Andrew Adesman, MD Developmental & Behavioral Pediatrics

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%)
Developmental Surveillance vs. Screening Milestones

ABP Content Specs Disorders of Cognition, Language, Learning (3.5%)
Intellectual Disability Autism Spectrum Disability Speech-Language Disorders Learning Disabilities

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

Externalizing Disorders Aggressive behaviors, ODD, CD, Anti-social behavior/delinquency Internalizing Disorders Phobias, Anxiety Disorders, OCD PTSD Mood and Affect Disorders Psychosomatic disorders

Suicidal behavior, psychotic behavior, thought disorders ADHD

Part 1: Normal Development

ABP Content Specs Growth & Development (5%)
Developmental Surveillance vs. Screening Milestones

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 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
11

Multiplication Table: Back to 3rd Grade !!

“You absolutely have to know these tables cold… Again, you absolutely have to know these tables cold, whether you want to or not.” MedStudy

Developmental Milestones Full Term Infant
Category Description Motor - Moro reflex Cognitive/Behavioral - Becomes alert with the sound of a bell or voice Language Social - Fixates on face/object and briefly follows

Developmental Milestones 2 Months
Category Description Motor - Follows objects past mid-line - Lifts head and shoulders off bed in prone position Cognitive/Behavioral Language Social

Category Description Motor - Head lag disappears by 5 months - Moro disappears by 3-6 months - Bears weight on forearms while prone - Rolls from prone to supine - Bears weight while held standing Cognitive/Behavioral Language - Laughs out loud and squeals Social - Imitates social interaction

Category Description Motor - Ability to transfer object from one hand to the other - Reaches for objects - Sits with support - Rolls over in both directions Cognitive/Behavioral - Turns directly to sound and voice Language - Babbles consonant sounds - Imitates speech Social

Category Description Motor - Bangs two blocks together - Sits without support Cognitive/Behavioral - Turns when name is called - Plays peek-a-boo Language - Mama and Dada (non-specific) Social - Stranger anxiety - Recognizes common objects and people

Category Description Motor - Takes a few steps - Pincer grasp - Drinks from a cup held by another person - Pulls to stand and cruises Cognitive/Behavioral - Assists with dressing Language - Speaks 1 additional word besides Mama and Dada - Mama and Dada specific Social - Follows a single step command with gesture

Category Description Motor - Gives and takes a ball - Drinks from a cup - Scribbles with a crayon - Puts cube into a cup - Walks independently - Stoops to floor and recovers to standing position Cognitive/Behavioral Language - Speaks 3-6 additional words besides Mama and Dada - Points to one body part - Follows single step command without gesture Social

Category Description Motor - Self-feeding with a spoon - Stacks 2 cube tower - Throws ball - Walks upstairs while holding hand Cognitive/Behavioral - Imitates household chores like sweeping, vacuuming, etc. Language word vocabulary Social

Developmental Milestones 16 - 19 Months
Category Description Motor - Builds a tower of 4 blocks - Releases a raisin into a bottle - Spontaneous scribbling (18 mo) Cognitive/Behavioral Language Social

Category Description Motor - Builds a tower of 6 cubes - Washes and dries hands - Removes clothing - Kicks a ball - Jumps with 2 feet Cognitive/Behavioral Language - Greater than 50 word vocabulary - Starts using pronouns -- such as I, me, and you - Speech is 50% intelligible to a stranger Social

Category Description Motor - Copies a circle - Puts on a t-shirt/shorts - Stacks a tower of 8 cubes - Stands on one foot for 1-2 seconds - Pedals tricycle - Climbs stairs, alternating feet Cognitive/Behavioral - Imitates a vertical line drawn with a crayon - Knows the name of a friend - Understands basic adjectives (tired, hungry) Language - Speaks with 5-8 word sentences - 75% of what is said is intelligible - Starts using “what” and “who” Social

Developmental Milestones 4 Year Old
Category Description Motor - Walks up and down stairs/steps - Draws a simple drawing of a person - Balances on 1 foot for 4 seconds Cognitive/Behavioral - Dresses and brushes teeth without help - Names 4 colors Language - Asks questions: -- Where? Why? How? What? - 100% intelligible to a stranger Social - Pretend plays

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

Category Description Motor - Draws a person with 6 body parts - Prepares a bowl for food - Skips, alternating feet Cognitive/Behavioral - Plays board games - Counts 5 blocks - Names all the primary colors Language - Defines words Social

Category Description Motor - Ties shoelaces - Rides a bicycle Cognitive/Behavioral - Writes name - Knows right from left Language - Counts ten objects Social

Block Stacking Age Task 13-15 months 2 block tower 18 months
3 years 3 block bridge 4 years 5 block gate

Feeding Skills Task Age Uses cup well 15 – 18 months Uses spoon well
2 years Uses fork well 4 years

Play Skills Task Age Symbolic Play 15 - 18 mo Parallel play, empathy
(use one object to represent another object and engage in one or two simple actions of pretend play) mo Parallel play, empathy 24 mo Fantasy Play (children engage in make-believe play involving several sequenced steps, assigned roles, and an overall plan and sometimes pretend by imagining an object without needing the concrete object present) 36 mo Cooperative Play 3-4 yrs

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
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 months of age For speech delay, always check hearing first

Suggestion: Use Bright Futures tables provided on course website
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Drawing Capabilities Age What They Can Draw 3 4 5 6 7

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

Gross Motor Milestones

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
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 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

ABP Content Specs Disorders of Cognition, Language, Learning (3.5%)
Speech-Language Disorders Intellectual Disability Autism Spectrum Disability Learning Disabilities

Language Delay in a Toddler or Preschooler
CONSIDER: Hearing Impairment Communication Disorders Global Developmental Delay: Intellectual Disability Pervasive Developmental Disorders Environmental Factors General Health 45 45

Hearing Impairment 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. 47 47

Hearing Impairment 50% Non-genetic: Ear/craniofacial anomalies
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 48 48

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
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
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 51 51

HEARING LOSS: Post-newborn
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) 52 52

Hearing Loss - Audiogram
Mild Moderate Severe 53 53

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 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
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 57 57

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 58 58

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 59 59

Articulation Intelligibility Rule of Quarters
Age % of spoken language that is intelligible to strangers 2 2/4 = 50% intelligible 3 3/4 = 75% intelligible 4 4/4 = 100% intelligible

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)
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) 63

IQ Testing The predictive validity of IQ testing increases with age

Red Flags for ID 2 to 9 Months
Age Deficiency Requiring Intervention 2 months Lack of visual attention/fixation 4 months Lack of visual tracking Lack of steady head control 6 months Failure to turn to sound or voice 9 months Inability to sit Lack of babbling

Red Flags for ID 18 to >36 months
Age Deficiency Requiring Intervention 18 months Inability to walk independently 24 months Failure to use single words 36 months Failure to speak in 3-word sentences >36 months Unintelligible speech

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 Prenatal (50-70%) Perinatal (<10%) Postnatal
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 68 68

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 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
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 72 72

Autism Spectrum Disorders DSM-V
Deficits in social communication and social interaction Restricted repetitive behaviors, interests and activities 73 73

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%) Seizures reported in 11-39% of individuals with ASD, between 12-60% of individuals with TSC meet criteria for ASD, 74 74

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 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 76 76

Language Delay in a Preschooler
CONSIDER: Hearing Impairment Communication Disorders Global Developmental Delay Intellectual Disability (Mental Retardation) Pervasive Developmental Disorders Environmental Factors General Health 77

Language Delays Red 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 “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 79

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” 80

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 (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

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Part 3: Behavioral & Mental Health Issues

Common Behavioral Issues (Birth – 12 years) Colic Nail biting Body rocking Bruxism Breath-holding Enuresis Night terrors vs. nightmares

Externalizing Disorders Aggressive behaviors, ODD, CD, Anti-social behavior/delinquency Internalizing Disorders Phobias, Anxiety Disorders, OCD PTSD Mood and Affect Disorders Psychosomatic disorders

Suicidal behavior, psychotic behavior, thought disorders ADHD

Colic Diagnosed based on history Stops after 3-4 months of age
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

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 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)
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 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)
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
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 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 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
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
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 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 Occur during the last third of the night
Child can be woken easily Child will recall the nightmare, often vividly Not mobile

“Externalizing Disorders”
ADHD Oppositional-Defiant Disorder Conduct Disorder 101 101

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. 102

ADHD Subtypes Combined Type (80%*)
Predominantly Inattentive Type (10-15%*) Predominantly Hyperactive-Impulsive Type (5%*) *in school-age children 103

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% 104

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) 105

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 106

“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” 107 107

Part 4: Sample Questions

2 months 4 months 6 months 8 months
?? 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: 2 months 4 months 6 months 8 months 5 109 109

12 month old 15 month old 18 month old 24 month old
??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: 12 month old 15 month old 18 month old 24 month old 6 110 110

42 months 48 months 60 months 72 months
?? 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: 42 months 48 months 60 months 72 months 6 111 111

?? 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 112 112

??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 6 113 113

??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) 6 114 114

??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 6 115 115

??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) 6 116 116

??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 6 117 117

??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) 6 118 118

Send Annie to rehab for physical therapy
??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: 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 5 119 119

?? 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 120 120

?? 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. 121 121

You most strongly suspect:
Mental Retardation Autistic Spectrum Disorder Mixed receptive/expressive language disorder Hearing Impairment Environmental under-stimulation 6 122 122

??Your first referral is to:
Social service Audiology Psychology Speech and Language Pathology 6 123 123

A 5 year old boy presents for health maintenance
??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: Learning Disability Mild Intellectual Disability (Mental Retardation) Cerebral palsy Autistic Spectrum Disorder Severe Intellectual Disability 6 124 124

?? 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 125 125

12 months 18 months 24 months 36 months 5
??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 C 5 126 126

??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) 6 127 127

??All of the following observations are considered risk factors for an Autism Spectrum Disorder 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 6 128 128

6 Borderline Intellectual Functioning Learning Disability
?? 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 = 108 WIAT 2: Word reading = 92, Reading comprehension = Numerical operations: 98, Math reasoning = 79 The child’s likely diagnosis is: Borderline Intellectual Functioning Learning Disability Attention-deficit/Hyperactivity Disorder Auditory Processing Disorder 6 129 129

?? 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 6 130 130

A distraught mother phones you asking for advice
?? 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. 6 131 131

Andrew Adesman, MD Developmental & Behavioral Pediatrics

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