DEVELOPMENT M Flashcards
What criteria must be met to diagnose a child with autism?
- Impairment in social interaction
- Impairment in communication
- Restricted, repetitive sterotyped patterns of behaviour and interests
What evaluations are required in medical evaluation of children with pervasive developmental disorders? (7)
- Careful physical exam to identify dysmorphic physical features
- Macrocephaly
- Wood’s lamp exam for tuberous sclerosis
- Formal audiologic evaluation
- Lead test in the states
- High resolution karyotype
- Molecular DNA testing for fragile X syndrome
What is the risk for recurrence of autism?
- One sibling affected: 5%
- two siblings affected: 30%
What are the 4 types of hearing loss?
- Conductive: most common in children = interference with mechanical transmission of sound through the external and middle ear
- Sensorineural hearing loss: failure to transduce vibrations to neural impulses within the cochlea or transmit impulses down the vestibulocochlear nerve
- Mixed hearing loss: combination of both due to damage throughout middle ear and inner ear
- Central hearing loss: defects in brainstem or higher processing centres of the brain
What is the treatment of ADHD? (3 main domains)
- Psychosocial treatments: educate parents, set goals for family to improve child’s interpersonal relationships
- Behaviourally oriented treatments: implement rules, consequences and rewards to encourage desired behaviours
- Medications: psychostimulant medications
What is the protocol for starting psychostimulant medications for chidlren with ADHD?
-different types of psychostimulants
Types of 1st line treatment:
- Methylphenidate (ritalin, concerta)
- Amphetamine
- Amphetamine + dextroampheatmine preps (Dexedrine, adderall, vyvanse)
Types of 2nd line treatment: (non-stimulants = norepi reuptake inhibitors)
- Atomoxetine (strattera, bupropion)
- TCAs
- Alpha agonists (clonidine)
Over the first 4 weeks, increase the med dose as tolerated to achieve maximum benefit
- if side effects prevent further dose adjustment or if ineffective, use an alternative class of stimulants
- ie. if methylphenidate is unsuccessful –> switch to amphetamine –> if unsuccessful, switch to atomoxetine
What are the guidelines for cardiac screening in psychostimulant medication?
In children with a positive or personal family history of cardiomyopathy, arrhythmias or syncope, then do ECG and possible cardio consult before starting med!
What are the most common side effects of psychostimulant medication?
- Appetite suppression
- Mild sleep disturbance
- Tics (unmasking)
What are the clinical features of oppositonal defiant disorder?
-clinical features of conduct disorder?
Oppositional defiant disorder: angry outbursts, arguing, vindictiveness, disobedience directed at authority figures
-to meet diagnosis: > 4 of these types of behaviours must be more frequent and more severe than children of a given developmental stage, must be present > 6 months, and impair youth’s function at home, school and with peers
Conduct disorder: serious rule-violating behaviuor including behaviours that harm others = little concern for the rights and needs of others
- Physical aggression to people and animals (bullying, fighting, weapon carrying, cruelty to animals, sexual aggression, 2. Destruction of property such as firesetting and breaking and entering
- Deceitfulness and theft
- Serious rule violations (running away from home, truancy)
- to meet diagnosis, need > 3 symptoms present at least 1 year and impair function at home, school or with peers
What is the treatment for oppositional defiant disorder?
-treatment for conduct disorder?
Parent management training: setting rules, praising and rewarding good behaviour, consequences for dangerous or destructive behaviour
-treatment for conduct disorder: multisystemic therapy (extensive contact between therapist and school/home/peer groups, social competence training, parent and family skills training, medications, etc.)
A child in your practice has expressive language delay. What does this put him at risk for later?
50% of children with early language difficulty develop READING DISORDER
- also risk factor for emotional dysfunction (anxiety specifically)
- boys with early language delay: increased risk for ADHD, conduct disorder, antisocial personality disorder
What are potential neurological sequelae of HIV in young infants and toddlers from perinatal transmission?
Subtle developmental delay to encephalopathy
- symmetric motor dysfunction
- marked apathy, spasticity, hyperreflexia, gait disturbance
- loss of developmental milestones
What percentage of normal children have head banging?
- when is it associated with developmental delay?
- what is the treatment?
20%
- associated with developmental delay if seen in > 5 yo child
- treatment: parental reassurance, ignore the behaviour, avoid highly emotional responses (do NOT need helmet)
What is the differential diagnosis for ectopia lantis?
-causes of superior vs. inferior ectopia lantis?
- Marfans: 80% of patients with Marfan have this but most have SUPERIOR/TEMPORAL ectopia lantis
- Marfans people are very tall so they will have SUPERIOR - Homocytinuria: INFERIOR AND NASALLY
- have FTT so will be small so inferior - Trauma
- Ocular disease
- uveitis
- intraocular tumor
- glaucoma
- high myopia
- aniridia
- cataracts - Ehrlos-Danlos
Contraindications to stimulant medications? (6)
- Personal or family history of cardiac issues
- Hyperthyroidism
- Moderate to severe hypertension
- Known hypersensitivity to sympathomimetics
- History of drug abuse
- Known tic disorder
What is the treatment for stuttering in 3 yo?
5% of preschool children will stutter and this can be absolutely normal (normal developmental dysfluency of childhood); refer if still present past 5-6 years old
-treatment: guidance to parents to reduce pressures associated with speaking and reassurance
What is on the differential diagnosis for microcephaly? (5)
- Intrauterine infection
- Premature closure of sutures
- Chromosomal abnormalities
- Metabolic disorders
- Perinatal insult
When do you stop using corrected GA to assess development/growth in premature babies?
Can stop at 2 yo since most premature infants catch up by then
At what age is it a developmental red flag to not have walked by? What about talked a single word?
Red flag to not have walked by 18 mo and not have spoken a single word by 24 mo
What are the two types of parasomnias?
- Occur in non-REM sleep (3): occur earlier in the evening (1st 3rd of the night!!!)
- sleepwalking
- night terrors
- confusional arousals - Occur in REM sleep: occur later in the night (second half of the night!!!)
- nightmares
- hypnogogic hallucinations
- sleep paralysis
What are clinical features of sleep walking?
-treatment?
- Positive family history
for sleep walking, night terrors, confusional arousals - Associated with safety concern
- Occurs during stage 4 non-REM sleep
Treatment:
- ensure safe environment: lock home doors
- avoid sleep deprivation
- can wake patient 15-30 minutes before regularly occurring sleep walking
If retinal hemorrhages occur as result from traumatic birth, at what age should they have resolved by?
3-4 wks of age
- can be caused by vacuum delivery
- do not cause permanent deficits
What are the MINIMUM amount of words a child should have at 15 months or else they should get referred?
-at 24 months?
3 single words at 15 months
-10 words at 24 months (normal = 50 at 24 months, 200 at 36 months)
When does the parachute reflex appear? Does it disappear?
Appears at 8 months and does NOT disappear
List the protective reflexes (development of equilibrium)/
***Think head downwards
4 mo: head righting
6 mo: bracing with their hands
8 mo: parachute reflex
When does the following disappear:
- moro
- hand grasp
Moro should disappear by 4 mo, hand grasp disappear by 3 mo
How long is a sleep cycle for a baby?
-sleep-onset association disorder: what is this?
Sleep cycle for baby: 60-90 minutes
- Sleep onset association disorder: falls asleep ONLY under certain conditions, does not develop ability to self-soothe
- treatment: gradual vs. rapid withdrawal of sleeping assistance
At what age does separation anxiety typically occur?
18 mo
What are the 5 abilities children should have before starting toilet training?
-what age should you consider toilet training?
- Language ready: make 2 word phrases and understand 2 step commands
- Need to understand cause and effect
- Body awareness: understand feelings of needing to go (18-30 months)
- Want independence
- Need sufficient motor skills to get up and down from toilet
Introduce potty at 2-3 years of age
What are the two types of breath holding spells?
- when do spells usually begin?
- treatment?
Involuntary breath holding that leads to brief period of unconsciousness and is usually triggered by anger, fear or pain
Two types of breath-holding spells:
1. Pallid = vasovagal reflex, often made worse by iron deficiency anemia, caused by reflex vagal-cardiac bradycardia, occurs in response to being surprised or scared
2. Cyanotic: result from prolonged expiratory apnea causing intrapulmonary shunting, usually from temper
- ***Each episode starts with a cry (often a “silent” cry and marked pallor in the case of the pallid type) and progresses to apnea and cyanosis
- spells usually begin between 6-18 months of age, can persist up to 4-6 yo
- syncope, tonic posturing and even reflex anoxic seizures may follow, particularly in breath-holding spells of the pallid type
- injury, anger, frustration, particularly with surprise are common triggers
- education and reassurance of parents is usually all that is needed as these episodes are self-limited and outgrown within a few years
- treatment of coexisting iron deficiency is needed if present (new evidence shows that you can actually just give iron!)
- Treatment:
1. do not provide secondary gain when episodes occur since this can reinforce the episodes = ignore the spells
2. prepare for unpleasant surprises (such as receiving a shot) rather than surprising the child - ***Rarely: may need anticholinergic drugs (atropine), CPR teaching, or antiepileptic drug therapy for anoxic seizures for recurrent episodes
How long does it take for babies born with IUGR to catch up with growth?
2 years
What is the chance of recurrence of depression once a patient is taken off anti-depressants?
Chance of recurrence of depression once taken off: 40% (relapse rate)
What are the side effects of SSRIs? (7)
- Irritability
- GI upset with decreased appetite
- Restlessness
- Diaphoresis
- Sleep disturbance
- Headaches
- Sexual dysfunction
What are the most common comorbidities associated with OCD? (3)
-what are modes of treatment?
- Anxiety
- Depression
- Tics
Treatment:
1. CBT
OR
2. CBT + SSRI for severe
What is the most common learning disability with an associated normal IQ?
- what is the underlying issue?
- clinical features?
Dyslexia
- problems decoding single words
- 50% will have one affected parent
- common with ADHD
- When they are speaking, they mispronounce multiple syllable words
- Speech is hesitant and choppy
- Have trouble sounding out words that are unfamiliar
- Hesitant to read outloud
- Poor spellers
- Terrible handwriting
What is the treatment for dyslexia?
- Phoenetic awareness: develop ability to focus and manipulate sound
- Practice sounding out letters
- Fluency: guided repeated oral reading
What is the definition of amblyopia?
- causes?
- diagnosis?
- treatment?
Amblyopia: loss of visual acuity due to lack of a clear image projecting onto the retina
- can be secondary to deviated eye (strabismic amblyopia), an unequal need for vision correction between the eyes (anisometropic amblyopia), a high refractive error in both eyes (ametropic amblyopia) or media opacity within the visual axis (deprivation amblyopia)
- diagnosis: complete ophtho exam revealed reduced acuity that is unexplained by organic abnormality
- usually asymptomatic and is detected only by screening programs
- treatment: remove media opacity or prescribe appropriate glasses so that well-focused retinal image can be produced in each eye.
- the sound eye is then covered (occlusion therapy) or blurred with glasses or drops (penalization therapy) to stimulate proper visual development of the more severely affected eye
- occlusion therapy can provide speedier improvement in vision but some children better tolerate atropine penalization
- need close monitoring by ophthalmologist
- series of prospective studies show that some children can achieve similar results with less patching or use of atropine drops
What are comorbidities associated with CP? (6)
- Behavioural disturbance (decreased attention, impulsivity, distractbility)
- Strabismus
- Hearing impairment
- Seizures
- Oral-motor dysfunction
- Learning disabilities/communication disorders
What is the most sensitive early marker of intellectual disability?
Impaired language development
What is the definition of colic?
Crying for at least 3 hours a day, at least 3 days per week for at least 3 weeks - peaks at 6-8 wks of age and should improve by 4 months but can persist up to 6 months
After what age does diurnal enuresis become abnormal?
-nocturnal enuresis?
Diurnal = age 4 Nocturnal = age 6
What is Kleine-Levin syndrome?
Syndrome of recurrent episodes of excessive sleepiness lasting days to weeks associated with binge eating, weight gain, hyperseuxality, and mood disorders
-usually seen in teen boys
In what phase of sleep does sleep walking occur?
Non-REM sleep
-remember that they can’t remember anything about the event thus non-REM! (in REM sleep, can remember, such as nightmares)
What are 3 effective methods to prevent child abuse?
- Parent-child education (ie. parenting classes)
- Screening for major psychological risk factors
- Schedule more visits with health care provider for support and counselling
What are the criteria for a panic attack?
Period of fear and discomfort followed by 4 of more of the following symptoms that develop abruptly and peak within 10 minutes:
- shortness of breath
- fear of losing control
- Palpitations
- Derealization or depersonalization
- Sweating
- Fear of dying
What is the differential diagnosis for anxiety?
- Hyperthyroidism
- Pheochromocytoma
- Arrhthymias
- Ingestion
- Caffeine
- Hypoglycemia
- Asthma
- Lead poisoning
- Migraines
- CNS tumor
What medications can mimic anxiety?
- Stimulants
- Cold and flu medications
- Sympathomimetics
- Ventolin/steroids
- SSRIs
What percentage of children presenting with depression will end up being bipolar disorder?
-what are medical treatment options for bipolar disorder?
20-40%
-bipolar disorder can often present with depressive episode first
Treatment:
- Valproic acid
- Lamotrigine
- Carbamazepine
- Lithium
In children with separation anxiety, what condition are they at increased risk of developing in the future?
-treatment of separation anxiety?
- predictor of early onset panic disorder
- treatment: CBT +/- SSRI
What condition is trichotillomania most related to?
-what does the hair look like? (aka how can you differentiate between other causes of alopecia)
OCD
- patchy hair loss
- hairs of different length from pulling
- broken or flame hair (edges of hair splay)
What are clinical features of social phobia/social anxiety disorder?
-what are clinical features of avoidant personality disorder?
Fear of one or more social situations:
- Concern about embarrassing themselves
- Exposure to social stressors provokes anxiety
- Avoidance of social stressors
- Lasts > 6 mo
- Onset before 18 yo
Avoidant personality disorder:
- feel inadequate and insecure thus don’t want to put themselves out there
- automatically think others won’t like them and won’t make fun of them
- worried they’re going to get rejected
- not worried as much about getting embarrassed8
What are side effects of risperidone? (9)
- Tardive dyskinesia
- QTc prolongation
- Leukopenia
- Neuroleptic malignant syndrome
- Diabetes
- Weight loss
- Acute dystonic reaction
- Transaminitis
- Dyslipidemia
What are clinical features of PTSD? (4)
- Experienced a traumatic event in which actual or threatened death or serious injury was possible
- Persistent reexperiencing of traumatic event (flashback, repetitive play, dreams)
- Increased arousal (sleep disturbance, irritability)
- Avoidance of stimuli associated with triggers
***Duration has to be more than 1 month, can’t be from drugs, has to impair their functioning
A 2 yo presents with temper tantrums. What advice do you want to give mom?
- Ensure they are not hungry or tired
- Try to distract or take them out of stimulation
- Do not reinforce the behaviour with attention
- Parents need to model anger control
- Provide simple choices to help child feel more in control
What is an easy way to remember average head circumferences?
Newborn: 35 cm 3 mo: 40 cm 9 mo: 45 cm 3 yo: 50 cm 9 yo: 55 cm
What is the diagnostic criteria for inattention subtype of ADHD?
Inattention: 6 or more symptoms
- Forgetfulness
- Trouble holding attention
- Distractability
- Trouble organizing tasks or activities
- Careless mistakes
- Don’t listen to when spoken to directly
- Do not follow through on instructions
- Fail to finish school work, chores, duties in work place
- Trouble organizing tasks and activities
- Avoids tasks that require mental effort over a long period of time
- Loses things
What is the diagnostic criteria for hyperactivity/impulsivity subtype of ADHD?
Need 6 or more symptoms of the following:
- Talk excessively
- Interrupts and intrudes on others
- Blurt out answers before question is being completed
- Trouble waiting their turn
- On the go
- Fidget
- Leave their seat when they stay seated
- Can’t take part in quiet leisurely activity
***Must have several symptoms before 12 yo, happen in more than one setting, impair functioning
What neurological disorders are associated with autism? (5)
- Fragile X
- FASD
- NF
- Rett’s syndrome
- Down syndrome
What is the treatment for persistant or injurious headbanging?
- Behavioural therapy is first line
2. If fails, SSRI
What are the diagnostic criteria for anorexia nervosa?
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
Name 6 radiological signs consistent with abuse.
- Posterior rib fractures
- Metaphyseal fractures
- Scapular fractures
- Spinal fractures
- Multiple fractures at different stages of healing
- Femur or humerus fracture in non ambulating child
What are reasons for referral to SLP in a stuttering child? (4)
-more common in boys vs. girls?
- Age > 4 yo
- Significant impairment (incomprehensible, more than 3 dysfluencies per 100 words)
- Avoidant or escape mechanisms (will nod to answer a question or refuse to speak)
- Causes anxiety or distress when speaking
- 4x more common in boys
What is your differential diagnosis for a child who is having difficulty in school? (5)
- Absence seizures
- Obstructive sleep apnea
- ADHD
- Learning disability
- Hearing impairment
