Objective methods of developmental assessment
Objective methods include the medical diagnostic processes that lead to the identification - at birth, or as soon as possible - of those children who have discernible disabilities, such as spina bifida or major metabolic disorders. When such children are identified, they should be enrolled immediately in programs that provide not only needed medical and health care, but ongoing developmental monitoring as well.

Other objective methods include the systematic use of specific developmental screening instruments, such as the Denver Developmental Screening Test II, for those children whose births were linked with events such as the occurrence of an IVH (intraventricular hemorrhage) in a low birth-weight child. In this circumstance we now know there is an increased likelihood the child will ultimately show the signs of cerebral palsy spastic diplegia. Such manifestation might have been suspected almost from birth, but because of a number of factors to be explained later, there is no way the diagnosis of cerebral palsy can be made earlier than during the second half of the first year of life.

Another group of children has also been identified who require a more formalized, objective method of developmental observation over time. This group includes children at "environmental risk." For example, the infant of a teenage mother who has dropped out of school, and whose social support system is inadequate, has a greater likelihood of developmental problems than the child who is being nurtured in a more stable and supportive environment.

Similarly, when screening identifies a child whose development is delayed, or when the developmental profile is quite unbalanced (for example, motor development is quite delayed although language development is age-appropriate), then a focused screening may be in order. This focused screening should be conducted by the health professional, and is devoted exclusively to determination of the child's developmental status. It should not be considered "diagnostic", but rather is done to confirm or rule out the necessity for referral to a developmental specialist.

Developmental Absolutes An experienced clinician should carry out a developmental assessment of any child who has not achieved the developmental skills below by the ages cited.
By this age, the child should be able to: 2 months Demonstrate a social response
3 months Absolutely affirm the ability to hear
9 months Move into and maintain an unsupported sitting position.
12 months Use a pincer grasp
20 months Speak single words
24 months Climb stairs Run Bend over from a standing position and pick up an object from the floor

Subjective Methods
Subjective assessment involves the close observation of the child's developmental progress at every health supervision interaction. When a child's medical and social history does not indicate the presence of previous or current life events that are typically associated with high risk factors, periodic probes of the child's family and peer interactions, combined with your observation of the child's behavior and interactions with the family, often provide an adequate developmental assessment. However, it must be emphasized that such "eyeball" examinations should be used only when there is good evidence that children in your care who have discernible disabilities have been identified, and that those who are at higher risk are engaged in a systematic process of developmental monitoring.

Why Careful Developmental Assessment is Important
There is good evidence that at least 2% of all newborns have a discernible disability, that is, a major malformation, or a sensory or physiological condition that will probably lead to the child's encountering problems in his or her educational or functional life. This figure is quite consistent throughout the United States.

In addition, those children will be joined by an additional 8% during the first six years of life, with the result that 10% of all school age children will demonstrate the need for special education or "related services" during their educational years.

The major reason for performing developmental assessment relates to the 8% of children who were not identified at birth as having a disability, but who will require special accommodations during their school years. Where did they come from? You might wonder if they have the residuals of childhood infection, or of some type of head trauma, but neither of these hypotheses is correct.

A portion of the group is made up of children who inherited a sensory, metabolic, or motor condition that does not manifest itself during the first year or so of life, but will do so over time, such as muscular dystrophy. Another portion arises among children whose births or neonatal course was affected by a metabolic or infectious process that caused a brain lesion, but because of the type or degree of the insult the developmental problem was not demonstrated until the child was required to use that particular brain mechanism later in life (e.g., a mild IVH resulting in mild cerebral palsy hemiplegia).

A third portion includes children who have severe, profound, or moderate degrees of mental retardation, but who, for obvious reasons, do not display their disability in the newborn period. Put simply, they will not be challenged by the functional tasks of life until well into their second year of life, and therefore will not demonstrate their disability until they come under rigorous developmental scrutiny. In most instances, the first indications of such delays can be detected during the first year of life by well-trained developmentalists.

The largest portion of the 8% comes from those who will ultimately demonstrate learning disabilities, Attention deficit with hyperactivity disorder (ADHD), mild mental retardation, or language dysfunctions. The concerns of most of these children will not surface until they are challenged with formal academic work in kindergarten or later. Some of these disorders are more significant and do begin to affect a child's development during the preschool years. Most such dysfunctions, however, are relatively mild and should not exclude the child from inclusion in regular education, as long as their learning problems have been appropriately identified and a course of special instruction has been tailored to their needs.

A final subset of the 8% includes children who require speech therapy because of developmental speech problems. Often these can be rather quickly modified using one or two years of education-oriented speech therapy.

Approximately one-tenth of those children who require special assistance from the education system will have a mental health or emotional disorder serious enough to interfere with their normal developmental progress. Therefore, the majority of the 8% who ultimately join the initial 2% of children to constitute the "special education" population demonstrate problems with intellectual or "processing" concerns, exclusive of those with sensory, motor, physiologic, or mental health disorders. In addition, the majority of such conditions, although they call for early identification and intervention, are relatively mild to moderate in terms of severity. Only one-half of one percent of all school aged children are estimated to have significant problems with their functional lives - that is, difficulty in moving about, communicating, demonstrating intellectual ability, or forming effective human relationships.

Planning Effective Developmental Assessment for the Children in Your Practice
From the preceding data it should be clear you can formulate and effectively implement a logical plan to adequately assess the development of all children in your practice. The key is the understanding that different cohorts of children require specific and targeted methods of developmental surveillance.

Likewise, an individual child can move from one cohort to another as circumstances change. A child without previous developmental concerns whose development is being subjectively monitored may experience a serious illness or an abrupt change in family circumstances due to illness, unemployment, divorce, or other disruptive factors. That child must then be identified as one whose development must be more objectively screened on a periodic basis. This, of course, is an excellent reason for health care providers to possess current information regarding the family, school, and living circumstances of each child in their care.

Developmental Surveillance - Organization and Helpful Hints.
Coming in the next issue of the EPSDT Care for Kids Newsletter.