Sridhar

Development Assessment

Dr.M.Sridhar

Introduction

• Development refers to maturation of functions and acquisition of various skills for optimal functioning of an individual. The maturation and myelination of the nervous system is reflected in the sequential attainment of developmental milestones.

Principles of Development

• Development is a continuous process from conception to maturity

• Development is intimately related to functional maturation of nervous system- opportunity to practice

• Sequence of development is same in all children but rate varies

• Development is in cephalocaudal direction

Principles of Development

•Certain primitive reflexes lost before corresponding voluntary movement is acquired•Initial disorganized mass activity replaced by specific and wilful actions

•Generalizations about development cannot be based on the assessment of skills in a single developmental domain. However, skills in one developmental domain do influence the acquisition and assessment of skills in other domains.

• Factors Affecting Development– Prenatal factors

1.Genetic factors. 2.Maternal factors.

Maternal nutritionExposure to drugsMaternal diseases and infections

– Neonatal factors- 1.IUGR 2.Prematurity 3.Perinatal asphyxia

– Post neonatal factors- •Nutrition Iron deficiency Iodine deficiency Infectious diseases Environmental toxins Acquired insults to brain Associated impairments

-Psychosocial factorsParentingPovertyLack of stimulationViolence and abuseMaternal depressionInstitutionalization

Protective Factors

Breast feedingMaternal education

Examination: Observations and Interactive Assessment

• Should take in place in a room with toys appropriate for child

• With one or both parents, but no prompting and helping

• Child’s behavior and interaction with parents during history taking should be observed prior to physical examination

• Normal functioning of motor, vision and hearing should be assessed

Prerequisites

• Infant or child in a good temper

• Should not be hungry, tired, unwell, had convulsion prior, under influence of sedative or antiepileptic drugs

Equipment Required

• Nine red cubes• Hand bell• Red ring tied to a sting• Colored and uncolored geometric forms• Red pencil and paper• Cards with circle, cross, square, triangle, diamond drawn

on them• spoon• Cup with handleo Paper Pellets( 8mm)

• Gross motor development

• Fine motor development

• Social/Cognitive/intellectual development

• Speech and language development

• Vision and hearing development

Different Domains of Development

Gross motor developmental milestone

Age Milestone

3 months Neck Holding; Brings hands together in midline

4months Asymmetric tonic reflex gone

5 months Rolls over

6 months Sits in tripod fashion

8 months Sitting without support

9 months Stands with support

12 Months Creeps well; walks but falls; stands without support

15 months Walks alone; creeps upstairs

18 months Runs; explores drawers

2 years Walks up and downstairs; jumps

3 years Rides tricycle; alternate feet going upstairs

4 years Hops on one foot; alternate feet going downstairs

Lift Head

Sit

Crawl

Walk

Fine motor developmental milestones

Age Milestone

4 months Bidextrous reach;palmar grasp gone

6 months Unidextrous reach; transfer object

9 months Immature pincer grasp; probes with forefinger

12 months Pincer grasp mature

15 months Imitates scribbling; tower of 2 blocks

18 months Scribbles; tower of 3 blocks

2 years Tower of 6 blocks; vertical and circular stroke

3 years Tower of 9 blocks; copies circle

4 years Copies cross; bridge with blocks

5 years Copies triangle;gate with blocks

Social and adaptive milestones

Age Milestones

2 months Social smile

3 months Recognizes mother; anticipates feeds

6 months Recognizes strange/ stranger anxiety

9 months Waves ‘bye-bye’

12 months Comes when called; plays simple ball game

15 months Jargon

18 months Copies parents in task

2 years Asks for food, drink, toilet; pulls people to show toys

3 years Shares toys; knows full name and gender

4 years Plays cooperatively in a group; goes to toilet alone

5 years Helps in household tasks; dresses and undresses

language milestones

Age Milestone

1 months Alerts to sound

3 months Coos

4 months Laugh loud

6 months Monosyllables

9 months Bisyllables

12 months 1-2 words with meaning

18 months 8-10 words vocabulary

2 years 2-3 words sentence, use pronouns ”I”, “me”, “you”

3 years Ask questions; knows full name and gender

4 years Says song or poem; tells stories

5 years Asks meaning of words

Hearing Development

• BAER hearing test (brainstem auditory evoked response) done at birth

• Ability to hear correlates with ability pronounce words properly

• Always ask about history of otitis media – ear infection

• Repeat hearing screening test

Copyright ©1997 American Academy of Pediatrics

Johnson, C. P. et al. Pediatrics in Review 1997;18:224-242

Orienting to sound of bell

5 months 7 months 9.5 months

VISION DEVELOPMENT

• 1 month – baby can fixate on his mother as she talks to him

• 3-4 months : child can fixate intently on an object shown to him (grasping with eye)

• 6 weeks : binocular vision begins and is well established by 4 months

• 6 months : child adjusts his position to follow object of interest

• 1 year : follow rapidly moving objects

Time of Assessment

• Developmental surveillance- every well- child visit

• Developmental screening- – May be completed by parent or clinician– Using standardized tool at 9, 18 and 30 months– Example-

• Denver II developmental screening test• Phatak’s Baroda Screening Test• Trivandrum Development Screening Chart• CAT/Clams ( Clinical adaptive test/ clinical linguistic and

auditory milestone scale) • Goodenough- Harris Draw-a-person test

Denver II Developmental Screening Test

• Most widely used test for screening• Assesses child development in four domains

gross motor

fine motor adaptive

language

personal social behavior• These domains are presented as age norms,

just like physical growth curves.

Phatak’s Baroda Screening Test

• Indian adaptation of Bayley’s Development scale

• India’s best known development testing system

• Used by child psychologists rather then physicians

Trivandrum Development Screening Chart

• Simplified adaption of Baroda Development Screening System

• Consist Domains are gross motor, fine motor and cognitive

• 0-2 years by para medical health worker• Consists of 17 items selected from BSID

Baroda norms• Time required- 5 mins• Sensitivity 0.67 specificity 0.79• Good for mass screening

INCLUDE 17 ITEMS1.Social smile2.Eyes follow pen/pencil3.Holds head steady4.Rolls from back to stomach5.Turns head to sound of bell/ rattle6.Transfer objects hand to hand7.Raises self to sitting position8.Standing up by furniture9.Fine prehension pellet10.Pat a cake11.Walk with help12.Throws ball13.Walk alone14.Says two words15.Walks backwards16.Walks upstars wiyh help17.Points to part of a doll

DEVELOPMENT ASSESSMENT TOOL FOR ANGANWADIS (DATA )

• Brief ,simple and psychometrically sound measure for anganwadis

• Mainly for toddlers

• Identify at risk ,mild delay ,moderate deley and severe delay

12 ITEMS

• GROSS MOTORKicks stationary ballJumps in place• FINE MOTORFolds paper in to half in imitationOpens stacking barrel and takes out beads• COGNITIVEFinds specific objects on requestPlaces objects on request

• PERSONAL SOCIAL Differentiate between edible and non edible substances

Proper bowel /bladder control• EXPRESSIVE LANGUAGE Combine two words to express possesion Can ask “what is this ? “• RECEPTIVE LANGUAGE Points to common objects described by its

use Points to picture of action

Clinical Adaptive Test

– Developmental Screening Test for age under 24 months

– Two test combination• Clinical Adaptive Test (CAT)

• Clinical Linguistic Auditory Milestone Scale (CLAMS)

– Language assessment tool– Distinguish Language Delay from mental retardation

Goodenough ‘draw a man test’

Definitive Tests

• Bayley Scales of Infant Development • Wechsler Intelligence Scale for children IV• Stanford-Binet Intelligence Scale 5th edition• Vineland adaptive behaviour scale II• Developmental activities screening inventory 2nd edition

Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)

• Age Range (in years) - Birth to3.5 years • Method of Administration/Format

Individually administered in play-based format for Cognitive, Language , and Motor Scales; caregiver questionnaire for Social-Emotional and Adaptive Functioning. Yields scaled scores, composite scores, and percentile ranks.

• Approximate Time to Administer –

50 min. for 1-12 mos.;

90 min. for 13-42 mos.

Subscales

Cognitive; Language (Receptive, Expressive, Total); Motor (Fine-Motor, Gross-Motor, Total); Social-Emotional; Adaptive Behavior (Communication, Community Use, Functional Pre-Academics, Home Living, Health & Safety, Leisure, Self-Care, Self-Direction, Social, Motor, Total)

Stanford-Binet Intelligence Scale

• Description– Intelligence Testing of ages 2 to 23 years and beyond– Yields Intelligence Quotient (IQ)

• Scoring

– Standardized Scoring– Composite mean of 100 with standard deviation of 16

• Interpretation: • Mental Retardation IQ Definitions

– Borderline mental retardation: 70 -79– Mild mental retardation: 65-69– Moderate mental retardation: 40-54– Severe mental retardation: 30-39– Profound mental retardation: <30

Wechsler Intelligence Scale

• Description– Intelligence Testing– Mean score of 100 with standard deviation of 15– Gives verbal and performance scores

– Broken into subtests each with a mean of 10• Age specific Wechsler tests

– Wechsler Preschool Primary Scale Intelligence (WPPSI-R)• Used for ages 3 to 7 years

– Wechsler Intelligence Scale for Children (WISCIII)• Used for ages 6 to 16 years

– Wechsler Adult Intelligence Scale (WAIS-R)• Used for ages 16 years and older

•

DEVELOPMENTAL ACTIVITIES SCREENING INVENTORY-SECOND EDITION (DASI-II)

• Age Range (in years)- Birth - 5 years• Method of Administration/Format

Individually administered informal screening measure; may be presented as a nonverbal test; 67 perceptual, motor, and cognitive tasks Yields Developmental Quotient

• Approximate Time to Administer -25-30 min • Subscales -Developmental Quotient

Developmental Quotient (DQ)

Ratio of the functional age to the chronological age. It is a means to simply express a developmental delay.

DQ= ((developmental age) / (chronological age)) * 100

• If the infant was born prematurely the chronological age should be corrected for the gestational age at birth during the first year of life.

• The adaptive developmental quotient uses a development measure such as the Gesell scales. Similar quotients may use IQ or other measures.

Interpretation

maximum score =100

> = 85 normal

71-84 mild-to-moderate delay

<= 70 severe delay

Vineland adaptive behavior scale II

• Age Range (in years)- Birth - 89 years• Method of Administration/Format

Measures personal and social skills in 4 domains (communication, daily living skills, socialization and motor skills)

• Approximate Time to Administer -30-60 min

Assessment of Development

• Developmental milestones serve as the basis of most standardized assessment and screening tools

• Two separate developmental assessment over time are more predictive than a single one.

• Developmental monitoring not only should be aimed at identifying children who have low function, but at directing the focus of anticipatory guidance to help promote normal development.

Approach

History and examination- Check for age appropriate milestone

Check for milestones achieved in the past- what and when

Check for milestones in the other domains

Global Developmental Delay Delay in specific domain

Absent

SIGNIFICANT DELAY

Discrepancy 25% or more OR 1.5 to 2 SD from normal

GLOBAL DEVELOPMENT DELAY

Delay in 2 or more domains of development

DEVELOPMENT DEVIANCE

When child develop milestone or skill outside typical acquisition of sequence

DEVELOPMENT DISSOCIATION

When child has widely differing rates of development in different domains of development

DEVELOPMENT REGRESSION

When child loses previously acquired skills or milestone

Purpose of Assessment

• Whether there is impairment or not in development• Make a diagnosis if possible

• Seek to intervene positively to improve outcome and function for the child and family– Reinforcing acquired skills– Teach developmentally appropriate skills– Provide missed experience– Make use of other skills to overcome difficulties– Use learning style to promote learning

Red Flags: Birth to three month

– Rolling prior to 3 months• Evaluate for hypertonia

– Persistent fisting at 3 months• Evaluate for neuromotor dysfunction

– Failure to alert to environmental stimuli• Evaluate for sensory Impairment

Red Flags: 4 to 6 months

– Poor head control• Evaluate for hypotonia

– Failure to reach for objects by 5 months• Evaluate for motor, visual or cognitive deficits

– Absent Smile• Evaluate for visual loss• Evaluate for attachment problems• Evaluate maternal Major Depression

• Consider Child Abuse or child neglect in severe cases


– Persistence of primitive reflexes after 6 months• Evaluate for neuromuscular disorder

– Absent babbling by 6 months• Evaluate for hearing deficit

– Absent stranger anxiety by 7 months• May be related to multiple care providers

– Inability to localize sound by 10 months• Evaluate for unilateral Hearing Loss

– Persistent mouthing of objects at 12 months• May indicate lack of intellectual curiosity


– Lack of consonant production by 15 months• Evaluate for Mild Hearing Loss

– Lack of imitation by 16 months• Evaluate for hearing deficit• Evaluate for cognitive or socialization deficit

– Hand dominance prior to 18 months• May indicate contralateral weakness with Hemiparesis

– Inability to walk up and down stairs at 24 months• May lack opportunity rather than motor deficit


– Advanced non-communicative speech (e.g. Echolalia)

• Simple commands not understood suggests abnormality

• Evaluate for Autism• Evaluate for pervasive developmental disorder

– Delayed Language Development• Requires Hearing Loss evaluation in all children

Best tests( in our setting)

• For infant: Phatak’s Baroda Screening Test

• For pre school child: Bayley Scales of Infant and Toddler Development-Third

Edition (Bayley-III)

• For school going child: Wechsler Intelligence Scale

Thank You

Health & Medicine

Sridhar