Knowledge of basic milestones is the foundation for pediatric assessment; yet the red flags discussed below are less likely to noticed. These may be a signal for further testing for early identification of problems. Research has shown that the presence of certain risk factors greatly increases the risk for developmental delay or disability.

1. Rolls before 3 months (evaluate for hypertonia = excessive muscle tone).

2. Continuously makes a fist with his/her hands at 3 months (evaluate for neuromotor dysfunction).

3. Does not attend to environmental stimuli (evaluate for sensory impairment).

4. Head drops back when he/she is pulled to sit position after 4 months (evaluate for hypotonia = low or lessened muscle tone).

5. Does not reach for objects by 5 months (evaluate for motor, visual, or cognitive deficits).

6. Cannot sit cross-legged by 6 months (evaluate for hypotonia).

7. Does not smile by 4-6 months (evaluate for visual loss, attachment problems, maternal major depression, consider child abuse or neglect in severe cases).

8. Persistence of primitive reflexes (retracts leg when touched, draws head back when face is touched, sucks everything placed in the mouth...) after 6 months (evaluate for neuromuscular disorder).

9. Does not babble by 6 months of age (evaluate for hearing deficit).

10. Lacks distrust for strangers by 7 months (may be related to multiple care providers).

11. "W-sitting" and bunny hoping at 7 months (evaluate for adductor spasticity or hypotonia).

12. No joint attention (shared gazes between adult and infant), smiles, or other facial expressions by 9 months or after (evaluate for autism or pervasive developmental disorders).

13. Lack of tool use (spoon, crayon) by 12 months (evaluate for fine motor or cognitive delay).

14. Does not participate in imitative play by 18 months (evaluate for hearing deficit or cognitive/socialization deficit; evaluate for autism).

15. Hand dominance prior to 18 months (evaluate for contralateral (opposite side of the body) weakness with hemiparesis (partial loss of movement on one side of the body due to muscle weakness from a brain injury).

16. Lack of protodeclarative pointing (early infant vocal and gestural behaviors that suggest commanding or requesting action on the part of the infant) by 16 -18 months (evaluate for problem in social relatedness, and autism).

17. No first words, other than "mama/dada," by 18 moths (evaluate for auditory expressive language).

18. Persistent poor transitions by 24 months (evaluate for pervasive developmental disorder).

19. No two-word sentences by 2 years (evaluate for auditory expressive language).

20. Advanced non-communicative speech/echolalia (the meaningless repetition of words or phrases) or not understanding simple commands by 24 months (evaluate for autism or pervasive developmental disorder).

21. Any loss of speech, babbling or social skills at any age (evaluate for autism or pervasive developmental disorder).

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