Development Problems in Children

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Development Problems in Children

• Dr Ros Jefferson
• GPVTS presentation Sept 08

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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

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Normal development

• Physical and neurodevelopmental growth
  development throughout childhood
• Normal milestones important
• Wide variation in normal so may need to see
  again.

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Influences on development

• Genetic
• Environmental family structure, housing,family
  support
• Stimulation
• Malnutrition
• SEC

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Areas of development

• Gross motor
• Fine Motor Vision
• Hearing Communication
• Social Personal

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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
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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, 3 brick bridge, copies circle, cuts w scissors Sentences, names 4 pictures Eats w fork spoon. Puts on clothing. Names friend
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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?

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Developmental delay

• Global
• Specific
• Deviance vs delay

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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

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History

• Parental concerns parents usually right
• Family History how compares with sibs
• Pregnancy
• Birth
• Postnatal
• Feeding
• Development
• Medical history

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Examination

• Look at the parents!!
• Observations of child
• Head circumference
• General examination
• Neurological examination

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Basic developmental kit

• Pencil/paper
• 1in cubes
• Simple formboard
• Simple book

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Global delay

• Downs 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/mosaici
  sm

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Downs syndrome

• Ring alarm bells diagnosis confirmed from
  chromosomes
• Multisystem
• Insert in PHR

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Downs syndrome - development

• Differences within DS population
• Mainstream education GCSEs vs no language
• Limited exercise tolerance vs sporting excellence
• 40 of children with DS are able to learn to read

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Downs syndrome - milestones
Milestone Mean age Range
Sitting 13m 6-30m
Standing 22m 9-48m
Walking 30m 12-60m
Single words 34m 12-72m
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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

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Local protocol

• 0-2y acute paediatrician follows up
• 2- 5y ( F/T school) community paediatrician
• gt5y - if no health problems, surveillance
  leaflet to family and GP, for GP follow up

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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

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Locomotor delay

• Variation in milestones walking 7/12 30/12
• First steps short, widebased with planus feet
• Mature gait not achieved till 4.5y

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Locomotor problems

• Normal variants all present with awkward gait
• Femoral/tibial rotations
• Bow legs normal in infant correct by 18m
• Knock knees
• Correct spontaneously

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Bottom shufflers

• Different patterns
• ve family history
• Dont crawl possibly later sitting
• Hypotonia resolving
• Vertical suspension hip flexion/knee extension
  posture
• Dislike prone position
• Mx reassure!

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Benign hypotonia

• Delayed, not deviant, pattern
• Low muscle tone
• Normal neurology
• /- bottom shuffle

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Toe walking

• Idiopathic
• Myopathic
• Neurological
• Key Neurological examination /- CK

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Scenario

• Johns 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

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• 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?

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Language delay

• May cover cognitive delay.
• Always refer for audiology assessment
• Language development influenced by
• Early input carer/child interaction
• Learning disability
• Genetic endowment

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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

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Bilingual child - ESL

• Often late recognition
• Problem in which language?
• How to treat which language?

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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

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Aetiology

• Often undetermined
• Familial element
• Syndromes associated, including
• Fragile X, Tuberous sclerosis, PKU, NF, Downs

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Management

• SALT
• Behavioural techniques
• Educational support
• Parent courses and support

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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

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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

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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

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Developmental Coordination Disorder

• clumsy child
• Parent/teacher concerns
• Overlap with other disorders e.g Asperger
  syndrome

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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

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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

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DCD Screening process
Motor difficulties identified

• Parents Teacher
• complete SDQ
• complete DCD-Q
• Send own observations

Action Neurological Examination by GP
Normal
DCD Team at Child Development Centre
Abnormal Neurology
Refer to Paediatrician
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DCD Screening process
Referral to Community OT Service
Child with SEN/SEN in process
Referral with DCD-Q/SDQ received by DCD Team
Movement problems (below 10th centile DCD-Q)
Complex Presentation
Joint OT/Paediatric Clinic
Motor skills difficulties only
OT Assessment
Abnormal Scores on SDQ or other primary diagnosis
Paediatrician Assessment
At Risk gt10th centile DCD-Q
Advice Pack sent
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Questions?