Developmental assessment for residents and MRCPCH exams

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Summary of Developmental assessment for paediatric residents and trainees

Summary of Developmental assessment for paediatric residents and trainees

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  • 1. Dr. Varsha Atul Shah Senior Consultant Singapore General Hospital Developmental Assessment For Residents and for MRCPCH Exam
  • 2. Visit link Free book download http://www.scribd.com/doc/44390551/Fro m-Birth-to-Five-Years Videos http://www.martindalecenter.com/Medica lClinical_Exams.html http://library.med.utah.edu/pedineurologic exam/html/home_exam.html
  • 3. What the examiner is looking for:  A basic knowledge of the main developmental milestones  An ability to summarise the findings quickly, and show some understanding of assessment and management planning for children with disability.  It is unlikely that you will be asked to carry out a global assessment on any child except an infant (insufficient time). Usually you will be asked to carry out only one of the motor or language assessment.  Fine motor assessment  Language assessment  Social skills/ Personal development assessment  Play with this child and describe  An ordered approach to assessment of behaviour  Gross motor assessment  Describe behaviour
  • 4. Development station is 9 min  Any child, with a developmental age of 6 months – 5 years  Commonly preschooler
  • 5. Causes of Developmental Delay Delayed Motor Development Delayed Speech / Language Global Developmental Delay ▪ central: cerebral palsy, hemiplegia ▪ peripheral lesions ▪ visual impairment → affecting fine motor ▪ systemic disorders: hypothyroidism etc ▪ environmental: malnutrition, lack of practice ▪ central: autism, global learning difficulty ▪ isolated speech delay ▪ hearing loss ▪ environmental: malnutrition, lack of practice cerebral malformations hypoxic ischemic encephalopathy chromosomal abnormalities TORCH infections toxin exposure metabolic causes
  • 6. Usual lead in is ‘Would you please perform a language/Motor assessment?  You may or may not be told age of the child?  Once you know 18 months of development ‘backwards’, including time of appearance and incorporation of primary reflexes, then you can fairly interpret the findings
  • 7. WIPE approach:  Wash/WIPE Hands/Stethoscope with rub,  Introduce, Interact, Initiate, Inspect  Position yourself and baby and Play,  Examine, eyeball, engage, EEENT Eye- Eyeball whole Environment and baby from head to toe, Examine-Use hands Ear-Hear Nose-Smell, Throat-Talk  Begin by introducing yourself to parents, hand rub etc. 1st only look see, play…and examine.  Inform examiner about your approach either: - live commentary or - summarize after full examination
  • 8. General Inspection, Eyeball 1. Inspect for growth parameters e.g. FTT, syndromes, under nutrition can have Developmental delay 2. Syndromic/Dysmorphic features e.g. Down’s and other Trisomy, Fragile X, Catch22, 3. Appearance of Ex premature infants(prominent forehead, pig nose), correct the age. Obvious neurological anomalies like floppy infants, posturing, hemiplegic posturing, and involuntary movements.
  • 9. Position child if infant: If child is on mum’s lap(most of the time) can do : -1st vision and hearing, -2nd Fine Motor, -3rd language and personal social, -4th Gross Motor examination • Do not separate for GM assessment. • Bigger kids can examine on chair. • Infants lie in bed-180 degree flip exam
  • 10. TOOLS NEEDED: 1. Red yarn pom pom (4 cm diameter) with string and dangling, 2. Bright color 12 cubes 2.5 cm, 3. Rattle with narrow handle 4. Raisins or cheerio's or honey stars or m and ms 5. Cup, spoon 6. A 4 size paper 7. Big size color pencils 7. Picture cards, multiple picture books (like bird, fish, dog, bus, fruits etc) on same page, 8. Tennis ball 9. Small doll 10. Bell 11. Stickers, sweets for rewards
  • 11. Vision • Always do vision before hearing. • Fixing and following pom pom ball. Distance 21 cm away. • Conjugated eye gaze(not rowing)/socially modulated eye contact Check ability to pick up hundreds and thousands, cubes are important. • Approached to toys • No rowing eye movement, No squint, No nystagmus • Wearing glasses
  • 12. Vision • Fix and follow wool ball(4cm) horizontally and vertically 20 cm from eye level
  • 13. Hearing: Distraction test • Use initial distraction with non noise making stimulus in front of child • Always ask examiner to ring the bell at 20 cm from both ears • Bell is brought towards ear from behind out of range from visual fields 20 cm away from ears. • Changes noted are facial expression, vocalizing sounds, head turns.
  • 14. Fine Motor:  Holds rattles (3 months),  hand regards(4 mths),  palmer grasp objects(5 mths),  transfer cubes(7 mths),  Raisins for pincer grip(9 mths),  2.5 cm blocks for stacking,  2 cubes 15 months,  3 cubes(18 months)  6 cubes(21 months).  6 cubes, turn pages (2 yrs),  8 cubes (2.5 yrs),  9 cubes (3 years), beads, thread, putting on biro, plastic knife, and fork. Comment on personal social interaction, language. Smiling, waving
  • 15. Fine Motor: Pincer Grasp
  • 16. Personal social Devt Chronologically 1. Focus on faces(4 weeks), 2. social smile(6 weeks), 3. excited with toys(4 months), 4. Castrate toys (5 months), 5. stranger anxiety, (6 months), 6. responds to No, imitates, (8 months), 7. clapping, bye bye, bang blocks (10 months), 8. peek boo(11 months), 9. picture books( 12 months), 10. kiss mirror (13 months), 11. points(15 months), 12. Body parts(21 months)
  • 17. GROSS MOTOR:  HH (16 weeks), Roll over,  Tripod (6 months),  Bear wt, bounces, lifts head(7 months) ,  sit well (8 months)  pull to sit and stand, crawl (10months),  Creep 11 months,  walk with support (1 year),  climb stairs with rail ,throw ball(18months),  walk upstairs(21 months)  up and down (2 years).
  • 18. GROSS MOTOR: 180 degree flip examination in infant < 8 months and gait for > 1 year  Supine: Note posture, abnormal ATNR, involuntary movements with CP. paucity of movements for hemiplegia.  Pull to sit: head lag. Sitting: Head and trunk control. Back is straight or rounded.  Weight bearing: scissoring, hypotonia, advanced weight bearing (CP)  Ventral suspension: Describe posture, low tone, increase extensor tone.  Prone: Observe ability to raise head, trunk above horizontal,
  • 19. Primitive reflexes: 1. Sucking/Rooting :( 0-4,6mths), 2. Palmer grasp; (0-3 months). 3. Placing, stepping: (0-6weeks) 4. ATNR: 2-6 Months. 5. Landau: on ventral suspension, normally extend head, trunk, and hip. Flex head and neck, response is flexion of hip, trunk.0-6 month). 6. Neck righting reflex: rotation of trunk 6mths-2 years. 7. Moro: 0-4 months. 8. Parachute: 6-12 months persist. Prone position, move rapidly, face down. Will extend both upper limbs.
  • 20. Speech and Language:  Cooing ( 2mths),  responds to human voice (4 mths),  Babbling (6mths),  Mamma, dada (9mths),  2 words plus mama, dada(12 mths),  Jargon, points (15mths),  10 words and says his name, points to 3 body parts, one picture (18mths),  2-3 word phrase, name 3 objects, 4 body parts, says no  (2 yrs), know name, age sex  (2.5yrs), preposition, count 1-10, 2 colours  (3 yrs), name 3 colours, converses (4 years)
  • 21. Gross Motor Milestones-1 Ball Jumping Stairs Walking Sitting 1 year ▪ throws ball 3 feet ▪ creeps up stairs ▪ walks holding on ▪ kneels & balances 18 months ▪ throws ball without falling ▪ walks up stairs ▪ creeps back down stairs ▪ walks well by 18 months 2 years ▪ throws ball overhead ▪ kicks ball ▪ hops with 2 feet ▪ jumps forward 4 feet ▪ 2 steps up & down ▪ runs ▪ walks around carrying toy ▪ starts & stops at ease around obstacles ▪ gets on to furniture and sits on their own 2.5 years ▪ catches ball into body ▪ stand on tip toes if shown
  • 22. Gross Motor Milestones-2 Ball Jumping Stairs Walking Sitting 3 yrs ▪ catches ball with arms extended ▪ kicks forcefully well ▪ riding tricycle ▪ stands on 1 foot for 3 secs ▪ walks on tip toes ▪ jumps down ▪ 2 steps up & 1 step down ▪ walk backwards & sideways hauling a large toy ▪ sits with ankles crossed 4 yrs ▪ throws ball underhand ▪ stands on 1 foot for 5 secs ▪ hops with 1 foot ▪ stands on tip toes ▪ jumps forward 30 feet ▪ 1 step up & down ▪ picks up object by bending forward with knees straight ▪ sits with knees crossed 5 yrs ▪ bounces and catches ball ▪ stands on 1 foot for 10 secs ▪ jumps across line & over string ▪ skips with both feet alternating ▪ does 3 sit ups
  • 23. Sequence of approach to gross motor assessment Walk → jump / hop → climb stairs → throw ball
  • 24. Fine motor Milestones-1 # give the crayon of appropriate length to test maturity of pen grip Formula for copying man: 3 + number of parts (paired parts are considered 1) , head O is excluded 4 Cubes Pen Drawing Book / Pages Cutting Others 1 yr ▪ mouthing cubes ▪ bangs cubes together ▪ picks cubes with 1 hand ▪ opens book ▪ throws and cast objects ▪ place 1 correct shapes in holes ▪ puts pellets in & out of cup/box when shown 15 months ▪ builds 2 cubes ▪ scribbles thru & fro 18 months ▪ builds 3 cubes ▪ hand preference at 18 - 24 mths ▪ turns 2-3 pages at the same time ▪ no more casting objects ▪ place 2 correct shapes in holes 2 yrs ▪ builds 6 cubes ▪ pen held in fist - palmar grasp (1.5 - 2 yrs) ▪ copies a single line: I then --- ▪ turns pages singly ▪ makes a cut with the scissors ▪ place 3 correct shapes in hole 2.5 yrs ▪ aligns 3 cubes ▪ stack a train ▪ inferior pen grip (2 - 2.5 yrs) ▪ removes screwed lid from bottle 3 yrs ▪ builds 9 cubes ▪ 3 cube pyramid ▪ 3 block bridge ▪ steadies paper with other hand ▪ copies O ▪ copies + (3 ½ yo) ▪ cuts along a line ▪ strings 4 beads ▪ puts 10 pellets in a bottle (3 ½ yo) ▪ laces 3 holds (3 ½ yo)
  • 25. Fine motor Milestones-2 Cubes Pen Drawing Book / Pages Cutting Others 4 years ▪ builds 10 -12 cubes ▪ 6 cube pyramid ▪ stack a gate ▪ static tripod pen grip (3 - 4 years) ▪ copies  ▪ cuts along lines of O ▪ buttons 1 button 5 years ▪ colours neatly within the lines ▪ dynamic tripod pen grip (4 - 5 years) ▪ copies ∆ ▪ writes name ▪ draws house ▪ draws 3 part man ▪ cuts along lines of  ▪ Folds paper in ½ lengthwise with edges parallel 6 years ▪ copies , ▪ draws 7 part man
  • 26. Use of pencils/Crayons Pencil Skills  Hand preference, functional grasp  Control, pressure, helper hand  Manipulation of writing tool ex. shift, rotation, etc. Cutting Skills  Orientation, grasps accuracy  Helper hand use Coloring Skills  Control, pressure, coverage, use of helper hand Visual Motor  Printing(writing), drawing Organization  Details of pictures, drawing lines & shapes
  • 27. Pencil grip
  • 28. Gesell's figures when use pencil
  • 29. Gesell's blocks
  • 30. Sequence of approach to fine motor assessment build blocks → place shape in hole → hold pen + scribble, → put pellets in bottle → lace holes →Thread Beads →cut paper → buttons → colors in lines → fold paper
  • 31. Language Milestones *1st ask the parent, what is the child’s dominant language and any history of hearing loss Length of sentences Words / Vocabulary Pointing Commands 1 yr ▪ knows 2 - 3 words ▪ says mama & pap specifically (15 mths) ▪ indicates needs by pointing & vocalisations (15 mths) ▪ follow 1 step commands w/o gesture: ‘ give to papa, come to mama’ 18 mon ths ▪ enjoys nursery rhymes & attempts to sing along ▪ knows 10 - 20 words ▪ jargons ++ ▪ echolalia ▪ talks to self during play ▪ 1 body part (15 months) ▪ 2 - 3 body parts (18 mths) ▪ understands simple instructions: ‘ come for dinner’, ‘don’t touch’ (15 mths) 2 yrs ▪ 2 -3 word phrases ▪ 20 - 50 words ▪ ask: what & where ▪ 5 body parts ▪ follow 2 step commands w/o gesture 2.5 yrs ▪ running commentary during play ▪ > 200 words ▪ knows full name & gender ▪ uses pleural, nouns ▪ names 5 body parts
  • 32. Language Milestones-2 Length of sentences Words / Vocabulary Pointing Commands 3 yrs ▪ 3 word phrases ▪ correct grammar, preposition, opposition ▪ left, right ▪ past, present ▪ out counts from 1 - 10 ▪ asks: why ▪ understood by family ▪ follows 3 step commands 4 yrs ▪ complete sentences ▪ knows age ▪ points to colours ▪ route counts from 1 - 20 , 1 - 2 counts from 1- 4 ▪ narrates long stories ▪ understood by strangers ▪ understands commands with above and below 5 yrs ▪ knows address, month, day, birthday ▪ knows morn / afternoon ▪ names 4 - 5 colours ▪ ask : how ▪ understands commands with before and after
  • 33. Personal social Milestones 1 yr 1 - 2 yr 2 - 3 yrs 3 - 4 yrs 4 - 5 yrs 5 - 6 yrs ▪ smiles spontaneously ▪ responds differently to strangers than to familiar people ▪ pays attention to own name ▪ responds to no ▪ copies simple actions of others ▪ recognises self in mirror or pictures ▪ refers to self by name ▪ plays by self, initiates own play ▪ imitate adult behaviours in play ▪ helps put things away ▪ plays near other children ▪ watches other children, joins briefly in their play ▪ defends own possessions ▪ beings to play house ▪ symbolically uses objects, self in play ▪ participates in simple group activities ▪ knows gender identity ▪ joins in play with other children, begins to interact ▪ shares toys, takes turns with assistance ▪ begins dramatic play, acting out whole scenes ▪ plays & interacts with other children ▪ dramatic play is closer to reality: attention paid to detail, time, space ▪ plays dress up ▪ shows interest in exploring sex differences ▪ chooses own friends ▪ plays simple table games ▪ plays competitive games ▪ engages in cooperative play with other children involving group decisions, role assignments, fair play ▪ feeds self cracker ▪ holds cup with 2 hands, drinks with assistance ▪ holds out arms and legs while being dressed ▪ uses spoon, spilling little ▪ drinks from cup with 1 hand unassisted ▪ chews food ▪ unzips large zipper ▪ indicates toilet needs ▪ removes shoes, socks, pants, sweater ▪ gets drink from fountain or faucet independently ▪ opens door by turning handle ▪ takes off coat ▪ puts coat on with assistance ▪ washes & dries hands w assistance ▪ pours well form small pitcher ▪ spreads soft butter with knife ▪ buttons & unbuttons large buttons ▪ washes hands independently ▪ blows nose when reminded ▪ uses toilet independently ▪ cuts easy foods with a knife ▪ laces shoes ▪ dresses self completely ▪ ties bow ▪ brushes teeth independently ▪ crosses streets safely
  • 34. Preverbal language  Point to body parts  Point to pictures and identifies pictures by pointing
  • 35. Language assessment Observe  Non-verbal communication: Eye gaze, eye contact (describe length, frequency and pattern of eye contact), modulation of facial expression pointing, body gesture, body language, socially aware not aware Receptive language/Comprehension: Following instructions e.g.  Call him by name and see response  Ask what is your name, age, sex?  Ask labelling of body parts  Ask him to bring ball 1-3 steps  Ask to use on, down, under
  • 36. Receptive language  Follows instructions  Try 1 step than 2, 3 etc  See if he echoes questions  Responds to name
  • 37. Expressive language  Expressive language: production of speech, voice quality, intonation, pitch, volume  Tells his name, age, sex  Labels body parts, pictures
  • 38. Types of pointing  Protodeclarative pointing: Child points indicate the desire to share an experience with another person, e.g., a child pointing to fish looks at you and than object and may look at again you. Protodeclarative pointing, child’s pointing requires joint attention, or the ability to share experiences with others by attracting or following their attention by looking or pointing.
  • 39. Types of pointing-2 Protoimperative pointing: points represent desire for an object eg fish e.g., pointing to fish or his needs like cookie, sweets, bread etc. So pointing for needs.
  • 40. Speech assessment-Quality  Articulation  Clarity  Pronunciation  Jargons  Apraxic  Dysfluency  Stuttering  Stammering
  • 41. Assessment of language in older child Language Pre language skills ▪ eye contact ▪ facial expression, modulation ▪ good attention span ▪ imitation & compliance ▪ joint attention ▪ joint referencing (child shows you something) Language skills - expressive & receptive ▪ higher order language: idioms, sarcasms, bargaining Problem with phonation 1. Can be due to hearing impairment ▪ dropping & simplifying clusters of consonants 2. Check locally for any cleft palate / tongue tie ▪ cleft → difficulty in making ‘CH’, sounds - e.g. childish children eating chilies ▪ rhinolalia → look for cleft or catch 22 - bob is a baby boy → mob is a mamy moy ▪ tongue tie → difficulty making the ‘L’ sounds Spatial Directions 1. Put the pencil behind your knees 2. Put the pencil between us but closer to you 3. Put the pencil above your ear 4. Touch the bottom of your chair 5. Put the pencil under this paper and put your hands on top of the paper ▪ 2 correct: 4 year level ▪ 3 - 4 correct: 5 year level ▪ 5 correct: 6 year level Temporal Directions 1. The boy saw the man who was carrying a red ball. Q: who was carrying the red ball? 2. The girl who played with my friend came home late last night Q: who came home late last night 3. The lady saw the man who was wearing a green hat Q: who was wearing the green hat? 4. Before it got dark, the man went to the shop. Q: when did the man go to the shop? 5. The baby ate the sweet after his mother called him. Q: when did the baby eat the sweet? ▪ 1 - 2 correct: 4 year level ▪ 3 - 5 correct: 5- 6 year level Understan ding I am going to tell you a story... ▪ tailor the difficulty of the story to the age of the child ▪ ask child to repeat the story back to you ▪ ask child questions about the story ▪ 6 year old should be able to tell you the story back with understanding and reasoning e.g. ‘why did the ice cream melt?’ Others Simple math (6- 7 yo) Test fine motor test + hand writing Compare big and small ‘ which circle is bigger?’, compare long & short
  • 42. Assessment of play Can be divided into concrete play & pretend play  2 - 2.5 years: needs to play with object to imagine it (symbolic play)  3 - 3.5 years: still require an object, but not so much & more imaginative about it  4 - 4.5 years: able to play & imagine things out of air  children with delay in symbolic play with have delay in language - because language is a ‘sound’ symbol for the object
  • 43. Assessment of play Approach to steps in assessing play 1. looks what that? - point to a toy and see if there is joint attention 2. do you wan to play with it? - bring the toy to the child 3. start playing & see if the child imitates you 4. add elements (pretend & fantasy) to the play - the doll is hungry, shall we feed the doll some cake? the cat is hungry how?, prompt the child to go on .. feed info when the child needs otherwise watch 5. extension of play → the child then continues the story and says perhaps, the doll is full, its time to sleep
  • 44. Assessment of play Age begins Type of play Interaction of play 18 mths ▪ functional play ▪ solitary play 2 yrs ▪ imitative play ▪ parallel play 2.5 yrs ▪ pretend play ▪ interactive play 3 yrs ▪ fantasy / symbolic play
  • 45. ASD Conditi on Triad Information Autism Qualitative impairments in social communication and interaction, together with presence of restricted, repetitive and stereotypic behaviour, interests and activities CHAT: Screening questionnaire for autism in children 18 - 36 months ▪ does your child enjoy being bounced on your knee? ▪ does your child take interest in other children? ▪ does your child like climbing things like chairs? ▪ does your child like playing peek-a-boo /hide & seek? ▪ does your child pretend while playing? ▪ does your child ever use his/her index finger to point to ask for something? ▪ does your child ever use his/her index finger to share something interesting with you? ▪ does your child play with small toys without mouthing, fiddling, dropping them? ▪ does your child ever bring objects to show you?
  • 46. ASD Neurodevelopmental disorders characterized by impairments in three domains: Triad 1. Socialization 2. Communication 3. Behavior Includes:  Autistic disorder  Asperger disorder  Rhett’s disorder  Childhood Disintegrating disorder  Pervasive developmental disorder, not otherwise specified (PDD-NOS)
  • 47. ASD  Occurs in ~1 in 150 to 1 in 500 children  Increasing incidence since 1970s—due to increased awareness/changes in case definition  MR /seizures common  Pathogenesis incompletely understood  Overwhelming evidence does not support association with immunizations and autism
  • 48. Autistic disorder—DSM-IV Criteria: A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
  • 49. 1. Qualitative impairment in social interaction, as manifested by at least two of the following:  Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction  Failure to develop peer relationships appropriate to developmental level  A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (eg, by a lack of showing, bringing, or pointing out objects of interest)  Lack of social or emotional reciprocity
  • 50. 2. Qualitative impairments in communication as manifested by at least one of the following:  Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)  In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others  Stereotyped and repetitive use of language or idiosyncratic language  Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
  • 51. 3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities As manifested by at least one of the following:  Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus  Apparently inflexible adherence to specific, non- functional routines or rituals  Stereotyped and repetitive motor mannerisms (eg, hand or finger flapping or twisting, or complex whole-body movements)  Persistent preoccupation with parts of objects
  • 52. ASD  Delays or abnormal functioning in at least one of the following areas, with onset before 3 years old: (1) Poor social communication (2) Poor social interaction (3) Poor pretend play  The disturbance is not better accounted for by Rett's Disorder or childhood disintegrative disorder.
  • 53. Diagnosis of Autism is a clinical one  Use DSM-IV Criteria  Sometimes referral to ASD specialists for definitive diagnosis Diagnostic tools available:  Autism Behavior Checklist (ABC)  Gilliam Autism Rating Scale (GARS)  Autism Diagnostic Interview-Revised (ADI- R)  Childhood Autism Rating Scales (CARS)  Autism Diagnostic Observation Schedule- Generic (ADOS-G)
  • 54. Atypical Autism Asperger disorder—similar to autism  No clinical significant delays in language  Higher levels of cognitive function  Greater interest in interpersonal social activity  Specific DSM-IV Criteria for diagnosis PDD-NOS—used for individuals with some, but not all, of the DSM-IV criteria for autistic disorder
  • 55. Rett Syndrome  Almost exclusively females  Develop normally initially, then gradually loose speech, purposeful hand use after 18 months of age  Deceleration in head growth  Mutations in MECP2 gene Childhood disintegrating disorder  Regression in multiple areas of functioning after two years of normal development
  • 56. ADHD Condition Examination Information ADHD • -Presence of hyperactivity, inattention and impulsivity, • -Presenting prior to age 7, • -Of sufficient degree to impairment social, academic or occupational functioning, • -Present for ≥ 6 months across ≥ 2 environments Steps in History taking: ▪ -exclude brain injury: hypoxia / infections, ASD ▪ -examine social setup: school, family, teachers, seat in class ▪ -perform diagnostic interviews as per DMS IV manuals ▪ -assess IQ, vision, hearing ▪ -assess for OSA: might result in ADHD ▪ -assess for EEG: for absence seizures
  • 57. GDD GDD ▪ Chronic sick kids usually have GDD ± syndromic ▪ look for a central cause - Dysmorphic. microcephaly - IUI? - VP shunt, eyes, hearing, cardiac murmur, hepatosplenomegaly - CP? - gait, spasticity of limbs - storage disease - hepatosplenomegaly, eyes ▪ GDD diagnosed when there are Child < 4 years of age with delays in speech and language domain, and in at least 1 other developmental domain ▪ -ask parents about functional status at home
  • 58. Motor Delay Motor delay  comment on hand dominance e.g. in hemiplegia  bring out the inequality of bilateral hand dexterity by doing threading & comment on it  In a child with neurological deficits → offer that ‘ I want to do a proper neurological examination, I am looking for dyskinetic CP.. etc’  look for vision problems that can hinder fine motor dexterity - especially if a young child is wearing spectacles  Comment that the child might have limitations due to ...., but has functionally adapted to ..  ask parents about functional status at home 
  • 59. Mental Retardation (MR), cognitive delay  a state of functioning beginning in childhood characterized by limitations in intelligence and adaptive skills  DSM-IV Criteria for MR:  Significant sub-average intellectual functioning  Adaptive functioning deficit or impairment  Onset before 18 years of age  Cognitive impairment requires IQ testing (accurate for ages ≥5 years)  Mild—50 to 70 IQ ( 70 is 2 SD from normal—100)  Moderate—40 to 50  Severe—20 to 40  Profound—<20
  • 60. Prognosis for MR Depends on severity:  Mild—can be taught to read/write, live independently and hold jobs as adults  Moderate—probably will not learn to read/write, but may live/work in semi- independent supervised settings  Severe/profound—require substantial lifelong support  Also dependent on etiology of MR and co- morbid conditions
  • 61. Learning difficulties  Achievement substantially below  expected given the child’s age,  intelligence and appropriate education
  • 62. Dyspraxia/ developmental coordination disorder  Motor planning issues  with deficits in conceptualisation, organisation and  execution of unfamiliar sequence of movement, often affecting attention and learning  Sensory integration disorder  Sensory defensiveness
  • 63. Sensory integration disorder  Sensory defensiveness and  Modulation issues
  • 64. Red flag signs of SLD 6 month -no response to sound ▪ Deaf infants coo/laugh/squeak at @ normal age then babble slightly later than Ń then stop babbling 1 yr no babbling, not localising sound 18 month no meaningful words except ma/pa not pointing to wanted things 2 yr vocab < 20 words no 2 word phrases 2.5 yr not understanding simple instructions 3 yr not understood by family 4 yr not understood by outside family 5 yr speech not clear, fluent, not complex not understood
  • 65. Important Milestones Domains Development Receptive language 12 month ▪ responding to their name 18 mth - 2 yrs ▪ pointing to body parts, parents, pictures 12 - 18 mths 2 yrs ▪ following instructions - 1 step: throw in the bin - 2 step put this ball in box and bring shoes Expressive language (verbal & non verbal) 12 month 2 yo 3yo 4yo 5yo ▪ mama & papa, pointing to what they want ▪ linking words, naming 2 - cat, dog ▪ repeats 3 word phrases ▪ gives name & identifies colours ▪ name colours, self, fluent ▪ repeats 4 - 6 word phrases Social Emotional Self help (ASD) 3 - 6 mth 18 - 24 mth ▪ eye contact ▪ reciprocal play ▪ pretend play ▪ joint referencing, share interest Gross motor - to test for GDD 12 - 18 mths 2 yr 3 yr 4 yr 5 yr ▪ walk ▪ walk sideways 2 steps, kick a ball ▪ stand on 1 foot, tiptoe 3 steps ▪ stand on 1 foot for 1 secs, tiptoe 4 steps ▪ hop 2 hops on 1 foots ▪ stand on 1 foot for 5 secs Fine motor - to test for GDD 18 mths 2 yr 3 yr 4 yr 5 yr ▪ scribbles / line ▪ line / circle ▪ circle / cross ▪ copies square ▪ copies triange ▪ 3 blocks ▪ 6 blocks ▪ 9 blocks Offer to test hearing Ask for f/h of delayed speech: more common in children with +ve f/h
  • 66. In DCD:  The single most common presenting concern was speech and language (S&L) delay (30%).  The most common clinical developmental diagnosis was autism spectrum disorder (ASD) (30%) • Global developmental delay (GDD)(10%) • ADHD(6%) • LD(4%) • Cognitive impairment(4%), • CP(3%) • Dyspraxia(2%)
  • 67. Approach to Developmental Delay-1  Assess if any medical problems like Neurologic, myopathy, dystrophy etc  Genetic, syndromes particularly Fragile X, Prader willi  Metabolic  Endocrine exclude Hypothyroidism for GDD  HIE, CP, IUI, ExPREM  Hearing loss  Vision loss, squint, lazy eye, astigmatism etc
  • 68. Approach to Developmental Delay-1,Medical Evaluation  Presence of biologic risks or medical problems associated with DD  Head circumference for micro/macrocephaly  Weight and height for growth deficiency  Dysmorphology (minor and major congenital abnormalities)  Eye exam for poor tracking, strabismus, etc  Ear exam for recurrent/chronic OM  Abdomen for HSM (metabolic disease)  Skin for neurocutaneous lesions  Neurologic exam for reflexes, tone, symmetry, strength
  • 69. Screening Tests:  Parents’ Evaluation of Developmental Status (PEDS)  Ages and Stages Questionnaires (ASQ) ~15 minutes, by the parent  Generates a pass/fail score in four development domains  Infant-Toddler Checklist for Language and Communication ~5-10 minutes, by the parent  Identifies scores 1.25 SD below normal  Brigance Screens-II
  • 70. Approach to Developmental Delay-2  Check growth percentiles, macro or microcephaly  FTT  Examine for Neurocutaneous syndromes like café au lait spots  Examine back for spina bifida occulta  Examine eye for squint, nystagmus, cataract, clouding  Do Neurologic examination
  • 71. Approach to Developmental Delay-3  Try to differentiate UMN/LMN lesions  Examine abdomen for HSM  Otoscopy for wax, Otitis Media  Mouth for tongue tie, cleft, tongue movement, gag
  • 72. Approach to Developmental Delay-4  Do Hearing test and Visual assessment with or without sedation for all developmental delay  For GDD consider TFT  For hypotonia, GDD doe Muscle enzymes CK, LDH and KIV aminoacidogram, metabolic screen  For Genetic Karyotyping, FISH  Refer Genetic/Neurologist/ENT/Eye/Endocrine as needed
  • 73. Evaluations-1  Formal hearing testing (BAER)  Vision testing (full ophthalmologic exam)  Thyroid function testing (if no NBS, or signs of thyroid disease)  Metabolic screening (if abnormal or no NBS)  Neuroimaging (MRI vs CT)
  • 74. Evaluations-2  Chromosomal/Cytogenetic Testing (if +family history)  Down Syndrome (karyotype), Fragile X (FMR1), Rett Syndrome(MECP2), Prader-Willi/Angelman (FISH)  EEG if suspected seizure activity/encephalopathy (Landau- Kleffner)  CPK/Aldolase if abnormal muscle tone (Muscular dystrophy)
  • 75. Approach to Developmental Delay- 5,Children 0-36 months—agencies  Refer to EIPIC)  Multidisciplinary  Speech and Language Pathologist  Occupational and Physical Therapy  Social Worker  Psychological evaluation if needed  Focus on need for services rather than diagnosis
  • 76. Children 3-5 years—preschool EIPIC/ICCP services  Continued services—may be in or out of classroom  Children older than 5 years—referrals usually made through public school system  Private evaluations/services are also available
  • 77. Children older than 5 year  Referrals usually made to DCD therapist  Private evaluations/services are also available  SPD  ICCP
  • 78. At 6 years age-1 If assessment shows need of special school  Do IQ test for school placement  If going to mainstream, no need to do IQ test, but can refer educational facilitator for informing school special need officer (SNO) regarding child’s diagnosis and accommodation needed  May need exemption from mOther Tongue  Extra Time in exam  Sitting in front of class, prompting, buddy
  • 79. At 6 years age-2 If assessment shows mild delay and potential to improve  Consider deferring primary 1  Inform MOE  Retain K2 (maximum 2 years retention allowed)  Review KIV IQ test or Refer EF after 1 year  Inform EIPIC for extension for 1 year
  • 80. Present the case as:  On general inspection of this cute little /Race/ New born/infant/toddler, who is well thrived, but would like to chart gender specific progressive percentiles for Occipitofrontal circumference, length, and weight, he is not syndromic, (no expremmie look), not floppy has good muscle tone moving all limbs equally. No involuntary movements seen.  On examination of vision he had eye gaze, socially aware, he fixed followed pompom ball, approached to toys, picked up raisins etc. On examination of distraction hearing test …, On personal social.., On language. On fine motor…On gross motor..NN reflexes  or there is a huge scatter across the developmental ages of his different abilities  In summary: this infant has DA of….GM … FM…. SL PS etc with Developmental quotient at __%  I.Q= Mental age x 100  Chronological age