Developmental Assessment - PLAY - OK

ASSESSMENT

2005 The Medicine Publishing Company Ltd13PSYCHIATRY 4:6

A child mental health assessment would not be complete without giving some thought to the childs developmental progress, just as a paediatric developmental assessment should include the emo-tional and mental health of the child and family. The differential diagnosis of a childs behavioural signs and symptoms includes the possibility of organic and developmental disorders. Conversely, behavioural and emotional disorders are much more common in disabled children than the general child population. Whereas physi-cal disease may be identified by laboratory tests, developmental markers help to identify the developmental disorders. The child psychiatrists toolkit must include competency to assess a childs development, and a working knowledge of typical developmental ages or milestones and red flag alerts ages that indicate signifi-cant delay requiring a referral for further assessment. Preschool children with behavioural concerns may be referred either to the local child and adolescent mental health service (CAMHS) or the child development service. Following initial assessment, some children will require referral from one team to the other. A close working relationship is therefore essential between the child development team and the CAMHS.

Child development

Child development is a dynamic process. From birth to 5 years, the typically developing child is transformed from a wholly depend-ent infant into a relatively independent child at school entry: mobile, dexterous, communicative, sociable and able to look after her/his basic needs directly or to seek assistance where neces-sary. Normal development varies enormously. It is determined by a complex interplay between environmental factors (maternal health antenatally, in utero conditions, the birth process, nutrition,

economic and social conditions facing the family) genetic factors and acquired pathology. These factors affect: rate of maturation (e.g. myelination of the nervous system) quality of a developing skill genetic potential and whether it is realized.

Warning signs of abnormal developmentSound knowledge of typical child development makes it possible to recognize when development is going wrong. It is worth con-sidering the common presentations, developmental red flags, and less common but important scenarios: delayed rate of development beyond accepted normal range of

variation in one or more developmental domains (e.g. echola-lia repetitive imitation of speech still present by 3 years)

absolute failure to develop skills (e.g. no canonical babble multi-syllable babble with intonation by 10 months)

disordered developmental sequence (e.g. hyperlexia advanced reading coexisting with delayed language)

motor asymmetry qualitative concerns about emerging skills and abilities developmental regression loss/plateauing of skills.

The developmental examination

History-taking should cover family history, social and family environment, and the pre-, peri- and postnatal history. The clinician should enquire into the parents concerns and seek information from others who know the child (e.g. teachers, health-care staff). It used to be thought that parents were not particularly good informants of their childrens development, but this was partly a result of asking too detailed questions about the age of acquisi-tion of particular skills. Asking open-ended questions and then requesting examples elicits the most reliable history. All parents are very good at remembering whether or not they had concerns and, if so, what those concerns were. They are particularly good at observing current behaviour if the right questions are asked. Parents interpretation of what their child does may be incorrect (e.g. he understands everything I say) but their observations are usually accurate (e.g. he will fetch his shoes only if they are visible). It is not only parents who find accurate estimates of comprehension difficult; so do professionals, unless a specific test is done. The assessor should ask for the parents view of causation. If the child has a development disorder, reassuring the parents about unwarranted concerns that they may have been responsible (e.g. a belief that autism could be caused by the mother going out to work, or being depressed) can reduce or remove their guilt. It is particularly important that developmental problems are not wrongly attributed to causes that are plausible but improbable, such as MMR immunization or obstetric intervention. A traumatic event, such as the umbilical cord around the neck of the child at birth or a forceps delivery, alone is an unlikely aetiology of a neurodevelopmental disorder. Nevertheless, it is valuable to estab-lish, from independent enquiry, the reason for obstetric interven-tion (e.g. foetal distress), the condition of the baby at birth (e.g. Apgar score

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Developmental differences exist between boys and girls (e.g. boys tend to lag behind in language). Boys are, on average, 1 month delayed in early language development compared to girls, but the difference accounts for less than 2% of the variation within the sexes and across ages. Gestational age should be considered when seeing a child under the age of 24 months, and correction should be made when assessing age-appropriate attainments, especially in the first postnatal year.

Observation and interactive assessment

A suitable selection of toys should be made available before meet-ing the family and interacting with the child. These should be appropriate for the age of the child and the domains of develop-ment to be assessed; for example: copying behaviour (bell) and understanding of cause and effect

(pop-up animals toy) definition by use (cup/spoon, doll/brush) and symbolic under-

standing (doll/teddy/tea set) fine motor/eyehand (bricks, crayons/pencil/paper, soft ball,

form boards, puzzles) language and play (books with single pictures and stories, range

of everyday toy objects, large and miniature world toys).Materials for play should be separate from those required for sys-tematic tests of developmental attainment. Some developmental assessment schemes are practical, taking 1520 minutes, and easy to learn, though each has drawbacks as well as strengths. Most children function better when an adult interacts with them, but time should be allowed for free play. The childs inability to organize the environment and generate ideas on their own is significant and may not be noticed if an adult is too helpful. The child may not be able to focus attention, in which case s/he will flit from one object to another, or very repetitive play may be noted. One of the cardinal rules of developmental assessment is to look not only at what the child does, but also how s/he does it. The quality of response should therefore be monitored as well as the actual achievement.

Developmental domains

Developmental milestones or norms are a way of describing devel-opment in a sequential manner. Delays in some developmental sequences may indicate an underlying neurological, visual or hear-ing problem that requires an early referral for further assessment. These are indicated below as red flag ages. Children with moderate

or severe developmental delay, plateauing or regression of develop-ment would also require further assessment and investigations.

Gross motorDelay in achievement of the gross motor milestones (Figure 1) may be an indicator of neurological abnormalities and is sometimes asso-ciated with a global developmental delay. Although the correlation between gross motor skills and global developmental level is weak, there is usually an impact on assessment of skills that depend on an intact motor system for their expression. Evaluation and interpreta-tion of test needs to be accommodated accordingly. Developmental assessment involves establishing the childs progress in the sequence of development and a qualitative descrip-tion of the childs mobility. Clinical interpretation requires combin-ing this information with the findings of physical examination.

Visual behaviour, eyehand coordination and problem solvingProgressive coordination of maturing vision with head, body and fine motor movements and an increasing ability to comprehend and solve problems can be observed through creating a range of test situations such as manipulation and use of pellet, rings, bell, cubes, crayon/pencil, form boards or puzzles. The use of a variety of such interesting and non-threatening test situations also helps to tease out the relative contributions of experience, emotional factors, motor and cognitive abilities. Childrens achievements in this domain represent the precursor to later non-verbal problem-solving abilities, correlate well with overall intellectual ability and may provide early markers for learning, psychological and psychiatric disorders.

Co-ordinated eye movements and eyehead co-ordination: the ear-liest developmental sequence starts with fixing gaze on the mothers face, then to following a face with eyes only, and then being able to co-ordinate eyehead movements to turn head to follow visually (Figure 2). Any abnormality of early visual behaviour should prompt an early referral for ophthalmological assessment.

Eyehand co-ordination: in this developmental sequence the infant shows visual awareness of hands and becomes increasingly refined in combining vision with hand movements for reaching, grasping, exploring and releasing objects (Figure 3).

Object concepts and relationships: this developmental sequence reflects infants growing understanding of the nature of objects, their relatedness to each other and in space (visuo-spatial) com-bined with a refined grasp and release ability (Figure 4).

Gross motor milestones

Developmental milestone Mean age (months)

Limit age red flag (months)

Hands open most of the time (not fisted)

3 4

Good head control when sitting. No head lag when pulled to sit

4 6

Sits independently 78 10

Walks alone 1113 18

1

Eyehead co-ordination milestones


Limit age red flag (months)

Visually alert, orients to face 1 Any delay

Visually follows face 2 Any delay

Co-ordinates eye movements with head turning

3 Any delay

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Copying cube models: this sequence shows childrens desire and ability to copy from models (combining the processes of encod-ing, decoding and executing) moving on from vertical alignment to horizontal alignment to making two- and three-dimensional models (Figure 5).

Drawing: children initially start jabbing pencil on paper just as they relate any other two objects together. This is followed by their interest in making a mark on the paper and then making vigorous uncontrolled scribble. By the end of the second year they can do

controlled circular scribble and soon imitate others hand move-ments to draw a line and later a circular shape before they are able to copy a pre-drawn circle or other shapes. Children gradually refine their grasp 50% of children by the age of 3 years and 80% by 4 years have a good tripod grasp of pencil (Figure 6).

Language and communicationIdentification of language impairment needs to combine infor-mation from parents, and observations/assessment. Parents reporting of expressive language is improved by making lists of spoken words or phrases. As children have good understanding of daily family routines, their language comprehension is often overestimated by parents. Infants show preference to the mothers voice within the first few days of birth, make responsive cooing sounds within the first few months and play lap games by 6 months. At around 9 months the infant begins to combine vocalizations and gestures to convey wishes, feelings, purpose and experience to others. At this stage, some infants may imitate the sounds of certain often-repeated family words. This is followed by the development of speech and

Eyehand co-ordination milestones


Holds objects briefly when placed in hands without visual regard

3

Visually examines own hand 4

Reaches out with a two-handed scoop 5

Reaches out and grasps objects on table surface with a raking grasp

6

Transfers from hand to hand 6

Explores with index finger 6

Picks up a pellet/raisin between thumb and finger 9

Picks up a string between thumb and finger 10

Can release in a container 10

Has mature grasp 12

Has precise release without pressing on surface 13

Builds towers of 2 cubes 13

Builds towers to 3 cubes 16

Turns pages of book one page at a time 24

3

Object concepts and relationships milestones


Permanence of object: looks for hidden object 8

Cast: drops repeatedly enjoys sound and attention

8

Cause and effect: presses or pushes to activate a toy 9

Meansend relationship: pulls toy placed out of reach with a string

9

Relating two objects together 10

Relating objects: enjoys putting things in and out of container

10

Simple posting games: round shapes 12

Matches simple shapes 1618

Matches three shapes with good scanning 24

4

Cube model copying milestones


Horizontal alignment of bricks 24

3-cube bridge 33

4-cube train with a chimney 39

3 steps with 6 cubes 4854

4 steps with 10 cubes 60

5

Drawing milestones


Shape copying

Makes a mark on paper 15

Scribble 18

Copies lines 24

Copies a circle 36 (90% by 42 months)

Copies a cross 42 (90% by 48 months)

Copies a square 48

Copies a triangle 60

Copies a diamond 6672

Drawing a person

Figure with head, other parts, no body

36 (80% by 45 months)

Figure with head, body, limbs 54

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language understanding and expression with a considerable vari-ation between children (Figure 7).

Play and social behaviourObservation of play offers a unique opportunity to look at a number of developmental sequences as they come together to create an increasingly complex tapestry of play (Figure 8).

Development of attentionChildren pass through a number of different developmental stages as their attention and listening skills improve. Below are the 6 main stages. Stage 1 children at this stage are very distractible. Their atten-tion is held momentarily by whatever is the dominant stimulus (Year 1). Stage 2 at this stage children can concentrate on a task of their own choice. They have to ignore all other things in order to focus on this one task. Children are very resistant to interference by an adult (Year 2). Stage 3 By now, children are beginning to allow an adult to shift them from one task to another. Attention must still be fully gained before changing focus (Year 3: single-channel attention). Stage 4 Children now start to become able to control their own focus of attention. They move gradually towards needing to look at an adult only when the directions become difficult to understand (Year 4: early integrated attention). Stage 5 At this stage, children are usually entering school. They can now perform an activity while listening to the teacher giving directions (Year 5: mature integrated attention). Stage 6 This is a mature stage where attention skills are flex-ible and sustained for lengthy periods.

Physical examination

The physical examination is generally left to the end of the assess-ment, as the child may become upset and this would interfere with a subsequent developmental examination. The following key guidelines should be observed. Motor function determine whether the child has a motor disorder or if any delay is part of global learning difficulty. Observe movement patterns and posture during the appointment and devel-opmental examination, when the child is walking, speaking and handling material. This should give a good idea of the nature and extent of any motor problem. Formal examination of tone, reflexes and power is largely confirmatory. Symmetry Compare the two sides of the body and determine the childs hand preference. The motor skill, tone reflexes or limb size may be significantly asymmetrical, suggesting hemisphere dysfunction or other pathology. Growth measure the head circumference, height and weight and plot on a centile growth chart. Compare the consistency of the parameters and assess the growth rate. If concerned about the head size, it may be advisable to measure the parents head circumference (familial inheritance is the usual reason for an excessively large head, and there may be inherited reasons for microcephaly). Sight Examination of the optic discs and fundi will usually not be possible, but it may be necessary to arrange this via the ophthalmologist or paediatrician (e.g. for septo-optic dysplasia, raised intra-cranial pressure). Malformation look for dysmorphic features and congenital malformations. They may suggest a particular syndrome or aetiol-

Language and communication milestones


Range (months)

Comprehension/receptive language

Understands no/bye 7 69

Recognizes own name 8 610

Understands familiar names 12 1015

Definition by use: using objects by 15

Giving objects on request by 15

Points to body parts on self/carer 15 1218

Points to body parts on doll 18 1521

Identifying objects on naming by 24

Follows a 2-step command 24 1827

Functional understanding 30 2133

Understands prepositions (in/on) 24 1833

Understands prepositions (under) 30 2439

Understands action words (e.g. eating, sleeping)

by 36

Understands simple negatives 36 3042

Understands comparatives 42 3648

Follows 2 instructions (4 ideas) 42 3648

Understands complex negatives 48 4260

Follows 3 instructions (6 ideas) 54 4866

Expressive language and non-verbal communication

Jargon 12 1015

Syllabic and tuneful babble 8 69

Pointing to demand 9

Pointing to share interest 10 914

One word 12 1018

26 words 15 1221

720 words 21 1824

50+ words 24 1827

2 words joining 24 1830

200+ words 30 2436

34 words joining 30 2536

Speech usually understandable 30 3042

Question words 36 3042

Pronouns 42 3648

Uses conjunctions (and, but) 48 3654

Sentences of 5+ words 48 3654

Complex explanations and sequences

54 4866

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ogy (e.g. fetal alcohol syndrome). Skin carefully examine the skin for pigmented and hypo-pigmented spots. Where there is significant developmental delay, and especially with epilepsy, a Woods ultraviolet light examina-tion should be performed (for ash-leaf skin patches in tuberous sclerosis) or arranged.

Developmental diagnosis and management

The outcome of the examination is a profile of developmental abilities and areas of difficulty, alongside the behavioural and mental health assessment. The combined picture may point to a specific developmental delay or disorder (e.g. learning disability, autism). Laboratory investigations may be indicated to look for specific medical causation. This also applies to an analysis of behavioural presentations. Specific concerns may also require referral for specialist assess-ments (e.g. referral to speech and language therapy, occupational therapy, physiotherapy, or the community paediatrician). Close links between CAMHS and the child development team aids such liaison greatly. The community paediatrician and the whole child development team will be available to discuss con-cerns. Referral (e.g. for language assessment) can be very helpful indeed for both family and psychiatrist. Ongoing management may require shared care through part-nership with one or more teams within the child development service. A clear management plan should be included in the assessment report incorporating referrals and further investigations; plan for who is to review and, where relevant, a named key worker for the family.

Framework for evaluation of developmental delay and planning investigations

Assessing developmental delayIt is helpful to consider moderate delay to be a developmental level where the age equivalent for achieved milestones is between two-thirds and half of chronological age (CA), and severe delay where milestones are equivalent to 50% or less of CA (allowing for prematurity up to 2 years). These examples are for ages com-monly seen at referral for developmental concerns: At 8 months: moderate delay developmentally 45 months (e.g. not sitting

without support, not rolling, no single-syllable babble) severe delay developmentally less than 4 months (e.g. not

lifting head).At 2 years: moderate delay developmentally 1218 months (e.g. no link-

age of words, less than 10 words and not following simple com-mands)

severe delay developmentally less than 12 months (e.g. no single words, not walking, no functional play, no joint atten-tion).

At 3 years and 6 months: moderate delay developmentally 2128 months (e.g. just

linking words, less than 50 words, minimal concepts, cannot draw circle)

severe delay developmentally less than 21 months (e.g. single words or less, simple commands, but no concepts).

Planning investigationsA differential diagnosis will be based on the results of the devel-opmental assessment, and provides a set of hypotheses about aetiology. Investigations are planned to test the most reasonable

Developmental sequences involved in play

Cognitive play sequence

Social play sequence

Object oriented exploratory play (maturing eyehand co-ordination and object concepts)

18 months9 months

Functional use of real objects on self and others (e.g. spoon, brush)

2430 months

Symbolic use of toys (e.g. toy, tea set, doll)

34 years

Pretend or imaginative play

612 months

Social anticipationLap games (e.g. peek-a-boo, pat-a-cake)

45 weeks

Social smile (90% by 6 weeks)

1015 months

Joint attentionPoints to show

33.5 years

Social imitative play(e.g. role play)

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hypotheses. The laboratory test most likely to yield positive results is chromosomal analysis. Before finalizing the plan, consider: what is the likelihood of the condition under investigation being

present? do children with the condition under investigation present in

this way? are there benefits from an early diagnosis: would it alter man-

agement and what bad outcomes would be prevented? will the diagnosis improve the parents ability to plan and

cope?The answers to these questions may not always be to hand but their purpose is to focus investigation and to remain alert to the possibility of over-investigating a child. However, there is also the danger of under-investigating. If impairments are not detected early then other disabilities may result, which may be a source of resentment in parents when a late diagnosis is made, e.g. late diagnosis of hearing loss associated with failure to develop oral language adequately. Even more distressing is the scenario where a delay in genetic diagnosis may have led to the parents going ahead with a subsequent pregnancy, which they would have avoided had they known that their delayed child had an autosomal or X-linked recessive condition. A balance needs to be struck between these two approaches the conservative and the aggressive when investigating the child with developmental delay. A cause is more

likely to be found in a child presenting with severe developmen-tal delay (80%) than in one with moderate developmental delay (45%). It is beyond the scope of this chapter to discuss the causes of developmental delay (termed mental retardation in the USA). Figure 9 offers guidance on the planning of investigations for developmental delay.

FURTHER READINGBaron-Cohen S, Wheelwright S, Cox A et al. The early identification of

autism: the Checklist for Autism in Toddlers (CHAT). J R Soc Med 2000; 93: 5215.

Bee H. The developing child. Boston, USA: Alleyn and Bacon, 2000.Capute A J, Pasquale J A. Developmental disabilities in infancy and

childhood. Baltimore, USA: Paul H Brooks, 1996.Egan D F. Developmental examination of preschool children. Oxford: Mac

Keith Press, 1990.Frost M, Sharma A. From birth to five years Mary D Sheridan (Revised

and updated). London: Routledge, 1997. Law J, ed. The early identification of language impairment in children.

London: Chapman Hall, 1992. Salt A, Gringras P, Dorling J, Hartley L. Developmental delay. In: Moyer V

A, Elliott E, Davis R et al. eds. Evidence based paediatrics and child health. BMJ 2000; 11724.

8 months 24 months 42 months

moderate severe moderate severe moderate severe

Chromosomes Fragile X CK (boys) Urate T4/TSH# Plasma AAs# FBC Viral antibodies

Toxoplasma CMV Rubella HIV Needs to be considered on an individual basis

Urine

CMV OAs$ MPS Woods light

9

* Early in presentation, it is reasonable ro review progress for a short period (e.g. 3 months) and to do investigations as in moderate column if moderate delay persists over time, with or without intervention. # If neonatal results available, then use them. If not, repeat. $ Urine organic acids if child shows moderate delay plus any feeding problems/vomiting.CK, creatinine kinase; T4/TSH, thyroxine/thyroid stimulating hormone; AA, amino acids; FBC, full blood count; CMV, cytomegalovirus; OA, organic acid; MPS, mucopolysaccharides.Reproduced with permission from Talukdar K, OSullivan T. Extract from unpublished work, 2004.

Investigations that should be considered in moderate and severe developmental delay

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Developmental Assessment - PLAY - OK