Pediatric Primary Care (132 page)

1.  Obsessive-compulsive disorder, Tourette syndrome.

2.  Conduct disorder, mental retardation, hearing disorder.

3.  Schizophrenia of childhood.

4.  Lead poisoning.

5.  Fragile X syndrome.

6.  Additional pervasive disorders.

7.  Asperger's syndrome.

a.  Impairment is primarily in social interactions, which includes repetitive and obsessive behaviors.

b.  Children usually do not have language impairments characteristic of autism.

c.  Rare disorder characterized by normal development until 2-4 years old, at which time there is severe mental and social deterioration.

8.  Childhood disintegrative disorder.

9.  Rett syndrome.

a.  Development normal until 1 year of age, at which time language and motor development regress.

b.  Microcephaly is usually evident by 1 year of age.

H.  Treatment.

1.  No single best evidence-based treatment.

a.  Treatment is individualized to the child.

•  Management of challenging behaviors.

Box 34-6
Autistic Measures

Autistic Diagnostic Observation Schedule (ADOS) Childhood Autism Rating Scale (CARS)

•  Sleep problems.

•  Social skills training.

b.  Medication.

•  For aggressive behaviors and irritability for children and teens with autism: resperidone and aripiprazole.

•  Stimulants for comorbid symptoms of ADHD.

•  Other comorbid conditions treated as appropriate by psychiatric specialists.

c.  Implement all early intervention services in home and school: speech therapy, occupational and physical therapy, behavior modification strategies.

2.  Diagnosis.

a.  Denver Developmental II screening test: valuable tool used to assist in early recognition.

b.  Screening Tool for Autism in Toddlers and Young Children.

c.  Autism Spectrum Screening Questionnaire for 6-17 years old.

d.  Refer to developmental neurologist and Early Intervention services (under age 5) as soon as symptoms are suspected.

3.  Comorbidity.

a.  ADHD.

b.  Intellectual disabilities.

c.  Mood disorders.

d.  Depression.

e.  Anxiety.

f.  Obsessive-compulsive behaviors.

g.  Phobias.

I.  Follow up.

1.  Recognize early signs and symptoms of autism, Asperger's syndrome, childhood disintegrative disorder, Rett syndrome, and make appropriate referrals.

2.  Support for parents, other primary caregivers is essential. Families may benefit from connecting with the Autism Society (
www.autism-society.org
).

3.  Encourage parents to find respite care for child.

J.  Complications.

Autism, 299

1.  Autism is a chronic disease with no cure.

K.  Education.

1.  Families need education about the disorder, what treatments have been proven to be successful; multidisciplinary interventions.

2.  Families need to be careful when investigating treatment programs and determine proven benefits from these programs. Families must consider own safety and that of their child.

3.  Internet resources.

a.  Autism Society:
www.autism-society.org
.

b.  Centers for Disease Control and Prevention:
www.cdc.gov
.

c.  American Academy of Pediatrics:
www.aap.org
.

IV.  BREATH HOLDING

A.  Characterized by episodes in which infant/young child holds breath, which leads to cerebral anoxia resulting in limp body and extremities, unresponsiveness. Two types: cyanotic spells and pallid spells.

B.  Etiology.

1.  Unknown.

C.  Occurrence.

1.  Usually begins after 6 months old.

2.  Highest incidence is at 2 years old.

3.  Usually resolves by 5 years old.

4.  Usually occurs in response to an upsetting, unexpected, or traumatic event.

5.  May occur with genetic conditions such as Rett syndrome.

6.  Associated with iron-deficiency anemia.

D.  Clinical manifestations.

1.  Cyanotic spells.

a.  Brief shrill cry followed by forced expiration and apnea.

b.  Onset of cyanosis.

c.  Loss of consciousness.

d.  Generalized clonic jerks.

e.  Bradycardia.

2.  Pallid spells.

a.  Usually follows fall in which child strikes head, causing pain.

b.  Cessation of normal breathing pattern; prolonged apneic episode.

c.  Loses consciousness.

d.  Pallor.

e.  Tonic seizure activity (occasional).

E.  Physical findings.

1.  Normal physical exam findings.

F.  Diagnostic tests.

1.  EEG. Referral to neurologist is recommended.

G.  Differential diagnosis.

Seizure disorder, 780.39

1.  Seizure disorder.

H.  Treatment.

1.  No treatment necessary.

2.  Parental support and reassurance.

3.  Avoid situations that provoke the breath-holding episodes.

4.  Treat iron-deficiency anemia if present.

I.  Follow up.

1.  Call within a few days to assess how family is dealing and answer questions.

2.  Parents' level of comfort with breath-holding spells determines further follow up.

J.  Complications.

1.  Head injury if child falls during episode.

K.  Education.

1.  Discussion of management plan that parents can follow consistently. Parents must feel comfortable with plan.

2.  Provide safe environment for child during and at conclusion of episode.

3.  Avoid reinforcement of these behaviors.

4.  Most children outgrow breath-holding episodes by 4 to 8 years old.

V.  NIGHTMARES AND NIGHT TERRORS

A.  Etiology.

1.  Actual cause unknown.

2.  Dysfunctional family relationships should be suspected.

B.  Occurrence.

1.  Occurs in 1–3% of children, mostly in boys between 5 and 7 years old.

C.  Clinical manifestations.

1.  Night terrors: sudden, unexpected screams during sleep; usually occurs within 2 hours of the time the child goes to sleep.