Topic Outline II.

NORMAL DEVELOPMENT
I. Principles of Development • Goes through defined stages and phases which are constant
II. Normal Development for normal children
A. For each individual ability
B. Categorized into Domains or Streams For each individual ability
C. Stages • Initial Age: age at which a few children first show the ability
D. Things to Remember (e.g. walking at 9 months)
E. Reach and Grasp Behavior Sequence; Use of • Median Age: age at which 50% manifest the ability (walking
Simple Objects in Assessment at 12 months)
III. The Development History • Limit Age: age at which majority show the ability
A. Other Things to Check o Most important among three
B. Patterns of Development o i.e. starts walking at 18 months (use as red flag!)
C. Tips for taking the Developmental History
D. Usual Concerns at Each Stage Categorized into Domains or Streams
E. Developmental Disabilities • Gross Motor
F. Prevalence of Developmental Disabilities o Walking, hopping
G. Role of Pediatricians • Fine Motor
IV. Developmental Surveillance and Screening o Eating with a spoon is both a fine motor skill and
A. Developmental Surveillance personal social.
B. Developmental Screening • Language
C. Developmental Evaluation o Receptive: follows 1-step commands, turns to name
Same lecturer + presentation from last year.
o Expressive: babbling, laughing
o Cooing vs babbling:
I. PRINCIPLES OF DEVELOPMENT
▪ Coo – vowels only at 3 mos.
• Development is a continuous process from conception to
▪ Babble – vowels and consonants at 6 mos.
maturity; it is intimately related to the maturation of the
o Jargoning – sounds like language
nervous system
▪ Immature jargon – cannot be understood by an adult,
o Development follows a definite sequence
at 12-13 mos.
▪ An infant must have head control first before being
▪ Mature jargon – some of the words can already be
able to roll over
understood, at 15-16 mos.
o Development shows cephalo-caudal and proximo-
distal progression • Personal Social/ Adaptive Skills
▪ Head control would develop first before sitting o Play is very important in the development of the child, it
▪ Possible manifestation of cerebral palsy: infants helps develop cognitive and emotional skills
maybe spastic and manifest as standing or sitting o Interacting with others, learning to share
▪ Performance of milestones correlated to myelination o social smile – absent in babies with autism
of nerves
o Development proceeds from gross undifferentiated skills Stages
to precise and refined ones • Infancy: 0-1 year (technically, 28 months -1 year)
• Variation occurs in the rate of development • Toddler: 1-2 years (early); 2-3 years (late)
• Preschool: 3-5 years
2 spectrums: NATURE VS NURTURE • School-age: 6-10 years
Gesell: “Development is dependent upon maturation of the • Adolescence: 10-19
nervous system.”
If there’s something in the brain, it would definitely affect the The Newborn
child • Video
Piaget: “The essence of development is the individual’s o Eyes are very sensitive to light - do not be surprised if
adaptation to his/her environment.” an infant placed under bright lights would not open
his/her eyes.
• Environmental stimulation of the right kind at the right time o Likes looking at bright objects/faces, especially their
will optimize development parents
o Media exposure not good for children <2 yrs. ▪ Can test tracking
▪ See objects 8-12 inches away from them – 8-12 is the
• Language development should be stimulated in the first 3
breastfeeding distance
years of life; great improvement in brain development
▪ Able to raise their head to see mother’s face
o Should also come with interactions
o Can hear and see
• Hearing impairment should be corrected before the start of
▪ Startles to sound
language milestones
o Flexor posture – extremities have flexion tone
• Now we know it’s an interplay between nature and nurture.

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Developmental Pediatrics EXAM 1
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o Arms and legs are tucked in Nine Months Old

▪ Hands are fisted but can let go • Crawls, gets to sitting, begins to pull to stand
o Body movements are symmetrical o Unlike creep – abdomen is still touching the floor
• Cry to communicate that they are hungry, overstimulated, or • Starts to point to objects, shouts for attention
needs attention • Variety of repetitive consonant and vowel sounds; imitates
sounds
Two Months Old • Develops object permanence
• Coos, vocalizes, attentive to voices o Crucial age for cognitive development
• Shows interest in visual and auditory stimuli • Plays peek-a-boo, stranger anxiety, waves bye-bye
• Smiles responsively; the social smile requires that the baby • Responds to name calling
smiles back at you (if the baby is just smiling with no • Feeds self with fingers, inferior pincer grasp
stimulus, it’s not counted) • Exhibits casting: throwing objects away
• Enjoys interactions with parents and caregivers o Often frustrates parents, however this is part of normal
• Lifts head, neck and upper chest with support on development and should not be punished
forearms (hands are still fisted) • Red flags: No interest in peek-a-boo, No attention to
• Has some head control in upright position gestures
• Video
Four Months Old o Develops object permanence
• Smiles, laughs, and squeals; babbles and coos ▪ “Things exist even if you don’t see them.”
• In prone position, holds head upright and raises body on ▪ Important in language development since the infant is
hands able to form concepts.
• Rolls over from front to back o Separation or Stranger Anxiety is expected
• Opens hands, holds own hands, grasps rattle ▪ Just let the infant calm down, either wait for the infant
o Refrain from putting mittens; might interfere with fine to settle on his/her own or give toys
motor development o Scooting, crawling (tummy drag)
• Limit age for controlling head well o “Head shaking” for no
• Looks at and may get excited by mobile (the crib toy, not the o Begins to pull to stand
phone) o Know how to differentiate mama with meaning from
• Loss of palmar reflex babbling

Six Months Old Table 2. Limit Ages for Various Child Abilities, 10-15 Months
• Babbles reciprocally Age (months) Refer if absent/doubtful:
• Turns to sounds Sits independently on firm surfaces
10 Bears weight on legs
• Sits with support
Babbling to self and others
• But some can already sit independently at this age 12 Attends to words
• Stands and bears weight, may “bounce” Releases held object – purposeful fine
o Walkers are not recommended! 15
motor skills
• Grasps and mouths objects
o Avoid toys with paint, and toys that are small enough to Eighteen Months Old
be choking hazards • Walks alone, seat self in chair
• Transfers cubes or other small objects from hand • Scribbles spontaneously – good time to introduce crayons
o Keep toys clean • Starts to name pictures
• Reaches for objects using one hand • Speaks a few words (10-25)
• Enjoys nursery rhymes
Table 1. Limit Ages for Various Child Abilities, 1-6 Mos
• Able to turn pages in a book
Age (Months) Refer if absent/doubtful:
• Follows simple commands/instructions
1 Some indication of attention
2 Attention to objects, reacts to sounds • Points to body parts and self
3 Head control • Exhibits joint attention
Hands not fisted (loss of palmar grasp o Joint attention is a triad: child, parent, and object
4 reflex) o Social-communicative skill in which two people (often a
Shows interest in people and playthings child and an adult) use gestures and gaze to share
5 Reaches for objects attention with respect to interesting objects or
Visual fixation and following established events.
Turns to sounds ▪ When the mother points and looks at the light, the
6
Asymmetrical Tonic Neck Reflex (ATNR) child must be able to follow and look at it as well.
not present o This is markedly impaired in children with autism.
7 Holds objects in hands • Assists with dressing and undressing
*Attention can be tested through sight and hearing.
• No casting (throwing things deliberately), mouthing or
*For head control, do not wait until the child is spastic already,
especially in preterm babies. Do intervention as early as possible.
drooling
• Parallel play

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Developmental Pediatrics EXAM 1
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• Red flags: Table 4. Median Ages for Various Child Abilities, 3-6 Years
o Hand dominance prior to 18 months may indicate Median Age Child can copy a:
contralateral weakness 3 years Circle
o No pointing, no joint attention, no eye contact 4 years Cross, square
o Has less than 3 words with meaning 5 years Triangle
• For less than two yrs. old, NO TV! 6 years Diamond
• Video
• Copy vs imitate
o Child is able to know where toys are kept
o Copy – image is drawn already prior to copying
o Learning to use the toys, may still be a little wobbly
o Imitate – child sees how the image is drawn and imitates,
o Loves using the stairs, able to push, pull, throw
the easier skill
o More precise hand and finger movements
• Video
o The use of puzzles can improve hand eye coordination
o Up to eight words, and put at least two together o The child can use spoon already and can scoop food on
o Echoes words his/her own
o Toilet training readiness
Two ½ Years Old ▪ Ambulatory
• Jumps up and down in place, runs well, climbs stairs ▪ Able to sit down
▪ No sphincter problems
• Copies a vertical line, builds a tower of 7 or more cubes
o Able to kick a ball
• Knows full name, asks who or what
o Goes up and down the stairs
• Speaks in 2-3 words, makes comments on interests and
o Dances
events, should
o Makes tower with >6 blocks
o Should have communicative intent and not just utter
o Able to feed self
words based on rote memory
o Tripod grip
o Echolalia –meaningless repetition of words
o Able to fold paper
o “Ano yan?” “Uwi na” “Saan ka”
o You can talk to and ask questions to him
• Play is starting to include other children as well as imaginary
play with toys, imitates activities, tantrums (parallel play)
School Age
• Schooling: no need to be advanced; motor and verbal
expression is the only expected developments during this Table 5. School Age Skills per Domain
period Age Gross Fine Personal-
Language
• Red flags: (Years) motor Motor Social
o Does not speak in 2-3-word phrases Pedals Greater
o Not jumping with both feet bicycle under-
Increasing
Comparing Prints standing of
6 link to peer
Four Years Old sizes, alphabet size, shape,
group
• Plays together, able to share weights, weight,
• Can go up and down the stairs without support distances distance
Needs
• Able to hop/balance on one foot
acceptance
• Able to print letters Begin to by peers
• Form tall block towers 8
join letters Wants to
• Has fully intelligible speech (“adult-like”) be part of a
• Able to distinguish sizes, colors, numbers, objects group
o Filipino parents are often proud if their children can All skills
Writing Ability to Form
memorize at younger ages, however this may disrupt performed
9-10 more well hypothesize same-sex
normal cognitive development more
established beyond groups
• Can follow three orders at the same time Sports
• Able to ask and answer who, what, when, where, why, how
• In Pediatric Physical Examination, you do an expanded
Table 3. Limit Ages for Various Child Abilities, 4-5 Years neurologic exam
Age (Years) Refer if absent/doubtful o Synkinesia (assessed by rapid finger tapping task) and
Hops Dysdiadochokinesia (impaired rapid alternating
Able to stack 10 blocks or copy a circle movements) are extinguished by 8 years in boys and
4 Understands prepositions 7 years in girls
Speech fully intelligible • Awkward upper extremity posturing on stressed gait tests
Toilet trained by day (tandem gait, toe walking, heel walking) is abnormal if it
Able to walk a straight line back and for the persists beyond 7 years
or balance on one foot for 10 seconds o Importance of neurological examination
5 Copy a cross • Tremors (chorea, athetosis) are abnormal and should not be
Uses proper syntax in short sentences
attributed to immaturity
Knows colors and letters
• 4 years old must be toilet trained by day
o If not, look for other reasons of enuresis

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Developmental Pediatrics EXAM 1
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Things to Remember THE DEVELOPMENTAL HISTORY

• Rule of thumb • Review each stream of development to check the age at
o From 2-5 years: Age in years = number of words in a which specific milestones were attained (parang review of
child’s sentences systems)
▪ 2 years old = 2 words • GOAL: try to get pattern of development
▪ 3 years old = 3 words • Some tips in doing developmental history:
o Age in years/4 = % of speech understood by strangers o Define developmental milestones in understandable
▪ 1 year = 1/4 or 25% intelligible to strangers terms (give examples)
▪ 2 years = 2/4 or 50% intelligible to strangers o Parents may give an interval during which a milestone
▪ 3 years = 3/4 or 75% intelligible to strangers occurred, or date it from a family holiday or event
▪ 4 years = 4/4 or 100% intelligible to strangers
• In general Add’l strategies: compare child with siblings, make 1 st birthday
o Note age appropriate milestones when doing your history as marker (walked, talked after 1st birthday?)
and physical examination such as:
▪ Eliciting the history of present illness and review of Other Things to Check
systems • Behavior
▪ Determine behavioral manifestations: “Nasasabi po o Problems with compliance, aggression, inattention,
ng bata ang karamdaman niya?” stereotypic behavior, self-injurious behavior
▪ Techniques in physical and neurologic examination o Stereotypic behavior: repetitive body movements of
objects common in many individuals with developmental
Reach and Grasp Behavior Sequence; Use of Simple disabilities
Objects in Assessment • Social and play skills
Raisin Behaviour • Lack of symbolic or pretend play (usually comes out during
• 5 mos: regards, mouthing, activation preschool), lack of desire to interact with other children
• 6 mos: rakes
• 7 mos: inferior pincer Patterns of Development
• 9 mos: pincer • Delay
o Child acquires skills in the typical sequence but at a
Pencil Behaviour slower rate
• 2 mos: follows with eyes horizontally o For Filipinos, ask what are the things the patient can do
• 3 mos: activates hands, follows vertically by his/her 1st birthday and other important events such as
• 4 mos: bimanual reach, opens hands if searching during Christmas, Holy Week, 2nd pregnancy, etc.
• 7 mos: anticipates shape with hand opening at the start of • Plateau: child fails to acquire new milestones after a
reach previous pattern of steady milestone attainment
• 18-24 mos: imitates stroke on paper o Very common in children with hearing impairment, would
• 30 mos: imitates circle plateau at 6-8 months, i.e. can babble
• 3-5 yrs: mature hold on pencil • Dissociation
o Child’s development is delayed in one stream and not on
another
Stethoscope Behaviour
o Four year olds can already identify letters
• 2 mos: regards across midline, follows vertically
• Deviation
• 3 mos: Bimanually swipes, brings to mouth if caught
o Child achieves milestones out of the usual sequence
• 5-6 mos: reliable reach, hands open on contact
o A child who is not talking suddenly reads
• 6-7 mos: reaches across midline if restrained
▪ Work up for autism
• 9-10 mos: unilateral reach with mirroring movements
• Regression
• 13 mos: unilateral reach with contralateral opening/ closing o Child loses previously acquired milestones
o Doing okay then biglang nawala yung skills
Block (1x1) Inch Behaviour while Sitting ▪ Work up for metabolic disorders or other
• 3-4 mos: waves blocks on the table, holds onto one if placed neurodegenerative diseases (Rett’s) or seizures
on hand ▪ Do not just label the child as having Global
• 4-5 mos: brings both hands to the block Developmental Delay
• 5-6 mos: brings block to mouth • Autism: Delay, Plateau, Regression
• 6-7 mos: picks up with one hand, holds onto one in each
hand Tips for taking the Developmental History
• 7-8 mos: brings block to table • Define developmental milestones in understandable terms
• 9-10 mos: bangs 2 blocks together • Parents may give an interval during which a milestone
• 10-13 mos: stacks 2 blocks occurred, or date it from a family holiday or family event
• 15 mos: stacks 3 blocks
• 18 mos: stacks 4 blocks Usual Concerns at Each Stage
• 24 mos: stacks 7 blocks • Referrals for motor delay most common in the first 6-18
• 36 mos: stacks 10 blocks months

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Developmental Pediatrics EXAM 1
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• Language delay most common referring complaint in the DEVELOPMENTAL SURVEILLANCE AND SCREENING
early preschool years Developmental Surveillance
• Behavior problems are major cause for referral in the later • A flexible, continuous process in which knowledgeable
preschool years professionals perform skilled observations of children
• Academic difficulties become the focus in the school age during child health care (in consultation with families,
years specialists, child care providers, etc.)
• Done by history and PE
Developmental Disabilities • Components of effective surveillance
• “…conditions characterized by physical, cognitive, o Eliciting and attending to the parent’s concerns
psychological, sensory, adaptive and/or communication o Maintaining a developmental history
impairments manifested during development” o Making accurate and informed observations of the child
• Seen as the “New Morbidity” of pediatric practice o Identifying the presence of risk and protective factor
• An estimated 5-10% of the pediatric population has a (always consider prematurity as a risk factor!)
developmental disability o Documenting the process and findings
• 10-20% of children have one or more mental or behavioral
problems Developmental Screening
• Does not aim to diagnose, uses standardized tests
Prevalence of Developmental Disabilities • Does not result in either a diagnosis or treatment plan but
Table 6. Prevalence of Developmental Disabilities rather identifies areas in which a child’s development
Disability Average Trend over time differs from same-age norms
Prevalence • Screening tools
Intellectual 10 per 1000 Higher in at risk o Developmental
Disabilities/ ▪ Denver Developmental Screening Test – II
MR ▪ Parent’s Evaluation of Developmental Status (PEDS)
Autism 2-7 per 1000 1:68 in US ▪ Ages and Stages Questionnaire
Cerebral Palsy 2-4 per 1000 No significant o Behavioral
change ▪ Pediatric Symptom Checklist
ADHD/LD 78-90 per 1000 10%?? ▪ Modified Checklist for Autism in Toddlers (M-CHAT)
Hearing 1-2 per 1000 No significant
• AAP Recommendations, Developmental Screening and
impairment change
Surveillance (2016)
o Each Visit: Developmental Surveillance; If with concerns
• Top 10 OPD Consults in 2016
→ do Developmental Screening
o 5th: Autism Spectrum Disorder
o At 9- and 30-months visit: General Developmental
o 7th: Attention-Deficit Hyperactivity Disorder
Screening (ALL children); can be done alongside
measles vaccination
Role of Pediatricians
o At 18-months visit: General Developmental Screening
• The first and sometimes only professional the child and the
(All children), Autism specific screening (all children)
family are in contact with prior to the child’s entry to school
o Prior to school entry: Screening for school readiness
• Accepted role of authority
• Positive Screen
• Aware of underlying social and familial factors in the child’s
o Refer child for developmental and medical evaluation
environment
o Refer child to Early Interventions service
• Developmental Surveillance: Process of identifying children
o Refer child to Early Childhood Services
who may be at risk for developmental delays
• Recommended ages are just a starting point
• Developmental Screening: Use of standardized tools to
• Surveillance should continue throughout childhood and that
identify and refine that identified risk
school-readiness screening should be performed at 4 years
• Developmental Evaluation: Complex process aimed at
of age
identifying developmental disorders
Developmental Evaluation
• Aims to identify the specific developmental disorder
affecting the child providing further prognostic information
Developmental and allowing prompt initiation of specific and appropriate
Screening therapeutic interventions
Acute Care • Complex processed aimed at identifying developmental
disorders
Advice to Parents
• Media use is already included in the developmental
Growth Records evaluation
o > 18 mos.: high quality apps/educational apps are okay
o 2 yo: not more than 1 hr/day of screen time; no TV in
child’s bedroom
Figure 1. The detection of developmental disorders is an integral END OF TRANSCRIPTION
component of well child care.

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