David A. Kube

Classification of Developmental Delays

Developmental delay is frequently used to identify children with delay in meeting developmental milestones in one or more streams of development. There is no consensus on the specific definition. Developmental delay is best viewed generically as a chief complaint rather than a diagnosis. A child suspected to have delays should always be assessed in each of the major streams of development: expressive and receptive language, including social communication; visual problem solving (nonverbal cognition); motor development; neurobehavioral development; and social-emotional development. A model developed by the National Center for Medical Rehabilitation Research is used to compare existing classifications of developmental delays. This model defines the five domains in the disability process: pathophysiology, impairment, functional limitation, disability, and societal limitation. An etiology domain is added. This model is used to illustrate how existing classification systems of cerebral palsy, mental retardation, autism, and language delay draw on information from one or more domains. The model illustrates some of the conflicts between different systems. For example, most classification systems for cerebral palsy emphasize only impairment (spasticity, dyskinesias, and topography). The current definition and classification system for mental retardation focuses on functional limitations (IQ), disability, and societal limitations, ignoring pathophysiology and details of impairment. Given the complexity of neurodevelopmental disabilities, it is unlikely that a single classification system will fit all needs.

Attention Deficit Hyperactivity Disorder: Comorbidity and Medication Use

Children evaluated for attention deficit hyperactivity disorder (ADHD) may have other disorders resembling ADHD leading to inappropriate stimulant medication use. This study was completed to identify relationships between referral complaints of ADHD, behavior problems or learning problems and age, gender, final diagnosis, and medication use. One hundred eighty-nine children ages 2 to 15 years referred for evaluation of ADHD, behavior or learning problems were evaluated by an interdisciplinary team. Diagnoses of ADHD, specific learning disability (SLD), mental retardation (MR), developmental language disorders (LANG), and other behavior disorders (DIS) were established. Medication use pre-and post-evaluation was reviewed. Forty-three percent of all subjects had a final diagnosis of ADHD. Forty percent referred specifically for presumed ADHD did not have it. More children older than 5 years were diagnosed as having ADHD than those 5 years old or younger (p<0.0001). More subjects 5 years old or younger were diagnosed as having LANG than those older than 5 years (p<0.0001). Fewer subjects with a chief complaint of ADHD were diagnosed with MR than those with behavior or learning problems (p=0.001). In subjects 5 years old or younger, 35% were diagnosed with MR and 49% with other DIS. In children older than 5 years, 41% were diagnosed with SLD. Ten percent of subjects without ADHD were using stimulants. Only 48% of subjects with confirmed ADHD took stimulants. Children presenting with behavior problems or those 5 years old or younger are at higher risk for MR, LANG, and DIS and less likely to have ADHD. Children presenting with learning problems or those older than 5 years are more likely to have SLD or ADHD. Multiple diagnoses were common for all ages and presentations. Ten percent of children without confirmed ADHD used stimulants before evaluation.

CAT/CLAMS: its use in detecting early childhood cognitive impairment

The Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS), a neurodevelopmental tool for the cognitive assessment of infants and toddlers, correlates well with the Bayley Scales of Infant Development. In 1993 the Bayley Scales were revised and the second edition published (BSID-II). This study was designed to determine how well the CAT/CLAMS correlates with the BSID-II and its utility in identifying mild and severe cognitive impairment. Sixty-eight infants and toddlers (age range = 14-48 months), referred for suspected developmental delays, were administered the CAT/CLAMS and BSID-II and the results compared. The correlation between the two instruments was strong (r = 0.89, P<0.0001). The CAT/CLAMS was sensitive (81%) and specific (85%) for detecting overall cognitive impairment (BSID-II less than 70) and was even more sensitive (100%) and specific (96%) in detecting severe cognitive impairment (BSID-II less than 50). The physician using the CAT/CLAMS formulated a clinical impression of cognitive impairment that was sensitive (95%) and specific (84%) compared with formal psychologic testing. The CAT/CLAMS correlates well with the BSID-II. It is useful for detecting and quantifying mild and severe cognitive impairment. It permits the physician to formulate an accurate clinical impression of cognitive impairment consistent with possible mental retardation.

Prevalence of developmental and behavioral disorders in a pediatric hospital

OBJECTIVE. The objective of this study was to estimate the prevalence of developmental and behavioral disorders in a convenience sample of children in an acute care pediatric hospital setting. We hypothesized that hospitalized children would have a higher prevalence of developmental and behavioral disorders than the general population. METHODS. Data for this cross-sectional study were collected during interviews with primary caregivers of 325 children from infancy throughout childhood who were admitted to a general pediatric service. Screening tests included the Child Development Inventory (3 months to 6 years), Parents’ Evaluation of Developmental Status (0–8 years), Pediatric Symptom Checklist (4–18 years), and Vanderbilt Attention-Deficit/Hyperactivity Disorder Parent Rating Scale (6–18 years). Children were classified as having a known developmental and behavioral disorder, a suspected developmental and behavioral disorder, or no developmental and behavioral disorder. RESULTS. The prevalence of developmental and behavioral disorders among the hospitalized children 6 months to 17 years of age was 33.5%. A total of 72 children (22.1%) had known developmental and behavioral disorders and 37 (11.4%) had suspected developmental and behavioral disorders. This high prevalence of developmental and behavioral disorders included high rates of cerebral palsy (6.1%) and mental retardation or developmental delay (8.6%). CONCLUSION. Hospitalization for treatment of acute conditions provides another opportunity for developmental surveillance. This higher prevalence of developmental and behavioral disorders in hospitalized children emphasizes the need to screen for developmental disabilities at every opportunity. Strategies to implement systematic screening of hospitalized children should be examined.

Persistent School Dysfunction: Unrecognized Comorbidity and Suboptimal Therapy

To determine reasons for continued school dysfunction in children previously diagnosed as having attention deficit hyperactivity disorder (ADHD) or enrolled in a special education program (spec. ed.), a retrospective chart review of patients referred for interdisciplinary evaluations at a tertiary center for hyperactivity and learning problems was completed. Interdisciplinary clinical recommendations were used to define reasons for treatment failure in 116 children with a prior diagnosis of ADHD or spec. ed. placement. Results showed 45% of children enrolled in spec. ed. had previously undiagnosed ADHD. Thirty-one percent of those with ADHD, 55% of those in spec. ed., and 55% of those diagnosed with ADHD and in spec. ed. (Both) received a new educationally handicapping diagnosis. Psychiatric comorbidity was present in 28% of those with ADHD, 18% of those in spec. ed., and 23% of Both subjects. Thirteen percent of those in spec. ed. had significant coexisting medical conditions. Special education services were insufficient in 55% of children in spec. ed. and 55% of Both subjects. A significant difference (P<0.01) in medication use was noted between the groups with 56% of the ADHD group, 55% of the Both group, and none of the spec. ed. group treated with medication. Of all subjects with ADHD, 76% were receiving insufficient or no medication. This review suggests the following: (1) Comorbidity in children with school dysfunction is frequently not recognized. (2) Educational therapy alone may not be sufficient treatment for school dysfunction, and in cases where the treatment program is failing, the appropriateness of the program should be reviewed. (3) ADHD is commonly seen in conjunction with other educationally handicapping conditions. Therefore, in cases of continuing school dysfunction, children previously diagnosed as having ADHD should be assessed for other educationally handicapping conditions; those previously diagnosed as educationally handicapped should be assessed for ADHD. (4) Suboptimal medication use may be associated with treatment failure.

ATTENTION-DEFICIT HYPERACTIVITY DISORDER: RELATIONSHIP BETWEEN EARLY CHILDHOOD AND FAMILY RISK FACTORS AND CHILDHOOD MENTAL HEALTH.: 180

Purpose In children with attention-deficit hyperactivity disorder (ADHD), (1) examine risk factors and parent/caregiver (P/G) perceptions of their children from pregnancy through childhood and (2) evaluate the relationship between these risk factors and perceptions and later childhood mental health. Methods Thirty families whose children had community-diagnosed ADHD were randomly selected from a group of children attending an ADHD camp. The child age range was 6 to 11 years, mean 8.7 ± 1.6. The parental age range was 31 to 65 years, mean 43.0 ± 8.7. In a retrospective interview, the P/G completed an Early Experience Survey (EES) and Brief Infant-Toddler Social and Emotional Assessment (BITSEA) evaluating risk factors associated with ADHD in pregnancy, toddlerhood, and childhood. P/Gs answered questions from the Behavior Assessment System for Children-Parent (BASC-P) regarding childhood depression and poor social skill. Children answered questions from the BASC-Child (BASC-C) regarding social stress and self-esteem. Results Data were analyzed using linear regression and analysis of variance. Pregnancy risk factors (maternal alcohol, drug, or tobacco use) were not predictors of BITSEA behavior problems (BBPs) but were significant predictors for poor social skills (p = .02). EES predictors for BBPs were delayed walking (p = .001), delayed fine motor skills (p = .01), and infant feeding problems (p = .02). Behavior difficulty in infancy (colic, irritability, easy frustration, and poor cuddling) predicted BBPs (p = .03). Other EES predictors for BBPs were toddlerhood aggression (p = .001) and chronic illness (p Conclusions Early and current family and child risk factors are associated with significant behavior problems in older children with ADHD. Screening children with these risk factors in infancy and toddlerhood may help detect children at risk of later mental health problems.

Clinical Adaptive Test/Clinical Linguistic Auditory Milstone Scales(CAT/CLAMS) is a Valid Pediatric Screening Tool for Detection of Mental Retardation in Early Childhood |[diams]| 653

Clinical Adaptive Test/Clinical Linguistic Auditory Milstone Scales(CAT/CLAMS) is a Valid Pediatric Screening Tool for Detection of Mental Retardation in Early Childhood ♦ 653