1- LECTURE ASSESSMENT OF DEVELOPMENT - Copy.pdf

ASSESSMENT OF
DEVELOPMENT
Dr. Reyad Ahmed Abdu Mansoor
consultant pediatrician in university of Science & Technology Hospital ,
consultant pediatrician . in Al-Sabeen Hospital
Associated Member Of The Arabic Board
3/23/2022 Dr. Reyad Ahmed Abdu Mansoor 1

INDEX
• DEFINITION
• FACTOR INFLUENCING DEVELOPMENT
• NORMAL DEVELOPMENT
• PRINCIPLE OF DEVELOPMENT
• MOTOR DEVELOPMENT
• GROSS MOTOR
• NEWBORN
• REFLEX
• GROSS MOTOR DEVELOPMENT
• FINE MOTOR MILESTONES
• LANGUAGE
• COGNITIVE DEVELOPMENT
• SOCIAL MILESTONES
• ALL DEVELOPMENTAL MILESTONES
• DEVELOPMENTAL SCREENING
• DEVELOPMENTAL DELAY
• INTELLECTUAL DISABILITY

DEFINITION
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DEVELOPMENT
• Definition:
• It is denned as maturation of function with age, reflected by the sequential
attainment of various developmental milestones
• Term ‘child development’:
• Describe skills acquired by children from birth to about 5 years of age
(rapid gains in mobility, speech, language, communication and
indepedence skills).
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FACTORS
AFFECTING
DEVELOPMENT
GENETIC FACTORS
MATERNAL FACTORS
HORMONAL FACTORS
NUTRITION
Neonatal risk
SOCIAL FACTORS
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1. Chromosomal abnormalities
2. Single gene disorders
3. Lissencephely
4. phenylketonuria
1. Age
2. Drug abuse
3. PHTN
4. STARCH
5. chorioamnionitis
1. Hypothyroidism
1.Maternal malnution
2.Calorie deficient
3.Iron deficiency
4.Iodine deficiency
1.LBW
2.Seizures
3.Insults to baby
1.Poverty
2.Emotional factors
3.Emotional
deprivation
4.EDUCATION

Principle of
Development
6
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3/23/2022 Dr. Reyad Ahmed Abdu Mansoor

Developmental principles
1. Neural maturation
2. Sensitive periods
3. "Stages" of development
4. Developmental direction
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Normal Development
• Attainment of maturity of functions (what a child learns to do as he grows up).
• Basic rules of development are as follows:
1) Developmental functioning depends upon the neurological status of child.
2) It is a continuous process, it starts from in utero life.
3) Sequence of attainment of milestones remains same.(however rate may vary)
4) The sequence is the same, the rate varies from child to child
5) from generalized stimulus based reflexes to specific goal-oriented reactions that become increasingly precise.
6) Primitive reflexes should be lost before the voluntary movement develops
7) “normal variation” is much broader in motor development than in other areas of development (walking 9-18
months)
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Normal development
• It is a continuous process, it starts from in utero life.
• The brain comprises 100 billion neurons at birth , each neuron develop about 15000 synapses by 3
years of age.
A. CRITICAL PERIOD
• Is a time window during which a specific function develops normally, provided conditions are
favourable
• 2 month gestational age post-delivery ≤ 3 years
B. SENSITIVE PERIOD,
• a window within which the effects of environmental stimulation on brain structure and function
are maximized.
• RELATED TO CNS MATURATION
• Maximum synaptic density between 15 months and 2—3 years, followed by a decline over the
next 16 years
• USE IT OR LOSE IT
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DEVELOPMENT
• Directional Pattern:
1. Cephalocaudal Pattern ( Head to Tail)
2. Proximal to Distal (Midline to peripheral)
3. Mass to specific (Differentiation)
4. Large muscles before small muscles
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Cephalocaudal direction
• The process of cephalocaudal
direction from head down to tail.
• This means that improvement in
structure and function come first in
the head region, then in the trunk,
and last in the leg region.
• head control precedes trunk control,
which precedes lower limbs control
11
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Proximodistal direction
• The process in proximodistal
from center or midline to
periphery direction.
development proceeds from near
to far - outward from central
axis of the body toward the
extremities
12
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• Development proceeds from general to specific responses
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MILESTONES
• Sequence of attainment of milestones remains same.(however rate may vary)
• Acquisition of a key skill
• Median age
• age at which half population the achieve that level
• Limit age
• age at which a skill should have been achieved, - 2SD from the mean
• Remember, some ore constant (eg. smile by 8/52), some ore not (crawling)
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Normal Development
•Developmental milestones are divided into four headings.
• They are also called DOMAINS OF DEVELOPMENT.
• When we are talking about normal development, we are talking about developing skills like:
1. Gross motor – Using large group of muscles to sit, stand, walk, run etc. Keep balancing
and changing positions
2. Fine motor – Using hands to be able to eat, draw, dress, play, write etc
3. Language – Speaking, using body language and gestures, communication and
understanding what others say.
4. Social - Interacting with others
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MOTOR DEVELOPMENT
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Motor development
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Motor development
• Involves function and myelination of neurons, development of proprioception , and muscular strength,
• Anything that interferes with these processes will result in delay or inability to attain motor milestones (or
regression)
1. Neuronal function: Cerebral palsy, traumatic or hypoxic/ischemic brain injury. Rett syndrome, etc.
2. myelination disorders: Niemann-Pick. Tay-Sachs. krabbe disease, Gaucher disease , metachromatic
leukodystrophy, etc.
3. Muscular strength: Muscular dystrophy
4. Developmental coordination disorder
• Acquisition and execution of motor skills below that winch is expected at given chronological ago. interfering w/ daily life:
• manifested by clumsiness or incoordination .
• Not otherwise explained by an intellectual disability or neuromuscular conditions affecting movement.
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GROSS MOTOR
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NEWBORN
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NEWBORN
• Gross motor
• supine position-flexed posture
• prone position-turns the head from side to side
• Ventral suspension-head sags
• Turns head from side to side;
• Social/communication
• Visual preference for human face
• Visual
• Able to fixate face on light in line of vision;
• “doll’s-eye” movement of eyes on turning the body
• Responds to visual threats by blinking
• Visual acuity is 20/400
• Reflex
• Moro, stepping, placing, and grasp reflexes are all active
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GROSS MOTOR DEVELOPMENT:
POSTURES:
1.Prone
2.Supine
3.Sitting
4.Standing
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• Supine Position
1. Less flexed as gravity tends to favor extension.
2. Shoulders are less protracted.
3. Arms are more abducted.
4. Hips are less flexed and more ER.
• Supine and Pull to Sit:
1. Head completely lags behind shoulder
2. Back is rounded.
• Sitting:
1. When the newborn infants are placed in sitting,
physiological flexion, joint immobility and
decreased flexibilty of soft tissue allow them to
maintain position briefly.
2. "Flopping like a rag doll"
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• Vertical Suspension:
1. Automatic stepping reaction observed.
2. Legs flex and extend reciprocally.
• Ventral Suspension:
1. Head flops down completely.
2. Back is rounded.
• Prone Position:
1. Head is turned to one side.
2. Pelvis is raised off the surface by excessive hip flexion.
3. Knees flexed and drawn up under abdomen.
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REFLEX
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Reflexes
Reflexes
Deep Tendon
Reflexes
Maturation
Reflexes
Primitive reflexes
Superficiel
Reflexe
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Reflexive Maturation : Function
• Survival Function of Reflexes
• Rooting reflex
• Blink reflex
• Developmental Function of Reflexes
• Neck righting →→→→Rolling
• Palmar grasp →→→→grasp
• Diagnostic Function of Reflexes
• Therapeutic Function of Reflexes
• postural reactions →→→→ promote the upright posture.
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Abnormal Developmental reflexes
1. delay in the disappearance
2. exaggeration of a developmental reflex
3. An obligatory developmental reflex

Reflexive Maturation : Function
Advanced postural reflexes
appear
Primitive reflexes
Disappear
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REFLEXES:
• Primitive reflexes elicited by a specific stimulus:
1. ATNR
2. Moro
3. Sucking/Rooting
4. Galant
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Sucking/ Rooting Reflex
Galants Trunk
Incurvatum Reflex
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FINE MOTOR DEVELOPMENT:
• Hand is fisted.
• Grasp Reflex.
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Primitive reflex & equilibrium response
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Reflex appearance Disappearance
Moro Birth 4 months
ATNR 2 weeks 6 months
Toe grasp Birth 8-15 months
Hand grasp Birth 3 months
X adductor Birth 7 months
Head writing 4-6 months Persist voluntary
Protective eq. 4-6 months Persist voluntary
Parachute 8-9 months Persist voluntary

Order of disappearance of primitive reflex
• Reflex Will Go Mainly AP
• Rooting - disappears at 2 months
• Walking reflex — Disappears at 2 months
• Grasp reflex ( palmar Grasp) — Disappears at 3 months
• Moros Reflex — Disappears at 5 months
• ATNR - Disappears at 6 months
• Plantar Grasp Disappears at 9 months
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• Primitive reflex is present at
birth, and gradually disappear as
postural reflexes develop.
• Essential for independent
sitting and walking.
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Primitive Reflex
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Newborn Developmental Red Flags
1. Hypotonia
2. Feeding difficulties
3. Does not respond to loud sounds
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GROSS MOTOR
DEVELOPMENT
• It deals with the posture of the child and what the child learns to
do as he grows up.
• ( Using large group of muscles to sit, stand, walk, run etc. Keep
balancing and changing positions)
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GROSS MOTOR:
• 1st MONTH
• In ventral suspension the head is below the plane
of rest of body (There is no neck control).
• 2nd MONTH
• In ventral suspension the head is in the plane of
rest of the body. (partial neck control)
• 3rd MONTH
1) In ventral suspension head goes above the plane
of rest of body.
2) Neck holding present
3) At prone position can lift head and shoulder above
the ground level and can bear weight on four arms
4) Vertical Suspension
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• 6th MONTH
1. He can bring his limbs to mid line (he can take his feet to mouth)
2. Sitting with support or sitting in tripod position.
3. Baby rolls over
1. The child rolls from prone to supine position.
2. Child rolls from supine to prone position.
GROSS MOTOR
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• 8th MONTH
1) The Child sits without support.
2) Crawling starts at 8 months
• 9th MONTH
• Standing with Support
• 10th MONTH
• Crawling starts at 8 months
GROSS MOTOR
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• 10 – 11 months:
1) Pivoting (to pick up toys placed behind him)
2) Cruising (can walk around the furniture holding the edges)
• 12 months:
1)The child stands without support
2)He walks with support or one hand held
3)Can walk on hands and feet like a bear.
GROSS MOTOR
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GROSS MOTOR
• 15 months
1) Creeps upstairs
2) Walks without support.
• 18 months
1) Goes upstairs and downstairs holding the side railing
2) Pulls the toys
3) Starts running
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GROSS MOTOR
• 2nd YEAR
1) Running well
2) Goes upstairs and downstairs with two feet per step.
(two feet per step)
3) Kicks a ball
4) Starts walking backwards also.
• 3rd YEAR
1) Goes upstairs with alternating feet, but downstairs two
feet per step
2) Starts RIDING A TRICYCLE.
3) Jumps
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• 4th YEAR
1) Goes upstairs and downstairs with alternating feet (one
foot per step).
2) Starts hopping.
• 5th YEAR
1) Starts skipping ; Skips on both feet
2) Can stand on one leg for more than 10 seconds.
• 5th YEAR
• Bicycle
GROSS MOTOR
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GROSS MOTOR MILESTONES
Cephalocaudal direction
Head to toe
First year
3 monthly
3 months : Head holding
6 months: Sit with own support
9 months: crawl
12 months: walk like a bear
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18 months: Run
2 years: Jump Up and down stairs 2 step at a time
3years: Tricycle
Climb upstairs one step at a time
4years : Hop Climb downstairs one step at a time
5 years: skip

DEVELOPMENT MILESTONE FOR NORMAL CHILD (GROSS MOTOR)
Median Ages
• Gross motor • Limit Ages
Head control 4 months
Sits unsupported 9 months
Stands independently 12 months
Walks independently 18 months
Limit Ages
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GROSS MOTOR DEVELOPMENT
(3)Head
support
(6)Sitting (9)crawl (12)stand
(15)Walk
(18)Run
(21)Go Up
stairs
(24)Go
down stairs
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DELAYED LOCOMOTOR DEVELOP.
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(5) Head
support
(10) Sitting
(15)
standing
(18)Walking

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3 months Neck holding
5 months Sitting with support , Foot regard
6 months Roll over , Sits in tripod position
8 months Sits without support
IO months Crawling, Stands with support
11 months Creeping, Pivot, cruises
12 months Walk with one hand held
15 months Walk alone with wide based gait

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18 months
Runs stiffly, Begins to jump.
Walks upstairs one hand held
2 years
Runs well.
Goes up & downstairs alone
(two feet per step)
3 years
Jumps well. Rides tricycle.
Goes upstairs (one foot per
step)
4 years
Hops on one foot,
Goes downstairs (one foot
per step)
5 years Skips on both feet
6 years Ride bicycle

FINE MOTOR
MILESTONES
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Fine Motor Development
• It mainly deals with what a child does using hands to be able to eat, draw, dress, play, write etc
• Fine Motor: The level of coordination of the different body parts.
1. Eye Coordination
2. Eye-hand Coordination
3. Hand-hand Coordination
4. Hand Mouth Coordination
• Milestones involving muscles of hands
1. Grasping milestones.
2. Drawing skills.
3. Arranging cubes.
4. Dressing skills.
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FINE MOTOR MILESTONES
• At 1 MONTH
1) Hands are kept close
2) Palmer grasp reflex , walking reflex present
• 3rd MONTH
1) Hands are kept open
2) Palmer grasp reflex lost (hence object can be held in his hand)
3) Hand regard appears.
• is seen in babies between 3-5 months of age
• persistence beyond 5months = Abnormal
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• 4th MONTH
1) Tries to reach an object, but overshoots (unable to catch hold of it)
• 5th MONTH
1) Bidiextrous grasp (Holding the object with two hands)
2) No Hand regard appears
3) Mouthing (it persists till 1 year of age)
4) Drops one cube when another given
• 6th MONTH
1) Unidextrous or palmar grasp
2) Can feed self a biscuit
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• 7th MONTH
1) Retains both cubes when another given
2) Transfers object from one hand to another
• 9th MONTH
1) Immature or assisted pincer grasp (able to pick up small object between thumb and fore figure).
• 12th MONTH
1) Mature or unassisted pincer grasp
• 12 – 13 MONTHS
1) Casting (Throwing out toys from bed to floor)
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Fine Motor: Pincer Grasp
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• 15 MONTHS
1) Scribbles spontaneously
2) Feeds self with a Cup
3) Can place a tower of two cubes
• 18 MONTHS
1) Feeds self with a Spoon
2) Can place a tower of three cubes
3) Turns 2 to 3 pages at a time
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2nd YEAR
1. Can make a tower of 6 cubes
• (Age x 3 cubes)
2. Turn pages singly (1 by 1)
3. Undresses by himself
4. Copies horizontal or vertical lines
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• 3rd YEAR
1) Can make a tower of 9 cubes
• (Age x 3 cubes)
2) Child can dress and undress by self except buttons
3) Copies a circle at 3 years of age
4) Handedness gets established (right or left handed)
4th YEAR
1) Child can button and unbutton by self
2) Copies a rectangle or plus (+) sign
3) Makes a bridge with 3 cubes
4) Can catch a ball reliably
5) Draws a man with 2-4 parts
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• 5th YEAR
1) Able to tie shoe laces.
2) Copies a triangle or multiplication or tilted cross.
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• At 6 years age:
1) Copies diamond
2) Makes steps of cube
3) Draws a man with seven parts
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Dressing skills
• 2 years: Undressing
• 3 years: Dressing + Undressing under supervision
• 5 years: Dressing + Undressing without supervision
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Fine Motor and Vision - Assess by Drawing
• Development of squiggling
• Lines and Shapes
• Goodenough Draw-a-Person test
• Assess in three steps
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Age Block test Pencil test
2 years a tower of 6 cubes Copies horizontal or vertical lines
3-31/2years Build a bridge Draw a circle ⭕
31/2 - 4 years
Draw a cross ➕
3-41/2 years Build a gate Draw square
5-6 years Build steps Draw triangle

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Developmental Milestones
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Fine motor milestones
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Newborn Grasp reflex
3 months Hand regard
5 months Bidextrous grasp
6 months Unidextrous grasp, mouthing
9-10 months Assisted or immature Pincer grasp
12 months
Unassisted or mature Pincer
grasp. Casting
Feeds with spoon with spilling
15 months
Tower of two cubes
Scribbles

Fine motor milestones
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18 months
Tower of four cubes
Turns pages 2-3 at a time
2 years
Tower of six cubes
Turns one page at a time
Circular scribbling
Copies vertical «& horizontal lin
3 years
Tower of nine cubes
Copies circle
4 years
Makes gait of cubes
Copies cross &. square
5 years
Copies triangle
Can tie shoelaces
6 years
Makes steps of cube
Copies diamond

DEVELOPMENT MILESTONE FOR NORMAL CHILD (VISION AND FINE MOTOR)
Median Ages
Gross motor Limit Ages
Fixes and follows visually 3 months
Reaches for objects 6 months
Transfers 9 months
Pincer grip 12 months
Limit Ages
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LANGUAGE
COMMUNICATION
• Must have understanding and cognition of commands
• Language skill is the best predictor of future intellectual performance
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LANGUAGE
Language
Speaking
using body language
and gestures
communication
understanding what
others say.
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LANGUAGE
• 1st MONTH:
• Child is showing some regard to sound
(Child quietens when a bell is rung)
• 2nd MONTH:
• Child vocalises
• 3rd MONTH
• Child produces cooing or more musical
sounds
• 4th MONTH
• Child laughs a loud
• 5th MONTH
• Child produces razzing sound
• 6th MONTH
• Speaks monosyllables like MA, BA, DA
also called babbling
• 9th MONTHS
• Speaks bisyllables without meaning
like MAMA
• 12th MONTH
• Speaks 2 to 3 words with meaning,
imitates simple sounds
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LANGUAGE
• 15 MONTHS
• Jargons speech (child has his own indigenous names
for different objects)
• 18 MONTHS –
• Child now has a vocabulary of ten words (knows 10-15
words with meanings)
• Point to 2-3 body parts
• 2 years –
• Speaks 2-3 word sentences. Also use pronouns like I,
Me, You and has a vocabulary of 50 to 100 words with
meaning
• Names1-2 colors,
• 3 years -
• Says 250 words
• 3 word sentences.
• Knows name, age, sex
• Speaks sentence of six syllables
• Child uses plurals and past tense also.
• Repeats 3 digits
• 4th year –
• Tells a story or poem and sings a song
• Counts upto 4 numbers
• 5th Year –
• Child can repeat 4 digits and name 4 colours.
• Can repeat sentence of I0 syllables
• Counts upto I0 numbers correctly
• Names 4-5 colors,
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Language milestones
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2 months Vocalizes- coos
3 months Babbles
6 months MonosyIlabic babble - Ma, Da
9 months Bisyllabic babble- mama, dada
I0 months Can understand meaning of some words
12 months 2-3 words with meaning
15 months Jargoning speech
18 months 10-15 words with meaning

Language milestones
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2 years sentence of three words 50-100 words
2.5 years
150 words
Names 1-2 colours
3 years
250 words
sentence of six syllables
Knows name, age, sex
4 years
Tells story
Counts upto 4 numbers
5 years
Repeat sentence of I0 words
Counts upto I0 correctly
Names 4-5 colors

DEVELOPMENT MILESTONE FOR NORMAL CHILD (HEARING, SPEECH AND LANGUAGE)
Median Ages
Polysyllabic babble 7 months
Consonant babble 10 months
Saying 6 words with meaning 18 months
Joins words 2 years
3-word sentences 2.5 years
Limit Ages
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COGNITIVE
DEVELOPMENT
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Cognitive development
• Intellectual development begins early in infancy, but accelerates more prominently
in the Second and third year of life ,
• The ability to learn or understand or to deal with new situations.
• Memory
• Representational competence (The ability to use representation of reality such as pictures,
symbols to perform logical operations)
• Attention
• Processing speed
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COGNITIVE DEVELOPMENT
Important Aspects Or
Cognitive Development
Language (receptive, productive)
Non-verbal communication
Object permanence
Identification of quantity and size
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• Slow or absent language development may be
1. hearing disorder, which should he the first thing you rule out
2. the first sign of mental retardation
3. other cognitive issues that affect language.
• Such as autism spectrum disorders.
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Piaget's Theory
Stage Age Range Description
Sensorimotor
0-2 years
Coordination of senses with motor response, sensory curiosity about the
world Language used for demands and cataloguing.
Object permanence developed
Prvoperational 2-7 years Symbolic thinking, use of proper syntax and grammar to express full
concepts. Imagination and intuition arc strong, but complex abstract
thought still difficult Conservation developed.
Concrete
Operational
7-1 1 years Concepts attached to concrete situations. Time, space, and quantity arc
understood and can be applied, but not as independent concepts
Formal Operations 11+ Theoretical, hypothetical, and counterfactual thinking. Abstract logic and
reasoning. Strategy and planning become possible. Concepts learned
in one context can be applied to another.
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SOCIAL MILESTONES
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Social and Emotional Development
• This area of development involves:
1. learning to interact with other people
2. understand and control your own emotions.
3. Babies start to develop relationships with the people around them right from birth,
but the process of learning to communicate, share, and interact with others takes
many years to develop.
4. Developing the ability to control your emotions and behavior is also a long
process.
5. Children continue to develop their social-emotional skills well into their teenage
years, or even young adulthood.
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SOCIAL MILESTONES
• This can be the hardest to assess as there appears to be less of a
narrative compared to the other areas
• Interacting with family, friends, teachers and responding to others
• The best way to assess is through play
• Observing the child
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SOCIAL MILESTONES
• 1st MONTH
• Child looks at the mother intently when talked to.
• 2nd MONTH
• Social smile (When you smile at the child, the child smile back)
• 3rd MONTH
• Child recognises mother
• 6th MONTH
• Mirror play appears (Child will smile and try to play with his mirror image)
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SOCIAL MILESTONES
• 6th to 7th MONTH
• Imitates cough or protrusion of tongue
• Stranger anxiety appears
• 8th MONTH
• Object permanence.
• 9th MONTH
• Waves bye bye, separation anxiety
• 10th MONTH
• Plays peek a boo
• 12th MONTH
• Comes when called, Plays a simple ball game.
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SOCIAL MILESTONES
• 15th MONTH
• Child points to objects
• 18th MONTH
• Domestic mimicry (Copies or mimics parents in task)
• 2nd YEAR
• Parallel play (playing on their own and not with others)
• Toilet control
• Handedness
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SOCIAL MILESTONES
• 3rd YEAR
• Joins in play. Child knows his own name, age and gender
• Dress , undressing fully except boutons
• Known sex different
• 4th YEAR
• Child goes to toilet alone and start asking questions
• 5th YEAR
• Dresses & undresses ( including buttoning and shoelaces)
• Child helps in house hold tasks. Distinguish morning from
evening.
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SOCIAL MILESTONES
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1 month Child looks at the mother intently when talked to.
2 months Social smile
3 months Recognizes mother
5 months Smiles at mirror image
Gets excited at sight of food & toys
6 months Imitates cough or tongue
protrusion
Peek-a-boo
7 months Stranger anxiety

SOCIAL MILESTONES
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9 months Waves bye-bye, Plays pat a cake
12 months Plays games up-down
Mimicry
15 months Demand behavior
Imitates mother in domestic duties
18 months Carries out two simple order
Kisses parents
Carries out 1wo simple orders
2 years Toilet control
Listens stories
Handedness

SOCIAL MILESTONES
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3 years Plays simple games
Washes hand
Helps in dressing
Knows sex difference
4 years Enjoys Play group
Imaginative play
Goes to toilet alone
Right-left discrimination
5 years Dresses & undresses fully
Asks questions about meaning
6 years Knows number of fingers
Names of days in a week

DEVELOPMENT MILESTONE FOR NORMAL CHILD (SOCIAL, EMOTIONAL AND BEHAVIOURAL)
Median Ages
Smiles 8 weeks
Fear of strangers 10 months
Feeds self/spoon 18 months
Symbolic play 2-2.5 years
Interactive play 3-3.5 years
Limit Ages
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ALL DEVELOPMENTAL
MILESTONES
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Age Gross motor Fine motor & vision Language Social
6 weeks  Head lag, pull to sit
 Head same level, ventral
suspension
 Fix on faces
 Follow objects 900 horizontal
plan
Smiles
3 months  No head lag
 On prone, lift face 45-90 0
from couch
 Follow objects 1800
 Hold objects placed in hands
 Vocalizes
 Turns head to sound,
level to the ear
Social smile
4 months  Reach for objects
 Hand regards
Laughs aloud
5 months Prone – weight on forearm  Feet to mouth
6 months  Prone – weight on hands,
extended arms
 Sit, hands forward for
support
 Rolls prone to supine (back
to front)
 Transfer objects from one
hand to the other
 Mouthing
Begins to
imitate cough
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7 months Rolls from supine to prone
(front to back)
Feeds self with biscuit Turns head to sound
below level of ear
8 months Sits unsupported
9 months Stands holding onto objects Looks for toys fallen from view  Shouts to gain
attention
 Understands no
 One word (baba)
Afraid from
strangers
10 month Crawls  Wave bye bye
 Helps to dress
 Index finger approach
 Pincer grip
12 month Walks one hand held 2-3 words with meaning
13 month Walks unsupported Mouthing stops
RETURN TO INDEX

15 month  Takes off shoes
 Feed from cup
 Tower of 2 cubs
Imitate mother
(domestic work)
18 month  Jumps
 Up and down stairs
holding rail
 Turns 2-3 pages at a time
 Tower of 3-4 cubs
 Points to 3 parts of body on
request
 Say more words
with meaning
 Follow one step
commands
 Toilet
control: dry
by day
 Feed from
spoon
2 years  Runs
 Kicks ball
 Draw vertical line
 Imitate horizontal line
 Tower of 6-7 cubs
 Turns pages singly
 Picture card; identifies 5
(where is the?)
 Names 3 (What is this?)
Joins 2-3 words to
make sentences
Mainly dry at
night
RETURN TO INDEX

2 ½ years  Tower; 8 cubes
 Picture card: identifies 7, names 5
 Imitate train with chimney
Follow 2 steps instructions Knows full
name, sex
3 years  Pedal tricycle
 Stand on one
foot
 Copies circles
 Tower of 9 cubs
 Imitate bridge
 Dress & undress fully
 Tell stories
 Knows more about
times, today and not
today
4 years Hops Copies a cross  Count to 10
 Identifies several colors
5 years Bounces &
catches ball
Copies squire  Prepositions; on, under,
in front of
 Opposites; hot/ cold,
big/small
Choose friends
RETURN TO INDEX

RETURN TO INDEX

DEVELOPMENTAL SCREENING IMPORTANT
Developmental Screening
Early Detection
Early Intervention
Improved Developmental, Social, Educational and Health Outcomes
RETURN TO INDEX

TERMINOLOGY
1. DEVELOPMENTAL SURVEILLANCE
• An ongoing process of monitoring the status of a child by gathering Information
about the child’s development and behavior from multiple sources
• If concerning do Developmental Screening
2. DEVELOPMENTAL SCREENING
• a brief assessment procedure designed to identify children who should receive more
intensive diagnosis or assessment
• If concern, make refers for developmental and medical evaluations
3. DEVELOPMENTALASSESSMENT
• A development assessment ‫؛‬s a comprehensive evaluation of a child’s physical .
Intellectual, languages, emotional and social development
RETURN TO INDEX

When to Screen
• LOW-RISK :
• 9, 18, 24, and 36 months
• Autism screen at 18 and 24 months
• HIGH-RISK:
• 3.5—6, 9, 12 and 18-month
• Autism screen- 18 and 24 months every 6 months, till 3 years
• annually till 2 years after school entry
RETURN TO INDEX

Who should be screened for development delay ?
• All young children
• Especially those with risk factor All young
RETURN TO INDEX

DEVELOPMENTAL MILESTONES
• Tools for screening
1. Denver Developmental Screening Test
2. Ages & Stages Questionnaires (ASQs)
3. Modified Checklist for Autism in Toddlers (M-
CHAT)
4. DEVELOPMENTAL OBSERVATION CARD
(DOC)
5. GOODENOUGH HARRIS DRAW A MAN TEST
RETURN TO INDEX

SCREENING TOOLS
1. Denver development screening test (DOST):
• For quick assessment of all four areas of development in children upto 6 years
of age
2. Gesell development schedule:
• For children upto 5 years of age. It is concerned with diagnosis and evaluation
of development abnormality
3. Bayley scale of infant development (BSID):
• Provides motor scale, mental scale and infant behavior record in children upto
30 months of age
Return to index

GOODENOUGH HARRIS DRAW A MAN
TEST
• The child is asked to draw the best person they can draw
• The starting point is a circle for the face at 3 years of age
• An additional point is then given for each item drawn, with each point being
worth an extra 3 months
• 3 years+ (numbers point X 3months)=MENTAL AGE
Return to index

DEVELOPMENTAL DELAY
• Developmental delay occurs when a child does not achieve developmental
milestones in comparison to peers of the same age range.
• A significant delay is defined as performance that is two or more standard
deviations below the mean on age-appropriate standardised norm-
referenced testing (usually conducted in secondary or tertiary care settings).
• Isolated developmental delay
• The delay can be in a single domain (i.e. isolated developmental delay) or more than
one domain.
• 10-15% of population
• global developmental delay
• A significant delay in two or more developmental domains affecting children under
the age of five years is termed global developmental delay (GDD)
• l-3% of population
RETURN TO INDEX

CASE SCENARIO
• A 2-years -old boy
• Delayed in development
• DEVELOPMENTAL HISTORY
• GROSS MOTOR  Standing with Support
• FINE MOTOR  Transfers object from one hand to another
• SOCIAL  laughs and squeals
• LANGUAGE  Speaks 2 to 3 words
Return to index

DEVELOPMENTAL QUOTIENT (DQ)
1. lnfant and young children < 5years
2. Developmental or behavioral problems.
Developmental tests assess gross motor, fine motor, social-adaptive, and language functions.
Developmental tests are used to judge the developmental age of the child
CALCULATE DQ
 =
×
= MENTAL AGE
The normal 90-110
Return to index

CALCULATE DEVELOPMENTAL QUOTIENT (DQ)
• A 2-years -old boy
• DEVELOPMENTAL HISTORY
Return to index
MILESTONES
GROSS MOTOR
FINE MOTOR
SOCIAL
LANGUAGE
BABY DO
Standing with Support
Transfers object from one hand to another
laughs and squeals
Speaks 2 to 3 words
MILESTONES AGE FOR NORMAL BABY
12th MONTH
7th MONTH
6th MONTH
12th MONTH

CALCULATE DEVELOPMENTAL QUOTIENT (DQ)
 =
×
 = = 9 MONTH
 =
×
= 38
Return to index
MILESTONES
GROSS MOTOR
FINE MOTOR
SOCIAL
LANGUAGE
MILESTONES AGE FOR NORMAL BABY
12th MONTH
7th MONTH
6th MONTH
12th MONTH

INTELLECTUAL
DISABILITY
Return to index

DEFINITIONS : INTELLECTUAL DISABILITY
ID is a neurodevelopmental disorder that begins in childhood and is characterized
by limitations in both
1. intelligence
2. adaptive skills with at least one of three adaptive domains (conceptual, social, and
practical) affected
3. Onset in developmental period; begin before 18 years of age
• Previous name is mental retardation The term replaces and improves upon the
older term of "mental retardation"
Return to index

DEFINITION
• Intellectual disability (ID) is a limitation in:
• Intelligence and
• Adaptive skills.
• Onset before 18 years of age
• Intelligence or Cognitive impairment:
• Measured by intelligence quotient: IQ
• Define as:
• IQ ≤ 70
• Or Two standard deviations below the mean (1 SD = 15 )
• Adaptive skills:
• are the functional skills of everyday life, including:
• Communication
• Living/self-care skills
• The ability to safely move at home and community.
Return to index

Global developmental delay
Global developmental delay (GDD)
is the preferred term to describe intellectual and adaptive impairment in children <5 years old who
fail to meet expected developmental milestones in several areas of intellectual functioning
as a significant delay in two or more developmental domains: ( 1) gross motor, (2 ) speech/language,
(3) cognition, (4) social/personal, and (5) activities of daily living.
The term ID usually is applied to children ≥5 years old, when the clinical severity of impairment is
more reliably assessed.
Specific developmental delay:
delay in one field of development or skill area
Return to index

Return to index
ETIOLOGY

Return to index
Causes of Intellectual Disability
• Etiology
• Physiologic (sub cultural)
• Genetic causes
• Chromosomal anomalies
• Non Chromosomal anomalies
• Single-gene disorders
• Environmental causes

Return to index
Physiologic (sub cultural)
• No demonstrable organic brain lesions
• Seen in children living in low socio economic standard with neglect
and poverty

Return to index
Chromosomal anomalies
• Autosomal anomalies:
• Down syndrome (trisomy 21)
• Sex chromosomes Abnormalities:
• Turner syndrome (45 xo),
• Klinefelter syndrome،47 XXY).

Return to index
Non Chromosomal anomalies
• Single-gene disorders
1. Neurocutaneous syndromes e.g. tuberous sclerosis.
2. inborn errors of metabolism e.g. goitrous hypothyroidism, phenylketonuria,
galactosemia.
3. Developmental brain abnormalities e.g. lissencephaly , Microcephay .
Congenital hydrocephalus. Craniostenosis
4. Degenerative brain diseases e.g. lipidosis and mucoploysacridosis

Return to index
Causes of Intellectual Disability
Prenatal 4-28%
Genetic syndromes
Environmental
influences
Maternal disease
Inborn errors of
metabolism
Perinatal 2-10%
delivery-related events
Postnatal 3-12%
Infections
traumatic brain injury
Severe and chronic
social deprivation
Toxic metabolic
syndromes and
intoxications
Unknown30-50%

CLASSIFICATION
Return to index

CLASSIFICATION; Psychological
Mental Retardation Level IQ Range
Borderline intellectual functioning 70-79
Mild mental retardation 50-69
Moderate mental retardation 35-49
Severe mental retardation 20-34
Profound mental retardation Below 20
Return to index

DIAGNOSIS
1. History:
1. prenatal, perinatal , and postnatal history
2. developmental history
3. family history
2. Physical examination
3. neurologic examination
4. INVESTIGATION
Return to index

Assessment of Mental Function
INTELLIGENCE TESTS
• Many Intelligence (psychometric) tests are available to judge the mental age of the child.
These tests assess
1. verbal functions
2. performance functions.
Return to index

Wechsler Intelligence Scales
• The Wechsler Intelligence Scales, provide a measure of nonverbal and verbal
functioning.
• The child’s perceptual organization abilities, verbal comprehension, shortterm
memory and attentional skills, and processing speed
Return to index

Wechsler Intelligence Scales
‫اﻷطﻔﺎل‬ ‫ﻟﺬﻛﺎء‬ ‫وﻛﺴﻠﺮ‬ ‫ﻣﻘﯿﺎس‬
‫اﻟﻠﻔﻈﯿﺔ‬ ‫اﻻﺧﺘﺒﺎرات‬
:
.1
‫اﻟﻤﻐﺮدات‬
.2
‫اﻟﻤﺘﺸﺎ‬
‫ﺑ‬
‫ﮭﺎت‬
.3
‫اﻟ‬
‫ﺤﺴﺎب‬
.4
‫اﻷرﻗﺎم‬ ‫إﻋﺎدة‬
.5
‫اﻟﻔﮭﻢ‬
.6
‫اﻟﻤﻌﻠﻮﻣﺎت‬
.
‫اﻹﺧﺘﺒﺎ‬
‫ر‬
‫ات‬
‫اﻟﻌﻤﻠﯿﺔ‬
:
.1
‫اﻟﺼﻮر‬ ‫ﺗﻜﻤﯿﻞ‬
.2
‫اﻟﻤﻜﻌﺒﺎت‬ ‫رﺳﻮم‬
.3
‫اﻻﺷﯿﺎء‬ ‫ﺗﺠﻤﯿﻊ‬
.4
‫اﻟﻤﺘﺎھﺎت‬
Return to index

MENTALAGE IQ
 =
×
The normal IQ 90-110
Return to index

DIAGNOSTIC CRITERIA (DSM-V)
1. Defect in Intellectual functioning: Intelligence quotient (IQ) <70
2. Defect in adaptive functioning (ability to adapt to environment) taking in
consideration his/her age and environment.
3. Onset of impairment before age of 18 years.
Return to index

INVESTIGATION
• Sensory test – assessment for vision, hearing.
• Standardized Intelligence tests: Wechsler scales
• Brain Imaging
• Chromosomal studies.
• Karyotyping
• Fragile X screen
• Serum T3, T4, and TSH.
• TORCH screening.
• Blood lead level.
• Metabolic screening: urine organic acids, serum amino acids, serum ammonia, and lactate
• EEG to exclude seizures.
• MRI, CT scan to study the structural abnormality of brain for example tuberous sclerosis
Return to index

TREATMENT
1. Treat the cause if possible
1. Congenital hypothyroidism
2. Galactosemia
3. Phenylketonuria
2. Interventions that should be applied early to improve short-term and long-term
outcomes.
3. Treat associated diseases
4. Specific drug therapy: No drugs raise the mental level
Return to index

CLASSIFICATION;
Return to index
Mild 50-70
Educable
special schools
Trainable
Keep house
Function
independently as adult
Moderate 35-50 Not educable
Trainable
•self-care
•simple tasks.
can talk
Able to function semi independently
Severe 20-35 Not educable Not trainable
No language
Minimal self-care
Profound < 20 Not educable Not trainable
No language
No self-care

PREVENTION
Return to index
Primary Prevention
(Early
Interventions)
Secondary
Prevention
(Control)
Tertiary Prevention
(Rehabilitation)

Primary Prevention
Primary
Prevention
Promotion of general health: Adequate nutrition & hygiene
Immunization programs
Prevention of trauma and injuries
Genetic counselling
Neonatal screening to identify preventable causes of MR (e.g. hypothyroidism , phenylketonuria)
Health education
Proper prenatal, natal and post-natal care
Treatment of neonatal jaundice, hypoglycemia, hypothyroidism ….
Prevention of poisoning and drug abuse
Return to index

Secondary Prevention
Secondary
Prevention
Pre symptomatic detection of certain disorders
lead surveillance
dietary restriction in metabolic diseases
thyroid hormone replacement
Treatment of associated conditions including vision and
hearing impairment, seizures, and other co-morbid
medical disorders
Return to index

Tertiary Prevention
Tertiary
Prevention
Access to and provision of appropriate comprehensive
services and resources
Early detection of complications
Treatment of comorbid conditions
Prevention and treatment of psychosocial disorders
Return to index

THE END
Return to index

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