An Overview for the General Pediatrics Boards Andrew Adesman MD Developmental amp Behavioral Pediatrics Steven amp Alexandra Cohen Childrens Medical Center of New York ABP Content Specs ID: 550668
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Slide1
Developmental & Behavioral Pediatrics: An Overview for the General Pediatrics Boards
Andrew Adesman, MD
Developmental & Behavioral Pediatrics
Steven & Alexandra Cohen Children’s Medical Center of New YorkSlide2
ABP Content SpecsGrowth & Development (5%)Developmental Surveillance vs. Screening
Milestones Slide3
ABP Content SpecsDisorders of Cognition, Language, Learning (3.5%)
Intellectual Disability
Autism Spectrum Disability
Speech-Language Disorders
Learning DisabilitiesSlide4
ABP Content Specs Behavioral & Mental Health Issues (4%)Common Behavioral Issues (Birth – 12 years)
Colic
Nail biting
Body rocking
Bruxism
Breath-holding
Enuresis
Night terrors vs. nightmaresSlide5
ABP Content Specs Behavioral & Mental Health Issues (4%)Externalizing Disorders
Aggressive behaviors, ODD, CD,
Anti-social behavior/delinquency
Internalizing Disorders
Phobias, Anxiety Disorders,
OCD
PTSD
Mood and Affect Disorders
Psychosomatic disordersSlide6
ABP Content Specs Behavioral & Mental Health Issues (4%)Suicidal behavior, psychotic behavior, thought disorders
ADHDSlide7
Part 1: Normal DevelopmentSlide8
ABP Content SpecsGrowth & Development (5%)Developmental Surveillance vs. Screening
Milestones Slide9
SurveillanceComprehensive child development surveillance includes:
Eliciting and attending to the parents’ concerns
Maintaining a developmental history
Making accurate and informed observations of the child
Identifying the presence of risk and protective factors
Periodically using screening tests
Documenting the process and findings Slide10
Screening In monitoring development during infancy and early childhood, ongoing surveillance is supplemented and strengthened by standardized developmental screening
tests:
- 9 months, 18 months, and 2 1/2 yrs
- at times when concerns are identifiedSlide11
Developmental MilestonesSlide12
Multiplication Table:Back to 3
rd
Grade !!Slide13
“You absolutely have to know these tables cold… Again, you absolutely have to know these tables cold, whether you want to or not.” MedStudy 2012Slide14
Developmental MilestonesFull Term Infant
Category
Description
Motor
- Moro reflex
Cognitive/Behavioral
- Becomes alert with the sound of a bell or voice
Language
Social
- Fixates on face/object and briefly followsSlide15
Developmental Milestones2 Months
Category
Description
Motor
- Follows objects past mid-line
- Lifts head and shoulders off
bed in prone position
Cognitive/Behavioral
Language
SocialSlide16
Developmental Milestones4 Months
Category
Description
Motor
- Head lag disappears by 5 months
- Moro disappears by 3-6 months
- Bears weight on forearms while
prone
- Rolls from prone to supine
- Bears weight while held standing
Cognitive/Behavioral
Language
- Laughs out loud and squeals
Social
- Imitates social interactionSlide17
Developmental Milestones6 Months
Category
Description
Motor
- Ability to transfer object from
one hand to the other
- Reaches for objects
- Sits with support
- Rolls over in both directions
Cognitive/Behavioral
- Turns directly to sound and voice
Language
- Babbles consonant sounds
- Imitates speech
SocialSlide18
Developmental Milestones9 Months
Category
Description
Motor
- Bangs two blocks together
- Sits without support
Cognitive/Behavioral
- Turns when name is called
- Plays peek-a-boo
Language
- Mama and Dada (non-specific)
Social
- Stranger anxiety
- Recognizes common objects
and peopleSlide19
Developmental Milestones12 Months
Category
Description
Motor
- Takes a few steps
- Pincer grasp
- Drinks from a cup held by
another person
- Pulls to stand and cruises
Cognitive/Behavioral
- Assists with dressing
Language
- Speaks 1 additional word
besides Mama and Dada
- Mama and Dada specific
Social
- Follows a single step
command with gestureSlide20
Developmental Milestones15 Months
Category
Description
Motor
- Gives and takes a ball
- Drinks from a cup
- Scribbles with a crayon
- Puts cube into a cup
- Walks independently
- Stoops to floor and recovers to standing
position
Cognitive/Behavioral
Language
- Speaks 3-6 additional words besides Mama
and Dada
- Points to one body part
- Follows single step command without
gesture
SocialSlide21
Developmental Milestones18 Months
Category
Description
Motor
- Self-feeding with a spoon
- Stacks 2 cube tower
- Throws ball
- Walks upstairs while holding
hand
Cognitive/Behavioral
- Imitates household chores like
sweeping, vacuuming, etc.
Language
- 10-20 word vocabulary
SocialSlide22
Developmental Milestones16 - 19 Months
Category
Description
Motor
- Builds a tower of 4 blocks
- Releases a raisin into a bottle
- Spontaneous scribbling
(18 mo)
Cognitive/Behavioral
Language
SocialSlide23
Developmental Milestones24 Months
Category
Description
Motor
- Builds a tower of 6 cubes
- Washes and dries hands
- Removes clothing
- Kicks a ball
- Jumps with 2 feet
Cognitive/Behavioral
Language
- Greater than 50 word vocabulary
- Starts using pronouns
-- such as I, me, and you
- Speech is 50% intelligible to a
stranger
SocialSlide24
Developmental Milestones36 Months
Category
Description
Motor
- Copies a circle
- Puts on a t-shirt/shorts
- Stacks a tower of 8 cubes
- Stands on one foot for 1-2 seconds
- Pedals tricycle
- Climbs stairs, alternating feet
Cognitive/Behavioral
- Imitates a vertical line drawn with a crayon
- Knows the name of a friend
- Understands basic adjectives (tired, hungry)
Language
- Speaks with 5-8 word sentences
- 75% of what is said is intelligible
- Starts using “
what”
and “
who”
SocialSlide25
Developmental Milestones4 Year Old
Category
Description
Motor
- Walks up and down stairs/steps
- Draws a simple drawing of a
person
- Balances on 1 foot for 4 seconds
Cognitive/Behavioral
- Dresses and brushes teeth without help
- Names 4 colors
Language
- Asks questions:
-- Where? Why? How? What?
- 100% intelligible to a stranger
Social
- Pretend playsSlide26
Rule of 4’sCount to 4Recite a 4-word sentenceIdentify 4 primary colorsDraw a 4-part personBuild a gate out of blocks (picture a #4 as a gate)
A stranger understands 4/4 (100%) of what they’re sayingSlide27
Developmental Milestones5 Year Old
Category
Description
Motor
- Draws a person with 6 body parts
- Prepares a bowl for food
- Skips, alternating feet
Cognitive/Behavioral
- Plays board games
- Counts 5 blocks
- Names all the primary colors
Language
- Defines words
SocialSlide28
Developmental Milestones6 Year Old
Category
Description
Motor
- Ties shoelaces
- Rides a bicycle
Cognitive/Behavioral
- Writes name
- Knows right from left
Language
- Counts ten objects
SocialSlide29
Block Stacking
Age
Task
13-15 months
2 block tower
18 months
4 block tower
24 months
6 block tower
30 months
8 block tower
3 years
3 block bridge
4 years
5 block gateSlide30
Feeding Skills
Task
Age
Uses cup well
15 – 18 months
Uses spoon well
2 years
Uses fork well
4 yearsSlide31
Play Skills
Task
Age
Symbolic Play
(use one object to represent another object and engage in one or two simple actions of pretend play)
15 - 18 mo
Parallel play, empathy
24 mo
Fantasy Play
(children engage in make-believe play involving several sequenced steps, assigned roles, and an overall plan and sometimes pretend by imagining an object without needing the concrete object present)
36 mo
Cooperative Play
3-4 yrsSlide32
Developmental Red FlagsNo head control by 3 monthsFisting beyond 3-4 months
Primitive reflexes persisting past 6 months
<50 words / no 2-word phrases by 2 years
Echolalia beyond 30 monthsSlide33
Tips for Clinical CasesIf a child is ill or uncooperative, consider a “low score” invalid
Chronic disease or recurrent hospitalizations can cause developmental delay
For premature infants, continue age correction until 18-24 months of age
For speech delay, always check hearing firstSlide34
Suggestion: Use Bright Futures tables provided on course websiteSlide35Slide36
Drawing Capabilities
Age
What They Can Draw
3
4
5
6
7Slide37Slide38
Gross Motor AchievementsWalking by 10–14 monthsClimbing by 2½ years
Throwing and kicking a ball by 2 years
Pedaling a tricycle by 3 years
Hopping by 4 years
Skipping by 6 yearsSlide39
Gross Motor MilestonesSlide40
Fine Motor AchievementsStacking three or four blocks by 18 monthsCompleting simple form boards by 2 years
Threading beads by 3½ years
Cutting a piece of paper by 3 years
Copying geometric shapes by 4 years
Tying shoelaces by 5 years
Printing legibly by 6 yearsSlide41
Speech & Language AchievementsSpeaking single words by 12 monthsMaking word combinations by 2 years
Making clear, simple sentences and being interested in books and stories by 3 years
Making conversation clear to others by 3 or 4 years
Reading by 5 to 6 yearsSlide42
Social AchievementsDressing by 2 yearsSelf-feeding using cutlery by 3 years
Being toilet-trained by 3½ years
Playing cooperatively in groups by 3 years
Playing team games by 7 yearsSlide43
Part 2: Disorders of Cognition, Language, Learning Slide44
ABP Content SpecsDisorders of Cognition, Language, Learning (3.5%)
Speech-Language Disorders
Intellectual Disability
Autism Spectrum Disability
Learning DisabilitiesSlide45
Language Delay in a Toddler or PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide46
Language Delay in a Toddler or PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide47
1-6/1000 newborns50% genetic 30% syndromic (e.g. Waardenburg, Pendred, Usher)
70% non-syndromic, (e.g. connexin 26/GJB2)
77% AR, 22%AD, 1% X-linked or mitoch.
Hearing ImpairmentSlide48
50% Non-genetic:TORCH infection Ear/craniofacial anomalies
Birth Weight < 1500 gm
Low Apgar Scores (0-3 at 5 min, 0-6 at 10 min)
Respiratory Distress/ Prolonged mechanical ventilation, hyperbilirubinemia requiring exchg transfusion
Bacterial meningitis/ Ototoxic meds
Hearing ImpairmentSlide49
Conductive Hearing LossFailure of sound to progress to the cochleaMost common cause is an effusion, in the absence of inflammation, usually due to otitis media
Clues of a mild conductive hearing loss would include ignoring commands and slight increasing of the TV volumeSlide50
Sensorineural Hearing Loss Secondary to MeningitisBacterial meningitis is the most common neonatal cause of hearing loss
Tends to occur early in illness, usually in the first 24 hours
It is not related to the severity of the illness, the age of the patient, or when antibiotics were startedSlide51
HEARING LOSS: Post-newborn Recurrent or persistent OME
at least 3 mo
Head trauma with fracture of temporal bone
Congenital CMV
often asymptomatic, HL may show up in later childhood (median age 44 months)
Childhood infectious diseases
e.g. meningitis, mumps, measlesSlide52
ChemotherapyStructural anomalies: e.g. Mondini malformation, enlarged vestibular aqueduct
Neurodegenerative disorders
e.g. Hunter syndrome, demyelinating diseases (e.g, Friedreich ataxia, Charcot-Marie-Tooth)
HEARING LOSS: Post-newborn Slide53
Mild
25-39
Moderate
40-68
Severe
70-94
Hearing Loss - AudiogramSlide54
Age Appropriate Hearing TestsConventional Pure Tone Audiometry Screen:Appropriate for school age children who can cooperate with commands
Tests each ear independently
Can differentiate between sensorineural and conductive hearing loss
Newborn Hearing Screening (3 tests; for newborns in the nursery):
Automated auditory brainstem response (AABR)
Transient evoked otoacoustic emissions (TEOAE)
Distortion product otoacoustic emissions (DPOAE)Slide55
Age Appropriate Hearing TestsBehavioral Observational Audiometry (BOA):For infants <6 months of age
Only a screening test; infants who fail this must undergo ABR testing
Visual Reinforcement Audiometry (VRA):
For “pre-school” children
Tests for bilateral hearing loss so intervention to prevent language development impairment can be startedSlide56
Language Delay in a Toddler or PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide57
Communication DisordersExpressive Language Disorders
Mixed Expressive / Receptive Disorders
Phonological Disorders
DSM 5 (May 2013):
- Language Disorder
(expressive and mixed receptive-expressive)
- Speech Sound Disorder
(new name for phonological disorder)
- Childhood-onset Fluency Disorder (stuttering)
- Social (pragmatic) Communication Disorder
Slide58
Expressive DisordersDisorders of morphology (form), semantics (word meaning), syntax (grammar), pragmatics (social use of language)Mixed Expressive/Receptive Disorders:Above plus comprehension deficits
Phonological Disorders
Disorders of articulation (motor movements), dyspraxias (motor planning)
Disorders of fluency (flow,rhythm)
Disorders of voice/resonance
Communication DisordersSlide59
Childhood-Onset Fluency Disorder
(“Stuttering”, Stammering”)
Disturbance in fluency and time patterning of speech
Begins age 2 ½ to 4, peak age 5
Normal up to age 3 or 4
Male:female ratio is 3-4: 1
75% of preschoolers will stop
Often disappears once vocabulary rapidly increasesSlide60
Articulation IntelligibilityRule of Quarters
Age
% of spoken language that
is intelligible to strangers
2
2/4 = 50% intelligible
3
3/4 = 75% intelligible
4
4/4 = 100% intelligibleSlide61
StutteringPersistence beyond school age will require a workup Indications for evaluation:
Family history of stuttering
Persists 6 months or more
Presence of concomitant speech or language disorders
Secondary emotional distressSlide62
Language Delay in a Toddler or PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide63
Intellectual Disability(Mental Retardation)
Characterized by:
Deficits in intellectual functions
Adaptive Skill Deficits
Onset before age 18
Level of severity determined by adaptive functioning, not IQ score (DSM V)Slide64
IQ TestingThe predictive validity of IQ testing increases with ageSlide65
Red Flags for ID2 to 9 Months
Age
Deficiency Requiring Intervention
2 months
Lack of visual attention/fixation
4 months
Lack of visual tracking
Lack of steady head control
6 months
Failure to turn to sound or voice
9 months
Inability to sit
Lack of babblingSlide66
Red Flags for ID18 to >36 months
Age
Deficiency Requiring Intervention
18 months
Inability to walk independently
24 months
Failure to use single words
36 months
Failure to speak in 3-word sentences
>36 months
Unintelligible speechSlide67
Lab Testing for Developmental DelayFor speech delay, always check hearing first
For a newborn/infant, always check previous metabolic screening done by state
For older children, serum lead level, ?TSH
Metabolic screening is not recommended for asymptomatic children with idiopathic IDSlide68
ID/MR- EtiologyPrenatal (50-70%)
genetic, CNS malformations, fetal compromise, infection, teratogens
Perinatal (<10%)
HIE, prematurity
Postnatal
Trauma, asphyxia, infection, toxins, vascular malformations, tumors, degenerative disease
Environmental (additive)
Deprivation/malnutrition
More severe forms, more likely to find definitive etiologySlide69
Fragile X SyndromeMost common form of inherited ID and the 2
nd
most common form of ID after Down’s Syndrome
Caused by repeat of CGG trinucleotide on X chromosome
Twice as likely to be seen in males vs. females
Diagnosis: DNA testing is more sensitive than karyotyping for a child with IDSlide70
Williams SyndromeFacial features: elfin faces, wide spaced teeth, and an upturned nose
Developmental delays and learning disabilities
Hypercalcemia and supravalvular aortic stenosisSlide71
Language Delay in a Toddler or PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide72
Pervasive Developmental Disorders
DSM IV
Autistic Disorder (total of 6, at least 2 from #1):
1. Qualitative impairment in social interaction
2. Qualitative impairment in communication
3. Restrictive, repetitive, stereotyped patterns of behaviors, interests and activities.
PDD NOS
Asperger
’
s Disorder
Rett’s Syndrome
Childhood Onset Disintegrative Disorder
“
Autism Spectrum Disorders
”
: DSM 5 (May, 2013)
1. Deficits in social communication and social interaction
2. Restricted repetitive behaviors, interests and activitiesSlide73
Autism Spectrum Disorders
DSM-V
Deficits in social communication and social interaction
Restricted repetitive behaviors, interests and activitiesSlide74
Autistic Spectrum Disorders: Key PointsPrevalence
(CDC 2012): ~ 1/88
Male: Female
4:1
Seen in association with:
Seizure disorders, congenital infection, metabolic abnl (PKU)
Neurocutaneous disorders
(TS, NF)
Genetic Disorders
(Fra X, Angelman
’
s, Smith-Lemli Opitz )
No proven ass
’
n with vaccines
(MMR, thimerosal)
Genetic Basis -
Concordance rates:
MZ twins (60-80%)
DZ twins, sibs (3-7%)Slide75
Rett SyndromeAffects girls almost exclusively
Characterized by autistic-like behavior and hand wringing
Normal development at first, but around age 4 months head growth decelerates
Stagnation of development from age 6-18 months
Loss of milestones (regression) from age 1-4 years
No further decline after regression period
Affected individuals
usually survive into adulthood
though never regain use of hands or attain meaningful ability to talkSlide76
Asperger’s Disorder
Qualitative impairment in social interaction
No clinically significant general delay in language
Impaired pragmatics
“
Little professors
”
No clinically significant delay in cognitive development or in the development of age-appropriate self-help skills
Motor coordination difficulties
This disorder is not included in DSM VSlide77
Language Delay in a PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay
Intellectual Disability (Mental Retardation)
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide78
Language DelaysRed Flags vs. Red HerringsA bilingual home and a second child (including a boy) with sibs and parents speaking for the child do not explain language delays
A hearing evaluation is needed, especially with a history of TORCH infections, hyperbilirubinemia, or meningitisSlide79
School Failure“
Slow Learner
”
: Borderline Intelligence
Learning Disorders: Average Intelligence
ADHD and Disruptive Behavior Disorders (Oppositional Defiant Disorder, Conduct Disorder)
Mood and Anxiety Disorders
Chronic Medical Illness
Psychosocial stressorsSlide80
Receptive language, expressive language
Basic reading skills, reading comprehension
Written expression
Mathematics calculation / reasoning
DSM 5 (May, 2013) : “Specific Learning Disorder”
Learning Disorders – Difficulties in:Slide81
Learning Disabilities (LD)A child can have a LD with normal or even superior intelligence; the two are not relatedHaving a LD means there is a specific difficulty in one of the following areas:Listening
Speaking
Reading
Writing
Reasoning
Math SkillsSlide82
Learning Disabilities (LD)Social problems may be a manifestation of a LD, but they are not considered learning disorders in and of themselves
A LD can often be compensated for in the early grades
LD are then picked up in the later grades when things get tougher and more challenging
A child who reverses the letters (e.g., b/d) or numbers (e.g., 6/9) may not have a LD. This can be a normal finding up to age 7Slide83
o
o
o
oSlide84
Part 3: Behavioral & Mental Health Issues Slide85
ABP Content Specs Behavioral & Mental Health Issues (4%)Common Behavioral Issues (Birth – 12 years)
Colic
Nail biting
Body rocking
Bruxism
Breath-holding
Enuresis
Night terrors vs. nightmaresSlide86
ABP Content Specs Behavioral & Mental Health Issues (4%)Externalizing Disorders
Aggressive behaviors, ODD, CD,
Anti-social behavior/delinquency
Internalizing Disorders
Phobias, Anxiety Disorders,
OCD
PTSD
Mood and Affect Disorders
Psychosomatic disordersSlide87
ABP Content Specs Behavioral & Mental Health Issues (4%)Suicidal behavior, psychotic behavior, thought disorders
ADHDSlide88
ColicDiagnosed based on historyPhysical exam rarely shows anything
No labs that confirm the diagnosis
Stops after 3-4 months of age
No “proven” methods to treat colic
Typical presentation is crying episodes in an otherwise healthy infant
Crying starts suddenlySlide89
ColicNormal crying patterns of infants is up to 2 hrs/day and 3 hrs/day (for ages birth-6 wks, and 6 wks+, respectively)When presented with a crying infant, add up the total hours crying (if it is only 3 hours, this is normal and nothing more than parental reassurance is needed)
Correct management is to reduce parental frustration by having another caretaker take over
Often disturbing sleep patterns may just be part of the “temperament” of the infant with no intervention requiredSlide90
Television Viewing
Known harmful effects of TV on children:
Trivializing violence and blurring lines between reality and fantasy
Encouraging passivity at the expense of activity
Increase of aggressive behavior and influence of the toys played with and cereals eaten
TV watching takes up more time than school
Children watch 23 hrs/week
Only the time spent sleeping exceeds the number of leisure hours watching TVSlide91
Nail Biting(onychophagia)Most common between ages 10 and 18 yearsSeen in 50% of children
<10 years: equal in boys and girls
>10 years: more common in boys
Tx: positive reinforcement
Praise when child is not biting his nailsSlide92
Body RockingOccurs at ~6 months in 5-20% of children
Sitting or crawling position
Most common around bedtime & lasts
~
½ hours
Usually stops by 2-3 years
Rarely continues into adolescence
May occur with standing in children with developmental disabilities
ASD, visual impairmentSlide93
Bruxism (clenching / grinding)Typically nocturnal during REM sleepIf prolonged, can cause T-M joint pain, tooth damage, tension headaches, face pain, and neck stiffness in adolescents
More common in boys
Familial
Children -- usually self-limited; tx not indicated
Teens -- splint or bite guards (dentist)Slide94
Breath-Holding Spells
Typical presentation: anger, frustration, or infant in pain
Occurs between ages 6-18 months
Simple breath holding-spell: child becomes pale or cyanotic
Complex breath holding-spell: child continues to cry until unconscious
Can progress to a hypoxic seizure with a postictal period
Association between anemia and incidence of BHSSlide95
Breath Holding SpellsUsually associated when child is angry, frustrated, in pain, or afraid Hold breath for up to 1 minute
Most common in ages 1 – 3 years
Reflexive, not purposeful
Brief loss of consciousnessSlide96
Breath Holding SpellsMay have a brief, benign seizure (not at risk for epilepsy)Cyanotic vs. Pallid
Dx is clinical; consider anemia
Family history is frequently positive
autosomal dominant with reduced penetrance
Tx: Reassurance
iron if anemicSlide97
EnuresisNocturnal Enuresis
Initial workup for new onset consists of history, physical, and urinalysis
Organic causes: SUDS (sickle cell trait, UTI, diabetes, seizure or sacral)
Short term treatment is desmopressin acetate
Enuresis alarms for long term management
Seen up to 20% of children at age 5
15% of cases per year will resolve with no interventionSlide98
EnuresisDiurnal Enuresis
Diurnal enuresis after a period of daytime continence is most likely due to an organic illness warranting workup
UTI, DM, DI, or kidney disease
97% of the time the cause is non-organic
Cannot be defined prior to age 3
Appropriate management is behavioral intervention by designing a voiding routineSlide99
Night Terrors
Occur during the first third of the night and happen rapidly
Often family history present
Occurs more in boys than girls
Child exhibits distinctive physical findings (deep breathing, dilated pupils, sweating, etc.)
Child can become mobile, which can result in injury
If woken up, child will be “disoriented” with no recall of episodeSlide100
NightmaresOccur during the last third of the night
Child can be woken easily
Child will recall the nightmare, often vividly
Not mobileSlide101
“Externalizing Disorders”
ADHD
Oppositional-Defiant Disorder
Conduct DisorderSlide102
Attention-Deficit/Hyperactivity DisorderSymptoms of Inattention, Impulsivity, Hyperactivity
Some symptoms present before age 7 years
DSM 5: Several inattentive or hyperactive-impulsive symptoms present prior to age 12
Impairment from the symptoms is present in two or more settings
DSM 5: Several symptoms in each setting
Clear evidence of clinically significant impairment in social, academic, or occupational functioning. Slide103
Combined Type (80%*)Predominantly Inattentive Type (10-15%*)
Predominantly Hyperactive-Impulsive Type (5%*)
*in school-age children
ADHD SubtypesSlide104
ADHD: Key PointsDisorder of dopamine and norepinephrine systems in frontostriatal circuitry
3-7% of school age children
Male: female (6:1-3:1)
Genetic Predisposition: 5-6 fold increase in first degree relatives
Environmental Factors: e.g. head trauma, lead exposure, VLBW, prenatal teratogens
Symptoms Persist into Adulthood in 60-80% Slide105
ADHD - Key points (cont’d)
Co-morbid Conditions:
Learning Disorders
Anxiety Disorders
Oppositional Defiant Disorder
Conduct Disorder
Tic Disorders
Mood Disorders
Substance abuse disorders (adolescents)Slide106
ADHD - TreatmentPsychopharmacologic: stimulants = first line
Inhibit reuptake of dopamine and norepinephrine
Stimulant Side effects: appetite suppression, headache, abdominal pain, growth suppression, irritability, onset/ exacerbation of tics
Behavioral InterventionsSlide107
Mood Disorders: e.g. Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder DSM 5: “
Disruptive Mood Dysregulation Disorder
”
Anxiety Disorders:
e.g. Generalized Anxiety Disorder, Separation Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, School Phobia
Obsessive-Compulsive Disorder
DSM 5: Included in
“
O-C and Related Disorders
”
, not
“
Anxiety Disorders
”
Post-traumatic Stress Disorder
DSM 5: Included in
“
Trauma- and Stressor-related Disorders
”
“
Internalizing Disorders
”Slide108
Part 4:Sample QuestionsSlide109
?? A baby is pulled to sit with no head lag, grasps a rattle, and follows an object visually 180 degrees. These milestones are typical for:
2 months
4 months
6 months
8 months
5Slide110
??Tanya is now walking well, and can stoop to the floor and get back up. She generally points to indicate what she wants, but can ask for her “bottle
”
, a
“
cookie
”
and her
“
blankie
”
. She drinks from a sippy cup and feeds herself cheerios. She places a toy bottle in her doll
’
s mouth. Tanya is most likely a typically developing:
12 month old
15 month old
18 month old
24 month old
6Slide111
?? Maria sits in your office with paper and crayons. She counts ten crayons and labels the colors. She can copy a square, print her first name and draw a picture of her mother with 6 body parts. Out in the hall she demonstrates hopping on each foot and skipping. Her age is closest to:
42 months
48 months
60 months
72 months
6Slide112
?? A 3 year old boy should have mastered each of the following except:Naming a red truck
Towering 6 cubes
Stating his name and gender
Hopping on one foot
Slide113
??On a pre-kindergarten screening a school official is most concerned about a 5 year old boy who cannot:Draw a Person with 6 parts
Copy a Square
Name 4 colors
Tandem Walk
6Slide114
??On a pre-kindergarten screening a school official is most concerned about a 5 year old boy who cannot:Draw a Person with 6 parts (50%ile ~4 ½
yrs
)
Copy a Square (50%ile ~ 5
yrs
)
Name 4 colors (50%ile ~ 3 ¾
yrs
)
Tandem Walk (50%ile ~ 4 ½
yrs
)
6Slide115
??You would be most concerned about:A one year old who doesn
’
t stand alone
A 15 month old who can
’
t
stoop and recover
A four year old who cannot hop on each foot
A two year old who cannot jump
6Slide116
??You would be most concerned about:A one year old who doesn
’
t stand alone
(50-90% of 1 year olds)
A 15 month old who can
’
t
stoop and recover
(>90% of 15 month olds)
A four year old who cannot hop on each foot
(50-90% of 4
yr
olds)
A two year old who cannot jump
(50-90% of 2
yr
olds)
6Slide117
??You would be less concerned about:A 3 year old who cannot answer a
“
why
”
question
An 18 month old who uses 2 words
A one year old who doesn’
t point
A 9 month old who doesn’
t babble
6Slide118
??You would be less concerned about:A 3 year old who cannot answer a
“
why
”
question
(50%
ile
~4-5
yrs
)
An 18 month old who uses 2 words (over 90% of 15
mo
olds)
A one year old who doesn’
t point
(over 90% of 1
yr
olds)
A 9 month old who doesn’
t babble
(over 90% of 9
mo
olds)
6Slide119
??Annie is a 16 month old brought by her parents who worry that she is not yet walking. Born at 25 weeks, she required oxygen, phototherapy and parenteral nutrition. She now eats with her hands, drinks from an open cup, pulls to stand and takes a step while holding on. Your exam is unremarkable. Your best recommendation is:
Send Annie to rehab for physical therapy
Request a neurological consultation
See Annie back in two months for follow up
Consider an MRI to r/o intraventricular hemorrhage
5Slide120
?? You are evaluating a 9 month old baby who is not yet sitting without support. She is a former 26 week premature infant. Brain MRI reveals periventricular leukomalacia. Of the following findings, which would you most likely expect to see:
Increased tone in all 4 extremities, especially the UE
Equally increased tone in all 4 extremities
Dyskinetic, choreoathetoid movements
Increased tone in all 4 extremities, especially the LE
Increased tone in the right upper extremities compared with the leftSlide121
?? Parents of a 3 year old girl present with concerns about speech and language delays. Their daughter has a vocabulary of about 10 words, and she recently began pointing to body parts and following single un-gestured commands. She can imitate a vertical line, jump in place, and broad jump. She is able to wash and dry her hands, and put on a t-shirt. In your office, she points to your stethoscope, and when you hand it to her she smiles at you and places it on her father
’
s chest. Slide122
You most strongly suspect:Mental Retardation
Autistic Spectrum Disorder
Mixed receptive/expressive language disorder
Hearing Impairment
Environmental under-stimulation
6Slide123
??Your first referral is to:Social service
Audiology
Psychology
Speech and Language Pathology
6Slide124
??A 5 year old boy presents for health maintenance. Developmental surveillance reveals that he can copy a circle, knows the adjectives “tired
”
and
“
hungry
”
and can broad jump, but cannot hop in place, draw a person in 3 parts or name 4 colors. You suspect:
Learning Disability
Mild Intellectual Disability (Mental Retardation)
Cerebral palsy
Autistic Spectrum Disorder
Severe Intellectual Disability
6Slide125
?? Devin has a vocabulary of about 300 words, speaks in 2-3 word combinations and understands and asks simple “what” questions. He can follow simple prepositional commands using “on” and “in”. His age is most likely:
18m
24m
30m
36m
42mSlide126
??
A stranger should be able to understand half of a child
’
s speech at age:
Remember the rule of fours!
12 months
18 months
24 months
36 months
5Slide127
??Three year old Jason is brought by frustrated parents due to constant tantrums. He is hyperactive, impulsive and often does not respond when called. He interacts mostly with adults in his daycare. You note that he grabs mother’s hand to reach a toy from a nearby shelf. Mother reports that he constantly watches “Thomas the Train” videos at home, and carries his toy Thomas figure everywhere. Based on this information, the first assessment tool you would consider would be:
Conners
III
Comprehensive Behavior Rating Scale
Wechsler Preschool and Primary Scales of Intelligence III
Childhood Autism Rating Scale II Edition
Preschool Language Scale V Edition
Child Behavior Checklist (CBCL)
6Slide128
??All of the following observations are considered risk factors for an Autism Spectrum Disorder except:
Lack of pointing at 12 months
Lack of babbling at one year
Lack of gaze monitoring at 10 months
Echoing phrases at 18 months
6Slide129
?? An 8 year old second grade boy was referred for evaluation due to academic difficulties. His psychological and psychoeducational evaluations revealed:WISC 4: Full scale IQ = 99,Verbal Comprehension = 85, Perceptual Reasoning = 105, Working Memory = 110,
Processing Speed = 108
WIAT 2: Word reading = 92, Reading comprehension = 81
Numerical operations: 98, Math reasoning = 79
The child’s likely diagnosis is:
Borderline Intellectual Functioning
Learning Disability
Attention-deficit/Hyperactivity Disorder
Auditory Processing Disorder
6Slide130
?? A 9 year old third grade boy is brought to your office by his mother who is distraught about his report card. He is below average in reading and spelling and his teaching states that he does not complete assignments and is distractible in class. He is not a management problem at home other than when it’s time to do his homework. He has friends and excels on the baseball field. An appropriate next step would be:
Request completion of parent and teacher Vanderbilt Questionnaires
Initiate a trial of methylphenidate
Order psychological and psychoeducational testing
Refer to Child Psychiatry
6Slide131
?? A distraught mother phones you asking for advice. She met with her 9 year old son’s teacher who states that your patient Johnny does not listen, talks back, and recently has been physically lashing out at other children. He is in jeopardy of repeating the 4th grade. Mother wonders whether a trial of “that medication my nephew takes that starts with r” would be helpful. You conclude:
Johnny
’
s behavior is most consistent with the lack of impulse control associated with ADHD.
Johnny
’
s behavior is likely to meet criteria for a disorder often co-morbid with ADHD, but not consistent with ADHD alone.
Johnny is also likely to be cruel to animals, to steal and to run away from home.
Johnny
’
s behavior is consistent with the general class of
“
internalizing
”
behaviors.
6Slide132