This document provides information about red flags in child development and signs of potential developmental delays or disabilities. It discusses monitoring children's development across physical, cognitive, language, social, and behavioral domains. Parents and caregivers are encouraged to track children's developmental milestones and seek further assessment if milestones are significantly delayed compared to peers. Early intervention can help address delays and improve outcomes for children. The document also provides specific examples of red flags in different developmental areas for various age groups.

2. WHAT ARE RED FLAGS?
Red Flags are signs that show a child is not developing at a “normal”
range. That is to say, they are not keeping pace with the developmental
milestones for their age.
We are all aware of how we monitor a child’s growth by measuring their
height and weight.
We also need to monitor their growth in other areas, such as how they act,
learn, speak, and play.
By monitoring all of these areas of the ways a child grows, we develop the
whole picture of a child and can act early to provide intervention and
help the child succeed!

3. WHAT TO WATCH FOR…
As a child grows and changes, so will the Red
Flags. The concerns that might be present for a
2 year old are very different from those of a 12
month old child.
Although each child is unique and will develop at
their own pace, it is important to be aware of
when most children of the same age master the
skills and compare them for significant
differences.
Refer for further assessment even if you are
uncertain if the flags noted are a reflection of a
cultural variation or a real concern.

4. PARENTS SPEAK

5. SENSITIVE ISSUES
One of the most difficult parts of recognizing a potential difficulty in a
child’s development is sharing these concerns with the parents/
guardians. It is important to be sensitive when suggesting that there
may be a reason to have further assessment done. You want parents/
guardians to feel capable and to be empowered to make decisions.
There is no one way that always works best, but there are some things
to keep in mind when addressing concerns.
►►Be sensitive to a parent/guardian’s readiness for information. If you
give too much information when people aren’t ready, they may feel
overwhelmed or inadequate. You might start by probing how they feel
their child is progressing. Some parents/guardians have concerns, but
have not yet expressed them.

6. SENSITIVE ISSUES CONTINUED
►►Be sure to value the parent’s/guardian’s knowledge. The ultimate
decision about what to do is theirs. Express what it is that you have to
offer and what they have to offer as well. You may say something like “I
have had training in child development, but you know your child. You
are the expert on your child.” When you try to be more of a resource
than an “authority”, parents/guardians feel less threatened. It is best to
have the parents/guardians discover how their child is doing and decide
whether or not extra help would be beneficial. You may want to offer
information you have by asking parents/ guardians what they would like
to know.
►► Have the family participate fully in the final decision about what to do
next. The final decision is theirs. You provide only information, support
and guidance.
►►Be genuine and caring. You are raising concerns because you want
their child to do the best that he can, not because you want to point out
“weaknesses” or faults”. Make sure only the CDC or HSW handle
parent/guardian conversations.

7. AND, FINALLY…
►►Your body language is important; parents may already be
fearful of the information.
►► ”Finally, it is helpful to offer reasons why it is not appropriate
to “wait and see”:
□□ Early intervention can dramatically improve a child’s
development and prevent additional concerns such as behavior
issues.
□□ The wait and see approach may delay addressing a medical
concern that has a specific treatment.
□□ Early intervention helps parents understand child behavior and
health issues, which will increase confidence that everything
possible is being done to ensure that the child reaches his full
potential.

9. SPECIFIC RED FLAGS: ATTACHMENT
0-8 months
□□ Is difficult to comfort by physical contact
such as rocking or holding
□□ Does things or cries just to annoy you
8-18 months
□□ Does not reach out to you for comfort
□□ Easily allows a stranger to hold him/her
18 months - 3 years
□□ Is not beginning to develop some independence
□□ Seems angry or ignores you after you have been apart

10. SPECIFIC RED FLAGS: ATTACHMENT CONTINUED
3-4 years
□□ Easily goes with a stranger
□□ Is too passive or clingy with you
4-5 years
□□ Becomes aggressive for no reason (e.g., with
someone who is upset)
□□ Is too dependent on adults for attention,
encouragement and help

11. SPECIFIC RED FLAGS: FINE MOTOR
... If a child is missing one or more of these expected age
outcomes, consider this a red flag:
By 2 months
□□ Sucks well on a nipple
□□ Holds an object momentarily if placed in hand
By 6 months
□□ Eats from a spoon (e.g. infant cereal)
□□ Reaches for a toy when lying on back
□□ Uses hands to reach and grasp toys

12. SPECIFIC RED FLAGS: FINE MOTOR CONTINUED
By 12 months
□□ Holds, bites and chews foods (e.g. crackers)
□□ Takes things out of a container
By 3 years
□□ Turns the paper pages of a book
□□ Dresses or undresses with help
□□ Holds a crayon with fingers
By 4 years
□□ Holds a crayon correctly
□□ Undoes buttons or zippers

13. SPECIFIC RED FLAGS: GROSS MOTOR
... If a child is missing one or more of these expected age outcomes,
consider this a red flag:
By 3 months
□□ Lifts head up when held at your shoulder
□□ Lifts head up when on tummy
By 6 months
□□ Rolls from back to stomach or stomach
to back
□□ Pushes up on hands when on tummy
□□ Sits on floor with support

14. SPECIFIC RED FLAGS: GROSS MOTOR CONTINUED
By 12 months
□□ Gets up to a sitting position on own
□□ Pulls to stand at furniture
□□ Walks holding onto hands or furniture
By 5 years
□□ Hops on one foot
□□ Throws and catches a ball successfully most of the time
□□ Plays on playground equipment safely and without difficulty

15. SPECIFIC RED FLAGS: VISION
... If a child is missing one or more of these expected age outcomes, consider this a red
flag:
By 6 weeks
□□ Stares at surroundings when awake
□□ Briefly looks at bright lights/objects
□□ Blinks in response to light
□□ Eyes and head move together
By 6 months
□□ Eyes move to inspect surroundings
□□ Eyes move to look for source of sounds
□□ Swipes at or reaches for objects
□□ Looks at more distant objects
□□ Smiles and laughs when he or she sees
you smile and laugh

16. Having your child’s vision checked is especially important if someone in your
family has had vision problems.
What are some signs of vision loss?
A child with vision loss might:
close or cover one eye
squint the eyes or frown
complain that things are blurry or hard to see
have trouble reading or doing other close-up work, or hold objects close to
eyes in order to see
blink more than usual or seem cranky when doing close-up work (such as
looking at books)
One eye of a child with vision loss could look out or cross. One or both eyes
could be watery, and one or both of the child’s eyelids could also look red-
rimmed, crusted, or swollen.

17. What can I do if I think my child may have vision loss?
Talk with your child’s doctor or nurse. If you or your doctor think there could be a
problem, you can take your child to see an ophthalmologist, optometrist, or other
specialist, and you can contact your local early intervention agency (for children
under 3) or public school (for children 3 and older). To find out whom to speak to in
your area, contact the National Information Center for Children and Youth with
Disabilities at www.nichcy.org/states.htm or call the Centers for Disease Control
and Prevention (CDC) at 1-800-232-4636.
Treating vision problems early may protect your child’s sight, and teaching children
with severe vision loss how to function as early as possible can help them reach
their full potential.
1-800-CDC-INFO | www.cdc.gov/ncbddd Hoja informativa sobre la pérdida de la
visión
National Center on Birth Defects and Developmental Disabilities Division of Birth
Defects and Developmental Disabilities

18. ¿Qué es la pérdida de la visión?
Pérdida de la visión significa que la visión de una persona no puede corregirse a
su nivel normal. La pérdida de la visión varía considerablemente de niño a niño y
sus causas pueden ser muchas.
¿Qué causa la pérdida de la visión?
La pérdida de la visión puede resultar por daños al ojo mismo, porque el ojo tiene
una forma incorrecta o incluso por problemas cerebrales. Algunos bebés nacen sin
poder ver, pero la pérdida de la visión puede ocurrir en cualquier momento durante
el transcurso de la vida de cualquier persona.
¿Cuándo se le debe hacer un examen de la visión a mi hijo?
La visión de su hijo debe de ser examinado por un oftalmólogo, optómetra,
pediatra u otro especialista entrenado en este campo:
recién nacido a 3 meses
6 meses a 1 año
a los 3 años aproximadamente
a los 5 años aproximadamente
En particular, es muy importante hacerle a su hijo un examen de la visión si
alguien en su familia ya ha tenido problemas de la vista.
¿Cuáles son algunos síntomas de la pérdida de la visión?
Un niño con pérdida de la visión puede:
cerrar o cubrirse un ojo
entrecerrar los ojos o arrugar el ceño
quejarse de que ve las cosas borrosas o que son difíciles de ver

19. SPECIFIC RED FLAGS: VISION CONTINUED
By 12 months
□□ Eyes turn inward as objects move close to
the nose
□□ Watches activities in surroundings for
longer time periods
□□ Looks for a dropped toy
□□ Visually inspects objects and people
□□ Creeps toward favorite toy
By 4-5 years
□□ Knows colors and shadings; picks out detail in objects and pictures
□□ Holds a book at a normal distance

20. SPECIFIC RED FLAGS: HEARING
... If a child is missing one or more of these expected age outcomes, consider this a red
flag:
By 6 months
□□ turns to source of sounds
□□ Startles in response to sudden, loud noises
□□ Makes different cries for different needs - I’m hungry, I’m tired
□□ Watches your face as you talk
□□ Smiles and laughs in response to your smiles and laughs
□□ Imitates coughs or other sounds - ah, eh, buh
By 18 months
□□ Understands the concepts of “in and out”, “off
and on”
□□ Points to several body parts when asked
□□ Uses at least 20 words

21. SPECIFIC RED FLAGS: HEARING CONTINUED
By 30 months
□□ Understands the concepts of size (big/little) and quantity (a
little, a lot, more)
□□ Uses some adult grammar - “two cookies”, “bird flying”
□□ Uses more than 350 words
□□ Uses action words - run, spill, fall
□□ Begins taking short turns with other children, using both toys
and words
□□ Shows concern when another child is hurt or sad

22. SPECIFIC RED FLAGS: SPEECH & LANGUAGE
... If a child is missing one or more of these expected age outcomes, consider
this a red flag:
By 3 months
□□ Cries and grunts; has different cries for different needs
□□ Makes a lot of “cooing” and “gooing” sounds
□□ Responds to parent/caregiver voice
By 18 months
□□ Tries to copy your sounds (sounds of our language)
□□ Uses at least 20-50 words consistently; words do not have to be clear
□□ Understands many more words than he can say

23. SPECIFIC RED FLAGS: SPEECH & LANGUAGE CONTINUED
By 2 years
□□ Tries to copy your words □□ Uses a variety of words and gestures to
communicate and ask for help (e.g. waving, pushing away, pointing)
□□ Uses 100-150 words and combines 2 words (e.g. more juice. Want cookie)
□□ Follows two step instructions (e.g. go find your teddy bear and show it to
Grandma)
By 4 ½ years
□□ Most of the time uses complete sentences with 4 or more words (e.g. I go
home now.)
□□ Uses correct grammar such as plural (e.g. books), past tense (e.g. walked)
and pronouns (e.g. I, he, she, me, you)
□□ Follows directions involving three or more steps “First get some paper, then
draw a picture, last give it to mom”
□□ Tells stories with clear beginning, middle and end

24. CHILDREN’S MENTAL HEALTH ISSUES

25. AUTISM
Autism is a lifelong developmental disorder
characterized by impairments in all of the following
areas of development:
communication, social interaction, restricted
repertoire of activities and interests, and
associated features, which may or may not be
present (e.g. difficulties in eating and sleeping,
unusual fears, learning problems, repetitive
behaviors, self-injury and peculiar responses to
sensory input).

26. A FEW STATISTICS
In 1979 – 1 in 1,500
In 2009 – 1 in 110
In 2012 – 1 in 88
In 2014 – 1 in 68
• ASD (Autism Spectrum Disorder) is reported to occur in all racial,
ethnic, and socioeconomic groups. It is the fastest growing
neurobiological condition in the world and is projected to rise another
14.7% by 2020.
• ASD is almost 5 times more common among boys (1 in 42) than among
girls (1 in 89).
• ASD is increasing globally, overall; however, many developing countries
are reporting much lower rates. In China, for example, it is estimated
that 1.1 in every 1,000 children are diagnosed with Autism.

27. SIGNS AND SYMPTOMS OF AUTISM
If the child presents any of the following behaviors, consider this a red flag:
Social Concerns
►►Does not smile in response to another person
►►Delayed imaginative play – lack of varied, spontaneous make-believe play
►►Prefers to play alone, decreased interest in other children
Communication Concerns
►►Language is delayed (almost universal)
►► Inconsistent response or does not respond to his name or instructions
►►Unusual language – repeating phrases from movies, echoing other people,
repetitive use of phrases, odd intonation

28. SIGNS AND SYMPTOMS OF AUTISM CONTINUED
Behavioral Concerns
►►Severe repeated tantrums due to frustration, lack of ability to communicate,
interruption of routine, or interruption of repetitive behavior
►►Narrow range of interests that she engages in repetitively
►►High pain tolerance and lack of safety awareness
►►Repetitive hand and/or body movements: finger wiggling, hand and arm
flapping, tensing of fingers, complex body movements, spinning, jumping, etc.
►►Unusual sensory interests (e.g. visually squinting or looking at things out of
the corner of the eye, smelling, licking, mouthing objects and/or
hypersensitive hearing)
►►Unusual preoccupation with objects (e.g. light switches, fans, spinning
objects, vertical blinds, wheels, balls)

29. STRATEGIES FOR PARENTS AND STAFF
Use visual supports (tools that are used to increase the understanding of
language, environmental expectations, and to provide structure and
support for children with ASD).
Determine the function of the negative behaviors and use the most
practical approach(es) to modify or replace those behaviors. There are
behaviors that are always associated with ASD and they can be shaped
and modified. Make sure the child has the skills to work through the
behavior.
REMEMBER: BEHAVIOR IS LEARNED, WHICH MEANS THAT, IF IT IS A
LEARNED BEHAVIOR, IT CAN BE UNLEARNED OR REPLACED. YOU
HAVE TO DIFFERENTIATE BETWEEN THE DISABILITY AND A
BEHAVIOR.
For example: A tantrum is a way to manipulate and is designed so the
child can get what they WANT, while a meltdown is an emotional
response to the child not getting what they NEED. So, which is which?
Always be prepared – build a bag of tricks!

30. IDEAS FOR PARENTS AND STAFF
Speak clearly and precisely; define personal space
Identify emotions – build an emotional vocabulary
Learn and teach the child a calming strategy /listen to rhythmic
music
Change the environment – lighting, noise, temperature, calming
scents, touch
Use technology – allow headphones
Offer “fidget” toys, gloves, weighted items in baggies, opportunity
for movement, assemble nuts and bolts, Legos, push golf tees
into Styrofoam
Simon Says, wall push-up, play with modeling clay, climbing
Yoga bands, bungee cords, blanket rolls, bean bag chairs

31. PROBLEM SIGNS AT A GLANCE
Children over 3 – trouble staying between lines when coloring
Avoids eye contact
Chews/licks non-food objects
Becomes upset during grooming
Has difficulty standing in line or close to other people
Always on the go; difficulty paying attention
Becomes anxious or distressed when feet leave the ground
Poor endurance
Craves a lot of touch
Has difficulty making friends

32. WHAT TO DO IF YOU OBSERVE RED FLAGS
- Trust yourself – if you have a concern about a child, talk to the
CDC or HSW at your Center. Share community resources with
parents. Find medical professionals with experience with
children with ASD. Encourage strong communication between
staff and parents
- Document concerns to provide a clear and accurate picture of
the child.

33. REFERENCES
www.cdc.gov/ncbddd/childdevelopment
www.healthunit.org/professionals/redflags/Red-Flags-Guide.pdf
www.parents.com/toddlers-preschoolers/development/growth/red-flags
www.preschoollearningcenter.org/index.php?Signs and symptoms...
www.education.com/reference/article/developmental-red-flags-ages-3-5
www.catherineshafer.com/redflags.html
childrensdevelopmentalcenter.org
www.albertinakerr.org/Youthamp;Family/ChildrensDevelopmentalHealth
www.cdc.org
www.american academyofpediatric.org
http://www.hhs.gov/open/
http://www.hhs.gov/
https://www.usa.gov/