Development is often divided into specific domains, such as gross motor, fine motor,

language, cognition, and social/emotional growth. These designations are useful, but
substantial overlap exists. Studies have established average ages at which specific milestones
are reached, as well as ranges of normality. In a normal child, progress within the different
domains varies, as in the toddler who walks late but speaks in sentences early (see
Developmental Milestones*).

Developmental Milestones*
Age

Behavior

Sleeps much of the time

Sucks
Birth
Clears airway
Responds with crying to discomforts and intrusions

Brings hands toward eyes and mouth

Moves head from side to side when lying on stomach
Eyes follow an object moved in an arc about 15 cm above face to the midline
4 wk
Responds to a noise in some way (eg, startling, crying, quieting)
May turn toward familiar sounds and voices
Focuses on a face

Regards objects in the line of vision

Begins to smile when spoken to
6 wk
Lies flat on abdomen
Head lags when pulled to a sitting position

3 mo

Holds head steady on sitting

Raises head 45 when lying on stomach

Age

Behavior

Opens and shuts hands

Pushes down when feet are placed on a flat surface
Swings at and reaches for dangling toys
Follows an object moved in an arc above face from one side to the other
Watches faces intently
Smiles at sound of caretakers voice
Vocalizes sounds

Holds head steady when upright

Sits with support
Rolls over, usually from stomach to back
Reaches for objects
56 mo

Recognizes people at a distance

Listens intently to human voices
Smiles spontaneously
Squeals in delight
Babbles to toys

7 mo

Sits without support

Bears some weight on legs when held upright
Transfers objects from hand to hand
Holds own bottle
Looks for dropped object

Age

Behavior

Responds to own name

Responds to being told no
Combines vowels and consonants to babble
Moves body with excitement in anticipation of playing
Plays peekaboo

Sits well
Crawls or creeps on hands and knees
Pulls self up to standing position
9 mo

Works to get a toy that is out of reach; objects if toy is taken away
Gets into a sitting position from stomach
Stands holding on to someone or something
Says "mama" or "dada" indiscriminately

Walks by holding furniture (cruising) or others' hands

May walk 1 or 2 steps without support
Stands for a few moments at a time
12 mo

Says "Dada" and "Mama" to the appropriate person

Drinks from a cup
Claps hands and waves bye-bye
Speaks several words

18 mo

Walks well
Can climb stairs holding on

Age

Behavior

Draws a vertical stroke

Makes a tower of 4 cubes
Turns several book pages at a time
Speaks about 10 words
Pulls toys on strings
Partially feeds self

Runs well/with coordination

Climbs on furniture
Jumps
Climbs up and down stairs without help
Handles a spoon well
Turns single book pages
22 yr
Makes a tower of 7 cubes
Opens doors
Scribbles in a circular pattern
Puts on simple clothing
Makes 2- or 3-word sentences
Verbalizes toilet needs

3 yr

Mature gait in walking

Rides a tricycle
Favors using one hand over the other

Age

Behavior

Copies a circle
Dresses well except for buttons and laces
Counts to 10 and uses plurals
Recognizes at least 3 colors
Questions constantly
Feeds self well
Can take care of toilet needs (in about half of children)

Alternates feet going up and down stairs

Throws a ball overhand
Hops on 1 foot
4 yr
Copies a cross
Dresses self
Washes hands and face

Skips
Catches a bounced ball
Copies a triangle
5 yr
Draws a person in 6 parts
Knows 4 colors
Dresses and undresses without help

Walks along a straight line from heel to toe

6 yr
Writes name

Age

Behavior

*The sequence is fairly consistent, but the timing of milestones varies; times above represent
median values.
Environmental influences, ranging from nutrition to stimulation and from the impact of
disease to the effects of psychologic factors, interact with genetic factors to determine the
pace and pattern of development.
Assessment of development occurs constantly as parents, school personnel, and clinicians
evaluate children. Many tools are available for monitoring development more specifically.
The Denver Developmental Screening Test II facilitates evaluation in several domains. The
scoring sheet indicates the average ages for achieving certain milestones and nicely shows the
critical concept of a range of normality. Other tools can also be used (see Developmental
Milestones*).

Motor Development
Motor development includes fine motor (eg, picking up small objects, drawing) and gross
motor (eg, walking, climbing stairs) skills. It is a continuous process that depends on familial
patterns, environmental factors (eg, when activity is limited by prolonged illness), and
specific disorders (eg, cerebral palsy, intellectual disability, muscular dystrophy). Children
typically begin to walk at 12 mo, can climb stairs holding on at 18 mo, and run well at 2 yr,
but the age at which these milestones are achieved by normal children varies widely. Motor
development cannot be significantly accelerated by applying increased stimulation.

Language Development
The ability to understand language precedes the ability to speak; children with few words
usually can understand a great deal. Although delays in expressive speech are typically not
accompanied by other developmental delays, all children with excessive language delays
should be evaluated for the presence of other delays in development. Children who have
delays in both receptive and expressive speech more often have additional developmental
problems. Evaluation of any delay should start with an assessment of hearing. Most children
who experience speech delay have normal intelligence. In contrast, children with accelerated
speech development are often of above-average intelligence.
Speech progresses from the utterance of vowel sounds (cooing) to the introduction of
syllables that start with consonants (ba-ba-ba). Most children can say Dada and Mama
specifically by 12 mo, use several words by 18 mo, and form 2- or 3-word phrases by 2 yr.
The average 3-yr-old child can carry on a conversation. A 4-yr-old child can tell simple
stories and can engage in conversation with adults or other children. A 5-yr-old child may
have a vocabulary of several thousand words.
Even before age 18 mo, children can listen to and understand a story being read to them. By
age 5, children are able to recite the alphabet and to recognize simple words in print. These

skills are all fundamental to learning how to read simple words, phrases, and sentences.
Depending on exposure to books and natural abilities, most children begin to read by age 6 or
7. These milestones are highly variable.

Cognitive Development
Cognitive development refers to the intellectual maturation of children. Increasingly,
appropriate attachments and nurturing in infancy and early childhood are recognized as
critical factors in cognitive growth and emotional health. For example, reading to children
from an early age, providing intellectually stimulating experiences, and providing warm and
nurturing relationships all have a major impact on growth in these domains. Intellect is
appraised in young children by observations of language skills, curiosity, and problemsolving abilities. As children become more verbal, intellectual functioning becomes easier to
assess using a number of specialized clinical tools. Once children start school, they undergo
constant monitoring as part of the academic process.
At age 2 yr, most children understand the concept of time in broad terms. Many 2- and 3-yrold children believe that anything that happened in the past happened "yesterday," and
anything that will happen in the future will happen "tomorrow." A child at this age has a vivid
imagination but has difficulty distinguishing fantasy from reality. By age 4 yr, most children
have a more complicated understanding of time. They realize that the day is divided into
morning, afternoon, and night. They can even appreciate the change in seasons.
By age 7 yr, children's intellectual capabilities become more complex. By this time, children
become increasingly able to focus on more than one aspect of an event or situation at the
same time. For example, school-aged children can appreciate that a tall, slender container can
hold the same amount of water as a short, broad one. They can appreciate that medicine can
taste bad but can make them feel better, or that their mother can be angry at them but can still
love them. Children are increasingly able to understand another person's perspective and so
learn the essentials of taking turns in games or conversations. In addition, school-aged
children are able to follow agreed-upon rules of games. Children of this age are also
increasingly able to reason using the powers of observation and multiple points of view.

Emotional and Behavioral Development

Emotion and behavior are based on the child's developmental stage and temperament. Every
child has an individual temperament, or mood. Some children may be cheerful and adaptable
and easily develop regular routines of sleeping, waking, eating, and other daily activities.
These children tend to respond positively to new situations. Other children are not very
adaptable and may have great irregularities in their routine. These children tend to respond
negatively to new situations. Still other children are in between.
Emotional growth and the acquisition of social skills are assessed by watching children
interact with others in everyday situations. When children acquire speech, the understanding
of their emotional state becomes much more accurate. As with intellect, emotional
functioning can be delineated more precisely with specialized tools.
Crying is infants' primary means of communication. Infants cry because they are hungry,
uncomfortable, distressed, and for many other reasons that may not be obvious. Infants cry

mosttypically 3 h/dayat age 6 wk, usually decreasing to 1 h/day by age 3 mo. Parents
typically offer crying infants food, change their diaper, and look for a source of pain or
discomfort. If these measures do not work, holding or walking with the infant sometimes
helps. Occasionally nothing works. Parents should not force food on crying infants, who will
readily eat if hunger is the cause of their distress.
At about age 9 mo, infants normally become more anxious about being separated from their
parents. Separations at bedtime and at places like child care centers may be difficult and can
be marked by temper tantrums. This behavior can last for many months. For many older
children, a special blanket or stuffed animal serves at this time as a transitional object that
acts as a symbol for the absent parent.
At age 2 to 3 yr, children begin to test their limits and do what they have been forbidden to
do, simply to see what will happen. The frequent "nos" that children hear from parents reflect
the struggle for independence at this age. Although distressing to parents and children,
tantrums are normal because they help children express their frustration during a time when
they cannot verbalize their feelings well. Parents can help decrease the number of tantrums
by not letting their children become overtired or unduly frustrated and by knowing their
children's behavior patterns and avoiding situations that are likely to induce tantrums. Some
young children have particular difficulty controlling their impulses and need their parents to
set stricter limits around which there can be some safety and regularity in their world.
At age 18 mo to 2 yr, children typically begin to establish gender identity. During the
preschool years, children also acquire a notion of gender role, of what boys and girls typically
do. Exploration of the genitals is expected at this age and signals that children are beginning
to make a connection between gender and body image.
Between age 2 yr and 3 yr, children begin to play more interactively with other children.
Although they may still be possessive about toys, they may begin to share and even take turns
in play. Asserting ownership of toys by saying, "That is mine!" helps establish the sense of
self. Although children at this age strive for independence, they still need their parents nearby
for security and support. For example, they may walk away from their parents when they feel
curious only to later hide behind their parents when they are fearful.
At age 3 to 5 yr, many children become interested in fantasy play and imaginary friends.
Fantasy play allows children to safely act out different roles and strong feelings in acceptable
ways. Fantasy play also helps children grow socially. They learn to resolve conflicts with
parents or other children in ways that help them vent frustrations and maintain self-esteem.
Also at this time, typical childhood fears like that of "the monster in the closet" emerge.
These fears are normal.
At age 7 to 12 yr, children work through numerous issues: self-concept, the foundation for
which is laid by competency in the classroom; relationships with peers, which are determined
by the ability to socialize and fit in well; and family relationships, which are determined in
part by the approval children gain from parents and siblings. Although many children seem to
place a high value on the peer group, they still look primarily to parents for support and
guidance. Siblings can serve as role models and as valuable supports and critics regarding
what can and cannot be done. This period of time is very active for children, who engage in
many activities and are eager to explore new activities. At this age, children are eager learners

and often respond well to advice about safety, healthy lifestyles, and avoidance of high-risk
behaviors.
Last full review/revision December 2012 by Daniel A. Doyle, MD
https://www.merckmanuals.com/professional/pediatrics/growth-and-development/childhooddevelopment#en-US