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Developmental & Behavioral Pediatrics: An Overview for the General Pediatrics Boards. Andrew Adesman, MD Developmental & Behavioral Pediatrics Steven & Alexandra Cohen Children’s Medical Center of New York. ABP Content Specs Growth & Development (5%).

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Developmental behavioral pediatrics an overview for the general pediatrics boards

Developmental & Behavioral Pediatrics:An Overview for the General Pediatrics Boards

Andrew Adesman, MD

Developmental & Behavioral Pediatrics

Steven & Alexandra Cohen Children’s Medical Center of New York


Abp content specs growth development 5

ABP Content SpecsGrowth & Development (5%)

  • Developmental Surveillance vs. Screening

  • Milestones


Abp content specs disorders of cognition language learning 3 5

ABP Content SpecsDisorders of Cognition, Language, Learning (3.5%)

  • Intellectual Disability

  • Autism Spectrum Disability

  • Speech-Language Disorders

  • Learning Disabilities


Abp content specs behavioral mental health issues 4

ABP Content Specs Behavioral & Mental Health Issues (4%)

  • Common Behavioral Issues (Birth – 12 years)

    • Colic

    • Nail biting

    • Body rocking

    • Bruxism

    • Breath-holding

    • Enuresis

    • Night terrors vs. nightmares


Abp content specs behavioral mental health issues 41

ABP Content Specs Behavioral & Mental Health Issues (4%)

  • Externalizing Disorders

    • Aggressive behaviors, ODD, CD,

    • Anti-social behavior/delinquency

  • Internalizing Disorders

    • Phobias, Anxiety Disorders,

    • OCD

    • PTSD

    • Mood and Affect Disorders

    • Psychosomatic disorders


Abp content specs behavioral mental health issues 42

ABP Content Specs Behavioral & Mental Health Issues (4%)

  • Suicidal behavior, psychotic behavior, thought disorders

  • ADHD


Part 1 normal development

Part 1: Normal Development


Abp content specs growth development 51

ABP Content SpecsGrowth & Development (5%)

  • Developmental Surveillance vs. Screening

  • Milestones


Surveillance

Surveillance

Comprehensive child development surveillance includes:

  • Eliciting and attending to the parents’ concerns

  • Maintaining a developmental history

  • Making accurate and informed observations of the child

  • Identifying the presence of risk and protective factors

  • Periodically using screening tests

  • Documenting the process and findings


Screening

Screening

In monitoring development during infancy and early childhood, ongoing surveillance is supplemented and strengthened by standardized developmental screening tests:

- 9 months, 18 months, and 2 1/2 yrs

- at times when concerns are identified


Developmental milestones full term infant

Developmental MilestonesFull Term Infant


Developmental milestones 2 months

Developmental Milestones2 Months


Developmental milestones 4 months

Developmental Milestones4 Months


Developmental milestones 6 months

Developmental Milestones6 Months


Developmental milestones 9 months

Developmental Milestones9 Months


Developmental milestones 12 months

Developmental Milestones12 Months


Developmental milestones 15 months

Developmental Milestones15 Months


Developmental milestones 18 months

Developmental Milestones18 Months


Developmental milestones 16 19 months

Developmental Milestones16 - 19 Months


Developmental milestones 24 months

Developmental Milestones24 Months


Developmental milestones 36 months

Developmental Milestones36 Months


Developmental milestones 4 year old

Developmental Milestones4 Year Old


Rule of 4 s

Rule of 4’s

Count to 4

Recite a 4-word sentence

Identify 4 primary colors

Draw a 4-part person

Build a gate out of blocks (picture a #4 as a gate)

A stranger understands 4/4 (100%) of what they’re saying


Developmental milestones 5 year old

Developmental Milestones5 Year Old


Developmental milestones 6 year old

Developmental Milestones6 Year Old


Block stacking

Block Stacking


Feeding skills

Feeding Skills


Play skills

Play Skills


Developmental red flags

Developmental Red Flags

  • No head control by 3 months

  • Fisting beyond 3-4 months

  • Primitive reflexes persisting past 6 months

  • <50 words / no 2-word phrases by 2 years

  • Echolalia beyond 30 months


Tips for clinical cases

Tips for Clinical Cases

  • If a child is ill or uncooperative, consider a “low score” invalid

  • Chronic disease or recurrent hospitalizations can cause developmental delay

  • For premature infants, continue age correction until 18-24 months of age

  • For speech delay, always check hearing first


Suggestion use bright futures tables provided on course website

Suggestion: Use Bright Futures tables provided on course website


Drawing capabilities

Drawing Capabilities


Gross motor achievements

Gross Motor Achievements

  • Walking by 10–14 months

  • Climbing by 2½ years

  • Throwing and kicking a ball by 2 years

  • Pedaling a tricycle by 3 years

  • Hopping by 4 years

  • Skipping by 6 years


Developmental behavioral pediatrics an overview for the general pediatrics boards

Gross Motor Milestones


Fine motor achievements

Fine Motor Achievements

  • Stacking three or four blocks by 18 months

  • Completing simple form boards by 2 years

  • Threading beads by 3½ years

  • Cutting a piece of paper by 3 years

  • Copying geometric shapes by 4 years

  • Tying shoelaces by 5 years

  • Printing legibly by 6 years


Speech language achievements

Speech & Language Achievements

  • Speaking single words by 12 months

  • Making word combinations by 2 years

  • Making clear, simple sentences and being interested in books and stories by 3 years

  • Making conversation clear to others by 3 or 4 years

  • Reading by 5 to 6 years


Social achievements

Social Achievements

  • Dressing by 2 years

  • Self-feeding using cutlery by 3 years

  • Being toilet-trained by 3½ years

  • Playing cooperatively in groups by 3 years

  • Playing team games by 7 years


Part 2 disorders of cognition language learning

Part 2: Disorders of Cognition, Language, Learning


Abp content specs disorders of cognition language learning 3 51

ABP Content SpecsDisorders of Cognition, Language, Learning (3.5%)

  • Speech-Language Disorders

  • Intellectual Disability

  • Autism Spectrum Disability

  • Learning Disabilities


Language delay in a toddler or preschooler

Language Delay in a Toddler or Preschooler

CONSIDER:

Hearing Impairment

Communication Disorders

Global Developmental Delay: Intellectual Disability

Pervasive Developmental Disorders

Environmental Factors

General Health


Developmental behavioral pediatrics an overview for the general pediatrics boards

1-6/1000 newborns

50% genetic

30% syndromic (e.g. Waardenburg, Pendred, Usher)

70% non-syndromic, (e.g. connexin 26/GJB2)

77% AR, 22%AD, 1% X-linked or mitoch.

Hearing Impairment


Developmental behavioral pediatrics an overview for the general pediatrics boards

50% Non-genetic:

TORCH infection

Ear/craniofacial anomalies

Birth Weight < 1500 gm

Low Apgar Scores (0-3 at 5 min, 0-6 at 10 min)

Respiratory Distress/ Prolonged mechanical ventilation, hyperbilirubinemia requiring exchg transfusion

Bacterial meningitis/ Ototoxic meds

Hearing Impairment


Conductive hearing loss

Conductive Hearing Loss

Failure of sound to progress to the cochlea

Most common cause is an effusion, in the absence of inflammation, usually due to otitis media

Clues of a mild conductive hearing loss would include ignoring commands and slight increasing of the TV volume


Sensorineural hearing loss secondary to meningitis

Sensorineural Hearing Loss Secondary to Meningitis

Bacterial meningitis is the most common neonatal cause of hearing loss

Tends to occur early in illness, usually in the first 24 hours

It is not related to the severity of the illness, the age of the patient, or when antibiotics were started


Hearing loss post newborn

HEARING LOSS: Post-newborn

Recurrent or persistent OME

at least 3 mo

Head trauma with fracture of temporal bone

Congenital CMV

often asymptomatic, HL may show up in later childhood (median age 44 months)

Childhood infectious diseases

e.g. meningitis, mumps, measles


Developmental behavioral pediatrics an overview for the general pediatrics boards

Chemotherapy

Structural anomalies:

e.g. Mondini malformation, enlarged vestibular aqueduct

Neurodegenerative disorders

e.g. Hunter syndrome, demyelinating diseases (e.g, Friedreich ataxia, Charcot-Marie-Tooth)

HEARING LOSS: Post-newborn


Developmental behavioral pediatrics an overview for the general pediatrics boards

Hearing Loss - Audiogram

Mild 25-39

Moderate  40-68

Severe 70-94


Age appropriate hearing tests

Age Appropriate Hearing Tests

  • Conventional Pure Tone Audiometry Screen:

    • Appropriate for school age children who can cooperate with commands

    • Tests each ear independently

    • Can differentiate between sensorineural and conductive hearing loss

  • Newborn Hearing Screening (3 tests; for newborns in the nursery):

    • Automated auditory brainstem response (AABR)

    • Transient evoked otoacoustic emissions (TEOAE)

    • Distortion product otoacoustic emissions (DPOAE)


Age appropriate hearing tests1

Age Appropriate Hearing Tests

  • Behavioral Observational Audiometry (BOA):

    • For infants <6 months of age

    • Only a screening test; infants who fail this must undergo ABR testing

  • Visual Reinforcement Audiometry (VRA):

    • For “pre-school” children

    • Tests for bilateral hearing loss so intervention to prevent language development impairment can be started


Communication disorders

Communication Disorders

Expressive Language Disorders

Mixed Expressive / Receptive Disorders

Phonological Disorders

DSM 5 (May 2013):

- Language Disorder

(expressive and mixed receptive-expressive)

- Speech Sound Disorder

(new name for phonological disorder)

- Childhood-onset Fluency Disorder (stuttering)

- Social (pragmatic) Communication Disorder


Developmental behavioral pediatrics an overview for the general pediatrics boards

Communication Disorders

  • Expressive Disorders

    • Disorders of morphology (form), semantics (word meaning), syntax (grammar), pragmatics (social use of language)

  • Mixed Expressive/Receptive Disorders:

    • Above plus comprehension deficits

  • Phonological Disorders

    • Disorders of articulation (motor movements), dyspraxias (motor planning)

    • Disorders of fluency (flow,rhythm)

    • Disorders of voice/resonance


Childhood onset fluency disorder stuttering stammering

Childhood-Onset Fluency Disorder (“Stuttering”, Stammering”)

Disturbance in fluency and time patterning of speech

Begins age 2 ½ to 4, peak age 5

Normal up to age 3 or 4

Male:female ratio is 3-4: 1

75% of preschoolers will stop

Often disappears once vocabulary rapidly increases


Articulation intelligibility rule of quarters

Articulation IntelligibilityRule of Quarters


Stuttering

Stuttering

  • Persistence beyond school age will require a workup

  • Indications for evaluation:

    • Family history of stuttering

    • Persists 6 months or more

    • Presence of concomitant speech or language disorders

    • Secondary emotional distress


Intellectual disability mental retardation

Intellectual Disability(Mental Retardation)

Characterized by:

Deficits in intellectual functions

Adaptive Skill Deficits

Onset before age 18

Level of severity determined by adaptive functioning, not IQ score (DSM V)


Iq testing

IQ Testing

The predictive validity of IQ testing increases with age


Red flags for id 2 to 9 months

Red Flags for ID2 to 9 Months


Red flags for id 18 to 36 months

Red Flags for ID18 to >36 months


Lab testing for developmental delay

Lab Testing for Developmental Delay

  • For speech delay, always check hearing first

  • For a newborn/infant, always check previous metabolic screening done by state

  • For older children, serum lead level, ?TSH

  • Metabolic screening is not recommended for asymptomatic children with idiopathic ID


Id mr etiology

ID/MR- Etiology

Prenatal (50-70%)

genetic, CNS malformations, fetal compromise, infection, teratogens

Perinatal (<10%)

HIE, prematurity

Postnatal

Trauma, asphyxia, infection, toxins, vascular malformations, tumors, degenerative disease

Environmental (additive)

Deprivation/malnutrition

More severe forms, more likely to find definitive etiology


Fragile x syndrome

Fragile X Syndrome

Most common form of inherited ID and the 2nd most common form of ID after Down’s Syndrome

Caused by repeat of CGG trinucleotide on X chromosome

Twice as likely to be seen in males vs. females

Diagnosis: DNA testing is more sensitive than karyotyping for a child with ID


Williams syndrome

Williams Syndrome

Facial features: elfin faces, wide spaced teeth, and an upturned nose

Developmental delays and learning disabilities

Hypercalcemia and supravalvular aortic stenosis


Pervasive developmental disorders dsm iv

Pervasive Developmental DisordersDSM IV

Autistic Disorder (total of 6, at least 2 from #1):

1. Qualitative impairment in social interaction

2. Qualitative impairment in communication

3. Restrictive, repetitive, stereotyped patterns of behaviors, interests and activities.

PDD NOS

Asperger’s Disorder

Rett’s Syndrome

Childhood Onset Disintegrative Disorder

“Autism Spectrum Disorders”: DSM 5 (May, 2013)

1. Deficits in social communication and social interaction

2. Restricted repetitive behaviors, interests and activities


Autism spectrum disorders dsm v

Autism Spectrum DisordersDSM-V

Deficits in social communication and social interaction

Restricted repetitive behaviors, interests and activities


Autistic spectrum disorders key points

Autistic Spectrum Disorders: Key Points

Prevalence (CDC 2012): ~ 1/88

Male: Female 4:1

Seen in association with:

Seizure disorders, congenital infection, metabolic abnl (PKU)

Neurocutaneous disorders (TS, NF)

Genetic Disorders (Fra X, Angelman’s, Smith-Lemli Opitz )

No proven ass’n with vaccines (MMR, thimerosal)

Genetic Basis - Concordance rates:

MZ twins (60-80%)

DZ twins, sibs (3-7%)


Rett syndrome

Rett Syndrome

  • Affects girls almost exclusively

  • Characterized by autistic-like behavior and hand wringing

  • Normal development at first, but around age 4 months head growth decelerates

  • Stagnation of development from age 6-18 months

  • Loss of milestones (regression) from age 1-4 years

  • No further decline after regression period

  • Affected individuals usually survive into adulthood

    • though never regain use of hands or attain meaningful ability to talk


Asperger s disorder

Asperger’s Disorder

Qualitative impairment in social interaction

No clinically significant general delay in language

Impaired pragmatics

“Little professors”

No clinically significant delay in cognitive development or in the development of age-appropriate self-help skills

Motor coordination difficulties

This disorder is not included in DSM V


Language delays red flags vs red herrings

Language DelaysRed Flags vs. Red Herrings

  • A bilingual home and a second child (including a boy) with sibs and parents speaking for the child do not explain language delays

  • A hearing evaluation is needed, especially with a history of TORCH infections, hyperbilirubinemia, or meningitis


School failure

School Failure

“Slow Learner”: Borderline Intelligence

Learning Disorders: Average Intelligence

ADHD and Disruptive Behavior Disorders (Oppositional Defiant Disorder, Conduct Disorder)

Mood and Anxiety Disorders

Chronic Medical Illness

Psychosocial stressors


Developmental behavioral pediatrics an overview for the general pediatrics boards

Learning Disorders – Difficulties in:

  • Receptive language, expressive language

  • Basic reading skills, reading comprehension

  • Written expression

  • Mathematics calculation / reasoning

  • DSM 5 (May, 2013) : “Specific Learning Disorder”


Learning disabilities ld

Learning Disabilities (LD)

  • A child can have a LD with normal or even superior intelligence; the two are not related

  • Having a LD means there is a specific difficulty in one of the following areas:

    • Listening

    • Speaking

    • Reading

    • Writing

    • Reasoning

    • Math Skills


Learning disabilities ld1

Learning Disabilities (LD)

  • Social problems may be a manifestation of a LD, but they are not considered learning disorders in and of themselves

  • A LD can often be compensated for in the early grades

  • LD are then picked up in the later grades when things get tougher and more challenging

  • A child who reverses the letters (e.g., b/d) or numbers (e.g., 6/9) may not have a LD. This can be a normal finding up to age 7


Developmental behavioral pediatrics an overview for the general pediatrics boards

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Part 3 behavioral mental health issues

Part 3: Behavioral & Mental Health Issues


Abp content specs behavioral mental health issues 43

ABP Content Specs Behavioral & Mental Health Issues (4%)

  • Common Behavioral Issues (Birth – 12 years)

    • Colic

    • Nail biting

    • Body rocking

    • Bruxism

    • Breath-holding

    • Enuresis

    • Night terrors vs. nightmares


Abp content specs behavioral mental health issues 44

ABP Content Specs Behavioral & Mental Health Issues (4%)

  • Externalizing Disorders

    • Aggressive behaviors, ODD, CD,

    • Anti-social behavior/delinquency

  • Internalizing Disorders

    • Phobias, Anxiety Disorders,

    • OCD

    • PTSD

    • Mood and Affect Disorders

    • Psychosomatic disorders


Abp content specs behavioral mental health issues 45

ABP Content Specs Behavioral & Mental Health Issues (4%)

  • Suicidal behavior, psychotic behavior, thought disorders

  • ADHD


Colic

Colic

  • Diagnosed based on history

    • Physical exam rarely shows anything

    • No labs that confirm the diagnosis

  • Stops after 3-4 months of age

  • No “proven” methods to treat colic

  • Typical presentation is crying episodes in an otherwise healthy infant

    • Crying starts suddenly


Colic1

Colic

  • Normal crying patterns of infants is up to 2 hrs/day and 3 hrs/day (for ages birth-6 wks, and 6 wks+, respectively)

    • When presented with a crying infant, add up the total hours crying (if it is only 3 hours, this is normal and nothing more than parental reassurance is needed)

  • Correct management is to reduce parental frustration by having another caretaker take over

  • Often disturbing sleep patterns may just be part of the “temperament” of the infant with no intervention required


Television viewing

Television Viewing

  • Known harmful effects of TV on children:

    • Trivializing violence and blurring lines between reality and fantasy

    • Encouraging passivity at the expense of activity

    • Increase of aggressive behavior and influence of the toys played with and cereals eaten

  • TV watching takes up more time than school

  • Children watch 23 hrs/week

  • Only the time spent sleeping exceeds the number of leisure hours watching TV


Nail biting onychophagia

Nail Biting(onychophagia)

  • Most common between ages 10 and 18 years

  • Seen in 50% of children

  • <10 years: equal in boys and girls

  • >10 years: more common in boys

  • Tx: positive reinforcement

    • Praise when child is not biting his nails


Body rocking

Body Rocking

  • Occurs at ~6 months in 5-20% of children

  • Sitting or crawling position

  • Most common around bedtime & lasts ~ ½ hours

  • Usually stops by 2-3 years

  • Rarely continues into adolescence

  • May occur with standing in children with developmental disabilities

    • ASD, visual impairment


Bruxism clenching grinding

Bruxism (clenching / grinding)

  • Typically nocturnal during REM sleep

  • If prolonged, can cause T-M joint pain, tooth damage, tension headaches, face pain, and neck stiffness in adolescents

  • More common in boys

  • Familial

  • Children -- usually self-limited; tx not indicated

  • Teens -- splint or bite guards (dentist)


Breath holding spells

Breath-Holding Spells

Typical presentation: anger, frustration, or infant in pain

Occurs between ages 6-18 months

Simple breath holding-spell: child becomes pale or cyanotic

Complex breath holding-spell: child continues to cry until unconscious

Can progress to a hypoxic seizure with a postictal period

Association between anemia and incidence of BHS


Breath holding spells1

Breath Holding Spells

  • Usually associated when child is angry, frustrated, in pain, or afraid

  • Hold breath for up to 1 minute

  • Most common in ages 1 – 3 years

  • Reflexive, not purposeful

  • Brief loss of consciousness


Breath holding spells2

Breath Holding Spells

  • May have a brief, benign seizure (not at risk for epilepsy)

  • Cyanotic vs. Pallid

  • Dx is clinical; consider anemia

  • Family history is frequently positive

    • autosomal dominant with reduced penetrance

  • Tx: Reassurance

    • iron if anemic


Enuresis nocturnal enuresis

EnuresisNocturnal Enuresis

Initial workup for new onset consists of history, physical, and urinalysis

Organic causes: SUDS (sickle cell trait, UTI, diabetes, seizure or sacral)

Short term treatment is desmopressin acetate

Enuresis alarms for long term management

Seen up to 20% of children at age 5

15% of cases per year will resolve with no intervention


Enuresis diurnal enuresis

EnuresisDiurnal Enuresis

Diurnal enuresis after a period of daytime continence is most likely due to an organic illness warranting workup

UTI, DM, DI, or kidney disease

97% of the time the cause is non-organic

Cannot be defined prior to age 3

Appropriate management is behavioral intervention by designing a voiding routine


Night terrors

Night Terrors

Occur during the first third of the night and happen rapidly

Often family history present

Occurs more in boys than girls

Child exhibits distinctive physical findings (deep breathing, dilated pupils, sweating, etc.)

Child can become mobile, which can result in injury

If woken up, child will be “disoriented” with no recall of episode


Nightmares

Nightmares

Occur during the last third of the night

Child can be woken easily

Child will recall the nightmare, often vividly

Not mobile


Externalizing disorders

“Externalizing Disorders”

ADHD

Oppositional-Defiant Disorder

Conduct Disorder


Attention deficit hyperactivity disorder

Attention-Deficit/Hyperactivity Disorder

Symptoms of Inattention, Impulsivity, Hyperactivity

Some symptoms present before age 7 years

DSM 5: Several inattentive or hyperactive-impulsive symptoms present prior to age 12

Impairment from the symptoms is present in two or more settings

DSM 5: Several symptoms in each setting

Clear evidence of clinically significant impairment in social, academic, or occupational functioning. 


Developmental behavioral pediatrics an overview for the general pediatrics boards

ADHD Subtypes

  • Combined Type (80%*)

  • Predominantly Inattentive Type (10-15%*)

  • Predominantly Hyperactive-Impulsive Type (5%*)

    *in school-age children


Adhd key points

ADHD: Key Points

Disorder of dopamine and norepinephrine systems in frontostriatal circuitry

3-7% of school age children

Male: female (6:1-3:1)

Genetic Predisposition: 5-6 fold increase in first degree relatives

Environmental Factors: e.g. head trauma, lead exposure, VLBW, prenatal teratogens

Symptoms Persist into Adulthood in 60-80%


Adhd key points cont d

ADHD - Key points (cont’d)

Co-morbid Conditions:

Learning Disorders

Anxiety Disorders

Oppositional Defiant Disorder

Conduct Disorder

Tic Disorders

Mood Disorders

Substance abuse disorders (adolescents)


Adhd treatment

ADHD - Treatment

Psychopharmacologic: stimulants = first line

Inhibit reuptake of dopamine and norepinephrine

Stimulant Side effects: appetite suppression, headache, abdominal pain, growth suppression, irritability, onset/ exacerbation of tics

Behavioral Interventions


Developmental behavioral pediatrics an overview for the general pediatrics boards

“Internalizing Disorders”

  • Mood Disorders:

    • e.g. Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder

    • DSM 5: “Disruptive Mood Dysregulation Disorder”

  • Anxiety Disorders:

    • e.g. Generalized Anxiety Disorder, Separation Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, School Phobia

  • Obsessive-Compulsive Disorder

    • DSM 5: Included in “O-C and Related Disorders”, not “Anxiety Disorders”

  • Post-traumatic Stress Disorder

    • DSM 5: Included in “Trauma- and Stressor-related Disorders”


Part 4 sample questions

Part 4:Sample Questions


Developmental behavioral pediatrics an overview for the general pediatrics boards

?? A baby is pulled to sit with no head lag, grasps a rattle, and follows an object visually 180 degrees. These milestones are typical for:

6

  • 2 months

  • 4 months

  • 6 months

  • 8 months


Developmental behavioral pediatrics an overview for the general pediatrics boards

??Tanya is now walking well, and can stoop to the floor and get back up. She generally points to indicate what she wants, but can ask for her “bottle”, a “cookie” and her “blankie”. She drinks from a sippy cup and feeds herself cheerios. She places a toy bottle in her doll’s mouth. Tanya is most likely a typically developing: 

6

  • 12 month old

  • 15 month old

  • 18 month old

  • 24 month old


Developmental behavioral pediatrics an overview for the general pediatrics boards

?? Maria sits in your office with paper and crayons. She counts ten crayons and labels the colors. She can copy a square, print her first name and draw a picture of her mother with 6 body parts. Out in the hall she demonstrates hopping on each foot and skipping. Her age is closest to:

6

  • 42 months

  • 48 months

  • 60 months

  • 72 months


A 3 year old boy should have mastered each of the following except

?? A 3 year old boy should have mastered each of the following except:

  • Naming a red truck

  • Towering 6 cubes

  • Stating his name and gender

  • Hopping on one foot


A 3 year old boy should have mastered each of the following except1

?? A 3 year old boy should have mastered each of the following except:

  • Naming a red truck (50%ile ~30 mos)

  • Towering 6 cubes (50%ile ~ 20 mos)

  • Stating his name and gender (50%ile ~ 3 yrs)

  • Hopping on one foot (50%ile ~ 4 yrs)


Developmental behavioral pediatrics an overview for the general pediatrics boards

??On a pre-kindergarten screening a school official is most concerned about a 5 year old boy who cannot:

  • Draw a Person with 6 parts

  • Copy a Square

  • Name 4 colors

  • Tandem Walk

6


Developmental behavioral pediatrics an overview for the general pediatrics boards

??On a pre-kindergarten screening a school official is most concerned about a 5 year old boy who cannot:

  • Draw a Person with 6 parts (50%ile ~4 ½ yrs)

  • Copy a Square (50%ile ~ 5 yrs)

  • Name 4 colors (50%ile ~ 3 ¾ yrs)

  • Tandem Walk (50%ile ~ 4 ½ yrs)

6


You would be most concerned about

??You would be most concerned about:

  • A one year old who doesn’t stand alone

  • A 15 month old who can’t stoop and recover

  • A four year old who cannot hop on each foot

  • A two year old who cannot jump

6


You would be most concerned about1

??You would be most concerned about:

  • A one year old who doesn’t stand alone (50-90% of 1 year olds)

  • A 15 month old who can’t stoop and recover (>90% of 15 month olds)

  • A four year old who cannot hop on each foot (50-90% of 4 yr olds)

  • A two year old who cannot jump (50-90% of 2 yr olds)

6


You would be less concerned about

??You would be less concerned about:

  • A 3 year old who cannot answer a “why”question

  • An 18 month old who uses 2 words

  • A one year old who doesn’t point

  • A 9 month old who doesn’t babble

6


You would be less concerned about1

??You would be less concerned about:

  • A 3 year old who cannot answer a “why”question (50% ile ~4-5 yrs)

  • An 18 month old who uses 2 words (over 90% of 15 mo olds)

  • A one year old who doesn’t point (over 90% of 1 yr olds)

  • A 9 month old who doesn’t babble (over 90% of 9 mo olds)

6


Developmental behavioral pediatrics an overview for the general pediatrics boards

??Annie is a 16 month old brought by her parents who worry that she is not yet walking. Born at 25 weeks, she required oxygen, phototherapy and parenteral nutrition. She now eats with her hands, drinks from an open cup, pulls to stand and takes a step while holding on. Your exam is unremarkable. Your best recommendation is:

6

  • Send Annie to rehab for physical therapy

  • Request a neurological consultation

  • See Annie back in two months for follow up

  • Consider an MRI to r/o intraventricular hemorrhage


Developmental behavioral pediatrics an overview for the general pediatrics boards

?? You are evaluating a 9 month old baby who is not yet sitting without support. She is a former 26 week premature infant. Brain MRI reveals periventricular leukomalacia. Of the following findings, which would you most likely expect to see:

  • Increased tone in all 4 extremities, especially the UE

  • Equally increased tone in all 4 extremities

  • Dyskinetic, choreoathetoid movements

  • Increased tone in all 4 extremities, especially the LE

  • Increased tone in the right upper extremities compared with the left


Developmental behavioral pediatrics an overview for the general pediatrics boards

??Parents of a 3 year old girl present with concerns about speech and language delays.

Their daughter has a vocabulary of about 10 words, and she recently began pointing to body parts and following single un-gestured commands. She can imitate a vertical line, jump in place, and broad jump. She is able to wash and dry her hands, and put on a t-shirt. In your office, she points to your stethoscope, and when you hand it to her she smiles at you and places it on her father’s chest.


You most strongly suspect

You most strongly suspect:

  • Mental Retardation

  • Autistic Spectrum Disorder

  • Mixed receptive/expressive language disorder

  • Hearing Impairment

  • Environmental under-stimulation

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Your first referral is to

??Your first referral is to:

  • Social service

  • Audiology

  • Psychology

  • Speech and Language Pathology

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Developmental behavioral pediatrics an overview for the general pediatrics boards

??A 5 year old boy presents for health maintenance. Developmental surveillance reveals that he can copy a circle, knows the adjectives “tired” and “hungry” and can broad jump, but cannot hop in place, draw a person in 3 parts or name 4 colors. You suspect:

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  • Learning Disability

  • Mild Intellectual Disability (Mental Retardation)

  • Cerebral palsy

  • Autistic Spectrum Disorder

  • Severe Intellectual Disability


Developmental behavioral pediatrics an overview for the general pediatrics boards

??Devin has a vocabulary of about 300 words, speaks in 2-3 word combinations and understands and asks simple “what” questions. He can follow simple prepositional commands using “on” and “in”. His age is most likely:

  • 18m

  • 24m

  • 30m

  • 36m

  • 42m


A stranger should be able to understand half of a child s speech at age remember the rule of fours

??A stranger should be able to understand half of a child’s speech at age:Remember the rule of fours!

  • 12 months

  • 18 months

  • 24 months

  • 36 months

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Developmental behavioral pediatrics an overview for the general pediatrics boards

??Three year old Jason is brought by frustrated parents due to constant tantrums. He is hyperactive, impulsive and often does not respond when called. He interacts mostly with adults in his daycare. You note that he grabs mother’s hand to reach a toy from a nearby shelf. Mother reports that he constantly watches “Thomas the Train” videos at home, and carries his toy Thomas figure everywhere. Based on this information, the first assessment tool you would consider would be:

  • Conners III Comprehensive Behavior Rating Scale

  • Wechsler Preschool and Primary Scales of Intelligence III

  • Childhood Autism Rating Scale II Edition

  • Preschool Language Scale V Edition

  • Child Behavior Checklist (CBCL)

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Developmental behavioral pediatrics an overview for the general pediatrics boards

??All of the following observations are considered risk factors for Autistic Spectrum Disorders except:

  • Lack of pointing at 12 months

  • Lack of babbling at one year

  • Lack of gaze monitoring at 10 months

  • Echoing phrases at 18 months

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Developmental behavioral pediatrics an overview for the general pediatrics boards

?? An 8 year old second grade boy was referred for evaluation due to academic difficulties. His psychological and psychoeducational evaluations revealed:WISC 4: Full scale IQ = 99,Verbal Comprehension = 85, Perceptual Reasoning = 105, Working Memory = 110, Processing Speed = 108WIAT 2: Word reading = 92, Reading comprehension = 81, Numerical operations: 98, Math reasoning = 79The child’s likely diagnosis is:

  • Borderline Intellectual Functioning

  • Learning Disability

  • Attention-deficit/Hyperactivity Disorder

  • Auditory Processing Disorder

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Developmental behavioral pediatrics an overview for the general pediatrics boards

?? A 9 year old third grade boy is brought to your office by his mother who is distraught about his report card. He is below average in reading and spelling and his teaching states that he does not complete assignments and is distractible in class. He is not a management problem at home other than when it’s time to do his homework. He has friends and excels on the baseball field. An appropriate next step would be:

  • Request completion of parent and teacher Vanderbilt Questionnaires

  • Initiate a trial of methylphenidate

  • Order psychological and psychoeducational testing

  • Refer to Child Psychiatry

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Developmental behavioral pediatrics an overview for the general pediatrics boards

?? A distraught mother phones you asking for advice. She met with her 9 year old son’s teacher who states that your patient Johnny does not listen, talks back, and recently has been physically lashing out at other children. He is in jeopardy of repeating the 4th grade. Mother wonders whether a trial of “that medication my nephew takes that starts with r” would be helpful. You conclude:

  • Johnny’s behavior is most consistent with the lack of impulse control associated with ADHD.

  • Johnny’s behavior is likely to meet criteria for a disorder often co-morbid with ADHD, but not consistent with ADHD alone.

  • Johnny is also likely to be cruel to animals, to steal and to run away from home.

  • Johnny’s behavior is consistent with the general class of “internalizing” behaviors.

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