Transcript EO_018.13 Recognize and Mange Behavior and

PEDIATRIC DEVELOPMENTAL
AND
BEHAVIORAL DISORDERS
EO 018.13
REFERENCES
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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
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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
FAILURE TO THRIVE (FTT)
• 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)
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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
CAUSES OF ORGANIC FTT
• 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
CAUSES OF ORGANIC FTT
• Increased energy requirements
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Pulmonary disease: CF
Cardiac disease
Endocrine: hyperthyroidism, DI, hypopituitarism
Malignancies
Chronic infections
Inflammatory: systemic lupus erythematosus (SLE)
CAUSES OF ORGANIC FTT
• 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.
• Possible problem
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Caloric insufficiency
Decreased intake
Hypermetabolic state
Increased losses
Normal HC
FAILURE TO THRIVE PATTERNS
• Growth Parameters
- Decreased Wt.
Decreased Ht.
• Possible problem
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Structural dystrophies
Endocrine disorder
Constitutional growth delay
Genetic short stature
Normal HC
FAILURE TO THRIVE PATTERNS
• Growth Parameters
- Decreased Wt. Decreased Ht. Dec. HC
• Possible problem
- Intrauterine insult
- Genetic abnormality
FAILURE TO THRIVE (FTT)
• 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
FAILURE TO THRIVE (FTT)
• 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
FAILURE TO THRIVE (FTT)
• 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
FAILURE TO THRIVE (FTT)
• 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 alcoholrelated 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
FETAL ALCOHOL
SYNDROME (FAS):
• High-risk Populations
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Women who drink and have the following characteristics:
Low socioeconomic status
Poverty
Lack of education
Smoker
Use of other illicit drugs
Poor health
FETAL ALCOHOL
SYNDROME (FAS):
• 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
FETAL ALCOHOL
SYNDROME (FAS
• 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
FETAL ALCOHOL
SYNDROME (FAS
• 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
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Fetal alcohol exposure
Intrauterine anoxia
Prematurity
Meningitis
Significant head injuries
ATTENTION DEFICIT
HYPERACTIVE DISORDER(ADHD)
• History
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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:
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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
RETENTIVE ENCOPRESIS
• 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
RETENTIVE ENCOPRESIS
• Physical exam:
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Abdominal exam
Urinary - urinalysis
Rectal exam: large fecal mass in rectal vault
Anal fissures (result from passage of hard stools
Abdominal x-ray
RETENTIVE ENCOPRESIS
• Treatment
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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:
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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