“A hundred years from now it will not matter what your bank account was, the sort of house you lived in or the kind of car you drove…but the world may be different because you were important in the life of a child”, said Forest Witcraft.
Identifying delays in a child’s development and addressing these delays are some of the most crucial and life-defining things anyone can think of! Since earlier identification can lead to early interventions and given that the effectiveness of early interventions is evidence-based and beyond doubt, therefore, it is imperative to know about a child’s development and address any issues without delay.
Charles Darwin, in 1877 published a detailed account of the development of one of his own ten children, and interest in child development arose. Since then, a massive amount of knowledge has accrued on children’s development. I shall cover the topic of ‘developmental delay’ in three separate articles because development is an enormous topic with numerous books written on this subject and many postgraduate qualifications solely dedicated to this.
In this first article, I have covered what developmental delay is? How common is it? What are the risk factors of developmental delay? How could one identify developmental delay? And finally, how do developmental assessments help us? I shall cover principles of child development, warning signs in child development, associated medical conditions, establishing developmental diagnoses and interventions for developmental delay in my subsequent articles.
So, what is Developmental Delay?
Developmental delay is a term used for a child under 5 years of age who has failed to meet the expected developmental milestones. In other words, the child has not yet acquired the developmental skills as would be expected of him or her, when compared with their age-appropriate peers.
The term developmental delay is replaced by the term ‘learning disability’ in a child over 5 years of age. It is worth noting that not all children with developmental delay go on to have a learning disability.
- Developmental delays could be in a child’s motor, language, communication, cognition, or social skill domains
- Moreover, development delay can be ‘Isolated DD,’ i.e. delay in a single domain or the delay could be ‘Global DD,’ i.e. when there is a significant delay in two or more developmental domains.
How common is Developmental Delay?
Developmental delay is common in children. The prevalence of developmental delay varies from 6% to 15%, in different surveys. The 2018 Annual Report from the Center for Disease Control and Prevention (CDC) in the USA estimated that approximately 16% of children had a developmental disability or a developmental delay.
How do you identify Developmental Delay?
Developmental delays can be identified in two ways:
- Developmental screening, and
- Developmental assessment
Developmental screening tests
- Are generally used to identify children whose development is not known.
- They are also undertaken when there is a suspicion of developmental delay.
- These screening tests can be undertaken by Health Visitors, General Practitioners, and professionals in primary care.
- The screening tests generally take the form of either a ‘yes or no questionnaire’ that are handed over to parents/carers to complete
- They can also be in the form of a ‘checklist’ where milestones gained are ticked
- Some examples of screening tests are the ‘Ages and Stages Questionnaire (ASQ)’ that is used in the UK or the ‘Ten Questions Screen’ that is widely used in the developing world/globally.
- Developmental assessments are undertaken when one needs to know “At what developmental age is this child functioning at and why?”
- A developmental assessment gives a detailed understanding of a child’s strengths, their weaknesses and their attainment levels
- Such an assessment is an in-depth evaluation of a child’s abilities and is carried out by Developmental Paediatricians, Psychologists and experienced Therapists
- Developmental assessment is usually carried out as part of establishing a ‘developmental diagnosis.’
- Some examples of developmental assessment tests are Griffiths Scales of Child Developmental or Bayley Scales of Infant & Toddler Development.
What aspects of the child are looked into during an assessment?
Various aspects of a child’s behaviour, function, and performance can be known from undertaking a developmental assessment. For example, an evaluation of a child’s ‘Locomotor/Gross motor’ domain can reveal insight into a child’s:
- Power & strength
- Agility & flexibility
- Depth perception
- Gross body coordination
- Gross visual-motor coordination, and
Assessment of the child’s ‘Language’ abilities can give information about his or her:
- Understanding of language abilities
- General knowledge (linguistic & applied)
- Memory (auditory, sequential, long term)
- Reasoning (verbal & semantic) and
- Expressive language abilities
Assessment of a child’s ‘Eye-hand coordination’ can provide information about:
- Form perception
- Bilateral coordination
- Size discrimination
- Form perception
- Form perception
- Manual dexterity
- Visual-spatial reasoning
Assessment of a child’s ‘Practical Reasoning/Cognitive’ abilities can give insight into a child’s:
- Moral, social or everyday reasoning
- Sequential reasoning
- Analogical reasoning
- Concept formation
- General cognitive functioning (memory, attention, learned knowledge)
Assessment of a child’s ‘Personal and Social skills’ can provide information about his or her:
- Social skills such as self-concept skills, interpersonal skills
- And personal skills such as eating, drinking, dressing, and self-care skills
Developmental assessments can also provide a great deal of other important information about a child. During my 15 years of teaching at Oxford, I encouraged my trainees to remember this by the acronym ‘ABCDEFG.’
- A = Attention
- B = Behaviour
- C = Concentration & Cooperation/refusal
- D = Disabilities, Dysmorphism
- E = Eye contact
- F = Interaction with Family (parent/carer)
- G = General or spontaneous speech and articulation
What are the risk factors for developmental delay?
The risk factors for developmental delay can be categorised into:
- Prenatal/before birth, e.g. exposure to alcohol, smoking, drugs, or infections in pregnancy
- Perinatal/during birth, e.g. infection, low birth weight, prematurity, lack of oxygen
- Postnatal/after birth, e.g. maternal depression, substance abuse, neglect, abuse, trauma, infections such as meningitis or encephalitis
- Genetic conditions, such as Down syndrome, Turner Syndrome, Fragile X, and many others
- Environmental factors, such as poverty, deprivation, poor housing, lack of social support, lack of sanitation, the state of the health service
- Medical conditions, e.g., Hypothyroidism, Heart or Chest or Gut problems
- Adverse experiences, e.g., war, food insecurity, racism, parental unemployment, illiteracy, parental mental illness, displacement because of political or climate events.
However, it is not all doom and gloom, as several protective factors have been identified that have shown to prevent or minimise developmental delays. These are:
- A stable and supportive family
- Active engagement of parents with their child’s school, and learning
- Regular household schedule for mealtimes, bedtimes
- Regular reading of stories or visits to the local library
- Opportunities to play with other children, participation in playgroups, visits to the local park, and outdoor activities
How do Developmental Assessments help us?
Apart from giving us an understanding of a child’s developmental level, their strengths and weaknesses, developmental assessments can also help us in several ways:
- Assessments facilitate earlier identification of problems and thus help in receiving earlier interventions
- The results help us in making referrals for appropriate therapeutic interventions, e.g. to a physiotherapist or an occupational therapist or a speech and language therapist
- The re-assessments can help evaluate the effectiveness of such therapy
- The results from assessments can help in choosing placement or educational options
- Assessments can reveal ‘developmental profiles’ that can suggest or support specific developmental diagnoses such as Dyspraxia, Learning Disability, ASD-high functioning/low functioning
- Assessments can help in the identification of problems with hearing, vision, behaviour, and communication
- Sometimes a delay in one area (e.g. vision) can affect development in other areas, e.g. gross & fine motor coordination, social interactions which could be prevented by an assessment
- Assessments can help in deciding about the need for further investigations
Children with undiagnosed developmental difficulties are at increased risk of developing low self-esteem, depression, anxiety, become disengaged with learning, refuse school, thus resulting in sub-optimal academic outcomes. Numerous studies have shown better outcomes, especially for children at-risk, when their developmental issues were identified early and addressed with appropriate interventions.
Studies have also shown that early intervention services for children with developmental disabilities have resulted in reduced teenage pregnancy rates, higher graduation rates, increased employment rates, increased integration into society and reduction in anti-social behaviours.
As you can see from the above, identifying developmental delay is of massive importance, and failure to do so can have severe consequences to the life outcomes of a child. Moreover, identifying these delays can lead to early interventions. And these evidence-based and effective early interventions can result in benefits not just to the child and his or her family, but also to the society at large.
Further reading and references
- National Center on Birth Defects and Developmental Disabilities (NCBDDD) Fiscal Year 2018 Annual Report. cdc.gov/ncbddd/aboutus/report/
- Gada S. Community Paediatrics. Oxford Specialist Handbook in Paediatrics. Oxford University Press. ISBN 978 0 19 969695 6. Published Sept 2012.
- Aites J, Schonwald A, Augustyn M, Torchia M. Developmental-behavioural surveillance and screening in primary care. UpToDate Inc. Wolters Kluwer. Accessed on 15 Nov 2020.
- Griffiths Mental Developmental Scales-Extended Revised (Now updated to Griffiths-III-Griffiths Scales of Child Development). Hogrefe Ltd.