This is simplified version for undergraduate medical and nursing students

1. Dr.Varsha Atul Shah
SC, Neonatal and
Developmental
Medicine, Singapore
General Hospital
VC, Dept. of Child
Development, KKH
Developmental Assessment
For medical students

2. Usual lead in is ‘Would you please
perform a developmental assessment’?
• You may or may not be told age of the
child?
• Once you know 18 months of development
‘backwards’, including time of appearance
and incorporation of primary reflexes, then
you can fairly interpret the findings

3. WIPE approach
• Watch/Wash-Scrub hands/WIPE Hands/Wipe Stethoscope with alcohol
rub
• Introduce, Interact, Initiate, Inspect
• Position yourself and baby and Play,
• Examine, eyeball, engage, EEENT Eye- Eyeball whole Environment and
baby from head to toe, Examine-Use hands Ear-Hear Nose-Smell,
Throat-baby talk
• Begin by introducing yourself to parents, hand rub etc. 1st only look see,
play…and examine.
• Inform examiner about your approach either:
- I would like to give live commentary or
- I would summarize after full examination
- Can ask permission if need to ask parents few milestones which you
could not perform

4. General Inspection, Observation is
the key, Eyeball 180 degree
1. Inspect for growth parameters e.g. FTT, syndromes, under
nutrition can have Developmental delay
2. Syndromic/Dysmorphic features e.g. Down’s, trisomy's
3. Appearance of Ex premature infants(prominent forehead,
pig nose), correct the age.
4. Obvious neurological anomalies like floppy infants,
posturing, hemiplegic posturing, and involuntary movements.

5. Scars of Expremature infants:
-Pig nose due to CPAP
-prominent forehead
-dolichocephalic head due to CPAP
-VP shunt due to Post IVH hydrocephalous
-scars due to multiple pricks
IV extravasations, OGT,
-Wearing glasses due to astigmatism/ROP,
-abdominal scar due to NEC, PDA ligation

6. Position child
• If child is on mum’s lap (most of the time) can do DA in
following sequence particularly toddlers:
-1st vision and hearing
-2nd Fine Motor
-3rd language and personal social
-4th Gross Motor examination last end with bye bye.
• Do not separate for GM assessment from start.
• Bigger kids can examine on chair.
• Infants lie in bed-180 degree flip exam, with NNR

7. TOOLS NEEDED:
1. Red yarn pom pom (4 cm diameter) with string
and dangling,
2. Bright color 12 cubes 2.5 cm,
3. Rattle with narrow handle
4. Raisins or cheerio's or honey stars or m and ms
5. Cup, spoon
6. A 4 size paper
7. Big size colour pencils
7. Picture cards, multiple picture books (like bird,
fish, dog, bus, fruits etc) on same page,
8.Tennis ball
9. Small doll
10. Bell
11. Stickers, sweets for rewards

9. Vision
• Always do vision before hearing.
• Fixing and following pom pom ball. Distance 21
cm away.
• Conjugated eye gaze(not rowing)/socially
modulated eye contact Check ability to pick up
hundreds and thousands, cubes are important.
• Approached to toys
• No rowing eye movement, No squint, No
nystagmus
• Wearing glasses

10. Vision
• Fix and follow wool ball (4cm) horizontally and
vertically 20 cm from eye level

11. Hearing: Distraction test
• Use initial distraction with non noise making
stimulus in front of child
• Always ask examiner to ring the bell at 20 cm
from both ears
• Bell is brought towards ear from behind out
of range from visual fields 20 cm away from
ears.
• Changes noted are facial expression,
vocalizing sounds, head turns.

12. Fine Motor:
• Holds rattles (3 months),
• hand regards (4 months),
• palmer grasp objects/block (5 months),
• transfer cubes (7 months),
• Raisins for pincer grip (9 months),
2.5 cm blocks for stacking
• 2 cubes 15 months,
• 3 cubes(18 months)
• 6 cubes(21 months).
• 6 cubes, turn pages (2 years),
• 8 cubes (2.5 years),
• 9 cubes (3 years), beads, thread, putting on biro, plastic knife, and fork. Comment on
personal social interaction, language. Smiling, waving

13. Tools Cubes Pen Drawing Book /
Pages
Cutting Others
1 year ▪ mouthing
cubes
▪ bangs
cubes
together
▪ picks cubes
with 1 hand
▪ opens
book
▪ throws and cast
objects
▪ place 1 correct
shapes in holes
▪ puts pellets in &
out of cup/box
when shown
15
months
▪ builds 2
cubes
▪ scribbles
thru & fro
18
months
▪ builds 3
cubes
▪ hand
preference at 18
- 24 months
▪ turns 2-3
pages at
the same
time
▪ no more casting
objects
▪ place 2 correct
shapes in holes
2 years ▪ builds 6
cubes
▪ pen held in fist -
palmar grasp
(1.5 - 2 yrs)
▪ copies a
single
line: I
then ---
▪ turns
pages
singly
▪ makes a cut
with the
scissors
▪ place 3 correct
shapes in hole
2.5 years ▪ aligns 3
cubes
▪ stack a
train
▪ inferior pen grip
(2 - 2.5 years)
▪ removes screwed
lid from bottle
3 years ▪ builds 9
cubes
▪ 3 cube
pyramid
▪ 3 block
bridge
▪ steadies paper
with other
hand
▪ copies O
▪ copies +
(3 ½ yo)
▪ cuts along a
line
▪ strings 4 beads
▪ puts 10 pellets in
a bottle (3 ½ yo)
▪ laces 3 holds (3 ½
yo)
Fine Motor:

14. Gesell's figures

15. How to memorize

17. Sequence of tools used for FM
Raisin->build blocks → place
shape in hole → hold pen +
scribble → put pellets in bottle
→ lace holes → cut paper →
buttons → colours in lines →
fold paper

18. Immature crude palmar grasp to
immature pincer grasp to mature pincer
grasp

19. Personal social Devt Chronologically
1. Focus on faces (4 weeks),
2. social smile (6 weeks),
3. excited with toys (4 months),
4. Castrate toys (5 months),
5. stranger anxiety (6 months),
6. responds to No, imitates (8 months),
7. clapping, bye bye, bang blocks (10 months),
8. peek boo (11 months),
9. picture books ( 12 months),
10. kiss mirror (13 months),
11. Points (15 months),
12. Body parts (21 months)

20. GROSS MOTOR:
• HH (16 weeks), Roll over(flip)
• Tripod (6 months)
• Bear weight, bounces, lifts head(7 months)
• sit well (8 months)
• pull to sit and stand, crawl (10months)
• Creep 11 months
• walk with support (1 year)
• Walk independently (14 months)
• climb stairs with rail ,throw ball (18months)
• walk upstairs (21 months)
• up and down, jumps well (2 years)

21. GROSS MOTOR:

22. GROSS MOTOR: 180 degree flip
examination in infant < 8 months and
gait for > 1 year
• Supine: Note posture, abnormalATNR, involuntary movements with
CP. paucity of movements for hemiplegia.
• Pull to sit: head lag. Sitting: Head and trunk control. Back is straight
or rounded.
• Weight bearing: scissoring, hypotonia, advanced weight bearing (CP)
• Ventral suspension: Describe posture, low tone, increase extensor
tone.
• Prone: Observe ability to raise head, trunk above horizontal.

23. Gross Motor Milestones-1
Ball Jumping Stairs Walking Sitting
1 year ▪ throws
ball 3 feet
▪ creeps up
stairs
▪ walks holding
on
▪ kneels &
balances
18 months ▪ throws
ball
without
falling
▪ walks up
stairs
▪ creeps
back
down
stairs
▪ walks well by 18
months
2 years ▪ throws
ball
overhead
▪ kicks ball
▪ hops
with 2
feet
▪ jumps
forward
4 feet
▪ 2 steps
up &
down
▪ runs
▪ walks around
carrying toy
▪ starts & stops at
ease around
obstacles
▪ Climb
furniture
and sits
on their
own
2.5 years ▪ catches
ball into
body
▪ stand on
tip toes
if shown

24. Primitive reflexes:
1 Sucking/Rooting :( 0-4,6mths)
2. Palmer grasp; (0-3 months)
3. Placing, stepping: (0-6weeks)
4. ATNR: 2-6 Months
5. Landau: on ventral suspension, normally extend
head, trunk, and hip. Flex head and neck, response is
flexion of hip, trunk.0-6 month)
6. Neck righting reflex: rotation of trunk 6mths-2 years
7. Moro: 0-4 months
8. Parachute: 6-12 months persist. Prone position,
move rapidly, face down. Will extend both upper limbs

25. Speech and Language:
• Cooing ( 2months)
• responds to human voice (4 months)
• Babbling (6months)
• Mamma, dada (9months)
• 2 words plus mama, dada(12 months)
• Jargon, points (15months)
• 10 words and says his name, points to 3 body parts, one picture (18mths)
• 2-3 word phrase, name 3 objects, 4 body parts, says no
• (2 years), know name, age sex
• (2.5years), preposition, count 1-10, 2 colours
• (3 years), name 3 colours, converses (4 years)

26. Language Milestones
*1st ask the parent, what is the child’s dominant language and any history of
hearing loss

27. Red flag signs of SLD-when to refer
to specialists

28. Present the short case as:
• On general observation/inspection of this cute little /Race/ New born/infant/toddler, who is well
thrived, but would like to chart gender specific progressive percentiles for Occipitofrontal
circumference, length, and weight, he is not syndromic, (no expremmie scars/look), not floppy has
good muscle tone moving all limbs equally. No involuntary movements seen/no obvious
nystagmus/squint.
• On examination of vision he had eye gaze, socially aware, he fixed followed pompom ball,
approached to toys, picked up raisins etc. On examination of distraction hearing test …, On personal
social.., On language. On fine motor…On gross motor..NN reflexes
• Do mention what child could do and could not do, so Devt age is= (withing 3 months range+, can not
say 12-18 month) . If CP GM may be more delayed than other domain, do specify each domain age
separately)
• In summary: this infant has DA of….GM … FM…. SL PS etc with Developmental quotient at __%
• I.Q= Mental age x 100
• Chronological age
• - Do offer: I would like to perform neurological exam, motor exams etc
• Scrub hands at the end of exam

29. MustWatchVideos
• Visit:
http://www.martindalecenter.com/MedicalClinical_Exams.html
• http://library.med.utah.edu/pedineurologicexam/html/home_exam
.html
• Visit link Free book download
http://www.scribd.com/doc/44390551/Fro m-Birth-to-Five-Years