, or be under the influence of sedatives
Observation: The professional will observe the child during play,
activities, and interactions with others.
Detailed Developmental assessment of one or four key
Developmental milestones
Standardized tests: These are tests that have been developed
and standardized to measure specific developmental skills.
Review of medical records: The professional will review the
child’s medical records to look for any signs of developmental
problems.
Causes of developmental delay
Motor delay Speech delay Global
• Physiologic • Normal Variants developmental
Variants “Late talkers” with normal
familial late walking subsequent development
delay
• Genetic /
(normal variant) • Hearing Loss
• Chromosomal
Central Nervous (conductive from otitis
Disorders
System Disorders media, sensorineural, or
Down syndrome (trisomy
Cerebral palsy, Brain mixed)
• 21)
malformations Developmental
• Fragile X syndrome
Neuromuscular Language Disorder
• Metabolic Disorders
Disorders (Specific Language
Inborn errors of metabolism
Duchenne and Becker Impairment)
(e.g.,
muscular dystrophy, Expressive or receptive
phenylketonuria
Spinal muscular atrophy language disorder
• Prenatal / Perinatal
• Orthopedic / • Anatomic
Insults
Structural Abnormalities of
Congenital infections
Disorders Speech Apparatus
(CMV, toxoplasmosis)
Developmental Cleft palate, Oral-motor
Hypoxic-ischemic
dysplasia of the hip, or dysfunction (e.g.,
encephalopathy
limb malformations dysarthria)
• • Prematurity
Environmental / Environmental &
• Postnatal Acquired
Other Medical Psychosocial Factors
Causes
Conditions Bilingualism may cause
CNS infections (meningitis,
Malnutrition or rickets transient delays, but is
encephalitis)
Hypothyroidism usually benign
Thank you