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52 Cards in this Set
- Front
- Back
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NORMAL DEVELOPMENT
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Focus on milestones
Development: Can occur in fits and starts Can include brief periods of regression Can be very discouraging for parents Essential to be able to diff nl from abnl or at least monitor closely & know when to refer |
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SCREENING - DEVELOPMENTAL DELAY
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AAP Recommends
Developmntl surveillance at every peds visit Dev Screening 9,18, 30 month visits or at 24 mos if 30 mos not part of practice. Parental Concern ID concern through surveillance Use of a specific screening tool No perfect tool Various considerations Tools Parents Evaluation of Developmental Status (PEDS) Ages & Stages (ASQ) Language Developmental Screener (LDS) |
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SCREENING - AUTISTIC SPECTRUM DISORDERS
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Use Autism Specific Screening tool
At the 18 and 24 month visits If ANY parental concerns arise, RED FLAGS present or sibling with ASD Tools: Modified Checklist for Autism in Toddlers (MCHAT) Other: Checklist for Autism in Toddlers (CHAT), Perva- sive Developmental Disorders Screening Test II-PCS (PDDST II PCS) |
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POSITIVE SCREEN:
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Parental Education
Audiology assessment Refer for general evaluation and service provision (DO NOT WAIT) Children < 3: Early Intervention for evaluation and im- plementation of Individualized Service Plan (IFSP) Children > 3: Public school system for complete Team evaluation, creation of an IEP and placement Refer for diagnostic evaluation: Developmental Med, Neuro, Psychology, Psychiatry, PT, OT, Speech for more in-depth assess prn Initial Diagnosis if comfortable |
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EARLY INTERVENTION
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Children 0-3 delayed or at risk for disabilities
Specifics vary by state Referrals can be made by: Parents, peds, or professionals Includes Direct services provision Speech and language therapy, OT, PT, Develop- mental Therapy Coordination of resources for children and families Individuals with Disabilities Education Act (IDEA) Early ID and referral center Development of an IFSP EI services provided in natural environments Interagency coordinating counsel |
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LANGUAGE DEVELOPMENT: INFLUENCES ON
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Genetic Predisposition
Family Hx of lang delays places child at much greater risk Children have differences in their style of acquirg language Gender: Girls progress faster than boys (by 1-2 months) Boys more likely to develop language disorders Exposure to Language: Positive language directed toward the child Bilingualism: Language development is NOT delayed, but lange mixing can occur. A bilingual child who is delayed needs eval. |
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SPEECH & LANGUAGE DELAY
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Pcp front line to ID
Approx 50 % of those delayed at 2 yo will be catch up by 3 yo Better receptive language and pretend play - better prog Otherwise diff to predict No agreed upon standard for Lang Delay 1.5 - 2 standard deviations below mean as measured by standardized instrument Delay of more than 25 % When to refer in children less than 2 yo Parental concern, postive screening test, provider concern |
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LANGUAGE DISORDER
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Deficit in the comprehension or production of language
that causes clinically sig impairment in functioning relative to developmental norms and cultural expec tations. Refer if a language disorder is suspected or diagnosed 5-8 % of preschool children experience speech-lang uage delays or disorders |
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DYSFLUENCY/STUTTERING
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Normal onset 2-5 years of age
Educate parents against interrupting, filling in, offering prompts to the child or providing pressure to speak 75-80 % will resolve spont in 1-2 years More likely to persist: Boys: (3 times greater) Family Hx Represents pathology after 5 yrs of age. |
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DYSFLUENCY/STUTTERING
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Criteria for referral:
Child 5 and older Severe stuttering Stuttering that does not respond to therapy in 6-8 wks Child or parental concern Other sx (repetitive body movements, etc) Speech: Articulation of all consonants is not complete until 6 years old |
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LANGUAGE DELAY: DD
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Hearing impairment
<20dB loss** Impoverished Env Child abuse, neglect, stress Neurologic Process Seizure disorder, neural inj Neurobiologic process Specific Language Impairment (SLI), Childhood Apraxia of Speech, ASD, Intellectual Impairment Antatomic Abnormality Cleft lip and palate, oral motor dysfunction |
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LANGUAGE DELAY - EVALUATION
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Audiologic eval
Screening tests Referral to a Speech and Language Pathologist Eval dependent on age and abilities Often more than one visit per assessment is needed Should include Parent interview, direct speech and lang testing, play based assessment in younger child, pragmatic (social) language Speech Questionnaires REEL-3*, Vineland Adaptive Behavior Scales, Rosetti** Receptive and Expressive Emergent Language 3 Rosetti Infant-Toddler Lang Scale (Birth-3) |
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AUTISTIC SPECTRUM DISORDERS ASD
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Group of neurobiologically based developmental disorders
characterized by the following 3 symptoms Delay or abnormality in social interaction, language use for social communication or symbolic or imaginative play with onset before age 3. |
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ASD
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Qualitative impairment social interactions
Most fundamental, poor nonverbal gestrures, poor peer relationships, decreased shared enjoyment, joint attn. |
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ASD
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Qualitative Impairment verbal and nonverbal communication
Language delay, poor conversation, atypical speech, and poor pretend play skills |
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ASD
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Restricted, repetitive and stereotyped patterns of behavior, interests and activities
Preoccupations, inflexibility, stereotyped behaviors |
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ASD - DSM IV
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AD
PDD, NOS Aspergers Syndrome Language intact. Cog skills more intact Childhood Disintegrative Disorder Retts Disorder Mostly females, nl dev followed by decline between 6 and 18 months. Hand wringing noted |
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ASD (proposed DSM V)
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ASD
Mild Mod Severe Profound |
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ASD
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Severity of sx vary by child
Presentation multifactorial Severity of sx Age Language skills Cognitive level Temperament Co-morbidities |
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ASD RED FLAGS
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No babbling by 12 months *
No gestures by 12 months (pointing, waving bye-bye)* No single words by 16 months* No two spontaneous words (not echolalic) by 24 months* Loss of language or social skills at ANY time* Lack of response to speech, echoing Poor eye contact Delayed or unusual play skills *Most Concerning |
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DDs of ASDs
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Global Dev Delay/Intellectual Dis
Social skills should be commensurate with intell functioning Hearing Loss Child may not respond to name and have Lang del but should have compensatory strategies Speech and Language Delay/ Language Disorder Speech and play will be impacted but child should be social and communicative Trauma Trauma or abuse hx |
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CAUSES OF AUTISM
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Highly heritable neurodevelopmental disorder
Complex Multifactoral etiology: Multigenetic-90% concordance rates in ID twins Env insults potentially via impact on fetal brain development In utero insults (maternal infections) immunologic factors Neurochemical factors, parental age (advanced paternal or maternal age) Majority of cases no specific etiology is found Small number of cases medical etiol identified: genetic disorder, metabolic disorder, infections, seizures, etc |
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ASD TREATMENT ***
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Early and Intensive targeted BEHAVIORAL interventions
result in the most substantial improvements No specific medical tx treat comorbidities - seizures, etc perform genetic testing RECOMMEND * CGH/chromosomal microarray, Fragile X (boys and girls) Other: PTEN, Rett's, Syndrome specific Behavioral Interventions ABA, Floortime, social groups etc. (videos found at www.autismspeaks.org) Medication for Symptom Management Attention, Hyperactivity, Impulsivity - Stimulant Anxiety/Obsessions - SSRIs Repetitive Behaviors - SSRIs, Atypical Antipsychotics Aggression, Self Injury - Atypical antipsychotics Depression - SSRIs Sleep Disorders - Melatonin CGH - Comparative genomic hybridization |
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ASD OUTCOMES
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Based on cognitive and social functioning
Progress but continued deficits 41% IQ < 70 (CDC 2009) Psychological problems, comorbidities Anxiety, depression Seizures Higher in children with ASD and Intellectual Dis |
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DEVELOPMENTAL DELAY
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Global Dev Del
Delay in 2 or more important domains of develop In Children who present with dev delay, early and intensive services result in the greatest outcomes When a child under 3 yo is IDd as delayed they are referred to Early Intervention |
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INTELLIGENT QUOTIENT IQ
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Psychometric measure which describes the structure and
organization of mental abilities IQ is thought to be predictive of acad functioning Predictive validity increases with age Performance on IQ test is impacted by Physical or social environment Rapport Distractibility/Off task behavior Motiviation/Interest Language fluency Cultural or sociodemographic factors Only valid for the population for which they were normed |
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IQ
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Multiple IQ measures: Wechsler Intelligence Scale for
Children (WISC-4), Stanford Binet Intelligence Scales-5 (SB), Differential Ability Scales (DAS-2) Mean 100 Divided into subtests, subtests clustered into domains or factors Subtests profile, or factor profile more important than FSIQ |
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ADAPTIVE BEHAVIOR
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Ability of an individual to engage in self care
Dressing, toileting, caring for the home, caring for self in the community, etc. Assessment Many questionnaires available for evaluating and monitoring adaptive functioning Vineland Adaptive Behavior Scales (VABS), Scales of Independent Behavior Revised (SIB-R) Adaptive Behavior Assessment System (ABAS) Ranges Similar to IQ |
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INTELLECTUAL DISABILITY (ID)
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Definition
Significant limitation in intellectual and adaptive function ing which impacts multiple areas of everyday function ing including social and practical skills Previously known as Mental Retardation IQ which is 2 standard deviations below the mean <70-75 Delays in communication, self care, social functioning, academic skills, work and leisure Onset prior to 18 years old Level of support in adulthood is influence by environment |
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ID - CLINICAL PRESENTATION
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Speech Delay
Language development is a better predictor of later cognitive ability than motor development Slow Learning Immaturity Delay in Adaptive Skills Toilet training, self care Seems "different" Age of presentation associated with severity Early presentation more severe |
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ID - CAUSES
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Account for 3/4 of contribution
chromosomal/genetic Cerebral Dysgenesis Perinatal Asphyxia Postnatal Deprivation Physical (poor nutrition) and environmental Exposures to toxins Medication, illicit drugs, ETOH, tobacco OTHER Idiopathic Metabolic Endocrine Trauma Infectious TORCH |
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ID EVALUATION
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Thorough Hx
Past medical hx Family Hx is important Detailed PE Dysmorphic features Neuro exam Abnormal skin findings Abnormal grwth Imaging MRI (50% abnl) if unusual head shape, microceph, focal neuro signs, seizures, and sometimes macroceph. Genetic Testing First Line Comparitive Genomic Hybridiization (CGH) 12-19% yield Second Line Fragile X Karyotype - only if suspected abnormality (T21, etc) Other studies as indicated by H & P (Angelman, Rett, VCFS, Williams) Metabolic Testing (low yield) Coarse features Organomegaly Neurodegenerative course Failed newborn screen |
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DEFICITS ASSOCIATED WITH ID
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Vis Impairment 1-15 %
Hearing Imp 7 - 10 % Seizures 10-20 % CP 10-20 % Specific Language Impairment |
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ID MANAGEMENT
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Treat underlying medical disorder or comorbidities
Refer for intervention School/EI Learning supports Behavior supports Family support Families often stressed during times of transition when delay is highlighted Community-Based support Children with disabilities are eligible for services thru state agencies Department of disabilities, behavioral health. |
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ID - OTHER CONSIDERATIONS
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Future planning
Start at 11, discuss each visit School until 22 Guardianship before 18 Residence Vocation |
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LEARNING DISABILITIES (LD)
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Definition: Neurobiological disorder that impacts brain
functioning and how an individual learns Impacts acquisition and use of listening, speaking, reading, writing, reasoning and math skills Prevalence 3-5 % in school age Includes diabilities in academic functioning Reading Disorder (D/O) or Dyslexia, D/O of Written Expression, Math D/O Sometimes defined as the difference in IQ vs achievement testing |
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LD
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Cognitive and academic skills can develop at different
rates for different children In addition to academics can impact overall functioning Social functioning, executive functioning Learning Disorders can present in children with high IQ Usually not outgrown but can be overcome |
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LD - EARLY INDICATORS
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Reading/Writing Disorder
Language delay (preschool) Difficulties with language comprehension or phonemic skills Failure to learn letters and numbers by kindergarden Failure to read simple words by the first greade Letter reversals can be normal for b and d through 7 years old Math Disorder Poor visual spatial skills More effort needed to complete work Children with higher cognitive functioning may present later May compensate using other skill sets in early childhood years |
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LD - PRESENTATIONS
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Academic failure
Inattention In content classes (eg social stud, science) can present as a failure secondary to reading prob Behavior problems Other indicators School refusal or disinterest Retention |
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LD
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Can be multifactorial
Comorbid conditions: Attn, social, env Other behavioral prob Individuals with LD are at inc risk for behav or mental health D/O Depression Anxiety SA Risky behav Delinquincy Dropout |
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LD EVAL
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Testing can be performed
By school Private Testing has limits Similar to cog testing Ensure that the test is evaluating the area of concern Rule out other neurodevelopmental dis Autism, ADHD, ID |
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LD EVAL - MEDICAL
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Hx of concerns
Hx from parents & teachers Which subjects, behavior in the classrm, school absncs Review current services Past MedHx Fam Hx LD runs in families (25-60% for Dyslexia) Vision and hearing assess is rec Utility of neuroimaging is limited Further med evaluation is necessary in certain circs Rapid or acute decline in abilities, trauma LD assoc with: CNS cond (SZ, myelomeningocele, NF, TS) Temporary in post-concussive syndrome |
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LD EVAL - PYSCHOEDUCATIONAL
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Perform or review psychoeducational testing
Cognitive testing Achievement (academic testing) Scores typically have a mean of 100, stand devs vary Access strengths and weaknesses Assess communicative ability Assess social ability LD is suspected or diagnosed when: Achievement<Cognitive especially with normal cgntn Uneven cognitive abilities VIQ>PIQ or PIQ>VIQ achievement testing eg WIAT, Woodcock Johnson |
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ACADEMIC FAILURE DD
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Neurobiological
LD in one subject ID Longstanding, more pervasive, deficits in adaptive functioning Attention disorder Worse later in the day or longer into testing, other signs of inattention Psychosocial/Environmental Drugs, truancy, illness, temperamental factors, emotional problems, family env, mental health Environmental Poor schooling |
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ACADEMIC FAILURE DD - MEDICAL
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Sensory impairment
Hearing, vision Other Medical Sz(partial or absence), Tourette's Chronic medical illness or their treatment GI,CF, immunodeficiencies, DM, arthritis Medications (antiepileptics, antihistamines) |
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LD - MANAGEMENT
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Special Education
Practice (remediation) Modification Decreased workload Targeted stratagies Accomodations Text on tape, oral testing, spell check, word processers placement in classroom, extra time |
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LD - MANAGEMENT
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Parent Ed
Child is not lazy Maintenance of self-esteem Extracurricular activities are essential Family support Treat underlying behaviors Special Educational Services (IEP, 504) University support services and accomodations are available for an adolescent beginning a college education |
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SPECIAL EDUCATION
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Criteria for educational placement might be
diff in diff states and cities Diff classrooms Self contained, resource room, tutoring, inclusion integrated Balance between placement where a child can receive app supports and interventions and exp to the reg class |
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RETENTION
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Not recommended after preschool
Short term bene wears off What didn't work the first time is not likely to work the second time Lowers self esteem High rates of Drop out (10-39%) High risk behavior Etoh, smoking, SA, driving with drinker, violence, SI, high risk sexual behavior Alternative to retention Evaluation of needs Appropriate service provision |
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PROGNOSIS FOR LD
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Prognosis:
Depends on time, level of intervention, self-esteem Child who have LD can reach high levels of achieve with app parent, school, and community support Children with LD at inc risk for Poor academic perf, not completing HS, exhibiting neg behaviors, poor self esteem Long-term outcomes Unemployment or employment at less than a living wage, restricted ed and work opportunities, poverty For dyslexia, often persistent reading problems into young adulthood |
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LD AND CAM
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Optometric training, Patterning, Sensory integration
Commonly used Controversial Evidence is lacking Parental guidance around CAM similar as in other scenarios Help parents to understand how to evaluate the benes risks and evidence Similar principle for CAM use in all areas of pediatrics |
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CONCLUSIONS
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Important to perform surveillance and screening for
Dev delays and disorders Refer early for eval and tx Help guide families toward app services Provide ongoing support |
