SCREENING FOR ABNORMAL CHILD DEVELOPMENT Low Poh Sim Contents Areas of child development Normal developmental patterns in the first 5 years Who is at risk of abnormal development When to refer for further assessment 1
The following four different areas of child development proceed in a normal child in an integrated manner. 1. Gross motor development 2. Vision and fine motor development 3. Hearing and speech 4. Social behaviour and play Gross motor development The ability to move through these developmental steps smoothly depends among other things on the normal muscle tone, strength and coordination. The expected norms of gross motor development are outlined in Table 1. Fine motor development It is important to realise that fine manipulative precision is dependent not only on the development of hand skills but also on normal vision. Reaching for an object, bringing an object to mouth, transfer of the object from hand to hand, development of the pincer grasp occurs in sequence as shown in Table 1. Hearing and Speech Delays in language development are more common than delays in other domains of development. Cognitive deficit is the most common reason for language delay. The development of speech is closely associated with the ability to hear. All children who have delayed language development should undergo hearing testing to rule out hearing loss. The child's behaviour around others is an important observation to make. A child who is hyperactive but not purposeful in what he does has broader functional disturbance of his brain of which lack of language development is just a feature. A child who is behaving as though in a world of his own with lack of ability to relate to others and avoiding eye contact may be autistic. Table 2 is a check-list of language milestones for the first 5 years of life. A clinical approach to a child with delayed speech development is shown on alogarithm 1. Social Behaviour and Play Infants triple their birth weight at about 12 months i.e. they put on an average of 12.5-15g/day from 5-12 months. During the preschool years, children are rapidly developing patterns of social behaviour. Table 3 summarises the early social behaviour of a child. Who is at risk? In general, allowance need to be made for prematurity, social and environmental factors that may result in lack of opportunities in attainment of milestones. 2
Those at risk for delay in gross and fine motor skills are children with problems of tone, power, coordination children with joint and ligament abnormalities children with mental retardation children with multiple disabilities children with problems with balance (gross motor skill) children with visual impairment (fine motor skill) Those at risk for delay in language development are children with mental retardation children with cerebral palsy children with deafness children with autism children with multiple disabilities Those at risk for abnormal social development are children with mental retardation children with autism children with hyperactivity When to refer for further assessment 1. Mother's suspicion that her child is not seeing, hearing, moving his limbs or taking notice like other children of his age is to be taken for evaluation very seriously. 2. Gross motor developmental signs a. A child rolling over before 3 months of age may have stiff limbs. b. Poor head control by 5 months. c. Persistent toe walking. 3. Fine motor developmental signs a. Hands that are persistently fisted at 3 months of age b. Fixed hand preference before the age of 18 months may indicate weakness of the less preferred hand. 4. Possible visual impairment a. Visual inattention b. Inability to visually fixate and to follow moving objects 5. Possible deafness a. Unresponsiveness to sound stimuli b. Delayed development of vocalisation or speech c. Absence of babbling at 6 months 3
6. Abnormal speech development a. Lack of spoken words by 18 months b. Persistence of echolalia at 2-2½ years 7. Abnormal social development a. Lack of interest in people or playthings b. Gaze avoidance Algorithm 1: Clinical Approach to Delayed Speech Development Delayed Speech Global Developmental Delay Isolated Speech Delay Developmental Speech Delay Exclude Mental retardation Multiple disabilities Cerebral palsy Good speech comprehension with face seen Good expressive pantomime Poor reaction to sounds Poor social interaction with other people Makes noise, echolalic Exclude Deafness ExcludeAutistic Spectrum Disorders 4
TABLE 1. MOTOR DEVELOPMENT IN THE FIRST FIVE YEARS OF AGE Age Gross Motor Skills Fine Motor Skills 1 mo Lying on tummy, head up Hands tightly fisted 3 mo Good head control. Lying on tummy, head up and rests on forearms 6 mo Rolls over Sits with support, propping up with own hands Bears weight in legs when supported to stand 9 mo Commando crawls Sits without support, gets into sitting position Pulls to stand 12 mo Crawls Stands alone Walks with one hand held / cruises / independent steps 18 mo Walks well alone Climbs on furniture Walks backwards Throws a ball while standing 24 mo Walks up / down stairs with hand held or holding to rail Jumps in place Kicks ball / throws ball over hand 2½ yrs Runs well Jumps with 2 feet together from low step 3 yrs Walks alone upstairs with alternating feet Walks downstairs 2 feet to a step Rides tricycle Stands momentarily on one foot 4 yrs Walks or runs up and down stairs, one foot to step Throws, catches, bounces and kicks a ball 5 yrs Skips, hops Skilful in climbing, sliding and swinging Hands unfisted Reaches for object, puts object to mouth, may be able to transfer object hand to hand Grasp a cube with palm, rakes objects with fingers into palm Immature pincer grasp Pokes / points with index finger Claps hands Waves Precise release of a pellet into small container Builds tower of up to 4 cubes Scribbles spontaneously Beginning to show hand preference Builds tower of 6 cubes Imitates vertical stroke Turns pages singly, enjoys picture books Imitates horizontal line and circle Copies circle. Imitates cross Draws man with head and 1 or 2 other parts Matches 2 or 3 primary colours Cuts with scissors Holds and uses pencil with good control (like adult) Draws a man with head, legs, trunk, arm and fingers Matches and names primary colours correctly Copies square and triangle Writes a few letters spontaneously 5
TABLE 2. DEVELOPMENT OF LANGUAGE SKILLS DURING THE FIRST 5 YEARS OF LIFE Age Receptive Expressive Warning Signs 1 mo Alert to sound Cries No response to sounds?deaf 2 mo Looks at speaker Social smile, coos, vocalises 4 mo Cries discriminately (hunger, pain) Laughs, says ah-goo Listens and vocalises in response 6 mo Laterally localises source of sound Babbles "baba, gaga" Absent babbling indicates possible hearing deficit 8 mo Plays peek-a-boo Mimics sounds 10 mo Comprehends "no" Answers to name 12 mo Looks at familiar family member when named Follows commands like "give me" 14 mo Looks appropriately when asked "Where is (familiar object)?" Follows command without gesture 18 mo Points to 3 body parts Points to self Carries out simple instructions Dada/Mama appropriately Waves Bye-bye First word Imitates simple sounds Immature jargoning 2 to 3 words 10-25 words Including thank you, let's go, I want Names one picture on command Inability to localise sound may indicate hearing loss 24 mo Points to 4-6 pictures Carries out 2-step commands Understands me/you 50+ words 2-3 word sentences (noun-verb) Refers to self by name Uses "I", "you", "me" Non-communicative speech (echoing, repeating by rote memory) may indicate autism 2½ yrs Knows full name Stuttering common 3 yrs Listens to stories, knows nursery rhymes 4 yrs Enjoys jokes Listens to stories Gives full name, sex and may be age Carries out simple conversations Asks many questions Sings nursery rhymes Tells imaginative stories Count by rote up to 20 5 yrs Enjoys riddles Speaks fluently 6
TABLE 3. DEVELOPMENT OF SOCIAL BEHAVIOUR AND PLAY IN THE FIRST FIVE YEARS OF AGE Age Behaviour 5-6 wks Social smile Stops crying when picked up or spoken to Responsive vocalisation 3 mo Gazes on mother's face when feeding Smiles, coos, excited movements to familiar situations like feeding or bathing 6 mo Grasps small toys Takes everything to mouth Shakes rattle for sound May begin to show anxiety with strangers 9 mo Distinguishes strangers from familiars Claps Plays peek-a-boo 12 mo Holds and drinks from a cup Takes toys to mouth less often Helps with dressing Stops drooling Gives toys to adults on request Waves bye bye 18 mo Holds cup between both hands, drinks with little spilling Takes off shoes, socks No longer takes toys to mouth Stills wets, may have bowel control Imitates simple daily activities such as feeding dolls 2 yrs Spoon feeds self with messing Indicates toilet needs Usually dry through day Very curious, demanding for attention and easily frustrated Rebellious, temper tantrums 3 yrs Feed self without spilling much Washes and dries hands and face Dry by day and night Puts on pants, shoes and socks but cannot button Understands sharing Active in make belief play 4 yrs Towel dry after a bath Brushes teeth Dresses completely, distinguishes front from back Understands turn-taking 5 yrs Bathes or showers without assistance Understands rules for games Understands meaning of clock-time 7