Assessment of development

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Assessment of development
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National Service Frameworkfor Children, Young
People and Maternity Services

• NSF advocates a shift within services being
  designed and around needs of children-child
  centred and looking at the whole child, not just
  the illness or problem, but rather the best way
  to pick any problem up early, take preventative
  action and ensure children have the best possible
  chance to realise their full potential 10 year
  plan
• National standards for childrens health and
  social care , which promote high quality, women
  and child-centred services and personalised care
  that meets the needs of parents, children and
  their families
• National Service Framework for Children, Young
  People and maternity services 2001
• Every Child Matters Green paper, 2003
• Every Child Matters Next Steps, 2004
• The Children Act 2004

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Standards

• Promoting health and well being, identifying
  needs and intervene early
• Supporting Parenting
• Child, young person and family centred Services
• Growing up into adulthood
• Safeguarding and promoting the welfare of
  children and young people
• Children and young people who are ill
• Children and young people who are in hospital
• Disabled children, young people and those with
  complex needs
• The mental health and psychological well-being of
  children and young people
• Medicine for children and young people
• Maternity services

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• Quiz
• Reminder
• SOGS
• Cases
• Questions

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• What are the objective of 6 weeks check?
• Head lag up till what age normal ? 4 weeks? 6
  weeks 10 weeks?
• Moro reflex at the age of 6 months worrying or
  not?
• Would you refer a child that does not sit at 9
  months? And who to?
• Would you refer a 18 months bottom shuffler? Who
  to?
• You are asked to see a boy who at the age of 2 is
  not walking yet and has also speech delay , what
  would you do?
• Toe walking at 3 years of age , normal finding?
• Poor balance on alternate feet at 4 , normal
  finding?
• Not fixing on faces at 6 weeks?
• No words at 2 and no copy play? Normal finding?
• No vocalisation or babbling at 9 months? What to
  do
• Hand preference at 12 months, normal finding?
• No hand preference at 4 , concerns what next?
• Day wetting at 4? Concerning?

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• INCIDENCE OF DEVELOPMENTAL PROBLEMS
• In a G.P. list of 2,000 patients, one would
  expect to see approximately
• Cerebal palsy 1 new case per 20
  years
• Severe learning difficulty 1 new case per 11
  years
• Downs syndrome 1 new case per 26 years
• Autism 1 new case per 130 years
• Duchenne Muscular Dystrophy1 new case per 270
  years

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• Our approach to surveillance for developmental
  problems will be listening to the parents report
  of the childs progress, coupled with observation
  of the child at each contact, rather than of
  routine specific developmental examination.
• Parental questioning and observation of the child
  to assess developmental normality should
  consciously focus on each of the 4 key areas of
  development
• Gross Motor
• Fine Motor/Manipulation (including vision)
• Speech and Language (including hearing)
• Social
• and should aim to assess the quality of
  performance in these areas, as well as the
  quantitative level of attainment.

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• -----Fine
  (Manipulation)
• MOTOR
• -----Gross
  (Mobility)
• -----Speech (Expression)
• LANGUAGE
• -----Understanding (Receptive)
• VISION
• HEARING
• COGNITIVE
• SOCIAL
• BEHAVIOUR

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Newborn

• Neonatal reflexes
• Tone Head Lag
• Posture
• Cry
• Eyes
• Alertness etc

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6-8 Week Check

• As above, and also-
• Smile
• Feeding (suck)
• Grasp
• Follows
• Stills to voice
• Fists?
• Vocalisation
• Sleep
• Raise Head

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Gross motor development lt1

• 6-8 weeks Raise chin from surface to 45 when
  prone
• Head in line a moment - Ventral Suspension
• Head Lag not complete
• 3 month Supports on forearms (prone)
• 4 months Good Head Control No head lag Face
  90prone
• 5 months Full head control
• 6 months Supine lifts head. Sits hands support
  (midline)
• Rolls front to back
• 7 months rolls front to back legs often straight
  held standing
• 8 months Sit no support Leans to reach for
  things.
• 9 months stands supported. May crawl
• 10 months pulls to sit or stand
• 11 months Pivots sitting Cruises
• 12 months walk 1 hand held (or bottom shuffle)

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Fine motor development lt1

• Nb Depends upon losing primitive grasp (3
  months)
• 3 months Retains objects placed in hand
  gtmomentarily,
• 4 months Hands together Shakes rattle (placed in
  hands)
• 5 months Reaches and gains objects
• 6 months Holds (and sucks) feet Drops cube when
  2nd given Palmar grasp
• 7 months Holds bottle Retains cube when 2nd
  given age of transfer hand to hand
• 8 months Mouthes bangs objects
• 9 months Index finger approach
• 10 months Claps
• 11 months Active release (? give and take)
  Pincer
• 12 months Casts (begins)

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Communication language development lt1

• Nb Develop understanding before expression.
• 6-8 weeks Vocalisation (simple) Smiles when
  spoken to
• 4 months Laughs, ? pitch/tone of vocalisation
  oreints to voice
• 6 months Babbles (? consonants) Chews
• 7 months mama, dada (non-specific) ? syllables
• 8 months Recognises name Understands some words
  Object permanence
• 11months Mama, Dada (specific) Imitates sounds
• 12 months 2 3 words with meaning Turns to
  name Understands more 1 words

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Social development lt1

• 6-8 weeks Regards face Fixes (follows 90)
  Stills to voice
• 3 months Hand regard (to 20/52) Reaches Turns a
  little to sound
• Excites with toys
• 4 months sees smaller objects enjoys looking
  Laugh
• 6 months Enjoys mirror Recognises strangers
  Beep-po
• Cranes to see
• 8 months Persistence Imitates eg tongue out
  beaker usedName Distraction test Comprehension
  starting Follows 180
• 10 months Waves Arm out for dressing Pulls at
  others
• 12 months Casting Mvt. And sound association
  Interest in books Shy Mouthing ? Follows fast
  objects

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Developmental Warning Signs (lt1yr.)

• Persistent Squint Any age
• Lack visual Fixation (face/light) Nb sound
  4/52
• Lack of Smile 8/52
• Persistent Fisting 2/12
• Head Lag (not in line with spine on pull to sit)
  3/12
• Persistent primitive reflexes
  3-4/12
• 
  (Awake) Persistent Hand Regard
  4/12
• Failure to Reach for Desired Object
  8/12
• Not Sit Unsupported 9/12
• Not Babbling 9/12
• Not Chewing 10/12
• Lack of Pincer Grip 11/12
• (Ages given, as corrected for Gestation)

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Gross motor

• 13 months walk independently
• 15 months Stands without pulling up Creeps up
  stairs
• 18 months Climb stairs (holds rail) Climbs to
  chairs starts to run throws ball (no fall)
• 21 months walks backwards squats in play
• 2 years stoops to
  retrieve (no fall) Running Kicks ball
• 2½ years 2 footed jump
  up Throws overarm
• 3 years Starts to pedal
  Climb stairs adult fashion
• Descends stairs (child)
  
• 4 years Stand 1 foot 5
  seconds Hops
• Descends stairs adult
  fashion.
• 5 years Heel to toe
  backwards Bounce catch ball
• Clears low objects in jump.

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Fine Motor

• 15 months 2 cube stack removes shoes
• 18 months Spoon feeds Scribbles Casting stops
  Turns pages
• 21 months 5-6 cube tower
• 2 years Turns door knob Imitates Pages turned 1
  at time wash dry hands
• 2½ years Pencil held in hand adult like 8 cube
  tower
• 3 years Dress (not buttons) and undress Can
  trust to carry things Threads beads well
• 4 years Buttons Catches ball Steps with bricks
  3 part man (humpty) Copies circle, cross /-
  square
• 5 years Competent to spread with knife Man, all
  featuresCopies triangle

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Language

• 15 months Learning jargon 4 6 words
• 18 months 20 words Points Symbolic play
  commences
• 21 months Points to 5 body parts
• 2 years picture/object match
  50 words combines 2-3 words
• 2½ -3 years Pronouns (me, you) plurals (word
  extension eg sheep?sheeps) Past tense (adds eg
  -ed) Questions Simple verbs In on start
  (simple prepositions) Actions / functions
  understood.
• 3-3½ years Syntax Gender known (he/she) The
  commences
• Relates experiences 4 word
  phrases understands 3 keywords
• 3½ - 4 years ? prepositions (behind, in front
  etc)
• Concepts of size used
  How? 6 word phrases
• Conjunctions used All
  colours known
• Songs from memory 4
  keywords understood Understands negatives
• 4 5 years Prints name Complex sentences
  Relative times (yesterday etc) Asks meanings 5
  key words understood. Simple reasoning

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Social Development

• 15 months Cup
• 18 months Points Feeding slows Symbolic play
  startsCopies actions Nb language
• 21 months Points to named objects Sleeping
  rituals Asks for food drink
• 2 years Parallel play pencil skills Adult
  vision
• 2½ years Toiletting (day) Tells full name
  dressing Helps wash dry hands
• 3 years Nursery rhymes Joins in play turn take
  / share
• Separates from mother toilets alone Questions
• 4 years Teeth brushing (alone) Tall tales
  Dresses alone (Nb buttons)
• 5 years Competitive games sticks to rules
  Chooses own friends Complex dramatic play
  Comforts others

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Developmental Warning Signs (1 2 Yrs.)

• Not sit (no support) or bear weight
  12/12
• Nb absent saving reactions
• No Words with Meaning 12/12
• Doesnt Stop Casting 15-18/12
• Drooling Persists 18/12
• Not Walking 18/12
• (Bottom Shufflers May not walk until 24 months)
• Not respond to 1 word commands 18/12
• No Symbolic Play 24/12
• No 2 3 word Phrases 24/12
• Not Turning Single Pages 24/12
• Inability to Stack Graded Cups 24/12

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Schedule of Growing Skills II

• A tool used for screening childrens development

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How the schedule of growing skills works

• When it is used
• What the pack includes
• Scoring method
• Eliciting information from parents and children

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When it is used

• Reassuring parents (yourself)
• Global or specific delay
• Determine route for referral
• Easy and fun test to use takes about 30 mins
• Usually administered by health visitor
• Also used by paediatricians at first assessment
  visits
• Important that you can understand the reports!

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Pack contents

• Colourful and interesting toys and puzzles
• Questionnaire style record sheets
• Scoring grid

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The record form

• Four page permanent record
• 9 skill areas
• passive postural, active postural, locomotor,
  manipulative, visual, hearing and language,
  speech and language, interactive social and
  self-care social
• Subdivided into skill sets
• See the form we have given you

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The record form filling it out

• Dont need to assess all nine skill areas
• passive postural skills 0 - 6 months
• active postural skills 0 - 12 months
• self care social 6 - 60 months
• Dont need to ask all questions - aim at rough
  level and adjust
• If you are concerned about the quality ? Q

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For example

• Manipulative skill area has four skill sets
• hand skills
• bricks
• drawing
• draw-a-person

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Scoring skill areas

• Add up highest scores in each set total for
  skill area
• Children can leapfrog scores
• If more then 12 months MUST give maximum score
  for first skill set Visual skills, Hearing and
  language skills and Speech and language

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Cognitive skills

• Simple item count rather then highest score
• Need to check that the child can do each item and
  then count the total number of ticks

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Profile form - age of the child

• ? 48 months draw line through age on chart in
  centre of blocks
• if no age shown, draw line through next lower
  printed age
• 48 - 53 months draw line through 48 months
• 54 - 59 months draw line between 48 and 60 months

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Q
Q
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Schedule of Growing Skills - When to refer

• Referral algorithm
• Clinical judgment is important
• Use your knowledge of child, family, local
  conditions
• Factors to consider include

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Schedule of Growing Skills - When to refer

• Referral algorithm
• Clinical judgment is important
• Use your knowledge of child, family, local
  conditions
• Factors to consider include
• Genetic factors, prematurity, family structure,
  educational background, social interaction, play
  opportunities and medical conditions (e.g. glue
  ear)

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Case 1 - Eleanor

• Age 20 months
• Asked to see by Social Services
• Concerns over several months of neglect, physical
  abuse and failure to thrive
• Bruising to face reported by paternal
  grandparents
• Seen with mother

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Eleanor - History

• Normal pregnancy and birth. No neonatal problems
• Generally healthy
• Early developmental milestones normal
• No concerns at 6 week and 8 month surveillance
  checks
• Mother - moderate learning difficulties,
  physically abused by father

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Eleanor - History

• Father - apprentice mechanic, verbally abusive,
  possibly physically abusive to his wife
• Brother 5 months - quiet baby, not particularly
  responsive

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Eleanor - Physical Examination

• Very quiet, placid, anxious, watchful
• Thin, not wasted, pale
• Poor weight gain over previous 6 months. Weight
  0.4th centile, Length 9th centile
• Bruise on thigh and right cheek

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Eleanor - Development

• Schedule of Growing Skills
• poor play skills
• silent
• unsteady on her feet
• poor interaction

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Q
Q
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Eleanor - Age 24 months

• Thrived in foster care
• Happy, sociable
• Good play skills
• Expressive and receptive language much improved

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Case 2 - Anna

• Age 32 months
• Mother concerned - speech delay
• HV concerned about possible generalised delay
• No significant birth, medical, family, social
  history

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Anna - SOGS Profile

• Hearing and language and Speech and language both
  delayed by 2 intervals
• Action - refer speech and language therapist,
  hearing assessment clinic

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But ...

• Also questionable delay in 2 other fields
• Indicates possibility of more generalised problem
• Use Cognitive skills subfield

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Anna - Action?

• Needs review
• Consider early referral to Education may need
  help with nursery/infant education

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Darryl - Age 36 months

• Seen with both parents
• Concerns about behaviour in pre-school setting
  and at home
• Pre-school setting suggested developmental review

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Darryl - SOGS

• Difficult to get co-operation
• Very short attention span
• ? Comprehension
• ? Interaction

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Darryl - SOGS Profile

• Locomotor score - delayed by three intervals.

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Darryl - SOGS Profile

• Locomotor score - delayed by three intervals.
• Darryl has cerebral palsy - spastic diplegia

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Darryl - SOGS Profile

• Locomotor score - delayed by three intervals.
• Darryl has cerebral palsy - spastic diplegia
• Manipulative score delayed by three intervals

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Darryl - SOGS Profile

• Locomotor score - delayed by three intervals.
• Darryl has cerebral palsy - spastic diplegia
• Manipulative score delayed by three intervals
• Combination of lack of cooperation and minor
  manipulative difficulties

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Darryl - SOGS Profile

• Significant delays in
• Hearing and language
• Interactive social skills
• Self care social skills
• Lack of concentration and cooperation
• WHY?
• ACTION?

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Darryl - Final diagnoses

• Cerebral palsy - spastic diplegia
• Moderate learning difficulties
• Autistic spectrum disorder

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Autistic spectrum disorder

• Remember core impairments
• Social interaction - aloof, passive or active but
  odd
• Communication
• Imagination
• plus repetitive and stereotyped activities
• Remember CHAT

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Cases
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Questions ?
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Working Model for Integrating Services
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