Normal Development and Assessing Developmental Delay

Question 1

How do you determine if a child’s development is normal?

Answer 1

• History from parents
• History from teacher / nursery
• Observation
• Informal assessment
• Formal assessment

Question 2

What are the 4 areas of development?

Answer 2

• Gross motor skills
• Fine motor skills and vision
• Language (comprehension and expression) and hearing
• Social, emotional, behaviour and personal skills

Question 3

Why is early identification of developmental delay very difficult?

Answer 3

• Because both timing of achievement of milestones and patterns of development vary massively (the normal range is very wide).
• The normal range for each is a widely distributed bell curve.
  
  • Children >2SD from the mean for a particular milestone fall in the bottom 2% and are more likely to include many children with underlying problems.

Question 4

What is the moro reflex?

Answer 4

Symmetrical abduction and extension of the arms followed by a return to the midline when ‘dropped’.

Note any absence or unilateral absence of the reflex.

Question 5

Describe the Galant reflex.

Answer 5

• The Galant reflex is elicited by holding the newborn in ventral suspension (face down) and stroking along the one side of the spine.
• The normal reaction is for the newborn to laterally flex towards the stimulated side.

Question 6

Describe the rolling over milestone.

Answer 6

• Rolling over is often one of the first major motor milestones that parents look forward to.
• Most infants roll over when they are between 2-6 months.
• First from their front to their back.
• Then from their back to their front.

Question 7

What is the positive support reflex?

Answer 7

• The development of postural reflexes is essential for independent sitting and walking.
• The positive support reflex is the first postural reflex to develop and is present by 3-4 months of age. When the baby is placed with the feet touching the mat, the baby will extend legs and attempts to support his weight while being balanced by the examiner.
• By 5-6 momtnsh of age the baby fully supports his weight while standing and by 7 months enjoys bouning.
• It is necessary for erect posture and blends into volitional standing.

Question 8

What is the Landau?

Answer 8

• Important postural reflex which should be developed by 4-5 months.
• When the infant is suspended by the examiner’s hand in the prone position, the head will extend above the plane of the trunk.
• The trunk is straight and the legs are extended so the baby is opposing gravity.
• When the examiner pushes the head into flexion, the legs drop into flexion.
• When the head is released, the head and legs will return to the extended position.

Question 9

What are the anterior and lateral propping postural reflexes?

Answer 9

• Anterior propping develops first, then lateral propping.
• Lateral propping or protective extension is essential for the baby to be able to sit independently.
• This postural reflex develops at 5-7 months of age.

Question 10

What is the parachute reflex?

Answer 10

• The last of the postural reflexes to develop.
• Usually appears at 8-9 months of age.
• When the baby is turned face down towards the mat, the arms will extend as if the baby is trying to catch himself.
• Prior to developing this reflex, the baby will actually bring the arms back to the plane of the body and away from the mat.

Question 11

By what age will 90% of babies roll over?

Answer 11

5.4 months

Question 12

By what age do 90% of babies sit with no support?

Answer 12

6.8 months

Question 13

By what age should 90% of babies walk well unsupported?

Answer 13

14.9 months

Question 14

By what age should 90% of babies use the thumb-finger grasp?

Answer 14

10.2 months

Question 15

By what age should 90% of babies be able to use one word with meaning?

Answer 15

15 months

Question 16

What are the developmental ‘limit ages’ for:

• Walks unsupported?
• Saying single words with meaning?
• Speaking in phrases?
• Responsive smiling?
• Reaching out?
• Sitting unsupported?

Answer 16

• Further assessment is indicated if these skills have not been acquired by this age:
  
  • Walking unsupported - 18 months
  • Saying single words with meaning - 18 months
  • Speaking in phrases - 30 months
  • Responsive smiling - 8 weeks
  • Reaching out - 5 months
  • Sitting unsupported - 9 months
• Socially most babies will be reponsively smiling by 6 weeks.

Question 17

What is cruising?

When does it develop?

Answer 17

• Walking along a piece of furniture while holding on.
• It usually develops between 10-12 months.
• Along with cruising, the infant can take steps while holding on but is not ready to walk unsupported.

Question 18

Describe toddler’s gait.

Answer 18

• 12 month infant has a typical gait of an infant that has just learned to walk.
• He has a wide base, is unsteady, and toddles.
• His arms are held at near shoulder level in a high guard position. This is a protective position and probably aids balance.
• As he matures, his arms will come down to a low guard position, then into the usual associated arm movements seen with mature walking.

Question 19

By what age can most toddlers walk up steps?

Answer 19

14-22 months

Question 20

By what age can 90% of toddlers hop on one foot?

Answer 20

4.2 years

Question 21

By what age do toddlers play in a group?

Answer 21

• Group play and sharing doesn’t usually evolve until age 3.
• Until then, most infants and young toddlers simply play by themselves next to each other, in parallel play.

Question 22

By what age should a child be able to eat with a spoon?

Answer 22

A milestone most children reach between 13 and 21 months is eating with a spoon although they may still be messy.

Question 23

By what age should a toddler be able to ride a tricycle?

Answer 23

Preschoolers can usually learn to pedal a tricycle once thay are ~3 years old.

Question 24

Describe how stacking blocks into a tower can be used to test development.

Answer 24

• Important developmental test.
• Considered to be a visual - motor / problem solving milestone and most kids can make a tower of:
  
  • 2 blocks by 15-21 months
  • 4 blocks by 17-24 months
  • 6 blocks by 18-30 months
  • 8 blocks by 24-36 months
  • 9 blocks after 3 years

Question 25

When should children be able to dress themselves?

Answer 25

• Take off clothes between 14 and 24 months.
• Put on some clothing between 21 and 30 months.
• Put on a t-shirt between 2.5-3.5 years.
• Moat children learn to tie shoe laces by age 5.

Question 26

Decribe the assessment of a child with ?developmental delay.

Answer 26

• When assessing a child with a query over development, antenatal and birth hx are essential.
• A hx of problems, or being one of a multiple birth, should lower referral thresholds.
• Premature birth affects development; children develop according to their developmental age, not their chronological age, although this becomes less significant by the age of 2.

Question 27

What are the social factors which may affect a child’s development?

Answer 27

• Child abuse may cause episodes of regression and recovery resulting in overall delay, together with behavioural and social problems at a very early age.
• Children who are overprotected may also show delays; for example, children who are never allowed to tumble because are are constantly in baby walkers or strapped in chairs may walk late.

Question 28

Why is it important to ask about the FHx in a child with ?developmental delay?

Answer 28

• When assessing a child whose parents are concerned, it is important to ask about other siblings and more distant family members such as cousins.
• Delayed speech development, clumsiness and delay in walking are often familial.

Question 29

What is regression in terms of child development?

Answer 29

• Regression of developmental skills is always important and requires urgent referral for investigation.
• Problems that might cause global regression include:
  
  • Abuse of any kind
  • Space-occupying lesions
  • Certain epileptic syndromes
  • Neurodegenerative conditions
• Regression of skills in always cause for concern.

Question 30

Describe the examination of a child with ?developmental delay.

Answer 30

• General examination including inspection for suspicious skin lesions.
• Consider neurofibromatosis, which may cause learning difficulties and deafness, and tuberous sclerosis which causes developmental delay, often with seizures.
• Plot growth chart with particular attention to OFC.
• Look for dysmorphism.
• The younger the child, the greater the possibility that a syndrome such as Down’s syndrome has been missed.
• Examination of gait, reflexes and tone may suggest cerebral palsy or neurological problems.

Question 31

What are Café au lait spots?

Answer 31

• Hyperpigmented lesions that may vary in colour from light brown to dark brown.
• Borders may be smooth or irregular.
• Usually the earliest manifestations of neurofibromatosis.
• The macules may be observed in infancy, although typically they are light in infants and may be difficult to appreciate.
• The skin lesions develop in early infancy. They may enlarge in size and become obvious after 2 years.

Question 32

Describe the diagnosis of neurofibromatosis type 1 (NF1).

Answer 32

• The diagnosis of NF1, an autosomal dominant disorder, requires the fulfillment of the Whitehouse criteria, including the presence of 5 or more CAL spots in children and 6 or more spots in adults.
• To be counted in the diagnosis of NF1, CAL lesions must be at least 1.5cm in diameter in patients older than 5 years and over 0.5cm in children younger than 5 years.
• The disorder can be very heterogenous, with members in the same family showing differing degress of severity.

Question 33

What is tuberculosis sclerosis?

Answer 33

• Tuberculosis sclerosis complex (TSC) is the 2nd most common neurocutaneous disease.
• TSC is inherited in an autosomal dominant pattern, although the rate of spontaneous mutation is high.
• Formerly characterised by the clinical triad of mental retardation, epilepsy, and facial angiofibromas, it is now recognised that patients with TSC may present with a broad range of clinical symptoms due to variable expressivity.

Question 34

Define global developmental delay.

Answer 34

• GDD is defined as a delay in 2 or more developmental domains of gross / fine motor, speech / language, cognition, social / personal and activities of daily living, affecting children under the age of 5.
• Considered significant when there is a deficit in performance at least 2SD below the age appropriate mean on accepted standardised assessment tests.
• Genetic and structural brain abnormalities are the most frequent cause.