Points for Concern & Intervention Through Play: Four to Six Years

This period is when children are getting ready for school education. All children should have a complete assessment in all areas, particularly vision, hearing and fine motor skills, as a part of their school readiness. Delay in one area can have an impact across all areas of functioning. Since impairment is often partial, it is easy to miss in a simple screening process.



At this age, most delays in motor skills are easy to spot. For delays in motor development, please refer to NIMH Manual on Early Intervention Series 2: Gross and Fine Motor.  Remember however, that an active child may meet major motor milestones and yet still be uncoordinated. The child may have difficulty throwing and catching a ball, kicking, hitting with a bat, or hopping on one leg, while still being able to run.  See also  Developmental Milestones: Gross and Fine Motor for guidelines on the development of motor skills.
Suggest activities such as manoeuvring through a maze which has changes in heights and spaces (squeezing through a gap, jumping over or crawling under a stool or table and so on) and taking a little car or cycle through paths that have obstacles and turns in them. Support the child initially by having the child follow you through the maze, and providing verbal or visual cues. Please refer to “The Normal Gait Cycle” for more ideas. 
If the child frequently trips, bumps into things, and knocks things over, check motor skills, especially balance and co-ordination, but also check if the child has a lower field vision loss. Look for other signs such as an exaggerated head tilt when locating objects near the feet. Children who are active during the day and suddenly become quiet, timid or afraid at night, may have vision issues that are affecting their retinal health. Please refer for clinical evaluation and consider nutrition and environmental interventions to support the child. Please refer Helping Children Who Are Blind, Chapters 10 & 11 for ideas on teaching movement and safety. 
Children may demonstrate difficulty in fine motor skills such as holding a pencil properly, colouring within lines, building a straight tower with several blocks, or manipulating tools that require both precision as well as power, such as a screw driver. Notice whether the pressure applied in drawing and writing is too weak or too strong. Give the child simple objects to manipulate such as keyboards and rotary telephones, and get them involved in play such as tearing paper and making collages, dressing dolls, and finger painting to develop fine motor coordination skills. Playing in sand, clay, dough, washing and squeezing doll clothes or small cloths all build finger and hand strength and coordination. Please refer to Disabled Village Children pages 305 – 306 for ideas for more activities.
Notice difficulties in motor planning, verbalizing needed action, clumsiness, and difficulties in balance and co-ordination to decide which intervention strategies may be helpful. A history of delayed milestones or a lack of experience can be supported by increasing opportunities for active problem solving through play. Children who are still unsure of which hand to use, haven’t really learnt left and right, or have difficulty in mirroring actions can benefit from crossing midline activities. Some activities include bouncing a ball with one hand and catching with the other, drawing large sleeping 8s in the air, holding a pencil with both hands together and scribbling and playing games with bat and ball, holding bat with both hands. You can refer to Crossing Midline and Creative Movement for some more ideas. 
Nothing About Us Without Us (Innovative Technologies) by David Werner is a good reference for aids and appliances that may be needed for seating / standing


By this age, children should be speaking clearly and mis articulation or unclear speech could indicate a hearing loss or oromotor issues. Children who have a history of frequent ear infections or who are hard of hearing could also have these issues. Please ensure that all clinical tests are completed. Also refer Helping Children Who Are Deaf, Chapter 5: What can your child hear? for testing suggestions. Children who are not speaking grammatically correct sentences, speaking complete sentences or who are still speaking in two or three word sentences could have many issues. Please refer to the Normal Development of Speech, Language and Communication to help identify areas of problems. Communication Decision Chart will give you specific ideas to support language and communication development. 
If children are not speaking, or have significant delays in speech for whatever reason, please consider using alternate methods of communication such as sign and pictures systems. Please refer to Helping Children who are Deaf, Chapter 4: Basic Communication Skills and Chapter 8: Learning to use a sign language and Augmentative and Alternative Communication. Other references include Curriculum and Teaching DSE (ASD) Manual, pg. 96 – 98, Developing Communication Skills and Training in Communication Skills from NIMH.
Children who are unable to relate a sequence of events or are not able to follow three step directions may have issues with understanding language or memory. These issues may be limited to language or could be with intellectual capacity. Refer to Helping Children who are Deaf, Chapter 3: Guidelines for Teaching Language for some activity ideas. 
Some children may repeat what others say rather than speaking their own thoughts or responding to the questions asked. This is often seen when children do not quite understand the question, or do not have the language skills or vocabulary to answer. Some children may repeat or say words or phrases, simply for the pleasure it gives them (self-stimulation) rather than for the meaning they convey. Refer to the “Communication Assessment” to make a beginning in understanding the child’s needs or you could refer to the “Autism Information and Resource Centre” on the National Trust website http://autismresourcecenter.in/Default.aspx# for resources and ideas. Refer to the CommDeall Intervention Manuals for Toddlers and Preschoolers, AYJNIHH Speech and Language Stimulation and NIMH Manual on Early Intervention Series 3 (Speech, language and communication) for activity suggestions. Please consider referral to Speech and Language Therapists as needed. 
Children who have not learnt rules of social conversation or not able to have a proper two way conversations may simply not have had enough appropriate early exposure and will benefit from language rich experiences. It may also be that the child may not have developed adequate vocabulary and will benefit from language stimulation activities – please refer to AYJNIHH Speech and Language Stimulation.
However, some children may have little desire to communicate. They may prefer to be alone and have poor relationships with peers and adults. They may have trouble understanding social situations and demonstrate difficulty in maintaining or giving eye contact while communicating. They may ignore other children, show little interest in fantasy play and not participate in interactive games. Please refer to the Sensory Processing Checklist and send for further evaluation as needed. Refer to Communication Assessment for an understanding of the child’s capacities and needs and CommDeall Intervention Manuals for Toddlers and Preschoolers for some activity ideas.


If a child is still not able to look after himself, and does not help in simple household chores, check for milestone delays. The reason could be a lack of opportunity to do things for himself, lack of training, inability to follow instructions, low vision or other sensory issues. Disabled Village Children, Section D: Helping Children Develop and Become More Self-Reliant has many suggestions across each area of self-care. The NIMH skills training series and CommDeall Intervention Manuals for Toddlers and Preschoolers have many suggestions as well.   


Children should have a good concept of time and be able to relate stories, and events that have happened to them in a structured way. They should be able to solve simple problems involving quantity, reason out a logical sequence and delays in these areas point to poor early experiences or larger issues in comprehension and reasoning. These children learn most effectively when concepts and skills are given through their daily routines. However, ensure that children are included in typical activities including education with their peer group and augment their experiences with a multi-sensory approach to learning. Refer to the NIMH Manual on Early Intervention Series 1 (Cognition, Audition and Fine Motor), and to Disabled Village Children page 316.
Children at this age should be able to spot differences in orientation such as the one fish facing the opposite direction in a line of fish. Children should be able to copy simple patterns involving a sequence of colours or shapes. You can test further by giving children the opportunity to copy shapes and letters even if they don’t know how to write and notice reversals and other issues of laterality. Problems in these activities could indicate problem in visual perception or specific visual processing impairment. Refer to Grade Level Assessment Device (GLAD) for Children with Learning Problems in Schools.
Notice whether children have difficulty in maintaining attention on a task for more than five minutes or show very high levels of needing physical activity and movement and refer for further testing to determine whether the child has attention deficit or hyperactivity.