Development
Assessment
Dr.M.Sridhar

Introduction
• Development refers to maturation of
functions and acquisition of various skills
for optimal functioning of an individual.
The maturation and myelination of the
nervous system is reflected in the
sequential attainment of developmental
milestones.

Principles of Development
• Development is a continuous process from
conception to maturity
• Development is intimately related to functional
maturation of nervous system- opportunity to
practice
• Sequence of development is same in all children
but rate varies
• Development is in cephalocaudal direction

Principles of Development
•Certain primitive reflexes lost before corresponding
voluntary movement is acquired
•Initial disorganized mass activity replaced by specific and
wilful actions
•Generalizations about development cannot be based on
the assessment of skills in a single developmental domain.
However, skills in one developmental domain do influence
the acquisition and assessment of skills in other domains.

• Factors Affecting Development
– Prenatal factors
1.Genetic factors.
2.Maternal factors.
Maternal nutrition
Exposure to drugs
Maternal diseases and infections
– Neonatal factors-
1.IUGR
2.Prematurity
3.Perinatal asphyxia
– Post neonatal factors-
•Nutrition
Iron deficiency Iodine
deficiency Infectious
diseases
Environmental toxins
Acquired insults to brain Associated
impairments

-Psychosocial factors
Parenting
Poverty
Lack of stimulation
Violence and abuse
Maternal depression
Institutionalization
Protective Factors
Breast feeding
Maternal education

Examination: Observations and
Interactive Assessment
• Should take in place in a room with toys
appropriate for child
• With one or both parents, but no prompting and
helping
• Child’s behavior and interaction with parents
during history taking should be observed prior to
physical examination
• Normal functioning of motor, vision and hearing
should be assessed

Prerequisites
• Infant or child in a good temper
• Should not be hungry, tired, unwell, had
convulsion prior, under influence of
sedative or antiepileptic drugs

Equipment Required
• Nine red cubes
• Hand bell
• Red ring tied to a sting
• Colored and uncolored geometric forms
• Red pencil and paper
• Cards with circle, cross, square, triangle, diamond drawn
on them
• spoon
• Cup with handle
o Paper Pellets( 8mm)

Different Domains of Development
• Gross motor development
• Fine motor development
• Social/Cognitive/intellectual development
• Speech and language development
• Vision and hearing development

Gross motor developmental milestone
Age Milestone
3 months Neck Holding; Brings hands together in midline
4months Asymmetric tonic reflex gone
5 months Rolls over
6 months Sits in tripod fashion
8 months Sitting without support
9 months Stands with support
12 Months Creeps well; walks but falls; stands without
support
15 months Walks alone; creeps upstairs
18 months Runs; explores drawers
2 years Walks up and downstairs; jumps
3 years Rides tricycle; alternate feet going upstairs
4 years Hops on one foot; alternate feet going downstairs
Lift Head
Sit
Crawl
Walk

Fine motor developmental milestones
Age Milestone
4 months Bidextrous reach;palmar grasp gone
6 months Unidextrous reach; transfer object
9 months Immature pincer grasp; probes with forefinger
12 months Pincer grasp mature
15 months Imitates scribbling; tower of 2 blocks
18 months Scribbles; tower of 3 blocks
2 years Tower of 6 blocks; vertical and circular stroke
3 years Tower of 9 blocks; copies circle
4 years Copies cross; bridge with blocks
5 years Copies triangle;gate with blocks

Social and adaptive milestones
Age Milestones
2 months Social smile
3 months Recognizes mother; anticipates feeds
6 months Recognizes strange/ stranger anxiety
9 months Waves ‘bye-bye’
12 months Comes when called; plays simple ball game
15 months Jargon
18 months Copies parents in task
2 years Asks for food, drink, toilet; pulls people to show
toys
3 years Shares toys; knows full name and gender
4 years Plays cooperatively in a group; goes to toilet alone
5 years Helps in household tasks; dresses and undresses

language milestones
Age Milestone
1 months Alerts to sound
3 months Coos
4 months Laugh loud
6 months Monosyllables
9 months Bisyllables
12 months 1-2 words with meaning
18 months 8-10 words vocabulary
2 years 2-3 words sentence, use pronouns ”I”, “me”,
“you”
3 years Ask questions; knows full name and gender
4 years Says song or poem; tells stories
5 years Asks meaning of words

Hearing Development
• BAER hearing test (brainstem auditory evoked
response) done at birth
• Ability to hear correlates with ability pronounce
words properly
• Always ask about history of otitis media – ear
infection
• Repeat hearing screening test

Orienting to sound of bell
Johnson, C. P. et al. Pediatrics in Review 1997;18:224-242
5 months 7 months 9.5 months
Copyright ©1997 American Academy of Pediatrics

VISION DEVELOPMENT
• 1 month – baby can fixate on his mother
as she talks to him
• 3-4 months : child can fixate intently on an
object shown to him (grasping with eye)
• 6 weeks : binocular vision begins and is
well established by 4 months
• 6 months : child adjusts his position to
follow object of interest
• 1 year : follow rapidly moving objects

Time of Assessment
• Developmental surveillance- every well- child
visit
• Developmental screening-
– May be completed by parent or clinician
– Using standardized tool at 9, 18 and 30 months
– Example-
• Denver II developmental screening test
• Phatak’s Baroda Screening Test
• Trivandrum Development Screening Chart
• CAT/Clams ( Clinical adaptive test/ clinical linguistic and
auditory milestone scale)
• Goodenough- Harris Draw-a-person test

Denver II Developmental Screening Test
• Most widely used test for screening
• Assesses child development in four domains
gross motor
fine motor adaptive
language
personal social behavior
• These domains are presented as age norms,
just like physical growth curves.

Phatak’s Baroda Screening Test
• Indian adaptation of Bayley’s
Development scale
• India’s best known development testing
system
• Used by child psychologists rather then
physicians

Trivandrum Development Screening Chart
• Simplified adaption of Baroda Development
Screening System
• Consist Domains are gross motor, fine
motor and cognitive
• 0-2 years by para medical health worker
• Consists of 17 items selected from BSID
Baroda norms
• Time required- 5 mins
• Sensitivity 0.67 specificity 0.79
• Good for mass screening

INCLUDE 17 ITEMS
1.Social smile
2.Eyes follow pen/pencil
3.Holds head steady
4.Rolls from back to stomach
5.Turns head to sound of bell/ rattle
6.Transfer objects hand to hand
7.Raises self to sitting position
8.Standing up by furniture
9.Fine prehension pellet
10.Pat a cake
11.Walk with help
12.Throws ball
13.Walk alone
14.Says two words
15.Walks backwards
16.Walks upstars wiyh help
17.Points to part of a doll

DEVELOPMENT ASSESSMENT TOOL
FOR ANGANWADIS (DATA )
• Brief ,simple and psychometrically sound
measure for anganwadis
• Mainly for toddlers
• Identify at risk ,mild delay ,moderate deley
and severe delay

12 ITEMS
• GROSS MOTOR
Kicks stationary ball
Jumps in place
• FINE MOTOR
Folds paper in to half in imitation
Opens stacking barrel and takes out beads
• COGNITIVE
Finds specific objects on request
Places objects on request

• PERSONAL SOCIAL
Differentiate between edible and non
edible substances
Proper bowel /bladder control
• EXPRESSIVE LANGUAGE
Combine two words to express possesion
Can ask “what is this ? “
• RECEPTIVE LANGUAGE
Points to common objects described by its
use
Points to picture of action

Clinical Adaptive Test
– Developmental Screening Test for age under
24 months
– Two test combination
• Clinical Adaptive Test (CAT)
• Clinical Linguistic Auditory Milestone Scale
(CLAMS)
– Language assessment tool
– Distinguish Language Delay from mental retardation

Goodenough ‘draw a man test’

Definitive Tests
• Bayley Scales of Infant Development
• Wechsler Intelligence Scale for children IV
• Stanford-Binet Intelligence Scale 5th edition
• Vineland adaptive behaviour scale II
• Developmental activities screening inventory 2nd edition

Bayley Scales of Infant and Toddler Development-
Third Edition (Bayley-III)
• Age Range (in years) - Birth to3.5 years
• Method of Administration/Format
Individually administered in play-based format for Cognitive, Language ,
and Motor Scales; caregiver questionnaire for Social-Emotional and
Adaptive Functioning. Yields scaled scores, composite scores, and
percentile ranks.
• Approximate Time to Administer –
50 min. for 1-12 mos.;
90 min. for 13-42 mos.
Subscales
Cognitive; Language (Receptive, Expressive, Total); Motor (Fine-Motor,
Gross-Motor, Total); Social-Emotional; Adaptive Behavior (Communication,
Community Use, Functional Pre-Academics, Home Living, Health & Safety,
Leisure, Self-Care, Self-Direction, Social, Motor, Total)

Stanford-Binet Intelligence Scale
• Description
– Intelligence Testing of ages 2 to 23 years and beyond
– Yields Intelligence Quotient (IQ)
• Scoring
– Standardized Scoring
– Composite mean of 100 with standard deviation of 16
• Interpretation:
• Mental Retardation IQ Definitions
– Borderline mental retardation: 70 -79
– Mild mental retardation: 65-69
– Moderate mental retardation: 40-54
– Severe mental retardation: 30-39
– Profound mental retardation: <30

Wechsler Intelligence Scale
• Description
– Intelligence Testing
– Mean score of 100 with standard deviation of 15
– Gives verbal and performance scores
– Broken into subtests each with a mean of 10
• Age specific Wechsler tests
– Wechsler Preschool Primary Scale Intelligence (WPPSI-R)
• Used for ages 3 to 7 years
– Wechsler Intelligence Scale for Children (WISCIII)
• Used for ages 6 to 16 years
– Wechsler Adult Intelligence Scale (WAIS-R)
• Used for ages 16 years and older
•

DEVELOPMENTAL ACTIVITIES SCREENING
INVENTORY-SECOND EDITION (DASI-II)
• Age Range (in years)- Birth - 5 years
• Method of Administration/Format
Individually administered informal screening measure; may
be presented as a nonverbal test; 67 perceptual, motor, and
cognitive tasks Yields Developmental Quotient
• Approximate Time to Administer -25-30 min
• Subscales -Developmental Quotient

Developmental Quotient (DQ)
Ratio of the functional age to the chronological age. It is a means to
simply express a developmental delay.
DQ= ((developmental age) / (chronological age)) * 100
• If the infant was born prematurely the chronological age should be
corrected for the gestational age at birth during the first year of life.
• The adaptive developmental quotient uses a development measure
such as the Gesell scales. Similar quotients may use IQ or other measures.
Interpretation
maximum score =100
> = 85 normal
71-84 mild-to-moderate delay
<= 70 severe delay

Vineland adaptive behavior scale II
• Age Range (in years)- Birth - 89 years
• Method of Administration/Format
Measures personal and social skills in 4
domains (communication, daily living skills,
socialization and motor skills)
• Approximate Time to Administer -30-60 min

Assessment of Development
• Developmental milestones serve as the basis of most
standardized assessment and screening tools
• Two separate developmental assessment over time are
more predictive than a single one.
• Developmental monitoring not only should be aimed at
identifying children who have low function, but at
directing the focus of anticipatory guidance to help
promote normal development.

Approach
History and examination
- Check for age appropriate milestone
Absent
Check for milestones achieved in the past- what and when
Check for milestones in the other domains
Global Developmental Delay Delay in specific domain

SIGNIFICANT DELAY
Discrepancy 25% or more OR 1.5 to 2 SD
from normal
GLOBAL DEVELOPMENT DELAY
Delay in 2 or more domains of development
DEVELOPMENT DEVIANCE
When child develop milestone or skill
outside typical acquisition of sequence

DEVELOPMENT DISSOCIATION
When child has widely differing rates of
development in different domains of
development
DEVELOPMENT REGRESSION
When child loses previously acquired skills
or milestone

Purpose of Assessment
• Whether there is impairment or not in development
• Make a diagnosis if possible
• Seek to intervene positively to improve outcome and
function for the child and family
– Reinforcing acquired skills
– Teach developmentally appropriate skills
– Provide missed experience
– Make use of other skills to overcome difficulties
– Use learning style to promote learning

Red Flags: Birth to three month
– Rolling prior to 3 months
• Evaluate for hypertonia
– Persistent fisting at 3 months
• Evaluate for neuromotor dysfunction
– Failure to alert to environmental stimuli
• Evaluate for sensory Impairment

Red Flags: 4 to 6 months
– Poor head control
• Evaluate for hypotonia
– Failure to reach for objects by 5 months
• Evaluate for motor, visual or cognitive deficits
– Absent Smile
• Evaluate for visual loss
• Evaluate for attachment problems
• Evaluate maternal Major Depression
• Consider Child Abuse or child neglect in severe
cases

Red Flags: 6 to 12 months
– Persistence of primitive reflexes after 6 months
• Evaluate for neuromuscular disorder
– Absent babbling by 6 months
• Evaluate for hearing deficit
– Absent stranger anxiety by 7 months
• May be related to multiple care providers
– Inability to localize sound by 10 months
• Evaluate for unilateral Hearing Loss
– Persistent mouthing of objects at 12 months
• May indicate lack of intellectual curiosity

Red Flags: 12 to 24 months
– Lack of consonant production by 15 months
• Evaluate for Mild Hearing Loss
– Lack of imitation by 16 months
• Evaluate for hearing deficit
• Evaluate for cognitive or socialization deficit
– Hand dominance prior to 18 months
• May indicate contralateral weakness with Hemiparesis
– Inability to walk up and down stairs at 24 months
• May lack opportunity rather than motor deficit

Red Flags: 12 to 24 months
– Advanced non-communicative speech
(e.g. Echolalia)
• Simple commands not understood suggests
abnormality
• Evaluate for Autism
• Evaluate for pervasive developmental disorder
– Delayed Language Development
• Requires Hearing Loss evaluation in all children

Best tests( in our setting)
• For infant:
Phatak’s Baroda Screening Test
• For pre school child:
Bayley Scales of Infant and Toddler Development-Third
Edition (Bayley-III)
• For school going child:
Wechsler Intelligence Scale

Thank You