Development Flashcards
what is the diagnostic criteria for Tourette disorder?
A. Multiple motor and one or more vocal tics have been present at some time during the illness (not necessarily concurrently)
B. The tics may wax and wane but have persisted for >1 year since first tic onset
C. Onset before 18 years of age
D. not due to a substance (cocaine) or another medical condition
what is the difference between persistent motor or vocal tic disorder, provisional tic disorder and Tourette disorder
Persistent motor or vocal tic disorder- motor OR vocal tic for >1 year
Provisional tic disorder- motor OR vocal tic <1 year
Tourette disorder- motor AND vocal tic for >1 year
what are the treatment options for mild tics, tics that are distressing or functionally impairing or severe impairment in quality of life?
mild tics- psychoeducation
distressing or functionally impairing- habit reversal therapy or comprehensive behavioural intervention for tics
severe impairment- haloperidol, pimozide, aripiprazole
what does Gotta Find Strong Coffee Soon stand for?
Gross motor fine motor speech/language cognitive/ problem solving social/emotional
what investigation should you do if there is gross motor delay?
Do a CK
What does an average 18 month old do?
Running Scribbling with fisted crayon 10-25 words Word explosion Word combinations Single step commands Lots of gestures pointing Know body parts Symbolic and parallel play
When is separation anxiety normal?
18-24 months
What is the most common teratogen causing ID?
ETOH
Key speech and language milestones
2-4M: Visual attention 6-9M: Babbling 12M: Langauge emergence 2Y: 2 word combo: 1/2 intelligible 3Y: 3 word combo: 3/4 intelligible 4Y: Phrased speech 4/4 intelligible
Key Motor Milestones 3 mo 6 mo 9 mo 12 mo
3 M: Head control 6 M: Arms 9M: Trunk 12M: Legs
Key social and emotional milestones 5-6 mo 9-15 mo 3-5 y 8-10 y 4-6 y
Anxiety: Stranger 5-6M Separation 9-15M Monsters: 3-5Y Death 8-10Y Best friend 4-6Y
Key Play Milestones
Functional play
2-3Y imaginative play
3-5 years reciprocal play
6 years knock knock jokes
at what age do children cruise?
9 months
at what age to roll supine to prone?
6 months
what age to bring hands to midline?
2 months
what age to point to express interest?
15 months
when does babinski reflex disappear?
9-10 months
when does parachute reflex appear?
7-9 months and persists
when does rooting, sucking, moro, ATNR reflex disappear?
rooting- 3-4 months
sucking- 3 months
moro 3-6 months
ATNR- 3-4 months
when does withdrawal reflex disappear?
stays for life
what is the order for drawing shapes?
lines, circle, cross, square, triangle horizontal line- age 2 circle- age 3 square- age 4 triangle- age 5
when do you refer a child to SLP
Receptive:
15 months- does not look/point at 5-10 objects
18 months- does not follow simple commands
24 months- does not point to pictures or body parts when named
30 months- does not verbally respond or nod/shake head to questions
Expressive:
15 months- not using 3 words
18 months- not using mama, dada or other names
24 months- not using 25 words
30 months- not using unique 2 word phrases
what is the triad for serotonin syndrome
mental status changes- agitation, hallucinations, delirium, coma
autonomic instability- tachycardia, hypertension (bp lability), hyperthemia, diaphoresis, flushing, dizziness)
neuromuscular symptoms- tremor, hyperreflexia, myoclonus, rigidity
18 month old. Mother asks about toilet training. List 3 questions you’d ask in determining readiness.
- Is he able to tell you when he has to pee?
- Is he able to follow simple commands?
- Is he able to walk to the potty and sit on it?
- Can he stay dry for several hours?
- Does he want to do things independently?
- Does he like to do what you ask?
what is an uncommon but late serious side effect of stimulants?
Depression is an uncommon but serious late onset side effect of stimulants
what treatment do you offer for head banging
most remit over time
redirect, take attention onto something else with time she will learn to communicate in different ways and this will stop
need to rule out that there are no other developmental disorders going on
rarely leads to serious injury
Name 3 conditions associated with Tourette’s
OCD ADHD behavioral issues Learning disability depression anxiety ASD
what is sleep onset association disorder?
special conditions are required for caregivers before child goes to/returns to sleep at night
tx: establish a bedtime routine
remove maladaptive sleep associations
teach children to fall asleep on their own (timed waiting or chair sitting strategy)
what is limit setting behavioural sleep insomnia?
Limit setting type - child refuses to go to bed and the parent demonstrates poor limit setting
what is Developmental coordination disorder
- The acquisition and performance of coordinated motor skills is substantially below that expected given the person’s chronological age and opportunity for skill learning and use
- The poor performance significantly and persistently interfere with activities of daily living appropriate to chronologic age and impact academic/school productivity, prevocational and vocational activities, leisure, and play
Name some underlying neurological disorders associated with autism (7)
Rett syndrome Fragile X Down syndrome Tuberous Sclerosis NF Angelman Seizures
Child who is 7 years old and very bad behavior, anger outburst, list 5 things to tell parents to help them have some tools to manage this behavior
Scheduled routine
Clear expectations of the child
Consequences for bad behaviour that are age-appropriate, immediate, and consistent (eg. Withdrawal or delay of privileges, and time-out) and realistic
Do not make empty threats, apply rules consistently
Give positive reinforcement for good behaviour
Parents need to model good behaviour
what is the most common cause of inherited ID
Fragile X
Physical features: Elongated face, large ears, high-arched palate, poor tone, flat feet, large testicles, joint laxity, mitral valve prolapse
what is psychosocial deprivation?
Absence of appropriate stimuli in physical or social environment which are necessary for emotional, social, intellectual development
what are some symptoms of psychosocial deprivation? (13)
- Unusual watchfulness
- Avoidance of eye contact
- Absent smiling or vocalization
- Lack of interest in environment
- Children over 5 months do not reach for interesting objects
- Negative response to cuddling ***
- Arches back, scissors legs OR lies limp
- Inability to be comforted
- Head banging
- Self stimulation (ano-genital manipulation)
- Immobility with infantile posturing
- Inappropriately seeking affection from strangers **
- Flat occiput
what is Rett syndrome
X-linked disease that occurs predominantly in females
developmental regression
acquired microcephaly
mutations in the MeCP2
ataxic gait or fine tremor of hand movements is an early neurologic finding
Most children develop peculiar sighing respirations with intermittent periods of apnea that may be associated with cyanosis.
The hallmark of Rett syndrome is repetitive hand-wringing movements and a loss of purposeful and spontaneous use of the hands; these features may not appear until 2-3 yr of age.
Autistic behavior is a typical finding in all patients.
Generalized tonic-clonic convulsions occur in the majority but may be well controlled by anticonvulsants.
what is recommended for good sleep hygiene?
Regular bedtime and wake up time
Age appropriate amount of hours asleep
Consistent routine before bed
Sleep environment: quiet, dark
Teach the child how to relax prior to sleep
Strict avoidance of television, computers, and video games prior to bedtime
Encourage reading prior to bedtime
Avoid hunger and eating prior to bedtime
Avoid caffeine alcohol and nicotine prior to bedtime
No TV in room
Do not use the bedroom for punishment
List 3 questions you’d ask in determining readiness for toilet training? (6)
- Is he able to tell you when he has to pee?
- Is he able to follow simple commands?
- Is he able to walk to the potty and sit on it?
- Can he stay dry for several hours?
- Does he want to do things independently?
- Does he like to do what you ask?
Name 3 DSM-V diagnostic criteria for ADHD - inattentive subtype.
close attention/mistakes sustaining attention does not listen when spoken to does not follow through on instructions poor organization avoids sustained mental effort lose things easily distracted forgetful in daily activities
6/9 required for the diagnosis**
functional impairment in more than one setting
criterion for age of onset= 12
Name 3 DSM-V diagnostic criteria for ADHD hyperactive/impulsive subtype
fidgets leaves seat runs/climbs no quiet play on the go/motor talks excessively blurts not wait turn interrupts/intrudes
6/9 required for the diagnosis**
functional impairment in more than one setting
criterion for age of onset= 12
Letter reversal can be normal through to what age?
age 8
what is a treatment option for night terrors?
consider timed awakening for night terrors if night terrors >3nights/ week
document the earliest time of episodes
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 the cycle
Short acting benzodiazepines if severe and patient is excessively violent and at risk of causing injury to themselves.
when should a child be able to copy a horizontal line?
age 2
when should a child be able to copy a circle?
age 3
what is the criteria for intellectual disability?
1) deficits in intellectual functioning
2) deficits in adaptive functioning (in one or more domains of activities of daily living)
3) onset of these deficits during the developmental period
what is Disinhibited social engagement disorder
is an attachment disorder in which a child may actively approach and interact with unfamiliar adults.
what is reactive attachment disorder
A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
The child rarely or minimally seeks comfort when distressed.
The child rarely or minimally responds to comfort when distressed.
18 month old: gross motor fine motor speech/language cognitive social/emotional
gross motor- stoops and recovers, runs
fine motor- tower of 4 blocks, fisted pencil grasp
speech/language- points to objects, 3 body parts, 10-25 words
cognitive- symbolic play with doll or bear
social/emotional- parallel play
24 month old: gross motor fine motor speech/language cognitive social/emotional
gross motor- jumps on two feet, up and down the stairs
fine motor- uses fork, handedness established
speech/language- 2 word phrases, 50% intelligible
cognitive- searches for hidden object after multiple displacements
social/emotional- testing limits, tantrums
36 month old: gross motor fine motor speech/language cognitive social/emotional
gross motor- pedals trike fine motor- undresses, draws circle speech/language- 3 step commands cognitive- compares 2 objects, counts to 3 social/emotional- cooperative play
12 month old: gross motor fine motor speech/language cognitive social/emotional
gross motor- walks a few steps, wide based gait
fine motor- fine pincer
speech/language- 1 word with meaning (besides mama, dada), no, 1 step command with gesture
cognitive- imitates gestures and sounds, uses objects functionally
social/emotional- points at wanted items
when do we see motor problems manifest? talking and coorination?behavioral, problem solving and social?
motor problems- 1st year
talking and coordination- 2nd year
behavioral, problem solving and social- 3rd year
key milestones for fine motor 4 months: 6-8 mo: 9-12 mo: 2 years: 4-5 years:
4 months: hands to midline, transfer objects
6-8 mo: palmar grasp
9-12 mo: pincer grasp
2 years: uses spoon, copies vertical line
4-5 years: draws 10+ part person, dresses with no buttons
key milestones for speech and language 6-9 mo: 12 mo: 2 years: 3 years: 4 years:
6-9 mo: babbling
12 mo: language emergence
2 years: 2 word combinations, 1/2 intelligible
3 years: 3 word combinations, 3/4 intelligible
4 years: phrased speech, 4/4 intelligible
key milestones cognitive
letter reversal
learn to read
read to learn
letter reversal normal between 5-8 years
learn to read- grade KG-2
read to learn: grade 3
everything should be normal by age 8
key milestones social and emotional stranger separation monsters death best friend
stranger: 5-6 months
separation: 9-15 months
monsters: 3-5 years
death: 7/8-10 years
best friend:4-6
what age group for each of the following:
imaginative play
reciprocal play
knock-knock jokes
imaginative play: 2-3 years
reciprocal play: 3-5 years
knock-knock jokes: 6 years
when to refer to developmental paediatrician?
parents are concerned**
regression **
by 9 months: not sitting well, decreased vocalization
by 12 months: no words or name recognition, not pulling to stand
by 18 months: less than 15 words, social communication concerns
what is the diagnostic criteria for ASD
3/3
- problems reciprocating social or emotional interaction
- severe problems maintaining relationships
- nonverbal communication problems
2/4:
- stereotyped or repetitive speech, motor movements or use of objects
- excessive adherence to routines, ritualized patterns of verbal or nonverbal behaviour, or excessive resistance to change
- highly restricted interested that are abnormal in intensity or focus
- hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment
what should you do next if you are worried about ASD (5)
refer to SLP refer to developmental paediatrician chromosomal microarray fragile x testing Audiology testing
what is one test for IQ (cognitive assessment)
WISC
Stanford- Binet
what is one test for academic achievement testing
WIAT
what is one test for adaptive behaviour assessment
adaptive behavior assessment scale
Vineland
what is global developmental delay?
significant delay in 2 domains (of 5)
temporary diagnosis for children who are unable to undergo standardized IQ evaluation
GDD becomes ID at school age
by 8 they should have formal psychoeducational assessment
what is the treatment for ADHD in preschool children? 6-11? adolescent?
evidence- based behaviour therapy
6-11: Start with meds and/or behaviour therapy
Preferably both
Adolescent: start with meds, maybe behaviour therapy
Preferably both
what are the physical exam features associated with FASD
small palpebral fissures epicanthal folds flat mid face short nose low nasal bridge thin upper lip indistinct philtrum
seeing the stereotypical facial features is the EXCEPTION not the rule!!
what are the two most common domains associated with global developmental delay
speech and language
fine motor
DDX for global developmental delay
Genetics (Downs, fragile X, angel mans, prayer will)
Brain malformation
Brain injury (HIE, hemorrhage, stroke, infection, tumor)
Toxins (FASD, lead)
what investigations should you do for ID
fragile x testing
microarray
hearing and vision
EEG if seizures suspected
Consider:
metabolic screen (Tier 1 investigations)
Rett (?MECP2)
neuroimaging (?MRI)
what is the management steps for someone you suspect has ASD
Audiology (and vision) testing
Referral to SLP for initiation of therapy
ASD specific screening instrument
Referral to Developmental Pediatrician/Centre for
multidisciplinary team assessment
Genetic testing: Chromosomal Microarray + Fragile X
Don’t forget the physical exam!!
Ht, Wt, HC (20% macrocephaly)
Skin exam for neurocutaneous markings (NF, TSC)
DDX Autism (7)
Language disorder developmental disability sensory impairments adhd ODD anxiety non verbal learning disability
Mother with one child with autism. She wants to know what the recurrence of autism in a second child will be?
increased risk 7-19% versus 1.5% in the general population** from new cps statement
what is the best predictor of autism?
does not point to things to show interest
what is one test for emotional/behavioral assessment?
Conners 3
child behaviour checklist
what is the purpose of psychoeducational testing?
- identify learning profile
- identify cognitive diagnoses
- look for other factors
- recommend appropriate programming
when can children draw a square
4
when can children draw a triangle
5
when do nightmares occur?
usually in preschoolers
REM sleep, usually second half of the night
able to rouse from nightmare
recalls nightmare in the morning
when do night terrors occur?
during non-REM sleep 1-3 hours after falling asleep child does NOT wake during episode does NOT recall episode in morning family history is common
what are management options for partial arousal parasomnias? (night terrors, sleep walking, confusional arousals)
adequate sleep establish bedtime routine do not wake during episode ensure safety for sleepwalking often increases during times of stress
what is the peak age for tantrums?
18 months- 3 years
what counselling can you offer for tantrums?
stay calm- model the behaviour you want use consistent limits <2- distraction, planned ignoring >2- understand cause and effect - before: count downs - after: time outs, explanations appropriate to language level don't forget positive reinforcements and offer positive alternative time out- number of minutes of their age
what are the top 3 red flags/early warning signs for autism spectrum disorder? (3)
- parental concerns around language delay
- lack of response to name
- limited eye contact
all children should be screened for ASD as part of routine developmental surveillance
what are two underlying neurological disorders that are
associated with ASD diagnosis?
- TS
- Rett syndrome
- Fragile X
- Down syndrome
* *25% of children with Down syndrome have ASD - NF
- Angelman
what percentage of kids with autism have macrocephaly?
20%!
How many children between 5-12 years have autism??
1/66
Criteria for a specific learning disorder
Selective impairment with AVERAGE intelligence
you cannot have a specific learning disorder with ID
must be at least 6 months
specifier ‘with impairment in’
what are the 3 criteria required for a diagnosis of global developmental delay
- deficits in IQ
- adaptive function
- age <18
what is the workup for global developmental delay
PHYSICAL EXAM GUIDES INVESTIGATIONS chromosomal microarray Fragile X MECP2 (only if symptoms) Thyroid Lead and ferritin (PICA) metabolic testing (only is strongly suspected) EEG only if seizures suspected neuroimaging * audiology (hearing impairment in 20%) * ophthalmology consults (vision impairment 10-50%)
Features of developmental disfluency
occasional (once every 10 sentences) brief (0.5s or less) repetition of sounds, syllables or words (no prolongation, beginning of words) worse when tired/excited no tension in the face
what are 3 early onset side effects of stimulants
appetite suppression
difficulty sleeping
tics
is prematurity a risk factor for ADHD?
Yes!!
ELBW (<1500g) and extremely preterm (<26 weeks) are twice as likely to develop ADHD
what is the most common comorbid disorder with ADHD
intellectual disability
what is first line for children with significant disruptive behaviours
Parent-training programs
what are 3 things that have a significant mediating effect on child well-being during divorce
- improving the quality of parenting
- improving the quality of child-parent relationship
- controlling hostile environment
ADHD affects 1 out ??? children
1/20 children
what are 3 reasons why extended release ADHD medications work better
- Better adherence
- Reduced stigma (ex. not taking pill at school)
- Less misuse
positive parenting in early years
ABCDE’s
Secure attachment relationship with at least one healthy adult
Ask questions
Build on each family’s relational strengths
Counsel with family-centred guidance
Develop plans for changing behaviours related to sleep or discipline, as needed, and
Educate about positive parenting strategies.
A boy has been diagnosed with a specific reading disorder. List four features of this condition.
Mispronunciations
Speech lacks fluency with many pauses
Word finding difficulties
Inability to come up with a verbal respond quickly when questioned
Struggles with word recognition
Listening comprehension is typically robust
Boy won’t speak at school, very shy. Speaks to parents at home. what is the diagnosis?
selective mutism
List 3 classes of drugs and their targeted behavior or symptom in autism.=
- aggressive behaviors- risperidone/aripiprazole
- anxiety/ depression- fluoxetine
- adhd- methylphenidate
- sleep disturbances- melatonin
