How Will I Learn about Development?

You will learn the basics of development during the clerkship, and your learning will be made easier if you make a conscious effort to observe infants, children, and adolescents wherever you encounter them, not just in the hospital or clinic. Ask yourself, “What does this child do that gives me clues about development?” Include observations about development at every clinical encounter, even for minor illnesses, and ask parents to tell you how they perceive their child’s development compared with siblings or peers at the same age. Ask whether parents have concerns about development. Listen to what parents say, even if you cannot immediately provide an answer. Efforts to categorize the development of each patient will enhance your overall clinical skills and will allow you to add important information to case presentations.

What Observations Should I Make?

Watch the reaction of each patient as you enter the examination room. Observe the ways that infants react to parents and to the environment around them, including you. Think about how the reactions of toddlers provide information about their developmental progress, which will also help you gain insight about how to interact more effectively with them. Watch children play so that you may gain an appreciation of the progress they make physically, cognitively, socially, and emotionally. Pay attention to the ways that children and adolescents interact with each other, with parents, and with you. Look at physical abilities—walking, running, climbing, holding, and manipulating objects. Listen to language—content, complexity, understandability. In short, keep your eyes and ears open!

How Do I Recognize the Patterns of Developmental Progress?

Initially, identify the changes that occur with advancing age. What does a 1-month-old baby do that a newborn does not? When do you first notice that an infant can voluntarily open and close a hand? Can a 2-year-old hop on one foot? How about a 3-year-old or a 4-year-old? When can you understand most of the words and phrases spoken by a child? What behaviors do you observe in toddlers, school-age children, and adolescents? How much cooperation does a patient demonstrate during the physical examination? Soon, you will recognize that skills in a variety of areas all have predictable patterns of developmental progress and can be organized into broad categories, which will make your observations more useful. You will learn to expect certain skills and behaviors in patients at a given age. You may even begin to predict the age of a child based on developmental achievements. Frequent use of a reference for expected developmental progress will let you evaluate the observations that you make and help you become conversant with the developmental sequence more rapidly: The Denver Developmental Assessment (Denver II) is a widely used screening tool for children up to age 6, Bright Futures is a useful online resource for health supervision, and the Early Language Milestones provides a timeline of language development.

What Are the Major Areas of Development?

Development is usually divided into broad categories: motor, language, cognition, problem solving, and psychosocial. These categories facilitate ongoing surveillance. Each links to the others and is influenced by progress in the others. An individual’s overall development represents the totality of the interaction. A practical approach to categorizing development can be found in the Denver II, which provides population-based norms for development in four “streams”: gross motor, fine motor/adaptive, language, and personal/social (Figure 9-1). A separate stream devoted to cognition does not appear in the Denver II, but the fine motor/adaptive, language, and personal/social streams all reflect cognitive development. Other, more formal developmental assessment tools use more complex categorization schemes, but for your purposes during the clerkship, simple schemes suffice. The Bright Futures Pocket Guide provides useful lists of age-related developmental skills for day-to-day clinical evaluations.

Figure 9-1 The Denver Developmental Assessment (Denver II).

From Frankenburg WK et al: The Denver II: A major revision and restandardization of the Denver Developmental Screening Test. Pediatrics, 89:91–97,1992.

How Do I Determine if Development Is Age-appropriate?

Most children that you encounter will have appropriate development, but some will be delayed. Your task is to understand the progress of development well enough to identify concerning patterns. The task starts with knowledge of expected development, coupled with the ability to make good observations. At some point in the clerkship, you will realize that “normal” development varies among healthy children of the same age. Some children follow the averages, whereas others “specialize” in a single area, such as language or motor development, and are “advanced” in that area and “average” or perhaps a bit “below average” in other areas. The differences are usually expected variations that do not signal the need for undue concern. Yet parents may voice worry that their child is not following the “prescribed” developmental pattern that they have read about in books, in magazines, or on the Web. They also may be worried because family and friends have commented about their child’s development. These concerns deserve serious attention.

How Do I Explain Development to a Parent?

First, you must know what “normal development” means and must understand how the child’s developmental variations fit within the expected progress for an individual at a given age. You must examine the child to assess development, looking especially for those delays that signal concerns. If no problems are identified, a plan for ongoing surveillance of development will generally reassure the family and reinforce the appropriateness of the child’s pattern. If, on the other hand, you encounter a child who has not achieved expected milestones or whose pattern deviates enough from the expected course to raise concerns, you must be able to compare the child’s actual abilities with expected development. Your carefully developed observational skills will help identify the problem and also reduce the likelihood that you might overlook something. Attention to communication of “bad news” will assist you to explain concerns to parents and help them understand the need for further assessment and possible referral to a developmental specialist (see Chapter 27).

What Do I Need to Know about Development at Different Ages?

Table 9-1 lists developmental milestones from birth through adolescence.

Table 9-1 Key Developmental Issues

How Can I Avoid Making Mistakes?

You can avoid errors by actively assessing every patient based on a solid knowledge base and sound clinical skills. Challenge yourself always to define “normal.” By doing so, you will develop the habit of looking for the characteristics that make development age appropriate. Review the child’s developmental milestones. Listen to parental descriptions and concerns. Take the time to observe. Describe your findings to parents. Do not make assumptions. Physicians often assume that the healthy, “beautiful” child could not possibly have cognitive problems (“He doesn’t look retarded”). Another dangerous assumption is that a delay in one area of development has no consequences (“She will grow out of it”). One common error is to focus only on the obvious, such as gross motor skills, while ignoring more subtle deficits in areas such as fine motor skills or language. Deficits in vision, hearing, and cognition can have a negative impact on the development of language, interactional, and problem-solving skills. Infants and young children will manifest sensory and cognitive problems by the ways that they respond to their environment. For example, a decline in vocalization between 3 and 6 months may indicate congenital neurosensory deafness, whereas delay in language later in the first or second year may suggest acquired conductive hearing loss. The combination of delays in language and social skills in a child whose development is otherwise on track may be the clue to autistic spectrum disorder. Remember that the social environment of the home has a huge influence on development, especially in language and personal and interactional skills. Knowledge of development gained from observation will prevent you from overlooking developmental problems, but it will also prevent you from labeling as “abnormal” developmental patterns and behaviors that are age appropriate.

KEY POINTS