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Welcome everybody. Uh My name is Katrina Harris and I'm a consultant committee, pediatrician. Um So pediatrician who's trained in child development, I work in North London. Um I put this like on the slides, name of my colleague, Doctor Priscilla Julius, who's a consultant, pediatrician as well in a uh another local hospital because some of these slides are borrowed from uh presentation that we did together um as a part of the training for medical students at University College London Hospital, Medical School. Um because child development is part of the normal curriculum of pediatrics and what I really hope that we achieve over the next hour and I'm just really checking time now. Uh is that um I just really will go through normal developmental milestones with you guys and I'll try to help you just summarize that and to present sort of relevant findings as we sort of uh go through it. Um um I also would like to speak a little bit about the risk factors for a child's normal development and really mentioned then a concept called red flags. Um because um motive just as the sort of development in Children is a very constant process which reflects a development of the braid. And while like the range of the normal is quite big, and while it's a sort of very useful to know what's normal. Um obviously, we, you need to know at what stage two sort of a voice concern because perhaps there is a time for a developmental peep the attrition to be involved really. And then um I also would like very briefly to show you or just to mention how to do an examination of growth, lot of development in the infant. And that way I cover what a sort of curriculum for medical students in this country um includes um when they do the pediatric training. But originally, when this, the sort of teaching was sort of put together, I had a look through the Ukrainian program and that was roughly what was included uh in your curriculum. So I think that it just gives you the basis for the um just considering the child development really as such. So what is the child development? Children are quite different from adults because they grow and they develop and their development um describes how they're acquiring skills and what do I mean by their skills? So how they walk and how they talk, how they sit and you know, it also um is sort of progressive really with their Children. So when we talk about the child development, we do prescribe a process of increasing physical intellectual, emotional and social abilities. And that is really what obviously, you know, that you see, because a baby can do maja less than a four year old and four year old, much less than 12 year old. And what such a 18 year old does and the child in uh um universally is considered a person under the age of 18. Um development. It used to be viewed far too narrowly um as a sort of maturation process of the brain really. But we have moved away from that way of thinking about childhood development um in a sort of uh uni dimensional way because we know that actually, it is a very such of uh complex process which sort of is sort of a continuously modify itself and it is influenced by many factors. And among those factors, we know that genetic uh factors which are such of inherited are really important, but not only so we know that the genetics is very strongly influenced by such of uh environmental factors. And really this is a whole sort of quite a sort of dynamic uh process which continuously alter each other because uh when you observe Children, um you know that they can have a different outcome. Of course, we never know really whether two Children have inherited the same predisposition. Nevertheless, um we can see how environmental positive environmental factors. Um so, no nurture versus nature can improve the outcome um for the child ready. And uh in addition to that, of course, we also have an influence of the such of uh you know, the census, they ever think what the child can see opportunities such of society and so on and so on. So um are actually all these complex are incredibly important. No, no long development um as a sort of a principle um within the normal development, we know that it is a such a continuous process of development across the four areas as we describe. So gross motor area, fine motor development, uh vision, language, hearing and social interaction. And um the sort of what is interesting is that for the normal development, we need to have really um the the same sort of uh sequence really of learning. So the sequence have to always be exactly the same. However, each child develops at the individual rate. And because of that, we have this wide range of the normal. So one child can, for example, walk at the age of nine year, nine months and another child will walk at the age of 15 months. So if you think about it that a six month difference, so this is the 50% of their child sort of life as a difference. So of course, really, you know, one parent will come and ask about it and then you still have to be able to reassure the finds that both of these pro processes such of are completely normal. Nevertheless, and the way how the child acquire the skills, they have to follow one um onto another one. And then if you think about the such of the, on the, if you think about the sort of gross motor of progression, it had the same sort of pattern. So it starts from the head, those from the sort of uh the head development. And so from the top and it's such a progressive down to the sort of, to the high risk. Uh we know that the we have first the development of reflection and then sort of it's sort of uh goes back into sort of uh expanding into the sort of uh extension. So the child has to achieve the stability and then such of cancer just starts to move ready with the sort of uh with the movement of the legs really. Um and, and such of achieve the term in the legs ready. Um Now we know that the child first already developed the control um on the back and then it just sort of moves to front, it starts from the small to the big. But I mean, for example, the child is able to use fingers before the, they can sort of use a sort of uh they can sort of walk etcetera, so small activity into big activity and it is reflecting the maturation of the nervous system. Nevertheless, this process can be such of uh influence. Now, we also know that uh while another principle sort of general principle of the development specifically in relation to the growth model development is that babies tend to uh just get rid of the primitive reflexes. And uh these have to be lost before the voluntary movements develop. And what it means really, it's simply really um uh sort of explains and suggests really that uh the primitive reflexes reflect really a lack of sort of control of the brain. And as more control, the baby's a sort of uh obtain a small voluntary movement, has less primitive reflexes up there. And presence of the primitive reflexes being beyond certain ages is always sort of a uh as a sort of uh and evidence for us that there is something wrong that we need to look for the underlying neurological uh problem. Um They are these sort of uh you know, um when such of you look at the babies, when you start dealing really with the babies, um you just such a really think how on earth am I going to sort of learn all the skills what the baby should do at the six weeks or it's six months or such a bit night? Uh And sort of many sort of bodies, sort of dealing with the sort of uh aspects of the health of the Children produce these tables which such of can be sort of used really as a such of uh um ammonic and as a sort of helper really when you really see the child uh we, we don't necessarily learn them all by heart. We do have some such a helpful quick moronic which will sort of help you to remember certain aspects. But actually, um with time, as more, you look at the Children, as more you such of uh observe them, you realize that actually there's a very logical progression which such of uh can help us really to think about it. Now, if you look at the table, each table has such of like two directions and that obviously will voice the such of the question to you. Uh whether should I learn the such of the development um horizontally? Uh because you have horizontal arms or should I learn it vertically and um sort of um that um yeah, so when you think horizontally, uh sorry, we start with vertically on this slide, I look at the next slide. So should I learn each of the area, gross motor skill, fine motor skills from birth to the point when such of when I see the child? Really? And so what the child is doing at six month with the child is doing at 66 weeks, six months, nine months, 12 months or should I really think what is this child really needing to do across all four areas of the development? But at specific age, which one is more helpful? Well, to be honest, both of them have to be really such a uh considered because as I said, from the beginning, the development isn't a unique as such of directionally progress. Um It is the progress which such of goes in both directions. Uh And in addition to that, that is impacted by the environment. However, from the point of view, really how to think about it is actually very important to think about the development as a sort of more tabular sort of development because to just sort of say, so if you have delay in one of the areas, then that will massively impact on the development of the other areas. If you have a delay or a problem, for example, with your sensory development. So if your vision is impacted or if your hearing is impacted, it will massively impact not only on your speech and language development, but it will also impact on the other areas. And because of that, it is important really to think both vertically and horizontally. However, you also have to remember that, for example, for being able to sit, you have to have a trunk, all such of control and had control, which already had been acquired really. So you cannot gain one scale, which such a fall somewhere a sort of halfway through that system, if you haven't such of learned the previous milestone. So you need to saying horizontally and virtually, if the conclusion now I'm going on, I've already been going on for about 15 minutes and you just really may think, why is it important to think about the developmental assessment. Is it really important? Well, it is really important because um as we've, as I've already mentioned, development reflects that the brain maturation and really child's ability to progress with learning all the new skins. So, um how should we do it really, we tend to um involve in screening but screening is only such a possible if you are able to do something about it. But we, we are doing some screening and um these sort of these screening goes on because develop mental impairments are very heterogeneous group of conditions and they start very early in the child's life and then they present with the delays or with the abnormal pattern of a progression and they are really, really common. Um It's about 5 15% of prevalence really and they often can be associated either with the later health problems. For example, if you have a growth model, uh delays, then you can sort of suspect that there is like a several policy underlying or the neuro mascular condition. So obviously with that will come um sort of uh later health problems if you have a problem with the communication development that very often later on presents with behavioral problems and there are such of old long term problems. So if you manage to identify those who are at such of uh early stages, you can hopefully support the best outcome and you can hopefully try to prevent the development of the such a later issues. And for example, last week I talked about autism and one of the messages which I tried to such agreed to everybody was that developing a functional communication in Children who did not had normal speech and language development was paramount because by developing communication, you hopefully prevent it behavioral problems really. So if you manage to identify that at early stages, then hopefully that will leave too long term, such of uh sort of uh support really. And obviously, then such of you have to think about the social adaptation and such of the long term mental health problems, etcetera, etcetera. So if you are screening, you can identify those at risk. And for example, you can sort of identify, for example, people with the letter say for example, with the chromosomally abnormalities and you know that they will have some other issues. But also you can hopefully reassure the parents if for example, they are concerned that their child has developmental problems while that perhaps is just within the range of the normal. Um we need to sort of remember that parents are uh experts on their Children. And then there are experts because they live with their Children for 24 hours and they spend all their life comparing their Children to um other Children. And they sort of um um they sort of will think, oh my child is not doing this, is that a problem really? Well, if you have really evidence that actually things are okay and that they're within normal range, perhaps you can reassure the parents support them and that will sort of make them to uh sort of to, to sort of look positively at the child and support the strength the child has. But you might be in the situation that actually you're able to diagnose an uh existing issue really. And uh what is it helpful for having the diagnosis is really very helpful because there's plenty of evidence that the early identification and early intervention improved outcomes. Enormously, you're empowering the parents by giving them explanation to their concern and you're empowering them to see, support their child so that they can sort of intervene and support them with this sort of whatever is needed. But you're also um supporting them with their ideas, how to help the sort of the child's development. And that way, obviously, um they sort of they feel happier really with that already because they can do something about it. Now, I was just thanking that we speak for a moment about the process of identification of developmental empowerment. So usually universally, all Children are seen by some sort of level of health professionals. And in the UK these professionals are called health visitors. But I'm sure that in your country in normal circumstances and there were some community nurses or you know, developmental practitioners who would see Children. And uh these practitioners thanks to see the families to promote good care and parenting. Um they will identify risk factors and they will early identify developmental difficulties. Um Let's just call them health visitors as we sort of do here just for easy really. And um these practitioners are able to perform some level of developmental examination and this is to verify the concerns which the parents have, but also perhaps really just to categorize what sort of developmental function the child has. And really also to verify whether there is a real risk of impairment. Because if this is the case, then obviously you need to sort of arrange the assessment investigations and then do something about it really. Now, once you have completed developmental examination, then a developmental assessment for established concerns can happen and this will hopefully describe what strength the child has, but also what weaknesses they are and then plan the management because with the developmental conditions you investigate uh and perhaps you fine find an underlying neurological condition. But many times there is really no explanation. And in the majority of cases you just try to involve, for example, a physiotherapist helping the child to such of balance and learn sort of stabilize and get stronger, Auspitz sign language therapist who will help the child and the parents to uh learn the skills of sort of speaking and then um the diagnostic or functional assessment, this is all just to give the name to the concern because the name will uh lead to some sort of management plan which hopefully will help. That was just the general principles of the sort of, uh sort of approaching the develop development. So let's just now concentrate very quickly on each of the areas of the development. We started with the gross motor development. And really let's just think about how we can such of uh, uh tackle it really what the child does, what I'm saying, really talking about now is how you tackle it in a vertical way. So from birth to sort of, let's say approximately two years old, um what I think is really important to remember is that the gross motor abilities have thera weak correlation to cognitive developmental um abilities. Um So many Children will progress with the normal motor development and yet that they can present with the very significant cognitive delay or difficulties or impairment and with each such of inter electoral disability. On the other hand, if you have a child who does not present with the normal growth, multi development, then you tend to investigate that in a sort of normal neurological way because you know that you will find a clear underlying cause and that in the vast majority and most commonly um in the vast majority of cases, it will be Sabra Party. So there will be some sort of underlying event at birth or just before the birth which causes the brain aspects. Eah, so the lack of oxygen and then sort of resulting from that, we will have a mortal problem. Really. Now, um the, we talked about the primitive reflexes which really should be gone and done already by four to such of uh six months. And once they are such of gone, then the child is sort of developing increasingly, they're such a voluntary, voluntary movement and the postural control. So we at the birth, when we look at the baby, at the new baby, we sort of observed the posture and I will in the next two slides, talk about about the six positions. It's in which we sort of examine the child. But then by six weeks of age, what usually the child does the child obtains a head control and, you know, uh 45 degrees, that's the academic, such a number. But you simply can see that the child starts to sort of, uh, sort of move their head backwards simply because if they're laying in the prone position, they obviously can't see anything. And Children are really very curious about the world. So they try to lift their head to such or to see. But by the time if you sort of move them to a sitting position, they're able to stabilize their head. Now by six months of age, it's sort of this baby really, um, to the left really, they start to sit without support, really, the back is around it. They haven't got a full, sort of, um, you know, full sort of tranquil control. Nevertheless, it is improving, but they have really a good head control by them. But by nine months of age they start to pull themselves to stand, they use the arms ready and then they're able really to sort of stand up while holding to the object. But if you are sitting, they sit with the noise straight back, they're able to use their hands ready to play with the toy. And then by 12 months of age, this is such a big joy for the parents because the majority of the Children works. But as I already mentioned, some babies work by nine months of age, other babies survive 15 or 18 months. And if the child doesn't work alone by 18 months of age, this is significant red flag. A red flag is just the way we sort of describe those moments in the child's development that you really need to consent and try to think how you can sort of investigated really because obviously there's something abnormal and then by two years of age, they're able to run and to jump. So when do you sort of examine the child from the motor point of view? As I said, we such uh sort of demonstrate, we, we look at them and demonstrate uh the movement in such of six positions. So we start off with the baby laying in a supine, so on their backs. And if you look at the three pictures on the left hand side, on the top of those pictures, you can see the newborn baby with flexed legs and arms ready, which they hold against the gravity. And this is a normal term child born, just a newborn. You can see that they still have a cord which is clamped ready. So the baby's uh sort of newborn, but it's got a normal tone and a really normal position. If you look at the second picture below, if you see a baby who's such of laying with the arms flat down, this is so called frog leg position. And you know that a baby like that is a baby who's hyper tongue with a low turn. This is a typical presentation of a child who's born premature. So under 37 weeks of gestation and um really um prematurity is not the only explanation the medical causes for hypertonia and both. Um but obviously, prematurity is the one of the most common one. Um chromosomally conditions can also explain hypotonia. But broadly speaking, a child laying with the frog leg position is hypertonic at birth. Sometimes we can see the child laying in a symmetrical position as the child on in the first column at the lower bottom picture. And then you have to ask yourself why this is the case because um as human, we have two sides of the brain and we are symmetrical in our movement. And when things are are symmetrical, then you have to ask yourself, what's the problem? Why is this happening in this particular choice after birth? Sometimes Children suffer from the um both injury and they injured there. Flexes, brachial plexus are resulted from that. They are able to lift one arm, but one of the arms as such of hanging down and physiotherapy can be helpful. Because luckily, uh we as humans, we have found uh living creature's, we have fantastic ability to um to heal really whatever injury happened. So the first position in which you examine the child is in sopon, then the next you're pulling the child to say to our examining the child's ability to move with the such of with the pulling movement like in these pictures and what you try to see, you see how much the child is controlling the head. In the first picture you see so called head lag, which is very common in very very young babies by the age of 68 weeks, you can see that the child starts to control the head, which is following with the child. And if you had a child with significant head lag by 23 months of age, that would be another red flag for apparent hypertension. Yeah. In slightly older Children in 34 months, you also see how much they sort of so called antipas, anticipate the pulling to sit and how much they brace themselves and help you with the shoulders to such as to being moved but the main purpose still is for sort of examining the child for the headline rate, which is normal birth. But by the time there are two months or so, it starts to be abnormal. And then once you sort of pulled the child to sit in, you obviously look at the child how well they control their trunk. And, um, at first they, there is a sort of control their head really, but the trunk is not controlled, it is surrounded and really it would be normal. Um, in a little baby who's 23 months old or birth. But by the time they're six months, they look like the child below where they sit with a perhaps around the trunk, which then with time becomes such a better controlled and straight ready. By the time they are seven months, no. And the fourth position in which were such of examine the Children is in a prawn position. And if you look at the bottom, this light, you can see the little six weeks old baby who just sort of is, um, sort of like posting their head and to what we spoke about 45 degrees in order trying to control it, but they're unable to support their chest of the ground. But by the time there for five months they lift up their sort of chest and then they stretch their arms and they're sort of getting ready for crawling from the prone position. You lift up the baby into ventral suspension and you do that because there's such of uh there's, there's a sort of uh back muscles allow them to control the trunk and the hips and the legs really against the gratitude. So if you look at the baby on the top picture in the ventral suspension column, you can see how this is a baby controls very well. They're back the head, they lift, they're sort of legs really against the gratitude and arms. While the lower bottom baby is the baby who's very clearly hyper term because the baby is just such a painting and even the babies at birth do not really um thing like this. This is the typical baby um which has the sort of problem with the controlling the muscle tone, for example, a baby with the chromosomal disorder and typical at birth hypertonia and then the sixth position in which you examine the infants, grossman, the sort of uh skills are pulled to stand or standing pus babies from very L A extend their legs and then sort of support themselves from perhaps 34 months, five months, definitely six months that with support they're able to stand really and even sometimes balance really. And obviously, as I say, by a 9, 10 months, they're able to pull themselves to stand themselves and then start to walk. So sex positions in which you examine every infant for gross motor skips. Now, future goals. So we talked about what they are able to do until they are such of uh uh 11 year. But they, by two years of age we only just talked about the gross motor skills at the top one, they're able to run and jump. And if they walk up, they are able to put 2 ft per step on the stairs. And, but the three years of age they are able to stand on three limbs. This is like a little meme Monica, really how to remember all these uh such of um milestones and then they can peddle their tricycle and my colleagues such of uh marked teeth for 33 T s. So they are standing on three limbs and they're sort of huddling a tricycle. And then by the four years, they're able to hop on one leg. So she put the little picture of the person who nearly looks like number four. Now let's just, just move to the fine motor skills. So the same way as such a um we started really with the gross motor skills. So at the birth, the baby is supposed to see shades really. And they sort of recognizing uh the mom already by smell more than buy proper vision, but they do orientate themselves to such a flight and to their faces. Now by the time they're six weeks old are able to fix and follow um sort of uh the objects, a bright object at over the 90 degrees really. And then by three months of age, 34 months, they wash their own hands, they sort of move the hands to the middle and they sort of play with the hands and they sort of look at their hands. This specific actions is called hand regard. And really the held regard beyond uh one year of age is really very abnormal and it is one of the red flags ready for abnormal social development. But the three and four month of age, it's such a shows the strength of the their vision and then uh fine motor development. Now with six months, by six month of age, the visual perception is improved. They such of are able to uh control their hands, they're reaching for objects and most of probability are looking for that. When they are searching, they transfer objects from one hand to the other and then they put the into their mouth. Three, they have developed their palmer grasp. So they held the choice with the whole such a hand. And then by 89 months of age, they start to explore such of toys with their finger approach really. And then by 10, 12 months of age, they develop the pencil grass, which is the really, you know, high function. So they can sort of hold objects with thumb and the finger by the thumb finger opposition. And they can sort of manipulate small object. But in addition to that by this stage, they started to cast objects, so they throw them and sort of just to get their reaction and they have developed object, eminent now object eminences, sort of really more a sign of the cognitive development than a vision and fine motor development. And it is really a very important developmental milestone um in the child development, in the sense that they have learned that if something has disc appeared from their vision, it doesn't mean that it's gone completely, it is simply not seen and it is sort of hiding really. Now, this is really important in terms of the attachment. Because by one year of age, babies learn that actually if their mom other disappeared from the room, she hasn't disappeared completely. She actually is just there and then she comes back. So from the attachment point of view and from the separation security, it is a very, very important milestone which most Children achieved by 12 months of age and then it sort of very briefly ready. Where does it lead us from one year? Because we have a pencil grip, we have a quite nice control of the sort of hand. So then the Children start to learn to build powers and by the sort of 15 month of age, they are able to put two bricks together than three bricks in a tower about 18 months really um by two years of their six bricks ready building tower and then um nine breaks by three years but also by three years of age they start to have really much more sophisticated ability to play, they're able to build bridges by bridge. I mean, the such a figure on the, in the right top corner where such of you can drive a little car under etcetera. And then by four years they built a step aerated. Now, the sort of uh we tend to use drawing, you know, these sort of uh these um uh these sort of uh a developmental assessments that is they have to be practical, quick and easy because you can't go around really with the boxes of toys, really, you can have few breaks, but also having a pan and such a bit of paper is quite useful because you allow the child to scribble on the paper and that tells you quite a lot uh um by 18 months of age, by 12 months of age, a little baby with a big crayon will just mark the paper by 18 months, they start to scribble a bit more freely by two years of age, they should be able to do the line and to remember it is just, you know, a line has to end. So two years to end now by, by three years of age, they should be able to draw a circle which is 360 degrees. And by four years of age, they should able to draw you a square which got like four corners really. And then triangle requires much more sophistication. That's why it happens later. Now, what happens to language and hearing at birth? The babies startled to noises and they respond and you can see it and uh it's very, very clear. But then by three months of age they such a coup and cooing is making sounds in response to other person such of uh talking to them. Now, by six or 12 months of age, they should be able to bubble. I'm really sorry, I apologize. Something happened to missing those two lines ready. And um they bubbling is quite important ready because the baby shows such a copy the syllable Baba, Baba, dada, dada and so on already. And they, before they are one year old, it's not about knowing their name. It's actually about being able to say one word with the meaning. It can be a baby language, it can be their own language. But they all when they say mama, they mean mama, they, when they say dada, they mean dada, when they say Baba, sometimes they mean at Holly or something else but they know what uh the parents know what the child is meaning by 12 months of age socially, they're waving bye bye. Uh two other people, etcetera. Now by 18 months of age, they say 6 to 20 words. And really that is where the world of the normal starts because some Children say six words. Some Children can say even more than 20 words and it is all within the normal range really. And those are a wide range of normal boys can sometimes say such of uh less, for example, um it is the family trade that people such of have a need more uh sort of a time, the Children need more time to develop their language really. However, they, they all have normal understanding of the language. So they may be a slow with saying things that they understand it. And the parents need to be able to evidence to you that they understand because parents always say, oh my child is very clever and understand everything. So you need to know specifically what do they mean by understanding everything. Now, by two years of age, they should be able to put two words together. For example, like mommy dues are Biba something or whatever and the number of words they have is hugely hugely varying. But this concept of putting two words together asking for something is what's typical for two years of age. And then by three years of age, they know their name, they know that their boys or girls, they know colors that know lots of words, they speak industry with sentences and those speeches quite clear to unfamiliar adults. And by five years of age they ask how and when and everything. So when I think about this social interaction, which so often is sort of uh sort of considered really um when um when we talk about autism. So by six weeks of age, you expect Children to smile responsively. Now, it is really important that it is responsive to human face and to human sort of interaction because parents will say, oh my child smiles from birth, indeed, some of them do in sleep. But this is in sleep, you know, smiling to whatever dreams they have, we are really talking about social interaction. So a baby smiles because they see a human person by three months of age, they low out loudly. And again, this is in response to other people because something what we sort of so often seeing Children with autism who are deficit in social communication skills is that they smile all the time. But this is not in a response, this is not reciprocal by nine month of age, they have stranger anxiety. So they differ family members from the strangers. They also start to develop gestures, they understand know by by they enjoy playing peek a boo so little social games. They then by 12 months of age they start to drink from a cup and they like doing it by themselves and they wave bye bye bye socially. So they are very social beings by that stage. And then by 18 months of age, they're able to name body parts and certainly to point to them and they can play simple symbolic places like feeding the babies and B is just feeding with the bottle or feeding cake or the old Children like playing t and eating cake together. The and by three years of age they make believe play and really by five years of age they're able to dress himself, use knife and fork, etcetera, etcetera. So the world of the Children becomes a world of adults. Already. By two years of age, Children really love to copy adult activities. That's why they spend time in the kitchen when they try to play with pots and pans ready because they copy what the adults do. So what do we do with that? All information in the real life and in clinical practice, as I already mentioned, you have to explore parental concerns because the parents compared their Children to others, uh other Children of the same age and they are very good at spotting problems. And we've already established that if the development is abnormal, it may indicate a long term condition. We take history, developmental history, which will include information about the pregnancy, about the risk factors, risk factors in pregnancy such as for example, alcohol, which is a really very bad news for the foetal development. We x explore risk factors related to take drugs in pregnancy. And again, some of the drugs are really bad news for the developing uh foetus in pregnancy. We developed risk factors around delivery. Perhaps there's history of decreased fetal movements, infection or prima maturity and that all will such of indicate that actually, you're dealing with the reduced amount of oxygen going to the baby through placenta and you will be dealing with the uh ischemic insult to the baby's brain and then apparent cerebral palsy. Now, we such uh explore developmental milestones ask about as parents how and when the child sort of gained particular skills really and that all has to be taken in the context of family history because as I said, the range of the normal is white and uh milestones and there is a genetic implication to have the child gained their milestones. So there's a family history. If they say that, for example, in their family, every child started walking at nine months of age, then a child who's not walk, OK, at 15 months of age is obviously an issue and you really need to take it seriously. You ask about the medication allergies, etcetera, etcetera. And then it's time for examination of the child weighing child, checking up measurement, checking out the hats a conference because all these parameters indicate how well the brain is developing and how healthy is the child. You look for the distinct the facial features because they may indicate that there is a chromosomal abnormality and that actually a genetic investigation would be helpful. You look at the child alertness, you look at the eyes mouth, you look for cleft palate, for example. And then you examine all the systems really in exactly the same way that you would be looking in any other child or adult. Now, every child should have a hearing assessment at birth because that can tell you whether they can hear. And as I already mentioned, uh impairment in one area will have a significant impact on the development in other areas. Now, when you think about the risk factors, um and what you should think about really, obviously, prematurity is a big risk factor for the development. Texas That here, for example, with boys really, they there is um it is normal for boys to speak a little bit later, but a little bit, I mean by, you know, a few months. However, the receptive language is completely normal, you need to think about the family history. Um So unexplained, severe childhood illness or death, is there sort of any genetic predisposition to a problem? You need to think about if there are hearing problems, neurological problems or learning problems in the family. Now you ask about the antenatal and birth history. We talked about them already and obviously consider whether there is a possibility to injury to the brain already. And if again, any feeding difficulties are a very good indicator that there was perhaps a problem. Now, how do you make a sense of all these findings, um developmental findings change over time for a specific child. And I already said that there is a large variation of the normal in the population. So that has to be discussed with the such a patient with the parents really. But then you're all also have to be able to interpret the findings um together with the examination ready because obviously that I will uh tell you how well the child will do. And um when you sort of uh you don't want to sort of over diagnose the developmental delay because sort of if there is a sensory impairment that might impact on the child, such a functioning, etcetera, etcetera. But you still have to make a good conclusion, you have to be able to plan investigations and sort of uh a sure that your clinical decision about those investigation is a sound. For example, if you find the child with the developmental delay and if you find any other evidence of the small physical or any other findings, actually, the yield for the genetic testing is positive. Genetic testing is high is approximately 40 or 50%. Really. Now you have to be really open to actually developmental regression because generally it is um unusual uh the true regression really. So what I mean by regression is that a child was able to do something and then they stop. Um Children with autism have about 50% of regression in terms of their social did development and language development between 1st and 2nd year of life. But when you particularly have a child who has like a severe seizures in first year of life, you very often will see actually regression both of uh the uh speech and language development of social development, but also of growth model development. And that all needs to be um uh investigated. Now something what is really important we sort of so often use the term developmental delay and this is a misleading term. One should be careful when you talk about delay, you may imply to, to the parents that their child will catch up and that isn't necessarily the case. So be careful how you use the term developmental delay. Don't be floppy in the use of the language, use very specific language really. And then uh we talked about the fact that early diagnosis is associated with better outcome. You can operate assurance when such of you think that such of, you know, the outcome will be good and that when you have indicators that it is only across one area because if it is across one area, there is a sort of uh possibility that actually the outcome will be good, but you also have to promote the child's development and appropriate referrals depending on what to use such a finds. Right now, the I mentioned the time of red flags. It is the term which we use when sort of the neurological uh sort of investigations have to happen or genetic investigations. So if you have any kind of uh inclination that those a vision or hearing loss ready that obviously have to be investigated properly, um If you have a child who has slowed down in the acquiring milestones or if they're late with the male stance, uh if they're lost previously acquired milestones, if you have a regression, this is the situation in which you have to medically investigated. If you have a child who doesn't sit by nine months or doesn't walk by 18 months or have problems with stairs or tiptoes, that has to be investigated. If you have a child who is not reaching or not pointing, it has to be investigated again with the language, a childhood has no words by 18 months, a red flag, it needs to be investigated and a childhood doesn't smile by eight weeks or doesn't show any conflict. This has to be investigated. Now, this slide was only two such of talk about this such of uh over the time increased um difference. So the top yellow line is the normal development, then you have the other yellow line and the sort of suggestion of the sort of intellectual disability, as you see when the child is young, if you look at the X axis, the difference between normal and abnormal is smaller and that increases over the time. Therefore, the reassurance that sort of your child will be okay over the time has to be guarded because it may mislead the parents. Now, if you look at the red and green lines, they say they are showing a true regression but the child has been developing okay over the certain period of time, then the development plateaus and then it tails of going down to the bottom. So one has to know and be specific in what one talks about. Um when one such of sees that the specific patterns of development. So thank you. This is really a big talk, really a lot of such of can be spoken about. But uh watching Children is found because child's development is fascinating. Uh There's such a anil strive to um to learn and to discover and the child's curiosity is enormous and I really think it's just such a fun discipline um to dedicate your professional life. Now, I'm just really looking whether there is any um is there any questions? No, I think that's all but done. So, thank you very much. Thank you very much. I can see as that has had. Uh Yes, yes, you said uh we shouldn't use the word development delay. So what, what we could say that element is not uh well, sometimes it is okay providing that it is delay across one area and that you think the child will catch up in their development, just giving an example, speech and language delay. If you have a child who's understanding of spoken language is normal, um if there's family history and uh then you can sort of think that perhaps you have a child who presents with delay and why, why? Because you know that that child should catch up with normal population and they will um you know, we'll progress with the normal development. However, if you see, let's say a child with the Trisomy 21 where you know that cognitive development is impaired and when you know that they will never read cognitive development of a normal child, then saying the developmental delay is incorrect because as this slide showed the difference, yeah, the difference between those with the lower I T s and those who have normal I twos increases. So they are not catching up. It sort of is really getting bigger and bigger. And because of that, it can be misleading. So um one has to be careful, impairment probably is a better word really. And as time goes by, we have to really do uh commit ourselves to intellectual disability or learning disability time really. That's all what it is really just be mindful and don't give her parents false hopes. One of the uh Hallmarks was uh was really smiling with a child when you smile to it in a child's smile. This is a hallmark of development, but this is also seen as a child who is not uh taking care of unknown Gleick did might not smile or might not interact properly or might not even interact at all. So for this, we can say either development delay or uh effect of neglect. So what we say, well, you can't really say neglect unless you have evidence that there is uh neglect going on really. And yes, psychosocial deprivation is a very well known factor to the Children not progressing with the normal development. However, obviously saying calling it neglect, you, you have to have evidence. It is just one of the explanations for the situation you see. And we cannot just simply uh specifically or more directly put a diagnosis of autism because that would be, first of all, that would be scaring or emulating the parents itself. And it will specify, are diagnosing autism, the many other factors which come together in one day, not just one delay. Well, when you talk, I think that didn't we have this discussion last week as that there was somebody who just with whom we sort of talked about autism and really possibility of autism as a present being caused by the sort of environmental factors. Firstly, autism is the condition where there is, there's a problem with social communication difficulties, not and not only just speech and language delay really. So it's a much developmental condition really while sometimes you have a Children who have problem just with speech, but actually they have a normal development otherwise. And then obviously the causes can be multiple really. So it's really quick that important, ready to identify what is the issue. Um Is it just because their cognitive development is such of slower? Is it because they've got the motor development problem? For example, they can have several policy and they can have weak muscles which do not help them to articulate and then they will have a speech and language difficulties. Thank you. I think there's somebody else who's, oh, no, maybe it's the same. I think that's all, isn't it? And let me just check up on the chat. Thank you very much for coming. It's a great pleasure and thank you and see you next time.