Developmental Delays

ARA LOMAX-REESE: Right now in studio we are joined by Dr. Donee Patterson. Welcome.

DONEE PATTERSON, MD: Thank you.

LOMAX-REESE: And Dr. Shyamali Godbole.

SHYAMALI GODBOLE, MD: Thank you.

LOMAX-REESE: We are talking about, and I think the timing is perfect, because it is back to school time and so a lot of parents are fixated on kind of I know me I am reflecting on how much didn’t my kids do over the summer. Are they really going to be prepared to be successful in the coming months and the coming year? A lot of what we are going to talk about today is more looking at developmental milestones, not just for children who are in school, but really before they even get to school. Dr. Donee, why don't you set it up for us.

PATTERSON: Exactly. Children develop, there is a huge range of physical and mental changes that happen in children throughout their lives and there is a huge range of normal and there is no child that develops the same way. We want to tell people what to look for. We want to teach them some red flags about if their children are regressing, if they've learned something, but now they are falling behind, or if they are just not meeting some of the developmental milestones that they should be because the sooner you get intervention the more help that we can give to the child and you can actually decrease some of the social and emotional stigmas that happen with some of these developmental delays as well. 

LOMAX-REESE: Excellent. Excellent. Why don’t we just kind of go through some of what should be red flags, what are kind of normal - because I am sure, like you said Dr. Donee, there is a real range. I know I have one child who is extremely chatty and I have one child who is extremely quiet. Why don’t you tell us, Dr. Godbole, what are some of the things that should be of concern versus what's kind of just a normal variation?

GODBOLE: I would love to do that. I firmly believe, and of course it is a known thing, children's brains are very plastic. That means they can change with support and services and with stimulation, and one thing that all parents need to remember is to just continuously stimulate their children's brains. You really can't spoil a child by doing too much of hugging and cuddling and talking and singing and exposing them to a variety of influences that will change the brain. Even if there are little areas that are glitchy, maybe a little behind in sequence that we will talk about, stimulating it provides new connections. The brain is still growing. Don’t stop hoping and providing the stimulation so that you can bring the brain into the same ballpark as the other children. 

PATTERSON:  Every day, do something every day. 

GODBOLE: Every day, play, play, play. It should be all about playing.

LOMAX-REESE: That's a great place for us to kind of jump into because a lot of times there is this question of nature versus nurture and whether it is environmental, the lack of stimulation or whatever your environment is is making the difference between being successful and not being successful. I read something when you compare the number of words that black children are exposed to versus white children and how that early exposure really affects their development, whether it is being read to or what have you. I wanted to see if you could talk a little bit more about kind of not just in school, but before you get to school and as early as, I don’t know, in utero. I don’t know. Should you be talking to your child? When is the starting point?

GODBOLE: That's a very good point to bring up, Sara. Thank you. Yes, the earlier you start, what can it harm? If you are listening to good music and speaking to your child when the child is on your stomach can it harm them? Absolutely not. Can it increase the stimulation? Well, research is on its way. There is nothing absolutely known. I think one study showed Mozart's music creating some connections in the math area, but again, these are more experimental. Research is continuing. Is there any side effect to it? Absolutely not. You have fun. Talk to your child and just wait for the child to come out and begin to interact with you. Right from the time the child is on your arms, don’t stop doing things with the child. 

LOMAX-REESE: Dr. Donee?

PATTERSON: I do want to mention, I don’t want to totally go off topic, but it's so important, since you brought it up, to talk about prenatal care and a lot of times women they just think that the education of a child or the development of a child starts when the child is born, but the child is developing their nervous system, their brain, their skin. Everything is growing inside. Even before a woman gets pregnant, she should be taking prenatal vitamins so that she gets lots of folic acid and other vitamins that help the baby grow from day one because if you think about it, once a woman realizes that she's pregnant, the baby has already been developing for four to six weeks. That baby has been deprived of healthy fruits and vegetables and healthy folic acid so that's when development starts and then you continue to take care of the baby throughout the development and then when the baby is born, that's where we pick up today. Start talking to your baby, showing them color, showing them different shapes, showing them different textures, just constantly giving them loving interaction and it really does make a difference for development. 

LOMAX-REESE: Dr. Godbole?

GODBOLE: Let me go over the milestones quickly.

LOMAX-REESE: Yes, please.

GODBOLE: What I would like to explain to parents is that it is not that difficult to remember if you know that the brain sequence is very logical. It proceeds in a very logical fashion. Let's give you a few hints to remember. For example, zero to three months, everything will be developing around neck and shoulders. Three to six months, everything will be developing around chest and upper back. Six to nine months, things are beginning to develop now, lower back and hips and then by 12 months, hopefully your child is upright. If you remember for zero to three months old, head and neck, that means that the neck should be getting steadier. By six months, they should be sitting at least with support. By nine months they should not only be sitting very well by themselves, but also able to crawl, pull up to stand, put their feet side to side, and by 12 months, hopefully walk one foot out into the open, maybe holding your hand, doesn’t have to be an independent walker at this time. It's a very logical sequence. 

LOMAX-REESE: What about speech and hearing because I know that there are some concerns. One of the developmental delays that gets a lot of publicity is autism, and I am not sure when that begins to reveal itself, but one of the things that I am clear on is like you said the earlier you are able to identify a challenge the sooner you can provide some type of intervention that might kind of repair it or lessen it.

GODBOLE: Again, you are absolutely right with that. Quickly I am going to talk about the milestones for speech and a little bit social because that's when the autism part comes in. Speech also is a motor function, which is all related to mouth, tongue, lips being involved. In the beginning it's all about crying and throaty sounds, then by zero to three months the baby begins to make those cooing sounds and as you coo to the baby the baby coos back. They begin to laugh right from their bellies, especially as you tickle them on their tummies. By six months they are beginning to babble and that means joining the lips together. Very often they will say dada first before mama, but that's not personal. Don’t take it personal. It's only because the lips are not developed yet. Then they begin to babble. The next stage, six to nine months, they begin to see that mama is not babbling. Mama is speaking in little cut sounds. So they begin to cut the babble into baba, mama, dada, may not associate it rightly with the right person, but they begin to do that and by one year they can actually say one word. Now here comes the social attachment to it, and this is the key for early detection of autism, and I think, Donee, you had already mentioned about the baby being hugging and cuddling and responding to your closeness and affection, and sometimes children with autism don't do that. They are almost resistant or don’t seem to ask for it or long for it. Those will be really early signs. By three months to six months, the baby is interactive with you, looking into your eyes, responding to your play and by nine months they are actually playing peek-a-boo with you. It's not the same as mommy playing peek-a-boo and the child laughing. The child actually responds by initiating peek-a-boo and that's what you want to see. 

LOMAX-REESE: These are all like the ideal circumstances where parents have time, they are socialized to be loving to their child, all of these things. I am curious what happens to the developing child if they are in a situation where there's not that nurturing, there's not that love, there's actual abuse or you're being reprimanded when you touch something. Does that short circuit developmental abilities?

PATTERSON: That's a great question.

GODBOLE: Sara, more then you can say. Absolutely. 

PATTERSON: Definitely. There's studies upon studies that show when the child doesn't have early interaction or early play that they actually do regress and they can get it back, but it's really difficult for them to get it back, and they need a lot of support to get some of those things back and it does depend on how long so time is a big factor. 

LOMAX-REESE: Dr. Godbole?

GODBOLE: And what it affects, is not just the language and social, even the motor gets affected. For children who have been in orphanages or who have been abused and maltreated, first of all the bonding and attachment is a problem. They don’t attach to people, forget about attaching to parents. They just have problems attaching with people. That's called an attachment disorder. Then they don’t speak so they have language delays, speech delay. They also will have motor delay because they are just left in the cribs forever. 

PATTERSON: Their muscles don’t develop.

GODBOLE: Their muscles don’t develop. They actually get contractures as if they had cerebral palsy. Neglect and abuse is just the opposite of good stimulation. It will absolutely cause regression and side effects of bad contractures and lack of language to the brain. 

PATTERSON: And then eventually that'll cause some emotional and social delays as they try to interact with people as they get older.

LOMAX-REESE:  One of the things that I always think about and I see and I hear is that children are so resilient. Children have the ability, even if they've been exposed to horrific experiences or what have you, they have the ability to kind of rebound or research. Can you talk a little bit about that whole notion of resiliency?

GODBOLE: There are two things that you have to remember for every child, actually three, let's talk about three. One is individual variation; one is developmental plasticity, so how that brain will react. You have two children in the same family with the same circumstances. One child responds and bounces back like a ball. The other one completely fades and breaks down and goes the opposite way. Here is where the nature nurture balance comes in. Part of it is genetics. Part of it is your genetic basis. The other is what support did you get in your life. Even if it is siblings, even twin siblings, if they're in two different classrooms, had different teachers and different classmates then the nurture part becomes different and each can show a separate outcome. The individual variation is also dependent on the child's temperament, which is a big thing. Some of the temperamental attributes of children include resilience, persistence, attention, adaptability, flexibility. Some children are high-demanding, inflexible, highly sensitive to everything, the others are not, easy going. So you have two children with different temperaments, same genetic background, or at least basis, and in the same house, but facing an event of some kind each responds in a different way.

PATTERSON: I think in the light of the troubles that the Philadelphia School District is having, this conversation is, again, so important because we can do something for our community. We can have mentoring, because if they are not getting that stimulation at home, then a positive mentor, a appositive teacher, someone to interact with that person can really help stimulate them and bring them out of that shell. There is something called post traumatic stress, but children, again, are very resilient and they can overcome that with the right interventions.

GODBOLE: Actually that's another great point that you brought up, Donee, because they have shown in studies what are the factors that contribute to resilience, one of which is having one person believe in you.

PATTERSON: Love it. Love it.

LOMAX-REESE:  That's interesting because I was having a conversation with a woman who was homeless when she was a child and she had a very turbulent, difficult childhood, but she had one person, her grandmother, who was there.

PATTERSON: Love it.

LOMAX-REESE:  Everything else was falling apart around her, but her grandmother - and she's now like a JD-MBA. She's like this incredible success, but she had, you know, and that's the thing, if you have one person who is going to like advocate and go to bat for you that can really…

GODBOLE: And that doesn’t have to be a family member. That can be anyone, a friend, a mentor, as you said. The other factor was involvement in community activities. Early involvement of children with you, either in church activities, on community activities, so that they have community support to turn to, that's another big factor for resilience.

PATTERSON: Awesome. It takes a village.

LOMAX-REESE: Yes, it is interesting because this reminds me a lot of the conversations I have around Alzheimer's, you know, to prevent, you know, the socialization and stimulation and community and all of those things. It's like at both ends of the spectrum, but I know we have to go - do we have to go to break for a second? Okay, when we come back from the break, I want to see if you guys can talk a little bit about nutrition, food and what role that plays in developmental development and breastfeeding versus formula and those kinds of things. We are talking today with Dr. Donee Patterson, a family medicine physician at the Einstein Department of Medicine and Dr. Shyamali Godbole, she is the Director of Developmental Pediatrics at Einstein Healthcare Center. What exactly is a Developmental specialist and how do people get to you? How do they access you?

GODBOLE: Thank you for asking. A developmental pediatrician is a pediatrician who has specialized and has board certification in looking after, evaluating, counseling, managing and treating children with special healthcare needs, which includes any kind of developmental delays, any kind of neurobiological disorders, whether it is like ADHD, autism, mental retardation, cerebral palsy, any genetic disorders, metabolic disorders, or even simple behavior problems at home, as well as learning problems in school. It is the kind of child who in a regular pediatrician's office is likely to take an hour because that's how long it takes for the speciality visit. What happens is that developmental pediatricians do pediatric residency, become pediatricians and then specialize in developmental pediatrics, which is separate.

LOMAX-REESE: Okay.

PATTERSON:  For our listeners I was just talking offline and explaining how I actually trained under Dr. Godbole at an outside center and she recently came to Einstein. I was very thrilled, but I have actually taken two of my children to her over the years just because I might have concerns about if they were hyperactive or had concerns about their reading and I thought that maybe it should be better. Even if you just have a concern it is nice to talk to your primary care doctor and then if you have concerns you can go a further step to take them to a developmental pediatrician. Often your primary care doctor will spend time, a half an hour, 40 minutes, but the developmental specialist is very in depth, and very hands on, and is very rewarding because I actually just got reassurance, nothing more, nothing less, but it was really what I needed at that time and it has helped me to be a better parent. 

LOMAX-REESE: Well there are two things that I want to try and get to before we are out of time. One is denial because I would imagine that's a big issue you might have to deal with.

PATTERSON: Yes. Yes.

LOMAX-REESE:  I commend you, Dr. Donee, for being proactive because I think that, I know for me, you know, I am probably like, oh, he's fine, he's fine, he's fine, because you don’t want to necessarily deal with what could be so I want to deal with that and I also want to talk about nutrition and food and breast feeding and those kinds of things in this developmental mix. Let's start with food and nutrition first and then we will go to denial.

GODBOLE: Nutrition is required for every cell in the body for the cell to grow, develop, prosper, move on. Development means to keep growing so that you can attack more complex tasks as you grow and that's the same with the brain. It's the same as with the rest of the body. Good nutrition is a key, not just for the child, first for the expectant mother and before the mother begins to expect she should already be in a good healthy status because you can't correct deficiencies when you become pregnant. You should already be on a health routine. No alcohol, no smoking, healthy diet and a planned pregnancy, that sets the way to a healthy child. 

PATTERSON: We have an epidemic of malnourished obesity in our city and in our country and so people they look thick or they look plump, but they are actually malnourished. They are not actually getting the fruits and the vegetables. I have spoken often about how different color fruits and vegetables each one has something different in it. They have cancer-fighting chemicals. They have immune-fighting chemicals. They have different types of things for digestion and brain development. It is very important to eat the rainbow and not Skittles, but eat lots of fruits and vegetables because every single phase of our lives we are growing, we are changing and we need those nutrients. 

LOMAX-REESE: Absolutely and breast feeding, that's definitely the gold standard.

PATTERSON: It's the gold standard. Again, the mom has to be healthy to be able to pass on healthy nutrition to the baby and the baby actually for up to a year and beyond doesn't need, well, not fully up to a year, they need solids at some point, but definitely in the early stages all they need is mom's breast milk and it is cheap and when the mom is healthy the baby can get everything that they need and it actually imparts immunity to your baby. You can share immunity until your baby has a chance to develop their own immunity, but you have to stay healthy in order for you to give that to your child and so it saves on a lot of formula. 

LOMAX-REESE: Absolutely. 

PATTERSON:  And it helps with bonding. It's been proven to show that there is an extra bonding that goes on with moms who breast feed.

LOMAX-REESE: Absolutely. Well, I am glad you've shared that. Let's move to denial, Dr. Godbole, because I would imagine that parents, we all have a certain kind of expectation of good health and all of those things, and when things aren't quite working out the way that you hoped or expected, it has got to be a real tough reality. 

GODBOLE: It absolutely is, but let me first start by saying that we do give a lot of validity to what parents say. They do know the child better then I would when they bring the child. However, when somebody has expressed a concern about the child, it is good for parents to go and get it checked out. Is it really there? Is it not? Because here is the thing, your child could maybe be a little hyperactive, maybe be talking excessively, and it is all right as long as in a group setting it doesn't bother the child or other people, but once you are in a pre-school setting or a daycare setting and you are the only two year old or three year old or four year old who sticks out like a red flag because you are not doing what other children are doing, then it is time to get a little concerned and have it checked out. Is this truly a disorder? Is it related to something in the environment? Is it something that you can treat right away or do you need it to be evaluated further?

PATTERSON:  Let me emphasize. We are not necessarily talking about medicine here. I know that listeners get really upset about that, and I do too, we are not talking about taking a medicine. We are talking about understanding how to help your child navigate through this world and it's confusing for parents because there is no handbook, but it is often nice to get help. Even for myself, I have had family members that would say to me, don't get them tested because they are going to classify your child and I was worried for a long time about that, but I said I have to do what's best for my child and I took them and the doctors helped me to understand a little bit about my child that I really hadn’t thought about it that way and so I was able to help my child, no medication, but I was able to help them. I am happy to say that I have teenagers now. I have two teenagers, a middle schooler and a preschooler, but they are all doing really well and I definitely think that that intervention helped me to, one, reassure myself that I was on the right track, but also to help steer my child to where they needed to get better help at school.

GODBOLE: May I make one more point?

LOMAX-REESE: Sure.

GODBOLE: I know people are really scared and worried about medication and sometimes medication doesn’t fix things at all because for any disorder there are at least five things that need to be looked at. One is the educational/instructional part, one is the behavioral part, just strategies that will help you manage behavior. One is psychosocial issues, family issues, logistics of who is living in the home, where, how, where, what, what needs they have. Then there is the emotional aspect, which is the child himself or herself. If they have low self-esteem giving them extracurricular activities, that's another important part of the treatment of any disorder. Medication is only the fifth arm there. If you just think I will start this medication, it will fix everything, that's not going to happen. You have to look at all five. Put all five treatments in place, maybe even hold off the medication until all the other four things are in place, and then see that you've done the instructional, you’ve done the behavioral, we've done the emotional and psychosocial, but this is still left over. It is not getting fixed. It is harming the child. Then you think of medication and add it to everything. 

LOMAX-REESE:  I think that's a great place to end on, even though we didn’t get to ADD and ADHD, we have got to have you come back. We didn’t really dive too deeply into autism.

PATTERSON: We should do that. We should come back.

LOMAX-REESE:  This is a very important topic and I think a lot of parents can find value in the information and next time we will take questions from the listening audience. I am sorry that we didn’t get to that as well. I want to thank you, Dr. Donee Patterson and Dr. Shyamali Godbole, for being here with us, very timely as we get set to prepare our kids to go back to school in a week or so. Thank you so much. Any last words, last thoughts as we leave out.

PATTERSON: One thing I do want to mention is about lead poisoning, just very quick, is if your child is becoming sluggish or they're starting to have GI or stomach upset or becoming more irritable, vomiting, you may want to get them some blood work done and to see if they have lead poisoning, which is common in an area like this because a lot of the houses were built before the 60's and so you want to clean off any rusty surfaces. You want to clean off any dusty surfaces because children will constantly put things in their mouths and lead poison is something that can damage. It's a heavy metal, and it can damage the brain and make the child regress so that's something for all of us to think about.

GODBOLE: My last word would be for parents to say it is a hard road. It is not easy to be a parent, but it can be very rewarding. What I would suggest is just learn to be a parent. Don’t be a pal. Be friendly…