KIDS
June 11, 2013

Developmental Delay, Or Just Delayed Development?

Baby still not crawling? The AAP helps you figure out when delays matter.

From early infancy through toddlerhood and into early childhood, skills develop in predictable and sequential patterns. This development of motor, thinking, communication, coordination, and social skills is watched with delight by friends and families, and monitored by health care providers.

There is no exact timetable for development. There is a range of time during which milestones are expected to emerge. Parents often worry that their baby is not rolling over or crawling when she should, simply because they hear stories from other parents about when their babies did these things. These developmental variations are rarely of any concern.

How can parents know what is a normal delay, and what suggests a more serious developmental issue?

But sometimes development does not occur as expected, and milestones are achieved slowly or not at all. So how can parents know what is a normal delay, and what suggests a more serious developmental issue?

It is important to identify motor delays early. Taking steps to intervene is best done sooner rather than later and can make the difference between a child who achieves his fullest potential or missing critical opportunities for supporting muscle and nerve development.

Guidelines from The New Report
The American Academy of Pediatrics (AAP) has just issued a clinical report to help pediatricians — and parents — monitor and evaluate physical and motor development. It also offers guidelines for comprehensive assessment of growing children in order to identify delays.

Delays are common in these milestones, and the report makes clear that many, if not most, resolve as the child grows and matures.

The report urges early and repeated screening for children to identify potential concerns in order to begin appropriate treatment as early as possible.

Movements like crawling, walking, and standing involve the large muscle groups. Delays are common in these milestones, and the report makes clear that many, if not most, resolve as the child grows and matures. Sometimes, however, motor delays can be a sign of a condition that leads to permanent disability, such as cerebral palsy, or another underlying neuromuscular disorder.

A child with motor delays may also have other developmental problems such as delays in communication and thinking skills and ultimately be diagnosed with global developmental delay. The AAP report stresses that such early identification of a child at risk, can help with planning therapy, education and other treatment interventions for the child and her family.

Parents and pediatricians should discuss development at every well child visit. Children should also be formally screened by their health care providers at 9-, 18-, 30-, and 48-months for developmental milestones to be sure that they have acquired the expected skills.

Major Milestones of the First Four Years
Here are the milestones healthcare providers should specifically assess at these interval visits:
  • By nine months the infant should roll to both sides, sit well without support, use each side of their body symmetrically (they aren’t right- or left-handed yet), and should be able to grasp and transfer objects from one hand to the other.
  • By 18 months, the toddler should sit, stand and walk independently and grasp and manipulate small objects
  • By thirty months, most motor delays will have already been identified. However, progressive neuromuscular disorders may begin to emerge and the child may lose some of the gross and fine motor skills that they had previously attained.
  • By forty-eight months the child should have early elementary school skills such as knowing the names of some colors, being able to play board or card games or understanding “same” and “different”.

Children should be screened more frequently if the child has known risk factors for delay, such as premature birth, severe illness or meninigitis early in life; or their medical providers, parents, or caregivers have concerns based on their observations of the child. In these cases, when concerns are raised by parents or those involved in the child’s care, education, or health, the AAP recommends that monitoring should continue throughout later childhood.

Pediatricians doing routine screening of motor development need to

  • Pay attention to parents’ concerns about their child’s development;
  • Keep an accurate and ongoing record of the child's developmental history as well as their own observations, process and findings.
  • Identify risk and protective factors (such as prenatal and neonatal history) that may affect motor development such as cerebral palsy or other neuromuscular condition.
Formal Screening for Motor Delays
In addition to what parents report, healthcare providers will administer a standardized screening test, appropriately selected for the child’s age if he or she suspects there may be a motor delay. There are numerous screening tools for a provider to choose from including the Denver Developmental Screening Test. Parental questionnaires can also help determine whether a child is attaining skills. Your child's doctor may attempt to elicit skills from the child, by prompting the child and demonstrating the task such as asking her to sit without support, jump and hop.

“Handedness” is not normal before about a year and a half, and if present before than that, may be a sign of weakness of lack of coordination on one side of the body.

The results of such a skills assessment are scored and compared with same-aged peers to determine whether the child is following normal patterns and sequences of development.

Neurological Assessment
During the neurologic exam the provider will not only assess what the infant or child can do, but how their muscles appear to be working. They will assess muscle tone to see whether the arms, legs or body posture are unusually stiff or unusually floppy. They will assess whether the child prefers to use one side over another. “Handedness” is not normal before about a year and a half and if present before than that, may be a sign of weakness of lack of coordination on one side of the body.

If A Child Has A Delay
If, as a result of a complete history, physical, neurological and developmental exam, there are delays or concerns identified, the provider may recommend further tests, specialist referrals, therapy, or other follow up.

One child may take her first steps at age 9 months, while another may not walk until 15 months but both are within the range of normal.

For example, if a child is suspected of having cerebral palsy, an MRI to look at the brain may be ordered. If a child has low tone or muscle weakness, tests to rule out muscular dystrophy or hypothyroidism may be advised. When a child has a constellation of features including muscular delay, abnormal physical appearance, or abnormalities in their internal organs, a genetic syndrome may be suspected and chromosomal testing may be suggested. Test results will help guide diagnosis and further referral for management and intervention.

If the examination reveals a motor delay, but evidence does not suggest any specific tests, it's likely you will be asked to return for close follow up to help your provider determine how the condition is evolving over time. Children with motor delays should also be referred to early intervention or special education resources to receive appropriate diagnostic and therapeutic interventions to address their delays.

What to Expect From Your Child's Doctor
If, even after a thorough evaluation, a specific delay is not clearly identified, the AAP recommends that the child continue to be followed closely. Pediatricians should schedule an early return for another surveillance visit to stay abreast of the situation. This will help them offer a timely response to parental concerns and refer the child, if necessary, to a specialist for new or evolving issues.

What Parents Need to Do
Parents have a major role in early identification of motor delays and in monitoring for impact of treatment or therapy. They have the opportunity to observe their children at play, and to informally see their progress. They are in a position to acquire a more complete picture of a child’s abilities than anyone else.

Sometimes parents may not know what to look for or what observations to report to their baby’s doctor. The AAP offers the following questions to help elicit the major elements of the motor history.

  • Is there anything your child is not doing that you think he or she should be able to do?
  • Is there anything your child is doing that you are concerned about?
  • Is there anything your child used to be able to do that he or she can no longer do?
  • Is there anything other children your child’s age can do that are difficult for your child?
The responses to these questions may help you pinpoint any concerns about delayed skills, involuntary movements or poor coordination, loss or regression of skills, strength coordination, and endurance problems.

Working with Your Healthcare Provider
It is important to bring your concerns about your child's development to the attention of his or her health care provider. The brief time spent on well child visits, as well as children's fears about the medical environment, may prevent the provider from having the opportunity to get an accurate assessment of a child’s skills.

If your provider recommends a “wait and see ” approach, it is up to you to make sure he or she revisits their concerns at each subsequent visit.

Parents should also be sure that their child’s health care provider is aware of any conditions that give them increased vulnerability for developmental delay. These might include premature delivery, health problems during the neonatal period, family history, lead poisoning, and significant early childhood illness such as meningitis.

Parents also need to be messengers who bring concerns of others who observe and interact with their child, such as baby sitters, family members, and teachers, to the attention of the care provider.

If your provider recommends a “wait and see” approach, it is up to you to make sure they revisit their concerns at each subsequent visit to be certain that the developmental issue is appropriately pursued. Parents should bring new or growing concerns back to the provider when necessary. When their child is identified as being delayed, parents must take on the added role of advocates, so their child receives the services to which he or she is entitled.

As mentioned at the beginning, it is important to recognize that although development is predictable and sequential, children achieve milestones at different rates and there is a range of ages during which new skills are expected to emerge and solidify. Thus one child may take her first steps at age 9 months, while another may not walk until 15 months but both are within the range of normal. Parents often compare their children to peers and siblings and may be come concerned about differences.

There are numerous web resources that describe age appropriate milestones as well as developmental delay.

It is well-documented that early intervention for delays in development can make a difference in the ultimate potential that a child and family achieve Taking steps to support development and intervene with any serious delays during critical periods of brain and muscle development are key to achieving the best possible outcome.

Parents and providers can use the guidelines offered in this AAP Clinical Report to better track and document children's motor development and to take appropriate steps to address any delays that may arise.

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