Developmental History

The developmental history should cover all major aspects of function and behavior. For details of devel­opmental milestones and testing, the reader is referred to Chapter 2. This discussion presents only guide­lines for the purpose of diagnostic interpretations.

Delayed accomplishments, primarily in motor function, suggest a neuromuscular deficit. One of the earliest signs that parents report is a lack of sponta­neous movements when the infant is held or placed in the crib. They may add that the baby feels limp or stiff, suggesting hypotonia or spasticity. In all cases of motor dysfunction, it is important to clarify whether the dysfunction was a steady, continuing delay from an early age, suggesting a static disease, or an arrest or regression noted at a particular point. However, the relatively fast pace of early motor development may mask slow deterioration due to progressive neurologic disease for a while.

Developmental history and subsequent assess­ment must take into consideration the interactive effect of coexistent deficits. A significant cognitive dysfunction by itself may delay gross and fine motor development (4). It also tends to enhance the func­tional consequences of a neuromuscular disability. Slow development in personal and adaptive tasks that require both motor and cognitive abilities may be related to impairment in either area. A combination of both can create the impression that the motor deficit is more severe than it actually is.

A history of delay in communication develop­ment raises several differential diagnostic possibili­ties: (a) true language dysfunction affecting receptive or expressive domains or both, (b) oral motor dys­function interfering with speech production, and (c) significant hearing loss.

The ability to follow simple and, at a later point, complex commands indicates preserved receptive lan­guage even in the absence of verbalization. Parents report a variety of responses, such as smiling, coo­ing, crying, pointing, or vocalization with inflection as a substitute for speech. Oral motor dysfunction is also associated with cerebral palsy, most often with spastic quadriparesis or dyskinetic disorders due to suprabulbar or pseudobulbar palsy. Bulbar palsy in medullary involvement affects speech production, for example, in spinal muscular atrophy or spina bifida with syringobulbia. There is a close associa­tion between anatomical structures and neurologic control for speech and oral feeding. Concurrent oral motor dysfunction with feeding difficulties is an add­itional sign of bulbar or pseudobulbar pathology and confirms the suspicion of speech production deficit. In such cases, history of early feeding is most relevant. For example, was there a good lip seal and strong suction on breastfeeding? When bottlefed, the infant can handle 4 ounces in about 10 minutes, and feed­ings every three to four hours are generally adequate. The need for longer and more frequent feeding to maintain weight gain, especially during the first few months; coughing; nasal regurgitation of liquids; dif­ficulty with drinking from a cup; and difficulty with introduction of solid food due to chewing problems are early symptoms of oral motor dysfunction and a possible subsequent deficit in speech production. Augmentative communication training should be ini­tiated early in such cases.

Hearing is an essential factor for speech devel­opment. Early cooing and babbling are innate char­acteristics of infants and involve the same vocal components, regardless of the language spoken in their environment.

For infants and young children, the history is obtained from parents or caretakers. While gathering information from one person about another, the exam­iner gains an understanding of both and establishes rapport with parents and child. Early school-aged chil­dren can provide some information about themselves and should be encouraged to do so. Preadolescents and particularly adolescents generally prefer to give an account of their problems and achievements. Adolescents often wish to have privacy without the parent present, at least for part of the visit.