Red Flags Guide 2018

RED FLAGS 2018
A QUICK REFERENCE GUIDE FOR EARLY YEARS AND

HEALTH CARE PROFESSIONALS IN YORK REGION
Early Identification of Red Flags in Child Development: Birth to Age Six
RED FLAGS 2018
A QUICK REFERENCE GUIDE FOR EARLY YEARS AND
HEALTH CARE PROFESSIONALS IN YORK REGION
Early Identification of Red Flags in Child Development: Birth to Age Six
DISCLAIMER NOTICE
Red Flags: A Quick Reference Guide for Early Years and Health Care Professionals in
York Region, Early Identification of Red Flags in Child Development: Birth to Age Six
is a quick reference guide designed to assist in deciding whether to
refer for additional advice, screening, assessment and/or treatment.
It is not a formal assessment or diagnostic tool.
The information contained in the Red Flags: A Quick Reference Guide for Early Years and Health
Care Professionals in York Region, Early Identification of Red Flags in Child Development: Birth to
Age Six (‘Red Flags’ or ‘this guide’) has been provided as a public service for professionals working
with children up to the age of six years. Although every attempt has been made to ensure its
accuracy, no warranties or representations, expressed or implied, are made concerning the accuracy,
reliability or completeness of the information contained in this guide.
This guide cannot substitute for the advice, formal assessment and/or diagnosis, of professionals
trained to properly assess the growth and development of infants, toddlers and preschool children.
Although this guide may be helpful to determine when to seek out advice and/or treatment, it
should not be used to diagnose or treat perceived growth and developmental limitations and/or
other health care needs.
This guide also refers to websites, screening tools, and other documents that are created or
operated by independent bodies. These resources 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 these independent sources.
Red Flags is being provided for your personal non-commercial use. This guide is available in hard
copy or online at york.ca/redflags. The most up to date version is available online.
This guide, 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 Regional Municipality of York. Consent may be
withheld at the sole discretion of The Regional Municipality of York or be given subject to such
terms and conditions as The Regional Municipality of York may, in its sole discretion, impose.
For more information about this guide please contact York Region Health Connection at
1-800-361-5653, TTY 1-866-512-6228, childfamily@york.ca
4 | RED FLAGS GUIDE 2018: A Quick Reference Guide for Early Years and Health Care Professional in York Regions
TABLE OF CONTENTS
Disclaimer Notice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Why early identification impacts the successful transition to school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
How to talk to parents/caregivers about concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Cultural competence when working with families. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Duty to report to child protection services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
DOMAINS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Abuse and neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Attention difficulty and/or hyperactive behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Autism Spectrum Disorder (ASD). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Behaviour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
| 5
Dental and oral health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Feeding skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Fetal Alcohol Spectrum Disorder (FASD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Fine motor skills. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Gross motor skills. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Learning Disabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Maternal mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Mild traumatic brain injury (concussion). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Nutrition (overweight and underweight). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Prematurity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Regulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Relationship and attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Selective mutism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Sensory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Smoking (second- and third-hand) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Social/emotional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Speech and language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Appendix A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Appendix C-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
INTRODUCTION
INTRODUCTION TO THE section for further information
RED FLAGS GUIDE • Refer for further assessment even if you are
uncertain whether the Red Flags noted are a
reflection of a cultural variation or a real concern
What is the Red Flags guide? • Note that some of the indicators focus on the
parent/caregiver or the interaction between the
Red Flags is a quick reference tool to assist early
parent/caregiver and the child, rather than solely
years and health care professionals in knowing
on the child
when and where to refer children from birth to
the age of six years for whom there are potential • If a child appears to have multiple domains
health, growth and development concerns. A requiring formal assessment by several
basic knowledge of healthy child development disciplines, it is encouraged to refer to all of
is assumed. Red Flags will assist professionals in the appropriate agencies
identifying when children could be at risk of not
meeting their expected health outcomes or • Contact information in York Region can be found
developmental milestones. It also includes other at the end of each domain under Where to go
areas that may impact child health, growth, and for help with further description of each contact
development due to the dynamics of parent-child found in Appendix B
interaction, such as maternal mental illness, abuse, etc.
• If referrals are made to private sector agencies,
Red Flags allows early years and health care alert families that they will be responsible for
professionals to review and better understand, costs incurred
on a continuum, the domains that are traditionally
outside of their own area of expertise.
Acknowledgement
This guide is evidence-informed. References are
indicated at the bottom of each page. We would like to acknowledge Simcoe Muskoka
District Health Unit for the creation of the original
Red Flags — Let’s Grow With Your Child, in 2003.
The purpose and goal of the The York Region Red Flags guide is made possible
through the joint efforts of community partners
Red Flags guide and York Region Public Health.
The purpose of Red Flags is to promote the early
We would like to thank all of our community
identification of children who may be in need of
partners for their contributions to this edition of
additional resources to meet their developmental
Red Flags. The name of each contributor and their
milestones and expected health outcomes.
associated organization/agency is listed at the end
The goal of Red Flags is to ensure that all children of each domain.
in York Region are able to achieve their optimal
The following indicators in the Sensory domain
developmental and health potential.
were reproduced with permission from NCS Pearson
and WPS.
How to use the Red Flags guide
• If children are not meeting the milestones for Editors
their specific age, further investigation is
The editors for Red Flags included a sub-committee
strongly recommended. Refer to the Where to
of the York Region Early Identification Network:
go for help section at the end of each domain
• Marlene Green — Speech-Language Pathologist,
• Screening tools may be used in conjunction with
York Region Preschool Speech and Language
this guide (see Appendix C)
Program, Child Development Programs, Markham
• Cultural competence is vital in assessing child Stouffville Hospital
health, growth, and development. Please see the
• Cheryl Simmonds — Public Health Nurse,
Cultural competence when working with families
York Region Public Health
INTRODUCTION | 9
• Mary Turfryer — Registered Dietitian-Public • Belonging: a sense of connectedness and
Health Nutritionist, York Region Public Health relationship to others
• Nadia Waddell — Public Health Nurse, • Well-Being: a state of mental wellness and
York Region Public Health physical health
• Engagement: a sense of involvement, curiosity

and wonder
WHY EARLY IDENTIFICATION • Expression: the ability to communicate for different
IMPACTS THE SUCCESSFUL purposes and in different ways
TRANSITION TO SCHOOL When these four foundations are the focus of

children’s early experiences both at home and
“Children are competent, capable of complex in the community, children are supported in the
thinking, curious and rich in potential. They grow development of:
up in families with diverse social, cultural and
• Playing and getting along with others
linguistic perspectives. Every child should feel that
he or she belongs, is a valuable contributor to his • Talking, listening, questioning and
or her surroundings, and deserves the opportunity problem solving
to succeed.”1
• Making decisions
Starting school is a significant milestone in the life
of a family. There are many factors that contribute • Creating, building, exploring, wondering,
to a child’s transition to school and ongoing success. investigating and sharing
The child’s capacity to learn when they enter school
• Showing interest in symbols and text
is strongly influenced by the neural wiring that takes
place in the early years of life.2 By doing everything • Feeling comfortable in new places
possible to enhance early development, a child can
be provided with an equal opportunity to maximize • Demonstrating self-help and self-regulation skills1
their potential.3
These above skills and abilities contribute to a
Current brain research shows that children’s child’s successful transition to school.
capacity for deep learning begins prior to birth
with 700 neural connections being made every
second in the first three years of life.4 The first Why the Red Flags guide?
years of a child’s life are a period of heightened Sometimes there are areas of a child’s growth and
opportunity and also a time of increased risk that can development that are delayed or not progressing
compromise optimal development for life.2 as expected which can hinder the child’s advance-
To maximize early potential, How Does Learning ment in these skills and abilities. Children “… are
Happen? establishes four foundational conditions not as ready for school as they should be … Ontario
or “ways of being” for children that optimize their children are entering school ‘vulnerable’ with
learning and healthy development: physical, emotional, cognitive or speech/language
issues that could be prevented.”5
1 Ontario Ministry of Education. How does learning happen? Ontario’s pedagogy for the early years [Report online]. Toronto:
Queens Printer for Ontario; 2014 [cited 2016 Aug 17]. Available from: edu.gov.on.ca/childcare/HowLearningHappens.pdf
2 McCain MN, Mustard JF, McCuaig K. Early years study 3: making decisions taking actions. Toronto: Margaret and Wallace Mc-
Cain Family Foundation; 2011.
3 McCain MN, Mustard JF, Shanker S. Early years study 2: putting science into action [Report online]. Toronto: Council for Early
Child Development; 2007 [cited 2016 Nov 11]. Available from: earlylearning.ubc.ca/media/publications/early_years_study_2.pdf
4 Center on the Developing Child at Harvard University. Five numbers to remember about childhood development [Internet].
Cambridge, MA: Center on the Developing Child at Harvard University;[date unknown][cited 2016 July 12]. Available from:
developingchild.harvard.edu/resources/five-numbers-to-remember-about-early-childhood-development/
5 Ministry of Ontario. Make no little plans. Ontario’s public health sector strategic plan [Government report online]. Toronto:
Queens Printer for Ontario; 2013 [cited 2015 Nov 5]. Available from: toronto.ca/legdocs/mmis/2013/hl/bgrd/background-
A ‘wait and see’ approach can be detrimental. communication is essential. It can be very difficult
Early identification of possible concerns in a child’s to relay these concerns to parents and caregivers;
development will lead to early referral, assessment however, for a child to reach his or her full
and intervention, ensuring that they start school at developmental potential, it is important to have
their full potential, ready to learn. these conversations. If concerns are presented in
a positive and caring manner, this will build trust
The community collectively wraps around children between the professional and the family.6
and their families and builds on their strengths.
The community also comes together to provide Sharing sensitive news can be challenging both
supports and services when the progression of a for the family and the person delivering the news.
child’s development differs from what is anticipated. Upon receiving this information about their child,
the parent/caregiver may react with a range of
The Red Flags guide has been developed to identify emotions including shock, anger, disbelief, fear
those children who need extra support. If there and sometimes relief at having their observations
are concerns about a particular area(s) of develop- and questions about their child acknowledged.6
ment for a child, refer to the appropriate domain
in this guide (see Table of Contents). Although there is no single way that works best
there are some things to keep in mind when
addressing concerns with a family. The following
Contributors framework will provide some tips and encourage-
ment for sharing concerns in a clear, informative,
Marlene Green, Speech-Language Pathologist,
and supportive manner:
York Region Preschool Speech and Language
Program, Child Development Programs, Markham
Stouffville Hospital Prepare for a successful conversation
Early Years Team, York Region District School Board • Know the facts
Nadia Waddell, Public Health Nurse, York Region • Plan to meet face to face
Public Health
• Meet in a private location
• Allow plenty of time without interruptions7

HOW TO TALK TO PARENTS/ Share the information
CAREGIVERS ABOUT CONCERNS • Begin by sharing the child’s strengths and
positive behaviours8
Sharing sensitive news • Ask the parents/caregivers what they know
One of the most challenging issues for a health about their child’s development6,7
care or early years professional working with
• Remember and remind parents/caregivers that
young children can be relaying concerns about
they know their child best8
a child’s health or development to a parent or
caregiver. When a potential concern is identified, • Share observations/concerns that have been
either by observation or screening, the family noted about the child’s development8
should be notified so that positive next steps can
be taken. In these circumstances, effective
file-57698.pdf
6 Sharing concerns physician to parent [webpage online]. First Signs Inc; c2001-2014 [cited 2016 Oct 14]. Available from:
firstsigns.org/concerns/doc_parent.htm
7 Tekolste K. Sharing sensitive news [Internet]. Seattle, WA: Washington State Medical Home Project; 2015 [updated 2015
Nov 13; cited 2016 Oct 14]. Available from: medicalhome.org/physicians/sharing-sensitive-news/
8 Best Start Resource Centre. On track supporting healthy child development and early identification in the early years:
A reference guide for professionals in Ontario [homepage on the Internet]. Toronto, ON: Best Start Resource Centre; [cited
2016 Apr 14]. Available from: beststart.org/OnTrack_English/
INTRODUCTION | 11
• Highlight the expected developmental mile-
stones for the child’s age8 CULTURAL COMPETENCE WHEN
• Show concern and compassion8 WORKING WITH FAMILIES
• Explain the consequences of not taking action Early years and health care professionals have
such as the wait and see approach6,8 the privilege of working with families from many
different cultural groups. Families come to us with
• Explain the range of possibilities for supporting the their own culture which is a set of “… distinctive
child such as referral, assessment, intervention, etc.8 patterns of beliefs and behaviours that are shared
by a group of people and that serve to regulate
Plan for next steps their daily living.”9 “The child-parent relationship
has a major influence on most aspects of child
• Thank parents/caregivers for their support development”,9, 10 and, since culture shapes how
parents care for their children,9 it therefore makes
• Provide available resources for further reading sense that parenting practices impact a child’s
and information growth and development.9 As such, to better
• Ensure that your concerns have been documented understand the child within the context of his or
and that there is a plan for follow-up action her growth and development, it is important for
professionals to provide culturally competent care
• Empower the parents/caregivers by enlisting and service. To do so, it is necessary for early years
their support to plan a course of action regard- and health care professionals to become culturally
ing next steps for their child aware and sensitive.11
• Allow time for questions and concerns by the Cultural awareness involves the ability to stand
parents/caregivers back and be conscious of the similarities and
differences between cultural groups,11 including
• Provide parents/caregivers with available resources one’s own. To be culturally sensitive is to build on
such as brochures or contact information8 this awareness by recognizing that these similarities
and differences affect one’s values, learning, and
Presenting information in this manner lends
behaviour.12 The components of cultural sensitivity
credibility to the concerns identified.6,7
include valuing and recognizing the importance
of one’s own culture, valuing diversity, and being
Contributors willing to learn about the traditions and charac-
teristics of other cultures.12 Cultural competence
Marlene Green, Speech-Language Pathologist, builds on sensitivity, and refers to the attitudes,
York Region Preschool Speech and Language knowledge, and skills needed to be effective early
Program, Child Development Programs, Markham years and health care professionals.11
Stouffville Hospital
As individuals and professionals, it is important
Cathy Saul, Supervisor, York Region Early Intervention to acknowledge that personal preferences and
Services, Social Services Branch, Community and misinformation may contribute to falling into the
Health Services stereotyping trap. To stereotype is to create a men-
tal image of a people group, over-generalizing to
Nadia Waddell, Public Health Nurse, York Region ascribe the same characteristics to all members of
Public Health that group, regardless of individual differences.13
9 Bornstein M. Cultural approaches to parenting. Parenting Sci Pract [serial online]. 2012 [cited 2016 Dec 8]; 12(2-3): 212-221.
Available from: ncbi.nlm.nih.gov/pmc/articles/PMC3433059/pdf/nihms385560.pdf
10 Parenting skills [webpage online]. Montreal, Quebec: Encyclopedia on Early Childhood Development. [updated 2015 Sept;
cited 2017 Jan 27]. Available from: child-encyclopedia.com/parenting-skills/according-experts
11 Cultural awareness or sensitivity [webpage online]. Ottawa, ON: University of Ottawa; [cited 2016 Dec 6]. Available from:
med.uottawa.ca/sim/data/Cultural_Awareness_e.htm
12 Mavropoulos Y. Welcome to our slide show on families and cultural sensitivity [powerpoint presentation online]. Vermont:
University of Vermont; 2000 [cited 2016 Dec 1]. Available from: uvm.edu/~cdci/prlc/unit3_slide/sld001.htm
13 Hate Crimes Community Working Group. Addressing hate crime in Ontario: final report of the Hate Crimes Community
All families, children and individuals are unique.
Although their ethnic, cultural, racial and DUTY TO REPORT TO CHILD
language backgrounds influence them, they are
not fully defined by them.14 Cultural patterns may
PROTECTION SERVICES
or may not be followed by individual parents/care- We all share a responsibility to protect children
givers within their cultural group, creating indi- from harm. This includes situations where children
vidual variations in child raising practices.9, 15 Many are abused or neglected in their own homes.
social and cultural factors powerfully affect each Ontario’s Child and Family Services Act (CFSA)
family and each member within that family. Cultures provides protection for these children. Section 72
are constantly changing and being reshaped15 of the CFSA states that the public, including pro-
by a variety of influences, including life experi- fessionals who work with children, must promptly
ences in Canada. Therefore, part of the role of report any suspicions that a child is or may be in
the professional in supporting families is helping need of protection to a children’s aid society (CAS).
them to interpret the new and dominant culture The CFSA defines the phrase “child in need of
in which they find themselves (Canada), helping protection” and explains what must be reported
them to navigate it effectively while adapting and/ to a CAS. It includes physical, sexual and emotional
or assimilating to it. In doing so, social and cultural abuse, neglect, and risk of harm. For more infor-
differences should be used to enhance the inter- mation, refer to the Abuse domain in this guide.
actions between the professional and the family
rather than to stereotype.15
Who is responsible for reporting a
The greatest resource for understanding each
family’s unique culture is the family themselves. By child in need of protection?
gaining the necessary knowledge, attitudes and Anyone who has reasonable grounds to suspect
skills of working with families of diverse culture, that a child is or may be in need of protection must
professionals will develop cultural competence promptly report the suspicion and the information
and become effective providers for the clients with upon which it is based to a CAS. Section 72 describes
whom they work.11 the specific circumstances that must be reported.
Contributors What are “reasonable grounds” to

Cathy Saul, Manager of Early Intervention Services, suspect child abuse or neglect?
York Region Early Intervention Services
It is not necessary for you to be certain a child is or
Nadia Waddell, Public Health Nurse, York Region may be in need of protection to make a report to a
Public Health CAS. “Reasonable grounds” refers to the information
that an average person, using normal and honest
judgment, would need in order to decide to report.
Working Group to the Attorney General and the Minister of Community Safety and Correctional Services [report online].
Toronto, ON: Hate Crimes Community Working Group; 2006 [cited 2016 Dec 1]. Available from: attorneygeneral.jus.gov.
on.ca/english/about/pubs/hatecrimes/HCCWG_full.pdf
14 Lynch EW, Hanson M. Developing cross-cultural competence: a guide for working with children and their families. 3rd ed.
Michigan: Paul H. Brookes Publishing; 2004.
15 Kongnetiman L, Okafor C. Immigrant & refugee women’s cultural health practices: a guide for health care professionals
[Internet]. Calgary: Alberta Health Services and Alberta Children’s Hospital; 2011 [cited 2016 Dec 1]. Available from:
http://fcrc.albertahealthservices.ca/publications/cultural/Womens-cultural-health-practices-November-2007.pdf
INTRODUCTION | 13
What is the age of the child to
whom the “duty to report” applies?
It applies to any child who is, or appears to be, under
the age of 16 years. It also applies to children already
under a child protection order who are 16 and 17
years old.
How and when to report

Abuse or neglect should be reported as soon as
you suspect it — 24 hours-a-day, seven days-a-week.
A phone call to a CAS will bring immediate help
to a child at risk. It is not your responsibility to
determine whether abuse or neglect has occurred.
CAS is responsible for the investigation and the
assessment of abuse and neglect of children and
also the ultimate management of a case when a
child is taken into care. Contact a CAS immediately
if you have concerns about a child!
What happens when I call?

When you call, you will speak to a child welfare
specialist who is specially trained to listen to your
concerns and ask questions before deciding how
urgent the situation is and what type of intervention
is needed. If a child is in imminent danger, a child
protection worker will respond immediately.
Contributor
Peter Ristevski, Supervisor, York Region Children’s
Aid Society
Reference
Child and Family Services Act, R.S.O 1990, c. C.11 as
am. by S.O. 2016, c.23, s.38. Available from:
ontario.ca/laws/statute/90c11
DOMAINS
In alphabetical order
ABUSE AND NEGLECT when a child exhibits the above serious behaviours
and the person having charge of the child does not
provide services or treatment to alleviate the harm.
What is abuse? Emotional abuse can also include exposure to
domestic violence. Emotional abuse happens when
Child abuse has many faces, and while all abuse a caregiver treats a child in an extremely negative
hurts, different kinds of abuse can hurt in different way that damages self-esteem and the concept
ways. Below are the definitions of each type of of “self.” This type of behaviour might include
abuse as well as their possible indicators. Abused constant yelling, demeaning remarks, rejection or
children do not always show obvious warning isolation, or exposing a child to domestic violence.
signs of abuse or neglect, but sometimes there are
subtle indicators. Know the subtle signs of abuse
and if you have any concerns at all about a child, Neglect1
contact a CAS immediately. A child is at risk of or has been harmed as a result
of the caregiver’s failure to adequately supervise,
Physical abuse1 protect, care for or provide for a child. Neglect
also occurs when a child has a medical, mental,
A child is at risk of or has suffered physical harm emotional or developmental condition that requires
inflicted by a person having charge of the child. services or treatment and the person having
It also occurs when a person fails to adequately charge of the child does not provide these services
supervise, protect, care for or provide for a child. or treatment.
Physical abuse also includes a pattern of neglect in
supervising, protecting, caring for or providing for Most parents and caregivers don’t intend to ne-
a child. Physical abuse can be one or two isolated glect their children. Instead, neglect is usually the
incidents or can occur over a prolonged period of result of ignorance about parenting and an inabili-
time. ty to plan ahead. When a caregiver fails to provide
a child’s basic needs like food, sleep, safety, super-
vision, appropriate clothing or medical treatment
Sexual abuse1* on a consistent basis, this is neglect.
A child is at risk of or has been sexually molested In addition to the above forms of abuse and neglect,
or sexually exploited by a person having charge of there are other forms of abuse which may be
a child or by another person. It also occurs when overlooked. These include abandonment/separa-
the person having charge of a child knows, or tion, caregiver incapacity, and domestic violence.
should know, of the possibility of sexual molesta- It is important to consider these in addition to the
tion or exploitation by another person and fails to above forms of abuse and neglect.
protect a child. Sexual abuse includes sexual touch-
ing, engaging in sexual activity with a child, expos-
ing genitals to a child, and incest. Abandonment/separation1
Abandonment/separation occurs when a child has
been left alone unsupervised, or when a parent
Emotional abuse1
has died or is unavailable to exercise his or her
A child is at risk of or has suffered emotional harm custodial rights over a child and has not made
demonstrated by serious anxiety, depression, with- adequate provision for a child’s care and custody.
drawal, self-destructive or aggressive behaviour It also occurs when a child is in residential place-
or delayed development and there are reasonable ment and the parent refuses, or is unable or
grounds to believe this harm results from the unwilling, to resume the child’s care and custody.
actions, failure to act or pattern of neglect by the
person having charge of the child. It also occurs
1 Child and Family Services Act, R.S.O 1990, c. C.11 as am. by S.O. 2016, c.23, s.38. Available from: ontario.ca/laws/statute/90c11
*In addition to providing protection from sexual abuse, the Child and Family Services Act states that a child is also in need of
protection when a caregiver is aware of the possibility of abuse and fails to protect the child.
DOMAINS | 17
Caregiver incapacity1 • Extremely aggressive or withdrawn
No harm has come to a child and no evidence is • Indiscriminately seeks affection

apparent that a child may be in need of inter-
• Extremely compliant and/or eager to please2
vention. However the caregiver demonstrates, or
has demonstrated in the past, characteristics that
indicate the child would be at risk of harm without Physical indicators
intervention. These characteristics can include a
history of abusing/neglecting a child, being unable • Injuries such as bruises, welts, cuts, fractures,
to protect a child from harm, problems such as burns and internal injuries
drug or alcohol abuse, mental health issues or • Injuries that are not consistent with explanation
limited caregiving skills.
• Presence of several injuries that are in various
stages of healing
Domestic violence1
• Presence of various injuries over a period of time
Domestic violence is characterized by violent or
abusive behaviours which occur within the child’s • Facial injuries in infants and preschool children
home environment. Domestic violence includes
but is not limited to partner violence. The violence • Injuries inconsistent with the child’s age and
occurs between the child’s parent/primary caregiver developmental phase2
and any other adult who resides in or frequents
the home. This may include the mother’s partner, PROBLEM SIGNS
adult relative, boarder, or anyone else who has a
relationship with the family. The frequency and If a child presents with one or more of the following
severity (intensity) of violence can range from ho- indicators of sexual abuse consider this a red flag:
micide or a single very serious incident resulting in
injuries that require hospitalization, to a pattern of
Behavioural indicators
less serious physical violence (e.g. slapping, push-
ing) and/or a pattern of verbal abuse, threats of • Age-inappropriate play of sexual nature with
harm or criminal harassment. toys, self or others
Domestic violence can have a profound effect on • Age-inappropriate sexually explicit drawing and/
children and may result in or raise the risk of child or descriptions
abuse or neglect.
• Bizarre, sophisticated or unusual sexual knowledge
PROBLEM SIGNS • Seductive behaviours2
If a child presents with one or more of the follow-

Physical indicators
ing indicators of physical abuse consider this a red
flag: • Unusual or excessive itching in the genital or
anal area
Behavioural indicators
• Torn, stained or bloody underwear (may be ob-
• Cannot recall how injuries occurred or offers an served if the child needs bathroom assistance)
inconsistent explanation
• Injuries to the genital or anal areas such as bruis-
• Wary of adults ing, swelling or infection
• Cringes or flinches if touched unexpectedly • Sexually transmitted disease2
• Displays a vacant stare (for infant)
2 Ontario Association of Child Welfare. Child welfare professional training series. Foundations of child welfare practice. Toronto, ON:
Ontario Association of Child Welfare; 2008. Course 3, Protecting children and strengthening families-part 2; p. 1-9.
PROBLEM SIGNS • Consistent lack of supervision2

ing indicators of emotional abuse consider this a Where to go for help
red flag:
If you suspect child abuse or neglect, you are le-
gally obligated to report to one of the local child
Behavioural indicators protection agencies:
• Severe depression • York Region Children’s Aid Society
1-800-718-3850
• Extreme withdrawal or aggressiveness
• Jewish Family and Child
• Overly compliant, too well mannered, too neat
905-882-2331
or too clean
Note: For related medical issues, contact the
• Extreme attention seeking
primary health care provider. Acute injuries may
• Display of extreme inhibition in play2 require that the child be taken to the emergency
department at the nearest hospital.
Physical indicators For more information about this domain or any
others in this guide, please contact York Region
• Bed wetting that is non-medical in origin
Health Connection at 1-800-361-5653,
• Frequent psychosomatic complaints, headaches, TTY 1-866-512-6228, childfamily@york.ca
nausea, abdominal pains
• Failure to thrive2 Contributor

Peter Ristevski, Supervisor, York Region Children’s
PROBLEM SIGNS Aid Society

ing indicators of neglect consider this a red flag:
ANXIETY
Behavioural indicators Anxiety disorders in children range from 2.4 per
• Pale, listless, unkempt cent to 17 per cent.3 Research suggests that there
can be long-term implication of experiencing
• Frequent absences from school anxiety in childhood including an increased risk for
additional diagnosis, mental health challenges in
• Inappropriate clothing for the weather, dirty clothes adulthood, as well as lower functioning in aca-
demic performance, peer relationships, and family
• Frequent forgetting of a lunch2
relationships.4, 5, 6
• Physical indicators
It is important to note that mild fears and anxi-
• Poor hygiene ety are part of normal human development. The
number of fears that children experience typically
• Unattended physical problems or medical needs decrease as children mature.7 Although childhood
such as dental work or glasses fears can be normal experiences, it is important
3 Kendall PC, editor. Child and adolescent therapy: cognitive behavioral procedures. 4th ed. New York (N.Y.): Guilford Press; 2012.
4 Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and
adolescence. Arc Gen Psychiatry. 2003; 60(8): 837-844.
5 Draper TW, James RS. Preschool fears: longitudinal sequence and cohort changes. Child Study Journal. 1985; 15: 147-155.
6 Aschenbrand SG, Kendall PC, Webb A, Safford S, Flannery-Schroder E. Is childhood separation anxiety disorder a predictor of adult
panic disorder and agoraphobia? A seven year longitudinal study. J Am Acad Child Adolesc Psychiatry. 2003; 42(12):1478-1485.
7 Verduin T, Kendall PC. Differential occurrence of comorbidity within childhood anxiety disorders. J Clin Child Adolesc Psychol.
DOMAINS | 19
to pay closer attention to experiences of anxiety Social anxiety
that are exaggerated and beyond what one would
expect given a situation.8 Children with social anxiety exhibit a fear of
situations in which they will have to interact with
Symptoms of anxiety that become more intense others or be the focus of attention. At the core
and more extensive, and that interfere with a of social anxiety is a fear of being embarrassed,
child’s school, peer or family functioning may humiliated or rejected. Typical feared situations
warrant mental health interventions. When overly include meeting new people, talking on the
anxious, most children exhibit physical symptoms telephone, joining team sports and talking at
including increased heart rate, increased breath- school or preschool.1,6
ing, sweating, nausea, stomach aches, headaches,
etc. as well as some form of avoidance of situa-
tions, people or objects that cause anxiety.9 PROBLEM SIGNS
If a child presents any of the following behaviours,
Types of anxiety in children consider this a red flag:
• Consistent avoidance of a specific feared situa-

Specific phobias tion or object
Children with specific phobias have fears that are • Emotional dysregulation or panicked in the pres-
specific to a particular situation or object. In general, ence of the feared situation or object
these children try to avoid contact with the situa-
tion or object. Examples of specific phobias include • Upset beyond what is expected when separated
dogs, the dark, spiders, storms and injections.3,8 from primary caregiver
• Child expression of concern about primary care-

Separation anxiety giver being hurt or getting sick
Children with separation anxiety exhibit an • Refusal to sleep at other people’s homes if par-
excessive fear related to being away from a main ents are not there
caregiver, most commonly the child’s mother. They
often fear that something terrible will happen to a • Complaints of stomach ache, feeling sick or other
parent while they are apart and they will never see somatic symptoms in anticipation of being sepa-
the parent again. At times, significant life stressors rated from caregiver
can trigger separation anxiety such as a change in • Difficulty staying or going into a room by them-
schools, a move or death of relative.1,6 selves, “clinging” behaviour, staying close to and
“shadowing” the parent around the house
Generalized anxiety
• Difficulty at bedtime and possible insistence that
This is a condition in which the child has many someone stay with them until they fall asleep
worries and fears. Children with generalized anxiety
are often described by parents as “worrywarts.” • Fear more than usual in new situations
Worries can be in the areas of health, schoolwork, • Fear of making mistakes and not performing well
sport performance, bills, burglaries, etc. New
situations often provoke an anxiety response.1,6 • Child asks lots of questions and often seeks reas-
surance from parents
• Worries more than usual after seeing a scary

movie or watching a news program
2003; 32(2): 290-295.

8 American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C:
American Psychiatric Association; 2013.
9 Woodward LJ, Ferguson DM. Lifecourse outcomes of young people with anxiety disorders in adolescence. J Am Acad of Child
and Adolesc Psychiatry. 2001; 40(9):1086-1093.
• Shyness
ATTENTION DIFFICULTY AND/OR
• Difficulty joining in activities and making
new friends HYPERACTIVE BEHAVIOUR
• Avoids speaking to new people or answers with A child should be referred for assessment if his/her
brief responses patterns of attention and/or hyperactivity difficul-
ties: interfere with functioning or development;
• Worries that someone will laugh at them or that demonstrate symptoms in more than one setting;
they will be embarrassed negatively impact social, academic, or work func-
tioning in a direct way; and some symptoms must
• Dislikes being centre of attention3,8 be present before age 12.10
Attention difficulties and/or hyperactive behaviours

Where to go for help can be seen at times in all typically developing
If there are concerns, advise the parent/caregiver children so it is important to consider the following
to contact: prior to making a referral for assessment:
• Blue Hills Child and Family Centre • The child’s developmental age e.g. children under
(905) 773-4323 the age of 18 months are generally not formally
bluehillscentre.ca assessed for attention difficulty and/or hyperactive
bluehills@bluehillscentre.ca behaviour; attention span and self-regulation
naturally varies in early childhood years
• Kinark Child and Family Services
1-888-454–6275 or 1-888-4-KINARK • Situational factors such as stress, time of day,
kinark.on.ca boredom, sleep and diet
info@kinark.on.ca • Environmental factors such as family disruption,
• The York Centre for Children, Youth and Families life changes and cultural influences
(905) 887-5896 There are other developmental/mental health
theyorkcentre.ca issues that can present with attention difficulty
info@theyorkcentre.ca and/or hyperactive behaviours including Learning
• Family Services York Region Disabilities, Autism Spectrum Disorder and Anxiety.
1-888-223-3999 Refer to the appropriate domains in the guide to
fsyr.ca determine other possible referrals for the child/family.
For more information about this domain or any

others in this guide, please contact York Region PROBLEM SIGNS
Health Connection at 1-800-361-5653, If a child consistently presents any of the following
TTY 1-866-512-6228, childfamily@york.ca behaviours, consider this a red flag:
Contributor Ages 18 months to 5 years
Zia Lakdawalla, Ph.D., Psychologist, Kinark Child • Unable to concentrate or pay attention for periods
and Family Services of time
• Restless or unable to sit still
• Poorly co-ordinated or clumsy
• Shifts quickly from one activity to another
10 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). 5th ed. Washington: American
Psychiatric Publishing; 2013.
DOMAINS | 21
• Wanders away11 • Learning Disabilities Association of York Region
905 884-7933
Ages 4 to 6 six years ldayr.org
• Easily distracted e.g. has difficulty paying atten- For more information about this domain or any
tion or listening to the speaker, easily sidetracked others in this guide, please contact York Region
• Excessive levels of activity i.e. hyperactive TTY 1-866-512-6228, childfamily@york.ca
e.g. has difficulty sitting still, fidgets often
regardless of activity
Contributors
• Impulsive e.g. runs into traffic, takes risky actions
without thinking, has difficulty taking turns, Donna Lamanna, Supervisor, The York Centre for
interrupts/blurts things when asked not to, Children, Youth and Families
talks excessively Christian Bouchard, Clinical Director, The York Centre
• Disorganized e.g. has problems organizing for Children, Youth and Families
personal belongings, loses things often, has
difficulty following schedule or difficulty
remembering routines/explanations12
AUTISM SPECTRUM DISORDER
Where to go for help (ASD)
If there are concerns, advise parents/caregivers to Autism spectrum disorder (ASD) is a lifelong
contact their primary health care provider. developmental disorder characterized by impair-
ments in social communication and the presence
Parents/caregivers may also contact: of repetitive and stereotyped behaviours. ASD
is often associated with other developmental,
• Blue Hills Child and Family Centre health and behavioural challenges such as
(905) 773-4323 language impairment, uneven cognitive and
bluehillscentre.ca adaptive skills, seizures, and attention deficit
bluehills@bluehillscentre.ca hyperactivity disorder (ADHD).
• Kinark Child and Family Services See the following domains in this guide for more
1-888-454–6275 or 1-888-4-KINARK information and other possible referrals:
kinark.on.ca
info@kinark.on.ca • Attention difficulty and/or hyperactive behaviour
• The York Centre for Children, Youth and Families • Behaviour
(905) 737-8927
theyorkcentre.ca • Regulation
info@theyorkcentre.ca • Sensory
• Family Services York Region • Social/emotional
1-888-223-3999
fsyr.ca • Speech and language
• York Region Health Connection The severity of symptoms for ASD can vary widely;
1-800-361-5653 however, all individuals with an ASD diagnosis have
childfamily@york.ca impairments in the ability to function in social
TTY 1-866-512-6228 settings and often in many other areas in daily life.
11 Achenbach TM, Rescorla LA. Manual for the ASEBA preschool forms and profiles. Burlington: University of Vermont Department
of Psychiatry; 2000.
12 InterRai. Child and youth mental health scale (ChYMH). London, ON: Child and Parent Resource Institute. 2015.
PROBLEM SIGNS Behavioural concerns
If a child presents any of the following behaviours, • Repetitive hand and/or body movements
consider this a red flag: e.g. finger wiggling, hand and arm flapping,
tensing of fingers, complex body movements,
spinning, jumping
Social concerns
• Severe repeated tantrums due to interruption of
• Does not smile in response to another person
routine, interruption of repetitive behaviour or
• Poor/decreased eye contact with people, unknown reasons
although may look intently at objects
• Unusual sensory interests e.g. visually squinting
• Lack of “joint engagement” e.g. does not play or looking at things out of the corner of the
peek-a-boo games eye, smelling, licking, mouthing objects, hyper-
sensitive hearing
• Lack of imitation e.g. does not wave bye-bye
• Narrow range of interests in which they engage
• Limited showing, giving, sharing and directing of repetitively
others’ attention
• Insistent on maintaining sameness in routine,
• Delayed imaginative play or lack of varied, activities, clothing, etc.
spontaneous make-believe play
• Unusual preoccupation with objects e.g. light
• Prefers to play alone i.e. decreased interest in switches, fans, spinning objects, vertical blinds,
other children wheels, balls
• Poor interactive play • Unusual response to pain i.e. high or low tolerance
• Regression i.e. any loss of social skills at any age
Where to go for help
• Prefers to do things for them self rather than ask
for help If there are concerns, advise parents/caregivers to:
• Awkward or absent greeting of others • Arrange a referral to a pediatrician through their
child’s primary care provider or
Communication concerns
• Contact York Region Early Intervention Services/
• Delayed or atypical language York Region Preschool Speech and Language
Program 1-888-703-5437
• Unusual language e.g. repeating phrases from
movies, echoing other people, repetitive use of The parent/caregiver may also access the following:
phrases, odd intonation (echolalia)
• The Autism Parent Resource Kit from
• Inconsistent response or lack of response to their The Ontario Ministry of Children and Youth
name or instructions i.e. may respond to sounds Services at children.gov.on.ca
but not language
• Autism Ontario York Region Chapter
• Decreased ability to compensate for delayed at 905-780-1590 or autismontario.com/york
speech by gesturing/pointing
• Geneva Centre for Autism at 416-322-1877
• Poor comprehension of language (words or autism.net
and gestures)
For more information about autism for
• Regression i.e. any loss of language skills at any age the professional:
(regression), particularly between 15 and 24 months
• Improving the Odds Healthy Child Development
• Inability to carry on a conversation at ocfp.on.ca/docs/research-projects/improving-
the-odds-healthy-child-development-manual-
2010-6th-edition.pdf
DOMAINS | 23
For more information about this domain or any Behaviour is also a child’s way of telling their care-
others in this guide, please contact York Region giver that he or she is in physical pain or discomfort,
Health Connection at 1-800-361-5653, tired, hungry or ill.14
TTY 1-866-512-6228, childfamily@york.ca
Generally, a child demonstrates certain behaviour
in the presence of certain people and not others,
Contributor in specific situations or environments, and under
some conditions while not in others.15
Karen Dillon, Manager, Children’s Treatment Net-
work of Simcoe York When determining if a behaviour is of concern, it
is important to keep in mind the context, the age
and stage of the child, as well as to ascertain if
Sources there is an explanation for the behaviour.16
Dr. Anita Jethwa, MD, FRCP(C), Developmental When challenging behaviour happens many times
Pediatrician, Children’s Treatment Network of each day, for long periods of time, or presents an
Simcoe York immediate risk to the child or others it may require
assessment and intervention from a professional.
Dr. Nicola Jones-Stokreef, MD, FRCP(C),
Developmental Pediatrician, Orillia Soldiers’
Memorial Hospital and Children’s Treatment PROBLEM SIGNS
Network of Simcoe York
If a child presents any of the following behaviours,
consider this a red flag:
Reference
American Psychiatric Association. Diagnostic and Self-injurious behaviour
statistical manual of mental disorders (DSM-5).
• Bites self; hits self; grabs at self
5th ed. Washington: American Psychiatric
Publishing; 2013. • Picks at skin; sucks excessively on skin; bangs
head on surfaces
• Eats/ingests inedible items

BEHAVIOUR • Vomits when no obvious illness16
All children engage in challenging behaviour from
time to time which may or may not persist or be Aggression towards others
of concern. Behaviour is often a child’s way of
communicating their wants and needs and in • Hits; kicks; scratches; bites; pulls hair; pushes; shoves
some cases may be their only method of communi-
cation.13 A child makes their needs known through • Cruelty to animals
observable actions. For example a child may indi-
• Throws objects at a person16
cate with gestures that they want a certain item
or don’t want something they’ve been given, that
they want more or less of your attention or that of Property destruction
a peer, that they don’t want to do a certain task or
• Bangs, throws, slams, breaks objects
to go to a particular place, or that they don’t want
to stop doing an activity that they are enjoying. • Sets fires17
13 Carr EG, Durand VM. Reducing behaviour problems through functional communication training. J Appl Behav Anal. 1985;
18(2):111-126.
14 Gedye A. Behavioral diagnostic guide for developmental disabilities. Vancouver: Diagnostic Books; 1998.
15 Robert E, O’Neill KS, Albin RW, Sprague JR, Horner RH. Functional assessment and program development for problem
behavior: A practical handbook. 2nd ed. Toronto, ON: Wadsworth Publishing; 1997.
16 Aman MG, Singh NN. Aberrant behaviour checklist. East Aurora, NY: Slosson Educational Publications; 1994.
17 Reiss S, Valenti-Hein D. Reiss scales for children’s dual diagnosis. Ohio: IDS Publishing; 1990.
Difficulties with social behaviour • Difficulty managing transitions/routine changes16
• Unable to remain on task for specified length • Often needs physical prompting to move or to
of time17 do things; consistently tired or sleepy16
• Excessively energetic or physically over active17

Sleep
• Restless; unable to sit still; continuously standing
up, sitting down, or moving17 • Excessive tiredness e.g. yawning, falling asleep
• Screams; cries excessively; swearing and/or • Reports nightmares, frequent awakenings

verbal threats17 • Late/early bedtimes and awakenings14
• Name-calling17
Repetitive behaviour (in excess, or in the absence
• Hoards; steals; lies17 of functional play skills)
• Has no friends; socially isolated; will not make • Hand-flapping; hand wringing; rocking; swaying16
eye or other contact; withdrawn16
• Taps surfaces16
• Anxious; fearful/extreme shyness; agitated17
• Twirling; object manipulation i.e. lining up toys,
• Sudden mood changes; laughing, crying and/or spinning wheels, etc.17
screaming for no obvious reason16
• Compulsive behaviour; obsessive thoughts; Communication

bizarre talk17
Limited or no means of communication through:
• Undresses in public16
• Verbal i.e. words
• Touches self or others in inappropriate ways16
• Augmentative or alternative communicative
• Advanced/inappropriate knowledge/behaviour system e.g. Picture Exchange Communication
of a sexual nature for developmental age appro- System, American Sign Language,
priateness16 Proloquo2Go, etc.
• Flat affect, inappropriate emotions, unpredict- • Engages in any of the above behaviours in
able angry outbursts16 order to gain access to items or to avoid or
leave a situation16
Cooperation If you identify any of the above Red Flags, please
• Refusal to follow instructions; needs several also refer to the following domains in this guide
verbal prompts to complete a task for other possible referrals:
• Difficulty following multiple step instructions • Autism
• Runs away • Nutrition
• Resists any form of physical contact including • Sleep

when provided assistance16 • Speech and language
Life skills
• Deficits in age appropriate skills e.g. eating,
toileting, dressing, play, etc.14 If there are concerns, advise the parent/caregiver
to contact:
• Loss of skill previously mastered14
• York Region Early Intervention Services
• Change in typical habits e.g. eating, sleeping, 1-888-703-5437
toileting, etc.14
DOMAINS | 25
• Blue Hills Child and Family Centre
(905) 773-4323 DENTAL AND ORAL HEALTH
bluehillscentre.ca Poor oral health care can result in the development
bluehills@bluehillscentre.ca of early childhood caries (ECC). ECC is a severe form
• Kinark Child and Family Services of cavities with tooth decay in the baby teeth of
1-888-454–6275 or 1-888-4-KINARK children up to six years of age.18,19 It is considered
kinark.on.ca to be a chronic disease which affects more than
info@kinark.on.ca 10 per cent of preschool-age children in Canada.20
ECC often begins on a child’s upper front teeth just
• The York Centre for Children, Youth and Families under the lip.20 Chalky white or brown spots may
(905) 737-8927 be signs of caries (tooth decay/cavities).20 ECC can
theyorkcentre.ca lead to pain, infection, difficulty eating and sleep-
info@theyorkcentre.ca ing, speech problems, poor health and higher risk
of tooth decay in later years.18 Dental problems in
• Mackenzie Health — Centre for Behaviour early childhood have been shown to impact gen-
Health Sciences eral growth and cognitive development and cause
1-888-557-5550 poor school behaviour and negative self-esteem.19
Therefore, access to dental care and early develop-
ment of good oral hygiene habits are important
for children.
PROBLEM SIGNS
Contributors If one or more of the following risk factors are
present consider this a red flag:
Leanne Brock, Behaviour Consultant, Centre for
Behaviour Health Sciences, Mackenzie Health Exposure of teeth to fermentable carbohydrates
(foods/liquids that can easily break down into
Melissa Sweet, Coordinator of Behavioural
acids) through:
Services, Centre for Behaviour Health Sciences ,
Mackenzie Health • Too much sugar in diet18
• Going to sleep or walking around with a bottle

or sippy cup containing anything but water18
• Retaining the nipple in an infant’s mouth

for prolonged periods when not actively
breastfeeding20
• If using pacifiers, dipping them in anything
sweet such as syrup, sugar or honey18
• Long-term use of sweetened medication18
18 Oral health for babies and children [Internet]. Newmarket, ON: York Region Community and Health Services, Public
Health; c2016 [cited 2016 Nov 21]. Available from: york.ca/wps/wcm/connect/yorkpublic/bec62176-245e-4de4-96e6-
6930ba468a0e/Oral+Health+for+Babies+and+Children.pdf?MOD=AJPERES&CACHEID=bec62176-245e-4de4-96e6-6930ba4
68a0e
19 American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): classifications, consequences, and preven-
tive strategies [policy online]. Chicago: American Academy of Pediatric Dentistry; 2014 [cited 2014 Jul 8]. Available from:
aapd.org/media/Policies_Guidelines/P_ECCClassifications.pdf
20 College of Dental Hygienists of Ontario. Oral health matters. From head to toe: for you and your baby [Internet]. Toronto:
College of Dental Hygienists of Ontario; 2012 [cited 2014 Jul 8]. Available from: cdho.org/docs/default-source/pdfs/oral-
health-rpt/oralhealthmatters_yourbaby.pdf
cdho.org/docs/default-source/pdfs/oral-health-rpt/oralhealthmatters_yourbaby.pdf
Physiological factors • No dental visit by age one or shortly after primary
teeth begin to erupt18, 21, 24
• Sharing toothbrushes or utensils or intimate con-
tact such as kissing (this can transfer oral bacteria Note: The Canadian Dental Association recom-
from parent/caregiver to the child) 19, 20, 21 mends that the first visit to a dentist should occur
within six months of the eruption of the first tooth
• Lack of exposure to fluoridated water20 or by one year of age.24, 26
• Factors associated with poor enamel devel-
opment, such as prenatal nutritional status of Where to go for help
mother, poor prenatal health and malnutrition
of the child22 If there are concerns, advise parents/caregivers
to contact:
• Prematurity or low birth weight (possible enamel
deficiencies)22 • Their dentist
• York Region Public Health Dental Program at

Other risk factors 1-800-735-6625 or 905-895-4512. Children may
• Lack of routine infant oral health care i.e. not be eligible for the Healthy Smiles Ontario (HSO)
wiping baby’s mouth and gums after each program, which provides no-cost urgent or
feeding18 regular dental care to children from families in
financial hardship who meet financial eligibility
• Poor oral hygiene i.e. ineffective or infrequent requirements
brushing less than twice per day23
• Parent/caregiver not performing tooth brush- others in this guide, please contact York Region
ing or oral health care for child (children up to Health Connection at 1-800-361-5653,
six years of age are not able to brush or floss TTY 1-866-512-6228, childfamily@york.ca
effectively, so parent/caregiver has to do it for
them)18, 23
Contributor
• Sibling history of early childhood caries22
Katie Chida, Health Educator, York Region
• Parent/caregiver with untreated dental disease19, 20 Public Health
• Lower education level of parent/caregiver25
• Lower socioeconomic status20, 22, 24
• Limited access to dental care25

• Deficit in the parental/caregiver dental knowledge21
• Use of bottle or sippy cup beyond 18 months19
21 Ontario Dental Hygienists Association. Dental hygiene facts. Oral health for children — a parent’s guide [Internet].
Burlington, ON: Ontario Dental Hygienists Association; 2012 [cited 2014 Jul 8]. Available from: odha.on.ca/wp-content/up-
loads/2016/08/ODHA-Facts-children.v2.pdf
22 Avery DR, Dean JA, McDonald RE. McDonald and Avery’s dentistry for the child and adolescent. 9th ed. Maryland Heights:
Mosby Elsevier; 2011.
23 Darby ML, Walsh MM. Dental hygiene theory and practice. 4th ed. St. Louis: Saunders Elsevier; 2015.
24 Canadian Dental Association. Position paper on access to oral health care for Canadians [Internet]. Ottawa, ON: Canadian
Dental Association; 2010 [cited 2014 Jul 8]. Available from: cda-adc.ca/_files/position_statements/accessToCarePaper.pdf
25 American Academy of Pediatric Dentistry. Guideline on infant oral health care [guideline online]. Chicago, IL: American
Academy of Pediatric Dentistry; 2014 [cited 2014 Jul 8]. Available from: aapd.org/media/Policies_Guidelines/G_infantOral-
HealthCare.pdf
26 Canadian Dental Association. CDA position on the first visit to the dentist [position statement online]. Ottawa, ON: Canadian
Dental Association; 2012 [cited 2014 Jul 8]. Available from: cda-adc.ca/_files/position_statements/firstVisit.pdf
DOMAINS | 27
FEEDING SKILLS 12 to 18 months
• No transition to cup drinking

Good feeding skills are an important part of
the overall development in childhood. As they • Not eating a variety of foods from each food
progress in a step-wise manner, each depending group
on the one before, it is important to support and
encourage the progression, especially during the • Not self-feeding any table foods30
early stages.
18 months
PROBLEM SIGNS • Not self-feeding most soft table foods30
If a child experiences one or more of the following,
consider this a red flag: 2 years
• Not chewing pieces of a variety of food textures

0 to 6 months and consistencies30
• Persistent breast refusal27
• Inability to effectively remove adequate milk

from breast when latched well27 If there are concerns, advise the parent/caregiver
to contact:
• Inability to co-ordinate sucking, swallowing and
breathing during feeding27 • York Region Public Health Breastfeeding Clinic —
for telephone support and/or to make an
• Consistent coughing during feeds that is not
appointment (no charge) call York Region
caused by the flow being too fast28
• Insufficient weight gain29 TTY 1-866-512-6228, childfamily@york.ca
• Children’s Treatment Network of Simcoe York at

6 to 8 months 1-866-377-0286, ctnsy.ca
• Lack of interest in solid foods For more information about this domain or any
• No transition to solids i.e. purees Health Connection at 1-800-361-5653,
• No introduction to cup drinking30 TTY 1-866-512-6228, childfamily@york.ca
9 to 12 months Contributors
• No transition to table foods i.e. soft pieces of Glynnis DuBois, Registered Nurse, Speech-
food30 Language Pathologist, Feeding Assessment
and Consultation Services, Children’s Treatment
27 Watson GC. Supporting sucking skills in breastfeeding infants. New York: Jones & Bartlett; 2017.
28 Marcus S, Breton S. Infant and child feeding and swallowing. Occupational therapy assessment and intervention. Bethesda,
MD: American Occupational Therapy Association; 2013.
29 Dietitians of Canada, Canadian Paediatric Society, College of Family Physicians of Canada, Community Health Nurses of Canada.
Promoting optimal monitoring of child growth in Canada: using the new WHO growth charts [report online]. Toronto, ON:
Dietitians of Canada; 2010 [updated 2011 Feb 16; cited 2015 Jun 15]. Available from: dietitians.ca/Downloadable-Content/
Public/tcg-position-paper.aspx
30 H
ealth Canada. [homepage on the Internet]. Ottawa, ON: Health Canada; Nutrition for healthy term infants: recommendations
from six to twenty four months; c2015 [updated 2015 Aug 18; cited 2015 Jun 15]. Available from: hc-sc.gc.ca/fn-an/nutri-
tion/infant-nourisson/recom/index-eng.php
Ann Ciniglio, Public Health Nurse, York Region The following are common characteristics of children
Public Health with FASD:
Mary Turfryer, Registered Dietitian —

Public Health Nutritionist, Nutrition Services, Infants
York Region Public Health • Low birth weight; failure to thrive; small size;
small head circumference
• Disturbed sleep; unpredictable sleep patterns/

FETAL ALCOHOL SPECTRUM cycles
DISORDER (FASD) • Often trembling and difficult to sooth; may cry a lot
Fetal Alcohol Spectrum Disorder (FASD) is an • Problems with bonding

umbrella term used to describe a variety of effects
resulting from exposure to alcohol during preg- • Weak sucking reflex; little interest in food; feed-
nancy. If a mother drinks alcohol during preg- ing difficulties
nancy, this can cause facial abnormalities, growth • Weak muscle tone
deficiencies and hearing and vision impairments
in the growing fetus. It can also affect learning, • High susceptibility to illness
behaviour, sleep, social and cognitive skills and
mental health concerns.31 The diagnosis of FASD • High sensitivity to sights, sounds and touch33
requires a multidisciplinary team and involves a
complex physical and neurodevelopmental assess- Preschoolers
ment.32 For a diagnosis of FASD to be made, the
individual must meet either of two sets of criteria: • Slow to acquire skills
FASD with facial features or FASD without facial
• Feeding and sleep problems
features.32
• Poor motor co-ordination and poor fine and
Alcohol exposure does not have the same impact
gross motor control
on every fetus and there are many factors that can
affect the impact. It is important to remember that • Short attention span
each baby is an individual and may be affected
differently. • Difficulty following directions or doing
as instructed
Though exact rates of FASD are not known and
vary from community to community, it is estimat- • Hypersensitivity i.e. irritability, stiffness when
ed that approximately one in 100 Canadians have held or touched, refusal to brush hair or teeth,
FAS.32 FASD crosses all races and socioeconomic over-reaction to injury
boundaries. Although there is no known cure for
FASD, it is preventable. With appropriate supports • Easily distracted or hyperactive
and services, the outcomes for an affected child • Difficulty with changes and transitions; prefers
are much improved. This is why early diagnosis and routines
intervention is critical.
• Receptive and expressive language delays33
31 Ministry of Children and Family Development. Baby steps: caring for babies with prenatal substance exposure. 4th ed.
Vancouver: Ministry of Children and Family Development; 2014.
32 Cook JL, Green CR, Lilley CM, Anderson SM, Baldwin ME, Chudley AE, et al. Fetal alcohol spectrum disorder: a guideline for
diagnosis across the lifespan. CMAJ [serial online]. 2016 [cited 2016 May 2]; 188(3):191-197 Available from: cmaj.ca/
content/188/3/191.full.pdf+html
33 Healthy Child Manitoba. What early childhood educators need to know about fetal alcohol spectrum disorder (FASD) [report on-
line]. Manitoba: Healthy Child Manitoba; 2010 [cited 2016 May 2]. Available from: gov.mb.ca/healthychild/fasd/fasdearly_en.pdf
DOMAINS | 29
School-age children • Health Canada
1-866-999-7612
• Sleep difficulties hc-sc.gc.ca
• Difficulty processing received information • FASD Coalition of York Region
• Difficulty with comprehension e.g. reading 1-877-464-9675 ext. 2015
• Ongoing expressive and receptive language

delays Contributor
• Poor attention span; low impulse control Linda Wheeler, Supervisor, York Region
Community and Health Services Department,
• Difficulty keeping up as school demands become Social Services Branch
increasingly abstract
• Consistent repetition needed to learn a skill or to

transfer learning from one situation to another FINE MOTOR SKILLS
• Ongoing sensory difficulties which may lead to Fine motor skills are actions and abilities involving
behaviour changes or challenges the small muscles in the hands and fingers.
Examples of fine motor activities include picking
• In need of constant reminders33
up objects, drawing/writing, dressing, and using
hands to eat and play. These skills also involve
Where to go for help hand-eye coordination.34
If there are concerns, advise the parent/caregiver

to contact their child’s primary care provider for Healthy child development
referral to one of the following diagnostic centres:
If a child is missing one or more of these expected
• Motherisk (birth to 16 years of age) age outcomes, consider this a red flag:
1-877-327-4636 or 416-813-6780
or motherisk.org By 4 months
• St. Michael’s Hospital (children and adults) • Brings hands to mouth35
416-360-4000 (ask for the FASD Diagnostic Clinic)
• Turns head from side to side to follow a toy or an
For more information on FASD and substance adult face35
abuse:
• Brings hands to middle of their body while lying
• Fasworld Toronto on their back35
416-264-8000
fasworld.com
By 6 months
• Best Start
416-408-2249, 1-800-397-9567 • Reaches for a toy when lying on back36
beststart.org • Uses hands to reach, grasp, bang and splash35
• Canadian Centre on Substance Abuse
ccsa.ca
34 Caringforkids. Your child’s development: what to expect? [webpage online]. Ottawa, ON: Caringforkids; c2017 [updated
2014; cited 2016 May 2]. Available from: caringforkids.cps.ca/handouts/your_childs_development
35 Nipissing district developmental screen. North Bay: Nipissing District Developmental Screen Intellectual Property Association; 2000.
36 Markham Stouffville Hospital, York Region Health Services, Early Intervention Services. Early Referral Identification Kit
(ERIK)- Referral for 6 months [Internet]. c2013 [cited 2016 Feb 22]. Available from: childdevelopmentprograms.ca/backend/
wp-content/uploads/New-ECE-6-month-ERIK-2016.pdf
By 9 months By 2 years
• Picks up small items using thumb and • Puts items into a small container35
first finger35, 37
• Takes off own shoes, socks or hat35, 40
• Passes an object from one hand to the other 35
• Scribbles with crayons or marks paper40
• Releases objects voluntarily 37
• Eats with a spoon with little spilling35, 40
• Bangs objects on table or floor 37
By 3 years
By 12 months
• Turns the pages of a book35
• Holds, bites and chews food, e.g. crackers 35
• Dresses or undresses with help35, 41
• Takes things out of a container35
• Turns lid off a jar or turns knobs35
• Points with index finger 35, 38
• Holds a pencil between thumb and fingers42
• Plays games like peek-a-boo38
• Copies a circle already drawn41
• Holds a cup to drink using two hands 38
• Picks up and eats finger foods34, 38 By 4 years
• Holds a crayon or pencil correctly35

By 18 months
• Undoes buttons or zippers35
• Helps with dressing by putting out arms
and legs35 • Cuts with scissors35, 43
• Stacks three or more blocks34, 39 • Dresses and undresses with minimal help43
• Picks up and eats finger foods35 By 5 years
• Uses scissors to cut along a thick line drawn on

paper35
• Dresses and undresses with little help35
40 Markham Stouffville Hospital, York Region Community and Health Services, Early Intervention Services. Early Referral Identi-
fication Kit (ERIK)- Referral for 24 months [Internet]. c2013 [cited 2016 Feb 22]. Available from: childdevelopmentprograms.ca/
backend/wp-content/uploads/New-ECE-24-month-ERIK-2016.pdf
41 Markham Stouffville Hospital, York Region Community and Health Services, Early Intervention Services, Early Referral Iden-
tification Kit (ERIK)- Referral for 36 months [Internet]. c2013 [cited 2016 Feb 22]. Available from: childdevelopmentprograms.ca/
42 Erinoakids Centre for Treatment and Development. Occupational Therapy [webpage online]. Ontario: Erinoakids Centre for
Treatment and Development; c2016 [updated 2015 Oct 19; cited 2016 Apr 28]. Available from: erinoakkids.ca/Services/Services/
Occupational-Therapy.aspx
43 Markham Stouffville Hospital, York Region Community and Health Services, Early Intervention Services. Early Referral Iden-
DOMAINS | 31
PROBLEM SIGNS Examples include crawling, sitting, standing, walk-
ing, running, keeping balance, jumping, climbing
If a child is experiencing any of the following, and changing positions.44
Infants
Healthy child development
If a child is missing one or more of these expected
• Inability to hold or grasp an adult finger or a toy/
age outcomes, consider this a red flag:
object for a short period of time36
By 2 months
All children
• Holds head up when held to an adult’s shoulder
• Hands are fisted most of the time
• Lifts head up when on tummy45
• Inability to play appropriately with a variety
of age-appropriate toys; avoids crafts and
manipulatives By 4 months
• Consistently ignores or has difficulty using one • Keeps head in line with the middle of their body
side of body; uses one hand/arm36 and brings hands to chest when lying on back
• Lifts head and chest and supports self on fore-

Where to go for help arms when placed on tummy
If there are concerns, advise the parent/caregiver • Holds head steady when supported in a sitting
to contact: position45
• York Region Early Intervention Services at

By 6 months
1-888-703-KIDS (5437)
• Rolls from back to side46
• The child’s primary care provider
• Pushes up on hands when on tummy45, 46
Contributor • Sits with support45
Nadia Brown, Physiotherapist, Clinical Supervisor,
Early Intervention Services, York Region Community By 9 months
and Health Services, Social Services Branch
• Sits on floor without support 45, 47
• Moves self forward on tummy or rolls continu-
GROSS MOTOR SKILLS ously to get an object47
• Stands with support45, 47

Gross motor skills are actions and abilities involving
the movement of our large muscles. These include
movements of our arms, legs, feet or entire body.
44 CaringforKids. Your child’s development: what to expect? [webpage online]. Ottawa, ON: Caringforkids; c2017 [updated
2014 Feb; cited 2016 May 2]. Available from: caringforkids.cps.ca/handouts/your_childs_development
45 Nipissing district developmental screen. North Bay: Nipissing District Developmental Screen Intellectual Property Association; 2000.
46 Markham Stouffville Hospital, York Region Community and Health Services, Early Intervention Services. Early Referral
Identification Kit (ERIK)- Referral for 6 months [Internet]. c2013 [cited 2016 Feb 22]. Available from: childdevelopmentpro-
grams.ca/backend/wp-content/uploads/New-ECE-6-month-ERIK-2016.pdf
Identification Kit (ERIK)- Referral for 9 months [Internet]. c2013 [cited 2016 Feb 22]. Available from: childdevelopmentpro-
By 12 months By 4 years
• Gets up to a sitting position from lying down • Stands on one foot for one to three seconds
without help45 without support45
• Pulls to stand at furniture45 • Goes up stairs using alternating feet 45, 53
• Walks holding onto furniture or hands of an • Runs, stops, and starts without falling53
adult45, 48
• Catches a large ball with outstretched arms45
By 18 months
By 5 years
• Walks alone45, 49
• Hops on one foot several times
• Crawls up stairs49
• Throws and catches a ball successfully most of
• Squats to pick up a toy and stands back up with- the time
out falling45
• Plays on playground equipment without difficulty45
By 2 years
PROBLEM SIGNS
• Walks backwards or sideways pulling a toy45
If a child is experiencing any of the following,
• Able to throw and attempt to catch ball without consider this a red flag:
losing balance50
• Kicks a ball51 By 3 months
• Little or no movement in legs; not kicking

By 3 years motion when lying on back
• Stands on one foot briefly45, 52 • Unable to lift head when lying on tummy50
• Climbs stairs using the handrail45
By 6 months
• Throws a ball forward at least one meter
(three feet)45 • Unable to sit using hands for support
• Difficulty controlling head movements50
48 Markham Stouffville Hospital, York Region and Community Health Services, Intervention Services. Early Referral Identifica-
tion Kit (ERIK)- Referral for 12 months [Internet]. c2013 [cited 2016 Feb 22]. Available from: childdevelopmentprograms.ca/
49 Markham Stouffville Hospital, York Region Community and Health Services, Early Intervention Services. Early Referral Identifica-
tion Kit (ERIK)- Referral for 18 months [Internet]. c2013 [cited 2016 Feb 22]. Available from: childdevelopmentprograms.ca/
50 Erinoakids Centre for Treatment and Development. Occupational Therapy [webpage online]. Ontario: Erinoakids Centre for
Treatment and Development; c2016 [updated 2015 Oct 19; cited 2016 Apr 28]. Available from: erinoakkids.ca/Services/Services/
Occupational-Therapy.aspx
52 Markham Stouffville Hospital, York Region Community and Health Services, Early Intervention Services, Early Referral Iden-
DOMAINS | 33
By 9 months
HEARING
• Unable to sit independently
Permanent hearing loss affects approximately
• Uses only one side of the body to move one to three children out of 1000.54 The hearing
loss may affect one ear or both and may be of
• Legs crossed or stiff any degree from a mild hearing loss to complete
deafness. It can be difficult to identify a child with
• Legs unable to bear weight50
hearing loss, particularly when the loss is relatively
mild since the child may seem to respond to many
By 12 months sounds. Many children may also experience
temporary hearing losses, particularly if they have
• Stiff arms or legs
a history of issues with congestion or ear infec-
• Not yet pulling to stand tions. Any degree of hearing loss may have an
impact on a child’s ability to learnº speech and
• Only able to sit with weight to one side50 language or to hear clearly in a noisy situation but
this is especially true as the severity of the hearing
By 18 months loss increases.54
• Not able to walk or stand independently50

By 24 months If a child is missing one or more of these expected
age outcomes, consider this a red flag:
• Not walking up or down stairs even with support
• Falls easily50 By 6 months
• Makes cooing sounds55

• Increases or decreases sucking behaviour in
If there are concerns, advise the parent/caregiver response to sound56
to contact:
• Startles, blinks, cries, quiets or changes breathing
• York Region Early Intervention Services rate in response to a sound57
at 1-888-703-KIDS (5437)
• Startles in response to sudden, loud noises58
• The child’s primary care provider
• Stirs or awakens when sleeping quietly and
someone talks or there is a sudden noise57
Contributor
• Makes different cries for different needs–such as
Nadia Brown, Physiotherapist, Clinical Supervisor, hungry, tired58
Early Intervention Services, York Region Community
and Health Services, Social Services Branch • Recognizes familiar voices and quiets when
spoken to58
54 Patel H, Feldman M. Universal newborn hearing screening. Paediatr Child Health [serial online]. 2011[cited 2016 Mar 10];
16(5):301-310. Available from: ncbi.nlm.nih.gov/pmc/articles/PMC3114997/pdf/pch05301.pdf
55 Speech-Language and Audiology Canada. Speech, language and hearing milestones [Internet].[place unknown]: SAC; 2014
[cited 2016 Mar 10]. Available from: sac-oac.ca/sites/default/files/resources/SAC-Milestones-TriFold_EN.pdf
56 American Speech-Language-Hearing Association. How does your child hear and talk? [Internet].[place unknown]: ASHA;
c1997-2016 [cited 2016 Mar 10]. Available from: asha.org/public/speech/development/chart
57 Canadian Academy of Audiology. Hearing loss in adults and children [Internet]. Toronto, ON: CAA; 2015 Jun 17 [cited 2016
Mar 10]. Available from: canadianaudiology.ca/for-the-public/hearing-loss-in-adults-and-children
58 Ontario Ministry of Children and Youth Services. Can your baby hear? [Government report online]. Toronto, ON: Queen’s
Printer for Ontario; c2010-2015 [updated 2016 May 12; cited 2016 Jun 10]. Available from: children.gov.on.ca/htdocs/English/
topics/earlychildhood/hearing/brochure_hear.aspx
• Responds to changes in the tone of parent/care- • Combines lots of sounds as though talking —
giver voice56 abada baduh abee58
• Watches parent/caregiver’s face as they speak58 • Shows interest in simple picture books58
• Smiles and laughs in response to parent/caregiver’s

smiles and laughs58 By 18 months
• Imitates coughs or other sounds e.g. ah, eh, buh58 • Sometimes startles to sudden loud noises57
• Babbles for attention and uses vocal play57 • Understands the concepts of “in and out”, “off
and on”58
• Turns head toward voices and interesting
sounds57 • Points to several body parts when asked58
• Enjoys musical toys or toys that make noise57 • Uses at least 20 words58
• Starts to put words together55

By 9 months
• Responds with words or gestures to simple
• Responds to their name questions — “Where’s teddy?”, “What’s that?”58
• Responds to the telephone ringing or a knock at • Looks at your face when talking to you55
the door
• Makes at least four different consonant sounds
• Understands being told “no” — b, n, d, g, w, h58
• Gets what they want through sounds and gestures, • Enjoys being read to and looking at simple books
such as reaching to be picked up with you58
• Plays social games with you such as peek-a-boo

By 2 years
• Babbles and repeats sounds e.g. babababa,
duhduhduh58 • Follows two-step directions, for example “Go find
your teddy bear and show it to Grandma”58
By 12 months • Uses 100 or more words58
• Localizes correctly to sound by turning head to- • Understands more words than they can say55
ward the sound55
• Uses at least two pronouns, e.g. “you”, “me”, “mine”58
• Follows simple one-step directions, for example
“sit down”58 • Uses own name57
• Looks across the room to something you • Consistently combines two or more words in
point to54 short phrases - “daddy hat”, “truck go down”58
• Recognizes words for common items like “cup”, • Asks simple questions, for example “What’s that?”55
“shoe”, “book” or “juice”56 • Enjoys being with other children58
• Uses three or more words58 • Begins to offer toys to peers and imitates other
• Uses gestures to communicate, for example children’s actions and words58
waves “bye bye”, shakes head “no”58 • People can understand their words 50 to 60 per
• Pays attention when spoken to 55 cent of the time58
• Gets parent/caregiver’s attention using sounds, • Takes turns in a conversation55

gestures and pointing while looking at their eyes58 • Forms words and sounds easily and effortlessly58
• “Performs” for attention and praise58 • “Reads” to stuffed animals or toys58
DOMAINS | 35
By 3 years • Understands words for some shapes, like circle
and square56
• Is alert to environmental sounds57
• Understands words for family, like brother,
• Responds to someone talking out-of-view grandmother and aunt56
(particularly when there are no distractions)57
• Responds to voices on the telephone57 By 5 years
• Understands the concepts of size (big/little) and • Pronounces most speech sounds correctly55
quantity (a little, a lot, more)58
• Participates in and understand conversations
• Uses some adult grammar — “two cookies”, “bird even in the presence of background noise55
flying”, “I jumped”58
• Recognizes familiar signs, for example stop sign55
• Uses more than 350 words 58
• Makes up rhymes
• Uses action words, for example “run”, “spill”, “fall”58
• Hears and understands most of what is said at
• Uses sentences of three or more words most of home and school55
the time55
• Listens to and retells a story and asks and
• Answers simple questions, for example “Where is answers questions about a story55
the car?”55
• Understands words for order like first, next
• Participates in short conversations55 and last56
• Begins taking short turns with other children, • Understands words for time like yesterday, today
using both toys and words58 and tomorrow56
• Puts sounds at the start of most words58 • Follows longer directions like “Put your pajamas
on, brush your teeth and then pick out a book”56
• Produces words with two or more syllables or
beats, for example “ba-na-na”, “com-pu-ter”, • Follows classroom directions like “Draw a circle
“a-pple”58 on your paper around something you eat”56
• Listens to and enjoys hearing stories for longer

periods of time57 PROBLEM SIGNS
• Remembers and understands familiar stories58 If a child is experiencing any of the following,
By 4 years • Early babbling stops59
• Tells a short story or talks about daily activities55 • Frequently gets colds and ear infections59
• Talk in sentences with adult-like grammar55 • Frequently pulls at ears59
• Generally speaks clearly so people understand55 • Does not understand people unless facing them59
• Hears you when you call from another room55 • Intently watches the face of the person speaking57
• Listens to television at the same volume as others55 • Speaks loudly or turns up the volume of the tele-
• Answers a variety of questions 55 vision or radio59
• Understands words for some colours, like red, • Does not respond when called59
blue and green56 • Uses “what?” or “huh?” frequently57
59 Speech-Language and Audiology Canada. Children [Internet]. [place unknown]: SAC; c2016 [cited 2016 Mar 10]. Available
from: sac-oac.ca/public/children
• Has difficulty understanding speech in Contributor
group activities57
Louise Tanaka, Audiologist, Clinical Coordinator
for Screening and Audiology, Tri-Regional Infant
Where to go for help Hearing Program
If there are concerns for a child under 24 months

of age:
LEARNING DISABILITIES
• Contact the Tri-Regional Infant Hearing Program:
Learning Disabilities (LDs) are the result of
→Call
→ 1-888-703-5437 (choose option 4 for impairment in one or more psychological processes
Infant Hearing) or that affect acquisition, retention, understanding,
organization or use of verbal and/or non-verbal
→Download
→ a referral form from information.60 LDs are lifelong. LDs are distinct
childdevelopmentprograms.ca/resource/ from intellectual disabilities as they are specific,
hearingreferral and fax it to 905-472-7553 not global impairments. LDs may co-exist with
Note: Referrals can be made by the parent/ other conditions including attention disorders,
caregiver or an early years/health care behavioural and emotional disorders, sensory
professional impairments or other medical conditions.
LDs can affect how a person interprets, remembers,

If there are concerns for a child over 24 months
understands and expresses information. LDs take
of age:
many forms and vary in severity and intensity and
• Refer the child to an audiologist: may impact many areas of functioning from child-
hood into adulthood. LDs may affect academic
→With
→ a referral from the child’s family physician or performance (e.g. spelling, reading, listening,
focusing, remembering and writing), social function-
→Contact
→ the Ontario Association of
ing, life skills (e.g. planning, organizing, predicting)
Speech-Language Pathologists and Audiologists
and physical interaction with the world (e.g. balance,
at 1-800-718-6752 or visit osla.on.ca for a list of
coordination, movement).61
private audiologists
Between five and 10 per cent of Canadians have
For more information on hearing:
LDs.62 LDs are not widely understood and are not
• American Speech-Language and Hearing Associa- caused by factors such as cultural or language
tion (ASHA) differences, inadequate or inappropriate instruction,
asha.org/Default.aspx socioeconomic status or lack of motivation.
• Canadian Academy of Audiology Typically, LDs are diagnosed by an educational

canadianaudiology.ca psychologist only after the child enters school and
is learning to read and write.
• National Institute on Deafness and Other
Communication Disorders
nidcd.nih.gov/health/voice/pages/speechand- PROBLEM SIGNS
language.aspx
If a child is experiencing a delay in one or more of
• Speech-Language & Audiology Canada the following domains in this guide consider this a
sac-oac.ca/public/children red flag:
60 Official definitions of LDs [Internet]. Toronto: Learning Disabilities Association of Ontario; 2015 [cited 2016 April 6].
Available from: ldao.ca/introduction-to-ldsadhd/what-are-lds/official-definition-of-lds/
61 Different types of LDs [Internet]. Toronto: Learning Disabilities Association of Ontario; 2015 [cited 2016 Apr 6]. Available
from ldao.ca/introduction-to-ldsadhd/what-are-lds/different-types-of-lds/
62 LDs [Internet]. Toronto: Learning Disabilities Association of Ontario; 2015 [cited 2016 Apr 6]. Available from: ldao.ca/intro-
duction-to-ldsadhd/what-are-lds
DOMAINS | 37
• Attention Difficulty and Hyperactive Behaviour PROBLEM SIGNS
• Behaviour If a mother is experiencing any of the following
for more than two weeks after the birth of a baby,
• Fine motor skills
• Social/emotional
• General feelings of unhappiness without reason
• Speech and language
• Crying
• Mood swings
• Anxiety
Refer to the specific domains above to find out
where to go for help as early as possible to reduce • Insomnia
the impact on the child’s learning. Long term sup-
port is usually indicated. • Changes in appetite
For more information about learning disabilities: • Irritability
• Learning Disabilities Association of York Region • Loneliness or isolation

at 905-884-7933
• Worry about their ability as a mother
info@ldayr.org
ldayr.org • Conflicts in their roles and relationships
• Inability to cope64
Contributor
Postpartum or baby blues are very common. Up to
Stephanie Gatti, Program Coordinator, Learning 84 per cent of new mothers will experience it. The
Disabilities Association of York Region negative feelings usually peak on day three to five
postpartum and will improve by day 12.65
Depression occurs in up to 19 per cent of women.64

MATERNAL MENTAL ILLNESS Encouraging women to speak to a health care
provider and get help early benefits both them-
Mental illnesses such as depression and anxiety are selves and their children.
conditions where a person’s thinking, mood and
behaviours severely and negatively impact how a Women with certain risk factors may be more vulner-
person functions in his or her life. Mental illness able to experiencing maternal mental illness.
that occurs in pregnancy or after having a baby is
If a woman has any of the following risk factors,
referred to as maternal mental illness.
If left untreated, maternal mental illness can have
• Personal history of anxiety, depression or other
negative effects on both the mother and her baby.
mental illnesses
For example, it can put a woman at risk for prema-
ture delivery or may affect her ability to meet her • Family history of poor mental health
own self care needs and those of her child. This can
put the child’s health and development at risk.63 • Conflict with the partner relationship
63 National Collaborating Centre for Mental Health. Antenatal and postnatal mental health. Clinical management and service
guidance [report online]. London: British Psychological Society and the Royal College of Psychiatrists; 2014 [cited 2016 Mar 10].
Available from: nice.org.uk/guidance/cg192/evidence/full-guideline-193396861
64 O’Hara MW, Wisner KL. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol
2014;28(1):3-12.
65 Milgrom J, Gemmill AW, Bilszta JL, Hayes B, Barnett B, Brooks J, et al. Antenatal risk factors for postnatal depression: a large
prospective study. J Affect Disord 2008;108(1-2):147-157.
• Lack of practical, financial or emotional supports • Out of touch with reality; cognitive impairment
• Poor social support • Delusions and/or hallucinations
• Stressful life events, e.g. infertility, pregnancy • Severe depression

loss, unhealthy relationships, loss of a family
member or friend64, 65 • Agitation
• Confusion
Where to go for help • Thoughts of harming self or baby64, 66
If there are concerns of maternal mental illness, or If the mother has any of the above symptoms of
if the woman has risk factors: postpartum psychosis, do not wait:
• Advise the woman/family to contact her primary • Establish the safety of the baby and/or child(ren)
health care provider
• Do not leave the mother alone
For further support, the woman may also contact:
• Get help:
• York Region Health Connection at1-800-361-5653,
TTY 1-866-512-6228 or email childfamily@york. →Contact
→ Community Crisis Response Services
ca to access the following York Region Public 24 hour crisis line:
Health programs: 1-855-310-COPE (2673), TTY 1-866-323-7785
or
→Healthy
→ Babies Healthy Children program
York Region Public Health Healthy Babies →Accompany
→ the mother to your local hospital’s
Healthy Children Program and/or emergency department
→Transition
→ to Parenting group
youtube.com/watch?v=s1KiMuzOaxQ Contributor
York Region Public Health Mental Health
and Wellness Pauline Ingber-Brooks, Public Health Nurse,
York Region Public Health
• Bounce Back Program offered by
Canadian Mental Health Association
1-866-345-0224
cmha-yr.on.ca/programs-services/bounce-back/ MILD TRAUMATIC BRAIN INJURY
Postpartum psychosis is a rare but serious mental (CONCUSSION)
illness with risks to the mother and baby. The onset
usually happens rapidly, in the first few weeks A mild traumatic brain injury is also called a
after childbirth. Postpartum psychosis requires “concussion.”67 In children under the age of six
immediate medical attention. years, concussions are most commonly caused by
falls, motor vehicle crashes, bicycle crashes or other
sports related injuries, being struck by/against
If the mother is experiencing any of the following
objects, and assault.67 It can be more difficult to
symptoms of postpartum psychosis, consider this
recognize the symptoms of a concussion in infants,
a red flag:
toddlers or preschoolers because they communicate
• Dramatic changes in mood i.e. from elated differently than older children.
to depressed
66 BC Reproductive Mental Health Program, Perinatal Services BC. Best practice guidelines for mental health disorders in the
perinatal period [report online]. British Columbia: BC Reproductive Mental Health Program and Perinatal Services BC; 2014
[cited 2016 Mar 10]. Available from: perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/MentalHealth-
DisordersGuideline.pdf
67 Mild Traumatic Brain Injury/Concussion Infants & Toddlers [brochure on the Internet]. Hamilton: CanChild McMaster University;
[updated 2012 Jun 27; cited 2015 Dec 11]. Available from: canchild.ca/system/tenon/assets/attachments/000/000/290/
original/MTBI_Infant_Toddler_Brochure.pdf
DOMAINS | 39
PROBLEM SIGNS • Slurred speech68
If a child experiences one or more of the following • Weakness, numbness in arms/legs68

• Changes in behaviour e.g. irritability, aggression68
• Headache or persistent rubbing of their head
• Nausea or vomiting Where to go for help

• Unsteady walking, loss of balance or If you suspect a child has had a concussion:
poor coordination
• Take the child to the local emergency department/
• Loss of ability to carry out newly learned skills, seek medical help immediately68
e.g. toilet training, speech
• Lack of interest in favourite toys Contributor

• Cranky, irritable or difficult to console Karen Dillon, Manager, Children’s Treatment
• Changes in eating or sleeping patterns
• Tiring easily or listlessness Source
• Sensitivity to light or noise Jennifer Saltzman-Benaiah, PhD, CPsych,
• Visual problems 67 Clinical Neuropsychologist, Behaviour and
Health Sciences Centre, Mackenzie Health, and the
If any of the following symptoms develop, Children’s Treatment Network of Simcoe York
consider this a red flag and take the child to the
local emergency department/seek medical
attention immediately:
• Loss of consciousness68
NUTRITION (OVERWEIGHT AND
• Large bumps, bruising or unexplained swelling
UNDERWEIGHT)
on the head67 Poor nutrition in babies and young children can
lead to many negative outcomes such as failure
• Increased drowsiness or difficult to rouse67, 68 to thrive, obesity, anemia, restrained eating, poor
• Neck pain67, 68 eating habits that become lifelong, lack of school
readiness and inability to learn at school.69 Further
• Repeated vomiting68 investigation, including possible referral to a
registered dietitian (RD) for nutrition assessment
• Blood or fluid in the ear67 and ongoing follow-up may be warranted for
• Pupils are unequal in size67 infants and children who present with Red Flags.
• Seizures67, 68
PROBLEM SIGNS
• Increased confusion e.g. cannot recognize people
or places68 If one or more of the following risk factors are
present, consider this a red flag:
68 McMaster Children’s Hospital. Do you think your child may have a concussion? [Internet]. Hamilton: Hamilton Health Sciences;
[cited 2015 Dec 11]. Available from: mcmasterchildrenshospital.ca/body.cfm?id=438
69 Randall Simpson J, Keller H, Rysdale L, Beyers J. Nutrition screening tool for every preschooler (NutriSTEP): Validation and
test-retest reliability of a parent-administered questionnaire assessing nutrition risk of preschoolers. Eur Clin Nutr [serial
online]. 2008 [cited 2015 Jun 15]; 62(6):770-780. Available from: nature.com/ejcn/journal/v62/n6/pdf/1602780a.pdf
General nutrition risk factors • Inadequate access to a sufficient variety and
quantity of food77
• Growth measurements plot below the third or
above the eighty-fifth percentile on the WHO
Growth Charts for Canada70 Age-specific nutrition risk factors
• There is a sharp incline or decline in serial growth Birth to 6 months

measurements or the growth-line remains flat on
the WHO Growth Charts for Canada70 • After five days of age, has less than six wet dia-
pers each day78
• If provided, infant formula is prepared and/or
stored incorrectly71, 72 • Within the first two weeks, loses more than 10
per cent of birth weight78
• Uses a propped bottle71 or is not supervised
during feeding71 • By two weeks, does not regain birth weight or
does not gain 20 grams or more per day78
• Unsafe or inappropriate foods are given,
e.g. raw eggs, unpasteurized milk and foods that • Not fed based on baby’s cues,3 e.g. not fed on
are choking hazards73 demand, day and night79
• Feeding is forced or restricted71, 72 • Not receiving vitamin D supplement of 400 IU
daily if breastfed or receiving breastmilk71
• Is pressured to eat through prodding, scolding,
punishment, pleading, bribing or coercing, • Drinks cow’s or goat’s milk, vegetarian beverages
e.g. “clean your plate” or “come on, you’ve tried (e.g. soy, rice, almond), homemade evaporated milk
it before”73, 74 formula, water, juice, herbal teas or other liquids71
• Diet is restricted e.g. food allergy, vegan, gluten-free75 • Consumes infant cereal or other pureed foods
before 4 months80, including cereal or pureed
• Food storage or cooking facilities are inadequate76 foods in a bottle81
70 Dietitians of Canada, Canadian Paediatric Society, College of Family Physicians of Canada, Community Health Nurses of Canada.
Promoting optimal monitoring of child growth in Canada: using the new WHO growth charts [report online]. Toronto: Dietitians
of Canada; 2010 [ cited 2015 Jun 15]. Available from: dietitians.ca/Downloadable-Content/Public/tcg-position-paper.aspx
71 Health Canada, Canadian Pediatric Society. Dietitians of Canada, Breastfeeding Committee of Canada. Nutrition for healthy
term infants: recommendations from birth to six months [Internet]. Ottawa, ON: Health Canada; 2015 [cited 2015 Jun 15].
Available from: hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php
72 Government of Canada. Preparing and handling powdered infant formula [Internet]. Ottawa: Health Canada; 2012 [updated
2011 Apr 12; cited 2015 Jun 15]. Available from: healthycanadians.gc.ca/kids-enfants/food-aliment/formula-nourrisson-eng.php
73 Health Canada, Canadian Paediatric Society, Dietitians of Canada. Nutrition for healthy term infants: recommendations from
six to twenty four months [Internet]. Ottawa, ON: Health Canada; 2015 [cited 2015 Jun 15]. Available from: http://www.cps.ca/
en/documents/position/nutrition-healthy-term-infants-6-to-24-months
74 Leung A, Marchand V, Sauve R; Canadian Paediatric Society. The ‘picky eater’: the toddler or preschooler who does not eat.
Paediatr Child Health [serial online]. 2012 [cited 2015 Jun 15]; 17(8): 455-57. Available from: ncbi.nlm.nih.gov/pmc/articles/
PMC3474391/pdf/pch17455.pdf
75 Kirby M, Danner E. Nutritional deficiencies in children on restricted diets. Pediatr Clin North Am. 2009; 56(5): 1085-1103.
76 Health Canada. Improving cooking and food preparation skills [Government report online]. Ottawa, ON: Her Majesty the
Queen in Right of Canada; 2010 [cited 2016 Sep 9]. Available from: hc-sc.gc.ca/fn-an/alt_formats/pdf/nutrition/child-enfant/
cfps-acc-synthes-eng.pdf
77 Roshanafshar S, Hawkins E. Food insecurity in Canada. Ottawa: Statistics Canada; 2015. (Catalogue no.82-624-X).
78 Kleinman RE. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village (IL): American Academy of Pediatrics; 2009.
79 Kent J, Mitoulas L, Cregan M, Ramsay D, Doherty D, Hartmann P. Volume and frequency of breastfeedings and fat content of
breast milk throughout the day. Pediatrics [serial online]. 2006 [cited 2015 Jun 15]; 117e387-95. Available from:
pediatrics.aappublications.org/content/pediatrics/117/3/e387.full.pdf
80 Boyce JA, Assa’ad A, Burks A. Guidelines for the diagnosis and management of food allergy in the United States: report of
the NIAID-sponsored expert panel. J Allergy Clin Immunol [serial online]; 2010 [cited 2015 Jun 15]; 126(6): S1-S58. Available
from: jacionline.org/article/S0091-6749(10)01566-6/fulltext
81 Dietitians of Canada. Infant nutrition – complementary feeding evidence summary [Internet]. 2014 [cited 2014 Jun 11].
Available from: Dietitians of Canada: Practice based evidence in Nutrition (PEN), by subscription.
DOMAINS | 41
• Consumes honey, including pasteurized or • Drinks fruit drinks/punch, sports drinks, pop or
cooked73 beverages containing artificial sweeteners or
caffeine (e.g. coffee, tea, hot chocolate)
6 to 9 months • Drinks more than 750 mL (24 oz.) of cow’s or
• Does not eat iron-rich foods daily, such as meat, goat’s milk a day
meat alternatives and iron fortified cereal • Drinks more than 175 mL (six oz.) of juice a day
• By nine months, does not eat two to three larger • Consumes honey, including pasteurized or
feedings (meals) and one to two smaller feedings cooked73
(snacks) daily
• Not receiving vitamin D supplement of 400 UI 1 to 2 years

daily if breastfed or receiving breastmilk
• Does not eat iron-rich foods daily, such as meat
• Drinks cow’s or goat’s milk, vegetarian beverages and meat alternatives73
(e.g., soy, rice, almond) or homemade formula as
milk source • Does not eat a variety of family foods with varying
textures such as ground, mashed or chopped
• Drinks fruit drinks/punch, sports drinks, pop or foods with a tender consistency, including finger
beverages containing artificial sweeteners or foods73
caffeine (e.g. coffee, tea, hot chocolate)
• Does not eat three small meals plus two to three
• Drinks more than 175 mL (six oz.) juice a day nutrient-dense snacks a day, generally following
the advice in Canada’s Food Guide73
• Consumes honey, including pasteurized or
cooked73 • Dietary fat intake is restricted73
• Not receiving vitamin D supplement of 400 IU

9 to 12 months daily if breastfed or receiving breastmilk
• Does not eat iron-rich foods daily, such as meat, • Consumes mostly breastmilk and little solid
meat alternatives and iron fortified cereal food74, 82, 83
• By nine months, foods with lumpy textures have • By 18 months, has not transitioned from bottle
not been introduced or consumed to an open cup84
• By 12 months, does not eat a variety of family • Drinks more than 750 mL (24 oz.) of cow’s or
foods with various textures goat’s milk a day73
• By 12 months, does not eat two to three larger • Drinks more than 175 mL (six oz.) of juice a day73
feedings (meals) and one to two smaller feedings
(snacks) daily • Drinks skim or low-fat cow’s or goat’s milk,
vegetarian beverages (e.g. soy, rice, almond) or
• Not receiving vitamin D supplement of 400 IU homemade formula as main milk source73
daily if breastfed or receiving breastmilk
• Drinks fruit drinks/punch, sports drinks, pop or
• Drinks skim or low-fat cow’s or goat’s milk, beverages containing artificial sweeteners or
vegetarian beverages (e.g. soy, rice, almond) or caffeine (e.g. coffee, tea, hot chocolate)73
homemade formula as main milk source
82 Baker R, Greer F. Clinical report - diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and
young children (0-3 years of age). Pediatrics [serial online]. 2010 [cited 2015 June 15]; 126(5): 1040-1050. Available from:
pediatrics.aappublications.org/content/pediatrics/early/2010/10/05/peds.2010-2576.full.pdf
83 Coulthard H, Harris G, Emmett P. Delayed introduction of lumpy foods to children during the complementary feeding period
affects child’s food acceptance and feeding at 7 years of age. Matern Child Nutr 2009; 5(1): 75-85.
84 Maguire J, Birken C, Jacobson S, Peer M, Taylor C, Parkin P, et al. Office-based intervention to reduce bottle use among toddlers:
TARGet kids! pragmatic, randomized trial. Pediatrics [serial online]. 2010 [cited 2015 Jun 15]; 126(2): e343-50. Available from:
pediatrics.aappublications.org/content/pediatrics/early/2010/07/12/peds.2009-3583.full.pdf
• By 24 months, often coughs and chokes • Contact EatRight Ontario to speak with a
when eating85 registered dietitian by calling 1-877-510-5102,
or using the Email a Dietitian service on the
• Scores “high nutrition risk” on Toddler Nutri- website eatrightontario.ca
STEP® nutrition screen nutritionscreen.ca86
For more information on healthy eating:
2 to 6 years • York Region Public Health Nutrition Services
• Does not eat a variety of foods from the four york.ca/nutrition
food groups in Canada’s Food Guide87
• Does not eat three small meals plus two to three Source
nutrient-dense snacks each day73 Adapted from: Pediatric Nutrition Guidelines (Birth
• Drinks large amounts of fluids and little solid to Six Years) for Health Professionals, 2014, Ontario
food78, 88 (e.g. more than 750 ml or 24 oz. of milk Society Nutrition Professionals in Public Health
a day74, 88 or more than 175 mL or six oz. of juice osnpph.on.ca/upload/membership/document/pe-
a day)88 diatric-nutrition-guidelines-for-health-profession-
• Consumes mostly breast milk and little solid als-2014_1.pdf#upload/membership/document/
food74, 82, 83 pediatric-nutrition-guidelines-for-health-profes-
sionals-2014_1.pdf
• Drinks most of their milk and other beverages
from a bottle or sippy cup84
Contributor
• Regularly drinks fruit drinks/punch, sports drinks,
pop or beverages containing caffeine, e.g. coffee, Mary Turfryer, Registered Dietitian-Public Health
tea, hot chocolate78, 88 Nutritionist, York Region Public Health
• Rarely or never eats meals with their family88, 89
• Depends on vitamin/mineral supplement vs. vari-

ety of foods88
PREMATURITY
Typically, a fetus spends an average of 40 weeks
• Scores “high nutrition risk” on Toddler or Pre- growing and developing before birth. According
schooler NutriSTEP® nutrition screen nutrition- to the World Health Organization (WHO), babies
screen.ca69, 86 born before completing 37 weeks are defined as
preterm or premature.90 In the majority of cases,
these infants are healthy and experience typical
Where to go for help development. However, many infants born pre-
If there are concerns, advise the parent/caregiver to: maturely require medical care after birth and
some have continuing challenges that affect their
• Talk to their child’s primary care provider growth and development. Several factors influence
85 Nipissing District Developmental Screen Inc. Nipissing District Developmental Screen [Internet]. North Bay: NDDS; 2011[cited
2015 Jun 15]. Available from: ndds.ca/ontario
86 Randall Simpson J, Gumbley J, Whyte K, Lac J, Morra C, Rysdale L et al. Development, reliability and validity testing of toddler
NutriSTEP®: A nutrition risk screening questionnaire for children 18-35 months of age. Appl Physiol Nutr Metab. 2015;
40(9):877-86.
87 Health Canada. Eating well with Canada’s food guide: A resource for educators and communicators [Government report
online]. Ottawa, ON: Health Canada; 2011 [cited 2015 Jun 15]. Available from: hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/
pdf/pubs/res-educat-eng.pdf
88 Dietitians of Canada. Toddler and preschool nutrition knowledge pathway [Internet]. 2012 [cited 2014 May 20]. Available
from: Dietitians of Canada: Practice – based evidence in nutrition (PEN) by subscription.
89 Satter E. Secrets of feeding a healthy family. 2nd ed. Madison, Wis: Kelcy Press; 2008.
90 Aboutkidshealth. About premature babies [Internet]. Toronto: Hospital for Sick Children; 2009.; [cited 2016 May 5]. Available
from: aboutkidshealth.ca/En/ResourceCentres/PrematureBabies/AboutPrematureBabies/Pages/default.aspx
DOMAINS | 43
whether or not a child born prematurely will • York Region Early Intervention Services to obtain
experience medical care and/or ongoing support. the physician’s referral form for the neonatal
These factors include how prematurely the child follow-up clinics 1-888-703-KIDS (5437)
was born, the baby’s birth weight, and if the baby
experienced complications at birth that are known Primary care providers can refer directly to one of
to put them at risk for challenges as children and the three hospitals’ Neonatal Follow-Up Clinics:
adults.91 • Mackenzie Health
There are a variety of reasons that children can Telephone: 905-883-1212 ext. 3069
be born premature. Prematurity may be linked Fax: 905-883-2052
to maternal conditions (e.g. high blood pressure, • Markham Stouffville Hospital
infection, substance abuse, trauma, chronic illness) Telephone: 905-472-7534
or fetal conditions (e.g. fetal malformation, chromo- Fax: 905-472-7535
somal abnormalities, infection).90 Sometimes the
reason for a premature birth is unknown. • Southlake Regional Health Centre
Telephone: 905-895-4521 ext. 5608
Regardless of the reason for prematurity, there Fax: 905-830-5982
is a higher risk of developmental concerns and
these children will need consistent monitoring to
ensure that they are developing appropriately for Contributor
their age. Regular monitoring of a child’s growth
and development by a professional is important to Nadia Brown, Clinical Supervisor, Early Intervention
ensure that children at risk can access appropriate Services, York Region Community and Health
services. York Region Early Intervention Services Services, Social Services Branch
(EIS) provides this support in partnership with the
three York Region hospitals (Mackenzie Health,
Markham Stouffville Hospital and Southlake
Regional Health Centre) at Neonatal Follow-Up REGULATION
Clinics located within each hospital. The Neonatal
The development of self-regulation is rooted in
Follow-Up Clinics are staffed by multidisciplinary
the relationship/attachment system that exists
teams which include physicians, physiotherapists,
between an infant and his or her caregiver.92, 93, 94
occupational therapists and early interventionists.
Babies are not born with the capacity to regulate
The focus of the multidisciplinary clinic team is to
their feelings, actions or bodies and rely completely
provide assessment, monitoring and early interven-
on their caregivers to attune to their distress.
tion to promote optimal developmental outcomes.
When caregivers can recognize their own stress,
The Neonatal Follow-Up Clinics specifically target
stay calm and then provide the nurturing and
infants/children at the greatest risk for delay
structure needed to alleviate their baby’s dis-
including: infants born less than 33 weeks gestation,
tress they have used their secure relationship to
birth weight less than 2000 grams, at risk for
help the child regulate. In the first three years
neurological impairments, small for gestational
of a child’s life, the child is dependent on his
age (SGA), metabolic conditions, or those with
or her parents to interpret their distress and
complex needs.
support them to calm down and regulate. This
is a process known as co-regulation and its growth
Where to go for help and development is closely aligned with the relation-
ship and attachment between a parent and
Advise the parent/caregiver to contact: child.92, 93, 95 Beyond the child’s third birthday,
91 Aboutkidshealth. Looking ahead [Internet]. Toronto: Hospital for Sick Children; 2009 [cited 2016 May 5]. Available from:
aboutkidshealth.ca/En/ResourceCentres/PrematureBabies/LookingAhead/Pages/default.aspx
92 Hughes DA. Attachment -focused parenting. New York: W.W. Norton & Company; 2009.
93 Lillas C, Turnbull J. Infant/child mental health, early intervention, and relationship-based therapies. A neurorelational frame-
work for interdisciplinary practice. New York: W.W. Norton & Company; 2009.
94 Zeanah CH Jr. Handbook of infant mental health. New York: Guilford Press; 1993.
95 Schore AN. Affect regulation and repair of self. New York: W.W Norton & Company; 2003.
the child begins to meaningfully use words to are unable to calm themselves, understand their
identify feelings and thoughts. Their emerging child’s needs and respond to their child in ways
language skills then begin to help them think, that soothe. The Adverse Childhood Experiences
wait, problem solve, ask for help and remember (ACE) Study identifies a number of parental risk
ways to calm themselves down when they are factors including involvement in abuse, neglect,
distressed. Initially infants need a tremendous substance use, separations or loss, and criminality
amount of co-regulation from others to manage that might compromise parents’ ability to notice
distress. They will need less and less adult support and offer support to their child.93
as children as their own capacity to regulate
increases.92, 93, 95
PROBLEM SIGNS
In the first three years, the role of the parent is to
help the child recover from stress and prevent the If a child presents any of the following behaviours,
child from feeling overloaded. Common stressors consider this a red flag:
might include hunger, fatigue, worry, fear, pain,
• Shows distress easily
being alone or sensory overload (voice tone, anger,
lighting, temperature). Toxic stress occurs when • Has difficulty adapting to changes
the child experiences distress too frequently, too
quickly, when they can’t adapt to “normal” chal- • Has difficulty making transitions
lenges and transitions, when it takes a long time
• Takes more than 20 minutes to calm down after
to recover (more than 10 to 20 minutes) or when
being upset
distress affects a healthy sleep cycle.93 Toxic stress
also interrupts a child’s ability to regulate if the • Sleeps too much for their age
caregiver has not been successful or mostly consis-
tent in soothing the child.96, 92, 97 Children who have • Sleeps too little for their age
experienced toxic stress will react more frequently
and more intensely with little or no understood • Reacts frequently with little or no understanding
provocation. They will react with actions that fall of what provoked them
into the categories of fight (physical or verbal), • Reacts with intensity
flight (running behaviours) or freeze/immobilize
(hiding, spacing out, daydreaming). Children who • Engages in physical fighting, verbal aggression
experience this level of toxic stress tend to have and poor social skills
disruptions to normal sleep patterns so that they
sleep too much, sleep too little or can’t get into • Runs away
a sleep pattern that allows them to feel rested.93 • Hides from
These children often are defined by what is seen as
“bad behaviour” when the root of the reaction is • Daydreams more than usual93, 98, 99, 100
that their needs have not been met and their brain
interprets that as dangerous. The brain then reacts
with fighting, flight or freezing.93 Where to go for help
Red Flags exist within this domain for parents who If there are concerns, advise the parent/caregiver
to contact one of the following:
96 Harvard University, Centre on the Developing Child. A decade of science informing policy: the story of the national scientific
council on the developing child [Internet]. Boston: Centre on the Developing Child at Harvard University; 2014 [cited 2016 Aug 26].
Available from: developingchild.harvard.edu/wp-content/uploads/2015/09/A-Decade-of-Science-Informing-Policy.pdf
97 Murray DW, Rosanbalm K, Christopoulos C, Hamaoudi, A. Self-regulation and toxic stress: foundations for understanding
self-regulation from an applied developmental perspective OPRE Report #2015-21 [report online]. Washington DC: Office of
Planning, Research and Evaluation, Administration for Children and Families, US Department of Health and Human Services;
2015 [cited 2015 Dec 3]. Available from: acf.hhs.gov/sites/default/files/opre/report_1_foundations_paper_final_012715_
submitted_508.pdf
98 Porges SW. The Polyvagal theory: neurophysiological foundations of emotions, attachment, communication, and
self-regulation. New York: W.W. Norton & Company; 2011.
99 Ray DC. A therapist’s guide to child development. The extraordinarily ordinary normal years. New York: Routelage; 2015.
100 Siegel DJ. The developing mind: how relationships and the brain interact to shape who we are. New York: Guildford Press; 2001.
DOMAINS | 45
• Ontario Early Years Centre (OEYC) with These relationships can be described and under-
locations in Markham, Oak Ridges, Thornhill, stood in the context of Mary Ainsworth’s four
Vaughan-King-Aurora, and York North attachment styles: secure, anxious-ambivalent,
anxious-avoidant, and disorganized.103
• To access the contact information for the locations
in York Region, visit centralhealthline.ca It is important to note and remember that most
parent child interactions result in a secure attach-
• York Region Early Intervention Services ment pattern.103
1-888-703-5437
Secure attachment: This is a relationship in which
• Blue Hills Child and Family Centre the infant or child can feel physically and emo-
905-773-4323 tionally safe. The parent is able to meet the needs
bluehillscentre.ca of the child, soothe the child and experience joy
bluehills@bluehillscentre.ca in their relationship with the child. The parent,
• Kinark Child and Family Services through this experience, “serves” the child positive
1-888-454–6275 or 1-888-4-KINARK and rich physical, emotional and verbal messages
kinark.on.ca that the child “returns” to the parent with smiles,
info@kinark.on.ca gurgles and cuddles. The child experiences a world
(the extent of their world is their parent) that is
• The York Centre for Children, Youth and Families safe, responsive and can make them feel calm
(905) 737-8927 when distressed.103, 104, 105
theyorkcentre.ca
info@theyorkcentre.ca Anxious-ambivalent attachment: This is a relation-
ship in which the infant or child experiences some
level of uncertainty or stress in their relationship
Contributor with their parent/caregiver. The anxiety or stress
the child experiences may result from a variety
Janet MacQuarrie, Registered Psychotherapist, of situations such as a loss, illness, parental men-
Supervisor of Play and Early Learning, Blue Hills tal health, poverty, physical abuse, neglect, poor
Child and Family Centre nutrition, prenatal maternal stress and parental
trauma where the parent is sometimes attentive
and responsive and sometimes not. As a result of
RELATIONSHIP AND ATTACHMENT this uncertainty, the child might seem unsure and
display some ambivalence wanting to approach his
or her parent for comfort while also showing some
One of the most significant contributions to
resistance to that approach.103, 104, 105
healthy brain development in a child’s life is the
parent-child relationship.101 These interactions Anxious-avoidant attachment: Much like the
form the building blocks for future relationships anxious-ambivalent attachment pattern, this is a
creating an internal model the child uses to relationship in which the infant or child experi-
reference how all future relationships are inter- ences some level of uncertainty or stress in their
preted and measured. The new understandings relationship with their parent/caregiver. The
we have from the field of neurobiology lays the anxiety or stress the child experiences may result
foundation for brain development that is rooted from a variety of situations such as a loss, illness,
in the connection and relationship an infant and addictions, parental mental health, poverty, physical
child experiences with his or her caregiver.101, 102
101 Clinton, J. The power of positive adult child relationships: connection is the key [Government report online]. Toronto, ON:
Queen’s Printer for Ontario; 2013. Available from: edu.gov.on.ca/childcare/Clinton.pdf
102 Porges SW. The Polyvagal theory: neurophysiological foundations of emotions, attachment, communication, and
Self-regulation. New York: W.W. Norton & Company; 2011.
103 Becker-Weidman A, Ehrman L, LeBow DH. The attachment therapy companion: key practices for treating children and families.
New York: W.W. Norton & Company; 2012.
104 Cassidy J, Shaver PR, editors. Handbook of attachment. 2nd ed. New York: Guilford Press; 2006.
105 Gough P, Perlman N. Attachment disorder. CECW Information Sheet #37E [Internet]. Toronto: University of Toronto; 2006
[cited 2016 Feb 3]. Available from: cwrp.ca/sites/default/files/publications/en/AttachmentDisorder37E.pdf
abuse, neglect, poor nutrition, prenatal maternal • Seem passive in relating to the parent
stress and parental trauma and the parent has
proven to the child that his or her responses are • Show minimal interest in the parent
not predictable and reliable. As a result of this • Seem independent resisting help from others
uncertainty, the child avoids the parent and may
either seem inconsolable or show little or no • Explore the room and toys busily
affect.103, 104, 105
• Not use the parent as a secure base to seek
Disorganized attachment pattern: The disorganiz- proximity when stressed
ing attachment pattern is the most concerning and
the most difficult to notice. This occurs when the • Show minimal acknowledgement when the parent
caregiver who is supposed to be the person who leaves the child
responds to the child’s needs for safety, comfort,
• Ignore or avoid the parent when the parent
feeding and connection is actually frightening or
returns to the room
frightened of the child. This child is caught in a
difficult dilemma as the person who is supposed • Easily go with strangers or talk to strangers
to be safe is actually scary. Survival drives the child
to the caregiver but the caregiver is the source of • Be overly sensitive to sounds, textures, food or smells
the child’s distress. The frightening parents might
• Be overly tolerant/ignoring of things like noises,
be abusive, neglectful or hostile toward the child
dirty hands, lighting or wet clothing
or they use language or voice tones that are fright-
ening. The developing brain needs cues from the • Be reactive and angry without noticeable
parent’s facial expressions to regulate and grow.102 provocation
Examples of the still face experiment show that
the infant who does not see responsiveness in the • Fight, flee (run) or freeze when in distress (become
parent’s facial expression becomes distressed and immobile, look dazed, daydream, forgetful, shut
dysregulated.103, 104, 105 down emotionally)
The parent who is frightened of their child may be • Cry with a weak or angry response
slow to move in to respond, unable to read his or
her baby’s cues and know what the baby actually • Whine constantly
needs from them. This parent is unable to consis- • Resist cuddling
tently calm his or her child or respond to the child,
and often carries a worried look on their face. This • Use poor eye contact or seem uncomfortable
stresses the child who is then unable to respond to with eye contact
the parent in ways that encourage the parent to
engage with them again.106 • Not respond to smiles
A child who has experienced an insecure or disor- • Show delayed physical motor skill development
ganizing caregiver might: (in combination with other flags)103, 104, 106, 107
• Explore their environment and other people only

minimally either reluctantly or without interest Where to go for help
• Be preoccupied and clingy with the parent If there are concerns, advise the parent/caregiver
to contact one of the following:
• Become distressed and anxious if the parent
leaves, even for a short period • Ontario Early Years Centre (OEYC) with
locations in Markham, Oak Ridges, Thornhill,
• Reach out for the parent and then resist them Vaughan-King-Aurora, and York North
• Seem angry and rejecting toward the parent
106 Siegel DJ. The developing mind: How relationships and the brain interact to shape who we are. New York: W.W. Norton &
Company; 2001.
107 Lillas C, Turnbull J. Infant/child mental health, early intervention, and relationship-based therapies: A neurorelational
framework for interdisciplinary practice. New York: W.W. Norton & Company; 2009.
DOMAINS | 47
• To access the contact information for the locations PROBLEM SIGNS
in York Region, visit centralhealthline.ca
If a child habitually uses the following ways of
• York Region Early Intervention Services thinking, consider this a red flag:
1-888-703-5437
• Takes things personally and blames self or others
• Blue Hills Child and Family Centre for the stressful situation
905-773-4323
bluehillscentre.ca • Expresses belief that the stressful situation is
bluehills@bluehillscentre.ca permanent
• Kinark Child and Family Services • Expresses belief that the stressful situation will
1-888-454–6275 or 1-888-4-KINARK affect many areas of life109
kinark.on.ca
info@kinark.on.ca
• The York Centre for Children, Youth and Families
(905) 737-8927 If there are concerns, advise parent/caregiver
theyorkcentre.ca to contact:
info@theyorkcentre.ca • York Region Health Connection at 1-800-361-5653,
TTY 1-866-512-6228, childfamily@york.ca for
resources, programs, and possible referrals
Contributor
Children often rely on their parent/caregiver for
Janet MacQuarrie, Registered Psychotherapist,
support and comfort during times of stress. If a
Supervisor of Play and Early Learning, Blue Hills
parent/caregiver’s ability to provide support and
Child and Family Centre
comfort is compromised, it is important to refer
the parent/caregiver to York Region Health
Connection for information on community
RESILIENCE resources and supportive programs.
Resilience is the ability to “bounce back” from

stressors and difficult situations. It helps adults Contributor
and children handle stress, overcome childhood Gail Lyubarsky, Public Health Nurse, York Region
disadvantage, recover from trauma and reach out Public Health
to others. Studies show that resilient people have
happier relationships and are less prone to de-
pression, more successful in school and jobs, and
live healthier and longer lives.108 The way a person
thinks about life’s challenges can affect his or her
SELECTIVE MUTISM
ability to cope with them. Parents have “think- Selective mutism is the persistent inability to
ing habits” that can help or hinder responses to speak in specific situations where speaking is
stressful situations. Young children mimic the way expected, despite being able to speak in oth-
significant adults in their lives respond to these er situations. This difficulty must last beyond
situations. If the parent or caregiver demonstrates one month and must not be limited to the first
any of the red flag thinking habits, the child may month of school or daycare. Selective mutism
develop these thinking habits too. typically emerges when children are two to five
108 Reivich K, Shatte AJ. The resilience factor: 7 keys to finding your inner strength and overcoming life’s hurdles. New York:
Harmony; 2002.
109 Pearson J, Hall D. The child and family partnership: Reaching IN…Reaching OUT resiliency guidebook. Toronto: The Child
and Family Partnership; 2006.
years old.110, 111 Despite this early age of onset, • Avoids speaking and will respond with averted
children with this disorder are most common- gaze, blushing or other symptoms of anxiety
ly identified when they first enter daycare or
school, when a lack of verbal communication • Speaks quietly or privately to other children, but
is first observed outside of the home. Research not to adults
suggests that selective mutism occurs in up to • May express a fear of being heard or seen speaking
two per cent of children in elementary school112 in specific situations
and occurs one and half to two times more often
in girls than in boys.113 The most common pro- • Covers mouth when speaking so others cannot
file of children with selective mutism are those see his or her lips moving
that speak freely at home, are less comfortable
speaking freely outside of the home — for • Experiences accompanying somatic symptoms,
example, at the grocery store, or at a restaurant particularly when going into unfamiliar environ-
— and least comfortable speaking at school.111 ments where speaking is required114
Factors that contribute to the development of
selective mutism include a shy or anxious tem-
perament, a family history of anxiety or shyness,
speech and language challenges, adjustment If there are concerns, advise the parent/caregiver
to a new culture, and limited social interactions to contact:
with peers outside of school.114
905-773-4323
PROBLEM SIGNS bluehillscentre.ca
bluehills@bluehillscentre.ca
If a child is experiencing any of the following
behaviours, consider this a red flag: • Kinark Child and Family Services
1-888-454–6275 or 1-888-4-KINARK
• Does not speak in a specific situation, for more
kinark.on.ca
than one month, excluding the first month of
info@kinark.on.ca
school or daycare
• Clear discrepancy in the quality and quantity of
(905) 737-8927
spoken language between the home and other
theyorkcentre.ca
environments
info@theyorkcentre.ca
• Relies heavily on nonverbal communication
• Family Services York Region
in certain situations; for example, pointing,
1-888-223-3999
nodding, and other gestures
fsyr.ca
• Speaks “through” the parents in public situations
such as whispering to them instead of conversing
directly to others
Contributor
Zia Lakdawalla, Ph.D., Psychologist, Kinark Child
• Reluctance to speak to teachers, students,
and Family Services
principals or school secretaries
110 Black B, Uhde T W. Psychiatric characteristics of children with selective mutism: a pilot study. JAmer Acad. Child Adolesc
Psychiatry.1995; 41:938-946.
111 Cunningham CE, McHolm A, Boyle MH, Patel S. Behavioural and emotional adjustment, family functioning, academic
performance, and social relationships in children with selective mutism. J Child Psychol Psychiatry. 2004; 45(8):1363- 1372.
112 Kumpulainen K, Rasanen E, Raaska H, Somppi V. Selective mutism among second graders in elementary school. European
Journal of Child and Adolescent Psychiatry. 1998; 7:24-29.
113 Steinhausen H, Juzi C. Elective mutism: An analysis of 100 cases. J Amer Acad Child Adolesc Psychiatry. 1996; 35:606-614.
114 McHolm AE, Cunningham C, Vanier M. Helping your child with selective mutism: practical steps to overcome a fear of
speaking. Oakland,(CA): New Harbinger Publications Inc.; 2005.
DOMAINS | 49
SENSORY Taste/smell
• Avoids certain tastes/smells that are typically

Sensory processing or sensory integration refers to part of the child’s diet116
the ability of our nervous system to receive information
through our senses (taste, smell, auditory, visual, • Chews/licks non-food objects120
touch, movement and body position) and organize
it in a meaningful and appropriate way.115 • Gags easily119
• Is a picky eater, especially regarding textures,

PROBLEM SIGNS flavours, smells and temperature116
If a child presents any of the following behaviours Movement and body position
in extreme or with exaggeration, and these
behaviours do not seem typical for a child of his or • Continually seeks out all kinds of movement
her age, consider this a red flag: activities (e.g., being whirled by adult, play-
ground equipment, moving toys, spinning,
Auditory rocking)118
• Responds negatively to unexpected or loud noise116 • Becomes anxious or distressed when feet leave
the ground116
• Is distracted or has trouble functioning if there is
a lot of background noise116 • Has poor endurance – tires easily; seems to have
weak muscles119
• Enjoys strange noises/seeks to make noise for
noise sake116 • Avoids climbing, jumping, uneven ground or
roughhousing120
• Seems to be “in their own world”117
• Bumps into things, failing to notice people or
objects in the way117
Visual
• Seems not to get dizzy when others usually do118
• Needs help to find objects that are obvious to
others117
Touch
• Avoids eye contact117
• Becomes upset during grooming e.g. during hair
• Squints or looks out of the corner of the eye118 cutting, face washing, fingernail cutting116
• Is attracted to bright, flashing objects like TV or • Has difficulty standing in line or close to
computer screens117 other people, or stands too close, always
touching others116
• Is more bothered by bright light as compared to
same age children e.g. blinks, squints, cries, closes • Shows an emotional or aggressive response to
eyes, etc.119 being touched119
• Fails to notice when face or hands are messy

or wet116
• Craves lots of touch: heavy pressure, long-sleeved

clothing, hats, and certain textures119
115 Delaney T. The sensory processing disorder answer book. Illinois: Sourcebooks; 2008
116 Dunn W. Short sensory profile. Toronto: NCS Pearson, Inc; 2014.
117 Dunn W. Sensory profile 2 School companion teacher questionnaire. Toronto: NCS Pearson, Inc; 2014.
118 Parham D, Ecker C. Sensory processing measure (SPM)-preschool (home form). California:WPS; 2010.
119 Dunn W. Sensory profile 2 Caregiver questionnaire. Toronto: NCS Pearson Inc; 2014.
120 6. Kuhaneck HM, Henry DA, Glennon TJ. Sensory processing measure (SPM)-preschool (school form). California: WPS; 2010.
Activity Level
SLEEP
• Always on the go; difficulty paying attention
Sleep is a critical activity of child development.
• Very inactive — seems to tire easily and will often Adequate sleep promotes self-regulation, growth,
slump in chairs or lean against objects for support physical health, memory and cognitive function-
ing. In typically developing infants and toddlers,
• Seems unaware of pain119 lack of sleep has been associated with parental
stress, attachment difficulties and maternal depres-
Social/emotional sion. In atypically developing infants, sleep prob-
lems are often attributed to neurological or phys-
• Needs more protection from life than other children ical abnormalities, although psychosocial factors
i.e. defenseless physically or emotionally also play a role.121
• Has difficulty with changes in routines, plans It takes time for infants to develop a sleep-wake
or expectations cycle and some infants take longer than others.
Various factors such as time, cues, biology, envi-
• Is stubborn or uncooperative; easily frustrated
ronment and infant temperament all play a part.122
• Has difficulty making friends The amount of sleep varies greatly from one child
to the other. Infants up to six months of age may
• Has difficulty understanding body language or spend up to 16 hours in a 24 hour day sleeping,
facial expression but as little as 10 hours has also been reported.
Infants from six to 12 months may sleep up to 14
• Does not feel positive about own accomplish- hours per day, toddlers about 10 to13 hours and
ments i.e. low self-esteem119 preschoolers 10 to 12 hours.123
Where to go for help PROBLEM SIGNS

If there are concerns, advise the parent/caregiver If a child presents any of the following behaviours,
to contact: consider this a red flag:
• York Region Early Intervention Services at • Dependence on caregiver presence and soothing
1-888-703-KIDS (5437) or actions i.e. nursing or rocking121
• The child’s family physician for a referral to a • Resistance to or fears and anxieties around
developmental pediatrician or a private sleeping121
occupational therapist
• Poor airway functioning/airway obstruction
i.e. noisy breathing, snoring or breathing pauses
Contributor due to enlarged adenoids or respiratory infection121
Nadia Brown, PT, Clinical Supervisor, Early • Excessive crankiness or temper tantrums124
Intervention Services, York Region Community
and Health Services, Social Services Branch
121 The Best Start Resource Centre. The Best Start Resource Centre; On track – Supporting healthy child development and early
identification in the early years [Internet]. Toronto, ON: Best Start Resource Centre; 2015 [cited 2016 Sept 27]. Available
from: beststart.org/OnTrack_English/pdf/OnTrack_PDF.pdf
122 Centre of Excellence for Early Childhood Development [homepage on the Internet]. Montreal: Strategic Knowledge Cluster
on Early Child Development; [updated 2016 July 14; cited 2016 Sep 6]. Available from: excellence-earlychildhood.ca/home.
asp?lang=EN
123 Caringforkids. Healthy sleep for your baby and child [Internet]. Toronto, ON: Canadian Pediatric Society; 2012 [cited 2016
Sep 6]. Available from: caringforkids.cps.ca/handouts/healthy_sleep_for_your_baby_and_child
124 Douglas Institute. Sleep and children: the impact of lack of sleep on daily life [Internet]. Montreal: Douglas Mental Health
University Institute; 2015 [updated 2015 Sept 17; cited 2016 Jul 14]. Available from: douglas.qc.ca/info/sleep-and-children-
impact-of-lack-of-sleep-on-daily-life
DOMAINS | 51
• Problems in cognitive functioning i.e. attention, Contributors
learning and memory125
Donna Lamanna, Supervisor, The York Centre for
• Coordination problems e.g. accidents, injuries, Children, Youth and Families
slower reaction time126
Christian Bouchard, Clinical Director, The York Centre
for Children, Youth and Families
to contact their primary health care provider. SMOKING (SECOND- AND
The parent/caregiver can also contact:
THIRD-HAND)
Tobacco smoke is likely to be the most important
905-773-4323
indoor pollutant that is harmful for human health,
bluehillscentre.ca
particularly for children.127 Children are most at risk
bluehills@bluehillscentre.ca
for serious health problems from tobacco smoke.128
• Kinark Child and Family Services
A baby or child may be exposed to tobacco smoke
1-888-454–6275 or 1-888-4-KINARK
at home, daycare, or other environments.
kinark.on.ca
info@kinark.on.ca Second-hand smoke is exhaled by the smoker
into the air and inhaled by other people in close
proximity.129 There is no safe limit of exposure.130
(905) 737-8927
theyorkcentre.ca Third-hand smoke is the chemical residue that is
info@theyorkcentre.ca left on furniture, carpets, toys, fabrics and dust
after a cigarette, cigar or pipe is put out. It has the
• Family Services York Region
same toxic chemicals as second-hand smoke and
1-888-223-3999
can remain for months or years. Young children
fsyr.ca
can take in many times more third-hand smoke
than adults.131
125 Moturi S, Avis K. Assessment and treatment of common pediatric sleep disorders. Psychiatry [serial online]. 2010; 7(6): 24-
37. Available from: ncbi.nlm.nih.gov/pmc/articles/PMC2898839/
126 WebMD. Sleep problems in children [Internet]. Atlanta: WebMD LLC; c2005-2016. [updated 2016 Jul 25; cited 2016 Sep 6].
Available from: webmd.com/sleep-disorders/guide/children-sleep-problems
127 Gilmour I, Jaakkola M, London SJ, Nel A, Rogers, CA. How exposure to environmental tobacco smoke, outdoor air pollutants, and
increased pollen burdens influences the incidence of asthma. Environ Health Perspect [serial online]. 2006 [cited 2016 Aug
3]; 114(4): 627-633. Available from: ncbi.nlm.nih.gov/pmc/articles/PMC1440792/pdf/ehp0114-000627.pdf
128 U.S. Dept. of Health and Human Services; Centers for Disease Control and Prevention; Coordinating Center for Health
Promotion; National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. The
health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General [Internet]. Atlanta, Ga: US
Department of Health and Human Services; 2006 [cited 2016 Aug 10]. Available from: surgeongeneral.gov/library/reports/
secondhandsmoke/fullreport.pdf
129 Canadian Cancer Society. Second-hand smoke [Internet]. Toronto, ON: Canadian Cancer Society; c2017 [cited 2017 Mar 27].
Available from: cancer.ca/en/prevention-and-screening/live-well/smoking-and-tobacco/second-hand-smoke-is-danger-
ous/?region=on
130 Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. Health effects of
secondhand smoke [Internet]. Atlanta, Georgia; Centres for Disease Control and Prevention; c2017 [cited 2017 Mar 27].
Available from: cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/
131 Canadian Lung Association. Third-hand smoke [Internet]. Toronto, ON; The Association; c2012 [cited 2015 Nov 12]. Available
from: http://crc.poumon.ca/protect-protegez/tobacco-tabagisme/second-secondaire/thirdhand-tertiaire_e.php
While planning for a pregnancy, as well as during PROBLEM SIGNS
pregnancy, exposure to tobacco smoke can affect
the health of the baby and it can also make it If a child is experiencing the following, consider
difficult for individuals to conceive.132 this a red flag:
Children are most at risk for health and growth • Regular exposure to second- and/or third-hand
and development concerns when exposed to second- tobacco smoke
and third-hand smoke due to the following:
• Frequent asthma attacks, respiratory and
• They breathe faster ear infections
• Their bodies are smaller

• It’s harder for them to break down the chemicals
found in tobacco smoke If the parent/caregiver is a tobacco user, encourage
them to work toward a tobacco-free life and keep
• They cannot remove themselves from smoking vehicles and homes smoke-free by suggesting they
environments access one or more of the following resources:
• Babies crawl on the floor and put their hands • Best Start: A smoke-free environment for
and objects in their mouths taking in more chem- your children
icals then adults133 beststart.org/resources/tobacco/pdf/tobacco_
handout_eng_FINAL.pdf
Children who are regularly exposed to second- and
third-hand smoke are at risk for the following: • Smokers’ Helpline
1-877-513-5333
• Sudden Infant Death Syndrome (SIDS)
smokershelpline.ca
• Sleep challenges
• Break it off
• Colic breakitoff.ca
• Coughing and/or wheezing more frequently • Pregnets

pregnets.org
• Asthma
• Dads in Gear: smoke-free dads
• Bronchitis, ear infections, pneumonia and croup dadsingear.ok.ubc.ca
• Learning challenges that lead to lower scores in • Families Controlling and Eliminating Tobacco
math, reading, and logic facet.ubc.ca
• Behavioural issues such as hyperactivity • York Region Public Health
york.ca/tobacco
• Heart disease in adulthood
• Smoking themselves as a teenager or adult133

Contributors
Rosemary Lamont, Public Health Nurse, York Region
Public Health, Tobacco-Free Living Services
132 U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the
Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services; 2014 [cited 2016 Aug 3]. Available from:
surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf
133 Best Start Resource Centre. A smoke-free environment for your children [Internet]. Toronto, ON; Best Start Resource Centre;
2010 [cited 2017 Mar27]. Available from: beststart.org/resources/tobacco/pdf/tobacco_handout_eng_FINAL.pdf
DOMAINS | 53
SOCIAL/EMOTIONAL responds to others in an atypical way
• Avoids close contact

Social and emotional development encompass
both intrapersonal skills (i.e. understanding and • Inability to self-soothe or calm themselves139, 140
managing one’s own emotions) and interperson-
al skills (i.e. the ability to effectively verbally and
Ages 9 to 12 months
non-verbally communicate with other people), as
it looks at the child’s experience, demonstration, • Lack of interest in peers
and control of emotions and the capacity to
create meaningful and reciprocal relationships • Great difficulty waiting for something
with others.134, 135 The main characteristics of social
• Rigidity in regards to routine, clothing, toys,
and emotional development in a child include:
food, etc.
• Recognizing and comprehending both his or her
• Little to no eye contract
own feelings as well as others
• Lack of imitation to simple actions
• Coping with deep emotions and expressing them
in a productive way • Lack of response to his or her name
• Regulating their behaviour • Lack of shared attention between two people on
an item
• Developing and preserving connections with
people136, 137 • Lack of ability for turn-taking in games
It is important to note that social and emotional • Responds in the same way with familiar people
development is a lengthy process and children and strangers137, 139, 140
continue with development in this domain well
into the teenage years and at times into young
adulthood.138 Ages 1 to 2 years
• Moves from one activity to another and only

stays at an activity for a brief time
PROBLEM SIGNS
• Requires support to stay on task
If a child consistently exhibits any of the following
behaviours, consider this a red flag: • Lack of ability to show/explain objects to others
• Frustration when changes occur

Ages 0 to 9 months
• Lack of interest in objects and/or activities in
• Lack of response to sounds
which peers are engaging
• Lack of expression/smile in response to others/
• Lack of initiation of self-play135, 137, 140, 141
134 Crick N, Ladd G. Children’s perceptions of their peer experiences: attributions, loneliness, social anxiety, and social
avoidance. Dev Psych. 1993; 29(2):244–254.
135 McKinnon K, Krempa J. Social skills solutions. New York, NY: DRL Books Inc.; 2002.
136 Coie J, Dodge K. Multiple sources of data on social behavior and social status in the school: a cross-age comparison. Child
Dev. 1998; 59(3): 815–829.
137 Sundberg ML. VB-MAPP, Verbal behavior milestones assessment and placement program. 2nd ed. AVB Press; 2014.
138 Kazdin A. Overt and covert antisocial behavior: child and family characteristics among psychiatric inpatient children. J Child
Fam Stud. 1992; 1(1): 3–20.
139 Eisenberg N, Fabes R, Guthrie I, Reiser M. Dispositional emotionality and regulation: their role in predicting quality of social
functioning. J Pers Soc Psychol. 2000; 78(1): 136–157.
140 Lemerise EA, Arsenio WF. An integrated model of emotion processes and cognition in social information processing. Child
Dev. 2000; 71(1): 107–118.
141 Calkins S, Gill K, Wilford A. Externalizing problems in two year olds: implications for patterns of social behavior and peers’
responses to aggression. Early Educ Dev. 1999; 10(3): 267–288.
Ages 2 to 3 years • Early Intervention Services of York Region
1-888-703-5437
• Lack of interest in pretend play
• Difficulty with separation from caregiver 905-773-4323
• Lack of initiation or response to interactions bluehillscentre.ca
with peers bluehills@bluehillscentre.ca
• Prefers to play in a different area than peers • Kinark Child and Family Services
1-888-454–6275 or 1-888-4-KINARK
• Lack of symbolical use of objects kinark.on.ca
info@kinark.on.ca
• Lack of participation in group activities
• Unusual expression in intensity of aggression (905) 737-8927
theyorkcentre.ca
• Displays severe fears that hinder daily living135, 140, 141
info@theyorkcentre.ca
Ages 3 to 5 years • Family Services York Region

1-888-223-3999
• Lack of initiation or joining in play with peers fsyr.ca
• Lack of sharing with peers For more information about social/emotional,
contact:
• Lack of cooperative play skills e.g. group decisions,
role duties, just play • York Region Health Connection at 1-800-361-5653,
• Inability to select own friends
• Learning Disabilities Association of York Region
• Demonstrates dependency on caregivers for
at 905 884-7933
majority of needs and wants
• Demonstrates passivity or fearfulness that limits

engagement with activities in which peers are
Contributor
participating134, 135, 136 Jenna Emery, Autism Consultant,
Kerry’s Place Autism Services
to contact their primary health care provider. SPEECH AND LANGUAGE
The parent/caregiver can also contact: Approximately one in 10 preschool children has
difficulties acquiring speech, language and/or
• Ontario Early Years Centre social communication.142, 143 Because communication
skills are critical to the child’s future success in
Locations in Markham, Oak Ridges, Thornhill, socialization, learning to read and write (literacy)
Vaughan, King, Aurora and North York and do math (numeracy), it is important to identify
those children who might need support in this
To access the contact information for the locations domain.142, 143
in York Region visit: centralhealthline.ca
142 Ontario Ministry of Children and Youth Services. Your baby’s speech and language skills from birth to 30 months [webpage
online]. Toronto, ON: Ontario Ministry of Children and Youth Services; c2010-2015[updated 2016 May 12; cited 2016 Dec 3].
Available from: children.gov.on.ca/htdocs/English/earlychildhood/speechlanguage/brochure_speech.aspx
143 Ontario Ministry of Children and Youth Services. Your preschool child’s speech and language development [webpage
online]. Toronto, ON; Queen’s Printer for Ontario; c2010-2015 [updated 2016 may 12; cited 2016 Dec 3]. Available from:
children.gov.on.ca/htdocs/English/earlychildhood/speechlanguage/brochure_preschool.aspx
DOMAINS | 55
This domain considers development of attention, • Gets attention or help,146 or what they want,
comprehension, expression via gestures and words, through gestures e.g. reaching to be picked up142, 145
the development of clear intelligible speech, social and sounds146
skills and play skills.
• Plays social games with parent/caregiver
e.g. peek-a-boo142, 145
• Enjoys being around people142, 145
if a child is missing one or more of these expected
age outcomes, consider this a red flag: • Fusses or cries if familiar caregiver looks or
behaves differently146
By 6 months • Babbles and repeats sounds such as “babababa”

or “duhduhduh”142, 145
• Turns to source of sounds
• Mouths and chews on objects147
• Startles in response to sudden loud noises
• Looks for dropped object or hidden toy146
• Makes different cries for different needs i.e.,
hungry, tired
By 12 months
• Watches the face of parent/caregiver as they talk
• Follows simple one-step directions such as “Sit
• Smiles/laughs in response to parent/caregiver down”, “Find your shoes”142, 148
smiles and laughter
• Follows simple requests and questions such as
• Imitates coughs or other sounds such as “ah,” “Where is the ball?”147
“eh,” buh”142, 144
• Looks across the room to something when an
adult points to it142, 148
By 9 months
• Consistently uses three or more ‘words’ such as
• Responds to his or her name142, 145 “dada” or “mama,” using the same sounds to
indicate same object or person, even if these
• Turns to look for a source of sound,146 or re-
‘words’ are not pronounced accurately142, 148
sponds to the telephone or a knock at the
door142, 145 • Uses specific gestures to communicate needs or
to protest e.g. waves hi/bye, shakes head “no”142, 148
• Understands being told “no”, 142, 145
and other
short instructions146 • Gets attention using sounds, gestures and point-
ing while looking at the eyes of parent/caregiv-
• Imitates facial expressions146
er142, 148
Identification Kit (ERIK)-Referral for 6 months [Internet]. c2013 [cited 2016 Dec 3]. Available from: childdevelopmentpro-
Identification Kit (ERIK)-Referral for 9 months [Internet]. c2013 [cited 2016 Dec 3]. Available from: childdevelopmentpro-
146 Nipissing district developmental screen. North Bay: Nipissing District Developmental Screen Intellectual Property Association;
2000.
147 Best Start Resource Centre. On Track. Supporting healthy child development and early identification in the early years: a
reference guide for professionals in Ontario [Internet]. Toronto, ON: Best Start Resource Centre; [date unknown] [cited
2016 Apr 14]. Available from: beststart.org/OnTrack_English/pdf/OnTrack_PDF.pdf
148 Markham Stouffville Hospital, York Region Community and Health Services, Early Intervention Services. Early Referral Identifi-
cation Kit (ERIK)-Referral for 12 months [Internet]. c2013 [cited 2016 Dec 3]. Available from: www.childdevelopmentpro-
• Brings/extends toys to show parent/caregiver142, 148 • Consistently combines two to four words in short
phrases e.g. “daddy hat,” “truck go down”150
• “Performs” for social attention and praise142, 148
• Forms words/sounds easily and effortlessly150
• Combines lots of sounds together as though
talking e.g. “abada baduh abee”142, 148 • Uses words that are understood by others 50 to
60 per cent of the time150
• Shows an interest in simple picture books142, 148
• Enjoys being around other children150
• Starts and plays social games with parent/
caregiver; takes turns e.g. “peek-a-boo,” • Begins to offer toys to peers and imitate other
“patty cake”146 children’s actions and words150
• Finger-feeds him/herself some foods147 • Holds books the right way up and turns pages
one at a time150
• Holds, bites and chews crackers142, 147
• “Reads” to stuffed animals or toys142
By 18 months • Scribbles with crayons150
• Understands the concepts of “in and out,” “off
and on” By 30 months
• Points to three or more body parts when asked • Understands the concepts of size such as big/lit-
tle and quantity such as a little/a lot, more151
• Responds with words or gestures to simple
questions e.g. “Where’s teddy?”, “What’s that?” • Uses some adult grammar e.g. “two cookies,”
“bird flying,” “I jumped”151
• Uses at least 20 words consistently, even if not clear
• Uses more than 350 words151
• Makes at least four different consonant sounds
e.g. p, b, m, n, d, g, w, h • Uses action words e.g., run, spill, fall151
• Enjoys being read to and sharing simple books • Produces words with two or more syllables or
beats e.g. “ba-na-na,” “com-pu-ter,” “a-pple”151
• Points to familiar pictures using one finger
• Uses consonant sounds at the beginning of
• Demonstrates some pretend play with toys e.g. words e.g. “big” instead of “ig”151
gives teddy a drink, pretends a bowl is a hat142, 149
• Begins taking short turns with peers, using both
By 24 months words and toys151
• Follows two-step directions e.g. “Go find your • Demonstrates concern when another child is
teddy bear and show it to grandma”150 hurt/sad151
• Uses 100 or more words150 • Demonstrates pretend play involving several

actions e.g. feeds dolls and then puts them to
• Uses at least two pronouns such as “you,” sleep; puts blocks in train then drives train and
“me,” “mine”150 drops blocks off151
tion Kit (ERIK)-Referral for 18 months [Internet]. c2013 [cited 2016 Dec 3]. Available from: childdevelopmentprograms.ca/
DOMAINS | 57
• Recognizes familiar logos and signs involving • Asks and answers a lot of questions e.g. “Why?”,
print e.g. golden arches of McDonalds, “What are you doing?”146
“Stop” sign142
• Uses adult-type grammar143
• Remembers and understands familiar stories151
• Tells stories with a clear beginning, middle
• Speaks in sentences of at least three words151 and end143
• Tries to join in with singing songs or making • Talks with adults and other children to try to
rhymes151 solve problems143
• Recognizes self in a mirror or a photo151 • Speaks clearly enough to be understood by

strangers almost all the time143
By 3 years • Demonstrates increasingly complex imaginative
• Understands “who,” “what,” “where” and play using words, characters, action and interac-
“why” questions143 tions with peers143
• Creates long sentences using five or more words143 • Able to generate simple rhymes e.g. “cat-bat”143
• Talks about past events e.g. trip to grandparents’ • Matches some letters with their sounds e.g. “let-
house, day at childcare143 ter T says ‘tuh’143
• Tells simple stories143 • Enjoys singing children’s songs146
• Understood by most people outside of the family, • Participates with peers in small group
most of the time143 activities, sharing and taking turn e.g. catch,
snakes and ladders146
• Shows affection for favourite playmates143
• Engages in multi-step pretend play with actions By 5 years

and words e.g. pretending to cook a meal or • Follows group directions e.g. “All the boys get
repair a car143 a toy”143
• Understands and uses some describing words e.g. • Understands directions involving “if…then”
“big,” “dirty,” “wet”146 e.g., “If you’re wearing runners, then line up
• Joins in play with a group of two or more peers152 for gym”143
• Listens to stories or music for five minutes with • Describes past, present and future events
an adult152 in detail143
• Aware of the function of print e.g. in menus, lists, • Uses almost all of the sounds of their language
signs143 with few to no errors143
• Beginning interest in, and awareness of, rhyming143 • Seeks to please his/her friends143
• Shows increasing independence in friendships143

By 4 years
• Knows all the letters of the alphabet143
• Follows directions involving three or more steps
e.g. “Get some paper, draw a picture, and give it • Identifies the sounds at the beginning of some
to mom”143 words e.g., “Pop starts with the ‘puh’ sound”143
• Shows four colours when asked146
PROBLEM SIGNS If there are concerns after the child starts JK,
please advise parent/caregiver to contact the
If a child is experiencing any of the following, child’s school for referral to a Speech-Language
consider this a red flag: Pathologist through the school board.
• Stuttering i.e. using repetitions of words, sylla- For more information about speech and language:
bles, sound prolongations, or blocks e.g. “I-I-I”,
“da-da-daddy”, “mmmommy” “b—all”153 For a list of private Speech-Language Pathologists,
visit osla.on.ca or call the Ontario Association of
• Ongoing hoarse voice or unusual voice quality154 Speech-Language Pathologists and Audiologists at
1-800-718-6752
• Difficulty with feeding or swallowing155
• Excessive drooling155
Contributor
Speech and language challenges are sometimes
Marlene Green, Speech-Language Pathologist,
associated with other developmental concerns.
York Region Preschool Speech and
Also refer to the following domains in this guide
for other potential referrals: Language Program, Child Development Programs,
Markham Stouffville Hospital
• Autism Spectrum Disorders (ASD)
7Domains
• Hearing
• Feeding skills
VISION
A great deal of a child’s early learning occurs
If there are concerns: through vision. Children who are born with (or
acquire in early childhood) blindness or low vision
• Refer to the York Region Preschool Speech and are at a greater risk for developmental delays and
Language Program by completing an ERIK referral communicative disorders. It is important to monitor
available at childdevelopmentprograms.ca; a child’s visual development since early identification
fax referral to 905 762-2115 can often reduce or eliminate the risk of long-
• Advise parent/caregiver to contact York Region term complications. The Canadian Association of
Preschool Speech and Language program at Optometrists recommends children have their first
1-888-703-KIDS (5437) and visit the website at eye exam between ages six and nine months, and
childdevelopmentprograms.ca for resources. annually thereafter.156
Note: Children must be referred to the York Region

Preschool Speech and Language Program before Healthy child development
August 31 of the year they begin junior kinder- If a child is missing one or more of these expected
garten (JK). If there are concerns about stuttering, age outcomes, consider this a red flag:
referrals may be made during the JK year.
153 American Speech Language Hearing Association. Stuttering [webpage online]. Rockville, MD: American Speech Language
Hearing Association; c1997-2017[cited 2017 Feb 3]. Available from: asha.org/public/speech/disorders/stuttering/
154 American Speech Language Hearing Association. Voice [webpage online]. Rockville, MD: American Speech Language
Hearing Association; c1997-2017 [cited 2017 Feb 3]. Available from: asha.org/public/speech/disorders/voice/
155 American Speech Language Hearing Association. Feeding and drooling [webpage online] Rockville, MD: American Speech
Language Hearing Association; c1997-2017 [cited 2017 Feb 3]. Available from: asha.org/public/speech/swallowing/Feed-
ing-and-Swallowing-Disorders-in-Children/
156 Seven tips for good eye health [Internet] Ottawa, ON: Canadian Association of Optometrists; c2014 [cited 2016 Apr 23].
Available from: opto.ca/health-library/six-tips-for-good-eye-health
DOMAINS | 59
By 6 weeks • Looks where they are going when walking and
climbing157
• Stares at surroundings when awake
• Briefly looks at bright lights/objects PROBLEM SIGNS

• Blinks in response to light If a child is experiencing any of the following,
• Eyes and head move together157 consider this a red flag:
• Swollen or encrusted eyelids

By 3 months
• Bumps, sores or sties on or around the eyelids
• Eyes glance from one object to another
• Drooping eyelids
• Eyes follow a moving object or person
• Lack of eye contact by three months of age
• Stares at a caregiver’s face
• Does not watch or follow an object with the eyes
• Begins to look at hands and food157 by three months
• Haziness or whitish appearance inside the pupil

By 6 months
• Frequent “wiggling,” “drifting” or “jerky” eye
• Eyes move to inspect surroundings movements; misalignment of the eyes (eye turns
• Reaches for objects or crossing of eyes)
• Looks at more distant objects • Lack of co-ordinated eye movements
• Smiles and laughs when they see you smile • Drifting of one eye when looking at objects
and laugh157 • Turning or tilting of the head when looking
at objects
By 12 months
• Squinting, closing or covering of one eye when
• Eyes turn inward as objects move close to looking at objects
the nose
• Excessive tearing when not crying
• Watches activities in surroundings for longer
time periods • Excessive blinking or squinting
• Looks for a dropped toy • Excessive rubbing or touching of the eyes
• Visually inspects objects and people • Avoidance of, or sensitivity to, bright lights157
• Creeps towards favourite toy157

By 2 years If there are concerns advise the parent/caregiver
to contact their local optometrist. To find a local
• Uses vision to guide reaching and grasping optometrist visit the Ontario Association of
for objects Optometrists website at optom.on.ca
• Looks at simple pictures in a book The parent/caregiver can also contact the Regional
• Points to objects or people Blind-Low Vision Early Intervention Program at
1-888-703-KIDS (5437) for information about
• Looks for and points to pictures in books services and/or to make a referral- parents/caregivers,
157 Ontario Ministry of Children and Youth Services; Blind-Low Vision Intervention Services. Services for children who are blind
or have low vision [Internet]. Toronto: The Ministry; c2014 [cited 2016 Apr 23]. Available from: children.gov.on.ca/htdocs/
English/documents/earlychildhood/vision/Vision-EN.pdf
family physicians, optometrists or ophthalmologists
and other professionals can refer to Tri-Regional Blind-
Low Vision Program by downloading a referral
form from childdevelopmentprograms.ca/vision/
eligibility-criteria-and-referrals/ and faxing it to
905-762-2115 (An ophthalmologist’s referral is
needed prior to admission to services; however,
this program can assist with obtaining a referral
if the family does not already have one and can
provide support in the interim)
For more information about vision:
• Ontario Association of Optometrists website at

optom.on.ca
• Canadian National Institute for the Blind website

at cnib.ca
• Canadian Association of Optometrists website at

opto.ca
Contributor
Trisha Strong, Manager, Tri-Regional Blind- Low
Vision Program
DOMAINS | 61
RESOURCES
APPENDIX A
Important telephone numbers
POLICE, AMBULANCE, FIRE
Emergency number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-1-1
YORK REGIONAL POLICE, NON-EMERGENCY NUMBERS

Markham and Vaughan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-881-1221
Aurora, Georgina, Newmarket, Nobleton and Sharon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-895-1221
Oak Ridges, Richmond Hill and Thornhill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-773-1221
CRISIS INTERVENTION
York Region Children’s Aid Society . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-895-2318
Toll Free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-718-3850
Jewish Family and Child Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416-638-7800
Kids Help Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-668-6868
Community Crisis Response Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-855-310-COPE (2673)
Domestic Abuse and Sexual Assault Care Centre (DASA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-832-1406 ext.0
Toll Free . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-521-6004
Women’s Support Network of York Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-895-3646
HOSPITALS
Southlake Regional Health Centre (Newmarket) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-895-4521
Mackenzie Health (Richmond Hill) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-883-1212
Markham Stouffville Hospital (Markham) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905-472-7000
OTHER
York Region Health Connection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-361-5653
Telehealth Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-797-0000
RESOURCES | 65
APPENDIX B
Contacts and resources
Autism Ontario: Bounce Back Program
York Region Chapter of the Canadian Mental Health Association
905-780-1590 1-866-345-0224
autismontario.com/york cmha-yr.on.ca/programs-services/bounce-back/
Provides information, education, advocacy, and a An evidenced-based, free self-help program

self-help support group with links to community designed to help adults overcome symptoms of
agencies for families living with autism spectrum mild to moderate depression, low mood, or stress,
disorder (ASD). Twice monthly educational work- with or without anxiety. The program is based on a
shops, monthly support group meetings and summer five areas approach which addresses: life situations,
day camp. problems, and difficulties; symptoms in the body;
unhelpful thinking; altered feelings; altered
behaviour and reduced activities.
Best Start Resource Centre

Ontario’s Maternal Newborn and
Early Child Development Resource Centre Canadian National Institute
for the Blind (CNIB)
1-800-397-9567 or 416-408-2249
beststart.org 1-800-563-2642
cnib.ca
Works with diverse partners to build healthy,
equitable and thriving communities. The Best Start Community-based, registered charity committed to
Resource Centre supports service providers who research, public education and vision health for all
work in preconception health, prenatal health and Canadians. CNIB provides the services and support
early child development. necessary for people to enjoy a good quality of life
while living with vision loss. Staff and volunteers
often provide support to clients in their homes and
in rural communities. CNIB provides vital programs
Blue Hills Child and Family Centre and services, innovative consumer products, research,
905-773-4323 peer support and one of the world’s largest libraries
bluehillscentre.ca for people with print disabilities.
A full-service Children’s Mental Health Agency.

Working collaboratively with families and with
service system partners, children birth to 18 and
their families are offered comprehensive supports
through various community-based programs, day
treatment classrooms and latency-aged residential
treatment. Partnership programs supporting the
Child Welfare, Education system and Mediation
services also are part of the wide array of services.
Canadian Cancer Society Children’s Treatment Network of
Smokers’ Helpline Simcoe York (CTN)
1-877-513-5333 1-877-719-4795
smokershelpline.ca ctnsy.ca
A free, confidential and non-judgmental service Serves children with multiple disabilities and their
available to clients who want to quit tobacco families in Simcoe County and York Region. They
use or need help staying smoke-free. Through a include children with physical, developmental
multi-modal approach, Smokers’ Helpline offers and communications needs who may already
evidence-based phone, online and text messag- be receiving services from network partners and
ing services. With proven tips and tools, Smoker’s require more ongoing, intensive or specialized
Helpline can significantly increase one’s chance of rehabilitation treatment. Services are available
becoming tobacco-free. to kids from birth to age 19 with a wide range
of disabilities and complex conditions, including:
cerebral palsy, muscular dystrophy, acquired brain
injury, developmental and learning difficulties,
Canadian Centre on Substance spina bifida, autism or pervasive developmental
Abuse (CCSA) disorder (PDD), chronic and/or long-term medical
conditions that require intensive therapy, specialized
613-235-4048
equipment or travel to treatment centres outside
ccsa.ca
of the community.
Provides evidence-informed analysis and advice to
mobilize collaborative efforts to reduce alcohol-related
and other drug-related harms. Community Crisis Response Service
of York Support Services Network
Centre for Behaviour Health Sciences, (YSSN)
Mackenzie Health 1-855-310-COPE (2673)
yssn.ca/310-COPE
905-773-3038 or 705-728-9143
Offers a range of case management and community
Provides care for individuals living in York Region crisis services to support individuals with a develop-
or Simcoe County who have a developmental mental disability and/or a serious mental illness.
disability with a significant cognitive delay, autism YSSN also provides services within the Children’s
or are living with the effects of an acquired brain Services Sector, offering Children’s Case Coordination.
injury. Services are offered within the community to
individuals living in York Region or Simcoe County.
Eat Right Ontario
1-877-510-5102
eatrightontario.ca
A free service that connects residents of Ontario to

the trusted advice of a Registered Dietitian to help
you make healthier food choices and answer your
nutrition questions.
RESOURCES | 67
Family Services of York Region (FSYR) Fetal Alcohol Spectrum Disorder
Georgina (FASD) Coalition of York Region
905-476-3611 1-877-464-9675 ext. 2015
Markham A regional coalition of service providers that offers
1-866-415-9723 a bi-annual conference, periodic educational
Newmarket opportunities for professionals, parents and foster
1-888-223-3999 parents, an FASD resource library and a monthly
parent/foster parent support group.
Richmond Hill
1-888-820-9986
fsyr.ca Geneva Centre for Autism

A not for profit, charitable organization commit- 416-322-7877
ted to excellence in the provision of counselling for autism.net
children, youth, women, men and their families.
Offers a wide range of clinical services which are
All counselling services seek to promote the fullest
determined individually for each person with an
development of the individual. FSYR partners with
autism spectrum disorder (ASD). All of the services
agencies across York Region to ensure that clients
are supported by a team of speech-language
receive the help they need.
pathologists, behaviour analysts, therapists,
early childhood educators, occupational therapists,
developmental pediatricians, psychiatrists,
FAS World psychologists and social workers.
416-264-8000
fasworld.com
Health Canada
Provides support and information to parents, care-
givers, and professionals dealing with Fetal Alcohol 1-800-622-6232
Spectrum Disorders (FASD), as well as individuals hc-sc.gc.ca
living with FASD. Encourages the development of
Health Canada is the federal department respon-
new programs for individuals with FASD and their
sible for helping Canadians maintain and improve
families, women of childbearing age and their
their health, while respecting individual choices
partners, and individuals struggling with alcohol
and circumstances.
and substance issues.
Fetal Alcohol Spectrum Disorder

Diagnostic Clinic:
St. Michael’s Hospital
416-360-4000
fasdchildwelfare.ca
Uses a multi-disciplinary team approach to assess

individuals of all ages: infants, children and adults.
A pre-assessment process is used to determine if
criteria for full assessment are met, and to ensure
earlier entry into the diagnostic process. The clinic
also offers a developmental clinic for infants,
toddlers, and children up to seven years old.
Jewish Family and Child, Motherisk
York Region Branch Motherisk Helpline
416-638-7800 416-813-6780 or 1-877-439-2744
jfandcs.com Alcohol and Substance
Has a mandated responsibility for all Jewish children 1-877-327-4636
in the Greater Toronto Area, under the age of 16, motherisk.org
who are in need of care, protection, and a permanent
home. As a Children’s Aid Society, investigates all A clinical, research and teaching program at
allegations or reports of child abuse, including The Hospital for Sick Children in Toronto dedicated
neglect. Child welfare social workers are highly to antenatal drug, chemical, and disease risk
trained in recognizing evidence of abuse and in counselling. Provides evidence-based information
making the difficult decision to apprehend a child. and guidance about the safety or risk to the
When a child’s safety and well-being are at stake, developing fetus or infant, of maternal exposure
they may make the decision to take that child into to drugs, chemicals, diseases, radiation and
their care. environmental agents; information on the effects
of medication and drugs for the breastfeeding
mother and child; FASD diagnostic services.
Kinark Child and Family Services
1-888-454-6275 (Central intake) Neonatal Follow-Up Clinics
kinark.on.ca
Mackenzie Health:
A children’s mental health organization that 905-883-1212 ext. 3069
provides help to children and youth, families and
communities. Their mission states “caring, helping, Markham Stouffville Hospital:
healing - so children and youth can live socially 905-472-7534
and emotionally healthy lives.” Kinark supports
children with Autism Spectrum Disorder and their Southlake Regional Health Centre:
families, as well as offering institutionally and 905-895-4521 ext. 5608
community-based forensic services. Kinark also Available for infants and children in York Region
operates the Kinark Outdoor Centre in Minden at higher risk for development delay who require
Ontario providing programming, respite and developmental follow-up. Clinics are available at
therapeutic recreation. all three York Region hospitals. The clinics are run
in partnership with hospital staff and York Region
Early Intervention Services. They are attended by a
Learning Disabilities Association of multi-disciplinary team including a physician (neo-
natologist or pediatrician), an early interventionist,
York Region and either a physiotherapist or occupational
905-884-7933 therapist. Clinic appointments include develop-
ldayr.org mental screening, education/recommendations,
and connections to appropriate services as required
Provides information, support, guidance and for the child’s first three years.
resources to individuals five years and above with
learning disabilities (LD) and attention deficit hy-
peractivity disorder (ADHD). They try to help peo-
ple increase their opportunities and realize their
potential. Furthermore they provide leadership in
learning disabilities advocacy, research, education
and services and in advancing the full participation
of children, youth and adults with learning disabil-
ities in today’s society.
RESOURCES | 69
Ontario Association of Ontario Early Years Centres
Speech-Language Pathologists Markham:
and Audiologists (OSLA) 905-479-0002
1-800-718-6752 or 416-920-3676 Oak Ridges:

osla.on.ca 905-883-6901 or 1-866-297-9622
Represents, promotes, and supports its members Thornhill:

in their work on behalf of all Ontarians, especially 905-709-6159
those with communication disorders, swallowing
difficulties, or hearing health care needs. OSLA Vaughan-King-Aurora:
provides a wide range of services, including 905-751-1011 or 1-866-404-2077
provincial advocacy, promotion of the professions, York North:
educational opportunities, and professional resources. 905-853-0754
OSLA ensures that speech, language, swallowing,
hearing and balance are recognized as part of total centralhealthline.ca
wellness. OSLA works with other professional
associations and consumer organizations and Offer universal access to programs, information
is dedicated to ensuring Ontarians have access services and resources to families with children
to the services provided by Audiologists and prenatal to six years, including for children with
Speech-Language Pathologists. special needs. Staffed by experts, professionals and
volunteers, including early literacy experts.
Ontario Early Year Centres York Region sites

Ontario Association include Markham, Oak Ridges, Thornhill,
Vaughan-King-Aurora, and York North. Each of
of Optometrists these main sites has many satellite sites.
1-800-540-3837
optom.on.ca
Professional organization representing nearly Ontario Ministry of Children and

1,600 Doctors of Optometry in Ontario. Learn Youth Services (MCYS)
about vision and/or find a Doctor of Optometry
by visiting the website. 1-866-821-7770
children.gov.on.ca
The purpose of MCYS is to make it easier for

families to find the services to give kids the best
start in life, access the services they need at all
stages of a child’s development, and help youth
become productive adults.
The York Centre for Children, Tri Regional Infant Hearing Program
Youth and Families 1-888-703-KIDS (5437)
905-737-8927 childdevelopmentprograms.ca/hearing/
theyorkcentre.ca Brochure:
An accredited children’s mental health centre www.childdevelopmentprograms.ca/backend/
providing day treatment and other mental health wp-content/uploads/CDP-Brochure.pdf
services to clients in York Region. There is no residential Fact Sheet:
component to the services. The York Centre will childdevelopmentprograms.ca/backend/wp-con-
provide a range of preventative, therapeutic and tent/uploads/IHPFactSheet.pdf
educational interventions developed in partner-
ship with families and community resources. A voluntary program funded by the Ontario
Ministry of Children and Youth Services. Its goal is
to identify permanent hearing loss in infants prior
to 4 months of age and provide communication
Tri-Regional Blind- Low Vision programming by 9 months of age. Early detection
Early Intervention Program and intervention is critical to future language
development.
1-888-703-KIDS (5437)
childdevelopmentprograms.ca/vision/ The program provides:
Brochure: • Hearing screening of all infants in hospital or in
www.childdevelopmentprograms.ca/backend/ the family’s local community
wp-content/uploads/CDP-Brochure.pdf
• Audiology assessments of infants who receive a
Fact Sheet: refer result from screening in order to rule out or
childdevelopmentprograms.ca/Tri-Reginal-Blind- identify a hearing loss
Low-Vision-Fact-Sheet
• Monitoring of infants who may be at risk for
Supports families with children who are blind or hearing loss
have low vision. Families are given the resources
they need to support the healthy development • Support to families of infants that have an iden-
of their child in the first years of life from birth until tified hearing loss
they enter grade one. Partnerships have been
• Communication programming for infants and
developed with Canadian National Institute for
toddlers who have permanent hearing loss in-
the Blind (CNIB), and the Ontario Foundation for
cluding instruction in American Sign Language
Visually Impaired Children (OFVIC), infant develop-
and Auditory Verbal Therapy or both prescrip-
ment and early intervention services as well as the
tions for assistive devices, if required.
network of pediatric ophthalmologists, optometrists
and physicians across the region.
RESOURCES | 71
York Region Health Connection York Region Early Intervention
1-800-361-5653 Services (EIS)
york.ca/healthconnection 1-888-703-5437 (KIDS)
A free and confidential health information/ york.ca/childrenservices/specialneedsservices
education telephone service provided by public Available to families and children ages birth to
health nurses and inspectors. The health care school entry who are at risk of delayed develop-
professionals at Health Connection can provide ment due to prematurity/low-birth weight, have
you and your family with current health infor- delayed development, and have a condition such
mation and can provide support and counselling as cerebral palsy, autism or Down syndrome. EIS
for your individual health related concerns also provides the Preterm Care Pathways program
and questions. Public health professionals offer to children born prematurely (37 weeks gestation
confidential information and advice on public or earlier). The different EIS programs will:
health-related topics, resources, services and other
community programs, including: family health, in- • Screen and assess children
fectious disease, sexual health, dental health, and
health protection. • Help families understand their child’s growth
and development
• Provide intervention programs
York Region Children’s Aid Society
• Assist parents and caregivers to teach children
(CAS) new skills
1-800-718-3850 or 905-895-2318 • Provide occupational and/or physiotherapy
yorkcas.org consultation
A non-profit organization whose mission is to • Offer play groups for children with special needs
work in partnership with our increasingly diverse
community to protect children from abuse and • Promote and support participation in a community
neglect and provide a safe, secure and caring child care program
environment. CAS works to keep children safe and
families together by providing child protection • Consult with and support child care providers
services 24 hours per day, seven days per week, • Connect families with community resources
engaging and supporting families at risk, in problem
solving, linking with essential community services • Offer workshops for parents and caregivers of
to ensure the best outcome, and providing prevention children with special needs
and awareness programs to keep children safe and
families strong. The CAS goal is, whenever possible, • Educate the community about developmental
to maintain a child in the home or with extended delays
family, but if this is not viable, children are placed in
• Work closely with school board staff to facilitate
safe, nurturing environments, including foster homes.
a smooth transition to elementary school
York Region Preschool Speech and York Region Public Health Dental
Language Program (YRPSLP) Program — Healthy Smiles Ontario
1-888-703-KIDS (5437) (HSO) Program
childdevelopmentprograms.ca/speech-and-lan- 905-895-4512 or 1-800-735-6625
guage/ york.ca/dental
Brochure: Dental Program provides services to promote the
www.childdevelopmentprograms.ca/backend/ dental health of York Region residents, including
wp-content/uploads/CDP-Brochure.pdf health promotion for parents/caregivers, teachers,
Fact Sheet: and students in the school community.
childdevelopmentprograms.ca/YRPSLP-Fact-Sheet HSO Program provides no cost regular and urgent
YRPSLP partners with York Region Early Intervention dental care for families in financial hardship with
Services and Markham Stouffville Hospital — Child eligible children, 17 years of age and under.
Development Programs (formally known as Beyond
Words). Delivers programs which provide services
to children from birth to junior kindergarten with York Region Public Health —
a focus on prevention, early identification and
treatment of speech and language, hearing, and
Nutrition Services
vision. Programs include York Region Preschool 1-877-464-9675 ext. 74335
Speech and Language, Tri-Regional Infant Hearing, york.ca/nutrition
and Tri-Regional Blind Low Vision.
Offers a range of nutrition programs, resources
and services to promote healthy eating, access to
healthy food and the development of supportive
York Region Breastfeeding Clinic nutrition environments. Current and reliable infor-
1-800-361-5653 mation and fact sheets on a variety of nutrition
TTY 1-866-512-6228 topics including feeding babies and young children
childfamily@york.ca available on the website.
york.ca/healthconnection
Available at no cost for parents who live in York

Region. Parents receive breastfeeding support one
York Region Public Health —
to one with a registered nurse who has breastfeeding Quitting Smoking
expertise. Clinics are available throughout York
Region by appointment. 1-800-361-5653
york.ca/tobacco
Offers supports and resources for quitting smoking.
RESOURCES | 73
APPENDIX C
A guide to screening
WHAT IS INVOLVED WHEN SCREENING FOR HEALTH, GROWTH OR
DEVELOPMENT CONCERNS?
Screening young children is one way to gauge In this guide, The Where to go for help section
developmental progress and determine meaning- in each domain provides a list of the appropriate
ful next steps.1 It is the act of identifying within a community resources to which a child/family may
large group or population for which concerns have be referred for assessment. (See Appendix B for
not yet been identified, those individuals who may more detailed information on these community
have needs, issues, or risks that may compromise resources.)
their healthy development, including parenting
ability.2, 3, 4 Screening involves the use of a brief,
inexpensive, standardized tool to identify potential What screening tools are available?
health, growth and development concerns in an
There are a multitude of available screening tools
individual.5, 6 It can be the first step to intervention
in Ontario. Some can be used by parents/care-
and must occur early for intervention to be successful.2
givers while others are for professional use only.
Appendix C-1 in this guide outlines a few of the
What happens after screening? childhood screening tools that are used in York
Region. It is important to remember that screening
Screening is the first step in helping to identify the tools assist in early identification of concerns,
“Red Flags” in development, health and growth for but cannot substitute for a full assessment by a
which the child/family may require intervention, and qualified professional.4
it helps ensure that children and families who need a
full assessment receive one. A positive screen should
be followed up with “assessment” through referral
to professionals who can confirm or exclude the
suspected delay or condition, and are able to provide
the appropriate services and/or intervention.4 A full
assessment can only be performed by a professional
in the specific area of expertise.
1 Ages & Stages Questionnaires. Why screening matters [Internet].[place unknown]: ASQ; c2016 [cited 2016 May 26]. Available
from: agesandstages.com/research-results/why-screening-matters/
2 Ontario Ministry of Health and Long-Term Care. Healthy babies healthy children policy statement on universal screening and
assessment for healthy child development prenatal to school-age [Internet]. Toronto, ON: OMHLTC; c2002 [updated 2012 Jun
27; cited 2016 Apr 13]. Available from: health.gov.on.ca/english/providers/pub/child/hbabies/policy_statement.html
3 Ontario Ministry of Health and Long-Term Care. Healthy babies healthy children protocol [report online]. Toronto, ON:
Queen’s Printer for Ontario; 2012 [cited 2016 Apr 13]. Available from: health.gov.on.ca/en/pro/programs/publichealth/
oph_standards/docs/hbhc.pdf
4 Best Start Resource Centre. On Track. Supporting healthy child development and early identification in the early years: A
reference guide for professionals in Ontario [Internet]. Toronto, ON: Best Start Resource Centre; c2015 [cited 2016 Apr 14].
Available from: www.beststart.org/OnTrack_English/pdf/OnTrack_PDF.pdf
5 McAfee O, Leong D J, Bodrova, E. Basics of assessment: a primer for early childhood educators. Washington: National for the
Education of Young Children. 2004.
6 Tonelli M, Parkin P, Leduc D, Brauer P, Pottie K, Jaramillo GA, et al. Recommendations on screening for developmental delay.
CMAJ. 2016 [cited 2016 Sept 23]. Available from: cmaj.ca/content/early/2016/03/29/cmaj.151437
Appendix C-1
Inventory of childhood screening tools used in York Region
Nipissing District Developmental NutriSTEP® and Nutri-eSTEP

Screen (ndds) Nutrition Screening Tools for Toddlers
and Preschoolers
Focus: Eight Developmental Domains
Focus: Nutrition, weight, feeding and swallowing
1. Emotional
2. Fine Motor Age Range: 18 to 35 months, 3 to 5 years
3. Gross Motor
4. Learning and Thinking To identify children at nutritional risk.
5. Self-help These tools screen for physical growth and
6. Social development, weight concerns, food and fluid
7. Communication intake, physical activity, screen time, and factors
8. Vision and Hearing affecting food intake such as responsive feeding
Age Range: 1 month to 6 years and food security.
The Nipissing District Development Screen (ndds) is For ages 18 to 35 months

a developmental checklist that follows a child from
one month of age to six years. It provides a snap- Toddler NutriSTEP® (print version) and
shot of a child’s development and can be completed Toddler Nutri-eSTEP (online version)
by a parent, caregiver or professional.
If one or more “No” responses are made, a health For ages 3 to 5 years
care provider should be consulted. Preschooler NutriSTEP® (print version) and
This one-page developmental tool is easy-to-use, Preschooler Nutri-eSTEP (online version)
and features a detachable sheet of activities for An order form for print copies of NutriSTEP® is
enhancing a child’s development. available at: york.ca/wps/wcm/connect/yorkpub-
There are 13 ndds which are free for Ontario residents. lic/8ea76af6-53c0-4564-bce9-2864e32531c2/
NutriSTEP+description+and+order+form.pdf?-
To access online or to order multiple checklists, MOD=AJPERES
please visit ndds.ca
A Nutri-eSTEP flyer is available to download at:
The electronic Nipissing District Developmental eatrightontario.ca/EatRightOntario/media/ERO_
Screen (endds) is an online version of the ndds that PDF/Promotional%20Material/Nutri-eSTEP-fly-
parents can use to register their child to get email erE_2014.pdf
reminders of when it’s time to take the next checklist.
Included are tips, suggested activities and resources NutriSTEP® is embedded into some Electronic
to help encourage their child’s development. Medical Record (EMR) systems.
Research: A robust reliability and validation study For detailed information visit: NutriSTEP.ca
of the new ndds was completed. A summary of the Research: Randall Simpson JA, Keller HH, Rysdale
results are posted on ndds.ca LA, Beyers JE. Nutrition screening tool for every
Available Languages: preschooler (NutriSTEP®): validation and test-retest
reliability of a parent-administered questionnaire
ndds: English, French, Chinese, Spanish, Vietnamese, assessing nutrition risk of preschoolers. Eur J
Arabic, Russian, Farsi Clic Nutr[Internet]. 2008 [cited 2016 April 21];
62(6):770-80. Available from: nature.com/ejcn/
endds: English, French journal/v62/n6/pdf/1602780a.pdf
RESOURCES | 75
Randall Simpson J, Gumbley J, Whyte K, Lac J, To help monitor child’s dental development. It also
Morra C, Rysdale L, Turfryer M, et al. Development, provides dental health care tips.
reliability and validity testing of Toddler Nutri-
STEP®: A nutrition risk screening questionnaire for This tool represents an oral health supplement to
children 18-35 months of age. Appl Physiol Nutr the Nipissing District Developmental Screen (ndds)
Metab2015;40(9):877-886. Research: Validity and reliability testing were
Carducci B, Reesor M, Haresign H, Rysdale L, conducted. For full details refer to:
Keller H, Beyers J, et al. NutriSTEP® is reliable for Prakash P, Jokovic A, Locker D. Development and
internet and onscreen use. Can J Diet Pract Res. validation of a pediatric dental screening instrument.
2015;76(1):9-14. Report No. 22. Toronto, ON: Community Dental
Available Languages: Health Services Research Unit. Health Measurement
and Epidemiology; 2006
Toddler NutriSTEP®: English, French
Preschooler NutriSTEP®: English, French, Punjabi,

Simplified Chinese, Spanish, Tamil, Traditional Ages and Stages Questionnaire®
Chinese, Vietnamese (ASQ-3) and Ages and Stages Social Emotional
Questionnaire® (ASQ:SE-2)
Focus: Communication, Gross motor, Fine motor,

Dental Screening Problem-solving, Personal Social skills
Focus: Dental and Oral Health Age Range: 1 month to 5 ½ years of age
Age Range: 17 years and under A screening and monitoring tool designed to identify
This screening is a quick visual inspection by a dental infants and children who may require further
hygienist to see if an obvious dental condition exists assessment for possible developmental delays.
and to identify children at risk for Early Childhood ASQ provides reliable, accurate developmental and
Caries (ECC). social-emotional screening for children between birth
As determined by Ontario Public Health Standards and age 6. Drawing on parents’ expert knowledge,
2016, Child Health Standard as per Oral Health ASQ has been specifically designed to pinpoint
Assessment and Surveillance protocol developmental progress and catch delays in young
children—paving the way for meaningful next
Research: Ministry of Health and Long-Term Care, steps in learning, intervention, or monitoring.
Population and Public Health Division. Oral health
assessment and surveillance protocol, 2016. Toronto, ASQ-3 is a low-cost, reliable tool for screening infants
ON: OMHLTC; 2016. Available from: health.gov. and young children for developmental delays.
on.ca/en/pro/programs/publichealth/oph_stan- ASQ:SE-2 is a low-cost, reliable tool for screening infants
dards/docs/oral_health_assess.pdf and young children for social-emotional delays.
Available Languages: English Research: Reliability studies completed on the
ASQ-3 include test–retest reliability, and inter-observer
reliability. In addition, internal consistency of ASQ-3
Dental Screening Tool items was examined using correlational analyses
and Cronbach’s coefficient alpha (Cronbach, 1951).
Healthy Teeth Healthy Kids For full details refer to: Squires J, Twombly MS,
Focus: Dental and Oral Health Bricker D. ASQ-3 User’s Guide. Baltimore, MD: Paul
H. Brookes Publishing Co; 2009.
Age Range: 18 to 36 months
Available Languages: English
Early identification of children at risk for or having
dental caries (oral diseases and/or disorders).
ERIK: Early Referral Identification Kit
• Cognitive delays
• Emergent literacy delays
• Feeding difficulties
• Fine and gross motor delays
• Hearing loss
• Language delays and disorders
• Sensory difficulties
• Social skills difficulties
• Speech and language delays (including motor

speech disorders, articulation delays: stuttering;
voice disorders)
Age Range: 6 months to 4 years
A developmental screening tool for early identifi-

cation and referral of children at risk for develop-
mental delays to York Region Early Intervention
Services and York Region Preschool Speech and
Language Program.
Norms and Red Flags have been drawn from exist-

ing screening tools to form the ERIK.
A parent-friendly ERIK Growth Chart has been

developed based on ERIK. This allows parents to
track their children’s height as well as develop-
ment and make referrals when necessary. Norms
are listed for children at 6, 9, 12, 18, 24, 30, 36 and
48 months. It includes Red Flags for children aged
16 months and older.
ERIK Growth Charts may be ordered through

childdevelopmentprograms.ca
To download ERIK:
childdevelopmentprograms.ca/resource_category/
referral-forms/
Research: Not available
Available Languages: English
RESOURCES | 77
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RED FLAGS 2018

A QUICK REFERENCE GUIDE FOR EARLY YEARS AND

It is not a formal assessment or diagnostic tool.

Cultural competence when working with families. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Duty to report to child protection services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Attention difficulty and/or hyperactive behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Autism Spectrum Disorder (ASD). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Fetal Alcohol Spectrum Disorder (FASD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Fine motor skills. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Gross motor skills. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Maternal mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Mild traumatic brain injury (concussion). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Nutrition (overweight and underweight). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Relationship and attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Smoking (second- and third-hand) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Speech and language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

• Engagement: a sense of involvement, curiosity

TRANSITION TO SCHOOL When these four foundations are the focus of

• Allow plenty of time without interruptions7

Contributors What are “reasonable grounds” to

How and when to report

What happens when I call?

No harm has come to a child and no evidence is • Indiscriminately seeks affection

PROBLEM SIGNS • Seductive behaviours2

If a child presents with one or more of the follow-

• Cringes or flinches if touched unexpectedly • Sexually transmitted disease2

• Displays a vacant stare (for infant)

If a child presents with one or more of the follow-

• Failure to thrive2 Contributor

If a child presents with one or more of the follow-

• Consistent avoidance of a specific feared situa-

• Child expression of concern about primary care-

• Worries more than usual after seeing a scary

2003; 32(2): 290-295.

Attention difficulties and/or hyperactive behaviours

For more information about this domain or any

Contributor Ages 18 months to 5 years

• Restless or unable to sit still

• Poorly co-ordinated or clumsy

• Shifts quickly from one activity to another

• Eats/ingests inedible items

• Excessively energetic or physically over active17

• Screams; cries excessively; swearing and/or • Reports nightmares, frequent awakenings

• Compulsive behaviour; obsessive thoughts; Communication

• Difficulty following multiple step instructions • Autism

• Runs away • Nutrition

• Resists any form of physical contact including • Sleep

• Going to sleep or walking around with a bottle

• Retaining the nipple in an infant’s mouth

• Long-term use of sweetened medication18

• York Region Public Health Dental Program at

• Lower socioeconomic status20, 22, 24

• Limited access to dental care25

• Use of bottle or sippy cup beyond 18 months19

• No transition to cup drinking

• Not chewing pieces of a variety of food textures

• Inability to effectively remove adequate milk

• Children’s Treatment Network of Simcoe York at