Developmental Red Flags for Children Ages 3-5

Red Flags

Be alert to a child who, compared with other children the same age or 6 months older or younger, exhibits these behaviors:

• Does not seem to recognize self as a separate person, or does not refer to self as “I”
• Has great difficulty separating from parent or separates too easily
• Is anxious, tense, restless, compulsive, cannot get dirty or messy, has many fears, engages in excessive self-stimulation
• Seems preoccupied with own inner world; conversations do not make sense
• Shows little or no impulse control; hits or bites as first response; cannot follow a classroom routine
• Expresses emotions inappropriately (laughs when sad, denies feelings); facial expressions do not match emotions
• Cannot focus on activities (short attention span, cannot complete anything, flits from toy to toy)
• Relates only to adults; cannot share adult attention, consistently sets up power struggle, or is physically abusive to adults
• Consistently withdraws from people, prefers to be alone; no depth to relationships; does not seek or accept affection or touching
• Treats people as objects; has no empathy for other children; cannot play on another child’s terms
• Is consistently aggressive, frequently hurts others deliberately; shows no remorse or is deceitful in hurting others

How to Screen

1. Observe child.
   • Note overall behavior. What does the child do all day? With whom? With what does child play?
   • Note when, where, how frequently, and with whom problem behaviors occur.
   • Describe behavior through clear observations. Do not diagnose.
2. Note family history.
   • Make-up of family: Who cares for the child?
   • Has there been a recent move, death, new sibling, or long or traumatic separation?
   • What support does the family have—extended family, friends?
3. Note developmental history and child’s temperament since infancy.
   • Activity level
   • Regularity of child’s routine—sleeping, eating
   • Distractibility
   • Intensity of child’s responses
   • Persistence/attention span
   • Positive or negative mood
   • Adaptability to changes in routine
   • Level of sensitivity to noise, light, touch

Motor Development—Fine Motor, Gross Motor, and Perceptual—Which Includes

• Quality of movement
• Level of development
• Sensory integration

Red Flags

Pay extra attention to children with these behaviors:

• The child who is particularly uncoordinated and who
  • Has lots of accidents
  • Trips, bumps into things
  • Is awkward getting down/up, climbing, jumping, getting around toys and people
  • Stands out from the group in structured motor tasks—walking, climbing stairs, jumping, standing on one foot
  • Avoids the more physical games
• The child who relies heavily on watching own or other peoples’ movements in order to do them and who
  • May frequently misjudge distances
  • May become particularly uncoordinated or off balance with eyes closed
• The child who, compared to peers, uses much more of her or his body to do the task than the task requires and who
  • Dives into the ball (as though to cover the fact that she or he cannot co-  ordinate a response)
  • Uses tongue, feet, or other body parts excessively to help in coloring,  cutting, tracing, or with other high-concentration tasks
  • Produces extremely heavy coloring
  • Leans over the table when concentrating on a fine motor project
  • When doing wheelbarrows, keeps pulling the knees and feet under the  body, or thrusts rump up in the air
• The child with extraneous and involuntary movements, who
  • While painting with one hand, holds the other hand in the air or waves
  • Does chronic toe walking
  • Shows twirling or rocking movements
  • Shakes hands or taps fingers
• The child who involuntarily finds touching uncomfortable and who
  • Flinches or tenses when touched or hugged
  • Avoids activities that require touching or close contact
  • May be uncomfortable lying down, particularly on the back
  • Reacts as if attacked when unexpectedly bumped
  • Blinks, protects self from a ball even when trying to catch it
• The child who compulsively craves being touched or hugged, or the older child who almost involuntarily has to feel things to understand them, who both may
  • Cling to, or lightly brush, the teacher a lot
  • Always sit close to or touch children in a circle
  • Be strongly attracted to sensory experiences such as blankets, soft  toys, water, dirt, sand, paste, hands in food
• The child who has a reasonable amount of experience with fine motor tools but whose skill does not improve proportionately, such as
  • An older child who can still only snip with scissors or whose cutting  is extremely choppy
  • An older child who still cannot color within the lines on a simple  project
  • An older child who frequently switches hands with crayon, scissors, paintbrush
  • An experienced child who tries but still gets paste, paint, sand, water everywhere
  • A child who is very awkward with, or chronically avoids, small manipulative materials
• The child who has exceptional difficulty with new but simple puzzles, coloring, structured art projects, and drawing a person, and who, for example, may
  • Take much longer to do the task, even when trying hard, and produce a final result that is still not as sophisticated compared to those of  peers
  • Show a lot of trial-and-error behavior when trying to do a puzzle
  • Mix up top/bottom, left/right, front/back, on simple projects where a model is to be copied
  • Use blocks or small cubes to repeatedly build and crash tower structures and seem fascinated and genuinely delighted with the novelty of the crash (older child)
  • Still does a lot of scribbling (older child)

How to Screen

Note level and quality of development as compared with other children in the group.

Speech and Language Development, Which Includes

• Articulation (pronouncing sounds)
• Dysfluency (excessive stuttering—occasional stuttering may occur in the early years and is normal)
• Voice
• Language (ability to use and understand words)

Red Flags

• Articulation. Watch for the child
  • Whose speech is difficult to understand, compared with peers
  • Who mispronounces sounds
  • Whose mouth seems abnormal (excessive under- or overbite; swallowing difficulty; poorly lined-up teeth)
  • Who has difficulty putting words and sounds in proper sequence
  • Who cannot be encouraged to produce age-appropriate sound
  • Who has a history of ear infections or middle ear disorders

Note: Most children develop the following sounds correctly by the ages shown (i.e., don’t worry about a 3-year-old who mispronounces t).

2 years—all vowel sounds

3 years—p, b, m, w, h

4 years—t, d, n, k, h, ng

5 years—f, j, sh

6 years—ch, v, r, l

7 years—s, z, voiceless or voiced th

• Dysfluency (stuttering). Note the child who, compared with others of the same age,
  • Shows excessive amounts of these behaviors:
    • repetitions of sounds, words (m-m-m; I-I-I-I-)
    • prolongations of sounds (mmmmmmmmmmmmmmm)
    • hesitations or long blocks during speech, usually accompanied by  tension or struggle behavior
    • putting in extra words (um, uh, well)
  • Shows two or more of these behaviors while speaking:
    • hand clenching
    • eye blinking
    • swaying of body
    • pill rolling with fingers
    • no eye contact
    • body tension or struggle
    • breathing irregularity
    • tremors
    • pitch rise
    • frustration
    • avoidance of talking
  • Is labeled a stutterer by parents
  • Is aware of her or his dysfluencies
• Voice. Note the child whose
  • Rate of speech is extremely fast or slow
  • Voice is breathy or hoarse
  • Voice is very loud or soft
  • Voice is very high or low
  • Voice sounds very nasal
• Language (ability to use and understand words). Note the child who
  • Does not appear to understand when others speak, though hearing is normal
  • Is unable to follow one- or two-step directions
  • Communicates by pointing, gesturing
  • Makes no attempt to communicate with words
  • Has small vocabulary for age
  • Uses parrotlike speech (imitates what others say)
  • Has difficulty putting words together in a sentence
  • Uses words inaccurately
  • Demonstrates difficulty with three or more of these skills:
    • making a word plural
    • changing tenses of verb
    • using pronouns
    • using negatives
    • using possessives
    • naming common objects
    • telling function of common objects
    • using prepositions

Note: Two-year-olds use mostly nouns, few verbs. Three-year-olds use nouns, verbs, some adverbs, adjectives, prepositions. Four-year-olds use all parts of speech.

How to Screen

1. Observe child. Note when, where, how frequently, and with whom problem occurs.
2. Check developmental history—both heredity and environment play an important part in speech development.
3. Look at motor development, which is closely associated with speech.
4. Look at social–emotional status, which can affect speech and language.
5. Write down or record speech samples.
6. Check hearing status.
7. Note number of speech sounds or uses of language.

Hearing

Even a mild or temporary hearing loss in a child may interfere with speech, language, or social and academic progress. If more than one of these red flag behaviors is observed, it is likely that a problem exists.

Red Flags

• Speech and language. Look for the child
  • Whose speech is not easily understood by people outside the family
  • Whose grammar is less accurate than other children of the same age
  • Who does not use speech as much as other children of the same age
  • Who has an unusual voice (hoarseness, stuffy quality, lack of inflection, or voice that is usually too loud or soft)
• Social behavior (at home and in school). Look for the child who
  • Is shy or hesitant in answering questions or joining in conversation
  • Misunderstands questions or directions; frequently says “huh?” or  “what?” in response to questions
  • Appears to ignore speech; hears “only what he wants to”
  • Is unusually attentive to speaker’s face or unusually inattentive to  speaker, or turns one ear to speaker
  • Has difficulty with listening activities such as storytime and following  directions
  • Has short attention span
  • Is distractible and restless; tends to shift quickly from one activity to  another
  • Is generally lethargic or disinterested in most day-to-day activities
  • Is considered a behavior problem—too active or aggressive, or too  quiet and withdrawn
• Medical indications. Look for the child who
  • Has frequent or constant upper respiratory tract infections, congestion  that appears related to allergies, or a cold for several weeks or months
  • Has frequent earaches, ear infections, throat infections, or middle ear  problems
  • Has had draining ears on one or more occasions
  • Is mouth breather and snorer
  • Is generally lethargic; has poor color

How to Screen

1. Observe current behavior related to speech and hearing.
2. Consult behavioral and medical history.
3. Consult audiologist or communication disorders specialist.

Vision, Which Includes

• Skills
• Acuity (ability to see at a given distance)
• Disease

Red Flags

• Eyes
  • Are watery
  • Have discharge
  • Lack coordination in directing gaze of both eyes
  • Are red
  • Are sensitive to light
  • Appear to cross or wander, especially when child is tired
• Eyelids
  • Have crusts on lids or among lashes
  • Are red
  • Have recurring sties or swelling
• Behavior and complaints
  • Rubs eyes excessively
  • Experiences dizziness, headaches, nausea on close work
  • Attempts to brush away blur
  • Has itchy, burning, scratchy eyes
  • Contorts face or body when looking at distant objects, or thrusts head forward; squints or widens eyes
  • Blinks eyes excessively; holds book too close or too far; inattentive  during visual tasks
  • Shuts or covers one eye; tilts head

How to Screen

1. Has child had an eye exam? If not, recommend one.
2. Screen using a screening tool appropriate for young children, such as the Snellen E chart or Broken Wheel cards.