Pediatric Annotations # 2

1. Various tests:

A] Tests for Development: I] Based upon info from parents:

1. PEDS ( Parents' Evaluation of Developmental Status)

2. Ages and Stages Questionnaire

3. Infant Development Inventory

II] Based upon eliciting skills from children:

1. DDST II: Denver. Do you know Denver can be scored also! 0- 6 yrs

2. CAT/ CLAMS Development Assessment: infact our B&D likes it extensively. 0-36 months

I have seen our B & D using CAT-CLAMS more often than DDST, though in Peds Clinic, DDST is used invaribaly.

3. BINS (Bayley Infant Neurodevelopmental Screen) 3- 24 Mo

4. BDIST ( Battelle Developmental Inventory Screening Test) 12- 96 Mo

B] Cognitive or Intelligence tests:

1. WISc- III (Weshsler Intelligence Scale for Children): 6- 16 years

It obtains a Verbal IQ, Performance IQ, and full IQ scale

2. Stanford Binet Intelligence scale - IV edition: 2- yrs- adults

Measures verbal reasonong, quantitative reasonong, abstract/visual reasonong, ST memory, obtain a Test Composite

3. Kaufman Assessment Battery for Children (K-ABC)

4. Whereas in B&D clinic, we saw them using peabody test and Einstein Test very frequently.

C] For autism:

M- CHAT: Modified Checklist for autism in Toddlers

Recommended use at 18-24 Mo

23 yes or no questions. Theses responses are then converted to pass-fail items

Checklist failed when 2 or more of 6 'Critical Items' failed or when any 3 items failed.

D] For ADHD:

1. ADHD rating Scales:

Connors' Parent rating scale (CPRS)

Connors' Teacher rating Scale (CTRS)

2. DePauls's ADHD rating Scale

I have seen our B&D using these 2 scales very often.

Some more comments:

1. And then, we see "Early Childhood Inventory- 4: Teacher Checklsit" (children 3- 6 yrs age) is a yellow form and " "Early Childhood Inventory- 4: Parent Checklist" )ages 3- 6 yrs)- a green colored form- is often given to parents and teachers to be completed. This checklist has sets of questiosn ttesting in for various disoreders like ADHD, ODD, autism, depression,etc

2. CPT Continuous Practice test): A computer test done to check for inattention. In B & D clinic, we see kids sent to a computer room and work on the test. The test is 'deliberately made boring' as someone there aptly said. To assist while testing for ADHD.

3. Achembach: Is a child behavior checklist

4. A kid of ADHD is on medication. test uesd for follow-up onn such kids: Vanderbilt Test

E) Achievement tests:

WRAT: The wide Range Achievement Test: evaluates arithmatic, readinga nd spelling skills.

F) Personality Tests:

1. Minnesota Multiphasic personality inventory (MMPI-2)

2. Rorschach Test

3. Thematic apperception test

4. Sentence completion test (SCT)

2. PDD: Pervasive Developmenta Disorders

Though DSM-IV and DSM-IV-RT (revise text) classifies these disorders as PDD, many prefer to call them ASD (Autism Spectrum Disorders). They include:

Autism, Asperger syndrome, Rett syndrome, Childhood disintegrative disorder, and PDD-NOS (not otherwise specified)

3. Nightmares and nightterrors

NM: Are 'upsetting' dreams. Are universal occurrence

NT: Are a disorder of arousal, occurring during an abrupt (rather than thr usual slow) transition from stage 4 non-REM sleep to REM sleep. Occurs in approx 3 % population.

Night Terror versus Night Mares

a] Stage of sleep: NREM REM

b] Consolability Poor Good

c] Amnesia for event Yes No

d] Interest in returing to sleep: High Low

Remember this way: *Nightmare is a bad dream that occurs in REM phase and the kid is scared, hence 'consolable'; does not forget this 'bad dream' and does not want to go to bed easily beacuse he is still remebers it and is scared.

* Night terror: The kid can not be awakened and has no memory of the dream

NB: Onset of NTs in adolesence may indicate Temporal lobe epilepsy.

4. Primitive reflexes: Are neonatal reflexes which should be taken seriously if they are persisting beyond 6- 8 months of infancy.

There are many, but remember these:

a] Moro

b] Tonic labyrinthine reflex

c] Assymetric Tonic neck reflex (ATNR)

d] Positive support reflex

Tonic Labyrinthine Reflex:

In supine position, baby's head is gently extended to about 45 degree below horizontal. This produces realtive shoulder retarction and leg extension, resulting in the "surrender posture".

While with head flexion to 45 degree: Arms come forward (shoulder protraction) and legs flex.

This reflex is the baby's way of responding to gravity, hence it is otherwise known as "the baby balance reflex".
In extension, the TLR helps the baby to straighten out from the flexus habitus position.

5. Fragile X syndrome:

Macro-orchidism and prominent jaw.

6. Landau-Kleffner Syndrome:

Also called Aquired epileptic aphsia, this is oftern considered a differential dx in cases of PDD (pervasive developmental disoreders). The kid presents with seizures 3- 7 yers of age, and shows rwegression of milestones (speech and language). Sleep -deprived EEG will diagnose the disorder.

7. Selective Mutism:

A childhood anxiety disorder. Inability of the child to speak in certain social settings (such as daycare, school), despite speaking in other ,usually more familiar, settings (such as home).

8. Three subtypes of ADHD:

a] Predominantly Inattentive type: Minimum 6/9 symptoms from the inattention menu.

b] Predominantly Hyperactive/impulsive type: Minimum 6/9 symptoms from the hyperactive/impulsive menu

c] Combined type: minimum 6/9 from each menu

9. MTA (Multimodal Treatment study of children with ADHD) carried in 1999 concluded that drug therapy vastly helps ADHD.

10. FDA approved meds for ADHD:

a] Stimulants:

i) MPH/ Methyl Phenidate: Concerta, Focalin (Short acting)

ii) Dextro-amphetamine: Adderall

b] Non-stimulants:

Atomoxetin( strattera)

Clonidine

Note: a] Ritalin is a short-acting (effect lasts 3-4 hrs). Actually Ritalin LA (6- 9 hrs) and Ritalin SR (slow release) have replaced it for all practical purposes. Use of ritalin: Nowadays used to boost up effect of concerta or focalin as an additional dose if some home-work or late evening academics is needed. b] For all practical purposes, focalin XR or concerta is used as a first med for ADHD (or a patch form- Daytrana).

These meds are given q day as effect lasts reliably upto 10- 12 hrs. On week-days, parents may choose to not to use the meds.

c] Focalin XR is made by bead technology, concerta by OROS technology (tablet is compartmentalized, thus med releases slowly).

d] Straterra: Do not use on patient on albuterol solution (inhaled is not a c/I).

e] Long-term use of stimulants:

NO LT bad effects or good effects have been shown.

f] Clonidine:

If pt has an additional element of OD (oppositional defiant) behavior, clonidine is much more beneficial for ADHD.

11. Side effects of Stimulants used for ADHD:

1. Appetite suppression

2. Difficulty falling asleep: obvioulsy as they are stimulants!

3. Stomachaches: generally for initial 2-3 days

4. headaches

5. May precipitate tics: Tics are not an absolute C/I to use

6. Increased threshold for seizures: In a pt with seizure disorder, let his/her neurologist know about these meds.

NB: * Never take stimulants with orange juice as that will increase renal excretion.

* Chemical hepatitis and rare cases of liver failure with pemoline (cylert), but this med is no longer a first line med now a days.

12. Co-morbidities assoc with ADHD:

LD (learning disabilities), mild MR, ODD, conduct disorder, mood disorders, anxiety disorders

Tic disorder: 50 % kids with Tourettes syndrome have ADHD.

13. Prematurity is generally corrected until 2 years of age while following the kids for growth curves and milestones.

14. Stranger anxiety: 7- 11 months

Separation anxiety: 11- 15 Mo

Pincer grasp: 7- 11 months (typically 10 months)

15. Disorders of NREM phase of sleep:

Somnambulism

Night terrors

Bed wetting

Bruxism

Head banging

16. IQ : Mental age (MA)/chronological age (CA) x 100

17. Project DOCC: Delivery of chronic care. This is a mandatory topic for residency,in which residnts visit a home and meet caregivers of a kid who is on chronic care (eg, a pt of CP) or a lecture by a caregiver in clinic and residents interview them.