Behavioral & Developmental Pediatrics Flashcards
When do primitive reflexes (moro reflex) appear? When do they disappear?
Present at birth and usually disappear between 3 and 6 months of age
What does it mean when an infant shows stronger and more-sustained primitive reflexes?
Central nervous system injury
Infants with CNS damage may have delayed development of ________ reactions
postural
Gross Motor Milestones
- Birth:
- 2 months:
- 4 months:
- Birth: Turns head to side
- 2 months: Lifts head when lying prone, head lag when pulled from supine position
- 4 months: Rolls over, no head lag, pushes chest up with arms
Gross Motor Milestones
- 6 months:
- 9 months:
- 12 months:
- 6 months: Sits alone, leads with head when pulled from supine position
- 9 months: Pulls to stand, cruises
- 12 months: Walks
An infant’s fine motor skills progress from control over ______ muscles to control over ______ muscles
Proximal; Distal
What are the primitive reflexes?
- Moro reflex: symmetric abduction and extension of arms with trunk extension
- Hand grasp: reflex grasp of any object placed in palm
- Atonic neck reflex: If head is turned to one side, arms and legs extend on same side and flex on the opposite
- Rooting reflex: turning of head toward same side as stimulus when corner of infant’s mouth is stimulated
What are the postural reactions, and when do they start?
- Head righting: ability to keep head vertical despite body being tilted (4-6 months)
- Parachute: Outstretched arms and legs when body is abruptly moved head first in downward direction (8-9 months)
What are the fine motor milestones?
- Birth:
- 3-4 months:
- 4-5 months:
- Birth: Keeps hands tightly fisted
- 3-4 months: Brings hands together to midline and then to mouth
- 4-5 months: Reaches for objects
Fine motor milestones:
- 6-7 months:
- 9 months:
- 12 months:
- 6-7 months: Rakes object with whole hand; transfers object from hand to hand
- 9 months: Uses immature pincer (ability to hold small object between thumb and index finger)
12 months: Uses mature pincer (between thumb and tip of index finger)
What is the earliest sign of neuromotor problems in development?
Persistent fisting beyond 3 months of age
What red flags in motor development indicate spasticity?
Early rolling over, early pulling to a stand instead of sitting, and persistent toe walking
Early hand dominance (before 18 months of age) may be a sign of…
weakness in the opposite upper extremity associated with hemiparesis
Delays in ______ development are more common than delays in other domains
language
When is the window of opportunity for optimal language acquisition?
first 2 years of life
What is the difference between language and speech?
- Language: refers to the ability to communicate with symbols
- Speech: The vocal expression of language
At what age are cooing and musical sounds expected?
2-3 months
At what age is there babbling? When are words first used?
6 months: babbling
12 months: 1-3 words (mama, dada)
By 18 months, a child should know __ - __ words
By 3 years, more than __% of the child’s speech should be intelligible
By 18 months, a child should know 20-50 words
By 3 years, more than 75% of the child’s speech should be intelligible
What is the prespeech period?
0-10 months: expressive language consists of musical like vowel sounds (cooing) and adding consonants to the vowel sounds; receptive language is characterized by increasing ability to localize sounds
What is the naming period?
10-18 months: Characterized by the infant’s understanding that people have names and objects have labels
What is the word combination period?
18-24 months: Early word combinations are “telegraphic” (no prepositions, pronouns, articles)
Intellecutal development depends on what three things?
- Attention
- Information processing
- Memory
What is the single best indicator of intellectual potential?
Language
What are the 5 stages of cognitive development? When does each start?
- Sensorimotor period - Physical manipulation of objects (birth to 2 years)
- Stage of functional play (begins at about 1 year of age)
- Stage of imaginitve play (24-30 months)
- Concrete thinking (preschool and early elementary years)
- Abstract thinking (Adolescent years)
Object permanence develops at about _ months
As a result of this ability to maintain an image of a person ______ _______ develops when a loved one leaves the room
9 months; separation anxiety
What is magical thinking?
A normal state of mind during the preschool toddler years when a child assumes inanimate objects are alive and have feelings
What are some red flags in cognitive development?
- Skills significantly delayed in language and problem solving: mental retardation
- Language skills delayed: hearing impairment of communication disorder
- Problem solving skills delayed: Visual or fine motor problems
- Discrepance between language and problem solving skills: Learning disabilities
Social skill milestones in order include…
- Attachment
- A sense of independence
- Social play
What is cerebral palsy?
A group of static (nonprogressive) encephalopathies caused by injury to the developing brain in which motor function is primarily affected
How is cerebral palsy diagnosed?
Repeated neurodevelopmental examinations
- Increasing tone or spasticity
- Hypotonia
- Assymetric reflexes or movement
- Abnormal primitive reflexes or emergence of postural responses
- Maternal risk factors for cerebral palsy:
- Prenatal:
- Perinatal:
- Maternal: multiple gestation; preterm labor
- Prenatal: intrauterine growth retardation; congenital malformations, infections (TORCH)
- Perinatal: Prolonged, traumatic delivery; Apgar score < 3 at 15 minutes; Premature or postdates
What are postnatal risk factors for cerebral palsy?
- Hypoxic-ischemic encephalopathy
- Intraventricular hemorrhage
- Trauma
- Kernicterus
What are the two types of cerebral palsy?
Spastic cerebral palsy; Extrapyramidal cerebral palsy
What are the three types of spastic cerebral palsy?
- Spastic diplegia: involves lower extremities > upper extremities or face
- Spastic hemiplegia: unilateral spastic motor weakness
- Spastic quadriplegia: motor involvement of head, neck, and all four limbs
What is extrapyramidal cerebral palsy (athetoid cerebral palsy)?
Patients have problems modulating control of the face, trunk, and extremities, often writhing; significant oral motor involvement often occurs
Define mental retardation
Significantly subaverage general intellectual functioning associated with deficits in adaptive behavior such as self care, social skills, work, and leisure
What IQ ranges are associated with mild, moderate, severe, and profound mental retardation?
- Mild:
- Moderate:
- Severe:
- Profound:
- Mild: (IQ = 56-69)
- Moderate: (IQ = 40-54)
- Severe: (IQ = 25-39)
- Profound: (IQ < 25)
What are some genetic causes of mental retardation?
What are some environmental causes?
- Genetic:
- Chromosomal abnormalities
- Inborn errors of metabolism
- Single gene abnormalities
- Environmental:
- Psychosocial deprivation
- Parental mental illness
What is the most common cause of learning disabilities?
Idiopathic
What are the two types of learning disabilities?
- Deficiencies in specific academic subjects
- Defects in processing of information
Autism
- Onset:
- More common in:
Autism
- Onset: prior to 3 years of age
- More common in: boys
What are the clinical features of autism?
- Difficulty using language to communicate with others
- Unusual ways of relating
- Unusual or restrictive ranges of interests
- Unusual perseverative behavior or sterotypic movement rituals
- Self injurious behaviors
What is echolalia?
A clinical feature of autism - repetitive words and phrases
What are the clinical features of Asperger syndrome?
- Qualitative impairment in peer relationships and social interactions
- Repetitive, restricted, and stereotyped patterns of behavior, activities, and interests
- No clinically significant language delay
Characteristics of ADHD include…
What associated behavior may or may not be present?
poor selective attention, difficulty focusing, or distractibility
Hyperactivity may or may not be present
The cause of ADHD is unknown. Abnormalities in neurotransmitter function, especially ______ and ________, also leads to symptoms
dopamine; norepinephrine
What specific criteria must be present to diagnose ADHD? (don’t memorize)
- Symptoms before 7 years of age
- Symptoms in more than one environment
- Impairment in functioning in school or personal relationships
- Symptoms of inattention
- Symptoms of hyperactivity
- Symptoms of impulsivity
- Social adjustment problems
- Damage to self-esteem
- Impaired relationships with parents and peers
- Difficulty learning
What is the key focus of assessments for ADHD?
identifying the child’s strengths and coping strategies
What are some non-medical treatments for ADHD?
- Demystification - explain ADHD to child and family
- Classroom modifications - elimination of distractions
- Educational assistance
- Counseling
What is the first line pharmacologic treatment for ADHD?
- Mechanism of action:
- Dosage
- Side effects:
Stimulants (methylphenidate (Ritalin) and amphetamines (adderall))
- MOA: enhance catecholamine transmission in the CNS (increase dopamine and norepinephrine)
- Dosage: Varies among patients
- Side effects: anorexia, insomnia, GI pain, headache, palpitations, Tics
What is the second line medical therapy for ADHD?
Nonstimulant medications - Tricyclic antidepressants, and adrenergic agents such as clonidine (best for comorbid aggression or tic disorders)
Permanent hearing loss occurs in at least ______ newborns
1/600
Outcome of hearing-impaired children is demonstrably better if it occurs before what age?
6 months of age
What are some sequelae of late identification of hearing impairment?
- Delayed speech and language skills
- Academic and behavioral problems
What are some variables influencing impact of hearing loss on function and development
- Degree of loss
- Etiology (inherited > acquired)
- Family atmosphere
- Age at onset (better if after language acquisition)
- TIming of amplification (earlier = better)
- Cochlear implants
During medical evaluation for hearing loss, which lab is important to order and why?
Creatinine level because of association between kidney disease and ear abnormalities (Alport syndrome)
What are the three leading causes of blindness in children?
- Trachoma infection (primary cause worldwide)
- Retinopathy of prematurity
- Congenital cataracts
What is haptic perception?
Feeling someone’s face to form a mental image of them by combining kinesthetic spatial feedback and input from tactile sensation
What is colic?
Crying that lasts > 3 hours per day and occurs > 3 days per week
What re the characteristic features of colic?
- Occurs in healthy, well fed infants
- Begins at 2-4 weeks of age and resolves by 3-4 months of age
- Involves periods of irritability (typically late afternoon or early evening)
What is the general management for colic?
- Treat identified conditions
- Reassure patients that their infant is health
- Recommend comfort measures
What are the two classifications of enuresis?
- Nocturnal vs diurnal
- Primary (never been consistently dry) vs. secondary (at least 6 months of prior consecutive dryness)
Which chromosome has a genetic association with nocturnal enuresis?
Stong famililal tendency for nocturnal primary enuresis found with gene identified on chromosome 13
What are some causes of secondary enuresis in children?
- Stressful situations
- Birth of a sibling
- Death of a family member
- Separation of parents
What should be included in a physical examination of enuresis?
Evaluate the abdomen, genitals, perineal sensations, anal wink reflex, and lower spine
A neurologic exam should be performed
What labs should be oredered in evaluation of enuresis?
Urinalysis and urine culture
What medications can be used for enuresis? What should they be combined with for maximum effectiveness?
DDAVP (Desmopressin acetate) and Tricyclic antidepressants (Imipramine is the most widely used)
Best efficacy uses a combination of medications, alarms, and behavioral modification
What is the management for diurnal enuresis?
- Bladder stretching exercises (if small bladder capacity is suggested)
- Schedule timed voiding every 90-120 mintes
- Treatment of and coexisting constipation may be effective
What are normal sleep patterns for newborns?
- Day-night reversals are common in the first weeks of life; normal patterns is random sleep for 4 weeks, after which clustering of sleep time occurs
- Sleeping through the night is defined as sleeping more than 5 hours after midnight for a 4 week period
What is trained night waking? How is it managed?
Trained night waking: between 4-8 months of age when the infant does not resettle without parental intervention during normal night stiffings and awakening
Management: Establishing routines and placing infant in bed while drowsy but still awake
What is trained night feeding? How is it managed?
Infant continues to wake to eat because the parents keep responding witha feeding
Management: lengthening intervals of daytime feeding and teaching parents not to respond with a feeding every time the infant stirs
Nightmares are common after __ years of age
3
At what stage of sleep do nightmares occur?
During REM sleep
How are nightmares managed?
Reassurance by the parents and comforting measures are helpful; important to address the child’s needs for security and to promote regular sleep patterns and good sleep habits
In what age range are night terrors common?
At what stage of sleep do they occur?
3-5 years of age
Stage 4 non-REM sleep
What is the difference in history between nightmares and night terrors?
Nightmare: Child is able to give a detailed recall of extended and frightening dreams
Night terror: Parents describe child who suddenly arouses screaming and thrashing with signs of autonomic arousal - The child does NOT remember the incident the next day
What is the management of night terrors?
Reassuring parents, telling them that the episodes usually terminate spontaneously and will resolve over time
Appetitie normally decreases after __ _____
1 year of age
What is the key issue surrounding toddler feeding problems?
Control - autonomy is more importan than hunger to the child at this stage
What are symptoms of school phobia?
Complaints such as abdominal pain, diarrhea, fatigue and headache typically occur in the morning and worsen on departure for school
Symptoms frequently disappear on the weekends and during summer vacation
Temper tantrums are common between _ and _ years of age
1 and 3 years of age
Define a temper tantrum
Expressions of emotion (usually anger) that are beyond the child’s ability to control
Why do temper tantrums decrease after age 3?
The ability to verbalize feelings decreases tantrums
What is a breath-holding spell?
Benign episodes in which children hold their breath long enough to cause parental concern; the spells are involuntary in nature, harmless, and always stop by themselves
What are the two types of breath-holding spells?
- Cyanotic spells: Most common and usually precipitated by an event that makes the child frustrated or angry
- Pallid spells: Often provoked by unexpected event that frightens the child, resulting in hypervasovagal response - child becomes pale and limp
How do you manage breath-holding spells?
- Reassure the parents that the episodes will resolve without harm
- Counsel parents not ot undertake potentially harmful resuscitation efforts
- Iron has been reported to help some patients
The arrival of a newborn is especially stressful for children younger than __ years of age
3 years of age
At what age does the average child achieve bowel control?
Bladder control?
Bowel control: 29 months of age (16 - 48 range)
Bladder control: 32 months of age (18-60 range)
What can cause resistance to toilet training in a child?
Pressure or force tends to make the child uncooperative - creates power struggle between child and parents
When do children develop self-control?
between 3 and 4 years of age
Before _____ months, no discipline is indicated
6 months
What discipline methods are effective between 18 months and 3 years of age?
Ignoring, time-out, and disapproval (both verbal and nonverbal)
When are logical consequences an effective disciplinary tool?
Preschool children
After 5 years of age, what discipline is effective?
Negotiation and restriction of privileges
How long should a timeout be?
1 minute per year of age (maximum 5 minutes, even in the older child)
What is the most likely cause of childhood hearing impariment?
Genetic factors - autosomal recessive inheritance
