Updated evidence-based developmental attainments for children: First 6 years

Abstract

An accurate and well-rounded understanding of child development is essential to optimize child functioning and health. The First Six Years Developmental Attainments chart empowers clinicians to give parenting guidance and to evaluate age-specific developmental attainment of their pediatric patients. A practical knowledge translation tool, the chart integrates a comprehensive array of developmental skill attainments, citing the range of sources from classic to current literature. It includes definitions, explanations, and examples for skills, attainment age range, percentile, and oldest age of attainment where available so that the reader can ‘estimate the age’ for a child’s skills in each developmental sector. Sub-headings focus the clinician’s search for skills. This updated office reference is of critical use when clinicians guide parents with strategies suited to the child’s level of developmental skills. With levels of evidence described, this clinical tool could be used for future national or international studies to develop strategies most useful for clinicians, trainees of different levels, and parents supporting child development.

Graphical Abstract

Graphical Abstract.

INTRODUCTION

This article presents a developmental attainments chart (Supplementary Tables 1–5), which is a new knowledge translation tool of evidence-based information for primary care clinicians and consultants who address child development and behaviour in their practice. This tool is pivotal in filling critical gaps in knowledge of typical child development and behaviour (1,2), particularly for 36% of Canadian children presenting with such concerns (3,4).

WHAT IS THE DEVELOPMENTAL ATTAINMENTS CHART?

The “oldest age milestones” chart was the groundbreaking clinical tool that first provided references, level of evidence, age range, and percentile for age-of-development attainments (5). Our First Six Years Developmental Attainments chart builds on that standard by further documenting pertinent evidence, content experts’ descriptions of attainments, and a broader array of skills deemed essential in supporting child development (such as social communication, problem-solving, memory, attention, feeding, primary social-emotional milestones, regulation, and sleep). The table framework created by Dr. Debbi Andrews (2009) uses vertical columns to demonstrate the sequence of skill development within six sectors and to underscore development as a continuous growth of skills through predictable stages (6). Although all children have individual differences in the quality of skills and their rate of growth, the patterns generally follow a predictable vertical trajectory (6). For ease, sub-headings focus the search when looking for skills in the midst of clinical activities.

WHY IS IT ESSENTIAL TO UNDERSTAND AND SUPPORT CHILD DEVELOPMENT?

Understanding child development is integral to pediatric health care (6). Detection and management of developmental problems by health care providers will directly impact a child’s brain development, progress in developing new skills, and, ultimately, adult health and social outcomes (7,8). Current standard-of-practice models followed by family physicians, community health nurses, nurse practitioners, and pediatricians include developmental surveillance at routine health supervision visits through 5 years of age to detect children who might have significantly slow, rapid, or atypical development that places them at risk for a diagnosis of developmental, regulatory, behavioural, or mental health disorder (9). Monitoring includes soliciting parental concerns and observation/history-taking of developmental skills attainment using a short checklist of typical skill-age or red flags; alternatively, the higher sensitivity of a standardized developmental screening instrument is used (9). Additional components of surveillance include physical examination, identification of risk and protective factors, medical record documentation, and, when concerns are present, referrals to allied health and medical specialists (9).

Parent or clinician concerns detected through surveillance lead to parenting guidance. Yet, even when parent and clinician have no concerns, anticipatory guidance proactively supports optimal development because typical and predictable problems will emerge in each developmental stage (9,10). For example, noncompliance at toddler age and tantrums and selective eating at 2 years are expected. As well, because the brain disorganizes when moving toward a new maturation profile, regressions may occur when progressing to the next attainment (such as walking) or experiencing change (such as starting school) and resolve after a few weeks with supportive responses from the parent (6,10,11). Parenting guidance is especially important; apart from the genetic potential with which a child is born, parenting that shapes behaviour and mediates adverse environmental risks is the critical factor for young children, which supports optimal development of the brain and of the external skills the child uses (7,11). Guidance pertinent to the child’s developmental level must come from a “developmental age estimate” that may or may not match the child’s chronological age.

Parent concern is an evidence-based risk factor for identifying developmental disorders. Developmental evaluation (assessment) is performed either by the clinician implementing surveillance activities or by a carefully chosen specialist, depending on the needs of the child and clinician (9). Evaluation includes a thorough review of attainments within all developmental sectors. (In motor development, the quality of skill cannot be exclusively captured in a chart; it is important to ask whether there were any skills the parent had to spend extra time teaching and to observe the quality of movement during physical examination, tasks, and play. A difference in skills from those described in the chart could prompt exploration with the family, who might explain the cultural and language expectations, or exposure to experience underlying the difference.) Accurately understanding the level and quality of skills typically expected at the child’s age, and determining whether unmet attainments are isolated to one sector or exist across sectors, allow the clinician to generate the most likely diagnosis that the child may have, such as excessive emotion dysregulation requiring treatment or risk for attention deficit hyperactivity disorder requiring intervention at preschool. Unmet attainments indicate the need for hearing and vision screening or evaluation by audiology and optometry/ophthalmology (the latter depending on results of history and physical exam) (9). Even concerns localized to one sector may require appropriate referrals for formal diagnostic evaluation and treatment recommendations. A cognitive delay or delay in two or more sectors prompts referral to an early intervention program.

Lack of familiarity with age-expected development and behaviour may lead to a missed opportunity as clinicians may not elicit parent concerns. The First Six Years Developmental Attainments chart could optimize clinical practice by empowering clinicians to explore parental concerns and by improving their ability to refine guidance, evaluate development, and make appropriate and timely referrals.

SCENARIO FOR USING THE CHART

During a 4-year old’s asthma treatment visit, a school readiness screen is completed by the parent, using the standardized broad band instrument PEDS (Parents’ Evaluation of Developmental Status) with PEDS:DM (Developmental Milestones). It is positive for concerns of language and fighting with her best friend. Milestones are not met for receptive language, expressive language, and pre-reading. At follow-up for parenting guidance and developmental evaluation, Supplementary Table 4 is viewed for the horizontal row representing age 4 years. (Attainments are generally placed in the age row corresponding to the oldest age of attainment in most children. When references report percentile, the oldest age represents the 85th or 90th percentile. When they do not, the oldest age represents oldest within the age range of acquisition. Some references, instead of reporting oldest age or age range, report 50th percentile attainment age or average age.) The clinician “estimates the age” the child currently shows from history and physical exam. The child meets expected 4-year skills in the vertical columns Gross motor, Cognitive, Feeding eating and sharing meals, and Social-emotional. If desired, the clinician could highlight the skills attained on the chart.

Some 4-year skills have not been attained in the Fine motor/visual-motor and Communication sectors. Reading (visual-spatial aspect), she does not recognize her name or sight words; pre-writing, she does not copy a cross or draw a 10-parts person; pre-reading (phonological awareness aspect), she does not recognize rhymes or beginning sounds of words; receptive language, she does not point to named shapes; and expressive language, when reporting on a recent family outing, she does not describe sequence of events, state her full name, or describe her family.

This child’s “estimated age” for areas of unmet attainments is 3 years: pre-reading (recognizes favourite books by their covers, usually holds book right-side up, when pretending to read, shows top to bottom and left to right orientation, and identifies some letters of her name), pre-writing (copies circle, human figure drawing is simple with arms/legs extending from head), receptive language (follows 2-step commands, understands almost everything her parents say), and expressive language (speaks simple sentences, describes herself by what she looks like, says I, you, and she, asks why questions, recites numbers 1 to 10) (Supplementary Table 3).

Developmental evaluation suggests that the most likely diagnosis is a risk for specific learning disorder (SLD) in reading, with a suspected cause being delayed attainment of language, phonological awareness, and visual-spatial perception. The clinician explains the results to the child’s parents, recommends preschool programming if available, gives parenting guidance in the areas of concern, and plans follow-up to review referral results and continue surveillance. In this case, referrals include speech language pathology and audiology (suspected delays in receptive language, expressive language, and pre-reading [phonological awareness] skills). The clinician also refers to occupational therapy and does vision screening for suspected delays in pre-reading (visual-spatial) skills.

Looking horizontally across different developmental sectors of the chart reveals how skill acquisition in one sector is impacted by skills that have developed in other sectors—“you can’t do one without the others with regard to brain development.” For instance, this child’s “3-year” Communication sector skills of receptive language and using emotion words help her attain “4-year” Cognitive theory of mind (understands other people have different thoughts and feelings than her own) and Social-emotional problem-solving, which help her attain “4-year” Social-Emotional sharing more consistently. This knowledge of developmental skills helps the clinician develop parenting guidance.

Specific parenting strategies follow to address the parent’s concern of language delay and fighting with a friend and the clinician’s concern of reading. Help the child talk about events by asking her about her thoughts, feelings, and memories (“Remember when you dropped your ice cream? How did you feel?” “You look excited. What are you looking forward to, when Grandma comes to visit?”) (12). Coach conflict resolution with the child and friend together, such that both children participate in problem-solving (express feeling, define problem, generate potential solutions, try best one, and review what worked) (13). Do daily shared reading with conversation about the book (ask why questions, discuss what the characters might be thinking and feeling, and help her recognize rhymes) (12,13).

CHART RIGOUR

The First Six Years Developmental Attainments chart integrates a well-rounded range of reference sources (Supplementary Table 5), from “classic” descriptions of development (6,10,14–18), to newer integrations of the literature or original research (12,13,19–30), to current knowledge from interpersonal neurobiology research (7,11,31,32), with standardized instruments providing the highest quality evidence (33–39). Lower quality evidence for skill age attainment (40–48) is important to include when high-quality evidence is lacking because it forms a picture of development as a whole (6).

We started by using sources that are standardized instruments in the field and other sources recommended by 14 peer reviewers. We subsequently used sources that had been cited as references in the original sources or cited in our literature review of specific attainments. In-depth peer review of the chart was accomplished specifically by content matter experts and by health advocacy and medical education end-users of the tool locally, across Canada, and in the United States. Initial peer review was conducted during formation of the updated chart (2014–2017); final peer review was conducted (2020–2021) following the pilot years. Content matter experts were interdisciplinary colleagues who see children with developmental concerns in their practice. Peer review was requested using content questions specific to their designated expertise. In addition, an informal survey was used for the final peer-review. Advice was sought from 31 experts. Our questions were answered by 25 of the 28 responders (15 of the 25 peer reviewers were initial peer reviewers, 16 were final peer reviewers, and 6 peer reviewed at both times).

All modifications that were suggested by 10 peer reviewers were made and then approved by the respective peer reviewer. Clarifying explanations and examples to describe the definitions of skill terms, and additional information or skills, were provided by 14 peer reviewers and included in the chart. Multiple content revisions with additional feedback and approval over time (on 3 or more occasions) were received from 11 peer reviewers (3 initial peer reviewers, 6 final peer reviewers, and 2 peer reviewers at both the initial and final peer reviews).

Interim peer review was gathered at our local Clinician and Learner Rounds (Division of Developmental Pediatrics, January 2017), following pilot of the update by our local pediatric residents (2014–2017); six out of 12 present at the Rounds provided consensus on skills to retain in the chart. The resulting shorter version with some skills excluded was piloted (2017–2020) with our pediatric residents. However, excluded skills were subsequently re-entered into the chart due to their utility during patient encounters in clinic.

LIMITATIONS AND OPPORTUNITIES FOR FURTHER WORK

The chart is limited by lack of structured peer review for inclusion and exclusion criteria of skills retained in the chart. However, this clinical tool is intended as a thorough compendium, the first of its kind, fostering the clinician’s comprehensive and updated understanding of child development. We hope that it will be used in future by national or international health promotion centres interested in conducting studies with more rigorous methodology for several purposes of study. Such studies might examine which skills to retain for developmental evaluation, parenting guidance, and use by trainees of primary care and consultant care. They might also show which skills are valued by parents and what terminology is family-friendly.

CONCLUSION

The First Six Years Developmental Attainments chart is a practical office reference that fills a gap in education and practice for clinicians providing parenting guidance and conducting developmental evaluation. An updated expansion of the “oldest age milestones” chart, it includes a broader array of skills to reflect current concepts. The chart describes level of evidence and includes attainment age range, oldest age of attainment, and percentile where available in the literature so that the reader can “estimate the age” for a child’s skills in each developmental sector.