Assessment of Development

Dr Sunil Agrawal

1st yr, MD Pediatrics

IOM

Topics

• Introduction• Principles of development• Value of developmental assessment• Different domains of development• Assessment of development• Screening tests• Definitive tests• Development Quotient• Conclusion

Introduction

• Development is the individual level of functioning, a child is capable of, as a result of maturation of the nervous system and psychological reactions

• It is the qualitative and quantitative changes and acquisition of a variety of competencies for functioning optimally in a social setting.

• Developmental assessment – milestone acquisition occurs at a specific rate and in an orderly and sequential manner

• Abnormality can be delay, deviancy, or dissociation

Principles of Development

• Development is a continuous process from conception to maturity

• Sequence of development is same in all children but rate varies

• Development is intimately related to maturation of nervous system- opportunity to practice

• Generalized mass activity replaced by specific individual response

Principles of Development

• Development is in cephalocaudal direction

• Certain primitive reflexes lost before corresponding voluntary movement is acquired

• Generalizations about development cannot be based on the assessment of skills in a single developmental domain. However, skills in one developmental domain do influence the acquisition and assessment of skills in other domains.

Value of Developmental Assessment

• For parents-– If previous pregnancy miscarriage or stillbirth

or proved to be mentally or physically handicapped

– If there was any antenatal problem or difficult delivery

– Family history of mental sub normality, cerebral palsy or other handicap

• For pediatrician-– When faced with sucking and swallowing

problem in neonate, or child with unusual appearance or behavior

– Early diagnosis of defects of hearing or vision– Effect of treatment of metabolic disorders,

exposure to toxic substances, convulsions, meningitis

• Gross motor development

• Fine motor development

• Social/Cognitive/intellectual development

• Speech and language development

• Vision and hearing development

Different Domains of Development

Assessment of Development

Assessment of Development

• Developmental milestones serve as the basis of most standardized assessment and screening tools

• Two separate developmental assessment over time are more predictive than a single one.

• Developmental monitoring not only should be aimed at identifying children who have low function, but at directing the focus of anticipatory guidance to help promote normal development.

When to suspect abnormalities of development

• From history- Parents( 75-80% sensitivity to childhood disability and 70-80 % specificity for normal development)

• From examination- – During routine examination- Developmental

screening as recommended by AAP– Follow up examination in high risk babies

• Risk factors for likelihood of developmental impairment-– Prenatal-

• Use of drugs or alcohol, severe toxemia and viral inf.

– Perinatal factors- • Prematurity, LBW, obstetric complications

– Neonatal factors- • Neonatal encephalopathy, infections like sepsis or meningits

and severe hyperbilirubinemia

– Post natal factors- • Injury or meningitis, encephalitis, exposure to toxins, severe

continuous failure to thrive and severe epilepsy

– Family history- • Visual and hearing as well as specific learning

Developmental History

• Whether or not parents have concern• Right questions- Parents interpretation of what

their child does may be incorrect but observations are usually accurate

• Age specific questions• Check doubtful reply with a question kept on a

different way• Check the answer about one milestone by

another and by examination

• Family history- – First and second degree relatives– A diagnosis even if definite should be pursued

if it might be relevant

• Social history- – Capacity to cope with a child with a disability

Examination: Observations and Interactive Assessment

• Should take in place in a room with toys appropriate for child

• With one or both parents, but no prompting and helping

• Chair and table• Child’s behavior and interaction with parents

during history taking should be observed prior to physical examination

• Normal functioning of motor, vision and hearing should be assessed

Prerequisites

• Infant or child in a good temper

• Should not be hungry, tired, unwell, had convulsion prior, under influence of sedative or antiepileptic drugs

Equipment Required

• Ten 1- inch cubes• Hand bell• Simple formboard• Goddard formboard• Colored and uncolored geometric forms• Picture cards• Cards with circle, cross, square, triangle, diamond drawn

on them• Patellar hammer• Paper• Pellets( 8mm)

Physical Examination

• General- – Height, weight, head circumference, cardiac

murmurs, midline defects

• Dysmorphic features

• Neurological examination

Assessment of Gross Motor Development

• The acquisition of gross motor skill precedes the development of fine motor skills.

• Both processes occur in a cephalocaudal fashion– Head control preceding arm and hand control– Followed by leg and foot control.

Gross Motor Development

• Newborn: barely able to lift head• 6 months: easily lifts head, chest and upper

abdomen and can bear weight on arms

Head Control

Newborn Age 6 months

Sitting up

• 2months old: needs assistance

• 6 months old: can sit alone in the tripod position

• 8 months old: can sit without support and engage in play

Sitting Up

Age 2 months Age 8 months

Ambulation

• 9 month old: crawl

• 1 year: stand independently from a crawl position

• 13 month old: walk and toddle quickly

• 15 month old: can run

Ambulation

13 month old

Nine to 12-months

Gross motor developmental milestone

Age Milestone

3 months Neck Holding

5 months Rolls over

6 months Sits in tripod fashion

8 months Sitting without support

9 months Stands with support

12 Months Creeps well; walks but falls; stands without support

15 months Walks alone; creeps upstairs

18 months Runs; explores drawers

2 years Walks up and downstairs; jumps

3 years Rides tricycle; alternate feet going upstairs

4 years Hops on one foot; alternate feet going downstairs

Lift Head

Sit

Crawl

Walk

Fine Motor - Infant

• Newborn has very little control. Objects will be involuntarily grasped and dropped without notice.

• 6 month old: palmar grasp – uses entire hand to pick up an object

• 9 month old: pincer grasp – can grasp small objects using thumb and forefinger

Fine Motor Development

6-month-old

12-month-old

Fine motor developmental milestones

Age Milestone

4 months Bidextrous reach

6 months Unidextrous reach; transfer object

9 months Immature pincer grasp; probes with forefinger

12 months Pincer grasp mature

15 months Imitates scribbling; tower of 2 blocks

18 months Scribbles; tower of 3 blocks

2 years Tower of 6 blocks; vertical and circular stroke

3 years Tower of 9 blocks; copies circle

4 years Copies cross; bridge with blocks

5 years Copies triangle

Play and Social Interaction

• Observe exploration and free play, use of real size and small toys on self and other and initiation and response to social games( eg- peek-a-boo, pat-a-cake)

• Note initiating interactions and responding to parent/ examiner/ other children and use of eye contact and gestures

Social and adaptive milestones

Age Milestones

2 months Social smile

3 months Recognizes mother; anticipates feeds

6 months Recognizes strange/ stranger anxiety

9 months Waves ‘bye-bye’

12 months Comes when called; plays simple ball game

15 months Jargon

18 months Copies parents in task

2 years Asks for food, drink, toilet; pulls people to show toys

3 years Shares toys; knows full name and gender

4 years Plays cooperatively in a group; goes to toilet alone

5 years Helps in household tasks; dresses and undresses

Language and Communication

• Observe vocalization and gestures to attract other’s attention, to indicate needs. In response to others’ vocalization and to share emotions

• Note speech quality, use of language to express need, comment, describe, share interest and initiating and responding for conversation

language milestones

Age Milestone

1 months Alerts to sound

3 months Coos

4 months Laugh loud

6 months Monosyllables

9 months Bisyllables

12 months 1-2 words with meaning

18 months 8-10 words vocabulary

2 years 2-3 words sentence, use pronouns ”I”, “me”, “you”

3 years Ask questions; knows full name and gender

4 years Says song or poem; tells stories

5 years Asks meaning of words

Hearing Development

• BAER hearing test (brainstem auditory evoked response) done at birth

• Ability to hear correlates with ability pronounce words properly

• Always ask about history of otitis media – ear infection

• Repeat hearing screening test• Speech therapist as needed

Copyright ©1997 American Academy of Pediatrics

Johnson, C. P. et al. Pediatrics in Review 1997;18:224-242

Orienting to sound of bell

5 months 7 months 9.5 months

Time of Assessment

• Developmental surveillance- every well- child visit

• Developmental screening- – May be completed by parent or clinician– Using standardized tool at 9, 18 and 30 months– Example-

• Denver II developmental screening test• Phatak’s Baroda Screening Test• Trivandrum Development Screening Chart• CAT/Clams ( Clinical adaptive test/ clinical linguistic and

auditory milestone scale) • Goodenough- Harris Draw-a-person test• Gesell figures• Gesell block skills

Denver II Developmental Screening Test

• Most widely used test for screening• Assesses child development in four domains gross motor fine motor adaptive language personal social behavior• These domains are presented as age norms, just

like physical growth curves.

Phatak’s Baroda Screening Test

• Indian adaptation of Bayley’s Development scale

• India’s best known development testing system

• Used by child psychologists rather then physicians

Trivandrum Development Screening Chart

• Simplified adaption of Baroda Development Screening System

• Consist of 17 items selected from BSID Baroda norms

• Time required- 5 mins• Good for mass screening

Clinical Adaptive Test

– Developmental Screening Test for age under 24 months

– Two test combination• Clinical Adaptive Test (CAT)• Clinical Linguistic Auditory Milestone Scale

(CLAMS)– Language assessment tool– Distinguish Language Delay from mental retardation

Goodenough ‘draw a man test’

Definitive Tests

• Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)

• Stanford-Binet Intelligence Scale• Wechsler Intelligence Scale• Developmental Activities Screening Inventory-SECOND

EDITION (DASI-II)

Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)

• Age Range (in years) - Birth to3.5 years

• Method of Administration/Format

Individually administered in play-based format for Cognitive, Language , and Motor Scales; caregiver questionnaire for Social-Emotional and Adaptive Functioning. Yields scaled scores, composite scores, and percentile ranks.

• Approximate Time to Administer –

50 min. for 1-12 mos.;

90 min. for 13-42 mos.

Subscales

Cognitive; Language (Receptive, Expressive, Total); Motor (Fine-Motor, Gross-Motor, Total); Social-Emotional; Adaptive Behavior (Communication, Community Use, Functional Pre-Academics, Home Living, Health & Safety, Leisure, Self-Care, Self-Direction, Social, Motor, Total)

Stanford-Binet Intelligence Scale

• Description

– Intelligence Testing of ages 2 to 23 years and beyond

– Yields Intelligence Quotient (IQ)

• Scoring

– Standardized Scoring

– Composite mean of 100 with standard deviation of 16

• Interpretation:

• Mental Retardation IQ Definitions

– Borderline mental retardation: 70 -79

– Mild mental retardation: 65-69

– Moderate mental retardation: 40-54

– Severe mental retardation: 30-39

– Profound mental retardation: <30

Wechsler Intelligence Scale

• Description

– Intelligence Testing

– Mean score of 100 with standard deviation of 15

– Gives verbal and performance scores

– Broken into subtests each with a mean of 10

• Age specific Wechsler tests

– Wechsler Preschool Primary Scale Intelligence (WPPSI-R)

• Used for ages 3 to 7 years

– Wechsler Intelligence Scale for Children (WISCIII)

• Used for ages 6 to 16 years

– Wechsler Adult Intelligence Scale (WAIS-R)

• Used for ages 16 years and older

•  

DEVELOPMENTAL ACTIVITIES SCREENING INVENTORY-SECOND EDITION (DASI-II)

• Age Range (in years)- Birth - 5 years• Method of Administration/Format Individually administered informal screening measure; may

be presented as a nonverbal test; 67 perceptual, motor, and cognitive tasks Yields Developmental Quotient

• Approximate Time to Administer -25-30 min • Subscales -Developmental Quotient

Developmental Quotient (DQ)

Ratio of the functional age to the chronological age. It is a means to simply express a developmental delay.

DQ= ((developmental age) / (chronological age)) * 100

• If the infant was born prematurely the chronological age should be corrected for the gestational age at birth during the first year of life.

• The adaptive developmental quotient uses a development measure such as the Gesell scales. Similar quotients may use IQ or other measures.

Interpretation maximum score =100 > = 85 normal 71-84 mild-to-moderate delay <= 70 severe delay

Conclusion

Approach

History and examination- Check for age appropriate milestone

Check for milestones achieved in the past- what and when

Check for milestones in the other domains

Global Developmental Delay Delay in specific domain

Absent

Purpose of Assessment

• Whether there is impairment or not in development• Make a diagnosis if possible

• Seek to intervene positively to improve outcome and function for the child and family– Reinforcing acquired skills– Teach developmentally appropriate skills– Provide missed experience– Make use of other skills to overcome difficulties– Use learning style to promote learning

Red Flags: Birth to three month

– Rolling prior to 3 months• Evaluate for hypertonia

– Persistent fisting at 3 months• Evaluate for neuromotor dysfunction

– Failure to alert to environmental stimuli• Evaluate for sensory Impairment

Red Flags: 4 to 6 months

– Poor head control• Evaluate for hypotonia

– Failure to reach for objects by 5 months• Evaluate for motor, visual or cognitive deficits

– Absent Smile• Evaluate for visual loss• Evaluate for attachment problems• Evaluate maternal Major Depression• Consider Child Abuse or child neglect in severe

cases

Red Flags: 6 to 12 months

– Persistence of primitive reflexes after 6 months• Evaluate for neuromuscular disorder

– Absent babbling by 6 months• Evaluate for hearing deficit

– Absent stranger anxiety by 7 months• May be related to multiple care providers

– Inability to localize sound by 10 months• Evaluate for unilateral Hearing Loss

– Persistent mouthing of objects at 12 months• May indicate lack of intellectual curiosity

Red Flags: 12 to 24 months

– Lack of consonant production by 15 months• Evaluate for Mild Hearing Loss

– Lack of imitation by 16 months• Evaluate for hearing deficit• Evaluate for cognitive or socialization deficit

– Hand dominance prior to 18 months• May indicate contralateral weakness with Hemiparesis

– Inability to walk up and down stairs at 24 months• May lack opportunity rather than motor deficit

Red Flags: 12 to 24 months

– Advanced non-communicative speech (e.g. Echolalia)

• Simple commands not understood suggests abnormality

• Evaluate for Autism• Evaluate for pervasive developmental disorder

– Delayed Language Development• Requires Hearing Loss evaluation in all children

Take Away Message

Best tests( in our setting)

• For infant: Phatak’s Baroda Screening Test

• For pre school child: Bayley Scales of Infant and Toddler Development-Third

Edition (Bayley-III)

• For school going child: Wechsler Intelligence Scale

References

• Ghai Essential Pediatrics, OP Ghai, 7th Edition• Nelson textbook of Pediatrics, 19th Edition, Kliegman,

Behrman, Schor, Stanton, St. Geme• Forfar and Arnold’s textbook of Pediatricss, Sixth Edition• IAP textbook of Pediatrics, 4th Edition• ^ Frankenburg, William K.; Dobbs, J.B. (1967). "The Denver

Developmental Screening Test". The Journal of Pediatrics• Illingworth, Ronald S: THE DEVELOPMENT OF THE INFANT &

YOUNG CHILD, 9th edition, ELSEVIER• Google.com• Answers.com

Thank You