Development Flashcards
Gross Motor Red Flags
4m Head control
9m Sits unsupported
12m Stands unsupported
18m Walks independently
Vision and Fine Motor Red Flags
3m Fixes and follows
6m Reaches for objects
9m Transfers
12m Pincer grip
Hearing, Speech and Language Red Flags
7m Polysyllabic babble 10m Consonant Babble 18m 6 words with meaning 2y Joins words 2.5y 3-word sentances
Social Behaviour Red Flags
8w Smiles 10m Fear of strangers 18m Feeds self/spoon 2-2.5y Symbolic play 3-3.5y Interactive play
Primitive Reflexes
Moro Grasp Rooting Stepping response Asymmetrical tonic neck reflex Sucking reflex
Postural Reflexes
Labyrinthine Righting
Postural support
Lateral propping
Parachute
Childhood thought processes (Piaget)
Centre of the world
Inanimate objects are alive and have feelings
Magical element to environment
Everything has purpose
Healthy child surveillance programme
Provided in primary care
Screening, immunisations, developmental review and health promo
Hearing testing
Otoacoustic emission- newborn screening
Auditory brainstem- newborns with abnormal screen
Distraction testing- prev. hearing screening at 7-9m (requires object permeance ability)
Visual reinforcement- hearing impairment 10-18m, children with learning disability
Performance speech and discrimination- toy use in younger children.
Audiometry- >4y
Vision testing
Newborn- aware of light 6w- fix and follow 6m- fixates and visually directed reach 12m - fixates on 1mm crumb 1-2y preferential acuity test .e.g. Cardiff cards 2-3y picture matching .e.g. kay or lea 3y + letter matching .e.g. logMAR
Gross motor milestones
Newborn- limb flexed, symmetrical posturing, lag head 6w raises head 45' in prone 6m sits unsupported arched back 8m sits unsupported straight back 9m crawling 10m stands and cruises 12m walks unsteady broad based gait 15m walks steadily
Vision and fine motor milestones
6w fixes and follows 4m reaches for toys 6m palmar grasp 7m transfers toys 10m mature pincer grip 18m marks with crayon
Blocks Milestones
18m tower of 3 2y tower of 6 2.5y tower of 8 or 4 block train 3y bridge from model 4y steps after demo
Drawing shapes milestones
2y line 3y circle 3.5y cross 4y square 5y triangle (Drawing from copy 6 m before)
Hearing, speech and language milestones
Newborn- startles to loud noise
4m vocalises when alone, coos and laughs
7m turns to sound out of sight, sound indiscrimate
10m discriminate sound to mama/dada
12 m 2-3 words
18m 6-10 words, localises 2 parts of body
20-24m joins 2 words for simple sentences
2.5-3y talks constantly 3-4 word sentences
Social and behaviour milestones
6w smiles 8m food to mouth 10m waves bye-bye, plays peek-a-boo 12m drinks from a cup with 2 hands 18m holds spoon and transfers to mouth 18-24m symbolic play 2y dry by day, pulls off some clothes 2.5-3y parallel play 3-3.5y interactive play
Age of presentation- developmental areas
Newborn- 18m Motor
18m-3y Speech and language
2-4y Social communication
Global developmental delay features
Delay in acquisition of all skills
Presents within first 2 years of life
Causes abnormal motor development
Central motor deficiet .e.g. cerebral palsy
Congenital myopathy/primary muscle disease
Spinal cord lesions .e.g. spina bifida
Global developmental delay
Presentation motor delay
Between 3m and 2y
Abnormal motor signs
Delay in acquisition of motor skills
Early hand dominance (<1-2y)
Definition Cerebral Palsy
Non-progressive abnormality of brain development resulting disorder of motor function and posturing
Brain injury must occur before 2 years old
Antenatal causes of cerebral palsy
- cerebrovascular haemorrhage/ischamia
- cortical migration disorder
- structural maldevelopment
Postnatal causes of cerebral palsy
Meningitis Encephalitis Encephalopathy Head trauma symptomatic hypoglycaemia hydrocephalus hyperbilirubinemia
Preterm complications causing CP
Periventricular leukomalacia associated with ischaemia or severe intraventricular haemorrhage and venous infarction
Presentation cerebral palsy
Abnormal limb/trunk posture and tone Delayed infancy milestones Slowing of head growth Feeding difficulties: oromotor co-ordination, slow feeding, gagging, vomiting Asymmetric hand function <12m Persisting primitive reflexes
Categories of cerebral palsy
Spastic: bilateral, unilateral and not specified (90%)
Dyskinetic (6%)
Ataxic (4%)
Other
Gross motor function classification
I walking without limitation
II walking with limitation
III walking with handheld mobility device
IV self-mobility with limitation .e.g. uses powered mobility aid
V transported in manual wheelchair
Spastic Cerebral Palsy Types
Bilateral (quadriplegia)
Unilateral (hemiplegia)
Bilateral (diplegia)
Pathology Spastic Cerebral Palsy
Damage to UMN
Pyrimidal or corticospinal tracts
Signs Spastic Cerebral Palsy
Brisk deep reflexes Extensor plantar reflex Velocity dependant spasticity Dynamic catch (hallmark feature) Presents early: seen in newborn period Initial hypotonia of head and trunk
Features unilateral hemiplegia CP
Unilateral involvement of arm and leg Arm>>leg Sparing of face Present at 4-12m Fisting of affected hand Flexed, pronated arm Asymmetric reaching Tip-toe walking on affected side Typically due to neonatal stroke
Features bilateral quadriplegia CP
All 4 limbs affected
Trunk involvement- opisthotonus (extensor posturing)
Poor head control
Low central control
Associated with seizures and microcephaly
Perinatal hypoxic-ischaemic encephalopathy
Features bilateral diplegic CP
All 4 limbs affected Legs>>arms Normal hand function Abnormal walking Associated with prematurity (periventricular brain damage)
Features Dyskinetic CP
Involuntary uncontrolled movements (>1y) Chorea/athetosis/dystonia Variable muscle tone Primitive motor reflexes Unimpaired intellect Basal ganglia damage- usually bilateral Associated with kernicterus
Features Ataxic CP
Usually genetically determined Early trunk and limb hypotonia Poor balance Delayed motor development Inco-ordinated movements Intention tremor
Mx Cerebral Palsy
MDT approach
Early diagnosis and counselling for parents
Botulinum Toxin (hypertonia)
Dorsal rhizotomy (selective cutting of spinal cord nerve)
Intrathecal baclofen
Deep brain stimulation for basal ganglia
Causes of Speech and Language Delay
Hearing loss Global developmental delay Difficulty in production due to anatomy Environmental deprivation/neglect Normal variant/familial pattern
Testing language development
Symbolic toy test: early language development
Reynell test: receptive and expressive language (pre-school children)
Mx Speech and Language delay
Hearing test Assessment by SALT Neurodevelopmental paeds referral Audiology physician involvement SALT Alternative methods of communication Specialist schooling
ASD Impaired social interaction Features
Does not seek comfort/share pleasure Does not form friendships Prefers own company No interest in interaction with peers Gaze avoidance Lack of joint attention Socially and emotionally inappropriate behaviour No appreciation of others thoughts and feelings Lack appreciation of social cues
ASD Speech and Language Features
Delayed development
Limited use of gestures and facial expression
Formal pedantic language, monotonous voice
Impaired comprehension with over literal interpretation
Echos questions, repeats instruction, refers to self as ‘you’
Superficially good expressive speech
ASD Routines and ritualistic behaviour
Violent temper tantrums if disrupted Imposition on self and others Unusual stereotypical movements Concrete play Poverty of imagination Peculiar interests and repetitive adherence Restriction of behavioural repertoire
ASD Co-morbidities
General learning and attention difficulties
Seizures- presenting in adolescence
Affective disorders .e.g. anxiety, sleep disturbance
Mental health disorder .e.g. ADHD
ASD Epidemiology
3-6/1000 live births
More common in boys
Presentation aged 2-4 (social development)
Asperger’s Syndrome Features
Milder version of ASD Near-normal speech development Difficulty in give/take social interaction Stilted speaking Narrow, unusual and intense interests
Mx ASD
Parental support
Behavioural modification: 25-30h individual therapy
Appropriate educational placement
Learning Disability and IQ
IQ 70-80 Mild, requires learning support, mainstream school
IQ 50-70 Moderate
IQ 30-50 Severe
IQ <35 Profound
Dyspraxia Features
Disorder of motor planning
Higher cortical processing disorder
Perception problems, use of language and putting thoughts together
Dyspraxia Presentation
Awkward, messy, slow, irregular, poorly spaced writing Difficulty dressing Difficulty cutting up food Poorly established laterality Problems copying and drawing Messy eating Dribbling of saliva
Mx Dyspraxia
SALT assessment
Visual assessment
Therapy on sensory integration, sequencing, executive planning
Improvement with maturity
Verbal dyspraxia definition
Difficulty with speech production in the absence of muscle or nerve damage
Dyslexia Features
Disorder of reading skills disproportionate to IQ
Child’s reading age is more than 2 years behind chronological age
Features of ADHD
Overactive in most situations Impaired concentration Unable to sustained attention and complete tasks Socially disinhibited Difficulty taking turns/sharing Interrupt and butt into others conversations and play Worse in unfamiliar or boring situations Lose possessions and generally disorganised Short tempers Form poor relationships Poor school performance Low self-esteem
Behavioural Mx ADHD
Promotion of behavioural and educational progress
Parenting intervention
Clear rules and expectations
Consistent rewards and consequences for behaviour
Medical Mx ADHD
Children >6y
Stimulants .e.g. methylphenidate, dexamphetamine
Non-stimulants .e.g. Atomoxetine (reduces excessive motor activity)
Annual off-medication trial to assess need
Causes sensorineural hearing loss
Genetic (most common) Antenatal/perinatal infection Prematurity Hyperbilirubinaemia Hypoxic-ischemic encephalopathy Meningitis/encephalitits Head injury Medications .e.g. aminoglycosides, furosemide Neurodegenerative disorder
Causes conductive hearing loss
Otitis media with effusion
Eustachian tube dysfunction .e.g. Down’s, Pierre Robin, midfacial hypoplasia
Wax (rare)
Mx Sensorineural hearing loss
Amplification or cochlear implantation
Specialist schooling
Use of makaton
School adjustments: placed in front of the classroom
Mx Conductive hearing loss
Insertion of tympanostomy tubes
Removal of adenoids
Hearing aids used if recurrence following surgery
Audiogram in hearing loss
Sensorineural >95dB hearing loss
Conductive maximum 60dB hearing loss
Presentation of visual impairment
Obvious ocular malformation Absent red reflex or leukocoria Not smiling by 6w post-term Concerns re poor visual responses Poor eye contact Roving eye movements Nystagmus Squint
Features Nystagmus
Repetitive involuntary rhythmical eye movement
Usually horizontal
May be associated with structural or cortical defect
Types of squint
Concomitant- nonparalytic, common, due to refractive error
Paralytic- rare, due to paralysis of motor nerve
Transient misalignement- common until 3m
Causes of squint
Refractive error (most common)
Cataracts
Retinoblastoma
Intra-ocular
Ix Squint
Corneal light reflex test- torch at a distance, asymmetry of reflection
Cover test- covering fixing eye causes movement of squinting eye to take up fixation
Refractive errors
Hypermetropia (long sighted)- most common
Myopia (short-sighted)- presents in adolescents/preterms
Astigmatism (abnormal corneal curvature)- unilateral may cause amblyopia
Amblyopia- permanent reduction of visual acuity in an eye which has not received a clear image (Mx<7y)
