Development Topic Reviews Flashcards
(167 cards)
1
Q
CPS Distinguishing tics from seizure?
A
Tics
- suppressible
- stereotyped
- associated with a premonitory urge
- worse during times of stress, fatigue, anxiety, excitement, talking about tics
- individuals can usually be distracted away from tics
- tics almost never interfere with volitional movement
2
Q
Diagnostic criteria for Tourette Syndrome
A
- Requires 2 or more motor and 1 or more vocal tics at some point in the disorder
- have had tics for at least 1 year or more
- tics begin before age 18 years
3
Q
Difference between simple and complex motor tics?
A
Simple
- brief, sudden, meaningless, involve one or only a few muscle groups
- usually presents in head and neck around 6-7 years old
- eye blinking, eye movement, nose twitching, head jerks, facial grimacing
Complex
- appear more purposeful, often are slower and more sustained duration, involve several muscle groups
- relatively coordinated movements
- brushing back hair bangs, tapping the foot, imitating someone else’s movement (echopraxia), making a sexual or obscene gesture
- can have dystonic posturing with writhing movements, jumping, abdominal flexion, etc
4
Q
Difference between simple and complex vocal tics?
A
Simple
- repetitive sniffling, throat clearing, barking, snorting
- blocking tics that stop sound and can be confused with stuttering
Complex
- echolalia (repeating others’ words), palilalia (repeating one’s own words), coprolalia (repeating obscenities)
5
Q
Diagnostic criteria Transient Tic Disorder?
A
Single or multiple motor and/or vocal tics that occur many times per day, nearly every day for at least 4 weeks, but no longer than 12 months
Onset before age 18
Criteria not met for Tourette or chronic motor or vocal tic disorder
6
Q
Natural history of tics?
A
Waxing and waning course
Maximal tics in early adolescence
90% persist into adulthood but most are very minor
7
Q
Management of mild tics?
A
Most mild tics don’t require treatment
Ensure parents know not to draw attention to tics –> should actively ignore them
Strategies for parents:
Ensuring the young person has adequate sleep and follows a regular sleep routine to prevent fatigue.
Agreeing on basic strategies for the young person to release the tics in a way that they are comfortable with:
identifying a quiet and safe place for them to go to when they feel the need to release tics
taking quick short breaks from a stressful activity
Switching to a different activity when tics build up
Guiding the young person to build self-awareness of stress levels and use of mindfulness techniques. This may include deep breathing exercises, colouring in or listening to music.
8
Q
Management of more moderate to severe tics?
A
Treatment is indicated for tics that interfere with psychosocial or physiological functioning
CBIT: 1st line therapy
Comprehensive behavioural intervention for tics
Pharmacology
- alpha agonists tier 1 - clonidine, guanfacine –> monitor for hypotension and bradycardia (and rebound hypertension when discontinuing)
- antipsychotics tier 2
- topiramate
9
Q
ADHD and Tics –> treatment options?
A
Per 2021 guidelines, safe to prescribe stimulants in co-occurring ADHD - Tic disorders
Requires careful monitoring of tic worsening
Where stimulants are not tolerated, trial of atomoxetine is suggested
10
Q
What is the most important investigation for a child with a receptive or expressive language delay?
A
Hearing test
11
Q
What are red flags for receptive language delay?
A
Does not respond to sounds, particularly parent’s voice (any age)
Does not look at/point at objects (15 months)
Does not follow simple directions (18 months)
Does not point to pictures or body parts when they are named (2yo)
Does not verbally respond or nod/shake head to questions (2.5 years)
Does not understand action words, does not follow 2-step commands (3yo)
12
Q
What are red flags for expressive language delay?
A
Does not babble (6-9 mo)
Does not say mama, dada, other names, <3 consistent words (15 mo)
Does not use word combinations (2yo)
Speech is very difficult for strangers to understand (3yo)
Does not ask for things (3yo)
13
Q
When does stuttering usually start, what is the natural history?
A
Stuttering usually begins 2-4y, M>F (4:1), common from 18 mon-7 years
Most resolve by adulthood but some need intervention
Often improves while singing, reading aloud, or talking to pets or toys; it increases with anxiety-inducing situations
14
Q
DSM diagnostic criteria for Childhood Onset Fluency Disorder (aka Stuttering)?
A
15
Q
What are indications for referral to SLP with stuttering?
A
- Parent or child concern
- Frequent episodes of dysfluency (b-b-but; th-th-the; you, you, you) > 3+ dysfluencies per 100 syllables
- Speech is completely blocked
- Discomfort or anxiety while speaking
- Presence of secondary behaviors (eye blinking, jaw jerks, head or other involuntary movements)
- Impaired function (social) or mental health (anxiety) associated with it
- Family Hx of stuttering or other speech-language disorder
- Persistent stuttering > age 4yrs
16
Q
1st line therapy for stuttering
A
Can trial indirect approaches but screen for indications for SLP REFERRAL early.
Indirect approach =
1. LIMIT situations & EXPECTATIONS that cause increased dysfluencies and stress
2. Demonstrate and model how to ADJUST SPEAKING RATE and complexity of language rather than reprimanding children for their speech errors or asking them to slow down
3. INCREASE OPPORTUNITIES for the child to experience fluent communication
17
Q
Difference between stuttering and developmental dysfluency?
A
Developmental dysfluency
- 5% of children are likely to be dysfluent between ages 2.5-5yo
- Brief periods of stuttering that resolve by school age
- occasional occurrence and brief (Once every 10 sentences or less)
- no tension in the facial muscles
- Normal tempo in speech
- Absent pauses within a word
- No marked pauses before attempting speech
- No frustration associated with speech
- Normal eye contact
Stuttering
- Can have faster than normal tempo, interrupted airflow, vocal tension, silent pauses within a word or before a speech attempt, frustration associated with speech, wavering eye contact, more frequent episodes of dysfluency
18
Q
3 most common conditions associated with school refusal?
A
Anxiety
Depression
Oppositional behaviour
19
Q
Best management for school refusal?
A
Screen for anxiety disorder
Parent management training and family therapy
Work with school personnel
Calmly send the child to school and reward child for each completed day of school
In cases of ongoing school refusal, referral to a child and adolescent psychiatrist and psychologist is indicated
SSRI may be helpful
20
Q
Risk factors for learning disorders?
A
Perinatal risk factors:
VLBW
Severe IUGR
Perinatal HIE
Prenatal exposure to substances including EtOH and drugs
Other risk factors:
Environmental toxins such as lead
Drugs like cocaine
Infections (meningitis and HIV)
Head trauma
Periventricular leukomalacia
21
Q
Diagnosis of specific learning disorder?
A
To be diagnosed with SLD, a person must have difficulties in at least one of the following areas for > 6 months despite targeted help:
- Difficulty reading
- Difficulty understanding the meaning of what is read
- Difficulty with spelling
- Difficulty with written expression (e.g. problems with grammar, punctuation or organization)
- Difficulty understanding number concepts, facts or calculation
- Difficulty with mathematical reasoning (e.g. applying math concepts or solving math problems)
These difficulties must not be due to:
- Intellectual disabilities
- External factors such as economic or environmental disadvantage or lack of instruction
- Vision or hearing problems, a neurological condition (e.g. pediatric stroke) or motor disorders
22
Q
Best way to diagnose learning disability?
A
Psychoed testing
23
Q
What age group is M-CHAT used for in Autism screening?
A
16-30 months
SCREENING tool
24
Q
What age group is the social responsiveness scale used in Autism screening
A
2.5-4.5 years
25
What age group is the autism spectrum rating scale used in?
2-15 years
SCREENING tool
26
What age group is the CAST (Child autism spectrum test) used in?
4-11 years old
SCREENING tool
27
What diagnostic tool is most commonly used in autism and what is it?
ADOS - Autism Diagnostic Observation Schedule: used for children 12 months to adult range. It evaluated social interaction, play, communication, behaviours and interest
DIAGNOSTIC test
28
What age group is the childhood autism rating scale used for?
2+ years
29
What two symptom domains does autism spectrum disorder encompass
1) social communication impairments
2) restricted, repetitive patterns of behaviours and interests.
30
Risk factors for autism (name 2)
male sex
positive family history
31
Early warning signs in children at risk for autism
- reduced or limited smiles
- limited or no eye contact
- limited reciprocal sharing of sounds and expresisons
- limiting babbling and gestures
- does not respond to name
- emerging repetitive behaviours
- lack of pretend play
- limited joint attention
-no meaningful phrases
- developmental regression
- parental concerns
32
What developmental milestones would you expect for a 6 month old?
sits tripod, rolls both ways
raking grasp
babbles
stranger anxiety
expresses emotions
33
What is a developmental red flag warranting referral for a 6 month old?
not able to sit tripod
no babbling
not smiling or back and forth interaction with parents
34
What developmental milestones would you expect for a 9 month old?
sits well (doesn't need hands)
pulls to stand
primitive pincer grasp
says "mama" "dada"
waves "bye-bye" and gestures "up"
object permanence (the object exists even when out of view)
separation anxiety
35
What is a developmental red flag warranting referral for a 9 month old?
not sitting well
decrease in vocalizations
36
What developmental milestones would you expect for a 12 month old?
walks a few steps, wide-based gait
fine pincher grasp, throws objects, feeds self cheerios
functional toy use (rolls a car)
1 word with meaning (beyond mama/dada)
understands 1 step command
Responds to own name
points at wanted items
explores from secure base
37
What is a developmental red flag warranting for a 12 month old?
no words or name recognition
not pulling to stand (9mo milestone)
38
What is a developmental red flag warranting referral for a 15 month old?
<5 words
does not understand 1 command (no gesture)
cannot point to 1 body part
no shared attention: not point at interesting items to show parents or bringing toys to parents
39
What developmental milestones would you expect for a 18 month old?
runs
removes clothing
tower of 4 blocks
knows 3 body parts
10-25 words
imitates housework; symbolic play (Teddy wants tea)
parallel independent play
40
What is a developmental red flag warranting for a 18 month old?
less than 15 words
not bringing toys to parents or showing items to parents (social considers for autism)
41
What developmental milestones would you expect for a 2 year old?
jumps
up and down stairs marking time
handedness established
6 blocks
2 step commands, 2 word phrases
>50 words, 50% intelligible to others (1/2)
temper tantrums, "mine" "no!"
42
What is a developmental red flag warranting for a 2 year old?
not able to go up and down stairs
<50 words, <2 word phrases
43
What developmental milestones would you expect for a 3 year old?
pedal tricycle, up/down stairs alternating feet
undresses
toilet trainined (2.5-3.5yrs)
turns pages of book, draws circle
3 step commands
200 words, 75% intelligible (3/4)
knows name, age and gender
counts to 3
shares, empathy, cooperative play
pretend play (role play)
44
What developmental milestones would you expect for a 4 year old?
hops on one foot
buttons, cuts shapes with scissors
100% intelligble
tells a store
counts to 4
has preferred friend
elaborate fantasy play
45
What is developmental coordination disorder?
problems with motor coordination that interfere with academic performance and social integration in otherwise healthy children
46
Which population does developmental coordination disorder typically present?
early school years
males >females
47
Common associated features/conditions co-occurring with developmental coordination disorder?
prematurity
male sex
LEFT-HANDED or ambidextrous
ADHD, Autism, learning disabilities, language impairment, anxiety and depression
48
Presentation of developmental coordination disorder?
clumsy
difficulty with running, bike riding, spots
difficulty with buttons, scissors, writing, shoelaces
low normal tone
4 or 5 strength raiting
small joint hypermobility (hands/feet)
49
Red flags that point away from developmental coordination disorder?
"hard neuro signs"
hyper or hypotonia (beyond low normal tone)
abnormal reflexes
cerebellar signs
50
DSM criteria for developmental coordination disorder?
A: motor skill testing substantially below expectations for age
B: negatively impacts daily functioning
C: onset in early development
*motor milestones achieved at typical age but difficulty in LEARNING MOTOR SKILLS
D: not better explained by intellectual disability, visual impairment, cerebral palsy, muscular dystrophy
51
how is motor skill testing completed in patients suspected to have developmental coordination disorder?
dx by OT or PT with Movement Assessment Battery for Children-2 (MABC-2) standardized tool
52
Treatment of developmental coordination disorder?
Pediatrician to make diagnosis
OT/PT
Assess for ADHD, LD, mental health, obesity, poor self-esteem
school supports like keyboard or more time for fine motor activities
*Motor deficits of DCD usually persist into adulthood
53
what age does autism usually present?
12-24 months (red flag for alternate dx if presents before 6mo)
54
typical presenting parent concerns for child with suspected autism?
Parent initial concerns may be:
- language delay
- lack of response when the child’s name is said,
- limited eye contact
55
risk factors for autism?
male
family history of autism (especially siblings)
Lacking "protodeclarative gestures" at 18 mo (sharing interests – vs protoimperative indicates just a want/need – 12mo)
56
DSM 5 Criteria for autism? *need to know
A: Impairment in social interaction and communication (all three subcriteria required)
1. Social reciprocity (eg reduced sharing of interests)
2. Non-Verbal (eg eye contact)
3. Relationships
B: Abnormal and restricted, repetitive behaviours, interests and activities (2 out of 4 needed)
1. Stereotyped speech/behaviours
2. Insistence on sameness
3. Restricted, fixated interests
4. Sensory
C: Presents in early development (may not be fully evident until later)
D: Interferes with daily functioning
E: Not better explained by intellectual disability or global developmental delay
57
Work up for children with autism?
chromosomal microarray for all
Consider:
- Fragile X
- MECP2 testing for Rett syndrome in girls with intellectual disability or regression
- PTEN gene testing if macrocephaly
- Metabolic screen
- TSH, T4 ?for missed congenital hypothyroidism?
- CBC, ferritin if restricted diet
- Neuroimaging if dysmorphism, microcephaly, extreme macrocephaly or seizures
- EEG if staring episodes or other suspicion for seizure
58
Treatment for autism?
intensive behavioural intervention as early as possible (2-3 yrs) (eg applied behavioural analysis)
if aggressive and >5yrs: risperidone (or intuniv)
if ADHD: methylphenidate (intuniv 2nd line)
if anxiety/depression: SSRI
if poor sleep: melatonin
59
When can a kid graduate from a rear-facing car seat to a front facing car seat (with 5 point restraint)?
>1 yrs old per AAP (>2yrs per CPS)
weight >10kg (22lb)
60
what age can kids graduate from front facing car seat to booster seat?
4 yrs old and >18 kg (40 lbs)
61
when can a kid graduate from a booster seat to a seat belt (still in the back seat)?
> 4ft 9inches(145cm), usually ~9 - 12 years old
Need to be tall enough to use the seat belt
62
When can a kid sit in the front seat?
13 yrs old
63
Key features of Rett syndrome?
Girl with normal development initially followed by:
loss of speech (*regression), limited eye contact
deceleration of head growth*
stereotyped hand movements (hand wringing/washing)
GTC seizures common
Sighing respirations with apnea +/- cyanosis
consider Rett if evaluating for autism
64
Diagnosis of Rett Syndrome?
MECP2 molecular analysis
65
inheritance patter and gene involved in Rett syndrome?
X-linked Dominant
presents in girls bc mutation to the MECP2 gene is lethal in males!
66
How do night terrors present?
child awakens abruptly from sleep with a loud scream, agitated, flushed face, sweating, and tachycardic
child may jump out of bed as if running away from an unseen threat
usually unresponsive, and, paradoxically, may become even more agitated by the parent/caregiver's efforts at calming
child usually does not remember the episode later.
occurs in the first third of sleep
typically around the same time each night
67
age group typical for night terrors
4-12 yrs old
68
treatment for night terrors?
Anticipatory awakening (scheduled awakening 30min prior to typical start time of night terror)
69
Common comorbidities of OCD?
- Tic disorders (30%)
- Major depression (26%)
- Developmental disorders (24%)
- ADHD
70
CPS approved Screening Tool for OCD
HINT = there are 2
#1 CY-BOCS
(Childrens Yale-Brown Obsessive Compulsive Scale)
- Age range: 5-18yrs
- Completed by: Parent, Self.
- Duration: 20-30min
#2 MOVES
(Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey)
- Age range: Schoolaged-adolescents
- Completed by: Self-report
- Duration: 5min
71
Diagnostic Criteria for OCD
A. PRESENCE of OBSESSIONS, COMPULSIONS, or BOTH
+
B. Obsessions or compulsions are TIME-CONSUMING (>1hr/day) or cause SIGNIFICANT DISTRESS or FUNCTIONAL IMPAIRMENT (social, occupational, ect)
+
C. Symptoms NOT ATTRIBUTABLE to physiologic EFFECTS OF SUBSTANCE (ex: drugs, meds) or MEDICAL CONDITION.
+
D. Disturbance is NOT BETTER EXPLAINED by the symptoms of ANOTHER MENTAL DISORDER
72
In OCD diagnosis how would you define an "obsession"?
Obsessions = (1) AND (2):
1. Recurrent, persistent intrusive thoughts / urges causing marked distress.
2. Subsequent attempt to ignore thoughts / urges to neutralize them by performing a compulsion.
73
In OCD diagnosis how would you define an "compulsion"?
Compulsions = (1) AND (2):
1. Repetitive behaviours / mental acts the individual feels compelled to perform in response to obsessions / rigid self-imposed rules.
2. Goal of repetitive behaviours / mental acts is to reduce distress or prevent a dreaded event (even if they are unrealistic).
74
What is the treatment for OCD (Obsessive Compulsive Disorder)?
PSYCHOEDUCATION for child and family
- Parents attend SPACE (Supportive Parenting for Anxious Childhood Emotions) programs to support and prevent enabling.
PSYCHOTHERAPY
- CBT subtype called ERP (Exposure & Response Prevention) therapy
+/- CHILD PSYCHIATRY REFERRAL
+/- MEDICATIONS
- SSRIs (Sertraline, Fluoxetine, Fluvoxamine) in >6yrs
- Rarely Clomipramine or Antipsychotics
75
CPS Screening Tool for Anxiety (2 tools) ?
#1. SCARED
(Screen for Child Anxiety Related Emotional Disorders)
- Age range: 8-18yrs
- Completed by: Self, Parent
- Duration: 10mins
#2. RCADS
(Revised Children Anxiety and Depression Scale)
- Age range: 8-18yrs
- Completed by: Self, Parent
- Duration: 5-10min
76
CPS Screening Tool for pediatric Depression (3 tools) ?
#1. MFQ
(Mood and Feelings Questionnaire)
- Age range: 6-19yrs
- Completed by: Parents, Self
- Duration: 5min
#2. CES-DC
(Center for Epidemiological Studies Depression Scale for Children)
- Age range: 6-17yrs
- Completed by: Self
- Duration: 5-10min
#3. RCADS
(Revised Children Anxiety and Depression Scale)
- Age range: 8-18yrs
- Completed by: Self, Parent
- Duration: 5-10min
77
CPS Screening Tool for Suicidality (2 tools) ?
#1. ASQ-suicide
(Ask Suicide Screening Questionairre)
- Age range: >10yrs
- Completed by: Clinician
- Duration: 5mins
#2. C-SSRS
(Columbia-Suicide Severity Rating Scaling)
- Age range: All ages
- Completed by: Clinician
- Duration: 10-15min
78
CPS Screening Tool for Childhood Trauma (2 tool) ?
#1. CTQ
(Childhood Trauma Questionnaire)
- Age range: >12yrs
- Completed by: Self
- Duration: 5-10min
#2. ACE-Q
(Adverse Childhood Experiences Questionnaire)
- Age range: 1-12yrs & >13yr
- Completed by:Parent, Self
- Duration: 5min
79
CPS Screening Tool for Selective Mutism (1 tool) ?
SMQ
(Selective Mutism Questionnaire)
- Age range: 3-11yrs
- Completed by: Parent
- Duration: 5-10min
80
CPS Screening Tool for Eating Disorder (1 tool) ?
EAT-26
(Eating Attitude Test)
- Age range: middle-to-high school aged children + teens
- Completed by: Self
- Duration: 5-10min
81
CPS Screening Tool for Sleep (1 tool) ?
BEARS Sleep Screening Tool
(Bedtime resistance, Excessive daytime sleepiness, Awakenings, Regularity, Snoring)
- Age range: 2-18yrs
- Completed by: Clinician
- Duration: 5min
82
CPS Screening Tool for ADHD (4 tools) ?
#1. SNAP-IV
(ADHD Parents and teacher rating scale)
- Age range: 5-18yrs
- Completed by: Parent, Teacher
- Duration: 15min
#2. ADHD Rating Scales
- Age range: 5-18yrs
- Completed by: Self, Parent, teacher
- Duration: 5-10min
#3. SWAN Rating Scale
(Strengths and Weaknesses of ADHD Symptoms and Normal Behaviour Scale)
- Age range: 6-17yrs
- Completed by: Parent, Teacher
- Duration: 5-10min
#4. VADRS
(Vanderbilt ADHD Diagnostic Rating Scale)
- Age range: 6-12yrs
- Completed by: Parent
- Duration: 5min
83
CPS Screening Tool for Substance Abuse (3 tools) ?
#1. CRAFFT Questionnaire
(Substance Use Disorder)
- Age range: 12-18yrs
- Completed by: Self or Clinician
- Duration: 5-10min
#2. BSTAD
(Brief Screening instrument for adolescent Tobacco, Alcohol, Drug use)
- Age range: 12-17yrs
- Completed by: Self
- Duration: 5min
#3. S2BI
(Screening to Brief Intervention Tool)
- Age range: Adolescents, Young adults
- Completed by: Self or Clinician
- Duration: 5min
84
As per CPS, how would you define a 'Disruptive Behaviour Disorder'?
A cluster of disruptive behaviours is considered to be at the disorder level when the following criteria are met:
1. Behaviours are ATYPICAL for child’s DEVELOPMENTAL AGE AND persist for > 6 MONTHS
2. Behaviours occur ACROSS SITUATIONS AND result in IMPAIRED FUNCTIONING
3. AND/OR BEHAVIOURS cause significant DISTRESS for both child and family
85
In a child with disruptive behaviours, what comorbidities or alternate diagnoses should you screen for?
- HEARING impairments
- VISION impairments
- FEEDING difficulties
- SLEEPING difficulties
- ?Early ADHD (impulsivity, hyperactivity, inattention)
- Language and Social COMMUNICATION DELAYS (Primary language communication disorder, ASD)
- ANXIETY (Excessive, persistent fears)
86
CPS Screening Tool for Disruptive Behaviour Disorders (3 tools) ?
#1. CBCL
(Achenback Child Behaviour Checklists)
- Age range: 1.5-5yrs, 6-18yrs
- Completed by: Parent, Patient
- Duration: 10-15min
#2. SDQ
(Strengths and Difficulties Questionnaire)
- Age range: 2-17yrs
- Completed by: Parent, Self
- Duration: 10-15min
#3. Pediatric Symptom Checklist
(Psychosocial screening)
- Age range: >4yrs
- Completed by: Parent, Self
- Duration: 5-10min
87
Term that refers to the distress that can arise from the incongruence between an individual’s experienced gender and their sex assigned at birth.
Gender dysphoria is a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)
88
Term that describes the way a person portrays gender to others through external means, such as clothing, appearance, or mannerisms; this may or may not reflect gender identity
Gender Expression
89
What is the clinician's roles in 'Positive Parenting'?
HINT: 5 roles
1. Help them build loving, responsive relationships with children (ex: rich with interaction, predictable, emotionally responsive, security)
2. Helping them accept that there are reasons for all behaviours (positive or negative). Many challenging behaviours can be managed through …
- Secure parent–child relationships
- A loving and attentive home environment
- Purposeful guidance from parents
3. Help mitigate the impact of early ACEs (adverse childhood experiences) in both children and parents by encouraging protective factors within families. Watch parent-child interaction. Reinforce what parents are doing well.
4. Recognize and respect difference (ex: Family approaches to crying, sleep, and behaviour vary culturally). Create a culturally safe environment by navigating points of variance with sensitivity.
5. Be aware and informed of the parenting literature, credible websites, and books for parents. Build links with local early years resource including child development and parenting programs, food banks, housing services, legal aid and job centres, literacy supports, and health services.
90
Term that describes ‘experienced’ or ‘affirmed’ gender, this is an individual’s internal, psychological sense of their own gender
Gender identity
91
In the Positive Parenting approach describe the (8) tenants of "Connect & Redirect".
Connect & Redirect Tenants:
- Reduce words
- Embrace emotions
- Describe (without lecturing)
- Involve the child in discipline
- Reframe a ‘no’ into a ‘yes’ (with conditions)
- Emphasize the positive
- Creatively approach a disciplinary situation
- Teach
92
Term that describes a person’s marked and persistent experience of an incompatibility between their gender identity and the gender expected of them based on their sex assigned at birth.
Gender incongruence is a diagnostic term used in the International Classification of Diseases Eleventh Revision (ICD-11) - use of this term should be limited to diagnostic contexts
93
In Positive Parenting, it is important for parents to understand the ‘ABCs’ of positive discipline in order to help identify patterns and make links between what is happening from child’s perspective and a specific behaviour.
What are the ABCs of positive parenting?
- A - Antecedents
- B - Behaviours
- C - Consequences
94
Term that describes the process of undergoing medical treatment to align one’s physical experiences with one’s gender identity (e.g., by using hormone blockers or gender-affirming hormones)
Medical transition
95
1. Define a Time-Out vs a Time-in
2. In CPS / Positive Parenting strategies, do they recommend Time-outs or Time-ins?
1.
- Time-out: Premise behind Time-Outs was that attention feeds behaviour. Therefore the goal is to create a brief break in all behaviours (ex: demands, explanations, apologies, eye contact, hugs) in distraction-free spot (ex: safe quiet chair).
- Time-In: Caregiver invites the child to sit and talk about their feelings and behaviour in an age-appropriate way which emphasizes connection and comfort.
- - - -
2. Time-Ins now recommended by CPS. Time-outs no longer recommended by CPS unless in situations of specific misbehaviours in children >3yrs.
96
Term that describes the process of expressing one’s gender identity outwardly to others through such actions as changing name, pronouns, and/or gender expression (e.g., clothing, hair style)
Social transition
97
There are certain commonalities amongst Parenting Training programs. List some parenting skils that are taught in these community based programs.
HINT: there are 10 total
1. Ensure positive and NURTURING PARENT-CHILD RELATIONSHIPS
2. Set DEVELOPMENTALLY APPROPRIATE EXPECTATIONS for the child
3. Provide clear, consistent EXPECTATIONS, limits and routines
4. Identify TRIGGERS for positive and negative behaviours (e.g., fatigue, hunger, disappointment)
5. Use POSITIVE PARENTING SKILLS such as giving salient rewards (e.g., praise or affordable items/activities) for select positive child behaviours
6. REDUCE negative or HARSH parent–child INTERACTIONS
7. IGNORE negative behaviours that are MINOR (i.e., ‘Pick your battles’)
8. Implement TIME-OUTS SELECTIVELY (i.e., for specific behaviours such as hitting) with clear parameters (e.g., limited duration of time in time-out)
9. Work as a TEAM with other parents and caregivers
10. COMMUNICATE with child care staff or schoolteachers
98
Umbrella term used to describe all individuals with a gender identity that differs from their sex assigned at birth and physical sex characteristics
Transgender - not all gender-diverse individuals identify with this term
99
Term referring to a person who identifies as having both a masculine and a feminine spirit, this term is used by some Indigenous communities and can encompass cultural, spiritual, sexual and/or gender identity
Two-Spirit
100
At what age do children identify differences between sexes
2 years of age
101
At what age do children label their gender with ease
3 years of age
102
At what age do children develop appreciation for gender stability - the notion that gender is stable over the life course
preschool years (ages 3 to 5)
103
Hallmarks of Gender Identity in the preschool years ( ages 3-5)
- gender stability - the notion that gender is stable over the life course
- gender is attributable to external features and appearances
- attunded to gender roles and behaviors
- align closely with those of the same gender and expressing preferences for toys or activities that are stereotypically associated with their gender
104
At what age do children begin to appreciate gender as an identity independent of external features
Ages 6 - 7 years
105
At what age is intensive reflection on the alignment of assigned and experienced gender trigger
Pubertal onset
106
As per CPS, what percentage of school-attending youth when asked about gender identity reported difference between sex assigned at birth and experienced gender
9.2% of respondents
107
Term that describes distinct, chronic stressors minorities experience related to their stigmatized identities, including victimization, prejudice, and discrimination
minority stress
108
Mental health concerns transgender youth are at elevated risk for
1. Depression
2. Anxiety
3. Eating Disorders
4. Self Harm
5. Suicide
6. Exposure to harassment and violence
109
Strategies to mitigate risk of mental health concerns and exposure to harassment and violence in transgender youth
Affirming experiences and environment
1. supportive parents
2. early social transition
3. inclusive and non-judgmental interactions with the health care system
110
Factors associated with reduced mental health conditions in transgender individuals
Younger age and earlier pubertal stage at time of presentation for medically affirming care
111
Diagnostic Criteria for Gener Dysphoria
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following (one of which must be Criterion A1):
1. A strong desire to be of the other gender or an insistence that one is other gender (or some alternative gender different from one’s assigned gender).
2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
3. A strong preference for cross-gender roles in make-believe play or fantasy play.
4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
7. A strong dislike of one’s sexual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.
112
Diagnostic Criteria for Gender Dysphoria in Adolescents and Adults
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:
1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced and/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
3. A strong desire for the primary and /or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
113
Strategies for proving a gender-affirming health care experience
1. Craft an affirming space
2. Employ inclusive language
3. Provide adolescent-oriented care
114
Pediatric Behavioural Insomnia definition
repeated difficulty with sleep initiation, duration, consolidation or quality that occurs despite age appropriate time and opportunity for sleep which results in some form of daytime functional impairment for the child or family
115
Features of sleep-onset assosciation disorder
Occurs in 6 months to school age
Infants/children who require parental presence to initiate sleep and at times of night waking
116
Limit setting disorder features
Occurs in toddlers to school age
Present with difficulty establishing limits, including but not limited to bedtime routines
117
Sleep timing disorder features
Occurs in school age to adolescents
Children/adolescents who prefer and early or later sleep onset and offset
118
Management for Pediatric Behavioral Insomnia
1. Behavioural Intervention - most effective treatment in typically developing children
2. Sleep hygiene and bedtime routines
119
Red flags in Pediatric Behavioural Insomnia (7)
1. Loud snoring or difficult breathing at night
2. Symptoms of mental health disorder
3. Extreme restlessness or unusual movements in sleep
4. Significant daytime behavior disorder in addition to behavioral insomnia
5. Insomnia in a child with mental health and/or physical health comorbidity that does not respond to behavioral treatment
6. Insomnia leading to school failure or academic difficulties
7. Excessive daytime sleepiness from insomnia
120
121
For the following reflexes describe their age of APPEARING and their age of DISAPPEARING:
- Sucking reflex
- Rooting reflex
- Moro reflex
- Adductor spread knee jerk
- Landau reflex
- Palmar grasp
- Parachute reflex
- Plantar grasp
- Tonic Neck Reflex (aka fencing)
- Babinskis (upgoing vs downgoing)
122
You have diagnosed a child with ADHD and want to start them on stimulant medications.
As per CTS, what red flags that should prompt referral to cardiology pre-starting stimulant medications?
(HINT: Red flags on HISTORY / PMHx / FHx / EXAM)
HISTORY:
- Shortness of breath with exercise (more than other children of the same age) in the absence of an alternative explanation (eg, asthma, sedentary lifestyle, obesity)
- Poor exercise tolerance (in comparison with other children) in the absence of an alternative explanation (eg, asthma, sedentary lifestyle, obesity)
- Fainting or seizures with exercise, startle or fright
- Palpitations brought on by exercise
- FHx of sudden or unexplained death including SIDS, unexplained drowning or unexplained MVCs (in first- or second-degree relatives)
- - - -
PMHX / FHx:
- Long QT syndrome or other Familial Arrhythmias
- WPW syndrome
- Cardiomyopathy
- Heart transplant
- Pulmonary hypertension
- Unexplained MVC or drowning
- Implantable defibrillator
- - - -
EXAM:
- Hypertension
- Organic (not functional) murmur present
- Sternotomy incision
- Other abnormal cardiac findings
123
Definition of ADHD
neurodevelopmental disorder that is a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
124
What significant adverse outcomes are associated with ADHD?
-educational difficulties
- difficult peer relationships
- increased rate of impulsive behavior in adolescence (MVAs, substance use, trauma etc.)
125
predictors of persistence of ADHD symptoms into adolescence or adulthood
- Combined inattention/hyperactivity
- Increased symptom severity
- Comorbid major depressive or other mood disorder
- High comorbidity (>3 additional DSM disorders)
- Parental anxiety
- Parental antisocial personality disorder
126
genetic conditions with higher prevalence of ADHD (consider in ddx)
Fragile X syndrome
Turner syndrome
Tuberous sclerosis
Neurofibromatosis
22q11 deletion syndrome
127
DSM-5 diagnostic criteria for ADHD
Inattentive type
- poor listening skills
loses or misplaces items
- sidetracked by external stimuli
- forgets daily activities
- diminished attention span
- lacks ability to complete schoolwork
- avoids homework or activities requiring concentration
- fails to focus on details and makes careless mistakes
Hyperactive/Impulsive type
- squirms/fidgets when seated
- marked restlessness
- driven by a motor
- lacks ability to play in quiet manner
- incapable of staying seated
- overly talkatative
Impulsive (difficulty waiting turn, interrupts conversations, blurts out answers)
Sx > 6mo in >/=2 settings, present prior to age12
128
Approach to diagnosis of ADHD
- several interviews for evaluation
- detailed complete history including birth history, development, medical history, family history.
- review academic progress with use of standardized scales.
- Perform thorough physical, neuro and dysmorphology exams
129
Differential for ADHD (conditions commonly misdiagnosed as ADHD)
- Learning disorder
- Sleep disorder
- Conduct disorder or ODD
- Anxiety disorder
- Intellectual disability
- Language disorder
- Mood disorder
- tic disorder
- Autism spectrum disorder
- Developmental coordination disorder
- Substance use disorder
130
Approach to non-pharmacological management of ADHD
Non-pharmacological
- psychoeducation
- parent behavioral therapy (first line in preschool age children)
- shared decision making
- classroom interventions
- CBT
- diet, exercise
131
List all categories and names of ADHD medications
Stimulants (first-line):
- methylphenidate (biphentin, concerta, foquest, quillivant)
- amphetamine (adderrall, vyvanse, dexedrine)
Non-stimulants:
- Atomoxetine (Strattera)
- Alpha-2 agonists (guanfacine or Intuniv XR, clonidine)
132
Which ADHD medications can be crushed or chewable?
Vyvanse - chewable and capsules sprinkled or diluted
Biphentin - granules can be sprinkled
Foquest - granules can be sprinkled
Quillivant - oral suspension or chewable
133
Side effects of Stimulant medications
1. Appetite Suppression
2. Sleep initiation difficulties
3. Depression - late side effect
4. Personality changes (irritable or moody)
5. Vasculopathic symptoms (Raynaud's phenomenon)
6. Slight tachycardia and hypertension (orthostatic hypotension in intuniv)
7. Psychosis (rare)
8. Priapism (rare)
9. Syncopal episodes (intuniv)
134
Indication for ECG prior to initiation of stimulants in children
Children at risk for stimulant-induced cardiovascular adverse effects (based on family history or a personal history/cardiac exam) should have ECG or cardiology consult before starting stimulants
135
Indications for pediatric cardiologist referral pre-starting stimulants
- Shortness of breath or poor exercise tolerance with no alternate dx
- Fainting or seizures with exercise, startle or fright
- Palpitations brought on by exercise
- FHx of sudden or unexplained death including SIDS, unexplained drowning or unexplained MVCs
- Long QT syndrome or other familial arrhythmias
- Wolff-Parkinson-White syndrome
- Cardiomyopathy
- Heart transplant
- Pulmonary hypertension
- Implantable defibrillator
- Hypertension
- Organic (not functional) murmur present
- Sternotomy incision
- Other abnormal cardiac findings
136
Which ADHD medications cannot be abruptly stopped and for what reason?
Unlike atomoxetine, stimulant drugs must be tapered slowly to prevent rebound HTN, tachycardia or rarely hypertensive encephalopathy
137
Management of disruptive and aggressive behaviour in patients with ADHD, ODD or CD
psychostimulants >> non-stimulants
risperidone has most evidence in absence of ADHD
138
What are areas per DSM-V that a person must have difficulties in to meet criteria for specific learning disorder
Difficulty reading
Difficulty understanding the meaning of what is read
Difficulty with spelling
Difficulty with written expression
Difficulty understanding number concepts, facts or calculation
Difficulty with mathematical reasoning
At least one area for more than 6 months despite targeted help.
139
Generally what level is IQ in Specific learning disorders
IQ is normal or above average – cannot have intellectual disability and learning disorder
140
At what age groups are letter reversal normal
between 5-8 years old
all should be normal by 8 - Magic 8!
141
What is dyslexia?
Specific learning disorder with impairment in reading
developmental uncoupling between reading and IQ
142
etiology of dyslexia
familial and heritable
50% of children have a parent with dyslexia
50% of siblings of dyslexic persons
143
clinical manifestations of dyslexia
problems in spoke and written language with mispronunciations, word-finding difficulties, lack of fluency in speech, labored reading.
Robust listening comprehension
144
When should chromosomal microarray gesting be offered?
any child with developmental disability, dysmorphic features, or congenital anomaly
1st line investigation with HIGHEST diagnostic yield.
145
In what cases are Karyotype offered instead of CMA?
Clinically suspected aneuploidy - Turner syndrome, Trisomy 21
Fam hx of chromosomal abnormalities
multiple spontaneous abortions
146
First line genetic investigations for child with GDD/ID
Chromosomal microarray
Fragile X DNA testing (FMR1) - most common genetic cause of ID (associated with macrocephaly)
147
Clinical presentation suspicious for Rett syndrome
initially normal development followed by loss of speech and purposeful hand use, stereotypical hand movement, gait abnormalities
148
genetic testing for Rett syndrome
MECP2 molecular analysis
149
When to consider whole-exome or genome sequencing testing?
coding regions for known genes, identifies causal mutations in up to 40% of patents with severe Intellectual disability
NOT recommended as 1st line for PCPs.
150
What standardized tests are used for IQ and reading evaluation?
IQ - WISK
Reading - WYAT
151
red flags suggestive of inborn errors of metabolism t o consider workup in kids with GDD/ID
- Recurrent episodes of vomiting, ataxia, seizures, lethargy, coma
- History of being severely symptomatic and needing longer to recover with benign illnesses (e.g. URTI)
- Unusual dietary preferences (e.g. protein or carb aversion)
- Regression in developmental milestones
- Behavioral or psych problems (psychosis at a young age)
- Movement disorder (e.g. dystonia)
- Family history of IEM or developmental disorder or unexplained neonatal or sudden infant death
- Consanguinity
- IUGR
- FTT
- HC or stature growth abnormality (>2SD above or under the mean)
- Facial dysmorphism (e.g. coarse facial features)
- Organomegaly
- Severe hypotonia
- Congenital nonfacial anomalies
- Sensory deficits, especially if progressive (e.g. cataracts, retinopathy)
- Noncongenital progressive spine deformities
- Neuroimaging abnormalities
152
Definition of nocturnal enuresis (primary)
Urinary incontinence during sleep in children >5 yrs old
Primary when bladder control never obtained
153
Secondary nocturnal enuresis definition
incontinence reoccurs after at least six months of continence
154
Non-Monosymptomatic enuresis definition
enuresis plus one of:
- Excessive (≥8 times/day) or minimal (≤3 times/day) voiding frequency
- Voiding postponement, holding maneuvers
- Daytime incontinence
- Urgency or dysuria (without urinary tract infection)
- Interrupted flow
- Sensation of incomplete emptying
155
comorbidities associated with enuresis
Constipation (82%)
Developmental Delay
OSA
Mental Health Issues
156
Etiologies of enuresis
diabetes mellitus or diabetes insipidus
renal disease
Hyperthyroidism
spinal dysraphism (=spina bifida occulta)
Infections
seizure disorders
cardiac arrhythmias
child maltreatment, trauma, psychosocial stressors, including bullying
157
Investigations for secondary and mono-symptomatic enuresis
Urinalysis
Voiding diary
158
First line treatment for primary enuresis
education and reassurance
159
Second and third line treatments for primary enuresis
Time voiding q2-3h
Drink less water after dinner
Avoid constipation
Bed wetting alarm x4months (use until 14 dry nights in a row) - highest success rate
DDAVP - short term use
160
How does DDAVP work for bed wetting and what must you counsel on?
synthetic analogue of ADH
dose 0.2mg before bed
STRICT water restriction 1h prior to avoid water intoxication
161
Selective mutism definition
- failure to speak in specific social situations despite speaking in other situations
- Children with selective mutism talk almost exclusively at home
- >1 month duration
162
treatment of selective mutism
reduce general anxiety rather than focusing on mute behaviours (typically underlying anxiety disorder)
- consider fluoxetine with CBT for children who school performance is severally limited
163
Dose of vit D supplement for infant 0-12mo?
400 IU/day
if high risk + breastfeeding, 800 IU/day (supplement beyond 12mo if still high risk)
164
Description of the presence of accessory nipples affects 1-6% off the population
Polythelia
165
Pain that increases before menses associated with firm, mobile nodularity
benign fibrocystic changes
166
differential diagnosis for breast mass in an adolescent female
1. fibroadenoma - most common
2. cysts
3. abscess
4. fibrocystic change
5. breast trauma
6. malignancy - rare
167
Suspicious features for a breast mass
1. painless
2. hard
3. irregular mass
4. mass > 5 cm fixed to surrounding tissue
5. skin changes
6. nipple retraction
7. regional adenopathy
