Details of the usual patterns of development in the areas of locomotor skills, vision, hearing, communication, language and speech are considered and suggestions made as to when it may be necessary to refer a child for specialist investigation.
It is important that parental concerns are responded to appropriately, as parents are often the first to identify a problem.
A brief explanation of testing procedures for checking vision and hearing is also included, although it is essential that these are carried out by trained personnel and that their limitations are recognised.
The development of these skills is helped by their interest and motivation and by playful interactions with carers.
The speed of development of motor progress is influenced by many factors and, while most children follow a fairly similar pattern, there is a wide variability in the age at which various skills may be achieved.
Infants born very prematurely and nursed mainly on their backs may show early progress with supported standing, but be delayed in sitting unsupported.
Lack of opportunities for infants to move freely, either because of being left in the cot, lack of stimulation of prolonged use of baby walkers, may delay progress during early childhood development stages.
Infants with severe visual impairment may also show a delay in acquiring locomotor skills in early childhood development stages.
Children with excessively low muscle tone - floppiness (hypotonia)- or with high muscle tone - stiffness (hypertonia) - also show differences in the pattern and age of achievement of these skills.
A small number of children may miss out the crawling stage and move from sitting independently to beginning to stand and walk in early childhood development stages.
Between 10 and 15 per cent of children may follow a different pattern of achievement of these skills.
They may prefer to move by rolling or bottom-shuffling before getting to stand and walk, which may be achieved as late as twenty to twenty-eight months.
Such a child often has a low muscle tone, and a similar history may be present in the family.
By three years of age, most children have acquired the ability to hold a pencil between the first two fingers and thumb using the preferred hand.
There is a great deal of variability in the timing of establishing handedness, although most children establish it from the second year onwards.
A strong preference for the use of one hand before the first birthday should indicate the need for further professional advice.
Although the majority of those who follow a less common pattern or are not walking by the age of eighteen months are likely to be normal, careful examination is required to rule out any problems.
When held in an upright position, newborn infants usually turn their eyes towards any large light source.
The eye movement are not yet well coordinated; however, a constant squint occurring at any stage is abnormal in early childhood development stages.
During the first month of life infants stare at objects close to their face and show special interest in a human face, looking intensely into the eyes, particularly when they are being fed.
They follow slow movement of the adult face through 90 degrees or more. A defensive blink is present from four to six weeks.
At three months of age infants start watching the movement of their own hands and fingers and will follow activities in their surroundings.
At six months, infants will look and fix on a 2.5 centimetre brick at 30 centimetres, and will regard it closely.
They also look around with interest and recognise carers and familiar toys from across the room.
By nine months they will look at, and use their fingers to poke, small objects up to 1 millimetre in size (e.g crumbs or 'hundreds and thousands' cake decorations) at a distance of approximately 30 centimetres.
Recognition of familiar adults from across the street also occurs at this time.
By the age of one year infants point to demand objects, and, when outdoors, watch movements of people, animals, cars, etc., with prolonged and intense regard.
A careful inspection of the eyes is a mandatory part of newborn examination.
An ophthalmoscope should be used with a +3 lens from a distance of 20-25 centimetres to look for the red reflex.
The inspection and examination should be repeated at six to eight weeks. Parental concerns can identify many early and serious visual problems and the use of parental checklist can be helpful in early childhood development stages.
Parents should be asked, soon after the birth and at any subsequent visit, whether they have any concerns about their baby's vision.
Specialist examination is required for known high-risk groups, including low-birth weight infants at risk of retinopathy of prematurity, babies with a close family history of potentially heritable eye disorder, and children with dysmorphic syndromes or neurodevelopmental problems.
Tests of visual behaviour, including the observation of sharp fixation for sweets of 1 millimetre diameter at a distance of 30 centimetres, only exclude serious visual problems and do not offer any measurement of visual acuity.
Methods of forced choice preferential looking, visual-evoked responses and optokinetic nystagmus are used for specialist assessment.
From the age of three years, visual acuity for distance vision can be assessed using picture tests or letter charts with matching cards or letters.
A Snellen-type chart is preferable to single letters (Stycar tests or Sheridan Gardener cards) because the latter may seriously underestimate or miss the diagnosis of amblyopia.
Each eye must be tested separately, with the other eye occluded. The Sonksen-Silver test of visual acuity is validated for use at 3 metres distance.
The majority of manifest squints are first recognised by parents, and they should always be asked whether they have noticed any squint, laziness or turning of one eye.
Some squints are not noticeable on simple inspection and the corneal reflection test (observing the symmetry of refection in both eyes), the cover-uncover test or the alternate cover test may be used.
The performance and interpretation of these methods is not easy, and orthoptic assessment should be arranged in case of doubt and the presence of parental concern or relevant family history.
Their eyes may reflexly turn towards the direction of the sound. By one month of age they pause to listen and may turn their eyes and head to sounds.
By the age of four months infants consistently turn towards sounds.
Over the next six months their attempt to locate the sound matures, head and neck control improves and the ability to sit is developed.
By the age of six or seven months they turn immediately towards the parent's or carer's voice and visually engage.
By the age of nine months they begin to search for very quiet sounds made out of sight and make precise attempts to locate them.
At this early development childhood stages an infant is able to distinguish meaningful sounds, such as the parent's or carer's voice.
Infants with an impairment of hearing, or those brought up in a noisy environment, may fail to develop interest and ability in hearing, and this failure often raises parental concerns.
The use of a parental checklist helps to alert parents to the existence of hearing loss.
It is important that parents are asked whether they have any concerns regarding their child's hearing, and if there is any family history of hearing problems.
Parents are more likely to identify severe and profound hearing loss, and may easily overlook less severe or high-frequency impairments.
At this stage, brainstem-evoked response audiometry and evoked otoacoustic emissions are the most promising methods.
Beyond ten months of age, the development of object permanence and increasing sociability make this test more difficult.
Two trained personnel, working in collaboration, are required to perform the test. Quiet conditions, proper equipment, adequate sound level monitoring and careful technique are all essential.
One person, the distractor, works in front of the infant to hold the infant's attention using toys, etc.
When the infant is distracted towards the toy the distractor hides the toy and the second person presents the test stimulus from behind the child.
The second source should be located at a level horizontal with the infant's ear, at a distance of approximately one metre from the ear and outside the infant's field of vision (or at a specified distance if warblers are used).
The distractor observes the infant's response. The definite response is a full 90-degree head turn towards the sound source.
Any other outcome is an indication to re-test in four to six weeks, or to refer immediately if the parents are concerned or there are special circumstances.
For screening purposes the sounds are produced at minimal levels (less than 35 decibels). High and low frequencies are tested separately.
A special Manchester rattle (or Nuffield rattle), the consonant 's' repeated rhythmically for high frequencies and an unmodified voice 'hum' or rhythmical repetition of a nursery rhyme (low frequency) are used.
Whispering or quiet speaking is not acceptable. Frequency-modulated 'warble' tones are used to test a range of frequencies.
When inadequately performed, this test can be harmful by delaying identification of problems or by generating a large number of false positive referrals.
Good results can be obtained if initial and regular refresher training is provided to the testers to ensure meticulous technique.
Traditionally, this has involved asking the child to point to parts of the body or to follow simple requests like 'give it to Mummy', without any visual clues.
From the age of two years onwards, speech discrimination tests like the McCormick Toy Test can be performed.
The test has fourteen words in seven pairs, and a child with normal hearing should identify at least 80 per cent of the items at a voice level of 40 dB.
An automated version of the test is now available.
Note: It is important to be aware that a child may fail a speech discrimination test either because of hearing difficulty or because of delayed language development.
The test can also be performed using the voice. The sounds 'go' (low frequency) and 'ss' (high frequency) can be used to prompt the required response from the child.
The voice should be lowered to 40 dB and visual clues avoided by covering the mouth.
However, there are wide variations among normal children in the rate of language acquisition.
The child's social interaction skills and the ability to understand language need to be considered to define the nature of the problem.
As these responses become more complex, reciprocal interactions around caregiving and play activities emerge so that, by six to eight weeks, an infant smiles in response to a social interaction, giving great pleasure to carers.
From three to six months, infants show their preference for an object by sustained looking. They show readiness for interaction by turning and looking in an interested manner with a varying facial expressions.
By eight to ten months, infants can coordinate their interest in objects and people by gaining carer's attention and looking at or grasping an object at the same time.
Gestures are increasingly used in combination with vocalisation to demand objects and to share feelings about objects and events.
Pointing with the index finger is one of the most important communicative gestures to develop, as it draws others into interaction with the child and also elicits naming; it begins to be seen from nine months and, by eighteen months, infants point to objects to express their interest and to share this interest with others.
They are able to follow when an object is pointed out to them during early childhood development stages. Carers can help to establish communication by looking at and pointing to objects and naming them.
There is enormous diversity in the way that children develop their early understanding of language.
This reflects both the contribution of the individual child and also the variety of games and social interactions in which different families engage.
From six to nine months an infant may recognise one or two words for objects, such as 'tick-tock' for clock, or may show an appropriate response to 'bye-bye' or 'clap hands'.
From now onwards the infant begins to show an understanding of frequently repeated words and short sentences when used in familiar situations, assisted greatly by gestures and actions.
By their first birthday, most children will recognise some everyday objects without the help of gestural clues.
During their second year, children will recognise new words at an ever-increasing rate and understand up to two key words in familiar commands.
during their third year they will understand prepositions of increasing complexity (in, or, under), action words (eating, running), and will begin to understand size differences (little dolls).
From the age of three years, children develop their understanding of colour, position and negatives; they understand pretend situations and increasingly use language for thought and reasoning.
By the age of five, children understand long and complex sentences and such concepts as 'what happens next'?
At about four months of age laughter-like sounds emerge.
Babbling becomes increasingly complex, and towards the end of the first year strings of syllables like 'mamama' or 'papapa' are produced.
From about ten to fourteen months, infants may produce word-like sounds - 'pre-words' (dis, na, da) - to convey approval, disapproval, request or rejection.
Gestures are often used with these sounds to add meaning. The age at which the first recognisable word is spoken is highly variable, even within the same family.
By the first birthday most children are using a combination of tuneful babble and pre-words, while some also have a few recognisable words.
Gradually the babble, pre-words and gestures are added to and then replaced by an expanding recognisable spoken vocabulary.
Within the next few months children will use simple three-element sentences ('Mummy see me'). In the next stage children begin to develop grammatical systems, simple clause structure and the use of interrogatives.
All children initially make certain 'errors' to simplify the task, such as using past tense constructions such as 'comed' and 'goed', which persist for quite some time before being gradually dropped.
By the age of four years a child may be able to retell a simple story using coordinate clauses ('After we finished our dinner, we went outside and played a game').
From this stage onwards a child is able to hold simple conversations which gradually increase in complexity.
As their vocabulary increases during the later part of the second and the early part of the third year, children seem to simplify the task by using different strategies.
They may miss out the first or the final consonant (ish for fish), replace the first with the final consonant and sometimes add an extra vowel at the end (gouge for dog), replace certain sounds (tea for sea, tup for cup) or reduce words (pam for pram).
They will modulate the tone of their speech sounds to express emotional meaning, to emphasise or to question.
By four years of age most children are intelligible to strangers, although certain immaturities may persist well into primary school.
Between the ages of two and nine years, when children are learning to talk at a rapid rate, many children, often when excited or angry, have mild features of dysfluency (stammering).
This usually takes the form of repetition of sounds (M-M-M-Mummy), syllables (Mum-Mum-Mum-Mummy) and words (what-what-what).
Like other speech skills, fluency gradually improves with age. Preventive specialist advice is needed if there is parental concern, a history of stammering in the family, or the child shows signs of tension while struggling to speak.
Children are extremely open to distraction during the first year of life as their attention is held momentarily by whatever is interesting in the environment.
During the second year, children rigidly attend to their own choice of activity, particularly when the rewards are immediate and are part of the activity.
They do not like external directions and interruptions. During the third year, children are usually able to interrupt a task to receive directions.
Before any directions are given, their attention must be fully focused, and help may be needed in relating them to the task.
Most children begin to control their attention from the age of four years, and are able to listen to any directions without interrupting the task.
Although failure to talk is the most obvious cause of concern during the early childhood development stages, the child's ability to interact, to use gestures, to imagine or pretend and to understand language are more significant indicators of a child's normalcy or need for help.
The age norms given above are averages, and can only serve as a guide to the way language skills usually develop.
However, any delay or unusual features can be the first indication of a problem for which a child may need help.
Note: Hearing problems can adversely affect children's speech and language, and it is important to get a child's hearing tested if there are any concerns.
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