15-Jul-18

 She is not reading well.. She has no

interest in studies..

 He is not walking yet… same age

children are walking well..

 He is not talking yet.. He seems to be

“hyper”

Dr. Srinivasa Raghavan. R

Assistant Professor, Department of Pediatrics,
Mahatma Gandhi Medical College and Research
Institute, Puducherry

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 Evaluate and counsel children

› Developmental delays and disabilities like
autism spectrum disorder, intellectual
disability, and cerebral palsy
› Learning disabilities
› Externalizing disorders- ADHD, ODD
› Tics, Tourette syndrome, and other habit
disorders
› Feeding issues, enuresis and encopresis, and
sleep problems

 Simple developmental surveillance

› Key milestones to be asked at various ages
› Identifying Red flags
 Common developmental problems
› Toddler age group- When to suspect ASD?
› School going age group- When to suspect ID/
SLD?
 Role of Pediatrician in parenting-
developmental stimulation

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 Well child visits at 9, 18, 24-30 months

 Every visit
› Use list of milestones

 M-CHAT at 18-24 months

 Ask for parental concerns- checklist can

be filled prior to coming for visit

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 Measuring tape- pink/ yellow colour

 Torch

 Infant- Red woolen ball suspended by a

string, bell/ rattle, plastic spoons

 Toddler- picture book, doll, building blocks-

6-9- various colours, crayons and paper,
shape sorter

 Older child- story book, pencil and pen

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 Floppiness while in supine and during pull to

sit

 Scissoring or crossing the legs when lifted up

 Standing on toes when made to stand

 Preferential use of one hand

 Head circumference, look for FTT

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 Holding out a toy

› Tracking, turning to
rattle

 Smiling at hand
puppet and reaching
for it

 Taking both toes to

mouth

 Making child stand-

bearing weight on
both feet

 Delayed head control

or rolling over

 Preferential hand use

 Not turning to sounds

of rattle by 6 months

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 7 month old child cooing, babbling,

laughing aloud but not holding his head
steady and not rolling over.

 What would you think?

 Disconnect between motor milestones

and other domains- Neuromuscular
weakness- Floppiness, diminished or
absent reflexes

 5 month old boy- not attained head

control
 Child was born at 32 weeks, hospital stay
for VLBW care- no other risk factors

 Concerned?
 Preterm children- corrected gestational
age

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Focus: motor skills

 Milestones
› Sits well
› Stand by holding
furniture
› Babbling
› Peek a boo play

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 Smile or wave at the child-

looks at you?

 Hide an object under a

towel- remove towel to
find the object?

 Hold out a raisin/ sugar

crystal- Pincer to pick up

 Looks at fan/ light

 Explores mother’s face

 Unable to sit by
himself

 Not looking at
faces/ poor eye
contact

 Bottom shuffling/
awkward crawl

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 Standing on toes

 Unable to sit with legs stretched

forward- W sitting

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 13 month old boy- concerns of standing on

toes and not walking yet
 Well child, no asphyxia, term delivery
 Other milestones- within limits
 Able to glide around on walker, crawls well
 When standing with support- stands on toe
 Neurologically normal

 What may be the reason?

 Name- misnomer
 Walker-experienced infants sat, crawled,
and walked later than no-walker controls
 Affect posture of the child- toe walking,
unstable gait
 Moves around very fast prone for injuries

 Banned in many countries

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Focus: Delays in communication and

language, Autism features

 Able to walk well, runs

well

 Language- follows one

step commands, kinship
words

 Joint attention- pointing

to show/ comment

 Domestic mimicry

 Eye contact when

bathing, dressing

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 Pointing of body parts- able to tell 6 parts

 Offer a toy- hugs stuffed doll- looks at

mother for approval? Smiles at her if he
likes

 Functional object use- comb use

 Picture book- turns pages, shows mother

familiar objects

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 Social referencing
› Anxious- looks at you and mother before getting
down
› Encountering new situations- reads parents faces

 18 months- Look for cues from caregiver

when encountering something new

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 Play with a puppet- approach close to

child- eye contact

 No intent to communicate
› Poor gestures- not even nodding or waving
or pointing

 Poor eye contact and poor response to

name calls

 Not able to stand/ walk steadily without

support

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 2 word phrases

 Indicates basic needs

 Runs, jumps, throws ball overhand, walks

downstarirs

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 Answers to question- what is your name?

nods yes

 Book- identifies pointed objects

 Blocks- Tower of 9 cubes, sorts shapes

 Flying kiss, high five

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 Crayon and paper- standing and

sleeping line, circular scribbles, copies
circle

 See the child as he enters in- greet you

spontaneously/ on prompt- eye contact,
gestures

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 Pretend play- putting a doll to sleep, offering

food
 Imitating doctor

 Child and caregiver look at the toy

jointly and then child and parent look at
each other and smile
 Ability of child to communicate to
caregivers regarding a common focus

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 No intent to communicate
› No sharing of interests- only need based
communication
› No sharing of interests, no joint attention/ social
referencing

 No pretend play/ redundant pattern of

play- lining up cars

 Stays aloof, likes being alone

 Poor response to name calls

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TALKING

UNDERSTAND

PLAY

LOOKING AND LISTENING

 Most common symptom: Speech delay

 Poor response to name calls

 Poor eye contact and gestures
 Not sharing interests- Failure to share
enjoyment, achievements
 Prefers to play alone- no pretend play
 Stereotypies- motor
 Sensory issues- visual/ auditory/ tactile

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 Joint attention

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 Unusual response to common sensory

stimuli
› Does not like to be touched by certain
objects or textures

› Extreme resistance to brushing/ head

bath

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 20 Questions- administered to parents

 HIGH-RISK: Total Score is 8-20- refer

immediately

 Scoring: Response No score 1- item 2, 5,

12- for Yes give 1

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 Modifying environmental factors such as-

cutting down gadget exposure
 Simple home based interventions till the
assessment is complete.
› Simple naming and pointing games with
charts
› Encourage games like hide and seek, run and
catch, etc.
› Imitative games- dancing for a rhyme,
clapping, waving, etc

 Peek-a-boo game

 Dressing table with child on the lap- talk

and wave to child on the mirror

 Eye gaze- funny glasses, bubbles

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 Mirror- tap and point at child

 Point at picture books

 Imitation- rolling a car with sound, copy

tower of blocks

 Functional communication: Cookie inside a

jar out of reach- show him how to ask by
making him touch the jar/ pointing

 Multidisciplinary management
› Child psychologist
› Speech therapist
› OT

 Role of drugs: for repetitive behaviour

and aggression- risperidone, aripiprazole

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 Boys speak later than girls- Leads to delay

in presentation- valuable time lost..

 Girl child hence she is reserved- again

time delay..

 Hyperactivity = ADHD

 Autism child cant live a normal life..

 1 yr 9 month girl brought to OPD for

speech delay

 See the video

 What do you notice?

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 2 yr old boy comes to clinic with fever and

cough
 Gets down from mother- walks to the
window and sees through the window-
looks at the rain outside and shouts in joy
 Conversation between doctor and mother-
doesn’t notice
 Call him- no response
 Mother says he is not talking yet

 Any concerns?

 1.5 year old girl- brought for vaccine visit

 Mother says she is not speaking yet- she sits on
mother’s lap and looks around
 Looks at you- as you wave, she initially hides
her face and then again looks at you
 As you give shake hand- looks at her mother
and then at you and nervously gives her hand
 Smiles when you smile at her

 Mother feels she is too shy and wants to know if

she is having Autism..

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 Parental concerns in vision and hearing

 Academic performance at school- of

concerns in what areas

 ADL independence- bladder control

 Organized in his routine

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 Standing on one foot for 10 seconds, 10

sit-ups

 Draw-a-man test

 Recite a story from a picture

 Writes name, tells 4 colours

 1.5- Vertical line

 2- Horizontal line
 3- circle
 4- cross
 5- square
 6- Triangle
 7- British flag
 8- Diamond
 9- 2D plus
 10- Cylinder
 11- Cube

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 Mental age = 3 + (Number of parts drawn/4)

 Poor academic performance

 Vision and hearing concerns raised by

parents

 Unexplained behaviour problems- may

be a sign of neuro-developmental
problems

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 Academic underachievement
 Frequent complaints from teachers
 No interest in studies but well in other
aspects
 Branded as lazy child/ adamant child,
poor memory

 Behavioural problems increasing

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 A child with average or above average

intelligence

 Has the potential but whose academic

achievement does not match it

 Gap between oral and written skills

 More strengths in non- academic areas

than the academic areas

 Concepts good when telling verbally but

cannot express it written

 Reverses letters (soiled/ solid, left/ felt, b/d),

mirror images

 Makes mistakes/ avoids reading aloud,

avoids writing assignments

 Jumbling up phrases –saying "hecilopter"

instead of "helicopter", or "beddy tear"
instead of "teddy bear”

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 ID- borderline intelligence- slow learners

 Usually have delayed development in
other domains as well
 Significant limitations in adaptive
behaviour- money concept, following
social rules, personal care and ADL

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 Child is not lazy or stupid, no problems

with memory- condition can be
frustrating for the child

 Patience, rather than force, is to be

encouraged

 Refer to a special educator/ mother can

get trained

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 Only difficulty in deciphering the written

word- if knowledge is imparted to them in
other ways, they in fact understand better

 Allowing extra time for work/ exams

 Exempting from second language/ use

of scribe

 Allowing calculator use

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 8 year old boy is brought to you for complaints

of poor scholastic performance.
 Mother feels he is interested in drawing and
sports but totally not interested in studies
 The boy is warm- smiles. Watches mother talk to
you. You notice he is remorseful when she
describes his academic problems
 He solves the Rubik’s cube
 You ask him to read out a nursery story book-
he declines initially. On prodding, he reads but
very slowly
 When you ask him to draw he readily agrees
and draws. He tells a story from the pictures.

 What should you do?

 11 year old boy- poor scholastic

performance
 Mother says poor memory and wants
“vitamins”
 Problems since class 1- so far school has
passed him. Present year 5th standard
coping up is difficult. Repeating same class
again
 He has to be taken to school by parents,
not able to copy down home work, not
able to tell important facts told in school to
parents
 At home, plays with small kids.

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ROLE OF A PEDIATRICIAN

 Preventable/ treatable causes

› Hypothyroidism

 Early intervention services- follow up of at

risk children

 Advising parents on developmental

surveillance

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 Recognition of concerns- appropriate

referral to multi-disciplinary team
 Early management- good outcomes

 Esp. evolving CP, Autism, SLD

 Home environment- must support child’s

health and development

 Quality family time

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 Working parents, nuclear family

 Focus too much on preventing illness and

“weight” of the child

 Psychological and emotional well being-

back-seat

 Ready for exams/ jobs- but ready for life?

 Expensive gifts = Time spent with the child

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 No stimulation- developmental delay

 Poor social skills, poor empathy

 Poor coping up strategies- psychological

issues

 Infants- take in hand, cuddle often, talk to

child often, more interaction

 Older child- play with child, take outside,

avoid visual media, interaction with others

 School going child

› Eat together- tech-free times
› Encourage reading books, hobbies
› Emotional support when in need
› Exercise to keep fit

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 Obesity
 Sleep rhythm disturbance
 Poor speech, executive functioning,
creative skills, social skills
 Poorer family functioning

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 Children younger than 2 years

› Need hands-on exploration and social
interaction with trusted caregivers to
develop their cognitive, language, social-
emotional skills
› Cannot learn from traditional digital media
as they do from interactions with caregivers
 < 18 months- discourage use of screen
media other than video-chatting

 Impulse control, emotion regulation, and

creative thinking- best taught through
unstructured and social (not digital) play,
and parent–child interactions

 Touch screen- affects writing skills

 > 2 years, limit media to 1 hour or less -

essential for parents to sit with child

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 No screen during meals and 1 hour

before bedtime
 Daily physical activity (1 hour) and
adequate sleep (8 hours)
 Avoid violent content

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 Travel faster across distances.. Air travel,

faster trains, better buses..

 Communicate easier across distances..

Computers- networking, email..
Telecommunication- cell phones
revolutionized communication..

 But……………………

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 Developmental surveillance can be

done easily in office..
Age Key aspects
9 months Motor milestones

18 months Communication, social skills- watch for ASD

30 months Communication, cognitive watch for ASD

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 Look for Autism in toddlers with speech

delay

 Look for Intellectual disability and SLD in

child with poor school performance

 Encourage reading to
children, story telling

 No tabs, no
educational CDs, no
TV- early childhood

 Human to human
interaction in home
and school-
encourage

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 Encourage parents

 Good outcomes with early interventions

 http://www.autism-india.org/inclusive-activities.php
 http://www.autism-india.org/identifying-autism.php

 Diploma in Education in Special Education - Autism

Spectrum Disorders (D.Ed.Spl Ed-ASD) is a two-year
intensive training programme for those interested in
developing a career in special needs, with a particular
focus on autism. Action for Autism (AFA) conducts this
course in affiliation with NIEPMD, Chennai-
http://www.autism-india.org/diploma-special-
education.php

 Teaching children with Autism- autismspeaks.org

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For parental/ teacher training:

 Madras dyslexia association
 Prayatna

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