Clinical Review

Developmental assessment of children

BMJ 2013; 346 doi: (Published 15 January 2013) Cite this as: BMJ 2013;346:e8687

Re: Developmental assessment of children

I enjoyed the article ‘Developmental assessment of children’ and found the table of ‘normal developmental milestones’ and the list of ‘red flag’ indicators very useful. However, as a speech and language therapist, I believe there was an important omission in that there were no pointers for detecting difficulties with the comprehension of spoken language. This is more subtle than a child’s expressive language to detect, and can be easily missed, yet the implications can be more serious.

In box 3 you suggest asking ‘Do you have concerns about how your child talks and understands what you say?’ which is a good lead-in question. However, in my experience many parents think that their child understands what is being said to them whereas they are often picking up visual clues from the situation e.g. the family is ready to go out and the child responds to ‘get your shoes’.

I would therefore suggest that at 2 years a ‘red flag’ warning should be given if the child is not responding to their name, and shows no situational understanding. Also if they are not able to understand one key word from what is said to them e.g. ‘Where’s mummy?’, ‘Where’s the ball?’ (from a selection of 3 objects e.g. a cup, a ball and a spoon’) or‘Get your spoon’. It is better if objects are used before pictures as this follows the developmental sequence.
At 3 years there should be a red flag warning if the child is not following simple instructions e.g. ‘Give me the car’ or ‘Give the banana to mummy’. It will of course be important for the professional not to give cues in the form of eye pointing or a hand gesture so that it is clear that the child is responding to spoken language. It will also be important to take into account the child’s single channelled attention span between the ages of 2 – 3 years so that if the child is playing, he may not be able to listen at the same time.

The earlier that comprehension difficulties are identified, the sooner that support can be given in the form of reducing the language that is used when talking to the child, slowing the pace by using pauses, the use of signing alongside language and using visual prompts, such as objects and pictures, when conversing with the child.

In practice I have seen many children (usually boys) between the ages of 2 years to 2 years 6 months who may be using very little expressive language but who have good comprehension, and they will often go on to develop skills within the normal range. Therefore, to a speech and language therapist alarm bells will ring if a child is not understanding spoken language rather than the emphasis you have given in your article to the number of words that a child is saying at a given stage.

Competing interests: No competing interests

20 January 2013
Maeve Guly
Speech and Language Therapist
The Shrubbery, Bedford Rd, Horrabridge, Devon, PL20 7QH