Emeritus Professor

Introduction —  We wish to express our sincere gratitude to the organizers of this conference for asking us to deliver this keynote address. We are sure that the conference will achieve its aim of raising sufficient awareness on issues of Child Developmental Disorders in Nigeria so that relevant strategies can be adopted to prevent them and improve the outcome for affected children.

Those of us who are familiar with events in this university will recollect that the 1990s were difficult years for the institution. As one historical account puts it,

“But all too soon, the university’s steady growth and internal harmony appeared to flounder…..The once integrated community which was united in a single course for the pursuit of academic excellence, had lost cohesion and diversified its interest to less edifying concern.” 1

So it was that at the turn of the millennium, we all in this university collectively wished for a crisis-free institution – from the point of frequent student rampage and vandalization and recurrent academic and non academic staff work stoppages. The university community wished for a drastic improvement in water and electricity supplies which had become some of the flashpoints that ignited mass discontent. We aspired to do something about our academic institutions – the structures and the delivery as well as supervision of academic work. It was our desire to liberalize and expose the University in a local as well as international manner.

Among the many important organs which the university set up at that time to enable it achieve these lofty aims and aspirations, was The Linkage and Exchange Unit of the Vice-Chancellor’s Office, which was charged with the responsibility, among others, of establishing

Local and international linkages with philanthropic organizations tertiary educational institutions, professional bodies, industry and government.

It is therefore gratifying to note that this important conference which has brought persons of diverse academic and professional disciplines together in an intersectoral collaboration has been midwifed by the Linkages and Exchange Unit of the Vice Chancellor’s Office of the University of Port Harcourt in fulfillment of that mandate. We all wish the Unit more of such successes.

Next we wish to congratulate the budding Association of Child Development and Communication Disorders of Nigeria and the Department of Linguistics and Communication Studies of this university for concerning themselves with a highly neglected area of work in this country – the total development of the child, including the ability to communicate properly, an issue that should really remain the right of every child. For indeed a strong relationship does exist between appropriate development and the ability to communicate properly.

In all this, we all must remember and pay due reverence to the memory of the Mother of Linguistics in Nigeria, the late Professor Kay Ruth Williamson (1935-2005). Born into an aristocratic family in Britain, she, as of choice, lived the life of a true academic among the lowly in Nigeria. If her earthly possessions were few, like all genuine scholars, her academic portfolio was gigantic, consisting, among others of 12 Books and Monographs, 77 Articles and Chapters and 17 Practical Booklets!

She left Nigeria in her complete form for medical attention abroad, but was returned to us in Ashes, following an unexpected death and cremation – a situation that prompted a short poem as part of the special convocation that was held in her honour on the 26th of March, 2005; some excerpts:

ASHES

…..

But where now the forty thousand books? Where now the thousand laurels?

And how about the lonely brown beetle she so cherished? All drained into these spent ashes too?

O gracious gift spent to nourish other lives. Earth’s choicest seed, our Dean, our Monument, our Mother

Show us our emptiness at this hour. But feed us still as you secretly secret nectar

For the meek and famished. Dear Pilgrim, may your sacred flame lead us To the heights you soared

May Uniport and humanity. Tell of your native charm through eternity. 2

With this as introduction, the main text of the lecture will consist of a short review of Global concerns on the issue of Child Development followed by Definitions and Explanations, which would seek to clarify some terms that would be used during the lecture for ease of reference; we shall then briefly explain Normal Pattern of Development and their Determinants as a foundation for understanding aspects of developmental disorders; next we shall look at Developmental Disorders themselves – their causes, and indicate how they could be detected; this will lead us on to a discussion on the Prospects and Challenges of Developmental Disorders where we shall ventilate some approaches for tackling the problem. We shall conclude by advancing reasons why the proposed Development Centre for Children with Developmental Disorders should be sited in Port Harcourt and at the University of Port Harcourt.

Global Concerns

As a means of domiciling the issue of Child Development in its proper perspective, we wish to observe the serious concerns of the global community on the matter. The Millennium Development Goals (MDGs), 3 which were ratified by 189 Heads of State and Governments in 2000, probably constitute the most audacious plan ever made by mankind to improve the quality of life and to assure the well-being of all. The Goals refer frequently, albeit in a tangential manner, to the issue of proper Child Development as a precursor to subsequent healthy living in a number of the 8 development goals, 21 quantifiable targets, and 60 indicators by the target date of 2015. Specifically, MDG 2 requests that by that target date, children everywhere, boys and girls, should be able to complete a course of primary school education. This target cannot be met unless early proper development of all children, including the development of their communications skills, is assured. Furthermore, in The State of the World’s Children 2008, 4 it is stated:

Depriving infants and young children of basic health care and denying them the nutrients needed for growth and development sets them up to fail in life. But when children are well nourished and cared for and provided with a safe and stimulating environment, they are more likely to survive, to have less disease and fewer illnesses, and to fully develop thinking, language, emotional and social skills. When they enter school, they are more likely to succeed. And later in life, they have a greater chance of becoming creative and productive members of society.4

Here in Nigeria, the Nigeria’s Child Rights Act of 20035 states, among others, that every child has a right to survival and development. It defined free, compulsory basic education as the right of every child and charged government with the responsibility of providing this. Furthermore, it pleaded with governments, guardians and institutions to endeavour to provide for the child, the best attainable state of health.

These rights can only be attained when the myriads of children with different degrees of developmental disorders are identified and a system of support provided to ensure they attain their optimal developmental potentials. The theme of this conference is therefore apt to the current efforts to attain the MDGs in Nigeria. It is our expectation that at the end of the deliberations, we shall derive useful strategies that will meet the needs of children with developmental disorders.

Definitions/Explanations

• Development: Progressive acquisition of physical (motor), cognitive (thought), linguistic (communication) and social (emotional) skills and or attributes.
• Developmental Disorders: Any one of the group of conditions arising in infancy or childhood that are characterized by delays in biologically determined functions of language, movement and actions.
• Prospect: Possibility of something happening soon; vision of the future.
• Challenge: A difficulty which stimulates interest or efforts.

Our task at today’s presentation therefore is to review child development and developmental disorders. Furthermore we are to discuss how to ameliorate the difficulties involved in enabling the child with developmental disorders to have an improved quality of life.

Normal Pattern of Development and their Determinants6-10

As was defined earlier, development is the progressive acquisition of physical (motor), cognitive (thought), linguistic (communication) and social (emotional) skills and/or attributes. It is an increase in the function and complexity of these skills in an individual. It is influenced by biological, psychological and social factors. These may act singly or in combination to determine the course of the child’s development. It is therefore important that all who are involved in the care for children, either at home, school or within the community get conversant with the normal development so that developmental disorders can be detected on time and appropriately managed in order to reduce their impacts on the child as a whole.

Normal neurological development in a child requires the maturation and intactness of the nervous system. Abnormal formation of the nervous system or its damage are the bases for delayed or non-acquisition of neurological developmental mile stones. This development in children starts from the head down wards- i.e.- cephalo-caudal and progresses in proximo-distal direction with the gross skills being acquired before the fine ones and proximal parts being developed before distal ones- thus a child must acquire neck control before sitting and must sit before walking.

Development starts from fetal life through adolescence but at different rates for different children – some children being faster than others but all must follow the same sequence. Neurological development is however most crucial in the first 3 years when neurons divide and aborise with increasing complexity (Fig 1).9 Table 1 shows the acceptable ages at which different mile stones should be achieved in the first two years of life.10

Regarding the classifications of the factors that affect normal pattern of development, these can be divided into Maternal, Fetal and Environmental Conditions. Maternal conditions include substance abuse like alcohol and drugs which result in malformations such as the Fetal Alcohol Syndrome – involving brain damage, mental retardation, impaired growth as well as head and face abnormalities; intrauterine infections like rubella and HIV/AIDS10 which may give rise to HIV encephalopathy and AIDS Dementia Complex (ADC). Obstructed labour in the mother could also result in cerebral injury in the baby and birth asphyxia.

Prematurity, birth injuries, complications arising from the vaccine preventable diseases and trauma are all serious conditions that could compromise the development of the child. But none would probably compare in severity to the damage that could be done in the short and long term, to the development of the child by malnutrition.11-12 Here, both overall calorie deficit and the inadequacy of some elements in the diet of the child are important – a good example of which is Iodine.

Iodine plays a very crucial role in brain development and its absence or deficiency may cause serious neurological sequelae which could give rise to irreversible intellectual disability. Although the hormones thriodotyronine (T3) and thyroxin (T4) are thyroid hormones which are synthesized and metabolized essentially in that gland, they play a vital role in the early growth and development of most organs, especially the brain. Since the fetus is unable to manufacture these hormones in the first trimester of intrauterine life, it is completely dependent on maternal supply for its requirements and this underscores the need for support for the Universal Salt Iodisation (USI) policy of our country’s National Agency for Food & Drug Administration & Control (NAFDAC) to ensure a reliable source of iodine in the diet of everyone, especially pregnant women.12

As for environmental conditions, lead and fluoride poisoning are common examples. They give rise to dental caries, bony structural deformities and possibly, congenital malformations.

Developmental Disorders

Learning and developmental disabilities (LDDs) include functional limitations that manifest in infancy or childhood as a result of disorders of or injuries to the developing nervous system (Institute of Medicine Committee on Nervous System Disorders in Developing Countries 2001). These limitations range from mild to severe and can affect cognition, mobility, hearing, vision, speech, and behaviour. 13These disorders can be categorized into pervasive conditions in which many types of development are involved e.g. autism or specific disorders in which the handicap is an isolated problem-e.g. dyslexia. Developmental disorders occur worldwide with the poorer nations having higher incidences than the richer ones.

Although the global incidence is not known, in high-income countries it is estimated that10 to 20 percent of children have some learning and developmental disorders.13 The American Academy of Paediatrics noted that about 16-18% of American children had disabilities such as speech-language impairments, learning disabilities, and emotional/behavioral disturbances. It also documented that although children with developmental disorders are twice as likely to seek health care, only 20-30% of them are diagnosed before school entry.14 The incidence in Nigeria is not known but the existence of neurology clinics in several tertiary health facilities in Nigeria and the large numbers of deformed children begging on our streets attest to the magnitude of the problem in our setting. Additionally, the subtle nature of many development disorders and the fact that many affected children may appear to be developing normally in the early years, contribute to the under-diagnosis and possibly, the neglect of the problem.

In spite of these difficulties, it is important to ensure early detection of these conditions as this has been shown to increase the chances of affected children to graduate from high school, hold jobs, live independently, avoid teenage pregnancies, delinquency and violent crimes. Developmental disorders can occur at any age but they are commoner in the early years when the growth of the brain is most rapid (Fig. 1).9 Males are said to be more affected than females.

The known causes of LDD are numerous and include genetic factors, nutritional factors, infections, toxic exposures, trauma, perinatal factors, and multifactorial conditions.13 These conditions can start before, during and after pregnancy. Factors operating in the mother such as drug/alcohol abuse, malnutrition can affect the baby before and after conception. Prolonged use of alcohol during pregnancy has been associated with birth defects termed fetal alcohol syndrome. Other risk factors such as intrauterine infections like rubella, syphilis, Human Immunodeficiency Virus (HIV), malaria, etc all increase the risk for developmental disorders because of their effects on the growing brain. But probably, the most celebrated case is the thalidomide disaster of the 1950s and 60s in which thalidomide, a drug that was given to pregnant women to relieve early morning sickness and induce sleep, caused severe limb defects in over 12,000 children (Fig.2)13.

After birth, factors such as prematurity, low birth weight, perinatal asphyxia, neonatal jaundice and infections all increase the risk of the child getting a disorder. In the post neonatal period, traumas (head injury), infections especially those affecting the nervous system such as meningitis, tuberculosis, poliomyelitis, and others increase the risk of the child getting brain damage, becoming blind, deaf and dumb or with various forms of limb disabilities.

An adverse socioeconomic environment also contributes to increased risk of developmental disorders- as for example, environmental lead poisoning. It is estimated that 15 to 18 million children in developing countries suffer from some form of permanent brain damage from lead poisoning and that worldwide, about 4% of minor mental retardation is attributable to lead poisoning (Fig. 3). Unfortunately, lead is so common in the environment in paints and water distribution pipes, that estimates indicate that hundreds of millions of children and pregnant women are exposed to different sources of lead. Another important environmental poison which also affects children’s intellectual development is fluoride poisoning. Fluorosis is endemic in 25 countries in the world and the sources of the fluoride include water and air. Iatrogenic sources of fluoride are from burning high-fluoride coal as in China where more than 10 million people were affected with dental and skeletal fluorosis. Dental and skeletal fluorosis are devastating problems in many countries, most commonly from fluoride contaminated water, followed by an excessive use of dental preparations to prevent caries. Fluorosis leads to deformities / abnormalities, short stature (cretinism), bow-leg, knock-knee, deaf mutism, low IQ and mental retardation (Fig. 4)

Types of disorders

Developmental disorders have been classified into the following7

• Disorders of motor function- cerebral palsy
• Disorders of cognition(mental sub normality)
• Neurobehavioural disorders-e.g. attention deficit hyperactivity disorder, autism spectrum disorders
• Learning disorders of childhood-dysgraphia, dyslexia, dyscalculia

These will be discussed briefly:

Disorders of motor function- the commonest example of this group of disorders is cerebral palsy- a chronic disorder of posture and movement resulting from a non progressive but permanent damage to the growing nervous system. It is of various types – hemiplegia, diplegia, dikinesia, ataxia, mixed forms, etc. Cerebral palsy can exist alone or in association with other disorders like hearing, visual and mental impairments.

Disorders of cognition-Mental subnormality-this is said to be present in a child if his/her mental capacity is so impaired that he/she requires special care, education or placement in special institutions to help him/her cope with the activities of daily living. The determination of the existence of mental subnormality is done using specific assessment tests (Table 2) of which the Intelligence Quotient test and the Draw a person test, are common examples. Using the intelligent quotient test, mental sub normality is classified as follows:

• IQ <20 Profound
• IQ 20-35 Severe
• IQ 36-51 Moderate
• IQ 52-67 Mild
• IQ 68-83 Borderline

A child with profound mental sub normality is unable to protect himself from physical dangers, cannot speak more than a few words and requires care just like a baby. In moderate to severe mental sub normality, the child can protect himself from physical danger, speaks a little, can read and write and only requires close supervision. The well adjusted mildly sub mentally developed child can live as a well adjusted adult. Such children form the majority of the mentally subnormal and would require special class placement to go through school.

Neurobehavioural disorders: These are varied and include the following:

• Attention deficit hyperactive disorder:-This is a condition characterised by inattentiveness and hyperactivity/impulsivity. It is present in about 3-10% of school children aged 6-12 years.
• Autism spectrum disorders:- Autistic disorder, a prototype of the Autistic Spectrum Disorders, is a chronic neuron-developmental disorder characterised by quantitative impairment of the triad of social, communicative and imaginative development. Other disorders in the spectrum are Aspergner Syndrome and Childhood Disintegrative Disorder.

Learning Disorders of childhood: These result from impaired ability of the child to learn. They are often under reported. The different forms of these disorders are:

• Dyslexia:-a failure of a child to learn to read with normal proficiency despite conventional instruction, proper motivation, intact senses, normal intelligence, and freedom from gross neurological deficit. It is called specific reading disability or congenital word blindness. Males are more affected than females.
• Dysgraphia: This disorder involves the inability of a child who sees what he wants to write clearly but can neither write nor copy words or figures.
• Dyscalculia: The child is unable to do mathematics- he is unable to do simple calculations identify symbols and ideas.

Detection of developmental disorders

The most important factor in the early detection of developmental disorders is to have a high index of suspicion. Parental/guardian concerns that their child has a problem should be taken seriously as these may serve as pointers to the existence of developmental delays or disorders. Additionally the presence of some signs should also raise the possibility of the existence of developmental disorders (Table 3). In order to recognize the problems early specific features indicating the type of disorder in the child should be sought for. For example, a child with speech and language problem may have the following features:

• Failure to talk by the age of 2 years
• Speech is largely unintelligible by the age of 3 years
• Child leaves off many beginning consonants after the age of 3 years
• Child is not using 2-3 word sentences by the age of 3 years
• Child uses mostly vowel sounds in his speech
• Word endings are consistently missing after the age of 5 years
• Voice is monotone, too loud, too soft, or of poor quality that may indicate hearing loss.

Developed countries have used the practice of surveillance to aid early detection of developmental disorders.14 Surveillance is a longitudinal process that commences with routinely eliciting and addressing parents’ concerns, followed by reviewing medical history, maintaining a record of developmental progress, making accurate and informed observation of the child and parent interaction, identifying risks and protective factors that often predict developmental risks or resilience and ensuring that needed interventions are promptly delivered. The child who through surveillance is considered to have a developmental disorder is screened using appropriate tools. The screening can be carried out at any contact of the child with the health system but additionally at 9, 18, 24 and 30 months of age when the risk is highest. Some centres use parent- administered screening tools which have been shown to have a number of limitations. These include the level of education of the parents, the over diagnosis of the problem because the educated parents will tend to use criteria such as intelligence, academic ability, language skills and those with numerous psychological risk factors.

When there is a suspicion of developmental delay or disorder, the child should be assessed to confirm its existence, ascertain the extent and plan the management strategies for the child. This assessment involves history taking to establish the existence of a delay/disorder, its evolution, possible aetiology and what had already been done. The child will then undergo a detailed physical examination and developmental evaluation using some assessment tools.8,14 It should however be noted that the child’s performance during these assessment tools can be affected by factors such as illnesses, sadness or fright, strange environment and test objects. Prematurity can also affect the child’s level of development and therefore corrections for the gestational age are recommended for up to 18-24 months. Table 4 shows some of these processes.

Prospects and Challenges

Early detection of children with developmental, behavioural and emotional delays, as well as risks and disability problems is an important concern not only of physicians but also of parents and all those who are involved in the quest for a better life for all children. The concern and goodwill that is generated by the global unease on the matter should be exploited to tackle the challenges of childhood developmental disorders especially in resource-poor settings like Nigeria.

Unfortunately, in this country, we have, for too long, ignored the need to optimize the development of children and that of those with developmental disorders. Although the government has adopted the Child Rights Act (2003)5 and is signatory to the MDGs, enough is not being done to promote the growth and development of children – the following questions remain to be answered:

• What is the national/local prevalence of developmental disorders?
• How can we ensure early diagnosis so that prompt interventions can be put in place?
• Can something spectacular be done to improve the management of affected children?
• Do we have special facilities for the management of affected children as in most cases the prospects of cure do not exist?
• How are parents of affected children supported in our society?
• What are we doing about preventing disability in children?

It is desirable for national and local surveys to be done to determine the exact burden of the situation so that specific strategies can be put in place to address the needs for optimal development in children. This is especially important where utilisation of health facilities for preventive and promotive services is very low. Since Promotion of Mental Health is one of the components of the Primary Health Care System in Nigeria, can we strengthen this level of health care so as to detect and refer affected children early?

The attainment of the MDGs is one of the most important expectations of the present century. However, since its laudable goals cannot be completely achieved without attention being paid to the development of children including those with developmental disorders, is it not possible for us to review our strategies to ensure they are made more inclusive and effective? Can the currently high prevalence of aetilogical factors: intrauterine infections, teratogenic agents, childhood infections, malnutrition, and environmental pollutants be addressed through preventive measures and improved services? Can we not implement some well-mapped out programmes of maternal and child health, environmental health and sanitation that will ensure that the child, his mother and the environment are made safer for the growth and upbringing of children?

With regards to the challenges, some of what has to be addressed include using what is available to optimise the care and support for the developmentally disordered child and his/her family. It would appear that at the national level the efforts to address the needs of these physically and mentally challenged persons are inadequate to meet the needs of the ever increasing numbers of such persons. For example- is there provision for them to hear the news and other public addresses through lip reading in churches and other public gatherings? Do we have provisions for them in the facilities for conveniences? What of educational institutions? Individual organizations have made some inputs but these are not enough. The Pacelli School for the Blind in Surulere, Lagos, which was established 40 years ago by Catholic Missionaries, is Nigeria’s premier institution for the blind for Primary School Education. There are other schools for the blind as well as those for the deaf and dumb and other disabilities. But how many of these schools are equipped with the state-of-the-art teaching and communication technologies- electronic billboards, multimedia projectors, induction loops, brail machines, hearing aids, and captioned telephones.

Even for our diagnostic purposes, can we maximize the use of modern technology like MRI and CT Scans with our current level of electricity supply? What national support programmes are available for parents and guardians who cope daily with the rigors of looking after a brain dead child or polio paralytic?

If the large numbers of destitutes and disabled who are seen on our streets and highways are anything to go by, it becomes clear that our society has not yet evolved satisfactory means of dealing with the problem. To our minds, what is required is the formulation of proper legal instruments that would protect the rights of disabled persons in Nigeria and which would compel governments and other agencies to respect those rights.

Available information confirms that when properly looked after, many disabled persons rise up to commanding heights in the society as if to confirm the slogan of “ability in disability” and that “disable does not mean unable”. Franklin Roosevelt with poliomyelitis became the 32nd President of the United States of America. Ray Charles overcame abject poverty and blindness at the age of 7 and became known as the “Genius” from crossing countless perceived boundaries throughout his career. He redefined the very nature of jazz and soul music. Stevie Wonder, another icon and blind musical maestro, is an instant celebrity. Nick Vujicic, born without hands and legs in Melbourne Australia, after completing a bachelor’s degree became a motivational speaker and now travels round the world sharing his story and testimony. The former Chancellor of the Exchequer of Great Britain, who is now the Prime Minister of the country, Mr. Gordon Brown, lost his sight in one eye at an early age.

Some of these icons also exist in our own communities here in Nigeria. A blind physiotherapist and schoolmate of mine at the Lagos University Teaching Hospital not only rose to become the Head of that Department, but was also able to marry into a very respectable family and raise lovely children. Some persons with disabilities are professors in this university and Mr. Peter Bema, a blind boy of 20 is now the organist of the Royal Male Choir – a leading musical organization in the city of Port Harcourt.

Preventing disabilities

From the above, it is evident that the lot of the disabled child can be improved upon through a proper management of the currently available resources. The major challenge and prospect for disability is its prevention using the available methods and technologies. Prevention of LDD involves primary, secondary, and tertiary prevention activities: 13

• Primary prevention includes efforts to control the underlying cause or condition that results in disability. Examples include (a) maternal antiretroviral therapy to reduce the risk of mother-to-child transmission of HIV and (b) fortification of the food supply to prevent birth defects such as spina bifida and iodine deficiency disorders.

• Secondary prevention aims at preventing an existing illness or injury from progressing to long-term disability. Examples include newborn screening for metabolic disorders followed by dietary restrictions to prevent damage to the nervous system and effective emergency medical care for head injury.

• Tertiary prevention refers to rehabilitation and special educational services to mitigate disability and improve functional and participatory or social outcomes once disability has occurred.

We must therefore not just end with detecting developmental disorders but must develop appropriate strategies to prevent/reduce their occurrences in our environment.

Conclusion

In conclusion we wish, once again, to commend the wisdom in the formation of the Association of Child Development and Communication Disorders in Nigeria (ACDCDN). We observe that the task before the nascent association is one of sensitizing governments and members of the public to be alive to their responsibilities, researching on ways of preventing the disorders and advocating for the proper care of the disabled. This task is enormous.

The Association should therefore be as inclusive as possible in attracting to its fold, from all disciplines and professions, like-minded persons with interest in its core theme – The Developmentally Disabled Child. Furthermore, it should pursue, with tenacity, its dream of establishing a Development Centre for Children with Developmental Disorders, where issues of the developmentally disabled child can be studied, researched upon and subjected to scientific analyses.

Not withstanding its present predicament, Port Harcourt, suggests itself as the location of such a centre – It has an international airport as well as a seaport and is well connected to the other parts of Nigeria through good roads. With a strong Faculty of Humanities which harbours a vibrant Department of Linguistics and Communication Studies as well a robust College of Medicine where a Birth Defect Group already exists, the University of Port Harcourt, which has acquired experience in nurturing such centres, should house the Development Centre for Children with Developmental Disorders.

Table 1 Development Mile stones

Age	Psychosocial	Gross Motor Fine	Motor and Visual	Communication and Hearing
1 month	• Follows faces to themidline	• Moves all extremities equally• Lifts head when lying onStomach	• Opens handsspontaneously	• Startled by loud sounds• Cries• Quiets when fed andcomforted
2 months	• Follows faces past the midline• Smiles responsively	• Lifts head up 45 degrees when on stomach	• Looks at own hand	• Makes baby sounds such as cooing, squealing and gurgling
3 months	• Recognizes mother• Smiles responsively	• Can support head for a fewseconds when held upright	• Opens handsFrequently	• Responds to voices• Laughs
4 months	• Follows an object witheyes for 180 degrees• Regards own hand• Anticipates food on sight	• Bears weight on legs• Good neck control when pulled to sitting position• Lifts chest and supports self on elbows when lying on stomach	• Brings hands together in midline (clasps hands)• Grabs an object such as a rattle• Reaches for objects	• Turns head to sound
6 months	• Reaches for familiarpeople	• Rolls from stomach to back or back to stomach• Sits with anterior support	• Plays with hands by touching them together• Sees small objects such as crumbs	• Responds to name• Babbles
9 months	• Indicates wants• Waves “bye-bye”• Has stranger anxiety	• Can sit without support• Creeps or crawls on hands and knees	• Looks for a toy when it falls from his/her hand• Takes a toy in each hand• Transfers a toy from one hand to the other	• Responds to soft sounds suchas whispers
9 months	• Indicates wants• Waves “bye-bye”• Has stranger anxiety	• Can sit without support• Creeps or crawls on hands and knees	• Looks for a toy when it falls from his/her hand• Takes a toy in each hand• Transfers a toy from one hand to the other	• Responds to soft sounds such as whispers
12 months	• Has separation anxiety• Social interactions areintentional and goaldirected	• Pulls self up to standing position• Walks with support	• Points at objects withindex finger	• Says at least 1 word• Makes “ma-ma” or “da-da” sounds• Locates sounds by turning head
15 months	• Imitates activities• Finds a nearby hiddenObject	• Can take steps on own• Can get to a sitting positionfrom a lying position	• Can stack one cube ontop of another	• Able to say “mama” and“dada” to respective parents(sounds to identify caretakers)
18 months	• Initiates interactions by calling to adult	• Walks without help	• Can take off own shoes• Feeds self	• Says at least 3 words
2 years	• Does things to please others• Engages in parallel(imitative) play	• Runs without falling	• Looks at pictures in a book• Imitates drawing a vertical line	• Combines 2 different words

Source: HIV curriculum for Health Professions-Baylor College Paediatric HIV Initiative 200610 –page 122

The State of the World’s Children 2001- produced by UNICEF- page 12

Fig. 2: A child with limb abnormalities following the use of thalidomide in the pregnancy

Fig. 3: Effect of lead exposure on Population Intelligence Quotient (from Dr. Philip Landrigan (based on work by Dr. Herbert Needleman)

Fig. 4: Chinese children with Fluorosis (Pictures from A. K. Susheela of Fluorosis Research & Rural Development Foundation of India Fluorosis Research And Rural Development)

Table 2: Categories of Causes of Learning and Developmental Disorders13

Category Examples

Genetic

Chromosomal Down syndrome, chromosomal rearrangements

Segmental autosomal syndromes Prader-Willi syndrome, Angelman syndrome

Sex-linked, single gene Fragile X syndrome, Rett syndrome

Autosomal recessive Phenylketonuria, Tay–Sachs disease

Autosomal dominant Neurocutaneous syndromes, such as neurofibromatosis

Multifactorial

Genetic and nutritional Neural tube defects

Nutritional

Prenatal: maternal iodine deficiency Developmental iodine deficiency disorder

Childhood: vitamin A deficiency Xerophthalmia, night blindness

Infections

Prenatal or perinatal Toxoplasmosis, rubella, cytomegalovirus, herpes, gonorrhea, syphilis, group B streptococcus, chlamydia,trichomonas vaginalis, bacterial vaginosis, herpes simplex virus, HIV

Postnatal or childhood Encephalitis, meningitis, varicella, cerebral malaria, polio, trachoma, otitis media

Toxic exposures

Prenatal Alcohol, lead, mercury, antimicrobials (such as sulfonamides, isoniazid, ribavirin), anticonvulsants (such as phenytoin, carbamazepine), and other drugs (such as accutane, thalidomide)

Postnatal or childhood Lead, mercury

Other maternal disorders

Thyroid disease Cerebral palsy

Other perinatal complications

Brain injuries associated with Cerebral palsy, cognitive disabilities, seizure disorders premature birth, birth asphyxia

Injury

Traumatic brain injuries and other Cognitive, motor, speech, vision, hearing, seizure, and behavioral disabilities disabling injuries from vehicle crashes, child abuse and neglect, falls, burns, warfare, etc

Poverty, economic disadvantage

Social and cognitive deprivation Mild mental retardation

Unknown LDD of unknown cause

Table 3: Developmental Red Flags

Age	Developmental Problem
Birth to 3 months	• Failure to alert to environmental stimuli• Rolling over before 2 months (indicative of hypertonia)• Persistent fisting at 3 months
4-6 months	• Poor head control• Failure to smile• Failure to reach for objects by 5 months
6-12 months	• No baby sounds or babbling• Inability to localize sounds by 10 months
12-24 months	• Lack of consonant production• Hand dominance prior to 18 months (indicates contra lateral weakness)• No imitation of speech and activities by 16 months
Any age	• Loss of previously attained mile stones

Table 4: Commonly Used Developmental Screening Tools

Tool	Age of Child	Skills Assessed	Special Limitations or Benefits
Ages and StagesQuestionnaire	4-60 months	• Communication• Gross and fine motor• Problem-solving• Social•	Completed by parent
BayleyScales of InfantDevelopment II	1-42 months	• Mental development (memory, language,problem-solving)• Motor development (coordination, fine motormovement, body control)	• Requires standardized kit• Requires about 45 minutes to administer
Clinical AdaptiveTest/Clinical Linguistic andAuditory Milestones Test(CAT/CLAMS)	Under 24months	• Similar to DDII (see below)• Helps to distinguish isolated language delayfrom mental retardation	• Requires standardized kit
Denver DevelopmentalScreening Test (DDII)	Birth to 6years	• Fine motor• Gross motor• Personal/social• Language	• Requires about 20 minutes to perform• Requires standardized kit• Low sensitivity and specificity
Kaufman Assessment Battery for Children	2.5-12.5 years	• 16 subsets of cognitive skills	• Requires 40-90 minutes to administer
McCarthy Scales ofChildren’s Abilities	2.5-8.5 years	• Cognitive abilities• Gross and fine motor abilities	• Requires 45-60 minutes to administer• Requires standardized kit
WechslerIntelligence Scales	3-7 years and6-16 years	• Verbal and nonverbal intelligence • Time-consuming to administer (>1 hour)	• Requires standardized kit

REFERENCES

1. Nimi D Briggs. Antecedents. In Briggs N. (Ed.) Turning the Tide. Spectrum Books Publishers. 2006: 4

2. Nimi D Briggs. Funeral Orations. In Briggs N. (Ed.) Thoughts on University Education in Nigeria. Williams Wodi (ed) Spectrum Books Publishers. 2006: 320

3. WHO. Introduction. Health and the Millennium Development Goals. World Health Organisation; 2005:7-12.

4. United Nations Children’s Fund. Child Survival: Where we stand. The State of the World’s Children. UNICEF, New York, 2008:1-25.

5. Federal Republic of Nigeria, UNICEF. Child’s Rights Act 2003: Abridged version: 7-8.

6. Njokanma OF, Nkanginieme KEO. Growth and Development. In: Azubuike JC and Nkanginieme KEO (Editors)- Paediatrics and Child Health in a Tropical Region 2nd Edition (ISBN-978-2411582-hard cover and 9782411 612-soft cover). Printed by University of Port Harcourt Press-Port Harcourt 2007: 56-69.

7. Alikor EAD. Common Growth and Development Problems. In: Azubuike JC and Nkanginieme KEO (Editors)- Paediatrics and Child Health in a Tropical Region 2nd Edition (ISBN-978-2411582-hard cover and 9782411 612-soft cover). Printed by University of Port Harcourt Press-Port Harcourt 2007: 70-83.

8. Overby KJ. Pediatric Health Supervision. In: Rudolph AM, Hoffman JIE, Rudolph CD (Editors); Rudolph’s Pediatrics. 20th Edition-(International Edition);Appleton and Lange; A Simon and Shuster Company; 1996: 1-36

9. United Nations Children’s Fund, Early Childhood. The State of the World’s Children. UNICEF, New York, 2001; pages 7-66.
10. Lowenthal, ED, Millon JC, Growth and Development in HIV infected children. In Baylor International Pediatric AIDS Initiative. HIV curriculum for Health Professions-Baylor College Paediatric HIV Initiative 2006; 117-129

11. United Nations Children’s Fund. Malnutrition: Causes, consequences and solutions. The State of the World’s Children. UNICEF, New York, 1998:7-90.

12. Maxiya Dixon B, Akinyele IO, Oguntona EB, Nokoe S, Sanusi RA, Haris E. Nigeria Food Consumption and Nutrition Survey 2001-2003 Summary. International Institute of Tropical Agriculture, 2004. Ibadan, Nigeria

13. Durkin MS, Schneider H, Pathania VS, Nelson KB, Solarsh GC, Bellows N, Scheffler RM, and Hofman KJ. Learning and Developmental Disabilities. Millennium Development Goals. A custom publication of the Disease Control Priorities Project. The International Bank for Reconstruction and Development / The World Bank; Washington DC: 2006: 933-951.

14. Glascoe FP, Shapiro HL. Introduction to Developmental and Behavioural Screening. Reprinted from dbpeds.org. on 2/11/2008.7Child Development and Developmental Disorders in Nigeria: Prospects and Challenges for the 21st Century, Keynote Address by NIMI BRIGGS (MD; FAS; PROFESSOR). ALICE NTE (FWACP; READER) UNIVERSITY OF PORT HARCOURT CONGRESS OF THE ASSOCIATION OF CHILD DEVELOPMENT AND COMMUNICATION DISORDERS, NIGERIA ORGANISED BY THE EXCHANGE AND LINKAGE PROGRAMME UNIT, UNIVERSITY OF PORT HARCOURT, EBITIMI BANIGO AUDITORIUM, UNIVERSITY OF PORT HARCOURT on 23RD – 26TH JUNE, 2008