Red Flags Guide

Red Flags
for children birth to six years
A quick reference guide for

early years professionals
Early Identification in
Leeds, Grenville & Lanark
Adapted November 2007

RED FLAGS: Table of Contents
Red Flags Introduction
Red Flags Committee . ...........................................................................................1
Early Identification...................................................................................................2
What is Red Flags?.................................................................................................2
Who Should Use Red Flags? .............................................................................2
How to use this document....................................................................................2
Sensitive Issues..........................................................................................................3
Duty to Report........................................................................................................................5-7
Growth & Development:
Attachment.................................................................................................................8
Fine Motor...................................................................................................................9
Gross Motor............................................................................................................. 10
Vision.......................................................................................................................... 11
Hearing...................................................................................................................... 13
Sensory...................................................................................................................... 14
Speech & Language . ........................................................................................... 15
Literacy & Numeracy ........................................................................................... 18
Social/Emotional.................................................................................................... 20
Behaviour................................................................................................................. 21
Nutrition & Oral Health:
Nutrition................................................................................................................... 22
Feeding & Swallowing......................................................................................... 24
Dental........................................................................................................................ 25
Abuse:
Witnessing Family Violence................................................................................ 26
Physical...................................................................................................................... 28
Sexual........................................................................................................................ 29
Emotional................................................................................................................. 30
Neglect...................................................................................................................... 31
Special Needs:
Autism . .................................................................................................................... 32
Fetal Alcohol Spectrum Disorder.................................................................... 33
Learning Disabilities............................................................................................. 34
Intellectual & Developmental Disabilities.................................................... 35
Mild Traumatic Brain Injury............................................................................... 36
Other Factors:
Family Environmental Stressors...................................................................... 37
Postpartum Depression..................................................................................... 38
Getting Ready for Kindergarten....................................................................................... 39
Subsidy Information.............................................................................................................. 40
Where to Go for Help ........................................................................................................... 41
Disclaimer Notice
Red Flags is a Quick Reference Guide designed to assist early years
professionals in deciding whether to refer for additional services. It is not a
formal screening or diagnostic tool.
The information contained in Red Flags for children, birth to six years (this
document) has been provided as a public service. Although every attempt
has been made to ensure 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 children, birth to six years. 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 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 Red Flags Committee, which consent may be withheld at the sole
discretion of Red Flags Committee or be given subject to such terms and
conditions as Red Flags Committee may, in its sole discretion, impose.
INTRODUCTION
INTRODUCTION TO RED FLAGS
RED FLAGS COMMITTEE Shannon Brown, Early Literacy Specialist,
Ontario Early Years Centre, United Counties of
The original Red Flags document was developed by
Leeds and Grenville
the Simcoe County Early Intervention Council and
Jill Brul, Home Visiting Coordinator,
piloted in 2002. It was printed and disseminated Connections Program, Lanark
by the Healthy Babies Healthy Children program,
Rebecca Carnochan, Open Doors for Lanark
Simcoe County District Health Unit as Red Flags Children and Youth
- Lets Grow With Your Child in March 2003. Emily Cassell, Data Analysis Coordinator, Lanark
Since that time York Region Early Identification Jessica Deschamp-Baird, Data Analysis
Planning Coalition and the Kingston, Frontenac and Coordinator, United Counties of Leeds and
Lennox & Addington Red Flags Committees have Grenville
reviewed and revised the original document. Darleen Desgens, Healthy Babies Healthy
Children Program Assistant, Leeds, Grenville
With permission of the Kingston, Frontenac and and Lanark District Health Unit
Lennox & Addington (KFLA) Red Flags Committee, Fiona Dufour, Public Health Nurse, Leeds,
the KFL&A Red Flags document was reviewed and Grenville and Lanark District Health Unit
revised by the School Readiness Sub-Committee of France Dupuis, Catholic District School Board of
the Healthy Babies Healthy Children Coalition of the Eastern Ontario
Leeds, Grenville and Lanark District Health Unit and Laurie Ann Glenn, Nurse Practitioner, Primary
other early years professionals who serve children in Health Care, North Lanark County Community
Health Center
Leeds, Grenville and Lanark. The School Readiness
Committee consists of members from: Jane Hess, Director of Family Health, Leeds,
Grenville and Lanark District Health Unit
Brockville and Area YMCA; Catholic District School Rebecca Langin, Administrative Coordinator,
Board of Eastern Ontario; Childrens Resource on The Language Express Preschool Speech
Wheels; Connections Program; Developmental - Language Service System
Services of Leeds and Grenville-Inclusive Child Care Dixie OReilly, Infant & Child Development
Program; Healthy Babies Healthy Children Program; Program, Leeds and Grenville
Infant & Child Development Programs; Lanark Catherine Robinson, Clinical Coordinator, The
County Childcare Providers; Lanark Early Integration Language Express Preschool Speech-Language
Service System
Program; Lanark Ontario Early Years Centres-Early
Rosemary Sheahan, Healthy Babies Healthy
Literacy Specialist and Data Analysis Coordinator;
Children Coordinator, Leeds Grenville and
Leeds, Grenville and Lanark District Health Unit; Lanark District Health Unit
North Lanark County Community Health Center; Oksana Shewchenko, Production Artist, Leeds
Open Doors for Lanark Children and Youth; The Grenville and Lanark District Health Unit
Language Express Preschool Speech-Language Shona Stewart, Inclusive Child Care Program-
Service System; United Counties of Leeds and Developmental Services of Leeds and Grenville
Grenville-Ontario Early Years Centres, Early Literacy
Specialist and Data Analysis Coordinator; and the Funding:
Upper Canada District School Board.
Healthy Babies Healthy Children, Leeds, Grenville
and Lanark District Health Unit
Acknowledgments: In-Kind-Committee community partner agencies
The Leeds, Grenville and Lanark District Health Unit listed above
would like to acknowledge the following for their For further information, additional copies, to suggest
contributions to the resource: revisions to this document, or for information on
Angle Blaskie, Lanark Early Integration sources used, please contact the Leeds, Grenville
Program and Lanark District Health Unit at 613-345-5685 or
Kathy Boelsma, Early Literacy Specialist, Lanark 1-800-660-5853 or forward an email to:
redflags@healthunit.org
November 2007 Red Flags: Early Identification in Leeds, Grenville & Lanark 1
INTRODUCTION
Early Identification How to use this document
Thanks to Dr. Fraser Mustard and other scientists, This is a quick reference to look at child
most professionals working with young children development by domain, reviewing each domain
are aware of the considerable evidence about from birth to six years (unlike screening tools
early brain development and how brief some that look at a particular childs development
of the windows of opportunity are for optimal across many areas of development at a specific
development of neural pathways. The early years age). It includes other areas that may impact
of development from conception to age six, child health, growth and development due to
particularly for the first three years, set the base the dynamics of parent-child interaction, such as
for competence and coping skills that will affect postpartum depression, abuse, etc.
learning, behaviour and health throughout life 1.
Red Flags allows professionals to review and
It follows, then, that children who may need better understand domains on a continuum
additional services and supports to ensure that are traditionally outside their own area of
healthy development must be identified as expertise. This increased awareness will help
quickly as possible and referred to appropriate professionals better understand when and where
programs and services. Early intervention during to refer for further investigation or treatment.
the period of the greatest development of neural
Use Red Flags in conjunction with a screening
pathways, when alternative coping pathways
tool, such as Nipissing District Developmental
are most easily built, is critical to ensure the best
Screens or Ages Stages Questionnaire (ASQ) to
outcomes for the child. Time is of the essence!
review developmental milestones and problem
signs in a particular domain or indicator. Some
What is Red Flags? information is cross-referenced to other domains,
Red Flags is a quick reference guide for Early such as speech with hearing, to assist the
Years professionals. It can be used in conjunction screener in pursuing questions or gut feelings.
with a validated screening tool, such as Nipissing
If children are not exhibiting the milestones
District Developmental Screens (the Nipissing
for their age, further investigation is needed. If
Screen 2) or Ages and Stages Questionnaire
using Nipissing District Developmental Screens,
(ASQ). Red Flags outlines a range of functional
remember that the screening tools are age-
indicators or domains commonly used to
adjusted; therefore, the skills in each screen are
monitor healthy child development, as well as
potential problem areas for child development.
Footnotes
It is intended to assist in the determination of
1. Early Years Study: reversing the real brain drain, Hon.
when and where to refer for additional advice, Margaret McCain and Fraser Mustard, April, 1999. See report
formal assessment and/or treatment. at www.eldis.org/ .
2. Nipissing District Developmental Screens refer to 13
parent checklists available to assist parents to record and
Who should use Red Flags? monitor development of children from birth to age 6. The
screens cover development related to vision, hearing,
This quick reference guide is intended to be communication, gross and fine motor, social/emotional
used by any professional working with young and self-help and offers suggestions to parents for age
children and their families. A basic knowledge appropriate activities to enhance child development.
Parents are encouraged to call the Health Action Line of the
of healthy child development is assumed. Red Leeds, Grenville and Lanark District Health Unit at 1-800-660-
Flags will assist professionals in identifying when 5853 if two or more items are checked No. A public health
nurse will review the results of the screen and suggest next
a child could be at risk of not meeting his health steps. It is particularly important for a screen to be reviewed
and/or developmental milestones, triggering an by a professional if a problem is identified. For additional
information about Nipissing District Developmental Screens
alert for the need for further investigation by the or to obtain copies, visit the website at www.ndds.ca
appropriate discipline.
2 Red Flags: Early Identification in Leeds, Grenville & Lanark November 2007
INTRODUCTION
expected to be mastered by most children at Sensitive Issues
the age shown. If there are two or more No
One of the most difficult parts of recognizing
responses, refer to a professional for assessment.
a potential difficulty in a childs development
Refer for further assessment even if you are is sharing these concerns with the parents/
uncertain if the flags noted are a reflection of a guardians. It is important to be sensitive when
cultural variation or a real concern. suggesting that there may be a reason to have
further assessment done. You want parents/
Note that some of the indicators focus on the
guardians to feel capable and to be empowered
parent/guardian, or the interaction between the
to make decisions. There is no one way that
parent and the child, rather than solely on the
always works best, but there are some things to
child.
keep in mind when addressing concerns.
Contact information is indicated at the end of
Be sensitive to a parent/guardians readiness
the document in the Where to Go for Help
for information. If you give too much
section.
information when people arent ready, they
If a child appears to have multiple domains may feel overwhelmed or inadequate. You
requiring formal investigation by several might start by probing how they feel their
disciplines, screeners are encouraged to refer to child is progressing. Some parents/guardians
the agencies that can coordinate a collaborative have concerns, but have not yet expressed
and comprehensive assessment process. them. Having a parent use a tool such as the
If referrals are made to private sector agencies, Nipissing District Developmental Screen may
alert families that fees will not be funded by help open the way for discussion. It may help
OHIP. to specify that the screening tool is given
to parents to help them look at their childs
development more easily and to learn about
How to Use Red Flags new activities that encourage growth and
development.
Service providers may contact any agency
for general information. If a specific case Be sure to value the parents/guardians
will be discussed, ensure consent to share knowledge. The ultimate decision about
information is obtained in accordance with what to do is theirs. Express what it is that
the Ontario Privacy of Personal Information you have to offer and what they have to offer
Act. as well. You may say something like: I have
had training in child development, but you
Step 1: Identify area of concern. know your child. You are the expert on your
Step 2: Speak to parents about your child. When you try to be more of a resource
concerns. than an authority, parents/guardians
feel less threatened. It is best to have the
Step 3: Call agency in the Where to Go for
parents/guardians discover how their child is
Help section for additional advice.
doing and decide whether or not extra help
Step 4: Encourage parents to call agency would be beneficial. You may want to offer
in the Where to Go for Help information you have by asking parents/
section to initiate a referral. guardians what they would like to know.
Have the family participate fully in the
final decision about what to do next. The
final decision is theirs. You provide only
information, support and guidance.
INTRODUCTION
Give the family time to talk about how they Dont entertain too many what if questions.
feel, if they choose to. If you have only a A helpful response could be, Those are good
limited time to listen, make this clear to them, questions. The professionals who will assess
and offer another appointment if needed. your child will be able to answer them. This
is a first step to indicate if an assessment is
Be genuine and caring. You are raising
needed.
concerns because you want their child to do
the best that he can, not because you want to Finally, it is helpful to offer reasons why it is
point out weaknesses or faults. Approach not appropriate to wait and see:
the opportunity for extra help positively; You
Early intervention can dramatically
can get extra help for your child so he will be
improve a childs development and prevent
as ready as he can be for school. Also try to
additional concerns such as behaviour
balance the concerns you raise with genuine
issues.
positives about the child (e.g., Johnny is a real
delight. He is so helpful when things need The wait and see approach may delay
tidying up. I have noticed that he seems to addressing a medical concern that has a
have some trouble . . .). specific treatment.
Your body language is important; parents may Early intervention helps parents
already be fearful of the information. understand child behaviour and health
issues, which will increase confidence that
everything possible is being done to ensure
that the child reaches his full potential.
DUTY TO REPORT
DUTY TO REPORT
Ontarios Child and Family Services Act (CFSA) Child and Family Services Act
provides for a broad range of services for families CFSA s.72(1)
and children, including children who are or may Despite the provisions of any other Act, if a
be victims of child abuse or neglect. person, including a person who performs
The paramount purpose of the Act is to
professional or official duties with respect to
promote the best interests, protection and children, has reasonable grounds to suspect
well being of children. one of the following, the person shall forthwith
report the suspicion and the information on
The Act recognizes that each of us has a which it is based to a society.
responsibility for the welfare of children. It
states clearly that members of the public, The child has suffered physical harm, inflicted
including professionals who work with by the person having charge of the child or
children, have an obligation to report caused by or resulting from that persons failure
promptly to a childrens aid society if they to adequately care for, provide for, supervise or
suspect that a child is or may be in need of protect the child, or pattern of neglect in caring
protection. for, providing for, supervising or protecting the
child.
The Act defines the term child in need
of protection and sets out what must be There is a risk that the child is likely to suffer
reported to a childrens aid society. This physical harm inflicted by the person having
definition (CFSA s.72(1)) is set out in detail charge of the child or caused by or resulting
on the following pages. It includes physical, from that persons failure to adequately care for,
sexual and emotional abuse, neglect and risk provide for, supervising or protecting the child.
of harm. The child has been sexually molested or sexually
This section summarizes reporting exploited, by the person having charge of the
responsibilities under Ontarios Child and Family child or by another person where the person
Services Act. It is not meant to give specific legal having charge of the child knows or should know
advice. If you have questions about a given of the possibility of sexual molestation or sexual
situation, you should consult a lawyer or your exploitation and fails to protect the child.
local childrens aid society. There is a risk that the child is likely to be sexually
molested or sexually exploited as described in
Duty to Report paragraph 3.
Responsibility to report a child in need The child requires medical treatment to cure,
of protection CFSAs.72(1) prevent or alleviate physical harm or suffering
If a person has reasonable grounds to suspect and the childs parent or the person having
that a child is or may be in need of protection, charge of the child does not provide, or refuses
the person must promptly report the suspicion or is unavailable or unable to consent to, the
and the information upon which it is based to a treatment.
childrens aid society.
The child has suffered emotional harm,
The situations that must be reported are listed in demonstrated by serious
detail below. anxiety,
depression,
withdrawal,
self-destructive or aggressive behaviour, or
DUTY TO REPORT
delayed development, serious damage to another persons property,
and there are reasonable grounds to services or treatments are necessary to prevent
believe that the emotional harm suffered a recurrence and the childs parent or the person
by the child results from the actions, failure having charge of the child does not provide, or
to act or pattern of neglect on the part refuses or is unavailable or unable to consent to,
of the childs parent or the person having those services or treatment.
charge of the child.
The child is less than 12 years old and has on
The child has suffered emotional harm of the more than one occasion injured another person
kind described in subparagraph i, ii, iii, iv or v of or caused loss or damage to another persons
paragraph 6 and the childs parent or the person property, with the encouragement of the person
having charge of the child does not provide, or having charge of the child or because of that
refuses or is unavailable or unable to consent to, persons failure or inability to supervise the child
services or treatment to remedy or alleviate the adequately.
harm.
Ongoing duty to report
There is a risk that the child is likely to suffer
CFSA s.72(2)
emotional harm of the kind described in
subparagraph i, ii, iii, iv or v of paragraph 6 The duty to report is an ongoing obligation. If
resulting from the actions, failure to act or a person has made a previous report about a
pattern of neglect on the part of the childs child, and has additional reasonable grounds
parent or the person having charge of the child. to suspect that a child is or may be in need of
protection, that person must make a further
There is a risk that the child is likely to suffer report to a childrens aid society.
emotional harm of the kind described in
subparagraph i, ii, iii, iv or v of paragraph 6 and Persons must report directly
that the childs parent or the person having CFSA s.72(3)
charge of the child does not provide, or refuses The person who has the reasonable grounds
or is unavailable or unable to consent to, services to suspect that a child is or may be in need of
or treatment to prevent the harm. protection must make the report directly to a
The child suffers from a mental, emotional or childrens aid society. The person must not rely
developmental condition that, if not remedied, on anyone else to report on his or her behalf.
could seriously impair the childs development
and the childs parent or the person having What are reasonable grounds to suspect?
charge of the child does not provide, or refuses You do not need to be sure that a child is or
or is unavailable or unable to consent to, may be in need of protection to make a report
treatment to remedy or alleviate the condition. to a childrens aid society. Reasonable grounds
The child has been abandoned, the childs parent are what an average person, given his or her
has died or is unavailable to exercise his or her training, background and experience, exercising
custodial rights over the child and has not made normal and honest judgment, would suspect.
adequate provision for the childs care and
Special responsibilities of professionals and
custody, or the child is in a residential placement
officials, and penalty for failure to report
and the parent refuses or is unable or unwilling
CFSA s.72(4), (6.2)
to resume the childs care and custody.
Professional persons and officials have the same
The child is less than 12 years old and has killed duty as any member of the public to report a
or seriously injured another person or caused suspicion that a child is in need of protection.
DUTY TO REPORT
The Act recognizes, however, that persons Professional confidentiality
working closely with children have a special CFSA s.72(7),(8)
awareness of the signs of child abuse and The professionals duty to report overrides
neglect, and a particular responsibility to report the provisions of any other provincial statute,
their suspicions, and so makes it an offence to specifically, those provisions that would otherwise
fail to report. prohibit disclosure by the professional or official.
Any professional or official who fails to report That is, the professional must report that a child
a suspicion that a child is or may be in need of is or may be in need of protection even when
protection, where the information on which the the information is supposed to be confidential
or privileged. (The only exception for privileged
suspicion is based was obtained in the course
information is in the relationship between a
of his professional or official duties, is liable on
solicitor and a client.)
conviction to a fine of up to $1,000.
Professionals affected Protection from liability

CFSA s.72(5) CFSA s.72(7)
Persons who perform professional or official If a civil action is brought against a person who
duties with respect to children include the made a report, that person will be protected
unless he acted maliciously or without reasonable
following:
grounds for his suspicion.
health care professionals, including
physicians, nurses, pharmacists and What will the childrens aid society do?
psychologists; Childrens aid society workers have the
teachers and school principals; responsibility and the authority to investigate
social workers and family counsellors; allegations and to provide services to protect
priests, rabbis and other members of the children.
clergy; A childrens aid society worker may, as part of the
operators or employees of day nurseries; investigation and plan to protect the child, involve
youth and recreation workers; the police and other community agencies.
peace officers and coroners;
solicitors; WHERE TO GO FOR HELP
service providers and employees of service
If you have concerns about a child, please call
providers; and your local childrens aid society immediately. All
any other person who performs CASs have emergency service 24 hours a day, so
professional or official duties with respect you can call anytime.
to a child.
Lanark County: Childrens Aid Society,
This list sets out examples only. If your work 613-264-9991 or 1-866-664-9991.
involves children but is not listed above, i.e., a
Leeds and Grenville Counties: Family and
volunteer or student, you may still be considered Childrens Services of Leeds and Grenville, 613-
to be a professional for purposes of the duty to 498-2100 or 1-800-481-7834. After hours, call
report. If you are not sure whether you may be the local number and the answering service will
considered to be a professional for purposes contact the person on call.
of the duty to report, contact your local
The Ontario Association of Childrens Aid Societies
childrens aid society, professional association, or
www.oacas.org/childwelfare/how
regulatory body.
then click on Report Child Abuse, then How and
When to Report.
GROWTH & DEVELOPMENT
ATTACHMENT
Childrens Mental Health research shows that the quality of early parent-child relationships has an
important impact on a childs development and his ability to form secure attachments. A child who
has secure attachment feels confident that he can rely on the parent to protect him in times of distress.
This confidence gives the child security to explore the world and establish trusting relationships
with others. As a result, current mental health practice is to screen the quality of the parent-child
interactions.
The following items are considered from the parents perspective, rather than the childs. If a parent
states that one or more of these statements describes their child, the child may be exhibiting signs of
an insecure attachment; consider this a red flag:
0-8 months
Is difficult to comfort by physical contact Problem signs ...
such as rocking or holding if a mother or primary caregiver is frequently
Does things or cries just to annoy you displaying any of the following, consider this
a red flag:
8-18 months Being insensitive to a babys
Does not reach out to you for comfort communication cues
Easily allows a stranger to hold him/her Often unable to recognize babys cues
Provides inconsistent patterns of

18 months - 3 years responses to the babys cues
Is not beginning to develop some
independence Frequently ignores or rejects the baby
Seems angry or ignores you after you have Speaks about the baby in negative terms
been apart
Often appears to be angry with the baby
Often expresses emotions in a fearful or

3-4 years
intense way
Easily goes with a stranger
Is too passive or clingy with you
4-5 years
Becomes aggressive for no reason (e.g., WHERE TO GO FOR HELP
with someone who is upset) See Attachment in the Where to Go for Help
Is too dependent on adults for attention, section at the back of this document.
encouragement and help
FINE MOTOR
Healthy Child Development
... If a child is missing one or more of these expected age outcomes, consider this a red flag:
By 2 months By 3 years
Sucks well on a nipple Turns the paper pages of a book
Holds an object momentarily if placed in Dresses or undresses with help
hand Unscrews a jar lid
By 4 months Holds a crayon with fingers
Sucks well on a nipple Draws vertical and horizontal lines in
Brings hands or toy to mouth imitation
Turns head side to side to follow a toy or an Copies a circle already drawn
adult face By 4 years
Brings hands to midline while lying on back Holds a crayon correctly
By 6 months Undoes buttons or zippers
Eats from a spoon (e.g., infant cereal) Cuts with scissors
Reaches for a toy when lying on back Dresses and undresses with minimal help
Uses hands to reach and grasp toys By 5 years
By 9 months Draws diagonal lines and simple shapes
Picks up small items using thumb and first Uses scissors to cut along a thick line drawn
finger on paper
Passes an object from one hand to the Dresses and undresses without help except
other for small buttons, zippers, snaps
Releases objects voluntarily Draws a stick person
By 12 months
Holds, bites and chews foods (e.g., crackers) Problem signs...
Takes things out of a container if a child is experiencing any of the
Points with index finger following, consider this a red flag:
Plays games like peek-a-boo
Infants who are unable to hold or grasp
Holds a cup to drink using two hands
an adult finger or a toy/object for a
Picks up and eats finger foods short period of time
By 18 months Unable to play appropriately with a
Helps with dressing by pulling out arms variety of toys; or avoids crafts and
and legs manipulatives
Stacks two or more blocks
Consistently ignores or has difficulty
Scribbles with crayons
using one side of body; or uses one
Eats foods without coughing or choking
hand exclusively
By 2 years
Takes off own shoes, socks or hat
WHERE TO GO FOR HELP
Stacks five or more blocks
See Fine Motor in the Where to Go for Help
Eats with a spoon with little spilling
section at the back of this document.
GROSS MOTOR
By 3 months By 3 years
Lifts head up when held at your shoulder Stands on one foot briefly
Lifts head up when on tummy Climbs stairs with minimal or no support
By 4 months Kicks a ball forcefully
Keeps head in midline and brings hands
to chest when lying on back
By 4 years
Lifts head and supports self on forearms
Stands on one foot for one to three seconds
on tummy
without support
Holds head steady when supported in
Goes up stairs alternating feet
sitting position
Rides a tricycle using foot peddles
By 6 months Walks on a straight line without stepping
Rolls from back to stomach or stomach off
to back
By 5 years
Pushes up on hands when on tummy
Hops on one foot
Sits on floor with support
Throws and catches a ball successfully most
By 9 months of the time
Sits on floor without support Plays on playground equipment safely and
Moves self forward on tummy or rolls without difficulty
continuously to get item
Stands with support
By 12 months Problem signs...
Gets up to a sitting position on own if a child is experiencing any of the
Pulls to stand at furniture following, consider this a red flag:
Walks holding onto hands or furniture
Baby is unable to hold head in the
By 18 months middle to turn and look left and right.
Walks alone
Unable to walk with heels down four
Crawls up stairs months after starting to walk.
Pushes or pulls toys or other objects
Asymmetry (i.e., a difference between
when walking
two sides of body; or body too stiff or
By 2 years too floppy).
Walks backwards or sideways pulling a
toy
Plays in a squat position
Kicks a ball WHERE TO GO FOR HELP
See Gross Motor in the Where to Go for Help
VISION
Current research suggests that approximately 1 in 6 children has a vision problem. Children born
with poor vision do not know what normal vision is like. They often think that everyone sees
the same way that they do. Therefore, do not wait for your child to tell you that they have a vision
problem. An eye examination is covered by OHIP once a year until the individuals 19th birthday.
The Ontario Association of Optometrists recommended frequency for childrens eye examinations:
6 months of age, 3 years of age and then every 12 months or as recommended by the optometrist

0-3 months 12 months-2 years

Focuses on your face, bright colors and Moves eyes and hands together (e.g.,
lights; follows slow-moving, close objects stack blocks, place pegs)
Blinks when bright lights come on or if a Judges depth e.g., climbs up and down
fast moving object comes into close view stairs
Watches as you walk around the room Links pictures with real life objects
Looks at hands and begins to reach out Follows objects as they move from above
and touch nearby objects head to feet
4-6 months 2-3 years
Tries to copy your facial expression Sits a normal distance when watching
Reaches across the crib for objects/ television
reaches for objects when playing with Follows moving objects with both eyes
you working together (coordinated)
Grasps small objects close by 3-4 years
Follows moving objects with eyes only Knows people from a distance (across
(less moving of head) the street)
7-12 months Uses hands and eyes together (e.g.,
Plays games like peek-a-boo, pat-a-cake, catches a large ball)
waves bye-bye Builds a tower of blocks, string beads;
Reaches out to play with toys and other copies a circle, triangle and square
objects on own 4-5 years
Moves around to explore whats in the Knows colours and shadings; picks out
room; searches for a hidden object detail in objects and pictures
Holds a book at a normal distance
(See VISION problem signs on

following page)
VISION continued
Problem signs...
if a child is experiencing any of the Covering one eye; has difficulty, or is
following, consider this a red flag: irritable with reading or with close work
Blinking and/or rubbing eyes often; a lot Eyes that cross, turn in or out, move
of tearing or eye-rubbing independently
Headaches, nausea, dizziness; blurred or Holding toys close to eyes, or no interest in

double vision small objects and pictures
Eyes that itch or burn; sensitive to bright Bumping into things, tripping; clumsiness,
light and sun restricted mobility
Unusually short attention span; will only Squinting, frowning; pupils of different
look at you if he hears you sizes
Avoidance of tasks with small objects Redness, soreness (eyes or eyelids);

recurring styes; discoloration
Turning or tilting head to use only one
eye to look at things Constant jiggling or moving of eyes side-
to-side (roving)

See Vision in the Where to Go for Help
HEARING

Startles, cries or wakens to loud sounds Listens to a simple story
Moves head, eyes, arms and legs in Follows two requests (e.g., Get the ball and
response to a noise or voice put it on the table.)
Smiles when spoken to, or calms down; Learns new words every week
appears to listen to sounds and talking 3-4 years
4-6 months Hears you when you call from another
Responds to changes in your voice tone room
Looks around to determine where new Listens to the television at the same
sounds are coming from loudness as the rest of the family
Responds to music and peoples voices Answers simple questions
Begins to make speech-like sounds e.g., Speaks clearly enough to be understood
buh, ma, boo most of the time by family
Turns or looks up when his name is called Pays attention to a story and answers
Responds to the word no simple questions
Listens when spoken to Hears and understands most of what is said
Knows common words like cup, shoe, at home and school
mom Family, teachers, child care providers, and
9-12 months others think he hears fine
Responds to requests such as Want more? Speaks clearly enough to be understood
Come here. Wheres the ball? most of the time by anyone
Babbles sounds in a series e.g., bababa,
dadada, mememe Problem signs...
Says first word if a child is experiencing any of the
12 months-2 years following, consider this a red flag:
Turns toward you when you call their name Early babbling stops
from behind
Follows simple commands Ear pulling (with fever or crankiness)
Tries to talk by pointing, reaching and Does not respond when called
making noises
Draining ears; a lot of colds and ear
Knows sounds like a closing door and a infections
ringing phone
Loud talking
Listens to simple stories, rhymes, and sings
Imitates sounds and words
See Hearing in the Where to Go for Help section
at the back of this document.
SENSORY
Sensory integration refers to the ability to receive input through all of the senses - taste, smell,
auditory, visual, touch, movement and body position, and the ability to process this sensory
information into automatic and appropriate responses to the sensation.
Problem signs...
if a childs responses are exaggerated, irrational, extreme, and/or oppositional and do not seem
typical for the childs age, consider this a red flag:
Auditory Does not enjoy a variety of playground
Responds negatively to unexpected or equipment
loud noises Enjoys exaggerated positions for long
Is distracted or has trouble functioning if periods (e.g., lies head-upside-down off
there is a lot of background noise sofa)
Enjoys strange noises/seeks to make noise Touch
for noise sake Becomes upset during grooming (hair
Seems to be in his own world cutting, face washing, fingernail cutting)
Visual Has difficulty standing in line or close to
Children over 3 - trouble staying between other people; or stands too close, always
the lines when colouring touching others
Avoids eye contact Is sensitive to certain fabrics
Squinting, or looking out of the corner of Fails to notice when face or hands are
the eye messy or wet
Staring at bright, flashing objects Cannot tolerate hair washing, hair cutting,
Taste/Smell nail clipping, teeth brushing
Avoids certain tastes/smells that are Craves lots of touch: heavy pressure, long-
typically part of a childs diet sleeved clothing, hats and certain textures
Chews/licks non-food objects Activity Level
Gags easily Always on the go; difficulty paying
Picky eater, especially regarding textures attention
Movement and Body Position Very inactive, under-responsive
Continually seeks out all kinds of Emotional/Social
movement activities (being whirled by Needs more protection from life than other
adult, playground equipment, moving children
toys, spinning, rocking) Has difficulty with changes in routines
Becomes anxious or distressed when feet Is stubborn or uncooperative; gets
leave ground frustrated easily
Poor endurance - tires easily; seems to Has difficulty making friends
have weak muscles Has difficulty understanding body
Avoids climbing, jumping, uneven ground language or facial expressions
or roughhousing Does not feel positive about own
Moves stiffly or walks on toes; clumsy or accomplishments
awkward, falls frequently
WHERE TO GO FOR HELP See Sensory in the Where to Go for Help section at the back of this document.
SPEECH & LANGUAGE
By 3 months Tries to copy new sounds (e.g., ba, animal

Cries and grunts; has different cries for sounds, car noises)
different needs Makes sounds to get attention, to make
Makes a lot of cooing and gooing sounds needs known, or to protest
Responds to parent/caregiver voice (e.g.,, Responds to hearing own name
Watches your face as you talk) Understands no and simple requests (e.g.,,
Give it to mommy. Dont touch. Wheres the
ball?)
By 6 months
Babbles using different sounds Plays social games with you (e.g., peek a
boo)
Lets you know by voice sounds to do
something again Enjoys being around people
Makes gurgling noises
Understands some words (e.g., daddy, bye By 18 months
bye) Tries to copy your sounds (sounds of our
language)
Smiles or laughs
Uses at least 20-50 words consistently;
Vocalizes pleasure and displeasure (e.g.,
words do not have to be clear
squeals with excitement, grunts in anger)
Understands many more words than
Enjoys music, songs and rhymes
he can say
Brightens to sound, especially to peoples
Understands simple directions or questions
voices
(e.g.,, Where is your nose? Get the ball.)
Smiles and laughs in response to parent/
Demonstrates some pretend play with toys
caregiver smiles and laughs
(e.g., give Teddy a drink)
Imitates sounds in his/her repertoire (e.g.,
Enjoys tickle, bounce and nursery rhymes
coughs or other sounds ah, eh, buh)
Makes at least four consonant sounds from
p, b, m, n, d, t, w, h
By 12 months
Identifies pictures in a book (e.g., Show me
Consistently uses three to five single words the baby)
Takes turns with sounds (e.g., Buh, animal Enjoys being read to and looking at books
sounds, car noises)
Points to familiar people and to some body
Waves hi/bye (emerging) and begins to use parts when asked
other gestures (e.g., hands up means pick
me up) Understands the concepts of in and out, off
and on
Gives a few familiar objects on verbal
request
Uses a variety of different voice sounds By 2 years
when playing (e.g., bababa, dadada, Tries to copy your words
nanana) Uses a variety of words and gestures to
Combines lots of sounds as though talking communicate and ask for help (e.g., waving,
(e.g., abada, baduh, abee) pushing away, pointing)
continued ...
Uses 100-150 words and combines 2 words Uses pronouns: I, you, me and mine
(e.g., More juice. Want cookie.) Understands questions using who, what,
Follows two step instructions (e.g., go find why, when and where
your teddy bear and show it to Grandma) Is learning the meaning of several new
Takes turns in a conversation words every week (in spoken language)
Asks for something by pointing and using Sings simple songs and familiar rhymes
sounds or words Talks about past events
Begins to offer toys to peers and imitates Tells simple stories
other childrens actions and words
Shows affection for favourite playmates
People can understand his/her words 50 to
60 per cent of the time Engages in multi step pretend play
cooking a meal, repairing a car
Uses many different speech sounds at
beginning of words (p,b,m,t,d,n,h,w) Shows ability to participate in routines
Enjoys being with other children
Learns and uses one or more new words a By 4 years
week; may only be understood by family Most of the time uses complete sentences
with 4 or more words (e.g., I go home now.)
Uses correct grammar such as plural
By 30 months
(e.g., books), past tense (e.g., walked) and
Understands the concepts of size (big/little) pronouns (e.g., I, he, she, me, you)
and quantity (a lot, little, more)
Follows directions involving three or more
Uses some correct grammar two steps First get some paper, then draw a
cookies; bird flying picture, last give it to mom
Uses more than 350 words Tells stories with clear beginning, middle
Uses action words run, fall and end
Begins taking turns with other children Talks to try to solve problems with adults
using both toys and words and other children
Shows concern when another child is hurt Demonstrates increasingly complex
or sad imaginative play
Combines several actions in play feeds Is understood by adults outside the family
dolls then puts him/her to sleep almost all the time
Produces words with two or more syllables Is learning the meaning of and using several
or beats: ba-na-na, com-pu-ter new words every week (in spoken
language)
By 3 years Recites nursery rhymes and sings familiar
Responds to simple questions or directions songs
Understands location words like in, on and Understands just one

under Enjoys being read to
Identifies some objects by their functions Can identify 4-6 colours by name
(e.g., What is a spoon for?)
Is understood by most people outside of
the family most of the time
Uses long sentences, using 5-8 words
By 5 years
Talks easily with other children and adults Problem signs...
and is understood if a child is experiencing any of the
Understands spatial relationships, on top following, consider this a red flag:
of, under, behind, in front of, etc. Stumbling or getting stuck on words
Explains concepts using words (e.g. ,What is or sounds (stuttering)
a cup? What is a car?) Ongoing hoarse voice
Understands many descriptive words (e.g., Excessive drooling
long/short, soft/hard)
Problems with swallowing or chewing,
Follows group directions All the boys get or eating foods with certain textures
a toy (gagging).
Understands directions involving e.g., See also Feeding and swallowing
ifthen If you are wearing runners, section
then line up for gym Lack of eye contact and poor social
Describes and can retell past, present, and skills for age
future events in detail Frustrated when verbally
Seeks to please his or her friends communicating
Shows increasing independence in
friendships
Uses almost all the sounds of his or her
language with few to no errors See also
Uses complete sentences with good Literacy & Numeracy
grammatical structure Speech and language difficulties are often
Is learning the meaning of and is using associated with weak literacy skills.
several new words every week (in spoken
language)
Can recall a brief story that has just been
heard

See Speech & Language in the Where to Go for
Help section at the back of this document.
LITERACY & NUMERACY By 2 years
Asks for favourite books to be read over and
By 3 months over again
Shows interest in contrast between light
Pretends to read
and dark
Names familiar pictures
Makes eye contact with pictures in book
Scribbles
Looks intensely at pictures for several
minutes Holds books the right way up and turns
pages easily, one at a time
Relates events in books to his/her own past
By 6 months
experiences
Enjoys music, songs and rhymes
Notices print rather than just the pictures
Reaches for and explores books with hands
and mouth Can join in and recite phrases
Sits on lap and holds head up steadily
Shows preference for photographs of faces By 30 months
Produces words with two or more syllables
Uses both hands to manipulate the book to
or beats: ba-na-na, com-pu-ter
make the pages open and close
Recognizes familiar logos and signs -
(e.g., stop sign)
By 12 months
Remembers and understands familiar stories
Shows interest in looking at books
Holds book with help
By 3 years
Tries to turn several pages at a time
Sings simple songs and familiar rhymes
Looks at pictures, vocalizes and pats picture
Pretends to read familiar books aloud
Sits up without support
Knows how to use a book (holds/turns pages
Plays social games with you (e.g., peek a one at a time, starts at beginning,
boo) points/talks about pictures)
Looks carefully and makes comments about
By 18 months books
Points at pictures with one finger Fills in missing words/phrases in familiar
Enjoys tickle, bounce and nursery rhymes books that are read aloud
Identifies pictures in a book (e.g., Show me Holds a pencil/crayon with pincer grasp and
the baby) uses it to draw/scribble
Able to carry book and turn pages well Imitates writing with linear scribbles
Holds a crayon or pencil in fist and marks Copies a circle, vertical and horizontal lines
paper, scribbles when shown
Labels a particular picture with a specific Talks about past events
sound Tells simple stories
Enjoys being read to and looking at books Engages in multi step pretend play cooking
Relates an object or an action in a book to a meal, repairing a car
the real world Is aware of the functions of print
in menus, signs
Has a beginning interest in, and awareness
of, rhyming
Requests adult to read or write Knowledge of the basic concepts of print
Understands that print carries a message shows in childs writing (letters instead of
scribbles, letter groupings that look like
Shows ability to participate in routines
words, invented spelling)
Points to and says the name of most letters
By 4 years of the alphabet when randomly
Tells stories with clear beginning, middle presented (upper and lower case);
and end recognizes how many words are in a
Matches some letters with their sounds sentence
(e.g., Letter t says tuh) Prints letters (by copying, or in her full
Recites nursery rhymes and sings familiar name, or when attempting to spell words)
songs Makes predictions about stories; retells the
Reads a book by memory or by making up beginning, middle and end of familiar
the story to go along with the pictures stories
Can guess what will happen next in the Can recall a brief story that has just been
story heard
Retells some details of stories read aloud When being read a story, connects
but not necessarily in order information and events to real life
experiences
Traces circle, triangle, square using
templates Can identify the beginning and ending
sounds in words e.g., Pop starts with the
Recognizes signs and symbols in daily puh sound
environment (e.g., traffic signs, washroom
signs) Can shift attention from meanings of words
to sounds of words
Holds a pencil correctly
Draws diagonal lines and simple shapes
Identifies the names of 10 alphabet letters
(likely from own name) Able to sort objects by size, colour, use, etc.
Understands the concept of rhyme; Able to understand simple patterning
recognizes and generates rhyming words One to one correspondence for numbers
Changes a sound in a word to make a new from 1 through 10o for hel
word in familiar games and songs
Enjoys being read to
See also
Is motivated to try to read
Speech & Language
Speech and language difficulties are often
By 5 years associated with weak literacy skills.
Can match all letter symbols to letter
Note: Low literacy level of parents is also a risk
sounds
factor for literacy development.
Reads some familiar vocabulary by sight
(high frequency words)
Can label pictures quickly
Knows parts of a book See Literacy & Numeracy in the Where to Go for
Understands the basic concepts of print
(difference between letters, words,
sentences, how the text runs from left to
right, top to bottom, white space between
words)
SOCIAL/EMOTIONAL
Problem signs ...
if a child is experiencing any of the following, consider this a red flag:
0-8 months parent/guardian when distressed or after

Failure to thrive with no medical reason separation
Parent/guardian and child do not engage Child is excessively distressed by
in smiling and vocalization with each other separation from parent
Parent/guardian ignores, punishes or Child freezes or moves toward parent
misreads childs signals of distress by approaching sideways, backwards or
Parent/guardian pulls away from infant or circuitously
holds infant away from body with stiff arms Child alternates between being hostile
Parent/guardian is overly intrusive when and overly affectionate with parent
child is not wanting contact Parent/guardian seems to ignore,
Child is not comforted by physical contact punish or misunderstand emotional
with parent communication of child
Parent/guardian uses inappropriate
8-18 months behaviour management techniques
Parent/guardian and child do not engage
in playful, intimate interactions with each 3-5 years
other Child ignores adult or becomes worse
Parent/guardian ignores or misreads childs when given positive feedback
cues for contact when distressed Child is excessively clingy or attention
Child does not seek proximity to parent seeking with adults, or refuses to speak
when distressed Child is hyper vigilant or aggressive
Child shows little wariness towards a new without provocation
room or stranger Child does not seek adult comfort when
Child ignores, avoids or is hostile with hurt, or show empathy when peers are
parent after separation distressed
Child does not move away from parent to Childs play repeatedly portrays abuse,
explore, while using parent as a secure base family violence or explicit sexual
Parent/guardian has inappropriate behaviour
expectations of the child for age Child can rarely be settled from temper
tantrums within 5-10 minutes
18 months - 3 years Child cannot become engaged in self-
Child and parent have little or no playful or directed play
verbal interaction Child is threatening, dominating,
Child initiates overly friendly or affectionate humiliating, reassuring or sexually
interactions with strangers intrusive with adult
Child ignores, avoids or is hostile with Parent/guardian uses inappropriate
behaviour management techniques

See Social/Emotional in the Where to Go for Help section at the back of this document.
BEHAVIOUR
Children may engage in one or more problem behaviours from time to time. Some factors should be
considered in determining whether the behaviour is truly of concern. These include:
injuring themselves or others
behaving in a manner that presents immediate risk to themselves or others
frequency and severity of the behaviour
number of problematic behaviours that are occurring at one time
significant change in the childs behaviour
withdrawal
If the child presents with any type of the following behaviours, consider this a red flag:
Self-Injurious Behaviour Touches self or others in inappropriate ways,

Bites self, slaps self, grabs at self precocious knowledge of a sexual nature
Picks at skin, sucks excessively on skin/ Flat affect, inappropriate emotions,
bangs head on surfaces unpredictable angry outburst, disrespect or
Eats inedibles striking
Intentional vomiting (when not ill)
Potentially harmful risk taking (e.g., running Life Skills
into traffic, setting fires) Oppositional behaviour
Running away
Aggression Resisting assistance that is
Temper tantrums, excessive anger, threats inappropriate to age
Hits, kicks, bites, scratches others, pulls hair
Bangs, slams objects, property damage
Self-Stimulatory Behaviour
Cruelty to animals
Deficits in expected functional behaviours
Hurting those less able/bullies others
(e.g., eating, toileting, dressing, poor play
skills)
Social Behaviour Regression, e.g., loss of skills, refusal to eat,
Difficulty paying attention/hyperactive, sleep disturbances
overly impulsive Difficulty managing transitions/routine
Screams, cries excessively, swears changes
Hoarding, stealing Hand-flapping, hand wringing, rocking,
swaying
No friends, socially isolated, will not make
eye or other contact, withdrawn Repetitious twirling, repetitive object
manipulation
Anxious, fearful/extreme shyness, agitated
Compulsive behaviour, obsessive thoughts,
bizarre talk WHERE TO GO FOR HELP
Exhibiting inappropriate behaviour in
See Behaviour in the Where to Go for Help
public (e.g., undressing)
NUTRITION & ORAL HEALTH
NUTRITION
The warning signs of poor nutritional health are often overlooked.
Problem signs...
if an infant/child experiences any of the following signs, it should be considered a red flag:
0-6 months Pablum is offered in a bottle
Typical weight gain guidelines not met: Highly allergenic foods are offered (egg white,
nuts, sesame, peanuts, shellfish)
0-3 months, 4-8 oz (140-227g)/week
Honey is given under one year
3-6 months, 3-5 oz (85-142g)/week
Formula fed baby is not held during feeding
Birth weight is expected to be regained by
to ensure infant and mother/caregiver
10 days of age
bonding
Crosses 2 percentile ranks on the growth chart
Sudden decrease in wet and soiled diapers
Sudden and rapid weight loss or gain
Consistent green watery stool
Diet includes anything other than breastmilk
Hard pellet like stool
or iron fortified infant formula
Urine has a fishy smell
Breastmilk or formula is not being fed on
demand Urine or stool has blood in it
Using softened, distilled or unsterilized water

to make formula 9-12 Months
Infant formula is not stored or prepared
correctly
Birth weight not tripled by 1 year old
to ensure safety and promote bonding Typical weight gain guidelines not met -
1.5-3 oz (42-85 g)/week
Pablum is offered in a bottle
Baby is drinking lower fat milk (skim, 1%, 2%),
Honey is given under one year
unpasteurized milk, goats milk or soy/rice
Sudden decrease in wet and soiled diapers milks
Consistent green watery stool Drinking more than 4 oz ( cup) of diluted
Hard pellet like stool fruit juice per day
Urine has a fishy smell Consuming fruit drinks or soft drinks
Urine or stool has blood in it Honey is given under one year
to ensure safety and promote bonding
6-9 Months
Still eating only pureed food
Birth weight not doubled by six months
Eating highly allergic foods (egg white, nuts,
Crosses 2 percentile ranks on the growth chart sesame, peanut, shellfish)
Typical weight gain guidelines not met - Sudden decrease in wet and soiled diapers
1.5 3 oz (42-85 g)/week
Consistent green watery stool
Complementary foods have not been
Hard pellet like stool
introduced
Urine has a fishy smell
Drinking cows milk
Urine or stool has blood in it
Drinking fruit juice/drinks or soft drinks
12-24 Months Preschooler 3-6 Years

Not eating a variety of foods
Birth weight not tripled by 12 months Drinking less than 16 oz (2 cups) or more
than 24 oz (3 cups) of milk per day
Not eating a variety of foods
Drinking more than 6 oz ( cup) of juice per
Refuses mashed or chopped foods
day
Still eating pureed food
Consuming fruit drinks or soft drinks
Drinking lower fat milk (skim, 1%, 2%),
Still being spoon-fed
unpasteurized milk, goats milk or soy/rice
drinks Still drinking from a bottle
Drinking more than 4-6 oz (- cup) per day Does not eat at regular times throughout
of diluted fruit juice the day (breakfast, lunch, and supper and
Consuming fruit drinks or soft drinks 2-3 between meal snacks)
Drinking less than 12 oz (1 cups) or more Parents/guardians restrict intake or demand
than 20 oz (2 cups) milk/day increased food consumption
Not self-feeding Family is experiencing problems around
Consuming nuts, peanuts, shellfish or sesame feeding mealtimes are unpleasant
Not consuming snacks between meals Food is used as a reward or punishment
Not supervised while eating

Food allergy symptoms or reactions (e.g.,
diarrhea, vomiting, hives, swelling of tissues,
anaphylaxis, etc.)
Toddlers 2-3 Years

Crosses 2 percentile ranks on the growth
chart
Not eating a variety of foods.
Drinking more than 6 oz ( cup) of juice per
day
Consuming fruit drinks or soft drinks
Drinking less than 12 oz (1 cups) or more
than 20 oz (2 cups) milk/day
Still drinking from a bottle
Parents/guardians restrict intake or demand
increased food consumption
Food is used as a reward or punishment
See Nutrition in the Where to Go for Help
Not self-feeding
Food allergy symptoms or reactions (e.g.,
diarrhea, vomiting, hives, swelling of tissues,
anaphylaxis, etc.)
FEEDING & SWALLOWING
Problem signs
It is advisable to consult an expert if a child:
Has lost weight or has not gained weight Omits complete food groups from his diet
within the last month (less time if pertaining (e.g., no meats; no vegetables)
to an infant)
Has severe tantrums or aversive behaviours on
Must be fed around the clock to gain weight a regular basis when presented with food or
properly (infants require feeds every 2-4 the highchair
hours)
Cannot eat without major distraction or
Cannot suck for more than 5 minutes at a entertainment
time
Can easily go for hours (if not days) without
Consistently takes less than 10 minutes or asking for food
more than 45 minutes to eat a meal
Will not feed himself (at least partially) by 14-
Cannot progress from liquids to purees 15 months
after 6 months, or from purees to pieces by
Most importantly, parents should consult
14 - 16 months
an expert if feeding is a frustrating, draining,
stress-filled experience day in, day out
See also
Speech & Language
Nutrition
Fine Motor

See Feeding & Swallowing in the Where to Go
for Help section at the back of this document.
DENTAL
The Ontario Association of Public Health Dentistry recommends the first visit to a dentist should
occur at one year of age.
Problem signs
the presence of any of the following risk factors for early childhood tooth decay should be
considered a red flag:
Prolonged exposure of teeth Other Risk Factors

to sugars Poor oral hygiene
Through the use of bottle, breast, sippee cups,
Sibling history of early childhood tooth decay
plastic bottles with straws (includes formula,
juice, milk and breast milk) Lack of knowledge of primary caregiver
regarding risk
High sugar consumption
Lower socioeconomic status
Sweetened pacifiers
Limited access to dental care
Long term sweetened medication
Deficits in parenting skills and child
Going to sleep with a bottle containing
management
anything but water
Prolonged use of a bottle beyond one year
Breastfeeding or bottle feeding without

cleaning gums and teeth
Physiological Factors
Those associated with poor enamel
development, such as prenatal nutritional
status of mother and child, poor prenatal
health, and malnutrition of the child
Possible enamel deficiencies related to
prematurity or low birth weight
Mother and childs lack of exposure to fluoride
Transference of oral bacteria from another

person to a child between 19-31 months of
age, through frequent kissing or sharing of
utensils

See Dental in the Where to Go for Help section
ABUSE
WITNESSING FAMILY VIOLENCE
When a child is hurt intentionally or when a parent or caregiver fails to protect a child in their care, this is
abuse. It is against the law. When children witness violence at home, the effects are comparable to the
child being the direct victim of assault. It is a misuse of parental power and can lead to lifelong negative
consequences. There are different kinds of child abuse: physical abuse, sexual abuse, emotional abuse and
neglect. The abuser can be male or female. Abusive behaviour crosses all economic, social and religious
boundaries.
One or two of the warning signs are not necessarily an indication of abuse at home. A child displaying several
of these signs should raise suspicions that the child may be experiencing some type of disruption in his life.
Physical indicators in children Afraid of:

The child does not meet developmental someones anger
milestones as expected self or other loved ones being hurt or killed
Failure to thrive e.g., poor weight gain
being left alone and not cared for
sudden loud noises
Often complains of medical ailments, nausea,
Problems sleeping, e.g., cannot fall asleep,
headaches, stomach aches without any
obvious reason. heightened fear of the dark, resistance to
bedtime, nightmares
Physical harm, whether deliberate or
Sleep disturbances/disruption in eating routines
accidental, during or after a violent episode
Bed-wetting, food-hoarding
May suffer serious unintended injuries
Tries to hurt oneself, cruel to animals
May exhibit signs and symptoms of post
traumatic stress syndrome, e.g., nightmares, Stays around the house to keep watch, or tries
hypervigilence. not to spend much time at home, runs away
Rigid body when experiencing stress
from home
Problems with school
Fussy and distressed
Expects a lot of oneself and is afraid to fail and
Listlessness
so works very hard, perfectionist
Always tired
Overly responsible
Takes the job of protecting and helping the
Behavioural indicators in children mother, siblings
May be aggressive and have temper tantrums, Assumes role of parent
e.g., destructiveness Does not get along well with other children
May exhibit regressive behaviours, e.g., May begin to develop the belief:
bedwetting that it is all right for men to hit women
May show withdrawn, depressed, and that violence is a way to win arguments
nervous behaviours, e.g., excessive shyness, that men are bullies who push women
clinging, whining, excessive crying, excessive and children around
separation anxieties that big people have power they often
Acts out what has been seen or heard
misuse
between the parents, discloses family that women are victims and cant
violence, may act out sexually take care of themselves
Tries too hard to be good and to get adults to Scared to explore and play
approve Impulsiveness
Attention problems
Destruction of property
ABUSE
Behaviours observed in adults

Abuser has trouble controlling self The abused person is not able to care
properly for the children because of
Abuser has trouble talking and getting along
isolation, depression, trying to survive. The
with others
abuser uses money to control behaviour
Abuser uses power games and withholds basic needs
Abuser uses threats and violence, e.g., Holds the belief that the abuser has the
threatens to hurt, kill, or destroy someone or power and the partner has to obey
something that is special, cruel to animals,
Violence is utilized as a way to win, to get
intimidation
what they want - assert power and control
Forces the child to watch a parent/partner
Uses drugs or alcohol
being hurt
Discloses family violence
Abuser is always watching what the partner is
doing Discloses that the abuser assaulted or threw
objects at someone holding a child
Abuser insults, blames, and criticizes partner
in front of others, distorts reality The abused person seems to be frightened,
humiliated and full of shame with a
Abuser instills fear through looks or actions
heightened sense of powerlessness
Jealous of partner talking or being with
Inability to take responsibility for their
others
behaviour - blame others
Abuser does not allow the child or family to
talk with or see others

For any child abuse concerns, please call your local
Childrens Aid Society immediately.
In Lanark County, contact the Childrens Aid Society of
Lanark County at 613-264-9991 or 1-866-664-9991.
For the counties of Leeds and Grenville, contact
Family and Childrens Service of Leeds and Grenville at
613-498-2100 or 1-800-481-7834. After hours, call the
local number and the answering service will contact
the person on call.
For additional help, consult the Where to Go for Help
Interval House:
In Leeds and Grenville counties,
call 613-342-4724 or 1-800-267-4409
In Lanark County, call 1-800-267-7946
ABUSE
PHYSICAL ABUSE
Physical abuse is any deliberate physical force or Breathing causes pain
action (usually by a parent, guardian or caregiver) Difficulty raising arms
that results, or could result, in injury to a child. Human bite marks
Physical abuse is also any harm to a child caused Cuts and scrapes inconsistent with normal play
by an action or omission of action. It is different
Signs of female genital mutilation, e.g., trouble
from what is considered reasonable discipline. It going to the bathroom
can include punching, slapping, beating, shaking,
burning, biting or throwing a child. Injuries may Behavioural indicators in children
include bruises, welts, cuts, fractures, burns, or Cannot remember how injuries happened
internal injuries. Physical abuse can be one or two
The story of what happened does not match the
isolated incidents or can occur over a prolonged injury
period of time.
Refuses or is afraid to talk about injuries
The signs and indicators of abuse and neglect may Is afraid of adults or of a particular person
include but are not limited to those that follow. It Does not want to be touched
is important to realize that the presence of any one May be very:
indicator is not conclusive proof that a child has aggressive
been abused. In most instances, abused children unhappy
will exhibit a number of behavioural and physical withdrawn
indicators. obedient and wanting to please
uncooperative
Physical indicators in children Is afraid to go home
Injuries that are not consistent with explanation Runs away
Presence of several injuries that are in various Is away a lot and when comes back there are
stages of healing signs of healing injury
Presence of various injuries over a period of time Does not meet developmental milestones as
expected
Facial injuries in infants and preschool children
Does not get along well with other children
Injuries inconsistent with the childs age and
Tries to hurt himself, e.g., cutting himself, suicide
developmental phase
Discloses abuse
A lot of bruises in the same area of the body
Bruises in the shape of an object, e.g., spoon, Behaviours observed in adults who abuse children
hand/fingerprints, belt
Does not tell the same story as the child about
Burns: how the injury happened
from a cigarette
May say that the child seems to have a lot of
in a pattern that looks like an object, e.g., iron
accidents
wears clothes to cover up injury, even in
warm weather Severely punishes the child
Cannot control anger and frustration
Patches of hair missing
Expects too much from the child
Signs of possible head injury:
swelling and pain Talks about having problems dealing with the
nausea or vomiting child
feeling dizzy Talks about the child as being bad, different, or
bleeding from the scalp or nose the cause of my problems
Signs of possible injury to arms and legs: Shows no affection toward the child
pain Does not go to the doctor right away to have
sensitive to touch injury checked
cannot move properly Has little or no help caring for the child
limping
ABUSE
SEXUAL ABUSE
Sexual abuse is any sexual exploitation of a Behavioural indicators in children
child by an older person where the child is Copying the sexual behaviour of adults
being used for a sexual purpose. The Criminal Knowing more about sex than expected
Code of Canada identifies a number of types of
Details of sex in the childs drawings/writing
sexual abuse, including sexual interference, an
Sexual actions with other children, including
invitation to sexually touch, sexual exploitation
siblings, or adults that are inappropriate
of a young person, parent, guardian or caregiver
Fears or refuses to go to a parent, relative, or
procuring sexual activity from a child, household
friend for no clear reason
permitting sexual activity, exposing genitals to a
Does not trust others
child, and incest.
Changes in personality that do not make
The signs and indicators of abuse and neglect sense, e.g., happy child becomes withdrawn
may include, but are not limited to, those that
Problems or change in sleep pattern, e.g.,
follow. It is important to realize that the presence nightmares
of any one indicator is not conclusive proof that a
Very demanding of affection or attention, or
child has been abused. In most instances, abused
clinging
children will exhibit a number of behavioural and
Goes back to behaving like a young child, e.g.,
physical indicators.
bed-wetting, thumb-sucking
Refuses to be undressed or, when undressing
Physical indicators in children
shows fear
A lot of itching or pain in the throat, genital or
Tries to hurt oneself
anal area
Discloses abuse
A smell or discharge from the genital area
Underwear that is bloody
Pain when: Behaviours observed in adults
trying to go to the bathroom who abuse children
sitting down
May be very protective of the child
walking
swallowing Clings to the child for comfort
Blood in urine or stool Is often alone with the child
Injury to the breasts or genital area: May be jealous of the childs relationships with
redness others
bruising Does not like the child to be with friends
cuts unless the parent is present
swelling Talks about the child being sexy
Touches the child in a sexual way
May use drugs or alcohol to feel freer to
sexually abuse
Allows or tries to get the child to participate in
sexual behaviour
Uses the child to make money, e.g., child
pornography
ABUSE
EMOTIONAL ABUSE
Emotional abuse includes all acts of omission Criticizes oneself a lot
or commission which result in the absence of a Does not participate because of fear of failing
nurturing environment for the child. It occurs when
the parent/guardian/caregiver continually treats May expect too much of him so gets frustrated
the child in such a negative way that the childs and fails
concept of self is seriously impaired. Emotionally Is afraid of what the adult will do if he does
abusive behaviour by the parent/guardian/ something the adult does not like
caregiver can include constant yelling, demeaning
Runs away
remarks, rejecting, ignoring or isolating the child,
or terrorizing the child. Emotional abuse can be the Has a lot of adult responsibility
most difficult to identify and prove. Does not get along well with other children
The signs and indicators of abuse and neglect may Discloses abuse
include but are not limited to those that follow. It
Displays extreme hesitancy in play
is important to realize that the presence of any one
indicator is not conclusive proof that a child has
been abused. In most instances, abused children Behaviours observed in adults
will exhibit a number of behavioural and physical who abuse children
indicators. Often rejects, insults or criticizes the child, even
in front of others
Physical indicators in children Does not touch or speak to the child with
The child does not meet developmental affection
milestones as expected Talks about the child as being the cause for
Often complains of nausea, headaches,
problems and things not going as wished
stomach aches without any obvious reason Talks about or treats the child as being different
from other children and family members
Wets or soils pants
Compares the child to someone who is not
Is intentionally not given adequate food,
liked
clothing and proper care.
Does not pay attention to the child and refuses
May have unusual appearance causing to help the child
humiliation or embarrassment (e.g., strange Isolates the child, does not allow the child to
haircuts, dress, accessories) see others both inside and outside the family
Bedwetting, non-medical in origin (e.g., locks the child in a closet or room)
Child fails to thrive, e.g., poor weight gain Does not provide a good example for children
on how to behave with others (e.g., swears all
Behavioural indicators in children the time, hits others)
Is unhappy, stressed out, withdrawn, Lets the child be involved in activities that
aggressive or angry for long periods of time break the law
Severe depression Uses the child to make money (e.g., child
pornography)
Goes back to behaving like a young child (e.g.,
Lets the child see sex and violence on TV,
toileting problems, thumb-sucking, constant
rocking) videos and magazines
Terrorizes the child (e.g., threatens to hurt
Tries too hard to be good and to get adults to
or kill the child or threatens someone or
approve
something that is special to the child)
Too neat or too clean Forces the child to watch someone special
Tries really hard to get attention being hurt
Tries to hurt oneself Asks the child to do more than he can do for
himself (e.g., extreme chores)
ABUSE
NEGLECT
Neglect occurs when a parent/guardian/ Behavioural indicators in children
caregiver fails to provide basic needs such Pale, listless, unkempt
as adequate food, sleep, safety, supervision, Frequent absence from school
clothing or medical treatment. Most do not
Inappropriate clothing for the weather, dirty
intend to neglect their children. It usually results clothes
from ignorance about appropriate care for
Frequently forgets a lunch
children or an inability to plan ahead.
Does not meet developmental milestones as
The signs and indicators of abuse and neglect expected
may include but are not limited to those that Appears to have little energy
follow.
Cries very little
It is important to realize that the presence of any Does not play with toys or notice people
one indicator is not conclusive proof that a child Does not seem to care for anyone in particular
has been neglected.
May be very demanding of affection or
In most instances, neglected children will exhibit attention from others
a number of behavioural and physical indicators. Takes care of a lot of their needs on their own
Has a lot of adult responsibility at home
Discloses neglect (e.g., says there is no one
Physical indicators in children at home)
Poor hygiene
Unattended physical problems or medical Behaviours observed in adults
needs (e.g., dental work, glasses) who neglect children
Consistent lack of supervision Does not provide for the childs basic needs
An infant or young child may: Has a disorganized home life, with few regular
not be growing as expected routines (e.g., always brings the child very
early, picks up the child very late)
be losing weight
Does not supervise the child properly (e.g.,
look pale
leaves the child alone, in a dangerous place,
not be eating well or with someone who cannot look after the
not dressed properly for the weather child safely)
dirty or unwashed May indicate that the child is hard to care
bad diaper rash or other skin problems for, hard to feed, describes the child as
demanding
always hungry
May say that the child was or is unwanted
lack of medical and/or dental care
May ignore the child who is trying to be loving
Has difficulty dealing with personal problems
and needs
Is more concerned with own self than
the child
Fails to use services offered/recommended or
to keep childs appointments
Does not act on concerns that are discussed
SPECIAL NEEDS
AUTISM
Autism is a lifelong developmental disorder Communication Concerns
characterized by impairments in all of the Language is delayed (almost universal)
following areas of development: communication, Inconsistent response or does not respond to
social interaction, restricted repertoire of his name or instructions
activities and interests, and associated features, Unusual language - repeating phrases from
which may or may not be present (e.g., movies, echoing other people, repetitive use
difficulties in eating and sleeping, unusual fears, of phrases, odd intonation
learning problems, repetitive behaviours, self- Decreased ability to compensate for delayed
injury and peculiar responses to sensory input). speech by gesture/pointing
If the child presents any of the following Poor comprehension of language (words and
behaviours, consider this a red flag: gestures)
Any loss of language skills at any age
Social Concerns (regression), but particularly between 15 and
24 months
Does not smile in response to another person
Inability to carry on a conversation
Delayed imaginative play - lack of varied,
spontaneous make-believe play
Behavioural Concerns
Prefers to play alone, decreased interest in
Severe repeated tantrums due to frustration,
other children
lack of ability to communicate, interruption of
Poor interactive play routine, or interruption of repetitive behaviour
Poor eye contact - this does not mean it is Narrow range of interests that she engages in
absent repetitively
Less showing, giving, sharing and directing High pain tolerance and lack of safety
others attention than expected for his age awareness
Any loss of social skills at any age (regression) Insistence on maintaining sameness in
Prefers to do things for himself rather than ask routine, activities, clothing, etc.
for help Repetitive hand and/or body movements:
Awkward or absent greeting of others finger wiggling, hand and arm flapping,
tensing of fingers, complex body movements,
spinning, jumping, etc.
Unusual sensory interests (e.g. visually
squinting or looking at things out of the
corner of the eye, smelling, licking, mouthing
objects and/or hypersensitive hearing)
Unusual preoccupation with objects (e.g.,
light switches, fans, spinning objects, vertical
blinds, wheels, balls)
See also
Speech & Language

See Autism in the Where to Go for Help section
SPECIAL NEEDS
FETAL ALCOHOL SPECTRUM DISORDER
Fetal Alcohol Spectrum Disorder (FASD) is an umbrella term for the range of harm that is caused by
alcohol use during pregnancy. It includes Fetal Alcohol Syndrome (FAS), partial FAS (pFAS), and Alcohol
Related Neurodevelopment Disorder (ARND). FASD is preventable, but not curable. Early diagnosis
and intervention can make a difference. Children exposed prenatally to alcohol, who do not show the
characteristic physical/external or facial characteristics of FAS, may suffer from equally severe brain
damage.
The following are common characteristics of FASD:
Facial dysmorphology - the characteristic Information processing problems, problems
facial features include small eye openings, sequencing and making choices
flat mid-face, thin upper lip, flattened ridges Difficulty with transition
between base of nose and upper lip
Difficulty reading non-verbal cues, poor social
Low birth weight, failure to thrive, small size, judgment
small head circumference, and ongoing slow
Responds better one-on-one
growth
Impaired motor skills (e.g., clumsy,
Disturbed sleep, irritability, persistent
poor hand-eye coordination)
restlessness
May have physical birth defects
Infants may be floppy or too rigid because of
poor muscle tone
Failure to develop routine patterns of Caution:
behaviour The most sensitive time for brain development
Excessively busy toddlers/preschoolers is the first trimester; before many women
Hyperactivity know they are pregnant. Alcohol use, some
Inconsistent behaviours medications and drugs used during pregnancy
Impulsive can cause similar learning and behaviour
problems. Some genetic conditions and acquired
Poor memory
brain injury also look similar to FASD. Care needs
Unable to relate cause and effect
to be taken when discussing a possible referral
Unable to comprehend danger for FASD diagnosis, so as not to stigmatize the
Easily over-stimulated, sensitive to sound, mother.
lights and being touched
Highly tactile (likes to touch things)
Discrepancy between good expressive and WHERE TO GO FOR HELP
poor receptive language (is less capable than See FASD in the Where to Go for Help section at
he looks) the back of this document.
SPECIAL NEEDS
LEARNING DISABILITIES
Current research indicates that early appropriate intervention can successfully remediate many
disabilities, particularly those related to reading. The following is a list of characteristics that may point
to a learning disability. Most people will, from time to time, see one or more of these warning signs in
their children. This is normal.
Learning disabilities are related to difficulties in processing information:
the reception of information,
the integration or organization of that information,
the ability to retrieve information from its storage in the brain, and
the communication of retrieved information to others.
If a child exhibits several of the following characteristics consider this a red flag:
Preschool School Age

Speaks later than most children Learning Disabilities are diagnosed by a
Has pronunciation difficulties psychologist, and generally after the child enters
school and is learning to read and write.
Slow vocabulary growth, often unable to
find the right word The psychologist will assess:
Has difficulty rhyming words auditory and visual perceptual skills
Has trouble learning colours, shapes, days (understanding)
of the week, numbers and the alphabet processing speed
Fine motor skills are slow to develop organization
Is extremely restless and easily distracted memory (short and long term storage and
Has difficulty following directions and/or retrieval)
routines fine motor skills
Has trouble interacting appropriately with gross motor skills
peers
attention (focus)
abstractions (interpreting symbolism)
social competence (effective interactions
with others)

See Learning Disabilities in the Where to Go for
SPECIAL NEEDS
INTELLECTUAL & DEVELOPMENTAL DISABILITIES
Intellectual and developmental disabilities (mental retardation) refers to a range of cognitive, social/
emotional, adaptive and motor delays or impairments. These deficits often impact on the childs ability
to communicate, learn, interpret and respond to social cues. The child may also exhibit challenging
behaviour (self-injury, aggression, destruction) associated with frustration from the latter deficits.
If the child presents any of the following behaviours, consider this a red flag:
Cognitive Concerns Behaviour affecting ability to learn new things

Significant attention difficulties Socially inappropriate behaviour (e.g., taking
Poor concentration, poorly focused and another childs food, stripping in public)
organized Poor/lack of ability to empathize (e.g., if
Is extremely restless and distractible another child is crying)
Memory impairments
Adaptive Concerns
Poor problem solving (planning, organizing
and initiating tasks) Has delays in two or more age-appropriate
life skills domains (e.g., toileting, dressing,
Slow to process verbal information/slow to
feeding, face and hand washing)
understand what is said
Shows no age-appropriate awareness of
Slow to process visual and non-verbal
danger
information (e.g., gestures, signs, social cues)
Difficulty learning new tasks Communications Concerns
Has difficulty following directions and/or Poor expressive communication (language,
routines gestures, signs)
Poorly developed basic concepts (e.g., colours, Poor comprehension of language (words,
shapes, body parts) gestures, pictures)
Social/Emotional/ Behavioural Concerns Physical Concerns

Poorly developed play skills (for his age) Poorly developed fine motor skills (e.g.,
Awkward or absent greeting of others holding a pencil, picking up beads)
Has very few friends/alienates other children Poorly developed gross motor skills (e.g.,
May be withdrawn/passive due to inability to
awkward gait, poor coordination, poor
communicate balance)
Seizures or frequent periods of blank staring
Has trouble interacting appropriately with
peers
Narrow range of interests that he engages in
Frequent tantrums, aggression, destruction or
See Intellectual & Developmental Disabilities in
self-injury due to frustration, lack of ability to
communicate, interruption/change in routine, the Where to Go for Help section at the back of
not getting what he wants, mind gets stuck this document.
on one issue
May present with oppositional/defiant
behaviour due to inability to process
information - does not know what is expected
of him
SPECIAL NEEDS
MILD TRAUMATIC BRAIN INJURY
Changes in behaviour may be related to a mild traumatic brain injury (e.g., falls, accidents, medical
treatment, shaken baby syndrome).
If the child presents with one or more of the following behaviours that are different from the childs
norm, consider this a red flag:
Physical Learning new information (increased time

Dizziness required for new learning to occur)
Headache, recurrent or chronic Abstract thinking
Blurred vision or double vision Reduced motor speed
Fatigue that is persistent Inflexible thinking; concrete thinking
Reduced endurance that is consistent Decreased processing speed
Insomnia/severe problems falling asleep Not developing age-appropriately
Poor coordination and poor balance Difficulties with multi-tasking and sequencing
Sensory impairment (change in ability to
smell, hear, see, taste the same as before)
Significantly decreased motor function
Behavioural/Emotional (Severe)
Irritability, aggression
Dramatic and consistent increase or
decrease in appetite Impulsivity, confusion, distractibility,
mind gets stuck on one issue, emotional
Seizures
rollercoaster
Persistent tinnitus (ringing in the ears)
Loss of self esteem
Retinal hemorrhages
Poor social judgment or socially inappropriate
Bulging fontanel behaviour
Bruises Decreased initiative or motivation, difficulty
handling transitions or routines
Personality change, sleep disturbances
Cognitive Impairments
Withdrawal, depression, frustration
Decreased attention
Anxiety
Gets mixed up about time and place
Decreased ability to empathize, egocentricism
Decreased concentration
Reduced perception
Memory or reduced learning speed WHERE TO GO FOR HELP
Develops problems finding words or See Mild Traumatic Brain Injury in the Where
generating sentences consistently to Go for Help section at the back of this
Problem solving (planning, organizing document.
and initiating tasks)
OTHER FACTORS
FAMILY ENVIRONMENTAL STRESSORS
If any one of these stressors is found, this could affect a childs development and should be considered
a red flag:
Parental Factors A series of losses in a short time frame

Misusing adult privilege Recent death of a parent/child
Bullying behaviours Lack of a support network or caregiver relief
History of abuse as a child Immigrant status, language barrier
History of domestic violence Experiencing discrimination because
Severe mental health or physical health of race, culture
problems Substandard shelter
Chronic substance misuse No fixed address over a time frame/transient
Difficulty controlling anger or aggression
Feelings of inadequacy, low self-esteem
Economic Factors
Lack of knowledge or awareness of child
Inadequate income
development
Unemployment
A young, immature, or developmentally
delayed parent Lack of access to consistent medical care/no
health coverage
History of postpartum depression
Business failure
History of crime or incarceration of parent/
guardian Debt
Low literacy Inadequate housing or eviction

Change in economic status related to
immigration
Social/Family Factors
Multiple partners
Family breakdown and/or family violence
Multiple births
For child protection concerns:
Several children close in age with little For Lanark County, contact the Lanark
family/social support County Childrens Aid Society at
613-264-9991.
A special needs child
For Leeds and Grenville Counties, contact
An unwanted child Family and Childrens Services of Leeds
Prematurity and low birth weight and Grenville at 613-498-2100 or
1-800-481-7834.
Personality and temperament challenges in
child or adult After hours, call the local number and the
answering service will contact the person
Mental or physical illness, or special needs on call.
of a family member
For additional help, consult the Where to Go for
OTHER FACTORS
POSTPARTUM DEPRESSION
Postpartum blues are considered normal. They affect up to 80% of new mothers. They can occur 3
to 4 days after birth and can last up to 2 weeks. With good physical care and emotional support, these
symptoms will go away (e.g., crying spells, feeling sad, irritability, frustration).
Untreated postpartum depression impacts a childs development, as parents may have altered
ability to be attentive, attuned and able to respond appropriately to the infant or child{ren}. For
more information on how red flag behaviours may be present in families experiencing postpartum
depression, please see sections on: Attachment, Social/Emotional, Abuse, Behaviour, Family
Environmental Stressors.
Postpartum Depression may start prenatally, and is part of the spectrum of postpartum mood
disorders. A woman who has a personal or family history of depression/anxiety and/or history of abuse
or neglect may be at increased risk of postpartum depression.
Red Flags for Postpartum Depression:

If mom is experiencing any of the following beyond 2 weeks of the birth of the child:
Sad and tearful Repeated scary thoughts about the baby
Exhaustion Thoughts of harming self or baby
Changes in eating and sleeping patterns Altered mood; anxiety and/or depression
Feeling overwhelmed with inability to Lack of supports/partner

concentrate
Recent stressful life event
Reduced interest or pleasure in family
Isolation, lack of transportation
and/or activities
Financial concerns which may lead to
Hopelessness and frustration
inadequate access to food and/or housing
Restlessness, irritability or anger
Unrealistic expectations of self or child
Extreme highs, full of energy
Substance abuse
Guilt and shame, thinking she is not a
good mother
Poor attachment (e.g., unable to read WHERE TO GO FOR HELP
babys cues) See Postpartum Depression in the Where to Go
Afraid to be alone with baby for Help section at the back of this document.
KINDERGARTEN
GETTING READY FOR KINDERGARTEN
Is this child ready for Kindergarten?
The child should be able to: By Kindergarten entry, children should have:
Get dressed Vision checkup by 6 months of age
Go to the bathroom
(www.optom.on.ca)
Dental checkup by age 1 (www.oaphd.on.ca)
Engage in healthy practices, i.e. blow nose,
wash hands Up to date immunizations
Open lunch items
Be away from parent/guardian
Ask for help Problem signs...

Share and take turns with other children If the child presents with any of the following
Follow routines behaviours consider this a red flag:
Communicate so a teacher and other Significant attention difficulties
students can understand
Behaviour affecting ability to learn new
Be able to follow one, two, and three step things
instructions
Sudden change in behaviour
Understand basic safety rules uncharacteristic for the individual
Feel good about trying new things
Difficulties with pre-academic skills/
Take part in group activities concepts (e.g. colours, shapes)
Do simple chores History of learning disabilities in the family
Know what their printed name looks like
Delay in self-help skills
Respect authority
Inconsistent performances (cant do what
Communicate feelings he could do last week)
Make choices
Poorly focused and unorganized
Listen to a story
See also:
Speech & Language
Literacy & Numeracy
Fine Motor
SUBSIDY INFORMATION
SUBSIDY INFORMATION
ONTARIO CHILD CARE SUPPLEMENT FOR WORKING FAMILIES
If you are in a low-to-middle income family with children under age seven, you could qualify for the Ontario Child
Care Supplement for Working Families. If you would like more information contact the Ministry of Finance at 1-
877-533-2188 or www.fin.gov.on.ca
WHAT IF I ALREADY RECEIVE THE ONTARIO ARE YOU FINANCIALLY ELIGIBLE FOR
CHILD CARE SUPPLEMENT FOR WORKING CHILD CARE SUBSIDY?
FAMILIES? Eligibility is determined by your level of income
If you are eligible to receive child care fee subsidy as shown on Line 236 of your most recent Federal
and are already in receipt of the Ontario Child Care Notice of Assessment or net income as shown on
Supplement for Working Families, it is in your best your Canada Child Tax Benefit Notice. In some cases
interest to notify the Ministry of Finance at the families are eligible for a partial subsidy, but this will
above telephone number or Website address in be determined during your appointment.
order to avoid a possible overpayment.
HOW DO YOU MAKE AN APPOINTMENT?
WHO IS RESPONSIBLE FOR You must call Childrens Services to make an
CHILD CARE FEE SUBSIDY? appointment or receive an application. Please be
LEEDS & GRENVILLE: The United Counties advised that there may be a waiting list at times.
of Leeds and Grenville Childrens Services Leeds and Grenville Counties:
Department manages and determines eligibility 613-342-3840 or 1-800-770-2170
for child care fee subsidies for residents of Leeds Lanark County: 613-267-4200 ext 2302 or 2304
and Grenville under the authority of the Day or 1-888-952-6275
Nurseries Act. Our offices are open daily from 8:30 a.m. to 4:00 p.m
LANARK COUNTY: The County of Lanark Childrens
WHAT DO YOU NEED TO BRING
Services Department manages and determines
TO YOUR APPOINTMENT?
eligibility for child care fee subsidies for residents
of Lanark County and the Town of Smiths Falls You must provide your most recent Federal Notice
under the authority of the Day Nurseries Act. of Assessment or Canada Child Tax Benefit Notice
(your eligibility cannot be determined without this
document). To order either of these documents call
DO YOU QUALIFY FOR CHILD CARE FEE SUBSIDY?
1-800-959-8281 and the Canada Revenue Agency will
Subsidies are available for children ranging in mail one to you.
age from infant to twelve (12) years of age where
the parent(s) is/are employed or enrolled in an For a list of licenced childcare programs in your area:
educational or retraining program (exceptional Residents of Lanark: call Lanark County Social
circumstances may be considered). Child care fee Services at 613-267-4200 or 1-888-952-6275
subsidy applies only to contracted services which
Residents of Leeds and Grenville: call United
are licensed under the Day Nurseries Act.
Counties of Leeds and Grenville Social Services
at 613-342-3840 or 1-800-770-2170
If there are concerns in any area, advise the Attachment pg.8
parent to contact any one of the following, as For residents of Lanark:
appropriate: Infant & Child Development Program, Lanark
their family physician Community Programs
Ages: 2 years and under
their nurse practitioner
613-257-7121 or 1-800-667-2617
the Health Units Health Action Line at
613-345-5685 or 1-800-660-5853 Open Doors for Lanark Children and Youth
any Ontario Early Years Centre:
613-283-8260 or 1-877-232-8260
Lanark:

613-283-0095 or 1-800-267-9252
For residents of Leeds & Grenville:
Leeds & Grenville: Infant & Child Development Program
613-341-9044 or 1-866-433-8933 Ages: 2 years and under
613-345-1662
If the concerns pertain to a child protection
issue, contact the local Childrens Aid Society: Child & Youth Wellness Centre
Lanark County Childrens Aid Society: 613-498-4844 or 1-800-809-2494
613-264-9991 or 1-866-664-9991
Family and Childrens Services of Leeds and
Grenville: 613-498-2100 or 1-800-481-7834 Autism pg.32
Families who suspect Autism but do not have a
For specific concerns, see the individual diagnosis should proceed towards assessment
categories listed in this section. by having their family doctor make a referral
A physicians referral is not always required to requesting diagnostics for autism to either:
contact individual agencies. 1. Childrens Hospital of Eastern Ontario (CHEO)
613-737-7600
2. Ottawa Childrens Treatment Centre (OCTC)
Abuse pg.26 - 31 1-800-565-4839
Please call your local Childrens Aid Society 3. Hotel Dieu, Child Development Centre
immediately if the concerns relate to a child (Kingston) - 613-544-3400, ext. 3174
protection issue. (Or hire the services of a private practice
psychologist.)
For residents of Lanark:
Lanark County Childrens Aid Society Referral to the South East Region Autism
613-264-9991 or 1-866-664-9991 Intervention Program can be made by completing
the Autism Intervention referral*, Consent to
Interval House
Share Information* and submitting these with the
613-257-5960 or 1-800-267-7946 assessment/diagnostic documentation to:
For residents of Leeds and Grenville: Coordinator, Behaviour Development and
Family and Childrens Services Autism Intervention,
Lanark Community Programs,
of Leeds and Grenville
30 Bennett Street,
613-498-2100 or 1-800-481-7834
Carleton Place ON K7C 4J9
Interval House 1-866-257-7618, ext. 242
613-342-4724 or 1-800-267-4409
(*forms available at: http://lcp-home.com/autism.
php)
For additional information, visit the autism Children in Need of Treatment (CINOT) Program.
Ontario website at www.autismontario.com, visit For additional information, visit www.oaphd.on.ca.
Improving the Odds: Healthy Child Development Baby Oral Health online video at: www.utoronto.
(Appendix K and L: Checklist for Autism in Toddlers ca/dentistry/newsresources/kids. Or refer to the
(CHAT) at www.beststart.org/resources or the yellow pages of your local phone book.
Geneva Centre for Autism at www.autism.net
Behaviour pg.21 Family Environmental Stressors pg.37

Please call your local Childrens Aid Society
For residents of Lanark:
immediately if the concerns relate to a child
Open Doors for Lanark Children and Youth protection issue.
613-283-8260 or 1-877-232-8260 For residents of Lanark:
Lanark County Childrens Aid Society
Behaviour Development Program, Lanark 613-264-9991 or 1-866-664-9991
Community Programs
Ages: 2 years and up Connections Program
613-257-7619 or 1-800-667-2617 Ages: 0-6 years
613-257-2779 or 1-888-284-2204
Infant & Child Development Program, Lanark
Community Programs Interval House
Ages: 2 years and under 613-257-5960 or 1-800-267-7946
613-257-7121or 1-800-667-2617
For residents of Leeds and Grenville:
Lanark Early Integration Program, Lanark Family and Childrens Services of Leeds and
Community Programs Grenville
Ages: 2 years 12 years 613-498-2100 or 1-800-481-7834
613-257-7121 or 1-800-667-2617
Interval House
For residents of Leeds & Grenville: 613-342-4724 or 1-800-267-4409
Child and Youth Wellness Centre
Ages: 18 years and under Feeding & Swallowing pg.24
613-498-4844 or 1-800-809-2494 A physicians referral is required.
Developmental Services of Leeds and Grenville Childrens Hospital of Eastern Ontario (CHEO)
613-345-1290 or 1-866-544-5614 613-737-7600
Inclusive Child Care Program, Developmental Child Development Centre,
Services of Leeds and Grenville Hotel Dieu Hospital, Kingston
Ages: Children from birth to 10 years of age with 613-544-3400, ext. 3175
an identified developmental delay or who are at
risk for later delays. Fetal Alcohol Spectrum Disorder pg.33
613-345-1290 or 1-866-544-5614
If there are concerns, advise parents to contact
their physician or if they do not have a physician,
Dental pg.25 contact:
If there are dental concerns, advise parents to Childrens Outpatient Centre, Hotel Dieu
contact their dentist, or call: Hospital, Kingston
Dental Services, Leeds, Grenville and Lanark 613-544-3400, ext. 3150 or 3151
District Health Unit
For a diagnosis, a physician may make a referral
613-345-5685, or 1-800-660-5853.
to: CHEO Genetics Clinic, Ottawa
Children aged 0-14 years may be eligible for the 613-737-2275
Medical Genetics, Kingston If the child is in a ministry licensed daycare
613-533-6310 program 613-345-1290 or 1-866-544-5614
If the child is in kindergarten, contact the teacher
St. Michaels Hospital in Toronto has a FASD
to connect with appropriate services.
diagnostic clinic for people of all ages. Referrals
are accepted from any source. The clinic is based
on a multidisciplinary approach. The process Getting Ready for Kindergarten pg.39
begins by calling 416-867-3655 and requesting a Contact your local Ontario Early Years Centre
questionnaire. It is recommended that a service
Lanark: 613-283-0095 or 1-800-267-9252
provider assist the family with the questionnaire
and include their contact information, as the Leeds and Grenville:
questionnaire is lengthy and requires a thorough 613-341-9044 or 1-866-433-8933
family history. Once this is filled in and mailed
back, a clinic appointment will be made. Gross Motor pg.10
For a FASD Resource Guide, call the Health Action For residents of Lanark:
Line of the Leeds, Grenville and Lanark District Infant & Child Development Program, Lanark
Health Unit at 613-345-5685, or 1-800-660-5853 Community Programs
Ages: under 3 years
For additional information on FASD, visit the Public 613-257-7121 or 1-800-667-2617
Health Agency of Canada at www.publichealth. Community Care Access Centre
gc.ca and www.alcoholfreepregnancy.ca as well Ages: over 3 years
as the website for the Leeds, Grenville and Lanark 613-283-8012 or 1-800-267-6041
District Health Unit at www.healthunit.org
Lanark Early Integration Program, Lanark
Community Programs
Fine Motor pg.9 If the child is in a ministry licensed daycare
For residents of Lanark: program
Infant & Child Development Program, Lanark 613-257-7121 or 1-800-667-2617
Community Programs
Ages: under 3 years
613-257-7121 or 1-800-667-2617
Community Care Access Centre For residents of Leeds & Grenville:
Ages: over 3 years Paediatric Physiotherapy,
613-283-8012 or 1-800-267-6041 Brockville General Hospital
If the child is in kindergarten, contact the teacher 613-345-5645
to connect with appropriate services. Infant & Child Development Program
For children with global delays
For residents of Leeds & Grenville: 613-345-1662
Infant & Child Development Program
Inclusive Child Care Program, Developmental
Ages: under 3 years
613-345-1662 Services of Leeds and Grenville
If the child is in a ministry licensed daycare
Community Care Access Centre
program
Ages: over 3 years
613-345-1290 or 1-866-544-5614
613-283-8012 or 1-800-267-6041
Inclusive Child Care Program, Developmental
Services of Leeds and Grenville
Hearing pg.13 Learning Disabilities pg.34
The first 2 years of life are the most important for If there are concerns, advise the parents to
speech and language development. By 2 years contact their family physician, their childs school
of age children should receive a hearing test if or:
they dont seem to be developing speech and
Learning Disabilities Association of Kingston
language at the normal rate.
613-546-8524
www.kingston.jkl.net/~ldak/index.htm
Southeastern Region Infant Hearing Program
Kingston, Frontenac and Lennox & Addington Learning Disabilities Association
Public Health of Ottawa Carleton
613-549-1232, ext. 1145 or 613-567-5864
1-800-267-7875, ext. 1145 www.ldao-c.ncf.ca
Or visit their website at www.healthunit.on.ca.
Or refer to the yellow pages of your local phone
book. Literacy & Numeracy pg.18 - 19
Language Express Preschool Speech and
Language Services
Intellectual & Developmental Disabilities Ages: 0-5 years
pg.35 613-283-2742 or 1-888-503-8885
If there are any concerns, advise the parent www.language-express.ca
to arrange a referral to a paediatrician or
psychologist through their family physician. Early Literacy Specialists, Ontario Early Years
If there is suspicion of a diagnosis of mental Centres:
retardation, a referral can be made to: Lanark: 613-283-0095 or 1-800-267-9252
Developmental Services of Leeds and Grenville Leeds & Grenville: 613-341-9044
613-345-1290 or 1-866-544-5614 or 1-866-433-8933
Lanark Community Programs
613-257-7121 or 1-800-667-2617
Mild Traumatic Brain Injury pg.36
For more information about intellectual deficits If a parent reports changes in their childs
and mental retardation, visit the American behaviour, advise them to contact their family
Association on Intellectual and Developmental physician or paediatrician, who can make a
Disabilities AAIDD (formerly the American referral to:
Association on Mental Retardation AAMR) Rehabilitation Services, CHEO
at www.aaidd.org. Refer also to the Red Flags 613-737-7600, ext. 2500
sections on Autism, Mild Traumatic Head Injury,
Speech and Language, Behaviour and Learning Child Development Centre,
Disabilities. Hotel Dieu Hospital, Kingston
613-549-2680 (direct intake line) for a medical
assessment and referral to the appropriate
specialist.
Nutrition pg.22 If the child is in kindergarten, contact the teacher
Registered Dietitians, Leeds, Grenville and Lanark
District Health Unit
613-345-5685 or 1-800-660-5853
Ages: under 3 years
Postpartum Depression pg.38 613-345-1662
For initial assessment of PPD: Community Care Access Centre
Lanark County Mental Health Ages: over 3 years
613-283-2170 613-283-8012 or 1-800-267-6041
or their Crisis Line: 1-866-281-2911 Inclusive Child Care Program, Developmental
Brockville Mental Health Centre Services of Leeds and Grenville
(Brockville Psychiatric Hospital) If the child is in licensed day care
613-345-1461 613-345-1290 or 1-866-544-5614
or their Crisis Line: 613-345-4600 If the child is in kindergarten, contact the teacher
Leeds, Grenville and Lanark District Health Unit
613-345-5685 or 1-800-660-5853.
For ongoing support: Postpartum Depression
Social/Emotional pg.20
Support Groups are offered in both Lanark and in For residents of Lanark:
Leeds & Grenville once an initial assessment has Open Doors for Lanark Children and Youth
been completed. 613-283-8260 or 1-877-232-8260
If you have reasonable grounds to suspect Infant & Child Development Program, Lanark
that a child is or may be in need of protection, Community Programs
promptly report your suspicions, concerns and the Ages: 2 years and under, with a developmental
information on which they are based to your local disability or at risk for a developmental disability
Childrens Aid Society. 613-257-7121 or 1-800-667-2617
Lanark Early Integration Program,
Sensory pg.14 Lanark Community Programs
For residents of Lanark: For children attending a ministry licensed
daycare program
Infant & Child Development Program,
613-257-7121 or 1-800-667-2617
Lanark Community Programs
Ages: under 3 years The Lanark County Childrens Aid Society
613-257-7121 or 1-800-667-2617 613-264-9991 or 1-866-664-9991
Community Care Access Centre

Ages: over 3 years
Child and Youth Wellness Centre
613-283-8012 or 1-800-267-6041
613-498-4844 or 1-800-809-2494
Lanark Early Integration Program, Lanark
Community Programs
Ages: under 3 years
If the child is in a ministry licensed day care
613-345-1662
program
1-800-667-2617
Inclusive Child Care Program, Developmental The Ontario Association of Optometrists
Services of Leeds and Grenville recommended frequency for childrens eye
For children attending a ministry licensed examinations:
daycare program 6 months of age
613-345-1290 or 1-866-544-5614 3 years of age and then
Family and Childrens Services of Every 12 months or as recommended by
Leeds and Grenville the optometrist
613-498-2100 or 1-800-481-7834.
For more information about vision loss, visit the
Canadian National Institute for the Blind website at
Speech & Language pg.15 - 17 www.cnib.ca
Language Express Preschool Speech and
Language Services If there are any concerns about a childs vision,
Ages: 0-5 years advise the parent to arrange for a vision test with
613-283-2742 or 1-888-503-8885 an optometrist, or contact their family physician
www.language-express.ca for a referral to an ophthalmologist. Children up
to 6 years of age who are diagnosed as blind or
Early Literacy Specialists, Ontario Early Years low vision by an ophthalmologist can be referred
Centres: to:
Lanark: 613-283-0095 or 1-800-267-9252 Southeastern Ontario Blind-Low Vision Early
Leeds & Grenville: 613-341-9044 Intervention Program
or 1-866-433-8933 Kingston, Frontenac and Lennox & Addington
Public Health
613-549-1232, ext. 1145
or 1-800-267-7875, ext. 1145
Vision pg.11
Or visit their website at www.healthunit.on.ca
Current research suggests that approximately
Or refer to the yellow pages of your local phone
1 in 6 children has a vision problem. Children
book.
born with poor vision do not know what normal
vision is like. They often think everyone sees the
same way they do. Therefore, do not wait for your
child to tell you they have a vision problem.

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Red Flags Guide

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Red Flags

for children birth to six years

A quick reference guide for

Adapted November 2007

This document cannot substitute for the advice and/or treatment of

This document is being provided for your personal non-commercial use.

Professionals affected Protection from liability

Provides inconsistent patterns of

Often expresses emotions in a fearful or

Healthy Child Development

0-3 months 12 months-2 years

(See VISION problem signs on

Headaches, nausea, dizziness; blurred or Holding toys close to eyes, or no interest in

Avoidance of tasks with small objects Redness, soreness (eyes or eyelids);

WHERE TO GO FOR HELP

0-3 months 2-3 years

By 3 months Tries to copy new sounds (e.g., ba, animal

Understands location words like in, on and Understands just one

WHERE TO GO FOR HELP

0-8 months parent/guardian when distressed or after

WHERE TO GO FOR HELP

Self-Injurious Behaviour Touches self or others in inappropriate ways,

0-6 months Pablum is offered in a bottle

Using softened, distilled or unsterilized water

12-24 Months Preschooler 3-6 Years

Not supervised while eating

Toddlers 2-3 Years

WHERE TO GO FOR HELP

Prolonged exposure of teeth Other Risk Factors

Breastfeeding or bottle feeding without

Transference of oral bacteria from another

WHERE TO GO FOR HELP

Physical indicators in children Afraid of:

Behaviours observed in adults

WHERE TO GO FOR HELP

Blood in urine or stool Is often alone with the child

WHERE TO GO FOR HELP

Preschool School Age

WHERE TO GO FOR HELP

Cognitive Concerns Behaviour affecting ability to learn new things

Social/Emotional/ Behavioural Concerns Physical Concerns

Physical Learning new information (increased time

Parental Factors A series of losses in a short time frame

Low literacy Inadequate housing or eviction

Red Flags for Postpartum Depression:

Sad and tearful Repeated scary thoughts about the baby

Exhaustion Thoughts of harming self or baby

Feeling overwhelmed with inability to Lack of supports/partner

Open lunch items

Be away from parent/guardian

Ask for help Problem signs...

Behaviour pg.21 Family Environmental Stressors pg.37

Community Care Access Centre

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