Transcription:
Developmental Red Flags

Melanie Cole (Host):  There’s no handbook for your child’s health. But we do have a podcast, featuring worldclass clinical and research physicians covering everything from your child’s allergies to zinc levels. This is Kids Health Cast by Weill Cornell Medicine. I’m Melanie Cole and I invite you to listen as we discuss developmental red flags for your children. Joining me is Dr. Sherry Huang. She’s the Site Medical Director for Pediatrics, Lower Manhattan and an Assistant Professor of Clinical Pediatrics at Weill Cornell Medicine. Dr. Huang, it’s such a pleasure to have you join us today. As a parent, I know what I was like when I was wondering about those milestones and red flags and developmental issues. Tell us what are some milestones children should hit at each age, whether they’re cognitive, gross developmental, social and emotional. Give us a brief overview of how our little kiddos grow.

Sherry Huang, MD (Guest):  Sure. Thank you for having me Melanie. Developmental milestones are things that a child can do by a certain age. Some examples are a child’s first steps, first words, waving bye bye or riding a tricycle. We assess a child for milestones in different areas. This includes language and communication, this is the way a child communicates with speech and language, cognitive development which is the child’s ability to think and solve problems, physical development which includes gross motor skills which involve large muscles such as standing, walking, or pulling up to stand and fine motor skills which involve small muscle movements such as grasping objects, writing, moving fingers and toes and hand eye coordination.

Then there’s social, emotional behavior development. This is the way the child interacts socially, behaves or expresses feelings and finally there are adaptive skills which is a child’s ability to perform self-care such as dressing, brushing teeth, feeding himself, making choices or initiating activities. So, starting at the very first newborn visit we ask about milestones. At a few days of age, a baby should be moving the arms and legs equally and reacting to noise. As the baby grows to two months, she should follow faces or objects with her eyes, make cooing noises or smile in response to attention and raise the head and chest when doing tummy time. As the child gets older, he should be rolling over, sitting up and responding to his name at six months and should be standing or walking at around 12 months.

A child should be pointing to things and have a few more words by 18 months and are speaking in short sentences by age two. By age three, the child should be peddling a bicycle and dressing and undressing himself and by four years, the speech should be clear, and the child should be interacting well with you and her friends.

Host:  Thank you for that overview Dr. Huang. So, what kind of screenings do you do in the office when parents come to see you?

Dr. Huang:  We do monitoring so we ask these questions about a child’s abilities. We physically assess the child and then there are formal screenings that we do at different ages. So at nine months, 18 months and 24 months.

Host:  And what if and I think this is every parent’s biggest question and fear. What if they don’t hit these milestones? I mean we know Doctor; children don’t grow at the same levels and I know these milestones are but a guideline but what if a child isn’t hitting them? Do we watch and wait? Or do we intervene right away?

Dr. Huang:  You’re absolutely right. Children develop at their own pace and some will be faster or slower to gain new skills. Milestones do give us an idea of when we expect children to acquire skills. However it’s important to remember that for each developmental milestone, the age at which we expect the child to master the skill spans at least a few months. So parents should not be too concerned if the child does not hit each and every milestone exactly “on time.” As long as the child is making progress and gaining skills, parents should be reassured.

Host:  That is really very encouraging and great information. So important for parents to hear from a pediatrician saying this. So, now tell us what are some of the signs a parent might notice of developmental delays. What are some red flags Doctor that might require a developmental screening or a call to the pediatrician?

Dr. Huang:  Sure. So, the term developmental delay describes when a child is slower to reach developmental milestones compared to other children their age. I’ll review some red flags that should prompt a developmental evaluation. However, this list is by far not comprehensive and I do encourage parents to discuss any individual concerns about their child with their pediatrician. Some general red flags are any time a child loses skills she once had; you should let your pediatrician know. But this rule has an exception too. Even healthy kids can temporarily regress during times of illness. Any concerns about a child’s vision or hearing. Any child who is persistently low in tone, floppy or high in tone, very stiff or has tight muscles. Or any child who has asymmetric movements. Now some age specific red flags include at five months, if the child is unable to hold an object in the hands, at six months if the child shows no affection for caregivers, so no big warm smiles, no engaging expressions or has limited or no eye contact, doesn’t roll over in either direction, is not reaching for objects or has difficulty getting things to the mouth.

Some twelve month red flags include not saying words like mama or dada or babbling, not learning gestures like waving or shaking the head, can’t sit unsupported or is not standing when supported. At 18 months, we are concerned when the child doesn’t point to show things to others, doesn’t imitate others, is not saying at least a few words or is not gaining new words, doesn’t notice or mind when a caregiver leaves or returns or is not walking. And some two year red flags include not using two word phrases for example drink milk or give me. When a child doesn’t know what to do with common things like a brush, phone, fork or spoon. Doesn’t follow simple instructions, doesn’t walk steadily. At 30 months, if they are not running or there’s persistent toe walking and then some four year red flags are unclear speech, not using pronouns like me and you correctly, not jumping in place, has trouble scribbling or shows no interest in interactive games or make believe or ignores other children or doesn’t respond to people outside the family. Can’t retell a favorite story or is not following three part commands.

Host:  That’s so comprehensive Dr. Huang. What an excellent summary. So who should be involved in developmental monitoring and screening? Speak about early intervention, why it’s so important for the child’s wellbeing and then if they do have to go to early intervention and they have this evaluation, this developmental evaluation; what’s that like for a child?

Dr. Huang:  So, those are really great questions. Definitely parents, caretakers and pediatricians should be involved in developmental monitoring. If the parents are not the main caretakers, so if a nanny or a relative is with the child most of the time, or the child attends daycare; then the parents should speak with the main caretaker about the child’s development and ask if there are any concerns prior to each well visit with the pediatrician. Parents, caregivers and daycare providers should all learn about typical developmental milestones. Some good resources for this are the CDC, which has some great milestone information and great videos. It also has milestone trackers that parents can download. And the New York State Department of Health website and the American Academy of Pediatrics also has checklists of developmental milestones.

So, parents, if they notice that there are any delays, they should not wait until the next visit to discuss their concerns with the pediatrician. They should make an appointment relatively quickly and after the pediatrician has assessed the child, a plan can then be made with the parents to take immediate action or to wait one to three months and see if the child improves or outgrows a problem. Watchful waiting may be a good plan if the delay is mild. Now if we do decide the child needs an evaluation, there are options.

If the child is from zero to three years of age, we will refer the child to a great program run by the State’s Department of Health called Early Intervention which will arrange for an evaluation and provide therapy suited to the child’s delays. Parents should know that they don’t need a diagnosis to receive early intervention services. And in fact, waiting for a diagnosis of your child before seeking services, may mean a delay in starting necessary therapies. If a child is not delayed enough to warrant therapies for early intervention, we may recommend finding private therapies, parent training, and then a reevaluation by early intervention three to six months later if the child has not made progress.

If there are any concerns about speech or language, we also refer the child to a pediatric audiologist for a hearing evaluation. If the child is three years and older, parents can request the Department of Education, so it’s the Committee for Preschool Special Education or for five years and above, the Committee for Special Education to evaluate the child. And at any point, in conjunction with any of the above, we may also refer the child to specialists that are trained to evaluate and care for children with developmental delays. These include pediatric behavior and developmental specialists, a pediatric neurologist, or a pediatric psychologist. However, the first step should be early intervention or the Department of Education as sometimes it may take a few months to see these specialists.

Now some parents are anxious at the thought of these evaluations because they worry about their child getting labeled at a young age. But we always tell parents that many infants and toddlers need extra help and that timely evaluation and support always is the best plan to get kids back on track and ready to thrive when they start school. Now Melanie, you asked about the importance of early intervention. And this is really important. In the first years of a child’s life, the brain connections or neurocircuits which are the foundation for lifelong learning and behavior are the most adaptable.

So, these connections are more difficult to change when a child is older. Targeted interventions at an early age as soon as a delay is detected is more effective and can change a child’s developmental trajectory so that the child can reach his or her best potential.

Host:  Well thank you again. Dr. Huang, just briefly tell us the types of therapy. I know that you are not an occupational therapist or physical therapist, but you do this every day. What are these therapies like for a child? How well do they tolerate them? Are they fun? Are they easy for the children and the parents to go through? Tell us a little bit about what these therapies really entail.

Dr. Huang:  Of course. So, the therapies are play based, interactive and one to one with the child. Some therapies include training parents to interact with the child. Children tolerate the therapies really well and often they look forward to seeing the therapists. So, some of the different therapies are speech and language therapy. So, these therapists interact with the child by talking and playing using books, pictures or other objects to stimulate language development. They may also model correct sounds and help the child work on musculature or feeding issues.

Physical therapy, these therapists work through play and activities to help the child improve large movements, like crawling, walking and running. They help children work on balance and coordination and help them become stronger and more active. There’s occupational therapy. So, occupational therapists work with the child and the family to promote a child’s independence and self-confidence when performing day to day routines such as getting ready for school, sleep, mealtimes and participation in social or family activities. They use interactive play to improve gross motor skills, and fine motor skills for self-care and learning such as using zippers, buttons, scissors, crayons, or self-feeding or toileting. And they can also address behavior, emotional or sensory problems.

Some children may get the therapy called special instruction and a special instruction therapist uses activities to promote cognitive skills and social interactions. Now you might notice that there’s overlap among the different therapies. Just remember that the therapists work together as a team to deliver interventions designed to target each child’s delays.

Host:  So, how long does it take for parents listening to see results? Will they still need these therapies? You mentioned that early intervention is from zero to three so what happens once they enter school and what can parents do at home to help their children with these delays? Give us some tips for home strategies that can help.

Dr. Huang:  Of course. So, because each child is different, and there’s a wide spectrum of delays you may see improvement in a few weeks, or it may take a few months. The good news is that many children improve so much they don’t require additional therapies beyond age three. Some may continue to need support until kindergarten or beyond. Reevaluations can be done at ages three and five to see if therapies are still needed.

So, in terms of what parents can do at home to help their children. If the child is receiving therapies, it is helpful for parents to watch and work with the therapists on a regular basis and ask the therapists to teach them techniques to help their child build skills at home. Afterall the therapists are only with the child a few hours a week whereas parents and caretakers spend so much more time. At home, I suggest carving out a small fun space, so the child has his own space to learn or play. I recommend making every day activities fun and opportunities for interaction. So, if you are preparing dinner, have your child help you with some small chores such as breaking up broccoli florets, peeling oranges, kneading dough. This helps with fine motor development. Talk about all the ingredients you’re going to use. If you are cleaning up, encourage your child to imitate you or help you move clothing to the hamper or furniture or other items to one end of the room. This helps them build strength, coordination and tires them out. Offer your children opportunities to communicate and make choices. Ask them what they’re feeling. Ask if they want to wear the blue shirt or the yellow shirt for the day.

If your child has speech or socialization delays, always offer positive reinforcement if he initiates communication. Finally, I ask parents to have patience. Some children with delays can become frustrated when they cannot express themselves and this may lead to tantrums. Now we understand that parents may be anxious, stressed or even angry if the child has delays. However, children can sense these emotions and are affected by them. So, it’s always important for parents to find help deal with their own emotions or struggles. Interactions should be positive, and a child should never be punished if he or she is unable to master a new skill.

Host:  Great information. Wrap It up for us Dr. Huang, this is such an educational and informative episode for parents. Tell us what you’d like them to know about developmental milestones and how not to worry if they don’t always happen exactly on time but when you feel it’s important that they call their pediatrician.

Dr. Huang:  Sure. So, we know that the first years of development are crucial for lifelong learning and developmental skill building. Parents and caretakers should provide a nurturing, stimulating environment and monitor how their child communicates, learns, moves and acts. Any concern should be addressed sooner rather than later. We can help to increase awareness by speaking with relatives, friends and neighbors about developmental delays and encouraging conversations with pediatricians. And finally, remember kids develop at their own pace. And they should be fine as long as they are making progress and gaining new skills.

Host:  Great information. Thank you so much Dr. Huang for joining us today and sharing your incredible expertise for parents. This is a great topic. And Weill Cornell Medicine continues to see our patients in-person as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine. Thank you so much to and Weill Cornell Medicine will continue to offer video visits for consultations and discussion to minimize travel and you can be confident of the safety of in-person appointments if needed. Thank you so much to Dr. Huang and to our listeners. That concludes today’s episode of Kids Health Cast. Please remember to subscribe, rate and review this podcast and all the other Weill Cornell Medicine podcasts. For more health tips and updates please follow us on your social channels. I’m Melanie Cole.