Early intervention for developmental delays in primary care

Primary Steps for Primary Care | August 12, 2025 | Sangeeta Elhence, M.D.

One in six children in the U.S. experience developmental delays. These delays can affect a child’s cognitive, learning, speech, language skills, as well as other areas. Children with autism spectrum disorder (ASD) may exhibit both developmental delays and atypical development.

The crucial role of primary care physicians

Primary care physicians are vital in identifying developmental delays. By using developmental surveillance and screening, they help spot issues early. A "wait and watch" approach may lead to missed opportunities, especially during the first three years of life when a child’s developing brain is most amenable to intervention. Acting during this critical period can significantly improve long-term development. Most primary care doctors are skilled at screening patients for these red flags.

Screening tools

General developmental screening:

ASQ (ages and stages questionnaire)
PEDS (pediatric evaluation of developmental status)
CDI (child development inventory)
SWYC (survey of well-being of young children)

Autism-specific screening tools:

Level 1 screens

M-CHAT R/F (modified checklist for autism in toddlers, revised with follow-up interview): Recommended for children ages 16-30 months. While initial M-CHAT R results can have low sensitivity and specificity, these significantly improve when combined with a follow-up interview.

Level 2 interactive screens (for improved sensitivity and specificity). Primary care physicians can utilize these tools after undergoing specific institutional training.

RITA-T (rapid interactive screening test for autism in toddlers): Training course available at https://www.kennedykrieger.org/research/centers-labs-cores/rita-t-research/training-course
STAT-MD (screening tool for autism in toddlers and young children): Training for physicians at https://vkc.vumc.org/vkc/triad/training/stat/physicians/

Emerging technologies (ongoing trials):

AI-powered eye gaze tracking tools: These are being developed as early screening tools for ASD. Some, like EarliTech, are FDA-approved but are currently expensive and not typically reimbursed by insurance. EyecontactDx, an Israeli company, is currently undergoing trials in the U.S. In the future, these AI-based tools could expedite early screening for high-risk children and facilitate timely referrals for intervention and evaluation.

Indicators of autism spectrum disorder (ASD)

9-12 months:

No consonant sounds
No babbling
Inconsistent response to their name
Doesn't respond to games like peek-a-boo
Inconsistent eye contact with parents or strangers
More interested in toys or objects than people
Overly distressed by loud sounds
Doesn't imitate simple tasks like brushing/combing or using toys

12-15 months:

No repetitive babbling (e.g., "mamama," "bababa")
Not pointing with index finger to get another person's attention
Inconsistent response to their name
Inconsistent eye contact with parents or strangers
Doesn't monitor or look at an adult's face to see their reaction to things
Only does a few "babyish" things with toys (shakes, bangs, throws)
Overly distressed by loud sounds

15-18 months:

No single words (e.g., "mama," "dada," "more," "all gone," "bye," "cookie," "up," "go")
Doesn't understand simple commands
Inconsistent response to their name
Doesn't look at an adult's face to see what to do next or when to take a turn
Inconsistent eye contact with parents or strangers
Doesn't request desired things with looks, vocalizations or gestures
Doesn't imitate (e.g., clapping hands)
Doesn't engage in pretend play (e.g., talking on the phone, feeding a doll or stuffed toy)
Unusual or repetitive play with toys (e.g., spinning wheels of toy cars, lining up objects, stacking them)
Repetitive motor movements like hand flapping, spinning around, pacing back and forth

18-24 months:

Doesn't have at least a 50-word vocabulary or isn't putting two distinct words together
Doesn't wave "bye-bye" or respond to "come give me a hug"
Doesn't look at objects held by a parent
May favor just a few types of toys and performs the same actions with them repeatedly
Loses words or communication skills they previously had
Suddenly or over a period of weeks/months stops being socially interactive or making eye contact
No pretend play

24-30 months:

Not expanding the number of words and sentences
Not following multiple directions (2-3 step commands)
Not using language for pretend play
Prefers self-directed play; doesn't join in play with others
When playing with objects in the presence of a caregiver, doesn't offer eye contact, vocalizations, or smiles
Doesn't share attention or reciprocate
Doesn't engage in back-and-forth social interaction
Is "hard to read" in terms of emotions
Has difficulty with transitions or regulating emotions (easily frustrated, tantrums)
Repeats what they've heard (e.g., from a favorite video)
Particularly interested in certain objects like naming letters or numbers, or doing complex puzzles, but not doing other age-appropriate activities
Carries an unusual object around much of the day
Obsessed with videos and watches the same one repeatedly
Flaps hands, toe-walks
Sensory sensitivities (e.g., loud noises, textures, water on face, bright lights)

Next steps for suspected delays

If you suspect any developmental delays, please take the following steps:

Refer for audiology and early childhood intervention (ECI) services immediately, even before a referral to a specialist.
Consider referral for private speech therapy (ST) and occupational therapy (OT) evaluations.
Refer for a physical therapy (PT) evaluation if motor difficulties or delays are suspected.
Refer for a feeding evaluation if extreme feeding difficulties are present.
Referral to early intervention (even before an official diagnosis) capitalizes on the neuroplasticity of the developing brain. Multiple studies have shown that early intervention significantly improves outcomes and cognitive scores.
Referral to Developmental Pediatrics.
Send a referral through EPIC.

Fax a referral to 682-303-9245.

Consultations and Referrals
682-885-2500

Cook Children's Neurology team

Great outcomes begin with great input. Having a medical system where every department, doctor, and care team member works together means that your child can have quick access to testing, diagnosis and treatment, and that means better outcomes now and in the future.

Contact the Jane and John Justin Neurosciences Center at Cook Children's to refer a patient: 682-885-2500.