Development

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  • Dev assessment / screening is only a part of child health surveillance.
  • Dev screening is aimed at presymptomatic detection of disability by examining children serially to determine whether they are developmentally normally developed? Screening process should be brief, simple, cheap and reliable. Appropriate timing is 6 weeks, 8 mo, 18 mo, 2 ½ yrs and 4-5 yrs. Screening may be combined with immunization or routine visits. Done by a doctor, health worker or a trained person. Dev assessment is carried out on a child discovered by dev screening to have dev dela or behavioural disorder to establish wheher there is a problem and if so the type and causes. This carried out by a team lead by a developmental pediatrician
  • Child playing with foot and hands and keep foot in the mouth. Starts at about 4 mo and should disappears by 9 mo. Persistence beyond 1 yr indicates dev delay
  • Development

    1. 1. Developmental Pediatrics DR.N.UDAYAKUMAR, ASSOCIATE PROFESSOR OF PEDITRICS, SRMC&RI, PORUR. 1
    2. 2. Formal Screening Tests ASQ Clams Cat Early screening inventory DenverII Denver I TDSC ELM Busy Pediatrician
    3. 3. “ 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
    4. 4. 25 million yearsEvolution Development 25 months
    5. 5. Develop. Screening All Children Develop. Assessment Quick Subjective Gen. Pediatrician in his clinic Children with perinatal events, risk factors, delay suspected Time consuming Objective - tests Dev. Pediatrician || Neurologist ENT Surgeon Ophthalmic Ortho Child psych. Physiotherapist occupational, speech School teacher Mother
    6. 6. Objectives • Sensitization - Dev. Screening • Early identification & appropriate referral • Simple format using – Ordinary tools – Within 10 - 15 minutes – Clinic / OP settings – Subjective assessment
    7. 7. Beyond the Scope of this Lecture • Detail Assessment • Formal - objective tests Specific disabilities • ADHD, deafness, MR, autism, LD Special investigation • BERA
    8. 8. Why should we assess ? • To reassure parents • Early diagnosis and management of disability • Feedback for obstetrician and neonatologist • Prevention in next sibling
    9. 9. 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
    10. 10. Four Aspects of Development • 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
    11. 11. 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
    12. 12. 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. 14
    13. 13. • 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. 15
    14. 14. • 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. 16
    15. 15. • 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. 17
    16. 16. Prevalence Low frequency high morbidity – Cerebral palsy Visual or hearing impairment – Autism – Mental retardation High frequency low morbidity – Learning disability – ADHD
    17. 17. 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
    18. 18. Three part assessment • History - Medical & Social • Examination - General & CNS • Developmental Screening
    19. 19. History • Risk factors – Prematurity – Adverse perinatal events – Family history • Warning signals – Mother’s suspicion – Inattention to sound • Dev. History – Tracking of Milestones
    20. 20. Physical examination • Growth parameters • Congenital anomalies • Skin findings • Eye findings • Abnormal facies • Organomegaly
    21. 21. Neurological examination • Classical • Extended examination – Symmetry – Quality of movement – Primitive reflexes – Postural response
    22. 22. Scissoring posture
    23. 23. Dev. 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
    24. 24. 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
    25. 25. Ideal Environment for Assessment Place Mother’s lap Non threatening Time Not hungry, not sleepy Not sick, not fatigued Method By History Observation of play Formal examination
    26. 26. 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)
    27. 27. 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
    28. 28. 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
    29. 29. Testing 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
    30. 30. New born Ventral suspension 6 weeks Head in same plane 18 weeks Head held up 12 weeks Floppy child12 weeks Floppy child
    31. 31. 4 weeks Complete head lag 2 months Partial head lag 4 months No head lag Lifting headup slightly
    32. 32. 6 weeks Chin off couch intermittently 10 - 12 weeks Forearm support 24 weeks Hand support
    33. 33. 10 - 20 weeks Hand regard
    34. 34. 44 weeks creeping position 52 weeks Bear walk
    35. 35. 6 months Immature grasp 8 months Intermediate grasp 1 year Mature grasp 10 months Index finger approach 10 months Pincer grasp
    36. 36. 3 weeks Palmar grasp reflex
    37. 37. 4 weeks Rooting reflex
    38. 38. 4 weeks Visual tracking
    39. 39. 6 weeks Concentrating on rattle Beginning of eye - hand coordination
    40. 40. 6 weeks Social smile
    41. 41. 4 months Head control, eye contact, good interaction
    42. 42. 4 months Holding head & looking further away
    43. 43. 5 months Palmar grasp and biting the rattle
    44. 44. 5 months Reaching out for rattle
    45. 45. 6 months Bearing weight on legs
    46. 46. 6 months Holding and exploring rattle
    47. 47. 6 months Turning to sound of rattle
    48. 48. 6 months Sitting with support examining the mat
    49. 49. 7 months Sits steadily
    50. 50. 10 months Finding hidden objects
    51. 51. 1 year Examining the soap box with interest (house hold objects can be used)
    52. 52. 1 year Communicating with gestures Mother holding out hand - baby gives the toy Communicating with gestures Mother holding out hand - baby gives the toy
    53. 53. 1 year Walking with broad base in response to mother’s call Walking with broad base in response to mother’s call
    54. 54. 1 year Making gestures to communicate pointing with leaf
    55. 55. 1 year Imitating and copying Both are striking the wooden blocks Imitating and copying Both are striking the wooden blocks
    56. 56. 2 years 2 1 /2 years 3 years 4 years 4 1 /2 years 5 1 /2 years 6 1 /2 years Drawing tests - L O C S T D
    57. 57. Interpretation • Give allowance for prematurity, fatigue, illness, familial pattern • If in doubt, repeat later • Remember - wide range of normal deviation
    58. 58. After 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 ?
    59. 59. • 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 Variant
    60. 60. Causes of Motor Delay • Normal or Familial variation bottom shuffling • Chronic illness • CP • Neuromuscular diseases - DMD, SMA • Orthopedic - CDH • Rickets • Emotional neglect
    61. 61. 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
    62. 62. Language delay • Reception is well advanced than expression – Hearing defects – Familial & genetic – Global delay – Autism – Environmental
    63. 63. Global Delay • Chromosomal defects • Syndromes • CP • Structural brain defects • Neurometabolic problems • Postnatal causes
    64. 64. Factors affecting development • Genetic • Physical • Nutritional • Emotoinal • Sociocultural • Neurological 66
    65. 65. Developmental Quotient • Computed by the following formula • Developmental age / Chronological age X 100 67
    66. 66. INTELLECTUAL QUOTIENT • MENTAL AGE /CHRONOLOGICAL AGE. • <70- MENTAL RETARDATION. • GLOBAL DEVELOPMENTAL DELAY <3 YEARS. 68
    67. 67. Development 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) 69
    68. 68. BONE 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) 77
    69. 69. WHO 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. 78
    70. 70. SLEEP 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. 79
    71. 71. 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
    72. 72. Decisions • Abnormal • Probably normal • Doubtful • Normal See again Refer
    73. 73. 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
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