Developmental & Behavioral Pediatrics: An Overview for the General Pediatrics Boards

1. Developmental & Behavioral Pediatrics:An Overview for the General Pediatrics Boards Andrew Adesman, MD Developmental & Behavioral Pediatrics Steven & Alexandra Cohen Children’s Medical Center of New York

2. ABP Content SpecsGrowth & Development (5%) • Developmental Surveillance vs. Screening • Milestones

3. ABP Content SpecsDisorders of Cognition, Language, Learning (3.5%) • Intellectual Disability • Autism Spectrum Disability • Speech-Language Disorders • Learning Disabilities

4. ABP Content Specs Behavioral & Mental Health Issues (4%) • Common Behavioral Issues (Birth – 12 years) • Colic • Nail biting • Body rocking • Bruxism • Breath-holding • Enuresis • Night terrors vs. nightmares

5. ABP Content Specs Behavioral & Mental Health Issues (4%) • Externalizing Disorders • Aggressive behaviors, ODD, CD, • Anti-social behavior/delinquency • Internalizing Disorders • Phobias, Anxiety Disorders, • OCD • PTSD • Mood and Affect Disorders • Psychosomatic disorders

6. ABP Content Specs Behavioral & Mental Health Issues (4%) • Suicidal behavior, psychotic behavior, thought disorders • ADHD

7. Part 1: Normal Development

8. ABP Content SpecsGrowth & Development (5%) • Developmental Surveillance vs. Screening • Milestones

9. Surveillance Comprehensive child development surveillance includes: • Eliciting and attending to the parents’ concerns • Maintaining a developmental history • Making accurate and informed observations of the child • Identifying the presence of risk and protective factors • Periodically using screening tests • Documenting the process and findings

10. Screening In monitoring development during infancy and early childhood, ongoing surveillance is supplemented and strengthened by standardized developmental screening tests: - 9 months, 18 months, and 2 1/2 yrs - at times when concerns are identified

11. Developmental MilestonesFull Term Infant

12. Developmental Milestones2 Months

13. Developmental Milestones4 Months

14. Developmental Milestones6 Months

15. Developmental Milestones9 Months

16. Developmental Milestones12 Months

17. Developmental Milestones15 Months

18. Developmental Milestones18 Months

19. Developmental Milestones16 - 19 Months

20. Developmental Milestones24 Months

21. Developmental Milestones36 Months

22. Developmental Milestones4 Year Old

23. Rule of 4’s Count to 4 Recite a 4-word sentence Identify 4 primary colors Draw a 4-part person Build a gate out of blocks (picture a #4 as a gate) A stranger understands 4/4 (100%) of what they’re saying

24. Developmental Milestones5 Year Old

25. Developmental Milestones6 Year Old

26. Block Stacking

27. Feeding Skills

28. Play Skills

29. Developmental Red Flags • No head control by 3 months • Fisting beyond 3-4 months • Primitive reflexes persisting past 6 months • <50 words / no 2-word phrases by 2 years • Echolalia beyond 30 months

30. Tips for Clinical Cases • If a child is ill or uncooperative, consider a “low score” invalid • Chronic disease or recurrent hospitalizations can cause developmental delay • For premature infants, continue age correction until 18-24 months of age • For speech delay, always check hearing first

31. Suggestion: Use Bright Futures tables provided on course website

33. Drawing Capabilities

35. Gross Motor Achievements • Walking by 10–14 months • Climbing by 2½ years • Throwing and kicking a ball by 2 years • Pedaling a tricycle by 3 years • Hopping by 4 years • Skipping by 6 years

36. Gross Motor Milestones

37. Fine Motor Achievements • Stacking three or four blocks by 18 months • Completing simple form boards by 2 years • Threading beads by 3½ years • Cutting a piece of paper by 3 years • Copying geometric shapes by 4 years • Tying shoelaces by 5 years • Printing legibly by 6 years

38. Speech & Language Achievements • Speaking single words by 12 months • Making word combinations by 2 years • Making clear, simple sentences and being interested in books and stories by 3 years • Making conversation clear to others by 3 or 4 years • Reading by 5 to 6 years

39. Social Achievements • Dressing by 2 years • Self-feeding using cutlery by 3 years • Being toilet-trained by 3½ years • Playing cooperatively in groups by 3 years • Playing team games by 7 years

40. Part 2: Disorders of Cognition, Language, Learning

41. ABP Content SpecsDisorders of Cognition, Language, Learning (3.5%) • Speech-Language Disorders • Intellectual Disability • Autism Spectrum Disability • Learning Disabilities

42. Language Delay in a Toddler or Preschooler CONSIDER: Hearing Impairment Communication Disorders Global Developmental Delay: Intellectual Disability Pervasive Developmental Disorders Environmental Factors General Health

43. 1-6/1000 newborns 50% genetic 30% syndromic (e.g. Waardenburg, Pendred, Usher) 70% non-syndromic, (e.g. connexin 26/GJB2) 77% AR, 22%AD, 1% X-linked or mitoch. Hearing Impairment

44. 50% Non-genetic: TORCH infection Ear/craniofacial anomalies Birth Weight < 1500 gm Low Apgar Scores (0-3 at 5 min, 0-6 at 10 min) Respiratory Distress/ Prolonged mechanical ventilation, hyperbilirubinemia requiring exchg transfusion Bacterial meningitis/ Ototoxic meds Hearing Impairment

45. Conductive Hearing Loss Failure of sound to progress to the cochlea Most common cause is an effusion, in the absence of inflammation, usually due to otitis media Clues of a mild conductive hearing loss would include ignoring commands and slight increasing of the TV volume

46. Sensorineural Hearing Loss Secondary to Meningitis Bacterial meningitis is the most common neonatal cause of hearing loss Tends to occur early in illness, usually in the first 24 hours It is not related to the severity of the illness, the age of the patient, or when antibiotics were started

47. HEARING LOSS: Post-newborn Recurrent or persistent OME at least 3 mo Head trauma with fracture of temporal bone Congenital CMV often asymptomatic, HL may show up in later childhood (median age 44 months) Childhood infectious diseases e.g. meningitis, mumps, measles

48. Chemotherapy Structural anomalies: e.g. Mondini malformation, enlarged vestibular aqueduct Neurodegenerative disorders e.g. Hunter syndrome, demyelinating diseases (e.g, Friedreich ataxia, Charcot-Marie-Tooth) HEARING LOSS: Post-newborn

49. Hearing Loss - Audiogram Mild 25-39 Moderate  40-68 Severe 70-94

50. Age Appropriate Hearing Tests • Conventional Pure Tone Audiometry Screen: • Appropriate for school age children who can cooperate with commands • Tests each ear independently • Can differentiate between sensorineural and conductive hearing loss • Newborn Hearing Screening (3 tests; for newborns in the nursery): • Automated auditory brainstem response (AABR) • Transient evoked otoacoustic emissions (TEOAE) • Distortion product otoacoustic emissions (DPOAE)