The 10 Aspects of a Neurodevelopmental Assessment
“Details matter. It’s worth waiting to get it right”, said Steve Jobs, founder of Apple. I am frequently asked what is a Neurodevelopmental Assessment? And what does it involve? Neurodevelopmental assessments (NDAs) are a detailed and comprehensive evaluation of your child’s abilities, difficulties, and needs. Therefore, it is paramount to get this right. Hence, a NDA needs to be carried out by a trained and competent person according to NICE.
NDAs are part of a process of establishing a neurodevelopmental diagnosis. I have covered ‘How to prepare for a neurodevelopmental assessment’ in ten tips in my previous video. In this article, I have broken down the complicated subject of neurodevelopmental assessment into 10 simple and easy to understand pieces.
As you can appreciate, every child is different. Hence these assessments are tailored according to the needs of the child, the parental enquiry, and are guided by history. Moreover, this is not a sequence that is set in stone. We, as paediatricians, must juggle and modify our assessment sequence based on the child’s condition, cooperation, interest, and motivation. We do so to get the best and complete information about a child’s strengths, weaknesses, and needs.
#1: Clinical Observations
The observations I make can be summarised by the acronym ABCDEFG! They stand for attention, behaviour, concentration, dysmorphism (an unusual feature in a body structure), eye contact, family interaction and general aspects such as spontaneous speech, articulation, exploratory behaviours, and speed of doing things. Clinical observations which are being studied throughout the assessment help us to notice tics, anxiety, mood, sensory behaviours, and the higher mental functions of a given child.
#2: Scoring Test tools
After listening to your concerns or reading your referral letter, we will have sent some specific forms for you as parents and for your child’s teachers to complete. These could be test tools such as Conners Rating Scales for potential ADHD, SCQ (Social Communication Questionnaire) for possible ASD, or M-ABC (Movement Assessment Battery for Children) for suspected Dyspraxia. Ideally, in my practice, I try to score these before the assessment wherever possible. This enables me to focus on the aspects that need your and your child’s engagement. From decades of experience, I have also found this method to be time-efficient and effective. I then start with some non-verbal items from a developmental assessment.
#3: Developmental assessment
The purpose of the developmental assessment is to find out where exactly is your child functioning in relation to his peers. We are not just interested in what they do, but also how they do a given task. Depending on the nature of enquiry either a developmental screening test such as the Ten Questions test, Denver-II test, or ASQ-3 (ages and stages-3) or a detailed assessment such as Bayley-III or GMDS-ER. These tools can provide information about a child’s motor, speech, language, and cognition abilities. Specific developmental profiles are suggestive and supportive of certain neurodevelopmental disorders. My practice is to start with non-verbal test items that help the child settle and then introduce language items before moving on to the specific assessments.
#4: Specific assessments
Once again, depending on the nature of the parental concern and the presenting features of your child’s difficulties, certain specific assessments are considered. These could be assessments such as ADOS-2 (Autism Diagnostic Observation Schedule) for ASD or a diagnostic interview for ADHD or motor examination and evaluation for Dyspraxia that would give us an estimate of where your child is functioning in relation to his peers. During the above assessments’ signs of a speech disorder, language disorder, intellectual disability, or any sensory impairments if present, become clear. By this time, many children have warmed up and are ready to cooperate with growth and subsequent assessments.
#5: Growth assessment
We measure a child’s height, weight and head circumference and plot these on the growth charts. We will be able to give you the centiles of each growth parameter and let you know your child’s BMI (Body Mass Index). Growth assessment is vital to carry out, as many genetic conditions and syndromes that cause learning disability or developmental delay can also be associated with abnormalities in the above growth parameters. Growth assessment is just one aspect of looking for dysmorphology or defects.
#6: Dysmorphology
This basically means we are on the lookout for any abnormal differences in the body structure that could give us clues to a genetic disorder. A head-to-toe check is carried out to pick up or rule out any abnormal features. Most children with neurodevelopment disorders do not have a syndrome or an identifiable genetic condition as a cause of their difficulties. Nevertheless, there are dozens of genetic syndromes, some well-known ones such as Fragile X or Foetal Alcohol Syndrome, that can present as ADHD or ASD or both. The exercise to look out for any abnormal features flows imperceptibly into a full physical check.
#7: General physical examination
Just like a MOT check for your vehicle, a systems check is undertaken to make sure that all the systems of your child’s body are working properly. More importantly, a physical examination helps in ruling out the possibility of an underlying medical disorder, impacting on your child’s development and behaviour. As part of this, we examine the following systems, cardiovascular, respiratory, gastrointestinal, spine and more. I then move to examine the nervous system as most children have relaxed by now.
#8: Neurological examination
Assessment of neurology, as you may guess, is of prime importance in the neurodevelopmental evaluation. Several neurocutaneous and neurogenetic disorders can be associated with neurodevelopmental disorders. Moreover, the development and behaviour of the child could be a manifestation of the underlying neurological issues. As part of this we examine, a child’s range of movements, reflexes, resistance in muscles to passive movement of a joint, assess for any hypermobility, any weakness, any asymmetry, head, face, and neck for any abnormalities. We look for the presence of any birthmarks, any skin signs, or signs of any movement disorder. I then make brief notes to help me collect my thoughts, interpret the findings, that help me in carrying out a differential diagnosis/diagnosis.
#9: The process of differentiation
It is common to have more than one neurodevelopmental disorder, e.g. a child with ASD (Autism Spectrum Disorder) could also have ADHD (Attention Deficit Hyperactivity Disorder) and Dyspraxia. You can read more about Differential Diagnosis, in one of my previous articles. These ND disorders do not just co-occur but make our task more difficult by sharing some similar signs or symptoms. For example, a child with ASD can be referred to as possible ADHD and vice versa. So, ADHD can be a co-morbidity as well as a confounding factor. This is because these disorders share similar pathways in the brain and hence can display similar behaviour or development issues. Therefore, the process of differentiating and ruling out other conditions must be thorough and systematic. We then interpret information gained from history, reports received from school, from therapists, and all the above components of NDA, before arriving at a diagnosis.
#10: Management plan
A diagnosis of a neurodevelopmental disorder is a life-long one. And since a wrong diagnosis can result in poor outcomes for the child, and their family, due diligence is required before you arrive at a plan to manage. A decision is made regarding the need for undertaking any investigations such as hearing, vision, imaging, or genetic tests. A robust diagnosis will help the clinician to detail the numerous facets, strategies and resources in his/her management plan that would enable the child and help empower the family with necessary support and information.
I have summarised these 10 pointers about aspects of NDA in a short video below :
I shall cover the ‘management plan’ in detail in my next article. As you can see from the above, NDAs are like piecing together a jigsaw puzzle to build a complete and comprehensive picture of a child’s strengths, weaknesses, and needs. One should never make a ‘spot’ diagnosis. There are no short cuts, and the NDA process cannot be rushed through. Also, identifying co-morbidities and or any other disabilities is a time-intensive process. This usually is the only occasion in a child’s life, to have a paediatrician examine your concerns thoroughly and to assess your child’s needs and or disabilities completely. ‘You miss 100% of the shots you don’t take’, said Wayne Gretzky”. Every child has potential, but not everyone can see it.
References
- Gada S. Community Paediatrics. Oxford Specialist Handbook in Paediatrics. Oxford University Press. ISBN 978 0 19 969695 6. Published Sept 2012.
- National Institute for Health and Care Excellence. Autism spectrum disorder in under 19s: recognition, referral, and diagnosis. Clinical guideline [CG128]. September 2011, last updated December 2017.
- Kelly AM, Seal A, Robinson G. Assessment and Formulation chapter. Children with Neurodevelopmental Disabilities: The essential guide to assessment and management. Mac Keith Press. ISBN 978 1 908316 62 2.
- Hyman SL, Levy SE, Myers SM. Identification, Evaluation and Management of Children with Autism Spectrum Disorder. American Academy of Paediatrics, Council on Children with Disabilities, Section on Developmental and Behavioural Paediatrics. PEDIATRICS Volume 145, number 1, January 2020.
- Augustyn M, Erik von Hahn L, Patterson M, Bridgemohan C, Torchia MM, Autism spectrum disorder: Evaluation and diagnosis. UpToDate. Updated Jul 2019 accessed Jan 2020.
