Developmental milestones

developmental milestones in children

1. Dr.Azad A Haleem AL.Mezori MRCPCH,DCH, FIBMS Assistant Professor University Of Duhok College of Medicine Pediatrics Department [email protected] Developmental Milestones In Children

2. Growth & Development Growth refers to an increase in physical size of the whole body or any of its parts. It is simply a quantitative change in the child ’ s body. It can be measured in Kg, pounds, meters, inches, … .. Etc Development refers to a progressive increase in skill and capacity of function. It is a qualitative change in the child ’ s functioning. It can be measured through observation.

3. Developmental domins : Includes four areas: Gross Motor: sitting, walking, jumping, and overall large muscle movement Fine Motor: Eye hand coordination, manipulation of small objects, and problem solving Language (Expressive and Receptive): Hearing, understanding, and using language Cognitive/Social/Adaptive: Getting along with people and caring for personal needs

4. Important notes We will assess two ages; infant and older children. Be a good observer. during assessment of development: say ? 'Demonstrated' is better than 'can' or 'cannot'. It means that the parents cannot correct you? Remember you are only assessing the child over a few minutes. We will decide on today the child can not demonstrate? And not; he can not ?

5. TOOLS NEEDED: 1. Red yarn pom pom wool ball 2. Bright color cubes 3. Rattle with narrow handle 4. Raisins 5. Cup, spoon 6. A 4 size paper 7. Big size color pencils 7. Picture cards, multiple picture books (like bird, fish, dog, bus, fruits etc) on same page, 8. Tennis ball 9. Small doll 10. Bell 11. Stickers, sweets for rewards

6. vision and hearing Fine Motor language personal social Gross Motor examination Infants

7. Developmental domins : Include following areas: If child is on mum’s lap(most of the time) can do : -1 st vision and hearing, -2 nd Fine Motor, -3 rd language -4 th personal social, -5 th Gross Motor examination Do not separate for Gross Motor assessment. Bigger kids can examine on chair.

8. Vision Always do vision before hearing. Fixing and following pom pom ball or wool ball horizontally and vertically . Check ability to pick up cube. Approached to toys Observe: Wearing glasses. Conjugated eye gaze and eye contact. No rowing eye movement, No squint, No nystagmus

9. Hearing: Distraction test 6-18 months of age Use initial distraction with non noise making stimulus in front of child Always ask examiner to ring the bell at 20 cm from both ears Bell is brought towards ear from behind out of range from visual fields 20 cm away from ears. Changes noted are facial expression, vocalizing sounds, head turns.

10. Fine Motor Fine Motor: use toys ( rattle) See grasp and how he explore it? Look: move from one hand to another and mouthing. Small toy for pincer grasp. Pointing.

11. Fine Motor: Holds rattles (3 months), palmer grasp objects(5 mths ), transfer cubes(7 mths ), Raisins for pincer grip(9 mths ), blocks for stacking,: 2 cubes 15 months, 3 cubes(18 months) 6 cubes(21 months). 6 cubes, turn pages (2 yrs), 8 cubes (2.5 yrs), 9 cubes (3 years), beads, thread, putting on biro, plastic knife, and fork. Comment on personal social interaction, language. Smiling, waving

12. Language Language: any vocalization you heard Cooing. Babble. Responding to name. Mama and Baba; not understand. First word.

13. Speech and Language: Cooing ( 2mths), responds to human voice (4 mths ), Babbling (6mths), Mamma, dada (9mths), 2 words plus mama, dada(12 mths ), Jargon, points (15mths), 10 words and says his name, points to 3 body parts, one picture (18mths), 2-3 word phrase, name 3 objects, 4 body parts, says no(2 yrs), know name, age sex (2.5yrs), preposition, count 1-10, 2 colours (3 yrs), Name 3 colours, Converses (4 years)

14. Social Interaction with you and parents. Smiling. Laugh. Stranger awareness. Clapping , Bye bye . Give something and ask to return back.

15. Personal social Development Chronologically Focus on faces(4 weeks), social smile(6 weeks), excited with toys(4 months), stranger anxiety, (6 months), responds to No, imitates, (8 months), clapping, bye bye , bang blocks (10 months), picture books( 12 months), kiss mirror (13 months), points(15 months), Body parts(21 months)

16. 180 degree flip examination. Supine : Note posture, abnormal tone and power, involuntary movements with CP. paucity of movements for hemiplegia . Pull to sit : head lag. Sitting: Head and trunk control. Back is straight or rounded. Weight bearing : scissoring, hypotonia , advanced weight bearing (CP) Ventral suspension : Describe posture, low tone, increase extensor tone. Prone : Observe ability to raise head, trunk above horizontal, Gross Motor: posture & movement

17. GROSS MOTOR Head Hold (16 weeks), Tripod (6 months), Bear wt, lifts head(7 months) , sit well (8 months) pull to sit and stand, crawl (10months), Creep 11 months, walk with support (1 year), climb stairs with rail ,throw ball(18months), walk upstairs(21 months) up and down (2 years).

18. Gross Motor Fine Motor Language Cognitive/Social/Adaptive Older children

19. Developmental domins : Includes four areas: Gross Motor: sitting, walking, jumping, and overall large muscle movement Fine Motor: Eye hand coordination, manipulation of small objects, and problem solving Language (Expressive and Receptive): Hearing, understanding, and using language Cognitive/Social/Adaptive: Getting along with people and caring for personal needs

20. Walking , walk backward Running Jumping Standing on one foot. Tiptoe Ride tricycle and bicycle. Hope climbing stairs Skip Throwing and Kick ball. Gross Motor Sequence of approach to gross motor assessment: Walk → jump / hop → climb stairs → throw ball

21. Fine Motor Blocks & Cubes Book Papers & pencil: Threading beads. Using scissor buttons Sequence of approach to fine motor assessment build blocks → hold pen + scribble, → put pellets in bottle →Thread Beads →cut paper → buttons → colors in lines → fold paper

22. Language Call him by name and see response Ask what is your name, age, sex? Ask labelling of body parts Ask him to bring ball Counting. Birth day. Words and sentences. Vocabulary and understand.

23. Social & play Feeding: Drinking, Eating. Dressing. Self care: Out of nappy, Toilet, teeth brushing. Playing: alone, play with others, talking while playing, roles of games Age begins Type of play Interaction of play 18 mths functional play solitary play 2 yrs imitative play parallel play 2.5 yrs pretend play interactive play 3 yrs fantasy / symbolic play  

24. Important Milestones Domains   Development Receptive language 12 month responding to their name 18 mth - 2 yrs pointing to body parts, parents, pictures   12 - 18 mths 2 yrs following instructions 1 step: throw in the bin 2 step put this ball in box and bring shoes Expressive language (verbal & non verbal) 12 month 2 yo 3yo 4yo 5yo mama & papa, pointing to what they want linking words, naming 2 - cat, dog repeats 3 word phrases gives name & identifies colours name colours, self, fluent repeats 4 - 6 word phrases Social Emotional Self help (ASD) 3 - 6 mth 18 - 24 mth eye contact reciprocal play pretend play joint referencing, share interest Gross motor   - to test for GDD 12 - 18 mths 2 yr 3 yr 4 yr 5 yr walk walk sideways 2 steps, kick a ball stand on 1 foot, tiptoe 3 steps stand on 1 foot for 1 secs, tiptoe 4 steps hop 2 hops on 1 foots stand on 1 foot for 5 secs Fine motor   - to test for GDD 18 mths 2 yr 3 yr 4 yr 5 yr scribbles / line line / circle circle / cross copies square copies triange 3 blocks 6 blocks 9 blocks   Offer to test hearing Ask for f/h of delayed speech: more common in children with + ve f/h

25. Red Flag Age Missed Milestones Requiring Intervention 2 mo Lack of visual fixation No social smile 4–6 mo Fails to track person or object No steady head control No response/turn to sound or voice 6 mo Decrease/absence of vocalizations 9–12 mo Fails to sit independently 18 mo Fails to walk independently Does not seek shared attention to object/event with caregiver 24 mo No single words 36 mo No three word sentences Cannot follow simple commands >3 y Speech unintelligible Dependence on gestures to follow commands

26. In general: The single most common presenting concern was speech and language delay. The most common clinical developmental diagnosis was autism spectrum disorder. Global developmental delay. ADHD Learning Disabilities Cognitive impairment CP

27. Causes of developmental delay

28. Approach to child with Developmental Delay

29. History A good history is essential to help determine the cause and appropriate investigations. Information is required on Perinatal , Birth history, Gestational age, Post natal; HIE, CP , prematurity. Family history may give the strongest clue to a chromosomal disorder. Enquire about previous pregnancy losses. Presence of medical problems associated with Developmental Delay. Assess if any medical problems like Neurologic, myopathy , dystrophy , Genetic, syndromes particularly Fragile X, Prader willi Metabolic disorder Endocrine exclude Hypothyroidism

30. Examination A thorough examination is essential. Neurodegenerative conditions affecting the grey matter tend to present with dementia and seizures. Conditions affecting the white matter tend to present with spasticity, cortical deafness and blindness.

31. Inspect for: Sex of child- X-linked conditions such as fragile X, Menkes , Hunter, Lesch-Nyhan syndromes. Age of the child: First 6 months - Tay -Sachs disease, Leigh disease, infantile spasms, tuberose sclerosis Toddlers- infantile metachromatic leukodystrophy , mucopolysaccharidoses , infantile Gaucher , Krabbe disease Older children- juvenile Batten disease, SSPE, Wilson disease, Huntington chorea

32. Dysmorphic features - Down syndrome, mucopolysaccharidoses Neurocutaneous signs- ataxia telangiectasia , Sturge -Weber syndrome, incontinentia pigmenti , tuberose sclerosis Extrapyramidal movements- cerebral palsy, Wilson disease, Huntington chorea Tremor - Wilson disease, Friedreich's ataxia, metachromatic leukodystrophy Inspect for:

33. Note growth of child Large head -Alexander, Canavan , Tay -Sachs syndromes, mucopolysaccharidoses Small head- cerebral palsy, autosomal recessive microcephaly , Rubinstein- Taybi , Smith- Lemli - Opitz , Cornelia de Lange syndromes Growth pattern (e.g. faltering growth with metabolic disease, gigantism with Soto syndrome)

34. Systematic examination Eyes - corneal clouding, cataract, cherry-red spot, optic atrophy Neurological examination including gait, scoliosis, tremor, extrapyramidal movements, tone, power and reflexes of limbs Associated system involvement (e.g. cardiac abnormalities, organomegaly in metabolic disease) Genitalia Hearing and vision should be checked Further assessment often involves input from other professionals of the child development team, e.g. speech and language therapists and physiotherapist.

35. Investigations A thorough history and examination may lead to targeted investigations, e.g. a specific genetic test or metabolic test. For approximately 40% of cases no cause is found. The two most useful investigations are genetic studies and brain imaging.

36. If no specific diagnosis is suggested then consider: Blood tests Chromosomal analysis Thyroid function tests TORCH serology in infants (TORCH, toxoplasmosis, other (congenital syphilis and viruses), rubella, cytomegalovirus and herpes simplex virus) Plasma amino acids Ammonia Lactate White cell enzymes Investigations

37. Urine tests Urinary organic acids Urinary amino acids Urinary mucopolysaccharidoses Brain imaging This will identify congenital brain abnormalities and diagnose degenerative conditions such as the leukodystrophies and grey matter abnormalities. EEG This will identify SSPE, Batten disease Investigations

38. Management This is multidisciplinary . The precise make-up of the team depends on local resources. It can include: Community paediatrician Speech and language therapist Physiotherapist Occupational therapist Child psychologist/psychiatrist Play therapist Pre-school therapist, e.g. portage Nursery teachers Health visitors Social workers

39. THANKS FOR YOUR ATTENTION