From seven to eight!

On 14th September, 2019, this rose bush had seven flowers. The day marked completing  seven years at MOSC Medical College, Kolenchery for Anna and myself.

It is also the completion of seven years for the Department of Developmental Paediatrics and Child Neurology.

Today the same rose bush has eight flowers!

As I looked at the addition of one more rose flower overnight, I paused to think of the change from seven to the eighth year we are making at the  Developmental Paediatrics and Child Neurology. 

The eighth flower on the first day of the eighth year is hope giving.

Yesterday Susan showed me a graph Shalini made, comparing the number of children we welcomed for consultation, Early Learning Centre, Learning support Centre, etc form 2015 to 2018.There was a dip in the number of children who visited us in 2017, but the trend is turning upward now. 

In health care, an upward trend in statistics of those seeking help is seen as a healthy sign. 

There was a concern in 2017 when we noticed that our numbers were on the decline! Fortunately that did not consume us to desperation. We knew that with long periods with lesser professionals, the number would dip. 

We looked the time that a consultation or learning support session would take. What was evident was that the consultation time which was on average 45 minutes is now reaching one hour. Similarly the learning support sessions have also become longer!

Are we less efficient! 

What became clear to us yesterday was that, we now engage the families in a wider range of issues. Sleep monitoring record, behaviour check list, home environment, diet record, video-recording of child at play, clinical history, etc are the regular sources of information we seek from parents during a visit. During a learning support session, similarly four or five check lists are filled to get data that might give us a direction in diagnostic screening and developmental planning. 

I include about twenty steps in the clinical examination, which give us valuable information to make a clinical diagnosis as a prelude to make a developmental diagnosis. As morphological screening is included in the clinical examination, it often leads to search for a morphological diagnosis. About sixty percent of children have morphological variations, which make this exercise of clinical screening regular for all children. 

As we know and learn more, we also search for clarity. 

A dip in the number of children welcomed might have many valid reasons other than decline in efficiency! 

Now as there is also a preliminary developmental appraisal of language and communication, cognitive functions and family state of wellness, with each new consultation which the new consultation takes almost 90 minutes. The advantage of this is that there is more preciseness to our diagnostic approach.This is bordering to a tertiary care level in clinical assessment of children. As almost  hundred percent children would have an EEG and blood results to interpret and about 75 percent would have the MRI of brain to study, the time taken for all these steps prolong an initial consultation.  

So we begin the eight year with a new awareness that 100 percent of children who visit us are referred from elsewhere and most of them come for a second or third opinion. We make a clinical diagnosis of a morphological syndrome in about 35 percent of children during the first visit, which in  itself is a departure from what happens in  a regular neuro-developmental clinic. 

We have pursued this direction of upscaling the academic level, hoping that this facility can become a  place for training professionals in Developmental Paediatrics. It is a dream and not a reality as of now! We lost an opportunity in not inviting paediatricians to join when they came seeking for training! 

My own perspective in developmental Paediatrics changed in 1990, when I started going to the clinical meetings at the Institute of Neurology, Government Medical College, Chennai. Until then for about seven years, I had a symptom based approach in Developmental Paediatrics. If a child had spasticity, it needs to be treated. If a child needs mobility or learning support offer them.

When I became regular a the clinical meetings at the Institute of Neurology, I got to know Professor Velmurugendran, and few others, who having noticed my interest in child development encouraged me to pursue the neurological basis for all developmental disorders. That is what got me interested in the study the neurological basis of common developmental disorders. They dissuaded me in registering for adult neurology training as I was serious about my commitment to developmental paediatrics. There was no facility for Paediatric Neurology training in India at that time. It was because of this curiosity to get formal training, I joined for a clinical PhD programme in 1993 at the Institute of Neurology. The Paediatric Neurology training programme started at the All India Institute of Medical Sciences around the same time. By then I got entrenched at the Institute of Neurology academically and clinically that I chose to continue at the Institute of Neurology.

At the end of the three years, my perspectives had changed remarkably. The search for neurological basis, morphological basis, developmental basis, behavioural basis and psychological basis in neuro-developmental disorders became my interest. When in 1997, at the convocation of the TN Dr MGR Medical University, when I was conferred the PhD in Developmental Neurology, it was  a turning point in my clinical journey, because I had vouched to set my direction to pursue the practice of Developmental Paediatrics from a neurological perspective from then onwards. This meant that for every neuro-developmental disorder, I was committed to explore to discover the causal pathway as much as possible.

Having had this opportunity to be in the interface of child development and Developmental neurology for the last 19 years, I feel that this journey has given me a broad canvass of understanding that was unknown to me until then. It is this perspective I explore to practice in my work now.

So here we are with an eighth flower in the rose bush, and the ninth, tenth and eleventh in bud form as of today!

Let me suggest that the latter years can be more effective than the former years in the Developmental Paediatrics and Child Neurology departement at MOSC Medical College! 

M.C.Mathew(text and photo)