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Assessment of development sunil


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Assessment of development sunil

  1. 1. Assessment of Development Dr Sunil Agrawal 1st yr, MD Pediatrics IOM
  2. 2. Topics• Introduction• Principles of development• Value of developmental assessment• Different domains of development• Assessment of development• Screening tests• Definitive tests• Development Quotient• Conclusion
  3. 3. Introduction• Development is the individual level of functioning, a child is capable of, as a result of maturation of the nervous system and psychological reactions• It is the qualitative and quantitative changes and acquisition of a variety of competencies for functioning optimally in a social setting.
  4. 4. • Developmental assessment – milestone acquisition occurs at a specific rate and in an orderly and sequential manner• Abnormality can be delay, deviancy, or dissociation
  5. 5. Principles of Development• Development is a continuous process from conception to maturity• Sequence of development is same in all children but rate varies• Development is intimately related to maturation of nervous system- opportunity to practice• Generalized mass activity replaced by specific individual response
  6. 6. Principles of Development• Development is in cephalocaudal direction• Certain primitive reflexes lost before corresponding voluntary movement is acquired• Generalizations about development cannot be based on the assessment of skills in a single developmental domain. However, skills in one developmental domain do influence the acquisition and assessment of skills in other domains.
  7. 7. Value of Developmental 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 normality, cerebral palsy or other handicap
  8. 8. • For pediatrician- – When faced with sucking and swallowing problem in neonate, or child with unusual appearance or behavior – Early diagnosis of defects of hearing or vision – Effect of treatment of metabolic disorders, exposure to toxic substances, convulsions, meningitis
  9. 9. Different Domains of Development• Gross motor development• Fine motor development• Social/Cognitive/intellectual development• Speech and language development• Vision and hearing development
  10. 10. Assessment of Development
  11. 11. Assessment of Development• 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.
  12. 12. When to suspect abnormalities of development• From history- Parents( 75-80% sensitivity to childhood disability and 70-80 % specificity for normal development)• From examination- – During routine examination- Developmental screening as recommended by AAP – Follow up examination in high risk babies
  13. 13. • Risk factors for likelihood of developmental impairment- – Prenatal- • Use of drugs or alcohol, severe toxemia and viral inf. – Perinatal factors- • Prematurity, LBW, obstetric complications – Neonatal factors- • Neonatal encephalopathy, infections like sepsis or meningits and severe hyperbilirubinemia – Post natal 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
  14. 14. Developmental History• Whether or not parents have concern• Right questions- Parents interpretation of what their child does may be incorrect but observations are usually accurate• Age specific questions• Check doubtful reply with a question kept on a different way• Check the answer about one milestone by another and by examination
  15. 15. • Family history- – First and second degree relatives – A diagnosis even if definite should be pursued if it might be relevant• Social history- – Capacity to cope with a child with a disability
  16. 16. Examination: Observations and Interactive Assessment• Should take in place in a room with toys 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
  17. 17. Prerequisites• Infant or child in a good temper• Should not be hungry, tired, unwell, had convulsion prior, under influence of sedative or antiepileptic drugs
  18. 18. Equipment Required• Ten 1- inch cubes• Hand bell• Simple formboard• Goddard formboard• Colored and uncolored geometric forms• Picture cards• Cards with circle, cross, square, triangle, diamond drawn on them• Patellar hammer• Paper• Pellets( 8mm)
  19. 19. Physical Examination• General- – Height, weight, head circumference, cardiac murmurs, midline defects• Dysmorphic features• Neurological examination
  20. 20. Assessment of Gross Motor Development• The acquisition of gross motor skill precedes the development of fine motor skills.• Both processes occur in a cephalocaudal fashion – Head control preceding arm and hand control – Followed by leg and foot control.
  21. 21. Gross Motor Development• Newborn: barely able to lift head• 6 months: easily lifts head, chest and upper abdomen and can bear weight on arms
  22. 22. Head ControlNewborn Age 6 months
  23. 23. Sitting up• 2months old: needs assistance• 6 months old: can sit alone in the tripod position• 8 months old: can sit without support and engage in play
  24. 24. Sitting UpAge 2 months Age 8 months
  25. 25. Ambulation• 9 month old: crawl• 1 year: stand independently from a crawl position• 13 month old: walk and toddle quickly• 15 month old: can run
  26. 26. Ambulation 13 month oldNine to 12-months
  27. 27. Gross motor developmental milestone Lift HeadAge Milestone3 months Neck Holding5 months Rolls over6 months Sits in tripod fashion Sit8 months Sitting without support9 months Stands with support12 Months Creeps well; walks but falls; stands without support Crawl15 months Walks alone; creeps upstairs18 months Runs; explores drawers2 years Walks up and downstairs; jumps Walk3 years Rides tricycle; alternate feet going upstairs4 years Hops on one foot; alternate feet going downstairs
  28. 28. Fine Motor - Infant• Newborn has very little control. Objects will be involuntarily grasped and dropped without notice.• 6 month old: palmar grasp – uses entire hand to pick up an object• 9 month old: pincer grasp – can grasp small objects using thumb and forefinger
  29. 29. Fine Motor Development6-month-old 12-month-old
  30. 30. Fine motor developmental milestonesAge Milestone4 months Bidextrous reach6 months Unidextrous reach; transfer object9 months Immature pincer grasp; probes with forefinger12 months Pincer grasp mature15 months Imitates scribbling; tower of 2 blocks18 months Scribbles; tower of 3 blocks2 years Tower of 6 blocks; vertical and circular stroke3 years Tower of 9 blocks; copies circle4 years Copies cross; bridge with blocks5 years Copies triangle
  31. 31. Play and Social Interaction• Observe exploration and free play, use of real size and small toys on self and other and initiation and response to social games( eg- peek-a-boo, pat-a-cake)• Note initiating interactions and responding to parent/ examiner/ other children and use of eye contact and gestures
  32. 32. Social and adaptive milestonesAge Milestones2 months Social smile3 months Recognizes mother; anticipates feeds6 months Recognizes strange/ stranger anxiety9 months Waves ‘bye-bye’12 months Comes when called; plays simple ball game15 months Jargon18 months Copies parents in task2 years Asks for food, drink, toilet; pulls people to show toys3 years Shares toys; knows full name and gender4 years Plays cooperatively in a group; goes to toilet alone5 years Helps in household tasks; dresses and undresses
  33. 33. Language and Communication• Observe vocalization and gestures to attract other’s attention, to indicate needs. In response to others’ vocalization and to share emotions• Note speech quality, use of language to express need, comment, describe, share interest and initiating and responding for conversation
  34. 34. language milestonesAge Milestone1 months Alerts to sound3 months Coos4 months Laugh loud6 months Monosyllables9 months Bisyllables12 months 1-2 words with meaning18 months 8-10 words vocabulary2 years 2-3 words sentence, use pronouns ”I”, “me”, “you”3 years Ask questions; knows full name and gender4 years Says song or poem; tells stories5 years Asks meaning of words
  35. 35. Hearing Development• BAER hearing test (brainstem auditory evoked response) done at birth• Ability to hear correlates with ability pronounce words properly• Always ask about history of otitis media – ear infection• Repeat hearing screening test• Speech therapist as needed
  36. 36. Orienting to sound of bell Johnson, C. P. et al. Pediatrics in Review 1997;18:224-242 7 months 9.5 months 5 monthsCopyright ©1997 American Academy of Pediatrics
  37. 37. Time of Assessment• Developmental surveillance- every well- child visit• Developmental screening- – May be completed by parent or clinician – Using standardized tool at 9, 18 and 30 months – Example- • Denver II developmental screening test • Phatak’s Baroda Screening Test • Trivandrum Development Screening Chart • CAT/Clams ( Clinical adaptive test/ clinical linguistic and auditory milestone scale) • Goodenough- Harris Draw-a-person test • Gesell figures • Gesell block skills
  38. 38. Denver II Developmental Screening Test• Most widely used test for screening• Assesses child development in four domains gross motor fine motor adaptive language personal social behavior• These domains are presented as age norms, just like physical growth curves.
  39. 39. Phatak’s Baroda Screening Test• Indian adaptation of Bayley’s Development scale• India’s best known development testing system• Used by child psychologists rather then physicians
  40. 40. Trivandrum Development Screening Chart• Simplified adaption of Baroda Development Screening System• Consist of 17 items selected from BSID Baroda norms• Time required- 5 mins• Good for mass screening
  41. 41. Clinical Adaptive Test– Developmental Screening Test for age under 24 months– Two test combination • Clinical Adaptive Test (CAT) • Clinical Linguistic Auditory Milestone Scale (CLAMS) – Language assessment tool – Distinguish Language Delay from mental retardation
  42. 42. Goodenough ‘draw a man test’
  43. 43. Definitive Tests• Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)• Stanford-Binet Intelligence Scale• Wechsler Intelligence Scale• Developmental Activities Screening Inventory-SECOND EDITION (DASI-II)
  44. 44. Bayley Scales of Infant and Toddler Development- Third Edition (Bayley-III)• Age Range (in years) - Birth to3.5 years• Method of Administration/Format Individually administered in play-based format for Cognitive, Language , and Motor Scales; caregiver questionnaire for Social-Emotional and Adaptive Functioning. Yields scaled scores, composite scores, and percentile ranks.• Approximate Time to Administer – 50 min. for 1-12 mos.; 90 min. for 13-42 mos.Subscales Cognitive; Language (Receptive, Expressive, Total); Motor (Fine-Motor, Gross-Motor, Total); Social-Emotional; Adaptive Behavior (Communication, Community Use, Functional Pre-Academics, Home Living, Health & Safety, Leisure, Self-Care, Self-Direction, Social, Motor, Total)
  45. 45. Stanford-Binet Intelligence Scale• Description – Intelligence Testing of ages 2 to 23 years and beyond – Yields Intelligence Quotient (IQ)• Scoring – Standardized Scoring – Composite mean of 100 with standard deviation of 16• Interpretation:• Mental Retardation IQ Definitions – Borderline mental retardation: 70 -79 – Mild mental retardation: 65-69 – Moderate mental retardation: 40-54 – Severe mental retardation: 30-39 – Profound mental retardation: <30
  46. 46. Wechsler Intelligence Scale• Description – Intelligence Testing – Mean score of 100 with standard deviation of 15 – Gives verbal and performance scores – Broken into subtests each with a mean of 10• Age specific Wechsler tests – Wechsler Preschool Primary Scale Intelligence (WPPSI-R) • Used for ages 3 to 7 years – Wechsler Intelligence Scale for Children (WISCIII) • Used for ages 6 to 16 years – Wechsler Adult Intelligence Scale (WAIS-R) • Used for ages 16 years and older•
  47. 47. DEVELOPMENTAL ACTIVITIES SCREENING INVENTORY-SECOND EDITION (DASI-II)• Age Range (in years)- Birth - 5 years• Method of Administration/Format Individually administered informal screening measure; may be presented as a nonverbal test; 67 perceptual, motor, and cognitive tasks Yields Developmental Quotient• Approximate Time to Administer -25-30 min• Subscales -Developmental Quotient
  48. 48. Developmental Quotient (DQ)Ratio of the functional age to the chronological age. It is a means tosimply express a developmental delay. DQ= ((developmental age) / (chronological age)) * 100• If the infant was born prematurely the chronological age should becorrected for the gestational age at birth during the first year of life.• The adaptive developmental quotient uses a development measuresuch as the Gesell scales. Similar quotients may use IQ or other measures. Interpretationmaximum score =100> = 85 normal71-84 mild-to-moderate delay<= 70 severe delay
  49. 49. Conclusion
  50. 50. Approach History and examinationAbsent - Check for age appropriate milestone Check for milestones achieved in the past- what and when Check for milestones in the other domainsGlobal Developmental Delay Delay in specific domain
  51. 51. Purpose of Assessment• Whether there is impairment or not in development• Make a diagnosis if possible• Seek to intervene positively to improve outcome and function for the child and family – Reinforcing acquired skills – Teach developmentally appropriate skills – Provide missed experience – Make use of other skills to overcome difficulties – Use learning style to promote learning
  52. 52. Red Flags: Birth to three month– Rolling prior to 3 months • Evaluate for hypertonia– Persistent fisting at 3 months • Evaluate for neuromotor dysfunction– Failure to alert to environmental stimuli • Evaluate for sensory Impairment
  53. 53. Red Flags: 4 to 6 months– Poor head control • Evaluate for hypotonia– Failure to reach for objects by 5 months • Evaluate for motor, visual or cognitive deficits– Absent Smile • Evaluate for visual loss • Evaluate for attachment problems • Evaluate maternal Major Depression • Consider Child Abuse or child neglect in severe cases
  54. 54. Red Flags: 6 to 12 months– Persistence of primitive reflexes after 6 months • Evaluate for neuromuscular disorder– Absent babbling by 6 months • Evaluate for hearing deficit– Absent stranger anxiety by 7 months • May be related to multiple care providers– Inability to localize sound by 10 months • Evaluate for unilateral Hearing Loss– Persistent mouthing of objects at 12 months • May indicate lack of intellectual curiosity
  55. 55. Red Flags: 12 to 24 months– Lack of consonant production by 15 months • Evaluate for Mild Hearing Loss– Lack of imitation by 16 months • Evaluate for hearing deficit • Evaluate for cognitive or socialization deficit– Hand dominance prior to 18 months • May indicate contralateral weakness with Hemiparesis– Inability to walk up and down stairs at 24 months • May lack opportunity rather than motor deficit
  56. 56. Red Flags: 12 to 24 months– Advanced non-communicative speech (e.g. Echolalia) • Simple commands not understood suggests abnormality • Evaluate for Autism • Evaluate for pervasive developmental disorder– Delayed Language Development • Requires Hearing Loss evaluation in all children
  57. 57. Take Away Message Best tests( in our setting)• For infant: Phatak’s Baroda Screening Test• For pre school child: Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)• For school going child: Wechsler Intelligence Scale
  58. 58. References• Ghai Essential Pediatrics, OP Ghai, 7th Edition• Nelson textbook of Pediatrics, 19th Edition, Kliegman, Behrman, Schor, Stanton, St. Geme• Forfar and Arnold’s textbook of Pediatricss, Sixth Edition• IAP textbook of Pediatrics, 4th Edition• ^ Frankenburg, William K.; Dobbs, J.B. (1967). "The Denver Developmental Screening Test". The Journal of Pediatrics• Illingworth, Ronald S: THE DEVELOPMENT OF THE INFANT & YOUNG CHILD, 9th edition, ELSEVIER••
  59. 59. Thank You