1. Assessment of Development
Dr Sunil Agrawal
1st yr, MD Pediatrics
IOM

2. Topics
• Introduction
• Principles of development
• Value of developmental assessment
• Different domains of development
• Assessment of development
• Screening tests
• Definitive tests
• Development Quotient
• Conclusion

3. Introduction
• Development is the individual level of
functioning, a child is capable of, as a
result of maturation of the nervous system
and psychological reactions
• It is the qualitative and quantitative
changes and acquisition of a variety of
competencies for functioning optimally in a
social setting.

4. • Developmental assessment – milestone
acquisition occurs at a specific rate and in
an orderly and sequential manner
• Abnormality can be delay, deviancy, or
dissociation

5. Principles of Development
• Development is a continuous process from
conception to maturity
• Sequence of development is same in all children
but rate varies
• Development is intimately related to maturation
of nervous system- opportunity to practice
• Generalized mass activity replaced by specific
individual response

6. Principles of Development
• Development is in cephalocaudal direction
• Certain primitive reflexes lost before corresponding
voluntary movement is acquired
• Generalizations about development cannot be based on
the assessment of skills in a single developmental
domain. However, skills in one developmental domain do
influence the acquisition and assessment of skills in
other domains.

7. Value of Developmental
Assessment
• For parents-
– If previous pregnancy miscarriage or stillbirth
or proved to be mentally or physically
handicapped
– If there was any antenatal problem or difficult
delivery
– Family history of mental sub normality,
cerebral palsy or other handicap

8. • For pediatrician-
– When faced with sucking and swallowing
problem in neonate, or child with unusual
appearance or behavior
– Early diagnosis of defects of hearing or vision
– Effect of treatment of metabolic disorders,
exposure to toxic substances, convulsions,
meningitis

9. Different Domains of Development
• Gross motor development
• Fine motor development
• Social/Cognitive/intellectual development
• Speech and language development
• Vision and hearing development

10. Assessment of Development

11. Assessment of Development
• Developmental milestones serve as the basis of most
standardized assessment and screening tools
• Two separate developmental assessment over time are
more predictive than a single one.
• Developmental monitoring not only should be aimed at
identifying children who have low function, but at
directing the focus of anticipatory guidance to help
promote normal development.

12. When to suspect abnormalities of
development
• From history- Parents( 75-80% sensitivity
to childhood disability and 70-80 %
specificity for normal development)
• From examination-
– During routine examination- Developmental
screening as recommended by AAP
– Follow up examination in high risk babies

13. • Risk factors for likelihood of developmental
impairment-
– Prenatal-
• Use of drugs or alcohol, severe toxemia and viral inf.
– Perinatal factors-
• Prematurity, LBW, obstetric complications
– Neonatal factors-
• Neonatal encephalopathy, infections like sepsis or meningits
and severe hyperbilirubinemia
– Post natal factors-
• Injury or meningitis, encephalitis, exposure to toxins, severe
continuous failure to thrive and severe epilepsy
– Family history-
• Visual and hearing as well as specific learning

14. Developmental History
• Whether or not parents have concern
• Right questions- Parents interpretation of what
their child does may be incorrect but
observations are usually accurate
• Age specific questions
• Check doubtful reply with a question kept on a
different way
• Check the answer about one milestone by
another and by examination

15. • Family history-
– First and second degree relatives
– A diagnosis even if definite should be pursued
if it might be relevant
• Social history-
– Capacity to cope with a child with a disability

16. Examination: Observations and
Interactive Assessment
• Should take in place in a room with toys
appropriate for child
• With one or both parents, but no prompting and
helping
• Chair and table
• Child’s behavior and interaction with parents
during history taking should be observed prior to
physical examination
• Normal functioning of motor, vision and hearing
should be assessed

17. Prerequisites
• Infant or child in a good temper
• Should not be hungry, tired, unwell, had
convulsion prior, under influence of
sedative or antiepileptic drugs

18. Equipment Required
• Ten 1- inch cubes
• Hand bell
• Simple formboard
• Goddard formboard
• Colored and uncolored geometric forms
• Picture cards
• Cards with circle, cross, square, triangle, diamond drawn
on them
• Patellar hammer
• Paper
• Pellets( 8mm)

19. Physical Examination
• General-
– Height, weight, head circumference, cardiac
murmurs, midline defects
• Dysmorphic features
• Neurological examination

20. Assessment of Gross Motor
Development
• The acquisition of gross motor skill
precedes the development of fine motor
skills.
• Both processes occur in a cephalocaudal
fashion
– Head control preceding arm and hand control
– Followed by leg and foot control.

21. Gross Motor Development
• Newborn: barely able to lift head
• 6 months: easily lifts head, chest and upper
abdomen and can bear weight on arms

22. Head Control
Newborn Age 6 months

23. Sitting up
• 2months old: needs assistance
• 6 months old: can sit alone in the tripod
position
• 8 months old: can sit without support and
engage in play

24. Sitting Up
Age 2 months Age 8 months

25. Ambulation
• 9 month old: crawl
• 1 year: stand independently from a crawl
position
• 13 month old: walk and toddle quickly
• 15 month old: can run

26. Ambulation
13 month old
Nine to 12-months

27. Gross motor developmental milestone
Lift Head
Age Milestone
3 months Neck Holding
5 months Rolls over
6 months Sits in tripod fashion
Sit
8 months Sitting without support
9 months Stands with support
12 Months Creeps well; walks but falls; stands without
support Crawl
15 months Walks alone; creeps upstairs
18 months Runs; explores drawers
2 years Walks up and downstairs; jumps
Walk
3 years Rides tricycle; alternate feet going upstairs
4 years Hops on one foot; alternate feet going downstairs

28. Fine Motor - Infant
• Newborn has very little control. Objects
will be involuntarily grasped and dropped
without notice.
• 6 month old: palmar grasp – uses entire
hand to pick up an object
• 9 month old: pincer grasp – can grasp
small objects using thumb and forefinger

29. Fine Motor Development
6-month-old
12-month-old

30. Fine motor developmental milestones
Age Milestone
4 months Bidextrous reach
6 months Unidextrous reach; transfer object
9 months Immature pincer grasp; probes with forefinger
12 months Pincer grasp mature
15 months Imitates scribbling; tower of 2 blocks
18 months Scribbles; tower of 3 blocks
2 years Tower of 6 blocks; vertical and circular stroke
3 years Tower of 9 blocks; copies circle
4 years Copies cross; bridge with blocks
5 years Copies triangle

32. Play and Social Interaction
• Observe exploration and free play, use of
real size and small toys on self and other
and initiation and response to social
games( eg- peek-a-boo, pat-a-cake)
• Note initiating interactions and responding
to parent/ examiner/ other children and
use of eye contact and gestures

33. Social and adaptive milestones
Age Milestones
2 months Social smile
3 months Recognizes mother; anticipates feeds
6 months Recognizes strange/ stranger anxiety
9 months Waves ‘bye-bye’
12 months Comes when called; plays simple ball game
15 months Jargon
18 months Copies parents in task
2 years Asks for food, drink, toilet; pulls people to show
toys
3 years Shares toys; knows full name and gender
4 years Plays cooperatively in a group; goes to toilet alone
5 years Helps in household tasks; dresses and undresses

34. Language and Communication
• Observe vocalization and gestures to
attract other’s attention, to indicate needs.
In response to others’ vocalization and to
share emotions
• Note speech quality, use of language to
express need, comment, describe, share
interest and initiating and responding for
conversation

35. language milestones
Age Milestone
1 months Alerts to sound
3 months Coos
4 months Laugh loud
6 months Monosyllables
9 months Bisyllables
12 months 1-2 words with meaning
18 months 8-10 words vocabulary
2 years 2-3 words sentence, use pronouns ”I”, “me”,
“you”
3 years Ask questions; knows full name and gender
4 years Says song or poem; tells stories
5 years Asks meaning of words

36. Hearing Development
• BAER hearing test (brainstem auditory evoked
response) done at birth
• Ability to hear correlates with ability pronounce
words properly
• Always ask about history of otitis media – ear
infection
• Repeat hearing screening test
• Speech therapist as needed

37. Orienting to sound of bell
Johnson, C. P. et al. Pediatrics in Review 1997;18:224-242
7 months 9.5 months
5 months
Copyright ©1997 American Academy of Pediatrics

38. Time of Assessment
• Developmental surveillance- every well- child
visit
• Developmental screening-
– May be completed by parent or clinician
– Using standardized tool at 9, 18 and 30 months
– Example-
• Denver II developmental screening test
• Phatak’s Baroda Screening Test
• Trivandrum Development Screening Chart
• CAT/Clams ( Clinical adaptive test/ clinical linguistic and
auditory milestone scale)
• Goodenough- Harris Draw-a-person test
• Gesell figures
• Gesell block skills

39. Denver II Developmental Screening Test
• Most widely used test for screening
• Assesses child development in four domains
gross motor
fine motor adaptive
language
personal social behavior
• These domains are presented as age norms,
just like physical growth curves.

40. Phatak’s Baroda Screening Test
• Indian adaptation of Bayley’s
Development scale
• India’s best known development testing
system
• Used by child psychologists rather then
physicians

41. Trivandrum Development Screening Chart
• Simplified adaption of Baroda Development
Screening System
• Consist of 17 items selected from BSID Baroda
norms
• Time required- 5 mins
• Good for mass screening

42. Clinical Adaptive Test
– Developmental Screening Test for age under
24 months
– Two test combination
• Clinical Adaptive Test (CAT)
• Clinical Linguistic Auditory Milestone Scale
(CLAMS)
– Language assessment tool
– Distinguish Language Delay from mental retardation

43. Goodenough ‘draw a man test’

45. Definitive Tests
• Bayley Scales of Infant and Toddler Development-Third
Edition (Bayley-III)
• Stanford-Binet Intelligence Scale
• Wechsler Intelligence Scale
• Developmental Activities Screening Inventory-SECOND
EDITION (DASI-II)

46. Bayley Scales of Infant and Toddler Development-
Third Edition (Bayley-III)
• Age Range (in years) - Birth to3.5 years
• Method of Administration/Format
Individually administered in play-based format for Cognitive, Language ,
and Motor Scales; caregiver questionnaire for Social-Emotional and
Adaptive Functioning. Yields scaled scores, composite scores, and
percentile ranks.
• Approximate Time to Administer –
50 min. for 1-12 mos.;
90 min. for 13-42 mos.
Subscales
Cognitive; Language (Receptive, Expressive, Total); Motor (Fine-Motor,
Gross-Motor, Total); Social-Emotional; Adaptive Behavior (Communication,
Community Use, Functional Pre-Academics, Home Living, Health & Safety,
Leisure, Self-Care, Self-Direction, Social, Motor, Total)

47. Stanford-Binet Intelligence Scale
• Description
– Intelligence Testing of ages 2 to 23 years and beyond
– Yields Intelligence Quotient (IQ)
• Scoring
– Standardized Scoring
– Composite mean of 100 with standard deviation of 16
• Interpretation:
• Mental Retardation IQ Definitions
– Borderline mental retardation: 70 -79
– Mild mental retardation: 65-69
– Moderate mental retardation: 40-54
– Severe mental retardation: 30-39
– Profound mental retardation: <30

48. Wechsler Intelligence Scale
• Description
– Intelligence Testing
– Mean score of 100 with standard deviation of 15
– Gives verbal and performance scores
– Broken into subtests each with a mean of 10
• Age specific Wechsler tests
– Wechsler Preschool Primary Scale Intelligence (WPPSI-R)
• Used for ages 3 to 7 years
– Wechsler Intelligence Scale for Children (WISCIII)
• Used for ages 6 to 16 years
– Wechsler Adult Intelligence Scale (WAIS-R)
• Used for ages 16 years and older
•

49. DEVELOPMENTAL ACTIVITIES SCREENING
INVENTORY-SECOND EDITION (DASI-II)
• Age Range (in years)- Birth - 5 years
• Method of Administration/Format
Individually administered informal screening measure; may
be presented as a nonverbal test; 67 perceptual, motor, and
cognitive tasks Yields Developmental Quotient
• Approximate Time to Administer -25-30 min
• Subscales -Developmental Quotient

50. Developmental Quotient (DQ)
Ratio of the functional age to the chronological age. It is a means to
simply express a developmental delay.
DQ= ((developmental age) / (chronological age)) * 100
• If the infant was born prematurely the chronological age should be
corrected for the gestational age at birth during the first year of life.
• The adaptive developmental quotient uses a development measure
such as the Gesell scales. Similar quotients may use IQ or other measures.
Interpretation
maximum score =100
> = 85 normal
71-84 mild-to-moderate delay
<= 70 severe delay

51. Conclusion

52. Approach
History and examination
Absent - Check for age appropriate milestone
Check for milestones achieved in the past- what and when
Check for milestones in the other domains
Global Developmental Delay Delay in specific domain

53. Purpose of Assessment
• Whether there is impairment or not in development
• Make a diagnosis if possible
• Seek to intervene positively to improve outcome and
function for the child and family
– Reinforcing acquired skills
– Teach developmentally appropriate skills
– Provide missed experience
– Make use of other skills to overcome difficulties
– Use learning style to promote learning

54. Red Flags: Birth to three month
– Rolling prior to 3 months
• Evaluate for hypertonia
– Persistent fisting at 3 months
• Evaluate for neuromotor dysfunction
– Failure to alert to environmental stimuli
• Evaluate for sensory Impairment

55. Red Flags: 4 to 6 months
– Poor head control
• Evaluate for hypotonia
– Failure to reach for objects by 5 months
• Evaluate for motor, visual or cognitive deficits
– Absent Smile
• Evaluate for visual loss
• Evaluate for attachment problems
• Evaluate maternal Major Depression
• Consider Child Abuse or child neglect in severe
cases

56. Red Flags: 6 to 12 months
– Persistence of primitive reflexes after 6 months
• Evaluate for neuromuscular disorder
– Absent babbling by 6 months
• Evaluate for hearing deficit
– Absent stranger anxiety by 7 months
• May be related to multiple care providers
– Inability to localize sound by 10 months
• Evaluate for unilateral Hearing Loss
– Persistent mouthing of objects at 12 months
• May indicate lack of intellectual curiosity

57. Red Flags: 12 to 24 months
– Lack of consonant production by 15 months
• Evaluate for Mild Hearing Loss
– Lack of imitation by 16 months
• Evaluate for hearing deficit
• Evaluate for cognitive or socialization deficit
– Hand dominance prior to 18 months
• May indicate contralateral weakness with Hemiparesis
– Inability to walk up and down stairs at 24 months
• May lack opportunity rather than motor deficit

58. Red Flags: 12 to 24 months
– Advanced non-communicative speech
(e.g. Echolalia)
• Simple commands not understood suggests
abnormality
• Evaluate for Autism
• Evaluate for pervasive developmental disorder
– Delayed Language Development
• Requires Hearing Loss evaluation in all children

59. Take Away Message
Best tests( in our setting)
• For infant:
Phatak’s Baroda Screening Test
• For pre school child:
Bayley Scales of Infant and Toddler Development-Third
Edition (Bayley-III)
• For school going child:
Wechsler Intelligence Scale

60. References
• Ghai Essential Pediatrics, OP Ghai, 7th Edition
• Nelson textbook of Pediatrics, 19th Edition, Kliegman,
Behrman, Schor, Stanton, St. Geme
• Forfar and Arnold’s textbook of Pediatricss, Sixth Edition
• IAP textbook of Pediatrics, 4th Edition
• ^ Frankenburg, William K.; Dobbs, J.B. (1967). "The Denver
Developmental Screening Test". The Journal of Pediatrics
• Illingworth, Ronald S: THE DEVELOPMENT OF THE INFANT &
YOUNG CHILD, 9th edition, ELSEVIER
• Google.com
• Answers.com

61. Thank You