Pediatric Residency Training Program
Behavioral and Developmental Pediatrics
Elizabeth Mumper M.D.
Peter Blasco M.D.
- Normal Developmental Milestones
- General Principles
- Developmental assessment and surveillanceare central components of health maintenance.
- Developmental domains include motor development, language development, problem solving, and psychosocial skills.
- It is essential to understand normal developmentand acceptable developmental variations to recognize pathologic patterns. In addition, it is important to monitor the attainment of developmental milestones in each domain to accurately diagnose children with developmental disabilities who may benefit from referral to early intervention programs.
- Development occurs in an orderly, predictable, intrinsic manner.
- Development proceeds from head to toein a proximal to distal fashion.
- Generalized reactions to stimuli develop into more specific, goal-directed reactionsthat become increasingly precise.
- Development progresses from total dependence to independence.
- Infants normally vary in their attainment of milestones.
- Development may be influenced by both intrinsic factors(e.g., child's physical characteristics, state of health, temperament, and genetic attributes) and extrinsic factors (e.g., personalities of family members, economic status, depression or mental illness in caregivers, availability of learning experiences in the environment, cultural setting into which the child is born).
- Developmental Assessment
- Developmental milestonesprovide a systematic way to assess an infant's progress.
- Attainment of a particular skill depends on the achievement of earlier skills(only rarely are skills skipped).
- Delays in one developmental domain may impair development in another domain(e.g., deficits caused by neuromuscular disorders may affect a child's ability to explore the environment, which in turn affects cognitive development).
- A deficit in one developmental domain may compromise the assessment of skills in another domain(e.g., it may be difficult to assess problem-solving skills in the child with cerebral palsy who understands the concept of matching geometric forms but lacks the physical ability to demonstrate that knowledge).
- Developmental screening tests provide structured methods of assessing developmental progress. Because many developmental screening tests lack sensitivity, parental concern should not be disregarded, even if the initial screen is normal.
- Developmental quotientsare used to determine whether a child's development is delayed and to measure the extent of delay. The quotient may be calculated as follows:
- DQ > 85: normal
- DQ < 70: abnormal
iii. DQ 70–85: close follow-up is warranted
- Developmental domains
include motor development, language skills, cognitive development, and social skills.
- Motor development.Information about motor milestones should be obtained from the history as well as from observation during the physical examination.
- Gross motor development evaluationincludes an assessment of milestones and neuromaturational markers. Milestones of gross motor development are listed in Table 2-1. Neuromaturational markers should also be assessed; these include primitive reflexes and postural reactions, as described in Table 2-2.
- Primitive reflexes, such as the Moro reflex, develop during gestation and are present at birth.They usually disappear between 3 and 6 months of age. Each primitive reflex requires a specific sensory stimulus to generate the stereotypical motor response. Infants with central nervous system (CNS) injuries show stronger and more-sustained primitive reflexes.
- Postural reactions, such as the parachute reaction, are not present at birth (i.e., they are acquired). These reactions, which help facilitate the orientation of the body in space, require a complex interplay of cerebral and cerebellar cortical adjustments to proprioceptive, visual, and vestibular input. Infants
with CNS damage may have delayed development of postural reactions.
Table 2-1. Gross Motor Milestones*
- Fine motor skillsinvolve the use of the small muscles of the hands. An infant's fine motor skills progress from control over proximal muscles to control over distal muscles. Fine motor milestones are listed in Table 2-3.
- During the first year of life, as balance in sitting and ambulatory positions improves, the hands become more available for the manipulation of objects. As control over distal muscles improves, reaching and manipulative skills are enhanced.
- During the second year of life, the infant learns to use objects as tools (e.g., building blocks).
Table 2-2. Primitive Reflexes and Postural Reactions*
Table 2-3. Fine Motor Milestones*
- Red flags in motor development
- Persistent fisting beyond 3 months of age is often the earliest sign of neuromotor problems.
- Early rolling over, early pulling to a stand instead of sitting, and persistent toe walking may all indicate spasticity.
- Spontaneous postures, such as scissoringin a child with spasticity or a frog-leg position in a hypotonic infant, are important visual clues to motor abnormalities.
- Early hand dominance (before 18 months of age) may be a sign of weakness of the opposite upper extremity associated with a hemiparesis.
- Differential diagnosis of motor delayincludes CNS injury, spinal cord dysfunction, peripheral nerve pathology, motor endplate dysfunction, muscular disorders, metabolic disorders, and neurodegenerative conditions.
- Language skills
- General principles
- Delays in language development are more common than delays in other domains.
- Receptive language is always more advanced than expressive language(i.e., a child can usually understand 10 times as many words as he or she can speak).
- Language and speech are not synonymous. Languagerefers to the ability to communicate with symbols (i.e., in addition to speech, this includes sign language, gestures, writing, and “body language”). Speech is the vocal expression of language.
- A window of opportunity for optimal language acquisition occurs during the first 2 years of life.
- Basic speech and language milestones are listed in Table 2-4.
- Periods of speech development
Table 2-4. Basic Language Milestones
- Prespeech period (0–10 months):Expressive language consists of musical-like vowel sounds (cooing) and adding consonants to the vowel sounds (babbling). Receptive language is characterized by an increasing ability to localize sounds.
- Naming period (10–18 months) is characterized by the infant's understanding that people have names and objects have labels.
- Word combination period (18–24 months):Early word combinations are “telegraphic” (e.g., without prepositions, pronouns, and articles). Typically, children begin to combine words 6–8 months after they say their first word.
- Differential diagnosis of speech or language delay
- Global developmental delay or mental retardation
- Hearing impairment
- Environmental deprivation
- Pervasive developmental disorders, including autism spectrum disorders
- Cognitive developmentinvolves skills in thinking, memory, learning, and problem solving.
- General principles
- Intellectual development depends on attention, information processing, and memory.
- Infant intelligencecan be estimated by evaluating problem solving and language milestones. Language is the single best indicator of intellectual potential. Gross motor skills correlate poorly with cognitive potential.
- In the school-age child, standardized intelligence tests measure both verbal skills and performance (nonverbal) skills. Significant discrepancies between verbal and nonverbal abilities suggest possible learning disabilities.
- Stages in cognitive development
- The sensorimotor period(birth to age 2 years) is a time during which the infant explores the environment through physical manipulation of objects. At first, the infant brings objects to the mouth for oral exploration. As peripheral motor skills improve, the infant's ability for precise manual-visual manipulation improves, leading to true inspection of objects. The infant therefore progresses from “learning to manipulate” to “manipulating to learn.”
- The stage of functional play begins at about 1 year of age when the child recognizes objects and associates them with their function(e.g., a 15-month-old boy puts a toy telephone to his ear and vocalizes).
- The stage of imaginative play begins when the child is able to use symbols(24–30 months; e.g., a young child uses blocks to build forts or uses sticks as eating utensils or guns).
- Concrete thinking(i.e., interpreting things literally) evolves during the preschool and early elementary school years.
- Abstract thinking(i.e., manipulating concepts and contingencies) evolves during the adolescent years.
- Cognitive concepts that evolve over time
- Object permanence, developing at about 9 months, is the concept that people and objects continue to exist even when an infant cannot see them. As a result of this ability to maintain an image of a person, separation anxiety (common at 6–18 months) develops when a loved one leaves the room.
- Cause and effectis understanding which actions cause certain results (e.g., learning that dropping toys over the high chair tray makes them fall to the floor). Infants typically explore this concept at 9–15 months.
- Magical thinkingis a normal state of mind during the preschool toddler years when a child assumes that inanimate objects are alive and have feelings.
- Red flags in cognitive development.Language development estimates verbal intelligence, whereas problem-solving skills estimate nonverbal intelligence.
- If skills are delayed significantly in both language and problem-solving domains, mental retardationshould be considered.
- If only language skills are delayed, hearing impairment or a communication disordershould be considered.
- If only problem-solving skills are delayed, visual or fine motor problemsthat interfere with manipulative tasks may be present.
- If there is a significant discrepancy between language and problem-solving skills, the child is at high risk for learning disabilities.
- Social skillsare the ability to interact with other people and the environment. Development of social skills is dependent on cultural and environmental factors. Milestones, in order, include developing:
- Attachment.Bonding with a primary caregiver begins at birth. Developing empathy is critical during the first 3 years of life.
- A sense of self and independence.The process of separation and individuation begins at about 15 months of age.
- Social play.Toddlers exhibit parallel play during the first 2 years of life. They learn to play together and share at about 3 years of age.
- Disorders of Development
- Motor Deficits
- Cerebral palsy
- Definition. Cerebral palsyis a group of static (i.e., nonprogressive) encephalopathies caused by injury to the developing brain in which motor function is primarily affected. Intelligence may be normal, but injuries to the brain that cause cerebral palsy often lead to other neurologic effects, including seizures, cognitive deficits, mental retardation, learning disabilities, sensory loss, and visual and auditory deficits.
- Epidemiology and etiology. Risk factorsare listed in Table 2-5. The timing of the injury may be prenatal or perinatal, or occur during the first few years of life. Prevalence of cerebral palsy is 0.2–0.5%. Five to fifteen percent of surviving infants with birth weight < 1500 g have cerebral palsy.
- Diagnosis.The basis of diagnosis is repeated neurodevelopmental examinations showing increasing tone or spasticity, hypotonia, asymmetric reflexes or movement disorder, or abnormal patterns in the disappearance of primitive reflexes or emergence of postural responses.
- Classification of cerebral palsy(Table 2-6)
- Spastic cerebral palsy.Affected patients have increased tone. This type of cerebral palsy may be subclassified into three groups.
Table 2-5. Risk Factors for Cerebral Palsy
Table 2-6. Classification and Characteristics of Types of Cerebral Palsy
- Spastic diplegiainvolves the lower extremities more than the upper extremities or face.
- Spastic hemiplegiais characterized by unilateral spastic motor weakness.
- Spastic quadriplegiais characterized by motor involvement of the head, neck, and all four limbs.
- Extrapyramidal cerebral palsy(commonly referred to as athetoid cerebral palsy). These patients have problems modulating
the control of the face, trunk, and extremities, often writhing. Significant oral motor involvement often occurs.
- Other causes of motor deficits include metabolic abnormalities(see Chapter 5, section IV), chromosomal abnormalities (see Chapter 5, section III) motor neuron diseases, degenerative diseases, spinal cord injury, congenital myopathies, leukodystrophies, and CNS structural defects.
- Cognitive deficits include mental retardation and learning disabilities
- Mental retardationis defined as significantly subaverage general intellectual functioning associated with deficits in adaptive behavior, such as self-care, social skills, work, and leisure. It is manifested before 18 years of age.
- Etiology. Causesare listed in Table 2-7.
- Classification and diagnosis.Using the Wechsler Intelligence Scale for Children or another appropriate psychometric measure of the intelligence quotient (IQ), the degree of mental retardation can be classified as:
- Mild(IQ = 55–69)
- Moderate(IQ = 40–54)
- Severe(IQ = 25–39)
- Profound(IQ < 25)
- Early intervention programs promote optimal development.
- Behavior management strategies are used to teach activities of daily living.
- Community resources and parent support groups are helpful.
Table 2-7. Causes of Mental Retardation
- There is a trend away from institutionalization of mentally retarded individuals. Many live in foster care or group homes and work in sheltered or supported environments.
- Learning disabilitiesare defined as a significant discrepancy between a child's academic achievement and the level expected on the basis of age and intelligence.
- Etiology.Causes include CNS insults (e.g., prematurity, closed head injury, lead poisoning, fetal alcohol syndrome), genetic disorders (e.g., fragile X syndrome), andmetabolic disorders (e.g., galactosemia). The most common cause is idiopathic.
- Types. Learning disabilitiesmay involve deficiencies in specific academic subjects (e.g., developmental disorders of reading, mathematics, or written expression) anddefects in processing of information (e.g., visual or auditory processing disorders).
- Management.Classroom accommodations, special education, individualized instruction, and bypass strategies (e.g., presenting information visually for the child with an auditory processing disorder) may be used to help compensate for the learning disability.
- Pervasive developmental disorder (PDD)
This spectrum of developmental disabilities affects multiple developmental areas, especially behavior and learning, with a wide range of severity.
- Autism. This condition is the prototypical PDD.
- Incidenceis subject to debate.
- Onset is prior to age 3 years.
- Autism is more common in boys.
- Clinical features
- Difficulty using language to communicate with others.Speech may be absent or limited and may have atypical intonation, cadence, and inflection. Children may useecholalia (i.e., repetitive words and phrases). At one extreme, there is no verbal language. At the other extreme, there are mild deviations in social language that may not be obvious to the casual observer.
- Unusual ways of relatingto people, objects, and events. Infants and toddlers may show decreased eye contact or may be difficult to console.
- Unusual or restrictive ranges of interests, play, and responses to sensations
- Unusual perseverative behavior or stereotypic movement rituals.Young children may have preoccupations with ideas, spinning objects, or shiny surfaces, whereas older children may develop more symbolic preoccupations, such as with train or bus schedules.
- Self-injurious behaviorssuch as head banging, hand flapping, or body slapping
- Associated clinical features.Other findings may include seizures, mental retardation, chronic diarrhea, constipation, difficulty toilet
training, multiple ear infections, sensitivity to sensory input, or unusual pain thresholds.
- Asperger syndrome
- This syndrome is also more common in boys.
- Clinical features
- Qualitative impairment in peer relationships and social interactions
- Repetitive, restricted, and stereotyped patterns of behavior, activities, and interests
- No clinically significant language delay.Language, in fact, may be advanced.
III. Dysfunctions of Attention (Attention Deficit/Hyperactivity Disorder, ADHD)
- Characteristics of ADHD include poor selective attention, difficulty focusing, or distractibility.Hyperactivity may or may not be present.
- Children with disorders of attention may show impulsivity, distractibility, disinhibition, and general behavioral immaturity.
- Epidemiology and etiology
- ADHD is more common in boys.
- The cause of ADHD is unknown.
- Genetic factors play a large role;30–50% of affected children have a first-degree relative with ADHD.
- Abnormalities in neurotransmitter function, especially dopamine and norepinephrine, also lead to symptoms.
- Differential Diagnosis
- Clinical Features
Specific criteria must be present, including:
- Symptoms before 7 years of age
- Symptoms in more than one environment (e.g., school and home)
- Impairment in functioning in school or in personal relationships
- Symptoms of inattention, including not being able to focus during classroom instruction, difficulty with organization, and forgetfulness
- Symptoms of hyperactivity, which may include fidgeting, acting as if driven by a motor, excessive talking, and difficulty remaining seated in the classroom
- Symptoms of impulsivity, which may include behavior such as blurting out answers before a question is completed
- Effect of attention problems on the child with ADHD
- Difficulty conforming to classroom routine
Table 2-8. Differential Diagnosis of Attention Deficit/Hyperactivity Disorder
- Social adjustment problems
- Damage to self-esteem
- Impaired relationships with parents and peers
- Difficulty learning
- Possible comorbidities: anxiety, conduct disorder, oppositional-defiant disorder, and obsessive-compulsive disorder
- Assessment and diagnosis of ADHD
- Methodsinclude parent and teacher questionnaires, psychoeducational testing, direct observation, a complete physical examination, and hearing and vision testing.
- Most valid, reliable assessments use several sources(teachers, parents, and counselors) and combine several methods. Direct and specific observations are most useful.
- The key focusof assessments should be to identify the child's strengths and coping strategies.
Therapy is multifaceted and includes:
- Demystification.This vital process explains ADHD to the child and family.
- Classroom modifications.Preferential seating and elimination of distractions may be useful.
- Educational assistance.Help should be tailored to the individual needs of the student. Strategies include placement in small groups or one-on-one teaching, help with organizational skills, and strategies to bypass weak areas (e.g., keyboarding if handwriting is a problem).
- Counseling.Topics to address may include self-esteem enhancement, depression, anxiety, behavioral modification, and social skills training. Parents also need support, education, and training.
- Stimulantsare first-line pharmacologic treatment. These drugs may improve attention, impulsivity, and hyperactivity.
- Mechanism of action. Stimulants appear to enhance catecholamine transmissionin the CNS. Higher levels of dopamine and norepinephrine improve ADHD symptoms.
- Dosage. The dosage needed to control symptoms varies among patients.
- Side effects (Table 2-9). Medication effects should be monitoredusing side effect diaries and behavior rating scales.
- Useful stimulants. Optionsinclude methylphenidate (Ritalin) and amphetamines (e.g., dextroamphetamine, dextroamphetamine-amphetamine combination [Adderall]).
- Nonstimulant medicationsmay be considered as second-line therapy. These drugs include tricyclic antidepressants and adrenergic agents such as clonidine. Clonidine may be especially useful at bedtime to counter stimulant effects or in combination with a stimulant for patients who have comorbid aggression or tic disorders. The treatment of comorbid depression or anxiety with selective serotonin reuptake inhibitors or bupropion may improve attention problems.
- Specific Sensory Impairments
- Hearing Impairment
- Epidemiology. Permanent hearing lossoccurs in at least 1:600 newborns.
Half these infants are normal newborns who have no obvious evidence of suspected hearing impairment.
Table 2-9. Common Side Effects of Stimulants
- Early identificationof the hearing-impaired child is vital because outcome is demonstrably better if intervention occurs before 6 months of age. Sequelae of late identification include delayed speech and language skills and academic and behavior problems.
- Genetic factorsaccount for at least 80% of childhood hearing impairment; 80% of genetic transmission occurs by autosomal recessive inheritance.
- About 20% of childhood hearing loss is caused by perinatal, prenatal, or postnatal factors (e.g., congenital infections, prematurity, bacterial meningitis, middle ear anomalies).
- Prognostic factors. Variables influencing impactof hearing loss on function and development include:
- Degree of loss
- Etiology.Children who inherit deafness usually fare better than those with acquired deafness. Children with acquired deafness are at higher risk for other neurologic impairment.
- Family atmosphere.Family willingness and ability to use sign language have a major impact on the child.
- Age at onsetof acquired deafness. Children who become deaf before 2 years of age are at a disadvantage compared with those who are able to incorporate language structure before deafness.
- Timing of amplificationand educational interventions. The earlier this occurs, the better.
- Cochlear implants.Although these may lead to dramatic improvements in hearing, their use is controversial in some deaf communities.
- Medical evaluationfor hearing loss
- Complete history (including history of perinatal infections and antibiotic exposure) and physical examination, focused on a thorough ear examination
- Genetics evaluationand chromosome studies if there are suspicious clinical findings or family history
- Creatinine level, because of the association between kidney disease and ear abnormalities (Alport syndrome; see Chapter 11, section VII. B)
- Viral serologiesif clinically indicated, looking for toxoplasmosis, rubella, cytomegalovirus, herpes, and other viruses that can cause deafness (i.e., TORCH infections)
- Consider a computed tomography scan of the inner ear if etiology is undetermined.
- Hearing screening recommendationsare given in Chapter 1, section IV.D.
- Visual Impairment
- Incidenceis 1:1600 children.
- Classification of blindnessuses measures of corrected acuity in the
better eye as determined by Snellen chart testing and by determination of visual fields.
- Leading causesof blindness in children
- Trachoma infectionis common in developing nations and is the primary cause of blindness worldwide.
- Retinopathy of prematurity(see Chapter 18, section VII)
- Congenital cataracts(see Chapter 18, section VIII.A)
- Effects of blindness on developmentinclude delayed locomotion, decreased fine motor skills, and difficulties with attachment.
- Adaptive skills
- Developing auditory perception skills
- Using haptic perception, (e.g., feeling someone's face to form a mental image of them by combining kinesthetic spatial feedback and input from tactile sensation)
- Vision screeningis described in Chapter 18, section I.
- Common Behavioral Concerns
- Colic. Colic is significant because it has the potential to disrupt attachment
between infant and parents, and it can be a source of family stress.
- Definition. Colic is crying that lasts > 3 hours per day and occurs > 3 days per week.(Normal crying usually lasts up to 2 hours/day at 2 weeks of age and increases to 3 hours/day at 3 months.)
- Epidemiology.Colic occurs in approximately 10% of newborns.
- Etiology. Colic has an unknown basis and may have many causes.
- Characteristic features
- Occurs in healthy, well-fed infants
- Begins at 2–4 weeks of age and resolves by 3–4 months of age
- Involves periods of irritability, which typically begin in late afternoon or early evening
- Differential diagnosis.Sources of pain and discomfort that may be confused with colic include intestinal gas, milk protein intolerance, food allergy, corneal abrasion, otitis media, testicular torsion, inguinal hernia, and digital ligature (i.e., hair wrapped around finger or toe).
- Treat any identified conditions.
- Reassure parentsthat their infant is healthy and that the colic is not the parents' fault.
- Recommend comfort measures, which may include decreased sensory stimulation (e.g., placing in front of a blank wall), increased sensory stimulation by movement or vibration (e.g., automobile rides, rocking, stroller rides), or positioning (e.g., swaddling or placing infant on side or stomach while awake).
- Definition.Enuresis is urinary incontinence beyond the age when the child is developmentally capable of continence.
- Classificationis based on the timing and history.
- Nocturnal(occurs only during sleep) versus diurnal (daytime)
- Primary(never been consistently dry) versus secondary (at least 6 months of prior consecutive dryness)
- Nocturnal enuresis is more common in boys.
- Incidence is based on age.Bed-wetting occurs at least monthly in:
- 30% of 4 year olds
- 15–20% of 5 year olds
- 10% of 6 year olds
- 3% of 12 year olds
- Fifteen to twenty percent of those with nocturnal enuresis also have diurnal enuresis.
- Etiology. Causes may include:
- Genetics. Strong familial tendency for nocturnal primary enuresisis supported by a gene identified on chromosome 13.
- Psychosocial. Secondary enuresisis often associated with stressful situations, such as the birth of a sibling, death of a family member, or the separation of parents.
- Chaotic social situationat home may contribute to poor voiding habits and daytime enuresis.
- Sleep–arousal mechanismsplay an elusive role. Although not proven, parents frequently report children with nocturnal enuresis have deeper sleep and are more difficult to arouse than dry siblings.
- Urine volume.Some patients may produce large volumes of dilute urine, which may be caused by lack of normal diurnal variation in vasopressin release.
- Bladder capacity.Some children may have a small bladder capacity.
- Organic causesof secondary enuresis. Etiologic factors include urinary tract infections, child abuse, and diabetes mellitus.
- Constipation is a comorbid or etiologic factorin some patients. Hard stool can impinge on the bladder. Symptoms of encopresis may be present.
- Historyshould include questions about family history, pattern of enuresis, associated symptoms, time of onset, and parental interventions or attempts at therapy.
- Physical examinationshould be complete and evaluate the abdomen, genitals, perineal sensation, anal wink reflex, and lower spine. A neurologic examination should be performed.
- Laboratory evaluation
- Urinalysis and urine culture
- Additional laboratory or imaging studiesshould be tailored to the history and physical examination. Imaging of the kidney and bladder or magnetic resonance imaging of the spine or other studies may be appropriate.
- Management of uncomplicated nocturnal enuresis
- Education–demystification.It may help to uncover misconceptions, remove blame from the child, and explain anatomy and physiology.
- Conditioning alarms.An alarm sounds every time urine is produced, and the child learns to respond in anticipation. This technique is successful in two thirds of cases, but itrequires patient motivation and parental support. This therapy must be used for a minimum of 3–5 months.
- Pharmacotherapy. Medications, if used alone, result in frequent relapses.Best efficacy uses a combination of alarms, medications, and behavioral modification.
- Desmopressin acetate (DDAVP), which decreases urine volume, is used because the child with enuresis may have no normal circadian rhythm for release of arginine vasopressin. Although a child may achieve complete dryness with DDAVP, relapse after termination of medication is common.
- Tricyclic antidepressantshave limited efficacy to decrease the frequency of nighttime wetting. Imipramine is the most widely used agent. Patients often relapse after medication is discontinued, and there is a danger of fatal cardiac dysrhythmias with an overdose.
- Other management options. Behavioral modification(e.g., star charts, praise for dry nights, limited fluids before bed, voiding before bed), hypnotherapy, and treating coexisting constipation may be useful.
- Management of diurnal enuresis.Bladder stretching exercises, if small bladder capacity is suggested; schedule timed voiding every 90–120 minutes; and treatment of any coexisting constipation may be effective.
(see Chapter 10, section VII)
- Sleep Problems
- Epidemiology.It is estimated that more than half of infants experience sleep problems as perceived by parents.
- Normal sleep patterns
- Day–night reversals are commonin the first weeks of life. The normal pattern is random sleep for 4 weeks, after which clustering of sleep time occurs.
- Sleeping through the nightis defined as sleeping more than 5 hours after midnight for a 4-week period. Fifty percent of infants sleep through the night at 3 months of age.
- Abnormal sleep patterns
- Trained night wakingoccurs between 4 and 8 months of age when the infant does not resettle without parental intervention (e.g.,
feedings, rocking, attention) during normal night stirrings and awakenings. Management includes establishing routines and placing the infant in bed while drowsy but awake.
- Trained night feedingoccurs when the infant continues to wake to eat because the parents keep responding with a feeding. Management includes lengthening intervals of daytime feeding and teaching parents not to respond with a feeding every time the infant stirs.
- Common sleep problems
- Nightmaresare common after 3 years of age, although they may occur as early as 6 months of age. These frightening dreams tend to have themes of threats to security, separation, self-esteem, or survival. They occur during rapid eye movement (REM) sleep.
- History. The child is able to give a detailed recallof extended and frightening dreams. The child rapidly becomes alert and oriented after awakening.
- Management.Reassurance by the parents and comforting measures are helpful. It is important to address the child's needs for security and to promote regular sleep patterns and good sleep habits. Any inciting causes (e.g., frightening movies) should be identified and eliminated. Nightmares are usually transient and not very disruptive.
- Night terrorsare common at 3–5 years of age but have a pattern distinct from ordinary nightmares. Night terrors occur 90–120 minutes after sleep onset during non-REM stage 4 sleep.
- History.Parents describe a child who suddenly arouses screaming and thrashing with signs of autonomic arousal such as tachypnea, tachycardia, and diaphoresis. The child does not respond to visual or verbal cues, and parents report the child stares “glassy-eyed” without seeing. The child does not remember the incident the next day.
- Management.Reassuring parents and telling them that the episodes usually terminate spontaneously and will resolve over time is helpful.
- Eating Problems
- Overfeeding during infancy is common.Parents may equate food with love and enjoy seeing their infant grow and thrive.
- Toddler feeding.Parents may report problems such as food refusal, food gorging, and a perception that the toddler does not eat enough.
- Appetite normally decreases after 1 year of age.
- Control is the major issue in toddler feeding problems.Autonomy is more important than hunger to the child at this stage.
- Managementincludes avoiding power struggles, offering food without comment, and counseling parents to avoid bribes, pressuring, or forcing the child to eat.
- School Phobia
- Definition.The typical child with school phobia is a healthy-appearing child who misses school because of vague physical complaints.
- Child is usually fearful of leaving the home and caregiver.
- Although it is unusual for the child to be fearful of anything in particular at school, the potential impact of bullies, learning problems, and fear of violence must be considered.
- Symptoms.Complaints such as abdominal pain, diarrhea, fatigue, and headache typically occur in the morning and worsen on departure for school. They often begin in September or October and frequently disappear on the weekends and during summer vacation.
- It is necessary to perform a thorough history and physical examination to ensure the child is healthy.
- The child must be returned to school; however, if the child insists on staying home, a visit to a physician should be scheduled. Peer relationships should be encouraged.
- Temper Tantrums
These expressions of emotions (usually anger) are beyond the child's ability to control.
- Epidemiology.Temper tantrums are common between 1 and 3 years of age.
- Etiology. Frustration or fatiguemay cause tantrums. Children with poor fine motor skills or expressive language delays are likely to have more tantrums because of frustration.Tantrums are not necessarily manipulative or willful.
- Tantrums that demand something should be ignored.
- The ability to verbalize feelings(learned by 3 years of age) decreases tantrums.
- Children having rage attacks or harmful tantrums may need to be held by a parent, who can provide a sense of calm and control.
- Breath-holding spells
- Definition.Breath-holding spells are benign episodes in which children hold their breath long enough to cause parental concern. The spells are involuntary in nature, harmless, and always stop by themselves.
- Epidemiology.Breath-holding spells occur in 5% of young children, usually starting between 6 and 18 months of age and disappearing by 5 years of age.
- Cyanotic spellsare most common and are usually precipitated by an event that makes the child frustrated or angry. The child cries and becomes cyanotic, and in some cases becomes apneic and unconscious, or may have a seizure.
- Pallid spellsare often provoked by an unexpected event that frightens the child, resulting in a hypervasovagal response, in which the child becomes pale and limp.
- Reassurethe parents that the episodes will resolve without harm.
- Counsel parentsnot to undertake potentially harmful resuscitation efforts.
- Ironhas been reported to help some patients, but the mechanism is not clear.
- If the spells are precipitated by exercise or excitement rather than by frustration or fright, an electrocardiogrammay be indicated to rule out a dysrhythmia (e.g., prolonged QT syndrome or supraventricular tachycardia).
- Sibling Rivalry
- Manifestationsinclude bids for attention, regressive symptoms (e.g., wanting a bottle or going back to diapers), and aggression toward a new sibling. The arrival of a newborn is especially stressful for children younger than 3 years of age. Jealousy is frequently demonstrated up to 5 years of age.
- Before arrival of newborn. Methods for preventioninclude talking about the arrival of the new baby and praising the child for mature behavior. Mastery of new skills (e.g., toilet training) should not be demanded during this stressful time.
- In older children.Children should be encouraged to settle their own arguments without hitting, name calling, or property damage. Parents should try to keep out of arguments, teach children how to listen to one another, protect each child's personal possessions, and praise children for good behavior.
- Toilet Training
- Age normals.The average child achieves bowel control by 29 months of age, with a wide range of normal of 16–48 months. The average child achieves bladder control by 32 months, with a wide range of normal of 18–60 months.
- Understand meaning of words such as wet, dry, pee, poop, clean, messy, and potty
- Prefer being dry to being wet or soiled
- Recognize the sensation of bladder fullness and the urge to defecate, be able to hold urine and stool, and have the ability to tell the caregiver
- Method. Stress encouragement, praise, and patience.Avoid shaming or blaming the child. Parents should:
- Allow multiple practice tries with praise for cooperation. It may be necessary to give small treats, but social reinforcement is best.
- Avoid pressure or force, which tends to make the child uncooperative. Resistance to toilet trainingsymbolizes a power struggle between child and parents.
- Point out that autonomy issues are importantin toilet training, which proceeds optimally when parents appreciate the child's need for mastery.
- Discipline Issues
- The basic premise of discipline is teaching the child limits. Parents must teach the child to respect the rights of others and control his or her behavior. Parents must provide external controls over the child's behavior, beginning at about 6 months of age. Child should start developing internal controls (self-control) between 3 and 4 years of age.
- Discipline techniquesare most effective when they are based on the developmental needs and stages of the child.
- Before age 6 months, no discipline is indicated.
- As the infant becomes more mobile, distraction and redirectioncan be used to ensure the child's safety.
- From 18 months to 3 years of age, ignoring, time-out, and disapproval(both verbal and nonverbal) may be effective.
- In preschool children, logical consequences(e.g., losing a toy that is used to hurt another child) may be effective.
- After 5 years of age, negotiation and restriction of privilegesare used.
- Rules must be clear, concrete, and consistent.Parents should state explicitly what the desired behaviors are and ignore unimportant misbehavior.
- Guidelines for using punishment.Apply consequences and make the punishment brief and immediate. Follow the consequence with love and trust. Direct the punishment toward the behavior, not the person.
- Time-out is a highly effectiveform of discipline when used appropriately and consistently, but it is frequently used inappropriately and inconsistently by parents.
- Definition.The caregiver interrupts misbehavior by isolating the child from social interactions for a brief period of time.
- Purpose.The child has time to think about the misbehavior and what acceptable behavior could be.
- Length.A time-out should be 1 minute per year of age (maximum 5 minutes, even in the older child).
Review Questions and Answers
- The parents bring a 13-month-old child to the office for a routine health maintenance visit. The child has been well since the last health maintenance visit, and the parents have no concerns today. The parents report he is sleeping through the night in his own crib and has a balanced diet and normal elimination patterns. During your physical examination, you perform a screening developmental evaluation. Which of the following findings on your developmental assessment would be most likely to merit a referral for a more thorough developmental evaluation?
(A). The child cruises but is not walking independently.
(B). The child's only words are mama, dada, dog, and ball.
(C). The child is afraid of strangers.
(D). The child neither eats with a spoon nor drinks from a cup.
(E). The child appears to be left-handed.
- You are seeing a 1-month-old male infant in your office for a routine health maintenance visit. He was born at 32 weeks' gestation and had Apgar scores of 3 at 1 minute and 8 at 5 minutes. His hospital course was unremarkable, and he has been feeding and growing well since going home. His mother is now concerned that he is at a higher risk for cerebral palsy because of his prematurity. It would be most appropriate to make which of the following comments?
(A). It is unlikely that the child has cerebral palsy because his growth and development so far is normal.
(B). If cerebral palsy does develop, it will cause loss of developmental milestones.
(C). The child is at high risk for cerebral palsy because of his prematurity.
(D). Repeated examinations will be necessary to assess for cerebral palsy.
(E). Laboratory testing can determine whether the child has cerebral palsy.
- At a routine health maintenance visit, the parents of a 1-year-old child would like to learn more about toilet training. Which of the following information is most appropriate to give the parents?
(A). It is important that toilet training begin now.
(B). Toileting is a skill to be learned just like any other and depends on the interests and readiness of the child.
(C). It is important that the parents establish control over toileting now or the pattern will be set for losing power struggles later.
(D). Toilet training should be finished as soon as possible for the good of caregivers and the environment.
(E). Whatever the parents and grandparents agree on is appropriate.
- The parents of a 3-year-old child are concerned that their child may have autism based on the ways in which their child interacts socially. Which of the following might suggest the diagnosis of Asperger's syndrome rather than autism?
(A). The parents report that their child does not enjoy playing with other children and prefers to play alone.
(B). The parents report that their child is clumsy.
(C). The parents describe that their child engages in repetitive and stereotyped patterns of behavior.
(D). The child is a boy.
(E). Your developmental assessment reveals no clinically significant language delay.
- The parents of a 7-year-old boy bring him to see you because of secondary enuresis. He achieved daytime dryness when he was 2.5 years of age and was dry at night by 3 years of age. Recently, he has developed dribbling incontinence, which embarrasses him at school. The parents do not report any recent psychosocial stress, but they are concerned that he trips often when he runs or walks quickly. Examination is normal, except you cannot elicit an anal wink reflex. Urinalysis and urine culture are both normal. Which of the following would be the most appropriate next management step?
(A). Neuroimaging studies of the brain and spine
(B). Bladder stretching exercises
(C). Trial of desmopressin (DDAVP)
(D). Trial of imipramine
(E). Psychological counseling
- You are evaluating a toddler during a routine health maintenance visit, which includes a thorough developmental assessment. The parents report that their son is able to point to three to five body parts, uses 20–30 words that his parents understand, and is beginning to put together two-word phrases. Assuming his language skills are normal for age, how old is this child?
(A). 13 months
(B). 15 months
(C). 18 months
(D). 24 months
(E). 30 months
- On screening in the newborn nursery, an infant has an abnormal hearing screen. His examination is otherwise normal. Which of the following etiologic factors most likely explains the hearing loss in this infant?
(A). Prenatal factors, such as maternal substance abuse
(B). Perinatal factors associated with a traumatic or preterm delivery
(C). Postnatal infection, such as meningitis
(D). Autosomal recessive genetic defect
(E). Autosomal dominant genetic defect
- The mother of a 9-year-old boy brings him to the pediatrician because her son is exhibiting hyperactivity and inattention in school. Before this year, the boy has performed well in school and has shown no signs of hyperactivity or inattention. His teacher reports that the boy is restless in the classroom and frequently leaves his seat. His mind seems to wander during the teacher's lectures. On questionnaires, the teacher confirms the inattention and hyperactivity. The boy shows no symptoms at home, and he does well at church school and at camp. The most appropriate first step in managing this patient would be:
(A). Explaining to the parents that he meets criteria for attention deficit/hyperactivity disorder and what that diagnosis means.
(B). Looking for other causes of the hyperactivity and inattention in the differential diagnosis.
(C). Beginning an empiric trial of stimulant medication to see whether his symptoms improve with pharmacologic intervention.
(D). Working with the school to modify the boy's assignments and the classroom setting.
(E). Referring to a counselor for self-esteem enhancement, social skills training, and behavior modification.
- The parents of a 3.5-year-old boy are concerned that their son is experiencing nightmares. On further questioning, you make the diagnosis of night terrors. Which of the following factors would most support your diagnosis of night terrors and not nightmares?
(A). This child's events occur approximately 30 minutes after sleep onset.
(B). Nightmares tend to decrease in frequency after age 3 years.
(C). The child responds to the parent's attempts to comfort him during the events.
(D). The child becomes alert and oriented immediately after the event.
(E). The child does not remember the event the next day.
- A 2-month-old male infant is brought to your office with concerns about excessive crying. Based on the history, you suspect colic. Which of the following findings on your evaluation best supports this diagnosis?
(A). The crying spells usually occur in the morning hours, lasting 2 hours every day, 5 days every week.
(B). The infant's weight has decreased by two growth isobars since birth.
(C). The parents have noticed an intermittent bulge in the infant's right inguinal region associated with crying spells lasting anywhere from 2 to 6 hours.
(D). The infant has been growing at the 10th percentile consistently since birth, with 3–4 hours per day of crying, 4 days every week.
(E). The infant appears to be thriving but cries for 2 hours every day of the week, more commonly in the early afternoon or evening hours.
- The parents of an 18-month-old boy are very concerned because he has had several episodes in which he became frustrated and angry, held his breath, and turned blue. Which of the following is appropriate information for parents about breath-holding spells?
(A). The spells are voluntary, and the boy is very likely deliberately trying to gain attention from the parents.
(B). The age of onset for these spells is unusual.
(C). The boy is unlikely to lose consciousness during a spell.
(D). An electrocardiogram is indicated if the spells are associated with physical activity.
(E). The spells may eventually cause learning disabilities and poor attention if they are allowed to continue.
- A child is still in the sensorimotor stage of development. He is beginning to look over the high chair to see where a dropped object has gone and is starting to use a brush and comb on his hair. He has not yet started building forts with blocks. Assuming he is normal cognitively, his age is most likely to be:
(A). 6–9 months
(B). 10–14 months
(C). 15–18 months
(D). 18–24 months
(E). 24–27 months
The response options for statements 13–14 are the same. You will be required to select one answer for each statement in the set.
(A). 4 months
(B). 6 months
(C). 8 months
(D). 10 months
(E). 12 months
For each of the following infants, select the most likely age of the infant based on the infant's developmental milestones.
- While playing with blocks with an infant, the infant becomes upset when you hide the blocks out of view. The infant is only able to say mamaand becomes upset when his mother leaves the room. He is able to hold a small object between his thumb and his index finger.
- An infant is able to transfer objects from hand to hand and to sit alone. He is also able to mix both vowel and consonant sounds, although he is not yet saying mamaanddada.You are not able to elicit a parachute reaction.
Answers and Explanations
- The answer is E[I.C.1.c]. An early hand preference may indicate weakness or spasticity of the contralateral upper extremity. It is unusual to see a hand preference in an infant younger than 18 months of age. Infants walk at a mean age of 12 months, and the range of normal (two standard deviations) is 9–15 months. Using two words in addition to mama anddada is appropriate for a 13-month-old child. Stranger anxiety is both common and normal between 6 and 18 months. A 13-month-old child may play with household objects but may not use them appropriately in imitation until 15–18 months of age.
- The answer is D[II.A.1.c]. Periodic developmental evaluations and physical examinations are necessary to monitor for signs of cerebral palsy. Although it is important to evaluate this infant's tone and reflexes, abnormalities of the motor examination are frequently not appreciated until the infant is older than 6 months of age. Cerebral palsy is a nonprogressive encephalopathy and should not lead to loss of milestones. Only a minority of extremely low birth weight premature infants (≤ 1000 g) develop cerebral palsy (15–25% incidence). No specific laboratory testing is available to diagnose or predict the course of the disease.
- The answer is B[V.J]. The age of toilet training coincides with the psychological stage of developing autonomy and mastering new skills. The basic principles of rewarding appropriate behaviors apply to toileting as well as to the achievement of other new skills. One year of age is too early to begin toilet training and is likely to lead to frustration and power struggles. Although environmental issues and caregiver convenience are important considerations, they are not paramount issues. Harmony between generations is desirable, but overly coercive training by controlling parents is associated with later encopresis.
- The answer is E[II.C.2]. Children with Asperger's syndrome do not have language delay. In fact, they often speak like “little professors,” using words that are more advanced than the language of their peers. The impairment in social relationships and peer interactions is the hallmark of Asperger's syndrome; however, it is also seen in autism. Clumsiness is not associated with either condition. Children with Asperger's syndrome have many autistic-like behaviors, including repetitive and stereotyped patterns of behavior and interests. Difficulty using language to communicate with others is the hallmark of autism, although the spectrum ranges from no verbal language to subtle deviations. People with autism may have difficulty “reading” facial expressions and hand gestures. Both Asperger's syndrome and autism are more common in males.
- The answer is A[V.B.5]. This child's history is concerning for a potential neurologic abnormality because of the reported tripping. The abnormal anal wink reflex on examination suggests spinal cord compression or spinal nerve entrapment and the need for neuroimaging studies. Bladder stretching exercises may be appropriate for the child who wets when his functional bladder capacity is exceeded, but the history here does not suggest that small bladder capacity is the problem. Conditioning alarms, desmopressin (DDAVP), and imipramine have all been used for nocturnal enuresis, whereas this child has daytime enuresis. Secondary enuresis is usually associated with an identified stress such as the birth of a sibling, divorce in the family, or a recent move. Psychological counseling can sometimes be useful in such situations.
- The answer is C[Table 2-4]. The language milestones described are usually achieved around the age of 18 months. At 13 months, most children use about three words that the parents understand, and they are also able to play peek-a-boo and patty-cake. At 15 months, children may understand more than 20–30 words receptively but are usually only able to express between 12 and 15 words. At 24 months, children should be using multiple telegraphic two-word sentences. At 30 months, children begin to use adjectives and adverbs, ask questions, and use sentences longer than two words.
- The answer is D[IV.A.3]. Eighty percent of childhood hearing impairment is caused by genetic factors. The inheritance of most of these genetic defects is autosomal recessive. Maternal substance abuse, traumatic deliveries, and prematurity are less frequent causes of isolated hearing impairments. Although meningitis and prenatal congenital infections are also potential causes of hearing impairment, they are among the nongenetic factors that account for about 20% of hearing loss in infants.
- The answer is B[III.D]. It is important to establish the correct diagnosis before beginning therapeutic interventions. This child does not meet the criteria for the diagnosis of attention deficit/hyperactivity disorder (ADHD) because his symptoms appeared after 7 years of age and are present in only one setting (school). It would be important to assess whether factors such as the teacher's expectations, classroom dynamics, or peer issues are impacting his classroom behavior and performance. If a child meets the criteria for ADHD, all of the other management options become reasonable parts of a therapeutic plan.
- The answer is E[V.D.4]. Children with night terrors do not respond to their parents' attempts to comfort them, do not become oriented during their arousals from sleep, and do not remember the event the next day. In contrast, children with nightmares rapidly become alert and oriented, recall details of the frightening dreams on awakening, and often recall the next day that they had a bad dream during the night. Nightmares occur in REM (rapid eye movement) sleep, whereas night terrors occur in stage 4 non-REM sleep 90–120 minutes after sleep onset. The peak incidence for night terrors is between 3 and 5 years of age; nightmares are common after age 3.
- The answer is D[V.A]. To qualify for a diagnosis of colic, the infant must be between the ages of 2 weeks and 4 months, be healthy and well-fed, and cry for more than 3 hours a day more than 3 days a week. Periods of crying with colic typically increase in the late afternoon or early evening hours. Known causes of pain must be excluded to make the diagnosis of colic, including corneal abrasion, hair tourniquet wrapped around a digit, and inguinal hernia that may be intermittently incarcerated. Infants who have concurrent failure to thrive must be evaluated for other etiologic factors.
- The answer is D[V.H]. Breath-holding spells are common, occurring in as many as 5% of children. These spells generally begin in children at 6–18 months of age and may continue up until 5 years of age. They are harmless and involuntary in nature. Even if they produce a loss of consciousness, which may occur in some children, learning problems or other long-term sequelae do not result. Spells that are associated with exercise or physical activity should be evaluated with an electrocardiogram to look for an underlying dysrhythmia.
- The answer is B[I.C]. Knowing that this child is still in the sensorimotor stage places his age at less than 2 years. This child is old enough to start using tools for their function, which would not be seen in a typical infant who is 6–9 months of age. He is not using symbolic play, which begins at about 24–30 months. He is beginning to process the concept of cause-and-effect; infants usually start looking over the high chair for dropped objects at about 9 months of age. This developmental clue places him at the early stage of functional play, making an age of 10–14 months more likely than ages older than 15 months.
- The answers are D[I.C.3.c; Tables 2-3 and 2-4] and C [Tables 2-2, 2-3 and 2-4], respectively. Infants develop “object permanence,” an understanding that objects continue to exist even when the infant cannot see them, at about 9 months of age. Infants usually begin saying mama and dada between 9 and 12 months of age and usually have between one and three additional words in their vocabulary by 12 months of age (1 year). Separation anxiety may develop anytime between 6 and 18 months of age when a loved one leaves the infant's vision. An immature pincer, or the ability to hold a small object between the thumb and the index finger, usually develops about 9 months of age. Based on the choices provided, this infant is most likely to be 10 months of age.