Transcript Developmental Pediatric: a useful way to assess and to be

Jean-François Lemay, MD FRCPC
Professor of Pediatrics
Dept of Pediatrics
ACH, University of Calgary
Sept 6 2012
Learning about Normality
Objectives
The participant will learn:
– general principles in infant growth and
development
– essential to understand normal
development and acceptable variations in
normal developmental patterns
Once upon a time …
… a miracle was born !
Important message
Infant development occurs in an
orderly and predictable manner that is
determined intrinsically
Question:
What is the difference between:
–Developmental screening
–Developmental assessment
–Developmental surveillance
General principles
Physician’s role
– Performing routine developmental screening,
(assessment) and surveillance
– Discussion of normal developmental
variations with parents and professionals
– Explaining test results to parents
– Acknowledging parental concerns
– Providing referral/facilitating management
interventions
What areas of development
are monitored in any child ?
Developmental Spheres
Motor
Social
Speech-Language
Adaptive
Sensory
Cognitive
Stages of development
Step 1: Standing
Step 2: Speaking
Step 3: Thinking
Step 4: Practicing
Step 1: Standing (0 -1 year)
Innate will to reach the world
This will is the impulse to be alive, to learn,
to become
Sitting position: offers a new view of life-can
reach for, and grasp objects, etc.
Then, tries to stand with support
By the end of the 1st yr, baby can stand
freely and begin his-her first steps
3 goals of the 1st yr of life
Sitting
Grasping
Walking
Motor skills: summary FM and
GM-first year of life
Step 2: Speaking (1-2 years)
Language:
– exists and is understood long before it is
spoken
– follows walking
– Develops through imitation
– World begins to make sense when speech
is developing
– 3 periods: pre-speech, naming period, and
word combination period
Stage 1 : Newborn
Predisposed to make order
out of chaos
Able to find human faces
Able to imitate human
actions
Process bits of human
language
They can hear, and they
can produce reflexive
vocalizations-such as
crying, sneezing, and of
course burping!
Prefer to hear mother ’s
voice quite soon in life
Distinguish voices at 4
weeks of age—mom and
dad
Sensitive +++ to language
sounds
Linguistic stimulation is
crucial-contact with
human faces +++
Come prepared to learn
language
Stage 2, 3 and 4
Stage 2: Coos 2-3 months
Stage 3: Gurgles 4-6 months
Stage 4: Babbles 6-7 months
– first babbling sounds that sound like real words-gaga, mama,
dada, etc.
-What is the crucial factor that
stimulates this vocalization process?
answer… eye gaze!!!!
If babies are so capable, why
don’t they talk sooner?
Reason: infant vocal tract resembles the
vocal tract of non human primates
prevents babies from using the mouth as an
instrument in the ways necessary for speech
Oral cavity has lengthened and expanded at
1 yr. of age-first word
Stage 5: First word !
Spent a year preparing for this
achievement-enormous mental leap
Around 12 months (10 mo-24 mo.)
Now can communicate and represent
objects, actions, and events in
his/her mind
TABLE A : EXPRESSIVE LANGUAGE DEVELOPMENT: AVERAGE AGE OF ACQUISITION AND
AGE INDICATING SIGNIFICANT DELAY OR RED FLAG
Expressive Language Milestones
Average Age Range
Significant Delays
and Red Flags
Cooing
2-3 mo
6 mo
Babbling
6-8 mo
10 mo
Nonverbal purposeful messages
(requests with a reach; shows objects)
9-10 mo
12 mo
Pointing
10-11 mo
14 mo
Says 3 different spontaneous words
12-15 mo
16 mo
Vocabulary at least 35-50 words
18-22 mo
24 mo
Production of 2-word phrases
(“Mommy sock”; “No water”)
18-22 mo
24 mo
Simple sentences (“I want juice”;
“Where’s my ball?”)
24-30 mo
36 mo
Intelligibility to unfamiliar adult at >
50%
30-36 mo
42 mo
Able to tell about a past event with
parent asking questions (personal
narrative)
24-30 mo
36 mo
Able to tell or retell a familiar story
36-48 mo
54 mo
Fully intelligible to an unfamiliar adult
(despite some immature sounds, such
as consonant clusters or /r/ and /l/
48-54 mo
60 mo
Fully mature speech sounds
Up to 72 mo
> 72 mo
TABLE B: RECEPTIVE LANGUAGE DEVELOPMENT: AVERAGE AGE OF ACQUISITION AND
AGE INDICATING SIGNIFICANT DELAY OR RED FLAG
Receptive Language Milestones
Average Age of Acquisition
Significant Delays
and Red Flags
Alerts or quiets to sound
Birth to 1 mo
2 mo
Turns to the source of sound
Birth to 1 mo, then again 3-5 mo
6 mo
Responds to own name
6-8 mo
10 mo
Follows verbal routines/games (‘Wave
bye-bye”)
8-10 mo
12 mo
Understands simple questions
(“Where’s mommy?”)
9-11 mo
15 mo
Stops when told “No”
9-10 mo
15 mo
Understands at least 3 different words
10-13 mo
15 mo
Points to 3 different body parts
12-16 mo
18 mo
Follow simple commands (“Show me
the ball” or “Get your shoes”)
12 mo
18 mo
Follows 2-part commands (“Get your
shoes and give them to Dad”)
24 mo
30 mo
Answers simple questions (“Who is
that?” or What are you doing?”)
24-30 mo
36 mo
Important tips:
Expressive language
Age in months/minimal amount of words
•12 months: 1 x 2 or 1+2
•15 months: 1 x 5 or 1+5
•18 months: 1 x 8 or 1+8
•Vocabulary Spurt
•24 months: 24 mo x 2y
•36 months: 36 mo x 3y
Step 3 : Learning-Thinking
Infants learn to do virtually everything
that is typically human during the first 2
years of life
Defined as a change of behaviour
resulting from experience and practice
Exploration-practical reasoning
Step 4: Practicing
Now you are ready to use your skills
Kindergarten is starting at age 5: why?
Similarities with medical school students
Preparation to medical school
- Step I: Year 1 and 2 of Med School
- Step 2: Clerkship
- Step 3: MCC exam
- Step 4: Residency
In order to determine if a child is
normal or abnormal, you need to do…
History and Physical Examination
Detailed history
–
–
–
–
Family
Prenatal
Perinatal
Postnatal
Detailed Physical Examination
Family History
Three generations, maternal and paternal
Consanguinity, Pedigree
Previous pregnancy outcomes:
– miscarriages, stillbirths, neonatal or childhood
deaths, infertility
Family history of birth defects, childhood
deaths, MR, SD, LD, ASD, and known genetic
conditions
Ethnic background
Prenatal History
Potential teratogens
– Alcohol, medications,vitamins, maternal
infection (rubella, toxoplasmosis,varicella)
– Maternal diabetes, hyperthermia, maternal
PKU
Fetal movements
Prenatal tests
– Eg. amniocentesis, ultrasound
Perinatal History
Gestation, mode of delivery, APGAR,
resuscitation
BW, length, HC
Feeding, muscle tone, other problems
Postnatal History
Developmental Milestones, school performance
Evidence of regression
Unusual behavior, personality, temperament
Coordination, seizures, unusual movements,
increased or decreased tone
Growth, nutrition, sleeping
Vision, Hearing
Previous illnesses
Complete review of systems
Physical Examination
Syndromic versus Non-syndromic
developmental delay
Growth parameters
Complete physical examination
Careful neurological examination
Careful skin examination
Question
At birth…
– Head Circumference :
– Weight:
– Height:
At 12 months…
Social
Summary
Infant development occurs in an
orderly and predictable manner that is
determined intrinsically
It proceeds from cephalic to caudal and
proximal to distal as well as from
generalized reactions to stimuli to
specific goal-directed directions that
become increasingly precise
Review of developmental skills and
quiz/questions
6 Months
Babbles “baba”, “gaga”
Interacts with others
Looks to floor when
drops toy
Discriminates strangers
Transfers objects handto-hand
Immature rake of pellet
Sits propped on hands
Red flags-may
indicate
Not rolling or poor head
control-neuromotor
dysfunction
Absence of babblinghearing loss
12 Months
Follows commands
with gesture
One word with meaning
Point for object
Removes lid to find toy
Fine pincer grasp
Marks on paper with
crayon
Stands alone, may even
take a few steps
Red Flags-may indicate
No protective reactionsneuromotor disorder
Persistent mouthing or
not looking for hidden
object-cognitive delay
No “mama”, “dada”speech language delay
18 Months
Points to self and 3
body parts
Average 20-50 word
vocabulary (minimal 810)
Matches pairs of
objects
Functional use of items
Scribbles
spontaneously
Tower of 4 blocks
Walks confidently
Able to seat self at
small table
Throws ball while
standing
Red flags-may indicate
Lack of imitation or of
protodeclarative pointingdeficits in cognition or social
development
Lack of walking-neuromuscular
or neuromotor condition
Hand dominance< 18 monthscontralateral weakness
<10 words- language delay
Does not show affection-delayed
social development
Doesn’t play functionally with
toys-delayed cognition/social
development
2 Years
Follows 2-step commands
Understands me, you
Average 100-250 words
(Minimal 50)
Combines noun + verb (2 words
together)
Uses basic pronouns
Plays parallel to others
Matches objects to pictures
Train of cubes, no stack
Imitates vertical stroke
Jumps in place
Kicks a ball and throws
overhand
Walks down stairs holding rail
Red Flags may indicate
Absent symbolic playcognitive and/or social
development problems
Not climbing stairs-may
reflect lack of opportunity, or
neurodevelopment disorder
Not scribblingneurodevelopment disorder
Lack of categorizingcognitive delay
No novel 2-word
combinations-speech,
language delay
The period between age 2 and 3:
– The miraculously rapid development of
functional language
– Refinement of basic fine motor skills for
eating and manipulating objects
– Increased knowledge about concepts of
shapes, colors and daily routines as well
as social skills (please, thank you)
– Time of social reactivity as children strive
to gain increasing self-control
Motor milestones: 3 and 4 years
3 years old
– Feeds self with spilling
– Opens doors
– Holds glass with one
hand
– Holds crayons well
– Throws a ball overhead
– Dresses self with help
– Uses toilet with help
– Kicks balls forward
– Jumps with both feet
– Pedals tricycle
4 years old
– Feeds self, uses fork
– Holds pencils-tries to
write
– Draws circle, face
– Cuts with small scissors
– Brushes teeth with help
– Unbuttons
– Uses toilet alone
– Tries to skip
– Catches a bouncing ball
– swings
Developmental age?
An infant who will walk with one hand
held, has a 3-word vocabulary, will give
an object to another person on request
and waves bye-bye is closest
Your answer:
Developmental age?
This child has a fine pincer grasp, will
put to stand, and uses dada and mama
non specifically
Developmental age ?
A child who is able to run and jump,
scribbles in a circular pattern, uses a
spoon and puts three words together
Question
You would expect a 15-month-old child to
be able to do all the following except:
A-Walks about the room independently
B-Can say 8 words in addition to mama
C-Begins to use cup
D-Responds to one-step verbal command
E-Spontaneously doing a circle
Question
You would expect a 24-month-old child
to be able to do all the following
except:
A-walks unassisted up and down stairs
B-copies a cross
C-50% of speech intelligible to stranger
D-removes simple clothing
E-kicks ball
Question
You would expect a 3-year-old child to
be able to do all the following except:
A-copies a circle
B-engages in group play
C-can tell his/her name
D-speaks in sentences of 3-6 words in
length
E-Draws a person with six body parts
Developmental age ?
A child who is able to ride a tricycle,
copy a circle, count to three,
discriminate colors, and remove his
clothing
At what age are infants able to
perform the following motor skills?
Sit up by themselves
Walk
Crawl
Smile
Hold their head up
Combine words
Understand speech
Uncover a toy that is hidden by a scarf
At what age are infants able to
perform the following motor skills?
Tom Brady (NFL quarterback NE
Patriots) comes to you with his 3-yearold son distressed that he can’t catch a
ball yet. You reassure Tom that
children are not expected to perform
that motor skill until they are what age?
Other questions
By what age are 90% of children
walking? 99%?
For an apparently normal appearing
child who is saying no words at 18
months, what is the best thing to do?
Case
A 15-month-old is saying “baba” and
has no other words. He points at
objects all the time and gestures his
understanding of what things are used
for (phone to ear). He can understand
simple commands. His motor
development is normal- he is walking.
Mother is worried. What do you tell
her?
Neurodevelopmental
assessment
Child from 3-5 yrs
Social: name, eye contact, compliance
Orientation: child’s ability to establish various
spatial ordinates with regard to his own body
– IDENTIFY BODY PARTS: eyes, nose, ears, knee,
elbow, shoulder, cheeks, heel, ankle
– IMITATE FINGER MOVEMENTS: 1-2,1-3,1-4,1-5 on
one hand then repeat on the other hand; look for
associated mvts (soft neurological signs)
– VISUAL TRACKING
Gross Motor
– Stressed gait: walks forward and backward;
runs, jumps, stairs-up and down
– Stands on one foot
– Motor stance; Romberg
– Kicks, hops, catches balls
Fine Motor
–
–
–
–
–
–
–
–
–
Dominance: right, left
Grasping pencil: mature or immature
Drawing
Copying figures
Scissors
Puzzles
Blocks (tower; figure)
Turns pages
Dress, undress
What do you need to be ready
for toilet-training ???
Toilet Training: Developmental Readiness
Language Skills
– 2-step command
– 2-word phrases
Cognitive Skills
– Initiates actions
– Understands cause and
effect
Emotional Skills
– Desire to please parents
– Diminishing oppositional
behavior
Autonomy/Independence
– Drive for autonomy and
independence in self-care
– Pride and positiveness
towards belongings
Motor Skills
–
–
–
–
Ambulation
Undress independently
Can sit for 5 minutes
Urinary and anal sphincter
control
Body Awareness
– Awareness of wet or soiled
diaper
– Manifests signs of urge to
void or defecate
The End