Abnormal Motor Development

1
Abnormal Motor Development

• Dr Valerie Orr
• Consultant in Paediatric Neurodisability
• RHSC, Yorkhill

2
Objectives

• To be able to identify abnormal motor development
• To develop understanding of common motor disorders

3
Does early detection matter?

• Parents value early diagnosis
• Improved outcome
• Improved quality of life for child and family
• Access to educational and social services
• Early detection is of little value unless
  parents subsequently experience a well-organised
  service with a clear referral pathway to
  definitive diagnosis and management
• Ref Health for all Children 4th Edition (Hall 4)

4
How do we identify children with abnormal
development?

• Follow-up of high risk infants
• Screening
• Listening to parents
• Opportunistic recognition
• Ref. Hall 4

5
Gross motor milestones when to refer

• Head control 4 months
• Sits unsupported 9 months
• Stands independently 12 months
• Walks independently 18 months
• Remember to adjust for prematurity until 2yrs

6
Features that may suggest underlying motor
disorder

• Delayed motor milestones
• Asymmetrical movement patterns
• Abnormalities of muscle tone
• Persisting primitive reflexes
• Other difficulties
• e.g. feeding difficulties
• unexplained irritability
• respiratory problems

7
Worrying signs / Red flags

• Not reaching grasping objects by 6 months
• Hand preference before 1 year
• Hypertonicity
• e.g. closed hand posture, extensor posturing,
  scissoring
• Hypotonia
• Loss of previously acquired motor skills at any
  age

8
Floppy infant assessment

• History
• Pregnancy and birth
• Feeding
• Development
• Examination
• Weight OFC ?thriving
• Facial features ?dysmorphism
• Movement ?antigravity mvts

9
Floppy infant - causes

• Prematurity, illness drugs - transient
  hypotonia
• Benign congenital hypotonia
• Global developmental delay
• Evolving cerebral palsy
• Genetic syndromes
• e.g. Downs, Prader-Willi syndrome
• Neuromuscular problems (rare!)
• e.g. congenital myotonic dystrophy,
• spinal muscular atrophy

10
Clinical scenario

• A mother brings her 18mth old son to the
• surgery with a minor illness. She mentions that
• she is concerned that he is not yet walking.
• What particular points would you look for in the
  history and examination?
• What action might you take?

11
Delayed walking (gt18mths)

• Normal variants
• Associated with bottom shuffling
• Cerebral palsy or minor neurological problems
  lt10
• Consider CK in boys

12
Toe walking

• Causes
• Idiopathic toe walking
• Muscle spasticity
• e.g. cerebral palsy, spinal cord lesion
• Muscle disease
• e.g. Duchenne muscular dystrophy, Charcot Marie
  Tooth
• Treatments depend on cause
• e.g. physiotherapy, casting, orthotics, surgery

13
Cerebral Palsy a multi-system disorder

• Description not diagnosis!
• Primarily a motor disorder
• Other impairments often associated
• Vision Cognition
• Hearing Feeding
• Manual dexterity Seizures
• Speech language Behaviour problems

14
Aetiology of cerebral palsy

• Incidence 2 per 1000 live births
• Antenatal 70
• e.g. prematurity, fetal neonatal stroke,
  brain malformations, maternal infection
• Perinatal 10-15
• e.g. neonatal encephalopathy
• Postneonatal events 15
• e.g. trauma, meningoencephalitis, stroke

15
Cerebral Palsy Interventions

• Aims
• Maximise potential
• Prevention of secondary dysfunction
• Promotion of improved function and participation
  in society
• Examples of tone management
• Orthotics
• Botulinum toxin
• Oral medications e.g. Baclofen
• Intrathecal baclofen
• Orthopaedic surgery

16
Duchenne Muscular Dystrophy

• X-linked disorder
• High rate of new mutations
• Incidence 1 in 3500 male live births
• Mutation of dystrophin gene Xp21
• 8-10 of female carriers have some manifestations
  of disease
• Loss of ambulation at mean age of 9yrs
• Average life expectancy now mid-20s

17
Duchenne muscular dystrophy Diagnosis

• Check CK in boys
• not walking by 18 months
• 4-6 months behind in general development at 2
  years
• awkward or clumsy gait under 4 years
• unable to run or jump by 4 years
• painful hips or legs under 4 years
• Ref. Mohamed K et al. Delayed diagnosis of
  Duchenne muscular dystrophy.
• Eur J Pediatr Neurol 2000

18
Duchenne muscular dystrophy Management

• Multidisciplinary team approach
• Use of steroids
• Prolongation of ambulation
• Reduction in complications e.g. scoliosis
• Improvement in respiratory function
• Increased use of non-invasive ventilation
• Cardiac surveillance every 2yrs
• Spinal surgery

19
Developmental Coordination Disorder

• Male Female 3 1
• Impaired motor control planning
• difficulties with dressing and toileting
• messy feeding
• poor handwriting and drawing skills
• poor ball skills
• Can become socially isolated
• Poor self esteem and schooling difficulties

20
Developmental Coordination DisorderDSM-IV
diagnostic criteria

• Marked impairment of the development of motor
  co-ordination
• Impairment significantly interferes with academic
  achievement and activities of daily living
• Problem not due to a recognised medical condition
• Not a pervasive developmental delay
• NHS QIS publication I still cant tie my
  shoelaces...
• Quick Reference Guide to Identification and
  Diagnosis of DCD

21
Developmental Coordination Disorder Management

• Reassure the child that there is no medical
  disease process or refer to Paediatrician for
  assessment
• Referral to Occupational Therapist
• Classroom support
• Group interventions to promote motor skills and
  self-esteem e.g. Rainbow Gym

22
Summary

• Limit ages can guide need for referral
• Neurological examination should identify worrying
  signs
• Be alert to motor disorders that might present
  later in childhood
• Listen and respond to parents concerns!

23
Useful sources of information

• From Birth to Five Years. Mary Sheridan.
• Health for All Children 4th Edition. Hall D.
• Developmental delay Identification and
  management. Aust Fam Phys 2005, Vol 34 9739-742
• Voluntary organisations e.g. Hemihelp,
  SCOPE, Contact a Family

24
Developmental Coordination Disorder useful
references

• I still cant tie my shoelaces...
• Quick Reference Guide to Identification and
  Diagnosis of DCD
• www.healthcareimprovementscotland.org/our_work/re
  productive,_maternal__child/programme_resources/dc
  d_review_response.aspx
• Why every office needs a tennis ball a new
  approach to assessing the clumsy child
• Cheryl Missiuna et al. CMAJ August 29, 2006 175
  (5)
• www.cmaj.ca/content/175/5/471.full