Developmental assessment


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Developmental assessment

  1. 1. Development Assessment Presentation By: Binisha Sinha M.Sc.Nursing Child Health Nursing Batch 2013
  2. 2. Contents • • • • • • • • • • • • • • • • • Introduction Goal of Developmental Assessment Principles of Development Value of Developmental Assessment Some Developmental Assessment Tools Examination: Observation and Interactive Assessment Basic Bedside Tool for Assessment Indications for Developmental Assessment Developmental History Developmental Milestones Risk factors for likelihood of Developmental Impairment Different Domains of Development Developmental Delay Target Milestones Developmental Screening Charts Interpretation of Findings References
  3. 3. Introduction • Development specifies maturation of functions. It is related to the maturation and myelination of the nervous system and indicates acquisition of a variety of skills for optimal functioning of the individual. • It is the qualitative and quantitative changes and acquisition of a variety of competencies for functioning optimally in a social setting. • Developmental assessment includes early identification of problems through screening and surveillance, and more definitive assessment including both standardized and non-standardized measures, as well as integration of information from the developmental, social, and family history and the medical history and examination.
  4. 4. Goal of Developmental Assessment • The goal of developmental assessment is not only to generate a diagnosis, but equally important to analyze the pattern of strengths and weaknesses in the child, family, and available developmental, educational, and social support systems, in order to direct treatment. • The maturation of central nervous system is characterized by coordination of motor activity and as infants grow they respond to their environment in a purposeful manner with the help of special senses (acoustic and auditory inputs), integrity of labyrinthine, vestibular and musculoskeletal systems.
  5. 5. • Children achieve neuro-motor milestones of development at predictable ages within a narrow range of few weeks or months. • Development is dependent upon interaction between innate genetic potential and environmental factors like emotional security, love and attention, stimulating home environment, optimal nutrition, ethnic and cultural factors. • Neuro-motor retardation may occur due to gestational immaturity, perinatal hypoxia, birth trauma, metabolic disorders (inborn errors of metabolism), hypoglycemia, kernicterus, intrauterine infections, postnatal CNS infections, hypothyroidism, developmental and chromosomal disorders.
  6. 6. Principles of Development  It is the most distinctive attribute of childhood and is a continuous process from conception to maturity.  Development is intimately related to the maturation of central nervous system.  The sequence of development is identical in all children but the rate of development varies from child to child.  The child with odd-looking face does not necessarily have associated mental sub normality.  The attributes like creativity, future potentiality, IQ and mental superiority cannot be predicted in an individual child by developmental assessment.
  7. 7.  The generalized mass activity of early infancy is replaced by specific and subtle individual responses.  It is a common observation that when shown a bright object, an infant shows wild excitement by moving trunk, arms, legs and babbling while an older child merely smiles and reaches for the object.  The development proceeds in a cephalo-caudal direction. The infant initially develops head control followed by ability to roll over, grasp, sitting, crawling, standing, walking etc..  Certain primitive reflexes like grasp reflex and walking reflex must be lost before corresponding voluntary movements are required.
  8. 8. Value of Development Assessment For Parents • If previous pregnancy miscarriage or stillbirth or proved to be mentally or physically handicapped. • If there was any antenatal problem or difficult delivery. • Family history of mental sub normaility, cerebral palsy or other handicap.
  9. 9. For Paediatric Nurse • When faced with sucking and swallowing problem in neonate, or child with unusual appearance or behaviour. • Early diagnosis of defects of hearing or vision. • Effect of treatment of metabolic disorders, exposure to toxic substances, convulsions, meningitis.
  10. 10. Some Developmental Assessment Tools 1. Gessel Development Tool 2. Amiel-Tison Method of Assessment 3. Vineland Social Maturity Scale 4. Bayley Scales of Infant Development 5. Brazelton Neonatal Behaviour Scale 6. Vojta Technique 7. Denver Developmental Screening Test 8. Trivandrum Developmental Screening Chart. 9. Baroda Developmental Screening Chart. 10. Seguin Form Board
  11. 11. Developmental Screening • The American Academy of Pediatrics recommends that all children be screened for developmental delays and disabilities during regular well-child doctor visits at: 1. 2. 3. 9 months 18 months 24 or 30 months • Additional screening might be needed if a child is at high risk for developmental problems due to preterm birth, low birth weight, or other reasons.
  12. 12. Developmental Screening Developmental delay • Developmental delay occurs in up to 15% of children under 5 years of age. This includes delays in speech and language development, motor development, social-emotional development and cognitive development. • It is has been estimated that only about half of the children with developmental problems are detected before they begin school. • Parents are usually the first to pick up signs of possible developmental delay, and any concerns parents have about their child's development should always be taken seriously. However, the absence of parental concern does not necessarily mean that all is well.
  13. 13. • Parental recall of their child's developmental milestones has been demonstrated in a number of studies to be inaccurate, but it is generally more accurate when milestones are significantly delayed. The main purpose of developmental assessment depends on the age of the child: • Tests may detect neurological problems such as cerebral palsy in the neonate. • Tests may reassure parents or detect problems in early infancy. • Testing in late childhood can help detect academic and social problems early enough to minimize possible negative consequences (although parental concern may be just as good a predictor for some problems).
  14. 14. • No developmental screening tool can allow for the dynamic nature of child development. A child's performance on one particular day is influenced by many factors. Development is not a linear process - it is characterized by spurts, plateaux and, sometimes regressions. • Gradually screening has been replaced by the concept of developmental surveillance. This is a much broader concept. It involves parents, allows for context and should be a flexible, continuous process.
  15. 15. Examination: Observation and Interactive Assessment • • • • Should take in place in a room with appropriate for child. With one or both parents, but no prompting and helping. Chair and table. Child’s behavior and interaction with parents during history taking should be observed prior to physical examination. • Normal functioning of motor, vision and hearing should be assessed. Prerequisites • Infant or child in a good temper. • Should not be hungry, tired, unwell, had convulsion prior, under influence of sedative or anti-epileptic drugs.
  16. 16. Basic Bedside Tool for Assessment • The examiner must acquire simple objects and instruments to undertake bed-side assessment of development whenever indicated. • These items include torch, dangling red ring of 6.5cm diameter, red ball of 5.0cm diameter, ten 2-5cm sized colorful cubes, temple bells, rattle, cup with a handle, bunch of keys, pellets or beads, picture book, paper and crayons and percussion hammer.
  17. 17. Indications for Developmental Assessment 1. Follow up of high risk neonates for early detection of cerebral palsy and or mental retardation. 2. Complete evaluation of children with developmental, chromosomal and neurological disorders. 3. To differentiate children with retardation in specific fields of development as opposed to those with global retardation.
  18. 18. Developmental History • Whether or not parents have concern. • Right question-parents interpretation of what their child does may be incorrect but observations are usually accurate. • Age specific question. • Check doubtful reply with a question kept on a different way. • Check the answer about one milestones by another and by examination.
  19. 19. • Family examination: • First and second degree relative • A diagnosis even if definite should be pursued if it might be relevant. • Social history • Capacity to cope with a child with a disabilty.
  20. 20. Cont….Developmental History • Accurate history of developmental milestones is often difficult to obtain due to poor observation and educational status of the mother. • Early events in the life of child’s development may be forgotten by the parents. The milestones should be asked in a chronological order in a simple and lucid manner. • The social smile must be differentiated from spontaneous smile which even newborn babies may exhibit during sleep or fantasy. • The mother should be asked whether the child interacts and plays with children of his age or likes the company of younger children.
  21. 21. • It is equally if not more important to know the quality of head control and whether he could sit without support with a straight back or in a crouched posture. • It is important to ask the mother as to how the development of the index child compares with his siblings. She can recollect comparison more readily rather than precise ages for achieving various skills. • The effects should be made to identify whether child is globally retarded or backward only in an individual or specific field e.g. delayed speech in a deaf child, delayed walking in a child with congenital dislocation of hips etc. the developmental progress of older children is best evaluated by consideration of school performance, proficiency in games, motor dexterity and social behavior.
  22. 22. Developmental Milestones • Developmental milestones serve as the basis of most standardized assessment and screening tools. • Two separate developmental assessment over time are more predictive than a single one. • Developmental monitoring not only should be aimed at identifying children who have low function, but at directing the focus of anticipatory guidance to help promote normal development.
  23. 23. • Apart from assessing the developmental milestones, the examiner should undertake a detailed neurological examination, evaluate the muscle tone (adductor angle, scarf manouvre, Landau reflex, Parachute reaction etc..) and special senses (vision and hearing). All high-risk infants must be subjected to detailed assessment of hearing and vision at the age of 6 months. • Factors associated with deafness during infancy include prematurity, meningitis, cranio-facial malformations, hypoxic-ischemic encephalopathy, congenital viral infections, kernicterus, prolonged use of aminoglycosides and furosemide, parental consanguinity and family history of deafness.
  24. 24. • The child is placed in different postures and positions depending upon his chronological age and assessed for expected developmental responses as given below. • In preterm babies corrected age (conceptional age) should be used as the chronological age especially during first year of life.
  25. 25. Risk Factors for likelihood of developmental impairment Prenatal factors • Use of drugs or alcohol, severe toxemia and viral infection. Perinatal factors • Prematurity, LBW, obstetric complications. Neonatal factors • Neonatal encephalopathy, infection like sepsis or meningitis and severe hyperbilirubinemia.
  26. 26. Postnatal factors • Injury or meningitis, encephalitis, exposure to toxins, severe continuous failure to thrive and severe epilepsy. Family history • Visual and hearing as well as specific learning.
  27. 27. Different Domains of Development 1. Gross motor development. 2. Fine motor development. 3. Social/ cognitive/ intellectual development. 4. Speech and language development. 5. Vision and hearing development.
  28. 28. Ventral Suspension • The examiner suspends the infant in a prone position by supporting the abdomen of the baby on his palm. The extension of neck and flexion of the extremities is observed.
  29. 29. Ventral Suspension Newborn Head hangs completely and back is rounded. 4 weeks Head momentarily lifted up, elbow flexed. 6 weeks Head held momentarily in the same plane as rest of the body. 8 weeks Head maintained in the same plane as rest of the body and momentarily lifted beyond this. 12 weeks Head maintained well beyond the plane of the rest of the body.
  30. 30. Prone Position Newborn Head is kept to one side, pelvis is raised, knees are drawn up under the abdomen. 4-6 weeks Hips and knees are partially extended, can lift chin off the couch momentarily. 8 weeks Head maintained in midline with chin lifted off the couch. 16 weeks Chest is maintained off the couch, arms are stretched out in full extension. 20 weeks The body is supported on forearms. 24 weeks Weight is supported on hands, and baby rolls prone to supine. Indian babies first learn roll from supine to prone because they are usually not nursed in a prone position.
  31. 31. Supine Posture and Sitting • The infant is placed supine on the couch and pulled to sitting position by lifting at the forearms (traction response).
  32. 32. Newborn Complete head lag. 4 weeks Head maintained in plane of the body momentarily when baby is held in a sitting position, back is rounded. Chin may be lifted up momentarily. 12 weeks Head held up when supported in a position but it tends to bob (bend) forwards. 16 weeks When pulled up, there is slight head lag during the beginning and then head is flexed beyond the plane of the body. When held in sitting position and baby is swayed (swung), the head wobbles. 20 weeks No head lag, head is stable without wobbling (shaking) and back is straight. 24 weeks When about to be pulled up, lifts head off the couch in anticipation. Can sit supported in a pram (baby carriage) or high chair. 28 weeks Can sit on the floor with hands forward for support. 32 weeks Can sit momentarily on the floor without support. 36 weeks Sits steadily without support and can lean forward and recover his balance. 40 weeks Can sit up from supine position. 48 weeks Can turn side ways and twist around to pick up an object.
  33. 33. Ventral Suspension Standing and Walking • • • • • • • • • Newborn 8 weeks 24 weeks 28 weeks 36 weeks 44 weeks 48 weeks 1 year 15 months Walking reflex for 2 to 3 weeks. Can hold head up more than momentarily. Puts almost all weight of the body on the legs. Bounces with pleasure. Pulls self to stand, can stand with support. Lifts one foot while standing. Walks two hands held or on holding the furniture. Walks few steps independently. Creeps upstairs, can kneel without support.
  34. 34. • 18 months • 2 years • 2 ½ years • 3 years • 4 years • 5 years Can get up and down the stairs without help, pull a wheeled toy. Walks up and down the stairs with two feet on each step, walks backwards on imitation, picks up objects from floor without falling, runs, can kick a ball. Can walk tiptoes, jumps on both feet. Goes upstairs with one foot on each step, jumps off the bottom step. Comes down stairs with one foot on each step, can skip on one foot. Skips on both feet.
  35. 35. Social Mental and Language 4 weeeks Watches mother intently when she speaks to him. Follow a dangling object upto 900, quietens on sound of bell. 6 weeks Social smile, follows moving person. 8 weeks Fixes and focuses gaze, eye-to-eye contact, vocalizes. 12 weeks Hand regard, recognizes mother, can follow an object upto 1800 , babbles when spoken to, squeals with pleasure and gets excited on seeing a toy. 16 weeks Demonstrates excitement when feed is being prepared, laughs loud, turns head towards sound of bell/ rattle. 20 weeks Smiles at mirror image, dry during day time if toilet trained. 28 weeks Imitates actions and sounds, enjoys ‘peek-a-boo’ and ‘pat-a-cake’ games, responds to name, pats mirror image, says monosyllables like ba, da, ma. 32 weeks Imitates sounds, responds to ‘no’, produces disyllables like ma-ma, ba-ba, da-da etc 40 weeks Pulls clothes of mother to attract attention, waves bye-bye, repeats performance which is laughed at. 1 year Gives toy to examiner, interested in picture book, shakes head for ‘no’, says 2-3 words with meaning. 1.5 year Jargon speech, indicates the need for pottie and when parts are wet. 3 year Normal speech, attends to toilet needs except for wiping, can dress and undress.
  36. 36. Developmental Milestones: Gross Motor Development Age • • • • • • • • • • • 3 months 5 months 8 months 9 months 10 months 11 months 12 months 13 months 18 months 24 months 36 months Milestone Neck holding Sitting with support Sitting without support Standing with support Walking with support Crawling (creeping) Standing without support Walking without support Running Walking upstairs Riding tricycle
  37. 37. Fine Motor Age Milestone 4 months Grasps a rattle or rings when placed in hand 5 months Reaches out to an object and holds it with both hands (intentional reaching with bidextrous grasp) 7 months Holding objects with crude grasp from palm (palmar grasp) 9 months Holding small object, like a pellet, between index finger and thumb (pincer grasp).
  38. 38. Language Age Milestone 1 month Turns head to sound 3 months Cooing 6 months Monosyllables (‘ma’, ‘ba’) 9 months Bisyllables (‘mama’, ‘baba’) 12 months Two words with meaning 18 months Ten words with meaning 24 months Simple sentence 36 months Telling a story
  39. 39. Personal Social Age Milestone 2 months Social smile 3 months Recognizing mother 6 months Smiles at mirror image 9 months Waves ‘bye-bye’ 12 months Plays a simple ball game 36 months Knows gender
  40. 40. Developmental Delay • During periodic visits of the child to the physician for health assessment and immunization, the child should always be screened for behavioral development by a relatively simple method which could be performed rapidly and accurately even by a non-professional clinical assistant. • If this behavioral assessment indicates delayed development, the child should be examined in detail to determine the cause for such delay. • Lewis R First and Judith S Palfrey (1994) outlined several risk factors in developmental delay that can be easily identified in routine clinical and developmental examination. • A developmental delay should be suspected if a child is not able to perform the given tasks by the indicated ages.
  41. 41. Developmental delay should be suspected if the child is not able to : • Pull up to sit by 4 months. • Roll over by 5 months. • Sit without support by 7-8 months. • Stand holding on by 9-10 months. • Walk by 15 months. • Climb up or down the stairs by 2 years. • Jump with both feet by 2.5 years. • Stand momentarily on one foot by 3 years. • Hop (step) by 4 years and walk in a straight line back and forth or balance on one foot for 5-10 seconds by 5 years.
  42. 42. Target milestones The developmental milestones are achieved by healthy normal children within a narrow range of several weeks. The recommended corrected ages (calculated from the expected date of delivery) for undertaking developmental assessment are 4 months, 8 months, 12 months and then every 6 months till 3 years of age. The upper age limits for achievement of some of the target milestones are given below: 1. 2. 3. 4. Lack of social smile by 2 months. Absence of stable head control by 4 months. Inability to recognize the mother by 6 months. Inability to sit when pulled to sit by 6 months and lack of independent sitting without support by 8 months.
  43. 43. 5. 6. 7. 8. 9. 10. Lack of creeping by 9 months. Inability to stand without support by one year. Inability to walk without support by 18 months. Absence of syllabic babbling by the age of one year and to make meaningful sentences by 3 years of age. Lack of pincer grasp by the age of one year. Inability to play interactive games by the age of one year. failure These children should be subjected to a detailed developmental assessment by an experienced developmental psychologist. The developmental milestones are achieved by healthy normal children within a narrow range of several weeks. The recommended corrected ages (calculated from the expected date of delivery) for undertaking developmental assessment are 4 months, 8 months, 12 months and then every 6 months till 3 years of age.
  44. 44. Developmental Screening Charts • Sophisticated developmental testing instruments are time consuming and requires the services of a trained developmental psychologists. • They are useful for detection of borderline abnormalities s well as research purposes. • There is a need to develop reliable simple developmental charts which can be used by a medical health worker or clinician of the related field.
  45. 45. Bayley Developmental Screening Chart • The Bayley Scales of Infant Development (BSID) measure the mental and motor development and test the behavior of infants from one to 42 months of age. • The BSID are used to describe the current developmental functioning of infants and to assist in diagnosis and treatment planning for infants with developmental delays or disabilities. • The test is intended to measure a child's level of development in three domains: cognitive, motor, and behavioral.
  46. 46. • The BSID were first published by Nancy Bayley in The Bayley Scales of Infant Development (1969) and in a second edition (1993). • The scales have been used extensively worldwide to assess the development of infants. The test is given on an individual basis and takes 45–60 minutes to complete. It is administered by examiners who are experienced clinicians specifically trained in BSID test procedures. The examiner presents a series of test materials to the child and observes the child's responses and behaviors. • The test contains items designed to identify young children at risk for developmental delay .
  47. 47. BSID evaluates individuals along three scales: • Mental scale: This part of the evaluation, which yields a score called the mental development index, evaluates several types of abilities: sensory/perceptual acuities, discriminations, and response; acquisition of object constancy; memory learning and problem solving; vocalization and beginning of verbal communication; basis of abstract thinking; habituation; mental mapping; complex language; and mathematical concept formation. • Motor scale: This part of the BSID assesses the degree of body control, large muscle coordination, finer manipulatory skills of the hands and fingers, dynamic movement, postural imitation, and the ability to recognize objects by sense of touch (stereognosis).
  48. 48. • Behavior rating scale: This scale provides information that can be used to supplement information gained from the mental and motor scales. • This 30-item scale rates the child's relevant behaviors and measures attention/arousal, orientation/engagement, emotional regulation, and motor quality. • The BSID are known to have high reliability and validity. The mental and motor scales have high correlation coefficients (.83 and .77 respectively) for test-retest reliability.
  49. 49. Trivandrum Developmental Screening Chart (TDSC) • It is suitable for developmental screening of children below 2 years by a paramedical health worker. • The range of each test item has been taken from the norms obtained on the Bayley scales of infant development. • It is based on 17 simple test items carefully chosen from among 67 motor items of Bayley scales of infant development (Baroda norms).
  50. 50. • The left hand side of each horizontal dark line represents age at which 3 percent of children passed the item and the right edge represents the age at which 97 percent of the children passed the item in studies conducted at Trivandrum. • A plastic ruler or pencil is kept vertically at the level of chronological age of the child being tested. If the child fails to pass any item that lies to the left side of the age marker, the child is considered to have developmental delay. • It is simple to use and takes 5 to 7 minutes to administer. It is best suited to use in infants around one year of age because most of the test items are concentrated around that age period.
  51. 51. Baroda Developmental Screening Test (BDST) • To simplify the Bayley scales of infant development, 22 motor items and 31 mental items, not requiring any standardized equipment have been retained. These items were grouped age wise, one monthly in the first 12 months and 3 monthly thereafter till 30 months. • The 50 percent and 97 percent age placement of each item has been plotted on a graph and joined to have two smooth curves. The total number of items passed by a child is plotted against his chronological age (or corrected age if preterm). • When this point falls below 97 percentile curve, the child is considered to have developmental delay and is subjected to detailed assessment.
  52. 52. Vineland Social Maturity Scale (VSMS) • The Vineland Social Maturity Scale measures social competence, self-help skills, and adaptive behavior from infancy to adulthood. It is used in planning for therapy and/or individualized instruction for persons with mental retardation or emotional disorders. • The Vineland Social Maturity Scales (VSMS), published by Edgar Doll in 1935, measures social maturity or social competence in individuals from birth to adulthood. • The Vineland scale, which can be used from birth up to the age of 30, consists of a 117-item interview with a parent or other primary caregiver. (There is also a classroom version for ages 3-12 that can be completed by a teacher.)
  53. 53. • Doll classified eight categories of items on the VSMS (Doll, 1935): selfhelp general, self-help dressing, self-help eating, communication, selfdirection, socialization, locomotion, and occupation. • Although there is some difference of opinion as to whether Doll's categorization is the best, the perception of adaptive behavior as multidimensional has survived from one generation to the next. • The test is untimed and takes 20-30 minutes. Raw scores are converted to an age equivalent score (expressed as social age) and a social quotient.
  54. 54. • Personal and social skills are evaluated in the following areas: 1. daily living skills (general self-help, eating, dressing); 2. communication (listening, speaking, writing); 3. motor skills (fine and gross, including locomotion); 4. socialization (interpersonal relationships, play and leisure, and coping skills); 5. occupational skills; 6. and self-direction. (An optional Maladaptive Behavior scale is also available.)
  55. 55. Denver Developmental Screening Test (DDST) • The Denver Developmental Screening Test (DDST) is a widely used assessment for examining the developmental progress of children from birth until the age of six, devised in 1969. • There were concerns raised from that time about specific items in the test and, coupled with changing normal values, it was decided that a major revision of the test was necessary in 1992. It was originally designed at the University of Colorado Medical Center, Denver, USA.
  56. 56. Test design The test consists of up to 125 items, divided into four parts: • Social/personal: aspects of socialisation inside and outside the home, eg smiling • Fine motor function: eye/hand co-ordination, and manipulation of small objects, eg grasping and drawing • Language: production of sounds, ability to recognise, understand, and use of language, eg ability to combine words • Gross motor functions: motor control, sitting, walking, jumping, and other movements • Ages covered by the tests range from birth to six years.
  57. 57. Application • No special training is required. • The test takes approximately 20 minutes to administer and interpret. • There may be some variation in time taken, depending on both the age and co-operation of the child. • Interviews can be performed by almost anyone who works with children and medical professionals. • The items are recorded through direct observations of the child plus, for some points, the mother reports whether the child is capable of performing a given task. • Younger infants can sit on their mother's lap. • The test should be given slowly.
  58. 58. Interpretation of the test • The data are presented as age norms, similar to a growth curve. • Draw a vertical line at the child's chronological age on the charts; if the infant was premature, subtract the months premature from chronological age. • The more items a child fails to perform (passed by 90% of his/her peers), the more likely the child manifests a significant developmental deviation that warrants further evaluation.
  59. 59. Seguin Form Board (SFB) • The Seguin Form Board Test is based on the single factor theory of intelligence, measures speed and accuracy. • It is useful in evaluating a child's eye-hand co-ordination, shape-concept, visual perception and cognitive ability. The test primarily used to assess visual-motor skills. • It includes Gesell figures where in the child is ask to copy ten geometrical figures to evaluate visual-motor ability. Test materials consist of ten differently shaped wooden blocks and a large form board with recessed corresponding shapes.
  60. 60. Interpretation of Findings 1. 2. 3. 4. 5. 6. The global developmental delay in all the spheres (motor, adaptive, social, language etc..) is suggestive of mental retardation. Isolated delay in gross motor development may occur due to poor physical growth due to protein energy malnutrition. Lack of environmental stimulation and poor interaction by parents may adversely affect neuromotor development. Delay in an isolated sphere of motor development like walking may be due to congenital dislocation of hips. Isolated delay in the development of speech is most commonly due to deafness. Autistic children must be differentiated from children with mental retardation. Autistic children may have normal development upto certain age and then regress especially in their social and communication skills.
  61. 61. • The childhood autism rating scale and autism behavior checklist are useful assessment tools. Patients with fragile X syndrome, congenital rubella syndrome, tuberous sclerosis and Rett syndrome may have some autistic mannerisms. • Children with attention deficit hyperactivity disorder (ADHD) may have learning disability and school problems due to hyperactivity and poor attention span.
  62. 62. • They may have antisocial behavior like disobediency, defiance, lack of discipline, destructiveness, fire setting and inflicting harm to others. • They have associated language and learning disability due to distractibility and short attention span. • The diagnosis is facilitated by using Connors questionnaires which are comprised of 28 items for teacher and 48 items for parents for objectivized evaluation of children with ADHD.
  63. 63. References • • • • • • • • • Singh M. Paediatric Clinical Methods.2nd ed. New Delhi. Sagar Printers and publishers, New Delhi. Ghai O.P. Essentials of Paediatrics. 6th ed. New Delhi. CBS Publishers. Retrived from InfantDevelopment.html#ixzz2hWEqqZMu on 10th October 2013. Retrived from on 14th Nov 2013. Retrived from on 14th Nov 2013. Retrived from on 1st Dec 2013. Retrived from on 1st Dec 2013. Retrived from on 1st Dec 2013. Retrived from on 1st Dec 2013.