Child development Flashcards
What happens to the cerebellum in the first year in life
It quadruples in size
Why does the brain continue developing so much post-term
If it were to be fully developed in utero, then our heads would be too big and inflexible to fir through the pelvis.
Summarise the key features of the association cortices
Association cortices
function less predictable
not organised topographically
left-right symmetry weak or absent
Describe the organisation of the lateral cortical spinal tracts
Dorsal to ventral: Sacral Lumbar Thoracic Cervical
Injury to the back- more likely to affect sacral and lumbar function and thus. lower limb function first.
Describe the function of the rubrospinal tract (extra-pyramidal)
automatic movements of arm in response to posture/balance changes
Describe the function of the Reticulospinal tract
coordinate automated movements of locomotion and posture (e.g. to painful stimuli)
Describe the function of the vestibulospinal tract
regulates posture to maintain balance, and facilitates mainly α motoneurones of the postural, anti-gravity (extensor) muscles
Summarise the morbidity of childhood developmental issues
20% children have special educational needs
2% have severe disability
What is meant by development
Development is the global impression of a child which encompasses growth, increase in understanding, acquisition of new skills and more sophisticated responses and behaviour. It serves to endow the child with increasingly complex skills in order to function in society.
o A dynamic process of growth, transformation, learning and acquisition of abilities to respond to and adapt to the environment in a planned, organised and independent manner.
o A process by which each child evolves into an independent adult.
What are the 4 domains of the development assessment
§ There are 4 domains:
o Gross motor performance.
o Vision and fine motor.
o Hearing, speech and language.
o Social, emotional and behavioural.
What are the gross motor skills
Walking Running Sitting Head lag Positioning
What are the fine motor skills
Vision is important for these tasks. Use of hands Grasp and fine pincer Bricks Crayon puzzles
What are the social skills
social interaction
stranger reaction
eating skills
dressing
What are the speech and language skills
vocalisation
words
understanding
imaginative play
What is meant by a milestone
§ Acquisition of a key performance skill is referred to as a milestone.
§ For each skill, normal range of attainment varies widely.
o Constant pattern but variable rate of attainment.
Define median age and limit age
§ Definitions:
o Median age – age when half of the standard population of children achieve that level.
o Limit age – age by which they should have achieved the level and is equal to 2 S. Ds from the mean age.
§ Both corrected for prematurity until age 2.
What are the developmental milestones for gross motor skills
o New-born – limbs flexed in symmetrical posture, head lag on pulling up.
o 6-8 weeks – raises head to 45degrees in prone.
o 6-8 months – sits without support.
o 8-9 months – crawling.
o 10 months – cruising around furniture.
o 12 months – walks unsteadily.
o 15 months – walks steadily.
Name the primitive reflexes that should have disappeared by 4-6 months
§ Primitive reflexes – these are protective and serve to promote support, balance and orientation:
o Reflexes – should disappear by 4-6 months:
§ Stepping.
§ Moro.
§ Grasp.
§ Asymmetric tonic reflex – which way babies head is turned, arm outstretches.
§ Rooting.
Describe the protective reflexes that should have developed from 5 months
Downward parachute reflex- when held and rapidly lowered, the infant extends and abducts both legs and the feet are plantigrade - 5month
Sideward protective reflex- infant puts arm out to save if tilted offbalance- 6 month
Forward protective reflex -7 month- arms and hands extend on forward decent to ground
backward protective reflex - 9 months- backward protective extension of arms when pushed backwards.
Describe the milestones for fine motor skills
§ Object permanence is attained at 9 months of age – the idea that when out if sight, not out of mind.
§ Milestones:
o 6 weeks – turns head to follow object.
o 4 months – reaches out to toys.
o 4-6 months – palmar grasp.
o 7 months – transfers between hands.
o 10 months – mature pincer grip.
o 16-18 months – marks with crayons.
o 14 months-4 years – towering.
o 2-5 years – ability to draw without seeing how it’s done (after seeing it can be done 6m earlier).
Describe the milestones for language and hearing
§ Milestones:
o New born – startles.
o 3-4 months – vocalises alone or when spoken to.
o 7 months – turns to soft sounds out of sight.
o 7-10 months – uses sound indiscriminately or discriminately.
o 12 months – two to three words other than dada or mama.
o 18 months – six to ten words.
o 20-24 months – makes simple phrases.
o 1.5-3 years – talk constantly in 3-4 word sentences
Describe the milestones for social skills
§ Milestones:
o 6 weeks – smile responsively.
o 6-8 months – puts food in mouth.
o 10-12 months – wave bye, play peek-a-boo.
o 12 months – drink from cut with two hands.
o 18 months – can eat by themselves.
o 18-24 months – symbolic play.
o 2 years – potty trained.
o 2.5-3 years – parallel play.
What are the different patterns of abnormal development
Patterns of abnormal development. These may be slow but steady, plateau or regression
o Over time, the gap widens so the deficit becomes more apparent.
Give some examples of limit ages
§ Examples of limit ages:
o Walking independently 18 months.
o Fixes and follows visually 3 months.
o Joins words 2 years.
o Symbolic play 2-2.5 years.
Distinguish between delay and disorder
§ Key facts:
o Delay – slow acquisition of skills.
§ May occur in one or more domain.
· One domain affected = domain-specific.
· >= 2 domains affected = global.
· All domains affected equally = consonant delay.
· All domains affected differently = dissonant delay.
o Disorder – mal-development of a skill.
State some common developmental problems
Delayed walker
Clumsy child (cerebellum)
Delayed speech and language (wernicke and Broca)
Odd social interaction- ASD/Aspergers
Hyperactivity (ADHD- 2-3% of school population- prefrontal cortex affected- dopamine low- lack of attention- leading to hyperactivity and impulsivity).
Common behaviours –
sleep onset/freq night waking
eating
Toileting
Specific Learning difficulties
Summarise autism
Distinguished by a pattern of symptoms rather than just one single symptom.
The main characteristics are impairments in social interaction, impairments in communication , restricted interests and repetitive behaviour.
Describe the assessment of ADHD
Diagnostic criteria – (1 )Inattention; (2) Hyperactivity; (3) Impulsivity; (4) Lasting > 6 months; (5) commencing < 7 years and inconsistent with the child’s developmental level
These features should be present in more than one setting, and cause significant social or school impairment.
These children also have an increased risk of: conduct disorder, anxiety disorder & aggression
Risk factors – Boys > girls, ratio 4:1; Learning difficulties and developmental delay
Neurological disorder, e.g. epilepsy, cerebral palsy; first-degree relative with ADHD; family member with depression, learning disability, antisocial personality or substance abuse
A significant proportion of children with ADHD will become adults with antisocial personality and there is an increased incidence of criminal behaviour and substance abuse.
How do we manage ADHD
Psychotherapy – Behavioural therapies
Family therapy
Drugs – If behavioural therapy alone insufficient; stimulants, e.g. methylphenidate (Ritalin), amphetamines (dexamphetamine)
Diet – Some children benefit noticeably from exclusion of certain foods from their diet, e.g. red food colouring
Describe autism
Prevalence is 3-6 per 1000 live births
Boys>girls
Usually presents between 2 – 4 years of age
Features include (1) impaired social interaction; (2) speech and language disorder; and (3) imposition of routines with ritualistic and repetitive behaviour.
Comorbidities include learning and attention difficulties, and epilepsy
How do we mange autism
Intensive support for child and family
Describe cerebral palsy
Cerebral palsy: disorder of movement and posture, arising from non-progressive lesion of the brain acquired before the age of 2 years (most antenatal) - associated with learning difficulties, epilepsy, visual impairment, hearing loss, poor growth and respiratory problems
Describe the features of cerebral palsy
§ Features:
o Manifestations emerge over time – reflects balance between normal/abnormal cerebral maturation.
o Most common cause of motor impairment in children.
o Prevalence – 2.5-2.7 per 1000 children. Incidence – 2-2.5 per 1000 live births.
§ Most causes are antenatal (80%) – genetic syndromes and congenital infection.
o 10% due to hypoxic-ischaemia injury at birth, 10% due to postnatal origin (infection, trauma).
§ Presentation:
o Abnormal limb tone and delayed milestones.
o Feeding difficulties.
o Abnormal gait once walking achieved.
o Asymmetric hand function before 12 months.
o Primitive reflexes persist.
Describe the different types of cerebral palsy
§ Types:
o 70% Spastic
o 10% (each) Ataxic hypotonic, Dyskinetic, Mixed Pattern
Describe the associated problems and management of cerebral palsy
§ Associated problems – learning difficulty, epilepsy, visual impairment, hearing loss, feeding difficulty, poor growth, respiratory problems.
§ Management – minimise spasticity and manage associated symptoms
Summarise learning disability
Prevalence of moderate learning difficulty is 30 per 1000 children
Prevalence of severe learning difficulty is 4 per 1000 children
25% of children with severe learning disability have no identifiable cause
Causes include – (i) chromosome disorders (30%); (ii) other identifiable syndromes (20%); (iii) postnatal cerebral insults (20%); (iv) metabolic or degenerative diseases (1%)
Classified as mild, moderate, severe or profound
May present with reduced intellectual functioning, delay in early milestones, dysmorphic features, ± associated problems (epilepsy, sensory impairment, ADHD)
Describe how we manage patients with learning difficulties
Involves establishing a diagnosis and input from the multidisciplinary team with long term follow up.
What factors can lead to delayed development
Ill health
Sensory/motor impairment
lack of physical or psychological stimuli
reduced inherent potential
two types:
global (all domains)
specific (one domain)
Summarise the different causes of global delay
Chromosomal abnormalities
e.g. Down’s syndrome, Fragile X
Metabolic
e.g. hypothyroidism, inborn errors of metabolism
Antenatal and perinatal factors
Infections, drugs, toxins, anoxia, trauma, folate def
Environmental-social issues
Chronic illness
Summarise the different causes of motor delay
Cerebral palsy Global delay eg Down’s syndrome Congenital dislocation hip Social deprivation Muscular dystrophy-Duchenne’s Neural tube defects: spina bifida Hydrocephalus
Describe the complications of spina bidifa
o Neurogenic bowel and bladder incontinence.
o Lower limb paralysis.
o Fractures and joint contractures.
o Developmental deformities and learning disabilities.
o Hydrocephalus and meningitis
Summarise the different causes of language delay
Hearing loss Learning disability Autistic spectrum disorder Lack of stimulation Impaired comprehension of language -Developmental dysphasia Impaired speech production -stammer, dysarthria
Describe the importance of parents
PARENTS KNOW SOMETHING IS WRONG BEFORE PROFESSIONALS DO
Describe the factors that can affect development
o Environmental causes of damage to brain development:
§ Antenatal – infections maternally, toxins, drugs.
· Infectious agents – TORCH – Toxoplasmosis, O (Syphilis/HIV/HepC), Rubella, Cytomegalovirus, Herpes.
· Hormones – androgenic agents, DES, maternal diabetes, maternal obesity.
· Drugs – listed above right – focus VALPROIC ACID and ALCOHOL.
§ Postnatal – infections, metabolic disorders, toxins, trauma, domestic violence (maltreatment), malnutrition, maternal mental health disorders.
Birth –Prematurity, Prolonged/complicated labour
Outline an approach to the development assessment
Need to assess
Milestones preceding age
Expected milestones for age
ASK, OBSERVE AND TASK
Outline a history for investigating child development
Antenatal – illnesses/infections; medications; drugs; environmental exposures
Birth –Prematurity, Prolonged/complicated labour
Postnatal – illnesses/infections; Trauma
Consanguinity – increases chances of chromosomal or autosomal recessive conditions
Developmental milestones from parent
Parental anxiety
Birth history
Family history
What should you look for in the PMHX
Developmental history
Current skills
Outline an approach to the examination
Growth parameters – height, weight and head circumference
Dysmorphic features
Neurological examination and skin
Systems examination to identify associations, syndromes
Standardised developmental assessment – SOGSII, Griffiths
Developmental assessment, + general and neurological examination
Investigations – as appropriate
List some commonly used assessment tools
Standardised tests
Schedule of Growing Skills (II)
Griffiths developmental scale
Bailey developmental scale
Denver developmental screening tests
OFFER THE RIGHT TOOLS, OBSERVE, LISTEN
Summarised the focusses physical examination
Look of child Growth OFC Hearing and vision Skin Genitalia
Summarise the bloods and imaging
FBC and ferritin TSH Chromosomes Lead US CT/MRI
What are the objectives of management
Maximise mobility
Minimise discomfort
Promote speech and language
Promote social and emotional health
Summarise the management
§ Management:
o Investigations – cytogenic studies, metabolic screens (function tests and blood profiles), blood ammonia and lactate, urine and blood amino-acids, creatine kinase, imaging and nerve/muscle biopsies.
o Other professionals – referral to the MDT.
Summarise the MDT
Paediatrician
Assessment, investigation and diagnosis
Continuing medical management
Coordination of input from therapists and other agencies – health, social services, education
Specialist health visitor
Helps coordinate multidisciplinary and multi-agency care
Advice on development of play or local authority schemes
E.g. portage
Psychologist (clinical and educational)
Cognitive testing
Behavioural management
Educational advice
Social worker/Social services Advice on benefits: disability, mobility, housing, respite care, voluntary support agencies Day nursery placements Advocate for child and family Register of children with special needs
Occupational therapist Eye-hand coordination ADL (activities of daily living) – feeding, washing, toileting, dressing, writing Seating House adaptations
Physiotherapist Balance and mobility Postural maintenance Prevention of joint contractures, spinal deformity Mobility aids, orthoses
Speech and Language Therapist Feeding Language development Speech development AAC (augmentative and alternative communication aids e.g. Makaton sign language, Bliss symbol boards, voice synthesisers
Dietician
