Paediatrics and Child Health

Paediatrics and Child Health The child with developmental delay / learning difficulties

Learning outcomes you should be able to … 1. Recognise the key stages of normal childhood development 2. Make an outline assessment of a child with developmental delay 3. Use playtime to assess the nature and degree of delay 4. Recognise major differences between global and isolated areas of delay

… more learning outcomes 5. Identify major categories of developmental delay in patients 6. Initiate appropriate investigations for the cause of developmental delay 7. Work with the multidisciplinary team in the assessment and care of patients with developmental delay 8. Assess the impact of delay and / or complex needs on the child and the family 9. Recognise multiple factors impacting on a child’s ability to learn

1. Recognise the key stages of normal childhood development

Typically developing children • Sequence of acquired skills • Areas of development in young children • Quality of skills

Four Domains of Development • Gross motor skills • Fine motor and visual skills • Hearing, speech and language skills • Social, emotional and behavioural skills Cognitive development refers to higher mental function

Reviews Newborn examination 6-8 weeks 6-9 month 18-24 months 3-3 ½ years Preschool review Developmental surveillance

Age for walking for typically developing children

‘Normal’ • Median age for walking is 12 months • Limit age (2 standard deviations above average) is 18 months

Newborn examination: limbs flexed, marked head lag 6-8 weeks: Lying prone, lifts head to 45 degree 6-9 month: little or no head control on pull-to-sit (3m), rolls back to front (6m), sits without support (8m) Typically Developing Child:Gross motor

Gross motor (12-18 months): crawls (10m) stands independently (11m) walks independently (12m)

Gross motor 18 -24 months: squats to pick up an object (18m) Runs (2y) runs (2y) walks upstairs holding on and two feet to a step (2y), 3-3 ½ years: walks alone upstairs with alternating feet per step (3 y) pedals tricycle (3y) 4 years: Hops (4y)

Limits ages: Gross motor skills • Still has head lag at 4 months (not in line with spine on pull to sit) • Persistent primitive reflexes 3-4 months • Unable to sit unsupported at 9m • Not walking independently at 18m • Nb asymmetry at any age

Fine motor and visual skills Newborn examination: hands closed 6-8 weeks: Does your baby watch your face and follow with his/her eyes? Fixes and follows briefly 6-9 month:Have you noticed a squint? Palmar grasp (5m) Passes toy from hand to hand (6m) Inferior (raking) pincer grasp (9m) Looking for falling toys: object prmanence (9m).

Fine motor 12-18 months: Refined pincer (10 ½ m) Tower of two bricks (15m) Scribbles spontaneously (15m) Imitates stroke (18m)

Fine motor 18-24 months: Tower 3 bricks (18m) Tower 6 or 7 bricks (2 years)

Fine motor 3 – 4 years: Copies (pre-drawn) circle (3y) Draws person: head and one other part (3y) Copies (pre-drawn) cross (4y) Draws person: head, legs and arms (4y) Copies pre-drawn square (4 ½ y) Draws person: face, trunk,legs, arms(5y)

Limits ages: Fine motor skills • Not fixing and following visually at 3 m • Not reaches for objects at 6 m • Not transferring objects at 8m • Not developed pincer grasp at 12m • Not turning pages 24m • Inability to stack graded cups 24m

Hearing, speech and language Newborn: startles to loud noises 6 - 8 weeks: vocalises when pleased 6 ½ weeks 6 – 9 months: Turns to sounds (7m) Babbbles (6 ½ m) monosyllabic then polysyllabic

Hearing and language 12 – 18 months: Knows and turns to own name (12m) Shows undersatnding of familiar objects and people (12m) Points to show interest (15m) Can point to two named body parts (on self) (15m) on doll (18m) Uses 2 to 6 recognisable words (15m)

Hearing and language 18 – 24 months: • Follow a two-step command (2y). Put the brick in the cup. • Puts 2 or more words together to form simple sentences (2y) e.g.‘Daddy car’ (Do Not count phrases that are heard together e.g. Thank you) 3 – 3 ½ years: • Understands commands with three key words (3y) • Understand negatives (3y) • Uses ‘what’ and ‘how’ (3 y) • Uses personal pronouns (me/ you) (3 ½ y)

Hearing and language 4 years: Asks why? When? how.? (4y) Able to tell long stories (4y) Counts (by rote) to 20 (4y)

Limits ages: Hearing, speech and language • No double syllable babble aged 12 m • No words with meaning at 12m • Fewer than 6 words at 18 m • Not responding to one word commands at 18 m • No 2 – 3 words phrases at 2 ½ y • Unintelligible/ repeating phrases without meaning at 3 y • The child who appears not to understand • Parental / professional concern

Social, emotional and behavioural skills 6 – 8 weeks: Smiles responsively 6 – 9 months: Takes everything to mouth (7m): should disappear by 12m Put hand up to bottle/ breast when feeding (6m) Stranger awareness (9m) Plays peek-a-boo (9m)

Social, emotional and behavioural skills 18 – 24 months: Holds spoon and gets food to mouth (18m) Plays alongside other children (2y) 3 – 3 ½ years: Shares toys.(3y)Simple make- believe play with peers (3y) Eats with fork and spoon (3y) Able to postpone urination during the day (3y) Can pull pants up and down.

Social, emotional and behavioural development 4 years: Eats with knife and fork. Understands taking turns. Dress and undress excluding fastenings (3 ½ to 4 y)

Limits ages: Social, emotional and behavioural skills • Not smiling at 8 weeks • Persistent mouthing at 12m • No symbolic play at 3.5 years • Not playing with peers at 3.5 years • Other concerns

Further reading: • Illustrated Paediatrics • From Birth to Five Years Children’s Developmental Progress, Mary D Sheridan

2. Make an outline assessment 3. Use playtime to assess delay Observe: Start with some typically developing children. Observe the child’s play History: Ask parents about developmental milestones Their baby’s gestation at birth and current age Do the parents have any concerns Examination: Use available toys: bricks, pencil paper, books, balls to test 4 domains of development: Gross motor, fine motor and vision, language and hearing, social Interpretation: Consider the 4 domains of development. Is the child achieving expected developmental progress in all areas?

Developmental Assessment Tools Standardised assessment tools you may see in use: • The “Schedule of Growing Skills” (Nelson) • The Denver charts • The Griffiths Scales During your training you should aim to: 1. Observe a developmental assessment in clinic 2. See a child at home with a health visitor 3. Carry out some outline assessments (start with a typically developing child)

Developmental assessment in clinic • History • Antenatal history • Birth history • Medical History • Developmental history • Family and social history • Developmental assessment • Fine motor, language and then gross motor (we start with tasks the child can do). Usually dependent on Hx for self-care and interactive social skills. Qualitative observations • Examination inc OFC, Ht, Wt

4. Difference between global and isolated delay John Smith, aged 3, was slow to walk … at what age would you expect most children to be walking independently? Adam Scott, aged 10 months, was slow to babble … when would you expect a baby to babble? …and what about first words, when do they emerge?

Delayed walking Neuromuscular Problem Global delay Isolated late walking Differential diagnosis

Clinical Evaluation • Antenatal history • Fetal movements, IUGR • Risk factors for cerebral palsy, drugs , alcohol, Rx • Birth history • Medical history • Serious illness • Developmental history • Fine motor, language, social skills, red book • Social history • Deprivation • Family history • Delayed walking, illness, consanguinity

Clinical examination • Neurological • Movement and posture, muscle mass, power, tone, reflexes, sensation, bladder and bowel control • ? muscle, neuromuscular, motor neuron, CNS • OFC, vision, hearing, dysmorphism, skin • Developmental • General developmental assessment • ? global v. isolated • Importance of follow up and monitoring progress

Investigations • Creatine kinase (boys not walking by 18 months) • Other investigations as indicated to support clinical diagnosis

Delayed talking Check hearing Global delay Isolated speech delay Language problem Communication disorder Differential diagnosis

Speech delay • Is there a hearing problem? • Is there evidence of global delay? • Is there a speech or language problem? • Is this a pervasive communication problem?

Clinical Evaluation • History • Examination • Developmental assessment • Investigations • All children with delayed talking should have a hearing test • Other investigations depend on clinical picture e.g. Fragile X, Woods light and others for child with autism • MRI and high resolution karyotyping inc FrX positive yield in 1 in 6 undiagnosed cases

Delayed speech Normal comprehension Delayed comprehension Speech problem Language problem Is there a speech and language problem

Peter Small, aged 7, was difficult to engage in conversation in clinic, what kind of conversation would you expect to have with a child of this age? Think of some reasons why a 7 year old child may have difficulty holding a conversation

Is this a pervasive communication problem? • Does the child have normal non-verbal communication skills? • Smiling, gaze fixation • Turn taking • Pointing • Waving • Showing and sharing

Is there ‘autistic’ behaviour? • Clinically • Social interactions (‘avoidance’) • Play skills (‘mechanical’ not ‘imaginative’) • Obsessions (video, routes, routines) • Standardised assessment • DSM IV / ICD 10 criteria • Autism Diagnostic Interview • Autism Diagnostic Observations Schedule

Normal Development

Severity of Developmental delay Developmental abilities and intelligence in the childhood population follow a normal distribution curve just like height or weight. Children whose attainments fall below the 2nd centile have a significant delay. Intelligence quotient (DQ) <70 (Average DQ = 100) 20 % child population 5 0 70 100 140 Developmental quotient • Delays are divided into: DQ • Mild 60-70 • Moderate 50-60 • Severe 40-50 • Profound <40

Identifying developmental delay During the first year of life …. • the most dramatic changes seen in development are in the area of gross motor skills as the child learns to walk • Severe or moderate global developmental delay may be first noticed because the child is slow to sit, roll, crawl and walk – but the sequence of these events will follow the normal pattern • Detailed assessment will show if the delay is global or specific

Patterns of developmental delay Communication Gross motor social Fine motor Typically developing child cognitive Global delay - all areas e.g. Down syndrome Specific delay - gross motor skills e.g. Spastic diplegia, spina bifida

During the second year of life • The child makes a lot of progress with speech and language development • It is often during the second year of life that children with autism present with a specific delay of language and social skills • Loss of skills is always significant Gross motor cognitive Fine motor Communication Typically developing chilc social Specific delay – Social skills and communication

During the fourth year of life • Cognitive abilities become more apparent with increasing age. • As children approach school age mild or moderate learning difficulties may be noticed for the first time by pre-school teachers who will refer to the educational psychologist and paediatrician.

Case Study • Amy is a 7 year old school girl. She was healthy at birth. Her 7 month health visitor developmental screen suggested that her development was within satisfactory limits • What does this mean in terms of the four areas of development discussed earlier?

Paediatrics and Child Health