1. Dr .Raghavendra S

2. Developmental delay, defined as a 25% departure from typical performance in 2 developmental domains (e.g., receptive language, expressive language, fine motor, gross motor, social-emotional, cognitive/pre-academic, and behavior). Developmental Deviance In addition to delays in development, physicians should also recognize deviations in development. Deviance occurs when a child develops milestones or skills outside of the typical acquisition sequence. An example of this can be seen in conditions such as cerebral palsy, in which the infant rolls over early secondary to increased extensor tone 3. Developmental dissociation Dissociations arise when a child has widely differing rates of development in different developmental domains. For example, children with autism often have typical gross motor development but significantly delayed language development, therefore language development has dissociated from gross motor development.issoc Developmental regression Regression is when a child loses previously acquired skills or milestones, and although less common than the other patterns, should cause the greatest concern since it is often associated with serious neurological and inherited metabolic disorders. 4. Of children with measurable delays or disabilities, the most common (and least well-identified) condition is speech-language impairment (17.5% at 30-36 mo) Other common conditions are social-emotional disorders (9.5-14.2%) attention-deficit/hyperactivity disorder (7.8%) learning disabilities (6.5%) intellectual disabilities (1.2%) autism spectrum disorders (0.6-1.1%) Less common conditions include cerebral palsy (physical impairments) (0.23%), hearing impairment (0.12%), vision impairment (0.8%) and other forms of health or physical impairments (e.g., Down syndrome, fragile X syndrome, traumatic brain injury). 5. Prevalence and significance As estimated by the World Health Organization (WHO), about 5% of the worlds children 14 years of age and under have some type of moderate to severe disability In India, sources have found prevalence of 1.5-2.5% of developmental delay in children under 2 years of age Evidence supports that early treatment of developmental disorders leads to improved outcomes for children and reduced costs to society studies in the US have shown only about 1/3 of children are identified prior to school entrance, and as a result, miss out on the proven long term benefits of early intervention 6. Risk factors for Developmental Delay history of abuse or neglect parents with less than a high school education parental mental health problems (depression or anxiety) housing and food instability ethnic or linguistic minority 3 children in the home authoritarian parenting style (e.g., highly directive, rarely engaging verbally in children's unique interests, punitive) 7. Only about 25% of children with developmental delays are detected prior to school entrance, meaning that most children with problems will have missed opportunities for early intervention. Although clinicians are effective at detecting severe disabilities associated with congenital, metabolic, or genetic abnormalities, providers are far less adept at discerning the more common conditions because these typically lack overt dysmorphology 8. Reasons for underdetection in primary care dependence on nonstandard administration of standardized screens (including selected items from longer measures) and informal milestones checklists; both approaches lack proof of validity and criteria for making accurate decisions failure to continually check on developmental progress clinical judgment (because it tends to depend heavily on dysmorphology and organicity, which are not present in the majority of children with disabilities) requirement of repeated screening test failure before making a referral (due to lack of awareness that quality screening measures are highly reliable and that a repeated screen is likely to yield identical results); 9. false optimism about outcome (children rarely outgrow developmental problems in the absence of intervention); discomfort at delivering difficult news lack of familiarity with tools effective for busy primary care settings 10. To improve better detection in primary care, the American Academy of Pediatrics recommends developmental screening and surveillance at well visits. Developmental screening refers to the administration of brief, standardized, and validated instruments that have been researched for their sensitivity in detecting children with probable problems and specificity in determining when children probably do not have problems. Standards for screening test accuracy are 70- 80% sensitivity and specificity Screening is defined as a brief, formal, standardized evaluation that aids in the early identification of patients at risk for a developmental and/or behavioral disorder 11. The ideal screening method should use a standardized and validated tool with established psychometric qualities, be easy to perform and interpret, be inexpensive to administer, and have good sensitivity and specificity. Furthermore, this tool should be norm referenced and standardized on a population which is representative of the group to be tested. The American Academy of Pediatrics (AAP) describes "good" screening tools as those with sensitivity and specificity in the 70-80% range 12. Screening tools can assist in identifying at-risk children they do not provide diagnoses. When a child passes a screening test it provides an opportunity to promote developmentally appropriate activities and discuss age appropriate milestones. Children who fail a screening test need close follow- up and additional assessment. Additional assessment and early intervention referral should not be delayed by what has typically been called a "wait and see" approach Referral for an in-depth diagnostic evaluation by a developmental-behavioral specialist and referral for interventions (i.e. speech and language therapy, occupational therapy, physical therapy, special educational services etc.) do not require a diagnosis. 13. Developmental surveillance Developmental surveillance is defined as a flexible, longitudinal, continuous process through which potential risk factors for developmental and behavioral disorders can be identified Five components to surveillance: Eliciting and attending to the parents concerns about their childs development, Documenting and maintaining a developmental history, Making accurate observations of the child, Identifying risk and protective factors, and Maintaining an accurate record of documentation of the surveillance process and findings 14. Approaches to Screening The three approaches to screening include informal, routine and focussed developmental screening Informal screning is based on observing the child during a routine pediatric check up and asking parents about their concerns about child's development. The pediatrician, how- ever, needs to be familiar with the various developmental milestones at different ages. Such an approach is not a very sensitive way of screening as it is only useful for not missing major delays in a busy office practice Routine formal screening entails systematic developmental screening of all children with the help of standardized screening instruments. However, such an approach is highly time consuming as it requires large number of trained manpower and may not be warranted given the low incidence of developmental problems among low risk population of children 15. Focussed screening involves developmental screening of the following groups of children: (a) Children whose parents express developmental concerns or in whom teachers and physicians suspect problems. (b) Newborns with conditions that have known to have high risk for develop- mental delay 16. High Risk Infants Needing Periodic Assessments Very low birth weight (