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18-Month Checkup

Red flags can be revealed during 18-month checkup.

Eighteen months is a critical developmental stage in your child’s life, when many milestones are being reached. When children miss some of these milestones, it can be an indicator of a developmental delay.

In 1993, a group of early intervention professionals in North Bay, Ont., found a number of children experiencing developmental delays had not been identified until after age three. So a committee of speech language pathologists, occupational therapists, physiotherapists, nurses, teachers, social workers and parent-infant therapists developed the Nipissing District Developmental Screen (NDDS), a checklist of skills and milestones to help doctors and parents more readily identify children with delays.

Health toddler doctor - 18-month checkupIn 2009, the government of Ontarioadopted the not-for-profit organization’s checklist and funded a longer 18-month well baby visit to allow doctors the time to go over the screen with caregivers. “There has always been a scheduled 18-month well baby doctor’s appointment, but it used to be a standard checkup with a booster shot and some brief questions about milestones and injury prevention,” says Dr. Janine Flanagan, a developmental pediatrician in Toronto. “But now it’s a more serious assessment of developmental health. The hope is to identify kids who are at risk for language or developmental delay, or autism. Brain development in these early years really affects future learning and long-term health. If we can identify these kids early and intervene, it can make a huge difference.”

Parents are asked to fill out 17 yes-or-no questions, which provide the physician with a snapshot of the child’s development; it is not meant as a diagnostic tool or a formal developmental assessment, but rather a quick way to determine any areas that need further investigation. The enhanced visit is now much more focused on identifying children who may require referral to specialized services, from vision or hearing testing, speech and language therapy, to an assessment from a developmental pediatrician to screen for autism.

“There are certain questions that are really helpful in terms of highlighting a potential problem,” says Dr. Flanagan. “Such as Number 2: Does your child use familiar gestures? Kids with autism don’t really point, wave, shake or nod easily. If a baby isn’t using those gestures by 18 months it’s an immediate red flag. Numbers 15 and 17 – Does your child show affection towards people and pets, and look at you when you are talking – negative responses to those questions are also good indicators that something might be wrong.” (For more info on the questionnaire, visit

The 18-month visit was chosen to introduce the NDDS for a couple of reasons, says Dr. Flanagan. First, because it’s the last mandatory scheduled visit before school starts. “The next immunization doesn’t happen until age four, so some kids don’t see their doctor for over two years. When I see a three year-old who hasn’t been seen since 18 months, that’s half of his or her lifetime that’s gone by.” And if the child happens to be autistic, those months are critical.

The second reason is that 18 months is a pivotal time in a child’s life; by this age, a number of major motor and communications milestones should have been reached, and developmental concerns are easily detected. Parents are beginning to navigate the choppy waters of toddlerhood at this point, and the extended visit at 18 months gives them the opportunity to discuss any concerns and questions they have with their physician. The doctor should also take the time to discuss the challenges specific to this age, as well as local community programs, early learning and the importance of literacy skills.

“All doctors’ visits at all ages are important, but this particular 18-month one is so critical now,” says Dr. Flanagan. “Identifying any issues and getting on top of them early can make such a difference in children’s and their families’ lives.”

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