Delayed Development
Definition
Development means the change of function and maturity of organs including the person him/herself. In general, normal development can be divided into 4 aspects;
1. Physical development: The ability of stability and movement using gross motor and eye-hand coordination (fine motor-adaptive).
2. Cognitive development: the ability of learning self-surrounding relation, thinking, ration, and ability of problem solving. Language and fine motor are involved in cognitive development.
3. Emotional development: the ability of appropriateness of emotional expression and control including the self esteem development.
4. Social development: the ability of relationship development, self help in daily life (personal-social), spiritual development meaning knowing the value of life, morals, responsibility, and the ability to choose the way of life to support society.
Delayed development means the ability to do something later than the same age, for example, a 20-month child still cannot walk while the normal child has developed walking skill since 9-15 months old.
Delayed development may be found for one aspect or many aspects (global developmental delay) and delayed development may result in delay in other aspects.
Causes of delayed development
1. Genetic disease Children will have delayed development at birth or it may be observed shortly after birth. The Down syndrome is the most common chromosome disorder which causes delayed development (intellectual disability). It has been noticed that many genetic diseases have specific clinical features chromosome study frequently yields normal result, i.e. Fragile X syndrome, Prader-Willi syndrome and Velocardiofacial syndrome. In Thailand, now there is a confirmation laboratory diagnosis. Velocardiofacial syndrome is a syndrome that causes cardiac disorder, cleft palate, and delayed development especially language skill. The special technique, i.e. fluorescent in situ hybridization (FISH) can be diagnosed by chromosome aberration of pair 22. Therefore, children with delayed development coming to the doctor and have been found mild disability at birth, especially the child with family history of delayed development should be examined by the genetic specialist.
2. Nervous system disease most of the children with delay development often have neurological signs and the most common are epilepsy and abnormal muscle tone. In the case the child comes with delay development and epilepsy, the history taking about the age of beginning and physical examination in detail should be performed in order to differential diagnosis. The case of the static or progressive pathology or developmental regression should be considered refer to neurologist.
3. Infection: Intrauterine infection is the most common type of infection. The child usually presents with low birth weight, microcephaly, splenomegaly, hepatomegaly, hearing impairment, and cataract. Besides serum examination to determine infection evidences of toxoplasma, rubella, cytomegalovirus, syphilis and histoplasma, the examination to determine human immunodeficiency virus infection should be performed. Post natal infections such as encephalitis, meningitis, are also occasionally found.
4. Metabolism disorder: Hypothyroidism is still health problem of Thailand. In the case of congenital occur and not be cured by 2-3 months old the child will have permanently subnormal intelligence even the thyroid hormones is given afterward. Other diseases in this group include abnormal metabolism of amino acid which is low incidence and it is limited by laboratory diagnosis causes some children have not been diagnosed. In present, diagnosis of inborn error of metabolism is advanced. There are idenfiable disorders of cellular component such as mitochondria, peroxisome, etc. Even the treatment limitation some disease turns the good result such as biotinidase deficiency. The child may have delay development, rash, alopaecia convulsion and acidosis. Some children come with either convulsion or hypotonia. Biotin may improve the child to normal. Therefore, when the child from consanguinous marriage is found or there is a family history of disorders,regression of development or diagnosed to be cerebral palsy with unknown cause, should diagnose when there is mild illness, vomitting failure to thrive, convulsion, delay development. The differential diagnosis should include inborn error of metabolism. Even many disorders have poor prognosis, the parents should receive counselling about appropriate family planning.
5. Perinatal complications the most common condition related to the delay development is prematurity, low birth weight, and birth asphyxia. Those factors are not the direct cause of the disease, for example, low birth is the sign of intrauterine infection.
6.Chemical substance lead is the most impact to the child and most studied. Partly, people have more chance to receive this substance from daily activities. The effect that is most studied is that when the children have high prolonged accumulated blood lead level, they will have subnormal intelligence. Another chemical substance that delays the fetal development is alcohol and is believed to be teratogen. The baby born will have the fetal-alcohol syndrome, physically small, small eye, upper lip and philtrum hypoplasia. The baby will also have congenital heart disease such as atrial septal defect and will also have a behavioral and developmental problems. Whether the child will have this syndrome depend on the maternal factors, i.e. genetics, duration and quantity of alcohol intake. There are many chemical substances that will affect the childs development. Therefore, the history of living place and parents profession will be crucial for the diagnosis of the cause.
7. Inappropriate upbringing and malnutrition this factor even affects development it will not cause the severe symptoms therefore if the delay development is severe, other causes should be investigated.
Symptoms of delay development
The delays can be found in many characteristics, i.e. gross motor, fine motor and cognitive, expressive and receptive language, self - help and personal social . In addition, the neuromuscular disorders, for example, the primitive reflexes which still exist even at the age that it should be presented, hypotonia or hypertonia, hearing or visual impairment, may also be found.
Guideline for the diagnosis of delay development
1. History taking
1.1 Diseases known to associate with mental retardation e.g. epilepsy
1.2 Family illnesses such as delayed development, learning problem, neurological diseases, etc.
1.3 Risk of genetic disorders such as presence of delayed development in family members, consanguinity, premature death in siblings.
1.4 Pregnancy including the antenatal care history, illnesses during pregnancy, and toxic substances such as alcohol, cigarette, including other addictive drugs that mother received during pregnancy.
1.5 Birth histories such as gestational age, mode of delivery, interventions indicators, birth weight, Apgar scores, birth difficulty, perinatal illnesses and complications.
1.6 The time that parents noticed their childs delay development and whether such delay development is regression type, for example, the child used to be able to sit and then cannot sit.
1.7 The past developments; developments that are easily seen by parents, for example, the history of gross motor development, rolling, sitting, crawling, walking, and speaking.
1.8 Language development, for example, babling, sound imitation, following the command, speak the first meaningful word, speaking two words consecutively.
1.9 Playing in accordance with age, self help
1.10 Behavioral problems which are commonly found among the children with delayed development.
1.11 Problems concerning eating, sleeping, elimination which are significant to the child and caregiver. The history of associated problems such as hearing and visual impairment.
1.12 Other histories useful to assess the environment suitable for children for example, parents marital status, educational level of parents or caring of the caregivers, family s socioeconomic status, public services such as early intervention, physical therapy and , and registration as a special child, etc.
After performing the history taking the following shall be told
- The delayed development is static or progressive encephalopathy
- Does the child really have delay development? How? In what level?
- Any indicators to be the risk of genetic disorders.
- Cause of delayed development
- What type of intervention/rehabilitation the child being received?
2. Physical examination
2.1 General examination on every system and growth that might indicate the cause of delay development, for example, dysmorphology examination for both major dysmorphic and minor dysmorphic which can be found in the children with genetic abnormality.
2.2 Hepatosplenomegaly which indicates some inborn errors of metabolism
2.3 Skin such as cutaneous markers, i.e. café-au-lait spots which indicates tuberous sclerosis, the cause of delay development.
2.4 Nervous systems in detail and always measure the head circumference to detect mildly delayed development.
2.5 Observe about child abuse; special child is considered risky group.
2.6 Visual and hearing systems, the multiple handicaps commonly found.
3. Laboratory examination
3.1 At present there is no standard on how to perform the chromosomal examination. In some countries the chromosomal examination will be applied to all patients because this practice can locate the cause of some diseases such as fragile X syndrome which is the genetic inheritance and the prevention measure or disease control is feasible. In the developing country, there are a lot of limitations that the chromosomal examination can be performed on individual basis. The indications that the chromosomal examination is to be performed are the fragile X syndrome, the history taking may be from the male relatives of mother, learning and developmental problems, developmental delay within the family without clear cause,1 major dysmorphic or 2 minor dysmorphic is found on the physical examination. In addition, the first child or the next child is desire is one of the examination indicators. The medical doctor, however, is responsible for giving information the examination decision is to be made by the parents.
3.2 Additional examination may be useful for caring and finding the disorders commonly found together, i.e. thyroid function test, seeing and hearing examination.
3.3 Extraordinary examinations such as ultrasound, CT scan, and MRI usually help in cause and pathology diagnosis but may not support treatment thus parental talking is required before the examination.
Caring guide
1. To seek for the cause of delay development by bringing the child to podiatrist and child development doctor. Some children with the delay development, however, cannot tell the cause while some can be told with considerable causes, especially those with the genetic in heritance. This will be beneficial for the repetition prevention.
2. To search or the abnormalities in common: some children with development delay have sensational impairments such as seeing, hearing, eating, malnutrition, etc. The lack of some certain nutrients such as iron will result in concentration and attention of learning.
3. Direct cure to the cause of disease, as an example, to provide the thyroid hormones. Although the major cause of the delay development cannot be completely cured, to know the cause will help preventing the later side effect or repetition on the next child.
4. Development enhancement: principally, the development enhancement is to do what to do to the normal children to the delay children in daily life basis. However some steps may need to divided into sub-activities, and if found from the assessment that the babysitter does not have sufficient skill on child practice, to receive training in the medical service will be recommended such as development enhancement clinic or community service. The heart of development stimulation is to follow the instructions given during the training regularly.
5. Provide consultation to the family about further knowledge sources they can gain such as books, websites, or associations about special children.
Caring of children with development disorder
1. Developmental screening
2. Developmental assessment
3. Diagnosis
4. Treatment and early stimulation
5. Follow up and evaluation
Recommendations
1. When found that the child is a little development delay with no risk factors (for example premature birth, low birth weight, physical problem, living in a deductive environment, etc) and the baby sitter seems no worry or refuse the diagnosis, the recommendation for preliminary development shall be given. At the later time the examination shall also be performed.
2. If the child has the problem with muscular and nervous system, he/she shall be taken care of by the physical therapist to prevent the stunted and tensed muscles. If the child has a speaking problem, he/she shall also be taken care by the speech therapist. If the behavior and learning problem occurs the occupational therapist and the psychiatrist shall play their role.
Development Assessment
The development assessment is crucial in that the sooner we can tell which child has development problem the better the child will benefit from the diagnosis and treatment and the development stimulation given. In general, the development assessment can be divided into:
1. Informal assessment test: The assessment will be conducted based on the parental inquiry. From studies in the past it was found that the reliability of babysitter inquiry is related to the level of development closely to the use of development screening test in the case the babysitter has close relationship with the child. Therefore, this is a way that enables us to know the continuous development. Sometimes in practical there are many factors that we cannot assess entirely, for example, emotion background of the child that makes him/her an adaptive difficulty and this limits him/her expression to be limited. However, be careful about the less or more than the fact of the information given. The podiatrist shall additionally observe the childs behavior in the room as well in order to consider whether the child is to be sent for further examination by the specialist or not.
2. Assessment used in the medical practice using development test currently used
2.1 Denver II test: the version update in 1992 which will be used for the children of 1 month to 6 years old. The assessment covers 4 aspects:
- Personal social: the skill for self help for routine activities and interpersonal relation.
- Fine motor: the synchronization of hand and eye muscles in solving problems.
- Language: the ability to hear, understand and use language.
- Gross motor: stability and movement.
2.2 The Goodenough-Harris Drawing Test: for children 3-15 years old
2.3 Gesell Drawing Test for Visual motor perception
2.4 Capute Scales (CAT/CLAMS) the development screening test that composes of using the fine motor in problem solving (CAT : Cognitive Adaptive Test) and understanding test of language use (CLAMS : Clinical Linguistic and Auditory Milestone Scales). It is for 1-36 months child.
2.5 Bayley Scales of infant Development test: detailed development assessment composing a lot of sub items which is for 1 42 months old child. It is divided into 2 aspects, i.e. movement and stability (motor scale) and intelligence and problem solving (mental scale).
2.6 Child development assessment by the development enhancement manual for children 0-5 years old, the Rajanukul Hospital can be used to screen, assess, and enhance the development.
References
Nittaya Kotchapakdee. Child Development. In: Wundee Warayuth, Praputh Siripun, Surang Jiamjunya, editor. Pediatrics Textbook (reviewed edition, volume 3). Bangkok: Holistic Publishing, 1998:1-6
2. Aditsuda Feungfung. Delayed Development. In: Srisupalak Singkalawanich, Chaiyasit Saengthaweesin, Somjit Sri-udomkhajorn, Somjai Karnchanapongkul, Pediatric disease commonly found. Bangkok: Krungthep Wechasarn Press, 2006: 34-47.
