Más contenido relacionado


assessment of growth and development.pptx

  1. Assessment of Growth & Development
  2. ⦁ Growth and development are sometimes used interchangeably. ⦁ Growth is defined as net increase in the size or mass of tissues. It is largely due to multiplication of cells,increase in the intracellular substance (quantitative ) ⦁ Development is defined as maturation of functions and acquisition of skills. (qualitative growth) ⦁ Early childhood : Cognitive growth and development difficult to differentiate from neurologic and behavioural maturation. ⦁ Later childhood, it can be measured by communicative skills and cognitive abilities influenced by the physical, emotional and social environment. INTRODUCTION
  3. Changes in bodily proportions with age Predictable Sequence -Cephalo-caudal (head down to toes) - Proximodistal (center of the body to peripheral) - General to specific
  4. Principles ofGrowth 1. Continous process from conception onward Orderly - definite time limits for growth. Any time lost during a rapid growth period may prevent catch-up growth. 2. Unique for each individual - genetic and environment factors 3. Growth is governed by complex chain of hormonal interactions.The growth in the first year is mainly controlled by inherent potential of the cells and later by several factors (environmental and genetic).
  5. ⦁ 4. Growth spurts occur in late foetal period ; pubertal period. It is a dynamic process • 5. Growth does not follow normal distribution curve. • 6. Each stage of G&D is affected by the preceding types of development Principles of Growth
  6. Differential growth • Each child grows in his/her own unique way. • Not all body parts grow in the same rate at the same time ⦁ C N S :Neuronal division essentially complete by 1 year, ⦁ Bone,Muscle,and Fat cells continue to divide until later in childhood. ⦁ Other - Skin,gastrointestinal epithelial cells,and liver retain the capacity for hyperplasia throughout life. • Don’t progress at the same rate (↑ periods of GR in early childhood and adolescents & ↓ periods of GR in middle childhood)
  7. Stages of Growth and Development ⦁ Infancy ⦁ Neonate ⦁ Birth to 1 month ⦁ Infancy ⦁ 1 month to 1 year ⦁ Early Childhood ⦁ Toddler ⦁ 1-3 years ⦁ Preschool ⦁ 3-6 years ⦁ Middle Childhood ⦁ School age ⦁ 6 to 10 years (Girls) ⦁ 6 to 12 years (Boys) ⦁ Late Childhood (Adolescent) ⦁ Prepubescent : 10-12 yrs () 12-14 yrs () ⦁ Pubescent : 12- 14 yrs(ƒ );14-16 yrs () ⦁ Post Pubescent :14 -18 yrs(ƒ); 16- 20 yrs ()
  8. Factors Affecting Growth 1. Genetic factors a. Race b. Sex c. Chromosomal 2.Nutritional Factors 3.Hormonal-Thyroxine GH
  9. 4. Environmental factors a) Altitude, temperature b) Pollutants 5. Social Factors a) Socioeconomic class b) Education of parents c) Education of child
  10. Measurement of human growth • Assessment of human growth is done using similar methods so that their data are comparable between individuals in the same study and between samples in different studies. • A book “Practical Human Biology” forms the source for many scientists who wish to use standard techniques to anthropometric measurement • This book also has many other techniques that are applied in research in human biology such as dermatoglyphics, physiological measures, salt and water balance, thermal comfort, nutritional status, etc
  11. Importance of growth assessment • Growth is fundamental characteristic of childhood. • Normal growth is indicator of optimum health. • Deviation from the normal pattern is indicative of pathological process. • Periodic assessment facilitates early detection of growth faltering, which may be first manifestation of undernutrition/infection/ disease.
  12. Context of measurement; screening, surveillance and monitoring • Assessment of human growth and development is directly dependent on the methods employed to measure • The context will usually be one of three types:  Screening  Surveillance  Monitoring
  13. Screening • It is the identification of a particular subset of the population with certain prescribed characteristics. • is a cross-sectional, once-off activity and usually involves large samples of children. • it will lead on to further assessment or intervention
  14. Requirement for screening • Large sample sizes needed • Need for high levels of measurement efficiency, • only a few dimensions such as height and weight are measured • Instrumentation tends to be basic and portable • Assessment is undertaken by more than one observer
  15. Surveillance • It is assessing the process of growth on more than one occasion on a sample of children • Usually follows a screening exercise. • Children selected to partake in a nutritional supplementation program are re-assessed at some future date • This re-assessment may happen over several months and/or years
  16. • This leads to the identification of a child with an unusual pattern of growth • This child is regularly reassess in a clinical situation with access to treatment regimes if a treatable disorder is diagnosed. Requirement for surveillance • Description of growth requires more dimensions to be assessed • Number of observers will be fewer
  17. Monitoring • Long-term high-frequency assessment of a single child or small sample of children. Requirements for Monitoring • Specialist setting with dedicated space • High quality instrumentation • Broad range of dimensions to properly assess all aspects of the pattern of growth.
  18. • Screening provides only cross-sectional data • Surveillance and monitoring provides both cross- sectional and longitudinal components. • Surveillance and monitoring provides information regarding both current size of the child and of the growth rate i.e. “growth velocity”.
  19. VIMAR • It describes the most important elements to be considered when designing an anthropometric scenario Stands for: Validity Instrumentation Minimum unit of measurement Accuracy Reliability
  20. Validity • It is the appropriateness of the dimension to be assessed • For example, relationship between height and arm span is well recognized • So we can use development of regression equations to predict height from arm span • But it is better that dimension of interest ought to be measured and not predicted from another dimension
  21. Instrumentation • whether the instrument of choice is best able to measure the dimension of interest • For example, an infant length measuring board is designed to measure the supine length of infants and produces more accurate and reliable data than using a tape measure.
  22. Minimum unit of measurement • Smallest unit of measurement should be used on the chosen instrument. • For example, stadiometers, used to measure height, usually have their smallest unit as millimetres that should be used • This has important implications for both the accuracy and reliability of measurement.
  23. Accuracy • “in exact conformity with truth.” Improve the accuracy and decrease error by ensuring that we use a valid, specifically designed instrument, with precision By using a properly trained observer.
  24. Reliability • An observer or instrument should consistently and accurately measures a particular dimension. Reliability involves 3 sources of error: 1. the observer 2. the instrument 3. the subject
  25. The accuracy of these measurements can be maintained by following a few simple rules: 1. Ensure the subject is in minimum of clothing so there is no interferes with the identification of surface landmarks 2. Familiarize the subject with the instrumentation, so as to ensure that he/she is relaxed 3. Measure the left-hand side of the body 4. Apply the instruments gently but firmly 5. Establish the reliability of measurement prior to the study using subjects with similar characteristics (age, sex, etc.) 6. During the study create a quality control procedure by repeating measurements on randomly selected subjects 7. Do not try to measure too many subjects in any one session. Fatigue
  26. MEASUREMENT PARAMETERS Postnatal growth patterns of normal children are well characterized, resulting in several clinical parameters for assessment of growth. 1.Linear growth (Length/Height) 2.Weight and body mass index 3.Weight/Height 4.Head circumference 5.Mid arm circumference 6.Body proportions (arm span and upper-to-lower segment ratio) 7.Growth velocity 8.Growth patterns 9.Dentition 10.Bone Age
  27. Growth can be measured in terms of: 1. Physical anthropometry 2. Assessment of tissue growth 3. Bone age 4. Dental age
  28. Physical anthropometry Age dependent anthropometry- 1. Weight 2. Length or Height 3. Head circumference 4. Chest circumference
  29. Age independent anthropometry 1. Midarm circumference(1-5 yrs) 2. Weight for height 3. Mid upper arm/height ratio 4. Midarm/Head circumference ratio 5. Quetlet’s index 6. Ponderal index 7. Dugdale’s index 8. Body mass index
  30. Calculation formulae Weight gain •Newborn 1st 3 months - 200 gm/ week •Next 3 months – 150 gm/ week •Next 6 months – 100 gm/ week •Doubles by 4 months;Triples by 1 year •Quadruples by 2 years; •Thereafter 2kg /yr added on till 6 years •Thereafter 3 kg/yr added till puberty Length gain Doubles ( ie.. 100 cm) by 4 years  6 cm / year till puberty  Triples by 12 years Head circumference 1st 3 months: 2cm/month Next 3 months: 1cm/month Next 6 months : 0.5 cm/month
  31. Weight measurement ⦁ Weighing scales are of 3 types: ⦁ A) Beam balance ⦁ Platform scale ⦁ Beam scale/ TANSI scale ⦁ B) Spring Balance ⦁ Salters weighing scale ⦁ Bathroom scale ⦁ C) Electronic scale Measure to the nearest 10 gm for infants and 100 gm for children.Weighing together with mother.
  32. Calculation of expected weight Weech’s formula: • 3-12 months Expected weight (kg)=Age(months)+9 2 • 1-6 yrs Expected weight (kg)=2y+8 • 7-12 yrs Expected weight (kg)=7y – 5 2
  33. Welcome trust classification of PEM (1970) >80% of expected weight Normal 60 – 80% of expected weight W ith edema :Kwashiorkor W ithout edema :Underweight <60% of expected weight With edema: Marasmic kwashiorkor W ithout edema :Marasmus
  34. Gomez Classifaction Nutritional Status Weight for age(%) for 50th pecentile of Harvard Standard Normal >90 Grade I 70-90 Grade II 60-70 Grade III <60 Other systems of classification :
  35. LENGTH/HEIGHT Below 2 yrs- supine length with infantometer. For older children- Harpenden Stadiometer
  36. Prerequisites ⦁ Without footwear ⦁ Heels & back touching the wall ⦁ Looking straight ahead in frankfurt plane. ⦁ Gentle but firm pressure upwards applied to the mastoids from underneath ⦁ Record to last 0.1cm
  37. Waterlow’s classificati on Classification Height for Age (% of expected) Normal >95 First degree stunting 90-95 Second degree stunting 85-89 Third degree stunting <85
  38. Equipment: sitting base of a known height (e.g., 50 cm x 40 cm x 30 cm) and a wall-mounted stadiometer Technique: The child is placed as erect as possible with buttocks, shoulders, and head in contact with backboard of the stadiometer.Total height is measured.The height of the sitting surface is then subtracted from the total height. Plotting and Interpretation: The measurement can be plotted on the CDC charts for stature-for-age. Even if measurements fall below the 5th percentile, they establish a growth pattern over time. Sitting height
  39. Height measurements Iliac Height (IH) ⦁ The distance between the summit of the iliac crest and the floor. Subischial Leg Length (SLL) ⦁ The difference between stature and sitting height. ⦁ It assumes that in a seated position the proximal landmark corresponds to the hip joint, which is very difficult to locate. ⦁ Useful to measure upper to lower body proportions
  40. Calculation of Target Height and Target Height Centile Measure the parent’s heights and make a note of their heights on the chart. Calculate the child’s target height (TH) and plot it at 18 years and mark it with an arrow on the growth chart. This represents the child’s projected height and the target range is produced by plotting two points 7.5 cms above and below for a boy and 6 cm above and below for a girl (representing the 10th and the 90th centile for that child). Cowell CT. Short Stature. In: Clinical Pediatric Endocrinology, 3rd edn. Ed. Brook CGD. London, Blackwell Science, 1995; pp 136-172.
  41. WATERLOW Classification Weight for Height Waterlow Classification >= 80 % < 80 % Height for >= 90 % Normal Wasted Age < 90 % Stunted Wasted and stunted
  42. WHO Classification Wt/Age Ht/Age Wt/Ht Intepretation Normal Normal Normal Normal Decreased Normal Decreased Acute Malnutrition Decreased Decreased Normal Chronic Malnutrition Decreased Decreased Decreased Acute Or Chronic Malnutrition
  43. Head Circumference Brain growth is rapid during infancy and it is unaffected by mild to moderate degree of malnutrition Should not be measured within 24 hrs after birth Bony land marks – superior orbital ridge (ant), external occipital protuberance (post) Place the measuring tape around the largest circumference of the infant's head, across the occiput and the forehead.
  44. Expected head circumference in children Age Head Circumference (cm) At birth 35 2 months 38 3 months 40 4 months 41 6 months 42-43 1 yr 45-46 2 yr 47-48 5 yr 50-51
  45. Approximate gain in head circumference between 0 and 5 yrs Age Growth velocity of head circumference 0-3 months 2 cm/month 3-6 months 1 cm/month 7-12 months 0.5 cm/month 1-3 yrs 1 cm/6 months 3-5 yrs 1 cm/yr
  46. Chest circumference Not used universally Useful measurement for comparison with the head circumference when a problem is suspected with either the head size or chest size. Wrap the measuring tape around the infant's chest ideally taken at xiphisternum / substernal notch just below the nipple line, midway between inspiration and expiration firmly but not tight enough to cause an indentation of the skin. read to the nearest 0.5 cm
  47. Chest Circumference • Measured at the level of nipples on mid inspiration. • < 5 yrs – Lying down position • > 5 yrs – Standing position • At birth – HC is 3cm more than CC • At 1 year – HC = CC • After 1 year – CC > HC
  48. Internipple distance ⦁ Trunk physical parameter as in special situations ⦁ Internipple distance calculated by using Sliding callipers with child at rest and at end of expiration. ⦁ Internipple Index = Internipple distance X 100 Chest circumference Value > 28 % diagnostic
  49. Upper-to-Lower Segment Ratio • The upper-to-lower segment ratio is calculated when a child's body may have inappropriate proportions between the head and trunk to the extremities. • Measure the lower body segment (distance from the symphysis pubis to the floor when a child stands). • Calculate the upper body segment by subtracting the lower body segment from the total height.Then divide the upper body segment by the lower body segment to calculate the ratio.
  50. • Expected ratios by age are ♦At birth—1.7 ♦At 3 years—1.3 ♦After 7 years— 1.0 ♦By about 11 years of age, adult proportions are reached • Increase: Rickets,achondroplasia, Untreated hypothyroidism • Decrease: spondyloepiphyseal dysplasia, vertebral anomalies
  51. Normal upper segment/ lower segment ratio in children Age Upper segment/lower segment ratio At birth 1.7:1 6 months 1.6:1 1 yr 1.5:1 2 yr 1.4:1 3 yr 1.3:1 4 yr 1.2:1 7 yr 1.1:1 10 yr 1:1 18 yr 0.9:1
  52. ⦁ Arm length – Acromion to tip of 3rd finger with arm in full extension and parallel to the body. ⦁ Upper segment of arm – Acromion to Olecranon with elbow bent at 90º ⦁ Foream / Lower segment of arm – Olecranon process to distal end of styloid process of radius with elbow bent at 90º ⦁ Hand length – Distal wrist crease to tip of 3rd finger ⦁ Palm length – Distal wrist crease to prox. Crease of 3rd finger Individual components
  53. Skeletal dysplasia ⦁ Rhizomelia (Upper arm / Proximal shortening) ⦁ Mesomelia (Forearm / Middle shortening) ⦁ Acromelia (Palm &Fingers / Distal shortening) ⦁ Acromesomelia (Forearm, Palm, fingers /Middle & distal) ⦁ Micromelia (Whole upper limb shortening)
  54. Midarm Circumference • Measured on left upper arm midway b/w acromion and olecranon process with arm hanging by side of body. • Shakir tape • Bangle test • At birth: 9-11 cm • 1-5years: 16-17 cm
  55. Mid Upper arm circumference (MUAC) Steps of MUAC measurement Ask the mother to remove any clothing that covers the child’s arm. If possible the child should stand erect and sideways to the measurer. Estimate the mid-point of the left arm. Straighten the child’s arm and wrap the tape around at the mid-point. Make sure that the numbers are right side up. Make sure the tape is flat around the skin. Inspect the tension of the tape on the child’s arm. Make sure the tape has the proper tension and is not too tight or too loose. Repeat any step as necessary. When the tape is in the correct position and correct tension on the arm, read and call out the measurement to the nearest 0.1 cm. Immediately record the measurement.
  56. Shakir Tape MUAC (cm) Inference >13.5 Normal 12.5-13.5 Borderline <12.5 Under nutrition
  57. Bangle Test • Used for quick assessment. •Fibre glass ring of internal diameter of 4cm is slipped up arm. •If it passes above elbow , suggests MAC <12.5 cm and child malnourished.
  58. QUAC STICK • Quakers arm circumference stick • Consists of rod with 2 sets of markings height • MAC corresponding to ht • If ht > ht for expected MAC – child is malnourished • Modified quack stick – colored rod
  59. Weight for height Calculated as: weight of child(kg) X100 Expected weight for a healthy child of same height
  60. Classification Weight for height (% expected of expected) Normal >90 Mild wasting 80-90 Moderate wasting 70-79 Severe wasting <70
  61. WHO Classification Weight for Height Inference Z- score < -2 (70-79% of expected) Moderate wasting Z- score < -3 (<70% of expected) Severe wasting Height for age Inference Z- score < -2 (85-89% of expected) Moderate stunting Z - score < -3 (<85% of expected) Severe stunting Edema +/-
  62. Quetlet Index • Calculated as: weight(kg) { Height(cm)}2 X 100 • Normal:0.14-0.16 • <0.14 indicate malnutrition
  63. Ponderal Index Calculated as: weight(g) height(cm) 3 X 100 Ponderal Index Significance in newborn >2.5 Term,AGA baby <2 Asymmetrical IUGR (Severe PEM) >2 Symmetrical IUGR
  64. Skinfold thickness Skinfold thickness by age and sex, as measured by Harpenden skinfold calipers over triceps and under scapula. A caliper is used to measure the thickness of a fold of the baby’s skin with its underlying layer of fat (the subcutaneous fat).
  65. • Measurements are taken from the following body sites: • Subscapular • Flank • Triceps • Quadriceps
  66. Waist circumference and waist-hip ratio: ⦁ Both waist circumference (WC) and waist-hip ratio are indicators of visceral fat or abdominal obesity in children and adolescents age 2–19 years. ⦁ Increased visceral adiposity measured by WC increases the risk of obesity-related morbidity and mortality. ⦁ WC should be measured at the highest point of the iliac crest when the individual is standing and at minimal respiration. ⦁ Waist-hip ratio is calculated as a ratio of waist circumference (cm) and hip circumference (cm).
  67. GROWTH VELOCITY ⦁ The most critical factor in evaluating the growth is determining GROWTH VELOCITY. ⦁ Observation of child’s height pattern in the form of “CROSSING PERCENTILE LINES” on a linear growth curve is the simplest method of observing abnormal growth velocity. ⦁ Atleast 3 measurements with preferably 6 months interval in between is necessary to comment on growth pattern.
  68. WeightVelocity 1st year :6 kg Pre-school:2kg/year School :3 kg/yr till puberty
  69. Growth patterns ⦁ From the end of infancy until puberty begins, growth normally proceeds along a channel that closely corresponds to a given height-attained percentile on cross- sectional growth standards. A child normally establishes this channel by 2 to 3 years age, although, on rare occasions, a gradual drift by as many as 40 percentile positions in height attained may occur over a period of several years in normal children. ⦁ The velocity of growth (cm per year) actually decelerates slightly during this period and averages about 6 cm per year in midchildhood.However, normal children cross height-velocity percentiles to maintain their height channel. ⦁ A growth velocity that is consistently along the third percentile will lead to a subnormal height.The growth channel seems to be genetically determined. Children grow as if to reach a genetically predetermined height. ⦁ This target height, which represents the child’s genetic potential, can be approximated by calculating the MPH.
  70. ⦁ Growth should be measured and compared with statistical norms in a standard chart wit h growth charts. Also called as “road-to-health" chart. It was first designed by David Morley and was later modified by WHO. ⦁ Growth is assessed by plotting accurate measurements on growth charts and comparing each set of measurements with previous measurements obtained at health maintenance visits or at other visits if there is a concern over the child's growth pattern. ⦁ Serial measurements more useful than single measurements to detect deviations from a particular child's growth pattern even if the value remains within statistically defined normal limits (percentiles) GROWTH MONITORING Males 78 74 70 66 62 58 54 50 46 42 38 34 30 Height Height (cm) 2 4 6 8 10 12 14 16 18 20 Age (y) 200 190 180 170 160 150 140 130 120 110 100 90 80 70 +2 +1 0 -1 -2 Growth charts are visible display of child’s physical growth and development.
  71. Growth standard reference • Rate of growth of children is one of the finest indicators of the health of a community. • Growth monitoring followed by suitable action prevents illness, malnutrition and even death. • It provides reassurance about child’s health and prevents parental anxiety. • A growth reference simply describes the growth of a sample of individuals, whereas a standard describes the growth of a healthy population and suggests an aspirational model.
  72. • WHO growth charts are growth standards. A reference is representative of the existing growth pattern of children and allows us to study the secular trends in height, weight and obesity. • On community and national level it helps identify children at risk of morbidity and mortality. • It thus helps in implementation of national programmes for nutritional and medical interventions like supplementary feeding, foods to vulnerable group, underprivileged school children, etc. • It is also a method to evaluate programs for improving child health and nutrition and can form the basis for policy making.
  73. WHO - MGRS / reference indicators Attained growth  weight-for-age  length/height-for-age  weight-for-length/height  head circumference-for-age  mid-upper arm circumference-for-age  triceps skinfold-for-age  subscapular skinfold-for-age  body mass index-for-age Velocity  weight  length  head circumference
  74. ⦁ Deviations in growth patterns may be nonspecific or may be important indicators of serious and chronic medical disorders. ⦁ An accurate measurement of length/height,weight,and head circumference should be obtained at every health supervision visit. GROWTH MONITORING
  75. Time schedule child anthropometry Measurement Time frame Frequency No. of visits Weight, length, head circumference Birth Once 1 Weeks 2-8 Bi-weekly 14 3-12 months Monthly 10 14-24 months Bi-monthly 6 Arm circumference Skinfold thicknesses 3-12 months Monthly 10 14-24 months Bi-monthly 6 W H O Multicentre Growth Reference Study (2006)
  76. Bone Age Or SkeletalMaturity • Chronological age at which skeletal maturation is normally attained • Radiological examination of bones is used for the assessment of maturity. • Usually, radiological examination of wrist and elbow is done to assess bone age (1-13 years). • For infants (3-9 months), radiograph of shoulder is useful.
  77. G & P Method • Patient’s film is compared with the standard of the same sex and nearest age • It is next compared with adjacent standard, both older and younger to get the closest match
  78. Tanner-Whitehouse (TW) method The TW2 (Tanner- Whitehouse 2) methods: • RUS (radius-ulna-short bones): 13 bones including the radius, ulna and short bones of the thumb, middle and little fingers • carpus: 7 carpal bones • 20-bones method: combines the two
  79. • Each bones compared to a standard set of bones at different stages of maturation. • A score is assigned to each bone based on maturation and sex of the patient. • Once all the bones have been scored, a total score is generated and plotted on a graph to determine how the bone age relates to the chronological age.
  80. • Bone age Better correlate with SMR Predictor of future height • Delayed bone age Constitutional short stature Hypothyroidism Celiac disease GH deficiency
  81. Bone age: an algorithm for boys UnnikrishnanAG,Kumar H,J ayakumar RV. Bone age in a minute: a simple algorithm. Amrita JMed 2006;2:39-41
  82. Bone age: an algorithm for girls UnnikrishnanAG,Kumar H,J ayakumar RV. Bone age in a minute: a simple algorithm. Amrita JMed 2006;2:39-41
  83. C AVEATS TO INFORMATION IN BONE AGE • Subjectivity: Interobserver variation • Normal children radiographs comparability possible but non-applicability to spl. context- skeletal dysplasias, genetic causes. BAYLEY-PINNEAU and RWT (Roche,Wainer,Thissen) CHARTS
  84. Dental development
  85. Dental development ⦁ Dental development includes mineralization, eruption, and exfoliation. ⦁ Initial mineralization begins as early as the second trimester (mean age for central incisors, 14 wk) and continues through 3 yr of age for the primary (deciduous) teeth and 25 yr of age for the permanent teeth. ⦁ Mineralization begins at the crown and progresses toward the root. ⦁ Eruption begins with the central incisors and progresses laterally. ⦁ Exfoliation begins at about 6 yr of age and continues through 12 yr of age. Eruption of the permanent teeth may follow exfoliation immediately or may lag by 4-5 mo.The timing of dental development is poorly correlated with other processes of growth and maturation.
  86. Sexual maturity rating ( SMR): • Also known as Tanners stages • Used in older children • Total 5 stages included in each gender Always Perform Sexual Maturity Rating
  87. MALES: SMR Pubic Hair • Stage 1 Preadolescent • Stage 2 Scanty, long, slightly pigmented, primarily at base of penis • Stage 3 Darker, coarser, starts to curl, small amount • Stage 4 Coarse, curly; resembles adult type but covers smaller area • Stage 5 Adult quantity and distribution, spread to medial surface of thighs
  88. SMR – Genitals Penis Testes Stage 1 Preadolescent Preadolescent Stage 2 Slight or no enlargement Beginning enlargement of testes and scrotum; scrotal skin reddened, texture altered Stage 3 Longer Further enlargement of testis and scrotum Stage 4 Larger in breadth, glans penis develops Testes & scrotum nearly adult Stage 5 Adult Adult
  89. SMR Females SMR Pubic Hair • Stage 1 Preadolescent • Stage 2 Sparse, slightly pigmented, straight, at medial border of labia • Stage 3 Darker, beginning to curl, increased amount • Stage 4 Coarse, curly, abundant, but amount less than in adult • Stage 5 Adult feminine triangle, spread to medial surface of thighs
  90. SMR Breasts • Stage 1 Preadolescent; elevation of papilla only • Stage 2 Breast and papilla elevated as small mound; areola diameter increased • Stage 3 Breast and areola enlarged with no separation of their contours • Stage 4 Projection of areola and papilla to form secondary mound above the level of the breast • Stage 5 Mature; projection of papilla only, areola has recessed to the general contour of the breast Tanner JM. 1962. Growth at Adolescence (2nd ed.). Oxford, England: Blackwell Scientific Publications.
  91. ASSESSMENT OFDEVELOPMENT • Development is a process of acquiring variety of competencies for the optimal functioning in the society. • Development is a qualitative change. • If developmental delay is recognized early, intervention to reduce long term sequel can be started. • It is important to monitor growth and development at every stage. • A child is said to have developmental delay if the child does not reach the expected developmental milestones for the age.
  92. Purposes of developmental assessment • To determine if any developmental delay exists. • To identify strengths and needs. • To develop strategies for intervention. • To serve as a basis for reporting to parents. • To determine the progress on significant developmental achievements.
  93. What is developmental delay? ◦ Developmental Delay is when a child does not reach their developmental milestones at the expected times. ◦ It is an ongoing major or minor delay in the process of development. ◦ Delay can occur in one or many areas—for example, gross or fine motor, language, social, or thinking skills.
  94. ◦ Developmental delay is not uncommon and occurs in 2-3% of all children. ◦ The term developmental delay is often used until the exact nature and cause of the delay is known. ◦ The significance of the delay is often only determined by observing the child’sdevelopment over time.
  95. Transient developmental delay ◦ Some children have a transient delay in their development. ◦ For example, some extremely premature babies may show a delay in the area of sitting, crawling and walking but then progress on at a normal rate. ◦ Other causes of transient delay may be related to physical illness and prolonged hospitalization, immaturity, family stress or lack of opportunities to learn.
  96. Persistent developmental delay ◦ If the delay in development persists it is usually related to problems in one or more of the following areas:  understanding and learning  moving  communication  hearing  seeing. ◦ An assessment is often needed to determine what area or areas are affected. ◦ Disorders which cause persistent developmental delay are often termed developmental disabilities.
  97. Developmental disability ◦ Developmental disability is estimated to occur in 5-10% of the population with enormous psychological, motional, and economic impact on the affected individuals and society. ◦ Studies have shown that developmentally delayed children who are recognized at an early age receive more developmental optimization and greater gains than those who are identified later in life. ◦ Early recognition of children with developmental problems is therefore important. ◦ There are several disabilities in the classification of developmental delay:
  98. Disability Description Gross motor delay Significant delay in fine or gross motor skills with no impairment in other developmental areas Developmental language disorders Significant delay in receptive and/or expressive language skills with no delay in other developmental domains Global developmental delay Significant delay in two or more developmental streams as measured by appropriate standardized screening tests. This term is reserved for children less than 5 years of age Cerebral palsy Early-onset non-progressive motor impairment with associated abnormalities in muscle tone Hearing sensory impairment A reduction in the ability to hear sound, ranging from slight to complete deafness
  99. Disability Description Visual sensory impairment An optically or medically diagnosable condition in the eye(s) or visual system that affects the development and normal use of vision, ranging from slight to complete blindness Learning disabilities Significantly lowered individual achievement than predicted by intellectual ability as measured by standardized psycho-educational tests assessing reading, mathematics, or written expression Pervasive developmental delay (PPD) / Autism Impairments in social skills, communication skills and restrictive / repetitive patterns of behavior Pervasive developmental disorders not otherwise specified / Autism Spectrum Disorder Similar to PDD but not enough symptoms to warrant a PDD diagnosis
  100. What are developmental milestones? ◦ Developmental milestones are a set of functional skills or age-specific tasks that most children can do at a certain age range. ◦ A pediatrician uses milestones to help check how a child is developing. ◦ Although each milestone has an age level, the actual age when a normally developing child reaches that milestone can vary quite a bit. Every child is unique! ◦ CDC’s milestone checklists
  101. In these categories… ◦ Gross motor: using large groups of muscles to sit, stand, walk, run, etc., keeping balance, and changing positions. ◦ Fine motor: using hands to be able to eat, draw, dress, play, write, and do many other things. ◦ Language: speaking, using body language and gestures, communicating, and understanding what others say. ◦ Cognitive: Thinking skills: including learning, understanding, problem-solving, reasoning, and remembering. ◦ Social: Interacting with others, having relationships with family, friends, and teachers, cooperating, and responding to the feelings of others.
  102. 1month • Makes jerky, quivering arm thrusts • Brings hands within range of eyes and mouth • Moves head from side to side while lying on stomach • Head flops backward if unsupported • Keeps hands in tight fists • Strong reflex movements Movement Milestones
  103. 1month • Focuses 8 to 12 inches (20.3 to 30.4 cm) away • Eyes wander and occasionally cross • Prefers black-and-white or high- contrast patterns • Prefers the human face to all other patterns • Hearing is fully mature • Recognizes some sounds • May turn toward familiar sounds and voices Visual and Hearing Milestones
  104. 1month • Prefers sweet smells • Avoids bitter or acidic smells • Recognizes the scent of his own mother’s breastmilk • Prefers soft to coarse sensations • Dislikes rough or abrupt handling Smell and Touch Milestones
  105. 3 months • Raises head and chest when lying on stomach • Supports upper body with arms when lying on stomach • Stretches legs out and kicks when lying on stomach or back • Opens and shuts hands • Pushes down on legs when feet are placed on a firm surface • Brings hand to mouth • Takes swipes at dangling objects with hands • Grasps and shakes hand toys Movement Milestones
  106. 3 months • W atches faces intently • Follows moving objects • Recognizes familiar objects and people at a distance • Starts using hands and eyes in coordination • Smiles at the sound of your voice • Begins to babble • Begins to imitate some sounds • Turns head toward direction of sound Visual and Hearing Milestones
  107. 3 months • Begins to develop a social smile • Enjoys playing with other people and may cry when playing stops • Becomes more communicative and expressive with face and body • Imitates some movements and facial expressions Social and Emotional Milestones
  108. 7 months • Rolls both ways (front to back, back to front) • Sits with, and then without, support of her hands • Supports her whole weight on her legs • Reaches with one hand • Transfers object from hand to hand • Uses raking grasp (not pincer) Movement Milestones
  109. 7 months • Develops full color vision • Distance vision matures • Ability to track moving objects improves Visual Milestones
  110. 7 months • Responds to own name • Begins to respond to “no” • Distinguishes emotions by tone of voice • Responds to sound by making sounds • Uses voice to express joy and displeasure • Babbles chains of consonants Language Milestones
  111. 7 months • Finds partially hidden object • Explores with hands and mouth • Struggles to get objects that are out of reach Cognitive Milestones
  112. 7 months • Enjoys social play • Interested in mirror images • Responds to other people’s expressions of emotion and appears joyful often Social and Emotional Milestones
  113. 12months • Gets to sitting position without assistance • Crawls forward on belly by pulling with arms and pushing with legs • Assumes hands-and-knees position • Creeps on hands and knees supporting trunk on hands and knees • Gets from sitting to crawling or prone (lying on stomach) position • Pulls self up to stand • Walks holding on to furniture • Stands momentarily without support • May walk two or three steps without support Movement Milestones
  114. 12months • Uses pincer grasp • Bangs two cubes together • Puts objects into container • Takes objects out of container • Lets objects go voluntarily • Pokes with index finger • Tries to imitate scribbling Milestones In Hand and Finger Skills
  115. 12months • Pays increasing attention to speech • Responds to simple verbal requests • Responds to “no” • Uses simple gestures, such as shaking head for “no” • Babbles with inflection • Says “dada” and “mama” • Uses exclamations, such as “oh-oh!” • Tries to imitate words Language Milestones
  116. 12months • Explores objects in many different ways (shaking, banging, throwing, dropping) • Finds hidden objects easily • Looks at correct picture when the image is named • Imitates gestures • Begins to use objects correctly (drinking from cup, brushing hair, dialing phone, listening to receiver) Cognitive Milestones
  117. 12months •Shy or anxious with strangers •Cries when mother or father leaves •Enjoys imitating people in play •Shows specific preferences for certain people and toys •Tests parental responses to his actions during feedings (What do you do when he refuses a food?) •Tests parental responses to his behavior (What do you do if he cries after you leave the room?) •May be fearful in some situations •Prefers mother and/or regular caregiver over all others •Repeats sounds or gestures for attention •Finger-feeds himself •Extends arm or leg to help when being dressed Social and Emotional Milestones
  118. 2 years • Walks alone • Pulls toys behind her while walking • Carries large toy or several toys while walking • Begins to run • Stands on tiptoe • Kicks a ball • Climbs onto and down from furniture unassisted • Walks up and down stairs holding on to support Movement milestones
  119. 2 years • Scribbles spontaneously • Turns over container to pour out contents • Builds tower of four blocks or more • Might use one hand more frequently than the other Milestones in hand and finger skills
  120. 2 years • Points to object or picture when it’s named for him • Recognizes names of familiar people, objects, and body parts • Says several single words (by fifteen to eighteen months) • Uses simple phrases (by eighteen to twenty- four months) • Uses two- to four-word sentences • Follows simple instructions • Repeats words overheard in conversation Language milestones
  121. 2 years • Finds objects even when hidden under two or three covers • Begins to sort by shapes and colors • Begins make-believe play Cognitive milestones
  122. 2 years • Imitates behavior of others, especially adults and older children • Increasingly aware of herself as separate from others • Increasingly enthusiastic about company of other children • Demonstrates increasing independence • Begins to show defiant behavior • Increasing episodes of separation anxiety toward midyear, then they fade Social and emotional milestones
  123. 3-4 years • Hops and stands on one foot up to five seconds • Goes upstairs and downstairs without support • Kicks ball forward • Throws ball overhand • Catches bounced ball most of the time • Moves forward and backward with agility Movement milestones
  124. 3-4 years • Copies square shapes • Draws a person with two to four body parts • Uses scissors • Draws circles and squares • Begins to copy some capital letters Milestones in hand and finger skills
  125. 3-4 years • Understands the concepts of “same” and “different” • Has mastered some basic rules of grammar • Speaks in sentences of five to six words • Speaks clearly enough for strangers to understand • Tells stories Language milestones
  126. 3-4 years • Correctly names some colors • Understands the concept of counting and may know a few numbers • Approaches problems from a single point of view • Begins to have a clearer sense of time • Follows three-part commands • Recalls parts of a story • Understands the concept of same/different • Engages in fantasy play Cognitive milestones
  127. 3-4 years •Interested in new experiences •Cooperates with other children •Plays “Mom” or “Dad” •Increasingly inventive in fantasy play •Dresses and undresses •Negotiates solutions to conflicts •More independent •Imagines that many unfamiliar images may be “monsters” •Views self as a whole person involving body, mind, and feelings •Often cannot distinguish between fantasy and reality Social and emotional milestones
  128. 4-5 years • Stands on one foot for ten seconds or longer • Hops, somersaults • Swings, climbs • Maybe able to skip Movement milestones
  129. 4-5 years • Copies triangle and other geometric patterns • Draws person with body • Prints some letters • Dresses and undresses without assistance • Uses fork, spoon, and (sometimes) a table knife • Usually cares for own toilet needs Milestones in hand and finger skills
  130. 4-5 years • Recalls part of a story • Speaks sentences of more than five words • Uses future tense • Tells longer stories • Says name and address Language milestones
  131. 4-5 years • Can count ten or more objects • Correctly names at least four colors • Better understands the concept of time • Knows about things used every day in the home (money, food, appliances) Cognitive milestones
  132. 4-5 years • Wants to please friends • Wants to be like her friends • More likely to agree to rules • Likes to sing, dance, and act • Shows more independence and may even visit a next-door neighbor by herself • Aware of sexuality • Able to distinguish fantasy from reality • Sometimes demanding, sometimes eagerly cooperative Social and emotional milestones
  133. What are the Warning signs of a physical developmental delay ?
  134. Newborn to 2 months • After 2 months, doesn't hold his head up when you pick him up from lying on his back • After 2 months, still feels particularly stiff or floppy • After 2 months, overextends his back and neck (as if he's pushing away from you) when cradled in your arms • After 2 or 3 months, stiffens, crosses, or "scissors" his legs when you pick him up by the trunk
  135. 3 to 6 months • by 3 or 4 months, doesn't grasp or reach for toys • by 3 or 4 months, can't support his head well by 4 months, isn't bringing objects to his mouth • by 4 months, doesn't push down with his legs when his feet are placed on a firm surface • after 4 months, still has Moro reflex (when he falls backward or is startled, he throws out his arms and legs, extends his neck, and then quickly brings his arms back together and begins to cry)
  136. 3 to 6 months • after 5 or 6 months, still has the asymmetrical tonic neck reflex (when his head turns to one side, his arm on that side will straighten, with the opposite arm bent up as if he's holding a fencing sword) • by 6 months, can't sit with help • after 6 months, reaches out with only one hand while keeping the other fisted • doesn't roll over in either direction (back to front or front to back) by 5 or 6 months
  137. 7 to 9 months • at 7 months, has poor head control when pulled to a sitting position • at 7 months, is unable to get objects into his mouth • at 7 months, is not reaching for objects • by 7 months, doesn't bear some weight on his legs • by 9 months, can't sit independently
  138. 9 to 12months • after 10 months, crawls in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg • at 12 months, is not crawling • at 12 months, can't stand with support
  139. 13 to 24 months • by 18 months, can't walk • after several months ofwalking, doesn't walk confidently or consistently walks on toes • after his second birthday, is growing less than 2 inches per year
  140. 36 months • Falls frequently or is unable to use the stairs • Drools persistently • Can't manipulate small objects
  141. Why is finding a cause important? ◦ Establishing a cause has many benefits for the child and family and improves overall quality of life: ◦ The family gains understanding of the condition, including prognostic information. ◦ Lessens parental blame. ◦ Ameliorates or prevents co-morbidity by identifying factors likely to cause secondary disability that are potentially preventable e.g. surveillance of other systems such as vision and hearing.
  142. Why is finding a cause important? ◦ Appropriate genetic counselling about recurrence risk for future children and the • wider family. ◦ Accessing more support (e.g. within education services and specific syndrome support groups). ◦ To address concerns about possible causes e.g. events during pregnancy or delivery. ◦ Potential treatment for a few conditions.
  143. Causes of Global Developmental Delay ◦ Global developmental delay can be the presenting feature of a huge number of neurodevelopmental disorders (from learning disability to neuromuscular disorders). ◦ It is not possible to provide an exhaustive list. ◦ Careful evaluation and investigation can reveal a cause in 50-70% of cases. ◦ This leaves a large minority where the cause is not determined. ◦ It is still useful to investigate globally delayed development whatever the age of the child (occasionally older children with significant disability may not have been investigated adequately)
  144. Causes of global developmental delay
  145. An Approach to a Child with Developmental Delay ◦ A child’s development is a dynamic process, and assessment at any point in time is merely a snap shot of the bigger picture and should be interpreted in the context of the child’s history from conception to the present. ◦ While a child may appear to have normal development for the first twelve months of life, a deviation in the course of the child’s development in subsequent years is indicative of an underlying disability. ◦ It is important to keep this in mind as you assess a child, and to keep reassessing children in subsequent office visits.
  146. • Developmental assessment involves three aspects: 1. Screening 2. Surveillance 3. Definitive diagnostic assessment
  147. Developmental screening • It is a process of identifying children who may need more comprehensive evaluation. • It is a brief assessment procedure designed to identify children who should receive more intensive diagnosis or assessment. • This is accomplished in the pediatrician’s office through thorough history taking +/- the use of screening tools such as the Denver or Bayley Scales of infant development.
  148. Developmental surveillance • It is a continuous process whereby the child is followed over time to pick up on subtle deficiencies in the child’s developmental trajectory. • The components of developmental surveillance include ⁃ eliciting and attending to parental concerns ⁃ obtaining a relevant developmental history ⁃ observing the child’s development in the office and referring for further assessment of development by other relevant professionals such as OT/PT for motor developmental concerns or hearing tests for concerns with language acquisition.
  149. Diagnostic assessment ◦ It is performed on a child who has been identified as having a potential problem. ◦ This step requires extensive involvement of various team players such as a psychologist, educator, social worker, developmental pediatrician, geneticist, and/or other medical professionals.
  150. History • To perform a developmental assessment, a detailed history from conception to the present is required to assess developmental level. • Knowing the appropriate milestones is key to this assessment. • Any signs of developmental regression should be regarded as a medical emergency and an urgent medical workup is indicated. • An underlying etiology for developmental delay should be sought through attention to the following clues on history:
  151. Prenatal History ◦ Complications ◦ Prenatal diagnoses made (eg. Down Syndrome) ◦ Infections (eg. TORCH includes toxoplasmosis, others (syphilis, hepatitis B), rubella, cytomegalovirus, herpes simplex.) ◦ Exposures (eg. FetalAlcohol Syndrome)
  152. Obstetrical History ◦ Complications ◦ APGAR scores ◦ Infections (eg. Group B Strep) ◦ Seizures ◦ Hearing test performed ◦ Newborn screening performed
  153. Past medical history and medications ◦ Ototoxic antibiotics eg. Gentamicin ◦ Frequent ear infections may lead to effusions affecting hearing
  154. Behavior since birth ◦ Behavioral disturbances – aggression, self injury, defiance, inattention, anxiety, depression, sleep disturbances, stereotypic behaviors, poor social skills, hyperactivity, difficult temperaments
  155. Family History ◦ Relatives with developmental delay,genetic abnormalities, syndromes ◦ Consanguinity
  156. Social History ◦ Evidence of neglect or abuse which may have a negative influence on development. ◦ Primary languages. ESL children may have relative delay in English language acquisition. ◦ In children with a previously identified delay it is important to assess the resources already accessed to support the family such as personal tutors in the educational system, OT/PT for speech and language therapy,etc.
  157. Screening Tools • Standardized tools are used for screening developmental changes in a systematic way. • Compare the achievements listed for normal children with developmental history and physical examination findings. • Children are observed for their activities.
  158. The Denver Developmental Screening Test (DDST) (Age Range 2 Weeks To 6 Years) • Developed by Frankenburg and Dodds, • It is simple, economic and useful test for screening developmental delays during infancy and preschool period. • Used as a screening tool.
  159. Assessment is done in four areas.  Social skills  Fine motor skills  Language skills  Gross motor skills • Make sure the child listens and pays attention to each task. • After scoring the test, interpret the results and inform the parents
  160. Bayley scale of infant development • It is used to evaluate children between 6 and 30 months of age. • Three general areas are evaluated 1. Mental development 2. Psychomotor development 3. Behavioral development.
  161. Brigance screening tool • Brigance is a screening tool widely used by schools for students in Pre-Kindergarten, Kindergarten and First Grade • Consists of 12 assessments, including language development, science and math proficiencies and gross motor skills. • Total score of 100 points. • Score is compared to a national average scale to indicate if the student is above, below, or of average ability level.
  162. Developmental Indicators for Assessment of Learning- Revised(DIAL-R)
  163. Ages and Stages Questionnaire (ASQ) • It looks at children’s skills in five developmental areas including: 1. Communication 2. Fine Motor 3. Gross Motor 4. Problem-Solving 5. Personal-Social • This developmental check-up is available for children 2-60 months.
  164. Parents' Evaluation of Developmental Status (PEDS) • Parents’ Evaluation of Developmental Status (PEDS) is an evidence-based method for detecting and addressing developmental and behavioral problems • Assessed in children aged from birth to seven years. • PEDS is a simple, 10-item questionnaire that is completed by the parent.
  165. Physical Examination ◦Athorough physical examination is important in the assessment of a developmentally delayed child. ◦Characteristic findings on physical exam may provide clues as to the cause of the developmental delay. ◦Some clinical signs and their corresponding clinical significance are listed below:
  166. Growth Parameters ◦Microcephaly: eg in Rett’s Disorder ◦Macrocephaly: eg in hydrocephalus ◦Short stature: Turner syndrome, Williams syndrome ◦Obesity: Prader-Willi syndrome, Beckwith- Wiedemann syndrome
  167. Head and Neck ◦ Flat occiput: Down syndrome, Zellweger syndrome ◦ Prominent occiput: trisomy 18 ◦ Craniosynostosis: Crouzon syndrome, Pfeiffer syndrome ◦ Midface hypoplasia: Fetal Alcohol Syndrome (FAS), Down syndrome ◦ Prominent nose and chin: Fragile X syndrome ◦ Round facies: Prader-Willi syndrome
  168. Head and Neck ◦Triangular facies: Turner syndrome ◦Hypertelorism: Fetal hydantoin syndrome ◦Hypotelorism: maternal PKU effect ◦Brushfield spots: Down syndrome ◦Prominent eyes: Beckwith-Wiedemann syndrome ◦Lisch nodules: neurofibromatosis
  169. Head and Neck ◦Large pinna: Fragile X syndrome ◦Malformed pinna: Treacher Collins syndrome, CHARGE association ◦Broad nasal bridge: Fragile X syndrome ◦Low nasal bridge: Down syndrome ◦Long philtrum: FAS
  170. Head and Neck ◦Cleft lip and palate: may either be isolated or part of a syndrome ◦Micrognathia: Robin sequence ◦Macroglossia: Beckwith-Wiedemann syndrome ◦Abnormal hair whorls: Down syndrome ◦Webbed neck: Turner syndrome
  171. Genitourinary ◦Macroorchidism: Fragile X syndrome ◦Hypogonadism: Prader-Willi syndrome
  172. Extremities ◦Small hands: Prader-Willi syndrome ◦Clinodactyly: trisomies including Down syndrome ◦Transverse palmer crease: Down syndrome
  173. Skin ◦Nail hypoplasia or dysplasia: FAS ◦Facial port wine hemangioma: Sturge- Weber syndrome ◦Café au lait spots: Neurofibromatosis ◦Ashleaf spots: Tuberous Sclerosis
  174. Neurological Exam ◦ Cranial nerves ◦ Specific vision tests: red reflex, normal fundi, response to visual stimuli, field of vision ◦ Specific auditory tests: response to auditory stimuli ◦ Receptive or expressive language delay ◦ Abnormal speech (eg. articulation) ◦ Persistently present Babinski response (older than 2 years of age)
  175. Neurological Exam ◦Hyper- or Hypotonia ◦Sensory ◦Motor strength ◦Gait ◦Deep tendon reflexes ◦Primitive reflexes – Moro, Gallant ◦Postural reflexes – propping response
  176. Investigations: Genetics ◦Karyotyping to assess for chromosomal abnormalities ◦FISH analysis to assess for microdeletions ◦Many of these investigations will be performed through specialist referral. Medical Genetics consultation should be done at this time.
  177. Endocrinology ◦TSH, free T4 ◦Referral to endocrinology should be considered.
  178. Metabolic ◦Metabolic screening – glucose, electrolytes, serum lactate, ammonia, liver function tests, pyruvate, albumin, triglycerides, uric acid, serum quantitative amino acids, urine organic acids, acylcarnitines, creatine phosphokinase (if suspecting myopathy) ◦Referral to metabolic diseases specialists should be considered.
  179. Neurology ◦EEG ◦Head CT ◦Referral to Neurologists if any of these tests are considered.
  181. ◦ After completion of a comprehensive medical and developmental evaluation of the child with developmental problems and the establishment of developmental diagnoses and identification of associated medical conditions, a plan for active treatment and comprehensive management can be initiated by the physician. ◦ Beginning with early identification of these problems, an affected child can receive educational and intervention services aimed at improvement of the child’s development through local early intervention and special education programs, as established in the United States through federal law under the Individuals with Disabilities Education Act.
  182. ◦ Beginning as early as birth and continuing through age 3 years, any child with a known disability, significant delay, or condition with a high risk for disability (eg, Down syndrome) is entitled to early intervention services that provide developmental therapies intended to improve performance in one of the developmental spheres. ◦ These can include traditional therapies, such as physical therapy, occupation therapy, and speech-language therapy, as well as broader services such as special instruction, counseling, and family training.
  183. ◦ Many programs provide for parent training or home- based therapy to allow for generalization of skills learned. ◦ For children 3 years and older and continuing into the school-age years, the child with disabilities is entitled to an individualized, free, and appropriate education along with related therapy services.
  184. ◦ Specific medical treatments targeted towards a child’s related medical conditions should also begin with diagnosis. ◦ For example, along with receiving physical therapy and other early intervention services, the child with cerebral palsy should be considered for medical treatment of tone abnormalities with oral agents, intramuscular botulinum toxin, or intrathecal baclofen. ◦ The child with behavior disorders accompanying a communication or intellectual disability is a candidate for psychopharmacologic treatments, such as stimulants for ADHD and risperidone for aggression.
  185. ◦ Finally, the child with a developmental disability should have a medical home as a child with special health care needs. ◦ This allows the primary care provider a program of chronic condition management for regular health monitoring for chronological age and developmental monitoring in order to provide anticipatory guidance for developmental age. ◦ Specialized, condition-related office visits, written care plans, explicit co-management with medical specialists, appropriate patient education, and an effective system for monitoring and tracking should be put in place
  186. ◦ Both the primary care physician and the specialist can refer the family to community-based support services, such as respite care, parent-to-parent programs, and advocacy organizations. ◦ Parent organizations such as Family Voices, and condition- specific organizations, such as Autism Speaks and The Ark, can provide further support, assistance, and information. ◦ Some children will qualify for additional benefits such as Supplemental Security Income, public insurance, waiver programs, and state programs for children with special health care needs.