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Book Assessment
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Signs & concerns
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Signs & concerns
If a child cannot play cooperatively, when should a frontline health worker escalate?
Cooperative play — sharing goals and taking turns — typically emerges by 3–4 years; before this, parallel play is normal. A frontline health worker should escalate to a developmental check when a child of 4 or older still cannot share a play goal, take turns or join other children, especially alongside delays in language, eye contact or responding to name. Escalation means early opportunity, not a diagnosis.
Read the answer AnswerWhen should a frontline worker escalate a coordination concern?
Coordination develops in a known sequence. A frontline health worker should escalate when a child clearly misses a motor milestone for their age, loses a skill once gained, shows one-sided weakness, floppiness or stiffness, or has coordination concerns alongside speech, hearing or social delays. Sudden change or lost movement needs same-day medical referral. This is timely routing, not a diagnosis — early review works best.
Read the answer AnswerWhen to escalate a child's counting difficulty
Counting develops gradually — rote counting around 2–3 years, true counting of objects closer to 4–5. A frontline worker should escalate for a developmental check when a child of 5 or older cannot count small sets with one-to-one matching, when number difficulty travels with delays in talking, understanding or play, when a skill is lost, or when a parent is worried. This is a reason to assess early, not a diagnosis.
Read the answer AnswerWhen to escalate a child's counting delay
Counting emerges gradually — rote-counting small numbers by 3–4 years, counting objects one-by-one by 4–5 years. A frontline worker should escalate when a child is well past the expected age, has had fair teaching and exposure, yet still cannot count or grasp small quantities — especially alongside delays in talking, understanding, attention or play, or when a parent or teacher is worried. This is a reason to refer for assessment, not a diagnosis.
Read the answer AnswerWhen should a frontline health worker escalate difficulty with craft participation?
Craft participation (joining in cutting, sticking, threading, drawing and shared making) reflects a child's hand skills, attention and social play. A frontline health worker should escalate to a developmental check when the difficulty is persistent across visits, clearly behind same-age peers, or travels alongside delays in speech, movement, social connection or self-care. This is not a diagnosis — it signals that an early, calm clinician review is wise, because early support works best.
Read the answer AnswerDaily living skills delay: when frontline workers should escalate
Frontline workers should escalate when a child's daily living skills (ICF d5 — feeding, dressing, washing, toileting) are clearly behind peers across several areas, when a skill once gained is lost, or when the delay travels with other concerns in talking, moving, hearing or understanding. A single lagging skill in a child with few chances to practise often responds to family coaching — re-check in 4–6 weeks. Broad delays, regression, paired developmental concerns, or suspected hearing/vision/seizure issues need prompt referral. This is routing, not diagnosis — early support works best.
Read the answer AnswerIf a child cannot manage dressing at the expected age, when should a frontline health worker escalate?
Dressing develops in stages — undressing near 1 year, helping by 2, loose clothes and big buttons by 3–4, and near-independence by 5. A frontline health worker should escalate when a child shows no steady progress over months, when dressing difficulty travels with delays in walking, hand use, speech or understanding, when a previously managed skill is lost, or when the family is worried. This signals a need to assess early — not a diagnosis.
Read the answer AnswerWhen Should a Frontline Worker Escalate Delayed Early Words?
Frontline health workers should escalate a child for a developmental check when there is no babbling or gesture by 12 months, no single words by 16–18 months, fewer than 50 words or no two-word phrases by 24 months, or any loss of words or social skills at any age. A hearing check comes first. These are escalation triggers, not diagnoses, and early referral matters because support works best when started early.
Read the answer AnswerEscalating emotional development concerns for frontline workers
Emotional skills — comforting, sharing joy, calming after upset, later naming feelings — unfold gradually with wide normal variation. A frontline health worker should escalate to a developmental check when a child consistently misses age-expected emotional milestones, loses a skill once present, or shows emotional differences alongside delays in talking, play or response to name. Escalate when a difference is persistent, worsening or accompanied by other delays — this is a referral, not a diagnosis.
Read the answer AnswerEscalating emotional inference concerns
Emotional inference — reading others' feelings from faces, voices and situations — develops gradually and varies widely. A frontline worker should escalate for a developmental check when a child consistently misses social-emotional milestones, shows little response to others' emotions, or when difficulty reading feelings travels with delays in talking, eye contact or play. Persistent or cross-domain concerns, family worry, or loss of a skill warrant referral now rather than later. This is a reason to assess early, not a diagnosis.
Read the answer AnswerWhen to escalate delayed emotional understanding
A frontline health worker should escalate for a developmental check when a child is clearly behind the expected age for emotional understanding (ICF b152) — not recognising or responding to feelings, not seeking comfort — and this persists, travels with other delays in language, social connection or play, or the parent is worried. Escalation routes the family to a clinician; it is never a diagnosis, and early support works best.
Read the answer AnswerIf a child cannot show empathy at the expected age, when should a frontline health worker escalate?
Empathy develops in stages across the early years, so a frontline health worker should escalate not for empathy alone but when reduced awareness of others' feelings persists well beyond the expected age and travels with other social-communication concerns — delayed speech, little eye contact, no response to name, no pointing, or loss of a skill. These are reasons to assess early, not a diagnosis. Trust the family's daily observations and route to a general developmental check.
Read the answer AnswerWhen to escalate concerns about a child's empathy development
Empathy develops gradually — toddlers show concern when others cry, and by 3–4 years many name feelings and comfort others. A frontline health worker should escalate to a developmental check not for one missed sign, but when reduced empathy travels with other concerns: little eye contact, few words, not responding to name, or no shared joy. This is a reason to assess early, not a diagnosis.
Read the answer AnswerEvent Description Delay: When Should a Frontline Worker Escalate?
A child usually begins describing a simple event in two-to-three words around 24–36 months. A frontline health worker should escalate to the PHC Medical Officer or a developmental check when this gap is clear and persistent, or when it travels with few words, poor eye contact, not following instructions, or loss of previously held skills. Escalate promptly — not at the next visit — if skills are lost, there is no response to sound, or the parent is distressed. This is early referral for support, not a diagnosis.
Read the answer AnswerEscalating Executive-Functioning Concerns
Executive functioning — holding instructions in mind, waiting, planning, switching tasks, managing frustration — matures slowly across childhood. A frontline ASHA/PHC worker should escalate to a developmental check not for one missed skill, but when difficulties are persistent, clearly behind peers, affect daily life or learning, or travel with delays in speech, attention or social connection. Escalation is a closer look, never a diagnosis, and early support works best.
Read the answer AnswerIf a child cannot make eye contact, when should a frontline health worker escalate?
Fleeting eye contact emerges by 6–8 weeks and social, shared gaze is established by 3–4 months. A frontline worker should escalate when a child consistently does not make eye contact by 4 months, or shows reduced gaze alongside no social smile by 3 months, no response to name by 6–9 months, or no pointing or shared attention by 12 months. Always rule out hearing and vision issues first. This is a reason for an early developmental check, not a diagnosis.
Read the answer AnswerWhen to escalate a child not learning “family values”
There is no expected age for learning "family values" — they grow across all of childhood through example, not a milestone schedule. A frontline health worker should escalate not on values, but on delays in the skills that let a child absorb family life: communication, social connection and play. Refer to the Medical Officer or a developmental check when a milestone is clearly missed, a skill is lost, or the family raises a concern — earlier is always better.
Read the answer AnswerWhen should a frontline worker escalate a fine motor delay?
Fine motor skills follow a predictable timeline. A frontline health worker should escalate when a child clearly misses age guideposts — no reach by ~6 months, no transfer by ~9 months, no pincer grasp by ~12 months, no scribble or 2-block stack by ~18 months — or when a skill is lost, one side is weak or stiff, or fine motor delay travels with gross motor, speech or social delay. This signals a developmental check, not a diagnosis, because early support works best.
Read the answer AnswerWhen to escalate concerns about fluid reasoning
Fluid reasoning — solving new problems and spotting patterns without being taught — grows steadily through early childhood, so one difficulty rarely worries. A frontline health worker should escalate to a developmental check when a child consistently struggles with simple new tasks for their age, especially alongside delays in language, play or daily skills, when there is no progress over follow-ups, or whenever a parent raises concern. Loss of a skill needs prompt referral. This is a referral signal, not a diagnosis — early support works best.
Read the answer AnswerWhen to escalate if a child cannot follow directions
Following directions grows in stages — name response and gesture-paired requests near 12–15 months, one-step instructions by 18–24 months, two-step by 3 years. A frontline worker should escalate when a child consistently fails age-appropriate instructions across settings, when it travels with delayed speech or poor name response, or when hearing is in question — and hearing is checked first. This is grounds to refer, not a diagnosis.
Read the answer AnswerFoot control delay: when frontline workers should escalate
Most children walk independently by around 18 months. A frontline health worker should escalate when a child is not bearing weight on the legs by ~12 months, not walking by 18 months, has lost a foot or leg skill once gained, or shows stiff, floppy, or one-sided leg movement at any age. These are reasons to assess early, not a diagnosis — and asymmetry, stiffness, or regression need prompt medical referral rather than watch-and-wait.
Read the answer AnswerWhen to escalate if a child isn't seeking friendships
Friendship seeking — wanting and approaching other children in play — develops gradually, so one missed moment is rarely a concern. A frontline health worker should escalate to a developmental check when a child consistently shows no interest in or response to peers, especially when this travels with delays in talking, eye contact, gestures or pretend play, or when a parent is worried. This is a referral signal, not a diagnosis — early support works best.
Read the answer AnswerWhen should a frontline worker escalate friendship-skill concerns?
Making friends is a skill that builds gradually — toddlers play alongside others, and true give-and-take friendships develop through the preschool and early-school years. A frontline worker should escalate to a developmental check when a school-going child consistently cannot join in, take turns, share or keep playmates, especially alongside delays in talking, eye contact or understanding feelings. This is not a diagnosis — it is an early, wise observation that opens the door to support.
Read the answer AnswerWhen should a health worker escalate a delay in game rule understanding?
Game rule understanding — turn-taking, waiting, following simple rules — usually develops between 3 and 6 years and varies with exposure. A frontline health worker should escalate for a developmental check when the difficulty persists past 5–6 years, clusters with other delays in speech, social connection or attention, or when the family is worried. A single lagging skill in a well-developing child usually warrants encouragement and review in 2–3 months, not immediate referral. Escalation means routing for assessment, never labelling the child.
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