Developmental milestone and

red flags
Development
• Development refers to a progressive increase
in skill and capacity of function.
• Continuous process
• Predictable Sequence
• Each stage of development is affected by the
preceding types of development
• Milestones
• Red flags
 Developmental monitoring

Developmental surveillance Flexible, continue,

milestone/ red flags
Pra skrening

Developmental screening brief standardized,

Identification of risk
Not to diagnose

diagnosis Comprehensive assessment

Early intervention (National Research Council and Institute

of Medicine, 2000; AAP, 2001 dan 2006
 Development domains
• Physical development
• Gross motor
• Fine/ adaptive
• Language and communication
• Social-personal
– Visual
– hearing
 Motor development
• manifestations of early development
• Motor delay may be the first or most obvious
sign of GDD
• Proceed in regular direction:
– Cephalo-caudal
– Proximal-distal
– from generalized stimulus-based reflexes to
specific goal-oriented reactions
PERKEMBANGAN GERAK KASAR

sekuensial
 PERKEMBANGAN GERAK HALUS

hand grasp midline hand play reaching-swiping toys

 Red flags of motor delays
• Loss of development, regression
• Aberrant milestone:
– attain motor milestones early
– Asymmetric grasp, asymmetric sitting
– development of handedness before 18 months
– standing before sitting
• Loose and floppy movements (low tone) or stiff and
tense (high tone)
 Red flags
• Not achieving indicated developmental
milestones
• Gross motor:
– No head control by 4 months
– does not sit without support by 7 months
– not walking by 15 mo or running by 24 mo
• Fine motor:
– does not have open grasp & midline activity by 4 mo
– reaching by 6 mo
– mouthing of toys persists as predominant mode of
exploration after 12-18 mo
 history
• Pregnancy, delivery
• Family history, recurrent abortion, still birth, infant
death  genetic
• Developmental milestone:
– More than 1 domain GDD
– Loss of development, regression
– Aberrant milestone
• Stimulation
 Physical Examination
• General appearance: dimorphic face
• head circumference, weight, and length/height
• Drooling or poor weight gain, Tongue fasciculation
 facial and oral motor weaknesses
• Ptosis  congenital myopathies or LMN
• tachypnea, retractions neuromotor conditions
• Organomegaly  glycogen storage diseases,
sphingolipidoses, or mucopolysaccharidoses.
 Physical Examination
• General appearance: dimorphic face
• head circumference, weight, and length/height
• Drooling or poor weight gain, Tongue fasciculation
 facial and oral motor weaknesses
• Ptosis  congenital myopathies or LMN
• tachypnea, retractions neuromotor conditions
• Organomegaly  glycogen storage diseases,
sphingolipidoses, or mucopolysaccharidoses.
 Neuromotor Examination
• Primitive reflex
• postural tone: ventral suspension, trunchal
positioning
• symmetrical posture
• observing the quality and quantity of movement,
• Strength, antigravity movement
• Gower maneuver
• Toe walking, while often a normal variant, may
be an early sign of a neuromuscular condition or
a central condition such as cerebral palsy
 Examples of primitive reflexes

• The Moro is normal in a newborn and should be

gone by 4 months
• The ATNR is normal in a newborn and should be
gone at 6 months
 Postural (or protective) responses

Lateral support: Parachute response:

(appears at 6 months) (appears at 10 months)

• Anterior (comes 1st) , lateral (2nd), and posterior

(3rd) support responses
• Parachute response
Extremity tone
 Central or Peripheral?

• Central/ UMN  MRI/ CT Scan

• Peripheral: CK/ TSH/Ft4
 Central vs. Peripheral
Sign Peripheral Cause Central Cause

Chest size May be small with bell Usually normal

shape
Facial movement Often weak “myopathic” Usually normal
with high arched palate
Tongue fasciculation May be present, Absent
particularly in SMA
Tone Reduced tone Reduced tone or
increased tone with
scissoring
Deep Tendon Reflexes Decreased or absent Increased, may have
clonus
Gait Toe walking Toe walking
Waddling Hemiparetic
Hyperlordotic Spastic
www.childmuscleweaknes.org
Signs of Muscle Weakness that Suggest
Peripheral Cause
• Tongue fasciculation
• Abdominal breathing or accessory muscle use
• Head lag when pulled to sit
• “Slipping through the hands” when held
suspended
• Difficulty rising from floor
 Red Flags for Immediate Referral to
Neurology
• Tongue fasciculation
• Loss of motor milestones
• CK>3x normal
. Facial dysmorphism, organomegaly, heart
failure  metabolic disease
 Differential diagnosis
• CP (UMN)
• neurodegenerative process (LMN, loss of
motor milestones
• GDD, hipotiroid
• Developmental coordination disorder
 Is a Developmental
Disorder Identified?
• Identify as a Child With Special Health Care
Needs and Initiate Chronic Condition
Management, even if that child does not have
a specific disease etiology
Language and communication
DEFINITIONS
• Communication : the process of exchanging
information, both verbal and non verbal
means
• Language : the understanding, processing,
and production of verbal and non verbal
comunication
• Speech : the mechanics of verbal (oral)
communication
Screening for Language and Communication Disorders in Preschool Children,
Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009
27
LANGUAGE SPEECH

 
 
As symbolic process
Vocal expressive of
for communication
language

28
Language learning in Childhood is a
Naturally Acquired Skill
• Language rich environtment
• Ability to hear, see, comprehend and
remember
• Sufficient motor skills to imitate oral motor
movements
• Social ability to interact with others
Screening for Language and Communication Disorders in Preschool Children,
Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009

29
 Receptive language

refers to the ability to understand,

encompasses visual (reading, sign language
comprehension) and auditory (listening
comprehension) skills

Expressive language

refers to the ability to produce symbolic

communication, this output may be either
visual (writing, signing) or auditory (speech)

30
 
 31
Central Significance of
Language Development
• Language provides a “window into the brain”
o Reflects cognitive development
o Critical for learning
o Modulates emotional and behavioral reactions
o Necessary for social development
• Normal language development typically reflects
normal brain development

Screening for Language and Communication Disorders in Preschool Children,

Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009
32
Table 1. Milestones of Language Development and Indications
for Evaluation of Language Problems
Age at which skill
Age of Skill is significantly Abnormal findings or “red flags” for
acquistion delayed full assessment at this age

Birth Response to sound Shortly after Lack of response to sound at any age
birth Lack of interest in interaction with
Birth Social interest in faces and Shortly after people at any age
people birth Lack of any drive to communicate
2 to 4 mos. Reciprocal cooing, turn-taking 4 mos. after 4 mos. of age
Loss of the early ability to see or
4 to 9 mos. Babbling (repetitive consonant 9 mos. babble
vowel combinations) Poor sound localization or lack of
6 mos. Response to name 9 mos. responsiveness
Poor comprehension of verbal
9 to 12 mos. Comprehension of verbal 15 mos. routines, such as wave bye-bye
commands Some pointing to indicate wants and
9 to 12 mos. Pointing 15 mos. needs, but no pointing out
interesting objects or actions
Failure to use words, add new words,
or loss of words previously learned
10 to 16 mos. Production of single words 18 mos. Does not point to body parts or
follow single step commands

10 to 16 mos. Pointing to body parts or 18 mos.

comprehension of single
words 33
 Age at which
Age of skill is Abnormal findings or “red flags” for
acquistion Skill significantly full assessment at this age
delayed
18 to 24 mos. Comprehension of simple 24 mos. Minimal comprehension and limited
sentences symbolic play, such as doll or truck
play
18 to 24 mos. Vocabulary spurt 30 mos. Less than 30 words at 24 months, 50
words at 30 months
18 to 24 mos. Two-word utterances 30 mos. Lack of two-word utterances when
vocabulary is > 50 words
24 to 36 mos. Good intelligibility to familiar 36 mos. > ½ utterances are unintelligible to
folks family after age 2 years
30 to 36 mos. Conversations through asking 36 mos. Frequent immediate or delayed
and answering questions repetition of what others say
(“echolalia”)
30 to 42 mos. Short stories, asks “why” 48 mos. Rote memorization with failure to
generate novel stories
36 to 48 mos. Good intelligibility to 48 mos. > ¼ utterances are unintelligible to
unfamiliar folks strangers after age 4 years
36 to 48 mos. Full, well-formed sentences 48 mos. Consistent use of only short and
simple sentences
5 years Correct production of basic Errors in consonants such as b, p, d, t,
consonants p, k, m, n, l, r, w, s.
7 years Correct production of all Immature production blends such as
speech sounds st, sh, sp.

Feldman HM. Language disorders. Dalam : Berman S, penyunting. Pediatric Decision

Making. Edisi ke-4. Philadelphia: Mosby, 2003.h.94-97 34
 PERKEMBANGAN BAHASA
Milestone perkembangan bahasa

Macias & Twyman, AAP 2011

Red flag perkembangan bahasa

Macias & Twyman, AAP 2011

 Specific Language Learning / Reading
Impairment Disorders

Abnormal Emotional /
Intellectual
Language Behavioral
Impairment
Development Problems

Autism
Severe – to – profound Social
Hearing Impairment Problems
Screening for Language and Communication Disorders in Preschool Children,
Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009 37
Language Development and
Reading/Learning Disorders
• Language comprehension at age 3 years is a
strong predictor of later language and early
reading problems
• Language and reading/learning disorders are
highly heritable
o 30% of children with a positive family history of a language/learning
impairments show academic difficulty at age 7 years
o Parental history of “dyslexia”, speech/language disorder, grade
retention, or 2+ years of language or reading support services

Screening for Language and Communication Disorders in Preschool Children,

Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009 38
 Intellectual Disability and
Language Development
• Most children with mild intellectual disability follow
a typical sequence of language development at a
slower rate
• Children with moderate – to – severe disability may
demonstrate very limited ability to speak
• Specific causes for intellectual disability may be
associated with unique pattern of language
development
o Fragile X syndrome
o Williams Syndrome
Screening for Language and Communication Disorders in Preschool Children,
Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009 39
Autism and Language Development
• Autism is a behaviorally defined syndrome
resulting from dysfunction of complex brain
networks affecting the development of
cognitive, communication, and social ability
• Limited ability to integrate linguistic input
with real world knowledge
• Inability to use different types of cues to
decipher the intended meaning of other
people’s messages

Screening for Language and Communication Disorders in Preschool Children,

Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009
40
Severe to Profound Hearing Impairment
and Languade Dedevelop
• The progression of speech and language
comprehension and production is severely
affected in infants with severe – to
profound hearing impairment

Screening for Language and Communication Disorders in Preschool Children,

Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009

41
Language Development and
Emotional / Behavioral Disorder
• Nearly 50% of children referred to speech
and language clinics have emotional /
behavioral disorders
o Attention deficit (20%), anxiety disorder (10%), and oppositional
and conduct disorders (7%)

• Language comprehension disorder more

strongly related to emotional/behavioral
problems (81%) than isolated speech
disorder (30%)
Screening for Language and Communication Disorders in Preschool Children,
Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009 42
Language Development and
Social Problems
• By age 4 years, social interactions with
peers are largely mediated through verbal
transaction
• A child’s social and emotional
development is correlated with his level of
language development

Screening for Language and Communication Disorders in Preschool Children,

Mark Simms, Presentation at 13th Asian Pacific Conference of Pediatrics,
Shanghai, October 14-18, 2009

43
 Table 2. Signs of speech or language delay by type of disability

Language feature Auditory expressive

Auditory visual
receptive
Etiology content intelligibility

Hearing loss variable normal

Mental retardation

Developmental language variable normal

disorders
Autism normal

Dysarthria variable normal normal

Parker S, Zuckerman B, Augustyn M. Developmental and Behavioral Pediatrics

(2nd ed): Language Delays. Philadelphia: Lippincott Williams & Wilkins,2005

44
 Red flags: preschool

• Inability to perform self-care tasks, hand

washing simple dressing, daytime toileting

• Lack of socialization

• Unable to play with other children

• Unable to follow directions during exam

 Red flags: school age

• School failure
• Lack of friends
• Social isolation
• Aggressive behavior: fights, fire setting,
animal abuse
 Red Flags
– Be concerned if a child does not show pride
in accomplishments by 12 m/o or social
relatedness by 15-18 m/o

– Be concerned if a child has excessive

temper tantrums, hyperactivity, or
persistent poor transitions at 24 m/o