2.

01​ ​Growth and Development II PEDIATRICS 1

Joselyn Alonzo-Eusebio, MD, FPPS, FPSDBP LE ​02
18 February 2020 TRANS ​01​ (v ​02​)

I. Development
OUTLINE
IV. Red Flags of Development
then he is also developing his social skills.​ ​ 📣
meets other children along the way and interacts with them,

A. Principles of Child A. PRINCIPLES OF CHILD DEVELOPMENT AND LEARNING

A. Possible Early Signs of
Development Developmental Problems ● National Association for the Education of Young Children
B. Requirement for B. Gross Motor (NAEYC) 2009 Position Statement: 12 Principles of
Satisfactory Development C. Fine Motor Development and Learning
C. Normal Child Development D. Receptive Language ● Follows a sequence
II. Domains of Development E. Expressive Language ○ Building on those already acquired
A. Motor development F. Socio-Emotional ○ Proceeds towards greater complexity

📣
B. Language development G. Cognition ■ Eg.: Gross motor skills: Head control → sitting → standing
C. Cognitive development H. School-Aged Children → walking → running ​
D. Personal development Red Flags ○ Advance when children are challenged with many
E. Social development I. Importance of Early opportunities to practice and appropriate stimulation.
III. Developmental Milestones Detection and ○ Cephalocaudal direction of development
A. Motor Skills Intervention of ■ The process of cephalocaudal direction from head down
B. Language Skills Developmental Problems to tail. This means that improvement in structure and
C. Cognitive Skills V. Responsibilities of Primary function come first in the head region, then in the trunk,
D. Personal Skills Care Physicians and last in the leg region
E. Social Skills A. Surveillance ■ It would be easier to remember the corresponding
B. Screening milestones if you correlate which part of the body is
involved in eliciting or doing that particular function.​
● Regard is expected at 1 month, and we make use of
📣
LEGEND
our eyes for regard.

📍 📣
Important Recording Book/Article Previous Trans
● Social smile is achieved in 2 months, and we make use
(Author (ed), pp.) (Year & Section)
of our facial muscles, particularly our lips.
● Head control at around 3-6 months and we make use
Objectives
of neck muscles and trunk muscles.
At the end of the lecture, the student should be able to:
● Sitting alone is 8-9 months and we make use of our
1. Comprehensively discuss child development
butt.
a. Definition
● At 1 year, standing alone wherein we make use of our
b. Principles of development
feet.
c. Factors affecting development
d. Domains of development
e. Essential milestones of development
2. Describe developmental surveillance
a. Definition
b. Components, including developmental screening
c. Rationale
3. Familiarize students with commonly used developmental
screening tools
4. Enumerate and describe the red flags of development
I. DEVELOPMENT
● RECALL: Development is sometimes interchanged with growth.
However, development is broader, it is qualitative. ​
● It is a process of unfolding, expanding, becoming fuller, more
📣
complex, and more complete
● It is a global impression of the child and encompasses growth.
○ Increase in understanding, acquisition of new skills and more Figure 1.​ Cephalocaudal direction of development.
sophisticated responses and behavior ○ Development and learning proceed at varying rates from
● Refers to the refinement and specialization of a child’s function child to child, as well as at uneven rates across different
with acquisition of increasingly complex abilities in various areas of a child’s individual functioning

📣
functional domains (Gupta, 1999) ● Result from a dynamic interaction of biological maturation and
● Domains of development experience (nature and nurture ​ ​)
○ Physical, Emotional, Social, Language, Cognitive ● Early experiences have profound effects
○ You can group emotional and social domain under Affective, ○ Emotional problems of mothers during pregnancy may not
and language and cognitive domain under Cognitive, so you
📣 affect the physical aspect of the child but can have a

📣
may have 3 domains: Physical, Affective, Cognitive​ ​ psychological impact on the child’s development and
○ Each domain is closely related with and influenced by each behavior​ ​
other ● Experiences shape motivation and approaches to learning

📣
○ Example: When a child starts to develop his motor skills by ○ Importance of environmental stimulation, specifically early
simply walking around and exploring his environment, he is experiences of child, while growing up ​
also developing his cognitive and language skills. When he ● Influenced by social and cultural contexts
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2.01​ ​Growth and Development II ver. ​02

● Develop best with secure, consistent relationships B. REQUIREMENTS FOR SATISFACTORY DEVELOPMENT

parents 📍📣
○ The most important thing that needs to be emphasized to
​
○ When a baby cries, there is a need that must be satisfied,
and when the caregiver attends to this baby, a secure

baby to be a secure person later in life.​ ​

● Children learn in a variety of ways
📣
attachment is developed. If this will foster, this will enable the

● Play is important
Principles of Development
1. Development is a ​continuous process from conception to
maturity.

the ​rate​ of development ​varies​ from child to child

3. Development of gross motor skills proceeds in a
📍
2. The ​sequence of development is the same in all children, but
Figure 2. ​Requirements for Satisfactory Development
● Nervous system - well formed & functioning
cephalocaudal direction
● Opportunities - to learn and act
○ Fine motor skills proceeds in a ​proximo-distal direction
● Environment - appropriate and adequate nutrition at all stages
4. Development is intimately related to the maturation of the
● Challenges & Rewards
nervous system
○ It is not good to give everything to children so easily. They
○ The central nervous system should be ready and prepared
for such particular milestones in order for a child to be able to
achieve it.​(2021 Batch Trans)
should also face challenges so they will know how to handle
frustrations and become resilient as they grow older. ​ 📣
○ A 6-month-old baby, no matter how much you practice him to C. NORMAL DEVELOPMENT

is not yet ready to do that particular skill. ​ 📣

walk, he will not be able to do that. Why? Because his CNS

5. Generalized mass activity is ​replaced by specific ​individual

● Interplay of ​nature​ and ​nurture
● Development is determined by genetic endowment and is
modified by biochemical influences and environmental events.
responses. ● To the clinician, child development serves as a window to the
○ When you apply a painful stimulus, a baby would react by genes, brain and environment
moving almost all different parts of the body accompanied by
Nature
crying. As the child gets older, there is a more specific
response such as pulling away from stimulus. ​(2021 Batch Trans) ● Some influence on behavior and development originate from
6. Certain primitive reflexes, such as the grasp and walking reflex, heredity
have to be ​lost before the corresponding voluntary movement ● Inborn traits​ that are inherited from parents
is acquired ○ One personal trait that is strongly inherited is temperament
○ You should know when these reflexes should be normally
present and normally disappear because one of the red flags ADHD​ ​ 📣
and a condition in children that is strongly hereditary is

of primitive reflexes.​ ​ 📣
or one of the early signs of cerebral palsy is the persistence Nurture
● Environmental influences before and after birth.
Table 1.​ Primitive Reflexes ○ Upbringing and experience
Primitive Reflex Normal Abnormal ○ Good nutrition
Moro Reflex Up to 4-6 Persistence
NEED-TO-KNOW
months after 6 months
● Development is a process of unfolding, expanding, becoming
Palmar Reflex Up to 4-6 Persistence Voluntary release of fuller, more complex, and more complete.
months after 6 months objects/fine motor skills ● Requirements for satisfactory development (CONE):
Asymmetric Up to 4-6 Persistence Precursor to the hand/eye ○ Challenges & Rewards
Tonic Neck months after 6 months coordination as it ○ Opportunities
prepares for voluntary ○ Nervous system
reaching/difficulty with ○ Environment
crossing hands in midline ● Primitive Reflexes
Parachute After 6-8 Absence after Protective reflex ○ Moro, Palmar, Asymmetric Tonic Neck, Parachute, Landau
months 8 months and ● Normal development is the interplay of nature and nurture.
if unilateral ● Children develop best with secure, consistent relationships
Landau Between 6 Failure to Assist with posture ○ The most important thing that needs to be emphasized to
months and develop by development parents!
2 ½ years 10-12 months ● The ​sequence of development is the same in all children, but
the ​rate​ of development ​varies​ from child to child.

CONCEPT CHECK
1. At 9 months old, a baby presents with palmar reflex. Normal or
abnormal?
2. At 10 months old, a baby presents with a parachute reflex.
Normal or abnormal?
3. What are the requirements for satisfactory development?
___________________________________________________
ANSWERS
1. Abnormal. Palmar reflex should not persist after 6 months.

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2. Normal. Parachute reflex should be present after 6-8 months. C.COGNITIVE DEVELOPMENT
3. Challenges & rewards, opportunities, nervous system, environment
● Ability to learn, understand, solve problems, verbal and
II. DOMAINS OF DEVELOPMENT non-verbal reasoning, and meet daily living demands
● Infant & Toddlers​: ​Fine Motor & Language milestones
● 6 domains
○ Gross Motor
○ Fine Motor
through ​object permanence​. ​
​ easoning abilities
● Preschool Child​: R
📣
○ Best way to test cognitive development during infancy is

○ Language
● School Child​: ​Neuropsychological assessment
○ Cognitive
○ Personal D.PERSONAL DEVELOPMENT
○ Social/Emotional ● Ability to perform activities of daily living such as feeding,
A. MOTOR DEVELOPMENT dressing, and bathing
● Self-help and adaptive skills​(Navarro)
● Motor development is dependent on brain maturity
○ BUT has​ the weakest correlation to IQ​
● Sequence:
📍 ● Cultural background
E.SOCIAL DEVELOPMENT
○ Gross - cephalocaudal ● Ability to interact, to form, and to maintain relationships with
○ Fine - proximodistal parents, peers, teachers, siblings, and people in general
1. Gross Motor ● Ability to initiate joint attention, to cooperate with others, and to
○ The ability to control large groups of muscles to sit, stand, be aware and responsive to the feelings of others
walk, run, and transfer from one position to another while
maintaining proper stance and gait
○ Develops in a ​craniocaudal sequence
Emotional Quotient (EQ). ​ 📣
● Involves intrapersonal and interpersonal, which constitutes

III. DEVELOPMENTAL MILESTONES

2. Fine Motor
○ The ability to use hands deftly to manipulate fingers in order NOTE: Dr. Eusebio gave age ranges for certain milestones because
to eat, dress, write, and play ​ dditional information from Nelsons
different references say different ages. A
are included in the appendix. Milestones in bold fonts were emphasized by
○ Concerned with eye-hand coordination, object manipulation,
Doc.
​
and problem-solving skills (Navarro)
A. MOTOR SKILLS
📍
○ Develops in a ​proximodistal sequence
Table 2.​ Gross Motor Milestones ​
Mean Age (mos.) Milestones

📣
PPT Nelsons

📣
3 2 Head control (3-6 mos.* )
5 Roll over (4-5 mos.* )

📣
6 Sit with support
8 6 Sit alone (8-9 mos.* )
9
📣
Pulls to stand holding on (9-11
mos.* )
11 Stand
📣
mos.* )
independently (12

15 12
📣
Walk alone (9-17 mos* (mean age
= 13 mos.) )
24
📣
Climb up and down stairs
(creeping) (48 mos.* )
24 16 Runs
36 Ride a trike
48 Hop on one foot, catching a ball

📣
Figure 3. ​A shows gross motor development in craniocaudal sequence. well
B shows fine motor development in proximodistal sequence. 5-6 years Backward walk
B. LANGUAGE DEVELOPMENT NOTE: Doc emphasized the ​ranges more than the mean age in gross
motor milestones. Table from Nelsons can be found in the appendix.
● The ability to comprehend and reproduce verbal and non-verbal
symbols to communicate needs, emotions, feelings, requests,
ad demands.
● Ability to initiate and maintain discourse in an articulate, fluent,
and intelligible speech
● Consists of ​comprehension and expression ​
○ Generally, comprehension precedes expression
📣
● Sequence: simple to complex
● Strongest correlation with IQ​
● Important prerequisites for language
📍
○ Intact auditory function
○ Integrity of oral-motor structures
○ Cognitive ability
○ Stimulating environment

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Table 3. ​Fine Motor Milestones ​ 📍 Table 5. ​Expressive Language Milestones ​📍

Age Age Age Age
Milestones Milestone Milestones Milestones
(mos.) (yrs.) (mos.) (yrs.)
3 Hands open 2 Make strokes 3 Vocalizes and coos 2; 2-word phrases
4 Midline play 3 Copy circle 19 mos. (e.g. mommy eat,
(Nelsons)

📣 📣
5 Grasps, transfers 3½ Copy cross (3-4 years* let’s go)
(4-5 mos* ) (5.5 ) 6 Babbles 3 3-word sentence
mos.​(Nelsons)) ​
(Nelsons)
(e.g. I want to eat

📣
6 Holds bottle 4 Copy square ​(4-5 years* Jollibee)
) Gives full name,
age, sex
9
mos.* ) 📣
Pincer grasp (9-12 5 Copy triangle (writing full
name and alphabet in
order and numbers 1-10
8 Says dada, mama
non-specifically
4 Repeats 3-word
sentence
in sequence; can be Speech 100%

📣screened for dysgraphia intelligible to

) non-family
15 Imitate scribble 6 Copy diamond members ​(​other
In Nelson, it’s just people should
scribbles (13 mos.) understand the
(Nelsons)
child 100%; he
18 Scribble 9 Copy cylinder should be
spontaneously
NOTE: Table from Nelsons can be found in the appendix. 📣
articulate already
)
10 First words other 5 Uses past tense of
B. LANGUAGE SKILLS (Nelsons)

📍
than mama, dada eat, run, go
Table 4. ​Receptive Language Milestones ​ 12 Immature jargon, 6 Gives word
Age Age second word, ​at definition
Milestones Milestones least 3 words with
(mos.) (mos.)
1 Startles, alert to sound 15 Points to one meaning ​(​specific
body part words,​ e.g. mama
4 Turns to noise and voice 18 Points to two refers to mommy
and dada to daddy)
(because of head
📣
control at​ ​4-6 mos. ​ ​)
body parts
(speaks 4-6 words:
15 mos.)
7 Responds to name 24 Follows 2-step
commands ​
18 (from At least 10 words
doc and from
9; Responds to word “no” 36 Nelsons)
with meaning
Identifies action
7 NOTE: Table from Nelsons can be found in the appendix.
(​ Nelsons)
in pictures
11; 48 Knows 4 colors, NICE-TO-KNOW
Follows 1-step ● Vocalization and cooing: pertains to vowel sounds (ooo, aaa)
7 address,
(Nelsons) command with gestures ● Babbling: pertains to consonant sounds (bababa, badawibada)
prepositions.
12; Follows 1-step 60 Follow 3-step
C. COGNITIVE SKILLS
10
(Nelsons)
command without
gestures
commands
Table 6. ​Cognitive Milestones ​📍
(ex: “clap your hands” Age (mos.) Milestones
then the baby claps Newborn Identify mother’s voice and smell
his/her hands) 3 Reach for dangling ring
6 Respond playfully to mirror
9; ​8​ (Nelsons)
​ Object permanence
12 Understand spatial relationships
15 Make tower of 3 cubes, insert 1 shape in FB
(form board puzzle)
24 Tower of 7 cubes, 3 shapes in FB
36 Imitate bridge, tower of 10 cubes
48 Imitate gate, answers how many
Table from Nelsons can be found in the appendix.
● Cognitive milestones depend so much on fine motor skills

📣
during the first year of life because there is paucity of verbal
output ​

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D. PERSONAL SKILLS
Table 7. ​Personal Milestones.​ 📍
Age Age
Milestones Milestones
(mos.) (yrs.)
3 Opens mouth 2 Expressed need to go
expectantly to bathroom,
cooperates in dressing
6 Holds bottle, 3 Puts on shirt and
finger-feeds, shorts; ​dry by night​;
feeds self with uses fork to pierce
crackers
12 Drinks well from 4 Dresses w/o Figure 4. ​Floppy/ Increased tone (Hypotonic infant)
cup ​(bottle-feeding
should be shifted to 📣
supervision ​(​buttoning
and unbuttoning​ ​ ​),
B. GROSS MOTOR RED FLAGS

training cups as
early as 1 year ​ ​);📣 brushes teeth w/
assistance
increased muscle tone [e.g. tiptoeing] )​ 📣
● If the milestones are too early (rolling over prior to 3 mos.,

● 4 months: Lack of steady head control when sitting

begins to hold ● 9 months: Inability to sit
spoon
18 Feeds self with
spoon
5 Ties shoes
● 12 months: Unable to stand up
● 18 months: Critical age for independent walking​
○ Inability to walk independently = Definite motor delay
📍
​ ​ NOTE: Table from Nelsons can be found in the appendix. ● Persistent toe walking (sign of spasticity), scissoring (sign
E. SOCIAL SKILLS of spasticity; notable in Cerebral Palsy patients), stands
Table 8. ​Social Milestones ​📍 when pulled to sit, difficulty diapering a baby
● Asymmetry
Age
Age
Milestones (yrs. Milestones C. FINE MOTOR RED FLAGS
(mos.)
) ● Persistent fisting at 3 months
3 Smiles 2 Parallel play ● Hand preference <18 months
responsively

📣
(can be as early
as 2 mos. )
○ Normally, children are ambidextrous before 18 months;
no hand preference yet before the age of 2 years ​ 📣
D. RECEPTIVE LANGUAGE RED FLAGS
​
(1.5 mos.(Nelsons)​
)
6 Imitates actions 3 Likes to “make-believe”
/ imaginative / creative
●
●
●
2months: Does not alert or quiet to sound
6 months: Does not localize/ turn to the source of sound​
10 months: Does not respond to own name
📍
play
Demonstrates caution ● 12 months: Does not follow verbal routines/ games
9 Plays 4 Responds to instructions; ● 15 months: Does not understand simple questions
patty-cake, Imitates tasks ○ Does not stop when told “NO”

12
peek-a boo
Comes when 5 Plays games with simple
○ Does not understand at least 3 words
● 18 months: Does not point to 3 body parts​
○ Does not follow simple commands
📍
called by name rules (tag, hide-and-seek)
18 Follows directions 6 Plays board games ● 30 months: Does not follow 2-part commands
related to routines ● 36 months: Does not answer simple questions
E. EXPRESSIVE LANGUAGE RED FLAGS
📣
NOTE: Table from Nelsons can be found in the appendix.
​​

📍
● Parallel play is just imitating what other children are doing ​ ● 6 months: Does not coo

bahay-bahayan”​ ​ 📣
● Make-believe or role-playing - “nanay-nanayan, tatay-tatayan, ● 10 months: Does not babble​
● 12 months: Absence of non-verbal purposeful messages (show
IV. RED FLAGS OF DEVELOPMENT
● Considered as ​warning signs
objects
● 14 months: Absence of pointing​ 📍
● Should alert you to closely monitor the child as he/she is at
increased risk of developmental/ behavioral problems
using gestures.​📣
○ Even if you could not verbalize, you could still communicate

○ Lead Pointing​: One of the hallmarks of autism. Majority of

A. POSSIBLE EARLY SIGNS OF DEVELOPMENTAL children with autism do not point. They are unable to make

● Excessive sleeping
PROBLEMS
lead you to where the object is ​ 📣
use of non-verbal gestures. Instead, they pull your hand and

● 16 months: Does not say 3 different spontaneous words

● Extremely irritable
●
●
Weak cry, poor suck
Shows little interest in surroundings even with stimulation word equates to a possible problem 📍
● 18 months: Critical period for language; ​Not uttering a single

📍📍
● Upon examination of motor skills: ● 24 months: Vocabulary of not more than 35-50 words; ​does
○ Hypotonic baby not not produce 2-word phrases​

📣
■ Floppy muscle tone manifested by extended, arched
position of the back ​
● 36 months: ​No simple sentences
○ Does not answer your simple questions​ ​
● 42 months: Intelligibly to unfamiliar adult at <50%
📣
○ Spastic baby

📍 📍
● 54 months: Not able to tell or retell a familiar story
📣
■ Increase in muscle tone or persistence of primitive
reflexes​ ​ ● 60 months: Not fully intelligible to an unfamiliar adult
● >72 months: Not fully mature speech sounds

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F. SOCIO-EMOTIONAL RED FLAGS

● 6 months: Lack of smiles or other joyful expressions​ 📍 📣
○ Spastic baby - ​Increase in muscle tone or persistence of
primitive reflexes​ ​

📣📍
● 9 months: ​Deadma baby​; lack of reciprocal (back-and-forth) ● Gross Motor Red Flags
sharing of vocalizations, smiles, or other facial expressions ○ If the milestones are too early (rolling over prior to 3
○ No interaction yet between the caregiver and the baby.​ months, increased muscle tone [e.g. tiptoeing])
● 12 months: Failure to respond to name when called​; ○ 18 months: Critical age for independent walking

reaching, waving) 📍
absence of babbling; lack of reciprocal gestures (showing, ○ Persistent toe walking ​(sign of spasticity)​, scissoring
(sign of spasticity; notable in Cerebral Palsy patients)​,

showing of gestures📍
● 15 months: Lack of proto-declarative pointing or other

📍 ●
stands when pulled to sit, difficulty diapering a baby
Fine Motor Red Flags

📍
● 18 months: Lack of simple pretend play ​ ○ Hand preference <18 months

📣
● ANY AGE: Regression ​ ■ Normally, children are ambidextrous before 18 months;
○ Any loss of previously acquired babbling, speech, language no hand preference yet before the age of 2 years ​
or social skills
○ A hallmark of autism.​📣 ● Receptive Language Red Flags
○ 6 months: Does not localize/ turn to the source of
G. COGNITIVE RED FLAGS sound
○ 18 months: Does not point to 3 body parts
● 2 months: Not alert to mother ● Expressive Language Red Flags
●
●
●
6 months: Not searching for dropped object
12 months: Absence/no concept of object permanence ​
18 months: No interest in cause-and-effect games
📍 ○ 10 months: Does not babble
○ 14 months: Absence of pointing
■ Lead Pointing​: One of the hallmarks of autism
●
● 3 years: Does not know full name 📍📍
2 years: Does not categorize similarities ● Majority of children with Autism do not point​.

● 4 ½ years: Cannot count sequentially 📣

Instead, they pull your hand and lead it to where the
object is ​
●
alphabet or colors 📍
5 years: Does not know/ lacks mastery letters of the ○ 18 months: Critical period for language; ​Not uttering a
single word equates to a possible problem

common even in normal children)​ 📍

● 5 ½ years: Does not know birthday or address ​(very ○ 24 months:​ ​Does not not produce 2-word phrases

H. SCHOOL AGED CHILDREN RED FLAGS

○ 36 months: No simple sentences
■ Does not answer your simple questions ​ 📣
○ 60 months: Not fully intelligible to an unfamiliar adult
● Slow to remember facts
○ E.g. ​Parents would often complain that today, their children ○ >72 months: Not fully mature speech sounds
● Socio-Emotional Red Flags
📣
know their lessons, but tomorrow, he/she doesn’t remember
anything about it ​
● Slow to learn new skills, relies heavily on memorization
○ 6 months: Lack of smiles or other joyful expressions
○ 9 months: ​Deadma baby​; lack of reciprocal
(back-and-forth) sharing of vocalizations, smiles, or other
📣
○ E.g. You are teaching a kid to write, then he/she will say
he/she is tired and it is hard to write his/her name.​ ​ facial expressions
○ 12 months: Failure to respond to name when called
📣
■ You might be dealing with a kid who is showing early
signs of ​dysgraphia​, a learning disability.​
● Poor coordination, unaware of physical surrounding and prone
○ 15 months: Lack of proto-declarative pointing
○ 18 months: Lack of simple pretend play
to accidents ○ ANY AGE: Regression
● Trouble with fine motor skills ■ Any loss of previously acquired babbling, speech,
○ May be awkward and clumsy
○ Inability to button or unbutton clothes or tie shoelaces
●
📣
language or social skills
■ A hallmark of autism.​
Cognitive Red Flags
I. IMPORTANCE OF EARLY DETECTION AND INTERVENTION ○ 12 months: Absence/no concept of object permanence
OF DEVELOPMENTAL PROBLEMS ○ 3 years: Does not know full name
● According to WHO ○ 4 ½ years: Cannot count sequentially
○ 10-20% of children have ​one or more mental or behavioral ○ 5 years: Does not know/ lacks mastery letters of the
problems alphabet or colors
■ Developmental and behavioral disorders in children are ○ 5 ½ years: Does not know birthday or address (very

📣
now ​considered the newest morbidities in pediatrics common even in normal children)
● School Aged Children Red Flags
● With ​early detection​, we can do ​early intervention​, and this ○ Slow to remember facts
will lead to ​better outcomes ​in the lives of the children ○ Slow to learn new skills, relies heavily on memorization,
difficulty writing name

📣
NEED-TO-KNOW ■ You might be dealing with a kid who is showing early
● Motor​ development: ​weakest correlation to​ ​IQ​. signs of ​dysgraphia​, a learning disability ​
● Language​ development: ​strongest correlation to IQ​. ○ Trouble with fine motor skills
● Developmental milestone tables are included in the Summary ● Developmental and behavioral disorders in children are now
under Need-to-Know. considered the newest morbidities in pediatrics
● Red Flags of Development ● With ​early detection​, we can do ​early intervention​, and this
○ considered as ​warning signs will lead to ​better outcomes ​in the lives of the children
○ should alert you to closely monitor the child as he/she is at
increased risk of developmental/ behavioral problems CONCEPT CHECK
● Possible Early Signs of Developmental Problems 1. T/F: Children are naturally ambidextrous until the age of 3.

extended, arched position of the back ​ 📣

○ Hypotonic baby - ​Floppy muscle tone manifested by 2. T/F: Loss of previously acquired speech, language, or social
skills can be seen in all age groups.

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2.01​ ​Growth and Development II ver. ​02
Figure 5.​ Developmental-behavioral surveillance/screening at well- visits with
3. Hallmarks of autism.
children from birth to 6 yr of age: step-by-st​ep (Nelsons,
​ p.91)
4. If the child shows slowness in learning new skills and relies
heavily on memorization, he/she might be showing early signs ● Eliciting and attending to the parents’ concerns
of __________. ○ Never neglect the parents’ concerns as this is the most
___________________________________________________ important for monitoring
ANSWERS
○ If a parent would tell you ​“I think my child is delayed in his
1. F. Children are naturally ambidextrous until the age of 2.
2. T
3. Lead pointing, Regression
speech” you have to lend an ear and be not deaf about it.
You might be dealing with a child with autism. ​
○ Nowadays, studies have shown that parental concerns are
📣
4. Dysgraphia
70-80% sensitive and specific
V. RESPONSIBILITY OF PRIMARY CARE PHYSICIANS ● Maintaining a developmental history
● As future physicians, we have to make sure that we take care of ○ Provides you with an opportunity to identify early on when
the children in a holistic manner the developmental problem first manifested
○ We make sure that they are growing physically, normally ● Making accurate and informed observations of the child
○ Free from illnesses ○ E.g. ​Here comes the child, instead of looking at you he went
○ Development is on track and is optimal straight to the toys and when you called him using his name,
dedma. Are you dealing with an autistic child or a child with a
● Developmental and behavioral disorders in children are now
considered as the newest morbidities in pediatrics ​
● How do we detect if a child has developmental delays?
📣 hearing problem? When you ring a bell, the child turns his
attention towards the bell but when you call him, dedma. This
○ Surveillance and Screening is called ​selective response which is a ​characteristic of
● Early detection → Early Intervention → Better Outcomes autism​(2021 Trans)
○ Autism is the most common cause of language delay. Time
A. SURVEILLANCE
is the essence for a diagnosis. Parents often report their
NOTE: Additional information from Nelsons is included in the child having speech problems
appendix. ○ Confirm what the parents’ concerns are while the baby is
A. What is surveillance? open for observation
● Identifying the presence of risk and protective factor
● A ​flexible, continuous process​, in which knowledgeable
○ Pre-/peri-/post natal status and history, which may be the risk
professionals perform skilled observations of children during
factors for the present condition of the child
child care (in consultation with families, specialist, child care
○ An asphyxiated child at birth/kernicterus in the early neonatal
providers, etc.)
period might turn out having cerebral palsy
● The ongoing monitoring (tracking over time) of such issues as
○ E.g. ​Is this a child who was born in a condition where the
parental concerns, children’s progress with milestones,
psychosocial risk and resilience factors, providers’ efforts to
both detect and address problems, and follow-up regarding
look at the profile ​ 📣
parents are separated? Or is he or she an orphan? Take a

​
child/family outcomes (Nelsons, p.91)

● It is a part of the well baby visit, and is ​not only just getting
● Documenting the process and finding
○ This you can do by doing a screening ​ 📣
📣anthropometrics or giving them immunization. You have to do it
D. How to Incorporate Screening into Surveillance
B. Who needs surveillance? ● Regular use of professionally administered ​tool​ for all children
● All Children: ​who have or are at increased risk for a chronic ● Periodic use at office visits
physical, developmental behavioral, or emotional condition ● When concern arise
● Typical Children: ​for changes in their mental health,
E. Key Ingredients of a Child Health Surveillance Program
developmental and/or health status
● All children need surveillance, not just the ones we suspect ​ 📣 ● Immunization
● Health and nutrition
C. Components of Developmental Surveillance ● Safety
● Developmental Screening
○ As equally important as the first 3 stated key ingredients
○ Ideally, should be done every month
○ Should form part of the routine well baby/child visit

months​ 📍
○ Recommended for ALL children at 9, 18, 24 and/or 30

○ The Phillippine Pediatric Society has the same

recommendation on their booklet: ​Preventive Pediatric

​ ooklet ​
called ​The Bright Futures B 📣
Health Care which was updated in 2018. In the US, it’s

NEED-TO-KNOW
● Surveillance is a flexible, continuous process in which
knowledgeable professionals performed skilled observations
of children during child call
● All Children needs surveillance
● Components of developmental surveillance includes
○ Eliciting and attending to the parent’s concern
○ Maintaining a developmental history
○ Making accurate and informed observations of the child

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○ Identifying presence of risk and protective factor

○ Documenting the process and finding
📣
○ Comes in a form of delay in motor skill, social skill, language
skill ​
● DISSOCIATION: when one phase of development is out of
● Developmental Screening is a part of routine in child visits and
synchrony with others
is recommended for ​ALL children at ​9, 18, 24 and/or 30
○ E.g. ​Cerebral palsy in which the motor skills are lagging
months.
behind

A. What is Screening?
B. SCREENING
some who can go to college ​ 📣
○ Not all CP patients will be intellectually disabled, there are

○ There is a discrepancy between the motor skills and the

● Administration of ​brief, standardized​, and ​validated language or cognitive skills
instruments shown to have high sensitivity in detecting children ● DEVIANCE:​ ​refers to non-sequential development
with probable problems and high specificity in determining when ○ E.g. ​“My child is one year old she can recite the alphabet, but
​
children probably do not have problems​ (Nelsons, p.91)
she doesn’t call me mommy nor answer a yes or no
● Should occur across all domains:​(Nelsons, p.91) question”
○ Language (expressive and receptive)
○ Motor (gross and fine)
○ Cognitive/academic (including features of autism spectrum
disorder 📍
○ Autism is the most deviant form of communicative

● These three types of abnormalities provide clues to the early

disorder) diagnosis of developmental disorders
○ Self-help
○ Social–emotional skills (including conduct, attention, and NEED-TO-KNOW
mental health). ● Screening’s goal is to differentiate children that are “probably
● Goal to differentiate children that are “Probably Okay” vs okay” vs “Needing additional Investigation”
“Needing additional Investigation” ● Screening is performed at a set point in time
● Performed at a ​set point in time ● Screening Tools used are ​DENVER II, ELMS ​(Early Language
B. DENVER II Milestone Scale), ​PEDS ​(Parent’s Evaluation of
Developmental Skills)
● Most widely used​, inexpensive, easy to administer
● PEDS is the most widely recognized developmental screening
● Used to screen children from birth to 6 years old across the 4
tool from birth up to 8 years.
domains of development
● Three types of Abnormalities identified with developmental
● Widely criticized for limited predictive validity and low sensitivity
screening includes; ​Delay, Dissociation and Deviance
especially in ​language
● Delay is the most common reason for referral

CONCEPT CHECK
5. Developmental Screening is recommended for all children at
what months?
6. The most highly recommended Screening tool?
7. Type of abnormality in screening where there is one phase of
development that is out of synchrony with others?
8. Give the most deviant form of communicating disorder?
___________________________________________________
ANSWERS
5. Month 9,18,24,30
Figure 6. ​Denver Kit Sample contains Red Yarn pom poms, Raisins, Tennis ball,
6. PEES
Rattle, a baby, and so on 7. Dissociation
C. Early Language Milestone Scale (ELMS) 8. Autism

● Administer in pass-fail fashion like Denver II

● Only screens for milestones across expressive, receptive and REFERENCES
visual language within 0-36 months ● Nelson Textbook of Pediatrics (20th ed.) Chapter 16
● Relatively high sensitivity to language and cognitive delays ● Eusebio, J. (2020). ​Child Development [​ Lecture PPT]
● 2021 Batch Trans
D. Parent’s Evaluation Of Developmental Skills (PEDS)
● Highly recommended screening tool REVIEW QUESTIONS

tool from birth up to 8 years​ 📍

● It is the most widely recognized developmental screening

● By Frances Glascoe, MD, was developed after a series of

2021 Feedback (same lecturer)
1. Of all the domains of development, this skill has the
strongest correlation to IQ
researches on children’s development and parental concerns
a. Language
● A parent checklist that queries briefly about locomotive,
b. Motor
cognitive, social and language skills of children
c. Personal
● 10 questions, for all children 0 to 8 years
d. Social
● Take about 5 minutes to complete, 2 to score
2. A is 10 years old in his upper segment to lower segment
● Available in multiple languages
ratio is?
● Sort children into high, moderate or low risk for developmental
a. 1.0
and behavioral problems
b. 1.7
● Used over time to track a child’s development
c. 2.4
E. Three Types Of Abnormalities Identified With d. 3.1
Developmental Screening 3. A is 2 years old and her review of developmental
● DELAY:​ in one or all areas of development
○ The most common reason for referral 📍 milestone revealed that she could recite the letters of the
alphabet and numbers however she was not calling her

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parents as mommy and daddy. Her language a. Language

development is…? b. Motor
a. Advanced c. Personal
b. Delayed d. Social
c. Deviant Answers: 1A, 2A, 3C, 4D, 5B, 6A, 7C, 8D, 9B, 10D, 11A, 12A, 13A, 14C, 15B, 16B
d. Normal
2020 Feedback (same lecturer)
4. Critical period of brain development happens during
a. Childhood and and adolescence 1. Justin can do the following: rides the bike, tells his
b. Infancy and adolescence name, age and sex. What is his developmental age?
c. Infancy and childhood ○ 3 yr old
d. Prenatal and infancy 2. Noel is 12 yr old, expected upper and lower segment
5. A child’s speech is 100% intelligible to non-family ratio is
members at the age of ○ Equals to 1
a. 3
3. Miguel can walk well, vertical stroke and utter 10 words
b. 4
with meaning.
c. 5
○ 15-18 months
d. 6
6. Which is true of development? 4. Alyssa is a 2 year old female. At 1 yr she can utter
a. Development of fine motor skills proceed in a mommy, daddy and ball. After this, these disappeared
proximo-distal direction and replaced by jargons and imitate words. Language
b. Pain sensation is from specific to general development is
c. Rate of development is the same for all children ○ Deviant
d. The sequence of development varies from child to child 5. Imaginative/ Make-believe play is evident by
7. The following are red flags for development EXCEPT: ○ 3 yrs old
a. Absence of babbling at 10 months 6. Which of the following is a red flag of gross motor
b. Hand preference less than 18 months development
c. Inability to walk independently at 15 months ○ Walking by 13 months
d. No concept of object permanence at 12 months 7. A child is expected to build a tower of 7 by
8. Interactive play at 3 years old. ○ 24 months
a. Advanced 8. A child’s speech is 100% intelligible to non family
b. Delayed members by
c. Deviant ○ 4 years old
d. Normal 9. The following statement is true of fine motor
9. Writing full name at 6 years old development
a. Advanced ○ It’s proximodistal
b. Delayed
c. Deviant 2019 Feedback (same lecturer)
d. Normal 1. Of all the domains of the development, it has the
10. Pedal a trike at 3 years old. strongest correlation to IQ:
a. Advanced a. Language skill
b. Delayed b. Motor skill
c. Deviant c. Personal skill
d. Normal d. Social skill
11. Read 2-3 letter words at 5 years old. 2. The PEDS is a developmental screening tool that is
a. Advanced highly recommended for children aged:
b. Delayed a. 0-2 years
c. Deviant b. 0-4 years
d. Normal c. 0-6 years
12. Follow 2 step commands without any gestures at d. 0-8 years
18 months. 3. Lito can do the following: pedals a bike, draws a circle,
a. Advanced and talks in sentences. What is his approximate
b. Delayed developmental age?
c. Deviant a. 2 years old
d. Normal b. 3 years old
13. Walk alone at 18 months c. 4 years old
a. Normal d. 5 years old
b. Delayed 4. On developmental screening, Mark was able to do the
c. Advanced following: backward heel to toe walk, read 2-3 letter words,
14. Understood prepositions at 3 years old mathematical calculation (addition and subtraction of single
a. Normal digit number); and dress self completely. Mark’s
b. Delayed development is best described as:
c. Advanced a. Advanced
15. Vocalizes and coos at 6 months b. Delayed
a. Normal c. Deviant
b. Delayed d. Normal
c. Advanced 5. Alyanna isa 3 years old and according to her mother, she
16. Weakest correlation to IQ? was able to speak three words with meaning at 1 year, after

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which these disappeared and were replaced by jargons or d. Normal

unrecognizable words. Her language development is best 11. Make-believe play at 5 years old
characterized as: a. Advanced
a. Advanced b. Delayed
b. Delayed c. Deviant
c. Deviant d. Normal
d. Normal 12. Pedaled a bike at 2 years old
6. A child normally points to his body parts, turns the pages a. Advanced
of a book and scribbles vertical strokes at: b. Delayed
a. 12-13 months c. Deviant
b. 15-18 months d. Normal
c. 24-30 months 13. Sat alone at 8 months
d. 36-44 months a. Advanced
7. Parallel play is normally achieved at: b. Delayed
a. 2 years old c. Deviant
b. 3 years old d. Normal
c. 5 years old 14. Object permanence at 15 months
d. 8 years old a. Advanced
8. A child can build a tower of 3 cubes at: b. Delayed
a. 15 months c. Deviant
b. 18 months d. Normal
c. 24 months 15. Drew a cross at 3 years old
d. 30 months a. Advanced
9. A child’s speech is 100% intelligible to non-family b. Delayed
members by: c. Deviant
a. 3 years old d. Normal
b. 4 years old 16. Dry by day at 4 years old
c. 5 years old a. Advanced
d. 6 years old b. Delayed
10. Walked alone at 18 months c. Deviant
a. Advanced d. Normal
b. Delayed Answers: 1A, 2D, 3B, 4B, 5C, 6B, 7A, 8A, 9B, 10B, 11B, 12A, 13D, 14B, 15D, 16B
c. Deviant
SUMMARY
NEED-TO-KNOW CONCEPTS

📣
DEVELOPMENT 11 Stand independently (12
● Development is a process of unfolding, expanding, becoming mos.* )

📣
fuller, more complex, and more complete. 15 12 Walk alone (9-17 mos* (mean age
● Requirements for satisfactory development (CONE): = 13 mos.) )
i. Challenges & Rewards
ii. Opportunities
iii. Nervous system
24 Climb up and down stairs
(creeping) (48 mos.* ) 📣
24 16 Runs
iv. Environment 36 Ride a trike
● Primitive Reflexes
48 Hop on one foot, catching a ball
i. Moro, Palmar, Asymmetric Tonic Neck, Parachute,
📣
well
Landau
5-6 years Backward walk
● Normal development is the interplay of nature and nurture.
● Children develop best with secure, consistent relationships
i. The most important thing that needs to be emphasized to
Table 3. ​Fine Motor Milestones ​ 📍
Age Age
parents! Milestones Milestone
(mos.) (yrs.)
● The ​sequence of development is the same in all children,
3 Hands open 2 Make strokes
but the ​rate​ of development ​varies​ from child to child.

📣)
4 Midline play 3 Copy circle
● Motor​ development: ​weakest correlation to​ ​IQ​.
● Language​ development: ​strongest correlation to IQ​. 5 Grasps,
📣
(4-5 mos.* ) (5.5
mos. ​(Nelsons))
transfers 3½ Copy cross (3-4 yrs*

DEVELOPMENTAL MILESTONES
Table 2.​ Gross Motor Milestones​📍 6 Holds bottle 4
📣
Copy square ​(4-5 yrs*
)
Mean Age (mos.) Milestones
PPT Nelsons
📣
9
mos.* 📣
Pincer grasp (9-12
)
5 Copy triangle (writing full
name and alphabet in

📣
3 2 Head control (3-6 mos.* )
order and numbers 1-10
5 Roll over (4-5 mos.* ) in sequence; can be

📣
6 Sit with support
8 6 Sit alone (8-9 mos.* ) 📣screened for dysgraphia
)
9
📣
Pulls to stand holding on (9-11
mos.* )
15 Imitate scribble 6 Copy diamond

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In Nelson, it’s just Table 6. ​Cognitive Milestones ​ 📍

scribbles (13 mos.) Age (mos.) Milestones
(Nelsons)
Newborn Identify mother’s voice and smell
18 Scribble 9 Copy cylinder 3 Reach for dangling ring
spontaneously
📍
6 Respond playfully to mirror
Table 4. ​Receptive Language Milestones​ 9; ​8​ (Nelsons)
​ Object permanence
Age Age 12 Understand spatial relationships
Milestones Milestones
(mos.) (mos.) 15 Make tower of 3 cubes, insert 1 shape in FB
1 Startles, alert to sound 15 Points to one (form board puzzle)
body part 24 Tower of 7 cubes, 3 shapes in FB
4 Turns to noise and voice 18 Points to two 36 Imitate bridge, tower of 10 cubes
(because of head
📣
control at​ ​4-6 mos. ​ ​)
body parts 48 Imitate gate, answers how many
Table 7. ​Personal Milestones.​ 📍
7 Responds to name 24 Follows 2-step
Age Age
commands Milestones Milestones
(mos.) (yrs.)
9; Responds to word “no” 36
Identifies action 3 Opens mouth 2 Expressed need to go
7
​(Nelsons) in pictures expectantly to bathroom,
cooperates in dressing
11; 48 Knows 4 colors,
Follows 1-step 6 Holds bottle, 3 Puts on shirt and
7 address,
(Nelsons) command with gestures finger-feeds, shorts; ​dry by night​;
prepositions.
feeds self with uses fork to pierce
12; Follows 1-step 60 Follow 3-step
crackers
10 command without commands
(Nelsons) 12 Drinks well from 4 Dresses w/o
gestures
(ex: “clap your hands”
then the baby claps
cup ​(bottle-feeding
should be shifted to 📣
supervision ​(​buttoning
and unbuttoning​ ​ ​),
his/her hands)
training cups as
early as 1 year ​ ​);📣 brushes teeth w/
assistance

Table 5. ​Expressive Language Milestones​ 📍 begins to hold

spoon
Age Age 18 Feeds self with 5 Ties shoes
Milestones Milestones
(mos.) (yrs.) spoon
3 Vocalizes and coos 2;
19
2-word phrases ​(e.g.
mommy eat, let’s go) Table 8. ​Social Milestones​ 📍
mont Age
Age
hs Milestones (yrs. Milestones
(mos.)
(Nelsons) )
6 Babbles 3 3-word sentence 3 Smiles 2 Parallel play
(Nelsons)
(e.g. I want to eat responsively
Jollibee)
Gives full name, age, as 2 mos.
​
📣
(can be as early
)
(1.5 mos. (Nelsons)​
)
sex
8 Says dada, mama 4 Repeats 3-word 6 Imitates actions 3 Likes to “make-believe”
non-specifically sentence / imaginative / creative
Speech 100% play
intelligible to Demonstrates caution
non-family members 9 Plays 4 Responds to instructions;
(​other people should patty-cake, Imitates tasks
understand the child peek-a boo
100%; he should be
📣
articulate already​ )
12 Comes when
called by name
5 Plays games with simple
rules (tag, hide-and-seek)
10 First words other 5 Uses past tense of 18 Follows directions 6 Plays board games
(Nelsons)
than mama, dada eat, run, go related to routines
12 Immature jargon, 6 Gives word definition
second word, ​at RED FLAGS OF DEVELOPMENT
least 3 words with ● Considered as ​warning signs
meaning ​(​specific ● Should alert you to closely monitor the child as he/she is at
words,​ e.g. mama increased risk of developmental/ behavioral problems
refers to mommy ● Possible Early Signs of Developmental Problems
and dada to daddy)
(speaks 4-6 words:
○ Hypotonic baby - ​Floppy muscle tone manifested by
extended, arched position of the back ​ 📣
​
18 (from
doc and from
15 months)
At least 10 words primitive reflexes​ ​
● Gross Motor Red Flags
📣
○ Spastic baby - ​Increase in muscle tone or persistence of

Nelsons)
with meaning
○ If the milestones are too early (rolling over prior to 3
months, increased muscle tone [e.g. tiptoeing])
○ 18 months: Critical age for independent walking

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○ Persistent toe walking ​(sign of spasticity)​, scissoring ​(sign ○ 5 ½ years: Does not know birthday or address (very
of spasticity; notable in Cerebral Palsy patients)​, stands common even in normal children)
when pulled to sit, difficulty diapering a baby ● School Aged Children Red Flags
● Fine Motor Red Flags ○ Slow to remember facts
○ Hand preference <18 months ○ Slow to learn new skills, relies heavily on memorization,

●
hand preference yet before the age of 2 years ​
Receptive Language Red Flags
📣
■ Normally, children are ambidextrous before 18 months; no difficulty writing name

📣
■ You might be dealing with a kid who is showing early
signs of ​dysgraphia​, a learning disability ​
○ 6 months: Does not localize/ turn to the source of sound ○ Trouble with fine motor skills
○ 18 months: Does not point to 3 body parts ● Developmental and behavioral disorders in children are now
● Expressive Language Red Flags considered the newest morbidities in pediatrics
○ 10 months: Does not babble ● With ​early detection​, we can do ​early intervention​, and this
○ 14 months: Absence of pointing will lead to ​better outcomes ​in the lives of the children
■ Lead Pointing​: One of the hallmarks of autism
● Majority of children with Autism do not point​. SURVEILLANCE

📣
Instead, they pull your hand and lead it to where the
object is ​
○ 18 months: Critical period for language; ​Not uttering a
● Surveillance is a flexible, continuous process in which
knowledgeable professionals performed skilled observations of
children during child call
single word equates to a possible problem ● All Children needs surveillance
○ 24 months:​ ​Does not not produce 2-word phrases ● Components of developmental surveillance includes
○ 36 months: No simple sentences
■ Does not answer your simple questions ​ 📣
○ 60 months: Not fully intelligible to an unfamiliar adult
i. Eliciting and attending to the parent’s concern
ii. Maintaining a developmental history
iii. Making accurate and informed observations of the child
○ >72 months: Not fully mature speech sounds iv. Identifying presence of risk and protective factor
● Socio-Emotional Red Flags v. Documenting the process and finding
○ 6 months: Lack of smiles or other joyful expressions ● Developmental Screening is a part of routine in child visits and
○ 9 months: ​Deadma baby​; lack of reciprocal (back-and-forth) is recommended for ​ALL children at ​9, 18, 24 and/or 30
sharing of vocalizations, smiles, or other facial expressions months.
○ 12 months: Failure to respond to name when called
○ 15 months: Lack of proto-declarative pointing SCREENING
○ 18 months: Lack of simple pretend play ● Screening’s goal is to differentiate children that are “probably
○ ANY AGE: Regression okay” vs “Needing additional Investigation”
■ Any loss of previously acquired babbling, speech, ● Screening is performed at a set point in time

●
■ A hallmark of autism.​
Cognitive Red Flags
📣
language or social skills ● Screening Tools used are ​DENVER II, ELMS ​(Early Language
Milestone Scale), ​PEDS ​(Parent’s Evaluation of Developmental
Skills)
○ 12 months: Absence/no concept of object permanence ● PEDS is the most widely recognized developmental screening
○ 3 years: Does not know full name tool from birth up to 8 years.
○ 4 ½ years: Cannot count sequentially ● Three types of Abnormalities identified with developmental
○ 5 years: Does not know/ lacks mastery letters of the screening includes; Delay, Dissociation and Deviance
alphabet or colors ● Delay is the most common reason for referral
CONCEPT CHECKPOINT
RED FLAGS OF DEVELOPMENT ○ Normal. Parachute reflex should be present after 6-8
1. T/F: Children are naturally ambidextrous until the age of 3. months.
○ F. Children are naturally ambidextrous until the age of 2. 7. What are the requirements for satisfactory development?
2. T/F: Loss of previously acquired speech, language, or social ○ Challenges & rewards, opportunities, nervous system,
skills can be seen in all age groups. environment
○ T
3. Hallmarks of Autism SURVEILLANCE and SCREENING
○ Lead pointing, Regression 1. Developmental Screening is recommended for all children at
4. If the child shows slowness in learning new skills and relies what months?
heavily on memorization, he/she might be showing early signs ○ 9, 18, 24, and 30 months
of __________. 2. The most highly recommended Screening tool?
○ Dysgraphia ○ PEDS (Parents’ Evaluation of Developmental Skills)
3. Type of abnormality in screening where there is one phase of
DEVELOPMENT development that is out of synchrony with others?
5. At 9 months old, a baby presents with palmar reflex. Normal or ○ Dissociation
abnormal? 4. Give the most deviant form of communicating disorder?
○ Abnormal. Palmar reflex should not persist after 6 months. ○ Autism
6. At 10 months old, a baby presents with a parachute reflex.
Normal or abnormal?

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APPENDIX
NOTE: The following were lifted from Nelson Textbook of Pediatrics (21st ED.)

Table 9. ​Development Milestones During the Infancy Period​📍

Domain Milestones Skills
Gross 3 months Hold head without head lag
Motor 5 months Roll over
7 months Sit (6 months WITH support, 8 months WITHOUT support)
9 months Pull himself/herself to stand
12 months Walk independently
Fine Motor 3 months Observed to have unclenched hands
5 months Hands are brought to midline
7 months Transfer object from one hand to another
9 months Pincer grasp
12 months Voluntary release of objects / able to throw objects
Language 3 months Alert to human voice
6 months Localize to sound
9 months Understand and follow the command “no”
12 months Follow 1-step command with gesture
Personal 2 months Social smile
-Social 3 months Coo
6 months Babble
9 months Say “mama/papa” but non-specific
12 months Speak single words with meaning

Table 9. ​Development Milestones From Toddlerhood to School-Age​ 📍

Domain Milestones Skills
Gross 15 months Run, pivot, walk backwards, and crawl upstairs
Motor 18 months Walk upstairs with rails and run stiffly
24 months Jump with both feet and run well; climb on furniture; walk up and down the stairs 1 step at a time
30 months Jump forward and pedal a tricycle; goes upstairs with alternating feet
3 years Ride a tricycle
4 years Hop; throws ball overhead; use scissors to cut out pictures
5 years Skip
7 years Climb and run
Fine Motor 15 months Scribble spontaneously; make tower of 3 cubes
18 months Imitate stroke on paper; make tower of 4 cubes
24 months Imitate vertical lines; make tower of 7 cubes
30 months Draw circle with series of perseverating lines; make tower of 9 cubes
3 years Draw circle and a person with 2 body parts; make tower of 10 cubes
3.5-4 years Draw a cross
4-4.5 years Draw a square
5 years Draw a triangle
6 years Copy letters but reverse some of it; draw a person with 12 parts
7 years Know right and left sides
Language 24 months Two word phrases; follow 2-step commands; know full name
3 years Speak 3-4 worded telegraphic sentences; understand prepositions
4 years Speak in complete sentences, tells story; understand concept of size
5 years Understand concept of time; follow 3-step commands; pronounce most of the sounds of the
English alphabet except F, V, S, Z
6 years Able to verbalize emotions; follow 3-serial commands
Personal 12 months Cooperate when being dressed by putting out limbs; egocentric symbolic play; play simple ball
-social game
15 months Indicate some desires by pointing; imitate chores; hug parents
18 months Feed self; seek help when in trouble; may complain when wet/soiled
24 months Handle a spoon well; parallel play; toitlet-trained by day; listen to stories when shown pictures;
often tell about immediate experiences
30 months Help in simple tasks (eg. like putting toys away); pretend in play
3 years Dress under supervision; wash hands
4 years Dress independently/correctly; gross play; go to toilet alone
5 years Do simple errands and help in household chores; ask questions about meaning of words; engage
in domestic role-playing
6 years Dress up completely; tie shoelaces

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Figure 7.​ Red flags in developmental screening and surveillance. (Nelsons

​ 20th Ed, p. 100)

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Figure 8. ​Developmental milestones in the first 2 years of life.​ ​(Nelsons 20th Ed, p. 66)

​PEDIATRICS 1 16​ of​ ​18

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Figure 9. ​Emerging patterns of behavior during the first year of life.​ (Nelsons
​ 20th Ed, p. 67)

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Figure 10. ​Emerging patterns of behavior from 1-5 years of age.​ (Nelsons
​ 20th Ed, p. 75

​PEDIATRICS 1 18​ of​ ​18