“Red Flags” That Warrant a Referral for Early Intervention or Preschool Therapy Services
At teachmetotalk.com I get so many questions from parents who want to know if their child should be evaluated by a speech-language pathologist or another developmental professional. Here’s a list I compiled several years ago and have recently updated for red flags in a baby’s development that warrant a discussion with your child’s pediatrician about his or her development. Usually you’ll always want to follow up with a referral for early intervention or preschool therapy services.
It’s critical that babies and toddlers with any kind of developmental lag get the help they need and the earlier, the better! When we catch and treat these problems early enough, many times a toddler completely catches up and will have no lingering effects of an early delay. Even when a child doesn’t fully catch up to her peers, she’s still going to be significantly better off than if her parents had waited and done nothing.
This list covers all areas of a child’s development and is a good place for parents to start if they’re wondering, “Should I be worried?”
Gross Motor Skills
Remember that this area refers to how a child uses the large muscles in his body like his legs, arms, and core. Talk with your pediatrician and request an early intervention or physical therapy evaluation in these situations:
If a child is…
- Not rolling by 7 months of age
- Not pushing up on straight arms, lifting his head and shoulders, by 8 months of age
- Not sitting independently by 10 months of age
- Not crawling (“commando” crawling–moving across the floor on his belly) by 10 months of age
- Not creeping (on all fours, what is typically called “crawling”) by 12 months of age
- Not sitting upright in a child-sized chair by 12 months of age
- Not pulling to stand by 12 months of age
- Not standing alone by 14 months of age
- Not walking by 18 months of age
- Not jumping by 30 months of age
- Not independent on stairs (up and down) by 30 months of age.
Here are some other gross motor “red flags:”
- “Walking” their hands up their bodies to achieve a standing position
- Only walking on their toes, not the soles of their feet
- Frequently falling/tripping, for no apparent reason
- Still “toeing in” at two years of age
- Unusual creeping patterns
- Has a medical diagnosis that includes gross motor delays such as Down syndrome, cerebral palsy, an injury such as stroke, congenital heart disease, etc…
Be sure you’re following up with your physician for referrals to therapists who can help your child learn to move.
Fine Motor Skills
This area refers to how a child uses the smaller muscles in his body such as his hands and fingers. Talk with your pediatrician and request an early intervention or physical or occupational therapy evaluation in these situations:
If a child is…
- Frequently in a fisted position with both hands after 6 months of age
- Not bringing both hands to midline (center of body) by 10 months of age
- Not banging objects together by 10 months of age
- Not clapping their hands by 12 months of age
- Not deliberately and immediately releasing objects by 12 months of age
- Not able to tip and hold their bottle by themselves and keep it up, without lying down, by 12 months of age
- Still using a fisted grasp to hold a crayon at 18 months of age
- Not using a mature pincer grasp (thumb and index finger, pad to pad) by 18 months of age
- Not imitating a drawing of a vertical line by 24 months of age
- Not able to snip with scissors by 30 months
Other fine motor “red flags” include:
- Using only one hand to complete tasks
- Not being able to move/open one hand/arm
- Drooling during small tasks that require intense concentration
- Displaying uncoordinated or jerky movements when doing activities
- Crayon strokes are either too heavy or too light to see
- Has a medical diagnosis that includes fine motor delays such as Down syndrome, cerebral palsy, an injury such as stroke, congenital heart disease, etc…
Be sure you’re following up with your physician for referrals to therapists who can help your child learn to use his body.
Cognition/Problem Solving Skills
Cognitive skills include how a child thinks, learns, pays attention, plans, and remembers. Talk with your pediatrician and request an early intervention, preschool, or speech therapy evaluation in these situations:
If a child is…
- Not imitating body actions on a doll by 15 months of age (kiss the baby, feed the baby)
- Not able to match two sets of objects by item by 27 months of age (blocks in one container and people in another)
- Not able to imitate a model from memory by 27 months (show me how you brush your teeth)
- Not able to match two sets of objects by color by 31 months of age
- Having difficulty problem solving during activities in comparison to his/her peers
- Unaware of changes in his/her environment and routine
Be sure you’re following up with your physician for referrals to therapists who can help your child learn.
Sensory skills refer to how a child processes incoming sensory information – things he sees, hears, feels, and tastes. Talk to your pediatrician about a referral to early intervention, preschool, or an occupational therapist in these situations:
If a child is…
- Very busy, always on the go, and has a very short attention to task
- Often lethargic or low arousal (appears to be tired/slow to respond, all the time, even after a nap)
- A picky eater
- Not aware of when they get hurt (no crying, startle, or reaction to injury)
- Afraid of swinging/movement activities; does not like to be picked up or be upside down
- Showing difficulty learning new activities (motor planning)
- Having a hard time calming themselves down appropriately
- Appearing to be constantly moving around, even while sitting
- Showing poor or no eye contact
- Frequently jumping and/or purposely falling to the floor/crashing into things
- Seeking opportunities to fall without regard to his/her safety or that of others
- Constantly touching everything they see, including other children
- Hypotonic (floppy body, like a wet noodle)
- Having a difficult time with transitions between activity or location
- Overly upset with change in routine
- Hates bath time or grooming activities such as; tooth brushing, hair brushing, hair cuts, having nails cut, etc.
- Afraid of/aversive to/avoids being messy, or touching different textures such as grass, sand, carpet, paint, playdoh, etc.…
NOTE: Sensory integration and sensory processing issues should only be diagnosed by a qualified professional (primarily, occupational therapists and physical therapists). Some behaviors that appear to be related to sensory issues are actually behavioral issues independent of sensory needs.
Be sure you’re following up with your physician for referrals to therapists and specialists who can help your child participate in everyday activities and get ready for school.
Vision and hearing problems are sensory problems that result in difficulty learning too.
Possible visual problems may exist if the child…
- Does not make eye contact with others or holds objects closer than 3-4 inches from one or both eyes
- Does not reach for an object close by
Ask your physician for a vision assessment with a pediatric opthamologist.
Possible hearing problems may exist if the child…
- Does not respond to sounds or to the voices of familiar people
- Does not attend to bells or other sound-producing objects
- Does not respond appropriately to different levels of sound
- Does not babble
Pursue an audiological or hearing assessment immediately. Language delays are inevitable in children who with unidentified hearing loss. Special services are required to help a child begin to communicate.
Self-care refers to how a child learns to take care of himself including eating, feeding, dressing, and toileting. Talk to your pediatrician in the following situations:
If a child is…
- Having difficulty biting or chewing food during mealtime
- Needing a prolonged period of time to chew and/or swallow
- Coughing/choking during or after eating on a regular basis
- Demonstrating a change in vocal quality during/after eating (i.e. they sound gurgled or hoarse when speaking/making sounds)
- Having significant difficulty transitioning between different food stages
- Not feeding him/herself finger foods by 14 months of age
- Not attempting to use a spoon by 15 months of age
- Not picking up and drinking from a regular open cup by 15 months of age
- Not able to pull off hat, socks or mittens on request by 15 months of age
- Not attempting to wash own hands or face by 19 months
- Not assisting with dressing tasks (excluding clothes fasteners) by 22 months
- Not able to deliberately undo large buttons, snaps and shoelaces by 34 months.
Be sure to speak to your doctor about referrals to speech-language pathologists who can help your child learn to eat new foods and swallow safely or an occupational therapist who can help teach self care skills so that a child can participate in everyday routines.
This developmental area includes how a child learns to interact with others. Talk with your pediatrician and ask for a referral for early intervention, preschool or to see other specialists in the following circumstances:
If a child is…
- Not smiling by 4 months
- Not making eye contact during activities and interacting with peers and/or adults
- Not performing for social attention by 12 months
- Not imitating actions and movements by the age of 24 months
- Not engaging in pretend play by the age of 24 months
- Not demonstrating appropriate play with an object (i.e. instead of trying to put objects into a container, the child leaves the objects in the container and keeps flicking them with his fingers)
- Fixating on objects that spin or turn (i.e. See ‘n Say, toy cars, etc.); also children who are trying to spin things that are not normally spun
- Having significant difficulty attending to tasks
- Getting overly upset with change or transitions from activity to activity
Be sure to speak with your physician for a referral so that your child can learn to interact, play with, and communicate with others.
This includes how a child communicates with others including how he understand and uses language. Talk with your pediatrician if these red flags are present:
- Difficulty making and maintaining eye contact with an adult by 6 months
- No big smiles or other warm, joyful expressions during interaction with another person by 6 months
- No back-and-forth sharing of sounds, smiles, or other facial expressions by 9 months
- No babbling by 12 months
- No back-and-forth gestures, such as pointing, showing, reaching, or waving by 12 months
- No consistent responding to their names by 12 month
- No words by 16 months
- No following simple and familiar directions by 18 months
- No two-word meaningful phrases without imitating or repeating?& says at least?50 words by 24 month
- No back-and-forth conversational turn-taking by 30 months
- Any loss of speech or babbling or social skills (like eye contact) at any age
Years ago I found a great list at www.sensory-processing-disorders.com.
I’ve updated it since then using resources from cdc. gov using resources from their Act Early campaign.