Published on September 16, 2014
Development Short Cases- Approach Ranjini S.Sivanesom IPHKL 30.08.14
Child Development Child development is a dynamic process Normal development is determined by a complex interplay between environmental factors, genetic factors and acquired pathology.
Warning Signs of Abnormal Development Echolalia- repetitive imitation of speech- still present by 3 years. Absoulte failure to develop skills (eg multi- syllable babble with intonation- by 10 months) Motor asymmetry Developmental regression- loss/ plateauing of skills
The Developmental Examination History taking: family history, social and family environment, pre-, peri- and postnatal history. Enquire into the parents concerns and seek information from others who know the child (eg. teachers, health- care staff)
Observation and interactive assessment Suitable selection of toys should be made available before meeting the family and interacting with the child. Appropriate toys for the age of the child and the domains of development to be assessed.
Observation and interactive assessment Examples: Copying behaviour (bell) and understanding of cause and effect (pop- up animal toys) Definition by use (cup/ spoon, doll/ brush) and symbolic understanding (doll/ teddy/ tea set) Fine motor/ eye- hand (bricks, crayons/pencil/paper, soft ball, form boards, puzzles) Language and play (books with single pictures and stories, range of everyday toy objects, large and miniature toys)
Observation and interactive assessment ‘Free Play’- the child’s inability to organize the environment and generate ideas on their own will be significant. Eg. May not be able to focus attention (flit from one object to another or repetitive play may be noted. Cardinal rule of DA: to look not only what the child does, but also how s/he does it. Quality of response should therefore be monitored as well as the actual achievement.
2014/9/5 Developmental Examination: Birth to 1 Year Gross motor Fine motor Speech language communication Social Cognitive
2014/9/5 Developmental Examination: Birth to 1 Year Motor Development Tone, movements and posture (eg head control, hands (open or fisted), spine curvature, legs posture, weight bearing) in supine, pull to sit, supported/ independent sitting and standing, ventral suspension and prone position (180* manoeuvre). Examine primary (Moro, grasp and ATNR) reflexes
2014/9/5 Developmental Examination: Birth to 1 Year Significant Delay Age Fisting of hands > 3/12 Poor head control 4/12 Persistence of primitive reflexes > 6/12 Persistence of flexor hypertonia in the LLs (popliteal angle < 150*) > 9/12 Unable to sit independently with straight spine 10/12 Not walking 18/12
2014/9/5 Developmental Examination: Birth to 1 Year Fine Motor Development Coordination of vision with head movement (6- 8 weeks) and hand movements - watches own hand (hand regard) or objects held in hands (3- 4 months) Two- handed reach replaced by single- handed reach (5- 6 months) Exploration with index finger (8- 9 months) Maturing grasp: improving apposition of tips of fingers with the tip of the thumb (palmar- 6/12, pincer (thumb- finger)- 9 to 10 months and finger tips (12 months) Release with open hands or with pressure (10 to 11 months); controlled release - puts one cube on top of another (13 months)
2014/9/5 Developmental Examination: Birth to 1 Year FINE MOTOR DEVELOPMENT Coordination of vision with head movement and hand movements - watches own hand (hand regard) or objects held in hands 6- 8 weeks 3- 4 months Two- handed reach replaced by single- handed reach 5- 6 months Exploration with index finger 8- 9 months Maturing grasp: improving apposition of tips of fingers with the tip of the thumb (palmar) - pincer (thumb- finger) - finger tips 6 months 9- 10 months 12 months Release with open hands or with pressure - controlled release - puts one cube on top of another 10- 11 months 13 months
2014/9/5 Development of Grasp: Cube
2014/9/5 Developmental Examination: Birth to 1 Year Speech, language and communication Common objects or large toys eg a ball, cup, plate, spoon, car or doll
2014/9/5 Developmental Examination: Birth to 1 Year Observation of language development: Birth to 1 year
2014/9/5 Developmental Examination: Birth to 1 Year Observation of language development: Birth to 1 year
2014/9/5 Developmental Examination: Birth to 1 Year Non- verbal communication Vocalisation- 3/12 Pointing to ask - 9/12 Pointing to show- (9- 12 months) Proto- imperative pointing (12 months) Proto- declarative pointing (16 months) Conventional gestures eg waving goodbye,blowing a kiss - (9- 12 months)
2014/9/5 Developmental Examination: Birth to 1 Year Social Development Social responsiveness and anticipation Social smile (6- 8 weeks) Responds to social games eg peek-a-boo and shows anticipation (6 months) Developing joint attention Follows other's finger point to look at an object (8 months) Uses finger and eye pointing to direct others' attention to share interest (9- 12 months)
2014/9/5 Developmental Examination: Birth to 1 Year Social Development Becoming stranger aware- reacting by withdrawing or crying (6 months) Social referencing - checking back by looking towards the caregiver in new situations (12 months)
2014/9/5 Developmental Examination: Birth to 1 Year Cognitive Development Observation of infant's cognitive abilities are made during fine motor, communication, play and social interaction activities 4 main structured tasks are used
2014/9/5 Developmental Examination: Birth to 1 Year 1. Physical rules and object relationships Offer 1 cube:reach, grasp, exploration, hand-to-hand transfer (reach out to grasp:5/12) Offer another cube: imitation of clicking of two cubes (6/12) Request for a cube back by putting open hand out- note release Put an open container and encourage releasing a cube into it and taking it out (9- 15 months) Inserting pegs into holes (15 months)
2014/9/5 Inserting Pegs into Holes (15 months)
2014/9/5 Developmental Examination: Birth to 1 Year 2. Cause- and- effect understanding and goal directed actions Pop up or other action toys Place a toy out of reach and the connected string near the child. Check grasp of string and pulling the string to get the toy Shake a bell - 7/12, using cause-and-effect toys- 9/12, pulling a toy with a string- 9/12, moving a car- 12 months Significant delay: No cause-and-effect play by 12 months
2014/9/5 Developmental Examination: Birth to 1 Year 3. Object permanence: Finding a hidden toy (partially/ completely covered with a cloth) Look for a partially hidden object: 6- 8 months Search for a toy which has been completely hidden in their view: 9- 10 months
2014/9/5 Object Permanence(9- 10 months)
2014/9/5 Developmental Examination: Birth to 1 Year 4. Categorisation Use common objects/ toys: a toy, car,cup,spoon, bell, telephone (on self/ doll/ mother) 10-12 months: infants use similar looking objects/ toys in the same way eg moving toys that look like a vehicle 14 months: show 'definition by use' eg using a hair brush to brush their hair Significant delay: not defining objects by their use by 18 months
2014/9/5 Categorisation: Common Toys
2014/9/5 Non- verbal perceptual-cognitive development 5. Drawing Scribble to and fro: 15- 18 months Circular scribble: 2 years Draw a man Copy shapes Grasp of crayon/ pencil: 3years (50%) - 4 years (80%) Handedness: appears from 2- 4 years. Appearance before 12 months, prompt neurological examination
2014/9/5 Developmental Examination: 1- 5 years 1. Motor development 2. Non- verbal perceptual- cognitive development 3. Speech, language and communication
2014/9/5 Non- verbal perceptual-cognitive development 1. Block (1- inch cube) construction tasks Imitate a model (child is shown how to do it) Copy a model (child is shown a completed model)
2014/9/5 Non- verbal skills tasks,1- 5 years
2014/9/5 Non- verbal perceptual-cognitive development 2. Shape sorting/ jig-saw puzzles/ form boards 30months: Match 3 basic geometric shapes (circle, triangle and square) even when the form board is reversed
2014/9/5 Form board with basic geometric shapes (30 months)
2014/9/5 Non- verbal perceptual-cognitive development 3. Colour matching and naming 30 months: 50% of children can match cubes/ cards by colour 42- 48 months: name 4 colours correctly
2014/9/5 Non- verbal perceptual-cognitive development 4. Sorting objects by size 3years: point to big/ small cube/spoon/cup 42- 54 months: point to a long/ short line drawn on a paper
2014/9/5 Crayon or Pencil Grasp Palmar- Supinate Grasp 1- 11/2 years Digital- Pronate Grasp 2- 3 years Static Tripod Posture 31/2 - 4 years Dynamic Tripod Posture 41/2- 6 years
2014/9/5 Goodenough Draw- A- Person Test Gross detail Attachments Head detail Clothing Hand detail Joints Proportion Motor Coordination Fine head detail Profile
Visual Behaviour, eye- hand coordination and problem solving Progressive coordination of maturing vision with head, body and fine motor movements can be observed through: manipulation and use of pellet, rings, bell, cubes, crayon/ pencil, form boards or puzzles. Achievement in this domain represent the precursor to later non- verbal problem solving abilities, correlate well with intellectual ability and may provide early markers for learning, psychological and psychiatric disorders.
Co-ordinated eye movements and eye-head co-ordination Earliest developmental sequence starts with fixing gaze on the mother’s face following a face with eyes only co- ordinate eye- head movements to turn head to follow visually Any abnormality of early visual behaviour should prompt referral for ophthalmological assessment
Eye- head co-ordinated milestones Developmental milestones Mean age Limit age (months) (months) Visually alert, orients to face 1 Any delay Visually follows face 2 Any delay Co-ordinates eye movements with 3 Any delay head turning
Eye- hand co-ordination The infant shows visual awareness of hands and becomes increasingly refined in combining vision with hand movements for reaching, grasping, exploring and releasing objects.
Eye- hand co-ordination milestones Developmental milestones Mean age (months) Holds objects briefly when placed in hands 3 without visual regard Visually examines own hand 4 Reaches out with a two- handed scoop 5 Reaches out and grasps objects on table surface with a 6 raking grasp Transfers from hand to hand 6 Explores with index finger 6 Picks up a pellet/ raisin between thumb and finger 9
Eye- hand co-ordination milestones Developmental milestones Mean age (months) Picks up a string between thumb and finger 10 Can release in a container 10 Has mature grasp 12 Has precise release- without pressing on surface 13 Builds tower of 2 cubes 13 Builds tower of 3 cubes 16 Turns pages of book one page at a time 24
Language and communication milestones Developmental milestone Mean age Range (months) (months) Comprehension/ receptive language Understands ‘no’/’bye’ 7 6- 9 Recognizes own name 8 6- 10 Understands familiar names 12 10- 15 Definition by use: using objects by 15 Giving objects on request by 15 Points to body parts on self/ carer 15 12- 18 Points to body parts on doll 18 15- 21 Identifying objects on naming by 24 Follows a 2- step command 24 18- 27 Understands preposition (in/on) 24 18- 33 Understands preposition (under) 30 24- 39 Understands action words by 36 (eg. eating/ sleeping) Understands simple negatives 36 30- 42 Understands comparative 42 36- 48 Follows 2 instructions 42 36- 48 Understands complex negatives 48 42- 60 Follows 3 instructions 54 48- 66
Language and communication milestones Developmental milestone Mean age Range (months) (months) Expressive language and non- verbal communication Jargon 12 10 – 15 Syllabic and tuneful babble 8 6- 9 Pointing to demand 9 Pointing to share interest 10 9- 14 One word 12 10 – 18 2- 6 words 15 12- 21 7- 20 words 21 18- 24 50+ words 24 18 – 27 2 words joining 24 18- 30 200+ words 30 24- 36 3- 4 words joining 30 25- 36 Pronouns 42 36- 48 Uses conjunctions (and, but) 48 36- 54 Sentences of 5+ words 48 36- 54 Complex explanations and sequences 54 48- 66
2014/9/5 Speech, language and communication 1. Comprehension 2. Expression 3. Speech sound and fluency: intelligible speech 2 years (50%), fully intelligible by 4 years 4. Pragmatics:21/2 - 3 years take turns in conversation, 4 years hold conversation skilfully
2014/9/5 Speech, language and communication Place some toys/ objects (eg a cup, spoon, plate, 1 inch cubes, key, fork, pencil, car, miniature toys and pictures for 24 months and above) near the child and ask questions
2014/9/5 Step 1 Comprehension Object labels (15- 18 months): 'look at the....', 'where is the....', 'give me the...." Identify by use (24- 30 months): 'which one do we eat with/ drink with/ sleep in?' (avoid pointing by finger or looking at the objects while asking) Expression Object labels (18- 20 months): 'What is this one', 'this is a ...."
2014/9/5 Step 2 Comprehension (30 months) Ask without pointing: 'show me who is eating/ sleeping/ running' Expression (30- 36 months) Ask while pointing at a picture: 'What is the boy/ girl doing)'
2014/9/5 Step 3 Comprehension Preposition (24- 36 months) Colour (identify or name 2 colours by 36 months and four by 48 months) Size: identify size (bigger/ smaller) of an object or picture (36 months), a longer line (42 months), the weight (heavier of cubes, 48 months) Numbers: rote counting as a nursery rhyme (3 years), 31/2 - 4 years - count four to six cubes/ objects correctly, 4- 41/2 years- can follow direction to 'put three cubes in the cup' 4+ keyword sentences (42 months): give direction in a single sentence eg 'put the big cube and the spoon in the box' Joined up sentences (48 months):'Put the spoon in the box and the pencil on the plate'
2014/9/5 Step 3 Expression Have a conversation with the child: school/ playtime Look at the picture and tell me what is happening (describing narrative: 41/2- 5 years) Describe common objects/ concepts:'What is a key/ friend?' (defining words: 52 months)
Play and social behaviour Observation of play offers a unique opportunity to look at a number of developmental sequences as they come together to create an increasingly complex tapestry of play.
Developmental sequences involved in play Cognitive play sequence 9 months Object oriented exploration play (maturing eye- hand co- ordination and object concepts) 18 months Functional use of real objects on self and others (eg. spoon, brush) 24- 30 months Symbolic use of toys (eg. Toy, tea set, doll) 3- 4 years Pretend or imaginative play
Developmental sequences involved in play Social play sequence 4- 5 weeks Social smile (90% by 6 weeks) 6- 12 months Social anticipation Lap games (eg. peek- a- boo, pat- a cake) 10- 15 months Joint attention Points to show 3- 3.5 years Social imitative play (eg. role play)
Classification of Play Actions into the Five Stages Stage I Exploratory Play Stage 2 Relational Play Stage 3 Self Pretending Stage 4 Decentered Pretending Stage 5 Sequence Pretending By physical By usage Properties Doll+ object Doll alone Same action Theme Mouthing Banging two Spoon Objects in cup Feeds self with spoon/cup Feeds doll with Hugs spoon/ cup doll Feeds doll Sleep -self sequence -adult Shaking/ Hitting Placing objects Pillow into another on bed Combs hair Combs doll’s Kisses Hair doll Pillow on bed Doll on bed – head on pillow Examining Placing objects ‘Sheet on’ bed/ on top of table another Washes self Washes doll Walks doll Combs doll Covers -self doll -adult with sheet Dropping/ Throwing Chair to table Sleeps on doll’s bed or pillow Lies doll Makes on pillow/ doll Bed jump Feeling/ Rubbing Sits on doll’s chair Dresses self with doll’s clothes Sits doll on -dance Chair -somersault Dresses/ undresses doll Puts doll Feeding on bed Bathing Child ‘sleeps’ Gestures adult to sleep
Tools Minitiature toys: Wood table, small spoon (spoon of different sizes), doll, bathtub, 1 aeroplane (small red one), 1 teapot with cover, 1 jug, 1 bowl, 1 small dog/ cat/ cow, 1 car, 2 cups and 2 saucers, 2 chairs (different colours eg white and red of same size). 1 plastic cup, teaspoon, brush, comb, shoe, sock ( 5 items to check on language) Dangling ball (wooly 12.5cm, plastic 6.25cm) Small targets (cube 2.25cm, smartie 1.25cm, HT 1.25mm)
Gross motor Delay in achievement of the gross motor milestones may be an indicator of neurological abnormalities and is sometimes associated with a global developmental delay.
Development of attention Stage I- extreme distractibility. Attention shifts from one object/ person/ event to another. Their attention is held momentarily by whatever is the dominant stimulus (Year 1) Stage 2- children can concentrate on a task of their own choice. They are v. resistant to interference by an adult (Year 2) Stage 3- can shift their full attention to speaker and back to task with adult support. (Year 3: ‘single- chained attention’)
Development of attention Stage 4- Children begin to become able to control focus of attention. Looks at an adult only when the directions become difficult to understand (Year 4: early ‘integrated attention’) Stage 5- Can integrate verbal commands related to a task. Attention span still short. (Year 5: mature ‘integrated attention’)
Development of attention Stage 6- Fully integrated attention. Auditory, visual and physical channels are integrated. Attention is well established.(5- 6 years)
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