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
– Colic
– Nail biting
– Body rocking
– Bruxism
– Breath-holding
– Enuresis
– Night terrors vs. nightmares
(Birth – 12 years)
ABP Content Specs
Behavioral & Mental Health Issues (4%)
• Externalizing Disorders
– Aggressive behaviors, ODD, CD,
– Anti-social behavior/delinquency
• Internalizing Disorders
–
–
–
–
–
Phobias, Anxiety Disorders,
OCD
PTSD
Mood and Affect Disorders
Psychosomatic disorders
ABP Content Specs
Behavioral & Mental Health Issues (4%)
• 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
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
Developmental Milestones
4 Months
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
Social
- Laughs out loud and squeals
- Imitates social interaction
Developmental Milestones
6 Months
Category
Motor
Description
- 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
- Babbles consonant sounds
- Imitates speech
Language
Social
Developmental Milestones
9 Months
Category
Motor
Cognitive/Behavioral
Language
Social
Description
- Bangs two blocks together
- Sits without support
- Turns when name is called
- Plays peek-a-boo
- Mama and Dada (non-specific)
- Stranger anxiety
- Recognizes common objects
and people
Developmental Milestones
12 Months
Category
Description
Motor
- Takes a few steps
- Pincer grasp
- Drinks from a cup held by
another person
- Pulls to stand and cruises
- Assists with dressing
Cognitive/Behavioral
Language
Social
- Speaks 1 additional word
besides Mama and Dada
- Mama and Dada specific
- Follows a single step
command with gesture
Developmental Milestones
15 Months
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
Social
- Speaks 3-6 additional words besides Mama
and Dada
- Points to one body part
- Follows single step command without
gesture
Developmental Milestones
18 Months
Category
Motor
Description
- 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.
- 10-20 word vocabulary
Language
Social
Developmental Milestones
16 - 19 Months
Category
Motor
Cognitive/Behavioral
Language
Social
Description
- Builds a tower of 4 blocks
- Releases a raisin into a bottle
- Spontaneous scribbling (18 mo)
Developmental Milestones
24 Months
Category
Motor
Description
- 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
Developmental Milestones
36 Months
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
- Pretend plays
Social
Rule of 4’s
•
•
•
•
•
Count to 4
Recite a 4-word sentence
Identify 4 primary colors
Draw a 4-part person
Build a gate out of blocks (picture a #4 as a
gate)
• A stranger understands 4/4 (100%) of what
they’re saying
Developmental Milestones
5 Year Old
Category
Motor
Description
- 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
Social
- Defines words
Developmental Milestones
6 Year Old
Category
Description
Motor
- Ties shoelaces
- Rides a bicycle
Cognitive/Behavioral
- Writes name
- Knows right from left
Language
Social
- Counts ten objects
Block Stacking
Age
Task
13-15 months
2 block tower
18 months
4 block tower
24 months
6 block tower
30 months
8 block tower
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
(use one object to represent another object and engage in one or two
simple actions of pretend play)
15 - 18 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 18-24 months of age
• For speech delay, always check hearing first
Suggestion: Use Bright Futures tables provided on
course website
Drawing Capabilities
Age
3
4
5
6
7
What They Can Draw
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
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.
Hearing Impairment
• 50% Non-genetic:
– TORCH infection
– Ear/craniofacial anomalies
– Birth Weight < 1500 gm
– Low Apgar Scores (0-3 at 5 min, 0-6 at 10 min)
– Respiratory Distress/ Prolonged mechanical
ventilation, hyperbilirubinemia requiring exchg
transfusion
– Bacterial meningitis/ Ototoxic meds
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
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)
Hearing Loss - Audiogram
Mild
25-39
Moderate 40-68
Severe
70-94
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
Communication Disorders
• Expressive Disorders
– Disorders of morphology (form), semantics (word
meaning), syntax (grammar), pragmatics (social
use of language)
• Mixed Expressive/Receptive Disorders:
– Above plus comprehension deficits
• Phonological Disorders
– Disorders of articulation (motor movements),
dyspraxias (motor planning)
– Disorders of fluency (flow,rhythm)
– Disorders of voice/resonance
Childhood-Onset Fluency Disorder
(“Stuttering”, Stammering”)
• Disturbance in fluency and time patterning of
speech
• Begins age 2 ½ to 4, peak age 5
• Normal up to age 3 or 4
• Male:female ratio is 3-4: 1
• 75% of preschoolers will stop
• Often disappears once vocabulary rapidly
increases
Articulation Intelligibility
Rule of Quarters
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)
IQ Testing
• The predictive validity of IQ testing increases
with age
Red Flags for ID
2 to 9 Months
Age
2 months
Deficiency Requiring Intervention
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
18 months
Deficiency Requiring Intervention
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%)
– genetic, CNS malformations, fetal compromise,
infection, teratogens
• Perinatal (<10%)
– HIE, prematurity
• Postnatal
– Trauma, asphyxia, infection, toxins, vascular
malformations, tumors, degenerative disease
• Environmental (additive)
– Deprivation/malnutrition
• More severe forms, more likely to find definitive
etiology
Fragile X Syndrome
• 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
Autism Spectrum Disorders
DSM-V
• Deficits in social communication
and social interaction
• Restricted repetitive behaviors,
interests and activities
Autistic Spectrum Disorders: Key Points
• Prevalence (CDC 2012): ~ 1/88
• Male: Female 4:1
• Seen in association with:
– Seizure disorders, congenital infection, metabolic
abnl (PKU)
– Neurocutaneous disorders (TS, NF)
– Genetic Disorders (Fra X, Angelman’s, Smith-Lemli Opitz )
– No proven ass’n with vaccines (MMR, thimerosal)
• Genetic Basis - Concordance rates:
– MZ twins (60-80%)
– DZ twins, sibs (3-7%)
Rett Syndrome
• 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 ageappropriate self-help skills
–
Motor coordination difficulties
This disorder is not included in DSM V
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
Learning Disorders – Difficulties in:
• Receptive language, expressive language
• Basic reading skills, reading comprehension
• Written expression
• Mathematics calculation / reasoning
DSM 5 (May, 2013) : “Specific Learning Disorder”
Learning Disabilities (LD)
• 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
o
o
o
o
Part 3:
Behavioral & Mental Health Issues
ABP Content Specs
Behavioral & Mental Health Issues (4%)
• Common Behavioral Issues
– Colic
– Nail biting
– Body rocking
– Bruxism
– Breath-holding
– Enuresis
– Night terrors vs. nightmares
(Birth – 12 years)
ABP Content Specs
Behavioral & Mental Health Issues (4%)
• Externalizing Disorders
– Aggressive behaviors, ODD, CD,
– Anti-social behavior/delinquency
• Internalizing Disorders
–
–
–
–
–
Phobias, Anxiety Disorders,
OCD
PTSD
Mood and Affect Disorders
Psychosomatic disorders
ABP Content Specs
Behavioral & Mental Health Issues (4%)
• Suicidal behavior, psychotic behavior,
thought disorders
• ADHD
Colic
• Diagnosed based on history
– Physical exam rarely shows anything
– No labs that confirm the diagnosis
• Stops after 3-4 months of age
• No “proven” methods to treat colic
• Typical presentation is crying episodes in an
otherwise healthy infant
– Crying starts suddenly
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
Attention-Deficit/Hyperactivity
Disorder
• Symptoms of Inattention, Impulsivity,
Hyperactivity
• Some symptoms present before age 7 years
– DSM 5: Several inattentive or hyperactiveimpulsive 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.
ADHD Subtypes
• Combined Type (80%*)
• Predominantly Inattentive Type (10-15%*)
• Predominantly Hyperactive-Impulsive Type
(5%*)
*in school-age children
ADHD: Key Points
• Disorder of dopamine and norepinephrine
systems in frontostriatal circuitry
• 3-7% of school age children
• Male: female (6:1-3:1)
• Genetic Predisposition: 5-6 fold increase in
first degree relatives
• Environmental Factors: e.g. head trauma,
lead exposure, VLBW, prenatal teratogens
• Symptoms Persist into Adulthood in 60-80%
ADHD - Key points (cont’d)
• Co-morbid Conditions:
–
–
–
–
–
–
–
Learning Disorders
Anxiety Disorders
Oppositional Defiant Disorder
Conduct Disorder
Tic Disorders
Mood Disorders
Substance abuse disorders (adolescents)
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
“Internalizing Disorders”
• Mood Disorders:
– e.g. Major Depressive Disorder, Dysthymic Disorder, Bipolar
Disorder
– DSM 5: “Disruptive Mood Dysregulation Disorder”
• Anxiety Disorders:
– e.g. Generalized Anxiety Disorder, Separation Anxiety
Disorder, Panic Disorder, Social Anxiety Disorder, School
Phobia
• Obsessive-Compulsive Disorder
– DSM 5: Included in “O-C and Related Disorders”, not “Anxiety
Disorders”
•
Post-traumatic Stress Disorder
– DSM 5: Included in “Trauma- and Stressor-related Disorders”
Part 4:
Sample Questions
?? 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:
8
m
on
t
hs
0%
hs
on
t
m
on
t
m
4
on
t
m
0%
hs
0%
hs
0%
6
2 months
4 months
6 months
8 months
2
1.
2.
3.
4.
6
??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:
24
m
on
th
ol
d
0%
ol
d
on
th
m
on
th
m
15
on
th
m
0%
ol
d
0%
ol
d
0%
18
12 month old
15 month old
18 month old
24 month old
12
1.
2.
3.
4.
6
?? 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:
A. 42 months
B. 48 months
C. 60 months
D. 72 months
0%
6
m
on
th
s
72
m
on
th
s
0%
60
m
on
th
s
0%
48
42
m
on
th
s
0%
?? A 3 year old boy should have
mastered each of the following except:
0%
is
in
gh
St
at
ef
oo
t
0%
on
on
ng
w
na
m
e
er
in
an
d
g6
ge
.. .
cu
b
tru
ck
To
re
d
ga
in
Na
m
0%
es
0%
Ho
pp
i
A. Naming a red truck
B. Towering 6 cubes
C. Stating his name
and gender
D. Hopping on one
foot
?? A 3 year old boy should have
mastered each of the following except:
A. Naming a red truck
(50%ile ~30 mos)
B. Towering 6 cubes
(50%ile ~ 20 mos)
C. Stating his name and
gender (50%ile ~ 3
yrs)
D. Hopping on one foot
(50%ile ~ 4 yrs)
??On a pre-kindergarten screening a
school official is most concerned about
a 5 year old boy who cannot:
A. Draw a Person
with 6 parts
B. Copy a Square
C. Name 4 colors
D. Tandem Walk
alk
W
de
m
co
lo
rs
e4
Na
m
Co
py
aS
qu
ar
ts
6p
wi
th
n
0%
Dr
aw
aP
er
so
0%
Ta
n
0%
ar
e
0%
6
??On a pre-kindergarten screening a
school official is most concerned about
a 5 year old boy who cannot:
A. Draw a Person with
6 parts (50%ile ~4
½ yrs)
B. Copy a Square
(50%ile ~ 5 yrs)
C. Name 4 colors
(50%ile ~ 3 ¾ yrs)
D. Tandem Walk
(50%ile ~ 4 ½ yrs)
6
??You would be most concerned
about:
p
ju
m
..
ot
ca
nn
ho
ca
n
w
ho
ye
ar
o
ld
w
tw
o
ol
d
ry
ea
r
fo
u
A
0%
op
no
th
to
o
’t
s
ca
n
ho
w
ol
d
th
m
on
15
A
0%
p
ta
n
es
n’
ts
do
ho
w
ol
d
ea
r
ey
on
A
0%
...
d.
..
0%
A
A. A one year old who
doesn’t stand alone
B. A 15 month old who
can’t stoop and
recover
C. A four year old who
cannot hop on each
foot
D. A two year old who
cannot jump
6
??You would be most concerned
about:
A. A one year old who
doesn’t stand alone
(50-
90% of 1 year olds)
B. A 15 month old who
can’t stoop and recover
(>90% of 15 month olds)
C. A four year old who
cannot hop on each foot
(50-90% of 4 yr olds)
D. A two year old who
cannot jump (50-90% of 2 yr
olds)
6
??You would be less concerned about:
le
es
n’
tb
es
n
do
do
ho
ho
dw
w
ol
ol
d
th
ea
r
9m
on
ey
on
A
0%
ab
b
oi
w
us
es
2
ho
w
ol
d
th
m
on
18
An
’t
p
..
ns
we
r
ta
no
ca
n
ho
w
ol
d
ea
r
3y
A
0%
nt
0%
or
ds
0%
A
A. A 3 year old who
cannot answer a
“why”question
B. An 18 month old who
uses 2 words
C. A one year old who
doesn’t point
D. A 9 month old who
doesn’t babble
6
??You would be less concerned about:
A. A 3 year old who cannot
answer a “why”question
(50% ile ~4-5 yrs)
B. An 18 month old who
uses 2 words (over 90%
of 15 mo olds)
C. A one year old who
doesn’t point (over 90% of
1 yr olds)
D. A 9 month old who
doesn’t babble (over 90%
of 9 mo olds)
6
??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:
...
sid
er
an
ba
c
M
ki
n
RI
to
tw
o
r/
o
m
ca
lc
og
i
eA
Se
0%
i. .
.
0%
.. .
0%
nn
ie
ta
qu
es
Re
Se
nd
An
ni
e
to
ne
ur
ol
re
ha
b
fo
r. .
.
0%
Co
n
A. Send Annie to rehab for
physical therapy
B. Request a neurological
consultation
C. See Annie back in two
months for follow up
D. Consider an MRI to r/o
intraventricular
hemorrhage
6
?? 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:
r ig
..
n
ei
to
n
d
se
re
a
In
c
0%
th
e
l4
al
n
ei
to
n
se
d
re
a
In
c
0%
ex
...
he
to
..
...
ch
or
ic,
ne
t
Dy
sk
i
0%
eo
at
ne
to
se
d
ea
in
cr
lly
0%
in
ex
...
l4
al
n
ei
to
n
E.
0%
Eq
ua
D.
se
d
C.
re
a
B.
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
In
c
A.
??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 tshirt. In your office, she points to your stethoscope,
and when you hand it to her she smiles at you and
places it on her father’s chest.
You most strongly suspect:
0%
0%
0%
0%
en
ta
Au
lR
t is
et
t ic
ar
Sp
da
ec
t io
M
tru
n
ixe
m
d
Di
re
so
ce
rd
pt
er
iv
e/
ex
pr
He
es
a
si.
r in
En
.
vi
g
ro
Im
nm
pa
ir m
en
ta
en
lu
t
nd
er
-st
i..
.
0%
M
A. Mental Retardation
B. Autistic Spectrum
Disorder
C. Mixed
receptive/expressive
language disorder
D. Hearing Impairment
E. Environmental understimulation
6
??Your first referral is to:
0%
0%
0%
eP
an
d
La
ng
ua
g
Ps
yc
h
ol
o
a.
..
gy
gy
ol
o
Au
di
So
c ia
ls
er
vi
ce
0%
Sp
ee
ch
A. Social service
B. Audiology
C. Psychology
D. Speech and
Language
Pathology
6
??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:
ty
bi
li
lD
is a
er
ct
ua
m
0%
ve
r
e
In
te
lle
tru
Sp
ec
0%
Di
so
rd
als
y
0%
al
p
bi
li.
Di
sa
ua
l
ct
Ce
re
br
Au
t is
t ic
bi
li
Di
sa
ng
In
te
lle
ar
ni
M
i ld
Le
0%
.
ty
0%
Se
A. Learning Disability
B. Mild Intellectual
Disability (Mental
Retardation)
C. Cerebral palsy
D. Autistic Spectrum
Disorder
E. Severe Intellectual
Disability
6
??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:
A. 18m
B. 24m
C. 30m
D. 36m
E. 42m
0%
42
m
0%
36
m
0%
30
m
0%
24
m
18
m
0%
??A stranger should be able to understand
half of a child’s speech at age:
Remember the rule of fours!
A. 12 months
B. 18 months
C. 24 months
D. 36 months
m
on
th
s
0%
36
m
on
th
s
0%
24
m
on
th
s
0%
18
12
m
on
th
s
0%
6
L)
Ed
he
V
vio
rC
Sc
ale
ck
lis
t(
CB
C
0%
Be
ha
ild
Ch
oo
0%
iti
o
II
E..
.
lL
an
gu
ag
e
Ra
tin
es
ch
Pr
0%
gS
ca
le
...
ar
y
Pr
im
d
Au
d
ild
ho
o
Ch
sle
r
ec
h
0%
tis
m
an
Pr
Co
m
pr
es
ch
oo
l
eh
e
ns
ive
Be
h
av
...
0%
W
E.
III
D.
er
s
C.
nn
B.
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)
Co
A.
n
??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:
6
??All of the following observations are
considered risk factors for Autistic
Spectrum Disorders except:
ito
hr
as
es
on
m
ho
i
ng
p
az
e
of
g
ck
La
0%
at
18
m
. ..
.. .
ga
rin
ne
to
ga
lin
ab
b
of
b
ck
La
0%
ye
m
...
t1
2
ga
tin
oi
n
of
p
ck
La
0%
ar
0%
Ec
A. Lack of pointing at 12
months
B. Lack of babbling at one
year
C. Lack of gaze monitoring
at 10 months
D. Echoing phrases at 18
months
6
?? 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 = 81, Numerical
operations: 98, Math reasoning = 79
The child’s likely diagnosis is:
...
...
gD
iso
ra
t/
yP
ro
ce
s
ef
ici
to
r
nd
nt
io
At
te
0%
sin
Di
sa
ng
ar
ni
Le
0%
Hy
pe
bi
li
...
lF
ct
ua
In
te
lle
r li
ne
rd
e
Bo
0%
ty
0%
Au
di
A. Borderline Intellectual
Functioning
B. Learning Disability
C. Attentiondeficit/Hyperactivity
Disorder
D. Auditory Processing
Disorder
6
?? 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:
Ps
yc
hi
a
...
try
0%
Ch
ild
ca
la
to
og
i
de
rp
Or
0%
nd
l..
.
et
hy
sy
c
tri
a
a
te
tia
In
i
ho
l
et
io
pl
om
tc
qu
es
Re
0%
lo
fm
n
of
p.
..
0%
Re
fe
r
A. Request completion of parent
and teacher Vanderbilt
Questionnaires
B. Initiate a trial of methylphenidate
C. Order psychological and
psychoeducational testing
D. Refer to Child Psychiatry
6
?? 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:
wi
..
sis
te
nt
to
.
el
cr
u
is
c
ob
on
e
to
av
io
r
eh
y’
sb
nn
Jo
h
yi
nn
Jo
h
0%
..
ee
...
0%
lik
el
yt
is
li k
el
y
sa
ls o
av
io
r
eh
y’
sb
nn
Jo
h
0%
m
sis
...
on
os
tc
is
m
av
io
r
eh
D.
0%
y’
sb
C.
nn
B.
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.
Jo
h
A.
6
Descargar

ewtwte