The present article serves as a quick office reference for clinicians, providing anticipatory guidance about the cognitive and social-emotional development of newborns, and children up to five years of age. The present review links recommendations to specific evidence in the medical literature, citing sources of developmental standards and advice, so that these may be further explored if desired. Practising primary care providers have indicated that these are areas of child development that are not well addressed by training and other available resources. The present article includes parenting information on important clinical presentations with which clinicians may be less familiar, such as promoting attachment, prosocial behaviours, healthy sleep habits, self-discipline and problem-solving; as well as on managing behaviours that are part of normal development, such as separation anxiety, tantrums, aggression, picky eating and specific fears. Information on the development of language, literacy and socialization are also included.
Keywords: Child development, Child guidance, Evidence-based practice, Preventive psychiatry, Problem solving, Psychological adaptation
Le présent document se veut un aide-mémoire pour les cliniciens qui donnent des conseils préventifs sur le développement cognitif et socio-affectif des enfants de la naissance à cinq ans. Il lie les recommandations à des données probantes précises contenues dans les publications médicales et cite les sources des normes et des conseils en matière de développement afin de les consulter, au besoin. Il s’agit de domaines du développement des enfants qui, selon les dispensateurs de soins de première ligne en exercice, sont mal explorés pendant la formation et dans les ressources accessibles. Le présent article contient de l’information à l’intention des parents et des présentations cliniques importantes que les cliniciens connaissent peut-être moins bien, tels que la promotion de l’attachement, les comportements qui favorisent la socialisation, de saines habitudes de sommeil, l’autodiscipline, la résolution de problèmes et la gestion de comportements qui font partie d’un développement normal, comme l’angoisse de la séparation, les crises de colère, l’agressivité, les caprices alimentaires et des peurs précises. Le développement du langage, l’alphabétisation et la socialisation sont également abordés.
Anticipatory guidance for development is education provided to parents in order to promote optimal developmental outcomes. Milestones are specific developmental attainments that occur in a predictable sequence over time, reflecting the interaction of the child’s developing neurological system with its environment. Each milestone does not correspond to a single point in time, but rather a range. When a milestone has not occurred by the time most of the population has attained it, usually 95% or 2 SD from the mean, it is described as delayed. Knowing the sequence of milestones allows professionals to help families understand what their child is currently doing and what comes next, so as to anticipate common developmental patterns, especially those that may prove difficult or puzzling to parents, and suggest parenting strategies demonstrated to be effective. Responsive parenting is one of the most important factors promoting healthy cognitive and social-emotional development (1,2). Evidence indicates that learning or behavioural difficulties are experienced by almost 30% of children (1). Such difficulties can affect social adjustment and physical health throughout childhood and into adulthood (3). Primary care clinicians are the most common professionals sought by parents for child-rearing advice during the preschool years (4), and physicians are encouraged to provide this advice during well-child and immunization appointments (5,6).
This ‘anticipatory guidance’ document is intended for use by clinicians during developmental surveillance at well-child visits, and its age intervals match the well-baby visit schedule for Canada. It can be used in conjunction with a health maintenance checklist such as the “Rourke Baby Record” . The present document serves as a quick office reference for the educational content required to promote cognitive and social-emotional development, and for their corresponding milestones. The reference is for clinician use and is not intended as a parent handout. The Canadian Paediatric Society offers health information for parents that includes related topics such as promoting literacy, using positive discipline and helping children deal with their fears.
The present article can serve as a model to help clinicians better understand and recognize markers of cognitive and social-emotional development in young children. The anticipatory guidance in this document is based on the typical development at each chronological age (7,8). Corresponding milestones in the domains of cognitive and social-emotional development are outlined in Tables 1 and and2 2 (7–14). The separation of cognitive and social-emotional milestones into discrete categories is sometimes artificial because the two domains are inextricably linked. The milestones tables generally use the upper limits of the normal range to place each attainment, with the age range of attainment in brackets. While many people are quite aware of the chronological sequences for gross motor, fine motor and speech-language skills, knowledge about the less visible domains of cognitive and social-emotional development is often limited, for both physicians and parents (1,4,15–18), and has been missing or inadequate in the charts and references used by physicians for training and clinical work. There is a great need for physicians to be familiar with the early signs of social and/or cognitive impairment that might be the first indicators of conditions such as autism or intellectual disability, so that they can refer such children for further assessment and intervention. The present document should not be used as a developmental screening tool. Clinicians should use more specific and validated instruments for this purpose, such as the “Parents’ Evaluation of Developmental Status” (PEDS) or the “Ages and Stages Questionnaire” (ASQ), which have moderate to high levels of sensitivity and specificity.
Cognitive and social-emotional milestones, newborn to 12 months of age
| Age | Cognitive milestones | Social-emotional milestones |
|---|---|---|
| Newborn | Best visual focal distance 8–12 inches (7) | Displays at least three emotions (anger, sadness, joy) (8) |
| Turns to visual and auditory stimuli that interest him (8) | Begins to self-regulate through states with less crying and more alert times (7,8) | |
| Prefers human face (8), contrast, colours, high-pitched voice (7) | Empathy: Cries when other infants cry, mood reflects emotions of others’ faces (8) | |
| 2 months | Follows slow horizontal arc through midline on both sides (2 months) (11) | Calms when spoken to (0–3 months) (13) |
| Increased length of visual concentration, uses actions to achieve a goal (0–6 months) (8) | Begins to be awake more during the day and sleep more at night (8 weeks) (10) | |
| 4 months | Watches own hands and their actions (2–3 months) (12) | Social smile, laughs in response to playful interactions (1.5–4 months) (7,12) |
| Visually searches the room to find familiar caregiver (3 months) (7) | Initiates interactions with compelling force (3–6 months) (7,8) | |
| Observes patterns of association (0–6 months) (7) | Has predictable sleep and eating schedule (3–6 months) (7,8) | |
| Anticipates routines (momentarily delays gratification) (3 months) (7) | Able to self-soothe briefly, usually settles self back to sleep (3–4 months) (7,8) | |
| 6 months | Sensorimotor exploration (mouthing, visual), prefers novelty (6–12 months) (8) | Turn-taking ‘conversations’ (3–6 months) (8) |
| Trial and error problem solving (0–6 months) (8) | Upset if parent does not respond to initiations (8) | |
| Concentrates for increasing periods of time on toys (0–6 months) (7,8) | Responds preferentially to familiar people (3–6 months) (8) | |
| Persists, self-corrects actions to achieve goals (0–6 months) (8) | Empathy: Shows interest in other infants (6 months) (8) | |
| Looks for dropped or partially hidden objects (4–6 months) (12) | Bangs objects together (3–6 months) (13) | |
| 9 months | Object permanence (7 months) (8) | Attachment (child → parent) development is established (7 months) (8) |
| Explores caregiver’s face (7 months), likes to look at self in mirror (4–8 months) (8) | Stranger and separation anxiety, when caregiver returns shows pleasure and can be comforted (9–12 months) (8) | |
| “Means-end behaviour” to purposefully search for hidden objects (7 months) (8) | Plays pat-a-cake (9 months) (11) | |
| Imitates sequences of adult actions (6–12 months) (8) | ||
| 12 months | Keeps mental picture of object, looks for one not seen hidden (12 months) (8) Trial and error exploration (6–12 months), functional use of toys (9–12 months) (8,13) Understands ‘no’ (9–12 months) (12), ‘cause and effect’ toys (6–12 months) (8) Intentional communication using gestures and vocalization (9–12 months) (8) | Uses gestures (reaches to be picked up, waves), plays peek-a-boo (9–12 months) (8,13) Joint attention: Shows by extending arm, pointing, or extending object (9–12 months) (8,13) Shows a variety of facial expressions (9–12 months) (8) Empathy: Starts to offer objects to other babies (12 months) (8) |
Numbers in parentheses indicate references
Cognitive and social-emotional milestones, 18 months to five years of age
| Age | Cognitive milestones | Social-emotional milestones |
|---|---|---|
| 18 months | Explores from ‘secure base’ of caregiver (7–24 months) (8) | Determined to do things independently (12–24 months) (8) |
| Imitates real-life activities using realistic props (15–18 months) (12) | ‘Clings’ to parent (16–19 months), uses transitional object (12–24 months) (7,8) | |
| Simple pretend play mostly self-related (13–24 months) (8) | Frequent temper tantrums (18 months) (7,8,12) | |
| 2 years | Begins to problem-solve without physical rehearsal (12–24 months) (8) | Noncompliance (12–24 months), temper tantrums, and aggression peak(30 months)(8) |
| Searches for hidden object after multiple displacements (21–22 months) (12) | Negativism ‘no’, possessiveness ‘mine’ (19–24 months) (8) | |
| Symbolic representation (12–24 months) (8) | Social referencing, empathy: Tries to comfort other who is upset (12–24 months) (8) | |
| Pretend play begins to be directed to others (13–24 months) (8) | Enjoys parallel play around other children, may offer toy or smile (13–24 months) (8) | |
| 3 years | Object constancy, separates easily (2–3 years) (7,8) | Social role play, doll as playmate (31–36 months), imaginary friend (3–7 years) (8,13) |
| Symbolic pretend play: Substitutes objects for other things (25–30 months) (8) | Initiates interactions with peers, cooperative play, shares toys (2–3 years) (8,13) | |
| Bedtime fears and nightmares (24–36 months) (8) | Understands rules (tells dolls, friends) (24–36 months) (8) | |
| Names 1 colour, counts 2 objects, sorts shapes, compares 2 items (30–36 months) (12,13) | Able to talk about emotions and situations that elicit them (24–36 months) (8) | |
| Feels guilt for hurting other child and may try to make things better (24–36 months) (8) | ||
| 4 years | Theory of mind established (3–4 years) (8) | Elaborate fantasy play (eg, superheroes) (3–4 years) (8) |
| Simple time concepts, plans ahead (3–4 years) (8) | Shows increasing emotional regulation over anger, aggression (4–6 years) (8) | |
| Identifies rules for problem-solving, tries solutions before frustration (3–4 years) (8) Generalizes rules from one situation to another (3–4 years) (8) Verbal self-talk changes to internal dialogue to solve problems (3–4 years) (8) Counts 4 objects, categorizes objects, understands opposites (3–4 years) (7,8) | Can resolve conflicts with discussion and negotiation (4–6 years) (8) Empathy: Might often offer comfort and sympathy to peers, listen to others (3–4 years) (8) Understands moral themes (right and wrong) in stories (3–4 years) (8) Usually compliant, shame and guilt if misbehaves (3–4 years) (8) | |
| 5 years | Takes turns in conversation, listens to other’s point of view, responds appropriately (4–6 years) (8) | Initiates separations from parents, plays away for several hours (4–5 years) (8) |
| Noncompliance rare, follows group rules, understands games with rules (4–6 years) (8) | ||
| Pre-literacy skills: Knows alphabet song, recognizes and produces rhymes (2–5 years), learns letter sounds and names (5–7 years) (14) | Develops sense of conscience, strict about rules, insists on them with peers (4–6 years) (8) | |
| Pre-numeracy skills: Counts 10 or more objects (7) | Understanding another’s perspective brings aggression under control (3–6 years) (18) | |
| Can display emotions other than the one felt underneath (3–6 years) (8) |
Numbers in parentheses indicate references
The newborn experiences relationships through his senses. The caregiver’s nurturing and sensory stimulation impact the baby’s brain development. A baby who is comforted learns more quickly how to self-soothe. He also eventually learns to cope better with emotions, control his own behaviour and to be caring toward others (3,7,8).
Crying: You will begin to recognize what actions console your baby when he is upset (eg, holding, speaking to him). You cannot spoil a baby (7–9,19,20).
Sleep onset: To help him fall asleep, follow his cues (eg, rock, feed to sleep) (10).
Language/literacy: Read to him daily, sing songs, use rhymes and games, and describe what he is seeing and doing throughout the day. Take your turn to listen to him attentively. Repeat your baby’s sounds and turn them into real words – this encourages him to eventually ‘talk back’ (8,21,22).
During this period of rapid growth, feeding consumes much of the parents’ time. Attachment is the close emotional relationship a child forms with the person who meets his needs. This helps the child to feel safe and secure, and to learn to trust others (7,8).
Attachment: Caregiving behaviours contribute to secure attachment. Be warm, loving and responsive. Take joy in your child; express your love and delight in his achievements. Learn to recognize your baby’s cues (eg, sounds, movements, facial expressions, eye contact) so you can meet his needs by responding in ways he finds satisfying. When he is upset, comfort him; hungry, feed him; smiling, smile back at him. Attend to his need for stimulation and quiet times (7,8,20,21).
Feeding: Feeding provides a wonderful opportunity to get to know your baby and is important for developing attachment. He will eat what he needs to grow properly when you respond supportively to feeding cues and let him control how much he eats (7,23).
Sleep onset: Set bedtime, waketime and naptimes either by the ‘two-hour rule’ (when you notice ‘tired’ signals) until nine to 12 months of age, or by the clock. Have a sleep-time routine of calming activities that encourage sleepiness (eg, story in bedroom, lullaby, kiss). Put baby down when he is ‘drowsy but awake’. Give him something to look at. He needs to practise soothing himself so that eventually, when he wakes in the night, he can get himself back to sleep. If he fusses, leave him for a few minutes. If he becomes very upset, do whatever you normally do to help him fall asleep (10).
A baby of this age is delightfully sociable with a positive emotional state for learning. He initiates interactive play, and thus begins to master social, language and motor skills (7).
Attachment: Keep baby near someone when he is awake (7).
Play: Play times with you are the main event of his day! Use colourful toys. Through play, children develop physical, cognitive, and social skills and confidence (7,9,21).
Sleep onset: Most babies can learn to soothe themselves to sleep at bedtime by three months of age, in the middle of the night between three to six months of age, when they no longer need night feeds, and at naptime once they are settling on their own at bedtime and sleeping through the night. Leave the bedroom after the bedtime routine. If your baby cries, wait. The duration depends on what works best for your child and what you can tolerate. Then ‘check-in’ with a brief (
Night wakings: Do what you normally do at bedtime to help your baby go to sleep (eg, rocking, feeding). Once he is settling himself at bedtime, he will naturally start sleeping through the night in approximately two weeks (10).
Now that baby is sitting with support, his hands are free to reach and grasp, fostering cognitive and social development. Separation and stranger anxiety begin to appear at about eight months of age (7,8).
Play: Provide a small variety of safe objects (eg, ‘touch and feel’ books, large building blocks, ball). An upright seat allows him to visually explore and verbally interact with people (7,9).
Feeding: When solid foods are introduced, let the baby explore them with his hands (7).
Routines: Maintaining a predictable daily routine (eg, awake-, meal-, and bedtimes) helps the baby feel secure, understand what to expect and learn how to manage emotions and behaviour (8,9,24).
Separation anxiety: ( Table 3 ).
Anticipatory guidance for social-emotional development: Normal behaviours