development and developing problems Flashcards
the change of nature and nuture with age and stage of child
- infants –
- primary school —
- young people —–
- totally depend on their parents
– can meet some of their physical depends and cope with many social relationship
– meet most of their physical needs while experiencing an increase in complex social and emotional needs
4 development domains
1) gross motor
2) vision and fine motor
3) hearing, speech and language
4) social (inc self care skill), emotional and behavioural
gross motor skills are …
fine motor skill requires …
Normal speech and language development depend on …
social, emotional and behavioural skills are …
- most obvious inital area
- good vision ( hence grouped together)
- good hearing (hence together)
- spectrum pf psychological development
normal pattern of learning new skills
- sequentially consistent
- considered longitudinal, relating each stage to what has gone before and what lies ahead
- varies in rate between children
what is development milestone and what to consider and a definitions of each consideration
- they are important skills
- median age which is when half the population of children achieve that skill (doesn’t tell you if the child’s skill is outside the normal range)
- Red flag age which is the age the development of the milestone should have been achieved
percentage of children taking their first step unsupported and what is the mean and red flag age and meaning of not achieving the red flag age and why not set the limit age earlier?
% by 11 months
% by 12 months
% by 13 months
% by 15 months
% by 18 months
25% by 11 months
50% by 12 months
75% by 13 months
90% by 15 months
97.5% by 18 months
mean age is 12 months and the red flag age is 18 months
not achieving red flag age means there could be an underlying problem like cerebral palsy, primary muscle disorder or global development delay
setting limit age early may allow earlier identification of problem but also increase number of false positive
the red flag of walking
children crawling –
bottom shuffle —-
children crawling – 18 months
bottom shuffle - 50% by 18months and 97.5% by 27 months ( some have gross motor variant patterns but other aspect of development normal)
the 8 primitive reflexes
- placing reflex –
- palmer grasp
- palmomental reflex
- rooting and suckling
- Glabellar tap reflex
- asymmetric tonic neck reflex (ATNR)
- Babinski reflex
- moro reflex
-when the dorsum of the foot touches the surface, they attempt to step on it and it disappears by 3 months
- flexion of fingers when the object is placed in the palm and disappears by 3 months
-involves puckering of skin on the ipsilateral side and brief contraction of the mentalis muscle after brisk stroking of the patient’s palm
- turn of head if touched near mouth and suck on nipple placed in mouth
- occurs in response to repeated tapping of the patient’s head between eyebrows, which elicits blinking that normally would disappear after 4 to 5 taps. This test should be performed from above and behind the patient to remove visual stimuli. This reflex is to protect newborn eyes from injury
- rotating the head to one side causing ipsilateral extension of the extremities towards which the face is turned and contralateral flexion of extremities (fencing position and is disappears by 5 months )
- involves the stimulation of the lateral foot resulting in dorsiflexion of the great toe and fanning of the other toes.
- while supporting the child’s head, sudden extension causes symmetrical extension and abduction followed by flexion and adduction of the arm
postural reflexes
- labyrinthine righting –
- postural support —
- lateral propping —-
- parachute
they appear from 4 to 12 months and are essential for independent sitting and walking
- head moves in opposite direction to which the body is tilted
- when held upright, legs take the weight and baby may bounce
- in sitting, on the side which the infant falls as a saving mechanism
- when suspended face down, the babies arm is extended to save themselves
adjustment for prematurity –
if born 3 months early, what to do –
why no correction after 2 years old –
- should calculate developing age from the expected date of delivery
- if born 3 months early they will more likely have development skills of 6 months old than the anticipated 9 month development skills
- as the number of weeks of prematurity no longer represents a significant proportion of the childs life
cognitive development:
- thoughts as preschool …
- dominant thoughts as a middle schooler
- thoughts in adolescence
- they are at the centre of the world, inanimate objects have feelings and thoughts, events have magical elements and everything has a purpose
- practical and orderly, tied to circumstance and specific experience (operational thoughts)
- adult style of abstract thoughts ( formal operational thoughts), has the ability of abstract reasoning, testing hypotheses and manipulating abstract concept
ALL STAGES ARE IMPORTANT, HAND DOMINANCE AT 1-2 YEARS AND NOT BEFORE THAT
mean age of gross motor development
- newborn -
-3 months - - 6-8 months -
- 8-9 months
- 10 months
- 12 months
- 15 months
- newborn - limbs flexed, symmetrical posture and marked head lag on pulling up
-3 months - no head lag
- 6-8 months - sit without support round back at 6 months and straight back at 8 months
- 8-9 months - crawling
- 10 months - stands independently and cruises around furniture
- 12 months - walks unsteadily, broad gait, hands apart
- 15 months - walks steadily
vision and fine motor median ages
- 6 weeks -
- 4 months -
- 4-6 months -
- 7 months -
- 10 months -
- 16 -18 months -
- 15 months -
- 2 years -
- 2.5 years -
- 3 yrs -
- 3.5yrs -
- 4 yrs -
- 5 yrs -
- 6 weeks - follows objects or face by turning the head
- 4 months - reaches out for toys
- 4-6 months - palmer grasp
- 7 months - tranfer toy from one hand to another
- 10 months - mature pincer grip
- 16 -18 months - makes marks with crayon
- 15 months - tower of three
- 2 years - tower of 6 and can draw line
- 2.5 years - tower of 8 bricks or a train on 4 blocks
- 3 yrs - bridge from a model and can draw circle
- 3.5yrs - can draw a cross
- 4 yrs - steps (after demonstration) and draw square
- 5 yrs - can draw triangle
hearing, speech and language (median ages)
new borns -
3-4 months -
7 months -
7-10 months-
12 months -
18 months
20-24 months -
2.5 - 3 yrs -
new borns - startle by loud noise
3-4 months - vocalises alone or when spoken to, coos and laugh
7 months - turns to soft sounds out of sight
7-10 months- at 7 month sound is indiscrimentely and at 10 month sound is discrimently
12 months - 2-3 words other than dada and mama
18 months - 6-10 words and show 2 body parts
20-24 months - joint 2 or more words to make simple phrases
2.5 - 3 yrs - talks constantle in 3-4 words
social, emotional and behavioural development (median age)
6 weeks
6-8 months
10-12 months
12 months
18 months
18-24 months
2 years
2.5-3 yrs
6 weeks - smiles responsively
6-8 months - put food in mouth
10-12 months - waves bye-bye and play peak a boo
12 months -drink from cup with 2 hands
18 months - holds spoon ang get food safely to mouth
18-24 months - symbolic play
2 years - dry by day and pulls off clothes
2.5-3 yrs - parallel play and interactive play evolving and takes turn
at diiferent ages, different development domains are dominant so what to ask in:
- less than 18 months
- 18 months to 2.5 yrs
- 2.5 - 4 years
- start to ask about the gross motor abilities and then the development of vision and hearing skills followed by hand skills
- start ask aboiut speech and language and fine motor and the about gross motor
- best focused around speech and language and social, emotional and behavioural
For formal development and screening and assesment
what is the England ages and stage questionnaire and what does it consist of and useful for
standardized questionnaires using 19 age specific development questions starting at 4 month and ending at 60 months
high specificity and negative predictive values, therefore identify CHILDREN NOT AT RISK OF DEVELOPMENT DELAY
3 tools to asses development
- screening:
- standardised test for overall development in infants and young children:
- Standardised assessment on specific aspects:
- screening: schedule of growing skills and the denver development screening test
- standardised test for overall development in infants and young children: Griffiths and Bailey infant development scales
- Standardised assessment on specific aspects: Reynell language scale, gross motor function measure, Autism Diagnostic interview and autism diagnostic observation schedule
when does child start to respond to noise and voice?
25-26 week gestation
and at birth startled by loud noises and has marked preference for for voices
risk factors for hearing loss ?
- family Hx
- gentic syndrome eg downs syndrome
- craniofacial anomalous of ear (inc cleft palate and lip)
- admission to NICU >48 hrs
- congenital infection eg) CMV, rubella
- bacterial meningitis
- severe hyperbilirubineamia
- ototxic drugs eg) gentamicin
- hypoxic - ischemic encephalopathy
why cleft lip and palate and NICU causes increase risk in hearing loss
-Glue Ear (Otitis Media) is a common condition in children with a cleft palate. This is thought to happen when the eustachian tube doesn’t function properly. The eustachian tube runs from the middle ear to the back of the nose and throat, and it works by equalizing air pressure between these two areas, sort of like what happens when you “pop” your ears
put on mechanical ventilation, he/she may have already sustained a high level of oxygen deprivation. A lack of oxygen can accelerate the deterioration of the sensory cells of the inner ear.
2 automated electrophysicology test for univeral neonatal hearing screening
Automated otoacoustic emision (AOAE)
Automated auditory brain response (AABR)
- soft earpiece placed inthe ear canal produces click that evokes faint sound or echo from outer har cell of healthy cochlea that is detected by microphone
- evoke brainwaves in response to a sound stimulus and test cochlea and auditory
advantages and disadvantages of AOEA
advantages:
- simple and quick to perform, though affected by ambient noise
- used to screen all infants
disadvantages:
- as function of the auditory nerve and brain not tested can miss auditory neuropathy
- high false positive in the first 24 hrs after birth as vernix or amniotic fluid still in ear canal
- not test of hearing but a test for cochlear function
advantages and disadvantages of AABR
advantage:
- screen hear from ear to brainstem
- low false positive rate
- used if no clear responce in AOEA or in NICU
disadvantage:
- affected by movement so babies need to be asleep and is time consuming
-complex computerised equipment but is mobile
-require electrodes applied to infants head
most common motor impairment in children
cerebral palsy
when is the term ‘delay’ used and definition of development delay and learning/intellectual disability
- delay is used only from 0-5 yrs and describes slow acquisition of skills but in correct order
- when development skill is both delayed and acquired in the incorrect order
- school aged children with significantly reduced ability to understand new or complex information, new skills and to cope independently
definition of impairment and disability
Impairment is the loss or abnormality of physiological function or anatomical structure
Disability is restriction or lack of ability due to the impairment
the 3 patterns of abnormal development?
1) slow but steady
2) plateau effect
3) Regression- acute regression following brain injury with sequent slow recovery but not to normal level or slow progression regression as with neurodegenerative disorder
examples of presenting features of potential neurodevelopment problems by age?
prenatal –
perinatal –
infancy –
preschool –
school age –
any age–
more examples in book ( pg 55 in part 1)
prenatal – +ve familyHx, tay-sachs disease, screening for downs, neural tube defect, hydrocephalus
perinatal – post perinatal asphyxia with neonatal hypoxic-ischemic encephalopathy, dysmorphic and neurocutaneous (ALSO IN INFANCY) features, abnormal neuro behaviours like tone and feeding
infancy – global development delay, vision or hearing concern, delayed or asymmetrical motor development, neurocutaneous features
preschool – speech and language delay, abnormal gait, poor communication skills, unusal behaviour
school age – learning difficulties, hyperactivities, specific learning difficulties,
any age– trauma, regression with loss of skill
During infancy and early childhood, which problems present specifically
first 18 months —
18 months - 3 yrs —-
2-4 years —
first 18 months — motor problem
18 months - 3 yrs —- speech and language
2-4 years — social and communication skills
conditions that cause abnormal development and learning development
prenatal –
perinatal –
postnatal –
prenatal – genetic (down syndrome), structural brain (cerebral dysgenesis), cerebrovasuclar (stroke), metabolic (hypothyrodism), tetrogenic (alchol abuse), congestal infection (CMV, HIV), neurocutaneous (neurofibromatosis)
perinatal – extreme premature (leukomalacia), perinatal asphyxia (hypo-ischemic encephalopathy), metabolic (hyperbilirubinaemia)
postnatal – infection (meninigitis, encephalitis), anoxia (suffocation, seizure), trauma, metabolic (hypoglycaemia), cerebrovascular (stroke), nutritional deficiency (malnutrition), other (chromic illness)
in investigations:
what IX for:
dysformaty –
impairment –
abnormal neurology –
dysformaty – genetic test
impairment – hearing & vision
abnormal neurology – cranial imaging
first Ix to consider for children with development delay and/or disorder
genetic –
biochemical–
metabolic
genetic – microarray, fragile X analysis, whole genome sequencing, development delay panel
biochemical– U&E, TFT, creatine kinase, LFT, lead CBC, feritin, B!@
metabolic
second line investigation to consider children with development delay/ or disorder
test ans possible indication
- imaging –
- neurophysiology –
- metabolic -
- imaging – test (CT brain, MRI brain, crainal US) and possible indication (ventricular dilation, structural malformation)
Neurophysiology – test (EMG, EEG, nerve conduction studies) and possible indication ( myopathy, storage disorder, peripheral nerve lesion)
- metabolic - second line metabolic Ix to be guided by specialist
causes of abnormal motor development inc
- central motor deficient eg cerebral palsy
- spinal cord lesion eg) spina bifida
- neuropathy
- congenital myopathy or primary muscle disease
- global development delay
definition cerebral palsy (CP) and epidemiology
perment disorder of movement and posture causing limitation, resulting from non progressive strutral abnormal (non progressive non curable, pure motor disorder)
effect 2-3.5 per 1000 live births in high income countries
accompanied by ..
causative lesion and clinical manifestation –
before 2 yrs and after 2 yrs —
– by disturbance of cognition, communication, vision, sensation, behaviour, seizure disorder, 2ndry musculoskeletal maturation
-non progressive, and damage to the brain is static. clinical manifestation changes over time
- before 2 yrs CP and after 2 yrs acquired brain injury
cause of CP:
prenatal
perinatal brain injury
postnatal
prenatal (80%) – cortical migration disorder or structural maldevelopment during gestation, cerebro Hge or ischemic, genetic, infection
perinatal brain injury (10%) – hypoxic-ischemic injury before or during delivery. injury also may results from arterial or venous stroke
postnatal - infection (meningitis, encephalitis), head trauma, symptomatic hypoglycemias, hydrocephalus and hyperbilirubin
early presentation of cerebral palsy
- feeding difficulties
-delay motor milestones ( eg. not sitting unsupported by 9 months) - poor head control
- abnormal gait
- global development delay
how to diagnosis and examination presentation
- Dx clinically and causes is determined by history and examination. MRI can identify cause.
- reduced central tone, exgerated responce, persistant primitive reflex, delayed motor milestone, abnormal gait, slow head growth, reduced or increase in tone
types of cerebral palsy and MC and what does the classification depend on
- spastic (bi- or unilateral): 80% - MC
- dyskinetic - 6%
- ataxic - 4%
- mixed - 10%
-depends on pre-dominant motor abnormality
gross motor function classification
(GMFC) score 6-12 yrs
grade 1 -
grade 2 -
grade 3-
grade 4-
grade 5-
grade 1 - walk without limitation
grade 2 - walk with limitation
grade 3- walk using handheld mobility devices
grade 4- self mobility with limitation (on wheelchar but can move the wheelchair by themselves)
grade 5- transport manual wheelchair (cant move chair)
what is spastic cerebral palsy
UMN pathway is damaged, causing an increase in spastic and associated with deep brisk tendon reflex (with fast, sudden movement as muscle is stretched faster and greater resistance ia made) can be claspknife spasm. present early and in neonatal period
sometime initially hypotonia, particularly in the head and neck
3 types of spastic palsy and cause
- unilatral (hemiplegic): due to perinatal stroke (MCA infarction)
- bilateral (diplegic): damage in periventricular areas often associated with prematurity and as leg motor fibers from homunculus close to the ventricles, they are more effected the arms
- bilateral (quadraplegia): extesive damage in periventricular area, inc cortex, usually from structural anamolies or genetics, may be due to perinatal asphyxia
clinical presentation of the the 3 types of spastic palsy
1) unilateral
- spastic or dystonic on one side AND arm more effect than legs
- presents 4-12 months with asymetrical hand function
- may have hemianopia on same affected side
- risk of learning difficulties and seizures and GMFCS of 1 and 2
2) diplegic
- predominantly effect legs and arms; subtle affects like supination, fine motor control
- mainly spastic motor type
-no feeding or communication difficulties and good cognition
- often associated with squints and has GFMC from 1-3
- walking on ther tiptoes
3) quadraplegia:
- predominately spastic and effect both legs and arms
-extensor position (opisthotonus of trunk)
- associated with feeding difficulties, learning difficulties
- seizures are common
- inc risk of hip subluxation, dislocation and sclosis
- depend on others and need powered mobility and associated with GMFCS of 4 -5
Definition and the cause of dyskinetic palsy (dystonia, athetosis, chorea)
other clinical presentation and what does MRI brain show
dyskinetic is involuntary, uncontrolled occasional stereotyped and often more evident with active movement or stress
- chorea - irregular, sudden and brief non-repetitive movements
-athesosis - slow writhing movement more distally like fanning of fingers
- dystonia - stim contraction of agonist and antagonist muscles of trunk and proximal muscles and appear as twisting. open mouth and internal rotation and extension of arms
caused by perinatal aphyxia, particularly affecting the basal ganglia. also kernicterus (due to Rh isoimmunization but now hypoxic ischemic encephalopathy) but it is rare.
-intellect may be unimpaired and can have floppiness, poor trunk control and delayed motor development and abnormal movement may only appear towards the end of first year of life
– MRI scan show bilateral change predominately in basal ganglia
what is ataxic (hypotonic palsy) and mixed
- ataxic - most genetically determined. if lesion in cerebellum, effect same side with relatively symmetry. first early trunk and limb hypotonia, then with age incoordinate movement , intention tremor and ataxic gait
-mixed cerebral palsy is combination of dyskinetic and spastic with involuntary movement and athetosis
red flags that are abnormal motor development but are not cerebral palsy
- absence of risk factors
- fam Hx of progressive neurological disorder
- loss of cognitive and development abilities
- development of focal neurological lesion
- atypical features like dysmorphism
- -ve MRI fining of cerebral palsy
management of cerebral palsy
- pallative as there is no cure (soeech therapy, hearing and vision test, protect against infection, multidisciplinary)
- baclofen and diazepam with orthoses for spasticity.
- IM botox injection followed by serial casting
- selective dorsal rhizotomy
- intrathecal baclofen
- deep brain stimulation of basal ganglia
prognosis of hemiplegic, diplegic, quadraplegia
a childs motor ability at 2 years can indicate future ambulation
- can sit -
-if cant sit but can roll
-if cant do either -
hemi- with no association, almost walk by 2
spastic di- walk by 3 yrs
spastic quad- 25% need hel with care and all day activities and 33% eventally walks
- can sit - likely walk by 6
-if cant sit but can roll - possible walk unaided by 6
-if cant do either - unlikely to walk unaided
% of autism in UK and most likely presentation and core features
1) 1%
2) preschool age 2-4 yrs
3 feature:
- persistant impairment in social communication
- persistent impairment in social interaction
- restricted and repetitive patterns of behaviours, interests and activities in sensory sensitivities
(features in books pg 68-69)
comorbidities of autism
- 2/3 have general learning and attention difficulties
-seizures
-anxiet, sleep disorder
-up to 70% mental health issue
-GI symptoms, eating problem - Behaviors that challenge
Asperger syndrome
separate diagnostic entity for those with social impairment of an autism spectrum but milder and near-speech development and normal intellect, typically characterized by narrow, unusual and often intense interests
in autism, the child presents with a triad of difficulties
- impaired social interaction like prefer own company
- speech and language disorder (delayed language development) and limited use of gesture and facial expression)
– imposition of routines with ritualistic and repetitive behaviour like violent temper if disrupted, flapping hands and spinning object
management of autism
- parents support
- 25-30 hrs of individual therapy each weeks
prevalence, subtype of ADHD, high prevelnce with ADHD
- 7% of 4-17 yrs has ADHDand 3 times more common in male than females (3:1)
- when inattentive is cardial feature or predominate hyperactive-impulsive
- extremely premature infants, child in care, mental disorder, epilepsy, acquired brain injury ( occur >2 yrs), autism
management of ADHD
-1st line mild-moderatley preschool and school age - active promotion of behavioural and educational progress
- insufficent, pharmacological management for over 6 yrs- methylphenidatre (SE: anxiety, weigh loss, HTN as a stimulant) -may cont into adulthood but period off to reassess the need
-parental and teach information and advice and parenting programmes along with psychosocial treatment
