Developmental Milestones by Dr. Hodges and Dr. Shagrin.
Learning Objectives.
At the end of this video, the viewer will be able to understand the importance of monitoring
child development, explain the difference between developmental surveillance and developmental
screening, and identify the major milestones from birth to five years of age.
Introduction.
Child development is central to the practice of pediatrics.
It begins at conception and continues into adulthood.
Prenatal development falls outside the scope of this video, but a child's in utero development
will impact his or her life course-- particularly if she is exposed to substances, born prematurely,
or affected by abnormal embryologic development.
Overall, there is an increasing awareness of how profoundly maternal health can impact
fetal and child development.
After birth, a child then progresses through subsequent stages of skill acquisition, which
pediatricians like to call developmental milestones.
Knowledge of what is happening and why at various stages help us support and foster
the growth of each individual child.
And to be able to recognize potential delays in development that might indicate a developmental
concern.
Early recognition and initiation of therapy is instrumental to address and treat developmental
delays.
For these reasons, developmental surveillance and screening are essential components of
pediatric visits.
Developmental surveillance is a term used for the skilled observations made by the pediatrician
of a child and their family that takes into account parental concerns and the child's
developmental history.
Developmental surveillance is ideally performed by every pediatrician at every visit.
Developmental screening is a term for the use of a standardized objective measure that
is given to the parent to assess development.
Developmental screening is recommended that least three times-- at nine, 18, and 24 months.
Autism-specific screening with the modified checklists for autism in toddlers is typically
performed at both 18 and 24 month visits.
Other screening tools, such as the Parents Evaluation of Developmental Status can also
be given at each well-child visit.
A child with one predictive concern is eight times more likely to have needs eligible for
services, such as speech or occupational therapy.
If two concerns, the child is 20 times more likely to be eligible for services.
Now that you have a brief overview of the importance of monitoring child development,
let us follow the development of one child-- acknowledging that we are only hitting the
surface of all that is happening and each age, but attempting to give you high yield
points you should know.
As you work to learn these milestones, consider why development is occurring at each stage
and how achieving a milestone allows a child to eventually move onto the next stage of
development.
Milestones fall into the categories of language, social, emotional, motor, and cognitive development.
Newborn to One Month.
A newborn infant spends most of her time eating and sleeping.
She should alert to sound, suck in a coordinated fashion, and fix her gaze on a face.
The newborn cries to make her needs known and ideally, these needs are met by the caregiver.
Discuss with caregivers how newborns learn by hearing parents speak to them and examining
their faces.
This is a good time to talk about attachment and to promote the important role of the new
parent in a child's development.
Following the newborn visit, the child visits the pediatrician at two, four, and six months.
What should that child be doing?
Two Months.
At two months, she is lifting her head when prone.
She now has a social smile, can track horizontally with her gaze, and can stay alert for longer
periods of time.
Four Months.
At four months, the child wants to engage with her environment more.
This is how she will learn and gain motor skills.
To allow that to happen, the atonic neck reflexes fade at four months and allows her to roll
from front to back.
She is making sounds to communicate, laughs, and orients to a parent's voice.
Cognitive skills are gained through sensory motor exploration so she loves looking around
at the environment.
At this point, she can bring her hands to midline and her fists will hold onto a toy
tightly that she then might put in her mouth.
Now that a child is rolling, falls are more of a risk.
Advise parents to never leave a baby unattended on a bed or couch.
Six Months.
At six months, she masters the ability to sit with support and begins to babble with
consonants.
She reaches for caregivers and for toys and will transfer a toy from one hand to the other.
She is really eager to explore and all of her primitive reflexes should be gone.
Persistent primitive reflexes beyond six months is a red flag and warrants further evaluation.
It is a good time to start child-proofing the home as the child is starting to move
around more and explore the environment.
Nine Months.
At nine months, sitting is getting boring and she needs to pull to stand and cruise
as she prepares to walk.
She will now turn her consonant sounds into "mama" or "dada" non-specifically.
She can use an immature pincer grasp to explore items or to pick up simple foods and put them
in her mouth.
She can turn the pages in a board book.
Cognitively-- she realizes that when she drops something, it doesn't just vanish, but objects
have permanence.
Thus, she is also developing emerging separation anxiety, realizing that mama and dada still
exist even though they aren't in the room.
Since the child is picking up smaller objects, this is a good time to discuss choking risks.
This also is the time for talking about separation anxiety.
12 Months.
As she reaches a year, her mama and dada are applied to the correct person.
She will also form at least one other word.
She realizes that sounds and gestures can tell other people what she wants and a point
will emerge.
She should begin to pair that point with eye contact and a sound or word to let others
know she wants that toy.
This is joint attention.
She takes her first independent steps.
She can also pick up small objects with a more developed pincer grasp, adding to her
ability to learn and explore in sensory motor fashion.
She can understand simple commands with a gesture, like, "Come here."
Hand preference before age one is a red flag, as this might indicate decreased strength
or tone on one side, suggesting an underlying neurologic deficit.
Another red flag is minimal response to name.
15 Months.
She refines her early language, motor, and cognitive skills by expanding to a three to
six word vocabulary.
Pointing not only to show what she needs, but also just to share her interest and showing
things to her parents.
She is more able to feed herself with a spoon and can use a cup.
She is refining her walking skills; stoops and recovers.
And also likes to scribble so keep the markers away from the furniture.
It's a good time to discuss how to handle tantrums.
These are a normal way that a child can express her sense of independence.
No words and no pointing are red flags at this age.
18 Months.
Her vocabulary is doubling.
She can now say between five to 10 words while doing plenty of jargoning.
She is using her pointing ability to label at least one body part, in addition to pointing
to show someone what she wants.
Now that she is making all of these gains, she starts using her language and motor skills
to imitate those around her.
Often trying to help out around the house.
You might find her stacking three blocks or starting to run.
Red flags at 18 months include not pointing to show things to others, can't walk, not
imitating, not gaining new words, or not noticing when caregiver leaves or returns.
24 Months.
Two years is a big time.
She really wants to increase her independence.
So what does she need to do?
She is putting two words together.
She has about 50 words to choose from, but only 50% understood by others.
She is following two-step commands.
And going up and down stairs two feet at a time, while holding onto a railing.
She is feeding herself with two utensils-- a spoon and a fork.
And jumping with two feet off the floor.
And realizes that two kids playing in parallel is pretty nice.
She is turning thin pages and drawing lines.
Her block tower has doubled to six blocks high.
Red flags at two years include not using two-word phrases-- for example, "drink milk," not knowing
what to do with common things, such as a brush, spoon, or phone, not imitating actions or
words, not following simple instructions, not walking steadily, or losing skills she
once had.
Three Years.
At her next birthday, she has places to go such as up or down stairs with alternating
feet or via pedaling a tricycle.
She is drawing circles and her cube tower has tripled to nine blocks high.
And she can build a three block bridge to add to her castle.
She is using pronouns correctly and thankfully, a stranger can understand 75% of her language,
which consists of three-word sentences.
She can put on her shoes and undress herself and brush her teeth with help.
She knows her name, and age, and can name colors.
She is interacting in group play and taking turns.
Play becomes more imaginative as children seek to understand the world around them and
explore it with other children.
She is most likely toilet-trained during the day.
Red flags at three years old that should be noted include, not playing pretend or not
playing with other children, falling frequently, no three-word phrases, and repetitive behaviors.
Four Years.
Her drawing skills now include a four-sided square or a cross and she can hop on one foot.
She can manipulate buttons.
She is fully understood by strangers and is answering what and when questions.
She knows how to follow the rules in a game or in play, such as a simple board game.
She knows at least four colors.
Red flags at four years old include difficulties with feeding, sleep, or toileting, speech
is not clear, not following three-part commands, or not speaking in short sentences.
Five Years.
As she prepares to enter kindergarten, she is skipping and tying her shoes.
She can draw a triangle and print her first name.
She draws a person with the head and body parts and she knows her left from her right.
She is ever curious, asking questions about what a word means or why we do things.
She can follow a three-step command and knows her address, birthday, and phone number.
She answers more complex why questions.
She can name the alphabet and count to 10.
Red flags to look out for five years include cannot perform basic tasks independently,
such as getting dressed difficulty attending to an activity for more than five minutes,
not talking about daily activities or experiences, or extreme behavior-- unusually fearful, aggressive,
shy, or sad.
Summary.
As you can see, child development is an ongoing nuanced process.
We hope that this video introduces you to some of the key milestones with which you
should be familiar.
But more importantly, to why these milestones are important.
Thank you for watching this video on developmental milestones.