Clinical approach to developmental neurology

The objectives and principles of neurological history and examination in children are the same as those in adults. This chapter therefore, will not provide an all-encompassing description of the neurological assessment of children, but highlights where the approach must differ substantially from that used in adults. Further it aims to provide a practical and useful approach to the examination of children, who may be preverbal and certainly will show less stamina for cooperation than adults. Of course as children get older, the examination can become more conventional and systematized. By adolescence the examination can be the same as the adult examination.The first and overriding factor for success is to be flexible and to make observations when the opportunity arises rather than to wait for abnormalities to arise during the course of a more systematic approach. Nonetheless a systematic approach to recording these results is essential, so as to bring together related observations made disparately in time. The history is of paramount importance in guiding the examination. Since it is unlikely that you will be able to complete a full examination, it is important to prioritize the observations needed in light of a differential diagnosis before you begin examining. Rather than rushing straight into the examination it is rewarding to gain a young child’s confidence by playing briefly with them. Also, instead of insisting on examining the child on a couch, it helps to become adept at examining young children on their parent’s or caretaker’s knee. Finally, no matter how cooperative a child is, potentially disturbing investigations should be left until last, including tendon reflexes or examination of the tongue, fundi, and ears. Otherwise all subsequent cooperation from the child may be lost after these examinations.The examination room environment is the key to a successful neurological examination and requires careful thought. There should be sufficient space to accommodate families and for the children to play. The room needs to be friendly and conducive to encouraging play. It needs to be equipped with carefully selected toys, pictures, pencils and paper, and books of interest to children over a wide age range. Observation of the child’s play whilst you are taking a history from the parents or caregivers will allow assessment of the child’s motor skills and developmental stage. Their use of play material can yield important clues to the nature of a deficit, by revealing ataxia, weakness, involuntary movements, tics, or spasticity. Play also provides an opportunity to assess the child’s behaviour, for instance their impulsivity, distractibility, and attention span. Interaction of the child with parents or caregivers can be observed also. If the child participates actively in the history taking, their understanding and contribution to the session allows you to make assessments of their language and intellectual skills.