Child Development Red Flags – Occupational Therapy Practice


  • Developmental problems in children can have lifelong implications on their health and wellbeing.
  • Early detection of developmental problems provides an opportunity for early intervention by occupational therapy practitioners and the team.
  • This provides the team with an opportunity to change the child’s developmental trajectory into a positive one that can promote their potential.
  • Keep in mind that children may meet developmental milestones or even skip them altogether.
  • Familiarize yourself with the common ‘normal’ developmental milestones at each month/age for gross motor, fine motor, self-help (ADLs), problem-solving, socio-emotional, and language milestones.
  • Sources of useful information throughout the occupational therapy process include parent, family, teacher, educator interviews and questionnaires, screening, assessments, history review, and observation.

Developmental Milestones

Task Age
Eyes follow past midline 6 weeks
Smiles 6 weeks
Legs bear weight with support 3-7 months
Sits with support 4-6 months
Sits without support 5-8 months
Crawls 6-9 months
Puts objects into mouth 4-8 months
Pulls to stand 6-10 months
First tooth appears 6-9 months
Walks while holding on 7-13 months
Drinks from a cup 10-15 months
Waves goodbye 8-12 months
Climbs stairs 14-20 months
Turns pages of books and magazines 2 years
Scribbles 1-2 years
Uses a spoon 14-24 months
Puts on clothing 21-26 months
Buttons up 30-42 months
Jumps 20-30 months
Rides a tricycle 21-36 months
Has bowel control 18 months – 4 years
Has bladder control (daytime) 8 months – 4 years
Hand preference 2-5 years
Source: Oberklaid F, Kaminsky L. Your
child’s health. Revised 4th. Melbourne: Hardie Grant
Books, 2006


  • Parental concern: parents spend the most time with their children and can be reliable observers of their children’s skills. Keep in mind that parents’ recall of developmental milestones can be inaccurate and biased towards normal.((Hart H, Box M, Jenkins S. The value of the developmental history. Developmental Medicine and Child Neurology 1976;20:442–52.))
  • Milestone checklists: development is often predictable but can be delayed and children will likely catch up with their peers. Use milestone checklists in conjunction with clinical judgment.
  • Clinical judgment: based on OT clinician’s training and clinical experience. While clinical judgment is an important component for the detection of developmental problems, it is not the only source.

Developmental Delay Types

  • Can be single domain (isolated developmental delays) or multi-domain.
  • Delays can be transient or persistent.
  • Global developmental delay is a significant delay in 2+ domains affecting children under age 5 years.((Shevell M, Ashwal S, Donley D, et al. Quality Standards Subcommittee of the American Academy of Neurology;Practice Committee of the Child Neurology Society. Practice parameter:evaluation of the child with global developmental delay:report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology. 2003;60:367–80.))
  • Presence of a developmental disorder: e.g., ADHD, ASD, Cerebral Palsy, Intellectual Disability, Hearing Loss, Visual Impairment
  • Abnormal patterns of development: atypical from the normal pattern of development
  • Developmental Arrest: development seemingly stops for particular skills
  • Developmental Regression: the child goes backward in one or more aspects of their development. Urgent referral to specialists for further intervention is ncessary.

Red Flags

  • Prematurity: most pertinent in pediatrics less than 28 weeks or low birth weight. 
  • Associated conditions considered high risk, e.g., chromosomal abnormalities, hearing loss, visual problems, dysmorphism, autism, or any clear abnormal neurological presentation
  • Major parental concerns
  • Failed screening tests
  • Psychosocial and family risk factors((Oberklaid, F., & Drever, K. (2011). Is my child normal?: Milestones and red flags for referral. Australian family physician, 40(9), 666-670.))
  • Variations in the pattern of development
    • Bottom shufflers do not crawl but shuffle around; tend to walk late with hypotonicity in the lower limbs
    • Commando crawling or no crawling
    • Varied rate of language acquisition, social skills, play, and behaviors

Facts vs Myths

  • Boys do not necessarily acquire language later than girls.((Hyde JS, Linn MC. Gender differences in verbal ability:a meta-analysis. Psychol Bull. 1988;104:53–69.))
  • Children from multilingual families tend to have delayed language acquisition.

Communication of Concerns

  • Provide a holistic approach (family-centered, culturally aware)
  • Listen
  • Elicit any concerns about development
  • Provide education, information, and guidance to parents
  • Provide relevant resources to programs
  • Follow-up
  • Refer to specialists as necessary