Behavioral & Developmental Variations

Behavioral & Developmental Variations

Development reflects changes in and acquisition of new functions Development classified as: •Neurodevelopmental: changes in behaviour over time, eg, reflexes, gross/fine motor skills •Cognitive: includes thought, learning, problem solving •Psychosocial: environmental interactions, interpersonal relationships

The acquisition of developmental abilities follows a similar pattern between children, but may vary in rate, and still be normal

Developmental milestones: the acquisition of important developmental skills Median age: when half the population acquire a skill; serves as a guide to normal pattern of development Limit age: when a skill should have been acquired; further assessment is indicated if not achieved

Development monitored by standardized developmental tables ,eg, Denver Developmental Screening Test (DDST) Primitive newborn reflexes appear and disappear in a certain order Absence or persistence indicates CNS dysfunction

Newborn reflexes

sic Stage Theories of Developme Theory

Infancy (0–1 yr)

Freud: Oral psychosexu al

Toddlerhoo Preschool d (3–6 yr) (2–3 yr)

School Age Adolescenc (6–12 yr) e (12–20 yr)

Anal

Latency

Oedipal

Adolescenc e

Erikson: Basic trust Autonomy Initiative vsIndustry vs Identity vs psychosoci vs shame guilt inferiority identity al and doubt diffusion Piaget: cognitive

Sensorimot Sensorimot PreoperatioConcrete Formal or (stages or (stages nal operations operations I–IV) V, VI)

From a motor perspective, children develop in a cephalocaudal direction •Lift their heads with good control at 3 months, •sit independently at 6 months, •crawl at 9 months, •walk at 1 year, and •run by 18 months. Walk has a wide-based gait at first; then with legs closer together, the arms move medially, a heel-toe gait develops, and the arms swing symmetrically by 18–24 months

0 – 3 months

4 -6 months

6 – 12 months

Second year

Preschool (2-5 years)- preoperational

Language development

Attendance at kindergarten at age 5 years marks an acceleration in the separation-individuation theme initiated in the preschool years Child is ready to relate to peers in a more interactive manner Sensorimotor coordination abilities are maturing and facilitating pencil-and-paper tasks and sports

Freud characterized ages 7–11 years as the latency years devote most of their energies to school and peer group interactions

Observable aspects of behaviour

Hidden aspects of behaviour

Cognitive function can be assessed objectively by formal IQ tests but disadvantages are that the tests: •may be affected by cultural background and linguistic skills •do not test all skill areas •do not necessarily reflect an individual child's ultimate potential •may be compromised by individual disabilities, such as a motor disorder as in cerebral palsy, necessitating care in interpreting results

Severe deficits in the development of language, motor skills, attention, abstract reasoning, visualspatial skills, and academic or vocational achievement are associated with mental retardation Mental Retardation Range

Intelligence Quotient (IQ) Mild mental retardation 50–69 Moderate mental retardation35–49 Severe mental retardation 20–34 Profound mental retardation < 20

Cause

Percentage of Cases 4–28 2–5 4–14 7–17 2–10 5–13

Chromosomal abnormalities Fragile X syndrome Monogenetic conditions Structural CNS abnormalities Complications of prematurity Environmental or teratogenic causes "Cultural-familial" mental 3–12 retardation Metabolic or endocrine causes 1–5

Treatment A combination of individual therapies, such as •speech and language therapy •occupational therapy or physical therapy, •special education support •behavioral therapy or counseling •medical intervention, which may include psychopharmacology.

Sleep is a complex physiologic process influenced by intrinsic biologic properties, temperament, cultural norms and expectations, and environmental conditions. Between 20% and 30% of children experience sleep disturbances at some point in the first 4 years of life. The percentage decreases to 10–12% in schoolage children.

Sleep disorders fall into two categories. Dyssomnias refer to problems with initiating and maintaining sleep or to excessive sleepiness. Parasomnias refer to abnormalities of arousal, partial arousal, and transitions between stages of sleep.

•consists of arousal from deep NREM sleep probably the most frightening for parents. •include night terrors, sleeptalking, and sleepwalking (somnambulism).

Night terrors •Occur within 2 hours after falling asleep, during the deepest stage of NREM sleep, occur in about 3% of children •Child may sit up in bed screaming, thrashing about, and exhibiting rapid breathing, tachycardia, and sweating •Episode may last up to half an hour, after which the child goes back to sleep and has no memory of the event the next day

Sleepwalking •Occurs during slow-wave sleep and is common between 4 and 8 years of age •Typically benign except that injuries can occur while the child is walking around. •Scheduled awakenings may also be used if the child sleep walks frequently and at a predictable time.

Nightmares •Frightening dreams that occur during REM sleep, typically followed by awakening, which usually occurs in the latter part of the night •Peak occurrence 3 - 5 yr (incidence 25% - 50%) •Child can often describe the frightening images, recall the dream, and talk about it during the day •Associated with stress, trauma, anxiety, sleep deprivation that can cause a rebound in REM sleep, and medications that increase REM sleep.

Dyssomnias •Problems going to sleep and maintaining sleep/nighttime awakenings •Dyssomnias are frustrating •Results in daytime fatigue for both the parents and the child, parental discord about management, and family disruption

Obstructive sleep apnea is characterized by obstructed breathing during sleep accompanied by loud snoring, chest retractions, morning headaches and dry mouth, and daytime sleepiness

•common between ages 12 months - 4 years, occurring about once a week in 50–80% •Child may throw him- or herself down, kick and scream, strike out at people or objects in the room, and hold his or her breath •Often a reflection of immaturity as the child strives to accomplish age-appropriate developmental tasks and meets with difficulty because of inadequate motor and language skills, impulsiveness, or parental restrictions

The range of effects that can occur in an individual exposed to alcohol prenatally •Fetal Alcohol Syndrome •Partial Fetal Alcohol Syndrome •Alcohol-Related Neurodevelopmental Disorder •Alcohol-Related Birth Defects

Fetal Alcohol Syndrome: Associated with prenatal alcohol exposure •Characteristic pattern of facial abnormalities (short palpebral fissures, thin upper lip, and indistinct or smooth philtrum) •Growth deficiency •Evidence of CNS damage and neurodevelopmental abnormalities

Fetal alcohol syndrome

Partial Fetal Alcohol Syndrome •Presence of some of the facial anomalies growth retardation •CNS neurodevelopmental abnormalities, or behavioral or cognitive abnormalities that are inconsistent with the child's developmental level and cannot be explained by familial background or environment.

Alcohol-Related Neurodevelopmental Disorder •Does not require the presence of dysmorphic facial features •Requires the presence of neurodevelopmental abnormalities or evidence of a pattern of behavioral or cognitive abnormalities.

Alcohol-Related Birth Defects •Presence of congenital anomalies including malformations and dysplasias in cardiac, skeletal, renal, ocular, or auditory areas (ie, sensorineural hearing loss). Binge drinking during the first trimester, the critical period of embryogenesis, leads to FASD.

Inability to attend to the task at hand, increased motor activity and impulsivity

Risk factors/ etiology: •Actual cause unknown •Problems with filtering environmental stimuli and controlling their own behaviour to socially acceptable norms •Imaging studies show a difference in brain structure and function between patients with ADHD and normal control subjects •Occurs more frequently in boys (4:1) •Associated with other childhood behaviour disorders

Presentation: Problems in attention, hyperactivity and impulsivity

DSM IV criteria: Inattentiveness: •Makes mistakes due to not paying attention •Has difficulty paying attention, doesn’t seem to listen •Doesn’t follow through on tasks •Has difficulty getting organized •Dislikes/ avoids sustained mental effort •Loses things easily •Easily distracted •Forgetful

Hyperactivity: •Fidgets, •Is out of seat often, •Does excessive running/climbing, •Has difficulty playing quietly, •Is always on the go, •Talks excessively Impulsivity: •Bursts out answers •Has difficulty awaiting turn •Interrupts/ intrudes

Diagnostic tests: ADHD is a clinical diagnosis •At least six criteria from inattentiveness, •Six from hyperactivity/impulsiveness or both •Symptoms must be seen by 7 years of age, last at least 6 months, be observed in more than one setting, be more than age appropriate, and impair function Psychologic testing helps in D/D , but there is no specific test for ADHD

Treatment Pharmacologic : •Methylphenidate •Dextroamphetamine •Pemoline •TCA •Clonidine •Buproprion Diets have absolutely no value Management of any associated learning disabilities

Complications: •About half of patients with ADHD have normal adult lives •Those who continue to be affected may have antisocial personalities and alcohol and drug abuse •Aggressive, defiant children tend to do worse as adults D/D: Other psychiatric disorders

•Involuntary passage of urine in a child who is reasonably expected to be toilet trained •Day and night bladder control usually attained by age 5 years Risk factors/ etiology •Incidence of enuresis declines with age •A strong genetic predisposition for primary nocturnal enuresis

Presentation Two major types: Primary enuresis (90%): The patient never achieved dryness for any significant period of time Secondary enuresis : •Usually secondary to emotional difficulties ( eg, birth of a sibling, significant loss, family discord) •Usually transient and has better prognosis

Primary enuresis: Nocturnal only Diurnal only Nocturnal/ diurnal

Nocturnal enuresis : Associated with •maturational developmental delay of the bladder •may be a disorder of sleep and arousal Diurnal enuresis: Associated with •waiting too long to void, •UTI, •constipation, •diabetes and •stress incontinence

Diagnostic tests: •Usually no pathologic condition associated •Anatomic abnormalities uncommon •History and physical exam •Screening urine analysis

Treatment: •Treatment of any associated anomaly or pathology •Reward systems, alarm systems, and pharmacotherapy •Relapse rates of up to 30% •Imipramine and desmopressin commonly used

•Fecal incontinence after the age of 4 years Risk factors/ etiology: •Occurs more commonly in boys (4 – 6: 1) The causes are usually •Psychological, secondary to toilet phobia •Overly aggressive management of constipation •Starting toilet training too early •Painful defecation after diarrhea, fissures, severe perianal rashes

Presentation •Secondary to stool retention, resulting in leakage of loose stool around the obstruction Treatment •Counseling for the child and parents •Gentle cleaning of impacted stool out of the colon

Autism: •A developmental disorder characterized by impaired social relatedness deficits in verbal and nonverbal communication, and unusual responses to the environment Risk factors/ etiology •Autism develops before 30 months of age •Cause unknown •More common in boys (4:1)

Presentation: •Failure to attach as an infant •Delayed/ absent social smile •Failure to anticipate interaction with the caretaker •Delay in verbal and nonverbal communication skills •Stereotypical movements and need for sameness and routines •Outbursts of anger •Self-injurious behaviour •Content to play alone •75% of patients are mentally retarded, although testing is difficult

Treatment: •Behavioural and educational programs geared to the individual patient’s need •Pharmacotherapy for some target behaviours Prognosis: Poor •A very small minority will grow up to be marginally self-sufficient •The majority will end up institutionalized •A better prognosis associated with patients who demonstrate functional speech and higher intelligence

•More communicative, •Appear more socially aware, and •Do not have language impairments found in autism •They have social impairments, repetitive behaviours and sometimes obsessional interests

•X-linked dominant, affecting exclusively girls •Development is normal until 1 year of age •Language and motor milestones regress •An acquired microcephaly is seen •Hand wringing and sighing are characteristic •They develop autistic behaviour