Normal Development and Early Identification of Delays

Transcription

1 Normal Development and Early Identification of Delays Robin K. Blitz, MD Developmental-Behavioral Pediatrician Children s Neuroscience Institute Phoenix Children s Hospital Clinical Associate Professor, University of Arizona College of Medicine

2 Key messages Pay attention to the child s development and behavior Listen to parents Use standardized screening tools If you have concerns, refer Do not tell a concerned parent to wait and see

3 Normal Development Cognitive Language receptive and expressive Motor fine and gross Social / Emotional Self-help

4 Development Occurs in predictable manner Influenced by extrinsic and intrinsic factors Achievements interrelated, and allow for more progress Physicians can monitor development by developmental surveillance Developmental Milestones Developmental screening tools Parental concern should not be ignored, even with a normal screen!

5 Cognitive Development: Intelligence and Learning Intelligence our rate of learning Using previous experiences in the solution of new problems Intellectual development depends on learning Learning has three parts: attention, information processing, memory Language the single best indicator of intellectual potential Gross motor skills - least predictive of cognitive potential

6 Problem-Solving Manipulating objects to solve a problem Depends on vision, fine-motor skills, cognitive processing Initially, objects are mouthed, but with mastery of this, objects held in order to inspect and learn This sensory-motor phase is the foundation for nonverbal intellectual development

7 Key Feature: Piaget s Concept of Object Permanence Interest in peek-aboo Looking for an object that has dropped Separation anxiety - also increasing memory

8 Key Feature: Causality An action produces an effect Infant will repeat action to obtain same effect Example: crying or smiling produces response

9 Language Delays in language more common than delays in other domains. Milestones less familiar to physicians Difficult to assess by observation in a clinic setting History particularly important

10 Language Divided into receptive and expressive Expression of language can mean speech, gestures, sign language, writing, typing Communicative intent needed Speech and language not synonymous Echolalia is not language

11 Three periods: Language Prespeech period (0 to 10 months) Naming period (10-18 months) Word combination Period (18-24 months)

12 Prespeech (0-10 months) First step in receptive language is the ability to localize sounds Initially in the development of expressive language have cooing Vowel sounds 3 mos, infant vocalizes upon hearing an adult talk 4-5 mos, appears to be listening to adults, and to mimic conversation ( vocal tennis )

13 Prespeech (continued) 6 months-consonants to vowel sounds: babbling When random vocalization interpreted to have meaning by an adult ( dada ), baby will see approval, and eventually meaning linked.

14 Naming (10-18 months) Realization of names and labels By 12 months - may understand 100 words Understand simple command with gesture By 2 nd year - no gesture needed with command

15 Naming Before first birthday, say one other word besides mama and dada Immature jargoning - vocalizes with intonation Mature jargoning - more real words added to jargon By 18 months, uses 25 words spontaneously Pointing more important

16 Protoimperative pointing - points to get the cookie Protodeclarative pointing emerges next - used to share interest in object (joint attention) A social act Classically missing in children with autism Pointing for naming Pointing

17 Word Combination Period (18-24 months) Differentiate chunked words ( thank you, stop it ), from true combinations Holophrases - points to keys and says mommy, sentence- like meaning with pointing and single word No combinations until expressive vocabulary of 50 words.

18 Word Combination Period Telegraphic speech appears first ( Go out ) At 2 years - speech begins to blossom By 3 years: 500 words 75% understandable why

19 Bilingual children The sum of words from both languages should be comparable to the number being used by the same-aged monolingual child Simultaneous bilingualism - both languages may be blended or mixed Sequential - build on the knowledge of the primary language, while learning the other Languages separated by age 4 years

20 Gross Motor Development Primitive reflexes Should resolve by 6 months old Red flags: asymmetrical, persistant, obligatory Postural / protective reactions Propping, forward parachute Red flags: opisthotonic posturing, asymmetric protective reactions

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23 Gait Movements gradually become more fluid, the base narrows, and arm swing evolves Sequence of prone milestones to sitting and then standing and walking Consider also the quality of movement Observation Formal neurological exam Adult pattern of walking by 3 years of age

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25 Fine Motor Development Use of hands / fingers in prehensory approach to grasping and manipulation of objects Primitive reflexes integrated and upper extremities under more cortical control First year- highlighted by the development of the pincer grasp Second year-objects used as tools Red flags: persistent fisting at 3 months of age, asymmetrical use of hands before 18 months, cortical thumbs

26 Social-Emotional Development: The child s personal reaction to the social culture in which she lives 1 m responsive smile 2-3 m recognizes parents 6-8 m stranger anxiety, responds to name 10 m repeats performance laughed at, waves bye, separation anxiety, social games 15 m mine, gives hugs 18 m seeks affection 24 m parallel play, smiles with praise, tantrums, imitates 30 m transitional objects, independence 36 m make-believe, cooperative play, delayed gratification, shows off

27 Self-Help Development Feeding Birth sucks and swallows 6 m holds bottle 8 m chews small lumps 10 m finger feeds 12 m holds cup 18 m spoon and open cup 24 m requests food 36 m uses spoon, fork, and can spread with knife Toileting 18 m indicates wet diaper m interest in toilettraining 36 m toilet-trained Dressing 3 m pulls at clothing 15 m takes shoes off 18 m socks off 24 m helps with dressing 30 m undresses 36 m chooses clothes and puts on some clothes

28 Delays and Early Detection 15-18% of children in U.S. have developmental or behavioral disabilities Delays exist when a child fails to reach milestones at the expected age Etiologies Biological Environmental Maternal depression

29 Detection Rates without Screening Tests Only 30% of children with developmental disabilities identified before K Only 20% of children with mental health problems identified

30 Listen to parents 37% of parents did not want to discuss concerns with pediatrician 35% visits where parents stated concerns, providers failed to address those concerns When parents have developmental concerns, more than 90% were confirmed 80% of children with mild MR walked at appropriate age

31 Surveillance versus Screening Developmental Surveillance: recognizing children who may be at risk of developmental delays Developmental Screening: using standardized tools to identify and refine risk of developmental delays.

32 AAP Recommendations Developmental Surveillance and Screening Surveillance at every visit Use standardized screening tool 9 m, 18 m, m, 3 yr, 4 yr, and 5 yr Child not reaching milestones on surveillance Child has known high-risk medical conditions Child has biological risk factors for developmental problems Child has significant environmental stresses Child has parent with concerns

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34 Detection rates WITH Screening Tests 70-80% of children with developmental disabilities correctly identified 80-90% of children with mental health problems correctly identified Most over-referrals on standardized screens are children with below average development and psychosocial risk factors

35 Why is it so Important to Find Delays Early? IDEA-emphasis on earlier identification by PCPs Early Intervention works Two years of intervention prior to kindergarten produces substantial economic, academic, and social benefits and saves society between $30,000 and $100,000 per child (Glascoe, 2000) Kids receiving early intervention are more likely to complete high school, maintain jobs, live independently, and avoid teen pregnancy (Glascoe)

36 Global Developmental Delay A child has delays in 2 or more areas of development and functioning By age 3 years full scale IQ can be determined, but many schools wait until a child is 5-6 years old A child with delay requires detailed physical exam, hearing and vision screens, and comprehensive psychosocial history

37 Why are We so bad at Detecting Delays? Mislead to think milestone checklists on encounter forms are validated or standardized They aren t Based on original Denver, which missed up to 50% of mental retardation! How many failed items are too many? No one knows!

38 Why are We so Bad at Detecting Delays? Development is a moving target Screening tests used only when problem noticed, not routinely The American Academy of Pediatrics Committee on Children with Disabilities recommends that Pediatricians use validated screening tools at each health supervision visit.

39 Parent Observations The most effective tools rely on information from the parent Don t need cooperation of the child in a 15 minute visit Many of these screens available in multiple languages

40 Parent Assessments are Credible What about parents who are less educated, have little parental experience, or appear depressed or anxious? Almost all parents if given appropriate screen, give accurate information In most of the screens parents indirectly asked to compare their child to others Remember about literacy, however

41 Examples of Screens for Primary Care PEDS ASQ Brigance Screens-II Bayley Infant Neurodevelopmental Screen (BINS) M-CHAT PDDST-II PSC

42 PEDS The Parent s Evaluation of Developmental Status 10 questions Takes 2 minutes to complete and score Simple criteria regarding when to refer, when to reassure, when to monitor closely Questions and their wording carefully selected to illicit concerns Score form clearly directs physician to a path of care Of those with 2 or more concerns, 70% on testing will display delays Further screening with 2 or more concerns to be avoided; leads to under-referrals

43 For children 0 to 8 years In English, Spanish, Vietnamese, Somali, Chinese Takes 2 minutes to score Elicits parents concerns Sorts children into high, moderate or low risk for developmental and behavioral problems 4 th 5 th grade reading level so > 90% can complete independently Score/Interpretation form printed front and back and used longitudinally PARENTS EVALUATION OF DEVELOPMENTAL STATUS A Method for Detecting and Addressing Developmental and Behavioral Problems

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46 PEDS Evidenced Based Decisions Path A: high risk of developmental disabilities, shows what kinds of referrals are needed Path B: moderate risk of disabilities, need for additional screening, developmental promotion, monitoring Path C: low risk of developmental disabilities but elevated risk for mental health problems, need for parent education, monitoring, and/ or additional behavioral screening Path D: moderate risk of developmental disabilities, problems with parental communication and need for hands-on screening Path E: low risk for either type of disability for which reassurance is the best response

47 PEDS Evidenced Based Decisions when and where to refer (e.g., mental health services, speech-language or developmental/school psychologists) when to screen further (or refer for screening) when to offer developmental promotion when to provide behavioral guidance or refer for mental health services when to observe vigilantly when reassurance and routine monitoring are sufficient

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49 PEDS Interpretation - Path A Path A - High Risk path, suggests possible developmental disabilities. Refer for evaluations through EI promptly. Path A suggests the type of evaluations needed based on the types of concerns Add your clinical judgment about what other kinds of services may be needed (e.g., social work, mental health, etc.) Additional screening with the M-CHAT is wise

50 Path B Path B - Moderate Risk for developmental disabilities In response, screen further or refer for screening Offer developmental promotion to those who don t qualify for special services and provide watchful waiting /extra monitoring Consider referrals to Head Start, after school tutoring, etc.

51 Path C Path C - Low risk of developmental disability, but elevated risk of mental health problems, especially in children 4 years and older; give mental health screens or refer for screening (child and family) For children under 4, give parents advice and written information, and monitor ; If such counseling is not effective, provide mental health screening or refer for screening (both child and family-focused)

52 Path D Path D rare, but is used for parent-provider communication difficulties (e.g., languagebarrier, teen parent who doesn t know much about his child, parent with serious mental health or language problems) Refer these children for hands-on screening (e.g, with the Brigance or ASQ)

53 Path E Path E - Low risk for problems, either in development or social-emotional areas Offer reassurance unless your clinical judgment suggests a problem

54 Electronic PEDS Web accessible PEDS for Licensed PEDS users Self-selected parents PEDS scoring Web service for EMR/EHR and other electronic systems

55 M-CHAT (optional on electronic PEDS)

56 ASQ Ages and Stages Questionnaires Ages 1 mo. to 60 mos. Looks at 5 areas of development Takes parent mins. to complete Written at 6 th grade level Easy scoring takes 5-7 mins. Takes 7 minutes Sensitivity 70-90%

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58 Ages and Stages Questionnaire (ASQ) 4 months to 6 years 19 color-coded questionnaires, each 6 7 pages long for use at 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60 months items per form describing skills Completed by parent report Taps most domains of development Takes about 15 minutes, and 5 minutes to score ASQ-Social-Emotional works similarly and measures behavior, temperament, etc.

59 ASQ Sample Items 3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil or crayon, without tracing? Your child s drawings should look similar to the design of the shapes below, but they may be different in size. Yes Sometimes Not Yet

60 ASQ Scoring Assign a value of 10 to yes, 5 to sometimes, 0 to never Add up the item scores for each area, and record these totals in the space provided for area totals. Indicate the child s total score for each area by filling in the appropriate circle on the chart below. Scores in shaded areas, prompt a referral Communication Gross Motor Fine Motor Problem solving Personal-social

61 ASQ - Other Features oinstructional video ocurriculum linkage guide omultiple language translations ocd-rom scoring oon-line version available

62 Autism Screening At 18 mo. and mo. Or, if parent or physician has concern M-CHAT, PDDST AAP and AAN have algorithms for screening and assessment Remember to get a hearing test!!!

63 Modified Checklist of Autism in Toddlers M-CHAT 23 yes-no questions Measures social reciprocity, language, some motor 18 months to 4 years of age Detects ASD, language impairment, MR

64 M-CHAT Sample Items Does your child ever use his/her index finger to point, to ask for something Can your child play properly with small toys without just mouthing, fiddling, or dropping them? Does your child take an interest in other children?

65 M-CHAT Details failing score if 2 or more critical items or any 3 items are failed free download or online (after purchase of PEDS) at 2 page scoring guide takes 7-10 minutes to complete recommended by AAN for use after a broadband screen is failed Recommended by AAP to use at 18 mos. and 24 mos., or when concerns

66 Screens of behavior, mental health and emotional well-being Pediatric Symptoms Checklist (4 18 yrs) Eyberg Child Behavior Inventory (2 11 yrs) Ages and Stages Questionnaire Social- Emotional (4 months to 60 months) Parents Evaluation of Developmental Status (ages 0 8 yrs)

67 Pediatric Symptom Checklist A Behavior screen Free from psc/psc_home.htm 4-16 yrs. Self-report of interview (7 minutes) 35 short statements of problem behaviors (externalizing and internalizing)

68 Take Home Messages Screening tests are workable in primary care Quality screens improve detection rates, 3-4-fold Developmental services are available Non medical providers need guidance on how best to work with medical providers Office Staff need to be engaged Parent education and referral materials are essential

69 Screening Blunders Waiting until a problem is observable If obvious, skip the screen Ignoring screening results Don t take a wait and see attitude Relying on informal methods Such as the checklist on encounter forms Confusing screen with diagnosis

70 CPT codes for Developmental Screening Developmental screening Second stage screening or assessment Administration and interpretation of health risk assessment (can include family psychosocial screen) Neurobehavioral status exam

71 A Delay is Suspected, But What Next? Under age 3 years refer to Early Intervention Nearly 3 years old or older School district - Child Find

72 Texas ECI Referral can be based on professional judgment or family concern Make a referral: Call the DARS inquiries line: or send to dars.inquiries@dars.state.tx.us. Will assess and determine eligibility Once eligible, will develop IFSP

73 Benefits of Early Intervention EI - critical to the development and well-being of children and their families EI - improves outcomes for participants EI - is socially and economically effective Bailey, Pediatrics, 2005; Guralnick, The Effectiveness of Early Intervention, 1997

74 IDEA School Intervention Public School service 3 yrs 22 yrs. Anyone can make referral School has 60 calendar days to assess, determine eligibility, develop IEP Coordination of education and medical needs

75 Helpful websites for other screens BITSEA (Brief Infant Toddler Social-Emotional Assessment) mos Child Development Inventory (0-6 yrs) Communication and Symbolic Behavior Scales Developmental Profile (CSBS DP ) 6-24 mos Temperament and Atypical Behavior Scale (TABS) mos Greenspan Social Emotional Growth Chart (0-42 mos)

76 More websites Developmental Screening Tool kit for PCP's from Boston Children's CDC website - "Facts about Developmental Screening tools" AAP - Division of Developmental-Behavioral Pediatrics website information about developmental screening tml

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