Developmental delay

&
Behavioral Disorders

Dr Mahendra Singh Parmar

 Normal development
Development refers to the maturation of functional
and acquisition of various skills for optimal
functioning of an individual.

Rules of development
Development is a continuous process,
starting in utero
It depends on the functional maturation of
the CNS.
The Development sequence is the same.
Development occurs in Cephalocaudal
and proximal to distal direction.
Primitive re exes must be lost for new
re exes(Palmar grasp must be lost before
voluntary grasp re ex comes).
During development progression,
disorganized activity is replaced by
speci c actions.

Development Milestones
Gross motor
Fine motor
Language
Social and cognitive
Vision and hearing
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 Abnormalities of Development (3 'D'S)
1. Delay
2. Dissociation
3. Deviancy
1. Developmental Delay
when a child's development is
signi cantly behind of what is expected

If developmental delay involves 2 or more

domains -
Global Developmental Delay
2. Developmental Dissociation
Substantial difference in the rate of
development of milestones in 2 or more
domains
Example: Isolated speech delay is a
developmental dissociation since only
language is hampered while all other
domains are normal.
3. Developmental Deviancy
Developmental milestones occurring out
of sequence.
Example: If Crawling appears before
sitting.
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Developmental Red Flags
• The upper time limit by which the milestones
should usually be attained.
ABNORMALITIES OF DEVELOPMENT

Gross motor Upper limit Usual time

Sitting with 9 months 6 months
support
Standing with 12 months 9 months
support
Walking with 15 months 12 months
support
Fine motor Upper limit Usual time
Pincer grasp 12 months 9 months
months
Scribbling 24 months 15 months
Social Upper limit Usual time
Social Smile 6 months 2-3 months
Waving bye-bye 12 months 9 months
Language Upper limit Usual time
Babbling 12 months 6 months
Single words 15-16 months 1 year
• If these milestones are not attained by this time,
then there is probably some underlying
abnormality of development.
Important causes of Development delay ("CDGP
PIC")
1. C- Chromosomal abnormalities (Trisomy
21, 13, 18)
2. D -Developmental brain abnormalities
(lissencephaly- brain appears smooth due
to less gyri & sulci, myelomeningocele)
3. G - Genetic syndromes (Fragile X
Syndrome, Rett syndrome, Prader Willi
syndrome Nooram syndrome)
4. P - Perinatal factors: Asphyxia, HIE
(Hypoxic Ischemic Encephalopathy)
5. P- Postnatal factors and acquired: (CNS
Trauma, infections,Hypothyroidism,
malnutrition)
6. I - Inborn errors of Metabolism: Maple
Syrup Urine Disease, organic Acidemia,
Tay sachs disease, GM Gangliosidosis,
Mucopolysaccharidosis
7. C - Congenital infections: TORCH group
(Toxoplasmosis, Rubella, CMV, Herpes)
How to Remember?
• CDGP PIC
Developmental Assessment

Developmental quotient [D.Q.]

D.Q= Developmental age/Chronological
age x 100
E.g. A child of 6 years of age has attained
milestones of that of a 3 year old only.
Calculate D.Q
Solution: DQ= 3yr/буг x 100 = 50

Screening Tests for Developmental Assessments

1. P-Phatak's Baroda Screening Tests
2. A - Ages & stages questionaire
3. R - Revised DDST (Denver Developmental
Screening Test)
4. T-Trivandrum development screening
chart
How to Remember?
• PART
 De nitive Tests for Intellectual & Developmental
Assessment
Name of test Age group
Vineland adaptive behavior Birth to 89 years
scale II
Bayley scale for infant 1 month-3.5 years
development ||
Stanford Binet Intelligence 2 years-85 years
scale
Wechsler Intelligence Scale for 6 years-17 years
Children
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Intelligence Quotient (IQ)
• IQ = Mental age/ Chronological age x 100
Degree IQ leval
Mild ID 51 - 70
Moderate ID 36 - 50
Severe ID 21-35
Profound ID 0 - 20

Moron 50-70
Imbecile 30-50
Idiot <30
The term mental disability is no longer
used now.
It has been replaced by term intellectual
disability.
Intellectual Disability
• Signi cant impairment in intellectual functioning,
social and adaptive skills
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Behavioural
disorders
 Nocturnal Enuresis
De nition
• Involuntary urination at night beyond 5 years of
age irrespective of a boy or a girl
M>F
Positive family history in 50% cases
1 parent = 44% risk
If both Parent = 77% risk
Types
1; Primary NE :-
-Child who has never attained
night time continence
2; Secondary NE : -
-child who had attained night time
continence previously
It can be d/t any acquired causes
-Polyuria d/t anyreasonlikeDiabetes
-Urinary tract infection

Management

1st line T/t :-

Lifestyle changes
Motivational therapy

2nd line T/t :-

Bed and alarm technique


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3rd line therapy-
Pharmacotherapy
Imipramine
Desmopressin(oral)
Oxybutynin(anticholinergic)
PICA
Persistent eating of non-food, non-
nutritive substances like paint, cement,
chalk, or paper for at least 1 month

mc - children with intellectual disability.

and autistic spectrum disorder

commonly a/w nutritional anemia, worm

infestation

Treatment: Behavioural therapy

Thumb Sucking
It is a self-soothing behaviour most
commonly seen during infancy

25% of children have it at 2 years of age

If thumb sucking persists at > 5 years of

age, it may be a/w.
Paronychia (Infection around nail bed) .
Anterior open bite or Dental malocclusion

Treatment: Behavioural therapy

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Bruxism (Teeth Grinding)
It is seen in 5-30% of children

It begins in rst 5 years of life

It is a/w increased day time anxiety (can

be due to parental separation or going to
school)

Persistent bruxism may be a/w temporo-

mandibular joint related problems/pain
and dental malocclusion

Treatment: Behavioural therapy

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Breath Holding Spells

Case scenario: A child 14 month old was

crying incessantly and suddenly the child
became pale and lifeless. On stimulation
the child regain consciousness and child
was anemic
Breath holding spells - Close differential
diagnosis of seizures in young children
It occurs due to immaturity of the
autonomic nervous system
most commonly seen b/w 6-18 months of
age

Triggers:-
-Ange
-Frustration
-Incessant crying
It usually begins with a Cry Syncope

Tonic posturing/ Atonic & lifeless

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Types
Pallid spell:
-It happens because of re ex vagal
bradycardia and asystole
- Baby will become pale for few seconds
to minutes
Cyanotic spell:
-It occurs due to prolonged expiration,
apnea, intrapulmonary shunting of blood
Treatment: Reassurance
Ensure to rule out seizures or any other
medical condition
Case scenarios and clinical history will be
typical of breath holding spells
Reassure the parents and treat any
underlying iron de ciency anemia
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Tics and Stereotypies

Tics: Sudden, non-rhythmic, rapid motor

movements or vocalisation e.g., Tourette
syndrome

Stereotypies: Stereotypic, rhythmic,

repetitive movements or pattern of speech
with lack of variation over time
 Autistic Spectrum Disorder (ASD)
De nition
Persistent impairment in reciprocal social
interaction and presence of restricted,
repetitive pattern of behaviour or interest
Child will not smile or hold an eye contact
with other people
Some children will be very intellectual or
bright while some of others will have
intellectual disability
Risk factors
Closure spacing of pregnancies
Extreme prematurity (<26 weeks of
gestation)
Any family member with learning or
psychological disorder
Antenatal exposure to thalidomide or
valproate
Antenatal exposure to rubella
Measles immunization is no longer
considered as risk factor
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 Lot of screen time i.e., long hours on
phone, less interaction with parents or
friends
Screening test
• M-CHAT (Modi ed Checklist of Autism for
toddlers)
Treatment
Cognitive behavioural therapy
Treatment of associated comorbidities
For hyperactivity - Atomoxetine or
Methylphenidate
More and more social interaction with
child is required
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 Attention De cit Hyperactivity
Disorder (ADHD)
De nition
Persistent hyperactivity/inattention or
impulsivity that interferes with day to day
functioning/development of child
Onset:
-Before 12 years of age that has been
present for at least 6 months in at least 2
different settings (school/home/play area)
without any underlying secondary known
cause
Epidemiology
MC neurobehavioral disorder of childhood
60-80% of children with ADHD will
continue to have symptoms till
adolescence
60% of adolescents with ADHD will have
symptoms till adulthood
2% of adults have ADHD
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Risk factors
Maternal smoking, alcohol, lead exposure,
mercury exposure
Genetic - DAT-1 & DRD-4 gene
CNS malformation
CNS trauma
Psychologic family stress
Epilepsy
Neurocutaneous conditions like Tuberous
sclerosis,Neuro bromatosis
Management
Behavioral therapy
Drugs: Methylphenidate, Amphetamines,
Atomoxetine
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Selective Mutism

It is a failure of a child to speak in speci c

social situations, while being able to
speak normally in other situations
E.g., Child speaking normally at home with
everyone but at school he does not speak
at all
It is a manifestation of underlying anxiety
disorder or excessive shyness or
dependency on parents
There can be history of anxiety symptoms
in one or both parents
Treatment: Behavioural therapy to reduce
underlying anxiety
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