Developmental Detail History- BR

**Present People:** Dr. Emily Carter (Paediatrician), Mrs. Sarah Jones (Mother), Master Thomas Jones (Patient) **Age:** 4 **Parental Concerns and Age of Onset:** 1. Difficulty with speech and language development, onset at 2 years 2. Frequent tantrums, onset at 3 years 3. Difficulty with social interactions, onset at 3.5 years **Previous Diagnosis / Assessments / Involved Agencies:** Speech and Language assessment conducted by a Speech Pathologist at 3 years old. Currently under review by the local Child Development Centre. **Family History:** Father: John Jones, 38, Teacher. Mother: Sarah Jones, 36, Nurse. No history of developmental or behavioural concerns in either parent. One sibling, Emily Jones, 7 years old, no known issues. No consanguinity. Both parents are of Caucasian ethnicity. Family has good financial stability and access to community support. **Perinatal History:** Full-term gestation, vaginal delivery, no complications. No notable events in the newborn period. **Medical History:** * Infancy: Breastfed for 6 months, good weight gain. * Current medical concerns: Recurrent ear infections. * Current medications: None. * Known allergies: None. * Immunisation status: Up to date. * Hearing assessments: Normal hearing screening at birth. * Vision assessments: Normal vision screening at 3 years old. * Dental assessments: Regular check-ups, no issues. * Dietary habits: Eats a varied diet, no restrictions. * Sleep-related information: Sleeps 10-11 hours per night, occasional night wakings. **School:** * Attends preschool. * Class: Preschool. * Teacher: Ms. Davis. * Most recent school report: Shows some difficulty following instructions and interacting with peers. **Developmental History:** **Gross Motor:** * Rolling: Achieved at 6 months. * Crawling: Achieved at 9 months. * Walking: Achieved at 12 months. * Running: Achieved at 18 months. * Climbing stairs: Achieved at 20 months. **Fine Motor:** * Right-handed. * Can draw basic shapes. * Uses a pincer grip. * Can use scissors. **Self-help Skills:** * Drinks from a cup independently. * Feeds self with a spoon and fork. * Dresses and undresses with some assistance. * Toilet trained during the day, occasional accidents. **Speech and Language:** **Expressive Language:** * Current level: Uses short phrases. * First meaningful words: 12 months. * 2–3 word spontaneous phrases: 24 months. **Receptive Language:** * Understands simple instructions and some complex instructions. * Understands approximately 100 words. **Pre-verbal Communication:** * Uses pointing to indicate wants. * Uses eye gaze to communicate. **Articulation:** * Speech is difficult to understand for unfamiliar adults. * Speech is mostly clear to family members. **Pragmatics of Vocalisations:** * Difficulty with reciprocal conversation, often engages in monologue. * Responds to his name, makes eye contact, and orients to sounds. **Other Aspects of Language:** * Some instances of echolalia. * Prosody is normal. **Social Skills:** * Makes eye contact. * Smiles socially. * Initiates interactions with peers occasionally. * Shows some social disinhibition, such as interrupting conversations. **Play and Friendships:** * Plays alongside other children. * Shows interest in peers. * Initiates play with other children. * Has a best friend. **Interests and Behaviours:** * Attachment to a specific toy. * Repetitive behaviours such as lining up toys. * Responds negatively to change. **Unusual Sensory Interests:** * Enjoys spinning. **Self-Stimulation and Mannerisms:** * Hand flapping. * Overall behaviour: Frequent tantrums, occasional aggression. **Attentional Skills:** * Short attention span. * Easily distracted. * Difficulty completing tasks. **Behavioural Profile (on average):** * Happy–sad. * Calm–anxious. * Quiet–busy. * Compliant–oppositional. **Anger Profile:** * Tantrums occur several times a week. * Tantrums are moderately disruptive. * Uses calming strategies, such as being held. **Temperament:** * Generally a sensitive child. **Physical Examination:** **Observations:** * Appears anxious during the examination. * Difficulty separating from mother. * Some fidgeting. **Growth Parameters:** * Weight: 18 kg. * Height: 105 cm. * FOC: 50 cm. **Physical Features:** * No dysmorphic features noted. * Teeth and palate are normal. * Ears and eyes are normal. * Systemic examination findings are normal. **PLAN:** 1. Referral to Speech Pathologist for further assessment and therapy. 2. Referral to Occupational Therapist for sensory integration therapy. 3. Review of current preschool placement and support. 4. Parent education on managing tantrums and behavioural strategies. 5. Follow-up appointment in 3 months. 6. Consideration for further developmental assessments.