An Overview of Common Developmental Problems in

Children

Outline of Presentation

• Development and Developmental Surveillance

• Common Developmental Problems

• Local Services and Community Resources

• References for Primary Care Doctors

• Q & A

Development

Perspectives on Development

• Development is a continuous process

• Nature vs Nurture

• Risk and Protective factors

Community School, social support, community functioning

Home Parent-child relations, trauma, family functioning

Integrated CNS functioning Self-esteem, morals

Basic CNS functioning cognition, temperament

CHILD

The Child in the context of his home

and in the community

Society Culture, TV...

6

Aspects of Development

• Physical and Sensory development · Gross motor · Fine motor · Hearing and Vision

• Cognitive and Language development · Cognition

· Language and Speech

• Emotional and Social development

• Literacy

Developmental Trajectories

世界衞生組織 (WHO) 國際身體功能, 健康及傷殘分類

International Classification of Function (ICF)

Health Condition

(disorder-disease)

Environmental

Factors

環境因素

Personal

Factors

個人因素

Activities

Limitation

活動

Body function & structure

Impairment 結構及功能

Participation

Restriction 參與

www.who.int/classification/icf

Developmental Surveillance

Developmental Surveillance

• a series of routine reviews conducted by health professionals, designed to achieve timely identification and referral of children with health and developmental problems

• include physical examination of the newborn child, periodic monitoring of the child's growth parameters, and formal hearing and vision screening tests at specific ages

• performed in partnership with parents through anticipatory guidance, eliciting parents' concern and observing the child

Timing of Developmental Surveillance

• health visits for immunisation

• opportunistic screening during episodic illness to family doctors

• children with identified risk factors (e.g. prematurity) as followed by paediatricians / specialists

• parents and carers express worries about their children’s development

Developmental Surveillance Scheme (發展監察)

DSS Level I

Anticipatory guidance to parents through MCHCs and FHS website

–Development leaflets

–Videos on normal child development (0 – 6 years)

–“Happy Parenting” workshops in MCHCs

–Web parenting resources

Developmental Surveillance Scheme (DSS)

DSS Level II

Developmental Surveillance Questionnaires (DSQ)

– 10 (routine + optional) DSQs from 0 to 5, administered by nurses

– Developmental areas covered: • motor (gross & fine)

• communication & language

• social behaviour & play

• cognition

• self-care

• vision & hearing

– Concern from parents elicited & discussed

Interviewing parent

Observation

Providing guidance

Developmental Surveillance Scheme (DSS)

DSS Level III

Developmental Assessment by MCH doctors

Doctor’s

Assessment

(Level III)

Referral to DH/HA CAC and/or

other HA SOPD

DSQ

by nurses

(Level II)

Follow-up by

Nurses

Some Questions to elicit Parents’ Concerns

• Do you have any concern about your child’s development, behaviour or learning?

對孩子的發展、行為或學習，你有沒有特別擔心?

• Do the teachers have any concern/complaint about your child’s development, behaviour or learning?

對孩子的發展、行為或學習，老師有沒有特別擔心?

• Is the child receiving or waitlisted for any specialist services, training, assessment or school placement?

孩子有否正在接受或輪候專科覆診、治療訓練、評估

或學位安排?

Developmental History

• Parent concern

• Antenatal and postnatal history

• Developmental milestone

• School (and extracurricular activities) performance

• Family history

• Psychosocial history

Developmental Milestones

• Examples of online developmental milestone checklists: – Family Health Service, Child Health Information

http://s.fhs.gov.hk/s649c

– Centers for Disease Control and Prevention. Developmental Milestones.

http://www.cdc.gov/ncbddd/actearly/milestones/index.html

– Parents’ Evaluation of Developmental Status (PEDS): Developmental Milestones

https://pedstest.com/index.html

– Ages & Stages Questionnaires. ASQ-3 http://agesandstages.com/

– ZERO TO THREE https://www.zerotothree.org/resources/72-infant-and-toddler- development-screening-and-assessment

Red Flags/ Warning Signs

• Red flags at any stage: – Strong parental concerns – Significant loss of skills – Lack of response to sound or visual stimuli – Poor interaction with adults or other children – Lack of or limited eye contact – Differences between right and left sides of body in strength,

movement or tone – Marked low tone (floppy) or high tone (stiff and tense) and

significantly impacting on development and functional motor skills

Child Development Program in conjunction with Brisbane North Primary Health Network. Red Flags Early Identification Guide [document on the Internet]. Queensland Government: Children’s Health Queensland Hospital and Health Service; July 2016

Some General Warning Signs

Consider vision/ hearing check ( e.g. MCHC or Eye/ ENT specialists) : • Parental or teacher concerns about vision/ hearing at any age

Consider investigation ( e.g. Paediatrician, Geneticists ) : • Abnormal muscle tone (including floppiness or increased muscle tone),

asymmetry of movements or other features suggestive of cerebral palsy or neuromuscular diseases

• Dysmorphic features

• Complex disabilities

• Abnormal growth parameters; e.g. Head circumference above 99.6th centile or below 0.4th centile, or crossed two centiles (up or down)

• Signs of neuromotor delay especially in the first year

Some Age Specific Warning Signs

Clinical Observation and Physical Exam

• Focused attention to specific cues on what the child can and cannot do according to the relevant stage of development, in particularly after eliciting the parent’s / carer’s concern

• Tools such as building blocks, small beads, books, pencil and paper, doll and tea-set toys etc. may be used to aid the assessment

• Physical examinations to detect medical problems and potential etiologies

Bellman M, Byrne O, Sege R. Developmental assessment of children. BMJ. 2013 Jan15;346:e8687.

Identify Risk and Protective Factors

• Biological and Environmental • Child and Family

• Some Risk factors: – Biological :

• genetic disorders, birth related issues (e.g. prematurity), chronic illness

– Environmental: • low parental education, parental mental illness, poverty and its

consequences, social isolation, poor housing, poor hygiene, cultural factors, poor quality services, and lack of access to services, victimization, disaster

• Some Protective factors: – A loving, supportive family – Opportunities to interact with other children – Opportunities to grow and learn in an environment with appropriate structure

Components of Developmental Surveillance

• Elicit and attend to parental concerns

• Obtain a relevant developmental history

• Make accurate and informative observations of children

• Identify risk and protective factors

• Maintain accurate record for documenting the process and findings

Some Common Developmental Problems

Some Developmental Problems

• Global Developmental Delay

• Intellectual Disability

• Hearing Impairment

• Visual Impairment

• Language Impairment

• Autism Spectrum Disorder (ASD)

• Attention Deficit/ Hyperactivity Disorder (ADHD)

• Dyslexia

Global Developmental Delay

• Refers to children, usually taken as under 5 years of age, whose developmental levels are substantially behind the average expectations of children of the same age across two or more developmental domains of development

• “Significant delay” is taken to refer to scores more than 2.0 SD below the mean on norm-referenced age-appropriate developmental tests, while “borderline delay” is taken as 1.5 to 2.0 SD below the mean

(Shevell et al. 2003, APA 2013)

Intellectual Disability

DSM-5 (APA, 2013)

• Intellectual disability involves impairments of general mental abilities that impact adaptive functioning in three domains, or areas (conceptual, social and practical).

• onset of intellectual and adaptive deficits occurs during developmental period

Intellectual Disability

• The conceptual domain includes skills in language, reading, writing, math, reasoning, knowledge, and memory.

• The social domain refers to empathy, social judgment, interpersonal communication skills, the ability to make and retain friendships, and similar capacities.

• The practical domain centers on self-management in areas such as personal care, job responsibilities, money management, recreation, and organizing school and work tasks.

Deficits in intellectual functions is defined as an IQ of approximately two standard deviations or more below the population mean (i.e.

about 70 or below).

-2SD

IQ score

Hearing impairment

Some Risk factors – Caregiver concern regarding hearing, speech, language

– Intrauterine infections

– Neonatal intensive care unit (NICU) admission ≧5 days

– Extracorporeal membrane oxygenation (ECMO)

– Severe hyperbilirubinaemia that requires exchange transfusion

– History of meningitis

– Recurrent or persistent otitis media for at least 3 months

– Head trauma, especially basal skull/ temporal bone fracture

– Exposure to chemotherapy or ototoxic medications

– Congenital syndromes e.g. neurofibromatosis, Usher syndrome

– Craniofacial abnormalities involving the pinna, ear canal, ear tags, ear pits and temporal bone e.g. cleft palate, deformed auricle, defects of ear canal

– Family history of childhood hearing impairment

Hearing impairment

Some early signs – During Infancy : ‧Not startled by sudden sound (1-3 months old)

‧Unable to turn to the source of sound (4-6 months old)

‧Do not look at the person being mentioned (7-9 months old)

‧Do not respond to own name (10-12 months old)

– During early childhood : ‧Language delay

‧Cannot hear clearly or request for repetition during conversation

‧Misinterpret instructions

‧Poor attention in class

‧Turn up the sound volume of television

Hearing impairment

• Universal hearing screening for newborn: – 2-stage Automated Auditory Brainstem Response (AABR) is used to

screen all babies born in hospitals of Hospital Authority.

– Automated Oto-Acoustic Emission (AOAE) Test is offered to babies, not screened before discharge from birthing hospitals, aged between 2 weeks and 4 months in MCHC.

• Hearing screening for students: – Routinely conducted by the Student Health Service (SHS) for all

primary 1 and secondary 2 students.

– Other students who have concerns about hearing could also request for hearing screening during annual health assessments.

Visual Impairment

Some early signs

– During Infancy: • Lack of eye contact

• Do not look at his/ her hands

• Do not blink to bright light

• Do not visually follow objects moving in front of his/ her face

• Do not reach out for toys

• Responds only to sound and slow response to visual hints

• No imitation of others’ action or facial expression

• Fear of gross motor activities like crawling

Visual Impairment – During early childhood:

• Lack of eye contact

• Tend to hold objects very close to eyes when looking at them

• Limited facial expression and body language

• Abnormal responses to bright light

• Often bump into objects or fall over

• Get confused with directions, use hands to search for directions

• May press on eyeballs with fingers

• Jerky movement of the eyeballs

• Abnormal head tilt when looking

• Maybe presented as emotional, behavioural and learning problem

• Physical signs such as strabismus, nystagmus, leukokoria or microphthalmia

Visual Impairment • Vision screening:

– Newborn / infant • eye examination for presence of red reflex

– Infants at risk for eye problems • e.g. retinopathy of prematurity, or those with family histories of

congenital cataracts, retinoblastoma, and metabolic and genetic diseases • early and regular ophthalmologic examinations by paediatricians and

ophthalmologists

– MCHC provides vision screening for preschool children • at 4 years or above

– SHS provides vision screening to school age students • annual visual acuity screening P1 to S6 • colour vision screening P6 • stereopsis screening P1 • an additional vision screening test for amblyopia for students aged 10 or

less who failed the visual acuity test

Language Impairment

• Specific language impairment/ Developmental language disorder is a developmental disorder that is diagnosed when a child's language development is disproportionately poor relative to other skills for no apparent reason

Language Impairment

Differential diagnoses

‧Normal variation

‧Developmental language disorder

‧Hearing impairment

‧Psycho-social deprivation

‧Other developmental problems – Autism Spectrum Disorder

– Intellectual disability / Global developmental delay

– Structural abnormalities e.g. cleft palate

– Disorders of oro-motor control e.g. cerebral palsy

Language Impairment

‧Communication intention

‧Verbal comprehension

‧Verbal expression

‧Phonology

Red flags of Language Development

Autism Spectrum Disorder

• A biologically based neurodevelopmental disorder characterized by impairments in two major domains:

– deficits in social communication and social interaction

– restricted repetitive patterns of behaviour, interests, and activities

Attention Deficit/ Hyperactivity Disorder

• AD/HD is a neurobiological disability characterized by developmentally inappropriate behaviour · inattention

· impulsivity

· hyperactivity

• Symptoms are maladaptive, persistent and present across different settings

• Comorbidities: may coexists with dyslexia, behavioural and emotional disorders, also ASD

• Response to stimulant medication

Behavioural / Emotional Problem

• Developmental history

• Parent and other carer report

• Teacher report, including extracurricular activities tutors

• Family history

• Clinical observation

Dyslexia

• A primary reading disorder due to abnormality in word decoding

• Not the direct result of intellectual disability, sensory impairment, environmental factors, inadequate educational opportunities, or social / emotional problems

• Difficulties in – Word recognition, spelling and dictation

– Reading comprehension (as a secondary problem)

Dyslexia

Some early signs:

Difficulty in recognizing and reading characters or words despite repeated studies. • Mixing up characters with ‧ similar shape, e.g. "毛"as "手“ ‧ similar or related meaning, e.g. read "快樂" as "高興", "秩序" as "規則"

• Slow in reading and sometimes may skip words or lines

Failure of accurate recall of simple words in dictation despite repeated studies. • Wrong patterns in writing words, including ‧ addition or deletion of strokes, e.g. “春” as “ ”. ‧ reversal of left and right component of a character, e.g. “如” as “𠯆”

• Characters are written slowly and in wrong sequence

Learning Problem

• Developmental history

• Medical history

• Education history

• School report / error pattern

• Family history

• Clinical observation: Word reading/ writing

Role of the Physician in Childhood Developmental Disorders

• Recognition and Identification

• Rule out medical causes / provide treatment

• Appropriate advice, referral and follow through with child’s progress and service availability

• Be the child and family’s advocate!

Management / Referral

• For children with significant developmental problem(s)

– continue service at existing service provider and follow up

– refer for further comprehensive assessment / investigation as indicated

– refer therapy / training as indicated

• For children with minimal problem/ suspected normal variation

– observe and monitor progress

– continue developmental surveillance/ annual health visits • Maternal and Child Health Centres (for preschool children) or

• Student Health Service Centres (for school aged children)

• For children with learning related problem

– encourage parents to inform school • Teacher observation and classroom support

• Assessment by educational psychologist as indicated

• Advice to parents

– Positive parenting

– Home safety

– Home stimulation

– Collaboration with school

– Local community resources

Local Services and Community Resources

Family Health Service 家庭健康服務

The Integrated Child Health & Development Programme (ICHDP)

幼兒健康及發展綜合計劃

www.fhs.gov.hk

e-Parenting Resources e-newsletter ; on-line self learning parenting programme

Printed Health Education Resources (html / pdf format)

The Preschool Component of Developmental Surveillance

Early Identification by Preschool teachers and Referral to MCHCs • Formal referral mechanism established between preschools and MCHCs

• Training kit for preschool teachers

• Provide training to preschool teachers on child development and parenting

• Distribution of child development warning sign leaflet to teachers and parents of K1 children through EDB

http://www.edb.gov.hk/en/edu-system/preprimary-kindergarten/comprehensive-child-development-service/index.html

Child Assessment Service 兒童體能智力測驗服務

www.dhcas.gov.hk

Child Assessment Service (CAS)

• Provide comprehensive developmental assessments, diagnosis, formulates rehabilitation plan, as well as review evaluation to children under 12 years of age who are suspected to have developmental problems

• Provide interim support to the parents to enhance their understanding of their children and community resources so that the parents could provide home-based training to facilitate the development and growth of the children

Child Assessment Service (CAS)

• Public Education – provide information and promote public awareness to the special needs of children with developmental problems

• Professional Education – provide clinical attachment to all Paediatrics trainees, including Developmental-Behavioural Paediatrics subspecialy

• Conduct clinical related research and studies such as epidemiological studies and assessment tools development for use by the professional community and for service planning.

Factsheets

Child Assessment Service (CAS)

Multi-disciplinary Structure of CAS

• The multi-disciplinary assessment team of DH CAS comprises Paediatricians, Clinical Psychologists, Audiologists, Speech Therapists, Optometrists, Physiotherapists, Occupational Therapists, Nurses and Medical Social Workers

Child Assessment Centres (CACs) • There are currently 7 CACs under DH located in

Kowloon and the New Territories serving the whole population in Hong Kong

* There is one CAC under HA in Hong Kong Island, DKCH

Developmental Assessment

• Conduct thorough diagnostic evaluation ∙ Developmental history ∙ Parent and teacher report ∙ Clinical observation ∙ Semi-structured/ standardized tools

• Identify associated medical, behavioural and other developmental comorbidities

• Provide supportive counseling and interim support service for parents

• Provide recommendations on appropriate, evidence-based educational and behavioural intervention, and to arrange appropriate specialist follow-ups and rehabilitation/ educational services

Student Health Service 學生健康服務

http://www.studenthealth.gov.hk/

Student Health Service (SHS)

• Provide health promotion and disease prevention services to all primary and secondary day school students through its 12 Student Health Service Centres

• Enrolled students will be given an annual appointment for health appointment for health assessment. Services include:

– Body Weight, height and blood pressure measurement

– Screening tests for vision, hearing and spinal assessment

– Health interview by nurse

– Doctor consultation: History taking and Physical Examination

– Psychosocial health assessment, questionnaires

– Mop-up immunisation for secondary school students

– Student Health Record

• Students found to have specific health problems will be referred to Special Assessment Centres of SHS, specialists, school social worker or other appropriate organisations for further assessment and management

Hospital Authority

Specialist clinics – Paediatrics

– Child & Adolescent Psychiatry

– ENT

– Ophthalmology

– Speech therapy

– Physiotherapy

– Occupational therapy

Rehabilitation Services for Preschool Children Social Welfare Department

Central Referral System for Rehabilitation Services – Subsystem for Disabled Pre-schoolers CRSRehab-PS 康復服務中央轉介系統-弱能兒童學前服務子系統 • Early Education Training Centre EETC 早期教育及訓練中心

• Integrated Programme in Kindergarten-cum-Child Care Centre IP / ICCC

幼稚園暨幼兒中心兼收弱能兒童計劃 • On-site Preschool Rehabilitation Service Pilot Scheme OPRS 到校學前康復服務試驗計劃

• Special Child Care Centre SCCC 特殊幼兒中心

• Social Welfare Department (Preschool Rehabilitation Services) http://www.swd.gov.hk/en/index/site_pubsvc/page_rehab/sub_listofserv/id_serpresch/

• Social Welfare Department (Training Subsidy Programme for Children on the Waiting List of Subvented Pre-school Rehabilitation Services) http://www.swd.gov.hk/en/index/site_pubsvc/page_rehab/sub_listofserv/id_tsp/

SEN Support for School ChildrenEducation Bureau

Special schools SEN support in mainstream schools

• Education Bureau: Special Education Resource Centre

教育局特殊教育資源中心 http://www.edb.gov.hk/index.aspx?nodeid=2524&langno=2

• 政府為懷疑有發展障礙的學齡兒童提供的評估服務

http://www.edb.gov.hk/attachment/tc/edu-system/special/resources/serc/download/dev%20disorder%20leaflet-chi.pdf

• 教育局及早識別和輔導有學習困難的小一學生計劃

http://www.edb.gov.hk/attachment/tc/edu-system/special/resources/serc/download/eii_chi_2016.pdf

The Primary Care Office (PCO) of Department of Health has published the

Hong Kong Reference Framework for Preventive Care for Children in Primary Care Settings to provide common reference to primary health care professionals to facilitate the provision of continuing, comprehensive and evidence-based children care in the community. - Module on Development - Posters on “Know More about Child Development”

(“兒童發展知多點”) https://www.pco.gov.hk/english/health_professionals/professionals_preventive_children_pdf.html

A4 summary chart on Development

Poster on Development (0-12m) Poster on Development (1-6 yr)

Welcome to PCO website for details

and hardcopies of posters!

https://www.pco.gov.hk

Q&A

Thank you!