Global Developmental Delay and Regression

Developmental delay occurs in approximately 1%–3% of children. Since developmental delay is common, monitoring a child’s development is an essential component of well-child care. Ongoing assessment of the child’s development at each well-child visit creates a pattern of development that is more useful than measuring the discrete milestone achievements at a single visit; therefore, developmental screening should be completed at each well-child visit ( ). Identification of a child with developmental delays should be accomplished as early as possible, because the earlier a child is identified, the sooner the child can receive a thorough evaluation and begin therapeutic interventions that can improve the child’s outcome. Developmental delay is common and one of the most frequent presenting complaints to a pediatric neurology clinic; therefore, neurologists should have a systematic approach to the child with developmental delay.

This chapter begins with a brief discussion of child development concepts related to typical and atypical development. Next, the clinical evaluation and management of developmental delay is reviewed. The chapter closes with a discussion of neurological regression.

Typical and Atypical Development

Child Development Concepts

A child’s development is a continuous process of acquiring new and advanced skills. This development depends on maturation of the nervous system. Although typical child development follows a relatively consistent sequence, it is not linear. Instead, there are spurts and lags. For example, motor development in the first year of life proceeds relatively rapidly. Babies typically mature from being completely immobile to walking in just over 12 months, but then motor development progresses less dramatically during the second year of life. Conversely, language development in the first year of life occurs slowly, but there is an explosion of language acquisition between a child’s first and second birthdays.

On average, most children achieve each developmental milestone within a defined and narrow age range ( Table 8.1 ). Since each developmental skill can be acquired within an age range, it is imperative that professionals know what is typical to better determine when a child’s development falls outside this range. These so-called red flags are important because they can be used to identify when a child has developmental delay for specific skills. For example, although the average age of walking is approximately 13 months, a child may walk as late as 17 months and still be within the typical developmental range. In this example, the red flag for independent walking is 18 months, and a child who is not walking by 18 months of age is delayed.

TABLE 8.1

Typical Developmental Milestones by Age (50th–75th Percentile)

Age	Language	Socialization	Motor	Cognitive	Adaptive
2 months	Coos (ooh, ah) Video 8.1c	Smiles with social contact ( )	Holds head up 45 degrees ( )	Focus on face, follows large contrasting object
3–4 months	Laughs and squeals , “ah-goo” sound	Sustains social contact, soothes to parent voice	Grasps objects, rolls front to back (4 months), stands with support ( ), no headlag ( )	Mouths objects, inspects own hands, shakes rattle
5–6 months	Razzes, reciprocal vocalizations	Prefers mother, smile/vocalize to mirror, stranger anxiety	Transfers objects between hands ( ), uses a raking grasp ( ), rolls back to front (5 months) ( ), sits with support ( ), hands to feet in supine ( ), pivots in prone ( )	Turns head to look for dropped object, removes cloth from face, bangs/shakes toys	Places hand on breast/bottle, opens mouth for spoon
8–9 months	Nonspecific “mama/dada,” inflection with babbling, looks for family member “where’s mama?,” orients to name	Uses sound to get attention, separation anxiety, follows a point	Sits alone ( ), creeps or crawls ( ), pulls to stand ( ), radial-digital grasp ( )	Object permanence ( )	Holds bottle, finger feeds diced foods
10–12 months	Says “dada/mama” specifically plus one other word, understands “no,” follows one-step command with gestures	Plays simple ball games, plays peek-a-boo, looks preferentially when name is called ( )	Stands alone, cruises (10 months), beginner walking (12 months) ( ), inferior pincer grasp	Looks at pictures in book, purposeful release	Adjusts body to dressing, finger feeds well
12–1 months	Immature jargon (13 months), says 2–4 words and/or signs (13 months) ( ), follows one-step command without gesture, understands 50–100 words	Indicates desires by pointing (12 months), points to indicate items of interest (14 months), functional play with toys	Walks alone ( ), stoops and recovers, transitions floor sit to stand (12–13 months) ( ), mature pincer grasp ( )	Dumps pellet from bottle, turns pages in book ( ), places circle in single shape puzzle	Cooperates in dressing, removes shoes/ socks, spoon to mouth (flips the spoon)
15–18 months	Says 4–6 words (15 months), says 10–15 words (18 months), uses giant words, animal sounds, points to self	Emerging pretend play, shows empathy	Walks up steps with a hand held, imitates scribbling, stacks two blocks	Points to one body part (15 months), points to three body parts (18 months)	Uses spoon, drinks from cup, removes garment
18–24 months	Emerging 2 word phrases, 25–50 words, points to 2–4 pictures	Reciprocal pretend play, kisses with pucker	Walks with reciprocal arm swing and heel strike ( ), kicks a ball ( ), goes up stairs holding rail one step at a time ( ), tower of 5–6 cubes, imitates vertical line	Points to 5–6 body parts (22 months), matches pairs of objects	Feeds self with spoon for entire meal, drinks from open cup, unzips zipper
24–30 months	Uses at least 50 words and 2-word sentences ( ), understands 250 words, follows two-step command, 50% intelligible	Parallel play, imitates adult activity	Runs well ( ), goes down stairs holding rail one step at a time, jumps clearing floor ( ), imitates circle, copies a horizontal line ( )	Sorts objects, matches object to picture, matches shapes, matches colors ( )	Takes off clothing without buttons, washes hands, verbalizes toileting needs
30–36 months	Uses pronouns, knows first and last name, counts to 3, asks questions	Reciprocally pretends in play, helps put things away	Climbs stairs with alternate feet, walks on tip-toe ×4 steps ( ), copies a vertical and horizontal line, imitates cross	8–10 cube tower ( ), 4-cube train ( ), points to body part by function, understands concept of one (Video 11c)	Toilet trained, puts on coat unassisted, brushes teeth withoutassistance
3 years	Counts 3 objects, 200+ words, three-word sentences, 75% intelligible, understands negatives	Emerging fears, imaginary play, begins to share	Rides a tricycle ( ), goes up stairs alternating feet without rail ( ), stands on one foot briefly, copies a circle, strings small beads	Copies 3 cube bridge ( ), knows age and gender, understands big versus little ( ), sorts by shape(Video 8.11f) , draws two-part person	Independent eating, unbuttons, toilet trained
4 years	Counts 4 objects, 300–1000+ words, tells a story, 100% intelligible, follows three-step instruction	Labels emotions with words, has a preferred friend, engages in group play, understands deception	Hops on one foot, one-leg balance ( ), standing broad jump ( ), uses scissors to cut out pictures ( ), copies a square and a cross	Draws 4–6 part person ( ), counts to 4, points to 4 colors	Independent toileting, washes own hands, uses fork well
5 years	Counts 10 objects ( ), 2000+ words, speaks in complete sentences, tells stories with beginning, middle, and end, responds to “why” questions	Makes friendships and has a preferred group of friends, apologizes for mistakes	Skips ( ), copies a triangle, uses dynamic tripod/quadruped grasp ( ), in-hand manipulation ( ), rotates pencil ( ), puts penny in bank	Draws 8–10 part person, names 8–10 colors ( ), identifies coins	Participates in domestic chores, spreads with knife well, dresses and bathes independently

Global Developmental Delay

Developmental History

Child development is classically divided into five interdependent domains or streams: motor (gross and fine), problem-solving/cognitive, language (receptive and expressive), socialization, and adaptive. The approach to a child with possible developmental delays is based on a working knowledge of these domains and the typical age ranges for acquiring specific milestones within each domain. Therefore, the clinician should begin the evaluation of a child with developmental concerns by obtaining a developmental history, and emphasis should be placed on the pattern of milestone acquisition as well as the child’s current developmental skills. Clinicians working in a busy clinical setting may need to base this history primarily on the caregiver’s report of the child’s developmental abilities. Clinicians may also use standardized tools to aid in this portion of the history, including the Ireton Child Development Inventory (CDI), the Ages and Stages Questionnaire (ASQ), the Parents’ Evaluation of Developmental Status (PEDS), and/or the Modified Checklist for Autism in Toddlers (MCHAT) ( ). However, if the clinician’s history confirms a developmental disability, standardized testing by a developmental specialist or clinical psychologist should be strongly considered; this formal evaluation will provide a much better assessment of the child’s developmental abilities.

When there is concern about developmental delay in a child, a developmental quotient should be calculated. The developmental quotient is the ratio of the child’s developmental age over the chronological age. The developmental quotient should be calculated for each developmental stream. Typical development is a developmental quotient greater than 70%, and atypical development is a developmental quotient less than 70%. Toddlers and young children with atypical development are at risk for lifelong developmental problems. The term global development delay is used if a child younger than 5–6 years of age has a developmental quotient less than 70% in two or more domains. Children with global developmental delay should receive a thorough medical evaluation to try to determine the cause of the delay and begin management for their developmental disabilities.

Infant Social Skills: Social Smile.

Infant Motor Skills: Prone Position.

Infant Social Skills: Social Laugh.

Resolved Head Lag in Infant.

Infant Motor Skills: Bears Weight.

Infant Motor Skills: Rolling.

Infant Motor Skills: Tripod Sit.

Infant Motor Skills: Hands to Feet.

Infant Motor Skills: Prone Extension.

Infant Motor Skills: Pivot in Prone.

Infant Motor Skills: Raking Grasp.

Infant Motor Skills: Hand Transfer.

Infant Object Permanence.

Infant Motor Skills: Pull to Stand.

Infant Play: Banging Cups.

Infant Motor Skills: Crawling.

Infant Motor Skills: Three-Finger Grasp.

Infant Motor Skills: Reciprocal Crawl.

Toddler Motor Skills: Early Walker.

Toddler Social Skills: Response to Name.

Toddler Motor Skills: Mature Pincer.

Toddler Social Skills: Pointing for Interest.

Toddler Motor Skills: Transition to Stand.

Toddler Motor Skills: Stoop and Recover.

Toddler Language Skills: Functional Sign Language.

Toddler Cognitive Skills: Pellet in Bottle.

Toddler Motor Skills: Kicking.

Toddler Motor Skills: Nonreciprocal Stair Pattern.

Toddler Motor Skills: Toddler Gait.

Toddler Cognitive Skills: Block Copy.

Toddler Motor Skills: Imitates Circle.

Toddler Cognitive Skills: Matching Colors.

Toddler Motor Skills: Jumping.

Toddler Motor Skills: Toddler Run.

Toddler Cognitive Skills: Unscrew Bottle Top.

Toddler Language Skills: Three-Word Phrase.

Toddler Language Skills: Labeling.

Toddler Cognitive Skills: Block Tower.

Toddler Motor Skills: Tiptoe Gait.

Toddler Cognitive Skills: Block Copy.

Toddler Motor Skills: Alternating Stairs.

Toddler Cognitive Skills: Concept of One.

Toddler Motor Skills: Tricycle.

Toddler Cognitive Skills: Big/Little.

Video 8.11f Toddler Cognitive Skills: Sorting, Counting.

Childhood Motor Skills: Broad Jump.

Childhood Motor Skills: One-Legged Balance/Hop.

Childhood Motor Skills: Scissor Use.

Childhood Cognitive Skills: Person Picture <10 Parts.

Childhood Language Skills: Counting.

Childhood Motor Skills: Dynamic Grasp.

Childhood Cognitive skills: Person Picture >10 Parts.

Childhood Motor Skills: Skipping.

Childhood Motor Skills: In-Hand Manipulation of Object.

Childhood Motor Skills: In-Hand Rotation of Pencil.

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