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Cognitive
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Signs & concerns
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Signs & concerns
When to escalate a child's memory retention concern
Memory retention develops gradually, so one slow patch rarely needs alarm. A frontline worker should escalate to a doctor or developmental check when a child consistently fails to recognise familiar people or follow daily routines past the expected age, when memory difficulty travels with delays in talking, understanding or play, or when a previously held skill is lost. Sudden memory loss, staring spells, or memory change after illness or a fall need urgent medical review first.
Read the answer AnswerWhen to escalate concerns about a child's mental effort
Mental effort (ICF d1) covers how a child focuses, persists and learns. A frontline worker should escalate when, for the child's age, they consistently cannot settle to a simple task, show little curiosity or persistence, fall clearly behind peers in learning, or show these alongside delays in talking, understanding or play — and always when a parent is worried or a skill is lost. Referral is a reason to assess early, never a diagnosis.
Read the answer AnswerWhen to escalate if a child cannot follow multi-step tasks
Following multi-step instructions develops gradually — two-step tasks around 2–3 years, three-step closer to 3–4 years. A frontline health worker should escalate for a developmental check when a child consistently cannot follow age-appropriate instructions despite clear prompts and good hearing, when delays in talking or understanding travel alongside, or when families are worried. Rule out hearing first. This is a reason to assess early, not a diagnosis.
Read the answer AnswerObject matching delay: when to escalate
Object matching usually emerges around 18–24 months. A frontline health worker should escalate for a developmental check when a child is clearly past the expected window with no matching at all, has lost a skill, or shows matching difficulty alongside delays in language, play, attention or social connection — or whenever the family is worried. This is a referral for assessment, not a diagnosis, and early review leads to the best outcomes.
Read the answer AnswerObject permanence delay: when a frontline worker should escalate
Object permanence — knowing a hidden object still exists — emerges around 8–12 months and is established by 18 months. A frontline health worker should escalate when a child shows no searching for hidden objects past 12 months, when the gap persists to 18 months, or when it travels with delays in eye contact, babbling, response to name or grasping. This is a routing decision, not a diagnosis, and early support works best.
Read the answer AnswerWhen to escalate object recognition delay
A child who isn't recognising familiar objects at the expected age — roughly 9–12 months for looking and reaching, 12–18 months for knowing items by use, 18–24 months for picking a named object — warrants escalation when clearly behind, when there's no progress over a few weeks, or when vision, hearing, language or social concerns travel alongside. Frontline workers should rule out vision and hearing first, then refer to the PHC medical officer and a developmental assessment. This is a referral decision, never a diagnosis.
Read the answer AnswerWhen to escalate a child's organisation-skill concern
A frontline health worker should escalate a child's organisation-skill concern when there is a clear, persistent gap from same-age peers seen across visits — not a single missed milestone. Escalate promptly when the gap travels with delays in language, attention or motor skills, when a skill is lost, or when a parent is worried. This is a routing decision for screening, never a diagnosis; early referral lets a clinician confirm or reassure.
Read the answer AnswerWhen to escalate concerns about a child's organisation skills
Organisation skills — planning, sequencing and completing everyday tasks — develop gradually and vary between children. A frontline health worker should escalate for a developmental check when difficulties are persistent, clearly behind same-age peers, interfering with daily routines or schooling, or travelling with delays in language, attention, motor skills or learning. This is a reason to assess early, not a diagnosis — early support works best.
Read the answer AnswerWhen should a frontline health worker escalate a pattern-recognition concern?
Pattern recognition develops gradually, so one missed skill is rarely a worry alone. Frontline health workers should escalate to a medical officer or developmental check when difficulty spotting or copying simple patterns clusters with other delays in language, play or daily skills, when there is no progress over visits or loss of a skill, or when a caregiver raises concern. This is early routing for monitoring, not a diagnosis — and early support works best.
Read the answer AnswerWhen to escalate a problem-solving concern
A frontline health worker should escalate a child's problem-solving concern when a clearly age-expected skill is absent, when problem solving lags alongside language, social or motor domains, when a previously held skill is lost, or whenever a caregiver is worried. These are reasons to refer for a developmental check — not a diagnosis. At every age, early review is safer than watch-and-wait, because timely support works best.
Read the answer AnswerWhen to escalate quantitative reasoning concerns
Quantitative reasoning develops gradually, so one missed milestone rarely means trouble. A frontline worker should escalate when a child around 5–6 years cannot reliably count, compare more and less, or recognise small quantities despite everyday practice, when there is no progress over a few months, or when number difficulty travels with delays in language, attention or play. Escalation routes the child to a developmental check — it is not a diagnosis, and early support works best.
Read the answer AnswerWhen to escalate if a child cannot compare quantities
Comparing quantities — knowing "more" from "less" — usually emerges between about 2 and 4 years. A frontline worker should escalate for a developmental check when a child is clearly behind same-age peers, shows no progress over three to six months despite everyday exposure, or when the difficulty travels with delays in talking, following instructions, play or attention. First rule out hearing and vision; then route on. This is a reason to assess, not a diagnosis.
Read the answer AnswerWhen to escalate a child's sequential memory concern
Sequential memory develops gradually, so one miss is rarely a worry. A frontline health worker should escalate to a developmental check when a child's difficulty remembering steps, sounds or routines is persistent, clearly behind same-age peers, and accompanied by delays in speech, understanding or daily routines — or when a parent is concerned. Urgent signs such as staring spells or regression need prompt medical referral. This is not a diagnosis but a wise, early opportunity for support.
Read the answer AnswerWhen to escalate a shape-recognition concern
Most children match and name simple shapes between 2.5 and 4 years. A frontline worker should escalate when a child of 3.5–4 years still cannot match or sort basic shapes despite everyday exposure, or at any age when shape difficulty comes with delays in vision, language, play or attention. First rule out hearing and vision, confirm the child has had real exposure to shapes, then refer for a developmental check — this is early assessment, not a diagnosis.
Read the answer AnswerWhen to escalate short-term memory concerns
A frontline health worker should escalate not on a single missed task but on a persistent pattern: a child who consistently cannot hold and use simple age-appropriate information — following instructions, recalling familiar names or objects — especially alongside delays in talking, attention, play or learning, or when the family is worried. Refer to the Medical Officer or a developmental check when difficulties persist over weeks and widen the gap with peers. This is a referral decision, never a diagnosis, and early referral opens early support.
Read the answer AnswerSimple Planning Delay: When a Frontline Worker Should Escalate
Simple planning — working out the steps to reach a goal — develops gradually in the toddler and preschool years. A frontline health worker should escalate for a developmental check when a child consistently cannot sequence familiar everyday tasks at the age peers manage them, when this travels with delays in language, play or self-help, or when a skill once present is lost. This flags the need for early assessment — not a diagnosis — because early support works best.
Read the answer AnswerWhen should a health worker escalate delayed social awareness?
Social awareness develops over the first two to three years. A frontline health worker should escalate to a medical officer or developmental check when a child misses several social milestones for their age, shows no progress over 2–3 months, or loses a skill once had. Refer sooner if the family is worried or there is birth-history risk. This is not a diagnosis — it opens an early door, when support works best.
Read the answer AnswerWhen to escalate a child who isn't sorting and categorising
Sorting and categorising emerges around 2–3 years, with steadier skill by 3–4. One late milestone alone rarely needs action. A frontline worker should escalate to a developmental check when a child of 3.5–4 years shows no matching or grouping, when the lag travels with delays in language, play, attention or social connection, on any regression, or when a parent is persistently worried. This is early assessment, not a diagnosis.
Read the answer AnswerWhen to escalate a spatial reasoning concern
Spatial reasoning develops through everyday play with wide normal variation. A frontline health worker should escalate when a child is clearly behind age-expected play skills (stacking, shape-sorting, puzzles, copying simple shapes), when the gap persists despite chances to play and learn, or when it travels with other delays in language, motor or daily skills — or whenever a parent is worried. This is grounds for an early developmental check, never a diagnosis.
Read the answer AnswerWhen to escalate a child's story-recall difficulty
Story recall — retelling a simple story — usually emerges around 3–4 years and strengthens by 5–6. A single difficulty is not a concern. A frontline health worker should escalate when a child consistently cannot retell an age-appropriate story across visits, is clearly behind same-age peers, or shows added delays in talking, understanding, attention or memory. This is not a diagnosis — it is an early, sensible referral for a clinician's closer look.
Read the answer AnswerWhen to escalate a sustained attention concern
Frontline health workers should escalate a child's attention difficulty when it is persistent across settings, clearly behind same-age peers, interferes with learning or daily routines, or travels with delays in speech, social connection or activity control. For under-3s, routine developmental monitoring is appropriate; from school-entry age, persistent cross-setting concerns warrant a structured review. Always rule out hearing, vision and seizure-type episodes first. This is a reason to assess early, never a diagnosis.
Read the answer AnswerWhen should a frontline worker escalate task-completion delay?
A frontline worker should escalate not on one missed task but on a persistent, age-discrepant pattern: a child who repeatedly cannot follow simple instructions or finish age-appropriate tasks over weeks, especially when this travels with delays in attention, language, play or self-care, or with loss of a skill. A single off day is monitoring; a steady cluster is a referral. This is screening, not diagnosis — early routing brings early, effective support.
Read the answer AnswerWhen should a frontline health worker escalate task-initiation delay?
Task initiation means starting an activity independently. A frontline ASHA or PHC worker should escalate to the medical officer or a developmental check when a child consistently cannot begin age-typical tasks even with prompting, when the difficulty travels with delays in language, social connection or motor skills, or when a skill once present is lost. This is a screen, not a diagnosis — early routing means early support, and a parent's concern is itself a reason to refer.
Read the answer AnswerWhen should a frontline worker escalate task management concerns?
Task management — starting, planning, finishing and shifting between activities — develops gradually through the toddler and preschool years. A frontline worker should escalate not on a single missed milestone but on a persistent pattern: the child consistently cannot follow age-expected instructions, never finishes familiar tasks, or cannot shift activities without major distress, especially alongside language, attention or play delays. Refer early to a developmental check; this is screening, never diagnosis.
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