Professional Documents
Culture Documents
Paediatric developmental
assessment
Ajay Sharma
Tony OSullivan
Gillian Baird
Child development
Child development is a dynamic process. From birth to 5 years, the
typically developing child is transformed from a wholly dependent infant into a relatively independent child at school entry:
mobile, dexterous, communicative, sociable and able to look after
her/his basic needs directly or to seek assistance where necessary. Normal development varies enormously. It is determined
by a complex interplay between environmental factors (maternal
health antenatally, in utero conditions, the birth process, nutrition,
PSYCHIATRY 4:6
13
ASSESSMENT
or severe developmental delay, plateauing or regression of development would also require further assessment and investigations.
Gross motor
Delay in achievement of the gross motor milestones (Figure 1) may
be an indicator of neurological abnormalities and is sometimes associated with a global developmental delay. Although the correlation
between gross motor skills and global developmental level is weak,
there is usually an impact on assessment of skills that depend on an
intact motor system for their expression. Evaluation and interpretation of test needs to be accommodated accordingly.
Developmental assessment involves establishing the childs
progress in the sequence of development and a qualitative description of the childs mobility. Clinical interpretation requires combining this information with the findings of physical examination.
Developmental domains
Developmental milestones or norms are a way of describing development in a sequential manner. Delays in some developmental
sequences may indicate an underlying neurological, visual or hearing problem that requires an early referral for further assessment.
These are indicated below as red flag ages. Children with moderate
Mean age
(months)
Developmental milestone
Any delay
Any delay
78
10
Any delay
1113
18
Sits independently
Walks alone
PSYCHIATRY 4:6
Mean age
(months)
14
ASSESSMENT
Developmental milestone
Mean age
(months)
Mean age
(months)
24
3-cube bridge
33
39
4854
60
10
10
12
13
13
16
24
controlled circular scribble and soon imitate others hand movements to draw a line and later a circular shape before they are
able to copy a pre-drawn circle or other shapes. Children gradually
refine their grasp 50% of children by the age of 3 years and 80%
by 4 years have a good tripod grasp of pencil (Figure 6).
Language and communication
Identification of language impairment needs to combine information from parents, and observations/assessment. Parents
reporting of expressive language is improved by making lists of
spoken words or phrases. As children have good understanding
of daily family routines, their language comprehension is often
overestimated by parents.
Infants show preference to the mothers voice within the first
few days of birth, make responsive cooing sounds within the first
few months and play lap games by 6 months. At around 9 months
the infant begins to combine vocalizations and gestures to convey
wishes, feelings, purpose and experience to others. At this stage,
some infants may imitate the sounds of certain often-repeated
family words. This is followed by the development of speech and
Mean age
(months)
10
10
Drawing milestones
Developmental milestone
Shape copying
12
1618
24
15
Scribble
18
Copies lines
24
Copies a circle
36 (90% by 42 months)
Copies a cross
42 (90% by 48 months)
Copies a square
48
Copies a triangle
60
Copies a diamond
6672
Drawing a person
PSYCHIATRY 4:6
36 (80% by 45 months)
54
15
ASSESSMENT
language understanding and expression with a considerable variation between children (Figure 7).
Mean age
(months)
Range (months)
69
Development of attention
Children pass through a number of different developmental
stages as their attention and listening skills improve. Below are
the 6 main stages.
Stage 1 children at this stage are very distractible. Their attention is held momentarily by whatever is the dominant stimulus
(Year 1).
Stage 2 at this stage children can concentrate on a task of
their own choice. They have to ignore all other things in order to
focus on this one task. Children are very resistant to interference
by an adult (Year 2).
Stage 3 By now, children are beginning to allow an adult to
shift them from one task to another. Attention must still be fully
gained before changing focus (Year 3: single-channel attention).
Stage 4 Children now start to become able to control their
own focus of attention. They move gradually towards needing
to look at an adult only when the directions become difficult to
understand (Year 4: early integrated attention).
Stage 5 At this stage, children are usually entering school.
They can now perform an activity while listening to the teacher
giving directions (Year 5: mature integrated attention).
Stage 6 This is a mature stage where attention skills are flexible and sustained for lengthy periods.
Comprehension/receptive language
Understands no/bye
Recognizes own name
610
12
1015
by 15
by 15
15
1218
18
1521
by 24
24
1827
Functional understanding
30
2133
24
1833
30
2439
by 36
36
3042
Understands comparatives
42
3648
42
3648
48
4260
54
4866
Physical examination
The physical examination is generally left to the end of the assessment, as the child may become upset and this would interfere
with a subsequent developmental examination. The following key
guidelines should be observed.
Motor function determine whether the child has a motor
disorder or if any delay is part of global learning difficulty. Observe
movement patterns and posture during the appointment and developmental examination, when the child is walking, speaking and
handling material. This should give a good idea of the nature and
extent of any motor problem. Formal examination of tone, reflexes
and power is largely confirmatory.
Symmetry Compare the two sides of the body and determine
the childs hand preference. The motor skill, tone reflexes or limb
size may be significantly asymmetrical, suggesting hemisphere
dysfunction or other pathology.
Growth measure the head circumference, height and weight
and plot on a centile growth chart. Compare the consistency of
the parameters and assess the growth rate. If concerned about
the head size, it may be advisable to measure the parents head
circumference (familial inheritance is the usual reason for an
excessively large head, and there may be inherited reasons for
microcephaly).
Sight Examination of the optic discs and fundi will usually
not be possible, but it may be necessary to arrange this via the
ophthalmologist or paediatrician (e.g. for septo-optic dysplasia,
raised intra-cranial pressure).
Malformation look for dysmorphic features and congenital
malformations. They may suggest a particular syndrome or aetiol-
12
1015
69
Pointing to demand
10
914
One word
12
1018
26 words
15
1221
720 words
21
1824
50+ words
24
1827
2 words joining
24
1830
200+ words
30
2436
34 words joining
30
2536
30
3042
Question words
36
3042
Pronouns
42
3648
48
3654
Sentences of 5+ words
48
3654
54
4866
PSYCHIATRY 4:6
16
ASSESSMENT
9 months
Object oriented
exploratory play
(maturing eyehand
co-ordination and
object concepts)
2430 months
34 years
Pretend or imaginative
play
612 months
Social smile
(90% by 6 weeks)
Social anticipation
Lap games
(e.g. peek-a-boo,
pat-a-cake)
1015 months
Joint attention
Points to show
33.5 years
Social imitative play
(e.g. role play)
PSYCHIATRY 4:6
Planning investigations
A differential diagnosis will be based on the results of the developmental assessment, and provides a set of hypotheses about
aetiology. Investigations are planned to test the most reasonable
17
ASSESSMENT
24 months
42 months
moderate
severe
moderate
severe
moderate
severe
Chromosomes
Fragile X
CK (boys)
Urate
T4/TSH#
Plasma AAs#
Toxoplasma
CMV
FBC
Viral antibodies
Rubella
HIV
Urine
CMV
OAs$
MPS
Woods light
* Early in presentation, it is reasonable ro review progress for a short period (e.g. 3 months) and to do investigations as in
moderate column if moderate delay persists over time, with or without intervention.
# If neonatal results available, then use them. If not, repeat.
$ Urine organic acids if child shows moderate delay plus any feeding problems/vomiting.
CK, creatinine kinase; T4/TSH, thyroxine/thyroid stimulating hormone; AA, amino acids; FBC, full blood count; CMV,
cytomegalovirus; OA, organic acid; MPS, mucopolysaccharides.
Reproduced with permission from Talukdar K, OSullivan T. Extract from unpublished work, 2004.
PSYCHIATRY 4:6
likely to be found in a child presenting with severe developmental delay (80%) than in one with moderate developmental delay
(45%). It is beyond the scope of this chapter to discuss the causes
of developmental delay (termed mental retardation in the USA).
Figure 9 offers guidance on the planning of investigations for
developmental delay.
FURTHER READING
Baron-Cohen S, Wheelwright S, Cox A et al. The early identification of
autism: the Checklist for Autism in Toddlers (CHAT). J R Soc Med 2000;
93: 5215.
Bee H. The developing child. Boston, USA: Alleyn and Bacon, 2000.
Capute A J, Pasquale J A. Developmental disabilities in infancy and
childhood. Baltimore, USA: Paul H Brooks, 1996.
Egan D F. Developmental examination of preschool children. Oxford: Mac
Keith Press, 1990.
Frost M, Sharma A. From birth to five years Mary D Sheridan (Revised
and updated). London: Routledge, 1997.
Law J, ed. The early identification of language impairment in children.
London: Chapman Hall, 1992.
Salt A, Gringras P, Dorling J, Hartley L. Developmental delay. In: Moyer V
A, Elliott E, Davis R et al. eds. Evidence based paediatrics and child
health. BMJ 2000; 11724.
18