Developmental

Question 1

ADHD

-comorbidities-

Answer 1

psychiatric disorder: 50-90%

• ODD 70% males, 40% females
• conduct disorder 33%
• learning difficulties 20-60%
• anxiety 20-30%
• depression 33%
• tic disorders 10-20%

Question 2

ADHD

-criteria-

Answer 2

One of the following 2:

A. Inattentive signs (6 or more; > 6 months duration)

• fails to give close attention or makes careless mistakes
• cannot sustain attention
• does not follow through or finish tasks
• difficulty organising tasks
• dislikes / avoids tasks requiring sustained mental effort
• easily distracted by external stimuli
• does not listen when spoken to
• loses things necessary for tasks
• forgetful

B. Hyperactive / Impulsive signs (6 or more; >6 months duration

– fidgets, squirms in seat

• leaves seat
• runs about / climbs
• cannot play quietly
• always “on the go” or “driven by a motor”
• talks excessively
• blurts out answers before questions completed
• difficulty waiting his turn
• interrupts or intrudes others (games, conversations)

Symptoms present before 7 yo (some symptoms required only)

Symptoms present in 2 or more settings (some symptoms required only)

Clinically significant impairment

Not associated or caused by another disorder

Question 3

Adolescent cognition

Answer 3

middle childhood (6-11)

• shift from “preoperational “ to “concrete logical operations” (Piaget)
• apply rules based on observations, factor in multiple points of view, and interpret their perceptions using physical laws

early adolescence (10-13)

• transition from concrete operational thinking to formal logical thinking
• reason from principles, weigh many opinions, and think about the process of thinking

middle adolescence (14-16)

• question and analyze extensively
• understand the intricacy of the world, see beyond themselves, and use moral and legal context

Question 4

Autism

Answer 4

DSM IV criteria

1. qualitative impairment of social interaction (>2)

2. qualitative impairment of communication (>1)

3. restrictive or repetitive patterns of behaviour, interests and activities (>1)

4. onset before 3 years

associations: seizures (1/3), ↓IQ (75%), vision/ hearing problems, ADHD, depression/ schizophrenia

screening: recommended 18mo-2yrs with Modified Checklist for Autism in Toddlers questionnaire (M-CHAT)

Question 5

Blindness

Answer 5

legal blindness: vision 20/200 or worse

incidence: 1/35,000

causes:

• retinopathy of prematurity (most common)
• amblyopia (usually secondary to cataracts)

others: albinism, hydrocephalus, infection, birth asphyxia

Question 6

Car restraints

Answer 6

Question 7

Cerebral palsy

Answer 7

incidence: 3.6/1000

definition: non-progressive motor impairment arising before or after birth

causes:

birth: preterm/LBW, congenital malformations, kernicterus

acquired: trauma, meningitis, stroke

unknown: 50% no identified risk

diagnosis: usually <18months with failure to obtain motor milestones or assymetric gross motor function, hypertonia, hypotonia

comorbidities: epilepsy, learning disorders, behavioural issues, sensory impairment

Question 8

Classification CP

Answer 8

Limb distribution:

• hemiplegia: 39%
• diplegia: 34%
• triplegia: 3%
• quadriplegia: 24%

Motor disorder:

• spastic: 83%
• dyskinetic: 6%
• ataxic: 5%
• hypotonic: 2%

Question 9

Constipation

Answer 9

prevalence:

• constipation: 37% 5 to 12 years
• constipation with overflow: 1-4%

Question 10

Crying

Answer 10

duration of crying:

2 weeks: minimal

6 weeks: 3 hours/day

12 weeks: 1 hour/day

excessive crying: less than 5% infants with excessive crying have pathology

Question 11

Deafness

Answer 11

inherited: 50% childhood deafness

genetics: 80% AR

Connexin 26 defect (50%): disrupts K+ flow in ear

• early onset deafness 1-6yrs

other: 18% AD with variable penetrance; 2% XLR

syndromes: Usher, Pendred, Jervell Lange-Nielson, Brachio-otorenal, Alport, treacher-collins, Waardenberg, NF-2

infections: TORCH, bacterial meningitis, mumps, mastoiditis, TB, Kawasaki, EBV, scarlet fever, pertussis

neonatal causes: hyperbilirubinaemia, hypoxia, GBS meningitis, PPHN, prolonged ventilation, LBW

drugs: aminoglycosides, frusemide

endocrine: hypothyroidism

Question 12

Denver Screening Test

Answer 12

age: birth to 6 yrs

domains:

• personal-social
• fine motor-adaptive
• gross motor
• language

use: screening tool but limited socioemotional development scale

Question 13

Development Table

Answer 13

Question 14

Developmental delay

Answer 14

Gross motor

2 yrs: not walking

3-5 yrs: not pedalling tricycle, clumsy, falling frequently, not hopping

5-8 yrs: unable to throw, catch or kick ball

Fine motor

<1 year: hand preference

10 mths: pincer grip

3-5 yrs: avoiding fine motor tasks

Personal/ social

3-5 yrs: disinterested in peers, little awareness of toileting needs, inability to dress self

Question 15

Developmental Delay

-investigations-

Answer 15

1st LINE:

• chromosomes (including fragile X)
• FBC/EUC/TFTs/CK/Lead/Urate/Ferritin/Biotinidase

2nd LINE:

metabolic screen: IF family hx/ consanguinity/regression/ organomegaly/ coarse face

neuroimaging: IF abnormal head size/ seizures/ focal neurology

EEG: IF speech regression/ seizures/ neurodegenerative

genetics: IF dysmorphic, abnormal growth, sensory impairment, odd behaviour, family hx

Question 16

Dyslexia

Answer 16

definition: difficulty with accurate and or fluent word recognition due to a deficit in the phonologic component of language

Question 17

Enuresis

Answer 17

definition: urinary incontinence in a child who is adequately mature enough to achieve continence

classification

• diurnal: daytime (day dryness from 4 yrs)
• noctural: night time (night dryness from 6 yrs)

distribution:

• 22% day only, 17% both day/night, 61% night only

prevalence noctural enuresis:

• 15% 5yr olds
• 7% 8 yr olds
• 1% 15 yr olds

Question 18

Erikson’s stages

Answer 18

Question 19

Global developmental delay

Answer 19

impairment in at least 2 of the following areas:

1. motor

2. speech and language

3. cognition

4. personal/social

5. daily-living skills

Question 20

Hearing impairment

Answer 20

causes:

conductive (mild-moderate)

• chronic middle ear effusion

SNHL (severe):

• congenital infection eg. rubella, CMV, meningitis
• birth asphyxia
• kernicterus
• ototoxic drugs
• tumours
• inherited defect

treatment:

hearing aids: amplification of sound

cochlear implant: >12months with severe SNHL

Question 21

Hearing tests:

Answer 21

neonatal:

otoacoustic emissions: measure sounds waves produced in middle ear by measuring echo when sounds are played

auditory brainstem response (ABR): measures how brain responds to sound via electrodes on the head

middle ear function:

pneumatic otoscope: most sensitive/specific

tympanometry/acoustic reflectometry: supportive

children:

audiometry: test conductive and sensory hearing in both ears

Question 22

Hymen anatomy prepuberty

Answer 22

variations:

• crescenteric (most common): no tissue at 12 o’clock
• annular (2nd most common)
• fimbriated: erratically shaped

Question 23

Intellectual Disability

Answer 23

Question 24

Intelligence scales

Answer 24

Bayley Scales: 0-2yrs

Differential Abilities Scales: 2.5- 17 yrs

Kaufman Assessment Battery for Children: 2.5- 12.5yrs

Leiter International Performance (non-verbal abilities): 2.5-18 yrs

McCarthy Scales of Children’s Abilities: 2.5- 8.5 yrs

Stanford-Binet Intelligence Scale: 2- 23 yrs

The Griffiths Mental Scales: 2-8 yrs

Wechsler Preschool + Primary Scale of Intelligence (WPPSI): 3-7 yrs

Wechsler Intelligence Scales for Children (WISC III): 6-12yrs

Question 25

Language development

Answer 25

3 months: cooing 6 months: babbling 1yr: 1 -2 words 2 yrs: 50 words, 2 word combos 3 yrs: 3 word combos, 3 colours, personal pronouns, able to be understood by family 4yrs: 4 word combos, 4 colours, able to be understood by stranger

Question 26

Overweight/Obese

Answer 26

**In children** _overweight:_ 85th-95th percentile _obese:_ \>95th percentile

Question 27

Piaget's

Answer 27

**Piaget's 4 stages of intellectual/cognitive development:** **sensorimotor:** birth through ages 18-24 months **preoperational:** toddlerhood (18-24 months) to childhood (age 7) **concrete operational:** 7 to 12 years **formal operational:** adolescence through adulthood

Question 28

Sexual abuse findings in females

Answer 28

**findings on examination in only 5-10%** **most suspicious findings:** 1. tears, deep notches or clefts in posterior hymen (3- 9 o’clock) 2. attachments of fusion between labia minora and hymen 3. AP diameter \> 20mm with no stool present (strong marker) – uncommon

Question 29

Sleep association disorder

Answer 29

**incidence:** 1/3 toddlers **clinical:** child wakes in middle of night and can't fall back to sleep unless learned associations are presents **management:** check in without physical contact at decreasing intervals for a period of time until the child learns to self-soothe

Question 30

Sleep stages

Answer 30

**_STAGES_** **Stage 1:** beginning, slow eye wave, hypnic jerks - EEG: theta waves **Stage 2:** unconscious, easily wakened, no eye movements - EEG: sleep spindles, k complexes **Stage 3:** slow-wave sleep associated deep sleep, dreaming/parasomnias more common - EEG: delta waves **REM:** rapid eye movements, low muscle tone, decreased HR/BP, increased gastric motility, deep sleep and hard to wake - EEG: rapid low voltage **Normal sleep pattern** - 4-5 cycles of 90-120 minutes each **Age related changes:** - birth: 50% sleep in REM - childhood/adulthood: 25% REM

Question 31

Speech disorders

Answer 31

**dysarthria:** both speech and non-speech difficulty due to lack of strength and muscle control **dysphonia**: phonation disorder usually secondary to anatomical problem **dyspraxia:** difficulty planning/coordinating the movements required to make speech **phonological delay:** problems producing different sounds required for speech **pragmatic language impairment:** have trouble understanding the meaning of what others are saying and trouble using words to get needs met

Question 32

Speech problems

Answer 32

**3 main areas:** _1. articulation_ - difficulty pronouncing sounds in syllables or saying words _2. fluency_ - the flow of speech is interrupted by abnormal stoppages eg. stuttering _3. resonance_ - problems with pitch, volume or quality of sound

Question 33

Straddle injury

Answer 33

**clinical:** typically unilateral and superficial to the anterior portion of the genitalia. - involve the mons, clitoral hood, labia minora anterior or lateral to the hymen - straddle injury to the hymen or posterior fourchette is rare **classified as penetrating or nonpenetrating** _nonpenetrating:_ minor trauma to external genitalia: lacerations or abrasions of the labia in girls _penetrating injuries:_ more serious/extensive and often indicative of sexual assault . **findings concerning for sexual abuse:** - \< nine months - perianal, rectal, vaginal, or hymenal injury without hx penetrating trauma - extensive or severe trauma - presence of nonurogenital trauma - lack of correlation between history and physical findings - abnormal genital secretions

Question 34

Temper tantrum

Answer 34

**definition:** 2-5 mins of out of control behaviour including screaming, stomping, hitting, head banging and falling down as a display of frustration, anger and inability to cope **age:** 1-3 yrs considered normal behaviour **prevalence**: 80% 2-3yrs approx once per week **treatment:** - parental education - identify triggers - alter environment to avoid triggers and limit frustration - use distraction - behaviour modification with positive/negative reinforcement

Question 35

Tympanometry

Answer 35

**use:** determines TM mobility by inserting pressure in the ear canal **abnormal:** - middle ear effusion/perforation: stiffness of TM

Question 36

Wechsler Intelligence Scale for children

Answer 36

**age:** 6-16yrs **time:** 45-65 minutes **assesses:** general intelligence with scores for 5 indexes 1. verbal comprehension index 2. visual spacial index 3. fluid reasoning index 4. working memory index 5. processing speed index **identify:** specific learning, dyslexia, dyscalculia **NOT tested:** reading ability

Question 37

GMFCS Gross Motor Function Classification System

Answer 37

**system:** 66 items developed for children with CP **5 levels:** _I (30%):_ walk independently, reduced coordination _II (20%):_ difficulty on uneven surfaces _III (10):_ assist device for walking, wheelchair for distance, sits independently _IV (12%):_ mobility device, support for sitting/transfers V (14%): no independant mobility **prognosis:** plateau at age 5

Question 38

Functional Mobility Scale | (FMS)

Answer 38

**Functional mobility for 3 distances:** - home: 5m - school: 50m - community: 500m **measures:** what your child actually does - allows responsive change to intervention

Question 39

Hip Surveillance

Answer 39

**who:** all CP GMFCS I to V **age:** 12 months corrected **tests:** clinical assessment and XR

Question 40

Movement Disorder

Answer 40

**spasticity:** velocity dependent resistance of a muscle to stretch - R1 "catch" - R2: passive end range **dystonia:** movement disorder with involuntary sustained or intermittent muscle contractions causing twisting/repetitive movements and postures - basal ganglia

Question 41

Medications for CP

Answer 41

**baclofen:** GABA agonist **diazepam:** facilitates GABA **tizanidine:** alpha 2 agonist **L-dopa:** dopaminergic **artane:** anticholinergic for dystonia **tetrabenazine:** dopamine depletor for dystonia \*trial medication for at least 3 months

Question 42

Other CP treatment

Answer 42

**Selective Dorsal Rhizotomy** - L1-S1 laminectomy/dorsal root transection - irreversible **Baclofen pump:** subfascial implant - small amount crosses - risk of malfunction: withdrawal **Deep brain stimulation: neurostimulator below clavicle** - dyskinetic CP - limited response

Question 43

Behavioural management

Answer 43

**4 pronged approach** **1. environmental modulation** - remove TV from room/ fences/ remove matches **2. time out for prioritised behaviour** - clear boundaries (if appropriate give a warning 1^st) - safe but boring environment - 1 min/yr of age (up to 5 mins) - if he comes out, he goes straight back in - usually works in 1-2 months - if \> 5 yrs – more effective to use removal of privledges **3. ignore other behaviours** - difficult for parents - avoid eye contact - walk away/ distract themselves/ separate room **4. praise for good behaviours** - be specific - immediate - sticker charts