Developmental and behavioural problems in primary care: 0-5 years

1. Developmental and behavioural problems in primary care:0-5 years Max Davie 7th July 2009

2. Objectives • Developmental and behavioural concerns, mainly 0-5 • Know when to worry (and when to reassure) • Know what to do about worry (who to involve) • Know what to advise in the meantime • No rarities!

3. Outline • 0-1: Stand up! • Gross motor development • 1-2: Speak up! • Early communication • 2-3: Play nicely! • Behaviour, sleep and eating • 3-4: Calm down! • Attention, emotion • 4-5 Get ready for school! • Clumsy, odd children

4. 0-1: Stand up! Case study • Baby born at term, no comps • Breastfeeding ‘OK’ • 6 week check • Head lag- briefly keeps up • Suspended prone- brief straightening only • Brief ankle clonus bilaterally • Hands fisted • Moro intact, symmetrical • Diagnosis?

5. ‘Floppy baby syndrome’ • If not sure, look for risk factors • Examination clues • Dysmorphism • Posture, movements at rest • No-one minds getting a referral for this

6. What can the doll do? • 4 months • 6 months • 9 months • 12 months • 15 months • 18 months • 2 years

7. Different ways up the mountain • Crawlers (83%) • Shufflers (9%) • Rollers (1%) • Creepers (1%)

8. Worry markers- gross motor • No rolling prone-supine by 7 months • No rolling supine-prone by 9 months • No unsupported sitting by 10 months • No independent steps by 18 months • No running by 2 years • No jumping by 3 years

9. ‘A very grabby little person’ • Primitive gives way to voluntary • Proximal- distal progression • Sequence rigid, timings flexible • Pronation before supination • Action before inhibition • Variation is required

10. Reach and grasp • 4 months • Open-hand reaching • Corralling, swiping, ulnar-palmar grasp • 6 months • Accurate reach • Radial-palmar grasp, raking a raisin • 10 months • Hand-shaping • Digital grasp of cube, pincer of raisin

11. Introducing the 5 minute development assessment • 0-3 years • Equipment • A box of raisins • Some 1” bricks (primary colours, 6 or so) • Some markers and paper • A stethoscope

12. 5 minute DA- 1 year

13. 1-2 Speak up!: Early communication • Do an impression of….. • 4 month old • 8 month old • 12 month old • 18 month old • 2 year old • 3 year old

14. The linking pitfall • Oh dear • All gone • Moo gone • Upsy daisy • Tessy doot

15. ‘Why isn’t he talking?’ • Myths • Hearing • Autism • GDD • SLI

16. Worrying signs • 6/12: No cooing/ response • 1 yr : No pointing, no words, no showing • 18 mo: <5 words • 2 years: No linking, no instructions • 3 years: Not understood by strangers, no body parts known

17. 5 minute DA- 2 years (nearly)

18. 2-3: Play nicely! • Behaviour • Tantrums • Violence • Lack of co-operation • Sleep • Eating

19. Behaviour- taking a history • Get examples- specific difficult scenarios • Mealtimes • Leaving for school • Shops • What happens before, during, after • What do parents do? • Ask for exceptions • Why different?

20. Webster-Stratton’s Pyramid • Arrange in order of importance • The incredible years • Services locally

21. Role plays (you love them, you do) • ‘He’s got no respect’ • ‘He won’t sleep in his bed’ • ‘She won’t eat anything’

22. 5 minute DA- 3 year old

23. 3-4: Calm down! • Attention, concentration • Fears and imagination

24. Is it ADHD, doctor? • What is ADHD? • Just bad parenting? • Expectations of abilities • Rest of development • Attention deficit or Deficit of attention? • Other factors • Specific learning difficulties • Sleep • Inconsistent parenting

25. Assessing ADHD • Hyperactivity • Impulsivity • Inattention • Questions to ask • The QB test

26. Referral and management • Diagnosis CAN be made in primary care • First line for mild/ moderate- parenting group/ school intervention • Refer CAMHS for 2nd line interventions

27. Fears and imagination • The emergence of magic • Emotions as behaviour • Imaginary friends • Lies and misdemeanours • Fears- concrete to imaginary • Night terrors vs nightmares

28. 4-5: Get ready for school! • Later motor problems • Gait • Co-ordination & motor planning • Social communication problems • Self-concept and mood

29. Problems with walking • Normal gait • Asymmetry • Toe-walking • Persistence of toddler pattern • Frequent falls

30. The clumsy child- DCD • Common, significant problem • Difficulties with planning and execution • Poor handwriting • ‘Behavioural’ issues • Frequent falls

31. Sensory issues • Difficulty in integrating sensory input with cognitive and motor activity • Leads to behavioural and communication problems • ALL sensory modalities • Proprioception • Taste • Out-of-sync child

32. DCD/ sensory - what to do • Assess expectations (handout) • Led by OT • Comm paeds initially • Questionnaire-based referral • Co-morbidity

33. Why go to medics? • Neurological disorders initially diagnosed as "DCD/dyspraxia" • Peripheral neuromuscular conditions • Becker muscular dystrophy • myotonic dystrophyhereditary motor and sensory neuropathy (HMSN) types Ia and IImyotonia congenita (autosomal recessive)congenital myasthenia • Central nervous system conditions • cerebral palsy brain tumour (slow growing in the posterior fossa)panthotenate kinase-associated neurodegeneration (Hallervorden–Spatz disease)perisylvian (opercular) syndromebenign familial choreaepilepsy • Mixed peripheral and central nervous system conditions • Friedreich’s ataxiaPelizaeus–Merzbacher disease • Miscellaneous • Ehlers–Danlos syndromeGM1 gangliosidosis (juvenile onset)

34. Autistic spectrum disorders • Triad of impairments • Social interaction • Language and communication • Rigidity of thought and behaviour • Dimensional not categorical • Still under-reported: at least 1% of children

35. Social interaction • Eye contact • Facial expression • Social response/ overtures • Shared enjoyment • Think of silent movies

36. Communication • Speech delay • Echolalia • Stereotyped/ formal language • Conversation • Reporting • Lack of gesture

37. Rigidity of thought and behaviour • Excessive interest • Mannerisms • Rituals • Sensory interests

38. Diagnosis of ASD • 3 elements: report, interview, observation • Diagnostic jargon • Full triad+ speech delay = Autism • Full triad and normal speech= Asperger’s • Social interaction + other = ?Atypical autism • All children with these three have an ASD • Other terms exist (for now)

39. “Kids in the mix” • Mix of disorders • Synergistic effect on functioning • Associated with relative poverty • Complex!

40. Self-image and self-esteem • Definition of self- categories • Gender/ sexual identity • Anger • Overt • Concealed • Moral development

41. Postscript: How to be the GP of a child with “complex” disability • Acute problems • Note interactions e.g. gut and head • Negotiate plan • Long-term issues • Checklist in handout • ‘Non-medical’ issues • Benefits • Wider family

42. Anything else?