Families of children with motor disabilities, such as cerebral palsy, Duchenne or Becker muscular dystrophies, or spinal muscular atrophy commonly describe a long and often heartrending “odyssey” of tests and consultations before they arrived at the correct diagnosis. As such, initiatives related to neuromotor screening and global motor delays are a priority area for the Program to Enhance the Health and Development of Infants and Children (PEHDIC)—a cooperative agreement between the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC).
Understanding the Need for Clinical Guidance Regarding Neuromotor Screening: Physician and Primary Care Provider Education
The AAP convened an Expert Panel focused on improving early detection of motor delays and examining current provider practices regarding medical work-up of children identified with global delays. Information gathered from focus groups and a Quality Improvement Innovation Networks (QuIIN) survey of primary care providers documented the need for clinical guidance regarding the identification, workup, and referral of children with possible neuromotor problems or delays. The focus groups revealed that many pediatricians often concentrate on developmental screening for social-emotional concerns such as autism, paying less attention to motor delays. To address this need, the first activity of the Expert Panel was to develop a clinical report.
Motor Delays: Early Identification and Evaluation
The AAP clinical report, Motor Delays: Early Identification and Evaluation, and accompanying algorithm, was published in the June 2013 issue of Pediatrics to guide pediatricians in the screening and workup of children with suspected motor delays. Specifically, the report offers guidance regarding children who demonstrate motor delays and variations in muscle tone, and contains an accompanying clinical decision algorithm to inform care provision. Subsequent physician and provider education opportunities are in development utilizing this clinical report.
Implementing the Neuromotor Screening Recommendations in Practice
Earlier identification of motor delays allows for timely referral for developmental interventions as well as diagnostic evaluations and treatment planning. Through the video vignettes below, three physicians discuss the ways in which primary care pediatricians can use the Motor Delays: Early Identification and Evaluation clinical report and algorithm to enhance their developmental surveillance and screening for neuromotor impairment.
Expert Panel Participants
|Joseph Hagan, Jr, MD, FAAP|
Dr Hagan is a clinical Professor in Pediatrics at the University of Vermont College of Medicine and the Vermont Children’s Hospital. He is also Co-editor of Bright Futures Guidelines for Health Supervision of Infants.
Watch Video: Screening as an important part of preventive services (1.38 min)
Q: Why is the early identification of global motor delay so important for primary care providers?
A: The Motor Delays: Early Identification and Evaluation clinical report and algorithm provides recommendations regarding screening and observation, as well as guidance regarding how to interpret findings, and start you on a path of care for the child in a timely fashion.
Watch Video: What if you find something wrong? (1.31 min)
Q: How can the algorithm be used when a global motor delay is identified?
A: The algorithm for surveillance and screening provides the first steps a pediatrician should take if he/she has a concern.
Watch Video: Neuromotor screening recommendations are simple (1.18 min)
Q: What do primary care physicians need to know about neuromotor screening?
A: The screening recommended in the Motor Delays: Early Identification and Evaluation clinical report and are simple. Pediatricians should leverage existing observation and physical exam techniques already a part of 9-, 18-, 30-, and 48-month visits.
Watch Video: Do you know what to look for? (3.19 min)
Q: What has the American Academy of Pediatrics done to address the issue of global motor delays?
A: The AAP conducted a needs assessment and focus groups with primary care physicians which revealed that many did not know proper way to assess for motor problems; in response the Motor Delay: Early Identification and Evaluation clinical report and algorithm provides simple screening and surveillance recommendations enhancing the activities already included in the 9-, 18-, 30-, and 48-month visits.
Watch Video: What are developmental surveillance and screening for motor delay? (2.20 min)
Q: Considerations for the primary care physician in looking for motor delays during well-child visits
A: Pediatric primary care physicians should been performing developmental surveillance; that is, watching for milestones. Physicians should pair this with use of a developmental screening tool and input from the family.
||Dipesh Navsaria, MD, FAAP, MPH, MSLIS|
Dr Navsaria is a pediatrician at the University of Wisconsin School of Medicine and Public Health. He serves as director for the Pediatric Early Literacy Projects at the UW School of Medicine and Public Health and as medical director for Wisconsin’s Reach Out and Read program.
Watch Video: What is good developmental screening? (2:46 min)
Q: Using early literacy promotion for developmental screening
A: How can the primary care physician perform good developmental screening – walk in with a book rather than a stethoscope to assess for gross motor, fine motor, social interaction, language, vision and hearing.
Watch Video: What can primary care pediatricians do to assess for motor delay? (1:07 min)
Q: What has the AAP done to address global motor delays?
A: The Motor Delay: Early Identification and Evaluation algorithm for developmental surveillance and screening provides primary care providers with an initial evaluation and easy to use background information so that pediatricians can assess earlier rather than taking an observational approach.
Watch Video: Observation skills are key to assessing for global motor delay (1:18 min)
Q: What are 3-5 important items a pediatric primary care provider should consider when evaluating an infant or young child for global motor delay?
A: Pediatricians need to relay on their observations skills – watch what the child is doing globally and determine if something does not seem right about the way they are moving. Take a moment to observe the child while not in his/her parent’s lap and assess the quality of the child’s movement.
Watch Video: What to look for regarding global motor delay (0.40 min)
Q: Why is early identification of global motor delays so important for primary care pediatricians?
A: Recent attention to delays of social, emotional and language delays has meant that global motor delays are not addressed as much during the exam. In addition to sitting and walking, pediatricians should look for discoordination, clumsiness, and apparent weakness.
||Michelle Macias, MD, FAAP|
Dr Macias is a developmental and behavioral pediatrician at the Medical University of South Carolina. She is the immediate past chairperson or the AAP Section on Developmental and Behavioral Pediatrics.
Watch Video: Early detection of children with neuromotor disorders (1:34 min)
Q: Can you discuss the algorithm from a developmental and behavioral specialist perspective?
A: The algorithm provides practical guidance that does not add to the burden for primary care doctors by reinforcing the motor exam as part of developmental screening. Screening at the 9-, 18-, 30-, and 48-month visits should bring down the age of diagnosis to facilitate early intervention and improve outcomes for children.
Watch Video: Co-management for children with a diagnosed motor delay (0.59 min)
Q: How do the developmental and behavioral specialist and the primary care physician work together to co-manage the care and treatment plan for a child with a motor delay?
A: The role of the developmental specialist is to support the medical home; co-management and level of input by the developmental specialist depends on the severity of the neuromotor impairment.
Watch Video: When to refer to Early Intervention (0.47 min)
Q: What should the primary care physician take into consideration when making a referral to Early Intervention?
A: Don’t wait to make the referral to Early Intervention; refer even if the child has not yet been seen by a specialist or subspecialist.
Watch Video: Tests that facilitate the diagnostic process (2.02 min)
Q: What tests should the primary care provider order before referring to specialist care?
A: The algorithm in the Motor Delays: Early Identification and Evaluation clinical report recommends that pediatricians order a CK and TSH for low tone and a neuroimaging for high tone as soon as concern is identified.
The following AAP groups are represented on the Expert Panel: Bright Futures Steering Committee
, Council on Children with Disabilities
, Committee on Genetics
, Section on Developmental and Behavioral Pediatrics
, Section on Neurology
, and Section on Orthopaedics
. External organizations represented on the group include CDC/National Center on Birth Defects and Developmental Disabilities
and American Academy of Cerebral Palsy and Developmental Medicine