Objectives
Developmental and behavioural concerns, mainly 0-5
Know when to worry (and when to reassure)
Know what to do about worry (who to involve)
Know what to advise in the meantimeNo rarities!
Outline 0-1: Stand up!
Gross motor development
1-2: Speak up! Early communication
2-3: Play nicely! Behaviour, sleep and eating
3-4: Calm down! Attention, emotion
4-5 Get ready for school! Clumsy, odd children
0-1: Stand up! Case study
Baby born at term, no compsBreastfeeding ‘OK’6 week check
Head lag- briefly keeps up Suspended prone- brief straightening only Brief ankle clonus bilaterally Hands fisted Moro intact, symmetrical
Diagnosis?
‘Floppy baby syndrome’
If not sure, look for risk factorsExamination clues
Dysmorphism Posture, movements at rest
No-one minds getting a referral for this
Worry markers- gross motor
No rolling prone-supine by 7 months
No rolling supine-prone by 9 months
No unsupported sitting by 10 months
No independent steps by 18 months
No running by 2 years
No jumping by 3 years
‘A very grabby little person’
Primitive gives way to voluntaryProximal- distal progressionSequence rigid, timings flexiblePronation before supinationAction before inhibitionVariation is required
Reach and grasp
4 months Open-hand reaching Corralling, swiping, ulnar-palmar grasp
6 months Accurate reach Radial-palmar grasp, raking a raisin
10 months Hand-shaping Digital grasp of cube, pincer of raisin
Introducing the 5 minute development assessment
0-3 yearsEquipment
A box of raisins Some 1” bricks (primary colours, 6 or so) Some markers and paper A stethoscope
1-2 Speak up!: Early communication
Do an impression of….. 4 month old 8 month old 12 month old 18 month old 2 year old 3 year old
Worrying signs
6/12: No cooing/ response1 yr : No pointing, no words, no showing18 mo: <5 words2 years: No linking, no instructions3 years: Not understood by strangers, no
body parts known
Behaviour- taking a history
Get examples- specific difficult scenarios Mealtimes Leaving for school Shops
What happens before, during, after What do parents do?
Ask for exceptions Why different?
Role plays (you love them, you do)
‘He’s got no respect’
‘He won’t sleep in his bed’
‘She won’t eat anything’
Is it ADHD, doctor?
What is ADHD? Just bad parenting?
Expectations of abilities Rest of development
Attention deficit or Deficit of attention?Other factors
Specific learning difficulties Sleep Inconsistent parenting
Referral and management
Diagnosis CAN be made in primary care
First line for mild/ moderate- parenting group/ school intervention
Refer CAMHS for 2nd line interventions
Fears and imagination
The emergence of magicEmotions as behaviourImaginary friendsLies and misdemeanoursFears- concrete to imaginaryNight terrors vs nightmares
4-5: Get ready for school!
Later motor problems Gait Co-ordination & motor planning
Social communication problems
Self-concept and mood
Problems with walking
Normal gait
Asymmetry
Toe-walking
Persistence of toddler pattern
Frequent falls
The clumsy child- DCD
Common, significant problem
Difficulties with planning and execution Poor handwriting
‘Behavioural’ issues
Frequent falls
Sensory issues
Difficulty in integrating sensory input with cognitive and motor activity
Leads to behavioural and communication problems
ALL sensory modalities Proprioception Taste
Out-of-sync child
DCD/ sensory - what to do
Assess expectations (handout)
Led by OT
Comm paeds initially
Questionnaire-based referral
Co-morbidity
Why go to medics? Neurological disorders initially diagnosed as "DCD/dyspraxia" Peripheral neuromuscular conditions Becker muscular dystrophy myotonic dystrophy
hereditary motor and sensory neuropathy (HMSN) types Ia and IImyotonia congenita (autosomal recessive)congenital myasthenia
Central nervous system conditions cerebral palsy
brain tumour (slow growing in the posterior fossa)panthotenate kinase-associated neurodegeneration (Hallervorden–Spatz disease)perisylvian (opercular) syndromebenign familial choreaepilepsy
Mixed peripheral and central nervous system conditions Friedreich’s ataxia
Pelizaeus–Merzbacher disease
Miscellaneous Ehlers–Danlos syndrome
GM1 gangliosidosis (juvenile onset)
Autistic spectrum disorders
Triad of impairments Social interaction
Language and communication
Rigidity of thought and behaviour
Dimensional not categorical
Still under-reported: at least 1% of children
Social interaction
Eye contactFacial expressionSocial response/ overturesShared enjoyment
Think of silent movies
Communication
Speech delay
Echolalia
Stereotyped/ formal language
Conversation
Reporting
Lack of gesture
Diagnosis of ASD
3 elements: report, interview, observationDiagnostic jargon
Full triad+ speech delay = Autism Full triad and normal speech= Asperger’s Social interaction + other = ?Atypical autism
All children with these three have an ASDOther terms exist (for now)
“Kids in the mix”
Mix of disorders Synergistic effect on
functioning Associated with
relative poverty Complex!
Self-image and self-esteem
Definition of self- categories
Gender/ sexual identity
Anger Overt
Concealed
Moral development
Postscript: How to be the GP of a child with “complex” disability
Acute problems Note interactions e.g. gut and head Negotiate plan
Long-term issues Checklist in handout
‘Non-medical’ issues Benefits Wider family