pediatric developmental and behavioral disorders eo 018.13

PEDIATRIC DEVELOPMENTALAND

BEHAVIORAL DISORDERSEO 018.13

REFERENCES

• C290- Nelson’s Essentials of Pediatrics• C277 - Toronto Notes• C 306 Toronto sick Kids Manual• Class handout• C20 Merck Manual- current edition• C291 Primary Care for the PA

OUTLINE

• Failure To Thrive (FTT)• Fetal Alcohol Syndrome ( FAS)• Attention Deficit hyperactivity Disorder(ADHD)• Enuresis• Encopresis• Autism ( briefly)• Learning Disorders ( briefly)• Dyslexia

FAILURE TO THRIVE (FTT)

• Definition: - Weight <3rd percentile, or falls below two major percentile

curves, or <80% of expected weight for height and age

- 50% organic, 50% non-organic

- Inadequate caloric intake most important factor in poor weight gain


• Normal energy requirements

- Wt: 0-10 kg: 100 cal/kg/day- Wt: 10-20 kg: 1,000 cal + 50 cal/kg/day for each kg

>10- Wt: 20 kg+: 1,500 cal + 20 cal/dg/day for each kg >20

- May have other nutritional deficiencies, e.g. protein, iron, vitamin D as well

NON-ORGANIC (FTT)

• Presents by 6-12 months• Often due to malnutrition• These children are often picky, poor eaters with

poor emotional support at home• Psychomotor, language and personal/social

development delays possible

CAUSES NON- ORGANIC (FTT)

• Inadequate intake• Inappropriate feeding practices• Emotional deprivation• Poor parent-child interaction• Dysfunctional home situation • Parental psychosocial stress• Child abuse and/or neglect must be considered

CAUSES OF ORGANIC FTT

• Insufficient breast milk production• CNS, neuromuscular, mechanical problems with

swallowing, sucking• Anorexia (associated with chronic disease)• Inadequate absorption- malabsorption: - Celiac disease- Cystic fibrosis (CF)- Pancreatic insufficiency


• Inappropriate utilization of nutrients

- Renal loss: e.g. tubular disorders- Losses from the GI tract: chronic diarrhea, vomiting- Inborn errors of metabolism- Endocrine disorders: type 1 diabetes, diabetes insipidus

(DI), hypopituitarism


• Increased energy requirements

- Pulmonary disease: CF- Cardiac disease- Endocrine: hyperthyroidism, DI, hypopituitarism- Malignancies- Chronic infections- Inflammatory: systemic lupus erythematosus (SLE)


• Decreased growth potential

- Specific congenital syndromes- Chromosomal abnormalities- Intrauterine insults e.g fetal alcohol syndrome (FAS)

FAILURE TO THRIVE PATTERNS

• Growth Parameters

- Decreased Wt.Normal Ht. Normal HC

• Possible problem - Caloric insufficiency - Decreased intake- Hypermetabolic state- Increased losses


• Growth Parameters- Decreased Wt. Decreased Ht. Normal HC

• Possible problem - Structural dystrophies- Endocrine disorder- Constitutional growth delay- Genetic short stature


• Growth Parameters- Decreased Wt. Decreased Ht. Dec. HC

• Possible problem- Intrauterine insult- Genetic abnormality


• History- Duration of problem- Detailed dietary and feeding history, appetite, behaviour

during feeds- Pregnancy, birth and postpartum history; - Developmental and medical history, including medications;- Social and family history (parental height and weight)- Assess child's temperament, child-parent interaction,

feeding behaviour and parental psychosocial stressors


• Physical Examination

- Height (Ht), weight (Wt), head circumference (HC), arm span, upper/ lower body segment ratio

- Assessment of nutritional status- Dysmorphic features- Evidence of chronic disease- Observation of a feeding session and parent-child interaction- Any signs of abuse or neglect


• Laboratory investigations: as indicated by clinical presentation

- CBC, blood smear, electrolytes, urea, ESR, T4, TSH, urinalysis

- Bone age x-ray- Genetic karyotype in all short girls and in short boys where

appropriate- Any other tests indicated from history and physical exam:

e.g. renal or liver function tests, venous blood gases, ferritin, immunoglobulins, sweat chloride, fecal fat


• Treatment: Non-organic FTT- Most are managed as outpatients with multidisciplinary

approach- Short hospitalization to monitor food/feeding to see if

child gains weight- Primary care physician, dietitian, psychologist, social

work, child protection services• Treatment: Non-organic FTT- Cause specific

FETAL ALCOHOL SYNDROME (FAS):

• Medical diagnosis referring to a set of alcohol-related disabilities associated with maternal use of alcohol during pregnancy

• Recognized in Canada as one of the leading causes of preventable birth defects and developmental delay in children

FETAL ALCOHOL EFFECTS (FAE):

• Birth defects or developmental abnormalities for which alcohol is being considered one of the possible causes

• Used to describe children with prenatal exposure to alcohol, but only some of the characteristics of FAS, including reduced or delayed growth, single birth defects, or developmental learning and behavioral disorders that may not be noticed until months or years after the child's birth


• High-risk Populations

- Women who drink and have the following characteristics:- Low socioeconomic status- Poverty- Lack of education- Smoker- Use of other illicit drugs- Poor health


• Diagnostic Criteria For FAS: - History of maternal alcohol consumption during pregnancy- Prenatal or postnatal growth retardation- Involvement of CNS, such as: - neurologic abnormalities

- developmental delay- behavioral dysfunction- learning disabilities or other intellectual impairments, - skull and brain malformations

FETAL ALCOHOL SYNDROME (FAS

• Diagnostic Criteria For FAS:

• Characteristic facial features:- Short eye slits (palpebral fissures)- Thin upper lip- Flattened cheek bones - Indistinct groove between the upper lip and the nose


• Prevention Strategies

- Screen all pregnant women about alcohol use- Advise stopping all use in pregnancy- Healthcare professionals working with members and

leaders of communities must be consistent in advising women and their partners that the prudent choice is not to drink alcohol during pregnancy


• Tertiary Prevention

- Strategies should include early diagnosis of the condition and programs designed specifically for children with FAS or FAE and their parents or caregivers

- Refer women who are at high risk to appropriate treatment resources for alcohol abuse

- Identify and treat women and their partners who already have one FAS/FAE child and who plan to have more children

ATTENTION DEFICIT HYPERACTIVE DISORDER(ADHD)• A cluster of behavioral symptoms:- Poor attention span- Impulsiveness- Hyperactivity

• Not all children with the disorder will exhibit all three behaviors

CAUSES ATTENTION DEFICIT HYPERACTIVE DISORDER(ADHD)• Genetic Syndromes- Fragile X syndrome- Phenylketonuria (PKU)- Gilles de la Tourette syndrome• Intrauterine or prenatal /postnatal damage- Fetal alcohol exposure- Intrauterine anoxia- Prematurity- Meningitis- Significant head injuries

ATTENTION DEFICIT HYPERACTIVE DISORDER(ADHD)• History

- Prenatal: pregnancy, exposure to drugs or alcohol- Perinatal: delivery, asphyxia, illnesses- Family history: ADHD, related behavioral disorders- Past medical history: illnesses such as meningitis, injuries,

hospital admissions- History of school progress and behavior (talk with teacher)- Symptoms usually present before child enters school

ATTENTION DEFICIT HYPERACTIVE DISORDER(ADHD)• Physical Examination

- Complete general examination: look for dysmorphic features of genetic conditions, FAS

- Examine ears and check hearing - Examine eyes and check vision - "Soft neurologic signs" often present (e.g., increased

reflexes, poor coordination, poor balance)- Educational evaluation done through the school system

ATTENTION DEFICIT HYPERACTIVE DISORDER(ADHD)• Appropriate management includes the

involvement of a multidisciplinary team, of which educational specialists are the mainstay

• Many specific methods can be used to overcome the child's weaknesses and take advantage of his or her strengths

• The medical role involves advocacy and sometimes the administration of medication

ATTENTION DEFICIT HYPERACTIVE DISORDER(ADHD)• Counsel parents or caregiver about behavioral

strategies:

- Decrease environmental stimuli- Focus on the child's positive traits to increase self-esteem- Give simple directions- Make eye contact with the child- Use "time out" as a prime disciplinary tactic

ATTENTION DEFICIT HYPERACTIVE DISORDER(ADHD)• Pharmacologic Interventions- Drug of choice:

• Methylphenidate (Ritalin) daily in two doses, morning and noon

• Dextroamphetamine another approved drug for use

ENCOPRESIS

• Fecal incontinence in a child at least 4 years old• Prevalence: 1-1.5% of school-aged children (rare

in adolescence)• M:F = 6:1• Must exclude medical causes (e.g. Hirschsprung

disease, hypothyroidism, hypercalcemia, spinal cord lesions, anorectal malformations)

RETENTIVE ENCOPRESIS

• Psychogenic Megacolon

• Causes

- Physical: anal fissure (painful stooling)

- Emotional: disturbed parent-child relationship, coercive toilet training


• History:

- Child withholds bowel movement- Develops constipation, leading to fecal impaction and

seepage of soft or liquid stool- Crosses legs or stands on toes to resist urge to defecate- Psychologically distressed by symptoms, soiling of

clothes- Toilet training hx: coercive or lackadaisical


• Physical exam:

- Abdominal exam- Urinary - urinalysis- Rectal exam: large fecal mass in rectal vault- Anal fissures (result from passage of hard stools- Abdominal x-ray


• Treatment

- Diet modification fiber, roughage- Enemas and suppositories completely clean-out bowel- Stool softeners (e.g. Senokot, Lansoyl at bedtime)- Toileting schedule- Positive reinforcement

CASE HISTORY

• Three year-old John presents with his mother to the office today because he "Just won't talk me, and won't play with his brother."

- With further questioning, she states that he does not engage in any verbal play, dress-up play, or appropriate play with toys

- The only words he says are words he hears on the television, or he repeats words back that he has heard.

- He does not come to her for hugs and kisses

- This has been going on for about a year, but she thought he would just "grow out of it".

CASE HISTORY

• Upon interacting with John, he will not make eye contact, and will not respond to questions posed to him

• His right hand "flaps" in an intermittent pattern• In observing John, he has taken one stuffed animal

from the toy area, and is repeatedly hitting it against the floor

• When this behavior is redirected, John dropped to the floor, crying

AUTISM

• Autism, as defined in the DSM-IV (APA, 1994, p. 66-71) is a Pervasive Developmental Disorder (PDD)

• The DSM-IV notes three areas from which diagnosis must be made, social interaction, communication, and behavior/motor activity. Additionally, cognitive impairments are commonly seen

• The diagnostic criteria from the DSM-IV are outlined specifically

AUTISM

• An overall prevalence rate of approximately 5/10,000

• Autism is four times as likely to strike a male as a female

• There is strong evidence that autism has a genetic component

• Intrauterine insult or birth insult cause is seen in many cases

• Brain defects have long been considered as a culprit in autism

AUTISM

• Symptoms may manifest in early infancy, with the infant shying away from the parents touch

• Not responding to a parent who returns after an absence

• No eye contact• The child may fail to meet early language and other

developmental milestones• This is the time when most parents begin to become

aware that there is something "different

AUTISM

• There is no "cure" for autism• However, as autism occurs on a spectrum from

mild to severe, there are varying degrees of functioning, which may be reached as an adult

• This ranges from holding a job to requiring complete 24-hour care

• Intense therapy before age 6 can have significant effects on overall outcomes

LEARNING DISABILITY

• Inability to process language and its symbols or lack of arithmetic-related skills at a level equal to peer group

• Affected children usually suffer from learning disability in a specific area and are normal in all other areas of development

LEARNING DISABILITY

• CAUSES

- Specific learning disabilities are generally thought to be biologic in origin, although the exact mechanisms and biology have not yet been determined

- Major psychiatric disturbances, social deprivation, or loss of vision or hearing can also produce poor learning skills and must be differentiated from specific disabilities

LEARNING DISABILITY

• History

- Current and past behavior and school performance - Look for specific patterns and for hyperactivity, which is

often associated with a learning disability- Perinatal history (perinatal asphyxia or intrauterine injury

may play a role in some cases), prematurity- Family history (such disorders often run in families)

LEARNING DISABILITY

• History

- Early development: recognition of risk factors such as delayed language development

- Social, environmental, family and social factors, which may aggravate the problem (e.g., constant derision may lead to low self-esteem)

- History of meningitis, head trauma

LEARNING DISABILITY

• Perform a physical examination to rule out the following conditions:

- Hearing and vision problems- Medical problems- Fetal alcohol syndrome (FAS)- Abuse- Iron deficiency anemia- Neurologic abnormality

LEARNING DISABILITY

• Refer the child to a Pediatrician for evaluation as soon as possible (elective)

• Management of this problem should be done through the education system

- Advocate for the child in the education system- Support the child's self-esteem- Support child and parents or caregiver with behavioral

strategies in conjunction with psychological counseling and education

DYSLEXIA

• Dyslexia is often referred to as a 'specific learning difficulty'

• Usually with symptoms such as difficulty with writing and spelling, and sometimes with reading and working with numbers.

• A dyslexic person may have problems putting things in order, following instructions, and may confuse left and right

DYSLEXIA

• In the school situation, a dyslexic child may find he or she is experiencing failure, but is not able to understand why

• This frequently results in low self-esteem and a severe loss of confidence, which can lead to the child being reluctant to go to school

• The first step is for an accurate diagnosis to be made. This usually undertaken by the school educational psychologist

DYSLEXIA

• The causes of dyslexia are not fully understood, but it is thought to be inherited as it usually runs in families

• There are well-developed courses of learning which can be used to bring child up to the average level for their age in the areas they find difficulty with

• Given the proper help, in most cases a dyslexic child can succeed at school at a level roughly equal to his or her classmates

pediatric developmental and behavioral disorders eo 018.13

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