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Development short cases approach

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Health & Medicine

Published on September 16, 2014

Author: teikbengkhoo

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Presentation at Mini-Mock exam
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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.

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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

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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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