Introduction
As with newborns, some parts of the neurological examination cannot be carried out in young children, particularly the examination of strength and sensory function. If you wish to determine the presence of impaired nervous system function, you can use the child psychomotor development examination.
In the Netherlands a child is usually seen regularly by a child health clinic physician from 4 weeks after birth onwards. This physician has the important task of establishing any delay in psychomotor development. To establish any retardation the Van Wiechen examination is usually used nowadays. General practitioners should also be able to use this examination to detect developmental delay, since not all children are seen regularly by child health clinic physicians, and because if a developmental delay is detected at the child health clinic, the child will first be referred to their general practitioner. When using the developmental milestones examination, a number of points should be borne in mind.
This examination was first drawn up by the general practitioner Van Wiechen. It was revised in 1982 and again in 1996 and since then has been used by all child health clinics. Another system used for early detection of developmental disorders is the Denver Development Screenings Test (DDST). The following points should be noted for the Van Wiechen examination:
- The child should possess the skills that fit with their calendar age. If you see a child for the first time and find that this is not the case, you should investigate the preceding items until you have established the child’s level of development. For premature infants the age will need to be corrected for the first 18 months, using the full-term date and not the date of birth.
- Some sections are followed by (M). This indicates that you can inquire about the development item if you do not see it during the examination. If the accompanying parent has already observed that item in the child, you should score M +.
- In most cases the items are classified based on the P90 age, in other words the age at which 90% of the children had acquired that item.
- An isolated abnormal finding should generally not lead to the conclusion of developmental delay. The child should be examined several times and only a progressive or consistently present developmental delay should be examined further.
- To enable you to assess psychomotor development, the child should feel as relaxed as possible. It will be very difficult or even impossible to examine a child that comes into the consultation room struggling and frightened.
- When assessing the development of the child you should also take other information into account such as visual acuity, hearing, social background, medical history.
Required material:
- blocks (about 6 cubes of equal size, approximately 4 cm)
- a small lightweight ball
- shape sorter
- picture book.
The Van Wiechen examination (0 – 12/15 months)
Fine motor skills, adaptation, personality and social behaviour
4 weeks
1. Fixing eyes.
Infant fixes their gaze briefly on the face of a person bending over them from a distance of 20-30 cm. Do not talk! Look for any adjusting eye movements.
8 weeks
2. Following with eyes and head.
Place the infant on its back and hold an interesting object (your smiling face) in their field of vision about 30 cm away. If you slowly move this object from side to side, the child should follow it with their eyes and head to at least an angle of 30 degrees. First catch the infant’s attention. Do not talk. Parents should be out of the infant’s field of vision and remain quiet.
13 weeks
3. Opening the hands from time to time.
Both hands are opened up now and again.
4. Looking at own hands (M).
Place the infant on their back and see whether they observe their own hands when these come into their field of vision.
26 weeks
5. Playing with hands in mid-front position.
Place the child on their back, with the head in the neutral position. Note whether the child brings the hands to the centre in front of the chest or face and whether they play with their own hands.
6. Grasping objects within reach when lying on back.
If you hold an object (rattle, stethoscope) within reach and view of the child, the child should reach for it and grasp it. The child should use both hands.
39 weeks
7. Taking the block.
Sitting (on parent’s lap or on the table), transfers block from one hand to the other; can also be offered to the child.
8. Holding onto the block, takes another block in the other hand.
Child sitting on parent’s lap or on the table. Have the child pick up two blocks, one after the other. The blocks can be offered on outstretched hand.
9. Playing with both feet (M).
Place the child on their back on the examination table and observe whether the child grasps both their feet together or alternately.
12 months
10 Grasps ball of paper with thumb and index finger.
The child should sit on the parent’s lap. Place a small ball of coloured paper or something similar within reach of the child. Stimulate the child to pick it up (with both the left hand and the right hand) and observe how the child does this. The child should pick up the paper ball using their thumb and index finger, and not using their whole hand.
15 months
11. Takes a block out of a box and puts it back in the box.
Give the child, who is sitting on their parent’s lap, a box with blocks and stimulate the child to take hold of the blocks and then to put them back in again (not immediately). If necessary demonstrate what is required.
12. Play ‘give and take’ (M).
Give the child a block. Once they have played with it a while, stretch out your hand and ask for it back in a friendly tone. You can also ask the parent to do this. The child should release the block on the outstretched hand of the parent or the investigator.
Communication
4 weeks
28. Responds to being spoken to (M).
Any response is good, such as frowning, quietening.
8 weeks
29. Smiles back (M).
In response to being spoken to and smiled at. Do not touch the child. Note the age of first smile.
13 weeks
30. Responds with sounds (M).
In response to being spoken to.
26 weeks
31. Makes varied sounds (M).
Variation in frequency of tone, loudness and use of speech organs such as crowing, growling, screeching.
32. Responds to being called by name (M).
Call the child by name without making any gestures or touching them. Any response is good, such as becoming quiet, turning the head in the right direction.
39 weeks
33. Says ‘dadda’, ‘babba’ of ‘gagga’ (M).
Produces ‘ah’ sounds in series, apparently meaningless as yet.
12 months
34. Chatters during play (M).
Tells long ‘stories’ with vocal intonation and pauses.
35. Responds to spoken commands (M).
Responds (by pointing or looking) to simple questions such as ‘where is the lamp?’. Do not make any suggestive gestures.
36. Waves bye-bye (M).
Of their own accord or mimicking; other communicative gestures are also valid.
15 months
37. Uses two word-like sounds with meaning (M).
Names actions or animals, … by their sound such as “huppa”, “moo”, ‘tick tock”; pronunciation may be imperfect.
38. Understands a number of every-day sentences.
Understands short sentences about the present. Do not make any suggestive gestures.
Gross motor function
4 weeks
55. Lifts chin momentarily from underlying surface.
Lying on their front with limbs in symmetrical position; if necessary place head in neutral position. The chin should be lifted momentarily off the underlying surface.
8 weeks
56. Lying on front, lifts head to a 45º angle.
Lying on their front, symmetrical posture: head is lifted for a few seconds. The angle between the trunk and the table should be ± 45º.
13 weeks
57. Lying on front, lifts head to 90°.
Lying on their front in a symmetrical position. The chest should be lifted free from the underlying surface and the angle between the face and the table should be ± 90°.
26 weeks
58. Bends legs or kicks when swung vertically.
Hold the child around the chest and swing them backwards and forwards or from side to side. Do not hold them over the examination table. The legs should not be stretched or display a scissor action.
39 weeks
59. Can roll from back to front (M).
Rolls over and back unassisted.
60. Can hold up head well when sitting.
The child sits up straight and firmly (without diaper the gluteal cleft should be visible). If necessary the child may be supported at the hips.
61. Sits on bottom with outstretched legs.
Have the child sit. If necessary support the trunk. Using your other hand straighten the child’s legs. Note whether the child keeps their back straight or whether it sits on the lower part of its back.
12 months
62. Sits stably, unassisted.
Place the child on a firm surface. Provoke rotation and sideways movements. With the latter, note how the child stops themselves falling.
63. Crawls forwards, stomach on the floor (M).
Have the child crawl across the floor on their stomach or lie it on the examination table, placing a toy just out of the child’s reach. Note whether the child moves towards the toy. The stomach is allowed to stay in contact with the table or floor for this item.
64. Pulls themselves up to a standing position (M).
Let the child sit on the floor next to a chair, for example. Place a toy out of the child’s reach on the chair, and stimulate the child to grasp the toy. Note whether the child pulls themselves up on the chair going from a kneeling to a standing position. Do not assist the child. The child should not stand on their toes constantly.
15 months
65. Crawls, with stomach off the floor (M).
Have the child lie on their stomach on the floor or examination table. Place a toy just out of their reach. The child should move towards the toy crawling on hands and knees or feet.
66. Walking along furniture (M).
Have the child stand next to a low table or chair, which it can hold onto. Using a toy, for example, stimulate the child to walk. The child is allowed to keep holding onto the chair or table. The child should stand on flat feet or alternate between flat feet and toes.
All ages
These items should be investigated at all ages and assessed according to age.
51. Arms move to equal extent.
52. Legs move to equal extent.
Observe the child in different positions if necessary.
53. Stays hanging when lifted up under armpits.
Lift the child up and hold it vertically by supporting it under the armpits. If necessary support the head with your fingers. The child should not slide down between your fingers.
54. Head follows when being pulled up into sitting position.
The child should lie on their back on the examination table. Take hold of the child’s forearms and slowly pull them into a sitting position. The head should now remain in one line with the back.
The Van Wiechen examination (15-48 months)
Fine motor skills, adaptation, personality and social behaviour
15 months
11. Takes a block out of a box and puts it back in the box.
Give the child, sitting on their parent’s lap, a box with blocks and stimulate them to take hold of the blocks and then put them back (not immediately).
If necessary demonstrate the action.
12. Plays ‘give and take’ (M).
Give the child a block. Once they have played with it a while, stretch out your hand and ask for it back in a friendly tone. You can also ask the parent to do this. The child should release the block onto the outstretched hand of the parent or the investigator.
18 months
13. Places one block on top of another (M).
The child should be sitting on the parent’s lap. Place four blocks on the table near the child. Observe whether the child places one block on top of another. You may demonstrate the action no more than twice. Note how often you need to give a demonstration.
14. Goes exploring (M).
Give the child the opportunity to walk or crawl around freely during the examination. If necessary stimulate the child by rolling a ball away.
2 years
15. Can make a tower with three blocks.
Refer to no. 13.
16. Mimics others (M).
Imitation behaviour is not usually displayed by a child during a consultation. You should therefore ask the parent whether the child imitates, for example vacuuming, washing up, feeding a doll.
2½ years
17. Can make a tower with six blocks.
Refer to no. 13.
18. Can insert a round shape into a shape sorter.
To carry out this item you need a shape sorter. Place the round shape next to the sorter and ask the child to put the shape in the correct hole in the sorter. You may not demonstrate the action, nor may you point. Note how they carry out the task (e.g. yoke movements (i.e. shoulder movements during reaching)).
19. Takes off item of clothing (M).
Before you start the physical examination, ask the child to take off their own shoes or socks, for example. It is permitted to assist with laces or buttons.
3 years
20. Mimics the building of a truck.
Place five blocks on a table and let the child see how you use these to build a truck: “look, all the blocks are in a row, with one on top”. Then break down your truck and ask the child to make a similar truck.
You may demonstrate it twice.
21. Places three shapes in a shape sorter.
Refer to no. 18. The child can put a round, square and rectangular shape in the sorter. To gain a positive score on this item, the child should carry out the task without mistakes, in other words they should select the correct hole immediately.
22. Draws a straight line following an example.
Place a blank sheet of paper and a pen or pencil on the table in front of the child. Make sure the child can reach easily. Draw a vertical line about 15 to 20 cm long in front of the child, moving towards the child. Ask the child to make a similar line. Their line should not deviate by more than 30˚ from the example. If necessary repeat the instructions once.
3½ years
23. Can build a bridge following an example.
Give a demonstration, explaining: “I’m building a bridge; one block here and the other there and then one on top”. Do not point out the opening. Leave the example standing. The bottom blocks should not be touching. If necessary repeat this instruction once.
24. Places four shapes in the sorter.
Refer to no. 18.
25. Can put on an item of clothing themselves (M).
After you have examined the child, ask them to put on their trousers themselves, for example. This does not need to go perfectly, and you are allowed to help with a belt orbutton.
4 years
26. Holds a pencil with their fingers.
Give the child a pencil and sheet of paper and ask them to draw. Note whether the child holds the pencil between their thumb, index finger and middle finger.
27. Can draw a circle following an example.
Show an example that you drew earlier. “Can you draw this shape?”. Do not say the word ‘circle’. They are allowed three attempts. The ends should meet.
Communication
15 months
37. Uses two sound words (M).
Names actions or animals, … using their sounds; e.g. “hupla”, “moo”, “tick tock”; pronunciation may not be perfect.
38. Understands a few every-day sentences.
Understands short sentences about the present. Do not make suggestive gestures.
18 months
39. Says three words (M).
It is not important whether the words are pronounced perfectly. These should be words other than ‘dadda’ and ‘mamma’, but can be made-up words.
40. Understands instructions in play (M).
If necessary inquire whether the parent has noticed that the child understands sentences such as ‘why don’t you give the doll a spoonful?’.
2 years
41. Uses two-word ‘sentences’ (M).
During the consultation try to talk to the child and assess whether they are using sentences consisting of two or more words, such as ‘sore tummy’, ‘play dolly’, ‘coat on’.
42. Can point out six body parts on a doll.
Ask “where are her eyes, where is her mouth, tummy, hand, foot, hair?”.
2½ years
43. Calls themself by their own name and uses ‘I’ to describe themself (M).
For this item you are not supposed to ask the child what their name is. The child should spontaneously refer to themselves as ‘I’ or use their own name.
44. Points out five pictures in a book.
Show the child a picture book and ask, for example ‘where is the cat, where is the tree?’.
3 years
45. Uses sentences of three words or more (M).
If necessary ask the parent whether the child uses sentences made up of three words. If so, ask them to give some examples.
46. Is comprehensible to those around them.
If necessary ask whether the child is comprehensible to those who know them well.
3½ years
47. Talks spontaneously about events at home / playgroup.
If necessary ask ‘when ………. comes home from playgroup, does he/she talk about it spontaneously?”.
48. Asks who, what, where and how questions.
If necessary ask whether the child asks who, what, where or how questions.
4 years
49. Is comprehensible to the examiner.
Examiner and child should have a conversation, during which the examiner should assess whether the child is comprehensible.
50. Asks questions about ‘how much’, ‘when’ and ‘why’.
If necessary ask whether the child asks how much, when or why questions.
Gross motor skills
15 months
65. Crawling, stomach off the floor (M).
Have the child lie on the stomach on the floor or examination table. Place a toy just out the child’s reach. The child should crawl on hands and knees or feet towards the toy.
66. Walks along furniture (M).
Have the child stand next to a low table or chair, which it can hold onto. Using a toy, for example, stimulate the child to walk. The child is allowed to keep holding onto the chair or table. The child should stand on flat feet or alternate between flat feet and toes.
18 months
67. Walks unassisted.
It is sufficient for the child to walk three wobbly steps. Legs may still be far apart. Note the age at which the child first walked unassisted.
68. Throws a ball without falling.
Give the standing child a ball and say ‘throw it to mummy’, for example. How the child throws is not important. The score is positive if the child does not fall over when throwing the ball.
2 years
69. Picks up object from squat position.
Have the child pick up a ball or a block that you have dropped. The child can do this by bending down or squatting, but should stand up unassisted.
70. Walks well unassisted.
The child should now easily walk around the consultation room without falling. The child should walk without asymmetry ,on flat feet. Note the symmetry of swing movements.
2½ years
71. Kicks the ball away.
The child should stand in the consultation room. Place a ball in front of their feet and ask them to kick the ball. The child should not hold on to anything. Examine left and right side. If necessary demonstrate the action.
72. Can rotate smoothly in a sitting position.
This should be evoked by placing toys to the side of the child. Rotation over a 45˚ angle should be smooth, both to the left and right. The pelvis should not move.
3 years
73. Walks smoothly.
Observe the gait pattern and symmetry of swing movements.
74. Cycles on a three-wheeler (M).
Clearly this question should be addressed to the parent. It will be positively scored if the child can move forwards by turning the pedals.
3½ years
75. Jumps with both feet at the same time.
Jumping over a seam in the linoleum, for example. If necessary demonstrate the action. Both feet should come off the floor and the child should not use any support.
4 years
All items should now score positively.