Developmental screening in children

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Developmental screening in children

  1. 1. Dr .Raghavendra S
  2. 2. Developmental delay, defined as a 25% departure from typical performance in ≥2 developmental domains (e.g., receptive language, expressive language, fine motor, gross motor, social-emotional, cognitive/pre-academic, and behavior). Developmental Deviance In addition to delays in development, physicians should also recognize deviations in development. Deviance occurs when a child develops milestones or skills outside of the typical acquisition sequence. An example of this can be seen in conditions such as cerebral palsy, in which the infant rolls over early secondary to increased extensor tone
  3. 3. Developmental dissociation Dissociations arise when a child has widely differing rates of development in different developmental domains. For example, children with autism often have typical gross motor development but significantly delayed language development, therefore language development has dissociated from gross motor development.issoc Developmental regression Regression is when a child loses previously acquired skills or milestones, and although less common than the other patterns, should cause the greatest concern since it is often associated with serious neurological and inherited metabolic disorders.
  4. 4. Of children with measurable delays or disabilities, the most common (and least well-identified) condition is speech-language impairment (17.5% at 30-36 mo) Other common conditions are social-emotional disorders (9.5-14.2%)  attention-deficit/hyperactivity disorder (7.8%) learning disabilities (6.5%) intellectual disabilities (1.2%) autism spectrum disorders (0.6-1.1%) Less common conditions include cerebral palsy (physical impairments) (0.23%), hearing impairment (0.12%), vision impairment (0.8%) and other forms of health or physical impairments (e.g., Down syndrome, fragile X syndrome, traumatic brain injury).
  5. 5. Prevalence and significance  As estimated by the World Health Organization (WHO), about 5% of the world’s children 14 years of age and under have some type of moderate to severe disability  In India, sources have found prevalence of 1.5-2.5% of developmental delay in children under 2 years of age  Evidence supports that early treatment of developmental disorders leads to improved outcomes for children and reduced costs to society  studies in the US have shown only about 1/3 of children are identified prior to school entrance, and as a result, miss out on the proven long term benefits of early intervention
  6. 6. Risk factors for Developmental Delay  history of abuse or neglect  parents with less than a high school education  parental mental health problems (depression or anxiety)  housing and food instability  ethnic or linguistic minority  ≥3 children in the home  authoritarian parenting style (e.g., highly directive, rarely engaging verbally in children's unique interests, punitive)
  7. 7. Only about 25% of children with developmental delays are detected prior to school entrance, meaning that most children with problems will have missed opportunities for early intervention. Although clinicians are effective at detecting severe disabilities associated with congenital, metabolic, or genetic abnormalities, providers are far less adept at discerning the more common conditions because these typically lack overt dysmorphology
  8. 8. Reasons for underdetection in primary care  dependence on nonstandard administration of standardized screens (including selected items from longer measures) and informal milestones checklists; both approaches lack proof of validity and criteria for making accurate decisions  failure to continually check on developmental progress  clinical judgment (because it tends to depend heavily on dysmorphology and organicity, which are not present in the majority of children with disabilities)  requirement of repeated screening test failure before making a referral (due to lack of awareness that quality screening measures are highly reliable and that a repeated screen is likely to yield identical results);
  9. 9.  false optimism about outcome (children rarely outgrow developmental problems in the absence of intervention);  discomfort at delivering difficult news  lack of familiarity with tools effective for busy primary care settings
  10. 10. To improve better detection in primary care, the American Academy of Pediatrics recommends developmental screening and surveillance at well visits. Developmental screening refers to the administration of brief, standardized, and validated instruments that have been researched for their sensitivity in detecting children with probable problems and specificity in determining when children probably do not have problems. Standards for screening test accuracy are 70- 80% sensitivity and specificity Screening is defined as a brief, formal, standardized evaluation that aids in the early identification of patients at risk for a developmental and/or behavioral disorder
  11. 11. The ideal screening method should use a standardized and validated tool with established psychometric qualities, be easy to perform and interpret, be inexpensive to administer, and have good sensitivity and specificity. Furthermore, this tool should be norm referenced and standardized on a population which is representative of the group to be tested. The American Academy of Pediatrics (AAP) describes "good" screening tools as those with sensitivity and specificity in the 70-80% range
  12. 12. Screening tools can assist in identifying at-risk children they do not provide diagnoses. When a child passes a screening test it provides an opportunity to promote developmentally appropriate activities and discuss age appropriate milestones. Children who fail a screening test need close follow- up and additional assessment. Additional assessment and early intervention referral should not be delayed by what has typically been called a "wait and see" approach Referral for an in-depth diagnostic evaluation by a developmental-behavioral specialist and referral for interventions (i.e. speech and language therapy, occupational therapy, physical therapy, special educational services etc.) do not require a diagnosis.
  13. 13. Developmental surveillance Developmental surveillance is defined as a flexible, longitudinal, continuous process through which potential risk factors for developmental and behavioral disorders can be identified Five components to surveillance: •Eliciting and attending to the parents’ concerns about their child’s development, • Documenting and maintaining a developmental history, • Making accurate observations of the child, •Identifying risk and protective factors, and • Maintaining an accurate record of documentation of the surveillance process and findings
  14. 14. Approaches to Screening  The three approaches to screening include informal, routine and focussed developmental screening  Informal screning is based on observing the child during a routine pediatric check up and asking parents about their concerns about child's development. The pediatrician, how- ever, needs to be familiar with the various developmental milestones at different ages. Such an approach is not a very sensitive way of screening as it is only useful for not missing major delays in a busy office practice  Routine formal screening entails systematic developmental screening of all children with the help of standardized screening instruments. However, such an approach is highly time consuming as it requires large number of trained manpower and may not be warranted given the low incidence of developmental problems among low risk population of children
  15. 15.  Focussed screening involves developmental screening of the following groups of children: (a) Children whose parents express developmental concerns or in whom teachers and physicians suspect problems. (b) Newborns with conditions that have known to have high risk for develop- mental delay
  16. 16. High Risk Infants Needing Periodic Assessments Very low birth weight (<1500 g) Neurologic conditions Intraventricular hemorrhage Gr. III or IV Periventricular leukomalacia Hypoxic ischemic encephalopathy Apgar score 0-3 at 10, 15 and 20 min Meningitis Persistent seizures Apnea beyond term Abnormal neurological condition during first week of life Hyperbilirubinemia Symptomatic hypoglycemia with seizures Septicemia
  17. 17.  The concept of "at risk" newborns is being replaced by some authors by the concept of "optimality". Newborns with a low "optimality score" are considered highly likely to develop neuro developmental disabilities later in life.
  18. 18. Strategies for Early Detection  In 2006, the AAP released a policy statement and algorithm for developmental surveillance and screening in children from birth to 3 years of age  The policy statement recommends developmental surveillance at each health maintenance visit in childhood, with the administration of a standardized developmental screening tool for those who have concerns by surveillance  it is recommended that a standardized developmental screening tool should be used routinely at the 9, 18, and 24- 30 month health maintenance checks, regardless of surveillance results
  19. 19.  If there are concerns by surveillance that do not yield concerns by developmental screen, the child should have early follow-up visits.  if the developmental screen is concerning, the child should be referred for early intervention, with developmental and medical evaluations planned.  The original policy statement did not specifically address older children, but screening at the 4 year or 5 year preventive visit was subsequently recommended for early detection of academic/learning problems  If a child passes a screen, praise and reassurance should be provided to the parents. However, if a child fails a screen, it should be explained to the parent that a more comprehensive evaluation is required. In the discussion of a failed screen, it is important to emphasize screening tools are not intended to diagnose a developmental disability, but are instead used as guides to further assessment of developmental delays.
  20. 20. Developmental Screening Tools  There are a variety of screening tests to choose from, many of which are completed by parents and require only a short period of time to administer and score. These questionnaire screening forms are convenient, as there are no directly administered test items and scoring requires minimal training  The Parents’ Evaluation of Developmental Status PEDS is a parent interview form that provides an algorithm to guide a need for referral, more screening, or continued surveillance. The PEDS has open ended questions to parents, such as "Do you have any concerns about how your child understands what you say?" It takes under 10 minutes to complete and has been translated into over 10 different languages.
  21. 21.  The Ages and Stages Questionnaire (ASQ) parent-completed questionnaire that may be used as a general developmental screening tool, evaluating five developmental domains: communication, gross motor, fine motor, problem-solving, and personal adaptive skills, for children 4 to 60 months old. It relies on specific questions to parents, such as, "Does your baby laugh?" The ASQ is estimated to take under 15 minutes  A validated autism screen widely used in the US is the Modified Checklist for Autism in Toddlers (M-CHAT), a 23- item parent completed questionnaire designed to screen children between 16 to 30 months of age. It is available in a number of languages with the validation of these translations underway.
  22. 22.  Denver Development Screening Test (DDST). The DDST is used to screen children from two weeks through 6 years of age in four developmental domains; gross motor, fine motor adaptive, personal social and language skills. The test consists of 5 items but only those items are administered which are appropriate to the child's age. Each item is scored pass or fail. A delay score is given to an item which is failed by the child that is passed by more than 90% of children in the normative age group. Scores are interpreted as "abnormal", "questionable", or "normal" in each sector. The main usefulness of the test is that it is easy to administer and score and does not require extensive training or experience in testing. The DDST is most useful in identifying children with moderate to severe motor or cognitive deficit. However its usefulness is limited in detecting more subtle delays
  23. 23.  Concerns about the inadequate psycho- metric properties of the DDST prompted a major revision of the test and led to the development of Denver II. The major differences between the DDST and Denver II are an increase in the language items, inclusion of articulation items, a new age scale, a new category of identifying milder delays, and a behavior rating scale. However, this test too has been criticized for its limited specificity and has not been extensively used in the Indian setting.  The DP II is designed to assess a child's development from birth through age 9Yrs. It is an 186 items inventory which assesses a child's functional developmental age in five domains, i.e., physical, self-help, social, academic and communication.
  24. 24. Scenario in India  minimal training required, which allows for ease of administration by house-to-house child development workers.  The Baroda Development Screening Test for Infants Developed from the Bayley Scales of Infant Development and normed on Indian children up to 30 months of age. It has motor and cognitive items and provides an age equivalent and a developmental quotient. It was designed to be a test easily administered by health workers for door- to- door surveys, as well as in clinical practice.
  25. 25.  The Developmental Assessment Tool for Anganwadis (DATA) designed for identifying toddlers aged 1.6 to 3 years attending Anganwadis (government sponsored preschool centers in India) and administered by Anganwadi workers, at risk for or with developmental delays. The DATA evaluates motor, cognitive, personal-social and language skills  Trivandrum Developmental Screening Chart (TDSC) developed from the Bayley Scales (using Baroda Norms). It is a 17 item screening tool for children up to 24 months of age, requiring minimal training for administration. he TDSC can be done in 5 minutes and covers mental and motor developmental milestones.
  26. 26.  The Disability Screening Schedule (DSS) broad based screen for the identification of major disabilities in children under 6 years of age. The authors of the DSS designed it to be distinct from among others as a one-time screening instrument for all major disabilities. It was also created to be easily administered with minimal training.  The Early Language Milestone Scale (ELM scale) is a screening test of speech and language development for use with children from birth to 36 months. The ELM scale consists of 41 items and covers 3 areas of language function: auditory receptive, auditory expressive and visual language. This scoring system is particularly useful in high risk settings such as Neurodevelopmental clinics, Audiology clinics, and Neonatal high risk follow up clinics.
  27. 27.  When concerns for potential developmental and behavioral problems are present either by surveillance or screening, a detailed medical history and physical examination is an essential part of decision making.  This should include reviewing results of the newborn metabolic screen, the most recent vision and audiologic screening, as well as environmental screening (e.g. lead testing).  Past medical history is important for eliciting risk factors including biological (e.g., prematurity), genetic (e.g., Down syndrome), environmental (e.g., lead exposure) and psychosocial factors (e.g., maternal education, family income, marital status etc.).  protective factors should also be documented and may include a supportive family structure, opportunities to interact with other children in a safe environment, and consistent expectations with age appropriate limitations
  28. 28.  A developmental history reviewing the acquisition of developmental milestones should be taken, evaluating gross motor, fine motor, expressive and receptive language, as well as social skills.  Family history should include reviewing for developmental delays, learning disabilities, hyperactivity, and other behavioral and psychiatric problems.  physical examination should include, but not be limited to, evaluating growth parameters, including head circumference, dysmorphology, and a complete neurologic examination. In evaluating growth parameters, careful attention should be paid to head circumference, looking for macrocephaly, microcephaly, or an increased growth velocity. Dysmorphologic examination should look at both minor and major anomalies that might explain the etiology of the developmental delay. A neurologic examination should review strength, tone, symmetry and evaluate for the presence or absence of primitive reflexes.
  29. 29. Laboratory Tests  The recommended laboratory and imaging studies and consultations recommended by the AAP, the American Academy of Neurology, and the American College of Medical Genetics include cytogenetic studies, DNA testing for Fragile X syndrome, and microarray-based chromosome analysis.  In the child with global developmental delay, 3-4% of the time, an abnormality may be found on standard chromosome analysis  For children with an autism spectrum disorder, an abnormal chromosome analysis occurs about 7% of the time  Neuroimaging with an MRI  An EEG  Metabolic screening - reserved for those with pertinent history or physical findings  audiologic and ophthalmologic assessment.
  30. 30. Neurological examination  Amiel-Tison has provided us a comprehensive system of neurological evaluation for first five years of life for instituting physical therapy program.  In Amiel-Tison meathod of neurological evaluation presence of hypotonia is identified by measuring the following angles 1. Adductor angle 2. Popliteal angle 3. Dorsiflexion angle of foot 4. Scarf sign
  31. 31. THANK YOU

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