3.pediatric development

2016 YSMU AFTER M. HERATSI. DEPARTMENT OF PEDIATRICS №1
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DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS
CASE STUDY
The parents of a 12-month-old are concerned that she is not walking yet. They report that she sat independently at 7
months and began crawling at 8 months. She can pull herself up to stand while holding on to furniture but is not
cruising. Her birth and medical history are unremarkable. The physical examination is within normal limits, and review
of your records reveals no concerns on a developmental screening test administered at 9 months of age.
Questions 1. What are the major areas in which development is assessed? 2. What are the gross motor, fine motor, and
personal/ social milestones for a 12-month-old? 3. What developmental screening tests could you administer to further
assess her development? 4. How is developmental delay in children defined?
Developmental assessment and screening
 Development refers to the acquisition of functional skills during childhood. Monitoring the growth and
development of children is an integral part of the assessment of pediatric patients.
 For ease of monitoring, these developmental milestones may be divided into 5 major domains or areas:
gross motor, fine motor, language, social, and self-help.
1. Gross motor skills are overall movements
of large muscles (eg, sitting, crawling,
walking, running).
2. Fine motor skills involve use of the small
muscles of the hands, the ability to
manipulate small objects, problem-solving
skills, and eye-hand coordination (e.g.
holding an object, drawing a shape).
3. Language skills include hearing,
understanding, and use of language.
4. Social skills involve socialization and
ability to care for personal needs.
5. Self-help skills (e.g. washing hands,
feeding with spoon, dressing and undressing
without help, toilet training)
CHILD DEVELOPMENT CHART (by Harold Ireton) outlines the normal pattern of development for each
of these skills. The chart lists the average age of attainment of these skills.

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Four principles apply to all aspects of development.
 First, motor development is a continuous process that proceeds in the cephalocaudal direction and
parallels neuronal myelination; therefore, developmental milestones reflect the maturation of the
nervous system.
 Second, the sequence of development is the same in all children, but the rate of development may vary
from child to child (eg, all children must walk before they run, but the age at which children walk or
run varies from child to child).
 Third, the rate of attainment of milestones in one area may not parallel that in another.
 Fourth, certain primitive reflexes must be lost before corresponding voluntary movements can be
attained (eg, the asymmetric tonic neck reflex must disappear before children can roll over).
Development in Newborns and Infants
Normal, full-term newborns enter the world capable of responding to visual, auditory, olfactory, oral, and
tactile stimuli. They can be quieted and can even soothe themselves. Newborns can signal needs (eg, crying
when hungry or wet), but they have a limited ability to respond to caregivers, primarily exhibiting
disorganized and seemingly purposeless movements when stimulated. The newborn’s reflexive generalized
symmetric movements (eg, arm waving and kicking) in response to environmental stimuli are eventually
replaced by cortically mediated voluntary actions in older infants and children. Additionally, in newborns,
certain primitive reflexes can be elicited by appropriate peripheral stimuli. Eventually, primitive reflexes
are replaced by reactions that allow children to maintain postural stability in response to a variety of
sensory inputs (proprioceptive, visual, and vestibular).
Primitive reflexes are mediated by the brain stem; they are
involuntary motor responses that are elicited by
appropriate peripheral stimuli and are present at birth but
disappear during the first 6 months of life (Table 1).
Normal motor development seems to be related to the
suppression of these reflexes. Persistence or reappearance
of these reflexes may indicate the presence of brain
damage.
Figure 1. Primitive reflex profile
(Capute AJ et al. 1978)
Postural reactions, which are ultimately smoothly integrated into adult motor function (Figure 1), appear
between 2 and 9 months of age. These reactions help maintain the orientation of the body in space and the
interrelationship of one body part to another (Table 2). The profile generated by combining primitive
reflexes and postural reactions can be used to monitor the course of normal development and identify cases
of problematic development. Persistence of primitive reflexes or failure of development of postural
reactions can signal developmental problems.

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Table 1. Selected Primitive Reflexes
REFLEX DESCRIPTION
AGE AT
APPEARANCE
AGE AT
DISAPPEARANCE
Moro Allowing the baby’s head to drop back
suddenly results in abduction and
upward movement of the arms followed
by adduction and flexion.
Birth 3-6 mo
Palmar
Grasp
Placing finger in infant’s palm results in
flexing of infant’s fingers
Birth 6 mo
Plantar
Grasp
To elicit this, stroke the sole of the foot
– the toes will curl to grasp the object
Birth 6-8 mo
Rooting Tactile stimulus about infant’s mouth
results in the mouth pursuing the
stimulus
Birth 4-6 mo
Trunk
incurvation
(Gallant)
Stroking the skin along the edge of
vertebrae produces curvature of the
spine with concavity on the side of the
stroke
Birth 4 mo
Stepping Hold the baby in a standing position and
slowly move the baby forwards with the
toes touching the bed – the baby will lift
the feet and place them in front of each
other, as if walking.
Birth 3-4 mo
Asymmetrical
tonic neck
With infant supine, turning of the head
results in ipsilateral extension of the arm
and leg with flexion of opposite
extremities in a “fencing” posture
Birth 3-4 mo
Babinski Stroking lateral aspect of sole from heel
up results in dorsiflexion of the great toe
and fanning of the remaining toes
Birth 12-18 mo

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Table 2. Selected Postural Reactions
REACTION DESCRIPTION
AGE AT
APPEARANCE
AGE AT
DISAPPEARANCE
Righting
Reactions
These allow the body to maintain normal postural relationships of
the head, trunk, and extremities during all activities. The different
reactions appear at different ages, beginning shortly after birth and
ranging up to 12 months of age.
Never
Protective
Equilibrium
Response
When gently pushed toward one side
while in a sitting position, infants
increase trunk flexor tone toward that
side to regain their center of gravity and
extend the arm on the same side to
protect against falling.
4-6 mo Never
Parachute
Refactions
When held in ventral suspension and
suddenly lowered (downward
parachute), infants extend their arms as
if to protect themselves from a fall;
similar reactions are seen with forward
and backward stimulation.
8–10 mo Never
Gross Motor Skills
During the first year of life, the ultimate goal of gross
motor development is walking. The first step toward
this goal is head control. By 6 months of age, children
are able to sit without support for a few seconds (Figure
2). At 9 to 10 months of age, children are able to pull
themselves to a standing position, and by 12 to 17
months of age, they are able to walk. Children then
learn to run, negotiate stairs, hop on one foot, and skip
— in that order.
Figure 2. Stages in the development of sitting. A, Head
control. B, “Tripod sitting.” C, Head steady and back
straight without support
Variation
There is wide variability in the ‘normal ranges’. This is
particularly so with walking – normal children may
walk from 11–18 months (Figure 3). If they bottom
shuffle (instead of crawling), they generally walk late
as bottom shuffling is so efficient.
Figure 3. Windows of milestone achievement expressed in months
[WHO Motor Development Study. Acta Pædiatrica, 2006; Suppl 450: 86_/95]

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Fine Motor Skills
Development of the 2-finger pincer grasp is the major
goal of fine motor development during the first year
(Figure 4). The hands primarily remain in a fisted
position until 3 months of age. Infants also discover the
midline at this age, and shortly thereafter they may
play with the hands in the midline. Four-month-olds
begin reaching for desired objects; by 6 months of age,
they are able to transfer objects from one hand to the
other. By 7 months, they have a 3-finger pincer grasp,
and by 9 to 10 months, they have developed the 2-
finger grasp, which allows them to manipulate small
objects such as raisins and pencils.
Figure 4. Development of the pincer grasp. A, Rake (4
months). B, Inferior pincer grasp (7 months). C, Fine
pincer grasp (9–12 months).
By 14 months, they begin to scribble, and by 3 to 5 years, they are able to copy geometric shapes. Children
with early preference for the use of one hand over another, especially prior to about 18 months of age,
should be assessed for the presence of paresis or other neuromuscular problems. Handedness may develop
by 3 years but often is not firmly established until the age of 4 to 5 years.
Social Skills
These skills enable children to interact and respond to the surrounding world. Deficits in the development of age-
appropriate social skills/social relatedness (eg, social orienting, social referencing, joint attention, pretend play) are a
defining feature of autism spectrum disorders (ASDs). For children within this spectrum, the development of social
skills is characteristically “out of sync” with their overall level of functioning. Joint attention is the inclination to
share enjoyment, interests, or achievement with other people, and like other developmental skills, it seems to
develop in graduated stages (early skills include reciprocal smiling at the sight of a familiar person, followed by later
emerging skills like the ability to isolate one’s index finger and point by 12–15 months of age). Lack of joint attention
seems to be a core deficit in ASDs; it also seems to be specific to ASDs.
Toilet Training
This is also very variable. Bladder and bowel control is usually attained by 2 years of age in girls and by 3 years in
boys. Nocturnal enuresis until 5 years is relatively common. Boys are notoriously slow.
The American Academy of Pediatrics (AAP) has outlined the following as indicating a toddler's readiness for toilet
training: Child stays dry for at least 2 hours, has regular bowel movements, follows simple instructions, walks to and
from bathroom and helps undress, is uncomfortable with dirty diapers, asks to use the toilet or potty, and asks to
wear "big girl" or "big boY' underwear.
CASE RESOLUTION
The parents of the child described in the case history may be reassured that their child is developing normally for her age. Although
most children begin walking at about 12 months of age, commencement of walking anywhere up to the age of 17 months is
considered to be within normal limits. The American Academy of Pediatrics (AAP) recommends that standardized developmental
screening should be performed when developmental surveillance identifies high risk factors and routinely at the 9-, 18-, and 24- or
30-month health maintenance visits. Administration of a formal screening tool is probably not necessary at this visit but can be
considered again at the 15-month visit if there is a lack of progression in her gross motor skills or if any other risk factor is identified
at that time.

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Speech and Language Skills
CASE STUDY
The parents of a 3-year-old girl bring her to see you. They are concerned because their daughter has only an 8- to 10-
word vocabulary and she does not put words together into phrases or sentences. They report that she seems to have no
hearing problems; she responds to her name and follows directions well. In general, she has been in good health. Her
development, aside from delayed speech, is normal. During the physical examination, which is also normal, the girl does
not speak.
Questions 1. What language skills should children have at 1, 2, and 3 years? 2. Approximately how many words should
3-year-olds have in their vocabulary? 3. By what age should children’s speech be intelligible to strangers at least 75% of
the time? 4. What factors may be associated with delayed speech development? 5. What tests are used to assess
children’s hearing, speech, and language development?
The ability to communicate through language is a uniquely human skill. Speech refers to the production of
sounds, whereas language involves comprehension and expression; it is the use of words, phrases, and
gestures to convey intent. Receptive language refers to the ability to understand others, while expressive
language is the ability to produce communication to convey meaning to others. Normal hearing is essential
for the development of speech and language.
The left hemisphere of the brain is responsible for language skills in 94% of right-handed adults and
approximately 75% of left-handed adults. Peripheral auditory stimuli are transmitted to the primary
auditory areas in both temporal lobes. Sounds then undergo a series of analyses, primarily in 3 main areas in
the left cerebral cortex: Wernicke area (or auditory association area), which is responsible for the
comprehension of language; Broca motor speech (or motor encoding) area, which is responsible for the
preliminary conversion of language into motor activity; and the primary and supplementary motor
cortexes, which control the movements necessary for speech. This complex process is responsible for the
comprehension and production of language.
Speech and language develop in a predictable, orderly sequence. Language skills can be receptive or
expressive. Early receptive milestones refer to ability to hear and respond to sound, whereas later
milestones reflect ability to understand spoken words. Early expressive milestones relate to speech
production; later, children use language to convey their intent to others. In the first year of life, receptive
skills are more advanced than expressive skills.
Children’s language skills evolve primarily through parent-child interactions. Language begets language;
children must first receive language before they are able to express themselves with language. Eye contact,
social smiling, and ability to share attention with others, or joint attention (developed by 12–15 months of
age), are children’s first experiences with shared meaning, crucial for language development. Evidence
exists that by the time a child is 4 years of age, the differences in word exposure between children living in
higher socioeconomic environments as compared with those living in lower socioeconomic environments
may be up to 30 million words. Research also suggests that expressive language vocabulary at age 3 predicts
language and reading achievement up to 9 to 10 years of age.
Knowledge of normal receptive and expressive language skills (Table 3) is essential to recognition and
identification of developmental delays.

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Table 3. Receptive and Expressive Language Milestones (Birth to 3 Years)
Skill Mean Age Normal Range
Receptive Milestones
Alerts to sound Newborn
Orients to sound/turns to voice 4 mo 3–6 mo
Responds to name 4 mo 4–9 mo
Understands “no” 10 mo 9–18 mo
Follows 1-step command with gesture 12 mo 10–16 mo
Follows 1-step command without gesture 15 mo 12–20 mo
Points to several body parts 18 mo 12–24 mo
Follows 2-step command with gesture 24 mo 22–30 mo
Expressive Milestones
Cooing (vowel sounds) 3 mo 1–4 mo
Laughs 4 mo 3–6 mo
Babbling (consonants added to vowel sounds) 6 mo 5–9 mo
Dada/Mama nonspecifically 8 mo 6–10 mo
Dada/Mama specifically 10 mo 9–14 mo
3- to 5-word vocabulary 12 mo
Immature jargoning (gibberish with inflection) 13 mo 10–18 mo
Mature jargoning (gibberish with occasional word) 18 mo 16–24 mo
50-word vocabulary 24 mo
2-word phrases 24 mo 20–30 mo
Uses pronouns indiscriminately 24 mo 22–30 mo
States first name 34 mo 30–40 mo
Uses pronouns appropriately 36 mo 30–42 mo
250-word vocabulary 36 mo
75% of speech intelligible to strangers 36 mo

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DEVELOPMENTAL DISORDERS. BEHAVIORAL AND
PSYCHOSOCIAL ISSUES IN CHILDREN
Concerning signs in early development
 No social smiling by 2 months
 Not sitting alone by 9 months
 Not crawling by 1 year
 Not walking by 18 months
 No speech by 18 months
 Hand preference development < 1 year (this usually develops at 18–24 months)
 DEVELOPMENTAL DELAY
Children are said to be developmentally delayed if they fail to reach developmental milestones at the
expected age. This age ranges widely because of the wide variation among normal children. Individual
children may be delayed in one area or several areas of development.
Transient developmental delay
Some children have a transient delay in their development. For example, some extremely premature babies
may show a delay in the area of sitting, crawling and walking but then progress on at a normal rate. Other
causes of transient delay may be related to physical illness and prolonged hospitalisation, immaturity,
family stress or lack of opportunities to learn.
Persistent developmental delay
Disorders which cause persistent developmental delay are often termed developmental disabilities.
Examples are cerebral palsy, muscle disorders, language disorders, autism, emotional problems and
disorders of vision and hearing. All these conditions can cause developmental delay. However, one of the
most common causes is an intellectual disability (formerly mental retardation).
Intellectual disability (ID) is defined as significantly subaverage intellectual functioning existing
concurrently with deficits in adaptive behavior (e.g., communication, self-care, self-direction) and
manifested during the developmental period.
Differential diagnosis
Three factors are involved in the differential diagnosis of children with developmental delays:
 determination of the area or areas of development in which delay is apparent;
 if motor delay is evident, determination of whether the condition is progressive or nonprogressive;
 assessment to see if developmental milestones previously achieved are lost or if age-appropriate
milestones were achieved at all.

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Children with an early history of normal development who subsequently experience a slowing of
developmental progression, often associated with cognitive delays or seizures, may have a metabolic defect.
Children who attain developmental milestones and subsequently lose them may have a neurodegenerative
disease (eg, multiple sclerosis, adrenoleukodystrophy) or a lesion of the spinal cord or brain. The presence
of habitual rhythmic body movements (eg, body rocking, head banging) may be a sign of a pervasive
developmental disorder such as ASDs.
Cerebral palsy, the classic example of nonprogressive motor abnormality, is a form of static encephalopathy
characterized by abnormal movement and posture. The type of cerebral palsy depends on which area of the
brain is injured. Spastic cerebral palsy, seen most commonly, is secondary to upper motor neuron injury.
The ataxic form of the disease is related to lesions of the cerebellum or its pathways. Dyskinetic cerebral
palsy manifests as uncontrolled and purposeless movements that often result from a basal ganglia lesion (eg,
athetosis following bilirubin deposition in the basal ganglia). Onset of symptoms is in infancy or early
childhood. The key factor in making the diagnosis is establishing that the motor deficits are static and not
progressing.
Autism spectrum disorders (ASDs) are characterized by profound impairment in social interaction (e.g.,
lack of eye contact, poor peer relationships); restricted, repetitive, and stereotyped patterns of behavior
(e.g., unusual preoccupations, inflexibility, stereotyped motor movements); and altered communication
(verbal and nonverbal) ranging from nospeech to jargon, echolalia, and "pedantic speech."
CAUSES OF DEVELOPMENTAL DELAY
Motor
 Normal, e.g. delay in walking in commando crawlers or bottom shufflers
 Neurological disorder, e.g. cerebral palsy
 Neuromuscular disorder, e.g. Duchenne muscular dystrophy
 Any cause of global developmental delay
Communication (speech, language and non-verbal)
 Hearing disorder
 Visual disorder
 Lack of stimulation
 Articulation defect – neuromuscular disorder, physical abnormality, e.g. cleft palate
 General developmental delay
 Autism
 Communication is also affected by general intelligence and motor function
Global
 Genetic low intelligence
 Lack of stimulation
 Chronic illness
 Psychological upset
 Genetic disorder or syndrome, e.g. Down syndrome; metabolic disorder, e.g. phenylketonuria; brain abnormality, e.g.
hydrocephalus
 Antenatal disorder – congenital infection; teratogens
 Birth asphyxia
 Prematurity
 Hypothyroidism
 Neurological insult – head trauma; meningitis, encephalitis; metabolic, e.g. hypoglycaemia

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 COMMON BEHAVIORAL AND PSYCHOCOCIAL PROBLEMS
Infants Colic
 A late afternoon, early evening fussy period is very common in many babies between 2 weeks
and 3 to 4 months of life. Generally these babies respond to soothing by the parent.
 Colic can be defined as > 3 hours of crying per day for more than 3 days in a week. This can be
viewed as an exaggerated form of the normal fussy period described above. In colic, the crying
episodes are more intense, of longer duration, and less responsive to the parent's attempt to
soothe. The age interval tends to be the same (2 weeks to 3 or 4 months).
 History and physical exam should rule out feeding problems (under- or overfeeding), medical
conditions (e.g., gastroesophageal reflux), or other causes of pain (e.g., hair tourniquet).
Toddlers Feeding problems
 Parental concerns about decreased food intake in toddlers is extremely common.
 Power struggles over feeding reflect the toddler's emerging mastery (desire to feed self) and
autonomy (having control over what foods he or she will accept).
Temper tantrums
 Tantrums are normative behavior in the toddler age range. They include crying, screaming,
hitting, kicking, and throwing self to floor. Tantrums are an expression of acute frustration,
often in response to a parental "no" or the child's inability to master a specific skill or task.
 Some potential "red flags" that tantrums are beyond the normative range include:
− Frequent, prolonged tantrums (more than three times a day or longer than 15 minutes)
− Occurring before 1 year of age or after age 4
− Excessive emotional response (e.g., anger, guilt) by parent to the tantrums
− Injury to self or others (parents should remove child to a safe location and not allow child to
hit the parent or anyone else)
Preschool years Lying at this age is generally not a cause for concern, as the preschooler does not yet have a firm
grasp on the distinction between fantasy and reality.
Aggression, which is normative in the 18-month-old toddler, should be greatly diminished in the
preschool years. Persistent aggressive behavior in a preschooler is an indication for both
behavioral and developmental assessment.
School-age
years
Behavioral concerns in the school-aged child can present as academic difficulties (e.g., due to
attentional weakness), social concerns, and/or disruptive behaviors.
Depression and anxiety disorders are important psychiatric concerns confronting the schoolage
children. They have different clinical presentations than seen in older adolescents and adults. For
example, symptoms of inattention and overactivity can be seen in children with anxiety,
depression, or both. Such children are at risk for being mistakenly diagnosed and treated for
ADHD.
Attention deficit hyperactivity disorder (ADHD) (Table 4) is a behavioral syndrome characterized
by inadequate attention span, impulsivity, and hyperactivity. The syndrome gives rise to
challenges in academic performance, behavior, and social functioning. Boys are affected more
frequently than girls.

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Table 4. Selected Symptoms Associated with Attention Deficit Hyperactivity Disorder
Symptoms Associated with Inattention Symptoms Associated with Hyperactivity/lmpulsivity
• Often makes careless mistakes
• Problems sustaining attention in school and at play
• Problems Mth organization and forgetfulness
• Lack of follow-through on schoolwork and chores
• Easily distracted
• Often fidgets, squirms, or is out of seat
• Often "on the go" and frequently running
• Excessive talking
• Often blurts out answers or interrupts others
• Problems awaiting a tum
CASE RESOLUTION
The child described in the case history has delayed development of expressive language skills. At the age of 3 years, she
should have a 250-word vocabulary and speak in 3-word sentences; in addition, her speech should be primarily
intelligible to strangers. Because of the delay, she should be referred immediately for a hearing assessment and speech
and language evaluation. Hearing loss is an important diagnosis to rule out. Simply because her parents report no
hearing problems does not mean she does not have a deficit. She may have learned to respond to nonverbal cues, or she
may hear only some things.
Danger Signals in Language Development
• Inconsistent or lack of response to auditory stimuli at any age
• No babbling by 9 months
• No intelligible speech by 18 months
• Inability to respond to simple directions or commands (eg, “sit down,” “come here”) by 24 months
• Speech predominantly unintelligible at 36 months
• Dysfluency (stuttering) of speech noticeable after 5 years
• Hypernasality; inappropriate vocal quality, pitch, or intensity at any age
REFERENCE
1. American Academy of Pediatrics Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical
Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home:
an algorithm for developmental surveillance and screening. Pediatrics. 2006;118(1):405–420
2. Gerber RJ, Wilks T, Erdie-Lalena C. Developmental milestones: motor development. Pediatr Rev. 2010;31(7):267–277
3. Gerber RJ, Wilks T, Erdie-Lalena C. Developmental milestones 3: socialemotional development. Pediatr Rev. 2011;32(12):533–536
4. Johnson CP, Myers SM; American Academy of Pediatrics Council on Children With Disabilities. Identification and evaluation of children with autism spectrum disorders.
Pediatrics. 2007;120(5):1183–1215
5. Roberts G, Palfrey J, Bridgemohan C. A rational approach to the medical evaluation of a child with developmental delay. Contemp Pediatr. 2004;21:76–100
6. Shevell M, Ashwal S, Donley D, et al. Practice parameter: evaluation of the child with global developmental delay: report of the Quality Standards Subcommittee of the
American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2003;60(3):367–380
7. Wilks T, Gerber RJ, Erdie-Lalena C. Developmental milestones: cognitive development. Pediatr Rev. 2010;31(9):364–367
8. Scharf RJ, Scharf GJ, Stroustrup A. Developmental Milestones. Pediatrics in Review 2016;37;25

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