Red Flag Guidelines for Behavioural and Neuro Development Assessment (With exclusions for Online Assessments)

Red Flags at any age1-2

  1. Strong parental concerns about child’s development/ Behaviour/ Learning.
  2. Lack of response to sound or visual stimuli.
  3. Poor interaction with adults or other children.
  4. Lack of, or limited eye contact.
  5. Differences between right and left sides of body in strength, movement or tone.
  6. Marked low tone (floppy) or high tone (stiff and tense) and significantly impacting on developmental and functional motor skills.
  7. Significant loss of skills.
  8. Scholastic underachievement.

Key questions to ask parents:

  1. “Do you have any concerns about your child’s development? Behaviour? Learning?”*
  • “What changes have you seen in your child’s development since your last visit?”
  • Asking about age-specific skills in the various domains of development (ie, gross motor, fine motor, adaptive [self-help], cognitive/academic, communication [receptive and expressive language], social-emotional):
    • 0 through 12 months (Annexure)
    • 12 through 24 months (Annexure)
    • 2 through 3 years (Annexure)
    • 4 through 8 years (Annexure)
  • Assess age-specific motor skills (Annexure) during well-child visits as part of developmental surveillance, as recommended by the AAP Neuromotor Screening Expert Panel.3

*absence of parental concern does not rule out the possibility of serious developmental delays.

Observing Parent – Child Interaction:

Observation of the parent-child interaction may aid in identifying children with delayed development. It is essential to note certain features of child and parent-child interaction, like

  • the warmth, caring, and responsiveness of the parent to the child’s cues, as well as
  • the extent to which the child looks to the parent for comfort and support.4

Identifying the Presence of Risk Factors:

Children with established risk factors (Environmental, genetic, biological, social, and demographic factors (described below) may be referred directly for developmental evaluation

  • Risk factors for developmental and behavioral problems include:5-9
  • Prenatal exposures (eg, infections, alcohol, smoking)
  • Birth complications (eg, prematurity or low birth weight)
  • Perinatal infections (eg, herpes simplex virus, Zika virus)
  • Medical conditions (eg, lead poisoning, congenital heart disease)
  • Genetic conditions (eg, Down syndrome, fragile X syndrome)
  • Adverse childhood or family experiences (eg, poverty, including housing or food insecurity; exposure to discrimination; abuse or neglect)
  • Parental unemployment or mental health problems (eg, depression, anxiety, substance use)
  • Parents with limited education/literacy
  • Teenage parents

At 9-, 18-, or 24/ 30-Month Visit?

In the absence of established risk factors or parental concerns, a general developmental screen is recommended at the

  • 9-
  • 18-, and
  • 24/ 30-month visits.

Nine months of age:

At 9 months of age, many issues may be identified, involving:

  1. Motor skills development
  2. Visual and hearing abilities
  3. Social and nonverbal communication, including vocalizations and gestures
  4. Early communication skills, like eye contact, orienting to name being called, or pointing, may be emerging— evidence suggests symptoms of autism, such as lack of eye contact, orienting to name being called, or pointing, may be recognizable in the first year of life.

Eighteen months of age:

Delays in communication and language development are often evident by 18 months of age.

Mild motor delays that were undetected at the 9-month screening may be more apparent at 18 months of age.

Thirty months of age:

By 24$/ 30 months of age, most motor, language, and cognitive delays may be identified. ($ – in case 30 months visit is not possible for patient then an assessment at 24 months can be done).

The AAP recommends that, in addition to a general developmental screening tool, an autism-specific tool^ should be administered at 18- and 24-month visits for all children. (^-M-CHAT (Modified Checklist for Autism in Toddlers). This is easily available online for all health care providers.

Children ≥ 4 years

  • Developmental-behavioral screening at the four-year visit should focus on   school readiness
    • social-emotional well-being,
    • family engagement in the child’s education,
    • promotion of the five Rs [reading, rhyming, routines, rewards, relationships] and   risk factors for developmental problems.10
  • Screening at age 4 years provides the opportunity for remediation before kindergarten entry to optimize successful kindergarten participation and peer interaction.11

Children ≥ 5 years

  • To screen asymptomatic children ≥5 years annually for mental health disorders and impaired psychosocial functioning with a validated behavioral screening test.12
  • Additional indications for mental health screening include:
    • Psychosocial concerns identified by the family
    • Family disruption
    • Poor school performance
    • Behavioral difficulty
    • Recurrent somatic complaints
    • Involvement of a social service or juvenile agency


  1. Jennifer Aites, Alison Schonwald, Developmental-behavioral surveillance and screening in primary care. Section Editor: Marilyn Augustyn; Deputy Editor: Mary M Torchia. htpps://
  2. Verma M, Singh T, Gupta I, Gupta V. Behavioral problems in school-going children: implications for medical teachers in developing countries. Educ Health (Abingdon). 2001;14(2):309-11. doi: 10.1080/13576280110051082. PMID: 14742030.
  3. Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev 1992; 13:453.
  4. Sameroff AJ, Seifer R, Barocas R, et al. Intelligence quotient scores of 4-year-old children: social-environmental risk factors. Pediatrics 1987; 79:343.
  5. King EH, Logsdon DA, Schroeder SR. Risk factors for developmental delay among infants and toddlers. Child Health Care 1992; 21:39.
  6. Slomski A. Chronic mental health issues in children now loom larger than physical problems. JAMA 2012; 308:223.
  7. McPhillips M, Jordan-Black JA. The effect of social disadvantage on motor development in young children: a comparative study. J Child Psychol Psychiatry 2007; 48:1214.
  8. Ozkan M, Senel S, Arslan EA, Karacan CD. The socioeconomic and biological risk factors for developmental delay in early childhood. Eur J Pediatr 2012; 171:1815.
  9. Nelson BB, Dudovitz RN, Coker TR, et al. Predictors of Poor School Readiness in Children Without Developmental Delay at Age 2. Pediatrics 2016; 138
  10. Individuals with Disabilities Education Act (Accessed on November 06, 2020).
  11. Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev 1992; 13:453.
  12. Lipkin PH, Okamoto J, Council on Children with Disabilities, Council on School Health. The Individuals With Disabilities Education Act (IDEA) for Children With Special Educational Needs.Pediatrics 2015; 136:e1650.
  13. Vitrikas K, Savard D, Bucaj M. Developmental Delay: When and How to Screen. Am Fam Physician. 2017 Jul 1;96(1):36-43.
  14. Mukherjee SB, Aneja S, Krishnamurthy V. et al. Incorporating developmental screening and surveillance of young children in office practice. Indian Pediatr 51, 627–635 (2014).