Continuing Education Activity

Developmental milestones are markers of a child’s development from infancy into childhood. They help determine if a child is undergoing typical development versus if a child has delayed in a given area or over multiple areas in the process of aging development. Milestones are social/emotional, gross and fine motor, language, and cognitive. This activity highlights the role of the interprofessional team in assessing developmental milestones.

Objectives:

• Identify the common stages of development milestones.
• Assess the indications for assessing development milestones in infants and children.
• Identify the importance of diagnostic tests in regards to development milestones.

Introduction

Developmental milestones are a set of goals or markers that a child is expected to achieve during maturation. They are categorized into 5 domains: gross motor, fine motor, language, cognitive, and social-emotional and behavioral. Understanding and identifying the developmental milestones can help the provider more adeptly recognize delayed development, facilitating earlier interventions and improving outcomes.

Typical Milestones

• Six months: Stranger anxiety; Rolls over; begins to say consonants while babbling; brings things to mouth.
• Nine months: Separation anxiety; stands on hands and feet, sits without support, crawls, pincer grasp; understands “no,” points with a finger, says “mama” or “baba;” plays “peek-a-boo.”
• Twelve months: Puts out arm or leg when dressed; cries when familiar people leave; stands well; responds to simple commands, makes gestures, puts things in a cup and removes them, bangs things together.
• Eighteen months: Engages in pretend play, kisses/hugs familiar people, walks alone, walks up steps, eats with utensils, says several individual words, points to 1 body part, scribbles with crayon, marker, or pen.
• Two years: Begins playing with other children, parallel play; stands on tiptoes, kicks a ball, throws a ball overhand; 2 to 4-word sentences, points to things in a book, strangers can understand 50% of language; stacks 4 or more blocks, follows 2-step instructions.
• Three years: Dresses/undresses self, copies others, takes turns; walks up and downstairs with 1 foot per stair, runs easily; strangers can understand 75% of language; stacks 6 or more blocks, turns pages in a book, pushes buttons, and turns knobs.
• Four years: Likes to play with others, more imaginative play; hops on 1 foot, can stand on 1 foot for 2 seconds, cuts with scissors; can recite a poem or sing songs, understands basic grammar; identifies some colors and numbers, draws a person with 2 to 4 body parts.
• Five years: Differentiates between real and pretend, wants to be like friends; can stand on 1 foot for 10 seconds, can somersault; easily understood by others, tells stories, uses future tense; counts to 10, draws a person with 6 body parts, prints some letters and numbers.[1]

Function

The processes of surveillance and screening guide the assessment of developmental disorders. Surveillance is the process by which children at risk or with developmental delays are identified.[2] It is done at every well-child care visit and can be performed using an age-appropriate checklist of milestone records. Special attention must be given to the 4 to 5-year visit before the start of school. Screening is the process by which asymptomatic children at risk of developing a disorder are identified via standardized testing.[1] Once a child screens positive, he or she should undergo a subsequent developmental-behavioral evaluation.[2] The American Academy of Pediatrics recommends screening at ages 9, 18, and 30 months. The Denver Developmental Screening Test and the Ages and Stages Questionnaires are 2 examples of screening tools in use.

When evaluating a child, it is important to take into consideration the gestational age at birth, as premature infants have a higher risk of long-term neurodevelopmental disabilities. To assess a premature infant's normal growth and development, the clinician must adjust the chronological age to the appropriate gestational age and the milestones to the corrected gestational age. For example, a baby is born at 32 weeks, and it is 8 weeks premature, based on a full-term baby born at 40 weeks of gestation. One would expect this 32-week-old baby to reach their milestones 2 months behind their chronological age.  Implementing both surveillance and screening enhances early identification, enabling more prompt intervention and promoting improved outcomes.[3] 

Issues of Concern

The developmental milestones evolve with the child as he or she ages. Clinicians must develop familiarity with the normative dynamic process of maturation so that delays can be promptly identified. Responsiveness to intervention is most prominent in early childhood. The later the developmental aberration is identified, the more pronounced the risk becomes for developing emotional, social, and academic dysfunction.[2] Delays in development can be overlooked for a multitude of reasons. Sometimes, the delay is subtle and undetectable on a brief exam. Furthermore, parents may negate the existence of a perturbation and not report any abnormalities to providers. Because delays can be missed, it is important to maintain routine surveillance.

Developmental delays can be specific (present in 1 area) or global (present in greater than 2 areas). Children can present initially with only a specific delay but can go on to develop subsequent delays in additional areas of functioning, thus advancing to a global delay.[1] Of the 5 areas of development, language may be considered the most salient to assess, as it is an important predicting factor for literacy level and cognitive skills and benefits the most from earlier interventions.[4][5]

Clinical Significance

Children with delays qualify for early intervention, a program that can help them catch up to development typical for their age. These interventions may include speech therapy, physical therapy, and occupational therapy. The earlier delays are identified and addressed, the more positive the prognosis.[6][7] Once a delay in development is identified, the clinician must try and find the etiology of the delay. A child with a speech delay may have an underlying hearing problem, whereas children with visual problems may have delays in motor development. Genetic and metabolic conditions can also precipitate developmental delays, often global. Children with cerebral palsy also present with global delays. A thorough workup should include hearing screening, thyroid function testing, lead testing, and a microarray.[8][9]

In disorders such as autism, one may begin to see deviations in development, especially in the social/emotional and verbal areas, as early as 6 months of age. The importance of detecting this early on is that the earlier a child has interventions, the more likely a child is to become more functional. The older a child gets without detecting these delays, the therapies, while still useful and worth the effort, may become less effective. Unfortunately, many children with an autism spectrum disorder do not receive a diagnosis until after age 5. Many pediatric offices use screening tools, the most well-studied of which is the Modified Checklist for Autism Screening in Toddlers and subsequent variations of this tool.[10] Other examples include intellectual disability, attention deficit hyperactivity disorder, hearing impairment, and cerebral palsy. Regardless of the disorder, developmental milestones help uncover the developmental aberration and promote prompt intervention.

Enhancing Healthcare Team Outcomes

How a child's development progresses in the first years of life can dictate the individual's lifelong development and the level of success they could achieve in adulthood. The role of the primary care physician is crucial in the recognition of normal development and the identification of developmental delays. The provider should outline appropriate anticipatory guidance to the caregiver and educate them on what they should expect their child to achieve as they grow. Developing a strong relationship with parents is important to ensure that when any abnormality in the child's development is identified, the parents acknowledge the perturbation and acquiesce to recommended intervention strategies and treatment plans. 

Developmental delays, such as speech and language delay, can be a presenting feature of conditions such as autism spectrum disorder and also serve as a prognostic factor.[10] Therefore, the recommendation of the American Academy of Pediatrics is to screen at 9, 18, and 30 months and screening for autism spectrum disorder at 18 and 24 months.[1] A child with motor delay should have a thorough physical examination, including a complete neurological exam; laboratory testing should include creatine kinase and thyroid function, and brain imaging should be considered. 

A further, complete evaluation is necessary if screening results concern developmental delay. Evaluations ideally performed by developmental specialists (neurodevelopmental pediatricians, developmental-behavioral pediatricians, pediatric neurologists, and pediatric psychiatrists) can occur at home or medical centers. Early childhood professionals such as educators, psychologists, social workers, and therapists must be included in the multidisciplinary team to ensure the child receives appropriate care. 

Referral to early intervention programs as early as possible is valuable to ensure more positive outcomes. These programs provide complete evaluations and connect families with the required services, providing them with service coordinators and social workers who can assist families with issues such as transportation, home visits, counseling, and insurance. It is essential to recognize that a specific diagnosis is not required to refer to Early Intervention and to educate parents that they can also request the referral.[2]

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

References

1.

Scharf RJ, Scharf GJ, Stroustrup A. Developmental Milestones. Pediatr Rev. 2016 Jan;37(1):25-37; quiz 38, 47. [PubMed: 26729779]

2.

Lipkin PH, Macias MM., COUNCIL ON CHILDREN WITH DISABILITIES, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS. Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics. 2020 Jan;145(1) [PubMed: 31843861]

3.

Anderson LM, Shinn C, Fullilove MT, Scrimshaw SC, Fielding JE, Normand J, Carande-Kulis VG., Task Force on Community Preventive Services. The effectiveness of early childhood development programs. A systematic review. Am J Prev Med. 2003 Apr;24(3 Suppl):32-46. [PubMed: 12668197]

4.

Lejarraga H, Kelmansky DM, Passcucci MC, Masautis A, Insua I, Lejarraga C, Nunes F. Assessment of child psychomotor development in population groups as a positive health indicator. Arch Argent Pediatr. 2016 Feb;114(1):23-9. [PubMed: 26914071]

5.

Preston JL, Frost SJ, Mencl WE, Fulbright RK, Landi N, Grigorenko E, Jacobsen L, Pugh KR. Early and late talkers: school-age language, literacy and neurolinguistic differences. Brain. 2010 Aug;133(Pt 8):2185-95. [PMC free article: PMC3139938] [PubMed: 20826428]

6.

Garg A, Dworkin PH. Applying surveillance and screening to family psychosocial issues: implications for the medical home. J Dev Behav Pediatr. 2011 Jun;32(5):418-26. [PMC free article: PMC3111883] [PubMed: 21522019]

7.

Lipkin PH, Okamoto J., Council on Children with Disabilities. Council on School Health. The Individuals With Disabilities Education Act (IDEA) for Children With Special Educational Needs. Pediatrics. 2015 Dec;136(6):e1650-62. [PubMed: 26620061]

8.

Weitzman C, Wegner L., Section on Developmental and Behavioral Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. Council on Early Childhood. Society for Developmental and Behavioral Pediatrics. American Academy of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems. Pediatrics. 2015 Feb;135(2):384-95. [PubMed: 25624375]

9.

Guevara JP, Gerdes M, Localio R, Huang YV, Pinto-Martin J, Minkovitz CS, Hsu D, Kyriakou L, Baglivo S, Kavanagh J, Pati S. Effectiveness of developmental screening in an urban setting. Pediatrics. 2013 Jan;131(1):30-7. [PubMed: 23248223]

10.

Kover ST, Edmunds SR, Ellis Weismer S. Brief Report: Ages of Language Milestones as Predictors of Developmental Trajectories in Young Children with Autism Spectrum Disorder. J Autism Dev Disord. 2016 Jul;46(7):2501-7. [PMC free article: PMC4903886] [PubMed: 26936159]

Disclosure: Sevan Misirliyan declares no relevant financial relationships with ineligible companies.

Disclosure: Annie Boehning declares no relevant financial relationships with ineligible companies.

Disclosure: Manan Shah declares no relevant financial relationships with ineligible companies.