DEVELOPMENTAL ASSESSMENT

VISHNU PRIYA.M
FACTORS AFFECTING
DEVELOPMENT

Physical factors
psychological needs

Stimulation at optimal age

Prenatal and perinatal factors

PRINCIPLES OF
DEVELOPMENT
It is the most distinctive attribute of childhood and is a
continous process from conception to maturity.
Sequence of development is identical but the rate of
development varies from child to child.
Development proceeds in a cephalo-caudal direction.

Development of language is early and an advanced in

girls as compared to boys.
The child with odd-looking face does no have to be
assoociated with mental subnormality necessarily.
METHODS OF
ASSESSMENT
GESSEL- gross motor, social, adaptive behaviour &
language
AMIEL-TISSON muscle tone, neurosensory
responses, neurobehavioural assessment.
VINELAND & RAVALS SOCIAL MATURITY
SCALE social & adaptive mental development.
OTHER METHODS FOR NEUROMOTOR
ASSESSMENT
* BAYLEY scales of infant development
 Contd.,
* BRAZELTON neonatal behaviour scale
* VOJTA technique
* DENVER DEVELOPMENTAL
SCREENING TEST
DEV. QUOTIENT
DQ = DEV AGE/ CHR AGE X 100
development is slow or retarded if D.Q. is less
than 70.
INDICATIONS

Cerebralpalsy or mental retardation

Dysmorphism, development, chromosomal
& neurological disorders
Learning disabilities
Retardation in specific fields
TOOLS OF DEVELOPMENT
ASSESSMENT
History
Physical examination
Denver developmental chart
Specialized developmental testing tools
History

Prenatal and perinatal

history(preterm delivery)
Environmental history
Relevant illnesses-malnutrition
Rate of development
Past history
DEVELOPMENT
HISTORY

Simple language
Whether skill developed, when, how often
Be precise: smiling, talking, sitting,
etc
Assess reliability of the history
Aims at.,

Developmental assessment by
examination
Verifying developmental history
Assessment of quality of milestone
asssessment for etiology of any delays
identified
PHYSICAL
EXAMINATION

Physical growth
Primitive reflexes
Righting reflexes
Protective reflexes
Neurological examination
Developmental testing
ABILITIES AND
REFLEXES OF THE
NEWBORN
Eye reflexes:
Blink reflexes: response to various
stimulus.
Dolls eye response: in the first 10 days
Pupil reflexes: at birth
Resistance to passive opening: at birth
PRIMITIVE
REFLEXES
Survival reflexes that evolve in utero
sequentially
Automatic stereotyped movements
executed by the brain stem
Inhibited by higher cortical centers as
the stereotyped movement pattern is
broken up and integrated into complex
voluntary movements
PRIMITIVE
REFLEXES
Oral reflexes: Sucking, rooting, disappear
around 3 months
Grasp reflexes: palmar grasp disappears
at 3 months, plantar grasp disappears at
6 months
PRIMITIVE
REFLEXES
Moro reflex: disappears by 3 months
Trunk incurvation (Galants reflex):
disappears at 9-18 months
Placing and walking reflexes:
disappear by 5-6 weeks
PRIMITIVE
REFLEXES
The tonic neck reflexes:
Asymmetrical tonic neck reflex (ATNR):
disappears by 3-4 months
Symmetrical tonic neck reflex (STNR): appears
at 6-8 months and disappears with crawling
Landau reflex: develops at 3-10 months and is
lost by 36 months
STNR and Landau are bridging reflexes
ASYMMETRICAL
TONIC NECK
REFLEX
SYMMETRICAL
TONIC NECK
REFLEX
Landau
reflex
POSTURAL AND
PROTECTIVE
REFLEXES
Righting reflexes:
Occulo-head righting reflex
Labyrinthine-head righting reflex
Body righting
Parachute reaction: appears 6-9 mo., persists
through life
HEAD RIGHTING
REFLEXES
PARACHUTE
REFLEX
Primitive reflexes have to be lost before
corresponding voluntary movements can
be acquired
DEVELOPMENTAL
MILESTONES

Gross motor
Fine motor
Social and adaptive
language
GROSS MOTOR

4 months head control, rolls over, between

supported on forearms in prone position
6 months sits with support & round back
8 months sits without supp with a straight
back
10 months climbs and stands with support
CONTD.,
12 months stands without support
15 months walks without support and creeps upstairs
18 months runs, throws a ball while standing
2 years jumps, walks up & downstairs with 2 feet on
each step
3 years rides tricycle, goes upstair with one step on each
step
4 years hop and skip on one foot
5 years skips on both feet
 Red
flags in motor
development:
Persistent fisting beyond 3 months of age
Spontaneous postures: frog like, scissoring,
opisthotonus
Delays in postural reactions, persistent
primitive reflexes
Abnormal movement patterns
Hand dominance prior to 18 months
FROG LIKE
POSITION
SCISSORING
OPISTHOTONUS
FINE MOTOR
3 months holds a pen when placed in hand
4 months reaches out for object with both hands
6 months approaches object wit one hand, transfers it to
other hand
9 months pincer grasp
1 year finger thumb pincer grasp
15 months self feeds wit a cup
18 months self feeds wit a spoon, turns 2-3 pages of a
book at a time
2 years turns a page at a time, imitates vertical &
circular strokes
CONTD.,
3 years can dress & undress, draws a circle
4 years can make a bridge wit blocks, can
copy a square & cross, can button &
unbutton
5 years can copy a triangle, can tie shoe
lays
 Social and
adaptive
2 months social & interactive smile
3 months recognizes mum, excited to see a toy, anticipates feed
6 months pats mirror image, stranger anxiety
9 months waves bye bye
12 months comes when name is called, shakes head for NO
15 months jargon speech
18 months imitates household tasks
2 years asks for food & drink, tells need for toilet
3 years knows his name, age & gender, shares toys
4 years toilet trained, plays cooperatively in a group
5 years dresses & undresses, helps in household tasks
LANGUAGE
1 month quietens or alerts to sounds
3 months babbles & coos when spoken to
4 months laughs loud, turns towards sound
6 months speaks monosyllables
9 months utters disyllables
12 months speaks 2-3 words wit meaning
18 months jargon speech with 7-10 words vocabulary
2 years can make 2-3 word sentences wit a vocabulary
of 50 words, can repeat what is said
CONTD.,

3 years can make 3 word sentences & has

vocabulary of 250 words, normal speech, asks
questions
4 years tells a story, recite a poem, sings a song
5 years chatter box & asks meaning of words
DEVELOPMENTAL
SCREEN
RED FLAGS
Finemotor:
Motor:
4mo: fisting
6 mo: not sitting
10mo: no pincer
15 mo: not walking
20mo: unable to
2yrs: not climbing
remove socks
stairs
2yrs: no scribble
3yrs: not stand on
3yrs: not copy circle
one foot
4yrs: not copy
4yrs: not hopping
square
DEVELOPMENTAL
SCREEN
Language: Psychosocial:
6mo: not babbling 3mo: no smile
9mo: no dada/mama
8mo: no laughing
18mo: < 3 words
1yr: hard to console
2yrs: no 2 word
phrases 2yrs: kicks, bites,
3yrs: not poor eye contact
comprehensible 3yrs: no playing
4yrs: no prepositions with other kids
ASSESSMENT OF
MUSCLE TONE

It should be assessed when baby is alert, wide

awake, not crying & should lie in supine wit
head in midline
The muscle tone is evaluated by
Looking for abnormal posture of limbs
Palpation of muscles for flabby or firm feel
Range of motion & resistance encountered at
major joints
By shaking unsupported limb for range &
flaility or stiffness of movements
RANGE OF
MOVEMENTS AT
MAJOR JOINTS IS
TESTED AS FOLLOWS
ADDUCTOR ANGLE:
Infant lies supine wit legs extended & head in
midline. Both hips are abducted maximally by
holding at knees wit index finger over front of
thighs. The angle between thighs is adductor
angle. The angle is narrow & resistance is
encountered during procedure when infant is
hypertonic. Asymmetry between R & L leg
should b noted.
ADDUCTOR
ANGLE
POPLITEAL
ANGLE:
The infant lies supine. The hips are
flexed completely on to the abdomen by
holding at knees. The legs are then extended
by gentle pressure with examiners hands
placed behind legs & popliteal angle is
measured. The resistance encountered is
noted on both sides. The angle is measured
separately on both sides.
POPLITEAL
ANGLE:
DORSIFLEXION
ANGLE OF
FOOT:
The foot is passively dorsiflexed by
applying slight pressure with thumb
placed over sole. Angle between dorsum
of foot & front of leg is noted. During
infancy dorsiflexion angle at ankle is 70
r less
Heel-to-ear
maneuver:
With the infant lying supine, legs
extended at knees are held together &
lifted as far as backwards as possible
towards ears without lifting the pelvis
from the table. Increased resistance on
one side is suggestive of asymmetry of
tone on two sides.
Scarf sign:

The muscle tone in upper limbs is tested by assessing range

of movements at shoulders. The infant lies supine.
Upper limb, flexed at elbow, is pulled as far as possible
across the chest by holding at hand & wrist. The
position of elbow in relation to midline of body is noted.
One limb is tested at a time followed by both limbs
together.
Transitory tone abnormalities (especially hypotonia)
may be noted during first 6 months & they normalize
by the age of one.
Parachute
response:
Hold the child in prone position wit both
hands by waist & suddenly lower him over
a table top. There ll b brisk extension &
abduction of upper limbs wit extension of
fingers as if to break the fall. It is a
protective reflex & appears around 8-9
months of age. It is abs in infants wit
spastic type of CP.
LANDAU
REFLEX:
The infant is suspended in prone position
by supporting abdomen of baby on palm.
The infant spontaneously extends neck,
trunk & legs aft the age of 10 months.
Forcible flexion of neck is associated wit
flexion of hips & legs.
The reflex is absent if there is a disorder of
muscle tone especially in floppy infants.
DEVLOPMENTAL REFLEXES:
REFLEX AGE OF APP. AGE OF
DISAPP.
Rooting BIRTH 3 MONTHS

Moro BIRTH 5-6 MONTHS

Palmar grasp BIRTH 6 MONTHS

Tonic neck BIRTH 9-10 MONTHS

Add spread f BIRTH 7-8 MONTHS

knee jerk
Landau 10 MONTHS 24 MONTHS

Parachute 8-9 MONTHS PERSISTS IN

NORMAL CHILD
Age Adductor Popliteal Dorsiflexion Scarf
(months) angle(in angle angle of the sign
degrees) foot

0-3 40-80 80-100 60-70 Elbow

does not
cross the
midline
4-6 70-110 90-120 60-70 Elbow
crosses
the
midline
7-9 110-140 110-160 60-70 Elbow
goes
beyond
the
anterior
axillary
line
10-12 140-160 150-170 60-70
DEV SCREENING TOOLS:
TRIVANDRUM DEV SCREENING CHART:
It is suitable for screening of children
below 2 years
Range of each item is taken from norms of
bayley scales of infant development
A plastic ruler is kept vertically at level of
chronological age of child being tested.
If it fails to pass any item to left side of
age marker, child is considered to have dev
delay.
BARODA DEV SCREENING TEST:
o 22 motor items & 31 mental items r used.
They were grouped age-wise. One monthly
in first 12 months & 3-monthly thereafter
till 30 months.
o The total number of items passed by a child
is plotted against his chromosmal age.
o When this pt falls below 97 percentile, the
child is considered to have developmental
delay.
Develpomental
delay
Developmental delay in two or more spheres is
called GLOBAL delay & is suggestive of MR.
ISOLATED DELAY in development may occur
in single skill (DQ<70)
DEVIANCY is atypical development within
single stream when a milestone may be skipped or
occur out of sequence.
CONTD.,
DISSOCIATION is significant difference in
rate of deviation between two streams of skill.
DEV REGRESSION is diagnosed when child
loses previously acquired milestones.
Children wit development disturbances are at
risk to manifest behavioural disorders
MENTAL
RETARDATION
Mild: 50-70
Incidence 20-30/1000
Severe: <50

Incidence 3-4/1000
The more severe the retardation, the more
likely an underlying cause is identified
MENTAL
RETARDATION
Majority of prenatal causes are cytogenetic
Down syndrome: most common
microscopically identifiable cause
Fragile X syndrome: most common
inherited cause in males
Rett syndrome: most common genetic cause
of mental retardation in girls
MENTAL
RETARDATION
Other prenatal causes include
Congenital hypothyroidism
CNS malformations
TORSCH infection
Toxins and teratogens
Inborn errors of metabolism
 DOWN
SYNDROME

Most common chromosomal

abnormality among live born infants
Most common cause of mental
retardation caused by microscopically
demonstrable chromosomal abnormality
DOWN
SYNDROME

1/1000 live births

Maternal age:

33yrs: 1/625 live births have chromosomal

anomaly
45yrs: 130 live birth have chromosomal
anomaly
Genetics:

Trisomy 21: 47, +21

Robertsonian translocation
DOWN SYNDROME-
DYSMORPHIC
FEATURES
Head and neck:
Brachycephaly
Upslanting palpebral fissures
Epicanthal folds
Flat nasal bridge
Folded or dysplastic ears
Small ears
Open mouth and protruded, furrowed tongue
Short neck
DOWN SYNDROME-
DYSMORPHIC
FEATURES
Extremities

Short broad hands

Incurved fifth finger
Transverse palmar crease (simian crease)
Space between first and second toes
Hyperflexibility of joints
FRAGILE X
SYNDROME
Mild to severe mental retardation,
behavioral problems, and speech and
language delays
Narrow face, large jaw, elongated
prominent ears, macroorchidism
Diagnosed by assessment of CGG repeats
(cell culture in follate deficient medium not
reliable)
RETT SYNDROME
Young females
Normal early development and head
circumference
Loss of communication skills
Deceleration of head growth
CONGENITAL
HYPOTHYROIDISM
Most common treatable cause of MR
Inverse relationship between age at
diagnosis and IQ later in life
Asymptomatic at birth, sporadic
Most common cause is thyroid dysgenesis,
15% are hereditary related to inborn errors
of thyroid hormone synthesis
SPEECH AND
LANGUAGE DELAY
Expressive language delay: the most
common delay encountered
Delayed language and speech cause
significant social and educational
disruption
HEARING LOSS
All children with speech and language
problems should have an audiometric
assessment
Congenital sensorineural hearing loss is the
most common birth defect
The greater the hearing loss the greater the
deficit
Early diagnosis improves outcome
MOTOR DELAY
Motor delay may be combined with other
delays, e.g. MR, or isolated
Gross motor delay: e.g. CP, ataxia,
myopathy,
If there is no motor delay, the child does
not have CP
Fine motor delay: visual impairment, erbs
palsy, hemiplegia,
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