Developmental assessment and screening

assessment by screening and survillance

1. Developmental assessment and screening PRESENTED BY Dr.Nasreen Ali GUIDED BY Dr.T.V.Ramkumar

2. CONTENT INTRODUCTION PRINCIPLES OF DEVELOPMENT GOALS OF DEVELOPMENTAL ASSESSMENT DIFFERENT DOMAINS OF DEVELOPMENT ASSESSMENT OF DEVELOPMENT SCREENING TESTS DEFINITIVE TESTS DEVELOPMENT QUOTIENT CONCLUSION (NORMAL DEVELOPMENTAL MILESTONES NOT DISCUSED).

3. INTRODUCTION DEVELOPMENT SPECIFIES MATURATION OF FUNCTIONS.IT IS RELATED TO MATURATION AND MYELINATION OF NERVOUS SYSTEM AND INDICATES ACQUISITION OF A VARIETY OF SKILLS FOR OPTIMUM FUNCTIONING OF THE INDIVIDUAL. DEVELOPMENTAL ASSESSMENT INCLUDES EARLY IDENTIFICATION OF PROBLEMS THROUGH SCREENING AND SURVILLANCE.

4. PRINCIPLES IT IS A CONTINUOUS PROCESS FROM CONCEPTION TO MATURITY DEVELOPMENT IS INTIMATELY RELATED TO THE MATURATION OF CENTRAL NERVOUS SYSTEM THE SEQUENCE OF DEVELOPMENT IS IDENTICAL IN ALL CHILDREN BUT THE RATE OF DEVELOPMENT VARIES FROM CHILD TO CHILD PROCESS OF DEVELOPMENT PROGRESSES IN A CEPHALO CAUDAL DIRECTION PRIMITIVE REFLEXES HAVE TO BE LOST INITIAL DISORGANIZED MASS ACTIVITY IS REPLACED BY SPECIFIC AND USEFUL ACTIONS

5. GOAL THE GOAL OF DEVELOPMENTAL ASSESSMENT IS NOT ONLY TO GENERATE A DIAGNOSIS BUT ALSO TO ANALYSE THE PATTERN OF STRENGTHS AND WEAKNESS IN ORDER TO DIRECT TREATMENT.

6. INDICATIONS OF DEVELOPMENTAL ASSESSMENT FOLLOW UP OF HIGH RISK NEONATES FOR EARLY DETECTION OF CEREBRAL PALSY AND\OR INTELLECTUAL DISABILITY COMPLETE EVALUATION OF CHILDREN WITH DEVELOPMENTAL,CHROMOSOMAL OR NEUROLOGICAL DISORDERS TO DIFFERNTIATE CHILDREN WITH RETARDATION IN SPECIFIC FIELDS OF DEVELOPMENT AS OPPOSED TO THOSE WITH GLOBAL RETARDATION

7. FACTORS AFFECTING DEVELOPMENT PROTECTIVE B REAST FEEDING MATER NAL EDU

8. Domains of development GROSS MOTOR FINE MOTOR PERSONAL AND SOCIAL LANGUAGE VISION HEARING

9. DEVELOPMENTAL ASSESSMENT

10. PROCEDURE DEVELOPMENTAL MILESTONES SERVE AS AN IMPORTANT BASIS OF MOST STANDARDIZED ASSESSMENT AND SCREENING TOOLS TWO SEPARATE DEVEVELOPMENTAL ASSESSMENT OVER TIME ARE MORE PRODUCTIVE THAN A SINGLE ONE

11. PREREQUISITES Should be done in a place free from distractions Child should not be – hungry, tired, ill or irritated Playful mood with mother around Adequate time to make child & family comfortable Carry a development kit

12. Equipment required Ten one inch cubes Hand bell Simple formboard Goddard formboard Coloured and uncoloured geometric forms Picture cards Cards with circle,cross,sqare,triangle and diamond drawn on them copying or imitation. Patellar hammer Paper Pellets(8mm ) Spoon

13. DEVELOPMENTAL HISTORY WHETHER PARENTS ARE CONCERNED OR NOT RIGHT QUESTIONS AGE SPECIFIC QUESTIONS CHECK DOUBTFUL REPLY CHECK THE ANSWERS ABOUT ONE MILESTONES BY ANOTHER AND BY EXAMINATION

14. FAMILY HISTORY -FIRST, SECOND AND THIRD DEGREE RELATIVE SOCIAL HISTORY -CAPACITY TO COPE WITH A CHILD WITH DISABILITY

15. ASSESSMENT OF NORMAL DEVELOPMENT PRE SCHOOL AGE- PLAY,CLIMBING STAIRS,SPEECH,FEEDING PERFORMANCE- understanding, matching colour COMPREHENSION OF LANGUAGE

16. ASSESSMENT OF NORMAL DEVELOPMENT SCHOOL AGE Test for reading ,arithmetic function Test for deafness and physical examination Vision by 3-5 years of age Intelligence assessment

17. PHYSICAL EXAMINATION GENERAL EXAMINATION - weight, height and head circumference, malnutrition ,pallor, rickets and dysmorphic facies SYSTEMIC EXAMINATION . BONES AND JOINTS -deformities and contracture NEURO MUSCULAR EXAMINATION IN INFANTS- tone, deep tendon reflex , primitive reflex and postural reflex.

18. Red flag signs:birth to 3 months Rolling prior to 3 months- EVALUATE FOR HYPERTONIA Persistent fisting for 3 months- NEUROMOTOR DYSFUNCTION Failure to alert to environmental stimuli-S ENSORY IMPAIREMENT

19. RED FLAGS FROM 4 TO 6 MONTHS Poor head control- HYPOTONIA Failure to reach for objects for 5 months-MOTOR,VISUAL OR COGNITIVE DEFECTS Absent smile-VISUAL LOSS,ATTACHMENT PROBLEMS,MAJOR MATERNAL DEPRESSION,CHILD ABUSE OR NEGLECT

20. RED FLAG 6 TO 12 MONTHS Persistence of primitive reflex after 6 months-NEUROMUSCULAR DISORDER Absent babbling for 6 months- HEARING DEFECT Absent stranger anxiety by 7 months- MULTIPLE CARE PROVIDERS Inability to localize sound by 10 months-UNILATERAL HEARING LOSS Persistent mouthing of object by 12 months-LACK OF INTELLECTUAL CURIOSITY

21. RED FLAG 12 TO 24 MONTHS Lack of consonant production by 15 months- MILD HEARING LOSS Lack of imitation by 16 months- HEARING OR COGNITIVE OR SOCIALIZATION DEFECT Hand dominance prior to 18 months- C/L WEAKNESS WITH HEMIPARESIS Inability to walk up and downstairs by 24 month-LACK OF OPPPORTUNITY MORE THAN MOTOR DEFICIT

22. NEUROLOGICAL EXAMINATION AMIEL TISONS ANGLES- - Adductor angle Heel to ear Popliteal angle Dorsiflexion angle of foot Scarf sign

23. Neurological assessment ANGLES 1-3 MONTHS 4-6 MONTHS 7-9 MONTHS 10-12 MONTHS ADDUCTOR 40-80 70-110 100-150 130-150 HEEL TO EAR 80-100 90-130 120-150 140-170 POPLITEAL 80-100 90-130 120-150 140-170 DORSI FLEXION 45 45 45 45 SCARF SIGN ELBOW NOT CROSS MIDLINE ELBOW CROSS MIDLINE ELBOW REACHES AXILLA ELBOW BEYOND AXILLA

24. ASSESSMENT OF GROSS MOTOR DEVELOPMENT The acquisition of gross motor skills precedes the development of fine motor skills Both process occur in cephalocaudal fashion -head control precedes arm and hand control -followed by leg and foot control

25. Play and social interaction Observe exploration and free play and initiation of response to social games like peek a boo Note initiating interaction and responding to parent/examiner/other children and use of eye contact and gestures

26. Test cognitive and adaptive milestones Object permanence Causality Imitation Colour and shape recognization Language mainly receptive Fine motor

27. Language and communication Observe vocalization and gestures to attract others attention, to indicate needs . in response to others vocalization and to share emotion Note speech quality ,use of language to express and responding to conversation

28. Hearing development 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

29. Assessment of 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

30. screening It is a brief assessment procedure designed to identify children who should receive more intensive diagnosis or assessment. TYPES- Informal screening Routine formal screening Focused screening-more important in high risk infants.

31. Why Screening? To aid early intervention services. Early identification of early co-morbid development disabilities. It follows a standardized form. Advantages More accurate than informal clinical impressions. They reinforce importance of development to the caregiver. Efficient way to record observations.

32. Limitations of screening The assessors need some training in following the instructions and appropriate scoring. It cannot be used to make diagnosis. One cannot stop with screening.

33. Reasons for not practicing development screening in India Parents are unaware of its existence Health care seeking is prioritized for acute illness which is not an accurate opportunity for screening If parents express concerns they are given false assurance Lack of such services to provide appropriate screening and treatment.

34. SELECTION OF A TOOL PSYCHOMETRICS : sensitivity and specificity should be atleast 70-80% Time\staffing required Cost Parent completed vs directly administered Cultural and linguistic sensitivity

35. Screening tests for Indian infants Phatak`s Baroda screening test: by Clinical psychologists. Dr. Promila Phatak . Indian adaptation of Bayley`s development scale. Trivandrum Development screening test. ICMR scales Denver II (0-60 months) Good Enough Harris Drawing test (4-14yrs) Goddard formbards (3-8 yrs) CAT/CLAMS (clinical adaptive test/clinical linguistic and auditory milestone scale) NIMHANS Bengaloru learning disability test (2002): 5-15 yrs 1,2,3: 0-30 months

36. Comparison of Developmental Screening Tools of International Origin

37. Factors Denver DevelopmentalScreening Test  II Bayley Infant Neuro -developmental Screen  (BINS) Parents Evaluation of Developmental Status (PEDS) Ages and stages questionnaire (ASQ)  Developmental* Profile II/ III  AGE FORMAT 0-6 years Directly administered 3-24  month Directly administered 0-8 years Parent-report 1 -66  /3- 66 m Parent report 0-9 y/ 12 y11m Parent report    SCREENS\DOMAINS Expressive & receptive,language , gross motor, fine motor, personal,social Neurological processes, expressive and receptive functions& cognitive Cognitive, expressive&  receptive language fine &  gross motor, social-emotional, behavior, self-help& school Communication, gross motor, fine motor,problem -solving, andpersonal adaptive skills Physical, Self-help/   Adaptive, Social/Social- emotional,Academic / cognitiveand Communication    ITEMS 125 11-13 10 22-36 186\180 SCORING\RESULT Normal\abnormal\questionable High/low/moderate Low /medium/high Pass/fail Total score gives domain wise age equivalents

38. TIME(min) 10-20 10 2-10 10-15 10/20-40 LANGUAGE English/ spanish English english English/ hindi english PSYCHOMETRIC PROPERTIES sensitivity- 0.56-0.83 0.75-0.86 Specificity- 0.43-0.80 0.75-0.86 0.74-0.79 0.70-0.80 0.70-0.90 0.76-0.91 Validity coefficients 0.52-0.72 VALIDATED IN INDIA NOT NOT SN 62% SP 65% 83.3% 74.5% NOT Used extensively COST$ 111 325 30 249 240 Factors Denver DevelopmentalScreening Test  II Bayley Infant Neuro -developmental Screen  (BINS) Parents Evaluation of Developmental Status (PEDS) Ages and stages questionnaire (ASQ)  Developmental* Profile II/ III 

39. Comparison of Indian Developmental Screening Tools

40. FACTORS BARODA DEVELOPMENTAL SCREENING TEST(BDST) TRIVANDRUM DEVELOPMENTAL SCREENING CHART(TDSC) ICMR PSYCHOSOCIAL DEVELOPMENTAL SCREENING TEST DEVELOPED FROM BAYLEY SCALE OF INFANT DEVELOPMENT,NORMATIVE DATA FROM INDIAN CHILDREN BAYLEY SCALE OF INFANT DEVELOPMENT(BARODA NORMS) PROGRAMME FOR ESTIMATING AGE RELATED CENTILES USING PIECE WISE POLYNOMIALS AGE 0-30 MONTHS 0-24 MONTHS 0-6 YEARS FORMAT 54 ITEMS 17 ITEMS PARENTS INTERVIEW 64 ITEMS DOMAINS MOTOR AND COGNITIVE MENTAL AND MOTOR GROSS MOTOR.VISION,HEARING,FINE MOTOR AND SOCIAL SKILLS

41. SCORING/RESULTS AGE EQUIVALENT AND DEVELOPMENT QUOTIENT CALCULATED WITHIN AGE RANGE 3 RD ,5 TH ,25 TH ,50 TH, 75TH,95 TH AND 97 TH CENTILE.SIGNIFICANT DELAY IN <3 RD CENTILE(2SD) TRAINING MINIMAL MINIMAL NONE SETTING COMMUNITY/OFFICE COMMUNITY/OFFICE COMMUNITY/OFFICE TIME TAKEN(MIN) 10 10 MINIMAL PSYCHOMETRIC PROPERTIES SN-65-93% SP-77.4-94.4% 66.8% 78.8% NOT GIVEN COST INEXPENSIVE INEXPENSIVE FREE FACTORS BARODA DEVELOPMENTAL SCREENING TEST(BDST) TRIVANDRUM DEVELOPMENTAL SCREENING CHART(TDSC) ICMR PSYCHOSOCIAL DEVELOPMENTAL SCREENING TEST

42. DEVELOPMENTAL SCREENING TOOLS OF FUTURE GUIDE FOR MONITORING CHILD DEVELOPMENT(GMCD) -parents report 0-3.5 years Developed in turkey 7 items 5-10 min Sensitivity-86 & specificity-93 A 5 year project is underway in India,Turkey,Argentina and South Africa since 2010 Aim is to standardize GMCD for universal use

43. INCLEN NEURODEVELOPMENTAL SCREENING TEST(NDST)- Developed by neuro -developmental experts of india and abroad Screens 10 neuro developmental disorders Autism Spectrum Disorders, Learning Disorder, Attention Deficit and Hyperactivity Disorder, Vision Impairment, Hearing Impairment, Intellectual Disability, Speech and Language Disorders, Epilepsy, Cerebral Palsy and other Neuro -Muscular Disorders. Diagnostic criteria (Consensus Clinical Criteria) have been developed for establishing each diagnosis which are sequentially applied according to an algorithm when the screening test is positive

44. Birth to one year DEVELOPMENTAL OBSERVATION CARD Completed 2 months-social smile Completed 4 months-holds head steady Completed 8 months-sits alone Completed 12 months-stands alone

45. Birth to two years TRIVANDRUM DEVELOPMENTAL SCREENING CHART Can be used in large scale community by anganwadi workers

46. Trivandrum development screening chart 3% 97%

47. Two to four years DEVELOPMENTAL ASSESSEMENT TOOLS FOR ANGANWADI(DATA) BRIEF,SIMPLE AND PSYCHOMETRICALLY STRONG FOR ANGANWADI TO DIFFERENTIATE THOSE WHO ALREADY HAVE DELAYS AT 2.5 YEARSFROM THOSE WHO ARE AT RISK OF DEVELOPMENTAL DELAY REGULAR DEVELOPMENTAL ASSESSMENT AT 3.5YRS,4.5YRS

48. FOUR TO SIX YEARS NURSERY EVALUATION SCALE TRIVANDRUM(NEST)-ABRIDGED This tool has been developed and validated at Child Development Centre, Thiruvananthapuram , Kerala. It is a functional assessment of pre-school children between 4 – 6 years. It is a guideline to pre-school teachers as to the individual child’s holistic development. It serves as a screening tool to identify pre-school children who needs one-to-one instructions. 

49. DENVER DEVELOPMENTAL SREENING TEST 2 Assessment of infant and pre school children 125 items 4 categories-gross motor\fine motor or adaptive\language\personal or social Items are arranged in chronological order according to the ages at which most children pass them Performance rated as PASS\CAUTION\DELAY

50. DEVELOPMENTAL ASSESSMENT SCALE FOR INDIAN INFANTS Gold standard for developmental evaluation Two scales-mental and motor scale Mental development index –MDI Psychomotor development index -PDI

51. DEFINITIVE TESTS If screening tests or clinical assessment are abnormal Some common scales Bayley scale for infant development II Wechsler intelligence scale for children IV and Wechsler preschool and primary scale of intelligence ( indian version: Dr. Mahendrika Bhatt) Stanford- Binet intelligence scales , 5 th editn. Developmental Activities Screening Inventory

52. STANFORD-BINNET INTELLIGENCE SCALE Intelligence testing for ages 2-23 years and beyond Yields intelligence quotient(IQ) Scoring- standardized scoring Composite mean 100 with SD 16 INTERPRETATION- Boderline ID-70-79 Mild ID-65-69 Moderate ID-40-64 Severe ID-30-39 Profound<30

53. Wechsler intelligence scale DESCRIPTION Intelligence testing Mean score-100 with SD 15 Gives verbal and performance score Broken into subsets each with a mean of 10 AGE SPECIFIC WECHLER TEST Wechsler preschool primary scale intelligence(WPPSI-R)-3-7 YEARS Wechsler intelligence scale for children(WISC 3)-6-16 YEARS Wechsler adult intelligence scale(WAIS-R)->16 YEARS

54. DEVELOPMENTAL ACTIVITIES SCREENING INVENTORY SECOND EDITION-DASI 2 Age range in years-birth to 5 years Method of administration/format- Individually administered informal screening measure,may be presented as non-verbal test 67 tests Yield development quotient Time -25-30 min Sub scales -developmental quotient

55. Developmental quotient DQ= developmental age\chronological age*100 For The infants who were born prematurely should the chronological age should be corrected during the gestational age till 2yrs of life Interpretation- >=85-normal 71-84-mild to moderate <=70-severe delay

56. THERE SHOULD BE A CHILD DEVELOPMENT AND EARLY INTERVENTIONAL CLINIC- CDEIC

57. DEIC District early intervention centres Interdisciplinary approach NHM

58. Conclusion IAP group

59. Thank you