A Clue to Developmental Disorders
DEVELOPMENTAL DELAY: A Clue to Developmental Disorders by Joel D. Lazaro (www.youngnutrition.net)
Developmental delay is a common problem of children with an estimated prevalence as high as 10% (Batshaw, 1993). Despite its common occurrence, cues to developmental delay remains to be difficult and challenging for most doctors. It is known that early identification of developmental delay leads to early intervention that promotes good outcome reducing the chances of long- term disability in the child. It is the objective of this article to determine the approach for identifying developmental delay in infants and young children and discuss the approach in the management of a child with developmental delay.
What is the definition of a developmental delay?
Delay is said to exist when a child does not reach developmental milestones at the expected age. This may seem to be a simple definition but in actual clinical practice may be a complicated process to determine. The reasons behind this are as follows: First, there is a wide variation as to what constitute 'normal'. Indeed, normality is infinitely more variable than abnormality and allowance has to be given to cover a broad variation in children’s abilities. Second, children's developmental skills are continuously evolving making it difficult to decide if the delay is something permanent or transient in nature. A common pitfall committed even by doctors is to say that 'the child will outgrow' the delays even before an extensive evaluation has been made. Finally, development is a transactional process with many forces and influences in the child's environment affecting its course throughout life making it difficult to make definitive prognosis regarding future outcomes.
What are the signs to watch out for?
The early identification of developmental disabilities in children rests on the hands of parents and physicians who are attuned to the developmental progress of children. The first order of the day is to be familiar and knowledgeable about the normal progress of development in children. This should be followed by learning the 'red flags' or danger signals of developmental delay in various areas of developmental function as enumerated in Tables 1-4 (Palfrey, 1994). The 'red flags' serve as a guide for healthy professionals on when to recommend for a more extensive neurodevelopmental evaluation
Table 1 Gross Motor: Red flags
4.5 months - Does not pull up to sit
5 months - Does not roll over
7-8 months - Does not sit without support
9-10 months - Does not stand while holding on
18 months - Not walking
2 years old - Not climbing up and downstairs
2.5 years old - Not jumping with both feet
3 years old - Unable to stand on one foot momentarily
Table 2 Fine Motor: Red flags
3.5 months - Persistence of grasp reflex
4-5 months - Unable to hold rattle
7 months - Unable to transfer objects from one hand to another
10-11 months - Absent pincer grasp
15 months - Unable to release objects from hand
2 years old - Unable to scribble
Table 3 Language: Red flags
6 months - Does not turn eyes/head to sound
10 months - Not babbling
15 months - Does not respond to 'no' , 'bye-bye'
18 months - Does not have meaningful words beyond mama/papa
2 years old - No two word phrases
3 years old - No simple sentences
Table 4 Psychosocial: Red flags
3 months - Not smiling socially
6-7 months - Not laughing in playful situation
8-9 months - No interest in peek-a-boo
12 months - Does not search for hidden objects
15-18 months - No interest in cause and effect games
2 years old - Does not engage or interact with other kids
How is developmental delay diagnosed?
The child with developmental delay requires an extensive diagnostic evaluation which aims to: (1) describe the child's current healthy status; (2) describe the child's current functional status, including developmental abilities and disabilities; (3) identify the etiologic cause of the condition; and (4) describe the child's socio-environmental condition (Lepta, 1998).
Clinical History
The physician must perform a systematic history taking with emphasis on identifying established biologic and environmental risk factors implicated in cases of developmental delay (table 5).
Table 5 Risk Factors for Developmental Delay
Prenatal Maternal Factors - Substance abuse (drug/alcohol),Chronic illness
(diabetes), Previous stillbirths or miscarriage
Perinatal factors - Prematurity, Low birth weight, Obstetrical problems
Neonatal factors - Sepsis, meningitis, Seizures, Bleeding, Jaundice
Postnatal factors - Exposure to lead, other toxins,
Seizures,Meningitis/Encephalitis, Growth retardation
Socio-environmental Factors - Child abuse/neglect, Poverty, Stressful life events(death, divorce), Single, teenage parent
The family history may also be helpful because many developmental disorders are genetically based and are passed on from one generation to another. The developmental history is also extremely important as this will chronicle the acquisition of developmental skills at a particular age over a period of time. If accurately gathered, the information will help the health professional in determining whether the developmental delay is inborn or acquired. It should also help distinguish whether there was delayed acquisition of skills or loss/regression of skills.
What are the physical tests to perform?
Abnormalities on physical examination may serve as an indirect indicator of the presence of developmental delay. It may also provide a clue to the etiologic cause of the delay. Anthropometric measurements such as height, weight and head circumference are vital in the assessment as many children developmental delay have co-existing abnormalities in growth patterns. The presence of congenital anomalies or dysomorphic features are also important markers as many genetic syndromes have co-existing developmental disabilities. Functional assessment of sensory functions e.g. hearing and vision must also be included. Finally, a developmentally oriented neurologic examination is vital to the diagnostic process of a child with developmental delay.
What is developmental evaluation?
Standardized evaluation of development is indicated in the comprehensive evaluation of a child who has developmental delay. These may include tests of general intelligence, language, fine motor skills, gross motor skills and social adaptation. The selection of test should relate to the child's condition and should provide a profile of the child's strengths and weaknesses, not just a series of scores. The tests to be valid must also be administered by competent and trained professionals. The results of developmental evaluation will help the health professionals in formulating a developmental diagnosis.
Are the laboratory tests?
There are no standard or routine laboratory studies indicated for a child with developmental delay. The decision to choose a particular diagnostic test will depend on the etiologic cause being implicated as a cause of developmental delay. The test selections are varied and wide-ranging which includes genetic studies, imaging studies, metabolic studies, and electrophysiologic tests (EGG, BAER).
MANAGEMENT OF A CHILD WITH DEVELOPMENTAL DELAY
Regardless of the specific nature of the child's developmental delay, there is unanimous opinion from different sectors (e.g. medical, educational, etc) that early identification of developmental delays leads to early intervention and better outcome for the child. There is sufficient evidence in medical research that the best chance for effecting developmental change is while the nervous system of the very young child is still malleable and responsive (Palfrey, 1994). This concept is called ¡®neuroplasticity'.
Management of a child with developmental delay needs a multidisciplinary approach involving many disciplines providing a variety of effective educational and therapeutic interventions depending on the specific nature and/or etiologic cause of developmental delay. Aside from those mentioned, additional treatment includes (1) health maintenance, (2) treatment of underlying cause (if possible), (3) treatment of associated conditions, (4) relief of symptoms, (5) anticipatory guidance to prevent secondary complications and (6) environmental support (Lipak, 1996). The prognosis of a child with developmental delay varies widely according to the type and severity of the underlying disorder.
Developmental delay is a common problem of children with an estimated prevalence as high as 10% (Batshaw, 1993). Despite its common occurrence, cues to developmental delay remains to be difficult and challenging for most doctors. It is known that early identification of developmental delay leads to early intervention that promotes good outcome reducing the chances of long- term disability in the child. It is the objective of this article to determine the approach for identifying developmental delay in infants and young children and discuss the approach in the management of a child with developmental delay.
What is the definition of a developmental delay?
Delay is said to exist when a child does not reach developmental milestones at the expected age. This may seem to be a simple definition but in actual clinical practice may be a complicated process to determine. The reasons behind this are as follows: First, there is a wide variation as to what constitute 'normal'. Indeed, normality is infinitely more variable than abnormality and allowance has to be given to cover a broad variation in children’s abilities. Second, children's developmental skills are continuously evolving making it difficult to decide if the delay is something permanent or transient in nature. A common pitfall committed even by doctors is to say that 'the child will outgrow' the delays even before an extensive evaluation has been made. Finally, development is a transactional process with many forces and influences in the child's environment affecting its course throughout life making it difficult to make definitive prognosis regarding future outcomes.
What are the signs to watch out for?
The early identification of developmental disabilities in children rests on the hands of parents and physicians who are attuned to the developmental progress of children. The first order of the day is to be familiar and knowledgeable about the normal progress of development in children. This should be followed by learning the 'red flags' or danger signals of developmental delay in various areas of developmental function as enumerated in Tables 1-4 (Palfrey, 1994). The 'red flags' serve as a guide for healthy professionals on when to recommend for a more extensive neurodevelopmental evaluation
Table 1 Gross Motor: Red flags
4.5 months - Does not pull up to sit
5 months - Does not roll over
7-8 months - Does not sit without support
9-10 months - Does not stand while holding on
18 months - Not walking
2 years old - Not climbing up and downstairs
2.5 years old - Not jumping with both feet
3 years old - Unable to stand on one foot momentarily
Table 2 Fine Motor: Red flags
3.5 months - Persistence of grasp reflex
4-5 months - Unable to hold rattle
7 months - Unable to transfer objects from one hand to another
10-11 months - Absent pincer grasp
15 months - Unable to release objects from hand
2 years old - Unable to scribble
Table 3 Language: Red flags
6 months - Does not turn eyes/head to sound
10 months - Not babbling
15 months - Does not respond to 'no' , 'bye-bye'
18 months - Does not have meaningful words beyond mama/papa
2 years old - No two word phrases
3 years old - No simple sentences
Table 4 Psychosocial: Red flags
3 months - Not smiling socially
6-7 months - Not laughing in playful situation
8-9 months - No interest in peek-a-boo
12 months - Does not search for hidden objects
15-18 months - No interest in cause and effect games
2 years old - Does not engage or interact with other kids
How is developmental delay diagnosed?
The child with developmental delay requires an extensive diagnostic evaluation which aims to: (1) describe the child's current healthy status; (2) describe the child's current functional status, including developmental abilities and disabilities; (3) identify the etiologic cause of the condition; and (4) describe the child's socio-environmental condition (Lepta, 1998).
Clinical History
The physician must perform a systematic history taking with emphasis on identifying established biologic and environmental risk factors implicated in cases of developmental delay (table 5).
Table 5 Risk Factors for Developmental Delay
Prenatal Maternal Factors - Substance abuse (drug/alcohol),Chronic illness
(diabetes), Previous stillbirths or miscarriage
Perinatal factors - Prematurity, Low birth weight, Obstetrical problems
Neonatal factors - Sepsis, meningitis, Seizures, Bleeding, Jaundice
Postnatal factors - Exposure to lead, other toxins,
Seizures,Meningitis/Encephalitis, Growth retardation
Socio-environmental Factors - Child abuse/neglect, Poverty, Stressful life events(death, divorce), Single, teenage parent
The family history may also be helpful because many developmental disorders are genetically based and are passed on from one generation to another. The developmental history is also extremely important as this will chronicle the acquisition of developmental skills at a particular age over a period of time. If accurately gathered, the information will help the health professional in determining whether the developmental delay is inborn or acquired. It should also help distinguish whether there was delayed acquisition of skills or loss/regression of skills.
What are the physical tests to perform?
Abnormalities on physical examination may serve as an indirect indicator of the presence of developmental delay. It may also provide a clue to the etiologic cause of the delay. Anthropometric measurements such as height, weight and head circumference are vital in the assessment as many children developmental delay have co-existing abnormalities in growth patterns. The presence of congenital anomalies or dysomorphic features are also important markers as many genetic syndromes have co-existing developmental disabilities. Functional assessment of sensory functions e.g. hearing and vision must also be included. Finally, a developmentally oriented neurologic examination is vital to the diagnostic process of a child with developmental delay.
What is developmental evaluation?
Standardized evaluation of development is indicated in the comprehensive evaluation of a child who has developmental delay. These may include tests of general intelligence, language, fine motor skills, gross motor skills and social adaptation. The selection of test should relate to the child's condition and should provide a profile of the child's strengths and weaknesses, not just a series of scores. The tests to be valid must also be administered by competent and trained professionals. The results of developmental evaluation will help the health professionals in formulating a developmental diagnosis.
Are the laboratory tests?
There are no standard or routine laboratory studies indicated for a child with developmental delay. The decision to choose a particular diagnostic test will depend on the etiologic cause being implicated as a cause of developmental delay. The test selections are varied and wide-ranging which includes genetic studies, imaging studies, metabolic studies, and electrophysiologic tests (EGG, BAER).
MANAGEMENT OF A CHILD WITH DEVELOPMENTAL DELAY
Regardless of the specific nature of the child's developmental delay, there is unanimous opinion from different sectors (e.g. medical, educational, etc) that early identification of developmental delays leads to early intervention and better outcome for the child. There is sufficient evidence in medical research that the best chance for effecting developmental change is while the nervous system of the very young child is still malleable and responsive (Palfrey, 1994). This concept is called ¡®neuroplasticity'.
Management of a child with developmental delay needs a multidisciplinary approach involving many disciplines providing a variety of effective educational and therapeutic interventions depending on the specific nature and/or etiologic cause of developmental delay. Aside from those mentioned, additional treatment includes (1) health maintenance, (2) treatment of underlying cause (if possible), (3) treatment of associated conditions, (4) relief of symptoms, (5) anticipatory guidance to prevent secondary complications and (6) environmental support (Lipak, 1996). The prognosis of a child with developmental delay varies widely according to the type and severity of the underlying disorder.
posted by Nurul Amani at 8/29/2006
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