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INTRODUCTION

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The previous chapter presented a medical model for pediatric medical providers to use to assess children presenting with chief complaints about development or behavior. In this model, a failed developmental screen or concerns identified through developmental surveillance function as a chief complaint, and this is followed by a comprehensive developmental history detailing the temporal acquisition of developmental milestones across developmental streams. The developmental history focuses on milestones that are easily remembered and those that are temporally current and provides data on the pattern of developmental delay (static, progressive, or acute) that helps guide decisions for medical laboratory workup and intensity of therapeutic services to order. The developmental history also identifies the three potential problems than can occur with development: developmental delay, developmental dissociation, and developmental deviation. Developmental delay represents a lag in the acquisition of developmental milestones compared to what is typically observed in children of similar chronologic age. Given that the majority of etiologies for developmental delay affect the brain diffusely (eg, chromosomal disorders), developmental delay more commonly presents as global delays across all streams of development. Developmental dissociation occurs when one stream of development is significantly more delayed than other streams. Since global developmental delay is a more commonly presenting scenario, developmental dissociation can be considered a more atypical presentation, and dissociations between developmental streams can be problematic, even in a setting without any significant developmental delay (as can be seen in learning disabilities or attention-deficit/hyperactivity disorder [ADHD]). Developmental deviation occurs when a child acquires developmental milestones in a nonsequential fashion; children with developmental deviation acquire higher-level developmental milestones within a developmental stream before acquiring lower-level developmental milestones within that stream. Thus, developmental deviation is defined by development or behavior that is atypical at any age. Once the developmental history has been completed, a neurodevelopmental examination, which includes a traditional neurologic examination and an extended developmental evaluation, is performed. In most cases, the neurodevelopmental examination should confirm findings from the developmental history, increasing the validity of the developmental conclusions drawn from this pediatric neurodevelopmental assessment process. Once the pediatric neurodevelopmental assessment has been completed, specific developmental-behavioral diagnoses can be made.

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CAPUTE’S TRIANGLE

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Dr. Arnold J. Capute (1923–2003), a pediatrician who was on the original staff of the John F. Kennedy Institute for Habilitation of the Mentally and Physically Handicapped Child (now the Kennedy Krieger Institute), and who established fellowship training in developmental pediatrics at the Johns Hopkins University School of Medicine in Baltimore, Maryland, is generally considered the “father” of the field of neurodevelopmental disabilities. Dr. Capute established a model for understanding the spectrum and continuum of developmental-behavioral diagnoses—from lower-incidence, higher-morbidity disorders such as intellectual disability, autism spectrum disorder, and cerebral palsy to higher-incidence, lower-morbidity disorders such as learning disability, ADHD, and motor incoordination (gross motor dyspraxia, fine motor dysgraphia, and speech articulation disorders). This model begins with a simple triangle that represents the three primary streams of neurodevelopment: the neurocognitive stream, the ...

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