Journal of developmental and behavioral pediatrics: JDBP

Published by Lippincott, Williams & Wilkins
Print ISSN: 0196-206X
Publications
Children with developmental or psychiatric disorders often have problems with social interaction. This study reports on the development of the Ghuman-Folstein Screen for Social Interaction (SSI), a parent/caregiver questionnaire designed to measure the capacity for basic social interaction skills across a variety of contexts in preschool children. The SSI was administered to 51 clinically referred children with a high probability of deficits in social interaction and 60 healthy control subjects to establish reliability and validity. The children were 24 to 61 months of age, with diverse ethnic and socioeconomic backgrounds. Strong internal consistency, significant correlation for test/retest reliability, moderate correlation for interrater reliability and support for external validity of the SSI was established. The SSI scores differentiated between the clinically referred subjects and healthy control subjects and between children with pervasive developmental disorder (PDD) of the autistic type and other non-PDD developmental disorders. The SSI is a relatively simple, efficient, reliable, and valid measure for the capacity for basic social interaction skills in children 24 months to 5 years of age. The SSI has a potential to be useful in primary health care settings to identify children at risk who may need tracking and/or further evaluation and treatment services.
 
Intracranial hemorrhage (ICH) is a major problem for the premature infant, occurring in more than one-third of surviving infants weighing less than or equal to 1,500 g at birth. The literature on perinatal ICH, as it relates to neurodevelopment outcome, is briefly reviewed, and preliminary results from our two-year followup of 75 less than or equal to 1,200-g infants are summarized. An analysis of pathophysiology, diagnosis, classification, and followup indicates that risk for ICH and its sequelae increases as gestational age and birth weight decrease. Hydrocephalus apparently no longer presents significant risk beyond that conveyed by the original hemorrhage. However, persistent posthemorrhagic ventriculomegaly and/or periventricular abnormalities serve as significant "markers" of risk for neuromotor delay through two years of age. In contrast, recovery of normal ventricular morphology by term gestational age apparently indexes a degree of recovery from ICH and predicts a more normal developmental outcome through the first two postnatal years.
 
: To investigate whether temperament in 1.5 year olds predicts their consumption of potentially obesogenic foods and drinks at 3 and 7 years of age. : Participants were 6997 mothers and infants from the Norwegian Mother and Child Cohort Study. Questionnaires were collected during pregnancy, at birth, and at 6 months and 1.5, 3, and 7 years of age. Predictor variables included children's temperament at 1.5 years of age (internalizing, externalizing, surgent) and mothers' negative affectivity. Outcome variables included children's consumption of sweet foods, sweet drinks, and fruits/vegetables at 3 and 7 years of age (dichotomized at the 85th percentile). : Controlling for covariates, internalizing 1.5 year olds (anxious, dependent) were 77% and 63% more likely to consume sweet drinks daily at 3 and 7 years of age, respectively; they were 55% and 43% more likely to consume sweet foods daily at 3 and 7 years, respectively. Externalizing 1.5 year olds (hyperactive, aggressive) were 34% more likely to consume sweet drinks daily at 7 years of age; they were 39% and 44% more likely to consume sweet foods daily at 3 and 7 years, respectively, and they were 47% and 33% less likely to consume fruits/vegetables daily at 3 and 7 years of age, respectively. Surgent 1.5 year olds (active, sociable) were 197% and 78% more likely to consume 2 portions of fruits/vegetables daily at 3 and 7 years, respectively. The association of maternal negative affectivity was limited to the child's consumption of sweet foods at 3 and 7 years. : Early child temperament is a risk factor for obesogenic diet in later childhood. Mechanisms explaining this association need to be explored.
 
We compared the prevalence of learning disabilities at age 8 years in a subgroup of 68 of 129 (53%) regional cohort of extremely low birth weight (ELBW) children who were considered "normal" neurologically and intellectually (IQ greater than or equal to 85) with that of 114 term group matched controls (C). Both groups were tested with a battery of psychoeducational measures, and parents and teachers completed questionnaires on the school performance of the children. ELBW children were comparable with C on measures of intelligence (ELBW 101 +/- 8, C 104 +/- 11), language, and academic achievement but fared significantly less well in motor performance (p less than .0001). The prevalence of learning disabilities (by predefined criteria) in ELBW children (26%) was not increased compared with C (19%). However, teachers rated significantly more ELBW children as performing below grade level than were C (31% vs 16%, p less than .05), and by parent report, a higher proportion of ELBW children had received special assistance in school compared with C (37% vs 16%, p less than .001). We conclude that although the prevalence of learning disabilities in normal ELBW children was not different from that in controls, ELBW children did less well and utilized more special resources.
 
A cohort of 219 children with extremely low birth weight (<1000 g, extremely low birth weight [ELBW]) born from 1992 to 1995 was followed to mean age 8 years to evaluate outcomes and identify risk factors. We compared 204 of these children with 176 term-born normal birth weight (NBW) controls on neuropsychological skills, academic achievement, and adaptive behavior. The ELBW group had worse outcomes than the NBW on all measures. Within the ELBW group, lower scores on NEPSY tests of executive function and memory were related to <750 g birth weight, B (SE) = -0.93 (0.36), p =.010; cranial ultrasound abnormality, B = -1.03 (0.22), p =.002; postnatal steroid therapy, B = -1.00 (0.33), p =.003; and necrotizing enterocolitis, B = -2.26 (0.75), p =.008. A lower score on the Test of Motor Proficiency was related to chronic lung disease, B = -7.33 (1.98), p <.001. Neuropsychological skills mediated the effects of neonatal risk on achievement and adaptive functioning. The findings document the neuropsychological consequences of ELBW at school age in a recently born cohort and identify risks for adverse outcomes.
 
CASE: Tony is an 11-year old boy in the fifth grade whose mother describes him as “really a good kid who is bright and tries to be friendly. But he’s always doing things that get him in trouble at school and sometimes at home.” Tony was diagnosed with ADHD (combined type) 2 years ago. Stimulant therapy improved his attention and concentration during school, decreased hyperactivity in the classroom and improved educational achievements. However, Tony is oppositional and disruptive on the playground, during team sports and at home. His teacher observed that he wants to fit in, but he quickly gets in arguments with other children. He has difficulty sustaining friendships because he typically annoys others with unreasonable demands. He often has temper tantrums when things do not go his way; the tantrums are not prolonged but frequent. At home, on several occasions Tony hit his younger sister, and he once threw a dinner plate against the wall during a family meal. Although his mother describes these behaviors as present for many years, they seem to be escalating. Tony lives with both parents and his younger sister. There is no history of marital discord or major life event change in the past year. Standardized achievement tests demonstrate average to above average achievement scores. He continues to get mostly B grades and an occasional C. Tony’s parents have tried to limit television time as a punishment for disruptive behaviors without any apparent effect. His mother reports that she yelled at him on several occasions when he refused to carry out household chores. “He gets angry at the simplest request for help.” After meeting with Tony and his mother and completing a normal physical examination, the pediatrician referred Tony to a child psychologist for behavioral therapy.
 
Case: Tony is an 11-year old boy in the fifth grade whose mother describes him as "really a good kid who is bright and tries to be friendly. But he's always doing things that get him in trouble at school and sometimes at home." Tony was diagnosed with ADHD (combined type) 2 years ago. Stimulant therapy improved his attention and concentration during school, decreased hyperactivity in the classroom and improved educational achievements. However, Tony is oppositional and disruptive on the playground, during team sports and at home. His teacher observed that he wants to fit in, but he quickly gets in arguments with other children. He has difficulty sustaining friendships because he typically annoys others with unreasonable demands. He often has temper tantrums when things do not go his way; the tantrums are not prolonged but frequent. At home, on several occasions Tony hit his younger sister, and he once threw a dinner plate against the wall during a family meal. Although his mother describes these behaviors as present for many years, they seem to be escalating. Tony lives with both parents and his younger sister. There is no history of marital discord or major life event change in the past year. Standardized achievement tests demonstrate average to above average achievement scores. He continues to get mostly B grades and an occasional C. Tony's parents have tried to limit television time as a punishment for disruptive behaviors without any apparent effect. His mother reports that she yelled at him on several occasions when he refused to carry out household chores. "He gets angry at the simplest request for help." After meeting with Tony and his mother and completing a normal physical examination, the pediatrician referred Tony to a child psychologist for behavioral therapy.
 
Brian is an 11-year-old boy who presented to the emergency room with suicidal ideation and hearing voices. In the preceding weeks, he had escalating symptoms of oppositional defiant disorder, attention-deficit hyperactivity disorder (ADHD), and bipolar disorder. His medical history was notable for complex partial epilepsy with onset at age 4 that had been well controlled with divalproate. He had several mental health diagnoses by various practitioners including oppositional defiant disorder, ADHD, and bipolar disorder. Brian's family and social history was notable for the absence of identifiable risk factors for seizures or psychiatric problems. Over the course of a week-long psychiatric hospitalization, his complaints of depression and hearing voices seemed incongruent with his behavior. His parents endorsed a long history of Brian manipulating family and friends, such as conning his friends into stealing money and giving it to him. There was increasing suspicion that Brian was contriving his presenting symptoms for secondary gains. When his parents visited, he consistently bargained for prized items such as a long sought after cell phone and his own bedroom to improve his mood. His prior diagnoses (ADHD, a mood disorder, and oppositional defiant disorder) did not capture what seemed to be his core problem--an ability and willingness to manipulate others for his own self-serving purposes. Three months later, he was seen in the pediatric neurology clinic for increased seizure frequency. In the interim, he had several very serious altercations including setting fire to his family church, an attempted break-in-and-entry, assaulting his principal and resisting the arresting officer, and a malicious planned attack on his father where he struck him in the head with a crescent wrench "in cold blood, without any emotion."
 
This study investigated the behavioral and psychological differences between 39 uninfected children born to human immunodeficiency virus (HIV)-seropositive mothers (HIV-seroreverter [SR]) and 78 children with no family history of HIV infection. Caretakers completed the Child Behavior Checklist and the Gittelman modification of the Conners' Parent's Questionnaire, whereas children completed the Children's Manifest Anxiety Scale and the Children's Depression Inventory. In 14 SR children and 28 controls, narrative task was also evaluated. The personalities of SR children, as measured by the caretaker-completed scales, revealed significantly more problems of social adjustment and attention and more externalizing symptoms than did the personalities of control children. On the child-completed scales, SR children showed significantly more anxiety and depression than did controls. Caretakers reported consistently fewer symptoms of anxiety and depression in the children than did the children themselves. Difficulties in verbal recall included aspects of depressive and anxious feelings; on the narrative task measure, SR children showed poorer skill in free verbal recall than did control children, and they simplified episodes with mixed emotions. In addition, ambiguous episodes elicited significantly more negative feelings in SR children than in controls. These findings show that there is a great necessity for assisting SR children. It will be important to determine whether these children will remain at risk for emotional consequences in their adult lives.
 
Scott, an 11-year-old boy in the fifth grade, is brought to his pediatrician, Dr. Lewis, by his maternal grandparents with the principal concern that "he lies constantly." Scott lived with his maternal grandparents since he was 2 years old, and they have full custody. His mother and father had serious substance abuse problems. The grandparents provide a stable home for Scott and his 15-year-old sister. Scott has had no contact with his mother in more than 6 years and sees his father infrequently. During the last visit with his father, he was so inebriated that he was thrown out of the movie theatre and barely avoided several car accidents on the way home. He left the children at the curb of their home and made them promise that they would lie to their grandparents about the reasons for the early return. Scott was diagnosed with attention-deficit hyperactivity disorder (ADHD) in second grade. Methylphenidate (36 mg) provides improvement in attention and concentration. His grandfather describes Scott as highly unpredictable. When he is the "good Jake," he is eager to help, polite, and caring. When Scott gets behind in school or is avoiding his chores and assignments, he lies by saying that he got it all done, even though he knows his grandfather will discover the lie and punish him. When confronted with reports from school, Scott often lies and may develop more elaborate confabulatory stories. His grandfather admits that he becomes irate at these moments. He responds by removing Scott's privileges. When he planned to take Scott to see his favorite sport team in the playoffs, Scott was caught in a lie the day of his departure. His grandfather offered him a chance to fess up, pay a small price in extra chores, and save the trip. Scott stubbornly refused to admit that he lied and lost the trip. His grandfather worries that Scott has no "moral compass." He takes things that do not belong to him and violates household curfew rules. He has never been physically aggressive or has never stole items from a store. He takes his sisters CD player or his grandfathers cell phone even when he has been told not to. He will then lie that he did not take it. Even when it is pulled out of his backpack, he will say he did not put it in there. His grandfather is a businessman with high moral integrity. He loves his grandson and is eager to help him. He asks Dr. Lewis what they should do about Scott's persistent lying.
 
Case: Maggie and Lily are 11 month-old twins who are brought by their parents to the Developmental-Behavioral Pediatric Clinic for a life-long history of feeding difficulties. The twins are this couple's first children. Their mother is tearful as she recounts a stressful pregnancy complicated by pre-term labor beginning at 24 weeks gestation with strict bed rest for the remainder of the pregnancy. The twins were delivered at 35 weeks gestation by Caesarian Section. Lily weighed 5 lbs 11 oz; Maggie was small-for-gestational age with a birth weight of 3 lbs 13 oz. Maggie required oxygen with nasal prongs for only a few hours after birth. She remained in the Neonatal Intensive Care Unit (NICU) with initial nasogastric tube feeding; she was advanced to bottle feeding prior to discharge. Both Maggie and Lily were slow to initiate and sustain formula feeding. They required over 1 hour to consume 2 ounces of formula and "tire easily". At 1 month of age, Maggie resisted feedings by crying and arching her back. By 5 months of age, both children cried at the sight of the bottle and tried to push it away. However, they never lost weight. Maggie was treated with intermittent naso-gastric tube feeding at 5-6 months of age in order to gain adequate weight. At 11 months of age, both girls continued to resist feeding, but their mother was able to "get in" 24 ounces each day of a 31-calorie/ounce formula "with a lot of work". Dad observed that his wife's entire day revolved around getting the twins to eat and that became a significant stress for her as well as on their relationship. The children had a gastroenterology evaluation including an upper gastrointestinal series, pH probe and gastro-duodenal endoscopy with biopsies. All studies were normal. Trials of omeprazole, metoclopramide and thickened feeds did not improve their feeding problem. They are currently not on any medications. They have not had a history of vomiting, diarrhea, or diaphoresis with feeds, and they have experienced only 1 mild upper respiratory infection. One or two soft bowel movements occur each day. Developmentally, they are on track for their age. The parents report that they can pull up to a stand and cruise, use a pincer grasps, and speak "mama" discriminately. A review of their growth charts reveal that their weight is consistently between the 10-25% percentiles; weight is currently at the 25% percentile. Head circumference and height are between the 25-50% percentiles.
 
Case: Scott, an 11-year-old boy in the fifth grade, is brought to his pediatrician, Dr. Lewis, by his maternal grandparents with the principle concern that "he lies constantly." Scott lived with his maternal grandparents since he was 2 years old, and they have full custody. His mother and father had serious substance abuse problems. The grandparents provide a stable home for Scott and his 15-year-old sister. Scott has had no contact with his mother in more than 6 years and sees his father infrequently. During the last visit with his father, he was so inebriated that he was thrown out of the movie theatre and barely avoided several car accidents on the way home. He left the children at the curb of their home and made them promise that they would lie to their grandparents about the reasons for the early return. Scott was diagnosed with attention-deficit hyperactivity disorder (ADHD) in second grade. Methylphenidate (36 mg) provides improvement in attention and concentration. His grandfather describes Scott as highly unpredictable. When he is the "good Jake," he is eager to help, polite, and caring. When Scott gets behind in school or is avoiding his chores and assignments, he lies by saying that he got it all done, even though he knows his grandfather will discover the lie and punish him. When confronted with reports from school, Scott often lies and may develop more elaborate confabulatory stories. His grandfather admits that he becomes irate at these moments. He responds by removing Scott's privileges. When he planned to take Scott to see his favorite sport team in the playoffs, Scott was caught in a lie the day of his departure. His grandfather offered him a chance to fess up, pay a small price in extra chores, and save the trip. Scott stubbornly refused to admit that he lied and lost the trip. His grandfather worries that Scott has no "moral compass." He takes things that do not belong to him and violates household curfew rules. He has never been physically aggressive or has never stole items from a store. He takes his sister's CD player or his grandfather's cell phone even when he has been told not to. He will then lie that he did not take it. Even when it is pulled out of his backpack, he will say he did not put it in there. His grandfather is a businessman with high moral integrity. He loves his grandson and is eager to help him. He asks Dr. Lewis what they should do about Scott's persistent lying.
 
Case: Scott, a 13-year 7-month old white male with no prior psychiatric history, presented to the emergency department after three days of decreased attention span and increased distractibility. An initial examination revealed that he was internally preoccupied (focused on responding to auditory hallucinations), displayed thought blocking (sudden interruption in the flow of his thoughts that prevented him from completing an idea), and he had periodic vague suicidal ideation due to intense guilt. He noted hearing two to three voices accusing him of being rude during an incident with a peer at school. He could not accept reassurance from his mother and grandparents that this incident had not actually occurred. Scott found evidence of his wrongdoing by misinterpreting words on signs and medical equipment that he felt indicated that others also knew of his malicious actions. A recent stressor included the conclusion of his active football season a day prior to the onset of his symptoms. Scott and his family denied a history of prodromal symptoms, mental or medical illnesses, including head injury. After a physical/neurological examination, a negative urine drug screen, and a normal complete blood count and metabolic panel, Scott was transferred to a psychiatric hospital. Scott returned to the emergency department two days later with worsening psychotic symptoms despite a trial of olanzapine. He had deteriorated dramatically from his initial presentation. He was now rigid, unable to speak, move his body, follow directions, eat, drink, or provide any additional history. After being admitted to the pediatrics floor an extensive medical workup was completed that included neurology and infectious disease consults, brain magnetic resonance imaging and angiography studies, a 24-hour electroencephalogram, lumbar puncture, urinalysis, complete blood count, comprehensive metabolic panel, ceruloplasm, anti-nuclear antibody, anti-DNAase, erythrocyte sedimentation rate, heavy metal screen, ammonia, rapid plasma reagin (RPR), and human immunodeficiency virus. All laboratory studies were normal.
 
Case: Scott, a 13-year 7-month old white male with no prior psychiatric history, presented to the emergency department after three days of decreased attention span and increased distractibility. An initial examination revealed that he was internally preoccupied (focused on responding to auditory hallucinations), displayed thought blocking (sudden interruption in the flow of his thoughts that prevented him from completing an idea), and he had periodic vague suicidal ideation due to intense guilt. He noted hearing two to three voices accusing him of being rude during an incident with a peer at school. He could not accept reassurance from his mother and grandparents that this incident had not actually occurred. Scott found evidence of his wrongdoing by misinterpreting words on signs and medical equipment that he felt indicated that others also knew of his malicious actions. A recent stressor included the conclusion of his active football season a day prior to the onset of his symptoms. Scott and his family denied a history of prodromal symptoms, mental or medical illnesses, including head injury. After a physical/neurological examination, a negative urine drug screen, and a normal complete blood count and metabolic panel, Scott was transferred to a psychiatric hospital. Scott returned to the emergency department two days later with worsening psychotic symptoms despite a trial of olanzapine. He had deteriorated dramatically from his initial presentation. He was now rigid, unable to speak, move his body, follow directions, eat, drink, or provide any additional history. After being admitted to the pediatrics floor an extensive medical workup was completed that included neurology and infectious disease consults, brain magnetic resonance imaging and angiography studies, a 24-hour electroencephalogram, lumbar puncture, urinalysis, complete blood count, comprehensive metabolic panel, ceruloplasm, anti-nuclear antibody, anti-DNAase, erythrocyte sedimentation rate, heavy metal screen, ammonia, rapid plasma reagin (RPR), and human immunodeficiency virus. All laboratory studies were normal.
 
Case: Erica is a 13-year old female who was hospitalized for a 4-week history of "barking" noises and 2 weeks of generalized shaking episodes. Four weeks prior to admission, she had a viral upper respiratory infection (URI) with cough which was treated with over-the-counter cough syrup. After resolution of the URI, she developed a persistent cough that turned into a "bark"-like vocalization. Both the mother and patient demonstrated the bark as an "arf" sound like that of a small dog at times, a large dog at others. These vocalizations were unrelenting, occurring 3-10 times per minute only while awake. They were not precipitated by any known factors nor were there alleviating factors. She could not voluntarily suppress the sound. In addition to the vocalizations, episodes of generalized shaking of the extremities began 2 weeks prior to admission. According to Erica's mother, each episode lasted about 10-60 seconds and occurred 30-40 times a day only when she was awake. These episodes were not rhythmic or symmetric, and they were not associated with bowel or bladder incontinence. There was no alteration of consciousness following the episodes. Erica denied any recollection of the barking or shaking. The medical evaluation did not reveal an etiology. It included a complete physical examination, a neurological examination, biochemical laboratory studies, and a negative video EEG study that captured 10 episodes of shaking. Child psychiatry was consulted. Erica was a pleasant, quiet female with slightly constricted affect and a normal speech pattern. She reported that she was a straight-A honors student who had difficulty trusting others; she said that she had no friends, only "associates." She said that she had periods of feeling "sad" and crying easily, but could not identify any recent stressful event. Episodes of barking and shaking diminished during the hospitalization. Erica was discharged home with outpatient psychiatric follow-up.
 
Case: Erica is a 13-year old female who was hospitalized for a 4-week history of "barking" noises and 2 weeks of generalized shaking episodes. Four weeks prior to admission, she had a viral upper respiratory infection (URI) with cough which was treated with over-the-counter cough syrup. After resolution of the URI, she developed a persistent cough that turned into a "bark"-like vocalization. Both the mother and patient demonstrated the bark as an "arf" sound like that of a small dog at times, a large dog at others. These vocalizations were unrelenting, occurring 3-10 times per minute only while awake. They were not precipitated by any known factors nor were there alleviating factors. She could not voluntarily suppress the sound. In addition to the vocalizations, episodes of generalized shaking of the extremities began 2 weeks prior to admission. According to Erica's mother, each episode lasted about 10-60 seconds and occurred 30-40 times a day only when she was awake. These episodes were not rhythmic or symmetric, and they were not associated with bowel or bladder incontinence. There was no alteration of consciousness following the episodes. Erica denied any recollection of the barking or shaking.The medical evaluation did not reveal an etiology. It included a complete physical examination, a neurological examination, biochemical laboratory studies, and a negative video EEG study that captured 10 episodes of shaking. Child psychiatry was consulted. Erica was a pleasant, quiet female with slightly constricted affect and a normal speech pattern. She reported that she was a straight-A honors student who had difficulty trusting others; she said that she had no friends, only "associates." She said that she had periods of feeling "sad" and crying easily, but could not identify any recent stressful event. Episodes of barking and shaking diminished during the hospitalization. Erica was discharged home with outpatient psychiatric follow-up.
 
Case: John, a 14-year old white male of European Jewish descent without a prior history of medical or psychiatric problems, presented following several days of increased need for sleep (16-20 hours per day), disorientation, difficulty maintaining attention and concentration, bizarre behaviors. He was sexually inappropriate toward his mother, sister, and housekeeper, masturbated in public, and sang nonsense lyrics. In addition, he had brief periods of agitation, paranoia (including fear that he was being followed and that he would be hurt by the physicians), and periods of distraction by auditory and visual hallucinations. His appetite increased significantly during this time. One week prior to the onset of these symptoms, he traveled to the Midwest where he experienced several days of nausea, vomiting, and diarrhea.John's physical and neurological examinations were normal except for the behaviors noted above. A medical evaluation revealed a normal brain computerized tomogram (CT) and magnetic resonance imaging (MRI). Urine toxicology screen, a comprehensive metabolic blood panel, and a complete blood count were normal. A lumbar puncture demonstrated a slightly elevated opening pressure (24 centimeters); the cerebrospinal fluid examination was unremarkable for cells, protein and glucose. Following the lumbar puncture, for which he had received midazolam, he had a brief, 30-45 minute episode of lucidity in which he was able to describe feeling like he was "in a fog."John was transferred to a psychiatric hospital where he recovered over several days and was discharged home. After three weeks of complete recovery, he acutely developed profound fatigue and the previously seen bizarre behaviors returned and persisted for 2 weeks. Following a 2-week period without symptoms, a similar behavior pattern recurred for the third time. The third episode differed from the first two in that he initially developed mental status changes and then developed symptoms of hypersomnolence. John has now been completely recovered from the third two week episode for one week and is taking summer school classes and enjoying socializing with his friends.
 
The Pediatric Examination of Educational Readiness at Middle Childhood (PEERAMID) is a neurodevelopmental examination for 9- to 14-year-old children. The examination was designed largely for use by developmental-behavioral pediatricians as a way of assessing certain critical developmental functions, including attention, memory, language, and motor coordination in children with school problems. Preliminary field testing of the PEERAMID was carried out in one community, and subsequently a revised version was standardized on randomly selected subjects from three communities near Boston, Massachusetts, and on groups of children from those towns said to be having significant problems at school. Additionally, the examination was used for the evaluation of 106 consecutive patients referred to the School Function Program at The Children's Hospital in Boston. Statistically significant performance differences discriminated between children with normal academic performance and those with school problems in the community as well as in the referral setting. It was discovered that children with school problems tended to have clusters of dysfunction, whereas normally achieving youngsters more often harbored no developmental dysfunctions or perhaps one or two areas of difficulty. It is believed that the PEERAMID can be a useful instrument in serving as part of a pediatric contribution to a multidisciplinary assessment in children in this age group.
 
The aim of this study was to compare cognition, academic progress, behavior, and self-concept children of very low birth weight (VLBW, birth weight < 1501 g) born in the period 1980 to 1982 with randomly selected children of normal birth weight (NBW, birth weight > 2,499 g). At 14 years of age, 130 (84.4%) of 154 VLBW and 42 (70.0%) of 60 NBW children were assessed. Ten VLBW children and one NBW child who had cerebral palsy were excluded. VLBW children scored at a significantly lower level on all three composite scales of the Wechsler Intelligence Scale for Children, 3rd Edition. VLBW children were also significantly disadvantaged on more specific cognitive processes, including tests of visual processing and visual memory and on subtests reflecting learning and problem solving. Only in arithmetic was a difference between the groups discerned on tests of achievement. Significantly more VLBW children were rated by teachers as socially rejected and by their parents as having learning problems at school. VLBW children had significantly reduced self-esteem. VLBW children had more cognitive, academic, and behavioral problems and lower self-esteem at 14 years of age than NBW control subjects.
 
Case: John, a 14-year old white male of European Jewish descent without a prior history of medical or psychiatric problems, presented following several days of increased need for sleep (16-20 hours per day), disorientation, difficulty maintaining attention and concentration, bizarre behaviors. He was sexually inappropriate toward his mother, sister, and housekeeper, masturbated in public, and sang nonsense lyrics. In addition, he had brief periods of agitation, paranoia (including fear that he was being followed and that he would be hurt by the physicians), and periods of distraction by auditory and visual hallucinations. His appetite increased significantly during this time. One week prior to the onset of these symptoms, he traveled to the Midwest where he experienced several days of nausea, vomiting, and diarrhea. John's physical and neurological examinations were normal except for the behaviors noted above. A medical evaluation revealed a normal brain computerized tomogram (CT) and magnetic resonance imaging (MRI). Urine toxicology screen, a comprehensive metabolic blood panel, and a complete blood count were normal. A lumbar puncture demonstrated a slightly elevated opening pressure (24 centimeters); the cerebrospinal fluid examination was unremarkable for cells, protein and glucose. Following the lumbar puncture, for which he had received midazolam, he had a brief, 30-45 minute episode of lucidity in which he was able to describe feeling like he was "in a fog." John was transferred to a psychiatric hospital where he recovered over several days and was discharged home. After three weeks of complete recovery, he acutely developed profound fatigue and the previously seen bizarre behaviors returned and persisted for 2 weeks. Following a 2-week period without symptoms, a similar behavior pattern recurred for the third time. The third episode differed from the first two in that he initially developed mental status changes and then developed symptoms of hypersomnolence. John has now been completely recovered from the third two week episode for one week and is taking summer school classes and enjoying socializing with his friends.
 
This study examines the outcome at ages 2 and 3 years of very-low-birth-weight infants (N = 105) at double risk. Double risk was defined with reference to Fagan's model of intelligence. According to this model, cognitive-processing ability and culturally provided information produce knowledge. The Fagan Test of Infant Intelligence was used to assess processing ability, whereas parental socioeconomic status (SES) was used as an indicator of available information. Knowledge was measured by means of well-known psychometric tests of young children's abilities. Children at double risk were consistently delayed with respect to knowledge of intellectual skills and language as compared with children who were not at double risk. The data suggest that the assessment of processing ability and parental SES may provide a better foundation for detecting developmental delay than does a medical main-effect model.
 
Deletion within the proximal region of chromosome 15q11.2 between breakpoints 1 and 2 (BP1-BP2) has been proposed to be a risk factor for intellectual disability, seizure, and schizophrenia. However, the clinical significance of its reciprocal duplication is not clearly defined yet. We evaluated 1654 consecutive pediatric patients with various neurological disorders by high-resolution microarray-based comparative genomic hybridization. We identified 21 patients carrying 15q11.2 BP1-BP2 deletion and 12 patients carrying 15q11.2 BP1-BP2 duplication in this cohort, which represent 1.27% (21/1,654) and 0.7% (12/1,654) of the patients analyzed, respectively. Approximately 87.5% of the patients carrying the deletion and 80% of the patients carrying the duplication have developmental delay or intellectual disability. Other recurrent clinical features in these patients include mild dysmorphic features, autistic spectrum disorders, and epilepsy. Our observations provide further evidence in favor of a strong association of 15q11.2 BP1-BP2 deletion with a variety of neuropsychiatric disorders. The diversity of clinical findings in these patients expands the phe-notypic spectrum of individuals carrying the deletion. In addition, possible etiological effects of 15q11.2 BP1-BP2 duplication in neuropsychiatric disorders are proposed.
 
Case. A 16-year-old white male visited his new pediatrician for a health supervision appointment. He had been in good general health, enjoyed playing music, and was doing well academically in high school. His only concerns were a small ganglion cyst on the wrist and the growth of his right scrotum over several months associated with an achy feeling. Symptoms of depression, associated with episodes of anxiety, started about 2 years previously. Paroxetine (20 mg/day) was prescribed by a psychiatrist who saw him every other week for counseling. He was taking minocycline 100 mg/day for acne. Symptoms of sadness, fatigue, and poor motivation improved modestly with treatment. He continued to have periods of anxiety, described as feeling tense and worried. He described these periods as "mini panic attacks." At times, these feelings surfaced suddenly without a specific triggering event or thought. He was never hospitalized. There were several family members with either depression or anxiety under the care of a physician. Physical examination revealed normal growth parameters (height, 75th percentile; weight, 40th percentile). Blood pressure (BP), as recorded by a female nurse, was 140/88 mm Hg, followed by 130/75 after 10 minutes supine and taken by a male physician. The examination was normal except for a large right scrotal mass that transilluminated, the ganglion cyst on his right wrist, and symmetrical hyperreflexia limited to both knees without weakness, spasticity, or any focal neurological signs. There was moderate pustular acne over the back and mild facial acne. Laboratory tests to evaluate hypertension included a normal blood urea nitrogen (BUN), creatinine, serum electrolytes, cholesterol, and complete blood count. Normal thyroid studies included a levothyroxin (T4) = 6.7 μg/dL and thyroid-stimulating hormone (TSH) = 2.34 μlU/mL. Plans for home monitoring of BP and office follow-up were made. An ultrasound of the scrotum demonstrated a large right hydrocele. At the next office visit 6 weeks later, his BP was 138/96 mm Hg (by the nurse), followed by 135/80 and 138/85 mm Hg taken by the physician. Recordings at home averaged 132/70-80 mm Hg. He reported feeling anxious and experiencing an increased heart rate at the doctor's office. In addition, he stated that he was feeling more anxious in general with episodes of what he described as "panic attacks." His psychiatrist increased the paroxetine to 30 mg daily. He was referred to a urologist for evaluation and surgical treatment of the hydrocele. Shortly after the initiation of anesthesia with propofol, becuronium, and meperidine, his BP was recorded as 260/110 mm Hg (BP normal at the hospital before anesthesia). The BP normalized within 15 minutes after discontinuation of anesthesia without pharmacological intervention. A cardiac examination, including four extremity blood pressures and an EKG, was normal; serum electrolytes and BUN and a comprehensive urine drug screen were negative. He saw his pediatrician the following day. BP in the office was 126/74 mm Hg (pulse = 76). He did not appear anxious or depressed and showed appropriate concern with the hypertension. The pediatrician ordered a 24-hour urine collection for catecholamines. The test was positive for norepinephrine (491 UG/G creatinine); normal value for 11 to 17 year olds is 4 to 105 U/G creatinine). The other catecholamines were normal: epinephrine = 5 UG/G creatinine, dopamine = 388 UG/G creatinine, and vanillylmandelic acid (VMA) = 7.3 MG/G creatinine. Additional history revealed that the patient's symptoms of anxiety and "panic" had an episodic pattern associated with pallor and sweating. A magnetic resonance imaging study demonstrated a 4- to 5-cm mass between two renal arteries on the left side. There was a 2-cm lesion at the right aortocaval region near the kidney. A second lesion was visualized on the left side. A metaiodobenzyl guanidine (MIGB) scan, a specific radionuclear study for neural crest tumors, revealed uptake in the same areas without other evidence of tumor. These studies are consistent with pheochromocytoma.
 
To determine in low birth weight infants the relations of being small for gestational age at birth, microcephalic at birth, low weight for age at 2 years, and microcephalic at 2 years to full scale intelligence quotient (FSIQ) at the age of 16 years. A prospective observational study of 422 of 837 eligible nondisabled low birth weight (<2000 g) adolescents from the newborn brain hemorrhage cohort with weight and head circumference at birth and at the age of 2 years in whom FSIQ was assessed with the Wechsler Abbreviated Scales of Intelligence at the age of 16 years. In a multiple regression analysis, being small for gestational age (beta = -0.14, p = .02) and microcephalic at 2 years (beta = -0.18, p < .001), but not low weight for age at 2 years or microcephaly at birth, had significant independent effects on 16-year FSIQ. After adjusting for pre-, peri-, and postnatal risk factors for poor cognitive performance, the independent effects of being small for gestational age (beta = -0.13, p = .004) and microcephalic at 2 years (beta = -0.13, p = .01) persisted. In this analysis, birth social risk had the largest significant independent effect on 16-year FSIQ (beta = -0.28, p < .001). Being small for gestational age at birth, but not low weight for age at 2 years, and microcephaly at 2 years, but not at birth, were independently related to FSIQ of nondisabled low birth weight adolescents, both with and without control for pre-, peri-, and postnatal risk factors.
 
To describe cognitive and behavioral features of patients with chromosome 16p11.2 deletion syndrome, a recently identified and common genetic cause of neurodevelopmental disability, especially autism spectrum disorder (ASD). Twenty-one patients with 16p11.2 deletion were evaluated by medical record review. A subset of 11 patients consented to detailed cognitive, behavioral, and autism diagnostic assessment. Patients with 16p11.2 deletion had varying levels of intellectual disability, variable adaptive skills, and a high incidence of language delay. Attention issues were not as frequent as had been reported in previous clinical reports. Atypical language, reduced social skills, and maladaptive behaviors were common, as was diagnosis of ASD. Based on medical record review, 7 of 21 patients (33%) had an ASD diagnosis. Among patients receiving detailed phenotyping, 3 of 11 (27%) met full criteria (met cutoff scores on both Autism Diagnostic Observation Schedule and Autism Diagnostic Interview) for an ASD diagnosis, whereas 6 other patients (55%) met criteria for ASD on either the Autism Diagnostic Observation Schedule or the Autism Diagnostic Interview, but not both measures. Rates of ASD were similar to previous reports that are based on medical record reviews, but formal assessment revealed that a majority of patients with 16p11.2 deletion demonstrate features of ASD beyond simple language impairment. All patients with 16p11.2 deletion should receive formal neurodevelopmental evaluation including measures to specifically assess cognitive, adaptive, language, and psychiatric/behavioral issues. Clinical evaluation of this patient population should always include assessment by Autism Diagnostic Interview and Autism Diagnostic Observation Schedule to detect behaviors related to ASD and possible ASD diagnosis.
 
The Pediatric Symptom Checklist-17 (PSC-17) is a brief form of the Pediatric Symptom Checklist that is designed to screen for behavioral health problems in primary care settings. It has been proposed to have three subscales: externalizing, internalizing, and attention problems. In the context of developing a behavioral health screening program in an inner-city primary care practice, we evaluated the construct validity of the PSC-17. A total of 331 families with children between 4 and 12 years of age who were seen for well-child care during the study were invited to complete the PSC-17 and 320 families (96.5%) did so. A confirmatory factor analysis was performed and the Comparative Fit Index and root mean square error of approximation fit statistics were calculated to determine whether the data fit the proposed three-factor model. We found that although the PSC-17 contained three subscales, several items did not load predominantly on the subscale that they were proposed to measure. Specifically, although the five items on the internalizing subscale loaded only on this subscale, only four of the seven externalizing items loaded exclusively on the externalizing subscale, and only two of the five attention items loaded exclusively on the attention problems subscale. Clinicians using the PSC-17 in urban low-income communities should recognize that the externalizing and attention problems subscales of the PSC-17 may not be valid measures of these dimensions of child behavior in this population.
 
Learning and behavior problems occur frequently in children with neurofibromatosis (NF), although, to the best of our knowledge, no one has described the types of problems encountered. This paper presents psychological test data on 23 NF children referred to a Learning Disorders Clinic. A high incidence of visual-perceptual disability was found in isolation (56%) or in conjunction with language deficits (30%). This pattern was found to differ from that seen in children with developmental learning disorders, without NF. The need for physicians to incorporate questions about learning and behavior into their history-taking process is stressed.
 
To describe the cognitive and behavioral phenotypic features of the Potocki-Lupski syndrome (duplication 17p11.2), a recently recognized syndrome with multiple congenital anomalies and developmental delays. Fifteen subjects were enrolled in an extensive multidisciplinary clinical protocol. Cognitive and behavior evaluations included a parent-report medical and psychological history form, intellectual assessment and assessments of adaptive behavior, executive functioning, and maladaptive behavior and emotions. Eight of the families completed an Autism Diagnostic Interview-Revised and Autism Diagnostic Observation Schedule-Generic. The majority of patients (13 of 15) presented with intellectual disability. Moreover, the majority of patients also had moderate to severe behavioral difficulties, including atypicality, withdrawal, anxiety, and inattention. Many patients characterized also presented with autistic symptom pictures, some of whom (10 of 15) met diagnostic criteria for an autistic spectrum disorder, namely autistic disorder or pervasive developmental disorder not otherwise specified. This work expands on the behavioral phenotype of duplication 17p11.2 (Potocki-Lupski syndrome). Further phenotypic analysis will aid in clinical diagnosis, counseling, and management of this newly characterized microduplication syndrome. The association between this syndrome and autistic spectrum disorder may contribute to further understanding the etiology of the pervasive developmental disorders.
 
To investigate the impact of child gender, maternal education, and birth order on language comprehension (LC) status at 18 and 36 months of age and on the change in LC between these time points. Gender interactions and interactions between maternal education and birth order are also examined. This study is based on data from the Norwegian Mother and Child Cohort Study conducted by the Norwegian Institute of Public Health. Maternal report data on education, birth order, and child language in a sample of 44,921 children were used in linear regression analyses. At 18 and 36 months of age, first-born girls of mothers with high educational attainment had the highest level of LC. Between 18 and 36 months of age, first-born boys of mothers with high educational attainment had the highest increase in LC. Having a highly educated mother contributed more to the increase in LC in boys than in girls. The boys whose mothers had the highest education level had lower scores than the girls whose mothers had the lowest educational level, at both ages. Although significant, the considerable effect of high maternal education was not substantially dependent on birth-order status. Boys develop LC at a faster rate than girls between 18 and 36 months, but girls still remain superior in their level of LC at 36 months of age. Being firstborn or having a highly educated mother does not compensate for this lag.
 
Obstructive sleep apnea (OSA) affects a person's quality of life. A questionnaire, the OSA-18, is available to measure quality of life in children with OSA not caused by specific craniofacial syndromes. We assessed the internal consistency, test-retest reliability, and discriminative validity of the OSA-18 in children with syndromic and complex craniosynostosis; we also applied the OSA-18 in healthy children to obtain reference values. The OSA-18 was translated in the Dutch language using the procedure of multiple forward and backward translations. Test-retest reliability and internal consistency were examined. In a prospective study, the craniosynostosis patients underwent an ambulatory polysomnography to diagnose OSA. The ability of the OSA-18 to discriminate between subgroups of patients with or without OSA was evaluated. We compared OSA-18 scores of children with syndromic or complex craniosynostosis with scores in healthy children. The Cronbach's alpha was ≥ 0.70 for the total OSA-18 score and for most of the domains in both the craniosynostosis and general population. In the craniosynostosis group, the test-retest intraclass correlation coefficients were ≥ 0.70, except for the domain physical suffering at 0.69. The discriminative validity of the domains sleep disturbance, physical suffering, caregiver concerns, and total OSA-18 score was significant between the general and craniosynostosis population. This study supports the reliability and validity of the OSA-18 in children with syndromic or complex craniosynostosis.
 
The purpose of this study was to examine family adaptation to a traumatic brain injury (TBI) in young children during the first 18-month postinjury, when compared with children who had an orthopedic injury. A concurrent cohort/prospective research design was used with repeated assessments of children aged 3 to 6 years with TBI or orthopedic injury requiring hospitalization and their families. Shortly after injury and at 6-, 12-, and 18-month postinjury, parents of 99 children with TBI (20 severe, 64 moderate, 15 mild) and 117 with orthopedic injury completed standardized assessments of family functioning, parental distress and coping, injury-related burden, and noninjury-related parent stressors and resources. Mixed models analyses examined group differences in parental burden and distress adjusted for race and social demographic factors. Both moderate and severe TBI were associated with higher levels of injury-related stress than orthopedic injury, with stress levels diminishing over time in all groups. Severe TBI was also associated with greater psychological distress on the Brief Symptom Inventory but not with more depressive symptoms. Family functioning and social resources moderated the relationship of TBI severity to injury-related burden and caregiver distress, respectively. Lower child adaptive skills were associated with poorer family outcome but group differences remained even when controlling for this effect. Severe TBI in young children has adverse consequences for parents and families during the first 18-month postinjury. The consequences lessen over time for many families and vary as a function of social resources.
 
This study investigated predictors of delayed language development at 18 months of age in a large population cohort of Norwegian toddlers. Data were analyzed on 42,107 toddlers. Language outcome at age 18 months was measured using a standard parent report instrument, the Ages and Stages Questionnaire, communication scale. Confirmatory factor analysis was conducted on the Ages and Stages Questionnaire items. A theoretically derived set of child, family, and environmental risk factors were used to predict delayed language development at age 18 months using Generalized Estimating Equation. A number of child factors, including being a boy, low birth weight or gestational age, or a multiple birth child were all significantly associated with low scores on the language outcome at age 18 months. Maternal distress/depression and low maternal education, having older siblings, or a non-Norwegian language background also predicted low scores on the language outcome at age 18 months. Overall, estimated variance in language outcome explained by the model was 4% to 7%. A combination of early neurobiological and genetic factors (e.g., male gender, birth weight, and prematurity) and concurrent family variables (e.g., maternal distress/depression) were associated with slower language development at age 18 months. This finding replicated previous research conducted on slightly older language-delayed 2 year olds but also detected the importance of factors related to family resources for the first time in this younger age group. Despite this finding, most of the variability in language performance in this cohort of 18 month olds remained unexplained by the comprehensive set of purported risk factors.
 
This prospective study examined the effects of ongoing maternal drug use, parenting attitudes, and a home-based intervention on mother-child interaction among drug-using women and their children. At 2 weeks postpartum, mothers and infants were randomly assigned to either an Intervention (n = 67) or Control (n = 64) Group. Intervention families received weekly visits until 6 months postpartum and biweekly visits from 6 to 18 months by trained lay visitors. The home intervention was designed to increase maternal empowerment and promote child development. Control families received brief monthly tracking visits. Mother-child interaction was evaluated at 18 months through observation of play. Mothers who continued to use cocaine and/or heroin had lower competence scores (p <.05); poor parenting attitude was also associated with lower competence scores during mother-child interaction (p <.05). Although the intervention had no measured effect, ongoing maternal drug use and poor parenting attitudes were associated with less optimal maternal behavior during mother-child interaction.
 
Behavioral characteristics of very low birth weight infants (less than 1,501 gm) were determined with the term Brazelton Neonatal Behavioral Assessment Scale and selected items from a preliminary form of the scale for premature and at-risk infants. The behavior of 188 infants was assessed at a time as optimal as possible for social interaction. Our very low birth weight infants were upset less easily, had several reflexes with below average scores, and were less responsive to visual stimuli than term infants of other studies. Improved description of interactive abilities and tolerance of the testing procedure was made possible with some items from the preliminary premature scale. Orienting responses in 6 infants tested after 44 weeks because of prolonged illness were less than optimal with a single exception. This suggests that behavioral capacity, not age, should define where the Brazelton scale is not applicable. Perinatal factors including birth weight, gestational age, and age that weight gain began, predicted some motoric and state control responses. Whether this predictive capacity will persist or change with time awaits results of follow-up of these infants.
 
The authors examined the association of psychological adjustment, styles of coping, and disease severity for children with recurrent syncope. Participants were 44 children and adolescents with a history of recurrent syncope and 40 healthy comparison control children. Dependent variables were measures of internalizing adjustment (e.g., anxiety, depression, withdrawal) reported by children and their parents and styles of coping reported by children. Parents reported higher frequencies of the internalizing of behavioral symptoms (i.e., anxiety, withdrawal) for children with recurrent syncope compared with their healthy counterparts. Children's self-reports did not reveal significant differences between the syncope and comparison groups in psychological adjustment and styles of coping. The authors conclude from these findings that adjustment difficulties, including symptoms of anxiety and social withdrawal, may occur with recurrent syncope. Implications for clinical practice and future research are discussed.
 
Developmental characteristics of three girls with 18p- syndrome are described, with detailed history and results of psychological and speech/language evaluations completed at various ages. Results suggest that some children with 18p- syndrome have average abilities in selected areas, despite previous reports that these children have mild to severe mental retardation. Two of the three girls had more severe deficits in linguistic, as opposed to nonlinguistic, abilities. All had similar difficulties with speech articulation. It is suggested that children with speech/language delays who have physical features associated with this syndrome have chromosome analysis performed. It is also recommended that children identified as having 18p- syndrome be referred for comprehensive developmental assessments and remedial special education programming before a specific prognosis is determined.
 
This study examined the role of cranial sonography and neurological examination in the prediction of developmental progress during the first 19 months of life in extremely preterm infants. Forty-seven infants with mean birth weight 993 +/- 197 g and gestational age 27.9 +/- 1.9 weeks were studied. Each infant was classified as normal, suspect, or abnormal using cranial sonography and a structured neurological examination. Developmental outcome was assessed using the Infant Neurological International Battery (INFANIB) at 4, 8, and 14 months and the Rockford Infant Developmental Evaluation Skills (RIDES) at 19 months. Sonographic classification was the best predictor of outcome through 14 months, F(2.72) = 12.4, p < .001. The neurological examination predicted performance only at 4 months. No infant classified as normal on both examinations was abnormal on follow-up. Infants with suspect or abnormal neurological examinations had normal outcomes if their sonographic findings were normal.
 
Case: A 19-year-old female was admitted to a children's hospital weighing 75 pounds. She lost 75 pounds over 2 years and did not menstruate for a year. Despite her dissatisfaction with her thin appearance and desire to weigh more, her inpatient treatment focused on "disordered eating." Adolescent medicine, nutrition, and gastroenterology specialists were consulted. A pediatric psychology consultation was initiated to address anxiety associated with eating as well as abnormal toileting behaviors. The patient reported that she had chronic constipation since the age 3 years with a large, hard, and painful bowel movement once every 1-3 weeks. She had numerous medical and nutritional interventions to improve her bowel functioning, including extensive laxative use and a diet high in fiber (mostly fruits and vegetables). Additionally, an extensive medical evaluation to look for physiological causes for chronic constipation, including Hirschsprung's disease, was not diagnostic. The patient described purposeful stool withholding due to her concern over painful bowel movements. She also avoided peer activities because she did not want to use toilets outside her home. The patient acknowledged that her disordered eating stemmed largely from her toileting difficulties. She described altering her eating habits to avoid bowel movements (e.g., eating small meals, not eating at school) and anxious thoughts while defecating. Defecation anxiety was now affecting other areas of her life. For example, she frequently used copious amounts of toilet paper to ensure thorough cleaning. The patient's parents confirmed her need to thoroughly clean after toilet use, using "almost half a roll of toilet paper." They described other concerning "routines," including refusing to use towels after showering. She dried herself with a fan because of fear that her towel may be dirty. They indicated that during early adolescence, she frequently washed her face to prevent acne breakouts. According to parents, the patient followed doctors' instructions "as though they (were) gospel," deviating from suggestions only with extreme resistance.
 
A 19-year-old female was admitted to a children's hospital weighing 75 pounds. She lost 75 pounds over 2 years and did not menstruate for a year. Despite her dissatisfaction with her thin appearance and desire to weigh more, her inpatient treatment focused on "disordered eating." Adolescent medicine, nutrition, and gastroenterology specialists were consulted. A pediatric psychology consultation was initiated to address anxiety associated with eating as well as abnormal toileting behaviors. The patient reported that she had chronic constipation since the age 3 years with a large, hard, and painful bowel movement once every 1-3 weeks. She had numerous medical and nutritional interventions to improve her bowel functioning, including extensive laxative use and a diet high in fiber (mostly fruits and vegetables). Additionally, an extensive medical evaluation to look for physiological causes for chronic constipation, including Hirschsprung's disease, was not diagnostic. The patient described purposeful stool withholding due to her concern over painful bowel movements. She also avoided peer activities because she did not want to use toilets outside her home. The patient acknowledged that her disordered eating stemmed largely from her toileting difficulties. She described altering her eating habits to avoid bowel movements (e.g., eating small meals, not eating at school) and anxious thoughts while defecating. Defecation anxiety was now affecting other areas of her life. For example, she frequently used copious amounts of toilet paper to ensure thorough cleaning. The patient's parents confirmed her need to thoroughly clean after toilet use, using "almost half a roll of toilet paper." They described other concerning "routines," including refusing to use towels after showering. She dried herself with a fan because of fear that her towel may be dirty. They indicated that during early adolescence, she frequently washed her face to prevent acne breakouts. According to parents, the patient followed doctors' instructions "as though they (were) gospel," deviating from suggestions only with extreme resistance.
 
Case: Jose is a 13-year-old boy who presents to his primary care provider after struggling in school for many years. When he was in the first grade, he was diagnosed at a tertiary center with attention-deficit hyperactivity disorder. Multiple medication trials have produced few benefits and many side effects including poor sleep, morbid thoughts, lack of motivation, and, according to his parents, "he seemed like a robot."He comes now for his annual physical in April, and the parents tell you that the school is threatening that he be retained in the seventh grade. Parents are very adamant they do not want to try another medication. They have brought you their own and his advisor's Vanderbilt's, which each endorse 7 of 9 inattentive symptoms including trouble organizing, poor attention to detail, and easily distracted and forgetful in daily activities. His birth history and developmental history before beginning formal schooling are unremarkable. His first language was English whereas his parents speak Spanish to each other but not the children. He is healthy and without a history of head trauma, seizures, meningitis, or lead poisoning. An aunt has "learning problems."Jose's family lives in a crowded section of a large urban area. They share an apartment with another family, and both parents are employed full time with his father holding 2 full time jobs working double shifts. Their annual income is at the poverty line. There are 4 children in the family aged between 6 and 13 years.His school has been deemed a "recovery school" because of performing below standard on district-wide achievement tests. His classroom has 27 students, many of whom are English language learners, and he is not on an individualized education plan or 504 accommodations.The family is very concerned about the possibility of retention but have decided that "medicine does not help," and they look to you for other recommendations. Where do you go next?
 
The type and prevalence of psychiatric disorders were assessed in 200 children with speech and language disorders referred to a suburban speech and hearing clinic. Possible correlates of psychiatric disorder, including demographic factors, medical and developmental problems, psychosocial stressors, and speech and language factors, were also assessed. Standardized psychiatric and speech and language evaluations were done for all subjects, as were IQ and academic testing. Approximately 50% of the sample had some definable psychiatric disorder. The most common diagnoses were behavior disorders, followed by emotional disorders. The presence of psychiatric disorder was strongly correlated with speech and language factors, as well as psychosocial stressors. These findings have implications for primary care practitioners and speech and language therapists involved in planning treatment programs for such children.
 
Past research indicates that non-Hispanic black (NHB) children are less likely than non-Hispanic white (NHW) children to have an autism spectrum disorder (ASD) diagnosis, even if they seem to meet criteria for the disorder. This study examined differences in community identification of ASDs between NHB and NHW children identified by a population-based surveillance system. Participants were identified as an ASD surveillance case by the Metropolitan Atlanta Developmental Disabilities Surveillance Program in surveillance years 2000, 2002, 2004, and 2006. Health and education records were abstracted and reviewed to determine ASD surveillance case status; community identification was defined by a documented ASD diagnosis, special education eligibility, and behaviors noted in records. Children were placed in 1 of 5 mutually exclusive categories on the basis of ASD specificity. Total ASD prevalence was higher for NHW than NHB children, but NHB children were more likely than NHW children to have autistic disorder and autism eligibility at a public school documented in records. NHB children were less likely than NHW children to have pervasive developmental disorder-not otherwise specified and Asperger's disorder documented in records, even after controlling for socioeconomic status. NHB children were more likely than NHW children to have co-occurring intellectual disability. NHB children were less likely than NHW children to have been identified with less severe ASDs, which might have prevented or delayed intervention services that would have catered to their needs. This study illustrates the need for continued professional education, particularly concerning milder ASDs in minority groups.
 
Past research is inconsistent in the stability of autism spectrum disorder (ASD) diagnoses. The authors therefore sought to examine the proportion of children identified from a population-based surveillance system that had a change in classification from ASD to non-ASD and factors associated with such changes. Children with a documented age of first ASD diagnosis noted in surveillance records by a community professional (n = 1392) were identified from the Autism and Developmental Disabilities Monitoring Network. Children were considered to have a change in classification if an ASD was excluded after the age of first recorded ASD diagnosis. Child and surveillance factors were entered into a multivariable regression model to determine factors associated with diagnostic change. Only 4% of our sample had a change in classification from ASD to non-ASD noted in evaluation records. Factors associated with change in classification from ASD to non-ASD were timing of first ASD diagnosis at 30 months or younger, onset other than developmental regression, presence of specific developmental delays, and participation in a special needs classroom other than autism at 8 years of age. Our results found that children with ASDs are likely to retain an ASD diagnosis, which underscores the need for continued services. Children diagnosed at 30 months or younger are more likely to experience a change in classification from ASD to non-ASD than children diagnosed at 31 months or older, suggesting earlier identification of ASD symptoms may be associated with response to intervention efforts or increased likelihood for overdiagnosis.
 
Top-cited authors
Randi J Hagerman
  • University of California, Davis
Jacquelynne S Eccles
  • University of California, Irvine
Jennifer Gootman
  • Inter-American Development Bank
Philip R. Nader
Judith Owens
  • Boston Children's Hospital