Dr.Khalid Hama salih,
Pediatrics specialist
M.B.Ch.; D. C.H
An estimated 12-16% of children have a
developmental and/or behavior disorder
Only 30% are identified before school entrance
Those detected after school entrance miss out
on early intervention services proven to have
long term health benefits
Delay - implies slow acquisition of all skills
(global delay) or of one particular field or area
of skill (specific delay), particularly in relation
to developmental problems in the 0-5 years
age group.
Development delay
the condition where a child does not reach one
of the stages of development at the expected
For example, if the normal range for learning
to walk is between 9 and 15 months, and a 20month-old child has still not begun walking,
this would be considered a developmental
Chromosome/DNA disorders, e.g. Down's
syndrome, fragile X syndrome
Cerebral dysgenesis, e.g. microcephaly, absent
corpus callosum, hydrocephalus, neuronal
migration disorder, vascular occlusion
Hypothyroidism, phenylketonuria
Alcohol and drug abuse
Congenital infection
Rubella, cytomegalovirus, toxoplasmosis
Tuberous sclerosis, neurofibromatosis
Extreme prematurity
Intraventricular haemorrhage/periventricular
Birth asphyxia
Hypoxic-ischaemic encephalopathy
Symptomatic hypoglycaemia, hyperbilirubinaemia
Meningitis, encephalitis
Suffocation, near drowning, seizures
Head injury - accidental or non-accidental
The severity can be categorised as:
Types of delay
1.Global developmental delay implies delay in
acquisition of all skill fields (gross motor,
vision and fine motor, hearing and
speech/language, social/emotional and
behaviour). It usually becomes apparent in
thefirst 2 years of life.
. However, some children present later with,
for instance, delay in speech and language but
review of their developmental history may
reveal delayed gross and fine motor Global
developmental delay is likely to be associated
with cognitive difficulties although these may
only become apparent several years later.
2.Specific developmental delay is when one
field of development or skill area is more
delayed than others or is developing in a
disordered way
Abnormal motor development
This may present as delay in acquisition of
motor milestones, e.g. head control, rolling,
sitting, standing, walking or as problems with
balance, an abnormal gait, asymmetry of hand
use, involuntary movements or rarely loss of
motor skills. Concern about motor
development usually presents between 6
months and 2 years of age when acquisition of
motor skills is occurring most rapidly
Causes of abnormal motor
development include:
cerebral palsy
congenital myopathy/primary muscle disease
spinal cord lesions, e.g. spina bifida
global developmental delay as in many
syndromes or of unidentified cause
Fine motore &vision:
Visual impairment may present in infancy
with: loss of red reflex from a cataract
a white reflex in the pupil, which may be due
to retinoblastoma, cataract or retinopathy of
prematurity (ROP).
not smiling responsively by 6 weeks post-term
lack of eye contact with parents
visual inattention, random eye movements
nystagmus ,squint
Hearing speech and language
Abnormal speech and language development
A child may have a deficit in either receptive
or expressive speech and language, or both.
The deficit may be a delay or a disorder.
Speech and language delay may be due:
global developmental delay
to hearing loss
difficulty in speech production from an
anatomical deficit, e.g. cleft palate, or
oromotor incoordination, e.g. cerebral palsy
environmental deprivation/lack of opportunity
for social interaction
normal variant/familial patter
Abnormal development of
social/communication skills
Children who fail to acquire normal social and
communication skills may have an autistic
spectrum disorder. The prevalence of autistic
spectrum disorder is 3-6/1000 live births. It is
more common in boys. Presentation is usually
between 2 and 4 years of age when language
and social skills normally rapidly expand. The
children present with a triad of difficulties and
associated co-morbidities
Developmental Quotient (DQ)
 Divide child’s developmental or best milestone
age (DA) by child’s chronological age (CA)
 DQ = DA/CA x 100
 DQ of 100 = mean or average rate
 DQ < 70 is approx. 2 standard deviations
below the mean
Developmental Quotient
DQ > 80 may be considered normal
DQ 70-80 borderline
DQ < 70 is abnormal
Investigations or assessment to
karyotypeCytogenetic 4-2.
abnormal developmTable
*Fragile X analysis
analysis, e.g. for chromosome 7, 15
consider for
Thyroid function tests, liver function tests, bon
chemistry, urea and electrolytes, plasma a
Creatine kinase, blood lactate, VLCFA (very lo
chain fatty acids), ammonia, blood gases, white
(lysosomal) enzymes, urine amino and organic
acids, urine mucopolysaccharides (GAG) reduc
Maternal amino acids for raised phenylala
Congenital infection screen
CT and MRI brain scans
Skeletal survey
Cranial ultrasound in newborn
EEG (may be specific for seizures, some
progressive neurological disorders)
Nerve conduction studies, EMG, VEP (visual
Assistive technology (devices a child might
 Audiology or hearing services
 Counseling and training for a family
 Educational programs
 Medical services
Nursing services Nutrition services
 Occupational therapy Physical therapy
 Psychological services Respite services
 Speech/Language

Delayed Developmental Milestones – Dr. Khalid