Red Flags in Child Development

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• Motor (gross and fine)
• Language
• Cognition
• Socio-emotional
• Adaptive

• Crucial scaffolding for locomotion, communication, and learning
• Proceeds from head to toes
• Progresses from the center of the body outward

• Intertwined with cognition
• Receptive skills develop in advance of expressive skills
• Follows a well-established pattern

• In early infancy, prespeech communication (i.e. crying)
• Cooing
• Babbling
• Protolanguage - intentional communicative behavior by infants that involves gestures and vocalization
• Holophrasic Stage - single words convey greater meaning than simply using the word as a label
• Telephrasic Phase - two words put together, but typically nouns, verbs, and adjectives only
• Children's acquisition of new words is slower as toddlers, and then becomes quite rapid, with expressive skills averaging about 5 to 8 words per day and receptive skills averaging more than 20 words per day across the ages 1 to 6 years.

• Dominant theory by Piaget
• Stages from infancy through adolescence occur in order
•     Sensorimotor Functioning
•     Preoperational Thought
•     Concrete Formal Thought
•     Formal Operations

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Sensorimotor Functioning

• Characterized by infant's progressive ability to organize and coordinate sensations and preceptions with movements and actions
• Most significant accomplishment is the understanding of object permanence

• Characterized by the concentration on one feature of a situation to the exclusion of others (centration) and irreversibility
• Development of preconceptual thought
• Expansion of symmbolic and representational systems

• Discrete emotional responses in the neonate are interest, disgust, distress, and startle like surprise emerge by four months
• Fear and shyness emerge by 12 months
• No agreement about whether emotions emege as a result of developmental in the cognition, perception and motor ability or independent of it.
• More differentiated emotions emerge in the second year of life
•     Embarrassment
•     Envy
•     Empathy
•     Pride
•     Shame
•     Guilt

• Development of reciprocal processes
• Examples
•     Social Smile
•     Social Play

• Smile detected several weeks after delivery are not social
• Smile at any face by three months
• Smile at familiar faces preferentially by five months and stop smiling at unfamiliar faces
• Stranger distress between seven and 10 months

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   Social Play

• Characterized by the beginning of emotional sharing and social referencing
• Two-year olds prefer playing with peers to playing alone

• Concerns about gross motor, social skills, self-help skills not significantly associated with a real problem
• Concerns about behavior and emotions and speech associated with a real problem between 40 and 50% of the time
• Concerns about fine motor skills and global concerns associated with a real problem between 75 and 80% of the time
• Medical providers should provide developmental surveillance
• Parents with a concern should talk to their medical provider
• The medical provider can assess the concern and screen the child
• The medical provider can then refer the child if needed or reassure the parents
• If parents still have a concern and the child is under the ages of three, the parents can refer the child to First Steps

• Gross Motor
•     Not holding head up by three months
•     Not sitting with support by 7 months
•     Not supporting weight on legs by 7 months
•     Not cruising by 15 months
• Fine Motor
•     Not using both hands by 9 months
•     Not self-feeding finger foods by 12 months
•     Showing a hand preference before 24 months
• Speech/Language
•     Not tolerating pureed foods by 9 months
•     Not tolerating solid foods by 12 months
•     Not babbling by 12 months
•     Sudden onset of babbling followed by cessation
•     Not gesturing (pointing, waving bye-bye, etc.) by 12 months
•     No single words by 16 months
•     No two-word spontaneous phrases by 24 months
•     No pretend play by 24 months
•     ANY loss of ANY language or social skills at ANY age

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• Important for environmental awareness and developing linguistic and physical skills

• "Sensory Integration is the ability to take in information through senses,...to put it together with prior information, memories and knowledge stored in the brain, and to make a meaningful response."

• Hyperactivity
• Distractibility
• Behavior problems
• Poor Speech development
• Disorders or muscle tone and coordination
• Learning disabilities
• Social problems
• Autism
• Juvenile delinquency

• Premature infants
• Low birth weight
• Genetic anomalies
• Pervasive Developmental Disorders
• Other CNS abnormalities

• 1. Sensory reactivity
• 2. Sensory processing
• 3. Muscle tone, motor planning, and sequencing

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• The child may frequently respond to or register sensory information without the ability to screen out nonessential sensory information, or the child may fail to register the input from one or more senses.

• Distractible, hyperactive, uninhibited
• Unresponsive to stimuli
• Difficulty establishing sleeping and eating patterns
• Unable to calm or console themselves
• Irritable, difficult to soothe, emotionally liable
• Hypersensitive to touch
• Aggressive
• Avoidant, withdrawing
• Intolerant of daily routines
• Rigid about textures, "feel"
• Hypersensitive to auditory, visual, olfactory, vestibular stimuli
• Lacks purpose in activity
• Does not manipulate toys or play with them creatively
• Does not explore the environment
• Plays very repetitively with toys
• Prefers only one type of activity
• Seeks excessive amout of vigorous sensory input

• The child may have a "flight or fight" as well as a fright response to sensory information most individuals would consider harmless

• The child may use movement in a nonfunctional way

Resources for Parents

• The Difficult Child Stanley Turecki
• The Challenging Child Stanley Greenspan
• The Child with Special Needs Stanley Greenspan and Serena Wider

• Autistic Disorder
• Rett's Disorder
• Childhood Disintegrative Disorder
• Asperger's Disorder
• Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS)

• Qualitative impairment in social interactions
• Qualitative impairment in verbal and nonverbal communication
• Restricted and repetitive patterns of behaviors

• Autism is not rare
•     Previous estimates of 4-5/10,000 for infantile autism
•     New estimates of 1/500
•     More common in children than Down syndrome, spina bifida, cancer and diabetes
• The male to female ration depends on IQ
•     2:1 males to females with severe dysfunction
•     4:1 males to females with normal IQ
•     Fewer females with normal IQ diagnosed because females tend to have better social skills
• There seem to be two groups of children with autism
•     Those who are impaired at birth
•     Those who seemingly have normal development until 18 months to 2 years and then seem to lose skills
• The percentage of children with mental retardation is not clear
•     Previously thought that 75 to 80% were mentally retarded
•     New estimates that 30 to 40% are mentally retarded
•     Important because long-term prognosis depends on IQ

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• Earlier educational planning and treatment
• Provision for family supports and education
• Reduction  of family stress and anguish
• Delivery of appropriate medical care to the child

• Intensive early intervention in optimal educational settings results in improved outcomes in most young children with autism, including speech in 75% or more and significant increases in rates of developmental progress and intellectual performance.

• Eye Contact
• Orienting to one's name
• Joint attention behaviors (pointing, showing)
• Pretend play
• Imitation
• Nonverbal Communication
• Language Development

• Developed by Baron-Cohen and associates in England
• Screening test based on parental report and provider observation
• Initiated at the 18-month well child visit
• http://www.featwa.org/autism/chat/chat.htm

• Section A:
• Does your child ever PRETEND, for example, to feed himself/herself or a doll with milk and cookies from an empty cup and plate or pretend other things? YES/NO
• Does your child ever use his/her index finger to point, to indicate INTEREST in something? YES/NO
• Section B:
• Get the child's attention, then point across the room at an intersting object and say "Oh, look! There's a [name of toy]!" Watch the child's face. Does the child look across to see what you are pointing at? YES/NO
• Get the child's attention, then give the child a miniature toy cup and a doll and say, "Can you feed the doll/give the doll a drink?" Does the child predtend to feed the doll? YES/NO
• Say to the child "Where's the light?" or "Show me the light." does the child POINT with his/her index finger at the light? YES/NO

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• Pointing out something of interest
• Looking where someone else is pointing
• Pretend play

• Negative answers to these five items:
• Pointing out something of interest (items A7 and Biv)
• Looking where someone else is pointing (item Bii)
• Pretend play (items A5 and Biii)
• Failing on all five indcates "high risk for autism" - these children should be referred for evaluation
• Failing on the two items relating to pointing out something of interest but passing at least one of the other key items indicate "medium-risk for autism" - these childrencan be rescreened at the next visit.

• Even if the child passes the screening, if there are concerns about social, behavioral, communication, and/or restricted interests, he or she should be referred for evaluation.

• Parental Concern
• Sensory integration problems
• Symptoms of autism