Developmental Surveillance and the Developmental/Behavioral History

If concerns about development or behavior are presenting complaints, they should be pursued in detail. When no developmental difficulties have been identified, a surveillance approach is appropriate. Simply incorporating questions about development and behavior in the general history is one method of first-level surveillance. Such an approach might be used, for example, when taking the complete history of a child presenting with a problem unrelated to development. General questions for this purpose are suggested in the remainder of this section.

Alternatively, you may choose to use a structured tool such as the Parents’ Evaluation of Developmental Status (PEDS) or the Rourke Baby Record, which has a section on development. Each tool provides a structured system of eliciting parent observations and concerns and can increase detection of delayed development in younger children. If you obtain information indicating possible concern, development screening can then be done.

Unless you are using such a structured tool, you should routinely include questions about development and behavior in your functional inquiry (review of systems). I emphasize this point because students and physicians who have not made such questions an automatic part of the history often forget to inquire about these areas. (Like many physicians, I organize the functional inquiry in a head-to-toe fashion and have found it helpful to visualize these areas of investigation as floating around the head.)

Do not forget the importance of the general or open-ended question! In fact, my favorite way to find out how parents perceive their child’s behavior is to say, “Tell me about your child’s behavior.” Alternatively, you might ask, “Do you or does anyone else have any concerns about your child’s behavior?”

For a child who is attending day care or school, supplement these questions by asking specifically about the youngster’s behavior in those settings. If parents express concern about the child’s behavior but have difficulty being specific, try suggesting that they describe everyday situations, such as mealtime, bedtime, or shopping expeditions. Also ask about the approach to discipline in the family.

Surveillance questions about development should be very general at first. For example, you might ask, “Do you have concerns about how your child is learning and developing?” Although you should always ask how a school-aged child is doing in school, I would caution you against simply asking, “How is he/she doing in school?” My experience has been that the answer is often “Fine,” even when the child is having difficulties. It is better to ask specifically what grade the child is in and whether he or she has repeated any grades or has required any additional help with reading or other schoolwork.

Other sections of the functional inquiry obviously are very relevant to the area of development, particularly those that touch on vision, hearing, and neurologic symptoms. Information learned elsewhere in the history sometimes suggests the need to look closely at development and behavior, such as evidence of abnormal growth patterns, chronic illness, nutritional deficiency, or medication use. For the child with asthma, for example, you should ask how many days the child has missed school and whether the parents have observed any behavioral side effects of the therapies used. Learning more about the child’s behavior pattern improves your management of chronic illnesses. Asking questions about behavior also provides an opportunity to discuss how the child and family are coping.

It is traditional to ask about developmental milestones in the medical history. I do not find this approach terribly useful except in children in whom a developmental problem is suspected, in which case questions about developmental milestones provide helpful information about the pattern of development. In most other cases, I suggest focusing on the current rather than the past level of development. For example, I would go back to ask at what age a child walked independently or talked only if I had uncovered concerns about development. Remember that precise recall of many of these milestones is difficult for parents, particularly several years after the fact or in families with multiple children. Recollection is fairly reliable for the age at which a child walked independently, but for other milestones, it generally is not reliable.

Most parents’ reports about their child’s current developmental skills and their ability to identify developmental problems are quite accurate, although there are exceptions. Discrepancies between reports and observations of performance may arise if the informant is not the child’s regular caretaker or is not a good observer. Examples of those who may not be good sources for observations about the child’s performance include foster parents who have not had a child with them for very long, ill, depressed, or substance-abusing parents, or parents who have had little recent contact with the child. Some parents overinterpret their child’s language comprehension or overreport developmental skills as a coping mechanism, although this phenomenon is not common.

If you are not confident about a parent’s general sense of the child’s learning, have a higher level of concern, or simply wish to be more thorough, you should either proceed to using a formal screening tool, such as the Ages and Stages Questionnaires (ASQ), or ask some additional questions based on your knowledge of what is typical for that age group. The ASQ uses the parental report to examine multiple domains of development and can be completed independently by the parent or done as an interview.

I strongly recommend using a surveillance tool but recognize that there also are times when you will need to ask about development in a more informal way. For preschool children, ask one or two surveillance questions in each key area of development: gross motor, fine motor–adaptive, personal-social, and receptive and expressive language. The milestones indicated in Tables 6–1 and 6–2 provide some suggestions. If you are pressed for time, focus on high-yield areas: for preschoolers, ask about language function and personal-social skills, and for school-aged children, ask about reading and math skills. Remember, you generally will have an opportunity to observe the child’s gross motor and fine motor skills during the physical examination.

Patterns of Developmental Abnormality

It is important to distinguish the child who has always shown developmental delay from one who began normally and has subsequently slowed or regressed. The latter pattern may indicate the need for assessment for conditions such as metabolic disorders, neurodegenerative diseases, autistic spectrum disorder, or seizures. In such cases, a review of past acquisition of skills and earlier milestones is helpful. I encourage families to consult the child’s baby book for accurate information.

Family History

Developmental and behavioral problems can run in families. If you suspect a developmental problem in the child, ask specifically about the early development and educational level of other members of the immediate family rather than simply asking, “Did anyone in the family have learning problems?” If parents or other family members left school early, find out why. Ask whether those individuals had to repeat any grades and about their current reading and mathematical abilities. This information is important not only for understanding the child’s risk factors but also for future management.

When children have developmental problems, it is important to ask specifically about consanguinity.

Social History

To understand a child’s risk factors for developmental problems, you need to know as much as you can about the child’s environment. I like to find out how a child spends his or her days, including the details of child care arrangements, the amount of time spent watching television, the toys he or she plays with, and how much time the child spends sleeping or in a crib, playpen, or stroller. I also ask about any family involvement with social agencies, parent support groups, and intervention resources, such as speech/language pathology, occupational therapy, physiotherapy, psychology, and early intervention programs.

Behavior Problems

If behavioral problems are the presenting complaints or if concerns about behavior are revealed during the functional inquiry, you will need to obtain more details. It helps to record specific examples of difficult behaviors. Find out how the child functions in different settings—at home, at school, with other caretakers, and with one parent or the other.

Behavior problems take many forms. Parents may be concerned about a specific issue, such as sleeping behavior, feeding behavior, or aggression. Alternatively, they may be worried about their child’s general tendency toward noncompliance, hyperactivity, or poor social adjustment.

In children whose development is delayed, especially those with language delay, it is particularly important to ask about behavioral patterns suggestive of an autistic spectrum disorder (described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM IV] in the section on Pervasive Developmental Disorders). Controversy exists about the prevalence of autistic spectrum disorders. Most authorities believe that the spectrum manifests in at least 1 in every 250 children.

Children with an autistic behavior pattern show impairment in the following three key areas:

Such patterns often are associated with delays in one or more areas of development. Recognize that in these children, development may be uneven, and there may be areas of strength that make the initial picture confusing.

A condition with even higher prevalence is ADHD, estimated to occur in 2% to 5% of children. (Some authors suggest a prevalence as high as 10%!) The full diagnostic criteria for this disorder, as with the pervasive developmental disorders, can be found in the DSM IV. The characteristics generally can be divided into three areas: behaviors suggestive of inattention, hyperactivity, and impulsivity.

Problems may manifest in the academic environment with poor persistence at tasks, easy distractibility, and disorganization. They may manifest in home and play situations as well. The behaviors can include poor social skills, difficulty waiting (e.g., interrupting conversations), and a high level of physical activity. No specific diagnostic tests exist for ADHD, and the criteria for diagnosis are based on consensus or convention.

If a child’s behavior pattern suggests the possible diagnosis of ADHD, I recommend that you use a checklist based on the DSM IV or one of the standardized questionnaires designed to help look at concerns about these behaviors.

It is crucial that information be obtained directly from teachers about any child who has behavior problems in school, including those suggestive of ADHD. Parental observations of behaviors of inattention or hyperactivity have been shown to be quite sensitive to detection of such problems but are not sufficiently specific to be used in isolation.

You need to ask as well about problems suggesting conditions that are often comorbid with ADHD. Oppositional-defiant or conduct disorders, learning problems, depression, substance abuse, poor self-esteem, enuresis, encopresis, and tic disorders are all more common in children with ADHD. Like other developmental and behavioral problems, ADHD often runs in families, and I emphasize again the importance of taking a complete family history for ADHD and its comorbidities in relatives.

Developmental Screening and Examination

The point of screening is to see if there is an indication of developmental difference that warrants further assessment. If you clearly know that a child’s development is not within the normal range, you do not need to screen. You may wish to screen in other areas, however. For example, if you hear that a 2-year-old is not walking yet, there is no point in doing a screening assessment of gross motor function if the goal is to determine whether he or she is delayed in that domain. However, you might use a screening tool such as the ASQ with that child to help determine whether concerns exist in other domains. An instrument such as the ASQ can provide a general sense of whether a child is performing within the expected age range. Such screening assessments are designed to indicate whether a child needs further developmental assessment with more detailed methods. A screening tool such as the ASQ should never be used to produce a developmental quotient, a developmental level, or a diagnosis; thus, you cannot administer the ASQ and then state that a child “shows language skills at a 12-month level according to the ASQ.”

Another option would be to do an informal examination of development. Such an examination can help you look for signs of developmental delay and/or to better describe current function. I have provided tables and activity suggestions that can assist with this process and help familiarize you with typical developmental achievements that you might ask about in your interview. (I find it is essential to match what I learn from the parents’ history with what I observe on direct assessment; doing so helps me understand the child’s development better.)

Direct Developmental Examination

Strategies to enhance the child’s participation

You need the child’s full and active cooperation to assess his or her developmental abilities. Assessment can be particularly difficult when a child is inordinately shy, hyperactive, inattentive, anxious, fearful, oppositional, or if the parents are unusually intrusive during the procedure.

Shy and Frightened Children

You know you are in trouble when you walk into the room, introduce yourself, and the youngster immediately dives for his mother and buries his face in her lap. When this happens, you may have the urge to take refuge yourself and refuse to participate—but all is not lost. Most shy children can be won over with a gentle, nonthreatening approach. First, remove any items that the child may consider threatening, including your white coat. Medical equipment should not be hanging around your neck or protruding from your pockets (Fig. 6–1). For children in the hospital, a change of environment may help; a parent counseling room or conference room often offers a less threatening environment.

FIGURE 6–1 The wrong way of approaching a child for developmental assessment. Avoid holding medical equipment, wearing a white coat, and towering over the youngster.

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