Behavioral/Developmental Peds Flashcards
Development generals
Motor, language, problem solving, psychosocial
Head to toe, prox to distal, gross before fine
Intrinsic and extrinsic factors, dont skip oe skill, go in order, delays in one domain may affect another, or compromise assessment in another
Many of the tests lack sensitivity so listen to the parents!!
DQ = dev. age/chrono age (DQ >85 = normal, <70 = abnormal, followup in between)
General milestone info
Primitive reflexes like Moro present at birth, desappear at 3-6 mos, need sensory stim to generate steerotypical motor response, cns injuries = stronger/more sustained.
Postural rxns = parachute rxn, acquired, faciliated orientation of body in space, adjust things. CNS damage = delayed development of postural rxns
Fine motor skills - during first year of life, hands can do more, conrol of distal muscles improves
Gross Motor Milestones
Birth- turns head side to side,
2 months- lifts head when lying prone, head lag when pulled from supine,
4 mo- rolls over, no head lag when pulled from supine, pushes chest up w/ arms,
6 mo- sits alone, leads with head when pulled from supine
9 mo- pulls to stand, cruises
12 mo- walk
Moro
Symmetric abduction/extension of arms w/ trunk extension, followed by adduction of upper extremeties, from birth- 4 mos
Hand grasp
Grab anything, birth to 1-3 months
Atonic neck reflex
IF head to one side, arms/legs extend on same side and flex on opposite. Fencer position
2-4 weeks to 6 months
Rooting reflex
Turning of head to same side as stimulus when corner of mouth stimulated, birth to 6 months
Head righting
keep head vertical despite body being tilted, 4-6 months and persists
Parachute
Outstretched arms/legs when body is abruptly moved head first in downward direction, starts at 8-9 months
Fine Motor Milestones
Birth- keep hands tightly fisted
3-4 months- bring hands together to midline and then to mouth
4-5 mo- reaches for objects
6-7- rakes objects/transfers from hand to hand
9- immature pincer, hold small obj between thumb/index
12- mature pincer (just tip of index)
Fine motor skills
By second year of life, use objects as tools.
Red flags- persistent fisting beyond 3 mos = earliest sign of neuromotor issues
Early roll over/pulling to stand/toe walking = spasticity
Spont postures like scissoring in spazzy kid or frog-leg in hypotnoic
Early hand dominance pre 18 mo may = weakness in other side
Ddx of motor delay
CNS injury, spinal cord dysfn, periph nerve path, motor endplate dysfn, musc disorder, met disorder, neurodegen conditions
Language skills!
Language = most common delay domain, receptive always mroe advanced than expressive (understand 10x more than speak)
Window of opp for optimal acquisition in first two years
Lang isnt speech?
Lang = ability to comm w/ symbols (signs, writing, body) Speech = vocal only.
Language Milestones
Birth = attunes to human voice, diff recog of parent’s voices, 2-3 mo = cooing, musical, 6 mo = babble, 9-12 = jargon (babble + consonants)
12 mo- 1-3 words mama/dada, 18 mo- 20-50 words, 2 word phrases, 2 years = telegraphic 2 word sentences, 25-50% intelligible, 3 years = 3 word sentences 3/4 understandable
Periods of speech development
Prespeech = 0-10 cooing, babbling (w/ consonants), naming = 10-18, ya get that things have names/labels, word combo period- 18-24 mo, telegraphic,
DDx speech/language delay
Global delay, hearing impariment, environ deprivation, pervasive developmental disorders (autism specturm)
Cog development
Intellectual development dep on attention, info processing, memory. Infant intel look at prob solve/language.
Lang = BEST indicator of intellectual potential (more than gross motor)
big diff between verbal vs. nonverbal = maybe learning disabled
Stages in cog development
Sensorimotor birth to 2 years, from learning to manipulate to manipulating to learn
Functional play at 1yo, imaginative play at 24-30 mo, concrete thinking in late preschool/early elem, abstract in adolescent
Cognitive concepts over time
1) Objective permanence- things exist when ya can’t see em, separation anxiety develops (9 mts, 6-18 mos)
2_ Cause and effect- 9-15 months
3) Magical thinking- normal state of mind, objects are alive/have feelings
Red flags in cog development
Sig delay in language + prob solving = MR
Only language? maybe hearing issue, or commu disorder
Only problem solving? Visual/fine motor problems, cant do manipulation
Diff in language vs. problem solving? Learning disabilities
Social skill milestones
Attachment- bonding w/ primary caregiver, empaty developing in first 3 years
Sense of self/indep - process of separation/individuation at 15 months
Social play- parallel play during first 2 years, play together and share at 3 years
Cerebral Palsy
Static encephalopathies where motor function affected, intelligence may be normal, but CP brain inuries => seizures, cog deficits, MR, learning disab, sensory loss, aud deficits
Timing prenatal or perinatal, .2-.5% incidence, dx from repeated neuro exams w/ spasticit, hypotonia, assym reflexes, weird reflex disappearance
CP Risk factors
Maternal = multiple gest, ptl Prenatal = IUGR< congen malform, TORCH Perinatal = prolonged/precip/trauma delivery, apgar <3 at 15 min, preemie/postdates Postnala = HIE, IVH, trauma, kernicterus (bili in brain)
Spastic CP
Increased tone, can be:
1) Diplegia- weakness in lower more than upper, early rolling over, scissoring, preemie
2) Hemiplegia- unilateral weakness, more upper etremity, early hand pref, grasp on one side- perinatal vasc insult, postnatal trauma, CNS malform
3) Quadriplegia- all limbs/head/neck/scoliosis, weak face, dysphag, GERD/FTT, speechf rom HIE, CNS infec, trauma, malform :(
Extrapyrimadal CP
Nonspastic, athetoid mvts, problems moduating face/neck/trunk/limbs, ARMS more than legs, oral involvement prominent
Why motor deficits?
Met abnormalities Chormo abnormal Neuron diseases Degen diseases SCI, congen myopathy, leukodystrophy, CNS
Mental retardation
Subavg gen intel w/ deficits in adaptive behavior before 18 y/o, look at IQ or Wchsler Scale…Mild = 55-69, mod = 40-54, severe = 25-39, profound 25. MGMT early intervention, behavior MGMT< community
MR Causes
Genetics, prenatal/perinatal (upi, fetal mal, brain malform, drugs), enviro, postnatal infec/near drown/head truama
Learnign disabilities
Sig discrep between academic achievement vs. age/intelligence
Why? CNS insults, genetic disorders, met disorders, idiopathic (most common)
Types = specific subject or processing
MGMT = special ed, bypass strategies
Autism
(PDD), prior to 3 yo onset, more in boys, hard to use language to communicate with others, maybe echolalia (repetitive words),
unusual way of relating to others, down eye contact, unusual/restrictive interest range, perseverative heavior/stereotypic mvt, preocupations, self-inj behavior
Clin fx- seizures, MR, chronic diarrhea, constipation, toilet training issue, ear infec, sensory sensitivity
Asperger
More common in boys, qualitative impairment in peer relationships, restricted/stereotyped behavior, activity, interest
NO language delay, maybe advanced
ADHD
poor selective attention, hard to focus, distractable, maybe hyperactiveimpulsive, distracted, disinhib, general immature
More in boys, unknnown cause, def genetic (30-50% w/ relative), NT fn dopa and NE
Clin fx- before age 7, in more than one place, impaired fn at school/w relationsh, inattention/organizing issues, hyperactive, impulsive.
Issues w/ classroom conform, social adjust, impaired parent/peer relation, difficult learning
Ddx
Hearing/vision issue, sleep disorder (OSA), food rxn, thyroid, anemia, lead poison, anxiety/dep/bipolar, MR, specific LD, med s/e (albuterol, decongest, antihist,), fam dysfn, normal kid but parents have weird expec, caffeine
Diagnose/Manage ADHD
Parnt/teacher questionnaires, psychoed testing, direct obs, p/e, use several sources, think abt kid’s strengths
MGMT = demystify (explain to kiddo), modify classroom, edu assist, counsel
Meds = stimulants (improve attention/impulse), MOA = enhance catechol transmission (up dopa and NE)), dose diff, s/e, methyphen and amphetamine
Nonstim also as second line (TCA, clonidine (adrenergic at night))
SSRI if comorbid depression
Stimulant side effects?
Arex, insomnia, Naus/ab pain, h/a, irritable, CV palipations/HTN, decrease growth velocity, tics (maybe from underlying tourette’s)
Hearing Impairment
1:600 newborns will get perm hearing loss, early ID key to not delay speech/lang/academic/behav
Genetics = 80% of impairment, recessive. 20% = perinatal,pre/post
Prog factors- degree of loss, etio (inherited fare better than acquired), fam atmosphere, age at onset (before 2 years = disadvg), timing of amplification earlier is better, cochlear implants!
Med eval = complete hx/phys, genetics, CR level (kidney ear alport), viral serologies for TORCH, maybe CT inner ear
Visual impaired
1:1600 children, classify using measures of corrected acuity
Leading causes = trachoma (biggest worldwide), retinopathy of preemies, congen cataracts
Blind=> delayed loco, less fine motor, difficulty attaching
But get better auditory, haptic perception (feel fac and make an image!)
Colic
Crying that lasts >3 hours per day, >3 days/ week
Epid = 10%, Why unknown
Clin fx- healthy well fed babies, starts 2-4wks, to 3-4 mos, w/ periods of irritability
Ddx = pain sources/discom like gas, intol, corneal abrasian, OM, test torsion, inguinal hernia, etc
MGMT = reassure parents, comfort baby (decrease sensory stim or increase it, position diff)
Enuresis
Urinary incontinence beyond age appropriate
Classify= nocturnal versus diurnal, primary (never dry), vs. secondary
Why? More common in boys, 30% 4, 15-20% 5, 10% 6, 3% 12, 15-20% with noc have diurnal
More Enuresis
Why? genetics on chromo 13, psychosocial- after stressful, chaotic social situation, sleep-arousal issues (deeper sleep), urine volume (lack of variation in daytime release), constipation = comorbid
Eval- hx, p/e (anal wink!), lab eval w/ ua/uc, extra labs of kidney/bladder
MGMT = education/demyst, conidtioning alarm, pharma therapy- ADH/DDAVP (decreases urine volume, but may relapse after meds), TCA
IMPRAMINE most often used!
Also, behavioral mod, diurnal w/ bladder stretching, scheduled voiding
Sleep problems
1/2 infants have issues (so parents think)
Day/night reverse common in first 4 weeks
Sleep through night (more than 5 hours), 50% babes do it at 3 mos
Abnormal patterns- trained night waking at 4-8 mo, infant can’t resettle w/out parental help, MGMT w/ routines,
trained night feeding- parents keep responding. BE STRONG PARENTS
Nightmares/terrors
Mares = after 3 y, maybe at 6 mo! Occur in REM, kid can tell story, MGMT = reassurance, promot regular sleep/habits. Terrors = 3-5 years, 90-120 min after sleep onset, in stage 4 non-REM, autonomic arousal, glassy-eyed, kiddo doesn't remember, usual terminate on own
Eating issues
Over feeding in infancy common
Toddler feeding- food refusal/gorging or not eating enough
App normally down after 1 y/o, control is major issue (autnomy over hunger, MGMT = avoid power struggles, don’t bribe
School Phobia
Misses school b/c of vague phys complaints
Why? Kid afraid of leaving home, maybe bullies/violence
Sx- ab pain, diarrhea, fatigue, h/a in morning, begin in Sept/Oct, totes fine on weekends
MGMT = hx/pe, return kid to school
Temper Tantrums
1-3 y/o, frustration or fatigue cause these, poor fine motor skills/less language => more trantrums, not always willful
MGMT = if demanding something, ignore them, wait for them to increase talking
Breath holding spells
Benign, involuntary, harmless. Why? 5% of kids, 6-18 mo
Types- 1) Cyanotic- kid gets frustrated, cries, cyanotic, maybe apneic/seize
2) Pallid = frightened kid, hypervasovagal, pale/limp
MGMT = reassure, counsel to not resuscitate, iron may help, if from exercise/excitement, do an EKG to r/o dysrhytmia
Sibling Rivalry
Bid for attn, regressive sx, aggression, arrival fo newbie
MGMT- before baby comes, get kiddo ready, praise maturity
In older kids- settle arguments without hitting baby, be nice
Toilet training
Bowel control by 29 mo age, 16-48 mo range, bladder control by 32 (18-60)
Prereqs- know words (wet dry, etc), like being dry, recog sensations
Method- encourage, praise, patience, no pressure/force, (avoid power struggle)
Discipline issues
Teach the child limits, respect right of others, control behavior
Self-control by 3-4 y/o
before 6 mo, no discip. When kid mobile, distract/redirect. 18 mo- 3 y/o, ignore, time out/disapproval. Preschool? Logical consequences (take away toy if used as weapon). After , negotiate/restrict privileges
Rules clear/conc/consistent
Guidelines- apply conseq, make punishment brief/immediate
USE TIMEOUTS EFFECTIVELY!!! 1 min/year of age, no more than 5 min!
