Developmental Milestones and Behavioral Issues in Infancy and Early Childhood, Resúmenes de Medicina

¡Descarga Developmental Milestones and Behavioral Issues in Infancy and Early Childhood y más Resúmenes en PDF de Medicina solo en Docsity! 229 Chapter 9 Development, Behavior, and Mental Health Julia Thorn, MD See additional content on Expert Consult I. WEB RESOURCES • Attention deficit/hyperactivity disorder (ADHD): www.chadd.org • ADHD Medication Guide: www.ADHDMedicationGuide.com • American Academy of Pediatrics (AAP)—Developmental and Behavioral Pediatrics: www.dbpeds.org • Autism Speaks: www.autismspeaks.org • Bright Futures: www.brightfutures.org • Cerebral Palsy Foundation: www.yourcpf.org • Child and Adolescent Psychiatry Practice Parameters: www.aacap.org • Disability Programs and Services: www.disability.gov • Individuals with Disabilities Education Act (IDEA): idea.ed.gov • Intellectual Disability: aaidd.org • Mental health patient and provider handouts: www.nimh.nih.gov • National Center for Learning Disabilities: www.ncld.org • National Dissemination Center for Children with Disabilities (NICHCY) legacy resources: http://www.parentcenterhub.org/nichcy-resources/ • National Early Childhood Technical Assistance Center: www.ectacenter.org • Reach Out and Read: www.reachoutandread.org II. DEVELOPMENTAL DEFINITIONS1 A. Developmental Streams 1. Gross Motor Skills: Descriptions of posture and locomotion—in general, how a child moves from one location to another 2. Fine-Motor and Visual-Motor Problem-Solving Skills: Upper extremity and hand manipulative abilities and hand-eye coordination. Require an intact motor substrate and a given level of nonverbal cognitive ability 3. Language: The ability to understand and communicate with another person. The best predictor of intellectual performance, in the absence of a communication disorder or significant hearing impairment. 4. Personal-Social Skills: Communicative in origin, and represent the cumulative impact of language comprehension and problem-solving skills 5. Adaptive Skills: Skills concerned with self-help or activities of daily living 230 Part II Diagnostic and Therapeutic Information B. Developmental Quotient (DQ) 1. A calculation that reflects the rate of development in any given stream, and represents the percentage of normal development present at the time of testing. DQ = (developmental age/chronologic age) × 100 2. Two separate developmental assessments over time are more predictive of later abilities than a single assessment 3. In contrast to DQ, intelligence quotient has statistical reliability and validity C. Abnormal Development 1. Delay a. Performance significantly below average (DQ < 70) in a given area of development. May occur in a single stream or several streams (“global developmental delay”). 2. Deviancy a. Atypical development within a single stream, such as developmental milestones occurring out of sequence. Deviancy does not necessarily imply abnormality but should alert one to the possibility that problems may exist. Example: An infant who rolls at an early age may have abnormally increased tone. b. Deviancy may also denote emergence of a presentation that is not typically part of the developmental sequence. Example: A toddler showing no interest in peers. 3. Dissociation a. A substantial difference in the rate of development between two or more streams. Example: Increased motor delay relative to cognition seen in some children with cerebral palsy. III. GUIDELINES FOR NORMAL DEVELOPMENT AND BEHAVIOR A. Developmental Milestones (Table 9.1) 1. Developmental assessment is based on the premise that milestone acquisition occurs at a specific rate in an orderly and sequential manner. B. Reach Out and Read Milestones of Early Literacy (Table 9.2) C. Age-Appropriate Behavioral Issues in Infancy and Early Childhood (Table 9.3) IV. DEVELOPMENTAL SCREENING AND EVALUATION A. Developmental Surveillance and Screening Guidelines 1. Developmental surveillance should be included in every well-child visit, and any concerns should be addressed immediately with formal screening. Five components: Text continued on p. 235 Chapter 9 Development, Behavior, and Mental Health 233 9 TABLE 9.2 REACH OUT AND READ MILESTONES OF EARLY LITERACY Age Motor Cognitive 6–12 mo Reaches for books, turns pages with help Looks at pictures, pats pictures 12–18 mo Carries book, holds book with help, turns several board pages at a time Points to pictures with a single finger, points to specific items on page, gives book to adult 18–24 mo Turns one board page at a time Repeats and retells parts of known stories 24–36 mo Begins to turn paper pages Looks at favorite books on own, repeats and retells whole phrases and stories, associates pictures with text of story 3 yr Turns paper pages easily Growing attention span, recites favorite stories, begins to identify single letters 4 yr and older Writes name Uses past tense and plurals, answers “what will happen next?” From Reach Out and Read National Center: www.reachoutandread.org. TABLE 9.3 AGE-APPROPRIATE BEHAVIORAL ISSUES IN INFANCY AND EARLY CHILDHOOD Age Behavioral Issue Symptoms Guidance 1–3 mo Colic Paroxysms of fussiness/ crying, 3+ hr per day, 3+ days per wk, may pull knees up to chest, pass flatus Crying usually peaks at 6 wk and resolves by 3–4 mo. Prevent overstimulation; swaddle infant; use white noise, swing, or car rides to soothe. Avoid medication and formula changes. Encourage breaks for the primary caregiver. 3–4 mo Trained night feeding Night awakening Comfort quietly, avoid reinforcing behavior (i.e., avoid night feeds). Do not play at night. Introducing cereal or solid food does not reduce awakening. Develop a consistent bedtime routine. Place baby in bed while drowsy and not fully asleep. Continued 234 Part II Diagnostic and Therapeutic Information TABLE 9.3 AGE-APPROPRIATE BEHAVIORAL ISSUES IN INFANCY AND EARLY CHILDHOOD—cont’d Age Behavioral Issue Symptoms Guidance 9 mo Stranger anxiety/ separation anxiety Distress when separated from parent or approached by a stranger Use a transitional object (e.g., special toy, blanket); use routine or ritual to separate from parent; may continue until 24 mo but can reduce in intensity. Developmental night waking Separation anxiety at night Keep lights off. Avoid picking child up or feeding. May reassure verbally at regular intervals or place a transitional object in crib. 12 mo Aggression Biting, hitting, kicking in frustration Say “no” with negative facial cues. Begin time out (1 minute per year of age). No eye contact or interaction, place in a nonstimulating location. May restrain child gently until cooperation is achieved. Need for limit setting Exploration of environment, danger of injury Avoid punishing exploration or poor judgment. Emphasize child-proofing and distraction. 18 mo Temper tantrums Occur with frustration, attention-seeking rage, negativity/refusal Try to determine cause, react appropriately (i.e., help child who is frustrated, ignore attention-seeking behavior). Make sure child is in a safe location. 24 mo Toilet training Child needs to demonstrate readiness: shows interest, neurologic maturity (i.e., recognizes urge to urinate or defecate), ability to walk to bathroom and undress self, desire to please/ imitate parents, increasing periods of daytime dryness Age range for toilet training is usually 2–4 yr. Give guidance early; may introduce potty seat but avoid pressure or punishment for accidents. Wait until the child is ready. Expect some periods of regression, especially with stressors. Chapter 9 Development, Behavior, and Mental Health 235 9 TABLE 9.3 AGE-APPROPRIATE BEHAVIORAL ISSUES IN INFANCY AND EARLY CHILDHOOD—cont’d Age Behavioral Issue Symptoms Guidance 24–36 mo New sibling Regression, aggressive behavior Allow for special time with parent, 10–20 min daily of one-on-one time exclusively devoted to the older sibling(s). Child chooses activity with parent. No interruptions. May not be taken away as punishment. 36 mo Nightmares Awakens crying, may or may not complain of bad dream Reassure child, explain that he or she had a bad dream. Leave bedroom door open, use a nightlight, demonstrate there are no monsters under the bed. Discuss dream the following day. Avoid scary movies or television shows. Night terrors Agitation, screaming 1–2 h after going to bed. Child may have eyes open but not respond to parent. May occur at same time each night May be familial, not volitional. Prevention: For several nights, awaken child 15 min before terrors typically occur. Avoid overtiredness. Acute: Be calm; speak in soft, soothing, repetitive tones; help child return to sleep. Protect child against injury. From Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and Development. St Louis: Mosby, 2000. a. Eliciting and attending to the parent’s concerns: “Do you have any concerns about your child’s development? Behavior? Learning?” b. Maintaining a developmental history: “What changes have you seen in your child’s development since our last visit?”; “How old would you say your child acts?” c. Making accurate and informed observations of the child d. Identifying the presence of risk and protective factors e. Documenting the process and findings 2. Standardized developmental screening should be administered at 9-month, 18-month, and 30-month well-child visits, in the absence of developmental concerns. If a 30-month visit is not possible, this screening can be done at the 24-month visit. 3. See full American Academy of Pediatrics (AAP) guideline for developmental screening algorithm2 236.e2 Part II Diagnostic and Therapeutic Information Eye detail: □ Brow or lashes □ Pupil □ Proportion □ Glance directed front in profile drawing Chin: □ Present; forehead □ Projection Profile: □ Not more than one error □ Correct Normal Values Age (yr): 3 4 5 6 7 8 9 10 11 12 13 Score: 2 6 10 14 18 22 26 30 34 38 42 BOX EC 9.A GOODENOUGH–HARRIS DRAW-A-PERSON TEST SCORING Chapter 9 Development, Behavior, and Mental Health 236.e3 9 FIGURE EC 9.A Block skills. (From Capute AJ, Accardo PJ. The Pediatrician and the Developmentally Disabled Child: A Clinical Textbook on Mental Retardation. Baltimore: University Park Press; 1979:122.) 15 mo 18 mo 3 yr 2 yr 21/2 yr 3 yr 4 yr 6 yr 236.e4 Part II Diagnostic and Therapeutic Information TABLE EC 9.A PRIMITIVE REFLEXES Primitive Reflexes Elicitation Response Timing Moro reflex (“embrace” response) of fingers, wrists, and elbows Supine: Sudden neck extension; allow head to fall back about 3 cm Extension, adduction, and then abduction of UEs, with semiflexion Present at birth; disappears by 3–6 mo Galant reflex (GR) Prone suspension: Stroking paravertebral area from thoracic to sacral region Produces truncal incurvature with concavity toward stimulated side Present at birth; disappears by 2–6 mo Asymmetrical tonic neck reflex (ATNR, “fencer” response) Supine: Rotate head laterally about 45–90 degrees Relative extension of limbs on chin side and flexion on occiput side Present at birth; disappears by 4–9 mo Symmetrical tonic neck reflex (STNR, “cat” reflex) Sitting: Head extension/flexion Extension of UEs and flexion of LEs/flexion of UEs and LE extension Appears at 5 mo; not present in most normal children; disappears by 8–9 mo Tonic labyrinthine supine (TLS) Supine: Extension of the neck (alters relation of the labyrinths) Tonic extension of trunk and LEs, shoulder retraction and adduction, usually with elbow flexion Present at birth; disappears by 6–9 mo Tonic labyrinthine prone (TLP) Prone: Flexion of the neck Active flexion of trunk with protraction of shoulders Present at birth; disappears by 6–9 mo Positive support reflex (PSR) Vertical suspension; bouncing hallucal areas on firm surface Neonatal: momentary LE extension followed by flexion Present at birth; disappears by 2–4 mo Mature: extension of LEs and support of body weight Appears by 6 mo Stepping reflex (SR, walking reflex) Vertical suspension; hallucal stimulation Stepping gait Disappears by 2–3 mo Crossed extension reflex (CER) Prone; hallucal stimulation of LE in full extension Initial flexion, adduction, then extension of contralateral limb Present at birth; disappears by 9 mo Plantar grasp Stimulation of hallucal areas Plantar flexion grasp Present at birth; disappears by 9 mo Palmar grasp Stimulation of palm Palmar grasp Present at birth; disappears by 9 mo 9 TA BL E 9. 4 DE VE LO PM EN TA L AN D M EN TA L H EA LT H S CR EE N IN G TE ST S BY D IA GN OS IS Sy m pt om s or Di ag no si s Ev al ua te d Sc re en in g Te st Ag e Ad m in is tr at io n Ti m e Co m pl et ed b y Co m m en ts W eb lin k DE VE LO PM EN T Co gn iti ve /m ot or de ve lo pm en t Ag es a nd S ta ge s Qu es tio nn ai re (A SQ ) 4– 60 m o 10 –1 5 m in Pa re nt In cr ea se d tim e ef fic ie nc y (c an fi ll ou t w hi le w ai tin g) Do cu m en t m ile st on es th at a re di ffi cu lt to a ss es s in th e of fic e ht tp :// ww w. ag es an ds ta ge s. co m De ve lo pm en ta l a nd be ha vi or al pr ob le m s Pa re nt s’ E va lu at io n of De ve lo pm en ta l S ta tu s (P ED S) 0– 8 yr 2– 10 m in Pa re nt M ay a ls o be u se fu l a s a su rv ei lla nc e to ol ht tp :// ww w. pe ds te st .c om La ng ua ge , pr ob le m -s ol vi ng de ve lo pm en t Ca pu te S ca le s: C lin ic al Li ng ui st ic a nd A ud ito ry M ile st on e Sc al e (C LA M S) , Cl in ic al A da pt iv e Te st (C AT ) 3– 36 m o 15 –2 0 m in Cl in ic ia n Gi ve q ua nt ita tiv e DQ s fo r l an gu ag e (C LA M S) a nd v is ua l-m ot or / pr ob le m -s ol vi ng (C AT ) a bi lit ie s ht tp :// ww w. br oo ke sp ub lis hi ng .c om / re so ur ce -c en te r/s cr ee ni ng -a nd - as se ss m en t/t he -c ap ut e- sc al es / Au tis m s pe ct ru m di so rd er s M od ifi ed C he ck lis t f or A ut is m in To dd le rs , R ev is ed w ith Fo llo w- Up (M -C HA T- R/ F) 16 –3 0 m o 5– 10 m in Pa re nt Po si tiv e sc re en s re qu ire c lin ic ia n fo llo w- up ww w. m -c ha t.o rg Co m m un ic at io n an d Sy m bo lic Be ha vi or S ca le s an d De ve lo pm en ta l P ro fil e (C SB S DP ; I nf an t T od dl er C he ck lis t) 6– 24 m o 5– 10 m in Pa re nt Th e In fa nt T od dl er C he ck lis t i s a on e- pa ge q ue st io nn ai re th at is pa rt of a la rg er s ta nd ar di ze d sc re en in g to ol (C SB S DP ) Ca n be u se d in p at ie nt s as y ou ng as 6 m on th s ww w. br oo ke sp ub lis hi ng .c om / ch ec kl is t.p df Ch ild ho od A ut is m S cr ee ni ng Te st (C AS T) 4– 11 y r 10 m in Pa re nt On ly sc re en in g to ol e va lu at ed in pr es ch oo l p op ul at io n ht tp :// ww w. au tis m re se ar ch ce nt re .c om / pr oj ec t_ 9_ ca st C on tin ue d TA BL E 9. 4 DE VE LO PM EN TA L AN D M EN TA L H EA LT H S CR EE N IN G TE ST S BY D IA GN OS IS — co nt ’d Sy m pt om s or Di ag no si s Ev al ua te d Sc re en in g Te st Ag e Ad m in is tr at io n Ti m e Co m pl et ed b y Co m m en ts W eb lin k M EN TA L H EA LT H Ge ne ra l p sy ch os oc ia l sc re en in g Pe di at ric S ym pt om C he ck lis t (P SC ) 4– 16 y r <5 m in Pa re nt o r ch ild / ad ol es ce nt As se ss es a tte nt io n, e xt er na liz in g, an d in te rn al izi ng s ym pt om s ht tp :// ww w. m as sg en er al .o rg / ps yc hi at ry /s er vi ce s/ ps c_ ho m e. as px At te nt io n de fic it/ hy pe ra ct iv ity di so rd er (A DH D) Va nd er bi lt Di ag no st ic R at in g Sc al es 6– 12 y r 10 m in Pa re nt Te ac he rs Se pa ra te s ca le s fo r f un ct io ni ng in di ffe re nt d om ai ns (h om e, sc ho ol ) ht tp :// ww w. ni ch q. or g/ ch ild re ns -h ea lth /a dh d/ re so ur ce s/ va nd er bi lt- as se ss m en t- sc al es AD HD p lu s ot he r do m ai ns Co nn er s’ R at in g Sc al es -R ev is ed 3– 17 y r 20 m in Pa re nt o r pa tie nt if 12 –1 7 ye ar s Te ac he r Si x di st in ct s ca le s th at a ss es s op po si tio na lit y, co gn iti ve pr ob le m s/ in at te nt io n, hy pe ra ct iv ity , a nx ie ty /s hy ne ss , pe rfe ct io ni sm , s oc ia l p ro bl em s, an d ps yc ho so m at ic p ro bl em s ww w. m hs .c om /c on ne rs 3 An xie ty Se lf- Re po rt fo r C hi ld ho od An xie ty R el at ed E m ot io na l Di so rd er s (S CA RE D) 8+ y r 5 m in Pa re nt Pa tie nt Se pa ra te s ca le s fo r p ar en t a nd pa tie nt Do es n ot a ss es s fo r O CD , P TS D ht tp :// ww w. m id ss .o rg /c on te nt / sc re en -c hi ld -a nx ie ty -r el at ed -d is or de rs -s ca re d Sp en ce C hi ld re n’ s An xie ty S ca le 2. 5– 12 y r 5– 10 m in Pa re nt o r pa tie nt if 8– 12 y ea rs M ul tip le s ub sc al es o f a nx ie ty ht tp :// ww w. sc as we bs ite .c om / De pr es si on Pa tie nt H ea lth Q ue st io nn ai re -2 (P HQ -2 ) 13 + yr 1 m in Pa tie nt Br ie f s cr ee ni ng to ol fo r ad ol es ce nt s or p ar en ts (e .g ., po st pa rtu m d ep re ss io n) ht tp :// ww w. cq ai m h. or g/ pd f/t oo l _p hq 2. pd f Ce nt er fo r E pi de m io lo gi ca l St ud ie s De pr es si on S ca le fo r Ch ild re n (C ES -D C) 6– 17 y r 5– 10 m in Ch ild / ad ol es ce nt Or ig in al ly us ed in a du lt po pu la tio ns ht tp :// ww w. br ig ht fu tu re s. or g/ m en ta lh ea lth /p df /p ro fe ss io na ls / br id ge s/ ce s_ dc .p df M od ifi ed fr om A m er ic an A ca de m y of P ed ia tri cs . I de nt ify in g in fa nt s an d yo un g ch ild re n wi th d ev el op m en ta l d is or de rs in th e m ed ic al h om e: a n al go rit hm fo r d ev el op m en ta l s ur ve ill an ce a nd s cr ee ni ng . P ed ia tri cs . 2 00 6; 11 8: 40 5- 42 0; Am er ic an A ca de m y of P ed ia tri cs . I de nt ifi ca tio n an d ev al ua tio n of c hi ld re n wi th a ut is m s pe ct ru m d is or de rs . P ed ia tri cs . 2 00 7; 12 0: 1 18 3- 12 15 ; A m er ic an A ca de m y of P ed ia tri cs . M en ta l h ea lth s cr ee ni ng a nd a ss es sm en t t oo ls fo r pr im ar y ca re . F ro m A dd re ss in g M en ta l H ea lth C on ce rn s in P rim ar y Ca re : A C lin ic ia n’ s To ol ki t. 20 10 ; R ob in s DL , C as ag ra nd e K, B ar to n M , e t a l. Va lid at io n of th e M od ifi ed C he ck lis t f or A ut is m in T od dl er s, R ev is ed w ith F ol lo w- up (M -C HA T- R/ F) . P ed ia tri cs . 2 01 4; 13 3: 37 -4 5. Chapter 9 Development, Behavior, and Mental Health 239 9 C. Laboratory Investigations, Imaging Studies, Other Tests 1. Hearing and vision screening: Hearing or vision loss may be part of a broader syndrome. Formal audiologic testing is indicated for all children with global developmental delay or any delay in communication or language. FIGURE 9.1 Gesell figures. (From Illingsworth RS. The Development of the Infant and Young Child, Normal and Abnormal. 5th ed. Baltimore: Williams & Wilkins; 1972:229-232; and Cattel P. The Measurement of Intelligence of Infants and Young Children. New York: Psychological Corporation; 1960:97-261.) 15 months Imitates scribble 18 months Scribbles spontaneously 2 years Imitates stroke 21/2 years Differentiates horizontal and vertical stroke 3 yr 4 yr 5 yr 6 yr 6 yr 7 yr 41/2 yr 11 yr 9 yr8 yr 242 Part II Diagnostic and Therapeutic Information c. Identifiable features of known associated genetic syndrome (e.g., Trisomy 21, Fragile X, Rett syndrome) 3. Diagnosis a. Diagnostic criteria: 1) deficits in intellectual functioning, 2) deficits in adaptive functioning, 3) onset of these deficits during the developmental period b. Deficits in adaptive functioning must be in one or more domains of activities of daily living i. ID is further categorized as mild, moderate, severe, or profound in the DSM-5 based on the degree of functional deficit (Table EC 9.C) 4. Interventions/treatment a. Support, employment, and recreational programs through resources such as The Arc (www.thearc.org) C. Communication Disorders 1. Definition a. Deficits in communication, language, or speech b. Can be subdivided into receptive/expressive language disorder [includes social (pragmatic) communication disorder], speech sound disorders, childhood-onset fluency disorder (stuttering), and voice disorders c. Differential diagnosis includes ID, hearing loss, significant motor impairment, or severe mental health difficulties 2. Interventions/treatment a. Referrals to speech-language pathology (SLP), audiology D. Learning Disabilities (LDs) 1. Definition a. A heterogeneous group of deficits in an individual’s ability to perceive or process information efficiently and accurately 2. Diagnosis a. Achievement on standardized tests that is substantially below expected for age, schooling, and level of intelligence in one or more of the following areas: basic reading skills, reading comprehension, reading fluency skills, oral expression, listening comprehension, written expression, mathematic calculation, and mathematic problem solving b. There is no alternative diagnosis such as sensory impairment or ID6,7 E. Cerebral Palsy (CP) 1. Definition and epidemiology a. A group of disorders of the development of movement and posture causing activity limitation that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain8 Chapter 9 Development, Behavior, and Mental Health 242.e1 9 TABLE EC 9.C SEVERITY LEVELS FOR INTELLECTUAL DISABILITY (INTELLECTUAL DEVELOPMENTAL DISORDER) Severity Level Conceptual Domain Social Domain Mild For preschool children, there may be no obvious conceptual differences. For school-aged children and adults, there are difficulties in learning academic skills involving reading, writing, arithmetic, time, or money, with support needed in one or more areas to meet age-related expectations. In adults, abstract thinking, executive function (i.e., planning, strategizing, priority setting, and cognitive flexibility), and short-term memory, as well as functional use of academic skills (e.g., reading, money management) are impaired. There is a somewhat concrete approach to problems and solutions compared with age mates. Compared with typically developing age mates, the individual is immature in social interactions (e.g., difficulty in accurately perceiving peers’ social cues). Communication, conversation, and language are more concrete or immature than expected for age. There may be difficulties regulating emotion and behavior in age-appropriate fashion; these difficulties are noticed by peers in social situations. There is limited understanding of risk in social situations; social judgment is immature for age, and the person is at risk of being manipulated by others (gullibility). Moderate All through development, the individual’s conceptual skills lag markedly behind those of peers. For preschoolers, language and preacademic skills may develop slowly. For school-aged children, progress in reading, writing, mathematics, and understanding of time and money occurs slowly across the school years, and is markedly limited compared with that of peers. For adults, academic skill development is typically at an elementary level, and support is required for all use of academic skills in work and personal life. Ongoing assistance on a daily basis is needed to complete conceptual tasks of day-to-day life, and others may take over these responsibilities fully for the individual. The individual shows marked differences from peers in social and communicative behavior across development. Spoken language is typically a primary tool for social communication, but is much less complex than that of peers. Capacity for relationships is evident in ties to family and friends, and the individual may have successful friendships across life and sometimes romantic relations in adulthood. However, individuals may not perceive or interpret social cues accurately. Social judgment and decision-making abilities are limited, and caretakers must assist the person with life decisions. Friendships with typically developing peers are often affected by communication or social limitations. Significant social and communicative support is needed in work settings for success. Continued 242.e2 Part II Diagnostic and Therapeutic Information TABLE EC 9.C SEVERITY LEVELS FOR INTELLECTUAL DISABILITY (INTELLECTUAL DEVELOPMENTAL DISORDER)—cont’d Severity Level Conceptual Domain Social Domain Severe Attainment of conceptual skills is limited. The individual generally has little understanding of written language or of concepts involving numbers, quantity, time, and money. Caretakers provide extensive support for problem solving throughout life. Spoken language is quite limited in terms of vocabulary and grammar. Speech may be single words or phrases, and may be supplemented through augmentative means. Speech and communication are focused on the here and now within everyday events. Language is used for social communication more than for explication. Individuals understand simple speech and gestural communication. Relationships with family members and familiar others are a source of pleasure and help. Profound Conceptual skills generally involve the physical world rather than symbolic processes. The individual may use objects in goal-directed fashion for self-care, work, and recreation. Certain visuospatial skills (e.g., matching and sorting based on physical characteristics) may be acquired. However, co-occurring motor and sensory impairments may prevent functional use of objects. The individual has very limited understanding of symbolic communication in speech or gesture. He or she may understand some simple instructions or gestures. The individual expresses his or her own desires and emotions largely through nonverbal, nonsymbolic communication. The individual enjoys relationships with well-known family members, caretakers, and familiar others, and initiates and responds to social interactions through gestural and emotional cues. Co-occurring sensory and physical impairments may prevent many social activities. Reprinted with permission from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington: APA; 2013. Chapter 9 Development, Behavior, and Mental Health 245 9 TA BL E 9. 7 CO M M ON LY U SE D PS YC H IA TR IC D RU GS A N D CO RR ES PO N DI N G AG ES O F FD A AP PR OV AL ( YE AR S) An tid ep re ss an ts /A nx io ly tic s* St im ul an ts (A DH D) * An tip sy ch ot ic s* Fl uo xe tin e (P ro za c) 7– 17 y r ( OC D) 8– 18 y r ( M DD ) De xt ro am ph et am in e + am ph et am in e (A dd er al l) 3– 12 y r Ar ip ip ra zo le (A bi lif y) 6+ y r ( irr ita bi lit y wi th A SD ) 10 + yr (B PD ) 13 + yr (s ch izo ph re ni a) Se rtr al in e (Z ol of t) 6– 17 y r ( OC D) M et hy lp he ni da te (C on ce rta , R ita lin ) 6– 12 y r (R ita lin ) Ha lo pe rid ol (H al do l) No t e st ab lis he d Es ci ta lo pr am (L ex ap ro ) 12 –1 7 yr (M DD ) De xm et hy lp he ni da te (F oc al in ) 6– 17 y r Ri sp er id on e (R is pe rd al ) 5– 16 y r ( irr ita bi lit y wi th AS D) 10 + yr (B PD ) 13 + yr (s ch izo ph re ni a) Li sd ex am fe ta m in e (V yv an se ) 6 yr –a du lt Qu et ia pi ne (S er oq ue l) 10 + yr (B PD ) 12 + yr (s ch izo ph re ni a) *F or m or e de ta ile d dr ug in fo rm at io n, in di ca tio ns , a nd d os in g, p le as e re fe r t o th e Fo rm ul ar y (C ha pt er 2 9) . AS D, A ut is m s pe ct ru m d is or de r; BP D, b ip ol ar d is or de r; GA D, g en er al ize d an xie ty d is or de r; M DD , m aj or d ep re ss iv e di so rd er ; O CD , o bs es si ve –c om pu ls iv e di so rd er . Ad ap te d fro m th e Ce nt er s fo r M ed ic ar e an d M ed ic ai d Se rv ic es fa ct sh ee ts (w ww .C M S. go v) a nd th e Fo od a nd D ru g Ad m in is tra tio n (F DA ). 246 Part II Diagnostic and Therapeutic Information VII. DEVELOPMENTAL REFERRAL AND INTERVENTION A. State Support 1. The Individuals with Disabilities Education Act (IDEA) sets forth regulations in the following areas for states that receive federal funding:7,18 a. Entitles all children with qualifying disabilities to a free and appropriate public education in the least restrictive environment. b. Early intervention services: Infants and toddlers younger than 3 years may be referred for evaluation to receive developmental services. Eligibility criteria vary by state; see The National Early Childhood Technical Assistance Center (www.ectacenter.org) for details. c. Qualifying disabilities: Children aged 3–21 years with autism, ID, specific LD, hearing or visual impairment, speech or language impairment, orthopedic impairment, traumatic brain injury, emotional disturbance, or other health impairment are eligible. d. Individualized Education Program (IEP): Written statement that includes a child’s current capabilities, goals and how they will be measured, and services required. A comprehensive team is needed to develop and implement the IEP. 2. Head Start and Early Head Start are programs instituted by the federal government to promote school readiness of low-income children aged 3–5 years and younger than 3 years, respectively, within their communities.19 3. Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) prohibit discrimination against individuals with any disability, more broadly defined as an impairment that limits function. B. Multidisciplinary involvement 1. Neurodevelopmental pediatrician, child neurologist, developmental/ behavioral pediatrician, other medical subspecialties as indicated 2. Genetic counseling for families of children with a genetic condition 3. Psychologists for formal testing, counseling 4. Rehabilitation and therapists 5. Educators VIII. DISORDERS OF MENTAL HEALTH A. Overview 1. Very common in the pediatric population, with an estimated 15%–20% of children in primary care practices requiring ongoing intervention for mental health or psychological problems.20 2. Surveillance for mental health issues should occur at all routine well-child visits from early childhood through adolescence, including history of mood symptoms and any behavioral issues. Chapter 9 Development, Behavior, and Mental Health 247 9 3. The Pediatric Symptom Checklist (PSC) is a general mental health checklist that screens for a broad array of disorders (see Table 9.4). 4. See the DSM-5 for a complete list of psychiatric diagnoses and full diagnostic criteria for the disorders mentioned.5 5. Pharmacotherapy for many disorders may be managed or monitored by the pediatrician. See Pediatric Psychopharmacology for Primary Care.21 B. Attention Deficit/Hyperactivity Disorder 1. Definition and epidemiology a. Persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development. b. Prevalence continues to rise. Affected 11.0% (6.4 million) of children in the United States in 2011, increased from 9.5% (5.4 million) of children in 2007.22,23 c. Majority of children continue to meet diagnostic criteria through adolescence, and ADHD does not typically remit after onset of puberty. Symptoms may last through adulthood, with significant impairment noted. 2. Screening a. Evaluate all children aged 4–18 years who have academic and/or behavioral issues for ADHD and common comorbid conditions (depression, anxiety, oppositional defiant disorder, conduct disorder)24 3. Diagnosis a. Diagnostic criteria: Inattention, impulsivity/hyperactivity that are more frequent and severe than typically observed in children of the same developmental age b. Symptoms must persist for at least 6 months, occur before the age of 12 years, and be evident in two or more settings5,25 c. Subtypes include combined (inattention, hyperactivity, and impulsivity), predominantly inattentive, or predominantly hyperactive/impulsive d. Diagnosis is made using history, observation, and behavioral checklists such as the Vanderbilt Assessment Scale (see Table 9.4) e. If the medical history is unremarkable, no further laboratory or neurologic testing is required f. Psychological and neuropsychological testing are not required for diagnosis but are recommended if other academic or developmental concerns are present25 4. Treatment a. Studies show pharmacologic treatment works best with behavioral therapy as an adjunct. b. Before starting a stimulant medication, history should be taken to exclude cardiac symptoms, Wolff–Parkinson–White syndrome, sudden 250 Part II Diagnostic and Therapeutic Information initiation of medication. Patients should be followed closely for the first 2–4 weeks, then every other week thereafter. d. Refer to the Physicians Med Guide prepared by the American Psychological Association (APA) and American Academy of Child and Adolescent Psychiatry (AACAP) for guidelines regarding medication use for depression in adolescent patients (parentsmedguide.org/ physiciansmedguide.htm).33 E. Feeding and Eating Disorders 1. Definition and epidemiology a. Includes not only anorexia nervosa and bulimia nervosa, but also pica, rumination disorder (repeated regurgitation), avoidant/restrictive food intake disorder, and binge eating disorder b. 12-month prevalence of 0.4% (anorexia nervosa) and 1%–1.5% (bulimia nervosa); 10 : 1 female-to-male ratio5 c. Common comorbidities include depressive, bipolar, and anxiety disorders 2. Diagnosis a. Anorexia nervosa i. Energy intake restriction and low weight (BMI < 18.5 kg/m2; severity of the disorder is stratified by BMI) ii. Fear of gaining weight iii. Disturbance in perception of body weight or shape b. Bulimia nervosa i. Recurrent episodes of binge eating that occur at least once per week for 3 months ii. Recurrent inappropriate compensatory mechanisms to prevent weight gain, or purging (self-induced vomiting, medication use such as diuretics or laxatives, exercise) iii. Self-evaluation excessively influenced by body shape or weight5 3. Treatment a. Aimed at nutritional rehabilitation and therapy (family-based or as a component of day treatment programs). Hospitalization may be needed in the case of medical instability. b. SSRIs indicated in the treatment of bulimia nervosa (see Table 9.7; no medications have been approved for use in anorexia nervosa34). F. Substance Use Disorders 1. Definition and epidemiology a. Lifetime diagnosis of alcohol abuse: 0.4%–9%, and dependence: 0.6%–4.3%35 b. Lifetime diagnosis of drug abuse or dependence: 3.3%–9.8%35 c. Common comorbid conditions: Disruptive behavior disorders, mood disorders, anxiety disorders Chapter 9 Development, Behavior, and Mental Health 251 9 2. Clinical presentation a. Acute change in mood, behavior, and cognition i. Mood: Low mood to elevated mood ii. Behavior: Disinhibition, lethargy, hyperactivity, agitation, somnolence, and hypervigilance iii. Cognition: Impaired concentration, changes in attention span, perceptual and overt disturbances in thinking (e.g., delusions) b. Impairment in psychosocial and academic functioning (family conflict/ dysfunction, interpersonal conflict, academic failure) c. Deviant or risk-taking behavior35 3. Diagnosis a. Establish standards of confidentiality b. Administer CRAFFT Questionnaire (see Box 5.2 in Chapter 5) c. Evaluate for age of onset of use; progression of use for specific substances; circumstances, frequency, and variability of use; and types of agents used d. Urine/serum toxicology workup should be part of any routine evaluation if any concern for substance use 4. Treatment a. Determine goals and readiness for change, and promote behavioral change through motivational interviewing36 b. Families should be involved with treatment c. Medications can be used to manage withdrawal symptoms and/or cravings d. Treatment of comorbid conditions should occur at the same time35 e. Find a treatment center at: www.SAMSHA.org IX. MENTAL HEALTH REFERRAL AND INTERVENTION A. Referral to outside mental health services may be necessary if patient care needs exceed scope of the provider’s practice, or if incorporated liaisons such as social workers or counselors are not available B. Varying levels of care depending on level of severity or concern 1. Outpatient treatment and therapy a. Cognitive-behavioral therapy (CBT): Recognition and replacement of harmful or maladaptive behaviors and the thinking patterns that may accompany them 2. Day treatment: Provides services such as counseling and skill building for at least 4 hours per day 3. Inpatient hospitalization: Indicated for patients with active SI, concern for self-harm, severe eating disorders, or any other unsafe situation 4. Emergency and crisis services: Resources available for crisis or emergency scenarios at all times, such as the National Suicide Prevention Lifeline (1-800-273-8255) or outreach teams37 252 Part II Diagnostic and Therapeutic Information REFERENCES 1. Capute AJ, Shapiro BK, Palmer FB. Spectrum of developmental disabilities: continuum of motor dysfunction. Orthop Clin North Am. 1981;12:3-22. 2. American Academy of Pediatrics. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118:405-420. 3. Moeschler JB, Shevell M, Committee on Genetics. Comprehensive evaluation of the child with intellectual disability or global developmental delays. Pediatrics. 2014;134:e903-e918. 4. Michelson DJ, Shevell MI, Sherr EH, et al. 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