Developmental and behavioural
problems in primary care:
0-5 years
Max Davie
7th July 2009
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!
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
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?
‘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
What can the doll do?
 4 months
 6 months
 9 months
 12 months
 15 months
 18 months
 2 years
Different ways up the mountain
Crawlers (83%)
Shufflers (9%)
Rollers (1%)
Creepers (1%)
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
‘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
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
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
5 minute DA- 1 year
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
The linking pitfall
Oh dear
All gone
Moo gone
Upsy daisy
Tessy doot
‘Why isn’t he talking?’
Myths
Hearing
Autism
GDD
SLI
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
5 minute DA- 2 years (nearly)
2-3: Play nicely!
Behaviour
Tantrums
Violence
Lack of co-operation
Sleep
Eating
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?
Webster-Stratton’s Pyramid
Arrange in order of importance
The incredible years
Services locally
Role plays (you love them, you do)
‘He’s got no respect’
‘He won’t sleep in his bed’
‘She won’t eat anything’
5 minute DA- 3 year old
3-4: Calm down!
Attention, concentration
Fears and imagination
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
Assessing ADHD
Hyperactivity
Impulsivity
Inattention
Questions to ask
The QB test
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
Fears and imagination
The emergence of magic
Emotions as behaviour
Imaginary friends
Lies and misdemeanours
Fears- concrete to imaginary
Night terrors vs nightmares
4-5: Get ready for school!
Later motor problems
Gait
Co-ordination & motor planning
Social communication problems
Self-concept and mood
Problems with walking
Normal gait
Asymmetry
Toe-walking
Persistence of toddler pattern
Frequent falls
The clumsy child- DCD
Common, significant problem
Difficulties with planning and execution
Poor handwriting
‘Behavioural’ issues
Frequent falls
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
DCD/ sensory - what to do
Assess expectations (handout)
Led by OT
Comm paeds initially
Questionnaire-based referral
Co-morbidity
Why go to medics?
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Neurological disorders initially diagnosed as "DCD/dyspraxia"
Peripheral neuromuscular conditions
Becker muscular dystrophy
myotonic dystrophy
hereditary motor and sensory neuropathy (HMSN) types Ia and II
myotonia congenita (autosomal recessive)
congenital myasthenia
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Central nervous system conditions
cerebral palsy
brain tumour (slow growing in the posterior fossa)
panthotenate kinase-associated neurodegeneration (Hallervorden–Spatz disease)
perisylvian (opercular) syndrome
benign familial chorea
epilepsy
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Mixed peripheral and central nervous system conditions
Friedreich’s ataxia
Pelizaeus–Merzbacher disease
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Miscellaneous
Ehlers–Danlos syndrome
GM1 gangliosidosis (juvenile onset)
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
Social interaction
Eye contact
Facial expression
Social response/ overtures
Shared enjoyment
Think of silent movies
Communication
Speech delay
Echolalia
Stereotyped/ formal language
Conversation
Reporting
Lack of gesture
Rigidity of thought and behaviour
Excessive interest
Mannerisms
Rituals
Sensory interests
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)
“Kids in the mix”
 Mix of disorders
 Synergistic effect on
functioning
 Associated with
relative poverty
 Complex!
Self-image and self-esteem
Definition of self- categories
Gender/ sexual identity
Anger
Overt
Concealed
Moral development
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
Anything else?