Normal Development in Children is a very important chapter in Paediatrics subject curriculum. It is one of the diagnostic criteria for early detection of developmental deviation in children.

2. Lecture-2
Prof. Dr. Sunil Natha Mhaske
Dean
Dr. Vithalrao Vikhe Patil Foundation’s Medical College and Hospital,
Ahmednagar (M.S.) India-414111
Mo- 7588024773
Mail-sunilmhaske1970@gmail.com
Normal Development of Child

3. Development-
Definition : Development is defined as- maturation of
organ function, acquisition of skills and ability to stand
stress and strain of life.
Age-related development periods-
- Newborn (ages 0–4 weeks)
- Infant (ages 4 weeks – 1 year)
- Toddler (ages 12 months-24 months)
- Preschooler (ages 2–5 years)
- School-aged child (ages 6–12 years)
- Adolescent (ages 13–19)

4. • Child development involves the biological, psychological and
emotional changes that occur in human beings between birth and the
conclusion of adolescence.
• Child development refers to the sequence of physical, language,
thought and emotional changes that occur in a child from birth to the
beginning of adulthood.
• During this process a child progresses from dependency on their
parents/guardians to increasing independence.
• Child development is strongly influenced by genetic factors and
events during prenatal life. It is also influenced by environmental
facts and the child’s learning capacity.

5. Child development includes-
 Cognition – the ability to learn and problem solve.
 Social interaction and emotional regulation – interacting with
others and mastering self-control.
 Speech and Language – understanding and using language,
reading and communicating.
 Physical skills – fine motor (finger) skills and gross motor (whole
body) skills.
 Sensory awareness – the registration of sensory information for
use.

6. Importance of child development -
 Observing and monitoring child development is an important tool to ensure that
children meet their ‘developmental milestones’.
 Developmental milestones act as a useful guideline of ideal development.
 By checking a child’s developmental progress at particular age markers against
these arbitrary time frames, it allows a ‘check in’ to ensure that the child is roughly
‘on track’ for their age. If not, this checking of developmental milestones can be
helpful in the early detection of any hiccups in development.
 The earliest possible detection (and early intervention treatment if appropriate) of
developmental challenges can be helpful in minimizing the impact these
developmental hiccups can have on a child’s skill development and subsequently
their confidence, or serve as an indicator of a possible future diagnosis.
 Developmental milestone checklists or charts are used as a guide as to what is
‘normal’ for a particular age range and can be used to highlight any areas in which
a child might be delayed.
 it is important to be aware that while child development has a predictable
sequence, all children are unique in their developmental journey and the times
frames that they meet the many developmental milestones.

7.  Principle of Continuity: Development follows
continuity. It goes form womb to tomb and never ceases.
 Principle of Uniform Pattern: The process of
development has uniformity and few individual
differences.
 Principle of Individual Differences: Psychologists give
due importance to the principle of individual differences.
 Principle of Integration: Where it is true that
development proceed from general to specific or from
whole to parts, it is also seen that specific response or
part movements are combined in the later process of
learning or development.
 Principle of interrelation: The growth and development
in various dimensions like physical, mental, social etc.
are inter-related and interdependent. Growth and
development in any one dimension affects the growth and
development of the child in other dimensions.
Principle of Child Development-

8. Principles of development-
1. Principle of Maturation and Learning: In the process of
Growth and development maturation and learning plays an
important role.
2. Principle of Joint Product of Heredity and
Environment: Child growth and development is the joint
product of heredity and environment.
3. Principle of Total Development: The physical
development in human beings is as per time and side-by-side
the different aspects of human personality also develops like
social, physical, emotional, mental etc. All these aspects are
dependent on each other and affect each other.

9. 4. Principle of Development Direction: Growth and
development have their own definite direction. In human
body, first of all, head becomes of adult size and legs in end-
a. Caphalo Cadual Sequence: Human child grows from
head to legs and not vice versa.
b. Proximo-distal Sequence: This development starts
from back have one and then external Promixo-distal
sequence starts.
c. Structure Precede Functions: Firstly all the body
parts develop then they are used, but before that their
muscles should develop.
5. Development Proceeds from General to Specific
Responses: In all phases of child’s development, general
activity precedes specific activity.

10. 6. Principle of Comulation and
Recapitulation: Development is net average of experiences
and is not based on the experience. Development is also
recapitulation that experience are used again and again.
7. Principle of Predicability of Development: Research
has made it clear that it is possible to predict development.
8. Principle of Outer Control to Inner Control: Small
children depend on others for values and principles. When
they grow up they develop their own value system,
conscious, inner control and outer control.
9. Development Continues throughout Life:

11. Factors affecting development-
A. Prenatal Factors:
1. Genetic factors:
e.g. Down’s Syndrome,
Fragile X Syndrome,
Subtelomic deletions,
Phenylketonuria, etc.
2. Maternal factors:
• maternal drug or alcohol abuse,
• pregnancy induced hypertension,
• hypothyroidism,
• malnutrition,
• feto-placental insufficiency,
• infections,
• exposure to free radicals.

12. B. Neonatal Risk factors:
1. Low Birth Weight
2. Neonatal Seizures
C. Postnatal Factors:
1. Nutritional Factors
2. Acquired insults to brain
3. Endocrine factors
4. Associated impairments
5. Others like toxins
D. Social Factors:
1. Parenting
2. Poverty
3. Lack of stimulation
4. Violence & Abuse

13. Normal Development studied under Four Headings:
I. Motor Development
a) Gross Motor Development
b) Fine Motor Development
II. Social Development
III. Language Development
IV. Hearing & Vision

14. Gross Motor Development:
3 months neck holding
5 months rolls over
6 months sits in tripod fashion (sitting with own support)
8 months sitting without support
9 months stands holding on (with support)
12 months creeps well, walks but falls, stands without support.
15 months walks alone, creeps upstairs.
18 months runs, explores drawers
2 years walks up & downstairs (2 feet/ step); jumps.
3 years rides tricycle; alternate feet going upstairs
4 years hops on one foot; alternate feet going downstairs

16. Fine Motor Development:
• 0-3 Months : hands most often remain closed, has grasp reflex
(palmar grasp)
• 2-4 Months: reaches for ("swipes at") objects inaccurately.
• 3-31/2 Months: clasps hands together often.
• 3 1/2- 4 Months: begins purposeful, visually directed reaching.
• 3-7 Months: can hold small objects in hand.
• 4-8 Months: can transfer objects from one hand to the other can
pick up cube/medium sized object easily (immature pincer grasp)
• 4-10 Months: develops accurate forward and side reach.
• 5-9 Months: "rakes" or "scoops" small
objects to pick them up (i.e. Using
fingers/palm/whole hand to scoop up
cheerios, raisins etc.
Palmar grasp

17. 7-9 Months: intentionally able to drop/release objects.
7-12 Months: able to pick up small objects using thumb and finger/fingers (Mature
pincer grasp)
10 Months: pokes and/or points with index finger.
12-18 Months: holds crayon with whole hand, thumb up.
2 Years: holds crayon with thumb and all fingers, forearm turned so thumb is pointing
down, puts on shoes, socks, and shorts; takes off shoes and socks, can use a spoon by
himself, keeping it upright, can draw and copy a vertical line, can build tower of 6
blocks.
21/2- 3 Years: strings large beads, snips paper with scissors, can draw and copy a
horizontal line.
3-31/2 Years: able to complete simple puzzles, can build a tower of nine small blocks
or more, can get himself dressed/undressed independently; only needs help with
buttons; still confuses front/back for clothes, and right/left for shoes, can feed himself
with little or no spilling, drinks from a cup/glass with one hand. Copies circle, Tower of
9 blocks.
31/2- 4 Years: can pour his own drink from a pitcher if not too heavy, can place small
pegs into small holes, able to string small beads, can hold a pencil with a "tripod grasp"
(3 fingers), but moves forearm and wrist to write/draw/color.

18. 4-41/2 Years: can use scissors to follow and cut both straight and curved lines,
can manage buttons, zippers, and snaps completely, can draw and copy a cross
(one vertical and one horizontal intersecting lines), bridge with blocks.
41/2- 5 Years: can hold fork using his fingers, can feed himself soup with little or
no spilling, folds paper in half, making sure the edges meet, puts a key in a lock
and opens it, copies rectangle.
5 Years: can get dressed completely by himself, and usually tie shoelaces, cuts
square, triangle, circle, and simple pictures with scissors, able to draw and copy a
triangle. uses a "tripod grasp" on writing utensils (thumb & tips of 1st two
fingers) and uses fingers only (because small muscles of hand have developed) to
write/draw/color.
51/2- 6 Years: can build a five block "bridge" , sufficient bilateral hand
coordination to cut out complex pictures, accurately following the outline, able to
copy a sequence of letters or numbers correctly
6 Years: able to complete complex puzzles, Can draw rectangle with diagonal
cross in it.
7 Years: Can draw a tilted square
8 Years: Can draw a doubled lined cross
9 Years: Can draw a cylinder
11 Years: Can draw a cube

19. Language Development
It is the receptive ability & understanding which precedes expressive
abilities.
1 month: Alerts to sounds
3 months: Coos ( musical vowel sounds)
4 months: laugh loud
6 months: Monosyllables (ba, da, pa), ah-goo sounds
9 months: Bisyllables (mama, dada, papa)
12 months: 1-2 words with meaning
18 months: 8-10 words vocabulary
2 years: 2-3 word sentences, uses “I”, “me”, “you”.
3 years: Asks questions, knows full name & gender.
4 years: Says song or poem, tells stories
5 years: Asks meaning of words.

20. Social & cognitive development
2 months: Social smile (smile after being talked to).
3 months: Recognizes mother, anticipates feeds.
6 months: Recognizes strangers / Stranger anxiety
9 months: Waves “bye bye”
12 months: comes when called, plays simple ball game.
15 months: Jargon, points to object in which he is interested
18 months: copies parents in tasks (sweeping, etc)
2 years: Asks for food, drink, toilet; Pulls people to show toys.
3 years: Shares toys; knows full name & gender.
4 years: Plays cooperatively in a group; goes to toilet alone.
5 years: Helps in household tasks;
Dresses & undresses himself without supervision.

21. • Newborns respond sounds by startle, blink, cry, quieting or
change in ongoing activity.
• Access pattern of evolving maturity of hearing by producing
sound 1.5 feet away from ear & out of field of vision.
• At 3-4 months, he turns his head towards source of sound.
• At 5-6 months, he turns head to one side & then downwards if
sound is made below level of ears; & after 1 month, recognizes
sound made above level of ears.
• At 10 months, child looks directly to the
source of sounds diagonally.
Hearing:

22. Vision-
• Best stimulus to check visual behavior is primary caretaker’s
face.
• At birth, baby can fixate on & follow a moving person or a red
ring held at 8-10 inches up to 45˚, which reaches to 90˚ till 4
weeks & 180˚ till 12 weeks.
• At 1 month, baby can fixate on his mother as she talks to him.
• At 3-4 months, he can fixate intently on an object shown to him
(grasping with eyes).
• Binocular vision begins to develop around 6 weeks of age & is
well established around 4 months.
• At 6 months, he adjusts his position to follow objects of
interest.
• At 1 year, he can follow rapidly moving objects.
• Later, vision get matured more in respect to
identifying & recognizing small objects.

23. Evaluation of development
Prerequisites:
1) Examination place should be free of distractions.
2) Child should not be hungry, tired, ill or irritated.
3) Assess child when he is in a playful mood with his mother
around.
Equipment:
1) A red ring (diameter 6-7 cm) tied to a string.
2) 9 red cubes
3) Paper pellets, Spoon
4) Cup with handle
5) A book with thick pages, Picture book
6) Red pencil & paper
7) Doll & mirror
8) List of key milestones with normal age of their achievement.

24. Development Screening:
It is a “brief assessment procedure designed to identify children who
should receive more intensive diagnosis or assessment”.
It helps early intervention services, making a positive impact on
development, behavior & subsequent school performance.
It also helps in early identification of co-morbid developmental
disabilities.
To whom screen?
• high risk infant
• Birth weight -<2kg.
• Asphyxia-did not cry for 15 min after birth.
• Hypotonia-limpness and floppy child.
• Feeding difficulties-not sucking well in 1st 2days
• Respiratory distress in 1st 2days.
• Jaundice within 1st 2days
• convulsions

25. Development Screening:
Advantages:
1. Standardized & norms are explicitly stated.
2. More accurate to access developmental status than informal
clinical impressions.
3. Reinforce importance of development to caregiver.
4. Efficient way to record observations.
5. Help to identify more children with developmental delay.
Limitations:
1. Assessor may not be fully trained, may not scoring properly.
2. Relaying on screening test alone to make an assessment.
3. Using screening test as a diagnostic tool.
4. Not following screening tests with further evaluations can be
damaging.

26. Red flag signs in child development
Milestone Age
No visual fixation or following by 2 months
No vocalization by 6 months
Not sitting without support by 9-10 months
Not standing alone by 16 months
Not walking alone by 18 months
No single words by 18 months
Lack of imaginative play at 3 years
Loss of comprehension, single words or phrases At any age

28. Mental age / Chronological age.
Intelligence quotient (IQ)
Psychologist Alfred Binet
IQ Range IQ Classification
130 and above Very Superior
120–129 Superior
110–119 High Average
90–109 Average
80–89 Low Average
70–79 Borderline
69 and below Extremely Low

29. Theories of Child Development
Sigmund Freud devised a psychosexual stage theory of development. He
believed that children move through specific stages of development due to innate
unconscious sexual drives. Freud's stage theory ends at adulthood.
Erik Erikson also created a stage theory of development, but his is a bit
different from Freud's. Erikson focused more on social relationships as a driving
force in development and referred to the developmental tasks as psychosocial
stages. Erikson's theory is one of the most comprehensive and covers human
development from birth through old age.
Lev Vygotsky's theory of development also focuses on social interactions as
important in development. His theory views children in an apprentice role with
parents mentoring them through developmental tasks.

30. Jean Piaget theory-
Stage- I. Sensorymotor: (birth to about age 2) This is the first stage in
Piaget's theory, where infants have the following basic senses: vision,
hearing, and motor skills. In this stage, knowledge of the world is
limited but is constantly developing due to the child's experiences and
interactions.
Stage -2. Preoperational: (begins about the time the child starts to talk,
about age 2)
During this stage of development, young children begin analyzing their
environment using mental symbols. These symbols often include words
and images and the child will begin to apply these various symbols in
their everyday lives as they come across different objects, events, and
situations

31. Stage -3. Concrete: (about first grade to early adolescence)-
During this stage, children between the age of 7 and 11 use appropriate
logic to develop cognitive operations and begin applying this new
thinking to different events they may encounter. Children in this stage
incorporate inductive reasoning, which involves drawing conclusions
from other observations in order to make a generalization.
Stage -4. Formal operations: (about early adolescence to mid/late
adolescence)
The final stage of Piaget's cognitive development defines a child as now
having the ability to “think more rationally and systematically about
abstract concepts and hypothetical events”. Some positive aspects
during this time is that child or adolescent begins forming their identity
and begin understanding why people behave the way they behave.

32. Erikson's eight stages-
• Trust vs. mistrust (infant)
 Autonomy vs. shame (toddlerhood)
 Initiative vs. guilt (preschooler)
 Industry vs. inferiority (young adolescent)
 Identity vs. role confusion (adolescent)
 Intimacy vs. isolation (young adulthood)
 Generativity vs. stagnation (middle adulthood)
 Ego integrity vs. despair (old age)

33. Theories of child development-
 Field Theory: This theory holds that all parts of the
psychological environment influence the individual’s
behavior, and it can be compared to field theory in
physics which is concerned with electromagnetic fields
and how they change.
 Stimulus- Response Theory: The basic elements of a
stimulus- response theory include the assumption that most
human behavior is learned, and that this is done piecemeal
rather than all at once.

34.  Cognitive Theory: Piaget divides the child’s
development into four main periods.
First- the sensory-motor period of the first two
years, where the child is acquiring skills and learning to
integrate information from his different senses. He sees
the world as a permanent place, not one whose
existence depends upon his perceiving it.
Second-the years of two to seven build a
conceptual scheme, which becomes organized and
properational. During this period, the child over
simplifies his thinking.
Third- From seven to eleven comes the third
period, that of concrete operations, where the child
organizes things well and thought processes are stable
and reasonable.

35. Asynchronous development-
- Asynchronous development occurs in cases when a child’s
cognitive, physical, and/or emotional development occur at
different rates.
- Asynchronous development is common for gifted children when
their cognitive development outpaces their physical and/or
emotional maturity, such as when a child is academically
advanced and skipping school grade levels yet still cries over
childish matters and/or still looks his or her age.
- Asynchronous development presents challenges for schools,
parents, siblings, peers, and the children themselves, such as
making it hard for the child to fit or frustrating adults who have
become accustomed to the child's advancement in other areas

36. Aspects of Development-
1) Physical: Physical development is about the physique i.e.
their height and weight.
2) Motor: Motor development is about the muscular
development and their co-ordination.
3) Cognitive: Cognitive development is about mental growth
and intellectual development.
4) Language: Language development is about the way
children learn the language, the age at which they acquire
different components of language.
5) Personality Development: It is about the total
development of a personality.
6) Emotional: Emotional development is about different
emotions at various stages and how they grow over a
period of time.
7) Moral: It deals with what is right and what is wrong at the
age at which this knowledge is acquired and with the rules
of punishment and justice.
8) Vocational: It deals with the choices about career and who
they develop and are pursued in life.

37. The American Academy of Pediatrics (AAP) recommends
developmental and behavioral screening for all children during
regular well-child visits at these ages:
 9 months
 18 months
 30 months
In addition, AAP recommends that all children be screened
specifically for autism spectrum disorder (ASD) during regular
well-child visits at:
 18 months
 24 months

38. Developmental Surveillance:
Common screening tools for developmental surveillance are –
1) Phatak’s Baroda Screening Test
2) Denver Developmental Screening Test
3) Trivandrum Developmental Screening Chart
4) CAT / CLAMS (clinical adaptive test / clinical linguistic & auditory
milestone scale)
5) Goodenough Harris Drawing Test.
Definitive Tests:
1) Bayley Scale of Infant Development – II
2) Stanford Binet Intelligence Scale
3) Wechsler Intelligence Scale for Children – IV & Wechsler Preschool &
Primary Scale of Intelligence.
4) Vineland Adaptive Behavior Scales
5) DAS - II

39. Phatak’s Baroda Screening Test-
• It is based on Baroda norms on BSID research form 1961.
• It is studied at the child developmental unit of Department of
Paediatrics in K.E.M. Hospital, Pune.
• Screening validity, sensitivity & specificity were more than 76%,
66%, 77% respectively.
Denver Developmental Screening Test-
• The Denver Developmental Screening Test (DDST), commonly
known as the Denver Scale, is a test for screening cognitive and
behavioural problems in preschool children (0-6 years).
• It was developed by William K. Frankenburg and first introduced by
him and J.B. Dobbs in 1967.
• The test is currently marketed by Denver Developmental Materials,
Inc., in Denver, Colorado, hence the name.
• According to a study commissioned by the Public Health Agency of
Canada, the DDST is the most widely used test for screening
developmental problems in children.

40. Trivandrum Developmental Screening Chart-
• The Trivandrum Developmental Screening Chart (TDSC)
was designed by selecting 17 test items from BSID (Baroda
Norms).
• It was validated both at the hospital and community level
against the standard DDST.
• TDSC had a sensitivity of 66.7% and specificity of 78.8%,
which makes it an acceptable simple screening tool even for
the community level worker.

41. CAT / CLAMS (clinical adaptive test /clinical linguistic
& auditory milestone scale)
• Correlations between the CAT/CLAMS and the Bayley Scales of
Infant Development--Mental Scale (BSID) were examined in 61
infants and toddlers with suspected developmental delay.
• Highly significant correlations were found between the two
instruments.
• Gender, race, and gestational age did not influence the relationship
between CAT/CLAMS and BSID scores.
• The CAT/CLAMS was both sensitive (88%) and specific (67%) for
mental retardation (BSID < 70).
• The CAT/CLAMS correlates with the BSID and can be used as an
instrument for detecting cognitive delay.

42. • Goodenough Harris Drawing Test
• Bayley Scale Of Infant Development – II
• Stanford Binet Intelligence Scale
• Wechsler Intelligence Scale For Children –
IV & Wechsler Preschool & Primary Scale
Of Intelligence.
• Vineland Adaptive Behavior Scales
• DAS – II (Differential Ability Scales)

43. Disorders of Development-
Impairment - An abnormality of body structure or function
e.g. mild backwardness, clumsiness, delayed speech and
language.
Disability - Reduced ability to perform a task or function.
e.g. learning disability (reading, writing, spelling)
Handicap - A continuing impairment or disability of body intellect
or personality.
e.g. MR, CP, autism, deafness, blindness
Soft neurological signs –
e.g. poor fine motor co-ordination.

44. Thanks a lot