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
Crawls, perhaps backward at first
Recovers sitting position if leaning forward, but cannot do so if leaning sideways
|
Beginning of intelligence
Assigns symbols to events
Goal-directed activities
|
Might show fear of going to bed or of being alone | |
| 10 months |
Crawls, pulling self forward by hands
Stands holding on to furniture
Might cruise (step sideways holding on to furniture)
Recovers balance readily if sitting
|
Comprehends dada, mama
Might say one word
|
As for 9 months |
Waves bye-bye
Extends toys to others but does not release toy
Repeats activities that attract attention
Plays pat-a-cake
Cries when scolded
|
| 11 months |
Creeps with abdomen off floor
Pivots when sitting (reaches backward to pick up an object)
Intentionally drops objects for them to be picked up
Places objects inside each other
Holds crayon to make mark on paper
|
Imitates speech sounds | As for 9 months |
Expresses frustration when restricted
Plays so-big, up-down, peek-a-boo
|
| 12 months |
Birth weight tripled
Head and chest circumference equal
Cruises well
Walks with help
Can sit from standing without help
Drinks from cup and eats from spoon but requires help
Cooperates in dressing
Neat pincer grasp
Turns several pages of book at a time
Lumbar nerve develops, with resulting lordosis when walking
|
Says two or more words in addition to mama and dada
Recognizes objects by name
Imitates sounds of animals
|
As for 9 months |
Responds to simple commands
Explores actively
Clings to mother in unfamiliar situations
Might take security objects
Shows emotions
|
| 13–18 months |
Anterior fontanel closes
Abdomen protrudes
Walks with wide-based gait
Walks up stairs with help; creeps down stairs
Throws ball overhand
Seats self on small chair
Climbs
Pulls toys behind and pushes light furniture
Imitates housework
Puts shaped objects into holes
Scribbles vigorously
Imitates vertical and circular strokes
Builds tower of two or three cubes
Sleeps 10–12 hours; has one afternoon nap
Might uncover self during sleep
|
Can say 4–6 words by 15 months and 10 words or more by 18 months
Points to desired object
Points to two or three body parts (18 months)
|
Trial and error learning
Active experimentation
Solicits help of adults to bring about results
Understands relationship between object and use
|
Drinks well from cup but might drop it when finished
Holds cup well in both hands
Uses spoon but turns bowl of spoon downward before it reaches mouth
Might discard bottle
Less fearful of strangers
Hugs and kisses significant others and pictures in books
Temper tantrums begin
Beginning sense of ownership
Takes off simple clothes
|
|
Preoperational Stage (2 to 7 years)
Preconceptual thinking (about 2 to 4 years)
|
||||
| 24 months |
Average yearly weight gain 1.8–2.7 kg (4–6 lb)
Chest circumference larger than head circumference
Physiologic systems stable except for reproductive and endocrine systems
Gait steadier, more adult
Jumps crudely
Might pedal tricycle
Walks up and down stairs with two feet on each step; holds on to rail
|
Approximately 300 words in vocabulary
Short sentences of two or three words
Uses pronouns
Gives first name
Verbalizes need for food, drink, and toilet
|
Inventions of new means through mental combinations
Beginning of mental problem solving and play
|
Dawdles
Negativistic
Temper tantrums decrease
Treats other children as objects
Wants to make friends but doesn’t know how
Cannot share possessions
Engages in parallel play
|
|
Picks up objects without falling
Kicks ball forward without overbalancing
Turns doorknob and unscrews lids
Builds tower of six or seven cubes
Turns pages of book one at a time
Might be daytime toilet trained
|
Has insight and forethought
Able to delay imitation for several days
|
Shows increased independence from mother
Chews with mouth closed
Uses straw
Puts on simple clothing
|
||
| 30 months |
Birth weight quadrupled
Primary dentition complete
Builds tower of eight cubes
Copies circle from model
Throws large ball 1.2–1.5 m (4–5 ft)
Takes a few steps on tiptoe
|
Gives first and last names
Enjoys rhymes and singing
|
Separates more easily from parent
Notices sex difference
Independent in toileting except for wiping
|
|
| 36 months |
Average yearly weight gain 1.8–2.7 kg (4–6 lb)
Balances on one foot for 5 seconds
Jumps from a low step
Walks upstairs, alternating feet
Might attempt to dance but balance still insecure
Pours fluid well from a pitcher
Begins to use scissors
Strings large beads
Builds tower of 9 or 10 cubes
Copies cross (X) from model
Washes hands
Might be nighttime toilet trained
Sleeps 10–15 hours; takes fewer naps
|
Vocabulary of about 900 words
Talks in sentences of about six words
Uses telegraphic speech
Asks many questions
|
Repeats three numbers
Remainder as for 30 months
|
Less negativistic
Friendly
Begins to understand taking turns
Able to share but uses “mine” often
Begins to learn meaning of simple rules, but rules subject to own interpretation
Names appropriate sex of others
Boys tend to identify more strongly with father
Can dress with minimal assistance
Feeds self completely
Begins to use fork but holds it in fist
Uses adult form of chewing
Might have fears, especially of dark or animals
|
| Intuitive thought (4 to 7 years) | ||||
| 48 months |
Length at birth doubled
Balances on one foot for 10 seconds
Hops on one foot
Catches bounced ball
Laces shoes
Imitates bridge with cubes
Uses scissors to cut out picture
Immunoglobulin G reaches adult levels
Draws man in three parts
|
Vocabulary of 1500 words
Knows simple songs
Exaggerates, boasts, might be mildly profane
Understands concepts of under, on top of, beside, in front of
Understands simple analogies
|
Time linked with daily events
Counts but does not clearly understand what numbers mean
Believes thoughts cause events
Cannot conserve matter
Egocentricism decreases
Repeats four numbers
Names one or more coins
|
Tattles
Might have imaginary playmate
Independent
Aggressive; takes out aggression on family members
Exhibits mood swings
Engages in cooperative group play without rigid rules (associative play)
Enjoys entertaining
Do’s and dont’s important
Identifies with parent of opposite sex
|
| 5 years |
Permanent dentition begins
Handedness established
Jumps rope
Walks backward heel-to-toe
Might be able to tie shoelaces
Can form some letters correctly
Might print first name
Draws man in six or seven parts
Uses scissors or pencil well
Copies triangle and diamond
|
Vocabulary of about 2100 words
Talks constantly
Asks meanings of words
|
Uses time words with more comprehension
Interested in facts associated with environment
Names four or more colors
Names coins
Names days of week
|
Comfortable
Trustworthy
Fewer fears
Eager to do things the right way
Might seek out mother more often because of more outside activities such as school
Identifies strongly with parent of same sex
|
| 6 years |
Dexterity increasing
Jumps rope
Skates, rides bicycle
Can sew crudely
|
Describes objects in pictures |
Knows right from left
Recognizes many shapes
Reads from memory
Obeys three commands in succession
|
Enjoys bossing others
Might be defiant and rude
Jealousy of younger siblings more apparent
Might have temper tantrums
Cheats to win
Enjoys table games
|
|
Concrete
Operations
Stage (7–11 years)
|
||||
| 7 years |
Mechanical in reading
Might skip words such as he, it
|
Repeats three numbers backward
Reads time to quarter hour
|
Enjoys teasing
Girls play with girls, and boys with boys
Modest about sexual matters
Anxious over failures
Occasional periods of shyness or sadness
Increasing interest in spiritual matters
|
|
| 8–9 years |
Increased speed and smoothness in motor activities
Uses common tools such as hammer and household utensils
More individual variation in skills
|
Age of relational thinking; able to classify, seriate, arrange in hierarchies
Learns principle of conservation
Knows date
Gives days of week and months in order
Counts backward from 20 to 1
Makes change correctly from a quarter
|
Expansive; wants to become involved in everything
Actively seeks company of others
Likes clubs and fads
Hero worship begins
Likes to help
Might reject Santa Claus, Easter Bunny
Might show lack of interest in God
|
|
| 10 years |
Slow increase in height
Rapid increases in weight
Body changes associated with puberty may begin to appear
Remainder of teeth erupt
Cooks, sews, paints, draws
Washes and dries own hair
|
Likes writing letters
Reads for enjoyment or practical purposes
|
Performs complex operations on problems as long as problems are concrete | |
| Formal Operational Stage (about 11 years and beyond) | ||||
| 11–14 years |
Maximum increase in height, weight (in North America, girls have peak weight spurt at an average of 12.7 years, and adult stature is reached at an average of 13 years; boys have their peak height and weight spurt at an average of 14 years)
Girls might commence menses
Girls might look more obese
Secondary sex characteristics appear
Might be clumsy and have poor posture
Might have fatigue
Immunoglobulins A and M reach adult levels
|
Spends long periods on telephone |
Logical thinking and ability to use abstract thought develops
Clumsy and inconsistent in abstract thinking
Thinking is reflective, futuristic, multidimensional
Low point in creativity
|
Differences intolerable
Conforms to group standards
Tries on various roles
Ambivalent
Mood swings
Boys gravitate toward sports; girls discuss clothes, makeup
Daydreams a great deal
|
| 14–17 years |
Girls reach physical maturity
Secondary sex characteristics well advanced
|
Able to maintain an argument |
Increased capacity for abstract reasoning
Enjoys intellectual powers
Concerned with philosophic and social problems
Creative period
|
Introspective
Self-centered
Emotions still labile
Parent-child relationship might reach low point; major conflicts over independence and control
Disengagement from dependent parentchild relationship occurs
Fears rejection by peers
Adheres to group norms
Sexual preference becoming established
Dating becomes important
|
| 17–20 years | Physically mature |
Complex thinking
Creativity fading
|
Pursues career
Sexual identity established
More comfortable with self
Fewer conflicts with family
Peer group less important
Emotions more controlled
Forms stable relationships
Might publicly identify as gay, lesbian, or bisexual
|
Early assessment and detection of speech and language disorders are important in planning interventions that will assist the child with interactions, learning, and later, employment and career. Language refers to the system of symbols used to convey meaning to others and can be expressive (speaking) or receptive (understanding). Speech refers to the production of language, including articulation of sounds, rhythm (e.g., stuttering), tone, and quality (e.g., hypernasality). Communication impairments often occur in conjunction with other developmental delays or severe disabilities (cerebral palsy, mental retardation, autism) and can also reflect hearing deficits. To assess children for speech and language difficulties, it is important to distinguish what is developmentally appropriate and what would be considered deviations (Table 22-2).
| Age | Normal Development | Intelligibility | Signs of Communication Impairment |
|---|---|---|---|
| 1 year |
Able to say two to three words with meaning
Omits most final and some initial consonants
Imitates animal sounds
|
Intelligible about 25% of time if listener not familiar with child |
Lack of response to noise
Failure to localize sounds
Failure to follow directions
Absence of babble or inflection
|
| 2 years |
Two-to three-word phrases
Articulation lags behind vocabulary
Uses pronouns (“I,” “you”)
|
50% intelligible in context |
Failure to speak any meaningful words spontaneously
Failure to respond to sound consistently
Failure to follow directions
Uses gestures rather than words
|
| 3 years |
Four-to five-word sentences
About 900 words in vocabulary
Rhythm shows hesitations and repetitions
Uses “what,” “who,” “where,” plurals, prepositions, pronouns
|
75% intelligible |
Omission of initial or final consonants on frequent basis
Use of vowels instead of consonants
Failure to use sentences of at least three words
|
| 4–5 years |
Uses complete sentences
Able to use most grammatical forms correctly
Vocabulary of about 1500–2100 words
|
100% intelligible although some sounds still imperfect |
Stutters
Many sound substitutions
Omits word endings
Noticeable impairment of sentence structures
|
| 5–6 years |
Vocabulary of 3000 words
Might still distort s, z, sh, ch, j sounds
Comprehends “because,” “if,” “why”
|
By age 7, sound substitutions, omissions, or distortions are indicative of communication impairment
Unusual confusions or reversals, inappropriate vocal pitch, and poor voice quality might be indicative of impairment
|
Impaired verbal communication: related to decrease in circulation in brain, psychologic barriers, physical barriers, anatomic defects, brain tumor, differences related to developmental age, absence of significant others, physiologic conditions, alteration of central nervous system, emotional conditions.
Altered growth and development: related to separation from significant others, environmental and stimulation deficiencies, effects of physical disability, inconsistent responsiveness.
Risk for altered development, prenatal: related to maternal age, substance abuse, genetic or endocrine disorders, poor prenatal care, inadequate nutrition, poverty, illiteracy, (individual) prematurity, seizures, brain damage, hearing impairment, vision impairment, chronic illness, dependence on technology, failure to thrive, lead poisoning, chemotherapy, radiation therapy, natural disaster, behavior disorder, substance abuse, (environmental) poverty, violence, abuse, mental retardation, severe learning disability.
Impaired social interaction: related to limited physical mobility, communication barriers.
Social isolation: related to inability to engage in satisfying personal relationships, unaccepted social behavior, inadequate personal resources, immature interests, alterations in physical appearance, altered state of wellness.
Altered parenting: related to lack of access to resources, lack of resources, social isolation, poor home environment, lack of knowledge about child health maintenance, inability to recognize and act on infant cues, physical illness, premature birth, handicapping condition or developmental delay.
Risk for altered parent/infant/child attachment: related to ill infant.
Altered family processes: related to situation transition or crisis.
