The First Thousand Days

Somewhere in most homes with a small child there is a Road to Health booklet, an app, or a printed sheet from a clinic sister, and on it a sequence of achievements with ages attached. Sits unsupported. Transfers an object between hands. Walks. Points. Uses two words together. Parents read these lists in a way their authors never intended — as a schedule, with a pass mark.

The lists are useful. They are also blunt instruments, and the ages on them describe a broad population rather than any particular child. Typical development is not a narrow track; it is a wide corridor with a great deal of room in it. Children walk anywhere between about nine and eighteen months and end up equally competent. Some skip crawling. Some say almost nothing until they are two and then arrive in sentences.

So the first thing an occupational therapist working with under-fives usually does is neither reassure nor alarm. It is to look properly, and to work out which of these two very different situations is in front of them.

What development actually is

It is tempting to think of a milestone as a switch that flips. It is closer to a construction project, where each stage is built on the last and the foundations matter more than the visible storey.

A baby lying on their front lifts their head, building neck and shoulder strength. Pushing up on the forearms builds the shoulder girdle, which will later stabilise the arm so the hand can be precise. Sitting frees both hands to explore. Crawling develops the arches of the hand, weight-bearing through the palm, and the coordination of two sides of the body doing different things.

None of this is about the milestone itself. It is about what the milestone builds. This is why therapists are less interested in whether a child has ticked a box and more interested in how they are doing things — whether a child sits with a straight back or props themselves in a wide, effortful base; whether they reach with either hand or consistently ignore one side; whether movement looks fluent or laboured.

When difference matters

Most variation is simply variation, and most children who are a little late arrive perfectly well on their own. There is no virtue in medicalising an ordinary childhood, and a great deal of harm in teaching parents to watch their child with anxiety.

But some patterns genuinely warrant a proper look, and they are hard to tell from ordinary lateness without training. A therapist pays closer attention to asymmetry — a strong hand preference before about eighteen months, or one side consistently doing less. To regression, where a child loses a skill they had. To a child slow across several areas at once. To stiffness or floppiness in how a body is held. And to a child not seeking connection: not sharing attention, not bringing things to show, not checking back for a reaction.

None of these is a diagnosis. Each is a reason to have the child seen rather than to keep waiting.

One caution belongs particularly to practising here. Most standardised developmental assessments used in South Africa were normed on North American or European children, and a score reflects the population the test was built on as much as the child sitting in front of you. A toddler who has grown up carried on a back, who sleeps in a shared room, and who speaks two languages at home before meeting a therapist in a third is not well described by those norms. Careful assessment therefore leans hard on observation, on history and on what the family reports, and treats a test score as one piece of evidence rather than a verdict.

Why early matters, and what it does not mean

The case for early intervention rests on something real. The young brain is forming and pruning connections at a rate it will never match again, and it is doing so in response to what the child actually experiences. Support offered while that process is at its most active tends to go further than the same support offered later.

Early support also interrupts the secondary effects. A child who finds movement difficult explores less, and so gets less practice, and so falls further behind — not because of the original difficulty but because of the loop it started. Intervening early is frequently about preventing the second problem rather than curing the first.

What it does not mean is that a window slams shut at three, or five, or seven. Children keep learning and changing throughout childhood, and parents who arrive later with an older child are not too late. That message gets distorted in the telling, and it produces a great deal of unnecessary guilt in people who were doing their best with what they knew.

Working through the parent

Therapy for a two-year-old is not really delivered to the two-year-old. It is delivered through whoever is with them for the other hundred and sixty-seven hours of the week, which means the practical unit of intervention is the parent, the grandmother, the crèche practitioner.

This changes what a session should contain. A therapist who spends forty-five minutes demonstrating their own skill and then hands over a photocopied sheet has achieved very little. One who coaches a parent through a nappy change or ten minutes on the floor — noticing aloud what the child did, and why it mattered — has changed something that will still be happening next month.

It also asks for some humility about whose expertise is whose. Parents of a young child know things no assessment will capture: what the crying means, which position settles them, what they were like before. A good early years therapist treats that as data rather than as anecdote, and builds on it.

The first years are short, exhausting and lived largely in a fog of broken sleep. What they need is not vigilance but attention of a warmer kind — someone willing to look carefully, say what they see, and be honest about the difference between a child who needs help and one who simply needs more time.