Transcript Development Problems in Children

Development Problems in
Children
Dr Ros Jefferson
GPVTS presentation Sept 08
Aims
• Identify child who does not obviously fall
between normal limits & who needs further
assessment
• To give framework for assessment of child
who is ‘not quite right for his age’
• When to reassure/when to refer
Normal development
• Physical and neurodevelopmental growth &
development throughout childhood
• Normal milestones important
• Wide variation in ‘normal’ – so may need to
see again.
Influences on development
• Genetic
• Environmental – family structure,
housing,family support
• Stimulation
• Malnutrition
• SEC
Areas of development
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Gross motor
Fine Motor & Vision
Hearing & Communication
Social & Personal
Major normal milestones (average age)
Gross Motor
Fine motor &
vision
Hearing &
language
Social
6 weeks
Head level with
body in ventral
suspension
Fixes & follows
Stills to sound
smiles
3 months
Head at 90deg in
ventral
suspension
Holds object
placed in hand
Turns to sound at
ear level
Laughs & squeals
Hand regard
6months
No head lag. Sits
w support. Up on
forearms when
prone
Reach w palmar
grasp.
Transfers
between hands
Babbles
Works for toy
May finger feed
9 months
Crawls
Sits steadily &
pivots
Pincer grasp,
index finger
approach, bangs
2 cubes
2 syllable babble.
Distraction
hearing test
possible
Waves bye-bye
Pat-a-cake
Indicates wants
Major normal milestones (2)
Gross motor
Fine motor &
vision
Hearing &
language
Social
12 months
Pull to stand,
cruise, stand
alone. Walks
alone (13m)
Puts block in cup.
Casting
1-2 words
Imitates
activities, plays
ball, object
permanence
18 months
Walks well &
runs
Tower of 2-4
cubes.
Scribbles
6-12 words
Uses spoon,
helps in house,
symbolic play
24 months
Kicks ball. Climbs
stairs 2 ft /step
Tower of 6-7
cubes. Circular
scribble
Joins 2-3 words
5-6 body parts
Identifies 2
pictures
Removes a
garment
36 months
Throws overarm,
stairs 1 ft/step,
stands briefly on
1 ft
Tower of 6 cubes, Sentences,
3 brick bridge,
names 4 pictures
copies circle, cuts
w scissors
Eats w fork &
spoon. Puts on
clothing. Names
friend
Scenario
• Mona, a single mother, brings her 12 weeks
baby for her first (late!) immunisation and
baby check. Before she comes into the room,
you try and remind yourself what you would
expect a 12 week baby to be doing.
• What do you jot down in each field of
development?
Developmental delay
• Global
• Specific
• Deviance vs delay
Developmental delay
• Specific delay may have repercussions in other
areas of development
– Vision & motor/language
– Hearing & language
– Language & social
– Attention control & difficulty learning to read
History
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Parental concerns – ‘parents usually right’
Family History – how compares with sibs
Pregnancy
Birth
Postnatal
Feeding
Development
Medical history
Examination
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Look at the parents!!
Observations of child
Head circumference
General examination
Neurological examination
Basic developmental kit
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Pencil/paper
1in cubes
Simple formboard
Simple book
Global delay
• Down’s syndrome
– Commonest & most familiar
– Incidence 1 in 660 LB
– Increasing risk with maternal age
– Recurrence: twice DS risk in subsequent
pregnancy
– Chromosomal non-dysjunction/
translocation/mosaicism
Downs syndrome
• Ring alarm bells – diagnosis confirmed from
chromosomes
• Multisystem
• Insert in PHR
Downs syndrome - development
• Differences within DS population
– Mainstream education +GCSE’s vs no language
– Limited exercise tolerance vs sporting excellence
– 40% of children with DS are able to learn to read
Downs syndrome - milestones
Milestone
Mean age
Range
Sitting
13m
6-30m
Standing
22m
9-48m
Walking
30m
12-60m
Single words
34m
12-72m
Management
• Multidisciplinary
• Congenital heart disease - 40-50% AV canal
defects, PDA, ASD,VSD. Cardiologist
• Atlanto-axial instability – rare, insidious onset.
No routine X-ray- variability. Watch for change
in gait/manipulative skills, neck pain,
sphincter disturbances
• No contraindications to immunisation +/- flu
vaccine
Local protocol
• 0-2y – ‘acute’ paediatrician follows up
• 2- 5y ( F/T school) – community paediatrician
• >5y - if no health problems, surveillance
leaflet to family and GP, for GP follow up
Basic medical surveillance for people
with Downs syndrome (DSMIG)
• Growth
– Measurements at least annually in childhood, at regular intervals
thereafter. Plotted on Downs specific charts
• Thyroid
– Guthrie spot TSH + biochemistry card attached to distinguish from
neonatal Guthrie 1-2yearly
– OR Venous blood for T4, TSH, thyroid Abs 2-3yearly
• Hearing
– Check 2 yearly throughout life – more often if problems. Audiology/school
nurse
• Vision
– After 4y of age vision checked at least every 2y throughout life - optician
• Heart
– Cardiac check advised in early adulthood +/- routine echo
Locomotor delay
• Variation in milestones – walking 7/12 – 30/12
• First steps – short, widebased with planus feet
• Mature gait not achieved till ~4.5y
Locomotor problems
• Normal variants – all present with ‘awkward
gait’
– Femoral/tibial rotations
– Bow legs – normal in infant; correct by 18m
– Knock knees
• Correct spontaneously
Bottom shufflers
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Different patterns
+ve family history
Don’t crawl; possibly later sitting
Hypotonia – resolving
Vertical suspension – hip flexion/knee
extension posture
• Dislike prone position
• Mx = reassure!
Benign hypotonia
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Delayed, not deviant, pattern
Low muscle tone
Normal neurology
+/- bottom shuffle
Toe walking
• Idiopathic
• Myopathic
• Neurological
• Key = Neurological examination +/- CK
Scenario
John’s mother brings him to see you because
she thinks he is ‘slow’. At the age of 18m he is
not yet walking although he pulls himself to
stand and cruises, he chucks objects from his
high chair and has about 3 words with
meaning’
What questions might you want to ask Mum
about his gross motor development
• She tells you that he bottom-shuffles and so
did his Dad. He sat at 6m and rolled at about
the same time. Examination is completely
normal.
• What do you tell his mother about his gross
motor development?
Language delay
• May cover cognitive delay.
• Always refer for audiology assessment
• Language development influenced by
– Early input – carer/child interaction
– Learning disability
– Genetic endowment
Patterns of communication disorder
• Primary problem is with speech production
because of mechanical (anatomical) defects or
impaired neuromuscular control of the speech
apparatus
• Specific Language Impairment (SLI) –problems of
language comprehension/expression for which
no identifiable explanation
• Children who stop talking – rare
• Impaired language and social interaction – ASD
etc
Bilingual child - ESL
• Often late recognition
• Problem in which language?
• How to treat – which language?
ASD
• Pervasive developmental disorder determined
by presence of abnormal/impaired
development manifest pre 3y of age affecting:
-social interaction
- communication
- restricted repetitive behaviour/interests
ICD 10
Aetiology
• Often undetermined
• Familial element
• Syndromes associated, including:
– Fragile X, Tuberous sclerosis, PKU, NF, Downs
Management
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SALT
Behavioural techniques
Educational support
Parent courses and support
Important points
• +ve family history language delay/learning
difficulties
• Early behaviour – passive/irritable
• Feeding skills
• Play underpins language development
(depends on symbolic understanding)
• Parents often over estimate language
comprehension
Key points
• Majority of normal babies born around
expected due date smile by 8 weeks. Failure to
do so is a warning sign.
• Make allowances for prematurity
• Developmental regression rings alarm bells –
refer!
• Known existing disabilities may impair
performance in other fields of development
wo relevance to intellectual development
Key points (2)
• Late walking more common in babies who
bottom shuffle. How get about currently –
familial element
• Delayed gross motor development is least
significant pointer to general delay – but can be
most obvious and worrying to parent.
• Child presenting with language delay may have
unrecognised global delay
• Watch for persistence of immature patterns of
play & behaviour as well as failure to progress at
normal rate
Developmental Coordination Disorder
• ‘clumsy child’
• Parent/teacher concerns
• Overlap with other disorders –e.g Asperger
syndrome
Definition
• In the absence of any known neurological
condition or intellectual impairment, dyspraxia
is the inability to plan, organise and coordinate
movement.
• Brown D, cited in Bowens & Smith. Childhood dyspraxia,
1999
History & Background
• Incidence – 5%
• No standardised approach for screening, diagnosis
& treatment
• Previously all children with concerns regarding
motor coordination were seen by a paediatrician
and then an OT
• Long waiting list up to 2 yrs for OT assessment
• New secondary screening started in Dec 2004
using MABC* (Movement Assessment Battery for
Children) checklist & SDQ. Now use DCD-Q and
SDQ
* Henderson & Sugden, 1992
DCD Screening process
Motor difficulties
identified
Action:
Neurological
Examination by GP
Abnormal
Neurology
Refer to Paediatrician
Normal
Parents & Teacher
•complete SDQ
•complete DCD-Q
•Send own observations
DCD Team at Child
Development Centre
DCD Screening process
Referral with
DCD-Q/SDQ
received by DCD
Team
Movement
problems:
(below 10th
centile DCDQ)
At Risk:
>10th centile
DCD-Q
Child with SEN/SEN
in process
Referral to
Community OT
Service
Complex
Presentation
Joint
OT/Paediatric
Clinic
Motor skills
difficulties only
OT Assessment
Abnormal Scores on
SDQ or other
primary diagnosis
Paediatrician
Assessment
Advice Pack sent
Questions?