NORMAL DEVELOPMENT

DEVELOPMENT IS…
A process of evolution:
from immature to mature
from no control to full control
** over self
** over environment
A continuous process from conception to
maturity
Direction is cephalo-caudal
Sequence is the same but rate varies
General Differentiation Specialization
HOLISTIC DEVELOPMENT

A perfect balance of development at various

domains, viz.:
 Gross motor
 Fine motor
 Personal-Social
 Adaptive
 Emotional
 Cognitive
 Language
The different Aspects:

PHYSICAL: Ability to move & control over body

PERSONAL SOCIAL: Development of self
identity, personality & relationship
ADAPTIVE: React & adjust to new experiences
LANGUAGE: Communicate with others:
verbally & non-verbally
SEQUENCE OF DEVELOPMENT

GROSS MOTOR: More prominent in the 1st

year of life

FINE MOTOR :Prominent from later part of

1st year till well into 3rd year

SOCIAL, COGNITIVE & SPEECH gain

momentum in the 2nd year and onwards
Look at him GROW!
supine

2 mnths
4 wks

4 mnths
7 mnths
prone

4 wks 2 mnths

4 mnths 7 mnths
Pull to sit

4 wks 2 mnths

4 mnths 9 mnths
sitting

4 wks 4 mnths

7 mnths 12 mnths
Sitting &playing
standing

9 mnths 12 mnths
FINE MOVEMENTS
WHY GROWTH?
To achieve….

 Motor skills, gross then fine

 Gains control over self
 Interest evoked in surroundings
 Explores & analyses the surroundings
 Relates oneself to the surroundings
 Tries to gain control over surroundings
 MILESTONES:
At 4 wks

 Baby lies in flexed posture, but supple

 Head lag +
 In prone, legs extended & momentary lift of
head
 In prone, head sustained in plane of body
 Watches human face
 Begins to smile
At 8 weeks (2 mo)

 Follows object 180*

 Smiles
 Listens to voice
At 12 weeks (3mo)

 Lying supine, reaches & waves at toys

 Prone: arms extended, head above body
plane
 Early head control, bobbing
 Sitting: back rounded
 Listens to music
 Vocalization
 16 weeks (4mo)

 Supine: symmetric posture, hands in midline

 Reaches for, grasps and brings toy to mouth
 Sits with truncal support
 Head steady
 Laughs
28 weeks (6-7mo)
 Rolls over: prone supine, supineprone
 Pivots in prone posture
 Starts to crawl
 On pulling, pushes with feet & bounces
 Hand to hand transfer of object
 Raking movement at pellet
 Prefers mother
 Separation anxiety (sense of impermanence)
 Emotional response
 Enjoys mirror
 Babbles
40 weeks (9mo)

 Sits up alone, without support

 Back straight, pivots to reach for object
 Pulls to stand, cruising
 Pokes at pellet
 Assisted pincer grasp
 Plays hide & seek
 Responds to name
 Dada, mama
1 year

 Walks with hand held

 Unassisted pincer grasp
 Releases object on request
 Plays ball
 Helps dress
 Few words with meaning
15 mnths

 Walks alone
 Indicates desires
 Inserts pellet into bottle
 Line with crayon
 Tower of 3
 Hugs parents
 Jargon
18 mnths

 Runs stiffly
 Dumps pellet from bottle
 Imitates scribbling
 Feeds self
 Seeks help
 Clinging vs. resistance
 Names pictures & body parts, parts of doll
2 years

 Runs well
 Climbs furniture
 Opens door
 EXPLORES
 Parallel play
 Listens to story
 Helps undress
 3 word sentence
 SOCIAL SMILE : at 2 months
 HEAD HOLDING : at 4 months
 SITS ALONE: at 8 months
 STANDS ALONE : at 12 months
 SEES, HEARS & LISTENS
Screening Tool: TDSC
DEVELOPMENTAL
CHALLENGES
What may go wrong?

 Delay in acquiring motor skills

 Tone abnormalities
 Spastic?
 Floppy?
 Regression of milestones
 Abnormal head size
 Dysmorphism
Contd:

 Delayed speech
 Vision/ hearing impaired
 Lack of age appropriate interest
 Poor interaction
 Behavioural problems
 School failure : learning problems
An insult to the developing
brain may lead to
 Global Developmental delay
 Mental retardation
 Cerebral Palsy
 Autism
 Learning disabilities
 Behavioural problems
 Hearing & Speech defects
 Visual defects
ALL ARE LIFE LONG ACCOMPANIMENTS & need
EARLY INTERVENTION
INTELLECTUAL DISABILITY
MENTAL RETARDATION
DEFINITION

Mental retardation means significantly sub-

average intellectual functioning, with
deficits in adaptive behavior, that manifests
during the developmental period of life (upto
18 yrs), adversely affecting a child's
educational performance.
CRITERIA
 An IQ score of ≈70 or below(2SD below
mean).
 Concurrent deficits in adaptive functioning in
at least two of the following areas:
communication, self-care, home living,
social/interpersonal skills, use of community
resources, functional academic skills etc.
 The onset is before age 18 years
 GRADING OF SEVERITY
ACCORDING TO IQ:

 Mild Mental Retardation: 50–55 to ≈70

 Moderate Mental Retardation: 35–40 to 50–55

 Severe Mental Retardation: 20–25 to 35–40

 Profound Mental Retardation: below 20–25

 ADULT ATTAINMENTS
Degree of MR IQ range Adult attainments
Mild 50-70 Literacy+
Self help++
Good speech++
Semi skilled work+
Moderate 35-50 Literacy+/-
Self help+
Domestic speech+
Un skilled work (with/without
supervision)

Severe 20-35 Assisted Self help+

Minimum speech+
Assisted household work
Profound <20 Self help+/-
Domestic speech+/-
 AGE-WISE SUSPICION
 Newborn : Dysmorphic syndromes, microcephaly
 Early infancy (2–4 mo) :
 Failure to interact with the environment,
 vision and hearing impairments
 Later infancy (6–18 mo) : Gross motor delay
 Toddlers (2–3 yr) : Language delays
 Preschool (3–5 yr) :
 Language difficulties
 Behavior difficulties
 Delays in fine motor skills: cutting, coloring, drawing
 School age (>5 yr)
 Academic underachievement Behavior difficulties
 
NEURO PATHOLOGY

 Malformation syndromes
 Disorders of cell migration, proliferation,
differentiation & arborization
 Post natal destructive changes: infection,
trauma, metabolic insult
The aetiology & epidemiology varies
distinctly in

 mild MR (IQ<50%) and

 severe MR (IQ>50%)
Mild MR

Commonly associated with environmental

influences such as
 poor socio-economic conditions,
 deprivation,
 lack of stimulation,
 poor maternal education,
 poor nutrition
SPECIFIC CAUSE

 Identifiable in < 50% cases which include:

 genetic syndromes with multiple minor
congenital anomalies
 fetal deprivation (Iron, folate def, maternal
malnutrition)
 prematurity, perinatal insults
 intrauterine exposure to drugs of abuse/
radiation.
 PREVENTION
These are largely preventable.
 Prevent early pregnancy, consanguinity, multiple
pregnancy etc
 Better health & education in mothers
 Proper antenatal, natal & neonatal care
 Increasing the public's awareness of the adverse effects
of alcohol and other drugs of abuse on the fetus
 Improve maternal & infant nutrition
 Neonatal screening
 Early intervention for cognitive development
 SEVERE MR
 Biologic cause can be identified in >75% of
cases.
 Causes include
 chromosomal (Down syndrome) and other genetic
syndromes (fragile X syndrome),
 abnormalities of brain development (lissencephaly)
 Congenital & perinatal infections & their sequelae.
 Endocrine causes: Hypothyroidism
 inborn errors of metabolism
 neurodegenerative disorders
(mucopolysaccharidoses)
 PREVENTABLE

 Infections : Intranatal, neonatal & later in

childhood
 HIE : preventable by better perinatal care
 IEM like galactossaemia, PKU (SCREENING)
 Trauma & head Injury
 Poisons & toxins
 MR in Hypothyroidism can be prevented, if
detected & treated early.
PRE-SYMPTOMATIC DETECTION

EARLY Detection is the hallmark of management.

 Prenatal screening for congenital malformations &
genetic disorders (Downs)
 Neonatal screening for hypothyroidism, PKUetc.
Tandem mass spectrometry is very useful.
 Developmental assessment: DDST, DASII, BSID
 Intelligence tests: VSMS, Binet-Kamat, MISIC
 Regular re-evaluation
AUTISM
What is Autism?
 Autism is a neuro-developmental disorder of
unknown etiology, with a strong genetic basis
 It is characterized by a behavioral phenotype
that includes qualitative impairment in :
 Language development
 Communication skills
 social interactions and reciprocity
 imagination and play.
PREVALENCE

 Current prevalence of ASD, as reported from

the US in 2012 is 1/68 in 8-year old children

 Indian statistics ?? Incidence is on the rise

AETIOLOGY: still unknown
 The aetiology is multi factorial, with a variety of
genetic and environmental factors playing a
role.
 At least 1 autism linked abnormality has been
found in almost every gene, though changes
noted in chromosomes X, 2,3,7,15, 17 & 22 are
most specific. Maternally derived 15q
duplications are common.
 Male predominance also suggests an X
chromosome involvement.
PRESENTATION

 Parents may report that their babies are

different during the first months of life
 Delayed speech may be reported during the
2nd year
 Regression in the 2nd year in 25-30% cases.
 May present at school age for poor peer
interaction/ hyperactivity/ school failure.
 SOCIAL SKILL DEFECTS

 Content being alone

 Poor eye contact
 Joint attention deficit : does not enjoy sharing
an object, event or emotion
 Inappropriate peer relationships
 Difficulty understanding the perspective of
others.
 ‘mindblindedness’
COMMUNICATION DEFICITS

 Speech delay
 Lack of desire to communicate
 Lack of non-verbal communication
 Scripted and stereotyped Speech.
 Echolalia
 Pop-up words:
 Use of giant words: phrases uttered as single
words
PLAY SKILLS

 Lack of pretend play

 Persistence of sensory-motor and ritualistic
play
 Repetitive play with lack of creativity &
imagination (eg. Spinning wheels of cars)
 BEHAVIOURAL PATTERN

 Peculiar mannerisms : Repetitive & stereotyped

movements like rocking, head rolling, flapping hands
• Unusual attachment to objects
• Compulsive behaviour: rigidly follows certain rules
like stacking, arranging in lines
• Obsessive about sameness: resistant to change
• Ritualistic behaviour:
• Restricted behavior is limited in focus, interest, or
activity, such as preoccupation with a single
television program, toy, or game
DIAGNOSIS

 Basically CLINICAL
 Only presence of MR, dysmorphism, focal
neurological features and positive family
history should prompt aetiological
investigations
EARLY INTERVENTION
WHAT IS EARLY INTERVENTION?

 Early Intervention programs help meet the

developmental needs of children (0-5 yrs)
with or at risk of developmental delay.

 Early Intervention can help young children

acquire the skills they need to grow into
happy and healthy members of the
community by building upon the natural
learning occurring in the first few years
THE SCIENCE BEHIND IT

Early Intervention is based on the theory of

Neuroplasticity:

In order to reconnect, the neurons need to be

stimulated through activity.
 WHO NEEDS E.I?

 All children upto 5 yrs of age with ANY

developmental delay

 All newborns at risk

EARLY INTERVENTION

 EARLY DIAGNOSIS
 EARLY STIMULATION
 WHO PROVIDES?

A specialised team comprising of:

Physiotherapist
Occupatioanl therapist
Speech language Therapist
Developmental Psychilogist
DEVELOPMENTAL PAEDIATRICIAN
WHAT IS DONE?
EI in NICU:BASIC PRINCIPLES

 Regular handling by mother: breast feeding

and KMC
 ‘Nesting’ posture
 Gentle tactile stimulation; stroking, oro-
motor stimulation etc
 Light auditory stimulation : soft music
 No glaring lights: dim lights at night
 No extra handling or pricks
Services

Multisensory stimulation
for early motor, visual,
auditory, speech, cognitive
& development of
early behavioral skills.