Paediatrics and Child
Health
The child with developmental
delay / learning difficulties
Learning outcomes
you should be able to …
1. Recognise the key stages of normal childhood
development
2. Make an outline assessment of a child with
developmental delay
3. Use playtime to assess the nature and degree of
delay
4. Recognise major differences between global and
isolated areas of delay
… more learning outcomes
5. Identify major categories of developmental delay in
patients
6. Initiate appropriate investigations for the cause of
developmental delay
7. Work with the multidisciplinary team in the
assessment and care of patients with developmental
delay
8. Assess the impact of delay and / or complex needs
on the child and the family
9. Recognise multiple factors impacting on a child’s
ability to learn
1. Recognise the key stages of
normal childhood development
Typically developing children
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Sequence of acquired skills
Areas of development in young children
Quality of skills
Four Domains of Development
1.
2.
3.
4.
Gross motor skills
Fine motor and visual skills
Hearing, speech and language skills
Social, emotional and behavioural skills
Cognitive development refers to higher mental
function
Developmental surveillance
Reviews
 Newborn examination
 6-8 weeks
 6-9 month
 18-24 months
 3-3 ½ years
 Preschool review
Age for walking for typically
developing children
100
90
80
70
60
50
40
30
20
10
0
% Walking and
age in months
11 12 13
15
18
‘Normal’

Median age for walking
is 12 months

Limit age (2 standard
deviations above
average) is 18 months
Typically Developing
Child:Gross motor
Newborn examination: limbs flexed, marked head lag
6-8 weeks: Lying prone, lifts head to 45 degree
6-9 month: little or no head control on pull-to-sit (3m), rolls back
to front (6m), sits without support (8m)
Gross motor
(12-18 months):
crawls (10m)
stands independently (11m)
walks independently (12m)
Gross motor
18 -24 months:
squats to pick up an object (18m) Runs (2y)
runs (2y)
walks upstairs holding on and two feet to a step (2y),
3-3 ½ years:
walks alone upstairs with alternating feet per step (3 y)
pedals tricycle (3y)
4 years:
Hops (4y)
Limits ages: Gross motor
skills
Still has head lag at 4 months
(not in line with spine on pull to
sit)
 Persistent primitive reflexes 34 months
 Unable to sit unsupported at
9m
 Not walking independently at
18m
 Nb asymmetry at any age

Fine motor and visual skills
Newborn examination: hands
closed
6-8 weeks: Does your baby
watch your face and follow
with his/her eyes? Fixes and
follows briefly
6-9 month: Have you noticed a
squint?
Palmar grasp (5m)
Passes toy from hand to hand
(6m)
Inferior (raking) pincer grasp (9m)
Looking for falling toys: object
prmanence (9m).
Fine motor
12-18 months:
Refined pincer (10 ½ m)
Tower of two bricks (15m)
Scribbles spontaneously (15m)
Imitates stroke (18m)
Fine motor
18-24 months:
Tower 3 bricks (18m)
Tower 6 or 7 bricks (2 years)
Fine motor
3 – 4 years:
Copies (pre-drawn) circle (3y)
Draws person: head and one other part (3y)
Copies (pre-drawn) cross (4y)
Draws person: head, legs and arms (4y)
Copies pre-drawn square (4 ½ y)
Draws person: face, trunk,legs, arms (5y)
Limits ages: Fine motor skills
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Not fixing and following
visually at 3 m
Not reaches for objects at 6 m
Not transferring objects at 8m
Not developed pincer grasp at
12m
Not turning pages 24m
Inability to stack graded cups
24m
Hearing, speech and language
Newborn: startles to loud noises
6 - 8 weeks: vocalises when
pleased 6 ½ weeks
6 – 9 months:
Turns to sounds (7m)
Babbbles (6 ½ m) monosyllabic then
polysyllabic
Hearing and language
12 – 18 months:
Knows and turns to own name
(12m)
Shows undersatnding of familiar
objects and people (12m)
Points to show interest (15m)
Can point to two named body
parts (on self) (15m) on doll
(18m)
Uses 2 to 6 recognisable words
(15m)
Hearing and language
18 – 24 months:


Follow a two-step command (2y). Put the brick in the cup.
Puts 2 or more words together to form simple sentences (2y)
e.g.‘Daddy car’
(Do Not count phrases that are heard together e.g. Thank you)
3 – 3 ½ years:
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Understands commands with three key words (3y)
Understand negatives (3y)
Uses ‘what’ and ‘how’ (3 y)
Uses personal pronouns (me/ you) (3 ½ y)
Hearing and language
4 years:
Asks why? When? how.? (4y)
Able to tell long stories (4y)
Counts (by rote) to 20 (4y)
Limits ages: Hearing, speech
and language

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No double syllable babble aged
12 m
No words with meaning at 12m
Fewer than 6 words at 18 m
Not responding to one word
commands at 18 m
No 2 – 3 words phrases at 2 ½ y
Unintelligible/ repeating phrases
without meaning at 3 y
The child who appears not to
understand
Parental / professional concern
Social, emotional and
behavioural skills
6 – 8 weeks:
Smiles responsively
6 – 9 months:
Takes everything to mouth (7m): should disappear by 12m
Put hand up to bottle/ breast when feeding (6m)
Stranger awareness (9m)
Plays peek-a-boo (9m)
Social, emotional and
behavioural skills
18 – 24 months:
Holds spoon and gets food to mouth (18m)
Plays alongside other children (2y)
3 – 3 ½ years:
Shares toys.(3y)Simple make- believe play
with peers (3y)
Eats with fork and spoon (3y)
Able to postpone urination during the day
(3y)
Can pull pants up and down.
Social, emotional and
behavioural development
4 years:
Eats with knife and fork. Understands taking turns.
Dress and undress excluding fastenings (3 ½ to 4 y)
Limits ages: Social, emotional
and behavioural skills
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Not smiling at 8 weeks
Persistent mouthing at 12m
No symbolic play at 3.5 years
Not playing with peers at 3.5
years
Other concerns
Further reading:


Illustrated Paediatrics
From Birth to Five Years Children’s
Developmental Progress, Mary D Sheridan
2. Make an outline assessment
3. Use playtime to assess delay
Observe: Start with some typically developing children. Observe
the child’s play
History: Ask parents about developmental milestones
Their baby’s gestation at birth and current age
Do the parents have any concerns
Examination: Use available toys: bricks, pencil paper, books, balls
to test 4 domains of development: Gross motor, fine motor and
vision, language and hearing, social
Interpretation: Consider the 4 domains of development. Is the
child achieving expected developmental progress in all areas?
Developmental Assessment Tools
Standardised assessment
tools you may see in use:
 The “Schedule of
Growing Skills” (Nelson)
 The Denver charts
 The Griffiths Scales
During your training you should aim to:
1. Observe a developmental assessment in clinic
2. See a child at home with a health visitor
3. Carry out some outline assessments (start with a typically
developing child)
Developmental assessment in
clinic

History
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Developmental assessment
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Antenatal history
Birth history
Medical History
Developmental history
Family and social history
Fine motor, language and then gross motor (we start with
tasks the child can do). Usually dependent on Hx for selfcare and interactive social skills. Qualitative observations
Examination inc OFC, Ht, Wt
4. Difference between global and
isolated delay
John Smith, aged 3, was slow to walk … at
what age would you expect most children to
be walking independently?
Adam Scott, aged 10 months, was slow to
babble … when would you expect a baby to
babble? …and what about first words, when
do they emerge?
Differential diagnosis
Delayed walking
Neuromuscular Problem
Global delay
Isolated late walking
Clinical Evaluation

Antenatal history
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Birth history
Medical history
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Fine motor, language, social skills, red book
Social history
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Serious illness
Developmental history
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Fetal movements, IUGR
Risk factors for cerebral palsy, drugs , alcohol, Rx
Deprivation
Family history

Delayed walking, illness, consanguinity
Clinical examination
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Neurological
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Movement and posture, muscle mass, power, tone,
reflexes, sensation, bladder and bowel control
? muscle, neuromuscular, motor neuron, CNS
OFC, vision, hearing, dysmorphism, skin
Developmental
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General developmental assessment
? global v. isolated
Importance of follow up and monitoring progress
Investigations
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
Creatine kinase (boys not walking by 18
months)
Other investigations as indicated to support
clinical diagnosis
Differential diagnosis
Delayed talking
Check hearing
Global delay
Isolated speech
delay
Language problem
Communication
disorder
Speech delay
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Is there a hearing problem?
Is there evidence of global delay?
Is there a speech or language problem?
Is this a pervasive communication problem?
Clinical Evaluation
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History
Examination
Developmental assessment
Investigations
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All children with delayed talking should have a
hearing test
Other investigations depend on clinical picture e.g.
Fragile X, Woods light and others for child with autism
MRI and high resolution karyotyping inc FrX
positive yield in 1 in 6 undiagnosed cases
Is there a speech and
language problem
Delayed speech
Normal
comprehension
Delayed
comprehension
Speech problem
Language problem
Peter Small, aged 7, was difficult to engage in
conversation in clinic, what kind of conversation
would you expect to have with a child of this age?
Think of some reasons why a 7 year old child may
have difficulty holding a conversation
Is this a pervasive
communication problem?
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Does the child have normal non-verbal
communication skills?
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Smiling, gaze fixation
Turn taking
Pointing
Waving
Showing and sharing
Is there ‘autistic’ behaviour?
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Clinically
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Social interactions (‘avoidance’)
Play skills (‘mechanical’ not ‘imaginative’)
Obsessions (video, routes, routines)
Standardised assessment
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DSM IV / ICD 10 criteria
Autism Diagnostic Interview
Autism Diagnostic Observations Schedule
Normal Development
Severity of Developmental
delay
20
5
0
% child population
Developmental abilities and
intelligence in the childhood
population follow a normal
distribution curve just like
height or weight.
70
100
140
Developmental quotient
Children whose attainments
fall below the 2nd centile have
a significant delay.
Intelligence quotient (DQ) <70
(Average DQ = 100)
Delays are divided
into:
DQ
Mild
60-70
Moderate 50-60
Severe
40-50
Profound <40
Identifying developmental delay
During the first year of life ….
 the most dramatic changes seen in development are
in the area of gross motor skills as the child learns to
walk
 Severe or moderate global developmental delay
may be first noticed because the child is slow to sit,
roll, crawl and walk – but the sequence of these
events will follow the normal pattern
 Detailed assessment will show if the delay is global
or specific
cognitive
social
Communication
Fine motor
Gross motor
Patterns of developmental
delay
Typically developing
child
Global delay - all areas
e.g. Down syndrome
Specific delay - gross motor skills
e.g. Spastic diplegia, spina bifida

cognitive
social
Communication

The child makes a lot of
progress with speech and
language development
It is often during the second
year of life that children with
autism present with a specific
delay of language and social
skills
Loss of skills is always
significant
Fine motor

Gross motor
During the second year of life
Typically
developing chilc
Specific delay –
Social skills and
communication
During the fourth year of life
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Cognitive abilities become
more apparent with increasing
age.
As children approach school
age mild or moderate learning
difficulties may be noticed for
the first time by pre-school
teachers who will refer to the
educational psychologist and
paediatrician.
Case Study

Amy is a 7 year old school girl. She was
healthy at birth. Her 7 month health visitor
developmental screen suggested that her
development was within satisfactory limits

What does this mean in terms of the four
areas of development discussed earlier?
Thinking time ….
At 7 months Amy was able to Gross motor
Fine Motor
Communication
Social
sit independently on the
floor
pass a toy from hand to
hand
vocalise and babble
turn when called
look to see where a
fallen toy has gone
Case study 1 continued

Amy then had an episode of encephalitis of
unknown cause. Her parents were
devastated. She recovered and she is now a
happy seven year old school girl, but she has
an acquired cerebral palsy affecting all four
limbs and severe learning difficulties. Amy is
well supported at home and at school
Write a list of people, whom you think will be
involved in her care …
The support network includes..
1. Parents and
family
2. Professionals  Health

Social Services

Education
Parents and professionals form
the multi-agency team who
together develop a “care plan” to
meet all Amy’s needs
The best way to find out more is
to talk to parents and
professionals and sit in on a
multi-agency meeting
The support team - school
Amy has a special seat at school and a special
tricycle for playtime. She does daily physio with her
teachers aid as well as school work, such as
threading beads and posting shapes.
She knows her shapes and colours, but her speech
is difficult to understand, so she is learning to use
Makaton signs and she has an Alphasmart to record
her ideas. Her peers are reading, writing and
running about at play time. They like to come and
help Amy, but she can’t join in with all their games.
The support team - home
At home Amy has a hoist to lift her onto her bed
and into the bath. How do you think she gets up
stairs? Who will advise her about her exercises
and equipment needs? Who advises about
about extra help at school and at home? Are
these people on your list?
Consider the day to day reality for Amy’s parents
as they care for her, helping her to stay healthy
and learn new skills. Parents react in different
ways. Find out from parents and young people
what kind of help they need.
Factors that influence
development and learning
Many factors affect a child’s ability
to progress and achieve their potential
social
Poor nutrition
Poor housing
Poor parenting
physical
Muscle weakness
Pre-maturity
Ear Infection
emotional
More Resources
1.
2.
3.
4.
5.
6.
The cerebral palsy website www.scope.org.uk
The national autistic society website
www.nas.org.uk
Contact a family website www.cafamily.org.uk
www.downs-syndrome.org.uk
There is also a good site written by a
parent/paediatrician of a child with down’s
syndrome www.ds-health.com
Paediatric information www.pier.org.uk
remember….
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Children learn through play and are continually
gaining new skills

You can learn about children by watching them
at play and playing with them

Understanding normal development helps you to
recognise the child with developmental delay like all new skills this takes time

Parents know their child best – ask them what
their child can do and if they have concerns
Specialty evaluation
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Confirmation and categorisation of child’s
developmental delay
Identification of underlying aetiology
Referral to, and assurance of, the provision of
appropriate therapy services and resources
Counselling of family regarding diagnosis. Aetiology
and prognosis
Identification of any possible co-existing conditions
that may require medical intervention and ongoing
management