Developmental Surveillance

Patty Huang

INTRODUCTION

Primary care physicians play a vital role in identifying children at risk for developmental disabilities and in referring them for appropriate early intervention services. Developmental surveillance involves using information obtained from the history, physical examination, and developmental screening tests to assess development on an ongoing basis. This ongoing monitoring of development is critical for two reasons. First, new circumstances (e.g., medical illness, family or environmental disruption, or injuries) may interfere with development. Second, as children develop, they gain new categories of skills that are difficult to assess at earlier stages (e.g., one cannot usually detect isolated language delays in children younger than 18 to 24 months, the point at which children begin to develop a good repertoire of language skills). In 2006, the American Academy of Pediatrics published guidelines recommending developmental surveillance at every well-child visit, as well as additional periodic developmental screening using a standardized test at the 9-, 18-, and 30-month-old visits.

HISTORY

The following information should be elicited:

Parental concerns regarding the child’s development. In most cases, parental concerns regarding the child’s language development, articulation, fine motor skills, or global development are likely to be associated with true developmental delays. Parental concerns about behavior or personal-social skills are associated with developmental delays in some cases.
Risk factors for developmental disabilities (Table 3-1).
Attainment of developmental milestones (Table 3-2).

PHYSICAL EXAMINATION

Head Circumference

Brain growth is the principal stimulus for increasing head circumference. Therefore, a small head circumference may indicate abnormalities in brain growth that place a child at risk for developmental disabilities. A large head circumference may be a sign of hydrocephalus, a genetic syndrome, or a metabolic storage disease (see Chapter 51, “Macrocephaly”). However, before assuming pathology in a child, one should measure the head sizes of parents as a small or large head circumference may be a family trait.

TABLE 3-1 Risk Factors for Developmental Disabilities

Prenatal

Maternal illness, infection, or malnutrition

Maternal exposure to toxins, teratogens, alcohol, illicit drugs, anticonvulsants, antineoplastics, or anticoagulants

Decreased fetal movements

Intrauterine growth retardation

Family history of deafness, blindness, or mental retardation

Chromosomal abnormalities

Perinatal

Asphyxia: Apgar scores of 0-3 at 5 min

Prematurity, low birth weight

Abnormal presentation

Postnatal

Meningitis, encephalitis

Seizure disorder

Hyperbilirubinemia: bilirubin >25 mg/dL in full-term infant

Severe chronic illness

Central nervous system trauma

Child abuse and neglect

TABLE 3-2 Developmental Milestones from Birth to 5 Years of Age

Age (Months)	Adaptive/Fine Motor	Language	Gross Motor	Personal-Social
1	Grasp reflex (hands fisted)	Facial response to sounds	Lifts head in prone position	Stares at face
2	Follows object with eyes past midline	Coos (vowel sounds)	Lifts head in prone position to 45°	Smiles in response to others
4	Hands open Brings objects to mouth	Laughs and squeals Turns toward voice	Sits: head steady Rolls to supine	Smiles spontaneously
6	Palmar grasp of objects	Babbles (consonant sounds)	Sits independently Stands, hands held	Reaches for toys Recognizes strangers
9	Pincer grasp	Says “mama,” “dada” nonspecifically; comprehends- “no”	Pulls to stand Feeds self	Waves bye-bye
12	Helps turn pages of book 2-4 words Follows command with gesture	Stands independently Walks, one hand held	Points to indicate wants
15	Scribbles	4-6 words Follows command without gesture	Walks independently	Drinks from cup Imitates activities
18	Turns pages of book	10-20 words Points to four body parts	Walks up steps Feeds self with spoon
24	Solves singlepiece puzzles Combines 2-3 words Uses “I” and “you”	Jumps Kicks ball	Removes coat Verbalizes wants
30	Imitates horizontal and vertical lines	Names all body parts	Rides tricycle using pedals	Pulls up pants Washes, dries hands
36	Copies circle Draws person with three parts	Gives full name, age, and sex Names two colors	Throws ball overhand Walks up stairs (alternating feet)	Toilet trained Puts on shirt, knows front from back
42	Copies cross	Understands “cold,” “tired,” and “hungry”	Stands on one foot for 2-3 sec	Engages in associative play
48	Counts four objects Identifies some numbers and letters	Understands prepositions (under, on, behind, in front of) Asks “how” and “why”	Hops on one foot Dresses with	little assistance Shoes on correct feet
54	Copies square Draws person with six parts	Understands opposites	Broad-jumps 24 in.	Bosses and criticizes Shows off
60	Prints first name Counts 10 objects	Asks meanings of words	Skips (alternating feet)	Ties shoes