1. Development Problems in Children Dr Ros Jefferson GPVTS presentation Sept 08

2. 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

3. Normal development Physical and neurodevelopmental growth & development throughout childhood Normal milestones important Wide variation in ‘normal’ – so may need to see again.

4. Influences on development Genetic Environmental – family structure, housing,family support Stimulation Malnutrition SEC

5. Areas of development Gross motor Fine Motor & Vision Hearing & Communication Social & Personal

6. Major normal milestones (average age) Gross MotorFine motor & vision Hearing & language Social 6 weeksHead level with body in ventral suspension Fixes & followsStills to soundsmiles 3 monthsHead at 90deg in ventral suspension Holds object placed in hand Turns to sound at ear level Laughs & squeals Hand regard 6monthsNo head lag. Sits w support. Up on forearms when prone Reach w palmar grasp. Transfers between hands BabblesWorks for toy May finger feed 9 monthsCrawls 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

7. Major normal milestones (2) Gross motorFine motor & vision Hearing & language Social 12 monthsPull to stand, cruise, stand alone. Walks alone (13m) Puts block in cup. Casting 1-2 wordsImitates activities, plays ball, object permanence 18 monthsWalks well & runs Tower of 2-4 cubes. Scribbles 6-12 wordsUses spoon, helps in house, symbolic play 24 monthsKicks 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 monthsThrows 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

8. 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?

9. Developmental delay Global Specific Deviance vs delay

10. 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

11. History Parental concerns – ‘ parents usually right’ Family History – how compares with sibs Pregnancy Birth Postnatal Feeding Development Medical history

12. Examination Look at the parents!! Observations of child Head circumference General examination Neurological examination

13. Basic developmental kit Pencil/paper 1in cubes Simple formboard Simple book

14. Global delay Down’s 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/mosaicism

15. Downs syndrome Ring alarm bells – diagnosis confirmed from chromosomes Multisystem Insert in PHR

16. Downs syndrome - development Differences within DS population – Mainstream education +GCSE’s vs no language – Limited exercise tolerance vs sporting excellence – 40% of children with DS are able to learn to read

17. Downs syndrome - milestones MilestoneMean ageRange Sitting13m6-30m Standing22m9-48m Walking30m12-60m Single words34m12-72m

18. 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

19. Local protocol 0-2y – ‘acute’ paediatrician follows up 2- 5y ( F/T school) – community paediatrician >5y - if no health problems, surveillance leaflet to family and GP, for GP follow up

20. 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 DSMIG recommendations

21. Locomotor delay Variation in milestones – walking 7/12 – 30/12 First steps – short, widebased with planus feet Mature gait not achieved till ~4.5y

22. Locomotor problems Normal variants – all present with ‘awkward gait’ – Femoral/tibial rotations – Bow legs – normal in infant; correct by 18m – Knock knees Correct spontaneously

23. Bottom shufflers Different patterns +ve family history Don’t crawl; possibly later sitting Hypotonia – resolving Vertical suspension – hip flexion/knee extension posture Dislike prone position Mx = reassure!

24. Benign hypotonia Delayed, not deviant, pattern Low muscle tone Normal neurology +/- bottom shuffle

25. Toe walking Idiopathic Myopathic Neurological Key = Neurological examination +/- CK

26. Scenario John’s 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

27. 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?

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

29. 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

30. Bilingual child - ESL Often late recognition Problem in which language? How to treat – which language?

31. 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

32. Aetiology Often undetermined Familial element Syndromes associated, including: – Fragile X, Tuberous sclerosis, PKU, NF, Downs

33. Management SALT Behavioural techniques Educational support Parent courses and support

34. 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

35. 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

36. 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

37. Developmental Coordination Disorder ‘clumsy child’ Parent/teacher concerns Overlap with other disorders – e.g Asperger syndrome

38. 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

39. 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

40. DCD Screening process Motor difficulties identified Action: Neurological Examination by GP Abnormal Neurology Refer to Paediatrician Parents & Teacher complete SDQ complete DCD-Q Send own observations DCD Team at Child Development Centre Normal

41. DCD Screening process Referral with DCD-Q/SDQ received by DCD Team Child with SEN/SEN in process Referral to Community OT Service Movement problems: (below 10 th 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: >10 th centile DCD-Q Advice Pack sent

42. Questions?