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Rochelle Pacifico Date of Lecture: Feb 1, 2012 Transcriptionist: Miu <3 Pages: 7
Neurodevelopmental Asessment Developmental Moni ting: Recogni zing Red Fla g Signs Introduction Prevalence of Devt d/o – 12 -16% Onl y 30% benefi ts from appropria te ea rl y intervention Pedia tri cians – pri ma ry professionals in bes t position to identify them ea rl y Ea rl y identi fi cati on by prima ry ca re providers of development dela ys leads to ea rl y referral for evalua tion and trea tment I. Human development A complex process of growing and a cqui ring skills Founda tion a re geneti c make-up and envi ronment Principles of Development Continuous process from conception to ma turi ty Sequence is the same in all children BUT the ra te va ries o Some babies does not crawl and lea rns to cruise Inti matel y related to the matura tion of the CNS General mass a cti vi ty is replaced by specifi c indi vi dual responses o before an infant learns to use his thumb and fingers, he mus t lea rn how to use his a rm or enti re body toes fan out after the sole of the foot has been fi rml y s troked. It is normal until 12months of age. Protecti ve form to take awa y feet from noxious s timulus . Rooting reflex - automa ti cally turn thei r fa ce towa rd the s timulus and make sucking (rooting) motions wi th the mouth when the cheek or lip is touched. The rooting reflex helps to ensure breas tfeedi ng. Moro reflex - referred to as the sta rtle rea ction, s ta rtle response, s ta rtle reflex or embra ce reflex. Present a t birth, peaks in the fi rs t month of life and begins to disappea r a round 2 months of a ge. It is likel y to occur i f the i nfant's head s uddenl y shifts position, the tempera ture changes abruptl y, or the y a re sta rtled by a sudden noise. The legs and head extend while the a rms jerk up and out wi th the palms up and thumbs flexed. Shortl y a fterwa rd the a rms a re brought together and the hands clench into fis ts , and the infant cries loudl y. Ma y ha ve helped the infant cling to his mother while she ca rried him a round all da y. If the infant l ost i ts balance, the reflex caused the infant to embra ce its mother and regain its hold on the mother’s body. Palmar Grasp reflex - appea rs at bi rth and persists until fi ve or si x months of a ge. When an object is pla ced i n the infant's hand a nd s trokes thei r palm, the fingers will close and they will grasp i t. Swimming reflex - An infant pla ced fa ce down in a pool of wa ter will begin to paddle and ki ck i n a swi mming moti on. The reflex disappea rs between 4–6 months . Its s urvi val function is to help the child s ta y ali ve i f i t is drowning so a ca regi ver has more time to sa ve it. Tonic neck reflex - also known as as ymmetri c toni c neck reflex or 'fencing posture' is present a t one month of a ge and disappea rs a t a round four months. If i t’s in this position, the baby won’t be able to roll over.
Proceeds i n cephalocaudal di rection o Why cephalocaudal? It is rela ted to no.3 o Brai n develops fi rs t and directs other a reas of devel opment o the fi rs t movement will be those pa rts close to the brain Certain primi ti ve reflexes ha ve to be los t to a cqui re corresponding volunta ry movement o Reflexes a re automati c and involunta ry movement and a ct as protection Babinzki Reflex – occurs when the bi g toe moves towa rd the top s urfa ce of the foot and the other
Risk Factors in Development
Biologic o Prema turi ty Imma ture development of organs and not ready to function well o Intra cra nial hemorrha ge o Intra uterine growth reta rda tion Inside the mother’s womb, the baby is not growing and reta rded, wha t more if the baby will be deli vered? o Hypoxi c is chemi c encephalopa thy (HIE) Low oxygen s uppl y 2O to low blood suppl y in the brain o Brai n abnormalities on i maging studies o Bi ochemical abnormalities Hypothyroidism cretinism and mental reta rdation o Mi crocephal y Small brain o Congeni tal malforma tion o Sepsis/meni ngi tis o Lung disease can lead to HIE o Neona tal sei zure o Ma ternal subs tance abuse – crosses pla cental ba rrier Environmental o Continuous exposure to envi ronmental toxi cants (e.g insect spra y) o Low SES (inadequate nutri tion) o Absence of medical insurance o Teena ge mother o MR i n a pa rent or ca re gi ver o Chil d abuse/neglect o Dysfunctional/disrupted famil y o Inadequa te pa renting s kills o La ck of pre-na tal ca re C. Causes of Normal Variations in Development Fa milial predisposi tion o For exa mple both pa rents a re small, thus do not expect the baby to be tall when he grows up Pos ture o Someti mes i t depends on how the infant’s position while s till inside the womb. For example, the baby is so big tha t the thigh/feet a re flexed abnormall y so when the baby grows and lea rn to walk coxa va rus Ra ce o Bla ck Ameri cans develop motor skills ea rlier than Caucasians while the Caucasians develop communi ca tion skills than bla ck Ameri cans
Under-s timulation Twins o Some twins is grea ter or s maller than the other Ethni c cul ture Sex o They sa y tha t the gi rls spea ks earlier than the boys while the boys walk ea rlier than the gi rls
Four Areas of Development 1. Gross motor a . pos ture and movement b. devt of locomotion; c. Progresses from a cephalo caudal pri nciple Fi ne motor a . eye-hand coordina tion; b. finger control , ma nipulation, rea ching, grasping, pla cing and replaci ng object c. Progress in a proximo-distal manner Language: a . communi ca tion skills b. 2 components : comprehension % expression c. progress from simple to more complex Social Beha vior and Pla y a . adapti ve development; b. self-ca re s kills; c. problem sol ving skills d. combina tion of the fi rs t three mentioned above
Before we proceed wi th the devt miles tone, please bea r these terms in mind for this is so very i mporta nt!!! ***Mean a ge – 50% of the children s hould ha ve a cqui red the s kills ***Ra nge – 2nd pri nciple of development kicks in here. Not all children will a cqui re same skills at the same time. ***Limi t a ge – this is very i mportant beca use this will be the ol dest a ge a t whi ch you can expect a skill to develop. If i t does not develop until limi t a ge, then red flag sign is up!
Gross Motor Milestone Milestone Holds head Roll over Si tting Cra wling Sta nding Wal king Runni ng Mean age (mos) 3 5 7 8 11 13 30 Fine Motor Milestone Ha nds open 3 2-4 Ha nds midline 4 2-5 (s ucking, feeding, holding putting things i n mouth) Transfer object 5 4-6 Rea ches 6 5-7 Pincers grip 9 8-10 Voluntary release 11 9-12 Scribbling 15 12-18 ***Volunta ry release – ha ve you seen a baby and tell him/her to gi ve you the toy? Then she’ll extend his/her a rm as if gi ving i t to you but ins tead he’ll take it ba ck. By the time of 12 mos , the baby should ha ve resol ved this and should be able to gi ve things in his/her hand to you. Language Skills (Expressive) Coos 3 1-4 Ba bbles (mama = ma ma , da da = 5 4-8 ma ma , milk = mama , ya ya = ma ma, lola = ma ma ; indiscri mina te) Dis crimi nate (ma ma/dada ) 8 5-14 Jabbers /jargon/gibberish 12 9-18 Fi rs t word 14 10-23 Gestures 14 11-19 2 word phrase 20 18-24 ***Dra ’s exa mple: Do not consider the child 10-23 mos delayed in development i f he speaks onl y one word. For example, dra : hello. …. child: hi …..dra : where’s the light? (the child uses his finger to point light) ***Mnemoni cs: 2 yea rs old = 2 words Language Skills (Comprehension/Receptive) Rea cts to sound Turns to voi ce Inhibits to “No” (they s top when you sa y no.) Follow simple commands Name Body pa rts Name, age, sex ***Localize sound a t 6 mos Sta rts a t bi rth 4 8 10 17 30 0-1 2-6 7-10 6-14 15-21 24-36 Ra nge (mos ) 1-4 2-6 5-9 6-11 8-16 13-18 18-36
Personal and Social Miles tone Smiles Recognize fa ces Peek-a -boo* Dri nks from cup Undresses Feed sel f Toilet trained Intera cti ve pla y (not pa rallel; parallel eh ung baby1 has a toy and baby 2 has a toy but they don’t i ntera ct or sha re) Sepa ra tes from Mom 2 2 8 12 30 24 24 30 1.5-5 1-5 5-13 9-17 20-36 18-36 14-48 24-36
***Object permanence – hi de the object and they know they s till exis ts ; from undress to sepa ra te from should be present therefore the child is ready for s chooling. Fi rs t evidence of problem sol ving skill. ***Skills mentioned above should be es tablished by 4 yea rs old; this will gi ve the pa rents the sign tha t the child is ready to go to s chool
Limit Ages for Various Childhood Abilities Age 1 2 3 4 5 6 7 9 10 Abili ty Some indi ca tion of a ttention Attention to objects ; respond to everyda y noises Hea d erect Ha nds open; ordina ry interes t in people and pla ythings Rea ches for objects (-) Ass ymetri c Toni c Neck Reflex; visual fi xation and following established; turns to sound Hold objects in hand Gi ves a ttention to ges tures Si ts alone on firm surface; tuneful babble Bears most weight on legs Chews lumpy foods Attends to words Releases head object Wal ks alone; no cas ting (randoml y throws things), no mouthing, no drooling Ki cks when s tanding; single word wi th mea ning 2-3 word phrases Sta nds on one leg, talks sentences Full y i ntelligible speech (hindi na dapa t bulol )
12 15 18
21 27 36 48
Developmental Abnormalities a. Certain behavior that almost always indicate developmental abnormalities fetal hyper/hypoa cti vi ty o hypera cti vi ty inside the womb can be a sign of ADHD o hypoa cti vi ty, on the other hand, can be an indi ca tion of reta rda tion Failure to thri ve o wei ght two sta nda rd below the a vera ge Archi ng o You ask to patient to bend ba ckwa rd, if s tiff = cerebral palsy) Sta ndoffishness o Wa nts to s tand-out and doesn’t want to join the group Toe walking o Normal until two yea rs age; after 2 dapa t planta r flexion Echolalia o repea ts whatever you sa y; like a pa rrot; can indi ca te autis tism o dra : ask about di nosaur… child: (tells her all thi ngs about dinosaur like an expert)…dra : oka y tell me your na me….child: dinosaur…trex..etc etc Acting as if deaf (e.g autis ti c) Acting as if blind Quietness Clinical neurologic signs that place an infant at risk Abnormal mus cle tone or pos ture pa tterns As ymmetry of mus cle tone, pos ture and reflexes Abnormal head growth Sei zures Occulomotor disturbances o Stra bismus normal until 4y.o Dis turbances in suck – swallow mechanism Developmental surveillance a. Is the method of choi ce for moni toring development in children Invol ves screening and assessment
Surveillance – the identifi ca tion of risk fa ctors for devt d/o and dela ys ; should be performed a t all well child visi ts include: a ttending to pa rental concerns Obtaining relevant devt his tory ma king a ccura te observa tion of the child (what a child can do and cannot) sha ring concerns with other professionals Maintaining record of fi ndings provides the context for s creeni ng
Screening – a procedure or a tool tha t is brief, formal, s tanda rdi zed evalua tion tha t i dentifies children a t risk for a devt d/o determines need for further inves ti gation not a diagnostic has es tablished ps ychometri c qualities (precision, accura cy, inexpensi ve, eas y to unders tand) Eas y to perform a nd i nterpret, i nexpensi ve and a cceptable to child/pa rents Shoul d be done a t 9,18,24,30 months ad i f wi th concerns
Common Screening Tests : 1. 2. 3. 4. Pedia tri c Evaluiation of Devt Sta tus (PEDS) Denveor Devt s creening Tes t (DDST) Modified checklis t for autism i n Toddlers (MCHAT) s ta rting 18mos SNAP-IV Ra ting Scale for ADHD
Fa ctors to consider in evaluati ng development Presence of risk fa ctors Fa mil y his tory of development d/o or dys morphol ogy Age of skills a cquisiti on according to s tanda rd norms Quali ty of skill performance Appropria teness of use or appli cation (normal nga na na gsasalita , talkati ve na man!) Pa ttern of a cqui ring s kills throughout all areas devt Dysmorphologi c feature Anthromopometri c measurements Sei zure/neurologi c a bnormalities
Devt surveillance – broader pra cti ce, s creening tool + ques tioning + hx ta king + advi ce + check famil y Devt assessment – objecti ve is to a rri ve a t diagnosis, main objecti ve is to make sure tha t child is gi ven a ctual s timulation and no red flags
Early intervention Mul tidis ciplina ry s cope (all people ) Fa cili tate a chievement of ma xi mum potential Di minish the effects of the impai rment Prevent seconda ry disability o ADHD has seconda ry lea rning disability not because they a re ha ve cogni ti ve disabilities but because they a re ina ttenti ve Further diagnos ti c evalua tion Ha bilita ti ve (Occupa tional thera py, speech thera py, Physi cal Therapy) Special educa tion/medi ca tion intervention
*i rregula ri ties in any one of these fa ctors menti oned wa rra nt formal devt assessment Early Identifcation is founded on two basic assumption: 1. 2. Leads to better outcomes Once i dentified, children will be able to recei ve effecti ve therapeuti c servi ces -
TRIVIA (lifted from past tranx) Brai n plasti ci ty – if a child has a problem in neurogenesis tha t is picked up when the brain is plasti c (occurs during 35 yea rs of a ge), you can tea ch the other pa rts of the brain to take the function of parts affected. ------ End of tranx----
Addtl notes from pas t tranx but this was not dis cussed by Dra nor found in her ppt I. II. Devt s creening – uses s tanda rdi zed s creening tool Devt moni tori ng – as ks the child/pa rents wha t she and cannot do
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