Abnormal Motor Development

1. Abnormal Motor Development Dr Valerie Orr Consultant in Paediatric Neurodisability RHSC, Yorkhill

2. Objectives • To be able to identify and make appropriate referrals for children with abnormal motor development • To develop knowledge of current paediatric management of children with motor disorders

3. Does early detection matter? • Parents value early diagnosis • Improved outcome • Improved quality of life for child and family • Access to educational and social services ‘Early detection is of little value unless parents subsequently experience a well-organised service with a clear referral pathway to definitive diagnosis and management’ Ref: Health for all Children 4th Edition (Hall 4)

4. How do we identify children with abnormal development? • Follow-up of ‘high risk’ infants • Screening • Listening to parents • Opportunistic recognition Ref. Hall 4

5. Gross motor milestones – median ages Ref. Illustrated Textbook of Paediatrics

6. Gross motor milestones – median agesRef. Illustrated Textbook of Paediatrics

7. Early locomotor patternsRef. Illustrated Textbook of Paediatrics

8. Gross motor milestones – limit agesRef. Illustrated Textbook of Paediatrics • Head control 4 months • Sits unsupported 9 months • Stands independently 12 months • Walks independently 18 months *Remember to adjust for prematurity until 2yrs

9. Features that may suggest underlying motor disorder • Delayed motor milestones • Asymmetrical movement patterns e.g. early hand preference • Abnormalities of muscle tone i.e. hypotonia (‘floppy’) or hypertonia (‘stiff’) • Other difficulties e.g. feeding difficulties unexplained irritability respiratory problems

10. Worrying signs / Red flags • Not reaching & grasping objects by 6 months • Hand preference before 1 year • Hypertonicity • e.g. closed hand posture, extensor posturing, scissoring • Hypotonia • Loss of previously acquired motor skills at any age

11. Floppy infant – assessment History • Pregnancy and birth • Feeding • Development Examination • Weight & OFC ?thriving • Facial features ?dysmorphism • Movement - floppy & strong vs floppy & weak Referral • Paediatrician (Urgent if feeding difficulties or poor weight gain)

12. Floppy infant – aetiology Includes • Prematurity, illness & drugs • Evolving cerebral palsy • Genetic syndromes e.g. Downs, Prader-Willi syndrome • Neuromuscular problems (rare!) e.g. congenital myotonic dystrophy, spinal muscular atrophy

13. Clinical scenario A mother brings her 18mth old son to the surgery with a minor illness. She mentions that she is concerned that he is not yet walking. • What particular points would you look for in the history and examination? • What action might you take?

14. Delayed walking (>18mths) • Normal variants • Associated with bottom shuffling • Cerebral palsy or minor neurological problems <10% • May occur in context of global developmental delay • Consider CK in boys

15. Toe walking Possible causes • Idiopathic toe walking • Muscle spasticity e.g. cerebral palsy, spinal cord lesion, hereditary spastic paraparesis • Muscle disease e.g. Duchenne muscular dystrophy, Charcot Marie Tooth (HMSN)

16. Duchenne muscular dystrophy Check CK in boys: • not walking by 18 months • 4-6 months behind in general development at 2 years • awkward or clumsy gait under 4 years • unable to run or jump by 4 years • painful hips or legs under 4 years Ref. Mohamed K et al. Delayed diagnosis of Duchenne muscular dystrophy. Eur J Pediatr Neurol 2000

17. Developmental Coordination Disorder • ‘Dyspraxia’, ‘clumsiness’ • Male : Female 3 : 1 • Impaired motor control & planning • difficulties with dressing and toileting • messy feeding • poor handwriting and drawing skills • poor ball skills • Can become socially isolated • Poor self esteem and schooling difficulties

18. Developmental Coordination Disorder:DSM-IV diagnostic criteria • Marked impairment of the development of motor co-ordination • Impairment significantly interferes with academic achievement and activities of daily living • Problem not due to a recognised medical condition • Not a pervasive developmental delay NHS QIS publication: ‘I still can’t tie my shoelaces...’ Quick Reference Guide to Identification and Diagnosis of DCD

19. Developmental Coordination Disorder: Management • Examine and ensure that there is no underlying medical problem or refer to paediatrician for further assessment • Referral to Occupational Therapist • Group interventions to promote motor skills and self-esteem e.g. Rainbow Gym • Classroom support

20. Management of motor disorders • Multidisciplinary team approach • Holistic, child /family centred care • Often need to access support from education services, social services and voluntary agencies WHO ICF Framework

21. Cerebral Palsy ‘A disorder of movement and posture due to defect or lesion of the immature brain’ Incidence ~2 per 1000 live births • Antenatal ~70% e.g. prematurity, fetal & neonatal stroke, brain malformations, maternal infection • Perinatal 10-15% e.g. neonatal encephalopathy • Postneonatal events ~15% e.g. trauma, meningoencephalitis, stroke

23. Cerebral Palsy: Interventions Aims • Maximise potential • Prevention of secondary dysfunction • Promotion of improved function and participation in society Examples of spasticity treatments • Orthotics • Botulinum toxin • Oral medications e.g. Baclofen • Intrathecal baclofen • Orthopaedic surgery

24. Transition • Children with motor disorders become adults with ongoing and often complex health needs • GP becomes key health professional for most young people with cerebral palsy

25. Summary • ‘Limit ages’ can guide need for referral • Neurological examination should identify worrying signs • Be alert to motor disorders that might present later in childhood • Listen and respond to parents concerns!

26. Useful sources of information and support • From Birth to Five Years. Mary Sheridan. • Hall D. Health for All Children. 4th Edition • Developmental delay: Identification and management. Aust Fam Phys 2005, Vol 34; 9:739-742 • NICE guideline 2012 Spasticity in children and young people with non-progressive brain disorders • www.scope.org.uk • Muscular Dystrophy Campaign www.muscular-dystrophy.org

27. Developmental Coordination Disorder: useful references • NHS Quality Improvement Scotland publication ‘I still can’t tie my shoelaces...’ ‘Quick Reference Guide to Identification and Diagnosis of DCD’ • Why every office needs a tennis ball: a new approach to assessing the clumsy child Cheryl Missiuna et al. CMAJ August 29, 2006; 175 (5)