This document provides guidance on developmental examinations for children from birth to 5 years. It outlines typical developmental milestones and domains to be assessed at different ages, including motor skills, cognition, language, and social development. The developmental examination involves taking a family history, observing the child's interactions and abilities, and using structured tasks to assess skills such as object permanence, categorization, and fine motor coordination. Delays in reaching milestones or abnormalities in behaviors could indicate atypical development requiring further evaluation.

1. Development Short Cases- Approach
Ranjini S.Sivanesom
IPHKL
30.08.14

2. Child Development
Child development is a dynamic process
Normal development is determined by a complex interplay between environmental factors, genetic factors and acquired pathology.

3. Warning Signs of Abnormal Development
 Echolalia- repetitive imitation of speech- still present by 3 years.
Absoulte failure to develop skills (eg multi- syllable babble with intonation- by 10 months)
Motor asymmetry
Developmental regression- loss/ plateauing of skills

4. The Developmental Examination
History taking: family history, social and family environment, pre-, peri- and postnatal history.
Enquire into the parents concerns and seek information from others who know the child (eg. teachers, health- care staff)

5. Observation and interactive assessment
Suitable selection of toys should be made available before meeting the family and interacting with the child.
Appropriate toys for the age of the child and the domains of development to be assessed.

6. Observation and interactive assessment
Examples:
Copying behaviour (bell) and understanding of cause and effect (pop- up animal toys)
Definition by use (cup/ spoon, doll/ brush) and symbolic understanding (doll/ teddy/ tea set)
Fine motor/ eye- hand (bricks, crayons/pencil/paper, soft ball, form boards, puzzles)
Language and play (books with single pictures and stories, range of everyday toy objects, large and miniature toys)

7. Observation and interactive assessment
‘Free Play’- the child’s inability to organize the environment and generate ideas on their own will be significant.
Eg. May not be able to focus attention (flit from one object to another or repetitive play may be noted.
Cardinal rule of DA: to look not only what the child does, but also how s/he does it.
Quality of response should therefore be monitored as well as the actual achievement.

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Developmental Examination: Birth to 1 Year
Gross motor
Fine motor
Speech language communication
Social
Cognitive

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Developmental Examination: Birth to 1 Year
Motor Development
Tone, movements and posture (eg head control, hands (open or fisted), spine curvature, legs posture, weight bearing) in supine, pull to sit, supported/ independent sitting and standing, ventral suspension and prone position (180* manoeuvre).
Examine primary (Moro, grasp and ATNR) reflexes

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Developmental Examination: Birth to 1 Year
Significant Delay
Age
Fisting of hands
> 3/12
Poor head control
4/12
Persistence of primitive reflexes
> 6/12
Persistence of flexor hypertonia in the LLs (popliteal angle < 150*)
> 9/12
Unable to sit independently with straight spine
10/12
Not walking
18/12

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Developmental Examination: Birth to 1 Year
Fine Motor Development
Coordination of vision with head movement (6- 8 weeks) and hand movements - watches own hand (hand regard) or objects held in hands (3- 4 months)
Two- handed reach replaced by single- handed reach (5- 6 months)
Exploration with index finger (8- 9 months)
Maturing grasp: improving apposition of tips of fingers with the tip of the thumb (palmar- 6/12, pincer (thumb- finger)- 9 to 10 months and finger tips (12 months)
Release with open hands or with pressure (10 to 11 months); controlled release - puts one cube on top of another (13 months)

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Developmental Examination: Birth to 1 Year
FINE MOTOR DEVELOPMENT
Coordination of vision with head movement and hand movements - watches own hand (hand regard) or objects held in hands
6- 8 weeks
3- 4 months
Two- handed reach replaced by single- handed reach
5- 6 months
Exploration with index finger
8- 9 months
Maturing grasp: improving apposition of tips of fingers with the tip of the thumb (palmar)
- pincer (thumb- finger)
- finger tips
6 months
9- 10 months
12 months
Release with open hands or with pressure - controlled release - puts one cube on top of another
10- 11 months
13 months

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Development of Grasp: Cube

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Developmental Examination: Birth to 1 Year
Speech, language and communication
Common objects or large toys eg a ball, cup, plate, spoon, car or doll

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Developmental Examination: Birth to
1 Year
Observation of language development: Birth to 1 year

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Developmental Examination: Birth to
1 Year
Observation of language development: Birth to 1 year

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Developmental Examination: Birth to 1 Year
Non- verbal communication
Vocalisation- 3/12
Pointing to ask - 9/12
Pointing to show- (9- 12 months)
Proto- imperative pointing (12 months)
Proto- declarative pointing (16 months)
Conventional gestures eg waving goodbye,blowing a kiss - (9- 12 months)

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Developmental Examination: Birth to 1 Year
Social Development
Social responsiveness and anticipation
Social smile (6- 8 weeks)
Responds to social games eg peek-a-boo and shows anticipation (6 months)
Developing joint attention
Follows other's finger point to look at an object (8 months)
Uses finger and eye pointing to direct others' attention to share interest (9- 12 months)

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Developmental Examination: Birth to 1 Year
Social Development
Becoming stranger aware- reacting by withdrawing or crying (6 months)
Social referencing - checking back by looking towards the caregiver in new situations (12 months)

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Developmental Examination: Birth to 1 Year
Cognitive Development
Observation of infant's cognitive abilities are made during fine motor, communication, play and social interaction activities
4 main structured tasks are used

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Developmental Examination: Birth to 1 Year
1. Physical rules and object relationships
Offer 1 cube:reach, grasp, exploration, hand-to-hand transfer (reach out to grasp:5/12)
Offer another cube: imitation of clicking of two cubes (6/12)
Request for a cube back by putting open hand out- note release
Put an open container and encourage releasing a cube into it and taking it out (9- 15 months)
Inserting pegs into holes (15 months)

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Inserting Pegs into Holes (15 months)

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Developmental Examination: Birth to 1 Year
2. Cause- and- effect understanding and goal directed actions
Pop up or other action toys
Place a toy out of reach and the connected string near the child. Check grasp of string and pulling the string to get the toy
Shake a bell - 7/12, using cause-and-effect toys- 9/12, pulling a toy with a string- 9/12, moving a car- 12 months
Significant delay: No cause-and-effect play by 12 months

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Developmental Examination: Birth to 1 Year
3. Object permanence: Finding a hidden toy (partially/ completely covered with a cloth)
Look for a partially hidden object: 6- 8 months
Search for a toy which has been completely hidden in their view: 9- 10 months

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Object Permanence(9- 10 months)

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Developmental Examination: Birth to 1 Year
4. Categorisation
Use common objects/ toys: a toy, car,cup,spoon, bell, telephone (on self/ doll/ mother)
 10-12 months: infants use similar looking objects/ toys in the same way eg moving toys that look like a vehicle
14 months: show 'definition by use' eg using a hair brush to brush their hair
Significant delay: not defining objects by their use by 18 months

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Categorisation: Common Toys

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Non- verbal perceptual-cognitive development
5. Drawing
Scribble to and fro: 15- 18 months
Circular scribble: 2 years
Draw a man
Copy shapes
Grasp of crayon/ pencil: 3years (50%) -
4 years (80%)
Handedness: appears from 2- 4 years.
Appearance before 12 months, prompt
neurological examination

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Developmental Examination: 1- 5 years
1. Motor development
2. Non- verbal perceptual- cognitive
development
3. Speech, language and communication

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Non- verbal perceptual-cognitive development
1. Block (1- inch cube) construction tasks
Imitate a model (child is shown how to do it)
Copy a model (child is shown a completed model)

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Non- verbal skills tasks,1- 5 years

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Non- verbal perceptual-cognitive development
2. Shape sorting/ jig-saw puzzles/ form boards
30months: Match 3 basic geometric shapes (circle, triangle and square) even when the form board is reversed

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Form board with basic geometric shapes (30 months)

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Non- verbal perceptual-cognitive development
3. Colour matching
and naming
30 months: 50% of children can match cubes/ cards by colour 42- 48 months: name 4 colours correctly

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Non- verbal perceptual-cognitive development
4. Sorting objects by size
3years: point to big/ small cube/spoon/cup
42- 54 months: point to a long/ short line drawn on a paper

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Crayon or Pencil Grasp
Palmar- Supinate Grasp 1- 11/2 years
Digital- Pronate Grasp 2- 3 years
Static Tripod Posture
31/2 - 4 years
Dynamic Tripod Posture
41/2- 6 years

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Goodenough Draw- A- Person Test
Gross detail
Attachments
Head detail
Clothing
Hand detail
Joints Proportion
Motor Coordination
Fine head detail
Profile

40. Visual Behaviour, eye- hand coordination and problem solving
Progressive coordination of maturing vision with head, body and fine motor movements can be observed through: manipulation and use of pellet, rings, bell, cubes, crayon/ pencil, form boards or puzzles.
Achievement in this domain represent the precursor to later non- verbal problem solving abilities, correlate well with intellectual ability and may provide early markers for learning, psychological and psychiatric disorders.

41. Co-ordinated eye movements and eye-head co-ordination
Earliest developmental sequence starts with fixing gaze on the mother’s face  following a face with eyes only co- ordinate eye- head movements to turn head to follow visually
Any abnormality of early visual behaviour should prompt referral for ophthalmological assessment

42. Eye- head co-ordinated milestones
Developmental milestones Mean age Limit age
(months) (months)
Visually alert, orients to face 1 Any delay
Visually follows face 2 Any delay
Co-ordinates eye movements with 3 Any delay
head turning

43. Eye- hand co-ordination
The infant shows visual awareness of hands and becomes increasingly refined in combining vision with hand movements for reaching, grasping, exploring and releasing objects.

44. Eye- hand co-ordination milestones
Developmental milestones Mean age (months)
Holds objects briefly when placed in hands 3
without visual regard
Visually examines own hand 4
Reaches out with a two- handed scoop 5
Reaches out and grasps objects on table surface with a 6
raking grasp
Transfers from hand to hand 6
Explores with index finger 6
Picks up a pellet/ raisin between thumb and finger 9

45. Eye- hand co-ordination milestones
Developmental milestones Mean age (months)
Picks up a string between thumb and finger 10
Can release in a container 10
Has mature grasp 12
Has precise release- without pressing on surface 13
Builds tower of 2 cubes 13
Builds tower of 3 cubes 16
Turns pages of book one page at a time 24

46. Language and communication milestones
Developmental milestone Mean age Range
(months) (months)
Comprehension/ receptive language
Understands ‘no’/’bye’ 7 6- 9
Recognizes own name 8 6- 10
Understands familiar names 12 10- 15
Definition by use: using objects by 15
Giving objects on request by 15
Points to body parts on self/ carer 15 12- 18
Points to body parts on doll 18 15- 21
Identifying objects on naming by 24
Follows a 2- step command 24 18- 27
Understands preposition (in/on) 24 18- 33
Understands preposition (under) 30 24- 39
Understands action words by 36
(eg. eating/ sleeping)
Understands simple negatives 36 30- 42
Understands comparative 42 36- 48
Follows 2 instructions 42 36- 48
Understands complex negatives 48 42- 60
Follows 3 instructions 54 48- 66

47. Language and communication milestones
Developmental milestone Mean age Range
(months) (months)
Expressive language and non- verbal communication
Jargon 12 10 – 15
Syllabic and tuneful babble 8 6- 9
Pointing to demand 9
Pointing to share interest 10 9- 14
One word 12 10 – 18
2- 6 words 15 12- 21
7- 20 words 21 18- 24
50+ words 24 18 – 27
2 words joining 24 18- 30
200+ words 30 24- 36
3- 4 words joining 30 25- 36
Pronouns 42 36- 48
Uses conjunctions (and, but) 48 36- 54
Sentences of 5+ words 48 36- 54
Complex explanations and sequences 54 48- 66

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Speech, language and communication
1. Comprehension
2. Expression
3. Speech sound and fluency: intelligible
speech 2 years (50%), fully intelligible by 4
years
4. Pragmatics:21/2 - 3 years take turns in
conversation, 4 years hold conversation skilfully

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Speech, language and communication
Place some toys/
objects (eg a cup,
spoon, plate, 1
inch cubes, key,
fork, pencil, car,
miniature toys and
pictures for 24
months and
above) near the child
and ask questions

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Step 1
Comprehension
Object labels (15- 18 months): 'look at the....', 'where is the....', 'give me the...."
Identify by use (24- 30 months):
'which one do we eat with/ drink with/ sleep in?' (avoid pointing by finger or looking at the objects while asking)
Expression
Object labels (18- 20 months): 'What is this one', 'this is a ...."

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Step 2
Comprehension (30 months)
Ask without pointing: 'show me who is eating/ sleeping/ running'
Expression (30- 36 months)
Ask while pointing at a picture: 'What is the boy/ girl doing)'

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Step 3
Comprehension
Preposition (24- 36 months)
Colour (identify or name 2 colours by 36 months and four by 48 months)
Size: identify size (bigger/ smaller) of an object or picture (36 months), a longer line (42 months), the weight (heavier of cubes, 48 months)
Numbers: rote counting as a nursery rhyme (3 years), 31/2 - 4 years - count four to six cubes/ objects correctly, 4- 41/2 years- can follow direction to 'put three cubes in the cup'
4+ keyword sentences (42 months): give direction in a single sentence eg 'put the big cube and the spoon in the box'
Joined up sentences (48 months):'Put the spoon in the box and the pencil on the plate'

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Step 3
Expression
Have a conversation with the child: school/ playtime
Look at the picture and tell me what is happening (describing narrative: 41/2- 5 years)
Describe common objects/ concepts:'What is a key/ friend?' (defining words: 52 months)

54. Play and social behaviour
Observation of play offers a unique opportunity to look at a number of developmental sequences as they come together to create an increasingly complex tapestry of play.

55. Developmental sequences involved in play
Cognitive play sequence
9 months Object oriented exploration play (maturing eye- hand co- ordination and object concepts)
18 months
Functional use of real objects on self and others (eg. spoon, brush)
24- 30 months Symbolic use of toys (eg. Toy, tea set, doll)
3- 4 years Pretend or imaginative play

56. Developmental sequences involved in play
Social play sequence
4- 5 weeks
Social smile
(90% by 6 weeks)
6- 12 months
Social anticipation
Lap games
(eg. peek- a- boo, pat- a cake)
10- 15 months Joint attention Points to show
3- 3.5 years
Social imitative play
(eg. role play)

57. Classification of Play Actions into the Five Stages
Stage I
Exploratory
Play
Stage 2
Relational Play
Stage 3
Self
Pretending
Stage 4
Decentered
Pretending
Stage 5
Sequence
Pretending
By physical By usage
Properties
Doll+ object Doll
alone
Same action Theme
Mouthing
Banging two Spoon
Objects in cup
Feeds self with spoon/cup
Feeds doll with Hugs spoon/ cup doll
Feeds doll Sleep
-self sequence
-adult
Shaking/ Hitting
Placing objects Pillow
into another on bed
Combs hair
Combs doll’s Kisses
Hair doll
Pillow
on bed
Doll on
bed –
head on
pillow
Examining
Placing objects ‘Sheet on’ bed/
on top of table
another
Washes self
Washes doll Walks
doll
Combs doll Covers
-self doll
-adult with
sheet
Dropping/ Throwing
Chair to table
Sleeps on doll’s bed or
pillow
Lies doll Makes
on pillow/ doll
Bed jump
Feeling/ Rubbing
Sits on doll’s chair
Dresses self with
doll’s clothes
Sits doll on -dance
Chair -somersault
Dresses/ undresses
doll
Puts doll Feeding
on bed Bathing
Child ‘sleeps’
Gestures adult to sleep

58. Tools
Minitiature toys: Wood table, small spoon (spoon of different sizes), doll, bathtub, 1 aeroplane (small red one), 1 teapot with cover, 1 jug, 1 bowl, 1 small dog/ cat/ cow, 1 car, 2 cups and 2 saucers, 2 chairs (different colours eg white and red of same size).
1 plastic cup, teaspoon, brush, comb, shoe, sock ( 5 items to check on language)
Dangling ball (wooly 12.5cm, plastic 6.25cm)
Small targets (cube 2.25cm, smartie 1.25cm, HT 1.25mm)

59. Gross motor
Delay in achievement of the gross motor milestones may be an indicator of neurological abnormalities and is sometimes associated with a global developmental delay.

60. Development of attention
Stage I- extreme distractibility. Attention shifts from one object/ person/ event to another. Their attention is held momentarily by whatever is the dominant stimulus (Year 1)
Stage 2- children can concentrate on a task of their own choice. They are v. resistant to interference by an adult (Year 2)
Stage 3- can shift their full attention to speaker and back to task with adult support. (Year 3: ‘single- chained attention’)

61. Development of attention
Stage 4- Children begin to become able to control focus of attention. Looks at an adult only when the directions become difficult to understand (Year 4: early ‘integrated attention’)
Stage 5- Can integrate verbal commands related to a task. Attention span still short. (Year 5: mature ‘integrated attention’)

62. Development of attention
Stage 6- Fully integrated attention. Auditory, visual and physical channels are integrated. Attention is well established.(5- 6 years)

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72. Thank You