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Early Intervention is the key to better outcomes!
The earlier we can evaluate and intervene for children 3 and under, the more improved functioning we can see by Kindergarten. Medically necessary therapies are very different than educational therapies through TEIS or school systems. Most children need both to make huge gains in development! Families rely solely on their pediatrician’s referral for medically based therapies. Using the Bayley Scales of Infant Development and other standardized assessments, we can evaluate to see if a child is greater than 25% delayed and may need therapy. The sooner we can evaluate, the sooner the family will know if therapy is going to benefit their child.
Here are some “red flags” to know when to refer for medically based pediatric therapies.
Gross Motor
If a child is…
Not rolling by 6 months of age
Not pushing up on straight arms, lifting his head and shoulders, by 7 months of age
Not sitting independently by 7 months of age
Not crawling (”commando” crawling–moving across the floor on his belly) by 9-10 months of age
Not creeping (on all fours, what is typically called “crawling”) by 11 months of age or any abnormal creeping patterns like bottom shuffling or scooting.
Not sitting upright in a child-sized chair by 9 months of age
Not pulling to stand by 10 months of age
Not standing alone by 12 months of age
Not walking by 14 months of age
Not jumping by 28 months of age
Not independent on stairs (up and down) by 30 months of age
“walking” their hands up their bodies to achieve a standing position
only walking on their toes, not the soles of their feet
frequently falling/tripping, for no apparent reason
still “toeing in” at two years of age
unusual creeping patterns
any known medical diagnosis can be considered a “red flag”: Down’s syndrome, cerebral palsy, congenital heart condition, frequent ear infections, sensory avoiders, low muscle tone or high tone, etc.
Fine Motor
If a child is…
Frequently in a fisted position with both hands after 6 months of age
Not bringing both hands to midline (center of body) by 10 months of age
Not banging objects together by 10 months of age
Not clapping their hands by 12 months of age
Not deliberately and immediately releasing objects by 12 months of age
Not able to tip and hold their bottle by themselves and keep it up, without lying down, by 12 months of age
Still using a fisted grasp to hold a crayon at 18 months of age
Not using a mature pincer grasp (thumb and index finger, pad to pad) by 18 months of age
Not imitating a drawing of a vertical line by 24 months of age
Not able to snip with scissors by 30 months
Using only one hand to complete tasks
Not being able to move/open one hand/arm
Drooling during small tasks that require intense concentration
Displaying uncoordinated or jerky movements when doing activities
Crayon strokes are either too heavy or too light to see
Any know medical diagnosis can be considered a “red flag”: Down’s Syndrome, cerebral palsy, low or high tone, other developmental delays.
Cognition/Problem Solving
If a child is…
Not imitating body action on a doll by 15 months of age (ie, kiss the baby, feed the baby)
Not able to match two sets of objects by item by 27 months of age (ie, blocks in one container and people in another)
Not able to imitate a model from memory by 27 months (ie, show me how you brush your teeth)
Not able to match two sets of objects by color by 31 months of age
Having difficulty problem solving during activities in comparison to his/her peers
Unaware of changes in his/her environment and routine
Sensory
If a child is…
Very busy, always on the go, and has a very short attention to task
Often lethargic or low arousal (appears to be tired/slow to respond, all the time, even after a nap)
A picky eater
Not aware of when they get hurt (no crying, startle, or reaction to injury)
Afraid of swinging/movement activities; does not like to be picked up or be upside down
Showing difficulty learning new activities (motor planning)
Having a hard time calming themselves down appropriately
Appearing to be constantly moving around, even while sitting
Showing poor or no eye contact
Frequently jumping and/or purposely falling to the floor/crashing into things
Seeking opportunities to fall without regard to his/her safety or that of others
Constantly touching everything they see, including other children
Hypotonic (floppy muscles, weak grasp, poor trunk tone, usually poor motor coordination)
Having a difficult time with transitions between activity or location
Overly upset with change in routine
Hates bath time or grooming activities such as; tooth brushing, hair brushing, hair cuts, having nails cut, etc.
Afraid of/aversive to/avoids being messy, or touching different textures such as grass, sand, carpet, paint, playdoh, etc.
Sensory integration/sensory processing issues should only be diagnosed by a qualified professional (primarily, occupational therapists and physical therapists). Some behaviors that appear to be related to sensory issues are actually behavioral issues independent of sensory needs.
Possible visual problems may exist if the child…
Does not make eye contact with others or holds objects closer than 3-4 inches from one or both eyes. Any eye turns in or out separate from another.
Does not reach for an object close by
Avoids doing near work, poor at puzzles, and avoids eye contact
Self-Care
If a child is…
Having difficulty biting or chewing food during mealtime
Needing a prolonged period of time to chew and/or swallow
Coughing/choking during or after eating on a regular basis
Demonstrating a change in vocal quality during/after eating (i.e. they sound gurgled or hoarse when speaking/making sounds)
Having significant difficulty transitioning between different food stages
Not feeding him/herself finger foods by 14 months of age
Not attempting to use a spoon by 15 months of age
Not picking up and drinking from a regular open cup by 15 months of age
Not able to pull off hat, socks or mittens on request by 15 months of age
Not attempting to wash own hands or face by 19 months
Not assisting with dressing tasks (excluding clothes fasteners) by 22 months
Not able to deliberately undo large buttons, snaps and shoelaces by 34 months
Social/Emotional/Play Skills
If a child is…
Not smiling by 4 months
Not making eye contact during activities and interacting with peers and/or adults
Not performing for social attention by 12 months “in their own world”
Not imitating actions and movements by the age of 24 months
Not engaging in pretend play by the age of 24 months
Not demonstrating appropriate play with an object (i.e. instead of trying to put objects into a container, the child leaves the objects in the container and keeps flicking them with his fingers)
Fixating on objects that spin or turn (i.e. See ‘n Say, toy cars, etc.); also children who are trying to spin things that are not normally spun
Having significant difficulty attending to tasks
Getting overly upset with change or transitions from activity to activity
Water play fun!
Communication:
· Difficulty making and maintaining eye contact with an adult by 6 months
· No big smiles or other warm, joyful expressions during interaction with another person by 6 months
· No back-and-forth sharing of sounds, smiles, or other facial expressions by 9 months
· No babbling by 12 months
· No back-and-forth gestures, such as pointing, showing, reaching, or waving by 12 months
· No consistent responding to their names by 12 months
· No words by 16 months
· No following simple and familiar directions by 18 months
· No two-word meaningful phrases without imitating or repeating & says at least 50 words by 24 months
· No back-and-forth conversational turn-taking by 30 months
· Any loss of speech or babbling or social skills (like eye contact) at any age
Most babies who are doing well with development exceed these milestones by leaps and bounds. These are very, very low thresholds for all the skills listed. If your child or patient is not meeting these basic guidelines, please don’t dismiss your feelings. Seek professional help from your pediatrician and ask for a medical based therapy evaluation. The earlier we can evaluate, the earlier we can see improved development!
