developmental delay

[arpithagboraiah]

hi...
we have this patient in our hospital...she is two years of age and was born premature. she has motor developmental delay. she isn't even sitting on her own as yet. we are doing the swiss ball routine...the treatment isn't affecting as it should because of her fear towards everybody in the doctor's garb...tried treating without it and seen no improvement...what would be the best way to go about treating her?

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[thomas bibu]

hi aprithagboraiah,

just thought of sharing one of my clinical experience with you. a couple of years back we did encounter a similar experience. on follow up examination we discovered that the patient had an hearing deficit. following hearing aid treatment to be honest we could not believe her progress with therapeutic PT management.

hence just thought of elaborating the term "developmental delay" so that you don't leave any stones unturned.

well, each child develops in his or her own unique way, although there are recognized patterns of normal development.

generally these patterns are measured in five different areas:
1.motor: rolling, sitting, walking, hand usage
2.social: eye contact and emotional interaction
3. language: understanding and speaking of verbal language as well as communication by pointing and gesturing.
4. cognition: reasoning and thinking
5. activities of living : feeding and play.

developmental delay is identified as being present if a child is behind in any of these areas. of course, global developmental delay is diagnosed if a child is over 50% behind in two or more areas.

the diagnosis of developmental delay is confirmed through specific testing of each of the five areas of development. an early intervention specialist, physical therapist, occupational therapist, pediatrician and or a child neurologist may do the testing. the testing will
determine areas of development that are delayed
determine the severity of each delay
identify if there is a need for therapy
may identify patterns which need further evaluation, either medical or developmental

well, most children with development delay do have one of the three patterns:
motor delay
language and social delay
global developmental delay

motor delays often are associated with abnormalities of muscle tone (tension in muscles) or with weakness. tone can be increased (hypertonia or spasticity) or decreased (hypotonia). these abnormalities make it difficult for a child to develop rolling, sitting, walking, and coordinated hand use.

children with language and social delays often do not have any clear physical abnormalities. their delays are related to processing of information.

global developmental delay is a significant delay in two or more areas of development.

it is also possible for a child to have limited delays, or mild delay in more than one area, and not fall in to a typical pattern.

what causes developmental delay?

there are hundreds of causes of developmental delay, and yet many children never have a cause identified. the known causes are often grouped as being neurologic, genetic, or metabolic, although there is overlap among these areas. examples of these are
neurologic:
brain injury from infection, low oxygen, trauma, or stroke
abnormalities of brain development
seizure-associated developmental delays
genetic:
major chromosome abnormalities such as Down’s syndrome
micro-deletions of chromosomes
syndromes recognized by common clinical features without yet identified chromosome abnormalities, such as seen in familial autism.
metabolic:
low thyroid
rare abnormalities of metabolism of proteins, sugars, or fats

most of these causes are apparent from the child’s medical history and physical examination. every child with developmental delay should be evaluated with:
complete medical history, including family history
physical examination
review of newborn screening, the blood work performed at birth which tests for biochemical abnormalities
hearing and vision testing

additional testing may be helpful, but is not indicated unless delays are significant or persistent. this testing has a low chance of finding the cause of the developmental delay. this additional testing, if needed, may include:
consultation with specialists such as a child neurologist, developmental pediatrician, or geneticist
blood and urine tests, looking for genetic or biochemical problems
MRI, which provides a picture of the brain structure

regarding the treatment
it is very rare that a medical cause can be identified and cured. medical treatment is directed to helping the child receive needed evaluations and care. this is provided by a primary care provider and perhaps specialists. the management will include:
identification and treatment of any factors limiting development such as poor nutrition, hearing loss, visual impairment, or recurrent illness.
monitoring the need for tests to evaluate the cause of developmental delay
physical therapy to work with large motor skills
occupational therapy to work with hand skills as well as sensory concerns
speech and language therapy to address feeding issues and communication in all forms, verbal as well as social and gestures
early interventionists or teachers to work on play and thinking skills

as a physical therapist the areas to be monitored are
motor disabilities
cerebral palsy - disorder of motor tone and control
developmental coordination disorder, awkwardness particularly with fine motor tasks
apraxia, a difficulty planning motor movements
language and social disabilities
autism spectrum disorders, disorders of social connectedness that are highly variable in severity
learning disabilities

the purpose of medical follow-up visits?

well the initial visit is directed towards identifying developmental delay, performing medical studies, and initiating therapy services. follow-up visits help;
monitor development to be certain it follows a steady course. as in growth, each child will establish a personal curve and monitoring this curve will allow us to recognize if a child is outgrowing the delay or if a specific pattern of disability is evolving. it also will allow us to identify the rare child who further slows in developing and needs additional testing.
determine if current intervention is appropriate or if additional support might be appropriate.
assist in transitions from birth to 3 years to early childhood, and on to school
identify new issues that may arise and require additional consultation or evaluation.

all the best.

cheers

thomas

[arpithagboraiah]

hi thomas,

thanks for all that information...really...it helped me understand quite a few things. but as i have specified...my patient has motor developmental delay and yeah...i had her hearing and vision checked...all clear...so we are taking the help of some child psychiatrists to reach to her and hopefully her tantrums will stop. but thanks again for the information. helped a lot...

[estherderu]

dear colleague,

How about using touch..... ( give a massage and teach her parents to massage her)
Let this child feel that you are a loving caring person that wants to help them... not stick needles in them (just an example)
a few ideas are:
1.Give a lot of sensory information and support. The trick is to find positions in which you can entice her to move, to touch something or lift her legs. Do this in a good supported position, not in cushions, but with a firm support. It is easier to start moving with firm support than from soft moving support such as soft cushions.
2.Put her on a slope ( supine or prone) and let her "feel" the effects of weight change and gravity......I prefer a slope to the ball, the ball is too unstable. You can do so much... changing het environment to fascilitate moving is one of the easiest.
3.Use your ( or parents ) lap, balancing her on a leg, close to the ground to help her move.
4. Gentle move her passively a few times ( example roll from side to side)... then wait, see if she reacts and wants more and wait for her to respond.....

One of the things to keep in mind is that children with developmental delays need a lot more time TO REACT... so please give them that time.......

Hope this helps a bit.... good luck to you both

Esther