Special Needs

Question 1

STUDY DEVELOPMENTAL MILESTONES

Question 2

Abnormal Patterns of Development

the child acquires skills in the typical sequence but at a
slower rate. It may occur within a single stream or across several
dev’tl milestones

Answer 2

Delay

Question 3

devt is delayed in one stream and not another

Answer 3

Dissociation

Question 4

child achieves milestones out of the usual
sequence within a stream of devt; ex: uses words before meaning
is understood

Answer 4

Deviancy/ deviation

Question 5

child is losing milestones, but can more subtly be
recognized when a child stops acquiring new devt skills or has a
slowing in rate of devt’l progress over time

Answer 5

Regression

Question 6

What is ASD?

Answer 6

CH 30: AUTISM SPECTRUM DISORDER (ASD)
Etiopatho
- As much as 15% of ASD are associated with a known genetic mutation
- M>F (4:1)
- abN in frontal and temporal lobes and cerebellum, dec cerebral GABA, oxidative stress, reduced glutathione,
N-acetylaspartate. Neurophysiologic dysfunction in serotonin, oxytocin, and vasopressin
- The best established prognostic factors for individual outcome are
o Presence or absence of associated
intellectual disability
o Language impairment

Question 7

clinical manifestations of ASD

Answer 7

CM
1. Sx are typically recognized and observed during the 2nd YOL

2. Deficits in 2 core domains (Triad of impairments):
   social communication/social interaction AND restricted
   repetitive patterns of behavior, interests, and activities
3. Deviance – nonsequential unevenness in achievement
   of milestones within 1 or more streams of devt (expressive language: knows >200 words but unable to
   say “mama/papa”)

Question 8

Diagnostics

Answer 8

DIAGNOSTIC CRITERIA
A. Persistent deficits in social communication and social interaction
1. Deficits in social-emotional reciprocity
*abnormal social approach
*failure of normal back-and-forth conversation
*reduced sharing of emotions, interests or affect

2. Deficits in nonverbal communicative behaviors used for social interaction
   *abnormal eye contact and body language
   *deficit in understanding and use of gestures
   *total lack of facial expressions
3. Deficits in developing, maintaining and understanding relationships
   *absence of interest in peers
   *difficulties in making friends

B. Restricted, repetitive patterns of behavior, interests or activities manifested by at least 2 of the ff: (4Rs)
1. stereotyped or repetitive motor movements, use of objects or speech)
2. Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior
3. highly restricted, fixated interests that are abnormal in intensity or focus
4. hyper- or hypo-reactivity to sensory or unusual interest in sensory aspects of the environment

C. symptoms must be present in the early development period

D. Symptoms cause clinically significant impairment in social, occupational or other important areas of current functioning

E. Disturbances are not better explained by intellectual disability or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur

Question 9

RED FLAGS for ASD from 1-3yo

Answer 9

—–Social symptoms—–
Abnormal eye contact
Limited social referencing
(poor joint attention)
Limited interest in other
children
Limited functional play/no
pretend play
Limited motor imitation
Limited range of facial
expressions/ social smile
Contented to be left alone

—–Communication symptoms—–
Poor response to name
Failure to share interests
(thru pointing, giving, etc)
Failure to respond to
communicative gestures
Use other’s hands as a tool
Hand and finger mannerisms
Unusual sensory behaviors
Inappropriate use of objects

Question 10

Screening fro ASD

Answer 10

Mgt
1. Screening
AAP recommendations for screening:
a. 9 mos = vision/hearing, gross and fine motor, receptive language

b. 18 mos = gross and fine motor,
personal/social, receptive and expressive language

c. 24 or 30 mos = receptive and expressive language, personal/social
d. Prior to school entry

Question 11

As a general pediatrician, the MOST important role is to do the ff:

Answer 11

1. Surveillance in every well child check-up/ clinical encounter
   o Flexible, longitudinal continuous and cumulative process aimed to may have developmental problems
2. Screen
   o Administration of a brief standardized tool for identification of children at risk
   - MCHAT revised: done at 16-30 mos old
3. Refer for early intervention (OT, parent support, and education) and for formal assessment
4. Provide a medical home
   - Primary care that is accessible, continuous, comprehensive, family-centered, coordinated,
   compassionate, and culturally effective
   - Pediatrician works in partnership with family and patient to assure all medical and nonmedical needs of
   child are met
   - Thru partnership, HCP helps family and coordinate specialty care, educational services, out-of-home care, family support
   - Recognize important role of community in supporting
   healthy behavior among families
5. Risperidone (age 5-16yo) and aripiprazole (age 6-17yo)
   – tx of irritability of ASD (physical aggression, selfinjury,
   severe tantrum behavior)
   - To facilitate the child’s adjustment and engagement with behavioral, educational, and communication
   interventions

Question 12

What is ADHD?

Answer 12

CH 33: ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD)

Etiopatho
- Characterized by difficulty paying attention, excessive activity, and acting without regards to consequences, which are otherwise not appropriate for a person’s age
- M>F

Question 13

Pathophysiology of ADHD

Answer 13

Patho
- Exact cause is unknown in the majority.
- Possible dysfunction in the frontal, prefontal, parietal
lobe, cerebellum. Depressed dopamine activity in
caudate and limbic regions.

Question 14

DSM-5 Diagnostic criteria for ADHD

Answer 14

A. A persistent pattern of inattention and/or hyperactivity/impulsivity
that interferes with functioning or development, as characterized
by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms of
   inattention have persisted for ≥6 mo to a degree that is inconsistent with development level and that negatively impacts directly on social and academic/occupational activities:
   a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other
   activities (e.g., overlooks or misses details, work is inaccurate).
   b. Often has difficulty sustaining attention in tasks or play activities.
   c. Often does not seem to listen when spoken to directly.
   d. Often does not follow through on instructions and fails to
   finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
   e. Often has difficulty organizing tasks and activities.
   f. Often avoids, dislikes, or is reluctant to engage in tasks
   that require sustained mental effort (e.g., schoolwork, homework).
   g. Often loses things necessary for tasks or activities (e.g., toys,
   school assignments, pencils, books, tools).
   h. Is often easily distracted by extraneous stimuli.
   i. Is often forgetful in daily activities.
2. Hyperactivity/impulsivity: Six (or more) of the following
   symptoms of inattention have persisted for ≥6 mo to a degree
   that is inconsistent with development level and that negatively
   impacts directly on social and academic/occupational activities.
   a. Often fidgets with hands or feet or squirms in seat.
   b. Often leaves seat in classroom or in other situations in which
   remaining seated is expected.
   c. Often runs about or climbs excessively in situations in which
   it is inappropriate (in adolescents or adults, may be limited
   to subjective feelings of restlessness).
   d. Often has difficulty playing or engaging in leisure activities
   quietly.
   e. Is often “on the go” or often acts as if “driven by a motor.”
   f. Often talks excessively.
   Impulsivity.
   g. Often blurts out answers before questions have been
   completed.
   h. Often has difficulty awaiting turn.
   i. Often interrupts or intrudes on others (e.g., butts into
   conversations or games).

B. Several inattentive or hyperactive/impulsive symptoms were present before 12 yr of age.
C. Several inattentive or hyperactive/impulsive symptoms are
present in 2 or more settings (e.g., at school [or work] or at home)
and is documented independently.
D. There is clear evidence of clinically significant impairment in
social, academic, or occupational functioning.
E. Symptoms do not occur exclusively during the course of
schizophrenia, or another psychotic disorder, and are not better
accounted for by another mental disorder (e.g., mood disorder,
anxiety disorder, dissociative disorder, personality disorder,
substance intoxication or withdrawal).

Question 15

• Inattention domain – 5/9 behaviors if >17yo
• Hyperactivity domain – behaviors 1-6
• Impulsivity domain – behaviors 7-9

Question 16

wandering off task, lacking persistence,
having difficulty sustaining focus, being disorganized; NOT due to
defiance OR lack of comprehension

Answer 16

Inattention Domain

Question 17

excessive motor activity when it is not appropriate

Answer 17

Hyperactivity

Question 18

hasty actions that occur in the moment without
forethought, with high potential for harm to the individual;
inability to delay gratification

Answer 18

Impulsivity

Question 19

Management of ADHD

Answer 19

Mgt
1. Pre-school (4-5yo) – parent and/or teacher administered
behavior therapy (Grade A)
- May prescribe MPT if behavior interventions do not provide significant improvement (grade B)
2. School-aged (6-11yo) – medication (Grade A) and/or parent/teacher-administered behavior therapy (Grade B)
3. Adolescents (12-18yo) – medication (Grade A)
- May prescribe behavior therapy (Grade C)

Question 20

Medications for ADHD

Answer 20

Medications
Stimulants: Methylphenidate – inhibits reuptake of dopamine or
norepinephrine
- Ritalin 2.5-20mg BID-TID
- Ritalin SR, Metadate ER 20-60mg OD
- Concerta 18-74mg OD
- Metadate CD, Ritalin LA 10-60mg OD

Question 21

Management plan for ADHD

Answer 21

Management Plan
Small class size (10-12 students) with accommodations (front of
class, give work in smaller parts, make them teacher’s aid)

Question 22

What are the 3 main types of learning disability?

Answer 22

3 Main types of learning disability:
1. Reading disability (dyslexia)
2. Writing language disability (dysgraphia)
3. Math disability (dyscalculia)

Question 23

What is dyslexia?

Answer 23

DYSLEXIA
- Unexpected difficulty in reading unexpected in relation to intelligence, chronological age/grade level,
education, or professional status
- Developmental uncoupling between reading and IQ
- MC learning disability (80%)

Question 24

What is the etiology of dyslexia?

Answer 24

Etiology
- Multifactorial; genetic and environmental factors
Pathogenesis
- Neural signature of dyslexia: inefficient functioning of
left hemisphere posterior brain systems pattern

Question 25

Clinical manifestations of dyslexia

Answer 25

CM 1. Labored, effortful approach to reading involving decoding, word recognition, and text reading in schoolage children and adults – cardinal sign 2. Spoken language difficulties – mispronunciations, lack of glibness, non-fluent speech with many pauses/hesitations/”ums”, slow verbal response 3. Robust listening comprehension 4. Remain slow readers 5. Difficulty handwriting

Question 26

Diagnostics of dyslexia

Answer 26

Dx - Clinical dx 1. Oral reading – sensitive measure of reading accuracy and fluency 2. Slow and laborious reading and writing – MC and telling sign of a reading disability in an accomplished young adult

Question 27

Management of dyslexia

Answer 27

Mgt Effective intervention programs provide systematic instruction in 5 key areas: 1. phonemic awareness – 1-2 types of phoneme manipulations, small group learning 2. phonics 3. fluency 4. vocabulary – active interaction between the reader and text 5. comprehension strategies – listen to texts

Question 28

Management of dyslexia

Answer 28

Mgt 1. Early referral from proper dx and mgt 2. Stuttering – tx is most effective if started during the preschool period

Question 29

CH 43/494: PALLIATIVE CARE FOR CANCER PATIENTS

Answer 29

At all stages of caring for children with cancer, principles of Palliative care – should be applied to relieve pain and suffering and to provide comfort at all stages of care Pain – serious cause of suffering among patients with cancer. - It may be the result of organ obstruction or compression or bone metastasis, or it may be neuropathic. - WHO, managed in accordance with the principles of selecting the appropriate analgesic, prescribing the appropriate dosage, administering the drug by the appropriate route, and choosing an appropriate dosing schedule to prevent persistent pain and to relieve breakthrough pain The goals in the care of dying patients are: - to avoid distress for the patient, family, and caregivers - to provide care consistent with the patient’s and family’s wishes - to comply with and advocate for clinical, cultural, and ethical standards

Question 30

other differentials

Answer 30

DDx: Cerebral palsy (p. 250) Intellectual disability (p. 251)