Developmental Delay - Tutorial

Question 1

When is development normal?

Answer 1

• When within 2 standard deviations from mean

Question 2

4 main domains of development

Answer 2

• Gross motor
• Fine motor
• Speech and language
• Social and self care

Question 3

Normal patterns of delay in development

Answer 3

• Can be late talking or walking if family history
• Language development may seem delayed at first in children of bilingual families - count total words in both languages
• Black and indian ethnicity infants more likely to have advanced motor skills

Question 4

What affects development? - groups

Answer 4

Nature (biological) and nurture (environmental)
Biological split into ante, peri and post natal

Question 5

Biological factors affecting development

Answer 5

• Genetic disorders

Antenatal - zygotes to delivery
* Early maternal infections - rubella, toxoplasma, CMV - TORCH
* Late maternal - varicella, malaria, HIV
* Toxins - alcohol, pesticides, radiation, smoking
* Drugs - eg cytotoxics, antiepileptics

Perinatal:
* Hypoxic ishcaemic encephalopathy

Post natal:
* Infections - meningitis, encephalitis
* Toxins - lead, mercury
* Trauma inc head injury
* Malnutrition
* Hypothyroidism

Question 6

Environmental factors affecting development

Answer 6

• Poverty
• Child neglect
• DV
• Low maternal education
• Parental MH issues
• Poor parental skills
• Disadvantaged neighbourhood

Question 7

Define developmental delay

Answer 7

• Two or more standard deviations away from mean on age appropriate standardised norm

Question 8

Types of developmental delay

Answer 8

• Isolated - just one area affected
• Global - 2 or more areas affected
• Learning disability - more than 5 years old, intellectual ability affected
• Specific learning difficulties - if more than 5 years old - dyslexia, dyspraxia, dyscalculia

No developmental delay if older than 5 years - changes name

Question 9

Why is identifying developmental delay important?

Answer 9

• Improves outcomes if picked up earlier
• Provide support
• Genetic counselling
• Prevent problems with social adaptation, difficulties in learning and adverse MH outcomes

Behavioural problems and mental health issues if perceive themselves as different and not sure why

Question 10

Where can developmental delay be identified?

Answer 10

• Screening programmes - eg health visitor
• Identified risk - prematurity, FH
• Parents concerned
• Professionals in nursery/day care
• Opportunistically at health contacts for another reason

Question 11

Two types of developmental assessmenrt

Answer 11

• Under 5s and above 5s
• If above 5, this is for learning diability or diffiuculty

Question 12

What to ask in history for developmental delay?

Answer 12

• As usual
• Pre-natal, perinatal and post-natal events - red book
• Pregnancy and mode of delivery
• Condition at birth
• APGAR
• Newborne screening tests - hearing, blood

SH
* Environment
* Social support
* Cosanguinity - marrying relatives - are parents related?

FH:
* Developmental problems/difficulties

Question 13

General exam - what to look for?

Answer 13

• Head circumference and weight measurement - micro/macrocephaly, Prader Willi
• Dysmorphic features
• Skin abnormalities - cafe au lait, neurofibromas, hypopigmented patch
• Observe childs movements - unsteadiness, Gower’s sign
• Eyes
• Cardio
• Resp

Question 14

What is gowers sign?

Answer 14

• Climb themselves to stand up
• Indicates muscle weakness eg duchennes

Question 15

Down syndrome features phenotype

Answer 15

• Upward slanting eyes
• Large tongue - flops down

Question 16

Prader willi syndrome phenotype

Answer 16

• Obesity
• Almond eyes

Question 17

Condition associated with cafe au lait

Answer 17

Neurofibromatosis type 1

Question 18

Features of tuberous sclerosis

Answer 18

• Ash leaf spot - hypopigmented - glows under woods lamp
• Shagreen patch - thickened skin

Question 19

Examining babies - different positions

Answer 19

• Prone - should be flexed arms and flexed legs (otherwise hypotonia if limbs straight)
• Pull to sit - via pulling arms - child will help you, back stays straight if few months (initially curved in newborn) - good tone
• Standing - assess tone, can even do for few seconds in baby
• Ventral suspension - hold baby on hand, see position of hands and arms - looking for flexion and extension

Question 20

Gross motor development milestones

Answer 20

• 6 months - sit to support
• 9 months - pull to stand
• 12 months - start walking
• 18 months - run
• 2 yrs - stairs on own
• 3 yrs - tiptoes, tricycle
• 4 yrs - skip, hop
• 5 yrs - runs on toes

Question 21

Fine motor milestone

Answer 21

• 6 weeks - fix and follow objects
• 6M - reaches for objects, transfer one to another hand
• 1yr - neat pincer (finger and thumb)
• 18m - scribble
• 2 1/2 - lines
• 3yrs - circle

FINISh

Question 22

Speech and language normal milestones

Answer 22

• 12 months - first meaningful word eg mama, dada
• 2 years - give name, one colour, two word sentences
• 3 years - full name, gender, 2 colours, 3 sentences, count to 10
• 4 yrs - 3 colours, fluent conversation, 4 word sentences
• 5 years - 4 colours, can tell story, know age

Question 23

Social/daily self care

Answer 23

• 6 weeks - social smile
• 6-8m - stranger anxiety
• 9M - object permanence
• 10M - wave bye bye
• 15M - help with dressing, use spoon with mess
• 18M - spoon without mess, indicates toilet needs, use cup
• 2yrs - dry by day, dressing
• 3 yrs - dry by night, eat with spoon and fork
• 4-5yrs - dress and undress alone, eat with knife and fork

Question 24

What could hand preference before 1 year old suggest?

Answer 24

Cerebral palsy

Question 25

When is toe walking normal?

Answer 25

* Up to age of 3 and child is otherwise normal

Question 26

Red flags for gross motor

Answer 26

If child can't: * Sit unsupported by 12 months * Stand at 18 months * Walk by 18 months boys or 2 yrs girls - check CK * Walk other than tiptoes * Run by 2.5yrs * Persistence of neonatal reflexes - after 6 months eg moro, rooting (follow finger when touch angle mouth), sucking (finger in mouth) archer (when tilt head form archery position) * Excessive head lag after 6 weeks

Question 27

Fine motor questions to ask

Question 28

Red flags for fine motor skills

Question 29

Red flags for hearing, speech and language

Question 30

What are social development milestone examples?

Question 31

Red flags for social developmemt delay

Question 32

Tools for developmental assessment - primary and secondary care

Answer 32

* Primary care - ASQ, Denver developmental screening * Secondary care - SOGS II, Griffiths mental development scales, Wechsler pre school and primary scale intelligence

Question 33

What investigations are done for ?developmental delay?