When developmental screening and surveillance suggest thepresence of significant developmental lags, the physician shouldtake responsibility for coordinating the further assessment ofthe child by the team of professionals and provide continuity ofcare. The physician should become aware of local facilities andprograms for assessment and treatment. If the child is at highrisk for delay (e.g., prematurity), a structured follow-up programto monitor the child’s progress may already exist. Under federallaw, all children are entitled to assessments if there is a suspecteddevelopmental delay or a risk factor for delay (e.g., prematurity,failure to thrive, and parental mental retardation [MR]). Special programs for children up to 3 years of age are developedby states to implement this policy. Developmental interventionsare arranged in conjunction with third-party payers with localprograms funding the cost only when there is no insurance coverage. After 3 years of age, development programs usually areadministered by school districts. Federal laws mandate that special education programs be provided for all children with developmental disabilities from birth through 21 years of age.
Children with special needs may be enrolled in pre-K programs with a therapeutic core, including visits to the programby therapists, to work on challenges. Children who are of traditional school age (kindergarten through secondary school)should be evaluated by the school district and provided an individualized educational plan (IEP) to address any deficiencies. An IEP may feature individual tutoring time (resourcetime), placement in a special education program, placement inclasses with children with severe behavioral problems, or otherstrategies to address deficiencies. As part of the comprehensiveevaluation of developmental/behavioral issues, all childrenshould receive a thorough medical assessment. A variety ofother specialists may assist in the assessment and intervention,including subspecialist pediatricians (e.g., neurology, orthopedics, psychiatry, developmental/behavioral), therapists (e.g.,occupational, physical, oral-motor), and others (e.g., psychologists, early childhood development specialists).
The physician’s main goals in team assessment are to identify thecause of the developmental dysfunction, if possible (often a specific cause is not found), and identify and interpret other medicalconditions that have a developmental impact. The comprehensive history (Table 10-1) and physical examination (Table 10-2)include a careful graphing of growth parameters and an accuratedescription of dysmorphic features. Many of the diagnoses arerare or unusual diseases or syndromes. Many of these diseasesand syndromes are discussed further in Sections 9 and 24.
The comprehensive neurologic examination is an excellent basis for evaluating motor function, but it should be supplemented by an adaptive functional evaluation (see Chapter 179). Observing the child at play aids assessment of function. Specialists in early childhood development and therapists (especially occupational and physical therapists who have experience with children) can provide excellent input into the evaluation of age-appropriate adaptive function.
Information to Be Sought during the History Taking of a Child with Suspected Developmental Disabilities
Parental concerns Parents are quite accurate in identifying development problems in their children.
Current levels of Should be used to monitor child’s developmental progress functioning
Temperament May interact with disability or may be confused with developmental delay
Alcohol ingestion Fetal alcohol syndrome; index of caregiving risk
Exposure to medication, Development toxin (e.g., phenytoin); illegal drug, or toxin may be an index of caregiving risk
Radiation exposure Damage to CNS
Prenatal care Index of social situation
Injuries, hyperthermia Damage to CNS
Maternal illness Toxoplasmosis, Syphilis (Other in the (so-called “TORCH” mnemonic), Rubella, Cytomegalovirus, infections) Herpes simplex virus infections
Gestational age, birth Biologic risk from prematurity and small weight for gestational age
Labor and delivery Hypoxia or index of abnormal prenatal development
APGAR scores Hypoxia, cardiovascular impairment