Red Flags - Oxford County

Transcription

Project3:Red Flag covers
12/15/08
2:56 PM
Page 1
A Quick Reference Guide for Early Years Professionals
E ar ly Identification in Oxford County
For Infant, Toddler and Preschool Children
January 2009
12/15/08
2:56 PM
Page 2
Public Health & Emergency Services
1-800-755-0394 519-539-9800
The Development of Red Flags
The original Red Flags document was developed by the Simcoe County Early Intervention Council. It
was printed and distributed by the Healthy Babies Healthy Children program, Simcoe County District
Health Unit as Red Flags – Let’s Grow with Your Child, in March 2003.
With the permission of colleagues in Simcoe County, the document was reviewed and revised by the
York Region Early Identification Planning Coalition and supported by York Region Health Services
through 2003. Many additions were made with the assistance of professionals serving young children
in York Region.
In September 2006, Peterborough’s Early Identification Committee obtained permission from York
Region Early Identification Planning Coalition, through the York Region Health Services Department,
to adapt their version of Red Flags. The Peterborough Red Flags Sub-committee reviewed and
revised content to reflect local programming and the most recent guidelines, research, and best
practice.
In June 2007, Oxford County Public received permission from the Simcoe County Early Invention
Council, the York Region Identification Planning Coalition, and the Peterborough County-City Health
Unit, to adapt their respective versions of Red Flags for the County of Oxford.
The Oxford County Red Flags Committee was established consisting of representatives from:
•
Oxford County Public Health and Emergency Services
•
Ontario Early Years Centre – Oxford County
•
Women’s Emergency Centre - Oxford
•
Community Living Tillsonburg
•
Good Beginnings Day Nursery
•
Child and Parent Resource Institute
For permission to reproduce this document, further information, or any questions or feedback, please
contact the Manager of Health Promotion at Oxford County Public Health at (519) 539-9800 or 1-800755-0394.
The information contained in “Red Flags” (herein referred to as “this document”) has been provided as a
public service. Although every attempt has been made to ensure its accuracy, no warranties or
representations, expressed or implied, are made concerning the accuracy, reliability or completeness of
the information contained in this document. The information in this document is provided on an “as is”
basis without warranty or condition.
This document cannot substitute for the advice and/or treatment of professionals trained to properly
assess the development and progress of infants, toddlers and preschool children. Although this document
may be helpful to determine when to seek out advice and/or treatment, this document should not be used
to diagnose or treat perceived developmental limitations and/or other health care needs.
This document also refers to services, websites and other documents that are created or operated by
independent bodies. These references are provided as a public service and do not imply the investigation
or verification of the websites or other documents. No warranties or representations, expressed or
implied, are made concerning the products, services and information found on those websites or
documents.
This document is being provided for your personal non-commercial use. This document, or the
information contained herein, shall not be modified, copied, distributed, reproduced, published, licensed,
transferred or sold for a commercial purpose, in whole or in part, without the prior written consent of the
Oxford County Red Flags Committee, which consent may be withheld at the sole discretion of the Red
Flags Committee or be given subject to such terms and conditions as the Red Flags Committee may, in
its sole discretion, impose.
NOT TO BE USED TO DIAGNOSE OR LABEL A CHILD
Disclaimer Notice
Red Flags - A Quick Reference Guide is a document designed to assist early years
professionals in deciding whether to refer a child for additional advice, assessment and/or
treatment. It is not a formal screening or diagnostic tool. It is not intended for parents.
Table of Contents
Table of Contents
Why Early Identification?
.................................................................... 3
What is “Red Flags?”
.................................................................... 3
Who Should Use “Red Flags?”
.................................................................... 3
How to Use this Document
.................................................................... 4
Attachment
.................................................................... 5
Cognitive
.................................................................... 7
Dental
.................................................................... 8
Family and Environmental Stressors
.................................................................... 9
Feeding and Swallowing
.................................................................. 10
Fine Motor
.................................................................. 12
Gross Motor
.................................................................. 14
Hearing
.................................................................. 16
Literacy
.................................................................. 17
Neglect and Abuse
.................................................................. 19
•
Neglect
.................................................................. 19
•
Emotional Abuse
.................................................................. 20
•
Physical Abuse
.................................................................. 21
•
Sexual Abuse
.................................................................. 22
•
Sexual Behaviour
.................................................................. 23
•
Witnessing Family Violence
.................................................................. 25
Nutrition
.................................................................. 26
Postpartum Mood Disorders
.................................................................. 28
School Readiness
.................................................................. 30
Sensory
.................................................................. 31
Sleep
.................................................................. 32
Social and Emotional - Behaviour
.................................................................. 33
Speech and Language
.................................................................. 35
Vision
.................................................................. 37
References
.................................................................. 38
Appendices
How to talk to parents about sensitive issues
.................................................................. 40
Interagency Authorization for Sharing of
Information
Sample Letter to Physician
.................................................................. 42
.................................................................. 43
Agency Directory
.................................................................. 44
For the most current version of this document please see www.oxfordcounty.ca
2
Red Flags
Why Early Identification?
Thanks to the work of Dr. Fraser Mustard and other scientists, most professionals working with young
children are aware of the considerable evidence about early brain development and how brief some
of the “windows of opportunity” are for optimal development of neural pathways. The early years of
development from conception to age six and particularly for the first three years, set the base for
competence and coping skills that will affect learning, behaviour and health throughout life.
It follows then, that children who may need additional services and supports to ensure healthy
development must be identified as quickly as possible and referred to appropriate programs and
services. Early intervention during the period of the greatest development of neural pathways, when
alternative coping pathways are most easily built, is critical to ensure the best outcomes for the child.
Time is of the essence!
What is “Red Flags”?
“Red Flags” is a quick reference guide for early years professionals. It can be used in conjunction with
a validated screening tool, such as Nipissing District Developmental Screens™ (NDDS), Rourke
Baby Records (RBR), Ages and Stages Questionnaires® (ASQ) or NutriSTEP®. Red Flags outlines a
range of functional indicators or domains commonly used to monitor healthy child development, as
well as potential problem areas for child development. It is intended to assist in the determination of
when and where to refer for additional advice, formal assessment and/or treatment at the earliest
possible sign.
Who Should Use “Red Flags”?
This reference guide is intended to be used by any professional working with young children and their
families. A basic knowledge of healthy child development is assumed. Red Flags will assist
professionals in identifying when a child could be at risk of not meeting his/her health and/or
developmental milestones, triggering an alert to the need for further investigation by the appropriate
discipline.
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Red Flags
How to Use this Document
This reference guide is designed to identify areas of concern regarding child development from birth
to age six. It includes other areas that may impact child health and growth and development due to
the dynamics of parent-child interaction, such as postpartum mood disorders, and neglect and abuse.
• Use “Red Flags” in conjunction with a screening tool, such as Nipissing District Developmental
Screens™, Rourke Baby Record, Ages and Stages Questionnaires® (ASQ) or NutriSTEP® to
review developmental milestones and problem signs.
- Nipissing District Developmental Screens™ refers to 13 parent checklists available to
assist parents to record and monitor development of children from birth to age 6. The
screens cover development related to vision, hearing, communication, gross and fine
motor, social/emotional and self-help and offer suggestions to parents for age
appropriate activities to enhance child development.
- Copies of the screens can be obtained by calling the Oxford County Public Health
Health Matters Line at (519) 539-9800 or 1-800-755-0394 or by visiting
www.ndds.ca.
• Check other related domains as some information is cross-referenced, such as speech with
hearing, to assist the screener in pursuing questions or ‘gut feelings’.
• Call the Children’s Aid Society of Oxford County when there is any suspicion of child abuse or
neglect. There is a “duty to report” to the Children’s Aid Society (Child and Family Services Act,
1990, amended 2002).
- The Children’s Aid Society of Oxford County can be reached at (519) 539-6176 or
1-800-250-7010.
• Refer for further assessment even if you are uncertain if the flags noted are a reflection of a
cultural variation or a real concern.
• Note that some of the indicators focus on the parent/caregiver or the interaction between the
parent and the child, rather than solely on the child.
• Contact and referral information are indicated at the end of each heading.
• Refer to the agencies that can coordinate a collaborative and comprehensive assessment
process if a child appears to have multiple concerns or delays requiring formal investigation by
several disciplines.
• Alert families that fees will not be funded by OHIP if referrals are made to private sector
agencies.
Throughout this document the Oxford County Public Health Health Matters Line is often the first
contact in the “Where to go for help?” sections. The Health Matters Line (519) 539-9800 or 1-800755-0394 is the main telephone number for parents and professionals to call about any topics in this
document. A Public Health Nurse is available to discuss concerns, provide information, and refer
individuals to the appropriate program in the community, Monday to Friday, 9:00 a.m. to 4:00 p.m.
4
The following items are considered from the parent’s perspective, rather than the child’s.
If parents state that one or more of these statements describes their child, the child may be at risk
for the development of an insecure attachment. Consider this a red flag:
0-8 months

Is difficult to comfort by physical contact such as rocking or holding
8-18 months

Does not seek comfort or proximity to a caregiver at times when he or
she is experiencing fear, hurt or wariness
Is overly disinhibited with strangers (seeks close physical contact or
will “walk off” with a complete stranger)
Does not appear to have a clear means of coping with distress (may
appear disorganized or rely on self-stimulation or self-harm behaviours
when distressed)

18 months - 3 years

Appears fearful of being separated from parents most of the time or at
low stress times (e.g. at home)
Does not seek comfort from or proximity to caregivers when distressed
Is overly disinhibited with strangers
Is overly controlling or aggressive in interactions with caregivers
3-4 years

Is overly disinhibited with strangers
Is too passive or clingy with parent/caregiver
Has significant difficulties with separation
Displays regressive “babyish” behaviours
Is not interested in reciprocally sharing emotional experiences with
caregivers
4-5 years

Becomes aggressive for no reason (e.g. with someone who is upset)
Is too dependent on adults for attention, encouragement and help
Appears chronically angry, controlling or resistant with caregivers
Problem Signs… if a primary caregiver is frequently displaying any of the following, consider this
a red flag:

Does not experience enjoyment or delight in his/her relationship with the baby
Is insensitive to a baby’s cues of emotional distress or need
Is often unable to recognize baby’s cues
Is often withdrawn or unavailable in interactions with the baby
Provides inconsistent patterns of responses to the baby’s cues
Frequently ignores or rejects the baby
Speaks about the baby in negative terms or has inappropriate attributions for the baby’s
behaviour (e.g. “He’s trying to hurt me.”)
Often appears to be angry with the baby
Often displays behaviour that frightens the baby or child when interacting
5
Attachment
Child development research has established that the quality of early parent-child relationships has an
important impact on a child’s ability to form secure attachments, with consequent implications for
development. A child who has secure attachment feels confident that he or she can rely on the parent to
protect, comfort or organize him or her in times of distress. This confidence gives the child security to
explore the world and establish trusting relationships with others. Secure attachment is associated with
positive long-term outcomes in terms of social, cognitive and adaptive development.
Attachment
WHERE TO GO FOR HELP
Oxford Child and Youth Centre Early Years Program. (519) 539-0463 or 1-877-539-0463. Self-referral.
Support around attachment and early relationships.
Oxford County Public Health Health Matters Line. (519) 539-9800 or 1-800-755-0394. Self-referral. For
Healthy Babies Healthy Children program.
Ontario Early Years Centre - Oxford County. (519) 539-9800 or 1-800-755-0394 ext. 3392. Self-referral.
Education and programming around enhancing parent-child attachment.
Woodstock General Hospital Mental Health Services. (519) 421-4223. Self-referral. Mental health
assessments, screening, and individual and family therapy.
Thames Valley Children’s Centre. (519) 685-8680. Self-referral.
Developmental Resources for Infants. (519) 685-8710. Self-referral. For children less than two years of
age if child is at risk for or has developmental or physical disabilities.
6
By 3 months

Watches faces closely
Follows moving objects
Recognizes objects and people he/she knows
By 8 months

Tracks a moving object
Finds an object that is partially hidden
Explores objects and environment with hands and mouth
Struggles to get objects that are beyond reach
Looks from one object to another
Watches a falling object
By 12 months

Explores objects in different ways (e.g. shaking, banging, throwing)
Knows the names of familiar objects
Responds to music
Begins to explore cause and effect
Imitates gestures
By 18 months

Uses objects as tools
Tries to fit related objects together (e.g. shape sorters)
By 24 months

Begins to play using ‘make-believe’ or imaginative play
Begins to sort objects by shape and colour
By 3 years

Matches an object in his/her hand or in the room to a picture in a book
Includes stuffed toys, animals and dolls in make-believe play
Sorts easily by shape and colour
Completes a puzzle with 3 or 4 pieces
Understands the difference between the numbers 1 and 2
Names body parts and colours
Begins to have a sense of time
By 4 years

Understands the concept of counting
Follows a 3 part instruction
Recalls parts of a story
Makes up and tells simple stories
Understands “same” and “different”
Enjoys rich fantasy play
Knows his/her address
Cognitive
Healthy Child Development…if a child is missing one or more of these expected age outcomes,
consider this a red flag:
Contact physician or paediatician. Self-referral.
A Child First. Woodstock (519) 421-0687 ext. 22. Tillsonburg (519) 842-9000 ext. 254. Self-referral.
Community Living Tillsonburg. (519) 842-9000. Self-referral.
Woodstock and District Developmental Services. (519) 539-7447. Self-referral.
7
Dental
Risk Factors for Early Childhood Tooth Decay…the presence of one or more of these risk factors
should be considered a red flag:
Risk of prolonged
exposure of teeth to
fermentable
carbohydrates
(includes formula,
juice, milk and breast
milk)

Physiological Risk
Factors

Other Risk Factors

Use of bottle, sippy cups, plastic bottles with straws
High sugar consumption in infancy
Sweetened pacifiers/soothers
Long-term sweetened medication
Going to sleep with a bottle containing anything but water
Prolonged use of a bottle beyond one year
Breastfeeding or bottle feeding without cleaning teeth
Frequent in between meal snacks containing sugar or cooked
starch (cariogenic snacks) without oral hygiene
Examples of cariogenic foods and drinks:

sugar and chocolate confectionary, candy

sugared breakfast cereals

fruit in syrup, jams, preserves and honey

cakes, buns, pastries, biscuits

soft drinks, sugared milk-based beverages

potato chips
Factors associated with poor enamel development, such as poor
prenatal nutrition, poor prenatal health and malnutrition of the child
Possible enamel deficiencies related to prematurity or low birth
weight
Lack of exposure of child’s teeth to fluoride
Transference of saliva containing oral bacteria from the
parent/caregiver to the child during the first two years of life,
through frequent, intimate contact by kissing on the mouth, licking
the child’s pacifier or bottle to “clean” it or by tasting the child’s food
Poor oral hygiene – visible plaque or gingivitis
Sibling history of early childhood tooth decay
Parent/caregiver with untreated dental disease
Lack of education of caregivers
Lower socioeconomic status
Limited access to dental care, including routine medical
preventative care and family dental care
Deficits in parenting skills and child management
Lack of routines for mealtimes, hygiene
Child’s exposure to second hand cigarette smoke
New immigrant status
Lack of knowledge of official languages
Late establishment of a dental facility and late first visit to a dentist
Previous history of tooth decay
Infrequent dental care and treatment for emergencies only
Physical and/or mental handicaps, developmental delays
Craniofacial anomalies, such as cleft lip and palate
Cancers
Refer also to Nutrition, and Feeding and Swallowing sections.
Contact dentist. Self-referral.
Oxford County Public Health Dental Services. (519) 539-9800 or 1-800-755-0394. Self-referral. Families
with limited finances may be eligible for the Children in Need of Treatment (CINOT) Program.
Healthy Babies Healthy Children program. Parenting support, information on early childhood tooth decay.
8
Parental Factors

History of abuse – parent or child
Severe health problems
Substance abuse*
Partner abuse*
Difficulty controlling anger or aggression*
Feelings of inadequacy, low self-esteem
Lack of knowledge or awareness of child development
A young, immature or developmentally delayed parent*
History of postpartum depression
History of crime
Lack of parent literacy
Social/Family Factors

Family breakdown
Multiple births
Several children close in age
A child with special needs
An unwanted child
Personality and temperament challenges in child or adult
Mental or physical illness* or special needs of a family member
Alcohol or drug abuse*
Lack of a support network or caregiver relief
Inadequate social services or supports to meet family’s needs
Prematurity or low birth weight
Economic Factors

Inadequate income
Unemployment
Business failure
Debt
Inadequate housing or eviction*
Change in economic status related to immigration
Family and Environmental Stressors
If any one of these stressors is found, this could affect a child’s normal development and should
be considered a red flag:
* Duty to Report: If there are suspicions or concerns about child protection you are legally
obligated to consult or report to the Children’s Aid Society of Oxford County at (519) 539-6176 or
1-800-250-7010. This includes any incident of a child witnessing family violence.
Healthy Babies Healthy Children program. Information and referrals to community resources and
supports. Information regarding adult education, literacy, employment counseling, family counseling
services.
Women’s Emergency Shelter Abused Women’s Help Line 24 hours a day. (519) 539-4811 or 1-800-2651938. Self-referral.
Mental health counseling and treatment.
Oxford County Social Services and Housing. (519) 539-9800 or 1-800-755-0394. Self-referral. Ontario
Works. Oxford County Housing.
9
0-3 months

Opens mouth wide when nipple touches lips
Sequences two or more sucks before pausing to breathe or swallow
Uses a sucking pattern and loses some liquid during sucking
4-6 months

Sequences 20 or more sucks from the breast or bottle
Swallows following sucking with no obvious pauses when hungry
Pauses infrequently for breaths
May have periodic choking, gagging or vomiting
Has voluntary control of mouth
Blows bubbles with saliva
7-8 months

No longer loses liquid during sucking
Drinks from a cup held by an adult
Uses a sucking motion with cup drinking, wide jaw movements with loss of
liquid
Eats soft food from a spoon
Swallows some thicker pureed foods and tiny, soft, slightly noticeable
lumps
Does not push food out of mouth with tongue, but minor loss of food will
occur
Moves the tongue up and down in a munching pattern with no side to side
movement
Does not yet use teeth and gums to clean food from lips
Enjoys holding food (finger-feeding introduced)

9-12 months

Is weaning from nipple as drinking from a cup increases
Takes up to three sucks before stopping or pulling away from the cup to
breathe
Has increasingly coordinated jaw, tongue and lip movements
Feeds at regular times
Easily closes lips on spoon and uses lips to remove food from spoon
Holds a soft cracker between the gums or teeth without biting all the way
through
Chews with up-down and diagonal rotary movements (circular motion)
Uses side to side tongue movement with ease when food is placed on the
side of the mouth
Finger-feeds self

Has sequences of at least three suck-swallows
May cough and choke if liquid flows too fast
May lose food or saliva while chewing
Has coordinated phonation, swallowing and breathing
Accepts all textures of food
Has lateral tongue motion (side to side motion)
Is able to bite a soft cracker
Is able to drink from a straw

13-18 months
10

24-36 months
(2-3 years)

Does not protrude the tongue from the mouth or rest the tongue beneath
the cup during drinking
Attempts to keep lips closed during chewing to prevent spillage
Swallows with lip closure
Does not lose food or saliva during swallowing but may still lose some
during chewing
Has precise up and down tongue movements
Exhibits rotary chewing
Is able to bite through a hard cracker
Predominantly self-feeds
19-24 months
Has rapid and skillful side to side chewing without a pause in the centre
Has lip closure with chewing and no longer loses food or saliva when
chewing
Will use tongue to clean food from the upper and lower lips
Is able to open jaw to bite foods of varying thicknesses
Holds a cup with one hand and drinks from an open cup without spillage
Fills a spoon with use of fingers
Self-feeds, uses fork
Problem Signs…if a child is experiencing any of the following, consider this a red flag:

Arching or stiffening of the body during feeding
Irritability or lack of alertness during feeding
Refusal of food or liquid
Failure to accept different textures of food
Difficulty chewing
Difficulty breastfeeding
Frequent choking or coughing during or after meals
Gurgly, hoarse or breathy voice quality
Recurring pneumonia or respiratory infections
Poor weight gain associated with feeding difficulties
New onset of refusing specific food thicknesses
Significant infant lethargy during feeds resulting in poor weight gain
Repeated swallows to clear food from mouth
Pauses in breathing or turning blue during feeds
See also Fine Motor Skills Section for self feeding. For nutritional concerns, see Nutrition Section.
tykeTALK. (519) 663-0273 or 1-877-818-TALK (8255). Self-referral. Indicate there are concerns regarding
feeding and swallowing.
Community Care Access Centre – South West. (519) 539-1284 or 1-800-561-5490. Self-referral. Provide
assessments regarding needs for nursing support, dietician referrals and speech language pathologist
referrals.
11
Fine Motor
By About 3 Months

Holds head in the middle or brings hands to middle when lying on
back
Pushes up on forearms to raise head when lying on stomach
Bats at toys or grasps a toy placed in hand
Brings hands to mouth
Has these grasps:

Rolls using arms to help
Pushes up on straight arms or raises arm to reach when lying on
stomach
Picks up and grasps objects in hands without help
Releases objects on purpose
Reaches for toys
Has these grasps:
By About 8 Months

Raises arm to reach when on hands and knees
Experiments by dropping, throwing, pushing and pulling objects
Can point
Attempts to release objects into containers
Passes objects from hand to hand
Can hold own bottle
Finger-feeding introduced
Has these grasps:
By About 12 Months

Puts hands out in all directions, including back to stop a fall
Has replaced mouthing toys with playing with the hands
Imitates scribbling
Has these grasps:
By About 18 Months

Spontaneously scribbles
Can build a 3-4 block tower
Can fill up a cup with blocks
Places large pegs in a peg board
Uses both hands at the same time to play with toys
Removes objects from a container by dumping
Grasps a pencil as shown
By About 6 Months
12

Turns pages of a book without help
Can put small objects into a container with a small opening
Can put simple shapes into a form board
Imitates drawing an “I” stroke
Snips with scissors
Holds own cup and uses a spoon
Grasps a pencil as shown:
By About 36 Months
(3 years)

Can draw a I, — and O
Can unbutton buttons
Copies block designs like
and
Can cut across a piece of paper
Eats independently (not knife)
By About 48 Months
(4 years)

Can draw a + and
Can trace a straight line
Can string small beads
Can cut on a straight line or around a circle
Shows a hand preference
By About 60 Months
(5 years)

Can connect dots with a straight line
Can button buttons

Copies complex block designs like
Can cut out a square
Is coordinated and fast at manipulating small objects
Fine Motor
By About 24 Months
(2 years)
Ontario Early Years Centre – Oxford County. (519) 539-9800 or 1-800-755-0394 ext. 3392. Self-referral.
Education and recommendations on fine motor activities.
Community Care Access Centre – South West. (519) 539-1284 or 1-800-561-5490. Self referral or
referral from principal or resource teacher if registered in school. Occupational and physical therapy
assessments for school-aged children.
13
Gross Motor

Rolls from front to back
Controls head and neck movement when sitting
Raises his/her head and chest when lying on stomach
Stretches out and kicks his/her legs when lying on his/her stomach
or back
Pushes down with his/her legs when feet are on a firm surface
By 9 months

Rolls both ways (front to back, back to front)
Sits on his/her own without support
Supports his/her whole weight on legs with support
Controls his/her upper body and arms
By 12-14 months

Reaches a sitting position without help
Crawls on hands and knees or scoots around on his/her bum
Gets from a sitting to a crawling or prone (on stomach) position
Pulls up to a standing position holding on to furniture
Stands briefly without support
Walks holding onto adult’s hands or furniture
May take 2 or 3 steps on his/her own
Starts to climb stairs with help
By 18 months

Walks alone or without help
Climbs stairs one at a time with help
Climbs into a chair
By 2 years

Pulls a toy while walking
Carries a large toy or more than one while walking
Begins to run
Kicks or throws a ball
Climbs into and gets down from a chair without help
Walks up and down stairs with help
By 3 years

Walks up and down stairs, alternating feet (one per stair)
Runs easily
Jumps in place
Throws a ball overhead
By 4 years

Hops and stands on one foot for up to 4 seconds
Kicks a ball forward
Catches a bounced ball
By 5 years

Hops on one foot
Throws and catches a ball successfully most of the time
Plays on playground equipment safely and without difficulty
Stands on one foot for more than 10 seconds
By 4 months

Problem signs…if a child is experiencing any of the following, consider this a red flag:

14
Asymmetry between two sides of the body
Infant with significant flattening of head
Baby prefers to hold head to one side - can be as early as birth
Baby is unable to hold head in the middle to turn and look left and right
Unable to walk with heels down four months after starting to walk
Ontario Early Years Centre – Oxford County. (519) 539-9800 or 1-800-755-0394 ext. 3392. Self-referral.
Education and recommendations on gross motor activities.
Community Care Access Centre – South West. (519) 539-1284 or 1-800-561-5490. Self-referral or
referral from principal or resource teacher if registered in school. Occupational and physical therapy
assessments for school-aged children.
15
Gross Motor
Hearing
By 6 months

Turns to source of sounds
Startles in response to sudden, loud noises
Makes different cries for different needs – I’m hungry, I’m tired
Watches your face as you talk
Imitates coughs or other sounds – ah, eh, buh
By 9 months

Responds to his/her name
Responds to the telephone ringing or a knock at the door
Understands being told “no”
Babbles and repeats sounds – babababa, duhduhduh
By 12 months

Follows simple one-step directions – “sit down”
Gets your attention using sounds, gestures and pointing
Combines lots of sounds as though talking – abada baduh abee
By 18 months

Uses at least 20 words consistently
Responds to simple questions – “Where’s teddy? “What’s that?”
Makes at least four different consonant sounds – p, b, m, n, d, g, w, h
Enjoys being read to and looking at simple books with you
By 24 months
(2 years)

Follows two-step directions – “go find your teddy bear and show it to Grandma”
Uses 100 to 150 words
Consistently combines two to four words in short phrases – “daddy hat”, “truck go
down”
By 30 months

Uses some adult grammar – “two cookies”, “bird is flying”, “I jumped”
Puts sounds at the start of most words

Has earaches
Is irritable or fussy
Interrupted sleep
Ear pulling (with fever or crankiness)

Loss of balance
Loud talking
Little response to quiet sounds
Fluid draining from ears
Refer also to the Speech and Language section.
Contact audiologist directly or contact physician for a referral to an audiologist.
Oxford County Public Health Health Matters Line. (519) 539-9800 or 1-800-755-0394. For a list of
audiologists.
tykeTALK. (519) 663-0273 or 1-877-818-TALK (8255). Self-referral. To obtain support for any child from
birth to six years of age identified with permanent hearing loss.
Infant Hearing Program. (519) 663-0273 or 1-877-818-TALK (8255). Self-referral. For infant hearing
screening.
16
If a child is missing one or more of these expected age outcomes, consider this a red flag:
By 6
months

Looks with interest at pictures in books
Prefers pictures of faces
Listens quietly to a story for a short time
Responds to songs, rhymes or stories
By 9
months

Shows a preference for certain books or rhymes
Reaches for books
Puts pages of book in mouth
Vocalizes and pats pictures
By 12
months

Points to pictures in books
Turns the pages with an adult’s help
Bounces in response to music and tries to sing along
By 18
months

No longer mouths the book right away
Gives books to an adult to read
Holds a book with help
Turns books right side up
Turns pages of a board book, several at a time
Points at pictures in a book with one finger
May make the same sound for a specific picture
Realizes the picture in a book is a symbol for a real object
Points when asked: “Where’s ….?”
By 24
months
(2 years)

Turns board book pages easily, one at a time
Points out and names familiar pictures
Knows words of favourite books and can fill in when you pause
Sings along with familiar songs and rhymes
Imitates finger plays and games with songs and rhymes
Pretends to read a book to dolls or stuffed animals
Attention span changes and is not consistent
By 30
months

Knows how to turn paper pages
Starts at the beginning of the book
Looks through a book for favourite pictures
Answers questions about the story
Points at pictures and makes comments about the story
Asks questions (e.g. “What’s that?”)
Asks for a favourite story to be read over and over
By 3 years
(36
months)

Turns paper pages one at a time
Recites whole phrases from the story
Reads familiar books to self
Protests when an adult gets a word wrong in a familiar story
Matches an object in his/her hand or room to a picture in a book
Makes some letter-like forms when scribbling
Knows his/her full name
Is starting to learn to count
By 4 years
(48
months)

Listens to longer stories
Recalls and retells familiar parts of a story
Reads a small book from memory or by making up the story
Protests when the adult skips a page when reading
17
Literacy
Literacy includes the ability to think, comprehend, communicate, read and write. From the time they are
born, children are continually developing a variety of important skills they will need to be able to read and
write. Very young children need opportunities to develop important early literacy skills. A supportive
environment and regular literacy experiences are important in building a solid foundation for a child’s later
reading and writing development.
Knows that you read words not pictures when reading a story
Guesses what comes next in a story
Is able to talk about the story when the story is over
Makes up and tells simple stories
Recognizes print in his/her environment (e.g. stop signs, restaurant signs)
Can identify about 10 letters of the alphabet
Makes up rhyming words
Recites nursery rhymes and sings simple songs
Is starting to hear sounds in words
Counts from 1 to 10
By 5 years
(60
months)

Knows that a book is read from front to back, top to bottom and left to right
Can repeat a phrase from a pattern book
Connects story to own experiences
Expresses personal views about the book
Prints his/her name
Recognizes patterns in words (e.g. cat, sat, mat)
Claps out 2 or 3 syllable words
Prints some letters by copying them
Names some book titles and authors
By 6 years
(72
months)

Listens attentively when hearing stories being read aloud
Correctly answers questions about stories that have been read aloud
Understands what they read by knowing the who, what, where, when and why
Makes a connection between the story and real life situation
Follows the written words when hearing stories being read aloud
Recognizes some familiar words by sight
Reads simple pattern books smoothly and easily with expression
Can say a word that rhymes with a spoken word
Can connect the sounds to the letters in three and four letter words
Recognizes and can name all of the upper and lower case letters of the alphabet
Prints many upper and lower case letters of the alphabet
Prints some letters and words when they are dictated
Understands each letter makes a sound and can use the sounds of letter and
letter knowledge to invent or spell creatively and independently
Literacy

Shows no interest in looking at books or listening to stories even when read expressively
Can not sit still to pay attention to a story
Does not understand when asked questions about the story
Is not able to hold and scribble with a crayon or pencil
Refer also to the Speech and Language, Hearing, and Vision sections.
Community-based parenting resource centres that provide early learning and literacy programs, including
reading circles, school readiness programs and learning through play. An Early Literacy Specialist is also
available.
tykeTALK. (519) 663-0273 or 1-877-818-TALK (8255). Self-referral. To obtain support for any child from
birth to six years of age identified with permanent hearing loss.
18
Indicators are the signs, symptoms or clues that when found on their own or in various combinations may
point to child abuse. Indicators may be apparent in the child’s physical condition and/or manifested in the
child’s behaviour.
Indicators do not prove that a child has been abused. They are clues that should alert staff that abuse
may have occurred. It is not the job of staff to assess the physical or psychological state of a child or
others involved. It is staff’s responsibility to report any suspicions to the Children’s Aid Society. The
assessment and validation of allegations of child abuse or family violence is the role of a Children’s Aid
Society and/or police.
Possible Indicators of Neglect
•
•
•
•
•
•
•
•
Physical Indicators in
Children
infants or young children
may display: abnormal
growth patterns, weight
loss, wizened “old man’s”
face, sunken cheeks,
dehydration, paleness,
lethargy, poor appetite,
unresponsiveness to
stimulation, very little
crying, delays in
development (which may
be suggestive of failure to
thrive syndrome)
inappropriate dress for the
weather
poor hygiene (i.e. dirty or
unbathed state)
severe/persistent diaper
rash or other skin disorder
not attended to
consistent hunger
untreated physical/dental
problems or injuries
lack of routine medical,
dental care
signs of deprivation (e.g.
diaper rash, hunger), which
improve in a more nurturing
environment
Behavioural Indicators in
Children
• does not meet
developmental
milestones
• appears lethargic,
undemanding, cries very
little
• unresponsive to
stimulation
• uninterested in
surroundings
• demonstrates severe lack
of attachment to parent,
unresponsive, little fear of
strangers
• may demonstrate
indiscriminate attachment
to other adults
• may be very demanding
of affection or attention
from others
• older children may
engage in anti-social
behaviours (e.g. stealing
food, substance abuse,
delinquent behaviour)
• shows poor school
attendance or
performance
• assumes parental role
• discloses neglect (e.g.
states there is no one at
home)
• independence and selfcare beyond the norm
Behaviours Observed in Adults
Who Neglect Children
• maintains a chaotic home life,
with little evidence of regular
routines (e.g. consistently
brings the child to care early,
picks up child very late)
• overwhelmed with own
problems and needs and puts
own needs ahead of child
• may indicate that child is hard
to care for, hard to feed or
describes the child as
demanding
• may indicate that the child was
or is unwanted
• fails to provide for the child’s
basic needs
• fails to provide adequate
supervision: often unaware of
or has no concern for the child’s
whereabouts, leaves child
alone or with unsuitable
caregivers
• cares for or leaves the child in
dangerous environments
• may display ignoring or
rejecting behaviour to the child
• has little involvement in the
child’s life, apathetic toward
child’s daily events, fails to
keep child’s appointments,
unresponsive when approached
with concerns
• may ignore child’s attempts at
affection
Duty to Report: If there are suspicions, you are legally obligated to consult or report to the Children’s
Aid Society of Oxford County at (519) 539-6176 or 1-800-250-7010. This includes any incident of a
child witnessing family violence.
19
Neglect and Abuse - Neglect
POSSIBLE INDICATORS OF CHILD ABUSE AND OF EXPOSURE TO FAMILY VIOLENCE
Neglect and Abuse - Emotional
Possible Indicators of Emotional Abuse
Children
• child fails to thrive
• frequent
psychosomatic
complaints (e.g.
headaches, nausea,
abdominal pain)
• wetting or soiling
• dressed differently
from other children in
the family
• has substandard
living conditions
compared to other
children in the family
• may have unusual
appearance (e.g.
bizarre haircuts,
dress, decorations)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Children
developmental lags
prolonged unhappiness,
stress, withdrawal,
aggressiveness, anger
regressive behaviours
and/or habit disorders (e.g.
toileting problems, thumbsucking, constant rocking)
overly compliant, too well
mannered
extreme attention-seeking
behaviours
self-destructive behaviour
(e.g. suicide threats or
attempts, substance abuse)
overly self-critical
such high self-expectations
that frustration and failure
result or avoids activities for
fear of failure
sets unrealistic goals to
gain adult approval
fearful of the consequences
of one’s actions
runs away
assumes parental role
poor peer relationships
discloses abuse
•
•
•
•
•
•
•
•
•
•
•
•
•
Behaviours Observed in Adults who
Abuse Children
consistently rejects the child
consistently degrades the child,
verbalizing negative feelings about
the child to the child and to others
blames the child for problems,
difficulties, disappointments
treats and/or describes the child as
different from other children and
siblings
identifies child with a disliked/hated
person
consistently ignores the child, actively
refuses to help the child or
acknowledge the child’s requests
isolates the child, does not allow the
child to have contact with others both
inside and outside the family (e.g.
locks the child in a closet or room)
corrupts the child, teaches or
reinforces criminal behaviour,
provides antisocial role modeling,
exploits the child for own gain
terrorizes the child (e.g. threatens the
child with physical harm or death,
threatens someone or something the
child treasures)
forces the child to watch physical
harm being inflicted on a loved one
withholds physical and verbal
affection from the child
makes excessive demands of the
child
exposes the child to
sexualized/violent media (e.g. videos,
TV)
Duty to Report: If there are suspicions, you are legally obligated to consult or report to the
Children’s Aid Society of Oxford County at (519) 539-6176 or 1-800-250-7010. This includes any
incident of a child witnessing family violence.
.
20
Physical Indicators in Children
•
•
•
•
•
•
•
•
•
•
•
injuries on questionable sites
bruise patterns, clustered
bruising or welts (e.g. from a
wooden spoon, hand/finger
print marks, belt)
burns from a cigarette,
patterned burns (e.g. iron,
electric burner), burns
suggesting that something was
used to restrain a child (e.g.
rope burns on the wrists,
ankles, neck), hot water
immersion burns
head injuries: nausea, absence
of hair in patches, irritability
skull fractures: possible
swelling and pain, vomiting,
seizures, dizziness, unequal
pupil size, bleeding from scalp
wounds or nose
fractures, dislocations, multiple
fractures all at once or over
time, pain in the limbs,
especially with movement,
tenderness, limitation of
movement, limping or not using
a limb, any fractures in children
under 2
fractures of the ribs: painful
breathing, difficulty raising arms
distorted facial appearance with
swelling, bleeding, bruising
human bite marks
lacerations and abrasions
inconsistent with normal play
evidence of recent female
genital mutilation (e.g. difficulty
voiding, chronic infections,
“waddling”)
Children
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
cannot recall or describe how
observed injuries occurred
avoids or offers inconsistent,
incomplete explanations, is
distressed explaining injuries
or denies injury
wary of adults generally or of
a particular gender or
individual
may cringe or flinch with
physical contact
may display over-vigilance, a
frozen watchfulness or vacant
stare
extremes in behaviour:
extremely aggressive or
passive, unhappy or
withdrawn, extremely
compliant and eager to
please or extremely noncompliant (provokes
punishment)
tries to take care of the parent
may be dressed
inappropriately to cover
injuries
is afraid to go home, runs
away
is frequently absent with no
explanation or shows signs of
a healing injury on return
evidence of developmental
lags, especially in language
and motor skills
academic or behavioural
problems
self-destructive behaviour
(e.g. self-mutilation, suicide
threats or attempts)
discloses abuse
•
•
•
•
•
•
•
•
•
•
Neglect and Abuse - Physical
Possible Indicators of Physical Abuse
Behaviours
Observed in Adults who
Abuse Children
gives harsh, impulsive or
unusual punishments
shows lack of self-control
with low frustration
tolerance, is angry,
impatient
may provide inconsistent
explanations as to how
the child was injured
socially isolated, little
support or parenting relief
may have little knowledge
of child development
and/or have unrealistic
expectations of the child
may often express having
difficulties coping with the
child or makes
disparaging remarks,
describes child as
different, bad or the
cause of own difficulties
may demonstrate little or
no genuine affection,
physically or emotionally
for the child
may state that the child is
accident prone or clumsy
may delay seeking
medical attention
may appear
unconcerned, indifferent
or hostile to child and
injury
Duty to Report: If there are suspicions, you are legally obligated to consult or report to the Children’s
Aid Society of Oxford County at (519) 539-6176 or 1-800-250-7010. This includes any incident of a
child witnessing family violence.
21
Neglect and Abuse – Sexual
Possible Indicators of Sexual Abuse
Children
• unusual or excess
itching or pain in the
throat, genital or anal
area
• odor or discharge
from genital area
• stained or bloody
underclothing
• pain on urination,
elimination, sitting
down, walking or
swallowing
• blood in urine or stool
• injury to the breasts
or genital area;
redness, bruising,
lacerations, tears,
swelling, bleeding
• poor personal
hygiene
• sexually transmitted
disease
• pregnancy
Behavioural Indicators in Children
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
age-inappropriate sexual behaviour
with toys, self, others
re-enactment of adult sexual
activities
age-inappropriate explicit drawings,
descriptions
bizarre, sophisticated or unusual
sexual knowledge
sexualized behaviours with other
children, adults
sexual behaviour with other children
involving force or secrecy
reluctance or refusal to go to a
parent, relative, friend for no
apparent reason, mistrust of others
recurring physical complaints with
no physical basis
unexplained changes in personality
(e.g. outgoing child becomes
withdrawn, global distrust of others)
nightmares, night terrors and sleep
disturbances
clinging or extreme seeking of
affection or attention
regressive behaviour (e.g. bedwetting, thumb-sucking)
resists being undressed or when
undressing shows apprehension or
fear
changes in school performance
engages in self-destructive or selfmutilating behaviours (e.g.
substance abuse, eating disorders,
suicide)
child may act out sexually or
become involved in prostitution
runs away
discloses abuse
Behaviours observed in
Adults who Abuse Children
• may be unusually
overprotective, overinvested in the child (e.g.
clings to the child for
comfort)
• is frequently alone with the
child and is socially isolated
• may be jealous of the
child’s relationships with
peers or adults
• discourages, disallows child
to have unsupervised
contact with peers
• states that the child is
sexual or provocative
• shows physical contact or
affection for the child that
appears sexual in nature
• relationship with the child
may be inappropriate,
sexualized or spousal in
nature
• may abuse substances to
lower inhibitions against
sexually abusive behaviour
• permits or encourages the
child to engage in sexual
behaviour
22
Children’s sexual behaviour must be considered along a continuum, like other areas of growth. Many
behaviours are to be expected, are healthy and within the normal range for children. Some behaviours
are problematic and certainly of concern. These are the “worrisome” behaviours and should not be
ignored or seen as child’s play. These behaviours may require some degree of redirection or intervention.
Other behaviours are problematic and may be dangerous physically or psychologically to the child and
others. Staff may require consultation regarding these behaviours, as these children may need
professional help.
Sexual Behaviour in Toddlers and Preschoolers
Type of Behaviour
Curiosity
Behaviours
•
•
Self-Exploration
•
•
•
•
•
•
Behaviour with
Others
•
•
•
•
•
•
Okay
asks age appropriate
questions about
where babies come
from, sexual
characteristics
children learn to
name body parts
likes to be nude
has erections
explores own body
with curiosity and
pleasure
touches own genitals
as a self-soothing
behaviour (e.g. when
going to sleep, when
feeling sick, tense or
afraid)
toilet training
highlights the child’s
awareness of genital
area
puts objects in own
genitals or rectum
without discomfort
through play,
inspects the bodies of
other children,
explores differences
looks at nude
persons when the
opportunity arises
wants to touch
genitals to see what
they feel like
may show his/her
genitals or buttocks
to others
may strip in public
emotional tone of
behaviour is fun, silly,
may be embarrassed
•
•
•
•
•
•
•
•
•
•
Worrisome
shows fear or
anxiety around
sexual topics
self-stimulates on
furniture, uses
objects to selfstimulate
imitates sexual
behaviour with
dolls or toys
continues to selfstimulate in
public after being
told that this
behaviour should
take place in
private
puts something in
genitals, rectum,
even when it
feels
uncomfortable
continues to play
games like
“doctor” after
limits set
confused about
male and female
differences, even
after they have
been explained
continually wants
to touch other
people
tries to engage in
adult sexual
behaviours
simulates sexual
activity with
clothes on
•
•
•
•
•
•
•
•
•
•
Get Help
asks almost endless
questions on topics
related to sex
knows too much
about sexuality for
age and stage of
development
self-stimulates
publicly or privately to
the exclusion of other
activities
self-stimulates on
other people
causes harm to own
genitals, rectum
forces, bullies other
children to disrobe,
engage in sexual
behaviour
dramatic play of sad,
angry or aggressive
scenes between
people
demands to see the
genitals of other
children or adults
manipulates or forces
other children into
touching of genitals,
simulating sexual
activity with clothes
off, oral sex
sexual behaviour with
other children
involves secrecy
23
Neglect and Abuse - Sexual Behaviour
CHILDREN’S SEXUAL BEHAVIOUR IN CONTEXT
Neglect and Abuse - Sexual Behaviour
Bathroom,
Toileting and
Sexual
Functions
•
•
•
•
Relationships
•
•
•
•
•
Behaviour with
Animals
•
interest in urination,
defecation
curious about, peeks
at people performing
all bathroom
functions, including
shaving, putting on
makeup
some preschoolers
want privacy in the
bathroom and when
changing
uses inappropriate
language or slang for
toileting and sexual
functions
plays house with
peers
will role play all
aspects of
male/female lives to
learn, explore,
rehearse
kisses and hugs
people who are
significant to him/her
may exchange
information on sexual
discoveries
may imitate sex in a
rudimentary fashion
•
•
curiosity about how
animals have babies
•
•
•
•
•
•
•
•
smears feces
purposefully
urinates in
inappropriate
places
often caught
watching others
perform intimate
bathroom functions
continues to use
inappropriate
language or slang
after limits are set
•
focuses on sexual
aspects of adult
relationships
afraid of being
kissed or hugged
talks or acts in a
sexualized manner
with others
uses sexual
language even
after limits set
talks or engages in
play about sex to
the exclusion of
other topics
•
touches genitals of
animals
•
•
•
•
•
•
•
•
repeatedly smears
feces
continues to urinate
in inappropriate
places
does not allow others
privacy in the
bathroom or bedroom
continually uses
inappropriate
language or slang
without regard for
limits set
graphically imitates or
re-enacts adult
sexual behaviour
displays fear or anger
about babies and
giving birth
physical contact with
others causes anxiety
talks in a sexualized
manner with others,
including unfamiliar
adults
sexualizes all
interactions with
other children and
adults
sexual behaviour with
animals
24
Children
• child fails to thrive
• frequent
psychosomatic
complaints (e.g.
headaches,
stomachaches)
• physical harm,
whether deliberate
or accidental,
during or after a
violent episode,
including while
trying to protect
others or as a
result of objects
thrown
Behavioural Indicators in Children
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
aggressive, acting-out, temper tantrums
re-enactment of parental behaviour
exhibits withdrawn, depressed and
anxious behaviours (e.g. clingy, whining,
excessive crying, separation anxiety)
cuddles or manipulates in an effort to
reduce anxiety
overly passive, patient, compliant and
approval seeking
fearful (e.g. of self/family members being
hurt/killed, of being abandoned, of the
expression of anger by self or others)
low tolerance for frustration
sleep disturbances (e.g. insomnia, resists
bedtime, fear of the dark, nightmares)
bed-wetting
self-destructive behaviour (e.g. eating
disorders, substance abuse, suicide
threats or attempts)
hovers around the house or avoids home
clumsy, accident-prone
problems with school (e.g. poor
concentration, academics, attendance)
high/perfectionist self-expectations, with
fear of failure resulting in high academic
achievement
assumes responsibility to protect/help
other family members
runs away from home
cruelty to animals
involvement in crime or delinquency (e.g.
stealing, assault, drugs, gangs)
homicidal thoughts/actions
child may act out sexually, becomes
involved in prostitution
child expresses the belief that s/he is
responsible for the violence
discloses family violence
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Behaviours Observed in
Adults
abuser has poor selfcontrol, social skills
and/or communication
skills
abuser controls using
threats and violence (e.g.
terrorizes with threats of
harm or death to others
or to something the
person treasures, cruelty
to animals)
exposes the child to
physical/emotional harm
inflicted on parent/partner
excessive monitoring of
partner’s activities
abuser publicly degrades,
insults, blames or
humiliates partner
jealous of partner’s
contact with others
isolates the child/family
members from friends,
other family and supports
parent/partner neglects
children due to
inaccessibility to
resources, isolation,
depression or focus on
self-survival
expresses strong belief in
traditional male/female
roles
abuser makes excessive
demands of partner
substance abuse
discloses family violence
victim appears fearful
discloses that the abuser
assaulted or threw
objects at someone
holding a child
Women’s Emergency Shelter Abused Women’s Help Line 24 hours a day. (519) 539-4811 or 1-800-2651938. Self-referral.
25
Neglect and Abuse - Witnessing Family Violence
Possible Indicators of Exposure to Family Violence
Nutrition
If a child presents one or more of the following risk factors, consider this a red flag:
Birth to 6 months

6-9 months

9-12 months

12-24 months
(1 – 2 years)

26
Newborn not being fed whenever he/she shows signs of hunger
Healthy, full term breastfed infant does not have at least 6 wet diapers
each day by day 4 with urine that is clear or pale yellow and/or does not
have at least 3 bowel movements each day after day 1
Exclusively breastfed infant is not receiving a vitamin D supplement,
particularly one at risk of a vitamin D deficiency
Infant formula is not iron-fortified
Liquids (including water) or solids other than breastmilk or iron-fortified
formula are given before 4 months (6 months is recommended)
Infant is using a propped bottle
Infant cereal is given in a bottle
For the first 4 months, water for infant formula is not brought to a rolling
boil for 2 minutes
Private well water used for infant feeding is not being regularly tested
Infant formula is not being mixed correctly (i.e. correct dilution)
Breastfed or partially breastfed infant is drinking less than 32 oz (1 L)
formula and not receiving a vitamin D supplement, particularly one at
risk of a vitamin D deficiency
Cow’s milk is given instead of breastmilk or infant formula
Iron-containing foods have not been introduced by 7 months
Infant is not eating willingly or parents imply that they force-feed
Infant is drinking more than 4 oz (125 mL) of fruit juice per day
Fruit drinks, pop, coffee, tea, cola, hot chocolate, soy beverages, other
vegetarian beverages, herbal products, egg white or honey is given
Infant is fed using a propped bottle
Infant cereal is given in a bottle
Infant formula is not being mixed correctly (i.e. correct dilution)
Breastfed or partially breastfed infant is drinking less than 32 oz (1 L)
formula not receiving a vitamin D supplement, particularly one at risk of
a vitamin D deficiency
At 10 months, consistently refuses lumpy or textured foods
Infant is not supervised during feeding
Fruit drinks, pop, coffee, tea, cola, hot chocolate, soy beverages, other
vegetarian beverages, herbal products, egg white or honey is given
Breastfed child not receiving a vitamin D supplement
Skim milk is regularly given
Soy beverage, other vegetarian beverages or herbal teas are given
Drinking liquids primarily from a baby bottle
Not eating a variety of table foods
Consistently refuses lumpy or textured foods
At 15 months, does not finger/self feed
Parents not recognizing and responding to verbal and non-verbal
hunger cues
Parents pressure or reward child to eat
Child is not supervised during feeding
Child does not finger/self feed
Excessive fluid consumption, e.g. milk (more than 24 oz a day), juice
(more than 4-6 oz a day), pop and fruit drinks

BMI-for-age ≥ 95th centile
Drinking liquids primarily from a bottle
Excessive fluid consumption, e.g. milk (more than 24 oz a day), juice
(more than 4-6 oz a day), pop and fruit drinks
Child does not self feed
Parent not allowing the child to decide how much to eat
Parents are using a highly restrictive approach to feeding
More than 2 hours of TV watching a day
Does not eat at regular times throughout the day (breakfast, lunch and
supper and 2-3 snacks)
Does not eat a variety of table foods from the four food groups in
Canada’s Food Guide
Nutrition
2-6 Years

Breastfed infant is not receiving a vitamin D supplement
Unexpected and/or unexplained weight loss or gain
Rate of growth is falling off the growth curve
Healthcare professional identifies that infant or child is not following his/her percentile curve on
growth chart
Food allergies (e.g. cow’s milk) or food intolerance (e.g. lactose intolerance)
Problems with sucking, chewing, swallowing, gagging, vomiting or coughing while eating
Frequent constipation and/or diarrhea, abdominal pain
Displays signs of iron deficiency (e.g. irritability, recurrent illness)
Follows a “special diet” that limits or includes special foods
Eats non-food items
Suffers from tooth or mouth problems that make it difficult to eat or drink
Mealtimes are rarely pleasant
Consistently not eating from one or more of the food groups
Excludes all animal products including milk and eggs
Drinks throughout the day and is not hungry at mealtimes
Unsafe or inappropriate foods are given (e.g. raw eggs, unpasteurized milk, foods that are
choking hazards, herbal teas, pop, fruit drink)
Home has inadequate food storage/cooking facilities
Parent or caregiver is unable to obtain adequate food due to financial constraints
Parent or caregiver offers inappropriate amounts of food or force feeds
Refer also to the Feeding and Swallowing section.
Oxford County Public Health Health Matters Line. (519) 539-9800 or 1-800-755-0394. Self-referral.
Public Health Registered Dietician. Breastfeeding support. NutriSTEP®.
Woodstock General Hospital – Registered Dietician. (519) 421-4211. Physician referral.
Community Care Access Centre – South West. (519) 539-1284 or 1-800-561-5490. Self-referral. Dietician
and case manager assessments.
Eat Right Ontario. 1-877-510-510-2. Call toll-free to speak with a Registered Dietician Monday through
Friday 9 am – 5 pm.
27
Parental mood disorders are a significant factor that can place children’s development and health at risk.
Mood disorders can cause mothers to be inconsistent with the way they care for their children. The
following statements are reflective of the parent’s ability to be attentive, attuned and able to respond
sensitively to the infant.
If the parent states that one or more of these statements are true, consider this a red flag:

Tearful, crying more than usual or for no reason
Describes mood as low, depressed, sad, irritable
Anxiety about baby’s health or own ability as a mother
Loss of interest or loss of enjoyment in activities that used to give them pleasure
Significant weight loss or gain
Changes in appetite, loss of desire for or enjoyment of food
Unable to sleep when baby sleeps, difficulty falling asleep and staying asleep
Sense of exhaustion despite obtaining sleep or rest
Feelings of being slowed down, moving slowly or experiencing sluggishness
Feelings of being restless, jumpy, on edge
Excessive and inappropriate feelings of guilt, worthlessness, hopelessness
Inability to concentrate, slowed thinking
Difficulty finishing a job or making simple decisions
Excessive sweating, heart palpitations
Nausea, faintness
Extreme irritability, frustration or angry feelings*
Thoughts about hurting oneself or the baby, preoccupation with death*
Risk Factors for Postpartum Depression (PPD)
Although hormonal variables play a role in precipitating PPD, current evidence suggests that social and
psychological factors play an equal or greater role. Prolonged or chronic, untreated postpartum
depression may hamper mother-infant attachment and could possibly hinder the child’s cognitive and
behavioural development.

Depression during pregnancy
Anxiety during pregnancy
Personal history of depression or mood disorder
Family history of depression or mood disorder (immediate family)
Stressful recent life events (moving, death of a loved one)
Lack of social support (either perceived or received)
Maternal personality (worrier, negative thinking styles, anxious, “nervous”)
Low self-esteem
Relationship difficulties
Low socio-economic status (SES) or change is SES
Obstetric and pregnancy complications
Postpartum Psychosis
The most severe and very rare form of postpartum mood disorder, which requires an immediate
emergency psychiatric referral.

28
Extreme depressed or elated mood (mania), may fluctuate rapidly between these two states
Bizarre, disorganized behaviour
Confused or perplexed
Psychotic symptoms including:
o delusions - false fixed beliefs that have no rational basis in reality
o hallucinations – perceptual distortions that have no external stimulus
auditory – hearing noises or voices that other people cannot see
visual – seeing things that are not present and that other people cannot see
o Examples of psychotic symptoms: the mother believes that her baby has special powers,
the mother believes that she is a famous artist, the mother hears voices that are telling
her to do something
Canadian Mental Health Association 24 hour Crisis Line. (519) 539-8342 or 1-877-339-8342. Selfreferral. Crisis intervention - Professional Crisis Support Workers respond by phone and/or personal
contact to individuals experiencing a sudden or unexpected event that places them in distress.
* Duty to Report: If there are suspicions or concerns about child protection you are legally
obligated to consult or report to the Children’s Aid Society of Oxford County at (519) 539-6176 or
1-800-250-7010. This includes any incident of a child witnessing family violence.
Contact physician, obstetrician/gynecologist or midwife for further assessment. Self-referral.
Canadian Mental Health Association Oxford County Branch. (519) 539-8055 or 1-800-859-7248. Selfreferral. Information and referral service for mental health supports and services.
Woodstock General Hospital’s Mental Health Services. (519) 421-4223. Self-referral. Mental health
assessments and treatment, individual and group counseling and psychiatric consultations.
Healthy Babies Healthy Children program. Information and referrals to community resources and
supports.
29
School Readiness
School Readiness…if a child is missing one or more of these expected age outcomes and/or
health needs, consider this a red flag:
Has had all of his/her shots
Has had a dental and medical check-up
Has had vision checked
Is toilet trained during the day
Can wash hands independently
Health Needs

Physical
Abilities

Social Abilities

Speaks clearly enough for others to understand what he/she is saying
Understands that words can be written as well as spoken
Follows two-step directions
Usually plays well with other children, takes turns, shares some toys
Can sit for up to 10 minutes doing an activity
Follows rules
Can work on an activity alone for a short time
Learned
Abilities

Sits and listens to a short (2-5 minute) story
Can say his/her first and last name and age
Can say 3-5 songs or rhymes
Tells and retells familiar stories
Names colours and some shapes
Identifies common zoo/farm animals (e.g. elephant, horse, cow)
Can name 6 parts of his/her body
Safety
Knowledge

Gets on and off a bus safely
Walks safely to school with supervision
Can say his/her address and telephone number
Walks, runs and climbs
Jumps and skips
Stands on one foot for the count of 5
Walks up and down stairs using alternating feet
Holds and uses a pencil, crayons and scissors
Can dress himself/herself, including buttons and zippers
Can print his/her name using capital and lower case letters (e.g. John)
Holds a book upright and turns pages from front to back
Can throw a ball overhand
Can build a tower of 10 or more blocks
* Bolded areas are more common in children who are 5 years old
Oxford County Public Health Health Matters Line. (519) 539-9800 or 1-800-755-0394. Self-referral.
Preschool screening.
Early learning, literacy and school readiness programs for children ages 0-6 and their parents and
caregivers.
Ready for School. http://readyforschool.ca. A 4 day school readiness program for children starting school
in September.
Community Care Access Centre – South West. (519) 539-1284 or 1-800-561-5490. Self-referral.
Assessments for School Health Support Services.
30
Problem signs…if a child’s responses are exaggerated, extreme and do not seem typical for the
child’s age, consider this a red flag:
Auditory

Over- or under-responsive to loud, high-pitched or low-pitched noises
Blocks out unwanted noise with humming or singing
Visual

Avoids eye contact, has difficulty focusing on objects
Appears sensitive to sunlight, bright lights or changes in lighting
Does not respond when new people enter a room
Focuses on patterns, shadows, reflections, spinning objects
Taste and
Smell

Regularly avoids particular foods, food categories, consistencies and textures,
temperatures or a entire food group
Over- or under-responsive to strong smells or tastes
Chews or licks non-edible objects
Touch

Avoids touch or contact, resists being held
Has little response to touch or pain
Over-responsive to certain fabrics, weight of clothing, bathing
Over- or under-responsive to temperature
Does not appear to notice if diaper is wet or dirty
Does not notice if face or hands are messy or wet
Avoids categories of toys (i.e. vibrating, stuffed, rough textured toys)
Seeks pressure (squeeze between furniture, heavy blankets, firm massages)
Movement and
Body Position

Distressed with sudden movements (jumping, riding a merry-go-round)
Fearful of heights, climbing, playground equipment
Clumsy, has poor balance
Frequently engages in repetitive, non-purposeful movement
Activity Level

Has difficulty with unexpected change and/or transitions in activities
Very inactive, under-responsive or very active and fidgety
Has difficulty falling asleep or staying asleep
Engages in solitary play, avoids group activities
31
Sensory
Sensory integration refers to the ability to receive input through all of the senses and the ability to process
this sensory information into automatic and appropriate adaptive responses.
Sleep
Research indicates that the development of healthy sleep habits is important for the emotional well being
and cognitive development of young children. In addition, sleep problems can have a negative impact on
the parent-child relationship and/or general family functioning. Different families have different
philosophies around where and how children should sleep; however, what is important is that children
and their parents are achieving restful and restorative sleep on a regular basis.
Guide to Average Sleep Needs:
Age
Average Hours
0 - 2 months
16 – 18 hours
2 – 6 months
14 – 16 hours
6 – 12 months
13 – 15 hours
1 to 3 years
12 – 14 hours
3 to 5 years
10 – 11 hours
If the following concerns are noted, consider this a red flag.
If over nine to twelve months of age the infant or child:

Is still waking several times a night and not able to fall back to sleep on his/her own
Sleep pattern is not improving after the age of 3 months i.e. sleeping longer stretches at night
Expresses significant anxiety (e.g. screaming, vomiting) when put to bed
Is unable to fall asleep on his/her own at night or naptime and this is causing stress for the family and
interfering with child sleep
Is reliant on a parent or activity (e.g. drinking a bottle, being carried around) and this is causing stress
for the family and interfering with child sleep
Does not have any set schedule for sleep onset or wakening or naps
Does not have periods when he/she is well rested, playful and alert
Appears tired and cranky during the day due to lack of sleep
If over two years of age the toddler or child:

Refuses to stay in his/her bed or room at night time
Has difficulty getting up in the morning
Falls back asleep after being woken and needs to be woken repeatedly
Lacks interest, motivation and attention
Has persistent and loud snoring or experiences pauses or any difficulty with breathing during sleep
Has persistent or frequent nightmares, night terrors or sleepwalking
Previously was a good sleeper and suddenly becomes a restless sleeper
Has nightmares that are affecting the child’s ability to function during the day and/or are causing the
development of secondary bedtime fears
Support around sleep difficulties in infants or young children.
Healthy Babies Healthy Children program. Information on infant sleep patterns.
32
By 3 months

Smiles when smiled at or spontaneously
Is expressive and can communicate with his/her face and body
Is able to copy some body movements and facial expressions
By 8 months

Reaches for people that are recognized
Smiles at self in a mirror
Responds to other people’s expressions of emotion
Can be comforted by a familiar person when upset
By 12 months

May develop separation anxiety when separated from caregiver
Enjoys imitating people in play
Shows preferences for certain toys and people
Tests limits placed on them by familiar adults
Is able to communicate a need without crying
Enjoys being picked up and held
Expresses a variety of emotions, such as fear, anger and happiness
By 18 months

Follows simple instruction, helps with simple tasks when asked
Is curious and enjoys exploring
May be very possessive, doesn’t understand “mine” vs. “someone else’s”
Is easily distracted
May express his/her self in a physical manner, such as tantrums, hitting, biting
to achieve a desired object or toy
By 24 months

Shows increasing independence
Imitates behaviour of others, particularly of adults and older children
Begins to show defiant behaviour
Is aware of self as separate from others
Is able to follow a single direction at a time
Handles transitions from one activity to another with little difficulty
Is able to play beside peers with his/her own toys and materials
By 3 years

Shows spontaneous affection for playmates they know, greets familiar adults
Begins to take turns, understands the concept of “mine” vs. “someone else’s”
Objects to changes in routine, anticipates daily activities
Puts toys away
Asks for help
Is able to express his/her self using verbal communication and gestures
Is able to complete an activity or task in a logical order (e.g. dressing)
Ends one activity and moves to another with little frustration
By 4 years

Looks forward to new experiences
Cooperates with other children
Is able to show empathy towards others
Seeks approval from others, wants to feel important
Seeks attention from others in appropriate ways
Is inventive and imaginative, imagines monsters, plays “Mom” or “Dad”
Is able to negotiate solutions to conflicts
Is able to problem solve simple tasks without becoming easily frustrated
Controls impulses, self regulates emotions
Is toilet trained during the day
33
Behaviour should not be looked at in isolation, but within the context of the circumstances a child
is in. Behaviour should be looked at according to age appropriateness, developmental level,
frequency and severity.
Problem signs…if the child presents any of the following behaviours, consider this a red flag:

Injures self (e.g. bites or slaps self, picks or sucks on skin, eats inedible items, intentionally
vomits, bangs head)
Injures others (e.g. unprovoked hitting, kicking, biting or hurting those less able)
Is cruel to animals
Is extremely aggressive (e.g. excessive threats towards others, unpredictable outbursts)
Screams, swears or cries excessively
Exhibits potentially harmful risk taking activity (e.g. running into traffic, setting fires)
Has deficits in or loses previously acquired life skills (e.g. eating, toileting, dressing)
Engages in repetitive movements (e.g. spinning, hand-flapping, hand wringing, rocking)
Has an unusual preoccupation with objects such as fans, light switches or clocks
Exhibits compulsive behaviours or has obsessive thoughts that interfere with daily activities
Behaves in socially inappropriate ways (e.g. undresses in public, touches self or others in
inappropriate ways)
Has a flat affect, inappropriate emotions, is passive or withdrawn
Has difficulty paying attention, is hyperactive, overly impulsive, restless or fidgety
Is excessively cautious, timid, fearful or anxious, is afraid to try new things
Is defiant (i.e. child does the opposite of what is requested)
Has difficulty with transitions and unexpected changes
Shows decreased interest in other children, engages in only solitary play
Is difficult to engage in interactions, avoids eye contact, appears indifferent to other people
Exhibits delayed or no imaginative play
Support around behaviour management, individual and family therapy.
Parent workshops on behaviour, discipline and parenting styles.
Healthy Babies Healthy Children program. Lists of private counseling services.
Community Care Access Centre – South West. (519) 539-1284 or 1-800-561-5490. Self referral. Case
manager assessments.
Woodstock General Hospital Child Mental Health Program. (519) 421-4223. Self-referral. For mental
health assessments, screening and individual and family therapy.
34
0-3
months

Cries and grunts, has different cries for different needs
Makes lots of “cooing” and “gooing” sounds
4-6
months

Startles in response to loud noises
Babbles using different sounds
Tells you with voice sounds to do something again
Makes “gurgling” noises
Watches your face as you talk
Smiles and laughs in response to your smiles and laughs
By 9
months

Responds to his/her name
Understands being told “no”
“Performs” for social attention
Gives very familiar objects when asked
Babbles using repetitive sounds (e.g. mama, bababa)
Uses sounds or gestures to let you know what he/she wants
By 12
months

Strings many different sounds together, as if he/she really talking
Imitates interesting sounds that you make like “wee” or “uh-oh”
Imitates or uses gestures like waving hi/bye
Consistently uses 3-5 words (e.g. mama, “doo” for juice)
Follows simple directions like “sit down” or “come here” with gestures
By 18
months

Uses 20 or more words consistently and uses more new words every week
Begins to put two words together in a phrase
Answers “What’s this” questions
Makes these sounds: p, b, m, n, d, g, w, h
Understands more words than he/she can say
Follows simple directions without gestures (Show me the ___)
Points to three body parts
Uses toys for pretend play
Enjoys being read to and looking at simple books
By 24
months

Uses 150-300 different words
Uses 2 pronouns (e.g. I, me, you)
Uses two word combinations most of the time (e.g. Daddy car)
Speaks clearly enough to be understood about 2/3 of the time
Points to familiar actions/activities in pictures (e.g. sleep, eat)
Holds books the right way up and turns pages
“Reads” to stuffed animals or toys
Follows directions to put objects “on”, “off” or “in”
Chooses among common objects when asked (find the ball)
By 30
months

Uses at least 450 different words
Begins to use verbs with “ing” endings (e.g. eating)
Says his/her first name when asked
Answers questions like “Where is teddy?”
Uses sentences of up to 3 words combining nouns and verbs (e.g. Daddy go car)
Puts sounds at the beginning and end of most words
Produces sounds with two or more syllables (e.g. ap-ple, ba-na-na)
Understands concepts such as “big” and “little”
Begins to point to objects from a group by their function and parts (e.g. Which one
has wheels? Or which one can we eat?)
Recognizes familiar logos and signs (e.g. stop sign)

Uses 900-1000 different words
Uses sentences of three or more words
Asks questions like “Who”, “Where”, and “Why”
By 3 years
Speech and Language
consider this a red flag
35
Speech and Language

By 4 years

By 5 years

Tells simple stories and talks about things that happened in the past
Speaks clearly enough for people outside the family to understand most of the time
Follows two-part directions like “Go to the kitchen and get your hat” without
gestures
Engages in multi-step pretend play (e.g. cooking a meal)
Is aware of the function of print (e.g. menus, lists, signs)
Begins to have interest in and awareness of rhyming words
Uses four to five word sentences that have adult-like grammar
Tells a story that is easy to follow, with a beginning, middle and end
Predicts what might happen next in a story
Gives first and last name, gender and age
Speaks clearly enough to be understood by people outside the family almost all of
the time
Follows three-part directions like “Get your boots, put them on, and wait by the
door”
Is beginning to generate simple rhymes (cat-bat)
Follows group directions (e.g. All of the boys get a toy)
Understands directions involving “if….then” (e.g. If you are wearing running shoes,
then line up for the gym)
Uses most consonant and vowel sounds correctly
Describes past, present and future events in detail
Seeks to please his/her friends
Knows the letters of the alphabet
Identifies the sounds at the beginning of some words (e.g. “pop” starts with a “puh”
sound)
Problem signs…if a child is experiencing any of the following, consider this a red flag:

Stumbling or getting stuck on words (stuttering)
Ongoing hoarse voice
Excessive drooling not associated with teething
Chronic ear infections
Problems with swallowing, chewing or eating foods with certain textures (gagging)
Frustrated or embarrassed when communicating verbally
Refer also to Behaviour, Social and Emotional, Literacy, and Hearing sections.
tykeTALK. (519) 663-0273 or 1-877-818-TALK (8255). Self-referral.
Community Care Access Centre – South West. (519) 539-1284 or 1-800-561-5490. Self referral or
referral from principal or resource teacher if registered in school. Provide assessments regarding needs
for nursing support, speech language pathologist referrals and the School Health Support program.
36
By 6 weeks

Stares at surroundings when awake
Briefly looks at bright lights/objects
Blinks in response to light
Moves eyes and head together
By 3 months

Eyes glance from one object to another
Eyes follow a moving object/person
Stares at caregiver’s face
Begins to look at hands, food and bottle
By 6 months

Eyes move to inspect surroundings
Eyes move to look for source of sounds
Swipes at or reaches for objects
Looks at more distant objects
Smiles and laughs when he or she sees you smile and laugh
By 12 months

Eyes turn inward as objects move close to the nose
Watches for activities in surroundings for longer time periods
Looks for a dropped toy
Visually inspects objects and people
Creeps toward favourite toy
By 2 years

Guides reaching and grasping for objects with vision
Looks at simple pictures in a book
Points to objects or people
Looks for and points to pictures in books
Looks where he or she is going when walking and climbing
Vision
consider this a red flag

Swollen or encrusted eyelids
Bumps, sores or styes on or around
the eyelids
Drooping eyelids
Does not make eye contact with you
by three months of age
Does not follow an object with the
eyes by three months
Haziness or whitish appearance inside
the pupil
Wiggling or jerky eye movements
Misalignment between the eyes (eye turns
or crossing of eyes)

Lack of coordinated eye movements
Drifting of one eye when looking at
objects
Turning or tilting of the head when
looking at objects
Squinting, closing or covering of one
eye when looking at objects
Excessive tearing when not crying
Excessive blinking or squinting
Excessive rubbing or touching of the
eyes
Avoidance of or sensitivity to bright
lights
Contact physician or optometrist. Self-referral. Vision testing.
Contact ophthalmologist. Physician referral. Vision testing.
Canadian National Institute for the Blind (CNIB). 1-888-275-5332 ext. 5327. Self-referral. Support,
information and training for individuals and families affected by vision loss.
Southwest Region Blind-Low Vision Early Intervention Program. (519) 663-5317 ext. 2224 or 1-877818-8255. Self-referral. Support and information for individuals and families affected by vision loss.
37
References
References:
Why Red Flags:
1. McCain, M.N., & Mustard, J.F. (1999). Early Years Study: Reversing the Real Brain Drain. Retrieved from
http://www.gov.on.ca/children/english/resources/beststart/index.html
Attachment
1. Berlin, L. J., Ziv, Y., Amaya-Jackson, L., & Greenber, M. (Eds.). (2005). Enhancing early attachments:
Theory, research, intervention, and policy. New York: Guilford Press.
2. Goldberg, S. (Ed.). (2000). Attachment and development. New York: Oxford University Press.
3. Solomon, J., & George, C. (Eds.). (1999). Attachment disorganization. New York: Guilford Press.
Cognitive
1. Canadian Paediatrics Society. (2008). Growing and learning. Your child’s development: What to expect.
Retrieved from http://www.caringforkids.cps.ca/growingandlearning/Development.htm
Dental
1. Alsada, L., Sigal, M., Limeback, H., Fiege, J., & Kulkarni, G.V. (2005). Development and testing of an
audio-visual aid for improvement of infant oral health through primary caregiver education. Journal of the
Canadian Dental Association, 71 (4), 241a-241h.
2. Poranganel, L., Titley, K., & Kulkarni, G. (2006). Establishing a dental home: A program for promoting
comprehensive oral health starting from pregnancy through childhood. Oral Health, 96 (1), 10-15.
3. Dr. Gajanan Kulkarni, Associate Professor, Pediatric and Preventive Dentistry, Faculty of Dentistry,
University of Toronto, Tel: 416-979-4929 ext. 4460. Email: g.kulkarni@utoronto.ca
1. American Speech-Language Hearing Association. (2008). Feeding and swallowing disorders (Dysphagia)
in children. Retrieved from www.asha.org/public/speech/swallowing/FeedSwallowChildren.htm
2. Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding assessment and management (2nd
ed.). New York: Singular Publishing Group.
3. Morris, S.E., & Dunn-Klein, M. D. (1987). Pre-feeding skills: A comprehensive resource for feeding
development. (2nd ed.). Tucson, AZ: Therapy Skill Builders.
4. Morris, S.E. & Dunn Klein, M. D. (2000). Pre-Feeding Skills. (2nd ed.). San Antonio, TX: Therapy Skill
Builders.
5. Thames Valley Children Centre. (2008). Feeding and swallowing: Who should be referred. Retrieved from
www.tvcc.on.ca/who-should-be-referred.htm
Fine Motor
1. Adapted with permission from the Stratford General Hospital Department of Rehabilitation Services
Pediatric O.T. Service.
Gross Motor
1. American Academy of Pediatrics. (2004). Developmental stages. Retrieved from
http://www.aap.org/healthtopics/stages.cfm
Hearing
1. Adapted from the Ministry of Children and Youth Services. (2007). Ontario’s Best Start Plan.
http://www.gov.on.ca/children/english/programs/beststart/hearing/index.html
2. Canadian Paediatric Society. (2002). Ear infections (Otitis Media). Retrieved from
http://www.caringforkids.cps.ca/whensick/EarInfections.htm
Literacy
1. Canadian Paediatric Society. (2008). Read, speak, sing to your baby: How parents can promote literacy
from birth. Retrieved from http://www.caringforkids.cps.ca/growingandlearning/Reading2Babies.htm
Neglect and Abuse/Family Violence
1. Rimer, P. (2007). Making a difference: The community responds to child abuse (5th ed.). Toronto: Boost
Child Abuse Prevention and Intervention.
38
Sensory
1. Yack, E., Sutton, S., & Aquilla, P. (1998). Building bridges through sensory integration. Las Vegas:
Sensory Resources, LLC.
2. Miller, L.J., Lane, S., Cermak, S., Osten, E., & Anzalone, M. (2005). Primary diagnosis: Axis 1:
Regulatory-Sensory Processing Disorders. In S.I. Greenspan and S. Wieder (Eds.), Diagnostic manual for
infancy and early childhood mental health, developmental, regulatory-sensory processing and language
disorders and learning challenges (ICDL-DMIC). Retrieved from
http://www.spdfoundation.net/pdf/Miller_Lane.pdf
Sleep
1. Weiss, S. (2006). Better sleep for your baby and child: A parent’s step-by-step guide to healthy sleep habits.
The Hospital for Sick Children. Toronto: Robert Rose, Inc.
Social and Emotional – Behaviour
1. American Academy of Pediatrics. (2004). Developmental stages. Retrieved from
http://www.aap.org/healthtopics/stages.cfm
3. Miller, L.J., Lane, S., Cermak, S., Osten, E., & Anzalone, M. (2005). Primary diagnosis: Axis 1:
Regulatory-Sensory Processing Disorders. In S.I. Greenspan and S. Wieder (Eds.), Diagnostic manual for
infancy and early childhood mental health, developmental, regulatory-sensory processing and language
disorders and learning challenges (ICDL-DMIC). Retrieved from
http://www.spdfoundation.net/pdf/Miller_Lane.pdf
4. National Institute of Mental Health. (2006). Attention Deficit Hyperactivity Disorder. Bethesda, MD:
National Institute of Mental Health, US Department of Health and Human Services. Retrieved from
http://www.nimh.nih.gov/health/publications/index.shtml
5. National Institute of Mental Health. (2004). Autism Spectrum Disorders (Pervasive Developmental
Disorders). Bethesda, MD: National Institute of Mental Health, US Department of Health and Human
Services. Retrieved from http://www.nimh.nih.gov/health/publications/index.shtml
Speech and Language
1. Ministry of Children and Youth Services. (2007). Preschool speech and language program. Retrieved from
www.children.gov.on.ca
2. Thames Valley Preschool Speech and Language Alliance. tykeTALK’s communication checklist. Retrieved
from http://www.tyketalk.com/talk.htm
Vision
1. Blind-Low Vision Early Intervention Program (2007). Services for children who are blind or have low
vision. Retrieved from www.children.gov.on.ca\
Talking to the Family About Your Concerns
1. Managing Challenging Behaviour (2003). New South Wales Department of Community Services. Retrieved
from http://www.childlink.com.au/behaviours.htm
39
References
Nutrition
1. Ontario Society of Nutrition Professionals in Public Health. (2008). Pediatric nutrition guidelines for
primary health care providers. Family Health Nutrition Advisory Group. Retrieved from
http://www.osnpph.on.ca/pdfs/ImprovingOddsJune-08.pdf
1. Ross, L., Dennis, C.L., Robertson Blackmore, E., & Stewart, D.E. (2005). Postpartum depression: A guide
for front-line health and social service providers. Toronto: Centre for Addiction and Mental Health.
Talking to the Family about Your Concerns – Tip Sheet
Developing a partnership with the family is
very important when we share the care of their
child. We communicate with parents on a daily
basis. We often talk about their child’s
achievements, friends or the things he
particularly enjoyed doing. We talk about how
their child is settling in, our program, and the
philosophy and goals of our service.
But, how do we tell the family about our
perception that their child may be experiencing
difficulties with their behaviour or
development?
Remember, what we see as a problem may
not be viewed this way by the family. This has
significant implications for:
• What concerns we raise
• When we raise concerns
• How we raise concerns with the family
Once a concern has been identified, it is
important to consider both the needs of the
family and all the members of the teaching
team, including yourself. It is possible that
neither party may want to talk about the
concern - both staff and family can be reluctant
to discuss areas of difficulty.
Understanding the family’s reluctance to
hear the message
A family can react quite differently than
expected to information about their child.
• You may have observed your areas of
concern for some time, while it may be the first
time the family has considered these concerns.
The family may not feel “ready” to consider
these issues about their child.
• A family may also go into “threat” mode when
approached about their child. The parents may
see it as a criticism of their parenting skills.
Understanding staff reluctance to deliver
the message
Why is it difficult to move from discussing what
the child ate and with whom they played, to
raising what you believe is an area of concern?
Here are some possible reasons:
• Staff can feel threatened, too.
40
• We may not feel comfortable about the
information we are reporting or we may not
have had enough time to build a good rapport
with the family before we need to raise
concerns.
• We may feel under-resourced and are not
sure where to refer the family or are afraid of a
negative reaction from a defensive parent.
• We may even feel so concerned about the
possible feelings of a family that we avoid the
issue entirely.
If we really do have concerns about a child, we
need to try talking to the family for the benefit
of the child.
Raising Concerns
Before you raise concerns with the family,
consider the following suggestions:
• Talk to colleagues about your concerns. You
may want to discuss the issue with your
Supervisor and/or inform yourself about the
centre’s protocol for communicating with
parents.
• Determine who would be the appropriate
person to talk with the family – perhaps the
Supervisor, another team member or you.
• Talk to the family as soon as possible. If
there are two parents/guardians, try to see
them together.
• Find a time to discuss your concerns with the
family WITHOUT the child being present.
• Demonstrate an attitude of respect towards
the family’s particular culture, religion, socioeconomic, and linguistic background.
• Timing is important:
- While the child is clinging to his mother’s
leg, not wanting her to leave or as she is
hurrying off to work, is not the best time
to approach a parent.
- Likewise, at the end of the day, a few
words about how the day went are good,
but it may not be the best time for
informing a parent about a concern.
- Allow adequate time for the meeting and
provide a location that ensures privacy.
When meeting with families consider the
following suggestions:
-
Have a list of different services and
appropriate support groups (with the
names of relevant people), to which the
family can be referred.
-
Develop an action plan with the family
about what to do next. Have some ideas
ready to suggest to the family.
Be prepared to consider what the family
suggests, even if it is quite different from
what you had in mind.
• Be positive, supportive, and honest about the
child when raising concerns.
• Give the family examples of the child’s
strengths or areas that have shown
improvement. Remember the importance of a
positive approach when talking to a family.
• Plan ahead and think about what you are
going to say. You may even wish to write it
down before meeting with the family.
• Acknowledge that your concerns are based
on your observations in only one setting and
that there are many reasons for behaviour.
• Be prepared:
- Have concrete examples of your
concerns make sure they are objective.
-
• Reassure the family that staff members are
happy to work with them to achieve the best
outcome for their child.
Though breaking the news can be difficult, it is
important that the issue be raised as soon as
possible. This may allow for earlier
intervention, which could provide the support
necessary for their child to reach his/her
potential.
Adapted with permission from ConnectABILITY: A Project of Community Living Toronto. www.connectability.ca
41
Oxford County’s Interagency Protocol for Service Coordination
for Families with Children 0 to 6 Years
AUTHORIZATION FOR SHARING OF INFORMATION
I, __________________________________________________, hereby give my permission for the
(Adult/Parent/Guardian)
listed persons or organizations to request/release/receive information (written, verbal, electronic) for
the purpose of coordination of services regarding the persons identified below:
1.
5.
2.
6.
3.
7.
4.
8.
(Adult)
(DOB)
(Child)
(DOB)
(Child)
(DOB)
(Child)
(DOB)
(Child)
(DOB)
1.
2.
3.
4.
This consent will remain in effect until _________________________ (maximum 1 year), or
until it is revoked by me, whichever occurs first.
___________________________
(Date)
_____________________________________
(Caregiver Signature)
____________________________________
_____________________________________
(Printed Name)
____________________________________
(Service Coordinator Signature)
(Printed Name)
This information is collected under the authority of Ontario Regulation 147/91 (as amended) of the Health Cards and Numbers Control Act and the Health Protection and
Promotion Act, R.S.O. 1990 chapter H.7 as amended, section 5. It will be used for identification of families in need of support, referral to appropriate community resources and
to provide data for planning, coordinating, and evaluating services. Questions regarding this collection should be forwarded to one of the organizations listed above.
42
Sample Referral Letter
January 1, 2009
Dr. (
)
General Physician
265 North Street
London, ON N4E 1W7
Dear Dr. (
)
Re: (client name), D.O.B. (mm/dd/year)
I have been involved with (client name) since (date), in my role as an (professional title) at (location of
service).
During my involvement with (client name), I have observed him/her to have many age appropriate
skills; like running, jumping and climbing, he/she is able to express his/her ideas to others and activity
participates in small group activities. During activities which require him/her to do fine motor work like
crafts and toys with small pieces he/she has difficulty and will avoid participating in these activities.
To assist the family to help meet their child’s needs, we are asking for your assistance to refer the
family on to a Paediatician for further investigation of (client’s name) fine motor skills.
Enclosed is a copy of the Nippissing Developmental Screen which was completed on (client name) by
(name of screener) on (date).
A signed Release of Information is also included for your file.
Thank you in advance for your assistance in this matter.
Sincerely,
(Professionals name)
(position/title)
(location)
Encl.
43
Agency Directory
For more information about these and other services please go to
www.informationoxford.ca
or phone the Health Matters Line 539-9800 or 1-800-755-0394
A Child First
A Child First believes that a child is a child first despite individual differences. This program, provided
by Community Living Tillsonburg and Good Beginnings Day Nursery, works with families of children
with special needs ages 0-12 years. We support families involved in inclusive child care programs
and Ontario Early Years Centre programs throughout Oxford County. Referrals can be made by
families or agencies (with informed written parental consent) at either the Tillsonburg or Woodstock
offices.
Community Living Tillsonburg (serving South of Highway 2)
(519) 842-9000 ext. 254
www.communitylivingtillsonburg.on.ca
Good Beginnings Day Nursery (serving Woodstock and North of Highway 2)
(519) 421-0687 ext. 22
www.goodbeginningsday.com
Blind-Low Vision Early Intervention Program – Southwest Region
Families with children who are blind or have low vision are given the resources they need to support the
healthy development of their child in the first years of life from birth until they enter Grade 1. A referral can
be made to the program by a physician, ophthalmologist, optometrist, parent or caregiver.
(519) 663-5317 ext. 2224; 1-877-818-8255.
CNIB (Canadian National Institute for the Blind)
CNIB is a nationwide, community-based, registered charity committed to research, public education and
vision health for all Canadians. CNIB Early Intervention Services assist children aged 0-6 to build a
foundation for their future growth and development that is consistent with their individual potential, in
partnership with parents/guardians, caregivers, teachers and therapists. Referrals can be made without
medical information.
Stacey Adams, Early Intervention Specialist at 1-800-265-4127 ext. 5128.
Canadian Mental Health Association – Oxford County Branch.
This organization offers support to individuals with serious or persistent mental illness through case
management, life skills education, supportive permanent housing, and Court Diversion/Court Support.
Educational presentations and information are available to all individuals, groups and organizations in
Oxford County. A 24 hour mobile crisis response service is also available for all residents of Oxford
County. Offices are located in Woodstock, Tillsonburg and Ingersoll.
General Information: (519) 539-8055; 1 800-859-7248.
For 24 Hour Mobile Crisis Response: (519) 539-8342; 1-877-339-8342.
www.cmhaoxford.on.ca
Canadian Mental Health Association - Oxford County Branch – 24 Hour Mobile Crisis Response
Line
This is a 24-hour service available to adults, children and youth who live in or receive medical services in
Oxford County. Crisis/Community Support Workers respond by phone and/or mobile personal contact
when deemed appropriate to individuals experiencing a sudden or unexpected event that places them in
distress. Professional staff can provide referral to appropriate agencies and offer follow up service to
ensure that appropriate community linkages are in place.
Children and youth may access this service after regular business hours: 4:30 pm to 8:30 am
Monday to Thursday and on weekends (Friday 4:00 pm to Monday 8:30 am.)
(519) 539-8342; 1 877-339-8342
For Child and Youth Crisis Response during regular business hours: contact either Oxford Child and
Youth Centre urgent services (519) 539-5857; 1-877-539-5857 or the Woodstock General Hospital
Mental Health Services at (519) 421-4223.
www.cmhaoxford.on.ca
44
Children’s Aid Society of Oxford County
Children’s Aid Society of Oxford County (CAS) is responsible for intake and investigation of referrals and
reports made to the CAS. The referrals and reports made to CAS usually involve allegations of some form
of child abuse or neglect i.e. physical, sexual, emotional or psychological.
(519) 539-6176; 1-800-250-7010
www.casoxford.on.ca
Community Care Access Centre
This organization provides nursing, health professional support (home or school), medical
supplies/equipment, social work, occupational therapy, physiotherapy, and speech therapy services. This
includes home and school health services for children with special needs.
(519) 539-1284; 1-800-561-5490
www.ccac-ont.ca
Community Living Tillsonburg – Family Support Program
This program supports families in caring for their children with intellectual disabilities and/or special needs
through empowerment, advocacy and co-ordination. Services include information, referrals/liaison with
other agencies, assistance with Government forms, attending meetings with family members, and coordination of respite care. Family’s can self refer or agencies with informed written consent.
(519) 842-9000
www.communitylivingtillsonburg.ca
Dental Services (Oxford County Public Health)
Children in Need of Treatment (C.I.N.O.T.) provides access to dental care for children who have dental
conditions requiring urgent care and no access to dental insurance or any other government program
(e.g. Ontario Works, Ontario Disability Support Program). The parent must also sign a written declaration
stating that the cost of the necessary dental treatment would result in financial hardship.
539-9800; 1-800-755-0394
www.oxfordcounty.ca
Developmental Resources for Infants (DRI).
This program is a combination of resources from four different organizations for families of children under
two years of age with developmental concerns. The aim is to work together to provide easy-to-access,
family centered services. The DRI partner organizations: the Developmental Follow up Clinic St Joseph's
Health Care London, Home Visiting Program for Infants, Child and Parent Resource Institute (CPRI),
Thames Valley Children's Center, Children's Hospital of Western Ontario.
(519) 685-8710.
Dietician
A Registered Dietitian can assist you with the assessment of your child’s eating habits, provides sound
nutrition advice and will assist in the development of nutrition care goals. A physician referral is required
to see a Registered Dietitian.
Woodstock General Hospital
(519) 421-4211 ext 2346 or 2125
www.wgh.on.ca
Alexandra Hospital
(519) 487-1700
www.alexandrahospital.on.ca
Tillsonburg and District Memorial Hospital
(519) 842-3611
www.tillsonburghospital.on.ca
45
Agency Directory
Child and Parent Resource Institute (CPRI).
This children’s centre is located in London and provides a variety of specialized services to children who
have received some assistance in their local community and find a need for more specialized diagnostic,
assessment and short-term treatment services for developmental disabilities, emotional disturbances and
behavioural disorders.
(519) 858-2774
www.cpri.ca
Agency Directory
Eat Right Ontario
EatRight Ontario helps you improve your health and quality of life through healthy, nutritious eating. This
service provides easy-to-use nutrition information to help make healthier food choices easier. You can
ask nutrition-related questions and receive feedback by phone or email from a Registered Dietician.
1-877-510-510-2
www.eatrightontario.ca
Health Matters Line (Oxford County Public Health)
A Public Health Nurse is available to discuss concerns, provide health information, and refer individuals to
appropriate programs in the community, Monday to Friday, 9:00 a.m. to 4:00 p.m., excluding holidays.
(519) 539-9800; 1-800-755-0394
www.oxfordcounty.ca
Healthy Babies Healthy Children (Oxford County Public Health)
A prevention/early intervention initiative intended to improve the well being and long term prospects of
children. Through the home visiting component, Public Health Nurses and Parent Resource Visitors (lay
home visitors) provide home visiting to identified families whose children are at risk of poor development.
This service supports families who would benefit from learning more about growth and development,
positive parenting and community resources.
(519) 539-9800; 1-800-755-0394
www.oxfordcounty.ca
Infant Hearing Program
Conducts hearing screening for all newborn infants in the hospital or in the community. Provides follow-up
supports and services for all infants identified with permanent hearing loss including family support,
audiology and communication development.
(519) 663-0273; 1-877-818-TALK (8255)
www.healthunit.com
Journeys – group for children who have been exposed to violence in the home.
Journeys program is offered through the Women’s Emergency Centre – Oxford, several times a year.
Mothers also attend a group at the same time. Children explore feelings, anger control, conflict resolution,
self-esteem, safety planning and abuse prevention. Moms are provided support in parenting issues. Self
referral. No fee.
(519) 539-7488; 1-800-265-1938
www.wec-oxford.shelternet.ca
Oxford County Department of Social Services and Housing
The Department of Social Services and Housing is responsible for numerous programs. Person’s
requiring financial assistance, geared-to-income housing, help acquiring family support, or subsidy for
child care can contact the department to see if they are eligible. Person’s already receiving social
assistance may also be eligible for additional help with health, employment, transportation, back to school
expenses, moving, or funeral and burial expenses. The department also is the lead agency for the
Ontario Early Years Centre programs in Oxford County. Refer to the Ontario Early Years Centre listing for
its program details.
(519) 539-9800; 1-800-265-1015
www.oxfordcounty.ca
Ontario Early Years Centre - Oxford County
The Ontario Early Years Centre - Oxford County is a place for children ages 0-6, their parents and
caregivers to go where they can take part in early learning and literacy activities. A variety of programs
and services are available throughout Oxford County. Services available include early learning and
literacy programs for parents and children; parent workshops; information about early child development;
pre- and post-natal resources as well as information about other early years programs and services in the
community. All programs and services are offered free of charge.
(519) 539-9800; 1-800-755-0394
www.earlyyearsoxford.ca
46
Thames Valley Children's Centre
A regional rehabilitation centre for children with physical disabilities, communication disorders,
developmental needs living in Southwestern Ontario. A community-oriented Centre providing
assessment, diagnosis, consultation and therapy to help young people reach their potential in terms of
independence, self esteem and participation in society.
(519) 685-8680
www.tvcc.on.ca
tykeTALK
Provides prevention, early identification/assessment and treatment for children from birth to school entry
who are at risk for or have problems with speech and language development.
www.tyketalk.com
(519) 663-0273; 1-877-818-TALK
Women's Emergency Centre -Oxford
A variety of services across the county are offered for women who are abused by their partner and their
dependent children. Short term, safe housing is available. Individual support is available to women in
Ingersoll and Tillsonburg. Group programs and sexual assault counseling is offered in Woodstock. 24
hour support, information and referrals. Risk assessments and safety planning. Specialized support for
children. Self referral and no fee.
Administration (519) 539-7488; Helpline (519) 539-4811, 1-800-265-1938
www.wec-oxford.shelternet.ca
Woodstock and District Developmental Services (W.D.D.S.)
WDDS is a non profit agency providing a range of services for persons with developmental disabilities
living in our community. The Family Support Program at WDDS offers resource information, guidance,
and advocacy for families who have children with special needs.
(519) 539-7447 ext. 230
www.wdds.ca
Woodstock General Hospital Mental Health
Services for Children, adolescents, adults, families or couples who may be feeling anxious, depressed, or
stressed from lifestyle changes and relationships, eating disorders, first episode psychosis (FEP), as well
as individuals with persistent mental health disorders. Individuals with an addiction and/or family violence
may be referred to specialized services. Outpatient counseling is also provided. Individuals, community
agencies, families and physicians can contact this service to make an appointment.
(519) 421-4223
www.wgh.on.ca
47
Agency Directory
Oxford Child and Youth Centre
Oxford Child and Youth Centre is an accredited Children's Mental Health Centre. They provide mental
health counseling and treatment to children and adolescents up to 18 years of age. Referrals can be
made to the Intake Secretary by parents, guardians or self. They have a Crisis Support Program servicing
children under the age of 16 and a 24/7Crisis Line is also available to ages 18 and under.
Crisis: (519) 539-5857; 1-877-539-5857
Intake: (519) 539-0463; 1-877-539-0463
www.ocyc.on.ca
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Public Health & Emergency Services
1-800-755-0394 519-539-9800