Development and NAI Flashcards
What is development?
Progressive acquisition of skills in line with the maturing central nervous system and emotional development of a child
Encompasses physical, socio-emotional, cognitive and emotional development
What are the developmental domains?
Gross motor
Fine motor and vision
Speech and language
Social skills/ emotion/ behaviours/ cognition
Gross motor milestones
6 weeks: head lag, head held in same plane in ventral suspension
6 months: can roll over, sits briefly or with some support
1 year: crawling, pulls to stand, cruising, walking in some
2 year: climbs and descending stairs, runs, kick ball
3 year: pedals tricycle, jumps well, momentarily balances on one foot
4 years: stands on one foot well, hops
5 years: walks backwards/ hells/toe,
Fine motor and vision milestones
6 weeks: maintains fixation, follows objects through 180degrees horizontal plane
6months: transfers, reaches out for objects, mouths objects
1 years old: pincer grip, bangs 2 bricks together
2 years: copies vertical line, builds tower of 8 bricks
3 years old: copies a circle, matches two colours
4 years old: copies a cross and a square, imitates bridge with 3 bricks, draws man with 3 parts
5 months: copies triangle, draws man with six parts, copies 3 steps from 6 bricks, does buttons
Hearing and speech milestones
6 weeks: throaty noises
6 months: babble, turns to name being called
1 year old: two words with meaning, responds to simple instructions, shows recognition of objects
2 years: uses plurals/pronouns, selects toys from others, follows 2 step requests
3 years: 3-4 word sentences, knows three colours, pronouns and plurals, prepositions
4 years: counts to 10, identifies several colours, lots of questions, tells story
5 years: comprehension, understanding of prepositions, opposites
Social milestones
6 week: Smiles in response to stimuli
6 months: plays with feet, holds onto bottle when fed
1 year old: waves bye, claps hands, empties cupboards
2 years old: plays alone/ alongside others, eats with spoon
3 years: out of nappies, separates from mother easily, eats with knife and fork
4 years: shares toys, out of nappies at night, brushes teeth, toilets alone
5 years old: chooses friends, acts out role play
Developmental screening/assessment tools
Ages and stages questionnaires
Denver developmental assessment and Schedule of growing skills
Bayley and Griffiths
Red flags in developmental assessment
Abnormal muscle tone Not holding object in hand by 5 months Not sitting up supported by 12 months Not walking independently by 18months Asymmetry of skills/ early hand dominance No speech by 18 months Not pointing to objects/ toys to share interest by 2 years Any loss of skills/ regression Any new onset of fits/possible seizures
Gross motor development 1 month
1 month: symmetrical movement in all limbs, normal muscle tone, head lag when pulled up
Gross motor development 3 months
3 months: almost no head lag when pulled to sit, lifts head and chest when prone
Gross motor development 6 months
6 months: rolls from back to front, stands and sits with straight back when held, bears most of own weight
Gross motor development 9 months
Sits without support
Stands holding onto furniture
Moves around the floor, e.g. wriggling, commando crawling
Gross motor development 12 months
Stands without support
Crawls, bottom shuffles or bear walks
Cruises along furniture
May walk unsteadily
Gross motor development 15 months
Generally walks without support
Crawls upstairs
Gross motor development 18 months
Walks steadily, stopping safely
Squats to pick up a toy
Climbs stairs holding a hand or a rail
Gross motor development 2 years
Runs safely
Throws a ball overhand
Walks up and down stairs, both feet on each step
Gross motor development 30months
Jumps on 2 feet
Kicks a ball
Gross motor development 3 years
Walks backwards and sideways
Rides tricycle
Catches a large ball with arms outstretched
Gross motor development 4 years
Stands, walks and runs on tiptoes
Runs up and down stairs
Gross motor development 5 years
Hops
Catches a ball
Heel-toe walking
May ride a bike
Fine motor development 1 month
Grasps finger when placed in the palm
Fine motor development 3 months
Watches their own hands
Brings hands to their mouth
Holds a toy briefly
Fine motor development 6 months
Palmar grasp
Reaches for toys
Puts objects into mouth
Fine motor development 9 months
Passes toy from one hand to another
May have pincer grip
Fine motor development 12 months
Fine pincer grip
Points to object of interest
Releases object intentionally
Fine motor development 15 months
Imitates to and fro scribbles
Builds a tower of 2 cubes, when demonstrated
Fine motor development 18 months
Makes a tower of 3 blocks
Fine motor development 2 years
Builds a tower of 6 blocks
Draws a horizontal line with preferred hand, may draw vertical lines
Turns pages of a book individually
Fine motor development 30 months
Thread beads on a string
Make a tower of 7 or more blocks
Holds a pencil with a tripod grip
Fine motor development 3 years
Builds a bridge using blocks
Draws a circle
Draws a person with a head
Fine motor development 42 months
3.5 years
Draws a cross
Fine motor development 4 years
Build steps using blocks
Draws a square
Draws a person with head/face, arms and legs
Fine motor development 5 years
Uses a knife and fork competently
Draws a triangle
Copies alphabet letter
Newborn speech and language
Cries
Speech and language 6-8 weeks
Coos
Speech and language 3 months
Laughs and vocalises
Speech and language 6 months
Understand word such as mama, dada or bye-bye
Babbles spontaneously, initially monosyllables
Uses a tuneful, singsong voice
9 months speech and language
Imitates adult sounds, e.g. coughs
Understands simple commands
Understands no
Speech and language 12 months
Knows and responds to own name
Uses 2-6 words and understands many more
Speech and language 18 months
Uses 6-40 recognisable words
Can point to parts of body
Tries to sing
Speech and language 2 years
Speaks over 200 words, understands many more
Joins words together
Omits opening or closing consonants
Speech and language 30 months
Continually asks questions
Speech and language 3 years
Can name 2 or 3 colours
Knows and repeats song or nursery rhymes
Counts to 10
Has simple conversations
Speech and language 4 years
Talks fluently
Counts to 20
Enjoys jokes
Speech and language 5 years
Fluent in speech and mostly grammatically correct
Interested in reading and writing
Social, emotional and behavioural newborn
Responds to being picked up
Enjoys feeding and cuddling
Social, emotional and behavioural 6 weeks
Gazes at adult faces
Social smile
Social, emotional and behavioural 3 months
Smiles at familiar faces and at strangers
Social, emotional and behavioural 6 months
Feeds self with fingers
Shows stranger fear
Social, emotional and behavioural 9 months
Waves bye
Plays peek-a-boo
Shows likes and dislikes
Social, emotional and behaviour 12 months
Drinks from a cup with2 hands
Has separation anxiety
Social, emotional and behavioural 18months
Uses a spoon
Plays contentedly alone, near a familiar adult
Eager to be independent
Social, emotional and behavioural 2 years
Displays frustration
Dresses self
Begins to express feelings
2.5 years social, emotional and behavioural
Eats skilfully with spoon, may use a fork
May use the toilet independently
Plays along and alongside other children (parallel play)
Enjoys pretend play
Social, emotional and behavioural 3 years
Shows affection for younger siblings
Probably toilet-trained, though may still be wet at night
Enjoys helping adults, imitating household tasks
Has friends
Social, emotional and behavioural 4 years
Eats skilfully with fork and spoon
Brushes own teeth
Shows sensitivity to others
Takes turns
Social, emotional and behavioural 5 years
Very definite likes and dislikes
Shows sympathy and comforts friends
Dresses without help, except laces
Engages in co-operative and imaginative play, observing rules
Newborn hearing and vision
Fascinated by human faces
Turns head towards light
Startled by sudden noises
Hearing and vision 1 month
Turns head towards diffuse light and stares at bright objects
Startles to loud noises
Hearing and vision 3 months
Focuses eyes on same point
Moves head deliberately to gaze around them
Prefers moving objects to still ones
Hearing and vision 6 months
Adjusts position to see objects
Turns towards the source of sounds
Hearing and vision 12 months
Sees almost as well as an adult
Knows and responds to own name
Hearing and vision 18months
Recognises themselves in the mirror
Hearing and vision 2 years
Recognises familiar people in photographs
Listen to conversations with interest
Hearing and vision 2.5years
Recognises self in photographs
Recognises small details in picture books
Hearing and vision 4 years
Matches primary colours
Listens to long stories with attention
Hearing and vision 5 years
Can match 10 colours
In-toeing gait
Femoral torsion- knees and feet point inwards
Tibial torsion- knees point forward and feet inwards
Bowlegs gait
Common from birth to early toddler-hood: resolve by 18months
Often with out-toeing
Toe walking
Common up to 3 years
Knock knees
Common and associated with in-toeing
Most resolve by 7 years
Flat feet
Most children have normal flexible foot and normal arch on tiptoeing
Usually resolves by 6 years
Ataxic gait signs
Unsteady, broad based
Difficulty heel-toe walking
Causes of ataxic gait
Cerebellar cause, e.g. brain tumour, post-viral
Spastic hemiplegic gait
Arm held flexed, adducted, internally rotated
Leg extended, stiff and in plantar flexion
Leg dragged in circumduction (semi-circle)
Spastic hemiplegia causes
Cerebral palsy
Acquired brain lesions, e.g. stroke
Spastic diplegia signs
Tightness of adduction pulls knees together/ legs to cross the midline; gives ‘scissoring gait.’
Dragging and circumduction of both legs
Spastic diplegia causes
Cerebral palsy
Waddling gait signs
Results from hip adductor weakness or hip pain
Pelvis drops on contralateral side to the leg bring lifted (Trendelenberg sign)
Abdomen pushed forward due to lumbar lordosis
Waddling gait causes
Hip pain, e.g. DDH, SCFE, Perthes
Proximal myopathy, e.g. Duchenne MD
Foot drop ‘high stepping’ neuropathic gait signs
Leg on the side affected has to be lifted high to avoid the foot dragging along the floor
Foot drop ‘high stepping’ neuropathic gait causes
Common peroneal nerve palsy
Peripheral neuropathy
Dyskinetic gait signs
Irregular, jerky, involuntary movements
Dyskinetic gait causes
Basal ganglia lesions
Arthrogryposis
This is a heterogeneous group of usually sporadic congenital conditions characterised by joint stiffness and contractures affecting more than one joint
in the body.
Flexion contractures of the knees, elbows and wrists, dislocation of the hips
and other joints and scoliosis is common.
The aetiology of these may be multifactorial an d include connective tissue disorders and genetic factors.
Whilst some of these conditions may be associated with either a central or peripheral nervous system problem also, the underlying cause of these conditions is not solely neurological.
Cerebral palsy
Cerebral palsy is an umbrella term for a permanent disorder of motor movement and/or posture due to a non-progressive abnormality of the developing brain.
The key here is that the underlying problem is static but the nature of the child’s motor, neurological or functional impairments may change over time.
Cerebral palsy investigation
MRI brain and spine
Periventricular leukomalacia
Abnormality of the white matter of the brain
Role of the occupational therapist
Help people of all ages overcome the effects of disability caused by illness, ageing or accident
So that they may carry out everyday tasks or occupations
Can give advice and help with the supply of equipment
Role of orthotics
Assess patients for the provision of outhouses which fit onto the body to help problems caused but disability, illness or deteriorating conditions
Role of physiotherapy
Helps to restore movement and function when someone is affected by injury, illness or disability
Can also help to reduce your risk of injury or illness in the future
Takes a holistic approach that involves the patient directly in their own care
Role of speech and language therapy
Speech: expression and understanding
Swallow
Where are some common sites for accidental bruising after 6-9months?
Bony prominences
Elbows, knees, shoulders
Rare in non-mobile child
Typical sites of accidental injury
Head injuries: parietal bones, occiput, forehead
Nose, chin
Palm of hand
Knee, shins
Non-accidental injury sites
Head/ neck
Ears- especially pinch marks involving both sides of ear
Black eyes, especially if bilateral
Soft tissues of cheeks
Intra-oral injuries (haemorrhages)
Non-accidental injury
Torso
The triangle of safety: ears, side of face and neck, top of shoulders
Back and side of trunk except over the bony spine
Chest and abdomen
Any groin or genital injury
Non-accidental injury of limbs
Forearms- when raised to protect self
Inner aspects of arms or thigh
Soles of feet
Child risk factors of abuse
Failure to meet parental expectations and aspirations, e.g. disabled, ‘wrong’ gender, ‘difficult’ child
Born after forced, coercive, or commercial sex
Parent/carer risk factors for child abuse
Mental health problems
Parental indifference, intolerance or over-anxiousness
Alcohol, drug abuse
Family risk factors for child abuse
Step-parents Domestic violence Multiple/closely spaced births Social isolation or lack of social support Young parental age Poverty, poor housing
Features in history which should rouse suspicion of child abuse
- Plausibility and/or reasonableness of the explanation for the injury
- Any background, e.g. previous child protection concerns, multiple attendances to ED/GP.
- Delay in reporting the injury
- Inconsistent histories from caregivers and from child
- Inappropriate reaction of parents or caregivers who are vague, evasive, unconcerned, or excessively distressed or aggressive. It is important to take histories from both parents and, if possible, the child by themselves
More subtle presentations of child abuse
Inappropriate attachment to caregiver Inappropriate affection towards strangers Persistent nappy rash with broken skin Persistent infestations with lice Poor attendance at school Poor presentation at school Children can often disclose sexual abuse or physical abuse at school Poor educational achievement
Further tests for child presenting with NAI
Clotting screen
Full blood count and film: thrombocytopenia and haematological malignancies, acute lymphocytic leukaemia
Factor VIIIc (haemophilia A)
VWf: can often present quite late in life
Discuss with paediatric haematology
Which fractures are associated with NAI?
Humeral and femoral spiral fractures
Metaphyseal corner fractures (bucket handle fractures) from shaking
Spiral fractures and tibia/fibula are more likely to be accidental
Claviclular fractures are most common after birth
Which fractures would make you highly suspicious of NAI?
Rib fractures, especially posterior rib
Metaphyseal fractures
Skull fractures: non-parietal skull fractures, involves multiple bones, crosses sutures, depressed fracture
Fractures which are moderately specific for NAI
Bilateral fractures with fractures of differing ages
Digital fractures in non-ambulance children
Vertebral fractures or vertebral subluxation
Spiral humeral fractures
Separation of epiphysis
Fractures which have low specificity for NAI
Middle clavicular fractures
Linear simple fractures of parietal bone (tibia or fibula)
Single fractures in diaphysis (spiral humeral fracture is an exception)
Greenstick fractures
First-line investigations in as child who presents with suspected NAI
Bone profile: calcium, phosphate, alkaline phosphate. Rule out Paget’s, hyperparathyroidism
Osteogenesis imperfecta
FBC: help identify malabsorption, reduced bone strength
Skeletal survey
CRP: osteomyelitis
What does safeguarding involve
Safeguarding children involves working in partnership with the family and professionals from other agencies. It is the responsibility of the paediatrician to recognise and report when abuse may be occurring and to assist statutory agencies (police, social services, NSPCC). The first agency to contact is often the local social care service as they may have information about the family from other agencies and be aware if the child is on a child protection plan. If a child requires an urgent place of safety due to concerns regarding NAI, they can be placed with another family member that is approved by social care or an emergency foster placement. If such a placement is not possible, then the child may need to be admitted to the hospital while a safe place is found. Medical notes and reports may be formally requested by the police/courts and so it is important to document thoroughly- a body map or photographs may be useful also.
Which screening tools are useful in the assessment of ADHD?
Conners questionnaire
Dundee difficult times of the day scale
SNAP-IV
Strengths and difficulties questionnaire
Which members of the MDT are involved in the diagnosis of ADHD
community paediatrician
Speech and language therapist
Educational psychologist
When does adult gait and posture occur?
From 8 years old m
In-toeing gait
Normal hair variation
Femoral torsion- knees and feet point inwards (commonest 3-8 years)
Tibial torsion- knees point forward and feet inward
Bowlegged gait
Normal gait variation
Common from both to early toddler- hood- resolve by 18 months
Often with out-toeing
Knock knees gait
Common and associated with in-toeing
Most resolve by 7 years
Flat feet
Most children have normal flexible foot and normal arch on tiptoeing
Usually resolves by 6 years
Dyslexia
Difficulty in reading, writing and spelling
Dysgraphia
Specific difficulty in writing
Dyspraxia
Developmental co-ordination disorder
Difficulty in physical coordination
More common in boys
Delayed gross and fine motor skills and a child that appears clumsy
Non-verbal learning disability
Specific difficulty in processing non-verbal information
Body language and facial expressions
Classification of learning difficulties
IQ 55-70 Mild 40-55 moderate 25-40 severe <25 profound
Conditions associated with learning disabilities
Down’s syndrome
Antenatal problems, fetal alcohol syndrome and maternal chickenpox
Problems at birth, prematurity and hypoxic ischaemic encephalopathy
Problems in early childhood, such as meningitis
Autism
Epilepsy
Risk factors for learning disability
FH Abuse Neglect Psychological trauma Toxins
