Developmental Screening - 8 and 18 Month Checks

Many congenital abnormalities should have been detected at neonatal and 8 week screening. At these later stages, the objective is to detect behavioural problems and/or delays in development for which early management can be advantageous.¹
Early detection of congenital disorders can also allow genetic counselling for future pregnancies.²

Community screening at 8 months can sometimes pick up conditions not evident at earlier ages.⁴ Problems may also be noticed by parents, and this warrants a complete physical examination.

• If doubts about descent of testes at 8 weeks, check this and refer if not present. It is widely recommended that boys should be referred before the age of 18 months, but one study suggested that significant numbers are missed.⁵
• Always look for signs of congenital dislocation of the hip, listen to the heart and check for signs of congenital heart disease.
• Review developmental progress.
• Talk with parents about baby's health and growth. Ask them about baby's ability to tell between them and other familiar adults. Ask about vocalisations.
• Ask parents to call to him/her and observe response - does the baby listen and do they try to join in?
• Ask about other forms of communication - excitement at meal times, demanding attention, can he/she play games such as 'peep-bo'.
• Ask parent to offer child a toy - observe use of hands.
• Check gross motor development - observe sitting balance. In prone position should be able to roll over, may be able to push arms up enough to lift pelvis clear of floor. Can child sit up on its own or be helped by being pulled to sitting with very little support?
• Hold baby in vertical suspension and suddenly lower him/her to the floor. The child should brace their legs with feet plantigrade as the surface approaches. If the child is a shuffler, bring their legs to a horizontal position.
• Check hearing - at this age 95% babies can localise a sound source accurately except directly behind their head. Ask the parents how they know the child can hear (common responses: 'He listens and turns to voices'; 'He wakes up when we open his bedroom door'). Check with the distraction test. This involves one person standing in front of the child attracting their attention with a toy. The toy is gradually hidden from view whilst another person standing behind and to one side of the child makes a noise. If the child turns their head towards the sound, it is deemed positive.⁶ The test is not very accurate and may well be superseded to some extent by the technology used in the NHS Newborn Hearing Screening Programme.⁷
• Look for signs of problems - left handedness (higher incidence of autism, hyperactivity, dyslexia, learning disabilities and developmental co-ordination disorder),⁸ making fists, presence of primitive reflexes, squint.

Early signs of autism, autistic spectrum disorder or learning difficulties may be present at this age. Although it may not be possible to make a definitive diagnosis, any suspicion of developmental delay should be referred for more detailed assessment. One study of children under six with learning disabilities found that there was significant delay in detection and referral for remedial treatment.¹

Gross motor ability³

Should be able to:

• Achieve sitting position (usually at 6-11 months)
• Pull to standing position (usually at 6-10 months)
• Walk supported by furniture (usually at 7-13 months)
• Walk unsupported (usually at 10-15 months)

May be able to:

• Climb stairs (usually at 14-22 months)
• Walk backwards (usually at 12-22 months)

Fine motor ability

Should be able to:

• Point with index finger (usually at 9-15 months)
• Use careful pincer grip (usually at 10-18 months)
• Bang two bricks together (usually at 7-13 months)

May be able to:

• Scribble (usually at 12-24 months)
• Put 3-4 bricks on top of each other (usually at 16-24 months)

Hearing and talking

Should be able to:

• Turn towards sound of own name
• Jabber constantly

May be able to:

• Say 'Mama' and 'Dada' (usually at 11-20 months)
• Say 3 words other than 'Mama' and 'Dada' (usually at 10-21 months)
• Point to named facial features (usually at 14-23 months)
• Follow simple instructions (usually at 15-30 months)

Behaviour

May be able to:

• Hold spoon and take food to mouth (usually at 14-30 months)
• Explore surroundings (usually at 13-20 months)
• Remove shoes and socks (usually at 13-20 months

In March 2008 the Department of Health published a document called The Child Health Promotion Programme - Pregnancy and the first five years of life. This seeks to build on the guidance in the National Service Framework for Children, Young People and Maternity Services. It requires health service commissioners to focus not only on deficiencies but also on strengths, and to address the social and emotional needs of children (and their families) as well as the purely physical aspects of their development.

In terms of developmental screening, it identifies various levels of checks from those which all children should have (universal) to those focussed on particular problems (progressive).
It recommends, between six months to one year, a health review which includes:

• An assessment of the childs physical, social and emotional needs
• A discussion of parental concerns and/or any support required
• Growth monitoring
• Health promotion - raise awareness of dental health and prevention, healthy eating, injury and accident prevention relating to mobility, safety in cars, and skin cancer prevention.

It further recommends a health review between two to two and a half years, largely to review the topics discussed at the first review, but also to include language development.