Developmental Screening in Young Children Key Points

• Always refer the child to audiology if language is delayed.

• Never ignore parents' concerns.

• Suspect delays and refer early.

• Developmental screening, using parent report measures, is more accurate than clinical judgment.

• Autism usually manifests as language delay.

Every encounter between a physician and child involves developmental and behavioral issues. Attention to such matters can benefit every child. By monitoring development, the primary care physician has the opportunity to customize anticipatory guidance based on the child's current abilities and temperament (Sturner and Howard, 1997).

Additionally, the family physician has a responsibility to identify children with delayed development. Federal law (Individuals with Disabilities Education Act [IDEA]) mandates physicians to refer children with suspected delays to early intervention (birth to 3 years) or early childhood services (3 to 5 years). The specifics of these services vary from state to state but are free and individualized according to the child's and family's needs (AAP Committee on Children with Disabilities, 1999). As the professional with the most frequent—and sometimes only—contact with young children, the family physician is in the ideal position to detect possible developmental problems. Additionally, parents may feel more comfortable sharing concerns and seeking advice from a trusted physician.

Early detection of delays is important, because brain development is most malleable in the early years of life (Shonkoff and Phillips, 2000). Early intervention has been shown to be cost-effective, resulting in better intellectual, social, and adaptive behavior, increased high school graduation and employment rates, and decreased criminality and teen pregnancy (Gomby et al., 1995; Reynolds et al., 2001). Unfortunately, less than half of children with developmental difficulties are identified before kindergarten (Pelletier and Abrams, 2002).

Research shows that clinical impression alone is quite poor at detecting developmental delays (Glascoe, 2000). This has led the AAP to recommend routine monitoring (surveillance) at all preventive care visits and use of standardized developmental screening tests at 9, 18, and 24 or 30 months of age, with the addition of autism-specific screening at 18 and 24/30 months (AAP Council on Children with Disabilities, 2006). Newer screening tools based on parent report can facilitate fulfilling this recommendation. Parent report has been found to be a reliable way to identify children in need of further developmental assessment, particularly if the concerns are elicited and interpreted in a standardized manner (Glascoe, 2003).

Table 23-7 Temperament Characteristics and Profiles





Frequency and speed of involvement


Regularity of physiologic functions (e.g., hunger, sleep, elimination)


Immediate reaction of child to new stimuli


Degree of ease or difficulty with which child adjusts to new stimuli


Energy level of responses, without regard to positive or negative quality of the response


Predominance of pleasant and friendly versus unfriendly behavior during waking

Attention span/ persistence

Length of time the child will engage in a single activity with or without interruption


Degree of ease with which extraneous stimuli interfere with child's task performance

Sensory threshold

Amount of external stimulation required to evoke a response


Easy (40% of children)

Regularity of biologic functions; positive approach responses to new stimuli; high adaptability to change; mild to moderately intense mood that is predominantly positive

Difficult (10% of children)

Irregularity of biologic functions; negative withdrawal responses to new stimuli; no or slow adaptability to change; intense expressions of mood that are predominantly negative

Slow to warm up (15% of children)

Negative responses of mild intensity to new stimuli, with slow adaptability with repeated contact; mild intensity of reactions

Modified from Chess S, Thomas A. Dynamics of individual behavior development. In Levine MD, Carey WB, Crocker AC (eds). Developmental-Behavioral Pediatrics. Philadelphia, Saunders, 1992, p 86.

Table 23-8 Developmental Milestones in Young Children


Gross motor

Fine motor/Reflex motor

Social/Adaptive/ Cognitive



Flexed attitude, turns head side to side when prone without lifting, head sags if unsupported, body sags on ventral suspension

Reflex: Moro symmetric, grasp reflex, stepping reflex, suck reflex, placing reflex

Fixates on face or light, moves in cadence with sound

Alerts to voice

1 mo

Extends legs more, holds chin up briefly when prone, head lag persists

Reflex: Persistence of neonatal reflexes, tonic neck posture

Watches person, visually tracks to midline, begins to smile, body moves in cadence with voice

Throaty noises, range of cries to signal hunger, pain, etc.

2 mo

Raises head from prone position, sustains head in plane with body or ventral suspension, head lag on pull to sit

Reflex: Stepping reflex fades

Smiles on social contact, attracts to voice


4 mo

Head up to vertical axis in prone position, bears weight on arms, extends legs, symmetric posture with hands in midline in supine position, no head lag on pull to sit, pushes with feet in standing position, holds head erect in sitting position

Fine: Grasps and attains object, brings to mouth Reflex: Grasps, Moro, tonic neck fade; downward parachute present

Laughs out loud, voices displeasure if contact is broken, excites at sight of food, regards a small pellet

Vowel sounds, visually searches for speaker

6 mo

Sits alone with rounded back, rolls over, pivots, creeps

Fine: Rakes at pellet, transfers, turns body to reach Reflex: Sideways parachute present

Prefers mother, responds to emotion, imitates banging, visually follows dropped objects

Polysyllabic babble, blows bubble ("raspberry"), laughs

9 mo

Sits with erect back, crawls, walks holding both hands, pulls to stand, can get to sitting position

Fine: Pokes with forefinger, uses assisted pincer grasp Reflex: Forward (7 mo) and backward parachute present, plantar grasp fades

Plays "peekaboo," "pat-a-cake"; waves bye-bye; finds an object after watching it hidden; may cry at sight of unfamiliar person

Responds to some verbal commands: "no"; imitates some sounds; uses "mama," "dada" nonspecifically

12 mo

Cruises holding on, stands alone, may take several steps, walks holding hand

Fine: Neat pincer grasp, releases on request; puts 2 cubes in cup, pellet in bottle

Plays ball, adjusts posture when dressing, drinks from a cup, imitates activity (talks on toy phone)

1-2 true words, symbolic gestures (e.g., shakes head "no"), points to indicate wants

15 mo

Walks alone, crawls up stairs, walks backward, rises after stooping

Fine: Dumps pellet from bottle or draws line with crayon when demonstrated, scribbles spontaneously, stacks 2 cubes

Feeds self with utensils, performs simple household tasks (pick up toys), hugs parent

Points to body parts, jargons, follows 1-step command without gestures

18 mo

Runs stiffly, sits on small chair, walks up stairs with hand holding rail

Fine: Tower of 4 cubes, dumps pellet on request, imitates line with crayon

Feeds self with utensils; kisses parent with pucker; explores drawers, wastebaskets; removes garment; seeks help when in trouble

10 words, says "no," names pictures, points to 1 body part

24 mo

Runs well; walks up and down stairs, one at a time; jumps in place, climbs on furniture; kicks ball

Fine: Tower of 7 cubes, "train" of 4 cubes; imitates vertical and circular crayon stroke; imitates folding paper

Listens to story with pictures, helps to undress, dresses with help, parallel play, uses spoon well

30-50 words; 2- or3-word sentences; uses pronouns, sometimes incorrectly; relates recent experience; speech 50% intelligible

36 mo

Alternates feet climbing stairs, stands on one foot briefly, broad jumps with both feet, pedals tricycle, throws ball overhand

Fine: Tower of 10 cubes, imitates "bridge" of 3 cubes, imitates cross, copies circle, attempts to draw person

Knows age and gender, counts 3 objects, repeats 3 serial numbers, understands turn-taking, washes and dries hands, helps with dressing

States full name; uses complete sentences; speech 75% intelligible to stranger; uses plurals, past tense, pronouns correctly



Table 23-8 Developmental Milestones in Young Children—cont'd


Gross motor

Fine motor/Reflex motor

Social/Adaptive/ Cognitive


48 mo

Hops on one foot, throws ball overhand, balances on each foot 2-3 seconds

Fine: Uses scissors to cut out pictures; copies cross, square; draws man with head and 2-4 body parts (pairs count as 1 part); tells a story

Counts 4 objects correctly, group play with role playing, toilets independently, dresses with little supervision

60 mo

Skips, balances on each foot 4-5 seconds

Fine: Copies triangle, 8- to10-part person

Counts 10 objects, prints first name, domestic role playing, asks meaning of words, dresses and undresses independently

Uses complete sentences, names 4 colors, repeats 10-syllable sentence, follows 3-stage command

Compiled from Vaughn VC, Litt IF. Growth and development. In Behrman RE, Kliegman RM, Nelson WE, Vaughn VC (eds): Nelson Textbook of Pediatrics, 14th ed. Philadelphia, Saunders, 1992, pp 41-42.

Parent report measures can be used in a variety of ways. They can be completed in the waiting room, sent out to be returned at the next appointment, or completed via an interview, either in person or by telephone with a staff member. It is helpful to have a staff member routinely inquire if the parents would like someone to go over the measure with them; this ensures that literacy or language issues are not barriers to screening. Even if staff administer the parent report, parent report measures are the most accurate and time-effective and cost-efficient method of developmental screening currently available. Accurate screening tools with acceptable sensitivity and specificity (70%-80%) are listed in Table 23-9. Physicians can bill for screening, although reimbursement varies widely (Glascoe, 2003). More information regarding developmental screening, including coding and billing aspects, can be found at the Developmental Behavioral Pediatrics website.

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