Developmental Flashcards
ADHD
-comorbidities-
psychiatric disorder: 50-90%
- ODD 70% males, 40% females
- conduct disorder 33%
- learning difficulties 20-60%
- anxiety 20-30%
- depression 33%
- tic disorders 10-20%
ADHD
-criteria-
One of the following 2:
A. Inattentive signs (6 or more; > 6 months duration)
- fails to give close attention or makes careless mistakes
- cannot sustain attention
- does not follow through or finish tasks
- difficulty organising tasks
- dislikes / avoids tasks requiring sustained mental effort
- easily distracted by external stimuli
- does not listen when spoken to
- loses things necessary for tasks
- forgetful
B. Hyperactive / Impulsive signs (6 or more; >6 months duration
– fidgets, squirms in seat
- leaves seat
- runs about / climbs
- cannot play quietly
- always “on the go” or “driven by a motor”
- talks excessively
- blurts out answers before questions completed
- difficulty waiting his turn
- interrupts or intrudes others (games, conversations)
Symptoms present before 7 yo (some symptoms required only)
Symptoms present in 2 or more settings (some symptoms required only)
Clinically significant impairment
Not associated or caused by another disorder
Adolescent cognition
middle childhood (6-11)
- shift from “preoperational “ to “concrete logical operations” (Piaget)
- apply rules based on observations, factor in multiple points of view, and interpret their perceptions using physical laws
early adolescence (10-13)
- transition from concrete operational thinking to formal logical thinking
- reason from principles, weigh many opinions, and think about the process of thinking
middle adolescence (14-16)
- question and analyze extensively
- understand the intricacy of the world, see beyond themselves, and use moral and legal context
Autism
DSM IV criteria
1. qualitative impairment of social interaction (>2)
2. qualitative impairment of communication (>1)
3. restrictive or repetitive patterns of behaviour, interests and activities (>1)
4. onset before 3 years
associations: seizures (1/3), ↓IQ (75%), vision/ hearing problems, ADHD, depression/ schizophrenia
screening: recommended 18mo-2yrs with Modified Checklist for Autism in Toddlers questionnaire (M-CHAT)
Blindness
legal blindness: vision 20/200 or worse
incidence: 1/35,000
causes:
- retinopathy of prematurity (most common)
- amblyopia (usually secondary to cataracts)
others: albinism, hydrocephalus, infection, birth asphyxia
Car restraints
Cerebral palsy
incidence: 3.6/1000
definition: non-progressive motor impairment arising before or after birth
causes:
birth: preterm/LBW, congenital malformations, kernicterus
acquired: trauma, meningitis, stroke
unknown: 50% no identified risk
diagnosis: usually <18months with failure to obtain motor milestones or assymetric gross motor function, hypertonia, hypotonia
comorbidities: epilepsy, learning disorders, behavioural issues, sensory impairment
Classification CP
Limb distribution:
- hemiplegia: 39%
- diplegia: 34%
- triplegia: 3%
- quadriplegia: 24%
Motor disorder:
- spastic: 83%
- dyskinetic: 6%
- ataxic: 5%
- hypotonic: 2%
Constipation
prevalence:
- constipation: 37% 5 to 12 years
- constipation with overflow: 1-4%
Crying
duration of crying:
2 weeks: minimal
6 weeks: 3 hours/day
12 weeks: 1 hour/day
excessive crying: less than 5% infants with excessive crying have pathology
Deafness
inherited: 50% childhood deafness
genetics: 80% AR
Connexin 26 defect (50%): disrupts K+ flow in ear
- early onset deafness 1-6yrs
other: 18% AD with variable penetrance; 2% XLR
syndromes: Usher, Pendred, Jervell Lange-Nielson, Brachio-otorenal, Alport, treacher-collins, Waardenberg, NF-2
infections: TORCH, bacterial meningitis, mumps, mastoiditis, TB, Kawasaki, EBV, scarlet fever, pertussis
neonatal causes: hyperbilirubinaemia, hypoxia, GBS meningitis, PPHN, prolonged ventilation, LBW
drugs: aminoglycosides, frusemide
endocrine: hypothyroidism
Denver Screening Test
age: birth to 6 yrs
domains:
- personal-social
- fine motor-adaptive
- gross motor
- language
use: screening tool but limited socioemotional development scale
Development Table
Developmental delay
Gross motor
2 yrs: not walking
3-5 yrs: not pedalling tricycle, clumsy, falling frequently, not hopping
5-8 yrs: unable to throw, catch or kick ball
Fine motor
<1 year: hand preference
10 mths: pincer grip
3-5 yrs: avoiding fine motor tasks
Personal/ social
3-5 yrs: disinterested in peers, little awareness of toileting needs, inability to dress self
Developmental Delay
-investigations-
1st LINE:
- chromosomes (including fragile X)
- FBC/EUC/TFTs/CK/Lead/Urate/Ferritin/Biotinidase
2nd LINE:
metabolic screen: IF family hx/ consanguinity/regression/ organomegaly/ coarse face
neuroimaging: IF abnormal head size/ seizures/ focal neurology
EEG: IF speech regression/ seizures/ neurodegenerative
genetics: IF dysmorphic, abnormal growth, sensory impairment, odd behaviour, family hx
Dyslexia
definition: difficulty with accurate and or fluent word recognition due to a deficit in the phonologic component of language
Enuresis
definition: urinary incontinence in a child who is adequately mature enough to achieve continence
classification
- diurnal: daytime (day dryness from 4 yrs)
- noctural: night time (night dryness from 6 yrs)
distribution:
- 22% day only, 17% both day/night, 61% night only
prevalence noctural enuresis:
- 15% 5yr olds
- 7% 8 yr olds
- 1% 15 yr olds
Erikson’s stages
Global developmental delay
impairment in at least 2 of the following areas:
1. motor
2. speech and language
3. cognition
4. personal/social
5. daily-living skills
Hearing impairment
causes:
conductive (mild-moderate)
- chronic middle ear effusion
SNHL (severe):
- congenital infection eg. rubella, CMV, meningitis
- birth asphyxia
- kernicterus
- ototoxic drugs
- tumours
- inherited defect
treatment:
hearing aids: amplification of sound
cochlear implant: >12months with severe SNHL
Hearing tests:
neonatal:
otoacoustic emissions: measure sounds waves produced in middle ear by measuring echo when sounds are played
auditory brainstem response (ABR): measures how brain responds to sound via electrodes on the head
middle ear function:
pneumatic otoscope: most sensitive/specific
tympanometry/acoustic reflectometry: supportive
children:
audiometry: test conductive and sensory hearing in both ears
Hymen anatomy prepuberty
variations:
- crescenteric (most common): no tissue at 12 o’clock
- annular (2nd most common)
- fimbriated: erratically shaped
Intellectual Disability
Intelligence scales
Bayley Scales: 0-2yrs
Differential Abilities Scales: 2.5- 17 yrs
Kaufman Assessment Battery for Children: 2.5- 12.5yrs
Leiter International Performance (non-verbal abilities): 2.5-18 yrs
McCarthy Scales of Children’s Abilities: 2.5- 8.5 yrs
Stanford-Binet Intelligence Scale: 2- 23 yrs
The Griffiths Mental Scales: 2-8 yrs
Wechsler Preschool + Primary Scale of Intelligence (WPPSI): 3-7 yrs
Wechsler Intelligence Scales for Children (WISC III): 6-12yrs
Language development
3 months: cooing
6 months: babbling
1yr: 1 -2 words
2 yrs: 50 words, 2 word combos
3 yrs: 3 word combos, 3 colours, personal pronouns, able to be understood by family
4yrs: 4 word combos, 4 colours, able to be understood by stranger
Overweight/Obese
In children
overweight: 85th-95th percentile
obese: >95th percentile
Piaget’s
Piaget’s 4 stages of intellectual/cognitive development:
sensorimotor: birth through ages 18-24 months
preoperational: toddlerhood (18-24 months) to childhood (age 7)
concrete operational: 7 to 12 years
formal operational: adolescence through adulthood
Sexual abuse findings in females
findings on examination in only 5-10%
most suspicious findings:
- tears, deep notches or clefts in posterior hymen (3- 9 o’clock)
- attachments of fusion between labia minora and hymen
- AP diameter > 20mm with no stool present (strong marker) – uncommon
Sleep association disorder
incidence: 1/3 toddlers
clinical: child wakes in middle of night and can’t fall back to sleep unless learned associations are presents
management: check in without physical contact at decreasing intervals for a period of time until the child learns to self-soothe
Sleep stages
STAGES
Stage 1: beginning, slow eye wave, hypnic jerks
- EEG: theta waves
Stage 2: unconscious, easily wakened, no eye movements
- EEG: sleep spindles, k complexes
Stage 3: slow-wave sleep associated deep sleep, dreaming/parasomnias more common
- EEG: delta waves
REM: rapid eye movements, low muscle tone, decreased HR/BP, increased gastric motility, deep sleep and hard to wake
- EEG: rapid low voltage
Normal sleep pattern
- 4-5 cycles of 90-120 minutes each
Age related changes:
- birth: 50% sleep in REM
- childhood/adulthood: 25% REM
Speech disorders
dysarthria: both speech and non-speech difficulty due to lack of strength and muscle control
dysphonia: phonation disorder usually secondary to anatomical problem
dyspraxia: difficulty planning/coordinating the movements required to make speech
phonological delay: problems producing different sounds required for speech
pragmatic language impairment: have trouble understanding the meaning of what others are saying and trouble using words to get needs met
Speech problems
3 main areas:
1. articulation
- difficulty pronouncing sounds in syllables or saying words
2. fluency
- the flow of speech is interrupted by abnormal stoppages eg. stuttering
3. resonance
- problems with pitch, volume or quality of sound
Straddle injury
clinical: typically unilateral and superficial to the anterior portion of the genitalia.
- involve the mons, clitoral hood, labia minora anterior or lateral to the hymen
- straddle injury to the hymen or posterior fourchette is rare
classified as penetrating or nonpenetrating
nonpenetrating: minor trauma to external genitalia: lacerations or abrasions of the labia in girls
penetrating injuries: more serious/extensive and often indicative of sexual assault .
findings concerning for sexual abuse:
- < nine months
- perianal, rectal, vaginal, or hymenal injury without hx penetrating trauma
- extensive or severe trauma
- presence of nonurogenital trauma
- lack of correlation between history and physical findings
- abnormal genital secretions
Temper tantrum
definition: 2-5 mins of out of control behaviour including screaming, stomping, hitting, head banging and falling down as a display of frustration, anger and inability to cope
age: 1-3 yrs considered normal behaviour
prevalence: 80% 2-3yrs approx once per week
treatment:
- parental education
- identify triggers
- alter environment to avoid triggers and limit frustration
- use distraction
- behaviour modification with positive/negative reinforcement
Tympanometry
use: determines TM mobility by inserting pressure in the ear canal
abnormal:
- middle ear effusion/perforation: stiffness of TM
Wechsler Intelligence Scale for children
age: 6-16yrs
time: 45-65 minutes
assesses: general intelligence with scores for 5 indexes
- verbal comprehension index
- visual spacial index
- fluid reasoning index
- working memory index
- processing speed index
identify: specific learning, dyslexia, dyscalculia
NOT tested: reading ability
GMFCS
Gross Motor Function Classification System
system: 66 items developed for children with CP
5 levels:
I (30%): walk independently, reduced coordination
II (20%): difficulty on uneven surfaces
III (10): assist device for walking, wheelchair for distance, sits independently
IV (12%): mobility device, support for sitting/transfers
V (14%): no independant mobility
prognosis: plateau at age 5
Functional Mobility Scale
(FMS)
Functional mobility for 3 distances:
- home: 5m
- school: 50m
- community: 500m
measures: what your child actually does
- allows responsive change to intervention
Hip Surveillance
who: all CP GMFCS I to V
age: 12 months corrected
tests: clinical assessment and XR
Movement Disorder
spasticity: velocity dependent resistance of a muscle to stretch
- R1 “catch”
- R2: passive end range
dystonia: movement disorder with involuntary sustained or intermittent muscle contractions causing twisting/repetitive movements and postures
- basal ganglia
Medications for CP
baclofen: GABA agonist
diazepam: facilitates GABA
tizanidine: alpha 2 agonist
L-dopa: dopaminergic
artane: anticholinergic for dystonia
tetrabenazine: dopamine depletor for dystonia
*trial medication for at least 3 months
Other CP treatment
Selective Dorsal Rhizotomy
- L1-S1 laminectomy/dorsal root transection
- irreversible
Baclofen pump: subfascial implant
- small amount crosses
- risk of malfunction: withdrawal
Deep brain stimulation: neurostimulator below clavicle
- dyskinetic CP
- limited response
Behavioural management
4 pronged approach
1. environmental modulation
- remove TV from room/ fences/ remove matches
2. time out for prioritised behaviour
- clear boundaries (if appropriate give a warning 1st)
- safe but boring environment
- 1 min/yr of age (up to 5 mins)
- if he comes out, he goes straight back in
- usually works in 1-2 months
- if > 5 yrs – more effective to use removal of privledges
3. ignore other behaviours
- difficult for parents
- avoid eye contact
- walk away/ distract themselves/ separate room
4. praise for good behaviours
- be specific
- immediate
- sticker charts
