Behavioral &

Developmental Variations
Development reflects changes in and acquisition
of new functions
Development classified as:

•Neurodevelopmental: changes in behaviour over

time, eg, reflexes, gross/fine motor skills

•Cognitive: includes thought, learning, problem

solving

•Psychosocial: environmental interactions,

interpersonal relationships
The acquisition of developmental abilities follows
a similar pattern between children,
but may vary in rate, and still be normal
Developmental milestones: the acquisition of
important developmental skills

Median age: when half the population acquire a

skill; serves as a guide to normal pattern of
development

Limit age: when a skill should have been

acquired; further assessment is indicated if not
achieved
Development monitored by standardized
developmental tables ,eg, Denver Developmental
Screening Test (DDST)

Primitive newborn reflexes appear and disappear

in a certain order
Absence or persistence indicates CNS
dysfunction
Newborn reflexes
sic Stage Theories of Developme

Theory Infancy Toddlerhoo Preschool School Age Adolescenc

(0–1 yr) d (3–6 yr) (6–12 yr) e
(2–3 yr) (12–20 yr)
Freud: Oral Anal Oedipal Latency Adolescenc
psychosexu e
al
Erikson: Basic trust Autonomy Initiative vsIndustry vs Identity vs
psychosoci vs shame guilt inferiority identity
al and doubt diffusion
Piaget: Sensorimot Sensorimot PreoperatioConcrete Formal
cognitive or (stages or (stages nal operations operations
I–IV) V, VI)
From a motor perspective, children develop in a
cephalocaudal direction

•Lift their heads with good control at 3 months,

•sit independently at 6 months,
•crawl at 9 months,
•walk at 1 year, and
•run by 18 months.

Walk has a wide-based gait at first; then with legs closer

together, the arms move medially, a heel-toe gait
develops, and the arms swing symmetrically by 18–24
months
0 – 3 months
4 -6 months
6 – 12 months
Second year
Preschool (2-5 years)- preoperational
Language development
Attendance at kindergarten at age 5 years marks
an acceleration in the separation-individuation
theme initiated in the preschool years

Child is ready to relate to peers in a more

interactive manner

Sensorimotor coordination abilities are maturing

and facilitating pencil-and-paper tasks and sports
Freud characterized ages 7–11 years as the
latency years

devote most of their energies to school and peer

group interactions
Observable
aspects of
behaviour

Hidden aspects
of behaviour
Cognitive function can be assessed objectively
by formal IQ tests but disadvantages are that the
tests:
•may be affected by cultural background and
linguistic skills
•do not test all skill areas
•do not necessarily reflect an individual child's
ultimate potential
•may be compromised by individual disabilities,
such as a motor disorder as in cerebral palsy,
necessitating care in interpreting results
Severe deficits in the development of language,
motor skills, attention, abstract reasoning, visual-
spatial skills, and academic or vocational
achievement are associated with mental
retardation
Mental Retardation Range Intelligence Quotient
(IQ)
Mild mental retardation 50–69
Moderate mental retardation35–49
Severe mental retardation 20–34
Profound mental retardation < 20
Cause Percentage of
Cases
Chromosomal abnormalities 4–28
Fragile X syndrome 2–5
Monogenetic conditions 4–14
Structural CNS abnormalities 7–17
Complications of prematurity 2–10
Environmental or teratogenic 5–13
causes
"Cultural-familial" mental 3–12
retardation
Metabolic or endocrine causes 1–5
Treatment

A combination of individual therapies, such as

•speech and language therapy
•occupational therapy or physical therapy,
•special education support
•behavioral therapy or counseling
•medical intervention, which may include
psychopharmacology.
Sleep is a complex physiologic process
influenced by intrinsic biologic properties,
temperament, cultural norms and expectations,
and environmental conditions.

Between 20% and 30% of children experience

sleep disturbances at some point in the first 4
years of life.
The percentage decreases to 10–12% in school-
age children.
Sleep disorders fall into two categories.

Dyssomnias refer to problems with initiating and

maintaining sleep or to excessive sleepiness.

Parasomnias refer to abnormalities of arousal,

partial arousal, and transitions between stages of
sleep.
•consists of arousal from deep NREM sleep
probably the most frightening for parents.

•include night terrors, sleeptalking, and

sleepwalking (somnambulism).
Night terrors
•Occur within 2 hours after falling asleep, during
the deepest stage of NREM sleep,
occur in about 3% of children

•Child may sit up in bed screaming, thrashing

about, and exhibiting rapid breathing,
tachycardia, and sweating

•Episode may last up to half an hour, after which

the child goes back to sleep and has no memory
of the event the next day
Sleepwalking
•Occurs during slow-wave sleep and is common
between 4 and 8 years of age
•Typically benign except that injuries can occur
while the child is walking around.

•Scheduled awakenings may also be used if the

child sleep walks frequently and at a predictable
time.
Nightmares
•Frightening dreams that occur during REM
sleep, typically followed by awakening, which
usually occurs in the latter part of the night
•Peak occurrence 3 - 5 yr (incidence 25% - 50%)
•Child can often describe the frightening images,
recall the dream, and talk about it during the day

•Associated with stress, trauma, anxiety, sleep

deprivation that can cause a rebound in REM
sleep, and medications that increase REM sleep.
Dyssomnias

•Problems going to sleep and maintaining

sleep/nighttime awakenings

•Dyssomnias are frustrating

•Results in daytime fatigue for both the parents

and the child, parental discord about
management, and family disruption
Obstructive sleep apnea is characterized by
obstructed breathing during sleep accompanied
by loud snoring, chest retractions, morning
headaches and dry mouth, and daytime
sleepiness
•common between ages 12 months - 4 years,
occurring about once a week in 50–80%

•Child may throw him- or herself down, kick and

scream, strike out at people or objects in the
room, and hold his or her breath

•Often a reflection of immaturity as the child

strives to accomplish age-appropriate
developmental tasks and meets with difficulty
because of inadequate motor and language
skills, impulsiveness, or parental restrictions
The range of effects that can occur in an individual
exposed to alcohol prenatally

•Fetal Alcohol Syndrome

•Partial Fetal Alcohol Syndrome

•Alcohol-Related Neurodevelopmental
Disorder

•Alcohol-Related Birth Defects

Fetal Alcohol Syndrome:
Associated with prenatal alcohol exposure

•Characteristic pattern of facial abnormalities

(short palpebral fissures, thin upper lip, and
indistinct or smooth philtrum)
•Growth deficiency
•Evidence of CNS damage and
neurodevelopmental abnormalities
Fetal alcohol syndrome
Partial Fetal Alcohol Syndrome

•Presence of some of the facial anomalies

growth retardation

•CNS neurodevelopmental abnormalities, or

behavioral or cognitive abnormalities that are
inconsistent with the child's developmental level
and cannot be explained by familial background
or environment.
Alcohol-Related Neurodevelopmental
Disorder

•Does not require the presence of dysmorphic

facial features

•Requires the presence of neurodevelopmental

abnormalities or evidence of a pattern of
behavioral or cognitive abnormalities.
Alcohol-Related Birth Defects

•Presence of congenital anomalies including

malformations and dysplasias in cardiac, skeletal,
renal, ocular, or auditory areas (ie, sensorineural
hearing loss).

Binge drinking during the first trimester, the

critical period of embryogenesis, leads to FASD.
Inability to attend to the task at hand, increased
motor activity and impulsivity
Risk factors/ etiology:
•Actual cause unknown
•Problems with filtering environmental stimuli and
controlling their own behaviour to socially
acceptable norms
•Imaging studies show a difference in brain
structure and function between patients with
ADHD and normal control subjects
•Occurs more frequently in boys (4:1)
•Associated with other childhood behaviour
disorders
Presentation:
Problems in attention, hyperactivity and
impulsivity
DSM IV criteria:
Inattentiveness:
•Makes mistakes due to not paying attention
•Has difficulty paying attention, doesn’t seem to
listen
•Doesn’t follow through on tasks
•Has difficulty getting organized
•Dislikes/ avoids sustained mental effort
•Loses things easily
•Easily distracted
•Forgetful
Hyperactivity:
•Fidgets,
•Is out of seat often,
•Does excessive running/climbing,
•Has difficulty playing quietly,
•Is always on the go,
•Talks excessively

Impulsivity:
•Bursts out answers
•Has difficulty awaiting turn
•Interrupts/ intrudes
Diagnostic tests:
ADHD is a clinical diagnosis

•At least six criteria from inattentiveness,

•Six from hyperactivity/impulsiveness or both
•Symptoms must be seen by 7 years of age, last
at least 6 months, be observed in more than one
setting, be more than age appropriate, and impair
function

Psychologic testing helps in D/D , but there is no specific

test for ADHD
Treatment
Pharmacologic :
•Methylphenidate
•Dextroamphetamine
•Pemoline
•TCA
•Clonidine
•Buproprion

Diets have absolutely no value

Management of any associated learning
disabilities
Complications:
•About half of patients with ADHD have normal
adult lives
•Those who continue to be affected may have
antisocial personalities and alcohol and drug
abuse
•Aggressive, defiant children tend to do worse as
adults

D/D:
Other psychiatric disorders
•Involuntary passage of urine in a child who is
reasonably expected to be toilet trained
•Day and night bladder control usually attained by
age 5 years

Risk factors/ etiology

•Incidence of enuresis declines with age
•A strong genetic predisposition for primary
nocturnal enuresis
Presentation
Two major types:
Primary enuresis (90%):
The patient never achieved dryness for any
significant period of time

Secondary enuresis :
•Usually secondary to emotional difficulties ( eg,
birth of a sibling, significant loss, family discord)
•Usually transient and has better prognosis
Primary enuresis:

Nocturnal only
Diurnal only
Nocturnal/ diurnal
Nocturnal enuresis : Associated with
•maturational developmental delay of the bladder
•may be a disorder of sleep and arousal

Diurnal enuresis: Associated with

•waiting too long to void,
•UTI,
•constipation,
•diabetes and
•stress incontinence
Diagnostic tests:
•Usually no pathologic condition associated
•Anatomic abnormalities uncommon
•History and physical exam
•Screening urine analysis
Treatment:
•Treatment of any associated anomaly or
pathology
•Reward systems, alarm systems, and
pharmacotherapy
•Relapse rates of up to 30%
•Imipramine and desmopressin commonly used
•Fecal incontinence after the age of 4 years

Risk factors/ etiology:

•Occurs more commonly in boys (4 – 6: 1)

The causes are usually

•Psychological, secondary to toilet phobia
•Overly aggressive management of constipation
•Starting toilet training too early
•Painful defecation after diarrhea, fissures,
severe perianal rashes
Presentation
•Secondary to stool retention, resulting in leakage
of loose stool around the obstruction

Treatment
•Counseling for the child and parents
•Gentle cleaning of impacted stool out of the
colon
Autism:

•A developmental disorder characterized by

impaired social relatedness deficits in verbal and
nonverbal communication, and unusual
responses to the environment

Risk factors/ etiology

•Autism develops before 30 months of age
•Cause unknown
•More common in boys (4:1)
Presentation:
•Failure to attach as an infant
•Delayed/ absent social smile
•Failure to anticipate interaction with the caretaker
•Delay in verbal and nonverbal communication
skills
•Stereotypical movements and need for sameness
and routines
•Outbursts of anger
•Self-injurious behaviour
•Content to play alone
•75% of patients are mentally retarded, although testing is difficult
Treatment:
•Behavioural and educational programs geared to
the individual patient’s need
•Pharmacotherapy for some target behaviours

Prognosis: Poor
•A very small minority will grow up to be
marginally self-sufficient
•The majority will end up institutionalized
•A better prognosis associated with patients who
demonstrate functional speech and higher
intelligence
•More communicative,
•Appear more socially aware, and
•Do not have language impairments found in
autism

•They have social impairments, repetitive

behaviours and sometimes obsessional interests
•X-linked dominant, affecting exclusively girls

•Development is normal until 1 year of age

•Language and motor milestones regress
•An acquired microcephaly is seen

•Hand wringing and sighing are characteristic

•They develop autistic behaviour