3. “ I regard developmental examination as an
essential part of everyday practice with a
minimum of equipment, in an ordinary mixed
clinic, and not in a special room, or at a
special time, or with special complicated
equipment or by a special doctor ”
R.S. Illingworth
5. Develop. Screening
All Children
Develop. Assessment
Quick
Subjective
Gen.
Pediatrician in
his clinic
Children with perinatal
events, risk factors, delay
suspected
Time consuming
Objective - tests
Dev. Pediatrician
||
Neurologist
ENT Surgeon
Ophthalmic
Ortho
Child psych.
Physiotherapist
occupational, speech
School
teacher
Mother
6. Objectives
• Sensitization - Dev. Screening
• Early identification & appropriate referral
• Simple format using
– Ordinary tools
– Within 10 - 15 minutes
– Clinic / OP settings
– Subjective assessment
7. Beyond the Scope of this Lecture
• Detail Assessment
• Formal - objective tests
Specific disabilities
• ADHD, deafness, MR, autism, LD
Special investigation
• BERA
8. Why should we assess ?
• To reassure parents
• Early diagnosis and management of
disability
• Feedback for obstetrician and
neonatologist
• Prevention in next sibling
9. What to do ?
• Just passively observe his play and
spontaneous activity
• Use TDSC to screen
• Go little more deeper with Development Chart
(Lingam S. UK)
• Need not memorise
• Keeps the charts over the table and assess
10. Four Aspects of Development
• Motor - Body posture & large movements
• Fine movement, vision and manipulative
skills
• Hearing and speech
• Social behaviour & spontaneous play
Development Assessment is most
conveniently divided into four fields
Development Assessment is most
conveniently divided into four fields
11.
12. Developmental screening scale (S.Lingam 1987, UK)
4-6 weeks 3 months 6 months 9 months
GROSS MOTOR Supine: head on sides, fencing,
hands closed, thumbs in
Pulled to sitting head momentarily
erect and fall
Held sitting: back curved
Ventral suspension: Head in line
with trunk
Walking, stepping
Supine: Head in midline
Hands open, moves arm
symmetrically
Hands together in midline
Pulls to sitting little or no headlag
Kicks vigorously
Ventral suspension-Head above
trunk
Prone lifts head with forearm
support
Supine: Raises head, lifts legs,
grasp foot
On grasping hand pulls self to sit
Prone: Hand support
Sitting with support straight back
Downward parachute: Bears
weight on feet
Sits alone – 10-15 minutes
Leans forward without losing
balance
Attempts to crawl
Pulls to stand to crawl
Forward parachute ( 7 m)
Rolls over back to prone
FINE MOTOR Turns eyes and head towards light
Shuts eyes to bright light
Regards mother face
Follows ball ¼ circle
Follows adult movements with
available field
Follows ball ½ circle
Hand regard
Finger play
Defensive blink
Moves head and eyes early in all
directions
Fixes eyes on objects
Reaches and grasp
Palmar grasp
Transfers object from one had to
other
Very attentive
Visual: Good peripheral vision
Pokes at small objects
Pincer grasp
Watches rolling ball at 10 feet
LANGUAGE ‘Startle’, stiffens
Blinks, screws up eyes
Fan out fingers
Cries or freeze in response to
noise
Quietening or smilling to mother’s
voice
Turns immediately to mothers
voice
Mono and double syllable
Responds to distraction hearing
test at 1½ feet at ear level
Laughs and chuckles
Long repetitive string of syllable-
Mama, Dada
Understands no, no, bye bye
Hearing test response 3 feet below
and above
SOCIAL Turns to regard nearby speaker’s
face
Stops crying when picked up and
spoken to
Social smile
Fixes eyes on mother
Unblinking, purposeful gaze
Smiles, coos to familiar situations
Reach and grasp small toys
Takes to mouth
Shakes rattle
Holds bottle and feeds
Still friendly with strangers
Plays peek-A-Boo
Holds, bites and chews biscuits
Reserved with strangers (7m)
Imitates hand clapping
Finds a toy partly hidden
WARNING SIGNS
FOR FURTHER
EVALUATION
Not responding to nearby voices by
8 weeks
Absent ‘Startle’
No social smile by 3 months
Not showing interest in people/
playthings by 3-4 months
No head control by 5 months
No vocalization
Persistent moro, asymmetric tonic
neck reflex
Not visually alert
Not reaching for objects
No hand transfer
Not sitting
No repetitive babble even by 10
months
13. Developmental Milestones Age Milestones
• 1 month Raises head slightly when prone; alerts
to sound; regards face, moves extremities
equally.
• 2-3 months Smiles, holds head up, coos,
reaches for familiar objects, recognizes parent.
• 4-5 months Rolls front to back and back to
front; sits well when propped; laughs, orients to
voice; enjoys looking around; grasps rattle, bears
some weight on legs.
14
14. • 6 months Sits unsupported; passes cube
hand to hand; babbles; uses raking grasp; feeds
self crackers.
• 8-9 months Crawls, cruises; pulls to stand;
pincer grasp; plays pat-a-cake; feeds self with
bottle; sits without support; explores
environment.
• 12 months Walking, talking a few words;
understands "no"; says “mama/dada”
discriminantly; throws objects; imitates actions,
marks with crayon, drinks from a cup.
15
15. • 15-18 months Comes when called; scribbles;
walks backward; uses 4-20 words; builds tower of
2 blocks.
• 24-30 months Removes shoes; follows 2 step
command; jumps with both feet; holds pencil,
knows first and last name; knows pronouns.
Parallel play; points to body parts, runs, spoon
feeds self, copies parents.
16
16. • 3 years Dresses and undresses; walks up and
down steps; draws a circle; uses 3-4 word
sentences; takes turns; shares. Group play.
• 4 years Hops, skips, catches ball; memorizes
songs; plays cooperatively; knows colors; copies
a circle; uses plurals.
• 5 years Jumps over objects; prints first name;
knows address and mother's name; follows game
rules; draws three part man; hops on one foot.
17
17. Prevalence
Low frequency high morbidity
– Cerebral palsy
Visual or hearing impairment
– Autism
– Mental retardation
High frequency low morbidity
– Learning disability
– ADHD
18. Clinical Presentation
Early infancy
– Poor suck, abnormal tone, lack of response to
auditory or visual stimuli
Late infancy
– Motor delay
II & III year
– Language & behavioral abnormalities
School entry
– ADHD, learning disability
19. Three part assessment
• History - Medical & Social
• Examination - General & CNS
• Developmental Screening
20. History
• Risk factors
– Prematurity
– Adverse perinatal events
– Family history
• Warning signals
– Mother’s suspicion
– Inattention to sound
• Dev. History
– Tracking of Milestones
24. Dev. Screening - Tools of the Trade
• One inch cubes
• Hand bell
• Pencil, paper
• Small safe object
• Safe interesting toy
• Fluffy red wollen ball
Plus (if possible) a smiling doctor
25. Order of testing
• Develop. examination prior to P.E.
• Language → social → fine → gross motor
• Spend sometime in making friendship
• Just observe him while he plays
• Do quickly and efficiently
26. Ideal Environment for Assessment
Place
Mother’s lap
Non threatening
Time
Not hungry, not sleepy
Not sick, not fatigued
Method
By History
Observation of play
Formal examination
53. 1 year
Communicating with gestures
Mother holding out hand - baby gives the toy
Communicating with gestures
Mother holding out hand - baby gives the toy
54. 1 year
Walking with broad base
in response to mother’s call
Walking with broad base
in response to mother’s call
56. 1 year
Imitating and copying
Both are striking the wooden blocks
Imitating and copying
Both are striking the wooden blocks
57. 2 years
2 1
/2 years
3 years
4 years
4 1
/2 years
5 1
/2 years
6 1
/2 years
Drawing tests - L O C S T D
58. Interpretation
• Give allowance for prematurity, fatigue, illness,
familial pattern
• If in doubt, repeat later
• Remember - wide range of normal deviation
59. After the Developmental Examination
• Is there any delay ?
• Can it be a normal variant ?
• Is it global delay or dissociation between fields ?
• If not definite, can I decide after repeating the test ?
• Can I ask for help ?
60. • Language perception is well advanced than
expression
• Some do bear walk
• Some bounce around floor (Bottom shuffling)
• Some do side stroke, crawl backwards or roll
• Some never crawl; they stand and walk
Normal Variant
61. Causes of Motor Delay
• Normal or Familial variation
bottom shuffling
• Chronic illness
• CP
• Neuromuscular diseases - DMD, SMA
• Orthopedic - CDH
• Rickets
• Emotional neglect
62. Warning Signals in Language
Development
• Risk of deafness
• Mother’s suspicion
• No response to everyday sounds
• No repetitive babble by 10 months
• No word by 21 months
• Not putting 2 - 3 words together by 21
/2 years
63. Language delay
• Reception is well advanced than expression
– Hearing defects
– Familial & genetic
– Global delay
– Autism
– Environmental
67. INTELLECTUAL QUOTIENT
• MENTAL AGE /CHRONOLOGICAL AGE.
• <70- MENTAL RETARDATION.
• GLOBAL DEVELOPMENTAL DELAY <3 YEARS.
68
68. Development assessment scales
• Denver Development Chart
• Baroda Developmental Screening chart
• Trivandrum Developmental Screening chart
• Bayley Scale of Infant Development (BSIS)
• Developmental Assessment Scale for Indian
Infants(DASII)
69
69. BONE AGE
• AT BIRTH UPTO 4 MONTHS- KNEES AND HIP.
• 4-12 MONTHS-SHOULDER.
• 1 -10 YEARS- WRIST.
• > 8- 14 YEARS-ELBOW.
• ( LEFT SIDE BONES ARE ASSESSED)
77
70. WHO GROWTH CHART
• In an effort to set an internationally usable standard for optimal
growth in young children, the World Health Organization is
conducting the Multicenter Growth Reference Study (MGRS) to
develop growth curves that can be used for assessing early growth
among children from around the world.
• MGRS describes the growth of children who are raised under
optimal conditions, following recommended health practices, such
as environments that support exclusive breast-feeding, Baby-
Friendly Hospitals, and mothers who agree to breast-feed their
infants.
• Six study sites represent 5 continents in the major regions of the
world: United States, Brazil, Norway, Ghana, Oman, and India.
78
71. SLEEP EVALUATION
• The BEARS instrument is divided into 5 major
sleep domains, providing a comprehensive
screen for the major sleep disorders affecting
children 2–18 years old. Each sleep domain has a
set of age-appropriate “trigger questions” for use
in the clinical interview.
79
72. To conclude …...
Screen the development in all well children
• Observe his play and spontaneous activity
• Use TDSC to screen
• Go little more deeper with Development Chart
(Lingam S. UK) - if there is suspicion
• Keeps the charts over the table
74. Developmental
assessment
by
MKC Nair
Manual of child
development
by
Lingam S
First 5 years
by
Mary Sheriden
PCNA - Child with
developmental
disabilities
- June 1993
For further
reading
Editor's Notes
Dev assessment / screening is only a part of child health surveillance.
Dev screening is aimed at presymptomatic detection of disability by examining children serially to determine whether they are developmentally normally developed? Screening process should be brief, simple, cheap and reliable. Appropriate timing is 6 weeks, 8 mo, 18 mo, 2 ½ yrs and 4-5 yrs. Screening may be combined with immunization or routine visits. Done by a doctor, health worker or a trained person. Dev assessment is carried out on a child discovered by dev screening to have dev dela or behavioural disorder to establish wheher there is a problem and if so the type and causes. This carried out by a team lead by a developmental pediatrician
Child playing with foot and hands and keep foot in the mouth. Starts at about 4 mo and should disappears by 9 mo. Persistence beyond 1 yr indicates dev delay
