Development Flashcards by Sindu Govi

Describe an average 18 month old

 Running
 Scribble with fisted crayon
 15-25 words
 “Word explosion”
Embedded jargon-communicative babbling
 Joint attention
 Single step commands
 Lots of gestures, pointing
 Know body parts
 Symbolic and parallel play

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Describe the speech of an average 2 year old

200 words
Too many to count!

2-3 word phrases

Pronoun use

2 step unfamiliar commands

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When should a patient with speech delay be referred?

-When the parent is concerned

By 9 months:
–Vocalizing to initiate social interaction

By 12 months:
–Not babbling, not pointing

By 18 months:
-Less than 15 words

Social communication concerns

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Differential diagnosis of speech and language delay

•CNS processing
–Autism spectrum disorder, global developmental delay, specific language impairment

•Hearing loss

•Environmental
–Social, abuse, deprivation

•Anatomic
–Cleft palate, craniofacial

•Production problems
–Stuttering, Apraxia of speech

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List 3 management steps for a patient with speech and language delay

Hearing test

Referral to local preschool speech and language initiative

Tips for parents about language facilitation

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Describe 5 ways parents can facilitate language development

Read to him at night
Make him stop his activity and look at you when you talk
Do not complete his sentences
Get down to the child’s level and play with what he/she is interested in
Talk to your child throughout the day about things you are doing and seeing together in all everyday activities.
Let them touch and hold books while you point to and name the pictures.
Take the time to listen/respond to your child’s communications, whether they are eye gazes, gestures, sounds, or words.
Imitate the sounds and words that your child makes.
Sing songs and include your child in the actions.
Take your child to play groups, so they can first watch other children, and then begin interacting with them.
Encourage parents to use whichever language they are more comfortable with

.It takes 2 to talk-Hanen program book

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In what age group is stuttering/dysfluencing most common?

Common between 3-8 years

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Does most stuttering persist through to adulthood?

Resolves in 80% of children by adulthood

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Name 5 characteristics of developmental dysfluency?

Occasional (once every 10 sentences)
Brief (0.5 seconds or less)
Repetition of sounds, syllables or words (no prolongations, at start of word)
Worse when tired, excited, complex language, questions, anxious

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Name 5 indications for referring a patient with developmental dysfluency to SLP?

Parental and/or child concern
Presence of secondary behaviours (e.g. eye blinking, jaw jerks, head or other involuntary movements)
Repetitions are parts of words or single sounds (e.g. li-li-li-like; a-a-a-apple)
Speech seems to get blocked (trying to make sound but no sound coming out)
Persists for more than 8 weeks

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Under what age can one use the term Global Developmental Delay?

<5 years of age

After becomes intellectual disability (disturbance in adaptive functioning)

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List 3 investigations in the workup of GDD

For all patients:

1. Chromosomal Microarray (10-15%)

2. Fragile X (2.5% of males, 1.5% of females)

Hearing and vision

Consider:

4. MECP2 (1.5% of females mod-severe ID)

5. Thyroid (4% or nearly 0% with normal newborn screen)

6. Lead and Ferritin (only if mouthing/PICA)

7. Metabolic testing (1-5%)
•Blood: amino acids, homocysteine, acylcarnitine profile
•Urine: organic acids, GAA/creatinine metabolites, purines/pyrimidines, MPS screen, oligosaccharide screen

8. Neuroimaging (MRI 10-55%)-focal neuro signs, micro/macrocephaly

9. EEG (only if seizures suspected) (<1%)

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What percentage of ASD is syndromic?

10%

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Name 4 syndromic causes of ASD

Fragile X
Tuberous sclerosis
Rett’s syndrome, Angelman’s syndrome
NF

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What are the DSM V Criteria for ASD?

•Impairments in Social Communication (3/3)
–Deficits in socio-emotional reciprocity
–Deficits in nonverbal communication used for social interaction (eye contact, gestures, facial expressions)
–Deficits in developing, maintaining and understanding relationships (peer relations, sharing imaginative play)

• Restricted, repetitive patterns of behaviour, interests, activities (2/4)
–Stereotyped/repetitive motor movements
–Insistence on sameness, routine
–Highly restricted, fixated interests
–Hyper or hypo-reactivity to sensory stimuli
•Symptoms in early developmental period
•Impact on current functioning

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List 8 red flags for autism in a 12-18 month old child

Reduced or atypical:

eye gaze and shared joint attention
sharing of emotion
social or reciprocal smiling
social interest and shared enjoyment
orienting when his or her name is called
coordination of different modes of communication
babbling
language comprehension and production
unusual tone of voice
development of gestures (pointing, waving)
imitation of actions
functional and imaginative play
excessive or unusual manipulation or visual exploration of toys and other objects
repetitive actions with toys and other objections
atypical visual tracking, visual fiation
under or over reaciton sounds
repetitive motor behaviours

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Name 5 conditions in the differential for social communication deficit

Language disorder
Developmental disability
Sensory impairments
Attention deficit hyperactivity disorder
Oppositional defiant disorder
Anxiety (rigid, like routines, tantrums)
Non verbal learning disability (difficulty with perceptual reasoning, social realm-can’t read cues)

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Name 5 steps in the management of ASD

Audiology testing
Referral to SLP for initiation of therapy
ASD specific screening instrument

-Referral to Developmental Pediatrician/Centre for
multidisciplinary team assessment

-Behavioural intervention:
•Intensive Behavioural Intervention (IBI)
•Applied Behavioural Analysis (ABA)

Treat medical co-morbidities – sleep, feeding, seizures, GI
Specialized school programming
FAMILY SUPPORT – Autism Speaks, Autism Ontario, Geneva Centre for Autism

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What is the definition of a learning disability?

Average or higher cognitive abilities
Specific processing weakness
Unexpectedly behind in academics

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What are the DSM V criteria for ADHD?

1) Inattentive symptoms (6/9)
•Inattentive
•Does not listen
•Needs repeated instructions
•Careless errors
•Disorganized
•Avoids/dislikes homework
•Loses things
•Distractible
•Forgetful

2) Hyperactive/Impulsive symptoms (6/9)
•Often fidgets or squirms in seat
•Leaves seat when remaining seated is expected
•Inappropriately runs about/climbs
•Difficulty with quiet leisure activities
•“On the go”, “Driven by motor”
•Talks excessively
•Blurts out answers before questions completed
•Difficulty waiting turn
•Interrupts or intrudes on others

Symptoms for at least 6 months

Symptoms present before 12 years

Functional impairment
Several symptoms are present in two or more setting

Symptoms are not better explained by another mental disorder

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Name 5 conditions that can mimic ADHD

Hearing/vision problems
Learning disability
Gifted children
ASD
Metabolic disorders (eg, adrenoleukodystrophy, mucopolysaccharidosis type III)
Neurodevelopmental syndromes (eg, fragile X, fetal alcohol syndrome, Klinefelter syndrome)
Mood/behavioural disorder (anxiety, ODD)
Substance use disorder
Lead poisoning
Thyroid abnormalities
Absence seizures
Sleep disorders

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What is recommended management of ADHD?

Preschool (age 4-5)-behavioural therapy, meds if necessary

- Everyone else, meds +behavioural therapy

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What is a late onset side effect of stimulants?

Depression

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What ADHD medications should be started in children >6 years old?

Long acting stimulant (e.g. concerta)

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What ADHD medication should be used if there is a risk of substance abuse/diversion?

Vyvanse | Strattera (atomoxetine)

Approach to patient with ADHD who fails treatment

- Assess for compliance - Rule out possibility of medication diversion - Revisit whether the expectations are realistic - Assess for comorbid psychiatric diagnosis - Rule out rebound - Increase dose (to maximum recommended dose) - Switch to another stimulant medication - If above fails, try non stimulant

List 10 side effects of stimulants

``` Decreased appetite Poor growth Mood lability Insomnia Tics Priapism (methyphenidate and atomoxetine) ```

Name 4 clinical features of FASD

- Typical facial features - Cognitive and learning disorders - ADHD (severe and refractory) - Poor judgement, poor sense of cause and effect

What is sleep onset association disorder?

* Inability to fall asleep on own * Falls asleep easily when parent present * Frequent night wakenings

Name 3 interventions to address sleep onset association disorder

- Establish a bedtime routine - Remove maladaptive sleep associations (rocking, patting, singing, with parent beside them, bottle or pacifier, parents bed then moving to own bed) - Teach child to fall asleep on their own (timed waiting and chair sitting strategy)

Name 3 types of partial Arousal Parasomnias

–Confusional arousals –Night terrors –Sleep walking

During what part of phase to partial arousal parasomnias occur?

Deep (slow-wave) NREM sleep (first third of the night)

List 5 characteristics of partial arousal parasomnias

* Occur 1-3 hours after falling asleep * Deep slow-wave, non-REM sleep * Child does NOT wake during episode * Does NOT recall episode in morning * Confused after episode * Family history is common

Name 5 interventions in the management of partial arousal parasomnias

``` •Establish bedtime routine •Ensure adequate amount of sleep •Do not wake during episode •Ensure safety for sleepwalking •Often increases during times of stress -Consider timed awakenings for patients with >3 night terrors/week ```

Describe 3 reasons why children between 18 months and 3 years tantrum

–Asserting independence –Limited language –Limited self-regulation

List 3 counselling points for tantrums

•Stay calm - model the behaviour you want •Use consistent limits –Same expectations across situations and parents •<2 years – distraction; planned ignoring •>2 years – understand cause and effect –Before: count downs, if-then –After: time outs; explanations appropriate to language level •Positive reinforcements

Over what age is not being toilet trained a concern?

>4 years | Typically 2-4 years

Name 5 ways to assess readiness for toilet training

Physiologic - Walks to potty, stable on potty - Can remain dry for several hours Communication - Expresses need - Understands simple commands Psychologic -Desire to please parent & independence

5 tips to assist parents in successful toilet training

* Expose to potty chair * Allow child to watch parent * Sit on potty fully clothed * Sit on potty after wet/soiled diaper removed * Offer potty often (child’s timing) * PRAISE!!

Gross motor: Jumps on two feet, Up & down stairs "marking time" Fine motor: Handedness established, Uses fork Tower of 6 blocks, Imitates vertical stroke Speech: Follows 2-step command 50+ words, 50% intelligible 2 word phrases "I", "me", "you", plurals Cognitive: New problem-solving strategies without rehearsal, Searches for hidden object after multiple displacements Social: Testing limits, tantrums, Negativism (“no!”), Possessive (“mine!”)

2 years

Gross motor: Balance on one foot 10 secs, Skips, May learn to ride bicycle (if available) Fine motor: Draw person (10 body parts) Tripod pencil grasp Prints name, copies letters Independent ADLs, incl tying Speech: 5000 words Future tense Word play, jokes, puns Phonemic awareness Cognitive: Counts to 10 accurately Recite ABC’s by rote Recognises some letters Pre-literacy and numeracy skills Social: Has group of friends Follows group rules Games with rules

5 years

Gross motor: Postural reflexes, Sits tripod, Rolls both ways Fine motor: Raking grasp, Transfers hand to hand Speech: Babble, (nonspecific) Cognitive: Stranger anxiety, Looks for dropped or partially hidden object Social: Expresses emotions: happy, sad, mad Memory lasts ~24 hrs

6 months

Gross motor: Stoops and recovers, Runs Fine motor: Carries toys while walking, Removes clothing,Tower of 4 blocks Scribbles, fisted pencil grasp Speech: Points to object, 3 body parts 10-25 words, Embedded jargoning Labels familiar objects Cognitive: Imitates housework, Symbolic play with doll or bear, eg "Give teddy a drink" Social: increased independence Parallel play

18 months

Gross motor: Walks well Fine motor: Uses spoon, open top cup, Tower of 2 blocks Speech: Points to 1 body part 1-step command no gesture 5 words Jargoning Cognitive: Looks for moved hidden object if saw it being moved Experiments with toys to make them work Social: Shared attention: points at interesting items to show to parent Brings toys to parent

15 months

Gross motor: Hops on one foot Down stairs alternating feet Fine motor: Draws x, , diagonals Cuts shape with scissors Buttons Speech: Sentences,100% intelligible Tells a story Past tense Cognitive: Counts to 4, Opposites, Identifies 4 colours Social: Has preferred friend Elaborate fantasy play

4 years

Gross motor: Pedals tricycle, stand briefly on one foot, Up stairs alternating feet Fine motor: Helps undress himself, Toilet trained (2 1⁄2 - 3 1⁄2 yrs) Draws circle, cross + Turns pages of books Speech: 3-step commands 200 words, 75% intelligible 3-4 word phrases W questions ("why?") States full name, age, gender ``` Cognitive: Simple time concepts Identifies shapes Compares 2 items (eg "bigger") Counts to 3 Names 3 body parts ``` ``` Social: Separates easily Sharing, empathy Cooperative play Role play ("pretending") ```

3 years

Gross motor: Head steady when held, Head up 45 degrees prone Fine motor: Hands open half of time, Bats at objects Speech: Turns to voice, cooing Cognitive: prefers usual caregiver, attends to moderate novetly, follow past midline Social: social smile

2 months

Gross motor: Gets from all 4s to sitting, Sits well with hands free, Pulls to stand Crawls on hands and knees Fine motor: Inferior pincer grasp, Pokes at objects Speech: "Mama", "dada" (specific) Gestures "bye bye", "up" Gesture games ("pattycake") Cognitive: Object permanence, Uncovers toy "Peek-a-boo" Social: Separation anxiety

9 months

Gross motor: Walks a few steps Wide-based gait Fine motor: Fine pincer (fingertips) Voluntary release Throws objects Finger-feeds self cheerios Speech: 1 word with meaning (besides mama, dada) Inhibits with “no!” Responds to own name 1-step command with gesture Cognitive: Cause & effect Trial & error Imitates gestures and sounds Uses objects functionally, eg rolls toy car Social: Explore from secure base Points at wanted items Narrative memory begins

12 months

Gross motor: Sits with support, Head up 90 degrees prone, arms out Rolls front to back Fine motor: Palmar grasp Reaches and obtains items Brings objects to midline Speech: Laugh, razz, "ga", squeal Cognitive: Anticipates routines Purposeful sensory exploration of objects (eyes, hands, mouth) Social: Turn-taking conversations Explores parent's face

4 months

What is the most common cause of bilateral CP?

Periventricular Leukomalacia (PVL)

5 recommendations for teenagers regarding sleep

- Sleep in only one hour later on weekends - Eliminate caffeinated beverages after 12 noon - Have breakfast each morning - No TV in room - No late night or evening exercise

DSM 5 criteria for learning disability

Selective impairment with average intelligence ‘Specific learning disorder’: A neurodevelopmental disorder of biological origin manifested in learning difficulty and problems in acquiring academic skills At least 6 months Not attributed to ID, ‘developmental disorders’, neurological (including sensory) or motor disorders Specifier ‘with impairment in…’ (reading, mathematics, written expression)’ NOT dyslexia, dyscalculia etc.

List 7 tips for talking with a child with developmental dysfluency

1. Speak in an unhurried way, pausing frequently 2. Reduce the number of questions you ask 3. Use your facial expressions and other body language to convey your as listening to content, not how she is talking 4. Set aside a few minutes at a regular time each day when you can give your child undivided attention 5. Help all members of the family learn to take turns talking and listening 6. Observe the way you interact with your child 7. Above all, convey that you accept your child is as he is

When should psychoeducational testing be done?

Grade 2-3 (before that not as stable)

What are the 2 domains affected in intellectual disability?

1. Deficits in intellectual functions - Reasoning - Problem solving - Planning - Abstract thinking - Judgement 2. Deficits in adaptive funcitons - Academic - Social participation - Independent living

In DSM V, the severity of intellectual disability is based on IQ or adaptive function?

Adaptive function

Name 5 characteristics of Angelman syndrome

``` Seizures Gait ataxia Tremulous movement of limbs Easily excitable personality Happy demeanour Profound ID Lower extremity spasticity ```

Name 5 diseases in the ddx for GDD

Genetic/metabolic (fragile x, T21, angelman's, cornelia de lange, Retts) Brain malformation Brain injury (HIE, trauma, hemorrhage, infection, tumour) Toxins (FASD, lead)

Name 5 early signs of ASD (<2 years)

``` No response to name Reduced joint attention Intense visual inspection Repetitive actions More negative affect ```

What is the recurrence risk of autism?

Slightly increased risk if sibling has autism

List 5 differential diagnoses for school problems (medical, developmental, home, school)

Medical - OSA - Seizures (absence) - Vision/hearing impairment - Hypothyroidism Developmental - Learning disability - ADHD - ODD - ASD - ID - Anxiety - Depression Home - Parental conflict/divorce - Food insecurity - Abuse - Parental depression/substance use School - Bullying - Lack of continuity - Teacher/student fit

Asking about which 3 is most helpful when you're taking an ADHD history? (OSCE)

At mealtime While doing homework While playing quiet games (e.g. board games)

Name 5 interventions for decreased appetite with ADHD meds

1. Supplemental strategies-protein shakes, high colorie pre-made drinks 2. Engage child in meal prep 3. Nutritious snacks for grazing 4. Switch to whole milk 5. If familial short stature, drug holidays 6. Encourage to eat when hungry-early morning and evening

Why is commado crawling concerning?

CP | No reciprocal movement of hands and feet (dragging feet behind)

List 5 interventions for management of insomnia with ADHD meds

1 Quiet, comfortable sleep envt 2. Consistent bed time and waking time 3. Stop physical activity within 2 hours of bed time 4. Avoid passive stimulation activities (watching TV, computer games) before bed time 5. No homework/TV in bed 6. Trial melatonin

At white time should melatonin be adminsitered for insomnia?

Melatonin 3-6 mg should be administered at least 30 minutes | (up to 2-3 hours) before the desired bedtime

What is timed waiting as a strategy for managing sleep onset association disorder?

Graduated timing of amount of time left alone before going to sleep

What is the chair sitting strategy?

Parent can sit in chair while child goes to sleep If child gets out of bed, parent leaves Slowly move chair out of room

What phase of sleep do nightmares happen?

Second half of night (REM sleep)

What is the difference between night terrors and nightmares?

Nightmares - Rouse from sleep - Recall in morning - Happens in REM sleep (second half of sleep) Night terrors - DO NOT rouse from sleep - Cannot recall in morning - Happens in NREM (first third of sleep)

Describe the technique of timed awakenings for night terrors

* Document the earliest time of episodes (usually occur within 30 min window) * Wake the child 15 minutes before the earliest time * Ensure child is awake, ask who you are, then allow to fall back asleep * Requires at least 5 consecutive nights to break cycle * Resistant cases may require medication (e.g. benzodiazepine

Under what age are time outs not effective?

<2 years

If a child tantrums after attempting toilet training, what should you do?

Take a 1-3 month break from toilet training