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Book Assessment
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Signs & concerns
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Signs & concerns
Social referencing: when a frontline worker should escalate
Social referencing — a baby checking a trusted adult's face for cues in uncertain moments — emerges around 8–10 months and is well established by 12–14 months. A frontline health worker should escalate for a developmental check when a child over 12 months consistently shows no checking-back, especially alongside no response to name, little eye contact, no pointing, or any loss of skills. This is a reason to refer early, not a diagnosis.
Read the answer AnswerDifficulty sharing: when should a frontline worker escalate?
Sharing develops slowly — true turn-taking usually only begins around 2–3 years, and reluctance to share is normal into the preschool years. A frontline worker should escalate not for a single missed sharing behaviour, but when difficulty relating to others travels with broader social-communication concerns (no pointing, no joint play, no response to name, regression) or a parent's persistent worry. This is a referral for a developmental check, never a diagnosis.
Read the answer AnswerEscalating Social Understanding Delays
Frontline health workers should escalate a child for a developmental check when social-understanding milestones (responding to name, shared attention, eye contact, turn-taking, social play) clearly lag for the child's age, when a parent raises a worry, when a gained skill is lost, or when social differences appear alongside delays in talking or play. Escalation is a referral for closer assessment, not a diagnosis, and early action gives the best outcomes.
Read the answer AnswerWhen to escalate concerns about a child's sprinting ability
For an ASHA/PHC worker, sprinting is not a screening milestone — it sits at the top of a long motor staircase. Escalate instead on the foundational red flags: not walking by 18 months, not running steadily by ~2 years, frequent falling, asymmetry, persistent tip-toe walking, or loss of a skill once gained. These are reasons to refer for a developmental check, not a diagnosis — early support works best.
Read the answer AnswerWhen 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 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 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 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 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 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 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 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.
Read the answer AnswerWhen to escalate a child's delay in understanding
A frontline health worker should escalate when a child understands clearly less than peers and the gap persists — for example no response to name or simple words by 18 months, or not following one-step instructions by 2 years in the home language. Any loss of understanding once present needs prompt referral, and hearing should always be checked first. This is a reason to assess early, never a diagnosis.
Read the answer AnswerWhen should a frontline health worker escalate a speech delay?
A frontline health worker should escalate when a child misses key speech milestones — no babbling by 12 months, no single words by 16–18 months, no two-word phrases by 24 months — or shows any loss of words or social skills at any age. Parent worry alone justifies referral. Always pair the referral with a hearing check, since undetected hearing loss often underlies speech delay. Early referral is an opportunity, not a diagnosis.
Read the answer AnswerWhen to escalate a verbal-knowledge delay
A frontline health worker should escalate a verbal-knowledge concern when a child clearly lags age milestones — no babble or gestures by 12 months, no words by 18 months, fewer than ~50 words by 24 months — or when words are lost, hearing is in doubt, or the family is worried. Check hearing first and refer early for a developmental assessment; this is screening, not diagnosis, and early support works best.
Read the answer AnswerWhen to escalate a child's verbal reasoning delay
Verbal reasoning develops gradually through the preschool years. A frontline health worker should escalate for a developmental check when a child is clearly behind peers in understanding or using language, isn't gaining new words or ideas over time, has lost a skill, or shows language gaps alongside hearing or social concerns. Always check hearing first. This signals early assessment, not a diagnosis.
Read the answer AnswerWhen to escalate vestibular processing concerns
Vestibular processing — balance and movement sense — develops gradually, so there is no single pass-or-fail age. A frontline health worker should escalate to a developmental check when balance or movement difficulties persist beyond the expected age and interfere with play, walking or safety, especially alongside motor, speech or social delays. Sudden unsteadiness, head tilt or dizziness with vomiting needs prompt medical review. This guides early assessment, never diagnosis.
Read the answer AnswerWhen should a frontline worker escalate visual processing concerns?
Visual processing develops steadily, so there is no single failure age. Frontline workers should escalate when a child does not fix on or follow a face by 2–3 months, has eyes that do not move together by 6 months, or shows a white/cloudy pupil, wobbling eyes, strong light sensitivity, head-tilting, or bumping into things — refer same-day for white pupil or wobbling eyes. These are reasons to refer early, not a diagnosis, because vision concerns are time-sensitive.
Read the answer AnswerWhen to escalate a visual-reception concern
If a child is not meeting visual-reception milestones at the expected age, a frontline health worker should escalate to the PHC Medical Officer when the gap is clear or does not resolve at a short follow-up. Escalate the same week for red flags: no fixing or following a face by 3 months, no tracking by 4 months, a white reflex, constantly wandering or misaligned eyes, or loss of a skill. This is early routing, not a diagnosis.
Read the answer AnswerWhen to escalate visual-spatial processing concerns
Visual-spatial processing develops gradually, so occasional difficulty is normal. A frontline health worker should escalate to a developmental check when the difficulty is persistent for age, clearly behind peers, affecting everyday play or self-care, or travels with other delays. Always rule out a vision problem with an eye examination first. This is a reason to assess early, not a diagnosis.
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