A common refrain from the parents of infants and toddlers whom I see in my practice in developmental and behavioral pediatrics at Einstein’s Children’s Evaluation and Rehabilitation Center is: “We almost cancelled this appointment. Since the doctor referred us, the baby started to roll over, sit, walk, talk, behave, socialize . . . etc.” Sometimes the parents disagree with each other, one insisting that the child, for example, can sit or point or respond when called, while the other parent disagrees vehemently.
The regularity with which these discussions play out in my office suggests that the information physicians seek is not always so black-and-white as it may seem. Humans gradually acquire these seemingly discrete skills and there are often periods when a child is on the way to attaining a skill, but isn’t quite there yet.
So it is that I am baffled by certain trends in my field of child development.
Patients Need to be Seen
The first is reliance on developmental screening questionnaires (often completed by parents online at patient portals and scored by office staff) as a way of monitoring whether a child’s development is progressing as it should. Yes, these questionnaires are quick and efficient. There are many that have been found to have good sensitivity and specificity for picking up developmental delays in children. And yet the idea that the child need not be present in order for us to determine whether development is on track bothers me greatly.
Now, you should know that I’m one of those doctors who make it a point to listen carefully to parents of my patients. I’m usually the one telling parents that they are the experts on their children, while empowering parents to tell their children’s stories and advocate for their needs.
Watch this video featuring Dr. Shulman to see motor milestones from birth to two years.
Parents as Reliable Reporters
I have, however, found over the years that parents of every age, educational level and socioeconomic status can be excellent reporters about their children or, alternatively, can have their reporting ability be clouded by love, narcissism, fear, competing responsibilities or lack of knowledge about child development. There are some things I feel I simply must observe with my own senses. I want to see the skill in question with my own eyes, hear it with my own ears and often use my sense of touch to sort this matter out.
Powers of Observation
Rather than relying fully on parent reports or pitting one parent against the other, I have devised simple maneuvers to get the needed information. For example, when considering the 9-month-old baby referred to our office because the baby is not yet sitting, and whose parents disagree about that, or another who has made great strides since the original referral, I put out a mat with baby toys and simply ask the parents to place the children on the mat. It is a reality of parenting that if babies can sit independently, no parent will place them lying down (or they will scream).
Once the babies are on the mat, I observe: Do the parents then anxiously hover, afraid the children will topple over after a couple of seconds, or can the parents resume sitting in the office chairs? In addition to parental behavior in these situations, I can look at the children’s posture in sitting, their use of their arms to prop themselves up, or their ability to protect themselves if they start to fall off balance. Visually, I can get a great deal of information about where the children are on the path to independent sitting.
It is amazing how early children begin to pay attention and understand language, how quickly they communicate their wants and preferences. It is common for me to ask the parents of 15-month-olds how the babies communicate what they want and whether they can follow any commands, and find first-time parents looking with uncertainty at each other. That often silent exchange is meaningful to me. It suggests to me that the parents have not been aware that such young children should be expected to have these skills. In my office I place a very appealing colorful toy out of reach on a shelf. How does a child let me know that he or she wants it? If the child can point, I will see it.
The walk from the waiting area to my office is full of information for my senses. I talk to children and listen to their responses. If the children can walk, I ask the parents to have them walk to the office, so I can see the pattern of the gait. Sometimes I will hear an asymmetry to the gait pattern with a delay in step on one side. A walk up and down a few stairs tells me even more.
With my eyes and my ears, I obtain the information I need to suggest diagnoses such as autism, cerebral palsy or muscular dystrophy.
Touching to Learn
As good as is my ability to see certain things and hear others, though, the information I can obtain through touch is at least as valuable. When I hold the children, are they tight or slipping through my fingers? When I push them off balance, do they place out their arms to break the fall? In all directions? Is it symmetric? Are there full ranges at the joints, or asymmetries of strength or reflexes?
That brings me to another confusing trend in the field of child development: the rush to use head imaging such as MRIs or CTs of the brain. Parents with concerns about their child’s development often arrive requesting an MRI. Guidelines in my field also recommend head-imaging studies when children do not sit or walk by various ages. So, what about what we doctors see, hear and feel? Where do those senses fit in? Where does my ability to help parents better observe their children come in?
In our busy, technologically savvy world, I worry that questionnaires filled out online and the rush to use MRIs are taking the place of the rich tapestry of information gleaned from the senses that make up the art of medicine, possibly causing us to miss out on developmental clues that only an experienced physician—with a keen eye, sharp listening skills and an experienced sense of touch—would recognize.
