What Now?

If your child has been given a diagnosis of autism spectrum disorder, developmental delay, dyslexia, etc., flagged for services through school, or is simply demonstrating some trouble communicating or completing daily tasks, we’re here to help. Read the drop down menus to learn about milestones, red flags, next steps, and resources.

Speech and Language Milestones +

Birth to Six Months

Hearing and Understanding

  • Startles at loud sounds.
  • Quiets or smiles when you talk.
  • Seems to recognize your voice.
  • Moves his/her eyes in the direction of sounds.
  • Responds to changes in your tone of voice.
  • Notices toys that make sounds.
  • Pays attention to music.


  • Makes cooing sounds.
  • Cries change for different needs.
  • Smiles at people.
  • Coos and babbles when playing alone or with you.
  • Makes speech-like babbling sounds, like pa, ba, and mi.
  • Giggles and laughs.
  • Makes sounds when happy or upset.

Seven Months to One Year

Hearing and Understanding

  • Turns and looks in the direction of sounds.
  • Looks when you point.
  • Turns when you call his/her name.
  • Understands words for common items and people-words like cup, truck, juice, and daddy.
  • Starts to respond to simple words and phrases, like, "No," "Come here," and "Want more?"
  • Plays games with you, like peek-a-boo and pat-a-cake.
  • Listens to songs and stories for a short time.


  • Babbles long strings of sounds, like mimi upup babababa
  • uses sounds and gestures to get and keep attention.
  • Points to objects and shows them to others.
  • uses gestures like waving bye, reaching for "up," and shaking his/her head no.
  • Imitates different speech sounds.
  • Says 1 or 2 words, like hi, dog, dada, mama, or uh-oh. This will happen around his/her first birthday, but sounds may not be clear.

1-2 Years

Hearing and Understanding

  • Points to a few body parts when you ask.
  • Follows 1-part directions, like "Roll the ball".
  • Responds to simple questions like "Who's that?"
  • Listens to simple stories, songs, and rhymes.
  • Points to pictures in a book when you name them.


  • Uses a lot of new words.
  • Uses p, b, m, h, and w in words.
  • Starts to name pictures in books.
  • Asks questions, like "What's that?"
  • Puts 2 words together, like "more apple," no bed," and "mommy book."

2-3 Years

Hearing and Understanding

  • Understands opposties, like go-stop, big-little, and up-down.
  • Follows 2-part directions, like "Get the spoon and put it on the table."
  • Understands new words quickly.


  • Has a word for almost everything.
  • Talks about htings that are not in the room.
  • uses k, g, f, t, d, and n in words.
  • Uses words like in, on, and under.
  • Uses two-or three-words to talk about and ask for things.
  • People who know your child can understand him/her.
  • Asks "Why?"
  • Puts 3 words together to talk about things. May Repeat some words and sounds.

3-4 Years

Hearing and Understanding

  • Responds when you call from another room.
  • Understands words for some colors, like red, blue, and green.
  • Understands words for some shapes, like circle and square.
  • Understands words for family, like brother, grandmother, and aunt.


  • Answers simple who, what, and where questions.
  • Says rhyming words, like hat–cat.
  • Uses pronouns, like I, you, me, we, and they.
  • Uses some plural words, like toys, birds, and buses.
  • Most people understand what your child says.
  • Asks when and how questions.
  • Puts 4 words together. May make some mistakes, like “I goed to school.”
  • Talks about what happened during the day. Uses about 4 sentences at a time.

4-5 Years

Hearing and Understanding

  • Understands words for order, like first, next, and last.
  • Understands words for time, like yesterday, today, and tomorrow.
  • Follows longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book.”
  • Follows classroom directions, like “Draw a circle on your paper around something you eat.”
  • Hears and understands most of what she hears at home and in school.


  • Says all speech sounds in words. May make mistakes on sounds that are harder to say, like l, s, r, v, z, ch, sh, and th.
  • Responds to “What did you say?”
  • Talks without repeating sounds or words most of the time.
  • Names letters and numbers.
  • Uses sentences that have more than 1 action word, like jump, play, and get. May make some mistakes, like “Zach gots 2 video games, but I got one.”
  • Tells a short story.
  • Keeps a conversation going.
  • Talks in different ways, depending on the listener and place. Your child may use short sentences with younger children. He may talk louder outside than inside.

Does my child need speech therapy? +

Children: Signs of a Language Disorder

  • Does not smile or interact with others (birth and older)
  • Does not babble (4-7 months)
  • Makes only a few sounds or gestures, like pointing (7-12 months)
  • Does not understand what others say (7 months-2 years)
  • Says only a few words (12-18 months)
  • Words are not easily understood (18 months-2 years)
  • Does not put words together to make sentences (1.5-3 years)
  • Has trouble playing and talking with other children (2-3 years)
  • Has trouble with early reading and writing skills* (2.5-3 years)

*Early reading and writing skills include:

  • 8 months–1 year: Likes to hear you talk and read; looks at pictures in books when you read
  • 1–2 years: Makes sounds or words when looking at pictures in books; points or touches pictures in books when you name them; turns pages in books
  • 2–3 years: Knows that books have a front and back; enjoys books that have rhymes; points to and names many pictures in books

Children: Signs of a Speech Sound Disorder

  • Says p, b, m, h, and w incorrectly in words (1-2 years)
  • Says k, g, f, t, d, and n incorrectly in words (2-3 years)
  • Produces speech that is unclear, even to familiar people (2-3 years)

Children Signs of Stuttering (Disfluency)

  • Repeats first sounds of words—“b-b-b-ball” for “ball”
  • Speech breaks while trying to say a word—“—–boy” for “boy”
  • Stretches sounds out—“ffffff-farm” for “farm”
  • Shows frustration when trying to get words out

Children: Signs of a Voice Disorder

  • Loss of voice
  • Uses a hoarse or breathy voice
  • Speaks with strain and effort

Source Identify the Signs

Next steps if you think your child has a speech-language problem +

  • Get your child's hearing checked at his/her pediatrician.
  • Contact us at Puzzle Piece and request a speech-language evaluation. SLPs help people who have problems with speech, language, and thinking skills. SLPs also work with people who have trouble feeding and swallowing. They can test and suggest ways to help your child.

Fine Motor Development Milestones +

Birth to 3 Months

  • Arm movement is mostly random (non-goal directed) and asymmetrical
  • Hands are fisted
  • Grasping reflex when placing a finger or object in hand
  • Brings hands to mouth
  • Watches the movements of his/her hands

3-6 Months

  • Movements are mainly purposeful and more symmetrical
  • Reaches for toys with both hands
  • Hands are primarily open with thumbs out
  • Holds toys with palm and fingers but not thumb
  • Brings hands to midline
  • No longer stares at his/her hands
  • Looks at objects a few feet away

6-9 Months

  • Transfers objects hand to hand
  • Straightens elbows when reaching
  • Rakes pellet-sized items with fingers
  • Holds items with fingers and thumb
  • Claps hands

9-12 Months

  • Points with index finger
  • Uses a neat, tip to tip pincer grasp on small pellet-sized items
  • Places items into an open container or into adult’s hand

12-18 Months

  • Stacks two to three small blocks
  • Holds crayon in closed fist (power grasp)
  • Scribbles with a crayon using whole arm movements
  • Turns pages in a cardboard book (more than one at a time)
  • Holds object with one hand and manipulates it with the other
  • Places small items in a closed-neck bottle • Places one to two shapes in a three-shape geometric puzzle
  • Places large pegs in a pegboard

18-24 Months

  • Stacks three to five blocks
  • Snips paper with scissors
  • Strings two to three beads
  • Imitates vertical and circular scribbles
  • Turns pages of a book one at a time
  • Places three shapes in a three shape geometric puzzle

2-3 Years

  • Imitates simple horizontal and vertical block designs
  • Imitates a circle and vertical and horizontal lines
  • Unscrews screw-top lid
  • Begins manipulating small items within the hand
  • Cuts paper into two pieces
  • Holds crayon with fingers, not fist (pronated grasp)
  • May use one hand consistently in most activities

3-4 Years

  • Stacks five to seven small blocks
  • Imitates circle and cross
  • Manipulates clay and dough (pinches, rolls balls, snakes)

4-5 Years

  • Copies a square and cross
  • Cuts on a straight line
  • Begins to use thumb and index finger to hold pencil/crayon (tripod grasp)
  • Touches each finger to thumb
  • Buttons and unbuttons one button • Stacks 10 plus small blocks

5-6 Years

  • Colors inside the lines
  • Cuts out simple shapes
  • Copies triangle
  • Writes first name
  • Handedness well established
  • Mature, adult grasp of pencil well established (dynamic tripod)

7-8 Years

  • By 7 to 8 years of age, children generally are proficient with most fine motor skills. As with many skills, practice improves performance; therefore, refinement of already acquired fine motor skills can continue into adulthood.
  • Information provided by Tara Calder, OTR/L with Super Duper Handy Handouts!

Does my child need occupational therapy? +

Occupational therapy treats difficulty with self-care, fine-motor, and visual perception skills. Difficulty in the following areas may indicate a need for an occupational therapy evaluation and/or treatment:

  • Functionally moving, sitting, crawling, or walking independently.
  • Paying attention and following directions.
  • Bathing, dressing, eating, drinking, and toileting independently
  • Manipulating toys and puzzles
  • Holding a pencil and poor handwriting, letter/number formation
  • Using zippers, buttons, shoelaces
  • Coloring, drawing, tracing, prewriting shapes
  • Poor ball skills
  • Poor balance
  • Overly sensitive or heightened reactivity to sound, touch, or movement
  • Under-responsive to certain sensations (e.g., high pain tolerance, doesn't notice cuts/bruises)
  • Constantly moving, jumping, crashing, bumping
  • Easily distracted by visual or auditory stimuli
  • Inability to calm self when upset
  • Difficulty managing school demands
  • Decreased independence with higher level cognitive tasks, (e.g.,money management, organizing and completing long-term projects).

Next steps if you think that your child may have a fine motor, handwriting, visual perception, or self-care problem +

  • Request a referral from your pediatrician for an occupational therapy evaluation.
  • Contact Puzzle Piece to schedule an evaluation appointment.

Does my child need to be evaluated and/or treated for dyslexia? +

Red Flags for Dyslexia: Preschool

  • Difficulty with rhyming and hearing beginning sounds in words
  • Trouble naming letters

Red Flags Grades K-1st

  • Trouble with phonemic awareness tasks (taking apart and putting together speech sounds in words)
  • Trouble learning and applying phonics (sounds of letters)
  • Difficulty remembering high frequency “sight” words
  • Poor spelling
  • Poor handwriting

Source: International Dyslexia Association