Red Flag Indicators

Early Identification

2009-08-29T01:49:02Z

(Adapted from Early Identification in York Region, Red Flags for Infant, Toddler and Preschool children)

Red Flags indicators are intended for use as a Quick Reference Guide to assist parents and early years professionals in deciding whether to refer for additional advice, assessment and/or treatment. It is not a formal screening or diagnostic tool.

The information contained in the “Red Flags for Infant, Toddler and Preschool Children” document has been provided as an informational resource. This information cannot substitute for the advice and/or treatment of professionals trained to properly assess the development and progress of infants, toddlers and preschool children. The information might be helpful to determine when to seek out advice and/or treatment, but should not be used to diagnose or treat perceived developmental limitations and/or other health care needs.

Dental – Cavity Prevention

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Age	Risk Factors	Problem signs … if a child is experiencing any one of the following, consider this a red flag:
Up to 3 years	Prolonged exposure of teeth to fermentable carbohydrates (include formula, juice, milk and breast milk)	Through use of bottle, breast, sippee cups, plastic bottles with straws High sugar consumption in infancy Sweetened pacifiers Long term sweetened medication Going to sleep with a bottle containing anything but water Prolonged use of a bottle beyond one year Breastfeeding or bottle feeding without cleaning teeth
	Physiological Factors	Factors associated with poor enamel development, such as prenatal nutritional status of mother and child, poor prenatal health, and malnutrition of child Possible enamel deficiencies related to prematurity or low birth weight Mother & child’s lack of exposure to fluoridated water Window of infectivity: transference of oral bacteria from parent/caregiver to the child between 19 – 31 months of age, through frequent, intimate contact or sharing of utensils
	Other Risk Factors	Poor oral hygiene Sibling history of early childhood decay Lack of education of caregivers Lower socioeconomic status Limited access to dental care Deficits in Parenting skills & child management
If there are concerns, contact Dental Hygienist at Interior Health, phone 851-7300

Feeding

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Age	Expected Age Outcomes	Problem signs … if a child is experiencing any one of the following, consider this a red flag:
2 years	Drinks from a cup and swallows solid food with easy lip closure; no loss of liquid Chewing motion is rapid and skilful from side to side without pausing in the centre Will use tongue to clean food from the upper and lower lips Able to open jaw to bite foods of varying thicknesses	Arching or stiffening of the body during feeding Irritability or lack of alertness during feeding Won’t accept different textures of food Takes a long time to eat (more than 30 minutes) Lots of drooling or leaking food or liquid from mouth Gurgly, hoarse or breathy voice quality Coughing, gagging, or throwing up during or after meals Frequent pneumonia or chest infections Difficulty coordinating breathing with eating or drinking Frequent spitting up Less than normal weight gain or growth Pocketing food in the mouth for a prolonged period of time.
3 years	Eats the same food as the rest of the family	Any of the above red flags Extremely picky eater.
If there are concerns, advise the parent to contact the Children's Therapy & Family Resource Centre at 371-4100 (Speech Therapy or Occupational Therapy department)

Nutrition

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Age	Risk Factors/Red Flag	General Risk Factors:
1 -2 years	Drinking less than 16 oz(2 cups) or more than 24 oz (3 cups) of milk per day Drinking more than 4 oz (1/2 cup) per day of juice Not eating a variety of table foods Parent or caregiver still feeding child; not allowing child to self-feed (finger, spoon, cup) A low fat cow’s milk is provided before the age of 2 Food is used as a reward or punishment	Rate of growth is falling off the growth curve Identified as Failure to Thrive * Identified as overweight or obese by a health care professional Unexpected and/or unexplained weight loss or gain Food allergies (e.g. cow's milk) or food intolerance (e.g. lactose intolerance) Problems with sucking, chewing, swallowing, gagging, vomiting or coughing while eating Frequent constipation and/or diarrhea; abdominal pain Displays signs of iron deficiency (e.g. irritability, recurrent illness) Follows a "special diet" that limits or includes special foods Eats non-food items Suffers from tooth or mouth problems that make it difficult to eat or drink Mealtimes are rarely pleasant Consistently not eating from one or more of the food groups Excludes all animal products including milk and eggs Unsafe or inappropriate foods are given (e.g. raw eggs, unpasteurized milk, foods that are choking hazards, herbal teas, pop, fruit drink) Home has inadequate food storage/cooking facilities Parent or care provider is unable to obtain adequate food due to financial constraints Parent or care provider offers inappropriate amounts of food or force feeds
2 –5 years	Drinking less than 16 oz (2cups) or more than 25 oz (3cups) of milk per day Drinking more than 4 oz (1/2 cup) per day of juice Still drinking from a bottle; still being spoon fed Not eating a variety of table foods from the four food groups Does not eat at regular times throughout the day (breakfast, lunch, and supper plus 2 – 3 between meal snacks) Spending a long time at meals (e.g. an hour) Lack of physical activity (i.e. Watches TV or videos, uses the computer. Food is used as a reward or punishment
If there are concerns, advise parents to call Dial A Dietician 1 – 800 – 667-3438.

Vision

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Age	Expected Age Outcomes	Problem signs … if a child is experiencing any one of the following, consider this a red flag:
2 – 3 years	Sits a normal distance when watching television Follows moving objects with both eyes working together (coordinated)	Blinking and/or rubbing eyes often ; a lot of tearing or eye-rubbing Headaches nausea, dizziness; blurred or double vision Eyes that itch or burn; sensitive to bright light and sun Unusual short attention span; will only look at you if he or she hear you Avoidance of tasks with small objects Turning or tilting head to use only one eye to look at things Covering one eye; has difficulty, or is irritable with reading or with close work Eyes that cross, turn in or out, move independently Holding toys close to eyes, or no interest in small objects and pictures Bumping into things, tripping; clumsiness, restricted mobility Squinting, frowning; pupils of different sizes Redness, soreness (eyes or eyelids); recurring styles; discoloration Constant jiggling or moving of eyes side-to-side
3 – 4 years	Knows people from a distance (across the street) Uses hands and feet together (i.e. catches a large ball) Builds a tower of blocks, string beads; copies a circle and square	Eyes do not follow what hand are doing
If there are concerns about a child's vision, advise the parent to arrange for a vision test with an optometrist, or contact the family physician who can refer the child to an ophthalmologist.

Literacy

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Age	Expected Age Outcomes
2 years	Asks for help using words or actions Joins two words together (ie. “want cookie”, “more milk” Learns and uses one or more new words a week; may only be understood by family Asks for favourite books to be read over and over again
3 years	Can be understood by strangers approx 75% of the time Uses 5 word sentences Is learning meaning of several new words every week (in spoken language) Sings simple songs and familiar rhymes Knows how to use a book (holds/turns pages properly, starts at beginning, points/talks about pictures) Looks carefully at and makes comments about books Fills in missing words in familiar books that are read aloud Holds a pencil and uses it to draw/scribble
If there are concerns, advise the parents to contact: Children’s Therapy & Family Resource Centre at 371-4100 or Interior Public Health at 851-7300.

Attachment

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If a parent states that one or more of these statements describes their child, the child may be exhibiting signs of an insecure attachment; consider this a red flag if:

Age	Risk Factors from a parent’s perspective	Problem signs … if a child is experiencing any one of the following, consider this a red flag:
18 months – 3 years	Is not beginning to develop some independence Seems angry or ignores you after you have been apart
3 – 4 years	Easily goes with a stranger Is too passive or clingy with you
If there are concerns, advise parent to contact Infant Development program at 371-4140 when child is under 36 months. For children who are 36 months and older contact the area Public Health Nurse at 851-7300.

Social Emotional

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

Age

Red Flags

18 months – 3 years

Child and parent have little or not playful or verbal interaction
Child initiates overly friendly or affectionate interactions with strangers
Child ignores, avoids or is hostile with parent when distressed or after separation
Child is excessively distressed by separation from parent
Child freezes or moves toward parent by approaching sideways, backwards or circuitously
Child alternates between being hostile and overly affectionate with parent communication of child
Parent uses inappropriate or ineffective behaviour management techniques

Doesn’t smile in response to another person
Delayed imaginative play – lack of varied, spontaneous make-believe play
Prefers to play alone, decreased interest in other children
Poor interactive play
Poor eye contact – this does not mean it is absent
Less showing, giving sharing and directing others’ attention than usual
Any loss of social skills at any age (regression)
Prefers to do things for him/herself rather than ask for help

Awkward or absent greeting of others

If there are concerns, contact Children’s Therapy & Family Resource Centre at 371-4100 or Infant Development Program at 371-4140.

Sensory

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Sensory integration refers to the ability to receive input through all of the senses – taste, smell, auditory, visual, touch, movement and body position and the ability to process this sensory information into automatic and appropriate adaptive responses.

Problem signs if a child’s responses are exaggerated, extreme and do not seem typical for the child’s age, consider this a red flag.

Auditory	Responds negatively to unexpected or loud noises Is distracted or has trouble functioning if there is a lot of background noise Enjoys strange noises/seeks to make noise for noise sake Seems to be in his/her own world
Visual	Children over 3 – trouble staying between the lines when coloring Avoids eye contact Squinting or looking out of the corner of the eye Staring at bright, flashing objects
Taste/Smell	Avoids certain tastes/smells that are typically part of a child’s diet Chew/licks non-food objects Gags easily Picky eater, especially regarding textures
Movement and Body Position	Continually seeks out all kinds of movement activities (being whirled by adult, playground equipment, moving toys, spinning, rocking) Becomes anxious or distressed when feet leave ground Poor endurance – tires easily; seems to have weak muscles Avoids climbing, jumping, uneven ground or roughhousing Moves stiffly or walks on toes; clumsy or awkward, falls frequently Does not enjoy a variety of playground equipment Enjoys exaggerated positions for long periods (e.g. lies head-upside-down off sofa)
Touch	Becomes upset during grooming (hair cutting, face washing) Has difficulty standing in line or close to other people; or stands too close, always touching others Is sensitive to certain fabrics Fails to notice when face or hands are messy or wet Cannot tolerate hair washing, hair cutting, nail clipping, teeth brushing Craves lots of touch: heavy pressure, long-sleeved clothing, hats and certain textures
Activity Level	Always on the go; difficulty paying attention Very inactive, under-responsive
Emotional/Social	Needs more protection from “life“ than other children Has difficulty with changes in routine Is stubborn or uncooperative; gets frustrated easily Has difficulty making friends Has difficulty understanding body language or facial expressions Does not feel positive about own accomplishments
If there are concerns, advise parent to contact Children’s Therapy & Family Resource Centre at 371-4100.

Behaviour

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Children may engage in one or more problem behaviours from time to time. Factors to consider in determining whether the behaviour is truly of concern include:

Injuring themselves or others
Behaving is a manner that present immediate risk to themselves or others
Frequency and severity of the behaviour
Number of problematic behaviours that are occurring at one time
Significant change in the child’s behaviour

If the child presents any of the following behaviours, consider this a red flag:

Self-injurious Behaviour	Bites self; slaps self; grabs at self Picks at skin; sucks excessively on skin/bangs head on surfaces Eats inedibles Intentional vomiting (when not ill) Intentional vomiting (when not ill) Potentially harmful risk taking (e.g. running into traffic, setting fires) High pain tolerance
Aggression	Temper tantrums; excessive anger, threats Hits; kicks; bites; scratches others; pulls hair Bangs, slams objects; property damage Cruelty to animals Hurting those less able/bullies others
Social Behaviour	Difficulty paying attention/hyperactive; overly impulsive Screams; cries excessively; swears; severe tantrums Hoarding; stealing No friends; socially isolated; will not make eye or other contact; withdrawn Anxious; fearful/extreme shyness; agitated Compulsive behaviour in public; undressing in public Touches self or others in inappropriate ways; precocious knowledge of a sexual nature Flat affect, inappropriate emotions, unpredictable angry outburst, disrespect or striking female teachers are examples of post trauma red flags for children who have witnessed violence Narrow range of interests that he/she engages in repetitively Insists on maintaining sameness in routines, activities, clothing, etc
Non-compliance	Oppositional behaviour Running away Resists assistance that is appropriate to age (ie: holding hands to cross the road)
Life Skills	Deficits in expected functional behaviours (e.g. eating, toileting, dressing, poor play skills) Regression; loss of skills; refusal to eat; sleep disturbances Difficulty managing transitions/routine changes
Self-Stimulatory Behaviour	Hand-flapping; hand wringing; rocking; swaying Repetitious twirling; repetitive object manipulation Unusual sensory interest – visually squinting or looking at things out of the corner of eye; smelling; licking; mouthing objects, etc
If there are social-emotional concerns, advise the parent to contact Child & Youth Mental Health at phone: 851-3600, Children’s Therapy & Family Resource Centre at 371-4100, or the Infant Development Program at phone 371-4140.