Developmental History

Obtaining a thorough and systematic developmental history is one of the first steps to understanding a child’s level of functioning, identifying red flags for possible developmental problems, and documenting developmental trajectory over time. When taking a developmental history, the focus should be on the age of attainment of skills or milestones in different developmental domains.

The major domains of child development are:

• motor development

• speech and language development

• cognitive development

• social and emotional development

• adaptive skills

The CDC’s initiative Learn the Signs. Act Early provides a comprehensive review of developmental milestones that can be used to determine the specific questions to ask during a developmental history. Primary care providers should feel comfortable and knowledgeable about asking the right questions when they are concerned about a child’s development. In addition to obtaining a history pertaining to all developmental domains, primary care providers should collect information on birth history, medical and surgical history, and family and social history to determine potential causative factors. Inquiry about supportive services the child has received to date, as well as a thorough neurological examination, is important to inform subsequent medical recommendations.

In 2022, the CDC in collaboration with the American Academy of Pediatrics (AAP), updated the developmental milestones in Learn the Signs. Act Early. The updates are family friendly to help caregivers and other providers interpret the guidelines. The revisions reflect milestones that 75% of children (versus 50% previously) are expected to meet at certain ages. Additionally, checklists were added for children ages 15 and 30 months and included new social and emotional milestones. Overall, the revisions have made developmental expectations clearer to providers and families in an effort to avoid delays in diagnoses and access to care.

Motor Development

The physical developmental domain refers to the development of motor skills, including gross and fine motor skills, coordination, and balance.

Gross Motor Skills

A gross motor history can provide important information about conditions that are central neurologic or neuromuscular based.

Gross motor milestones: Clinicians should be familiar with motor developmental milestones when obtaining a gross motor history (e.g., raising head, sitting, crawling, walking, running, kicking and throwing balls, ascending and descending stairs).

Examples of questions about gross motor milestones may include the age at which a child:

• first sat unsupported

• crawled on their hands and knees

• walked independently

• reached other milestones (e.g., rolling, pulling to stand, cruising)

Examples of questions about a child’s motor coordination skills include the age at which a child:

• began to run

• kicked a ball

• threw a ball

If the child is old enough, information about motor development and coordination may be helpful, including:

• how the child ascends and descends stairs

• if and how they ride a tricycle or bicycle

Information also may be obtained about motor endurance. Limited endurance and easy fatiguability can be due to reduced muscle strength or tone, which are associated with certain medical and developmental conditions.

Fine Motor Skills

Parents are less likely to report concerns about delays in fine motor development than concerns about gross motor skills. Therefore, it is important to include questions about fine motor skills to identify delays.

Fine motor milestones: Fine motor skills include types of grasps, transferring in midline, handedness, drawing, certain play skills, and dressing.

Questions about fine motor skills are also age-dependent and include:

• type of grasp (e.g., raking, pincer) and pencil grasp (e.g., fisted, tripod)

• if or when the child developed handedness

• avoidance of fine motor tasks (may indicate an area of difficulty)

• functional skills (e.g., use of cutlery to feed, undressing and dressing, drawing, and playing)

Speech and Language Development

A speech and language history should include information about the child’s expressive and receptive language development, including areas of language morphology (structure and construction of words), syntax (grammar), semantics (meaning of language), and pragmatics (functional use of language). History also includes information about speech sound production and speech intelligibility, and use of nonverbal means to communicate (e.g., gestures, signs, or pictures). Some children may use alternative and augmentative communication (AAC) such as a communication device recommended by a speech-language pathologist. Reliable hearing testing is important to obtain when there are concerns about speech and language skills, even in the context of normal neonatal hearing tests. For information on speech and language development, see Communication Disorders in this rotation guide, and for more on hearing and vision screening, see Prevention and Screening in the Preventive/Well Child Care rotation guide.

Speech and language milestones: Pre-language and language development milestones include response to noise, smiling, laughing, cooing, babbling, imitating sounds, understanding common words, and responding to commands. A common misconception is that children exposed to multiple languages experience speech and language delay. Children learning multiple languages actually experience the same developmental stages as monolingual children and acquire all the other skills of the speech domain (e.g., gestures or nonverbal skills) at a normal age. Multilingual children should continue to fall within the normal age range of expressive language development. Importantly, the child’s combined vocabulary (in all the languages spoken) should be the same size as a similar-aged monolingual child.

• Expressive language is the language that the child uses to communicate. Questions about expressive language development should ascertain how the child communicated to others in infancy and how their language development progressed as they got older. Prelingual skills (e.g., time of cooing, babbling, jargon production) can provide useful information. Generally, parents remember their child’s first word with meaning. The goal is to determine if the child’s language progressed as expected or experienced a prolonged plateau or regression in language at any point. A plateau or regression in language may warrant further medical workup.

• Receptive language refers to the child’s understanding of language. Infants should understand “no” by age 4 to 6 months and respond to their name by 9 months. Parents most often raise concern about their child’s receptive language skills after the first year of life if the child does not follow simple instructions. Parents may report that their child does not listen to them. It is important to discern if the problem is due to a receptive delay, inattention, or hearing loss. Concerns about receptive language delay warrant further evaluation to rule out associated medical or behavioral issues.

Cognitive Development

Jean Piaget’s theory of cognitive development suggests that children move through different stages of mental development as they interact with the world, continually building new knowledge. Children learn and develop important skills while playing, and play skills often align with future language and cognitive development. The stages of play are:

• sensorimotor

• cause and effect

• early functional

• pretend play

Children begin to develop object permanence in infancy; followed by a sense of cause and effect, in which they become aware that an action of theirs can lead to an environmental effect; and then they develop functional and symbolic play skills that evolve into more-advanced pretend play skills.

Social and Adaptive Skills

Social Skills

Social skills emerge in infancy as infants develop social and emotional interactions with caregivers and then progress to interacting and playing with other children of similar age. Development of social skills often depends on the development of motor and language skills (i.e., the ability to ambulate and communicate promotes social interactions). Delayed ability to engage with others and atypical development of social skills are characteristic of children with autism spectrum disorder (see Autism Spectrum Disorder in the Pediatric Mental Health rotation guide).

Adaptive Skills

A child’s adaptive abilities are the skills they use to help themselves and become independent in their environment. Key adaptive skills include learning to feed, dress, and toilet independently. Adaptive skills can also include practical life skills such as handling money and understanding the concept of time. Although a child’s adaptive skills usually track with cognitive skills, developmental, psychosocial, and behavioral conditions exist in which there are discrepancies between cognitive and adaptive skill functioning (e.g., autism, anxiety, depression). Some children may have a high intellectual quotient (IQ) and yet need daily support in adaptive skills. Supports and qualifications for services are often based on the child’s intellectual and adaptive skills and where the child resides. Adaptive skills may be modified and improve over time with adequate supports in place.

Other Elements of the Developmental History

In addition to obtaining a developmental history pertaining to all domains, it is important for the primary care provider to collect information on:

• prenatal and birth history

• medical and surgical history

• family and social history (to determine potential causative factors)

• supportive services the child has received to date

• neurologic examination (may inform subsequent medical recommendations)

Prenatal and Birth History

The prenatal and birth history may provide clues to a potential etiology for the child’s developmental delays and identify risks to subsequent pregnancies.

Prenatal history:

• Conception: The prenatal history includes information on type of conception (natural or assisted reproductive technology [ART]).

• Complications: Information about prenatal, perinatal, and immediate postnatal complications should be explored. Prenatal complications may include maternal infections, including known exposure to viruses or infections that can impact fetal development, such as Zika virus, varicella-zoster virus, or cytomegalovirus (CMV). Other potential complications include gestational diabetes, clotting disorders, hypertension, and bleeding.

• Maternal exposure: Document if the mother took any medication(s) during the pregnancy, as well as exposure history to tobacco, alcohol, marijuana, or other illicit drugs.

• Fetal testing: Document any evaluation during the fetal period, such as ultrasounds, echocardiograms, or blood tests.

Birth history: The birth history should include the following information:

• the age of each biological parent at the time of birth

• the mother’s parity, including the number of miscarriages

• the delivery process, including fetal distress, Apgar scores, and estimated gestation age, as well as other problems during the delivery

• infant’s condition after delivery, including if the child was admitted to a neonatal intensive care unit (NICU) and for how long

• complications, including any concerns for hypoxia-ischemia, sepsis, intraventricular hemorrhage, seizures, congenital anomalies, or other complications

Medical and Surgical History

Information from a thorough medical and surgical history can guide further medical evaluations and provide clues about possible etiologies of developmental delay and an opportunity to screen for comorbidities, including:

• insults that occur in the pre-, peri-, or postnatal periods (including deprivation and genetic, metabolic, toxic, and infectious factors)

• history of seizures, head trauma, meningitis and encephalitis, or chronic medical conditions, including metabolic and genetic conditions

• serious acute illnesses, prolonged recovery from illnesses, regression of developmental skills with illness, or frequent hospitalizations

Advances in genetics have resulted in fewer developmental conditions that are considered idiopathic. Examples of gene-environment interactions that play a role in some developmental issues include the following:

• genetic factors: Down syndrome, fragile X syndrome

• metabolic factors: pyruvate dehydrogenase deficiency, severe hypoglycemia

• toxins: lead, alcohol

• infectious factors: encephalitis, meningitis

• deprivation: poverty, food insecurity

Family Medical History

A family history should explore conditions that are present in other family members. Ideally, a three-generation history should be obtained, with a focus on genetic disorders; neurodevelopmental diagnoses, such as autism and intellectual disability; psychiatric disorders; congenital anomalies; and history of recurrent miscarriages in the female members of the family. It can be helpful to know if any family members have a history of speech delay, difficulty learning in school, or attention deficit-hyperactivity disorder (ADHD). Families may not know if other family members have specific diagnoses, although they may provide insight if they have a general idea of the functioning of other relatives. General questions can be asked about whether any family members had developmental delays or needed special education services in school or other supports throughout childhood.

Social History

Evaluation of a child’s social history and environment should emphasize social determinants of health, including information about abuse, neglect, foster care placement or adoption, food insecurity, homelessness, and other high-risk social situations. For an overview of social determinants of health, see Community and Societal Pediatrics in the Preventive/Well Child Care rotation guide.

Supports and Services

Some children who present with developmental delays may already be receiving developmental services to support their needs. The clinician should ask what types of interventions and supports the child currently receives and has received in the past. Many children may have received therapies through early intervention services until the age of 3 years. For children older than 3 years, information on the child’s individualized education program (IEP) or 504 plan should be documented, along with types of therapies they are receiving in school and privately.