An Overview for the General Pediatrics Boards Andrew Adesman MD Developmental amp Behavioral Pediatrics Steven amp Alexandra Cohen Childrens Medical Center of New York Hofstra Northwell School of Medicine ID: 561174
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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 York
Hofstra Northwell School of MedicineSlide2
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 DisordersAggressive 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 disordersADHDSlide7
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 3rd
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 monthsPrimitive 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” invalidChronic 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
Drawing Capabilities
Age
What They Can Draw
3
4
5
6
7Slide35Slide36
Gross Motor AchievementsWalking by 10–14 monthsClimbing by 2½ yearsThrowing and kicking a ball by 2 years
Pedaling a tricycle by 3 years
Hopping by 4 years
Skipping by 6 yearsSlide37
Gross Motor MilestonesSlide38
Fine Motor AchievementsStacking three or four blocks by 18 monthsCompleting simple form boards by 2 yearsThreading 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 yearsSlide39
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 yearsSlide40
Social AchievementsDressing by 2 yearsSelf-feeding using cutlery by 3 yearsBeing toilet-trained by 3½ years
Playing cooperatively in groups by 3 years
Playing team games by 7 yearsSlide41
Part 2: Disorders of Cognition, Language, Learning Slide42
ABP Content SpecsDisorders of Cognition, Language, Learning (3.5%)
Speech-Language Disorders
Intellectual Disability
Autism Spectrum Disability
Learning DisabilitiesSlide43
Language Delay in a Toddler or PreschoolerCONSIDER:Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide44
Language Delay in a Toddler or PreschoolerCONSIDER:Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide45
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 ImpairmentSlide46
50% Non-genetic:TORCH infection Ear/craniofacial anomaliesBirth 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 ImpairmentSlide47
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 volumeSlide48
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 startedSlide49
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, measlesSlide50
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 Slide51
Mild
25-39
Moderate
40-68
Severe
70-94
Hearing Loss - AudiogramSlide52
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)Slide53
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 startedSlide54
Language Delay in a Toddler or PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide55
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
Slide56
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 DisordersSlide57
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 increasesSlide58
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% intelligibleSlide59
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 distressSlide60
Language Delay in a Toddler or PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide61
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)Slide62
IQ TestingThe predictive validity of IQ testing increases with ageSlide63
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 babblingSlide64
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 speechSlide65
Lab Testing for Developmental DelayFor speech delay, always check hearing firstFor 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 IDSlide66
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 etiologySlide67
Fragile X SyndromeMost common form of inherited ID and the 2nd
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 IDSlide68
Williams SyndromeFacial features: elfin faces, wide spaced teeth, and an upturned nose
Developmental delays and learning disabilities
Hypercalcemia and supravalvular aortic stenosisSlide69
Language Delay in a Toddler or PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay: Intellectual Disability
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide70
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 DisorderSlide71
Autism Spectrum Disorders
DSM-V
Deficits in social communication and social interaction
Restricted repetitive behaviors, interests and activitiesSlide72
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%)Slide73
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 talkSlide74
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 VSlide75
Language Delay in a PreschoolerCONSIDER:
Hearing Impairment
Communication Disorders
Global Developmental Delay
Intellectual Disability (Mental Retardation)
Pervasive Developmental Disorders
Environmental Factors
General HealthSlide76
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 meningitisSlide77
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 stressorsSlide78
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:Slide79
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 SkillsSlide80
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 7Slide81
o
o
o
oSlide82
Part 3: Behavioral & Mental Health Issues Slide83
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. nightmaresSlide84
ABP Content Specs Behavioral & Mental Health Issues (4%)Externalizing DisordersAggressive behaviors, ODD, CD,
Anti-social behavior/delinquency
Internalizing Disorders
Phobias, Anxiety Disorders,
OCD
PTSD
Mood and Affect Disorders
Psychosomatic disordersSlide85
ABP Content Specs Behavioral & Mental Health Issues (4%)Suicidal behavior, psychotic behavior, thought disordersADHDSlide86
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 suddenlySlide87
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 requiredSlide88
Television ViewingKnown 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 TVSlide89
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 nailsSlide90
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 impairmentSlide91
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)Slide92
Breath-holding SpellsTypical 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 BHSSlide93
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 consciousnessSlide94
Breath-holding SpellsMay have a brief, benign seizure (not at risk for epilepsy)Cyanotic vs. PallidDx is clinical; consider anemia
Family history is frequently positive
autosomal dominant with reduced penetrance
Tx: Reassurance
iron if anemicSlide95
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 interventionSlide96
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 routineSlide97
Night TerrorsOccur 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 episodeSlide98
NightmaresOccur during the last third of the night
Child can be woken easily
Child will recall the nightmare, often vividly
Not mobileSlide99
“Externalizing Disorders”
ADHD
Oppositional-Defiant Disorder
Conduct DisorderSlide100
Attention-Deficit/Hyperactivity DisorderSymptoms of Inattention, Impulsivity, HyperactivitySome 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. Slide101
CombinedPredominantly Inattentive
Predominantly Hyperactive-Impulsive
ADHD
Presentations
(formerly “Subtypes”)Slide102
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% Slide103
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)Slide104
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 InterventionsSlide105
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
”Slide106
Part 4:Sample QuestionsSlide107
An 8-year-old boy has an above-average intelligence quotient, but he is struggling in school and consistently brings home failing grades. He is generally well behaved, but he gets angry with the poor grades. He enjoys being with his friends and is active in after-school activities.Of the following, the MOST appropriate intervention is to:
Have the parents set up a behavioral chart to encourage him to improve his grades
Reassure the parents that he is smart and schedule a follow-up appointment in 6 months
Refer him for psycho-educational evaluation
Refer him to a psychiatrist
Tell the parents to punish him if he continues to failSlide108
The parents of an 18-month-old boy contact you after he has two episodes of holding his breath and fainting. Most recently, he was upset when he had to leave the playground and began to scream and cry. He turned blue while holding his breath prior to losing consciousness. He had a similar event 1 month ago when he cut his finger and saw that it was bleeding. The anxious parents ask what they should do. Of the following, the MOST appropriate intervention is to
Obtain a complete blood count
Pick up the child quickly and comfort him when he starts to cry
Reassure the parents that this is a benign event
Refer the child for behavioral therapy
Refer the child for electroencephalographySlide109
A 7-year-old girl is having behavioral problems in school. Her academic skills are strong, but she is impulsive and has difficulty staying on task and remaining quiet while the teacher is talking. When the students line up, she pushes to be at the head of the line. At home, her parents have problems getting her to comply with their requests. She needs frequent reminders to sit and do her homework.
Of the following, the MOST appropriate next step is to
Begin a trial of stimulant medication
Complete Vanderbilt questionnaires
Have the parents institute a token economy behavior plan
Obtain a thyroid function test
Refer the child for
psychoeducational
testingSlide110
A 15-month-old boy bangs his head when he gets upset and does not get his way as well as when he falls asleep in his crib. He currently says about five words and is ambulating independently. His parents are concerned that he will seriously hurt himself and are puzzled about how to decrease this behavior.Of the following, the MOST appropriate next step is to
Have the child fitted for a soft helmet
Have the parents hold him when he begins to bang his head
Instruct the parents to ignore the behavior
Monitor the child for possible autism
Refer the boy for an early intervention evaluationSlide111
An 8-year-old boy is having attention difficulties in his 3rd grade classroom. He has undergone psycho-educational testing and has not had a learning disability identified. His parents and teachers have completed Vanderbilt rating forms, and the results are significant for inattention and impulsivity. You are considering starting the child on medication to treat his ADHD.
Of the following, the MOST significant historical information that would affect your decision to start treatment with a stimulant medication is
Absence epilepsy in his 6-year-old sister
Bipolar disorder in his paternal uncle
Mild motor tic in the child
Myocardial infarction in the paternal grandfather at the age of 65 years
Sudden death of his 15-year-old brother while playing basketballSlide112
A 3-year-old child is showing evidence of significant delay in his expressive and receptive language; other aspects of his development are normal. His hearing has been tested and is normal. You review the situation with his mother. Of the following, the MOST appropriate action is to
Have the boy evaluated for an augmented communication device
Have the boy return for a follow-up visit in 6 months
Have the mother begin to teach him simple signs to minimize his frustration
Refer the boy for a psycho-educational evaluation
Refer the boy for speech-language evaluation and therapy as indicatedSlide113
An 8-year-old boy in your practice has ADHD and learning issues. He currently is receiving specialized educational services and methylphenidate for his attention difficulties and hyperactivity. He does well with the structure that is in place at school but has issues with compliance at home when completing his homework. His parents seek guidance in establishing a behavioral modification approach for him at home.Of the following, the BEST intervention is:
Extinction
Habit reversal
Spanking
Stress anxiety reduction procedures
Token economySlide114
During a health supervision visit, a boy calls to his father by saying “dada.” His mother enters the room holding a snack. The child reaches out to her and cries loudly “mama.” When the boy notices his mother is holding a banana, he smiles and says “nana.” His mother picks him up and offers him the banana. You inquire if he is saying any other words. His mother replies “not yet.” Of the following, these findings are MOST expected for a typically developing child who is:
9 months old
12 months old
15 months old
18 months old
24 months oldSlide115
The parents of a 2 yo request help dealing with her temper tantrums. She has been healthy with appropriate growth and normal language, social, and motor development. She has daily episodes of screaming and crying that are occasionally accompanied by kicking and hitting; these episodes last 1 or 2 minutes. The parents have tried both ignoring the behavior and holding her when she has an episode. Three days a week she is cared for by an experienced babysitter who does not note any particular problems with the girl’s behavior.
Of the following, the most appropriate recommendation for this family is:
Do not take her to the babysitter anymore
Place the child in a 5-minute time-out after each temper tantrum
Praise the child whenever the parents observe her behaving well
Refer the parents to a counselor
Use a star chart for positive rewardsSlide116
A 6-yo is having problems in school. As part of the eval for special education services, the school performed a full individual evaluation. On a standardized aptitude test, his IQ score is 60. His birth history, PMH, and PEx are unremarkable. Hearing and vision screen are normal. Parents report the patient had some early language developmental delay, but deny any regression of milestones. There is a FHx of some adults with learning difficulties.
Of the following tests, the BEST next step is to perform
Electroencephalogram
Genetic testing
Magnetic resonance imaging of the brain
Serum amino acids
Urine for cytomegalovirusSlide117
A child can walk backwards, use a cup and spoon, make a stack of 2 blocks, and follow one-step commands without gestures? Of the following, the age that BEST describes this child’s developmental abilities is:
12 months old
15 months old
18 months old
21 months old
24 months oldSlide118
A 9-month-old girl can sit without support, feed herself with her fingers, play peek-a-boo, wave bye-bye, and uses a scissor-like grasp to pick up small objects. Of the following, the MOST likely additional task she can accomplish is to:
Climb onto furniture
Crawl up stairs
Bang two blocks together
Release a block into a cup
Walk independentlySlide119
The parents of a 2-year-old boy are concerned because he speaks in 2- to 3-word utterances and they can only understand about 50% of what he says. He is noted to stutter occasionally when he is trying to get his point across. Of the following, you are MOST likely to:
Provide reassurance to the parents
Refer the child for audiologic testing
Refer the child for developmental testing
Refer the child for speech therapy
Refer the child to otolaryngology to evaluate for possible
ankyloglossiaSlide120
A 3-year-old boy enters the examination room. His mother calls his name and he does not respond. He grabs your hand and puts it on a bottle of bubbles. His mother hands him a toy car that he turns over and begins to spin the wheels while saying the sound “eeh.” He then begins to jump up and down while looking out the window. According to his developmental history, he is speaking 5 single words on an inconsistent basis. He will primarily repeat words in a nonfunctional manner. He began walking at age 12 months.
Of the following, the MOST likely diagnosis for this boy is:
Attention-deficit/hyperactivity disorder
Autism spectrum disorder
Cerebral palsy
Epilepsy
Language delaySlide121
?? 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
6Slide122
??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
6Slide123
?? 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
Slide124
??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
6Slide125
??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)
6Slide126
??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
6Slide127
??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)
6Slide128
??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
6Slide129
?? 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 leftSlide130
?? 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. Slide131
You most strongly suspect:Mental Retardation
Autistic Spectrum Disorder
Mixed receptive/expressive language disorder
Hearing Impairment
Environmental under-stimulation
6Slide132
??Your first referral is to:Social service
Audiology
Psychology
Speech and Language Pathology
6Slide133
??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
6Slide134
??
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
6Slide135
??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 his 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)
6Slide136
?? 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
6Slide137
?? 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
6Slide138