Development is multifactorial and is the interplay among temperament, environment, and biophysical factors. Many observations about development can be made informally during the health interview and during the neurologic and musculoskeletal assessments; however, some observations need to be made more formally using tools such as the Denver Developmental Screening Test II (Denver II) and other objective tests.
The nurse needs to be aware that “normal” encompasses a wide range of behavior at any given stage and that delays in development can only rarely be attributed to one factor. Knowledge of behaviors that can be expected at various stages is essential to assessment of development.
Rationale
Complete periodic, systematic assessment of development enables early detection of problems, identification of parental and child concerns, anticipatory guidance, and teaching about age-appropriate expected behaviors. Judgments about an infant’s or child’s development must never rest solely on one assessment of development. Illness, stress, the examiner’s approach, and a strange environment can alter a child’s usual performance.
Preparation
Ask the parent to describe the infant’s or child’s development. Inquire whether the parent has specific concerns about the infant’s or child’s development (e.g., indistinct speech or language delays). Ask about the mother’s prenatal history, including miscarriages stillbirths, exposure to medications or radiation, drug or alcohol use, maternal endocrine disorders, toxemia, hydramnios, infection, or abnormal bleeding. Inquire about the birth history of the infant or child, including type of delivery, fetal distress, birth weight, prematurity, respiratory problems, jaundice, hypoglycemia, seizures, irritability, poor muscle tone, or feeding problems. Inquire about family history of health concerns.
Assessment of Development Using the Denver II
Developmental screening tests are used as part of the developmental assessment. Developmental screening involves comprehensive health assessment and partnerships, including partnership with the parents. Several developmental screening tests are available (e.g., Ages and Stages Questionnaire, Revised Prescreening Developmental Questionnaire, Batelle Developmental Inventory), but the Denver developmental tests (DDST, DDST-R, Denver II) remain among the most widely used. The Denver II is not an IQ test but a series of standard developmental tasks that are used for children from birth to 6 years to determine how a child compares developmentally with other children of the same age. The test assesses personal, social, fine motor, adaptive, language, and gross motor skills and is useful for monitoring children who are at risk for developmental delays. The tests do not tell why developmental delays have occurred and should not be used for diagnosis.
Equipment for Assessment with Denver Screening Tests
▪ Approved Denver II manuals, test kit, and forms
Method of Assessment
Before beginning the screening, tell the parents that the results will be discussed with them after all the items have been finished. Explain that the test involves activities that are familiar to infants and children and that there is nothing painful about the screening. In screening infants and children, approach the testing like a game. Take a toy out of the kit when needed for a particular item and replace the toy before moving on to the next item.
It is important to note that stress, illness, fear, shyness, and separation from the parent can affect the outcome of screening. In addition, the nurse must adjust the age of the child for prematurity. For children 24 months and younger, adjust for prematurity by subtracting the number of weeks of missed gestation from the child’s current age; test at that age.
A caution is failure of the child to perform an item passed by 25% to 90% of children of that age. A delay is failure to pass an item to the left of the age line. A normal test is one with no delays and a maximum of one caution. A suspect test is one or more delays and/or two or more cautions. If a child cannot be tested or in the case of a suspect test, retest in 1 to 2 weeks.
When the screening is complete, ask the parents whether the child’s performance is what they would expect at other times. If they respond that it is, then explain the results.
Before administering the screening, it is important to consult the instruction manual for the Denver II for complete details about administering the Denver II.
Significance of Findings
All children are not expected to pass all items. If a child fails one or more items that fall completely to the left of the age line, consider the child’s developmental and health histories before deciding whether to retest at a later date.
Assessment of Growth and Development
Assessment of development requires knowledge of what can be expected at various stages in development. Table 22-1 gives a general summary of normal growth and development that can be used during observation of an infant or child.
| Age | Physical/Motor | Language | Cognition | Socialization |
|---|---|---|---|---|
| 1 month |
Average weekly weight gain 140–200 gm (5–7 oz) until 6 months of age
Average monthly gain in length 2.5 cm (1 in) until 6 months of age
Obligate nose breather
Head sags when not supported
Back rounded in sitting position
Hands held in fists
Can turn head to side when prone
Makes crawling movements when prone
|
Cries when uncomfortable
Makes low throaty sounds
|
Sensorimotor Stage (birth to 18 months)
Egocentric
No intentionality; no expectations
|
Regards faces intently |
| 2 months |
Posterior fontanel closes
Can lift head 45 degrees when prone
When supported in sitting position, head is held up but bobs forward
Visually pursues objects and sounds
Hands held open more
Grasp reflex fading
|
Crying differentiated
Coos
Vocalizes
Voluntarily repeats activities, thereby demonstrating beginning connection between action and result
Anticipates feeding
Begins to separate self from others
|
Responds differently to different objects | Might smile socially |
| 3 months |
Holds hands in front and stares at them
Holds rattle but does not reach for it
Raises chest, supported on forearms
Little head lag
Visually pursues sound by turning head
Able to bear some weight on legs when held in standing position
Palmar grasp reflex weakening
|
Squeals
Vocalizes in response to other voices
|
As for 2 months |
Recognizes familiar face and unfamiliar situations
Stops crying when parent approaches
|
| 4 months |
Holds head steady in sitting position
Almost no head lag when pulled to sitting position
Sits erect if propped
Lifts head and shoulders 90 degrees when prone
Turns from back to side
Plays with hands
Reaches for objects but overshoots
Grasps objects with both hands
Visually pursues objects that have been dropped
Begins drooling
Moro’s, tonic neck, extrusion, and rooting reflexes disappear
Sleeps 10–12 hours at night
Naps two to three times a day
|
Makes consonant sounds (b, g, k, n, p) interspersed with vowel-like sounds
Vocalization varies with mood
|
As for 2 months |
Sociable
Bored if left alone
Demands attention by fussing
|
| 5 months |
No head lag
Back straight when pulled to sitting
Bears most of weight on legs when standing
Sits for longer periods if back supported
Plays with feet
Takes objects to mouth at will
Teeth might begin to erupt
Birth weight doubled
|
As for 4 months |
Searches for objects at point of disappearance
Recognizes partially hidden objects
Repeats interesting actions
Wide repertoire of activities (kicking, batting, pulling, patting) that produce novel results
Imitates others
|
Recognizes strangers
Can have rapid mood swings
Vocalizes displeasure if preferred object is taken
|
| 6 months |
Average weekly weight gain 90–150 gm (3–5 oz) for next 6 months
Chews and bites
Can hold own bottle but prefers it to be held
Lifts chest and abdomen off flat surface, bearing weight on hands
Sits in highchair with back straight
Can turn completely from stomach to back to stomach
Picks up objects that have been dropped
Manipulates small objects
Pulls feet to mouth
Adjusts posture to visually pursue an object
Exhibits Landau reflex (when held prone, head raises and spine and legs extend)
|
Vocalizes to mirror
Makes one-syllable sounds (ma, da, uh)
Begins to mimic sounds (e.g., coughing)
|
As for 5 months |
Shows fear of strangers
Holds out arms when wants to be picked up
Becomes excited when familiar persons approach
Laughs when head is covered with towel
|
| 7 months |
Sits in tripod position
Lifts head off table if supine
Bounces if held in standing position
Transfers cube from hand to hand
Holds cube in each hand
Bangs cube on table
Rakes at small objects
Can approach toy and grasp it with one hand
Responds to own name
Evidences taste preferences
|
Chains syllables (mama, dada) but does not attach meaning
Is able to produce four distinct vowel sounds
|
As for 5 months |
Increasing fear of strangers
Imitative
Coughs, snorts to attract attention
Closes lips in response to dislike of food
Bites and mouths
Plays peek-a-boo
|
| 8 months |
Sits alone steadily
Can stand holding on to something
Beginning pincer (thumb-finger) grasp
Regards a third cube while holding a cube in each hand
Releases objects voluntarily
Rings bell purposely
Reaches for toys out of reach
Might have night awakenings
Patterns emerge in bowel and bladder elimination
|
Makes d, t, w sounds
Responds to simple commands
|
As for 5 months
Coordination of secondary schemes
Object permanence
|
Increased stranger anxiety and fear of separation from parent
Begins to respond to “no-no”
Searches for hidden objects
Shows interest in pleasing parent
|
| 9 months |
Pulls self to standing position
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