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On noticing a noticeable difference. (editor's desk).

It's not an unusual scenario. Concerned parents bring their infant to the pediatrician to report something they are observing or not observing. The physician calms the parents by saying "it's not so unusual," or "let's look at it in another six months." Most of the time the developmental milestone is reached, albeit on a timetable that isn't always by the book. Sometimes the parents will do their own rationalizing and turf the decision to mention it to the doctor, or not even see the doctor for another six months.

When growth deficits, developmental delays, sensory deficits or serious behavioral problems manifest themselves, they occur on a continuum. A child doesn't suddenly get diagnosed with failure to thrive or fine motor impairment or autism. When is something that's noticed noteworthy?

By age 2 years, the typical child runs well.

When do we see the red flags? When do we call for an assessment, when do we initiate treatment, when do we bring in the labels? When does "runs" become "runs well?"

The answer, of course, is based on perception, judgment, experience, school of thought and--certainly--comfort level. The latter reflects that of the clinician, the parent, the payors and the community. "Aggressive" pediatricians will perceive (and act on) things differently from conservative pediatricians. The actions of either will, of course, be modulated by the insistence of the parents, their practice environment and their instincts.

The preschool child normally grows about 3 to 5 pounds and 2.5 to 3 inches per year.

How does a thermos bottle know whether it's full of hot or cold liquid? How does a clinician know when to mobilize the troops of inquiry?

Most of the pediatricians I know will usually be at a loss to answer that question. You'll hear things like: "You just know;" "You'll know when you know;" "It somehow announces itself"; or "It will hit you." Not exactly pearls of wisdom the medical student can transfer from case to case, nor a response that would be applauded by an attending physician on rounds. So how does a clinician know and, more important, how does a parent know when to be alerted to these things? when does a mental note become an office visit?

By 7 to 9 months an infant will use partial thumb opposition to grasp pellets (and where do parents get these pellets, anyhow?).

How do we take what we observe as parents and professionals and assign them to the front or back burner of concern? when does "Oh" become "Oh!" or "Oh my!" or the defining "Oh my God!"? How do parents monitor coordination, when grasping and reaching (gradually) come under visual guidance and voluntary control? How do our perceptions of these things kick into gear? What's the impact of our fears, dreams, nightmares--and how do they temper, delay, or magnify our recognition of our kids' "red herrings"?

There's a science to these things, complete with laws, fractions, ratios and derived statistical measurements. Dally, parents and clinicians (and teachers, therapists and grandparents) unknowingly apply Weber's Ratio, Fechner's Law and Steven's Magnitude Estimation and decide whether what they see is worth one, two or three eyebrow raises. The "difference threshold" (or difference limen) is the smallest difference between two stimuli necessary to detect them as different. The difference threshold tries to answer questions: "is that response autistic or just indifference, that dropped coin clumsiness or pincer impairment?"

Only science could come up with the JND unit, the Just Noticeable Difference. How far do we have to increase the intensity of a tone before we can tell there's a difference? The magnitude of this difference in intensity specifies the difference threshold. How can parents become comfortable with "let's wait and see?" How do parents and professionals use the JNDs to form impressions, initiate action and redefine the notion of allowable and acceptable?
 When does something become some THING? When does a drizzle become rain?
 When do words become prose? When does an oral feeder become tube-fed? When
 does consistent become constant? And when does sensation become perception?
 And when does "watchful wait" become "doing nothing"?

Beyond the framework of psychophysics, which examines the relationships between physical stimulation and subjective experience, lies your gut; and whether the gut is the gut of a surgeon, a soldier, a salesman or an exceptional parent, it's something you can often rely on. Sometimes it's the only bullet on the belt. Often you know it before the anthrometrics hit the boundaries of the borders. Call it a gut feeling, intuition, a voice from within or hoofbeats, it's there. And it's something that both parents and clinicians need to recognize, respect, consider and explore.

Early intervention begins with early assessment and early determination; and these assuredly begin with an early feeling, usually perceived somewhere in the center of a lawless land we call the gut.

Rick Rader, MD Editor-in-Chief Director, Morton J. Kent Habilitation Center Orange Grove Center, Chattanooga, TN
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Title Annotation:child development
Author:Rader, Rick
Publication:The Exceptional Parent
Article Type:Brief Article
Geographic Code:1USA
Date:Feb 1, 2002
Previous Article:Jeremy Joins the Bunch.
Next Article:Lessons taught by the class of 2001. (letters to the editor).

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