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					                     Developmental
                    Assessment of the
                    Paediatric Patient



        Jill Houbé, MD, MPhil, FAAP, FRCP(C)
Asst. Professor, Division of Developmental Paediatrics
                UBC Dept. of Paediatrics
                    November 2004
     Developmental Assessment of
         the Paediatric Patient
1.    Incidence of developmental abnormalities
2.    Importance of screening
3.    Developmental surveillance
4.    Parental input
5.    Screening tests
6.    Cases
 High prevalence of problems
within pediatric practice setting
  – specific learning disability
  – attention-deficit/hyperactivity disorder
  – speech/language impairment
  – mental retardation
  – cerebral palsy
  – hearing impairment
  – serious emotional disturbance
            Dobos et al, J Dev Behav P ediatr 1994;15:348
Developmental Disabilities:
       Incidences
         Diagnosis           Incidence
      Mental retardation     3%
        Cerebral Palsy       .3 - .5%
   Communication disorders   common
   Autism Spectrum Disorder .67%
     Learning Disabilities   5 - 7%
            ADHD             10 - 14%
          Blindness          .01 - .05%
          Deafness           .1 - .2 %
             FAS             .01 - .1%
            NORMAL DEVELOPMENT                     Parents
              minimal psychosocial                often need
   Parents        risk factors                      advice
 often need                                         about
  training,                                        behavior
 and social     BELOW AVERAGE
  services.       DEVELOPMENT
  Children
    need    frequent psychosocial risk
enrichment            factors              Children
  tutoring,       DISABLED               need special
mentoring,                                education,
   mental some psychosocial risk factors    speech
   health,      and/or organicity        therapy, etc.
     etc.
                                  Glascoe, 1997
         High Risk Children
• Established Risk
  – Chromosomal abnormalities, e.g. Down Syndrome

• Environmental Risk
  – Poverty
  – Maternal mental health issues

• Biological Risk
  – Prenatal exposure to drugs and alcohol
  – Low birth weight and/or prematurity
       Effects of Psychosocial
     Risk Factors on Intelligence
      125                                                         Percentiles
      120
      115                                                           84th
      110                                                           75th
      105

IQ    100                                                             50th
       95
       90                                                             25th
       85                                                             16th
       80
            0    1   2       3         4        5        6       7+
                     Risk Factors
                     Poor health status, > 3 children, stressful events, single parent,
                     parental mental health problems, less responsive parenting,
 Glascoe, 1997       poverty, minority status, limited social support
     Developmental Differences:
      Delay, Dissociation, Deviance
• Delay:
  – Not necessarily abnormal
  – Implies child may catch up

• Dissociation:
  – A difference between rates of change ≥ two domains of development
  – e.g. Mental retardation
      • Motor development may be ahead of language or cognitive abilities

• Deviance:
  – Always abnormal
  – e.g. Autistic 3 year old child with no interest in social or imaginative play
Developmental Trajectories

                       Normal
M
I
L
E
S                      Illness
T
O
N
E
S
                           Delay
                 HIV


         TIME
       Why Does Early Identification
                Matter?
Access to early intervention
   •   Less-differentiated brain of younger child
       amenable to intervention
   •   EI results in lower rates of morbidities
   •   EI results in less severe morbidities

Prevention of secondary disabilities
   •   Maladaptive behavior
   •   School failure
   •   Low self-esteem
   •   Family dysfunction

Legal Mandate
   •   Canadian Charter of Rights and Freedoms (1985)
       −   Section 7 Legal rights
       −   Section 15 Equality Rights

   •   BC Human Rights Code (1996)
   •   BC School Act (revised 1989)
                                                    Guralnick 1987
          Options for Early Detection:
          Developmental Surveillance

“…flexible, continuous process in which
knowledgeable professionals perform skilled
observations of children during child health
care.”
With proper techniques, surveillance is
family-focused, accurate, efficient, and can
guide clinical decision making
                                  Dworkin, 2004
Developmental Surveillance
• Components
  – eliciting/attending to parents’ concerns
  – obtaining a relevant developmental history
  – skillfully observing children’s development
  – sharing opinions with other professionals




                                     Dworkin, 2004
Developmental Surveillance and Investigation




                                     Prieto 2004
Developmental Surveillance and Investigation


    PRENATAL                  POSTNATAL




    PRESENT                    FAMILY
   Domains of Development
               Fine
1. Motor
               Gross

2. Speech and Language

3. Cognitive

4. Adaptive/Personal-
   social
Developmental Surveillance
Children’s developmental competencies
 are best determined over time
  – “spurts” and pauses, not linear fashion
  – variable rate across domains
  – longitudinal aspect of health supervision



                                    Dworkin, 2004
     Attending to Parents’ Concerns
• Strong relationship between parents’
  concerns and child’s developmental status
  (Glascoe, Peds In Rev 2000. Chis, Peds Rev 2000)


• Parents have high levels of sensitivity for
  problems regarding fine motor, language,
  cognitive and school skills (Glascoe, Peds 95, 97;
  Glascoe, Ped 91. Diamond , J Div Early Childhood 87)


• Parental concerns about gross motor,
  hearing and medical status are highly
  related to developmental problems (Glascoe, Clin
  Pediatr 91, 94)
                                                         Dworkin, 2001
     DEVELOPMENTAL SURVEILLANCE
           Parents’ Appraisals
• In 87% of children with ADHD, parents have
  concerns related to impulsiveness, inattention
  or over activity (Mulhern et al, Am J Dis Child. 93)

• Absence of parental concerns or concerns in
  other areas (self-help or socialization)
  correlates with children without developmental
  disorders           (Glascoe FP, Am J Dis Child 89)
 DEVELOPMENTAL SURVEILLANCE
Elicit Parents’ Opinions and Concerns
 • Information available from parents
   – appraisals (opinions of children’s
     development)
      • concerns
      • estimations
      • predictions
   – descriptions
      • recall
      • report
                                          Dworkin, 2004
DEVELOPMENTAL SURVEILLANCE
      Parents’ Appraisals
 • Concerns
   – accurate indicators of true problems
      • speech and language
      • fine motor
      • general functioning (“he’s just slow”)
   – self-help skills, behavior less sensitive
 • “Please tell me any concerns about the
   way your child is behaving, learning,
   and developing”
   – “Any concerns about how she…”               Dworkin, 2004
 DEVELOPMENTAL SURVEILLANCE
       Parents’ Appraisals
• Estimations
  – “Compared with other children, how old would
    you say your child now acts?”
  – correlate well with developmental quotients
     • cognitive, motor, self-help, academic skills
     • less accurate for language abilities
• Predictions
  – likely to overestimate future function
     • if delayed, predict average functioning
     • if average, “presidential syndrome”            Dworkin, 2004
 DEVELOPMENTAL SURVEILLANCE
      Parents’ Descriptions

• Recall of developmental milestones
  – notoriously unreliable
  – reflect prior conceptions of children’s development
  – accuracy improved by records, diaries
  – even if accurate, age of achievement of limited
    predictive value


                                        Dworkin, 2004
 DEVELOPMENTAL SURVEILLANCE
      Parents’ Descriptions
• Report
  – accurate contemporaneous descriptions of
    current skills and achievements
  – importance of format of questions
    • recognition: “Does your child use any of the
      following words…”
    • identification: “What words does your child say?”
  – produces higher estimates than assessment
    • child within a familiar environment
    • skills inconsistently demonstrated           Dworkin, 2004
          Developmental Surveillance
     Eliciting Parents’ Opinions and Concerns


Caveat: Detection without referral/intervention is
   ineffective and may be judged unethical
    (Perrin E. Ethical Questions about Screening. J Dev Behav Pediatr
    1998; 19: 350-352)




                                                                  Dworkin, 2004
  Developmental Surveillance
An appropriate response to parents’ behavioral
concerns is to seek additional information about
children’s development
– important indicators of children’s status
– need for cautious interpretation



                                         Dworkin, 2004
  Developmental Surveillance
Opinions of other professionals offer valuable
information regarding children's developmental
functioning
– input from preschool teachers, child care providers,
  visiting nurses
– preschool teachers’ predictions of school readiness,
  kindergarten success


                                          Dworkin, 2004
              Screens
• Identify the likelihood of a disability
• Do not provide a diagnosis
• Can help identify a range of possible
  diagnoses that help focus referrals


                                Prieto 2004
      Detection rates without
         screening tests

• 70% of children with developmental
     disabilities not identified
    (Palfrey et al. J PEDS. 1994;111:651-655)



• 80% of children with mental health
     problems not identified
    (Lavigne et al. Pediatr. 1993;91:649 - 655)
          Detection rates
       WITH Screening Tests
• 70% to 80% of children with developmental
     disabilities correctly identified
       Squires et al, JDBP. 1996;17:420 - 427

• 80% to 90% of children with mental health
     problems correctly identified
       Sturner, JDBP . 1991; 12: 51-64

• Most over-referrals on standardized screens are
    children with below average development
    and psychosocial risk factors
                           -
       Glascoe, APAM. 2001; 155:54-59.
          COMMON MYTHS

• common screening tests too long
• many difficult to administer
• children uncooperative
• reimbursement limited
• referral resources unfamiliar or
     seemly unavailable
                                     Glascoe, 1997
   Can parents read well enough
        to fill out screens?
• Usually! But first ask,
“Would you like to complete this on your own or
have someone go through it with you?”

• Also, double check screens for completion
   and contradictions


                                         Glascoe, 1997
 Can parents be counted upon to give
accurate and good quality information?
                YES!
• Screens using parent report are as
  accurate as those using other
  measurement methods
• Tests correct for the tendency of some
  parents to over-report
• Tests correct for the tendency of some
  parents to under-report.
                                  Glascoe, 1997
          Six Quality Tests
1. Parents’ Evaluation of Developmental Status
   (PEDS) (0 through 8 years)
2. Child Development Inventories (CDIs)
          (0 to 6 years)
3. Ages and Stages (0 to 6 years)
4. Pediatric Symptom Checklist (PSC)
     (4 through 18 years)
5. Brigance Screens (0 to 8 years)
6. Safety Word Inventory and Literacy Screener
   (SWILS ) (6 – 14 years
                               Glascoe, 1997
              Excluded Tests:
                      PDQ
                   Denver-II
            Early Screening Profile
                    DIAL-III
           Early Screening Inventory
                      ELM
                     Gesell

Due to absence of validation, poor validation, norming on
referred samples, and/or poor sensitivity/specificity
                                                 Glascoe, 1997
    Screen Selection Flow Chart
                 Age Range
0 – 4 yrs   4 – 6 yrs   6 – 8 yrs   8 – 18 yrs

PEDS or     PEDS or       PEDS      SWILS
CDIs or     CDIs or        or       and/or
ASQ         ASQ or       Brigance    PSC
or          Brigance        or
Brigance    ( + PSC)     SWILS
                         ( + PSC)

                                     Glascoe, 1997
THE ROLE OF MD IN THE DECTECTION OF
  DEVELOPMENTAL AND BEHAVIORAL
             PROBLEMS

• Screening tools are not diagnostic
• Further evaluation is mandatory if concerns
  are raised by the screen
• If the MD is uncomfortable administering the
  screening tool, the child should be referred to
  a paediatrician and/or child psychologist for
  further evaluation
                                        Prieto 2004
IDENTIFICATION OF THE CHILD WITH
 POTENTIAL DELOPMENTAL DELAY

 • Physical exam
   • Dysmorphic features
   • Abnormal neurological exam
   • Growth abnormalities
IDENTIFICATION OF THE CHILD WITH
POTENTIAL DEVELOPMENTAL DELAY
 • DETERMINATION OF AN ETIOLOGIC DIAGNOSIS HAS
    SIGNIFICANT IMPLICATIONS WITH RESPECT TO :
   PATHOGENESIS
   PROGNOSIS
   RECURRENCE RISKS
   SPECIFIC MEDICAL INTERVENTIONS


 • SPECIFIC LABORATORY TESTING SHOULD
   BE INDIVIDUALIZED


                               Majnemer A., Shevell M. J of Ped 95



                                                           Prieto 2004
                           Potential Laboratory Eval
                                                         THE MENU
   CBC                                             KARYOTYPE (+/-subtelomeric testing)
   CBG                                             FRAGILE X
   LACTATE                                         EEG
   AMMONIA                                         AUDITORY BRAIN-STEM POTENTIALS
   SERUM Amino Acids                               SOMATOSENSORY EVOKED POTENTIALS
   URINE Organic Acids                             COMPUTED TOMOGRAPHY
   Thyroid FT’S                                    MAGNETIC RESONANCE IMAGING
   Liver FT’S                                      LEAD LEVELS

   Refer to sub specialists

Filipek PA, Accardo PJ et al. Neurology 2000. Shevell MI , Majnemer A. J of Ped 2000.
      When Should You Ask for
        Further Evaluation?
• Sudden Unexpected Change In Developmental Trajectory

     – Unexplained regression

     – Sudden change in personality

     – Change in mood or emotional well-being
        • May be due to disease or illness
        • May reflect important events occurring at home
     When Should You Ask for
       Further Evaluation?
•   Global Developmental Delay
     – Persistent significant delay in all domains that cannot be attributed
       to other known factors

• Delays in a sphere of development that
    adversely impact the child’s functioning
     – At home
     – Daycare
     – School

• Significant Emotional Concerns
       What Do You Ask For?
• Community health unit and GP
   – Hearing screen
   – Vision screen
   – Speech and language evaluation
   – Paediatrician referral
• Sunny Hill Developmental Paediatric School
  Outreach Program
• Infant Development Program: good to have GP
  referral
• Child Development Centre: good to have GP referral
       Sunny Hill Health Centre
         Outpatient Clinics
• School Consults & SERT Team (Substance
  Exposure Resource Team)
• Brain Injury
• Craniofacial Clinic, Downtown Eastside Clinic &
  SERT Team
• Visually Impaired Program
• Preschool and Developmental-Genetics Clinic
• Hearing Loss Team
• SERT Team
• Neuromotor/Spasticity/Feeding
• Provincial Autism Program
 http://www.sunny-hill.bc.ca/sunnyhill/shhcc/default.asp
    Developmental Surveillance:
             Pitfalls
• Gross Motor Skills
  – Gross motor milestones DO NOT predict intelligence!
     • 35% of profoundly mentally retarded infants walk by 15 months
     • 80% of mildly mentally retarded infants have normal motor milestones

  – REMEMBER: a child with delayed motor milestones is not
    necessarily mentally deficient
     • e.g. cerebral palsy
  Developmental Surveillance:
           Pitfalls
• Appearance
  – Attractive children with mental retardation are
    identified later than unusual looking children
  – e.g. Autistic children usually look normal
   Developmental Surveillance:
            Pitfalls
• Language
  – Development of language doesn’t start with talking!
     • Attention needs to be paid to the child’s acquisition of
       pre-linguistic milestones:
         – Social smile
         – Gestures
         – Pointing
         – Appropriate facial expressions

  – Absence or delay in speech development cannot be
    attributed to otitis media!
    Developmental Surveillance:
             Pitfalls
• What Else Should You Be Thinking About?
  – Environment:
    • Neglect
    • Deprivation
    • Abuse

  – Maternal mental health issues
     Developmental Surveillance:
              Pitfalls
•   When does a child have abnormal attention?
    –   Attention is a developmental concept
    –   There are increasing expectations of the development
        of attention and other executive functions with age
    –   Symptoms of inattentiveness need to be seen in the
         context of:
        •   Family
        •   School
        •   Mental health
        •   Developmental and biological factors
        Developmental Surveillance:
                 Pitfalls
•   At what age can/should you consider a
    diagnosis of ADHD?
    –   Preschoolers have a wide range of attentional
        capabilities so assessment at age 3-5 years is difficult
    –   Severe symptoms at an earlier age seen in certain
        situations:
        •   Prenatal cocaine
        •   Prenatal alcohol exposure
     Developmental Surveillance:
              Pitfalls
•   Are there other things besides ADHD which
    present with abnormal attention? YES!
    – Children have a limited range of ways they
      can express themselves
    – Behaviours that can look like ADHD:
      •   Disruptive
      •   Acting out
      •   Withdrawn
   Developmental Surveillance:
            Pitfalls
• Possible Causes of Attention Problems
  – Sensory Deficit
  – Receptive Language Problem
  – Other Specific Learning Disabilities
    • Coexists in 12-60% of children with attention deficit
  – Seizures
  – Mood Disorders (e.g. depression)
    • Coexists in 18% of children with ADHD
    Developmental Surveillance:
             Pitfalls
• Possible Causes of Attention Problems
  – Anxiety Disorders
    • Coexists in 25%
  – Oppositional Defiant Disorder, Conduct Disorder
    • Coexists in 35% of children with ADHD
  – Parent – Child Interaction Problems
  – Mental Retardation
  – Sexual and/or Physical Abuse
  – Neglect
          Case History #1
6 year old girl in grade 1 at an inner city
school.

Referred because of teacher’s concerns
regarding:
  – Academic delay
  – Possible depression
         Case History #1
Past History
  – Normal pregnancy and birth
  – Medical history negative
  – Attended a licensed daycare since 18 months
    of age

Gross Motor
  – Walked: 16 - 17 months
  – Stairs: grade 1
  – Bike: hasn’t learned yet
         Case History #1
Fine Motor
  – Right handed, feeds herself
  – Can’t do buttons or zippers
  – Draws simple pictures

Speech
  – Started talking age 3 years
  – Has always had good non-verbal
    communication
         Case History #1

Social
  – No friends in class
  – Likes to play with younger children
  – Prefers “centres” to academics at school
             Case History #1
Family History
  – Mom struggled in school, has had difficulty keeping a
    job, on social assistance until 6 months ago
  – Father has never been involved
  – 2 older sisters, one dropped out in grade 10, other
    failing in grade 9
  – Mom has depression, on medication for 6 years
  – Feels she can barely cope most days
  – Tries to hide this from her children
  – Child doesn’t like school, says it is too hard
             Case History #1
Red Flags
• Global developmental delay from an early age
  despite early intervention in the form of licensed
  daycare
   – Gap is widening between her and her peers

   – Starting to appear to be depressed

   – Maternal depression

   – Discouragement about school
           Case History #1
Possible Steps: at preschool age
  – In daycare:
    • Do a Developmental Screen
    • Involve IDP
    • Monitor progress, etc

  – Talk to mom: suggest supports
  – Set-up appropriate transition planning into
    kindergarten
         Case History #2

5 year old boy in kindergarten and after
school daycare.

Child is in foster care, removed from his
biological parents because of neglect
            Case History #2
Teachers Concerns
  – Hasn’t adjusted well to routines, transitions
    are difficult
  – Very disruptive at circle time especially
  – Doing poorly socially, doesn’t get invited for
    play-dates
  – Expressive speech is mildly delayed
  – Short attention span
  – Unpredictable angry outbursts
             Case History #2
Daycare
 – Aggressive with other kids, then doesn’t understand
   why they won’t play with him
 – Gravitates to construction toys where he is quite
   attentive
 – Loves gross motor activities
 – Can’t listen to a story, even 1:1
             Case History #2
Red Flags
These concerns are atypical for ADHD
  – Inattention worse for activities requiring language
    comprehension
  – Not appreciating cause and effect relationships
  – Behaviour is not maturing with time
              Case History #2
Assessment:
  – Average non-verbal cognitive function
  – Significantly lower verbal abilities
  – Very low adaptive abilities (activities of daily living)
  – At risk for verbal learning disability

Diagnosis: Partial Fetal Alcohol Syndrome
                Case History #3
Peter is a 6 year old child whose parents are
concerned that he is not making friends at school.

• He has never been invited to a birthday party or to a play date.
• When his mother arranges for a child to come and play, her
      son will play beside the other child but doesn’t interact.

• He prefers not to have kids over because they leave his toys
       out of order and disturb his room.
             Case History #3
Teacher’s Observations:

• Peter is meeting grade expectation academically.
• He is very clumsy.

• He is a boring child because he talks non-stop about
      his favourite interest, dinosaurs.

• While his parents are concerned about his lack of
      friends, he doesn’t seem to care
       Case History #3
Red Flags
  – Lack of interest in socialization

  – Restricted range of interest
            Case History #3
Assessment:
  – Average cognitive function
  – Abnormal social understanding and interactions
  – Lack of imaginative play

Diagnosis: Autism Spectrum Disorder
                    References
• http://cshcnleaders.ichp.edu/Presentation
  s/screening.htm#PowerPoint%20Presentat
  ions
• http://www.aap.org/catch/6
• http://www.medicalhomeinfo.org/screening/Scree
  n%20Materials/PEDS%20EVALUATION.PPT
• Paediatric Developmental Assessment
  of the Preschool and School-Aged Children:
  The Role of the Frontline Worker, Barbara Fitzgerald and Jill
  Houbé, ECEBC 2003

				
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