Suzanne Bailey January 4th, 2012

A new mother is concerned that her 6-week-old infant is always crying. The infant has gained weight appropriately and is happy and alert in your office. You reassure her that infants communicate by crying to have their needs met, but the mother would like more information about infant crying. Of the following, the information that you are MOST likely to provide is that A. changing to a hypoallergenic formula can decrease the crying B. constantly picking up a crying baby increases the frequency of crying C. crying often is greater in the morning hours D. crying tends to peak at 6 weeks of age E. healthy newborns may cry 6 hours a day

 1962

study by Brazelton

Crying: up to 3 hr/day at 6 wks, 1 hr/day by 12

wks 3-11pm
Normal

psychomotor development
Response to

everything

During a health supervision visit, a mother reports that her child is only understood about 75% of the time when she speaks to other adults. Of the following, this finding is MOST expected for a typically developing child who is A. B. C. D. E. 18 months old 24 months old 30 months old 36 months old 48 months old

 Rule

of Fourths

2 yo: 2/4 of time 3 yo: of time 4 yo: 4/4 of time

Can still have difficulties with pronunciation of certain sounds until 7yo
First 8: m, b, y, n, w, d, p, h Last 8: sh, th (as in thirty), s, z, th (as in the), zh sound

typically spelled as s (as in pleasure), l and r

 Refer Failure to: x turn to a voice by 6 months x babble by 9 months x orient to name at 13 months x point to request or comment by 18 months x follow a simple command without a gesture by 18 months x use 10 to 25 single words by 24 months x speak in two-word phrases by 26 months x speak in three-word sentences by 36 months

Unintelligible speech in a child older than 36 months Regression in language skills at any age
Walker and Johnson. Mental retardation overview and diagnosis.

A 2-year-old boy is mildly delayed in reaching his gross motor milestones, but his language development is appropriate for his age. He can speak in three- to four-word sentences. His parents are concerned that he will have academic difficulties due to his motor deficiencies. His neurologic examination yields nonfocal results. Of the following, the MOST appropriate response is that A. gross motor development is an accurate predictor for school success B. his delays are associated with learning disabilities C. his delays will result in poor handwriting skills D. his mildly delayed gross motor skills suggest a diagnosis of cerebral palsy E. language development is an accurate predictor of intellectual function

 Language

correlates with cognition critical to cognitive and social development

Results of a cognitive test given to a 7-year-old girl indicate functioning in the moderate intellectual disabilities range (intelligence quotient between 40 and 50). Her parents ask what the future holds for their child academically and vocationally. Of the following, the MOST likely expectation is that the child A. can achieve a third- to sixth-grade reading level by adolescence B. can be employed in a competitive unskilled or semiskilled job C. can work in a sheltered workshop that provides close supervision D. will only be able to learn to read simple signs such as stop and exit E. will require help with activities of daily living from caregivers when an adult

 AAIDD

defines ID:

Disability characterized by significant limitation

both in intellectual function and in adaptive behavior as expressed in conceptual, social and practical adaptive skill. Originates before 18 yo

Image: http://www.google.com/imgres?q=fetal+alcohol+syndrome&hl=en&gbv=2&biw=1280&bih=551&tbm=isch&tbnid=u4I0PcSaKKhijM:&imgrefurl=http://en.wikipedia.org/wiki/Fetal_alcohol_syndrome&docid=HS8nyAPpdKNMrM&imgurl =http://upload.wikimedia.org/wikipedia/commons/thumb/7/72/Photo_of_baby_with_FAS.jpg/220pxPhoto_of_baby_with_FAS.jpg&w=220&h=265&ei=KqMDT5fzFOqFiAKb8fSwDg&zoom=1&iact=rc&dur=216&sig=101526035186133483121&page=1&tbnh=157&tbnw=130&start=0&ndsp=22&ved=1t:429,r:0,s:0&tx=30&ty=42

Levels of MR according to the DSM-IV-TR versus the AAMR.

Walker W O , Johnson C P Pediatrics in Review 2006;27:204-212

2006 by American Academy of Pediatrics

 Mild

ID:

20-30/1,000. Kindergarten - early elementary

school. IQ 50-55 to 70 No comorbidities Self sufficient in ADLs/communication Learn at -2/3 normal velocity 3rd-6th grade reading level by late adolescence employed in competitive unskilled, semiskilled, or in some cases, skilled jobs

 Moderate

ID:

5/1,000. Preschool IQ 35-40 to 50-55 Can do ADLs Express basic needs Learn at 1/3-1/2 velocity Achieve 1st-3rd grade reading level Supportive employment x More often in sheltered workshop, constant supervision

 Severe

ID:

3/1,000. <3 yrs IQ 20-25 to 35-40 Limited language skills, need support with ADLs Might learn simple signs Will need help as adults Often have identified genetic, medical and

neurologic causes

Profound ID:
1-2/1,000. < age 2 yr IQ <20-25 Assistance for ADLs Highest rates of identified genetic, medical and

neurologic causes

Instruments Frequently Used to Measure Cognition

Bayley Scales of Infant Development III Provides a measure of behavior and development in very young children (1 to 42 months) Provides standard scores and age equivalents for individual developmental domains Is technically not a test of intelligence and does not predict future intelligence well

Wechsler Preschool and Primary Scale of Intelligence III Provides IQ scores for children 2.5 to 7.25 years of age

Stanford-Binet Intelligence Scale (5th Ed) Provides a composite IQ score for individuals 2 to 85 years of age Kaufman Assessment Battery for Children II Provides a Mental Processing Composite IQ for children 3 to 19 years of age

Wechsler Intelligence Scale for Children (WISC-IV) Provides a Verbal, Performance, and Full-Scale IQ score for children 6 to 12 years of age

Walker and Johnson. Mental retardation overview and diagnosis.

The parents of an 18-month-old boy contact you after he has two episodes of holding his breath and fainting. Most recently, he was upset when he had to leave the playground and began to scream and cry. He turned blue while holding his breath prior to losing consciousness. He had a similar event 1 month ago when he cut his finger and saw that it was bleeding. The anxious parents ask what they should do. Of the following, the MOST appropriate intervention is to A. obtain a complete blood count B. pick up the child quickly and comfort him when he starts to cry C. reassure the parents that this is a benign event D. refer the child for behavioral therapy E. refer the child for electroencephalography

 Breath

holding spell

Involuntary stopping of breathing due to painful or

frustrating event 5% of kids Usually 6-18 mo Can lead to loss of consciousness or a seizure
Scary

but not life threatening

EEG will show slowing but no epileptiform activity

Image: http://www.google.com/imgres?q=breath+holding+spells&hl=en&gbv=2&biw=1280&bih=551&tbm=isch&tbnid=pKuAj05LaFcDOM:&imgrefurl=http://www.babybytes.nl/encyclopedie/B/Breath-Holding-Spells&docid=JcUsMrUsA7uYM&imgurl=http://www.babybytes.nl/images200/17662504.jpg&w=200&h=200&ei=w6UDT9GvDMakiQLPy9jEDQ&zoom=1&iact=rc&dur=14&sig=101526035186133483121&page=1&tbnh=108&tbnw=108&start=0&ndsp=22&ved=1t:429,r:7,s:0 &tx=29&ty=49

 Two main types: Cyanotic spell upset, cry, breath out, apneic,

cyanosis, loss of consciousness Pallid spells pain or startled, stops breathing, becomes pale, hypotonic, tonic seizure
Dont

reinforce the behavior No behavioral therapy, just modification CBC:

Only in severe cases Iron def and transient erythroblastopenia

Pie chart depicting percentages of patients with cyanotic, pallid, and both type BHS.

DiMario F J Pediatrics 2001;107:265-269

2001 by American Academy of Pediatrics

 Dimario, F. Prospective

study of children with cyanotic and pallid breath-holding spells.

Prospective cohort study structured interview initial consultation 1-year intervals type of BHS, frequency, assocd phenomenon,

sequelae, family history, age at termination

95 children (48 boys, 47 girls) Followed for 9-years no significant differences between

genders.

 Median onset 6-12 months old 15% <6 months. Median freq was weekly 30% experiencing 1 or more spells per day. Median age peak freq12-18 months (6

mo -

4 yrs)
Oldest age latest spell: 7 years Hypoxic convulsions in 15%. + family history 34% of all families equal between paternal and maternal sides.
Dimario, F. Prospective study of children with cyanotic and pallid breath-holding spells.

A grandmother brings in her 9-year-old grandson because she is concerned that he is behaving aggressively toward his siblings and cousins and recently destroyed some property. He is exhibiting aggressive behavior at school, with the teacher reporting that he is very hyperactive and distractible. In addition, his grades have fallen over the past year. The child has been placed in the grandmother's guardianship voluntarily by his mother while she seeks employment and divorce after years of domestic violence. The grandmother states that she has tried a variety of discipline techniques, including spankings, which seem to make things worse. She asks your opinion about this boy's prognosis and your recommendations for intervention. Of the following, the MOST appropriate next step in the management of this child's behavioral problems is A. administration of an atypical antipsychotic medication B. emergent evaluation for possible child sexual abuse at a specialty center C. prescription for stimulant medication D. referral for counseling that includes anger management strategies E. transfer of the child to a new school

 Notice

the risk factors: DV, corporal punishment, divorce, maternal unemployment

Suggested therapies: School-based counseling Peer group therapies After school activities Home and family based counseling Opportunities

for conflict resolution

You are the preceptor in a pediatric clinic and a resident has just finished seeing an adolescent male for a routine physical examination. This is the young man's first visit in the clinic, and as part of the routine screening, the resident takes a comprehensive psychosocial history. The patient reveals that he is more attracted to males than females. You guide the resident on the range of issues she should address. Of the following, the MOST immediate attention is required for A. contraception B. depression C. harassment D. social isolation E. substance use

 2/3

of us never ask about sexual orientation risk of self destructive behavior

Higher

marginalized and discriminated against Homelessness, prostitution, sexual abuse, substance

use and misuse

Suicide

is the leading cause of death among GLBT youth birth control with everyone

Discuss

2011 Prep Questions. Pedialink. Dimario, F. Prospective study of children with cyanotic and pallid breath-holding spells. Pediatrics Vol. 107 No. 2 February 1, 2001 pp. 265 -269 Walker, W and Johnson, C. Mental retardation management and prognosis. Pediatrics in Review Vol. 27 No. 7 July 1, 2006 pp. 249 -256 Walker, W and Johnson, C. Mental retardation overview and diagnosis. Pediatrics in Review Vol. 27 No. 6 June 1, 2006 pp. 204 -212