9
Child development and how to assess it
Chapter map
Child development is the gradual acquisition of new skills and behaviours through childhood. Knowledge of development helps you to understand the presentation and impact of illness in children, and will help you to adapt your history and examination for age. In this chapter we describe normal development and a practical approach to assessment.
9.1.2 Milestones are stepping stones
9.4 Limitations of developmental assessment
Healthy development has a wide range of ‘normal’.9.1 Normal development
Development is normally divided into several separate areas; learn these for a systematic approach, but be flexible.
PRACTICE POINT Four areas of development- Posture and movement (gross motor)
- Vision and manipulation (fine motor/adaptive)
- Hearing and speech (language)
- Social and play (personal/social).
9.1.1 Range of normal
The age at which a normal child achieves a particular physical or developmental goal is extremely variable; 50% of children can walk 10 steps unaided at 13 months, but a few can do this at 8 months, and others not until 18 months. It is best to talk to parents of the ‘usual’ age for developing a skill rather than the ‘normal’, since abnormal implies problems. Quite commonly one field of activity appears delayed in a normal child, but it is rare for all four fields of development to be delayed if the child is normal. In the preterm infant, correct age for gestation before assessing development.
Delayed development that is following a normal sequence is likely to be normal unless the delay is severe. Bizarre and unusual patterns of development are more worrying.9.1.2 Milestones are stepping stones
Parents tend to think of certain developmental skills as essential milestones. It is truer to regard them as stepping stones. In general, one cannot reach a particular stepping stone without using the previous ones – and a child does not run until she can walk, or walk until she can stand. However, different people may use different stepping stones, and occasionally miss one out. Most children crawl before they stand, but some shuffle on their bottoms, never crawl, yet stand and walk normally in the end. Bottom shuffling is a typical example of the sort of variation in development that can cause parents unnecessary worry, particularly as bottom shufflers tend to walk later than other children.
Using stepping stones, we may go in sudden bounds rather than at an even rate – children often develop that way, appearing static for a few weeks then suddenly mastering a new skill. If the next stepping stone is a particularly hard one, all the child’s energy may appear to be devoted to just one of the four areas of development, whilst the other three seem static; posture and movement skills may advance rapidly about the age of 1 year as walking is mastered, whilst hearing and speech development appear static.
- When we ‘test’ beyond expected skills – reassure that we do not expect the 9- to 12-month-old child to walk.
- Announce ‘results’ early – if development is normal, say so.
- Handle ‘failure’ carefully – be sure before you diagnose developmental delay.
9.2 Developmental assessment
There are two purposes of developmental assessment:
- Early detection of significant delay so that help (advice, physiotherapy, spectacles, hearing aid) can be provided early.
- To provide reassurance to parents.
There are two parts to developmental assessment:
- History
- Observation
The history is usually reliable and augments the clinical examination. Parents may exaggerate their child’s abilities or misinterpret involuntary movements.
9.2.1 History
- Ask in detail about present skills.
- Cover the four main categories.
- How do these compare with those of older siblings at that age? (This may influence parents’ perceptions.)
- School performance (if at school) – a significant developmental problem is unlikely if the child is coping well in a normal class.
- Past history – especially dates of early milestones.
- Some parents recall milestones well, others not at all. Many have documented them in the parent-held record. If an experienced parent says ‘she was very quick’, it may not be necessary to obtain exact detail of past achievements.
9.2.2 Observation
- Play with the child in the presence of the parent.
- Demonstrate each skill where possible.
- Define the limit of achievement by noting both the skills the child has and those he has not.
You can easily carry out the following simple tests in any surgery or clinic. No special equipment or expertise is needed. They are screening tests which identify children who need more detailed expert assessment. The ages given are the average ages at which the skill is seen.
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