AN INTRODUCTION TO

NEURODEVELOPMENTAL ASSESSMENT
Rochelle B. Pacifico, MD, FPPS, FPSDBP
November 6, 2014, 8:00-10:00 (A/B)
Pediatrics

“Nobody is one hundred percent perfect. Yung iba nga dito, medical student na nga, hindi parin makasagot eh and who is going to improve on that?
Me?! It is yourself and your will to change for the better, so that you can take on the role of being a doctor in the future.” – Dr. Rochelle Pacifico

GOALS OF A DEVELOPMENTAL ASSESSMENT PRINCIPLES OF DEVELOPMENT

PRIMARILY: To arrive at a DIAGNOSIS  Continuous process from conception to
 Determine functionality maturity
 Identify strengths and weaknesses  Sequence is the same in all children BUT the
 Identify other associated impairments or rate varies
systemic involvements  Intimately related to the maturation of the
 Lay out a plan of management – Early central nervous system
intervention is key!  General mass activity is replaced by specific
 Identify appropriate placement and network individual responses
potential with other agencies  Proceeds in cephalocaudal fashion
 Monitor progress  Certain primitive reflexes have to be lost before
 Prognosticate on future outcome acquiring corresponding voluntary movements
 Identify potential for hereditability (for the Remember that development for GAINING SKILLS proceeds in a
patient’s future pregnancies or children) CEPHALOCAUDAL fashion but for BRAIN DEVELOPMENT (in
 Maximize child’s potential utero) it matures in a CAUDOCEPHALAD nature.
Reflexes are present in infants (up to 6 months) as protective
DEVELOPMENTAL SCREENING mechanisms. They are involuntary and automatic responses. As an
individual matures, they should be able to function voluntarily and
 SCREENING – brief, formal, standardized
these primitive reflexes should be lost eventually for normal
evaluation that identifies children at risk for a development to occur.
developmental disorder
 Determines need for further BRAIN
investigation  Most complex organ system which together
 Not diagnostic with the spinal cord forms the central nervous
 Has established psychometric qualities system
(precision, accuracy, etc.)  Monitors and regulates the body’s actions and
 Easy to perform and interpret, reactions by receiving sensory information,
inexpensive, and accessible to analyzing these data and then responding by
child/parents controlling bodily actions and functions
 Should be done at 9, 18, 24 or 30  Decade of the brain (1990s): with the advent of
months and if with concerns more advance imaging studies ensued greater
understanding of its structure and development
A DEVELOPMENTAL ASSESSMENT is usually done when there is a
disorder that is already identified and a DEVELOPMENTAL IMPORTANT FACTS IN EARLY BRAIN
SCREENING is done to identify the children who are at risk.
It is important to identify children with disabilities as early as possible
DEVELOPMENT
so that intervention may be done during the period of BRAIN  16 days post conception: formation of
PLASTICITY. NEURAL TUBE which fully closes by the 27th
day, beginning transformation into the
PREREQUISITES IN INVESTIGATING embryonic brain and spinal cord
DEVELOPMENTAL DISABILITIES Remember, FORMATION is 16 days post-conception and CLOSURE
 Good understanding of the principles of th
is by the 27 day. This is a critical period because neural tube defects
development may be present if not fully closed by this time.
 Neuroanatomy and physiology (brain plasticity)  Critical nutritional substances:
 Normal developmental schedules  FOLIC ACID
 Presentation of developmental patterns  400 micrograms/day a month before
 History taking and physical examination conception up to the end of the 1st
 Risk factors for developmental problems trimester
 Red flag signs for developmental disorders  IRON
 Spectrum and continuum of developmental  Important for heme development
disorders needed by hemoglobin which carries
OXYGEN.
Transcribers: Lenz Lester Tan-Hoyumpa D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 1 of 8
Formatting: Gladys Dianne Hulipas
Editing: John Neal Bastona
  During fetal development, proliferation and
migration of neurons mostly occurs
 Approximately 100 billion neurons by 5 months
AOG
DENDRITES receive information (DATING) while AXONS send
information (AWAY). The axons connect with dendrites of
adjacent neurons. Synaptic clefts are where the
neurotransmitters are deposited. In the end of axons there are
vesicles that contain neurotransmitters and when an impulse
courses through the neuron, the vesicles will release
neurotransmitters and the receptor sites in the dendrites receive
them and ensure the transmission of an impulse. To have an
efficient impulse there should be a good concentration of
neurotransmitters, rich number of receptors and the enzymes
that cause reuptake of neurotransmitters should be kept at bay.
These should be understood because this where MEDICAL
INTERVENTION for developmental disorders come in to play.
 Neurotransmitters:
 Norepinephrine
 Dopamine
 GABA (γ-Aminobutyric acid)
CNS MATURES IN A CAUDO-CEPHALAD
NATURE
1st TRIMESTER: SPINAL CORD DEVELOPMENT
 5th week AOG: synapses form in the spinal cord
– First fetal movements (arching and curling of
the body)
 8th week AOG: limb movement
 10th week AOG: finger movement, stretching,
yawning, sucking, swallowing, thumb sucking
 End of the 1st trimester: rich fetal movement
which will be evident to mom between the 4th
and 5th month AOG
During history taking, it is important to ask the mother WHEN the
first movement was felt to know whether there is already a delay or
not.
Notice the application of the principle in neurodevelopment, gross
movement develops BEFORE fine motor movement.
2ND TRIMESTER: BRAINSTEM DEVELOPMENT
 Marks the onset of other critical reflexes
(breathing, coordinated sucking and
swallowing)
 Control of heart rate, breathing and blood
pressure
Transcribers: Lenz Lester Tan-Hoyumpa
Formatting: Gladys Dianne Hulipas
Editing: John Neal Bastona
3RD TRIMESTER: CEREBRAL CORTICAL
FUNCTION
 “Start of mental Life” (conscious experience,
voluntary actions and eventually, thinking and
remembering) (At this time, the fetus is already
able to hear the mother’s heartbeat.)
 Towards end of 3rd trimester: primary
sensory regions (touch, vision, hearing) and
primary motor regions
BRAIN
 At birth, brain size is ¼ an adult brain and
distinct parts are in place. >80% by 3 years old
and >90% by 5 years old

The brain of a five year old is already practically an adult brain –
this is important to know because this is the age-limit of brain
plasticity (3-5 years). So if you want an intelligent child with good
behavior and manners teach them well until they are 5 years old.
 High stores of fat (60% brain weight, 40% DHA)
DHA (Docosahexaenoic acid): is an omega-3 fatty acid that is a
primary structural component of the human brain and is needed for
myelin formation.
 Increased speed of neural processing during
infancy and childhood, to a maximum at 15
years old  MYELINATION (after this age,
myelination slows down)
 Necessary for clear and efficient
transmission of impulses
 Only adversely influenced by severe
malnutrition (more of lack of nutrition)
 CEREBRAL CORTEX: still primitive at birth.
Higher cognitive functions like perception,
thoughts, memories and feelings start to
develop after birth. Experiences play a large
role in development.
 After birth, formation of neuronal circuits, along
with neuronal death and rapid formation and
elimination of synapses occurs in the cerebral
cortex
 Period of exuberance: burst of synapse
formation (2 million/second) all over the cerebral
cortex throughout middle childhood (4-8
years old). From 8 years old to end of
adolescence synaptogenesis declines as
pruning occurs.
During the period of exuberance, a lot of synaptic pathways are
created and in time, these pathways will become chaotic. PRUNING
is the removal, by apoptosis, of the pathways that are seldom
used. This will enhance the capacity of the child to perform and
D L S H acquire
S I Mskills.
e d i c i n e B a t c h 2 0 1 6 | 2 of 8
efficiently
  “Use it or lose it” Principle: synaptogenesis is
“activity dependent”  BRAIN PLASTICITY
“USE IT OR LOSE IT” PRINCIPLE: INFORMATION AND
STRUCTURE that is used will remain while those not used will be lost.
BRAIN PLASTICITY is best during 3-5 years of life. During this
period, through correct intervention, other parts of the brain of a
child with neurodevelopmental problems can compensate and take
on the role of the parts that are damaged.
 Throughout increasing age and development,
brain structures increase in size and functions
become more specialized and coordinated.
Adult brain
EPIGENETICS
 Heritable changes in gene activity and
expression that occurs without alteration of
DNA sequence (as opposed to GENE MUTATION
where there is ALTERATION of DNA sequence)
 Alterations are non-genetic (if “switched on,”
these alterations are heritable and may be passed on
to the next generation)
 DNA methylation
 Histone modification
Transcribers: Lenz Lester Tan-Hoyumpa
Formatting: Gladys Dianne Hulipas
Editing: John Neal Bastona
 Ultimately regulate gene activity and expression
during development, differentiation or in
response to environmental stimuli
 Early environmental exposures and experiences
(triggers) can result in “switching on or off”
certain genetic predispositions that we can pass
on to subsequent generations
An example for epigenetics is an environmental change during early
exposure to screens (phones, TV or tablets). According to different
pediatric associations, no screen time should be allowed for children 2
years of age and below regardless of content because it may lead to
ADHD, autism etc.
These periods are protracted periods in an individual’s
development where certain skills are best stimulated because
they will respond very well to external stimuli. For instance,
VISION AND HEARING periods are very sensitive immediately
after a baby is born (birth-1.5 years old) so if you want a child to
have astute vision and good hearing then stimulate them at
these time periods. Introduce music for hearing and for vision,
stimulate them with red, black and white contrasting patterns
that are not moving. LANGUAGE is best stimulated at around 6
months, so if you want a multilingual child this is the best time
to teach them up until the age of 3-4.PEER SOCIAL SKILLS
starts at 2 years up to 3 years old. NUMBERS at 2-3 years of
age. EMOTIONAL CONTROL starts early and MORALITY
should have been taught by three years of age.
It is important to know the parts of the functional brain to assess
which corresponding functions may be lost when there are injuries
to any of its parts. This is important in planning the TREATMENT
for the patient.
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 EVOLUTIONARY PATTERN OF DEVELOPMENTAL
STAGE AGE EXPECTED MILESTONE
DELAY
 Grossly normal features  Dysmorphisms
 Feeding  Poor suck/cry
INFANCY  Ambulation  Hyper/hypotonus
(<24 months)  Awareness of surroundings  Poor head control
(TRUST)  Poor visual tracking
 Lack of auditory response
 Poor mother-child interaction
TODDLER  Language skills  Absent/delayed independent sitting, ambulation, vocalization
(2-3 years old)  Toilet training  Disorganized behavior
(AUTONOMY)
 Appropriate behavior  Delayed language development
PRE-SCHOOLER  School readiness  Hyperactivity, inattentiveness and poor impulse control
(4-6 years old)
 Graphomotor skills
(INITIATIVE)
 Bladder/bowel control
SCHOOL AGE  Socially acceptable behavior  Academic underachievement/school failures
(7-10 years old)  Academic achievement  Conduct problems
(INDUSTRY)  Aggression
 Puberty  Delayed sexual maturation
ADOLESCENT  Establishing self-identity  Poor social skills
(11-19 years old)
 Personality/conduct problems
(IDENTITY)
 Defiant behavior

RED FLAG SIGNS LANGUAGE

5-6 months Not babbling
SKILL MEDIAN AGE AGE RANGE
Walking 13 months 8 – 18 months 8-9 months Not saying “da” or “ba”
First word spoken 14 months 10 – 23 months 10-11 months No 2 syllable babble
1.5 years Has less than 3 words with meaning
 Limit ages become the basis for considering 2 years No 2 word phrases or repetition of phrases
non-acquisition of a skill as a developmental red 2.5 years Not using at least 1 personal pronoun
flag. Red flags will tell you that there is already 3.5 years Speech only half understandable
something wrong in the development of a child. 4 years Does not understand prepositions
 Non-acquisition of age expected milestone 5 years Not using proper syntax in short sentences
also helps determine the validity of a
PERSONAL AND SOCIAL
developmental concern.
3 months Not smiling socially
GROSS MOTOR 6-8 months Not laughing in playful situations
4.5 months Does not pull to sit up Hard to console
1 year
5 months Does not roll over Stiffens when approached
7-8 months Does not sit without support Kicks, bites and screams easily without
9-10 months Does not stand while holding on provocation
15 months Not walking 2 years Rocks back and forth in crib
2 years Not climbing up or down the stairs No eye contact nor engagement with other
2.5 years Not jumping with both feet children or any significant adult
3 years Does not stand momentarily on 1 foot In constant motion
4 years Not hopping 3-6 years Resists discipline
Unable to walk a straight line or balance on Does not play with other children
5 years COGNITION
foot for 5-10 seconds
FINE MOTOR 2-3 months Not alert to mother, without special interest
3-5 months Persistence of grasp reflex 6-7 months Not searching for dropped objects
4-5 months Unable to hold a rattle 8-9 months No interest in peek-a-boo
7 months Unable to hold a rattle in each hand 12 months Does not search for hidden objects
10-11 months Absence of pincer’s grip 15-18 months No interest in cause and effect games
15 months Unable to put in and out of container 2 years Does not categorize similarities
Unable to stack 5 blocks 3 years Does not know own full name
2 years 4 years Cannot pick shorter or longer of 2 lines
Not scribbling
2.5 years Not turning a single page of a book 4.5 years Cannot count sequentially
Unable to stack 8 blocks 5 years Does not know colors or any letter
3 years 5.5 years Does not know own birthday or address
Unable to draw straight line
Unable to stack 10 blocks
4 years
Unable to draw a circle
4.5 years Unable to copy a square
5 years Unable to build a staircase of blocks

Transcribers: Lenz Lester Tan-Hoyumpa D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 4 of 8

Formatting: Gladys Dianne Hulipas
Editing: John Neal Bastona
CERTAIN BEHAVIORS THAT ALMOST ALWAYS GROWTH MEASUREMENTS
INDICATE DEVELOPMENTAL ABNORMALITY GROWTH CHARTS
 Fetal hyper/hypoactivity (Mental retardation, Down  Number of standard deviations (SD) that an
syndrome) infant deviates from the mean
 Failure to thrive (Nutritional disorders, Inborn errors of  Z score = (measured value – mean) / SD
metabolism)
 Arching (Cerebral palsy) -3 Extremely low
 Standoffishness (walang pakialam sa iba) -2 Very low
 Toe walking (Autism, Cerebral palsy) -1 Low
 Echolalia (Autism) 0 Normal
 Acting as if deaf +1 High
 Acting as if blind (Autism) +2 Very high
 Quietness (Autism, Selective mutism, Language delay) +3 Extremely high

RISK FACTORS FOR DEVELOPMENTAL ASSESSING FOR WEIGHT STATUS

PROBLEMS
may possibly have a growth problem,
 Biologic and environmental risk factors would Above 2 to Above 3 but better assessed for weight-for-
usually be identified in the different parts of a length/height or BMI for age
pediatric history. A complete physical and 0 Median
neurologic exam must always be done. Below -1 Normal
Below -2 Underweight
BIOLOGIC RISK FACTORS Below -3 Severely underweight
(These are inherent to an individual. Innate and non-modifiable)
 Prematurity
 Intracranial hemorrhage
 Intrauterine growth retardation
 Poor development of the fetus even while inside
the mother (affects development of organs)
 Hypoxic ischemic encephalopathy
 Lack of oxygen supply, lack of blood supply
 Anything that can cause pathology to the brain
can affect development
 Brain abnormalities on imaging studies
 Biochemical abnormalities (E.g. hormone problems,
metabolic disorders)
 Microcephaly
 Congenital malformation
 Sepsis/Meningitis
 Lung disease
 Neonatal seizures ASSESSING FOR STUNTING
 Maternal substance abuse (maternal exposure) Above 3+ Very tall
(Anything that the mother takes in passes through the Above 2+ No stunting
placenta and goes to the baby, thus affecting the baby Above 1+ No stunting
as well) 0 Median
Below -1 No stunting
EXTERNAL RISK FACTORS Below -2 Stunted
(External risk factors, modifiable) Below -3 Severely stunted
 Continuous exposure to environmental toxicants
 Low socio-economic status
 Absence of medical insurance
 Teenage mother
 Mental retardation in a parent or care giver
 Child abuse/neglect
 Dysfunctional/Disrupted family
 Inadequate parenting skills
 Lack of pre-natal care

Transcribers: Lenz Lester Tan-Hoyumpa D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 5 of 8

Formatting: Gladys Dianne Hulipas
Editing: John Neal Bastona
ESTIMATING PROJECTED ADULT HEIGHT  Skin Findings:
 skin discolorations
Above 3+ Very tall
 moles
Above 2+ No stunting
 skin tags
Above 1+ No stunting
 abnormal hair patterns
0 Median
Below -1 No stunting  loose skin folds
Below -2 Stunted  pits and clefts
Below -3 Severely stunted  fibromas
 Organomegaly:
 hepato-splenomegaly
 Eye Findings:
 Cataracts
 lens dislocation
 optic atrophy
 retinal pigmentation
 Abnormal Neurologic Findings:
 gait or movement disorders seizures
 hypo/hyperreflexia
 asymmetrical responses
 abnormal motor tone and strength
 soft neurologic signs
 persistence of primitive reflexes (If there
are abnormalities present grossly then assess
for possible abnormalities internally.)

A formal assessment tool is utilized to generate a

ASSESSING FOR WASTING developmental profile, identify strengths and weaknesses
and attain a definitive diagnosis.
Above 3+ Obese
Above 2+ Overweight
Above 1+ Normal ASSESSING FUNCTIONALITY
0 Median DEVELOPMENTAL QUOTIENT
Below -1 Normal  Measure of a child’s rate of acquiring skills in any
Below -2 Wasted one developmental domain
Below -3 Severely wasted  Can be used to determine a child’s strength or
weakness in terms of developmental domain

𝐹𝑢𝑛𝑐𝑡𝑖𝑜𝑛𝑎𝑙 𝑎𝑔𝑒
𝐷𝑄 = 𝑥 100
𝐶ℎ𝑟𝑜𝑛𝑜𝑙𝑜𝑔𝑖𝑐𝑎𝑙 𝑎𝑔𝑒

*not reported in percentage

Average = 85-115
Deficient = less than or equal to 75
May be assessed as early as 1-2 months of age.

DEVELOPMENTAL PATTERNS
 A developmental pattern is formed after getting
the DQ for the four areas of development. (Gross
motor, Fine motor, Language and Personal/Social)

IMPORTANT CLUES IN PHYSICAL EXAMINATION

 Growth parameters:
 head circumference
 weight
 stature
 asymmetry
 Congenital Anomalies:
 facial dysmorphisms
 heart defects
 limb defects
 genital and gonadal defects
 bone deformities

Transcribers: Lenz Lester Tan-Hoyumpa D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 6 of 8

Formatting: Gladys Dianne Hulipas
Editing: John Neal Bastona
NORMAL
 All four areas of development are normal.
 The sequence of development acquired by the
child corresponds with the CORRECT/
EXPECTED age in ALL areas of development.
DELAYED
 All four areas of development are
abnormal/late (Global delay)
 The child’s acquisition of skills does not fall
within the normal age range
 The most significantly affected area for a
delayed developmental pattern will be the
Personal and Social Development (e.g. Mental
Retardation)
DISSOCIATED
 At least one area of development is delayed
while the other areas are normal.
 E.g. A child with Cerebral Palsy will have an
affected motor development but the language
development may be normal. A child with
hearing impairment will have a delay in language
development but the gross and fine motor
development will be normal.
Transcribers: Lenz Lester Tan-Hoyumpa
Formatting: Gladys Dianne Hulipas
Editing: John Neal Bastona
DEVIANT
 Skills within an area of development may
be abnormal while other skills are normal.
 Within one area of development, there are
some skills which are normal, and others that
are not. (That is why there are gaps.)The correct
sequence of acquiring skills is not followed and
does not progress continuously.
 E.g. A child with a cleft lip will have a problem in
the LANGUAGE area of development. The
expressive language skills, like speech, may be
impaired but the comprehensive language skills,
like following instructions, may be normal.
Children with autism will have a language delay
because they may not understand what people
are saying but they are able to read a whole page
in one glance. Children born without limbs may
have problems in personal and social
development because their ability to perform
skills that require ambulation will be affected
while other skills will be normal.
COMMON DIAGNOSTIC PROCEDURES UTILIZED
IN A DEVELOPMENTAL ASSESSMENT
 Formal assessment tool/Psychometric test
 Chromosomal analysis
 Imaging studies – CT scan, MRI, Cranial UTZ or
those of other organ systems (These are used to
check for small/big head circumference or asymmetry)
 Radiographic studies, Bone aging (AP view of the
LEFT wrist is checked because it develops first.)
 Newborn screening (To check for congenital
disorders that cause mental retardation, usually done
nd
in 2 Day of life, Congenital Hypothyroidism,
Congenital Adrenal Hyperplasia, Galactosemia, G6PD,
Phenylketonuria and Maple Syrup Disease)
 Urine metabolic screening (To check for metabolic
disorders. Patients will present as small and wasted
with organomegaly and frequent diarrhea/vomiting)
 Blood gas analysis
 Serum ammonia/Electrolytes
 Thyroid/Liver function tests (Application: If a child
who has mental retardation caused by
hypothyroidism persists beyond four months, then
there is nothing that may be done about it. Early
symptoms of hypothyroidism include hypotonia,
prolonged jaundice and fontanels that do not close.)
 EMG/NCV/EEG (EMG –Electromyography, NCV –
Nerve Conduction Velocity, EEG –
Electroencephalogram, OAE – Otoacoustic Emission)
 Audiologic brainstem evoked response, Play
audiometry, OAE
 Fundoscopy, Electroretinography, Visual evoked
response
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 7 of 8
GENERAL RULES IN PERFORMING A  The more significantly delayed a
DEVELOPMENTAL ASSESSMENT developmental profile, the more likely an
 Structural CNS anomalies ALWAYS suggest organic etiology will be identified
problems in development  The earlier the problem is manifested, the more
 Look for other dysmorphologies in the presence significant the developmental condition
of one  Severe developmental disorders are less
 More abnormalities found usually connote a frequently encountered compared to milder
forms
more significant disability
 Most disorders have genetic sources and are
 Multiple anomalies and organ involvement
usually suggest an earlier embryonic insult therefore often heritable
 The most common concern in development is
DELAYED EMERGENCE OF SPEECH

REVIEW QUESTIONS:
1. When are recommended time (in mos.) to conduct developmental assessment?
2. What are the expected milestones at Toddler stage?
3. At what age the absence of hopping is considered as a red flag sign?
4. What is the age range for the absence of interactive play considered as a red flag sign?
5. At what age range, electronic screens are ABSOLUTELY prohibited to children?
6. What is the pattern of brain development in children?
7. What is the pattern of skills acquisition in children?
8. A developmental pattern wherein only one area is delayed?
9. Give one example of a delayed developmental pattern?
10. At what trimester the brainstem starts its maximal development?

-END-

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Editor’s note: Memorize the Red Flag signs! Analyze the Developmental Patterns! Memorize the Scores for Growth
REMARKS Development!
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“If they can’t learn the way we teach, we teach the way they learn.”
- O. Ivar Lovass, on children with neurodevelopmental disorders

“You don't have to be disabled to be different, because everybody's different.”

- Daniel Tammet, Born on a Blue Day: Inside the Extraordinary Mind of an Autistic Savant

Transcribers: Lenz Lester Tan-Hoyumpa D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 8 of 8

Formatting: Gladys Dianne Hulipas
Editing: John Neal Bastona