development and its assessment for skills.pptx

Development

1. DEVELOPMENT AND ITS ASSESSMENT

2. Introduction Development refers to maturation of functions and acquisition of various skills for optimal functioning of an individual. The maturation and myelination of the nervous system is reflected in the sequential attainment of developmental milestones.

3. Rules of Development Development is CONTINEOUS process, starting in UTERO and progressing in an orderly manner until maturity. The child has to go through many developmental stages before a milestone is achieved. Development depends on functional maturation of nervous system. Manturity of the central nervous system is essential for a child to learn a particular milestone or skill, no amount of practice can make a child learn new skills in its absence. However, in absence of practice, the child may be unable to learn skills despite neural maturation.

4. The sequence of attainment of milestones is the same in all children. All infants babble before they speak in words and sit before they stand. Variations may exist in the time and manner of their attainment. The process of development progresses in a cephalocaudal direction. Head control precedes trunk control, which precedes ability to use lower limbs. The control of limbs proceeds in a proximal to distal manner, such that hand use is learnt before control over fingers.

5. Certain primitive reflexes have to be lost before relevant milestones are attained. palmar grasp is lost before voluntary grasp is attained and the asymmetric tonic neck reflex has to disappear to allow the child to turnover. The initial disorganized mass activity is gradually replaced by specific actions. Hence, when shown a bright toy, a 3-4-month-old squeals loudly and excitedly moves all limbs, whereas a 3-4-year-old may Just ask for it.

6. Factors Affecting Development Prenatal Factors Genetic factors: Intelligence of parents has direct correlation on the IQ of the child. Moreover certain developmental patterns are observed to follow parental patterns like speech. There are numerous genetic causes such as chromosomal abnormalities ( Down syndrome), X-linked mental retardation, subtelomeric deletions, single gene disorders causing disorders of brain formation (lissencephaly) and other metabolic disorders (phenylketonuria) for developmental delay and subsequent mental retardation(MR)

7. Maternal factors: Maternal nutrition: : Maternal malnutrition has adverse effect on birth weight and child development. Studies from developing countries suggest thay nutrition supplements have positive Impact on birlh weight as well as child development. Exposure to drugs and toxins: Various drugs and toxins such as maternal drug or alcohol abuse, antiepilcptic drugs and environmental toxins can have adverse effect on chlld development.

8. 3) Maternal disease and infection: Pregnancy induced hypertension, hypothyroidism, malnutrition and fetoplacental insufficiency due to any cause. Acquired infections (e.g. syphilis, toxoplasmosis, AIDS, rubella, CMV, herpes) can have a severe impact on fetal physical and brain growth. Exposure to free radicals and oxidants in utero (e.g. chorioamnionitis) has been incriminated in the causation of cerebral palsy and developmental impairment.

9. Neonatal Risk Factors Intrauterine growth restriction :Intrauterine growth restriction (IUGR) indicates constraints in fetal nutrition during a crucial period for brain development. In developing countries, intrauterine growth restriction is mainly due to poor maternal nutrition and infections. Studies have shown that IUGR infants are disadvantaged compared to their normal birth weight counterparts in terms of short-term as well as longterm neurocognitive development. Prematurity : Babies born before 37 weeks of gestation are more likely to have developmental impairment compared to term counterparts with babies born before 32 weeks gestation being at the highest risk. Premature babies are at risk due to complications, including intracranial bleed, white matter injury, hypoxia, hyperbilirubinemia and hypoglycemia.

10. 3) Perinatal asphyxia: Significant asphyxia occurs in approximately 2% of total births. Studies have indicated that over 40% of survivors of significant asphyxia suffer from major neurocognitive disabilities

11. Postneonatal Factors Infant and child nutrition: Severe calorie deficiency, as evident by stunting, is associated with apathy, depressed affect, decreased play and activities and insecure attachment. Calorie deficiency is often associated with deficiency of multiple micronutrients and vitamins (including zinc, vitamins A, B12, D, E, riboflavin and iodine) that contribute to developmental impairment. Iron deficiency: Iron deficiency has been shown to be associated with electrophysiological evidence of delayed brain maturation, poorer cognitive, motor and socialemotional development in infancy and early childhood

12. 3. Iodine deficiency: Iodine is a constituent of thyroid hormones, which affect central nervous system development and regulate many physiological processes. Iodine deficiency can lead to congenital hypothyroidism and irreversible mental retardation, making it the most common preventable cause of mental retardation. 4. Infectious diseases: A variety of infectious morbidities such as diarrhea, malaria, other parasitic infections and HIV are associated with poorer neurodevelopment.

13. 5. Environmental toxins: Children exposed to environmental toxins (lead, arsenic, pesticides, mercury and polycyclic aromatic hydrocarbons) prenatally through maternal exposure and postnatally through breast milk, food, water, house dust, or soil can have adverse influence on their neurocognitive development. 6. Acquired insults to brain: Traumatic or infectious insults (meningitis, encephalitis, cerebral malaria) and other factors (near drowning, trauma), particularly during early years of life, can have a permanent adverse effect on brain development. 7. Associated impairments Impairments : particularly those involving sensory inputs from the eyes or ears can have a significant impact on attainment of milestones. These impairments have to be actively sought in any child with delay as they offer opportunity for intervention.

14. Psychosocial Factors During the critical period of development and learning, several social factors have an important bearing on not only cognition but also attitudes, social-emotional competence and sensorimotor development. 1 Parenting: Cognitive stimulation, caregiver's sensitivity and affection and responsiveness to the child in the setting of other factors such as poverty, cultural values and practices have an important bearing on child development.

15. 2. Poverty: This is possibly the most common underlying factor for impaired child development worldwide. 3. Lack of stimulation: Social and emotional deprivation and lack of adequate interaction and stimulation is an important cause of developmental impairment, particularly evident in the setting of poverty. 4. Violence and abuse: Child abuse, physical and sexual, can have a profound psychological effect on the child. Problems of attention and cognition are more common in children exposed to violence or abuse. 5. Maternal depression: Low to middle income countries have a high incidence of maternal depressive symptoms, which is negatively associated with early child development and quality of parenting by virtue of unresponsive caregiving.

16. 6. Institutionalization: Institutional care (e.g. orphanages) during early life increases the risk of poor growth, illhealth , attachment disorders, attention disorders, poor cognitive function, anxiety, and autistic-like behavior.

17. Protective Factors Breastfeeding Maternal education

18. Domains of Development i . Gross motor development ii. Fine motor skill development iii. Personal and social development and general understanding iv. Language v. Vision and hearing

19. Gross Motor Development Supine and pull to sit The infant is observed in supine and then gently pulled to sitting position. Control of head and curvature of the spine is observed

20. Ventral suspension The child is held in prone position and then lifted from the couch, with the examiner supporting the chest and abdomen of the child with the palm of his hand. Up to 4 weeks of age, the head flops down. At 6 weeks, the child momentarily holds head in the horizontal plane and by 8 weeks, he can maintain this position well. By 12 weeks, he can lift his head above the horizontal plane

21. Prone position At birth or within a few days, the newborn turns the head to one side. At 2 weeks, the baby lies on the bed with high pelvis and knees drawn up. At 4 weeks, the infant lifts the chin up momentarily in the midline. The infant lies with flat pelvis and extended hips at 6 weeks. By 8 weeks, face is lifted up at 45° and by 12 weeks, the child can bear weight on forearms with chin and shoulder off the couch and face at 45°. At 6 months, he can lift his head and greater part of the chest while supporting weight on the extended arms.

22. Sitting: By the age of 5 months, the child can sit steadily with support of pillows or the examiner's hands. At first the back is rounded but gradually it straightens. He independently sits with his arms forward for support (tripod or truly 'sitting with support') by the age of 6-7 months. Steady sitting without any support generally develops at around 8 months.

23. Standing and walking: By 6 months, the child can bear almost all his weight when made to stand. At 9 months, the child begins to stand holding onto furniture and pulls himself to standing position. By 10 and 11 months, the child starts cruising around furniture. At about 12-13 months the child can stand independently and can walk with one hand held. 13 and 15 months the child starts walking independently. Runs by 18 months and at this age he can crawl up or down stairs and pulls a doll or wheeled toy along the floor. 2 yr , the child can also walk backwards, He can climbs upstairs with both feet on one step. 3 yr he can climb upstairs with one foot per step and by 4 yr he can move down the stairs in the same fashion. can ride a tricycle at 3 yr. can hop at 4 yr and skip at 5 yr

24. Fine Motor Development Hand eye coordination: Between 12 and 20 weeks, the child observes his own hands very intently, this is called hand regard. Its persistence after 20 weeks is considered abnormal. At 3 to 4 months, hands of the child come together in midline as he plays. If a red ring is dangled in front of him, he fixes his attention on it, and then tries to reach for it. Initially he may overshoot but eventually he gets it and brings it to his mouth.

25. Grasp is best assessed by offering a red cube to the child. A 6-month-old infant reaches and holds the cube (larger object) in a crude manner using the ulnar aspect of his hand. He can transfer objects from one hand to other by 6-7 months. The child is able to grasp from the radial side of hand at 8--9 months. By the age of 1 yr mature grasp (index finger and thumb) is evident by offering pellets (smaller object), finer hand skills are assessed. By 9-10 months, the child approaches the pellet by an index finger and lifts it using finger thumb apposition, termed 'pincer' grasp.

26. Hand-to-mouth coordination: At 6 months, as the ability to chew develops, the child can take a biscuit to his mouth and chew. At this age, he tends to mouth all objects offered to him. This tendency abates by around 1 yr of age. By this age, he tries to feed self from a cup but spills some of the contents. By 15 months, the child can pick up a cup and drink from it without much spilling. By 18 months, he can feed himself well using a spoon.

27. Advanced hand skills: With advancing age, the child can use hands to perform finer activities. Much of the advanced skills depend partly on the opportunity given by the caretakers to the child. At around 15 months, he turns 2-3 pages of a book at a time and scribbles on a paper if given a pencil (. By 18 months, he can build a tower of 2-3 cubes and draw a stroke with pencil. By 2 yr , he can unscrew lids and turn door knobs and his block skills also advance. He now draws a circular stroke. He now can turn pages of a book, one at a time. Drawing and block skills at various ages are shown in fig. In general copying of the skill comes 6 months after imitating the skills (doing it while seeing)

28. Dressing: Between 18 and 30 months of age, children are very eager to learn dressing skills. Undressing being easier, is learned before dressing. At 1 yr the child starts to pull off mittens, caps and socks. At around 18 months, he can unzip, but fumbles with buttons. By 2 yr , he can put on shoes or socks and can undress completely. By 3 yr , he can dress and undress fully, if helped with buttons. By 5 yr , he can tie his shoelaces as well.

29. Personal and Social Development and General Understanding

30. Hearing BERA hearing test done at birth Ability to hear correlates with ability to pronounce words properly Ask about the h/o otitis media Repeat hearing screening test  Speech therapist if needed

31. Vision New born-Follows red ring through 45* 4 weeks-Follows red ring through 90* 3 months--Follows red ring through 180* 4months- Follows red ring through 360* 3-5months-hand regard 5 months-excitement to see food being prepared

32. Developmental Assessment Developmental delay is estimated to be present in about 10% of children. It is possible to recognize severe developmental disorders early in infancy. Speech impairment, hyperactivity and emotional disturbances are often not detected until the child is 3-4 yr old. Learning disabilities are not picked up until the child starts schooling.

33. Prerequisites: The development assessment should be assessed in a place which is free from distractions. It is important that the child should not be hungry, tired, ill or irritated at time of development assessment. It would be desirable to assess him when he is in a playful mood with his mother around. Observation for alertness, concentration and skills of the child is an integral part of assessment carry a development kit.

34. Equipment for development assessment A red ring (diameter 6-7 cm) tied to a string Nine red cubes Paper pellets Spoon Cup with handle A book with thick pages Picture book Red pencil, paper Doll and mirror

35. Steps of assessment History: A detailed history is the starting point for any development assessment. well taken history will help in ( i ) determining the details of probable risk factors affecting development, (ii) evaluation of rate of acquisition of skills and differentiating between delay and regression, and (iii) forming a gross impression about the development age of the child. This helps to choose the appropriate tools for further evaluation and confirmation.

36. Examination: This should be done to assess physical growth and head circumference, (ii) do a physical assessment, particularly for dysmorphism, stigmata of intrauterine infections and signs of hypothyroidism, (iii) screen for vision and hearing, and (iv) conduct neurological examination and examine for primitive reflexes (if required).

37. The annoying maneuvers, including assessment of reflexes, head circumference, ventral suspension and pull to sit should be done at the end. It is preferable to perform the developmental assessment before the systemic examination so that the child's cooperation is solicited

38. By the end of the evaluation one should be able to arrive at a conclusion whether the neurological status and cognitive status are within normal range or not. Significant delays on screening is an indication for a detailed formal assessment of development status. By assessment, one can assign developmental quotient (DQ) for any developmental sphere. It is calculated as: DQ= ((developmental age) / (chronological age)) * 100

39. A DQ below 70% is taken as delay and warrants detailed evaluation. To obtain a DQ of a child, a formal assessment by an individual trained in developmental assessment using appropriate tools/ tests is needed. IQ tests mainly assess the cognitive/adaptive behavior part of the development. The age at which a particular test can be applied depends on the test items. However, in younger children (<5yr), it is more meaningful to have a global assessment of abilities; hence DQ testing is more comprehensive. Specific IQ tests (Stanford-Binet intelligence scales) are available to asses IQ starting from 2 yr of age.

40. Interpretation In babies born preterm, corrected age rather than postnatal age is used for determining developmental status till two years of age. For example, a child born at 32 weeks gestation (gestational age) seen at 12 weeks of age (postnatal age) should be considered as a 4-week-old (corrected age) child for development assessment.

41. While drawing any conclusions about development, one should remember the wide variations in normality. For example, let us consider the milestone of standing alone. The average age for attainment of this milestone in a WHO survey was 10.8 months (Fig. 3.42). However, the 3rd and 97th centiles for normal children were 7.7 and 15.2 months, respectively. The same is true for many other milestones as is shown in Fig. 3.42. The bars illustrate the age range for normal children to attain that particular milestone. This range of normalcy should always be kept in mind while assessing development

42. Retardation should not be diagnosed or suggested on a single feature. Repeat examination is desirable in any child who does not have a gross delay. Factors such as recent illness, significant malnutrition, emotional deprivation, slow maturation, sensory deficits and neuromuscular disorders should always be taken into account. One should keep in mind the opportunities provided to the child to achieve that milestone. For example, a child who has not been allowed to move around on the ground sufficiently by the apprehensive parents may have delay in gross motor skills.

43. At times, there can be significant variations in attainment of milestones in individual fields, this is called dissociation. For example, a 1-yr-old child who speaks 2-3 words with meaning and has finger thumb opposition (10-12 months), may not be able to stand with support (less than 10 months). Such children require evaluation for physical disorder affecting a particular domain of development. A child having normal development in all domains except language may have hearing deficit.

44. Development Screening Tests It also provides an opportunity for early identification of comorbid developmental disabilities Ideally, all children should be periodically screened but short of this, at least those with perinatal risk factors should be screened

45. Developmental Sucreening Child development is a dynamic process and difficult to quantitate by one time assessment. . Periodic screening helps to detect emerging disabilities as the child grows. However, using clinical judgment alone has a potential for bias and it has been suggested to use periodic screening tools for ongoing developmental surveillance. The physician should choose a standardized developmental screening tool that is practical and easy to use in office setting Screening tests popular in the west include Parents' Evaluations of Development Status (PEDS) and Ages and Stages Questionnaires (ASQ)

46. screening tools used in India Phatak's Baroda screening test: This is India's best known development testing system that was developed by Dr Promila Phatak . It is meant to be used by child psychologists rather than physicians. It is the Indian adaptation of Bayley's development scale and is applied to children up to 30 months. It requires several testing tools and objects that are arranged according to age. The kit is available commercially.

47. Denver development screening test The revised Denver development screening test (DOST) or Denver II assesses child development in four domains, i.e. gross motor, fine motor adaptive, language and personal social behavior, which are presented as age norms, just like physical growth curves.

48. Trivandrum development screening: chart This simplified adaptation of the Baroda development screening system is applicable to children up to 2 yr of age. It consists of 17 items selected from Bayley Scale of infant development (BSID) and Baroda tests. It is a simple test that can be administered in 5 min by a health worker, and is useful as a mass screening test.

49. Clinical adaptive test and clinical linguistic and auditory milestone scale (CAT/CLAMS): This easy to learn scale can be used to assess the child's cognitive and language skills. It uses parental report and direct testing of the child's skills. It is used at ages of 0-36 months and takes 10-20 min to apply. It is useful in discriminating children with mental retardation (i.e. both language and visual motor delay) and those with communication disorders (low language scores)

50. Goodenough-Harris drawing test: This simple nonverbal intelligence test requires only a pencil or pen and white unlined paper. Here the child is asked to draw a man in the best possible manner and points are given for each detail that the child draws. One can determine the mental age by comparing scores obtained with normative sample. This test allows a quick but rough estimate of a child's intelligence, and is useful as a group screening tool.

51. Definitive Tests These tests are required once screening tests or clinical assessment is abnormal. They are primarily aimed to accurately define the impairments in both degree and sphere. For example, by giving scores for verbal, performance abilities and personal and social skills, these can be differentially quantified.

52. • Bayley Scales of Infant Development • Wechsler Intelligence Scale for children IV • Stanford-Binet Intelligence Scale 5th edition • Vineland adaptive behaviour scale II • Developmental activities screening inventory 2nd edition

53. Bayley Scales of Infant and Toddler DevelopmentThird Edition (Bayley-III) Age Range (in years) - Birth to3.5 years Method of Administration/Format Individually administered in play-based format for Cognitive, Language , and Motor Scales; caregiver questionnaire for Social-Emotional and Adaptive Functioning. Yields scaled scores, composite scores, and percentile ranks. Approximate Time to Administer – 50 min. for 1-12 mos.; 90 min. for 13-42 mos. Subscales Cognitive; Language (Receptive, Expressive, Total); Motor (Fine-Motor, Gross-Motor, Total); Social-Emotional; Adaptive Behavior (Communication, Community Use, Functional Pre-Academics, Home Living, Health & Safety, Leisure, Self-Care, Self-Direction, Social, Motor, Total)

54. Stanford-Binet Intelligence Scale • Description – Intelligence Testing of ages 2 to 23 years and beyond – Yields Intelligence Quotient (IQ) • Scoring – Standardized Scoring – Composite mean of 100 with standard deviation of 16 • Interpretation: • Mental Retardation IQ Definitions – Borderline mental retardation: 70 -79 – Mild mental retardation: 65-69 – Moderate mental retardation: 40-54 – Severe mental retardation: 30-39 – Profound mental retardation: <30

55. Wechsler Intelligence Scale Description – Intelligence Testing – Mean score of 100 with standard deviation of 15 – Gives verbal and performance scores – Broken into subtests each with a mean of 10 • Age specific Wechsler tests – Wechsler Preschool Primary Scale Intelligence (WPPSI-R) • Used for ages 3 to 7 years – Wechsler Intelligence Scale for Children (WISCIII) • Used for ages 6 to 16 years – Wechsler Adult Intelligence Scale (WAIS-R) • Used for ages 16 years and older

56. Vineland adaptive behavior scale II Age Range (in years)- Birth - 89 years • Method of Administration/Format Measures personal and social skills in 4 domains (communication, daily living skills, socialization and motor skills) • Approximate Time to Administer -30-60 min

57. Early Stimulation Infants who show suspected or early signs of development delay need to be provided opportunities that promote body control, and acquisition psychosocial of motor skills, language development and psychosocial maturity. these inputs, termed early stimulation, include measures such as making additional efforts to make the child sit or walk, giving toys to manipulate, playing with the child, showing objects, speaking to the child and encouraging him to speak and prompting the child to interact with others, etc

58. There is a general lack of evidence for effectiveness of these early interventions in improving neurodevelopmental outcome and motor abilities. However, studies in premature babies, cerebral palsy, institutionalized children and other children at high risk for adverse neurodevelopmental outcomes suggest that these interventions are effective if started early. Compliance to interventions is important for favorable results on neurodevelopment. Systematic reviews suggest that the effect of these interventions is sustained in later childhood. For example, play and reading were effective in early childhood in lowand middle-income countries, and kangaroo mother care was effective for low birth weight babies in resource poor settings.

59. Promoting Development by Effective Parenting Comprehensive care to children requires focus on preventive efforts including child-rearing information to parents. Parenting has an immense impact on emotional, social and cognitive development and also plays a role in the later occurrence of mental illness, educational failure and criminal behavior. Creating the right conditions for early childhood development is likely to be more effective and less costly than addressing problems at a later age.

60. Television Viewing and Development Television viewing in younger children has been shown to retard language development. It is a passive mode of entertainment and impairs children's ability to learn and read, and also limits creativity. Children can pick up inappropriate language and habits by watching TV shows and commercials. Violence and sexuality on television can have a lasting impact on the child's mind. Parents need to regulate both the quantity and quality of TV viewing, limiting the time to 1-2 hr per day and ensuring that the content they see is useful

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