DBP Conditions Flashcards
1
Q
Global Developmental Delay
A
Under age 5 (clinical severity cannot be assessed)
Fail to meet expected milestones in several areas (>1.5 to 2 SD below mean or >25% delay in at least 2 areas)
Requires reassessment over time
2
Q
Intellectual Disability criteria
A
1) deficit in cognitive (IQ < 70)
2) deficit in adaptive
3) onset during developmental period (infancy through adolescence)
3
Q
Intellectual disability 3 adaptive domains
A
1) conceptual: language, literacy, numeracy, understanding time and money
2) social: social judgment, interpersonal skills, social problem solving
3) practical: personal care, ADLs, transportation, occupational skills
4
Q
Mild ID
A
IQ range 50-55 to 70-75 with 3rd to 6th grade skills.
May achieve independent living and employability but most will need some support in these domains
Eg assistance with household activities such as budgeting, grocery shopping, food preparation, transportation
5
Q
Moderate ID
A
IQ range 30-35 to 50-55
1st to 3rd grade skills
Will need supportive living and structured/supervised employment and recreation
Learn personal care and household tasks with extended teaching
6
Q
Severe ID
A
IQ 20-25 to 35-40
Basic sight word reading
Self help and daily living skills require supervision and support
May succeed in sheltered work setting
7
Q
Profound ID
A
IQ <20-25
No reading, lack verbal communication
Will require support for self help and daily living skills
Remain dependent for all or most activities
8
Q
Most common teratogen causing ID
A
Alcohol
9
Q
Most common genetic disorder causing ID
A
Fragile X
10
Q
4 indications for neuro imaging in ID
A
1) abnormal head size
2) seizures
3) loss of skills
4) focal neurological signs
11
Q
7 Indications for metabolic testing in ID
A
1) family history
2) frequent miscarriages or early infant death
3) recurrent unexplained illness
4) organomegaly
5) loss of skills
6) unexplained deafness
7) optic atrophy, retinitis
12
Q
Most common co occurring condition in ID
A
Epilepsy
(Next ASD then ADHD)
(Then sensory impairment and CP w/ higher rates in more severe ID)
13
Q
When do we correct gestational age to?
A
Age 2, then stop correcting
14
Q
ASD severity level 3
A
Few words of intelligible speech who rarely initiates interactions and when does makes unusual approaches to meet needs only and responds to only very direct social approaches
Inflexibility of behavior and extreme difficulty coping with change. RRBs markedly interfere with functioning. Great distress or difficulty changing focus or action
15
Q
ASD severity level 2
A
Speaks simple sentences, interaction limited to narrow special interests, markedly odd nonverbal communication
Inflexibility of behavior and difficulty coping with change. RRBs frequent enough to be obvious to casual observer and interfere with functioning. Distress or difficulty changing focus or attention
16
Q
ASD severity level 1
A
Able to speak in full sentences and engages in communication but whose to and fro conversation with others fails and whose attempts to make friends are odd or unsuccessful
Inflexibility of behavior causes significant interference with functioning in 1 or more contexts, difficult switching between activities, problems with organization and planning hamper independence
17
Q
Mean age of ASD diagnosis
A
4 years (51 mo)
18
Q
Risk of ASD in siblings
A
12-19% (other studies say 3-14%)
About 30-33% risk if have >1 child with ASD
19
Q
Percentage of kids with autism that present with typical development then show loss and plateau of social or language skills (and age this typically happens)
A
25%
Approx 18-24 mo
20
Q
At what age can autism be reliably diagnosed?
A
14-16 mo
21
Q
Difference in presentation with girls
A
Lower level of RRBs
Restricted interests more socially acceptable
Girls better at compensating and camouflaging social deficit
22
Q
Factors associated with no longer meeting criteria for ASD
A
Higher cognitive skills at age 2
Participation in EI
Decrease in repetitive behaviors over time
23
Q
Early markers of ASD concern (demonstrated by 12 mo)
A
Decreased social attention and communication (less sharing of positive affect)
Inconsistent response to name
Delays in joint attention
Atypical object exploration (spinning, rotating)
Intense object oriented visual interests and unusual visual exploration
24
Q
Markers of ASD concern that show up closer to 24 months
A
Sensory aversions and interests (persistent mouthing, covering ears)
Motor stereotypies
Repetitive or limited or unusual use of toys
Narrow or intense interests
25
Screening for ASD
18 and 24 mo visits
MCHAT is approved 16-30 mo
26
Components of autism evaluation (medical tests and referrals)
Genetics: WES if available or CMA and fragile X
Audiology if speech delay
Vision if vision concern (other than poor eye contact) or prematurity/genetic condition
Metabolic testing (if symptoms like cyclic vomiting, lethargy, hypoglycemia with illness, organomegaly, poor growth, progressive loss of skills)
Lead if environmental risk factors
EEG if concern for seizure
MRI if other indication for MRI from neurology perspective
27
Differential ASD vs ID
Communication and behavior symptoms consistent with developmental age do not meet criteria for ASD
Repetitive behaviors may be seen in ID
If cognitive age 12 mo or younger can be difficult to diagnose ASD
28
Percent of ASD with ID
About 1/3
29
Differential ASD language disorders
Language disorders have normal nonverbal and no RRBs
Social pragmatic communication disorder if show impairment in social communication without RRBs
30
Differential ASD vs selective mutism
In selective mutism, early development is not disturbed.
In selective mutism, appropriate communication skills in certain contexts and settings
Even in setting where child is mute, social reciprocity is not impaired
In selective mutism, don’t see RRBs
31
Differential ASD and Rett
Rett shows disruption of social interaction during regressive phase (age 1 to 4 years) then it improves
32
Differential ASD stereotypic movement disorder
Stereotypic movement disorder has typical social communication
Don’t diagnose both unless the stereotypies lead to self injury and become the focus of treatment
33
Differential ASD and childhood onset schizophrenia
Period of normal or near normal development
Prodromal: social impairments, atypical interests and beliefs
Hallucinations and delusions are not features of ASD
34
What percentage of people with ASD have ADHD?
50-80%
35
Differential ASD and ADHD
Abnormalities of attention (overly focused and distractible) and hyperactivity are common to both
Comorbid if attentional difficulties/hyperactivity exceeds that typically seen in individuals of comparable mental age
36
What percentage of people with ASD have 1 comorbid mental disorder? What about two or more?
70%
40%
37
Differential anxiety and ASD
Common features: social withdrawal, difficulty with transitions, sensory reactivity
38
Percentage of those with ASD who have epilepsy
6-25%
Higher frequency in those with ID, lower gestational age, and females
39
If child with nonverbal/language deficits and ASD presents with changes in sleep/eating, increased challenging behavior, evaluate for:
Anxiety and depression
Medical
40
7 strategies used in ABA
Reinforcing
Shaping
Fading
Chaining
Extinction/punishment
Modeling
Prompting
41
What is ABA and how does it work?
Applying principles of learning theory to improve socially significant behaviors to a meaningful degree
Identify the ABC of behavior
Reinforce skills related to communication and social skills
Minimized behaviors that interfere with progress (Idea to teach skill so individual can have needs met without using problem behavior)
42
ABA strategy: Reinforcing
Reinforcement: consequence that increases probability of behavior
43
ABA strategy: shaping
Successive approximations of behavior
44
ABA strategy: fading
Gradually decreasing the amount of prompting
45
ABA strategy: chaining
Breaking down tasks into individual parts
46
ABA strategy: extinction
Removing reinforcement of behavior
47
ABA strategy: modeling
Demonstrating how to complete a task
48
ABA strategy: prompting
Providing varying levels of assistance to teach correct response
49
Amount of ABA
Lovaas EIBI 40 hrs
In practice at least 25 hours especially if focusing on foundational skills (joint attention and imitation)
Hours decreased for older kids working more on social/adaptive (15 hrs)
50
Advantages of center based and home based ABA
Center based: same age peers for modeling and practicing, increased frequency of 1:1 therapist driven interactions
Home based: in natural environment, improved generalization with family and community
Few studies on setting
51
Components of discrete trial training
1:1, distraction free setting, data based, trials repeated many times
5 steps: cue (instruction or question), prompt (gradual fading), response (correct vs incorrect), consequence (reinforcement or extinction), intertrial intervals
52
Limitations of discrete trial training
Implementation errors (inadequate reinforcement, too harsh consequences, poorly timed trials)
Poor generalization
53
Early start Denver model: what is it and the core strategies
Developmentally informed. ABA and relationship based. Intensive has most benefit
Core strategies 1) interpersonal exchange and positive affect, 2) shared engagement with real life materials and activities, 3) adult responsivity and sensitivity to child cues, 4) focus on verbal and nonverbal communication
54
Pivotal response training (PRT)
Naturalistic play based reinforcement of communication attempts and therapist modeling
Pivotal areas: 1) motivation to interact with others 2) self management 3) self initiation, 4) responsiveness to multiple cues, 5) parent training component
Outcomes impacted by age, symptom severity, parental stress, language proficiency
55
Relationship models
RDI = relationship development intervention
DIR = developmental individual difference relationship based
RDI parent based clinical treatment program teaching dynamic intelligence to enhance social reciprocity and flexibility
DIR circles of communication, mutual attention and engagement meeting child at their level, floor time
Overall less evidence and more concerns about outcome validity
56
TEACCH: treatments execution of autistic and related communication handicapped children
Highly structured and need a lot of training
Close relationship between parents and practitioners
Adapted to individual characteristics with goals based on standardized test results
Optimize learning and avoid frustration. Organize activities in predictable fashion
Minimize reliance on adult direction
Target ADLs, communication, social skills, EF, attention, engagement
57
Components of educational autism interventions
Early and intensive, least restrictive (small class, inclusion with supports)
Language based (alternative systems of communication, pragmatic and social support)
Behavioral modalities (FBA and behavior plan)
Address sensory issues
Teach adaptive skills
Skill generalization and maintenance
Objective monitoring
58
Speech therapy for ASD
Receptive and expressive deficits
Pragmatic (social scripts, video modeling, role play)
Nonverbal communication reinforced with signs, picture exchange, AAC
59
OT for ASD
Focus on ADLs and classroom skills
Upper extremity skills and visual motor
Sensory issues: limited evidence to support sensory strategies, sensory integration training
60
CAM for ASD: effective or emerging effective and well tolerated
Melatonin
Animals, music, yoga/exercise can be helpful in treating hypersensitivity, anxiety, improve social skills, mindfulness (emerging)
61
CAM GF, CF diets for ASD
unknown evidence, consult with doctor and assess overall nutrition before consideration
Some children may demonstrate increased immune activity to gluten distinct from celiac
62
CAM no/unknown evidence and unsafe/unknown safety, not well tolerated
Chelation (chelation agents to remove heavy metals and toxins, only if lead poisoning)
Hyperbaric oxygen
Stem cell transplant
63
CAM cannabis
Limited research and no clinical guidance
Used for insomnia, hyperactivity, epilepsy, anxiety, pain
Risk of cannabinoid disorder
64
CAM vitamins and supplement for ASD
Omega 3, vitamin B6, magnesium: don’t replace conventional treatments. Inconclusive, small sample sizes. No evidence and possible side effects of too much B6 (sensory neuropathy)
(One prep question says at least one high-quality study with several small limitations)
B12 (subcutaneous) and folinic acid may have benefit, low risk to try . Presence of folate receptor antibody may predict treatment response
Vitamin D treat to normalization
Consult doctor on supplements. Many not studied in children and can interact with other medications or supplements
Natural does not equal safe
65
CAM prebiotics/probiotics for ASD
Can influence microbiota composition and regulate gut brain axis. Improve GI symptoms, behavioral symptoms and reduce inflammation
Weak evidence (small sample sizes, qualitative self report questionnaires) but can try to
66
ADHD genetics
Risk in first degree relative 30-50%
Heritability 70-80%
Polygenetic
67
Genetic disorders associated with ADHD
Klinefelter
Turner
Fragile X
NF1
Williams
22q11
68
Diagnosis of ADHD
Symptom counts
At least 6 months
At least 2 setting
Some symptoms before age 12
Causes functional impairment
Not explained by another disorder
69
ADHD environmental etiology factors with most consistent evidence
Low birth weight
Prenatal cigarette
Extreme psychological trauma
70
Neurobiology of ADHD
Hyperactivity in frontal region (dorsolateral prefrontal cortex, inferior prefrontal, orbitofrontal), anterior cingulate, superior parietal, caudate, thalamus
Impairment in connectivity between frontoparietal and frontocerebellar
71
Stimulants mechanism of action
Methylphenidate: blocks reuptake of domaine and norepinephrine , promotes release of stored dopamine
Amphetamine: decreases reuptake and enhances release of new dopamine
72
DDx Comorbidities in ADHD
*a lot of things can cause to look inattentive
ODD/Conduct
Learning disorders
Anxiety
Depression
Medical: sleep, seizures, Tourette’s
73
Persistence of ADHD
Diagnosed at 3-7 years, 70% meet criteria at 12 years
Into adult 30-40%
Higher rates of persistence with psychiatric comorbidities, family history, childhood adversity
Anxiety or substance use in greater to 50% of those with childhood ADHD
74
Evidence based parenting programs
PCIT ages 2-7 single family
Incredible years ages 3-6 groups of parents
Triple P ages 0-12 single family
Parent management training ages 4-12 single family
Do not need an ADHD diagnosis for parent training behavior management
75
Findings from MTA study
Meds superior to behavioral
No difference in combination vs med only though combined lower med doses
Combined improved associated behaviors (anxiety, social skills, oppositionality, parent child relationship)
76
Behavioral/educational treatment algorithm for ADHD
1) psychoeducation, discuss risk/benefit of modalities and develop plan, begin evidence based behavioral treatment focused on areas of functional impairment (PBMT, school based eg report card, token economy, social skills, organizational skills)
2) obtain rating scales, reassess. If no concerns, maintenance monitoring. If continued impairment then choose intensified behavioral treatment or meds
77
Medication treatment algorithm for ADHD
1) psychoeducation, baseline ADHD symptoms and functional status and side effects, establish treatment goals
2) initiate MPH or AMP at lowest dose
3) assess response and side effects.
-inadequate response and minimal SE: increase dose and reassess, consider intensified behavioral
-treatment goals achieved minimal SE: continue current dose and behavioral
-symptoms improved with side effects: can side effects be managed? If yes manage side effects and continue. If no change meds and consider intensified behavioral
-inadequate progress toward treatment goals and significant side effects: change meds
78
Algorithm for ADHD and ASD
1) ensure child receiving evidence based behavioral/educational treatment for ASD (ABA, therapy to address communication, home and school base behavioral services, special ed)
2) if symptoms of ADHD persist, ask if the impairing behavioral symptoms are core ADHD (inattention, hyperactivity, impulsivity) or aggression, disruptive behavior, irritability.
3) if they are ADHD, med algorithm for ADHD. If they are not, ensure intensive behavioral treatment and consider neuroleptic if severe
79
Algorithm ADHD and tics
1) are tics chronic or severe? If no, back to the regular behavioral educational management algorithm. If yes, assess for anxiety or OCD
2) if has anxiety or OCD, ask if this is more impairing than the tics. If so, go to the ADHD anxiety algorithm. If not, ask if tics are more impairing than the ADHD.
3) If does not have anxiety or OCD, ask if tics are more impairing than ADHD
4) if tics are more impairing, establish treatment goals, initiate CBIT, consider continuing medical treatment of ADHD if already started, consider adding alpha agonist.
5) if tics not more impairing, back to the behavioral educational algorithm
80
Algorithm ADHD and substance use disorder
<8 no screen
9-11: screen by asking about friends use first then patient. If any use, brief intervention and consider referral for further evaluation or treatment
12+: how many times in the past year used tobacco, alcohol, marijuana. If none, exit pathway. If between 1-2x and monthly, assess use of other substance and brief intervention, continue to treat and monitor. If weekly or more often, severe SUD, assess use of other substance, brief intervention and referral
81
Algorithm ADHD and anxiety
***if the question implies urgency and really struggling with functional impairment (failing classes) start with stimulant then refer for CBT because that can have more immediate effect
1) are anxiety symptoms more impairing, if no go the the behavioral educational algorithm
2) if yes, begin treatment with CBT. If anxiety improves, back to the ADHD behavioral algorithm. If no, more intense CBT and if still no SSRI.
3) once anxiety symptoms are improving and less impairing than ADHD back to the ADHD behavioral algorithm. Until then keep treating anxiety with meds/CBT
82
Algorithm ADHD and depression
1) Red flag symptoms (suicidality, homicial ideation or behavior, signs of psychosis or mania) psych referral or ED/crisis
2) are depressive symptoms more impairing than ADHD? If no back to the ADHD behavioral algorithm.
3) if yes, treat depression with CBT and or SSRI.
4) once depression symptoms improving and not more impairing than ADHD back to the behavioral treatment algorithm. If not contour to adapt psychotherapy and meds for depression
83
Algorithm ADHD and disruptive behavior disorder
1) is impairment from DBD severe (suspension, severe/ dangerous aggressive behavior, delinquency)? If no, to the ADHD behavioral algorithm
2) if yes, evaluate current service and supports (therapies, special education) /!: implement intensive evidence based behavioral treatment.
3) if impairment from DBD is not as severe anymore, continue the behavioral supports and go the ADHD algorithm
4) if impairment is still there, adapt behavioral or consider pharmacology treatment (ADHD med algorithm)
84
Preschool ADHD algorithm
1) behavioral/education treatment
2) if inadequate response, obtain baseline rating scales, assess baseline functional status and side effects, consider intensified behavioral treatment
3) does child have severe baseline impulsivity, aggression, oppositional behavior, irritability, or concerns about mood/affect?
4) if no, start MPH IR 2.5. If yes, start alpha agonist (clonidine 0.1 or guanfacine .25 to .5 tablet)
5) assess response to treatment and side effects as per other algorithm.
6) if doing well for kids on MPH consider change to longer acting
85
Mechanism of action alpha agonists
Bind to alpha 2 adrenergic receptors in the prefrontal cortex which increases norepinephrine signaling in this region.
Improve behavioral inhibition and ability to concentrate
Also decrease sympathetic response making child calmer
86
Mechanism of action strattera
Selective inhibition of presynaptic norepinephrine reuptake in the prefrontal cortex
Capsule have to swallow
87
CAM ADHD: low risk, potential benefit
Still don’t stop conventional treatment for any of this, need more info
Omega 3
Iron (check ferritin and if low supplement even if not anemic)
Neurofeedback
Mindfulness
88
Mechanism of action viloxazine
=quelbree
Norepinephrine reuptake inhibitor
Also effects serotonin and has serotonin activity
Capsule can open
Effect size similar to other nonstimulants
89
When to consider non stimulants
When stimulants cause insufficient or intolerable side effects, concern for substance use or diversion, patient/family preference
90
Phoneme
The smallest unit of sound system that can change meaning
91
Phonology
The inventory of phonemes in language and the way they are sequenced and distributed
92
Morpheme
The smallest unit of meaning in language (word or word part)
93
Syntax
Rules for combining words and morphemes (grammar)
94
Semantics
Meaning of words or groups of words
95
Pragmatics
Social use of language encompassing verbal and nonverbal
Discourse management: initiating, maintaining, ending conversation), narrative discourse: generating a successful narrative
Nonverbal: picking up on facial, gestural or tonal cues
96
Features of social pragmatic communication disorder
Criteria
1. Deficits in communication for social purposes (greeting, sharing info) in manner appropriate to social context
2. Impairment in ability to change communication to match context or needs of listener
3.Difficulty following rules for conversation and storytelling (taking turns, rephrasing, how to use verbal and nonverbal cues)
4. Difficulties understanding what is not explicitly stated (making inferences) and non literal meanings of language
Impairs functioning (bullied/ostracized in school, problems with peers, emotional issues, conduct problems, school functioning)
Onset early developmental period but deficits may not manifest until social communication demands exceed capacity
Not attributable to other medical or neurological condition or language disorder or are not better explained by ASD or ID
97
Red flags for language disorder at various ages
10-12 months
18 months
2 years
3 years
4 years
5 years
No polysyllabic babbling
No words
No phrases, <25 words (most children have 50)
No short sentences, don’t understand wh ?s
No ABC song, can’t retell story
No understanding of rhymes, no interest in reading/writing
98
DSM V language disorders
Persistent difficulties in acquisition and use of language across modalities due to deficits in comprehension or production that include the following:
1. Reduced vocabulary (word knowledge and use)
2. Limited sentence structure (ability to put words and word endings together to form sentences based on grammar and morphology)
3. Impairments in discourse (ability to use vocabulary and connect sentences to explain or describe a topic or series of events or have a conversation)
Language abilities below expected for age, result in functional impairment, onset in early developmental period, not due to sensory impairment or medical or neurological condition or not better explained by ID
By age 4 years, individual differences in language are more stable. If impairments persist beyond 5 years, consider this diagnosis.
99
Speech sound disorders include:
Articulation errors
Phonological errors
Diagnosed when sound production not what would be expected by age and developmental stage
Not result of structural, neurological, or hearing impairment
100
Articulation error
Speed sound errors based on motor production deficit. Involves coordination of oral articulation
Eg: lateral lisp where s sounds like th. Never developmentally appropriate
101
Phonological errors
Speech sound errors based on inappropriate use of language rules related to linguistic aspects of speech production.
Eg reducing consonant clusters (tick for stick, boom for broom) or dropping final consonant (dah for dog, cuh for cup)
Can say the sound in other context
102
Age most speech sounds should be pronounced clearly and accurately according to age and community norms
Age 7
103
The late 8: sounds that are most frequently misarticulated
l
r
s
z
th
ch
dzh
zh
Can be within normal limits up to age 8
104
Apraxia/ dyspraxia
Impaired motor planning of speech movement sequences in the absence of neuromuscular deficit (weakness, paralysis)
Apraxia is more severe
Child wants to say words correctly but can’t. Inconsistent speech errors
If suspect: SLP eval and SLT is treatment
(The DCD of speech)
105
Dysarthria
Motor speech disorder. Problems with articulation, respiration, phonation, prosody. Associated with paralysis, weakness, poor coordination. Seen in CP, stroke, head trauma, progressive neuromuscular disorder
106
Dysfluency (what is it and when is it typical)
Pauses, hesitations, interjections, prolongations, and repetitions in speech
Typical in ages 2.5 to 4 years
If increasing or excessive, early sign of stuttering
107
Stuttering (childhood onset fluency disorder)
Disturbance in fluency and time patterning of speech inappropriate for age and language skills. One or more of:
1) sound and syllable repetitions, 2) sound prolongations of consonants and vowels. 3) broken words (pauses within words), 4) audible or silent blocking (filled or unfilled pauses in speech), 5) circumlocutions (word substitutions to avoid problematic words), 6) words produced with excess of physical tension, 7) monosyllabic whole word repetition
Causes anxiety about speaking or limitations in effective communication
Onset in early developmental period, not attributable to speech motor or sensory deficit or neurological insult
108
Descriptive gestures
Pantomime actions used when describing or representing an action, object or event
109
Conventional gestures
Have a standard social meaning
(Head shake, wave, thumbs up)
110
Informational gestures
Used to convey information (hold up 2 fingers for two)
111
Emotional gestures
Gestures to show emotion (shake fist for anger, wave arms in air for hooray, hand to mouth + gasp)
112
Emphatic gestures
Hand movements/beats with speech
113
Deitic gestures
Used to draw attention to object or event (showing, giving, pointing)
114
5 points in differential diagnosis for language disorders
1) hearing impairment
2) cognitive delay
3) social skills deficit, ASD (+RRBs)
4) if genetic disorder or neurologic disorder present
5) selective mutism (context)
115
Areas of brain where language is processed
Left hemisphere for all right handed and 2/3 of left handed
Left frontal gyrus activated in males, both sides in females
116
Prognosis of language delay at 2-3
Half or more resolve by age 5/K
117
2 Features weakly associated with improvement of language delays
Good receptive language
Mature symbolic play
118
Language delay and reading ability
Speech delay often precedes oral language disorders and dyslexia
Most late talkers do not go on to have language based learning disorder
40% if those with language delays have reading or cognitive deficits
119
Side effects of alpha agonists
Sedation
Dry mouth
Dizziness
Constipation/abdominal pain
Hypotension/bradycardia (monitor at baseline, with dose increase, and periodically). Don’t stop abruptly because of risk of rebound hypertension
120
Guanfacine vs clonidine effects
Guanfacine more selective to alpha2a receptors, less likely to result in sedation and dizziness
121
Some genetic disorders with increased risk of learning disabilities
NF
TSC
Turner
Klinefelter
Williams
122
Dyslexia
Term used to refer to a pattern of learning difficulty characterized by problems with accurate and fluent word recognition, poor decoding, and poor spelling.
Must specify if other problems are present (reading comprehension or math)
123
How to diagnose learning disability
-different academic areas
-time frame and criteria for diagnosis
Deficit in academic achievement in these areas:
Reading=word reading, accuracy, fluency, comprehension
Written expression= spelling, grammar, punctuation, clarity/organization
Mathematics= number sense, arithmetic facts, accuracy and fluency of calculation, math reasoning
Persist at least 6 months DESPITE provision of interventions that target these difficulties (evidence based curriculum)
Difficulty in academic skills substantially and quantifiably below expected for age AND causes difficulty with functioning
(At least 1.5 SD below, SS 78 or less, but criteria not necessarily that strict)
Not accounted for by another diagnosis
124
Red flags for future learning disorder in preschoolers
Trouble learning colors, shapes, letters, numbers
Difficulty with rhyming and lack of interest in playing rhyming games
Difficulty learning nursery rhymes
Poor pencil grip
Slower speech development, mispronounce words
Restless/distracted
Harder time following directions
125
Red flags for learning disorder in early elementary school and middle grades
Early elementary:
Slower to develop letter sound associations
Prolonged letter reversals (should resolve by end of second grade)
Sign confusion (+/-)
Fine motor delays
Middle grades (4-6)
Slower to learn prefix and suffix
Inversion of words (soiled/solid) or skip parts of words
Problems with word problems
Poor recall of math facts
Poor reading comprehension
Both:
Harder time with friendships, bullying
Behavior problems (short attention span, oppositional)
Takes a long time to do homework
Anxiety
somatic complaints
126
Response to intervention
-definition and elements
-tiers
School based approach that helps students struggling with academics/at risk of LD/not making expected progress to meet grade level.
Elements include:
-Universal screening
-Progress monitoring
-Intervention
Tiers
1. Whole class instruction
2. Small group intervention
3. Intensive intervention
127
Phonological awareness
Awareness that spoken words are made of unique sounds
128
Phonemic awareness
Awareness of how to segment and blend phonemes
One of the strongest predictors in future reading ability (look at rhyming in preschoolers)
129
Decoding
Sounding out words letter by letter
130
Orthographic mapping
Storing words along with their pronunciation and meaning of sight words
131
Screening in K and 1/2
K: letter identification, letter sound knowledge, manipulate phonemes in words presented orally
1/2: single word and nonsense word fluency and comprehension
132
Basic elements of learning disorder treatment
1. Remediation: specialized instruction
2. Accommodations: extended time, preferential seating, keyboarding, scribe, notes, etc
3. Modifications: decrease amount of work
133
Buzzwords for reading intervention
Systematic and highly structured program that focuses on explicit instruction for phonemic awareness and decoding
134
The brain for beginning readers
Visual areas (read word) —> parietotemporal region (letters linked to sound) —> left inferior frontal gyrus (Broca’s area; word analysis and articulation)
135
The brain for skilled readers
Activation of left occipitotemporal region (library of existing neural models, word form area)
136
The brain in dyslexia
Gray matter reduction in bilateral parietotemporal regions and left occipitotemporal region
Overactivation of left frontal gyrus (Broca’s area) —> compensation
137
Brain area for phonological awareness
Left parietotemporal
138
Brain area for rapid automatized naming
Left occipitotemporal
139
ASD severity level
Few words of intelligible speech who rarely initiates interactions and when does makes unusual approaches to meet needs only and responds to only very direct social approaches
Inflexibility of behavior and extreme difficulty coping with change. RRBs markedly interfere with functioning. Great distress or difficulty changing focus or action
Level 3
140
ASD severity level
Speaks simple sentences, interaction limited to narrow special interests, markedly odd nonverbal communication
Inflexibility of behavior and difficulty coping with change. RRBs frequent enough to be obvious to casual observer and interfere with functioning. Distress or difficulty changing focus or attention
Level 2
141
ASD severity level
Able to speak in full sentences and engages in communication but whose to and fro conversation with others fails and whose attempts to make friends are odd or unsuccessful
Inflexibility of behavior causes significant interference with functioning in 1 or more contexts, difficult switching between activities, problems with organization and planning hamper independence
Level 1
142
Age letter reversals appropriate until
7-8 years (second grade)
143
Atypical antipsychotics mechanism of action
Block dopamine and serotonin 5HT2A
Agonist 5HT1A
144
Side effects of atypical antipsychotics
Increased appetite, weight gain, hyperlipidemia, hyperglycemia
Sedation
Headache
Elevated prolactin (with risperidone)
Extrapyramidal in 10-20%
145
Antipsychotics monitoring
Baseline, at 3 mo and then annual
Height weight BMI
BP
Lipids (fasting)
LFTs
HbA1c and fasting glucose
EKG and prolactin at baseline (repeat only for symptoms)
146
Atypical antipsychotics extrapyramidal side effects
Acute dystonic reactions: involuntary muscle contractions that cause twisting or turning movements
Akathesia: restlessness and inability to sit still
Tardive dyskinesia: chronic involuntary movements that develop after prolonged use of antipsychotics
Cause by: blocking dopamine receptors in the brain (dopamine plays a role in motor control)
147
Atypical antipsychotics neuroleptic malignant syndrome
Fever, tachycardia, rigidity
Life threatening emergency go to the ER
148
Extended release guanfacine
-dosing and titration
Titrate no more than 1mg per week
Initial effects at 2 hours, max at 6, and duration 24
Max 4mg daily
Cannot cut
149
Bilingualism:
-language delays and bilingual status
-how to assess
Simultaneously learning 2 languages takes longer than learning one and rate of development in each language is somewhat slower than the rate of single language development. Receptive ability may be stronger than expressive (lags less)
Being exposed to two languages does not confuse children. They are good at distinguishing and code switch
Evaluate with bilingual assessment though monolingual norms lack validity
150
When to consider ADHD medication for preschoolers
Functional impairment persists despite implementation of psychosocial treatments OR if treatments inaccessible
Medication effectiveness is lower and side effects higher
Start with MPH
151
Guardianship
Term that describes a legal assignment of a surrogate decision maker for an individual for a variety of reasons which vary state to state. Once assigned, the guardian’s decisions for the individual are final
Reach of guardian’s power should only extend to areas in which individual has reduced decision making capacity (limited or partial guardianship)
Total guardianship remains more common in most states
152
Supported decision making
Methodology that leaves final decisions to the individual but allows and accounts for the roles of advice, influence, and support that others may play in that individual’s decision process
There is a push to move from guardianship to supported decision making with several states having formal laws
153
Recommended rate of discontinuation of guanfacine ER
1mg q3-7 days
154
Game based cognitive training for ADHD
Cognitive training is a non-pharmacologic method of ADHD treatment developed to target clinical symptoms and their coexisting neural cognitive deficits. Cognitive training is typically a computer intervention with game activities aimed at strengthening brain networks and improving cognitive abilities.
Classroom training programs through electronic games have shown some benefits and attention and hyperactivity, significant academic, or cognitive gains have not been shown.
Improvements in attention, span, and intervention setting, no transference to new settings
Little or no potential harm of game based therapies and evidence that improvement does occur in some cases however, stability and extent of benefits needs further investigation
155
Neuro feedback for ADHD
Non-pharmacologic strategy that aims on improving self regulation of brain activity. Auditory or visual modalities are used with feedback applications (games) to drive response. Several studies have been done with positive results though a few studies with large numbers and long-term follow up.
156
Instrumental gesture
Intended to achieve a goal, such as beckoning another person to come nearer, holding hand out to get something, arms up to have someone carry
