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Child Growth Stages



Child Developmental Problems in Children


Developmental Problems in Children

Some of the developmental problems of children includes intellectual and special sensory deficits, motor dysfunction, and psychosocial disorders caused by nonprogressive central nervous system (CNS) dysfunction.

With developmental problems, diagnosis is often delayed due to overreliance on normal variation as explanations of subtle findings, inattention to specific milestone delays when the child is otherwise normal, reliance on strictly clinical impressions in deference to cumbersome screening devices, and the physician's or parents' reluctance to discuss their fears.

I. Diagnosis

History should include open-ended questioning of the parents regarding their child. The medical history should document established developmental risk, such as known sensory deficit, chromosomal abnormality, myelomeningocele, and HIV infection.

Risk factor assessment
Biologic risk factors may be summarized as significant maternal disease, hazardous exposure, obstetric complication, congenital infection and malformations, and significant neonatal, infant, or childhood neurologic, cardiopulmonary, infectious, somatic, or metabolic disease.
Also, family history may reveal risk factors, such as familial developmental or sensory deficits or chromosome abnormalities.
Psychosocial risks include mental retardation, serious emotional disturbance, substance abuse, or lack of parenting skills in caregivers, and stress, violence.

Physical examination
Examination is essential for the detection of risk of developmental delay.
Attention should be paid to growth abnormalities, congenital anomalies, skin findings , eye findings, organomegaly, postural and transition movement disorders, as well as the neurologic examination.

Developmental surveillance
This should be performed at each well-child visit by the use of milestones. This may be done along with immunizations, in children who are only presented for episodic care.
Developmental delay is defined as actual development that is 25% or more behind the expected rate in any or all of the four major streams of gross motor, fine motor, language, and personalsocial developments.
Development should occur in an orderly, predictable, intrinsically controlled fashion. Parents and providers may focus on growth in the first 810 months, disregarding gross motor delay.
Warning flags are abnormal head size and failure to have hands unfisted at least 50% of the time by 3 months.
The presence of handedness earlier than 18 months may represent an opposite-side hemiplegia.
Language development is the best predictor of intellectual potential and is therefore combined with cognitive development.
Linguistic capacity develops in sequential, critically timed phases and depends on the adequacy of stored utterances in infancy. A common pitfall is to ignore a language milestone delay until age 2.
One more cognitive warning flag is lack of appreciation of object permanence by the end of the first year.
The average age of diagnosis of congenital deafness is 2 years. Expressive skills that are advanced in comparison with receptive skills may be a sign of a pervasive developmental disorder.

Further assessment
There is no routine laboratory workup. The results of state screening for certain inborn metabolic disorders must be known, and testing augmented if there is loss of milestone skills, vomiting and lethargy, movement or cutaneous disorders, failure to thrive, unusual body odor, or suggestive family history.
Thyroid disorders must always be ruled out in developmental delay.
Children with abnormal muscle tone should be screened with creatinine phosphokinase and aldolase.
Neuroimaging or electroencephalography, or both, is indicated for children with focal neurologic findings, abnormal head growth, craniofacial anomalies, many genetic syndromes, seizures, sensory impairments, and other unexplained findings.
Children with major or multiple anomalies suggestive of a syndrome should have karyotyping (done best in consultation with a geneticist).
DNA testing for fragile X syndrome should be considered in boys with mental retardation and autism.
Learning disabilities are confirmed by neuropsychometric testing.

II. Specific syndromes and management

Learning disabilities
Learning disabilities are associated with increased comorbidities, including depression, anxiety, substance abuse, and sleep and eating disorders.
Dyslexia is the most common disability, and it may affect written language and mathematical skills development.
Preschool diagnosis is often difficult, and problems may not arise until adolescence and persist or even present in adulthood.
Treatment should be individualized.

Mental retardation
Mental retardation is defined as a deficit resulting from disease, injury, or abnormality that existed prior to age 18, IQ of 7075 or below, and deficits in at least 2 of the following 10 areas of adaptation like communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work.
Mild retardation may be isolated, but severe retardation is often accompanied by associated deficits that also affect prognosis.
Fetal alcohol syndrome, fragile X syndrome, Down's syndrome, and DiGeorge's syndrome (deletion of chromosome 22) are the common identifiable causes of severe retardation.

Cerebral palsy
Cerebral palsy is a collection of disorders that manifest as abnormal motion and posture caused by early CNS injury (most commonly during intrauterine development).
Approximately two thirds of affected children have associated mental retardation; most of those with normal intelligence have perceptual problems that may result in learning disabilities.
Treatment may include neurosurgery or orthopedic surgery or devices; medical treatment for seizures, spasticity, constipation, and gastroesophageal reflux; and appropriate therapies.

Autism and related disorders
This division includes a spectrum of brain-based developmental disabilities with multiple etiologic factors, involving impaired reciprocal social interactions, communication, and imaginative activity.
About 25% of patients manifest seizures.
Educational, language, and behavioral therapy and highly predictable daily routines and preparedness are treatment mainstays. New medications are being tested.

Hearing impairment
Risk factors for hearing loss include family history, congenital infections, craniofacial anomalies, birth weight less than 1,500 g, severe hyperbilirubinemia, bacterial meningitis, asphyxia, ototoxic medications, mechanical ventilation for 5 or more days, and suspected syndromes that may include hearing loss.

Visual impairment
Visual impairment is present in many of those with developmental disorders.
An increased prevalence of developmental problems is seen in the visually impaired.
Prompt diagnosis and referral to an ophthalmologist skilled in the care of children is essential.

Down's syndrome
Down's syndrome or trisomy 21, is a common cause of mental retardation and may serve as a prototype for other chromosomal abnormalities with a wide range of medical, developmental, sensory, and emotional manifestations.
Specific Down's syndrome growth charts should be used along with screening for heart defects, hypothyroidism, atlantoaxial instability, and other associated conditions.

Failure to thrive
Unexplained weight loss or poor weight gain may be caused by a variety of psychosocial, environmental, neurologic, and anatomical factors and their interactions.
There is evidence for a sensitive period for mental development that is mitigated by poor postnatal somatic growth, placing these infants at risk for cognitive delay.

Neurodevelopmental abnormalities due to HIV infection
These are a spectrum of motor, cognitive, communication, social, and behavioral problems that may ultimately be seen in infected children.

Comprehensive primary care for children with developmental delay
This includes coordination and management of a team of medical and sometimes surgical and dental specialists, counselors (genetic, parental, family), habilitation or rehabilitation therapists, medical device services, and special educators.
Knowledge of community and social services as well as advocacy for the child and family are essential.

Advice for the parents begins with frank, factual, unhurried, and compassionate discussions as soon as the diagnosis of delay is entertained.
Maximizing communication in children with language disorders and helping parents foster special strengths of their child should help minimize the child's frustration and consequent additional emotional, behavioral, or social disturbances.
Sports activities, including Special Olympics, are often helpful for weight management, fitness, development of physical coordination, and improvement of self-esteem.

Consistent discipline, appropriate for the level of understanding, is important for the child, particularly in the context of his or her siblings.

III. Prevention

Prevention involves optimization of preconceptual, prenatal, and postnatal care. The latter includes not only avoidance of untoward exposure; early identification of toxic, metabolic, and medical disorders; appropriate therapy; and optimization of neurologic outcome, but also providing a nurturing environment.
For the very premature, this should include careful restriction of stimuli and protected rest time.
It also empowers the family to be proactive in maximizing the child's abilities, perhaps avoiding secondary emotional and physical disability.


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