Development short cases approach

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.

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)

‘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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Developmental Examination: Birth to 1 Year
Gross motor
Fine motor
Speech language communication
Social
Cognitive

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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

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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

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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)

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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

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Development of Grasp: Cube

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Speech, language and communication
Common objects or large toys eg a ball, cup, plate, spoon, car or doll

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Developmental Examination: Birth to
1 Year
Observation of language development: Birth to 1 year

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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)

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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)

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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)

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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

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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)

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Inserting Pegs into Holes (15 months)

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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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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

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Object Permanence(9- 10 months)

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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

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Categorisation: Common Toys

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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

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Developmental Examination: 1- 5 years
1. Motor development
2. Non- verbal perceptual- cognitive
development
3. Speech, language and communication

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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)

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Non- verbal skills tasks,1- 5 years

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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

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Form board with basic geometric shapes (30 months)

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3. Colour matching
and naming
30 months: 50% of children can match cubes/ cards by colour 42- 48 months: name 4 colours correctly

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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

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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

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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

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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

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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

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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 ...."

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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)'

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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'

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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 coordination 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’)

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’)

Stage 6- Fully integrated attention. Auditory, visual and physical channels are integrated. Attention is well established.(5- 6 years)

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Development short cases approach

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