Developmental and behavioural problems in primary care:

0-5 years

Max Davie

7th July 2009

Objectives

Developmental and behavioural concerns, mainly 0-5

Know when to worry (and when to reassure)

Know what to do about worry (who to involve)

Know what to advise in the meantimeNo rarities!

Outline 0-1: Stand up!

Gross motor development

1-2: Speak up! Early communication

2-3: Play nicely! Behaviour, sleep and eating

3-4: Calm down! Attention, emotion

4-5 Get ready for school! Clumsy, odd children

0-1: Stand up! Case study

Baby born at term, no compsBreastfeeding ‘OK’6 week check

Head lag- briefly keeps up Suspended prone- brief straightening only Brief ankle clonus bilaterally Hands fisted Moro intact, symmetrical

Diagnosis?

‘Floppy baby syndrome’

If not sure, look for risk factorsExamination clues

Dysmorphism Posture, movements at rest

No-one minds getting a referral for this

What can the doll do?

4 months

6 months

9 months

12 months

15 months

18 months

2 years

Different ways up the mountain

Crawlers (83%)Shufflers (9%)Rollers (1%)Creepers (1%)

Worry markers- gross motor

No rolling prone-supine by 7 months

No rolling supine-prone by 9 months

No unsupported sitting by 10 months

No independent steps by 18 months

No running by 2 years

No jumping by 3 years

‘A very grabby little person’

Primitive gives way to voluntaryProximal- distal progressionSequence rigid, timings flexiblePronation before supinationAction before inhibitionVariation is required

Reach and grasp

4 months Open-hand reaching Corralling, swiping, ulnar-palmar grasp

6 months Accurate reach Radial-palmar grasp, raking a raisin

10 months Hand-shaping Digital grasp of cube, pincer of raisin

Introducing the 5 minute development assessment

0-3 yearsEquipment

A box of raisins Some 1” bricks (primary colours, 6 or so) Some markers and paper A stethoscope

5 minute DA- 1 year

1-2 Speak up!: Early communication

Do an impression of….. 4 month old 8 month old 12 month old 18 month old 2 year old 3 year old

The linking pitfall

Oh dearAll goneMoo goneUpsy daisyTessy doot

‘Why isn’t he talking?’

MythsHearingAutismGDDSLI

Worrying signs

6/12: No cooing/ response1 yr : No pointing, no words, no showing18 mo: <5 words2 years: No linking, no instructions3 years: Not understood by strangers, no

body parts known

5 minute DA- 2 years (nearly)

2-3: Play nicely!

Behaviour Tantrums Violence Lack of co-operation

SleepEating

Behaviour- taking a history

Get examples- specific difficult scenarios Mealtimes Leaving for school Shops

What happens before, during, after What do parents do?

Ask for exceptions Why different?

Webster-Stratton’s Pyramid

Arrange in order of importance

The incredible years

Services locally

Role plays (you love them, you do)

‘He’s got no respect’

‘He won’t sleep in his bed’

‘She won’t eat anything’

5 minute DA- 3 year old

3-4: Calm down!

Attention, concentration

Fears and imagination

Is it ADHD, doctor?

What is ADHD? Just bad parenting?

Expectations of abilities Rest of development

Attention deficit or Deficit of attention?Other factors

Specific learning difficulties Sleep Inconsistent parenting

Assessing ADHD

HyperactivityImpulsivityInattention

Questions to askThe QB test

Referral and management

Diagnosis CAN be made in primary care

First line for mild/ moderate- parenting group/ school intervention

Refer CAMHS for 2nd line interventions

Fears and imagination

The emergence of magicEmotions as behaviourImaginary friendsLies and misdemeanoursFears- concrete to imaginaryNight terrors vs nightmares

4-5: Get ready for school!

Later motor problems Gait Co-ordination & motor planning

Social communication problems

Self-concept and mood

Problems with walking

Normal gait

Asymmetry

Toe-walking

Persistence of toddler pattern

Frequent falls

The clumsy child- DCD

Common, significant problem

Difficulties with planning and execution Poor handwriting

‘Behavioural’ issues

Frequent falls

Sensory issues

Difficulty in integrating sensory input with cognitive and motor activity

Leads to behavioural and communication problems

ALL sensory modalities Proprioception Taste

Out-of-sync child

DCD/ sensory - what to do

Assess expectations (handout)

Led by OT

Comm paeds initially

Questionnaire-based referral

Co-morbidity

Why go to medics? Neurological disorders initially diagnosed as "DCD/dyspraxia" Peripheral neuromuscular conditions Becker muscular dystrophy myotonic dystrophy

hereditary motor and sensory neuropathy (HMSN) types Ia and IImyotonia congenita (autosomal recessive)congenital myasthenia

Central nervous system conditions cerebral palsy

brain tumour (slow growing in the posterior fossa)panthotenate kinase-associated neurodegeneration (Hallervorden–Spatz disease)perisylvian (opercular) syndromebenign familial choreaepilepsy

Mixed peripheral and central nervous system conditions Friedreich’s ataxia

Pelizaeus–Merzbacher disease

Miscellaneous Ehlers–Danlos syndrome

GM1 gangliosidosis (juvenile onset)

Autistic spectrum disorders

Triad of impairments Social interaction

Language and communication

Rigidity of thought and behaviour

Dimensional not categorical

Still under-reported: at least 1% of children

Social interaction

Eye contactFacial expressionSocial response/ overturesShared enjoyment

Think of silent movies

Communication

Speech delay

Echolalia

Stereotyped/ formal language

Conversation

Reporting

Lack of gesture

Rigidity of thought and behaviour

Excessive interest

Mannerisms

Rituals

Sensory interests

Diagnosis of ASD

3 elements: report, interview, observationDiagnostic jargon

Full triad+ speech delay = Autism Full triad and normal speech= Asperger’s Social interaction + other = ?Atypical autism

All children with these three have an ASDOther terms exist (for now)

“Kids in the mix”

Mix of disorders Synergistic effect on

functioning Associated with

relative poverty Complex!

Self-image and self-esteem

Definition of self- categories

Gender/ sexual identity

Anger Overt

Concealed

Moral development

Postscript: How to be the GP of a child with “complex” disability

Acute problems Note interactions e.g. gut and head Negotiate plan

Long-term issues Checklist in handout

‘Non-medical’ issues Benefits Wider family

Anything else?