1. Board Review 4/30/2013

2. Which topic would you prefer for our final board review? A. Emergency Care B. Disorders of the Eye

4.  Intelligibility of speech by a stranger:  Age 2: 50%  Age 3: 75%  Age 4: 100%  Dysfluency of speech is normal during the rapid attainment of speech in preschool children (around age 2-3)  Typically resolves by age 4  Articulation of all consonant sounds is not complete until 6-8 years of age

5.  Exposure to language  Economically disadvantaged homes have less exposure to language and varied verbal interactions  The more parents talk to their children the more rapid their vocabulary growth  Exposure to reading  Amount of time being read to influences reading proficiency

6. You are seeing a 3yo boy for a health supervision visit. He has a vocabulary of 50 words and does not combine words. Past medical history is negative. He has no history of recurrent ear infections and achieved gross motor milestones at appropriate ages. He resides in a bilingual household. His father had delayed speech, his older brother received speech therapy in elementary school, and his older sister had difficulty with reading comprehension. Of the following, the MOST likely contributing factor for this boy's language delay is A. A bilingual household B. Being third born C. Genetic predisposition D. Hearing loss E. His gender

7.  Language development in infancy and early childhood is a better predictor of cognitive function than motor development  ‘Language Disorder’ refers to a deficit in the comprehension (receptive) or production (expressive) of language  ‘Disorder’ = causes impairment in functioning  Delayed language may or may not be clinically significant  need speech-language clinician to help  13-18% of toddlers have “late-talking”  50% of these will have persistent language deficit  Factors that are associated with delays: family history**, low socioeconomic status, richness of language environment

8.  Bilingual family is NOT a risk factor for language delay  First words may emerge slightly later but within normal limits  Mixing of words or grammar can be seen until age 3 or 4

9.  Specific Language Impairment (SLI)  Biologically based neuodevelopmental disorder of oral language acquisition  No other cause identified (autism, brain damage, hearing loss, etc)  Problems with syntax, grammar, tenses, plurals, possessives, open- ended questions, reading comprehension  Presents in preschool years or kindergarten  Phonologic Disorder  Impaired ability to articulate speech sounds  Childhood Apraxia of Speech  Severe and persistent speech intelligibility disorder  Impaired ability to imitate and produce speech sounds  Due to CNS-based problems planning, sequencing, and coordinating oral-motor movements  Likely genetic in origin

10. During a health supervision visit for a 5-year-old girl, her father reports that she has developed a stutter over the past 6 months. He explains that at times she seems a little frustrated when she speaks but otherwise is happy and well-adjusted. You notice the father also has a mild stutter. Of the following, the risk factor that MOST strongly suggests the need for speech therapy for the girl is: A. Age of onset of the stutter B. Her reaction to stuttering C. Her gender D. The father’s stutter E. Time since onset of stutter

11.  Stuttering  M > F (3:1), strong genetic component  Onset typically around 4-5 years  **Normal dyfluency of speech until age 4, after this age a referral is warranted for the stutter**  Dysarthria  Disorder of motor control of muscles required for speech production  Dyslexia  Deficit in the ability to recognize words in print and phonemes within words  Genetic influence  Hearing Impairment  Auditory input is critical for organizing the neural pathways associated with speech  Concern for ANY speech/language delays should involve an audiologic assessment  Autism/Genetic Syndromes

12.  Surveillance for child’s speech development at all health supervision visits

13.  Formal screening at 9, 18, and 24 or 30 months  No “gold standard” screening tool  Ages and Stages is an example of one  Risk factors: positive family history, prematurity, male sex  Obvious risk factors: hearing impairment, craniofacial abnormalities, syndromes associated with language impairment  Immediate referral for evaluation and treatment

14. You are seeing an 20-month old boy who does not say any words at all. His parents are concerned that he is not developing like his peers and that he is not yet talking. Other than two episodes of otitis media in the past year he has been in good health. His physical exam is normal. Of the following options, the most appropriate next step is to: A. Order EEG B. Order brain MRI C. Reassure the parents and follow up in 6 months D. Refer the child for a neurologic evaluation E. Refer the child to audiology

15.  Suspected speech/language problem   Refer to audiology and speech specialist  Age <3: refer to local early intervention program  Age > 3: refer to public school early childhood program  Concern about global delay or autism  further diagnosis and evaluation by development specialist  Educate parents  Language-rich environment, child-directed conversation, early reading, vocabulary building

16.  Speech Therapy!!  Interventions range from clinician-directed to child- centered  If speech therapy has limited success: they will consider an augmented communication device  Range from picture communication boards to computers that have synthesized speech output.  Once speech therapy is initiated, psychoeducational evaluation may be considered to determine if additional specialized educational services are required

18.  Diagnosis is difficult prior to age 3  However, early intervention initiated prior to age 3 has research proven positive benefits for these children  There are signs of ASDs that are present as early as 14-18 months:  Lack of spontaneous seeking to share enjoyment  Lack of social and emotional reciprocity  Impairment in the use of non-verbal behaviors  Delay or lack of spoken language

19.  Development of social skills and language is delayed or “out of sync” with motor, adaptive, and cognitive function  Lack of social relatedness  Often content being alone  Deficits in “joint attention”  Normal:  Follow a point (10-12mos)  ‘requesting’ (12-14mos)  ‘commenting’ (14-16mos)  Video: http://www.autismspeaks.org/what- autism/video-glossary/glossary-terms [2,3,2]http://www.autismspeaks.org/what- autism/video-glossary/glossary-terms

20.  Deficits in social orienting  Normal: Turn head when name called (8-10mos)  Autism: Do not respond when name called  May create concern about hearing  Lack of or delayed symbolic play  Normal:  Simple pretend play (16-18mos)  Complex pretend play (18-20mos)  Autism  Remain in sensory-motor stage  Enjoy trial and error tasks; “rough house” play  Little interest in toys; or use them in unusual ways  Video [4,1,2]

21. During a health supervision visit for a 24 mo boy you notice that he does not respond to his name and he repeatedly echoes words and phrases. He recites a fairly complex car advertisement that plays on television. An audiology evaluation is normal. On a general developmental screening questionnaire, he is below the “cut-off” for both communication and personal-social development. He also scored in the risk range on the parent- completed autism-specific screening questionnaire. You refer him to a developmental-behavioral specialist, whose next available appointment is in 6 months. Of the following, the MOST appropriate additional step for this boy is to A. Order baseline EEG B. Encourage his mom to provide language stimulation activities and re-evaluate in 6 months C. Start an amphetamine medication D. Refer him for early intervention services E. Refer him for evaluation for an augmented communication device

22.  Delays in language or speech development have been the most common presenting signs in children diagnosed with ASD  Preverbal red flags:  Unusually quiet or irritable  Atypical vocalizations  Fewer gestures  Lack of to and fro babbling  Lack of inflection (jargoning) at 10-12 mos

23.  Absent or delayed speech  Usually sensed around 18mos by parents  Sometimes rationalized by the child being “shy” or an only child  Parents often overestimate the child’s receptive language ability  Referral for audiology and speech is appropriate first step  If hearing and receptive language are normal, can monitor and try to stimulate speech  If hearing is normal but receptive language is delayed  refer to developmental specialist or early intervention program  Confirmed diagnosis is not necessary to make referral  Language regression  Seen in 25-30% of children with autism

24.  Atypical Language  Echolalic (immediate or delayed), ritualistic, not functional (ie. pop-up words)  Exceptional verbal memory or labeling skills

25.  May form strong attachment to specific unusual item  Piece of string, pen, etc  Sterotypies  Hand flapping, twirling, finger movements, rocking, head nodding, toe walking, licking, sniffing  Repetitive behaviors  Lining objects up  Hypo or Hypersensitivities to stimuli

26. Of the following, which characteristic would make you more concerned about an Autism Spectrum Disorder over an isolated profound hearing loss? A. Child is hypervisual and makes eye contact to communicate B. Delay in onset of language C. Child uses expressive hand gestures to communicate his/her needs D. Child doesn’t respond to his mother’s voice or to any other environmental noise E. Child engages in self-injurious behavior when he is directed to a new activity

27.  Child with profound hearing loss  Child is hypervisual; uses eye-contact and gestures to communicate  No reaction to human voice OR environmental sound  Autism: will respond to environmental noise  Cerebral Palsy  Eye contact, sounds, facial expressions, conversations  Isolated Intellectual Disability  Don’t typically see language delays, odd interests/activities  Autism can be co-morbid with other conditions with intellectual disability (ie Fragile X)  Isolated Speech/Language Delay  Child uses eye-contact, gestures, social interaction

29. No Language Delay!

30.  No babbling by 9 months  No pointing or other gesture by 12months  No single words by 16 months  No 2-word spontaneous (not echolalic) phrases by 24 months  Loss of language or social skills at any age

31. The AAP published surveillance and screening guidelines for autism spectrum disorders as part of a clinical report on ASD. They recommend 3 referrals for children with greater than 2 risk factors for ASD. Which of the following is NOT one of those mandated referrals? A. Early intervention or school-based program based on the child’s age B. An ASD specialist or team of specialists for a comprehensive evaluation C. Neurology D. Audiology

32.  Surveillance at every health supervision visit  Standardized ASD-screening tool at the 18 month and 24 or 30 month visit or whenever a concern is raised  Risk factors:  Older sibling with ASD  Parental concern  Other caregiver concern  Physician concern  If ≥ 2 risk factors OR concerning results on ASD screening tool  refer!!  Early intervention ( 3yo)  ASD specialist for comprehensive evaluation  Audiology

33. A 9yo boy with Autistic Disorder is displaying severely aggressive behavior to his parents and teachers. He has frequent tantrums when frustrated or upset which include self-injurious behavior and throwing objects. This behavior has persisted even despite intensive behavioral and educational interventions. His parents are interested in medication to help handle him more safely at home. Of the following, the MOST appropriate medication with which to begin a trial is: A. Lithium B. Atypical antipsychotic C. Melatonin D. Serotonin reuptake inhibitor E. Stimulant medication

34.  Comprehensive evaluation by ASD specialist  Coordinated care between variety of practioners  Developmental/behavioral specialists, therapists, teachers, social workers, subspecialists, vocational staff  Treat co-existing medical, psychiatric, behavioral problems  Medications  Risperidone  Based on symptoms:  Hyperactivity/inattention  ADHD medications

36.  Can be a debilitating condition  Deafness is associated with an increased risk of learning disabilities and a resultant low reading level.  The first 36 months after birth represent a critical period in cognitive and linguistic development  Early identification and intervention are CRITICAL  Allows deaf and hearing-impaired children to approach their peers in language skills and academics  Those identified late often won’t reach the same level

37. You are seeing a newborn with sensorineural hearing loss on her newborn hearing screen. Mom’s reports prenatal history as unremarkable. On exam, the baby has microcephaly and hepatomegaly with NO other obvious physical abnormalities. The MOST likely cause of the hearing loss is A.Congenital cytomegalovirus infection B.Alport syndrome C.Middle ear effusion D.Prenatal rubella exposure E.Usher syndrome

38. 50%

39. You are seeing a 4 month old new patient in clinic today. The family recently moved to your area. You review the records sent from her previous PCP and note that she failed her ABR in the hospital as a newborn. The parents say they never made it to the follow-up test because of the move. Their reports on developmental history seem appropriate. The baby smiles, coos, and laughs out load during your exam. What do you want to do next? A. Ignore the test results from the newborn period. Obviously the baby is developing fine B. Perform an audiometry test in the office to test her hearing C. Refer her for formal hearing evaluation with an audiologist D. Reassure the parent but schedule a follow-up appointment in 1 month so that you can continue to monitor her language development

40.  Congenital hearing impairment cannot be detected through simple observation  Hearing-impaired infants achieve early language milestones  Smiling  Cooing  Babbling  Gesturing  There may be NO initial presenting complaints…or the problems may be very SUBTLE!  This is why mandatory newborn hearing tests are SO important!

41.  Should be performed in the newborn period…within 1 month after birth!!  Otoacoustic Emissions (OAE)  Detects sounds emitted from the cochlea in response to clicks or tones  Does not assess auditory neuropathy or cortical processing of sound  Significantly affected by fluid in the ear canal  Auditory brainstem response (ABR)  Measures the EEG response from the vestibulocochlear nerve  Can detect auditory neuropathy…a condition prevalent in the NICU population  Does not assess cortical processing of sound

42.  IF abnormal screening results are obtained  Formal hearing evaluation NO LATER than 3 months!  Referral to audiologist for formal testing with diagnostic ABR and other appropriate tests  Implementation of services BY 6 months!  False positives are fairly common, so reassure the parents but also emphasize importance of repeat test!  Unfortunately, all congenital hearing loss is NOT detected by newborn hearing screens  Pediatricians should remain aware of risk factors and signs of hearing loss in infants  Refer for formal evaluation if present

43.  We must be able to recognize presenting complaints in pre-school children with hearing impairment  Speech delay and difficulty with articulation  Asking people to repeat themselves  Not hearing instructions  Listening to a loud television or music  Behavioral problems  Other areas that require interaction for learning  Ability to understand and regulate emotions  Accomplish complex motor skills  We must ALSO recognize risk factors

44.  Because only 50% of children who have hearing loss are identified by the use of risk indicators, all children should have periodic objective assessment of their hearing.  Conventional audiometry not reliable until at least 4y

45. What is the MOST common infectious cause of acquired SENSORINEURAL hearing loss? A. Matoiditis B. Bacterial meningitis C. Pneumonia D. Otitis media E. Retropharyngeal abscess

46. The most common cause of acquired CHL is otitis media with effusion ***Among acquired infections, bacterial meningitis is the MOST COMMON cause of childhood SNHL in (infants and children), ranging from mild to profound depending on the severity of illness. ALL children who have meningitis should have a hearing screen as soon as possible!

49.  The severity of the hearing impairment impacts the level of language development in individual patients.  Mild-to-moderate impairment (hearing loss less than 90 dB)  Often improved with external amplification devices (hearing aids)  With early therapy services can reach full academic potential  Severe-to-profound impairment  If SNHL will benefit from cochlear implants  Will require more extensive educational activities/therapies  The onset of hearing loss after age 5 years has a smaller, but still significant, impact on language development.

50.  Educating deaf patients can be accomplished with appropriately trained personnel and involvement of the parents/family.  “Family involvement, including verbal and nonverbal (gestures) communication, has a more significant positive effect on language development than any other specific type of intervention.” (PREP)  The pediatrician should help facilitate this process.  Other approaches:  Hand-cued speech  Sign language  Manually coded English  Oral aural

52.  Intellectual disability  Formerly known as mental retartdation  Deficient performance (at or below 2 standard deviations from the mean)  Intellectual skills  Functional skills  Self help  Adaptive behavior  Learning disability  Normal intelligence and adaptive functioning  Isolated specific academic skills deficit

53.  DSM-IV Criteria  When the individual’s achievement on individually administered, standardized tests is substantially below that expected for age, schooling, and level of intelligence  Reading  Writing expression  Mathematics  Learning problem significantly interferes with academic achievement or activities of daily living that require these skills

54. You are seeing an 8yo little boy because mom is worried about his struggles in school, particularly with reading and attention. Which finding below is seen in the disorder with a nearly 50% incidence of reading disability? A B DC E

55.  Close to 3 million children from 6-11yo are affected by learning disabilities  Reading disability  Accounts for 80% of cases  Occurs in estimated 5-10% of population  Males > Females  Specific medical populations: Neurofibromatosis Type 1 patients can have a LD frequency of 50% or more

56.  Both genetic and neuroanatomic bases for disability  A detailed family history is important!  Inquire about parents, siblings, grandparents, uncles, aunts and cousins  History of any difficulty similar to the patient?  Anyone with difficulty learning to read, spell, or learn a foreign language?  Full physical exam with FOCUS on skin and neurologic evaluation  Remember NF1 and link to learning disability and/or ADHD  Assess neurologic “soft signs” on motor exam  School-related difficulties are often multifactorial…LD, attention problems, social issues, environment

57.  Different children may experience different degrees of impairment  Cognitive abilities and academic skills develop at different rates for individual children  Functioning is modulated by the presence or absence of environmental supports  Subtle presentation when compared to other developmental disorders  Often undetected until school entry or later  Compensatory memorization of sight words, especially in children with strong cognitive ability

58. Children with above average intelligence cannot present with learning disabilities. A. True B. False

59.  May present throughout a school career.  Once compensatory mechanisms are no longer working, the student will begin to have difficulty  This happens as the “learn to read” approach progresses to a “read to learn” mentality  Problems also become apparent in classes like Social Studies  May reflect reduced reading comprehension, short-term memory, or a slow reading rate  This will vary depending on the intellectual ability of the patient  Children with above average intelligence may have learning disabilities and academic failure at later onset!

60.  Our goal as the pediatrician is to recognize learning disabilities in the early stages…before progression to school failure!  Learning disability may present as an ATTENTION difficulty…OR the patient may also have ADHD.

61.  Intellectual disability  Delays in developmental milestones  Struggles in ALL subjects  ADHD  Distractability  Disorganization  Depression  Lack of interest  Friends  Activities  Sadness  OCD  Drug use/abuse

62. A mother of a 6-year-old boy in your practice is concerned that her son may have dyslexia. She has brought a sample of his printing to the visit in which the boy wrote “ded” instead of “bed” and “dad” instead of “bad”. She wants your advice on what she should do to help her son learn to write properly. A. Reassure the mother that letter reversal can be normal through age 7 years B. Recommend a comprehensive psychoeducational evaluation for learning disability C. Recommend neurologic evaluation D. Refer the child for oculometric therapy E. Reassure the mother that letter reversal can be normal through age 8 years

63.  Earlier signs of LD may assist in earlier identification  Risk factors: prematurity and family history of LD  Early indicators  Preschool delays in speech and language  Failure to learn letters and numbers by the end of kindergarten  Failure to learn to read simple words by the end of first grade  **Letter reversal (b and d) in writing/reading can be normal in children through age 7**  Successful intervention is more difficult when learning disabilities are detected late

64.  For ALL children with school failure or suspected LD, a focused H&P should be obtained, including  School history and school day schedule  History of previous evaluations  Developmental milestones  Pregnancy and birth history  Diagnostic medical tests (blood, urine, imaging) are generally not indicated unless…  Focal findings on neurologic exam  Skin findings suggestive of a neurocutaneous syndrome  PMH suggestive of genetic syndromes or nutritional deficiency  A hearing and vision screen should be performed!!!

65.  Physician’s role  Rule out hearing/vision impairments  Establish that the learning lag is not due to limited access to appropriate instruction  Diagnosis and management of related developmental or behavioral disorders  ADHD  Autism spectrum disorders  Identify psychosocial components  Collaboration between the physician and a team of non- medical professionals (psychologists, educators, therapists)  If a delay is seen, educational testing is the next step

66. You have sent a letter to the school requesting a formal psychoeducational evaluation of a 7 year old patient having trouble in math. He is failing is math class, despite increased efforts at home to study. His grades in all other classes are A/Bs. You suspect a learning disability. What would you expect to find upon reviewing the test results? A. Normal IQ and normal achievement tests. B. Low IQ and abnormal achievement test in math only C. Normal IQ and abnormal achievement test in math only D. Normal IQ and abnormal achievement test results in all domains E. What’s an achievement test?

67.  Domain-specific academic and cognitive testing  Tests a child’s cognitive abilities, including the areas of language processing, memory, attention, and nonverbal reasoning  Also assesses specific academic achievement in core areas…reading, math, written expression  Can take place through the school district as part of the IEP process  Private psychological services

68.  Diagnostic methods  Academic achievement tests vs. intelligence tests (IQ)  LD diagnosed when significant discrepancy is demonstrated between the two scores…low achievement test, normal IQ  Can lead to false negatives or positives, especially when testing patients with high or low IQ scores  RTI: no improvement in cognitive domain after steps  Assessment  Remedial instruction  Assessment  On IQ tests…as the discrepancy between verbal and performance IQ scores increases, so does the likelihood of a learning disability

69.  The pediatrician should be the patient’s advocate in ensuring that the initial testing is done and that the proper services are offered by the school once a diagnosis is made.  Formal psychoeducational testing should be done by the school or by a private agency  The results of these tests should guide further management in the school system  Educational criteria for placement in special classes are different in various communities  Repeating a grade is NOT always the answer!

70.  Individuals with Disabilities Education Act (IDEA)  Goals:  Any individual with a qualifying disability that meets the unique needs across his/her lifespan (birth to 21 years)  Free and appropriate education  Prepares that child for future educational, employment, and independence opportunities  “Least restrictive clause”  Children with learning disorders should be integrated in mainstream classroom as much as possible  Tutoring (public or private)  Pull out of class (“resource room”) for areas of difficulty  Self-contained class in more severe intellectual disabilities

71.  Individualized Education Plan (IEP)  Created for disabled students who by a multidisciplinary team within the school system  These students require specialized/individualized instruction  The team works in collaboration with the family to define objectives and strategies for both education and therapy services  The plan should be re-evaluated/revised annually  504 Plan  Allows for reasonable accommodations to be made for all students with disabilities…not just those requiring a specialized IEP  “levels the playing field”

72.  Patients with learning or developmental disabilities should be allowed access to special devices  Laptops in patients with grapho-motor difficulties  Tests on tape and oral testing in patients with reading disability  Use of word processors and spell check in patients with reading disability or problems with written expression

73.  A 10-year-old boy has been receiving specialized educational services in school due to a learning disability. His parents encourage after-school or sports activities to promote positive self-esteem. They realize that academics are a challenge for him, and they express concerns about his future as an adult. Of the following, the factor that has been shown to have the MOST positive effect on prognosis for such a child is A. His athletic ability B. Father’s level of education C. Having two or more siblings D. High IQ E. Strong family and community support

74.  Ranges from academic and social success to ongoing vocational and personal-social problems in adulthood  Frequent unemployment  Poverty  Affected children are at increased risk for  Poor academic performance  Not completing high school  Behavioral problems and mental health disorders  Poor self-esteem  Participation in extracurricular activities can help to increase the patient’s self-esteem  LD are usually not outgrown…problems persist into adulthood.

75.  Children CAN reach high levels of achievement with proper parent, school, and community support  Strong family support is the MOST IMPORTANT prognostic indicator in patients with learning disabilities  Children with LD can be gifted at other cognitive and creative talents that should be nurtured  Enhance self-esteem  Provide a sense of accomplishment

77.  S0me medical problems may present as complaints about school performance or behavior  Complex partial seizures  Absence seizures  Tourette syndrome  Visual problems  Mild conductive hearing loss

78.  Chronic illness and their treatments affect school performance  IBD  Asthma, CF, chronic respiratory conditions  Malignancy  Epilepsy  Diabetes  HIV/other infections  Truancy  Drug use  Emotional factors: divorce, death in family, moves, etc.

79.  The family environment affects school performance and behavior  Parental educational status  Socioeconomic class  Culture  Family structures  Emotional disorders (depression, anxiety, etc) can initially manifest as academic or behavioral problems  Medications may alter school performance  Antihistamines  Anticonvulsants (especially phenobarbital)

80.  Chronic school failure can lead to  Depression  Anxiety  Substance use and abuse  Reduced motivation for school work  Juvenile delinquency  School drop-out  Other risky behaviors

82.  Reduced numbers of Purkinje cells in the cerebellum  Abnormal maturation of the forebrain limbic system, including reduced neuronal size, increased cell-packing density, and decreased complexity of the neuropil (ie, the complex net of axonal, dendritic, and glial branching in which the nerve cell is embedded);  Abnormalities in frontal and temporal lobe cortical minicolumns, which are more numerous, smaller, and less compact in their cellular configuration and demonstrate reduced neuropil space in the periphery  Developmental changes in cell size and number in the nucleus of the diagonal band of Broca, deep cerebellar nuclei, and inferior olive  Brainstem abnormalities and neocortical malformations (eg, heterotopias)

83.  Red reflex  Look for bilateral equal color and brightness  Should fill entire pupil  Use ophthalmoscope set to “O” diopters  Defect could indicate: cataract, refractive error, retinoblastoma  Any concern  refer to ophthalmology  Fundoscopic exam  Requires more cooperation; difficult prior to age 3  Evaluate anterior structures with plus lenses (black or green numbers)  Posterior structures with minus lenses (red numbers)  Can help diagnose ROP (dilated disc vessels)

84.  Visual acuity testing  Varies based on age  Variations of Snellen chart (with cartoons, etc)  Difference of two lines between the eyes or vision less than 20/40 in either eye  refer to ophthalmology  Corneal reflex testing  Using a penlight to distinguish strabismus from pseudostrabismus  Cover testing  To identify tropias and phorias

85.  Congenital (ie TORCH) infections can have long term sequelae such as visual impairment  Legal blindness: corrected vision of 20/200 or worse in best eye  Approaches to education for visually impaired  Use touch, smell, and auditory input to orient to environment  Preschool: teach skills that promote independence in daily activities  Emphasize sensory experiences and auditory programs  School-age: child should have an Individualized Educational Plan  Child may participate in regular community-based classroom activities, focusing on reading, writing, travel needs, and eventually vocational training and independent living  Braille is used for nonvisual communication and audio recordings supplement reading.

86.  3 most common causes:  Fetal Alcohol Syndrome  Can have IQ in normal range  At risk for neurobehavioral deficits and psychiatric disorders  Down Syndrome  Increased risk for ADHD and ODD  Fragile X  Look for X-linked disorder (ie Uncles with “learning problems”)

87.  Language fluency, access to educational stimulation, educational resources, motivation, emotional functioning  IQ is affected by the child's genetic makeup and the quality of home and community life  A child of approximately 10 years of age tends to have little fluctuation in the IQ score.  An older child may have his or her score compromised when dealing with a life stress, such as divorce or death of a loved one.

88.  Subtest profile scores are more important than overall test scores on IQ tests (is WISC-IV)

89.  Early intervention programs  Goal to have children with developmental problems meet their full potential  Meet needs of the child and family  Promote the child’s development in a natural environment  Laws state that services for children with disabilities must be coordinated, family-based, culturally competent  Do not need a physicians referral, participation is not based on income

90.  Should be familiar with complimentary therapies  Parents are often driven to try nonstandard treatments  Striving for a more rapid solution  Frustration with medical/educational systems  Family pressure  Finances  Lack of community programs  Guilt/remorse