1. Abnormal Motor Development
Dr Valerie Orr
Consultant in Paediatric Neurodisability
RHSC, Yorkhill

2. Objectives
To be able to identify and make appropriate referrals for children with abnormal motor development
To develop knowledge of current paediatric management of children with motor disorders

3. Does early detection matter?
Parents value early diagnosis
Improved outcome
Improved quality of life for child and family
Access to educational and social services
‘Early detection is of little value unless parents subsequently experience a well-organised service with a clear referral pathway to definitive diagnosis and management’
Ref: Health for all Children 4th Edition (Hall 4)

4. How do we identify children with abnormal development?
Follow-up of ‘high risk’ infants
Screening
Listening to parents
Opportunistic recognition
Ref. Hall 4

5. Gross motor milestones – median ages Ref
Gross motor milestones – median ages Ref. Illustrated Textbook of Paediatrics

6. Gross motor milestones – median ages Ref
Gross motor milestones – median ages Ref. Illustrated Textbook of Paediatrics

7. Early locomotor patterns Ref. Illustrated Textbook of Paediatrics

8. Gross motor milestones – limit ages Ref
Gross motor milestones – limit ages Ref. Illustrated Textbook of Paediatrics
Head control 4 months
Sits unsupported 9 months
Stands independently 12 months
Walks independently 18 months
*Remember to adjust for prematurity until 2yrs

9. Features that may suggest underlying motor disorder
Delayed motor milestones
Asymmetrical movement patterns e.g. early hand preference
Abnormalities of muscle tone
i.e. hypotonia (‘floppy’) or hypertonia (‘stiff’)
Other difficulties
e.g. feeding difficulties
unexplained irritability
respiratory problems

10. Worrying signs / Red flags
Not reaching & grasping objects by 6 months
Hand preference before 1 year
Hypertonicity
e.g. closed hand posture, extensor posturing, scissoring
Hypotonia
Loss of previously acquired motor skills at any age

11. Floppy infant – assessment
History
Pregnancy and birth
Feeding
Development
Examination
Weight & OFC ?thriving
Facial features ?dysmorphism
Movement - floppy & strong vs floppy & weak
Referral
Paediatrician
(Urgent if feeding difficulties or poor weight gain)

12. Floppy infant – aetiology
Includes
Prematurity, illness & drugs
Evolving cerebral palsy
Genetic syndromes
e.g. Downs, Prader-Willi syndrome
Neuromuscular problems (rare!)
e.g. congenital myotonic dystrophy,
spinal muscular atrophy

13. Clinical scenario A mother brings her 18mth old son to the
surgery with a minor illness. She mentions that
she is concerned that he is not yet walking.
What particular points would you look for in the history and examination?
What action might you take?

14. Delayed walking (>18mths)
Normal variants
Associated with bottom shuffling
Cerebral palsy or minor neurological problems <10%
May occur in context of global developmental delay
Consider CK in boys

15. Toe walking Possible causes Idiopathic toe walking Muscle spasticity
e.g. cerebral palsy, spinal cord lesion, hereditary spastic paraparesis
Muscle disease
e.g. Duchenne muscular dystrophy, Charcot Marie Tooth (HMSN)

16. Duchenne muscular dystrophy
Check CK in boys:
not walking by 18 months
4-6 months behind in general development at 2 years
awkward or clumsy gait under 4 years
unable to run or jump by 4 years
painful hips or legs under 4 years
Ref. Mohamed K et al. Delayed diagnosis of Duchenne muscular dystrophy.
Eur J Pediatr Neurol 2000

17. Developmental Coordination Disorder
‘Dyspraxia’, ‘clumsiness’
Male : Female 3 : 1
Impaired motor control & planning
difficulties with dressing and toileting
messy feeding
poor handwriting and drawing skills
poor ball skills
Can become socially isolated
Poor self esteem and schooling difficulties

18. Developmental Coordination Disorder: DSM-IV diagnostic criteria
Marked impairment of the development of motor co-ordination
Impairment significantly interferes with academic achievement and activities of daily living
Problem not due to a recognised medical condition
Not a pervasive developmental delay
NHS QIS publication: ‘I still can’t tie my shoelaces...’
Quick Reference Guide to Identification and Diagnosis of DCD

19. Developmental Coordination Disorder: Management
Examine and ensure that there is no underlying medical problem or refer to paediatrician for further assessment
Referral to Occupational Therapist
Group interventions to promote motor skills and self-esteem e.g. Rainbow Gym
Classroom support

20. Management of motor disorders
Multidisciplinary team approach
Holistic, child /family centred care
Often need to access support from education services, social services and voluntary agencies
WHO ICF Framework
International Classification of Functioning, Disability and Health (ICF) Framework

21. Cerebral Palsy
‘A disorder of movement and posture due to defect or lesion of the immature brain’
Incidence ~2 per 1000 live births
Antenatal 80% e.g. prematurity, fetal & neonatal stroke, brain malformations, maternal infection
Perinatal 10% e.g. neonatal encephalopathy
Postneonatal events 10%
e.g. trauma, meningoencephalitis, stroke

22. Cerebral Palsy: Interventions
Aims
Maximise potential
Prevention of secondary dysfunction
Promotion of improved function and participation in society
Examples of spasticity treatments
Orthotics
Botulinum toxin
Oral medications e.g. Baclofen
Intrathecal baclofen
Orthopaedic surgery

23. Transition
Children with motor disorders become adults with ongoing and often complex health needs
GP becomes key health professional for most young people with cerebral palsy

24. Summary ‘Limit ages’ can guide need for referral
Neurological examination should identify worrying signs
Be alert to motor disorders that might present later in childhood
Listen and respond to parents concerns!

25. Useful References From Birth to Five Years. Mary Sheridan.
Developmental assessment of children. Bellman M et al,
BMJ Jan 2013
Managing common symptoms of cerebral palsy in children. Sewell et al, BMJ Sep 2014
NICE guideline 2012 Spasticity in children and young people with non-progressive brain disorders
NHS QIS ‘I still can’t tie my shoelaces…’ Quick Reference Guide to Identification and Diagnosis of DCD’