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Developmental - Assessment, P. Bolton
Developmental - Assessment, P. Bolton
32–42
Bolton/Bellman
Developmental assessment
Patrick Bolton
Assessment of development constitutes one of the a variety of sources (parents, teachers, other profes-
core components of any psychiatric evaluation. This sionals) and to use a number of different methods of
is because evaluation of psychopathology generally gauging progress (developmental history, current
entails determining the extent to which behaviours functioning by report and on specific tests). This
and experiences are appropriate for an individual’s may require input from a range of professionals
age and stage of development and because develop- (psychiatrists, psychologists, speech/language and
mental disorders are common and frequently associ- occupational therapists, physiotherapists) and
ated with psychiatric and behavioural disorders. I entail some form of multi-disciplinary evaluation.
will describe methods of evaluating and diagnosing Before an assessment, it is helpful to obtain details
developmental disorders, but the principles and of any earlier assessments conducted by other
techniques also apply to evaluating development professionals (e.g. speech therapists, educational
during any comprehensive psychiatric assessment.
The main developmental disorders classified in
ICD–10 (World Health Organization, 1993) are sum- Box 1 ICD–10 classification of developmental
marised in Box 1. Disorders characterised by global disorders
delays in development (e.g. mild, moderate, severe
and profound forms of ‘mental retardation’) are Mental retardation
distinguished from disorders that affect specific Mild
functional domains (e.g. specific disorders of speech Moderate
and language, scholastic skills or motor function), Severe
as well as from conditions that exhibit distinctive Profound
patterns of deviation from the normal developmental
trajectory (e.g. the pervasive developmental disor- Pervasive developmental disorders
ders). The conditions are not mutually exclusive, Autism
however, and varying degrees of overlap may occur. Atypical autism
Frequently, therefore, it is necessary to evaluate the Asperger’s syndrome
extent to which development is progressing at the Disintegrative disorder
right rate, as well as the extent to which it is follow- Rett’s syndrome
ing the correct path. Other and unspecified
Specific developmental disorders
Speech and language: articulation; expressive
Approaches to assessment speech; mixed expressive and receptive
speech
Literacy: reading; spelling
General principles Numeracy
Motor coordination
To establish an accurate understanding of develop- Mixed specific developmental disorder
mental progress, it is best to obtain information from
Patrick Bolton is a lecturer at the University of Cambridge (Section of Developmental Psychiatry, Douglas House, 18b Trumpington
Road, Cambridge CB2 2AH) and Honorary Consultant in Child Psychiatry for Lifespan Healthcare Trust. He is co-director of
the Autism Research Centre at the University of Cambridge (www.psychiatry.cam.ac.uk/arc). His research interests focus on
the genetics and brain basis of social communication disorders, including autism, and the psychopathology of tuberous sclerosis.
Developmental assessment APT (2001), vol. 7, p. 33
and clinical psychologists and developmental you will be asking about these details when you
paediatricians) and to review the reports from these meet with them and that they may find it helpful to
evaluations. The information in these reports can bring to the interview baby books, etc. In addition, it
be useful in filling in gaps in the developmental is often helpful to get parents to focus on specific
history, when parents have forgotten aspects of the events that took place, as these can act as anchor
child’s early development, and in cross-checking points for dating milestones. For example, ask the
the accuracy of the parents’ recall of the child’s parents to focus on events such as the first birthday,
behaviour with contemporaneous descriptions. the birth of a sibling, move of home or change of job,
It may be necessary to undertake an initial and then to describe memories of the child’s behav-
evaluation, and then supplement this with further iour and abilities on these occasions. Cross-checking
assessments selected to address specific issues. This that the details reported on one occasion are consis-
can prevent unnecessary testing and can have the tent with descriptions obtained about another event
added advantage that conducting evaluations at closely related in time is also a useful way of ensur-
different times and in different settings makes it ing that the report is accurate. For example, when a
possible to determine the extent to which difficulties sibling was born at around the time of the child’s
are persistent and context-dependent. second birthday, ask for descriptions of the child’s
behaviour on both occasions and compare them.
The second issue concerns parents’ perceptions
Assessing the significance of delays and preconceptions about the child’s developmental
and deviations in development status and behaviour. Not infrequently, the meaning
of behaviours or skills is not fully appreciated by
There are several ways in which the significance of parents, and achievements may be imbued with special
delays and deviations can be assessed. First, the age but unwarranted significance. The onus is on the clin-
at which milestones in development were achieved ician, therefore, to obtain a descriptive account of
can provide a yardstick to the pace of development. the child’s behaviour rather than an account of the
For example, the ages at which the child was first parents’ views on the abilities of their child. Clearly,
able to sit, walk and speak can be compared to the the clinician must be familiar with the key milestones
normal range, to determine whether or not they were in development, as well as the signs and symptoms
out of the ordinary. Second, standardised tests of of abnormal deviations from the developmental path-
development can be administered to check how much way. This ensures that appropriately focused ques-
the child’s current functioning is consistent with tions are asked and that the coverage is comprehensive.
expectations. Ordinarily, these tests use some statis-
tically determined cut-off point (often a score falling
more than two standard deviations below the mean)
Framework for assessing
to differentiate abnormal delays from normal vari- development
ations in development. Third, the duration, pervas-
iveness and modifiability of symptoms and signs, It is useful to use a framework for collecting and
as well as the extent to which they are associated collating information. Boxes 2, 3 and 4 summarise
with impairments in social role functioning, can be schemes for evaluating different aspects of the devel-
used to judge the significance of any deviations from opment of communication and social skills, as well
the normal path of behavioural development. as patterns of play, interests and activities. Box 5
summarises approaches to cognitive assessment,
and Box 6 discusses the procedure for making a
Obtaining a developmental history differential diagnosis. More detailed accounts of
approaches to taking a developmental history are
Interviewing parents or other informants about a given by Rutter (1985), and descriptions of the psycho-
child’s early developmental history should be metric tests used for assessing development, along
approached with two issues in mind. First, there is with their relative merits, are reported by Sparrow
the need to ensure that the interview is conducted & Davis (2000) and Volkmar & Marans (1999).
in a way that helps the parent/informant to remem- The framework for obtaining a developmental
ber details of the child’s development and the timing history described here focuses on three key phases.
of events as accurately as possible. Not surprisingly, The interviewer asks the parents first for details
perhaps, parents are better at recalling whether a about the child’s early development, then for a
milestone has been reached or behaviour exhibited description of the strengths and weaknesses of the
than they are at recollecting the child’s age when child at age 4–5 years and finally for an account of
this happened. To improve their recall for the timing the child’s current abilities. This scheme clearly
of events, it can be helpful to forewarn parents that needs to be adapted according to the child’s age.
APT (2001), vol. 7, p. 34 Bolton/Bellman
Difficulties can arise in deciding when a child- be a long history of these rituals and routines,
hood interest or hobby is more than just a craze or although the focus of interest may change from time
fashion, as well as in differentiating obsessive– to time. Resistance to changes in the environment
compulsive phenomena from the rituals and routines may be manifest in an insistence that objects or
found in children with pervasive developmental ornaments be placed in specific locations in the
disorders. As a general guide, autistic-like interests house.
and hobbies are unusual in their content and are
pursued intensively, excessively and repetitively, to
the exclusion of other activities. In addition, the Observation and cognitive
interest or activity is often followed in a solitary evaluation
manner, without any desire to share experiences
with others. Similarly, distinctions between obses- As outlined in Box 5, it is important to observe the
sive–compulsive phenomena and autistic-like child in a variety of contexts (e.g. with their family,
rituals and routines are made on the basis of their on their own, in school and at the clinic), as well as
content and the manner in which the behaviours to observe how they manage in situations that vary
are manifest. Thus, isolated contamination fears in the amount of structure provided (e.g. during cog-
with repeated hand-washing, evening-up phenom- nitive and behavioural evaluation, play and mental
ena or complex compulsions involving counting or state assessment). Cognitive assessments by a clin-
touching things in special sequences would not ical psychologist and speech/language therapist
usually typify an autistic-like ritual or routine. More may require several separate appointments. Test
often, the interests and rituals focus on specific objects, results should not be considered in isolation, but
such as lamp-posts, fans, toilets, lights, washing interpreted in the light of all available information.
machines, trains, routes, dates and lists, as well as A variety of psychometric tests have been developed
on collecting and categorising things. Moreover, the to evaluate cognitive functions, and in addition to
interests are pursued willingly and without any the few outlined here there are numerous others
attempt to resist doing them. Frequently, there will available for identifying more specific neuropsycho-
logical deficits. Cognitive testing is usually possible
if undertaken by a skilled psychologist using
ingenuity and patience (Berger, 1994). It is important
Box 4 Assessing the development of interests, to start with items that are within the child’s
activities and play capability, so that he or she does not lose interest
and heart; it is also important to ensure that rewards
Milestones for participating in the tests are provided. Care must
Giving and showing be exercised in selecting tests tailored to the child’s
Symbolism and pretence age and abilities. When children with severe prob-
Parallel play lems or autism are being evaluated, tests that entail
Joint interactive play complex verbal instructions are best avoided.
The results of tests aimed at evaluating specific
Age 4–5 years
cognitive skills, such as speech, language, literacy
Social aspects: interest; playfulness; recip-
and numeracy, must be interpreted in the context of
rocity; enjoyment
the individual’s general level of intelligence. This is
Cognitive level: curiosity; grasp; complexity
because the diagnosis of a specific developmental
(rules; drawing; puzzles; inventive-
disorder is based on demonstrating that the child’s
ness); imagination (spontaneity; pretence;
abilities fall below those expected according to their
creativity)
age and intelligence. The recent editions of the
Content, type and quality: initiation; flexibil-
Wechsler intelligence scales and the accompanying
ity; rituals/routines; odd preoccupations;
tests of language, literacy and numeracy are well
unusual attachments; resistance to change;
suited for this purpose, as they have been specifically
repetitive stereotyped movements; unusual
developed to be used together (Wechsler, 1989, 1991,
sensory interests
1993, 1996a,b, 1997a,b, 1999). Other useful tests (see
Current function Box 5) include the Mullen Scales (Mullen, 1995), the
Adapt schema from age 4–5 years Clinical Evaluation of Language Fundamentals –
Circumscribed interests (timetables, fixtures, Revised (Semel et al, 1980), the Reynell Develop-
results, scores, listings, classification, mental Language Scales (Reynell, 1990), the
categorisation) Symbolic Play Test (Lowe & Costello, 1976), and the
Collecting and hoarding Vineland Adaptive Behaviour Scales (Sparrow &
Cicchetti, 1985). Motor coordination can be assessed
Developmental assessment APT (2001), vol. 7, p. 37
well in some situations (usually the family home), Bailey, A., Le Couteur, A., Gottesman, I., et al (1995) Autism
as a strongly genetic disorder: evidence from a British
but are mute in others (at school or when strangers twin study. Psychological Medicine, 25, 63–77.
visit). Social reciprocity and play are, however, normal. Barton, M. & Volkmar, F. (1998) How commonly are known
Children who have been seriously neglected and medical conditions associated with autism? Journal of
Autism and Developmental Disorders, 28, 273–278.
abused or raised in poor-quality institutional homes Berger, M. (1994) Psychological tests and assessment. In
exhibit abnormalities in their attachments and peer Child and Adolescent Psychiatry: Modern Approaches (eds
relationships. Abused children who develop a reac- M. Rutter, E. Taylor & L. Hersov), 3rd edn, pp. 94–109.
Oxford: Blackwell Scientific.
tive attachment disorder may be hypervigilant and Bishop, D. V. M. (1994) Developmental disorders of speech
wary of people, but also aggressive towards peers. and language. In Child and Adolescent Psychiatry: Modern
They exhibit very contradictory and ambivalent Approaches (3rd edn) (eds M. Rutter, E. Taylor & L. Hersov),
pp. 546–568. Oxford: Blackwell Scientific.
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hibited attachment disorder are rather indiscrimin- control family history study of autism. Journal of Child
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Fombonne, E. (1999) The epidemiology of autism: a review.
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the frequent changes in caregivers that take place in disorders: a review of the literature. Developmental Medicine
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Multiple choice questions
Commentary
M. H. Bellman
Growth and development are at the core of paediatric development and how to measure them. This is fairly
practice and are the fundamental factors that make straightforward with regard to physical character-
medical work with children different from adult istics, but more difficult for mental development.
medicine. All paediatricians must have an under- However, it is a skill that must be familiar to chil-
standing of the basic science of growth and dren’s doctors working in the fields of neurological
Martin H. Bellman is a consultant neurodevelopmental paediatrician at Camden and Islington Community Services and the
Royal Free Hospital, London (Greenland Road Children’s Centre, 4 Greenland Road, London NW1 0AS). His main interest is
assessment and management of long-term developmental disorders of children.