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

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

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)

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

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

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

Early locomotor patterns Ref. Illustrated Textbook of Paediatrics

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

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

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

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)

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

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?

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

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)

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

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

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

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

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

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

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

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

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!

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’