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Signs & concerns
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Signs & concerns
When to escalate a squatting-balance delay
Most children squat, balance and rise without using their hands by about 18–24 months. A frontline health worker should escalate when a child is well past this and still cannot squat-and-balance, must push off to stand, has lost a skill, or shows stiffness, floppiness or trouble walking. These are reasons to refer for a developmental and medical check — not a diagnosis — because early review catches treatable causes and supports best outcomes.
Read the answer AnswerStair climbing delay: when a frontline worker should escalate
Most children climb stairs with help around 18 months and more independently by 24–36 months. A frontline health worker should escalate to the Medical Officer when a child of 18 months or older cannot climb stairs even with a hand held, when walking is delayed beyond 18 months, when a motor skill once had is lost, or when stair difficulty comes with floppiness, stiffness, frequent falls, asymmetry or other delays. This means assess early — not a diagnosis.
Read the answer AnswerWhen to escalate delayed standing balance
Standing balance usually settles between 11 and 15 months, with independent standing by 18 months. Frontline workers should escalate for a developmental check if a child cannot stand with support by 12 months, cannot stand alone by 18 months, has lost a standing skill, or shows stiff/floppy legs, asymmetry or tight toe-walking. A missed gate plus a quality or asymmetry flag matters most. This is a reason to assess early, not a diagnosis.
Read the answer AnswerWhen should a frontline health worker escalate a static balance delay?
Static balance develops on a broad timeline, so a frontline health worker should escalate when a child clearly misses the expected milestone window, when balance is worsening rather than improving, or when poor balance travels with other delays or warning signs such as abnormal muscle tone, one-sided weakness, frequent falls, or loss of a previously held skill. This is a screen-and-refer decision, not a diagnosis. Prompt medical review is needed for any sudden loss of skill or stiffening-and-staring episodes.
Read the answer AnswerWhen to escalate stereotyped behaviours in a child
Most repetitive movements in young children are typical self-soothing and fade with growth. A frontline health worker should escalate to a developmental check when the movements cause self-injury, are very hard to interrupt, crowd out play and learning, or travel with delays in talking, social connection or motor skills. Any sudden new movement or stare-and-stiffen episode needs prompt medical review. This is a reason to assess early — not 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 Delayed Storytelling Skills
Storytelling skills typically emerge between 3 and 5 years, growing from simple sentences into linked events with a beginning, middle and end. A frontline health worker should escalate for a developmental check when a child of 4–5 years cannot sequence two or three connected ideas, when storytelling lags alongside other language or social delays, or when a family is worried. Always rule out hearing first. This is a referral for early support, not a diagnosis.
Read the answer AnswerWhen to escalate a delay in a child's postural support
If a child cannot support themselves at the expected age, a frontline health worker should escalate at the next screening visit, or sooner if delay is clear: no head control by 4 months, not sitting with support by 6 months or alone by 9 months, or not bearing weight by ~12 months. Refer urgently the same day for floppiness, stiffness, asymmetry, or loss of a skill. These are reasons to assess early, not a diagnosis.
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 to escalate tactile processing concerns
Tactile processing — how a child makes sense of touch — varies widely in early childhood, so one observation is rarely the full picture. A frontline health worker should escalate to a developmental check when touch differences are persistent and distressing, interfere with feeding, dressing, play or learning, or come with delays in talking, movement or social connection. This is not a diagnosis but a reason to assess early, because timely support works best.
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.
Read the answer AnswerWhen to escalate task monitoring concerns
Task monitoring — keeping track of a step-by-step activity and self-correcting — grows gradually in early childhood. A frontline health worker should escalate to a developmental check when a child consistently cannot follow or fix age-appropriate steps, when the gap is widening, or when it travels with delays in language, attention, play or movement. This is a reason to assess early, not a diagnosis.
Read the answer AnswerWhen should a frontline worker escalate delayed task participation?
A frontline health worker should escalate when a child's difficulty joining age-expected everyday tasks is persistent, clearly behind peers, paired with delays in talking, moving or social connection, or when a parent is worried. Use the routine developmental checklist at each contact and refer to the Medical Officer or a developmental centre without waiting. This is an early referral, not a diagnosis — early support works best.
Read the answer AnswerWhen to escalate poor task persistence in a child
Task persistence (ICF b152) grows with age, so brief lapses alone are normal. A frontline worker should escalate to the medical officer when poor persistence is well below age expectation, is seen across home and anganwadi, persists over weeks despite an interesting calm activity, or comes with delays in speech, social connection, play or learning. First rule out hunger, sleep, illness, hearing or vision issues. This is a reason to assess early, not a diagnosis.
Read the answer AnswerWhen should a frontline worker escalate a task-responsibility delay?
Self-care and daily-task milestones (ICF d5) grow gradually, so a single missed task rarely matters. A frontline worker should escalate when a child is persistently behind peers across several routines, shows no progress over three to six months, has delays alongside in language or movement, or has lost a skill once managed. This is a reason to assess early, not a diagnosis — and early support works best.
Read the answer AnswerIf a child cannot keep age-expected task speed, when should a frontline worker escalate?
Most children who are slow with everyday tasks catch up with practice. A frontline health worker should escalate to the Medical Officer or a developmental check when slow task speed is clearly behind the local age norm, isn't improving over a few weeks, travels with delays in talking, movement, understanding or play, or whenever a parent is worried. Any loss of a previously held skill needs prompt review. This is a signal to assess, not a diagnosis — early support works best.
Read the answer AnswerWhen to escalate a delay in temporal concepts
Temporal concepts (now, later, before, after, yesterday, tomorrow) emerge gradually between ages 3 and 6. A frontline health worker should escalate when a child beyond age 5–6 still cannot use or understand everyday time words or follow time-order instructions, especially alongside broader language delays. This signals the need for an early developmental check, not a diagnosis.
Read the answer AnswerWhen to escalate a child who cannot tiptoe balance
Tiptoe balance usually appears between about 3 and 4 years. A frontline worker should reassure and re-check when it is simply not yet present in an otherwise active child, but escalate to the medical officer when the delay persists past the expected window, comes with other gross-motor lags, asymmetry, tight-heeled toe-walking, or any regression. This is structured routing, not a diagnosis — early review gives the best opportunity for support.
Read the answer AnswerToe-Walking: Frontline Escalation Guide
Toe-walking is usually a normal early phase that settles by around age 2. A frontline health worker should escalate to the Medical Officer or a developmental review when it persists past 2–3 years, occurs on one side only, comes with calf stiffness or an inability to put the heel flat, or travels alongside delays in walking, talking or social connection. This is an early-assessment decision, not a diagnosis.
Read the answer AnswerWhen should a frontline health worker escalate a toileting-skills delay?
Toilet training usually begins at 18–30 months, with many children dry by 3–4 years and some later — much of this is normal. A frontline health worker should escalate when a child is well past 4 years with no daytime control, loses skills after learning them, shows pain, straining, blood or constant wetness, or when toileting delay comes with other developmental delays. Physical or urinary signs need prompt medical review first; broader delays warrant an early developmental check — a reason to assess, never a diagnosis.
Read the answer AnswerWhen to escalate transition difficulties in a child
Brief upset at transitions is normal for toddlers. A frontline health worker should escalate for a developmental review when a child aged 3 or more still has intense, prolonged distress at almost every change, does not improve with simple supports like warnings or picture schedules, or when transition difficulty travels with delays in talking, social connection, play or following instructions. This means assess early — not a diagnosis.
Read the answer AnswerWhen to escalate delayed turn-taking skills
Turn-taking emerges through the first and second years and matures in the preschool years. A frontline health worker should escalate to a developmental check when turn-taking is clearly behind for age, not improving with everyday play over a few weeks, or comes with delays in talking, eye contact, responding to name or shared play. This is a reason to assess early, not a diagnosis.
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