Individual diagnostic program for children 4-5 years old

Diagnostics for children 3-4 years old

Compiled by:

additional education teacher

Odinokova Bozhena Olegovna

Diagnostics of the level of speech development for 3-4 years

(literacy training)

Target:

identifying the level of speech of preschool children.

The examination of the level of speech development is carried out according to the following parameters, which are built taking into account the age-related psychological characteristics of children with developmental disabilities:

• speech understanding;

• development of phonemic hearing;

• subject and verb dictionary;

• syllabic structure of words;

• level of development of active speech;

• state of the articulatory apparatus and sound pronunciation.

Let's consider methods for examining children's speech (5 series of tasks).

SERIES 1

The tasks are aimed at helping the child understand the speech addressed to him.

1. SHOW THE TOY.

The child’s ability to distinguish a certain toy from others (choice from four) and to perform actions according to verbal instructions is determined.

Equipment:

toys - car, matryoshka, bear, bunny.

Examination technique:

Toys are laid out on the table in front of the child, and then the teacher suggests: “Show me where the bunny is. Take the matryoshka doll. Take the typewriter. Put the matryoshka doll in the car.”

Fixed:

the child selects a toy and performs actions according to instructions
(1 point)
.

2. SHOW THE PICTURE.

The child's understanding of the functional purpose of the objects depicted in the pictures is clarified.

Equipment:

pictures depicting objects familiar to the child: hat, mittens, glasses, needle and thread, umbrella, scissors.

Examination technique:

Pictures are laid out in front of the child and a verbal instruction is presented that does not correspond to the sequence of the pictures laid out. The child must choose a picture among others, focusing on the following tasks and questions: “Show me what you will put on your head when you go for a walk. If your hands get cold, what do you put on them? What does mom need to sew on a button? What does grandma need to see better? How will you cut the paper? What will you take outside if it rains?”

Fixed:

the child’s choice of a picture in accordance with the instructions
(1 point).
3. FIND A PICTURE.

The child's understanding of the singular and plural of a noun is clarified.

Equipment:

pictures depicting one or several objects.

Examination technique:

The pictures are laid out in pairs in front of the child and asked: “Show me where the ball and balls are. Show me where the mushroom and mushrooms are. Show me where the doll and dolls are. Show me where the apple and apples are. Show me where the chair and chairs are. Show me where the pencil and pencils are.”

Fixed:

display pictures according to instructions.

The formation of coherent speech in a child and the closely related acquisition of the grammatical structure of his native language is impossible without mastering the sound system of speech. The acquisition of the sound side of a language includes two interrelated processes: the development of the perception of sounds (phonemic hearing) and the formation of the pronunciation of speech sounds. Therefore, the prerequisites for speech development consider the state of phonemic hearing, the readiness of the articulatory apparatus to pronounce sounds and the pronunciation of individual sounds (1 point).

Diagnostics of thinking 3-4 years

Target:

identify the level of development of elementary mathematical concepts.

Cross out the extra item (1 point for each group, maximum number of points – 3).

For each group 1 point, maximum number of points – 3.

1 point per task, maximum 2 points.

Methodical manual “Pedagogical diagnostics by type of activity for children 4-5 years old”

(Middle group)

Dear Colleagues!

The proposed tables are designed to optimize the educational process in any institution working with children 4-5 years old, regardless of the preferred educational program and the number of children. This is achieved by using generally accepted criteria for the development of children 4-5 years old and a leveled approach to assessing a child’s achievements according to the principle “The lower the score, the more problems in the child’s development.” The monitoring system contains 9 types of activities that comply with the Federal State Educational Standard: motor, play, communication, self-service and basic household work, perception of art. literature and folklore, educational and research, design from various materials, visual arts, music. All this allows for an integrated approach to assessing a child’s development.

Assessment of the child’s level of mastery of the necessary skills and abilities in educational areas:

• 1 point – the child cannot complete all the proposed tasks, does not accept adult help;
• 2 points – the child, with the help of an adult, completes some of the proposed tasks;
• 3 point – the child completes all the proposed tasks with partial assistance from an adult;
• 4 points – the child completes all the proposed tasks independently and with partial help from an adult;
• 5 points – the child completes all the proposed tasks independently.

Tables of pedagogical diagnostics of the educational process are filled out twice a year - at the beginning and end of the school year (it is better to use pens of different colors) to conduct comparative diagnostics. The technology for working with tables is simple and includes two stages.

Stage 1. Opposite the surname and name of each child, points are entered in each cell of the specified parameter, from which the final indicator for each child is then calculated (the average value can be obtained if all the points are added up (on a line) and divided by the number of parameters, rounded to tenths ). This indicator is necessary for writing a profile for a specific child and conducting individual accounting of intermediate results of mastering the general education program, as well as for drawing up an individual educational route for children 4-5 years old.

Stage 2 . When all children have passed the diagnosis, the final indicator for the group is calculated (the average value can be obtained if all the scores are added up (in a column) and divided by the number of children, rounded to tenths). This indicator is necessary to describe group-wide trends in the development of children’s personality (in compensatory groups - to prepare for a group medical-psychological-pedagogical meeting), as well as to keep records of group-wide intermediate results of mastering the general education program.

A two-stage diagnostic system allows you to quickly identify children with problems in personality development. This allows us to timely develop individual educational routes for children. The average values ​​for each child or the general group development parameter can be considered as normative options for personality development: more than 3.8. The same parameters in the range of average values ​​from 2.3 to 3.7 can be considered indicators of problems in the development of a child of social and/or organic origin. Average values ​​less than 2.2 will indicate a pronounced discrepancy between the child’s development and age. (The indicated intervals of average values ​​are advisory in nature, since they were obtained using psychometric procedures used in psychological and pedagogical research, and will be refined as the results of children of this age become available).

The presence of mathematical processing of the results of monitoring the levels of children’s mastery of the necessary skills and abilities in educational areas is due to the qualification requirements for a modern teacher and the need to take into account the intermediate results of each child’s mastery of the basic general education program of preschool education.

.

Difficulties in diagnosing and treating bronchial asthma in children of the first five years of life

Over the past two decades, significant advances have been made in the management of patients with bronchial asthma (BA) through the use of improved strategies for diagnosis, therapy and prevention of the disease. Progress was due to the introduction into clinical practice of the global initiative on the strategy for the treatment and prevention of asthma - GINA [23], International (PRACTALL) [6], and national programs [2]. Despite the fact that the same mechanisms are involved in the formation of the disease in children and adults, there are certain differences in the course of asthma and the response to anti-asthmatic drugs in adults and children. Russia is one of the few countries where the National Program “Bronchial Asthma in Children” has been adopted. Treatment and prevention strategy." This guideline, now in its third edition in 2008, has had a significant impact on medical practice and, as a result, improved patient outcomes. However, asthma often begins in early childhood, and there are special challenges associated with the diagnosis and treatment of asthma in children in the first five years of life [28].

Clinical diagnosis

The current definition of asthma focuses on a chronic inflammatory process in the airways that involves many cells and cellular elements. Asthma has four main components:

1. symptoms;
2. reversibility of bronchial obstruction;
3. bronchial hyperreactivity;
4. inflammation.

No single domain can be the basis for diagnosis, but not all researchers are able to objectively assess all four components, especially in pediatrics. Therefore, in children of the first five years of life, it is recommended to use a thorough collection of family and individual history, analysis of symptoms, and physical examination to make a diagnosis of asthma.

Anamnesis

For children five years of age and younger who have recurring respiratory symptoms, a family history suggests the diagnosis of asthma - indications of the presence of asthma in close relatives (especially the mother), and/or atopy (atopic dermatitis, eczema), food allergies, allergic rhinitis in blood relatives or the child himself.

Symptoms

The main symptoms of asthma include wheezing, episodes of shortness of breath, cough, and chest congestion.

Wheezing

Wheezing (wheeze) is a continuous musical sound lasting at least 250 ms and caused by vibration of the opposite walls of the airways, which leads to their narrowing until complete closure. Crackles can be high- or low-pitched, consisting of one or more sound shades that occur during both inspiration and expiration, created by airways of any size - from large extrathoracic to small intrathoracic. The appearance of wheezing can result from obstruction of: the upper and lower extrathoracic airways, the lower respiratory tract. Asthma is not the most common cause of wheezing. In children, especially those under three years of age, there is an extremely high prevalence of chest wheeze and cough, even in the absence of asthma [18, 29]. There are three types of wheezing in the younger age group:

Transient early wheezing:

• often associated with prematurity and parental smoking;
• Children often outgrow these wheezes in the first three years of life.

Persistent wheezing with early onset (before age three years) in children without signs of atopy or a family history of atopy:

• episodes of wheezing in the chest caused by respiratory viral infections: in children under two years of age with respiratory syncytial viral infection; in preschool children over two years old - with other viral infections;
• These episodes, as a rule, continue into school age; by the age of 12 they can be identified in a significant proportion of children.

Late-onset wheeze/BA:

• observed throughout childhood and into adulthood;
• a history of atopy (often manifested as atopic dermatitis/eczema) and bronchial obstruction characteristic of asthma are typical;
• Asthma is characterized by periodic wheezing, as well as wheezing that occurs during sleep, laughter, and crying.

Cough

Cough as a symptom of asthma in children of the younger age group has the following features:

• occurs periodically or is constantly present (not associated with a cold or respiratory infection);
• often accompanied by wheezing and difficulty breathing, shortness of breath;
• typical cough occurs at night or before waking up;
• physical activity, laughter, and crying worsen the cough.

Additional examination methods to confirm the diagnosis of asthma

Pulmonary function testing is often not a reliable method in young children. Children aged 4–5 years can learn to use a peak flow meter, but peak flow measurements must be performed under parental supervision to obtain accurate results.

For scientific purposes, large research centers use methods such as body plethysmography to measure airway resistance, determine lung volumes, gas dilution methods (usually using helium) and washout of inert tracer gases (usually nitrogen); pulse oscillometry, increased forced expiratory volume during thoracoabdominal compression (RVRTC - Raised-Volume Rapid Thoracoabdominal Compression), etc. [5, 30]. These studies require complex equipment, which makes their application in routine clinical practice difficult. In Russia, a method of bronchophonography was proposed, which allows one to analyze breathing patterns using a computer and provides additional information about the nature of respiratory dysfunction [1].

Occasional respiratory symptoms, such as wheezing and cough, can often occur in children without asthma, especially in the first two years of life. Since in this age group there is no opportunity to assess bronchial obstruction and its reversibility using objective methods, the additional use of tests to detect atopy and the detection of allergen-specific IgE may be an additional argument to confirm the diagnosis of asthma. Allergic sensitization is a major risk factor for asthma development, persistence, and severity. The presence of atopic dermatitis in a child and/or food allergies increases the risk of sensitization to inhalant allergens and may be a predictor of the development of asthma.

In children of the younger age group, more informative than skin tests (prick-test) is the detection of allergen-specific IgE in serum using laboratory tests (Phadia: ImmunoCAP System® - the “gold standard” of diagnosis according to WHO recommendations; multiple diagnosis of allergies using chemiluminescent analysis (MAST); immunoblot for the diagnosis of allergen-specific IgE antibodies in human serum based on panels with individual allergens using the Rida® Allergy Screen system; enzyme-linked immunosorbent assay (ELISA), etc.).

A useful method to confirm the diagnosis of asthma in this age group is a trial of short-acting bronchodilators and inhaled corticosteroids (ICS): marked clinical improvement during therapy for 8–12 weeks and worsening after its cessation support the diagnosis of asthma.

Non-invasive markers of inflammation in the respiratory tract (determination of nitric oxide in exhaled air - NOx or carbon monoxide COx) are non-specific for asthma, also require special equipment and are not yet recommended for routine practice in young children [25].

Chest X-ray does not play a major role in the diagnosis of asthma. This method helps to exclude other diseases. In children, these are most often structural abnormalities of the airway (eg, congenital malformations, congenital lobar emphysema, vascular ring) or other diagnoses [28].

Thus, approaches to diagnosing asthma in children aged five years and younger differ from other age groups. The diagnosis of asthma is usually based only on complaints, history and examination, and typical symptoms.

Signs of probable asthma in children aged five years and younger include:

• frequent episodes of wheezing in the chest (more than one per month);
• cough or wheezing caused by exercise;
• cough at night in the absence of a viral infection;
• absence of seasonal changes in wheezing, as well as persistence of symptoms after three years.

Differential diagnosis

To make a final decision on the diagnosis of asthma, it is necessary to exclude diseases that may also be accompanied by repeated episodes of wheezing in children:

• infectious processes (repeated viral infections of the lower respiratory tract, chronic rhinosinusitis, tuberculosis);
• congenital anomalies (bronchopulmonary dysplasia, primary ciliary dyskinesia syndrome, cystic fibrosis, immunodeficiency; malformations causing narrowing of the intrathoracic airways; congenital heart defects, tracheomalacia);
• mechanical problems (foreign body aspiration, gastroesophageal reflux).

The experience of studying and practical use of the knowledge and provisions of evidence-based medicine that leading experts have accumulated in diagnosing asthma in children of younger age groups has proven useful for assessing the prognosis of asthma development in young children with wheezing. In children aged five years and younger, a combination of wheezing with one “major” risk factor (major risk factors include asthma or eczema in a parent) or two or three “minor” risk factors (minor risk factors include eosinophilia; the presence of wheeze in absence of colds; allergic rhinitis) is a predictor of the development of asthma in older age. To assess the prognosis of asthma development, an asthma prognosis index (Asthma Predictive Index - API) has been developed. It has been shown that children who have four or more episodes of bronchial obstruction in a year and an API of 4 to 10 have a chance of developing asthma between the ages of 6 and 10 years, while 95% of children with a negative API do not have asthma. develops [8, 12, 14, 15, 19].

Treatment of asthma in children five years of age and younger

After verification of the diagnosis of asthma, optimal strategies for therapeutic interventions are selected from the point of view of evidence-based medicine.

An important component of treatment is the creation of partnerships between the doctor and parents (guardians) and family members of the sick child. Educational programs increase the effectiveness of therapy.

The definition of the disease is as follows: “Bronchial asthma is a chronic disease of the respiratory tract in which many cells and cellular elements are involved. Chronic inflammation causes bronchial hyperresponsiveness, which leads to repeated episodes of wheezing, shortness of breath, chest tightness and cough, especially at night or in the early morning. These episodes are usually associated with widespread but variable airway obstruction in the lungs, which is often reversible either spontaneously or with treatment.” Based on this definition, it is impossible to talk about recovery from the disease, so the goal of therapy is to achieve control. The concept of asthma control includes two mandatory components - not only current control (control “now” - absence of symptoms, minimal need for emergency medications, normal pulmonary function tests, as well as the patient’s ability to lead an active lifestyle), but also reducing risks in future ("tomorrow" control), as presented in the new version of GINA (

).

The significance of the differences between “current control” (measured by the effect on symptoms, clinical signs of asthma, their reduction or disappearance in the last few weeks or months) and “future risks” (the likelihood of developing complications of drug therapy, exacerbations, slowing lung development) and relationships between these two components has been less studied in young children than in other age groups. But, nevertheless, there is now convincing evidence that the clinical manifestations of asthma, symptoms, sleep disturbances, limitations in daily activities, impaired pulmonary function, and the frequency of use of bronchodilators can be well controlled with appropriate basic therapy.

Children of the younger age group have their own characteristics in assessing levels of control (

). They are based on clinical signs, there is no definition of external respiratory function (RFF), and the approach to defining uncontrolled asthma is different [2, 6, 27, 28].

Despite the fact that ICS therapy is the cornerstone of therapy in children of a younger age group, the subject of debate remains the question of how early basic therapy should be started, and whether it is worth including ICS on a regular basis in young children after 1-2 episodes of bronchial obstruction . There are some concerns about the early (after 1-2 episodes of obstruction) administration of ICS in young children. The reserved attitude is due to the fact that ICS may affect alveolar growth, there are certain difficulties in predicting good effectiveness, long-term treatment with ICS in young children does not always affect the natural course of the disease, and, in addition, cellular inflammation and remodeling may depend on other pathogenetic mechanisms . Since there is no evidence yet that the use of ICS in such cases is beneficial, most experts believe that the use of ICS should be limited only to children with atopic eczema, or allergic sensitization, or a family history of atopy with three or more episodes of bronchospasm that developed during background of viral infection [7, 9, 24, 28]. Equipotent doses of ICS for children in this group are presented in Table. 3.

As in other age groups, inhalation therapy is preferred in children five years of age and younger. The choice of inhalation device is carried out on an individual basis [2, 6, 13, 17, 23, 28]. Possible delivery methods are presented in table. 4.

When using low doses of ICS, no clinically significant serious systemic side effects were established in clinical trials and the drugs are considered safe (evidence level A). Higher doses may be accompanied by some systemic effects [2, 3, 23].

Antileukotriene drugs

In addition to ICS, antileukotriene drugs (ALDs) are an important treatment option for children with asthma aged ≤ 5 years. This view is based on a large body of evidence demonstrating the effectiveness of the antileukotriene drug montelukast in improving asthma control [2, 7, 23, 28, 31]. Montelukast has been shown to be effective in treating childhood asthma caused by common triggers (viruses, exercise, allergens). Montelukast is currently recommended as one of two initial treatment options for children with persistent asthma.

In addition, ALPs reduce the frequency of exacerbations of asthma caused by viral infection in children aged 2–5 years with a history of intermittent asthma.

The role of montelukast as an alternative to first-choice drugs (ICS) for the basic treatment of asthma once again indicates the importance of early treatment of inflammation and expands the doctor’s ability to individually select therapy.

Of all the antileukotriene drugs for childhood asthma, only montelukast (a potent selective cis-LT-1 receptor antagonist) has been studied, which has demonstrated a high safety profile in young children.

Cromony

Sodium cromoglycate and nedocromil sodium play a small role in the long-term treatment of asthma in children [2, 28, 35].

Cromones have a very weak anti-inflammatory effect and are less effective than even low doses of ICS.

The results of one meta-analysis showed that long-term sodium cromoglycate therapy in children with asthma was not statistically significantly superior to placebo. Data from another meta-analysis confirmed the superiority of low-dose ICS over sodium cromoglycate in persistent BA.

Nedocromil sodium was shown to reduce the frequency of exacerbations, but its effect on other parameters of asthma did not differ from the effect of placebo.

A single dose of sodium cromoglycate or nedocromil sodium reduced the severity of bronchospasm caused by physical activity or inhalation of cold air.

Cromones have a high safety profile. Side effects include cough, pharyngeal irritation and bronchospasm in a small proportion of patients receiving sodium cromoglycate. The most common side effects of nedocromil are unpleasant taste, headache and nausea [28].

A Cochrane review concluded that there is no evidence of benefit from treatment with cromolyn sodium in preschool children (level A evidence) [35], and nedocromil has not been studied in preschool children. Therefore, cromones are not recommended for the treatment of AD in this age group.

Theophylline

There is a lack of evidence-based studies in children aged five years and younger, but the few data that have been obtained support some clinical benefit from theophylline. In several studies in children five years of age and younger, the clinical effect of regular theophylline use was small and mostly statistically insignificant [32]. Theophylline is less effective than low-dose ICS and side effects are common (Evidence Level D).

Long-acting beta2-agonists (LABAs)

The most recent FDA Panel voted unanimously that the risks of LABA monotherapy outweigh the benefits in children.

LABAs are not presented as a treatment option for any stage of therapy in this age group [16, 20, 24, 28, 34]. Prescribing a LABA as an alternative to increasing the dose of ICS is not considered; preference is given to increasing the dose of GCS.

In children aged five years and younger, the effects of long-acting inhaled beta2-agonists or combination drugs (LABA/ICS) have not been well studied [2, 28]. Combination drugs (LABA/ICS) are licensed for use in children 4–5 years of age, but no evidence-based studies have been conducted in children under four years of age.

Approaches to stepwise pharmacotherapy of asthma in children five years of age and younger from the standpoint of achieving and maintaining control are presented in

. [6, 28].

Short-acting beta2-agonists

As can be seen from, for all patients, short-acting inhaled beta2-agonists, which are the most effective situational drugs, can be used as bronchodilator therapy [2, 6, 28]. The preferred delivery method for asthma attack relief in children five years of age and younger is a metered-dose aerosol device with a spacer (Evidence Level A). If the inhalation technique is not feasible (due to lack of compliance, distress, or due to the severity of bronchospasm and hypoxia), nebulizer therapy can be used. Oral bronchodilators are not recommended due to their slow onset of action and increased incidence of systemic effects. Inhaled short-acting beta2-agonists are the drugs of choice, and in comparison with them, the administration of inhaled ipratropium bromide does not play an important role in the daily management of children five years of age and younger with asthma (Evidence Level A) [21].

Some children may not be sensitive to the effects of ICS. In such cases, it is necessary to discuss compliance issues with parents and check the inhalation technique. If all the conditions for proper treatment are met, you should think about the asthma phenotype that is difficult to treat [4, 10, 22, 24, 26, 33] and reconsider the prescribed therapy. An important component of the controlled course of asthma is the prevention of acute asthma attacks [11].

The following therapy is not recommended for asthma attacks:

• sedatives (strictly contraindicated);
• mucolytic drugs (may worsen cough);
• all types of physical therapy, including chest physical therapy (may increase patient discomfort);
• hydration for older children and adults with large volumes of fluids (may be necessary for younger children and infants);
• antibiotics (do not treat an exacerbation, but may be indicated for those who have underlying pneumonia or another bacterial infection, such as sinusitis);
• mild exacerbations can be treated at home if the child/family is prepared for this and there is an individual self-management plan that includes step-by-step activities);
• Moderate exacerbations are likely to require, and severe exacerbations usually require treatment in a medical facility.

Special protocols are used to treat exacerbations.

The introduction into clinical practice of evidence-based methods for diagnosing and treating asthma in children five years of age and younger will contribute to the effective and safe management of the youngest patients.

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N. G. Astafieva , Doctor of Medical Sciences, Professor I. V. Gamova , Candidate of Medical Sciences, Associate Professor D. Yu. Kobzev E. N. Udovichenko , Candidate of Medical Sciences I. A. Perfilova SSMU named after. V. I. Razumovsky , Saratov

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Asthma control levels (GINA, 2009) [23] Asthma control levels in children 5 years and younger [27, 28]

Asthma management approach focused on asthma control for children 5 years of age and younger