Chapter 2 - Development and Behavior Flashcards
1
Q
Development of a child may be influenced by intrinsic or extrinsic factors. What are some extrinsic factors that may affect development?
A
- personalities of family members
- economic status
- depression or mental illness in caregivers
- availability of learning experiences
- cultural setting into which the child is born
2
Q
True or false? Attainment of a particular developmental milestone or skill depends on the achievement of earlier skills.
A
almost always true, rarely are skills skipped
3
Q
Give two ways in which a delay or deficit in one developmental domain may affect another domain.
A
- delay in one domain ay impair development in another
- a deficit in one developmental domain may compromise the assessment of skills in another domain
4
Q
How might motor deficits affect a child’s cognitive development?
A
neuromuscular disorders affecting the child’s ability to explore the environment may compromise cognitive development
5
Q
True or false? A normal developmental screening test should outweigh parental concern.
A
often false; because many developmental screening tests lack sensitivity, parental concern should not be disregarded
6
Q
What is a developmental quotient and how is it calculated?
A
DQ = (developmental age/chronological age) x 100
- it is used to determine whether a child’s development is delayed and to measure the extent of the delay
- > 85 is considered normal, < 70 is considered abnormal, and between 70-85 requires close follow-up
7
Q
Gross motor development evaluation includes assessment of what two sets of actions?
A
- developmental milestones
- neuromaturational markers (i.e. primitive reflexes and postural reactions)
8
Q
What are neuromaturational markers?
A
a term used to describe primitive reflexes and postural reactions
9
Q
What is the difference between a primitive reflex and a postural reaction?
A
- primitive reflexes are present at birth and then disappear (usually between 3-6 months); infants with CNS injuries show stronger and more-sustained primitive reflexes
- postural reflexes are acquired and help facilitate the orientation of the body in space; CNS injuries delay development of postural reactions
10
Q
How will CNS injury affect primitive reflexes and postural reactions?
A
- primitive reflexes are likely to be stronger and more sustained
- postural reactions are more likely to be delayed in developing
11
Q
Describe the moro reflex, when it appears, and when it should disappear.
A
- symmetric abduction and extension of the arms, followed by adduction of the upper extremities
- present at birth
- disappears by 4 months of age
12
Q
Describe the hand grasp reflex, when it appears, and when it should disappear.
A
- a reflexive grasp of any object placed in the palm
- present at birth
- disappears by 1 - 3 months of age
13
Q
Describe the atonic neck reflex, when it appears, and when it should disappear.
A
- if the head is turned to one side, the ipsilateral arms and legs extend while the contralateral side flexes
- present around 2 - 4 weeks of age
- disappears by 6 months of age
14
Q
Describe the rooting reflex, when it appears, and when it should disappear.
A
- stimulation of the corner of the infant’s mouth causes ipsilateral head turning
- present at birth
- disappears by 6 months
15
Q
Describe the head righting postural reaction, when it appears, and when it should disappear.
A
- it is the ability to keep the head vertical despite the body being tilted
- first seen around 4 - 6 months of age
- persists
16
Q
Describe the parachute postural reaction, when it appears, and when it should disappear.
A
- when the body is abruptly moved head first in a downward direction, the arms and legs outstretch
- first seen around 8 - 9 months of age
- persists
17
Q
What general change occurs in the second year of life with regards to fine motor skills?
A
infants learn to use objects as tools
18
Q
Give four red flags with regards to delayed motor development.
A
- persistent fisting beyond 3 months of age (earliest sign)
- early rolling over, early pulling to a stand instead of sitting, and persistent toe walking (may indicate spasticity)
- spontaneous postures, such as scissoring
- early hand dominance before 18 months of age may be a sign of weakness of the opposite upper extremity associated with hemiparesis
19
Q
What is usually the earliest sign of neuromotor problems through the course of infant development?
A
persistent fisting beyond 3 months of age
20
Q
Early rolling over, early pulling to a stand instead of sitting, and persistent toe walking could all be indicators of what?
A
spasticity
21
Q
When should hand dominance first arise in children? What is early hand dominance often a sign of?
A
- should be seen after 18 months of age
- early dominance may be a sign of weakness of the opposite upper extremity associated with hemiparesis
22
Q
Delays in which developmental domain are most common?
A
delays in language
23
Q
How does the development of receptive language compare to expressive language?
A
receptive language is always more advanced; children usually understand 10 times more words than they speak
24
Q
What is the difference between speech and language?
A
- language is the ability to communicate with symbols
- speech is the vocal expression of language
25
What is the optimal time period of life for language acquisition?
during the first two years of life
26
What and when are the three basic periods of speech development?
- the prespeech period (0-10 months): expressive language consists of cooing and babbling while receptive language is characterized by an increasing ability to localize sounds
- the naming period (10-18 months): is when infant's understand that people have names and objects have labels
- the word combination period (18-24 months): is when early word combinations are present but telegraphic
27
Children begin to combine words how long after saying their first word?
typically combine words 6 - 8 months after saying their first word
28
What are the four primary differential diagnoses for speech or language delay?
- global developmental delay/mental retardation
- hearing impairment
- environmental deprivation
- pervasive developmental disorders including autism
29
Intellectual development depends on what three other abilities?
- attention
- information processing
- memory
30
What is the single best indicator of intellectual potential in an infant?
language; gross motor skills correlate very poorly with cognitive potential
31
On standardized intelligence tests, significant discrepancies between verbal and non-verbal (aka performance) abilities suggests what?
possible learning disabilities
32
Describe the stages of cognitive development.
- sensorimotor period (birth to 2 years): infants explore their environment through physical manipulation of objects, first bringing objects to the mouth for oral exploration and then, as peripheral motor skills improve and precise manual-visual manipulation is possible, true inspection of objects; the infant goes from learning to manipulate to manipulating to learn
- functional play (begins at 1 year): the child recognizes objects and associates them with their function
- imaginative play (begins at 24-30 months) when the child is able to use symbols, for example using blocks to build a fort or using sticks as guns
- concrete thinking (preschool and early elementary school years): interprets things literally
- abstract thinking (develops adolescent years)
33
What is the sensorimotor period of cognitive development?
- a period from birth to 2 years of age
- begins by learning to manipulate objects and then manipulating objects to learn
- they explore their environment through physical manipulation of objects, first bringing objects to their mouth for oral exploration
- true, precise, manual-visual manipulation begins as the child's peripheral motor skills improve
34
What is the functional play stage of cognitive development?
- a period beginning at about 1 year of age
| - the child recognizes objects and associates them with their function
35
When should imaginative play, concrete thinking, and abstract thinking develop?
- imaginative play begins at 24-30 months of age
- concrete thinking begins in preschool or early elementary school
- abstract thinking develops during adolescence
36
When does object permanence develop?
around 9 months of age
37
When and why do babies develop separation anxiety?
it begins sometime between 6-18 months as the child develops an understanding of object permanence and can maintain an image of a person
38
When do babies begin to explore and understand cause and effect?
around 9-15 months
39
When is magical thinking normal?
during the preschool and toddler years it is normal for children to assume that inanimate objects are alive and have feelings
40
How do we estimate verbal and non-verbal intelligence?
by assessing language development and problem solving skills, respectively
41
What would be considered warning signs for poor cognitive development?
- if skills are delayed in both language and problem solving domains, this suggests mental retardation
- if only language skills are delayed, hearing impairment or communication disorder are possible
- if only problem solving is delayed, visual or fine motor problems that interfere with manipulative tests may be present
- if there is a significant discrepancy between language and problem solving skills, there is a high risk for learning disability
42
When do babies develop a sense of self and independence?
individuation begins at about 15 months of age
43
What kinds of social play do babies partake in and at what ages is this true?
- parallel play occurs in the first two years of life
| - they learn to play together and share at about three years
44
Cerebral Palsy
- a group of non-progressive (i.e. static) encephalopathies caused by injury to the developing brain, primarily affecting motor function but often leading to seizures, cognitive deficits, or visual and auditory deficits
- risk factors include maternal (multiple gestation, preterm labor), prenatal (intrauterine growth retardation, congenital malformations or infections), perinatal (prolonged or traumatic delivery, apgar less than 3 at 15 minutes, premature or postdate birth), or postnatal factors (hypoxic-ischemic encephalopathy, intraventricular hemorrhage, trauma, or kernicterus)
- the diagnosis is made based on repeated neurodevelopmental examinations showing increased tone or spasticity, hypotonia, asymmetric reflexes or movement disorder, or abnormal patterns of primitive reflexes or postural responses
- can be classified as spastic cerebral palsy with increased tone and further divided into spastic diplegia, hemiplegia, or quadriplegia or as extrapyramidal cerebral palsy
45
What are the risk factors for cerebral palsy?
- maternal: multiple gestation or preterm labor
- prenatal: intrauterine growth retardation, congenital malformations, or congenital infections
- perinatal: prolonged or traumatic delivery, apgar score less than 3 at 15 minutes, premature or postdate birth
- postnatal: hypoxic-ischemic encephalopathy, intraventricular hemorrhage, trauma, or kernicterus
46
How is cerebral palsy classified?
- spastic: affected patients have increased tone
- spastic diplegia affecting lower more than upper limbs
- hemiplegia: unilateral spastic motor weakness
- quadriplegia: motor involvement of head, neck, all limbs
- extrapyramidal: problems modulating the control of the face, trunk, and extremities
47
Spastic Diplegia Cerebral Palsy
- a static encephalopathy characterized by primarily spastic motor weakness in the lower extremities more than upper
- other symptoms may include seizures, cognitive deficits, and auditory or visual defects
- prematurity is the primary risk factor
- clinical clues include a history of early rolling over, increased tone, and scissoring posture
48
Spastic Hemiplegia Cerebral Palsy
- a static encephalopathy characterized by primarily unilateral motor weakness
- other symptoms may include seizures, cognitive deficits, and auditory or visual defects
- perinatal vascular insult, postnatal trauma, and CNS malformations are the primary risk factors
- clinical clues include early hand dominance, which may manifest as always attempting grasps with one hand and fisting or absent pincer on the affected side
49
Spastic Quadriplegia Cerebral Palsy
- a static encephalopathy characterized by primarily motor weakness affecting all four limbs, the head, and neck
- other symptoms may include seizures, cognitive deficits, and auditory or visual defects
- clinical clues are seizures, scoliosis, weakness of the face and pharyngeal muscles with dysphagia, gastroesophageal reflux or aspiration pneumonia, FTT, speech problems and sensory impairments
- risk factors include hypoxic-ischemia encephalopathy, CNS infections, CNS trauma, or CNS malformations
50
Extrapyramidal Cerebral Palsy
- a static encephalopathy characterized primarily by involvement of extrapyramidal motor systems, resulting in athetoid movements
- problems involve modulating control of the face, neck, trunk, and limbs with the arms more affected than the legs and prominent oral motor involvement
- likely to present with marked hypotonia of the neck and trunk, intermittent posturing, and problems with feeding, speech, and drooling
- risk factors are full-term infant with hypoxia-ischemia or kernicterus damaging the basal ganglia
51
Mental Retardation
- significantly subaverage general intellectual functioning which affects development of adaptive behavior
- can be classified as mild (55
52
What is the difference between mental retardation and learning disability?
- mental retardation is a general intellectual functioning deficit which affects adaptive behavior and daily living
- learning disabilities are defined by a significant difference between academic achievement and expectation based on age and intelligence
53
Learning Disability
- a significant discrepancy between a child's academic achievement and the level expected based on age and intelligence
- usually idiopathic but can be due to CNS insult, genetic disorder, or metabolic disorder
- deficiencies may be in specific academic subjects or there may be defects in processing of information
- managed with classroom accommodations, special education, and bypass strategies
54
What are bypass strategies for those with learning disability?
methods for bypassing their information processing deficiency such that an individual with auditory processing disorder gets information only by visual aid
55
What are pervasive developmental disorders?
- a spectrum of developmental disabilities affecting multiple developmental areas, especially behavior and learning, with a wide range of severity
- Autism is the prototype
56
Autism
- the prototype pervasive developmental disorder (one affecting multiple areas of development, especially behavior and learning)
- onset prior to age 3 and more common in males
- presents with difficulty using language to communicate with speech sometimes absent or having atypical features; unusual ways of relating; unusual or restrictive ranges of interests; unusual perseveration behavior or stereotypic movement rituals; and self-injurious behavior
57
How does Asperger syndrome differ from Autism?
Asperger syndrome has both qualitative impairment in peer relationships and social interactions as well as repetitive, restricted, and stereotyped behaviors but has no clinically significant language delay
58
ADHD
- defined by symptoms before age 7; symptoms in more than one environment; impaired functioning; and symptoms of inattention, hyperactivity, or impulsivity
- dopamine and NE are typically low and medications focus on raising levels
- often assessed with parent and teacher questionnaires but direct and specific observations are most useful
- managed with demystification (explaining ADHD), classroom modifications, educational assistance, counseling, and stimulants (methylphenidate aka Ritalin and amphetamines aka Adderall)
- TCAs and adrenergic like clonidine are second line
59
What are the common side effects of the stimulants used to manage ADHD?
- anorexia, nausea, and abdominal pain
- palpitations and hypertension
- insomnia
- headache
- irritability, particularly as it wears off
60
What is the cause of most cases of pediatric hearing loss?
autosomal recessive genetic conditions
61
Hearing Loss
- 80% of cases are genetic and 80% of these are autosomal recessive conditions
- likely to affect speech development and language skills, limit academic achievement, and lead to behavioral problems
- prognostic factors include degree of impairment; etiology with those who inherited deafness usually faring better and those who acquired deafness at greater risk for other neuro impairments; family willingness and ability to use ASL; age at onset with those who become deaf after two years of age and after incorporating some language structure doing better; early identification and intervention
- evaluation includes a history of perinatal infections and antibiotic exposures, a creatine level to check for any associated kidney defect, and viral serologies
62
Visual Impairment
- classification of blindness depends on measures of corrected acuity in the better eye
- trachoma infection is the leading cause worldwide; retinopathy of prematurity and congenital cataracts are also common causes
- this impairment may delay locomotion, decrease fine motor skills, and cause difficulties with attachment
- however, patients may compensate with auditory perception skills or haptic perception
63
Colic
- crying that lasts more than 3 hours per day and occurs more than 3 days per weeks
- it begins in healthy, well-fed infants at 2-4 weeks of age, resolves by 3-4 months of age, and most often begins in the late afternoon or early evening
- problematic because it may disrupt attachment and cause family stress
- reassure parents and recommend comfort measures like decreased or increased sensory stimulation and positioning
64
What is the difference between colic and normal crying?
- normal crying usually lasts up to two hours per day at 2 weeks of age and increases to 3 hours a day at three months
- colic is crying that lasts more than three hours per day and occurs more than three days per week beginning at 2-4 weeks of age
65
Enuresis
- defined as urinary incontinence beyond the age when the child is developmentally capable of continence
- can be nocturnal or diurnal and primary (never been continent) or secondary (at least 6 prior months of consecutive dryness)
- bed-wetting is seen in 30% of 4-year-olds
- there can be many contributing factors including a gene on chromosome 13, psychosocial factors (especially secondary enuresis), chaotic home situations, impaired sleep arousal mechanisms, urine volume, bladder capacity, child abuse, and constipation, UTI, or diabetes mellitus
- manage with education and removal of blame from child, use of conditioning alarms (trial requires minimum of 3-5 months), behavioral modification, and medications
- medications include desmopressin acetate and TCAs but when used alone, relapses are extremely common
66
What is the incidence of bed-wetting by age?
- 30% of 4 year olds
- 15-20% of 5 year olds
- 10% of 6 year olds
- 3% of 12 year olds
67
Why is desmopressin acetate an effective medication for nocturnal enuresis? What is the primary limitation?
- decreases urine volume, and may be especially helpful in children with no normal circadian rhythm for release of arginine vasopressin
- if used alone, relapse is likely once medication is withdrawn
68
What are day-night reversals and when are they considered normal?
common in the first weeks of life, it is a normal pattern of random sleep for four weeks, after which clustering of sleep time occurs
69
How do we define sleeping through the night and when does it typically occur in an infants life?
- it is defined as sleeping more than 5 hours after midnight for a 4-week period
- fifty percent of infants sleep through the night by 3 months of age
70
What is trained night waking?
- an abnormal sleep pattern that typically occurs between 4 and 8 months of age during which the infant will not resettle without parental intervention during normal night stirrings and awakenings
- best managed by establishing routines and placing the infant in bed while drowsy but awake
71
What is trained night feeding?
- an abnormal sleep pattern in which the infant continues to wake to eat because the parents keep responding with a feeding
- management involves lengthening intervals of daytime feeding and teaching parents not to respond with a feed
72
When in a child's life do nightmares typically begin? How should they be managed?
- common after 3 years of age
- managed with reassurance by the parents and comforting measures; promote regular sleep patterns and good sleep habits; remove any inciting causes like scary movies
73
When are night terrors common? How should they be managed?
- they are common between 3 and 5 years of age
| - reassure parents that they usually terminate spontaneously
74
How does toddler feeding compare to that during infancy?
appetite normally decreases after 1 year of age
75
What is the root cause of most toddler feeding problems? How should this be managed?
- control is the major issue as autonomy is more important than hunger to the child at this stage
- management involves avoidance of power struggles
76
School Phobia
- the child is usually fearful of leaving home and the caregiver and misses school due to vague physical complaints
- complaints typically occur in the morning, worsen on departure for school, and disappear on weekends
- ensure the child is healthy and return them to school while encouraging peer relationships
77
Temper Tantrums
- expressions of emotions, usually anger, which are beyond the child's ability to control and are not necessarily manipulative or willful
- commonly seen in those 1 to 3 years old
- more common in those with poor fine motor skills or expressive language delays, which increase frustration
- frequency decreases as the ability to verbalize feelings emerges (learned by 3 years of age)
- tantrums that demand something should be ignored
78
Breath-Holding Spells
- involuntary, benign episodes that are harmless and always stop by themselves
- most often occurring between 6 to 18 months of age and disappearing by age 5
- cyanotic spells are most common, are precipitated by frustration or anger, and involve crying, becoming cyanotic, and occasionally apnea and unconscious
- pallid spells are provoked by an unexpected event that elicits fear and results in a hypervasovagal response during which the child becomes pale and limp
- reassure parents and counsel them not to undertake resuscitation efforts which may be harmful; if the spells are precipitated by exercise or excitement, an ECG may be indicated
79
Sibling Rivalry
- includes bids for attention, regressive symptoms, and aggression toward a new sibling
- the arrival of a newborn is especially stressful for those less than 3 years old
- prevent by talking about the new arrival, praise the child for being mature, avoid demanding mastery of new skills like toilet training at this time
- older children should be encouraged to settle their own arguments without violence; parents should try to stay out of these, teach children to listen to one another, protect each child's personal possessions, and praise good behavior
80
When do bowel and bladder control typically develop?
- bowel control is achieved by 29 months on average
- bladder control is achieved by 32 months on average
- both have wide ranges
81
What are the prerequisites for toilet training?
- understanding the meaning of words such as wet and dry
- prefer being dry
- recognize the sensation of bladder fullness
- ability to hold urine and stool
- ability to tell the caregiver about this need
82
How should toilet training be taught?
- stress encouragement, praise, and patience
- allow multiple practice tries with praise for cooperation; social reinforcement is better than treats of some kind
- avoid pressure as this can lead to a power struggle
83
When should children begin developing self-control?
between 3 and 4 years of age
84
How should discipline change with a child's age?
- before 6 months, no discipline is indicated
- distraction and redirection can be used to ensure the child's safety as the infant develops more mobility
- from 18 to 36 months, ignoring, time-out, and disapproval may be effective
- preschool children should have logical consequences
- negotiation and restriction of privileges can be used after five years of age
85
What are the typical guidelines for using punishment to control discipline issues?
- rules must be clear, concrete, and consistent
- consequences should be brief and immediate, followed by love and trust; direct the punishment towards the behavior, not the person
- time-out should be 1 minute per year of age with a maximum of five minutes
