Child development is a highly complex biological and psychosocial process that takes place over several years. It begins in the prenatal stage, continues through various stages of childhood and extends into young adulthood.

In some markets, children are insured for various products from a very young age, including products for Disability, Critical Illness and Long-term care. In medical risk assessment, underwriting children presents different challenges compared to underwriting adults. It is essential for risk assessors to understand how childhood development progresses, and how disturbances are medically assessed, documented and treated, if necessary.

This article provides an overview of the typical stages of development. The aim is to develop a better understanding of delays or deviations from the development process defined as normal in medical documentation, and how to recognise potentially relevant pre-existing conditions or disorders.

Developmental Stages From Birth to Adolescence

During the first years of life, children go through several defined development stages affecting physical (e.g. growth, motor skills), linguistic, cognitive, emotional and social areas. Individual differences are already apparent in infancy, but these are often still within the normal range. Child development can be divided into five main phases, each with typical milestones and medically relevant observation points:^1,2,3

Developmental Abnormalities – Delay Versus Disorder

In general, child development is determined by various factors, such as genetics, external environmental influences and social environment. The course of child development is therefore highly variable. There can be individual differences in the speed of development as well as a wide range of differences in learning styles. For example, children may skip crawling altogether when learning to walk, even though crawling is considered a typical milestone in the development of walking skills. Child development is also adaptive, meaning that healthy children have the ability to adapt to changing environmental conditions. This allows them to catch up on developmental milestones that are defined as normal.

A basic distinction can be made between developmental delay and developmental disorder. Developmental delay is characterised by the possibility of catching up in the development of certain skills. In contrast, developmental disorder is a permanent impairment that usually begins early and progresses steadily.⁴

Late Manifestation of Disorders

Not all developmental or health disorders can be accurately diagnosed during routine check-ups. Some diseases or developmental disorders become apparent only later in childhood or in adolescence. Others can be correctly diagnosed only at a later stage. This is particularly true for neurobiological or psychological disorders for which complex diagnostic features (e.g. child/parent interviews, behavioural observation, developmental tests, etc.) involving multiple examinations and interviews are usually necessary.⁵

Developmental delays or deviations from the norm are common, especially at a very young age, and are not necessarily pathological. The decisive factor is whether the delay was temporary, whether treatment or training were necessary to catch up, if it was successful, and whether the child has reached the age-appropriate level of development over time. In cases where the process is unclear or the information available is insufficient, it is advisable to wait and see how the child’s development continues.

“Red flags” in Risk Assessment of Children

When assessing health risks in children and adolescents, in addition to diagnosis, developmental abnormalities, incomplete documentation and certain medical documentation content play a central role. Some abnormalities may indicate an existing illness or an important change in a health status. There are some so‑called red flags which, depending on the context, may need further investigation.⁶

Incomplete or missing check‑up exams may be a warning sign in healthcare systems which have scheduled examination of children at a specific age. Incomplete documentation, especially in the sensitive phase between the ages of 1 and 5, may indicate limited use of offered paediatric or other medical care. In countries which use vaccination cards, their absence is noteworthy. In such cases, the medical health record should be requested.⁷

A decrease in weight or reduced increase of height may be a warning sign. Many healthcare systems use percentiles for assessment of children’s physical development. A drop in weight or height of two or more percentile lines is considered abnormal and may be a sign of a growth disorder. Possible causes range from chronic diseases such as coeliac disease or endocrine disorders to psychosocial stress. Malnutrition or child welfare issues should also be considered. Growth charts or a specialist medical report can be helpful in clarifying the situation.⁸

Deviations potentially indicating neuro(bio)logical or cognitive developmental disorders may hide in expressions such as “speech delay – speech therapy initiated”, “development not age-appropriate” or “suspected autism spectrum disorder – referral to specialist”. The decisive points for risk assessment are whether a specialist medical examination has been carried out, whether a diagnosis has been confirmed or ruled out, and whether therapeutic measures have been successfully completed or are still ongoing. It should be noted that final diagnoses are often made only much later and on an interdisciplinary basis.

Children with previous or current referral to a specialised paediatric medical centre often have a relevant medical history. These children usually suffer from developmental disorders, chronic illnesses or multiple stress factors.

At adolescence mental health issues may become visible. Documented information from interviews, such as withdrawal, depressive moods or emotional distress, should be carefully reviewed. Important follow‑up questions here are: is there a current mental illness? Has treatment been initiated? If so, the type, course and success of treatment are information of crucial importance.⁹

Chronic illnesses in childhood – such as asthma, epilepsy, type 1 diabetes, congenital heart defects or previous oncological illnesses – often have long-term medical and insurance-related implications. Serious acute events, such as severe or intensive medical treatment in the past, can also have serious physical or psychological long-term consequences. Current treatment reports, information on medication and the course are crucial here.¹⁰

Behavioural problems and school difficulties – such as repeated grade repetition, fear of school or signs of concentration disorders – should also be taken into account. Statements such as “conspicuous group behaviour” may indicate a relevant stress situation.

Missing or refused vaccinations – e.g. no measles vaccination (although it is compulsory in some countries for school attendance) – can also indicate medical neglect or a lack of access to the healthcare system. In these cases, vaccination records, medical statements or proof of past infectious diseases can be helpful.

Finally, family circumstances, such as fostering or adoptive status, or the presence of siblings or parents with chronic conditions, may also indicate particular psychological or health problems.

In summary, not every documented abnormality constitutes a criterion for exclusion from insurability. The decisive factor is whether a medically relevant problem existed or still exists, and whether adequate treatment or support was provided. However, it applies to both the clinical field and medical underwriting that assessment of children is generally difficult, as the applicant to be insured does not usually provide information him/herself. Instead, parents/carers almost always take on the task of providing health information. But parents are often the first ones to recognise abnormalities or differences between their child and others, sometimes before seeing a paediatrician.

Furthermore, neurobiological and psychological diagnoses are particularly difficult to establish in early childhood and often become clear only as the child develops and undergoes multiple medical and/or psychological examinations. Due to the limited objectivity of medical risk assessment, in cases of doubt it is advisable to wait and see how the child develops. Insuring children, or even more so, a decline or postponement insuring children, has the potential to trigger a wide range of emotions in parents, requiring particular sensitivity in medical underwriting. In case of deviating results and unclear health situations, underwriters should above all refrain from making any suspected diagnoses or even communicating them to external parties. Even if the applicant sometimes points out that such documented, deviating findings are no longer relevant and have been medically clarified, it is always advisable to remain calm but cautious. If necessary, a comprehensive written medical statement on the course of deviating findings and the definitive exclusion of potential suspected diagnoses may be helpful. The safest approach is to allow time to pass, because the older a child, the higher the probability that relevant findings will be recognised, diagnosed and treated.