Points for Concern: Three to Four Years

A young child with glasses uses a braille writer

A gait that is awkward, slow or seems unusual, poor transitioning between positions and regression in any motor milestones are immediate reasons for detailed clinical assessment. By four, a child should be able to hold a squat position with stability and rise from squat independently and if not achieved, should be referred for physiotherapy assessment.

Children should be able to throw a ball with one hand and catch with both and be able to hit a ball with a bat. Poor motor planning, low vision or low muscle power could be a cause of problems in these areas. Check nutritional status, muscle strength, visual capacity and motor planning and refer Disabled Village Children, Chapter 6: “Guide for Identifying Disabilities” for assessment and resource suggestions, “Typical Gait” and Helping Children who are Blind, Chapter 4 “Finding out what your child can see” for ideas.

Problems in fine motor skills are often easily seen in buttoning and unbuttoning. Review the child’s development in this area using “Sequential Development of Grasp". Notice if the child has problems in finger strength, dexterity and grasp. If the child has problems in these areas, you are likely to also see problems in drawing, writing, colouring and other such activities. Refer to “Developing Grasp” & “Developing fine motor skills” in Fine Motor Resources for activity ideas. Children with low vision, visual perception problems, learning disabilities or intellectual disability could also have difficulties in these areas. Mild sensory or processing issues are easy to miss unless a professional evaluation is done. Meanwhile, you can refer to some of the resources such as the Grade Level Assessment Device (GLAD) for Children with Learning Problems in Schools, Helping Children who are Blind, Chapter 4 "Finding out what your child can see” to identify possible areas of concern. Refer to the NIMH Manual on Early Intervention Series 1 (Cognition, Audition and Fine Motor).

Problems in articulation combined with problems in chewing, swallowing, drinking or eating could point to oromotor problems and require clinical assessment. If children do not have clear speech, good expressive language, grammatically correct sentences and good comprehension, refer to the “Communication Assessment” to make a beginning in understanding the child’s needs. 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 are excessively shy, stay away from social situations, do not interact with peers or family members need support in developing social skills. Explore their early experiences and current routines to see if the child has adequate social stimulation. Check also for other signs - children who talk irrelevantly, respond to questions by repeating the question, talking to themselves or using phrases out of context need assessment and differential diagnosis to determine the appropriate intervention strategies. Please refer to the “Autism Information and Resource Centre” on the National Trust website http://autismresourcecenter.in/Default.aspx# for resources and ideas and refer for further professional evaluation and guidance. Oversensitivity or strong seeking to certain sounds, textures, touch, movement, light or colours point to sensory issues that need further investigation and support. Please refer to the Sensory Processing Checklist and send for further evaluation as needed.