PRINTS

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THE

INTRODUCTORY
COURSE

10. Neurodevelopment
assessment

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 Neurodevelopmental Assessment

Developmental Milestones

Developmental milestones are a set of functional skills or age-specific tasks that most children
perform at a certain age range. They are an essential part of the pediatric neurological
examination, which assesses the function of the basal ganglia, brain stem, and more caudal
structures. Also, they provide a reflection of the maturation of the child’s nervous system. It is
used to assess the development, focusing on discrete behaviors that the clinician can observe.
The clinician compares the patient’s behavior with a uniform sequence within a specific age of
many children. Finally, delay in obtaining developmental milestones and abnormal patterns of
development are important indicators of underlying neurological disease.

Developmental Assessment

Developmental assessment includes an evaluation of physical growth, neurodevelopmental

maturation, and cognitive and psychosocial development.

Developmental Domains

● Gross motor skills, which involve using large muscles to control the head and shoulders
to sit, stand, balance, walk, and run.

● Fine motor skills, which Involves using small muscles to apply the pincer grasp to pick up
an item, turn the pages of a book, stack blocks, and use a crayon to draw or a pencil to
write.

● Cognitive development, which Includes intellectual and adaptive skills. For example,
infants first use reflexes but then develop cognitive abilities. Cognitive development
progresses in the following order:

1. Toddlers learn to match items.

2. Preschoolers develop memory.
3. school-aged children and adolescents develop advanced reasoning abilities.

● Language development, which begins with receptive abilities, progressing to expressive

abilities. A child first recognizes the sound of words, then the meaning of words, and finally
the rules of grammar. Adult articulation abilities are usually achieved by 7-8 years of age.
Factors affecting speech and language gaining in young children include:

1. Child abuse and neglect.

2. Autism spectrum disorder.
3. Traumatic brain injury.

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 4. Cerebral palsy.
5. Fetal drug or alcohol exposure.
6. Hearing impairment.
7. Intellectual ability.
8. Diagnosed language impairment.

● Socio-emotional development, which encompasses many areas of child psychosocial

development, including:
1. Behavior.
2. Temperament (‫)اﻟطﺑﺎع‬.
3. Parent-child interaction.
4. Social interaction with peers and others or school performance.

Key principles of Neurodevelopment

Now, the development of motor control development runs from head to toe. First, the baby
develops head control, then trunk control (sitting), and finally controls the lower extremities
(walking). Also, primitive reflexes (like the Moro, grasp, and Galant) are normally present in the
term infant and diminish over the next 4-6 months of life. On the flip side, the postural reflexes
(like parachute and positive support reflex) emerge at 3-8 months of age. Note that the
persistence of primitive reflexes and lack of development of postural reflexes are the hallmark of
an upper motor neuron abnormality.

Screening Tools

The examiner should know the age when social, motor, land language skills are normally
acquired. There are several screening tools that can be used, including the Denver
Developmental Screening Test II.

Evaluating Child Development

To evaluate the child developmental abilities, you should include the following information:
1. History, which identifies causes and risk factors for developmental delay.
2. Prenatal history.
3. Neonatal history.
4. Medication.
5. Family history.
6. Social history.

Risk factors for developmental delays include prenatal drug or alcohol exposure, prematurity, low
birthweight. hypoxic birth injuries, perinatal hyperbilirubinemia, perinatal infection, head or
neurologic injury, hearing or vision impairment, seizure disorders, inborn metabolic disorder, and
physical or emotional abuse.

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Major Developmental Milestones
Red flags: alarm or warning signs and symptoms that suggest a potentially serious underlying
disease.

0-2 WEEKS

● Gross Motor: Head lag, moves all extremities.

● Fine Motor: Grasps.
● Cognitive: Primitive reflexes present.
● Language: Alert to sound, cry, startles to loud sounds.
● Social: fixes and follows face.

Developmental Red Flags (3 Months)

● Rolling before 3 months.

● Persistent fisting by 3 months.
● Unable to push-up on arms, pushing back with head at 3 months.

4 MONTHS

● Gross motor: No head lag, rolls from prone to supine.

● Fine motor: plays with hands, brings objects to mouth.
● Cognitive: primitive reflexes disappear by age of 4 months.
● Language: babble.
● Social: enjoy social interaction.

Developmental Red Flags (4-6 Months)

● Head lag after 4 months.

● Persistent primitive reflexes after 4 months.
● Failure to reach objects by 5 months.
● No smile by 4-6 months.
● Poor or no head control at 6 months.

Developmental Red Flags (6-12 Months)

● No cooing after 6 months.

● Absent stranger anxiety after 7 months.
● W-sitting at 7 months.
● Rounded back, poor use of arms, stiff legs.
● Cannot bear weight when pulled to stand at 8 months.
● No reciprocal vocalization by 9 months.
● Failure to localize sounds by 10 months.

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Developmental Red Flags (12-18 Months)

● Cannot pull to stand, stiff legs.

● Toe walking.
● Hand dominance before 18 months.
● No imitative play after 18 months.

Developmental Red Flags (18-24 Months)

● No first word (beside “mama” and ”dada”) by 18 months.

● Has > 10-12 episodes of otitis media.
● No two –word sentences by age of 2 years.

Developmental Red Flags (3 Years)

● Does not speak in full sentences.

● Incorrect use of pronouns.
● Cannot independently spoon feed.
● Trips when running.

Developmental Red Flags (4 Years)

● Cannot balance on one foot for 2 seconds.

● Cannot copy a circle or hold a pencil correctly.
● Cannot name two or three colors.
● Aggression.

Developmental Red Flags (5 Years)

● Excessive fears, night terrors.

● Unable to identify colors.
● Incomprehensible speech.

Developmental Red Flags (At any time)

● Parental concerns.
● Slow or excessive physical growth.
● Changes in gait.
● Cease of walking.
● Persistent sleep disturbance.
● Difficulty with schoolwork.
● Any loss of milestones achieved.

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Primitive Reflexes

Primitive reflexes are movements that are mediated by the brain stem and induced by specific
sensory stimuli. Examination of primitive reflexes provides an assessment of the brainstem and
basal ganglia. Many of these reflexes are present at birth, symmetrical and disappear at 4-6
months, due to the maturation of descending inhibitory cerebral influences. After primitive reflexes
disappear, postural reflexes develop. Asymmetry or persistence of these reflexes may indicate a
focal brain or peripheral nerve lesion.

● Sucking Reflex

Appears from 26 to 28 gestational weeks.

Disappears from 3 to 4 months.
Induced by placing a gloved finger in the mouth.

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 ● Rooting Reflex

Appears from 30 to 34 gestational weeks.

Disappears from 3 to 4 months.
Induced by touching the corner of the mouth.
Response: The head should turn towards the stimulus and the
mouth should open.

● Palmar Reflex

Appears from 24 to 30 gestational weeks.

Disappears from 3 to 6 months.
Induced by stimulating the palmar surface of the hand with a
finger.
Response: Baby should grasp the finger.

● Plantar Reflex

Appears from 24 to 30 gestational weeks.

Disappears from 8 to 10 months.
Induced by stimulating the sole of the foot with a finger.
Response: the toes should curl around the finger.

● Asymmetric Tonic Neck Reflex

Appears from 28 to 30 gestational weeks.

Disappears from 3 to 4 months.
Baby in supine position with head turned to one side.
Response: Extension of the arm and leg on the side towards which the head
is turned. Flexion of the opposite arm and leg.

● Moro Reflex (Startle reflex)

Appears from 28 to 32 gestational weeks.

Disappears from 3 to 6 months.
Induced by sudden loss of support to the head and the shoulder by
falling onto the bed.
Response: Extension and abduction of the arms, followed by flexion
with closing of the fist.

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 ● Stepping Reflex

Appears from 32 to 36 gestational weeks.

Disappears from 6 to 8 months.
Induced by holding the baby upright and allowing the feet to
touch a flat surface.
Response: Stepping movement can be observed.

● Placing Reflex

Appears from 32 to 36 gestational weeks.

Disappears from 6 to 8 months.
Induced by gently scraping the dorsum of the foot alongside
the edge of a table.
Response: Flexion of the leg as if stepping onto it.

● Truncal Incurvation (Galant) Reflex

Appears from 28 to 32 gestational weeks.

Disappears from 2 to 4 months.
Induced by firmly applying pressure with thumb on the trunk, parallel to the
spine.
Response: flexion of the pelvis towards the side of the stimulus.

● Babinski Reflex

Appears between birth to 12-18 months gestational weeks

(should get a positive response).
Disappears after the child starts walking.
Induced by stimulating the sole of the floor from heel to toe.
Response: toes extend and fan out (positive response).

● Parachute Reflex

Appears from 8 to 12 months of age

Persists through life.
Induced by holding the infant in ventral suspension and tilting him abruptly
towards the floor.
Response: extending the arms, hands and fingers on both sides in a
protective movement.

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Head circumference (HC)

Head circumference measures a child’s head at the largest occipitofrontal

circumference. Measurement of HC is a routine part of growth assessment in
children 3 years and younger. It reflects neurological functions and the
developmental milestones achievement. To take head circumference, follow
these steps:

1. Use a paper or metal measuring tape.

2. Place the tape around the head, just above the eyebrows and the pinna, and around the
occipital prominence. (Line A in diagram above).
3. Plot the measurement on the appropriate growth chart.

Normal measurement should fall between the 5th and 95th percentile and should be consistent
with the child’s previous measurements.

Abnormalities of Head Size

● Microcephaly and macrocephaly:

If HC is 2 standard deviations below or above the mean, respectively. Measurements plotted over
time show an accelerating rate of growth (hydrocephalus) or decelerating rate (brain injury or
degenerative neurological disorder).

● Craniosynostosis:
It is premature closure of one or more cranial sutures, resulting in an unusual shape of the head.
Primary is caused by abnormalities of the mesenchymal matrix. Secondary is associated with
another disease, like hematological diseases and hypothyroidism.

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Fontanelles

Fontanelles are the spaces between the bones of an infant’s skull where
sutures meet. They are covered by a tough membrane that protects the
underlying soft tissues and brain. Fontanelles allow the fetal head to change
shape while passing through the birth canal.

1. Anterior fontanelle (AF): The junction where the 2 frontal and 2 parietal bones meet.
Slightly depressed and pulsatile when a calm infant is sitting upright. A tense or building
fontanelle may indicate increased intracranial pressure (ICP) but may also be seen in an
agitated or febrile infant. It Closes by 9-18 months.

2. Posterior fontanelle (PF): The junction of the 2 parietal bones and the occipital bone. It
closes by 2 months.

General Physical Examination

1. Somatic growth, which measures height and weight.

2. Abdomen might show organomegaly which indicates storage disease.
3. Neck and spine should be carefully examined for midline defects (myelomeningocele,
cutaneous dimples, sinus tracts, hair tufts, and subcutaneous lipomas). Nervous system
abnormalities may result in spine abnormalities (kyphosis or scoliosis).
4. Dysmorphic features, like midface anomalies, which are associated with underlying brain
malformation. Abnormal shape, location or condition of the face, eyes, nostrils, philtrum,
lips or ears are found in many genetic syndromes.
5. Eye examination searches for epicanthic folds, coloboma, conjunctival telangiectasias and
cataracts. Using a direct ophthalmoscope, the optic disc and macula can be assessed for
abnormalities like papilledema or a cherry red spot.
6. Skin examination. The brain and skin share the same embryonic origin (ectoderm). So,
abnormalities of the skin, hair, teeth and nails are associated with congenital brain
disorders (neurocutaneous disorders). Some of these disorders include
Neurofibromatosis with its characteristics Café-au-lait and Tuberous sclerosis can present
with Ash-leaf spots.

Café-au-lait (flat, light brown macula) Ash-leaf spots (hypopigmented macules)

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Tone Assessment

Tone assessment describes the dynamic resistance of muscles to passive stretch. Lower motor
and cerebellar lesion lead to decreased tone (hypotonia). Upper motor lesion present with
increased tone (spasticity). In extrapyramidal disease, an increased resistance is present
throughout passive movements of joints (rigidity).

● Abnormal postures:

Scissoring: baby’s knees are pressed together with his legs crossed (spasticity).

Frog-like position: when supine, the baby’s hips are abducted, and knees are flexed (hypotonia).

Head lag, which normally disappears by 3- months.

Vertical suspension. Slipping through is a sign of hypotonia

Ventral suspension. Head should be maintained above the body with the back flat. C shaped baby
describes head flops down with a rounded back is a sign of hypotonia.

Written by Hamza Al-yassin

Scissoring Frog-like Head Lag

Vertical Suspension Ventral Suspension

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