ASSESSING A CHILDS MILESTONES

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ASSESSING A CHILDS MILESTONES

• Dr. Renzo De Gabriele M.D.

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Developmental Milestones

• A set of functional skills or age-specific tasks
  that most children can do at a certain age range
• Every child is unique.
• Although each milestone has an age level, the
  actual age when a normally developing child
  reaches that milestone can vary quite a bit. 

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SCREENING FOR DISORDERS

• 12 to 16 of children had developmental
  disabilities.1
• Early intervention is crucial.
• It helps to maximize a child's
• developmental potential
• functional abilities (social communication,
  mobility and adaptive skills).
• It helps to limit maladaptive functioning.
• It will help in providing preventive strategies.
• early diagnosis of a genetic disorder, metabolic
  or infectious disease can prevent another child
  from being born with the same disability
• parental understanding and collaboration
• 1 Boyle CA, Decoufle P, Yeargin-Allsoop MY.
  Prevalence and health impact of developmental
  disabilities. Pediatrics
• 1994 93863-865

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Obstacles in identifying problems

• Natural wide variation among children
• Normal developmental spurts and lags within the
  child
• Adjust milestones according to prematurity
• Gender differences
• Fears and unwillingness to confront reality
• "The child will grow out of it"

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Prenatal Maternal Risk Factors

• Acute or chronic illness e.g. HIV ve mothers
• Poor nutrition
• Use of drugs or alcohol
• Eclampsia

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Perinatal Risk Factors

• Obstetric complications
• Prematurity (less than 33 weeks)
• Low birth weight (less than 1500g)
• Multiple births

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Neonatal Risk Factors

• Neurological events e.g. seizures
• Sepsis or meningitis
• Severe jaundice
• Hypoxia due to breathing difficulties
• Neonatal intensive care unit admission for more
  than 5 days

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Postnatal Risk Factors

• Seizures
• Sepsis or meningitis
• Recurrent ear infections
• Poor feeding
• Poor growth
• Exposure to lead or other toxins

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Risk Factors in the Family History

• Developmental delay (difficulty walking, talking,
  learning)
• Neurological disease (muscle weakness, seizures,
  migraines)
• Deafness/Blindness
• Known chromosomal abnormalities

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Risk Factors in the Social History

• History of abuse or neglect
• Limited financial or social support
• Teenage/Single parent
• Mentally retarded parent
• Stressful life events (e.g. separation of
  parents, death or unemployment of parent)
• Substance abuse in the home

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Assessment

• General appearance
• Eyes
• Cardiovascular Genitourinary systems
• Hips checked for congenital dislocation

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Assessment

• small or large head circumference
• very short or very long stature
• obesity
• limb and other skeletal deformities
• unusual shape or position of ears

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Assessment

• Information from parents is very important
• Your Childs Guide to Health booklet
• Ages Stages Questionnaires

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Assessment

• The best predictors of development are skills
  relating to brain functioning.
• Motor milestones
• excellent indicators of movement skills
• correlate poorly with intellectual functioning
• Language and problem solving milestones
• the best insights into intellectual potential
• Psychosocial abilities
• critical to understand the whole child
• critical in making a meaningful assessment about
  behaviour
• do little in assessing motor and intellectual
  skills

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Age 4 to 6 weeks

• Movement
• Brings hands within range of eyes and mouth
• Head flops backward if unsupported
• Keeps hands in tight fists
• Strong reflex movements

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Age 4 to 6 weeks

• Vision
• Eyes wander and occasionally cross
• Prefers black-and-white or high-contrast patterns
  
• Prefers the human face to all other patterns
• Hearing
• May turn toward familiar sounds and voices

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Age 3 months

• Movement
• When lying on stomach, raises head and chest
  supports upper body with arms
• Opens and shuts hands
• Pushes down on his legs when his feet are placed
  on a firm surface
• Brings hand to mouth
• Takes swipes at dangling objects with hands

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Age 3 months

• Vision
• Watches faces intently
• Follows moving objects
• Recognizes familiar objects and people at a
  distance
• Starts using hands and eyes in coordination
• Hearing and Speech
• Smiles at the sound of your voice
• Begins to babble
• Turns head toward direction of sound
• Social/Emotional
• Begins to develop a social smile
• Enjoys playing with other people, and may cry
  when playing stops
• Imitates some movements and facial expressions

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Age 7 months

• Movement
• Rolls both ways (front to back, back to front)
• Sits with, and then without, support on hands
• Supports whole weight on legs
• Reaches with one hand and transfers objects from
  hand to hand
• Vision
• Ability to track moving objects improves

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Age 7 months

• Hearing and Speech
• Responds to own name
• Begins to respond to "no"
• Can tell emotions by tone of voice
• Uses voice to express joy and displeasure
• Social and Emotional
• Enjoys social play
• Responds to other people's expressions of emotion
  and often appears joyful
• Cognitive
• Finds partially hidden object
• Explores with hands and mouth

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Age 12 months

• Movement
• Crawls forward on belly
• Pulls self up to stand
• Walks holding on to furniture
• May walk two or three steps without support
• Fine Movement
• Uses pincer grasp
• Bangs two objects together
• Puts objects into and out of container
• Pokes with index finger
• Tries to imitate scribbling

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Age 12 months

• Hearing and Speech
• Responds to simple verbal requests like no
• Uses simple gestures, such as shaking head for
  "no"
• Babbles with inflection (changes in tone)
• Says "dada" and "mama" and tries to imitate words
  
• Cognitive
• Explores objects in many different ways (shaking,
  banging, throwing, dropping)
• Looks at correct picture when the image is named
• Begins to use objects correctly (drinking from
  cup, brushing hair, dialing phone, listening to
  receiver)

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Age 12 months

• Social and Emotional
• Shy or anxious with strangers
• Cries when mother or father leaves
• Shows specific preferences for certain people and
  toys
• Repeats sounds or gestures for attention
• Finger-feeds himself

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Age 24 months

• Movement
• Begins to run
• Pulls toys behind while walking
• Stands on tiptoe
• Kicks a ball
• Climbs onto and down from furniture unassisted
• Walks up and down stairs holding on to support
• Fine movements
• Scribbles
• Builds tower of four blocks or more
• Might use one hand more often than the other

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Age 24 months

• Hearing and Speech
• Recognizes names of familiar people, objects, and
  body parts
• Uses 2 to 4 word sentences (by 18 to 24 months)
• Follows simple instructions
• Social
• Imitates behaviour of others
• More excited about company of other children
• Demonstrates increasing independence
• Begins to show defiant behaviour
• Cognitive
• Begins to sort by shapes and colors
• Begins make-believe play

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Age 36 months

• Movement
• Walks up and down stairs, alternating feet (one
  foot per stair step)
• Pedals tricycle
• Fine movement
• Makes up-and-down, side-to-side, and circular
  lines with crayon
• Turns book pages one at a time
• Builds a tower of more than six blocks

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Age 36 months

• Hearing and speech
• Recognizes and identifies almost all common
  objects and pictures
• Can say name, age, and sex
• Uses pronouns (I, you, me, we, they) and some
  plurals (cars, dogs, cats)
• Strangers can understand most of his words
• Cognitive
• Makes mechanical toys work
• Plays make-believe with dolls, animals, and
  people
• Completes puzzles with three or four pieces

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Age 36 months

• Social
• Imitates adults and playmates
• Spontaneously shows affection for familiar
  playmates
• Can take turns in games
• Objects to major changes in routine

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Vision Assessment

• Impaired vision may affect a childs general
  development and the whole family if the early
  intervention does not start really early.
• In vision screening we have two goals
• to find children who are visually impaired (lt1 -
  2)
• to find children with strabismus and/or
  amblyopia, or at risk of developing them (2-4)
• More than 60 of children with vision problems
  have at least one other impairment or chronic
  illness that affects their functioning

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Examination of vision - Red Reflex

• Shadows may be caused by
• cloudiness of the cornea opacities in the lens
• dislocation of the lens
• vitreous floaters
• remaining foetal structures in the vitreous
• Infants with a large shadow in the red reflex
  need to be referred without delay.

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Examination of vision - Large Eyes

• Large, beautiful eyes that are growing faster
  than usual should raise an alarm.
• Increased pressure may cause
• Photophobia
• Tearing,
• Rubbing of the eyes
• This may be misdiagnosed as allergic
  conjunctivitis.
• The diagnostic feature is the abnormally
  increasing size of the diameter of the iris.

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Ptosis

• This is seen as a drooping lid.
• May disturb development of binocularity and lead
  to amblyopia of the eye with ptosis.
• Ptosis needs to be evaluated early in infancy. If
  the drooping lid does not cover the centre of the
  pupil (the optical axis), the risk of amblyopia
  is small during the first few months of life
  (before the infant learns to sit).
• When the child starts to sit, test that the
  infant uses both eyes equally - cover test.

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Strabismus

• A constant turn of an eye or restricted movements
  of an eye are always an abnormal finding and the
  infant needs to be examined by an
  ophthalmologist.
• After the age of six months, strabismus should
  not occur more than briefly when the child is
  tired.

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Pseudostrabismus

• If there are nasal folds covering the inner part
  of the sclera in both eyes, the child may seem to
  have esotropia (inward squint).
• Especially, when the head is slightly turned, the
  eye seems to be squinting inward.
• This obviously does not need any ophthalmological
  referral.

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Visual Acuity

• Preferential looking test - quantifies visual
  acuity in infancy
• Single symbols test - at the age of 13-14 months.
• General vision screening at the age of 4 years
• designed for detection of amblyopia
• Number or letter charts are used

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Hearing

• Hearing provides for
• emotional contact
• language development
• assistance in the awareness of posture and body
  orientation
• Tests should be done at 6 to 9 months of age and
  at the preschool examination.
• Babies up to 6 months can only be done with
  sophisticated apparatus like brainstem evoked
  response audiometry.

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Childhood Deafness

• Conductive deafness
• affects 4 of school children
• is due to middle ear dysfunction
• almost all cases are due to glue ear following
  otitis media.
• Sensorineural deafness
• occurs in 0.3 of school children
• is due to cochlear or auditory nerve problems

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Testing for Hearing Loss

• The most common type is due to middle ear
  dysfunction.
• Examining for otitis media is very important.
• Careful management and follow-up of children
  reduces the incidence of glue ear.
• If it does not clear with appropriate treatment,
  grommet insertion and adenoidectomy is necessary.

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Distraction Performance Responses

• Distraction Responses
• Infants will turn their head towards the source
  of a quiet sound.
• The examiner stands on one side of the child and
  just outside his range of vision.
• The sound stimulus should be given at ear level.
• One can use a high pitched rattle, spoon in a
  cup, or hand bell.
• A free field pure tone audiometer may be used.
• Performance responses
• From 3 years, a child will play a game of putting
  a toy in a box whenever he hears the sound.

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Audiometry

• Pure tone audiograms
• In the sensorineural type, there is equal
  impairment of bone and air conduction of sound.
• In the conductive type, there is an air-bone gap,
  with bone conduction hearing better than air
  conduction.

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Take-HomeMessages

• Developmental milestones are a set of functional
  skills or age-specific tasks that most children
  can do at a certain age range. 
• Although each milestone has an age level, the
  actual age when a normally developing child
  reaches that milestone can vary quite a bit.
• Identifying and addressing these concerns is of
  great importance so that appropriate intervention
  can be instituted.