The document provides guidance for assessing the development of children aged 6 months to 5 years during a 9 minute station. It outlines the key areas to assess including motor, language, social, and behavioral development. Sample milestones are provided for different ages. The approach involves introducing yourself, observing the child, then focusing the assessment on one area such as fine motor or language skills. The goal is to demonstrate understanding of developmental milestones and how to summarize findings and management plans for children with delays.

1. Dr. Varsha Atul Shah
Senior Consultant
Singapore General Hospital
Developmental Assessment
For Residents and for MRCPCH
Exam

2. Visit link
Free book download
http://www.scribd.com/doc/44390551/Fro
m-Birth-to-Five-Years
Videos
http://www.martindalecenter.com/Medica
lClinical_Exams.html
http://library.med.utah.edu/pedineurologic
exam/html/home_exam.html

3. What the examiner is looking for:
 A basic knowledge of the main developmental milestones
 An ability to summarise the findings quickly, and show some
understanding of assessment and management planning for
children with disability.
 It is unlikely that you will be asked to carry out a global
assessment on any child except an infant (insufficient time).
Usually you will be asked to carry out only one of the motor
or language assessment.
 Fine motor assessment
 Language assessment
 Social skills/ Personal development assessment
 Play with this child and describe
 An ordered approach to assessment of behaviour
 Gross motor assessment
 Describe behaviour

4. Development station is 9 min
 Any child, with a developmental age of 6
months – 5 years
 Commonly preschooler

5. Causes of Developmental
Delay
Delayed Motor
Development
Delayed Speech / Language Global Developmental
Delay
▪ central: cerebral palsy,
hemiplegia
▪ peripheral lesions
▪ visual impairment →
affecting fine motor
▪ systemic disorders:
hypothyroidism etc
▪ environmental:
malnutrition, lack of
practice
▪ central: autism, global
learning difficulty
▪ isolated speech delay
▪ hearing loss
▪ environmental:
malnutrition, lack of
practice
cerebral malformations
hypoxic ischemic
encephalopathy
chromosomal
abnormalities
TORCH infections
toxin exposure
metabolic causes

6. Usual lead in is ‘Would you please
perform a language/Motor
assessment?
 You may or may not be told age of
the child?
 Once you know 18 months of
development ‘backwards’, including
time of appearance and incorporation
of primary reflexes, then you can
fairly interpret the findings

7. WIPE approach:
 Wash/WIPE Hands/Stethoscope with rub,
 Introduce, Interact, Initiate, Inspect
 Position yourself and baby and Play,
 Examine, eyeball, engage, EEENT Eye- Eyeball whole
Environment and baby from head to toe, Examine-Use
hands Ear-Hear Nose-Smell, Throat-Talk
 Begin by introducing yourself to parents, hand rub etc. 1st
only look see, play…and examine.
 Inform examiner about your approach either:
- live commentary or
- summarize after full examination

8. General Inspection, Eyeball
1. Inspect for growth parameters e.g. FTT, syndromes, under
nutrition can have Developmental delay
2. Syndromic/Dysmorphic features e.g. Down’s and other
Trisomy, Fragile X, Catch22,
3. Appearance of Ex premature infants(prominent forehead, pig
nose), correct the age. Obvious neurological anomalies like
floppy infants, posturing, hemiplegic posturing, and involuntary
movements.

9. Position child if infant:
If child is on mum’s lap(most of the time) can
do :
-1st vision and hearing,
-2nd Fine Motor,
-3rd language and personal social,
-4th Gross Motor examination
• Do not separate for GM assessment.
• Bigger kids can examine on chair.
• Infants lie in bed-180 degree flip exam

10. TOOLS NEEDED:
1. Red yarn pom pom (4 cm diameter) with string and
dangling,
2. Bright color 12 cubes 2.5 cm,
3. Rattle with narrow handle
4. Raisins or cheerio's or honey stars or m and ms
5. Cup, spoon
6. A 4 size paper
7. Big size color pencils
7. Picture cards, multiple picture books (like bird, fish, dog,
bus, fruits etc) on same page,
8. Tennis ball
9. Small doll
10. Bell
11. Stickers, sweets for rewards

11. Vision
• Always do vision before hearing.
• Fixing and following pom pom ball. Distance 21
cm away.
• Conjugated eye gaze(not rowing)/socially
modulated eye contact Check ability to pick up
hundreds and thousands, cubes are important.
• Approached to toys
• No rowing eye movement, No squint, No
nystagmus
• Wearing glasses

12. Vision
• Fix and follow wool ball(4cm) horizontally and
vertically 20 cm from eye level

13. Hearing: Distraction test
• Use initial distraction with non noise making
stimulus in front of child
• Always ask examiner to ring the bell at 20 cm
from both ears
• Bell is brought towards ear from behind out
of range from visual fields 20 cm away from
ears.
• Changes noted are facial expression,
vocalizing sounds, head turns.

14. Fine Motor:
 Holds rattles (3 months),
 hand regards(4 mths),
 palmer grasp objects(5 mths),
 transfer cubes(7 mths),
 Raisins for pincer grip(9 mths),
 2.5 cm blocks for stacking,
 2 cubes 15 months,
 3 cubes(18 months)
 6 cubes(21 months).
 6 cubes, turn pages (2 yrs),
 8 cubes (2.5 yrs),
 9 cubes (3 years), beads, thread, putting on biro, plastic knife, and
fork. Comment on personal social interaction, language. Smiling,
waving

15. Fine Motor: Pincer Grasp

16. Personal social Devt
Chronologically
1. Focus on faces(4 weeks),
2. social smile(6 weeks),
3. excited with toys(4 months),
4. Castrate toys (5 months),
5. stranger anxiety, (6 months),
6. responds to No, imitates, (8 months),
7. clapping, bye bye, bang blocks (10 months),
8. peek boo(11 months),
9. picture books( 12 months),
10. kiss mirror (13 months),
11. points(15 months),
12. Body parts(21 months)

17. GROSS MOTOR:
 HH (16 weeks), Roll over,
 Tripod (6 months),
 Bear wt, bounces, lifts head(7 months) ,
 sit well (8 months)
 pull to sit and stand, crawl (10months),
 Creep 11 months,
 walk with support (1 year),
 climb stairs with rail ,throw ball(18months),
 walk upstairs(21 months)
 up and down (2 years).

18. GROSS MOTOR: 180 degree flip
examination in infant < 8 months
and gait for > 1 year
 Supine: Note posture, abnormal ATNR, involuntary
movements with CP. paucity of movements for hemiplegia.
 Pull to sit: head lag. Sitting: Head and trunk control. Back is
straight or rounded.
 Weight bearing: scissoring, hypotonia, advanced weight
bearing (CP)
 Ventral suspension: Describe posture, low tone, increase
extensor tone.
 Prone: Observe ability to raise head, trunk above horizontal,

19. Primitive reflexes:
1. Sucking/Rooting :( 0-4,6mths),
2. Palmer grasp; (0-3 months).
3. Placing, stepping: (0-6weeks)
4. ATNR: 2-6 Months.
5. Landau: on ventral suspension, normally extend head,
trunk, and hip. Flex head and neck, response is flexion of hip,
trunk.0-6 month).
6. Neck righting reflex: rotation of trunk 6mths-2 years.
7. Moro: 0-4 months.
8. Parachute: 6-12 months persist. Prone position, move
rapidly, face down. Will extend both upper limbs.

20. Speech and Language:
 Cooing ( 2mths),
 responds to human voice (4 mths),
 Babbling (6mths),
 Mamma, dada (9mths),
 2 words plus mama, dada(12 mths),
 Jargon, points (15mths),
 10 words and says his name, points to 3 body parts, one
picture (18mths),
 2-3 word phrase, name 3 objects, 4 body parts, says no
 (2 yrs), know name, age sex
 (2.5yrs), preposition, count 1-10, 2 colours
 (3 yrs), name 3 colours, converses (4 years)

21. Gross Motor Milestones-1
Ball Jumping Stairs Walking Sitting
1 year ▪ throws
ball 3 feet
▪ creeps up
stairs
▪ walks holding on
▪ kneels & balances
18
months
▪ throws
ball
without
falling
▪ walks up
stairs
▪ creeps back
down stairs
▪ walks well by 18
months
2 years ▪ throws
ball
overhead
▪ kicks ball
▪ hops with 2
feet
▪ jumps forward
4 feet
▪ 2 steps up
& down
▪ runs
▪ walks around
carrying toy
▪ starts & stops at
ease around
obstacles
▪ gets on to
furniture
and sits on
their own
2.5 years ▪ catches
ball into
body
▪ stand on tip
toes if shown

22. Gross Motor Milestones-2
Ball Jumping Stairs Walking Sitting
3 yrs ▪ catches ball
with arms
extended
▪ kicks forcefully
well
▪ riding tricycle
▪ stands on 1 foot
for 3 secs
▪ walks on tip
toes
▪ jumps down
▪ 2 steps up &
1 step down
▪ walk backwards &
sideways hauling a
large toy
▪ sits with ankles
crossed
4 yrs ▪ throws ball
underhand
▪ stands on 1 foot
for 5 secs
▪ hops with 1
foot
▪ stands on tip
toes
▪ jumps forward
30 feet
▪ 1 step up &
down
▪ picks up object by
bending forward
with knees straight
▪ sits with knees
crossed
5 yrs ▪ bounces and
catches ball
▪ stands on 1
foot for 10 secs
▪ jumps across
line & over
string
▪ skips with both
feet alternating
▪ does 3 sit ups

23. Sequence of approach to gross motor
assessment
Walk → jump /
hop → climb
stairs → throw
ball

24. Fine motor Milestones-1
# give the crayon of appropriate length to test maturity of pen grip
Formula for copying man: 3 + number of parts (paired parts are considered 1) , head O is excluded
4
Cubes Pen Drawing Book / Pages Cutting Others
1 yr ▪ mouthing
cubes
▪ bangs cubes
together
▪ picks cubes
with 1 hand
▪ opens
book
▪ throws and cast
objects
▪ place 1 correct
shapes in holes
▪ puts pellets in &
out of cup/box
when shown
15 months ▪ builds 2
cubes
▪ scribbles
thru & fro
18 months ▪ builds 3
cubes
▪ hand preference
at 18 - 24 mths
▪ turns 2-3
pages at
the same
time
▪ no more casting
objects
▪ place 2 correct
shapes in holes
2 yrs ▪ builds 6
cubes
▪ pen held in fist -
palmar grasp (1.5
- 2 yrs)
▪ copies a
single line:
I then ---
▪ turns pages
singly
▪ makes a cut with
the scissors
▪ place 3 correct
shapes in hole
2.5 yrs ▪ aligns 3
cubes
▪ stack a train
▪ inferior pen grip
(2 - 2.5 yrs)
▪ removes screwed
lid from bottle
3 yrs ▪ builds 9
cubes
▪ 3 cube
pyramid
▪ 3 block
bridge
▪ steadies paper
with other hand
▪ copies O
▪ copies + (3
½ yo)
▪ cuts along a line ▪ strings 4 beads
▪ puts 10 pellets in a
bottle (3 ½ yo)
▪ laces 3 holds (3 ½
yo)

25. Fine motor Milestones-2
Cubes Pen Drawing Book /
Pages
Cutting Others
4 years ▪ builds
10 -12
cubes
▪ 6 cube
pyramid
▪ stack a
gate
▪ static tripod
pen grip (3 - 4
years)
▪ copies

▪ cuts along
lines of O
▪ buttons 1
button
5 years ▪ colours neatly
within the lines
▪ dynamic tripod
pen grip (4 - 5
years)
▪ copies ∆
▪ writes
name
▪ draws
house
▪ draws 3
part man
▪ cuts along
lines of 
▪ Folds paper
in ½
lengthwise
with edges
parallel
6 years ▪ copies
,
▪ draws 7
part
man

26. Use of pencils/Crayons
Pencil Skills
 Hand preference, functional grasp
 Control, pressure, helper hand
 Manipulation of writing tool ex. shift, rotation, etc.
Cutting Skills
 Orientation, grasps accuracy
 Helper hand use
Coloring Skills
 Control, pressure, coverage, use of helper hand
Visual Motor
 Printing(writing), drawing
Organization
 Details of pictures, drawing lines & shapes

27. Pencil grip

29. Gesell's figures when use pencil

30. Gesell's blocks

31. Sequence of approach to fine
motor assessment
build blocks → place shape in hole → hold pen +
scribble, → put pellets in bottle → lace holes
→Thread Beads →cut paper → buttons → colors
in lines → fold paper

32. Language Milestones
*1st ask the parent, what is the child’s dominant language and any history of hearing loss
Length of sentences Words / Vocabulary Pointing Commands
1 yr ▪ knows 2 - 3 words
▪ says mama & pap
specifically (15 mths)
▪ indicates needs by
pointing & vocalisations
(15 mths)
▪ follow 1 step commands
w/o gesture: ‘ give to
papa, come to mama’
18
mon
ths
▪ enjoys nursery
rhymes &
attempts to sing
along
▪ knows 10 - 20 words
▪ jargons ++
▪ echolalia
▪ talks to self during play
▪ 1 body part
(15
months)
▪ 2 - 3 body
parts (18
mths)
▪ understands simple
instructions: ‘ come for
dinner’, ‘don’t touch’ (15
mths)
2 yrs ▪ 2 -3 word
phrases
▪ 20 - 50 words
▪ ask: what & where
▪ 5 body
parts
▪ follow 2 step commands
w/o gesture
2.5
yrs
▪ running
commentary
during play
▪ > 200 words
▪ knows full name &
gender
▪ uses pleural, nouns
▪ names 5
body
parts

33. Language Milestones-2
Length of
sentences
Words / Vocabulary Pointing Commands
3 yrs ▪ 3 word
phrases
▪ correct
grammar,
preposition,
opposition
▪ left, right
▪ past, present
▪ out counts from 1 - 10
▪ asks: why
▪ understood by
family
▪ follows 3 step commands
4 yrs ▪ complete
sentences
▪ knows age
▪ points to colours
▪ route counts from 1 - 20 ,
1 - 2 counts from 1- 4
▪ narrates long stories
▪ understood by
strangers
▪ understands commands
with above and below
5 yrs ▪ knows address, month,
day, birthday
▪ knows morn / afternoon
▪ names 4 - 5 colours
▪ ask : how
▪ understands commands
with before and after

34. Personal social Milestones
1 yr 1 - 2 yr 2 - 3 yrs 3 - 4 yrs 4 - 5 yrs 5 - 6 yrs
▪ smiles
spontaneously
▪ responds
differently to
strangers than to
familiar people
▪ pays attention to
own name
▪ responds to no
▪ copies simple
actions of others
▪ recognises self in
mirror or pictures
▪ refers to self by
name
▪ plays by self,
initiates own play
▪ imitate adult
behaviours in play
▪ helps put things
away
▪ plays near other
children
▪ watches other
children, joins
briefly in their
play
▪ defends own
possessions
▪ beings to play
house
▪ symbolically uses
objects, self in
play
▪ participates in
simple group
activities
▪ knows gender
identity
▪ joins in play with
other children, begins
to interact
▪ shares toys, takes
turns with assistance
▪ begins dramatic play,
acting out whole
scenes
▪ plays &
interacts with
other
children
▪ dramatic play
is closer to
reality:
attention paid
to detail,
time, space
▪ plays dress
up
▪ shows
interest in
exploring sex
differences
▪ chooses own
friends
▪ plays simple table
games
▪ plays competitive
games
▪ engages in
cooperative play
with other
children involving
group decisions,
role assignments,
fair play
▪ feeds self cracker
▪ holds cup with 2
hands, drinks
with assistance
▪ holds out arms
and legs while
being dressed
▪ uses spoon,
spilling little
▪ drinks from cup
with 1 hand
unassisted
▪ chews food
▪ unzips large
zipper
▪ indicates toilet
needs
▪ removes shoes,
socks, pants,
sweater
▪ gets drink from
fountain or
faucet
independently
▪ opens door by
turning handle
▪ takes off coat
▪ puts coat on with
assistance
▪ washes & dries
hands w
assistance
▪ pours well form
small pitcher
▪ spreads soft butter
with knife
▪ buttons &
unbuttons large
buttons
▪ washes hands
independently
▪ blows nose when
reminded
▪ uses toilet
independently
▪ cuts easy
foods with a
knife
▪ laces shoes
▪ dresses self
completely
▪ ties bow
▪ brushes teeth
independently
▪ crosses streets
safely

35. Preverbal language
 Point to body parts
 Point to pictures and identifies pictures by
pointing

36. Language assessment
Observe
 Non-verbal communication: Eye gaze, eye contact
(describe length, frequency and pattern of eye
contact), modulation of facial expression pointing,
body gesture, body language, socially aware not
aware
Receptive language/Comprehension: Following
instructions e.g.
 Call him by name and see response
 Ask what is your name, age, sex?
 Ask labelling of body parts
 Ask him to bring ball 1-3 steps
 Ask to use on, down, under

37. Receptive language
 Follows instructions
 Try 1 step than 2, 3 etc
 See if he echoes questions
 Responds to name

38. Expressive language
 Expressive language: production of
speech, voice quality, intonation, pitch,
volume
 Tells his name, age, sex
 Labels body parts, pictures

39. Types of pointing
 Protodeclarative pointing: Child points indicate the desire to
share an experience with another person, e.g., a child pointing to
fish looks at you and than object and may look at again you.
Protodeclarative pointing, child’s pointing requires joint attention,
or the ability to share experiences with others by attracting or
following their attention by looking or pointing.

40. Types of pointing-2
Protoimperative pointing: points represent
desire for an object eg fish e.g., pointing to
fish or his needs like cookie, sweets, bread
etc. So pointing for needs.

41. Speech assessment-Quality
 Articulation
 Clarity
 Pronunciation
 Jargons
 Apraxic
 Dysfluency
 Stuttering
 Stammering

42. Assessment of language in older child
Language Pre language skills
▪ eye contact
▪ facial expression, modulation
▪ good attention span
▪ imitation & compliance
▪ joint attention
▪ joint referencing (child shows you something)
Language skills - expressive & receptive
▪ higher order language: idioms, sarcasms, bargaining
Problem with phonation
1. Can be due to hearing impairment
▪ dropping & simplifying clusters of consonants
2. Check locally for any cleft palate / tongue tie
▪ cleft → difficulty in making ‘CH’, sounds
- e.g. childish children eating chilies
▪ rhinolalia → look for cleft or catch 22
- bob is a baby boy → mob is a mamy moy
▪ tongue tie → difficulty making the ‘L’ sounds
Spatial
Directions
1. Put the pencil behind your knees
2. Put the pencil between us but closer to you
3. Put the pencil above your ear
4. Touch the bottom of your chair
5. Put the pencil under this paper and put your hands on top of the paper
▪ 2 correct: 4 year level
▪ 3 - 4 correct: 5 year level
▪ 5 correct: 6 year level
Temporal
Directions
1. The boy saw the man who was carrying a red ball.
Q: who was carrying the red ball?
2. The girl who played with my friend came home late last night
Q: who came home late last night
3. The lady saw the man who was wearing a green hat
Q: who was wearing the green hat?
4. Before it got dark, the man went to the shop.
Q: when did the man go to the shop?
5. The baby ate the sweet after his mother called him.
Q: when did the baby eat the sweet?
▪ 1 - 2 correct: 4 year level
▪ 3 - 5 correct: 5- 6 year level
Understan
ding
I am going to tell you a story...
▪ tailor the difficulty of the story to the age of the child
▪ ask child to repeat the story back to you
▪ ask child questions about the story
▪ 6 year old should be able to tell you the story
back with understanding and reasoning e.g.
‘why did the ice cream melt?’
Others Simple math (6- 7 yo)
Test fine motor test + hand writing
Compare big and small ‘ which circle is bigger?’, compare long & short

43. Assessment of play
Can be divided into concrete play & pretend
play
 2 - 2.5 years: needs to play with object to
imagine it (symbolic play)
 3 - 3.5 years: still require an object, but not
so much & more imaginative about it
 4 - 4.5 years: able to play & imagine things
out of air
 children with delay in symbolic play with
have delay in language - because language is
a ‘sound’ symbol for the object

44. Assessment of play
Approach to steps in assessing play
1. looks what that? - point to a toy and see if there is
joint attention
2. do you wan to play with it? - bring the toy to the
child
3. start playing & see if the child imitates you
4. add elements (pretend & fantasy) to the play - the
doll is hungry, shall we feed the doll some cake? the
cat is hungry how?, prompt the child to go on .. feed
info when the child needs otherwise watch
5. extension of play → the child then continues the
story and says perhaps, the doll is full, its time to
sleep

45. Assessment of play
Age
begins
Type of play Interaction of play
18 mths ▪ functional play ▪ solitary play
2 yrs ▪ imitative play ▪ parallel play
2.5 yrs ▪ pretend play ▪ interactive play
3 yrs ▪ fantasy / symbolic play

46. ASD
Conditi
on
Triad Information
Autism Qualitative impairments in
social communication and
interaction, together with
presence of restricted,
repetitive and stereotypic
behaviour, interests and
activities
CHAT: Screening questionnaire for autism in children 18
- 36 months
▪ does your child enjoy being bounced on your knee?
▪ does your child take interest in other children?
▪ does your child like climbing things like chairs?
▪ does your child like playing peek-a-boo /hide & seek?
▪ does your child pretend while playing?
▪ does your child ever use his/her index finger to point
to ask for something?
▪ does your child ever use his/her index finger to share
something interesting with you?
▪ does your child play with small toys without
mouthing, fiddling, dropping them?
▪ does your child ever bring objects to show you?

47. ASD
Neurodevelopmental disorders characterized by
impairments in three domains: Triad
1. Socialization
2. Communication
3. Behavior
Includes:
 Autistic disorder
 Asperger disorder
 Rhett’s disorder
 Childhood Disintegrating disorder
 Pervasive developmental disorder, not otherwise
specified (PDD-NOS)

48. ASD
 Occurs in ~1 in 150 to 1 in 500 children
 Increasing incidence since 1970s—due to
increased awareness/changes in case
definition
 MR /seizures common
 Pathogenesis incompletely understood
 Overwhelming evidence does not support
association with immunizations and
autism

49. Autistic disorder—DSM-IV
Criteria:
A total of six (or more) items from (1), (2),
and (3), with at least two from (1), and one
each from (2) and (3):

50. 1. Qualitative impairment in social interaction,
as manifested by at least two of the following:
 Marked impairment in the use of multiple nonverbal
behaviors such as eye-to-eye gaze, facial expression,
body postures, and gestures to regulate social
interaction
 Failure to develop peer relationships appropriate to
developmental level
 A lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people (eg, by a
lack of showing, bringing, or pointing out objects of
interest)
 Lack of social or emotional reciprocity

51. 2. Qualitative impairments in communication
as manifested by at least one of the following:
 Delay in, or total lack of, the development of spoken
language (not accompanied by an attempt to compensate
through alternative modes of communication such as gesture
or mime)
 In individuals with adequate speech, marked impairment in
the ability to initiate or sustain a conversation with others
 Stereotyped and repetitive use of language or idiosyncratic
language
 Lack of varied, spontaneous make-believe play or social
imitative play appropriate to developmental level

52. 3. Restricted repetitive and stereotyped
patterns of behavior, interests, and activities
As manifested by at least one of the following:
 Encompassing preoccupation with one or more
stereotyped and restricted patterns of interest that
is abnormal either in intensity or focus
 Apparently inflexible adherence to specific, non-
functional routines or rituals
 Stereotyped and repetitive motor mannerisms (eg,
hand or finger flapping or twisting, or complex
whole-body movements)
 Persistent preoccupation with parts of objects

53. ASD
 Delays or abnormal functioning in at least
one of the following areas, with onset before
3 years old:
(1) Poor social communication
(2) Poor social interaction
(3) Poor pretend play
 The disturbance is not better accounted for
by Rett's Disorder or childhood
disintegrative disorder.

54. Diagnosis of Autism is a clinical one
 Use DSM-IV Criteria
 Sometimes referral to ASD specialists for
definitive diagnosis
Diagnostic tools available:
 Autism Behavior Checklist (ABC)
 Gilliam Autism Rating Scale (GARS)
 Autism Diagnostic Interview-Revised (ADI-
R)
 Childhood Autism Rating Scales (CARS)
 Autism Diagnostic Observation Schedule-
Generic (ADOS-G)

55. Atypical Autism
Asperger disorder—similar to autism
 No clinical significant delays in language
 Higher levels of cognitive function
 Greater interest in interpersonal social
activity
 Specific DSM-IV Criteria for diagnosis
PDD-NOS—used for individuals with
some, but not all, of the DSM-IV criteria for
autistic disorder

56. Rett Syndrome
 Almost exclusively females
 Develop normally initially, then gradually
loose speech, purposeful hand use after 18
months of age
 Deceleration in head growth
 Mutations in MECP2 gene
Childhood disintegrating disorder
 Regression in multiple areas of functioning
after two years of normal development

57. ADHD
Condition Examination Information
ADHD • -Presence of hyperactivity,
inattention and impulsivity,
• -Presenting prior to age 7,
• -Of sufficient degree to
impairment social, academic or
occupational functioning,
• -Present for ≥ 6 months across ≥
2 environments
Steps in History taking:
▪ -exclude brain injury: hypoxia /
infections, ASD
▪ -examine social setup: school, family,
teachers, seat in class
▪ -perform diagnostic interviews as per
DMS IV manuals
▪ -assess IQ, vision, hearing
▪ -assess for OSA: might result in
ADHD
▪ -assess for EEG: for absence seizures

58. GDD
GDD ▪ Chronic sick kids
usually have GDD ±
syndromic
▪ look for a central cause
- Dysmorphic.
microcephaly
- IUI? - VP shunt, eyes,
hearing, cardiac
murmur,
hepatosplenomegaly
- CP? - gait, spasticity
of limbs
- storage disease -
hepatosplenomegaly,
eyes
▪ GDD diagnosed when
there are Child < 4 years
of age with delays in
speech and language
domain, and in at least 1
other developmental
domain
▪ -ask parents about
functional status at
home

59. Motor Delay
Motor
delay
 comment on hand dominance e.g. in hemiplegia
 bring out the inequality of bilateral hand dexterity by doing
threading & comment on it
 In a child with neurological deficits → offer that ‘ I want to do a proper
neurological examination, I am looking for dyskinetic CP.. etc’
 look for vision problems that can hinder fine motor dexterity - especially
if a young child is wearing spectacles
 Comment that the child might have limitations due to ...., but
has functionally adapted to ..
 ask parents about functional status at home


60. Mental Retardation (MR),
cognitive delay
 a state of functioning beginning in childhood
characterized by limitations in intelligence and
adaptive skills
 DSM-IV Criteria for MR:
 Significant sub-average intellectual functioning
 Adaptive functioning deficit or impairment
 Onset before 18 years of age
 Cognitive impairment requires IQ testing (accurate for
ages ≥5 years)
 Mild—50 to 70 IQ ( 70 is 2 SD from normal—100)
 Moderate—40 to 50
 Severe—20 to 40
 Profound—<20

61. Prognosis for MR
Depends on severity:
 Mild—can be taught to read/write, live
independently and hold jobs as adults
 Moderate—probably will not learn to
read/write, but may live/work in semi-
independent supervised settings
 Severe/profound—require substantial
lifelong support
 Also dependent on etiology of MR and co-
morbid conditions

62. Learning difficulties
 Achievement substantially below
 expected given the child’s age,
 intelligence and appropriate education

63. Dyspraxia/ developmental
coordination disorder
 Motor planning issues
 with deficits in conceptualisation,
organisation and
 execution of unfamiliar sequence of
movement, often affecting attention and
learning
 Sensory integration disorder
 Sensory defensiveness

64. Sensory integration
disorder
 Sensory defensiveness and
 Modulation issues

65. Red flag signs of SLD
6 month -no response to sound
▪ Deaf infants coo/laugh/squeak at @ normal age
then babble slightly later than Ń then stop
babbling
1 yr no babbling, not localising sound
18
month
no meaningful words except ma/pa
not pointing to wanted things
2 yr vocab < 20 words
no 2 word phrases
2.5 yr not understanding simple instructions
3 yr not understood by family
4 yr not understood by outside family
5 yr speech not clear, fluent, not complex
not understood

66. Important Milestones
Domains Development
Receptive language 12 month ▪ responding to their name
18 mth - 2 yrs ▪ pointing to body parts, parents, pictures
12 - 18 mths
2 yrs
▪ following instructions
- 1 step: throw in the bin
- 2 step put this ball in box and bring shoes
Expressive language
(verbal & non verbal)
12 month
2 yo
3yo
4yo
5yo
▪ mama & papa, pointing to what they want
▪ linking words, naming 2 - cat, dog
▪ repeats 3 word phrases
▪ gives name & identifies colours
▪ name colours, self, fluent
▪ repeats 4 - 6 word phrases
Social Emotional
Self help
(ASD)
3 - 6 mth
18 - 24 mth
▪ eye contact
▪ reciprocal play
▪ pretend play
▪ joint referencing, share interest
Gross motor
- to test for GDD
12 - 18 mths
2 yr
3 yr
4 yr
5 yr
▪ walk
▪ walk sideways 2 steps, kick a ball
▪ stand on 1 foot, tiptoe 3 steps
▪ stand on 1 foot for 1 secs, tiptoe 4 steps
▪ hop 2 hops on 1 foots
▪ stand on 1 foot for 5 secs
Fine motor
- to test for GDD
18 mths
2 yr
3 yr
4 yr
5 yr
▪ scribbles / line
▪ line / circle
▪ circle / cross
▪ copies square
▪ copies triange
▪ 3 blocks
▪ 6 blocks
▪ 9 blocks
Offer to test hearing
Ask for f/h of delayed speech: more common in children with +ve f/h

67. In DCD:
 The single most common presenting concern
was speech and language (S&L) delay (30%).
 The most common clinical developmental
diagnosis was autism spectrum disorder
(ASD) (30%)
• Global developmental delay (GDD)(10%)
• ADHD(6%)
• LD(4%)
• Cognitive impairment(4%),
• CP(3%)
• Dyspraxia(2%)

68. Approach to Developmental
Delay-1
 Assess if any medical problems like
Neurologic, myopathy, dystrophy etc
 Genetic, syndromes particularly Fragile X,
Prader willi
 Metabolic
 Endocrine exclude Hypothyroidism for GDD
 HIE, CP, IUI, ExPREM
 Hearing loss
 Vision loss, squint, lazy eye, astigmatism etc

69. Approach to Developmental
Delay-1,Medical Evaluation
 Presence of biologic risks or medical problems
associated with DD
 Head circumference for micro/macrocephaly
 Weight and height for growth deficiency
 Dysmorphology (minor and major congenital
abnormalities)
 Eye exam for poor tracking, strabismus, etc
 Ear exam for recurrent/chronic OM
 Abdomen for HSM (metabolic disease)
 Skin for neurocutaneous lesions
 Neurologic exam for reflexes, tone, symmetry,
strength

70. Screening Tests:
 Parents’ Evaluation of Developmental Status
(PEDS)
 Ages and Stages Questionnaires (ASQ)
~15 minutes, by the parent
 Generates a pass/fail score in four
development domains
 Infant-Toddler Checklist for Language and
Communication
~5-10 minutes, by the parent
 Identifies scores 1.25 SD below normal
 Brigance Screens-II

71. Approach to Developmental
Delay-2
 Check growth percentiles, macro or
microcephaly
 FTT
 Examine for Neurocutaneous syndromes
like café au lait spots
 Examine back for spina bifida occulta
 Examine eye for squint, nystagmus,
cataract, clouding
 Do Neurologic examination

72. Approach to Developmental
Delay-3
 Try to differentiate UMN/LMN lesions
 Examine abdomen for HSM
 Otoscopy for wax, Otitis Media
 Mouth for tongue tie, cleft, tongue
movement, gag

73. Approach to Developmental
Delay-4
 Do Hearing test and Visual assessment with
or without sedation for all developmental
delay
 For GDD consider TFT
 For hypotonia, GDD doe Muscle enzymes
CK, LDH and KIV aminoacidogram,
metabolic screen
 For Genetic Karyotyping, FISH
 Refer
Genetic/Neurologist/ENT/Eye/Endocrine as
needed

74. Evaluations-1
 Formal hearing testing (BAER)
 Vision testing (full ophthalmologic exam)
 Thyroid function testing (if no NBS, or
signs of thyroid disease)
 Metabolic screening (if abnormal or no
NBS)
 Neuroimaging (MRI vs CT)

75. Evaluations-2
 Chromosomal/Cytogenetic Testing (if
+family history)
 Down Syndrome (karyotype), Fragile X
(FMR1), Rett Syndrome(MECP2),
Prader-Willi/Angelman (FISH)
 EEG if suspected seizure
activity/encephalopathy (Landau-
Kleffner)
 CPK/Aldolase if abnormal muscle tone
(Muscular dystrophy)

76. Approach to Developmental Delay-
5,Children 0-36 months—agencies
 Refer to EIPIC)
 Multidisciplinary
 Speech and Language Pathologist
 Occupational and Physical Therapy
 Social Worker
 Psychological evaluation if needed
 Focus on need for services rather than
diagnosis

77. Children 3-5 years—preschool EIPIC/ICCP services
 Continued services—may be in or out of
classroom
 Children older than 5 years—referrals
usually made through public school
system
 Private evaluations/services are also
available

78. Children older than 5 year
 Referrals usually made to DCD therapist
 Private evaluations/services are also
available
 SPD
 ICCP

79. At 6 years age-1
If assessment shows need of special school
 Do IQ test for school placement
 If going to mainstream, no need to do IQ
test, but can refer educational facilitator for
informing school special need officer (SNO)
regarding child’s diagnosis and
accommodation needed
 May need exemption from mOther Tongue
 Extra Time in exam
 Sitting in front of class, prompting, buddy

80. At 6 years age-2
If assessment shows mild delay and
potential to improve
 Consider deferring primary 1
 Inform MOE
 Retain K2 (maximum 2 years retention
allowed)
 Review KIV IQ test or Refer EF after 1
year
 Inform EIPIC for extension for 1 year

89. Present the case as:
 On general inspection of this cute little /Race/ New
born/infant/toddler, who is well thrived, but would like to chart
gender specific progressive percentiles for Occipitofrontal
circumference, length, and weight, he is not syndromic, (no
expremmie look), not floppy has good muscle tone moving all limbs
equally. No involuntary movements seen.
 On examination of vision he had eye gaze, socially aware, he fixed
followed pompom ball, approached to toys, picked up raisins etc.
On examination of distraction hearing test …, On personal social..,
On language. On fine motor…On gross motor..NN reflexes
 or there is a huge scatter across the developmental ages of his
different abilities
 In summary: this infant has DA of….GM … FM…. SL PS etc with
Developmental quotient at __%
 I.Q= Mental age x 100
 Chronological age