Screening for Developmental -Behavioural and Learning ...

Screening for Developmental -Behavioural and Learning ...

Screening for Developmental, Behavioural, and Learning Problems in Children Roger Thomas, MD, Ph.D., CCFP, FCFP, MRCGP Professor, Department of Family Medicine, University of Calgary Cochrane Collaboration Coordinator U of Calgary Shirley Leew PhD, R. SLP, SLP(C) (for slides on language impairments) Goals: Using screening tools 1. Identify the prevalence of developmental, emotional and behavioural problems in children. 2. Which screening tools have acceptable sensitivity and specificity. Parental Evaluation of Developmental Status (PEDS) PEDS Developmental Milestones (PEDS:DM) Ages and Stages (ASQ) [The Rourke Baby Record has no validity, reliability, sensitivity or specificity data] 3. When children are identified as developmentally delayed, what % is referred for expert help.

4. Is surveillance an acceptable screening tool. Goals: Screening for specific problems 6. Motor Milestones 7. Adverse events of childhood 8. Positive parenting practices 9. Speech and language problems 10. ADHD 11. Adolescent depression 12. Tourette syndrome What is the prevalence of parents concerns about their childs development? (n = 210,242 children) 37 studies: using the Parents Evaluation of Developmental Status (PEDS) 12 countries: USA 18, Canada 4, Australia 4, Philippines 3; UK, Malaysia, Indonesia, Singapore, Tanzania, India, Spain, Thailand one each Parents concern

% 95%CI High developmental risk 13.8 10.9, 16.8 Moderate developmental risk 19.8 16.7, 22.9 Parental Evaluation of Developmental Status (PEDS) 1.Please list any concerns about your childs learning, development, and behavior. 2.Do you have any concerns about how your child talks and makes speech sounds?

3.Do you have any concerns about how your child understands what you say? 4.Do you have any concerns about how your child uses his or her hands and fingers to do things? 5.Do you have any concerns about how your child uses his or her arms and legs? 6.Do you have any concerns about how your child behaves? 7.Do you have any concerns about how your child gets along with others? 8.Do you have any concerns about how your child is learning to do things for himself/herself? 9.Do you have any concerns about how your child is learning preschool or school skills? 10.Please list any other concerns. (Online version of these questions can be found at Use the PEDS to ask about the childs skill repertoire As you ask about the negatives (parental concerns) on the PEDS, then for each question ask positively for all the skills the child has: This should provide a complete picture. Q2. Tell me all the words and sounds your child makes of any kind Q3. Tell me all the ways your child understands what you say Q4 Tell me all the ways your child uses his hands and fingers to do things

Q5. Tell me all the ways your child uses his arms and legs Q6. Tell me all the ways your child behaves that you like or concern you Q7. Tell me all the ways how your child gets on with others Q8. Tell me all the ways your child has learned to do things for her/himself Q9. Tell me what preschool skills your child has learned. Parental Evaluation of Developmental Status (PEDS) Sensitivity: 70-94% by age group (older age groups high sensitivities) Specificity: 77-93% by age group 36 languages From left hand margin choose: 1. Tools online: choose Trial of PEDS online then choose CLICK HERE (30 days free or 10 trials) 2. The Book. Choose: Chapter 4. Measuring Development and Behavior Including Tools (or download free pdf) PEDS Developmental Milestones (PEDS:DM)

Age range: birth to 8 years Domains: Fine motor, gross motor, social-emotional, selfhelp, expressive language, receptive language, reading and math (for older children) 6-8 items per age-range 5 minutes to complete Based on: Brigance Inventory of Early Development II (IED-II) Brigance Comprehensive Inventory of Basic Skills-Revised (CIBS-R) PEDS Developmental Milestones (PEDS:DM) Normed on: 49,150 families in 38 US states nationally representative of US population census (ethnicity, High school education (e.g. 16% parents did not complete HS), language spoken at home, gender, poverty Sensitivity: 75-87% by age group Specificity: 71-88 % by age group PEDS Developmental Milestones

(PEDS:DM) Validity: sensitivity 85%, specificity 77% compared to gold standard screens Test-retest reliability: 96% Interrater reliability: (by professionals) 81% ACTIVITY with PEDS: Discuss with a colleague the cases of 9 month old Robert Someone and 18 month old Ottilie Green Discuss the cases you submitted to PEDS Or go on line and enter a case if you havent already ASQ: Ages and Stages Questionnaire (3rd ed) Sensitivity: 82-89% by age group Specificity: 77-92% by age group 30 questions: about developmental skills + overall concerns (whereas PEDS asks about parent concerns and PEDS:DM asks about milestones) 30 items (5-8 pages for each age group)

ASQ: Ages and Stages Questionnaire (3rd ed) The complete questionnaire with Video shows how to redefine items to reflect familys culture, create opportunities for child learning and development, and promote positive parent-child interaction Home visitor or video shows parents how to complete $US 295 for kit so OK if you refer to a psychologist who has this tool ASQ: Ages and Stages Socio-Emotional (2nd ed) Sensitivity: 71-85% by 9 age groups Specificity: 90-98% by 9 age groups Domains: Self-regulation, compliance, communication, adaptive functioning, autonomy, affect, interaction with people I checked costs on website 10 Dec 2016 : ASQ-3 complete package US$1219.75, plus quarterly screening charges. (ASQ-3 Questionnaires ($225); ASQ-3 Users Guide ($50); ASQ-3

Quick Start Guides (FREE); ASQ-3 Scoring and Referral DVD ($49.95); Ages & Stages Questionnaires on a Home Visit DVD ($49.95); ASQ-3 Learning Activities ($49.95); ASQ-3 Materials Kit ($295); ASQ Pro (1 year) ($149.95); ASQ Family Access (1 year) ($349.95) ACTIVITY with Ages and Stages: Discuss with a colleague Case for 30 month old you entered on the Ages and Stages form (available on the resident website) Use the same data with the Rourke (I have abstracted the items testing 4 domains in the attachment for the session) Brigance Early Childhood Screens III Alfred Brigance spent 30 years developing these screens and the PEDS is based on the most sensitive items 8 forms for each 12 month age range Domains: Speech-language, motor, readiness and general knowledge at younger ages, reading and math at

older ages, self-help, socio-emotional Sensitivity: 91%, specificity: 86% OK if the psychologist you refer to has paid the US$867 for the kit CONCLUSION: PEDS is the only nearly free EBM tool Children tested with both PEDS and ASQ (334 children 12-60 months, 80 primary care providers, North Bay and Sudbury, Ontario) Test Screening result No Developmental Sensitivity, developmental delay specificity delay

PEDS predictive concern 106 25 No concern 191 9 failed domain 66 No concern 231

ASQ 95%CI Sens 0.74 Spec 0.64 0.56, 0.87 0.59, 0.70 28 0.82 0.65, 0.93 6 Sens 0.82 Spec 0.78

0.65, 0.93 0.73, 0.83 Children tested with both PEDS and ASQ (334 children 12-60 months, 80 primary care providers, North Bay and Sudbury, Ontario) Children were tested on these detailed criteria for developmental delay: Bayley Scales of Infant Development III (children < 30 months) or Wechsler Preschool and Primary Scale of Intelligence, 3rd ed., (children 30 months) Vineland Adaptive Behavior Scales, 2nd ed. Preschool Language Scale, 4th ed. World Health Organisation Motor Development Study Six gross motor milestones children 4 to 24 months Ghana, India, Norway, Oman, USA

90% achieved milestones in same sequence 4.3% no recorded hand-knee crawling (instead bottom shuffling or tummy crawling) Screening for motor development: World Health Organisation Motor Development Study Milestone Average (months) 1st percentile (95% CI) 99th percentile (95%CI) Sitting without support 6

3.8 (3.7 to 3.9) 9.2 ( 8.9 to 9.4) Standing with assistance 7.6 4.8 (4.7 to 5.0) 11.4 (11.1 to 11.7) Hands and knees crawling 8.5 5.2 (5.0 to 5.3) 13.5 (13.0 to 13.9)

Walking with assistance 9.2 5.9 (5.8 to 6.1) 13.7 (13.4 to 14.1) Standing alone 11.0 6.9 (6.7 to 7.1) 16.9 (16.4 to 17.4) Walking alone 12.1

8.3 (8.2 to 8.4) 17.6 (17.1 to 18.0) Under-referral after screening (2083 mostly AfricanAmerican children, RCT by the US CDC of developmental screening, 4 urban practices) Screened Identified developmental concern With concern, referred for early intervention (n=2083) 434 (21%)

253 (12%) With concern, received multidisciplinary evaluation 129 (6%) Characteristic affecting referral to early intervention Adj OR 95%CI 2 developmental concerns 3.15 1.89, 5.24 Special health care needs 3.16

1.24, 8.06 Developmental screening without staff support 0.44 0.27, 0.72 Usual care 0.45 0.25, 0.81 Can we over refer? 70% of children identified on PEDS with delay but not confirmed on criterion screen were found to have multiple psychosocial risk factors. False positives are not the same as true

negatives: those who screen positive on initial screens but developmental problems are not initially confirmed, later are often found to have multiple psychosocial/familial problems Does surveillance miss problems? (95 children, Ohio primary care clinic) Surveillance: Nurse asks yes/no developmental questions, enters in EMR Questions at 18 months: If ball is rolled to child, child rolls it back, not hands it back Walks up steps Drinks from regular cup (not one with spout) Vocalises and gestures Speaks 6-10 words Laughs in response to others Follows simple instructions Can point to body part when asked, without prompting Does surveillance miss problems? (95 children, Ohio primary care clinic)

Surveillance concern Surveillance no concern ASQ fail 5 ASQ monitor 5 ASQ Pass 0 10 23 51 Screen for adverse events of childhood

(Chapman. Adverse childhood experiencesJ Affective Disorders 2004;82:217-225) Health Maintenance organisation, San Diego (n = 9460 adults) Lifetime depressive disorder (28.9% females, 19.4% males) Lifetime depressive disorder: 18.5% if 0 ACEs, 61% if 5 ACEs) Mentally ill household member when growing up (reported by 20% females, 15% males) Adverse events of childhood Adverse event % females reporting % males reporting Emotional abuse 14

7 Physical abuse 29 32 Sexual abuse 24 15 Battered mother 13 11

Household substance abuse 28 22 Parental separation or divorce 23 21 Criminal household member 3.5 3.2 Positive parenting practices (US National

Survey of Childrens Health 2011/2012) 847,881 households contacted, 187,422 with age-eligible children, 95,677 phone interviews Estimates 26% children 4 months to 5 years in US at risk of developmental, social or behavioral delays Screen for positive parenting practices (US National Survey of Childrens Health 2011/2012) N (%) Read to child 0 days/week Read to child 7 days/week Story telling/singing with child 0 days/week Story telling/singing with child 7 days/week Parent family meal with child 0 days/week Parent family meal with child 7 days/week Positive parenting practices

Score 0-5 Score 8-9 3.4 52.6 3.7 % no/low risk of delay 58.2 76.8 64.2 % moderate/high risk of delay 41.8 23.1 35.8 55.9

75.7 24.3 2.4 64.8 35.2 60.1 74.2 25.8 20.9 62.4 37.6

45.9 77.7 22.3 Screen for reading with child: Canadian Pediatric Society Position Statement: Reach Out and Read (ROR) Parents want information from physicians about learning 50% of parents who do not read daily would like to discuss literacy with their physician Parents receiving Reach Out and Read are 4 - 10 times more likely to read frequently (at least 3 days/ week) to their children. Effect greatest among poorest families Parents place more importance on reading to their children when book is given by physician Preschoolers in ROR higher receptive and

expressive language scores on standardized tests Canadian Pediatric Society Position Statement: Development milestones of early literacy Age Motor function 6 to 12 months Reaches for book. Brings book to mouth. Sits in lap. Holds head up steadily. 13 to 18 months Holds book with help.

Turns pages, several at a time. Sits without support. Able to carry book. Cognitive/social ability Looks at pictures, vocalizes, pats picture. Prefers photographs of faces. No longer mouths right away. Points at pictures with one finger. May label a particular picture with a specific

sound. Interaction with parents Parents holds child comfortably, faceto-face gaze. Parent follows babys cues for more and stop. Child gets upset if parent wont give up control of book. Child may bring book to read. If parent insists that the child listen, child may insistently refuse. Canadian Pediatric Society Position Statement: Development milestones of early literacy

Age 18-36 months 3 years and older Motor function Turns one page at a time. Carries book around house. Holds book without help. Turns normal thickness pages one at a time. Cognitive/social ability

Interaction with parents Names familiar pictures. Attention varies highly. Asks for the same story over and over. Reads books to dolls. Parent asks Whats that? and gives the child time to answer. Parent relates book to childs experience. Parent should be comfortable with fluctuating attention of toddler. Describes simple

actions. Can retell familiar story. Plays at reading, moving finger from left to right, top to bottom. Writes name (linear scribble). Parents asks questions like Whats happening? Parent validates childs response and elaborates on them. Parent does not drill child, but shows pleasure when child supplies word. Activity with a colleague Ask the colleague about parenting practices

used with a child they have observed; make suggestions Maker suggestions to a hypothetical parent about parenting and what reading a child should be able achieve at different ages; make suggestions Screening for behavioural problems: Conners Parent Rating Scale Revised (1998) Sample: 2200 students 3-17 years (average age 10 years), 200 schools throughout US and Canada Internal reliability: 0.85 to 0.92 (except psychosomatic scale 0.75 to 0.83 7 scales: Oppositional cognitive problems hyperactivity-impulsivity anxious/shy perfectionism social problems

psychosomatic Activity with a colleague Imagine a child with a problem on one or more of the 7 dimensions of Conners Parent Rating Scale. Discuss what strategies the parent and you as the family physician could use Developmental Delay: Developmental Domains Neurological Processes PPhysical/motorr Social Langua ge Perception

Emotional Cognitive Identification of Speech and Language Concerns: Speech and Language delays are the most commonly reported problems in early childhood Often 1st reported in complex delay and spectrum disorders Gateway for early intervention Early intervention can ameliorate future disorders and dysfunction Increase academic achievement Increase social success Strong association with life-long health outcomes Normal language Semantics (understanding meanings of words)

Morphology (capacity to change words systematically e.g. making plurals) Syntax (rules governing word order) Pragmatics (eye contact, interpreting nonverbal behaviours, interpreting literal/nonliteral meanings of words, polite requests, sustaining conversation topics) Speech production Voice (respiratory support to vocal folds) Fluency (rhythm and rate) Speech intelligibility (coordinated articulation of vowels and consonants) e.g. b uses lip closure to stop and release flow through the oral cavity, m is produced nasally Normal Speech production in children

1 4 months; As laryngeal, oral and respiratory control develop, babies produce pre-speech vowel-like sounds (cooing) 3 -8 months: definite vowel sounds, raspberries 5-10 months: sequential production of vowels and consonants (e.g. bababa); m b and p may be produced as they are produced anteriorly in the mouth and are easy to imitate may string together consonants and vowels in their own jargon By 8 months: language comprehension: Where is mummy? and infant will turn to mummy 10-15 months : one true word 2 years: expressive vocabulary >>> 50 words, combine two words Delays and Disorders of Speech and Language: (1) Stuttering/speech dysfluency Prolongations in sounds in words, difficulty starting (blocks), repetitions Referral if

dysfluency > 6 months tense pauses in speech blocks extraneous facial or body movements while talking or trying to start speaking NOTE: In a typically developing child between 2-3 years of age they begin to produce complex utterances & there may be a period of developmental dysfluency with effortless repetitions of syllables, words and phrases. Delays and Disorders of Speech and Language: (2) Childhood Apraxia of Speech Impaired volitional programming of speech Inconsistency in being able to produce speech sounds from one moment to the next Speech may be limited to vowel sounds, difficulty with consonants Lack of smooth transitions between sounds or syllables Inappropriate inflection patterns Instead may point, grunt or hit

Childhood apraxia of speech: case study (1) 8 year old has had 5 years of therapy with several speech pathologists (>50 sessions) for childhood apraxia of speech parents assess as minimal progress FHx: Severe learning problems in children on one side of the family Child has lots of programs: Lexia, Raz kids, Mathletics, IXL math, spelling, with all of which he struggles +++ I did a Medline search and found that many have very short shortterm memory (I cant remember). The reason is he has Speech Apraxia because he has minimal short-term memory. The solution is to switch to activities that require minimal words to build confidence Childhood apraxia of speech: case study (2) Whiteboard with activities (e.g. unload dishwasher) Copy any instructions onto his tablet

Teachers dictate instructions/tasks onto his tablet Buddy sits next to him in school and reminds him of tasks/instructions Cant remember what ice hockey coach says so have buddy play next to him Cant remember right from left so put bracelet on right wrist) Prepare for a career using manual skills: woodwork, construction toys, Fischer Technik (electrical trains and constructions), ($2.99/week for parent and child to paint together) Delayed language without cognitive delay (3) Specific Language Impairment (SLI)

In Kindergarten sample 5% of boys, 6% of girls Limited expressive vocabulary development Talking begins at about the same time as peers May not understand age-appropriate commands Smaller vocabulary, shorter utterances, omit grammatical endings, more grammatical errors Problems with inflection and word endings (morphology) Difficulty with learning words incidentally (from context) Difficulty generalizing word knowledge 29% of parents are aware of their childs SLI Difficulty with language, reading, and learning throughout school Not withdrawn Plays appropriately but at a level commensurate with language learning Normal age appropriate non-verbal problem solving skills and assembling of age-appropriate puzzles.

Risk for future emotional problems and for acting out Cognitive delays and disorders in pre-schoolers 1. Limited receptive and expressive language 2. Poor problem-solving atypical or delayed understanding of concepts such as object permanence, means-end and recognition of functions of objects 3. Poor memory skills reduced fast-mapping ability i.e., the ability to remember an event after one instance of that event 4. Poor learning skills reduced ability to acquire new skills or generalize old skills compared to same age peers 5. Plays and interacts like a younger child 6. Atypical social skills Poor ability to assess social cues and situations Early identification of language, communication delays and

disorders 1. Low rate of babbling by 12 months 2. Low or no vocal imitating; May seem to ignore people, doesnt interact much Inability to understand words that other babies understand May ignore or seem to ignore instructions 3. Atypical production of speech sounds (abnormal vowels or consonants) Omits speech sounds Produces unusual combinations of speech sounds Unintelligible speech A stranger should be able to understand approximately > > > > 25 % of what the child says by age one 50 % by age two, 75 % by age three, and 90 % or greater by age four.

Childhood milestones 0-5 years (Oberklaid F. Is my child normal? Milestones and red flags for referral. Australian Family Physician 2011) Risk Factors Biolgical: prematurity, low birth weight (< 1500 g), birth injury, vision or hearing impairment, chronic illness Environmental: low parental education, parental mental illness, social isolation, poverty Community: poor quality services, lack of access to services, poor housing Multiple risk factors Communication and language Average age Milestones Social smile

6 weeks Cooing 3 months Turns to voice 4 months Babbles 69 months Mamma/Dadda (no meaning) 89 months Mamma/Dadda (with meaning) 1018 months

Understands several words 1 year Speaks single words 1215 months Points to body parts 1422 months Able to name one body part 18 months Combines two words 1424 months

Speaks six or more words 1220 months Able to name five body parts 2 years Has 50 word vocabulary 2 years Uses pronouns (me, you, I) 2 years Developmental milestones (tasks) Average age

Follows eyes past the midline 6 weeks Smiles 6 weeks Bears weight on legs with support 37 months Sits with support 46 months Sits without support 58 months

Crawls 69 months Puts everything into mouth 48 months Pulls to standing position 610 months First tooth 69 months Walks holding on 713 months Drinks from cup

1015 months Developmental milestones (tasks) Average age Waves goodbye 812 months Climb stairs 1420 months Turns pages 2 years Scribbles

12 years Uses a spoon 1424 months Puts on clothing 2126 months Buttons up 3042 months Jumps on spot 2030 months Rides a tricycle

2136 months Bowel control 18 months 4 years Bladder control (day) 8 months 4 years Clear hand preference 25 years ADHD: Worldwide prevalence: 3-17 years = 9.5% 12-17 years = 12% >1/3 persist in adulthood (how many remain undiagnosed in adulthood?) Three types of symptoms

Inattentive type: at least 6/9 inattention behaviours Hyperactive-Impulsive type: at least 6/9 of hyperactiveimpulsive behaviours Hyperactive-inattentive type: at least 6/9 behaviours from both inattention and hyperactive-impulsive lists Should be present in at least two settings (home, school) ADHD symptoms: children Symptom Inattention Difficulty sustaining attention (except to video games) Does not listen Difficulty following multistep directions Loses things (e.g. school materials) messy locker, bookbag, or desk Easily distracted or forgetful Hyperactiveimpulsive Squirms and fidgets

Runs or climbs excessively Cannot play or work quietly Talks excessively On the go, driven by a motor Blurts out answers Cannot wait his/her turn Intrudes on or interrupts others Dysfunction at Difficulty sitting still school Easily overwhelmed Easily bored Speaks out in class ADHD symptoms: Adolescents Inattention Difficulty sustaining attention to reading or paperwork Poor concentration Difficulty finishing tasks Misplaces things (wallets, keys, mobile phones)

Poor time management, works twice as hard for half as much Easily distracted or forgetful; scattered at home or work Hyperactive Inner restlessness -impulsive Fidgets when seated (drums fingers, taps foot, flips pens) Easily overwhelmed Talks excessively Self-selects active jobs or activities Impulsive decisions Drives too fast, impulsive risks Often irritable, quick to anger Dysfunction Teachers complain inattentive, lack of motivation, being overly social at school Procrastination Missing assignments, poor grades Grades fall, avoids or cuts class or school Does the child have other conditions associated with hyperactivity?[Wolraich ML. ADHD among adolescents. Pediatrics 2005;115:1734-46.]

Summary based on 4 studies which followed children into adulthood: Oppositional defiant*/conduct disorder**36% 36% Anxiety disorder 48% Depressive/dysthmic disorder * Persistent negativistic, defiant, disobedient hostile behaviours to authority figures ** Repetitive persistent pattern of violating basic rights of others or major age-appropriate rules or norms How do parents rate the quality of life of the child with ADHD?) [Dankaerts syst rev] In 23 studies parents ratings were lower than childs self-rating: behaviour self-esteem role limitations

mental health family activities, family cohesion impact on parental time Activity with a colleague Invent ADHD symptoms for a 14 year old, complete the SNAP and compute the subscales. Screen for effectiveness of treatment: Systematic review of Rx for ADHD (Chan Treatment of ADHD in adolescents: A systematic review. JAMA 2016;035(28):1997-2008.) Change in ADHD Rating Scale (administered by professionals (range 0-54) Medication Decrease in Decrease in p

scores (treatment scores (placebo group) group) Methylphenidate (Concerta) Methylphenidate patch (Daytrana) Mixed amphetamine salts (Adderall XR) Lisdexamphetamine (prodrug) (Vyvanse) Atomoxetine (nonstimulant) -14.93 -9.58 0.001 -9.96

-6.53 <0.001 -17.8 -9.4 <0.001 -18.3 -12.8 <0.006 -13.94 -5.95

<0.001 Screen for side-effects: Concerta Contraindications: anxiety, thyrotoxicosis, hypertension, cardiomyopathy, structural cardiac defects, epilepsy, bipolar, mania, drug abuse Safety not established in children < 6 years Adverse effects compared to placebo: headache, insomnia, nausea, decreased appetite (also insomnia, stomachache, irritability, dizziness, weight loss, mild increase in pulse and Bp Dosage: (ages 6-18): start at 18mg, increase through 27mg, 36mg, max 54 mg daily Concerta (methylphenidate): Wilens (2006) RCT (industry funded) Measure % Reduction on Concerta

% Reduction on Placebo ADHD Rating Scale 47 31 Clinician rating on Child Conflict Index: Very much or much improved 51 33 Teen report

35 20 Screen for side-effects: Mixed amphetamine salts: Adderall XR(d- and l- amphetamine in 3:1 ratio): Action: non-catecholamine sympathomimetic amine. Action in ADHD unknown but thought to block reuptake of norepinephrine and dopamine in presynaptic neurons and increase release into epineuronal space Contraindications: same as Concerta Side effects: same as Concerta Safety not established in children < 6 years Dosage: 5, 10, 15, 20, 25, 30 mg tablets. No evidence better effect at > 20 mg/day (capsule may be opened) Amphetamines: Lisdexamfetamine (Vyvanse)

Action: A prodrug which is converted to active dextroamphetamine in bloodstream Capsules: 20, 30, 40, 50, 60 or 70mg (capsule may be opened) Side effects: Same as Concerta Screen for side effects: Strattera (atomoxetine); nonstimulant selective norepinephrine reuptake inhibitor CYP2D6: 7% Caucasians are poor metabolisers and will have 10 fold higher area under curve and 5x higher peak than extensive metabolisers. CYP2D6 inhibitors such as paroxetine and fluoxetine will markedly increase Strattera levels Contraindications: Same as Concerta. Side effects: Mania or psychotic symptoms in 0.2% and suicidal ideation in 0.4% [FDA black box warning for suicidal ideation]; headache, somnolence, abdominal pain, nausea, decreased appetite, vomiting, dizziness, rare hepatic failure Increased mydriasis so avoid in narrow angle glaucoma Strattera dosage (max 100mg or 1.4mg/kg whichever is less)

Weight (kg) Step 1 (0.5mg/kg/day) Step 2 (0.8mg/kg/day Step 3 (1.2mg/kg/day 20-30 10mg/kg/day 18mg/kg/day 25mg/kg/day 30-44

18 25 40 45-64 25 40 60 65-70 40 60 80

Behavioral therapy for ADHD: focus on adolescent daily functioning (Sibley MH. Child Psychol Rev 2014) RCTs of group CBT: ADHD scale decreased by 9.11 points (Chan 2016) Web-based grade portals for daily grade entry Computerised car driving Motivational interviewing Daily checklists and behavioral contracts motored with adult support (parents, teachers) Teen autonomy and self-efficacy by establishing collaborative teen-parent relationships Teach teens ways to voice ways in which would like more personal independence ADHD in adolescents differs from children Emotionally less mature, perform best with younger children or adults who tolerate their

immature behaviours Easily frustrated, short fuse Cognitive problems of procrastination and distraction, inability to complete projects may present to parents and teachers as behavioural problems Significant sleep disturbance ADHD in adolescents Adolescents markedly under-report symptoms and impairment Adolescents stop taking medications: Pelhams study reported of 87% who were medicated at some time, 28% stopped by age 11, 68% by 15 years Thiruchelvams study found 48% stopped between 9 and 15 years Cessation linked to lack of explanation of ADHD and medications by physician, fear of side-effects and persisting symptoms ADHD have 2-5 fold risk of developing 1 additional psychiatric disorder Enough information? Teachers provide in-class assessments (1 hour/day contact) , but may be able to provide less information about behaviour in hallways, cafeteria and buses

Activity with a colleague Advise the parent of a 14 year old with impulsivity and hyperactivity about: medication options side effects prescribe a starting dosage Outline elements of focused behavioural therapy you recommend Screening for Adolescent Depression (Lemstra M, et al. A Systematic Review of Depressed Mood and Anxiety by SES in Youth Aged 10-15 Years. Can J Public Health March-April 2008: 125-129)

Canadian national survey depression prevalence: 2.7% age 12-14 9.2% (95%CI 7.1 to 11.3) age 15-19 3 US population studies: depressive symptoms may start at 12 and peak 15 to 17 Ontario child health study: 16.1% of children with mental health disorders receive mental health or social service attention 20% have one anxiety disorder Lower SES rate of depression 2 - 3 > higher SES Preventing adolescent depression (Merry SN, et al. Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Review 2011) Time after intervention No of studies (n) Risk difference (95%CI) Immediately after

intervention 15 (n = 3115) 3-9 months 14 (n = 1842) 0.11 (-0.16 to -0.06) 12 months 10 (n = 1750) 0.06 (-0.11 to -0.01) 24 months 8 (n = 1750) -0.04 (0.11 to 0.03)

0.09 ( 0.14 to -0.05) 0.0003 p< Screening for Tourette Syndrome Multiple motor tics with one or more vocal tics Duration longer than 1 year Onset is usually around 7 years Tourette children have normal IQ range Ask family and society to adjust to the child rather than vice versa Screen for reactions of family members and school: Calgary Tourette society provides free

in-services in schools to teachers and pupils to describe syndrome and best responses Can Children Suppress Tics? Described as abnormal sensations in muscles (like waiting for a sneeze you cannot suppress) May suppress tic for several minutes, with great effort and some discomfort Suppression interferes with concentration on schoolwork Tics wax and wane, affecting schoolwork from day to day Tourette Syndrome + Most frequent additional syndromes in TS+: Attention Deficit Hyperactivity Disorder Obsessive Compulsive Disorder Social Skills Deficits Neurological Storms in Tourette Syndrome (due to dopamine surge)

students with TS+ may have neurological storms, which both parents and teachers find very disturbing the student exhibits a loss of emotional control often triggered by a minor event neurological storms are not temper tantrums. They are involuntary and non- manipulative. Often occur when students believe they are alone and student is unaware of event Let child go to quiet room in school and wait until neurological storm passes Dr. Samuel Johnson 1709-1784 An individual with Tourettes Plus Johnsons literary achievements Wrote first major Dictionary 1746-1753 by reading all the great works of literature after Dryden, and identifying the best definitions in literature wrote 58 Lives of the Poets (biographies and

critical appraisals of their poetry) His viewpoints are set out in brilliant essays in The Vanity of Human Wishes, The Rambler (208 newspaper essays), The Adventurer, The Idler, and Rasselas; wrote poetry in English, Greek and Latin Johnsons tics Held his head towards his right shoulder and shook it tremulously Rocked and seesawed his body, holding his head to the right, and rubbing his left knee with his palm Boswell (his biographer) noted Dr. Johnson planned an exact number of steps to enter doorways with the correct foot. Then he: formed a triangle with his heels or toes held his hands up with fingers bent as if in cramp, or against his chest like a jockey at full speed made a sudden and extensive stride across the threshold

Johnsons tics Mrs. Williams was a blind lady who lived with Dr. Johnson and when he escorted on entering a house he would whirl her about Made massive strides into rooms, smoothing the carpet in the middle of the room Made massive straddles in the street Touched every post in street and then he hastened to rejoin waiting friends with an air of great satisfaction (fortunately he did not touch people as is sometimes the case) When drinking tea, he stretched out his arm with a full cup of tea in every direction, to the great annoyance of neighbours and the imminent danger of Ladies Court Dress Conclusions 1. Screening with the evidence-based tools PEDS (or ASQ ), PEDS-Milestones, Q-CHAT at regular intervals is key for detection. 2. Nipissing and Rourke have no validity or reliability data.

3. Surveillance finds few problems. 4. The key developmental domain is language skills. Assessing language problems and providing prompt therapy and reading help are very important. 5. Childrens gross motor skills develop worldwide with the same median and 99%CI intervals. Conclusions 6. The more adverse events of childhood a child has the greater the effect on subsequent life career. 7. The more parenting skills parents learn the better the outcomes for children 8. If the family physician provides books through the Canada Reads program the parents are 4-10 x more likely to read to the child 9. ADHD causes major learning problems and is easily screened. Screen for parent-child conflict and the child stopping medication 10. Adolescent depression is common, is multifactorial, causes in family need treating, and needs sustained therapy. 11. There are no medications for the tics in Tourette syndrome. Co-morbidities need treating. Free in-services at school can explain the childs behaviour to peers and teachers. 12. As a family physician you provide crucial assessment and support to the child

for the first 20 years of educational and life careers.

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