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
• 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
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
4 1/2 years4 1/2 years
5 1/2 years5 1/2 years
6 1/2 years6 1/2 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
67
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.
68
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)
77
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
• Use TDSC to screen
• Go little more deeper with Development Chart
(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
• Use TDSC to screen
• Go little more deeper with Development Chart
(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