Developmental Assessment

See also autism spectrum disorder and cerebral palsy (moved to neurology during the neurology re-consolidation, as the canonical page for both categories).

Red flags for referral

Child abuse or neglect; a serious underlying medical condition; global developmental delay; signs of regression (loss of skills/milestones).

Surveillance vs screening

Developmental surveillance is the ongoing, opportunistic process of checking a child’s development at every well-child visit — not just a one-off formal check-up. Developmental screening applies a standardised tool at specific ages to asymptomatic children, so a positive screen leads to a full developmental-behavioural evaluation. Running both together catches more delays earlier than either alone. For a baby born preterm, adjust milestone expectations to the corrected gestational age (not chronological age) — an 8-week-premature baby is expected to reach milestones roughly 2 months behind same-aged peers born at term.

Assessment approach

Take your time — expect to need more than one long appointment. Consider biological, environmental and social risk factors: low parental education/learning or intellectual disability, parental mental illness, domestic violence, dysfunctional family/poor parenting/emotional neglect, alcohol/drug use, social isolation, poverty, poor housing, poor-quality or inaccessible services.

Screen development at any presentation using the CDC developmental milestone checklist, or arrange an Ages and Stages Questionnaire via a local child health nurse.

Examination

Growth; use toys to assess language/communication, social interaction, eye–hand coordination, and problem solving.

Clinical features suggestive of ASD:

• Eye contact — has the child made eye contact during the appointment?
• Gaze monitoring — point at an interesting object; does the child look where you’re pointing (not just at your hand)?
• Pretend play — e.g. will they “make you a cup of tea” with toys?
• Protodeclarative pointing — ask “where’s the light?”; does the child point with their index finger, looking up at your face around the same time?
• Block tower — can they build one? How many blocks?

Also assess: response to visual/auditory stimuli; signs of non-accidental injury (bruises, burns); dysmorphic features (e.g. low-set ears); neurological signs (neurocutaneous lesions, unilateral weakness, abnormal tone); ENT exam (glue ear); parent/carer mental state (depressed, intoxicated, uninterested).

Developmental red flags by age

Age	Social/emotional	Communication	Cognition/fine motor/self-care	Gross motor
6 months	Doesn’t smile/interact	Not starting to babble	Not reaching/holding toys; hands frequently clenched; doesn’t explore objects with hands/eyes/mouth; doesn’t bring hands to midline	Not holding head/shoulders up on tummy time; not holding head steady in supported sitting
9 months	Not sharing enjoyment via eye contact/expression	No gestures (pointing/showing/waving); no two-part babble	Doesn’t hold objects; doesn’t “give” on request; can’t transfer toy hand-to-hand	Not rolling; not sitting independently; not creeping/crawling; not weight-bearing when held standing
12 months	Doesn’t notice someone new; no turn-taking games	No babbled “talking” phrases; no response to familiar words	Doesn’t self-feed finger foods/hold cup; no pincer grip	No independent mobility; not pulling to stand with support
18 months	Lacks interest in playing/interacting	No clear words; can’t follow short requests	Doesn’t scribble; doesn’t attempt block-stacking	Not standing independently; not attempting to walk
2 years	Bangs/drops/throws toys rather than using them purposefully	Not learning new words; not combining two words	Doesn’t attempt spoon-feeding/help dressing	Not walking independently; can’t walk stairs holding on
3 years	No interest in pretend play or other children	Speech hard for familiar people to understand; no simple sentences	No self-care attempts; difficulty with small objects	Can’t walk stairs independently; not running/jumping
4 years	Unwilling/unable to play cooperatively	Speech hard to understand; can’t follow 2-step directions	Not day-toilet-trained; can’t draw lines/circles	Not confidently walking/running/climbing/jumping/using stairs; can’t catch/throw/kick a ball
5 years	Play differs markedly from peers; can’t tell a parent what’s wrong	Can’t answer simple conversational questions; teacher concerns re: school readiness	Can’t independently feed/dress; can’t draw a simple picture	Not confident with walk/run/climb/jump/stairs; can’t hop 5×/stand on one leg for 5 sec

Red flags at any age: strong parental concern; significant loss of skills; no response to sound/visual stimuli; poor interaction with adults or children; absent or limited eye contact; left–right asymmetry in strength/ movement/tone; marked hypotonia or hypertonia significantly affecting function.

A delay that starts in only one domain can go on to become a global delay across multiple domains as the child grows, so an isolated delay still needs review over time rather than being dismissed once referred. Of the domains, language delay is arguably the most important to pick up early, as it’s the strongest predictor of later literacy and broader cognitive outcomes and responds well to early intervention.

Management

• Vulnerable families: improve supports — refer to early intervention services, parenting programs, childcare; link with the early childhood health centre.
• Isolated delay (1 domain): refer to the relevant allied health provider. An isolated fine/gross motor delay in an otherwise well school-aged child, especially with handwriting difficulty or clumsiness, raises developmental coordination disorder (DCD/dyspraxia) — poor motor coordination not explained by intellectual disability, a neurological condition (e.g. cerebral palsy) or inadequate practice, often with comorbid ADHD or autism spectrum disorder. Refer for occupational therapy/physiotherapy assessment; task-oriented motor-training approaches are the best-supported treatment. No blood test or imaging is required to diagnose DCD itself, though thyroid function and neuroimaging can help exclude an alternative or coexisting cause.
• Global delay (>2 domains) or strong ASD suspicion: confirm the diagnosis; refer simultaneously to allied health and psychology (GP management plan + mental health plan); arrange early intervention without delay.

Referral for paediatric assessment if

Evidence/strong suspicion of abuse or neglect; severe delay in 1 domain; global delay across >2 domains; suspected autism spectrum disorder.