Developmental assessment and screening

DEVELOPMENTAL ASSESSMENT

AND SCREENINGPRESENTED BYDr.Nasreen Ali

GUIDED BYDr.T.V.Ramkumar

CONTENT INTRODUCTION PRINCIPLES OF DEVELOPMENT GOALS OF DEVELOPMENTAL ASSESSMENT DIFFERENT DOMAINS OF DEVELOPMENT ASSESSMENT OF DEVELOPMENT SCREENING TESTS DEFINITIVE TESTS DEVELOPMENT QUOTIENT CONCLUSION NORMAL DEVELOPMENTAL MILESTONES

NOT DISCUSED HERE.

INTRODUCTION DEVELOPMENT SPECIFIES MATURATION

OF FUNCTIONS.IT IS RELATED TO MATURATION AND MYELINATION OF NERVOUS SYSTEM AND INDICATES ACQUISITION OF A VARIETY OF SKILLS FOR OPTIMUM FUNCTIONING OF THE INDIVIDUAL.

DEVELOPMENTAL ASSESSMENT INCLUDES EARLY IDENTIFICATION OF PROBLEMS THROUGH SCREENING AND SURVILLANCE.

PRINCIPLES

IT IS A CONTINUOUS PROCESS FROM CONCEPTION TO MATURITY

DEVELOPMENT IS INTIMATELY RELATED TO THE MATURATION OF CENTRAL NERVOUS SYSTEM

THE SEQUENCE OF DEVELOPMENT IS IDENTICAL IN ALL CHILDREN BUT THE RATE OF DEVELOPMENT VARIES FROM CHILD TO CHILD

PROCESS OF DEVELOPMENT PROGRESSES IN A CEPHALO CAUDAL DIRECTION

PRIMITIVE REFLEXES HAVE TO BE LOST INITIAL DISORGANIZED MASS ACTIVITY IS

REPLACED BY SPECIFIC AND USEFUL ACTIONS

GOAL THE GOAL OF DEVELOPMENTAL

ASSESSMENT IS NOT ONLY TO GENERATE A DIAGNOSIS BUT ALSO TO ANALYSE THE PATTERN OF STRENGTHS AND WEAKNESS IN ORDER TO DIRECT TREATMENT.

INDICATIONS OF DEVELOPMENTAL ASSESSMENT FOLLOW UP OF HIGH RISK NEONATES

FOR EARLY DETECTION OF CEREBRAL PALSY ADD\OR MENTAL RETARDATION

COMPLETE EVALUATION OF CHILDREN WITH DEVELOPMENTAL,CHROMOSOMAL OR NEUROLOGICAL DISORDERS

TO DIFFERNTIATE CHILDREN WITH RETARDATION IN SPECIFIC FIELDS OF DEVELOPMENT AS OPPOSED TO THOSE WITH GLOBAL RETARDATION

FACTORS AFFECTING DEVELOMENT

•PARENTING•POVERTY•LACK OF STIMULAION

•VIOLENCE AND ABUSE

•MATERNAL DEPRESSION

•INSTITUTIONALIS

•INFANT AND CHILD NUTRITION

•IRON DEFICIENCY•IODINE DEFICIENCY•INECTIOUS DISEASE

• IUGR• PREMATURITY• PERINATAL

ASPHYXIA

• MATERNAL FACTORS

GENETIC FACORS

NEONATAL

PSYCHO-SOCIALPOST

NEONATALPROTECTIVEBREAS

T FEEDINGMATERNAL EDU

DOMAINS OF DEVELOPMENT GROSS MOTOR FINE MOTOR PERSONAL AND SOCIAL LANGUAGE VISION HEARING

DEVELOPMENTAL ASSESSMENT

PROCEDURE DEVELOPMENTAL MILESTONES SERVE

AS AN IMPORTANT BASIS OF MOST STANDARDIZED ASSESSMENT AND SCREENING TOOLS

TWO SEPARATE DEVEVELOPMENTAL ASSESSMENT OVER TIME ARE MORE PRODUCTIVE THAN A SINGLE ONE

DEVELOPMENTAL HISTORY WHETHER PARENTS ARE CONCERNED

OR NOT RIGHT QUESTIONS AGE SPECIFIC QUESTIONS CHECK DOUBTFUL REPLY CHECK THE ANSWERS ABOUT ONE

MILESTONES BY ANOTHER AND BY EXAMINATION

FAMILY HISTORY-FIRST, SECOND AND

THIRD DEGREE RELATIVE SOCIAL HISTORY-CAPACITY TO COPE

WITH A CHILD WITH DISABILITY

PREREQUISITES Should be done in a place free from

distractions Child should not be – hungry, tired, ill or

irritated Playful mood with mother around Adequate time to make child & family

comfortable Carry a development kit

ASSESSMENT OF NORMAL DEVELOPMENT PRE SCHOOL AGE- PLAY,CLIMBING STAIRS,SPEECH,FEEDING PERFORMANCE- understanding,

matching colour COMPREHENSION OF LANGUAGE

SCHOOL AGE Test for reading ,arithmatic function Test for deafness and physical

examination Vision by 3-5 years of age Intelligence assessment

EQUIPMENT REQUIRED

Ten one inch cubes Hand bell Simple formboard Goddard formboard Coloured and uncoloured geometric

forms Picture cards Cards with circle,cross,sqare,triangle

and diamond drawn on them Patellar hammer Paper Pellets(8mm)

PHYSICAL EXAMINATION GENERAL EXAMINATION- weight, height

and head circumference, malnutrition ,pallor, rickets and dysmorphic facies

SYSTEMIC EXAMINATION-cns BONES AND JOINTS-deformities and

contracture NEURO MUSCULAR EXAMINATION IN

INFANTS- tone, deep tendon reflex , primitive reflex and postural reflex.

NEUROLOGICAL EXAMINATION AMIEL TISONS ANGLES-- Adductor angle Heel to ear Popliteal angle Dorsiflexion angle of foot Scarf sign

NEUROLOGICAL ASSESSMENTANGLES 1-3

MONTHS4-6MONTHS

7-9MONTHS

10-12MONTHS

ADDUCTOR

40-80 70-110 100-150 130-150

HEEL TO EAR

80-100 90-130 120-150 140-170

POPLITEAL

80-100 90-130 120-150 140-170

DORSI FLEXION

45 45 45 45

SCARF SIGN

ELBOW NOT CROSS MIDLINE

ELBOW CROSS MIDLINE

ELBOW REACHES AXILLA

ELBOW BEYOND AXILLA

ASSESSMENT OF GROSS MOTOR DEVELOPMENT The acquisition of gross motor skills

precedes the development of fine motor skills

Both process occur in cephalocaudal fashion

-head control precedes arm and hand control

-followed by leg and foot control

PLAY AND SOCIAL INTERACTION Observe exploration and free play and

initiation of response to social games like peek a boo

Note initiating interaction and responding to parent/examiner/other children and use of eye contact and gestures

LANGUAGE AND COMMUNICATION Observe vocalization and gestures to

attract others attention, to indicate needs . in response to others vocalization and to share emotion

Note speech quality ,use of language to express and responding to conversation

HEARING DEVELOPMENT BERA hearing test done at birth Ability to hear correlates with ability to

pronounce words properly Ask about the h/o otitis media Repeat hearing screening test Speech therapist if needed

ASSESSMENT OF VISION New born-Follows red ring through 45* 4 weeks-Follows red ring through 90* 3 months--Follows red ring through 180* 4months- Follows red ring through 360* 3-5months-hand regard 5 months-excitement to see food being

prepared

TEST COGNITIVE AND ADAPTIVE MILESTONES Object permanence Causality Imitation Colour and shape recognization Language mainly receptive Fine motor

SCREENING IT IS A BRIEF,FORMAL,STANDARDIZED

EVALUATION AID IN THE EARLY IDENTIFICTION OF THE PATIENT WITH DEVELOPMENTAL\BEHAVIOURAL DELAY

TYPES- Informal screening Routine formal screening Focused screening-more important in

high risk infants.

SPECIFIC SCREENING TOOLS Neuromotor-INFANIB Autism-childhood autism rating scale(CARS) Modified checklist for autism in toddler(M-

CHAT) Preschool skills-Brigance pre school skills

test Behavioral problems-child behavior check

list(CBCL) Early childhood interventory-3-6 yrs Child and adolescent symptom

inventory>6YRS ADHD-conners rating scale(CRS)

COMPARISON OF DEVELOPMENTAL

SCREENING TOOLS OF INTERNATIONAL ORIGIN

Factors Denver DevelopmentalScreening Test  II

Bayley Infant Neuro-developmental Screen  (BINS)

Parents Evaluationof Developmental Status (PEDS)

Ages and stages questionnaire (ASQ) 

Developmental* Profile II/ III 

AGE FORMAT

0-6 yearsDirectly administered

3-24  monthDirectly administered

0-8 yearsParent-report

1 -66  /3- 66 mParent report

0-9 y/ 12 y11m Parent report  

SCREENS\DOMAINS

Expressive & receptivelanguage, gross motor, fine motor, personalsocial

Neurological processes, expressive and receptive functions& cognitive

Cognitive, expressive&  receptive language fine &  gross motor, social-emotional, behavior, self-help& school

Communication, gross motor, fine motor,problem-solving, andpersonal adaptive skills

Physical, Self-help/   Adaptive, Social/Social-emotional,Academic/ cognitiveand Communication   

ITEMS 125 11-13 10 22-36 186\180SCORING\RESULT

Normal\abnormal\questionable

High/low/moderate

Low/medium/high

Pass/fail Total score gives domain wise age equivalents

TIME(min) 10-20 10 2-10 10-15 10/20-40LANGUAGE English/

spanishEnglish english English/

hindienglish

PSYCHOMETRIC PROPERTIES

sensitivity- 0.56-0.83 0.75-0.86 Specificity- 0.43-0.80 0.75-0.86

0.74-0.79

0.70-0.80

0.70-0.90

0.76-0.91

Validity coefficients

0.52-0.72

VALIDATED IN INDIA NOT

NOT SN 62%SP 65%

83.3%74.5%

NOTUsed extensively

COST$ 111 325

30 249 240

COMPARISON OF INDIAN DEVELOPMENTAL

SCREENING TOOLS

FACTORS BARODA DEVELOPMENTAL SCREENING TEST(BDST)

TRIVANDRUM DEVELOPMENTAL SCREENING CHART(TDSC)

ICMR PSYCHOSOCIAL DEVELOPMENTAL SCREENING TEST

DEVELOPED FROM

BAYLEY SCALE OF INFANT DEVELOPMENT,NORMATIVE DATA FROM INDIAN CHILDREN

BAYLEY SCALE OF INFANT DEVELOPMENT(BARODA NORMS)

PROGRAMME FOR ESTIMATING AGE RELATED CENTILES USING PIECE WISE POLYNOMIALS

AGE 0-30 MONTHS 0-24 MONTHS 0-6 YEARS

FORMAT 54 ITEMS 17 ITEMS PARENTS INTERVIEW64 ITEMS

DOMAINS MOTOR AND COGNITIVE

MENTAL AND MOTOR

GROSS MOTOR.VISION,HEARING,FINE MOTOR AND SOCIAL SKILLS

SCORING/RESULTS

AGE EQUIVALENT AND DEVELOPMENT QUOTIENT CALCULATED

WITHIN AGE RANGE

3RD,5TH,25TH,50TH,75TH,95THAND 97TH CENTILE.SIGNIFICANT DELAY IN <3RD CENTILE(2SD)

TRAINING MINIMAL MINIMAL NONE

SETTING COMMUNITY/OFFICE

COMMUNITY/OFFICE

COMMUNITY/OFFICE

TIME TAKEN(MIN)

10 10 MINIMAL

PSYCHOMETRICPROPERTIES

SN-65-93%SP-77.4-94.4%

66.8%78.8%

NOT GIVEN

COST INEXPENSIVE INEXPENSIVE FREE

BIRTH TO ONE YEAR DEVELOPMENTAL OBSERVATION

CARD Completed 2 months-social smile Completed 4 months-holds head study Completed 8 months-sits alone Completed 12 months-stands alone

BIRTH TO TWO YEARS TRIVANDRUM DEVELOPMENTAL

SCREENING CHART Can be used in large scale community

by anganwadi workers

TRIVANDRUM DEVELOPMENT SCREENING CHART

3%

97%

TWO TO FOUR YEARS DEVELOPMENTAL ASSESSEMENT

TOOLS FOR ANGANWADI(DATA) BRIEF,SIMPLE AND PSYCHOMETRICALLY

STRONG FOR ANGANWADI TO DIFFERENTIATE THOSE WHO

ALREADY HAVE DELAYS AT 2.5 YEARSFROM THOSE WHO ARE AT RISK OF DEVELOPMENTAL DELAY

REGULAR DEVELOPMENTAL ASSESSMENT AT 3.5YRS,4.5YRS

FOUR TO SIX YEARS NURSERY EVALUATION SCALE

TRIVANDRUM(NEST)-ABRIDGED This tool has been developed and

validated at Child Development Centre, Thiruvananthapuram, Kerala. It is a functional assessment of pre-school children between 4 – 6 years. It is a guideline to pre-school teachers as to the individual child’s holistic development. It serves as a screening tool to identify pre-school children who needs one-to-one instructions. 

DENVER DEVELOPMENTAL SREENING TEST 2

Assessment of infant and pre school children

125 items 4 categories-gross motor\fine motor or

adaptive\language\personal or social Items are arranged in chronological order

according to the ages at which most children pass them

Performance rated as PASS\CAUTION\DELAY

DEVELOPMENTAL ASSESSMENT SCALE FOR INDIAN INFANTS

Gold standard for developmental evaluation

Two scales-mental and motor scale Mental development index –MDI Psychomotor development index -PDI

DEFINITIVE TESTS If screening tests or clinical assessment are

abnormal Some common scales

Bayley scale for infant development IIWechsler intelligence scale for children IVStanford-Binet intelligence scales , 5th editn.Developmental Activities Screening Inventory

STANFORD-BINNET INTELLIGENCE SCALE Intelligence testing for ages 2-23 years

and beyond Yields intelligence quotient(IQ) Scoring-standardized scoring Composite mean 100 with SD 16

INTERPRETATION- Boderline MR-70-79 Mild MR-65-69 moderateMR-40-64 Severe MR-30-39 Profound<30

WECHSLER INTELLIGENCE SCALE DESCRIPTION Intelligence testing Mean score-100 with SD 15 Gives verbal and performance score Broken into subsets each with a mean of 10 AGE SPECIFIC WECHLER TEST Wechsler preschool primary scale

intelligence(WPPSI-R)-3-7 YEARS Wechsler intelligence scale for children(WISC

3)-6-16 YEARS Wechsler adult intelligence scale(WAIS-R)->16

YEARS

DEVELOPMENTAL ACTIVITIES SCREENING INVENTORY SECOND EDITION-DASI 2 Age range in years-birth to 5 years Method of administration/format- Individually administered informal

screening measure,may be presented as non-verbal test

67 tests Yield development quotient Time-25-30 min Sub scales-developmental quotient

DEVELOPMENTAL QUOTIENT DQ=developmental age\chronological

age*100 For The infants who were born

prematurely should the chronological age should be corrected during the gestational age till 2yrs of life

Interpretation- >=85-normal 71-84-mild to moderate <=70-severe delay

CONCLUSIONTHERE SHOULD BE A CHILD DEVELOPMENT AND EARLY

INTERVENTIONAL CLINIC-CDEIC

RED FLAG SIGNS:BIRTH TO 3 MONTHS Rolling prior to 3 months-EVALUATE FOR

HYPERTONIA Persistent fisting for 3 months-

NEUROMOTOR DYSFUNCTION Failure to alert to environmental stimuli-

SENSORY IMPAIREMENT

RED FLAGS FROM 4 TO 6 MONTHS Poor head control-HYPOTONIA Failure to reach for objects for 5 months-

MOTOR,VISUAL OR COGNITIVE DEFECTS Absent smile-VISUAL LOSS,ATTACHMENT

PROBLEMS,MAJOR MATERNAL DEPRESSION,CHILD ABUSE OR NEGLECT

RED FLAG 6 TO 12 MONTHSPersistence of primitive reflex after 6

months-NEUROMUSCULAR DISORDERAbsent babbling for 6 months-HEARING

DEFECTAbsent stranger anxiety by 7 months-

MULTIPLE CARE PROVIDERSInability to localize sound by 10 months-

UNILATERAL HEARING LOSSPersistent mouthing of object by 12

months-LACK OF INTELLECTUAL CURIOSITY

RED FLAG 12 TO 24 MONTHS Lack of consonant production by 15

months-MILD HEARING LOSS Lack of imitation by 16 months-HEARING

OR COGNITIVE OR SOCIALIZATION DEFECT

Hand dominance prior to 18 months-C/L WEAKNESS WITH HEMIPARESIS

Inability to walk up and downstairs by 24 month-LACK OF OPPPORTUNITY MORE THAN MOTOR DEFICIT

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