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developmental delay & EI

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Pharmacology for General Practitioners 
(ISBN NO.81-87735-00-7) 
 page No.36-40, Vol.3,
                  No.3&4 
Dec.2001-March 2002.
 


 Developmental Delay & Early Intervention

According to The Persons With Disabilities Act 1995(Gazette No.1 of 1996,Chapter IV: Prevention & early detection of disability), it has become mandatory to screen the child for any developmental delay & refer to the appropriate services. Dont forget that it is right of the child. So we should better be aware of it.

 The term developmental delay refers to a wide range of childhood disorders & environmental situations. Children are considered to have developmental delays when they are unable to accomplish the developmental tasks typical of their chronological age. Developmental delays manifest themselves in many ways. They can be transient, as in some children prematurely, or last a lifetime, as in mental retardation. Some other children will develop normally for a period & then regress, such as those with Rett syndrome.

 They may be at risk or have developmental delays for variety of reasons. Three groups of children can be identified who have developmental delays or who are at risk for developmental deviations.

 Infants with established risk are those manifesting early appearing atypical development related to diagnosed medical disorders of known medical etiology (eg, Down syndrome, spinal bifida, visual impairment).

Infants at biologic risk are those who have an increased probability for delayed or atypical development from biologic insult(s) to the developing brain, acquired pre-, peri- or postnatally (eg, low birth weight, small-for-gestational age, fetal alcohol syndrome).

      Infants at environmental risk are those who, although biologically sound, may show developmental deviations due to depriving life experiences (eg, parental neglect, homelessness).

 These three categories are not mutually exclusive, and many infants have a combination of risk for developmental deviations affecting them, their families, and society.

 The term early intervention has several meanings, depending on the context in which it is used.

 In this section early intervention can be defined as a comprehensive, coordinated, community-based system for developmentally vulnerable or delayed young children from birth to age 3 years & their families.

 Objectives- Early intervention consists of multidisciplinary services designed to

 -Enhance child development

-Minimize potential delays

Remediate existing problems

Prevent further deterioration

-Limit the acquisition of additional handicapping conditions &

-Promote adaptive family functioning.

 The team-Early intervention team may comprise of the following specialists: pediatrician, developmental psychologist, occupational therapist, speech & physiotherapist.

 The goals of early intervention are accomplished by providing developmental & therapeutic services for children, and support and instructions for their families. Early intervention can be remedial or preventive in nature.

 Why Early intervention?

1.Early brain plasticity-During the prenatal & early childhood stages of life, the brain is experiencing rapid periods of development. Also the immature brain of a young child is capable of adaptive recovery to a greater degree than the more differentiated and mature brain of adult. It is known to be highly plastic & to have more potential for neuronal restructuring following a lesion.

 2.Importance of early experience- early experience is very important to childrens development.

 3.Critical periods for experience-Before birth and during early childhood, the brain is not only highly receptive to environmental influence but is also highly vulnerable to it.

 4.Importance of environment-the environmental context in which young children develop is crucial for development. So the Early Intervention makes the difference.

 5. Interrelatedness of behavior across developmental areas- Areas of development (cognitive, language, motor, perceptual, emotional) are interdependent. Developmental gains or gaps in some areas affect development in other areas. Therefore, for example, the motor delay should not be the only indication for early intervention.

 6.Economic expectations-Early intervention maximizes the potential of these children for future independent living skills.

   12-month-old male child who was having difficulty in rolling from supine to prone to supine, sitting without support, coming to sit. Mothers chief complaints were he is not able to stand. This was her concern because her friend who gave birth to the child around same child and who is walking by now. History revealed that he was having low birth weight & neonatal seizures. She has been going to the doctor regularly & once or twice she should have mentioned concerns about childs development. But physicians policy was wait & watch. Therapy was started, mainly Neuro-Developmental Technique (NDT) & within two month there was improvement in the form of increased sitting balance & able to sit without support.

Point to be noted is not how the therapy was effective but how early we can notify the problem & do something to intervene. As a medical or paramedical person we can do following things.

 1.Whenever there is a risk factor keep a watch on childs development. Alert the parents to keep a watch. Dont wait for this advice to give.

2.Listen with an open and sensitive attitude to parents worries & questions about their childs development & behavior. When parents express a concern about the development or behavior of their infant or young child, the concerns should be taken seriously. Routine developmental surveillance should always be performed.

3.When parents express a concern about the development or behavior of their child, you should refer the family promptly for a more complete developmental assessment to identify the nature of possible problem. You should assure the parents that thorough assessment is an important first step to whether problem exists.

4.If you are the person to convey to parents a diagnosis of a developmental disability or the possibility of developmental disability, you need to take care in how information is presented to parents.

5.You should be knowledgeable about the early intervention services in your community & should refer parents to them promptly. While acknowledging the childs disability, you also give parents hope & reduce their anxiety by referring them to & encouraging their participation in early intervention. I think you are in a unique position to support the hope the parents have for their childs future.

6.Present any statements about long-term prognosis carefully. Parents should be informed that information about prognosis is based on data for group of children, & long-term predictions about individual children are much less certain. The reality is that many predictions about future development are guesses, and parents are often better served by messages that provide hope rather than hopelessness.

7.On subsequent visits, ask questions about the childs early intervention services & the childs progress as a way of expressing encouragement of familys effort on behalf of their child.

First lets see which are the risk factors.

Developmental risk indicators for Early Intervention referral

Biological risk
Birth weight of 1500gms or less
Gestational age of 32 weeks or less
Small for gestational age (less than 10th percentile for weight)
Ventilator requirements for 30 hours or more
Intracranial hemorrhage: grades III or IV
Muscle tone abnormalities - hypotonia, hypertonia, asymmetry of tone /movement
Recurrent neonatal seizures (3 or more)
Feeding dysfunction
Symptomatic TORCH (toxoplasmosis, rubella, cytomegallovirus, herpes type II, syphilis)
Meningitis
Asphyxia with Apgar score less than 4 at 5 minutes

Established risk
Hydrocephalus
Microcephaly
Chromosomal abnormalities
Muscoloskeletal abnormalities (congenitally dislocated hips, limb deficiencies, arthrogryposis, joint contractures, congenital torticollis)
Multiple births greater than twins
Brachial plexus injuries (Erb's palsy, Klumpke's paralysis)
Myelodysplsia
Congenital myopathies and myotonic dystrophy
Inborn errors of metabolism

Environmental /social risk
High social risk (single parent, parental age less than 17 years, poor quality infant parent attachment)
Maternal drug or alcohol abuse
Behavioral state abnormalities (lethargy, excessive irritability, behavioral state liability)

Or combination of risk factors

How early intervention helps?

If above risk factors are present there are chances of brain damage. Early intervention helps to stimulate surviving brain. This might help the surviving brain to take over the function of the damaged portion.

POTENTIAL PROBLEM SIGNS TO WATCH FOR, BEFORE REFERRING TO EARLY INTERVENTION CLINIC

 

Signs to watch for from birth to 3 months of age

Yes/no

1.limited random movements

 

2.easy & frequent startle responses

 

3.poor head control

 

4.increased stiffness that may not look like true spasticity

 

5.reliance on head & neck hyperextension during movement

6.feeding problems

 

7.respiratory problems

 

Signs to watch for from 4 to 8 months of age

Yes/no

1.hypotonia

 

2.mass pattern of movement

 

3.limited variety of movement patterns

 

4.assymetry

 

5.limited spinal extension/limited control in prone

 

6.limited visual control

 

7.limited reach & grasp/fisted hands

 

Signs to watch for from 9 to 12 months of age

Yes/no

1.limited variety of movement

 

2.poor trunk control

 

3.poor protective responses

 

4.poor balance responses

 

5.poor manual skills

 

6.hypotonocity

 

7.hypertonicity

 

 According to me we should be committed to the development of children with disabilities to the fullest potential possible while providing guidance and support to their families.

 


 

 

 

 

 

 

 

 

 

 

 





above article titled
                  
Developmental
                  Delay & Early Intervention 
has been published in 
Pharmacology for General Practitioners 
(ISBN NO.81-87735-00-7)  
page No.36-40, Vol.3, No.3&4 
Dec.2001-March 2002.