Development

Developmental PediatricsDevelopmental Pediatrics

DR.N.UDAYAKUMAR,

ASSOCIATE PROFESSOR OF PEDITRICS,

SRMC&RI,

PORUR.

DR.N.UDAYAKUMAR,

ASSOCIATE PROFESSOR OF PEDITRICS,

SRMC&RI,

PORUR.

1

Formal Screening TestsFormal Screening Tests

ASQASQ

ClamsClamsCatCat

Early screening inventory

Early screening inventory

Denver II

Denver IIDenver IDenver I

TDSCTDSC

ELMELMBusy

PediatricianBusy

Pediatrician

“ I regard developmental examination as an essential

part of everyday practice with a minimum of

equipment, in an ordinary mixed clinic, and not in a

special room, or at a special time, or with special

complicated equipment or by a special doctor ”

R.S. Illingworth

“ I regard developmental examination as an essential

part of everyday practice with a minimum of

equipment, in an ordinary mixed clinic, and not in a

special room, or at a special time, or with special

complicated equipment or by a special doctor ”

R.S. Illingworth

25 million yearsEvolution

Development

25 months

Develop. ScreeningDevelop. Screening

All ChildrenAll Children

Develop. AssessmentDevelop. Assessment

QuickQuick

SubjectiveSubjective

Gen. Pediatrician in

his clinic

Gen. Pediatrician in

his clinic

Children with perinatal events, risk factors, delay

suspected

Children with perinatal events, risk factors, delay

suspected

Time consumingTime consuming

Objective - testsObjective - tests

Dev. Pediatrician ||

Neurologist

Dev. Pediatrician ||

Neurologist

ENT Surgeon ENT Surgeon

Ophthalmic Ophthalmic

OrthoOrtho

Child psych.Child psych.Physiotherapist occupational, speechPhysiotherapist occupational, speech

School teacherSchool teacher

MotherMother

ObjectivesObjectives

• Sensitization - Dev. Screening

• Early identification & appropriate referral

• Simple format using

– Ordinary tools

– Within 10 - 15 minutes

– Clinic / OP settings

– Subjective assessment

• Sensitization - Dev. Screening

• Early identification & appropriate referral

• Simple format using

– Ordinary tools

– Within 10 - 15 minutes

– Clinic / OP settings

– Subjective assessment

Beyond the Scope of this LectureBeyond the Scope of this Lecture

• Detail Assessment

• Formal - objective tests

Specific disabilities

• ADHD, deafness, MR, autism, LD

Special investigation

• BERA

• Detail Assessment

• Formal - objective tests

Specific disabilities

• ADHD, deafness, MR, autism, LD

Special investigation

• BERA

Why should we assess ?Why should we assess ?

• To reassure parents

• Early diagnosis and management of

disability

• Feedback for obstetrician and

neonatologist

• Prevention in next sibling

• To reassure parents

• Early diagnosis and management of

disability

• Feedback for obstetrician and

neonatologist

• Prevention in next sibling

What to do ? What to do ?

• Just passively observe his play and spontaneous

activity

• Use TDSC to screen

• Go little more deeper with Development Chart

(Lingam S. UK)

• Need not memorise

• Keeps the charts over the table and assess

• Just passively observe his play and spontaneous

activity



(Lingam S. UK)

• Need not memorise

• Keeps the charts over the table and assess

Four Aspects of Development Four Aspects of Development

• Motor - Body posture & large movements

• Fine movement, vision and manipulative

skills

• Hearing and speech

• Social behaviour & spontaneous play

• Motor - Body posture & large movements

• Fine movement, vision and manipulative

skills

• Hearing and speech

• Social behaviour & spontaneous play

Development Assessment is most

conveniently divided into four fields

Development Assessment is most

conveniently divided into four fields

Developmental screening scale (S.Lingam 1987, UK)

4-6 weeks 3 months 6 months 9 months GROSS MOTOR Supine: head on sides, fencing,

hands closed, thumbs in Pulled to sitting head momentarily erect and fall Held sitting: back curved Ventral suspension: Head in line with trunk Walking, stepping

Supine: Head in midline Hands open, moves arm symmetrically Hands together in midline Pulls to sitting little or no headlag Kicks vigorously Ventral suspension-Head above trunk Prone lifts head with forearm support

Supine: Raises head, lifts legs, grasp foot On grasping hand pulls self to sit Prone: Hand support Sitting with support straight back Downward parachute: Bears weight on feet

Sits alone – 10-15 minutes Leans forward without losing balance Attempts to crawl Pulls to stand to crawl Forward parachute ( 7 m) Rolls over back to prone

FINE MOTOR Turns eyes and head towards light Shuts eyes to bright light Regards mother face Follows ball ¼ circle

Follows adult movements with available field Follows ball ½ circle Hand regard Finger play Defensive blink

Moves head and eyes early in all directions Fixes eyes on objects Reaches and grasp Palmar grasp Transfers object from one had to other

Very attentive Visual: Good peripheral vision Pokes at small objects Pincer grasp Watches rolling ball at 10 feet

LANGUAGE ‘Startle’, stiffens Blinks, screws up eyes Fan out fingers Cries or freeze in response to noise

Quietening or smilling to mother’s voice

Turns immediately to mothers voice Mono and double syllable Responds to distraction hearing test at 1½ feet at ear level Laughs and chuckles

Long repetitive string of syllable-Mama, Dada Understands no, no, bye bye Hearing test response 3 feet below and above

SOCIAL Turns to regard nearby speaker’s face Stops crying when picked up and spoken to Social smile

Fixes eyes on mother Unblinking, purposeful gaze Smiles, coos to familiar situations

Reach and grasp small toys Takes to mouth Shakes rattle Holds bottle and feeds Still friendly with strangers

Plays peek-A-Boo Holds, bites and chews biscuits Reserved with strangers (7m) Imitates hand clapping Finds a toy partly hidden

WARNING SIGNS FOR FURTHER EVALUATION

Not responding to nearby voices by 8 weeks Absent ‘Startle’ No social smile by 3 months

Not showing interest in people/ playthings by 3-4 months No head control by 5 months No vocalization

Persistent moro, asymmetric tonic neck reflex Not visually alert Not reaching for objects

No hand transfer Not sitting No repetitive babble even by 10 months

Developmental Milestones Age Milestones Developmental Milestones Age Milestones

• 1 month Raises head slightly when prone; alerts to sound; regards face, moves extremities equally.

• 2-3 months Smiles, holds head up, coos, reaches for familiar objects, recognizes parent.

• 4-5 months Rolls front to back and back to front; sits well when propped; laughs, orients to voice; enjoys looking around; grasps rattle, bears some weight on legs.

• 1 month Raises head slightly when prone; alerts to sound; regards face, moves extremities equally.

• 2-3 months Smiles, holds head up, coos, reaches for familiar objects, recognizes parent.

• 4-5 months Rolls front to back and back to front; sits well when propped; laughs, orients to voice; enjoys looking around; grasps rattle, bears some weight on legs.

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• 6 months Sits unsupported; passes cube hand to hand; babbles; uses raking grasp; feeds self crackers.

• 8-9 months Crawls, cruises; pulls to stand; pincer grasp; plays pat-a-cake; feeds self with bottle; sits without support; explores environment.

• 12 months Walking, talking a few words; understands "no"; says “mama/dada” discriminantly; throws objects; imitates actions, marks with crayon, drinks from a cup.

• 6 months Sits unsupported; passes cube hand to hand; babbles; uses raking grasp; feeds self crackers.

• 8-9 months Crawls, cruises; pulls to stand; pincer grasp; plays pat-a-cake; feeds self with bottle; sits without support; explores environment.

• 12 months Walking, talking a few words; understands "no"; says “mama/dada” discriminantly; throws objects; imitates actions, marks with crayon, drinks from a cup.

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• 15-18 months Comes when called; scribbles; walks backward; uses 4-20 words; builds tower of 2 blocks.

• 24-30 months Removes shoes; follows 2 step command; jumps with both feet; holds pencil, knows first and last name; knows pronouns. Parallel play; points to body parts, runs, spoon feeds self, copies parents.

• 15-18 months Comes when called; scribbles; walks backward; uses 4-20 words; builds tower of 2 blocks.

• 24-30 months Removes shoes; follows 2 step command; jumps with both feet; holds pencil, knows first and last name; knows pronouns. Parallel play; points to body parts, runs, spoon feeds self, copies parents.

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• 3 years Dresses and undresses; walks up and down steps; draws a circle; uses 3-4 word sentences; takes turns; shares. Group play.

• 4 years Hops, skips, catches ball; memorizes songs; plays cooperatively; knows colors; copies a circle; uses plurals.

• 5 years Jumps over objects; prints first name; knows address and mother's name; follows game rules; draws three part man; hops on one foot.

• 3 years Dresses and undresses; walks up and down steps; draws a circle; uses 3-4 word sentences; takes turns; shares. Group play.

• 4 years Hops, skips, catches ball; memorizes songs; plays cooperatively; knows colors; copies a circle; uses plurals.

• 5 years Jumps over objects; prints first name; knows address and mother's name; follows game rules; draws three part man; hops on one foot.

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PrevalencePrevalence

Low frequency high morbidity

– Cerebral palsy

Visual or hearing impairment

– Autism

– Mental retardation

High frequency low morbidity

– Learning disability

– ADHD

Low frequency high morbidity

– Cerebral palsy

Visual or hearing impairment

– Autism

– Mental retardation

High frequency low morbidity

– Learning disability

– ADHD

Clinical Presentation Clinical Presentation Early infancy

– Poor suck, abnormal tone, lack of response to auditory or

visual stimuli

Late infancy

– Motor delay

II & III year

– Language & behavioral abnormalities

School entry

– ADHD, learning disability

Early infancy

– Poor suck, abnormal tone, lack of response to auditory or

visual stimuli

Late infancy

– Motor delay

II & III year

– Language & behavioral abnormalities

School entry

– ADHD, learning disability

Three part assessment Three part assessment

• History - Medical & Social

• Examination - General & CNS

• Developmental Screening

• History - Medical & Social

• Examination - General & CNS

• Developmental Screening

HistoryHistory

• Risk factors

– Prematurity

– Adverse perinatal events

– Family history

• Warning signals

– Mother’s suspicion

– Inattention to sound

• Dev. History

– Tracking of Milestones

• Risk factors

– Prematurity

– Adverse perinatal events

– Family history

• Warning signals

– Mother’s suspicion

– Inattention to sound

• Dev. History

– Tracking of Milestones

Physical examination Physical examination

• Growth parameters

• Congenital anomalies

• Skin findings

• Eye findings

• Abnormal facies

• Organomegaly

• Growth parameters

• Congenital anomalies

• Skin findings

• Eye findings

• Abnormal facies

• Organomegaly

Neurological examination Neurological examination

• Classical

• Extended examination

– Symmetry

– Quality of movement

– Primitive reflexes

– Postural response

• Classical

• Extended examination

– Symmetry

– Quality of movement

– Primitive reflexes

– Postural response

Scissoring postureScissoring posture

Dev. Screening - Tools of the TradeDev. Screening - Tools of the Trade

• One inch cubes

• Hand bell

• Pencil, paper

• Small safe object

• Safe interesting toy

• Fluffy red wollen ball

Plus (if possible) a smiling doctor

• One inch cubes

• Hand bell

• Pencil, paper

• Small safe object

• Safe interesting toy

• Fluffy red wollen ball

Plus (if possible) a smiling doctor

Order of testing Order of testing

• Develop. examination prior to P.E.

• Language social fine gross motor

• Spend sometime in making friendship

• Just observe him while he plays

• Do quickly and efficiently

• Develop. examination prior to P.E.

• Language social fine gross motor

• Spend sometime in making friendship

• Just observe him while he plays

• Do quickly and efficiently

Ideal Environment for Assessment Ideal Environment for Assessment

Place

Mother’s lap

Non threatening

Place

Mother’s lap

Non threatening

Time

Not hungry, not sleepy

Not sick, not fatigued

Time

Not hungry, not sleepy

Not sick, not fatigued

Method

By History

Observation of play

Formal examination

Method

By History

Observation of play

Formal examination

Primitive reflexes Primitive reflexes

Persistence beyond this, is abnormal

• Palmar grasp (3 - 4 months)

• MORO (5 months)

• Asymm. Tonic reflex (6 months)

• Plantar grasp (9 - 12 months)

Persistence beyond this, is abnormal

• Palmar grasp (3 - 4 months)

• MORO (5 months)

• Asymm. Tonic reflex (6 months)

• Plantar grasp (9 - 12 months)

Play - Events Play - Events

• Mouthing 6 months - 12 months

• Bruxism - When awake usually suggest mental sub

normality

• Hand regard - 2 - 6 months

• Casting (throwing) 1 - 11/2 yrs

• Handedness > 24 months

• Tripod holding of pen > 21/2 yrs

• Drooling usually stops after one year

• Mouthing 6 months - 12 months

• Bruxism - When awake usually suggest mental sub

normality

• Hand regard - 2 - 6 months

• Casting (throwing) 1 - 11/2 yrs

• Handedness > 24 months

• Tripod holding of pen > 21/2 yrs

• Drooling usually stops after one year

Testing of Hearing Testing of Hearing

• Response to Noise

– Startle, blinks, screws up eyes, cries or freeze in

response to noise

• Distraction testing (6 - 18 months)

• Co-operative testing (18 - 30 months)

• Performance test

• Speech discrimination

• Response to Noise

– Startle, blinks, screws up eyes, cries or freeze in

response to noise

• Distraction testing (6 - 18 months)

• Co-operative testing (18 - 30 months)

• Performance test

• Speech discrimination

Testing visionTesting vision

1 month : Fixing on mother’s face

2 months : Follow objects at 90 cms

Through 90o

3 months : Through 180o

10 months : Pick up raisin

1 year : Pickup 100s & 1000s

2 - 3 years : Miniature toys at 9 feet

3 - 5 years : Stycar matching letters

> 5 years : Snellen chart

1 month : Fixing on mother’s face

2 months : Follow objects at 90 cms

Through 90o

3 months : Through 180o

10 months : Pick up raisin

1 year : Pickup 100s & 1000s

2 - 3 years : Miniature toys at 9 feet

3 - 5 years : Stycar matching letters

> 5 years : Snellen chart

New born Ventral suspensionNew born Ventral suspension 6 weeks Head in same plane6 weeks Head in same plane

18 weeks Head held up18 weeks Head held up 12 weeks Floppy child12 weeks Floppy child

4 weeks Complete head lag4 weeks Complete head lag

2 months Partial head lag2 months Partial head lag 4 months No head lag4 months No head lag

Lifting headup slightlyLifting headup slightly

6 weeks Chin off couch intermittentlyChin off couch intermittently

10 - 12 weeksForearm support

10 - 12 weeksForearm support

24 weeksHand support

24 weeksHand support

10 - 20 weeks Hand regard

10 - 20 weeks Hand regard

44 weeks creeping position44 weeks creeping position

52 weeks Bear walk52 weeks Bear walk

6 monthsImmature grasp

6 monthsImmature grasp

8 monthsIntermediate grasp

8 monthsIntermediate grasp

1 yearMature grasp

1 yearMature grasp

10 monthsIndex finger approach

10 monthsIndex finger approach

10 monthsPincer grasp

10 monthsPincer grasp

3 weeks3 weeks

Palmar grasp reflexPalmar grasp reflex

4 weeks4 weeks

Rooting reflexRooting reflex

4 weeks4 weeks

Visual trackingVisual tracking

6 weeks

Concentrating on rattleBeginning of eye - hand coordinationConcentrating on rattleBeginning of eye - hand coordination

6 weeks

Social smileSocial smile

4 months 4 months

Head control, eye contact, good interaction

Head control, eye contact, good interaction

4 months 4 months

Holding head & looking further awayHolding head & looking further away

5 months 5 months

Palmar grasp and biting the rattlePalmar grasp and biting the rattle

5 months 5 months

Reaching out for rattleReaching out for rattle

6 months 6 months

Bearing weight on legsBearing weight on legs

6 months 6 months

Holding and exploring rattleHolding and exploring rattle

6 months 6 months

Turning to sound of rattleTurning to sound of rattle

6 months 6 months

Sitting with support examining the matSitting with support examining the mat

7 months 7 months

Sits steadilySits steadily

10 months 10 months

Finding hidden objectsFinding hidden objects

1 year

Examining the soap box with interest(house hold objects can be used)Examining the soap box with interest(house hold objects can be used)

1 year

Communicating with gesturesMother holding out hand - baby gives the toy

Communicating with gesturesMother holding out hand - baby gives the toy

1 year

Walking with broad basein response to mother’s call

Walking with broad basein response to mother’s call

1 year

Making gestures to communicate pointing with leafMaking gestures to communicate pointing with leaf

1 year

Imitating and copyingBoth are striking the wooden blocks

Imitating and copyingBoth are striking the wooden blocks

2 years2 years

2 1/2 years2 1/2 years

3 years3 years

4 years4 years




Drawing tests - L O C S T DDrawing tests - L O C S T D

Interpretation Interpretation

• Give allowance for prematurity, fatigue, illness,

familial pattern

• If in doubt, repeat later

• Remember - wide range of normal deviation

• Give allowance for prematurity, fatigue, illness,

familial pattern

• If in doubt, repeat later

• Remember - wide range of normal deviation

After the Developmental ExaminationAfter the Developmental Examination

• Is there any delay ?

• Can it be a normal variant ?

• Is it global delay or dissociation between fields ?

• If not definite, can I decide after repeating the test ?

• Can I ask for help ?

• Is there any delay ?

• Can it be a normal variant ?

• Is it global delay or dissociation between fields ?

• If not definite, can I decide after repeating the test ?

• Can I ask for help ?

• Language perception is well advanced than

expression

• Some do bear walk

• Some bounce around floor (Bottom shuffling)

• Some do side stroke, crawl backwards or roll

• Some never crawl; they stand and walk

• Language perception is well advanced than

expression

• Some do bear walk

• Some bounce around floor (Bottom shuffling)

• Some do side stroke, crawl backwards or roll

• Some never crawl; they stand and walk

Normal VariantNormal Variant

Causes of Motor Delay Causes of Motor Delay

• Normal or Familial variation

bottom shuffling

• Chronic illness

• CP

• Neuromuscular diseases - DMD, SMA

• Orthopedic - CDH

• Rickets

• Emotional neglect

• Normal or Familial variation

bottom shuffling

• Chronic illness

• CP

• Neuromuscular diseases - DMD, SMA

• Orthopedic - CDH

• Rickets

• Emotional neglect

Warning Signals in Language Development

Warning Signals in Language Development

• Risk of deafness

• Mother’s suspicion

• No response to everyday sounds

• No repetitive babble by 10 months

• No word by 21 months

• Not putting 2 - 3 words together by 21/2 years

• Risk of deafness

• Mother’s suspicion

• No response to everyday sounds

• No repetitive babble by 10 months

• No word by 21 months

• Not putting 2 - 3 words together by 21/2 years

Language delayLanguage delay

• Reception is well advanced than expression

– Hearing defects

– Familial & genetic

– Global delay

– Autism

– Environmental

• Reception is well advanced than expression

– Hearing defects

– Familial & genetic

– Global delay

– Autism

– Environmental

Global DelayGlobal Delay

• Chromosomal defects

• Syndromes

• CP

• Structural brain defects

• Neurometabolic problems

• Postnatal causes

• Chromosomal defects

• Syndromes

• CP

• Structural brain defects

• Neurometabolic problems

• Postnatal causes

Factors affecting developmentFactors affecting development

• Genetic

• Physical

• Nutritional

• Emotoinal

• Sociocultural

• Neurological

• Genetic

• Physical

• Nutritional

• Emotoinal

• Sociocultural

• Neurological

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Developmental QuotientDevelopmental Quotient

• Computed by the following formula

• Developmental age / Chronological age X 100

• Computed by the following formula

• Developmental age / Chronological age X 100

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INTELLECTUAL QUOTIENTINTELLECTUAL QUOTIENT

• MENTAL AGE /CHRONOLOGICAL AGE.

• <70- MENTAL RETARDATION.

• GLOBAL DEVELOPMENTAL DELAY <3 YEARS.

• MENTAL AGE /CHRONOLOGICAL AGE.

• <70- MENTAL RETARDATION.

• GLOBAL DEVELOPMENTAL DELAY <3 YEARS.

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Development assessment scalesDevelopment assessment scales

• Denver Development Chart

• Baroda Developmental Screening chart

• Trivandrum Developmental Screening chart

• Bayley Scale of Infant Development (BSIS)

• Developmental Assessment Scale for Indian Infants(DASII)

• Denver Development Chart

• Baroda Developmental Screening chart

• Trivandrum Developmental Screening chart

• Bayley Scale of Infant Development (BSIS)

• Developmental Assessment Scale for Indian Infants(DASII)

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BONE AGEBONE AGE

• AT BIRTH UPTO 4 MONTHS- KNEES AND HIP.

• 4-12 MONTHS-SHOULDER.

• 1 -10 YEARS- WRIST.

• > 8- 14 YEARS-ELBOW.

• ( LEFT SIDE BONES ARE ASSESSED)

• AT BIRTH UPTO 4 MONTHS- KNEES AND HIP.

• 4-12 MONTHS-SHOULDER.

• 1 -10 YEARS- WRIST.

• > 8- 14 YEARS-ELBOW.

• ( LEFT SIDE BONES ARE ASSESSED)

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WHO GROWTH CHARTWHO GROWTH CHART

• In an effort to set an internationally usable standard for optimal growth in young children, the World Health Organization is conducting the Multicenter Growth Reference Study (MGRS) to develop growth curves that can be used for assessing early growth among children from around the world.

• MGRS describes the growth of children who are raised under optimal conditions, following recommended health practices, such as environments that support exclusive breast-feeding, Baby-Friendly Hospitals, and mothers who agree to breast-feed their infants.

• Six study sites represent 5 continents in the major regions of the world: United States, Brazil, Norway, Ghana, Oman, and India.

• In an effort to set an internationally usable standard for optimal growth in young children, the World Health Organization is conducting the Multicenter Growth Reference Study (MGRS) to develop growth curves that can be used for assessing early growth among children from around the world.

• MGRS describes the growth of children who are raised under optimal conditions, following recommended health practices, such as environments that support exclusive breast-feeding, Baby-Friendly Hospitals, and mothers who agree to breast-feed their infants.

• Six study sites represent 5 continents in the major regions of the world: United States, Brazil, Norway, Ghana, Oman, and India.

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SLEEP EVALUATIONSLEEP EVALUATION

• The BEARS instrument is divided into 5 major sleep domains, providing a comprehensive screen for the major sleep disorders affecting children 2–18 years old. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview.

• The BEARS instrument is divided into 5 major sleep domains, providing a comprehensive screen for the major sleep disorders affecting children 2–18 years old. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview.

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To conclude …... To conclude …...

Screen the development in all well children

• Observe his play and spontaneous activity



(Lingam S. UK) - if there is suspicion

• Keeps the charts over the table

Screen the development in all well children

• Observe his play and spontaneous activity



(Lingam S. UK) - if there is suspicion

• Keeps the charts over the table

DecisionsDecisions

• Abnormal

• Probably normal

• Doubtful

• Normal

• Abnormal

• Probably normal

• Doubtful

• Normal

See againSee again

ReferRefer

Developmental

assessment

by

MKC Nair

Manual of child

development

by

Lingam S

First 5 years

by

Mary Sheriden

PCNA - Child with developmental

disabilities- June 1993

For further

reading

Development

Health & Medicine

Transcript of Development