Introduction

This article contains a bit of background info about normal child development. For info on milestones, please see:

Background Info

Most developmental abnormalities present within the first 5 years of life. During this period there is rapid development of motor ability, speech and language, communication and cognitive skills. After this age, development is mainly just cognitive.

Why detect problems early?

  • Early intervention can help children achieve their maximum potential
  • Provide prompt treatment – particularly important for hearing and vision – as after a certain age, there is nothing that can be done to develop these systems further.

Nature vs Nurture

It is now generally believed that:
  • Genetic makeup provides the child’s raw ability
  • Environmental factors are responsible for how much of this potential the child is able to achieve.
The only area we can really have much influence over is the environment (although gene therapy may change this in the future!)
Environmental needs are different in children of different age groups
  • Infants – rely on their parents/carers for almost all their needs
  • Older children – are able to deal with social situations, and some of their own physical needs (e.g. feed themselves – although meal preparation will still be required)
  • Adolescents – can meet virtually all of their ownphysical needs, but may have difficulty with complex social relationships
There are four main areas of child development:
  • Gross motor skills
  • Vision and fine motor skills
  • Hearing, speech and language
  • Social, emotional and behavioural

Pattern of development

Each child’s pattern of development should be identical – however, the rate at which goals are achieved varies from child to child. The pattern in which skills are acquired is very much longitudinal – with one goal acquired after another. Later goals are often dependent on the achievement of earlier goals within the same field.For example, the failure of development of hearing will impact the development of language skills.
The four areas of development should be assessed individually.

Birth Reflexes

These should be present in neonates, and typically disappear between 4-6 months of age:
Reflex
Test
Response
Moro
Sudden neck extension
Extension then flexion of the limbs
Grasp
Place an object in the palm of the hand
Baby will firmly grip the object by flexing the fingers
Rooting
Stimulus placed near the edge of the mouth
Baby will turn the head towards the stimulus
Placing / Stepping
Baby help in an upright position, and feet gently touched against a stimuli (edge of the bed)
Baby should lift the feet as if stepping. One foot followed y the other
Supporting reflex
Again, hold the baby upright, and this time, rest the baby on their feet
Baby should extend the legs in an attempt to support their own weight
Atonic neck reflex (ATNR)
Baby is laid on their back. Turn the baby’s head to one side
Baby should outstretch their arms to the side of the head turn.

Terms and concepts

  • Limit age’ – is the age at which a child ‘should’ have achieved a particular milestone. It is defined as two standard deviations away from the mean. Many children who are outside this will still be normal, but this is the point at which further investigation may be necessary.
  • Median age – is the age at which ½ of children will have reached the milestone
  • Preterm babies – it is important t adjust dates for pre-term babies – milestones should be measured from the expected due date, and not from the actual birth date.
    • This is not necessary after 2 years of age, when it becomes insiginificant.
  • Global developmental delay – development in all four fields is affected
  • Specific developmental delay – development only affected in one of the four areas. Typically, the older the child is (and thus the more milestones you have against which to judge), the easier it is to asses any developmental delay.

Cognitive Development

Typical ideas and beliefs in the pre-school child are sometimes called pre-operational thought, and include:
  • They are the centre of the world
  • Inanimate objects are alive and personified – they have emotions and motives
  • Events often have a magical basis
  • Everything has a purpose

In primary school age children, thought processes are called operational thought. Thought processes are practical and followed ordered patterns. They are still tied to the child’s own immediate beliefs and experiences.

In adolescence, the adult pattern of thought emerges. This is called formal operational thought. This allows reasoning behaviours and abstract concepts.

IQ testing

Is widely used and often quoted to describe the degree to which a disease affects cognitive functioning. It can be a very useful test, but does have some notable drawbacks:
  • Results can be influenced by cultural background and language skills
  • Does not test all skill areas
  • Does not reflect intellectual potential
  • Tends to give unfairly low results in cases of specific defects(e.g. cerebral palsy)
In children, particularly young children, testing is typically performed with:
  • Performance IQ testing (PIQ) – e.g a child is given a task or puzzle to complete
  • Verbal IQ testing (VIQ) – e.g. a child is asked to give answers to questions
  • The results are then combined to give an IQ score. Results need to be interpreted with care; e.g. a child with speech difficulty is likely to get a falsely low mark in cases of VIQ testing.
  • Development of motor ability is easiest to assess, but is not a good predictor of future learning difficulties
  • Development of language ability is a good predictor of future problems, but is more difficult to assess, and the accuracy of the results is related to the child’s age – more accurate the older the child.
  • Developmental issues typically present when development is most rapid.

Screening and observation

  • Always start by asking the parents about their child – e.g. any specific concerns. You could also ask about specific milestones
  • Some specific testing and screening programs now ask parents to fill in questionnaires about their child’s behaviour.
  • Make it a game for the child. Use toys and other objects to assess the various functions.

Specific Testing

There are loads of specific tests for loads of different areas. You are unlikely to have to know many of them, unless you become a specialist in child development!
For purposes on the ward / in a general clinic, details are given below:
  • Ask the parents! – ask if they think their child is developing normally. Particularly in relation to speech / cognitive and social skills. If they have any other children ask if they are developing at a similar rate to previous children. Ask if the child seems to be developing at a similar rate to their peer group (e.g. at nursery school)
  • Motor development – you should be able to get a good idea just by observing the child playing / walking around the room. You may use specific toys to test specific functions

Vision

Official visual testing is carried out in pre-school children (age 4-5) by optometrists. If there are any parental concerns, it can be tested before this. Normal visual development includes:
  • Newborn – visual acuity is approx 6/200
    • Retina is generally well developed but fovea is not
    • If pre-existing eye problem (e.g. cataracts) foveal development may not occur
    • Newborn should be able to fix and follow faces
  • 6 months – should be able to resolve objects of 1cm diameter
  • 8 months – should be able to resolve objects of 1mm diameter
  • 3-4 years – adults levels of visual acuity attained

Sound

Neonatal sound checks
  • Evoked otoacoustic emissions (EOAE) – an ear piece is placed into the ear. It emits a series of clicks. These are reflected back, and these echos can be detected by the ear piece. Analysis of the echo can determine if cochlear function is normal or not.
  • Auditory brainstem response (ABR) audiometry – the child is played a series of clicking sounds through an earpiece. Simultaneously, EEG waves are studied to check the response. This not only checks that the conduction system is working correctly, but also that neural auditory function is working at a basic level.
  • Early detection of problems allows for earlier treatment, and, ultimately better outcomes.

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