Development Flashcards
Gross motor milestones
By 4 mos: head control (red flag at 6mo)
By 6mo: sit well and roll both ways (red flag at 9 mo)
By 10mo: pull to stand (red flag at 15mo)
By 12 mo: first steps (red flat at 18 mo)
24 mo: run and jump
Stairs: 18mo railing, 24mo no railing
tricycle: 36 mo
hop: 48 mo
skip: 60 mo
Fine motor milestones
4 mo: hands to midline, reaching 6-8 mo: palmar grasp 9-12 mo: pincer grasp 2 yrs: spoon, copies vertical line 4-5 yrs: dresses without buttons, draws 10+ part person
Speech and language milestones
2-4 mo: visual attention 6-9 mo: babbling 12 mo: language emergence 2yrs: 2 word combos, 50% intelligible 3 yrs: 3 word combos, 75% intelligible 4 yrs: phrased speech, 100% intelligible
Speech and language delay first step
Audiology!
Social and emotional milestones
fears and friendships
- stranger anxiety: 5-6 mo
- separation anxiety: 9-15 months
- monsters: 3-5 yrs
- death:7/8 -10 yrs
- best friend: 4-6 yrs
Recurrence rates for autism in younger siblings
- 7-19% vs. 1.5%
Early autism warning signs
- parental concerns around language delay
- lack of response to name
- limited eye contact
Child with features of autism, what to do next?
- audiology (and vision)
- refer to SLP
- ASD specific screening instrument
- refer to developmental paediatrician or multidisciplinary team
- genetic testing: chromosome microarray and fragile x
Work up for intellectual disability to be considered (9)
- chromosome microarray
- fragile x
- MECP2 (if female with mod-severe and sx present)
- thyroid
- lead and ferritin (only if mouthing/pica)
- metabolic testing (only if strongly suspicious)
- ophtho and audiology!
- neuroimaging
- EEG (only if sx suspected)
Developmental dysfluency
- occasional (1x every 10 sentences)
- brief (0.5s or less)
- repetition of sounds, syllables or words (no prolongations)
- worse when tired, excited, anxious, complex language
- no tension in the facial muscles
ADHD management by age
Ages 4-5: behaviour therapy
- methylphenidate if you need to
Ages 6-18: start with meds and/or behaivour therapy (preferably both)
Late onset side effect of stimulants
depression!
FASD common issues
- cognitive and learning disorders
- ADHD (severe and refractory)
- poor judgement, poor sense of cause and effect
FASD facial features
- microcephaly
- low nasal bridge
- short nose
- short midface
- indistinct philtrum
- short palpebral fissures
- thin upper lip
- ADHD plus autism
- ADHD plus ID
- ADHD plus prematurity
ASD: > 50% of those with ASD meet criteria for ADHD
ID: 3-4x higher prevalence of ADHD
Prem <1500g, and <26 weeks: 2x as likely to have ADHD
Pros of pacifiers
- prevention from SIDS
- non-nutritive sucking has benefits
Cons of pacifiers
- contain microorganisms ?risk factor for OM
- may have negative effect on dentition (but better than finger sucking)
- ?breastfeeding challenges
Risks of screen use
- decreased opportuniteis for place and face/face interaction
- increased risk of depression and anxiety
- increased risky behaviours
- increases unehalthy eating
- impacts sleep
- distracted driving
When to begin sleep training
- after 6 months
Most infants sleep through night (uninterrupted sleep for 6-8 hrs) after 6 months
(many can sleep at least 5hrs by 3-4 months)
Positional plagiocephaly prevention recommendations and management
- Tummy time 10-15min 3x/day
- treat torticollis with physiotherapy if present
- moulding therapy (helments) can be consiered fro severe asymmetry
Peak crying time is:
up to 3 hours of day (normal)
at 6 weeks of age
Readiness for toileting (6)
- walk to potty
- sit with stability
- remain dry for several hours
- have appropriate language skills
- have desire for independence
- respond to positive reinforcement
Cardiac risk assessment for stimulants for ADHD
- history
- decreased exercise tolerance
- extreme SOB with exercise
- fainting or seizures or palpitation with exercise or startle/fright
- family hx: long QT, arrhythmia, WPW, cardiomyopathy, heart transplant, pulmonary HTN, unexplained death, implantable defibrillator
Cardiac risk assessment for stimulants for ADHD
- physical
- pathologic sounding murmur
- absent or femoral pulses
- sternotomy incision
- hypertension
Social history “ITHELPS”
income transportation housing education legal status literacy personal safety support
GDD criteria
2+ SD below mean in at least 2 developmental domains from:
- GM or FM
- Speech/language
- cognition
- social/personal
- ADL
ID criteria
- deficits in intellectual functioning
- deficits in adaptive functioning in 1+ of communication, social participation, independent living in across multiple enviornments
- onset from developmental period
Red flags suggestive of IEM
- Fam history of IEM or dev disorder or unexplained infant death
- Consanguinity
- IUGR/FTT
- HC or stature growth abnormality (>2SD)
- Recurrent vomiting, ataxia, seizures, lethargy, coma
- Hx of being severely symptomatic and needing longer to recover with benign illnesses (e.g. URTIs)
- Protein or CHO aversion
- Regression in developmental milestones
- Behavioural or psychiatric problems (psychosis at a young age)
- Movement disorder (dystonia)
- Facial dysmorphism (course facial features)
- Organomegaly
- Severe hypotonia
- Congenital anomalies
- Sensory deficits, especially if progressive (e.g. cataracts, retinopathy)
- Noncongenital progressive spine deformities
- Neuro-imaging abnormalities
First investigations for GDD/ID (after hx, physical, audiology and ophtho)
- chromosome microarray
- fragile X
- MECP2 for females with suggestive course
- brain MR is suggestive micro/macro
Tier 1 tests:
CBC, glucose, gas, urea, Cr, electrolytes, AST, ALT, TSH, CK, ammonia, lactate, amino acids, acylcarnitine profile, carnitine, homocysteine, copper
Urine orgnaic acids, creatine metabolites, purines, pyrimidines, glycosaminoglycans
+/- ferritin, vit B12, lead level, ceruloplasmin, biotinidase
Most important investigations in eval of GDD/ID
- chromosome microarray
2. fragile X testing
Maternal depression increases risk across ages
- infancy
- toddler/preschools
- school-aged and teens
Infants: insecure attachment, dysregulation
Toddlers/preschoolers: internalizing and externalizing, cognitive, social interactions, self control
Teens: adaptive functioning, learning disabilities, ADHD, psychopathology (anxiety and mood)
Three most important factors for a child’s well being during separation/divorce
- quality of parenting
- quality of parent-child interaction
- degree, frequency, intensity and duration of hostile conflict
Impacts of divorce by age
< 3 yrs: disorganized attachment, reflect caregiver distress
4-5 yrs: often blame themselves, separation anxiety
School age: prone to loyalty conflicts and may take sides
Adolescents: parents need effective communication and consistent limit-setting
Three approach to ASD diagnosis
- Single provider provides diagnosis based on clinical judgment and DSM-5
- Shared care model e.g. paediatrician and psychologist
- Multidisciplinary team assessment
Medical, behavioural mental health challenges in ASD to assess and manage post diagnosis
- GI conditions
- nutrition
- sleep
- anxiety, depression, mood, psychiatric disorders
- ADHD
Medications in ASD
Challenging behaviours: risperidone, aripiprazole Anxiety: fluoxetine or sertraline ADHD: methylphenidate/stimulant 1st line Depression: SSRI Sleep: melatonin
Disruptive behaviour criteria
- atypical for developmental age and persists for 5 mo or more
- impaired functioning
- significant distress
Red flag temper tantrums
- misbehaves in ways that are dangerous
- acts aggressively to try to get something he or she wants (vs. when upset)
- temper tantrums are daily and last > 5minutes
Toxic stress (re ACEs)
- major, frequent or prolonged periods of adversity
- affects neuro, immunologic, psychiatric, behavioural
Crying behaviours (infancy)
- developmentally normal
- peaks at 6-8 weeks
- generally settles by 3-4 months
Sleep intervention strategies to start at this age
6 months (circadian rhythm develops)
Features of “time ins”
- caregiver invites child to sit and talk about feelings and behaviour in age-appropriate way
- emphasizes connection and comfort
