Pediatric Physical Therapy Developmental Screenings by Andrew Leon

 

INTRODUCTION

The addition of pediatric physical therapy developmental screenings for infants and young children is of vital importance for the treatment of developmental delays. 

Article

Within the first few years of life, a child experiences an abundance of developmental changes that shapes their physical abilities throughout their remaining years. During the first year of a child’s life comes the integration of primitive reflexes, behavioral and social development, and gross motor development. The process of building motor skills is a progressive journey enhanced through sensory-motor development. Motor skill acquisition begins as early as 7 weeks gestation with lateral trunk bending and 9 weeks gestation with a child’s ability to bring their hands to mouth. While the timeline of these changes may be slightly variable from child to child, ensuring there are no major delays in motor milestones is essential for proper physical development. 

Developmental delays are common in childhood, occurring in 10-15% of preschool aged children. These delays occur when a child does not reach certain developmental milestones in comparison to children of the same age range. This can include a child’s ability to crawl at 8 months, stand independently at 11 months, jump off the ground at 30 months, and navigate stairs without support at 3 years old. Developmental delays can vary in severity from mild delays to severe which can result in lifelong impairments. There are many potential etiologies of developmental delay. This may include prenatal, perinatal, or postnatal complications. Prenatal causes may include genetic disorders, cerebral dysfunction, and vascular conditions. Perinatal causes include prematurity, asphyxia, and metabolic dysfunction. As well as postnatal causes such as infection, anoxia, vascular dysfunction, and trauma. While some of these children demonstrating delays may only experience mild, impermanent symptoms, a significant number of children undergo trauma that results in symptoms lasting a lifetime. 

As previously mentioned, complications during pregnancy can result in both mild and severe developmental delays. With developmental delay, many of these children experience motor impairments. One of the more common lifelong diagnoses yielding significant developmental motor impairments is cerebral palsy. Cerebral palsy describes a group of developmental disorders involving movement and posture, attributed to non-progressive disturbances that occurred during fetal or infant years. It occurs in about 3 out of every 1000 children in the United States and is generally diagnosed during the child’s first years of life. Neuroimaging as a diagnosis for cerebral palsy has a poor sensitivity and specificity, so diagnosis is often relied upon a physical exam assessing a child’s movement, reflexes, and overall behavior. Because of this, the importance of a thorough motor development examination increases significantly. One of the primary forms of treatment for cerebral palsy is physical therapy interventions. Physical therapy for cerebral palsy often begins shortly after diagnosis in early childhood and aims to address physical limitations such as gait abnormalities, muscle weakness, and postural control to improve overall function of the individual. Many children with cerebral palsy aren’t diagnosed until age 2 or later resulting in more significant developmental motor delays due to lack of treatment. Pediatric physical therapists are capable of making a massive improvement in the function of a child experiencing developmental motor delays, but physical therapists are only typically seen through a referral from the pediatrician or direct access once a persistent issue is yet to resolve with time. While some children may exhibit more severe symptoms of cerebral palsy within their first year of life, more mild symptoms may go unnoticed for an extended period of time unless for an evaluation of developmental motor milestones. Early childhood screenings performed by a physical therapist would work to identify red flags and provide a quicker diagnosis to allow the child to receive early intervention to address limitations.

Currently, pediatric physical therapists are not involved in the recommended screenings of infants and young children, which are solely conducted by a pediatrician. The American Academy of Pediatrics recommends standardized developmental screenings for all children, but only at ages 9 months, 18 months, and 30 months. A pediatrician typically conducts these developmental screenings assessing the motor milestones a child should be performing at each age range. At the 9 month visit, the pediatrician assesses the infant's ability to roll to both sides, sit unsupported, and grasp objects with each hand. While this is an appropriate assessment for the given age, these screenings should begin earlier than 9 months and should be conducted by a pediatric physical therapist in order to perform a more thorough examination to properly evaluate the child. While the current pediatrician screening utilizes similar components of the physical therapy examination including strength assessments through functional observation and movement analysis, the screening by the pediatric physical therapist would include a more in-depth evaluation of a child's ability. Pediatric physical therapists are experts in movement function and perform the most extensive analysis of developmental motor milestones. A pediatric physical therapy evaluation includes an assessment of joint mobility, muscle performance, muscle tone, neuromotor function, and functional skills. This also includes utilization of pediatric outcome measures such as the Alberta Infant Motor Scales (AIMS), Test of Infant Motor Performance (TIMP), and Peabody Developmental Motor Scales (PDMS2) to assess the child’s function in comparison to children of the same age peer reference group. A large portion of the pediatrician developmental screening involves administering a standardized screening tool to be completed by the parent and reviewed by the physician. This allows the parent to state any concerns about the child’s behavior to be addressed in the appointment. A physical examination of the child is not always performed if the caregiver doesn’t state any concerns to the pediatrician. While the parent typically spends more time than anyone with their child, they still may be unaware of typical motor development and unable to recognize abnormal behaviors. Regardless of the scoring of the standardized screening tool completed by the parent, a developmental motor examination should be performed to establish a baseline of the child’s ability, which can be used to assess developmental changes throughout the upcoming months and years.

As previously mentioned, waiting until 9 months for a child to undergo their first developmental screening puts a child experiencing developmental limitations at further risk for delays. As early as 2-3 months a child develops functional head control. Functional control of the head and trunk are the primary milestones for central nervous system integration and motor development. Without the emergence of visual-motor development and head control a child will be without gross motor movement. This will immediately lead to delays in necessary movement patterns such as rolling, sitting unsupported, and crawling, all which should occur prior to 9 months. Physical therapy screenings of children starting at 1-2 months of age would prevent worsening delays in movement patterns and allow the child to receive more immediate treatment if a red flag may present itself. While young children are recommended to visit the pediatrician for developmental screenings at the aforementioned ages, they are also encouraged to visit the pediatrician at 3-5 days old, 1 month, 2 months, 4 months, and 6 months. These appointments involve body measurements, behavioral/social/emotional screenings, and cardiovascular screenings. The presence of a pediatric physical therapist at these appointments to conduct development motor milestone evaluations in children as young as 1 month old would allow therapists to catch potential gross motor issues without delay. This would allow the patient to receive necessary treatment immediately to prevent further decline in motor development and improve the functional outcome of the individual. 

A 2015 article published in the journal American Family Physician reports that only 10% of children with developmental delays receive services by two years of age. The authors state that neuromuscular disorders in young children frequently result in a delayed diagnosis resulting in missed opportunities for therapies and interventions. The authors of this report state that screenings for early childhood development are a necessary component in their care, but not all clinicians adhere to the recommended guidelines. On top of the lack of adherence from clinicians, the standardized guidelines for development screenings for pediatricians do not contain as thorough of a movement evaluation as one performed by a pediatric physical therapist. Early recognition of developmental delays and identification of a particular diagnosis can not only ensure the child receives appropriate management and services, but potentially slow progression and improve functional outcomes. The addition of these pediatric physical therapy screenings in the recommended early childhood guidelines could make massive strides in the reduction of physical impairments and improvements in function. These changes would improve the quality of life of children and allow the child to participate in any activities of interest without difficulty. Every child should have the opportunity to move freely in their environment and participate in typical childhood activities. Providing interventions to address limitations as early as possible would set up a child for the best chance for an engaged and fulfilling life. 

References:

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