Child development is a key part of paediatrics and is commonly assessed by paediatricians. A very common exam scenario involves assessing the developmental milestones in a child to determine whether they are developing normally. Child development can be separated into four major domains:
- Gross motor
- Fine motor
- Personal and social
TOM TIP: The best way to learn the developmental milestones is to play with children and test their milestones. Try to find children that are developing normally aged 6 months, 1 year, 18 months, 2 years and 3 years. This will give you a good reference point when assessing new children to compare to. There will always been an element of rote learning, but this becomes easier when you can think back to a specific child at a specific age. People that have had their own children will find this much easier.
Gross motor refers to the child’s development of large movements, such as sitting, standing, walking and posture. Development in this area happens from the head downwards:
- 4 months: This starts with being able to support their head and keep it in line with the body
- 6 months: They can keep their trunk supported on their pelvis (i.e. maintain a sitting position) by 6 months, however they often don’t have the balance to sit unsupported at this stage.
- 9 months: They should sit unsupported by 9 months. They can start crawling at this stage. They can also keep their trunk and pelvis supported on their legs (i.e. maintain a standing position) and bounce on their legs when supported.
- 12 months: They should stand and begin cruising (walking whilst holding onto furniture).
- 15 months: Walk unaided.
- 18 months: Squat and pick things up from the floor.
- 2 years: Run. Kick a ball.
- 3 years: Climb stairs one foot at a time. Stand on one leg for a few seconds. Ride a tricycle.
- 4 years: Hop. Climb and descend stairs like an adult.
Fine motor refers to a the child’s development of precise and skilled movements, and also encompasses their visual development and hand-eye coordination.
- 8 weeks: Fixes their eyes on an object 30 centimetres in front of them and makes an attempt to follow it. They show a preference for a face rather than an inanimate object.
- 6 months: Palmar grasp of objects (wraps thumb and fingers around the object).
- 9 months: Scissor grasp of objects (squashes it between thumb and forefinger).
- 12 months: Pincer grasp (with the tip of the thumb and forefinger).
- 14-18 months: They can clumsily use a spoon to bring food from a bowl to their mouth.
- 12 months: Holds crayon and scribbles randomly
- 2 years: Copies vertical line
- 2.5 years: Copies horizontal line
- 3 years: Copies circle
- 4 years: Copies cross and square
- 5 years: Copies triangle
Tower of Bricks:
- 14 months: Tower of 2 bricks
- 18 months: Tower of 4 bricks
- 2 years: Tower of 8 bricks
- 2.5 years: Tower of 12 bricks
- 3 years: Can build a 3 block bridge or train
- 4 years: Can build steps
- Under 2 years: Palmar supinate grasp (fist grip)
- 2-3 years: Digital pronate grasp
- 3-4 years: Quadrupod grasp or static tripod grasp
- 5 years: Mature tripod grasp
- 3 years: Can thread large beads onto string. Can make cuts in the side of paper with scissors.
- 4 years: Can cut paper in half using scissors
Language refers to the child’s development of understanding and using speech and language to communicate. There are two components:
- Expressive language
- Receptive language
Expressive language milestones:
- 3 months: Cooing noises
- 6 months: Makes noises with consonants (starting with g, b and p)
- 9 months: Babbles, sounding more like talking but not saying any recognisable words
- 12 months: Says single words in context, e.g. “Dad-da” or “Hi”
- 18 months: Has around 5 – 10 words
- 2 years: Combines 2 words. Around 50+ words total.
- 2.5 years: Combines 3 – 4 words
- 3 years: Using basic sentences
- 4 years: Tells stories
Receptive language milestones:
- 3 months: Recognises parents and familiar voices and gets comfort from these
- 6 months: Responds to tone of voice
- 9 months: Listens to speech
- 12 months: Follows very simple instructions
- 18 months: Understands nouns, for example “show me the spoon”
- 2 years: Understands verbs, for example “show me what you eat with”
- 2.5 years: Understands propositions (plan of action), for example “put the spoon on / under the step”
- 3 years: Understands adjectives, for example “show me the red brick” and “which one of these is bigger?”
- 4 years: Follows complex instructions, for example “pick the spoon up, put it under the carpet and go to mummy”
You can also think receptive language in terms of the number of key words:
- 18 months: 1 key word, for example “show me the spoon”
- 2 years: 2 key words, for example “show me the spoon and the cup”
- 3 years: 3 key words, for example “put the spoon under the step”
- 4 years: 4 key words, for example “put the red spoon under the step”
Personal and Social
Personal and social refers to the child’s development of skills in interacting, communicating, playing and building relationships:
- 6 weeks: Smiles
- 3 months: Communicates pleasure
- 6 months: Curious and engaged with people
- 9 months: They become cautious and apprehensive with strangers
- 12 months: Engages with others by pointing and handing objects. Waves bye bye. Claps hands.
- 18 months: Imitates activities such as using a phone
- 2 years: Extends interest to others beyond parents, such as waving to strangers. Plays next to but not necessarily with other children (parallel play). Usually dry by day.
- 3 years: They will seek out other children and plays with them. Bowel control.
- 4 years: Has best friend. Dry by night. Dresses self. Imaginative play.
There are certain red flags for things that would suggest there is a problem:
- Lost developmental milestones
- Not able to hold an object at 5 months
- Not sitting unsupported at 12 months
- Not standing independently at 18 months
- Not walking independently at 2 years
- Not running at 2.5 years
- No words at 18 months
- No interest in others at 18 months
Performing a Developmental Assessment
During the initial part of the assessment try to develop rapport with the child so they engage with you. Make it a game and fun, and give plenty of praise when the child succeeds in a task. Make sure you remember and use their name. Children generally enjoy showing what they can do. If they are shy or don’t want to engage try using the parent to encourage them and don’t be afraid simply to observe and note what they are doing. If they absolutely do not want to engage you may want to ask their parent about the milestones.
Start by making a visual estimate of the rough age of the child and observing what they are doing before asking them to do something different. Test milestones that you think the child should be able to achieve at that age and work your way up until they are unable to complete the task. For example, if they look around 2 years and you want to assess fine motor, start with a tower and see how many bricks they can build, then challenge them to build a train, then a bridge, then steps. When they fail at a task, move on to assessing their drawing ability.
TOM TIP: When talking to the child, you can encourage them in a way that lets the examiner know you have noticed certain things, such as “that is a really good pincer grip”, “you built a tower of six bricks, that is great” and “that is really good walking”.
Last updated January 2020