Frederick B. Palmer

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.

Repetitive neonatal pain and neurocognitive abilities in ex-preterm children.

Burgeoning research has focused on the neurocognitive outcomes of prematurity among school-aged children [5,6,8,38] and young adults [10,45], because of its impact on adult cognition, physical and mental health, and employment status. Most studies reported that those born before 28 weeks’ gestation were particularly vulnerable to poor neurocognitive and behavioral outcomes [14]. One prospective longitudinal study, for example, found that independent risk factors for school age impairments were gestational age 24–28 weeks, chronic lung disease, and abnormal electroencephalogram (EEG) before hospital discharge [8]. Various risk factors were postulated to explain the poor neurocognitive outcomes of preterm children compared with their term-born peers, including perinatal infections or inflammation, birth asphyxia, recurrent apnea/bradycardia, prolonged ventilation, hypothyroidism, hyperbilirubinemia, nutritional deficiencies, or the drugs used to treat preterm neonates, including glucocorticoids, theophylline, morphine, and others [11,34,37]. Among all NICU experiences, acute pain is arguably the most physiologically disruptive and developmentally unexpected of all stimuli, though some clinicians do not consider it a risk factor for neurocognitive outcomes [37]. In this issue of Pain, however, Doesburg et al. [15] provide evidence linking repetitive neonatal pain with changes in the ratio of gamma to alpha oscillatory activity (which they interpret as a deviation of the developmental trajectory of thalamocortical activity) and with cognitive outcomes in school-age children. These are potentially ground-breaking observations because they identify abnormal patterns of cortex-wide activity, critical windows for pain exposure and development of visual-perceptual abilities, but they also establish recurrent neonatal pain as a risk factor for impaired neurocognitive outcomes. The carefully designed study procedures, exclusion of children with sensory, motor, or cognitive impairments, psychoactive medications, or cranial ultrasound abnormalities, inclusion of pretermand term-born controls, and their well-designed multivariable analyses underscore the importance of these results. For the reasons listed below, their conclusions linking neonatal pain with visual-perceptual abilities and the development of thalamocortical connections in 7–8-year old extremely low gestational age (ELGA) children suggest a number of additional research questions to clarify these relationships. First, the authors show that cumulative neonatal pain, while controlling for various confounders, was associated with cortexwide oscillatory activity in ELGAs, as measured by gamma/alpha ratios on magnetoencephalography (MEG). They also found that gamma/alpha ratios in ELGAs were negatively correlated with

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.

Gestational Vitamin 25(OH)D Status as a Risk Factor for Receptive Language Development: A 24-Month, Longitudinal, Observational Study

Emerging data suggest that vitamin D status during childhood and adolescence can affect neurocognitive development. The purpose of this study was to investigate whether gestational 25(OH)D status is associated with early childhood cognitive and receptive language development. The Conditions Affecting Neurocognitive Development and Learning in Early Childhood Study (CANDLE) study enrolled 1503 mother-child dyads during the second trimester of healthy singleton pregnancies from Shelby County TN. Among 1020 participants of the total CANDLE cohort for whom 25(OH)D levels were available, mean gestational 25(OH)D level during the second trimester was 22.3 ng/mL (range 5.9–68.4), with 41.7% of values <20 ng/dL. Cognitive and language scaled scores increased in a stair-step manner as gestational 25(OH)D levels in the second trimester rose from <20 ng/dL, through 20–29.99 ng/dL, to ≥30 ng/dL. When controlling for socioeconomic status, race, use of tobacco products, gestational age of the child at birth, and age at the 2-year assessment, the gestational 25(OH)D was positively related to receptive language development (p < 0.017), but not cognitive or expressive language.

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.