Developmental and behavioural problems in primary care 0
Developmental and behavioural problems in primary care: 0 -5 years Max Davie 7 th July 2009
Objectives l Developmental and behavioural concerns, mainly 0 -5 l Know when to worry (and when to reassure) l Know what to do about worry (who to involve) l Know what to advise in the meantime l No rarities!
Outline l 0 -1: Stand up! ¡ l 1 -2: Speak up! ¡ l Behaviour, sleep and eating 3 -4: Calm down! ¡ l Early communication 2 -3: Play nicely! ¡ l Gross motor development Attention, emotion 4 -5 Get ready for school! ¡ Clumsy, odd children
0 -1: Stand up! Case study l Baby born at term, no comps l Breastfeeding ‘OK’ l 6 week check ¡ Head lag- briefly keeps up ¡ Suspended prone- brief straightening only ¡ Brief ankle clonus bilaterally ¡ Hands fisted ¡ Moro intact, symmetrical l Diagnosis?
‘Floppy baby syndrome’ l If not sure, look for risk factors l Examination clues ¡ Dysmorphism ¡ Posture, l No-one movements at rest minds getting a referral for this
What can the doll do? l 4 months l 6 months l 9 months l 12 months l 15 months l 18 months l 2 years
Different ways up the mountain l Crawlers (83%) l Shufflers (9%) l Rollers (1%) l Creepers (1%)
Worry markers- gross motor l No rolling prone-supine by 7 months l No rolling supine-prone by 9 months l No unsupported sitting by 10 months l No independent steps by 18 months l No running by 2 years l No jumping by 3 years
‘A very grabby little person’ l Primitive gives way to voluntary l Proximal- distal progression l Sequence rigid, timings flexible l Pronation before supination l Action before inhibition l Variation is required
Reach and grasp l 4 months ¡ Open-hand reaching ¡ Corralling, swiping, ulnar-palmar grasp l 6 months ¡ Accurate reach ¡ Radial-palmar grasp, raking a raisin l 10 months ¡ Hand-shaping ¡ Digital grasp of cube, pincer of raisin
Introducing the 5 minute development assessment l 0 -3 years l Equipment ¡A box of raisins ¡ Some 1” bricks (primary colours, 6 or so) ¡ Some markers and paper ¡ A stethoscope
5 minute DA- 1 year
1 -2 Speak up!: Early communication l Do ¡ 4 an impression of…. . month old ¡ 8 month old ¡ 12 month old ¡ 18 month old ¡ 2 year old ¡ 3 year old
The linking pitfall l Oh dear l All gone l Moo gone l Upsy daisy l Tessy doot
‘Why isn’t he talking? ’ l Myths l Hearing l Autism l GDD l SLI
Worrying signs l 6/12: l 1 yr : No pointing, no words, no showing l 18 l 2 l 3 No cooing/ response mo: <5 words years: No linking, no instructions years: Not understood by strangers, no body parts known
5 minute DA- 2 years (nearly)
2 -3: Play nicely! l Behaviour ¡ Tantrums ¡ Violence ¡ Lack l Sleep l Eating of co-operation
Behaviour- taking a history l Get examples- specific difficult scenarios ¡ Mealtimes ¡ Leaving for school ¡ Shops l What happens before, during, after ¡ What l Ask do parents do? for exceptions ¡ Why different?
Webster-Stratton’s Pyramid l Arrange l The in order of importance incredible years l Services locally
Role plays (you love them, you do) l ‘He’s l ‘He got no respect’ won’t sleep in his bed’ l ‘She won’t eat anything’
5 minute DA- 3 year old
3 -4: Calm down! l Attention, l Fears concentration and imagination
Is it ADHD, doctor? l What is ADHD? ¡ Just bad parenting? l Expectations of abilities ¡ Rest of development l Attention deficit or Deficit of attention? l Other factors ¡ Specific learning difficulties ¡ Sleep ¡ Inconsistent parenting
Assessing ADHD l Hyperactivity l Impulsivity l Inattention l Questions to ask l The QB test
Referral and management l Diagnosis CAN be made in primary care l First line for mild/ moderate- parenting group/ school intervention l Refer CAMHS for 2 nd line interventions
Fears and imagination l The emergence of magic l Emotions as behaviour l Imaginary friends l Lies and misdemeanours l Fears- concrete to imaginary l Night terrors vs nightmares
4 -5: Get ready for school! l Later motor problems ¡ Gait ¡ Co-ordination l Social & motor planning communication problems l Self-concept and mood
Problems with walking l Normal gait l Asymmetry l Toe-walking l Persistence l Frequent of toddler pattern falls
The clumsy child- DCD l Common, significant problem l Difficulties with planning and execution ¡ Poor handwriting ¡ ‘Behavioural’ ¡ Frequent issues falls
Sensory issues l Difficulty in integrating sensory input with cognitive and motor activity l Leads to behavioural and communication problems l ALL sensory modalities ¡ Proprioception ¡ Taste l Out-of-sync child
DCD/ sensory - what to do l Assess l Led expectations (handout) by OT l Comm paeds initially l Questionnaire-based l Co-morbidity referral
Why go to medics? l l l l l Neurological disorders initially diagnosed as "DCD/dyspraxia" Peripheral neuromuscular conditions Becker muscular dystrophy myotonic dystrophy hereditary motor and sensory neuropathy (HMSN) types Ia and II myotonia congenita (autosomal recessive) congenital myasthenia Central nervous system conditions cerebral palsy brain tumour (slow growing in the posterior fossa) panthotenate kinase-associated neurodegeneration (Hallervorden–Spatz disease) perisylvian (opercular) syndrome benign familial chorea epilepsy Mixed peripheral and central nervous system conditions Friedreich’s ataxia Pelizaeus–Merzbacher disease Miscellaneous Ehlers–Danlos syndrome GM 1 gangliosidosis (juvenile onset)
Autistic spectrum disorders l Triad of impairments ¡ Social interaction ¡ Language ¡ Rigidity and communication of thought and behaviour l Dimensional l Still not categorical under-reported: at least 1% of children
Social interaction l Eye contact l Facial expression l Social response/ overtures l Shared enjoyment l Think of silent movies
Communication l Speech delay l Echolalia l Stereotyped/ formal language l Conversation l Reporting l Lack of gesture
Rigidity of thought and behaviour l Excessive interest l Mannerisms l Rituals l Sensory interests
Diagnosis of ASD l 3 elements: report, interview, observation l Diagnostic jargon ¡ Full triad+ speech delay = Autism ¡ Full triad and normal speech= Asperger’s ¡ Social interaction + other = ? Atypical autism l All children with these three have an ASD l Other terms exist (for now)
“Kids in the mix” Mix of disorders l Synergistic effect on functioning l Associated with relative poverty l Complex! l
Self-image and self-esteem l Definition l Gender/ of self- categories sexual identity l Anger ¡ Overt ¡ Concealed l Moral development
Postscript: How to be the GP of a child with “complex” disability l Acute problems ¡ Note interactions e. g. gut and head ¡ Negotiate plan l Long-term ¡ Checklist issues in handout l ‘Non-medical’ ¡ Benefits ¡ Wider family issues
Anything else?
- Slides: 42