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Growth & Development

• Growth refers to an increase in physical size of the whole body or any of its parts.

• It is simply a quantitative change in the child’s body.• It can be measured in Kg, pounds, meters, inches, ….. Etc• Development refers to a progressive increase in skill and

capacity of function. • It is a qualitative change in the child’s functioning.• It can be measured through observation.

Important notes

• We will assess two ages; infant and older children.• Be a good observer. • This child has a developmental age of X because:• Gross motor : I have demonstrated that they can do

this but not that• Fine motor : I have demonstrated, etc• 'Demonstrated' is better than 'can' or 'cannot'. It

means that the parents cannot correct you?• Remember you are only assessing the child over a few

minutes. We will decide on today the child can not demonstrate? And not; he can not ?

Developmental domins:

• Includes four areas:

• Gross Motor: sitting, walking, jumping, and overall large muscle movement

• Fine Motor: Eye hand coordination, manipulation of small objects, and problem solving

• Language (Expressive and Receptive): Hearing, understanding, and using language

• Cognitive/Social/Adaptive: Getting along with people and caring for personal needs

TOOLS NEEDED:

• 1. Red yarn pom pom wool ball • 2. Bright color cubes • 3. Rattle with narrow handle• 4. Raisins • 5. Cup, spoon• 6. A 4 size paper• 7. Big size color pencils• 7. Picture cards, multiple picture

books (like bird, fish, dog, bus, fruits etc) on same page,

• 8. Tennis ball• 9. Small doll • 10. Bell• 11. Stickers, sweets for rewards

vision and hearing Fine Motorlanguage

personal social Gross Motor examination

Infants

Developmental domins:

• Includes four areas: • If child is on mum’s lap(most of the time) can do :• -1st vision and hearing, • -2nd Fine Motor, • -3rd language • -4th personal social, • -5th Gross Motor examination• Do not separate for Gross Motor assessment. • Bigger kids can examine on chair.

Vision

• Always do vision before hearing.

• Fixing and following pom pom ball or wool ball horizontally and vertically .

• Check ability to pick up cube.

• Approached to toys

• Observe:• Wearing glasses.

• Conjugated eye gaze and eye contact.

• No rowing eye movement, No squint, No nystagmus

Hearing: Distraction test6-18 months of age

• Use initial distraction with non noise making stimulus in front of child

• Always ask examiner to ring the bell at 20 cm from both ears

• Bell is brought towards ear from behind out of range from visual fields 20 cm away from ears.

• Changes noted are facial expression, vocalizing sounds, head turns.

Fine Motor

• Fine Motor: use toys ( rattle)

• See grasp and how he explore it?

• Look: move from one hand to another and mouthing.

• Small toy for pincer grasp.

• Pointing.

Fine Motor:

• Holds rattles (3 months),

• palmer grasp objects(5 mths),

• transfer cubes(7 mths),

• Raisins for pincer grip(9 mths),

• blocks for stacking,:

• 2 cubes 15 months,

• 3 cubes(18 months)

• 6 cubes(21 months).

• 6 cubes, turn pages (2 yrs),

• 8 cubes (2.5 yrs),

• 9 cubes (3 years), beads, thread, putting on biro, plastic knife, and fork. Comment on personal social interaction, language. Smiling, waving

Language

• Language: any vocalization you heard

• Cooing.

• Babble.

• Responding to name.

• Mama and Baba; not understand.

• First word.

Speech and Language:

• Cooing ( 2mths), • responds to human voice (4 mths), • Babbling (6mths), • Mamma, dada (9mths), • 2 words plus mama, dada(12 mths), • Jargon, points (15mths), • 10 words and says his name, points to 3 body parts, one picture

(18mths), • 2-3 word phrase, name 3 objects, 4 body parts, says no(2 yrs), • know name, age sex (2.5yrs), • preposition, count 1-10, 2 colours (3 yrs), • Name 3 colours, • Converses (4 years)

Social

• Interaction with you and parents.

• Smiling.

• Laugh.

• Stranger awareness.

• Clapping , Bye bye.

• Give something and ask to return back.

Personal social Development Chronologically

1. Focus on faces(4 weeks),

2. social smile(6 weeks),

3. excited with toys(4 months),

4. stranger anxiety, (6 months),

5. responds to No, imitates, (8 months),

6. clapping, bye bye, bang blocks (10 months),

7. picture books( 12 months),

8. kiss mirror (13 months),

9. points(15 months),

10. Body parts(21 months)

• 180 degree flip examination. • Supine: Note posture, abnormal tone and power,

involuntary movements with CP. paucity of movements for hemiplegia.

• Pull to sit: head lag. Sitting: Head and trunk control. Back is straight or rounded.

• Weight bearing: scissoring, hypotonia, advanced weight bearing (CP)

• Ventral suspension: Describe posture, low tone, increase extensor tone.

• Prone: Observe ability to raise head, trunk above horizontal,

Gross Motor: posture & movement

GROSS MOTOR

• Head Hold (16 weeks), • Tripod (6 months), • Bear wt, lifts head(7 months) , • sit well (8 months) • pull to sit and stand, crawl

(10months), • Creep 11 months, • walk with support (1 year), • climb stairs with rail ,throw

ball(18months), • walk upstairs(21 months) • up and down (2 years).

Gross Motor

Fine Motor

Language

Cognitive/Social/Adaptive

Older children

Developmental domins:

• Includes four areas:

• Gross Motor: sitting, walking, jumping, and overall large muscle movement

• Fine Motor: Eye hand coordination, manipulation of small objects, and problem solving

• Language (Expressive and Receptive): Hearing, understanding, and using language

• Cognitive/Social/Adaptive: Getting along with people and caring for personal needs

• Walking, walk backward

• Running

• Jumping

• Standing on one foot.

• Tiptoe

• Ride tricycle and bicycle.

• Hope

• climbing stairs

• Skip

• Throwing and Kick ball.

Gross Motor

• Sequence of approach to gross motor assessment:

• Walk → jump / hop → climb stairs → throw ball

Fine Motor

• Blocks & Cubes

• Book

• Papers & pencil:

• Threading beads.

• Using scissor

• buttons

•Sequence of approach to fine motor assessment•build blocks → hold pen + scribble, → put pellets in bottle →Thread Beads →cut paper → buttons → colors in lines → fold paper

Language

• Call him by name and see response

• Ask what is your name, age, sex?

• Ask labelling of body parts• Ask him to bring ball • Counting.

• Birth day.

• Words and sentences.

• Vocabulary and understand.

Social & play

• Feeding: Drinking, Eating.

• Dressing.

• Self care: Out of nappy, Toilet, teeth brushing.

• Playing: alone, play with others, talking while

playing, roles of games

Age begins Type of play Interaction of play

18 mths ▪ functional play ▪ solitary play

2 yrs ▪ imitative play ▪ parallel play

2.5 yrs ▪ pretend play ▪ interactive play

3 yrs ▪ fantasy / symbolic play

In general:

• The single most common presenting concern

was speech and language delay.

• The most common clinical developmental diagnosis was autism spectrum disorder.

• Global developmental delay.

• ADHD

• Learning Disabilities

• Cognitive impairment

• CP

Red Flag Age Missed Milestones Requiring Intervention

2 mo Lack of visual fixation

No social smile

4–6 mo Fails to track person or object

No steady head control

No response/turn to sound or voice

6 mo Decrease/absence of vocalizations

9–12 mo Fails to sit independently

18 mo Fails to walk independently

Does not seek shared attention to object/event with caregiver

24 mo No single words

36 mo No three word sentences

Cannot follow simple commands

>3 y Speech unintelligible

Dependence on gestures to follow commands

Causes of developmental delay

Approach

• Begin by introducing yourself to parents, hand Wash etc. 1st only look see, play…and examine.

• Inform examiner about your approach either:

- live commentary or

- Summarize after full examination

• Generates a pass/fail score in four development domains

Approach to Developmental Delay

• In history try to focus on: • Family history, • Perinatal , Birth history, Gestational age, Post natal;

HIE, CP, IUI, prematurity.• Presence of medical problems associated with

Developmental Delay.• Assess if any medical problems like Neurologic,

myopathy, dystrophy , • Genetic, syndromes particularly Fragile X, Prader willi• Metabolic disorder • Endocrine exclude Hypothyroidism

Examination

• Inspect for growth parameters (Weight and height) e.g. FTT , under nutrition can have Developmental delay

• Head circumference for micro/macrocephaly• Syndromic/Dysmorphic features e.g. Down’s and other Trisomy,

Fragile X.• Ear exam for recurrent/chronic OM or Hearing loss• Mouth for tongue tie, cleft, tongue movement, gag• Check for Language and Communication• Examine eye for squint, nystagmus, cataract, clouding• Skin for neurocutaneous lesions like café au lait spots• Abdomen for HSM (metabolic disease)• Obvious neurological anomalies like floppy infants, posturing,

hemiplegic posturing, and involuntary movements.• Examine back for spina bifida occulta

Evaluation &Investigations

• Thyroid function testing

• Metabolic screening

• Neuroimaging (MRI vs CT)

• For Genetic Karyotyping, Chromosomal/Cytogenetic Testing ; Down Syndrome (karyotype), Fragile X (FMR1), Rett Syndrome(MECP2), Prader-Willi/Angelman (FISH)

• EEG if suspected seizure activity/encephalopathy (Landau-Kleffner)

• Muscle enzymes CK, LDH and aminoacidogram.

Treatment

• Treat underlying causes if treatable.

• Multidisciplinary

• Speech and Language Pathologist

• Occupational and Physical Therapy

• Social Worker

• Psychological evaluation if needed

• educational facilitator and special school

• Focus on need for services rather than diagnosis

Important MilestonesDomains Development

Receptive language 12 month ▪ responding to their name

18 mth - 2 yrs ▪ pointing to body parts, parents, pictures

12 - 18 mths2 yrs

▪ following instructions- 1 step: throw in the bin- 2 step put this ball in box and bring shoes

Expressive language(verbal & non verbal)

12 month2 yo3yo4yo5yo

▪ mama & papa, pointing to what they want▪ linking words, naming 2 - cat, dog▪ repeats 3 word phrases▪ gives name & identifies colours▪ name colours, self, fluent ▪ repeats 4 - 6 word phrases

Social EmotionalSelf help

(ASD)

3 - 6 mth18 - 24 mth

▪ eye contact▪ reciprocal play▪ pretend play▪ joint referencing, share interest

Gross motor

- to test for GDD

12 - 18 mths2 yr3 yr4 yr5 yr

▪ walk▪ walk sideways 2 steps, kick a ball▪ stand on 1 foot, tiptoe 3 steps▪ stand on 1 foot for 1 secs, tiptoe 4 steps▪ hop 2 hops on 1 foots▪ stand on 1 foot for 5 secs

Fine motor

- to test for GDD

18 mths2 yr3 yr4 yr5 yr

▪ scribbles / line▪ line / circle▪ circle / cross▪ copies square▪ copies triange

▪ 3 blocks▪ 6 blocks▪ 9 blocks

Offer to test hearingAsk for f/h of delayed speech: more common in children with +ve f/h

Summary developmental Milestones

THANKS FOR YOUR ATTENTION