Developmental delay 2

Question 1

What is general learning difficulty?

Answer 1

Borderline and mild learning difficulties- IQ 70-80:
Usually supported by additional helpers (learning support assistants) at mainstream schools
Moderate (IQ 50-70)
Severe (IQ 35-50)
Profound (IQ<35)

Question 2

Which conditions can cause abnormal development and learning difficulty?

Answer 2

Genetic- chromosomal and DNA disorders (e.g. Down syndrome, fragile X syndrome, chromosomal microdeletions or duplications); cerebral dysgenesis (e.g. microcephaly, hydrocephalus)
Cerebrovascular- stroke
Metabolic- hypothyroidism, phenylketonuria, (perinatal) hypoglycaemia and
hyperbilirubinemia, inborn errors of metabolism
Teratogenic- alcohol and drug abuse (during pregnancy)
Congenital infection- TORCH
Extreme prematurity- IVH, periventricular leukomalacia (necrosis of white matter near the lateral ventricles)
Birth asphyxia- hypoxic-ischaemic encephalopathy
Infection- meningitis, encephalitis
Anoxia- suffocation, near drowning, seizures
Trauma- accidental and non-accidental head injury
Nutritional deficiency- maternal deficiency (in breast fed infants), food intolerances, restrictions
Other- unknown (in ~ 25%), chronic illness, physical abuse, emotional neglect

Question 3

What is developmental dyspraxia?

Answer 3

A disorder of motor planning and/or execution with no significant findings on standard neurological examination
It is a disorder of the higher cortical processes and there may be associated problems with perception, use of language and putting thoughts together.

Question 4

What are the features of developmental dyspraxia?

Answer 4

Handwriting, which is typically awkward, messy, slow, irregular and poorly spaced
Difficulty planning, being on time
Forgetfulness and short term memory
Heightened sensory sensitivity and discomfort
Dressing (buttons, laces, clothes)
Cutting up food
Poorly established laterality
Copying and drawing
Messy eating from difficulty in coordinating biting, chewing and swallowing (oromotor dyspraxia)
Dribbling of saliva

Question 5

How is dyspraxia diagnosed?

Answer 5

OT and speech and language therapist when necessary. A visual assessment may also be helpful

Question 6

What is ADHD?

Answer 6

In true ADHD, the child is overactive in most situations and has impaired concentration with a short attention span or distractibility.
The underlying problem is a dysfunction of brain neuron circuits that rely on dopamine as a neurotransmitter and which control self-monitoring and self-regulation

Question 7

How do patients with ADHD present?

Answer 7

Unable to sustain attention or persist with tasks.
Cannot control their impulses, which manifest itself as being disorganized, poorly
regulated and excessively active
Have difficulty with taking turns or sharing
Are socially disinhibited
Butt into other people’s conversations and play
Their inattention and hyperactivity is worst in familiar or uninteresting situations. Children also cannot regulate their activity according to the situation. They are:
Fidgety
Generally unorganized
Have excessive movement inappropriate to task completion
Lose possessions
Typically have short tempers and form poor relationships with other children

Question 8

How is ADHD diagnosed?

Answer 8

Child must have 6 or more symptoms of hyperactivity or 6 or more symptoms of inattention. The child also must have:
Been displaying symptoms continuously for at least 6 months
Started to show symptoms before the age of 12
Been showing symptoms in at least two different settings
Symptoms that make their lives considerably more difficult
Symptoms that aren’t just part of developmental disorder or difficult pages and
aren’t better accounted for by another condition

Question 9

What is the psychological management for ADHD?

Answer 9

Active promotion of behavioural and emotional progress by offering specific advice to parents and teachers to build concentration skills, encourage quiet self-occupation, increase self-esteem and how to moderate extreme behaviour
1-2-3 magic parenting course
System of rewards should be used, rather than punishments

Question 10

What is the pharmacological management of ADHD?

Answer 10

Medications are used only in those children who failed to respond adequately to behavioural approach. Children are usually older than 6.
Medications reduce excessive motor activity and improve attention on task and focused behaviour. They include:
Stimulants such as methylphenidate or dexamphetamine
Non-stimulants such as atomoxetine
In severe cases, medical and behavioural approaches may be used simultaneously

Question 11

What is enuresis?

Answer 11

Lack of bladder control during the day in a child old enough to be continent (over the age of 3-5 years). Usually nocturnal enuresis is also present

Question 12

What is the epidemiology of enuresis?

Answer 12

Nocturnal enuresis with bedwetting greater than 2 nights/week is present in about 6% of 5 year olds. Boys are more often affected.
There is a genetic component in acquiring sphincter competence, with 2/3 of children with enuresis having an affected first-degree relative.
It is well recognized that emotional stress can interfere and cause secondary enuresis (relapse after a period of dryness), but most children with enuresis are psychologically normal.

Question 13

What are the organic causes of enuresis?

Answer 13

UTIs
Faecal retention (Dr Bowker patients)
Polyuria from osmotic diuresis (e.g. DM)
Neuropathic bladder- spina bifida, bladder is enlarged and fails to properly empty
Ectopic ureter- constant dribbling
Enuresis may also be associated with developmental delays

Question 14

What are the investigations for enuresis?

Answer 14

Urinalysis is only indicated if the bed wetting is of recent onset, if it occurs during the day and if there are features of UTIs, DM or general ill health

Question 15

What is the management for enuresis?

Answer 15

Explanation:
Punitive procedures should be stopped
Excessive or insufficient fluid intake and abnormal toileting patterns should be
addressed
Waking during the night does not promote long-term dryness
Star chart:
Child earns praise and a star can be awarded for agreed behaviour helping to
change the sheets rather than dry nights
Child does not get blamed for wet beds

Question 16

What is an enuresis alarm?

Answer 16

Used for children who don’t respond to star chart
A sensor, usually placed in child’s pants which sounds an alarm when it becomes wet
It must wake child up, who then goes to pass urine in the toilet and returns to help
remake the wet bed before going back to sleep
Takes several weeks to achieve dryness but is effective in most cases as long as the
child is motivated and follows the procedure
If the problem reoccurs, repeat treatment with alarm usually produces lasting
dryness

Question 17

What is the pharmacological management for enuresis?

Answer 17

Desmopressin: synthetic analogue of ADH taken as a tablet or sublingually
may be used in children over 7 years old if the treatment with alarm is not working or if short-term relief is required (e.g. for holidays or sleep overs)
Fluid intake should be restricted after use
May need to be continued for 3-6 months
In unstable bladder use oxybutynin to relax bladder

Question 18

What can cause secondary enuresis?

Answer 18

Emotional upset, UTI, polyuria
Inv: testing the urine for infection, glucose and protein, assessment of urinary concentrating ability and ultrasound of the renal tract.

Question 19

What is a stammer/stutter?

Answer 19

speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds (mostly vowels), syllables, words or phrases and involuntary silent pauses or blocks in which the stutterer is unable to produce sound
Many young children have age 2-5
Risk factors:
Genetics- 60% of those who stutter have a relative that does
Developmental delays
Differences int he brain’s processing of language
Interruption and competition with siblings

Question 20

What is a speech impediment?

Answer 20

o	Stuttering
o	Lisping- protruding the tongue between the front teeth while producing ‘s’ and ‘z’ sounds.
o	Muteness
o	Articulation disorders
o	Voice disorders
o	Dysarthria

Question 21

What are the causes of speech impediments?

Answer 21

congenital health conditions such as poor hearing and a cleft palate
Birth defects which affect the muscles and bones of the face, as well as the digestive system and larynx- many of these can be remedied by appropriate speech and language therapy